- Surgical Exam.com
- AO Foundation Surgical Reference
|VITAMIN C DIP|
In a surgeons gown a physician can cause inevitable damage to patients
- clinical presentation
- Structural/ Mechanical
- Inflammatory Genetic/ Congenital
- Old age/ Degenerative
- Spontaneous/ Idiopathic
|European Pressure Ulcer Advisory Panel classification system of pressure ulcer grades|
|Grade1||non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin|
|Grade2||partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion|
|Grade3||full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia|
|Grade4||extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss|
|Types of Dressings|
|GranuflexMepilex||Dry, granulating pressure sores and other dry wounds.|
|AquacellIodosorb||Wet wounds including pressure sores.|
|Kaltostatcarboflex||Fungating, malodorous wounds.|
|Iodoflex||Necrotic, ‘wet’ areas|
|INADINmepore||Simple dressing, good for acute wounds.|
|IntrasiteTegaderm||Dry necrotic wounds.|
|wound colours chronic wounds|
- surgical tutuor.org preop fitness
- NICE CG3 Preoperative tests Jun 2003
- NICE CG74 Surgical site infection Oct 2008
Diabetes Handbook TAYSIDE DIABETES MCN WEBSITE G Brennan, L Walton, D Voigt Tayside January 2008
Three aspects to the peri-operative management of diabetic patients:
1. General Assessment
Check for the presence of cardiac, renal and neurological sequelae of diabetes as the presence of these may complicate the peri-operative management and increase patient risk.
Please take this opportunity to ensure that patients have had their eyes screened for retinopathy within the last year (either retinal photo or attendance at an Ophthalmology Clinic). If eye screening has not been done, please contact the Retinal Screening team directly Ensure that no other diabetes-related problems need to be attended to.
2. Assessment of Glycaemic Control:
HbA1c is an indicator of recent control i.e. over the 6-8 weeks. If the HbA1c is above 9 %, control is poor and the Diabetes team should be involved. If above 12 %, consideration should be given to improving control before elective surgery is undertaken.
3. Careful Peri-operative Control of Blood Glucose:
Management of patients on diet alone or oral hypoglycaemic agents
Minor Operations (Body surface or endoscopic procedures)
Omit oral hypoglycaemic therapy on the day of operation and avoid glucose infusion
Check finger prick blood glucose on the morning of the operation and regularly thereafter as clinical circumstances dictate
The management of these patients is easier if they are operated on early in the morning. For afternoon cases, patients taking oral hypoglycaemic drugs should omit these in the early am and have clear fluids only thereafter.
There is no need to stop Metformin any sooner than on the day of surgery
Oral medication should be restarted as normally prescribed with the first meal. The only exception to this is for patients taking Metformi
NB Metformin and lactic acidosis. This is more likely if there is renal impairment present and so Metformin should not be restarted post operatively unless the renal function is OK
Metformin should not be used if eGFR <30 and doses not higher than 500mg BD are advised for patients with eGFR 30-45
If Metformin is contraindicated, then additional hypoglycaemic therapy may be required. If in doubt, contact the Diabetes team for advice
Patients undergoing major operations will require intravenous insulin. There is no advantage in starting intravenous insulin therapy until the patient is fasted as otherwise the glucose control will escape during eating
Patients on oral therapy who are inadequately controlled (i.e. random venous blood glucose >15.0 mmol/l or HbA1c >9%) should be stabilized on insulin pre-operatively and managed in the same way as insulin-treated patients
Management of patients on insulin (type 1 and type 2)
Pre operativelyAll patients on insulin should be adequately controlled pre-operatively and they should ideally be stabilised over 48 hours
For patients using twice daily insulin, this may be possible with their usual regime but it may involve switching them to a multiple injection regimen.
