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Stem Patient with known peptic ulcer disease, presented with hematemesis, OGD done showed bleeding gastric ulcer. Labs showed hypercalcemia. PMH: osteoarthritis on NSAID, smoker, CKD on dialysis. Define an ulcer? SpoilerAn ulcer is a local defect of the mucous membrane or the skin due to gradual disintegration of the surface epithelial cells OR Breach of the continuity of skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue. Risk factors of PUD? SpoilerH-pylori infection NSAIDs Smoking How can NSAIDs causes PUD? SpoilerTopical irritant effect on the epithelium Impairment of the barrier properties of the mucosa Suppression of gastric PG synthesis (inhibitors of cyclooxygenase) Reduction of gastric mucosal blood flow Interference with the repair of superficial injury What is H. pylori? SpoilerGram negative microaerophilic spiral bacteria found in the stomach After taking a gastric biopsy during endoscopy, what test can be done to the biopsy to confirm H. Pylori infection? SpoilerCLO test (campylobacter like organism) Describe how it's done? SpoilerIt depends on urease production by H. pylori A gastric mucosal biopsy is taken during gastroscopy and is placed in a medium containing urea and an indicator such as phenol red, SpoilerUrease production by H-pylori converts urea to ammonia which increase pH changing the colour (yellow to red) → positive test How does H. Pylori manage to survive in the gastric acidic medium? SpoilerBy production of urease which converts urea to ammonia which increase pH. Other test of Pylori? SpoilerUrease breath test Test for the stool antigen How can H. Pylori colonize the stomach? SpoilerFlagella, which allow the bacteria to be motile in viscous mucus Urease, which generates ammonia from endogenous urea, thereby elevating local gastric pH around the organisms and protecting the bacteria from the acidic pH of the stomach Adhesins, which enhance bacterial adherence to surface foveolar cells Toxins, such as that encoded by cytotoxin-associated gene A (CagA), that may be involved in ulcer or cancer development by poorly defined mechanisms Q: How does h pylori induce gastritis? SpoilerBy production of: Ammonia (from urea). Proteases Phospholipases → damage gastric mucosa and cause inflammation What's the type of cells in the gastric antral mucosa? SpoilerSimple columnar with goblet cells What are the types of gastric cancer caused H. Pylori infection? SpoilerAdenocarcinoma MALT (Mucosal associated lymphoid tissue tumour) Which immune endocrine disease is associated with it? SpoilerHashimoto thyroiditis How to treat symptomatic H. Pylori infection? Spoiler7 days twice daily of Full dose of PPI + metronidazole 400 mg + clarithromycin 250mg or Full dose of PPI + amoxicillin 1g + clarithromycin 500mg What's the mechanism of action of proton pump inhibitors? SpoilerPPI binds irreversibly to H⁺/K⁺ ATPase enzyme (proton pump) on gastric parietal cells and blocks secretion of H⁺, which combine with Cl⁻ in the stomach lumen to form HCL. What are the actions of gastric HCL? SpoilerActivate pepsinogen to pepsin (which help in proteolysis) Provide optimal PH for action of pepsin Stimulating small intestine to release secretin and CCK. Enhance absorption of Ca and Iron in small intestine. Antimicrobial What are the other possible causes of hematemesis in this patient? SpoilerHypercalcemia → increased gastrin release → increased HCl production → Mucosal erosion → bleeding What are the common causes of hypercalcemia? SpoilerMalignancy Hyperparathyroidism (PTH adenoma) Renal failure The patient had a history of recurrent renal stones, what's the possible cause? SpoilerHypercalcemia What's the commonest cause of primary hyperparathyroidism? SpoilerSolitary parathyroid adenoma What's the meaning of adenoma? SpoilerBenign epithelial neoplasm that takes glandular pattern or non-epithelial from glandular origin. How can the parathyroid glands be localized? SpoilerSestamibi scan (pre-operative) Frozen section (intra-operative) Where can they be found if not in their normal location? SpoilerIn superior mediastinum as it shares same embryological origin with the thymus (3rd pharyngeal pouch) What's frozen section and it is performed in simple words? SpoilerIt's a pathological laboratory procedure to perform rapid microscopic analysis of a specimen. Can you explain more the steps? SpoilerThe surgeon takes a small piece from a tissue or tumour and send it for analysis The pathologist freezes it and section it and immediately cut it The section will be stained and reported immediately when the results come out Why paraffin based histopathology is not convenient for intraoperative pathological testing? SpoilerAs it takes a week for paraffin to embed through the tissues What's the treatment of parathyroid adenoma? SpoilerExcision The patient underwent excision of the 4 parathyroid glands. You were given the following pathology report: 1 gland 0.2 g chief cells. The other 3 glands ranging from 0.08 to 0.09 g composed of oxyphilic and fat cells. What's your interpretation? SpoilerParathyroid adenoma in one gland with involution to the other glands What's the histological features of parathyroid adenoma? SpoilerMainly chief cells and few oxyphil cells and surrounded by non-neoplastic thyroid tissue separated by a fibrous capsule. How does this compare to parathyroid hyperplasia? SpoilerParathyroid hyperplasia composed primarily of chief cell hyperplasia and with water-clear cells. What are the types of hyperparathyroidism? And the treatment of each? SpoilerPrimary hyperparathyroidism (solitary adenoma) → treated by excision. Secondary hyperparathyroidism (chronic renal failure) → treated with dialysis. Tertiary hyperparathyroidism (after renal transplant) → treated firstly by conservative management, but if more than 12 months go for surgery. How to treat acute hypercalcemia? SpoilerHydration Forced diuresis Bisphosphonates: IV pamidronate Calcitonin

