10 Acute abdominal pain

Definitions
Abdominal pain is a subjective unpleasant sensation felt in any of the abdominal regions. Acute abdominal pain is usually used to refer to pain of sudden onset, and/or short duration. Referred pain is the perception of pain in an area remote from the site of origin of the pain.
KEY POINTS
The level of abdominal pain generally relates to the origin: foregut— upper; midgut—middle; hindgut—lower.
• Generally, colicky (visceral) pain is caused by stretching or contracting
a hollow viscus (e.g. gallbladder, ureter, ileum).
• Generally, constant localized (somatic) pain is caused by peritoneal
irritation and indicates the presence of inflammation/infection
(e.g. pancreatitis, cholecystitis, appendicitis).
• Associated back pain suggests retroperitoneal pathology
(aortic aneurysm, pancreatitis, posterior DU, pyelonephritis).
• Associated sacral or perineal pain suggests pelvic pathology
(ovarian cyst, PID, pelvic abscess).
• Generally, very severe pain indicates ischaemia or generalized
peritonitis (e.g. mesenteric infarction, perforated duodenal ulcer).
• Pain out of proportion to the physical signs suggests ischaemia
without perforation.
• Remember referred causes of pain: pneumonia (right lower lobe),
myocardial infarction, lumbar nerve root pathology.

KEY INVESTIGATIONS
• EBO: leucocytosis, infective/inflammatory diseases, anaemia, occult
malignancy, PUD.
• LETs: usually abnormal in cholangitis, may be abnormal in acute
cholecystitis.
• Amylase: serum level >1000 iu diagnostic of pancreatitis. Serum level
500—1000 iu, ?pancreatitis, perforated ulcer, bowel ischaemia, severe
sepsis. Serum level raised <500 iu, non-specific indicator of pathology.
• 3-HOG (serum): ectopic pregnancy.
• Arterial blood gases: metabolic acidosis—?bowel ischaemia,
peritonitis, pancreatitis.
• MSU: urinary tract infection (++ve nitrites, blood, protein), renal stone
(++ve blood).
• EGG: myocardial infarction.
• Chest X-ray: perforated viscus (free gas), pneumonia.
• Abdominal X-ray:
ischaemic bowel (dilated, thickened oedematous loops)
pancreatitis (‘sentinel’ dilated upper jejunum)
cholangitis (air in biliary tree)
acute colitis (dilated, oedematous, featureless colon)
acute obstruction (dilated loops, ‘string of pearls’ sign)
renal stones (radiodense opacity in renal tract).
• Ultrasound:
intra-abdominal abscesses (diverticular, appendicular, pelvic)
acute cholecystitis/empyema
ovarian pathology (cyst. ectopic pregnancy)
trauma (liver/spleen haematoma)
renal infections.
• OGD:
PUD, gastritis.
• CT scan:
pancreatitis, trauma (liver/spleen/mesenteric njuries), diverNcuhtis, leaking aortic aneurysm.
• IVU: renal stones, renal tract obstruction.

9 Vomiting

Definitions
Vomiting is defined as the involuntary return to, and forceful expulsion from, the mouth of all or part of the contents of the stomach. Waterbrash is the sudden secretion and accumulation of saliva in the mouth as a reflex associated with dyspepsia. Retching is the process whereby forceful contractions of the diaphragm and abdominal muscles occur without evacuation of the stomach contents.
KEY POINTS
• Vomiting is initiated when the vomiting centre in the medulla oblongata is stimulated, either directly (central vomiting) or via various afferent fibres (reflex vomiting).
• Vomiting of different origins is mediated by different pathways and transmitters. Therapy is best directed according to cause.
• Consider mechanical causes (e.g. gastric outflow or intestinal obstruction) before starting therapy.
Important diagnostic features
Central vomiting
• Drugs, e.g. morphine sulphate, chemotherapeutic agents.
• Uraemia.
• Viral hepatitis.
• Hypercalcaemia of any cause.
• Acute infections, especially in children.
• Pregnancy.
Reflex vomiting
Gastrointestinal causes (5HT3 and Ach mediated— treatment: promotilants, SHT3 antagonists)
• Ingestion of irritants.
Bacteria, e.g. salmonella (gastroenteritis).
Emetics, e.g. zinc sulphate, ipecacuanha.
Drugs, e.g. alcohol, salicylates (gastritis).
Poisons, e.g. salt, arsenic, phosphorus.

