Recovery after laparascopic surgery

Pain: Abdominal cramps and bloating, and shoulder tip pain, are common in the first 24 hours. Worsening pain after this period can be a sign of complications.

Other symptoms of complications: Loss of appetite for food or fluids, reluctance to mobilise, N&V, poor urine output.

Possible signs of complications: Pyrexia, tachycardia, abdominal tenderness or distension.

Time off work: There are no clear guidelines; play it by ear according to the person’s occupation, procedure, and recovery. As a rough rule of thumb, smaller procedures such as lap chol or appendicectomy typically only require a couple of weeks off. Larger procedures are likely to require more time off/more gradual return to work.

Return to driving: Requires the ability not just to do emergency stops, but to turn around enough to check blind spots and to react quickly. Might take one or two weeks for lap chol or appendicectomy and longer for groin surgery or more major procedures.

Heavy lifting: Not that much data. The advice is to avoid lifting anything heavier than a kettle/a shopping bag, and also to avoid pushing and pulling activities such as vacuuming, mowing the lawn, and hanging up heavy washing. One or two weeks should be enough for smaller procedures and four weeks for larger procedures.

Eating and drinking: Normally no restrictions, although a few procedures (gastric banding, anti-reflux surgery, surgery for oesophagogastric cancer) can require a liquid-only diet initially.

Recovery generally: Patients should expect to notice an almost daily increase in how much they can do without pain or discomfort.

Travel: Patients are advised not to fly for 24 hours after laparoscopy because of the possibility of expansion of carbon dioxide in the abdominal cavity. It’s considered sensible to use thromboembolic stockings if flying within the first month.

Swelling at the site: Might be due to haematoma, abscess, or seroma; important as seromas may be treatable conservatively, but abscesses and large haematomas are usually going to require surgical intervention.

  • Haematoma: Usually shows up within 24 – 48 hours of surgery. May be painful and there may be bruising present. Overlying skin temperature is normal.
  • Abscess: Typically 3 – 7 days after surgery. Likely to be very tender with hot, red overlying skin and sometimes visible purulent discharge.
  • Seroma: Usually show up over a week post-op and cause only slight discomfort. Skin colour and temperature are normal.

Note that superficial wound infections can probably be treated in general practice, but contact surgery if there is any concern about possible deeper infection.

Thromboprophylaxis: In cancer patients, and normally in patients who’ve had bariatric surgery for morbid obesity, this is continued for a month.

 

BMJ: Management of patients after laparoscopic procedures.

Advertisements
Posted in Credits 2018, Surgery | Leave a comment

Prophylaxis of recurrent UTI in women

Background: No official definition, but generally defined by most people as two or more episodes in six months or three or more per year. The only recommended prophylactic treatment currently is low-dose prophylactic antibiotics, which, based on one systematic review/meta-analysis, has a very good success rate with a NNT of 1.85 over a 6 – 12 month period (though unfortunately the studies on which this was based seem to have been of poor quality). The problem, of course, is our old bugbear of antibiotic resistance. This BMJ article discusses other methods.

Short version: Currently we don’t have much evidence to say that anything else works for prophylaxis. However, methenamine hippurate is looking promising, and topical vaginal oestrogens are probably helpful in post-menopausal women.

Methods discussed were:

Urinary alkalisation: No evidence as to whether or not it works because, in a recent review, none of 172 RCTs of the matter were good enough quality to include, which is a pretty scary comment on the state of our medical research today. Side-effects include nausea, flatulence, and mild diuresis. In practice, probably comes under the heading of ‘Might be worth a try’, but isn’t anything we can medically vouch for at this point.

Probiotics: Don’t seem to help, according to a recent Cochrane review, but again we have the problem of all the research being fairly poor quality, which means there may possibly be benefits that have been missed. Side-effects showed up in <5% of the women and included vaginal discharge, genital irritation, and diarrhoea. I’d file this as ‘Can’t hurt, but don’t expect too much’.

Chinese herbal medicine: Does seem to work according to a Cochrane review, but, again, problems with poor research; also, the existing research seems to have been in post-menopausal women and won’t necessarily apply to the pre-menopausal population. Not much work done on side-effects and, unfortunately, Chinese herbal medicine does have more potential for harm than the two above methods, so this is not one I’d recommend unless a lot more work gets done.

