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What is the primary risk factor for Paget-Schroetter Disease?
Superficial thrombophlebitis can be caused by trauma to a superficial vein.
True
What diagnostic tool is used for confirming primary upper limb DVT?
Doppler
The most common cause of superficial thrombophlebitis is _____ insertion.
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Match the following features with their respective conditions:
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Which type of mesenteric cyst is characterized by a thin wall and independent blood supply?
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Enterogenous mesenteric cysts typically contain sequestered lymphatic tissue.
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What is the recommended management procedure for enterogenous mesenteric cysts?
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The clinical features of mesenteric cysts include periumbilical swelling and a sign known as the ______ sign.
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Match the following features with the correct type of mesenteric cyst:
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Which of the following pairs of veins contribute to the majority of blood flow in the lower limb?
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A previous history of deep vein thrombosis (DVT) is a risk factor for developing another DVT.
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What is the definition of Lower Limb Deep Vein Thrombosis (DVT)?
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The primary complication of DVT that can be life-threatening is called a __________.
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Match the following risk factors with their corresponding categories:
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What is the preferred method of ventilation for patients with an internal hernia?
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Petersen's hernia occurs behind the Roux limb.
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What type of hernia occurs through the transverse mesocolon?
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A left paraduodenal hernia occurs due to a defect in the fusion of the _______.
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Match the following types of hernias with their descriptions:
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Which of the following is a common cause of venous thrombosis related to tissue factor?
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Phlegmasia cerulea dolens is characterized by a painful white limb.
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What is the most common vein affected in venous thrombosis?
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The condition known as milk leg refers to __________.
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Match the following signs to their descriptions:
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Which of the following is NOT a feature of post-thrombotic limb?
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Subtherapeutic anticoagulation is a risk factor for post-thrombotic limb after DVT.
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Name two types of prophylaxis used to prevent DVT.
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The appearance associated with lipödermatosclerosis is an inverted ______ bottle appearance.
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Match the following DVT risk factors with their descriptions:
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Which type of congenital diaphragmatic hernia is more common?
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Pulmonary hypoplasia is the second most common cause of death in congenital diaphragmatic hernia cases.
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What is the typical shape of the abdomen in a newborn with congenital diaphragmatic hernia?
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The Bochdalek hernia typically involves herniated contents such as the stomach, spleen, and ______.
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Match the type of hernia with its characteristics:
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Which of the following agents is a direct thrombin inhibitor?
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IVC filters can be used for patients with contraindications to anticoagulation.
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Name one complication of anticoagulation therapy.
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Streptokinase and urokinase are agents used in __________.
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Match the following anticoagulants with their types:
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What is the maximum score that can be assigned based on Wells' criteria?
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A score of -2 in Wells' criteria indicates a high probability of DVT.
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What is the first-line treatment for new DVT patients during the initial five days?
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The target INR for managing anticoagulation in patients with DVT is _____ to _____ for most cases.
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Match the following types of investigations with their purposes:
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Which of the following does NOT contribute to the Wells' score?
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Anticoagulants primarily serve to prevent the formation of new clots in DVT treatment.
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What is the recommended duration of treatment for a first episode of DVT?
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What is the most common type of obturator hernia defect seen in elderly, multiparous women?
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Strangulation is a complication that can occur with an obturator hernia.
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Name one characteristic clinical feature associated with obturator hernias.
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An obturator hernia is characterized by a defect in the tissues that normally hold the ______ closed.
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Match the following types of hernias with their characteristics:
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Which sign is characterized by shooting pain along the obturator nerve during hip movements?
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Obturator hernias are most frequently seen in males.
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What is the recommended surgical procedure to repair an obturator hernia?
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Study Notes
Mesenteric Cysts
- Mesenteric cysts are fluid-filled sacs in the mesentery, the tissue that holds the intestines in place
- Two main types: Chylolymphatic and Enterogenous
- Chylolymphatic cysts are more common and contain clear fluid, while Enterogenous cysts contain turbid fluid.
Clinical features
- Mesenteric cysts can attach to the mesentery, often near the junction of the duodenum and jejunum (DJ flexure)
- Tillaux triad:
- Periumbilical swelling
- Movement at right angle to attachment of mesentery (Tillaux sign)
- Transverse band of resonance
Investigations
- Imaging studies like Computed Tomography (CT with contrast) are used for diagnosis
Management
- Chylolymphatic cysts are usually removed surgically (enucleation)
- Enterogenic cysts require resection (removal) and anastomosis (reconnection of the bowel)
Upper Limb Deep Vein Thrombosis (DVT)
- DVT in the upper limb can be primary or secondary.
