Tuberculosis

S/S:

• Persistence cough 2 weeks
• Sputum occasionally blood stained
• LOA, LOW
• Fever
• SOB
• Night sweat
• Chest pain uncommon
• Consolidation, fibrosis, pleural effusion..
• erythema nodosum

S/s +ve = send for screening

Ix:

• Sputum smear AFB: 
• 3 specimen (1 in early morning)
• radiometric BACTEC for early diagnosis in smear -ve (2 weeks)
• CXR
• nodular lesion
• cavitation
• apical of upper lobe also in apical pt of lower lobe
• Mantoux test
• for screeening in asymptomatic patient only
• beware of false positive or negative
• 5 mm or more is positive in
  • HIV-positive person
  • Recent contacts of TB case
  • Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB
  • Patients with organ transplants and other immunosuppressed patients
• 10 mm or more is positive in
  • Recent arrivals (less than 5 years) from high-prevalence countries
  • Injection drug users
  • Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)
  • Mycobacteriology lab personnel
  • Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.)
  • Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories
  • previous BCG vaccine
• 15 mm or more is positive in
  • Persons with no known risk factors for TB
  • (Note: Targeted skin testing programs should only be conducted among high-risk groups)
A tuberculin test conversion is defined as an increase of 10 mm or more within a 2-year period, regardless of age.
• False Positive (low specificity)
• BCG
• skin being touch and scratch
• previous exposure
• False Negative (anergy)
• immunocompromise (HIV, Sarcoidosis, lymphoma, miliary TB)
• ESR- f up
• PCR- for rifampicin resistance
• New serological test use purified antigen, have good specificity but low sensitivity...
• Extrapulmonary TB usually need biopsy
• presentation usually non specific depends on site, LOW, LOA, fever
• TB lymphadenitis: FNA smear, culture, cytology, biopsy
• Pleural effusion: pleurocentesis and biopsy (protein >30mg/dl, glucose<30mg/dl, lymphocyte)
• Paritoneal TB: ascites AFB
• Genito-urinary: 3 early morning urine sample, sterile pyuria, urine culture, IVU, cystoscope, u/s
• TB bone and joints: vertebra collapse, paravertebrae abscess, x ray, biopsy
• Cutaneous TB (lupus vulgaris): jelly nodule
• TB meningitis: subacute, CSF microscopic, biochem, bacteriology, CT brain for basal tuberculoma or obstructive hydrocephalus
• Pericardial TB: pericardial effusion, constrictive pericarditis, *give steroid
• Miliary TB usually immunocompromised: retina, liver, LN, marrow, CXR-reticolar- nodular shadowing, +/- liver biopsy
• C+S in Ziehl- Nelson stain or LJ medium

Screening:

• Contact of sputum positive
• HIV infection
• Immigrant
• Institutional, prison, rehab centre
• other medical fac: DM,sarcoidosis, Renal failure, prolong corticosteroid, immunosupress, malignancy

Notify!!!

1. PTB
2. PTB smear +ve
3. PTB smear -ve
4. Extrapulmonary TB
5. Pulmonary with extrapulmonary TB

Terminology

New case: never tx or anti-TB drug ,4 weeks

Cure: (smear -ve at OR 1 month prior to) completion treatment AND on at least 1 previous occasion.

Relapse: 

1. sputum +ve relapse: declare cure after full course antiTB and become sputum smear +ve
2. sputum -ve relapse: declare cure after antiTB and become active TB bacteriologically, histo, clinical, radio

Chronic: remain or become smear +ve again after complete fully surpervised tx

Treatment failure: remain or become +ve again after 5 months OR patient smear +ve b4 treatment and smear +ve after 2 month treatment

Treatment after interruption: interrupted tx for >=2 month and return with smear +ve sputum or clinical or radiological

Transferred in case: transfered from another centre

radiological classification: mild moderate advance

Management

category 1: new case

category 2: relapse, treatment failure, treatment after interruption

New PTB- 6 months

Treatment:

1st line: 

1. Rifampicin (R)
2. Isonizide (H)
3. Pyrezinamide (Z)
4. Streptomycin (S)
5. Ethambutol (E)

I) NEW CASE

Intensive (3-4 drugs) (2month daily doses)

2SHRZ

2EHRZ

2HRZ

lead to rapid sputum conversion and reduce clinical symptoms

(resistance use ethambutol)

