MCQs and EMQs in Surgery - A Bailey _ Love[Shared by Ussama Maqbool]

990674_MCQ_As_Surgery_CV_3_ARNOLD 22/04/2010 15:21 Page B&L COMPANION GUIDE With over 1000 questions, MCQs and EMQs in Surgery is the ideal self-assessment companion guide to Bailey & Love’s Short Practice in Surgery The book assists readers in their preparation for examinations and enables them to test their knowledge of the principles and practice of surgery as outlined within Bailey & Love Sub-divided into 13 subject-specific sections, both MCQs and EMQs provide a comprehensive coverage of the surgical curriculum as well as the core learning points as set out in Bailey & Love Each section emphasises the importance of self-assessment within effective clinical examination and soundly based surgical principles, whilst taking into account the latest developments in surgical practice MCQs and EMQs in Surgery is an excellent companion to Bailey & Love and provides a valuable revision tool for those studying for MRCS One of the world's pre-eminent medical textbooks beloved by generations of surgeons To find out more visit www.baileyandlove.com I S B N 978-0-340-99067-4 780340 990674 Bailey & Love COMPANION GUIDE MCQs & EMQs in Surgery Datta Bulstrode Praveen About the authors Pradip K Datta MBE, MS, FRCS (Ed, Eng, Irel, Glas) is Honorary Consultant Surgeon, Caithness General Hospital, Wick, Member of Council and College Tutor, Royal College of Surgeons of Edinburgh Christopher J K Bulstrode MCh, FRCS (Orth) is Professor and Honorary Consultant Trauma and Orthopaedic Surgeon, University of Oxford, Member of Council, Royal College of Surgeons of Edinburgh B V Praveen MS, FRCS (Ed, Eng, Glas, Irel, Gen) is Consultant Surgeon and Associate Director of Medical Education, Southend University Hospital, Honorary Senior Lecturer, Queen Mary, University of London MCQs & EMQs in Surgery Bailey & Love Pradip K Datta, Christopher J K Bulstrode, B V Praveen Bailey & Love COMPANION GUIDE MCQs and EMQs in Surgery Pradip K Datta MBE, MS, FRCS (Ed, Eng, Irel, Glasg), Honorary Consultant Surgeon, Caithness General Hospital, Wick, Member of Council and College Tutor, Royal College of Surgeons of Edinburgh Christopher J K Bulstrode MCh, FRCS (Orth), Professor and Honorary Consultant Trauma and Orthopaedic Surgeon, University of Oxford, Member of Council, Royal College of Surgeons of Edinburgh B V Praveen MS, FRCS (Ed, Eng, Glasg, Irel, Gen), Consultant Surgeon and Associate Director of Medical Education, Southend University Hospital, Honorary Senior Lecturer, Queen Mary, University of London Prelimsxvi.indd i 4/14/2010 2:31:03 PM CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2010 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Version Date: 20121026 International Standard Book Number-13: 978-1-4441-2829-1 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents Foreword ix Contributors x Preface xi Acknowledgements xii List of Abbreviations Used xiii Introduction xvi PART 1: PRINCIPLES 1 The metabolic response to injury ■ Pradip Datta Shock and blood transfusion ■ Bandipalyam Praveen Wounds, tissue repair and scars 16 ■ Bandipalyam Praveen Surgical infection 22 ■ Bandipalyam Praveen Tropical surgery 31 ■ Pawanindra Lal, Sanjay De Bakshi Paediatric surgery 75 ■ Pradip Datta Oncology 84 ■ Bandipalyam Praveen Surgical audit and research 90 ■ Bandipalyam Praveen Surgical ethics 94 ■ Pradip Datta 10 Diagnostic imaging 96 ■ Pradip Datta PART 2: INVESTIGATION AND DIAGNOSIS 101 11 Gastrointestinal endoscopy 103 ■ Bandipalyam Praveen iii Prelimsxvi.indd iii 4/14/2010 2:31:04 PM CONTENTS 12 Tissue diagnosis 107 ■ Pradip Datta PART 3: PERIOPERATIVE CARE 111 13 Preoperative preparation 113 ■ Bandipalyam Praveen 14 Anaesthesia and pain relief 118 ■ Nigel Webster 15 Care in the operating room 122 ■ Pradip Datta 16 The high-risk surgical patient 124 ■ Bandipalyam Praveen 17 Nutrition and fluid therapy 127 ■ Nandini Rao 18 Basic surgical skills and anastomosis 135 ■ Pradip Datta 19 Laparoscopic and robotic surgery 137 ■ Bandipalyam Praveen 20 Postoperative care 144 ■ Pradip Datta PART 4: TRAUMA 151 21 Introduction to trauma 153 ■ Pradip Datta 22 Trauma epidemiology 156 ■ Christopher Bulstrode 23 Head injury 160 ■ Lynn Myles 24 Neck and spine 166 ■ Christopher Bulstrode 25 Trauma to the face and mouth 171 ■ Charles Perkins 26 Trauma to the chest and abdomen 176 ■ Pradip Datta iv Prelimsxvi.indd iv 4/14/2010 2:31:04 PM 185 ■ Christopher Bulstrode 28 Burns 