Hunt & Marshall's Clinical Problems in Surgery, 3e

 

Description:

Is surgery required? Is the patient effectively communicating symptoms to make the correct clinical diagnosis? Clinical Problems in Surgery, 3rd Edition supports medical students in applying clinical reasoning to problems they encounter in a clinical setup. Individual chapters are dedicated to specific regions of the body where surgeons encounter most of the problems. The content structure follows the logical step-by-step process of introducing a clinical problem; seeking history and conducting physical examination; diagnosing the patient and devising a treatment plan based on this informed diagnosis.

 

 

Table of Contents:

 

FIGURE 1 Iron deficiency anaemia may be A: the primary presentation of an occult carcinoma of the caecum; B: a secondary problem when carcinoma of the sigmoid presents with altered bowel habit

FIGURE 2 Forms of presentation of gastrointestinal blood loss A: melaena from a duodenal ulcer; B: occult blood loss and anaemia from a caecal carcinoma; C: acute colonic haemorrhage from diverticular disease; D: defaecatory bleeding from haemorrhoids

FIGURE 3 Forms of presentation of duodenal ulcer A: haemorrhage presenting as haematemesis and melaena; B: pyloric stenosis presenting as vomiting; C: perforation presenting as an acute abdomen. Duodenal ulcer most commonly presents as chronic epigastric pain.

The problem-oriented clinical approach

1 Collect and record the database

Take a history and examine the patient

Record the data in a systematic manner

History of the presenting complaint

Subjective data (S)

Objective data (O)

2 Constructing a problem list

3 Assessment and plan

4 Progress notes

5 Discharge summary

Medical record

Discharge summary

Student case presentations

Suggested format

What to put on visual aids such as computer presentation packages

Suggestions

Example case presentation

Format of bedside presentations

ISBAR

Chapter 1 Integument problems

1.1 Introduction

FIGURE 1.1 Focal skin lesionsA: macule; B: papule (1), nodule (2) or plaque (3); C: vesicle or pustule; D: wheal

The clinical history of a lump or ulcer

1 Onset and duration

FIGURE 1.2 Types of epithelial ulceration1. squamous cell carcinoma; 2. basal cell carcinoma; 3. venous ulcer; 4. neuropathic ulcer; 5. peptic ulcer; 6. anal fissure; 7. keratoacanthoma

2 Change and progression

3 Other symptoms

4 Multiplicity

The physical examination of a lump or ulcer

TABLE 1.1 Growth pattern of some common skin nodules

Box 1.1 Characteristics of a lump on physical examination

1 Situation and depth

2 Size

3 Shape and surroundings

4 Colour

5 Contour

6 Consistency

7 Temperature

8 Tenderness

9 Transillumination

10 Fluctuation and percussion

FIGURE 1.3 Testing fluctuationTwo watching fingers detect transmitted impulse (A) while the displacing finger applies compression (B).

11 Fixity

12 Fields

1.2 Focal skin lesions

Clearly benign lesions

FIGURE 1.4 Focal skin lesionsA: hyperkeratosis with central crusting on dorsum of hand, infective warts on index finger; B: calluses over first metatarsal head and over proximal interphalangeal joint in hammer toe

Box 1.2 Clearly benign macules and nodules in children

Pigmented lesions

Other lesions

Box 1.3 Clearly benign macules and nodules in adults

Non-pigmented lesions

Pigmented lesions

Common causes of benign skin lesions

In children

In adults

Clinical features, diagnostic and treatment plans

Children

Port-wine stain

Strawberry naevus (capillary haemangioma)

Benign mole

Intradermal, junctional and compound naevus

FIGURE 1.5 The histology of benign pigmented molesA: junctional naevus showing melanocytes at the epidermal–dermal junction; B: intradermal naevus with pigmented cells in the dermis. The histological combination of A and B is known as a compound naevus

Blue naevus

Freckles (ephelides)

Infective warts

Pyogenic granuloma

Adults

Senile freckling

Senile purpura

Callosity (callus)

Infective warts

Skin tag (benign squamous papilloma, soft fibroma)

Seborrhoeic keratosis (seborrhoeic wart)

Solar keratosis (senile keratosis, hyperkeratosis)

Sclerosing haemangioma (dermatofibroma, histiocytoma)

Senile haemangioma (Campbell-De Morgan's spots, cherry angioma)

Spider naevus

Xanthoma

Benign mole

‘Suspicious’ lesions

Causes of ‘suspicious’ skin lesions

Clinical features and diagnosis

1 Basal cell carcinoma

Box 1.4 Clinical forms of BCC

2 Squamous cell carcinoma

3 Keratoacanthoma

4 Pyogenic granuloma

5 Malignant melanoma

FIGURE 1.6 The ABCDE assessment aids in the identification of skin lesions suspicious of melanomaA: asymmetry – one half unlike the other; B: border – irregular edge; C: colour – variable pigmentation; D: diameter – usually larger than 6 mm; E: evolving – change in the lesion including increasing elevation

6 Kaposi sarcoma

Treatment plans

1 Basal cell carcinoma

2 Squamous cell carcinoma

3 Keratoacanthoma

TABLE 1.2 Malignancies and their mimics

4 Pyogenic granulomas

5 Melanoma

Box 1.5 Suspicious pigmented lesions

FIGURE 1.7 Prognosis in malignant melanoma is measured in two ways: depth of invasion (Clark's levels I–V) or simple measurement of tumour depth in millimetresComparison of the two methods is shown. Level I: an in situ lesion above the basement membrane of the basal layer of the epidermis, less than 0.75 mm in depth. Level II: the lesion is invading into the papillary dermis, equivalent to a depth 0.75–1.5 mm. Level III: the lesion fills the papillary dermis down to its junction with the reticular dermis, a depth of 1.5–2.25 mm. Level IV: the lesion extends into the reticular dermis, a depth of 2.25–3.0 mm. Level V: well into the subcutaneous tissue, a depth greater than 3.0 mm

TABLE 1.3 Tumour depth in melanoma influences management and prognosis

6 Kaposi sarcoma

7 Other malignant or infective skin lesions

Pigmented skin lesions

TABLE 1.4 Types of benign pigmented moles

Diagnostic and therapeutic plans

Box 1.6 Pigmented skin lesions – indications for excision

1.3 Subcutaneous lumps

Common causes

Clinical features and treatment plan

1 Lipoma

FIGURE 1.8 Lipoma and sebaceous cystA: the surface contour of a lipoma is classically lobulated; B: when a lipoma is pressed, it tends to slip from beneath the finger; C: these features are not seen in sebaceous cyst, which is fixed to the skin, has a spherical shape and a smooth contour

2 ‘Sebaceous’ cyst

FIGURE 1.9 Excision of a lipomaA–C: most lipomas can be shelled out after infiltration with a local anaesthetic and an incision directly over the lesion

FIGURE 1.10 Excision of a sebaceous cystInfiltration of local anaesthetic. A: bisection through the punctum and avulsion of each half using an artery forcep; B: formal excision using an elliptical incision. The cyst is freed from the subcutaneous tissue by blunt dissection.

3 Ganglion

FIGURE 1.11 Ganglion on the dorsum of the wrist joint is made more prominent by hyperflexion of the joint

4 Bursa

5 ‘Dermoid’ cysts

6 Neurofibromas

1.4 Cutaneous and subcutaneous infections

Pathology

Clinical features

Diagnosis and treatment plans

General principles

1 The primary site of infection

Box 1.7 The general principles of the treatment of surgical infection

FIGURE 1.12 Incision and drainage of subcutaneous infectionA: the central area of the abscess is infiltrated with local anaesthetic; B: the abscess is incised to allow free drainage; C: an appropriate dressing is used to allow the cavity to heal by secondary intention

2 The infectious agent

3 The susceptible host and measures to strengthen host resistance

Specific infections of skin and subcutaneous tissues

Common types

Clinical features and treatment plan

1 Infected epidermoid (sebaceous) cysts

2 Folliculitis, furuncle, carbuncle, hydradenitis

3 Erysipelas, cellulitis, impetigo

4 Necrotising soft tissue infections

5 Specific sites

1.5 Lymph node swellings

FIGURE 1.13 The Karydakis operation for chronic pilonidal sinusA: one side of the incision is placed further from the midline; B: the sinus and surrounding fibrous tissue is excised down to the fascia over the sacrum, creating a flap on one side; C: closure brings the flap away from the midline, avoiding a central unstable scar and thus reducing the chance of recurrence

FIGURE 1.14 Lymph nodes in the neck1: submental nodes drain the lip; 2: submandibular nodes drain the anterior two-thirds of the tongue, floor of mouth, gums and buccal mucosa; 3: upper jugular nodes of the deep cervical chain drain the oral cavity, nasopharynx, tonsil, base of the tongue, pharynx and larynx; middle nodes drain the thyroid, pyriform sinus and larynx; 4: supraclavicular nodes from the arm and mediastinum; 5: posterior triangle nodes drain the nasopharynx; 6: mastoid nodes drain the nasopharynx and parotid; 7: suboccipital nodes drain the posterior scalp; 8: pre-auricular nodes drain the scalp, ear and parotid; A: Stohr's node; B: the tonsillar node; C: Virchow's node; D: the Delphic node. Intralymphatic deposits of melanoma are visible on the chest wall together with a left axillary mass due to lymphadenopathy

FIGURE 1.15 Lymph nodes in the axillaA: the axilla can be exposed by abducting and/or extending the arm; B: the axilla can be considered a pyramidal space with the lymph node groups arranged as numbered below.1. subscapular nodes; 2. pectoral nodes drain lymph from the breast; 3. central nodes drain lymph from the breast and back; 4. apical nodes drain the other axillary node groups and are continuous with the supraclavicular nodes; 5. lateral nodes

FIGURE 1.16 Lymph nodes in the groin1. vertical group of superficial inguinal nodes drain the lower limb; 2. horizontal group of superficial inguinal nodes. The lateral group drain back below the iliac crest and the medial group drain the anterior abdominal wall, below the umbilicus, the perineum and external genitalia and the lower half of the anal canal; 3. deep inguinal nodes including the node of Cloquet (4) collect deep and superficial lymph fluid

Common causes

Localised lymph node swellings

Generalised lymph node swellings

Clinical assessment

Localised lymph node swellings

Generalised lymph node swellings

Diagnostic and treatment plans

Chapter 2 ENT, Head and neck problems

2.1 Introduction

History

Examination of the head and neck

Ear

Nose

Nose and sinuses

TABLE 2.1 Symptoms of ear, nose and throat conditions

TABLE 2.2 Referred or non-otologic otalgia

Throat

Mouth

Oropharynx

Hypopharynx

Nasopharynx

Head and neck lumps

FIGURE 2.1 Division of lymph node groups levels I–VI (VII)

TABLE 2.3 Thyroid examination – performed if thyroid disease is detected or suspected

TABLE 2.4 Screening examination of the cranial nerves

FIGURE 2.2a and b Voroscope

FIGURE 2.3 Nasolaryngoscope

Regional and developmental anatomy

2.2 Ear

TABLE 2.5 Outer ear, middle ear and inner ear components

FIGURE 2.4 Anatomy of the ear

Role of the ear

Nearby blood vessels

External ear

Wax and otitis externa

Management

Middle ear

Otitis media

FIGURE 2.5a Extracranial complications of otitis media

FIGURE 2.5b Intracranial complications of otitis media

Inner ear

Hearing loss

TABLE 2.6 Causes of hearing loss

Vertigo

Tinnitus

FIGURE 2.6 Tuning fork tests

FIGURE 2.7 Audiograms

FIGURE 2.8 Otologic causes for dizziness

TABLE 2.7 Causes of tinnitus

2.3 Facial weakness

Trauma

2.4 Nose and sinuses

Anatomy/physiology

FIGURE 2.9 Structure of the lateral nasal wall

Blood supply

Nerve supply

Olfactory nerve – cranial nerve I

FIGURE 2.10 Paranasal sinuses

Paranasal sinuses

Epistaxis

Nasal obstruction

Sinusitis, nasal polyps, allergy

Investigations

Treatment

2.5 Throat

Tonsils and adenoids

FIGURE 2.11 Laryngeal framework

TABLE 2.8 Related spaces and anatomy

Anatomy

Microbiology/pathology

Infectious mononucleosis

History and examination

TABLE 2.9 Organisms found in the tonsil

Diagnosis

Medical treatment

Surgical treatment

FIGURE 2.12 Bacterial tonsillitis

FIGURE 2.13 Infectious mononucleosis

2.6 Airway emergencies and tracheostomy

FIGURE 2.14 Quinsy

Tube types

FIGURE 2.15 Tracheostomy tubes

Complications

Avoiding complications

2.7 Snoring and obstructive apnoea

Treatment

2.8 Voice, dysphonia, hoarse voice

Anatomy

Nerve supply

Dysphonia

FIGURE 2.16 The larynx

TABLE 2.10 The anatomy of the larynx

TABLE 2.11 Organic and non-organic causes of dysphonia

2.9 Dysphagia

2.10 Congenital anomalies

Thyroglossal cysts

Branchial cysts

FIGURE 2.17 Congenital anomaliesa. Thyroglossal duct cyst

b. Type II Branchial cleft cyst

Vascular malformations

Nasolabial cyst, dermoids, cleft lip and cleft palate

2.11 Foreign bodies

Ear

History

Examination

Investigation

Treatment

Nose

History

Examination

Investigation

Treatment

Oropharyngeal/oesophageal

History

Examination

Investigation

Treatment

Upper airway

History

Examination

Investigation

Treatment

2.12 Head and neck cancer

2.13 Larynx

TABLE 2.12 TNM

Larynx

2.14 Parotid and salivary glands

TABLE 2.13 Staging for lip and oral cancer

TABLE 2.14 Staging for oropharyngeal carcinoma

TABLE 2.15 Staging for hypopharyngeal carcinoma

TABLE 2.16 Staging for nasopharyngeal carcinoma

TABLE 2.17 Staging for supraglottic carcinoma

FIGURE 2.18 Carcinoma of tonsil

TABLE 2.18 Staging for glottic carcinoma

TABLE 2.19 Staging for subglottic carcinoma

TABLE 2.20 Staging for salivary gland carcinoma

Investigations

2.15 Thyroid/parathyroid

Goitre

Common causes

Clinical features

History

TABLE 2.21 Physical examination of the thyroid

Common causes – specific clinical features

I General enlargements

1 Multinodular goitre

2 Graves' disease

3 Hashimoto's thyroiditis

4 Anaplastic carcinoma

II Single nodule

Benign lesion

FIGURE 2.19 Goitre – single noduleA: dominant nodule in a multinodular goitre; B: benign adenoma; C: celloid nodule within a haemorrhagic cyst; D: carcinoma (papillary) with nodes

