Definition

Reflux of gastro-duodenal contents into the oesophagus, causing symptoms that are sufficient to interfere with quality of life.

Incidence

20 to 25% of population have symptoms of GORD, oesophagitis is detected in 25 to 40% of gastroscopies performed on symptomatic patients. It is thought to be predisposed to by obesity, smoking and alcohol. Dietary factors such as excess fat, caffeine and citrus fruits; drugs such as atropine, calcium channel blockers and anti-histamines, various hormones and prostaglandins have also been described.

Aetiology and pathophysiology

Incompetence of lower oesophageal sphincter (LOS) due to predisposing factors or distortion of the acute angle of His as in hiatal hernia as well as absence of adequate length of intra-abdominal segment of oesophagus (< 2cm), destroyed mucosal rosette and deficient diaphragmatic crural mechanism. Finally, diminished oesophageal clearance by peristalsis and lowered mucosal resistance, normally maintained by its histological and biochemical properties; all these factors lead to reflux of gastric secretions into lower oesophagus exposing the mucosa to harmful gastric acid.

Natural history

90% asymptomatic. 10% of asymptomatic individuals develop complications such as reflux oesophagitis, ulceration and peri-oesophagitis; strictures and webs (Shatski's ring), which if severe can cause intermittent total obstruction (Steakhouse syndrome); columnar metaplasia (Barrett's oesophagus), where 10% of these progress to dysplasia which is precancerous.

Symptoms

Heartburn, regurgitation, water brash and dysphagia. Symptoms are aggravated with posture and are greater at night. Severity can be assessed by DeMeester scoring system which grades each of heartburn, regurgitation and dysphagia 0–3 according to severity. Clinical examination is usually performed to exclude other pathologies.

Definition

Bleeding from the gastrointestinal tract (GI) is an important surgical emergency that requires urgent evaluation and assessment if major morbidity and mortality is to be avoided. After initial assessment of haemodynamic status and resuscitation, attention should be drawn to trying to determine the site of bleeding as well as potential comorbidities.

Classification

Upper gastrointestinal haemorrhage is defined as bleeding occurring in the GI tract proximal to the ligament of Treitz (duodenojejunal flexure) whereas lower gastrointestinal haemorrhage is defined as bleeding arising in the bowel distal to this.

History

Patients commonly present with GI bleeding either to the emergency department, or often during hospital admission for another illness. In most cases the history offers the best clue as to the site of potential haemorrhage:

Bleeding: the mode of bleeding (haematemesis versus rectal bleeding), type (bright red, clotted, altered blood/melaena), and quantity of blood and duration of symptoms offer vital clues.Melaena refers to blood that has been partially digested by enzymes rendering it black and ‘tar-like’ in appearance and very foul smelling. Dark clotted blood usually results from a proximal lower GI bleed, but may be confused with melaena. Bright red bleeding usually implies a distal lower GI bleed.Note that a massive upper GI bleed may also present with bright red bleeding although the patient is usually very haemodynamically unstable in this case. Occult bleeding refers to a slow and intermittent pattern of blood loss and does not pose an immediate threat though warrants investigation.

Change in bowel habit: may signify underlying pathology.

Anion gap

Is calculated as: ([Na+] + [K+]) − ([Cl−] + [HCO3−]), all units in mmol/l (Normal: 16 ± 4 mmol/l).

Increases in anion gap seen in:

1. ▪ Diabetic ketoacidosis

2. ▪ Uraemic acidosis

3. ▪ Drug ingestion (e.g. salicylates)

4. ▪ Lactic acidosis

5. ▪ Hypokalaemia

6. ▪ Hypocalcaemia

7. ▪ Hypomagnesaemia

8. ▪ Hyperalbuminaemia

9. ▪ Laboratory error.

A decreased anion gap is less frequent but can be seen in:

1. ▪ Hypoalbuminaemia

2. ▪ Increased immunoglobulins (e.g. myeloma)

3. ▪ Hyperkalaemia

4. ▪ Hypercalcaemia

5. ▪ Hypermagnesaemia

6. ▪ Lithium therapy.

