Understanding Circumcision

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.

The most likely cause of a fever developing within the first 24 hours after surgery in an otherwise healthy patient is a physiological reaction to the operation. This is due to the inflammatory response to tissue damage caused by the surgery. Other potential causes such as cellulitis, pneumonia, and pulmonary embolism are less likely due to the absence of other symptoms and vital sign changes. Cellulitis may present with red and tender wounds, but without changes in other vital signs, it is not the likely cause. Pneumonia and pulmonary embolism typically occur after 48 hours and 2-10 days respectively, and would be accompanied by changes in heart and respiratory rates, which were not observed in this patient.

Post-operative pyrexia, or fever, can occur after surgery and can be caused by various factors. Early causes of post-op pyrexia, which typically occur within the first five days after surgery, include blood transfusion, cellulitis, urinary tract infection, and a physiological systemic inflammatory reaction that usually occurs within a day following the operation. Pulmonary atelectasis is also often listed as an early cause, but the evidence to support this link is limited. Late causes of post-op pyrexia, which occur more than five days after surgery, include venous thromboembolism, pneumonia, wound infection, and anastomotic leak.

To remember the possible causes of post-op pyrexia, it is helpful to use the memory aid of the 4 W’s: wind, water, wound, and what did we do? (iatrogenic). This means that the causes can be related to respiratory issues (wind), urinary tract or other fluid-related problems (water), wound infections or complications (wound), or something that was done during the surgery or post-operative care (iatrogenic). It is important to identify the cause of post-op pyrexia and treat it promptly to prevent further complications. This information is based on a peer-reviewed publication available on the National Center for Biotechnology Information website.

Bariatric Surgery as a First-Line Option for Patients with High BMI

Patients with a BMI greater than 50 kg/m² can be referred to bariatric surgery as a first-line option, provided they have no contraindications. If the patient has medical conditions that are affected by weight, surgery can be considered at a BMI greater than 35 kg/m². There are no restrictions on referral for bariatric surgery based on BMI, but the decision will involve an anaesthetic risk assessment based on multiple factors.

Referral for bariatric surgery in patients with a BMI greater than 40 kg/m² does not require them to have a medical condition affected by their weight. However, for patients with a BMI greater than 35 and up to 40 kg/m², a medical condition affected by weight is required for referral. A dietary management plan may benefit the patient, but the request for surgical consideration does not need to be delayed for a further 6 months.

While awaiting surgical assessment, Orlistat could be trialled, but this does not need to delay the referral. In summary, bariatric surgery can be considered as a first-line option for patients with a high BMI, and referral should be made without delay, taking into account the patient’s medical history and anaesthetic risk assessment.

Bariatric Surgery for Obesity Management

Bariatric surgery has become a significant option in managing obesity over the past decade. For obese patients who fail to lose weight through lifestyle changes and medication, the risks and costs of long-term obesity outweigh those of surgery. The National Institute for Health and Care Excellence (NICE) guidelines recommend early referral for bariatric surgery for very obese patients with a BMI of 40-50 kg/m^2, especially if they have other conditions such as type 2 diabetes mellitus and hypertension.

There are three types of bariatric surgery: primarily restrictive, primarily malabsorptive, and mixed operations. Laparoscopic-adjustable gastric banding (LAGB) is the first-line intervention for patients with a BMI of 30-39 kg/m^2. It produces less weight loss than other procedures but has fewer complications. Sleeve gastrectomy reduces the stomach to about 15% of its original size, while the intragastric balloon can be left in the stomach for a maximum of six months. Biliopancreatic diversion with duodenal switch is usually reserved for very obese patients with a BMI over 60 kg/m^2. Roux-en-Y gastric bypass surgery is both restrictive and malabsorptive in action.

There is strong evidence indicating that epidural analgesia can speed up the recovery of normal bowel function following abdominal surgery. This is supported by research showing that patients who receive epidural analgesia experience a shorter time before the return of normal gastrointestinal transit, as measured by the first flatus post-surgery. As a result, epidural analgesia is frequently used in gastrointestinal surgery wards and is often the preferred method of pain management over other options.

Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdominoperineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileocolic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Women who are taking hormone replacement therapy, such as Femoston, should discontinue its use four weeks prior to any elective surgeries. This is because the risk of venous thromboembolism increases with the use of HRT. It is important to note that no changes are necessary for medications such as labetalol and amlodipine, as they are safe to continue taking before and on the day of surgery. Additionally, levothyroxine is also safe to take before and on the day of surgery, so there is no need to discontinue its use one week prior to the procedure.

