• SYMPTOMS:

1. Sudden onset of severe abdominal but the abdomen is soft and there is no finding in clinical examination of the abdomen.
2. Patient can present wih per rectal bleeding.
3. Severe hypovolemia.

• RISK FACTORS:

1. AF
2. MI
3. Aortic Aneurysm
4. Valvular heart disease

• CAUSE: Emboli
• INVESTIGATION: Arteriography
• MANAGEMENT:

1. IV fluids
2. Heparin
3. Gentamicin and metronidazole

CHRONIC MESENTERIC ISCHAEMIA

• SYMPTOMS:

1. Post-prandial pain.
2. Weight loss: Patient fear to eat

• RISK FACTORS:

1. HTN
2. DM
3. High cholesterol

• INVESTIGATION: Arteriography
• TREATMENT: reduce the risk of artherosclerosis

1. Paget’s disease
2. Duct papilloma especially if discharge is from the duct, usually single duct: Ductography/ ductogram is indicated.
3. Breast cancer

• CLEAR DISCHARGE: It is caused by intraductal papilloma ( discharge from the duct and should be investigated by Ductography or Ductogram.
• ORANGE, YELLOW CREAMY, GREEN DISCHARGE : It is caused by discharge from multiple ducts ( Duct ectasia) and should be investigated by Ductogram.
• PURULENT DISCHARGE: It is caused by breast abscess and is common is breast feeding mother. The causative organism is staphylococcal aureus. It should be treated by Flucloxacillin.
• MILKY DISCHARGE: It is caused by:

1. Prolactinoma: level of prolactin is >1000 units
2. Side effects of Anti- psychotics
3. Physiological: lactating mother

• Strong family history of breast cancer (genetic factors-BRCA 2 gene)
• Early menarche and late menopause
• Nulliparity

CLINICAL FEATURES

• Palpable, hard, irregular, fixed breast lump, usually painless
• Nipple retraction and skin dimpling
• Nipple eczema in Paget’s disease
• Peau d’orange ( cutaneous oedema secondary to lymphatic obstruction)
• Palpable axillary nodes

INVESTIGATIONS: Tripple assessment

TREATMENT

• Early breast cancer treatment is aimed at local control with wide excision, lymph node treatment and prevention of systemic relapse.
• Late breast cancer is usually palliative and mostly medical.

• Clinical examination of the breast including axillary lymph nodes
• If the lump is mobile, not attached to underlying structure, firm in consistence, smooth surface: It’s likely to be fibroadenoma, especially in young patient.
• If non-mobile lump, hard in consistency, attached to the underlying structure, irregular surface: It’s likely to be carcinoma.
• If there are lumps int he axilla it means carcinoma because that is a sign of metastasis.
• If there is no palpable masses the investigation of choice is stereotactic biopsy.

SECOND ASSESSMENT:

• If woman is <35 years : Perform USS only
• If woman is 35 years or above: Do mammography first and then USS

THIRD ASSESSMENT:

• Cytology
• In either case, you have done USS which will differentiate whether the lump is cystic or solid. If cystic, perform FNAC. Further management depends upon the type of fluid aspirated:

1. If aspirate is a clear fluid: Just aspirate and reassure the patient.
2. If blood stained: send the aspirate to lab for cytology.
3. If clear fluid but residual mass, perform core biopsy.
4. If the lump is solid, perform core biopsy.

BRANCHIAL CYST:

• Located in anterior triangle.
• Contains cholesterol crystals.
• Usually before the age of 30 years.
• It emerges under the anterior border of the sternocleidomastoid muscle where the upper 1/3 meets the lower 2/3.
• Investigation: US and FNAC.
• Treatment: surgical removal.

CAROTID BODY TUMOUR

• Located in anterior triangle.
• It moves side to side but not up and down.
• It may be pulsatile.
• It usually does not cause bruit.
• It is located just anterior to the upper 1/3 of sternocleidomastoid muscle.
• Investigation: Doppler USS and arteriography.
• Treatment: Surgical extirpation.