Continuation (2-3 drugs) (4 months or extended if severe, immunocompromise and extrapulmonary)

4H^2R^2

4S^2H^2R^2

3HR

4S^3H^3R^3

use rifampicin and isoniazide, if resistance add ethambutol)

II) RELAPSE, TREATMENT FAILURE, TREATMENT AFTER INTERRUPTION

Send MTB C+S (drug regime base on sensitivity and clinical response)

No initiate std therapy

Refer chest

III) CHRONIC TB

MTB C+S (rapid culture)

Refer Chest

MONITORING PATIENT:

Treatment

Initial sputum smear +ve >>> 2 months sputum smear >>> 4 months sputum smear >>> 6 months sputum smear >>> still +ve? need check sensitivity of drugs

Compliance

Education:

1. HIV testing
2. Prolong treatment and LFT monitoring
3. Taking right medication and DOTS
4. Compliance and toxicity of drug
5. Respiratory isolation

Contact tracing CDCC

Hospitalisation:

1. Gravely ill
2. Acute disseminatied TB
3. TB CNS< pericardium, adrenal, spine
4. MDR TB
5. Default frequently, compliance suspected
6. Complication: haemoptysis, pneuthorax, empyema
7. Associated factor uncontrol DM, renal failure
8. Severe side effects
9. Need desentisation to antiTB drug
10. Social reason

Chemoprophylaxis: (isoniazide 6 month, HIV +ve patient isoniazide or rifampicin 9 months)

1. young with tuberculin conversion
2. young immigrant heaf 3-4, no prior BCG
3. asymptomatic patient found by contact tracing or screening
4. HIV with mantoux +ve or contact with TB patient

DOTS (Direct Observed Treatment, Short-course)

DRUG TOXICITY MONITORING AND MX

Monitoring drug toxicity:

• Baseline: LFT, serum billirubin, serum Cr, Blood Urea, FBC, serum uric acid (pyrazinamide), any preexisting liver ds, or liver condition- alcohol
• Report and specific ask symptoms, 2monthly f/up, routine lab monitoring

Management toxicity:

• Hepatotoxicity (chemical- LFT X5 OR symptomatic LFT X3 >>>> STOP TREATMENT)
• Rifampicin (best drug, if S/E fail to use >> poor prognosis)
• Isoniazide
• Pyrizinamide
• Peripheral neuropathy (give vit B6)
• Isoniazide 
• Renal failure, orange urine
• Rifampicin
• Liver enzyme inducer (drug-drug interaction esp in HIV pt where liver met drug >>> reduce 1/2 life)
• Rifampicin
• Thrombocytopaenia, Shock
• Rifampicin
• Visual impairment 
• Ethambutol (Eye)
• 8th CN damage
• Streptomycin
• Athralgia
• pyrazinamide (contraindication in gout)
• Agranulcytosis and B6 deficiency
• Isoniazide
• Hypersensitivity
• GI upset
• Treat symptomatically if still, can withdraw

1. Challange test 
• If rash in 1st challange, NO PROCEED, wait subside and go next drug
2. Desensitization 
• Did when unable to device suitable regime without offending drug
• slowly increase dose till therapeutic dose
3. Drug interaction
• Isoniazide
• raise antiepileptic concentration (phenytoine, carbamazepine)
• Rifampicin
• induce liver enzzyme reduce 1/2 life of drug (PI, cyclosporin, corticosteroid, OCP, oral hypoglycaemic drug, oral anticoag, phenytoin, cimetidine, theophylline, digitalis glycoside)
• reduce biliary excretion of contrast
• disturb microb assay for folic acid and B12
• Streptomycin
• other ototoxicity and nephrotoxicity drugs (aminoglycoside, amphotheracin B, cephalosporin, cyclosporin, cisplatin, frsemide)
• potentiate neuromuscular blocking effect

DOTS (directly observed treatment, short course)
Standardised short-course TB treatment rigemen for 6 months under direct observation by trained supervisor (anyone) to ensure patient take every dose.
Advantage:

• cure 95%
• wide coverage via primary care
• detection via sputum is cheap, simple
• no hospitalisation and can remain towork
• prevent drug resistance which is fatal and vry expensive to treat
• follow patient to ensure cure
• economic invesment