Venous thromboembolism (VTE) is a serious condition that can lead to severe health complications and even death. However, it is preventable. The National Institute for Health and Care Excellence (NICE) has updated its guidelines for 2018 to provide recommendations for the assessment and management of patients at risk of VTE in hospital. All patients admitted to the hospital should be assessed individually to identify risk factors for VTE development and bleeding risk. The department of health’s VTE risk assessment tool is recommended for medical and surgical patients. Patients with certain risk factors, such as reduced mobility, surgery, cancer, and comorbidities, are at increased risk of developing VTE. After assessing a patient’s VTE risk, healthcare professionals should compare it to their risk of bleeding to decide whether VTE prophylaxis should be offered. If indicated, VTE prophylaxis should be started as soon as possible.

There are two types of VTE prophylaxis: mechanical and pharmacological. Mechanical prophylaxis includes anti-embolism stockings and intermittent pneumatic compression devices. Pharmacological prophylaxis includes fondaparinux sodium, low molecular weight heparin (LMWH), and unfractionated heparin (UFH). The choice of prophylaxis depends on the patient’s individual risk factors and bleeding risk.

In general, medical patients deemed at risk of VTE after individual assessment are started on pharmacological VTE prophylaxis, provided that the risk of VTE outweighs the risk of bleeding and there are no contraindications. Surgical patients at low risk of VTE are treated with anti-embolism stockings, while those at high risk are treated with a combination of stockings and pharmacological prophylaxis.

Patients undergoing certain surgical procedures, such as hip and knee replacements, are recommended to receive pharmacological VTE prophylaxis to reduce the risk of VTE developing post-surgery. For fragility fractures of the pelvis, hip, and proximal femur, LMWH or fondaparinux sodium is recommended for a month if the risk of VTE outweighs the risk of bleeding.

Healthcare professionals should advise patients to stop taking their combined oral contraceptive pill or hormone replacement therapy four weeks before surgery and mobilize them as soon as possible after surgery. Patients should also ensure they are hydrated. By following these guidelines, healthcare professionals can help prevent VTE and improve patient outcomes.

Proteus mirabilis is responsible for the majority of Proteus infections due to its ability to produce urease. This enzyme promotes urinary alkalinisation, which is a necessary condition for the development of staghorn calculi.

Renal Stones: Types and Factors

Renal stones, also known as kidney stones, are solid masses formed in the kidneys from substances found in urine. There are different types of renal stones, each with its own unique features and risk factors. Calcium oxalate stones are the most common type, accounting for 85% of all calculi. Hypercalciuria, hyperoxaluria, and hypocitraturia are major risk factors for calcium oxalate stones. Cystine stones, which are caused by an inherited recessive disorder of transmembrane cystine transport, are relatively rare, accounting for only 1% of all calculi. Uric acid stones, which are formed from purine metabolism, are more common in children with inborn errors of metabolism and are radiolucent. Calcium phosphate stones, which are radio-opaque, may occur in renal tubular acidosis, and high urinary pH increases the supersaturation of urine with calcium and phosphate. Struvite stones, which are slightly radio-opaque, are formed from magnesium, ammonium, and phosphate and are associated with chronic infections.

The pH of urine plays a crucial role in stone formation. Urine pH varies from 5-7, with postprandial pH falling as purine metabolism produces uric acid. The urine then becomes more alkaline, known as the alkaline tide. The pH of urine can help determine which type of stone was present when the stone is not available for analysis. Calcium phosphate stones form in normal to alkaline urine with a pH greater than 5.5, while uric acid stones form in acidic urine with a pH of 5.5 or less. Struvite stones form in alkaline urine with a pH greater than 7.2, and cystine stones form in normal urine with a pH of 6.5.

In summary, renal stones are a common condition with various types and risk factors. Understanding the type of stone and the pH of urine can help in the diagnosis and management of renal stones.

The drug that can cause drug-induced pancreatitis is mesalazine. This patient is exhibiting the typical symptoms of acute pancreatitis, such as severe epigastric pain that is relieved by leaning forward, accompanied by vomiting and fever. Although there can be multiple causes of this condition, drug-induced pancreatitis is a common one. Mesalazine has been identified as a causative agent, but the exact mechanism is still unknown. It is believed that salicylic acid may increase the permeability of the pancreatic duct, leading to inflammation.

Phenytoin is a medication used to manage seizures, but it has not been shown to cause pancreatitis, although it can cause hepatitis and other side effects. Clozapine is an atypical antipsychotic used to treat complicated schizophrenia, but it has not been linked to pancreatitis, although it can cause agranulocytosis, neutropenia, constipation, myocarditis, and seizures. Ramipril is an angiotensin-converting enzyme inhibitor that has not been associated with pancreatitis, but it may cause cough, angioedema, and hyperkalemia.