PAROTID TUMOUR

• Located in the anterior triangle at the upper posterior region at the angle of the jaw.
• Usually patient age >40 years
• Investigation: USS, mump test will be negative.
• Treatment: Surgical

MID-LINE LUMPS

THYROGLOSSAL CYST

• Trans-illuminating mid-line lump which moves on tongue protrusion.
• Investigation: USS.
• Treatment: Surgical removal.

THYROID LUMP:

• Mid-line lump which moves on swallowing but not on tongue protrusion.
• Investigation:

1. All patients with thyroid nodules must have TSH measurement .
2. If low, then measure T4 & T3.
3. USS recommended in patients with atypical solitary nodules and multiple goiter:

– If it is a CYST then treatment is surgical removal

-If it’s solid then FNAC (It is recommended in all patients with solitary nodules)

THYROID CANCER:

Risk Factors:

• Pre- existing goiter
• Radiation of neck in childhood
• Types including Frequency and Clinical features:

1. Papillary (60%) : Solitary thyroid nodule
2. Follicular (25%) : Slow growing thyroid mass, symptoms are usually from distant metastases.
3. Anaplastic (10%) : Rapidly growing thyroid mass causing tracheal and oesophageal compression.
4. Medullary (5%) : Thyroid lump, may have MEN II A ( medullary carcinoma, pheochromocytoma, hyperparathyroidism) or MEN II B (medullary thyroid carcinoma, pheochromocytoma, multiple mucosal neuromas, Marfanoid habitus ) syndrome.

Management:

• Papillary:

-Surgery: total thyroidectomy & removal of involved lymphnodes

-Adjunctive treatment: L-thyroxine to suppress TSH (it stimulates papillary tumour growth)

-Prognosis: Excellent

• Follicular

-Surgery: Thyroid lobectomy or total thyroidectomy if metastases are present.

-Adjunctive treatment: Radioactive iodine for distant metastases and L-thyroxine for replacement therapy to suppress TSH.

• Anaplastic

-Surgery: only palliative to relieve pressure symptoms

-No radiotherapy chemotherapy

-Prognosis: Very poor

• Medullary

-Excluded phaeochromocytoma before treating

-Surgery: Total thyroidectomy & excision of regional lymphnodes

DERMOID CYST:

• Midline lump that does not move on swallowing or tongue protrusion.
• If patient is less than 20 years the dermoid cyst is likely.
• Investigation: USS
• Treatment: Surgical removal

POSTERIOR TRIANGLE LUMPS

CERVICAL RIB (THORACIC OUTLET SYNDROME)

• Located in the posterior triangle.
• It is an extension of C-7.
• It can cause compression of upper arm vein or nerves therefore it can cause tingling and numbness or swelling of the arm.
• Symptoms depend on the compressed structure.
• Investigation: Cervical spine X-ray
• Treatment: Surgical removal

CYSTIC HYGROMA

• Located in the posterior triangle.
• These are massive distended lymphatic vessels.
• These can cause compression of the airway.
• They present at birth and trans-illuminate brightly.
• Investigation: USS
• Management: Surgical removal

PHARYNGEAL POUCH:

• Located in the posterior triangle.
• It is a diverticulum of the esophagus which comes out between the inferior pharyngeal constrictor muscles.
• Symptoms: regurgitation of undigested food particles, halitosis, swelling in the neck, bulging in the neck after drinking, dysphagia.
• Investigation: If it present as mass in the neck then investigation is USS.

If it present as a mass in the neck then investigation is barium meal.

• Treatment : Surgical

SUBCLAVIAN ARTERY ANEURYSM:

• It is a pulsatile mass located in the posterior triangle at the base of sternocleidomastoid muscle.
• Investigation: Doppler USS
• Treatment: Surgical repair of the aneurysm.

