Revision for Finals in Surgery Peripheral Vascular Disease Colorectal Cancer - PowerPoint PPT Presentation

1 / 46
About This Presentation
Title:

Revision for Finals in Surgery Peripheral Vascular Disease Colorectal Cancer

Description:

Jaundice (change in skin/stool/urine colour, itching) History ... Obstruction distal to ampulla of vater. Malrotation - EMERGENCY ... – PowerPoint PPT presentation

Number of Views:416
Avg rating:3.0/5.0
Slides: 47
Provided by: vij9
Category:

less

Transcript and Presenter's Notes

Title: Revision for Finals in Surgery Peripheral Vascular Disease Colorectal Cancer


1
Revision for Finals in SurgeryPeripheral
Vascular DiseaseColorectal Cancer
  • Vijay Joshi
  • 8/4/08

2
GI History
  • GI System Key Questions
  • Dysphagia
  • Dyspepsia
  • Abdo distension / pain
  • Nausea and vomiting
  • Appetite and weight loss
  • Change in bowel habit
  • Bleeding
  • Jaundice (change in skin/stool/urine colour,
    itching)

3
History
  • 65 year old male presenting with PR bleeding,
    change in bowel habit, weight loss (approx 2
    stone over past 3/12), and reduced appetite.
  • Suspect
  • colorectal malignancy
  • diverticular disease
  • colonic polyps.

4
Colorectal Cancer
  • Risk factors to enquire about
  • Low-fibre diet (controversial)
  • Known polyps
  • Inflammatory bowel disease
  • Family history of GI cancer or FAP
  • Other important questions
  • Co-morbidities to surgical intervention
  • Social History

5
Colorectal Cancer
  • Symptoms will depend on the location of the
    tumour
  • Right sided colon
  • Anaemia, weight loss, non-specific malaise
  • Left sided colon and rectum
  • Change in bowel habit, rectal bleeding mixed with
    stools, tenesmus (sensation of incomplete
    emptying)
  • Tumours can also present as an emergency
  • pain and distension caused by large bowel
    obstruction
  • haemorrhage or peritonitis as a result of
    perforation.

6
Discussion
  • What would you like to look for when performing a
    physical examination?
  • Signs of Anaemia
  • Hepatomegaly
  • Abdominal Mass
  • Shifting Dullness of ascites
  • RECTAL EXAM!

7
Discussion
  • What are this patients treatment options?
  • Surgery only curative treatment
  • Radiotherapy
  • given as neoadjuvent therapy to downstage rectal
    tumours prior to resection or as adjuvant therapy
    to prevent local recurrence
  • Chemotherapy
  • used as adjuvant therapy in Dukes C (sometimes
    B) colon cancer.
  • Agents 5-FU (Folinic acid), oxaliplatin
  • Can shrink liver mets to make for easier
    resection

8
Colonic Surgery
9
Rectal Surgery
10
Stomas
  • Where is it?
  • Ileostomy is commonly in RLQ
  • What does it look like?
  • Flush or spout, single or double lumen
  • What is in the stoma bag?
  • Why was it done?
  • Cancer, IBD, polyps, diverticular disease
  • Any complications present?
  • Fluid and electrolyte imbalance, ischaemia,
    obstruction, skin erosion, bowel prolapse,
    parastomal hernia

11
Discussion
  • How is the prognosis of colorectal cancer
    determined?
  • Dukes Staging
  • A Confined to bowel wall (80-90 survival)
  • B Breached serosa (60 survival)
  • C Breached serosa w/ LN (30 survival)
  • D Distant mets (lt 5 survival)
  • 5 year survival

12
Surgical Examination
  • This is a peripheral vascular exam please
    examine this patients legs.
  • Keep the same routine
  • Inspection
  • Palpation
  • Auscultation

13
Peripheral Vascular Disease
  • Inspection
  • Skin changes shiny and hairless, pale
  • Capillary refill time
  • Gangrene
  • Visible scars previous operation
  • Amputated limbs or toes
  • Arterial ulcers
  • Venous insufficiency

14
Peripheral Vascular Disease
  • Palpation (6 Ps)
  • Pain
  • Pallor with or without leg elevation
  • Pulseless
  • Polar
  • Paresthesia
  • Paralysis