• PUD: especially gastric ulcer; vomiting relieves the pain.
• Intestinal obstruction.
Hour-glass stomach (carcinoma of the stomach). Pyloric stenosis—infant: hypertrophic pyloric stenosis, projectile vomiting; adult: pyloric outlet obstruction secondary to PUD or malignant disease.
Small bowel obstruction: adhesions, hernia, neoplasm, Crohn’s disease.
Large bowel obstruction: malignancy, volvulus, diverticular disease.
• Inflammation: appendicitis, peritonitis, pancreatitis, cholecystitis, biliary colic.
General causes (ACh and D2 mediated—treatment:
anticholinergics, antidopaminergics)
• Myocardial infarction.
• Ovarian disease, ectopic pregnancy.
• Severe pain (e.g. kick to the testis, gonadal torsion, blow to the
epigastrium).
• Severe coughing (e.g. pulmonary TB, pertussis).
CA’S causes UVAdr andACh mediated—treatment:
anticholinergics, sedatives)
• Raised intracranial pressure.
Head injury.
Cerebral tumour or abscess.
Hydrocephalus.
Meningitis.
Cerebral haemorrhage.
• Migraine.
• Epilepsy.
• Offensive sights, tastes and smells.
• Hysteria.
• Middle ear disorders (H2 mediated—treatment: antihistamines). Menière’s disease.
Travel/motion sickness.

8 Dyspepsia

Definition
Dyspepsia is the feeling of discomfort or pain in the upper abdomen or lower chest. Indigestion may be used by the patient to mean dyspepsia, regurgitation symptoms or flatulence.
KEY POINTS
• Dyspepsia maybe the only presenting symptom of upper Cl malignancy. All older patients and patients with atypical history should have endoscopy.
• In young adults, gastro-oesophageal reflux and 1-/elicobacter-positive gastritis are common causes.
• Dyspepsia is rarelythe only symptom of gallstones they are more often incidental findings.
Differential diagnosis
Oesophagus
• Reflux oesophagitis: retrosternal dyspepsia, worse after large meal/lying down, associated symptoms of regurgitation, pain on swallowing.
• Oesophageal carcinoma: new-onset dyspepsia in older patient, associated symptoms of weight loss/dysphagia/haematemesis, failure to respond to acid suppression treatment.
Stomach
• Gastritis: recurrent episodes of epigastric pain, transient or short-lived symptoms, may be associated with diet, responds well to antacids/acid suppression.

• Gastric ulcer: typically chronic epigastric pain, worse with food, ‘food fear’ may lead to weight loss, exacerbated by smoking/alcohol, occasionally relieved by vomiting.
• Carcinoma stomach: progressive symptoms, associated weight loss/anorexia, iron-deficient anaemia common, early satiety, epigastric mass.
Duodenum
• Duodenal ulcer: epigastric and back pain, chronic exacerbations lasting several weeks, relieved by food especially milky drthks, relieved by bed rest, commoner in younger men, associated with Helicobacter infection.
• Duodenitis: often transient, mild symptoms only, associated with alcohol and smoking.
Gallstones
Dyspepsia is rarely the only symptom, associated RUQ pain, needs normal OGD and positive ultrasound to be considered as cause for dyspeptic symptoms.

KEY INVESTIGATIONS
• EBO: anaemia suggests malignancy.
• OCD: tumours, PUD, assessment of oesophagitis.
• 24-hour pH monitoring: WORD.
• Ultrasound: ?gallstones.

7 Haematemesis

Definitions
GI bleeding is any blood loss from the GI tract (from the mouth to the anus), which may present with haematemesis, melaena, rectal bleeding or anaemia. Haematernesis is defined as vomiting blood and is usually caused by upper GI disease. Melaena is the passage PR of a black treacle-like stool that contains altered blood, usually as a result of proximal bowel bleeding.
KEY POINTS
• Haematemesis is usually caused by lesions proximal to the duodenojejunal junction.
• Melaena may be caused by lesions anywhere from oesophagus to
colon (upper Cl lesions can cause frank PR bleeding).
• Most tumours more commonly cause anaemia than frank haematemesis.
• In young adults, peptic ulcer disease (PUD), congenital lesions and
varices are common causes.
• In the elderly, tumours, PUD and angiodysplasia are common causes.
Important diagnostic features
Ocsophagus
• Reflux oesophagitis: small volumes, bright red, associated with regurgitation.
• Oesophageal carcinoma (rare): scanty, blood-stained debris, rarely significant volume, associated with weight loss, anergia, dysphagia.
• Bleeding varices: sudden onset, painless, large volumes, dark red blood, history of (alcoholic) liver disease, physical findings of portal hypertension.
• Trauma during vomiting (Mallory—Weiss syndrome): bright red bloody vomit usually preceded by several normal but forceful vomiting episodes.

