INTESTINAL SYSTEM - TaiLieu.VN

tahir99 - UnitedVRG

12IntestInal system

Contd...

HIRSCHSPRUNG’S DISEASE

○ Male:female=4:1○ Absenceofganglioncellsinboth myenteric and submucous plexus○ Accompanyinghypertrophyofnervetrunks○ Rectalfullthicknessbiopsy—diagnostic○ Maypresentasacuteintestinalobstructiontochronicconstipationinlaterlife

○ Absenceoffecalsoilingdifferentiatesitfromothertypesofconstipation○ Surgeriesdone:Duhamel,Swenson,Soave

MECKEL DIVERTICULUM

○ Meckelsistruediverticulum,locatedinantimesentricborder○ M/ccongenitalanomalyofgastrointestinaltract(GIT)○ M/c ectopic mucosa:m/cisgastric(60%),pancreatic,colonic,Brunner'sglands,endometriosis

○ Rule of 2:Prevalence2%,2inchlength,located2feetproximaltoileocecal(IC)valve,presentsm/cin<2yearage

○ M/c complication in adults:Obstruction,children—bleeding,overall—bleeding

○ Littre's hernia:Meckel'sascontentinthesac(Amyand’shernia—appendix)○ Tc-99 m pertechnate scan:Diagnosisectopicgastricmucosa,angiographycandiagnoseactivebleed

○ Surgery:Simpleexcision,widemouthduringothersurgeriesleaveit○ Resectionofileumwithanastomosisisdoneif—pepticulcerinileum,gan-greneaffectingbase,rarelyifmalignancyassociated

tahir99 - UnitedVRG

119Intestinal System

DIVERTICULAR DISEASE○ Diverticulosis:Multiplediverticula○ Diverticulitis:Perforateddiverticulumduetoinflamma-tion

○ Diverticulosis:Bestdiagnosedbybariumenema(Saw-toothappearance).Shouldnotbedoneinacutesettings

○ Diverticulitis:Bestdiagnosedbycomputedtomography(CT)scan

○ False divericula:Arem/c○ Leftside(sigmoid)colon:M/csite○ Bleedingm/cfromrightside:Suppliedbysuperiormes-entricartery

○ In small bowel—Duodenum is m/c site, m/c on mesen-tric side, false diverticula.

○ Most sensitive test—Enteroclysis○ Smallboweldiverticulaareassociatedwithblindloopsyndrome:Bacterialovergrowth,B12deficiency—megalo-blasticanemia

POLYPS○ Pseudopolypsarenotpremalignant○ Non-neoplasticpolyps:Hyperplastic,juvenile,Peutz-Jegherspolyps

○ Neoplasticpolyps:Tubularadenomas,�illousadenomas,�a- Neoplasticpolyps:Tubularadenomas,�illousadenomas,�a-milialpolyposiscoli,Gardner'ssyndrome,Turcotsyndrome

○ Familial adenomatous polyposis (FAP): Autosomaldomi-nant(AD)disorder,5q*—colorectalcancerdevelopsinallpatientsatagebefore40yearsifuntreated.Prophylacticcolectomyneeded

○ Turcot syndrome:�amilialpancreaticcancer(�PC)+braintumorslikeglioma,medulloblastoma—AR

○ Gardner's syndrome: �PC+osteomas,epidermoidcysts,congenitalhypertrophyofretinalpigmentepithelium,desmoidtumor,retroperitonealfibrosis,polypsofstomach,smallintestine,adenomasinpan-creas,thyroid,adrenal,parathyroid

○ Peutz-Jeghers syndrome: Hamartomatous polyps in jejunum*andotherpart,pigmentationoflips,tumorsofovary,breast,endometrium,pancreas

○ Cronkhite canada syndrome: Juvenilepolypsarenotedalongwithalopecia,cutaneouspigmentation,atrophyofnailsandtoenail.

COLONIC CANCERRisk factors

○ Geographicvariation:HighestriskinWesterncoun-triesandlowestriskindevelopingcountries

○ Age:Riskincreasesharplyafterthe5thdecade○ Diet:Increasedwithtotalandanimalfatdiets○ Physicalinactivity:Increasedwithobesityandseden-tarylifestyle

○ Adenoma:Riskdependentontypeandsize�APpen-etranceingenecarriers100%

○ Hereditarynon-polyposiscolorectalcancer(HNPCC)penetranceingenecarriers80%

○ Hamartomatous syndromes: RiskincreasedwithPeutz-Jegherssyndromeandjuvenilepolyposis,butnotisolatedjuvenilepolyps

○ Previoushistoryofcoloncancer:Increasedriskforrecurrentcancer

○ Ulcerativecolitis:10%–20%after20year○ Radiation:Associatedwithamucinoushistologyandpoorprognosis

○ Ureterosigmoidostomy:100–200timesincreasedriskatoradjacenttotheureterocolonicanastomosis

Contd...

tahir99 - UnitedVRG

Nutshell Series for FMGE/DNB/NEET-PG—General Surgery120

PERCENTAGES○ M/c—rectosigmoid○ Rectum—38%○ Sigmoid—21%○ Caecum—12%○ Ascending—5%○ Descending—4%○ Transverse—5.5%Peak age:60-80years98%casesareadenocarcinomaSymptoms:�agueandnonspecific

MANAGEMENT○ MalignantobstructionistheM/c cause of large bowel obstruction○ Theprimarygoaloftreatmentisdecompressionofobstructedsegmenttopreventperforation

○ Removalofdiseasedsegmentissecondgoal

○ Bothshouldbedonewheneverpossible

○ Iflesionisunresectableadiver-sioncolostomyisdone

Right colon Left colon1.Stablecase—resectionandileocolicanasto-mosisinasinglestage

2.Unstable/perforatedcolon—twostage,resectionwithileostomy,lateranastomosis

1.Traditionallyandmostcommonlyperformedsurgeryisresectionoflesionandproximaldiversion(Hartmanns)

2.Stablepatientwithnoperitonitis,resectabletumors—primaryresectionandanastomosisorsubtotalcolectomyandileorectalanastomosis

Staging Dukes classification○ T1—Limitedtomucosaandsubmu-cosa

○ T2—Extendstomusculariso T3—ExtendsintoorthroughserosaDepthofpenetranceisanimpor-tantpredictorfordistantmets

Carcinoembryonicantigen(CEA)—markerforrecurrence

○ StageA:Limitedtomucosa○ StageB1:Extendingintomuscularispropria,butnotpenetratingthroughit;nodesnotinvolved

○ StageB2:Penetratingthroughmuscularispropria;nodesnotinvolved○ StageC1:Extendingintomuscularispropria,butnotpenetratingthroughit.Nodesinvolved

○ StageC2:Penetratingthroughmuscularispropria.Nodesinvolved○ StageD:Distantmetastaticspread

tahir99 - UnitedVRG


SMALL BOWEL TUMORS○ Duodenumism/csiteofsmallboweltumors○ Leiomyomaism/ctumor,m/cmalignanttumorisadeno-carcinoma

○ Adenocarcinomadoesnothavegoodprognosis

○ Insmallandlargeboweltumors,thelivermetsper seisnot a contraindicationforprimarycurativeresection

○ Chemotherapyisnotaproventreatmentforsmallbowelcancers

SMALL BOWEL CARCINOIDS○ Primary:Usuallysmall○ Secondary:ThosemetastasizedproducesmanysymptomstogetherknownascarcinoidsyndromeMost common site is ileum*, 2nd common is rectum, 3rd common site is lungs. Being the most common site previ-

ously appendix is now pushed to 4th place.

Features APUDomasArisefromenterochromaffinlikecells(ECL)alsoknownaskulchis-ky/argentaffiancells.

Produces—5HT(serotonin),ACTH,somatostatinandpeptideYY.80%areasymptomatic.Onlywhenserosaisinvadedtheyproduceintensedesmoplasticreactionpresentingwithabdominalpain,intusussceptionanddiar-rhea(mainlyduetopartialobstructionandnotduetoserotonin.)

○ Amineprecursoruptakeisderivedfromneuralcresttissueastheymigratetodifferentpartsofthebody.1.GIT—carcinoids2.Pancreas—insulinomas3.Centralnervoussystem(CNS)—neuroblastomas4.Adrenal—pheochromocytoma5.Lungs—smallcellcarcinoma.

Metastatic carcinoids (secondary) Carcinoid syndrome○ Metastasisdependson:1.Size:<1cm(<2%);>2cm(90%)2.Site:Appendix(3%);ileal(35%)leastwithappendix.3.Depthofinvasion.Malignantcarcinoidsyndromedevelopsonlylivermetsdevelop;becausealltheabovelistedhormonesaredetoxi-fiedinliver.

○ �asomotorsymptoms(80%):Cutaneousflushing○ GIT:Explosivediarrhea.Duetoserotonin○ Cardiovascular:Pulmonarystenosis(90%),tricuspidstenosisandinsufficiency

○ Asthmaticattacks:bronchospasm○ Malabsorptionandpellagra(dementia,diarrhea,dermatitis)duetoexcessivediversionoftryptophan.

Investigations Treatment24hoururinary5-hydroxyindoleaceticacid(5-HIAA)**arehighlyspecific

Neuroendocrinetumormarker—chromograninAPentagastrinprovocativetestsSmallbowelcarcinoids:DifficulttodiagnosepreoperativelyRecently:Somatostatin receptor scintigraphy with indium-111

labelled pentreotidehasshownhighersensitivitythanCTscan

• Ifsize<1cm—segmentalintestinalresection• Ifsize>1cm,nodes+oriftherearemultiplemetastasis—wideexcisionalongwithmesentry.

• Terminalileum:Righthemicolectomy.• Livermets:Resection,hepaticarteryligationorembolizationorradiofrequencyablation(R�A).

INFLAMMATORY BOWEL DISEASE (IBD)Crohn disease (CD) Ulcerative colitis (UC)○ HistopathologicexaminationofCrohn’sdiseasetypically

demonstrates transmural inflammationcharacterizedbymultiplelymphoidaggregatesinathick-enedsubmucosa

○ Non-caseating granulomasareavaluablediagnosticfeatureofCrohn’sdisease,buttheyareseeninonly50%ofresectedspeci-mensandarerarelyseen

○ TheearliestgrossmanifestationsofCrohn’sdiseasearethedevelopmentofsmallmu-cosalulcerationscalledaphthous ulcers

○ Asthediseaseprogresses,themucosabegintoerodeleavingonlysmallislandsofmucosathatresemblepolyps,butareactuallypseudopolyps

○ Histologically,thetypicalearlylesionconsistsofaninfiltrationofinflamma-torycells,primarilypolymorphonuclearleukocytes,intothecryptsatthebaseofthemucosa,formingcrypt abscesses

Contd...

tahir99 - UnitedVRG


INFLAMMATORY BOWEL DISEASE (IBD)Crohn disease Ulcerative colitis○ Serpiginous network of linear ulcerationsthatsurroundis-landsofedematousmucosaproducingtheclassic‘cobblestone’appearance.Mucosalulcerationsmaypenetratethroughthesubmucosatoformintramuralchannelsthatcanboredeeplyintothebowelwallandcreatesinuses,abscessesorfistulas.

○ Althoughulcerativecolitisisgenerallyconfinedtothemucosa and submucosa,inthemostsevereformsofthedisease,suchasfulminantcolitisortoxicmegacolon,thediseaseprocessmayextendtothedeepermuscularlayersofthecolonandeventotheserosa

Clinical features Ulcerative colitis Crohn diseaseLocation ○ Colononly • Anywhereinthealimentarytract

Anatomic distribution ○ Continuous,beginningdistally • Asymmetricalskip lesions

Rectal involvement ○ >90% • Occasionally

Diarrhea/gross bleeding ○ Severe,oftenbloodywithmucus • Lesssevere,infrequentbleeding

Abdominal pain ○ Yes • Occasionally

Perianal fistulas ○ Rare • Common

Abdominal mass (palpable) ○ Rare • Common

Strictures and obstructions ○ Uncommon • Common

Fistulas and perforations ○ Rare • Common

Extraintestinal manifestations ○ Common • Common

Recurrence after surgery ○ Ifretainedrectalmucosa • Yes

Endoscopic features Ulcerative colitis Crohn diseaseMucosal involvement ○ Contiguous • Discontinuous

Discrete ulcers (aphthous) ○ Rare • Common

Surrounding mucosa ○ Abnormal • Relativelynormal

Longitudinal ulcers (serpiginous) ○ Rare • Common

Cobblestoning ○ No • Inseverecases

Rectal involvement ○ >90% • Sparingcommon

Mucosal friability ○ Common • Uncommon

Vascular pattern ○ Distorted • Normal

Radiographic featuresSmall bowel abnormalities ○ No • Yes

Terminal ileum abnormalities ○ Rare • Yes

Segmental colitis ○ No • Yes

Asymmetric colitis ○ No • Yes

Stricturing ○ Occasionally • �requently

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


LOCAL COMPLICATIONS OF IBD

TREATMENT FOR IBDUlcerative colitis Crohn disease○ Conservative○ Surgical—Electiveandemergency○ Indicationsforsurgery

○ RememberUCcanbecuredbyresectionofaffectedsegment,butCDneedsonlypalliativecare

Emergency ElectiveProvenorsuspectedperforationofcolon

Intractabledisease

Massivehemorrhage Dysplasticchanges/cancerToxicmegacolonnotrespondingtomedicaltreatment

Chroniccolitis>10years

Emergency• Fulminant colitis:Totalcolectomywithendileostomyratherthanatotalproctocolectomy(rectumalsoremoved).Thisisbecauserectumsymptomsimproveinvariablyandalsofirstprocedureavoidsunnecessarytimewasteinpelvisdissectionincriticallyillpatient.

• Iftoounstable:Loopileostomyanddecompressingcolostomy

Elective Indications of surgery• Restorativeproctocolectomywithilealpouchanalanastomosis(procedureofchoice)

• Totalproctocolectomywithendileostomy• Totalproctocolectomywithcontinentileostomy(Kock’spouch)

�istulasIntra-abdominalabscessPerianalabscessStrictures

○ Toxicmegacolon○ Massivebleed○ Dysplasia/cancer○ Intractability

EXTRAINTESTINAL MANIFESTS1. Dermatologic

• Erythemanodosum• Pyodermagangrenosum(m/cinUC)

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


EXTRAINTESTINAL MANIFESTS1. Dermatologic• Sweetsyndrome• Psoriasis• Neutrophilicdermatosis• Perianalskintags(70%–80%casesofCD)• Orallesions(aphthousstomatitis,cobblestoneappear-ance—m/cinCD)

2. Rheumatologic• Peripheralarthritis(m/cinCD)*• Ankylosingspondylitis(m/cinCD)• Sacroilitis• Hypertrophicosteoarthropathy• Osteomyelitis• Relapsingpolychondritis

3. Ocular• Conjunctivitis,uveitis,episcleristis

4. Hepatobiliary• Hepaticsteatosis• Cholelithiasis(m/cinCD)• Primarysclerosingcholangitis

5. Urologic 6. Others Primarysclerosingcholangitis(PSC)ismostseriousandalsodoesnotresolveaftercolec-tomy

Colitisassociatedcoloncancerm/coccurinleftside,butinpatientswithPSC+UC—can-cerm/conrightside

• Calculi—m/cinCD• Ureteralobstruction• �istulas

• Thromboembolicmanifests• Osteoporosis• Amyloidosis• Endo,myo,pericarditis

TUBERCULOSIS OF ABDOMENTypes of tuberculosis (TB) Acquired as1.Ulcerative2.Hyperplastic

1.Primaryinfection:Mycobacterium bovis,infectedmilk—hyperplastic(TB)2.Secondaryinfection:Swallowingtuberclebacilli—ulcerative type TB—M/c form of

intestinal (TB)

Points Hyperplastic Ulcerative1.Cause ○ M. bovineprimaryingestion Secondarytoswallowinginfectedsputum2.M/csite ○ Ileocecalvalve Longerpartsofterminalileum3.Presentation ○ Asobstruction Astransverseulcers

Typhoidpresentswithtransverseulcers4.Clinicalfeatures ○ Acuteabdominalpainwithintermittentdiarrhea

○ Massinrightiliacfossa○ Blindloopsyndromemaydevelop

Diarrheaandweightloss

5.Bariummeal ○ Pulledupcecum,ileocecalanglebecomesobtuse Absenceoffillingoflowerileum6.Treatment ○ Augmentationtherapy(ATT)+surgeryifobstructed ATT+surgeryifperforated7.Complications ○ Obstruction Perforation,fistula

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


SHORT BOWEL SYNDROME○ Removalofsignificantportionofsmallbowel○ M/ccauses—mesentricinfarction,Crohndisease,trauma

○ Resectionofterminalileum—malabsorptionofbilesaltsandvitaminB12

Results in:1.Megaloblastic anemia2. Watery diarrhea—unabsorbedbilesaltsintocolon3. Malabsorptionoffatsolublevitamins4. Steatorrhea—reductioninbilesaltpool5. Oxalate kidney stones—unabsorbedfattyacidsbindwithcalcium6. Cholesterol gallstones—decreasedbilesaltinbile7. Increased gastrin secretion: duetoreducedhormonalinhibition

Risk factors for short gut syndrome• Smallbowellength<200cm• Absenceofileocecalvalve• Absenceofcolon• Diseasedbowelremaining(Crohndisease)• Ilealresection

TreatmentMedical treatment Non-transplant surgeries • Intestinal transplantation

H2antagonists/Protonpumpinhibitors(PPI)toreducegastricsecretion

Antimotilityagents—LoperamideOcterotideTotalparenteralnutrition(TPN)

Bianchiintestinallengtheningopera-tions

Serialtransverseenteroplasty

SUPERIOR MESENTERIC ARTERY (SMA) SYNDROME○ Wilkie’s syndrome○ Rareconditioninwhichthe3rdpartofduodenumcompressedbetweenSMAandaorta

Factors that precipitate the syndrome1.Suddenweightloss2.Rapidgrowthinheight3.Bodycastsapplication4.Supineimmobilization

Clinical features Treatment○ M/cseeninthinyoungfemale○ Presentswithgastricoutletobstruction(GOO)symptoms

○ Conservative/posturaltherapy○ Ifnotresponding—duodenojejunostomy

ENTEROCUTANEOUS FISTULA○ M/ccauseofenterocutaneous(EC)fistulaisiatrogenic○ Othercauses—Crohn’sdisease,diverticulitis,carcinomacolon

○ Highfistulasdrain>500mL/day

Complications of fistula1.�luidandelectrolytedisturbance2.Malnutrition3.Necrosisofskin4.Sepsisleadingtomultipleorganfailureanddeath

TreatmentCorrectionoffluidandelectrolyteimbalanceAntibioticsSkinprotection

TPNSurgeryindicated,iffistulafailstohealafter4-6week�istuloustractexcisionalongwithinvolvedsegmentandreanastomosis

Megacolon Toxic megacolon○ Megacolondescribeschronicallydilated,elongated,hypertrophiedlargebowel

○ Definedastransversecolondiameter>5–6cmwithlossofhaustration

Contd...

tahir99 - UnitedVRG


Megacolon Toxic megacolon○ Congenital:Hirschsprungs,○ Acquired:1.Chagasdisease:T. cruziinfection2.Medications:Anticholinergics3.Neurological:Polio,paraplegia,multiplesclerosis,motorneurondisease

4.Rectalcancer

○ Causedby:1.Ulcerativecolitis2.Crohndisease3.Salmonellosis4.Amebiccolitis5.Pseudomembranouscolitis6.Ischemiccolitis

Treatmentoftoxicmegacolon: Surgery is a must as it may go for perfora-tion.

Points• UnlikeUC,whichstartswithrectumandalmostalwaysinvolvesrectum,rectal sparing is seen in Crohn disease• AngiodysplasiaisavascularmalformationassociatedwithageingItoccursm/cinascendingcolonandcecum

• ApatientpresentswithlowerGIbleeding,biopsyfromsigmoidcolonulcersareflask-shaped-amoebiccolitisulcers—treatment:I�Metrogyl

APPENDIX

ACUTE APPENDICITISNormal position of appendix Etiology factors○ Retrocecal:70%○ Pelvic:20%○ Preilealandpostileal

○ Subcecal○ Paracecal○ Subhepatic

○ Idiopathic○ �ecolithsandworms○ �alveofGerlach:�alveatbaseofappendix

○ First symptom:Anorexiafollowedbypain○ Murphy’s triad:Pain,vomitingandfever○ Blumberg sign—reboundtenderness○ Rovsing’s sign (American):Palpationofleftiliacfossaproducespaininrightiliacfossabyshiftofbowels.

○ Rovsing’s sign (Europe):Retrogradestrikeoutsofleft-sidedcolonleadstopainintheascendingcolonandcecum

○ Douglas sign:Right-sidedpaininrectalorvaginalexamination

○ Sherren’s triangle hyperesthesia:TriangleformedbyASIS,umbilicusandpubicsymphysisduetoirritationoflowerabdominalnerves

○ Bastede’s sign:Paininrightiliacfossa,ifairisinsuf-flatedintorectum

Investigations• Clinicalexaminationisthediagnostic• Ultrasonography(USG)andCTscanareusedtocon-firmthediagnosis

• Onthebasisofclinicalexaminationnormalappendixisfoundin15%–30%cases

TestsCope’s psoas test:Retrocecalappendicitisonextensionofhipproducespainduetoirritationoverpsoasmajor

Cope’s obturator test:Pelvicappendicitis,flexionandfedialrotationproducespain.

Contd...

Contd...

ENTEROCUTANEOUS FISTULA

tahir99 - UnitedVRG


ACUTE APPENDICITISAlvarado scoring

• M—Migratorypain• A—Anorexia• N—Nauseaandvomiting• T—Tenderness

• R—Reboundtenderness• E—Elevatedtemperature• L—Leukocytosis• S—Shifttoleft,segmentedneutrophils

Score of > 7 is strongly suggestive of appendicitisComplications

1. Perforation 2. Appendicular mass○ Earlyantibioticsdonotpreventrupture○ Occursmostfrequentlydistaltoobstructionalongtheantimesen-tericborder

○ Suspectruptureifthereishighgradefever>39degrees○ Riskfactorsofperforation—extremesofage,immunosuppression,diabetesmellitus,fecolithobstruction,pelvicappendix,previousabdominalsurgery

○ Infectionsealedoffbygreateromentum,cecum,terminalileum,whichresultsinatendersofttofirmmassinRI�

○ Ochsner-Sherrensconservativeregimenfol-lowed

○ Intervalappendicectomydoneafter6weeks

3. Appendicular abscess○ Ifinfectionisnotproperlycontrolledabscessresultspresent-ingwithhighgradefeverandchills

○ Drainpelvicabscessviarectum,drainretrocecalabscessex-traperitoneally,preandpostilealabscessbylaparotomy.Inallcases,electiveappendicectomydoneinalaterdate

○ Diffuseperitonitisfollowingappendicitisoccurif per-foration occurs in < 24 hours of onset.Inlaterstagestheomentumandsmallbowelsusuallysurroundtheinflammedappendixandpreventspread

Incisions Special situations• McBurney’s grid iron incision• Lanz incision:Cosmetichorizontalskininci-sion

• Rutherford-Morrison incision:Musclecut-tingincisionandnotaskinincisionextend-ingupwardsandlaterally

• Iliohypogastricnerveisinjuredingridironincision

• Resultsindirectherniarightside

○ Cecal wall edematous and inflamed:Stumpmustnotbeinvaginatedandpursestringnotused

○ Base of appendix inflamed:Baseisnotcrushed,ligatedclosetocecumandstumpinvaginated

○ Base is gangrenous:Neithercrushednorligatedremovetheappendixclosetobaseandapplytwolayerstitchesatthececalwall

○ OnopeningappendixisnormalpatientishavingCrohndisease:IfCrohndiseaseisnotinvolvingbaseofappendixdoappendicectomy,ifitinvolvesleaveitassuch

MUCOCELESHistological types ○ Intraluminalaccumulationofmucoidsubstance

○ Benigntumor,lowgrademalignancy:Hencesimpleap-pendicectomyisenoughRetentioncysts

MucoushyperplasiaCystadenomaCystadenocarcinoma

CARCINOID APPENDIX○ Argentaffinomasorcarcinoidtumorsarethem/cneoplasmofappendix

○ M/cindistalthird○ Rarelymetastasistoliver

TreatmentDependsonsizeoftumor<2cm—plainappendicectomy>2cm—righthemicolectomy

Ifcecalwallormesoappendixorlymphnodesinvolveddorighthemicolectomy

Contd...

tahir99 - UnitedVRG


INTESTINAL OBSTRUCTIONIntusussception

○ Enteringtube—intussusceptum○ Returning—middletube○ Outertube—intussuscipiens○ M/ccauseofintestinalobstruction:age3monthsto6years

Causes• PediatricIdiopathic(70%–90%)Hypertrophiedpeyerspatch(m/c)Respiratoryinfection,gastroenteritis,urinaryinfectionareassociatedin30%

Rarely:Henoch-SchonleinPurpura•Older infants: Meckels diverticulum (M/C)•Adults: Tumours,polyps,submucosallipomas.•Colocolicvarietyiscommoninadults

TypesIleocolic(77%)Ileoileocolic(12%)Ileoileal(5%)

Colocolic(2%)MultipleRetrograde

Clinical features Investigation Treatment○ M/ctype:Ileocolic○ Characterizedby—severecrampyab-dominalpain

○ �omiting○ Red currant jelly stool○ P/A: Sausage-shapedmass○ Le dance sign: Emptyrightiliacfossa○ P/R: Apexmayseenprotruding

Bariumenema—Claw-sign,coiled-springsign

Ultrasound—Targetsign,pseudo-kidneysignandBullseyesign

X-rayplain—Targetsign(softtissuemasswithconcentricareaoflucencyduetomesentricfat)

• Hydrostaticreductionbycontrastagentorairenemaisdiagnosticandtherapeutic

• Suchprocedureiscontraindi-catedinperitonitisandhemody-namicinstability

MECONIUM ILEUS○ Neonatalmanifestofcysticfibrosis○ Pancreaticenzymedeficiencyandabnormalchloridesecretionresultsinviscouswaterpoormeconium

○ Obstruction of thick meconium occurs in ileum○ Presentsimmediatelyafterbirthwithprogressiveabdominaldistensionandinter-mittentbiliousvomiting

Plain X-ray○ Air fluid levels do not form in spite of complete small bowel obstruction be-

cause enteric contents are viscous and thick○ Dilatedloopsofsmallintestine○ Incaseofmeconiumileusinwhichperforationhasoccurred,intraperitonealeggshellcalcificationsarenoted

Management○ Conservative:GastrografinorMypaqueenema,whengivenwilleasilypasstoileumandmaydispersetheobstructionduetoitshighosmolarityanddetergentaction

○ Ifthismethodfailssurgeryindicated.

○ Bishop Koop operation resectionofmostdilatedseg-mentwithanendtosideanastomosisofcolontoileum.Thedistalilealopeningisformedintoanileostomythroughwhichthemeconiumisirrigatedpostopera-tively

tahir99 - UnitedVRG


CONGENITAL ATRESIAS○ Duodenalatresia(35%)○ Jejunalatresia(15%)○ Ileum(25%)○ Ascendingcolon(10%)○ Multiple(15%)Doublebubble—duodenalatresiaTriplebubble—jejunalatresia

SMALL BOWEL OBSTRUCTIONS1.Adhesions(60%):M/cfollowsappendicitisorotherpelvicopera-tions

Avoidimmediatesurgeryandobservefor<24hours

2.Malignancy(20%):M/cmetastasis.3.Hernias(10%)4.Crohn’sdisease(5%)○M/Ccauseofsmallbowelobstruction:Adhesions

Clinical features1.Abdominalcrampypain:Whenthebowelisstrangulatedpainbecomessteadyandmorelocalizedwithoutacolickycomponent

2.�omiting(followsonsetofpain)3.Obstipation4.Abdominaldistension5.�ever6.Bloodinstool(intussusception)

CAUSE OF DISTENSION1.Swallowedgas(m/c)2.�ermentationgasbybacteria

3.Extracellularfluidloss4.Gastrointestinalsecretions

ADHESION: CAUSES1. Ischemia 3. Infections—tuberculosis,

peritonitis4. Inflammatoryconditions—Crohn’sdisease

5.Radiationenteritis6.Drugs—practololSitesofanastomosis

RetroperitonealizationofrawareasTrauma�ascularocclusion

2.�oreignmaterial—talc,starch,gauze,silkRadiography To minimize adhesions○ Normal fluid levels ; 3–5 each < 2.5 cm is normal○ Fluid levels > 5 indicates small bowel obstruction○ Step ladder pattern: Small bowel obstruction

1.Goodsurgicaltechnique2.Washingperitonealcavitywithsalinetoremoveclots3.Minimizingcontactwithgauze4.Coveringanastomosisandrawperitonealsurfaces

Recurrent adhesions○ Repeatadhesiolysis○ Nobleplication

○ Charlesphillipsoperation○ IntraluminalBakerstubeviajejunostomy

tahir99 - UnitedVRG


PARALYTIC ILEUS (INORGANIC CAUSE)○ M/c—Postoperative○ Infections1.Peritonitis2.Intra-abdominalabscess3.Sepsis4.Pneumonia

○ Electrolyteabnormalities1.Uremia2.Hypokalemia3.Hyponatremia4.Hypomagnesemia5.Hypermagnesemia

○ Hypothyroidism○ MI○ Spinalcordinjury○ Retroperitonealhemorrhage

○ Mesentricischemia

○ Drugs1.Anticholinergics2.Opiates3.Phenothiazines4.Calciumchannelblockers5.Tricyclicantidepressants

Clinical features Differential diagnosis of organic and inorganic obstruction

○ Stateinwhichthereisfailureoftransmissionofperistalticwavessec-ondarytoneuromuscularfailure

○ Resultantstasisleadstoaccumulationfluidandgasinthebowelasso-ciatedwithdistension,vomiting,absentordiminishedbowelsounds.

○ Multipleairfluidlevel.

○ Onlydifferentiatingpointisgasincolonandrectuminparalyticileus

○ Otherclinicalpointsinfavorofparalyticileus 1.Diminishedbowelsounds 2.Nopaininabdomen

Management○ Usuallyresolvein3–5days○ Treatthecause

○ Ifprolongedbeyond5–7daysinterventionneededlaparoto- Ifprolongedbeyond5–7daysinterventionneededlaparoto-laparoto-mytor/ohiddencause

LARGE BOWEL OBSTRUCTIONS○ Twistingofasegmentoftheintestineonanaxisformedbyitsmesentryisvolvulus○ M/ccauseofcolonobstruction:Carcinomacolon.○ 2ndcommoncause:�olvulus○ M/csiteofvolvulus:Sigmoidcolon○ Coffeebeanappearance:Sigmoidvolvulus○ Clockwise:Cecalvolvulus○ Anticlockwise:Sigmoidvolvulus

Treatment○ �luidresuscitationfollowedbyendoscopicdecompressionusingsigmoidoscope○ Rectaltubeisinsertedtomaintainit○ Thisprocedureiscontraindicatedinevidenceofperforationorstrangulation○ Recurrencerateishigh○ Definitive treatment is—sigmoid colectomy

SALIENT POINTS IN LARGE BOWEL OBSTRUCTION○ M/csiteis:Sigmoidcolon○ Patentileocecalvalve—closedloopobstruction○ Closedloopobstruction:Colondistendsprogressivelyresultingingangreneandperfora- Closedloopobstruction:Colondistendsprogressivelyresultingingangreneandperfora-tion(m/csitebeingcecum)

Symptoms and signs○ Abdominaldistension—mostprominentinitialfinding○ Painislessseverecrampy○ �omitingislateandoccursifileocecalvalveisincompetent○ Obstipation○ Faeculent vomiting is seen in distal ileum obstruction and very rare in colon obstruction.

Resections○ Paul-Mikulicz operation—Proximalcolostomydistalbowelbroughtoutasfistulathatcanbeclosedextraperitoneallyinfuture.

○ Hartmann’s operation—Ifdistalbowelcannotreachthesurfaceitisclosedandreturnedtoperitonealcavityafterclosure.○ Secondstagecolorectalanastomosisisdoneifthepatientisfit

tahir99 - UnitedVRG


ACUTE MESENTERIC ISCHEMIA

1.SuddenocclusionofSMA(50%)AtherosclerosisEmbolism(m/ccause—90%cases)�asculitis(PAN)�ibromusculardysplasia

2.Mesentericveinocclusion(25%)Thrombosis:OCP,polycythemia,neoplasminfiltrating

3.Nonocclusiveobstruction(25%)Severeshock

Clinical features• Suddensevereabdominalpain,vomiting,abdominaldistension• �unctionalobstructionwithabsentbowelsounds• Shockandperitonitisisrapid• 100%mortalityifuntreated. Treatment

○ Resectionofnonviablebowelwithitsmesentery○ Secondlookoperation

MucosaisleastresistanttoischemiaIfmaintrunkofSMAisinvolvedinfarctionoccursfromduodenojeunalflexuretosplenicflexure

Classicallythepainiscentralandoutofproportiontophysicalfindings

Presenceofgasbubblesinmesentricveinispathognomonic

ISCHEMIC COLITIS○ M/csite:Splenicflexure○ Thumb print signonplainX-ray

X-ray finding○ Priortoinfarct:Plainabdominalfilm—normal.○ Adynamicileus,gaslessabdomen,smallbowelpseudo-obstruction.○ Pinkyprinting:�ormlessloopsofsmallintestine.○ Thumbprintingofrightcolon.○ Rarelypneumatosisorgasinportalvenoussystem.

Investigations○ UpperGIseries:Dilatedloops,thickenedfolds,mucosalulceration,scallopedbowelborder.

○ Duplex,CT,magneticresonanceimaging(MRI),positronemissiontomography(PET)scans.

○ Laparoscopy:Usefulonlyforserosallesions,mucosanotvisualized.

Management�luidresuscitationHeparinanticoagulationMesentricveinthrombosisisusuallyduetosmallperiph-eralveinthrombosis(SM�orIM�thrombosisisrare)

Hencethrombectomyisnotneeded(notindicated)If peritoneal signs are present—urgentlaparotomyneededIf peritoneal signs absent—heparin(5days),oralanticoag-ulationlifelongalongwithbowelrestandfluidsisenough.

PSEUDO-OBSTRUCTIONS○ Isaconditioninwhichtherearesignsandsymp-tomsofintestinalobstructionintheabsenceofactualphysicalcauseofobstruction

Types○ Acute : Ogilviesyndrome○ Chronic: Suspectthisinmedicalillpatient,withtympanicabdomenandnontender.

Contd...

tahir99 - UnitedVRG


PSEUDO-OBSTRUCTIONSEtiological classification

Primary Secondary [m/c]Motilitydisorder�amilialandsporadicvis-ceralmyopathy

Endocrine: Hypothyroidism,hypoparathy-roidism,diabetes

Neurological: Chagasdisease,Parkinson,spinalcordinjury

Smooth-muscle disorders:Collagenvasculardisorders,amyloidosis,musculardystrophy

Drugs: Phenothiazines,tricyclicantidepressants,opiates

Miscellaneous: Uremia,viralinfection,radiationenteritis,retroperitonealhematomas

○ Air fluid levels are unusual and should think of other causes

○ AcuteforminvolvesonlycolonwhereaschronicinvolvesotherpartsofGITalso

TreatmentColonoscopicdecompression(recurrence—25%)Whencolonoscopyfails:Subtotalcolectomyandileorectalanastomosis

RECTUM AND ANUSCANCER RECTUM

○ Earliestandm/csymptom—bleeding*○ Secondm/csymptomalterationinbowelhabits○ Earlymorningspuriousdiarrheaischaracteristicallyseen*○ Annularcanceratpelvirectaljunctionpresentswithconstipationandobstruction

○ Bestinvestigationfordiagnosis—Sigmoidoscopicbiopsy

○ Bestinvestigationforlocalspread—TransrectalUSG○ BestinvestigationforlocalTandNstaging—Tran-srectalMRI

Treatment part• Rectumlength—12cmisdividedintoupper,middleandlower1/3rd.Analcanal4cm

• Dentatelineisabout2.5cmfromanalverge• Internalsphincterisanorectaljunctionformedbypuborec-talismuscle.

• Rectal cancer needs a clearance atleast 2 cm distally.• Abdominoperinealresection(APR)isperformedwhenthesphinctercannotbepreservedCompleteexcisionofrectumandanusalongwithpermanentcolostomy

AlsoknownasMile’sprocedure

Anatomy of rectum �ortumorsinvolvingupper1/3rdanteriorresectionandfortumorsinvolvingmiddle1/3rdlowanteriorresection

Inotherwords…anteriorresectionisdonefortumorscon-finedtorectumhavingperitonealreflectionandlowanteriorresectionfortumorsinrectumwithoutperitonealreflection.Withtheadventinventionofstaplerslowanteriorresectionhasbecomeeasier

○ Upper1/3rd:Coveredbytheperitoneuminthefrontandthesides

○ Middle1/3rd:Coveredonlyinthefront.○ Lower1/3rd:Noperitonealcovering.○ Peritonealreflectionsformrectovesicalpouchinmalesandrectouterinepouchinfemalesanteriorly

Evenlower1/3rdtumorsaretakenupforsphinctersavinglowanteriorresection

Hartmann’sprocedureisdoneifthereistoomuchsepsisorobstruction,alsoifthepatientisveryelderlyandunsuitableforanytypeofresection.

Transanal excision of cancer rectum• T1N0orT2N0lesion<4cmindiameter• <40%circumferenceofthelumen• <10cmfromdentateline• Welltomoderatelydifferentiatedhistology• Noevidenceoflymphaticorvascularinvasiononbiopsy

ANAL CANCER○ M/c type:Squamouscellcarcinoma(alsoknownasepidermoidcarcinoma)

○ Second m/c type :Basalcellcarcinoma.

Contd...

Contd...

tahir99 - UnitedVRG


ANAL CANCER○ Chemoradiationisthetreatmentofchoice(Nigro

regimen)○ Morethan80%casesarecuredbychemoradiation.IfanyresidualtumorispresentAPRisdone

○ Chemousedare5-�U,mitomycinc○ Otheragentsarebleomycin,cisplatin,doxorubicin

Types of anal carcinomaAnal margin—distal to dentate line Anal canal—proximal to dentate line• Bowen’sdisease• Paget’sdisease• Basalcellcarcinoma• Analmarginsquamouscellcarcinoma• �errucouscarcinoma(Buschke-lowenstein)

• Epidermoidcarcinoma—tumorsarisingintransitionalzoneshareasimilarbehavior—cloacogenic,basaloid,squamouscellormucoepidermoidepithelial.

• Melanoma• Adenocarcinoma

Malignant melanoma anal canalAnalcanalisthirdm/csiteformelanomaafterskinandeyeRadioandchemoresistanttumorAge—50–60yearsNonspecificsymptoms—bleeding,painandmass

Only surgery—wide excision (treatment of choice) or APR (if wide area of anal canal in-volved). Both carry same survival and prognosis)

Recurrenceiscommon,butnotinthelocalarearesected.Occurssystemicallyratherthanlocally

HEMORRHOIDS○ Internalhemorrhoids—painless,locatedproximaltodentateline

○ Externalhemorrhoids—painful,locateddistaltodentateline

○ Recenttheoriesstatethathemorrhoidsarenormalanatomicalstruc-turesandtheyarecushionsofsubmucosaltissuecontainingvenules,arterioles,smoothmusclefibers,andelasticconnectivetissues.

○ Threehemorrhoidalcushionsarethereat3,7,11O’clockposition

Contd...

Contd...

tahir99 - UnitedVRG


HEMORRHOIDSTreatment

• Medical:1and2degreerespondstosoftfibrediet,stoolsofteners,dietregulation

• Rubber band ligation:1,2andselected3rddegree

• Sclerotherapy injec-tion:1,2,3rddegree

• Infrared photocoagula-tion:for1,2nddegreehemorrhoids

Surgery:4thdegree,mixedinternalandexter-nal,failureofnonoperativemanagement.

TheBarron’s bander isacommonlyavailabledeviceusedtosliptightelasticbandsontothebaseofthepedicleofeachhemorrhoid.

Injection sclerotherapy,thesubmucosalinjec-tionof5% phenol in arachis oil or almond oil,maybeadvisedusingGabriel syringe

TheopentechniqueismostcommonlyusedintheUKandisknownastheMilligan–Morgan operation:Namedafterthesurgeonswhodescribedit

FISSURE-IN-ANO○ Tearinanalmucosa,accompaniedbyseverepainattimeofdefecation

○ Characterizedbyfreshbleedingperanum.○ Perrectalexaminationiscontraindicated

○ M/csite:Midlineposterior○ M/csymptom:Pain○ Chronicfissureisaccompaniedbysentineltag○ Inpregnancy,itiscommonanteriorly

TreatmentConservative:Lignocaineandsteroidgellocalapplication

Surgery:Lateralsphincterotomy,whereinternalsphincteriscut

Maximumanaldilatationundergeneralanesthesiapreviouslydoneisnotallowednowadays

FISTULA-IN-ANO○ Dividedintotwotypeshighandlow,dependingwhethertheinternalopeningisaboveorbelowtheanorectalring

○ Highfistulasneedstagedoperationsasthereishigh-riskofincompetency

○ M/ctypeisintersphincteric○ Othertypesare—trans,supra,extrasphincteric○ Causesare:M/cfromcryptoglandularabscess(anorectalabscess).OthercausesareCrohn’sdiseasemalignancy,radiation,tuberculosis,actinomycosis

Goodsall’s rule• Anteriorlylocatedfistulasdraindirectlyintoanalcanal,whereasposteriorlylocatedfistulasdrainviaahorseshoetract.

ExceptiontoGoodsall’sisanteriorfistulalocatedgreaterthan3.5cmfromanalvergewillalsoformhorseshoetract

Treatment of fistula-in-ano○ �istulotomy○ Inhighanalfistulathereisriskofinjurytosphincter,hencesurgerymustbedonecarefully.

○ Inhighanalfistulas:Setons arespecialmaterials,whichareusedtohealthehighfistulaswithoutriskofinjurytosphincter

○ Asetonmaybeahorsehair,proleneareanyinertmaterial,whichisinsertedintothefistuloustractandbroughtviatheanalcanalandtiedtoallowfibrosis.

Contd...

tahir99 - UnitedVRG


NORMAL FECAL CONTINENCE REQUIRE○ Adequaterectalwallcompliance○ Appropriateneurogeniccontrol○ �unctionalinternalandexternalsphincters○ Anorectalanglemaintainsanacuteangle

○ Hemorrhoidalcushionsactsmechanicallybyblockinganalcanal

○ Anorectalring(puborectalis,deepexternalsphincter,internalsphincter)isveryimportantforcontinence

ANORECTAL ABSCESS○ Usually produces a painful, throbbing swelling in

the anal region.•Thepatientoftenhasswingingpyrexia• Subdividedaccordingtoanatomicalsiteintoperi-anal,ischiorectal,submucousandpelvirectal

•Underlyingconditionsincludefistula-in-ano (mostcommon),Crohndisease,diabetes,immunosup-pression

•Treatment isdrainageofpusinfirstinstance,togetherwithappropriateantibiotics

•Alwayslookforapotentialunderlyingproblem

Mostcommontypeofanalabscessisperianalab-scess.

Ischiorectalabscessspreadsfromonesidetootherinahorse-shoe-shapedtract.

PILONIDAL SINUS○ Thetermpilonidalsinusdescribesaconditionfoundinthenatalcleftoverlyingthecoccyx,consistingofoneormore,usuallynon-infected,midlineopenings,whichcommunicatewithafibroustracklinedbygranulationtissueandcontaininghairlyinglooselywithinthelumen.

○ ItiscommoninjeepdrivershencecalledJeeper’s bottom○ Itisthoughtthatthecombinationofbuttockfrictionandshearingforcesinthatareaallowsshedhairorbrokenhairs,whichhavecollectedtheretodrillthroughthemidlineskinorthatinfectioninrelationtoahairfollicleallowshairtoentertheskinbythesuctioncreatedbymovementofthebuttocks,socreatingasubcutaneous,chronicallyinfected,midlinetrack

Treatment• Manymethodsarethereforsurgery.�orthefirsttimewecanexcisethesinuswidelocallyandal-lowittohealbysecondaryintention.(Disadvan-tageisthehealingofwoundtakesalongtime)

• Excision of all tracks and then closure by some other means designed to avoid a midline wound (Z-plasty, Karydakis procedure)

• Bascom’s procedure involves an incision lateral to the midline to gain access to the sinus cavity, which is rid of hair and granulation tissue

PRURITUS ANI○ Thisisintractableitchingaroundtheanus,acommonandembarrassingcondition.Usually,theskinisreddenedandhyperkeratoticanditmaybecomecrackedandmoist.

○ Thecausesarenumerous.○ Ausefulmnemonicis‘pus,polypus,parasites,piles,psyche’

Causes• Lackofcleanliness• Perianaldischargeduetofistula,hemorrhoidsandfis-sure

Infectiouscauses:• Trichomonasvaginalis• Parasitecauses:Threadworms,scabies,etc.• Epidermatophytosis• Bacterialinfection:Corynebacterium diphtheriae

• Allergy:Hayfever• Skindiseases:Psoriasis,lichenplanus,contactdermatitis

• Psychosis• Diabetes

Contd...

tahir99 - UnitedVRG


PRURITUS ANITreatment

HygienicmeasuresStrappingbuttock

HydrocortisoneUnlessthereisconcomitantlesioninanusandrectumnoneedofsurgery.

IMPERFORATE ANUS○ Imperforateanus(strictly,itshouldbeanal‘agenesis’or‘atresia’)hashistoricallybeendividedintotwomaingroups○ Highandlow:Dependingonthelevelofterminationoftherectuminrelation to the pelvic floor

Boys Girls○ Themostfrequentdefectinboyswithimperforateanusisoneinwhichthedistalrectumissitedwithinthepuborectalissling,butterminatesasafistulaintothe bulbar urethra or prostatic urethraabovethemainanalsphinctercomplex.

○ Boyswithafistulaintothebladderneck(ahighdefect)havethepoorestprognosis,becauseoftheunderdevelopmentofthesacrumandpelvicandanalmusculature

○ Themostcommondefectingirlsisarectovestibularfistulainwhichthefis-tulaopensintotheposterior vestibule (not the vagina)

Investigation to diagnoseLateralproneradiographwithoutcontrastistakenat24hours,whenintestinalgasreachesrectum.

Invertogram*withbabyupsidedownX-rayshowsairindistalrec-tumat6hourswithacoinattheanalorificeplace.

TreatmentLowanomalieswithaperinealfistulacanbetreatedbyananoplasty.Morecomplexmalformationsrequireearlycolostomy,withdefinitiverepairperformedseveralmonthslater.

Thismayinvolveposterior sagittal anorectoplasty (PSARP,Pena,withorwithouttransabdominalmobilizationoftheleftcolonanddivisionofanycommunicationwiththeurinarytract)

RECTAL PROLAPSE○ Partial:Onlymucosaandsubmucosaprotrudesout○ Complet:Wholerectalwallprotrudes

Treatment of partial prolapseInchild—digitalreposition,submucousinjnof5%phenolInadults—submucousinjnofalmondoil,exciseprolapsedmucosa

Treatment of complete prolapseAdults

Perineal approach Abdominal approach Children:1.Thierschoperation2.Lockhart-Mummeryrectopexy Delormesoperation

ThierschoperationAltemeier’sprocedure

RipsteinsanteriorrectopexyWell’sposteriorrectopexy

Contd...

tahir99 - UnitedVRG


SOLITARY RECTAL ULCER○ Usuallyinanteriorrectum○ Causes:Intussusceptions,anteriorrectalwallprolapse,increasedintrarectalpressure

○ Increasedstrainingduetoconstipation

○ Pain,bleeding,mucusdischarge,outletobstruction○ Treatment:Diet(highfiberdiet,laxatives,avoidstraining)○ Surgeryreservedformedicallyfailedcases

ABDOMINAL COMPARTMENT SYNDROME○ Definitionofabdominalcompartmentsyndrome(ACS):○ Organdysfunctioncausedbyintra-abdominalhypertension(IAH)

Category• PrimaryoracuteACS:Intra-abdominalpathologyisdirectlyandproximallyresponsibleforthecom-partmentsyndrome.

• SecondaryACS:Novisibleintra-abdominalinjuryispresent,butin-juriesoutsidetheabdomencausefluidaccumulation.

Itisduesplanchnicreperfusionaftermassiveresus-citation.

• ChronicACS:Thisoccursinthepres-enceofcirrhosisandascites,ofteninthelaterstagesofthedisease.

Pathophysiology

Compression of kidneys Decreased venous return Increased intrathoracic pressure ○ Decreasedrenalbloodflow

○ Decreasedurineoutput.