15
Peripheral Vascular Disease
  • Auscultation
  • Stethoscope listen for bruits
  • Doppler presence of pulses
  • Check the rest of the body!
  • Radial pulse - AF
  • Eyes signs of hypertension or diabetes
  • Heart Auscultation - Murmurs, artificial valve
  • Abdo AAA

16
Discussion
  • What further tests would you like to perform on
    this patient?
  • Bloods - FBC, UE, Clotting, GS, lipids
  • ABP index - lt0.9 diseased, lt0.6 severe
  • Duplex Ultrasound
  • Information about blood flow velocity (related to
    stenosis)
  • ECG, Echo
  • Angiography
  • provides road map for surgical intervention

17
Discussion
  • What can cause acute limb ischaemia?
  • Emboli from heart, AAA, or blood vessel
  • Thrombosis of existing plaque or graft
  • Dissecting aneurysm
  • Trauma

18
Discussion
  • How is acute limb ischaemia treated?
  • EMERGENCY!
  • Resuscitate with O2 and IV fluids
  • Analgesia
  • Heparinisation
  • Embolectomy or bypass

19
Discussion
  • How is peripheral vascular disease treated?
  • Conservative lifestyle (smoking, exercise)
  • Control risk factors BP, DM
  • Anti-platelet Medications Aspirin
  • Angioplasty / stenting Iliac and SFA disease
  • Surgery Endarterectomy, bypass, amputation
  • Failure of conservative/medical treatment, tissue
    necrosis, infection, rest pain

20
Anatomy and Bypass
21
Ulcers
22
The Paediatric Abdomen
  • Vijay Joshi
  • 8/4/08

23
Basic Principles
  • Children are not small adults
  • Fluids and drug doses depend on body weight.
  • Body physiology is different with babies
  • Diagnosis usually varies depending on age.
  • Babies and young children cannot communicate
    symptoms.
  • Look for other abnormalities (VACTERL
    association, chromosomal)

24
Vomiting
  • Related to feeding?
  • Overfeeding, inadequate winding
  • Bile stained?
  • Obstruction distal to ampulla of vater
  • Malrotation - EMERGENCY
  • Associated with abdominal distension?
  • More pronounced in proximal obstruction
  • Term babies should pass meconium within 36h
  • Pyrexia?
  • Infection (UTI, chest infection, meningitis!)
  • Projectile?

25
Vomiting
  • Malrotation Volvulus (neonate)
  • EMERGENCY! Pass NG tube, fluids, AXR, Surgery
  • Pyloric Stenosis (3 6 weeks)
  • Projectile vomiting, Gasses (low Cl/K/Na,
    metabolic alkalosis), Test feed, USS.
  • NG tube, fluids until gasses normalise ? surgery.
  • Meconium ileus (neonate)
  • 15 of CF present like this, failure to pass
    meconium.
  • Fluids, NG tube, contrast enema (can be
    curative), surgery.

26
Vomiting
  • Intussusception (3 10 months)
  • Usually terminal ileum into caecum. Triad ?
    intermittant abdo pain (drawing up legs), red
    currant jelly stool, palpable abdo mass.
  • Resuscitate, analgesia, NGT, AXR, USS, air enema
    (recurrence), surgery
  • Hirschsprungs Disease (neonate)
  • Aganglionic segment of bowel (abnormal
    peristalsis), usually anorectal ? sigmoid
  • Bile stained vomitus, distension, failure to pass
    meconium
  • AXR, contrast enema (transition zone), rectal
    biopsy
  • Resuscitation, analgesia, decompression (NS
    washouts, stoma), surgery

27
Other Causes of Vomiting
  • Reflux
  • GI atresia (oesophageal, duodenal)
  • Gastroschisis
  • Incarcerated hernia
  • Anorectal malformation