195 CONTENTS 27 Extremity trauma ■ John McGregor 29 Plastic and reconstructive surgery 205 ■ John McGregor 30 Disaster surgery 212 ■ Christopher Bulstrode PART 5: ELECTIVE ORTHOPAEDICS 217 31 Elective orthopaedics: musculoskeletal examination 219 ■ Christopher Bulstrode 32 Sports medicine 224 ■ Christopher Bulstrode 33 The spine 233 ■ Christopher Bulstrode 34 The upper limb 238 ■ Christopher Bulstrode 35 The hip and knee 246 ■ Christopher Bulstrode 36 The foot and ankle 252 ■ Christopher Bulstrode 37 Infection and tumours 257 ■ Christopher Bulstrode 38 Paediatric orthopaedics 264 ■ Christopher Bulstrode PART 6: SKIN AND SUBCUTANEOUS TISSUE 271 39 Skin and subcutaneous tissue 273 ■ Pradip Datta PART 7: HEAD AND NECK 281 40 Elective neurosurgery 283 ■ Lynn Myles v Prelimsxvi.indd v 4/14/2010 2:31:04 PM CONTENTS 41 The eye and orbit 292 ■ Brian Fleck 42 Cleft lip and palate: developmental abnormalities of face, mouth and jaws 302 ■ John McGregor 43 The nose and sinuses 309 ■ Iain J Nixon 44 The ear 319 ■ Iain J Nixon 45 Pharynx, larynx and neck 330 ■ Iain J Nixon 46 Oropharyngeal cancer 341 ■ Iain J Nixon 47 Disorders of the salivary glands 351 ■ Iain J Nixon PART 8: BREAST AND ENDOCRINE 361 48 Thyroid and the parathyroid gland 363 ■ Nandini Rao 49 Adrenal glands and other endocrine disorders 375 ■ Nandini Rao 50 The breast 385 ■ Pradip Datta PART 9: CARDIOTHORACIC 389 51 Cardiac surgery 391 ■ Dumbor Ngaage 52 The thorax 397 ■ Dumbor Ngaage PART 10: VASCULAR 403 53 Arterial disorders 405 ■ Peter McCollum 54 Venous disorders 411 ■ Peter McCollum vi Prelimsxvi.indd vi 4/14/2010 2:31:04 PM 416 ■ Peter McCollum PART 11: ABDOMINAL 421 56 History and examination of the abdomen 423 CONTENTS 55 Lymphatic disorders ■ Pradip Datta 57 Hernia, umbilicus and abdominal wall 425 ■ Bandipalyam Praveen 58 The peritoneum, omentum, mesentery and retroperitoneal space 432 ■ Pradip Datta 59 The oesophagus 437 ■ Pradip Datta 60 Stomach and duodenum 441 ■ Bandipalyam Praveen 61 The liver 451 ■ Pradip Datta 62 The spleen 458 ■ Pradip Datta 63 The gall bladder and bile ducts 461 ■ Bandipalyam Praveen 64 The pancreas 468 ■ Pradip Datta 65 The small and large intestines 474 ■ Pradip Datta 66 Intestinal obstruction 488 ■ Bandipalyam Praveen 67 The vermiform appendix 495 ■ Pradip Datta 68 The rectum 499 ■ Pradip Datta 69 The anus and anal canal 504 ■ Bandipalyam Praveen vii Prelimsxvi.indd vii 4/14/2010 2:31:04 PM CONTENTS PART 12: GENITOURINARY 513 70 Urinary symptoms and investigations 515 ■ Pradip Datta 71 The kidneys and ureters 521 ■ Pradip Datta 72 The urinary bladder 533 ■ Pradip Datta 73 The prostate and seminal vesicles 541 ■ Pradip Datta 74 The urethra and penis 546 ■ Pradip Datta 75 The testis and scrotum 549 ■ Pradip Datta 76 Gynaecology 554 ■ Pradip Datta PART 13: TRANSPLANTATION 559 77 Transplantation 561 ■ Bandipalyam Praveen Index 569 viii Prelimsxvi.indd viii 4/14/2010 2:31:04 PM Foreword This innovative companion volume will certainly be considered as an essential complement to Bailey & Love’s Short Practice of Surgery The authors and contributors have recognised the fundamental changes that have occurred in surgical training and assessment where greater knowledge must be acquired in a shorter period of time, not only to ensure success in examinations but also to provide the comprehensive foundations on which to build clinical expertise The Silver Jubilee edition of Bailey & Love in 2008 emphasised its enduring importance for generations of surgeons internationally MCQs and EMQs in Surgery will define the indispensable elements for today’s surgical practitioners John D Orr, FRCS (Ed) ix Prelimsxvi.indd ix 4/14/2010 2:31:04 PM ➜ Pelvic inflammatory disease Which of the following statements about pelvic inflammatory disease (PID) is false? A The majority are caused by sexually transmitted ascending infection B Streptococcus is the most common organism C A low threshold for empirical treatment should be adopted D Outpatient antibiotic treatment should be started soon after the diagnosis is suspected E Some patients may need to be admitted for treatment Which of the following patients with suspected PID need to be admitted? A A surgical emergency, e.g acute appendicitis, cannot be excluded B Severe disease with constitutional symptoms C Tubo-ovarian abscess D PID in pregnancy E Fitz-Hugh–Curtis syndrome 76: GYNAECOLOGY C Previous medical termination D History of infertility E Past abdominal operation Extended matching