Patterns of occlusive disease

In the male general population aged 40-49 years the prevalence of intermittent claudication is approximately 0.5-1 . By 60-69 years this rises approximately four-fold. The prevalence in women is roughly half that in men. Typically the pain is described as 'cramp like' and felt after walking for a certain distance commencing more rapidly when walking rapidly or uphill. The pain is most often felt in the calf but may develop in the foot, thigh or buttock. It is usually relieved by resting for 2-3...

Prolapse

Rectal prolapse is a distressing condition for the patient. Approximately 50-75 of rectal prolapse patients suffer from associated anal incontinence, and the prolapse itself is socially embarrassing. Although the majority of patients are elderly women, prolapse can occur at all ages and is not infrequent in infants under the age of 2 years. Prolapse in infancy is usually precipitated by acute diarrhoeal illness or severe coughing however, the association of rectal prolapse in infancy and cystic...

Anaesthetic Emergencies

A rapid sequence induction is indicated when the stomach is not empty and therefore there is a high risk of vomiting or regurgitating on induction. This occurs in three groups of conditions. Firstly in emergency anaesthesia, when the condition precipitating the emergency is likely to also affect the emptying of the stomach this also includes emergency as well as elective Caesarean sections. Secondly in primary gastrointestinal pathology necessitating surgery this includes all forms of...

CNS infections

The CNS is particularly sensitive to infection and the infective agents can be bacterial, viral and fungal or agents such as prions (small-chain deoxyribose nucleic acid (DNA) fragments) which are the suspected causative agents in Creutzfeldt-Jakob disease. Bacteria and fungi cause meningitis or brain abscess, viruses lead to encephalitis and prions to spongiform encephalopathies. An acute infection of the subarachnoid space which invokes an inflammatory reaction from the meninges. Bacteria...

Renal replacement therapy

When the kidneys ultimately fail, RRT is needed. There are generally two forms of RRT utilized in the intensive care setting hemodialysis and hemofiltration. In hemodialysis, blood is pumped through a semi-permeable filter which is bathed in a dialysate fluid. Electrolytes and fluid move down a concentration gradient into the dialysate fluid and it is removed, carrying off potassium, phosphate, urea, water, etc. Hemodialysis utilizes rapid blood flow rates over a 2-4 h duration and is performed...

Molecular Genetics Of Cancer

The transformation of a normal to a malignant cell is a multistage process during which the orderly processes of proliferation and differentiation become uncoupled and the balance between proliferation and cell death is disturbed. Cancer cells proliferate unceasingly and do not proceed along normal maturation pathways. Cells cultured in the laboratory undergo two changes in phenotype (physical characteristics) during the route to malignancy Immortalization when the cells continue to proliferate...

Immunotherapy of cancer

Numerous attempts have been made to employ immuno-logical methods to treat cancer, but none have been very successful. The different techniques can be grouped together as active, passive and adoptive immunotherapy. Active immunotherapy refers to those techniques designed to enhance components of the immune system most likely responsible for antitumour activity. Bacillus Calmette-Guerin (BCG) has been used to enhance cellular immunity, particularly macrophage function, and various cytokines such...

Magnetic resonance scan

By employing a strong electromagnetic field, small magnetic changes can be stimulated in body tissues and the signal generated when the dipole is lost can be detected and measured. This non-invasive method of imaging is excellent at staging certain urological tumours, including prostate cancer. Lymph nodes can also be well demonstrated. Using catheters Micturating cystoureterogram A catheter is passed into the bladder and the urine drained out. Contrast is used to fill the bladder. The catheter...

Immunodiagnosis of cancer

If tumour cells express surface membrane, cytoplasmic or secreted products of specific antigenicity and in sufficient quantities, it should be possible to detect these by developing monoclonal antibodies against them. Unfortunately these techniques have not yet reached widespread application in either screening for early cancer or follow-up of cancer. The three most commonly used antigens used for these purposes are prostatic-specific antigen (PSA), used for screening and follow-up of prostate...

Gastric carcinoma

Gastric carcinoma has an incidence of 10-20 cases per 100 000 people in the UK and USA, a rate that has fallen from 35 per 100 000 in the 1920s. As with oesophageal cancer, the site of cancers is changing, with a decrease in the number of distal tumours, and an increase in the number of proximal tumours. Men are 2.5 times more likely to develop gastric cancer than women, and over three-quarters of patients are 65 years or older. Chronic gastritis, leading to metaplasia, has been implicated in...

