If a person is taking anticoagulants and has suffered a head injury, they should receive a CT head scan within 8 hours. This is the case for a 73-year-old man who sustained a head injury while gardening and is taking edoxaban. The NICE guidelines on head injury imaging algorithm recommend this course of action. An urgent CT scan within 1 hour is not necessary in this scenario as there are no risk factors for a severe head injury. Discharging the patient home with safety netting information is not appropriate, and an outpatient MRI scan is not necessary.

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.

The presence of bubbly urine in a woman with recurrent UTIs may indicate an enterovesical fistula, which is a connection between the bowel and bladder. This condition is often associated with colorectal cancer, as suggested by the patient’s tissue wasting. It is important to investigate this possibility. There are no symptoms of pyelonephritis or bladder stones, which would not cause gas in the urine. While the patient’s wasting could be a sign of malignancy, there is no indication that it is endometrial cancer, which typically presents with postmenopausal bleeding. The most common organism in UTIs is E. coli, which is a facultative anaerobe and does not produce large amounts of gas.

Fistulas are abnormal connections between two epithelial surfaces, with the majority arising from diverticular disease and Crohn’s in the abdominal cavity. They can be enterocutaneous, enteroenteric or enterocolic, enterovaginal, or enterovesicular. Conservative measures may be the best option for management, but high output fistulas may require octreotide and TPN for nutritional support. Surgeons should avoid probing perianal fistulae with acute inflammation and use setons for those secondary to Crohn’s disease. It is important to delineate the fistula anatomy using barium and CT studies for intraabdominal sources and recalling Goodsall’s rule for perianal fistulae.

Fractured Neck of Femur in Elderly Patients

Fractured neck of femur is a common injury that causes morbidity and mortality in elderly patients. This type of fracture occurs between the head and trochanteric region of the femur and can also occur in younger patients due to trauma or associated conditions. The fracture can be displaced or nondisplaced, and intracapsular or extracapsular.

For displaced fractures, there are two treatment strategies: reduction and fixation or replacement of the head and neck of the femur with a prosthesis. Physiologically younger and active patients with displaced extracapsular fractures should be treated with reduction and fixation, often with a dynamic hip screw. However, there is a risk of further surgery if the hip develops painful avascular necrosis, which may not be avoided despite the best surgical treatment. Displaced intracapsular fractures in younger patients are not straightforward to manage, and a total hip replacement may be considered.

In older patients, displaced fractures are best treated with replacement of the head and neck of the femur to avoid potential further surgery. It is important for patients to understand the risks and benefits of each treatment option and to work with their healthcare provider to determine the best course of action.

NICE suggests starting a low molecular weight heparin within 6-12 hours after elective total hip replacement surgery.

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.

Seminomas are often associated with elevated levels of LDH.
Prostate cancer is frequently accompanied by an increase in PSA.
Colorectal cancer is most commonly linked to elevated levels of CEA.
Melanomas and schwannomas often result in elevated levels of S-100.

Understanding Testicular Cancer

Testicular cancer is a type of cancer that commonly affects men between the ages of 20 and 30. Germ-cell tumors are the most common type of testicular cancer, accounting for around 95% of cases. These tumors can be divided into seminomas and non-seminomas, which include embryonal, yolk sac, teratoma, and choriocarcinoma. Other types of testicular cancer include Leydig cell tumors and sarcomas. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis.

The most common symptom of testicular cancer is a painless lump, although some men may experience pain. Other symptoms may include hydrocele and gynaecomastia, which occurs due to an increased oestrogen:androgen ratio. Tumor markers such as hCG, AFP, and beta-hCG may be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool for testicular cancer.

Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis for testicular cancer is generally excellent, with a 5-year survival rate of around 95% for seminomas and 85% for teratomas if caught at Stage I. It is important for men to perform regular self-examinations and seek medical attention if they notice any changes or abnormalities in their testicles.

A congenital hydrocele is a common condition in newborn male babies, which usually resolves within a few months. Therefore, reassurance and observation are typically the only necessary management. However, if the hydrocele does not resolve, elective surgery is required when the child is between 1-2 years old to prevent complications such as an incarcerated hernia. Urgent surgical repair is not necessary unless there is a suspicion of testicular torsion or a strangulated hernia. Therapeutic aspiration is not a suitable option for this condition, except in elderly men with hydrocele who are not fit for surgery or in cases of very large hydroceles. Reassurance and surgical repair after 4-5 years is also incorrect, as surgery is usually considered at 1-2 years of age.