1. General complications
2. Specific complications
3. Wound problems

GENERAL COMPLICATIONS

FEVER : It can be caused by following reasons:

A. PNEUMONIA:

• It can occur as a complication usually 48 hours onwards.
• Patient present with cough , fever, sob
• Investigation: CXR
• Rx: Antibiotics (amoxicillin)

B. URINARY TRACT INFECTION:

• Usually secondary to catheterization
• In elderly patient it can cause dysuria, frequency
• Investigation: MSU
• Rx: antibiotics (Trimethoprim)

C. ATELECTASIS:

• Lung collapse.
• Common in people who smoke.
• Presentation: Chest pain and mild fever.
• Usually occurs within first 48 hours after an operation which is close to the lung especially splenectomy.
• Investigations: CXR to R/O pneimonia.
• Rx: Physiotherapy.

D. WOUND INFECTION:

• Usually after 5 days post operative.
• Patient present with discharge from the wound, redness & tenderness around the wound.
• Investigations: wound swab, microscopy, culture and sensitivity.
• Rx: Antibiotics

E. INTRA-ABDOMINAL ABSCESS:

• Subphrenic abscess or sub hepatic abscess
• Usually after 5 days post operative.
• Patient presents with swinging fever.
• Investigations: CT abdomen
• Rx: Incision & drainage

F. ANASTOMOTIC LEAK:

• Usually after bowel resection
• Any physiological change after bowel resection is alwys anastomotic leak until proven otherwise.
• Never occur immediately after operation but after patient starts eating and drinking, usually 3-7 post operative day.
• Investigation: CT abdomen
• Rx: Antibiotics: IV immediately (cefuroxime+metronidazole)
• Laparotomy is the definitive treatment.

INTRA-ABDOMINAL BLEED: 

• Usually few hours after surgery
• Management : Laparotomy

CONFUSION: It can be caused by:

A. INFECTION:

• UTI
• Pneumonia
• usually in elderly and after 5 post operative day

B. MEDICATIONS:

• Opiate usually used during an operation

HYPOXIA/ SOB /DYSPNOEA:

A. PULMONARY EMBOLISM : chest pain, hamoptysis, 5 days onwards after an operation

B. PULMONARY OEDEMA: Post operative pulmonary oedema is almost always due to fluid overload.

C. PNEUMONIA

D. PNEUMOTHORAX:

• Usually occurs due to ventilation pressure especially if there was a small pneumothorax.
• Chest drain must be inserted if it is small.

E. MYOCARDIAL INFARCTION:

• Patient presents with chest pain radiating to the left arm.

HYPOTENSION:

A. BLEEDING: IV Fluid

OTHER MEDICAL CONDITIONS : MI, PE or Sepsis

OLIGURIA:

• Post operative oliguria is almost secondary to inadequate fluid replacement.
• Rx: IV Fluid

ANURIA:

• Almost always due to blocked cathter
• Check catheter

POSTOPERATIVE HYPONATRAEMIA:

A. SIADH: especiall after brain surgery

B. Over hydration, especially with colloids because sodium gets diluted.

DEEP VENOUS THROMBOEMBOLISM:

• Pteinets usually present with unilateral calf swelling, pitting oedema, calf pain.
• In post-operative patients we do not use D-dimer as an investigation. But the investigation of choice is always a Compression Ultrasound Scan.

          SPECIFIC POST-OPERATIVE COMPLICATIONS

1. MASTECTOMY:

• Common complication in lymphoedema (arm becomes swollen)
• Rx: Physiotherapy and arm exercise.

2. THYROIDECTOMY:

A. RECURRENT LARYNGEAL NERVE PALSY:

• Patient presents with hoarseness of voice.
• Usually resolves after 2-3 weeks if unilateral so just reassure.
• If bilateral , needs surgical airway.

B. TRACHEAL OBSTRUCTION BY HAEMATOMA:

• Usually presents with acute shortness of breath and stridor immediately after operation.
• Commonly seen when patient is still in recovery room
• Rx: release the stitches on the bedside

C. HYPOCALCAEMIA:

•  Usually due to injury  or aberrant removal of parathyroid glands during surgery.
• Patient presents with tetani, Chvostek sign and Troseau’s sign (carpopedal spasm), muscle irritability.

3. POST TURP SYNDROME:

• The irrigation fluid used to visualize and distend the urethra and bladder gains intravascular access through the venous circulation causing dilutional hyponatremia.
• Rx: Fluid restriction.