Methenamine hippurate: One trial of 30 people with recurrent UTI found this to be associated with a relative risk of UTI of 0.46, and several studies have found very low rates of adverse events; out of 2032 people in all studies in one Cochrane review, twelve had nausea, one had rash, one had diarrhoea, one had sore throat, and one had bladder ‘stinging’. Therefore, while there is not currently enough evidence to say this works, there is enough to be cautiously optimistic. Results of an ongoing multicentre RCT are awaited. Watch this space.

Cranberry juice: Seems, alas, to have been discredited; previous studies that showed benefits had a high dropout rate, and an updated Cochrane review did not see a statistically significant benefit. Another one bites the dust.

Oral immunostimulants: I’m not even sure what these are. Whatever they are, a meta-analysis of four RCTs found they helped, a further double-blind RCT found no effect, and the European Association of Urology supports their use, so overall it sounds as though they’re worth finding out about.

Topical vaginal oestrogen: In post-menopausal women, obviously. An analysis of two small RCTs did find a benefit, with a minority experiencing side-effects related to either hormonal (breast tenderness, vaginal bleeding, change in discharge) or local (vaginal irritation, burning or itching) effects.

Coming soon: Research papers on intravesical agents, vaccines, and D-mannose.

 

https://doi.org/10.1136/bmj.j5193

Posted in Credits 2018, Recurrent UTIs | Leave a comment

Migraine in pregnancy

The good news is that pre-existing migraine often gets better in pregnancy, especially migraine without aura and premenstrual migraine. However, it’s important to know a) how to treat it when it occurs and b) how to avoid confusing more dangerous causes of headache with migraine.

Treatment of pain

  • Paracetamol should be used first-line
  • Ibuprofen can be considered but has less safety data than paracetamol and should be avoided in the third trimester (risk of premature closure of the ductus arteriosus)
  • Opiates are considered safe in pregnancy, but can exacerbate nausea/reduce gastric mobility, so the article advises avoiding them, although frankly I think that may be too strong a piece of advice given that you may well end up without other safe options for treating someone in pain.

Treatment of nausea

The choice is better here. Cyclizine is first-line, but other acceptable choices include prochlorperazine, domperidone, ondansetron and metoclopramide (although avoid long-term use of the latter due to its extrapyramidal SEs).

Prophylactic treatment

  • Aspirin 75 mg od. Often helpful for migraine prevention in pregnancy (which makes me wonder whether it’s been tried as a prophylactic outside of pregnancy, since it would surely have a role there) and has been used safely up to 36 weeks gestation in a recent RCT.
  • Beta-blockers, such as propranolol 10 – 40 mg tds or the equivalent dose once daily. Studies did not find use in the first trimester to be associated with an increase in rate of congenital anomalies.
  • Low dose TCAs; e.g. amitriptyline 10 – 25 mg nocte.

 

Red flags

  • Sudden-onset headache reaching maximal intensity in <1 minute – could be a bleed
  • New onset severe headache or significant change in headache type.
  • Headaches progressively worsening over time
  • Features of meningitis
  • Features of RICP
  • Orthostatic headache (changes with posture)
  • New-onset focal neurological deficit
  • Visual disturbance or visual field defect
  • New-onset seizures or cognitive dysfunction
  • Impaired consciousness
  • Personality changes
  • Head or neck trauma in the past 3 months (and, unlike most of the others, this is one I wouldn’t have known to be a problem)
  • Unusual aura (e.g. >1 hr duration, associated motor weakness)
  • Symptoms of GCA
  • Symptoms of glaucoma
  • Raised BP/symptoms of pre-eclampsia

Also consider:

  • History of neurological conditions
  • History of pituitary problems
  • History of immunocompromise
  • History of malignancy
  • History of conditions associated with procoagulable state
  • FH of ICH

And, less urgently:

  • Medication that might contribute to the headache: e.g. CCBs.
  • Possible medication overuse headache.

