Keloid scars

Keloid scars differ from hypertrophic scars in that they extend outside the area of the original wound. Keloid scars tend to develop more commonly in those of African ancestry, and in certain parts of the body, notably over the shoulders, upper back and sternum. They are prone to develop following ear piercing. Their development is reduced if continuous pressure is exerted on the wound during healing and for up to 12 months afterwards elastic compression devices must be individually designed....

Hereditary haemorrhagic telangiectasia

Epistaxis requiring surgery in most patients arises from arterial bleeding. However, in the case of hereditary haemorrhagic telangiectasia epistaxis is due to both arterial and capillary bleeding. Results of any form of therapy, including arterial ligation are poor. These patients usually require a combination of arterial ligation (or embolization) together with local control. It is important to cause as little mucosal damage as possible as there is always need for repeated local therapy. A...

Immunodeficiency and cancer

Immunocompromised individuals such as patients after radiotherapy or chemotherapy, transplant patients on immunosuppressive drugs or those with an AIDS are at an increased risk of developing cancer. The risk is particularly for lymphoproliferative and cutaneous malignancies, which Figure 11.15. Histological slide of a patient with cancer of the breast. Note the infiltration of lymphocytes both into the connective tissue surrounding the cancer as well as directly into the cancer itself. Figure...

Staging of breast cancer

Several staging systems have been developed for use in patients with breast cancer. However, the TNM system is the one which is most frequently used and is given in Table 17.6. Table 17.6. Staging of breast cancer. TX Primary tumour cannot be assessed TIS Carcinoma in situ, Paget's disease T1 Tumour < 2 cm in greatest dimension T1b > 0.5cm but < 1.0cm in greatest dimension T1c > 1 cm but 2.0 cm in greatest dimension T2 Tumour > 2 cm but < 5 cm in greatest dimension T3 Tumour > 5...

Peptic ulcer

The management of peptic ulcer disease has changed dramatically in the last 20 years as the aetiology of peptic ulceration has become more clearly understood, and more powerful and effective medical treatment has evolved. At the same time there has been a dramatic decrease in both elective and emergency surgery for peptic ulceration. Aetiological factors in peptic ulceration include H. pylori infection, NSAID ingestion, smoking, renal failure, liver disease, and ZollingerEllison (ZE) syndrome....

Chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is the commonest form of chronic otitis media. Clinically it is characterized by otorrhoea and conduction hearing loss of variable severity. Otoscopy reveals a perforated eardrum. The condition is classified into the safe (tubotympanic) and unsafe (atti-coantral) variety depending on the likelihood of coexisting cholesteatoma. The safe variety is CSOM without cholesteatoma. It can be further classified into active or inactive depending on whether there is...

Insulinoma

Insulin is produced by the p-cells of the islets of Langerhans of the pancreas. These tumours are usually solitary, < 3 cm in diameter, and may be situated in any part of the gland. Over 90 are benign. Multiple insulinomata should alert to the possibility of MEN I. Clinically, patients usually present with psychiatric symptoms with bizarre behaviour, sweating and tremulousness. Whipple's triad is present in most cases symptoms precipitated by fasting significant hypoglycaemia during...

Perforated peptic ulcer

Complications of peptic ulcer disease are now much less common than 20 years ago due to improved medical management (see Peptic Ulcer, below), but perforations still imply a mortality of approximately 10 (higher in older patients). The well-recognised risk factors for developing a perforation are long-term non-steroidal anti-inflammatory drug (NSAID) use, and Helicobacter pylori infection. The usual presentation is a sudden onset of severe epigastric pain, followed quickly by signs of...

Complications of diverticular disease

Diverticulitis has been likened to appendicitis, with a diver-ticulum becoming obstructed by inspissated stool in its neck. The inflammatory process varies in severity from inflammation alone to pericolic abscess to free perforation of the colon with faecal peritonitis. Most patients present with symptoms of pain and signs of tenderness or a mass accompanied by varying degrees of systemic inflammatory response. CT scanning is regarded as the diagnostic modality of choice. Endoscopy is generally...

