SURGERY QUICK REFERENCE TABLE

Cerebellum's Hyperrevision 20th Course — Compiled Reference

ESOPHAGEAL DISORDERS
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Achalasia Allgrove syndrome Motility disorder of distal Dysphagia (liquids>solids), Mega/Sigmoid UGI Endoscopy (rule out UGI Scopy not Esophageal Manometry Type1(MC):Absent peristalsis+high
(AAA), Chagas disease esophagus. Absent Regurgitation, Weight loss esophagus (late) malignancy) diagnostic → Barium (HRM) — Chicago LES → Heller's Type2:+Pan-esoph
([Link]) peristalsis + elevated LES (Eckhardt score: + Heartburn = 4 swallow (Bird beak / Classification press → Heller's (best response)
pressure components) smooth tapering) Type3(Spastic):+Premature spasms
→ POEM Heller's: 6-7cm
esoph+2-2.5cm cardia (spare
mucosa)+Dor/Toupet fundoplication
POEM: 6cm esoph+2-3cm cardia
(spare adventitia)
Zenker's Diverticulum Weakness in inferior False diverticulum Halitosis, Regurgitation (food in Aspiration, recurrent Oral contrast imaging Barium swallow (lateral Barium Swallow / CT Dohlman procedure (endoscopic) OR
constrictor (Killian's (mucosal only), herniates pouch), Dysphagia (late) chest infection view) — posterior with oral contrast (NOT Stapled diverticulopexy
dehiscence) posteriorly through Killian's outpouching in neck endoscopy)
dehiscence
GERD Smoking, alcohol, tea, Reflux of gastric acid into Heartburn (MC/earliest), Epigastric Barrett's esophagus, UGI Endoscopy (1st step 24-hr pH study if: 24-hr pH study TOC: PPI + LSM (4-8 wks) Surgery
coffee, stress; Young M/F esophagus (Montreal pain, Regurgitation/water brash Hiatus hernia, + diagnostic — LA atypical symptoms / (DeMeester score indications: Intractable/volume reflux,
definition) (LATE) Atypical: Cough, laryngitis, Esophagitis (LA Grade grading) normal endo / not >14.7 = positive) complications Nissen: 360° (MC
dental erosions, asthma A-D) responding to PPI / complication: short-term dysphagia)
pre-surgery Toupet: 270° posterior (less
dysphagia) Dor: 180° anterior
(prophylactic with Heller's)
Barrett's Esophagus Chronic GERD Columnar metaplasia (squa Tongue-like salmon-pink Low grade dysplasia UGI Endoscopy + NBI Biopsy: Seattle protocol Endoscopy + Biopsy No dysplasia: PPI+LSM Low grade:
(persistent acid mous→columnar/intestinal) projections at GE junction on (0.7%/yr), High grade (Narrow Band Imaging) (4-quadrant, 2cm (Goblet cells = EMR/RFA High grade: MDT →
exposure) . Goblet cells on biopsy endoscopy (NOT erosions) dysplasia (7%/yr) → intervals) intestinal metaplasia) Excision+Surveillance
confirm intestinal Adenocarcinoma
metaplasia
Boerhaave Syndrome Alcohol binge → forceful Spontaneous esophageal Mackler's Triad: Chest pain Mediastinitis, septicemia, CT with water-soluble X-ray chest: CT with water-soluble Surgery if: significant leak,
vomiting against closed perforation (left lower (retrosternal) + Retching + pleural effusion contrast (NOT barium — pneumomediastinum, contrast unstable/sepsis/mediastinitis,
glottis esophagus — weak area) Subcutaneous emphysema (DDx toxicity) pleural effusion intra-abdominal perforation
Mallory-Weiss: hematemesis; Conservative: Cervical/small thoracic
Boerhaave: chest pain) perforation without leak
CA Esophagus SSSD: Smoking, SCC: mid 1/3 (MC in India) Dysphagia (painless, progressive, Obstruction, UGI Endoscopy + Biopsy EUS (local/T-staging), UGI Endoscopy + T1-T2: Surgery±adjuvant chemo
Spirits(alcohol), Adeno: distal 1/3 (MC in SOLIDS>LIQUIDS) tracheo-esophageal (1st step & diagnostic) PET scan (distant Biopsy T3-T4: Neoadjuvant chemo→Surgery
Sepsis(HPV/Candida), West) Elderly Male Smoker +Regurgitation+Wt loss = fistula, aspiration mets/lymph nodes) M1: Palliation (stenting/feeding)
Diet(N-Nitroso) SCC: Pseudoachalasia Spread: Ivor-Lewis (double):
Achalasia, Corrosive Trachea/[Link]/Aorta → Lung abdomen+[Link] → distal tumors
injury Adeno: Barrett's, mets McKeown (triple): +[Link] →
Obesity proximal/cervical tumors Conduit:
Gastric pull-up (1st), Colonic
interposition (2nd)
STOMACH & DUODENUM
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
CA Stomach SSSD: Smoking, Spirits, Adenocarcinoma; MC site: Elderly Male Smoker rule. GOO, perforation, UGI Endoscopy + Biopsy EUS (T-staging), PET UGI Endoscopy + Radical Gastrectomy (subtotal/total) +