Stomach
• Erosive gastritis: small volumes, bright red, may follow alcohol or NSAID intake/stress, history of dyspeptic symptoms.
• Gastric ulcer: often larger-sized bleed. painless, possible herald smaller bleeds, accompanied by altered blood (‘coffee
grounds’), history of PUD.
• Gastric cancer: rarely large bleed, anaemia commoner, associated weight loss, anorexia, dyspeptic symptoms.
• Gastric leiomyoma (rare): spontaneous-onset moderate-sized
bleed.
• Dieulafoy’s disease (rare): younger patients, spontaneous
large bleed, difficult to diagnose.
Duodenum
• Duodenal ulcer: past history of duodenal ulcer, melaena often
also prominent, symptoms of back pain, hunger pains, NSAID use.
• Aortoduodenal fistula (rare): usually infected graft post AAA
repair, massive haematemesis and PR bleed, usually fatal.

KEY INVESTIGATIONS
• FBC: carcinomas, reflux oesophagitis.
• LETs: liver disease (varices).
• Clotting: alcohol, bleeding diatheses.
• OCD: investigation of choice. High diagnostic accuracy, allows
therapeutic manoeuvres also (varices: injection; ulcers:
injection/cautery).
• Angiography: rare duodenal causes, obscure recurrent bleeds.
• Barium meal and follow through: useful for patients who are unfit for
OCD (respiratory disease) and ?proximal jejunal lesions.

MANAGEMENT
Minor bleed: Resusctaton Major bleed:
observation Continued resuscitation, urgent OCD
scheduled OCD _—
monitor haemoglobin and fluid balance. Peptic ulcer Varices Castritis
Endoscopic therapy Endoscopic therapy iv. PPI treatment
Re-bleed or high risk: surgery Sengstaken tube Early feeding
Surgery

6 Nipple discharge

Definition
Any fluid (which may be physiological or pathological) emanating from the nipple.
KEY POINTS
• Milky discharge is rarely pathological.
• Purulent discharge is usually benign.
• Bloody discharge is often associated with neoplasia.
• If a lump is present, always investigate ‘for the lump’ rather than ‘for
the discharge’.
Differential diagnosis
Physiological discharges
Milky or clear
• Lactation.
• Lactorrhoea in the newborn (‘witches’ milk’).
• Lactorrhoea at puberty (may be in either sex).
Pathological dischargcs
Serous yellow-green
• Fibrocystic disease: cyclical, tender, lumpy breasts.

• Mammary duct ectasia: usually multiple ducts, intermittent, may be associated with low-grade mastitis.
Bloody
• Duct papilloma: single duct, ?retro-areolar, ‘pea-sized’ lump.
• Carcinoma: ?palpable lump.
• Mammary duct ectasia: usually multiple ducts, intermittent,
may be associated with low-grade mastitis.
Pus ± milk
• Acute suppurative mastitis: tender, swollen, hot breast, multiple ducts discharging.
• Tuberculous (rare): chronic discharge, periareolar fistulae,
‘sterile’ cultures on normal media.

KEY INVESTIGATIONS
• MC+S: acute mastitis, TB (Lowenstein—Jensen medium, Ziehl—Neelsen
stains).
• Discharge cytology: carcinoma.
• Mammography: tumours, fibrocystic disease, ?ectasia.
• Ductal excision: maybe needed for exclusion of neoplasia.

5 Breast pain

Definition
Mastalgia is any pain felt in the breast. Cyclical mastalgia is pain in the breast which varies in association with the menstrual cycle. Non-cyclical mastalgia is pain in the breast which follows no pattern or is intermittent.
KEY POINTS
• Mastalgia is commonly due to disorders of the breast or nipple tissue
but may also be due to problems in the underlying chest wall or overlying
skin.
• Pain is an uncommon presenting feature of tumours but any
underlying mass should be investigated as for a mass (see Chapter 4).
• Always look for an associated infection in the breast.
• Mammography should be routine in women presenting over the age of
45 years to help exclude occult carcinoma.
Important diagnostic features
Non-breast conditions
• Tietze’s disease (costochondritis): tenderness over medial ends of ribs, not limited to the breast area of the chest wall, relieved by NSAIDs.
• Bomholm’s disease (epidemic pleurodynia): marked pain with no physical signs in the breast, worse with inspiration, no chest disease underlying, relieved with NSAIDs.
• Pleurisy: associated chest thfection, pleural rub, may be bilateral.
• Angina: usually atypical angina, may be hard to diagnose, previous history of associated vascular disease.
Mastalgia due to breast pathology
Mast itis! breast abscess
• During lactation: red, hot, tender lump, systemic upset.
Treatment: aspirate abscess (may need to be repeated), do not stop breast feeding, oral antibiotics.