For people with type 1 diabetes on multiple daily insulin regimens, it is advisable to continue their ‘usual’ daily long acting analogue insulin (Lantus or Levemir). This will reduce the risk of diabetic ketoacidosis if IV insulin is interrupted, and it will facilitate a smooth transition to subcutaneous insulin at a suitable mealtime post operatively
Remember that some patients with type 2 diabetes may be treated with both insulin and Metformin – see guidance above regarding monitoring of renal function post-operatively before re-starting Metformin
On the day prior to operation, check random venous blood glucose and urea and electrolytes
On the morning of the operation
Check the blood glucose and commence an intravenous infusion of glucose and insulin – use a GKI infusion unless specifically requested to do otherwise by the anaesthetist
Ensure that the patient does not receive any subcutaneous rapid acting or pre-mixed insulin on the day of surgery. The last dose of either type of insulin should have been given on the previous evening
Continue to check the blood glucose hourly, pre ,intra and post-operatively
Change to subcutaneous insulin post-operatively when eating normally
It is important to continue the IV insulin infusion for 60 minutes after the first subcutaneous insulin injection has been given
If the patient has been previously poorly controlled (HbA1c >9%) please refer to the Diabetes team for further advice before discharge
Management of patients on insulin undergoing day case surgery
Aim for “first on list”
For those on a multiple injection regimen, continue the usual basal (long acting) insulin on the evening prior to procedure
For patients on twice daily insulin, continue the usual evening insulin prior to the procedure
Fast from midnight and omit the morning insulin
Check a finger prick blood glucose before and after the procedure
Resume the usual insulin and diet after the procedure. If a BD insulin regimen is restarted at lunchtime it is recommended that half of the normal ‘breakfast’ insulin dose should be prescribed with lunch after procedure
The above applies if rapid recovery is expected i.e. the patient is expected to be eating within 2 hours of the procedure
If the patient is unable to tolerate diet or the blood glucose is >14 mmol/L, then a GKI infusion or alternative (see below) will be required
Glucose/Potassium/Insulin (GKI) Infusion
Take a 500-ml bag of 10% Glucose and add short acting insulin according to the table below. The insulin should be injected into the bag and mixed thoroughly
Add 10 mmols of Potassium Chloride to each bag. NB Omit potassium if patient has renal failure or pre op potassium > 5 mmols/L
A pre mixed bag of 10% Glucose with 10 mmols of Potassium Chloride may be used if available
Monitor potassium carefully
Run infusion at 100mls/hour, via infusion pump, e.g.-Braun, IVAC
Each change in units of insulin per bag requires a new bag
Target glucose 7-10 mmols /l
It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia < 4mmol/L should be avoided
Blood glucose mmol/L Insulin (units) in each 500mL bag
<4 Seek help
4 – 6.9 10
7 – 12.9 15
13 – 17 20
>17 Seek help
If blood glucose levels in the hypoglycaemic range, i.e.<3mmols/l, run in 50 mls of 10% glucose and re-check blood glucose before adding insulin
If the patient is obese or on steroids, add an additional 5 units of insulin to each bag
If the patient has significantly impaired renal function (eGFR < 30), seek advice as they may need a reduced insulin dose or a reduced infusion rate
Check fingerprick blood glucose immediately pre-op, at least hourly intra op and again immediately post-op. Once stable, the post op blood glucose may be checked 2 hourly
Recheck K+ on afternoon of operation, then urea and electrolytes daily if infusion continues
Change to subcutaneous insulin when eating normally. It is important to continue the IV insulin infusion for 60 minutes after the first subcutaneous insulin injection has been given
Patients previously on oral hypoglycaemic agents should usually be changed from insulin to their normal regime prior to discharge
If diabetes previously poorly controlled (HbA1c >9%) please refer to the Diabetes team for advice
Insulin via Pump (sliding scale) with Glucose/Potassium Infusion
This is an alternative to the GKI infusion which is more suitable for very ill patients peri- or post-operatively
Note it involves separate infusions of glucose and insulin and appropriate precautions should be taken to ensure both remain infusing e.g. by using a Protect-A-Line 2 Extension set, with anti-syphon and anti-reflux valves
The blood glucose and urea and electrolytes should be monitored as above
10% Glucose is infused at 100mls/hour (or less if renal or cardiac failure or raised intracranial pressure)
Add 10 mmols of Potassium Chloride to each 500 ml bag of 10% Glucose unless patient has renal failure or pre op potassium >5mmols/l. Monitor potassium carefully
A separate infusion pump with 50units of Actrapid in 50mls 0.9% saline is infused simultaneously. This is infused at the following rate
Blood glucose mmol/L Units of insulin/hour
<4 0.5 (inform doctor)
4 – 6.9 1
7 – 10.9 2
11 – 15.9 4
16 – 20 5 – consider changing glucose to 0.9% saline
>20 6 (inform doctor)
Optimal glycaemic control will aid recovery
Agree individual blood glucose level targets e.g. 7-10mmol/L and ensure IV insulin ratio in sliding scale is altered if this target is not being achieved
Occasionally the regime has to be adapted for a specific patient
It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia <4mmol/L should be avoided
Multiple Injection Regimen
A multiple injection regimen should consist of:
short acting soluble insulin (e.g. Humulin S or Actrapid, ) taken 30 min prior to meals with intermediate acting insulin (e.g. Humulin I, Insulatard) administered at 10 p.m.