Sepsis([Link]→Type B Antrum Borrmann Dysphagia, early satiety, bleeding, metastasis (1st step & IOC) scan (distant) Biopsy D2 Lymphadenectomy Margins:
gastritis), Diet(smoked classification (advanced) non-bilious vomiting (GOO if distal) Proximal >5cm, Distal: till D1 D1:
foods/soya) Virchow's node, Sister stations 1-6 (perigastric); D2: +stations
Premalignant: PU, Mary Joseph nodule, 7-11 Chemo: FLOT (5FU+Leucovorin
Adenoma, Krukenberg, Irish node +Oxaliplatin+Taxane)
Atrophic/Hypertrophic
gastritis
IHPS (Infantile Hypertrophic NOT congenital — Hypertrophy of pyloric Age 4-8 wks; Projectile non-bilious Metabolic triad: USG abdomen (pyloric X-ray: Single bubble USG Abdomen Step 1: Correct dehydration
Pyloric Stenosis) presents at 4-8 weeks muscularis causing vomiting after feeds; Olive-shaped Hypokalemia + thickness ≥4mm = (dilated stomach); (DNS+KCl) Step 2: Ramstedt's
after birth obstruction. NOT mass (RUQ); Visible peristalsis Hypochloremia + diagnostic) Barium: Mushroom sign Pyloromyotomy (cut
congenital — misnomer (L→R); best felt during feeding Metabolic Alkalosis with adventitia→muscularis, DO NOT cut
Paradoxical Aciduria mucosa) DDx: Neonatal GERD —
non-projectile, resolves with growth
Peptic Ulcer Disease [Link] (MC), NSAIDs, Acid-induced ulcers Epigastric pain, nausea, vomiting Bleeding (MC: posterior UGI Endoscopy + antral Barium meal (if UGI Endoscopy Medical: PPI+LSM; [Link]+: Triple
Smoking [Link]: lives in Johnson's: I(distal lesser GU: food→pain; DU: D1 wall→GDA), biopsy for [Link] endoscopy unavailable) therapy Surgical — GU Type I,IV,V:
antrum, produces urease curve, normal acid), pain→food→relief Perforation (MC: anterior (RUT/CLO test — turns Ulcer resection only DU/Type II,III:
→hypergastrinemia, II(lesser+DU, high acid), D1 wall), GOO pink if positive) Acid lowering surgery HSV: Best
CagA & VacA toxins III(pyloric, high acid), tolerated (<0.2% mortality, <5% SE,
IV(proximal lesser, normal), 2-10% recurrence) TV+Antrectomy:
V(anywhere, NSAIDs) Lowest recurrence (1%), highest SE
(10-20%) Billroth I:
gastroduodenostomy; Billroth II: GJ
Upper GI Bleed MC cause: Bleeding PU Source: proximal to Hematemesis, melena, Rebleed, mortality Stabilize + UGI Forrest Classification UGI Endoscopy Forrest Ia/Ib (active): Dual
(posterior D1 wall, GDA) ligament of Treitz hemodynamic instability (Rockall score), need for Endoscopy on endoscopy (diagnostic + endotherapy (any 2 of: clip, adrenaline
Others: varices, Hematemesis, Melena surgery therapeutic) injection, APC) Can attempt TWICE; if
Mallory-Weiss, Dieulafoy (black tarry stools) fails → Angioembolization GDA or
Surgery Forrest II (stopped): Medical
management Forrest III (clean base):
Medical management Rockall:
rebleed+mortality;
Glasgow-Blatchford: no endo findings;
Forrest: PU specific
PU Perforation NSAIDs use; anterior wall MC: Anterior wall of D1 Sudden acute abdominal pain, Peritonitis, septicemia, X-ray chest+upper If X-ray negative: CECT CECT Abdomen (if DU: Graham's Omental Patch Repair
D1 (perforates) vs Anterior=perforate; NSAID history, Cardboard-like abscess abdomen abdomen (IOC for X-ray negative) Ileal (TB/Typhoid): Simple suture
posterior (bleeds) Posterior=bleed (GDA rigidity/generalized guarding (pneumoperitoneum — perforation) repair Gastric: Simple suture repair +
erosion) free air under diaphragm) Biopsy DO NOT do endoscopy in
acute abdomen
INTESTINAL DISORDERS (GI)
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Intestinal TB Secondary TB — MC site: Terminal ileum/IC Pain + non-bloody diarrhea, Stricture → obstruction, If stable: Stool exam → If acute: X-ray Colonoscopy + Biopsy ATT: 2 months HRZE → 4-6 months
swallowing sputum from junction Ulcerative type constitutional symptoms Barium: Perforation → peritonitis, Colonoscopy → Biopsy abdomen → CECT (GeneXpert/CBNAAT, HRE Surgery ONLY for complications
pulmonary TB (poor immunity): Sterlin sign (hurry), String sign Peritoneal TB → Cocoon abdomen caseating granulomas) (stricture/perforation repair) DDx
transverse/circumferential (stricture), pulled-up cecum, abdomen, Multiple anal Crohn's: non-caseating granulomas,
ulcers → stricture deformed IC junction fistulae creeping fat, cobblestone, ASCA+,
Hyperplastic type NOD2 mutation
(moderate): fibrosis →
mass Typhoid ulcers:
LONGITUDINAL (no
stricture)