Primary Upper Limb DVT
-
Paget-Schroetter Disease:
- Thrombosis in the axillary vein, often caused by repetitive arm movements
- Diagnosed by Doppler ultrasound
- Managed with anticoagulation
Secondary Upper Limb DVT
- Can be caused by thoracic outlet obstruction or cannula insertion
Superficial Thrombophlebitis
- Inflammation and thrombosis of superficial veins, often caused by IV line insertion.
- Symptoms include tenderness and cord-like swelling
- Treated with Thrombophlebitis gel
Lower Limb Deep Vein Thrombosis (DVT)
- Defined as semi-solid coagulum in the deep veins
- Major complications: Pulmonary embolism and post-thrombotic limb
Risk factors
-
Virchow's Triad:
- Stasis (blood flow slowing)
- Hypercoagulability (increased clotting tendency)
- Endothelial injury (damage to vessel lining)
Patient factors
- Patient factors that increase the risk of DVT:
- Age, obesity, immobility, varicose veins, pregnancy, puerperium, high-dose estrogen therapy
Internal Hernias
- A type of hernia where a loop of intestine protrudes through a defect in the internal abdominal wall.
- Several types, including:
- Stemmer's hernia, Left paraduodenal hernia, Petersen's hernia, Right duodeno-jejunal hernia
Management of Internal Hernias
- Mechanical ventilation (IPPV) is the preferred method
- Surgical intervention: Circumferential incision over the diaphragm followed by mesh placement to cover the defect
Venous Thrombosis
- Causes of venous thrombosis can be divided into two categories: Disease or surgical procedure and patient factors.
Disease or surgical procedure
- Trauma or surgery
- Malignancies
- Heart failure
- Myocardial infarction
- Paralysis
- Infection
- Homocystinemia
- May-Thurner syndrome: Right iliac artery compressing the left iliac vein
Patient factors
- Conditions that increase susceptibility to clots (e.g., inflammatory bowel disease, nephrotic syndrome, polycythemia, paraproteinemia, PNH antibody or lupus anticoagulant, Behcet's disease, Factor V Leiden mutation, Protein C & S deficiency)
Clinical features
- Often asymptomatic, especially in the early stages
- More common in one leg, but can affect both
- The most common vein affected: Calf/soleal veins
Pulmonary embolism
- Most common vein affected: Ilio-femoral veins
- Symptoms:
- Chest pain
- Dyspnea (shortness of breath)
- Increased jugular venous pressure (↑ JVP)
- Decreased systolic blood pressure (↓ SBP)
Signs
- Signs associated with DVT:
- Limb edema (swelling)
- Moses sign: Pain on squeezing the calf muscles
- Homan's sign: Resistance in calf on dorsiflexion of the foot
Phlegmasia cerulea dolens
- Painful blue limbs, due to thrombosis of major axial veins and collaterals, leading to potential venous gangrene
Phlegmasia alba dolens (aka milk leg)
- Painful white limb, due to thrombosis of major axial veins without collateral involvement
- More common during pregnancy
Wells' Criteria for Predicting DVT
- A scoring system to predict the likelihood of DVT.
- Score is calculated based on clinical signs and risk factors.
Probability based on Score
- Low probability: Score -2 to 0
- Moderate probability: Score 1-2
- High probability: Score >2
Investigations
- Doppler/Duplex scan (color Doppler and B-mode ultrasound) is the initial investigation
- Magnetic Resonance Imaging (MRI) if Doppler inconclusive
- Pulmonary embolism:
- Gold standard: Pulmonary angiography (invasive)
- Initial investigation: CT angiography
- D-dimer: High negative predictive value
Management
- Anticoagulants:
- Mainstay treatment to prevent clot propagation
- Low-molecular-weight heparin (LMWH) and warfarin are commonly used
- Warfarin therapy monitoring is essential (INR)
- Target INR: 2-3
- INR target before surgery: 1.4-1.5
Post thrombotic limb
- Affects 2/3rd of patients with DVT
Features
- Varicose veins, pigmentation, lipodermatosclerosis (inverted champagne bottle appearance)
Risk factors
- Proximal DVT, subtherapeutic anticoagulation, recurrent DVT
DVT risk groups and Prophylaxis
- High-risk groups: Major orthopaedic surgery, major abdominal/pelvic surgery, major surgery in patients with previous DVT, PE or thrombophilia, lower limb paralysis, major lower limb amputation.
