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100 Cases in Surgery
ANSWER 35
The normal spleen is approximately 11 cm in length and is not normally palpable. The spleen classically enlarges towards the right iliac fossa, has a palpable notch and is dull to percussion. The superior border of the spleen cannot be reached on palpation, differentiating it from renal masses. The spleen is responsible for the synthesis of immunoglobulins and the clearance of micro-organisms, antigens and abnormal red blood cells from the circulation. Enlargement of the spleen is usually due to overactivity of its normal functions.
!Causes of enlargement of the spleen
•Infective:
•Acute: septicaemia, infective endocarditis, typhoid, infective mononucleosis
•Chronic: tuberculosis, hepatitis, brucellosis, hiv
•Parasitic: malaria, kala-azar (leishmaniasis), schistosomiasis
•Inflammatory:
•Rheumatoid arthritis
•Sarcoidosis
•Systemic lupus erythematosus
•Haematological:
•leukaemia
•lymphoma
•haemolysis (thalassaemia, sickle cell disease)
•myeloproliferative disorders
•Portal hypertension
•Miscellaneous:
•Storage disorders
•amyloid
•Causes of massive splenomegaly:
•Myelofibrosis
•Chronic myeloid leukaemia
•Chronic malaria
•Kala-azar
The blood film would suggest this patient has myelofibrosis. There is progressive scarring of the bone marrow leading to blood formation in extra-medullary sites, such as the liver and spleen, causing enlargement of these organs. The cause is unknown. The disorder usually develops slowly, in people over 50 years of age. It leads to progressive bone-marrow failure with severe anaemia. The diagnosis is made on examination of the blood films, showing teardrop-shaped red blood cells, and on bone-marrow biopsy.
There is no specific treatment for primary myelofibrosis. Blood transfusions and erythropoietin are given to correct the anaemia. A splenectomy may help if the enlarged size of the spleen causes thrombocytopenia. Splenectomy can be performed through a subcostal incision or laparoscopically. The patient should be crossmatched prior to the procedure, and platelets ordered if the platelet count is low. Those patients who undergo splenectomy have a lifetime risk of septicaemia and should receive immunizations against Pneumococcus, Haemophilus and Meningococcus.
KEY POINTS
the characteristics of the spleen on clinical examination are:
•the superior border cannot be felt
•the medial border is notched
•it is dull to percussion
•it enlarges towards the right iliac fossa
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Upper Gastrointestinal
CASE 36: FinDing at gaStroSCopy
history
A GP has referred a 56-year-old man for an oesophagogastroduodenoscopy. The patient presented to the GP 2 months previously with epigastric discomfort and bloating. He was prescribed a proton pump inhibitor, which failed to improve his symptoms. He has no history of gastro-oesophageal reflux or gallstones and is not on any other regular medication. He smokes 20 cigarettes a day. The GP also sent some blood tests, shown below.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
9.0 g/dl |
11.5–16.0 g/dl |
mean cell volume |
69 fl |
76–96 fl |
White cell count |
10.2 × 109/l |
4.0–11.0 × 109/l |
platelets |
252 × 109/l |
150–400 × 109/l |
Sodium |
137 mmol/l |
135–145 mmol/l |
potassium |
3.9 mmol/l |
3.5–5.0 mmol/l |
urea |
5.0 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
59 μmol/l |
44–80 μmol/l |
amylase |
78 iu/dl |
0–100 iu/dl |
aSt |
30 iu/dl |
5–35 iu/l |
ggt |
23 iu/dl |
11–51 iu/l |
albumin |
45 g/l |
35–50 g/l |
bilirubin |
12 mmol/l |
3–17 mmol/l |
glucose |
5.0 mmol/l |
3.5–5.5 mmol/l |
the endoscopy results are shown in Figure 36.1.
Figure 36.1 Finding on endoscopy.
Questions
•What does the endoscopy show?
•What do the blood tests reveal?
•What are the risk factors for this diagnosis?
•How should the patient be staged?
•What are the treatment options?
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100 Cases in Surgery
ANSWER 36
The gastroscopy has revealed a gastric tumour. The blood tests show a microcytic anaemia, as a result of chronic blood loss from the tumour. This patient will have had multiple biopsies taken at endoscopy and will now require staging. Gastric carcinoma is the second commonest cause of cancer worldwide. The majority are adenocarcinomas, with the remainder made up of lymphomas, stromal or neuroendocrine tumours. The highest incidence is in Eastern Asia, with a falling incidence in Western Europe. Diet and H. pylori infection are thought to be the two most important environmental factors in the development of gastric cancer. Diets rich in pickled vegetables, salted fish and smoked meats are thought to predispose to gastric cancer. These factors contribute to a premature atrophic gastritis, a precursor state to malignant transformation. Fruits and vegetables are protective.