Acute Appendicitis Young teens/20s; Obstructive appendicitis; Murphy's Triad: RIF pain (initially Appendicular Children: USG abdomen CECT abdomen Children: USG; Adults: Alvarado score ≥7/10 = likely
Obstruction of base by Retrocaecal ~70% (MC), periumbilical→migrates), lump/phlegmon, (diameter ≥6mm) Adults: (adults) CECT; Pregnancy: MRI appendicitis (MANTRELS) Acute:
hypertrophied Peyer's Pelvic 20-25% McBurney's Low-grade fever, Nausea/Vomiting perforation, peritonitis, CECT abdomen Laparoscopic appendectomy (TOC)
patch point: 2/3 from umbilicus to Blumberg, Rovsing, Psoas, pelvic abscess Lump/Phlegmon: Oschner-Sherren
ASIS Obturator signs Regimen (IV Abx, NPO) Tumor <1cm
at tip: appendectomy alone;
>2cm/base: right hemicolectomy MC
early complication: wound infection;
MC late: adhesive obstruction MC
nerve injured: iliohypogastric nerve
Sigmoid Diverticulosis Chronic constipation, False diverticula (mucosa Usually asymptomatic; Hemorrhage, Incidental: Colonoscopy Acute complications: CECT abdomen (acute Uncomplicated: No treatment
straining; Elderly only); Saw-tooth Diverticulitis: LIF pain, fever; diverticulitis, perforation or Barium enema CECT abdomen (NOT complications) Diverticulitis: IV Abx → elective
appearance on barium Hemorrhage: lower GI bleed (Hinchey classification) colonoscopy) sigmoidectomy Perforated:
enema Hinchey: 1a=phlegmon, Emergency sigmoidectomy
1b=abscess<4cm, Hartmann's procedure: rectal stump
2=pelvic/inter-loop sutured, descending colon as
abscess, 3=purulent colostomy
peritonitis, 4=fecal
peritonitis
Carcinoma Colon & Rectum Smoking, alcohol, Adenocarcinoma; MC site: Elderly male smoker rule; Blood in Obstruction, perforation, Stool examination (1st Colonoscopy + Biopsy Colon: CECT Early: Surgery→adjuvant chemo
low-fiber diet, red meat, Rectosigmoid stools by age: elderly→CRC, fistula, metastasis step) abdomen; Rectum: MRI Advanced colon: Neoadjuvant
gut microbiome change (38%+21%=~60%) Right: young→UC, child→polyp/Meckel's rectum; Mets: PET chemo→Surgery CA Rectum ONLY:
Premalignant: polypoid/cauliflower, blood Rectal: bleeding PR, tenesmus, scan; Marker: CEA Neoadjuvant
Adenomatous polyps PR Left: early morning spurious diarrhea CHEMORADIATION→Surgery
(Vogelstein), Ulcerative apple-core/infiltrating, High/proximal: Anterior resection; Low
colitis (higher risk than change in bowel habits (<2cm levator): APR+permanent
Crohn's) Hematogenous: MC site = colostomy; T1 early: taTME Nerve:
LIVER (50%) IMA ligation→L3-L4→retrograde
ejaculation; Lateral
dissection→S2-S4→impotence
Chemo: FOLFIRINOX
Intussusception Children: hypertrophied Telescoping of bowel into Age 6mo-1yr (weaning); Ischemia, perforation, USG abdomen Barium enema (claw USG abdomen Stable: High-pressure air/barium
Peyer's patches (lead adjacent bowel Children: Intermittent crying+drawing up legs; peritonitis (donut/target sign) sign) enema (hydro-reduction)
point); Adults: tumors ileocolic (MC); Adults: Red currant jelly stools (classic); Unstable/ischemia/failed: Surgery
colocolic (MC) Para-umbilical sausage-shaped (manual reduction if viable;
mass; Sign of Dance (empty RIF) resection+anastomosis if not)
Sigmoid Volvulus Elderly, chronic Anti-clockwise twist → Sudden massive abdominal Ischemia, perforation, X-ray abdomen (coffee CECT abdomen CECT abdomen No ischemia: Colonoscopic
constipation; Redundant closed loop obstruction → distension + obstipation (no peritonitis, septicemia bean sign / bent inner (assess ischemia) decompression → elective
sigmoid colon rapid dilatation+ischemia → flatus/feces) tube sign) sigmoidectomy 2-3 days later
TRUE SURGICAL Ischemia/failed: Emergency
EMERGENCY sigmoidectomy → anastomosis or
Hartmann's
 DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Rectal Prolapse Chronic constipation, Full-thickness protrusion of Rectal mass protruding from anus Strangulation, ulceration, Clinical examination Defecography if Clinical diagnosis Elderly/unfit (TAD mnemonic —
straining, elderly/weak rectum through anal verge bleeding needed perineal, higher recurrence): Thiersch:
pelvic floor, obstetric Children: partial (mucosal) anal wiring (outdated) Altemeier:
trauma — self-limiting; Adults: perineal resection+anastomosis
full-thickness → surgery (strangulated) Delorme: plication
Young/fit (abdominal, lower
recurrence): Wells/Ripstein: open
mesh rectopexy TOC: Laparoscopic
ventral mesh rectopexy (Ripstein =