Sinusitis

Sinusitis is a better defined clinical condition. The pathogenesis of sinusitis is better understood nowadays after the importance of mucous transportation is realized. Sinusitis is usually unilaterally its symptoms are better appreciated in four levels 1. Primary (Level 1) symptoms of sinusitis are unusual as the sinuses have no specific function. However if the involved sinus becomes totally blocked, local pain and tenderness may occur as tension develops within the sinus. 2. Secondary (Level...

Genetic testing

As a result of the identification of a number of mutated genes in hereditary non-polyposis colon cancer - MSH2, MSH1, PMS1 and PMS2, and in breast and ovarian cancer - BRCA1 and 2, the genetic testing of individuals for common cancers has become a reality. As over 20 of all cases of breast cancer have a family history (usually only a mother or aunt with the disease), breast cancer has become the spearhead for genetic testing. In the study of a family with a suspected inherited genetic disorder,...

Plantar fasciitis

This is an uncommon cause of hindfoot pain. It emanates from the plantar aspect of the heel where the plantar muscles and fascia arise from the os calcis. It presents as a sharp stabbing pain, particularly on weight bearing and can cause considerable discomfort. Clinically, there is an area of localized tenderness on the plantar aspect of the heel. Radio -graphically, there may be a plantar calcaneal spur, however this may be a coincidental finding. Underlying treatment usually involves...

Abdominal aortic aneurysms

90 of aortic aneurysms affect the infra-renal abdominal aorta, 8 the thoracic aorta and 2 both (thoraco-abdominal). If the aneurysm is operated on before rupture, the mortality should be 5 or less. Following rupture, it is thought that well over 50 of patients die, frequently undiagnosed, before arrival in hospital and the mortality of those receiving an operation approaches 50 . Ultrasound screening studies have shown an incidence of 5 in males aged 65-74, four times > that in females. A...

Gallstones

Gallstones are common, and are estimated to be present in 20-30 of people in developed countries. Only 20-30 of these people will develop problems related to their stones, and it is important to try and differentiate between symptomatic and asymptomatic stones. Gallstones contain cholesterol, bile pigments, or a mixture of these compounds, and it is clear that their aetiology is multi-factoral. Obesity, ileal resection, and haemolytic anaemia have all been linked to gallstone formation, the...

Cushings diseaseCushings syndrome

Cushing's disease is the excess production of glucocorticoids secondary to over-stimulation of the adrenal cortex by a pituitary tumour producing excess ACTH. Cushing's syndrome is the excess presence of glucocorticoids secondary to an autonomous glucocorticoid adenoma, adrenal carcinoma, ectopic ACTH production or the administration of large doses of steroids as medical therapy. Clinically the patient presents with truncal obesity, moon face, hypertension, diabetes, abdominal striae, acne and...

Colorectal Cancer Background and aetiology

Each year colorectal cancer affects 32 000 people in the UK and is responsible for around 22 000 deaths. In males it is second only to lung cancer and in females it falls third behind lung and breast cancer. In the developed world, life-time risk of colorectal cancer is around 1 25 and this is increased by genetic predisposition and certain conditions such as chronic colitis. Colorectal cancer is mainly a disease of the elderly with a marked rise in incidence after age 70 years, however, 10 of...

Lung cancer

Cancer of the lung is the leading cause of cancer-related death in males and the incidence is rising in females. Regrettably it is closely related to tobacco smoking and control in the future depends largely on government measures to reduce tobacco consumption. From a practical point of view, lung cancers are categorized as small or non-small cell cancers. Table 18.2. World Health Organization histologic classification of lung cancer. Dysplasia carcinoma in situ Squamous cell carcinoma Small...

Laryngeal and hypopharyngeal cancer

Hypopharyngeal Cancer

Over 90 of these malignancies are squamous cell carcinoma. The remaining malignancies arise from minor salivary gland or from supporting tissue such as fibrosarcoma, chondrosarcoma and rhabdomyosarcoma. Early stage squamous cell carcinoma of the larynx is usually treated by external radiation. Early or intermediate stage supraglottic laryngeal carcinoma can be treated by conservation surgery (supraglottic subtotal laryngectomy) and localized glottic carcinoma can be treated by hemilaryngectomy....