A hydrocele is a condition where fluid accumulates within the tunica vaginalis. There are two types of hydroceles: communicating and non-communicating. Communicating hydroceles occur when the processus vaginalis remains open, allowing peritoneal fluid to drain into the scrotum. This type of hydrocele is common in newborn males and usually resolves within a few months. Non-communicating hydroceles occur when there is excessive fluid production within the tunica vaginalis. Hydroceles can develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors.

The main feature of a hydrocele is a soft, non-tender swelling of the hemi-scrotum that is usually located anterior to and below the testicle. The swelling is confined to the scrotum and can be transilluminated with a pen torch. If the hydrocele is large, the testis may be difficult to palpate. Diagnosis can be made clinically, but ultrasound is necessary if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.

Management of hydroceles depends on the severity of the presentation. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years. In adults, a conservative approach may be taken, but further investigation, such as an ultrasound, is usually warranted to exclude any underlying cause, such as a tumor.

The posterior midline is where anal skin tags are commonly found. Genital warts, caused by HPV types 6 & 11, are small fleshy bumps that may be pigmented and cause itching or bleeding. Pilonidal sinus can cause pain and discharge in cycles due to hair debris creating sinuses in the skin, and if located near the anus, may cause anal discomfort.

Thrombosed haemorrhoids are characterized by severe pain and the presence of a tender lump. Upon examination, a purplish, swollen, and tender subcutaneous perianal mass can be observed. If the patient seeks medical attention within 72 hours of onset, referral for excision may be necessary. However, if the condition has progressed beyond this timeframe, patients can typically manage their symptoms with stool softeners, ice packs, and pain relief medication. Symptoms usually subside within 10 days.

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.

Bladder cancer typically presents with painless haematuria, which requires referral to a urology haematuria clinic. Approximately 5-10% of microscopic haematuria and 20-25% of frank haematuria will have a urogenital malignancy. Tests carried out in the haematuria clinic include urine analysis, cytology, cystoscopy, and ultrasound. Transitional cell carcinoma is the most common type of bladder cancer, and smoking increases the risk by threefold. Bladder stones and urinary tract infections may also cause bladder irritation and haematuria.

The correct diagnosis for the patient’s visible protrusion is an epigastric hernia, which is a lump located in the midline between the umbilicus and the xiphisternum. This is supported by the fact that the protrusion is 5 cm above the umbilicus in the midline. Other potential diagnoses such as femoral hernia, para-umbilical hernia, and Spigelian hernia are incorrect as they do not match the location and characteristics of the patient’s protrusion.

Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.

The patient’s presentation suggests a large bowel obstruction, as indicated by the abdominal distension, inability to pass stool or flatus, and presence of hard faeces on digital rectal examination. The history of rectal bleeding and weight loss further support this diagnosis. Acute mesenteric ischemia is unlikely due to the absence of severe pain and nausea/vomiting. Paralytic ileus is a possibility, but the presence of bowel sounds suggests a mechanical obstruction. A small bowel obstruction is unlikely given the patient’s family history and lack of vomiting.

Understanding Large Bowel Obstruction

Large bowel obstruction occurs when the passage of food, fluids, and gas through the large intestines is blocked. The most common cause of this condition is a tumor, accounting for 60% of cases. Colonic malignancy is often the initial presenting complaint in approximately 30% of cases, particularly in more distal colonic and rectal tumors. Other causes include volvulus and diverticular disease.

Clinical features of large bowel obstruction include abdominal pain, distention, and absence of passing flatus or stool. Nausea and vomiting may suggest a more proximal lesion, while peritonism may be present if there is associated bowel perforation. It is important to consider the underlying causes, such as any recent symptoms suggestive of colorectal cancer.

Abdominal x-ray is still commonly used as a first-line investigation, with a diameter greater than the normal limits being diagnostic of obstruction. CT scan has a high sensitivity and specificity for identifying obstruction and its underlying cause.