alternatively a rapid acting insulin analogue e.g. Insulin Lispro (Humalog), Insulin Aspart (Novorapid) or Insulin Glulisine (Apidra) may be injected immediately before main meals and is combined with a long acting insulin analogue e.g. Insulin Glargine (Lantus) or Insulin Detemir (Levemir). The latter is most commonly taken at teatime or bedtime, although less commonly, some patients do so at breakfast time
Contacting the Diabetes Team
Ideally difficult cases and patients undergoing major operations, particularly if insulin treated, should be discussed with the Diabetes team, well in advance if possible
- Drug Therapy in Relation to Surgery and Anaesthesia (Tayside Feb 06)
- Greek Study suggests antiplatelet therapy may be continued during simple tooth extraction NELM Aug 2011
The five W’s–post-operative fever
- Wind–pneumonia, atelectasis
- Water–urinary tract infection
- Wound–wound infections
- Wonderdrugs–especially anesthesia
- Walking–walking can help reduce deep vein thromboses and pulmonary embolus
GASTROINTESTINAL ENDOSCOPY/VARICEAL BLEEDING/SBP
Adapted from BSG guidelines 2009
high risk patients (prosthetic heart valve, previous endocarditis, surgically constructed systemic-pulmonary shunt or conduit synthetic vascular graft less than 1 year old)
No longer recommended – see BNF
ERCP or ultra sound guided drainage pancreatic pseudocyst or unlikely/unable to achieve complete biliary decompression Ciprofloxacin PO 750mg 60-90 minutes prior to procedure.
See Antibiotic Prophylaxis in General Surgery for ERCP guidance.
PEG tube insertion all patients
(if patient is already receiving broad-spectrum antibiotics additional prophylaxis is not required)
Co-trimoxazole 480mg/5mL suspension. 10mL (960mg) to be given through PEG tube just after insertion.
ANTIBIOTIC PROPHYLAXIS FOR SBP (Spontaneous Bacterial Peritonitis) IN PATIENTS WITH ASCITES
Co-trimoxazole 480mg/5mL suspension. 10mL (960mg) to be given through PEG tube just after insertion.
ANTIBIOTIC PROPHYLAXIS FOR SBP (Spontaneous Bacterial Peritonitis) IN PATIENTS WITH ASCITES
|Hepatomegaly Causes (UK)|
|Ca (mets, hepatoma lymphoma)||polycystic liver|
|Myeloproliferative diseases||Storage disease (glycoge, amyloid, Nieman Pick,)|
|Viral Hepatitis||Budd Chiari|
|Fatty Liver||Non Viral infections (TB, hydatid cyst, amoebic abcess, toxoplasmosid, schistosomiasis)|
|Biliary obstruction||(Aids to Clinical Exam Hayes MacWalter CL 1986)|
Anterior edge of normal liver is occasionally palpable just below right costal margin.
Liver enlargement described in cm below the costal margin.
(Upper border – dull to percussion up to 4th ICS)
Describe liver edge (regular or irregular)
Surface (smooth or nodular)
Consistancy (hard or firm)
Bruits or rub.
Spleen is normally impalpbale and has to enlarge 2-3 x normal before becoming palpable behind the left costal margin.
Look for associated
Clinical features of an enlarged spleen cf kidney in LUQ
- Has palpable notch on the anterior border.
- Can’t get your hand above it (unlike kidney)
- Not bimanually papable/ballotable
- Dull to percussion cg kidney (retroperitoneal) which is resonant due to overlying transverse colon.
- Moves with respiration
- Enlarges down and medially.
Causes of enlarged kidney
- Healthy left kidney is not normally palpbale but lower pole of right kidney can occasionally be felt in thin females.
- Nephrotic Syndrome
- Myeloproliferative disorders
|Causes of Ascites( free fluid in peritoneal cavity)|
Nephrotic syndromeTB peritonitis
Features of ascites
- Distended abdomen with fullness in flanks
- Fluid thrill and Shifting dullness
- Associated hepatosplenomegaly may be difficult to detect
May be dilated abdominal veins – caput medusa – due to portal obstruction and opening up of the round ligament between the portal and parietal veins. Direction of blood flow is away from umbilicus in all directions.