Acute pancreatitis is a condition that is mainly caused by gallstones and alcohol in the UK. A popular mnemonic to remember the causes is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. CT scans of patients with acute pancreatitis show diffuse parenchymal enlargement with oedema and indistinct margins. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine.

Subcutaneous emphysema is a possible finding in cases of Boerhaave’s syndrome, which involves a rupture of the oesophagus. This condition should be considered when a patient presents with chest pain, as it has a high mortality rate. The presence of subcutaneous emphysema and a history of vomiting make Boerhaave’s syndrome the most likely cause. The tear in the oesophagus allows air to travel up the mediastinum’s fascial planes and into the subcutaneous tissues, resulting in the characteristic ‘rice krispies’ crepitus.

Aortic dissection is a potential differential diagnosis for chest pain that feels like tearing. However, this type of pain typically radiates to the back, and the patient would likely have risk factors such as a connective tissue disorder, vasculitis, or trauma. The vomiting history makes aortic dissection less likely.

Mallory-Weiss tear is another possible cause of chest pain resulting from a partial-thickness tear of the oesophagus due to repeated vomiting. However, this condition would be more likely if the patient’s vomit contained blood suddenly, which is not the case in this scenario. Additionally, Mallory-Weiss tear would not present with subcutaneous emphysema as the tear is only partial thickness.

Mediastinitis is a potential complication of Boerhaave’s syndrome, which occurs when the mediastinum becomes infected. The patient would likely be systemically unwell and septic.

Myocardial infarction is another possible cause of central chest pain, but it is less likely in this case due to the vomiting history, lack of risk factors, and absence of ECG findings. Myocardial infarction would also not present with subcutaneous emphysema.

Boerhaave’s Syndrome: A Dangerous Rupture of the Oesophagus

Boerhaave’s syndrome is a serious condition that occurs when the oesophagus ruptures due to repeated episodes of vomiting. This rupture is typically located on the left side of the oesophagus and can cause sudden and severe chest pain. Patients may also experience subcutaneous emphysema, which is the presence of air under the skin of the chest wall.

To diagnose Boerhaave’s syndrome, a CT contrast swallow is typically performed. Treatment involves thoracotomy and lavage, with primary repair being feasible if surgery is performed within 12 hours of onset. If surgery is delayed beyond 12 hours, a T tube may be inserted to create a controlled fistula between the oesophagus and skin. However, delays beyond 24 hours are associated with a very high mortality rate.

Complications of Boerhaave’s syndrome can include severe sepsis, which occurs as a result of mediastinitis.

When patients with intracranial bleeds become unresponsive, it is crucial to promptly perform a CT scan to detect hydrocephalus. This diagnostic tool can quickly confirm or rule out the presence of hydrocephalus in these patients. CT angiograms are not appropriate for this purpose, as they are typically used to locate the source of subarachnoid bleeds. While arterial blood tests can reveal whether a patient with COPD is retaining carbon dioxide, this is not relevant for a patient without underlying lung pathology. Although hyponatremia is common in patients with intracranial bleeds, it does not present in a way that would warrant urgent investigation. While lumbar punctures can measure intracranial pressure, they should not be performed without first conducting a CT scan in these patients.

Types of Traumatic Brain Injury

Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. intracranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.

Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.

Antimuscarinic drugs are the first-line medication for patients with overactive bladder symptoms. These drugs, such as oxybutynin, tolterodine, or darifenacin, work by blocking receptors in the detrusor muscles of the bladder, reducing overactive symptoms. Conservative measures like fluid intake adjustments and bladder retraining should be tried first. If antimuscarinics do not improve symptoms, the beta-3 agonist mirabegron can be considered as a second-line treatment.

5-alpha reductase inhibitors are not useful for patients with predominantly overactive bladder symptoms. They are mainly used for patients with voiding symptoms caused by an enlarged prostate, such as hesitancy, poor stream, straining, and incomplete bladder emptying.

Calcium channel blockers do not play a role in the management of LUTS and may even worsen symptoms. Patients on calcium channel blockers who present with LUTS symptoms should consider changing to another antihypertensive medication before starting an additional medication for LUTS.

Alpha-blockers are also mainly used for patients with LUTS secondary to an enlarged prostate. They relax the smooth muscle in the bladder and are not helpful for patients with overactive bladder symptoms.

antidiuretic medications like desmopressin may be used for patients who mainly experience nocturia, but they are not typically used as first-line medication and have a limited role in patients with overactive bladder symptoms.