○ Decreasedcardiacoutput,ventricularenddiastolicvol-umeandstrokevolume

○ Increasedvascularresistance

○ Hypoxemiadueto:1.Increasedairwaypressure2.Decreasedcompliance3.Increasedcentralvenouspressure(C�P)

4.Increasedpulmonaryarterypressure

o Increased intra-cranial pressure

CausePrimary (i.e. acute) Secondary ChronicPenetratingtraumaIntraperitonealhemorrhagePancreatitisExternalcompressingforces,suchasdebrisfromamotorvehiclecollisionorafteralargestructureexplosion

PelvicfractureRuptureofabdominalaorticaneurysmPerforatedpepticulcer

○ Occurinpatientswithoutanintra-abdominalinjury (�luidaccumulatesinvolumessufficienttocauseIAH)Large-volumeresuscitation:Theliteratureshowsasig-nificantlyincreasedriskwhenmorethan3Lareinfused.

Largeareasoffullthicknessburns:PenetratingorblunttraumawithoutidentifiableinjuryPostoperativePackingandprimaryfascialclosure,whichincreasesincidence

Sepsis

Peritonealdialysis

Morbidobesity

CirrhosisMeigssyn-drome

Contd...

tahir99 - UnitedVRG


ABDOMINAL COMPARTMENT SYNDROMEClinical Complication○ Physicalexaminationreveals•Distendedabdomen•Wheezes,rales,increasedrespiratoryrate•Cyanosis

○ Renalfailure○ Respiratorydistressandfailure○ Bowelischemia(bacterialtranslocation)○ Increasedintracranialpressure○ �ailingcardiacoutputandrefractoryshock○ Hypotensionandasystole:Reperfusionsyndromeandde-creasedS�R

Reperfusion syndrome Image studies• Suddenlossofbloodpressureafterabdominaldecompression

• Noclearetiologyexists• Maybeduetoacombinationoffactors,includingthefollowing:○Washoutofproductsofanaerobicmetabolism(e.g.lacticacid),whichmaybedirectlytissuetoxic

○ SuddenlossofS�R○Prevention:I�resuscitationwithmannitolandNaHCO3immediatelybeforedecompression

• Examinetheabdominalseriesforevidenceoffreeairorbowelobstruction.

• (Realizeplainabdominalradiographicstudiesareoftenuselessinidentifyingabdominalcompartmentsyndrome)

• AbdominalCTscanningcanrevealmanysubtlefindings:Round-bellysignAbdominaldistentionwithanincreasedratioofanteroposterior-to-transverseabdominaldiameter(ratio>0.80;P<0.001)

CollapseofthevenacavaBowelwallthickeningwithenhancementBilateralinguinalherniation

• Abdominalultrasonography

Diagnosis○ ThefollowinggradingsystemhasbecomeacceptedifIAHispresent○ (NormalIAP:0–7cmH2O)•GradeI,13–20cmH2O•GradeII,21–35cmH2O•GradeIII,36–47cmH2O•GradeI�,greaterthan48cmH2O

Bladder pressure grading I. 10–15mmHg II. 16–25mmHg III. 26–35mmHgI�. >35mmHg

Measurement○ Direct:Needlepuncturetoperitonealcavity○ Indirect:a.Intermittent(commonlyperformed): Intraluminalbladderpressureb.Continuous:Balloontipcatheterintostomach

Management outlineGenerallynospecificbladderpressureneedsactiveinterventionunlessthepressureexceeds>35mmHg

Decompressionitselfmayleadtodangerifdonepresumptively60%mortalityifdonepresumptively70%mortalityifnotdoneatappropriatetime.

Treatment In ICU○ GIdecompression(mechanical,drugs)○ Diureticswithalbumin○ Sedationandmusclerelaxant○ Percutaneousfluiddrainage○ Laparoscopicdecompression:○ Surgicaldecompression

○ Inintensivecareunit(ICU),thecauseoftheseeventsmighteasilybemistakenforotherpathologiceventssuchashypov-olemiaiftheclinicianisnotalertedtothemorbidityassociatedwithACS.

○ TwotypesofdecompressioninICU1.OperativelyinICUitselfinhemodynamicallyunstable2.IncasesofprimaryACS—percutaneousdrainisbest.

Decompression by surgery○ Longmidlinelaparotomyistheproceduredone○ Thoughopenedfullmidlinemonitorbladderpressureevery4hoursassomepatientsmayneedrepeatdecom-pression

○ Theopenwoundmaybecoveredbymanyways:1.�ascialclosurewithmesh2.Splitskingrafts3.Methodofchoiceisvacuum-assistedclosure(�AC)devices.

Contd...

tahir99 - UnitedVRG


FMGE QUESTIONS

1. Routine management of paralytic ileus include all of the following, except: (Sep 2009, 2007)

a. Electrolytecorrection b. Nasogastricaspiration c. Parasympathomimetics d. IntravenousfluidsAns: c (Parasympathomimetics)Parasympathomimetics is used only in resistant casesandnotroutinely.Management of paralytic ileus:Bailey and Love (Page 1201, 25th edition)State inwhich there is failureof transmissionofperi-statlticwavessecondarytoneuromuscularfailure.�arieties: 1. Postoperative’—remainsfor24–72hours 2. Infection 3. Reflexileus—�ractureribs,spineorretroperitoneal

hemorrhagemayresultinileus 4. Metabolic—uremiaandhypokalemiaO/E:• Nobowelsounds(DD:Mechanicalobstruction—in-creasedbowelsounds)

• Obstipation(Notpassingstoolsaswellasflatus)Management:• Nasogastricsuction• Restrictionoforalintake• Correctelectrolytedisturbance• Intravenous(I�)fluids• Treatthecause• Noplaceforroutineperistalticstimulants*• Rarely in resistant cases—Cholinergic stimulants(e.g.neostigmine)canbeused—Catchpole regimen*

• Ifparalyticileusisprolongedweshoulddolaparoto-mytolookforanyhiddencauseforobstruction.

2. Ideal management in an old and frail patient pre-senting with intestinal obstruction with a mass situ-ated 15 cm away from anal orifice: (March 2010)

a. Abdominoperinealresection b. Colonoscopicremoval c. Hartmann’soperation d. AnteriorresectionAns: c (Hartmann’s operation)Explanation:• Thisisacaseofintestinalobstructionduetocancerrectuminupper-third.

• �orupper-thirdrectumcancersifthepatientisfitandhemodynamicallystableweoptforanteriorresection(explainedinmaterial).

• But,sincethispatientisoldandfrailwegoforHart-mann’s operation—proximal colostomy and distalclosure. Hartmann’s is a very useful procedure inemergencyconditions.

3. Which of the following is not associated with Crohn’s disease? (March 2010)

a. �istula b. Stricture c. Pseudopolyps d. GranulomaAns: c (Pseudopolyps)Explanation:inmaterial

4. Hirschsprung disease involves, which region of intestine commonly: (March 2007)

a. Colon b. Rectum c. Rectosigmoidpart d. TerminalileumAns: c (Rectosigmoid part)Explanation:BaileyandLove(Page86),25thedition• Theaganlionosisisrestrictedtorectumandsigmoidcolon(shortsegment)—75%

• Involvesproximalcolonalsoin15%(longsegment)• Entire colon and a portion of terminal ileum—10%(totalcolonicaganglionosis)

5. Hirschsprung disease in diagnosed by: (Sep 2006) a. USG b. CTscan c. Anogram d. RectalbiopsyAns: d (Rectal biopsy)Explanation:(BaileyandLovePage87,25thedition)• �amilial or associated with Down’s/other geneticdisorders

• Genemutationisidentifiedonchromosome10(RETprotooncogene*)andrarelyinchromosome13

• Definitive diagnosis is by Full thickness rectal biopsy*,whichwillshowabsenceofganglioncellsbothinauerbachandmyentericplexusandpresenceofhypertrophiednervetrunks.

tahir99 - UnitedVRG


6. Which of the following is the investigation of choice for diagnosing carcinoma colon? (Sep 2009)

a. X-rayabdomen b. CTscan c. Colonoscopy d. BariumenemaAns: c (Colonoscopy)Colonoscopyisthebestinvestigationtodiagnosecancerofcolonbecausewecantakebiopsyalso.

7. Uncommon complication of Meckel’s diverticu-lum is: (Sep 2007)

a. Intussusception b. Diverticulitis c. Malignancy d. IncreasedbleedingAns: c (Malignancy)• M/ccomplicationoverall—bleeding’• M/ccomplicationinadults—obstruction• M/ccomplicationinchildren—bleeding

8. Acute appendicitis is characterized by all of the following, except: (Sep 2005)

a. Anorexia b. Rovsing’ssign c. �ever>42degreecelsius d. PeriumbilicalcolicAns: c (Fever > 42 degree celsius)Explanation:Page1208(BaileyandLove,25thedition)• AcuteappendicitisischaracterizedbyMurphy’s triad* Pain(migratory) �omiting �ever• Patientgetspainfirstaroundtheumbilicus(Visceral

pain—Which is poorly localized)• Thepatientthengetsprogressiveinflammationandtheadjacentperitoneumgetsirritatedcalledsomatic pain—which is localised in the right iliac fossa.

• This classic visceral—somatic sequence of pain is seen in more than half of patients.

• Anorexiaisaconstantclinicalfeature• Fever:Pyrexiaisalwaysslight(37.2—37.7°C).Itwillnever reach beyond 38.5°C. If it goes beyond thattemperature other causes like mesenteric adenitismustbethought.

• Rovsing’s sign—PaininRI�oncompressingtheleftiliacfossaisafeatureofappendicitis

9. Enteroenteric fistula is found in all, except: (March 2005) a. Crohndisease b. Colorectalmalignancy

c. Actinomycosis d. UlcerativecolitisAns: d (Ulcerative colitis)Explanation:(Refermaterial)�istulaisafeatureofCrohndiseaseandnotseeninul-cerativecolitis.

10. Which of the following statement is false? (March 2011)

a. GranulomatousinflammationisfoundinCrohndisease.

b. PerianallesionsarecommoninCrohndisease. c. Strictureinvolvingthecolonisfoundinulcera-

tivecolitis. d. �istulaformationiscommoninCrohn’sdis-

ease.Ans: c (Stricture involving the colon is found in ulcera-tive colitis).Stricture isa featureofCrohndiseaseandnotseen inulcerativecolitis.

11. Which of the following is not a commoner cause of intestinal perforation (March 2004)

a. Gastriculcer b. Coloniccancer c. Typhoid d. CrohndiseaseAns: b (Colonic cancer)ExplanationAlltheabovecanproduceperforationandperitonitis.Butcoloniccancerveryrarelypresentwithperforation• Rightcoloncancerpresentswithmassandanemia• LeftcoloncancerpresentswithintestinalobstructionTyphoidcasespresentwithintestinalperforationon3rdweek.

12. A patient presents with history of mild diarrhea, blood in stools with multiple fistulas. What is the most probable diagnosis? (March 2007)

a. Intestinaltuberculosis b. Ulcerativecolitis c. Crohndisease d. TyphoidAns: c (Crohn disease) Explanation: Explained in material

13. Ochsner-Sherren regimen is used for: (March 2007, Sep 2010) a. Appendicularabscess b. Pelvicabscess c. Appendicularmass d. AcuteappendicitisAns: c (Appendicular mass) Explanation: Explained in material

tahir99 - UnitedVRG


14. Most common site of volvulus is: (Sep 2009, 2010) a. Ileum b. Appendix c. Sigmoidcolon d. CecumAns: c (Sigmoid colon)Explanation:• M/csiteofvolvulus—Sigmoidcolon• M/csiteforlargeintestinalobstruction—Malignancy(2ndcause—volvulus)

• Directionofsigmoidvolvulus—Anticlockwise• Directionofcecalvolvulus—Clockwise

15. The commonest cause of significantly lower gas-trointestinal bleed in a middle aged person with-out any known precipitating factor may be due to:

(Sep 2005) a. Ulcerativecolitis b. Ischemiccolitis c. Angiodysplasia d. DiverticulumofsigmoidcolonAns: d (Diverticulum of sigmoid colon)Explanation:MostcommoncauseoflowerGIbleedinginoldagepa-tientsisdiverticulumofcolon.Angiodysplasiaofcolon:• Itisavascularmalformationassociatedwithageing.• Incidencevariesfrom—5%–25%over60years• M/cinascendingcolonandcecumofelderlypatient.• Malformation consist of dilated tortuous vessels insubmucosaandinseverecasesmucosaisreplacedbymassivelydilateddeformedvessels.

16. Treatment of an incidentally detected appendicu-lar carcinoid measuring 2.5 cm is: (March 2008)

a. Righthemicolectomy b. Limitesresectionoftherightcolon c. Totalcolectomy d. AppendicectomyAns: a (Right hemicolectomy) (Refer: Bailey and Love- Page 1217)Carcinoid tumor of appendix:• Mostcommonindistalpartofappendix• Appendicealcarcinoidsrarelyproducemets.Treatment:• �ortumors<2cmandnotinvolvingcecalwall—ap-pendicectomyisenough

• �ortumors>2cm/baseinvolved/lymphnodesin-volved—righthemicolectomy.

17. A 26-year-old male presented with 4 day history of pain in the right sided lower abdomen with fre-quent vomiting. Patients GC is fair and clinically a tender lump was felt in the right iliac fossa. Most appropriate management for this case would be:

(Sep 2007) a. Exploratorylaparaotomy b. Immediateappendicectomy c. Ochsner-Sherrenregiman d. ExternaldrainageAns: c (Ochsner-Sherren regiman)ThiscaseofappendicularmassismanagedbyOchsner-Sherrenregimen

18. Lateral internal sphincterotomy is useful for: (Sep 2009, 2010) a. Analfistula b. Analcanalstrictures c. Hemorrhoids d. AnalfissureAns: d (Anal fissure)

19. Treatment of choice for 3rd degree hemorrhoids is: (March 2009, Sep 2010)

a. Sclerotherapy b. Bandligation c. Hemorrhoidectomy d. AlloftheaboveAns: d (All the above)

20. All of the following are true regarding pilonidal sinus, except: (March 2009)

a. Seenpredominantlyinwomen b. Occursonlyinsacrococcygealregion c. Tendencyforrecurrence d. ObesityisariskfactorAns: a (Seen predominantly in women)• Itsmostcommoninhairymalesnotinfemales.

21. Jeep disease is also known as: (March 2008) a. Analincontinence b. Hemorrhoids c. Pilonidalsinus d. AnalfissureAns: c (Pilonidal sinus)

22. Ideal investigation for fistula-in-ano is: (Sep 2005, 2007) a. Endoanalultrasound b. MRI c. �istulography d. CTscanAns: a (Endoanal ultrasound)

tahir99 - UnitedVRG


• EndoanalUSGisthemostaccurateinvestigationthanclinicalexamination

• ThoughMRI is acknowledged tobegold standard,becauseof its limitedavailability itsusefulonly forrecurrentfistula-in-ano.

23. Aim of surgery in carcinoma rectum is: (March 2004) a. Limitedexcisionoftherectum b. Sacrificinggastrointestinalcontinuity c. Preservingtheanalsphincter d. PreservingmesorectumAns. c (Preserving the anal sphincter)

24. A 10-month-old infant present with acute intesti-nal obstruction. Contrast enema X-ray shows the intussusception. Likely cause is: (March 2009)

a. Peyer’spatchhypertrophy b. Mekel’sdiverticulum c. Mucosalpolyp d. DuplicationcystAns: a (Peyer’s patch hypertrophy)

25. After undergoing surgery, for carcinoma of colon, a 44-year-old patient developed single liver metas-tasis of 2 cm. What do you do next? (Sep 2008)

a. Resection b. Chemoradiation c. Aceticacidinjection d. RadiofrequencyablationAns: a (Resection)

26. A 50-year-old male, working as a hotel cook, has four dependent family members. He has been di-agnosed with an early stage squamous cell cancer of anal canal. He has more than 60% chances of cure. The best treatment option is: (Sep 2008)

a. Abdominoperinealresection. b. Combinedsurgeryandradiotherapy. c. Combinedchemotherapyandradiotherapy. d. Chemotherapyalone.Ans: c (Nigro regimen—Chemoradiation)

27. The following is ideal for the treatment with in-jection of sclerosing agents: (Sep 2007)

a. Externalhemorrhoids b. Internalhemorrhoids c. Prolapsedhemorrhoids d. StrangulatedhemorrhoidsAns: b (Internal hemorrhoids)

28. In which of the following locations, carcinoid tu-mor is most common? (Sep 2003)

a. Esophagus b. Stomach c. Smallbowel d. AppendixAns: c (Small bowel)

29. Gardner’s syndrome is a rare hereditary disorder involving the colon. It is characterized by:

(Sep 2005) a. Polyposiscolon,cancerthyroid,skintumors b. Polyposisinjejunum,pituitaryadenomaand

skintumors c. Polyposisofcolon,osteomas,epidermalinclu-

sioncyst,fibroustumorsinskin d. PolyposisofGIT,cholangiocarcinomaandskin

tumorsAns: c (Polyposis of colon, osteomas, epidermal inclu-sion cyst, fibrous tumors in skin)

30. All of the following are true for patients of ul-cerative colitis associated with primary sclerosing cholangitis (PSC), except: (Sep 2006)

a. Theymaydevelopbiliarycirrhosis b. Mayhaveraisedalkalinephosphatase c. Increasedriskofcholangiocarcinoma d. PSCrevertsafteratotalcolectomyAns: d (PSC reverts after a total colectomy)

31. Patients of rectovaginal fistula should be initially treated with: (Sep 2008)

a. Colostomy b. Primaryrepair c. Colporrhaphy d. AnteriorresectionAns: a (Colostomy)

32. Most common cause of hepatic abscess in India is: (March 2007) a. Amebicabscess b. Infectedhematoma c. Ascendinginfection d. SecondarytocholelithiasisAns: a (Amebic abscess)

33. Not a complication of Crohn disease: (Sep 2005) a. Sclerosingcholangitis b. Granuloma c. �istula d. StrictureAns: None

tahir99 - UnitedVRG


• All the above mentioned complications can occurwithCrohndisease

• Ifyouwanttoexcludeyoucanexcludeprimaryscle-rosing cholnagitis—which is rare in Crohn’s com-paredtoulcerativecolitis.

34. Hirschsprung disease is most commonly involves: (Sep 2005) a. Rectosigmoidjunction b. Rectum c. Colon d. TransversecolonAns: b (Rectum)

35. Hirschsprung disease is diagnosed by: (Sep 2005) a. Rectalbiopsy b. USG c. CTscan d. BariumenemaAns: a (Rectal biopsy)

36. Brunners glands are seen in: (Sep 2006) a. Duodenum b. Ileum c. Stomach d. ColonAns: a (Duodenum)

37. Meckel’s diverticulitis associated with: (Sep 2006) a. Increasedbleeding b. Associatedwithinguinalhernia c. Pharyngealpouch d. AlltheaboveAns: a (Increased bleeding)

38. Acute appendicitis is not characterized by: (Sep 2006) a. �ever>42°C b. Anorexia c. Rightiliacfossapain d. �omitingAns: a (Fever >42°C)

39. Enterocutaneous fistula is found in: (March 2007) a. Crohndisease b. Ulcerativecolitis

c. Ischemiccolitis d. AmebiccolitisAns: a (Crohn disease)

40. Treatment of appendicular abscess are all, except: (Sep 2009) a. Intraperitonealdrainage b. Extraperitonealdrainage c. Emergencyappendicectomy d. ObservationAns: d (Observation)

41. Villous adenoma present as: (Sep 2010) a. Hypercalcemia b. Hypokalemia c. Hyperphosphatemia d. AlltheaboveAns. b (Hypokalemia)

42. Treatment of choice for small intestine carcinoma: (March 2011)

a. Radiotherpay b. Chemotherapy c. Surgery d. NoneoftheaboveAns. c (Surgery)

43. Which of the following is a dynamic cause of in-testinal obstruction: (March 2011)

a. Gallstone b. Paralyticileus c. Mesentericvascularobstruction d. OgilviesyndromeAns: a (Gallstone)• Dynamiccausemeansanymechanicalcauseforob-struction,e.g.hernia,adhesions,gallstones,etc.

• Adynamic orparalytic ileus there is nomechanicalcauseforobstruction

44. Enteoenteric fistula is seen in: (March 2011) a. Ulcerativecolitis b. Crohndisease c. Bothoftheabove d. NoneoftheaboveAns: b (Crohn disease)

tahir99 - UnitedVRG

13Hepatobiliary and pancreatic SyStem

Gallbladder and biliary tractAnatomy○ Capacity:50ml,7-12cm○ Cysticduct(CD):1-3mmdiameter○ CryptsofLuschka:mucousfoldsingallbladder(GB)○ Common hepatic duct: 2.5 cm○ Common bile duct: 7.5 cm and contains 4 parts1.Supraduodenal(SDP)(2.5cm)2.Retroduodenal(RDP)3.Infraduodenalorintrapancreatic(IfDP/IPP)4.Intraduodenal(InDP)

○ Enters duodenum at ampulla, located posteriorly 10 cm from py-lorus

○ Cystic artery arisesfromrighthepaticarterybehindcommonhepaticduct.Accessorycysticartery—fromgastroduodenalartery.

calot triangleo Formed between1. Inferior:CysticductandGB.2.Medial:Commonhepaticduct3.Above:Inferiorliversurface

Moynihans huMp and caterpillar turn○ Righthepaticarterytakesatortuouscourseinfrontoforiginofcysticduct○ MaybedamagedinCalot’striangle

lymphatic drainage○ CysticnodeofLund—sentinelnodeofGB○ PresentinCalot’striangle.

tahir99 - UnitedVRG

145Hepatobiliary and Pancreatic System

anoMalies of Gallbladder○ MCanomalyPhrygiancap(fundusisconstrictedandturnedbackonitself)○ OthersDoubleGB,septuminGB,diverticulosisinGBandHartmann’spouch.

cystic duct variations○ Lateralinsertion—15%to20%○ Anteriororposteriorinsertion—m/c40%

○ Spiralandmedial—35%○ Paralleltocommonbileductandinsertsdistally—5%.NormalsizeofCBD:6mm

functions of Gb1.Absorption:10timesconcentrationoccurs2.Secretion:SecretesH+ions,mucusdecreasesbilepHandhencekeepscalciumsaltssolubleinacid.

3.Motor:CCKstimulatescontractionofGBVagusnervestimulatescontractionInhibitionbyVIPandsomatostatin.

cholecystokinin causes biochemistry• Thegallbladdertocontract• Thehepatopancreaticsphinctertorelax• Asaresult,bileenterstheduodenum.

Cholesterolandphospholipidssynthesizedinliverareprincipallipidsinbile

Primarybilesalts(cholate,chenodoxycholate)aresynthe-sizedinliverconjugatedwithtaurineandglycine.

investiGationoral cholecystogram (Graham-cole test) plain X-ray• Dye used: Iopanoicacidbp• Mainlyusedfornonopaquestones.

• 10%gallstonesareradioopaque• Porcelain GB:CalcifiedGB(premalignant)

limey bile iv cholangiogram usG• Relatedtomultiplesmallgallstones• Notpremalignant.

• Biligrammeglumineioglyca-mate*

• First investigation for GB and bile duct.

hida scan ct scan• Tc 99m-labeled iminodiacetic acid• Secretedbyliverintobile,henceusefulincasesofobstruction

• Acutecholecystitis:mostaccuratetest—nonvisualizationofGB

• Tostudyjaundiceinneonates• Tolocateleaksandanastomoticpathology.

• Onlyincarcinomagallbladderandbileduct.Mrcp

• Mostaccuratenoninvasive.

ercp• Gold standard in gallstones• Inmodernworld,onlyusedforinterventionalpurposes*.Diagnosticpurposeisoutdated.

tahir99 - UnitedVRG


cholecystosis Gallbladder polyp risk of malignancy○ Chronic inflammatory changes with hyperpla-

siaCholesterosis—strawberry GB,associatedwithcholesterolstones

CholesterolpolyposisAdenomyomatosis—intramuraldiverticulosisDiverticulosisofGB—associatedwithblackpigmentstonesincryptsofluschka*.

Types:1.Cholesterolpolyps2.Adenomyomatosis3.Benignadenomas4.Malignantadenocarci-noma

1.Oldage2.Gallstonesassociated3.Documentedincreaseinsize4.Size>10mm○Cholecystectomyisdoneinsymp-tomaticpolypsandasymptomaticpolypswithanyofaboverisk.

Gallstones○ MC type of stone mixed stone○ Types of stonesCholesterolstonesBrownpigmentstonesBlackpigmentstonesMixed

Pathogenesis○ Lithogenicbile○ Nucleation○ Stasis

lithogenic bile○ Bilesaltsandphospholipidsinbilekeepcholesterolinsolutionbyform-ingmicelles

○ Normal ratioBileacids:cholesterol=20:1Criticalratio=<13:1atwhichcrystallizationoccurs.

○ Cholesterolisinsolubleinwater,whichismadesolublebybilesaltsandphospholipids

○ Increasedcholesterol1.Obesity2.High-cholesteroldiet3.Clofibratetherapy.

decreased bile salts1.Primarybiliarycirrhosis2.OCP/estrogens3.Geneticfactors○Decreased7-alpha-hydroxylase(Convertslivercholesteroltobileacids)

4.Decreasedenterohepaticcirculationa.Ilealdiseaseb.Ilealresectionc.Cholestyraminesd.Deoxycholates

nucleation stasis○ Processbywhichcholesterolmonohydratecrystalsformandagglomeratetobecomemacroscopiccrystals

○ Excesspronucleatingfactors—1.Mucins,2.Nonmucinglycoprotein,3.Infection.

○ DeficiencyofantinucleatingfactorsApolipoproteinsa1anda2

ProlongedTPNFastingPregnancyDrugs—OctreotidesOCPBurns,surgery.

predisposing factors• Fat,fertile,female,flatulent,fifty(5f’s)• Diabetesmellitus.

• Oldage○ Increasedcholesterollevel○Decreasedbileacidpool○Decreasedbladdermotility.

piGMent stones○ Namegivenwhencontainscholesterol<30% black pigment

Composition:Purecalciumbilirubinate+mucin predisposed by brown pigment

○ Geneticfactors○ Chronichemolysis○ Alcoholiccirrhosis○ Infection—E. coli,ascariasis,clonorchis○ Ilealresection/bypass○ Cysticfibrosis.

Composition:Calciumsaltsofunconjugatedbilirubin+cholesterol+calciumbilirubinate/palmitate/stearate.

black pigment○ MCinhemolyticstates1.Hereditaryspherocyto-sis,sicklecelldisease

2.Heartvalves(mechanical)

3.Livercirrhosis

4.Gilbertsyndrome5.Cysticfibrosis6. Ilealresection.

contd...

tahir99 - UnitedVRG


piGMent stonesbrown pigment acalculus cholecystitis

○ Rareingallbladder○ Primarybileductstoneformation

○ Duetobilestasisandinfection○ MCE. coli*

○ MCinpresenceofFB,stents,parasites○ E. colisecretesbetaglucuronidasethatdeconjugatesthesolubleconjugatedbilirubintoinsolublefreeunconjugatedbilirubin

○ Highestmortality*○ Mostcommonlymisseddiagnosis○ M/cinpatientsrecoveringfrommajorsurgeryandburns,trauma*

coMplications1.Silent2.Acutecholecystitis3.Chroniccholecystitis

4.Mucocele5.Empyema6.Gangrene

7.Carcinoma8.Fistula

Mucocele Mirrizzi syndrome○ Obstructionofstoneat

neckofgallbladder○ BiletotallyabsorbedandreplacedbymucousandsecretionofGB1.Empyema2.Perforation3.Gangrene.

○ Treatment:Earlycholecys-tectomy

○ Itreferstotheobstructionorstrictureofthecommonhepaticductasresultofextrinsiccompressionbyagall-stoneinthecysticduct.

typesType1:(11%)—extrinsiccompressionofCHDbyalargestoneinHartmann’spouch

Type2:(41%)—stonehasnowerodedintothehepaticducttoformafistulainvolvinglessthanone-thirdofcircumfer-ence

Type3:(44%)—lesionsinvolvetwo-thirdofcircumferenceType4:(<4%)—completelydestroyedhepaticduct.

fistulas from gallbladder saint triad• MCsiteduodenum(cholecystoentericfistula)• Diagnosissuspiciousbypresence of air in bile duct• Complication:Gallstoneileus• Othersitesoffistula:Colon.

○ Gallstones○ Diverticulosisofcolon○ Hiatushernia.

contd...

tahir99 - UnitedVRG


liMey bile• OnX-ray—calciumprecipitationinthewallofgallbladderproducingdiffusehazy,opacificationduetocalciumsaltsecretion.Clinicallyasymptomatic,butcholecystectomytobedoneThisconditionoccurswhenthereisgradualobstructionofcysticductorCBDduetochronicpancreatitisorcapancreas.Toothpaste-likematerialinGB.

treatMent options○ Operate for symptomatic gallstones○ Forasymptomaticstone,surgerymustinfollowingsituationsonly3cmsizeMultiplesmallstones(canpasstoCBD)PolypassociatedwithstonePorcelaingallbladderCongenitallyabnormalgallbladderDiabeteswithgallstonesImmunocompromisedpatients:ComplicationsarehighTransplantcases.

Medical treatment○ Usefulonlyforcholesterolgallstonesnotforpigmentstones

○ Mechanismisbyinhibiting3-hydroxy-3-methylglutar-yl-coenzymeA(HMGCo-A)reductaseincholesterolsynthesis,thusdecreasecholesterolsupersaturation.

○ Usefulonlyin:RadiolucentSize<10mmFunctioninggallbladderNonacutesymptoms.

coMMon bile duct stonesprimary secondaryFormedinbileductitselfBrownpigmentstonesmostcommonly.

FormedingallbladderandentersCBDCholesterolstones.

clinical featurescharcot triad reynaud pentad○ CBDstonecausingcholangitis Pain+Jaundice+Rigors ○ Charcotstriad+Septicshock+Mentalstatuschangescholangitis Lab findingsEtiological factors:○ CBDstone○ Endoscopicretrogradecholangiopancreatography(ERCP)

○ Benignandmalignantstric-tures

○ ParasitesM/CorganismsE. coli,

Klebsiella,Streptococcus faecalis,Bacteroides

In absence of cholangitis In presence of cholangitis First investigation to be done—USG

Definitive investigation—ERCP(GoldstandardforgallstonesinCBD)

Best non-invasive investi-gation—MRCP.

• Increasedserumalkalinephosphatase

• IncreasedGGT• Increasedbilirubin• MildincreaseinSGOT,SGPT.

• IncreasedWBCcount• SevereincreaseinSGOT,SGPT.

treatMent optionsin presence of cholangitis in absence of cholangitis1.ERCPwithsphincterotomyandstoneextraction(treatmentofchoice)2.PTCdrainage:ERCPfailedcasesBiliaryentericanastomosisIfobstructionismoreproximal.

3.Surgicaltreatment:Onlywhenabovetwoproceduresnotpossible.Decompression of CBD with T tube.

• LapcholecystectomywithCBDexplo-ration

• LapcholecystectomywithERCPstoneremovallater

CBD exploration and T tube removal Unexpected ductal calculi after cholecystecto-my or routine intraoperative cholangiogram (4% to 10%)

Laparoscopiccysticductextractionorimmedi-atepostoperativeERCPretrieval.

○ Postoperative(OP)cholangiogram—day7thPOD○ RemoveTtube—10to14days○ RemoveTtubeon2weeksfordiabetesandimmunocompromised.

tahir99 - UnitedVRG


Missed/retained/residual stones (< 2 years)if t tube present if t tube absent○ Flushingwithheparinizedsaline○ DissolutionwithMTBE(methylter-butylether)○ PercutaneousstoneextractionviaTtubetractafter4-6weeks(Burhennetechnique)*

○ ERCPstoneremoval

recurrent stones (> 2 years)○ M/Cduetononabsorbablesuturematerials,clips.○ Theygetinternalizedandgetcoveredwithcalciumbili-rubinatetoformbrown*pigmentstones

○ ERCP—firstapproach○ Ifductdilated>2cm—choledochoduodenostomyortrans-duodenalsphincteroplasty

choledochal cysts○ Congenitaldilatationofintraandextrahepaticducts○ Associatedwithanomalouspancreaticandbiliaryductjunc-tion(APBDJ).

Clinical features○ M/cinfemales○ M/cageofpresentationinfancy.

classic triad (seen only in 10%) types of cystsPainLumpIntermittentjaundice

• Type1—mostcommon*.Fusiformdilatationofbileduct

• Type2—diverticulumfromCBD• Type3(choledochocele)—dilatationofbiliarytractwithinduodenum

• Type4a—multipledilatationofintraandextrahepaticducts

• Type4b—multipledilatationofextra-hepaticducts

• Type5—(Carolidisease)*Multipledilatationofintrahepaticducts

complicationsRecurrentcholangitisPancreatitisGallstonesCholecystitisCirrhosiswithportalhypertensionPortalveinthrombosisMalignancyRiskfactorforcarcinomabileduct,GB,pancreas,liver,duodenum

treatmento Types1&2:CystexcisionwithRoux-en-yreconstructionwithjejunum

o Type3:Transduodenalsphinctero-plasty

o Type4&5:Livertransplantation

eXtrahepatic biliary atresiaOcclusionorevencompletedestructionofpartorallofextra-hepaticbileducts:Accompaniedbyavariabledegreeofintrahepaticdamagethatprogressivelydamagestheliverleadingtocirrhosisandliverfailure

Mostcommoncauseofsurgicaljaundiceinnewborn*.

types of biliary atresia○ Type1:obstructionwithincommonbileduct(gall-bladderhencecontainsbile)—5%

○ Type2:obstructionwithincommonhepaticduct(gall-bladderhasnobile)—3%

○ Type3:Obstructionatportahepatis—90%.

contd...

tahir99 - UnitedVRG


eXtrahepatic biliary atresia

clinical features○ Severeobstructivejaundiceduringfirstmonthoflifewithpaleacholicstools

○ Ifundiagnosedoruncorrectedleadstocirrhosisin3to6month.

differential diaGnosis of jaundice in infantsjaundice in newborn and infants (in india) pathology1.Hepatocellular cause:Neonatalhepatitis(47%),metabolic(4%),variedetiology

2.Obstructive:Biliaryatresia(34%),choledochalcyst(4%)3.Ductal paucity (3%)4.Idiopathic

○ InflammationandfibrosingstrictureofCBDandCHD○ Markedbileductularproliferationwithbileplugsonbiopsy

○ Inflammatorydestructionofhepaticductswithpaucityofbileducts

investigations treatment○ USG abdomen:tor/oothercausesofjaundice(choledochalcysts)○ Triangular cord sign:Fibrousconeofbileductremnantathepaticporta

○ TC99m-labeledradionuclidescan○ Liverbiopsy:Differentiatesneonatalhepatitisfromatresia(96%sensitive)

○ Goldstandardisintraoperativecholangiogram.

Kasai procedure:PortoenterostomyAnastomosisofportalplatethatcontainsmicro-scopicpatentbiliaryductuleswithRouxen-Yjejunumloop

Mostpatientswillprogressultimatelytolivertransplantation

Kasaiprocedureactuallyprovidessometimeforliverdonorarrangement.

prognosis after Kasai's procedure: after Kasai procedure prognosis depends on1.Ageofpatient(<6week—better)2.Absenceofcirrhosis

3.Microscopicductules>150microns4.Decreasednumberofcholangitisepisodes

•M/cindicationoflivertransplantininfants—EHBA

priMary sclerosinG cholanGitis• Fibrosingcholangitisofbileductulesleadingtoinflamma-torystrictureandobliterationofintraandextrahepaticductswithdilatationofpreservedsegments.

contd...

contd...

tahir99 - UnitedVRG


priMary sclerosinG cholanGitistype

Primary:Unknownetiology.AssociatedwithHLAB8,HLADR3,HLADQ2,DRW52A

Secondary:Ulcerativecolitis,Crohndisease.

clinical features pathology○ Agegroup:30–40year○ Male>females(2:1)○ Intermittentjaundice,weightloss,fatigue,pruritus,abdominalpain

○ AssociatedwithReidelthyroiditis,retroperitonealfibrosis

○ Fibrosingcholangitisofbileductswithlymphocyticinfiltrate,progressiveatrophyofbileductepitheliumandobliterationoflumen

○ Concentricperiductalfibrosisaroundobliteratedducts(onionskinappearance)

○ 10to20percentcasesdevelopcholangiocarcinomainvestigations treatment○ Asymptomaticpatientswillhaveincreasingserumalkalinephosphatase○ Clinicalcourseishighlyvariablewithcyclicremissionsandexacerbations○ Most sensitive:ERCP—multipledilatationandstrictureofintraandextrahepaticducts○ Noninvasive:MRCP

Livertransplantationonly.

vanishing bile duct syndrome bilhemia○ Adultbileductopenia○ Decreasednumberofbileductsonliverbiopsy○ Causes:1.Graftversushostdisease(GVHD)afterbonemarrowtransplant

2.Chronicgraftrejectionafterlivertransplant3.Sarcoidosis4.Drugslikechlorpromazine

○ Bileflowsintobloodstreameitherviaportalveinorhepaticartery○ Causes:HighintrabiliarypressureGallstoneerodingintoavesselAccidentaloriatrogenictrauma.

○ Investigationshowshighlyincreaseddirectbilirubinwithseptice-mia(despitenormalSGOTandSGPT)

○ Causesdeathiflargeamountbileemboliseslung

heMobilia○ Bleedingintobiliarytreefromanabnormalcommunicationbetweenabloodvesselandbileduct.classic triad causes ManagementBiliarycolickyObstructivejaundiceMelenaoroccultbloodinstool.

1.M/ccauseistrauma**(iatrogenic,PTCdrainage,surgeries,biopsy)

2.Gallstones3.Vascularcauses—aneurysms,angiod-ysplasia,hemangioma.

4.Malignancy5.Parasites(m/ccauseinoriental)

6.Liverabscess7.Cholangitis.

○ UGIscopy—bleed-ingfromampullaofvater

○ Investigation of choice—angiography.

carcinoMa Gallbladder○ M/cmalignancyofbiliarytract ○ M/cfemaleelderly ○ 70%to80%casesaregallstonesassociated

risk factorsGallstonesPolyps(>10mm)PorcelainGBCholedochalcyst

AnomalouspancreaticbileductjunctionTyphoidcarriers*SclerosingcholangitisUlcerativecolitis

CholecystoentericfistulaDrugs—estrogens(notOCP)*Carcinogens(nitrosamines,azodyes,rubberindustrychemicals).

clinical features• Pain(73%)• Anorexiaandweightloss(63%)

• Jaundice(54%)poorprog-nosticsign

• Fever

• Vomiting(mechanicalobstructionormalignantgastroparesis)

• O/E—masspalpable(50%),hepatomegaly,ascites

contd...

contd...

tahir99 - UnitedVRG


carcinoMa Gallbladder○ Pathology:Adenocarcinoma(90%),undifferentiated,squamouscellcarcinoma.

investigations contraindications for surgery• USG:Localizedexcessivethickeningofgallbladder(normalGBthicknessis<3mm)• CTcontrast(CECT):lymphnodes>10mmvisible• MRI+MRCP+MRA:ismostusefulthanallabove—helpsinplanningmanagement• FNAC:contraindicatedinoperabletumors(riskofdisseminationviatract).FNACisindicatedonlyininoperabletumors

• Diagnostic laparoscopy:Beforecurativeresectionbylaparotomy38%casesfoundinoperableamongthemplannedforcurativeresectionafterallaboveinvestigations.

• TumormarkersCEA,CA19-9

○ Poorgeneralcondition○ Livermets○ Extrahepaticmets○ Peritonealspread○ Distantnodes(coeliac,superiormesenteric,para-aortic)

○ Portalveinorhepaticarteryinvolved

○ Bilateralinvolvementofsecond-arybiliaryradicles

○ Extensiveduodenalinvolvement.

treatment palliative treatment○ Limited to mucosa:Simplecholecystectomy○ Reaching muscle:Extended cholecystectomy ○ Perimuscular connective tissues:Extendedcholecystectomy+segment4band5resection○ Extendedrighthepatectomyisdonefortumorsextendingtoliver.

1.Radiotherapy—rolenotclear

2.Chemotherapy—gemcit-abine+cisplatinregimen.

cancers diagnosed in cholecystectomy specimenso Exceptfortumorsconfinedtomucosaredo-laparotomyisadvisedwithresectionasperstagingalongwithlapportsitesexcision.

Palliation for○ Pain:Celiacplexusblock○ Jaundice:• Endoscopicstent(patentconfluence)Percutaneousbilestenting(notpatentconfluence)Segment3bypassifsurgeryisdone.

○ Obstruction (GOO):•GastrojejunostomymustnotbedoneasitmayleadtononfunctioningofGBandstasisandcholangitis

• Feedingjejunostomyornasojejunaltubebeyondobstructionisadvised.

bile duct cancersrisk factors pathology types clinical features• Primarysclerosingcholangitis• Choledochalcyst• Ulcerativecolitis• Clonorchissinensis• Chronictyphoidcarriers• Biliaryentericanastomosis• Thorotrast,dietarynitrosamines• Liverflukes• Others—methyldopa,isoniazid,OCP,asbestos.

1.Sclerosingvariety(m/c)2.Nodular3.Papillary(betterprognosis)typeofadenocarcinomas2/3rdlocatedathepaticductbifurcation(Klatskintumors—tumorsatbifurca-tion)

• M/cpresentation—painlessjaun-dice

• Courvoisier law exemption.Non-palpableGBwithjaundice:Obstructionduetocholan-giocarcinomaathilarlevel(e.g.Klatskintumors)

Hence,palpablegallbladdersuggestsdistalobstruction.

○ CBD stone is not a risk factor.

Bismuth classification○ Type1:Atcommonhepaticductonly○ Type2:Involvingconfluencewithoutinvolvementofsecondaryducts○ Type3a:Involvingrightsecondaryintrahepaticducts○ Type3b:Involvingleftsecondaryintrahepaticducts○ Type4:Involvessecondaryductsonbothsides.

contd...

contd...

tahir99 - UnitedVRG


bile duct cancersinvestigations

○ USG:IHBRdilatation○ ContrastenhancedCT:Toruleoutvascularinvolvement○ Percutaneoustranshepaticcholangiogram(PTC)○ CA19-9tumormarker(follow-uprecurrence**)○ ERCP is not the best invasive investigation, but PTC is best ….

why? Ifcontrastisinjectedintotheobstructedsegmentandifobstruc-tionisnotcompletelyrelieveditwillinvariablyresultincholan-gitis.

treatmentoperable tumors inoperable cancersSurgery involves• ExtensiveclearanceneedscaudatelobectomyandremovalofCBDuptosuperiorborderofheadandneckofpancreas

• Hilar,portal,commonhepatic,posteriorpancreaticnodesandeliacnodesremoved• Portalveinremovedifinvolved.Contraindications:• Peritonealspread,livermets,para-aorticnodes+ve

• Brachytherapy• Gemcitabine+5-fluorouracil• Metallicstents.

bile duct injuries• AnatomiclvariationsVariationsinanatomyofductsandvessels

• SurgeonsinexperienceRetractioninjuries,thermalinjuries,previousscars

• LocalpathologyAcuteinflammationShrunkengallbladderMirrizzisyndromeMoynihanshump○laparoscopiccholecystectomyassociatedwithhigherpercentageofinjuries(0.16–2.31)comparedtoopensurgeries(0.1–0.1).

clinical features○ Patientmaypresentwithindaystoseveralmonthsdepend-ingontheinjury

○ Presentingwithabdominalpain,distension,cholangitis,sepsis,ileus,jaundice,excessivebilefromdrain—thinkofbileductinjury

investigations• USG—firstinvestigationtoconfirm• CTscan—moresensitiveinconfirmingleaksandcollections• Biliaryscintigraphy—diagnosisleak,butnotthesite• ERCP—diagnosisleak,butnotdelineatesintrahepaticductalanatomyinpresenceofCBDorhepaticductdisruption

• MRCP—besttodecidetherapeuticapproach.Classifications

Bismuth classification: (based on location) Strasberg classification (based on patterns of injury)

• Type1:Lowcommonhepaticductstricture.stump>2cm• Type2:Proximalstricture.Stump<2cm• Type3:Hilarstricture.Confluenceintact• Type4:Destructedconfluence.Rightandleftductsseparated• Type5:InvolvementofrightaberrantsectoralductaloneoralongwithstrictureatCHD.

• TypeA:minorhepaticductorcysticductleaks• TypeB:Aberrantrighthepaticductorsectoralductdividedandligated

• TypeC:SameasB,butbileleak• TypeD:lateralinjurytoCBDorCHD• TypeE:Circumferentialinjurytomainducts.

contd...

contd...

tahir99 - UnitedVRG


bile duct injuriesManagement

Earlyrepairnotattempted.Onlydrainageprocedurescarriedout

Idealtimeofrepairis8to12weekstoallowinflammationtosubside**Roux-en-Yhepaticojejunostomyis ideal repair.

emphysematous cholecystitis chronic cholecystitis○ Acute cholecystitis associated with infection

by gas forming organisms like Clostridium welchii or perfringens.

○ Thisconditionoccursmostfrequentlyinelderlymenandinpatientswithdiabetesmellitus.

○ Can be seen on plain X-ray.○ The condition is very aggressive, may go for

gangrene and perforation.○ Emergency cholecystectomy must be done.

○ Ongoinginflammationwithrecurrentepisodesofbiliarycolicorpainfromcysticductobstructioniscalledchroniccholecystitis.

○ About2/3rdofthepatientswithgallstoneswillpresentwiththeserepeatedattacks.

○ Primarysymptom:○ Biliary colicky—constantpainthatbuildsinintensityandcanradiatetotheback,interscapularregionorrightshoulder.Painisconstantex-tendingfor1to5hours.Itusuallysubsidesbylessthan24,ifitpersistsbeyond24hoursthinkofacutecholecystitis.

○ Treatmentisnecessaryforsymptomaticcases—laparoscopiccholecys-tectomy.

pancreasanatomy

○ DuctofWirsung:Mainpancreaticduct○ DuctofSantorini:Minorpancreaticduct(accessoryduct)Mainduct—arisesfromtailandterminatesatpapillaofvaterliesposteriorlyMinorduct—extendsfrommainducttoenterduodenumatlesserpapillaly-ingmoreanteriorlyand2cmproximal.

physiology○ Secretin:Alkaline,bicarbonaterichfluid○ Cholecystokinin:Stimulatesenzyme.Serumamylase,lipase,ribonuclease.

pancreatic function test○ NBT-PABAtest ○ Pancreolauryltest ○ Fecalelastasetest

pancreatitisetiology (get smashed)

G-gallstonesE-ethanolT-traumaS-steroids

M-mumpsA-autoimmune(PAN,SLE,etc.)S-scorpionvenomH-hyperlipidemia,hypercalcemia,hypothermia

E-ERCP,emboliD-Drugs(azathioprine,thiazides,furosemide,tetracyclines,Lasparaginase,phenformin,procainamide,valproicacid,pentamidine,dideoxyinosine,etc.)

○ 4I’S infection/infestation/ischemia/idiopathic ○ Infectious causes: mumps,coxsackie,CMV.

M/c causesAdults:Gallstones(m/c)Alcohol(2ndcommon)

Children:Trauma.

contd...

contd...

tahir99 - UnitedVRG


pancreatitisprognostic indicators symptoms• Ransonscoring• Apache2• Glasgow• CTseverityindex• C–rectiveprotein

PainNauseaVomitingRetchingHiccough

Suddenabdominalpain(Mohammedprayersign)

Mimics:Acutecholecystitis,myocar-dialinfarction,perforatedpepticulcer,pneumonia,etc.

signs○ Tachypnea○ Tachycardia○ Hypotension○ Icterus

○ Facialflushing○ Cyanoticmarblingofanteriorabdominalwall○ Grey-Turnersign—hemorrhagicpigmentationaroundtheflanks

○ Cullensign—pigmentationaroundumbili-cus

○ Tenderrednodulesinlimbs○ Abdominaldistension—ileus○ Ascites.

Radiology findings investigationsNospecificradiologicalsign,SentinalloopofjejunumColon cut-off sign (gasfilledhepaticandsplenicflexuresseparatedbygaslesstransversecolon)

Calcifiedgallstones.

