Surgery (Colorectal, Orthopaedic) and Radiology Dr Jamie McPherson Many thanks to Radiopaedia/Wikipedia for images
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Surgery (Colorectal,
Orthopaedic) and Radiology
Dr Jamie McPherson Many thanks to Radiopaedia/Wikipedia for images
Surgical talk!
Please describe...
Ileostomy
Colostomy
Urostomy
Stomas
Comment on other scars eg laparotomy
Position – left generally colostomy, right generally ileostomy
Contents – urine/watery stool/thick stool
Number of openings – one (end) vs two (loop)
Spout – raised is ileostomy/urostomy
If colostomy - Offer to examine for presence of anus + rectal
stump – no anus indicates AP resection of rectal tumor
Causes – clubbing, other peripheral signs of IBD
Complications – ischaemia, parastomal hernia, excoriation,
high stoma output, retraction, prolapse
Indications for Stomas
Loop = easily reversed 3-6 months later
End Ileostomy – total colectomy (IBD – usually UC, FAP)
Loop ileostomy
Protect distal anastomosis
Defunction anastomotic leak
Defunction obstructing tumor
Defunction fistula tract
Faecal incontinence
End Colostomy – AP resection, Hartmann's (Cancer/diverticulitis)
Faecal incontinence
Loop colostomy – defunction distal obstruction/leak/fistula
Faecal incontinence
Diverticular disease
l Acquired herniation of the mucosa (weak points where vessels
cross mucosa)
l Caused by chronic constipation, low fibre diet
l Symptoms: can be asymptomatic, painless rectal bleeding, LIF
pain/fever/tenderness, change in bowel habit
l l COMPLICATIONS
PR bleed
Pericolic abscess
Fistula
Obstruction (fibrosis
+ stricturing)
Perforation
l
l
Diverticular disease
l Management
Rectal bleeding mostly settles spontaneously
Therapeutic endoscopy/mesenteric angio for
ongoing bleeding
Analgesia, antibiotics
Percutaneous drainage
Surgical intervention
l
l Investigations – bloods, CT
Hinchey classification; local diverticulitis, local
abscess, distal abscess, peritonitis,
faecal peritonitis
l
l
Bowel obstruction
l Abdo pain, N&V, distension, absolute constipation
l
l Investigation: Bloods, AXR +/- CT
l
l Small vs large
speed of onset of N&V vs absolute constipation
l
l Mechanical vs non-mechanical (ileus & pseudo-obstruction
(Ogilvie syndrome))
Colicky pain vs no pain/uncomfortable distension
l
l Etiology – logical thinking!
l
l
Extramural
Mural
Intramural
Small
Hernia
Adhesions
Crohn's
Radiotherapy
Tumour (rare)
Gallstone ileus
Bezoar
Meconium ileus
Large
Volvulus
Diverticulitis
Ischaemic colitis
Tumour
Faecal impaction
Management of bowel obstruction
Generic management – “drip + suck”
Why?
Management of specific causes:
Adhesions – initially conservative unless signs of
strangulation
Hernia - repair
Tumor – stenting/defunctioning/resection
Sigmoid volvulus – flexible sigmoidoscopy
Abdominal Xrays
What are the indications?
Do you have a logical system for interpreting them?
1 AXR = around 40 CXR
RCR indications for AXR
Obstruction/perforation (combined with eCXR)
Acute exacerbation of IBD
Dangerous foreign body
Followup of known renal stone
Interpretation of AXR
Basic details + technical adequacy –> diaphragm to pubis
Bowel: large vs small… approach from inside out
Diameter – 3,6,9cm rule
Anything visible within the bowel
Mucosal oedema
Outer wall visible? (Rigler's sign)
Liver/gallbladder – stones (10-20%), pneumobilia (infection/instrumentation)
Kidneys, ureter, bladder – stones (around 90%)
Pancreas – calcification
Aorta – over 3cm = aneurysmal
Bones and soft tissue
Small
Normal
Pneumoperitoneum –Rigler sign
LUQ
Sigmoid volvulus
AAA
Normal
Small
Caecal volvulus
Small
Colitis - “thumbprinting” (mucosal
oedema)
Large and small
Which is worse?