Initial management includes NBM, IV fluids, and nasogastric tube with free drainage. Conservative management for up to 72 hours can be trialed if the cause of obstruction does not require surgery. Around 75% of cases will eventually require surgery. IV antibiotics will be given if perforation is suspected or surgery is planned. Emergency surgery is necessary if there is any overt peritonitis or evidence of bowel perforation, which may involve irrigation of the abdominal cavity, resection of perforated segment and ischaemic bowel, and addressing the underlying cause of the obstruction.

To prevent the recurrence of an indirect inguinal hernia, pressure should be applied over the deep inguinal ring after reducing the hernia. This is because the hernia protrudes through the inguinal canal and covering the deep inguinal ring prevents it from reappearing during activities that increase intra-abdominal pressure, such as coughing. Noting bilateral herniae is not relevant to confirming or refuting the diagnosis, and there is no such thing as a femoral ring. If the lump reappears during coughing while covering the deep inguinal ring, it may indicate a direct hernia instead. It is important to distinguish between indirect and direct herniae during surgical repair, as they occur in different locations relative to the inferior epigastric blood vessels due to a hole in the internal oblique and transversus muscles.

Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.

The recommended treatment for acute renal colic includes the use of IM diclofenac, according to guidelines. The patient’s symptoms, such as sudden and severe pain in the loin-to-groin area and nausea, suggest renal calculi. NSAIDs, including diclofenac, are the first-line choice for analgesia in renal colic. Ibuprofen cannot be given intravenously, but IV paracetamol can be used if NSAIDs are not effective or contraindicated. Opioid analgesics should only be considered if both NSAIDs and IV paracetamol are ineffective or contraindicated, due to their side effects. Therefore, IV tramadol and oral morphine are not the first-line choice for analgesia.

The management of renal stones involves initial medication and investigations, including an NSAID for analgesia and a non-contrast CT KUB for imaging. Stones less than 5mm may pass spontaneously, but more intensive treatment is needed for ureteric obstruction or renal abnormalities. Treatment options include shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Prevention strategies include high fluid intake, low animal protein and salt diet, and medication such as thiazides diuretics for hypercalciuria and allopurinol for uric acid stones.

The most frequent type of renal tumors are renal adenocarcinomas, which usually impact the renal parenchyma. Transitional cell carcinomas, on the other hand, tend to affect urothelial surfaces. Nephroblastomas are extremely uncommon in this age range. While renal adenocarcinomas can cause cannonball metastases in the lungs that result in hemoptysis, this is not a characteristic of PKD.

Renal Cell Carcinoma: Characteristics, Diagnosis, and Management

Renal cell carcinoma is a type of adenocarcinoma that develops in the renal cortex, specifically in the proximal convoluted tubule. It is a solid lesion that may be multifocal, calcified, or cystic. The tumor is usually surrounded by a pseudocapsule of compressed normal renal tissue. Spread of the tumor may occur through direct extension into the adrenal gland, renal vein, or surrounding fascia, or through the hematogenous route to the lung, bone, or brain. Renal cell carcinoma accounts for up to 85% of all renal malignancies, and it is more common in males and in patients in their sixth decade.

Patients with renal cell carcinoma may present with various symptoms, such as haematuria, loin pain, mass, or symptoms of metastasis. Diagnosis is usually made through multislice CT scanning, which can detect the presence of a renal mass and any evidence of distant disease. Biopsy is not recommended when a nephrectomy is planned, but it is mandatory before any ablative therapies are undertaken. Assessment of the functioning of the contralateral kidney is also important.

Management of renal cell carcinoma depends on the stage of the tumor. T1 lesions may be managed by partial nephrectomy, while T2 lesions and above require radical nephrectomy. Preoperative embolization and resection of uninvolved adrenal glands are not indicated. Patients with completely resected disease do not benefit from adjuvant therapy with chemotherapy or biological agents. Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder.

Reference:
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update. European Urology 2010 (58): 398-406.

If a woman with breast cancer does not have any detectable lymph node swelling, a pre-operative axillary ultrasound can be used to identify any suspicious nodes. If a positive result is obtained, a sentinel node biopsy should be performed to determine the extent of nodal metastasis. This is preferred over a total axillary node clearance as it is less invasive. Letrozole is recommended for controlling the recurrence of the primary tumor in cases of ER+ disease. In situations where extensive nodal burden is identified during SNB, axillary radiotherapy can be used as an alternative to axillary node clearance. However, axillary clearance should not be the first option for managing axillary metastases, unless the sentinel node biopsy reveals a large number of involved nodes. The source of this information is the 2018 Nice guideline NG101.

