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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2738_Библиотеки_им_академика_М_И_Перельмана
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Indications
https://t.me/med1917
• Relieve ischaemic rest pain (where surgical Tx ineffective)
• Limb condition threatening life (gas gangrene / severe infec tion)
• Trauma (causing non-functionable limb)
Chapter 14: Vascular disease 185
Outcome:
• 30d mortality 15%
• 5y mortality 65%
Level of amputation
→ Most often digital (toe) or trans-metatarsal amputation secondary to diabetic
foot sepsis
→ Aim to establish arterial flow into foot to allow resultant wound to heal
• Below knee (trans-tibial)* = greater functional success than above knee but
requires well-perfused calf
• Above knee (trans-femoral)
• Through knee amputation
• Hip disarticulation
• Hind-quarter amputation
*not if fixed flexion deformity
of knee or severe OA
Rehabilitation
• Pre-amputation consultation with physiotherapist and occupational therapist
• Establish if patient will be able to use prosthesis
• Is home suitable for wheelchair use? (all patients are discharged in a
wheelchair)
50% of diabetics with major limb amputation
will have contralateral leg amputated in 2–3y
It requires 15% more energy to walk with a
below-knee prosthesis & >20% more energy
with an above-knee prosthesis
• Initial exercises to prevent knee flexion deformity and muscle strengthening
exercises
• Practise transferring and wheelchair mobility
• Consider use of pneumatic post-amputation mobility (PPAM) aid from 1w
• Once wound has healed, prosthetic measurements commence at 6–8w
Complications of amputation
Early Late
• Wound dehiscence
• Infection
• Contractures
• Phantom limb pain
Surgery
186 Chapter 14: Vascular disease
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Pathophysiology
Arterial spasm → reduced perfusion → ischaemia → necrosis
Types
→ Persistent diffuse cyanosis of hands & feet
→ Persistent mottled cyanosis of skin e.g. APS, SLE, polycythaemia
Raynaud’s syndrome affects
5% of the population
Features suggesting 2° disease:
• presentation in early childhood or >30y
• asymmetrical distribution
• male
= peripheral ischaemia associated with
smoking
→Intermittent cyanosis of hands/feet and digits
Raynaud’s syndrome
condition
• Autoimmune: scleroderma, SLE, RA, Sjögren’s,
dermatomyositis
• Arterial disease: atherosclerosis, thoracic outlet obstruction, Buerger’s disease
• Endocrine: DM, hypothyroidism
• Blood: lymphoma, polycythaemia
• Environmental: smoking, trauma, chemicals, chronic vibration
• Drugs: beta-blockers, COCP, cytotoxic agents
burning on rewarming
PALE
(ischaemia)
BLUE
(cyanosis)
RED (reactive
hyperaemia)
Must screen for these O/E
& with blood tests
Triggers:
→ cold
→ emotion
→ smoking
→ exercise
Fig. 14.4 Raynaud’s syndrome.
Surgery
1. Hx & examination
2. Bloods: FBC, U&Es, LFT, TFT, coag, glucose
3. Autoimmune screen: ANA, CRP
Refer to rheumatology / other specialty
if suspect underlying cause
→ Lifestyle: stop smoking, warm clothing / avoid cold & other triggers
(e.g. COCP/BBs)
→ ± Vasodilators: CCBs (nifedipine)
→ IV Prostaglandins: iloprost
→ ± Surgery = last resort (sympathectomy, embolectomy)
→ compression of neurovascular bundle within thoracic outlet
https://t.me/med1917
Causes
• Cervical rib
• Healed clavicular fracture
• Scalene muscle hypertrophy
• Malignancy (Pancoast tumour)
Clinical presentation
• Venous: DVT & peripheral swelling
• Arterial: claudication / limb ischaemia
• Neuro: pain, paraesthesia, weakness, muscle wasting → T1 distribution
Investigations
Chapter 14: Vascular disease 187
DDx: cervical myelopathy
1. Hx & examination
2. Bloods: FBC, clotting
3. CXR – show cervical ribs
4. Duplex USS – dynamic vascular compression
5. Nerve conduction studies
6. MRI – with arms fully abducted
Management
Venous: thrombolysis ± venoplasty / surgical decompression
Arterial: surgical decompression ± angioplasty/bypass
Neurological: physio & Botox ± surgical decompression
Surgery
188 Chapter 14: Vascular disease
https://t.me/med1917
Cephalic
Med cub
SCV
Axillary
Brachial
Basilic
UlnarRadial
Femoral
Popliteal
Small
saphenous
ILIAC
Sapheno–
femoral junction
Mid-thigh
perforator
Great
saphenous
Pathophysiology of venous disease
• Venous return driven by:
1. Muscle contraction
2. Intrathoracic pressure with inspiration
• Blood flow = superficial → perforating → deep veins
• Valves prevent BACKFLOW (absent in vena cava & common iliacs)
• In deep veins = deep venous insufficiency (usually after DVT)
• In superficial veins = VARICOSE VEINS
Upper limb
Deep
Lower limb
Superficial
Fig. 14.5 Venous systems of the upper
& lower limbs.