Lower urinary tract symptoms (LUTS) are a common issue in men over the age of 50, with benign prostatic hyperplasia being the most common cause. However, other causes such as prostate cancer should also be considered. These symptoms can be classified into three groups: voiding, storage, and post-micturition. To properly manage LUTS, it is important to conduct a urinalysis to check for infection and haematuria, perform a digital rectal examination to assess the size and consistency of the prostate, and possibly conduct a PSA test after proper counselling. Patients should also complete a urinary frequency-volume chart and an International Prostate Symptom Score to guide management.

For predominantly voiding symptoms, conservative measures such as pelvic floor muscle training, bladder training, and prudent fluid intake can be helpful. If symptoms are moderate or severe, an alpha-blocker may be offered. If the prostate is enlarged and the patient is at high risk of progression, a 5-alpha reductase inhibitor should be offered. If there are mixed symptoms of voiding and storage not responding to an alpha-blocker, an antimuscarinic drug may be added. For predominantly overactive bladder symptoms, moderating fluid intake and bladder retraining should be offered, and antimuscarinic drugs may be prescribed if symptoms persist. Mirabegron may be considered if first-line drugs fail. For nocturia, moderating fluid intake at night, furosemide 40 mg in the late afternoon, and desmopressin may be helpful.

Ketamine is a suitable choice for anesthesia in trauma patients as it does not lead to a decrease in blood pressure. This is particularly important for patients like the one in this case who have borderline low blood pressure and are at risk of experiencing low blood pressure during surgery. Ketamine is an NMDA receptor antagonist that can increase blood pressure, making it a useful option for anesthesia in trauma patients. Etomidate, although it has milder cardiovascular effects than propofol, is still not recommended for use in trauma or bleeding patients compared to ketamine. Midazolam, when used as an induction agent, can also cause a drop in blood pressure. Propofol, on the other hand, can cause hypotension in a dose-dependent manner and is therefore not ideal for patients who are already bleeding, have polytrauma, or have borderline blood pressure.

Overview of General Anaesthetics

General anaesthetics are drugs used to induce a state of unconsciousness in patients undergoing surgical procedures. There are two main types of general anaesthetics: inhaled and intravenous. Inhaled anaesthetics, such as isoflurane, desflurane, sevoflurane, and nitrous oxide, are administered through inhalation. These drugs work by acting on various receptors in the brain, including GABAA, glycine, NDMA, nACh, and 5-HT3 receptors. Inhaled anaesthetics can cause adverse effects such as myocardial depression, malignant hyperthermia, and hepatotoxicity.

Intravenous anaesthetics, such as propofol, thiopental, etomidate, and ketamine, are administered through injection. These drugs work by potentiating GABAA receptors or blocking NDMA receptors. Intravenous anaesthetics can cause adverse effects such as pain on injection, hypotension, laryngospasm, myoclonus, and disorientation. However, they are often preferred over inhaled anaesthetics in cases of haemodynamic instability.

It is important to note that the exact mechanism of action of general anaesthetics is not fully understood. Additionally, the choice of anaesthetic depends on various factors such as the patient’s medical history, the type of surgery, and the anaesthetist’s preference. Overall, general anaesthetics play a crucial role in modern medicine by allowing for safe and painless surgical procedures.

The preferred surgical procedure for obstructing cancers in the distal colon is a loop colostomy. This involves creating a stoma with two openings, one connected to the functioning part of the bowel and the other leading into the distal colon to dysfunction and decompress it. The stoma can be reversed at a later time. However, other procedures such as AP resection, ileocolic anastomosis, and ileostomy are not appropriate for this patient’s descending colon mass.

Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be spouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.

For patients over 65 years old who have experienced some form of loss of consciousness or amnesia after a head injury, a CT scan should be performed within 8 hours. This is important to assess the risk of complications from the injury. While this patient does not have any immediate indications for a CT scan, as they did not have a GCS score below 13 on initial assessment, suspected skull fractures, seizures, focal neurological deficits, or vomiting, they did lose consciousness during the fall. NICE guidelines recommend that any patient over 65 years old who experiences a loss of consciousness or amnesia following a fall should be offered a CT head 8 hours post-injury to identify potential complications such as intracranial bleeds. A CT scan within 1 hour is not necessary in this case.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury without other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Pilonidal and Perianal Abscesses

Pilonidal abscesses are a type of inflammatory condition that occurs when hair produces a sinus. These abscesses are typically found in or near the midline of the body, close to the natal cleft. They are more common in Caucasian males who are in their thirties, particularly those who are obese or have a lot of body hair.

When someone presents with a pilonidal abscess, they will typically undergo an incision and drainage procedure. However, if the disease becomes non-healing or recurrent, a more definitive procedure such as excision may be required.