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.

To prevent skin contact with the enzymes in the small intestine, a loop ileostomy is created. This type of ileostomy is typically located on the right iliac fossa and has a spouted shape, containing liquid faecal material. It is often performed as part of an anterior resection procedure, which involves removing the upper rectum and sigmoid colon. The loop ileostomy is temporary and will be reversed at a later time.

To distinguish between a colostomy and an ileostomy, several factors can be considered. The location of the stoma is one clue, with ileostomies typically found on the right side of the abdomen and colostomies on the left. However, the appearance of the output is also important. A spouted output indicates an ileostomy, as the small intestine’s contents can be irritating to the skin. In contrast, a flush output suggests a colostomy, as the large intestine’s contents are less likely to cause skin irritation. Additionally, ileostomy output is typically liquid, while colostomy output may be more solid.

Other types of ostomies include end and loop colostomies, which are flush to the skin and contain semi-solid faecal matter. A nephrostomy is a tube inserted into the renal pelvis and collecting system to relieve obstruction caused by kidney stones or infection. A urostomy is a bag used to collect urine after bladder removal, with the ureters connected to a segment of the small bowel that opens onto the abdominal wall.

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.

When deciding if a CT head is necessary for a patient with a head injury, clinical judgement should be utilized. If the patient has coagulopathy and has experienced some loss of consciousness or amnesia, according to the NICE head injury guidelines, a CT head should be conducted within 8 hours. This is because Von Willebrand disease is a type of coagulopathy.

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.

Diagnosis and Treatment of Femoral Hernia

The patient’s hernia is located in the typical position of a femoral hernia, which is below and to the side of the pubic tubercle. The patient has reported an intermittent swelling that has become irreducible. Based on these symptoms, it is likely that the femoral canal has been blocked by omentum, rather than a loop of bowel becoming trapped. Since the patient has no other concerning signs, it is safe for them to undergo hernia repair on the next available CEPOD list.

Phimosis can be caused by Balanitis Xerotica Obliterans, which is similar to lichen sclerosis in women. This condition can lead to scarring in uncircumcised males, making it difficult to retract the foreskin beyond the glans. BXO also increases the risk of squamous cell cancer and susceptibility to infections. However, it does not cause prostate hyperplasia or basal cell carcinoma, but instead, it can lead to squamous cell carcinoma.

Balanitis is a condition where the glans penis becomes inflamed, and sometimes the inflammation extends to the underside of the foreskin, which is known as balanoposthitis. The most common causes of balanitis are infective, such as bacterial and candidal infections, but there are also autoimmune causes to consider. Proper hygiene is crucial in treating balanitis, and a tight foreskin or improper washing can worsen the condition. Balanitis can present as either acute or chronic, and it affects children and adults differently.

To diagnose balanitis, a doctor will typically rely on a clinical examination and medical history. The history will reveal the acuteness of the presentation and other important features, such as the presence of itching or discharge. The doctor will also look for other skin conditions affecting the body, such as eczema, psoriasis, or connective tissue diseases. The clinical features associated with the most common causes of balanitis, their frequency, and whether they occur in children or adults are summarized in a table.

In most cases, a diagnosis can be made based on the history and physical appearance of the glans penis. However, in cases where the cause is unclear, a swab can be taken for microscopy and culture, or a biopsy can be performed. The management of balanitis involves gentle saline washes, proper washing under the foreskin, and the use of 1% hydrocortisone for more severe irritation and discomfort. Specific treatment depends on the cause of the balanitis. For example, candidiasis is treated with topical clotrimazole, while bacterial balanitis can be treated with oral flucloxacillin or clarithromycin. Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids, while circumcision can help in the case of lichen sclerosus.

Reference:
Scott, G. R. (2010). Sexually Transmitted Infections. In Davidson’s Principles and Practice of Medicine (21st ed.). Churchill Livingstone, Elsevier.

Flatus tube insertion is the primary management approach for unruptured sigmoid volvulus.

In elderly patients, sigmoid volvulus is a common condition that can be initially treated without surgery by decompressing the bowel using a flatus tube. This approach is preferred as surgery poses a higher risk in this age group. Flatus tube decompression typically leads to resolution of the volvulus without recurrence. If flatus tube decompression fails or recurrence occurs despite multiple attempts, the next step is to insert a percutaneous colostomy tube to decompress the volvulus.