Body mass index (BMI)

BMI = Weight (kg)/Height (m)2.

1. ▪ A BMI of ≤ 20 means the patient is underweight.

2. ▪ 20–25 is desirable.

3. ▪ 25–30 is overweight.

4. ▪ > 30 is obese.

Body surface area (BSA)

1. ▪ BSA (m2) = 0.20247 × Height (m)0.725 × Weight (kg) – Dubois and Dubois method.

2. ▪ BSA (m2) = (Height (cm) ×Weight (kg)/3600) – Mosteller method.

Cardiac output (CO) (Fick method)

The cardiac output can be estimated by dividing oxygen consumption by the difference in oxygen content between arterial and venous blood. The difference between the arterial and mixed venous blood oxygen concentration correlates with oxygen uptake per unit of blood as it flows through the lungs (Fick principle). The method is cumbersome due to the need to collect expired air and arterial blood gases.

where 1.34 ml per gram is the amount of oxygen that a gram of haemoglobin can carry if 100% saturated.

Eponymous: giving one's name to something, as to an institution or a clinical sign (from the Greek, ‘epi’ meaning to, and ‘onoma’ meaning name).

Achilles' tendon: the combined tendon of the gastrocnemius and soleus muscles of the leg. It joins the calf muscles to the calcaneum. From mythology it was the only part of Achilles’ body that was still at risk after his mother had dipped him holding him by his heel into the river Styx.

Artery of Adamkiewicz: the largest of the medullary arteries which supply the spinal cord by anastomizing with the anterior spinal artery. Injury to this artery can result in ischaemia of the lower spinal cord – anterior spinal syndrome.

Adson's test: a test for thoracic outlet syndrome. The radial pulse is palpated and the patient's head turned to the opposite side of the arm being examined on deep inspiration. In the presence of compression of the thoracic outlet such as a cervical rib, the radial pulse will disappear.

Allen's test: tests the arterial supply to the hand which involves compression and release of radial and ulnar vessels and observation of colour change. Should be used prior to taking arterial blood gas samples from the radial artery or inserting an arterial line into this vessel.

Amyand's hernia: an inguinal hernia involving the appendix.

Amyrand's triangle: a diagrammatic triangular representation of the concentration of the constituents responsible for gallstone formation (bile salts, phospholipids and cholesterol).

Angle of Louis: the angle formed between the junction of the manubrium and the body of the sternum lies at the level of T4.

Radiotherapy remains a mainstay in the treatment of cancer. Comparison of the contribution towards cure by the major cancer treatment modalities shows that of those cured, 49% are cured by surgery, 40% by radiotherapy and 11% by chemotherapy. Many more patients may benefit from radiotherapy to enhance quality of life through palliation of symptoms of recurrent or metastatic disease.

Definition

Radiotherapy is the use of ionizing radiation to treat disease. Ionizing radiation may be delivered by X-ray beams, beams of ionizing particles such as electrons, or by beta or gamma irradiation produced by the decay of radioactive isotopes.

Biological action of ionizing radiation

Ionizing radiation causes damage to cellular DNA both directly, and indirectly through toxic free radicals produced when radiation interacts with water within the cell. Rapidly proliferating cells are particularly sensitive to this damage. This leads to single and double DNA-strand breakage and unless repaired, causes reproductive death of the cell. Ionizing radiation can also cause DNA base mutation, and a risk of late carcinogenesis; an important consideration in the treatment of children, young adults and benign diseases with radiation.

External beam radiotherapy: X-rays, gamma-rays (clinically equivalent to X-rays but produced by radionuclide decay) or electrons emitted from an external source are incident on the skin and deposit energy either superficially or more deeply, depending on the characteristics of the beam. High-energy, penetrating therapeutic X-ray beams (and electrons) are typically produced by megavoltage linear accelerators. This complex equipment is located in radiotherapy departments, housed in bunkers to minimize radiation exposure to staff when the machine is activated.