Orthopaedics
Clinical case
l 85 year old man, Jack
l Admitted to ward 16 at Freeman
l following a fall from chair at home
l Unwitnessed fall in toilet
l Now complaining of pain in hip
l
l PMH Hypertension, vascular
l dementia, alcohol excess
l
l Social baseline: limited vocabulary,
l mobilises with wheelchair
l
Fracture management
Reduce Closed
Open
Restrict Non-operative
Traction, brace, sling,
cast, buddy strap
Operative
Internal fixation
K-wires, plate, screw, tension band, nail
External fixation
Rehabilitate
How to describe a fracture
l Basic details about the film; identifying features, type of
projection (AP/lateral)
l
l Type; transverse, oblique, spiral, comminuted (+ no. of
fragments)
l
l Joint involvement; Intra/extra articular
l
l Location; can use distal/medial/proximal thirds or
diaphysis/metaphysis/epiphysis l (Epiphysis is at the Emd of the bone!)
l
l Displacement; angulated, rotated, translocated
l
Big
Tough
Jocks
Love
Diathermy
l Basic details
l
l
l
l Type
l
l
l Joint involvement
l
l
l Location
l
l
l Displacement
No identifying features, technically
adequate
Transverse fracture
with no joint involvement
of distal radius
with volar angulaton
Osteoarthritis
Activity related joint pain in 45+ without morning stiffness
Risk factors: Obesity, age, previous trauma, nearby prosthetic
joint
O/E Tenderness, swelling, crepitus, reduced movement, varus
knees, leg length discrepancy, hallux valgus
Investigation: Clinical diagnosis. X ray findings…?
Management?
Management of OA
Conservative: Weight loss, exercise, TENS, orthotic shoes
Medical: Paracetamol, topical NSAID, topical capsaicin, oral
NSAID plus PPI, steroid injections
Surgical: Arthroplasty if refractory symptoms affecting quality
of life
MDT: Physio
Hip fracture
XR first line. CT/MRI if clinical suspicion high
Medical management: analgesia, optimise comorbidity,
orthogeriatric involvement
Undisplaced intracapsular: Internal fixation with screws
Displaced intracapsular: (consider fixation in young)
hemiarthroplasty
or THR if fit, walk with 1 stick only + cognitively
intact
Trochanteric fracture – dynamic hip screw
Subtrochanteric fracture – intramedullary nail
Hip XR
Spotting fractures:
Disruption of
Shenton's line
Break in cortex
Disruption of
trabeculae
Sclerosis
Shortening/rotation
R intracapsular
Hip OA - bilateral
L intertrochanteric
3 fragments
L intracapsular
R intracapsular
Subtle undisplaced L intracapsular
OA left hip. R total arthroplasty
Right subtrochanteric #nof
Underlying pathological fracture
Chest imaging
Approach to the chest X ray Basic details
Technical adequacy RIP: rotation, inspiration (rib 5-7 anterior),
penetration
A – Airway (trachea)
B – Breathing (lung fields)
Consolidation
Pneumothorax
Effusions
L hilum should be higher, L diaphragm should be lower
C – Circulation (heart)
Size
Upper lobe diversion
D – Da bones and soft tissues
Air under the diaphragm - always
E – Everything you've forgotten (lines, review areas, behind the
heart, artefacts)
Localising
consolidation:
RML: R heart
border
RLL: R diaphragm
Lingula: L heart
border
LLL: L diaphragm
RLL consolidation
L simple pneumothorax
Pulmonary oedema – prominent
interstitial lines
Lingular consolidation
Normal
Widespread fibrosis - IPF
Hyperinflation
Pneumoperitoneum
RUL collapse
Pulmonary oedema and
cardiomegaly
Pleural effusion (why not
collapse?)
LLL collapse
Golden S sign: collapse and mass
L clavicle fracture
Approach to the chest X ray
Good sites: Radiopaedia, Radiology Masterclass
Good books: Unofficial guide to Radiology, A&E Radiology: A
Survival Guide
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