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INDEX OF CASES
Case
Page number
The differential is large. However it can be narrowed by considering the lumps physical
characteristics. It is smooth, does not involve skin, there is no punctum, and if felt it is
soft, fluctuant and importantly is quite transilluminable.
2. Further treatment?
A simple cyst would be uncommon in this area so it was excised and submitted for
histopathology - this showed a simple cyst.
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3. She asks you about the 7% false negative rate. What does the figure mean?
The false negative rate means that of all those axillas truely involved 7% will be falsely
thought to be negative. It is the reverse of sensitivity (93%). This will lead to incorrect
downstaging of the patient resulting in potential undertreatment with adjuvant therapies.
One other issue needs to be considered in order to make sense of the false negative rate.
That is the incidence of involvement of the axilla in early breast cancer. If only 20% of
patients with early cancers have axillary disease and 93% of these will be correctly
detected then only 1.4% (7% of 20%) of all patients will have an incorrectly staged axilla.
4. How would you calculate the sensitivity and specificity for a test?
You will need to draw up a table with 4 potential result types. True positives, false
positives, false negatives and true negatives
Sensitivity equals true positives divided by true positives + false negatives =TP/(TP+FN)
Specificity equals true negatives divided by true negatives + false positives =TN/(TN+FP)
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There is a hemisperical raised lesion which is deeply purple in colour, smooth in contour,
which seems to be involving the overlying skin.
2. What is the differential diagnosis?
Malignant lesion - primary skin lesion or metastatic nodal disease involving skin. Less
likley would be an infected sebaceous cyst.
3. What else would you examine?
The skin of the head and neck, complete ENT exam, and other lymph node groups.
4. What do you see?
Pigmented skin lesions consistent with melanoma.
5. Now what is your likely diagnosis?
Nodal involvement of metastatic melanoma.
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Dorsal wrist ganglion. Clinical examination would confirm this, showing, a soft fluctuant
mass, transillumination, no punctum, and usually fixed to the underlying dorsal wrist
capsule. Sometimes they can arise from the extensor tendon sheaths.
Ganglionic Cysts of the Wrist----Wheeless' Textbook of Orthopaedics.
Case 19: Dead toe
This 69 year old man presented worried
about the apperance of his toe.
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He says that he occasionally gets crampy abdominal pains, and also suffers joint pains in
his knees, hips and in his right lower back.
1. What does it show?
A right sided colitis. There is confluent thickening of the entire right colon. The mucosa is
grossly thickened and protruding into the colonic lumen.
2. What does his plain Xray show?
With this history in mind, the xray does show, right sacroileitis. There is loss of the usual
joint space, and periarticular sclerosis. With all the above clinical information, the
diagnosis of inflammatory bowel disease seems likely in this patient.
Extraintestinal manifestations in inflammatory bowel disease
There are many extraintestinal manifestations in inflammatory bowel disease.
Approximately 2% of ulcerative colitis patients will develop primary sclerosing cholangitis,
a cholestatic liver disease diagnosed by the appearance of extrahepatic and intrahepatic
strictures on a cholangiogram. Primary sclerosing cholangitis is seen more often in
ulcerative colitis than in Crohn's disease patients.9 Other hepatic manifestations of
inflammatory bowel disease include fatty liver, chronic active hepatitis, amyloidosis, and
drug-induced disease from medications used to treat inflammatory bowel disease
(steroids, azathioprine, 6-mercaptopurine [6-MP], or sulfasalazine).
Erythema nodosum, seen in up to 3% of patients, is characterized by raised, tender,
erythematous nodules appearing typically on the extremities. Pyoderma gangrenosum, a
rare, ulcerating, and necrotic lesion, is seen in both Crohn's disease and ulcerative colitis.
Arthritis usually is seronegative, mono- or pauciarticular, and asymmetric. The large joints
are most often affected, and there is no synovial destruction. Ocular manifestations
include blurred vision, eye pain, photophobia, and keratitic precipitates. Patients are
susceptible to nephrolithiasis from calcium oxalate stones. Patients with uveitis often have
HLA-B27, whereas patients with episcleritis and iritis usually do not. Cerebrovascular
accidents and other thromboembolic events can result from hypercoagulability secondary
to chronic inflammation or to other inherited syndromes such as the factor V Leiden
mutation.