Introduction

Paediatric surgery encompasses a wide range of surgical pathologies based on the age of the patient (newborn to <16 years). Children <4 years old or with complicated pathologies and major medical co-morbidities are best managed in tertiary centres. Older paediatric patients with surgical conditions can be managed locally with medical paediatric advice. In children with a progressing surgical illness physiological derangement occurs rapidly and often without sufficient warning. Paediatric input is particularly important when managing the very ill and the very young. This applies particularly to newborns prior to referral/transfer to a tertiary surgical unit, who require cannulation etc. Inform the paediatric team early; their experience and practical skills will be invaluable. In the case of transfer to paediatric surgery tertiary referral units, clear communication is imperative to ensure they are adequately prepared for the child. Paediatric escort may be needed for safe transfer.

The parent

Can usually give important clues about a child's illness, especially the subtle changes of its early course. Children often give valuable clinical information which should not be ignored. History taking and examination in children requires patience, may not be in the usual order, and is best done with the parent and a paediatric nurse present. Consent for examination and procedures may be given by the mother or father (legally married) or a legal guardian. Further details on this are dealt with in the Consent and medico-legal considerations Chapter.

Fluid management

Careful fluid management is essential. Basic maintenance fluid requirements for infants and children can be calculated as below.

Introduction

About 27% of people > 55 yrs of age have peripheral arterial disease (PAD). Diabetics are 2–4 times more likely to have PAD. Around 15% develop PAD after 10 years of diabetes and 45% after 20 years. Diabetic foot accounts for the highest number of non-traumatic lower extremity amputations.

Definition

A neuroischaemic condition leading to soft tissue loss+/- infection over pressure-bearing areas.

Incidence

84% of patients with a 20-year history of diabetes have vascular disease and 75% die of vascular disease or its complications; primarily IHD and stroke. Gangrene occurs 50 times more commonly in diabetic males and 70 times more commonly in female diabetic patients as compared with non-diabetic patients.

Pathogenesis

Arterial occlusive disease in diabetics is a different pattern compared with atherosclerosis in non-diabetics. It mainly affects the distal popliteal segment, the tibial and metatarsal vessels with sparing of inflow and peroneal artery. Microscopically: thickening of the intima, increased thickness of the basement membrane, patchy distribution – diabetic microangiopathy.

Neuropathy: segmental demyelination of both sensory and motor nerves (defect in metabolism of Schwann cells) causing delayed nerve conduction. Distal nerves are affected more than proximal. Initial night cramps and paraesthesia progress to loss of vibratory sense and perception of light touch and pain and finally deep tendon reflexes are lost.

Motor dysfunction results in malfunction of the intrinsic muscles of the foot leading to distortion of foot architecture. It consists of extensor subluxation of the toes, plantar prominences of metatarsal heads and imbalance in action of flexors and extensors. The metatarsal arch then collapses. In its extreme form, the mid foot deteriorates leading to the so-called Charcot's foot.

Introduction

This procedure is the insertion of a drain into or aspiration of the peritoneal cavity.Drains can be inserted into the peritoneum in a trauma situation (diagnostic peritoneal lavage) and to manage renal failure (continuous ambulatory peritoneal dialysis). These will not be discussed here.

Indications

The indications for abdominal paracentesis are:

Therapeutic drainage of intra-abdominal fluid:

1. ▪ Relief of abdominal distension

2. ▪ Relief of pain

3. ▪ Respiratory compromise.

Diagnostics on peritoneal fluid:

1. ▪ Bacteriology

2. ▪ Chemical pathology – protein content

3. ▪ Cytology – suspected malignancy.

Contraindications

1. ▪ Severely scarred abdomen

2. ▪ Coagulopathy

3. ▪ Bowel obstruction

4. ▪ Pregnancy

5. ▪ Infected skin at insertion site.

Equipment

1. ▪ Either use a purpose-designed paracentesis set, or a Bonanno supra-pubic catheterization set can be used.

2. ▪ Drainage bag.

3. ▪ Sterile preparation.

4. ▪ Local anaesthetic.

5. ▪ Suture material.

6. ▪ Syringes and bottles for taking samples.

Technique

1. ▪ The patient is placed in a supine position.

2. ▪ The fluid/air interface is percussed out.