Carcinoma

TABLE 2.22 Thyroid carcinoma classification and staging

TABLE 2.23 Staging papillary or follicular carcinoma

TABLE 2.24 Staging undifferentiated – anaplastic carcinoma

TABLE 2.25 Thyroid carcinoma outcome statistics

TABLE 2.26 The Mayo Clinic carcinoma classification system

TABLE 2.27 The Lahey Clinic's AMES classification

Diagnosis

Thyroid function tests

Thyroid imaging

Aspiration cytology

Other biochemical tests

Treatment plan

I General enlargement

Generalised longstanding gland enlargement (multinodular goitre)

Graves' disease

Hashimoto's thyroiditis

Anaplastic invasive cancer

II Solitary thyroid nodules

2.16 Mouth ulcers and lesions

Common causes

Clinical features and treatment

Benign disease

Benign ‘dental’ ulcer

Herpes labialis (‘cold sore’)

Benign fissures and crusting of mucous membrane

Prosthetic ulcers and epulides

Pyogenic granuloma

Lichen planus

Candidiasis

Mucous retention cyst

Neutropenia

Pigmented and vascular lesions

Premalignant lesions

2.17 Approach to a head and neck lump

2.18 Neck pain

Clinical features, diagnostic and treatment plans

Cervical spondylosis and cervical disc degeneration

Whiplash

Cervical rib

Referred pain

Other causes

2.19 Cranial nerve evaluation

First (olfactory) cranial nerve

Second (optic) cranial nerve

Third, fourth and sixth cranial nerves

Fifth cranial nerve (trigeminal)

Seventh (facial) cranial nerve

Eighth cranial nerve

Ninth and tenth cranial nerves (glossopharyngeal and vagus)

Eleventh cranial nerve (accessory)

Twelfth cranial nerve (hypoglossal)

Chapter 3 Breast problems

3.1 Introduction

History

Physical examination

Box 3.1 Causes of unilateral enlargement of the breast or breast asymmetry

FIGURE 3.1 Asymmetrical breast development

FIGURE 3.2 Accessory nipple

FIGURE 3.3 Accessory breast tissue in the axilla

FIGURE 3.4 Upper outer breast distortion

FIGURE 3.5 Skin tethering due to cancer only demonstrable when the patient raises her arms

FIGURE 3.6 Breast examination

FIGURE 3.7 Scheme for recording the characteristics of breast lesions

Diagnostic tests

Imaging techniques: mammography, ultrasound

Cytology and histology

3.2 Breast pain

Common causes

Clinical features and diagnosis

FIGURE 3.8 Mammographic and sonographic images of the breastMammographic and sonographic images of the breast often demonstrate the features of benign and malignant breast lesions. (a) Breast cancer typically appears on a mammogram as a focal density with spiculate edges. (b) Microcalcification can be associated with benign and malignant breast pathology and is graded according to its morphology. Typically malignant calcification is variable in size and shape and may cast the branching pattern of the milk ducts. (c) Simple cysts may show as a discrete density on mammography, but ultrasound best demonstrates the smooth cyst wall and anechoic cyst fluid. (d) Fibroadenomas may also appear as a discrete density on mammography and on ultrasound. A benign solid lesion should have more breadth than height.

Treatment plan

3.3 Breast lump

Causes

History and physical examination

1 Carcinoma

FIGURE 3.9 Locally advanced breast cancer

Box 3.2 Breast cancer staging

Primary tumour (T)

Regional lymph node involvement (N)

Metastatic involvement (M)

2 Involutional change with stromal hyperplasia

3 Fibrocystic change (breast cyst)

4 Fibroadenoma

5 Mammary duct ectasia

6 Less common causes

Diagnostic plans

1 Fine needle aspiration cytology

2 Mammography

Treatment plan

1 Clinical staging

2 Curative surgical treatment for early disease

4 Stage IV disease and advanced local disease

3.4 Nipple discharge

TABLE 3.1 Differences between Paget's disease and eczema of the nipple

Common causes

Diagnostic plans

Discharge from many duct orifices (often bilateral)

FIGURE 3.10 Paget's disease of the nipple

FIGURE 3.11 Eczema affecting the areola

Unilateral bloody discharge from a single duct

FIGURE 3.12 Multiduct discharge in duct ectasia

FIGURE 3.13 Single duct discharge suggestive of a papilloma

Mammary duct fistula

FIGURE 3.14 Nipple discharge A spot of fluid is seen to appear from a single duct with pressure on the related breast segment.

Diagnostic plan

Treatment plan

FIGURE 3.15 MicrodochectomyA: identification of affected duct by local pressure and insertion of lacrimal probe; B: excision of a segment containing the duct and papilloma through a circumareolar incision

3.5 Gynaecomastia

Common causes

Clinical features

1 Puberty and old age

2 Systemic disease

3 Carcinoma of the lung and other tumours

4 Drug-induced gynaecomastia

Box 3.3 Common drugs associated with gynaecomastia

Diagnostic plan

Treatment plan

Chapter 4 Chest and chest wall problems

4.1 Introduction

Box 4.1 Assessment of exercise tolerance

History

TABLE 4.1 New York Heart Association classification of angina

Physical examination

General inspection

Examination of the periphery

TABLE 4.2 Grades of finger clubbing

Examination of the pulse

Examination of the head and neck

Jugular venous pressure and pulse

TABLE 4.3 Venous and arterial pulses and pressures in the neck

Examination of the heart

TABLE 4.4 Clinical manifestations of heart failure

Examination of the chest and lungs

4.2 Acute chest pain

Causes

Clinical features

1 Angina pectoris, myocardial infarction and oesophageal spasm

2 Pneumothorax

3 Pleurisy and pneumonia

4 Pulmonary embolus and infarction

5 Musculoskeletal disorders

6 Less common causes

Diagnostic plans

Chest x-ray

FIGURE 4.1 Chest x-ray showing an apical pneumothorax

Electrocardiogram

FIGURE 4.2 Chest x-ray showing a right-sided tension pneumothorax

FIGURE 4.3 Chest x-ray showing a pericardial effusion

Serum enzymes

Plasma D-dimers

Arterial blood gases

Ventilation/perfusion (V/Q) scanning

Echocardiography

Computed tomography pulmonary angiography (CTPA)

FIGURE 4.4 Computed tomography pulmonary angiogram (CTPA) showing a large pulmonary embolus (arrowed)

Lower limb venous Doppler

Gastrografin swallow

Treatment plans

1 Myocardial infarction (and oesophageal spasm)

2 Pneumothorax, tension pneumothorax, cardiac tamponade

3 Pleurisy and pneumonia

4 Pulmonary embolus

5 Musculoskeletal pain

6 Other causes

4.3 Pleural effusion

Common causes

I Transudate

II Exudate

Clinical features

Investigations

FIGURE 4.5 Chest x-ray showing a large left-sided pleural effusion

Treatment plans

4.4 Chronic cough and haemoptysis

Causes

Clinical features

1 Smokers' lungs

2 Carcinoma of the lung

TABLE 4.5 Pathological types of lung cancer

3 Postviral bronchitis

4 Foreign body

TABLE 4.6 Causes of coin lesion in the lung on chest x-ray

5 Tuberculosis

Diagnostic plans

Imaging

Endoscopic studies

FIGURE 4.6 Chest x-ray showing a lung cancer

FIGURE 4.7 CT scans showing a lung cancer

Box 4.2 TNM staging of lung cancer

Primary tumour (T)

Regional lymph node involvement (N)

Metastatic involvement (M)

Box 4.3 Stage groupings for lung cancer

Box 4.4 Five-year survival for the various stages of lung cancer

Treatment plan

1 Smokers' lungs

2 Carcinoma of the lung

3 Postviral bronchitis

4 Foreign body

5 Tuberculosis

6 Less common causes

4.5 Chest wall problems

Common causes

Clinical presentation and management plans

1 Congenital deformities of the thoracic cage

2 Soft tissue swellings

3 Bony swellings

4 Costochondral swellings

5 Infections

Chapter 5 Back and related limb neurological problems

5.1 Introduction: the back and spine

History

Examination

FIGURE 5.1 Straight leg raising test for nerve root compression

Neurological system

History

Examination

Motor nerve function

TABLE 5.1 The nerve and spinal roots that innervate the major muscle groups of the upper limb

Sensory nerve function

TABLE 5.2 The nerve and spinal roots that innervate the major muscle groups of the lower limb

Reflex function

FIGURE 5.2 Sensory dermatomes of the body

TABLE 5.3 The spinal segments involved in the common stretch reflexes

Gait

5.2 Back pain

Causes

Special tests in the assessment of spinal pain

Chronic lumbar ligamentous strain

Degenerative disc disease, spondylosis and osteoarthritis

FIGURE 5.3 Pathological sequence in degenerative back diseaseA: normal lumbar vertebrae and disc; B: herniation of the nucleus pulposus; C: disc space degeneration and flattening with early osteoarthritis of the facet joint; D: advanced lumbar degenerative spine disease with facet joint osteophyte formation and compression of the nerve root. Forward slip and arthritis may also lead to narrowing of the spinal canal.

Spondylolisthesis

Osteoporosis

Secondary carcinoma of the vertebral body

FIGURE 5.4 Vertebral collapseA: infection – the vertebral body appears intact because the infection usually lies adjacent to the disc; B: metastatic disease of vertebra leads to collapse with apparent preservation of the adjacent disc. Both conditions lead to kyphosis.

Spinal infection

Referred pain

Less common causes

Diagnostic plan

Treatment plan

5.3 Limb weakness and numbness – peripheral neuropathies

Clinical assessment of specific nerve palsies

Upper limb nerve palsies

Lower limb nerve palsies

Median nerve

Common causes

FIGURE 5.5 Median nerve lesionsThe long flexor of the thumb is tested by flexion of the distal interphalangeal joint against resistance.

Ulnar nerve

Common causes

FIGURE 5.6 Ulnar nerve lesionThe little finger is abducted away from the other fingers against resistance.

FIGURE 5.7 Ulnar nerve lesion – Froment's signOn the side that the adductor pollicis is weak, the patient can only hold the card by flexing the terminal joint of the thumb.

FIGURE 5.8 Causes of finger deformities and clawingA: normal finger; B: claw hand (ulnar nerve or T1 lesion); C: Volkmann's ischaemic contracture; D: intrinsic plus hand; E: Dupuytren's contracture

Radial nerve and posterior interosseous nerve

Common causes

Axillary (circumflex) nerve

Common cause

Brachial plexus

Common causes

Spinal nerve root lesions (cervical)

Lower limb: common peroneal nerve

Common causes

Posterior tibial nerve

Common causes

Sciatic nerve

Common causes

Femoral nerve

Common causes

Lumbo-sacral plexus and roots

Common causes

5.4 Limb weakness – other causes

Weakness with wasting

Wasting without sensory loss

Causes of wasting with normal sensation

Clinical features

1 Posttraumatic disuse

2 Motor neurone disease

3 Poliomyelitis

4 Purely motor peripheral neuropathy

5 Myopathy

Weakness without wasting

Central nervous system lesions – hemiplegia

Common causes

Clinical features

Deformity and posture

Muscle weakness without wasting

Hypertonicity

FIGURE 5.9 Typical features of hemiplegia

Diagnostic plan

Vascular stroke

Neurotrauma

FIGURE 5.10 Extracranial carotid bifurcation diseaseA: normal carotid arteries; B: severe stenotic plaque at internal carotid artery with emboli; C: post carotid endarterectomy and standard repair with patch at endarterectomised site

FIGURE 5.11 Carotid fibromuscular dysplasia

Treatment plan

Spinal cord lesions – paraplegia or quadriplegia

FIGURE 5.12 Carotid stentingA: angiographic appearance of severe internal carotid artery stenosis; B: carotid stent placed across the stenosis

Common causes

With compression

Without compression

History, examination and clinical assessment

Hemisection of the spinal cord (Brown-Séquard syndrome)

Diagnostic and treatment plans

Chapter 6 Limb problems

6.1 Introduction

Arterial circulation

History

Examination

Inspection

Palpation

FIGURE 6.1 Temperature change detected by applying the thin skin of the dorsal surface of the fingers to the lesions

FIGURE 6.2a The midinguinal pointA: lies halfway between the anterior superior iliac spine (1) and symphysis pubis (2) the deep inguinal ring; B: lies above the midpoint of the inguinal ligament, which attaches to the pubic tubercle (3); C: common femoral artery; D: common femoral vein; E: saphenous opening; F: great saphenous vein

FIGURE 6.2b The anatomy of the arterial system

Auscultation

Venous circulation

History

Examination

Inspection

Palpation

Neurological system

History

Examination

Motor nerve function

Sensory nerve function

Reflex function

Gait

Musculoskeletal locomotor system

History

Examination

Inspection

Palpation

Movement

6.2 Bony lumps

FIGURE 6.3 Apparent and true shorteningA: adduction deformity of the left leg. The legs are kept in line by pelvic tilt and the leg is apparently short (measured from umbilicus); B: when the pelvis is set square and the legs are matched for position the difference in length disappears; C: true shortening of the left leg (measured from ASIS) at the hip or femoral neck. Measured with the pelvis square and the legs matched for position.