FDC (fixed dose combination)

Advantage:

• reduce drug resistance TB
• effective regimen more likely
• decrease medication error
• prevent shortage of certain drug by logistic
• compliance
• decrease rifampicin useage on other disease

Disadvantage:

• bioavailability not sure
• hard to adjust dose

TB in HIV patient:

1. Mantoux -ve
2. Increase reactivation TB
3. Atypical presentation
4. BCG vaccine does not prevent
5. smear -ve AFB, smear taht +ve usually contain few AFB
6. Atypical CXR (lobar or bibasal pneumonia, LN)
7. extrapulmonary and miliary TB
8. Drug interaction btw HAART and Anti-TB
9. IRIS (immune reconstitution inflammatory response) result paradoxically worsening TB
10. Isoniazide prophylaxis may be needed (not life long) with clinically monitoring
11. Respiratory  isolation test TB against 1st and 2nd line drug

MDR-TB

• mortality in 80%
• early identification (suspicious CXR, MDR TB contact not until diagnosis) 
• complete treatment (make sure patient complete all drugs)
• isolation (N95 mask, automatic closing door with -ve pressure, sputum induction in isolation room) stop isolate if >3 sputum culture -ve
• screening (frequent Tuberculin skin surveillance for health care workers

DYSPHAGIA

Anatomy

Blood supply:- 1/3 (inf. thyroid), 1/3 (branch of disc. thoracic a.), 1/3 (L gastric a.)

Constriction:

Pharyngo-oesophageal constriction (15cm)

Aorto-brachial constriction (22cm)

Inferior oesophageal sphincter (38cm)

Causes:

Intra luminal: (1)

Foreign body (sharp things)

Intra mural: (5)

Caustic stricture

Achalasia

Plummer-Vinson syn

Pharyngeal pouch

Tumour of cardia and oesophagus

External compression: (3)

Lymph node (lymphoma)

Thoracic aorta aneurysm- syphilis??

Goitre

General: (3)

MG

Bulbar palsy

Pseudo-bulbar palsy

Sys sclerosis

 Oesophagitis- candida, reflux

Diphtheria??

History:

Sudden- foreign body

Weeks- CA

Months- benign stricture, achalasia

Sticking where- throat or chest

Throat: (oral, pharyngeal)

-Chocking, sialorrhoe, nasal regurgitation, voice, >aspiration pneumonia

Chest: (oesophagus)

-Chocking, recurrent pneumonia

Muz ask any caustic swallowed

Reflux

Achalasia (myenteric plexus degeneration)

Difficulty in swallow solid and liquid in the start?

Motility dis (achalasia, neurological), pharyngeal causes

No: stricture (benign and malignant)

Swallowing painful?

(CA, oesophagitis, achalasia, spasm)

Intermittent? Constant?

Intermittent- spasm

Constant and worsening- CA stricture

Neck bulge on drinking?

Pharyngeal pouch

Anaemia? Cachetic?

Neck supraclavicular LN, sys dis- systemic sclerosis, CNS ds

Cachetic- CA

Anaemia- Plummer-Vinson syn

Haemathemesis :

perforated oesophagus

Vomiting, surg (oesophagoscopy, dilatation, biopsy), swallow foreign body

Suprascapula crepitation (emphysema)

Severity:

Solid? Liquid?

GORD

Water/acid brash

Heart burn

Retrosternal discomfort on (raise intra-abd. pressure) stooping, lying down, straining, large meal,

Relief by antacid

Smoking, alcohol, coffee, tea, pregnancy, obese, big meal, drug (antichol, tricyclic), sys sclerosis, NG tube, repeated vomit esp with duodenal ulcer, resection of cardia (gastro-oesophageal anastomosis)

Can cause asthma (aspiration)

Oesophageal CA (50% middle 1/3)

>squamous, adenoCA

Dysphagia, reflux, retrosternal chest pain, horseness of voice (upper 1/3), paroxysmal cough if (aspiration pneumonia)

Local- trachea, aorta, mediastinal pleural, lungs

LN- para-oesoophageal, tracheo-bronchial, supraclavicular, subdiaphragmatic

2^nd- Liver, LN

Alcohol, smoking, betel nut chewing, achalasia, reflux, Barrett’s (ectopic acid secreting gastric mucosa), Plummer- Vinson