• Non-lactational abscesses: recurrent, associated with smoking, associated with underlying ductal ectasia.
Treatment: aspirate or incise and drain abscess, give oral antibiotics, stop smoking, prophylactic metronidazole for recurrent sepsis.
Jn,fècted sehaceous cyst
Single lump superficially in the skin of the periareolar region, previous history of painless cystic lump.
Treatment: excise infected cyst.
Fibrocystic disease
Irregular, ill defined, may be associated lumps, tender more than very painful.
Mastalgia without breast pathology
Pain often felt throughout the breast, often worse in the axillary tail, moderately tender to examination.
Treatment for cyclical mastalgia: ‘y linoleic acid (evening primrose oil), danazol, tamoxifen.
Treatment for non-cyclical mastalgia: NSAIDs, ylinoleic acid.

KEY INVESTIGATIONS
Non-breast origin
Chest X-ray, EGG (exercise)
Breast pathology
• ENAC (MC+S): associated palpable lump, ?fibrocystic disease,
?mastitis/abscess.
• Ultrasound (young women/dense breasts) or mammography (older
women/small breasts).
Mastalgia without breast pathology
Mammography in women over 45 years

4 Breast lump

Definition
A breast lump is defined as any palpable mass in the breast. A breast lump is the most common presentation of both benign and malignant breast disease. Enlargement of the whole breast can occur either uni- or bilaterally, but this is not strictly a breast lump.
KEY POINTS
• The commonest breast lumps occurring under the age of 35 years are
fibroadenomas and fibrocystic disease.
• The commonest breast lumps occurring over the age of 50 years are
carcinomas and cysts.
• Pain is more characteristic of infection/inflammation than tumours.
• Skin/chest wall tethering is more characteristic of tumours than benign
disease.
• Multiple lesions are usually benign (cysts orfibrocystic disease).

Differential diagnosis
Swelling of the whole breast
Bilateral
• Pregnancy, lactation.
• Idiopathic hypertrophy.
• Drug induced (e.g. stilboestrol, cimetidine).

Unilateral
• Enlargement in the newborn.
• Puberty.

Localized swellings in the breast
Mast itis! breast abscess
• During lactation: red, hot, tender lump, systemic upset.
• Tuberculous abscess: chronic, ‘cold’, recurrent, discharging
sinus.

Cysts
• Galactocele: commoner postpartum, tender but not inflamed,
milky contents.
• Fibrocystic disease: irregular, ill defined, often tender.
Solid lumps
Benign include:
• Fibroadenoma: discrete, firm, well defined, regular, highly
mobile.
• Fat necrosis: irregular, ill defined, hard, ?skin tethering.
• Lipoma: well defined, soft, non-tender, fairly mobile.
• Cystosarcoma phylloides: wide surgical excision (10% are
malignant).
Malignant include:
• Carcinoma
early: ill defined, hard, irregular, skin tethering late: spreading fixity, ulceration, fungation, ‘peau d’orange’.
Swellings behind the breast
• Rib deformities, chondroma, costochondritis (Tietze’s disease).

KEY INVESTIGATIONS
• ENAC: tumours, fibroadenoma, fibrocystic disease, fat necrosis, mastitis.
• Ultrasound: fibroadenoma, cysts, tumours (best for young women/
dense breasts).
• Mammography: tumours, cysts, fibrocystic disease, fat necrosis.
• Biopsy (‘Trucut/open surgical): usually provides definitive
histology (may be radiologically guided if lump is small or
impalpable—detected by mammography as part of breast screening
programme).

3 Haemoptysis

Definition
Haemoptysis (blood spitting) is the symptom of coughing up blood from the lungs. Blood from the nose, mouth or pharynx that may also be spat out is termed ‘spurious haemoptysis’.
KEY POINTS
• Blood from the proximal bronchi or trachea is usually bright red. It may be frankly blood or mixed with mucus and debris, particularly from a tumour.
• Blood from the distal bronchioles and alveoli is often pink and mixed with frothy sputum.
Important diagnostic features
The sources, causes and features are listed below.
Spurious haemoptysis
Mouth and nose
• Blood dyscrasias: associated nose bleeds, spontaneous
bruising.
• Scurvy (vitamin C deficiency): poor hair/teeth, skin bruising.
• Dental caries, trauma, gingivitis.
• Oral tumours: painful intraoral mass, discharge, fetor.
• Hypertensive/spontaneous: no warning, brief bleed, often
recurrent.
• Nasal tumours (common in South-East Asia).