- ruralhealthwest.com.au august 2011 respiratory
- Evaluation of Acute Abdominal Pain in Adults AAFP 2008
- Abdominal pain in elderly @ Emedicine
- Assessing Abdominal Pain In Adults June 1999 EB Medicine
- Evaluation of Acute Abdominal Pain Reviewed Medscape 2008
- Chronic and Recurrent Abdo Pain Merk Manual
Abdo Pain Children Periodic Syndrome Abdominal Migraines
Beware: intussusception, torsion of the testis, strangulated hernia and appendicitis
Children may not have typical symptoms or signs-as always take a careful history, examine and test the urine
Look out for UTI and test and culture
- Appendicitis BMJ 2011
- Paediatric Appendicitis Medscape
- Appendicitis Medscape
- Surgeons.org.uk Appendicitis
- Appendicitis AAFP
Mass in RIF
- Appenix abcess
- Tubo-ovarian mass
- Carcinoid tumour
- TB Omoeba
Arises in the ileum from persistant remnant of the foetal vitello-intestinal duct
Rule of 2s
- 2% of the population
- 2:1 male to female
- 2 inches long
- 2 feet from ileocoecal valve
Usually asymptomatic incidental finding.
Lined with ectopic gastric mucosa which may ulcerate and bleed or perforate
Or may become blocked and inflamed and present like acute appendicitis.
May be diagnosed by technetium 99 radionucleotide scan – HCl producing parietal cells selectively take up the isotope.
- Dysphagia Medscape
- Dysphagia AAFP
- Dysphagia Resource Centre
- Safer Practice for adults with learning disabilities with dysphagia NPSA
- Abdominal mass and weight loss in a 51 year old man
- abdominal mass in neonatal period
- A Child With An Abdominal Mass
- Abdominal Mass in Paediatric Urology
Dilatations of the fibrovascular venous cushions draining into the superior and inferior rectal/haemorrhoidal veins inside the anal canal.
Occur at 3 7 and 11 o’clock.
They may prolapse (‘come down’) on straining, when they may be visible as soft, purple grape-like swellings
protruding from the anus. They may cause bleeding, itching or discomfort.
Haemorrhoidal tissue consists of fibrovascular cushions that are suspended in the anal canal by a connective tissue framework derived from the internal anal sphincter and longitudinal muscle.
The venous plexus of each cushion is fed by arteriovenous communications that allow for enlargement of the cushion to help control continence. With age and the passage of hard stools, the connective tissue supporting the cushions becomes weaked so that these cushions may descend. Straining produces an increase in venous pressure and engorgement. The prolapsed cushion has an impaired venous return, which results in dilatation of the plexus and venous stasis. A decreased venous outflow can also result from, for example, spasm of the anal sphincter straining and tumours in the pelvis. Alternatively, arterial inflow can increase via infection or alcohol. Inflammation occurs with erosion of the cushion’s epithelium, resulting in bleeding.
|Grade 1||haemorrhoids that are only visible on proctoscopy (grade 1)|
|Grade 2||those that prolapse when straining, but which reduce spontaneously|
|Grade 3||those that spontaneously prolapse, but which can be reduced digitally|
|Grade 4||prolapse and cannot be reduced|
toilet habits and constipation
about any changes in bowel habit
about the relationship between rectal blood loss and defaecation (the amount, whether it is bright or dark red, the presence of mucus, and whether the blood is only on the toilet paper, or also in, or on the surface of, the faeces)
about pain (pain is not a symptom of uncomplicated haemorrhoids; if pain is present, this suggests an anal fissure (or a perianal haematoma)
about risk factors for colonic carcinoma (positive family history for polyposis coli or colon carcinoma, long-term ulcerative colitis).
When the patient strains, the GP should look for prolapse of haemorrhoids or mucosa.
The swelling of external haemorrhoids should be clearly visible.
During palpation and the digital rectal examination, check for induration, sphincter tension (hypotonia, hypertonia), tumours, and abnormalities of the prostate, the uterus and the pouch of Douglas. Internal haemorrhoids are not usually palpable. They will, however, be visible on proctoscopy.
Further investigation is usually unnecessary for blood loss resulting from haemorrhoids in patients under 50 years old without risk factors for colonic carcinoma. However, it is indicated for rectal blood loss with existing haemorrhoids in patients above this age, to exclude co-pathology.