The management of advanced cancer

The majority of bowel cancers are managed by surgical resection. The principle of surgery is to remove the primary tumour with draining lymph nodes while preserving anatomical planes around the mesentery. This is best demonstrated in the rectum where the application of this principle, termed 'total mesorectal excision' has resulted in a reduction in local recurrence of cancer. The main arterial supply and venous drainage are identified and divided. The bowel ends are then divided at appropriate...

Oesophageal Diseases

Investigation of oesophageal disease is primarily by oesophagoscopy, which can be rigid or flexible. The rigid oesophagoscope is particularly useful for examination of the cervical oesophagus and when removing difficult foreign bodies such as bones, whereas the flexible oesophagoscope (generally a gastroscope is used) allows full examination of the oesophagus, even in patients with other problems such as kyphoscoliosis, and also examination of the stomach and duodenum for associated disease. A...

Immediate complications

Associated vascular injuries resulting in ischaemia to parts distal to the fracture must be treated as an emergency or necrosis of tissues distal to the fracture site can result with the possibility of developing gangrene, necessitating amputation. Other local complications include neural injury from laceration of a nerve or secondary to external compression, for example neurovascular complications in supracondylar fractures of the humerus in children. It is also important to recognize the...

Structure and function

The brain is composed of neurons, neuroglia, and blood vessels. Each neuron is composed of a cell body, dendrites, which are short non-myelinated processes, and one or more axons whose length varies from a few millimetres to over 1 m. Neurons may be unipolar, bipolar or multipolar the first two are primarily afferent and convey sensory information from receptor endings to the central nervous system (CNS). The majority of neurons in the CNS are of the multipolar type. In the peripheral nervous...

Scars And Contracture Scars

Scarring is a normal part of tissue repair except during fetal and early neonatal life. Whenever there is damage, fibro-blasts are attracted and they multiply and align themselves before extruding collagen fibrils which mature and undergo shortening. As a result of this, a longitudinal incision often shortens over a period of months unless it is subjected to excessive strain, when it stretches. The collagen is remodelled in order to adjust the alignment of the fibrils to strains exerted on...

Immune response to a cancer

There is some evidence that cancer cells have surface membrane antigens called tumour-specific antigens (TSA) or tumour-associated antigens (TAA) that are recognized by the immune system as non-self, and can elicit an immune response. Antibodies secreted by B-lymphocytes will coat tumour cells and with the help of complement and phagocytic cells can cause tumour cell destruction. CD8+ T-lymphocytes and NK cells can cause direct tumour cell killing, whereas CD4+ T-cells release cytokines to...

Hormonal factors

Data has accumulated from different epidemiological studies that a prolonged exposure to oestrogens may increase the risk of subsequently developing breast cancer. Therefore, the following have been shown to increase the relative risks of developing breast cancer early menarche, delayed menopause, late age of birth of first child and nulliparity. The possible relationship of the oral contraceptive pill to breast cancer has also been considered and discussed in detail. A recent large study...

Ventilation

Intermittent positive pressure ventilation This is almost universally the only technique used when applying controlled ventilation under anaesthesia. It consists of positive pressure applied to the airway during inspiration and passive exhalation of gas due to elastic recoil of the lungs. Two types of ventilators are commonly used 1. Pressure generators These ventilators operate at relatively low pressures and changes in compliance or resistance may affect the tidal volume delivered. 2. Flow...

Otitis media with effusion

Otitis media with effusion (OME) is a condition with complex etiologies including anatomical variations, allergy, infections and inflammation. The interplay of these factors lead finally to structural and or functional abnormality of the Eustachian tube resulting in OME. The more horizontal lie of the Eustachian tube and frequent attacks of URTI contribute to the high prevalence of OME in infants and young children of any race. The reported cumulative incidence of first episode of OME reaches...

Functional Anorectal Disorders Constipation

There is a large variation in stool frequency between individuals and infrequent bowel actions in the absence of symptoms can be regarded as part of the normal spectrum of bowel function. However, constipation is a symptom that may affect a quarter of the population at some time and patients with decreased bowel frequency or impaired rectal evacuation have impaired quality of life and consume a large amount of healthcare resources. Many different processes can result in the final common...

Salivary gland tumours

Implantation Dermoid Ultrasound

Benign and malignant salivary gland tumours can arise from the parotid gland, submandibular gland and rarely the sublingual gland. They typically present as a parotid or sub-mandibular mass. Approximately 10 of parotid and 50 of submandibular gland tumours are malignant. Both ultrasound and FNA are useful in delineating the nature of the salivary gland lesions. A CT scan may be required to evaluate a complex mass such as deep lobe tumours and invasive tumours. Common benign tumours are...