BMJ 2018;360:k80

Posted in Credits 2018, Medication in pregnancy, Migraine, Pregnancy and Childbirth | Leave a comment

Peripheral arterial disease

Most patients are asymptomatic; however, note that this usually reflects more sedentary lifestyle rather than lesser severity, and asymptomatic patients with PAD are at just as much risk of complication. (Note that coexisting diabetic neuropathy also increases the chances of the leg being asymptomatic.)

 

Risk factors

  • Smoking probably causes about half of all cases.
  • Diabetes carries a similar risk level to smoking.
  • Increasing age increases prevalence.
  • Tends to show up in men at younger ages, but difference in prevalence levels is similar between men and women.
  • High cholesterol, hypertension, and CKD each increase risk by a factor of 1.5x.
  • Remember to check for AF as a risk factor for acute ischaemia.

 

Presentation

May be with claudication, acute limb-threatening ischaemia, or chronic limb-threatening ischaemia:

Claudication

Aching or burning in leg muscles, reliably reproduced at a set distance on walking, relieved within minutes on rest, not exacerbated by position, not present at rest. Pain is usually in the calf, but can be in the thigh if the iliac artery is affected.

Acute limb-threatening ischaemia

ALTI is thromboembolic in nature. Embolic ALTI is typically in a normal artery (most usually a result of AF) and comes on very suddenly; this is the one that presents with one or more of the 6 Ps, as per medical school teaching, and needs treatment within hours, including embolectomy. Cases caused by thrombus typically form in an artery with existing arteriosclerosis; they tend to be more gradual onset and (due to pre-existing collateral arterial formation) less severe than the embolic ones. Cases due to thrombus can often be medically managed.

Chronic limb-threatening ischaemia

Caused by narrowing of multiple arteries to the point where the foot becomes severely ischaemic. Presents with rest pain and/or tissue loss. Although it’s less dramatic than ALTI, it’s a serious condition with a high risk of limb loss or death and requires same-day discussion with a vascular surgeon.

Rest pain: note that this is usually in the forefoot/toes rather than the leg muscles. Typically, this is continuous and worse when the foot is elevated – hence patients will get more severe pain at night, hang their foot over the side of the bed to relieve pain, and often sleep in a chair to relieve pain. The latter, unfortunately, tends to start up a vicious circle as sleeping with dependent feet leads to an increase in foot oedema which can reduce the arterial circulation further.

Tissue loss: May be ulceration (usually over pressure areas; hence the toes, the heel, or the metatarsal heads) or gangrene (usually of the toes).

CLTI often presents without prior symptoms of claudication. This is partly because patients may not walk far enough to get claudication, and partly because coexisting diabetic neuropathy is, for obvious reasons, common in CLTI patients.

CLTI usually requires a revascularisation procedure (or, in 15%, amputation) but can be managed conservatively in about 20% of patients. However, always discuss with a vascular surgeon.

Note that CLTI is easily missed. (In fact, the article I’m taking this information from is in the ‘Easily Missed’ section of the BMJ.) It often presents insidiously and is easily mistaken for cellulitis, gout, or plantar fasciitis. The patient may still have foot pulses (not common, but it happens, even in cases of embolisation in the early stages) or may feel as though they have foot pulses when they don’t (there is a substantial false positive as well as false negative rate for palpation of foot pulses – even when vascular surgeons do it, which is reassuring or worrying depending on your point of view). ABPIs can be misleading, partly due to collaterals and partly due to arterial wall calcification (see below). The foot may look lovely and pink if the patient is sitting in a chair and hence getting lots of downward blood flow. Moral of the story? Have a high index of suspicion, and do Buerger’s test (see below).

 

Examination

  • Check peripheral pulses, obviously, going proximal to distal (I don’t know why or whether it matters which way you go, actually, but this is what the article says).
  • Look for hidden tissue loss on the heel and between toes.
  • Don’t bother too much with capillary refill, hair loss, or colour (I assume suspected acute ischaemia is an exception to the last) as they are of little diagnostic importance.
  • If CLTI is suspected at all, then do Buerger’s test; the foot turns pale on elevation due to ischaemia and red on dependency due to reactive hyperaemia.

