Surgery

Topics in This Section

Ophthalmology

Acute Angle Closure Glaucoma
Anterior Uveitis (Iritis)
Central Retinal Artery Occlusion (CRAO)
Central Retinal Vein Occlusion
Conjunctivitis
Corneal Abrasian
Foreign Body
Scleritis
Retinal Detachment

Plastic Surgery

Animal Bite
Ingrown Toenail
Melanoma
Non-Melanoma Skin Cancer
Trigger Finger

Urology

Benign Prostate Hyperplasia
Bladder Cancer
Epididymo-orchitis
Kidney Stones
Prostate Cancer
Renal Cancer
Renal Cyst
Scrotal Haematoma
Testicular Torsion
Testicular Cancer

Vascular Surgery

Abdominal Aortic Aneurysm
Aortic Dissection
Carotid Stenosis
Peripheral Vascular Disease
Varicose Veins
Venous Ulcer

 

 

 

 

 

 

 

 

Breast Endocrine

Adrenal Adenoma
Breast Cancer
Ductal Carcinoma in Situ
Graves' Disease
Mastitis
Phaechromocytoma
Primary Hyperparathyroidism
Thyroid Cancer

Gastrointestinal Surgery

Achalasia
Acute Appendicitis
Acute cholecystitis
Acute Mesenteric Ischaemia
Acute Pancreatitis
Ascending Cholangitis
Biliary Colic
Choledocholithiasis
Colorectal Cancer
Diverticulitis
Gastric Cancer
GORD
Haemorrhoids
Inguinal Hernia
Inflammatory Bowel Disease
Large Bowel Obstruction
Oesophageal Cancer
Oesophageal Varices
Pancreatic Cancer
Peptic Ulcer Disease
Small Bowel Obstruction
Intussusception

Head and Neck Surgery/ENT

Acute Otitis Media
Carcinoma of the Larynx
Cholesteatoma
Epistaxis
Ludwig's Angina
Malignant (Necrotising) Otitis Externa
Otitis Externa
Otitis Media with Effusion (Glue Ear)
Parotid Tumour
Pharyngeal Pouch
Sialolithiasis
Sinusitis
Tonsillitis
Wax Impaction


Breast-endocrine surgery

Adrenal adenoma

Clinical Features

  • Often asymptomatic and an incidental finding on abdominal CT.
  • Conn’s Syndrome (primary hyperaldosteronism): Hypertension, headache, polyuria, and weakness.
  • Cushing’s Syndrome (hypercortisolism): Hypertension, weight gain, hirsutism, moon facies, central obesity, and type 2 diabetes mellitus.
  • Phaechromocytoma: Paroxysmal (episodic) or sustained hypertension, headache, palpitations, diaphoresis, and “impending doom”.

Investigation:

  • Abdominal CT can visualize most adrenal tumours.
  • When a tumour is identified it is important to determine if it is a “functioning” tumour (is secreting hormones). Possible investigations include: 24 hour urinary cortisol, EUC, urinary catecholamines, adrenal androgens.

Treatment:

  • If: an adrenal adenoma is asymptomatic and there is no biochemical evidence that it is a functioning tumour AND <4cm in diameter. Then: it can be followed up with imaging (e.g. repeat CT at 6 and 12 months).
  • If: no further suspicious changes are detected. Then: no surgical intervention may be required.
  • Otherwise curative treatment is resection.

 

Breast cancer

Clinical Features:

  • Risk factors:
    • Previous or family history
    • High oestrogen (nullparity, late age of first pregnancy (>30), early menarche (<12), late menopause (>55)
    • Radiation exposure
  • Examination: Firm mass, skin/nipple retraction, axillary lymphadenopathy, tethering to chest wall, bloody nipple discharge.

Investigation:

  • Screening of general population (standard risk) asymptomatic individuals:
    • Mammogram every 2 years from 50-74 y/o.
  • Suspected breast cancer may be investigated with the “triple test”, which involves the following:
    • 1) Mammography (women under <40 or with dense breast tissue are recommended USS)
    • 2) Physical Examination
    • 3) Core biopsy
  • A confirmed breast cancer should be staged with the following:
    • Chest/abdo CT.
    • WBBS.
    • Bloods (Ca 15.3. CBE. LFT).
    • If: the lymph nodes are clinically positive. Then: axillary USS and FNA are recommended.
    • If: the lymph nodes clinically negative. Then: a sentinel node biopsy is recommended during operation.

Treatment:

  • Breast cancer is managed dependent on the size, stage and hormone status.
    • Surgery:
      • A lump (generally <4cm) can be managed with lumpectomy and adjuvant radiotherapy, if there are no other indications for mastectomy. This may enable positive cosmetic outcomes as it is breast-conserving therapy.
      • A mass is treated by mastectomy if it is too large for good cosmetic outcome OR ≥2 primary tumours in separate quadrants OR diffuse DCIS/malignant calcifications OR persistently positive margins at re-excision.
      • An axillary clearance is indicated if lymph nodes are positive (on FNA/sentinel node biopsy) or sentinel node can’t be identified.
    • Other:
      • Trastuzumab (Herceptin) is used if the cancer is HER2+ve.
      • Hormone therapy:
        • Tamoxifen (selective estrogen receptor blocker) is used in the setting of ER+ve and/or PR+ve and premenopausal/perimenopausal women
        • Aromatase inhibitor (e.g. letrozole) is used if the cancer is ER+ve and/or PR+ve and the women is postmenopausal

 

Ductal Carcinoma in Situ

Clinical features and investigations:

  • 80% of DCIS are non palpable, and detected by screening mammogram
  • Suspicious lesions on mammography are: poorly defined, speculated, and have microcalcifications.
  • Further Investigation will involve triple testing (see “Breast cancer” section) and core biopsy if inconclusive

Treatment:

  • Although a DCIS itself has no metastatic potential, there is up to a 35% risk of invasive ductal carcinoma in 10 years.
  • Local therapy involves mastectomy or breast conserving therapy (BCT). BCT includes lumpectomy +/- radiotherapy.
  • ER positive DCIS treated with BCT should be managed with endocrine therapy (tamoxifen) to reduce the risk of recurrence.

 

Graves’ disease

Clinical Features: 

  • General: Fatigue, weakness, anxiety
  • Sweating, loss of of lateral 1/3 eyebrow, alopecia, pretibial myoexedema (non-pitting oedema)
  • Tremors, weakness
  • Palpitations
  • Increased bowel motility
  • Irregular menstrual periods
  • Exophthalmos, diplopia, lid lag, lid retraction

Investigation:

  • Diagnostic: TFTs and Thyroid stimulating immunoglobulin (TSI)
    • Low TSH, Increased T3/T4
  • Also: ECG (for AF)

Treatment:

  • Initial:
    • Symptomatic relief is achieved with beta blocker (e.g. propranolol).
    • Carbimazole. Euthyroidism must be achieved before radioiodine ablation or surgery to prevent thyroid storm.
  • There are several options for definitive management of Graves' disease:
    • If: Small goiter or child-bearing age (no radiation). Then: carbimazole
    • If: Not pregnant or failed medical therapy. Then: radioiodine ablation
    • If: Large goiter or ophthalmopathy. Then: total thyroidectomy
  • Follow up:
    • Commence on thyroxine.