FIGURE 6.4 Typical sites of long bone tumoursA: an expanding swelling at the end of the bone is likely to be a giant cell tumour; B: a swelling to one side at the epiphysis is likely to be an exostosis; C: a swelling in the region of the metaphysis may be osteosarcoma, chronic osteomyelitis (Brodie's abscess) or a simple or aneurysmal bone cyst; D: a swelling in the middle of a long bone may be an eosinophilic granuloma, Ewing's sarcoma or callus formation

TABLE 6.1 Common causes of localised swelling of bone

Causes

History, physical examination and radiology

1 Callus formation

2 Acute osteomyelitis

3 Osteosarcoma

FIGURE 6.5 Bone infection commonly starts in the metaphysis below the epiphyseal plateA: the plate acts as a barrier to spread into the joint;B: spread through the cortex forms a subperiosteal abscess;C: stripping of the periosteum interrupts the blood supply to the cortex, which forms a sequestrum; the sequestrum forms a nidus for chronic ostemyelitis

4 Giant cell tumour of bone

5 Fibrosarcoma

6 Chondrosarcoma

7 Metastatic carcinoma

8 Less common causes

Diagnostic and treatment plans

FIGURE 6.6 Radiological features of common bone tumoursA: ecchondroma may be painful or may fracture; B: enchondromas are often multiple and may also fracture; C: osteoid osteoma is associated with increasing bone pain; D: osteosarcoma produces destruction of the cortex, elevation of the periosteum (Codman's triangle) and sunray appearance; E: osteoclastoma is a radiolucent lesion expaling the cortex and may extend to the articular surface

6.3 Musculotendinous lumps

FIGURE 6.7 A lump located within a muscleA: lumps superficial to muscle remain easy to feel when the muscle contracts; B: lumps within muscle become obscured or impalpable when the muscle contracts

Muscle swellings

Causes

Tendinous swellings

Cause

Clinical features, diagnostic and treatment plans of musculotendinous lumps

Muscle swellings

1 Muscle rupture

FIGURE 6.8 Ruptured long head of biceps brachii

2 Intramuscular haematoma

3 Muscle hernia

4 Benign or malignant intramuscular neoplasms

5 Less common causes

Tendinous swellings

Stenosing tenosynovitis

6.4 Painful shoulder

FIGURE 6.9 Surface landmarks of the shoulder1: clavicle; 2: coracoid process; 3: bicipital groove; 4: greater tuberosity; 5: acromion; 6: subacromial bursa

Causes

History and physical examination

1 Rotator cuff lesions

FIGURE 6.10 Anatomical basis of rotator cuff disordersA: 1: inflamed subacromial bursa; 2: degeneration and calcification of the supraspinatus tendon; B: the painful arc of shoulder movement through 60° and 120° of shoulder abduction

2 ‘Frozen’ shoulder

3 Bicipital tendinitis and rupture

4 Osteoarthritis of the acromioclavicular joint

5 Referred pain

6 Less common causes

Diagnostic plan

Treatment plan

6.5 Pain in the upper limbs

Common causes

Clinical features and diagnosis

1 Carpal tunnel syndrome

2 Tennis elbow

FIGURE 6.11 Tennis elbowA: the site of tenderness is over the extensor tendons just anterior to the lateral epicondyle

3 De Quervain's tenosynovitis

4 Repetitive strain injury

FIGURE 6.12 De Quervain's tenosynovitisThickening in the sheath of abductor pollicis longus and extensor pollicis brevis (A) where they cross the styloid process of the radius (B)

Treatment plan

6.6 Subcutaneous hand lumps

Causes

Clinical features and diagnostic plan

1 Ganglion

FIGURE 6.13 Dorsal wrist ganglionA: sectional view; B: surface view of a ganglion presenting between slips of the extensor digitorum longus

2 Synovioma of tendon sheath (benign giant cell tumour, xanthoma)

FIGURE 6.14 Ganglion1: sesamoid ganglia on the lateral palmar aspect of the metacarpophalangeal joints arising from the fibrous flexor tendon sheath; 2: sesamoid bones lie medially in relation to the volar aspect of the thumb

3 Dupuytren's disease

4 Traumatically induced lesions

5 Nodules associated with joint disease

6 Less common causes

Treatment plan: general

6.7 Hand deformities

FIGURE 6.15 The stronger power gripA: precision grip depends on the pinching movement; B: power grip requires wrist, elbow and shoulder as well as hand power

FIGURE 6.16 Skin incisionsSkin incisions are best placed in flexure skin creases, along lines of cleavage or along the lateral margins of the fingers in areas of relative skin immobility. Zig-zag oblique incisions between joint flexure lines ensure that the incision does not cross the crease line at right angles.

Common causes

FIGURE 6.17 Correct hand splinteringA: the position of function. The wrist is extended and the fingers progressively flexed; B: the position of rest of the hand and fingers. The wrist is in neutral; C: splintage position. Wrist extended, flexed metacarpophalangeal joints and relatively straight fingers (Z-position).

History and physical examination

1 Congenital contractures

2 Wound contractures

3 Dupuytren's contracture

FIGURE 6.18 Dupuytren's contracture

4 Ischaemic muscle contracture (Volkmann's)

FIGURE 6.19 Volkmann's contractureA: moderate flexion of the wrist with gross flexion of the interphalangeal joints; the metacarpophalangeal joints are in the neutral position or slightly extended; B: the thumb is partly spared in this case

5 Tendon disorders

FIGURE 6.20 The ‘intrinsic plus’ handThe intrinsic plus hand results from fibrous contracture or hypertonicity of the small muscles of the hand. Flexion of the metacarpophalangeal joints, interphalangeal joint extension and adduction of the thumb.

FIGURE 6.21 Trigger finger from stenosing tenosynovitis of the flexor tendonThe finger becomes locked in flexion. Forced extension leads to a sudden click and release.

FIGURE 6.22 Mallet fingerA: extensor tendon avulsion; B: avulsion of bone fragment, tendon intact

FIGURE 6.23 Boutonnière deformityA: normal tendon B: ruptured central slip; C: established deformity

FIGURE 6.24 Swan neck deformity

6 Deformities due to arthritis

7 Deformities due to neurological lesions

FIGURE 6.25 Rheumatoid hand1: ‘swan neck’ finger deformity; 2: mallet finger; 3: flexion contracture of M-P joint; 4: Z-thumb deformity; 5: muscle wasting; 6: synovial thickening; 7: thickening of the dorsal ligaments of the proximal interphalangeal joints; 8: ulnar deviation of fingers

FIGURE 6.26 Claw hand due to ulnar nerve palsy

Box 6.1 The causes of ‘claw hand’ deformities

Diagnostic plan

Treatment plan

1 Congenital contractures

2 Scar contractures

3 Dupuytren's contracture

4 Ischaemic contracture

5 Tendon lesions

6 Arthritis

7 Neurological lesions

6.8 Hand infections

Types of hand infection

Clinical assessment and diagnostic plan

Classification of treatment plan

1 Infected recent wounds

2 Subcutaneous infections

FIGURE 6.27 Finger infection1: nail fold suppuration (paronychia); 2: pulp space suppurative necrosis; 3: eponychium – cuticle; 4: pulp space with fascial septa

FIGURE 6.28 Pulp-space infection (Whitlow)Direct incision, adequate excision of slough and antibiotic treatment have reduced the need for older methods of extensive incision and irrigation.

3 Deep infections

FIGURE 6.29 ParonychiaA: raising the eponychium to release pus is sufficient in most cases; B: more severe infections require incision of the cuticle and removal of some or all of the nail

FIGURE 6.30 Surface markingsA: thenar fascial space; B: midpalmar fascial space

6.9 Nail disorders

TABLE 6.2 Nail changes in systemic disease

Common surgical disorders of the nail

History and physical examination

1 Subungual haematoma and melanoma

FIGURE 6.31 Anatomy of the nail1: visible nail; 2: nail covered by cuticle or eponychium; 3: lunule; 4: nail bed and germinal matrix; 5: terminal phalanx; 6: nail sulcus and lateral nail fold

2 Ingrown toenail

3 Paronychia

4 Periungual warts

5 Less common conditions

Diagnostic and treatment plans

1 Subungual haematoma and melanoma

2 Ingrown toenail

FIGURE 6.32 Correct (A) and incorrect (B) trimming of toenails

FIGURE 6.33 Digital nerve blockAdrenaline must not be added to local anaesthetic for a digital block.

3 Paronychia

FIGURE 6.34 Surgical treatment for ingrown toenailA: wedge excision procedure. The lateral third of the nail is avulsed. The nail bed is either excised, curetted or ablated with local phenol; B: Zadik's operation – the entire nail and nail bed, and the lateral nail folds, are excised

4 Periungual warts

5 Less common causes

6.10 Painful hip

Causes

Clinical assessment

FIGURE 6.35 Shortening at the hip jointA: Nelaton's line is drawn through the anterior superior iliac spine, the tip of the greater trochanter and the ischial tuberosity, and is a straight line when the femoral neck is of normal length; B: Bryant's triangle is constructed in a standing patient by drawing a horizontal line from the anterior superior spine to a vertical line drawn from the greater tuberosity. The vertical distance is reduced when shortening is at the hip or femoral neck.

FIGURE 6.36 Thomas' test for fixed flexion deformity of the hipLying supine, the flexion deformity of the right hip is masked by lordosis of the lumbar spine. When the sound hip is flexed, the deformity is revealed as the spine is flattened against the examination couch.

1 Osteoarthritis

FIGURE 6.37 Osteoarthritis of the right hip jointThe characteristic deformity is true shortening with external rotation of the lower limb. Flexion deformity may also be present.

2 Extrinsic causes of referred hip pain

3 Less common causes

Diagnostic plan

Treatment plan

6.11 Painful knee

Common causes

History and physical examination

FIGURE 6.38 Detection of fluid in the knee joint – medical aspect of the right legThe suprapatellar pouch is compressed with one hand while the other hand straddles the joint below and around the patella. Squeezing either hand transmits a fluid impulse.

FIGURE 6.39 McMurray's testThe McMurray test aims to induce jamming of the torn meniscus between the tibia and femur. The knee is flexed. The heel is grasped with the right hand and the knee steadied with the left hand. The knee is pressed medially and extended while the tibia is internally and externally rotated with the right hand.

FIGURE 6.40 Detection of cruciate ligament and meniscal damageThe tibial draw or glide test of cruciate ligament integrity. The examiner sits on the foot of the patient and with both hands, draws the tibia forward for anterior cruciate, and back for posterior cruciate damage.

1 Osteoarthritis and rheumatoid arthritis

2 Traumatic derangement of the knee

3 Bursitis

FIGURE 6.41 Swellings on the medial side of the knee1: prepatellar bursitis (housemaid's knee); 2: infrapatellar bursitis (clergyman's knee); 3: effusion in the suprapatellar pouch; 4: loose body; 5: pes anserinus bursa; 6: cyst of the medial meniscus; 7: Baker's cyst; 8: semimebranosus bursa; 9: popliteal aneurysm

4 Osteochondritis dissecans and osteonecrosis

Diagnostic plan

Radiology

Treatment plan

6.12 Painful foot

Clinical assessment

Common causes and clinical presentation

Pain in the forefoot (metatarsalgia)

FIGURE 6.42 Anterior flat footDropped transverse arch from collapse at the metatarsophalangeal joint is the most common cause of metatarsalgia and associated toe deformities. A: normal foot; 1: metatarsal; 2: proximal phalanx; B: anterior flat foot leading to hammer toe with callosity formation (3, 4); C: claw toe with flexion on both the proximal and distal interphalangeal joints

1 Anterior flat foot (with hallux valgus, hammer toe and claw toes)

FIGURE 6.43 Hallux valgusA: exostosis over the head of the first metatarsal with metatarsus varus; B: excision of the exostosis and excision of the proximal third of the first phalanx may correct the deformity (Keller's operation)

2 Stress or fatigue fracture (of the second or third metatarsal bones)

3 Morton's metatarsalgia

4 Plantar warts

FIGURE 6.44 Plantar wartA: papilloma with its clearly demarcated border; B: callous with its indistinct border

5 Ischaemic rest pain

Painful ankle and heel

1 Trauma

2 Overuse

FIGURE 6.45 Painful heel1: partial disruption of the lateral ligament of the ankle and tenosynovitis of the peroneal tendons; 2: subtalar arthritis with tenderness over the sinus tarsi just anterior to the lateral malleolus; 3: osteoarthritis of the ankle joint; 4: partial rupture of the Achilles tendon; 5: Achilles tendon bursitis; 6: calcaneal bursitis (tender heel pad); 7: plantar fasciitis

3 Spontaneous

Diagnostic plan

Treatment plan

Metatarsalgia

Painful ankle and heel

6.13 Swollen leg

Common causes

Acute swelling

Chronic swelling

Clinical features

Acute swelling

1 Deep venous thrombosis

Box 6.2 Risk factors for developing DVT

Abnormality/injury in the vein wall

Venous stasis

Hypercoagulability

2 Ruptured synovial cyst (pseudophlebitis)

3 Less common causes

Chronic swelling

1 Systemic disorders

FIGURE 6.46 Pitting oedemaChronic venous insufficiency is unlikely to be the cause of bilateral pitting oedema without other stigmata. A medical or systemic disorder is a much more common cause.

2 Chronic venous insufficiency

3 Lymphoedema

Diagnostic plan

Acute swelling

Chronic swelling

Box 6.3 Causes of lymphoedema

Primary

Secondary

Treatment plan

Acute swelling

Box 6.4 Management of DVT

Chronic swelling

Box 6.5 Instructions to patients for continued care of the leg damaged with chronic venous insufficiency

Box 6.6 Lymphoedema: objectives of treatment

6.14 Leg ulcer

Causes

History and physical examination

1 Chronic venous insufficiency (the ‘venous ulcer’)

FIGURE 6.47 Chronic venous stasis

2 Arterial insufficiency (the ‘arterial ulcer’)

3 Neuropathic ulcer (and often the ‘diabetic ulcer’)

FIGURE 6.48 Diabetic ulcer before and after WF10 treatment.Photographs of 56-year-old woman with DFU of 12 months' duration. A. neuropathic ulcer with positive probe to bone test before treatment; B. ulcer had healed after 1 cycle of WF10 treatment (photograph taken at week 5)

Box 6.7 The causes of neuropathic ulceration

Peripheral nerve lesions

Spinal cord lesions

4 Less common causes

Diagnostic plan

Treatment plan

Box 6.8 Local factors contributing to chronic leg ulceration

Box 6.9 Systemic factors contributing to chronic leg ulcer

1 Venous ulcer

Box 6.10 Compression treatment of varicose ulcers

Each morning

Each night

During the day

2 Arterial ulcer

3 The neuropathic ulcer and diabetic foot

FIGURE 6.49 Diabetic footThis patient had a neuropathic ulcer and necrotic toes but no arterial disease. The second and third metatarsals have been excised, together with all the necrotic tissue, in a ‘cake slice’ procedure. The wound was left open to heal by secondary intention, eventually giving a remarkably good functional result.

6.15 Varicose veins

Box 6.11 Caring for a diabetic foot

Common causes

Physiopathology

History

Examination

Diagnostic plan

Trendelenburg test

Venous groin cough impulse

Treatment plan

6.16 Limb ischaemia

Functional ischaemia – intermittent claudication

Causes

History

1 Occlusive peripheral vascular disease

2 Less common causes

Physical examination (see introduction, arterial examination)

Inspection

Palpation

Diagnostic plan

Treatment plan

Stop smoking – keep walking

Box 6.12 Management of peripheral vascular disease

Common causes

History and physical examination

General

Atherosclerotic large vessel disease

Other causes

Diagnostic plan

FIGURE 6.50a Intermittent embolic occlusionPatchy gangrene with palpable peripheral pulses suggests diabetes mellitus or emboli from a proximal aneurysm or plaque.