Perianal and ischiorectal abscesses, on the other hand, are caused by an infection of the anal glands found in the intersphincteric space. These abscesses can also be treated with incision and drainage procedures, but may require more extensive treatment if they become chronic or recurrent.

Overall, the causes and treatments of pilonidal and perianal abscesses is important for anyone who may be at risk for these conditions. By seeking prompt medical attention and following a proper treatment plan, individuals can manage these conditions and prevent them from becoming more serious.

Understanding Perianal Abscesses

A perianal abscess is a type of anorectal abscess that occurs when pus collects within the subcutaneous tissue surrounding the anal sphincter. It is the most common form of anorectal abscess, accounting for around 60% of cases, and is more prevalent in men with an average age of 40 years. Symptoms include pain around the anus, hardened tissue in the anal region, and pus-like discharge from the anus. In some cases, patients may also experience systemic infection.

Perianal abscesses are typically caused by gut flora such as E. coli, although those caused by Staph. aureus are more likely to be a skin infection. Diagnosis can be made through inspection of the anus and digital rectal examination, with further investigations such as colonoscopy and blood tests used to determine underlying causes. Imaging such as MRI and transperineal ultrasound may also be used in complicated cases.

Treatment for perianal abscesses involves surgical incision and drainage under local anaesthetic, with the wound either packed or left open to heal over several weeks. Antibiotics may be used in cases of systemic infection, but are not typically used for wound healing. It is important to note that perianal abscesses are just one type of anorectal abscess, with others classified by the layers and planes they occupy, such as ischiorectal, supralevator, intersphincteric, and horseshoe abscesses.

Overall, understanding perianal abscesses and their causes, symptoms, and treatment options is important for proper diagnosis and management of this common condition.

Fasting Guidelines Prior to Surgery

Fasting prior to surgery is important to reduce the risk of regurgitation and aspiration while under anesthesia, which can lead to aspiration pneumonia. The current guidance advises patients to refrain from consuming food for at least 6 hours before surgery. However, clear fluids such as water, fruit squash, tea, or coffee with small amounts of skimmed or semi-skimmed milk can be encouraged up to 2 hours before surgery to maintain hydration and aid in post-operative recovery.

The previous practice of nil by mouth from midnight is now considered unnecessary and outdated. It is now known that maintaining hydration and nutrition peri-operatively can lead to faster post-operative recovery. Patients with diabetes may require a sliding-scale insulin infusion to manage their blood sugar levels before and after surgery.

In summary, the recommended fasting guidelines prior to surgery are no food for 6 hours before surgery and clear fluids up to 2 hours before surgery. These guidelines help to minimize the risk of aspiration while under anesthesia and promote a smoother recovery process.

The patient’s pre-operative morbidity is assessed using the ASA scoring system, which takes into account various factors including BMI. Despite having no significant medical history and not smoking or drinking, the patient’s BMI is elevated and can be rounded up to 35 kg/m², placing her in the ASA II category. This category includes patients with a BMI between 30 and 40. A healthy patient who does not smoke or drink and has a BMI below 30 kg/m² is classified as ASA I. Patients with severe systemic diseases such as poorly controlled diabetes, hypertension, chronic obstructive pulmonary disease, or morbid obesity (BMI > 40 kg/m²) are classified as ASA III. ASA IV is reserved for patients with severe systemic diseases that pose a constant threat to life, such as ongoing cardiac ischaemia or recent myocardial infarction, sepsis, and end-stage renal disease.

The American Society of Anaesthesiologists (ASA) classification is a system used to categorize patients based on their overall health status and the potential risks associated with administering anesthesia. There are six different classifications, ranging from ASA I (a normal healthy patient) to ASA VI (a declared brain-dead patient whose organs are being removed for donor purposes).

ASA II patients have mild systemic disease, but without any significant functional limitations. Examples of mild diseases include current smoking, social alcohol drinking, pregnancy, obesity, and well-controlled diabetes mellitus or hypertension. ASA III patients have severe systemic disease and substantive functional limitations, with one or more moderate to severe diseases. Examples include poorly controlled diabetes mellitus or hypertension, COPD, morbid obesity, active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history of myocardial infarction, and cerebrovascular accidents.

ASA IV patients have severe systemic disease that poses a constant threat to life, such as recent myocardial infarction or cerebrovascular accidents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis. ASA V patients are moribund and not expected to survive without the operation, such as ruptured abdominal or thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology, or multiple organ/system dysfunction. Finally, ASA VI patients are declared brain-dead and their organs are being removed for donor purposes.