4. APPENDICECTOMY:

• Common complication is abdominal and pelvic abscess especially if it is perforated  or gangrenous appendicitis.
• Usually patient will have swinging fever
• Investigations: CT scan abdomen or abdominal ultrasound
• Rx: I & D

5. SPLENECTOMY:

• Spleen takes part in immune system so splenectomy cause low immune funtion and patient will have recurrent infections.
• Prophylaxis vaccine is required against following infections:

– Pneumococcal

-Meningococcal

– Haemophilus influenza

• Patient also requires long term antibiotics prophylaxis.

6. ABDOMINAL SURGERY:

A. PARALYTIC ILEUS:

• Usually presents  with abdominal distention, constipation, vomiting and reduced bowel sounds.
• Occurs few days after  the operation
• No abdominal pain
• Investigation: Plain abdominal X-ray  shows dilated bowel loops
• Management: Nasal gastric tube and intravenous fluid.

B. OBSTRUCTION SECONDARY TO ADHESIONS:

• This will occur after weeks, months or years
• Cardinal symptoms: Abdominal pain, vomiting , constipation, abdmoinal distension and increased bowel sounds

7. ERCP:

A. ACUTE PANCREATITIS

B. CHOLANGITIS

WOUND INFECTION

• Wound swelling , bleeding or discharge needs inspection/ exploration of the wound

1. LAPAROTOMY WOUND DEHISCENCE:

• Dehiscence of laparotomy wound is spontaneous opening of deep suture layers with or without superficial layer.
• Presents with serosanuinous discharge from wound and usually 7-10 days post operative.
• Rx: Resuture wound

2. WOUND BLEEDING:

• Usually bleeding is minor and settles spontaneously.
• Presents with oozing wound, haematoma on palpation.
• Rx: If minor bleeding, try gentle pressure for 5 minutes. If ongoing large amount of bleeding, patient may need to go to theatre

3. SUPERFICIAL WOUND INFECTION AND ABSCESS:

• Present with wound pain, pyrexia, pus like discharge
• Rx: Inspection/ exploration of wound
• If temperature >37.5, take blood cultures, CRP, FBC, U& E.
• If abscess: wound drainage, take swab for microscopy, culture & sensitivity.

1. Surgery of Gastric/Oesophageal surgery: The most common pathogens found are Enteric gram negative bacilli, gram positive cocci. Thus the antibiotics of choice would be single does of Gentamicin IV (First line) or Cefuroxime IV or Co-amoxicalv IV.
2. Colorectal surgery: The most common pathogens are Enteric gram negative bacilli, enterococci, anaerobes. Hence the preferred antibiotics include single does of Gentamicin IV +metronidazole Iv/PR or Cefuroxime IV +metronidazole Iv or Co-amoxicalv IV alone.
3. Appendicectomy: The most common pathogens are Enteric gram negative bacilli, enterococci, anaerobes. Hence the preferred antibiotics include single does of Gentamicin IV +metronidazole Iv/PR or Cefuroxime IV +metronidazole Iv or Co-amoxicalv IV alone.
4. Open Biliary Surgery: The most common pathogens are Enteric gram negative bacilli, enterococci, clostridia. Hence the preferred antibiotics include single does of Gentamicin IV +metronidazole Iv/PR or Cefuroxime IV +metronidazole Iv or Co-amoxicalv IV alone.
5. ERCP: The most common pathogens are Enteric gram negative bacilli, enterococci, clostridia. Thus the antibiotics of choice would be single does of Gentamicin IV (First line) or Ciprofloxacin IV/PO.
6. Vascular surgery: The most common pathogens are S. aureus, S. epidermidis, anaerobes in diabetes, gangrene or undergoing amputaion. So the antibiotic of choice is Single dose of cefuroxime IV or Flucloxacillin IV+ gentamicin IV. Add metronidazole for suspected anaerobic infection.
7. Lower limb amputation/major truma: The antibiotics of choice are Co-amoxiclav alone or (for penicillin allergy) cefuroxime IV + metronidazole 400-500 mg tds.