True hacmoptysis
Larynx and trachea
• Foreign body: choking, stridor, pain.
• Carcinoma: hoarse voice, bovine cough.
Bronchus
• Carcinoma: spontaneous haemoptysis, chest infections,
weight loss, monophonic wheezing.
• Adenoma (e.g. carcinoid): recurrent chest infections, carcinoid syndrome.
• Bronchiectasis: chronic chest infections, fetor, blood mixed
with purulent sputum, physical examination shows TB or severe
chest infections.
• Foreign body: recurrent chest infections, sudden-onset inexplicable ‘asthma’.
Lung
• TB: weight loss, fevers, night sweats, dry or productive cough.
• Pneumonia/lung abscess: features of acute chest sepsis,
swinging fever.
• Pulmonary infarct (secondary to PE): pleuritic chest pain,
tachypnoea, pleural rub.
• Aspergilloma.
Cardiac
• Mitral stenosis: frothy pink sputum, recurrent chest infections.
• LVF: frothy pink sputum, pulmonary oedema.

KEY INVESTIGATIONS
All
• Clotting: blood dyscrasias.
• EBO: infections, dyscrasias.
• Chest X-ray (AP and lateral).
?Foreign body ?Cardiac cause ?Tumour ?lnfection ?lnfarction/PE
Bronchoscopy. EGG Sputum cytology Sputum MC+S V/Q scan
Echocardiography. CT scan ?CT scan. CT scan.
Bronchoscopy.

2 Dysphagia

Definition
Dysphagia literally means difficulty with swallowing, which may be associated with ingestion of solids or liquids or both.
KEY POINTS
• Most causes of dysphagia are oesophageal in origin.
• In children, foreign bodies and corrosive liquids are common causes.
• In young adults, reflux stricture and achalasia are common.
• In the middle aged and elderly, carcinoma and reflux are common.
• Because the segmental nerve supply of the oesophagus corresponds
to the intercostal dermatomes, a patient with dysphagia can accurately
pinpoint the level of obstruction.
• Any new symptoms of progressive dysphagia should be assumed to be
malignant until proven otherwise. All need endoscopic or radiological
investigation.
• Tumour and achalasia may mimic each other. Endoscopy and biopsy
are advisable unless the diagnosis is clear.
Important diagnostic features
Mural
• Carcinoma of the oesophagus: progressive course, associated weight loss and anorexia, low-grade anaemia, possible small haematemesis.
• Reflux oesophagitis and stricmre: preceded by heartburn, progressive course, nocturnal regurgitation.
• Achalasia: onset in young adulthood or old age, liquids disproportionately difficult to swallow, frequent regurgitation, recurrent chest infections, long history.
• Tracheo-oesophageal fistula-recurrent chest infections, coughing after drinking. Present in childhood (congenital) or late adulthood (post trauma, deep X-ray therapy (DXT) or malignant).
• Chagas’ disease (Trypanosoma cruzi): South American prevalence, associated with dysrhythmias and colonic dysmotility.

• Caustic stricture: examination shows corrosive ingestion,
chronic dysphagia, onset may be months after.
• Scleroderma: slow onset, associated with skin and hair
changes.
Intraluminal
Foreign body: acute onset, marked retrosternal discomfort, dysphagia even to saliva is characteristic.
Extramural
• Pulsion diverticulum: intermittent symptoms, unexpected
regurgitation.
• External compression: mediastinal lymph nodes, left atrial
hypertrophy, bronchial malignancy.

KEY INVESTIGATIONS

All

EBO: anaemia (tumours much more commonly cause this than reflux). LETs: (hepatic disease).

OGD

(moderate risk, specialist, good for differentiating tumour vs. achalasia vs. reflux stricture, allows biopsy for tissue diagnosis,
allows possible treatment).
Barium swallow
(low risk, easy, good for possible fistula, high tumour, diverticulum, reflux).

If ?dysmotility
• achalasia
• neurogenic causes

If ?extrinsic compression

Video barium swallow
Oesophageal manometry

CXR (AP and lateral) CT scan: low risk, good for extrinsic compression, allows tumour staging