SerumamylaseSerumlipase:mostspecificSerumtrypsin(exclusivelybypancreas)Hypocalcemia.

normal serum amylase is seen in following cases• Greaterthan3dayafterattack• Massiveglanddestruction

• Completelydestroyedglandbypreviousattacks.

chronic pancreatitis• Alcohol• Pancreasdivisum• Tropicalpancreatitis

• Hyperparathyroidism• Trauma• Obstructivepancreatitis

• Idiopathicchronicpancreatitis• Cysticfibrosis• Hereditarychronicpancreatitis.

surGeries○ Child procedure:Distalpancreatectomy+sple-nectomy

○ Puestow procedure :Duct>8mmanasto-mosedtoRoux-en-yjejunum

○ Frey procedure:Headcor-inganastomosis

○ Beger procedure:Duodenumpreservingpancreaticheadresectionandanastomosis

contd...

tahir99 - UnitedVRG


pseudocyst pancreas• 6weekafterpancreatitis• Resolvesin6week

intervene ifPersists>6weekSize>6cm

ComplicationsdevelopSecondaryinfection

complications• Obstruction• Hemorrhage• Rupture• Pseudoaneurysmofsplenicartery• Infection

• Mostcommonsiteofpseudocyst—bodyandtail• Mostcommoncause—pancreatitis• Secondcause—trauma*• Mostcommoncauseinchildren—trauma.

ranson's criteriaon admission Within 48 hoursAge>55yearWBCcount>16,000/mm3

Bloodglucose>10mmol/lLDH>700u/lAST>250sigmafrankelunits %

BUN>5mg%ArterialO2saturationPaO2<60mmHgSerumcalcium<2.0mmol/lHematocritfall>10%Basedeficit>4mmol/lFluidsequestration>6l

pancreatic tuMors• Exocrine• Endocrine

o M/c type:Adenocarcinomao M/c site:Head

periampullary carcinoma• Tumorsinregionofampulla,lowerCBD,duodenum• M/cpresentationispainlessjaundice• Mostcommonsiteistheheadofthepancreas• Necroticpancreatictumorsincreasethromboplasticfactors• Thrombophlebitisseenasaresult• Nospecificbloodteststodiagnose

• Elevatedamylase,lipase,alkalinephosphatase,biliru-bin,CEA,C19-9

• CT,ultrasonography• Needlebiopsy• Paracentesis• ERCP: mostdefinitivediagnostictest

courvoisier law ○ Trousseau sign:migratorythrombophlebitis

○ Troisier sign:Leftsupra-clavicularnode

○ Inapatientwithjaundiceifthereisapalpablegallbladder,itisnotduetostones.

exceptionsDoubleimpactedstone(astonewhereGBpalpableduetomucuscollectioninit)

LargestoneinHartmannpouchKlatskintumor—alreadydescribed.

Whipple procedure○ Radicalpancreaticoduodenectomy○ Used for cancer of the pancreas head onlyRemoval ofPancreasheadDuodenumPartofstomachPortionofjejunumGallbladder.o Triple anastomosis:1—choledochojejunostomy,2—pan-creatojejunostomy,3—gastrojejunostomy.

o RememberportalveinisnotremovedinWhippleproce-dure

tahir99 - UnitedVRG


endocrine neoplasMs○ Thesearelesscommonthannon-endocrinetumorsandgenerallybenignandsometimesmultiple.Theyincludes:• Insulinoma(betacells)• Glucogonomas(alphacells)

• Others:Gastrinomas(Gcells)Somatostatatinomas(Dcells)Vipomas(vasoactiveintestinalpolypeptide)

insulinomas○ Mostcommontypeofendocrinetumorinpancreas.

○ Beta cell tumor:MostlysolitaryMostlybenign*(10%–15%malignant)m/csymptom—hypoglycemia(confu-sion,irritationanddisorientation)

Whipple triad• Signsandsymptomsofhypo-glycemia

• Bloodglucose<2.8mmol/l• ReliefofsymptomsbyIVglucose

Characteristicsymptomisweightgaininsteadofweightloss(onlymalignan-cy,wherethereisweightgain)

Most sensitive investigation:Intraop-erativeUSG

Treatment:Surgicalexcision

Gastrinomas○ Thetumorarisingfromtheisletscelloflangerhansinthepancreasandintheduodenalwall.

○ Themajority(60%)ofthesetumorsaremalignant.○ Theymaybeassociatedwith(MEN1),whichincludesparathyroidhyper-plasiaandpituitaryadenoma.

○ ThemostcommonpancreaticendocrinetumorinMEN1isgastrinoma.○ GastrinomagiverisetoZollinger-Ellisonsyndrome,whichconsistoftriad1.Hypersecretionofgastricacid2.Severepepticulceration3.Presenceofnonbetacelltumorofthepancreasorduodenum.

○ Presents with complaints of peptic ulcer:RefractoryUnusualsitesUnusualrecurrence

passaro triangleJunctionofCBDandcysticductJunctionofneckandbodyofpancreas Junctionof2ndand3rdpartofduodenum.

diagnosis ○ Investigation of choice: Somatostatinscintigraphy

○ Drug of choice:Protonpumpinhibitors.• Normalgastrinlevel<150pg/ml• BAO:>15mEq/h• Secretinstimulation:Increasesthegastrinsecretion>200pg/ml• Fastinggastrin>1,000pg/mlishighlysuggestive.

vipomas somatostatinomas Glucagonomas○ Verner-Morrison syndrome○ WDHA syndrome:Waterydiarrhea,hypokalemia,achlorhydria

○ Characterizedbysevereintermittentwaterydiarrhea

○ Mostsensitiveinvestigation:EUS

○ Inhibitoryhormonesomatostatinispro-ducedinexcess

○ Inhibitsbileandpancreaticsecretion○ HencepresentswithGallstonesDiabetesSteatorrhea

○ Diabetes+dermatitis○ Necrolyticmigratoryerythe-ma(perianal,lowerabdomen,perineum,foots)

eXtra points

Pancreatogenicdiabetesism/caftersurgicalresectionforchronicpancreatitis(alsoknownaspancreatogenicorTypeIIIdiabetes)

Doublebubblesign—duodenalatresia,annularpancreas Triplebubblesign—jejunalatresia.

tahir99 - UnitedVRG


fMGe questions

1. Which of the following is not a complication of pseudopancreatic cyst (Sep 2007)

a. Malignancy b. Rupture c. Hemorrhageintocyst d. InfectionAns: a (Malignancy)

2. All of the following are associated with the gall-stones, except: (Sep 2008)

a. Acutepancreatitis b. Acutecholecystitis c. Acuteappendicitis d. AcutecholangitisAns: c (Acute appendicitis)

3. Grey Turner sign is seen in: (Sep 2007) a. Acuteappendicitis b. Acutepancreatitis c. Acutecholecystitis d. AcutehepatitisAns: b (Acute pancreatitis)Explanation:Acute pancreatitis is characterized by the followingsigns:• Grey-Turnersign:Pigmentationinloin• Cullensign:Pigmentationaroundtheumbilicus• Mohammedprayersign:Painintheepigastricregionradiatingtotheback,whichisrelievedbysittingandleaningforwardlikeMuslimspraying.

• Colon cut off sign: A segment of intestinewithoutperistalsisseenonX-ray(plain)ascutoff.

4. Acute pancreatitis causes all of the following, except: (March 2007)

a. Hypercalcemia b. Increasedamylaselevel c. Subcutaneousfatnecrosis d. HyperlipidemiaAns: a (Hypercalcemia)Explanation:Metaboliccomplicationsofacutepancreatitis:• Hyperglycemia• Hypertriglyceridemia• Hypocalcemia• Encephalopathy• Suddenblindness(Purtscher retinopathy)*

5. Acute pancreatitis is associated with: (March 2005) a. Elevatedserumamylase b. Alcohol c. Gallbladderstones d. AlloftheaboveAns: d (All the above)

6. Investigation of choice for acute pancreatitis: (March 2008) a. X-rayabdomen b. CTscan c. USG d. ERCPAns: b (CT scan)• Investigation of choice for acute pancreatitis is CTscan.

• Balthazar,etalcriteriaiscriteriaforacutepancreatitisbasedonCTscan.

7. Charcoat triad is seen in: (Sep 2009, 2010, March 2008) a. Acutepancreatitis b. Acuteappendicitis c. Acutehepatitis d. CholangitisAns: d (Cholangitis)• Charcottriad:Pain,jaundiceandrigorisafeatureofacutecholangitis

• Reynaudpentad:Pain,jaundice,rigor+septicshockandmentalstatuschanges.

8. Investigation for assessing proper functioning of biliary system: (Sep 2008)

a. USG b. CTscan c. HIDAscan d. AlloftheaboveAns: d (All of the above)• ButHIDAscanisthebest**• Hydroxyiminodiaceticacid(HIDA)isgivenintrave-nously isabsorbedby the liverhepatocytesandse-cretedunchanged into the biliary radicles. ThedyeissecretedintothecommonhepaticductunchangedandcanbeseenonHIDAscan.

• HIDAscanisusedtostudythebiliarysystem.

tahir99 - UnitedVRG


9. Best way to diagnose gallbladder stones: (March 2007) a. USG b. Oralcholecystography c. Percutaneoustranshepaticcholangiography d. IntravenouscholangiogramAns: a (USG)

10. Charcot’s triad is defined by all of the following, except: (March 2007)

a. Fever b. Gallstones c. Jaundice d. PainAns: b (Gallstones)

11. Which of the investigation can itself lead to acute pancreatitis: (Sep 2003)

a. USG b. CTscan c. ERCP d. MRIscanAns: c (ERCP)

12. Most sensitive and specific for acute pancreatitis amongst the following is: (Sep 2007)

a. Serumamylase b. Serumalaninetransaminase c. serumlipase d. C-reactiveproteinAns: c (Serum lipase)

13. Pentad of pain, fever, jaundice, confusion and shock is seen in: (Sep 2010)

a. Pancreatitis b. Hepatitis c. Cholangitis d. AppendicitisAns: c (Cholangitis)

14. Most common type of gallstone in India is: (March 2007, 2009) a. Cholesterol b. Pigment c. Mixed d. BothAandCAns: c (Mixed)

15. Management of infected pancreatic necrosis in-cludes all of the following, except: (Sep 2010)

a. Percutaneousdrainage b. Pancreaticnecrosectomy

c. Manageconservativelywithantibioticsalone d. NutritionalsupportAns: c (Manage conservatively with antibiotics alone)

16. Investigation of choice for acute cholecystitis: (Sep 2007) a. Plainradiography b. USG c. CTscan d. HIDAscanAns: d (HIDA scan)

17. Calculous cholecystitis is associated with all of the following, except: (Sep 2007)

a. Oralcontraceptives b. Estrogen c. Obesity d. DiabetesAns: a (Diabetes)

18. Chronic calcific pancreatitis is associated with all of the following complications, except:

(March 2007) a. Hypercalcemia b. Diabetesmellitus c. Malabsorptionoffat d. SteatorrheaAns: a (Hypercalcemia)• Thoughhypercalcemiacanbecauseforchronicpan-creatitis,thecomplicationofpancreatitisishypocal-cemia*

19. Conjugated hyperbilirubinemia is seen in: (Sep 2006) a. Dubin-Johnsonsyndrome b. Gilbert’ssyndrome c. Crigler-NajjartypeI d. Crigler-NajjartypeIIAns: a (Dubin-Johnson syndrome)• Dubin-Johnson and Rotor syndrome are associatedwithconjugatedhyperbilirubinemia

(Pneumonic-DR-Conj)• Crigler-Najjar andGilbert are unconjugated hyper-bilirubinemia.

20. All of the following are seen with bile duct stone, except: (March 2009)

a. Obstructivejaundice b. Distendedandpalpablegallbladder c. Pruritis d. Clay-coloredstoolsAns: b (Distended and palpable gallbladder)

tahir99 - UnitedVRG


21. Reversed '3' sign on barium studies is seen in which condition: (Sep 2009)

a. Ampullarycarcinoma b. Carcinomastomach c. Carcinomaheadofpancreas d. InsulinomaAns: c (Carcinoma head of pancreas)

22. Investigation of choice for gallbladder stone is: (Sep 2009) a. OCG b. USG c. PTC d. X-rayAns: b (USG)

23. All of the following are false for gallbladder carci-noma, except, i.e which is true? (Sep 2006)

a. Carriesagoodprognosis b. Gallstonesmaybeapredisposingfactor c. Commonlysquamouscellcarcinoma d. JaundiceisrareAns: b (Gallstones may be a predisposing factor)

24. A 70-year-old male patient presented with history of chest pain and was diagnosed to have coro-nary artery disease. During routine evaluation, ultrasound of the abdomen showed presence of gallbladder stones. There was no past history of biliary colic or jaundice. What is the best treat-ment advice for such a patient for his gallbladder stones: (March 2003, Sep 2007)

a. Opencholecystectomy b. Laparoscopiccholecystectomy c. Nosurgeryforgallbladderstones d. ERCPandremovalofgallbladderstonesAns: c (No surgery for gallbladder stones)

25. Most common location of gastrinoma is: a. Duodenum b. Jejunum c. Stomach d. PancreasAns: a (Duodenum)

26. Acute pancreatitis cause all, except: (Sep 2005) a. Fatnecrosis b. Hypercalcemia c. Increasedamylase d. IncreasedlipaseAns: b (Hypercalcemia)

27. Amylase is increased in all the following, except: (Sep 2005) a. Acuteappendicitis b. Acutepancreatitis c. Duodenalperforation d. IntestinalobstructionAns: d (Intestinal obstruction)

28. Most common mode of spread of gallbladder can-cer: (Sep 2005)

a. Transcoelomicspread b. Lymphaticspread c. Hematogenicspread d. DirectextensionAns: d (Direct spread)

29. Chronic cholecystitis is associated with all, except: (Sep 2005) a. Palpablegallbladder b. M/cinwomen c. Associatedwithgallstones d. RokitanskycellsAns: a (Palpable gallbladder)• Incasesofchroniccholecystitisbecauseofchronicin-flammation,gallbladderwouldhaveshrunkenwiththickhypertrophiedmusculatureofgallbladderwall

• Rokitanksy aschoff sinuses are histologically out-pouchingsofgallbladdermucosaincasesofchroniccholecystitis.

30. The best way to diagnose gallstones in CBD intra-operatively: (March 2007)

a. Intraoperativecholangiogram b. CTscan c. MRI d. USGAns: a (Intraoperative cholangiogram)

31. Not a part of Charcot’s triad: (Sep 2009) a. Intermittentpain b. Intermittentvomiting c. Intermittentfever d. IntermittentjaundiceAns: b (Intermittent vomiting)

32. Pentad of pain, jaundice, fever, confusion and shock is seen in: (Sep 2009)

a. Acutepancreatitis b. Hepatitis c. Cholangitis d. CholecystitisAns: c (Cholnagitis)

tahir99 - UnitedVRG

14LIVER

Anatomy Blood supply○ Largestorganinthebody○ Barearea—posteriorsurface○ 5surfaces—anterior,pos-terior,right,superiorandinferior.

• 80%fromportalveinand20% from hepatic artery• Lefthepaticducthaslongestextrahepaticcourse2cmisaccessibleoutsideliver• TherightandlefthepaticveinsjointogetherandentertheIVC.TheinferiorhepaticveinsjointheIVCdirectlyonitsanteriorsurface

• Relationsintheportahepatisfrombehindforwards—Portalvein(posterior),hepaticartery(left)andhepaticducts(right)

• Commonhepaticarteryrunsoverthesuperiorborderofpancreasandrunsalongtherightsideofthelesseromentumanditascendstohilumandliesanteriortoportalveinandtoleftofhepaticduct.

○ Aberrant right hepatic arteryarisesfromsuperiormes-entricarteryandrunsposteriortothepancreashead

○ Replaced or accessory left hepatic arteryarisesfromleftgastricartery

○ An accessory cystic artery canoriginatefromgastrodu-odenalorpropercommonhepaticartery.

FunctionAl AnAtomy (couinAud's segments)○ Cantlie line:AnimaginarylinerunningfromgallbladdertoleftsideofIVC.○ Rightliversegments5,6,7,8○ Leftliversegments1,2,3,4○ Caudatelobeissegment1.Vascularinflowandbiliarydrainagetothecaudatelobeisfrombothrightandleftsystems

Contd...

tahir99 - UnitedVRG


FunctionAl AnAtomy (couinAud's segments)○ Reidel lobe: A tongue-like extension from the right liver inferiorly○ Segmentstotheleftoffalciparumsegment:Segment2and3○ Caudate lobeisthelobethatisnotaffectedinBudd-Chiarisyndromeandcir-rhosisofliverbecauseofitsdirectdrainageintoIVC(segment1)

○ Quadratelobeisthefourthsegment.

• Removalofsegments2-4(lefthepa-tectomy)

• Removalofsegments5-8(righthepatectomy)

• Removalofsegments5-8alongwith4(extendedrighthepatectomy)

• Removalofsegments2-4alongwith5and8(extendedlefthepatectomy)

Functions of liver liver function tests○ Maintainscorebodytemperature○ pHbalanceandcorrectionoflacticacidosis○ Synthesisofclottingfactors○ Glucosemetabolism,glycolysisandgluconeogen-esis

○ Ureaformationfromproteincatabolism○ Bilirubinformationfromhemoglobindegradation○ Drugandhormonemetabolism○ Removalofgutendotoxinsandforeignantigens.

○ Humanwillsurvivefor24-48hoursinanhepaticstatedespitefullsupportivetherapy.

○ Serum alkaline phosphatase—elevatedincholestasisorbiliaryobstruction.

○ AST/ALT—reflectsacuteliverdamage○ GGT—reflectsliverinjuryduetoacutealcoholingestion*○ synthetic functions—albuminlevelandprothrombinlevel.○ Clearance tests:Indocyanine,aminopyrine,lidocaineclearancetestsaretodiagnosefunctionallivercapacity.

Few important points• TheextravascularfluidcompartmentinsidetheliveriscalledasSpaceofDisse• Hepatic stellate cells (ito cells) containhighlipidcontentanditsmajorfunctionistostorevitaminAandsynthesizeextracellularcollagen.

normal valuesBilirubin:5-17µmol/LALP:35-150IU/L

AST:5-40IU/LGGT:10-48IU/L

Albumin:35-50g/LProthrombin time:12-16second

Acute liver FAilure cAuses• Viralhepatitis(hepatitisA,B,C,D,E)• Drugreactions:Halothane,isoniazid,rifampic-in,antidepressants,NSAIDs,valproicacid.

• Paracetamoloverdose• Mushroompoisoning• Shockandmultiorganfailure

• AcuteBudd-Chiarisyndrome• Wilsondisease• Fattyliverofpregnancy

Contd...

tahir99 - UnitedVRG

163Liver

modiFied child-pugh clAssiFicAtionclinical 1 2 33

Encephalopathy None 1or2 3or4Ascites None Mild Moderate

Bilirubin(mg/dL) 1–2mg/dL 2.1–3mg/dL ≥3.1mg/dLAlbumin(g/dL) ≥3.5g/dL 2.8–3.4g/dL ≤2.7g/dL

Prothrombintime(increaseinseconds) 1–4 4.1–6 ≥6oGrade A: 5–6 oGrade B: 7-9 oGrade C: 10-15points

chronic liver diseAseMost useful clinical sign—flapping tremor Ascite is a late feature

investigAtions• Ultrasound:Firstlineinvestigation• SpiralCT:Anatomicalplanningforliversurgery(goldstandardforliverimaging)

• MRI—incasesofiodineallergy,whereCTcannotbedone.• MRCP—goldstandardforbiliarytractimaging• ERCP—Itisthegoldstandard,ifbileductstonesissuspectedorwheninterventionisneeded

ercp percutaneous transhepatic cholangiography○ indications InterventionneededBileductstonesBrushbiopsyfrombiliarytract

○ Pre-requisitesProphylacticantibioticsCoagulationprofileneedstobechecked

○ ComplicationsPancreatitisCholangitisBleeding/perforationofduo-denum

○ indications1.WhereERCPfailedorimpossiblelikepolyagastrec-tomy.

2.Intrahepaticduct/hilarbileductcancers,whereERCPcannotreach.

Angiography nuclear scan• Todiagnosebleedingfrombiletract(hemobilia)

• TC99mscan(IoDIDA)—ifbileleakorbiliaryobstructionissuspected• Sulphurcolloidliverscan—allowsKupffercellsactivitytobedeterminedAdenomasandhemangiomaslackKupffercellsandhencenouptakeofsulphurcolloid.

• FDGPET—basedontheprinciplethatcanceroustissuetakesuphighamountofglucosethannormaltissue.

portAl hypertension And cirrhosis• Micronodular—alcoholiccirrhosis• Macronodular—posthepatiticcirrhosis

Contd...

tahir99 - UnitedVRG


portAl hypertension And cirrhosisrelated anatomy

Portalveinisformedbytheconfluenceofsuperiormesentricveinandsplenicveinbehindtheneckofpancreas.

Leftgastric(coronary)veinenterstheportalveinatitsorigin.Splenicveinisjoinedbyinferiormesentricveinjustbeforeitsconfluencewithsuperiormesentricvein.

Portalveinlength:6-8cmNormalpressureinportalvenoussystemis3-5mmHgand10–12cmH2o.

important points• M/ccauseofdeathinportalhypertension—hepaticfailure• 2ndcommoncauseofdeath—varicealhemorrhage

• M/ccauseofportalhypertension—alcoholiccirrhosis

left-sided portal hypertension• Duepancreaticneoplasmorinflammationofthesplenicveingetsthrombosedandresultsinleftsidedportalhypertension

• Thesuperiormesentricandportalvenouspressureisnormal.

• Leftgastroepiploicbecomesthemajorcollateralandhence,gastricvaricesdevelopratherthanesophageal

• Easilyreversedbysplenectomy

• What do you think, if there is an unexpected functional deterioration in a case of cirrhosis? Thinkofhepatocellularcarcinoma(elevatedafetoprotein)in60%cases.

• How will you take liver biopsy in a case of cirrhosis with coagulopathy or moderate ascites? Percutaneousliverbiopsymustnotbedone,transjugularorlaparoscopicbiopsyisadvised.

• What are the common serum electrolyte abnormalities in cirrhosis? Hyponatremia,hypokalemia,metabolicalkalosis• Therewillbehypersplenisminportalhypertension,whichresultsinplateletcount<50,000/cubicmm.• Becausemanycoagulationfactorsaresynthesizedinliver,thecoagulationfactorisalsoimpairedresultingincoagulopathy

sites oF portAcAvAl AnAstomosissite systemic portal1.Lowerendofesophagus

Accessoryhemiazygousvein

Leftgastricvein

2.Analcanal Middleandinferiorrectalveins

Superiorrectalvein

3.Umbilicus(caputmedusae)

Anteriorabdominalwallveins

Leftportalvein(viaparaumbilicalvein)

4.Bareareaofliver Phrenicandintercostalveins

Hepaticvenules

5.Liver IVC PatentductusvenosusconnectleftportalveintoIVC

6.Posteriorab-dominalwall

Retroperitonealveinsofabdominalwall

Veinsofretroperitone-alorganslikeduode-num,ascendingcolon,descendingcolon

Contd...

Contd...

tahir99 - UnitedVRG

165Liver

sites oF portAcAvAl AnAstomosismeasuring portal pressure gradient

1.Bytranshepaticorumbilicalvenouscannulationofportalvein2.Bytranscutaneouspuncturespleen•Portalpressurecanbeindirectlymeasuredbymeasuringhepaticvenouswedgepressuregradient(HVPG),butremem-berthepressurewillbenormalinpresinusoidalcausesofhypertension.

Bleeding in portal hypertension• ThemostcommoncauseofbleedinginPHTpatientsisfromesophago-gastricvarices(esophagus80%andgastric20%)

• Isolatedgastricvaricesmustraisethesuspicionofsplenicveinthrombosis

• Theonlynon-varicealcauseofportalhypertensivebleedingisportalhyperten-sivegastropathy(m/caftereradicationofvarices).

treatment○ Esophagogastricvariceswillnotbleeduntilthepressureexceeds12mmHg

• Resuscitation• Non-interventional

• Interventional• Surgical

resuscitation interventional• Isotoniccrystalloids,CVPmeasurement• About6unitscross-matched• IfPTisprolongedmorethan3secondsFFPtransfused

• Ifplateletcount<50,000—platelettransfusiondone

• Startprophylacticantibiotics

• Thefirstandforemosttreatmentnextisendoscopyandsclerotherapyorbanding

• othernon-interventionaltreatmentsstartedonlyifendoscopycouldnotbedoneduetobleeding

• Endoscopicbandingisadvantageousbecauseitdoesnotleadtonecrosisorulcerationofesophagus,butbothareequallyeffectiveincontrollingbleeding.

• Sclerosantsused—ethanolamineoleate,cyanoacrylate,sodiummorrhuateorsodiumtetradecylsulfate.

sengstAken-BlAkemore tuBe• Modifiedsengstakencontainsfour tubes(oldSengstaken-Blakemoretubecontainsthreetubes)• oneforaspirationfromstomach,onefromesophagus,oneforesophagealballoondilatationandlastoneforgastricbal-loondilatation.Thegastricballooninflatedto250mLofairandesophagealballoontoapressureof40 mm Hg.Thepotentiallylethalcomplicationisaccidentallyinflatinggastricballooninsidetheesophagusresultinginperforationofesophagus

Balloonsshouldbetemporarilydeflatedafter12hourstopreventesophagealnecrosis.

Contd...

Contd...

tahir99 - UnitedVRG


pharmacotherapy○ octreotide(long-actinganalogueofsomatostatin)andsomatostatinareeffectivelikeendoscopy○ Vasopressinpreviouslyusedisalsoeffective,butnitroglycerinemustbegivenalongwithittopreventcoronaryvesselsconstriction

trAnsjugulAr intrAhepAtic portAl shunt (tips)• Short-termbridgetolivertransplant• Insertedviainternaljugularvein(IJV)byinterventionalradiologist• Accesstheportalveininsidetheliverviaabranchofhepaticveinanddilatethetractto10mmthroughwhichexpandablemetallicstentisinserted.

• Itisnotusedasinitialtherapy,butcanbeusedifendoscopyandpharmacotherapyfails.• Itisatypeofnon-selective shunt

complicationsMainearlycomplicationisperforationoflivercapsuleandfatalintraperitonealhemor-rhage

Postshuntencephalopathyistheconfusionalstateduetothetoxicmetabolitesbypassingthemetabolisminliver

Long-termcomplicationisshuntstenosis,whichmayoccurin<1year

contraindicationsAbsolute:RightsideheartfailurePolycysticliverdisease

Relative:PortalveinthrombosisHypervascularlivertumorsEncephalopathy

prevention oF recurrent Bleed• Drugusedisnon-selectivebeta-blockers—propranololhasshowntoreducerebleed

• CombinationofISDNandpropranololhasbeenshowntobemoreeffectivethanvaricealligation

shunting surgeriesnon-selective shunts

1.Endtosideportocavalshunt(Eckfistula)2.Sidetosideportocavalshunt

3.Largediameterinterpositionshunts(>16mm)4.Conventionalsplenorenalshunts

5.TIPS

ConventionalsplenorenalshuntInvolvesremovalofspleenandinsertionofproximalsplenicveinintorenalvein.Theonlyadvantageofthisshuntishyper-splenismbeingeliminatedbysplenectomy

complication Advantages○ Portalshuntencephalopa-thyismorecommoninthisprocedure.

○ Thisshuntcompletelydivertthebloodfromportalsystemtocavalsystem○ Thistypeofshuntalsodecompressesthesplanchnicvenoussystemandintrahepaticsinusoidalnetworkhence,sidetosideshuntsaretheeffectiveincontrollingascitesandpreventingrebleed

selective shunts○ Splenorenalshunt—distal(Warrens) ○ Inokuchi:Leftgastricvenacavalshunt.Veingraftinterposedbetween

theleftgastricveinandinferiorvenacava.

Contd...

Contd...

tahir99 - UnitedVRG

167Liver

shunting surgeriesdistal splenorenal shunt

• Anastomosisofdistalendofsplenicveintotheleftrenalveinalongwithinterruptionofallcollaterals

• This shunt aggravates the ascitebecausesinusoidalandmesentrichyper-tensionismaintainedandimportantlymphaticpathwaysaretransectedduringdissection.

• Contraindications:Previoussplenectomy(absolute)Splenicveindiameter<7mm(relative)

partial shunts non-shunt operations• Smallprostheticgraftsize<10mmusedtobehaveaspartialshunt.

• Simplestnon-shuntoperationistransectionandreanastomosisofthedistalesophaguswithastaplingdevice.

• Extensiveesophagogastricdevascularizationcombinedwithsplenectomyandesophagealtransection(Sugiura operation)

• Mainindicationforthissurgeryisdistalsplanchnicvenousthrombosisandforpatientswithdistalsplenorenalshuntthrombosis

trAnsplAnt cAndidAtes• Non-alcoholiccirrhosisandabstinentalcoholiccirrhoticswithchildBorC

• Patientswithpoorqualitylifestyleduetoencepha-lopathy,fatigueofchildAwillalsobeindicated

Non-cirrhotic portal fibrosis (ncpF) and extrahepatic portal venous obstruction (ehpvo)

ncpF vs extrahepatic portal venous obstruction

○ Thetwocommoncausesofnon-cirrhoticportalhypertensioninIndiaare•NCPF—meanageofpresentationis30.5years•EHPVo—mostcommonsiteofobstructionisatportalveinformation(90%)AscitesistransientorabsentEsophagealvaricesseenin90%-95%andgastricvaricesin35%-40%M/cpresentationisvaricealbleedandsplenomegaly

○ Both the conditions present with similar features:Massivevaricealbleed (m/cpresentationofNCPF)

ModeratetomassivesplenomegalyNormalliverhistologyAbsenceofascitesNormalliverfunction

differentiation pointsNCPF—age:Youngadults(2ndor3rddecade)Smaller3rdand4thorderbranchofPVinvolved

EHPVO—age:Children(1stor2nddecade)Mainor1storderbranchofportalveininvolved

important pointsin india• Inpediatricagegroup—EHPVo(70%),cirrhosis(30%),NCPF(4%),congenitalhepaticfibrosis(4%)andBudd-Chiari(3%)• InIndia—thereisequalincidenceofbothcases

Contd...

tahir99 - UnitedVRG


pyogenic ABscess○ The potential routes of hepatic

exposure to bacteria follows:Biliarytree(mostcommonroute)Portalvein(pyelophlebitisduediverticulitis,appendicitis,PID,IBD,perforation,etc.)

Hepaticartery(systemicbacte-remia-associatedwithmultiplemicroabscess)

DirectextensionTrauma

clinical feature management○ M/cinrightlobe○ M/corganismsisolated–

E. coliandKlebseilla pneumo-niae.

○ M/cpresentingsymptom—fever,chills,abdominalpain.

○ ArarecomplicationofKleb-seillaabscessisendogenousendophthalmitis(3%),com-monindiabetics.

• USGandCTarethetwocommonlyusedtools.• CTscan95%-100%specific.• X-raychestshowselevatedrighthemidi-aphragm,pleuraleffusionandatelectasis.

• Treatment involvespercutaneouscatheterdrainagealongwithbroadspectrumantibi-otics.Surgeryisreservedforthosewhofailpercutaneoustechniqueandforthosewhomsurgeryisrequiredforsomeotherpathologylikeappendicectomy.

AmeBic ABscesspathogenesis

○ Entamoeba histolytica cystsareingestedthroughfeco-oralroute.○ Cystsarenotdegradedinstomachandtheypasstointestine,wherethetrophozoitesarereleased.○ Trophozoitespasstothecolonandcaninvadethemucosaresultinginthedisease.Fromwheretheyentertheportalsystem.○ Themajormechanismofabscessformationisenzymaticcellularhydrolysis.Theabscesscontainsacellularproteinaceousdebrissurrounded by a rim of invasive amoebic trophozoites

○ Duetoliquefactionnecrosisofliver,theabscessresultsanchovy sauce colored and odorless○ CharacteristicfeatureofamebicabscessisGLISoNcapsuleisresistanttoamoebicinvasion,henceabscessislimitedtoGlisoncapsule.

clinical feature investigation• M/cLFTabnormalityiselevatedprothrombintime• Enzymeimmunoassays(EIA)havesensitivity99%andspecificity>90%inpatientswithamebicabscess.

• USGcharacters:Hypoechoic and non homogenous rounded lesion abutting liver capsule without sig-nificant rim echoes.

• CT scan: Moresensitiveindifferentiatingpyogenicfromamebicbecausetherewillberimenhancementinpyogenicabscessoncontraststudy.

• Nuclear scan (Gallium or Tc):Helpsindifferentiatingbe-causeamebicabscessdoesnotcontainleukocytesandhencedoesnotlightuponthesescans

treatment percutaneous aspiration• Oral metronidazole—750mgthreetimes/10daysisthedrugofchoice.

• EmetineIMinjectionsisveryeffectiveforinvasiveamoebiasis.

• Aftertreatmentofliverabscess,luminalagentslikeiodoquinol,paromomycinanddiloxanidefuroateareadministeredtotreatcarrierstate.

• Therapeuticaspirationisusuallyavoided.Metrogylisthetreatmentofchoiceandabout90%casesrespondwell.

• Indicationsforaspiration:abscesswalldiameterlargerthan5cm(abscesswithhighriskofrupture)abscessintheleftlobeofliverfordiagnosticuncertaintyfailuretorespondin3-5days

○ Themostfrequentcomplicationofliverabscessisrupture.

diFFerentiAl diAgnosis oF AmeBic And pyogenic FeAturesFeatures Amebic pyogenicAge 20–40year >50yearMale : female ratio >10:1 1.5:1Solitary% 80% 50%Diabetes Uncommon CommonJaundice Uncommon CommonElevated alkaline phosphatase Common CommonPositive blood culture Negative PositivePositive amoebic serology Yes No

tahir99 - UnitedVRG

169Liver

hydAtid cyst○ Echinococcus granulosusisM/c.othersE. multilocularis,E. oligartus.○ Dogs are definitive hosts,inwhichadulttapewormisattachedinvilliofsmallintestine.

○ Sheeps are intermediate hoststhatconsumetheovapassedbythefecesofdogovergrasses.

○ Humansareaccidentalhostsconsumingtheseeggsthatcovertstoembryoinduodenumandreleasesanoncospherecontaininghookletsthatpenetratethemucosaandreachthebloodstream.

○ Theoncospherereachestheliver(m/c)orlungs,wheretheparasitedevelopsintolarvalstagecalledashydatidcyst.

○ Rememberhumansareend-stagehost.

pathogenesis clinical featureThreeweeksafteringestion,apericystderivedfromhosttissuewalldevelopssurroundingthehydatidcyst.

Thecystitselfhastwowalls:ectocyst (outergelatinous)andendocyst(innergerminal)layers.

Indefinitivehost,theydevelopintoadulttapeworm,butinintermediatehosttheydeveloponlyintonewhydatidcyst.

Daughtercystsaretruereplicaeofthemothercyst.

M/cinrightlobeofliver**Mostfrequentsign—hepatomegalyM/csymptoms—abdominalpain,dyspepsiaandvomiting.Complications:Ruptureintobiliarytree,bronchialtree,pleural,peritonealandpericardialcavity.

investigations• USG:Rosettelikeappearanceorwaterlilleyappearanceisseenwhendaughtercystsarepresent.Calcificationsinthewallarehighlydiagnostic

• Serologicaltests:ELISA,arc5test,IHAtest,immunoblasttest,whereavailableisthetestofchoice• Casoni test:Intradermalinjectionofsterilehydatidfluidproducesawhealof5cminhalfhourtreatment pAir○ Primarilysurgical,butintroductionofPAIRhastotallyreplacedit.

○ Duringsurgery,packingofftheabdomenfromthecystisveryimportantbecauseoftheanaphylacticreactionthatmayoccurifcystrupturesintoperitonealcavity

○ Surgicalprocedures:PericystectomyMarsupializationomentoplastyTotalcystectomyPartialhepatectomy

○ Remembersurgeryisnowpreferred,wherePAIRisnotpossibleorwhenitdoesnotrespondtoPAIRorwhenthereisanycommunicationtobiliarytree

• Percutaneous aspiration, infusion of scolicidal agents and reaspiraion (PAiR).

• Givenwithprophylacticcoverofalbendazole.• Scolicidalagents—20%hypertonicsaline,0.5%silvernitrate,95%ethanol,absolutealcohol,mebendazole2.4microgram/mL

• ContraindicationsforPAIR:1.Superficiallylocatedcyst(chanceofrupture)2.Honeycombingofcysts(multiplethickinternalseptae)3.Communicationwithbiliarytree4.Deadorinactivecysts

echinococcus multilocularis recurrent pyogenic cholangitis• Alwaysmultiloculated• Treatmentisalwayssurgicalresection

• Alsonamedasorientalcholangiohepatitisorhepatolithiasis.• Male:femaleissame.Age:20-40year• Usuallysecondarytobiliarystoneandstricture.

Benign liver tumorcharacter liver cell adenoma Focal nodular hyperplasia hemangiomaIncidence ○ Rare • Secondcommonbenigntumor ■ M/cincidentaloma

■ M/cbenigntumor

Contd...

tahir99 - UnitedVRG


Benign liver tumorAgegroup/sex ○ Youngwomen

○ 20-40year• Middleagedfemales ■ About45years

■ M/cinfemalesEtiology ○ Benignproliferationof

hepatocytes• Developmentalvascularmal-formation

■ Congenitalvascularmalformations

Associatedfactors ○ oCPandsteroids • FemalehormonesandoCP ■ -------Complications ○ Rupture and malignant

transformation • Rupture/hemorrhage ■ Rupture/hemorrhage

Histology ○ Benignhistocytescon-tainingglycogenorfat

• Characteristicallycentralfi-brousscarwithradiatingsepta

■ Smallcapillarytypeandlargecavernoustypesarethere

Imagingstudies ○ CT—heterogenousmasswithearlyenhancement

○ MRI—welldemarcatedmasswithfatorhemor-rhage

• Homogenousmasswithcen-tralscar

• Sulfur colloid liver scan: KupffercellsinFNHonlytakeupthecolloid.

■ CT/MRI—slowcontrastenhance-mentduetosmallvesseluptake.Typicalnodularperipheralen-hancement

Treatment o Laparotomy and resec-tion

• Asymptomaticandtypicalcasesrequirenotreatment

■ Canbeleftassuchunlesssympto-maticordoubtexists

■ Enucleationwithproximalcontrol• Kassabach meritt syndrome:Liverhemangioma+thrombocytopenia+consumptivecoagulopathy• Complication of large hemangiomas in children:Congestivecardiacfailuresecondarytoarteriovenousshunting• Giant hemangiomas:Size>5cm

mAlignAnt tumor○ M/cprimarymalignanttumor—hepa-tocellularcarcinoma

○ M/cmalignanttumor—metastaticlivercancer

○ M/csiteofprimaryformetstoliver—colon

hepatocellular carcinoma (hcc)risk factors clinical features• infections:HepatitisBvirus,hepatitisCvirus• Cirrhosis:Alcoholinduced,autoimmunehepatitis,primarybiliarycirrhosis

• Environmental:AflatoxinspyrrolizidinealkaloidsThorotrastN-nitrosylatedcompounds

• Metabolic diseases:Hemochromatosis,alpha1-antitrypsindeficiency,Wilsondisease,porphyriacutaneatarda,Type1and3glycogenstoragedisease,galactosemia,citrullinemia,hereditarytyrosinemia,familialcholestaticcirrhosis

• Most important risk factor is cirrhosis

○ M/cinmales;50-60year○ Presentation:1.Rightupperquadrantpain2.Weightloss3.Palpablemass4.Inknowncirrhotics—suddendecompensationofliverthinkofHCC.

5.Rupture6.Lessthan1%casespresentwithparaneoplasticsyndromemostcommonlyhypercalcemia,hypogly-cemia,erythrocytosis

diagnosis• MCQpoint—hepatocellularcarcinomahasthetendencytoinvadetheportalvein• USG—playssignificantroleinscreeningandearlydetectionofHCC• CTandMRI—aredefinitelyneededforplanningsurgeries• Serum AFP—used in diagnosing HCC Duetorecentadvancesininvestigations,itismainlyusedasadjuncttoimagingtests. Value>400mg/dLishighlysuggestiveAFPismainlyusedtomonitor recurrences intreatedpatientsAFPlevelsareelevatedinabout70%–80%cases

Biopsy■ Biopsyiscontraindicatedinsuspectedcases.Biopsyisdoneonlyininoperablecases/cases,whicharetriedfornon-opera-tivetherapies

■ Percutaneousbiopsycarriestheriskoftumorspillage,ruptureandbleeding

Contd...

Contd...

tahir99 - UnitedVRG

171Liver

mAlignAnt tumorAssessment of liver function treatment○ LiverresectionisthetreatmentofchoiceforHCC○ Child(modifiedbyPUGH)isthemostcommonlyusedsystem○ ChildCarenotcandidatesforresection○ ChildAcandidatescanusuallytoleratesomedegreeofresection○ ChildBareconsideredborderline.

○ CompleteexcisionofHCCbypartialhepatectomyorbytotalhepatectomywithlivertrans-plantationarethetreatmentofchoices.

Ablative1.Percutaneousethanolinjection2.Percutaneousaceticacidinjection3.ThermalablativetechniquesCryotherapyRadiofrequencyablation(RFA)microwave

○ RFAandcryotherapycanbedonepercutaneously.○ Maindisadvantageisheatsinkeffect,limitingtheusenearmajorbloodvessels.

transarterial ○ External beam ra-diotherapy—roleislimitedbecauseofthesurroundingtissuedamage.

○ Systemic chemothera-py

○ Basedonthefactthatmostofthetumorbloodsupplyisfromthehepaticartery1.HAI(hepaticarterialinfusion)chemotherapyusing5flouorouracil,cisplatin,doxorubicin2. Chemoembolization:EmbolizationparticlesandlipoidaloilsaddedwithchemotherapyagentsselectivelytakenupbyHCC

3.Transarterialradiotherapy

FiBrolAmellAr vAriAnt oF hcccharacters hcc FhccMale:Femaleratio o 8:2 • 1:1Medianage o 55 • 25Tumor o Invasive • WellcircumscribedResectability o <25% • 50%-75%Cirrhosis o 90% • 5%Alphafetoprotein o 80%elevated • 5%elevatedHEPBpositive o 65% • 5%FHCCalsohasacentralfibrousscarmakingitdifficulttodifferentiateitfromfocalnodularhyperplasia.FHCCdoesnotproducefetoprotein,butproducesneurotensinFHCChasabetterprognosisthanHCC

Hepatoblastoma metastatic liver tumor○ M/cprimaryhepatictumorofchildhood○ Ageofpresentation:18month(almost<3year)

○ Tumorderivedfromfetalhepatocytes○ Serumalphafetoproteinlevelselevated

○ M/cmalignanttumorofliver○ M/cfromcolorectalcancers○ Nowitisfoundhepatectomyiscurativeforcolorectalmets○ Theonlycontraindicationforliverresectionisinabilitytoresectalldisease○ Thethreecancers,wheresecondaryinliverisresected—colorectal,smallintestineandcarcinoids

Budd-chiAri syndrome• Youngfemalesareaffectedcommonly• Venousdrainageisoccludedbyeitheravenousthrombosisorobstructionbyavenousweb

• M/cpresentation—ascites*andabdominaldiscomfort

• CTscan—asciteswithlargecongestedliverorasmallcirrhotic,liverinwhichthereisgross enlargement of segment 1 (caudate lobe),becauseonlysegment1hasdirectdrainagetoIVC.

Contd...

Contd...

tahir99 - UnitedVRG


Budd-chiAri syndrome• Asaresultofvenousoutflowobstruction,thelivergetscon-gestedwithdevelopmentofimpairedliverfunctionwithsub-sequentportalhypertension,ascitesandesophagealvarices

• R/ounderlyingetiology—myeloprolifertaivedisorderorprocoagulantstatelikeproteinCSdeficiencyorantithrombindeficiency

• Confirmationofdiagnosis:Hepaticvenographyviatransjugularroute

• Treatment○Cirrhoticliver/fulminantliverfailure—livertrans-plant

○Non-cirrhotic—portocavalshunting

liver trAnsplAnt• M/cindicationinchildren:Biliaryatresia• M/cindicationinadults:Cirrhosis

indication in adult Absolute contraindications 1. Primarybiliarycirrhosis 2. Secondarybiliarycirrhosis 3. Primarysclerosingcholangitis 4. Carolisdisease 5. Cryptogeniccirrhosis 6. Chronichepatitiswithcirrhosis 7.Hepaticveinthrombosis 8. Fulminanthepatitis 9. Alcoholiccirrhosis10. Chronicviralhepatitis11. PrimaryhepatocellularCa12.Hepaticadenomas

1.Activeuntreatedsepsis2.Advancedcardiopulmonarydisease3.Extrahepaticmalignancy4.Metastasisinliver5.AIDS6.Life-threateningsystemicdiseases

indication in children1.Biliaryatresia2.Neonatalhepatitis3.Congenitalhepaticfibrosis4.Alagillesdisease5.Alpha1antitrypsindeficiency6. InheriteddisordersofmetabolismWilsons,tyrosinemia,glycogenandlysosomalstoragedisorders,hemophilia,oxalosis,etc.

types of graft○ Orthotopic graft—agraftplacedinitsnormalanatomicsite,e.g.liver

○ Heterotopic graft—agraftplacedinasitedifferentfromitsnormalloca-tion,e.g.kidneykeptiniliacfossa

important points in liver transplant• STARZLperformedfirstlivertransplant(1963)• Hepaticarterythrombosismayoccursponta-neouslyorasapartofacutegraftrejection.Itmaypresentasfever,bileleakorriseinserumtransaminaselevel.Thiscomplicationrequiresimmediateretransplantation.

• Portalveinthrombosisoccursinsidiouslyanddoesnotrequireretransplant

• Pediatriclivertransplantusingadultlateralsegmentofleftliver.• Chroniclivergraftrejectionoccursduetovanishingbileductsyn-drome

• Liverisresistanttohyperacuteandchronicrejection

Fmge questions

1. Which of the following statement is true regard-ing pyogenic liver abscess? (Sep 2005)

a. Diagnosiscanbeconfirmedbyserologicaltest b. Radiographicfeaturesarediagnostic c. Usuallyalargeandsingleabscessisseenin

casesofdirectspread d. SystemicmanifestationsareuncommonAns: c (Usually a large and single abscess is seen in cases of direct spread)Explanation:• Amebicliverabscessisdiagnosedbyserology*

• PyogenicliverabscessiscommonlycausedbyE. coli. Bloodculturemaybepositive

• If thespreadisbydirectmethod, it isusually largeand single, multiple abscess* seen only when thespreadisbyarterial(hepaticartery)route

• Systemicmanifestationsintheformfever,chillsandrigorsaresocommon.

2. investigation of choice for hydatid disease is: (March 2006) a. CTscan b. ELISA

Contd...

tahir99 - UnitedVRG

173Liver

c. Biopsy d. USGAns: a (CT scan)Explanation:• ThoughhydatidcystcanbediagnosedbyUSG,CTscanismuchmoreinformativeaboutthecommuni-cationwithbiliarytreeandregardingthesegmentofliverinvolved

• USGshowsWaterlillyappearance*• Calcificationsinthecystarealmostdiagnosticofhy-datidcyst

• Casoniintradermal*testwasonceusedtodiagnosehydatidcyst,butnotdonenowadays.

3. Number of lobes in liver as per Couinaud classifi-cation: (Sep 2009)

a. 3 b. 4 c. 6 d. 8Ans: d (8)Explanation:• Couinauddividedtheliverintotwolobesbyaline—Cantle’sline,whichisdrawnfromgallbladderfossatoleftofinferiorvenacava

• The classification isbasedon thehepaticveins fur-therinto8segments.

4. All of the following are true about fibrolamellar carcinoma of the liver, except: (Sep 2004)

a. Equalincidenceinmalesandfemales b. BetterprognosisthanHCC c. AFPlevelsalwaysgreaterthan>1000 d. occurinyoungerindividualsAns: c (AFP levels always greater than > 1000)Explanation:• Fibrolamellarvarietyofcancer in liverhaselevatedneurotensinB*astumormarker

• Commoninyoung individuals,goodprognosis, re-sectablerateisgood

• NotassociatedwithcirrhosisorhepatitisB*

5. Most common cause of liver abscess in india: (Sep 2005) a. Amebicabscess

b. Ascendinginfection c. Infectedhematoma d. SecondarytocholelithiasisAns: a (Amebic abscess)Explanation:• AmebicliverabscessisverycommoninIndia• Mostcommoninmales*.• Metronidazoleisthetreatmentofchoice*

6. Amebic abscess is commonly located in which part of liver? (March 2007)

a. Anteriorsuperior b. Posteriorsuperior c. Anteriorinferior d. PosteriorinferiorAns: d (Posterior inferior)

7. Most commonly ruptured organ in blunt trauma to abdomen is: (Sep 2010, March 2009)

a. Adrenals b. Kidney c. Liver d. SpleenAns: c (Liver)Explanation:Mostcommonorganinjuredinblunttraumaisliver.Mostcommonorganinjuredinblunttraumathatneces-sitateslaparotomyisspleen

8. Not a contraindication for doing percutaneous liver biopsy: (Sep 2009)

a. INR1.5 b. Hemangioma c. Biliaryobstruction d. PortalhypertensionAns: c. Biliary obstruction

9. Cause of hematemesis in a patient with mild sple-nomegaly: (Sep 2007)

a. Esophagealvarices b. Cancerstomach c. Pepticulcer d. GastritisAns: a. Esophageal varices

tahir99 - UnitedVRG

15Spleen

AnAtomy• Spleen size:12cmlength*7cmwidth*3-4cmthick• Weight:150g(75–250g)

• Longaxisliesalong10thrib• Parietalperitoneumadherestospleen:Exceptatsplenichilum.

