Anal Fissures: Symptoms and Treatment

Anal fissures are a common condition characterized by perianal pain that worsens during defecation and is often accompanied by fresh bleeding. The history of these symptoms is typical of a fissure, although visualization of the fissure is often not possible due to the pain associated with rectal examination. Most fissures are located in the midline posteriorly, and in the acute phase, GTN cream can provide relief in two-thirds of cases.

Nasopharyngeal Airway for Maintaining Airway Patency

Nasopharyngeal airways are medical devices used to maintain a patent airway in patients with decreased Glasgow coma score (GCS). These airways are inserted into the nostril after being lubricated, and they come in various sizes. They are particularly useful for patients who are having seizures, as an oropharyngeal airway (OPA) may not be suitable for insertion.

Nasopharyngeal airways are generally well-tolerated by patients with low GCS. However, they should be used with caution in patients with base of skull fractures, as they may cause further damage. It is important to note that these airways should only be inserted by trained medical professionals to avoid any complications. Overall, nasopharyngeal airways are an effective tool for maintaining airway patency in patients with decreased GCS.

The first step in addressing the issue is to establish bladder drainage, which can often resolve the problem. Patients may experience a substantial diuresis and related electrolyte imbalances. It is recommended to attempt the urethral route initially.

Hydronephrosis is a condition where the kidney becomes swollen due to urine buildup. There are various causes of hydronephrosis, including pelvic-ureteric obstruction, aberrant renal vessels, calculi, tumors of the renal pelvis, stenosis of the urethra, urethral valve, prostatic enlargement, extensive bladder tumor, and retroperitoneal fibrosis. Unilateral hydronephrosis is caused by one of these factors, while bilateral hydronephrosis is caused by a combination of pelvic-ureteric obstruction, aberrant renal vessels, and tumors of the renal pelvis.

To investigate hydronephrosis, ultrasound is the first-line test to identify the presence of hydronephrosis and assess the kidneys. IVU is used to assess the position of the obstruction, while antegrade or retrograde pyelography allows for treatment. If renal colic is suspected, a CT scan is used to detect the majority of stones.

The management of hydronephrosis involves removing the obstruction and draining urine. In cases of acute upper urinary tract obstruction, a nephrostomy tube is used, while chronic upper urinary tract obstruction is treated with a ureteric stent or a pyeloplasty. The CT scan image shows a large calculus in the left ureter with accompanying hydroureter and massive hydronephrosis in the left kidney.

Overall, hydronephrosis is a serious condition that requires prompt diagnosis and treatment to prevent further complications.

When it is difficult to obtain vascular access in an emergency situation, intraosseous access is often used. This method can be used for both adults and children, with the proximal tibia being the most common site for insertion. In paediatric cases, it is recommended to attempt two peripheral intravenous lines before moving on to intraosseous access. Other potential sites for insertion include the distal femur and humeral head.

Different Routes for Venous Access

There are various methods for establishing venous access, each with its own advantages and disadvantages. The peripheral venous cannula is easy to insert and has a wide lumen for rapid fluid infusions. However, it is unsuitable for administering vasoactive or irritant drugs and may cause infections if not properly managed. On the other hand, central lines have multiple lumens for multiple infusions but are more difficult to insert and require ultrasound guidance. Femoral lines are easier to manage but have high infection rates, while internal jugular lines are preferred. Intraosseous access is typically used in pediatric practice but can also be used in adults for a wide range of fluid infusions. Tunnelled lines, such as Groshong and Hickman lines, are popular for long-term therapeutic requirements and can be linked to injection ports. Finally, peripherally inserted central cannulas (PICC lines) are less prone to major complications and are inserted peripherally.

Overall, the choice of venous access route depends on the patient’s condition, the type of infusion required, and the operator’s expertise. It is important to weigh the benefits and risks of each method and to properly manage any complications that may arise.

After a subarachnoid haemorrhage, urgent intervention is necessary for intracranial aneurysms due to the risk of rebleeding. The most common treatment for this is coiling by an interventional neuroradiologist, which involves inserting soft metallic coils into the aneurysm to exclude it from intracranial circulation. This is less invasive than surgical clipping. While nimodipine is used to reduce vasospasm following a SAH, it is not sufficient on its own and additional intervention is required. Typically, nimodipine is administered for 21 days and targets the brain vasculature by inhibiting calcium channels.

A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.

The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.

Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.

Hypospadias is a reason why circumcision should not be performed in infancy as the foreskin is required for the repair process.

Circumcision is a practice that has been carried out in various cultures for centuries. Today, it is mainly practiced by people of the Jewish and Islamic faith for religious or cultural reasons. However, it is important to note that circumcision for these reasons is not available on the NHS.