One of the main reasons for considering neo-adjuvant chemotherapy in breast cancer treatment is to shrink the size of the tumor before surgery. This can potentially allow for breast conserving surgery instead of a mastectomy, which has several benefits. Firstly, it is a less invasive surgical procedure, reducing the risks associated with surgery. Additionally, it can lead to better cosmetic outcomes for the patient.

It is important to note that both NACT and surgery have their own set of side effects, which cannot be compared with each other. However, there is an exciting new area of breast cancer research that focuses on immunomodulation. Some trials have shown that anti-tumor immunity can be induced following cryoablation/radiotherapy and administration of immunomodulating drugs. Unfortunately, NACT does not have this effect.

One common side effect of NACT is nausea. The effect of NACT on overall survival rates has been mixed, but its main indication remains downsizing of the primary tumor.

Reference:
Nice guideline NG101 (2018).

Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.

Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and perimenopausal women and aromatase inhibitors like anastrozole in postmenopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.

Acute epididymo-orchitis cases are commonly caused by enteric organisms (such as Escherichia coli or Enterococcus faecalis) in men aged 35 years and above. This type of infection is often linked to urinary tract infections and may be related to structural issues in the urinary tract.

Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

Radical prostatectomy often leads to erectile dysfunction as a complication. Other complications that may arise after the surgery include incontinence, urethral stenosis, and retrograde ejaculation due to alpha-blocker therapy or transurethral resection of the prostate (TURP). However, blood in the sperm, testicular atrophy, and an overactive bladder are not caused by prostatectomy.

Management of Prostate Cancer

Localised prostate cancer (T1/T2) can be managed through various treatment options depending on the patient’s life expectancy and preference. Conservative approaches such as active monitoring and watchful waiting can be considered, as well as radical prostatectomy and radiotherapy (external beam and brachytherapy). On the other hand, localised advanced prostate cancer (T3/T4) may require hormonal therapy, radical prostatectomy, or radiotherapy. However, patients who undergo radiotherapy may develop proctitis and are at a higher risk of bladder, colon, and rectal cancer.

For metastatic prostate cancer, the primary goal is to reduce androgen levels. A combination of approaches is often used, including anti-androgen therapy, synthetic GnRH agonist or antagonists, bicalutamide, cyproterone acetate, abiraterone, and bilateral orchidectomy. GnRH agonists such as Goserelin (Zoladex) may result in lower LH levels longer term by causing overstimulation, which disrupts endogenous hormonal feedback systems. This may cause a rise in testosterone initially for around 2-3 weeks before falling to castration levels. To prevent a rise in testosterone, anti-androgen therapy is often used initially. However, this may result in a tumour flare, which stimulates prostate cancer growth and may cause bone pain, bladder obstruction, and other symptoms. GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon. Chemotherapy with docetaxel may also be an option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

If a patient presents with an anal fissure, the location of the fissure can provide important information about the cause. A fissure located posteriorly is likely a primary fissure caused by constipation or straining, and a high-fiber diet may be recommended as part of the management plan. However, if the fissure is located laterally, it suggests a secondary cause and further investigation is necessary, especially if the patient has experienced changes in bowel habits, weight loss, or blood in their stools. In this case, an urgent referral to a specialist team is required, and a routine colonoscopy is not appropriate.

For an acute, primary anal fissure caused by constipation or straining, a combination of bulk-forming laxatives, a high-fiber diet, lubricants, and analgesia may be recommended to make passing stools easier while the fissure heals. However, if the fissure is caused by persistent loose stools, this management plan would not be appropriate.

For a chronic, primary anal fissure, a trial of topical glyceryl trinitrate (GTN) may be recommended, but this would not be appropriate for a case requiring urgent investigation.

Understanding Anal Fissures: Causes, Symptoms, and Treatment

Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, underlying causes such as Crohn’s disease should be considered.

Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.

In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.

Surgical excision is the recommended treatment for fibroadenomas larger than 3 cm in size. This is because such masses can cause cosmetic concerns and discomfort, especially if they continue to grow. Given the patient’s expressed anxiety about the mass, surgical excision should be offered as a treatment option. Anastrozole, which is used to treat hormone-receptor-positive breast cancer in postmenopausal women, is not appropriate in this case as the patient has a benign breast lesion, and there is no information about hormone receptor status or menopausal status. Tamoxifen, which has been shown to reduce benign breast lump development in some pre-menopausal women, is not a primary treatment for fibroadenomas. Ultrasound-guided monochloroacetic acid injection is also not a suitable treatment option as it is used for plantar wart management and not for breast cryotherapy. While some centers may offer ultrasound-guided cryotherapy for fibroadenomas smaller than 4 cm, surgical excision is the more common treatment.