questions ➜ Gynaecological pathology A B C D E F Ectopic pregnancy Uterine fibroids Endometriosis Ovarian cyst Carcinoma of ovary Pelvic inflammatory disease (PID) Choose and match the correct diagnoses with each of the scenarios below: A 25-year-old woman has been admitted with severe right-sided lower abdominal pain of h duration The pain gradually spread to the left side It was colicky to start with but has now settled to a continuous agonising pain She is apyrexial, sweaty, with a blood pressure of 110/60 mmHg and a pulse of 120/min Abdominal examination reveals tenderness, rigidity and rebound tenderness over the entire lower abdomen A 35-year-old woman has been admitted with sudden onset of severe right-sided lower abdominal pain of h duration She is unsure about her last menstrual period and has been trying to conceive for the first time On examination she is apyrexial, looks pale, her blood pressure is 80/50 mmHg, and pulse is 120/min; she is extremely tender over the entire lower abdomen On vaginal examination there is cervical excitation and the os is closed In the outpatient clinic, a 38-year-old woman complains of severe dysmenorrhoea for several months Recently she has developed chronic pain deep in the lower abdomen She also suffers from mid-menstrual pain She has not conceived as yet, although she would like to She has chronic fatigue On examination she is tender in her lower abdomen, and vaginal and rectal examinations show tenderness in the fornices and irregular nodules are felt in the pouch of Douglas A 27-year-old woman complains of foul-smelling vaginal discharge of several months’ duration She has frequency of micturition and intermittent lower abdominal pain and fever She has an IUCD inserted at present On examination she looks in discomfort and is tender over her lower abdomen Vaginal examination shows foul-smelling cervical discharge 555 CH076.indd 555 4/2/2010 2:00:00 PM GENITOURINARY A 60-year-old woman complains of unexplained gain in weight and increase in her girth over the last months Recently she found that her clothes are getting tight and she has to wear skirts two sizes larger She has some generalised abdominal discomfort and shortness of breath Recently she has been constipated with frequency of micturition On examination she has generalised abdominal distension and ascites with shifting dullness and fluid thrill A 40-year-old woman complains of lower abdominal discomfort of several months’ duration She has heavy periods, frequency of micturition, constipation and backache On examination she looks pale; abdominal examination reveals a firm mass in the suprapubic area about cm long and cm wide The lower limit of the mass cannot be felt Answers: Multiple choice questions ➜ Anatomy and physiology A, B, C, D The uterine arteries arise from the anterior branch of the internal iliac arteries E The woman’s date of recollection of LMP may be wrong Therefore, the alternative practice is to use ultrasound measurements of fetal size ➜ Vaginal bleeding A, B, C, D, E Vaginal bleeding can be a sinister symptom and therefore needs to be thoroughly investigated History of being on tamoxifen or having had HNPCC or a family history of the condition should make the clinician wary of vaginal bleeding as it may herald the onset of endometrial cancer The patient should undergo US and endometrial biopsy In women below the age of 40 years without any risk factors, pathology is rarely found and therefore may be treated symptomatically Women who have been treated for HNPCC should be screened annually from the age of 35 years by transvaginal US to measure endometrial thickness and biopsy when appropriate ➜ Ectopic pregnancy E Salpingectomy is not always performed Salpingostomy may be performed as it is thought that subsequent intrauterine pregnancy rates are higher and recurrent ectopic rates are lower following conservative surgery This can be carried out by the laparoscopic route A, B, C, D A previous abdominal operation does not increase the chance of ectopic pregnancy ➜ Pelvic inflammatory disease B Chlamydia trachomatis is the commonest organism responsible for PID Probably the next common organism is Neisseria gonorrhoeae A, B, C, D, E Whilst all the above need admission, Fitz-Hugh–Curtis syndrome is interesting as it can be confused with acute cholecystitis These patients, besides having the usual clinical features of PID, also complain of pain in the right upper quadrant where