Acute otitis media

Acute otitis media most commonly occurs in young paedi-atric patients less than 6-7-year old. It typically occurs, following an upper respiratory tract infection (URTI), as ascending infection through the Eustachian tube. The natural course of acute otitis media is best described in four stages hyperaemic, inflammatory, suppurative and resolution phases. In the hyperaemic phase, the patient has otalgia without hearing loss and otoscopy reveals a hyperaemic eardrum. The inflammatory phase that...

Erectile dysfunction

Failure of normal erections occurs with advancing age and it is estimated that around 20 of men between 50 and 70 years of age have moderate or severe ED. The cause of this impotence may be psychogenic, but organic causes (such as diabetes, smoking and peripheral vascular disease) are more likely with increasing age. The mainstays of treatment are the phosphodiesterase type 5 (PDE 5) inhibitors, such as sildenafil, vardenafil and tadalafil. These drugs inhibit breakdown of cyclic guanosine...

Setting up mechanical ventilation

In setting up mechanical ventilation, a mode of ventilation should be chosen. Mode selection depends on the amount of support that a patient requires, pulmonary mechanics, patient sedation co-operation, and underlying pathology. Ventilator settings are determined with optimization of oxygenation and ventilation in mind. Once a patient is intubated, initially a high FiO2 is administered. An ABG is done after 20 min to determine the adequacy of oxygenation. Subsequently, FiO2 should be reduced to...

Umbilical Hernia In Adults

Umbilical hernias in adults can be a cause of considerable morbidity and if complications supervene they can lead to death. Umbilical hernias are much less frequent in the adult population than inguinal hernias and account for 0.03 of the hernia operations performed in the UK. Of the patients with umbilical hernias, 90 are women, invariably women who are overweight and multiparous. Umbilical hernias have a high risk of incarceration. When these hernias incarcerate and strangulate, they...

Other groin swellings

Other structures in the groin each contribute to the harvest of swellings, pains and discomforts patients complain of. These include 1. Vascular disease (a) Arterial - aneurysms of the iliac and femoral vessels these may be complicated by distal embolization or vascular insufficiency which will make the diagnosis easy. Femoral aneurysm as a complication of cardiac catheterization or transluminal angioplasty is a recent arrival in the diagnostic arena. (b) Venous - a saphenovarix could be...

Fibre

The term fibre covers a large variety of non-starch polysaccharides with different physical properties. Suggestions of an inverse relationship between the intake of dietary fibre and colon cancer risk in Africa were based on possible dilution and faster transit of dietary carcinogens through the colon. Fat-derived bile acids reaching the gut through the enterohepatic circulation were also diluted and less likely to contact colonic epithelium. Subsequent studies have failed to confirm the...

Osteoporosis

The World Health Organization (WHO) has established criteria for making the diagnosis of osteoporosis, as well as determining levels which predict higher chances of fractures. These criteria are based on comparing bone mineral density (BMD) in a particular patient with those of a 25-year-old female. BMD values which fall well below the average for the 25-year-old female (stated statistically as 2.5 standard deviations below the average) are diagnosed as 'osteo-porotic'. If a patient has a BMD...

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia is the commonest form of virilisation and is due to a genetic enzyme defect which results in deficient secretion of cortisol. This results in reduced negative feedback to the pituitary resulting in a very high ACTH. This produces adrenal hyperplasia and excess androgen production, especially androsterone which is converted to testosterone peripherally. Androsterone is a 17-ketosteroid and testosterone is not. Therefore, virilisation with an elevated urinary...

Axillary lymph nodes

Treatment of the axillary lymph nodes The lymphatic drainage of the breast has already been described in some detail (see previous section). It is essential to have an accurate histological assessment of the lymph nodes in the axilla because this will provide prognostic information about the disease (and determine the need for adjuvant therapies) and is also required to achieve adequate 'regional' control of disease. Clinical assessment of the axillary node status is most unreliable, in some...

Necrotizing otitis externa

Necrotizing otitis externa is also known as 'malignant otitis externa'. It is not that the condition may become malignant, but because of the occasional fatal outcome. This typically occurs in elderly patient who is diabetic or is immunocom-promised for other reasons. There is usually a long history of ear discharge and otalgia is frequently present and pronounced. The causative organism is Pseudomonas pyocyanea. The clinical features of 'necrotizing otitis externa' are often misleading and...