Treatment plan

FIGURE 6.50b Transfemoral angiography in two patients with rest painA: good run-off with a patent popliteal artery – suitable for surgical bypass; B: poor run-off – not suitable for reconstructive surgery

FIGURE 6.51 Percutaneous transluminal balloon or laser angioplastyA: a Grunzig balloon or laser light transmission fibre is passed along a vessel to the site of partial or complete occlusion; B: in balloon angioplasty the balloon is blown up to compress atheroma and recanalise the artery; C: laser light is delivered through an optical fibre at a wavelength that produces non-thermal destruction of atheromatous tissue

FIGURE 6.52 An excellent transtibial amputation stump with a long posterior flap myoplasty

Acute limb ischaemia

Common causes

Clinical features

Treatment plan

FIGURE 6.53a Acute ischaemic left footA: normal foot; B: foot with embolus

Raynaud's phenomenon

FIGURE 6.53b Aortic embolectomy using a Fogarty balloon catheter

Common causes

Clinical features

Treatment plan

Chapter 7 Abdominal and gastrointestinal problems

7.1 Introduction

History – analysis of abdominal pain

Location and migration

FIGURE 7.1 Migration of pain in common abdominal conditionsA: biliary pain – migration to below the top of the right scapula (‘wing sign’); B: perforated ulcer – down the right paracolic gutter; C: acute appendicitis – to the right iliac fossa; D: perforated diverticulitis – over the abdomen starting from the left iliac fossa; E: renal colic – from loin to groin

Onset and duration

Type and intensity

Radiation

Associated symptoms

Offsetting factors

Past history

Physical examination

Examination of the periphery

FIGURE 7.2 Physical signs of liver disease1: palmar erythema and ecchymoses; 2: xanthelasma, parotid enlargement; alcoholic facies; 3: spider naevi and gynaecomastia; 4: hepatomegaly; 5: splenomegaly (the main sign of portal hypertension); 6: dilated veins on the abdominal wall; 7: ascites; 8: testicular atrophy and loss of body hair; 9: pigmentation, ulceration and oedema; 10: proximal muscle wasting

Abdominal examination

FIGURE 7.3 Anterior surface markings of upper abdominal viscera

Anorectal examination

FIGURE 7.4 Posterior surface markings of abdominal visceraA: lung; B: pleura; C: kidney; D: pancreas; E: spleen

FIGURE 7.5 Regions of the abdomenA: epigastrium; B: right hypochondrium; C: lumbar region; D: periumbilical region; E: right iliac fossa; F: hypogastrium

FIGURE 7.6 Method of palpating the spleen

FIGURE 7.7 Palpable normal abdominal structures1: xiphoid process; 2: liver; 3: edge of rectus abdominis; 4: lower pole of right kidney; 5: caecum; 6: aorta; 7: ala of sacrum; 8: pregnant uterus; 9: full bladder; 10: sigmoid colon; 11: faecal loading

FIGURE 7.8 Shifting dullnessArea 1 is resonant when supine and dull in lateral position. Area 2 is dull when supine and resonant in lateral position.

TABLE 7.1 Typical physical characteristics of an enlarged liver, spleen and kidney

FIGURE 7.9 Rectal examinationDigital detection of a carcinoma of the rectum at about 10 cm from the anal verge. The characteristics on palpation are induration, elevation and ulceration. Blood may be seen on the glove after completion of the examination.

FIGURE 7.10 Anatomy of the anorectumThe anal canal extends from the anorectal ring, which is formed by the puborectalis, down to the anal verge, a distance of about 3 cm. 1: puborectalis muscle; 2: inferior haemorrhoidal plexus or cushion; 3: anal crypt; 4: dentate line; 5: interhaemorrhoidal groove; 6: anal verge; 7: external haemorrhoidal plexus; 8: external haemorrhoidal artery; 9: internal sphincter; 10: external sphincter

7.2 ‘Acute abdomen’ (acute abdominal surgical emergency)

Common causes of the ‘acute abdomen’

History and physical examination

1 Acute appendicitis with perforation (see also acute right iliac fossa pain)

2 Severe acute pancreatitis

TABLE 7.2 Comparison of perforated duodenal ulcer with acute pancreatitis

3 Perforated peptic ulcer

4 Diverticulitis with perforation

5 Strangulating intestinal obstruction

Box 7.1 Clinical features suggesting bowel strangulation

6 Vascular catastrophes

7 Ruptured ectopic pregnancy

8 Gastroenteritis

9 Less common causes

Diagnostic plan

Urine examination

Haematological examination

Biochemistry

Imaging techniques

FIGURE 7.11 Chest x-ray with gas under the diaphragm

FIGURE 7.12 Films of small bowel obstructionA: supine abdominal x-ray with dilated small bowel loops; B: erect abdominal x-ray with multiple air fluid levels (arrowed); C: typical ‘ladder’ pattern (arrowed) on supine abdominal x-ray

Treatment plan

1 Acute appendicitis with perforation

2 Severe acute (haemorrhagic) pancreatitis

Box 7.2 Acute pancreatitis: diagnostic plan

3 Perforated peptic ulcer

TABLE 7.3 Indicators of severity of acute pancreatitis (Glasgow system)

FIGURE 7.13 Common complications of acute pancreatitisA: pseudocyst of the pancreas in the lesser sac secondary to a leak from the main pancreatic duct; B: necrosis, haemorrhage and sepsis extends to the retroperitoneum. 1: inferior surface of the right lobe of the liver; 2: gall bladder; 3: stomach; 4: greater omentum; 5: transvese colon; 6: third part of the duodenum

Box 7.3 Significant risk factors in perforated duodenal ulcer

FIGURE 7.14 Simple closure of a perforated anterior duodenal ulcer (Roscoe-Graham method)Sutures are passed deep to the ulcer and tied over the omentum.

4 Perforated diverticulitis

5 Strangulating intestinal obstruction

6 Vascular catastrophes

FIGURE 7.15 Hartmann's procedureResection of the site of complicated diverticular disease is usually necessary if infection is to be controlled in patients with perforation. After excising the diseased segment, the risk of immediate bowel anastomosis in continuity is avoided by an end sigmoid colostomy (1) with closure of the rectal stump (2).

7 Ruptured ectopic pregnancy

8 Gastroenteritis

7.3 Acute upper abdominal pain

Causes

History

1 Acute gastritis and non-ulcer dyspepsia

2 Acute exacerbation of duodenal ulcer

3 Biliary ‘colic’ and acute cholecystitis

4 Acute (oedematous) pancreatitis

Examination

Gastritis and duodenal ulcer

Cholecystitis

Acute pancreatitis

Diagnostic plan

FIGURE 7.16 Pathology and natural history of gallstonesA: asymptomatic gallstones; B: biliary pain (chronic cholecysitis); B1: obstructive jaundice; B2: pancreatitis secondary to small stones; B3: ascending cholangitis; C: acute cholecystitis; C1: mucocele of gall bladder; C2: perforated empyema – with pericholecystic abscess; C3: free perforation; D: chronic cholecystitis; D1: cancer of gall bladder; D2: cholecysto-duodenal fistula and gallstone ileus

FIGURE 7.17 Acute cholecystitisAn acutely tender, palpable gall bladder is virtually diagnostic of acute cholecystitis. The gall bladder enlarges laterally rather than towards the umbilicus.

Haematological and biochemical examination

Radiology: plain erect film of chest and abdomen

Ultrasound and CT scanning

Radionuclide excretion scan

Gastrograffin swallow and meal

Late endoscopy and ERCP

Treatment plan

1 Acute gastritis and non-ulcer dyspepsia

2 Acute exacerbation of duodenal ulcer

3 Biliary ‘colic’ and acute cholecystitis

4 Acute (oedematous) pancreatitis

5 Less common causes

7.4 Acute right iliac fossa pain

Causes

History and physical examination

1 Acute appendicitis

TABLE 7.4 Comparison of clinical features of perforated pelvic appendicitis and gastroenteritis

FIGURE 7.18 Anatomy of the appendixThe caecum may be high (A) normal (B) or low (C) in position. The appendix may be free lying, paracaecal or retrocaecal, pre-ileal or postileal, or pelvic in position.

2 Acute mesenteric adenitis and acute Meckel's diverticulitis

3 Non-specific acute right iliac fossa pain

4 Gynaecological disorders

5 Urinary tract stone, infection or hydronephrosis

Diagnostic plan

Full blood count

Urine examination

Cervical swab and culture

Plain x-ray

Ultrasound

CT scan

Laparoscopy

HCG pregnancy test

Treatment plan

1 Acute appendicitis

2 Acute mesenteric adenitis and Meckel's diverticulitis

3 Non-specific acute right iliac fossa pain

4 Gynaecological disorders

5 Acute urinary tract stone, infection or hydronephrosis

6 Less common causes

7.5 Acute lower abdominal (pelvic) pain

Causes

History and physical examination

1 Diverticulitis

FIGURE 7.19 Complicated diverticulitisAcute abdomen due to: A: perforation of a pericolic abscess (purulent peritonitis); or B: perforation of an uninflamed diverticulum (faecal peritonitis).

2 Carcinoma of the colon

3 Pelvic appendicitis

4 Gynaecological disorders

TABLE 7.5 Acute abdominal pain in pregnancy

FIGURE 7.20 Sites of ectopic pregnancy implantation1: interstitial 4%; 2: isthmial 18%; 3: ampullary 55%; 4: abdominal cavity 1%; 5: fimbrial 20%; 6: ovarian 2%

Diagnostic plan

Full blood count, blood grouping and pregnancy test

Urine microscopy and analysis

Plain x-ray of the abdomen

Pelvic ultrasound

Laparoscopy

FIGURE 7.21 LaparoscopyThe uterus is stabilised per vaginum. The pelvis is inspected after insufflation of CO2 into the peritoneal cavity. An ectopic pregnancy is diagnosed here.

CT contrast study

Colonoscopy

Treatment plan

1 Diverticulitis

2 Carcinoma of the colon

3 Pelvic appendicitis

4 Gynaecological disorders

5 Less common causes

7.6 Chronic epigastric pain

Causes

History

1 Non-ulcer dyspepsia

TABLE 7.6 Features of the common causes of chronic epigastric pain

2 Gallstones and chronic cholecystitis

3 Duodenal ulcer

Box 7.4 Causes of combined upper and lower gastrointestinal symptoms

4 Gastric ulcer

5 Carcinoma of the stomach

TABLE 7.7 Comparison of the clinical features of duodenal and gastric ulcers

Examination

Diagnostic plan

Full blood examination

Ultrasound

Endoscopy

Contrast radiology

MRCP, CT cholangiography and ERCP

Treatment plan

1 Non-ulcer dyspepsia

2 Gallstones and chronic cholecystitis

Box 7.5 General instructions for relief of symptoms from gastritis or dyspepsia

3 Duodenal ulcer

FIGURE 7.22 Cholecystectomy – normal operative cholangiogramNo filling defects, normal duct anatomy and diameter, free flow of contrast into the duodenum, lower and upper reaches of duct well visualised.

4 Gastric ulcer

5 Carcinoma of the stomach

Box 7.6 Management of carcinoma of the stomach

FIGURE 7.23 Surgical management of carcinoma of the stomachA: antral tumours often present with vomiting and are managed by partial gastrectomy; B: body tumours present with chronic epigastic pain; total gastrectomy is usually required; C: tumours of the cardia present with dysphagia; oesophagogastrectomy required

FIGURE 7.24 Total gastrectomyTotal gastrectomy achieves best local control of disease. Reconstruction is by Roux-en-Y oesophagojejunostomy. The letters indicate the arrangement of structures before and after the gastrectomy and reconstruction.

6 Less common causes

Non-gastrointestinal causes

Gastrointestinal causes

FIGURE 7.25 Puestow's operationPuestow's operation (side-to-side Roux-en-Y pancreaticojejunostomy): for painful chronic pancreatitis with duct dilatation.

Box 7.7 Causes of postcholecystectomy syndrome

7.7 Chronic lower abdominal (pelvic) pain

TABLE 7.8 Postgastrectomy syndromes: management

Causes

History and physical examination

1 Chronic pelvic inflammatory disease

2 Pelvic congestion syndrome

3 Endometriosis

4 Functional bowel disorders and diverticular disease

Diagnostic plan

Full blood examination

Radiological examination

Microbiological examination

Laparoscopy

Treatment plan

1 Pelvic inflammatory disease

2 Pelvic congestion syndrome

3 Endometriosis

4 Functional bowel disorders and diverticular disease

5 Less common causes

FIGURE 7.26 Drainage of pelvic abscessA: An artery forcep is guided over the index finger through the point of maximum softening in the anterior rectal wall.

7.8 Bowel obstruction

Initial assessment: small or large bowel obstruction?

Box 7.8 Management plans in small bowel obstruction

Small bowel obstruction

Common causes

History

1 Adhesive obstruction

FIGURE 7.27 Clinical presentations of small bowel obstruction depend upon the level and cause of obstructionA: high obstruction (adhesive): vomiting early and profuse, pain atypical or absent, distention minimal, x-ray may be negative; B: distal small bowel, strangulated hernia: colicky pain, distension, vomiting; local symptoms not always prominent; C: obstructing carcinoma, right colon, distal small bowel obstruction

2 Hernias

3 Malignancies

4 Sigmoid diverticulitis and intraperitoneal abscess

5 Gallstone ileus and enteroliths

Examination

FIGURE 7.28 Intussusception1: possible foci for intussusception and diagrammatic representation of mechanism; 2: barium enema of the small bowel ‘into’ colon intussusception; 3: pathological specimen illustrating C – colon, I – intestine and A – appendix

Diagnostic plan

Haematological and biochemical examination

Radiology

FIGURE 7.29 Complicated diverticular diseaseSmall bowel obstruction secondary to diverticulitis with small bowel adherence to sigmoid colon affected by diverticulitis.

FIGURE 7.30 Diagrammatic depiction of radiological features of small bowel obstructionA: erect film; B: supine film

Treatment plan

Nasogastric drainage and decompression

Resuscitation

Box 7.9 Extracellular fluid replacement in small bowel obstruction*

Volume of replacement fluid

Composition of replacement fluid

Rate of replacement

Surgical intervention

Management of other causes

Large bowel obstruction

Common causes

FIGURE 7.31 Large bowel obstructionA: often the ileocaecal valve prevents retrograde decompression into the small bowel, creating a closed loop obstruction; B: alternatively, with spontaneous decompression into the small bowel the presentation is less acute and the danger of caecal perforation is less

History and physical examination

1 Colonic carcinoma

2 Sigmoid or caecal volvulus

3 Diverticular disease

4 Colonic pseudo-obstruction

5 Faecal impaction

FIGURE 7.32 Sigmoid volvulusA: diagram of sigmoid volvulus: direction of twist is usually anticlockwise. B: plain abdominal x-ray of sigmoid volvulus showing a distended loop arising from the pelvis; on sigmoidoscopy the site of obstruction can be seen at about 15–20 cm from the anal verge

Diagnostic plan

Treatment plan

1 Colonic carcinoma

2 Sigmoid or caecal volvulus

3 Diverticular obstruction

4 Colonic pseudo-obstruction

5 Faecal impaction

7.9 Abdominal mass

General assessment

1 Confirm a mass is present

2 Categorise the mass

FIGURE 7.33 Upper abdominal masses1: enlarged liver; 2: Riedel's lobe; 3: carcinoma of the right colon; 4, 5: gall bladder; 6: rounder lower poles of both kidneys; 7: abdominal aortic aneurysm; 8: splenomegaly; 9: pseudocyst of the pancreas

FIGURE 7.34 The life cycle of the hydatid parasiteA: Primary host – dog. After eating sheep offal (liver, lung) containing hydatid cysts, the scolices pass into the small intestine and grow into the adult tapeworm Echinococcus granulosus. The eggs produced by the terminal segments are shed and passed in canine faeces. B: Secondary hosts – sheep and humans. Ova are ingested, the chitinous enveloped is dissolved by acid and pepsin in the stomach. After absorption, ova pass via the portal blood to the liver and grow into adult hydatid cysts containing scolices.