Conservative management is not appropriate for patients with absolute constipation as the volvulus can become ischemic and perforate, which is associated with a high mortality rate. Anti-muscarinic agents are used to treat pseudo-obstruction, not volvulus. There is no evidence to support the need for a Hartmann’s procedure as perforation is not a concern.

Understanding Volvulus: A Condition of Twisted Colon

Volvulus is a medical condition that occurs when the colon twists around its mesenteric axis, leading to a blockage in blood flow and closed loop obstruction. Sigmoid volvulus is the most common type, accounting for around 80% of cases, and is caused by the sigmoid colon twisting on the sigmoid mesocolon. Caecal volvulus, on the other hand, occurs in around 20% of cases and is caused by the caecum twisting. This condition is more common in patients with developmental failure of peritoneal fixation of the proximal bowel.

Sigmoid volvulus is often associated with chronic constipation, Chagas disease, neurological conditions like Parkinson’s disease and Duchenne muscular dystrophy, and psychiatric conditions like schizophrenia. Caecal volvulus, on the other hand, is associated with adhesions, pregnancy, and other factors. Symptoms of volvulus include constipation, abdominal bloating, abdominal pain, and nausea/vomiting.

Diagnosis of volvulus is usually done through an abdominal film, which shows signs of large bowel obstruction alongside the coffee bean sign for sigmoid volvulus. Small bowel obstruction may be seen in caecal volvulus. Management of sigmoid volvulus involves rigid sigmoidoscopy with rectal tube insertion, while caecal volvulus usually requires operative management, with right hemicolectomy often being necessary.

Ketamine is a suitable anaesthetic option for patients who are haemodynamically unstable. Other anaesthetic agents can cause hypotension, which can be dangerous for patients who are already experiencing low blood pressure. Ketamine is often used in prehospital settings for pain relief and intubation, as it does not reduce blood pressure or cause cardiosuppression. Propofol, suxamethonium, desflurane, and thiopental sodium are not ideal options for induction of anaesthesia in haemodynamically unstable patients due to their potential to cause hypotension or other adverse effects.

Overview of Commonly Used IV Induction Agents

Propofol, sodium thiopentone, ketamine, and etomidate are some of the commonly used IV induction agents in anesthesia. Propofol is a GABA receptor agonist that has a rapid onset of anesthesia but may cause pain on IV injection. It is widely used for maintaining sedation on ITU, total IV anesthesia, and daycase surgery. Sodium thiopentone has an extremely rapid onset of action, making it the agent of choice for rapid sequence induction. However, it may cause marked myocardial depression and metabolites build up quickly, making it unsuitable for maintenance infusion. Ketamine, an NMDA receptor antagonist, has moderate to strong analgesic properties and produces little myocardial depression, making it a suitable agent for anesthesia in those who are hemodynamically unstable. However, it may induce a state of dissociative anesthesia resulting in nightmares. Etomidate has a favorable cardiac safety profile with very little hemodynamic instability but has no analgesic properties and is unsuitable for maintaining sedation as prolonged use may result in adrenal suppression. Postoperative vomiting is common with etomidate.

Overall, each of these IV induction agents has specific features that make them suitable for different situations. Anesthesiologists must carefully consider the patient’s medical history, current condition, and the type of surgery being performed when selecting an appropriate induction agent.

Lactational Breast Abscesses: Causes and Treatment

Lactational breast abscesses are a common occurrence during the first month of breastfeeding. These abscesses are typically caused by staphylococcal bacteria and can be treated with antibiotics and aspiration under ultrasound control. In some cases, multiple aspirations may be necessary to fully resolve the abscess. However, if the abscess does not respond to treatment or recurs, formal incision and drainage may be required. It is important for new mothers to be aware of the signs and symptoms of lactational breast abscesses, such as breast pain, redness, and swelling, and to seek medical attention promptly if they suspect an abscess. With proper treatment, lactational breast abscesses can be effectively managed, allowing mothers to continue breastfeeding their infants without interruption.

