Breast disorders

Disorder Features

Fibroadenoma Common in women under the age of 30 years

Often described as 'breast mice' due as they are discrete, non-
tender, highly mobile lumps

Fibroadenosis (fibrocystic Most common in middle-aged women

disease, benign mammary 'Lumpy' breasts which may be painful. Symptoms may worsen
dysplasia) prior to menstruation

Breast cancer Characteristically a hard, irregular lump. There may be

associated nipple inversion or skin tethering

Paget's disease of the breast - intraductal carcinoma associated

with a reddening and thickening (may resemble eczematous
changes) of the skin/areola

Mammary duct ectasia Dilatation of the large breast ducts

Most common around the menopause
May present with a tender lump around the areola +/- a green
nipple discharge
If ruptures may cause local inflammation, sometimes referred to
as 'plasma cell mastitis'

Duct papilloma Local areas of epithelial proliferation in large mammary ducts

Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge

Fat necrosis More common in obese women with large breasts

May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and
round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is
always warranted

Breast abscess More common in lactating women

Red, hot tender swelling

Lipomas and sebaceous cysts may also develop around the breast tissue.

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Breast cancer: management
Tamoxifen is used as the women is pre-menopausal. There is ongoing debate about whether
therapy should be for 5 years or longer.
The management of breast cancer depends on the staging, tumour type and patient
background. It may involve any of the following:

surgery
radiotherapy
hormone therapy
biological therapy
chemotherapy

Surgery
The vast majority of patients who have breast cancer diagnosed will be offered surgery. An
exception may be a very frail, elderly lady with metastatic disease who may be better managed
with hormonal therapy.
Depending on the characteristics of the tumour women either have a wide-local excision or a
mastectomy. Around two-thirds of tumours can be removed with a wide-local excision. The
table below lists some of the factors determining which operation is offered:
Mastectomy Wide Local Excision

Multifocal tumour Solitary lesion

Central tumour Peripheral tumour

Large lesion in small breast Small lesion in large breast

DCIS > 4cm DCIS < 4cm

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Women should be offered breast reconstruction to achieve a cosmetically suitable result
regardless of the type of operation they have. For women who've had a mastectomy this may
be done at the initial operation or at a later date.

Radiotherapy

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this
may reduce the risk of recurrence by around two-thirds. For women who've had a mastectomy
radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary
nodes

Hormonal therapy

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many
years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre-
and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as
anastrozole are used for this purpose*.
Important side-effects of tamoxifen include an increased risk of endometrial cancer, venous
thromboembolism and menopausal symptoms.

Biological therapy

The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin).
It is only useful in the 20-25% of tumours that are HER2 positive.

Trastuzumab cannot be used in patients with a history of heart disorders.

Chemotherapy

Cytotoxic therapy may be used to either downstage a primary lesion or after surgery depending
on the stage of the tumour, for example if there is axillary node disease.
*in post-menopausal women the process of aromatisation accounts for most oestrogen
production
A 49-year-old woman presents with a tender lump around the areola associated with a green
nipple discharge.>>> Mammary duct ectasia

An obese woman presents with an irregular lump on the lateral aspect of her right breast
associated with skin tethering. Biopsy excludes a malignant cause.>>> Fat necrosis

A 41-year-old woman presents with pain and an irregular mobile lump in her left
breast.>>> Breast cancer

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Ankle injury: Ottawa rules
The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the
following findings:

bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to
include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to
the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the
emergency department

There are also Ottawa rules available for both foot and knee injuries

Abdominal wall hernias

The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ
through the wall of the cavity that normally contains it.

Risk factors for abdominal wall hernias include:

obesity
ascites
increasing age
surgical wounds

Features

palpable lump
cough impulse
pain
obstruction: more common in femoral hernias
strangulation: may compromise the bowel blood supply leading to infarction

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Types of abdominal wall hernias:

Type of hernia Details

Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of
patients are male; men have around a 25% lifetime risk of developing an
inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare

Femoral hernia Below and lateral to the pubic tubercle

More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required

Umbilical hernia Symmetrical bulge under the umbilicus

Paraumbilical Asymmetrical bulge - half the sac is covered by skin of the abdomen directly
hernia above or below the umbilicus

Epigastric hernia Lump in the midline between umbilicus and the xiphisternum
Most common in men aged 20-30 years

Incisional hernia May occur in up to 10% of abdominal operations

Spigelian hernia Also known as lateral ventral hernia

Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus
abdominis muscle medially and the semilunar line laterally)

Obturator A hernia which passes through the obturator foramen. More common in
hernia females and typical presents with bowel obstruction

Richter hernia A rare type of hernia where only the antimesenteric border of the bowel
herniates through the fascial defect

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Abdominal wall hernias in children: Congenital inguinal hernias have a high rate of
complications and should be repaired promptly once identified.

Type of hernia Details

Congenital inguinal Indirect hernias resulting from a patent processus vaginalis

hernia Occur in around 1% of term babies. More common in premature babies
and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of
incarceration

Infantile umbilical Symmetrical bulge under the umbilicus

hernia More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5
years
Complications are rare

Congenital hernias

inguinal: repair ASAP

umbilical: manage conservatively

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Inguinal hernia
Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male;
men have around a 25% lifetime risk of developing an inguinal hernia.

Features

groin lump: disappears on pressure or when the patient lies down

discomfort and ache: often worse with activity, severe pain is uncommon
strangulation is rare

Whilst traditional textbooks describe the anatomical differences between indirect (hernia
through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal)
this is of no relevance to the clinical management.

Management

the clinical consensus is currently to treat medically fit patients even if they are
asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little
role in other patients
mesh repair is associated with the lowest recurrence rate

The Department for Work and Pensions recommend that following an open repair patients
return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks

Complications

early: bruising, wound infection

late: chronic pain, recurrence

A 62-year-old man with no significant past medical history presents with a right sided groin
lump which he noticed whilst having a shower. It has been present for 2 weeks and disappears
when he lies down. It never causes him any discomfort and there are no other gastrointestinal
symptoms of note. Examination reveals an small reducible swelling in the right groin. What is
the most appropriate management?