there is tenderness The condition is an extrapelvic manifestation of PID as a result of inflammation of the liver capsule and diaphragm US of the gall bladder will help in making the diagnosis 556 CH076.indd 556 4/2/2010 2:00:00 PM ➜ Gynaecological pathology 1D This young woman is a surgical emergency with sudden onset of severe lower abdominal pain with clinical features of peritonism – tenderness, rigidity and rebound tenderness She is apyrexial and has no constitutional symptoms She has developed a twisted ovarian cyst Confirmation is by US and/or laparoscopy This should be followed by an emergency laparotomy 76: GYNAECOLOGY Answers: Extended matching questions 2A This woman has the hallmarks of a ruptured ectopic pregnancy – features of hypovolaemic shock, sudden onset of lower abdominal pain and signs of peritonism in the pelvis She is unsure about her LMP and at 35 years of age, it is her first pregnancy She should be vigorously resuscitated and operated upon as an emergency A laparoscopy may be performed prior to laparotomy or the definitive procedure can be carried out by the laparoscopic route if expertise permits 3C This woman with dysmenorrhoea has lower abdominal symptoms of deep abdominal pain and internal examination showing tenderness in the vaginal fornices There are nodules felt in the pouch of Douglas She has the features of endometriosis, although sometimes a differential diagnosis of irritable bowel syndrome could be entertained Diagnosis is confirmed by laparoscopy 4F This woman has features of pelvic infection – foul-smelling vaginal discharge, lower abdominal pain, pyrexia and abdominal tenderness Presence of an IUCD in itself can cause PID Treatment should be started on empirical grounds, a vaginal swab sent, general blood tests done and the condition confirmed by laparoscopy 5E This woman, who is 60 years old, has developed gradual abdominal distension due to ascites She is short of breath, probably from her ascites She has the features of an ovarian carcinoma unless otherwise proven Blood should be sent for CA-125 followed by US and CT scan A chest X-ray is done to look for pleural effusion After staging, she is treated appropriately 6B This woman has heavy periods and symptoms from pressure to neighbouring structures – urinary bladder and rectum causing frequency of micturition and constipation She has a midline mass arising from the pelvis which is the fibroid An US would confirm the diagnosis and appropriate treatment is then instituted 557 CH076.indd 557 4/2/2010 2:00:00 PM This page intentionally left blank PART Transplantation 13 77 Transplantation CH077.indd 559 561 4/2/2010 2:00:15 PM This page intentionally left blank 77 Transplantation Multiple choice questions ➜ Transplantation terms Which of the following definitions are correct? A Allograft means an organ or tissue transplanted from one individual to another B Xenograft refers to a cadaveric donor C Autograft refers to transplants within the same species D Orthotopic graft refers to a bone graft E A heterotopic graft is placed in a site different from where the organ is normally located ➜ Human leucocyte antigen Which of the following statements regarding human leucocyte antigen (HLA) are true? A They are highly monomorphic B HLA class antigens are present in all nucleated cells C HLA antigens present on graft cells activate T-cells D HLA-A and B (class 1) and HLA-DR (class 2) are the most important in transplantation E Anti-HLA antibodies may cause hyperacute rejection ➜ Graft rejection Which of the following statements regarding graft rejection are true? A Hyperacute rejection is characterised by intravascular thrombosis B Acute rejection is T-cell-dependent C Chronic rejection usually happens after a period of months post-transplant D Acute rejection is irreversible E Acute rejection is the most common cause of graft failure Which of the following statements regarding hyperacute rejection are true? A It is due to preformed anti-HLA antibodies B It occurs 2–4 weeks after transplant C It can also occur due to ABO blood group graft incompatibility D The liver is resistant to hyperacute rejection E The antibodies are mainly towards HLA class antigens Which of the following statements regarding acute rejection are true? A It occurs within a month after transplant B It is usually reversible C It is predominantly mediated by T cells D A characteristic finding is mononuclear infiltration of the graft E Antibodies