Local therapy consists of treating the accompanying perianal dermatitis, cooling the area with ice (which reduces swelling, itching and pain), and warm baths, which relax the anal sphincter (thereby improving venous outflow) and protect the skin and mucous membrane.
Sclerotherapy or rubber-band ligation (for grades 1,2 and 3) or surgical therapy (for grades 3 and 4) should only be carried out if there are persistent symptoms.
Caused by a sudden leakage of blood from a ruptured tributory of one of the inferior rectal veins. small blood vessel near the anus. The blood stretches the sensitive skin and is very painful. It will gradually disperse, but if the patient presents early it is possible to radially incise it and relieve pain by expressing the blood clot.
Prolapsed Strangulated Piles
Presents similarly with painful lump at anal verge. Prolapsed piles become gripped by anal sphincter, venous return is obstructed and thrombosis occurs.
Midline split in the anal skin and deeper tissues due to passing a large, hard stool. 90%at 6 o’clock 10% 12 oclock – usually females. Causes pain and bleeding on defaecation. There is usually an associated tag of anal epithelium which points to the fissure (sentinel pile)
Sphincter spasm causes local ishaemia increasing pain and fear of defacaetion further hardening of stool pain spasm etc. Most will heal within 6 weeks, provided that the stools remain soft. Untreated this may result in a chronic fissure.
Anal fissures must be differentiated from other disorders of the anal skin including ulcerative colitis and Crohn’s disease. In 7% of patients with ulcerative colitis, fissures are present that are multiple in number, wide, infected and located outside the median line. In Crohn’s disease, the anal lesions are larger and the ulceration more extensive, and they are accompanied by oedema and large skin tags.
Act on the normal defecation reflex and to ensure the proper consistency of the faeces: a cellulose rich diet (fruit, fresh or raw vegetables, brown bread and rye bread), possibly supplemented for a short time with volume-increasing laxatives (e.g. psyllium seed, sterculia gum). Warm baths after a bowel movement can help prevent and relieve the anal spasm.
The pain can be treated locally by short-term, sparing use of a local anaesthetic ointment, such as lidocaine.
Topical glyceryl trinitrate ointment : every 3 hours (not during the night) to the entire anal dermis.
If the fissure has not healed at that point, the patient must be referred for further tests, and possibly, in the most extreme cases, for surgery or for ‘chemical denervation’ of the internal sphincter (with botulinum toxin). An operation must also be considered for a fissure accompanied by an abscess or fistula
Fistula in ano
- NICE CG49 Faecal incontinence in adults Jun 2007
- 4 questions
- Is there a hernia
- Is it reducible
- Is it inguinal or femoral
- If inguinal is it direct or indirect
- UCSD hernia/genital exam
- Inguinal Hernias Patient/Doctor UK
- femoral Aneuysm
- Femoral Hernia
- Incrcerated Inguinal Hernia
- Indirect Inguinal Hernia
- Psoas Abcess
- Saphena Varix
- Other Hernias
- SIGN 89
- Peripheral Arterial Disease PUK
- SIGN 120 Aug 2101 Venous Ulcers QRG
- Management of venous leg ulcers BMJ 2004
- Venous Leg Ulcer Guidelines @ RCN
Varicose /venous/gravitational ulcer
Due to venous incompetence (vvs previous DVT) leading to venous hypertension stasis and oedema, varicose eczema (haemosiderin deposition from damaged red cells squeezed out of the capillaries) , bacterial infection, then ulceration around medial malleolus and lower leg
elevation – foot higher than knee and knee higher than hip.
drynonadherent dressing + paste bandage + elastoplast bandage from toes to knee. Change weekly initially then more frequently as heals.
elastic stocking once healed
Arterial / Ischaemic ulcers
Seen in advanced PAD. Confirm by APBI and investigate with femoral arteriogram to assess location and degree of stenosis and collateral run off.
Rx Balloon angiography +/- stent. Surgical reconstruction with saphenous graft.
Deep indolent ulcers over lower legs .
Necrobiosis lipoidica diabeticorum
Red/yellow sclerotic plaques with ulceration seen on shins
Elevated purulent border with undermining of the skin and zone of erythema beyond the edge. Seen on legs and trunk. Seen in UC, MM and leukaemia.
Sickle cell disease
Punched out sharp edged round or oval lesions in Afro Caribean patient.