This patient has an asymptomatic inguinal hernia. Studies looking at conservative management
tend to find that many patients become symptomatic and eventually have surgery anyway. As
this patient is medically fit most clinicians would refer for surgical repair.

Inguinal hernias do not resolve spontaneously.

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A number of PCTs have begun to put asymptomatic inguinal hernias on the 'low clinical priority'
list. Whilst this may be reasonable for older patients who are 'not bothered' by their condition
it is debatable how feasible such a blanket policy is for all patients.

Ascending cholangitis
Ascending cholangitis is a bacterial infection of the biliary tree. The most common predisposing
factor is gallstones.
Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50%
of patients

fever is the most common feature, seen in 90% of patients

RUQ pain 70%
jaundice 60%
hypotension and confusion are also common

Management

intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve
any obstruction

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Renal stones: management
Calcium channel blockers are also sometimes used to aid the spontaneous passage of the
stone.
Acute management of renal colic

Medication

the British Association of Urological Surgeons (BAUS) recommend diclofenac

(intramuscular/oral) as the analgesia of choice for renal colic*
BAUS also endorse the widespread use of alpha-adrenergic blockers to aid ureteric
stone passage

Imaging

patients presenting to the Emergency Department usually have a KUB x-ray (shows 60%
of stones)
the imaging of choice is a non-contrast CT (NCCT). 99% of stones are identifiable on
NCCT. Many GPs now have direct access to NCCT

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for
severe cases.

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Prevention of renal stones
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general
population.

high fluid intake

low animal protein, low salt diet (a low calcium diet has not been shown to be superior
to a normocalcaemic diet)
thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones

cholestyramine reduces urinary oxalate secretion

pyridoxine reduces urinary oxalate secretion

Uric acid stones

allopurinol
urinary alkalinization e.g. oral bicarbonate

*Diclofenac use is now less common following the MHRA warnings about cardiovascular risk. It
is therefore likely the guidelines will change soon to an alternative NSAID such as naproxen

Abdominal pain
The table below gives characteristic exam question features for conditions causing abdominal
pain. Unusual and 'medical' causes of abdominal pain should also be remembered:

myocardial infarction
diabetic ketoacidosis
pneumonia
acute intermittent porphyria
lead poisoning

Condition Characteristic exam feature

Peptic ulcer Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved
disease by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen
(haematemesis, melena etc)

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Condition Characteristic exam feature

Appendicitis Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign: more pain in RIF than LIF when palpating LIF

Acute pancreatitis Usually due to alcohol or gallstones

Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-
Turner's sign) is described but rare

Biliary colic Pain in the RUQ radiating to the back and interscapular region, may be
following a fatty meal. Slight misnomer as the pain may persist for hours
Obstructive jaundice may cause pale stools and dark urine
It is sometimes taught that patients are female, forties, fat and fair although
this is obviously a generalisation

Acute cholecystitis History of gallstones symptoms (see above)

Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy's sign positive (arrest of inspiration on palpation of the RUQ)

Diverticulitis Colicky pain typically in the LLQ

Fever, raised inflammatory markers and white cells

Abdominal aortic Severe central abdominal pain radiating to the back

aneurysm Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute
(persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease

Intestinal History of malignancy/previous operations

obstruction Vomiting
Not opened bowels recently
'Tinkling' bowel sounds

A 49-year-old woman presents with pain in the right upper quadrant. This has been occurring
for the past 3 months and is often precipitated by a heavy meal. When the pain comes it is
typically lasts around 1-2 hours. Clinical examination is unremarkable other than mild
tenderness in the right upper quadrant.>>> Biliary colic

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A 37-year-old attends surgery due to a one day history of severe central abdominal pain
radiating through to the back. He has vomited several times and is guarding on examination.
Parotitis and spider naevi are also noted.>>> Acute pancreatitis

Parotitis and spider naevi suggest excessive alcohol intake which is one of the most common
causes of acute pancreatitis.

A 72-year-old woman who takes regular laxatives comes to surgery. Over the past two days she
has developed progressively worse pain in the left lower quadrant. On examination she has a
low-grade pyrexia and is tender on the left side of the abdomen >>> Diverticulitis

Gallstones
Asymptomatic gallstones which are located in the gallbladder are common and do not require
treatment. However, if stones are present in the common bile duct there is an increased risk of
complications such as cholangitis or pancreatitis and surgical management should be
considered.
Although gallstones found in the common bile duct may be asymptomatic there is a significant
risk of developing serious complications such as cholangitis or pancreatitis and therefore the
patient should be managed the same as someone with symptomatic gallstones with common
bile duct stones. The recommendation that treatment is required is based on the NICE 2014
guideline Gallstone disease: Diagnosis and management of cholelithiasis, cholecystitis and
choledocholithiasis.

The CKS advises the following management of a person with symptomatic gallstones:

Arrange surgical admission for people who are systematically unwell with a suspected
complication of gallstone disease, such as acute cholecystitis, cholangitis, or
pancreatitis.
Refer to a surgeon all other people with suspected symptomatic gallstone disease. This
would typically include people who are systematically well but have a history suggestive
of biliary colic or other symptoms suggestive of gallstone disease, with one or more
gallstones detected by an ultrasound scan.The urgency of referral depends on clinical
judgment.
Consider also referring people with a negative ultrasound scan if symptoms remain
consistent with gallstone disease, and other diagnoses have been ruled out.
Offer appropriate pain relief in the acute situation or whilst awaiting to be seen by
secondary care.

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Advise people:

To avoid any foods or drinks that trigger their symptoms until they have definitive
surgical management, about the tests and treatment options that may be offered in
secondary care.
That after recovering from an operation to remove the gallbladder there are no special
dietary restrictions and to seek medical advice if symptoms that occurred prior to the
operation persist, or new symptoms develop, of it any foods or drinks trigger any
symptoms.