have no role Which of the following statements regarding chronic rejection are true? A It usually occurs several years after the transplant B It is a rare cause of rejection C It is characterised by myointimal proliferation in graft arteries D Immunosuppressive therapy is not helpful E The liver is more resistant to this type of rejection ➜ Graft-versus-host disease Which of the following statements regarding graft-versus-host disease (GVHD) are true? A It is due to the donor lymphocytes reacting against the host antigens 561 CH077.indd 561 4/2/2010 2:00:15 PM TRANSPLANTATION B It frequently involves the skin with a rash over the palms and soles C GVHD is a minor condition D It can also involve the liver and gastrointestinal tract (GIT) E It commonly occurs after renal transplant ➜ Immunosuppressive therapy Which of the following statements regarding mode of action of immunosuppressive therapy are true? A Cyclosporin blocks IL-2 gene transcription B Corticosteroids cause widespread antiinflammatory effects C Azathioprine blocks IL-2 receptor signal transduction D Tacrolimus blocks IL-2 gene transcription E OKT3 monoclonal antibody causes depletion and blockade of T-cells Which of the following statements regarding complications of immunosuppression are true? A Risk of viral infection is highest in the first month after transplantation B Cytomegalovirus (CMV) is a major problem C Chemoprophylaxis has no role D There is increased incidence of squamous cancer of the skin E Post-transplant lymphoproliferative disorder (PTLD) is a recognised entity ➜ Brainstem death 10 Which of the following statements regarding brainstem death are true? A Traumatic head injury should not be present B Hypothermia should be ruled out C The diagnosis has to be confirmed by two consultant grade doctors D Electrophysiological tests are mandatory in the UK E The presence of spinal reflexes does not preclude brainstem death ➜ Organ donation 11 Which of the following statements regarding organ donation are true? A Primary tumours of the central nervous system (CNS) are an absolute contraindication for donation B The usual acceptable upper age limit for heart donation is 65 years C The retrieved organs are preserved between and 4ºC D The safe maximum cold storage time for the kidneys is h E The optimal cold storage time for the heart is less than h ➜ Renal transplantation 12 Which of the following statements regarding renal transplantation are true? A Living donor transplants account for about 25–30 per cent of all renal transplants in UK B The upper age limit to be considered for transplantation is 65 years C Peritransplant lymphoceles are usually asymptomatic D Delayed graft function is more common after living donor transplant than after cadaveric transplants E Graft survival after a cadaveric transplant is about 75 per cent at years ➜ Transplantation in general 13 Which of the following statements are true? A The graft survival after heart transplant is 70 per cent at years B GVHD is a particular problem after small-bowel transplant C Primary hepatic malignancy is not an indication for liver transplant D Bladder drainage of the exocrine pancreas is the preferred technique E Simultaneous pancreas and kidney transplant (SPKT) has better results than pancreas transplantation alone 562 CH077.indd 562 4/2/2010 2:00:15 PM 77: TRANSPLANTATION Extended matching questions ➜ Types of allograft reactions A B C D Chronic rejection Hyperacute rejection Graft-versus-host response Acute rejection Choose and match the correct diagnosis with each of the descriptions given below: This is due to ABO or preformed anti-HLA antibodies It is characterised by intravascular thrombosis This is T-cell-dependent and is characterised by mononuclear cell infiltration It is reversible This is the most common cause of graft failure and is characterised by myointimal infiltration, leading to ischaemia and fibrosis This is seen after liver and small-bowel transplants It frequently involves the skin, causing a characteristic rash on palms and soles This is serious and it can be fatal ➜ Mechanism of immunosuppressive agents A B C D E F Corticosteroids Cyclosporin / tacrolimus Sirolimus /everolimus OKT3 Antilymphocytic globulin (ALG) /antilymphocytic serum (ALS) Azathioprine Choose and match the correct drug with their mechanism of action below: Depletion and blockade of T-cells Prevents lymphocyte proliferation Widespread anti-inflammatory effects Depletion