ABDOMINAL, NOT perineal)
HEPATOPANCREATICOBILIARY (HPB) DISORDERS
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Hydatid Cyst of Liver Echinococcus granulosus MC site: Liver (2nd: Lungs Hepatomegaly; usually Rupture, anaphylaxis, LFT (normal) + USG CT (honeycombing/mul USG abdomen (Gharbi Inactive/calcified: Surveillance only
(Dog tapeworm); via portal vein); Usually asymptomatic; may rupture → secondary infection, abdomen (floating tiseptated) classification) Active/symptomatic: Step1:
Definitive host: Dog; asymptomatic; Gharbi anaphylaxis cysto-biliary membrane = water lily FNAC/Biopsy Albendazole ×3wks → Step2 (TOC):
Intermediate: Sheep; classification (USG activity) communication sign) CONTRAINDICATED PAIR procedure
Man: accidental (Puncture-Aspirate-Inject
scolicidal-Reaspirate) PAIR
contraindicated: deep/inaccessible,
multiseptated, cysto-biliary
communication → Surgery:
Pericystectomy
Pyogenic Liver Abscess Ascending cholangitis Usually multiple abscess High-grade fever, RUQ pain, tender Septicemia, rupture, LFT + USG abdomen CT abdomen (confirm, Image-guided Antibiotics + Drainage
(MC pathway), portal cavities; true pus hepatomegaly; Acute presentation pleural effusion guide drainage) aspiration (aspiration/pigtail catheter/surgical)
pyemia, biliary disease (USG/CT-guided) Drainage is ALWAYS needed (unlike
Organisms: [Link], amebic)
Klebsiella
Amebic Liver Abscess Entamoeba histolytica; Usually solitary; liquefactive Subacute, mild symptoms, RUQ Rupture into LFT + USG abdomen CT abdomen USG abdomen + TOC: Medical — High-dose
Feco-oral → gut → portal necrosis → anchovy sauce pain; organism produces histiolysin pleural/peritoneal cavity, serology Metronidazole + Luminal agent
vein → liver pus; sterile (organism at secondary infection (Diloxanide furoate) 10-14 days
border) Drainage indications: non-responsive,
size >5cm, subcapsular, left lobe
abscess
Gallstone Disease MC worldwide: Stone in GB Murphy's sign (cholecystitis); Cholecystitis, cholangitis, LFT + USG abdomen If LFT deranged/dilated USG abdomen (IOC for ERCP: therapeutic (remove CBD
Cholesterol/Mixed (Fat, (asymptomatic) → Cystic Charcot's triad (cholangitis: pancreatitis, gallstone CBD: MRCP gallstones/acute stone); NOT diagnostic MC
Fertile, Female, Forty) duct (biliary jaundice+pain+fever); Reynold's ileus (Rigler's triad: SBO (diagnostic) cholecystitis) complication of ERCP: Pancreatitis
MC in Asia: Pigment colic/cholecystitis) → CBD pentad +pneumobilia+radio-opac (1-3%) Cholecystectomy indications
stones (Black=hemolytic; (obstructive jaundice) → (+hypotension+encephalopathy = ity RIF), Mirizzi syndrome (asymptomatic): stone>3cm,
Brown=biliary infections) Cholangitis → Ampulla severe cholangitis) stone+GB polyp, stone+hemolytic
70-80% asymptomatic (biliary pancreatitis) → disorder, porcelain GB Critical View of
Duodenum (gallstone ileus) Safety (CVS): only cystic duct+cystic
artery seen entering GB before
clipping
Acute Pancreatitis MC: Biliary (gallstones) > Largely reversible Acute epigastric pain radiating to Pseudocyst (>4wks), Serum Lipase (preferred CECT abdomen (done CECT abdomen; CT Conservative: NPO, IV fluids,
Alcohol; Other: trauma, inflammation; Modified back, nausea, vomiting, low-grade Walled-off necrosis — more ≥72hrs from onset to Severity Index ≥7/10 = analgesia, treat cause Biliary
drugs, ERCP, Atlanta Classification: Mild fever Cullen's sign (periumbilical (WON>4wks), Infected specific+sensitive than detect necrosis) severe Other scores: pancreatitis: Cholecystectomy same
hypercalcemia, (no complications), bruising), Grey Turner's sign (flank necrosis, ARDS, amylase) Ranson/Glasgow admission Infected necrosis:
hypertriglyceridemia Moderate (local bruising) — hemorrhagic multiorgan failure (≥3=severe), APACHE Necrosectomy (high mortality)
complications/transient pancreatitis II (>8=severe), BISAP Amylase/lipase levels do NOT
OF<48h), Severe correlate with severity BISAP: done
(persistent OF>48h) MC anytime; Ranson: needs 48hrs
fluid collection site: Lesser
sac
Chronic Pancreatitis MC: Alcohol (unlike acute Irreversible pancreatic Triad: Chronic epigastric pain Pancreatic pseudocyst, Serum lipase/amylase + MRCP (ductal MRCP / CT abdomen Conservative: opioids, celiac plexus
where biliary is MC) inflammation with fibrosis (radiating to back), Steatorrhea diabetes, malnutrition, CT abdomen anatomy, strictures) block, enzyme supplements, insulin