Head injury: NICE guidance

Patients who've had a head injury and are on warfarin need to have a CT scan, regardless of
whether they have risk factors for an intracranial injury. NICE state:

For patients (adults and children) who have sustained a head injury with no other indications for
a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours
of the injury. A provisional written radiology report should be made available within 1 hour of
the scan being performed.

NICE has strict and clear guidance regarding which adult patients are safe to discharge and
which need further CT head imaging. The former group are also divided into two further
cohorts, those who require an immediate CT head and those requiring CT head within 8 hours
of injury:

CT head immediately

GCS < 13 on initial assessment

GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture.
any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid
leakage from the ear or nose, Battle's sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors
who have experienced some loss of consciousness or amnesia since the injury:

age 65 years or older

any history of bleeding or clotting disorders

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 dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an
occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or
5 stairs)
more than 30 minutes' retrograde amnesia of events immediately before the head
injury

If a patient is on warfarin who have sustained a head injury with no other indications for a CT
head scan, perform a CT head scan within 8 hours of the injury.

Haematuria
The management of patients with haematuria is often difficult due to the absence of widely
followed guidelines. It is sometimes unclear whether patients are best managed in primary
care, by urologists or by nephrologists.

The terminology surrounding haematuria is changing. Microscopic or dipstick positive

haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is
termed visible haematuria. Non-visible haematuria is found in around 2.5% of the population.

Causes of transient or spurious non-visible haematuria

urinary tract infection

menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse

Causes of persistent non-visible haematuria

cancer (bladder, renal, prostate)

stones
benign prostatic hyperplasia
prostatitis
urethritis e.g. Chlamydia
renal causes: IgA nephropathy, thin basement membrane disease

Spurious causes - red/orange urine, where blood is not present on dipstick

foods: beetroot, rhubarb

drugs: rifampicin, doxorubicin

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Management

Current evidence does not support screening for haematuria. The incidence of non-visible
haematuria is similar in patients taking aspirin/warfarin to the general population hence these
patients should also be investigated.

Testing

urine dipstick is the test of choice for detecting haematuria

persistent non-visible haematuria is often defined as blood being present in 2 out of 3
samples tested 2-3 weeks apart
renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood
pressure should also be checked
urine microscopy may be used but time to analysis significantly affects the number of
red blood cells detected

NICE urgent cancer referral guidelines were updated in 2015.

Urgent referral (i.e. within 2 weeks)

Aged >= 45 years AND:

unexplained visible haematuria without urinary tract infection, or

visible haematuria that persists or recurs after successful treatment of urinary tract
infection

Aged >= 60 years AND:

have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a
blood test

Non-urgent referral

Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection

Since the investigation (or not) of non-visible haematuria is such as a common dilemma a
number of guidelines have been published. They generally agree with NICE guidance, of note:

patients under the age of 40 years with normal renal function, no proteinuria and who
are normotensive do not need to be referred and may be managed in primary care

15
A 14-year-old boy develops visible haematuria following an upper respiratory tract infection.
>>> IgA nephropathy

IgA nephropathy is also called Berger's disease.

A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in
the left loin but examination is unremarkable other than a left varicocele. He also notes to
feeling intermittently hot and sweaty.>>> Renal cell carcinoma.

Features of renal cell carcinoma:

classical triad: haematuria, loin pain, abdominal mass

pyrexia of unknown origin
left varicocele (due to occlusion of left testicular vein)
endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone
(hypercalcaemia), renin, ACTH
25% have metastases at presentation

A 21-year-old female complains of dysuria for the past week, despite just completing a three
day course of trimethoprim. Urine dipstick is positive for blood + and leucocytes +. A MSSU
shows no organism.>>> Chlamydia

Features of Chlamydia

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria

A 68-year-old man presents with visible haematuria for the past two weeks. There is no history
of pain. MSSU confirms haematuria but fails to show any organism.>>> Transitional cell
carcinoma of the bladder .

A 3-year-old girl is brought to surgery as her parents have noticed blood in her urine.
Examinations reveals a loin mass. MSU shows no evidence of a urinary tract infection. The only
relevant family history is her grandmother who has chronic kidney disease.>>> Wilms'
nephroblastoma

Wilms' nephroblastoma is one of the most common childhood malignancies. It typically

presents in children under 5 years of age, with a median age of 3 years old.

Features

abdominal mass (most common presenting feature)

flank pain

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 painless haematuria
other features: anorexia, fever
unilateral in 95% of cases
metastases are found in 20% of patients (most commonly lung ).

A 57-year-old man presents with left sided abdominal pain radiating to his scrotum. The pain is
severe and not controlled by a combination of paracetamol and ibuprofen. Urine dipstick
shows: blood++, protein+, leucocytes++, nitrites negative. Clinical examination is
unremarkable.>>> Renal stones

De Quervain's tenosynovitis
De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor
pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged
30 - 50 years old

Features

pain on the radial side of the wrist

tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is
reproduced by movement of the wrist into flexion and ulnar deviation

Management

analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required

Minor surgery
Local anaesthetic (LA)

Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for
around 1 hour.

the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions
containing adrenaline), which equates to 3mg/kg for a 66kg patient. This is the
equivalent of 20ml of 1% solution or 10ml of 2% solution

17
 lidocaine is available pre-mixed with adrenaline. This increases the duration of action of
lidocaine and reduces blood loss secondary to vasoconstriction. It must never be used
near extremities due to the risk of ischaemia

Suture material

Non-absorbable Absorbable

Silk Vicryl
Novafil Dexon
Prolene PDS
Ethilon

Non-absorbable sutures are normally removed after 7-14 days, depending on the location.
Absorbable sutures normally disappear after 7-10 days. Removal times for non-absorbable
sutures are shown below:

Area Removal time (days)

Face 3-5

Scalp, limbs, chest 7 - 10

Hand, foot, back 10 - 14

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of
cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided
into:

seminomas
non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma

Non-germ cell tumours include Leydig cell tumours and sarcomas.