1 Neck lump

Definition
A neck lump is any congenital or acquired mass arising in the
anterior or posterior triangles of the neck between the clavicles
inferiorly and the mandible and base of the skull superiorly.
KEY POINTS
• Thyroid swellings move upwards (with the trachea) on
swallowing.
• Most abnormalities of the neck are visible as swellings.
• Ventral lumps attached to the hyoid bone, such as thyroglossal
cysts, move upwards with both swallowing and protrusion of the
tongue.
• Multiple lumps are almost always lymph nodes.
• Don’t forget a full head and neck examination, including the oral cavity,
in all cases of lymphadenopathy.
Differential diagnosis
• 50% of neck lumps are thyroid in origin.
• 40% of neck lumps are caused by malignancy (80% metastatic
usually from primary lesion above the clavicle; 20% primary
neoplasms: lymphomas, salivary gland tumours).
• 10% of neck lumps are inflammatory or congenital in origin.
Thyroid
• Goitre, cyst, neoplasm.
Neoplasm
• Metastatic carcinoma.
• Primary lymphoma.
• Salivary gland tumour.
• Sternocleidomastoid tumour.
• Carotid body tumour.
Inflammatory
• Acute infective adenopathy.
• Collar stud abscess.
• Cystic hygroma.
• Branchial cyst.
• Parotitis.
Congenital
• Thyroglossal duct cyst.
• Dermoid cyst.
• Torticollis.
Vascular
• Subclavian aneurysm.
• Subclavian ectasia.
Important diagnostic features
Children
Congenital and inflammatory lesions are common.
• Cystic hygroma: in infants, base of the neck, brilliant transillumination,
‘come and go’.
• Thyroglossal or dermoid cyst: midline, discrete, elevates with
tongue protrusion.
• Torticollis: rock-hard mass, more prominent with head flexed,
associated with fixed rotation (a fibrous mass in the sternocleidomastoid
muscle).
• Branchial cyst: anterior to the upper third of the sternocleidomastoid.
• Viral/bacterial adenitis: usually affects jugular nodes, multiple,
tender masses.
• Neoplasms are unusual in children (lymphoma most common).
Young adults
Inflammatory neck masses and thyroid malignancy are common.
• Viral (e.g. infectious mononucleosis) or bacterial (tonsillitis/
pharyngitis) adenitis.
• Papillary thyroid cancer: isolated, non-tender, thyroid mass,
possible lymphadenopathy.
Over-40s
Neck lumps are malignant until proven otherwise.
• Metastatic lymphadenopathy: multiple, rock-hard, nontender,
tendency to be fixed.
• 75% in primary head and neck (thyroid, nasopharynx, tonsils,
larynx, pharynx), 25% from infraclavicular primary (stomach,
pancreas, lung).
• Primary lymphadenopathy (thyroid, lymphoma): fleshy, matted,
rubbery, large size.
• Primary neoplasm (thyroid, salivary tumour): firm, nontender,
fixed to tissue of origin.
KEY INVESTIGATIONS
• U/S scan:
Solid/cystic.
• FNAC:
Colloid nodule
Follicular neoplasm
Papillary carcinoma
Anaplastic carcinoma.
All patients–FBC
?Thyroid
• Full examination:
Fundoscopy
Auroscopy
Nasopharyngoscopy
Laryngoscopy
Bronchoscopy
Gastroscopy.
• FNAC:
?Lymphoma/carcinoma.
• Biopsy:
?Lymphoma cell type.
• CXR
• CT scan:
Source of carcinoma.
LAD
• U/S scan.
• FNAC.
Primary tumours

CANCER SCREENING

Preventive Medicine
CANCER SCREENING
A 39-year-old woman comes to the clinic very concerned about her risk of developing cancer. When questioned further she attests to a family history of colon cancer—her father was diagnosed at the age of 43, and her mother was diagnosed with breast cancer at the age of 52. The patient states that she is sexually active with multiple partners and has not seen a physician since a motor vehicle accident that occurred 15 years ago. She denies any symptoms at this time, and physical examination is normal. At the end of the interview she asks what is recommended for a woman her age.
Screening is testing done on seemingly healthy people to identify those at increased risk of disease. Potentially, several harmful effects may result from screening tests. Any adverse outcome that occurs (large bowel perforation secondary to a colonoscopy) is iatrogenic. Screening may be expensive, unpleasant, and/or inconvenient. Screening may also lead to harmful treatment. Finally, there may be a stigma associated with incorrectly labeling a patient as “sick”.
Even if a test is available, that does not necessarily mean it should be used to screen for a particular disease. For all diseases for which screening is recommended, effective intervention must exist, and the course of events after a positive test result must be discussed with and be accept( able to the patient. Most important, the screening test must be valid; i.e., the test must have been
shown in a randomized, double-blinded trial to decrease overall mortality in the screened population.
For a screening test to be recommended for regular use it has to be extensively studied to insure that all of the above requirements are met. The three malignancies for which regular screening is recommended are cancers of the colon, breast, and cervix.
In the patient with no significant family history of colon cancer, screening should begin at the age of 50. The choices are annual fecal occult blood testing, sigmoidoscopy every 5 years, and barium enema. The preferred screening modality for colon cancer is colonoscopy every 10 years.
Patients who have a single first-degree relative with colorectal cancer diagnosed before the age of 60, or who have multiple first-degree relatives with colon cancer at any age, should undergo colonoscopy starting either at the age of 40 or at an age that is 10 years younger than the age at which the youngest affected relative was diagnosed, whichever age occurs earlier. In this group of high-risk patients, colonoscopy should be repeated every 5 years.