TIGAR-O: Toxic, (exocrine insufficiency), Pancreatic pancreatic duct stricture, (calcifications) Surgery (pain relief only, NOT
Idiopathic, Genetic, diabetes Type 3C (endocrine pseudoaneurysm curative): Beger: head coring (focal
Autoimmune, Recurrent insufficiency) head disease) Puestow: longitudinal
acute, Obstructive PJ drainage (dilated duct+strictures)
Frey: combined Beger+Puestow Ideal
treatment: pancreatic transplant (rare)
CA Pancreas (Exocrine) Smoking, alcohol, chronic Adenocarcinoma (MC Painless obstructive jaundice (if Biliary obstruction, LFT + USG abdomen CECT abdomen (IOC); CECT abdomen Whipple's procedure
pancreatitis, DM, obesity; pancreatic tumor); worst head), weight loss, back pain duodenal obstruction, CA 19-9 (tumor marker) (pancreaticoduodenectomy): Resect:
MC site: Head prognosis Double duct sign: Diabetes (new onset), steatorrhea distant metastasis head of pancreas+entire
(periampullary) dilated CBD+PD on CT duodenum+proximal
Courvoisier's law: painless jejunum+GB+distal CBD+LN 3
jaundice+palpable GB = Anastomoses: PJ+HJ+GJ MC
periampullary CA complication: wound infection,
gastroparesis Most dangerous: PJ
leak Metastatic: palliation
 DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Portal Hypertension + MC adults: Cirrhosis; MC Portal venous pressure Hematemesis, ascites, Variceal bleed, hepatic Stabilize + IV UGI Endoscopy → UGI Endoscopy Emergency stepwise: 1: Stabilize+IV
Variceal Bleed children: Portal vein >10mmHg → collaterals splenomegaly, hepatic encephalopathy, SBP, Terlipressin/Octreotide Band ligation Terlipressin/Octreotide 2: UGI
thrombosis (EHPVO) (varices, caput medusae) encephalopathy hepatorenal syndrome (preferred) or Endoscopy→Band
Classical triad: Sclerotherapy ligation/Sclerotherapy 3 (no
Ascites+Varices (hematem endoscopy): Balloon tamponade (SB
esis)+Splenomegaly tube=3 lumens; Minnesota=4 lumens)
4: TIPS (early complication:
encephalopathy; late: stent blockage
~50%/yr) Propranolol =
PROPHYLAXIS only (NOT
emergency)
UROLOGY
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Renal Cell Carcinoma Elderly Smoker Males Adenocarcinoma Gross hematuria in elderly male, IVC thrombus, distant Urine + USG abdomen CECT abdomen CECT Abdomen (triple T1A (≤4cm): Partial/nephron-sparing
(ESM) Clear cell (MC): (Hypernephroma/Grawitz renal mass Paraneoplastic: metastasis, (biopsy NOT phase) nephrectomy T1B (4-7cm): Partial (if
Von Hippel-Lindau if tumor) Hematogenous elevated ESR (MC), polycythemia, paraneoplastic mandatory) feasible) or Radical T2 (>7cm):
bilateral Papillary: dialysis spread: Lungs (cannonball Stauffer syndrome (hepatic syndromes Radical nephrectomy T3A-C (renal
patients; Medullary: sickle mets) Direct: IVC dysfunction — NOT mets) vein/IVC): Radical+IVC embolectomy
cell trait embolization (removable (CURABLE!) T4 (breached Gerota's
surgically!) Lymphatic: fascia): Palliation RCC is CHEMO and
para-aortic nodes RADIO RESISTANT — surgery only
BEP / BPH Arises from Periurethral Benign enlargement of Elderly male with BOO symptoms; Hydronephrosis, urinary PR exam + serum PSA Uroflowmetry (flow rate USG Prostate Medical (1st line): Alpha-1A blockers
Transitional Zone → early prostate causing bladder Enlarged prostate on PR exam retention, recurrent UTI, (normal) <10cc/sec = severe (Tamsulosin): quick relief 5-Alpha
urethral compression → outlet obstruction Voiding: bladder stones BOO); post-void reductase inhibitors
early BOO symptoms PISS (Precipitancy, residual (Finasteride/Dutasteride): late onset
Intermittency, Strain, Surgical TOC: TURP Limit:
Stream weakness) Storage: Verumontanum (avoid external
FUNN (Frequency, sphincter) Time: 60-90 min (prevent
Urgency, Nocturia, TUR syndrome) Irrigating fluid:
Nocturnal enuresis) Glycine MC complication: retrograde
ejaculation (internal sphincter injury)
Very large BPH: HoLEP
CA Prostate Arises from Peripheral Adenocarcinoma; Spread: Usually incidental; metastatic Skeletal metastasis, PR exam + PSA MRI pelvis (local Transrectal USG + T1-T2: Radical prostatectomy
Zone → late urethral Direct→Rectum; symptoms (low backache from ureteric obstruction, (<3.5=normal; spread) Biopsy (minimum 12 (robotic)+chemo T3-T4: Androgen