 

Mastitis

Clinical Features:

  • Usually unilateral
  • Breast tenderness
  • Palpable mass
  • Purulent nipple discharge

Investigation:

  • Initial: Typically clinical diagnosis

Treatment:

  • Lactation associated mastitis should be supported by ongoing breastfeeding to prevent accumulation of infected material.
  • Antibiotics:
    • 1st line: dicloxacillin or flucloxacillin
    • 2nd line: Clindamycin (if penicillin allergy)
  • Follow-up: In 2-3 days.
    • A non-resolving mastitis should be investigated by FNA/Ultrasound to exclude more sinister causes such as abscess or cancer.
    • A breast abscess may require surgical review for excision and drainage.

 


Phaeochromocytoma

Clinical Features: See adrenal adenoma section

Investigations:

  • Abdominal CT
  • 24 hour urinary catecholamines and metanephrines
  • A further MIBG scan can be used to check for metastases

Treatment:

  • The goal of treatment is surgical resection. The following sequence is required to avoid hypertensive crises:
    • Alpha blocker (phenoxybenzamine - irreversible). This must be commenced first because unopposed alpha stimulation (for example, if a beta blocker was commenced first) may cause refractory hypertension.
    • Beta blocker
    • Surgical resection

 

Primary hyperparathryoidism

Clinical Features:

  • The majority of symptoms are due to hypercalcaemia. The hypercalcaemia constellation of symptoms is classically remembered as: “Bones, Moans, Stones, Groans”
    • Bone pain (BONES)
    • Psychosis (MOANS)
    • Nephrolithiasis (STONES)
    • Vomiting/GI upset (GROANS)

Investigation:

  • Initial: Serum PTH and calcium. A urinary calcium/creatinine clearance ratio is required to exclude the possibility of familial hypocalciuric hypercalcaemia prior to any operative intervention.
  • A neck USS and Sestamibi nuclear scan is diagnostic and determines whether parathyroid adenoma or parathyroid hyperplasia is present.

Treatment:

  • The initial priority is to correct elevated serum calcium levels.
    • Severe hypercalcaemia (uncommon)
      Treat with: IV fluids, frusemide (only to treat fluid overload) and IV bisphosphonates.
  • Management:
    • Parathyroidectomy is recommended if:
      • Symptomatic
      • Or asymptomatic and any of: Osteoporosis or age <50 or kidney stones
    • Medical treatment involves: Maintain appropriate calcium and vitamin D for demographic, exercise, bisphosphonates and adequate hydration. Monitor with PTH, serum calcium and DEXA.

 

Thyroid cancer (papillary)

Papillary carcinoma most common - Key Features: “P’s”

  • Palpable lymph nodes
  • Positive I131 uptake
  • Psammoma bodies (histology)

Workup

  • Diagnostic: Neck US, radioactive iodine update (cold nodule) + FNA
  • Staging is done by neck CT (to check for local extension and lymph node mets) and CXR

Treatment:

    • Total thyroidectomy +/- removal of affected lymph nodes. Consider follow-up iodine-131 ablation of any remaining thyroid.
  • Follow up:
    • Commence on thyroxine. Monitor serum thyroglobulin for recurrence.

 

Gastrointestinal surgery

Achalasia

Clinical features:

  • Dysphagia
  • Regurgitation (especially nocturnal)
  • Chest pain
  • Reflux symptoms
  • Weight loss

Investigation:

  • Diagnostic: Oesophageal manometry.
  • Barium swallow (bird’s beak) is less sensitive.

Treatment:

  • Best:
    • 1st line: cardiomyotomy.
    • Alternative: Balloon dilation
    • If: poor surgical candidate. Then: may be managed medically (GTN and/or diltiazem)

 

Acute appendicitis

Clinical Features

  • Classical progression of pain: dull, non-localised periumbilical that becomes well localized and sharp over McBurney’s point (in right iliac fossa)
  • Low grade fever (38C) unless perforated
  • Nausea/vomiting
  • Specific signs: Rovsing’s sign (inferior appendix), psoas sign (retrocecal), obturator sign (pelvic appendix).

Investigation:

  • Initial: Generally clinical diagnosis
  • Diagnostic: Abdo USS or CT

Treatment:

  • Initial: Triple antibiotics (metronidazole, amoxicillin, gentamicin) and analgesics
  • Best:
    • 1st line: Appendicectomy

 

Acute cholecystitis

Clinical Features:

  • RUQ abdominal pain
  • Murphy’s sign
  • Low grade fever
  • Often history of biliary colic

Workup:

  • Suggestive investigations: CBE and LFTs (cholestatic picture)
  • Diagnostic: Abdominal Ultrasound
    • Observe for: stones, bile sludge, pericholecystic fluid and thickened gallbladder wall
    • Equivocal ultrasound: order a HIDA scan. Non-visualisation of the gallbladder will suggest acute cholecystitis.

Treatment:

  • Initial: antibiotics and analgesia
  • Best:
    • Surgery is non-emergent cholecystectomy: Laparoscopic cholecystectomy (<72 hours typically)

 

Acute mesenteric ischaemia

Clinical Features:

  • Severe generalised abdominal pain due to restricted intestinal blood flow.
  • Pain out of proportion to abdominal signs on examination
  • Bloody diarrhea
  • Shock
  • Classically accompanied by atrial fibrillation (source of embolus)

Investigation:

  • Clinical suspicion, especially with patients having known risk factors
  • Gold standard diagnostic investigation: CT angiography
  • Features suggestive of mesenteric ischaemia:
    • Abdominal XR/CT demonstrating bowel wall oedema and air within the bowel wall (pneumatosis intenstinalis)
    • Markers: metabolic acidosis, raised CK, raised LDH, raised LDH

Treatment:

  • Initial: Fluid resuscitation. Correct metabolic acidosis, nil by mouth and NGT stomach decompression, triple therapy empiric antibiotics, pain control and haemodynamic monitoring.
  • Mesenteric arterial occlusion: early surgical laparotomy with embolectomy
  • Mesenteric venous thrombosis: may only require anticoagulation, but progressing symptoms requires laparotomy
  • Early exploratory laparotomy + resection of infarcted bowel if perforation or peritonitis is evident

 

Acute pancreatitis

Clinical features

  • Epigastric pain, constant with possible radiation to back
  • Jaundice if obstruction of bile duct
  • Nausea and vomiting

Investigation:

  • Initial/diagnostic: Serum lipase (most sensitive)
  • Tests for Ranson’s criteria (CBE, BGL, LDH, AST. Then at 48 hours CBE, EUC, calcium, ABG for O2 and base deficit )
  • Abdo USS can be used to assess underlying cause (for gallstones)

Treatment:

  • Initial: Resuscitation and analgesia
  • Best: Treat underlying cause
    • If gallstones identified: ERCP and cholecystectomy
    • If alcohol: Encourage reduction of alcohol consumption and referral to appropriate drug and alcohol services

Complications

  • Shock
  • Pseudocysts: drain if symptomatic or growing
  • Abscess: antibiotics and drainage

 

Ascending cholangitis

Clinical Feature:

  • Charcot’s triad: RUQ pain, jaundice and fever
  • Reynold’s pentad (suggesting sepsis): Charcot’s triad + septic shock and altered mental status

Investigation:

  • Initial: Blood tests including blood cultures and lipase (to rule out pancreatitis).
  • Workup: Abdominal USS to identify obstructing stone/biliary tree dilatation.

Treatment:

  • Initial: Resuscitation + empiric antibiotics (gentamicin, metronidazole and amoxycillin) + ICU admission
  • Best:
    • ERCP is both diagnostic and therapeutic, decompression can be achieved by this means.