Ligaments Splenophrenic and splenocolicligaments—relativelyavascular Splenorenalligamentextendsfromanteriorleftkidneytohilumofspleenastwolayer,enclosessplenicvesselsandtailofpan-creasinvested.

Theabovetwolayercontinuetothegreatercurvatureofstomachtoformtwoleavesofgastrosplenicligament

Blood supply• Splenic artery:Branchfromceliacarteryrunsalongsuperiorborderofpancreas

• Splenic vein:Fivemajortributariesjointoformsplenicveininsplenorenalligamentandrunsinferiortoarteryandposteriortothepancreatictailandbody

• Joinwithsuperiormesentricveintoformportalveinatneckofpancreas

• Rememberinferiormesentericveinoftenemptiesintothesplenicvein.

SpLenic function1. Mechanical filtration (most important function) Asplenic condition (peripheral blood)○ Removalofsenescenterythrocytes○ ClearingpathogenthatresideinRBC(malaria,bartonella)○ Ironisremovedfromdegradedhemoglobinandreturnedtoplasma(culling)**

○ Essentialtomaintainnormalerythrocytemorphologyandfunc-tion.

○ Thisfunctionresultsinanemiainconditionassociatedwithab-normalredcellmorphology(e.g.hereditaryspherocytosis,sicklecellanemia,thalassemia,etc.)

Targetcells(immaturecells)Howell-Jollybodies(nuclearremnant)Heinzbodies(denaturedHb)Pappenheimerbodies(irongranules)StipplingSpurcells

Contd...

tahir99 - UnitedVRG

175Spleen

SpLenic function2. Immune function 3. pitting

○ SynthesisofimmunoglobinM○ Synthesisofproperdin,tuftsin(theseantibodiesareofB&Tcelloriginandreactwithbacteriaandfungitorenderthemmoresusceptibletophagocytosis.

○ Particulateinclusionfromredcellsareremovedandrepairedredcellsarereturnedtocirculation.

4. Reservoir function 5. cytopoiesis○ Contain8%ofredcellmass. ○ From4thmonthofintrauterinelife,somedegreeof

hemopoiesisoccurinfetalspleen.

SpLenic trAumA○ M/corganinjuredinbluntabdomentrauma○ M/cindicationforlaparotomyafterbluntinjuryabdomen

○ M/cassociatedfindingisleftlowerribfracture(44%case)

Clinical features Radiological feature of splenic rupture○ Classictriadofacutesplenicinjury:ElevatedlefthemidiaphragmLeftlowerlobeatelectasisPleuraleffusion.

○ Balance sign unilateralshiftingdullness○ Kehrs sign painreferredtotipofleftshoulderduetoirrita-tionofundersurfaceofthediaphragmwithbloodandthepainisreferredtotheshoulderthroughtheaffectedfibersofphrenicnerve(c4&c5)

1.Obliterationofpsoasshadow2.Obliterationofsplenicshadow(mostimportantradiologicalsign)

3.Elevationofleftdiaphragm4.Medicaldisplacementofgastricairbubble*

Grades of splenic injury• Grade 1—subcapsularhematoma<10%surfacearea,laceration<1cmdeep

• Grade 2—subcapsularhematoma10%–50%surfacearea,laceration1–3cmdeep.

• Grade 3—subcapsularhematoma>50%surfaceareaorexpanding,laceration > 3 cm deep

• Grade 4—lacerationinvolvingsegmentalorhilarvesselswithmajordevascularization

• Grade 5—shatteredspleen,hilarvesselinjurywithdevascularizedspleen.

Treatment○ Conservativetreatmentofsplenicrupturehasgainedfavoroverrecentyears

Complication of conservative management• PresenceofvascularblushonCTscanafter3dayindicatesfalseaneurysmsofintraparenchymalbranchesofsplenicarteries(theseaneurysmscausedelayedruptureofspleen)

Non-operative managementindications Indications of splenectomy in trauma○ Canbetriedforhemodynamicallystablecases.○ Evengrade4,5injuriesarenowtakenupforcon-servativemanagement

○ Recently splenorrhaphy for grade 2, 3 and mesh wrapping for 4, 5 injuries are done.

UnstablepatientWhenotherinjuriesinabdomenrequirepromptattentionSpleenisextensivelyinjuredwithcontinuousbleedingBleedingassociatedwithhilarinjuryRuptureofpathologicalspleen

Contd...

tahir99 - UnitedVRG


SpLenectomyindications

• Trauma:Immediate,delayed,spontaneousrupture• Neoplasms:Lymphomas,leukemias,hemangiomas• As part of other surgeries:D2resection(gastrectomy):pancreatectomy,splenorenalshunt:

• Miscellaneous:Abscess,infarct,aneurysm,cyst,topre-ventgraftrejection.

• Hematological:1.Foranemia2.Forpurpura3.Hypersplenism4.Myelofibrosis.

Splenectomy always indicated○ Primarysplenictumor○ Hereditaryspherocytosis

HemAtoLogicAL indicAtionSFor anemia

1. Intracellular defect•Membrane abnormality Hereditaryspherocytosis Hereditaryelliptocytosis

•Enzyme defect G6PDdeficiency Proteinkinasedeficiency

•HemoglobinopathiesThalassemiasSicklecelldisease(rarelyindicated3%)

2.Extracellular defect:Autoimmunehemolyticanemia○For purpuraIdiopathicthrombocytopenicpurpuraThromboticthrombocytopenicpurpura

○For primary hypersplenism ○For myelofibrosis

Splenectomy not indicated for:• Asymptomatichypersplenism• Splenomegalywithinfection• SplenomegalyassociatedwithelevatedIgM

• Hereditaryhemolyticanemiaofmoderatedegree• Acuteleukemias• Agranulocytosis.

○ MCindicationforsplenectomysplenictrauma○ MCindicationforsplenectomyinelectivesettingITP

compLicAtionS of SpLenectomy○ MCinfectionaftersplenectomyStreptococcus pneumonia

immediate Intermediate delayed• Hemorrhage• Gastricdilatation• Hematemesis

• Leftbasalatelectasis(MC complication after splenectomy—16%)

• Pancreaticfistula,pancreatitis,pseudocyst• Gastricfistula(duetoperforationassmallgastricvesselsarecutduringsurgery)

• Subphrenicabscess/hematoma.

• Thromboembolicepisodes(duetothrombo-cytosisasgreaterthansevenandhalflakhsplateletsgetsaddedaftersplenectomy)

• Overwhelmingpostsplenectomyinfection(OPSI)

• Portalveinthrombosis.

overwHeLming poStSpLenectomy infectionBacterial infection Protozoan infection after splenectomy• Streptococcus pneumonia• Haemophilus influenzatypeB• Meningococcus• GroupAStreptococcus

• Babesia• MalariaNo increased risk of viral infection

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/

177Spleen

overwHeLming poStSpLenectomy infectionThe following vaccination are given:

Two week before planned splenectomy Postsplenectomy prophylaxis○ Pneumococcalvaccine:boostedevery5years○ H.influenzatypeB(Hib)vaccine○ Influenzavaccine—annually○ Meningococcalvaccine:

AntibioticprophylaxiswithpenicillinV250mgbd(or)erythromycin250mgbdforlongerofthefollowing1.2yearspostsplenectomy(or),2.Uptoageof16years.

RiskofdevelopmentofOPSIishighforhematologicindicationsthenthose,whoundergosplenectomyfortrauma.

HemAtoLogic effect of SpLenectomyImmediately after splenectomy Returntonormalwithin2–3week

• Leukocytosis• Thrombocytosis.

Chronic manifestationsAnisocytosisandpoikilocytosisHowel-Jollybodies(nuclearremnants)Heizbodies(denaturedhemoglobin)Basophilicstipling.

SpLenic tumorS○ M/cbenigntumorofspleen—hemangioma○ M/cmalignanttumorofspleen—hemangiosarcoma

Accessory spleen○ M/ccongenitalanomalyofspleen○ 80%accessoryspleenareinsplenichilumandvascularpedicle○ Otherlocationsaregastrocolicligament,tailofpancreas,greateromentum,greatercurvatureofstomach,splenocolicligament,smallandlargebowelmesentry,leftbroadligamentinwomen,leftspermaticcordinman.

Splenosiso Ruptureofspleenanddistributionofitstissueonperitoneum

SpLenic-gonAdAL fuSion• Rarecongenitalanomalyinwhichectopicsplenictissueuniteswithagonad(<200casesreported)• Continuousordiscontinuous.• Continuous:Spleenconnectedtoectopicsplenicmassbycordofsplenicandfibroustissue.

• Discontinuous:Noconnectionbetweenspleenandectopicsplenicmass.

20%ofcontinuoustypesassociatedwithothercongenitaldefects,includingperomelus(fetuswithmalformedlimbs)andmicrognathiaalsotesticularectopia,inguinalhernia.

Diagnosis:TechnetiumTc-99msulfurcolloidscan

Treatment:Surgicalexcisionofectopicsplenictissuetopreventtesticu-laratrophy,torsionorinfarctionandpreservefertility.

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


Splenorenal fusion Hypersplenism Felty syndrome• Maybeduetosplenosisaftersplenictraumaorsplenectomyorlesscom-monly,beadevelopmentalanomalyresultinginfusionofsplenicandrenaltissue

• Maypresentasarenalmassorwithsymptomsofhypersplenism

• Itisaconditioncharacterizedbysplenomegaly,cytopenia(anemia,leucopeniaandsplenomegaly)normalorhyperplasticbonemarrowandanexcellentresponsetosplenectomy.

• Rheumatoidarthritis+leucope-nia+splenomegaly

• Splenectomyproducesonlyatransientimprovementinbloodpicture,butrheumatoidarthritispreviouslyresistanttosteroidnowrespondswell.

SpLenic Artery AneurySm• Incidence:0.04%–1%• M/cinfemales;m/cin6thdecade*• M/csolitary(multipleaneurysmsareseenin1/4thcases)

etiology1. Intra-abdominalsepsis2.Pancreaticnecrosis3.Arteriosclerosis(elderly)

Clinical features TreatmentUsuallyasymptomatic(83%caser)½thecasesruptureinyoungage<45-year-old,¼ruptureinpregnantwomen(inthirdtrimesteroratlabor)

○ Notreatmentneededinasymptomaticandlesions<2cm○ Symptomaticlesionandlesions > 2 cmrequiresurgery○ Treatmentofchoice—splenectomyandremovalofdiseasedartery○ Ifexcisioninnotpossibletheproximalanddistalendsofthesacareligatedtoallowthrombosisofsplenicartery.

○ Embolizationofsplenicartery(inunfitcases)

SpLenic infArctionetiology CT scan:Perfusiondefectinenlargedspleen

MyeloproliferativesyndromePortalhypertensionPancreaticdiseaseSplenicveinthrombosisSicklecelldisease

TreatmentConservativeonlySplenectomyconsideredonlywhenasepticinfarctcausesanabscess*

IdIoPATHIC THRoMBoCyToPeNIC PuRPuRA (ITP)• Autoimmunedisorder• Presentwithlowplateletcountandmucocutaneousandpetechialbleeding• Lowplateletisduetotheantiplatelet IgG autoantibodiesproducedinspleen

• Plateletcountlessthan10,000/mmcubeareatriskofinternalbleeding• Inadditiontolowplateletcount,presenceofimmature(megathrombocytes)ispathognomonicofITP

• Most common indication for elective splenectomy • Forpatientswithlowplateletcountshouldhaveplateletsavailableatsur-gery,butshouldbeinfusedonly after ligating the pedicle

• Shouldnotbegivenpreoperatively• Thetreatmentofchoiceismedical—oral prednisolone 1 mg/kg producesdramaticresponsein50%–70%cases

• Intravenousimmunoglobinisindicatedforinternalbleeding.

Splenectomy is indicated for: 1.Failureofsteroids.2.Undesirableeffectsduetolonguseofsteroids.

3.Mostcasesoffirstrelapse.

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/

179Spleen

fmge queStionS

1. True regarding hemangioma of the spleen: (March 2006)

a. Leastcommonbenigntumorofthespleen b. Maytransformtohemangiosarcoma c. Malignanttransformationmaybemanaged

conservatively d. NoneoftheaboveAns: b (May transform to hemangiosarcoma)

2. Splenectomy can lead to: (Sep 2008) a. Leukopenia b. Thrombocytosis c. Thrombocytopenia d. ThrombocytopeniaandleukopeniaAns. b (Thrombocytosis)

3. Indications of splenectomy are all, except: (Sep 2007) a. Hereditaryspherocytosis b. Trauma c. Polycythemia d. IdiopathicthrombocytopenicpurpuraAns: c (Polycythemia)

4. Splenectomy is most useful in: (March 2007) a. Hemophilia b. Polycythemia c. Hereditaryspherocytosis d. ThalassemiaAns: c (Hereditary spherocytosis)

5. All of the following are common cause of postsplenectomy infections, except: (Sep 2006)

a. H. influenza b. E. coli c. Meningococcus d. Streptococcus Ans. b (E. coli)

6. All of the following are true regarding splenic rupture, except: (March 2005)

a. Elevationoftheleftdomeofdiaphragm b. Obliteratedpsoasshadow c. Obliteratedcolonicgasshadow d. ObliteratedsplenicoutlineAns. c (Obliterated colonic gas shadow)

7. In which of the following conditions splenectomy is not useful: (Sep 2008)

a. Hereditaryspherocytosis b. Porphyria c. Thalassemia d. SicklecelldiseasewithlargespleenAns. b (Porphyria)

8. Splenectomy is not done in: (March 2011) a. Trauma b. Tuberculosisofspleen c. Hereditaryspherocytosis d. SplenicabscessAns: b (Tuberculosis of spleen)

tahir99 - UnitedVRG

16Urological SUrgery

KIDNEY AND URETERSTypes of renal calculus

1. Calcium oxalate calculus (Most common) They have hard, small and jagged surface

2. Phosphate calculus Usually calcium phosphate, but sometimes is combined with

ammonium and magnesium to form the triple phosphate cal-culus ammonium magnesium phosphate

Also k/a struvite stone Smooth and dirty white and solitary Seen in alkaline urine especially with proteus infection, which

split urea to ammoniaThistypeofcalculusmayenlargetofillallormostofrenalcol-

lecting system forming a staghorn calculus*3. Uric acid and urate calculus These are radiolucent

4. Cystine stones Uncommon, seen in cystinuria Appear only in acid urine*Theyarepinktoyellowwhenfirstremoved,

but they change color to a greenish hue when exposed to air

6. Indinavir calculiIndinavirisproteaseinhibitorusedinacquiredimmunodeficien-

cy syndrome (AIDS) patients. It results in calculi in ~ 6% patient who use indinavir.

Indinavir calculi are radiolucent7. Phosphate or struvite stones They are infection stones associated with urea splitting organ-

isms, i.e Proteus, Pseudomonas, Providencia, Klebsiella, Staphylococ-cus and Mycoplasma

The high ammonium concentration derived from urea—split-ting organisms results in an alkaline urinary pH, required for the precipitation of phosphate crystals

5. Xanthine calculi These are radiolucent Thesearesecondarytoacongenitaldeficiency

of xanthine oxidase

tahir99 - UnitedVRG

181Urological Surgery

Dietl crisis: After an attack of acute renal pain, a swelling in the loin is found. Few hours later, following the passage of large amounts or urine, the pain is relieved and swelling disappears

Position of stone Site of pain At pelviureteric junction or

upper ureter Pain radiates to the testicles

At middle of the ureter (i.e. at crossing of gonadal ves-sels and ureter)

Pain is referred to McBurneys point on the right resembling appendicitis and on left simulates diverticulitis

At lower ureter or at pelvic brim

Pain is referred to inner side of thigh, groin

In the intramural ureter Strangury (painful and fruitless desire to micturate)

METHODS OF STONE REMOVALExtracorporeal shock wave lithotripsy (ESWL) Stones in calyceal diverticulum○ TheleastinvasiveandmostwidelyusedisESWL○ Conservativeapproachisusedwhenthestoneis4 or 5

mm in diameter○ Alsoknow•Steinstrasse: Is a new medical term, literally meaning ‘stone streetItiscondition,whichfollowstheuseofESWL Small pieces of fragmented calculi collect and

obstruct in the distal ureter, like sand occluding a straw

• Calycealdiverticulasarecongentialanomalies.Thesediverticula are usually drained by a narrow connection to the collecting system. So when a calyceal stone is broken by ESWL,thepassageoffragmentsishamperedbythenarrowconnection.ThishasleadtolowsuccessrateofESWL

• Percutaneous nephrolithotomy (PCNL) is more effective than ESWL for stones in calyceal diverticulum

Inference:• EventhroughESWLisnotverysuccessfulforstonesof

calyceal diverticulum. It is not a contraindicationContraindications for ESWL

Absolute contraindications Relative contraindications1. Uncorrected bleeding disorder2. Pregnancy

1. Urinary tract infection (UTI)2. Urinary tract obstruction distal to stone3. Cardiac pacemaker4. Severe orthopedic deformity5. It is a contraindication only if it prevents proper positioning of the stone at the F2

focal point6. Severe renal failure7.Cysteinestones,becauseofthephysicalpropertiesofitscrystallattice,ESWLisnot

effective in fragmenting it 8.Weight>300pound9.Lowerureteralstonesinwomenofchildbearingage

URETEROSCOPY• ‘Ureteroscopicstoneextractionishighlyefficaciousfor

lower ureteral calcui’, stones can be caught in baskets or endoscopic forceps. Those that cannot be removed via baskets or endoscopic forceps, are fragmented using ureteroscopic lithotrites

• Any renal calculi that is 4 mm or less in size, is allowed some time (approx 4 week) to pass spontaneously

Contd...

tahir99 - UnitedVRG


URETEROSCOPYIndications for surgical removal of a ureteric

calculus Stone is too large to pass spontaneously Urine is infected Repeated attacks of pain and the stone is not moving It is enlarging

It causes complete obstruction Stone is obstructing solitary kidney or there is bilateral obstructions

PERCUTANEOUS NEPHROLITHOTOMY (PCNL)• PCNL:Shorthospitalstay• PCNL:Minimummorbidity

• PCNLsuccess:Similartoopenoperation• TheoverallcostmaynotbedifferentofopenandPCNLoperation

Indications Complications of pcnlLargecalculi>2.5cmsize Infected calculi Cystine calculi Obstructive uropathies FailedESWL Anatomic abnormalities Recurrent large calculi after open operation

Bleedingbloodtransfusion3%–10% Septicemia—more with struvite calculusPerforationandextravasationoffluid Pleural injury—upper calyceal puncture Duodenal Injury/colon injury (subcostal approach) Liverandspleeninjuries—rare Injury to vessels: Renal vein, renal artery or inferior vena cava (IVC)—rare

Contd...

tahir99 - UnitedVRG


RENAL CELL CARCINOMA○ Arenalcellcarcinoma(RCC)thathasspreadtorenalvein,IVCorevenuptothethorax(heart)isoperable○ ApreopbiopsyisnotnecessaryasaRCC is the most common malignant neoplasm of kidney (90%–95%) and any solid

renal mass is considered to be RCC until unless proved otherwise○ AchestX-rayshouldbedonetoruleoutpulmonarymetastasisasitwillmaketheCaofstageIVwithworstprognosis

and also decide the t/t plan

More about renal cell carcinoma Risk factors• Itisthemeningalcoreinomatosis(MC)malignantneo-plasmofkidney(90%–95%)

• MCsiteoforiginisproximalconvolutedtubules*• RCCoriginatesinthecortexandtendstogrowoutinto

perinephric tissue • Usuallysituatedatpoles(commonlyatupperpole)*• Malefemaleratiois2:1*• Age—5thto6thdecade

• Cigarettesmoking*• Obesity*• Polycystickidneydisease• Tuberoussclerosis*• VonHippel-Lindau(VHL)syndrome (cerebellar hemangioblastoma, retinal angimatosis and B/l

renal cell Ca)

○ Histologically RCC is an adenocarcinoma.IthasbeenreclassifiedintosubtypesofwhichclearcellsCaistheMCtype

Cytogenetics of various subtypes of renal cell (Ca)Clear cell carcinoma Papillary carcinoma

○ Itisthemostcommontype(70–80)○ Thesetumorscanbe• Familial•AssociatedwithVHLdiseaseor• Sporadic(95%)

Almost all (98%) of clear cell carcinomas are associated with loss of se-quences on short arm of chromosome 3. The lost sequences include the VHLgene.

TheVHLgeneactsastumor-suppressorgenetheloss,ofwhichisassoci-ated with clear cell Ca

○ Alsooccursinbothfamilialandsporadicforms

○ Thecytogeneticabnormalitiesassociatedwith papillary Ca are: Trisomies 7, 16 and 17 and loss of Y is

male patients for sporadic form Trisomy 7 in the familial formFamilialformisassociatedwithMET

proto-oncogene.

Chromophobe carcinoma Oncocytoma○ Oncytogeneticexaminations,thesetumors

exhibit multiple chromosome losses and extreme hypoploid

○ Associatedwithlossofchromosome1andY○ Renal medullary Ca is a relatively new histologic subtype of RCC that

occurs almost exclusively in association with the sickle cell trait.

Contd...

tahir99 - UnitedVRG


Classical triad of RCC consist of• Hematuria*• Flankpain*• Palpableflankmass*EarliestandMCpresentingfeatureis

hematuria*

Paraneoplasitc syndromes○ Feverofunknownorigin*○ Anemia*○ Erythrocytosis*(d/tsecretionoferythro-

poietin* by RCC) (butanemiaisamorecommonfinding)*

○ Hypertension○ Abnormalliverfunction

(stauffers syndrome, * i.e. nonmetastatic hepatic dysfunction)

○ Hypercalcemia*○ Neuromyopathy*○ Amyloidosis*○ Increased (ESR) (MC paraneoplastic syndrome)*○ Dysfibrinogenemia

○ Cushingsyndrome*○ Galactorrhea○ Feminizationandmasculinization

Important points in RCC• MCrouteofmetastasisishematogenous • MCsiteofdistantmetastasisislung* (canonball secondaries, secondaries may be

pulsatile)

• Investigationofchoice CT scan*• Treatmentofchoice Radical nephrectomy• Radiotherapy,chemotherapyorhormonaltherapyhavelittleroleinRCC

t/t

Treatment○ Partialnephrectomyisnowbeingusedasprimarysurgicaltherapyforpatientswithtumor<4cminsize. For tumor < 4 cm—partial nephrectomy For tumor > 4 cm—radical nephrectomy

Radical nephrectomy includes removal ofi. KidneyandGerota’sfasciaii. Ipsilateral adrenal

iii. Renal hilar lymph nodesiv. Proximal half of ureter

The renal cell Ca is prone to grow into the renal vein. Produce cannonball mets in lung and mets are highly vascular, which may pulsate (also in follicular Ca thyroid)

MC POINTS○ MCsiteofdistantmetastasisfromlungCa Adrenals *next is liver, brain○ MCsitefordistantmetastasisfrombreastCa Vertebrae ○ MCsitefordistantmetastasisfrombladderCaLung*○ MCsitefordistantmetastasisfromcolorectalCaLiver*○ MCsitefordistantmetastasisfrommelanoma(cutaneous) Skin/subcutaneous tissue lung*○ MCsitefordistantmetastasisfrommelanoma(ocular)Liver*○ MCsitefordistantmetastasisfromprostate bones*○ MCsitefordistantmetastasisfromsoft-tissuesarcomaLung*○ MCsitefordistantmetastasisfromtestisCaLung*○ MCsitefordistantmetastasisfromthyroidCaBone*,Lung*○ Metastasistolungismostcommonlyfrom Breast Ca*

RENAL CELL CARCINOMA

Contd...

tahir99 - UnitedVRG


WILM’S TUMORAnomalies associated with Wilm’s tumor

○ ChromosomalanomaliesassociatedwithWilm’stumor 8th & 11th○ MCandearliestsymptom Abdominal lump○ MCsiteofdistantmetastasis Lung○ MCpresentationispainlessabdominalmassusuallydiscoveredbythe

mother while routinely bathing the baby other signs and symptoms are Abdominal pain, fever, abdominal distention, hematuria Anorexia, hypertension, nausea and vomiting

• Hemihypertorphy• Perlmansyndrome• Aniridia• WAGRsyndrome{Wilmstumor,aniridia,genitouri-

nary anomalies (horseshoe kidney), retardation of intellect}

• Beckwith–Wiedemannsyndrome*• Cryptorchidism• Denysdrashsyndrome• Hypospadias

○ Thisisamixedtumorcontainingepitheliumandconnectivetissueelementsarising from embryonic nephrogenic tissue

○ Triad of: Abdominal mass Pyrexia Hematuria

Treatment○ Theimmediatetreatmentforunilateraltumorsissurgical

removal of the affected kidney even if pulmonary metasta-sis are present

○ Wilm’stumorisbothchemo sensitive and radiosensi-tive tumor. So both chemotherapy and radiotherapy play significantroleinitstreatment (cf. Renal cell Ca is both chemoresistant and radiore-

sistant)

○ CombinationchemotherapyusedinvincristineandactinomycininlocalizeddiseaseandDoxorubicin added for advanced disease.

○ Radiotherapyisusedforadvanceddisease.ThepostoperativeradiotherapyinWilm’stumoris

started within 10 day of surgery Delay in starting radiotherapy beyond ten days leads to

tumor cells repopulation and increases the relapse rate

THE FOLLOWING ARE THE DIFFERENTIATING FEATURE BETWEEN NEUROBLASTOMA AND WILM’S TUMORa.Calcification:Therearefactofcalcificationvisible in neuroblastoma (about

85%), which are generally less common and less prominent in Wilm’stumor(<15%)

b. Location Wilm’stumorandneuroblastomcanbedifferentiatedonlocationtoo.Computedtomograpy(CT)findingswillconfirmtheintrarenallocationofwilm’swhereasneuroblastoma will be seen above the kidney pushing it downwards and outwards

c. Intraspinal extension: IntraspinalextensionisseeninneuroblastomanotinWilm’s

tumor d. Crossing midline Wilm’stumorsaretypicallyconfinedtoonesideofthe

abdomen, whereas neuroblastoma usually cross the midline

e. Aorta and IVC invasion Wilm’stumorinvadesaortaandIVC.Whereasneuroblastoma

does not invade these structures

ANGIOMYOLIPOMA OF KIDNEY○ Angiomyolipomaisabenigntumorofkidney(infact,itisahamartomaandcharac-

teristically presents with fat in the lesion)○ Itischaracterizedby3majorhistologicalcomponents.○ Thereareasthenamesuggests:Bloodvessels,smoothmuscleandfatcells Angiomyolipoma may occur as an isolated phenomenon or in association with

tuberous sclerosis. Angiomyolipoma occurs in 50% of patients with tuberous sclerosis

Signs and symptoms and angiomyolipomas• Hematuria • Hypovolemicshock• Flankpain • Hypertension• Palpablemass • Anemia

Contd...

tahir99 - UnitedVRG


ANGIOMYOLIPOMA OF KIDNEY○ Sometimesitpresentswithspontaneous

retroperitoneal hemorrhage (k/a Wunderlich’s syndrome)

○ TheinvestigationofchoiceisCT scan, which shows the presence of fat within the lesion

Treatment• Inasymptomaticandlesionlessthan4cminsize observation and

follow-up with annual imaging • Inlesions>4cmwithnoormildsymptoms follow-up with biannual

imaging• Inlesionlargethan4cmwithmoderateorseveresymptomsuchaspain

and hemorrhage selectiveembolizationorpartialnephrectomy

GENITOURINARY TUBERCULOSIS (TB)• Genitourinarytuberculosisisalways

secondary to pulmonary infection, though in many cases has healed or is quiescent.

• Infectionoccursviathehematogenous route.

• Inearly renal tuberculosis, the only ra-diological abnormality may be irregular-ity or destruction of papillae.

• Most sensitive modality to detect it is intravenous urogram (IVU) as it can show detailed calyceal anatomy

Advanced changes are1.Calcification This may occur in any part of genitourinary tract, most commonly in kid-

ney, next in ureter2. Cavities 3. Fibrosis leading to obstruction Fibrotic strictures of the pelvis or ureters lead to hydronephrosis Strictures of the calyceal neck leads to hydro calyces (or hydrocalicosis)

4. Bladder changes Bladder wall may appear thickened and trabeculated and bladder may be

small, contracted (thimble bladder).Inlaterstagesvesicoureteralreflux(VUR)mydevelop

○ Computedtomography:Showsadvancedchangeswell,butislesssensitiveinearlystagesasitcannotdetailcalycealanatomy

○ ‘Sterilepyuria’istheruleButabout15%–20%ofpatientswithtuberculosishavesecondarypyogenicinfection,obscuringthecluepyuriaTheTuberclebacillicanbeidentifiedonAFBstainingof24hrurinespecimenorthefirstmorningurinecollectedon3

successive days. Acidfastbacilli(AFB)stainingispositiveinabout60%ofcases.

○ Mostcommonsiteofgenitourinarytuberculosisis Kidney ○ Commonestcauseofpyelonephritisis E. coli

RENAL TRAUMA○ Approachtokidneyshouldbetransperitoneal to exclude the pos-

sibility of damage to other abdominal organs ○ Approachshouldnotbelumbar.○ “Surgical exploration is needed in < 10% of closed injuries and

is indicated if either there is progressive blood loss or there is an expanding mass in the loin”

○ More than 90% of all blunt renal injuries are managed conserva-tively

• Anintravenouspyelogram(IVP) is done urgently to assess the damage to the kidney and to know the functioning of the other kidney

• Hematuria is the cardinal sign of a damaged kidney, but it may not appear until some hoursaftertheinjury.Thisispresentin>95%of patients with renal injury. The degree of hematuria does not precisely correlate with severity of injury

Closed renal injury almost always extraperitoneal. The exception is seen occasionally in young children with

very little extraperitoneal fat. Their peritoneum is in close contact to the kidney and can tear with the renal capsule.

Complications of renal trauma1. Pararenal pseudohydronephrosis2.Hypertensionresultingfromrenalfibrosismayoccur3

month or more after injury3. Aneurysm of renal artery

Contd...

tahir99 - UnitedVRG


POLYCYSTIC KIDNEY DISEASE• Adultpolycystickidneydisease(PKD)• Inheritanceisautosomaldominant(AD)• Diseasemanifestsitselfinadultlife

• InfantilePKD• Inheritanceisautosomalrecessive(AR)• Diseasemanifestsininfancyassevererenalfailureandlifeexpectancyis

short

Adult PKD• Almostalwaysbilateral (95%)• Diseaseordinarilydoesnotmanifestitselfbefore40 yr of age.• Pathology The kidney is enlarged 3 to 4 time Cysts are distributed evenly throughout the cortex and medulla Content of the cyst varies, but it is not urine Renal tissue is progressively replaced by cysts leading to chronic renal failure (CRF)

Associated anomalies with ADPKD Clinical presentation Urine examination1. Cysts in liver, spleen, pancreas and

ovaries (lungs)2. Berry aneurysm3. Mitral valve proplase4. Colonic diverticulosis 5.Congenitalhepaticfibrosis

• Mass• Pain• Hypertension (70%–80% of cases)• Hematuria• Infection• Uremia

• Highoutputofurine• Lowspecificgravity• Itmaycontaintracesofalbu-

min

○ Three forms of ADPKD have been identified• ADPKD 1 Accounts for 85% cases Its gene is found on chromo-

some 16p

• ADPKD 2 Its gene has been mapped to chromosome 4q It appears to have a later age of onset of symp-

toms and renal failure than ADPKD 1

• ADPKD 3 It has not been mapped to

a gene up till now

Treatment○ Decompositionoruncappingofcysts(Rovsingoperation)isofnouseinpreservingtherenalfunction○ ItultimatelyleadstoCRFandrenaltransplantationistheonlydefinitet/t

ECTOPIC URETER• Inthemale,theposterior urethra is the most

common site of termination of an ectopic ureter • Locationofectopicureters(indecreasingorder)

○ More about ectopic ureters•Ectopicuretersareusuallyassoci-

ated with duplicate ureters (in 80% cases) but may also occur in single ureters systems

•More common in females•Theuretersfromtheupperpelvis

opens distally and medially to its fellow ureters

•Mostcommonsymptom In males recurrent UTI In females incontinence (para-

doxical incontinence)

In males In femalesPosterior urethraSeminal vesicleProstatic utricleEjaculatoryductVas deferens

UrethraVestibuleVaginaCervix or uterusGartnerductUrethral diverticulum

• Inamalepatient;theectopicuretersopensalwaysabovetheexternalurethralsphincter(thebulbarurethraisbelowtheexternal urethral sphincter)

• Infemalespatients;anectopicuretersmayopenaboveorbelowtheexternalurethralsphincterEctopicopeningbelowtheexternalurethralsphincterleadstourinaryincontinence,‘continuousincontinenceinagirlwithanotherwisenormalvoidingpatternaftertoilettrainingistheclassicsymptomofanectopicureteralorifice’

tahir99 - UnitedVRG


CONGENITAL PELVIURETERIC JUNCTION OBSTRUCTION (PUJ OBSTRUCTION)• Itwasearlierbelievedthattheaberrantrenalvesselsisresponsibleforcausingthecong. Pelvi ureteric junction (PUJ) obstruction Bailey writes that “aberrant vessels probably

do not cause hydronephrosis, although a hydronephrotic renal pelvis bulge between renal vessels”

• Cambellsurologywrites “whether the aberrant vessel causes obstruction or is a co-variable that exist alone with an intrinsic narrowing is unclear”

Important points about congenital PUJ obstruction• CongenitalPUJobstructionisthemostcommoncauseofsignificantdilatationofthecol-

lecting system in the fetal kidney• Incidenceismore in boys (2 : 1)• Usually unilateral,butbilateralin10%–40%cases

Associated anomalies• Renaldysplasia• Multicysticdysplastickidney• Renalagenesis(5%ofchildren)

• Vesicouretericreflux• PUJobstructionwasnotedin21%ofchildrenwiththeVATERgroupanoma-lies(VATERstandsforvertebraldefects,imperforateanus,tracheoesophagealfistula,radialandrenaldysplasia)

Most common presentation of cong PUJ obstruction is asymptomaticDiagnostic tools Surgical repair• Majorityofcasesarediagnosedprenatallywithhelpofultra-

sound•Whitakertest(pressureflowstudies)canbeusedtofindoutobstructiontoflowofurine.InWhitakertest,cathetersareplaced in renal pelvis and bladder. Fluid is infused into the kidney and the pressures are measured. A differential pres-sure between kidney and bladder could then be indicative of obstructiontotheflow

• Retrogradepyleographycanbeusefultolocatethesiteofobstruction

• CongenitalPUJobstructionarecorrectedbyeitheropen surgical techniques or endoscopic and laparo-scopic approaches

• Outoftheopentechniques,theAnderson-Hynes dismembered pyeloplasty is the most commonly employed technique

• EndoscopicapproachesincludeEndoscopicpyelotomy Balloon dilation Stent placement

MEDULLARY SPONGE KIDNEY• Medullary sponge kidneyisacongenitaldisordercharacterizedbycysticdilationofinner

medullary and papillary collecting ducts• Patientsgenerallypresentwith: Kidney stones Recurrent hematuria Infection (UTI)

• Mostcasesaresporadic,whilesomeshowautosomaldominantinheritance• Involvementisbilateralinmostcases

RENAL TRANSPLANTATION• First the type of grafts○Allograft—anorganortissuetransplantedfromoneindividualto

the other○ Isograft—atransplantbetweenidenticaltwins○Orthotopicgraft—atransplantplacedinitsnormalanatomicsite

• Types of donorDonors are of 3 types:○Livingdonor○ Braindead,heartbeatingcadavericdonors○Non-heart-beating(asystolicdonors)

Contd...

tahir99 - UnitedVRG


RENAL TRANSPLANTATION○Heterotrophic—atransplantplacedinasitedifferentfromwheretheorgansisnormallylocated

• Renal transplant is a heterotrophic graft because the transplanted kidney is not placed in its normal anatomic position, but is placed in the iliac fossa in the retroperitoneal position leaving the native kidney in situ

Organ procurement○ Inbrainstemdeaddonor,theorgantobeprocuredshouldbe

preserved to maintain its functional integrity○ Forthispurposetheorganshouldbeperfusedwiththeorganpre-

servative solution twice, before it is transplanted to the recipient○ Thefirstperfusion is done just after the abdomen is opened at

laparotomy and the second perfusion is done just after the organs has been removed from the donor

○ CommonlyusedpreservativesolutionincludeUW solution (university of wisconsin) and Eurocol-lins solution

○ Afterremovalfromthedonor,theorganisplacedin two sterile bags and stored at 0–4°C by im-mersion in ice, while they are transported to the recipient centre

Immunosuppresive drug in renal transplant○ Calcineurin blockers are especially useful in renal transplant pa-

tients. These include cyclosporine and tacrolimus ○ Skin cancer is the commonest cancer on im-

munosuppression in renal transplant.

RENAL CASTS• Albuminsecretedfromtheglomerulidonotformcasts.Thiswe

know from our knowledge of various diseases, e.g. in nephritic syndrome there is hyperalbuminuria, but no casts are seen in urine

• Hyalinecast,whichmaybeseeninnormalindividualsareformedfrom Tamm-Horsfall proteins secreted by epithelial cells of loop of Henle

Types of casts • Waxycasts CRF• Broadcasts CRF• Browngranularcasts acute renal failure (ARF)• Whitebloodcells(WBC)cast pyelonephritis• Redbloodcells(RBC)cast glomerulonephritis

Some important appearancesRadiological features Seen in Spider leg appearance Polycystic kidney Cobra head appearance Ureterocele Flower vase appearance on ureters Horseshoe kidney Sandy patches Schistosomiasis of bladder Soap bubble appearance/Rim sign Hydronephrosis Apple-core lesion on barium enema Ca colon Claw appearance on barium enema Intussusceptions Saw tooth appearance Diverticula of colon Birds beak appearance of esophagus on barium meal Achalaisa Corkscrew appearance of esophagus on barium meal Diethylstilbestrol(DES) String sign of Kantor Crohn disease Thumb printing sign Ischemic colitis

XANTHOGRANULOMATOUS PYELONEPHRITIS○ Xanthomeanslipidfoamcells○ Xanthogranulomatouspyelonephritisisavariantof

chronic pyelonephritis that characteristically presents in middle aged patients with a poorly functioning kidney (as in diabetic)

○ Onhistologythereareareasofclearcellsthatarelipidladenmacrophages

○ Theseareasoflipidlaidenmacrophageappearasfatdensitylesion on U/S

○ Thispyelonephritisisoftenaccompaniedbyacalculus and proteus infection.

Contd...

tahir99 - UnitedVRG


NEPHRECTOMY APPROACHES• Therearetwocommonmethodstoapproachkidneyfornephrectomyorotherwise:○ Thetransperitonealabdominalapproach○Theretroperitonealloinapproach

• Theretroperitoneal loin approach is preferred method except for two conditions: Malignant tumors Renal injury (peritoneum is opened to exclude other

injuries)

• InloinapproachfollowingmusclearecutLatissimusdorsi Serratus posterior inferior 3 lateral muscle of the abdominal wall○Externaloblique○ Internaloblique○Transverseabdominis

URETEROCELE• The‘adder head ’ or ‘cobra head ’appearance on excretory urography

is noted in ureteroceles Ureterocele is a ballooning of the distal submucosal ureters into the

bladder Ureterocele is thought to result from congenital atresia of the ureteric orifice

Although present from childhood the condition is often unrecog-nizeduntiladultlife

It may get large enough to obstruct the vesical neck or the contralat-eral ureters

It is more common in females10%ofcasesarebilateral Often associated with duplicate ureters (always involve the ureters

draining the upper renal pole) Almost always associated with significanthydroureteronephrosis

URINARY BLADDER

CARCINOMA BLADDER○ Therearethreecommonhistologicaltypesofbladdercancer:1.TransitionalcellCa—~90% 2.SquamouscellCa—~5%–10% 3. Adenocarcinoma—~ 2%

Risk factor for transitional cell Ca of bladder1. Cigarette smoking isthemainetiologicalfactorandaccountsforabout50%ofbladdercancers2. Occupational chemicals • Thefollowingcompoundsmaybecarcinogenic: 2 naphthylamine combustion gases and soot from

coal 4 aminobiphenyl chlorinated aliphatic hydrocar-

bons 4 nitrobiphenyl certain aldehydes such as acrolein 4-4 diaminobiphenyl aniline dyes

• Occupationreportedtobeassociatedwithincreasedriskofbladder cancer

Autoworker Painters Truck drivers Drill press operatorLeatherworkers Metal workers

Textile workers Dye workers Petrol workers Rodent exterminators and

sewage worker

3. Schistosoma hematobium Risk factor for both transitional cell Ca and squamous cell Ca4.Drugssuchasphenacetinandchlornaphazine5. Cyclophosphamide therapy6. Pelvic irradiation

Contd...

tahir99 - UnitedVRG


CARCINOMA BLADDERRisk factor for squamous cell Ca of bladder

• Schistosomahemotobium○ ItisariskfactorforbothtransitionalcellCaandsqua-

mous cell Ca but more for squamous cell Ca

• Chronicirritationfromurinarycalculi,longtermin-dwelling catheters, chronic urinary infections

• Bladderdiverticula

Also remember• MCprimarytumor,whichgivessecondarytopenis blad-

der carcinoma• Commonesttumorofurinarybladder transitional cell Ca• CommonesttumorofUBinachild rhabdomyosarcoma• MCsymptomofrenalcellCa painless hematuria

• MCsymptomofWilm’stumor mass in abdomen• MCsymptomofbonymetastasis pain• MCsymptomofrenalstone pain• Earliestsymptomofvesicalcalculus frequency• Cardinalsymptomofrenaltrauma hematuria• MCsymptomofacutearterialocclusion pain

MANAGEMENT OF BLADDER CANCER• Cystoscopyandtransurethralresectionorbiopsy• Initiallyanypatientwithhematuriaisexamined

by cystoscopy and any tumor seen is removed by transurethral resection (if possible) or biopsied

• Furthertreatmentdecisionsaremadeaftertumorstaging on histology.

• Suchdecisionsarebasedontumorstagetumornodemetastasis(TNM),gradesize,multiplicityand recurrence pattern

Staging (TNM) • Nowthehistologicalgrading There are three histological grades—

grade I, II & III There is a strong correlation between

tumor grading and tumor recurrence progression and survival

Tis Ca in situTa Caconfined

to mucosa

T1 Caconfinedtosubmucosa

T2 muscle inva-sion

T3 perivesical fat invasionT4 invasion of adjacent struc-

tures (prostate, uterus, vagina, pelvic wall, abdominal wall)

Treatment options for bladder cancersCancer stage Initial treatment optionsTis Complete transurethral resection (TUR) followed by intravesical

bacilusCalmette-Guerin(BCG)Ta (single, low to moderate grade, not recurrent) Complete TURTa (large, multiple high grade or recurrent T1) Complete TUR followed by intravesical chemo or immunotherapy T2 –T4 1. Radical cystectomy

2.Neoadjuvantchemotherapyfollowedbyradicalcystectomy3. Radical cystectomy followed by adjuvant chemotherapy 4.Neoadjuvantchemotherapyfollowedbyconcomitantchemothera-

py and irritationAny T, N+, M+ Systemic chemotherapy followed by selective surgery or irradiation • Intravesical therapy: Common agents used for intravesical therapy are: Mitomycin C Doxorubicin Thiotepa BCG

• Amongtheseagents,BCG is the most effective

Contd...

tahir99 - UnitedVRG


BLADDER CALCULI• Ingeneral,mostofthebladdercalculiareformedwithinthebladderitself.Onlysomestonesareformedinthekidney

and pass into the bladder, where they grow by additions of crystals• Etiology of bladder calculi○Bladderoutletobstructionisthemostcommon

cause of vesical calculi in adults○Othercausesare:■Neurogenicbladderleadingtourinarystasis■Aforeignbody,e.g.Foleycatheterandforgotten

double-J (DJ) stent, which serve as midi for stones■Bladderdiverticula

• Bladderstonesarecommonlyseeninolder men (> 50 yr) usu-ally because of bladder outlet obstruction

• Common vesical stones are○Uricacidstones○ Struvitestones

• Otherlesscommonstonetypeare:○Oxalatestones○Cysteinstones

• Struvite stones are also know as ‘jack stones’ because of their rough surface as against the smooth surface of uric acid stones.

Based on origin Clinical features• Primary bladder stone is one that develops in sterile urine and

originates in kidney and passes down the ureters to the bladder, where it enlarges

• Secondary bladder stones occur in presence of some infections, bladderoutflowobstruction,impairedbladderemptyingoraforeign body such as non-absorbable sutures, metal staples or catheter fragments

• Most of the bladder stones are secondary. Only some stones are primary. Kidney stones, which are small enough to pass through the ureters into bladder are easily passed out through the urethra

• Mostbladderstonescontaincalciumandarethereforeradiopaque

○ Frequency is the earliest symptom○ Hematuriaiscommonandthismaybecharacter-izedbyfewdropsofbloodattheendofmicturition

○ Pain(strangury)mayoccurbecauseofspeculatedoxalate stone. It usually occurs at the end of mictu-rition and is usually referred to the tip of penis or to the labia majora. In young boys, screaming and pulling at the end of penis with hand at the end of micturition are indicative of bladder stone. Uric acid stones are primarily formed in bladder. Its oxalate stones are dropped from above

• Treatment of vesical calculus○ Smallstonescanberemovedorcrushedtransurethrally(cystolitholapaxy)○ Largerstonesareoftendisintegratedbytransurethralelectrohydrauliclithotripsy(shockwavegeneratingprobe),or

may require suprapubic transvesical removal (vesiolithotomy)

RUPTURE OF BLADDER• Bladderruptureisoftwotypes:1.Extraperitoneal—80%ofcases2.Intraperitoneal—20%ofcases

• Urethralruptureisalsooftwotypes:1. Bulbar urethral injury is MC2. Membranous urethral injury

○ Extravasation of urine in bladder & urethral injuries• Extravasation of urine (+ blood) in bulbar urethral

injuryItisasuperficialextravasation If the Buck’s fascia remains intact, extravasation of bloodandurineareconfinedtothepenileshaft.However, disruption of Buck’s fascia allows extrava-sated contents into a space limited by Colle’s fascia formsascrotalandperinealbutterflyhematoma,which can extend up the abdominal wall.

• Extravasation of urine in membranous urethral injury and extraperitoneal bladder rupture.Extravasationissameinboth It is a deep extravasation Urine extravasates in the layer of the pelvic fascia and the

retroperitoneal tissues Urine collects in the perivesical spaceThetypicalfindingoncystogramisextravasationofthe

contrast material into the pelvis around base of the bladder• Intraperitoneal rupture Usually occurs with a direct blow to lower abdomen with full bladder Blood and urine will extravasate into the peritoneal cavity producing signs of peritonitis

More about bladder and urethral injuries• Bladderinjuriesareusuallyassociatedwithpelvic#• Bladderrupturesassociatedwithpelvic#isextraperi-

toneal type

○ Urethralinjassociatedwith#pelvis membranous urethral inj○ Urethralinjcausinghighflyingprostate membranous

urethral inj.

Contd...

tahir99 - UnitedVRG


RUPTURE OF BLADDER

TUBERCULOSIS OF BLADDER• Bladdertuberculosisisalmostalways secondary to renal

tuberculosis• Thediseasestarts at the ureteric opening, the earliest evi-

dence being pallor of the mucosa due to submucosal edema• Subsequentlytinywhitetranslucenttuberclesdevelopallover.Graduallythesetuberclesenlargeandmayulcerate(butdo not cause bladder perforation)

• Thesetubercleslend‘cobblestone’ appearance on cystoscopy

• Thereisconsiderablesubmucousfibrosis,whichcaus-esdiminishedcapacityofbladder.Scarred&fibrosed,small capacity bladder is k/a thimble bladder

• Thefibrosis,whichusuallystartsaroundtheureters,contracts to cause a pull at the ureters. This either leads to a stricture or displaced, dilated and rigid wide mouthed ureters k/a golf hole ureters. This almost alwaysleadstoureteralreflux

PROSTATE AND SEMINAL VESICLES

ANATOMICAL DIVISION OF PROSTATEProstatehasfivelobes:○ Anterior lobes ○ Posterior lobes ○ Median lobes ○ Lateral lobes Is small isthmus con-

necting the two lateral lobes in front of the urethra.