compression → late BOO Lymph→Pelvic/Obturator; lumbar vertebrae mets) spinal cord compression 3.5-10=biopsy; cores) ablation (GnRH analogues:
MC malignancy in men Hematogenous→Lumbar >10=highly suggestive; Goserelin/Leuprolide + Antiandrogens:
>65 yrs Gleason score vertebrae via Batson's >35=metastatic) Flutamide/Bicalutamide) Active
≤6: not aggressive; >6: plexus (VENOUS route) surveillance:
aggressive Age>70+T1+Gleason≤6+PSA<10
(6-monthly PR+PSA)
Urinary Bladder Cancer Occupational: Dye Transitional Cell Carcinoma Gross hematuria (painless) Obstruction, fistula, Urine routine + USG KUB MRI pelvis (local), PET Cystoscopy + Biopsy pTa/T1 (NMIBC): TURBT +
factories, textile, (Urothelial) Direct: metastasis scan (distant) intravesical chemo (BCG/Mitomycin)
petrochemical Chemical: Rectum(M)/Uterus(F); pT2/T3 (MIBC): Radical cystectomy +
Naphthylamine, Aniline Lymph: pelvic/obturator; Ileal conduit + chemo pT4:
dyes, Cyclophosphamide Hematogenous: Neoadjuvant chemo → Surgery
Elderly, Smoker, Males Lungs+Bones 3-lumen Foley for bladder
irrigation+clot removal
Carcinoma Testis MC type: Seminoma; Age Painless testicular mass ± Painless testicular mass; ± Metastasis (stage 2=LN, USG testis + Tumor BIOPSY/FNAC USG testis; CT High Inguinal Orchidectomy
20s-30s Undescended epigastric lump (para-aortic epigastric mass from para-aortic LN stage 3=distant) markers (AFP=yolk sac, CONTRAINDICATED chest/abdomen/pelvis (diagnostic+therapeutic) Stage 1:
testis → increased risk of LN) Metastasis: mets βHCG=chorioCA, — spread to for staging Seminoma=RT or single chemo;
Seminoma para-aortic/abdominal LN LDH=general) scrotum→inguinal NSGCT=single chemo Stage 2+3:
(inguinal LN ONLY if nodes BEP chemo
scrotum involved) (Bleomycin+Etoposide+Platinum)
Seminoma: Radiosensitive; NSGCT:
NO RT Residual LN post-chemo:
RPLND NO Stage 4 — all stages
curable
BREAST
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Breast Cancer Estrogen-dependent MC type: Invasive Ductal Rapidly growing hard lump, bloody Lymphedema, arm Triple assessment: Age ≥40: Mammogram Triple assessment Early (T1-T2,N0-N1): Surgery (MRM
Menstrual: Early Carcinoma (NOS) MC site: nipple discharge (elderly) Dimpling swelling, Stewart-Treves Hx+Exam → Imaging → (BIRADS); Age<40: (99.9% accuracy) or BCT)→adjuvant
menarche(<12), late Upper Outer Quadrant (single Cooper's ligament), syndrome Tissue diagnosis (Core Sonomammogram; Mammogram (age≥40), chemo±RT±hormonal LABC
menopause(>55), Worst prognosis: Puckering (multiple), Nipple (lymphangiosarcoma biopsy preferred over BRCA+: MRI from Sonomammogram (T4,N2-N3): Neoadjuvant
nulliparity, 1st Inflammatory breast cancer retraction (lactiferous duct 10yrs later) FNAC) 25-30yrs (age<40), Core biopsy chemo→Surgery(MRM)→adjuvant
child>35yrs Other: HRT, (T4d) Metastasis: Axillary infiltration), Peau d'Orange RT+hormonal Metastatic (M1):
OCP, alcohol, obesity, LN → Internal mammary; (sub-dermal lymphatics — Palliation (simple/toilet mastectomy)
chest radiation Hematogenous→Lumbar AFFECTS T-STAGE) Only Peau MRM: entire breast+NAC+pectoral
BRCA1(AD): 50-85% vertebrae (Batson's) d'Orange affects T-stage fascia+axillary LN (levels I-II-III);
risk, Triple-negative; >Femur>Lungs>Brain preserves pec major+ribs
BRCA2(AD): 50-60% BCT=WLE(1cm
risk, more male breast margin)+SLNB+adjuvant RT
CA Breastfeeding >1yr: (compulsory); contraindications:
PROTECTIVE pregnancy, prior radiation, connective
tissue disease, multicentric tumor
Hormonal (ER/PR+): Tamoxifen or AIs
for 5-10 yrs MC complication MRM:
Seroma (30%); MC nerve:
Intercostobrachial
DCIS Chronic GERD, Barrett's In situ ductal; Unilateral, Often incidental finding Progression to invasive Mammogram Core biopsy (NOT Core biopsy WLE with 1cm margin ± adjuvant RT
esophagus solitary; Risk 8-10x↑; cancer (microcalcifications) FNAC) (if Van Nuys score ≥7) Van Nuys
Included in TNM staging (DCAS): Distance<1mm+Class(necro
Microcalcifications on sis)+Age<40+Size>4cm NO axillary
mammogram clearance, NO chemo (in situ — no
mets)
Fibroadenoma Young women 15-25 yrs Mixed tumor (benign); Mobile mass (Breast Mouse); soft Rare malignant USG (age<40) + Core biopsy if USG breast Observe (benign)
Staghorn arrangement on or firm transformation mammogram (age≥40) suspicious Excision/Enucleation if: >5cm (giant),
histology Popcorn cosmetic concern, symptomatic,
calcification on complex/suspicious
mammogram/USG