Right upper quadrant mass

Common causes

History and examination

1 Single mass in the liver

2 Mucocele of the gall bladder

3 Right renal swelling

4 Carcinoma of the right colon

Diagnostic plan

Treatment plan

FIGURE 7.35 The segmental anatomy of the liver displayed ex vivoRight hepatectomy: segments v, vi, vii, viii; left hepatectomy: segments ii, iii, iv; right lobectomy: segments iv, v, vi, vii, viii; left lobectomy: segments ii, iii; segments v, vi, vii, viii are supplied by the right hepatic artery, segments i, ii, iii, iv are supplied by the left hepatic artery.

FIGURE 7.36 Liver hydatidA: adventitia derived from the host; B: laminated chitinous layer; C: germinal layer – which gives rise to brood capsules containing scolices. Daughter cysts float free within the main cyst, together with detached brood capsules and scolices (hydatid sand).

Hepatomegaly

Common causes

Smooth regular liver enlargement

Irregular or nodular liver enlargement

Symptoms and signs

Box 7.10 Causes of massive hepatomegaly and splenomegaly

Hepatomegaly

Splenomegaly

Diagnostic and treatment plans

Haematological tests

Liver function tests

Scanning

Biopsy

Left upper quadrant mass

Common causes

History and examination

Diagnostic plan

Treatment plan

Splenomegaly

Common causes

History and examination

Diagnostic and treatment plans

Combined liver and spleen enlargement

Common causes

History and examination

Diagnostic and treatment plans

Epigastric mass

Common causes

History and examination

Gastrointestinal masses

Retroperitoneal mass

Abdominal aortic aneurysm

Diagnostic plan

Incidental imaging findings (‘incidentaloma’)

Treatment plan

Right iliac fossa mass

Causes

History and examination

FIGURE 7.37 Excision and replacement of abdominal aortic aneurysm with a synthetic graftThe adventitia of the aneurysmal wall is closed over the graft.

Diagnostic plan

Treatment plan

Less common causes

Left iliac fossa mass

Causes

History and examination

Diagnostic plan

Treatment plan

Less common causes

Abdominal swellings arising from the pelvis

Common causes

History and examination

FIGURE 7.38 Lower abdominal masses1: full urinary bladder; 2: ovarian cyst; 3: fibromyomas of uterus; 4: tender mass of appendiceal abscess; 5: pregnant uterus; 6: tender mass of diverticulitis

Diagnostic plan

Treatment plan

7.10 Abdominal distension

Common causes

History and examination

1 Fat

2 Pregnant uterus (fetus)

3 Accumulation of gastrointestinal gas (flatus)

4 Faecal impaction (faeces)

5 Ascites or encysted liquid (fluid)

Causes of ascites (free intraperitoneal fluid)

FIGURE 7.39 Collateral venous bloodflow on the anterior abdominal wallA: portal venous obstruction with ascites; B: inferior vena caval obstruction

Causes of encysted fluid

Diagnostic plan

Treatment plan

7.11 Retrosternal pain and heartburn

Causes

History

1 Ischaemic heart disease – angina pectoris

2 Reflux oesophagitis and hiatus hernia

3 Diffuse oesophageal spasm

4 Musculoskeletal or chest wall pain

Examination

Diagnostic plan

Haematological examination

Electrocardiography

Organ imaging and endoscopy

FIGURE 7.40 Oesophagus hiatus herniaA: sliding hernia – front (A1) and side (A2) views; B: paraoesophageal or rolling hernia. Reflux with oesophagitis occurs in about 50% of sliding hernias but is rare in rolling hernia where the main danger is intrathoracic incarceration and strangulation of the stomach.

Manometry

Treatment plan

1 Ischaemic heart disease – angina pectoris

2 Reflux oesophagitis and hiatus hernia

Box 7.11 General instructions for reflux oesophagitis with heartburn (hiatus hernia)

Box 7.12 Indications for anti-reflux oesophageal surgery

FIGURE 7.41 Nissen fundoplicationA: initially the hernia is reduced and the defect in the diaphragmatic hiatus is narrowed with sutures; B: the fundus is wrapped around the distal oesophagus down which has been passed a large bougie (50F); C: the wrapped fundus is sutured in place to produce a valve in the lower oesophagus from the pressure of the surrounding stomach, therefore preventing reflux and herniation

3 Diffuse oesophageal spasm

4 Musculoskeletal or chest wall pain

5 Less common causes

7.12 Dysphagia

Causes

History

1 Foreign body

2 Reflux oesophagitis and benign stricture

3 Carcinoma of the oesophagus

4 Achalasia and diffuse oesophageal spasm

Signs

Diagnostic plan

Haematological examination

Radiology

FIGURE 7.42 Contrast radiological features of achalasiaA: dilated oesophagus; B: rat-tail narrowing of the distal oesophagus; C: no gastric air bubble. Endoscopy demonstrates no organic stricture.

Endoscopy and biopsy

Manometry

Treatment plan

1 Foreign body

2 Reflux oesophagitis and benign stricture

FIGURE 7.43 Oesophageal dilatation of benign strictureOesophageal dilatation of benign stricture is performed using A: the Eder-Puestow (graded size metal olives); or B: Celestin dilators (stepped dilators in two sizes). Initially a flexible guide wire is passed under vision through the stricture into the stomach. The endoscope is then removed, leaving the guide wire in place and the dilators are passed over the wire.

3 Carcinoma of the oesophagus

Box 7.13 Management of benign stricture secondary to reflux

FIGURE 7.44 Palliative treatment of advanced carcinoma of the oesophagus in a poor-risk caseA: endoscopic intubation using an Atkinson or Celestin tube; B: neodymium:yttrium-argon laser photocoagulation

TABLE 7.9 Management of carcinoma of the oesophagus

4 Achalasia and diffuse oesophageal spasm

FIGURE 7.45 Ivor Lewis-Tanner oesophagogastrectomy for carcinoma of the middle and distal third of oesophagus, and gastric cardiaThe stomach is mobilised on the right gastric (1) and right gastroepiploic arteries (2). The left gastric artery (3) and short gastric arteries (4) are divided. After thoracotomy and resection of the tumour (5) the stomach is passed up into the right chest and its fundus (A) anastomosed to the oesophagus. The gastric resection line (B) has been closed primarily. A pyloroplasty aids gastric emptying.

5 Less common causes

FIGURE 7.46 Cricopharyngeal achalasia with pharyngeal (Zenker's) pouchPharyngeal pouch is a pulsion diverticulum secondary to high pharyngeal pressure above spasm of the cricopharyngeous muscle. A: Lateral view shows the pouch coming from between the cricopharyngeal and thyropharyngeal portions of the inferior constrictor. B: Posterior view shows Killian's dehiscence, an area of muscle deficiency and weakness through which the pouch develops. The pouch usually extends to the left side of the neck. As it enlarges, the opening comes in line with the oesophageal axis, making endoscopy potentially hazardous. C: Lateral image of contrast study.

FIGURE 7.47 Para-oesophageal hiatus herniaA: Para-oesophageal hiatus hernia. B: Volvulus of the stomach in a para-oesophageal hiatus hernial sac. The stomach has rotated on its long axis (organo-axial volvulus). This produces an acute kink in the distal oesophagus that causes dysphagia, bloating without vomiting, and prevents the passage of a nasogastric tube. An air–fluid level is seen in the chest behind the heart on plain x-ray.

7.13 Weight loss

Common causes

History

1 Depression

2 Abdominal malignancy

3 Diabetes mellitus

4 Thyrotoxicosis

5 Chronic infections

6 Malabsorption

Signs

1 Depression

2 Abdominal malignancy

3 Diabetes mellitus

4 Thyrotoxicosis

Diagnostic plan

Haematological and biochemical examination

Urine analysis and culture

Organ imaging and endoscopy

Weight gain

7.14 Vomiting

Box 7.14 Common causes of weight gain

Causes

History

1 Duodenal ulcer

2 Carcinoma of the pyloric antrum

3 Functional bowel disease and psychogenic vomiting

TABLE 7.10 Comparison of benign and malignant gastric outlet obstruction

4 Drug-induced vomiting

Examination

Box 7.15 Drugs that can cause chronic vomiting

Diagnostic plan

Urinalysis

Haematology

Biochemistry of urine and blood

Radiological investigation

Treatment plan

Nasogastric suction

TABLE 7.11 Pyloric stenosis: stages of fluid and electrolyte disorders

Correction of extracellular fluid loss and hypokalaemic alkalosis

Surgical intervention

5 Less common causes

FIGURE 7.48 GastrectomyB1 = Billroth gastrectomy, B2 = Billroth II (polya) gastrectomy and TG = total gastrectomy and Roux-en-Y oesophagojejunostomy

7.15 Jaundice

Causes

History

1 Stone in the bile duct

2 Carcinoma of the head of the pancreas

3 Alcoholic liver disease

4 Drug-induced jaundice

5 Viral hepatitis

Examination

Diagnostic plan

Haematology

Biochemistry

Diagnostic and interventional imaging: ultrasound and CT

Liver biopsy

FIGURE 7.49 Sonolucent gall bladderMost gallstones are radiolucent radiologically but, with ultrasound, they appear as mobile, shadowing, echogenic foci in a sonolucent gall bladder.

Endoscopic retrograde cholangiopancreatography

Percutaneous cholangiography

Treatment plan

FIGURE 7.50 Endoscopic sphincterotomyERCP diathermy sphincterotomy before basket removal of a stone or insertion of a stent to bridge an obstruction.

1 Stone in the bile duct

Box 7.16 Management of bile duct stone in four clinical situations

Incidental finding at cholecystectomy (operative cholangiography)

Resolving jaundice

Persistent jaundice

Suppurative cholangitis

2 Carcinoma of the head of the pancreas

Box 7.17 Management of carcinoma of the head of pancreas

FIGURE 7.51 Palliative double bypass for obstructing carcinoma of the pancreas or distal bile ductThe procedures performed are A: Roux-en-Y choledochojejunostomy to control jaundice; and B: gastrojejunostomy to prevent later symptoms from duodenal obstruction.

Less common causes

FIGURE 7.52 Whipple's procedureWhipple's operation (pancreatoduodenectomy) for resectable carcinoma of the head of the pancreas or ampullary tumours. The non-shaded areas are resected, vagotomy is performed and intestinal continuity is reestablished by A: invaginating the pancreas into the terminal jejunum; B: anastomosing the bile duct to the side of the jejunum; and C: completing a gastrojejunostomy.

Intrahepatic obstruction

7.16 Haematemesis and melaena (upper gastrointestinal haemorrhage)

Causes

Box 7.18 Principles of management of bleeding ulcer

History

1 Duodenal and gastric ulcer

2 Oesophageal varices

Box 7.19 Causes of portal hypertension

Intrahepatic

Presinusoidal

3 Haemorrhagic antral gastritis

4 Mallory-Weiss syndrome

Examination

TABLE 7.12 Grading of severity of liver disease (modified Child's criteria – according to Pugh)

Diagnostic plan

Haematological assessment

Endoscopy

Treatment plan

General measures

High-risk patients

1 Duodenal and gastric ulcer

2 Oesophageal varices

3 Haemorrhagic antral gastritis

FIGURE 7.53 Surgery for a bleeding duodenal ulcerA: the duodenum is opened and the bleeding point is overswen in the base of the ulcer; B: pyloroplasty is completed by closing the longitudinal incision transversely. The operation is completed by performing a total truncal vagotomy.

4 Mallory-Weiss syndrome

FIGURE 7.54 Ballon tamponade using the quadruple lumen Minnesota tubeThe four lumina are A: nasopharyngeal aspiration tube; B: port for the gastric balloon; C: gastric aspiration tube; D: port and pressure gauge for the oesophageal balloon; and E: traction (0.5 kg).

Box 7.20 General management of patients with bleeding varices

5 Less common causes

7.17 Acute lower gastrointestinal (colorectal) haemorrhage

Causes

History and examination

1 Diverticular disease

2 Colonic angiodysplasia

3 Ischaemic colitis

FIGURE 7.55 Diverticular haemorrhage as a cause of colonic haemorrhageA: the diverticulum appears through the defect in the inner circular muscle through which passes the vasa recta; the artery is often stretched over the fundus of the diverticulum; B: erosion of the vessel can occur beneath stercoral ulceration produced by a faecolith

4 Colorectal polyps

5 Colorectal cancer

6 Other causes

Diagnostic and treatment plans

Haemodynamically stable

Haemodynamically unstable

FIGURE 7.56 Diathermy snare colonic polypectomyA: the snare is tightened on the neck of the polyp; B: current is applied while the polyp is continuousy moved to avoid a local full thickness burn; C: the resected polyp is sucked against the tip of the colonoscope for removal

7.18 Iron deficiency anaemia

Common causes

History and examination

Diagnostic plan

Oesophagogastroduodenoscopy

Colonoscopy

Radionuclide scan and CT angiography

CT scan abdomen and pelvis with contrast

Treatment plan

FIGURE 7.57 Right hemicolectomy1: superior mesenteric artery; 2: middle colic artery; 3: right colic artery; 4: ileocolic artery. Dotted line represents line of resection

7.19 Anorectal bleeding

Common causes

FIGURE 7.58 Anorectal bleedingA: blood coming from the rectum is persistent, associated with tenesmus, and due to polyps, cancer or proctitis; B: bleeding from haemorrhoids in the anal canal is periodic, painless, profuse and bright red; C: bleeding from the anal verge is small in amount, bright red, seen only on the toilet paper and due to fissure or skin tag. 1: anorectal ring; 2: dentate line; 3: anal verge

History

1 Haemorrhoids

2 Carcinoma of the rectum

3 Anal fissure

4 Proctitis

Examination

FIGURE 7.59 Classification of haemorrhoids into four degrees based on the severity of the diseaseFirst-degree haemorrhoids presents with bleeding; second-degree haemorrhoids prolapse but return spontaneously; third-degree must be manually returned; and fourth-degree are permanently prolapsed.

Diagnostic plan

Treatment plan

1 Haemorrhoids

2 Carcinoma of the rectum and anus

FIGURE 7.60 Barron band ligation of internal hemorrhoidsWorking through a proctoscope a rubber band (A) is dislodged from the cylinder to encircle the neck of an internal haemorrhoid (B).