and blockade of lymphocytes Blocks IL-2 gene transcription Blocks IL-2 receptor signal transduction ➜ Post-transplantation complications A B C D E CMV infection Pneumocystis carinii infection Fungal infection PTLD Squamous cell carcinoma Choose and match the correct diagnosis with each of the scenarios given below: A 50-year-old male who had a liver transplant months ago presents with severe fever not responding to antibacterial medications He has also been having cough and finding swallowing painful Blood culture and sputum culture show organisms with characteristic colonies 563 CH077.indd 563 4/2/2010 2:00:15 PM TRANSPLANTATION A 40-year-old female who had a renal transplant months ago presents with fever, chest pain and persistent cough The diagnosis is confirmed on bronchoalveolar lavage and lung biopsies She is started on trimethoprim with good response A 60-year-old farmer who had a renal transplant 15 years ago presents with a rapidly growing lump on the dorsum of his hand for the past months It is painless but has recently become ulcerated with some bleeding and discharge It has not responded to the usual wound care and dressings A 38-year-old male who had a renal transplant months ago presents with high swinging fever and lethargy He has cough, right upper quadrant pain and some ocular symptoms He is found to have leucopenia A 10-year-old girl with a previous history of renal transplant, a few years ago, presents with an ‘infectious mononucleosis’ type illness She is found to have multiple lymphadenopathy, enlarged tonsils and a tender spleen Answers: Multiple choice questions ➜ Transplantation terms A, E Xenograft refers to a graft performed between different species In autografts, the donor and recipient are the same individual Orthotopic graft is a graft placed in its normal anatomical site ➜ Human leucocyte antigen C, D, E Human leucocyte antigens are strong transplant antigens by virtue of their special physiological role as antigen recognition units They are highly polymorphic cell surface molecules There are two types of HLA molecules: class and class The class antigens are present on all nucleated cells, whereas the class antigens are expressed more strongly on antigen-presenting cells, such as dendritic cells, macrophages and B-lymphocytes ➜ Graft rejection A, B, C Allografts provoke a powerful immune response that results in rapid graft rejection unless immunosuppressive therapy is given T lymphocytes play an essential role in mediating rejection A, C, D Hyperacute occurs immediately and is mediated by ABO or preformed antibodies against HLA class antigens This is characterised by intravascular thrombosis and graft destruction within minutes and hours It can be avoided by ensuring ABO group compatibility and by performing a cross-match test on recipient serum to ensure that there are antibodies against the donor HLA antigens Liver transplants rarely undergo hyperacute rejection B, C, D This usually occurs within the first months of transplantation but may occur later It is predominantly mediated by T-lymphocytes but alloantibodies may also play an important role Most episodes of acute rejection can be reversed by additional immunosuppressive therapy C, D, E This is the most common cause of graft failure and usually occurs after the first months The liver appears to be more resistant than other solid organs to the destructive effects of chronic 564 CH077.indd 564 4/2/2010 2:00:15 PM ➜ Graft-versus-host disease A, B, D This is the reciprocal problem of an immunological reaction mounted by the graft against the host The donor liver and small bowel both contain large numbers of immunocompetent lymphocytes which react against host HLA antigens This frequently involves the skin, liver and GIT GVHD is a serious and sometimes fatal complication 77: TRANSPLANTATION rejection The pathophysiology of chronic rejection is not completely understood The underlying mechanisms are immunological, and both alloantibodies and cellular effector mechanisms are involved The risk factors for chronic rejection after renal transplantation are previous episodes of acute rejection, poor HLA match, long cold ischaemia time, cytomegalovirus (CMV) infection, raised blood lipids and inadequate immunosuppression ➜ Immunosuppressive therapy A, B, D, E The agents used to prevent rejection act predominantly on T-cells, and different classes of agents act at different sites during T-cell activation Most