It connects the two lateral behind the urethra. It lies behind the me-dian lobe and the ejaculatory ducts. Carcinomas are most common in this lobe.

Liesbehindtheupperpartof the urethra, in front of the ejaculatory ducts just below the neck of the bladder.

Benign prostatic hyperplasia (BHP) arises in this lobe.

Lieoneoneachside of the urethra.

Zonal or surgical division of prostate• Prostatehasthreedistinctzonesa.Theperipheralzone(PZ)—accountsfor70%ofvolumeof

young adult prostateb.Thecentralzone(CZ)—accountsfor25%c.Thetransitionzone(TZ)—accountsfor5%

• Carcinoma of prostate arises most commonly in the peripheralzone.

• Benignprostatic hyperplasia originates in the transi-tionzone.

Contd...

tahir99 - UnitedVRG


COMPLICATIONS OF TURP1. Water intoxication is an important complication of TURP (transurethral resec-

tion of prostate)○ “Theabsorptionofwaterintothecirculationatthetimeoftransurethral

resection can give rise to congestive cardiac failure, hyponatremia and frequently confusion and other cerebral events often mimicking a stroke.

○Theincidenceofthisconditionhasbeenreducedsincetheintroductionofisotonic glycine for performing the resections and the use of isotonic saline for postoperative irrigation.Thetreatmentconsistsoffluidrestrictions”.

2. Perforation of bladder is one of the complications of TURP. It can present with periumblical pain after recovery from spinal anesthesia○ {Meteorism – is distention of the

abdomen or intestines by gas. This is seen in renal injury but not in TURP}

ABSOLUTE INDICATIONS FOR SURGICAL TREATMENT OF BPH1. Refractory urine retention (failing at least one attempt at

catheter removal)2. Recurrent UTI from BPH3. Bladder stones d/t BPH

4.Renalinsufficiencyd/tBPH5.LargebladderdiverticulasecondarytoBPH6. Recurrent goes hematuria from BPH

• “Theholmium: Yttrium aluminium garnet (YAG) laser is excellent for stone fragmentation and tissue ablation and is now the most popular system in use”

• BothHo:AG&Nd:YAGlasersystemscanbeusedforBPH,but only Ho: YAG is used for stone fragmentation. For BPH, Ho: YAG is preferred over Nd: YAG

• Duringtransurethralresectionofprostatestripsoftissuearecutfromthebladderneckdowntothelevel of verumontanum

SOLUTIONS IN TURP• Weallknowthatnormal salineisaverygoodconductorofelectricity(asitcontainions–Na+ & Cl– ions)• SoifitisusedwhileperformingTURP,thediathermycurrentusedintheprocedurewillcauseelectrolytedissociationofnormalsalineandthecurrentwillnotbelocalizedintheloopandhencecuttingofthetissuewillnotbeproper.

• Hence normal saline should not be used in TURP○ Youcanputupaquestionthatthesamecanoccurwiththeuseofdistilled water too. Distilled water can also conduct electricity but the current used during TURP is not very strong and distilled water is

not good conductor of electricity as normal saline. (you must be aware that distilled water is a worse conductor of electric-ity than normal water)

Therewerealsoargumentsthatdistilledwatercausesfluidoverload and therefore should not be used in TURP

True,distilledwatercausesfluidoverloadorTURPsyn-drome, but this complication is not common.

Distilled water is being replaced by 1.5% glycine but still can be used for TURP (and is used in many center when glycine is not available)

MEDICAL TREATMENT OF BPH• TwoclassesofdrugsarecommonlyusedforBPHa.α-adrenergicblockers,e.g.prazosin,terazosin(α1blockers)andtamsulosin(α1a blocker)b.5α-reductaseinhibitors,e.g.finasteride

Contd...

tahir99 - UnitedVRG


MEDICAL TREATMENT OF BPHα-adrenergic blockers 5α-reductase inhibitorSinceactivationofα1 reception in the blad-

der neck, prostatic urethra increases their smooth-muscle tone, their blockade relaxes these structures, reducing the dynamic obstructionandincreasingtheurinaryflowrate

These drugs prevent the conversation of testosterone into more active dihydrotestosterone responsible for androgen action in many tissues includingprostate.Theiruseresultsinreductioninthesizeoftheglandand improvement in symptom.

But 6 months of therapy is required to see the maximum effect on prostatesizeandsymptomaticimprovementisseenonlyinmenwithenlargedprostate(>40cm3)

Finasteride• UsesBPH—decreasesthesizeoflargeprostate(>40

cm3) and can retard disease progression. Male pattern baldness—in patients of male

pattern baldness, it promotes hair growth and prevents further hair loss.

• Sideeffects Impotence: It is a well documented although infrequent side

effect. Decreased libido Decreased volume of ejaculate Skin rashes Swelling of lips

CANCER PROSTATE○ Prostate is divided into following three

zones:Peripheralzone,whichliesintheouterpart

of prostate but mainly posterior.Centralzone,whichliesposteriortotheure-

thral lumen and above the ejaculatory ducts as they pass through the prostate

Periurethraltransitionalzone(TZ)

• As BHP arises from transitional zone and ‘prostatectomy’ one for BHP removes TZ leaving behind the PZ. The pt. is still at risk for prostatic carcinoma

• Prostaticcancerspreadstothebonesthroughbloodvessels;firstinto Batson’s periprostatic venous plexus and then into the internal vertebral plexus of veins. This metastasis is possible because of valve-less communication between the periprostatic and vertebral plexus of veins

• ApatientissuspectedtohaveCaprostateas: Prostatic Ca is the most common malignant tumor in men over 65

year of age Symptoms of bladder outlet obstruction and back pains (due

to bony metastasis in the pelvis and lumbar vertebra) indicate towards prostate Ca

TUMOR MARKERS IN CARCINOMA PROSTATE• SerumacidphosphataseisatumormarkerofprostateCa.• ButnowserumacidphosphataseassayhasbeensupersededbyPSAassay(prostatespecificantigen)

• Sinceprostatesepcificantigen(PSA)isnotspecificfor Ca,

• PSAvelocityandPSAdensityareusedtodetectprostate cancer

• PSAvelocityofmorethan75ng/mLyearissug-gestive of Ca

• PSA density is calculated by dividing the serum PSA by the estimated prostate weight (measured by TRUS). It was developed to correct for the con-tribution of BPH to the total PSA levelValues<0.10areconsistentwithBPH>0.15suggestcancer

• “Even so, the realities of clinical practice are that the combination of digital rectal examination and serum PSA monitoring is the most effective screening protocol”

Prostate specific antigen• Itisaglycoproteinproducedonlyintheprostaticcells(both

benign & malignant). It facilitates liquefaction of semen.• Itisneithersensitivenorspecificforearlyprostatecarcinoma,

nevertheless it gives some help in making a diagnosisNormalserumlevellessthan4ng/mL.4–10ng/mL this range is common for both BPH and CaMorethan10ng/mL approx 75% will have cancer More than 35 ng/mL is diagnostic of Ca

Contd...

tahir99 - UnitedVRG


CLINICAL FEATURES• Mostcommonmetastaticsitesofprostatecarcinomaarelymphnodesand

bones• Lymphaticmetastasisoccursmostcommonlytoobturatorlymphnodes• Otherlymphnodesinvolvedare: Common iliac Presacral Periaortic

• Mostcommonbonymetastasisoccursin(in decreasing order)Lumbarspine(mostcommon) Proximal femur Pelvis Thoracic spine Ribs

Staging of prostate cancer○ Tis carcinoma in situ○ T1 these are incidentally found tumors in a clinically benign gland T1a ≤5%oftissueinresectionfor‘benign’diseasehascancer,digitalrectalexamination(DRE)isnormal T1b >5%oftissueinresectionforbenigndiseasehascancer,DREisnormal T1c CadetectedbyelevatedPSAalone,normalDREandTRUS

○ T2 tumorpalpablebyDREorvisiblebytransrectalultrasonography(TRUS)andconfinedtoprostate○ T3 extracapsular extension with or without seminal vesicle involvement○ T4 tumor directly extends into bladder neck, sphincter, rectum, pelvic side walls, etc. T1 & T2 are early disease T3 & T4 are advanced disease

MANAGEMENT PLAN• Curativet/tcanonlybeofferedtopatientswithearly disease (i.e. T1 & T2) radical prostatectomy or radical radio-

therapy (both are equally effective)• RadicalretropubicprostatectomyisperformedforCaprostate• Hemorrhageisthemostcommonintraoperativecomplicationandthemostcommonlyinjuredvesselisdorsalvenous

complex• Thet/tforadvanceddisease(i.e.T3,T4oranymetastasis)isonlypalliative.Hormoneablationisthefirstlinetherapy

for palliation

• T1a disease These tumors found incidentally at TURP is by thedefinitionlowvolume(≤5%)andusuallywell differentiated and associated with very slow growth rate

They are managed by watchful waiting (regu-larfollow-upisdonebyDREandPSA)

• T1b, T1c & T2 disease Management depends on patient’s age, life expectancy, perfor-

mance status, and patient’s preferences Inyounger,fittermen(<70year),Maybetreatedbyradicalpros-

tatectomy or radical radiotherapy. Watchfulwaitingisanoptionforelderlywithlowlifeexpectancy(<10year).Evenyoungerpatientsmaychoosewatchfulwaitingwhencounseledaboutriskversusbenefit.

• Advanced disease (T3, T4 or any metastasis)○Onlypalliativet/tistheoption■Androgenablationisthefirstlinetherapy

• Itcanbeachievedby Orchidectomy or Drugs (medical castration)

• Palliativeradiotherapy Androgen ablation is the mainstay of therapy

for advanced prostatic cancer (T3, T4 ds or any metastasis)

Most prostatic carcinomas are hormone dependent and large number of men with advanced disease show response to androgen ablation therapies

• Androgen ablation Surgical orchidectomy is the ‘gold standard’ approach, but least

acceptable. Medical castration

• Drugsusedare:○Gonadotropin-releasinghormone(GnRH)analogues■Leuprolide■Goserline

○Estrogenssuchasdiethylstilbestrol■Notusednowbecauseofhigh-riskofcomplications

○Antiandrogens■ Flutamide,bicalutamide,nilutamide

○Ketoconazole○Cyproteroneacetate

tahir99 - UnitedVRG


SEMINAL VESICLES• Spermsareproduceintestisandthenstoredandmaturewithintheepididymis• Vasdeferenscarriesthespermsfromepididymistotheurethra,wheretheyopenbyseparateopeningsintotheprostatic

urethra• Justbeforeopeningvasdeferensisjoinedbyductsofseminalvesicles.Vasdeferensandseminalvesicleductsjointoform

the ejaculatory duct• Thesecretionsofseminalvesiclesformalargepartofseminalfluidandcontainfructoseandacoagulatingenzymecalled

the vesiculase

○ Semen analysis forms a important part of infertility assessment• Low ejaculatoy volume is caused by Retrograde ejaculation into the bladder

or Obstruction of the vas deferens or the

ejaculatory duct

■ Azoospermia may be seen in Testicular failure or Obstruction of vas deferens

■ Absence of fructose suggests Seminal vesicle agenesis or

obstruction

○ Semen that is low in volume with azoospermia and absence of fructose sug-gests either obstruction of the ejaculatory ducts or congenital absence of the vas deferens and seminal vesicles.

○ Theanatomyofthevasdeferensandseminalvesiclescanbevasography(wherecontrast medium is injected into the vas deferens) or TRUS (transrectal ultra-sonography) However TRUS is superior to vasography and is the investigation of choice.

• Alsoknow Semen specimen should be ob-

tained following at least 3 days of sexual abstinence and examined within 1 or 2 hour at least 2 speci-mens are examined several weeks apart.

PENIS AND URETHRA

HYPOSPADIAS• Hypospadiasisacondition,inwhichtheurethralmeatusopensontheunderside

of penis or the perineum (i.e. ventral surface of penis proximal to the tip of the glans penis.

• Thereareseveraltypesofhypospadiasaccordingtolocation

Types of hypospadiasa.Glandularopeningisintheglanspenis,proximaltothetipb. Coronal opening on the coronal sulcusc. Peniled. Penoscrotale. Perineal: This is the most severe abnormality. The scrotum is split and the ure-

thra opens between its two halves. There may be testicular maldescent, which maymakeitdifficulttodeterminethesexofchild.

• Glandular hypospadias is the most common type• Alsoknow Hypospadias is the most common congenital malformation of the urethra. In epispadias—the urethra opens on the dorsum of penis. It is a rare congenital anomaly that is commonly associated

with bladder exstrophy.• Besttimeforsurgeryforhypospadiasisbetween6–12 months of age

Contd...

tahir99 - UnitedVRG


HYPOSPADIASClinical features Complications of hypospadias• Besidestheabnormalpositionofexternalurethralmeatustheotherassociated

abnormalities are: In the penile variety the urethra and corpus spongiosum distal to the ectopic openingareabsent,insteadafibrouscordispresent.Duetocontractureofthisfibrouscord,thepenisis curved ventrally (in a downward direction) this is known as chordee. So the more proximal the ectopic opening is placed the greater is the change of chordee. This curved penis causes problem in inter-course as well as micturition.

Inallcases,inferioraspectoftheprepuceispoorlydeveloped.While,thesuperior aspect is normally developed. This cause prepuce to take the form of hood and is called hooded prepuce.

○ Difficultyindirectingtheurinarystream

○ Duetopresenceofchordee,erec-tionisdifficultandpainfulandtheintercoursemaybedifficultorimpossible

○ Infertilitycanoccur(usuallyassoci-ated with penoscrotal and perineal variety)

Treatment of hypospadias○ Treatmentofhypospadiasisverycomplex.Hereare

some important points○ Treatment is not required in glandular variety. ○ Incaseofothervarieties,aplasticoperationisper-

formed to bring the external urethral meatus to its normal position, and remove the chordee to straight-en the curvature

○ Operationcanbedoneinonestageortwostagesurgeries.Nowadaysonestagesurgeriesaremorepopular.• Indicationsfortwostageoperations○ Scrotalorperinealvariety○Chordee(inthefirststagechrodeeiscorrectedthenthe

opening is corrected)■ Circumcision is not done in patients with hypospadias as the

prepuce can later be used in surgical repair

Consolidated○ Anabnormalventralopeningoftheurethralmeatus○ Anabnormalventralcurvatureofthepenis(chordee)○ Aabnormaldistributionofforeskinwitha‘hood’presentdorsallyanddeficientforeskinventrally(hoodedprepuce)

○ Rememberthatcryptorchidismisnotafeatureofhypospadias.But it may be seen associated with hypospadias in 8%–9% of cases

• Ventralchordeeisseeninhypospadias• Dorsalchordeeisafeatureofepispadias• Metalstenosismaybeassociatedwithhypospa-

dias and needs meatotomy for correction.• Bifidscrotummaybeseeninpenoscrotaland

perineal hypospadias

PHIMOSIS• Ballooningofprepuceduringmicturi-

tion is suggestive of phimosis• Whentheopeningoftheprepuceisso

small that it cannot be retracted over the glans penis, the condition called phimosis

Phimosis is of two types1. Congential2. Acquired—it usually presents late in life and is associated with:• Inflammation•Trauma•Balanitisxeroticaobliterans•Cancer

Clinical features• Difficultyinmicturition: It is the main symptom. In a case of typically congenital phimosis the

mother complains that when the child micturates the prepuce balloons out and the urine comes out in thin stream.

• Inoldcasespatientpresentwith:Recurrentbalanitis(inflammationofglans)causingpainandpurulentdischarge Paraphimosis (the tight foreskin gets retracted and stuck behind the glans penis)

Contd...

Contd...

tahir99 - UnitedVRG


PHIMOSISComplications Treatment○ Balanoposthitis–(inflammationofglansandprepuce)○ Preputialstonesorcalculi○ Paraphimosis○ Hydroureter,hydronephrosis○ Carcinoma

The treatment is circumcisionNote,ifphimosisisassociatedwithconsiderable

infection dorsal slit is performed

PARAPHIMOSIS• EtiologyWhenaprepuceisforciblyretractedovertheglanspenis,itmaygetstuckbehindtheglans. Condition is k/a paraphimosis

• PathologyThisconstrictingbandofphimoticprepucecausesobstructiontothevenousflow,whichleadto

edema and congestion of the glansTheglansswellsleadingtomoredifficultyinretractingbacktheprepuce In neglected cases gangrene may result

Treatment○ Icebags,gentlemanualcompressionandinjectionofasolutionofhyaluronidaseinnormalsalinemayhelptoreducethe

swelling○ Ifconservativemethodfailsthenthepatientcanbetreatedbycircumcision• Itisuncommonfortheurethratobecompressed,sothemicturitionisnormallynotaffected.

INJURY TO URETHRA○ Thepartofurethramostlikelyinjuredinpelvicfractureis

membranous urethra (a part of posturethra) Posturethra includes prostatic + membranous urethra Anterior urethra includes bulbar + penile urethra

○ Theanteriorurethra(particularlybulbarurethra)isinjured due to direct blow to the perineum (straddle injuries)

○ Prostaticurethraismostdilatableandwidestpartofurethra (3 cm long)

○ Ejaculatoryductsopeninprostaticurethra.○ Membranousurethraisshortest(2cm)andleastdilat-

able part.

○ BulbourethralglandsofCowperthoughlocatedoneachsideof membranous urethra, their ducts open into penile urethra.

○ Externalurethralorificeismostnarrowestpartofurethra.

MCQ pointsa. Prostate is displaced superiorly (high lying prostate) in membranous urethral injury due to rupture of puboprostatic

fascia. Pelvic hematoma is seen in membranous urethral injuries (perineal hematoma is seen in bulbar urethral injury)b.OnceanurethralinjuryissuspectedthepatientisinstructednottopassurineandaRGUorascendingurethrogramis

performed to assess the injuryc. CatheterizationiscontraindicatedandispassedonlyiftheRGUisnormal

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


COMPARE THE TWO TYPES OF URETHRAL INJURIESBulbar urethral injury Membranous urethral injury

Common More commonMechanism of injury Direct blow to the perineum Blunt pelvic trauma with fracture pelvisSigns and symptoms • Retentionofurine

• Bloodaturethralmeatus• Perinealhematoma

• Retentionofurine• Bloodaturethralmeatus• Pelvichematoma• Highlyingprostate

Extravasation of urine

SuperficialextravasationUrinefirstcollectsintosuperficialperinealpouchandthenpassé into scrotum, penis and anterior abdominal wall

Deep extravasationUrine collects in the perivesical space

○ Thisisverywellknownthatinapatient of urethral injury, cathe-terizationisnotdoneb/citwouldconvert a partial tear into a com-plete transaction of the urethra

○ Blood at the urethral meatus is the single most important sign of urethral injury.

• Clinicalfeaturesseeninruptureofbulbarurethraoranteriorurethra: Patient usually presents with a history of fall on the perineum The triad of signs of a ruptured bulbar urethra is:○Retentionofurine○ Perinealhematoma○Bleedingfromtheexternalurinarymeatus Rectal examination in case of bulbar urethral injury reveals a normal situated

prostate (this differentiates it from membranous urethral rupture in prostate is displaced superiorly)

○ Bloodatthemeatusissuspiciousofurethralinjuryandanimmediateurethrographyisadvisedtoruleoutanyurethralinjury

Carcinoma of penis• Thecircumcisionthatisdonesoonafterbirthininfancy,

gives almost complete immunity against Ca penis • Butthatdoneinlaterinlifedoesnothavethesameeffect,

so muslims circumcised between the ages of 4 and 9 year still liable to the disease

• AboutCapenis○Mostcommonhistologicaltypeis squamous cell Ca

(98%) ○Erythroplasiaofqueretisprecancerousconditionitis

the in situ form of Ca penis

Premalignant lesions of Ca penisa. Penile cutaneous hornb. Balanitis xerotica obliteransc. Leukoplakiad. Viral (human papilloma virus) related dermatologic lesion■Condylomaacuminata(alsok/agenitalwarts)■Bowenoidpapulosis

• Theoneetiologicalfactormostcommonlyassociatedwithpenile carcinoma is poor hygiene

Clinical features• Age-penileCaoccursmostcommonlyinthe6th

decade of life, but its presentation in younger age not uncommon(‘40%ofpointsareunder40yearofage’—Bailey)

• Mostcommoncomplaintatpresentationisthelesionitself. Pain is rare

○ Most common site of involvement Glans ~ 48% Prepuce ~ 21% Both glans and prepuce 9% Coronal sulcus ~ 6% Shaft ~ 2%

○ Lymph node involvement Morethan50%ofpatientpresentwithaenlargedinguinallymphnodes(buthalfofthisarereactiveenlargementd/t

sepsis) The presence and the extent of metastasis to the inguinal region is the most important prognostic for survival in pa-

tients with Ca penis○ Distantmetastasisisinfrequent Diagnosis is made by biopsy of lesion Inguinal lymph nodes erode the skin of the groin and the death of patient may be due to involvement of the femoral or

external iliac artery with torrential hemorrhage

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


COMPARE THE TWO TYPES OF URETHRAL INJURIESManagement of carcinoma penis

Small non-invasive lesion can be treated by○ Fluorouracilcream○ Nd:YAGlaser○ Radiotherapy○ Suchtreatmentpreservesthepenis,butclosefollow-upismandatory

Invasive penile carcinomas○ The goal of t/t invasive penile carcinomas is complete excision with adequate margins

a. For lesion involving the prepuce: – Simple circumcision is effectiveb. For lesion of glans or distal shaft: – Partial penectomy with a 2 cm marginc.Forlesioninvolvingtheproximalshaftorwhenpartialpenectomyresultsinapenilestumpofinsufficientlengthfor

sexual function or directing the urinary stream: – Total penectomy with perineal urethrostomy

Inguinal lymph nodes• Palpableinguinalnodeshouldbet/tbyantibodiesfor6weeksfollowingt/toftheprimarylesiontoeliminateinfections

(this is to cure reactive lymphadenopathy d/t sepsis). Persistent adenopathy following antibiotic t/t is considered to be metastatic disease and bilateral ilioinguinal node dissection is performed

POSTERIOR URETHRAL VALVE• Poorurinarystreamin3-year-oldboysuggestsurinarytractobstruction(usuallyinfravesical)

and the most common of obstructive uropathy in a male child is posterior urethral valve • Posteriorurethralvalve: These are symmetrical folds of urothelium extending distally from prostatic urethra to

external urinary sphincter It most commonly lies just distal to the verumontanum or at the verumontanum It occurs only in malesItbehavesasflapvalvesso,althoughurinedoesnotflownormallyaurethral catheter can bepassedwithoutdifficulty

Sometimes, the valves are incomplete and the patient remains without symptoms until adolescence or adulthood

Approximately30%ofpatientsexperienceend-stagerenaldisease Vesicoureteralrefluxoccursin50%ofpatients

• Diagnosisismadeby:a. Voiding cystourethrogram b.Endoscopy

• Bothoftheseinvestigationsclearlydepictinsiteofobstruction• Thediagnosiscanbeestablishedprenatallybytheultrasound

Management:○ Firstasmallpolyethylenefeedingtubeisinsertedinthebladderandleftforseveraldays.Thenfurthermanagementis

done according to serum creatinine levelWithnormalserumcreatininetransurethralablationofthevalveleafletsWithincreasedserumcreatinineandtheworseningofcondition vesicostomy to bypass the obstruction and when

normal creatinine levels are achieved, transurethral ablation is done“Themostreliablemethodtoconfirmthediagnosisofposteriorurethralvalvesisvoidingcystourethrographythatmeansradiographsaretakenduringtheactofmicturitionafterthebladderhasbeenfilledwiththecontrastmedia”

Contd...

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


POSTERIOR URETHRAL VALVERadiological studies in urethral stricture

○ Retrogradeurethrography It is the mainstay of radiographic of stricture disease

○ Voidingcystourethrogram/micturatingcystourethrogram(MCU) MCU demonstrates the segment of urethraproximal to the

stricture

○ Endoscopy Retrograde urethroscopy Antegrade cystrourethroscopy

○ Sonographicurethrogram•MRIhasnoroleinthediagnosisofurethralstric-

tures

PEYRONIE’S DISEASE○ Peyroniediseaseisusuallyseenover40yearsofage○ ImportantpointsaboutPeyroniediseaseare:Itisalsok/apenilefibromatosisItisduetofibrousplaquesinoneorbothcorpuscavernosum.They

may later calcify or ossify Fibrous plaques leads to pain and curvature of the penis on erection Palpable induration or mass appears usually on the dorsolateral

aspect of the penisPalmarfibromatosis(Dupuytrencontracture),plantarfibromatosisandpenilefibromatosis(Peyroniedisease)arecomponentsofthesamepathologicalprocesscalledsuperficialfibromatosis

○ Theetilogyisuncertain,butitmaybearesultofpasttrauma○ Treatmentisdifficult,butsomecasesmayshowspontaneous

regression

○ Inthepeniledeformityisdistressing,Nesbitt opera-tion can be performed to straighten the penis

MCQ pointsa. Commonest cause of stricture in posterior urethra trauma with fracture pelvisb. Commonest cause of stricture in anterior urethra straddle injuries (direct trauma to the perineal region)Voiding cystouethography is the best method to visualize posterior urethra: Urethra can be imaged radiographically in two ways1. Anterograde techniques bestforvisualizationofposteriorurethra

(This is done along with voiding cystourethrography or with voiding following excretory urography)2. Retrograde technique best for examining the anterior (penile) urethra

(Contrast is injected through tip of urethra)

TESTIS AND SCROTUM

TESTICULAR TUMORSTesticular cancer is mainly of two types:1.Germcelltumors(GCT)~95%2.Non-germinalneoplasms~5%(includeLeydigcells,Sertolicells,

gonadoblastoma)

Germ cell tumors are of two types• Seminomas(morecommon,betterprognosis)• Non-seminomas,i.e.EmbryonalCa Teratoma ChoriocarcinomaYolksac(Endodermalsinus)carcinoma

Contd...

tahir99 - UnitedVRG


GERM CELL TUMOR STAGING AND TREATMENTExtent of disease Seminoma Non-seminoma Testis only, no vascular/lymphatic invasion (TI) Radiation therapy Retroperitoneallymphnodedissection(RPLND)or

observationTestis only, with vascular/lymphatic invasion (T2), or extension through tunica albuginea (T2), or involvement of spermatic cord (T3) or scrotum(T4)

Radiation therapy RPLND

Nodes<2cm Radiation therapy RPLNDorchemotherapyoftenfollowedbyRPLNDNodes2–5cm Radiation therapy RPLND+/-adjuvantchemotherapyorchemothera-

pyfollowedbyRPLNDNodes>5cm Chemotherapy Chemotherapy,oftenfollowedbyRPLNDDistant metastases Chemotherapy Chemotherapy, often followed surgery (biopsy or

resection)

MORE ABOUT TESTICULAR MALIGNANCY• Mostcommontesticulartumorabove50yearofage is lymphoma*

• Non-seminomasaremore malignant than seminomas *

Predisposing factors for testicular germ cell tumors (GCTs) are:a. Cryptorchidism b.Testicularfeminizationsyndromec. GCTofonetestisisariskfactorfortheothertestisd. Testicular Ca in a siblinge.KlienfeltersyndromeisassociatedwithmediastinalGCTf. Administrationofestrogens(e.g.DES)tothemotherduringpregnancyisassociated

SOME POINTS ARE WORTH MENTIONING ABOUT CRYPTORCHIDISM• Ofthepredisposingfactors,cryptorchidism

has the strongest association with testicular cancer

• Increasedriskisseenforboththetestis,i.ethe cryptorchid testes as well as the normally descended testis

• Abdominalcryptorchidtestesareatahigherriskthaninguinalcryp-torchid testis

• Seminoma is the most common type of testicular cancer seen in a cryptorchid testis

• Rememberthis:Placementofthecryptorchidtestisintothescrotum(orchiopexy) does not alter its malignant potential, however it facili-tates examination and tumor detection

TUMOR MARKERSSeminoma no marker Beta HCG

Alpha feto protein:Raised in: pure embryonal, terato carcinoma yolk sac tumor combined tumor

Raised in:100%choriocarcinoma60%embyonalcarcinoma 55% teratocarcinoma 25% yolk cell tumor 7% seminomas

Not raised in • purechoriocarcinoma• pureseminoma

○ Beta human chorionic gonadotropin (HCG): concentration is increased in both seminoma & non-seminoma

○ AFP: concentration is increased in only non-seminoma○ LDH:Itisincreasedinboth,itisnotasspecificaseitherofalphafetoprotein(AFP)orBetaHCG

Contd...

tahir99 - UnitedVRG


○ Seminomas representabout50%ofallgermcelltumorsoftestis

○ Medianageis4thdecade(Non-seminomasaremostfre-quent in the 3rd decade).

○ Seminomasfollowamoreindolentcourse

○ Most seminomas (70%) present with stage I disease (disease limited to testis).

○ About20%withstageIIdisease(withretroperitonealmetastases).And10%withstageIIIdisease(spreadbeyond retroperitoneum)

Non-seminomas:1/3patientspresentwithstageIdisease,1/3withstageIIand1/3withstageIIIdiseaseseminomasaswellasnon-seminomastypicallymetastasizethroughlymphatics(exceptchoriocarcinomawhichdemonstratesearlyhematogenous spread)

Seminomasareoneofthemostradiosensitivetumors(Non-seminomasareinsensitivetoradiation)

○ “ Lymphoma is the most common testicular tumor in a patient over the age of 50 and is the most common secondary neoplasm of the testis”

tahir99 - UnitedVRG


VARICOCELE TESTISIt is seen 95% of times on left side. A number of reasons are given for this left predilection, the main being = the valveless left testicular vein drains into the left renal vein at right angles whereas the right testicular vein (also valveless) drains obliquely into IVCThis drainage pattern creates high pressure in the left testicular vein.

Clinical picture • Age—youngadult• Tallthinmenarefrequentlyaffected*• Bagofworms*likefeelonpalpation• Theveinsemptyinsupineposition(soexaminationisalwaysdoneinstanding

position)• Infertility: Varicocele increases the temperature in the scrotum and this decreas-

es spermatogenesis (It must be confessed that at present there is no statistical support to this)

Varicocele may be secondary to renal cell carcinoma of the left kidney: The growth from renal cell carcinoma blocks the renal vein by venous permeation

So sudden onset of varicocele (left side) in middleaged man should arouse suspicion of a renal cell carcinoma of the left side In renal cell Ca, the variocele does not decompress in the supine position.

UNDESCENDED TESTIS • Inundescended testis, the testis is arrested in some part of its path to the scrotum

• Inectopic testis, the testis is abnormally placed outside its path

• Retractile testis,ininfancy80%ofinapparenttestis are retractile testis and required no t/t

• Approx70%–77%ofcryptorchidtestiswillspontaneously descend, usually by 3 months of age

• Morecommoninpreterm,smallforgestationalage,LBWandtwinneonates

• Morecommononright side• Secondarysexualcharacteristicsarenormal

Complications of incomplete descent• Torsionoftestis• Epididymo-orchitis• Anassociatedindirectinguinalherniaisfrequent• Atrophy

• Pain—atestissituatedintheingunialcanalisoftenliabletotrauma and give rise to pain in the groin

• Sterility—iftheconditionisbilateral• Malignancy—riskis40timesmorethananormallyplacedtestis

“Definitivetreatmentoftheundescendedtestisshouldoccur before 1 year of age”

tahir99 - UnitedVRG


Torsion of testis• Torsion of testis is the torsion of the spermatic cord caus-

ing strangulation of the blood supply to the testis and unless it is t/t within 3 to 4 hours, testicular atrophy is inevitable

• Itisseencommonlyinadolescent(10-25years)• Symptoms it presents sudden agonising pain in the groinandthelowerabdomen.Nauseaandvomitingarevery common

Predisposing factors Heavy straining often precipitates torsion due to vigorous contraction of cremaster muscle1. Inversion of testis

2. High investment of tunica vaginalis forming a mesentery like structure for testis (mesorchium), which makes the testishangdownhorizontally

3. Presence of gap between testis and epididymis makes testis hang and go for torsion

Signs in torsion testis○ Angel sign: It is a sign on the normal side (unaffected side).Oppositetestislieshorizontallybecauseofthepres-ence of mesorchium (the predisposing factor for torsion is same on both sides)

○ Deming sign: It is a sign on the affected side, where the affected testis is positioned high because of the twisting of the cord and spasm of muscles

• Itmustbedifferentiated from epididymo-orchitis by:○Prehns sign on elevation of testis the:■Painincreases in torsion■Paindecreases in epidydimo-orchitis

○Color Doppler detectsthedecreasedbloodflowtotestis in torsion.

It is the inv. Of choice to exclude torsion from the epididymo-orchitis○ Tc 99m pretechnate scan it demonstrates decreased bloodflow

• Treatment In the 1st hour the torsion can be treated by manipula-tion(butlateronsurgeryhastobedonetofixthetestis)

If not correctable by manipulation or more than one hour has passed then surgery has to be done. Surgery must be done within 4 hours. Otherwise the testis will be dead

Both the affected and unaffected testis should undergo orchiopexy because the anatomical variation responsible for torsion is likely to be bilateral

CONGENITAL HYDROCELE• “Congenitalhydroceleareaspecialformofindirectinguinalherniaandaretreatedbyherniotomy”• Congenitalhydrocele In this condition, the processus vaginalis remain patent so there is direct communication of the tunica vaginal with the peritonealcavity.Thecommunicatingorificeatthedeepinguinalringistoosmallforthedevelopmentofhernia

It is present since birth In contraindication to assumption. Congenital hydrocele is not easily reducible due to narrowness of the inguinal ring,

but when the child lies supine, it disappearsTreatment methods of hydrocele

• Forcongenitalhydrocele herniotomy• Forothertypes Jaboulay method forsmallandmedium-sized

hydroceleLordsprocedureforbig-sizedhydroceleExcisionofsac for hematocele, infected sac

• Alsoremember MC types of primary hydrocele is vaginal type Hydrocele en-bisac this type of hydrocele has two

intercommunicating sac one above and one below the neck of scrotum

tahir99 - UnitedVRG


Types of hydrocele Some other typesa. Vaginal hydrocele (most common)Thereisabnormalaccumulationofserousfluidwithinthetunica

vaginalis b. Infantile hydroceleThefluidcollectswithinthetunicavaginalisandprocessusvagi-

nalis, which are continuous, but the vaginalis is not communicating with the peritoneal cavity

c. Congenital hydrocele The processus vaginalis is present so there is direct communicating

of the tunica vaginalis with the pelvic cavityThecommunicatingorificeatthedeepinguinalringistoosmallfor

the development of hydrocele of the cordd. Hydrocele of the cord Here the central portion of the processus vaginalis is patient, but its

upper and lower parts are oblitera

e. Funicular hydrocele Here the processus vaginalis remains patents

upto top of the testis, where it is shut off from the tunica vaginalis

f. Hydrocele en-basic or bilocular hydrocele Here the hydrocele has two intercommuni-

cating sacs—one above and one below the neck of the scrotum. Upper sac has no con-nection with the processus vaginalis and it is in fact the herniated tunica vagina

g. Hydrocele of the canal of nuck This is female counterpart of the hydrocele of

the cord. It is seen in relation to the ground ligament

TUBERCULOSIS OF TESTIS○ Thediseasefirsteffectstheepididymis*while causing orchitis. The body

of testis may remain uninvolved for years, but the contralateral epididymis often becomes diseased

○ TreatmentisATT

○ Ifthisdoesnotresolve,epididymec-tomy is indicated

o Note: Syphilis will not affect the epididymis, while causing orchitis.

INFECTIONS OF TESTIS○ Acuteepididymitisandacuteepididymo-orchitisareinflammationoftheepididymisand

testis due to infective pathology• Infectionreachestheepididymisthroughthevasfromurethra.Sometimesitmaybeblood

borne•MCinfectiveorganisminsexuallyactiveyoungmaleisGonococus and Chlamydia and in

children and older men are d/t urinary pathogen such as E. coli• Clinical symptoms○Thepatientspresentswithafever, very painful, swollen, red, tender scrotum○Theepididymisandthetestisarebothswollen○Theacutepainfulconditionhastobedifferentiatedfromtorsionoftestis

• Pyuria is associated with epidydimo-orchi-tis, not with torsion of testis

• Treatment Antibiotics Rest Lotsoffluid

TUBERCULOSIS OF KIDNEY AND BLADDER○ InTBofkidney,agroupoftuberculousgranulomasforminthe

renal pyramid. They coalesce and form an ulcer. Untreated the le-sions enlarges and a tuberculous abscess may form in the paren-chyma.Graduallythekidneyisreplacedbycaseousmaterial(putty kidney),itmaybecalcified(cement kidney).Calcificationsmayappear on X-ray as calculi (pseudo-calculi)

○ Renaltuberculosisisoftenassociatedwithtu-berculosis of the bladder. TB of bladder leads to fibrosisandthuscontractureofbladder(thimble bladder)

○ Golf hole ureters are seen in TB bladder

VESICOURETERAL REFLUX (VUR)○ Theretrogradeflowofurinefromthebladdertotheuretersandtherenalpelvis○ TwotechniquesarecommonlyusedtodetectVUR. The radiocontrast MCU is most commonly used (excellent anatomic

details)

Contd...

tahir99 - UnitedVRG


VESICOURETERAL REFLUX (VUR) Isotope radionuclide cystography is more sensitive for detecting

VUR and causes less radiation exposure then the former, but pro-vides less anatomical details.

Most sensitive investigation for VUR is radionuclide cystography Investigation of choice for VUR is MCU

Grading of VUR is based on the appearance of the urinary tract on micturating cystourethrogramGradeI Refluxintoanon-dilateduretersGradeII RefluxintotheuppercollectingsystemwithoutdilationGradeIII Refluxintodilateduretersand/orbluntingofcalycealfornicesGradeIV RefluxintoagrosslydilateduretersGradeV Grossdilationoftheureters,renalpelvisandcalyces:calycesshowlossofpapillaryimpression

Complications of VURRefluxpredisposestorenalinfection(pyelonephritis) by facilitating the transport of bacteria from the bladder to the

upper urinary tractTheinflammatoryreactioncausedbyapyelonephriticinfectionmayresultinrenalinjuryorscarringExtensiverenalscarringimpairrenalfunctionandmayresultinreninmediatedhypertension,refluxnephropathy,renalinsufficiency,endstagerenaldisease,reducedsomaticgrowthandmorbidityduringpregnancy

Treatment○ Thegoalsoft/taretopreventpyelonephritis,renalinjuryandothercomplicationofreflux○ Treatmentmodalityiseithermedicalorsurgical

• MedicaltherapyIsbasedontheprinciplethatrefluxoftenre-

solves over time and the antibiotic maintain urine sterility and prevent infection and complication while awaiting spontaneous resolution

• Surgicaltherapy The basis for surgical therapy is that in selected children, ongo-ingrefluxhascausedorhassignificantpotentialforcausingrenal injury

The decision to do medical or surgical t/t is based on certain principles and parental, patient preference

Contd...

FMGE QUESTIONS

1. Investigationofchoiceinvesico-uretericrefluxis: (March 2005, Sep 2010)

a. CT scan b. Voiding cystourethrography c. Intravenous urography d. X-ray KUB Ans. b (Voiding cystourethrography)

2. Seminoma is carcinoma of: (March 2011) a. Kidney b. Urinary bladder c. Testes d. Penis Ans. c (Testes)

3. Reflexnephropathyisdiagnosedmainlyby: (Sep 2011) a. X-ray KUB b. Micturating cystourethrogram c. CT scan d. MRI scanAns. b (Micturating cystourethrogram)

4. Which one of the following is radiolucent stone: (March 2009)

a. Calcium oxalate b. Cystine c. Uric acid d. Phosphate Ans: c (Uric acid)

tahir99 - UnitedVRG


5. True about incompletely descended testis are all of the following, except: (March 2008)

a. Earlyrepositioningcanpreservefunction b. It may lead to sterility, if bilateral c. Poorly developed secondary sexual characters d. May be associated with indirect inguinal her-

nia Ans. c (Poorly developed secondary sexual characters)

6. Most radiosensitive testicular tumor is: (Sep 2007) a. Seminoma b. Teratoma c. Interstitial tumors d. LymphomaAns: a (Seminoma)

7. Erythroplasia of Queyrat occurs in: (Sep 2011) a. Scrotum b. Testes c. Penis d. Bladder Ans: c (Penis)

8. A 25-year-old man presents with varicocele on the left side. Associated condition could be a:

(March 2007) a. Nephroma b. Hepatic malignancy c. Testicular tumor d. Penile malignancy Ans: a (Nephroma)

9. Treatment of stage I teratoma is: (Sep 2009) a. Chemotherapy b. Radiotherapy c. Surgery d. Observation Ans: c (Retroperitoneal lymph node dissection is done)

10. Fourniers gangrene is seen in: (Sep 2007) a. Scrotum b. Shaft of penis c. Base of penis d. GlanspenisAns: a (Scrotum)

11. Most common testicular tumor in 4th decade is: (Sep 2005)

a. Teratoma b. Dermoid c. Seminoma d. All of the above Ans: c (Seminoma)

12. Following urethral rupture, immediate procedure to be done is: (March 2006)

a. Urinarycatheterization b. Suprapubic cystostomy c. Referral to a urologist d. Observation Ans: b (Suprapubic cystostomy)

13. Delirium, mental confusion and nausea in pa-tients who had undergone transurethral resection of prostate suggests: (March 2006)

a. Hypernatremia b. Sepsis c. Hepatic coma d. WaterintoxicationAns: d (Water intoxication)

14. Associated with urinary bladder carcinoma are all of the following, except: (Sep 2005)

a. Smoking b. Human papilloma virus infection c. Schistosomiasis d. Cyclophosphamide Ans: b (Human papilloma virus infection)

15. All of the following are radio-opaque stones, ex-cept: (Sep 2008)

a. Calcium b. Struvite c. Uric acid d. CystineAns: c (Uric acid)

16. Features of carcinoma penis include all, except: (March 2007)

a. Metastasizetoinguinallymphnodes b. Surgery is the treatment of choice c. Hypospadias is a premalignant lesion d. Circumcision provides protection Ans: c (Hypospadias is a premalignant lesion)

17. Chyluria is caused by all, except: (Sep 2007) a. Pregnancy b. Childbirth c. Filariasis d. Bile duct stonesAns: d (Bile duct stones)

18. All of the following are features of carcinoma pe-nis, except: (Sep 2007)

a. Surgery is the treatment of choice b. Balanoposthitis may be a predisposing factor c. Metastaizestoinguinalnodes d. Histologically a transitional cell carcinomaAns: d (Histologically a transitional cell carcinoma)

tahir99 - UnitedVRG


19. A 65-year-old male smoker presents with gross to-tal painless hematuria the most likely diagnosis is: (Sep 2009)

a. Carcinoma urinary bladder b. Benign prostatic hyperplasia c. Carcinoma prostate d. CystolithiasisAns: a (Carcinoma urinary bladder)

20. A 10 mm calculus in the right lower ureter associ-ated with proximal hydrouretero-nephrosis is best treated with: (Sep 2009)

a. Extracorporealshockwavelithotripsy b. Antegrade percutaneous access c. Open ureterolithotomy d. Ureteroscopic retrievalAns: d (Ureteroscopic retrieval)

21. Most common type of hypospadias is: (Sep 2011) a. Glandular b. Penile c. Coronal d. PerinealAns: a (Glandular)

22. A 70-year-old patient with benign prostatic hyperplasia underwent transurethral resection of prostate under spinal anesthesia. 1 hour later, he developed vomiting and altered sensorium. The most probable cause is: (Sep 2007)

a. Overdosage of spinal anaesthetic agent b. Rupture of bladder c. Hyperkalemia d. WaterintoxicationAns: d (Water intoxication)

23. The commonest cause of an obliterative stricture of the membranous urethra is: (Sep 2007)

a. Fall astride injury b. Roadtrafficaccidentwithfracturepelvisand

rupture urethra c. Prolongedcatheterization d. GonococcalinfectionAns:b(Roadtrafficaccidentwithfracturepelvisandrupture urethra)

24. Which of the following is an absolute indication for surgery in cases of benign prostatic hyperpla-sia: (Sep 2007)

a. Bilateral hydroureteronephrosis b. Nocturnalfrequency c. Recurrent urinary tract infection d. Voidingbladderpressures>50cmofwaterAns. a (Bilateral hydroureteronephrosis)

25. A 27-year-old man presents with a left testicular tumor with a 10 cm retroperitoneal lymph node mass. The treatment of choice is: (March 2009)

a. Radiotherapy b. Immunotherapy with interferon and inter-

leukins c. Lefthighinguinalorchidectomypluschemo-

therapy d. Chemotherapy aloneAns: c (Left high inguinal orchidectomy plus chemo-therapy)

26. The best time for surgery of hypospadias is: (March 2011)

a. 1–4 months of age. b. 6–10monthsofage. c. 12–18 months of age. d. 2–4 years of age.Ans: c (12–18 months of age)Before age of 2

27. Which of the following is most troublesome source of bleeding during radical retropubic pros-tatectomy ? (Sep 2006)

a. Dorsal venous complex b. Inferior vesical pedicle c. Superior vesical pedicle d. Seminal vesicular arteryAns: a (Dorsal venous complex)

28. The most sensitive imaging modality for diagnos-ing ureteric stone in a patient with acute colic is:

(March 2008) a. X-ray KUB b. Ultrasonogram c. Non-contrastCTscanofabdomen d. Contrast enhanced CT scan of abdomenAns: d (Contrast enhanced CT scan of abdomen)

29. Which of the following is not used as a tumor marker in testicular tumors? (Sep 2003)

a. AFP b. LDH c. HCG d. CEAAns. d (CEA)

30. Not a premalignant lesion is: (Sep2005) a. Condyloma lata b. Bowen’s disease c. Balanoposthitis d. ErythroplasiaofQueyratAns. a (Condyloma lata)

tahir99 - UnitedVRG


Premalignant conditions of cancer penis:Dermatologic conditions:Cutaneous horn: Develops from pre-existing skin lesion like warts, nevus, traumatic abrasion

or malignancy.Pseudo epitheliomatous Micaceous keratotic Balanitis :

Present as hyperkeratotic, micaceous growth on the glans and may have some microscopic features of verrucous carcinoma

Balanitis Xerotica obliterans : Genitalvariationoflichensclerosisetatrophicusthatpresentsaswhitepatchon the prepuce or glans, often involving the meatus extending into fossa navicularis M/C in uncircumcised makes of middle age and diabetics

Leukoplakia: Present as solitary/multiple whitish plaques that often involve the meatus.

1. Condyloma acuminatum (genital/veneral warts) ○ HPV6,11,42-44:LowgradedysplasiaandGrosscondylomata ○ HPV16&18;31,33,39:Highassociationwithmalignancy.