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Parasagittal meningioma Tumour: Parasagittal meningioma Typical presentation Gradually progressive contralateral lower limb weakness Focal seizures in the leg UMN signs Why Compression of the Paracentral lobule (leg area of the Primary motor cortex). Exam clue Progressive leg weakness + seizures → parasagittal meningioma. Acoustic neuroma (vestibular schwannoma) Tumour: Vestibular schwannoma Typical presentation Unilateral hearing loss Tinnitus Balance problems Later: Facial numbness Facial weakness Why Compression of: Vestibulocochlear nerve (CN VIII) Facial nerve (CN VII) Exam clue Progressive unilateral deafness. Pituitary adenoma Tumour: Pituitary adenoma Typical presentation Bitemporal hemianopia Why Compression of the Optic chiasm. Other clues: Hormonal symptoms (galactorrhoea, acromegaly, Cushing's). Exam clue Loss of temporal visual fields. Cerebellopontine angle tumour Often a Vestibular schwannoma. Symptoms Hearing loss Facial numbness Ataxia Structures involved: Trigeminal nerve Facial nerve Vestibulocochlear nerve Exam clue Multiple cranial nerve deficits in the cerebellopontine angle. Frontal lobe tumour Commonly a Glioma. Typical presentation Personality change Disinhibition Poor judgement Sometimes urinary incontinence Structure affected: Frontal lobe Exam clue Behavioural change before neurological deficit. ✅ Very high-yield MRCS pattern Symptom Likely tumour Leg weakness Parasagittal meningioma Unilateral deafness Vestibular schwannoma Bitemporal hemianopia Pituitary adenoma Behaviour change Frontal lobe tumour Multiple cranial nerve palsies CPA tumour

You are the SHO in the orthopaedic department. A 35-year-old man, Mr. James Carter, sustained a knee injury following a sports accident three months ago and was diagnosed with a post-traumatic meniscal tear. He was listed for an arthroscopic meniscectomy, but his operation has been cancelled twice before due to emergency cases. Unfortunately, his surgery has been postponed again today for the same reason. Your task is to update Mr Carter and address his concerns.