FH

I(x):

FBC- anaemia- plummer-Vinson syn                                     LFT

U&E- dehydration                                                                TFT

                                                                                             -TSH- neurogenic

CXR- carcinoma of cardia                                                    Endoscopic U/S

           Aspiration pneumonia                                                 - staging T1,2,3,4

           abscent of gastric bubble                                            -chemo/ surg.                           

          dilatation of oesophagus prox. to it                                

Barium swallow-         Bird beak                                          CT scan

(Use water soluble        Apple core                                        -staging local, LN, Mets

contrast)                       Crock skrew- abn contraction

OGDS and biopsy                                                                MRI

Oesophageal manometry (if normal barium swallow)

                                                                                            Assess nutritional status!!!

24 hour oesophageal pH- oesophagitis                               Palpate and auscultate neck

Reflux cough test

                                                                                              PET scan

Swallow electromyography- neuro disorder                         B12, CK, TSH- neurogenic

Laryngeal EMG- test muscle of voice box

FEES-fiberoptic endoscopic evaluation of swallowing

Scintigraphy

ENT- pharyngeal causes

Plummer- Vinson syn

Post-cricoid web

Dysphagia

Fe deficiency

Glossitis
Koilonychias

Caustic stricture:

Mouth also burn

Usu lower or middle ( causative agent hold up by aortic arch and cardia sphincter)

1) Acid

Coagulative necrosis- less dangerous

2) Alkaline

Liquefactive necrosis- more dangerous

Gastrostomy

Cannot do gastrostomy in caustic stricture because:

-Stomach also inflamm.

-Surgery sometimes need to join gaster to upper oesephagus

Also cannot do gastric lavage- aspiration of caustic agent into lungs and damage

Cut colon and join to the oesophagus

Can do on caustic stricture

Pharyngeal pouch

Killian’s dehiscence

Btw thyropharyngeal and cricopharyngeal constricture

Fetor oris, Displace oesophagus, dysphagia, regurgitation, palpable swelling at post. triangle

Achalasia

Neuromuscular failure to relax at lower oesophagus

T. cruzi- Chagas ds (intermuscular ganglionic cell)

Aspiration pneumonia

Approach to Breast Cancer Management

for mastectomy, preop psychological preparation of patients and her family is important to accept it. after surgery, if no reconstruction, prosthetic breast incorporated into cup is important.

Fischer's 

young, poor diff more likely have distal micromets on diagnosis which may reccurence. (fisher's theory- curative tx should be effective against disseminated ds by evidence 30% node negative patients relapse with distal mets)

Halsted's

cancer in old patient low mets potential diagnosed with tumour before mets (Halsted's theory- cancer spread fr focal lesion to regional nodes to bloodstream to harmatogenous mets)

10 yrs overall survivor- 74%, 20 yrs- 64% (lead-time-bias?, >improve adjuvant tx act on mets and primary)

Regional LN:

1. axillary
2. supraclavicular
3. internal mammary

Disseminated:

1. Brain: headache, epilepsy, ataxia, paresis, paraesthesia
2. Lung: usu asymp
3. pleural: effusion, SOB
4. liver: hepatomegaly, mass, jaundice, ascites
5. long bones: (skull, vetebrae, ribs, pelvis) pain, patho frac, spinal cord compression

Ix: 

tripple assessment:

clinical (history and PE)

radiological (<45yo-u/s or >45yo-mammography)

- mammagraphy (CA sensitivity 88% in old age)

2 plane cranial-caudal (CC), mediolateral oblique (MLO)

4 things to look (mass lesion, microcalcification, archetectual distortion, asymmetry)

CA feature is spiculated irregular border microcalcification (finer linear or granular)

DCIS- fine branching microcalcification

Benign feature is coarser hyperdense area with well-define margin

- u/s (CA sensitivity 85%, cyst 100%)

CA feature is irregular margin of hypoechoeic with acustic shadow, no posterior enhancement

benign tumour is hypoechoeic mass with regular margin, no posterior enhancement

cyst is most hypoechoeic with well circumscribe border with posterior enhancement

histological FNAC(95%) and core biopsy (98%)

FNAC eventually need core biopsy, if the tumour is big enough, straight core biopsy