 

Biliary colic

Clinical features:

  • Steady, dull epigastric pain for minutes-hours
  • The onset is classically following fatty meals

Investigation:

  • Initial/Diagnostic: Abdominal USS may demonstrate a stone in the cystic duct.

Treatment:

  • Initial: Analgesia and rehydration
  • Best:
    • An elective laparoscopic cholecystectomy is indicated

 

Choledocolithiasis

Clinical findings:

  • Tenderness in RUQ or epigastrium
  • Obstructive symptoms: Acholic stool, dark urine and fluctuating jaundice

Investigation:

  • Initial: CBE (to rule out cholangitis), lipase (to rule out pancreatitis) and LFTs
  • Diagnostic: Abdominal USS demonstrating intra/extra-hepatic dilatation

Treatment:

  • Best:
    • 1st line: ERCP and laparoscopic cholecystectomy.

Complications if untreated:

  • Cholangitis
  • Pancreatitis
  • Biliary stricture

 

Colorectal cancer

Clinical Features: dependent on locations

  • Right colon
    • Weight loss, rarely causes obstruction
  • Left colon
    • Constipation/diarrhea (alternative bowel patterns)
    • Abdominal pain
    • Decreased stool caliber
    • Rectal bleeding
    • Large bowel obstruction
  • Rectum
    • Obstruction
    • Tenesmus
    • Rectal bleeding
    • Palpable mass on DRE

Investigation:

  • Diagnostic: Colonoscopy and biopsy
  • Tumour marker: CEA
  • Staging: Chest/abdo/pelvis CT, WBBS, LFTs
  • Pelvic MRI is recommended in rectal cancer

Treatment:

  • Best:
    • Stage I: Resection of lesion and regional lymph nodes (in distribution of vascular territory)
    • Stage II or III: Resection + chemotherapy
    • Metastatic spread: palliative care
  • Follow-up:
    • Annual chest/abdo CT (for 3 years). 3 monthly clinical assessment and CEA estimation (for 2 years). Colonoscopy at 12 months

Screening guidelines:

  • Category 1 risk: FOBT 2 yearly from age 50
  • Category 2 risk: Every 5 years from age 50 or 10 years younger than the age of first diagnosis of CRC in the family
  • Category 3 risk: FAP (every 12 months from 12-15 to 30-35 years old, and 3 yearly afterwards) Lynch Syndrome (1-2 yearly from 25 or 5 years earlier than youngest affected family)

 

Difficult to locate suspected small bowel bleed (i.e. obscure GI bleeding)

Clinical features:

  • Bright red blood PR.
  • Colonoscopy/endoscopy reveals nothing to explain bleeding

Investigation:

  • Initial: CBE, group and hold
  • Diagnostic:
    • If: stable
      • 1st: endoscopy/colonoscopy
      • 2nd: If: nothing found. Then: capsule endoscopy
      • 3rd: If: still nothing found. Then: CT/MR enterography
      • Other: If: suspected Meckel’s diverticulum. Then: technetium 99 scan may be helpful

Treatment:

  • Initial: Resuscitation
  • Best: according to cause likely determined by endoscopy/colonoscopy

 

Diverticulitis

Clinical Features: 

  • Lower left quadrant pain
  • Constipation, diarrhea, urinary symptoms
  • Complications: abscess, fistula (eg. coloenteric), perforation, and peritonitis

Investigation:

  • Initial: Upright CXR to assess for free air suggestive of perforation
  • Diagnostic: Abdominal CT

Treatment:

  • If: Uncomplicated. Then:
    • Best: Oral antibiotics for 7-10 days. Ciprofloxacin recommended. Should be assessed 2-3 days after commencement of antibiotics and weekly afterwards. Progression of symptoms indicates inpatient admission.
      • Follow-up: After resolution of symptoms, a colonoscopy at 6 weeks is recommended for colon cancer screen and assess the extent of diverticular disease.
  • If: peritonitis is present, the patient has failed medical therapy, or is immunocompromised. Then: complicated.
    • Initial: Resuscitation
    • Best: Bowel rest. Empiric antibiotics (amoxicillin, gentamicin and metronidazole). Surgery (resection of bowel segment).



Gastric cancer

Clinical features

  • Postprandial fullness
  • Epigastric pain
  • Anorexia/weight loss
  • Dysphagia
  • Epigastric mass
  • Blood loss: haematemesis, melena, iron deficiency anaemia
  • Virchow’s node: metastasis to left supraclavicular node

Warning signs

  • Gastric ulcer failing to heal
  • Lesion on greater curvature of stomach or cardia

Investigation:

  • Initial/Diagnostic: Endoscopy with biopsy
  • Staging: Oesophageal US to assess T and N (for TNM staging), CT chest/abdo/pelvis, Laparoscopy

Treatment:

  • Best:
    • If: no local/distant spread: gastrectomy + perioperative chemotherapy
    • If: local/distant spread: palliative measures

 

GORD

Clinical features

  • Heartburn
  • Sour/acid regurgitation

Investigation:

  • Initial: None. Clinical diagnosis. Can trial PPIs.
  • If: Any red flag symptoms (new onset in >55 y/o, weight loss, progressive dysphagia, pain swallowing, persistent vomiting, evidence of GI bleeding). warrants gastroscopy.
  • If: Being considered for surgery. Then: pH studies and manometry, which determines LES tone (diagnostic)

Treatment:

  • Best:
    • 1st line: Lifestyle modification and weight loss
    • 2nd line: + antacids
    • 3rd line: + PPI or H2 antagonist
    • 4th line: If: failed medical therapy and oesophageal acid >7% in 24 hours. Then: Fundoplication
  • If: high volume reflux is main concern. Then: fundoplication
  • If: Barrett’s oesophagus. Then: Monitoring endoscopy annually + standard GORD treatment
  • If: High grade dysplasia detected. Then: 3 monthly endoscopy + biopsy or ablation or surgical resection

 

Hemorrhoids (external)

Clinical features:

  • Usually symptomatic
  • Pain after bowel movement
  • If they become thrombosed may be very painful

Investigation:

  • Diagnostic: Clinical diagnosis
  • If: Of age/symptoms where colorectal cancer may be present concurrently. Then: Colonoscopy

Treatment:

  • Best:
    • 1st line: Fiber, increase water intake
    • 2nd line: Stool softeners
    • 3rd line: Topical steroid cream
    • If: Thrombosed, consider surgical decompression

 

Hemorrhoids (internal)

Clinical features:

  • Painless rectal bleeding
  • Can cause prolapse, pruritis, rectal fullness

Investigation:

  • Diagnostic: Clinical diagnosis
  • If: Of age/symptoms where colorectal cancer may be present concurrently. Then: Colonoscopy

Treatment:

  • Best:
    • If: grade 1 (bleed but don’t prolapse). Then: High fiber diet, increase water intake. Topical steroid cream. Rubber band ligation.
    • If: grade 2 (bleed and prolapse but reduce automatically). Then: Rubber band ligation
    • If: grade 3 (bleed and prolapse but can be manually reduced). Then: Rubber band ligation. May required closed hemorrhoidectomy.
    • If: grade 4 (bleed and prolapse and can’t be reduced). Then: Closed hemorrhoidectomy.