Info

Definitive investigation is trans-abdominal ultrasound scanning. This will confirm obstruction of the biliary system, provide good views of the pancreas in 75 of cases and identify pancreatic masses, and may demonstrate metastatic disease in the liver if present. If a diagnosis of pancreatic cancer is suspected then a CT scan is the next step, and is part of the staging process. Modern CT scanning provides excellent cross-sectional imaging of the pancreas, and should be performed before any...

Primary hyperaldosteronism Conns syndrome

Hyperaldosteronism may be either primary or secondary. Primary disease Conn's syndrome is due to excess production of aldosterone, most commonly due to an adrenal adenoma. This results in excess sodium and water retention with loss of potassium and hydrogen ions. Patients therefore become hypertensive with hypokalaemic alkalosis. In this situation, the juxtaglomerular apparatus is not stimulated and renin levels are therefore low. Secondary disease is due to impaired renal perfusion most...

External anatomy the surface markings

Prominent Umbilicus

The abdominal wall, bounded by the lower margin of the thorax above, and by the pubes, the iliac crests and the inguinal ligaments below, is easily recognized in the upright man. Vertically down the centre of the abdomen the depression of Figure 14.4. Topographical anatomy of the abdomen shows the distinctly different male and female characteristics. Figure 14.4. Topographical anatomy of the abdomen shows the distinctly different male and female characteristics. the linea alba is obvious and is...

Nipple discharge

Nipple discharge is relatively common in the female population and is the third commonest cause of referral to a specialist breast clinic. However, it has been estimated that less than 10 of cancers are associated with breast discharge. Nipple discharge can be categorised into several types clear or watery, milky, serous, multicoloured or blood stained. In addition, the discharge may come from a single or from multiple ducts. The most common causes of the different types of nipple discharge are...

Nipple retraction inversion

The terms nipple retraction and inversion have come to be used interchangeably. However, nipple inversion is most often used when the whole of the nipple is permanently pulled inwards, whilst nipple retraction is used to describe variable degrees usually intermittent of the nipple being pulled inwards. Congenital nipple inversion of variable degree occurs in up to one-fifth of all women. This is usually of no clinical significance unless it interferes with breast feeding. The woman may present...

Complications after splenectomy and asplenism

Bleeding may occur from the splenic bed, pedicle or short gastric vessels. Especially important where splenectomy was performed for thrombocytopaenia. Left lower lobe atelectasis is common after splenectomy. Active physiotherapy may prevent this complication. The tail of the pancreas is in close relation to the hilum of the spleen and may be injured during the surgical procedure. This may lead to a pancreatic leak and collection. Postsplenectomy fever can occur in the absence of any source of...

Cancer of the GOJ

Cancer of the oesophagus and stomach is becoming more common at the GOJ, and this form of the disease presents its own particular problems. One issue is whether to treat such cancers as gastric or oesophageal, with important implications for chemotherapy and surgical approach. A classification is in use to help clarify the current situation Type I - cancer centered 1-5 cm above the GOJ. Type II - cancer centered at the GOJ from 1 cm above to 2 cm below . Type III - cancer centered 2-5 cm below...

DNA viruses

A number of groups, the hepadana viruses hepatitis B , papilloma viruses HPV and herpes viruses EBV are associated with hepatocellular carcinoma, uterine cervical cancer, Burkitt's lymphoma and nasopharyngeal carcinoma, respectively. Liver cancer, the eighth commonest cancer worldwide, is particularly prevalent in sub-Saharan Africa, China, Japan and East Asia. Cholangiocarcinoma, although commonest in Asia where it is associated with parasitic infections ,...

Granulation tissue

Vascular cells grow out from the torn and sealed capillaries to form loops which are at first solid and then become patent, extending, with associated fibroblasts into the damaged area. They are attracted into the fibrin fibronectin gel by chemoattraction. When seen from above in a raw area, the apices of the vascular loops appear granular, like minute cobblestones, which explains the name given to the tissue formed, that is, granulation tissue. This tissue fills in the defect as phagocytes...