Staging (treatment management, prognosis)

micromets cannot be detected inany reliable methods, if axillary LN affected= strongest predictor for micro mets-bone, liver, lung

contrasted CT TAP might be high to suprascapular region for LN

CXR

radioisotope bone scan

liver u/s

u/s abd

FBC

LFT 

ca153, CEA for monitoring treatment

oestrogen receptor after excise the tumour for hormonal treatment effectiveness 

Tis- in-situ (DCIS,LCIS, Paget's ds)

T1- <2cm

T2- 2-5cm

T3- >5cm

T4- any size with skin or chest wall invasion

N1-  movable ipsilat axillary LN

N2- fix ipsilat axillary LN

N3- ipsilat internal mammary nodes

M1- mets

Treatment:

Loco-regional treatment (control ds within breast and underlying chest wall)

1) surgery (mastectomy or conservative surgery)

2) radiotherapy

3) surgery+ radiotherapy

4) Breast conservative surgery:

(conservative surg done in single lesion, <3cm, 2cm away from nipple, low histo grade, no extensive in-situ, no extensive nodal involve)

5) lumpectomy, clear 1cm margin (risk of +ve resection margin)

6) wide local excision, clear 2-3cm macroscopic margin

7) quadrandectomy

Mastectomy (preserve pec mj and min) curative (wide spread DCIS) or paliative (local advances)

+/- reconstruction prosthetic or patient's tissue (transverse abdominis flap or latissimus dorsi flap)

pec minor remove for axillary LN clearence.

immediate breast reconstruction can be done via skin sparing mastectomy. breast remove via periaureolar biopsy and reconstruct via prosthetic material or tranverse rectus abdominis myocutaneous flap or lattisimus dorsi flap

breast reconstruction is greater ops and have greater morbidity. no effect on ca clearence.

Axillary Clearence

axillary nodal status= best prognostic factor. depends of the pec minor

some have skip mets

level:

1. below lower margin of pec minor
2. level of the muscle
3. above the muscle

LN sampling= excise at least 4 LN fr axillary tail/ level 1> level 2= at least 10 nodes removed> level 3 node clearence- will cause lymphoedema, pain, paraesthesia restrict shoulder mobility

if contain tumour cell, complete dissection and irradiation of axilla.

sentinel nodes biopsy (use dye to detect cancer nodes, more sensitive)

Radiotherapy:

improve loco regional control after breast conserving surg

reduce recurrence- 60%

reduce distal mets- 5%

improve survival- 10%

also give to poor differentiated with lymphovascular invasion >=4 nodes

if large tumour small local margin- give booster dose

Adjuvant systemic treatment:

when tere is occult metastasis spread which has micrometastasis, cannot be detected

Chemotherapy:

recomended in premenopause, young, with LN spread but without mets.

induce ovarian ablation

benefit to premenopausal women and under 50 yo (reduce 35%mortality  in 10 yrs)

age, menopause status, hormone receptor status.

SE: alopecia, nausea, vomiting, mucositis, neutropenia

long term: premature ovarian failure then early menopause, cardiomyopathy (anthracycline)

For your interest:
                              CMF (cyclo, metotraxate, 5-fluorouracil)

                              doxyrubicin (anthracycline)- Ab prvnt cell division

                              mets>50%:

                              taxanes- promote microtubule lead to cell death

Hormonal therapy :

ovarian ablation (LHRH analog or oophorectomy)

tamoxifen (selective action- preserve bone density and favour lipid profile)

block ER

thromembolism, endometrial ca, visual disturbance

aromatase inhibitor

inhibit syn of oestrogen in adipose tissue

Biological:

Herceptin- human monoclonal Ab to HER/neu (cerbB2) transmembrane receptor

35% response in mets, 50% reduce recurrence rate.

benifit in tumour with ER

greatest benifit in postmenopause  women (reduce mortality 30% in 10 yrs)

similar benifit in premenopause- can cause oestrogen withdrawal

normally clinically early ds can treat with curative intent but some have micromets which can progress to clinical mets

metastasis- paliative treatment

local advance:

chest wall- carcinoma en cuirasse

histological diag then neoadjuvant chemo to downgrade then operate

radio for skin, breast, chest, LN

Poor diff in young >spread to visceral organ

pul mets -pleural eff -->pleurodesis (obliterate pleural cavity by tetracyclin and bleomycin OR pleurodectomy)

liver mets --> ascites --> fulminant liver mets

Limphangitis carcinomatosa --> skin and lung

well diff, +ve ER, post menopause: >bone mets --> patho frac

lobular ca > skin, GIT mets

F/up

15% life time recurrence in other breast

>lobular ca

breast ca can occur at same time in multiple foci

f/up clinically + memography 3-5 yrs

prognosis:

50% "personal cure"

micromets can remain dormant for 35 yrs

Nottingham prognostic index : 0.2X size + histo grade + LN statue (node -ve=1, 1-3 +ve=2, 4 +ve=3)

Thyroid

normally in female however if a male with solitary nodule, higher chance of cancer. bcoz more female with other thyroid ds
usu female, solitary nodule, hard
INVESTIGATION
BLOOD:
- thyroid status: hyper, eu, hypo

1. fT4
2. TSH (usu low in hyper, high in hypo; however MNG usually have high TSH bcoz autonomous production of thyroxine)
3. T3 (use only when clinically hyper but normal fT4)
4. thyroid autoAB assay (autoimmune)
5. LATS (long acting thyroid stimulating factor):- diagnostic for Grave ds
6. anti thyroiglobulin, antimitochondria (anti-thyroid M):- Hashimoto's

MORPHOLOGY:

1. U/S- diagnose cyst and retrosternal extension
2. CT neck and thorax- if suspect malignancy or trachea deviated

TISSUE DIGANOSIS:

1. FNAC ~90% diagnosed
2. Core biopsy: esp Follicular ca to see capsular invasion (diff follicular ca and follicular adenoma is by capsular invasion)
3. Incisional biopsy

FUNCTIONAL ACTIVITY:

1. Radioisotope iodine

- Diffuse homogenous uptake (Grave or normal gland)

- generalise patchy uptake (MNG)

- cold nodule (non secreting: tumour, adenomatous, cyst)

- hot nodule (autunomous focus excess T4 secretion and surrounding normal tissue supressed. usu euthyroid)

- ectopic thyroid, retrosternal, mets

MANAGEMENT

ANTITHYROID DRUG: (not suitable for nodular toxicity bcoz recur)

• Carbimazole

recur 50% in 2 years

agranulscytosis, so have to ask any sore throat or infection

• Propylthiouracil

no agranulocytosis

- If poor control, alternating hyper and hypo, then block and replace regime (high dose Carbimazole and thyroxine replacement)

- If dangeroud thyrotoxicosis, give B-blocker (propanolol) till antithyroid drug action

RADIOACTIVE IODIDE
- 100X higher than diagnostic used
- Appropriate for middle age or elderly bcoz young will have prolong exposed and risk of getting thyroid ca when old
- Excreted via feces, kidney, sweat, saliva, breath, body
- Avoid preg in 6 months
- Keep 1m away fr pp >5 yo 10 days, child 3-5 yo 15 days, <3 yo 20 days
- chance of hypothyroid and if missing may cause cardiovascular death
So now aim for inducing hypothyroid within 6 month and replace with thyroxine.

SURGERY
- solitary nodule suspect malignancy
- Quick and effective cure, avoid long term drug, Grave
- Unsatifactory anti- thyroid drug
- MNG (not response well to drug and for cosmetic)
- Hot nodule to allow normal thyroid tissue to recover

preops:

1. Direct and indirect laryngealscopy!!! usu will have change voice due to external laryngeal nerve damage. patient should be INFORMED AND CONCENT!!!
2. Bring thyroid to euthyroid by anti thyroid or (thyroid toxic risk of anaesthetic arrhythmia and prevent thyrotoxic crisis)
3. lugol iodine orally  before surgery as anti thyroid drug in crease vascularity.

subtotal thyroidectomy 

remove enough gland to produce euthyroid and adequate hormone 

leave posterior to prevent from parathyroid hormone

complications:

early

1. haemorrhage (inferior thyroid and upper pole vessels slip ligature) causing major blood loss and compress laryngeal nerve (instrument for emergency reopen instrument stay at patient's side. (rapid neck swelling and profuse blood loss via wound drainage) mediastinum haemorrhage- hypovolaemia
2. unilar or bilat recurrent laryngeal nerve damage. if bilat need tracheastomy, unilat- horseness voice impaired cough
3. trachea or oesophagus peforation
4. laryngeal oedema- stridor (intubate)
5. thyrotoxic- excessive of: agitation, confuse, high fever, profuse sweating, tachycardia, arrhythmia (B- adrenergic blocker, IV hydrocort, K iodide) mortality from coma, pul oedema, circulatory collapse
6. tracheomalacia- collapse and stridor

late

1. hypoparathyroid in 36 H- muscle cramp, parasthesia, tetani (vit D and calcium)
2. unilat recurrent laryngeal n and ext laryngeal n damage
3. hypothyroidism (long term)
4. thyrotoxicosis (long term)