 

Inguinal hernia

Clinical features:

  • Direct: Medial to inferior epigastric vessels. Passes through external (superficial) inguinal ring only. Protrudes through Hesselbach’s triangle. More common in elderly.
  • Indirect: Lateral to inferior epigastric vessels. Passes through both internal (deep) and external (superficial) inguinal rings. Goes into scrotum. If reduced, herniation can be controlled with pressure over deep inguinal ring. More common in younger patients.
  • Vomiting, constipation
  • Palpable impulse with cough reflex
  • Tenderness that may be relieved by reduction

Investigation:

  • Diagnostic: Generally clinical diagnosis. Can be confirmed with US.

Treatment:

  • Best:
    • If it is painful and strangulated (compromised vascular supply). Then emergency surgical repair is required
    • If: incarcerated. Then: Urgent surgical repair
    • If: reducible. Then: Elective surgical repair



Inflammatory bowel disease

Clinical Features:

Ulcerative Colitis

  • Inflammation involves mucosa and submucosa only
  • Always involves the rectum and extends proximally in a continuous fashion
  • Bloody diarrhea, lower abdominal cramps, tenesmus, urgency
  • Extra-intestinal: primary sclerosing cholangitis, arthritis, pyoderma gangrenosum, erythema nodosum

Crohn’s Disease

  • Transmural inflammation of bowel wall
  • Presents as skip lesions, often sparing the rectum
  • Fever, abdominal mass, weight loss, watery diarrhea
  • Extra-intestinal: Perianal fissures, skin tags, fistulas

Investigation:

  • Initial: Fecal calprotectin (sensitive) and CBE
  • Diagnostic: Colonoscopy and biopsy (definitive)
  • Assessing disease activity/severity: MR enteroclysis

Treatment:

  • Best:
    • Crohn’s:
      • 1st line: Corticosteroids
      • 2nd line: Infliximab.
      • Other options: Azathioprine, methotrexate
      • Surgical: Resection and anastamosis/stoma.
    • Ulcerative colitis:
      • 1st line: 5-ASA +/- corticosteroids
      • 2nd line: Infliximab
      • Other options: azathioprine, methotrexate
      • Surgical: Proctocolectomy with ileoanal pouch/ileostomy.

 

 

Large bowel obstruction

Clinical features:

  • Obstipation
  • Abdominal pain – classically comes in waves 10-15 minutes apart
  • Abdominal distension/bloating
  • Hyper-resonant percussion note (tympanic abdomen)
  • Absent bowel sounds
  • Late: vomiting or perforation

Investigation:

  • Diagnostic: Supine and erect abdo XRs

Treatment:

  • Initial: Resuscitation and analgesia
  • Best:
    • For sigmoid volvulus: sigmoidoscopic decompression should be attempted. If this fails: surgery (resection and diverting colostomy, with later anastomosis)
    • Otherwise: surgery (resection and diverting colostomy, with later anastomosis)



Oesophageal cancer

Clinical Features:

  • Progressive dysphagia first involving solids and later liquids
  • Weight loss
  • Odynophagia
  • GI bleeding + vomiting

Investigation:

  • Diagnostic: Endoscopy and biopsy
  • Staging: Endoscopic US +/- FNA (for local staging), head/chest/abdo/pelvis CT

Treatment:

  • Best:
    • No local invasion: Oesophagectomy
    • Locally spread: Neoadjuvant chemoradiotherapy then oesophagectomy
    • Distant metastases: Palliative measures
    • High grade Barrett’s dysplasia: surgical resection

 

Oesophageal varices

Clinical Features:

  • Features of upper GI bleeding (hematemesis, melena).
  • May also have signs of liver cirrhosis

Investigation:

  • Initial: bloods (CBE, group and hold, platelets, PT, PTT, electrolytes)
  • Diagnostic: endoscopy

Treatment:

  • Initial:
    • IVT (sodium chloride)
    • IV Terlipressin/octreotide
    • Antibiotic prophylaxis for 7 days (oral norfloxacin or IV ceftriaxone)
    • If: lacking coagulation factors. Then: replace with fresh frozen plasma
  • Best:
    • Endoscopic ligation
    • If: continuous bleeding. Then: second course of endoscopic ligation or emergency TIPS
    • Secondary prevention with beta-blockers (propanolol)
    • Repeat band ligation until obliterated

 

Pancreatic cancer

Clinical Features

  • Head of pancreas
    • Obstructive jaundice
    • Courvoisier’s sign (palpable non-tender gallbladder)
    • Abdominal pain radiating to back
    • Trousseau’s sign (migratory thrombophlebitis)
  • Body or tail of pancreas
    • Usually presents late and inoperable
    • Less (10%) are jaundiced

Investigation:

  • Diagnostic: contrast abdo CT. This also assesses metastasis and resectability
  • Tumour marker: Ca 19-9
  • Serum markers non-specific: raised ALP/bilirubin

Treatment:

  • Best:
    • Resectable (<20%): Whipple procedure
    • Non-resectable: Palliative measures

 

Peptic ulcer disease

Clinical Features:

  • Dyspepsia
  • Epigastric burning pain
  • Complications
    • Bleeding (Upper GI bleeding symptoms, erosion of gastroduodenal arery)
    • Perforation (peritonitis features)
    • Gastric outlet obstruction (positive succussion splash)
    • Penetration (posterior ulcers to pancreas)

Investigation:

  • Initial:
    • If the patient is peritonitic or perforated suspected, perform an upright CXR which demonstrates gas under the diaphragm
    • If: Bleeding. Then: Group and hold.
  • Diagnostic: Endoscopy
    • Note that all gastric ulcers require biopsy for suspicion of gastric cancer

Treatment:

  • Initial:
    • If: Perforated/bleeding. Then: Resuscitation
  • Best:
    • If: Perforated. Then: triple therapy to cover GI organisms (amoxicillin, gentamicin, metronidazole) and open surgical repair
    • If: Bleeding. Then: Endoscopy and adrenaline injection at site/cauterisation/clip
    • Otherwise:
      • If: H pylori positive. Then: PPI, amoxicillin and clarithromycin. If: not symptom free after eradication. Then: urease breath test at 6 weeks
      • If: On NSAIDs. Then: Stop NSAIDs + PPI (8-12 weeks)
      • Follow-up: with endoscopy 2-3 months later to check ulcer healing (may be a cancer not picked up by first biopsy).

 

Small bowel obstruction

Causes

  • Intraluminal
    • Intussusception
    • Gallstones
  • Intramural
    • Crohn’s
    • Radiation stricture
    • Adenoma carcinoma
  • Extramural
    • Adhesions
    • Incarcerated hernia
    • Peritoneal carcinomatosis

Clinical Features:

  • Vomiting (early)
  • Abdominal pain – classically occurs in waves 2-3 minutes apart.
  • Abdominal distension
  • Hyperactive tinkling bowel sounds

Investigation:

  • Diagnostic: Abdo XR
    • Demonstrates stepladder pattern of dilated small bowel loops, air fluid levels and no gas in colon
  • Lab tests: May demonstrate dehydration and metabolic acidosis. Lactic acidosis is very concerning as it suggests bowel necrosis

Treatment:

  • Initial: Resuscitation and analgesia
  • Best:
    • If: No clinical features of perforation/bowel ischaemia. Then: conservative mx for 72 hours (NGT drainage, IVT). If: hasn’t resolved. Then: Surgery (bowel resection)
    • If: clinical features of perforation/bowel ischaemia. Then: surgery straight away (bowel resection)
    • If: Due to hernia. prompt surgical repair is recommended

 