FIGURE 7.61 Operative procedures performed for carcinoma of the distal large bowelA: anterior resection with primary anastomosis for middle- and upper-third rectal lesions; B: abdominoperineal resection with end sigmoid colostomy for distal-third rectal carcinoma. 1: inferior mesenteric artery; 2: left colic branch; 3: sigmoid branch; 4: superior rectal artery

3 Anal fissure

4 Proctitis

5 Less common causes

7.20 Altered bowel habit (constipation)

FIGURE 7.62 Forms of presentation of large bowel cancerA: right colon cancer usually presents with anaemia, often associated with mild dyspepsia or a mass; B: left colon cancer presents with altered bowel habit associated with varying degrees of pain from partial obstruction; C: cancer of the sigmoid colon sometimes presents with an acute abdomen from large bowel obstruction or perforation; D: distal large bowel and rectal cancers usually present with rectal bleeding associated with varying degrees of hypogastric pain and tenesmus

FIGURE 7.63 Common causes of tenesmusA: haemorrhoids; B: carcinoma of the rectum; C: rectal prolapse; D: faecal impaction; E: inflammatory bowel disease

Causes

History

1 Colorectal cancer

2 Functional bowel disorders

3 Psychiatric disorders

Box 7.21 Drugs that cause constipation

4 Drug-induced constipation

Examination

Diagnostic plan

Haematology

Sigmoidoscopy

Colonoscopy

Whole gut transit studies

Treatment plan

1 Colorectal cancer

Box 7.22 Common therapeutic agents used in the management of constipation

Hydrophilic bulking agents

Irritant purgatives

Suppositories

Enemas

2 Functional bowel disorders

3 Psychiatric disorders

4 Drug-induced constipation

5 Less common causes

High-fibre diet

7.21 Diarrhoea

Causes

History

1 Functional bowel disorders

TABLE 7.13 Diarrhoea: clinical features assisting the diagnosis

Box 7.23 Cardinal features of the syndrome of functional bowel disease

2 Inflammatory bowel disease

3 Colorectal cancer

Examination

Rectal examination – proctoscopy or rigid sigmoidoscopy

TABLE 7.14 Pathological features of inflammatory bowel disease

Diagnostic plan

TABLE 7.15 Radiological features of inflammatory bowel disease

Treatment plan

1 Functional bowel disorders

2 Inflammatory bowel disease

FIGURE 7.64 Diagrammatic representation of toxic megacolonThere is dilatation, gas in the bowel wall and loss of haustra in the transverse colon.

FIGURE 7.65 Segmental colectomyA: transverse colectomy for carcinoma of the transverse colon with division of the left main branch of the middle colic artery; B: left hemicolectomy for carcinoma of the descending colon, with ligation of the left colic artery

Box 7.24 Indications for surgery in ulcerative colitis

Acute disease

Chronic disease

3 Carcinoma of the colon

FIGURE 7.66 Surgical procedures used for ulcerative colitisA: protocolectomy and Brooke ileostomy; used mainly for emergency surgery and for older patients; B: ilioanal J-pouch with preservation of anal sphincters, used mainly as an elective operation in younger patients; contraindicated in Crohn's disease

Box 7.25 Indications for surgery in Crohn's disease

4 Less common causes

Box 7.26 Drugs that cause chronic diarrhoea

7.22 Acute anal pain

Causes (see Fig 7.67)

History

1 Perianal haematoma

FIGURE 7.67 Common causes of acute anal painA: perianal haematoma; B: anal fissure; C: strangulated haemorrhoids; D: perianal abscess

2 Anal fissure

3 Complicated haemorrhoids

4 Perianal abscess

Examination

FIGURE 7.68 Anatomical location of perianal abscessesA: perianal; B: intermuscular; C: supra-levator

FIGURE 7.69 Natural history of anal fissureA: acute fissure; B: chronic fissure – weeks later; C: chronic fissure – months later. 1: hypertrophied anal papilla; 2: sentinal pile; 3: subcutaneous fistula

Diagnostic plan

Treatment plan

1 Perianal haematoma

2 Anal fissure

3 Complicated haemorrhoids

4 Perianal abscess

5 Less common causes

7.23 Anal pruritus

FIGURE 7.70 Causes of anal or perianal dischargeA: advanced haemorrhoids; B: advanced carcinoma of the rectum (or villous adenoma); C: faecal impaction; D: pruritus ani; E: perianal fistula

FIGURE 7.71 Perianal discharge observed in left lateral position1: pruritus ani with exudation; 2: haemorrhoids; 3: perianal fistula; 4: furunculitis with chronic sinus formation

Common causes (see above)

History and examination

Box 7.27 Risk factors for pruritus ani

Diagnostic plan

Treatment plan

Measures to improve bowel habits

Local toilet hygiene

Box 7.28 Management of anal irritation

Diet

Hygiene

Local treatment

Remove irritants

Encourage healing

Surgery

7.24 Anorectal lump

Common causes

History and examination

1 Haemorrhoids

2 Rectal prolapse

FIGURE 7.72 Anal lumpsA: prolapsing lumps; 1: second- and third-degree haemorrhoids; 2: rectal polyp; 3: rectal prolapse; 4: hypertrophied anal papilla; B: persistent lumps; 1: condylomata; 2: skin tag; 3: carcinoma of the anal canal; 4: fourth-degree haemorrhoids; 5: perianal haematoma; 6: perianal fistula; 7: perianal abscess

FIGURE 7.73 Rectal prolapse1a: puborectalis spasm (anismus) with ineffective straining; 1b: treatment by division of the puborectalis muscle; 2: anteriror rectal wall descent with solitary rectal ulcer from abrasion of the apex; 3a: rectal prolapse; 3b: rectal prolapse treated by rectopexy (Ripstein repair)

3 Skin tags, hypertrophied anal papilla

4 Anal fistula

5 Carcinoma of the anus

Diagnostic plan

Treatment plan

1 Haemorrhoids

2 Anal fistula

3 Rectal prolapse

4 Skin tags and hypertrophied anal papilla

5 Carcinoma of the anus

7.25 Faecal incontinence

Common causes

History and examination

1 Anal sphincter injury

FIGURE 7.74 Anorectal incontinenceA: neurogenic and idiopathic incontinence; B: incontinence associated with rectal prolapse; C: traumatic incontinence; D: incontinence secondary to rectal Crohn's disease; E: rectovaginal fistula (pseudo-incontinence)

Box 7.29 Useful questions to ask for faecal incontinence

2 Constipation with overflow incontinence (see Ch 7.20)

3 Dietary factors and drugs

4 Idiopathic faecal incontinence

5 Neurological disease

6 Congenital disorders

Diagnostic plan

Treatment plan

Basic strategies

Pharmacotherapy

Sphincter reconstruction

Sacral neuromodulation (SNM)

Other procedures

7.26 Pneumaturia

Common causes

History and examination

Diagnosis

FIGURE 7.75 DiverticulitisPartial obstruction of the sigmoid colon by diverticulitis and a peridiverticular phlegmon. Obstructive symptoms are produced by extrinsic compression.

Treatment plan

FIGURE 7.76 Vesicocolic fistulaThe fistula is usually short, arising from a sigmoid peridiverticular abscess that has discharged into the bladder.

7.27 Anal fistula

Causes

History and examination

1 Anal fistula – crytoglandular origin

FIGURE 7.77 Perianal abscess leading to perianal fistula1: anal gland; 2: anal gland abscess; 3a, b: fistulous tract left after drainage; 4: established fistula

2 Anal fistula – Crohn's disease

FIGURE 7.78 Goodsall's ruleA: anterior fistulas open directly into an adjacent end crypt; B: posterior fistulas usually take a curved path to open into a midline posterior crypt; C: a horseshoe fistula may also have an anterior component

3 Malignant anal fistula

Diagnostic plan

Treatment plan

FIGURE 7.79 Anal fistulas1: anorectal (supraphincteric); 2: intermuscular; 3: high transsphincteric; 4: low transsphincteric; 5: subcutaneous (superficial), with anal fissure

1 Anal fistula – crytoglandular origin

FIGURE 7.80 Probing a fistula at operationA, B: the tract is gently probed to find the internal opening; C: the fistula is laid open by deroofing over the probe

2 Anal fistula – Crohn's disease

3 Malignant anal fistula

Chapter 8 Groin, scrotum and abdominal wall problems

8.1 Introduction

History

Physical examination

Examination: patient standing

Box 8.1 Risk factors for inguinal hernia

FIGURE 8.1 Surgical anatomy of the groinA: anterior superior iliac spine; B: external ring; C: femoral canal; D: femoral artery and vein; E: internal ring; F: inguinal ligament; G: abdominal crease

FIGURE 8.2 Examination: patient standingA: saphena varix; B: varicocele

FIGURE 8.3 Saphena varixPercussion over the saphenous vein in the thigh produces a transmitted impulse in the varix above.

Box 8.2 Typical features of a hernia

1 Is a hernia present? (Box 8.2)

2 Is the hernia inguinal or femoral?

FIGURE 8.4 Inguinal or femoral hernia?A: femoral hernia is sited below and lateral to the pubic tubercle (B); C: inguinal hernia appears at the external ring above and medial to the pubic tubercle

Examination: patient supine

3 Is the hernia reducible?

4 Is the hernia strangulated?

5 Is a scrotal lump present?

6 Can one get above the scrotal lump?

FIGURE 8.5 Scrotal examinationA: sequential examination of 1: testis; 2: tunica vaginalis; 3: epididymis; 4: cord; 5: superficial inguinal ring; B: palpation of epididymis

7 Is the lump arising from the testis or epididymis?

8 Does the lump arise from the coverings or from appendages?

General examination

8.2 Inguinoscrotal lumps

Scrotal lumps

Causes

Acute scrotal swelling

FIGURE 8.6 Scrotal lumpsA: acute: 1: torsion; 2: epididymo-orchitis, 3: torsion of the hydatid of Morgagni; B: chronic: 1: hydrocele; 2: haemoatocele; 3: epididymal cyst; 4: chronic epididymo-orchitis; 5: testicular neoplasm; 6: varicocele

Chronic scrotal swelling

Clinical assessment, diagnostic and treatment plans

Acute scrotal swelling

1 Torsion of testis

2 Acute epididymo-orchitis

3 Torsion of the hydatid of Morgagni

4 Traumatic haematocele

Chronic scrotal swellings

1 Hydrocele

2 Haematocele

3 Epididymal cysts

4 Chronic epididymo-orchitis

5 Testicular neoplasm

FIGURE 8.7 Presentation of testicular neoplasm1: painless lump in the testis; 2: ‘flash-fire’ presentation mimicking acute epididymo-orchitis; 3: large secondary hydrocele with occult primary – especially in younger patients; 4: secondary disease from occult primary

6 Varicocele

Groin and inguinoscrotal lumps

Causes

Clinical assessment and treatment plan

FIGURE 8.8 Varicocele1: absent valves in the left testicular vein lead to venous hypertension; 2: high ligation of the testicular vein; 3: inguinal canal and deep ring; 4: varicose pampiniform plexus

FIGURE 8.9 Inguinoscrotal lumpsA: inguinoscrotal hernia; B: varicocele; C: lipomatosis of the cord; D: encrysted hydrocele of the cord or canal of Nuck; E: testicular neoplasm with spread along the cord

Box 8.3 Clinical features of inguinal hernia

Indirect hernia

Direct hernia

FIGURE 8.10 Inguinal hernia: direct or indirect?1: indirect hernia runs within the spermatic cord through the external ring; 2: direct hernia emerges through the external ring behind the cord

FIGURE 8.11 Indirect inguinal herniaClassification A1–2: hernia magna; B1–2: funicular hernia; C1–3: sliding hernia (hernia-en-glissade). The sac consists in part of the serosal covering of the bowel, in this case sigmoid colon.

FIGURE 8.12 Strangulated indirect inguinal herniaA tense, tender, irreducible hernia with loss of the cough impulse. Bowel obstruction with early vomitting, abdominal (as well as local) pain, extracellular fluid loss and systemic toxicity.

FIGURE 8.13 Femoral herniaA: surface marking of femoral hernia; B: anatomy; 1: symphysis pubis; 2: lacunar ligament; 3: femoral hernia; C: large femoral hernia extending above inguinal ligament

FIGURE 8.14 Richter's herniaA variant of strangulated hernia seen most commonly with a femoral hernia. Part of the circumference of the bowel is entrapped.

Management plan

FIGURE 8.15 Inguinal herniorrhaphy1, 2: exposure of the inguinal canal; 3: opening canal; 4: dissection of the hernial sac from the cord; 5: excision of the hernial sac; 6: repair of the deep ring and posterior wall of inguinal canal

8.3 Abdominal wall problems

The umbilicus

Umbilical discharge

Common causes

Clinical features and treatment plan

1 Omphalitis

2 Embryological remnants

3 Intertrigo, umbilical concretions or granulomas

4 Ulcerated malignant nodule (Sister Mary Joseph's nodule)

5 Pilonidal sinus

Umbilical swellings and defects

Causes

Clinical features and treatment plan

1 Congenital abdominal wall defects

2 Umbilical hernias

FIGURE 8.16 Umbilical herniaA: The normal umbilicus lies over the linea alba, with the rectus abdominus muscle on either side. B: Primary umbilical hernias protrude through the umbilical scar. C: Acquired umbilical hernias are periumbilical so that the umbilical side of the skin dimple becomes an eccentric crescent-shaped slit.

Swellings of the abdominal wall

Causes

Clinical features and treatment plan

1 Subcutaneous and intramuscular swellings

FIGURE 8.17 Mayo repair of large umbilical herniaA: excision of sac; B: transverse repair using overlap

2 Abdominal wall hernias

FIGURE 8.18 Sites of ventral hernias1: epigastric; 2: incisional; 3: Spigelian; 4: umbilical

FIGURE 8.19 Diaphragmatic hernia1: foramen of Morgagni – between the sternal and costal slips of the diaphragm; 2: oesophageal hiatus; 3: foramen of Bochdalek

Chapter 9 Urogenital Problems

9.1 Introduction

History

Physical examination

Box 9.1 Lower urinary tract symptoms

Storage symptoms

Voiding symptoms

Diagnostic tests

FIGURE 9.1 Palpation of right kidney

9.2 Loin Pain

FIGURE 9.2a Cystoscopy and ureteric catheterisationA: tip of cystoscope with elevating bridge; B: trigone of bladder; C: ureteric oriface; D: interureteric bar

FIGURE 9.2b Normal right ureteric orifice as seen on cystoscopy

FIGURE 9.2c Right ureteric orifice with guidewire in situ

Causes

FIGURE 9.3 Radiation of ureteric ‘colic’Typically, a continuous severe pain that radiates from the renal angle and flank to the abdomen, parallel to the inguinal ligament, to the base of the penis and into the scrotum.

Clinical assessment

1 Renal pain (ureteric colic)

2 Pain referred from the ovary or other abdominal viscera

Box 9.2 Features of ureteric colic

3 Musculoskeletal pain

4 Less common causes

Diagnostic plan

Box 9.3 Types of urinary calculi

Treatment plan

Ureteric colic

FIGURE 9.4a Ureteric stoneRight-sided obstruction from stone causing hydronephrosis.