The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include:

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 cryptorchidism
infertility
family history
Klinefelter's syndrome
mumps orchitis

Features

a painless lump is the most common presenting symptom

pain may also be present in a minority of men
other possible features include hydrocele, gynaecomastia

Diagnosis

ultrasound is first-line

Management

treatment depends on whether the tumour is a seminoma or a non-seminoma

orchidectomy
chemotherapy and radiotherapy may be given depending on staging and tumour type

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I

5 year survival for teratomas is around 85% if Stage I

Benign prostatic hyperplasia

Goserelin (Zoladex) is not used in the management of benign prostatic hyperplasia

Finasteride: 5 alpha-reductase inhibitor - inhibits conversion of testosterone to

dihydrotestosterone

Finasteride treatment of BPH may take 6 months before results are seen

Alpha-1 antagonists are first-line in patients with benign prostatic hyperplasia

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Benign prostatic hyperplasia (BPH) is a common condition seen in older men.

Risk factors

age: around 50% of 50-year-old men will have evidence of BPH and 30% will have
symptoms. Around 80% of 80-year-old men have evidence of BPH
ethnicity: black > white > Asian

BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised
into:

voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy,

terminal dribbling and incomplete emptying
storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia
post-micturition: dribbling
complications: urinary tract infection, retention, obstructive uropathy

Management options

watchful waiting
medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination
therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial
surgery: transurethral resection of prostate (TURP)

Alpha-1 antagonists e.g. tamsulosin, alfuzosin

decrease smooth muscle tone (prostate and bladder)

considered first-line, improve symptoms in around 70% of men
adverse effects: dizziness, postural hypotension, dry mouth, depression

5 alpha-reductase inhibitors e.g. finasteride

block the conversion of testosterone to dihydrotestosterone (DHT), which is known to

induce BPH
unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow
disease progression. This however takes time and symptoms may not improve for 6
months. They may also decrease PSA concentrations by up to 50%
adverse effects: erectile dysfunction, reduced libido, ejaculation problems,
gynaecomastia.

20
Prostate cancer: PSA testing
Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant
prostate epithelial cells. It has become an important tumour marker but much controversy still
exists regarding its usefulness as a screening tool.

The NHS Prostate Cancer Risk Management Programme (PCRMP) has published updated
guidelines in 2009 on how to handle requests for PSA testing in asymptomatic men. A recent
European trial (ERSPC) showed a statistically significant reduction in the rate of death prostate
cancer by 20% in men aged 55 to 69 years but this was associated with a high risk of over-
diagnosis and over-treatment. Having reviewed this and other data the National Screening
Committee have decided not to introduce a prostate cancer screening programme yet but
rather allow men to make an informed choice.

Age-adjusted upper limits for PSA were recommended by the PCRMP:

Age PSA level (ng/ml)

50-59 years 3.0

60-69 years 4.0

> 70 years 5.0

PSA levels may also be raised by*:

benign prostatic hyperplasia (BPH)

prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at
least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract

Poor specificity and sensitivity

around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer.
With a PSA of 10-20 ng/ml this rises to 60% of men
around 20% with prostate cancer have a normal PSA

21
 various methods are used to try and add greater meaning to a PSA level including age-
adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA
doubling time)

*whether digital rectal examination actually causes a rise in PSA levels is a matter of debate
Following a complete prostatectomy the PSA level should be 'undetectable' which is defined
usually as a value less than 0.2ng/ml. Therefore following 3 months a value of 2 (albeit within
the normal range for patients who have not had treatment) would be considered a significantly
elevated value and would therefore warrant urgent refrral to oncology for further
investigation.

Prostate cancer: features

Prostate cancer is now the most common cancer in adult males in the UK and is the second
most common cause of death due to cancer in men after lung cancer.

Risk factors

increasing age
obesity
Afro-Caribbean ethnicity
family history: around 5-10% of cases have a strong family history

Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop
in the periphery of the prostate and hence don't cause obstructive symptoms early on. Possible
features include:

bladder outlet obstruction: hesitancy, urinary retention

haematuria, haematospermia
pain: back, perineal or testicular
digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median
sulcus.

22
Isotope bone scan (using technetium-99m labelled diphosphonates which accumulate in the
bones) from a patient with metastatic prostate cancer. The scan demonstrates multiple,
irregular, randomly distributed foci of high grade activity involving the spine, ribs, sternum,
pelvic and femoral bones. The findings are in keeping with multiple osteoblastic metastasis.

'If a hard, irregular prostate typical of a prostate carcinoma is felt on rectal examination, then
the patient should be referred urgently. The PSA should be measured and the result should
accompany the referral.'
It is vital to remember that the PSA test is not a sensitive test meaning that if a person has
prostate cancer the test will not always be elevated. Approximately 1 in 50 men (two per cent)
with fast-growing prostate cancer have a normal PSA level.

NICE recommend offering a PR and PSA test to men with any of the following unexplained
symptoms:

erectile dysfunction
haematuria
lower back pain
bone pain
weight loss, especially in the elderly.
Prior to doing a PSA, a urine dipstick/MSU should be done to exclude infection. After
treatment for a UTI, PSA should not be tested for 1 month.

If the age specific PSA is high or increasing, with a normal PR examination, refer urgently
even if the patient is asymptomatic.
In an asymptomatic patient with a PSA at the upper limit of normal, repeat PSA after 1-3
months. If the PSA is increasing, an urgent referral should be sent

23
You are discussing an elevated PSA result with one of your patients, a 62-year-old man with a
PSA level of 7.2 ng/ml. Which procedure is he most likely to have following referral to a
urologist?
A TRUS-guided biopsy is need to clarify the diagnosis as around two-thirds of such patients will
not have prostate cancer.