Skin Surgery

Skin Surgery
Cancer of the skin is seen in blond, blue-eyed, fair-skinned people who live where the sun is , fierce, and who by virtue of occupation or hobby are out in the sun all day. Basal cell carcinoma
accounts for about 50%, squamous cell for about 25%, and melanoma for 15%.. .or more “n’ (incidence is going up). They have preferred presentations (detailed below), but diagnosis in all of them is done by full-thickness incisional (or punch) biopsy done at the edge of the lesion
(including normal skin). Because they share etiology, they often coexist, and patients frequently ‘ have multiple lesions over the years.
Basal cell carcinoma may show up as a raised waxy lesion, or as a nonhealing ulcer. It has a pref erenc for the upper part of the face (above a line drawn across the lips). It does not metastasize, but can kill by relentless local invasion (“rodent ulcer”). Local excision with negative margins (1 mm is enough) is curative, but other lesions may develop later.
Squamous cell carcinoma of the skin shows up as a nonhealing ulcer, has a preference for the ? lower lip (and territories below a line drawn across the lips), and can metastasize to lymph
nodes. Excision with wider margins is needed (0.5 to 2 cm), and node dissection is done if they are involved. Radiation treatment is another option.
Melanoma usually originates in a pigmented lesion. A mnemonic to identify them is ABCD. ‘ They are asymmetric (A), have irregular borders (B), have different colors (C) within the lesion, and have a diameter (D) that exceeds 0.5 cm. They should also be suspected in any pigmented
lesion that changes in any way (grows, ulcerates, changes color and/or shape, bleeds, etc.). The
biopsy report must give not only the diagnosis, but also the depth of invasion. Lesions less than
, 1 mm deep have a good prognosis and only require local excision. Deeper lesions require exci sion with wide margins (2—3 cm). Lesions larger than 4 mm have a terrible prognosis. Lesions ‘ between 1 and 4 mm benefit most from aggressive therapy, including node dissection.
Metastatic malignant melanoma (from a deep, invasive primary) is a bizarre, unpredictable, and
fascinating disease. Melanoma metastasizes to all the usual places (lymph nodes, liver, lung, brain, and bone), but it also is the all-time champion for metastasizing to weird places (the muscle of the left ventricle, the wall of the duodenum.. .anywhere!). Furthermore, it has no predictable time table Some patients are full of metastases and dead within a few months of diagnosis, others go 20 years between the resection of their primary tumor and the sudden explosion of metastases.