*Thrombophlebitis without suspicion of DVT is
treated with topical NSAIDs only
Classifying symptoms:
• CEAP classification: Clinical, aEtiological,
Anatomical, Pathophysiological
• Venous Clinical Severity Score (VCSS)
Indications for NHS Tx:
Denition
→ Primary: idiopathic or no valve defect (women, pregnancy)
→ Secondary: to deep venous insufficiency
(DVT or pelvic pressure)
Clinical presentation
• Cosmetic
• May be itchy (venous eczema)
• May cause heaviness/aching & ankle oedema
• Venous ulceration
Complications
• Thrombophlebitis: inflamed vein due to clot → red, painful, hot
Tx: topical NSAIDs* or LMWH (if >5cm and within 3–5cm of SFJ)
• Bleeding: due to skin thinning (most often after a hot shower)
Immediate Tx: elevation + compression
• Venous ulcers: 50% caused by varicose veins
• Venous eczema: red & flaky skin
• Lipodermatosclerosis: brown haemosiderin ‘champagne bottle’
→ Recurrent thrombophlebitis
→ Venous ulcers
→ Bleeding
→ Chronic skin changes
(eczema/lipodermatosclerosis)
Signs of chronic venous insufficiency:
Surgery
Diagnosis
• Duplex USS
Management
1. Lifestyle: weight loss, exercise, avoid prolonged standing
2. Compression stockings: must r/o PAD first with ABPI (>0.8)
3. Endothermal catheter ablation: radiofrequency catheter passed up great
saphenous vein to heat vein & seal it
4. Foam sclerotherapy: inject foam containing sclerosing agent into vein to
sealvein
5. Surgery: disconnect great saphenous vein and strip it out
13
NICE (2013) Varicose veins [CG168]
13
Chapter 14: Vascular disease 189
https://t.me/med1917
Venous (70%) Arterial Neuropathic
Pathophysiology • Valve incompetence & reflux
• Calf muscle dysfunction
= toxins accumulate →
inflammation and necrosis
Risk factors DVT, varicose veins, age, pregnancy,
surgery
Location Gaiter area
(between malleolus and knee)
Features • Large and irregular
• Shallow with sloping edges
• Granulation tissue
= may be painful
Leg condition • Lipodermatosclerosis
• Venous eczema
• Haemosiderin (red/brown)
• Atrophie blanche
(smooth white sclerotic plaques)
• Heavy, aching, pruritus, oedema
• Atheromatous changes =
compromised blood flow
= hypoxia & toxins
accumulate → inflammation
and necrosis
Diabetes, HTN, smoking,
arterial disease, cholesterol
emboli, Raynaud’s disease,
trauma
Bony prominences
(lateral malleolus and toes)
• Smaller and round
• ‘Punched-out’ borders
• Little granulation tissue
& dry
= very painful
• Claudication / ischaemic
rest pain symptoms
• Cool, hairless, dry, shiny
skin
• Peripheral neuropathy
• Vascular disease & infection
Diabetes, trauma, prolonged pressure,
alcohol excess, B12/folate deficiency
Pressure areas
• Small, round, deep
• ‘Punched-out’ borders
• Thick rim
• Surrounding callus
• Loss of sensation
• Dry, cracked skin
Specific
treatment
General
treatment
Fig. 14.6
• Elevation and compression
1st-line: 4-layer bandaging
Other: stockings
• Superficial venous surgery
(prevents recurrence and
accelerates healing)
Must exclude coexisting arterial
insufficiency before starting
compression therapy (with ABPI)
• Dressings ± antibiotics ± emollients
• Debridement: dressings, surgery, larvae
Fig. 14.7 Fig. 14.8
• Manage vascular risk
factors
e.g. antiplatelets, stop
smoking
• Surgical revascularisation
(to restore vascular flow)
• Optimise glycaemic control
• Treat coexisting arterial disease
• Good foot care
• X-ray/MRI to find osteomyelitis
• Offload pressure
Surgery
190 Chapter 14: Vascular disease
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All patients have VTE risk assessment on
admission
→ prophylactic LMWH if indicated
Differentials of DVT:
→ Cellulitis: ± rash/pus
→ Chronic venous insufficiency: chronic skin
change signs
→ Superficial thrombophlebitis: erythema/
inflammation along vein
→ Acute arterial ischaemia: pallor, pain,
pulseless, etc.