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1. What manoeuvres can you use to get the contrast to flow 'up-hill'?
1. Tilt the patient head down
2. Use more contrast
3. Gently apply pressure over the region of the lower CBD with the side of a grasper to
increase resistance to flow.
2. You realise what the problem is at this stage. What does your cholangiogram
show?
The cholangiogram demonstrates cannulation of the CBD and all contrast is flowing down
and into the duodenum. This is evidenced by a tapering of the CBD by the Olsen-Reddich
clamp with no proximal flow, and no apparent cystic duct.
3. What structure is marked '1'?
The pancreatic duct
4. What is happening at '2'?
Free flow of contrast into the duodenum
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1. What are the two likely causes for such an appearance at the umbilicus?
1. Umbilical hernia.
2. Sister Joseph Nodule - of tumour at the umbilicus from peritoneal spread
2. If this was incarcerated small bowel, how would you proceed?
Open repair with possible small bowel resection if required. Tha ascites should be drained
through a separate drain to allow the wound to heal before establishing an ascitic fistula.
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1.
2.
3.
4.
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Case 50: Right upper quadrant abdominal pain, fever and jaundice.
A 73 year old man presented to the emergency department with right upper quadrant
abdominal pain, fevers with rigors, and had noticed his urine the colour of tea before you
put milk in it.
1. Right upper quadrant abdominal pain, fever and jaundice. Whose triad is this?
Charcot's triad
2. What is this investigation called?
MRCP - magnetic resonance cholangiopancreatography
3. Can you name the structures 1- 7?
1.Nasogastric tube
2.Left hepatic duct
3.Lower common bile duct with stone in lumen
4.Pancreatic duct
5.Cystic duct
6.Gallbladder
7.Right anterior and posterior sectoral ducts.
4. Can you see anything else near the 3 arrowhead?
A stone in the bile duct.
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No
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1. What concerns do you have for hernia repair in this man specifically?
This massive hernia obviously contains a significant volume of bowel. It may be difficult or
impossible to return it to the true abdominal cavity. It will certainly lead to compromised
ventilation from splinting of the diaphragm. In this man with COAD it could lead to
respiratory failure and the back up of intensive care would certainly be required before
attempting repair.
2. How would your technique for repair vary from your standard open approach?
Repair of this hernia will require major surgery with adequate planning of the surgical
technique and peri-operative care. Complete reduction of the hernia may require
laparotomy and a "relaxing" incision in the midline repaired with mesh to accomodate the
bowel. Alternatively implantable tissue expanders or even controlled pneumoperitoneum
have been used to gradually "stretch" the abdominal wall to increase its volume prior to
repair of similar massive hernias.
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1. What are the possible causes for this discoloration on the dressing?
The possibility of an enteric fistula should always be considered, especially if the dietitian has put blue food
colouring in the enteric feed to try and demonstrate such a fistula.
However, the most likely cause for this is a pseudomonas aeruginosa colonisation/infection of the wound.
2. What other features on examination would point to the diagnosis?
A strong pungent odour. Some say it is a fruity odour, however it is more like the smell of sweaty socks dipped in
ammonia.
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1. What reasons do you think he had to, over the phone, book the patient directly for theatre?
Tenderness.
This usually implies a compromised loop of gut that
either requires release, or if left too long, resection.
The fact that the patient had a 'virgin' abdomen and
no other cause for obstruction in the setting of an
anaemia increases the likelihood of the cause being
a carcinoma obstructing the ileocaecal valve.
2. What was the diagnosis?
A right colon carcinoma obstructing the ileocaecal valve
3. What are the options for treatment?
Formal right hemicolectomy, with proximal tie of the ileocolic vessels and resulting lymphovascular clearance. A
primary anastomosis is usually possible - especially if operated early before the bowel and the patient deteriorate.
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Lipomas
What is a lipoma?
A lipoma is a non-cancerous tumour that is made up of fat cells. It slowly grows under the skin in the
subcutaneous tissue. A person may have a single lipoma or may have many lipomas. They are very common.