You are a core surgical trainee in the outpatient clinic. A 52-year-old man is referred by his GP with recurrent upper abdominal pain and weight loss. He has a background of heavy alcohol use. Site of pain (epigastric, radiating to back) Onset and duration (acute vs chronic, recurrent episodes) Character of pain (deep, boring, constant) Radiation (especially straight through to the back) Severity and impact on daily activities Timing and relation to meals (worse after eating) Relieving/exacerbating factors (leaning forward, alcohol, food) Associated nausea and vomiting Weight loss and anorexia Steatorrhoea (pale, greasy, foul-smelling stools) Symptoms of diabetes mellitus (polyuria, polydipsia) History of alcohol intake (quantity, duration) Previous episodes of acute pancreatitis Gallstone history or biliary symptoms (jaundice, colic) Drug history (e.g. steroids, azathioprine) Family history of pancreatic disease or malignancy

MRCS B Prostate Gland Stem: A 68-year-old man presents to his GP with a 6-month history of increasing urinary frequency, nocturia, and a weak urinary stream with hesitancy. He denies any haematuria or weight loss. On examination, his abdomen is soft and non-tender, with no palpable bladder. What are the superior and inferior relations of the prostate gland? SpoilerSuperior – neck of the bladder Inferior – external urethral sphincter Describe the zonal anatomy of the prostate. Which zone is most commonly affected by carcinoma, and which by benign hyperplasia? SpoilerPeripheral zone – largest zone, most common site of prostate carcinoma, palpable on DRE Transition zone – surrounds the urethra, most common site of benign prostatic hyperplasia Central zone – surrounds the ejaculatory ducts What is the arterial supply to the prostate? SpoilerInferior vesical artery, from the anterior division of the internal iliac artery. What is the venous drainage of the prostate and how is it implicated in prostatic malignancy? SpoilerProstatic venous plexus Has a connection with the valveless vertebral veins, which may be a passage of spread of malignancy. Prostate symptoms can be classified as storage or voiding symptoms, give two examples of each. Storage SpoilerFrequency Nocturia Urgency Incontinence Voiding SpoilerTerminal dribbling Slow stream Slow to start voiding What is an important part of the examination of a male patient with storage or voiding symptoms? How may we distinguish between benign or malignant pathology? SpoilerDigital rectal examination. May feel a smooth enlargement suggestive of benign disease, or a craggy, hard mass, which would suggest malignant disease. What tumour marker is used to help diagnose and monitor prostate cancer, and what are its limitations? SpoilerProstate-specific antigen (PSA) Not specific to malignancy – can also be raised in BPH, prostatitis, and after instrumentation (e.g. catheterisation, DRE) Lacks sensitivity and specificity, so used alongside DRE and biopsy rather than as a standalone diagnostic test Give two options for the pharmacological management of benign prostatic hyperplasia. Spoiler5-alpha reductase inhibitors – e.g. Finasteride. Anticholinergic agents – e.g. Tolterodine Alpha blockers can also be used. Give two risk factors for prostate cancer. SpoilerEthnicity – more common in people of black ethnicity. Age – people aged over 50 are much more likely to have prostate malignancy.

@florianecaffart @Photosaurus hi hi merci !

Vagus nerve course in thorax & abdomen? Thorax: Left vagus nerve SpoilerCrosses in front of the left subclavian artery. Enters the thorax between the left common carotid and subclavian arteries. Descends on the left side of the aortic arch. Travels behind the phrenic nerve. Courses behind the root of the left lung. Deviates medially and downwards to reach the esophagus and form the esophageal plexus with the right vagus nerve. Right vagus nerve SpoilerCrosses in front of the first part of the subclavian artery. Travels behind the innominate vessels. Reaches the thorax on the right side of the trachea. Inclines behind the hilum of the right lung. Courses medially towards the esophagus to form the esophageal plexus with the left vagus nerve. Abdomen: SpoilerThe oesophageal plexus, formed by the union of the right and left vagus nerves, The vagus nerve enters the abdomen through the oesophageal hiatus at the level of the tenth thoracic vertebra (T10). It divides into the anterior and posterior vagal trunks, which innervate the stomach, small intestine, liver, gallbladder, pancreas, and spleen. Nerves in oesophageal hiatus? SpoilerAnt & post vagal trunks. What do they supply? SpoilerStomach, duodenum, jejunum, ileum, cecum, ascending colon, medial 2/3 of transverse colon, spleen, pancreas, gall bladder Muscle dissected to see thyroid? SpoilerSternohyoid muscle