Prostate cancer: management

Localised prostate cancer (T1/T2)

Treatment depends on life expectancy and patient choice. Options include:

conservative: active monitoring & watchful waiting

radical prostatectomy
radiotherapy: external beam and brachytherapy

Localised advanced prostate cancer (T3/T4)

Options include:

hormonal therapy: see below

radical prostatectomy
radiotherapy: external beam and brachytherapy

Metastatic prostate cancer disease - hormonal therapy

Synthetic GnRH agonist

e.g. Goserelin (Zoladex)

cover initially with anti-androgen to prevent rise in testosterone

Anti-androgen

cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes

Orchidectomy

Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting

gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial
24
stimulation of luteinising hormone release by the pituitary gland resulting in increased
testosterone levels.
The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.

Prostate cancer: prognosis

The Gleason score is used to predict prognosis in patients with prostatic cancer. The grading
system is based on the glandular architecture seen on histology following hollow needle biopsy

The most prevalent and the second most prevalent pattern seen are added to obtain a Gleason
score. The Gleason grade ranges from 1 to 5 meaning the Gleason score ranges from 2 to 10
(i.e. two values added)
The higher the Gleason score the worse the prognosis

Colorectal cancer: screening

Colorectal cancer screening - PPV of FOB = 5 - 15%

What is the lifetime risk of developing colorectal cancer in the United Kingdom? >>>> 5 %
Colorectal cancer is the third most common cancer in the UK, with approximately 30,000 new
cases in England and Wales per year.
There is also a 30-45% chance of having an adenoma with a positive faecal occult blood test.
Carcinoembryonic antigen may be used to monitor for recurrence in patients post-operatively
or to assess response to treatment in patients with metastatic disease
Overview

most cancers develop from adenomatous polyps. Screening for colorectal cancer has
been shown to reduce mortality by 16%
the NHS now has a national screening programme offering screening every 2 years to all
men and women aged 60 to 74 years. Patients aged over 74 years may request
screening
eligible patients are sent faecal occult blood (FOB) tests through the post
patients with abnormal results are offered a colonoscopy

At colonoscopy, approximately:

5 out of 10 patients will have a normal exam

4 out of 10 patients will be found to have polyps which may be removed due to their
premalignant potential
1 out of 10 patients will be found to have cancer

25
Colorectal cancer: referral guidelines
NICE updated their referral guidelines in 2015. The following patients should be referred
urgently (i.e. within 2 weeks) to colorectal services for investigation:

patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces (see below)

An urgent referral (within 2 weeks) should be 'considered' if:

there is a rectal or abdominal mass

there is an unexplained anal mass or anal ulceration
patients < 50 years with rectal bleeding AND any of the following unexplained
symptoms/findings:
- abdominal pain
- change in bowel habit
- weight loss
- iron deficiency anaemia

Faecal Occult Blood Testing (FOBT)

This was one of the main changes in 2015. Remember that the NHS now has a national
screening programme offering screening every 2 years to all men and women aged 60 to 74
years. Patients aged over 74 years may request screening.

In addition FOBT should be offered to:

patients >= 50 years with unexplained abdominal pain OR weight loss

patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency

26
Scrotal problems
Varicoceles may be associated with infertility

Epididymal cysts

Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

Features

separate from the body of the testicle

found posterior to the testicle

Associated conditions

polycystic kidney disease

cystic fibrosis
von Hippel-Lindau syndrome

Diagnosis may be confirmed by ultrasound.

Management is usually supportive but surgical removal or sclerotherapy may be attempted for
larger or symptomatic cysts.

Hydrocele

A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided
into communicating and non-communicating:

communicating: caused by patency of the processus vaginalis allowing peritoneal fluid

to drain down into the scrotum. Communicating hydroceles are common in newborn
males (clinically apparent in 5-10%) and usually resolve within the first few months of
life
non-communicating: caused by excessive fluid production within the tunica vaginalis

Hydroceles may develop secondary to:

epididymo-orchitis
testicular torsion
testicular tumours

27
Features

soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get 'above' the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large

Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or
if the underlying testis cannot be palpated.

Management

infantile hydroceles are generally repaired if they do not resolve spontaneously by the
age of 1-2 years
in adults a conservative approach may be taken depending on the severity of the
presentation. Further investigation (e.g. ultrasound) is usually warranted however to
exclude any underlying cause such as a tumour

Varicocele

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic
but may be important as they are associated with infertility.

Varicoceles are much more common on the left side (> 80%). Features:

classically described as a 'bag of worms'

subfertility

Diagnosis

ultrasound with Doppler studies

Management

usually conservative
occasionally surgery is required if the patient is troubled by pain. There is ongoing
debate regarding the effectiveness of surgery to treat infertility

28
A 31-year-old man presents as he and his partner have been having problems conceiving. On
examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful
and the testicle, which can be felt separately, is normal.>>> Varicocele

A 44-year-old man notices a pea-sized lump on his right testicle. On examination a discrete soft
mass can be felt posterior to the right testicle.>>> Epididymal cyst

A 75-year-old man presents with a swelling in his right scrotum. On examination a large, non-
tender swelling is found in the scrotum. You cannot palpate above the swelling during the
examination.>>> Inguinal hernia

A hydrocele is less likely as you cannot 'get above' the swelling on examination.

Haemorrhoids
Fibre supplementation has been shown to be as effective as injection sclerotherapy in some
studies
Haemorrhoids usually occur at the 3 o'clock, 7 o'clock and 11 o'clock position

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence.
These mucosal vascular cushions are found in the left lateral, right posterior and right anterior
portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are

29
said to exist when they become enlarged, congested and symptomatic

Clinical features

painless rectal bleeding is the most common symptom

pruritus
pain: usually not significant unless piles are thrombosed
soiling may occur with third or forth degree piles

Types of haemorrhoids

External

originate below the dentate line

prone to thrombosis, may be painful

Internal

originate above the dentate line

do not generally cause pain

Grading of internal haemorrhoids

Grade I Do not prolapse out of the anal canal

Grade II Prolapse on defecation but reduce spontaneously

Grade III Can be manually reduced

Grade IV Cannot be reduced

Management

soften stools: increase dietary fibre and fluid intake

topical local anaesthetics and steroids may be used to help symptoms
outpatient treatments: rubber band ligation is superior to injection sclerotherapy
surgery is reserved for large symptomatic haemorrhoids which do not respond to
outpatient treatments