ABPI of 0.9 or less is diagnostic of PAD and 0.5 or less suggests critical limb ischaemia. However, beware arterial calcification; this can cause falsely elevated ABPI values due to arterial incompressibility. Tends to show up in people with diabetes and/or CKD.

Also check:

  • Pulse (you still remember that Finals question, right?)*
  • BP
  • FBC/E&C/glucose or HbA1c/lipids
  • If patient under 50 yrs, thrombophilia screen
  • ECG

 

Indications for referral

Referral is not always necessary; asymptomatic patients and those with claudication only can be managed in primary care. (Document the ET at presentation in order to monitor whether progress is being made.) Note the following three situations:

1. Limb-threatening ischaemia, whether acute or chronic, requires urgent admission under the vascular team.

2. Diabetic foot ulcers in patients with PAD need urgent referral to the diabetic foot multidisciplinary team.

3. Patients with claudication symptoms that are affecting their quality of life and not improving after three months of supervised exercise therapy (see below) should be routinely referred to the vascular clinic for consideration of revascularisation.

 

Management

  • Stop smoking. Smoking cessation, for a PAD patient, not only reduces their risk of amputation, it also doubles their chance of surviving the next five years.
  • Antiplatelet treatment. Clopidogrel is first choice (best risk of harms/benefits), aspirin is second choice. Don’t use both, though – the bleeding risk with dual therapy is too high. Warfarin is normally only used in cases of arterial emboli (or AF, I assume). NOACs weren’t mentioned; don’t know offhand whether or not any of them are licenced for arterial emboli in PAD.
  • Exercise. There is apparently excellent evidence that supervised exercise programmes work significantly better than unsupervised exercise, but unfortunately the article didn’t clarify what ‘supervised’ was meant to mean here; I’m guessing I’m not actually meant to go out and watch all my patients with PAD walk several times a week. Anyway, the goal to aim for is walking for >30 minutes to near-maximal pain, at least three times a week for at least six months. Supervised exercise therapy actually works as well as angioplasty at improving both walking distance and quality of life. Interestingly, the improvement can occur even when ABPI remains the same.
  • Naftidrofuryl oxalate can be effective and is a possible second-line treatment in patients who are no better with walking therapy but don’t want secondary care referral. It should be tried for 3 – 6 months but stopped if not making a difference at that time. Cilostazol is also an option, but naftidrofuryl is both the most efficacious (up to 60% improvement) and the most cost-effective.
  • Advise weight loss if BMI >25, including giving ‘an optimal diet plan and a goal’. The article didn’t say what evidence there was for this.

Also, of course, PAD is a marker for other arteriopathy, so there are other things that aren’t particularly helpful for the PAD symptoms or risks but that are important to do anyway:

  • Statins. Reduce both CVA and all-cause mortality (OR 0.77 in each case) but not clear whether they affect walking distance. It’s secondary prevention, not primary; use Atorvastatin 80 mg od as first choice and aim to reduce non-HDL concentration by 40%.
  • Hypertension management. Ramipril is recommended as first-line therapy; the BMJ article says on page 202 that it doesn’t improve claudication symptoms (symptomatic review and meta-analysis) and on page 203 that ACE inhibitors improve walking distance in patients with claudication by an average of 86m. So, make what you will of that; maybe if I have time I’ll haul out the studies and try to figure it out. However, treatment of hypertension does of course improve overall cardiovascular risk, so worth going for anyway. Target is <140/90 in the under-80s and <150/90 in the over-80s.
  • Work for good glycaemic control in diabetes; it doesn’t seem to reduce amputation risk, but it does reduce the risk of microvascular complications. Target is <48mmol/l.

 

Prognosis

At five years from diagnosis of PAD:

  • Most patients with claudication will have stable or improved symptoms.
  • Between 1 and 3.3% will have progressed to amputation.
  • 20% will have died (I assume due to the association with other vasculopathies – MI, CVA, renovascular disease, vascular dementia, and mesenteric disease).

For patients with critical limb ischaemia the prognosis, not surprisingly, is a lot worse. By one year 30% will have had an amputation, and by five years 50% will be dead.