Phyllodes Tumor Elderly women Mixed tumor Huge mass, MOBILE, NOT FIXED; Local recurrence (high USG + core biopsy Core biopsy Core biopsy WLE (2cm margin) OR Simple
(epithelium+stroma); skin may stretch/tear but NO after simple excision); mastectomy NO MRM, NO axillary
Malignant if >10 abnormal ulceration rare distant mets clearance
mitosis/10HPF Cystic
spaces with leaf-like
arrangement on histology
NO lymph node metastasis
THYROID & ENDOCRINE
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Papillary Thyroid Cancer Neck radiation, MC thyroid cancer (85%); Thyroid mass, cervical Lymph node metastasis, FNAC (diagnostic for USG neck + RAI scan FNAC (IOC for Total thyroidectomy + Level VI central
(PTC) Thyroglossal duct cyst, FNAC is diagnostic lymphadenopathy recurrence, PTC) (post-op) diagnosis) compartment clearance If <1cm
Hashimoto thyroiditis Psammoma bodies + RAI-refractory disease (micropapillary): surveillance If <4cm:
Orphan Annie nuclei (clear hemithyroidectomy may be considered
nuclei) Metastasis: Lymph Post-op: RAI scan at 3-6wks; wait for
nodes (Level VI = TSH↑; if mets→RAI ablation Tumor
Delphian/pretracheal, MC) marker: Serum Thyroglobulin
Follicular Thyroid Cancer Long-standing MNG, 2nd MC thyroid cancer; Thyroid mass, possible bone mets Hematogenous mets to USG neck + FNAC (NOT Frozen section Intraoperative frozen Total thyroidectomy (NO level VI
(FTC) endemic goitre (iodine FNAC NOT diagnostic symptoms bone (skull, thoracic diagnostic) intraoperatively section clearance — doesn't metastasize to
deficiency) Frozen section needed vertebrae) (capsular/vascular level VI) Post-op: RAI scan+ablation if
(capsular+vascular invasion) mets Tumor marker: Serum
invasion) Least likelihood of Thyroglobulin
LN mets; Hematogenous
spread (skull, thoracic
vertebrae)
Medullary Thyroid Cancer Arises from C cells Amyloid stroma on Thyroid mass, diarrhea (calcitonin Lymph node mets, distant Serum Calcitonin + CEA USG neck; screen for Serum Calcitonin + Total thyroidectomy + Level VI
(MTC) (parafollicular); Usually histology; Both effect), MEN features if syndromic mets, MEN syndrome pheochromocytoma genetic testing (RET clearance ± modified radical neck
sporadic; MEN 2A, 2B hematogenous AND lymph complications (RET mutation carriers) mutation) dissection MEN 2A: prophylactic
RET gene mutation node mets Marker: Serum thyroidectomy at 5yrs MEN 2B:
Calcitonin + CEA prophylactic thyroidectomy at 1yr
(infancy)
Graves Disease Autoimmune; TSH Diffuse goitre with Hyperthyroidism symptoms: heat Thyroid storm (MC TFTs (TSH↓, FT3↑, RAI scan (diffuse hot TFTs + RAI scan Anti-thyroid drugs:
receptor antibodies hyperthyroidism; RAI scan: intolerance, weight loss, cause: inadequate preop FT4↑) uptake) Methimazole/Carbimazole/PTU +
(stimulating); Young diffuse hot uptake palpitations, tremors, prep) Beta-blockers Preop: Lugol's iodine
females exophthalmos, pretibial myxedema (Wolf-Chaikoff effect: reduces
(triad of Graves) vascularity and thyroid function) RAI
ablation (I-131) if not medically
controlled Surgery: Total
thyroidectomy (after achieving
euthyroid state)
TRAUMA
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Tension Pneumothorax Penetrating chest trauma, One-way air entry → Triad: Hypotension + Raised JVP + Cardiac arrest if CLINICAL DIAGNOSIS Chest X-ray or eFAST Clinical (primary survey 1st step: Needle
mechanical ventilation, progressive pneumothorax Hyperresonance + Tracheal untreated (do NOT wait for X-ray) to confirm B) decompression/thoracocentesis in
barotrauma → mediastinal shift → SVC deviation to OPPOSITE side Triangle of Safety (5th ICS, 14G/16G
compression → Reduced air entry (affected side) needle) Definitive: Intercostal Drain
OBSTRUCTIVE shock (ICD) ICD inserted along UPPER
border of rib (avoid intercostal vessels
on lower border)
Cardiac Tamponade Penetrating chest trauma Blood in pericardium (even Beck's Triad: Muffled heart sounds Cardiac arrest eFAST (1st probe = Needle eFAST (primary survey Penetrating trauma → Thoracotomy +
(stab/GSW), blunt 50cc) → reduced diastolic + Hypotension + Raised JVP subxiphoid for pericardial pericardiocentesis B) Repair (preferred, Bailey)
trauma, pericarditis filling → OBSTRUCTIVE Normal air entry, normal percussion fluid) (USG-guided) OR Non-traumatic/unstable/mechanism
shock Beck's Triad: Muffled Thoracotomy not specified → Needle