Head and neck surgery/ENT

Acute otitis media

Clinical Features

  • Otalgia, Fever, Conductive hearing loss
  • If the tympanic membrane is perforated, otorrhoea will be present
  • Infants/toddlers: ear tugging, irritability, anorexia, vomiting/diarrhea
  • Otoscopy: hyperemia, bulging behind TM and loss of landmarks (handle + long process of malleolus)

Investigation:

  • Diagnostic: Clinical diagnosis
  • CT if evidence of complications

Treatment:

  • Best:
    • Regardless of perforation:
      • If <6 months old or systemic symptoms: amoxycillin and analgesia
      • Otherwise analgesia and observation for 2 days. If symptoms persist or worsen, amoxicillin is recommended.
      • If there is no response to antibiotics in >72 hours, amoxicillin and clavulanate is indicated
      • In the setting of penicillin allergy, then: trimethoprim+sulfamethoxazole

Complications

  • Extracranial: hearing loss/developmental delay, TM perforation, cholesteatoma
  • Intracranial: meningitis, brain abscess
  • Mastoiditis

 

Carcinoma of the larynx

Clinical features:

  • Hoarseness
  • Sore throat
  • Ear pain
  • Cough
  • Lump in neck

Investigation:

  • Initial: CXR and Contrast Neck CT
  • Diagnostic: Laryngoscopy and biopsy

Treatment:

  • Best:
    • Surgical excision (partial or total laryngectomy) and post-op chemoradiotherapy

 

Cholesteatoma

Clinical Features:

  • Progressive hearing loss, otalgia, aural fullness
  • Congenital: small white pearly lump behind intact TM
  • Acquired (more common - generally a consequence of OM and Eustacian tube dysfunction):
    • Pearly mass behind TM, frequently associated with perforation or retraction pocket. Can cause chronic inflammation leading to destruction of bone.

Investigation:

  • Diagnostic: CT and audiogram

Treatment:

  • Surgical excision (typically involving mastoidectomy)

 

Epistaxis

Investigation:

  • Diagnostic: Clinical diagnosis
  • Workup: Depending on severity of bleed may assess coagulation, platelets, CBE,

Treatment:

  • Initial/Best:
    • If: necessary. Then: Resuscitate
    • 1st line: Compression for 10 minutes to create tamponade (or nasal tampon). Tilt head forwards.
    • 2nd line: If: compression fails. Then: Suction and cauterisation
    • 3rd line: If: all conservative measures fail. Then: transarterial embolisation

 

Ludwig’s angina

Clinical Features:

  • Dysphagia
  • Drooling
  • Fever
  • Severe; asphyxiation and death

Investigation:

  • Diagnostic: Usually clinical diagnosis
  • Once airway is secure: CT

Treatment:

  • Initial: secure airway
  • Best: incision and drainage. Antibiotics

 

Malignant (necrotizing) otitis externa

Clinical features:

  • Ear pain
  • Fever
  • Key finding: Granulation tissue at base of external auditory canal
  • Immunocompromised individual

Investigation:

  • Diagnostic: high resolution temporal bone CT. Technetium scan
  • Follow-up: Gallium scan

Treatment:

  • Best: IV antibiotics (gentamicin + tazocin). May require surgical debridement

 

Otitis externa

Clinical Features

  • Acute: pain by movement of auricle, otorrhoea, conductive hearing loss, aural fullness, posterior auricular lymphadenopathy
  • Chronic: pruritis of external ear, tympanic membrane may appear normal, no main with movement of auricle, atrophic and scaly epithelial lining

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • First step: Ear toilet. Second step (when ear clean and dry): corticosteroid + antibiotic combination ear drop
    • For chronic otitis externa, corticosteroid drops alone are indicated

 

Otitis media with effusion (glue ear)

Clinical Features:

  • Most frequently follows acute OM in children
  • Conductive hearing loss
  • Tinnitus
  • Aural fullness
  • Otoscopy: discolouration (dull gray), meniscus fluid level behind TM, air bubbles, retraction pockets, immobility of pneumotoscopy

Investigation:

  • Diagnostic: Clinical diagnosis or pneumatic otoscopy

Treatment:

  • Best:
    • 1st line: Grommets

 

Parotid tumor

Clinical Features:

  • Mass over angle of mandible
  • Facial nerve (unilateral lower motor neuron facial nerve palsy) involvement is suggestive of a malignant process

Investigation:

  • Diagnostic: US-guided FNA
  • If doubt whether malignant: head CT
  • If: CT doesn’t distinguish benign vs malignant. Then: MRI

Treatment:

  • Best:
    • If: Pleomorphic adenoma. Then: Superficial parotidectomy
    • If: Malignant (invasive). Then: Total parotidectomy

 

Pharyngeal pouch

Clinical Features:

  • Regurgitation of undigested food hours after eating
  • Bad breath
  • Gurgling sound in neck
  • Dysphagia
  • Aspiration and chronic cough

Investigation:

  • Diagnostic: Barium swallow

Treatment:

  • Best:
    • 1st line: Endoscopic diverticulotomy

 

Sialolithiasis

Clinical Features

  • Pain associated with mealtimes
  • Swelling of gland that is intermittent, lump may be felt
  • Decrease or lack of saliva (in complete obstruction)
  • Pus discharge from duct if infected

Investigation:

  • Diagnostic: Plain intra-oral XR
  • If: suspicion of chronic salivary gland damage. a sialogram is recommended
  • If: need help localising stone to guide management. Then: Head CT

Treatment:

  • Best:
    • First line management is medical – hydration, antibiotics and warm compression
    • 1st line: Surgical stone extraction.
      • If: Distal (able to be visualised looking in mouth). Then: Transoral removal of stone
      • If: evidence of chronic salivary gland damage on sialogram. Then: consider excision of gland
    • 2nd line: If: surgical stone extraction fails. Then: Excision of affected gland (generally submandibular)
      • If: Proximal and <4mm. Then: sialoendoscopic retrieval with basket
      • If: Proximal and >4mm. Then: Extracorporeal lithotripsy before removal

 

Sinusitis

Clinical Features

  • Facial pain/pressure/fullness
  • Nasal obstruction
  • Purulent nasal discharge
  • Hyposomia/anosmia

Investigation:

  • Diagnostic: Clinical diagnosis
  • If: immunocompromised or diplopia, impaired vision, altered mental status or perioribtal oedema. Then: ED and head CT

Treatment:

  • Best:
    • All: Paracetamol/NSAIDs, saline nasal spray, intranasal corticosteroids (not for longer than 3 days),
    • If: symptoms >7 days OR severe symptoms. Then: amoxycillin (If: allergic. Then: cefuroxime)

Complications

  • Periorbital/orbital cellulitis, Meningitis, Abscess, Pott’s Puffy tumour, Osteomyelitis

 

Tonsillitis

Clinical Features

  • Bacterial: Severe sore throat, fever, malaise
    • Pharngeal/tonsillar erythema and exudates, enlarged cervical lymph nodes, palatal petechiae
  • Viral: Mild sore throat, conjunctivitis, cough, rhinorrhea, flu-like symptoms

Investigation:

  • Diagnostic: Clinical diagnosis
  • If: suspected strep throat a rapid streptococcal antigen test is indicated

Treatment:

  • Best:
    • If a viral aetiology is suspected, there is no indication for antibiotics. Then: supportive treatment (as viral) (paracetamol and hydration)
    • If: otherwise, then: Penicillin V is recommended. Azithromycin can be a substitute in Penicillin allergy.
    • A tonsillectomy may be indicated in the setting of:
      • Sleep-disordered breathing
      • Recurrent throat infections (7 in 1 year, 5 infections/year for 2 years, 3 infections/year for 3 years)
      • Suspicion of malignancy

 

Wax impaction

Clinical features:

  • Conductive hearing loss
  • Wax visible on otoscopy

Investigation:

  • Diagnostic: clinical diagnosis

Treatment:

  • Initial/best:
    • 1st line: Softening ear drops
    • 2nd line: Ear syringing
    • Then: Refer to ENT

Note: Discourage use of cotton buds

 

Ophthalmology

Acute angle-closure glaucoma

Clinical Features

  • Red, painful eye
  • Unilateral
  • Decreased visual acuity
  • Non-reactive, mid-dilated pupil
  • Corneal injection and ciliary flush

Investigation:

  • Initial: Slit lamp investigation, IOP with iCare
  • Diagnostic: Gonioscopy demonstrating a closed angle

Treatment:

  • Initial: Acetazolamide
  • Best:
    • 1st line: laser iridotomy

 

Anterior uveitis (Iritis)

Clinical Features

  • Photophboia
  • Ocular pain
  • Globe tenderness
  • Decreased visual acuity
  • Ciliary flush

Investigation:

  • Diagnostic: Slit Lamp Examination showing cells in anterior chamber, keratitic precipitates, may also demonstrate hypopyon (collection of exudates in anterior chamber)

Complications

  • Inflammatory glaucoma
  • Posterior synechia (adhesions of iris to anterior lens capsule – demonstrated by irregular borders of iris)

Treatment:

  • Best:
    • 1st line: Intraocular Steroid drops
    • Urgent referral if hypopyon or hyphema present
    • Extensive workup to assess secondary causes

 

Central retinal artery occlusion (CRAO)

Clinical features

  • Sudden, painless loss of vision (if not secondary to GCA)
  • Relative afferent pupillary defect
  • Fundoscopy
    • Cherry red spot located at center of macula
    • Retinal pallor
    • Cotton wool spots (infarcts)

Investigation:

  • Initial: ESR and CRP to exclude GCA
  • Diagnostic: Retinal Exam via Slit Lamp

Treatment:

  • Initial: Urgent referral to ophthalmology

 

Central retinal vein occlusion

Clinical Features:

  • Painless, monocular, gradual or sudden loss of vision
  • May present with RAPD
  • Fundoscopy: “thunderstorm” appearance, diffiuse retinal haemorrhages, cotton wool spots, venous engorgement, macula oedema

Investigation:

  • Initial: Comprehensive ophthalmic/neurological exam, ESR/CRP
  • Diagnostic: Retinal exam with slit lamp

Treatment:

  • Best: Refer to ophthalmology, consider steroids
  • There is no evidence for treatment that can restore vision in ventral retinal vein occlusion

Sources: NSW Eye Manual, ABC of Eyes

 

Conjunctivitis

Clinical Features:

  • Viral conjunctivitis
    • Serous discharge
    • Lid oedema
    • Often bilateral
    • Subepithelial corneal infiltrates
  • Bacterial conjunctivitis
    • Purulent discharge
    • Lid oedema
    • Conjunctival injection (limbal pallour)
    • Chemosis (conjunctival oedmea)
    • Often unilateral

Investigation:

  • Initial: Slit Lamp examination
  • Diagnostic: Diffuse conjunctival injection on slit lamp

Treatment:

  • Best:
    • If viral: advise general hygiene, cool compresses/lubricants
    • If bacterial: Chlorsig drops qid for 5 days
    • If allergic: cool compresses, lubricants

 

Corneal abrasion

Clinical Features:

  • Pain, redness, tearing, photophobia, foreign body sensation

Investigation:

  • Diagnostic: fluorescent dye + cobalt blue light demonstrating de-epithelialised areas of staining

Treatment:

  • Initial/Best:
    • If: low velocity impact AND minimal reduced vision AND no residual foreign body. Then: Chlorsig (chloramphenicol) ointment. R/v in 48 hours and if: not healed, then: refer.
    • If: otherwise. Then: refer to ophthal

 

Foreign body

Clinical Features

  • Tearing, red eye, photophobia, foreign body sensation
  • Conjunctival injection

Investigation:

  • Initial:
    • For a suspected high speed foreign body an orbital x-ray is indicated
    • Visual acuity
  • Diagnostic: Slit lamp examination with fluorescein staining looking for epithelial defect

Treatment:

  • Initial: Topical antibiotics qid and oral analgesia PRN
  • If metal splinter: Consider referral to ophthalmology
  • Best:
    • 1st line: Foreign body removal under slit lamp with local anaesthesia and sterile needle

 

Scleritis

Clinical Features:

  • Severe pain, photophobia, red eye, loss of vision
  • Slit lamp: AC cell flare, corneal infiltrate, scleral thinning
  • Failure to blanch with topic phenylephrine (differentiates from episcleritis)

Investigation:

  • Diagnostic: Clinical diagnosis (scleral vessels are larger than conjunctival vessels)

Treatment:

  • Initial: Treat underlying cause
  • Best:
    • 1st line: Refer to ophthalmology if suspecting scleritis
    • Systemic steroids are usually required

 

Retinal detachment

Clinical features:

  • Sudden onset
  • Flashes of light
  • Visual floaters (hazy spots in vision)
  • Curtain of blackness/peripheral visual loss
  • Loss of central vision

Investigation:

  • Initial: Visual acuity assessment
  • Diagnostic: Retinal examination via slit lamp

Treatment:

  • Initial: Ophthalmology consult within 24 hours
  • Best:
    • 1st line: Laser therapy for small tear (clinical assessment)
    • Definitive: surgical repair under GA


 

Plastic surgery

Animal bite

Investigation:

  • Clinical diagnosis

Treatment:

  • Initial: Wash wound +/- debridement
  • Best:
    • 1st line: amoxicillin + clavulanic acid
    • If: allergic. Then: doxycycline + metronidazole
  • Consider status of rabies vaccination

 

Ingrown toenail

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • Trimming of nail by podiatrist. Antiseptic dressing.
    • If: recurrent. Then: surgery (e.g. phenol matrixectomy)

 

Melanoma

General: Multiple types of melanoma

  • Lentigo maligna (malignant melanoma in situ)
  • Lentigo maligna melanoma
  • Superficial spreading melanoma (70%) cases
  • Nodular melanoma (poor prognosis, rapidly evolving)
  • Acrolentiginous melanoma (palms, heels, subungual), often discovered late due to location of lesion

Description of a skin lesion (ABCDE)

  • Asymmetry
  • Border
  • Colour (variegated)
  • Diameter (increasing or >6mm)
  • Enlargement/elevation
  • Ulceration indicates a poor prognosis

Investigation & treatment:

  • Initial/diagnostic: Excisional biopsy (2mm margin)
  • Best:
    • If: in situ. Then: further surgical excision with 0.5cm margin
    • If: Breslow <1mm. Then: further surgical excision with 1cm margin
    • If: Breslow ≥1mm. Then: sentinel node biopsy. And further surgical excision with 2cm margiN
      • If: Sentinel node positive. Then: regional lymph node dissection.
      • Note that sentinel node biopsy, CT and elective node dissection have been shown in studies to have no patient survival benefit. It does offer information about prognosis for the melanoma or the opportunity for clinical trial.
    • If: Clinical evidence of metastases. Then: Staging investigations (chest/abdo/pelvis CT, PET scan) (otherwise staging investigations not indicated).
    • If: mets. Then: palliative chemoradiotherapy.

