MRCS Q 11-15

Q11) A 24 year old male suffers low velocity gun shot wound in lower abdomen. On exploration there is a 1 cm segment loss of left ureter above the pelvic brim. Best management is :

a) Ureterocystostomy

b) Uretero ureterostomy

c) Ureterostomy

d) Ligation of ureter 


Q12) A 56 year old male undergoes B/l knee replacement and is started on heparin and warfarin for DVT prophylaxis. On 3rd POD he develops massive lower GI bleed with BP 80/40, pulse 110/min, Hb drops from 14.6 to 8.8 and INR is 9. What will you do next ?

a) Give Vitamin K 10 mg IV stat

b) Give 4 U of FFP

c) Give 4 U of FFP and 4 U of platelets

d) Whole blood


Answer 

11) b

Injuries to the ureter are 

(I) above the pelvic brim

(ii) below the pelvic brim

Injuries above the pelvic brim can be managed by ureteral mobilization and end to end anastomosis. if there is loss of length less than 2 cm, adequate mobilization can be done and tension free anastomosis is possible.

If loss of length is more than 2 cm, external ureterostomy is preferred as tension free anastomosis will not be possible

If damage control has to be done, the transacted ureter can be tied off followed by nephrostomy.

In injuries below the pelvic brim, ureterocystostomy can be done after mobilization of the bladder.


12. d

Whole blood

This is a case of major bleeding

Examples of "major" bleeding:
1. Intracranial (CT or MRI documented)
2. Retroperitoneal (CT or MRI documented)
3. Intra-ocular (excludes conjunctival)
4. Spontaneous muscle haematoma associated with compartment syndrome
5. Pericardial
6. Non-traumatic intra-articular
7. Any invasive procedure to stop bleeding
8. Active bleeding plus either BP < 90 mmHg systolic, oliguria, or > 2 g/dl fall in
haemoglobin
Fresh frozen plasma (FFP) only increases factor levels to at best 20-30% and will not normalise the INR, whereas this may be achieved with the more potent prothrombin complex concentrates, containing factors II, V, VII and IX. Intra-venous vitamin K may reduce the INR within four hours

As the patient is in shock, immediate would be to give whole blood.

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