!Risk factors for gastric malignancy
•vitamin C deficiency
•Helicobacter pylori infection
•hypogammaglobulinaemia
•pernicious anaemia
•post-gastrectomy
Gastric cancer typically presents late and is associated with a poor prognosis. Clinical examination may reveal supraclavicular lymphadenopathy or hepatic enlargement, indicative of metastatic disease. Endoscopic ultrasound allows assessment of tumour depth and nodal involvement. CT also allows nodal spread and the extent of metastatic disease to be assessed (Figure 36.2).
Figure 36.2 Computerized tomography showing gastric wall thickening (arrow) as a result of gastric cancer. no liver metastases are seen.
Laparoscopy is useful to identify any peritoneal seedlings that are not detected on conventional imaging.
Antral tumours may be suitable for a sub-total gastrectomy. If the tumour is less than 5 cm from the gastro-oesophageal junction, the patient will require a total gastrectomy. For superficial tumours less than 1 cm in size, some centres are now carrying out endoscopic mucosal
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Upper Gastrointestinal
resection. Perioperative chemotherapy (before and after surgery) improves survival for those patients suitable for surgical resection.
KEY POINTS
•gastric cancer often presents late with metastatic disease.
•Surgical resection is not possible in the majority of patients.
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BREAST AND ENDOCRINE
CASE 37: aSSeSSment oF a breaSt lump
history
A 47-year-old female presents to the breast clinic complaining of a painful lump in her left breast. She has not noticed any nipple discharge, skin changes or changes in her breast shape. Her mother was diagnosed with breast cancer at 50 years of age. She has recently been through a divorce and has no children. She is a non-smoker and has been previously fit and healthy.
examination
A 4-cm irregular lump is found adjacent to the nipple in the left breast. The lump is hard in consistency and only mildly tender on palpation. It is slightly mobile with no tethering of the overlying skin. It does not appear deeply fixed. There are palpable left-sided axillary lymph nodes which are mobile. The right breast and axilla are normal. Abdominal and skeletal examinations are normal.
INVESTIGATIONS
a mammogram of the breast is shown in Figure 37.1.
Questions
• |
How should this lump be assessed? |
• |
What are the risk factors for |
|
developing breast cancer? |
• |
TowhatagegroupdoestheUKoffer |
|
a breast screening programme? |
• |
What is a sentinel lymph node |
|
biopsy? |
Figure 37.1 mammogram of the left breast.
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100 Cases in Surgery
ANSWER 37
Breast cancer is the commonest form of cancer amongst women. Any women presenting with a breast lump should undergo triple assessment:
•Clinical assessment (history/examination)
•Mammography and/or ultrasound
•Fine-needle aspiration cytology (FNAC) or core biopsy
The incidence increases with age, but at menopause the rate of increase slows. Risk factors for developing breast cancer include:
•Oestrogen exposure, unopposed by progesterone
•Nulliparous women in developed countries
•Mutations in the BRCA1 and BRCA2 genes
•Early menarche/late menopause
•Family history
•Saturated dietary fats
•Previous benign atypical hyperplasia
The breast screening programme was set up by the Department of Health in 1988 and is offered to women between the ages of 50 and 70 years. All women now have two views of the breast taken at every screen – craniocaudal and mediolateral views. It has reduced mortality rates in the 55–69-year age group.
In patients without systemic disease, surgery is potentially curative. Treatment options include mastectomy or breast-conservation surgery, such as wide local excision or quadrantectomy. Axillary lymph node status is a good prognostic indicator for breast cancer and is helpful in delineating further treatment pathways. Management of the axilla is controversial. Options include axillary node sampling, clearance or sentinel node biopsy. The sentinel node is the first lymph node the breast lymphatics drain to before reaching the axilla. Sentinel lymph node biopsy is an alternative to axillary sampling or clearance, which provides information on the probable tumour status of other axillary lymph nodes. The technique involves injection of a technetium-based radioisotope into the breast, often in combination with a dye. The sentinel node is detected with the use of a gamma camera or direct visualization on dissection (the dye is usually blue) before excision.
KEY POINT
• all patients presenting with a lump in the breast should undergo triple assessment.
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