immunosuppressive protocols use a combination of agents Azathioprine prevents lymphocyte proliferation Monoclonal antibodies directed against IL-2 receptors on T-lymphocytes (CD25) are used to augment the effects of calcineurin blockade during the early post-transplant period Polyclonal antibody preparations ALG /ALS cause depletion and blockade of lymphocytes Sirolimus /everolmus blocks IL-2 receptor signal transduction B, D, E Transplant recipients are at high risk of opportunistic infections, especially by viruses Chemoprophylaxis is important in high-risk patients The risk of viral infection is highest during the first months of transplantation and the risk of bacterial infection is highest in the first month Pre-transplant vaccination against community-acquired infection should be considered The important viral infections include CMV, herpes simplex and herpes zoster Protozoal infections due to Pneumocystis carinii and fungal infections due to Candida and Aspergillus are other important infections Post-transplant lymphoproliferative disorder is an abnormal proliferation of B-lymphocytes, usually in response to Epstein–Barr virus infection This can present as an infectious mononucleosis type of illness PTLD is a serious condition with a mortality rate of up to 50 per cent ➜ Brainstem death 10 B, E Brainstem death occurs when severe brain injury causes irreversible loss of the capacity for consciousness combined with the irreversible capacity for breathing In most countries it is accepted that the condition of brain death equates in medical, legal and religious terms with death of the patient The concept of brain death is important in management of patients with irreversible brain damage on life support with no prospect of recovery and in issues of organ transplantation Traumatic head injury and sudden intracranial haemorrhage are the most common causes of brainstem death It is important to exclude hypothermia, profound hypotension, metabolic and hormonal conditions, and drugs should be excluded before the diagnosis of brainstem death is made The UK guidelines state that the tests to confirm the diagnosis should be performed on two separate occasions by two clinicians experienced in this area At least one of them should be a consultant and neither should be connected to the transplant team The tests to determine brainstem death aim to confirm the absence of cranial nerve reflexes, absence of motor response and absence of spontaneous respiration In the UK there is no need to perform electrophysiological or brain perfusion studies 565 CH077.indd 565 4/2/2010 2:00:15 PM TRANSPLANTATION ➜ Organ donation 11 B, C, E Most of the organs used for transplantation are obtained from brainstem-dead, heart-beating donors, and in the majority of cases multiple organs are procured The presence of malignancy in the past years is an absolute contraindication, with the exception of primary tumours of the CNS, non-melanotic skin tumours and carcinoma in situ of the uterine cervix There is no upper age limit for kidney and liver donors The upper age limit for heart and lung donors is 65 years and it is 60 years for pancreas Various organ preservation solutions, such as University of Wisconsin (UW) solution, are available The safe maximum storage times for kidney, liver, heart and lung are 48, 24, and h respectively The optimal cold storage time, however, is usually half of this ➜ Renal transplantation 12 A, C, E In the UK, around 80–100 people per million of the population develop end-stage renal disease The living donor renal transplant activity is much higher in some countries, such as Scandinavia and India The justification for living donor renal transplant is based on the shortage of deceased donor transplants, superior results and the legislation There is no upper age limit for a renal donor Vascular complications after transplant are uncommon and include renal artery thrombosis (1 per cent), renal vein thrombosis (up to per cent) and renal artery stenosis (up to 10 per cent) which usually occurs years after the transplant Urological complications occur in about per cent of cases Peritransplant lymphoceles are usually asymptomatic but may occasionally cause ureteric obstruction and oedema of the ipsilateral leg Delayed graft function is defined as the need for dialysis post-transplantation This is as a result of acute tubular necrosis and occurs in up to 30 per cent of heart-beating deceased donors but is uncommon (