The medical benefits of circumcision are still a topic of debate. However, some studies have shown that it can reduce the risk of penile cancer, urinary tract infections, and sexually transmitted infections, including HIV.

There are also medical indications for circumcision, such as phimosis, recurrent balanitis, balanitis xerotica obliterans, and paraphimosis. It is crucial to rule out hypospadias before performing circumcision as the foreskin may be needed for surgical repair.

Circumcision can be performed under local or general anesthesia. It is a personal decision that should be made after careful consideration of the potential benefits and risks.

Types of Renal Stones and their Appearance on X-ray

Renal stones, also known as kidney stones, are solid masses that form in the kidneys due to the accumulation of certain substances. There are different types of renal stones, each with a unique appearance on x-ray. Calcium oxalate stones are the most common, accounting for 40% of cases, and appear opaque on x-ray. Mixed calcium oxalate/phosphate stones and calcium phosphate stones also appear opaque and make up 25% and 10% of cases, respectively. Triple phosphate stones, which develop in alkaline urine and are composed of struvite, account for 10% of cases and appear opaque as well. Urate stones, which are radiolucent, make up 5-10% of cases. Cystine stones, which have a semi-opaque, ‘ground-glass’ appearance, are rare and only account for 1% of cases. Xanthine stones are the least common, accounting for less than 1% of cases, and are also radiolucent. Stag-horn calculi, which involve the renal pelvis and extend into at least 2 calyces, are composed of triple phosphate and are more likely to develop in alkaline urine. Infections with Ureaplasma urealyticum and Proteus can increase the risk of their formation.

Clear cell carcinoma is the most frequent histological type of malignant renal cancer. The classic triad of renal cancer includes flank pain, mass, and haematuria, but it is unusual for all three symptoms to be present at the initial diagnosis. Clear cell carcinoma can be distinguished from a simple cyst by its variegated, septated interior. Transitional cell carcinomas are less common and typically originate from the ureter. Angiomyolipomas are also infrequent and are linked to tuberous sclerosis.

Understanding Renal Cell Cancer

Renal cell cancer, also known as hypernephroma, is a primary renal neoplasm that accounts for 85% of cases. It typically arises from the proximal renal tubular epithelium, with the clear cell subtype being the most common. This type of cancer is more prevalent in middle-aged men and is associated with smoking, von Hippel-Lindau syndrome, and tuberous sclerosis. While renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease, it can present with a classical triad of haematuria, loin pain, and abdominal mass. Other features include pyrexia of unknown origin, endocrine effects, and paraneoplastic hepatic dysfunction syndrome.

The T category criteria for renal cell cancer are based on the size and extent of the tumour. For confined disease, a partial or total nephrectomy may be recommended depending on the tumour size. Patients with a T1 tumour are typically offered a partial nephrectomy, while those with larger tumours may require a total nephrectomy. Treatment options for renal cell cancer include alpha-interferon, interleukin-2, and receptor tyrosine kinase inhibitors such as sorafenib and sunitinib. These medications have been shown to reduce tumour size and treat patients with metastases. It is important to note that renal cell cancer can have paraneoplastic effects, such as Stauffer syndrome, which is associated with cholestasis and hepatosplenomegaly. Overall, early detection and prompt treatment are crucial for improving outcomes in patients with renal cell cancer.

Subarachnoid haemorrhage is a potential complication of ADPKD.

A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.

The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.

Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.

Understanding Renal Cell Cancer

Renal cell cancer, also known as hypernephroma, is a primary renal neoplasm that accounts for 85% of cases. It typically arises from the proximal renal tubular epithelium, with the clear cell subtype being the most common. This type of cancer is more prevalent in middle-aged men and is associated with smoking, von Hippel-Lindau syndrome, and tuberous sclerosis. While renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease, it can present with a classical triad of haematuria, loin pain, and abdominal mass. Other features include pyrexia of unknown origin, endocrine effects, and paraneoplastic hepatic dysfunction syndrome.

The T category criteria for renal cell cancer are based on the size and extent of the tumour. For confined disease, a partial or total nephrectomy may be recommended depending on the tumour size. Patients with a T1 tumour are typically offered a partial nephrectomy, while those with larger tumours may require a total nephrectomy. Treatment options for renal cell cancer include alpha-interferon, interleukin-2, and receptor tyrosine kinase inhibitors such as sorafenib and sunitinib. These medications have been shown to reduce tumour size and treat patients with metastases. It is important to note that renal cell cancer can have paraneoplastic effects, such as Stauffer syndrome, which is associated with cholestasis and hepatosplenomegaly. Overall, early detection and prompt treatment are crucial for improving outcomes in patients with renal cell cancer.