List of abbreviations

AAA abdominal aortic aneurysm
AAT aspartate amino transferase
ABI ankle–brachial pressure index
Ach acetylcholine
ACN acute cortical necrosis
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
Adr adrenaline
AF atrial fibrillation
AFP α-fetoprotein
Ag antigen
Alb albumin
ANCA anti-neutrophil cytoplasmic antibody
ANDI abnormalities of the normal development and
involution (of the breast)
AP anteroposterior
APTT activated partial thromboplastin time
ARDS adult/acute respiratory distress syndrome
ARF acute renal failure
ATN acute tubular necrosis
AVM arteriovenous malfunction
AXR abdominal X-ray
BCC basal cell carcinoma
BCG bacillus Calmette–Guérin
BE base excess
BP blood pressure
BPH benign prostatic hypertrophy
C&S culture and sensitivity
CABG coronary artery bypass surgery
CBD common bile duct
CCF congestive cardiac failure
CD Clostridium difficile
CEA carcinoembryonic antigen
CK creatinine kinase
CLO Campylobacter-like organism
CMV cytomegalovirus
CNS central nervous system
COCP combined oral contraceptive pill
COPD chronic obstructive pulmonary disease
CPK-MB creatine phosphokinase (cardiac type)
CRC colorectal carcinoma
CRF chronic renal failure
CRP C-reactive protein
CSF cerebrospinal fluid
CT computed tomography
CVA cerebrovascular accident
CVP central venous pressure
CXR chest X-ray
D2 type 2 dopaminergic receptors
DIC disseminated intravascular coagulation
DMSA dimercaptosuccinic acid
Dop dopamine
DPTA diethylenetriaminepentaacetic acid
DU duodenal ulcer
DVT deep venous thrombosis
DXT deep X-ray therapy
EAS external anal sphincter
EBV Epstein–Barr virus
ECG electrocardiogram
ER oestrogen receptor
ERCP endoscopic retrograde cholangiopancreatographic
(examination)
ESR erythrocyte sedimentation rate
ESWL extracorporeal shock-wave lithotripsy
EUA examination under anaesthesia
FBC full blood count
FCD fibrocystic disease
FHx family history
FNAC fine-needle aspiration cytology
FSH follicle-stimulating hormone
5-FU 5-fluorouracil
γ-GT gamma glutamyl transpeptidase
GA general anaesthetic
GCS Glasgow Coma Scale
GFR glomerular filtration rate
GH growth hormone
GI gastrointestinal
GORD gastro-oesophageal reflux disease
GTN glyceryl trinitrate
GU genito-urinary
Hb haemoglobin
β-HCG β-human chorionic gonadotrophin
Hct haematocrit
HDU high-dependency unit
HIDA imido-diacetic acid
HLA human leucocyte antigen
Hx history
IBS irritable bowel syndrome
ICP intracranial pressure
ICS intercostal space
ICU intensive care unit
IgG immunoglobulin G
IPPV intermittent positive pressure ventilation
ITP idiopathic thrombocytopaenic purpura
IVC inferior vena cava
IVU intravenous urogram
JVP jugular venous pulse
LA local anaesthetic
LAD left anterior descending
LATS long-acting thyroid stimulating (factor)
LCA left coronary artery
LDH lactate dehydrogenase
LFT liver function test
LH luteinizing hormone
LH-RH LH-releasing hormone
LIF left iliac fossa
LOC loss of consciousness
LOS lower oesophageal sphincter
LPS lipopolysaccharide
LSE left sternal edge
LSF lesser sciatica foramen
LUQ left upper quadrant
LV left ventricle
LVF left ventricular failure
MC+S microscopy cultures and sensitivity
MCP metacarpophalangeal
MEN multiple endocrine neoplasia
MI myocardial infarction
MIBG meta-iodo-benzyl guanidine
MM malignant melanoma
MND motor neurone disease
MODS multiple organ dysfunction syndrome
MRCP magnetic resonance cholangio-pancreatography
MRI magnetic resonance imaging
MS multiple sclerosis
MSH melanocyte-stimulating hormone
MSU mid-stream urine
MT major trauma
MTP metatarsophalangeal
MUGA multiple uptake gated analysis
NAdr noradrenaline
NG nasogastric
NSAID non-steroidal anti-inflammatory drug
NSU non-specific urethritis
OA osteoarthritis
OGD oesophago-gastro-duodenoscopy
OGJ oesophago-gastric junction
PA posteroanterior
PAF platelet activating factor
PCA patient-controlled analgesia
PCV packed cell volume
PE pulmonary embolism
PHx past history
PIP proximal interphalangeal
PL prolactin
PMN polymorphonuclear leucocyte
POVD peripheral occlusive vascular disease
PPI proton pump inhibitor
PPL postphlebitic limb
PR per rectum
PSA prostate-specific antigen
PT prothrombin time
PTC percutaneous transhepatic cholangiography
PTH parathyroid hormone
PUD peptic ulcer disease
PUO pyrexia of unknown origin
PV per vaginum
PVD peripheral vascular disease
RBC red blood cell
RCC renal cell carcinoma
RIA radioimmunoassay
RIF right iliac fossa
RLN recurrent laryngeal nerve
RPLND retroperitoneal lymph node dissection
RUQ right upper quadrant
RV right ventricle
RVF right ventricular failure
Rx treatment
SCC squamous cell carcinoma
SFJ sapheno-femoral junction
SGOT serum glutamic oxalacetic transaminase
SIADH syndrome of inappropriate antidiuretic
hormone
SIRS systemic inflammatory response syndrome
SLE systemic lupus erythematosus
SLN superior laryngeal nerve
STD sodium tetradecyl
SVC superior vena cava
Sxr skull X-ray
T3 tri-iodothyronine
T4 thyroxine
TB tuberculosis
TCC transitional cell carcinoma
TED thrombo-embolic deterrent
TIA transient ischaemic attack
TNM tumour, node, metastasis (staging)
t-PA tissue plasminogen activator
TPHA treponema pallidum haemagglutination (test)
TPR temperature, pulse, respiration
TSH thyroid-stimulating hormone
TURP transurethral resection of the prostate
TURT transurethral resection of tumour
UC ulcerative colitis
UDT undescended testis
U+E urea and electrolytes
UTI urinary tract infection
VA visual acuity
VHL von Hippel–Lindau
VIP vasoactive intestinal peptide
VMA vanillyl mandelic acid
VSD ventricular septal defect
WCC white cell count