3. ▪ The site is marked with a pen. Preferred sites of entry are shown in Figure 141. These are either of the lower quadrants (lateral to the rectus muscle), or below the umbilicus. Paracentesis site should not be at a site of prior incision and must not be infected.

4. ▪ The patient is prepared and draped.

5. ▪ The anaesthetic is injected into the skin and infiltrated down into the abdominal wall.

6. ▪ Sampling: a 14-gauge needle with a syringe can be used to obtain peritoneal fluid.

7. ▪ Therapeutic drainage: a Bonanno catheter, CVP catheter or peritoneal dialysis catheter are inserted using a stylette or a Seldinger technique.

8. […]

This important condition has a significant morbidity and mortality and therefore requires a high index of suspicion. It can be missed as it often presents in the elderly and infirm.

Definition and classification

Volvulus is a rotation of a segment of bowel about its longitudinal mesenteric axis, resulting in occlusion of the proximal section. It most commonly affects the colon (the sigmoid and caecum) although small bowel (usually the lower ileum) or stomach may also be affected. It can be classified as primary (i.e. caused by congenital intestinal malrotation, abnormal mesenteric attachments or congenital ‘Ladd's’ bands), or secondary (more common), and can be either acute or chronic.

Incidence

Sigmoid volvulus is the most common type and is responsible for approximately 8% of all intestinal obstructions. Men are more commonly affected than women, most commonly in the sixth decade of life. Caecal volvulus is more common in women.

Aetiology

Associated with increasing age, chronic constipation, a high-roughage diet, lead poisoning, neurological conditions (e.g. Parkinson's disease), Surgical emergencies Hirschsprung's disease, patients in nursing homes and mental health facilities. Can be caused by round-worm infection and Chagas disease. Incomplete midgut rotation predisposes to caecal volvulus.

Pathology

Macroscopic: volvulus occurs secondary to a narrow mesentery in association with a long redundant sigmoid allowing two segments of bowel to come together and twist around the axis, usually anticlockwise in the case of the sigmoid volvulus, varying from 180° (35%) to 540° (10%) (Figure 43). Caecal volvulus usually involves clockwise axial rotation of terminal ileum, caecum and ascending colon around ileocolic vessels and mesentery (Figure 44). Microscopic: venous congestion andarterial compromise cause ischaemia and infarction.

The origins of the site-specific cancer multidisciplinary team

1. ▪ In 1991 the UK Department of Health consultative document ‘The Health of the Nation’ concluded that cancer accounted for 25% of all deaths, and that death and ill health from cancer should be reduced. ▪ In 1995 the Calman-Hine report took this further, setting out that ‘all patients should have access to a uniformly high quality of care … wherever they may live.’ This was the origin of the term‘postcode lottery’ in relation to cancer care.

2. ▪ In 1997 the NICE Clinical Outcomes Guidelines (COG) for colorectal cancer suggested that there were ‘significant variations both in process and outcomes of colorectal cancer care across the country’ recommending that treatment of cancers should be carried out by ‘a coordinated team with particular interest and expertise in this field‘.

3. ▪ In 2000, the NHS Cancer Plan was published, stating that ‘every patient diagnosed with cancer will benefit from pre-planned care’ and that this care should be ‘delivered by specialist teams in line with evidence on best practice’.

The cancer multidisciplinary team aims to bring together cancer diagnosticians and those involved in cancer treatment and patient support to discuss the diagnostics and all aspects of care of each cancer patient.

Specific responsibilities of the multidisciplinary team (MDT) are to:

1. ▪ Agree appropriate membership and ensure attendance.

2. ▪ Develop systems that collect and present all the relevant information needed for decision making.

3. ▪ Ensure that the care of every cancer patient is discussed at MDT meetings.

4. ▪ Record the decisions that are made.

5. […]

Congenital abnormalities

Congenital absence of the breast – complete absence of both the breast and nipple (amastia). Breast hypoplasia is more common and some degree of asymmetry can be seen in many women.

Accessory nipples – caused by failure of the regression of the primitive milk line, present in 1% of people; can be excised if problematic.

Accessory breast – polymastia.