Understanding Breast Fibroadenoma

Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30.

Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended.

In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.

If a patient shows minimal intra-abdominal bleeding without any impact on their haemodynamic stability, it is not necessary to perform a laparotomy. In such cases, the patient should be treated conservatively and their vital signs should be monitored regularly. The patient should also be catheterised and cannulated at this point.

If there is a small splenic haematoma and minimal free fluid in the abdomen, conservative management is the best course of action. Only severe splenic injuries and haemodynamic instability require exploratory laparotomy. A repeat CT scan of the abdomen is not necessary, and the patient should not be discharged. Instead, they should be closely monitored for any changes in their vital signs or level of consciousness.

Managing Splenic Trauma

The spleen is a commonly injured intra-abdominal organ, but in most cases, it can be conserved. The management of splenic trauma depends on several factors, including associated injuries, haemodynamic status, and the extent of direct splenic injury.

Conservative management is appropriate for small subcapsular haematomas, minimal intra-abdominal blood, and no hilar disruption. However, if there are increased amounts of intra-abdominal blood, moderate haemodynamic compromise, or tears or lacerations affecting less than 50%, laparotomy with conservation may be necessary.

In cases of hilar injuries, major haemorrhage, or major associated injuries, resection is the preferred management option. It is important to note that the management approach should be tailored to the individual patient’s needs and circumstances. Proper management of splenic trauma can help prevent further complications and improve patient outcomes.

The presence of an abdominal mass along with symptoms of lethargy and pallor may indicate the likelihood of colorectal cancer, which could also lead to anaemia.

Referral Guidelines for Colorectal Cancer

Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. In 2015, the National Institute for Health and Care Excellence (NICE) updated their referral guidelines for patients suspected of having colorectal cancer. According to these guidelines, patients who are 40 years or older with unexplained weight loss and abdominal pain, 50 years or older with unexplained rectal bleeding, or 60 years or older with iron deficiency anemia or change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients who test positive for occult blood in their feces should also be referred urgently.

An urgent referral should also be considered for patients who have a rectal or abdominal mass, unexplained anal mass or anal ulceration, or are under 50 years old with rectal bleeding and any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anemia.

The NHS offers a national screening program for colorectal cancer, which involves sending eligible patients aged 60 to 74 years in England and 50 to 74 years in Scotland FIT tests through the post. FIT is a type of fecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, under 60 years old with changes in their bowel habit or iron deficiency anemia, or 60 years or older who have anemia even in the absence of iron deficiency. Early detection and treatment of colorectal cancer can significantly improve patient outcomes, making it important to follow these referral guidelines.

The appropriate surgical procedure for a patient with distal transverse or descending colon cancer is a left hemicolectomy. This procedure involves removing the distal two-thirds of the transverse colon, the descending colon, and the sigmoid colon. The rectum is left intact and anastomosed with the proximal transverse colon, avoiding the need for a permanent stoma.

Other surgical options, such as Hartmann’s procedure, high anterior resection, low anterior resection, and right hemicolectomy, are not suitable for this patient’s condition. Hartmann’s procedure is reserved for emergencies, while high anterior resection and low anterior resection are used for rectal tumors. Right hemicolectomy is performed for cancers in the cecum, ascending colon, or proximal third of the transverse colon.

Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdominoperineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileocolic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Facial trauma can result in fractures of the facial bones, which are often caused by assaults or accidents. The location of the impact can determine the type of injury, with a punch to the cheek bone or eye area commonly resulting in a fractured zygoma. If the globe is ruptured, there will be a significant loss of vision. Monocular visual blurring may indicate a hyphaema, which can be diagnosed through inspection. A ramus fracture can cause difficulty opening the mouth, but will not affect vision. A maxillary antrum rupture may occur as a result of a comminuted maxillary fracture or blowout fracture of the orbit. If a patient has binocular vision and facial trauma, it may suggest a depressed fracture of the zygoma. Inspection and palpation of the orbital margins can reveal a step deformity or depressed contour of the cheek.

Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/furosemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.

Immediate CT head is necessary for head injuries with suspected open or depressed skull fractures.

In the given scenario, the patient has a depressed skull fracture, most likely at the pterion. As per NICE guidelines, urgent CT head is required as surgery may be necessary. Even though the patient is stable, critical features may be hidden, and delaying the CT may increase the risk of complications such as seizures and increased intracranial pressure.

CT head within 2 hours is not appropriate as the patient needs a CT within 1 hour of assessment.

CT head within 8 hours is also not appropriate as the patient requires immediate CT as per NICE guidelines.

If the patient had no features of a depressed skull fracture, they would still need a CT head within 8 hours due to the dangerous mechanism of injury.