30
 newer treatments: Doppler guided haemorrhoidal artery ligation, stapled
haemorrhoidopexy

Acutely thrombosed external haemorrhoids

typically present with significant pain

examination reveals a purplish, oedematous, tender subcutaneous perianal mass
if patient presents within 72 hours then referral should be considered for excision.
Otherwise patients can usually be managed with stool softeners, ice packs and
analgesia. Symptoms usually settle within 10 days

Anal fissure
Anal fissure - topical glyceryl trinitrate

The combination of pain and bleeding is very characteristic of anal fissures. Pain is a feature of
thrombosed external haemorrhoids but is unusual with internal haemorrhoids. Superficial anal
fissures may be difficult to see on examination.
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If
present for less than 6 weeks they are defined as acute, and chronic if present for more than 6
weeks. Around 90% of anal fissures occur on the posterior midline

Management of an acute anal fissure (< 6 weeks)

dietary advice: high-fibre diet with high fluid intake

bulk-forming laxatives are first line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics

-analgesia

topical steroids do not provide significant relief

31
Management of a chronic anal fissure (> 6 weeks)

the above techniques should be continued

topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary referral should be
considered for surgery or botulinum toxin

A 23-year-old man presents with a three week history of painless rectal bleeding. The bleeding
typically occurs post defecation and blood is noted in the toilet pan and on paper when he
wipes himself. He is otherwise well and his bowel habit is regular, though recently he has been
slightly constipated.>>> Haemorrhoids

Post defecatory rectal bleeding that is noted in the toilet pan and on toilet paper is often
haemorroidal in nature. In this age group detailed colonic assessments are not required
provided that digital rectal examination (and ideally proctoscopy) are concordant with this
diagnosis.

34-year-old lady presents with a long history of chronic constipation and occasional episodic
rectal bleeding. Abdominal examination is unremarkable, on digital rectal examination she has
an indurated ulcer located anteriorly approximately 4cm from the dentate line.>>> Solitary
rectal ulcer

Solitary rectal ulcers are well documented in patients with chronic constipation and repeated
straining. Their exact aetiology is not well understood. Biopsy of these lesions is mandatory and
the histological appearances are usually diagnostic and exclude malignancy. Treatment is
usually directed at correcting the reason for the underlying constipation.

A 23-year-old lady presents with a one week history of painful rectal bleeding that typically
occurs in association with the passage of the stool and is also noted on wiping the anus
afterwards. Examination of the anorectum is impossible due to pain. However, external
inspection reveals a midline sentinel skin tag.>>> Fissure in ano

Fissure in ano is a common cause of painful rectal bleeding. Examination of the anorectum
(which must be performed) is often best deferred until the fissure is less painful and hopefully
healed. The external appearance of a sentinel skin tag together with this history is strongly
suggestive of the diagnosis. Whilst posteriorly sited fissures are often related to the passage of
hard stool, those located anteriorly or if multiple are strongly suggestive of underlying organic
disease and merit endoscopy.

32
Circumcision
Circumcision has been performed in a variety of cultures for thousands of years. Today it is
mainly people of the Jewish and Islamic faith who undergo circumcision for religious/cultural
reasons. Circumcision for religious or cultural reasons is not available on the NHS.

The medical benefits of routine circumcision remain controversial although some evidence has
emerged that it:

reduces the risk of penile cancer

reduces the risk of UTI
reduces the risk of acquiring sexually transmitted infections including HIV

Medical indications for circumcision

phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis

It is important to exclude hypospadias prior to circumcision as the foreskin may be used in

surgical repair. Circumcision may be performed under a local or general anaesthetic.

Ankle-brachial pressure index

The ankle-brachial pressure index (ABPI) is the ratio of the systolic blood pressure in the lower
leg to that in the arms. Lower blood pressure in the legs (result in a ABPI < 1) is an indicator of
peripheral arterial disease (PAD). ABPI is therefore useful in evaluating patients with suspected

33
PAD, for example a male smoker who presents with intermittent claudication.

It is also important to determine the ABPI in patients with leg ulcers. Venous ulcers are often
treated with compression bandaging. Doing this in a patient with PAD could however be
harmful as it would further restrict the blood supply to the foot. ABPIs should therefore always
be measured in patients with leg ulcers.

Interpretation of ABPI

> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
1.0 - 1.2: normal
0.9 - 1.0: acceptable
< 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently

The ABPI is a good test, values less than 0.90 have been shown to have a sensitivity of 90% and
a specificity of 98%* for PAD.

Compression bandaging is generally considered acceptable if the ABPI >= 0.8.

*Yao ST, Hobbs JT, Irvine WT. Ankle systolic pressure measurements in arterial disease affecting
the lower extremities.

34
Peripheral arterial disease: management
A 60-year-old man is investigated for intermittent claudication. He is referred to the local
vascular unit and a diagnosis of peripheral arterial disease is made. His blood pressure is 128/78
mmHg and his fasting cholesterol 3.8 mmol/l. Following recent NICE guidelines which of the
following medications should he be taking?

As this patient has established cardiovascular disease he should be taking a statin, regardless of
the baseline cholesterol. The 2010 NICE guidelines on clopidogrel changed the previous advice
that all patients with established cardiovascular disease should be taking aspirin, unless there is
a contraindication. NICE propose that clopidogrel is now used first-line following an ischaemic
stroke and also in peripheral arterial disease.
Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should
be given help to quit.

Comorbidities should be treated, including

hypertension
diabetes mellitus
obesity

As with any patient who has established cardiovascular disease, all patients should be taking a
statin. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in
patients with peripheral arterial disease in preference to aspirin.
Exercise training has been shown to have significant benefits. NICE recommend a supervised
exercise programme for all patients with peripheral arterial disease prior to other interventions.