Developmental disorders

Excessive breastenlargement – minor degrees of enlargement can occur in infancy related to maternal oestrogens.

Male breast enlargement occurs in 30% of boys at puberty. Usually reverses spontaneously.

Gynaecomastia can occur in juveniles with hormonal abnormalities or hormone-secreting tumours. Other causes: hypogonadism, liver disease, hormone-secreting tumours and drugs e.g. spironolactone, cimetidine, isoniazid, omeprazole, finasteride, marijuana, thyroxine and digoxin.

Disorders of cyclical change

Benign mammary dysplasia – this usually affects pre-menopausal women and is characterized by pre-menstrual breast nodularity and pain commonly in the upper outer quadrant. If there is concern that a nodule may be malignant then a mammogram and a FNAC (fine needle aspiration and cytology) should be performed. This is an aberration of normal development and involution (ANDI) and includes the following conditions:

1. Fibrosis

2. Adenosis – multiplication of acini

3. Cyst formation – macro or microcysts

4. Epitheliosis – hyperplasia of epithelium

5. Papillomatosis – papillomatous overgrowth within the ducts.

Management – usually reassurance, analgesia, a well-fitting bra and evening primrose oil may help. Occasionally drugs such as danazol, tamoxifen or bromocriptine may be used. In very rare circumstances a mastectomy may be considered for symptomatic treatment.

Cystic disease – cysts occur commonly in women who are approaching the menopause and aspiration should be attempted.

History

The history from the patient is essential in helping you to establish the causes of disease and assessing whether there is an increased risk of malignancy. The history should be taken in a private place and it should be done with sympathy, as most breast patients are very anxious. This should cover:

Age of the patient: this is very important. Remember, cancers are uncommon below the age of thirty.

Lump: always ask about: the length of time it has been present. Its relation to the menstrual cycle. Exact location (note which breast). Does its size vary? Is it getting larger?

Pain: is the lump painful? Is this cyclical?

Nipple discharge: ascertain colour, quantity, pattern, frequency.

Skin changes of the breast/nipple.

Shape of breast: ask if she has noticed any nipple retraction, breast distortion.

Metastatic related symptoms: e.g. back pain, shortness of breath, jaundice.

Previous breast disease, and whether this was investigated/treated.

Family history: this is extremely important, and many clinics offer family counselling and screening.

Other risk factors for breast cancer (see Breast cancer Chapter).

Genetics of breast cancer: 5–10% of breast cancers are inherited in a dominant fashion. They are of an early onset and are associated with other tumours e.g. bowel, ovarian. The following genes have been isolated: BRCA1 (chromosome 17q21), BRCA2 (chromosome 13q24), P53 gene on chromosome 17p (associated with Li-Fraumeni syndrome).

Medication: HRT, OCP.

Gynaecological/obstetric history: all these symptoms should be related to the woman's normal cycle.

Definition

A branch of applied mathematics concerned with the collection and interpretation of quantitative data and the use of probability theory to estimate population parameters.

Basic terms

Mean: the sum of observations divided by the number of observations. For normal distributions, the mean is the better measure of central tendency as it does not fluctuate with the sample.

Median: the value which divides the observations into two equal halves when they are arranged in order of increasing value.

Mode: themost frequently occurring value in a distribution. It fluctuates with the sample and many distributions have more than one mode, hence it should not be used on its own.

Range: the difference between the largest and smallest values.

Percentiles: these divide a data set into 100 equally sized groups

Interquartile range: the difference between the 75th percentile and the 25th percentile.

Standard deviation (SD): can be regarded as being approximately equal to the average distance each individual lies away from the sample mean. 68% of the data will lie between 1 SD on each side of a normal distribution. 95.4% of the data will lie between 2 SDs and 99.7% between 3SDs.

Variance: a measure of how spread out a distribution is. It is equivalent to the standard deviation squared.

Standard error of themean(SE): the standard deviation of the subgroup gives a statistic that determines the spread of that subgroup. However, often it is useful to know how variable the means of a number of such subgroups would be so that the range over which the mean of the whole population lies can be assessed without actually taking measurements on the entire population.