Immediate MRI head is not necessary as it takes time, and a CT head can quickly identify urgent treatment requirements such as intracranial bleeding or raised intracranial pressure.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury without other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Common Nerve Injuries and their Effects on Upper Limb Function

The nerves of the upper limb are vulnerable to injury, particularly during surgical procedures or trauma. Understanding the effects of nerve damage on muscle function is crucial for accurate diagnosis and treatment. Here are some common nerve injuries and their effects on upper limb function:

Long Thoracic Nerve: Injury to this nerve results in denervation of the serratus anterior muscle, causing winging of the scapula on clinical examination. The patient will be unable to protract the scapula, leading to weakened arm movements.

Musculocutaneous Nerve: This nerve innervates the biceps brachii, brachialis, and coracobrachialis muscles. Damage to this nerve results in weakened arm flexion and an inability to flex the forearm.

Axillary Nerve: The teres minor and deltoid muscles are innervated by this nerve. Fractures of the surgical neck of the humerus can endanger this nerve, resulting in an inability to abduct the upper limb beyond 15-20 degrees.

Radial Nerve: The extensors of the forearm and triceps brachii muscles are innervated by this nerve. Damage to this nerve results in an inability to extend the forearm, but arm extension is only slightly weakened due to the powerful latissimus muscle.

Suprascapular Nerve: This nerve innervates the supraspinatus and infraspinatus muscles, which are important for initiating abduction and external rotation of the shoulder joint. Damage to this nerve results in an inability to initiate arm abduction.

In conclusion, understanding the effects of nerve injuries on muscle function is crucial for accurate diagnosis and treatment of upper limb injuries.

Plasma components pose the highest risk for transfusion associated lung injury.

When plasma components are infused, there is a possibility of transfusion lung injury. This can cause damage to the microvasculature in the lungs, resulting in diffuse infiltrates visible on imaging. Unfortunately, mortality rates are often high in such cases. It is worth noting that a normal central venous pressure (which should be between 0-6 mmHg) is not necessarily indicative of fluid overload.

Understanding Massive Haemorrhage and its Complications

Massive haemorrhage is defined as the loss of one blood volume within 24 hours, the loss of 50% of the circulating blood volume within three hours, or a blood loss of 150ml/minute. In adults, the blood volume is approximately 7% of the total body weight, while in children, it is between 8 and 9% of their body weight.

Massive haemorrhage can lead to several complications, including hypothermia, hypocalcaemia, hyperkalaemia, delayed type transfusion reactions, transfusion-related lung injury, and coagulopathy. Hypothermia occurs because the blood is refrigerated, which impairs homeostasis and shifts the Bohr curve to the left. Hypocalcaemia may occur because both fresh frozen plasma (FFP) and platelets contain citrate anticoagulant, which may chelate calcium. Hyperkalaemia may also occur because the plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+.

Delayed type transfusion reactions may occur due to minor incompatibility issues, especially if urgent or non-cross-matched blood is used. Transfusion-related lung injury is the leading cause of transfusion-related deaths and poses the greatest risk with plasma components. It occurs as a result of leucocyte antibodies in transfused plasma, leading to aggregation and degranulation of leucocytes in lung tissue. Finally, coagulopathy is anticipated once the circulating blood volume is transfused. One blood volume usually drops the platelet count to 100 or less, and it will both dilute and not replace clotting factors. The fibrinogen concentration halves per 0.75 blood volume transfused.

In summary, massive haemorrhage can lead to several complications that can be life-threatening. It is essential to understand these complications to manage them effectively and prevent adverse outcomes.

For patients with peripheral arterial disease, it is recommended that they undergo secondary prevention measures. This includes lifestyle modifications such as quitting smoking, improving diet, and exercising regularly. Additionally, all patients with established cardiovascular disease should be prescribed a statin, with the appropriate dose of atorvastatin being 80mg for secondary prevention and 20 mg for primary prevention. Aspirin may be used as an anti-platelet option, but it is not suitable for patients with a history of peptic ulcer disease. In such cases, clopidogrel is recommended as a first-line treatment. The use of phosphodiesterase III inhibitors is currently not advised by NICE. Blood pressure management is also important, with calcium channel blockers being the drug of choice for patients above the age of 55. However, in this patient’s case, amlodipine is not necessary as she does not have a history of high blood pressure and her current blood pressure is normal. GTN may be considered for its vasodilator effects, but it is contraindicated in certain conditions such as aortic stenosis, cardiac tamponade, and hypotensive conditions. Warfarin is not indicated for the secondary prevention of PAD.

Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions.

For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.

There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.