 

Non-melanoma skin cancer

Basal Cell Carcinoma

  • Most common cancer usually due to UVB exposure, involving malignant proliferation of basal keratinocytes of epidermis
  • Locally aggressive, rarely metastatic
  • Appears as skin coloured papule/nodule with rolled, translucent (pearly) telangiactatic border and depressed/ulcerated center.

Squamous Cell Carcinoma

  • Second most common type of cutaneous malignancy, often secondary to exposure to UV radiation, immunosuppression, and radiation therapy
  • Rapidly enlarging indurated nodule/papule with scale and ulceration common
  • Investigation:
    • Clinical diagnosis
    • Diagnostic: Otherwise histological analysis of punch biopsy or excisional biopsy

Treatment:

  • Best:
    • 1st line: Excision
      • BCC: 3mm margin (if uncomplicated)
      • SCC: 4mm margin (if uncomplicated)
    • Moh’s surgery (microscopic and minimally invasive, assessing surgical margins)
    • Other possibilities:
      • If: superficial lesion (actinic keratosis), liquid nitrogen can be considered
      • If: Bowen’s disease. 5-fluorouracil cream can be considered
      • If: Superficial BCC and can’t have surgery. Then: consider imiquimod or photodynamic therapy

 

 

Trigger finger

Clinical Features

  • Affects the digits of hands and thumb
  • Symptoms of snapping, catching or locking of finger
  • May have tenderness of palpation or nodule over A1 pulley (MCP)

Investigation

  • Typically a clinical diagnosis

Treatment

  • Conservative: NSAIDs, steroids, flexor tendon release
  • Surgical: Incision of A-1 flexor tendon pulley

 

Urology

Benign prostate hyperplasia

Clinical Features:

  • Obstructive symptoms: hesitancy, weak/intermittent stream, incomplete emptying, retention
  • Irritative: nocturia, daytime frequency, urge incontinence, opening haematuria
  • DRE: smooth, rubbery, uniformly enlarged prostate

Investigation:

  • Diagnosis is generally established by storage, voiding or irritative symptoms in conjunction with a diffusely large prostate on DRE.
  • Initial: Urine dipstick and MC&S (rule out infection), EUC (rule out obstruction, and renal insufficiency)
  • PSA and cystoscopy are not recommended for BPH monitoring

Treatment:

  • Initial: If: Severe bladder outlet obstruction occurs, this is treated by urinary catheterisation.
  • Best:
    • Can do international prostate symptom score (IPSS) to guide treatment
    • 1st line: Alpha-1 blocker + 5-alpha reductase inhibitor
    • 2nd line: TURP (following renal tract US and uroflowmetry and post-void residual)
      • Complications of TURP: clot formation → catheter blockage, TUR Syndrome: Hyponaetremia from continuous irrigation

 

Bladder cancer

Clinical Features:

  • Most often presents as haematuria, but may also be asymptomatic
  • Complications: Hydronephrosis due to ureter obstruction

Investigation:

  • Initial: Urine MC&S and cytology, contrast CT (filling defect) (before cystoscopy)
  • Diagnostic: Cystoscopy and biopsy

Treatment:

  • Best:
    • If: superficial (non-muscle invasive). Then: transurethral resection of bladder tumour and chemo/immunetherapy (intravesical BCG). This still has 40-60% recurrence rate.
    • If: invasive. Then: radical cystectomy and pelvic lymphadenectomy +/- neoadjuvant chemotherapy
    • If: Metastatic. Then: Palliate

 

Epididymo-orchitis

Clinical Features:

  • Sudden onset scrotal pain/swelling that may radiate to flank
  • Scrotal erythema/tenderness, fever, purulent discharge
  • Reactive hydrocele
  • Often history of unprotected sexual contact or underlying UTI

Investigation:

  • Initial: Scrotal US to rule out testicular torsion and support diagnosis. If torsion can’t be ruled out surgical exploration is required to rule it out.
  • Diagnostic:
    • For gonorrhoea/chlamydia: first-void urine for NAAT
    • For everything else: Urine MC&S

Treatment:

  • Initial/Best:
    • If: sexually active or unclear whether sexually active. Then:
      • 1st line: Empiric antibiotics. Doxycycline and ceftriaxone. To cover chlamydia and gonorrhoea.
    • If: not sexually active. Then:
      • 1st line: treat as UTI.

 

Kidney stones

Clinical Features:

  • Acute onset flank pain

Investigation:

  • Initial: CBE and urine analysis (microscopic haematuria, altered pH). KUB x-ray (radio-opaque stones only)
  • Diagnostic: Non-contrast abdominal CT. USS preferred for children or pregnancy.

Treatment:

  • Initial:
    • Analgesia & hydration
    • NSAIDs (lowers intraluminal pressure)
    • Medical expulsion therapy (alpha blockers - tamsulosin or calcium channel blockers - nifedipine)
    • Best:
      • If: Evidence of upper urinary tract infection (pyelonephritis). Then:
        • 1st line: ureteric stent
          • (3) Otherwise: Conservative treatment. NSAIDs +/- opioids, alpha-1 receptor blocker or calcium channel blocker, wait for stone to pass. R/v in 2-3 weeks if no improvement.
          • (2) If: stone >6mm or bilateral stones or one kidney or impaired renal function or ongoing pain preventing conservative treatment or no improvement after 2-3 weeks of conservative treatment. Then:
          • 2nd line: Laser lithotripsy
            • 1st line: External shockwave lithotripsy
            • 2nd line: nephrostomy. Indicated if patient can’t tolerate anaesthetic for procedure for stent.

 

 

Prostate cancer

Clinical Features:

  • Usually asymptomatic
  • May cause lower urinary tract symptoms such as hesitancy and incomplete emptying
  • DRE (hard, irregular nodule or diffuse induration involving one or both lobes)

Investigation:

  • Initial: PSA
  • Diagnostic: Trans-rectal US guided prostate biopsy (prostate MRI now has an increasing role)
    • Gleason score
  • Staging: CT chest/abdo/pelvis, PSA, WBBS

Treatment:

  • Best. Several options including:
    • Radical prostatectomy (younger patients <75 years old)
    • External beam radiation +/- androgen deprivation therapy (older patients with locally advanced disease)
    • Brachytherapy (low volume, and PSA)
    • If: Low risk (Gleason score). (Can consider active surveillance with possible curative intent)
    • If: local invasion. Then: Radiotherapy
    • If: Metastasised. Then: hormone therapy
       

Renal cancer

Clinical Features:

  • Often incidental finding on USS or CT
  • “Too late triad”: gross haematuria, flank pain, abdominal mass
  • Advanced: bone pain, anaemia, bone pain
  • Metastasis often seen in many new cases (bone, brain, lung, liver)

Investigation:

  • Initial: Normally picked up incidentally on abdo CT, serum calcium (PTHrP), CBE (EPO normocytic anaemia)
  • Diagnostic: Triple phase CT (arterial phase, venous phase and urogram phase)

Treatment:

  • Best:
    • 1st line: Laparoscopic nephrectomy +/- palliative radiotherapy (resistant to chemotherapy). If: urothelial tumour. Then: nephrouretectomy
    • Surveillance indicated for lesions <1cm in patients over age of 70 (6 monthly US/CT)


Renal cyst

Clinical features:

  • Normally picked up incidentally on abdo CT.