Laryngeal papilloma

The juvenile form is believed to be acquired during birth from maternal vaginal warts. The condition does not manifest, however, until months or years later when significant papillomata develop. In general, those who present early usually present with airway obstruction, while older children usually present with progressive hoarseness. Treatment is extremely difficult and frequent recurrence is a rule rather than exception. At laryngoscopy, there is usually extensive involvement of the whole...

Chemotherapy

Chemotherapy is associated with side effects which can impair the patients' quality of life and a considered decision must be made as to which patients are most likely to gain benefit (and what these benefits are) from chemotherapy. Patients who are most likely to benefit are those with a good performance status, metastatic disease in one or only a few sites and previous beneficial response to hormonal therapy. Combination chemotherapeutic regimens are used, most often containing one of the...

Screening for breast cancer

Clinical studies have demonstrated that mammographic screening of women can reduce the number of deaths from breast cancer. In particular, studies (USA, Europe) have demonstrated that if women aged 40-74 years of age underwent regular screening there was a decrease in mortality from breast cancer of approximately 25 over 15 years, with the most benefit being found in those women over 50 years of age. In 1988 a UK National Health Service Breast Screening Programme was introduced. The aim of this...

Microarchitectural changes

Adenosis is associated with an increase in acini and glandular tissue. There may be an increase in the myoepithelial component and in the connective tissue of the lobule. Figure 17.18. Histological appearances of fibrocystic disease - cyst formation, fibrosis and sclerosing adenosis (x150). Figure 17.18. Histological appearances of fibrocystic disease - cyst formation, fibrosis and sclerosing adenosis (x150). This is characterised by prominent intralobular fibrosis and proliferation of small...

Principles Of Cancer Treatment Curability

The logical objective of the treatment of cancer is destruction of all cancer cells. The disease is then eradicated and the patient 'clinically cured'. This definition of clinical cure is impractical as it can only be proven by a complete search for asymptomatic deposits of tumour on death. However, clinical cure should follow the complete removal of all non-invasive cancers, and also a number of small invasive cancers, particularly in superficial sites, which have not metastasized. Life is...

Urinary tract infections

Colonization of the urinary tract occurs quite commonly in the ICU. Almost all patients in the ICU have a urinary catheter and the risk of colonization increases with the duration of catheterization (estimated incidence is 5 per day). About 20-30 of patients go on to have a urinary tract infection. Differentiating colonization from infection in a critically ill patient is not easy. The presence of pus cells is important, but their absence does not exclude infection. With regard to bacterial...

Cohort study

The most informative of the observational studies is the cohort study in which a group of subjects is identified and then followed up long term. Theoretically, a cohort study can be based on retrospective data (the historical cohort study), but it is rare for adequate data to be available for such a study to be mounted and the majority of cohort studies are prospective. As the data are collected prospectively they can be tightly controlled but only those data identified at the start of the...

Primary breast tumour

Treatment of the primary breast tumour The treatments initially advocated for breast cancer were based on the belief that cancer cells spread in a centrifugal pattern - from the tumour to the regional-draining lymph nodes and then sequentially to the vascular system and distant metastatic sites. Thus, it was recommended that a radical mastectomy (which includes removing the pectoralis major muscle) should be undertaken. However, in the 1920s and 1930s this approach was challenged and surgeons...

Upper Gi Emergencies Acute cholecystitis

For more details see also the section Gallstones. Acute cholecystitis is an inflammatory condition of the gallbladder, often, but not always, associated with the presence of gallstones. It is a common surgical cause of emergency admission to hospital, and is more common in women than men in keeping with the distribution of stone disease. The symptoms will initially resemble biliary colic, with right upper quadrant pain, and nausea, but symptoms persist and patients become systemically unwell....

Clinical features

The majority of women present with a breast lump, which is confirmed on examination. In two-thirds of patients it is in the upper outer quadrant of the breast and characteristically is well defined, hard and with an irregular surface. The lump may be fixed to the skin or to the underlying chest wall and retraction or dimpling of the skin may be seen. The skin of the breast must be carefully examined for the presence of erythema which may indicate an inflammatory cancer (see Table 17.7. Staging...