2. Bowenoid papulosis:

3. Kaposi sarcoma: ○ Cutaneousneovascularlesion,raised,painful,Bleedingpapule;orasanulcerwithBluishdiscoloration. ○ HHV–8isthecausativeorganism. ○ Kaposi’ssarcomaofpenisisthe2ndcommonmalignancyofpenisaftersquamouscelltype. ○ Kaposi’ssarcomaofpenishasbecomearelativelycommonlesioninpatientswithAIDS. Termed carcinomas: • BuschkeLowenstein tumor (Verrucous carcinoma, giant condyloma acuminatum) • Carcinomain situ: ○ ErythroplasiaofQueyra—involvesglanspenis,prepuce ○ Bowen’sdisease—involvespenileshaft. • Pagetsdiseaseofpenis o Paget’s disease: It may often herald a deeply seated cancer with pageti cells running through ducts or

lymphatics to epidermal surface o It is seen to develop after radiation therapy to transitional cell carcinoma of bladder. Invasive carcinoma of penis M/c sites: Glans (48%), prepuce (21%) and shaft and coronal sulcus

Viral conditions

31. Thimble bladder is seen in (March 2011) a. Acute TB b. Chronic TB c. Schistosomiasis d. All the aboveAns: b (Chronic TB)32. Refluxnephropathyisdiagnosedby: (March 2005, Sep 2006) a. Micturating cystogram b. CT scan c. USG d. All the aboveAns: a (Micturating cystogram)

33. Which of the following causes orchitis without epididymitis: (Sep 2009)

a. TB b. Gonorrhea c. Syphilis d. ChlamydiaAns. c (Syphilis) 34. Drainage of venous blood after varicocelectomy is

through (Sep 2009) a. Pampiniform plexus b. Cremasteric vein c. Iliac vein d. Internal pudendal veinAns: b (Cremasteric vein)

tahir99 - UnitedVRG


35. Not a complication of prostatic surgery in an el-derly man: (Sep 2009)

a. Urinary retention b. Constipation c. Rupture of urethra d. EjaculatoryfailureAns: b (Constipation)

36. Following urethral rupture the immediate proce-dure to be done is: (Sep 2009)

a. Rail road tracking b. Suprapubic cystotomy c. Urinarycatheterization d. NoneAns: b (Suprapubic cystotomy)

37. Most common testicular tumor in 4th decade of life: (Sep 2009)

a. Seminoma b. Dermoid cyst c. Teratoma d. DysgerminomaAns: a (Seminoma)

38. Erythroplasia of Queyrat occurs in: (Sep 2009) a. Glanspenis b. Shaft of penis c. Base of penis d. ScrotumAns: a (Glans penis)• Carcinoma in situ of penis that occurs in the glans,

prepuce and urethral meatus is called as erythropla-sia of Queyrat

39. All of the following are predisposing factors for cancer penis, except: (Sep 2010)

a. Pagets disease b. Phimosis c. Balanoposthitis d. PapillomaAns. d (Papilloma)

40. BPH is most common in which zone? (Sep 2008) a. Peripheralzone b. Centralzone c. Transitionzone d. NoneAns. b (Central zone)

41. BPH is most common in which lobe? (Sep 2008) a. Median lobe b. Laterallobe c. Posterior lobe d. NoneAns. a (Median lobe)

42. Lord’s and Jaboulay’s operation is done for: (March 2011)

a. Rectal prolapse b. Fistula-in-ano

c. Inguinal hernia d. HydroceleAns: d (Hydrocele)

43. Golf-holeuretericorificeisseenin: (March2011) a. Ureteric calculus b. Ureteral polyp c. Tuberculosis of urinary bladder d. RetroperitonealfibrosisAns: c (Tuberculosis of urinary bladder)

44. Cause of bladder cancer are all, except: (March 2011) a. Alcohol b. Naphthylamineexposure c. Cigarette smoking d. Schistosoma hematobium Ans: a (Alcohol)

45. Painless hematuria is seen in all of the following, except: (March 2011)

a. Hypernephroma b. Renal TB c. Bleeding disorders d. Renal infarctionAns: d (Renal infarction)

46. Which of the following is not a self-retaining uri-nary catheter: (March 2011)

a. Foley b. Malecot c. Gibbon d. Red rubberAns: d (Red rubber)

47. Which of the followings renal stones may be large and still be asymptomatic for years: (March 2011)

a. Urate b. Oxalate c. Staghorn d. CystineAns: c (Staghorn)

48. Myoglobinuria is associated with which of the following: (Sep 2011)

a. Tumors b. Electricalinjury c. Crush injury d. All of the aboveAns: d (All of the above)

49. Orchidopexy for incompletely descended testis is done after the age of: (Sep 2011)

a. At birth b. 1 year c. 2 years d. 5 yearsAns: b (1 year)Ideal age = 6 months

tahir99 - UnitedVRG

17Hernia, UmbilicUs, abdominal

Wall and PeritoneUm

Contd...

Hernia Prolapse Eventration• Passageofaperitonealsacwithorwithoutabdominalcontentsthroughasiteofcongenitaloracquiredweak-nessintheabdominalwall.

• Abnormaldescentofastructure,butwithoutaperitonealcovering(sac)

• Example:Rectalprolapsed,uterineprolapse

• Itisaprotrusionofthewholecontentbecauseofabsence/defectofwall/structurethatpreventsthem

• Example:Eventerationofdiaphragm

○Hernia consists of three parts:Thesac,thecontentsofthesacandthehernialringHernial sacisprotrusionofperitoneum,whichhasaneck,abodyandafundus

Hernial ringisaweakplacethroughwhichpassesthehernialsac

The narrowest part of sac is neck

AnAtomy of inguinAl cAnAl (HousE of bAssini)3.75cmlengthExtendsfromdeepringtosuperficialringDeepringisasemiovalopeninginthefasciatransversalisSuperficialringisatriangularopeningintheexternalobliqueaponeurosis,guardedbytwocruraofmusclefibres

openings• Deep ring (DI):Halfinchabovemidinguinalpoint*(betweenanteriorsuperioriliacspineandpubicsymphysis)

• Superficial ring (SI):Justabovepubictubercle• Saphenous opening (S):4cmbelowandlateraltopubictubercle*

Walls of canalAnterior wall Posterior○ Skin,superficialfascia(superficialfattylayerofcamper,deepmembranouslayerofscarpa),deepfascialata,externalobliqueaponeurosis

○ Formedlaterallybytheaponeurosisofthetransversusabdominismuscleandthetransversalisfascia;intheremainder,theposteriorwallistransver-salisfasciaonly.Mediallytheposteriorwallisreinforcedbytheinternalobliqueaponeurosis

tahir99 - UnitedVRG


AnAtomy of inguinAl cAnAl (HousE of bAssini)superior inferior○ Theroofofthecanalisformedbythearchedfibersoftheloweredge(roof)oftheinternalobliquemuscleandbythetransversusabdominismuscleandaponeurosis.

○ Thewallofthecanalisformedbytheinguinalligament(Poupart’s)andthelacunarligament(Gimbernat’s)

contents of inguinal canalmales females○ Spermaticcordandilioingui-nalnerve(notiliohypogastricnerve)

○ Roundligamentinfemalesandilioinguinalnerve(notiliohypogastricnerve)

contents of spermatic cordArteries:Testicularartery,arteryofvas,arterytocremas-ter

Veins:PampiniformplexusofveinsVeinscorrespondingtoarteriesLymphaticsoftestisTesticularplexusofsympatheticnervesGenital branch of genitofemoral nerveVasdeferens

tyPEs of HErniA○ Vaginal(complete)—descendsuptoscrotumbase,testisnotfelt(sepa-rately)

○ Funicular—testisfeltseparately,processusvaginalisclosedaboveepi-didymis

○ Bubonocele—inguinalswellingonly

HEssElbAcH triAnglE○ Weakspotinanteriorabdominalwallthroughwhichdirecther-niaappears•Medial: Outerborderofrectusabdominis•Lateral: Inferiorepigastricvessels•Below: Medialpartofinguinalligament•Floor:Fasciatransversalis

○ InguinalherniaMConrightside○ Directhernianeveroccursinfemalesandrarelygetsstrangulated○ FemoralherniaisMCinfemalesthanmales○ IndirectinguinalherniaistheMCtypeofherniainfemales○ Cryptorchidismisassociatedwithindirecthernia○ Ofallherniasfemoralistheonemostliableforstrangulationbecauseofnarrowneck

Contd...

Contd...

tahir99 - UnitedVRG

215Hernia, Umbilicus, Abdominal Wall and Peritoneum

HEssElbAcH triAnglEfemoral hernia

○ Femoral canal : 2 x 2 cm size○ Medialcompartmentoffemoralsheath

Walls of femoral canalAbove—femoralringBelow—saphenousopeningAnteriorly—inguinalligamentPosteriorly—Cooper’sligamentMedially—lacunarligamentLaterally—femoralveinContents: Cloquet’snode Lymphatics Areolartissue

surgEriEs for fEmorAl HErniAlothiessen’s inguinal approach High approach of mcEvedy low operation of lockwoodInguinalincisionmadesimilartoinguinalhernia

FasciatransversalisopenedApproximateinguinalligamentwithiliopec-tinealandalsoconjointtendonwithinguinalligament

Preventsinguinalherniaalso

Verticalincisionmadeoverthefemoralcanalcontinuedabovetoinguinalligament

Veryusefulforirreducibleandstrangulatedhernia

GroincreaseincisionIndicatedinuncomplicatedfemo-ralherniaonly

Justapproximateinguinalliga-mentandiliopectinealligament

Notpreventsinguinalhernia

sliding HErniA○ MConrightside:Caecum*○ MConleftside:Sigmoidcolon*○ Others—appendix,urinarybladder,uterus,fallopiantube,ovary○ Partoftheposteriorwallformednotonlybytheperitoneum,butalsobypartofretroperitonealstructures

during surgery1.Donotdissectthesacfromtheretroperitonealstructures,justpushpartofthesacalongwiththem

2.Hernioplastyisdone

spigelian hernia Epigastric hernia of linea alba○ Occursviaspigelianfascia,whichiscomposedofaponeu-roticlayerbetweenrectusabdominisandsemilunarlinelaterally

○ OccursatorbelowarcuatelineArcuatelineliesmidwaybetweenumbilicusandpubicsymphysis

○ It is a variety of intraparietal hernia○ Itoccursinoldage>50years○ Highincidenceofstrangulation

○ Epigastricherniaorfattyherniaoflineaalba○ Itoccursvialineaalbaanywherebetweenxiphoidproceesandumbilicus

○ Alsoknownassacless hernia,onlypreperitonealpadoffatentersthedefectinalba

○ Symptomsmimicgastriculcer,endoscopyneeded

Contd...

tahir99 - UnitedVRG


strangulated herniaStrangulation:(Obstruction+irreducibility+arrestofbloodsupply)1.Colickyabdominalpainifcontinuesandbecomesgangrenouspaindisap-pears

2.Suddenincreaseinsizeofhernia;becomestenseandtender

management1.Resuscitation:Nasaloxygen,intravenousfluids2.Parenteralantibiotics.3.Delayshouldnotbemadeforoperation

richter hernia maydl hernia (hernia-in-W)○ Richters hernia isoneinwhichacircumfer-enceofintestinegetsstrangulated.TypicallystrangulatedRichtershernianevergoesforobstipationuntilparalyticileussupervenes

○ Alsothereoccursdiarrhea

• InthistypeofherniatheintestineentersintothesacintheshapeofW’withthemostdistalpartoftheintestineintheabdomencavity

• Soifgangreneoccursitstartsintheintra-abdomenportionofintestinefirst,.Whichmaybemissedifweexplorethescrotumforobstructedhernia

• Hencethetypeofstrangulationoccurringiscalledretrogradestrangulation

other herniae with eponyms• Ogilvie herina—smallrigidcircularorificeintheconjointtendonjustlateraltowhereitinsertswiththerectussheath• Malgaigne’s bulge—seeninindividualswithpoorabdominalmusculature• Sliding hernia (Hernia-en-Glissase)—apieceofextraperitonealbowelslidesdowntoformtheposteriorwallofthehernia• Interstitial Hernia—bulgewithinthemusclelayersofabdominalwall■Preperitoneal/intraparietal—bulgewithinperitoneumandfasciatransversalis■ Interparietal—bulgewithininternalobliquemuscleandexternalobliqueaponeurosis■Extraparietal—outsideexternalobliqueaponeurosis

• Richter hernia—onlyacircumferenceofthebowelbecomesstrangulated• Littre hernia—Meckel’sdiverticulumasacontentofhernia• Maydl hernia (Hernia-en-W/retrograde hernia)—twoloopsofbowelremaininthesacwiththeconnectingloopinsidetheabdomen.Connectingloopgoesinforstrangulation

• Pantaloon hernia—directandindirectherniaonthesameside• Petit hernia—inferiorlumbartrianglehernia• Phantom hernia—herniafollowingparalysisofthemusclesofthelumbarregion• Spigelian hernia—atthelevelofarcuatelinejustlateraltotherectusmuscleRaretypesoffemoralhernias:•Narath hernia—infrontoffemoralarteryandbehindtheinguinalligament•Cloquet hernia—behindthefemoralvesselsbulgewithinpectineusmuscleanditsfascia•Hesselbach hernia—lateraltofemoralartery•Laungier hernia—throughthelacunarligament

Contd...

tahir99 - UnitedVRG


surgEriEs for HErniAHerniorrhaphy lichtensteins1.Herniotomy2.Narrowingofthedeepringwith2’0prolene(Lytle’srepair)3.Approximationofconjointtendonwithinguinalligamentusing1’polypropylenematerial

○ Weuseprolene mesh tobridgethegapbetweeninguinalligamentandconjointtendon

○ Thepreferredapproachforallhernia*

shouldice technique stoppas procedure○ Hegaveadditionalstrengthtotheposteriorwallbydoublebreastingthefasciatransversalis

○ Bestamongallanatomicalrepairs(herniorrha-phy)

○ Leastrecurrenceamongherniorrhaphy

○ Forbilateraldirecthernia’s,amodifiedpfannensteilincisionmadeinthelowerabdomenandahugemeshplacedinbetweentheperito-neumandthefasciatransversalis(preperitonealmeshrepair)

○ AlsocalledasGPVRS—giantprostheticvisceralreinforcementsur-gery

laparoscopic repair○ Transabdominalpreperitonealmesh(TAPP).Peritonealcavityenteredandapproachthepreperitonealspaceviaabdomencavity

○ Totalextraperitonealrepair(TEP).Peritoneumnotentered.Extraperitonealspaceentered

dEsmoid tumor○ Desmoidisatumourarisingfromthemusculoaponeuroticstructuresofab-dominalwall

○ Clinicalfeaturesofdesmoids:80%occurinfemales*SeenbelowumbilicusUnencapsulatedfibromaandtendstoinfiltratemuscleinneighbourhoodShowsslowgrowthNosarcomatouschangeseen*Alsoknownasrecurrentfibromaofpagets*

Treatment:• Widelocalexcision• Moderatelyradiosensitive

rEctus sHEAtH HEmAtomA○ ThisisduetosuddenhemorrhagefromruptureofInferiorepigastricartery○ Thesiteofthehematomaisusuallyatthelevelofthearcuateline,wheretheposteriorsheathoftherectusabdominisislacking

○ Commoninthreeagegroup:ElderlyYoungthinathletesPregnantfemales

• Itmayfollowasuddenboutofcough• Treatment—minimalhematomasleftassuchtoresolve,biggeronesneedtobeletoutbysurgery

tahir99 - UnitedVRG


divAricAtion of rEcti• Divaricationoftherectusabdominisisseenprincipallyinelderlymultiparouspatients

• Whenthepatientstrains,agapcanbeseenbetweentherectusabdominis,throughwhichtheabdominalcontentsbulge

• Whentheabdomenisrelaxed,thefingerscanbeintroducedbetweentherectus

• Anabdominalbeltisallthatisrequired.Thereisnoriskofstran-gulation

raspberry tumor omphalitis• PersistenceofdistalpartofVitellointestinalduct(proximalpartpersistenceiscalledasMeckel’sdiverticulum)

• AlsocalledasUmbilicaladenoma• Surgeryhastobedone.umbilectomyisindicatedifitrecursafterexcisionoftumoralone

• Infectionofumbilicalcord,resultingincrustformation

• Antibioticsandlocalsilvernitrateap-plicationisbeneficial

umbilical granuloma umbolith (umbilical calculus)• Chronicinfectionoftheumbilicalcicatrixthatcontinuesforweekscausesgranulationtissuetopoutattheumbilicus

• Differentialdiagnosis—umbilicaladenoma• Treatment—localapplicationofsilvernitrate

• Thisisoftenblackincolorandiscomposedofdesquamatedepithe-lium,whichbecomesinspissatedandcollectsinthedeeprecessoftheumbilicus

• Thetreatmentistodilatetheorificeandextractthecalculusbut,topreventrecurrence,itmaybenecessarytoexcisetheumbilicus

rEtroPEritonEAl fibrosis○ Fibroticprocessentrapsandconstrictstheureterstherebycausingobstructiveuropathy

○ Types1. Primary Idiopathic(ormondsdisease)2.Secondary

clinical features• MCinmen• Dullachingpain,nausea,anorexia• Compressionofureter,aorta,IVC• Diagnosis—intravenouspyelogram—showslater-allydeviatedureter

• CurrentlyCTScanistheprocedureofchoice• IfrenalfunctionimpairedMRIisthechoice• Rememberureterism/cobstructedatlower1/3rd

causes of secondaryInflammatory-chronicpancreatitis,histoplasmosis,tuberculosis,actinomycosis

Drugs–methysergide,alphamethyldopa,betablockers,hydralazine,

Malignancies-prostate,NHL,sarcoma,carcinoid,gastriccancerAutoimmune-ankylosingspondylitis,SLE,PAN

PEritonitis• SpontaneousbacterialperitonitisE. coli (most common)

Klebsiella(2ndmc)• SecondarybacterialperitonitisE. coli and bacterioids

Pneumoperitoneum Pseudopneumoperitoneum• Hollowviscusperforation• Postoperativeabdomen• Laparoscopy• Diagnosticproceduresinvolvingfemalegenitaltract

• Peritonealdialysis

• Distendedviscus• Chilaiditi’ssyndrome(interposition of colon with gas between liver and

diaphragm)• Subphrenicabscess• Subdiaphragmaticfat,omentalfat• Unevendiaphragm• Subpulmonarypneumothorax• Curvilinearpulmonarycollapse• Intramuralgasinpneumatosisintestinalis

tahir99 - UnitedVRG


subPHrEnic AbscEssAnatomy

○ Thecomplicatedarrangementoftheperitoneumresultsintheformationoffourperitonealandthree*

○ extraperitonealspacesinwhichpusmaycollect.Extraperito-nealspacesareoneithersideofthebodyandoneisapproxi-matelyinthemidline

left superior (anterior) intraperitoneal (left subphrenic)Isboundedabovebythediaphragmandbehindbythelefttriangularligamentandtheleftlobeoftheliver

thegastrohepaticomentumandanteriorsurfaceofthestom-ach.Totherightisthefalciformligamentandtotheleftthespleen,gastrosplenicomentumanddiaphragm.Patientistoxic

Thecommoncauseofanabscesshereisanoperationonthestomach,thetailofthepancreas,thespleenorthesplenicflex-ureofthecolon

left inferior (posterior) intraperitoneal (left subhepatic)

right superior (anterior) intraperitoneal (right sub-phrenic)

Isanothernameforthe‘lessersac’Thecommonestcauseofinfectionhereiscompli-catedacutepancreatitis

Inpracticeaperforatedgastriculcerrarelycausesacollectionherebecausethepotentialspaceisoblit-eratedbyadhesions

LiesbetweentherightlobeoftheliverandthediaphragmItislimitedposteriorlybytheanteriorlayerofthecoronaryandtherighttriangularligaments,andtotheleftbythefalciformligament.Commoncauseshereareperforatingcholecystitis,aperforatedduodenalulcer,aduodenalcap‘blowout’followinggastrectomyandappendicitis

right inferior (posterior) intraperitoneal (right subhepatic)LiestransverselybeneaththerightlobeoftheliverinRutherfordMorison’spouchItisboundedontherightbytherightlobeoftheliverandthediaphragm.TotheleftissituatedtheforamenofWinslowandbelowthisliestheduodenum.Infrontaretheliverandthegallbladder,andbehind,theupperpartoftherightkid-neyanddiaphragm

Thespaceisboundedabovebytheliver,andbelowbythetransversecolonandhepaticflexureItisthedeepestspaceofthefourandthecommonestsiteofasubphrenicabscesswhichusuallyarisesfromappendicitis,cholecystitis,aperforatedduodenalulcerorfollowingupperabdominalsurgery

mEsEntric cyststypes—chylolymphatic (mc type) and enterogenous cyst

chylolymphatic cyst Enterogenous cystUsuallycongenitalasaresultofsequestrationoflymphatics Derivedfromdiverticulumofmesentricborderthat

hasbecomesequestratedCystwallisthin,lacksmuscularwall,notlinedbymucosa ThickwalllinedbymucosaUsuallysolitaryandoftenunilocularwithclearlymphorchyle ContentismucinousMostfrequentlyseeninmesentryofileumIndependentbloodsupply CommonbloodsupplyasadjacentbowelEnucleation is enough Resection anastomosis needed

tillaux triad ○ Recurrentattacksofabdominalpainwithorwithoutvomitingduetoobstruction

○ Acuteabdominalpainduetotorsionofmesentry,rup-tureofcyst,hemorrhageintocyst,infectionofcyst

1.Centralareaofdullnesswithzoneofresonanceallaround2.Swellingmovesperpendiculartomesentryfreely3.Softfluctuantswellingintheumbilicalregion

tahir99 - UnitedVRG


fmgE quEstions

1. Spigelian hernia is: (Sep 2005, 2007) a. Herniapassingthroughtheobturatorcanal b. Herniaoccurringthroughthelineaalba c. Herniathroughthetriangleofpetit d. HerniaoccurringatthelevelofarcuatelineAns: d (Hernia occurring at the level of arcuate line)

2. Strangulation most commonly occurs in: (Sep 2008) a. Femoralhernia b. Directinguinalhernia c. Indirectinguinalhernia d. LumbarherniaAns: a (Femoral hernia)

3. True regarding indirect inguinal hernia are all, except: (Sep 2009)

a. Mostcommontypeofhernia b. Alwaysunilateral c. Inguinalherniotomyisthebasicoperation d. Transilluminationdistinguishesitfromhydro-

celeAns: b (Always unilateral)

4. If caecum is involved as a part of the wall of herni-al sac and is not its content, then it will be known as: (Sep 2005)

a. Richter’shernia b. Spigelianhernia c. Slidinghernia d. InterstitialherniaAns: c (Sliding hernia)

5. Most common type of hernia in the young age group: (Sep 2006)

a. Femoralhernia b. Directinguinalhernia c. Indirectinguinalhernia d. UmbilicalherniaAns: c (Indirect inguinal hernia)

6. While operating upon strangulated hernia, the sac is opened at: (Sep 2009)

a. Neck b. Body c. Fundus d. MouthAns. c (Fundus)

7. Which of the following describes Richter’s hernia: (March 2009)

a. Thestrangulatedloopof‘W’lieswithintheabdomen

b. Herniaoccurringatthelevelofarcuateline c. Involvesonlyaportionofthecircumferenceof

thebowel d. HerniaoccurringthroughthelineaalbaAns: c (Involves only a portion of the circumference of the bowel)

8. Hernia which often simulates a peptic ulcer is: (March 2010)

a. Umbilicalhernia b. Incisionalhernia c. Strangulatedhernia d. FattyherniaoflineaalbaAns: d (Fatty hernia of linea alba)

9. Which of the following is the most pathognomon-ic sign of impending burst abdomen: (March 2007)

a. Fever b. Shock c. Pain d. SerosanguinousdischargeAns: d (Serosanguinous discharge)

10. All of the following regarding diagnosis of acute peritonitis are correc, except: (March 2006)

a. RaisedWBCcountinperitonealaspirate b. Moderatelyraisedamylaselevelsarediagnos-

ticofperitonitis c. CTscanmayaidindiagnosis d. Uprightfilmsshowsfreeairunderthedia-

phragmAns: a (Raised WBC count in peritoneal aspirate)(ReferPage995BaileyandLove,25thedition)Investigationsforperitonitis:• RaisedbloodWBCcountandCRP• Serumamylasemoderatelyelevated• Abdomen radiographs show free gas under dia-phragm,

• USGandCTaidindiagnosis• Peritonealdiagnosticaspirationmaybehelpful

11. A patient on antibiotics for treatment for peritoni-tis presents with mucus diarrhea. Most probable cause could be: (March 2008)

tahir99 - UnitedVRG


a. Ulcerativecolitis b. Activationoflatenttuberculosis c. Antibioticassociateddiarrhea d. GastritisAns: c (Antibiotic associated diarrhea)

12. All of the following conditions are associated with raised amylase level, except: (March 2006)

a. Carcinomapancreas b. Perforatedulcer c. Acutepancreatitis d. AcuteappendicitisAns: d (Acute appendicitis)Increasedbloodamylaselevelsmayoccurdueto:• Acutepancreatitis• Cancerofthepancreas,ovariesorlungs• Cholecystitis• Gallbladderattackcausedbydisease• Gastroenteritis(severe)• Infectionofthesalivaryglands(suchasmumps)orablockage

• Intestinalblockage• Macroamylasemia• Pancreaticorbileductblockage• Perforatedulcer• Tubalpregnancy(mayhaveburstopen)Decreasedamylaselevelsmayoccurdueto:• Cancerofthepancreas• Damagetothepancreas• Kidneydisease• Toxemiaofpregnancy 13. Serum amylase level is increased in all of the fol-

lowing, except: (March 2005) a. Intestinalobstruction b. Perforatedulcer c. Acutepancreatitis d. AcuteappendicitisAns: d (Acute appendicitis)

14. Pneumoperitoneum is created by: (March 2009) a. O2 b. CO

c. CO2 d. N2OAns: c (CO2)

15. Painful, tender, non reducible sac through the inguinal canal with absent cough impulse. Diag-nosis is: (Sep 2008)

a. Strangulatedhernia b. Orchitis c. Irreduciblehernia d. TorsiontestisAns: a (Strangulated hernia)

16. Which is not a cause for burst abdomen: (March 2011) a. Abdominaloperationlastingmorethan2hours b. Incompletesuture c. Infection d. PoorgeneralconditionofpatientAns: a (Abdominal operation lasting more than 2 hours)

17. Non-metabolic cause of abdominal pain: (March 2011) a. DKA b. Sicklecellanemia c. Hyperparathyroidism d. PorphyriaAns: b (Sickle cell anemia)Metabolicandendocrinecausesofpainabdomen:• Diabetesketoacidosis• Hypercalcemia• Acuteintermittentporphyria• Adrenalinsufficiency• Poisonsanddrugs

18. Viscera, forms a wall in which of the following hernia: (March 2011)

a. Lumbarhernia b. Slidinghernia c. Epigastrichernia d. FemoralherniaAns: b (Sliding hernia)

tahir99 - UnitedVRG

18ElEctivE NEurosurgEry

Raised intRacRanial pRessuRe• Normalintracranialpressure(ICP)variesfrom5to15mmHgintheadultatrest

• Resultsinreducedcerebralperfusionandbrainherniation• ThemajorcausesofraisedICParehematomas,tu-morsandhydrocephalus

Monro-Kellie doctrine• Skull contains—brain, cerebrospinal guild (CSF) andblood to-gethermaintaintheICT.

• Ifoneincreasestheotheronecompensatesforpressurebydecreasing.

Theremayalsobediplopiaduetoasixthnervepalsy;thisnerveisvulnerabletodownwardscerebralshiftofanycauseduetoitslongintracranialcourse,sometimescalleda false localising sign.Theremaybeabnormalitiesofconjugategaze.

Inparticular,impairedupgazeorsun-settingmaybeseenaspartofParinaud syndrome,causedbypressureonthedor-salmidbrain.

Sun set sign—hydrocephalus

signs of raised ict in infants○ Papilledema○ Sixthnervepalsy○ Impairedupgaze○ Focalneurologicaldeficits○ Impairedconsciouslevel

• Progressivemacrocephaly• Bulginganteriorfontanelle• Dilatedscalpveins• Sun-settingeyes

Cerebrospinal fluid pathway• CSFflowsfromthelateralventricles,throughtheforamenofMonro,intothethirdventricle

• ThenintothecerebralaqueductandfourthventriclebeforeexitingintothesubarachnoidspaceviathemidlineforamenofMagendieandlateralforaminaofLuschka

Contd...

tahir99 - UnitedVRG

223Elective Neurosurgery

CSF physiology ProductionHydrocephalusisaconditioninwhichthereisdis-equilibriumbetweenCSFproductionandabsorp-tion,leadingtoraisedICPandisoftenassociatedwithdilatedventricles.

Volume:150mL

• 20mLh–1,80%bychoroidplexus• Activeprocess• Absorptionatarachnoidvilli• Pressuredependent• Relativetoplasma• ReducedK+andCa2+• IncreasedCl–andMg2+• pH7.33–7.35(slightlyacidiccomparedtoplasma)

Types of hydrocephalusObstructivehydrocephaluslesionswithintheventricle Communicatinghydrocephalus ExcessiveCSFproduction(rare)• Lesionsintheventricularwall• Lesionsdistantfromthe• Ventriclebutwithamasseffect

• Posthemorrhagic• CSFinfection• RaisedCSFprotein

• Choroidplexus• Papilloma/carcinoma

Block at I: Foramen of Monro and 3rd ventricle Gliosis ChiasmalgliomasColloidcyst Craniophryngiomas ArachnoidcystsBlock at II: AqueductPinealtumors/ParinaudsyndromeductalstenosisPeriductal/subependymalgliosisBlockatIII:4thventricleandbasilarobstructionMedulloblastoma/ArachnoiditisEpendymomas/Arnold-ChiarisyndromeAstrocytomasDandy-WalkersyndromeBlockatIV:WhenpassingbasalcisternArachnoiditis—Posthemorrhagic,postmeningiticBlockatV:AbsorptiveobstructionArachnoiditis—Posthemorrhagic,Postmeningiticvenousthrombosis

investigationsLumbarpunctureiscontraindicatedinobstructivehydrocephalusbecauseoftheriskofcausingtonsillarherniationanddeath.

Magneticresonanceimaging(MRI)

• CTscan• Inchildren,chronicraisedICPcanresultincopperbeatingoftheskull

• Copper-beating-chronic raised intracranial pressure.

Treatment of hydrocephalus○ Aventriculoperitonealshuntinvolvestheinsertionofacatheterintothelateralventricle(usuallyrightfrontaloroccipital)

○ Thecatheteristhenconnectedtoashuntvalveunderthescalpandfinallytoadis-talcatheter,whichistunnelledsubcutaneouslydowntotheabdomenandinsertedintotheperitonealcavity.

○ IftheCSFpressureexceedstheshuntvalvepressure,thenCSFwillflowoutofthedistalcatheterandbeabsorbedbytheperitoneallining.

○ Otheroptionsfordistalcatheterplacementincludetherightatriumviathedeepfacialandjugularvein(ventriculoatrialshunt)orthepleuralcavity(ventriculo-pleuralshunt)

Contd...

tahir99 - UnitedVRG


intRacRanial tuMoRs○ Intracranialtumorsmaypresentwithseizures,focalneurologicaldeficit,raisedICPorendocrinedisturbanceCerebralmetastasesarethemostcommonintracranialtumorsBenigntumorsmaycauselife-threateningintracranialcomplicationsForaggressivetumours,managementoptionsincludesteroids,surgery,radiotherapyandchemotherapy

Feature of brain tumors• Intracranialtumorscanpresentwithseizures,focalneurologicaldeficits,raisedICP,seizuresorendocrinedysfunctionorcanbeincidentalfindings.

FND:• Withregardtothetime-courseofneurologicalsymptoms,asteadyprogressionofsymptomsovertimesuggestsastruc-turallesionmorethantheacutedeficitofvascularpathology.

• Anexceptiontothismaybetheacutedeficitproducedbyhemorrhageintoamalignantglioma,amelanomametastasisorpituitaryapoplexy.

• Frontal lobe lesions tendtopresentwithpersonalitychange,gaitataxiaandurinaryincontinence,contralat-eralhemiparesisifposteriorfrontalanddysphasiaifinvolvingtheleftinferiorfrontalgyrus.

• Parietal lesions areassociatedwithsensoryinatten-tion,dressingapraxia,astereognosisandifonthedominantside,acalculia,agraphia,left–rightdisorien-tationandfingeragnosia(Gerstmannsyndrome).

• Temporal lobe lesionsmaybeassociatedwithdisturbanceofmemory,contralateralsuperiorquadrantanopiaorhemipare-sisand,ifonthedominantside,dysphasia.

• Occipital lesions areoftenassociatedwithvisualfielddefi-cits,mostcommonlyanincompletecontralateralhomony-moushemianopia

• Otherclassicalfocaldeficitsassociatedwithtumorsinclude:bitemporalhemianopiawithapituitary macroadenoma;

• Anosmia,ipsilateralopticatrophyandcontralateralpapilledemawithananteriorskull base meningioma (Foster-Kenne-dy syndrome);

• Ipsilateralhearingloss,tinnitusanddysequilibriumwithavestibular Schwannoma.

ClassificationNeuroepithelial tumors○ Gliomas—astrocytomas,oligoden-drogliomas,ependymoma,choroidplexustumor

○ Pinealtumors○ Neuronaltumous—ganglioglioma,gangliocytoma,neuroblastoma

○ Medulloblastoma

Nerve sheath tumours—Vestibularschwannoma

Tumor-like malformations—Craniophar-yngioma,epidermoidtumor,dermoidtumorandcolloidcystMeningeal tumors:Meningioma

○ Pituitarytumors○ Germcelltumors—germinoma○ Lymphomasteratoma

Metastatic tumors○ Contiguousextensionfromregionaltumors,e.g.glomustumor

tahir99 - UnitedVRG

225Elective Neurosurgery

Supratentorial infratentorial (posterior fossa)• Astrocytoma(allgrades)(50%)• Craniopharyngioma(2%–5%)• Others:Pinealregiontumors,choroidplexustumors,ganglioglioma,DNET

• Medulloblastoma(15-20%)• Cerebellarastrocytoma(15%)• Ependymoma(9%)• Brainstemastrocytoma

Highgradeastrocytoma(e.g.glioblastomamultiforme(GBM)(12–15%)Metastasis(15%–30%,includesinfratentorial)Meningioma(15%–20%)Lowgradeastrocytoma(8%)Pituitaryadenoma(5%–8%)Oligodendroglioma(5%)Other:Colloidcyst,CNSlymphoma,dermoid/epidermoidcysts

MetastasisAcousticneuroma(Schwannoma)(5–10%)Hemangioblastoma(2%)Meningioma

age○ <15year○ Incidence:2–5/100,000/year○ 60%infratentorial

○ >15year○ 80%supratentorial

GlioMas○ Gliomasincludeastrocytomas,oligodendrogliomasandependymomas.TheyaregradedaccordingtotheWHOclassification.

○ AgradeItumor,suchasapilocytic astrocytoma,istheleastaggressive;agradeIVtumor,suchasaglioblastoma multiforme,isthemostaggressive

○ Pilocyticastrocytomaismostcommoninchildrenandyoungadults,withapeakincidenceattheageof10years.

○ Diffuse astrocytomas (WHOgradeII)aremostcommoninthe4thdecadeoflifeandoftenpresentwithseizuresorareincidentalfindings

○ High-gradegliomas,includinganaplastic astrocytomas (WHO grade III) and glioblastoma (WHO grade IV) aremostcommoninthe4thand6thdecadesofliferespec-tively.

○ Glioblastomaisthemostcommonadultglialtumor.

MC points from this area○ MCglioma—astrocytoma○ MCbraintumors—Metastasis(bailey) Astrocytomas(osbornneuro)○ MCastrocytomas—glioblastomamultiforme

treatmentSurgeryisusuallyfollowedbyhigh-dose(60Gy)focusedirradiationforthosepatientswithagoodperformancestatus.Chemotherapyoptionsincludeoraltemozolomide,eitherconcurrentlyorafterradiotherapy

ceRebRal Metastasis○ Cerebralmetastasesarebyfarthemost common intracranial tumorsandwillaffectapproximatelyoneineveryfourcancersufferers.

○ Themajorityofpatientswithcerebralmetastaseshavemultiplele-sionsandarenotsuitablecandidatesforsurgery.

○ Palliationwithsteroidsandwhole-brainirradiationremainoptions

Most common sites of primaryLung40Breast10–30Melanoma5–15Colon,renalUnknown15

MeninGioMa• Meningiomasarisefrommeningothelialcellsandrepresentaround15–20%ofallintracranialtumors.

• Meningiomasareusuallybenignalthoughatypicalandmalig-nantformscanoccur.Around80%aresupratentorial

• Meningiomasdisturbbrainfunctionbymasseffect,stimulationofvasogenicedema,directbraininva-sionorobstructivehydrocephalus.

• Treatmentisresection

tahir99 - UnitedVRG


Pituitary adenoma Pituitary tumors• Constituteabout10%–15%tumorsinbrain.• Themostcommonpituitaryadenomasareprolactinoma(30%),non-functioningadenoma(20%),growthhormonesecretingadenoma(15%)andadrenocorticotrophichormone(ACTH)—secretingadenoma(10%).

• Pituitary apoplexy resultsinthesuddenonsetofheadache,visualloss,ophthalmoplegiaandpossiblyalteredconsciouslevel.Itiscausedbyhemorrhagicinfarctionofapituitarytumor.ThesuddenheadacheandmeningismissimilartothepresentationofaneurysmalSAH.

• Mostcommonsellartumorsinadults• M/csellartumorinchildren—craniopharyn-gioma

• M/cpituitaryadenoma—prolactinoma• Theyarethem/ccauseofhyperpituitarism• Pituitarystone—duetodystrophiccalcifica-tionofprolactinoma.

pediatRic bRain tuMoRs○ Intracranialtumorsarethemostcommonsolidtumorsinchildren.○ In neonates,tumorstendtobeofneuroectodermaloriginandmost

are supratentorial.Tumortypesinclude:•Teratoma;•Primitiveneuroectodermaltumor;•High-gradeastrocytoma;•Choroidplexuspapilloma/carcinoma.

o Inolder children,themajorityoftumorsareinfratentorialandoneofthreetypes:•Medulloblastoma•Ependymoma•Pilocyticastrocytoma.

Othertumorsincludesupratentoriallow-gradegliomas,craniopharyngiomaandbrainstemgliomas

FMGe and dnb questions

1. TheCNStumorthatpresentwithcalcificationis: a. Oligodendroglioma b. Astrocytoma c. Medulloblastoma d. PheochromocytomaAns: a (Oligodendroglioma)

2. Suprasellarcalcificationwithpolyuriaisseenin: a. Medulloblastoma b. Pinealoma c. Craniopharygioma d. AstrocytomaAns: c (Craniopharygioma)

3. Which of the tumor is highly vascular in nature? a. Glioblastoma b. Meningioma c. Pituitaryadenoma d. EpidermoidatCPangle

4. Which of the following route is preferred for pi-tuitary surgery?

a. Transcranial b. Transethmoidal c. Transphenoidal d. TranscallosalAns: c (Transphenoidal)

5. Which of the following is the most common type of glial tumors?

a. Astrocytoma b. Medulloblastoma c. Neurofibroma d. EpendymomaAns: a (Astrocytoma):

6. Most common spinal tumor is: a. Meningioma b. Ependymoma c. Neurofibroma d. NeuroblastomaAnsc(Neurofibroma)M/c in spinal cord• M/cspinaltumor—metastasis• M/cprimaryspinaltumor—neurofibroma,schwan-noma(nervesheathtumor)

• M/cextraduraltumor—metastasis• Mostcommonintramedullarytumor—ependymoma• M/cintraduralextramedullarytumor—nervesheathtumor.

7. Raised intracranial pressure will cause:

(Sep 2007) a. Tachycardia b. Hypotension c. Papilledema d. NormallookinganteriorfontanelleininfantsAns: c (Papilledema)

tahir99 - UnitedVRG

19CardiothoraCiC Surgery

MediastinuMa. Superior mediastinumb. Anterior mediastinum c. Middle mediastinum d. Posterior mediastinum

anterior mediastinum• Thymoma(m/C)• Lymphoma• Germcelltumors• Mesenchymaltumors• Thyroidandparathyroidthymomas

Middle mediastinum• Cysts(m/c—pleuropericardial,bronchogenic,enterogenousandneuroenteric)

• Vascularmasses(aneurysm)• Lymphnodes• Mesenchymaltumors• pheochromocytoma

Posterior mediastinum Mostcommonanteriormediastinalmass—thymomaMostcommonmediastinalmass—neurogenictumorsMostcommonmalignantmassofmediastinum—lym-phomas

Mostcommonmediastinalmassinchildren—neuro-genictumor

• Neurogenictumors(m/coverall)• Meningoceles• Gastroentericcyst• Mesenchymaltumors• Pheochromocytoma• lymphoma

Bronchogenic cyst Congenitallunglesion,whicharisesfromtheanomalousdevelopmentofforegutortracheobronchialtree.

Contd...

tahir99 - UnitedVRG


Bronchogenic cyst○ Mostofthemariseinmediastinum,but15%occurinpulmonaryparenchyma.

○ Inlungsmostcommoninrightlung,lowerlobes.○ Linedbycuboidalorciliatedepitheliumandareusuallyfilledwith

mucoid material

complications of bronchogenic cyst Infection Atelectasis Tensionpneumothorax

Lung sequestration○ Asequestrationconsistsofnormallydevelopedbronchiolesandalveolisuppliedbysystemicratherthanpulmonaryarteries95%oftimethisbloodsupplyisfromaorta.M/cinlowerlobes,leftmorecommonthanright.

extralobar sequestration intralobar sequestration25% 75%Drainviaazygousvein DrainviapulmonaryveinDonotcommunicatewithlung Theyareincommunicationwithtracheo-

bronchialtreeAssociatedwithcongenitaldia-phragmatichernia

Pronetoinfectionandlungabscess

Pancoast tuMor○ Itisatumoroftheapexoflung(squamouscellorepidermoidcancer)○ Causesdestructionoffirstandsecondribs.○ Maygrowtocause—shoulderpain,erosionofribsandHornersyndrome

Lungs and PLeuraempyema of lungs

○ Empyema(pusinlungs)istheendstageofpleuralinfectionfromanycause;thepathologicaldiagnosisrequiresthepres-enceofthickpuswithathickcortexoffibrinandcoagulumoverlung.

causes complications of empyema• Infectionofanycause—TB,pneumonia(m/ccause)*,bronchiectasis,fungalandlungabscess

• Traumatichemothoraxgettinginfected

• Pleuraleffusionontreat-ment

• Surgeriesinthorax• Extrapulmonarysources—subphrenicabscess

• Boneinfections—ribosteomyelitis

• Empyemanecessitans(spon-taneousdecompressionofpusthroughthechestwall)

• Chronicempyema(withen-trappedlungandpulmonaryrestrictivedisease)

• Osteomyelitis• Pericarditis• Mediastinitis• Bronchopleuralfistula• Disseminatedinfectionofcentralnervoussystem

treatment• Drainageofpus—drainmustbekeptatthebottomofcavityandmustexitanteriortomidaxillaryline

• Ifthedrainageisinsufficientdecorticationofthelungisperformed

Contd...

tahir99 - UnitedVRG

229Cardiothoracic Surgery

hydatid cyst of lung amebic lung abscess• Lungissecondcommonsiteafterliverforhydatidcystinfec-

tion• Only10%ofthehydatidcystsoflungshaveassociatedhe-paticcyst

• 20%casesarebilateral• M/csiteislowerlobe*• Calcificationisveryrare(Itisverycommoninliverhydatidcyst)

• Mayruptureintobronchialtree

• Infectionspreadsdirectlythroughdiaphragm• M/careaoflunginvolvedisrightlowerlobe*• Amebicliverabscessmayruptureintorightlung(m/c)*,leftlung,rightorleftpleuralcavity,pericar-diumorperitonealcavity

• Itisthesecondcommoncomplicationofamebicliverabscess(m/ccomplicationofliverabscessissecondarybacterialinfection)

Foreign Body in Lung• Mostcommonsiteofdislodgementinlungsisrightmainstembronchusorrightlowerlobe*(becausetherightmainstemiswider,shorterandverticallyplaced)

Most common lobes for aspirationsupine position sitting or erect position• Rightupperlobe—posteriorsegment*• Rightlowerlobe—superiorsegment• Leftlowerlobe—superiorsegment

• Rightbasilarsegmentoflowerlobe(rightlowerlobe—basalsegment)*

Bronchogenic canceretiological factors Pathological types• Cigarettesmoking(85%–95%)• Atmosphericpollution• Occupation(radioactiveoreandchromiummining)

• Smallcelllungcancer(Oatcellcancer)• Non-smallcelllungcancer(NSCLC)Ratioofsmallcelllungcancer:Non-smallcelllungcancer(1:4)Pathologicalstagingisveryimportantformanagement.

histological types• Small cell lung cancer—(oat cell cancers) 20%EarlymetastasistolymphnodesandbybloodbornespreadMediansurvivalinmonthsRespondtochemotherapySurgeryhaslittleplace

• Squamous cell cancer:Appearsaswellcavitatingcancer

• Large cell undifferentiated:TypeofNSCLCandisincludedinneuroendocrine

tumor• Adenocarcinoma:MostcommonofNSCLChavingovertakensquamouscellcancernow

Increasedincidenceinwomen

• Bronchioalveolar carcinoma:Groundglassappearance

squamous cell ca adenocarcinoma small cell ‘ca’ Large cell ‘ca’○ McvariantinIndian○ Subcontinent○ Pancoast tumor is histologi-

cally SCC○ Mostlycentralindistribution○ Itcancavitate○ Best prognosis ○ M/cassociatedparaneoplas-ticsyndromeishypercalce-miaandhypophosphatemia*

○ T/tbysurgicalexcision

○ Overall Mc histological type ○ Mctypeinnon-smoker,youngandfemale

○ Mostlyperipheralindistribu-tion

○ Overallprognosisisgood○ Maymetastasizetooppositelung(thisisduetoaerosoltransmission and is seen more frequentlyinbronchoalveolartype)

○ Most aggressive form of lung ‘Ca’ (rapidly growing)

○ Mostlycentralindistribution○ Itrespondbesttochemother-apyandradiotherapy

○ Worst prognosis (Least resectability)

○ Mctypecausingextrathoracicmetastasis

○ Strong association with smoking

○ Itmaycausegyne-comastia

○ Galactorrheadueto ectopic prolac-tin secretion.

Lung‘Ca’istheleadingcauseofcancerdeathinbothmaleandfemale

McsiteofmetastasisisliverMcendocrineorganinvolvedisadrenal

LungCaisMctumormetastasizingtoheartBrainmetastasismaypresentwithneurologicaldeficit

Contd...

tahir99 - UnitedVRG


Bronchogenic cancerclinical features

• Hemoptysis—lessthan50%cases• Cough—commonsymptom,butnon-specific• Localizedpain—duetoinfiltrationofanintercos-talsnerve

• Pancoasttumor—invasionofapicalareamayinvolvebrachialplexus

• Dyspnea• Pleuraleffusion• Clubbingandhypertrophicpulmonaryosteoarthropathy(resolvewithexcisionofcancer)

• Hoarsenessofvoiceduetorecurrentlaryngealnerveinvolvement

• Dysphagia(esophaguscompression)

• Superiorvenacavalobstruction• Smallcellcarcinoma:DevelopmentofmyopathiesincludingEaton-Lambertsyndrome,whichissimilartomyastheniagravis

tumor, node, metastasis (tnM) staging○ T1:Tumor<3cm;notinvolvesmainbronchus○ T2:Tumor>3cm;involvesmainbronchus○ T3:Anysizeinvolvingchestwall,diaphragm,mediastinalpleura,parietalpericardium,ortumorsinmainbronchus <2cmfromcarina,butnotinvolvingcarina.

○ T4:Anysizeinvadesmediastinum,heart,greatvessels,tra-chea,esophagus,vertebralbody,carinaorpleuraleffusionorpericardialeffusion*orsatellitenodules

• N1:Ipsilateralperibronchialandipsilateralhilarnodesandintrapulmonarynodes

• N2:Ipsilateralmediastinalandsubcarinalnodes• N3:Contralateralmediastinalorhilar,ipsilateralorcontralat-eralscalenenodesorsupraclavicularnodes.

M1:Distantmetastasis.

Management modalitiescancer tnM staging small cell cancer non-small cell cancerEarlystage(IA/IB/IIA/IIB)

IA-T1N0M0 Radiotherapyandchemo-therapy

Preoperativechemotherapyfollowedbysurgery

IB-T2N0M0 “ “IIA-T1N1M0 “ “IIB-T2N1M0IIB-T3N0M0

“ “

Locallyadvanced,butsurgicallyresectable disease

IIIA-T3N1M0T1/2/3N3M0

Inoperable Combinedmodality(Chemotherapy+radiotherapy+Surgery)

Locallyadvanced,butsurgicallyunresectable

IIIB-T4N0/1/2M0T1/2/3/4N3M0

Inoperable Radiationtherapy+chemo-therapy

Metastatic disease IVM1

Inoperable Chemotherapyonly

Contd...

Contd...

tahir99 - UnitedVRG


Bronchogenic cancer5 year survival of each cancer

• Squamouscellcancer:35%–50%(Bestprognosis)• Adenocarcinoma:25%–45%• Adenosquamous:20%–35%

• Undifferentiated:15%–25%• Smallcellcarcinoma:0%–5%(badprognosis)*

Paraneoplastic syndrome (non-metastatic complication)small cell ‘cancer’ squamous cell ‘ca’ Large cell ‘ca’ adeno ‘ca’ExcessADHsecretioncausesSlADHandhyponatremia

EctopicACTHcauseshypokalemiaandCushingsyndrome

MyasthenicEaton-LambertsyndromeRetinalblindnessCerebellardegeneration

EctopicPTH’andPTHrelatedpeptideproductioncauses—hypercalcemiaand

hypophosphatemia#Clubbing—inallnon-smallcell‘Ca’

Gynecomastia Maycausehypertrophicpul-monaryosteoarthropathy.

Migratorythrombophlebitis (Trousseau’ssyndrome)DlCwithleukoerythroblasto-

sis.

other paraneoplastic manifestations• Peripheralneuropathies• Subacutecerebellarandcorticaldegeneration

• Polymyositisanddermatomyositis• Nephroticsyndromeandglomerulonephritis• Acanthosisnigricans

heartcardiac surgery

• Cardiopulmonarybypass(CPB)wasfirstsuccessfullyusedin1953byGibbon*• CPBmachinetakesovertheventilationandcirculation

coronary artery bypass graftinganatomy of coronary artery invasive methods of diagnosiso Coronaryarteriesarebranchesofascendingaorta.Rightfromanteriorsinusandleftfromleftposteriorsinus.