Prophylaxis: Types
- Pharmacological:
- LMWH (low-molecular-weight heparin) is preferred, last dose given 6 hours before surgery
- Mechanical:
- Early ambulation
- Pneumatic compression stockings.
Congenital Diaphragmatic Hernia (CDH)
- A birth defect where organs from the abdomen protrude into the chest.
- Two main types: Bochdalek and Morgagni hernia.
Bochdalek vs Morgagni hernia
| Feature | Bochdalek | Morgagni |
|---|---|---|
| Occurrence | More common | Less common |
| Location | Left postero-lateral | Right antero-medial |
| Defect | Defective development of pleuroperitoneal canal/membrane | Defective central tendon of diaphragm |
| Herniated contents | Stomach, Spleen, Transverse colon | Transverse colon |
Complications
- Pulmonary hypoplasia (underdevelopment of the lungs): Most common cause of death
- Pulmonary hypertension (high blood pressure in the lungs): Second most common cause of death
Features
- Mother: Polyhydramnios (excess amniotic fluid) during pregnancy
- Newborn child:
- Scaphoid abdomen (abnormal shape)
- Respiratory distress
Investigations
- Chest X-ray
Auscultation
- Bowel sounds can be heard in the chest cavity
Venous Thrombosis
- In-depth information on anticoagulants, direct thrombolysis, IVC filters.
Anticoagulants
- Sensitive to heparin:
- Fondaparinux: Factor Xa inhibitor
- Bivalirudin: Direct thrombin inhibitor
- Novel anticoagulants (NOAC):
- Rivaroxaban
- Apixaban
Direct thrombolysis
- Used to dissolve clots
- Agents: Streptokinase, urokinase
- Catheter-induced
- Reduces the risk of post-thrombotic limb
- Beneficial for early presentation
- Suitable for proximal DVT with moderate to severe symptoms
IVC filter/Greenfield filter
- Insertion into the inferior vena cava (IVC)
- Prevents clot embolisms to the lungs
Indications for IVC filter
- Recurrent thromboembolism despite anticoagulation
- DVT with contraindication to anticoagulation
- Chronic pulmonary embolism with pulmonary hypertension
- Complications of anticoagulation
Indications for retrievable IVC filters
- Prophylactic placement in high-risk trauma patients
- Short-term contraindication to anticoagulation
- Protection during venous thrombolytic therapy
- Extensive iliocaval thrombosis
Complications of anticoagulation
- Migration
- Bleeding
- IVC blockage by clot
Obturator hernia
- A type of hernia that occurs in the obturator canal, located in the pelvis near the hip.
- The hernia occurs because the tissues that hold the canal closed have a defect, and a part of the intestine might slip through.
Types
- Classified as:
- Children: Small defect
- Adults: Large defect
- Complications: Strangulation
Characteristics
- Known as Little Old Lady's hernia
- Most common in elderly, multiparous women
- Can be categorized by the size of the defect (narrow or large)
Complications
- Strangulation: Blood supply to the herniated intestine is cut off
- Richter's hernia: Very narrow defect
Clinical features
- Bowel obstruction
- Pain
Signs
- Howship-Romberg sign: Shooting pain along the obturator nerve during abduction and medial rotation of the hip
- Hannington-Kiff sign: Diminished or absent adductor reflex and normal patellar reflex.
- Compression: Often caused by obturator nerve compression.
Management
- Hernioplasty: Surgical hernia repair
Richter's hernia
- Very narrow defect
- Associated with paraumbilical, femoral, and obturator hernias
- Signs: Gastroenteritis, possible strangulation, or progression to peritonitis
- Rapid transit through the proximal part of the hernia, which contracts vigorously, leading to obstructed bowel and strangulation/peritonitis.
Maydl's hernia
- Large defect
- W-shaped hernia
- Located in the connecting portion within the intraperitoneal cavity
Diagrams
- Anatomical depictions of the hip region showing the obturator canal, surrounding ligaments, and the location of different structures
- Diagram depicting the progress of Richter's hernia and the progression of Maydl's hernia.
- The diagrams include labels for different anatomical features and indicate the location of the herniated intestine.
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Description
This quiz covers the essential aspects of mesenteric cysts and upper limb deep vein thrombosis (DVT). You'll learn about the types, clinical features, and management strategies for mesenteric cysts, as well as the differences between primary and secondary upper limb DVT. Test your knowledge on these important medical conditions.