Glucocorticoids

Approximately 15-20 mg of cortisol is secreted daily. Corticotropin releasing hormone (CRF) from the hypothalamus is carried to the anterior pituitary gland in a portal venous system and stimulates release of ACTH. The ACTH circulates to the adrenal cortex where it stimulates synthesis and release of cortisol (very little cortisol is actually stored in the adrenal gland). Approximately 95 of glucocorticoid circulates bound to an a-globulin and the remainder is free steroid. A negative feedback...

Acute pancreatitis

Acute pancreatitis is an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. It includes a spectrum of disease from a mild, self-limiting event, through to a severe, potentially fatal condition with associated multi-organ failure. There are 20-40 cases per 100 000 population per year in the UK, and the mortality rate remains unchanged at 10 . The majority of cases (80-90 ) are caused by gallstones or alcohol ingestion other...

Breast cancer in the elderly

The incidence of breast cancer continues to rise through life with 40 of all cases occurring in patients older than 70 years. A small number of these patients, because of concurrent disease, will be unfit for any form of loco-regional therapy other than tamoxifen (20-40 mg day). With tamoxifen as the sole therapy it has been shown that approximately one-half of the tumours will show a reduction in size and of these, up to 50 will be complete responses (6-12 months of treatment may be required)....

Fat protein and calories

Evidence for a positive interaction between dietary fat and cancer (particularly of the colon and breast) is supported by experimental studies and geographical correlations between fat intake and incidence, but large cohort studies of detailed dietary habits provide little support. Individual fatty acids may be more relevant than total fat intake. A high intake of monounsaturated fatty acids is associated with a reduced risk of breast cancer, which possibly explains the low incidence of breast...

The cancer family

Initial recognition that an inherited trait is associated with a cancer usually comes from knowledge of 'cancer families' in which the incidence exceeds that of the normal population. Historical examples are Napoleon's family, in which Napoleon, his father and sister all died from cancer of the stomach (and which was suspected also in two more sisters, his brother and a grandfather) and the family of the French surgeon Paul Broca in which 10 of 24 female members spanning three generations died...

Healthy lifestyle

Obesity is associated with an increased risk of breast cancer in post-menopausal women, the mechanisms of which may be hormonal. It has been demonstrated that obese women metabolise androstenedione (from the adrenal gland) into oestrogen in the adipocytes. The circulating levels of oestrone are higher in obese post-menopausal women than non-obese individuals. In pre-menopausal women obesity may be associated with a reduced risk of breast cancer, although the reasons for this difference are...

A new paradigm and novel therapies

The current model for treating cancer is based on the belief that cure can be achieved only by the eradication of each and every cancer cell. This model, which is derived from the need to destroy invading microorganisms, may not necessarily apply to cancer cells which are derived from their host. It has been suggested that the malignant cell should be regarded as part of a biological communications network where processes of cell growth, division and migration take place in an environment of...

Metastatic breast cancer

Patients with metastatic disease may present because of symptoms caused by the metastatic deposits. However, up to one-half of patients who present with a loco-regional recurrence of disease either have demonstrable metastatic disease at the time of presentation or shortly thereafter. Once metastatic breast cancer has been diagnosed the mean survival of these patients is approximately 18-24 months. Thus, the primary aim of any treatment is to palliate and improve the quality of life. Treatment...

Upper Gi Malignancy Oesophageal carcinoma

Cancer of the oesophagus has an incidence of 5-10 cases per 100 000 people in Western countries, but this varies widely throughout the rest of the world, and may get as high as 150-200 per 100 000 in parts of China and Iran. Worryingly, the incidence is increasing sharply, especially for tumours of the distal third of the oesophagus, and at the GOJ. Men are twice as likely to be affected than women, and people in their 60s and 70s are at highest risk. Aetiological factors are multiple, but...

Jaundice

Jaundice is the yellow appearance of sclera, skin, and other tissues, seen as the clinical manifestation of hyperbilirubi-naemia. The upper limit of normal for serum bilirubin is 17 mol l, and concentrations above this represent biochemical jaundice. Levels over 40-50 mol l present as clinical jaundice when the yellow discolouration appears obvious, initially seen at the sclera. Jaundice is classified into pre-hepatic, hepatic, and post-hepatic causes (see Table 12.11), and the latter (also...

Breast cancer during pregnancy and lactation

Breast cancer presenting during pregnancy or lactation occurs in up to 3 in 10 000 pregnancies, and comprises less than 2 of all breast cancer cases. The median age of these patients is 34 years or less, depending on the series. Earlier studies had suggested that the prognosis was worse in pregnant women with breast cancer, when compared with those who were not pregnant. This is partly due to the fact that presentation tends to be delayed and up to 70 of pregnant women with operable breast...