 

*In surgical finals, I was examining someone with possible PAD and started my presentation of examination findings by reeling off the pulse rate and rhythm. The examiner asked me why I mentioned that it was regular; turned out he was hoping I’d thought to exclude AF due to the increase in arterial thrombosis risk. Sadly, I wasn’t nearly that savvy and had simply been going through the standard list without thinking, so I missed a chance to impress him. It was a useful lesson, though (and I did pass, so I suppose that’s what matters).

Articles used in writing:

https://doi.org/10.1136/bmj.j5842 – PAD generally

https://doi.org/10.1136/bmj.j5460 – CLTI/ALTI

Posted in BMJ, Credits 2018, PAD, Vascular | Leave a comment

E-cigarettes

It’s official – e-cigarettes can be recommended as a smoking cessation aid. We still don’t know for sure how safe they are, but we do know that whatever risk they might carry is a heck of a lot less than that from smoking. So, we’re not going to give e-cigarettes the green light for a non-smoker, but if they’re what you need to get you off the real carcinogen-loaded article, go for it.

Also, some practical advice for those planning to replace smoking with vaping: Vaping takes practice. There are different types (as of the time of writing this post, the most up-to-date are the third-generation devices, which are probably the best available) and also different flavours and different nicotine doses. The current advice is to persevere until you find a type, flavour and dose that feels satisfying to you (ask for advice in a vape shop, if needed) and only then plan your quit date for the regular cigarettes, although plan it to be ASAP at that point.

http://www.bmj.com/content/360/bmj.j5543

Posted in Addiction, Credits 2018, Smoking | Leave a comment

Diagnosing childhood autism

This is just some rather quick notes I made on the video module ‘A practical guide to diagnosing autism in pre-school children’ on the BMJ Learning site.

Triad of symptoms for autism diagnosis:

  • Social communication
  • Social interaction
  • Social imagination

Presentation may include: Not developing language as expected, or regressing

Not responding to name

Not reciprocating

Poor eye contact – but eye contact/smiling don’t rule out autism.

More invasion of personal space than you’d expect; or discomfort with invasion of their personal space

Not happy with birthday parties/anxious over social situations

May be creative but not develop imaginative play; do they play with a variety of things, use things symbolically in non-repetitive way? Do they show signs of repetitive, stereotyped play?

Remember that you are not there to make the diagnosis; you are there to pick up concerns and refer where appropriate.

Also, from my own googling: The M-CHAT (Modified Checklist for Autism in Toddlers) is available online here.

Posted in Autism, Paediatrics | Leave a comment

Primary hyperaldosteronism

I know this as Conn’s syndrome, but that’s slightly misleading; Conn’s syndrome refers specifically to an adenoma causing the hyperaldosteronism, and in fact only accounts for less than 30% of cases of PHA. PHA is important to pick up, as the long-term cardiovascular outcomes are worse than those for patients with essential hypertension (the aldosterone can directly damage the myocardium and also cause vascular remodelling).

Presentation: As well as hypertension, hypernatraemia and hypokalaemia, it can cause non-specific symptoms; muscle weakness, palpitations, and emotional lability. To confuse matters, not only may electrolytes be normal, but also the aldosterone level may be normal. (The article didn’t explain why.)

Investigations: NICE guidelines and international guidelines advise screening for PHA in the following situations:

  • Treatment-resistant hypertension
  • Severe hypertension
  • Hypertension associated with hypokalaemia
  • Hypertension in younger patients

Investigations include:

  • Aldosterone:renin ratio
  • Sodium suppression test
  • Adrenal venous sampling
  • Abdominal CT or MRI

The article didn’t go into further detail about any of those except to say that diuretics (including spironolactone) should be stopped at least four weeks before checking the aldosterone:renin ratio, to avoid false negatives.

Treatment: Surgery is the treatment of choice; laparoscopic adrenalectomy. Apparently this is low-risk (despite how it sounds) and will usually produce long-term normotension, although some patients may have underlying essential hypertension as well as the PHA and will therefore continue hypertensive post-op.

(BJGP 2017; 67: 578 – 579)

Posted in BJGP, Cardiovascular, Credits 2018, Hypertension | Leave a comment