FIGURE 9.4b CT stone coronal view of a vesicoureteric junction (VUJ) stone

FIGURE 9.4c IVP demonstrating proximal ureteric stone

Management of urinary calculi

Box 9.4 Indications for removal/disruption of symptomatic renal or ureteric stone

FIGURE 9.4d URS/ureteroscopic view of stone

FIGURE 9.4e Extracorporeal shock wave lithotripsy (ESWL)

Management of recurrent urinary calculi

9.3 Painless Haematuria

Causes

Clinical assessment and urine microscopy

FIGURE 9.5 Common causes of painless haematuriaA: renal tumour; B: tuberculosis (now very uncommon); C: transitional cell tumour; D: engorged prostatic veins

Diagnostic and treatment plan

FIGURE 9.6a Staging of bladder tumourT1: confined to lamina propria; T2: invading the muscle wall of the bladder; T3: extending through the bladder wall; T4: involving other organs or nodal spread

FIGURE 9.6b Endoscopic photo of TCC

9.4 Lower urinary tract symptoms

Common causes

Clinical features and diagnostic plan

Urinary tract infections

Lower urinary tract infections

Upper urinary tract infections

Storage LUTS

Urinary tract pain

Voiding LUTS

9.5 Poor Urinary Stream

Common causes

Symptoms and signs

FIGURE 9.7a Effect of urinary obstructionA: obstruction effect; 1: prostatic hyperplasia, submucosal venular bleeding; 2: muscle trabeculation, detrusor muscle hypertrophy, bladder diverticula and stone; 3: hydronephrosis and renal failure. B: transurethral resection. The resectoscope is in position. The diathermy cutting loop is drawn back to remove hypertrophied prostate tissue in layers.

Benign prostatic obstruction

Carcinoma of the prostate

Diagnostic plan

FIGURE 9.7b The prostate on rectal examinationA: the normal prostate; B: benign prostatic hypertrophy; C: carcinoma of the prostate

Treatment plan

1 Prostatic obstruction

FIGURE 9.8a Endoscopic view of prostate pre-TURP

FIGURE 9.8b Endoscopic view of prostatic fossa post resection with verum montanum in foreground

2 Urethral stricture

3 Phimosis and meatal stenosis

9.6 Urinary Retention

Causes

Clinical assessment

Diagnostic plan

Treatment plan

FIGURE 9.9 Catheterisation of a distended bladder by percutaneous puncture

9.7 Urinary Incontinence

Types of urinary incontinence

Clinical features

1 Stress incontinence

2 Urge incontinence

3 Continuous or total incontinence

Treatment plan

1 Stress incontinence

2 Urge incontinence

FIGURE 9.10a Fascial sling for stress incontinence

FIGURE 9.10b A retropubic tape such as a TVT and a transobturator tape through the same pelvic bones

Management of complex cases of incontinence

9.8 Penile Lesions

Common causes

Clinical assessment and diagnostic tests

1 Disorders affecting the foreskin

2 Disorders affecting the urethral meatus

3 Disorders affecting the glans

4 Disorders affecting the shaft

5 Sexual and functional disorders

FIGURE 9.11 Peyronie's disease

6 Sexually transmitted infections

Treatment plan

References

Chapter 10 Preoperative medical problems in surgical patients

10.1 Introduction

10.2 Assessing patients for surgery

Box 10.1 A safe system of surgery

FIGURE 10.1 WHO surgical safety checklist

Grading of surgical and anaesthetic risk

TABLE 10.1 ASA classification of anaesthetic risk

Evaluation of the healthy patient

Evaluating elderly asymptomatic patients

Investigations and diagnostic (screening) tests before surgery

Urinalysis

Body weight

Temperature

Full blood examination

Blood typing

Chest x-ray

Electrocardiogram

Preoperative blood transfusion planning

Other tests

10.3 Cardiac disease

Box 10.2 Assessment for surgery: preoperative requirements and tests

All patients

Young, healthy patients (< 60 years), class I surgical risk

Healthy patients 60–70 years, class I surgical risk

Elderly patients > 70 years

Box 10.3 Cardiac risk index: high risk factors

History

Box 10.4 Common perioperative factors that precipitate cardiac decompensation

Box 10.5 Risk factors for ischaemic heart disease

Physical examination

Diagnostic and treatment plan

Non-invasive monitoring

Invasive monitoring

Common cardiac problems

Congestive cardiac failure

Box 10.6 Cardiovascular problems to be controlled before surgery

Ischaemic heart disease (coronary artery disease)

Valvular heart disease

Arrhythmias (and conduction defects)

Hypertension

10.4 Respiratory disease

History and physical examination

Diagnostic plan

Box 10.7 Indications for preoperative lung function tests

Box 10.8 Indicators of critically impaired lung function

Prevention and treatment plan

10.5 Cerebrovascular disease

10.6 Chronic liver disease

Complications arising from chronic liver disease

Box 10.9 Problems associated with alcoholic liver disease

History and physical examination

Diagnostic plan

Box 10.10 Preoperative testing in chronic liver disease

Treatment plan

Box 10.11 Drugs cleared predominantly by the liver

Alcoholic liver disease

10.7 Chronic renal disease

Diagnostic plan

Treatment plan

Box 10.12 Preoperative preparation of patients with chronic renal disease

Box 10.13 Nephrotoxic drugs

Box 10.14 Drugs cleared mainly by the kidney

10.8 Haemostatic and haemopoietic disorders

Box 10.15 Acute renal injury – indications for haemofiltration or dialysis

FIGURE 10.2 Mechanisms of coagulation

Box 10.16 Components of normal haemostasis

Common causes

Clinical assessment

Diagnostic plan

Whole blood clotting time

One-stage prothrombin time

Partial thromboplastin time

Thrombin time

Tests of platelet function

Tests of fibrinolysis

Treatment plan

1 Patients on oral anticoagulants or antiplatelet agents

2 Liver disease

3 Platelet disorders

4 Consumption coagulopathy

TABLE 10.2 Changes during bank storage of whole blood at 4° C after 2 weeks

5 Haemophilia, Christmas disease and Von Willebrand's disease

10.9 Anaemia

Causes of anaemia

Clinical features and diagnostic plan

Treatment plan

10.10 Diabetes mellitus

Diagnostic and treatment plans

Box 10.17 Preoperative management: diabetes mellitus

10.11 Mental health problems

Clinical states

Anxiety disorders

Depressive disorders

Somatoform disorders

Organic mental syndromes

Confusion

Delirium

Dementia

Causes of dementia

Drug dependence and abuse

Diagnostic and treatment plans

Anxiolytics, sedatives and hynotics

Antipsychotics

Antidepressant drugs

10.12 Additional preoperative preparation

Box 10.18a Preoperative preparation: oesophageal surgery

Box 10.18b Preoperative preparation: gastroduodenal surgery

Box 10.19a Preoperative preparation: chronic liver disease

Box 10.19b Preoperative preparation: jaundiced patient

Box 10.20 Preoperative preparation: colorectal surgery

Box 10.21 Preoperative preparation: urological surgery

Box 10.22 Preoperative preparation: vascular surgery

Box 10.23 Preoperative preparation: thyroid surgery

Box 10.24 Preoperative preparation: hernia surgery

Reference

Chapter 11 Postoperative problems

11.1 Introduction

11.2 Pain

TABLE 11.1 Postoperative complications

TABLE 11.2 Commonly used analgesics and dosage guide

11.3 Fever

TABLE 11.3 Causes of postoperative fever

FIGURE 11.1 Causes of fever and onset

11.4 Tachycardia

11.5 Shortness of breath and tachypnoea

Common causes

1 Basal lung atelectasis, bronchitis and bronchopneumonia: ‘the postoperative chest’

FIGURE 11.2 ‘The postoperative chest’A: breathing is impeded centrally and peripherally by wound pain, opiates and anaesthetics; B: ciliary action is depressed by anaesthetics, smoking and chronic bronchitis; C, D: atelectasis results from sputum retention

2 Adult respiratory distress syndrome – acute respiratory failure

Box 11.1 Factors contributing to the development of acute postoperative respiratory failure (adult respiratory distress syndrome)

3 Tension pneumothorax

4 Pulmonary embolism

5 Acute pulmonary oedema

11.6 Low urine output

Common causes

Clinical features and management plan

1 Prerenal – acute vascular insufficiency

TABLE 11.4 Acute renal injury: urine analysis

2 Renal – acute intrinsic renal failure (from acute tubular necrosis)

3 Postrenal – obstructive renal failure

11.7 Sudden collapse or rapid deterioration

TABLE 11.5 Causes of postoperative shock and collapse

Box 11.2 Characteristics of postoperative haemorrhage

Types

Causes

Site of bleeding

11.8 Nausea and vomiting

Box 11.3 Causes of postoperative vomiting

11.9 Confusion and altered mental state

11.10 Wound care problems

Box 11.4 Postoperative wound problems

Early

Late

Box 11.5 Causes of wound dehiscence

Technical error

Local factors

General factors

11.11 Abnormal investigations

Hypokalaemia

Hyperkalaemia

Hydrogen ion (acid–base) disorders

TABLE 11.6 Changes in arterial blood chemistry with hydrogen ion disturbances

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis and alkalosis

Chapter 12 Problems in surgical intensive care

12.1 Introduction: What is intensive care?

12.2 Patient selection

Post elective surgery

Post emergency surgery

Unplanned admission from the surgical ward

Scoring systems

12.3 Throughput and efficiency

12.4 ICU versus high dependency unit care

12.5 Postoperative ICU care

Monitoring – an overview

Invasive monitoring

Intra-arterial blood pressure monitoring

Central venous access and monitoring

TABLE 12.1 Examples of monitoring by systems

FIGURE 12.1 Swan-Ganz catheterA: line to inflate the balloon in pulmonary microvasculature; B: lumen for measuring pulmonary artery pressure/pulmonary capillary wedge pressure; C: lumen for measuring right atrial pressure (central venous pressure); D: thermistor catheter for measuring cardiac output by thermodilution

FIGURE 12.2 Radial artery cannulation

Pulmonary artery (Swan-Ganz) catheters

FIGURE 12.3 Central venous catherisationA: infraclavicular (subclavian) approach; B: internal jugular approach

Non-invasive monitoring

Nursing care

Organ preservation

Wound healing in the ICU

Pain management

Nutrition

Enteral feeding

FIGURE 12.4 Percutaneous jejunostomy

Parenteral feeding or total parenteral nutrition

FIGURE 12.5 Hickman catheterA: a silicone catheter is inserted into the right atrium via the cephalic vein: B: subcutaneous tunnel; C: a Teflon cuff reduces ascending infection and prevents inadvertent removal

12.6 Recovery and discharge from the ICU to the surgical ward

FIGURE 12.6 Parenteral nutritionA: TPN/balanced nutrient solution; B: monitoring pump; C: Hickman catheter; D: bag for collection of fistula loss; E: urinary catheter; F: blood collection for routine measurement of Na, K, Cl, PO4, HCO3, glucose, urea, creatinine, albumin and osmolality

12.7 General management of ICU patients

12.8 Cardiopulmonary arrest

12.9 Common problems in the ICU

Fever

Systemic inflammatory response syndrome

Sepsis

TABLE 12.2 Criteria for systemic inflammatory response syndrome

Hypoxia and hypercarbia

Hypotension and shock

TABLE 12.3 Causes of hypotension and shock, by group

Inotropes and vasopressors

Hypertension

Metabolic and electrolyte disturbances

Acid–base disorders

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

TABLE 12.4 Definitions of acidaemia and alkalaemia

TABLE 12.5 Causes of metabolic acidosis

Respiratory alkalosis

Other metabolic disorders

Electrolyte disorders

Sodium and water (disorders of tonicity)

Hyponatremia

Hypernatremia

Disorders of potassium

TABLE 12.6 Example causes of potassium imbalance

Magnesium

Oliguria/renal dysfunction and renal replacement

Box 12.1 Causes of renal dysfunction/oliguria in the ICU

Hepatic and gastrointestinal dysfunction

Neurological dysfunction

Box 12.2 Central causes of neurological dysfunction

Peripheral causes

Haematological dysfunction and haemorrhage

Massive haemorrhage

Multiple organ dysfunction syndrome (MODS)

12.10 The dying patient

12.11 Limitation of treatment/not for escalation of care orders

12.12 Withdrawal of treatment

12.13 Brain death and organ and tissue donation

Brain death

Organ and tissue donation

References

Chapter 13 Problems in injured patients

13.1 Introduction

Box 13.1 The ‘DRABC’ first aid action plan

13.2 Managing injured patients

Initial assessment

Primary survey and resuscitation

A Airway and cervical spine

TABLE 13.1 Important investigations and procedures following the primary survey and resuscitation

FIGURE 13.1a In the unconscious patient the tongue falls back

B Breathing and ventilation

FIGURE 13.1b Head tilt, chin lift and jaw thrust manoeuvres

FIGURE 13.2a Adequate airwayIn the unconscious patient the airway is first cleared by making sure that the tongue is forward and that the pharynx is clear of foreign bodies.

FIGURE 13.2b Endotracheal intubation: passage of an endotracheal tubeNasotracheal intubation is preferable when there is a danger of cervical spine injury.

Oxygenation

FIGURE 13.2c Nasopharyngeal airway with bag-valve mask and reservoir device

TABLE 13.2 Summary of airway management

C Circulation and control of haemorrhage

FIGURE 13.2d Oropharyngeal airway with bag-valve mask

TABLE 13.3 Recognition and initial management of life-threatening thoracic injuries

Fluid resuscitation

FIGURE 13.3 Venous cutdownA: incision above and anterior to the medial malleolus; B: the vein margins are defined; C: a length of vein is cleared; D: the vein is elevated and ligated; E: a bevelled incision is made and the vein is cannulated; F: the catheter is tied in and infusion begins

D Disability and neurological assessment

E Exposure and environmental control

Diagnostic peritoneal lavage

Secondary survey

History

Box 13.2 Useful questions to ask an ambulance officer at handover (e.g. for motor vehicle accident)

Examination

Neurological: Glasgow coma scale

Investigations and procedures following the secondary survey

Re-evaluation

Pain relief and splinting

Definitive care and transfer

Interhospital transfer

Medical records and documentation

Shock

FIGURE 13.4 Example of medical record/documentation

Clinical features of haemorrhagic shock

Diagnostic and treatment plan

13.3 Soft tissue injury and wound care

Classification of wounds

1 Clean wounds

2 Clean–contaminated wounds

TABLE 13.4 Classification of wounds

3 Contaminated wounds

4 Dirty–infected wounds

Principles of wound healing

Phases in wound healing

Factors adversely affecting wound healing

Local factors

General factors

Box 13.3 Local factors that interfere with wound healing

Box 13.4 General or host factors that interfere with wound healing

Definitive care

Wound care – debridement

Wound closure

Timing of wound closure

Wound closure techniques and materials

FIGURE 13.5 Local wound flapsIn random flaps without an axial blood supply the ratio of length to width should not exceed 1 : 1.