Marrow transplantation

The potentially lethal problems associated with intensive chemotherapy are infection and haemorrhage due to destruction of marrow cells. Initially these were countered by intensive antibiotic treatment, laminar-flow isolation and granulocyte and platelet transfusions, but with the development of marrow transplantation a more lasting solution evolved. Supralethal cytoreductive therapy followed by salvage allogeneic marrow transplantation, when practised during the initial remission of acute...

Other measures

The success of treatment is often monitored by survival rates over periods of 5 years, but as these are biased by the time at which the diagnosis was made (lead-time bias) and by the form of treatment given, better estimates of outcome are mortality rates based on the population at risk. The 'gap' between age-specific incidence and mortality may be taken to provide a rough guide to the success of treatment, but this may be biased by overdiagnosis of a cancer for example through the institution...

Acquired anorectal disorders

Anal fissure is the most common cause of minor rectal bleeding in infants and toddlers, and is associated with constipation and painful defaecation. The tear in the anal mucosa is typically located in the posterior midline. Chronic fissure is sometimes associated with a sentinel skin tag at 12 o'clock position. Treatment consists of stool softener, sitz bath and local anaesthetic gel application. Occasionally a chronic fissure requires topical nitroglycerin therapy or lateral sphincterotomy....

Adrenal Glands Anatomy

There are two adrenal glands, one situated above each kidney. Both glands have a rich arterial blood supply, mainly from the suprarenal arteries from the aorta, branches from the renal arteries, and branches from the phrenic vessels. The venous drainage is normally by a single vein, on the right side draining directly into the inferior vena cava, and on the left side into the left renal vein. Each gland consists of two parts, an inner medulla which secretes catecholamines, mainly epinephrine...

Indications For Nutritional Support

All patients admitted to hospital, even for elective surgical procedures, should have a nutritional screening, the results of which should be recorded clearly in the notes, with a comment about whether nutritional support is required. The routine history and clinical examination of a patient should enable patients to be placed in one of four groups 1. Obvious severe malnutrition (recent or long term) (> 10 recent weight loss serum albumin < 30 g l gross muscle wasting and peripheral...

Reproductive factors

Sexual behaviour affects cancer risk through the acquisition of sexually transmitted infections. Transmission of HPV and the HIV predispose to cancer of the uterine cervix, Kaposi's sarcoma and some other tumours. Cancer of the uterus is commoner in women cohabiting with men who have multiple sexual partners. Cancer of the penis is not associated with sexual activity but is commoner in the uncircumcized and those with poor hygiene. It is now 100 years since George Beatson, a Glasgow surgeon,...

Breast cancer in the male

Cancer of the male breast accounts for 0.5-1 of all breast cancers and less than 1 of all male malignancies. Only 5 of male breast cancers occur before the age of 40 years and the median age of presentation is 68 years (older than that of the female population who develop breast cancer). The aetiology of male breast cancer has not been elucidated but there are risk factors which may predispose to the development of breast cancer. These include increased levels of oestrogens either in the...

Bilateral breast cancers

A second primary cancer in the opposite breast may be found either at the time of the initial presentation (synchronous tumour, 0.5-2 ) or more commonly at a subsequent date (metachronous cancer, 3-9 ). A woman who has a primary breast cancer has a four- to sixfold risk of developing a cancer in the opposite breast. Other risk factors for the development of a cancer in the opposite breast include LCIS and multifocal disease. The prognosis for patients with bilateral breast cancers depends on...

Noninvasive breast cancer

There are two main types of non-invasive breast carcinoma ductal carcinoma in situ (DCIS) and LCIS. Of these, DCIS is the more common histological type. DCIS is characterised by an abnormal proliferation of breast epithelial cells lying within the duct but not penetrating the basement membrane (Fig. 17.20). Different types of DCIS can be recognised histologically (i) comedo (characteristic central necrosis) (ii) cribriform (sieve-like appearance) (iii) papillary or micropapillary (the...

Human Immunodeficiency Virus And Viral Hepatitis Infection

The viral infections which are of interest to clinicians, and especially surgeons, are human immunodeficiency virus (HIV) and hepatitis B and C viruses (HBV and HCV). This stems from their transmission risk from patient to healthcare worker or vice versa. Guidelines for reducing the risk of transmission of HIV, HBV and HCV are available for healthcare workers. Their main objective is to minimize exposure of any individual to blood and body secretions regardless of infective status of the second...