Severe PAD or critical limb ischaemia may be treated by:

angioplasty
stenting
bypass surgery

Amputation should be reserved for patients with critical limb ischaemia who are not suitable
for other interventions such as angioplasty of bypass surgery.

Drugs licensed for use in peripheral arterial disease (PAD) include:

naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects -
not recommended by NICE.

35
Complex regional pain syndrome
Complex regional pain syndrome (CRPS) is the modern, umbrella term for a number of
conditions such as reflex sympathetic dystrophy and causalgia. It describes a number of
neurological and related symptoms which typically occur following surgery or a minor injury.
CRPS is 3 times more common in women.

There are two types of CRPS:

type I (most common): there is no demonstrable lesion to a major nerve

type II: there is a lesion to a major nerve

Features

progressive, disproportionate symptoms to the original injury/surgery

allodynia
temperature and skin colour changes
oedema and sweating
motor dysfunction
the Budapest Diagnostic Criteria are commonly used in the UK

Management

early physiotherapy is important

neuropathic analgesia in-line with NICE guidelines
specialist management (e.g. Pain team) is required

36
37
A patient presents with allodynia, swelling and motor dysfunction of the right foot following a
severe ankle sprain four months ago. A diagnosis of complex regional pain syndrome is
suspected. What is the most appropriate management?

Amitriptyline + physiotherapy.

Antibiotic guidelines
The following is based on current BNF guidelines:

Respiratory system
Condition Recommended treatment

Exacerbations of chronic Amoxicillin or tetracycline or clarithromycin

bronchitis

Uncomplicated community- Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add

acquired pneumonia flucloxacillin if staphylococci suspected e.g. In influenza)

Pneumonia possibly caused Clarithromycin

by atypical pathogens

Hospital-acquired Within 5 days of admission: co-amoxiclav or cefuroxime

pneumonia More than 5 days after admission: piperacillin with tazobactam OR
a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone
(e.g. ciprofloxacin)

Urinary tract
Condition Recommended treatment

Lower urinary tract Trimethoprim or nitrofurantoin. Alternative: amoxicillin or

infection cephalosporin

Acute pyelonephritis Broad-spectrum cephalosporin or quinolone

Acute prostatitis Quinolone or trimethoprim

38
Skin
Condition Recommended treatment

Impetigo Topical fusidic acid, oral flucloxacillin or erythromycin if

widespread

Cellulitis Flucloxacillin (clarithromycin or clindomycin if penicillin-allergic)

Erysipelas Phenoxymethylpenicillin (erythromycin if penicillin-allergic)

Animal or human bite Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Mastitis during breast- Flucloxacillin

feeding

Ear, nose & throat

Condition Recommended treatment

Throat infections Phenoxymethylpenicillin (erythromycin alone if penicillin-

allergic)

Sinusitis Amoxicillin or doxycycline or erythromycin

Otitis media Amoxicillin (erythromycin if penicillin-allergic)

Otitis externa* Flucloxacillin (erythromycin if penicillin-allergic)

Periapical or periodontal abscess Amoxicillin

Gingivitis: acute necrotising Metronidazole

ulcerative

39
Genital system
Condition Recommended treatment

Gonorrhoea Intramuscular ceftriaxone + oral azithromycin

Chlamydia Doxycycline or azithromycin

Pelvic inflammatory Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral

disease doxycycline + oral metronidazole

Syphilis Benzathine benzylpenicillin or doxycycline or erythromycin

Bacterial vaginosis Oral or topical metronidazole or topical clindamycin

Gastrointestinal
Condition Recommended treatment

Clostridium difficile First episode: metronidazole

Second or subsequent episode of infection: vancomycin

Campylobacter enteritis Clarithromycin

Salmonella (non-typhoid) Ciprofloxacin

Shigellosis Ciprofloxacin

*a combined topical antibiotic and corticosteroid is generally used for mild/moderate cases of
otitis externa
In the context of fever and/ or significantly delayed presentation to a dentist, antibiotics may be
appropriate. The BNF recommends amoxicillin first line for dental abscesses and metronidazole
second line or for more invasive dental conditions.

GPs have little training in dental problems and this patient is best managed by her dentist.
Prompt drainage of the abscess is the best treatment. Antibiotics are generally not indicated for
otherwise healthy individuals when there no signs of spreading infection.

40
NICE CKS guidelines recommend only prescribe an antibiotic:

For people who are systemically unwell or if there are signs of severe infection (e.g.
fever, lymphadenopathy, cellulitis, diffuse swelling)
For high risk individuals to reduce the risk of complications (e.g. people who are
immunocompromised or diabetic or have valvular heart disease)

Obesity: bariatric surgery

Obesity - NICE bariatric referral cut-offs

with risk factors (T2DM, BP etc): > 35 kg/m^2

no risk factors: > 40 kg/m^2
Laparoscopic-adjustable gastric banding is the intervention of choice in patients with a
BMI < 40 kg/m^2.

Sibutramine has recently been withdrawn due to concerns about a possible increased
risk of cardiovascular events

The use of bariatric surgery in the management of obesity has developed significantly over the
past decade. It is now recognised that for many obese patients who fail to lose weight with
lifestyle and drug interventions the risks and expense of long-term obesity outweigh those of
surgery.

NICE guidelines on bariatric surgery for adults

Consider surgery for people with severe obesity if:

they have a BMI of 40 kg/m^2 or more, or between 35 kg/m^2 and 40 kg/m^2 and
other significant disease (for example, type 2 diabetes mellitus, hypertension) that could
be improved if they lost weight
all appropriate non-surgical measures have failed to achieve or maintain adequate
clinically beneficial weight loss for at least 6 months
they are receiving or will receive intensive specialist management
they are generally fit for anaesthesia and surgery
they commit to the need for long-term follow-up

Consider surgery as a first-line option for adults with a BMI of more than 50 kg/m2 in whom
surgical intervention is considered appropriate; consider orlistat before surgery if the waiting
time is long

41
Types of bariatric surgery:

primarily restrictive: laparoscopic-adjustable gastric banding (LAGB) or sleeve

gastrectomy
primarily malabsorptive: classic biliopancreatic diversion (BPD) has now largely been
replaced by biliopancreatic diversion with duodenal switch
mixed: Roux-en-Y gastric bypass surgery

Which operation?