Gold standardforimagingiscoro-naryangiography

Demonstratesextent,severityandlocationofstenosis

Reductionindiameter>70%isconsideredassevere

EvaluatessuitabilityofsurgeryAidsinprognosticassessment

Left coronary artery:• Worstprognosisintermsofsurvivalwithoutsurgery• Leftmainstemdisease• Branches:Leftanteriordescending(LAD)oranteriorinterventriculararteryandObtuse/marginalbranchesofcircumflexartery

• LADisthemostfrequentlydiseasedarteryandmostoftenbypassedduringcoro-naryarterybypassgrafting(CABG)

right coronary artery:• Continuesasposteriordescendingarteryorinterventricularartery

indications for surgery: surgery is indicated for symptomatic or prognostic reasons• >50%stenosisoftheleftmainstem(criticalleftmaindisease)*• >70%stenosisoftheproximalleftanteriorinterventricularartery

• Allthreemaincoronaryarteriesdiseased(Triplevesseldisease)

• Poorventricularfunctionassociatedwithcoronarydisease.

conditions and surgerieschronic stable angina: Percutaneous transluminal coro-naryangioplasty(PTCA)andstent-ingismorecommonlyusedthanCABGnow.

acute coronary syndrome:Unstableanginabecomeasymptomaticwithin48hourofmedicalantianginadrugs

IfthepatientdevelopsrecurrentanginaandECGchanges—thrombolysisandPTCAisusedmorethansurgery

IfsurgeryistobedoneelectiveCABGtobedoneatleastafter6week

Contd...

Contd...

tahir99 - UnitedVRG


heartcardiac surgery

Surgery for complication of myocardial infarction (MI): Myocyte necrosis and ventricular septal rupture:Presentsafter3to7daysofinfarctionwithpulmonaryedema,pansystolicmurmurandhypotension.RepairiswithapericardialorartificialDacronpatch.

Papillary muscle necrosis:Causesacutemitralregurgitation,apansystolicmurmurandpulmonaryedema.Mitralvalvereplacementisusuallynecessary.

Ventricular aneurysm:Partialthicknessnecrosisofventricularwall,iffreewallisreplacedwithnon-contractilefibroustissue.RepairisundertakenusingCPBandCABGisundertakenatthesametimeifnecessary.

contraindications for surgery• Smalldiffuselydiseasedarteries• Diffusediseaseandheartfailure

• AcuteMIover6hoursold• Moribundpatientsafterresuscitation

seLection oF conduitVenous grafts arterial graft○ Long saphenous vein*isthemostcom-monlyusedveinasaconduit

○ 10yearpatencyrateforlongsaphenousveingraftsisreportedtobe50%–60%with10%–15%occludingin1year

○ Alternativeveinsareshortsaphenousveinandcephalicvein

○ Left internal mammary artery or internal thoracic artery has become the conduit of choiceforLAD

○ 10yearpatencyratesare90%*○ Internalmammaryarterieshavesomelimitationslikesternalwoundinfec-

tions in diabetes○ Radialarteryisusedinthosecasesassecondoralternativearterialbypassgraft(Allens testhastobepeformedbeforeharvestingradialartery).Thistestlooksforthepatencyofulnararteryforpalmararch

Postoperative complications survival• Bleeding• Arrythmias(sinustachycardiaism/cfollowedbyatrialfibrillation)• Poorcardiacoutputstate• Neurologicaldysfunction• Woundinfection• Mortality(2%–3%)

• 95%at1year• 90%at5years• 75%at10years• 60%at15years.

MyxoMa•Mcprimarycardiactumor• Mostlyin3rdto6thdecade,withfemalepredilec-

tion. • Mostlysporadic,somefamilialAlzheimerdisease(AD)transmission

• Sporadicformsaresolitary,locatedmostlyinleftatria,arisingfrominteratrialseptumnearfossaovalis

• Familialformsaremultipleandventricularinloca-tionandisknownforrecurrence

clinical features• MCclinicalfeatureisthatofMSorMR• Ventricularformmaypresentwithobstructivefeature.• Embolicandconstitutionalsymptomsincludefever,weightloss,arthralgia,rash,clubbing,Raynaudphenomenon,hyper-gammaglobulinemia,anemia,polycythemia,thrombocytosisorthrombocytopenia,etc.

○ Diagnosis:2Decho,CTorMRItodeterminesize,shape○ Treatment:Surgicalexcision

Contd...

tahir99 - UnitedVRG


FMge questions

1. Which of the following subtype of lung carcinoma produces superior vena cava syndrome most com-monly: (Sep 2008)

a. Small cell carcinoma b. Adenocarcinoma c. Anaplastic carcinoma d. SquamouscellcarcinomaAns: a (Small cell cancer)

2. Vein used in bypass surgeries is: (Sep 2006)

a. Longsaphenousvein b. Shortsaphenousvein c. Cephalicvein d. none Ans: a (Long saphenous vein)

tahir99 - UnitedVRG

20Burns and CosmetiC surgery

Burns○ Effects of burns: Burnscausedamageinanumberofdifferentways,butbyfarthemostcommonorganaffectedistheskin

respiratory system○ WarningsignsofburnstotherespiratorysystemBurnsaroundthefaceandneckAhistoryofbeingtrappedinaburningroom

Changeinvoice Stridor

Dangers of smoke inhalationInhaledhotgasescancausesupraglotticairwayburnsandlaryngealedema

Inhaledsteamcancausesubglotticburnsandlossofrespiratoryepithe-lium

Inhaledsmokeparticlescancausechemicalalveolitisandrespiratoryfailure

Inhaledpoisons,suchascarbonmonoxide,cancausemetabolicpoisoning

Fullthicknessburnstothechestcancausemechanicalblockagetoribmovement

Metabolic problems following burns○ Burns produce an inflammatory reaction○ Thisleadstovastlyincreasedvascularpermeability○ Water,solutesandproteinsmovefromtheintratotheextravascularspace

○ Thevolumeoffluidlostisdirectlyproportionaltotheareaoftheburn

○ Above15%ofsurfacearea,thelossoffluidproducesshock

Contd...

tahir99 - UnitedVRG

235Burns and Cosmetic Surgery

BurnsOther complications of burns• Infectionfromtheburnsite,lungs,gut,linesandcatheters• Malabsorptionfromthegut

• Circumferentialburnsmaycompromisecircula-tiontoalimb

MajOr DeterMinants Of the OutcOMe Of a Burn• Percentageofsurfaceareainvolved • Depthofburns • Presenceofaninhalationalinjury

criteria for admission to a burns unit schwartz mentions the area○ Suspectedairwayorinhalationalinjury○ Anyburnlikelytorequirefluidresuscitation○ Anyburnlikelytorequiresurgery○ Patientswithburnsofanysignificancetothehands,face,feetorperineum○ Patientswhosepsychiatricorsocialbackgroundmakesitinadvisabletosendthemhome

○ Anysuspicionofnon-accidentalinjury○ Anyburninapatientattheextremesofage○ Anyburnwithassociatedpotentiallyserioussequelaeincludinghigh-ten-sionelectricalburnsandconcentratedhydrofluoricacidburns

○ Partialthicknessandfullthicknessburnstotaling>10%totalbodysurfacearea(TBSA)under10yearsage

○ Partialthicknessandfullthicknessburnstotaling>20%TBSAinotheragegroup.

○ Fullthicknessburns>5%TBSAinanyagegroup

○ Anyburnsinface,hands,feet,genitalia,perineumandmajorjoint

assessing the area of a burn

○ Thepatient’swholehandis1%TBSAandisausefulguideinsmallburns

○ TheLundandBrow-derchartisusefulinlargerburns

○ Theruleofninesisadequateforafirstapproximationonly

Ruleofnine(Alexander-Wallacerule)

o Eachupperlimb—9%TBSAo Eachlowerleg—18%TBSAo Anteriororposteriortrunk—18%TBSAo Headandneck—9%TBSAo Perineum—1%TBSAo Inchildrenheadandneckisrelativelylargemayaccountfor18%–21%

o Infants—21%TBSA

Contd...

tahir99 - UnitedVRG


superficial Burns have capillary filling○ Deeppartialthicknessburnsdonotblanch,buthavesomesensation

○ Fullthicknessburnsfeelleatheryandhavenosensation

Degrees Of Burns○ First degree involvesonlyepidermis○ Second degree involvesepidermisandsomepartofdermis.(alsoknownaspartialthicknessburns)

○ Furtherdividedinto:Superficialseconddegreeorsuperficialpar-tialthicknessinvolvesupperpartofdermis

Deepseconddegreeordeeppartialthick-nessextendsuptoreticularlayerofdermis. ○ Third degree orfullthicknessburnsinvolvesfullthicknessofdermis

○ Fourth degree burnsinvolvessubcutaneousfatanddeepstructures

first degree second degreesuperficial

second degreedeep

third degree

NoblisterformationBlanchtotouchPainfulHealwithoutscarringin5–10days

Blisters formedBlanchtotouchPainfulHealwithoutscarringin7–14days

BlistersseenMottledpinkandwhitecolorbecauseofvaryingbloodsupplytodermis

Pain is absentHeals with scar 3-9 week

Eschar formationBlackorbrownPainlessHealswithwoundcontractureorbysplitskingraft(SSG)only.

ManageMent Of Burnsimmediate care follow-up care○ Sedation○ Analgesicsandantibiotics○ Fluidresuscitation○ Escharotomy

○ Dressing○ Woundcover○ Latecare○ Skingrafting○ Contracturerelease

fluids for resuscitation ideal fluid○ Inchildrenwithburnsover10%TBSAandadultswithburnsover15%TBSA,considertheneedforintravenousfluidresuscitation

○ Iforalfluidsaretobeused,saltmustbeadded○ Fluidsneededcanbecalculatedfromastandardformula○ Thekeyistomonitorurineoutput

○ Therearethreetypesoffluidused.ThemostcommoniscrystalloidsCrystalloids:RingerlactateorHartmannsolution;Colloids:Humanalbuminsolutionorfresh-frozenplasma

Somecentersusehypertonicsaline.

about crystalloids hypertonic saline colloids○ Ringerlactateisthemostcommonlyusedcrystalloid.Crystalloidsaresaidtobeaseffectiveascolloidsformain-tainingintravascularvolume

○ Hypertonicsalinehasbeeneffectiveintreatingburnsshockformanyyears.Itproduceshyperosmolarityandhypernatremia

○ Plasmaproteinsareresponsiblefortheinwardoncoticpressurethatcounteractstheoutwardcapillaryhydrostaticpressure

Contd...

tahir99 - UnitedVRG


ManageMent Of Burnsabout crystalloid hypertonic saline colloids○ Theyarealsosignificantlylessexpen-sive

○ Anotherreasonfortheuseofcrystal-loidsisthatevenlargeproteinmol-eculesleakoutofcapillariesfollowingburninjury;however,non-burntcapillariescontinuetosieveproteinsvirtuallynormally

○ Thisreducestheshiftofintracellu-larwatertotheextracellularspace

○ Advantagesincludelesstissueedemaandaresultantdecreaseinescharotomiesandintubations

○ Withoutproteins,plasmavolumeswouldnotbemaintainedastherewouldbeedema

○ Proteins should be given after the first 12 hours of burn because,beforethistime,themassivefluidshiftscauseproteinstoleakoutofthecells

parkland formula Muir and Barclay formula○ TBSA%×weight(kg)×4=volume(mL)needed○ Halfofthisvolumeisgiveninthefirst8hoursandthesecondhalfisgiveninthesubsequent16hours

○ Thevolumereplacementisbycrystalloid

○ Thecommonestcolloid-basedformulaistheMuirandBarclayformula:

0.5×percentageofbodysurfaceareaburnt×weight=oneportion;periodsof4/4/4,6/6and12hourrespectively;oneportiontobegivenineachperiod

Maintenance○ Thekeytomonitoringofresuscitationisurineoutput.○ Itshouldbebetween0.5and1.0mL/kg/1bodyweightperhour.○ Iftheurineoutputisbelowthis,theinfusionrateshouldbeincreasedby50%

escharotomy○ Circumferentialfullthicknessburnstothelimbsrequireemergencysurgery

○ Thetourniqueteffectofthisinjuryiseasilytreatedbyincisingthewholelengthoffullthicknessburns.

○ Thisshouldbedoneinthemidaxialline,avoidingmajornerves.

level of escharotomies • Upper limb: Midaxial,anteriortotheelbowmediallytoavoidtheulnarnerve• Hand: Midlineinthedigits• Lower limb midaxial:Posteriortotheanklemediallytoavoidthesaphenousvein

• Chest:Downthechestlateraltothenipples,acrossthechestbelowtheclavicleandacrossthechestatthelevelofthexiphisternum

tOpical treatMent• Wounddressing• Vaselinedressingimpregnatedinchlorhexidine• Fenestratedsiliconesheet• Hydrocolloid dressings: Hydrocolloiddressingsneedtobechangedevery3–5days.Theyareparticularlyusefulinmixed-depthburnasthehighproteaselevelsundertheocclusivedressingsaidwiththedebridementofthedeeperareasofburn.Theyalsoprovideamoistenvironment,whichisgoodforepithelialization

• Biological, synthetic (e.g. Biobrane) and natural (e.g. amniotic membrane) dressings alsoprovidegoodhealing,theywillbecomedetachedifappliedtodeepdermalwoundsastheescharneedstoseparate.Theyarethere-forenotasusefulinmixed-depthwoundsandbetteronlyforsuperficialburnsasonestopmanagement

healing of a third degree burns Management of deep burns Delayed reconstruction of burns• Collagendressing• Grafting• Earlydebridementandgraftingisthekeytoeffectivelytreatingdeeppartialandfullthicknessburnsinamajorityofcases

• Meshedgrafts

• Deepdermalburnsneedtangentialshavingandsplit-skingrafting

• All,butthesmallestfullthicknessburnsneedsurgery

• Theanesthetistneedstobereadyforsignificantbloodloss

• Topicaladrenalinereducesbleeding• All,burnttissueneedstobeexcised• Stablecover,permanentortempo-rary,shouldbeappliedatoncetoreduceburnload

• Eyelidsmustbetreatedbeforeexpo-surekeratitisarises

• TranspositionflapsandZ-plastieswithorwithouttissueexpansionareuseful

• Full-thicknessgraftsandfreeflapsmaybeneededforlargeordifficultareas

• Hypertrophyistreatedwithpressuregarments

• Pharmacologicaltreatmentofitchisimportant

Contd...

tahir99 - UnitedVRG


cOsMetic surgeryMethods of wound closure

1.Graft: Itisone,whichistakenfromonesiteandkeptinanothersite,ithasnoownbloodsupplyandhastoderiveitsbloodsupplyfromtherecipientsite.

2.Flaps:Itisone,whichcarriesitsownbloodsupplywithittocovertherecipientsite.

facts aBOut skin grafts• Skingraftstakeswellovergranulationtissue,muscleandfat

• Itwouldnotadhereonbone,tendonandcartilagedevoidofperiosteum,paratenonandperichondriumrespec-tively.

two types of skin graft1.Fullthicknessuptothefulldermis—Wolfe graft2.Partialthickness:uptosuperficiallayerofdermis—Thiersch graftInpartialthicknessgraftasweareleavingapartofthedermis,skingrowsbyitselfandnoneedofanyclosureofthedonorsite

Infullthicknessgraftasthereisnodermisskincannotgrowtheresowehavetoclosethedonorsitebysomeway

partial thickness (thiersch) full thickness (Wolfe)• Easyuptakeandsurvival• Largegraftscanbederived• Samesitegraftcanbetaken• Cosmeticallyunacceptable• Donorsitehealswithoutcontarction• MCsiteisthigh

• Uptakeisdifficult• Onlysmallgraftscanbetaken• Cosmeticallygood• Donorsitehastobeclosedorelseitwillhealwithcontracture.• MCsiteisbehindear

cannOt We graft every WOunD? Why DO We neeD flaps?• Foragrafttosurviveavascularbedisamust• Ifawoundcangranulateandtheextrawaitingdoenotdamageexposedtissuesonecannotforagraft

• Ifwoundisincapableofgranulatingorifwaitingisharmfulaflapshouldbeused

• Exposedpacemaker• Radiationnecrosis• Heelpadavulsion—exposedcalcaneus

types Of flaps1.Pedicle flap:Theflap,whichhasitsownbloodsupplywithanamedbloodvesselisusedtocoveraexposedarea.

2.Free flap:Thisisatypeofflap,whichhasitsownbloodves-sel,buthastoundergomicrovascularanastomosiswithanybloodvesselneartherecipientarea

axial anD ranDOM flaps• Ifthebloodsupplyisnotderivedfromarecognizedartery,butrathercomesfrommanylittleunnamedvessels,theflapisreferredtoasarandom flap.Manylocalcutaneous(skin)flapsfallintothiscategory

• Ifthebloodsupplycomesfromarecognizedarteryorgroupofarteries,itisreferredtoasanaxial flap.Mostmuscleflapshaveaxialbloodsupplies

○ Rotation:Coverwoundsofvarioussizes○ Commonuse:Sacralpressuresores

○ Transposition:Usefulwhennotenoughlaxityofsurround-ingtissuetocreateothertypesofflaps

Contd...

tahir99 - UnitedVRG


axial anD ranDOM flaps○ Z-plasty:Usedtoreorientandlengthenascarattheex-penseofwidth(releasescarcontractures)

○ Commonuse:Dupuytrendisease

Advancement flaps (single/bipedicle, V-Y, Y-V)V-Yflaps:Woundswithlaxsurroundingtissue;thepedicleisthedeeptissueunderlyingtheflap

lOcal flap• Transpositionflap • Advancementflap • B/Lgluteusmaximusmyocutaneous

V-Yadvancementflap

terMs in plastic surgery• Plasma imbibition—graftsurvivesuptofirst48hourbyplasmaimbibition,absorptionofnutrientsintograft.

• Inosculation—designatestheperiodinwhichthedonorandrecipientcapillar-iesbecomealigned.

• Revascularization and angiogenesis—afterapproximately5dayrevasculari-zationoccursandgraftdemonstratesbotharterialandvenousoutflow.

time of each process • Plasmaimbibtion—upto24hours• Inosculation—24–72hours• Revascularization—after72hours

cleft lip/palate○ Thetypicaldistributionofclefttypesis:Cleftlipalone:15%Cleftlipandpalate:45%Isolatedcleftpalate:40%

• Cleftlipwithpalatepredominatesinmales • Whereascleftpalatealoneappearstobemorecommonin

females. • Inunilateralcleftlipthedeformityaffectstheleftsidein60%ofcases.

associated syndromes • PierreRobinsequenceremainsthemostcommonsyn-drome

• Stickler(ophthalmicandmusculoskeletalabnormalities),• Shprintzen(cardiacanomalies)• Downsyndrome• ApertandTreacher–Collinssyndromesaremostfrequentlyencountered

types

timing of surgery rule of 10 lip for cleft lip repair• Closureofcleftpalateshouldbedoneat6 month ageasitaidsinchildfeeding

• Pharyngealflapoperationisoperationofchoice• LangenbachoperationandWardilloperation

• Weightofbabyis10pound• Hemoglobinis10gm%• Ageof10week

Contd...

Contd...

tahir99 - UnitedVRG


cleft lip/palatetiming of repair for cleft lip alone

cleft lip alone timing○ Unilateral (one side) Oneoperationat5–6months○ Bilateral (both sides) Oneoperationat4–5months

timing of repair for cleft palate alone○ Soft palate alone Oneoperationat6months○ Soft and hard palate Twooperations Softpalate—6months

Hardpalate—15–18months

cleft lip and palatetypes timingUnilateral Twooperations Cleftlipandsoftpalateat5–6months

Hardpalatewithgumswithorwithoutrevisionoflipat15–18monthsBilateral Twooperations Cleftlipandsoftpalateat4–5months

Hardpalatewithgumswithorwithoutrevisionoflipat15–18months

DnB questiOns

1. Late deaths in burns is due to: a. Sepsis b. Hypovolemia c. Contracture d. NeurogenicAns: a (Sepsis)

2. An adult with both lower limb charred with exter-nal genitalia the percentage of burns is:

a. 18% b. 19% c. 36% d. 37%Ans: d (37%)

3. Sepsis in burns cases is due to: a. Proteus b. Pseudomonas c. Pneumococci d. StaphylococciAns: b (Pseudomonas)

4. In burns heat loss is due to: a. Dilatationofveins b. Exposedareabyevaporation c. Shock d. NoneAns: b (Exposed area by evaporation)

5. In second degree burns, re-epithelialization oc-curs around:

a. 1week b. 2weeks c. 3weeks d. 4weeksAns: c (3 weeks)

6. Late deaths in burns is due to: a. Sepsis b. Hypovolemia c. Contracture d. NeurogenicAns: a (Sepsis)

7. An adult with both lower limb charred with exter-nal genitalia the percentage of burns is:

a. 18% b. 19% c. 36% d. 37%Ans: d (37%)

8. In burns, which of the following is the medium of choice:

a. Dextrose b. Ringerlactate c. IsolyteM d. GlucoseAns: b (Ringer lactate)

tahir99 - UnitedVRG


9. All of the following are true regarding fluid resus-citation in burnt patients, except:

a. ConsiderIVresuscitationinchildrenwithburnsgreaterthan15%

b. Oralfluidsmustcontainsalts c. MostpreferredisRingerlactate d. Halfthefluidcalculatedisgivenin8hours.Ans: a (Consider IV resuscitation in children with burns greater than 15%)At 10% in children and 15% in adults fluid must be given

10. Within 48 hours of transplantation the graft sur-vives due to:

a. Amountofsalineingraft b. Plasmaimbibition c. Newvesselsgrowfromdonorsite d. Connectionbetweendonorandrecepientcap-

illariesAns: b (Plasma imbibition)

11. Ideal graft for leg injury 10*10 cm raw area expos-ing bone is:

a. Amnioticmembranegraft b. Pedicleflap c. SSGfullthickness d. PartialthicknessflapAns: b (Pedicle graft)Skingraftisabsolutelycontraindicatedwithinfectionsofstreptococci

12. True statement of axial flap is: a. Carriesitsownvesselswithinit b. Keptinlimb

c. Transverseflap d. CarriesitsownnervesupplyAns: a (Carries its own vessels within it)

13. Full thickness grafts can be taken from the follow-ing sites, except:

a. Elbow b. Backofneck c. Supraclavicularfossa d. UppereyelidsAns: None Fullthicknessgraftforfaceistakenfrombehindearandsupraclavicularareaforcolormatch.

14. What is the appropriate age for repair of cleft pal-ate?

a. 6monthsto1year b. 12to15month c. Atpuberty d. JustbirthAns: a (6 month to 1 year)

15. A midline cleft palate is due to failure of fusion between:

a. Maxillaryprocess b. Medialnasalprocess c. Medialandlateralnasalprocess d. Medialnasalandlateralmaxillaryprocess.Ans: a (Maxillary process)EmbryologyPremaxilla—medialnasalprocessPalatineprocess—derivedfrommaxillaryprocessSecondary palate: Fusion of twopalatine process (de-rivedfrommaxillaryprocess)andpremaxilla.Defectofthisresultsincleftpalate.

fMge questiOns

1. All of the following are true regarding fluid resus-citation in bum patients, except: (Sep 2009)

a. Considerintravenousresuscitationinchildrenwithburnsgreaterthan15%TBSA

b. Oralfluidsmustcontainsalts c. MostpreferredfluidisRingerlactate d. Halfofthecalculatedvolumeoffluidshould

begiveninfirst8hours

Ans: a (Consider intravenous resuscitation in children with burns greater than 15% TBSA)Explanation:

• IVresuscitationforchildrenwithburnsgreaterthan10%andforadultsabove15%

• Parklandformula—halfthecalculatedvolumegivenin8hoursandremaininghalfin16hours

tahir99 - UnitedVRG


2. According to 'rule of nines', burns involving peri-neum are: (Sep 2002, 2009)

a. 1% b. 9% c. 18% d. 27%Ans:a(1%)Explanation:*Wallaceruleof9%–1%forperinealburns

3. Which of the following is not seen in third degree burns: (Sep 2009)

a. Lossofskinappendages b. Novesicles c. Redcolor d. ExtremelypainfulAns: d (Extremely painful)Explanation:Thirddegreeburns(fullthicknessburns)•Involvesfulldermis•Escharformationiscommon•Painlessburns

4. In second-degree burns, re-epithelialization oc-curs around: (Sep 2008)

a. 1week b. 2weeks c. 3weeks d. 4weeeksAns : c (3 weeks)(Ref: Bailey and Love, 25th Edn, Page 382)Explanation:*Superficialpartialthicknessburns(2degree)—healsat2weeks*Deeppartial, thickness (third degree)—heals at 3 ormoreweeks

5. Which of the following is false regarding deep second degree burns: (Sep 2011)

a. Healbyscardeposition b. Painless c. Damagetodeeperdermis d. LessblanchingAns: d (Less blanching) (Ref: Bailey and Love, 25th Edn, Page 382• Thecolorofdeeppartialthicknesswillnotblanchun-dertheexaminersfingersonpressureunderexamin-ersfingers

• Deepdermalthicknessburnshealswithhypertroph-icscar.

• Sensationisreduced.Patientisunabletodistinguishsharpfrombluntpressurewhenexaminedwithnee-dle.

6. In bums management, which of the following is the medium of choice: (Sep 2008)

a. Dextrose5% b. Normalsaline c. Ringerlactate d. Isolyte-MAns: c (Ringer lactate)(AlreadyexplainedinTopic)

7. Graft is not taken up by the following tissue: (Sep 2011) a. Fat b. Muscle c. Skullbone d. DeepfasciaAns: c (Skull bone)

8. Most common congenital anomaly of the face is: (Sep 2011) a. Cleftlipalone b. Isolatedcleftpalate c. Cleftlipandcleftpalate d. AllhaveequalincidenceAns: c (Cleft lip and cleft palate)

9. Not seen in third degree burns. (Sep 2009) a. Novesicle b. Redcolor c. Painful d. LossofskinappendagesAns: c (Painful)

10. Palmar surface of hand corresponds to: (Sep 2010) a. 1%oftotalbodysurfacearea b. 2%oftotalbodysurfacearea c. 3%oftotalbodysurfacearea d. 4%oftotalbodysurfaceareaAns: a (1% of total body surface area)

11. In burns management (within 24 hours), which of the following is the medium of choice:

(March 2011) a. Dextrose5% b. Normalsaline c. Ringerlactate d. Isolyte-MAns: c (Ringer lactate)

tahir99 - UnitedVRG


12. A patient with burns die within 24 hours. What could be the most probable cause: (Sep 2011)

a. Circulatoryshock b. Physicalburninjurytotheairwaysabovethe

larynx c. Physicalburninjurytotheairwaysbelowthe

larynx d. CircumferentialburnAns: a (Circulatory shock) 13. Initial method to prevent infection in burm pa-

tients: (Sep 2011) a. Physiotherapy

b. Intravenousantibiotics c. Handwashing d. TopicalantibioticsAns: b (Intravenous antibiotics)

14. False statement about cleft palate repair is: (March 2011) a. Hemoglobinshouldbe10gram% b. Weightshouldbe10pounds c. Repairedimmediatelyafterbirth d. 2stageprocedure,ifassociatedwithcleftlipAns: c (Repaired immediately after birth)

tahir99 - UnitedVRG

21Vascular surgery

Venous systemVaricose veins

Etiology• Morecommoninwomen*• Morecommoninjobshavingprolongedstand-ing,e.g.policeman,petrolbunkworkers,tramdrivers,etc.

Causes for secondary varicose veins 1. Obstruction to venous out flow:PregnancyPelvicmass(ovary,fibroid)AbdominallymphadenopathyAscitesRetroperitonealfibrosisIliacveinthrombosis

2.Destruction of valves due to deep vein throm-bosis:OralcontraceptivepillsProgesterone

3.High pressure flow:Arteriovenous(AV)fistula

tests for VariCose Veins• Brodie-Trendelenburg test:Test1todiagnosesaphenofemoral(SF)incompetenceandtest2todiagnoseperforatorincompetence.

• Morrissey coughimpulse:SFjunction• Fegan test:Blowouts(weakperforators)

tahir99 - UnitedVRG

245Vascular Surgery

short saphenous inCompetenCyKlippel-trenaunay sydnrome Venous ulcer : (stasis ulcer)1.Abnormallateralvenouscomplex(shortsaphenous)2.Capillarynevus3.Bonyabnormalities4.Aplasiaofdeepveins5.Limblengthening.○ It is a mesodermal abnormality and not familial

• Site: Lowerone-thirdmedialsideofleg• Size: Variable• Shape: Ovaltocircular • Margin: Well-defined • Edge: Slopingedge(healing) • Floor: Formed by deepfascia• Surrounding:Pigmentation,eczema,varicosity• Base: Extenduptoperiosteum. • Deformity: Talipesequinovarus

Lipodermatosclerosis Complications of venous ulcer• Progressivesclerosisoftheskinandsubcutaneoustissuemayoccurduetofibrindeposition,tissuedeathandscarringduetochronicvenoushyper-tension.

○ Ulcercomplicatesvaricoseveininabout5%ofthepeople.○ Marjolin’s ulcer*:Malignantchangeinlong-standingvenousulcertosqua-mouscellCa.

○ Periosteitis tibia:Occursinlong-standingulceronmedialsurfaceoftibia.○ Equinus deformity:Walkingontoerelievespain,sopatientcontinueswalkingresultinginshorteningoftendo-Achilles

perforator inCompetenCei. Subfascial ligation of Cockett and Dodd:PreferableincasesoflipodermatosclerosisLongincisionmadetoopenthedeepfasciaandtheperforatorsareligateddeeptodeepfascia

ii.Suprafascial ligation of Linton:Thereshouldnotbelipodermatosclerosis Perforatorsareligatedabovethedeepfasciaiii. Subfascialendoscopicperforatorsurgery(SEPS)○ Nerveatriskduringgreatsaphenousvein(GSV) stripping issaphenousnerve○ Toavoidinjurydonotstripbeyondthemidcalflevel○ Nerveatriskatstripping of small saphenous vein (SSV) issuralnerve

Deep Vein thrombosis• MCcause—hospitaladmissionformedicalorsurgicalconditions• E-thrombosis:Thrombosisdevelopinginpeoplesittingattheircomputerforlongtime.• Bilateraldeepveinthrombosis(DVT)isseenin30%cases.SignsofDVT• Homan’s sign—forceddorsiflexion • Mosse’s sign—calftenderness • Pratt’s sign—calftendernesson

pressingfromsides

tahir99 - UnitedVRG


• Modified Perthes test—elastocrepebandagetesttodiagnoseDVT.

VirChow’s triaD• Endothelialdamage• Stasis• Increasedcoagulabilityofblood

Clinical featuresMCpresentation—painandswellingincalf.

treatment• Startheparinimmediately,followedbywarfarin10mg/day1,2and5mgfromday3• Thrombolysisisindicatedifthereisiliacveininvolvement• Surgicaltreatment:Palma operationIncasesofDVToftheexternaliliacveinononeside,thecontralateralsaphenousveinisanastomosedtothefemoralveinontheaffectedsitebelowthelevelofocclusionorstenosis.

Latest treatments to varicose veins○ Endovenous ablation of the GSV using radiofrequency (RF) or laser without high ligation is becoming a less invasive

alternative to ligation and stripping. ○ Endoscopicvenouslaserablation:EVLA○ TheELAS:VNUSclosure○ Ultrasound-guidedfoamsclerotherapy

Contd...

tahir99 - UnitedVRG

247Vascular Surgery

VirChow’s triaDsclerosants used

• Ideallypolidocanolisusedforultrasonography(USG)guidedfoamsclerotherapy.

• Complicationsoffoamsclerotherapy:CutaneousulcerationDVTifitentersdeepveinSevereheadaches(duetoairenteringheartandthentobrain)

TransientblindnessStroke

few Line about DupLex sCan○ ThebestinvestigationtodiagnosethevenousincompetencyandDVTisduplex(B-modecolorUSG)○ OnpressingtheveinsinthecalfandhavingtheprobeattheSFjunction○ Inference:Upwardflowofveinsisindicatedbyblue colorOnreleasingthepressurethereisnoreflux,whichwhenpresentisindicatedbyred color.

points from baiLey anD LoVe• Thecompressionstockingsusedforvaricoseveins

Class 2 stockings with30mmHgatankleand10-15mmHgatkneelevel.

• MostcommonlyuseddrugforinjectionsclerotherapyisSodium tetradecyl sulfate

• BestagentforfoamsclerotherapyisPolidocanol • M/canomalyofGSV—doublesaphenousvein

• M/ccomplicationofvaricoseveinsurgeryrecurrence.• M/csiteofaplasiaofvenoussystemisIVC• M/csiteofdeepveinthrombosisiscalf veins• May-Thurner and Cockett syndrome alsocalledasiliacveincompressionsyndrome:Membranousocclusionofleftcommoniliacveinwhenitpassesbehindtherightcommoniliacartery.

arteriaL systemaneurysm abdominal aortic aneurysm• MCsiteoflargevesselaneurysmisabdominalaorticaneu-rysm

• MCsiteofperipheralaneurysmispoplitealartery

• 95%aneurysmsareinfrarenal• Siteofrupture:m/csite=posterolateral(80%)• 2ndm/csite=anterior

Contd...

Contd...

tahir99 - UnitedVRG


arteriaL systemIndications for surgery • Allsymptomaticaneurysm(m/csymptomisbackandabdominaldiscomfort)• Aneurysmsizeis>55 mm* onUSGanteroposteriorly.

postoperative complication• MCisrespiratory—lowerlobeconsolidation,atelectasisandshocklungandcardiac—ischemiaandinfarction• Colonicischemiain10%cases—resolvesspontaneously*• Recentadvance—endovascularrepair

popLiteaL artery aneurysm• MCperipheralarteryaneurysm(70%)• Two-thirdbilateral• One-thirdaccompaniedbyaorticdilatation

• Complication—thrombosisfollowedbydistalischemiculceration• Indicationforsurgery—size>25mm• MCperipheralarteryaneurysm

○ Hunterian ligature: Ligationofthearteryproximaltotheaneurysmabovethefirstcollateral

myCotiC aneurysm• Misnomercausedbyinfectionduetostaphylococcal.• MCsiteisfemoralarteryfollowedbyaorta.

• MCcauseistraumafollowedbybacteremia• Falseaneurysm

amputationsConebearing(prosthesispossible)

Endbearing(wherelimbfittingfa-cilitiesarelimited)

• Belowknee(stump=8cmpreferably10-12cmbelowknee)

• Aboveknee(stump=20cmaboveknee)

• Gritti-stokes(transcondylaratlowerfemur)

• Throughknee• Symeamputation(tibiaandfibulaaresectionedabovetheanklejointpreserv-ingbloodsupplytocalcaneus)

Contd...

Contd...

tahir99 - UnitedVRG

249Vascular Surgery

amputations• ThroughAnkle(Syme)notsuitableforseverelyischemiclimbsbecauseofpoorhealingofflap• Lisfranc’s(tarso–metatarsal)

GanGrene• Wet (moist) Infectionandputrefactionarepresentwithinfectionpredominant,e.g.diabetic

• Drydryandwrinkledgangrene,e.g.atheromatous

arteriaL stenosis anD oCCLusion○ MCcauseatheromaIntermittentclaudication:• Broughtbywalking• Notpresentontakingfirststep(dd.Osteoarthrosis)• Relievedbystanding(dd.Lumbarandnerveproblems)

• MCsiteofclaudicationiscalf• Lerichsyndromebuttockclaudication+sexualimpotency

Choice of procedures Graft material• Aortofemoral• Femeropopliteal• Femorodistal• Axillobifemoral bypass:○ Salvageprocedureforpoorriskpatientswithbilateraliliacarteryocclusionusingalongprostheticgraft.

○Rememberitshouldnotbedoneforintermittentclaudica-tion.Itisadvisedonlyforimpendinggangrenecases

Best grafts• Superficialfemoralarteryocclusion—saphenousvein*• Infrapoplitealocclusions—saphenousvein*• AortoiliacDacron*Best materials• Aorta—2/0and3/0prolene• Femoral—4/0and5/0• Infrapopliteal—7/0prolenes

subCLaVian aneurysm• Occlusionoffirstpartofsubclavianarteryresultsinsubclavianstealsyndrome=vertebralarteryprovidingacollateraltoarmwithresultantcerebralischemia

ainhum• Usuallyaffectsblackmen• Barefootwalkers• Afissureappearsatthelevelofinterphalangealjointofatoe,littletoe• ComplicationNecrosis• Z-plastyandamputation.

seLDinGer’s teChnique• RetrogradeSeldingertechniqueisusedtoenterthevesselbypercutaneouspuncturetechnique• Usedforvariousdiagnosticandtherapeutictechniques• Especiallyforpercutaneoustransluminalangioplasty(PTA)forocclusionandstenosis

Contd...

tahir99 - UnitedVRG


buerGer’s Disease/thromboanGitis obLiteransshionaya criteria Clinical features• H/osmoking• Onsetbeforeageof50year• Infrapoplitealarterialocclusion• Eitherarminvolvementorphlebitismigrans• Absenceofriskfactorsforatherosclerosisotherthansmoking

• M/cinyoungmales(40–45years)• Claudicationoffeet,legsorarms,hands• Superficialthrombophlebitis(40%)• There will be involvement adjacent veins and nerves*• Onexaminationpoplitealpulseispresentandtherewillbeabsentdorsalispedisandanteriortibialonbothsides(bilateral)

investigations• Absence of other risk factors likediabetes,hypertensionandhypercholesterolemiamustberuledout• Angiographyshowstreeroot/spiderlegorcorkscrewcollaterals.

Lumbar sympatheCtomyprinciples indications○ Increasebloodflow(byvasodilatation)○ Nutritivevalueforsmallulcers○ Reducesischemicrestpain○ Noeffectoncollateralcirculation

○ Restpain*○ Ulcers*○ Superficialgangrene*○ Notusefulforintermittentclaudication**○ ContraindicatedifABPI>0.3andindiabetics**(Diabeticshaveautonomicneuropathyalreadysotherewouldnotbeanybenefitonsympathectomy)

Ganglia removed Cervicodorsal sympathectomy• L2andL3ganglionectomyadvised• IfL1isremovedpreserveitforatleastforoneside(retrogradeejaculationoccurs)

• Treatmentofpalmarhyperhidrosis*• T1,T2andT3removedpreservingthestellateganglion*(Hornersyndrome—ptosis,miosis,enophthalmosisandanhydrosisonremovalofstellateganglion*)

raynauD Disease• Primary—Idiopathic(Raynauddisease)**• Secondary—Raynaud’sphenomenonsecondarytoscleroderma,SLEandrheumatoidarthritis.

• Vibratingwhitefinger—secondaryRaynaudsyndromefollowusingvibratingtoolsinfactory.

Clinical features:• 70%–90%inyoungfemales• Upperlimb*m/caffected• AbnormalsensitivitytocoldStages:1.Localsyncope—white,

2.Localasphyxia—blue3.Recovery—crimsonred

Treatment○ Raynaud disease:Protectfromcold,avoidnailinfections,nifedipine,cervicodorsalsympathectomy

○ Raynaud syndrome treatthecause

acrocyanosis• ConfusedwithRaynaud,buttheimportantdifferenceisitispainlessandnotepisodic**

tahir99 - UnitedVRG

251Vascular Surgery

arterioVenous fistuLa• Abnormalcommunicationbetweenarteryandveineithercongenitaloracquired.• MCcauseforacquiredAVfistula—penetratingtrauma**

• MCcauseoverallissurgicallycreated**• Localgigantism

Changes Clinical features○ Structurally:Veinsaredilatedandtortuouswiththickwalled(arterialized)

○ Physiologically:Increasedvenousreturn,increasedpulserate,increasedpulsepressure,increasedcardiacoutput.

○ Localgigantism,ulcersandbleeding

PulsatilesuperficialswellingContinuousthrill(machinerymurmur)Nicoladoni sign or Branham sign**:Pressureproximaltofistulacausestheswellingtodiminishinsize,thrillandbruittoceaseandpulse rate slows (bradycardia)*

points from bailey and LoveDisappearing pulse:Incasesofstenosisorocclusionofvesselwhenthepatientexercisesthealreadypalpablepulsesgoesimpalpable.Thisisduetodilatationofvesselsonexercises.

Renal artery stenosis:PTAisprocedureofchoiceFogarty catheter isusedtoremovetheintra-arterialemboli.Air embolism treatment:Trendelenburgheaddownposition,placethepatientinleftlateral,airaspirationvialeftcostalmarginandnasaloxygen.

Parasites causing embolus:OvaofTaenia echinococcusandfilariasanguinishominis.Materialsusedfortherapeutic embolization : Gelfoamsponge,plastic,balloons,ethylalcoholandmetalcoils.

LymphatiC systemLymph edema

• MCcauseoflymphedemainIndia/alloverworld=filariasis* • MCcauseofupperlimblymphedema=filarial*• Classifiedintoprimaryandsecondary

types of primary lymph edemaCongenital Lymph edema praecox Lymph edema tarda ○ Onset<1year○ MCbilateral*○ Involvewholeleg○ Milroy disease*

○ Onset1–35years○ MCprimarylymphedema○ MCinwomen○ MCunilateral*○ Mostlyinvolvebelowkneesonly○`Meig disease*

○ Onset>35years

features○ Stemmers sign*—inabilitytopinchsubcutaneoustissueinlymphedema

treatment of established lymph edematypes of stockings Drugs bypass proceduresClass3—40–50mmHgstockings

Class4—50–60mmHgstockings

InUKonlydrugapprovedforvenous disease isoxerutin (paroven)andnodrugisapprovedforlymphedema

Benzypyronesarenaturaldrugusedforlymphedema

Neibulouwitz—anastomosisofnodestovein(lymphovenousanastomosis)

Kinmonth—usingilealmucosalpatchGillies—skinbridge.

tahir99 - UnitedVRG


Limb reDuCtion proCeDures○ Charles—wholesubcutaneousandslimexcuseduptodeepfasciaandSSGdone

○ Sistrunk—wedgeexcisionofskinandsubcutaneoustissueandwoundclosedprimarily.

○ Homans—skinflapraised,subcutaneoustissueremovedMostsatisfactoryoperationMaincomplicationisskinflapnecrosisContraindicatedinpresenceofvenousobstructionandmalignancy

○ Thompson—burieddermalflap.Commoncomplicationofthisprocedureispilonidalsinus.

points for memory○ Butchersthighisduetoinjurytofemoralarteryinfemoraltriangle

aneurysms types of aneurysms• Mostcommontypeof‘trueaneurysm’isfusiformtype• Mostcommonsiteofarterialaneurysmisinfrarenalpartofabdominalaorta.

• Poplitealaneurysms*arethemostcommonperipheralaneu-rysms.

• Themostcommonsitefordissectinganeurysmsisascendingaorta*

• MCcauseforabdominalaorticaneurysmisatherosclerosis*• Cirsoidaneurysms”arecommoninsuperficialtemporalartery.

• Berryaneurysm:Occursincircleofwillis• Micro aneurysms:Seenindiabetesandhypertension• Mycoticaneurysms:Areseeninbacterialinfections.• Aorticdissectinganeurysms:Duetodegenerationoftunicamedia.OccurinMarfanssyndromeandhypertension.

• Syphiliticaneurysmsorlueticaneurysms:Involveascendingaorta’”

• Pseudoaneurysmsfollowtraumamostcommonly

fmGe questions

1. Superficial thrombophlebitis is seen in: (Sep 2009)

a. AVfistula b. Raynauddisease c. Buergerdisease d. AneurysmAns: c (Buerger disease)

2. Which of the following is associated with Vir-chows triad: (March 2011)

a. Hypercoagulability b. Disseminatedmalignancy c. DVT d. AlloftheaboveAns: d (All of the above)Virchow’s triad:• Hypercoagulability• Stasis• Endothelialdamage

3. Most common vessels to be affected in Buergers disease: (Sep 2009)

a. Femoralartery b. Iliacartery c. Poplitealartery d. AnteriorandposteriortibialarteryAns: d (Anterior and posterior tibial artery)

4. Drug used for sclerotherapy of varicose veins are all of the following, except: (Sep 2009)

a. Ethanolamineoleate b. Polidocanol c. Ethanol d. SodiumtetradecylsulfateAns: c (Ethanol)

5. Raynaud syndrome occurs in all of the following, except: (Sep 2011)

a. SLE b. Rheumatoidarthritis

tahir99 - UnitedVRG

253Vascular Surgery

c. Osteoarthritis d. ColdagglutinindiseaseAns: c (Osteoarthritis)Causes of secondary Raynaud syndrome Connectivetissuedisorders• Mixedorundifferentiatedconnectivetissuedisease• Polymyositis/dermatomyositis• RA• Sjögrensyndrome• SLE• SystemicsclerosisEndocrinedisorders• HypothyroidismHematologicdisorders• Coldagglutinindisease• PolycythemiaveraNeoplasticdisorders• Carcinoid• ParaneoplasticsyndromeNeurologicdisorders• CarpaltunnelsyndromeTrauma• Frostbite• VibrationVasculardisorders• ThoracicoutletsyndromeDrugs• β-blockers• Cocaine• Ergotpreparations• Nicotine• Sympathomimeticdrugs

6. All of the following are true regarding DVT, ex-cept: (March 2009)

a. Pulmonaryemboliistheimmediaterisk b. Mayleadtolunginfarction c. AssociatedwithdeficiencyofproteinC d. PriorhistoryofDVTisanimportantriskfactorAns: b (May lead to lung infarction)

7. Sequence of color changes observed in Raynaud disease: (Sep 2006)

a. Red,blue,white b. White,blue,red c. Blue,red,white d. White,red,blueAns: b (White, blue, red)(Pneumonic:WBC—white,blueandcrimsonred)

8. Buerger’s disease usually affects all of the follow-ing, except: (Sep 2005)

a. Small-sizedarteries b. Medium-sizedarteries

c. Largearteries d. DeepveinsAns: c (Large arteries)

9. Nicoladoni-Branham’s sign is seen in: (March 2011) a. Buergerdisease b. Arteriovenous(AV)fistula c. Raynaud’sdisease d. PeripheralaneurysmAns: b (AV fistula)

10. Which of the following is spared in lumbar sym-pathectomy: (Sep 2011)

a. L1 b. L2 c. L3 d. L4Ans. a (L1)

11. Seldinger needle is used for: (Sep 2010) a. Suturingmuscles b. Arteriography c. Pulmonarybiopsy d. LymphographyAns: b (Arteriography)

12. If a patient with Raynaud disease immersed his hand in cold water, the hand will: (2003)

a. Becomered b. Remainunchanged c. Turnwhite d. BecomeblueAns: c (Turn white)

13. The Hunterian ligature operation is performed for: (Sep 2003)

a. Varicoseveins b. Arteriovenousfistulae c. Aneurysm d. AcuteischemiaAns. c (Aneurysm)

14. Sympathectomy is indicated in all the following conditions, except: (Sep 2009)

a. Ischemiculcers b. Intermittentclaudication c. Anhidrosis d. AcrocyanosisAns. c (Anhidrosis)

15. Lumbar sympathectomy is of value in the man-agement of: (March 2011)

a. Intermittentclaudication b. Distalischemiaaffectingtheskinoftoes

tahir99 - UnitedVRG


c. Arteriovenousfistula d. BackpainAns: b (Distal ischemia affecting the skin of toes)

16. Drug used for sclerotherapy of varicose veins: (Sep 2007) a. Tetracycline b. Ethanolamineoleate c. Phenolinalmondoil d. AlltheaboveAns: b (Ethanolamine oleate)

17. Brodie-Trendelenburg test is positive in: (Sep 2010) a. Deepveinthrombosis b. Saphenofemoralincompetence c. Thromboangitisobliterans d. BelowkneeperforatorincompetencyAns: b (Saphenofemoral incompetence)

18. Buerger disease usually affects all the following, except: (Sep 2010)

a. Small-sizedarteries b. Medium-sizedarteries

c. Largearteries d. VeinsAns. c (Large arteries)

19. A 60-year-old male has been operated for carci-noma of cecum and right hemicolectomy has been done. On the 4th postoperative day, the patient develops fever, swelling and pain in the legs. The most important clinical entity one should look for is: (March 2011)

a. Urinarytractinfection b. Intravenouslineinfection c. Chestinfection d. DeepveinthrombosisAns: d (Deep vein thrombosis)

20. Test, which is not done for varicose veins: (March 2011 a. Perthes’test b. Tourniquettest c. Trendelenburgtest d. AdsontestAns: d (Adson test)

tahir99 - UnitedVRG

22OncOsurgery

EpidEmiology of common cancEr○ Overall,1:3peoplewilldevelopsomeformofcan-cerduringtheirlife

○ Therearemorethan200differenttypesofcancer○ Breast,lung,colorectalandprostatecanceraccountforover50%ofnewcases

ageCanceroccurspredominantlyinolderpeople65%casesarediagnosedovertheageof65yearLessthan1%occurinchildren Breastcanceraccountsfor50%ofallcancersdiag-nosed40–60year

men• Prostatecancerhasovertakenlungcancerasthecommonestcancerdiagnosedinmen

• IncidenceofprostatecancerisrisingduetothewidespreaduseofPSA

• Lungcanceristhesecondmostcommoncancer• Incidenceoflungcancerisfalling

WomenBreastcanceristhecommonestcancerinwomenAccountsfor30%ofallfemalecancerThesecondcommonestcancerinwomeniscolorectalcancer

TubErous sclErosis○ AlsoknownasBourneville’s disease* ○ Characterizedbycutaneouslesions,seizuresandmen-talretardation.