Routes of administration

The majority of patients need nutritional support for less than a month. For these patients the best method of enteral delivery is via a fine-bore nasogastric feeding tube. The most frequent complication (in < 5 of patients) of these tubes is malposition when inserted, often into the trachea and bronchi. If this is not recognized, accidental intrapulmonary aspiration of feed may occur. This complication occurs most commonly in susceptible patients with altered swallowing, diminished gag...

Cancer

There is a wide range of incidence of adenocarcinoma of the prostate worldwide, but in the West it is the commonest cancer diagnosed in men over 65 years. Symptoms from the primary tumour may be indistinguishable from BPE, hence the importance of palpating the prostate and measuring the PSA in men with LUTS. When the diagnosis is in doubt, a biopsy (ideally guided by a transrectal ultrasound scanner) is required. The PSA level may be normal in localized prostate cancer, but its level is...

Spinal cord compression

The spinal cord lies within the vertebral canal from the foramen magnum to approximately the first lumbar vertebra, and thereafter continues as the nerve roots of the cauda equina. It is surrounded by the three meningeal layers of dura, arachnoid and pia. There is very little spare room within the vertebral canal and space-occupying pathological processes soon lead to spinal cord compression. To some extent the symptomatology depends on the vertebral level, the layer of meninges containing the...

Acute liver failure

Acute liver failure is the sudden development of liver parenchymal injury resulting in coagulopathy (INR > 1.5) in a patient who lacks underlying chronic liver disease. Progression to encephalopathy in such a patient is known as fulminant hepatic failure (FHF). The etiologies of acute liver failure include Viruses Hepatitis viruses A, B, C, D and E, rarely herpes simplex, varicella-zoster, and CMV. Drugs toxins Paracetamol, isoniazid, phenytoin, halothane, carbon tetrachloride, mushrooms...

Portal hypertension

If the pressure in the portal venous system is greater than 12 mmHg then portal hypertension exists. The commonest cause of this in Western countries is alcoholic cirrhosis causing obstruction to portal venous flow, but numerous other causes are recognised and are classified (as for jaundice) into pre-hepatic, hepatic, and post-hepatic (Table 12.12). The portal venous system has been described (see Anatomy), and in portal hypertension the sites of portal-systemic communication open up, commonly...

Surgical Anatomy

Accurate understanding of the pelvic anatomy is critical to achieving good oncological and functional outcomes after rectal excision. Heald et al. (1998) in Basingstoke introduced the concept of total mesorectal excision during the 1980s. Total Mesorectal Excision (TME) consists of separate high ligation of the inferior mesenteric vessels to define the proximal limits of the lymphatic clearance, followed by rectal mobilisation with sharp dissection under direct vision in the avascular plane...

Congenital dislocation and developmental dysplasia of hip

Previously this condition was known as congenital dislocation of the hip (CDH). However the correct term is developmental dysplasia of hip (DDH) because in many cases the condition is not present at birth but rather develops after birth. Secondly in a majority of cases there is no frank dislocation but a dysplasia (poorly developed acetabulum) leading to instability of the hip joint. This process covers a spectrum of conditions from acetab-ular dysplasia through to complete dislocation of the...

Back pain

Due to almost epidemic proportions of patients presenting to general practitioners, general orthopaedic clinics, and accident and emergency departments, a working knowledge of the assessment of the patient presenting with back pain, as well as an idea of the possible causes and their treatment is essential. The vast majority of patients presenting with back pain of a musculoskeletal origin will have symptoms secondary to degenerative spinal disease. Other conditions can occur such as trauma,...

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...

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...

Mammary duct ectasia

There has been much debate as to the relationship between periductal mastitis and mammary duct ectasia. Although it has often been held that these are variants of the same pathological process, with the former possibly resulting in the latter, the two conditions are probably different. Periductal mastitis occurs in young pre-menopausal women whilst mammary duct ectasia occurs more commonly in peri- and post-menopausal females. Histological examination shows there is dilatation of ducts filled...

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...

Brief History

An appreciation of the history of hernia surgery may prevent us repeating the mistakes of the past and put in perspective the knowledge that has been accumulated in order to allow development of the successful techniques used today. The high prevalence of hernia, for which the lifetime risk is 27 for men and 3 for women has resulted in this condition inheriting one of the longest traditions of surgical management. The Egyptians 1500 BC , the Phoenicians 900 BC and the Ancient Greeks...

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...