→ Baker’s cyst: swelling behind knee & knee
stiffness
Wells score for DVT:
Clinical features Points
Active cancer (including current Tx or
1
Tx in past 6m)
Paralysis / paresis / plaster
1
immobilisation of lower limb
Bedridden ≥3d or major surgery in
1
past 12w
Localised tenderness along deep
1
venous system
Entire leg swollen 1
Calf swelling ≥3cm larger than
1
other leg
Pitting oedema confined to
1
symptomatic leg
Collateral superficial veins
1
(non-varicose)
Previous DVT 1
Alternative diagnosis at least as
–2
likely as DVT
If suspicion of DVT/PE, start treatment dose
LMWH while waiting for scan results to confirm
or r/o
Risk factors
1. Blood stasis: immobility, surgery, varicose veins, long-haul travel
2. Hypercoagulability: obesity, pregnancy, dehydration, OCP, thrombophilia,
infection, malignancy, IVDU
3. Endothelial damage: age, trauma/surgery (especially orthopaedic)
Deep vein thrombosis (DVT)
Unilateral symptoms:
• Leg tenderness, warmth, swelling,
erythema
• Pitting oedema
• Distended superficial
veins / thrombophlebitis
1. Wells score: determines next step
2. d-dimer: not specific for DVT/PE
3. Compression USS: if no
compression = clot
4. Duplex USS: shows clot
Low risk
Score <2
d-dimer Urgent USS
−ve
Urgent USS
−ve
Calculate Wells score
Mod–high risk
Score ≥2
+ve +ve
+ve
−ve
−ve
d-dimer
Anti-
coagulate
+ve
Anti-
Fig. 14.9
coagulate
Pulmonary embolism (PE)
• Acute onset SOB
• Pleuritic pain
• Haemoptysis
O/E: tachycardia, hypotension, low-grade fever, JVP, signs of DVT
Differentials of PE:
→ MI/angina → COPD/asthma exacerbation
→ Pneumonia → Pneumothorax
→ CHF → Cardiac tamponade
Surgery
1. Wells score: determines next step
→ <4 = d-dimer (if +ve = urgent CTPA)
→ >4 = Urgent CTPA (V/Q scan if CTPA contraindicated)
2. Bloods: FBC, LFTs, U&Es, clotting, ABG
3. CXR: usually normal
4. ECG: sinus tachycardia (S1Q3T3)
5. Echo: may be considered to look for right heart strain
14
NICE (2020) Venous thromboembolic diseases [NG158]
Categorisation of PE:
https://t.me/med1917
Chapter 14: Vascular disease 191
1. Massive (5%): >50% pulmonary
circulation blocked
→ chest pain, severe SOB, hypotension
& hypoxia
2. Major (10%): mid-sized pulm arteries
blocked
→ chest pain, SOB, haemoptysis
3. Minor (85%): small peripheral vessels
blocked
→ may be asymptomatic, SOB
(no ECG changes)
4. Subacute: multiple small/medium
emboli accumulate
→ over weeks = JVP, cor pulmonale
(ECG = RV strain)
Management of thromboembolic disease
, fluids, analgesia
2
▶ 1st-line: DOAC (apixaban/rivaroxaban)
▶ Alternative: LMWH (until INR in range) then warfarin
(if unprovoked event / high risk = continue 6m)
NB: thrombolysis (alteplase) only indicated if
of cardiac arrest
massive
PE / resistant to fluid resuscitation / at risk
15
If high risk of PE & CTPA not immediately
available, then start anticoagulation
(don’t wait for CTPA confirmation)
If anticoagulation is contraindicated, or
recurrent VTE despite anticoagulation,
consider an IVC filter
• Bloods: FBC, U&Es, LFT, clotting, coag screen (APTT/PT)
• Antiphospholipid antibodies: APS
• Cancer screen: bloods, urinalysis, CXR, PSA/mammogram
• CT scan: may show iliac artery compression
NB: if features suggesting cancer = immediate CT CAP
of cancer)
(if not do bloods first, then CT CAP if concern
• CT venogram + referral to vascular surgery
• Consideration of catheter-directed thrombolysis ± venous stenting
Compression of left iliac artery
= May–Thurner syndrome
15
NICE (2020) Venous thromboembolic diseases [NG158]
Surgery
192 Chapter 14: Vascular disease
https://t.me/med1917
Chronic swelling due to fluid in soft tissues as the result of failed lymphatic
drainage
Aetiology
PRIMARY: due to inherited abnormality of lymphatic vessels (e.g. Milroy’s disease)
→ presents early in life
SECONDARY: due to obstruction of / damage to lymphatic vessels
→ infection/cellulitis → trauma → malignancy
→ venous disease / DVT → liver disease → renal disease
→ immobility/obesity → heart failure → cancer surgery / radiotherapy
Clinical presentation
• Non-pitting oedema usually in legs & arms
Investigations
1. Careful Hx & examination → measure circumference of limb
2. Lymphoscintigraphy → radioactive dye injected into lymphatic system
Management
1. Compression bandages
2. Skin care ± ABX – reduce risk of cellulitis
3. Exercise/mobilisation
4. Specialised massage techniques
Surgery
protein
https://t.me/med1917
193
(TBvaccine)
lithotripsy
Score
tumour
194 Chapter 15: Urology
1%
Familial disorders affecting cystine transport in kidneys
→
https://t.me/med1917
Complications:
Pain, infection, sepsis, hydronephrosis
& post‑renal AKI, obstructive uropathy
Clinical presentation
Acute: Loin → groin pain, flank tenderness, palpable kidney, infection, haematuria
Chronic: renal failure (oligo-/anuria)
Often restless / cannot keep still
Risk factors
1: renal pelvis
2: pelvic brim
3: VUJ
Fig. 15.1 Common sites of obstruction.