Sloughing gummatous ulcer with punched out edges below the knee seen in tertiary syphilis.
|0.5-0.7 /0.7-0.8||mixed arterial-venous ulcer|
|>1.2||possible calcific vessels|
- Varicose Ulcer
- Pressure Sores
- Ischaemic Ulcers
- Trophic Ulcers
- Malignant Skin Ulcers
- Siphilitic Ulcer
- Trophic Ulcers
- Superficial venous incompetence BMJ Clinical Review Jul 2011
Sterile inflammation of clotted stagnant blood in varicose vein.
Rx elevation and analgesia.
- White arteriolar spasm
- Blue dilated capillaries skin feels cold numb
- Crimson red reactive hyperaemia as vasosasm relaxes
Idiopathic paroxysmal spasm of digital arterioles in response to cold. Characteristic colour change as above. Mainly females.
Use gloves. Avoid smoking and betablockers. Try Ca antagonists eg diltiazem or nifedipine. Sympathectomy may be helpful.
- cervical rib
- arterial trauma
- vibratory white hand
Pernio in Children Paediatrics 2005
|6 Ps – MSK or Arterial Occlusion|
Cellulitis & Erysipelas
Organisms S. pyogenes. S. aureus.
PVL toxin is produced by 2% of S. aureus and produces recurrent abscesses or cellulitis.
Risk factors include young age, patients in close communities, contact sportsmen and possibly travel abroad (e.g. US, Australia).
1st line Flucloxacillin 1g four times daily for 7-14 days. In penicillin allergic patients, doxycycline 100mg twice daily for 7-14 days.
If history or risk of MRSA check sensitivities or start antibiotics as below and adjust in line with sensitivities.
If no improvement seek ID/Microbiology advice.
Always use dual therapy except for doxycycline or co-trimoxazole.
Details on decolonisation programme can be obtained from Infection Control.
1st line Doxycycline 100mg twice daily (7-14 days).
2nd line Trimethoprim 200mg twice daily and rifampicin 300mg twice daily (7-14 days).
The use of antibiotics in the treatment of leg ulcers is only recommended with clear evidence of clinical infection (pain, cellulitis, fever, progressing infection), refer to the SIGN guideline 26 – The Care of Patients with Chronic Leg Ulcer
Patients should be warned that rifampicin therapy may colour body secretions yellow or orange (including soft contact lenses).
Be aware of important drug interactions with rifampicin, e.g. failure of the oral contraceptive due to enzyme induction – consult current BNF for details.
- Primary – congenital defect of lymphatic drainage of the leg
- congenital (milroys disease)
- lymphoedema praecox
- lymphoedema tarda
- Secondary – extrinsic compression of lymphatic drainage
- metastatic lymh nodes radiotherapy block dissection
- severe bacterial or parasite infection eg filaiasis
|+1||minimal < 2mm|
|+2||depression 2-4 mm|
|+4||> 8 mm|
elevation, graduated compression stockings, intermittent pneumatic compression
Recurrent cellulitis from minor scratches or abrasions, dermatitis or tinea.
Antibiotics should be used early and patients should usually have a supply at home.
amoxicillin 500 mg tds for 2 weeks (or erythromycin 500 mg qds for 2 weeks)
if no improvement within 3 days change to clindamycin 300 mg bd.
In the presence of severe systemic upset, the patient will need to be referred to hospital.
Prophylactic antibiotics in recurrent attacks: penicillin V 500 mg od (or 500 mg bd)
- pancreatic cancer.org.uk/study for survival report
- guardian.co.uk gps spot signs pancreatic ca
- NICE CG131 Nov2011 Colorectal ca
- SIGN CG67 Colorectal Ca
- Bowel Ca Risk Factors and Early Diagnosis AAFP 1999
- Beating Bowel Cancer Cancer Symptoms
- Bowel Ca research
- NHS Bowel Cancer Screening
- Aspirin and colorectal surgery
- Whole Grains and Colorectal Ca BMJ Nov 2011
DUKES cancer Staging
- A AOK bowel wall only
- B breeched bowel wall
- C colonic/regional nodes
- D distant mets
- cancer.gov colorectal Ca genetics
- beating bowel cancer.org family-history
- cancerscreening.nhs.uk bowelcancer
- macmillan.org.uk Bowel cancer risk factors
- Clinica Cases Uncovered - Surgery Ellis and Watson 2010 Wiley-Blackwell ↵