Lipomas
A dome-shaped or egg-shaped lump about 2-10 cm in diameter (some may grow even larger)
It feels soft and smooth and is easily moved under the skin with the fingers
They are most common on the shoulders, neck, trunk and arms, but they can occur anywhere on the
body where fat tissue is present.
Most lipomas are symptomless, but some are painful on applying pressure. Lipomas that are tender or painful
are usually angiolipomas (adiposis dolorosa or Dercum disease). This means the lipoma has an increased
number of small blood vessels.
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Liposarcoma
Luckily the rare fatty cancer, liposarcoma, almost never arises in the skin. Liposarcoma tends to be deep
seated and most often grows on thigh, groin or at the back of the abdomen. However, if your lipoma is
enlarging or becomes painful, check with your doctor. A skin biopsy may be required.
Squeeze technique (a small incision is made over the lipoma and the fatty tissue is squeezed through
the hole)
Liposuction.
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When a colonic resection is performed many surgeons would elect not to insert mesh to reinforce the hernia repair
for fear of infection, although there is no firm evidence for this.
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The patient should be marked and educated by a stomal therapist during pre-operative planning. As a stoma is a
certainty with APR there is an argument to create the trephine before performing a midline laparotomy. This
ensures that the trephine passes straight through the abdominal wall and that there is no slippage between rectus
fascia and the subcutaneous fat and skin.
If the trephine is to be made after laparotomy then a straight Kocher's clamp is placed on the linea alba and the
dermis. These are then held together in the left hand. A disc of skin is excised at the marked site. A vertical
incision in the subcutaneous fat is then made with diathermy and deepened to the anterior rectus sheath with the
assistance of stoma retractors. A generous vertical incision is then made in the anterior sheath. A Robert's clamp
is used to split the rectus muscle vertically taking care to avoid the inferior epigastric vessels. With the posterior
sheath exposed a vertical incision is again made here. A pack should be held in the left hand and the index finger
can be pressed up into the trephine site. This aids dissection and allows diathermy to be used throughout with risk
to the underlying bowel.
The site is checked for haemostasis. Usually the passage of two fingers through the trephine ensures that it is of
sufficient calibre. Babcock's forceps are passed through the trephine and used to grasp the stapled closed end of
colon. It is bought out and held in position by the Babcock. There should be no tension and sufficient length to
allow for post operative abdominal distension.
The operation is then completed, the midline wound closed and dressed. The stoma is then matured by excisiong
the staple line and suturing the bowel to the dermis. This is a bowel anastomosis like any other and should be
performed with care. Several sutures should be placed and held on artery clips before excising the staple line to
prevent the bowel retracting into the peritoneum. After placement of sutures they are tied down to create a fluch
stoma and finally an appliance is fitted.
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1. What is it?
It is a ventriculo-peritoneal shunt used to treat hydrocephalus.
The problem with this hardware is not its identification, but the diagnostic confusion it can make.
These patients can present with abdominal pain which is difficult to discern. The pain could arise from a primarily
infected shunt or could also arise from a primary intraabdominal problem (as in this case)
Methods to differentiate include drawing off some CSF from the reservoir port (performed by the neurosurgeons,
if this shows pure growth of a characteristic skin organism then it is more likely a shunt problem) or performing a
diagnostic laparoscopy.
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Intraoperative photo.
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1. If you took a small punch biopsy of the edge of this lesion what do you think it may show?
Most likely - Basal Cell Carcinoma, next Squamous cell carcinoma, amelanotic melanoma is also a possibility.
Then possibly granulation tissue (if biopsy not accurate, foreign body reaction or mycobacterium infection)
2. The lesion feels to be fixed to the underlying pericranium. Now what are the options?
This is the classical 'rodent ulcer' of a locally invasive BCC. Excision will need to involve at least the
pericranium, the outer table of the skull, or more depending on its level of invasion.
Case 174: Endoscopic technique
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A 16 year old boy fell off a balcony onto his left side. He is brought into the emergency department with severe
left abdominal and chest pain. He is haemodynamically unstable but responds adequately to fluid resuscitation.
An urgent CT scan is performed.
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