Common sites of obstruction = narrowings:
1. Renal pelvic–ureteric junction (PUJ)
2. Pelvic brim
3. Vesico‑ureteric junction (VUJ)
Differentials:
• Gynaecology (e.g. ectopic, ovarian cyst etc.)
• Pyelonephritis
• Appendicitis
• MSK pain
• Bowel obstruction
• Ruptured AAA
• Biliary pathology
• Dehydration
• Diet (high protein, high salt)
• FHx or PHx
• Repeated UTIs
• Endocrine disorders (Addison’s,
Cushing’s, hyperparathyroidism,
hypercalciuria, cystinuria, gout)
80%
1
Calcium
Struvite
Uric acid
Cystine
Types of stone
7%
13%
Fig. 15.2
Clinical presentation
1. URETERIC COLIC: sudden onset
loin→ groin pain (in waves)
2. Nausea & vomiting
cramping pain that comes in waves
• Anatomical abnormalities
(horseshoe kidney, strictures, PUJ
obstruction)
• Drugs (steroids, chemotherapy, loop
diuretics)
40% Calcium oxalate
4% Calcium phosphate
36% Mixture
Magnesium, ammonium, phosphate (UTIs)
→ ‘Staghorn calculi’
→ Radiolucent
Smell like sulphur
(metabolic)
3. Haematuria (often microscopic)
4. Concurrent infection: fever, rigors,
sepsis
Fig. 15.3
Indications for emergency intervention?
YES
1. Drain kidney: JJ Stent or nephrostomy
2. Treat the stone: ESWL/PCNL/ureteroscopy
Distal ureteric
stone
• Conservative
• ESWL
• Rigid
ureteroscopy
Acute management:
ABCDE: fluids if NBM/vomiting
Analgesia: diclofenac, opiates, paracetamol
IV ABX: if signs of infection
⇒ Signs of infection
⇒ Renal impairment (AKI)
⇒ Kidney obstruction (hydronephrosis)
⇒ A single functioning kidney
Proximal ureteric
stone
• ESWL
• Rigid
ureteroscopy
• Conservative
Surgery
NO
Renal stone
• ESWL
• PCNL
• Flexi-
ureteroscopy
• Active
surveillance
Investigations
1. Hx & examination: renal angle tenderness
2. Urine dip & MCS – for infection, urine pH & haematuria
3. Bloods:
• FBC, CRP/ESR, clotting, VBG (metabolic acidosis)
• U&Es ( Cr suggests AKI/dehydration)
• Ca, PO4, urate, glucose
4. Basic imaging: non-contrast CT KUB = gold standard for stone visualisation
5. Specialist imaging: CT urogram (only if urology request)
Management options
Conservative: 80% stones pass on
2,3
PCNL (percutaneous
nephrolithotomy): nephroscope into
scan 2–3w, medical expulsive therapy,
safety-netting
ESWL (extra-corporeal shock wave
lithotripsy): US waves break up stone
so it can pass spontaneously
1
Alelign T, Petros B (2018) Kidney stone disease: an update on current concepts. Adv Urol,
2018:3068365.
2
NICE (2019) Renal and ureteric stones [NG118]
3
European Society of Urology (2021) Guidelines on urolithiasis
renal pelvis + lithotripsy to fragment
stone
Ureteroscopy + stone fragmentation:
endoscope up urethra & ureter, then
stone lithotripsy & removal
*** PREGNANCY TEST
IF WOMAN OF CHILDBEARING AGE ***
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