If a patient is over 60 years old and has unexplained non-visible haematuria along with dysuria or a raised white cell count on a blood test, they should be referred to a urologist using the suspected cancer pathway within 2 weeks to rule out bladder cancer. It is important to exclude bladder cancer as a potential cause, especially if the patient has a history of smoking. The urologist may request investigations such as a urine red cell morphology, CT intravenous pyelogram, and urine cytology. However, a CT scan of the kidneys, ureter, and bladder is not appropriate at this stage as it is used to detect radio-opaque stones in the renal tract. If resources are limited, the GP should initiate relevant investigations for bladder cancer while waiting for the urology appointment. In lower risk cases, reassurance and re-checking in 2-6 weeks may be considered.

Bladder cancer is the second most common urological cancer, with males aged between 50 and 80 years being the most commonly affected. Smoking and exposure to hydrocarbons such as 2-Naphthylamine increase the risk of the disease. Chronic bladder inflammation from Schistosomiasis infection is a common cause of squamous cell carcinomas in countries where the disease is endemic. Benign tumors of the bladder, including inverted urothelial papilloma and nephrogenic adenoma, are uncommon.

Urothelial (transitional cell) carcinoma is the most common type of bladder malignancy, accounting for over 90% of cases. Squamous cell carcinoma and adenocarcinoma are less common. Urothelial carcinomas may be solitary or multifocal, with up to 70% having a papillary growth pattern. Superficial tumors have a better prognosis, while solid growths are more prone to local invasion and may be of higher grade, resulting in a worse prognosis. TNM staging is used to determine the extent of the tumor and the presence of nodal or distant metastasis.

Most patients with bladder cancer present with painless, macroscopic hematuria. Incidental microscopic hematuria may also indicate malignancy in up to 10% of females over 50 years old. Diagnosis is made through cystoscopy and biopsies or transurethral resection of bladder tumor (TURBT), with pelvic MRI and CT scanning used to determine locoregional spread and distant disease. Treatment options include TURBT, intravesical chemotherapy, radical cystectomy with ileal conduit, or radical radiotherapy, depending on the extent and grade of the tumor. Prognosis varies depending on the stage of the tumor, with T1 having a 90% survival rate and any T with N1-N2 having a 30% survival rate.

If a patient has a suspicious digital rectal examination, an ultrasound guided biopsy of the prostate should be performed regardless of their PSA levels. In this case, the patient’s presentation suggests bladder outflow obstruction caused by prostate cancer, and urgent referral for further evaluation is necessary. Although a serum prostate-specific antigen level of <4.0 ng/ml is typically considered normal, a biopsy is still required for initial assessment. Managing the patient for benign prostatic hyperplasia would not be appropriate given the concerning examination findings. Therefore, options 4 and 5 are not recommended. Prostate cancer is currently the most prevalent cancer among adult males in the UK, and the second most common cause of cancer-related deaths in men, following lung cancer. The risk factors for prostate cancer include increasing age, obesity, Afro-Caribbean ethnicity, and a family history of the disease, which accounts for 5-10% of cases. Localized prostate cancer is often asymptomatic, as the cancer tends to develop in the outer part of the prostate gland, causing no obstructive symptoms in the early stages. However, some possible features of prostate cancer include bladder outlet obstruction, haematuria or haematospermia, and pain in the back, perineal or testicular area. A digital rectal examination may reveal asymmetrical, hard, nodular enlargement with loss of median sulcus. In addition, an isotope bone scan can be used to detect metastatic prostate cancer, which appears as multiple, irregular, randomly distributed foci of high-grade activity involving the spine, ribs, sternum, pelvic and femoral bones.

Mesalazine is a potential cause of drug-induced pancreatitis. This medication is commonly prescribed for Crohn’s disease, rheumatoid arthritis, and other conditions as an immunosuppressant. The patient’s symptoms, including epigastric pain radiating to the back, vomiting, low-grade fever, and lack of jaundice, suggest an acute presentation of pancreatitis induced by mesalazine. Although the exact mechanism is unclear, toxicity has been proposed as a possible explanation for mesalazine-induced pancreatitis. While hydroxychloroquine is used to treat systemic lupus erythematosus and rheumatoid arthritis, it is unlikely to cause pancreatitis and may even reduce the risk of this condition. Lithium, a mood stabilizer used to prevent bipolar disorder, has not been associated with pancreatitis. Similarly, metformin, a first-line medication for type 2 diabetes, has not been linked to pancreatitis.

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.