LAGB produces less weight loss than malabsorptive or mixed procedures but as it has
fewer complications it is normally the first-line intervention in patients with a BMI of 30-
39kg/m^2

42
 patients with a BMI > 40 kg/m^2 may be considered for a gastric bypass or sleeve
gastrectomy. The latter may be done as a sole procedure or as an initial procedure prior
to bypass
primarily malabsorptive procedures are usually reserved for very obese patients (e.g.
BMI > 60 kg/m^2)

Dupuytren's contracture
Dupuytren's contracture is actually a thickening of the palmar fascia rather than the tendons

Dupuytren's contracture has a prevalence of about 5%. It is more common in older male
patients and around 60-70% have a positive family history

Specific causes include:

manual labour
phenytoin treatment
alcoholic liver disease
trauma to the hand

Myxoid cyst

43
Myxoid cysts (also known as mucous cysts) are benign ganglion cysts usually found on the
distal, dorsal aspect of the finger. There is usually osteoarthritis in the surrounding joint. They
are more common in middle-aged women.

Ganglion
A ganglion presents as a 'cyst' arising from a joint or tendon sheath. They are most commonly
seen around the back of the wrist and are 3 times more common in women

Ganglions often disappear spontaneously after several months

Tumour markers
Tumour markers may be divided into:

monoclonal antibodies against carbohydrate or glycoprotein tumour antigens

tumour antigens
enzymes (alkaline phosphatase, neurone specific enolase)
hormones (e.g. calcitonin, ADH)

It should be noted that tumour markers usually have a low specificity

44
Monoclonal antibodies

Tumour marker Association

CA 125 Ovarian cancer

CA 19-9 Pancreatic cancer

CA 15-3 Breast cancer

Tumour antigens

Tumour marker Association

Prostate specific antigen (PSA) Prostatic carcinoma

Alpha-feto protein (AFP) Hepatocellular carcinoma, teratoma

Carcinoembryonic antigen (CEA) Colorectal cancer

S-100 Melanoma, schwannomas

Bombesin Small cell lung carcinoma, gastric cancer, neuroblastoma

My Notes

The most common joint that gout affects is the first

metatarsophalangeal joint.( E ).

45
A 37-year-old woman with a history of gallstones is listed to have a laparoscopic
cholecystectomy in three months time. She is currently prescribed Microgynon 30 (combined
oral contraceptive pill). The patient asks for advice as she is aware that her contraceptive pill
may increase the risk of blood clots. What is the most appropriate advice in this situation?

She should stop Microgynon 28 days before the procedure

6-year-old boy with a limp. His parents report that this has been getting steadily worse over the
past few weeks. He complains of pain in the right groin/hip region. An x-ray shows widening of
the right hip joint space with flattening of the femoral head.>>> Perthes disease

Pointers to Perthes:

gender: 5 times more common in boys

age: typical presents in children aged 4-8 years
x-ray findings

A 7-year-old boy is brought in by his mother. For the past day he has felt generally unwell with
a headache and nausea. This morning he complained of pain in his right hip and now just able
to walk with a limp. On examination flexion, extension and rotation of the hip is painful and
limited. Examination of the ears, throat and chest is normal. His temperature is 38.2C.
>>> Septic arthritis

This boy needs to admitted for further evalulation of a suspected septic hip joint. There is no
obvious alternative focus to explain his fever.

This degree of pain and fever is not common in transient synovitis.

4-year-old girl with a three month history of a limp. Her parents report that she has 'not been
right' for a few weeks now. She typically complains of pain in her left hip and right knee in the
morning which gets better during the day.>>> Juvenile idiopathic arthritis

This is a typical presentation of pauciarticular juvenile idiopathic arthritis.

You see a 48 year old presents with increasing pain whilst writing notes in her new job as a
secretary. She describes pain to her upper forearm which develops whilst she is writing. This is
only relieved when she stops writing and it progresses through the working day. On
examination she has elbow pain with wrist dorsiflexion and middle finger extension. There is no
weakness. What is the most likely diagnosis?

Tennis elbow or lateral epicondylitis is essentially a repetitive strain injury of the extensor
muscles of the forearm which insert at the lateral epicondyle of the elbow. Typically this causes
pain at the lateral epicondyle area which is exacerbated by gripping small objects and twisting

46
motions such as opening a jar. On examination passive extension of the wrist with the elbow in
full extension reproduces the pain. Pain can also be brought on by middle finger extension.
Like other sprains and strains it is treated conservatively with analgesia, rest, cold compresses
and sometimes physiotherapy.

Antiphospholipid syndrome: pregnancy

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both
venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a
primary disorder or secondary to other conditions, most commonly systemic lupus
erythematosus (SLE)

In pregnancy the following complications may occur:

recurrent miscarriage
IUGR
pre-eclampsia
placental abruption
pre-term delivery
venous thromboembolism

Management

low-dose aspirin should be commenced once the pregnancy is confirmed on urine

testing
low molecular weight heparin once a fetal heart is seen on ultrasound. This is usually
discontinued at 34 weeks gestation
these interventions increase the live birth rate seven-fold

Bisphosphonates
Bisphosphonates are analogues of pyrophosphate, a molecule which decreases
demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting
apoptosis.

Clinical uses

prevention and treatment of osteoporosis

hypercalcaemia
Paget's disease
pain from bone metatases

47
Adverse effects

oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)

osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft in patients taking
alendronate

The BNF suggests the following counselling for patients taking oral bisphosphonates

'Tablets should be swallowed whole with plenty of water while sitting or standing; to be
given on an empty stomach at least 30 minutes before breakfast (or another oral
medication); patient should stand or sit upright for at least 30 minutes after taking
tablet'

48