Papillary ca

branching with fibrous struc, psamoma body, well differentiated

LN
mets: lung, bone

Total thyroidectomy (high risk of other foci) and cervical LN removal

Recurrent local- radiotherapy, LN and Distance mets- chemotherapy. both can be treat by radioiodine

Plasma thyroglobulin as tumour marker detect recurrent

give thyroxine and maintain 0 TSH to prevent stimulate residual malignant cell

slow, 90% 10 yrs survival

15% to contralateral side

Follicular ca

old

follicular pattern, well differentiated

blood mets, usu distance mets lung and bone

good prognosis if microinvasion only

no capsular invasion- 100% 10 yrs survival

local invasion - 30% 10 yrs survival

removal of lobe with tumour (usu not multifoci)

total if capsular and vascular invasion to enhance radioiodine uptake by mets malignant cell

Anaplastic

elderly, usu vry hard

aggressive

poor differentiated

poor prognosis

usu with recurrent laryngeal n, treachea and oesophagus invasion

early LN and haematogenous spread lung, bone, brain.

poor response to radio and chemo.

paliative care, just put a stent

Medullary ca

AD

MEN 2 (parathyroid, phaeochromocytoma)

C-cell tumour- secrete calcitonin, serotonin, ACTH like

amyloid deposit

slow grow, LN > lung, bone liver

not response to radioiodine and radiotherapy, so have to do extensive surg (total thyroidectomy and cervical, mediastinal LN clearence)

no mets- surg=cure

LN- 50% 10 yrs

tumour marker calcitonin level

Approach to Colorectal Cancer

General surg 

History

CA, Benign polyps, diverticular ds, IBD, angiodysplasia, infection, thyroid, bleeding tendency, nerve?

presented with

associated symp:

lower GI bleed?

anaemia only?

alter bowel habit?

• bleed: 
•  > exophytic polyps- CA
• benign growth
• IBD
• angiodysplasia
• bleeding tendency
• haemorrhoid (dropping post defecation)

• anaemia: occult bloood- CA

IO s/s: colic, distension, consti, vomit

• > distal CA... others Crohn? or pain cause cannot BO- not consti
• continence flatus (complete IO)
• constipation with intermittent outfolw diarrhoe (incomplete IO)
• laxative not useful

(pseudo obstruction: no bowel sound, PR distended rectum (old, unfit, trauma, stroke, electrolyte imba, post procedure, peritonitis, sick))

LOW/ LOA: CA (LOW only?- malabsp in IBD)

mucus secreting: causing hypokalaemia

tenesmus

perianal pain: fissure, abscess, fistula, strangulated haemorrhoids, CA-( sacral plexus invasion)

CA risk:  old, constipation, diet (low fiber, high carb, high fat), alcohol, FH, UC, PMH several ca esp HNPCC

(smoking is risk of mortality after colorectal ca)

• family history (FAP/HNPCC/ peutz) ask age (>45yo- risk 1/50, <45yo- risk 1/10)
• HNPCC- associated with other ca (for own interest only: stomach, hepatobiliary, uro, ovarian, uterus, brain, skin)
• AD microsatellite mutation (3 family member in 2 generation, 1 <50 yo)
• FAP- AD, 40yo malignant changes, screen: retina pigment layer hypertrophy
• Peutz-Jeghers-AD, hyperpigmented freakles at hand, feet , mouth, genitalia (for own interes onlyt: ca SI, LI, stomach, pancreas, testis, breast)

presentation of diverticular ds and colon CA is so similar that need Ix to diff it (colonoscopy, gastrograffin enema, CT)

complication check:

psychosocial include what impression towards ca and family support

perforation: peritonitis, pericolic abscess

fistula: colovesicle (fecal urine, UTI)

gastrocolic

to skin

adhesion

stricture- also Crohn

malabsp

anaemia: fainted...

distal mets: liver, lungs

local invasion: bladder, ureter, uterus, peritoneal seedling (carcinomatosis peritonei), pelvic wall, sacral plexus

LN: peritoneal along thoracic duct causing compress duodenum and ureter, portal hepatis.