The preferred diagnostic test for chronic pancreatitis is a CT scan of the pancreas, which uses intravenous contrast to detect pancreatic calcification. This is because calcification may not be visible on plain abdominal X-rays, which are less sensitive. While a CT scan of the abdomen may also detect calcifications, it is less clear for the pancreas than a pancreatic protocol CT. MRI and ultrasound are not effective for imaging a non-inflamed pancreas, and MRI is particularly poor at detecting calcification as it relies on fluid in the imaged tissues, which calcified tissue lacks.

Understanding Chronic Pancreatitis

Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities like pancreas divisum and annular pancreas.

Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays can show pancreatic calcification in 30% of cases, while CT scans are more sensitive at detecting calcification with a sensitivity of 80% and specificity of 85%. Functional tests like faecal elastase may be used to assess exocrine function if imaging is inconclusive.

Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants, although the evidence base for the latter is limited. It is important to understand the causes, symptoms, and management of chronic pancreatitis to effectively manage this condition.

Patients diagnosed with peripheral arterial disease require treatment for secondary prevention of cardiovascular disease. This includes prescribing antiplatelet medication such as clopidogrel 75 mg (or aspirin 75 mg if clopidogrel is not suitable) and a high-intensity statin like atorvastatin 80mg. It is important to note that clopidogrel 300 mg and aspirin 300mg are loading doses and should not be taken daily. NICE recommends atorvastatin 80 mg as the statin of choice for secondary prevention of CVD.

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.

The definitive diagnostic investigation for small bowel obstruction is CT abdomen, while AXR is the first-line investigation for suspected bowel obstruction. Although AXR may provide information, it is not a definitive diagnostic tool.

Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.

Individuals who have an abdominal aorta diameter measuring 5.5 cm or more should receive an appointment with a vascular specialist within 14 days of being diagnosed. Those with an abdominal aorta diameter ranging from 3 cm to 5.4 cm should be referred to a regional vascular service and seen within 12 weeks of diagnosis. For individuals with an abdominal aorta diameter of 3 cm to 4.4 cm, a repeat scan should be conducted annually. As the patient is in good health, hospitalization is not necessary.

Abdominal aortic aneurysm (AAA) is a condition that often develops without any symptoms. However, a ruptured AAA can be fatal, which is why it is important to screen patients for this condition. Screening involves a single abdominal ultrasound for males aged 65. The results of the screening are interpreted based on the width of the aorta. If the width is less than 3 cm, no further action is needed. If it is between 3-4.4 cm, the patient should be rescanned every 12 months. For a width of 4.5-5.4 cm, the patient should be rescanned every 3 months. If the width is 5.5 cm or more, the patient should be referred to vascular surgery within 2 weeks for probable intervention.

For patients with a low risk of rupture, which includes those with a small or medium aneurysm (i.e. aortic diameter less than 5.5 cm) and no symptoms, abdominal US surveillance should be conducted on the time-scales outlined above. Additionally, cardiovascular risk factors should be optimized, such as quitting smoking. For patients with a high risk of rupture, which includes those with a large aneurysm (i.e. aortic diameter of 5.5 cm or more) or rapidly enlarging aneurysm (more than 1 cm/year) or those with symptoms, they should be referred to vascular surgery within 2 weeks for probable intervention. Treatment for these patients may involve elective endovascular repair (EVAR) or open repair if EVAR is not suitable. EVAR involves placing a stent into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. However, a complication of EVAR is an endo-leak, which occurs when the stent fails to exclude blood from the aneurysm and usually presents without symptoms on routine follow-up.

The correct diagnosis for this patient is ascending cholangitis, as evidenced by the presence of Charcot’s triad of fever, jaundice, and right upper quadrant pain. This condition is commonly caused by gallstones and is often seen in individuals with recurrent biliary colic. It is important to note that acute cholangitis is a medical emergency and requires immediate treatment with antibiotics and preparation for endoscopic retrograde cholangiopancreatography (ERCP).

Acute cholecystitis is a possible differential diagnosis, but it is less likely in this case as it typically presents without jaundice. Acute pancreatitis is also a potential differential, but it is characterized by epigastric pain that radiates to the back and is relieved by sitting up. A serum amylase or lipase test can help differentiate between the two conditions. Biliary colic is another possible diagnosis, but the presence of secondary infective signs and jaundice suggest a complication of gallstones, such as cholangitis.

Understanding Ascending Cholangitis

Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.