FIGURE 13.6 Local flaps: Z-plasty flap

Closed soft tissue (sporting) injuries

FIGURE 13.7 TRAM flap used for reconstruction after mastectomy

13.4 Burns

History

Types

Pathophysiology of burns

Local response to burns: Jackson's burn zones

Systemic response to burns: SIRS and MODS

First aid

FIGURE 13.8 Jackson's burn zones

Initial assessment

Extent of burns

FIGURE 13.9 ‘Rule of nines’ – calculating the percentage distribution of burnt skin in an adult and childA: adult burns chart B: paediatric burns chart

Classification of burn depth

Assessment of burn depth

FIGURE 13.10 Depth of burnsA: full-thickness (deep) burn; B: partial-thickness (superficial) burn

Burns to the respiratory tract

Subsequent assessment and definitive care

General management

Monitoring

Burn wound management

Box 13.5 Patients who fulfill the following criteria should be considered for transfer to a specialist burns unit

FIGURE 13.11 Locations for escharotomiesThe incisions are placed along the midmedial and midlateral lines of the extremities and the thorax (dashed lines). The skin is especially tight along major joints, and decompression at these sites must be complete (solid lines). Neck and digital escharotomies are rarely necessary.

13.5 Head injury

Classification and definitions

Primary injury: focal lesions

FIGURE 13.12a Mechanism of contrecoup injury

FIGURE 13.12b Coronal section of a patient undergoing herniations of the brain caused by an EDHA and B based on Williamson & Waxman 1998

Primary injury: diffuse lesions

Secondary injury

Initial assessment

Primary survey and resuscitation

Secondary survey

Examination of the scalp and face

Abnormal neurological signs

History

Re-evaluation

Investigations

Plain x-ray

TABLE 13.5 Head injury: testing of cranial nerve function after head injury

FIGURE 13.13 Conscious state and head injury chart

FIGURE 13.14 Guide to recording neurological observation chart

CT scan

Lumbar puncture

Magnetic resonance imaging

Cerebral angiography

Definitive care

General principles of management

Management of mild head injury (GCS 14–15)

Management of moderate head injury (GCS 9–13)

Management of severe head injury (GCS 3–8)

Management of specific complications

Box 13.6 Complications of head injury

FIGURE 13.15 Complications of basal skull fractureA: anterior fossa fracture with posterior conjunctival haemorrhage, CSF rhinorrhoea and epistaxis; B: middle fossa fractures with bleeding and CSF leak from the ear

13.6 Facial injury

Initial assessment

TABLE 13.6 Zonal classification of facial skeletal injuries

Le Fort classification

FIGURE 13.16 Blowout fracture of the orbital floor with an intact orbital rimThe entrapped inferior rectus muscle produces diplopia on upward gaze.

Mandibular fractures

Adjuncts to initial assessment

Definitive care

FIGURE 13.17 Le Fort classification of fractures of the maxillaI: the infraorbital rim remains stable as the maxilla is rocked; II: only the medial section of the infraorbital rim moves – associated infraorbital nerve damage is common; III: the whole of the infraorbital rim moves with the maxilla

13.7 Eye and orbital injury

Introduction

History taking

Examination

Chemical injury

First aid

Clinical assessment

Treatment plan

Corneal flash burns

Clinical assessment

Treatment plan

Perforating globe injuries

Clinical assessment

FIGURE 13.18 Anatomy of the globe

First aid

Diagnostic plan

Treatment plan

Superficial foreign body injury

Clinical assessment

Treatment plan

Closed globe injury

Clinical assessment

Diagnostic plan

Treatment plan

Injury to the orbit

Clinical assessment

FIGURE 13.19 Anatomy of the orbit

Diagnostic plan

Treatment plan

Injury to the eyelids

FIGURE 13.20 Anatomy of the lacrimal system

Clinical assessment

Treatment plan

13.8 Chest injury

Initial assessment

Primary survey

Secondary survey

Investigations

Definitive care

General management

Insertion of an intercostal catheter

Management of specific types of chest injury

FIGURE 13.21 Tube thoracotomyA: the fourth intercostal space is exposed in the midaxillary line; B: a tunnel is made with an artery forcep starting over the fifth rib and directed under the fourth rib; C: finger or artery forceps entry is made into the pleural space; D: a large tube is inserted in a posterosuperior direction and sutured to the skin; E: the intercostal tube is attached to underwater drainage

13.9 Abdominal injury

Blunt trauma

Box 13.7 Principles of surgical management of abdominal injury

Penetrating trauma

Initial assessment

Investigations

FIGURE 13.22 Blunt abdominal traumaCommon sites of injury – 1: liver; 2: pancreas; 3: duodenum; 4: spleen; 5: small bowel and mesentery; 6: caecum; 7: urinary bladder

Diagnostic modalities available for intra-abdominal trauma

FIGURE 13.23 Diagnostic peritoneal lavage in blunt trauma

Definitive care

Laparotomy and damage control principles

Damage control laparotomy

Abdominal compartment syndrome

Management of specific organ injuries

TABLE 13.7 The AAST splenic organ injury scaling system, 1994 revision

13.10 Nerve injury

FIGURE 13.24 Extraperitoneal injuries of the rectumA: defunctioning sigmoid colostomy; B: intraperitoneal drain; C: repair of rectal wound; D: extraperitoneal presacral drain

Classification

FIGURE 13.25 Peripheral nerve injuries1: endoneurium; 2: axon; 3: myelin. Peripheral nerve injuryA: neurapraxia; B: axonotmesis: axonal regrowth occurs at 1 mm per day; C: neurotmesis: a neuroma forms unless the axon has become connected with the distal sheath by suturing

Initial assessment

Sensory assessment

FIGURE 13.26 Common closed peripheral nerve injuries1: circumflex (axillary) nerve with deltoid paralysis and sensory loss; 2: radial nerve with wrist and finger drop and minor sensory loss; 3: ulnar nerve with sensory loss and inability to abduct the minimus; 4: median nerve with sensory loss and loss of palmar abduction of pollex; 5: sciatic nerve with foot drop, extensive sensory loss and loss of ankle jerk; 6: lateral popliteal (common peroneal) nerve with sensory loss and foot drop

Motor assessment

Definitive care

Open wounds with nerve injury

Autonomic dysfunction after injury – vasomotor dystrophy

13.11 Vascular injury

Classification

Initial assessment

Box 13.8 Common blunt injuries leading to closed vascular injury

Box 13.9 Major signs of vascular injury

Investigations

Definitive care

General principles

Principles of surgical management

FIGURE 13.27 Vascular repairA: end-to-end anastomosis; B: vein graft; C: synthetic graft; D: lateral suture with or without endarterectomy; E: patch angioplasty

Management of specific vascular injuries

FIGURE 13.28 Fasciotomy of the lower limbTwo skin incisions (A and B) are sufficient to decompress the anterior, lateral and posterior compartments (1, 2 and 3).

Box 13.10 Indications for fasciotomy

Box 13.11 Specific vascular injuries

FIGURE 13.29 Anatomical zones of the neck

Box 13.12 Reasons for failure of repair of a vascular injury

Box 13.13 Precautions to avoid inadvertent arterial injection

13.12 Urinary tract injury

Renal injury

Initial assessment

TABLE 13.8 AAST organ injury severity scale (1989) for the kidney

Definitive care

Surgical intervention

Conservative management

Ureteral injury

Bladder and urethral injury

Initial assessment

Bladder and posterior urethral injuries

Bladder injuries

Posterior (prostatomembranous) urethral rupture

FIGURE 13.30 Extraperitoneal rupture of the bladder or posterior (prostatomembranous) urethraUrinary extravasation above the urogenital diaphragm.A: shearing strain when the pelvic ring is broken and displaced; B: on rectal examination a haematoma obscures the prostate

Injuries to the anterior urethra

Investigations

Definitive care

In patients with suspected anterior urethral injuries

In patients with suspected posterior urethral or bladder injury

Posterior urethral injury

Bladder injury

13.13 Spinal injury

Classification of spinal cord injury

Neurological patterns of injury

FIGURE 13.31 Spinal cord injury: levels of function

Initial assessment

Primary survey

Secondary survey

Investigations

Definitive care

Management in an emergency department

Transfer to a spinal unit

13.14 Major fractures and joint injury

Initial assessment

Primary survey

Resuscitation

Secondary survey

Investigations

Definitive care

Principles of management

Methods of management

FIGURE 13.32 External fixation to facilitate soft tissue repairExternal fixation stabilises an open comminuted fracture of the tibia associated with extensive tissue damage, and facilitates soft tissue repair.

Compartment syndrome

Rhabdomyolysis and renal impairment

13.15 Hand injury

Initial assessment

Assessing the hand

Investigations

Definitive care

Principles of surgical management

Digital reimplantation and microsurgery

Wound closure

Postoperative management and secondary procedures

Chapter 14 Ophthalmological problems

14.1 Introduction

14.2 Who's who in eye care

Ophthalmologist

Optometrist

Orthoptist

14.3 Basic anatomy of the eye

14.4 Ocular symptoms

FIGURE 14.1 Basic anatomy of the eye

Box 14.1 Relevance of ophthalmology in general medicine and surgery

14.5 The basic eye examination

Visual acuity

TABLE 14.1 Clustering of ophthalmic symptoms

Distance visual acuity testing and recording

FIGURE 14.2 Occlusion with palm

FIGURE 14.3 Standard Snellen visual acuity chart, C chart and E chartThe patient should be encouraged to read the smaller letters or the next line even if they are not confident of the letters.

Pupils

Visual fields

FIGURE 14.4 Normal pupils

FIGURE 14.5 Relative afferent pupil defect (RAPD)

FIGURE 14.6 Confrontation field testing

Eye movements

Gross examination of the eye and adnexae

Eyelids and surrounding tissue

TABLE 14.2 Cardinal position of gaze, extraocular muscles and their cranial nerve supply

FIGURE 14.7 Eye movement testing

Gross inspection of the eye

Additional tests

Direct ophthalmoscope

Operating a direct ophthalmoscope

Clinical examination using a direct ophthalmoscope

FIGURE 14.8 The direct ophthalmoscope

Slit lamp examination of the eye and adnexae

FIGURE 14.9 Normal (A) and swollen (B) optic nerve appearance

14.6 Diagnosis of common problems

Loss of vision

Differential diagnosis

Acute loss of vision

Transient visual loss

Persistent visual loss lasting more than 24 hours

Gradual painless loss of vision

Binocular visual loss

History

Duration of symptoms

Associated symptoms

Previous ophthalmic history

Previous medical history including drug history

Family history

Social history

Examination

Visual acuity

Pupils

Visual fields

FIGURE 14.10 Localised corneal opacity secondary to infective microbial keratitis

Eye movements

Anterior segment examination

FIGURE 14.11 Diffuse corneal oedema due to congenital glaucoma

FIGURE 14.12 Corneal dendritic ulcer

FIGURE 14.13 HypopyonA hypopyon is the settling of inflammatory cells in the anterior chamber due to severe inflammation caused by infective or non-infective sight-threatening conditions.

FIGURE 14.14 HyphaemaA hypahema is the settling of red blood cells in the anterior chamber usually secondary to blunt trauma of the eye.

Fundoscopy

Primary management

Ongoing management

14.7 Double vision – ‘diplopia’

Monocular diplopia

Differential diagnosis

Binocular diplopia

Differential diagnosis

History

Nature of the double vision

Associated symptoms

Examination

Visual acuity with pinhole

Pupil examination

Inspection

Cover test

Eye movements

Cranial nerve examination

Primary management

Neuroimaging

Bloods

Ongoing management

14.8 Red or painful eye

History

Duration of symptoms

TABLE 14.3 Common systemic causes of red eye

Description of pain

Associated symptoms

Previous ophthalmic history

Previous medical history

Primary management

TABLE 14.4 Common differential diagnosis for a red painful eye

14.9 Common lumps and bumps around the eye

Eyelid swelling

Causes

14.10 Selected ophthalmic conditions

Preseptal and orbital cellulitis

Preseptal cellulitis

Aetiology

Signs

Treatment

1 Outpatient treatment

2 Inpatient treatment

Orbital cellulitis

Aetiology

TABLE 14.5 Common eyelid lumps and bumps

Symptoms and signs

Complications

Ocular

TABLE 14.6 Preseptal vs orbital cellulitis

TABLE 14.7 Causes of orbital cellulitis

Systemic

Investigations

Treatment

Microbial keratitis

Common bacterial pathogens

Clinical features

Symptoms

Signs

TABLE 14.8 Common predisposing factors

Differential diagnosis

Investigations

Treatment

Indications for hospital admission

Conjunctivitis

Adenoviruses

Symptoms

Signs

FIGURE 14.15 Conjunctival follicles – discrete, yellowish, slightly elevated lesions most prominent in the fornices

FIGURE 14.16 Conjunctival membrane secondary to viral conjunctivitis

Investigations

Management

Bacterial conjunctivitis in neonates: ophthalmia neonatorum

Aetiology

Signs

Systemic complications

Investigations

FIGURE 14.17 Purulent conjunctival discharge

Treatment

Lens and cataract

Symptoms

Signs

Treatment

FIGURE 14.18 Modern phacoemulsification cataract surgery

Acute angle closure

Risk factors

Symptoms

Signs

Complications of high IOP

Treatment

Emergency treatment and refer to an ophthalmologist

Definitive treatment

Diabetic retinopathy

Non-proliferative diabetic retinopathy

Proliferative diabetic retinopathy

Symptoms

Signs

Treatment

Systemic

Ophthalmic

Uveitis

Symptoms

Signs

Investigations

FIGURE 14.19 a. Posterior synechia (arrow) in a partially dilated pupil

b. Cells and flare in the anterior chamber on slit lamp examination

Treatment

Retinal detachment

Risk factors

Symptoms

Giant cell arteritis

Symptoms

Ophthalmic

Systemic

Signs

Ophthalmic

Systemic

Investigations

Systemic

Ophthalmic

Referral

Initial treatment

Prophylactic treatment

Temporal artery biopsy

Further treatment and follow up

Natural history

Principles of treatment

Visual prognosis

Ischaemic cranial nerve palsies: third, fourth and sixth

History

Examination

On follow-up

Ischaemic third nerve palsy

Specific history

Motility examination

Ischaemic fourth nerve palsy

Specific history

Motility examination

Ischaemic sixth nerve palsy

Specific history

Motility examination

Paediatric ophthalmology

Amblyopia

Abnormal red-reflex

FIGURE 14.20 A. Normal red reflex

B. Leucocoria due to retinoblastoma

Retinoblastoma

History

Investigations

FIGURE 14.21 Right eye retinoblastoma

Treatment

Reference

Picture Credits

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 6

Chapter 7

Chapter 9

Chapter 10

Chapter 13

Chapter 14

 

An aparitie	06-Apr-17
Autor	Julian A. Smith MBBS MS MSurgEd FRACS FACS FFSTRCSEd FCSANZ FAICD , Jane G. Fox MBBS FRACS
Dimensiuni	19.05 x 2.54 x 25.4 cm
Editura	Elsevier
Format	Paperback
ISBN	9780729542265
Limba	Engleza
Nr pag	560