heart sounds + pericardiocentesis
Hypotension + Raised JVP
Epidural Hematoma (EDH) Moderate intensity Arterial bleed (MMA); Lucid interval (hallmark) First Brain herniation, death if Clinical (primary survey D CT head CT Head (biconvex TRUE NEUROSURGICAL
trauma; Pterion fracture Biconvex unconscious → fine → unconscious untreated — GCS + pupils) (NON-CONTRAST) hyperdense lesion) EMERGENCY — Golden hour
→ Middle Meningeal (lenticular/idli-shaped), again Raised ICP symptoms concept Emergency Burr hole /
Artery injury WHITE (hyperdense) on Craniotomy 5% Dextrose AVOIDED in
CT LUCID INTERVAL head injury (hypotonic → worsens
(hallmark): unconscious→fi cerebral edema)
ne→unconscious
Subdural Hematoma (SDH) Acute: Severe trauma Venous bleed (bridging Acute: Raised ICP, no lucid interval Brain herniation, chronic Clinical + CT head CT head CT Head Decompression (clot evacuation)
(cortical bridging veins) veins); Concavo-convex Chronic: 1-2 wk history, headache, disability (banana-shaped lesion) Chronic SDH = Elderly+trivial
Chronic: Trivial trauma in (banana-shaped) Acute: imbalance, cognitive decline trauma+1-3wk history+hypodense
elderly/anticoagulants WHITE (hyperdense); crescent on CT
Chronic: BLACK
(hypodense) on CT
Blunt Abdominal Trauma RTA (MC), fall from AAST Grading Abdominal pain, signs of Hemorrhagic shock, eFAST (unstable patient CECT abdomen (stable CECT abdomen Unstable+eFAST positive: Exploratory
height, sports MC organ: (Spleen/Liver/Kidney): peritonism, hemodynamic instability peritonitis, solid organ — ONLY investigation in patient — AAST (stable); eFAST laparotomy Stable: CECT → AAST
Blunt=Spleen; Grade 1-3=mild-moderate; Spleen: Kehr's sign, L lower rib injury unstable) grading) (unstable) grading Grade 1-3+stable:
Penetrating=Liver; Seat Grade 4-5=severe Spleen: fractures; Liver: R rib fractures Conservative (observe) Grade 4-5:
belt=Mesentery small Kehr's sign (L shoulder pain Intervention (embolization or surgery)
bowel referred), Ballance sign Grade 3+contrast leak: Intervention
Kidney: hematuria hallmark Pringle maneuver: clamp
hepatoduodenal ligament (hepatic
artery+portal vein) → temp 15-30min
ANAL DISORDERS
DISEASE RISK FACTORS PATHOLOGY CLINICAL FEATURES COMPLICATIONS 1st INVESTIGATION NEXT STEP INV. IOC CLASSIFICATION / TREATMENT
Fistula in Ano Secondary to perianal Abnormal tract connecting H/o perianal abscess → perianal Recurrence, incontinence Clinical examination; MRI perineum (IOC) MRI Perineum Low fistula (Type 1,2): Fistulectomy
abscess (MC etiology) anal canal to perianal skin discharge ± pain; External opening (if sphincter damaged) Goodsall's Rule (predicts OR Fistulotomy Newer: LIFT, VAAFT,
Park's Classification: Type visible tract anatomy) FiLaC High/complex fistula:
1 (Intersphincteric, MC), Seton/Kshar-Sutra (sphincter-saving;
Type 2 (Transsphincteric, higher recurrence)
2nd MC), Type 3
(Suprasphincteric, Rare),
Type 4 (Extrasphincteric,
Least common) Types
1&2=LOW; Types
3&4=HIGH
Hemorrhoids Constipation, straining, Dilated superior Painless bleeding (splash in pan); Prolapse, thrombosis, DRE + Proctoscopy Proctoscopy Proctoscopy Grade 1 (asymptomatic): Conservative
low-fiber diet, pregnancy hemorrhoidal veins (above proctoscopy: hemorrhoids at 3,7,11 strangulation; MC Grade 1 (bleeding)/Grade 2: Barron's
dentate line) Grade 1: o'clock positions Do DRE first — if post-op: hemorrhage, band ligation OR Sclerotherapy Grade
inside anus; Grade 2: anal spasm → proctoscopy urinary retention 3: Stapled hemorrhoidopexy OR
exit+return spontaneously; CONTRAINDICATED Milligan-Morgan Grade 4: Stapled
Grade 3: exit, manually hemorrhoidopexy OR Milligan-Morgan
reducible; Grade 4: open hemorrhoidectomy
permanently outside,
irreducible
Fissure in Ano Constipation, trauma Tear/ulcer at anal verge Severe pain during defecation Chronicity, abscess Clinical examination (anal Proctoscopy under GA Clinical diagnosis Conservative: laxatives, lignocaine
during defecation (BELOW dentate line) Most (worst pain); streaky blood in formation spasm → proctoscopy if examination gel, sitz bath Surgery: Lateral Internal
painful condition; Blood in stools; anal spasm contraindicated) inadequate Sphincterotomy (of Notaras) — cut
stools: streaking pattern internal sphincter to relieve spasm
Sentinel pile: skin tag
covering ulcer (misnomer)