28
PR Bleeding
  • Meckels Diverticulum
  • Remnant of the vitellointestinal duct
  • 2 ft from the end of the small intestine
  • 2 in length
  • occurs in about 2 of the population
  • twice as common in males as females
  • can contain two types of ectopic tissue
  • Meckels scan, surgical resection.
  • NEC (premature infants)
  • Associated with hypoxia, sepsis
  • AXR (pneumatosis intestinalis, free air)
  • Conservative (IV fluids, abx, TPN) and/or
    surgical treatment
  • Others
  • Intussusseption, Ulcers, IBD, Malrotation
    Volvulus, Polyps, Fissure

29
(No Transcript)
30
Appendicitis
  • Very common in young children
  • Abdo pain (central ? RIF), Vomiting, loss of
    appetite.
  • Pyrexia, tender RIF, raised WCC/CRP
  • IV fluids, Antibiotics, Surgery
  • Normal, Inflamed, Perforated, Gangrenous
  • Differential
  • Mesentaric adenitits, UTI, gastroenteritis,
    Ovarian pathology, ectopic pregnancy

31
Abdominal Mass
  • Pyloric Stenosis (Olive shaped mass)
  • Intussusception (sausage shaped mass RUQ)
  • Meconium Ileus (dilated bowel RIF mass)
  • Hernia
  • Undescended Testicle
  • Tumour Neroblastoma or Wilms turmor

32
The Paediatric Heart
  • Vijay Joshi
  • 8/4/08

33
Classification
  • Acyanotic
  • ASD, VSD, Coarctation, PDA
  • Cyanotic
  • TOF, TGA
  • Cyanotic / Complex
  • Hypoplastic Left Heart Syndrome, Truncus
    Arteriosus, Atrioventricular Septal Defect

34
Basic Principles
  • 3 general physiological disturbances
  • L to R shunt ? increased pulmonary flow (can
    reverse if untreated Eisenmengers syndrome)
  • R to L shunt ? decreased pulmonary flow
  • Ventricular outflow tract obstruction
  • Presentation
  • CHF ? failure to thrive, tachycardia, tachypnea,
    hepatic enlargement, chest sounds
  • Cyanosis
  • Tests
  • Echocardiogram, Cardiac Catheterisation

35
Ventricular Septal Defect
  • Most common congenital heart defect
  • Failure of ventricular septum to fully close
    resulting in L ? R shunt.
  • gt 50 of patients will have additional congenital
    lesions.
  • Pansystolic Murmur
  • 25-50 have spontaneous closure
  • Surgical patch closure

36
(No Transcript)
37
Atrial Septal Defect
  • Abnormal communication between left and right
    atria
  • L to R shunt presents with CCF
  • If un-noticed / treated, patients will usually
    become symptomatic at age 30-40.
  • Systolic murmur at left sternal border
  • Closure during cardiac catheterisation or with
    surgery using pericardial / prosthetic patch.
  • Irreversible pulmonary hypertension is a
    contraindication to surgery.

38
(No Transcript)
39
Patent Ductus Arteriosus
  • Physiologic R ? L shunt between aorta and PA to
    bypass lungs.
  • Factors preventing closure hypoxia, raised
    prostaglandins, prematurity
  • Acyanotic, continuous machinery murmur
  • Treatment
  • Indomethacin (NSAID PG inhibitor)
  • Surgical ligation or closure with cardiac
    catheterisation.

40
(No Transcript)
41
Coarctation of the Aorta
  • Narrowing of the thoracic aorta, usually found
    near ductus / ligamentum arteriosum
  • Three types
  • Preductal (fatal if untreated), juxtaductal,
    postductal.
  • Collateral circulation via subclavian artery ?
    IMA ? intercostals (rib notching) ? decending
    aorta
  • SSx HA, high BP, lower limb claudication,
    systolic murmur heard over back.
  • Surgical treatment in the symptomatic patient or
    in the asymptomatic patient older than 3-4 years.
  • Endovascular repair an option for adults

42
(No Transcript)
43
Cyanotic CHD
44
(No Transcript)
45
(No Transcript)
46
Thank you
  • Images from Childrens Heart Federation
  • http//www.childrens-heart-fed.org.uk/
  • Vijayjoshi_at_doctors.net.uk
  • Feedback please
  • Content
  • Usefulness
  • Enjoyment
  • ? Improvement
Write a Comment
User Comments (0)
About PowerShow.com