Investigation and treatment:

  • You are really only worried about it being a renal cancer – this must be excluded Abdo CT with contrast to determine Bosniak class (risk of malignancy).
    • If: class I or II: unlikely cancer. No follow-up required.
    • If: class IIF: Repeat contrast CT in 6 months.
    • If: class III or IV Laparoscopic nephrectomy +/- palliative radiotherapy (as likely cancer) (resistant to chemotherapy)

 

Scrotal hematoma

Clinical Features

  • Usually follows trauma or surgery
  • Acute testicular pain, swelling, bruising, possible wounds
  • Transillumination with penlight demonstrating no transillumination

Investigation:

  • Initial/diagnostic: USS

Treatment:

  • Initial/Best:
    • If: blunt trauma and…
      • If: tear in tunica albuginea (rupture of testis). Then: surgery (d/t risk of necrosis)
      • If: no tear in tunica albuginea. Then: ice, scrotal support and bed rest
      • If: penetrating trauma. Then: exploratory surgery

 

Testicular torsion

Clinical features:

  • Sudden onset testicular pain
  • Effected testicle may be elevated and have a horizontal lie
  • Lifting testicles over pubic symphysis increases pain (negative Phren’s sign)
  • Absent cremasteric reflex on effected side
  • Scrotal erythema and swelling

Investigation:

  • Initial: Clinical suspicion adequate
  • Diagnostic: Doppler US (not usually done)

Treatment:

  • Urgent/Best: Surgical exploration of scrotum, intraoperative detorsion and orchidopexy.


Testicular Cancer

Clinical Features

  • Painless testicular enlargement (only painful in infarcted/infected)
  • Dull ache in lower abdomen, scrotum
  • May have associated hydrocele, gynaecomastia, lymphadenopathy

Investigation:

  • Initial: Testicular Ultrasound, Tumor markers (beta-hCG, alpha-fetoprotein,LDH)
  • Diagnostic: Ultrasound. Needle aspiration contraindicated (seeding of tumour)
  • Staging: CT Chest/Abdomen/Pelvis

Treatment:

  • Best:
    • 1st line: Orchiectomy + adjuvant therapy
    • 2nd line: Chemotherapy


Vascular surgery

Abdominal aortic aneurysm

Clinical Features

  • 75% are asymptomatic
  • Associated with HTN, PVD, CAD
  • Acute expansion symptoms: syncope, pain (chest, abdo, flank, back), palpable pulsatile mass
  • Rupture “triad”: hypotension/collapse, back/abdominal pain, palpable abdominal pass

Investigation:

  • Initial/diagnostic: Abdo US
  • Following this, If: patient is haemodynamically stable. Then: Abdo CT (provides details about anatomy of aneurysm to guide intervention)

Treatment:

  • If: leaking or ruptured
    • Initial: Resuscitation on way to laparotomy
    • Best:
      • If: bases of renal arteries are not involved, patent peripheral vessels, length of vessel pre- and post-rupture viable. Then: Endovascular repair
        • Otherwise: Open repair
        • If: incidental finding on CT:
          • If: <5.5cm and asymptomatic and not growing (at >1cm per year). Then: aggressive risk factor control and repeat US every 6 months.
          • If: >5.5cm, symptomatic or growing (at >1cm per year) on follow-up scan. Then: consider surgical repair


Aortic dissection

Important classification:

  • Stanford A: involving ascending aorta and arch
  • Stanford B: begins beyond brachiocephalic vessels

Clinical Features:

  • Sudden onset tearing chest pain that radiates to back
  • Hypertension
  • Asymmetric BP and pulses between arms
  • May cause MI type pain with involvement of coronary arteries
  • May have neurological features due to ischaemia of spinal cord or nerves

Investigation:

  • Initial: CXR (widened mediastinum), lactate (rule out ischaemic gut), lipase (rule out pancreatitis), troponin (rule out MI)
  • Diagnostic: CT angiography. If: contraindicated. Then: MRA

Treatment:

  • Initial: Morphine and HR then BP control
    • IV Beta blocker to control HR <60 and BP to 110 (if contraindicated use ca channel blocker) (if inadequate control use ACEi).
  • Best:
    • If: Type A
      • Then: BP and HR control as above.
    • If: Type B.
      • Then: BP and HR control as above.
      • If: spinal, mesenteric, limb ischaemia. Then: vascular surgery.
      • Otherwise: manage medically.
      • All: Cardiac surgery



Carotid stenosis

Clinical Features:

  • May be asymptomatic
  • Symptomatic features include: TIA or stroke

Investigation:

  • Initial/diagnostic: Doppler US

Treatment:

  • Initial (medical management): Aspirin/dipyridamole and medical risk factor reduction
  • Best:
    • If: female and symptomatic/asymptomatic and 70-99%. Then: CEA (2nd line: CAS)
    • If: male and symptomatic and 50-99%. Then: CEA (2nd line: CAS)
    • If: male and asymptomatic and 60-99%. Then: CEA (2nd line: CAS)
      • If: high surgical risk. Then: Carotid artery stenting (CAS)
    • If: otherwise (incl stenosis 100%). Then: medical management (as above).

Note: Percentage stenosis required prior to surgical intervention may be quite center-dependent.

 


Peripheral vascular disease

Clinical Features:

  • Claudication
    • Pain on exertion (usually calves)
    • Relieved by rest
  • Critical limb ischaemia:
    • Rest pain, night pain or tissue loss
    • Positive Buerger’s test
  • Absent pulses/ bruits present
  • Poor perfusion signs: hair loss, ulcerations, infections, slow capillary refill, prolonged pallor, rubour on dependency

Investigation:

  • Initial: If: critical limb ischaemia. Then: first step is to say referral to vascular surgery”
  • Diagnostic: ABI
  • If: ABI <0.5 (classed as critical limb ischaemia). Then: to establish location of stenosis:
    • First: Doppler US. Then:
    • If: renal function normal. Then: CT arteriography
    • If: renal function bad. Then: MR angiography

Treatment:

  • All: Lifestyle modification (including smoking cessation and exercise) + aspirin
  • Best:
    • If: ABI >0.5. Then: Lifestyle modification and aspirin only
    • If: ABI <0.5 and short stenotic segment. Then: angioplasty/stent
    • If: ABI <0.5 and long stenotic segment. Then: bypass
    • If: All management failed. Then: amputation



Varicose veins

Clinical Features:

  • Diffuse aching, fullness/tightness/nocturnal cramp
  • Worse at end of day (standing)
  • Visible long veins along leg and thigh
  • Ulceration, hyperpigmentation and induration
  • Brodie-Trendendelenburg test (for valvular competence)

Investigation:

  • Diagnostic: Doppler US

Treatment:

  • Initial: Compression stockings. Check ABI first for PVD
  • Best: May be required if tissue loss, pain, bleeding, thrombophlebitis, cosmesis.
    •  Ligation of varicosities or sclerotherapy

 

Venous ulcer

Clinical Features:

  • Usually appears in “gaiter region”: from mid calf circumferentially to medial and lateral malleoli
  • Moist granulating base, irregular border, oozing.

Investigation:

  • Initial: Wound swab
  • Diagnostic: Doppler US

Treatment:

  • Best:
    • 1st line: Moist occlusive dressings/compression bandaging
    • 2nd line: split skin graft
  • If: Cellulitis. Then: Di/flucloxacillin