      Virchow's node in late

PE

sign,or associated sign of certain syn, complication check, risk check

anaemia sign

bruises, jaundice

retinal pigment layer hypertrophy (refer ophthalmologist fundoscopic)

pigmentation of oral mucosa- peutz

LN virchow's 

any surgical scar before?eg.- HNPCC (endometrium), peutz

**stoma describe**

hepatomegaly

obstructing I/O- active bowel, distension, peristalsis visible, toxic

peritonitis?- silent bowel, generalise tender, rebound tender

abd mass/ pain?

PR- no anal opening?? (ant resec), describe mass, distance from anal verge, ant/ post/ circumference, invade and attachment to surrounding tissue (fix), anal tone (sphincter)

respi: crep, pleural effusion

bone tender, urine, lower limb

Ix

AXR IO-  with/without competency of caecal valve (emergency in competenc valve)

gastrograffin enema (apple core)

**faecal occult blood** 

sigmoidoscopy + biopsy, histo

colonoscopy +biopsy, histo (>100 polyps= FAP)

DUKES: (good enough)

A- bowel wall 90% 5 yrs survival

B- Extend tru bowel wall 60%

C- Regional LN 30%

D- Mets 10%

or

TNM staging 

T0

Tis-in-situ

T1- lamina propria/submucosa

T2- muscularis mucosa

T3- subserosal/ non peritoneal perimuscular

T4- invade other organ/struc

N0

N1- 1-3 pericolic n

N2- >=4 pericoloc n

N3- any node of vessel

M0

M1-mets

FBC and cross match: anaemia, transfuse (if suspected sever blood loss, tell 1st)

staging: CT TAP, PET scan, liver u/s + LFT, local spread use transrectal u/s and MRI

baseline tumour marker CEA

preop biochemical assessment ( RP, LFT, Coag, ECG, CXR), vital sign, dietary (fasting), antibiotic prophylaxis cefuroxime + metronidazole)

ops:

principally 5cm clearence of margin but if lower down- 2cm and inter-sphincter resection to preserve sphincter

R or L hemicolectomy or sigmoid colectomy

for rectal ca: APR or Ant resection + mesorectal resection (low)

adjuvant chemo and radiotherapy to increase prolong survival in Duke's B, C, D or TNM 3, 4

neoadjuvant only in rectal tumour:

1. chemoradiotherapy (long): (chemo- radio- chemo) to sensitized radio and to downgrade it and preserve sphincter. T>=T3 or N1

2. radiotherapy (short): to reduce local recurrent in all rectal ca

very ill just stent or stoma to release obstruction

post ops:

multidisiplinary approach: vital sign- bleed, pain management, clean ops site, stomal care, physiotherapy, mobility prvnt DVT, dietetics, counsel self stoma and wound care, prvnt any sepsis, do distal loopogram look for (anastomotic leak, anastomotic stricture and fistula), monitor CEA after tx, complete scope postop and f/up 3/12

aspirin (NSAIDS) and cox 2 inhibitor said to be a protective factor.

• proximal: polypoidal exophytic mass along ascen colon and caecum

     diarrhoea (ascend colon diameter large and faecal is fluid)

     >occult bleed

     IDA

     RIF mass

• distal: annular, encircling, constrictive > sigmoid or rectal

     constipation

     use laxative not effective (mayb can pass out little stool still not finish)

     >visible bleed  IDA

     LIF pain

     low rectal  feel tenesmus (mass stimulate rectum to expel the mass)

stoma: important topic

area

colour of stoma bag content

barrel

sproud

caliber

complication check

PR- any anus

• type of stoma
• hv to diff ilio/colo
• indication- permenant; temporary:- emergency, defunctioning, bowel rest
• what complication- 

early:

haemorrhage

ischaemia

high output in ilio (hypoK, Dehydrate)

retraction

obs 2 ot adhesion

late:

prolapse

parastomal hernia

peristomal excoriation (ilio)

stricture

psychogenic