○ Calcifiedsubependymalnoduleischaracteristic.

○ Associatedlesionsinclude:Subependymalgiantcellastrocytoma.Rhabomyomasofthemyocardium.Angiomyomasofkidney,liver,adrenalandpancreas.

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


nEurofibromaTosis 1 (von rEcklinghausEn’s disEasE)○ Mchereditaryneurocutaneousdis-ease(Phakomatosis).

○ Autosomaldominant.○ Numerousneurofibromasinskinandperipheralnerves.

○ Cafealllaitspot(earliestmanifesta-tion).

○ Fordiagnosis≥6spotsof≥5mmprepubertal.≥15mmpostpubertal

○ Frecklinginseenexposedarea(mostcommonlyaxilla,Crowesign).○ MelanotichematomaofirisLISCHnodule○ Pseudoarthrosisoftibia○ PlexiformneurofibromatosisElephantmandisease○ Generallyasymptomaticbutmaypresentwithcompressiverediculopathy,aqueductalstenosis,shortstature,hypertension,mentalretardation,epilepsy.

○ Increasedriskofdevelopingnervoussystemneoplasmmorecommonlyopticnerveglioma

○ NeurofibromasareunencapuslatedbenignneoplasmcontainingSchwanncellandfibroblast.Thereisnoplaneofcleavage,socannotberemovedwith-outsacrificingnerve.

nEurofibromaTosis 2○ Characterizedbydevelopmentofbilateralvestibularschwannoma(oracousticneuroma)in90%cases.

○ Presentwithprogressivedeafness(unilateralin3rddecade)(vestibularsystemadaptstotheslowlygrowingtumor,hencenovestibularsymptoms)

○ AssociatedwithpostsubcapsularCATARACTandothernervouscyst.Neo-plasm.

○ NF2gene,referencodingschwannomin(merlin).

○ Schawannoma(neurilemmoma)areencapsulatedtumorswithaplaneofcleavageseparating:itfromnerveandhencecanberesectedsurgically.

skin cancErslayers of skin Epidermis dermis○ Theskinisdividedintotwomainlayers:Surfaceepitheium(epidermis)

Dermis

○ Keratinizedstratifiedsquamousepithelium1.Stratumcorneum2.Stratumlucidum3.Stratumgranulosum4.Stratumspinosum(malphigianlayer,pricklecelllayer)5.Stratumbasale

1.Superficialpapillary2.Deepreticularlayer•Melanocytesarefoundinthejunctionbetweenbasallayeranddermis

Acquired melanotic nevus classified as Junctional nevi○ Based on location of nevus cells1.Junctional:Epidermis(Str.Basale),i.e.junction (m/csiteoforiginofmelanoma)2.Compound:Epidermisandpartlydermis3.Dermal:Atdermis

○ Commoninchildren,malignantpotentialinadultBasalcellCa—mostcommonSquamouscellCa—2ndcommon

Basal Cell CarCinomaBasalcellcarcinoma(BCC)arisesfromstratumbasale.Occasionallyitarisesfromthebasalcellsofhairfolliclesandsweatglands.Suchtumorsaremostlyseeninscalpandadolescentsaretheusualvictims.Theyarecalled‘turbantumors’or‘epitheliomaadenoidescysticum’ ○ Mcskinmalignancy○ Mcagegroup—40–80years○ Mcinmen○ Mcsiteisface○ Exclusivelyaffectswhiteskinnedpeople.

○ Extremelylowmetastaticpotential○ Arisesfromstratumbasalelayer

Clinical features• m/c site:InnercanthusofeyeOutercanthusofeyeNoseOnandaroundnasolabialfoldOntheforehead

○ Tearcancer—asitislocatedalongtheinnercanthus.○ Rodentulcer—duetoitspropertyofdestroyingthetissueitcomesincontactwith.

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/

257Oncosurgery

Basal Cell CarCinomaHistology shows:Peripheralpalisadingofcells*

Predisposing factors for BCC:Ultravioletlight—sunlight(strongestpredisposingfactor)Exposuretoarsenic,coaltar,aromatichydrocarbons.

subtypes of bccnodular bcc Superficial bccmost common subtype (50% of all)Nodularandnodulocysticvariantsaccountsfor90%UsuallyoccursinsunexposedareasUlcerationiscommon (rodent ulcer)

OftenmultipleUsuallyontrunkRedscalypatcheswithareasofbrown/blackpigmentation(DD:Actinickeratosis,psoriasis,eczema)

others spread of bcc○ Morpheaform○ Cysticform○ Geographicalvariety(Fieldfire/forestfire○ Superficialspreadingtype:Withadvancingedgeandhealingcenter,ithasanirregu-larraisededgearoundflatwhitescar.

○ Perineuralspread○ Nonodalspread(ifnodesarepresentthediagnosisshouldbequestioned)

○ Localspread:Slowgrowing,canerodelocaltissuesdeeplylikecartilage,bone(rodentlike)

○ Hematogenousmetastasis:Incidence0.0028%—0.1%

Treatment of choice• Excisionalbiopsyistreatmentofchoice

• ButifMOH’smicrographicsurgeryisthereinthechoice,optforit• Othermodes—topical5fluorouracilcreams,radiotherapy.

squamous cEll carcinoma○ Secondmostcommoncancer○ Males>Females

○ Itisthepricklecelllayer(St.Spinosum)fromwhichthetumorarisesandmigrateoutwardstothesurface(Baileymentionsitarisesfromstratumbasale)

premalignant conditions1. Bowen’s disease: Itisanintradermalprecancerouscondition.Itpresentsasbrownishindurationwithwell-definededge.(Erythroplasiaofqueyrat:Penis)

2.Paget’sdiseaseofnipple3.Leukoderma,erythroplakia4.Senile(or)solarkeratosis5.Radiation

6. Arsenic 7. Chronicscars:Marjolin’s 8. Xerodermapigmentosa 9. Chroniclupusvulgaris10. Prolongedirritationofskinbydyes,tar,soot,etc.11.HPV5and16

pathological types characteristic histology○ Thefirstclinicalevidenceofmalignancyisindura-tion

○ Thetissuearoundthegrowthishyperemic○ Macroscopictypes:Proliferative(Cauliflower-like)Ulcerative(MCtype)PlaguelikeVerrucous

○ Epithelialpearl(nest)formation.○ epithelial formation not seen in:RapidlygrowingtumorEsophagusSCCBladderSCCBroder’sgrading(1-4)basedonepithelialpearlformation.Thetumorstainspositiveforcytokeratin1and10

characteristic types variants of scc (without lymphatic spread) • Kangri cancer—Duetoconstantplacingofhotcharcoalpot(kan-gri)tocontrolcoldoverabdomenwallinKashmir.

• Kang cancer—SeeninButtockandheelofTibetans,duetosleep-ingoverovenbedtocontrolcold.

• Chimney sweeper cancer—Inscrotum duetoexposuretocon-stantirritationbytar.

○ Marjolinulcer:○ Verrucouscarcinoma

Contd...

tahir99 - UnitedVRG

http:/

/vip.p

ersian

ss.ir/


TrEaTmEnT of skin cancErs1. excision treatmentBCC: Surgicalexcisionisthemostcommonformoftreatmentover-allcurerate91%.Therefore, 4–6 mmmarginsforlesions>2cm.sCC: 4 mm marginisenoughfortumors<2cm.Largertumors>2cmrequirea1cmmargin.

2. moh’s micrographic surgery:3. Destructive management:1.Electrodissectionandcurette.2.Cryosurgery.3.CO2laser.4.Radiotherapy.

contraindications for rT prognostic factors for metastasis ○ Patientswithxerodermapigmentosum,epidermolysisverruciformis,basalcellnevussyndrome(maycausemoretumorinRTfield)

○ Verrucouscarcinoma(SCC)—mayconvertedtoaggressiveform.○ Closetotheeye.○ Lesionadherestoboneandcartilage(leadstoosteoradionecrosis)

○ Overallrateofmets=2%usuallytore-gionalnodes

○ Localrecurrence=20%1.Depth2.Size3.Grade

malignanT mElanoma○ 4%ofskincancer○ 79%ofskincancerdeaths○ 1.4%ofallcancerdeaths.○ IncidenceinIndia○ Male:0.5/lakh○ Female:0.2/lakh○ melanoma is the leading cause of death in women 25–35 year.○ mC cancer in age group from 20–39 year—malignant melanoma.

risk factors SunlightXerodermapigmentosaPast/familyhistoryofmelanomaDysplaticnevi(10%lifetimerisk)Immunocompromised—HIV,cyclosporinAtherapy,Hodgkindisease.

cutaneous melanoma subungual melanoma melanomaFeatures of melanoma:•a Asymmetry•B Borderirregularity•C Colorvariation •D Diameter>6mm•e Evolution,elevation,enlargement•F Funnylooking

○ Digitcommonlyinvolved(greattoe/thumb)

○ extension of pigment onto the proximal lateral nail fold (Hutchinson’s sign)

Superficialspreading—Mostcom-mon

Acrallentiginous—Mostcommonindarkskin

Nodular—WorstprognosisLentigomaligna—Bestprognosis

Superficial spreading (70%) Nodular melanoma (16%)○ M/ctypeoccurringinwhitepopulation○ Melanomasarisinginpre-existingdysplasticnevusareusu-allySSM.

○ MCSites:Males:TrunkFemales:Lowerlegsandback

○ Secondmostcommon○ Canoccuronanysurfaceofthebody,50–70years○ M/Csite:Head,neckandtrunk○ Onlyverticalgrowth,noradialspread.○ HighRiskgroupandpoorprognosis

Acral Lentiginous melanoma (10%)○ Palms, soles, mucosal surfaces, subungual○ Mostcommonindarkskinnedindividuals○ Becauseofthelocation,diagnosedverylate

subungual type:Arisefromnailmatrixm/c—greattoe/thumbnailsDiagnosticbiopsyincludesnailmatrix

poor prognosis: lentigo maligna melanoma (5%) Tumor markers for melanoma:• Melan-A• HMB-45(HydroxymethylBro-mide)

• S-100

Olderageindividuals.PreviouslycalledHutchinsonmelanoticfreckle.

Commoninface.

Mostcommonlyaffectswomenthanmen

Insituvariantiscalledlentigomaligna.Lowestmetastaticpotential

Contd...

tahir99 - UnitedVRG

259Oncosurgery

malignanT mElanomaspread

○ lymphatic: Regionallymphnodesbypermeation,embolization

○ Blood:Brain—Convulsion,raisedICPLung—Cannonballsecondaries,pleuraleffusion,hemoptysis,chestpainLiver—AscitesSkin—PigmentednodulesBones—Pathologicalfracture,paraplegia,neurologicaldeficit

○ in-transit or satellite nodules:Betweentheprimarylesionandregionallymphnodearea,duetoretrogradespreadtodermallymphatics

prognosTic facTorsDepth(mostimportant)UlcerationLymphnodestatus

SatellitelesionsDistantmets

othersSite—Extremities(good)Sex—Female(good)Histology—Lentigomaligna(good)

breslow thickness○ Basedonthicknessofinvasionbyopticalmicrometer I : Lessthan0.75mm II : Between0.76to1.5mm III : 1.51mmto4mm IV : Greaterthan4mm

clark level○ LevelI:Onlyinepidermis○ LevelII:Intopapillarydermis○ LevelIII:Fillingofpapillarydermiscompletelyuptothejunction.

○ LevelIV:Intoreticulardermis○ LevelV:Extensionintosubcutaneoustissue

saTElliTE nodulEs TrEaTmEnT○ Excisionbiopsywithpreferredmargins○ Sentinelnodebiopsy○ Blockdissectionifsentinelnodeispositive○ Reconstructionofdefects.○ Excisionclearance

Tumor thickness (mm) ‘T’ stage Excision margin In situ T0 0.5–1cm0–1 T1 1cm1–2 T2 1–2cm*2–4 T3 2cm>4 T4 Atleast2cm

sofT TissuE sarcomas• M/csofttissuetumorinachildisrhabdomyosarcoma.

• M/ctype:Embryonalrhabdo-myosarcoma.

• Resectionisthetreatmentofchoice.

• Softtissuesarcomasmostlyspreadhema-togeneously.

• Butlymphaticmetastasisisseeninembryo-nalrhabdomyosarcoma.

• Lowerextremityisthecommonestsite.• Gradeoftumordetectsprognosis

• Liposarcomaisthemcretroperito-nealtumor*.

• Lymphomaandretroperitonealsarcomaaremcretroperitonealmalignantlesions

Contd...

tahir99 - UnitedVRG


sponTanEous rEgrEssion is sEEn in○ Renalcellcarcinoma○ Retinoblastoma

○ Choriocarcinoma○ Neuroblastoma

○ Malignantmelanoma

radiaTion inducEd cancErsAcuteleukemia(MC)PappilaryCaofthyroidBreastcarcinoma

LungCa(Radon)Angisarcomaofliver(Thorotrast)Skincancers(BCC,SCC,melanoma)

BraintumorOsteosarcoma

sEnTinEl nodE biopsy is donE in○ Cabreast ○ Melanoma ○ Capenis

fmgE quEsTions

1. Basal cell carcinoma usually spreads by which route: (sep 2003)

a. Hematogenousroute b. Lymphaticroute c. Directspread d. Alloftheaboveans: c (Direct spread)

2. Which of the following is commonest site for ro-dent ulcer: (sep 2011)

a. Lips b. Outercanthusofeye c. Innercanthusofeye d. Cheekans: c (inner canthus of eye)

3. most common subtype of basal cell carcinoma is: (sep 2005)

a. Superficialbasalcellcarcinoma b. Nodularbasalcellcarcinoma c. Sclerosingbasalcellcarcinoma d. PigmentedbasalcellcarcinomaAns: a (Superficial basal cell carcinoma)

4. Which of the following soft tissue sarcomas fre-quently metastasizes to lymph nodes: (sep 2008)

a. Fibrosarcoma b. Osteosarcoma c. Embryonalrhabdomyosarcoma d. Alveolarsoftpartsarcomaans: c (embryonal rhabdomyosarcoma)explanation:Sarcomas are a heterogeneous group of tumors thatarise predominantly from the embryonic mesoderm,

but also can originate as does the peripheral nervoussystemfromtheectoderm.Incidence: 1%inadultcancers 7%inchildren’scancers.site of occurrence• Extremity(59%):Upperlimbs(15%)andlowerlimbs(45%)

• Trunk(19%)• Retroperitoneum(13%)• Headandneck(9%)occurrence of each types:• Malignantfibroushistiocytoma(28%)• Liposarcoma(15%)• Leiomyosarcoma(10%)• Synovialperipheralnervesheathtumors(6%)• Rhabdomyosarcoma(m/cinchildhood)lymph nodal metastasis: (sCerea)S—SynovialsarcomaC—ClearcellsarcomaE—EwingsarcomaR—RhabdomyosarcomaE—EpitheliodsarcomaA—Angiosarcoma

5. Prognosis of malignant melanoma depends upon: (march 2011)

a. Gradeoftumor b. Ageofthepatient c. Depthofinvasion d. Siteoflesionans: c (Depth of invasion)

tahir99 - UnitedVRG

23Pediatric Surgery

OmphalOcele• Congenitaldefectintheanteriorabdominalwallinwhichthebowelandsolidvisceraarecoveredbyperitoneumandamnioticmembrane.

• Umbilicalcordinsertsintosac• Incidence=1in5,000• Associatedcardiacanomaliesin20%–40%,withchromosomeanomalies

exomphalos minor exomphalos major• Defectissmall(<5cm)• Onlysmallbowelprotrudes• Umbilicalcordattachedtosummit• Strappingisenoughastreatment• Goodprognosis

• Defectis>5cm• Smallbowelandliverprotrudes• Umbilicalcordattachedtotheside• Treatmentisdifficultandneedsstagedoperation.

• Badprognosis

GastrOschisis• Congenitaldefectcharacterizedbydefectinanteriorabdominalwallvia,whichintes-tinalcontentsprotrude,nomembranecovering.

• Sizeofthedefectisusually<4cm• Defectisalmostalwaystotherightofumbilicus• Notassociatedwithcardiacanomalies,butmaybeassociatedwithintestinalatresia• NomembraneTreatment• Urgentsurgicalintervention• Reductionandcorrectionofintestinalatresia.

Gastroschisis OmphaloceleUmbilicalcordnormal UmbilicalcordgoestothedefectNoprotectivemembrane ThinmembranecoveringpresentAngrylookingbowel NormalbowelNeedsclosure Needsclosure

tahir99 - UnitedVRG


exstrOphy Of bladder (ectOpia vesicae)• Incidenceis1in50,000• M:F=4:1• Inmalesassociatedwith—broadandshortpenis,bilateralinguinalhernia*

• Infemalesassociatedwith—epispadias*andsplitclitoris

• otheranomalies–separationofpubicbone(Splitpelvis)

treatment• Closureofthedefectinthe1styearoflife.

• Osteotomyofiliacbones • Otheroptionsureterosigmoidos-tomy

cOnGenital diaphraGmatic hernia• Anteromedial:SpaceofLarrey(foramenofMor-gagni)MConrightsideCausesnosymptom.

• Posterolateral:CommonesttypeofCDHOccursviaforamenofBochdalekMConleftCauserespiratorydistressDeathofinfantduetoabdominalvisceralher-niation

pOints frOm cdh• Failureofdiaphragmaticdevelopmentleavesapos-terolateraldefectknownasaBochdalekhernia.Thisanomalyisencounteredmore commonly on the left(80%–90%).

• Prenatalultrasonographyissuccessfulinmakingthediagnosisofcongenitaldiaphragmatichernia(CDH)asearlyas15 week gestation○AusefulindexofseverityforpatientswithleftCDHisthelung-to-head ratio (LHR).

○AnLHRvalueof<1.0isassociatedwithapoorprognosis,whereasanLHR>1.4predictsamorefavorableoutcome

• Followingdelivery,thediagnosis of CDH is made by chest X-ray (CXR)

Contd...

tahir99 - UnitedVRG

263Pediatric Surgery

pOints frOm cdh• Overallmortalityinmostseriesisapproximately60%–70%.Itisinterestingthatthefirst24–48hourafterbirthareoftencharacterizedbyaperiodofrelativestability,withhighpartialpressureofarterialoxygen(PaO2)levelsandrelativelygoodperfusion

Thishasbeentermedthe‘honeymoonperiod’andisoftenfollowedbyprogressivecardiorespiratorydeteriorationinthemajorityofpatients

managementstep 1 step 2 Operative repair• Inthepast,correctionoftheherniawasfelttobeasurgicalemergency

• Itisnowacceptedthatthepresenceofpersistent pulmonary hypertensionthatresultsinright-to-leftshuntingacrosstheopenforamenovaleortheductusarteriosusandthedegreeofpulmonaryhypoplasia,aretheleading causes of cardiorespiratory insuffi-ciency*

• Therefore,currentmanagementisdirectedtowardpreventingorreversingthepulmonaryhypertensioninfantsareplacedonmechanicalventilation

• InfantswithCDHwhoremainseverelyhypoxicdespitemaximalventilatorycaremaybecandidatesfortreatmentoftheirrespira-toryfailurebyextracorpor-eal membrane oxygenation (ECMO)

• Thetimingofdiaphragmrepairiscontroversial.InpatientsthatarenotplacedonECMO,mostsurgeonsperformrepaironcethehemodynamicstatushasbeenoptimized

• Operativerepairofthedia-phragmaticherniaisbest ac-complished by an abdominal approach

Contd...

fmGe questiOns

1. Hernia of Morgagni passes through: (Sep 2006) a. Pleuroperitoneum b. DiaphragmviaLa c. Deepring d. ArcuatelineAns: b (Diaphragm via Larrey’s space)

2. Where does the diaphragmatic hernia of Boch-dalek occurs: (Sep 2008)

a. Leftsideanterior b. Rightsideanterior c. Posterolateral d. NoneAns: c (Posterolateral)Mostcommononleftposterolateral*

tahir99 - UnitedVRG

Index

AAbbe’s flap 36Abdominal aortic aneurysm 247 compartment syndrome 137 crampy pain 129 groans 72 injury 27 trauma 26Aberrant right hepatic artery 161 thyroid 56Abscess 3Absence of cholangitis 148Absorbable suture material 8Acalculus cholecystitis 147Accessory cystic artery 161 spleen 177Achalasia 98 cardia 98Acid urine 180Acinic cell tumor 51Acquired branchial sinus 44 immunodeficiency syndrome 180 melanotic nevus 256Acral lentiginous melanoma 258Acrocyanosis 250Actinomycosis 1Acute appendicitis 126 cholecystitis 154 coronary syndrome 231 gastric dilatation 112 liver failure 162 mesenteric ischemia 131 paronychia 4 subdural hematoma 22 submandibular sialadenitis 54

Adder head 190Adenocarcinoma 51, 100, 229 nodes 36Adenoid cystic carcinoma 51Adenolymphoma 51Adenoma 50, 76Adjustable banded gastroplasty 114Adrenal glands 70, 73 medulla 73Adriamycin 86Adson’s test 42Advanced gastric cancer 108 trauma life support 20Alexander-Wallace rule 235Alkaline urine 180Amebic abscess 168 colitis 126 lung abscess 229Anal canal 133 cancer 132 margin 133Anaplastic carcinoma 66Anatomical division of prostate 193Anatomy of coronary artery 231 inguinal canal 213, 214 rectum 132Anderson-Hynes dismembered pyeloplasty

188Anemia 107, 113, 176Angel sign 208Angelchik prosthesis 93Angiomyolipoma 185 of kidney 185Aniridia 185, 188Anomalies of gallbladder 145Anorectal abscess 135

Anterior dissection 36 gastric nerve 103 lesser curve seromyotomy 106 mediastinum 227 triangle of neck 44Antithyroid drugs 61Aphthous ulcers 121Appendicular abscess 127 mass 127Arterial graft 232 plane 48 stenosis and occlusion 249 system 247Arteriovenous fistula 251Artificial nutrition 4Askanazy cell 63Assessment of liver function 171Astley Cooper’s ligament 88Ataxia telangiectasia 83Auchincloss modification 85Auerbach’s plexus 92, 98Autogenous transplant 89Autosomal dominant mutation 83Axillary vessels 86Azoospermia 198

BBacterial infection 176Balance sign 175Balanced salt solution 8Bariatric surgery 114Barium enema 119Barrett esophagus 93, 94Barron’s bander 134Basal cell carcinoma 1, 256Bascom’s procedure 135Bastede’s sign 126

tahir99 - UnitedVRG


B-cell non-Hodgkin’s lymphoma 66Beckwith-Wiedemann syndrome 185Bell’s nerve 86Belsey mark intravenous operation 93Benign breast diseases 80 mixed tumor 50 thyroid disorders 58Beta cell tumor 157Bilateral breast cancer 83 neck dissection 35 subtotal thyroidectomy 66Bile duct cancers 152 injuries 153 vomiting 108Biliopancreatic diversion without duodenal

switch 114Bishop Koop operation 128Bismuth classification 152, 153Bladder calculi 192 cancers 191 pressure grading 138Bleeding in portal hypertension 165Block and replacement therapy 62Blood products 13 supply 57, 103, 161, 174 transfusion 11Blumberg sign 126Blunt myocardial injury 26 trauma 20Boerhaave syndrome 95Bone disease 107 marrow suppression 86Borchardt’s triad 114Bormann classification 108Bourneville’s disease 255Bowel injuries 27Bradycardia 251Brain tumors 224Branchial arches 43 cyst 44 fistula 2 sinus 44Branchiogenic carcinoma 44Branham sign 251Breast cancer syndrome 83 conservation surgery 89 disorders 78Breslow thickness 259Brodie-Trendelenburg test 244Bronchioalveolar carcinoma 229

Bronchogenic cancer 229 cyst 227, 228Brown pigment 147Buccal mucosa 34Buerger’s disease 250Bulbar urethra 136 urethral injury 201Burns produce inflammatory reaction 234Bypass procedures 251

CCalcineurin blockers 189Calcium homeostasis 71 oxalate calculus 180Called mixed tumor 50Calot’s triangle 144Calyceal diverticulum 181Cancer esophagus 100 prostate 195 rectum 132 stomach 108Carbimazole 61, 62Carbuncle 3Carcinoid appendix 127 syndrome 121Carcinoma 34, 50, 71 bladder 190 breast 81, 82 buccal mucosa 37 cheek 34 gallbladder 151 hard palate 35 in situ 82 lip 34, 36 lower alveolus 37 of penis 201 prostate 196 tongue 34Cardiac surgery 231Cardiogenic shock 11Cardiothoracic surgery 227Caroli disease 149Carotid body anatomy 40 tumor 40 triangle 47Caudate lobe 162Causes of distension 129 hypergastrinemia 113 recurrent ulcer 108 thoracic outlet syndrome 42Cellulitis 3, 4

Central neck dissection 66Cephalic vein 86Cerebral contusions 23 metastasis 225Cerebrospinal fluid pathway 222Cervical ribs 42Cervicodorsal sympathectomy 250Charcot triad 148Chemodectoma 40Chemoembolization 171Chemotherapy 65, 86Chimney sweeper cancer 257Choice of fluid 8Cholangitis 148Cholecystosis 146Choledochal cysts 149Cholesterol gallstones 125Chromophobe carcinoma 183Chronic breast abscess 81 cholecystitis 154 graft rejection 16 hyperplastic candidiasis 32 kidney graft rejection 16 liver disease 163 pancreatitis 155 paronychia 4 renal failure 187 stable angina 231 subdural hematoma 23 submandibular sialadenitis 54Chylolymphatic cyst 219Circadian rhythm 75Circulation 21Cirrhosis 170Classic radical neck dissection 35Classification of salivary gland tumors 50 shock 11Clear cell carcinoma 183Cleft lip and palate 239, 240Clonidine suppression test 74Cloquet hernia 216Clostridium perfringens 154 welchii 154Cobblestone’ appearance 122, 193Cobra head 190Cock peculiar tumor 3Cold abscess 4 in neck 46 storage time 17Colloids 7, 8, 236Colonic cancer 119Colovesical fistula 2Commando operation 35Common bile duct stones 148

tahir99 - UnitedVRG

267Index

hepatic duct 144 vesical stones 192Completion total thyroidectomy 64Complications of bronchogenic cyst 228 burns 235 conservative management 175 empyema 228 enteral nutrition 5 incomplete descent 207 parotid surgery 52 peptic ulcer disease 106 renal trauma 186 sclerotherapy 100 shock 12 splenectomy 176 surgery 107 venous ulcer 245 kidneys 137Computed tomography scan 119Congenital atresias 129 diaphragmatic hernia 262 hydrocele 208, 209 hypertrophic pyloric stenosis 113 pelviureteric junction obstruction 188 PUJ obstruction 188 torticollis 45Congestive cardiac failure 194Conn’s syndrome 76Contents of inguinal canal 214 spermatic cord 214Control of intracranial pressure 23Cope’s obturator test 126 psoas test 126Copper-beating-chronic raised intracranial

pressure 223Corecut biopsy 80Coronary artery bypass grafting 231Corynebacterium diphtheriae 135Costoclavicular compression 42Couinaud’s segments 161Course of branchial sinus tract 44Courvoisier law 152, 156Cowden disease 83Crile’s operation 35Crohn disease 121-123, 126Cronkhite Canada syndrome 119Crypt abscesses 121Cushing disease 75, 76 syndrome 75, 76, 184 ulcers 111Cutaneous melanoma 258Cyclophosphamide 86Cylindroma 51Cystic artery 144 duct variations 145 hygroma 2, 45

Cystosarcoma phyllodes 81, 88Cysts 2 of jaw 38Cytogenetics of various subtypes of renal

cell 183Cytopoiesis 175

DDalrymples sign 61Dangers of smoke inhalation 234De Quervain’s thyroiditis 63Deep palmar abscess 4 vein thrombosis 244, 245Deformities of stomach 106Degrees of burns 236Delayed reconstruction of burns 237Deming sign 208Dental cyst 38, 39Dentigerous cyst 38, 39Denys Drash syndrome 185Dercum disease 2Dermis 256Dermoid cyst 2 tumor 217Destruction of valves 244Diagnostic peritoneal lavage 26Diaphragmatic injury 26Diarrhea 108Diffuse esophageal spasm 97 hyperplastic goiter 59Diseases of esophagus 92Distal splenorenal shunt 167Distant metastasis 87Distributive shock 11Diurnal variation 75Diverticular disease 119Diverticulitis 119Diverticuloesophagectomy 99Diverticulosis 119Diverticulum esophagus 98 in stomach 112Dohlmann operation 99Douglas sign 126Down syndrome 95Duct ectasia 81Ductal anomalies 56 carcinoma 82Dukes classification 120Dumb bell tumor 50Dunhill’s classification of malignant thyroid

63Duodenal stricture 112 stump blow out 108, 110 ulcer 104-106

Duodenum 103Dupuytren’s contracture 4Dyspepsia 106Dysphagia 96 lusoria 96

EEarly gastric cancer 109, 113Echinococcus granulosus 169 multilocularis 169Ectocyst 169Ectopia vesicae 262Ectopic testis 207 thyroids 56 ureter 187Eczema 80Elevated arms test 42Emergency thoracotomy 26Emphysematous cholecystitis 154Empyema of lungs 228Endocrine neoplasms 157 shock 11Endocyst 169Enterocutaneous fistula 125, 126Enterogenous cyst 219Enzyme defect 176Epidemiology of common cancer 255Epidermis 256Epididymal cyst 2Epigastric hernia of linea alba 215Epithelial formation 257 polyps 113 tumors 50Epulis 38Equinus deformity 245Erysipelas 3, 4Erythroplakia 32Esophageal injury 26 varices 99Esophagogastric junction 93Estlander’s flap 36Estrogen receptor status 86Exogenous hormones 83Exomphalos major 261 minor 261Exstrophy of bladder 262Extended radical dissection 36 mastectomies 85, 86External beam radiotherapy 65, 171 fistula 2 laryngeal nerve 57

tahir99 - UnitedVRG


Extracorporeal membrane oxygenation 263 shock wave lithotripsy 181Extradural hematoma 22Extrahepatic biliary atresia 149 portal venous obstruction 167Extralobar sequestration 228

FFacial nerve involvement 52 trichilemmoma 83Faeculent vomiting 130False capsule 48 divericula 119Familial adenomatous polyposis 119Fascial planes 4Fegan test 244Feminization 184Femoral hernia 215Finasteride 195First bite syndrome 41Fistula 2Flail chest 25Flank pain 184Floor of mouth 34Fluid therapy 7, 12Focal nodular hyperplasia 169Focused abdominal sonogram of trauma 27Follicular adenoma 59 cancer 64, 65 infections 3 odontoma 38, 39Foramen of Monro 223Fordyce’s disease 3Foreign body in lung 229Foster-Kennedy syndrome 224Frey procedure 155 syndrome 52, 53Fries modification of Bernard flap 36Frontal lobe lesions 224

GGabriel syringe 134Galactorrhea 184Gallbladder and biliary tract 144 polyp 146Gallstones 146Gangrene 249Gardner’s syndrome 3, 119Gastric lymphoma 111

outlet obstruction 106, 112, 125 ulcer 105Gastrin secretion 125Gastrinomas 157Gastroduodenal artery 106Gastroenteric cyst 227Gastroesophageal reflux disease 93Gastrointestinal stromal tumors 111 tract 118Gastrojejunostomy 106, 108Gastroschisis 261Gastrostomy 5Genital branch of genitofemoral nerve 214Genitourinary anomalies 188 tuberculosis 186Germ cell tumors 185, 204Giant fibroadenoma 81, 88 hemangiomas 170Gifford’s test 61Glasgow coma scale 21 outcome score 23Gliomas 225Goodsall’s rule 134Grades of splenic injury 175Graft versus host disease 16Graham-Cole test 145Grave’s disease 61Great saphenous vein 245

HHair follicle infection 3Halstead radical mastectomy 86 test 42Hamartomatous polyps in jejunum 119 syndromes 119Hartley Dunhill procedure 66Hartmann’s operation 130 pouch 145Hashimoto’s thyroiditis 63Hay fever 135Head injury 21Healing of third degree burns 237 ulcer 1Heinke Mickulicz pyloroplasty 106Heinz bodies 188Helicobacter pylori infection 105Hemangioma 169Hematogenous metastasis 64 route 186

Hematoma 67Hematuria 184, 186Hemihypertorphy 151Hemobilia 151Hemoglobinopathies 176Hemorrhagic cystitis 86Hemorrhoids 133Hepatic artery 161Hepatobiliary and pancreatic system 144Hepatoblastoma 171Hepatocellular carcinoma 170Hereditary non-polyposis colorectal cancer

119Hernia 213, 216Herniorrhaphy 217Hesselbach hernia 216 triangle 214Heterotopic graft 172Hiatus hernia 94Hidradenitis 3 suppurativa 3High pressure flow 244 selective vagotomy 107Hill procedure 93, 106Hilton’s method 46Hirschsprung’s disease 98, 118Holmium:yttrium aluminium garnet laser

194Homan’s sign 245Hormone replacement therapy 84 therapy 86Horner syndrome 228Horseshoe kidney 188Howell-Jolly bodies 188Hunt-Larence pouch 110Hurthle cell 63 carcinoma 65Hydatid cyst 169 of lung 229Hydrocele 2 of cord 209Hydrocolloid dressings 237Hypercalcemia 7Hyperkalemia 6Hypernatremia 7Hyperplasia 71, 76Hypertension 75, 187Hypertonic saline 8, 236, 237Hypertrophic scar 6Hypocalcemia 7, 67, 110Hypokalemia 6Hyponatremia 7Hypospadias 185, 198Hypovolemia 12Hypovolemic shock 11

tahir99 - UnitedVRG

269Index

IIdiopathic thrombocytopenic purpura 178Immature cells 106Immunosuppression 17Impacted tooth 39Imperforate anus 136Implantation dermoid 3Incidence of carcinoma breast 82Infantile hydrocele 209Infective thyroiditis 63Inflammatory bowel disease 121 carcinoma breast 88Infraclavicular subclavian vein 5Inguinal lymph nodes 202Injection sclerotherapy 134Inoperable node 36 secondaries 36 tumors in cardiac end 111Insulinomas 157Intermittent dysphagia 96Internal fistula 2Interstitial hernia 216Intestinal obstruction 128 system 118 transplantation 125Intracellular defect 176Intracranial tumors 224Intralobar sequestration 228Intramammary abscess 80Intraperitoneal rupture 193Intraspinal extension 185Intrathoracic goiter 67 pressure 137Intravenous urogram 186Intravesical therapy 192Intusussception 128Invasive cancers 82 ductal carcinoma 82 lobular carcinoma 82, 83 penile carcinomas 202Iron granules 174Ischemic colitis 126, 131

JJack stones 192Japanese classification 109Jaundice in infants 150 newborn and infants 150Jeeper’s bottom 135Jejunal interposition 110Jejunostomy 5Jellinek’s sign 61

Joffroy’s sign 61Johansson step ladder 36Johnson classification 104

KKarydakis procedure 135Kasai’s procedure 150Kassabach Meritt syndrome 170Kehrs sign 175Keloid 6Kidney and ureters 180 stones 168Klebseilla pneumoniae 168Klippel-Trenaunay sydnrome 245Krukenberg’s tumor 81

LLanz incision 127Laparoscopic repair 217Large bowel obstruction 120, 130Laryngocele 45Larynopharyngeal reflux of

gastroesophageal reflux disease 93Lateral aberrant thyroid 56 neck dissection 35Latissimus dorsi 86Laungier hernia 216Laurens classification 109Layers of skin 256Left coronary artery 231 sided portal hypertension 164Lentigo maligna melanoma 258Leukemia 83Leukoplakia 32Level of escharotomies 237 nodes 33, 78 verumontanum 194Lid lag sign 61Li-Fraumeni syndrome 83Ligaments of Cooper 78Limb reduction procedures 252Limey bile 145, 148Lingual thyroid 56Lipodermatosclerosis 245Lipoma 2Lithogenic bile 146Littre hernia 118, 216Liver 161 cell adenoma 169 function tests 162 transplant 172Lobectomy 66Lobular carcinoma 82

Long sinus forceps 46Lothiessen’s inguinal approach 215Low ejaculatory volume 198 operation of Lockwood 215Lower esophageal sphincter zone 93Ludwig’s angina 38Lugol iodine 62Lumbar sympathectomy 250Lung abscess 99 sequestration 228Lymph edema 251 praecox 251 tarda 251 node metastasis 52Lymphatic drainage 34, 57, 78, 104, 144 system 251Lymphoma 50, 59, 227Lyre sign 40

MMacis scale 64Mackler triad 95Major vascular injuries 26Malabsorption 125Malgaigne’s bulge 216Malignant ascites 81 exophthalmos 61 melanoma 258 anal canal 133 pheochromocytoma 74 tracheoesophageal fistula 100 transformation 50 tumor 170Mallory-Weiss tear 95Mammography 79Management of bladder cancer 191 burns 236, 237 carcinoma penis 202 deep burns 237 oral cancers 36Mandibulectomy 36Manifestation of organs 16Manometry 97Marjolin’s ulcer 245Masculinization 184Massive hemothorax 25Maydl hernia 216Mayos operation 106McBurney’s grid iron incision 127Measuring portal pressure gradient 165Meckel diverticulum 118, 128Meconium ileus 128Medial abberant thyroid 56

tahir99 - UnitedVRG


Mediastinum 227Medullary carcinoma 65, 82, 83 sponge kidney 188Megaloblastic anemia 125Meissner plexus 98Melanoma 258Membranous urethral injury 201Menarche 84Menetrier’s disease 108, 112Meningeal tumors 224Meningioma 225Meningocele 2, 227Menopause 84Mesenchymal tumors 227Mesentric cysts 219Metabolic diseases 170Metastatic cancer thyroid 66 carcinoids 121 liver tumor 171Methods of stone removal 181 wound closure 238Middle mediastinum 227Midline swellings 46Milligan-Morgan operation 134Minor salivary gland tumor 51Mirrizzi syndrome 147Misnomers 56Modified child-Pugh classification 163 Perthes test 246 radical mastectomy 85 neck dissection 35, 66Moebius sign 61Mondor’s disease 81Monomorphic adenoma 50Monro-Kellie doctrine 222Morrissey cough impulse 244Mosse’s sign 245Motility disorders 96Moynihans hump 144MRI breast 79Mucinous carcinoma 82, 83Mucocele 127, 147Mucoepidermoid carcinoma 51Muir and Barclay formula 237Multiple adenomas 71 diverticula 119 hamartoma syndrome 83Mumps 54Murphy’s triad 126Muscular elements 43Mutilating surgery 86Mycobacterium bovis 124Mycotic aneurysm 248Myelofibrosis 176

Myenteric and submucous plexus 118 plexus 92, 98Myxoma 232

NNaffziger’s test 61National Institute for Health and Clinical

Excellence 22Near-total thyroidectomy 66Neck dissection for nodal metastasis 66Neoadjuvant chemotherapy 86Neoplasia 59Nerve plane 48 sheath tumors 224 supply of parotid gland 49Neuroepithelial tumors 224Neurofibromatosis 256Neurogenic tumors 86Nicoladoni sign 251Nigro regimen 133Nipple retraction 80Nissens partial fundoplication 93Nodular goiter 59 melanoma 258 swelling 60Non-caseating granulomas 121Non-cirrhotic portal fibrosis 167Nonepithelial tumors 50Non-small cell cancer 230Normal position of appendix 126 saline 8 serum amylase 155Nutcracker esophagus 97

OOat cell cancers 229Obesity 114, 183Obstruction to venous outflow 244Obstructive shock 11Odontogenic cyst 38Odynophagia 98Ogilvie herina 216Omphalitis 218Omphalocele 261Oncocytoma 183Oncosurgery 255Open pneumothorax 25Operable neck nodes 36 tumors 153Ophthalmoplegia 61Optimal storage time 17

Oral cavity 32 carcinoma 32 cholecystogram 145 contraceptives 84 lichen planus 32 submucosal fibrosis 32Organ donation 17 procurement 189 transplantation 11, 16Orocutaneous fistula 2Orthotopic graft 172Osteomalacia 107Osteomyelitis 1Osteosarcoma 83Otic ganglion 49Oxalate kidney stones 125

PPacked cell volume 107Paget disease 82 of nipple 82Palliative procedures 110Palpable flank mass 184Pancoast tumor 228, 229Pancreas 27, 154Pancreatic function test 154 tumors 156Pancreatitis 154Pantaloon hernia 216Papillary carcinoma 64, 82, 83 cystadenoma lymphomatosum 51Papilloma 83Pappenheimer bodies 174Paradoxical incontinence 187Paragangliomas 40Paraneoplastic syndrome 184, 231Paraphimosis 200Parathyroids 70Parenteral nutrition 5Parkland formula 237Parotid duct 49 gland 48, 49, 50 surgeries 52Paroxysmal spells 74Parts of ulcer 1Passaro triangle 157Paterson-Brown-Kelly syndrome 101Patey’s modification 85 pectoralis 85Pathology of oral cancers 34Paul-Mikulicz operation 130Peau d’orange 88Pectoralis major 86 minor 86

tahir99 - UnitedVRG

271Index

Pediatric brain tumors 226 surgery 261Peptic ulcer disease 104Percutaneous aspiration 168, 169 nephrolithotomy 181, 182 transhepatic cholangiography 163Perforator incompetence 245Periampullary carcinoma 156Pericardial tamponade 24Periductal mastitis 81Perimuscular connective tissues 152Periodontal cyst 38, 39Periosteitis tibia 245Peritonitis 218Perlman syndrome 227Persistent pulmonary hypertension 263Petit hernia 216Peutz-Jeghers syndrome 119Phantom hernia 216Pharyngeal pouch 46, 99Pheochromocytoma 40, 73, 227Phimosis 199Phyllodes tumor 88Pigment stones 146Pigmentation of lips 119Pilonidal sinus 1, 135Pituitary adenoma 76, 226 macroadenoma 224 tumors 226Plasma imbibition 239Pleomorphic adenoma 50, 51Plummer-Vinson syndrome 101Plunging ranula 53Pneumoperitoneum 218Polycystic kidney disease 183, 187Polyps 119Popliteal artery aneurysm 248Port-wine stain 6Postcibal syndrome 107Posterior gastric nerve 103 mediastinum 227 sagittal anorectoplasty 136 triangle 47 swelling 99 urethral valve 203 vestibule 136Posterolateral dissection 36Potato tumor 40Pott puffy tumor 3, 4Pratt’s sign 245Preauricular sinus 1Prehns sign 208Preparation of thyroid crisis 61Pretibial myxedema 61Prevention of recurrent bleed 166

Primary bladder stone 192 hemorrhage 13 hyperaldosteronism 76 hyperparathyroidism 71 hypersplenism 176 sclerosing cholangitis 150 survey 21 therapy 5 thyrotoxicosis 61Progressive dysphagia 96Propylthiouracil 61, 62Prostate and seminal vesicles 193 specific antigen 196Prostatic hyperplasia 193 urethra 136Proteus infection 180Proton pump inhibitors 93Protozoan infection after splenectomy 176Pseudoachalasia 98Pseudocyst pancreas 156Pseudomembranous colitis 126Pseudopneumoperitoneum 218Puestow procedure 155Pulmonary contusion 26Pulse rate slows 251Pyogenic abscess 4, 168

RRadiation induced cancers 260Radical excision of submandibular gland 53 mastectomy 86 parotidectomy 52Raised intracranial pressure 222Ranson’s criteria 156Ranula 2, 53Raspberry tumor 218Raynaud disease 250 syndrome 250Reactionary hemorrhage 13Reactive hypoglycemia 107Reconstruction of breast 89Rectal cancer 132 prolapse 136Rectum and anus 132Rectus sheath hematoma 217Recurrent adhesions 129 hematuria 174 infection 44 laryngeal nerve 57, 58 pyogenic cholangitis 169 stones 149Reflux esophagitis 93

Reidel lobe 162 thyroiditis 63Removal of breast tissue 86 internal mammary 86Renal casts 189 cell carcinoma 183, 184 medullary carcinoma 183 transplantation 188 trauma 186 tuberculosis 193Reperfusion syndrome 138Respiratory dyspnea 67 system 234Resuscitation 12Retractile testis 207Retroperitoneal fibrosis 218 loin 190Retrosternal goiter 60Richter hernia 216Right colon 120 coronary artery 231Ringer lactate 8Rodent ulcer 1Rolling hernia 94Roos test 42Roux-en-y gastric bypass 114Rovsing’s sign 126Rubber band ligation 134Rule of 10 lip for cleft lip repair 239 nine 235Rupture of bladder 192Rutherford-Morrison incision 127, 219

SSacless hernia 215Saint triad 147Salivary gland 48 tumors 49Salmon patch 6Salmonellosis 126Saphenous nerve 245 opening 213Sarcomas 88Satellite nodules treatment 259Saw-tooth appearance 119Scanlon modification 85Schatzki rings 101Schistosoma hematobium 190Sclerotherapy injection 134Seat belt injuries 20Sebaceous cyst 3 horn 3

tahir99 - UnitedVRG


Secondary bladder stones 192 hemorrhage 13 hyperaldosteronism 76 hyperparathyroidism 72 thyrotoxicosis 61 varicose veins 244Seldinger’s technique 249Selective estrogen receptor modulators 87Seminal vesicles 197Seminomas 206Sengstaken-Blakemore tube 95, 165Sentinel node biopsy 260Serocystic disease of Brodie 88Serpiginous network of linear ulcerations

122Serum alkaline phosphatase 162Severity of shock 12Shamblin classifications 41Sherren’s triangle hyperesthesia 126Shionaya criteria 250Shock 11Short bowel syndrome 125 saphenous incompetency 245Shortening of esophagus 93Shouldice technique 217Shunting surgeries 166Sialadenitis 54Sideropenic dysphagia 32Significant hydroureteronephrosis 190Signs of base of skull fracture 21 inoperability 109Simple goiter 59 mastectomy 85Single adenoma 72Sinus 1Skeletal elements 43Skin cancers 256Skull base meningioma 224Sliding hernia 94, 215, 216Sloping ulcer 1Small bowel carcinoids 121Small bowel obstructions 129 tumors 121 cell cancer 230, 231 carcinoma 229 lung cancer 229 stomach syndrome 108Smooth muscle disorders 132Soft tissue sarcoma 81, 83, 259Solitary nodule thyroid 59 rectal ulcer 137Spigelian hernia 215, 216Spleen 27, 174

Splenectomy 176, 177 in trauma 175Splenic artery 106, 174, 178 gonadal fusion 177 infarction 178 trauma 175 tumors 177 vein 174Splenocolic ligaments 174Splenophrenic ligaments 174Splenorenal fusion 178 ligament 174Splenosis 177Spread methods 109Spur cells 174Squamous cell 92 cancer 229 carcinoma 1, 100, 229, 257, 231Stafne bone cyst 53Staghorn calculus 180Staphylococcus aureus 54, 80Starch iodine test 52Stauffers syndrome 184Steatorrhea 125Stellwag’s sign 61Stenson’s duct 48Stewart-Treves syndrome 88Stomach 27Stoppas procedure 217Strangulated hernia 216Strasberg classification 153Strawberry angioma 6Streptococcus pneumonia 176 pyogenes 4 viridans 54Stripping of small saphenous vein 245Structures within gland 48Struma ovary 56Struvite stone 180, 192Stylomandibular ligament 48Subarachnoid hemorrhage 23Subclavian aneurysm 249Subcutaneous tissue 4Subfascial endoscopic perforator surgery 245 ligation of Cockett and Dodd 245Sublingual duct 49Submandibular duct 49 gland 49, 50 excision 53 triangle 46Submucosal plexus 92Subphrenic abscess 219Subtotal thyroidectomy 66Subungual melanoma 258Sulfur colloid liver scan 170Superficial

parotidectomy 52 ring 213 spreading 258Superior laryngeal nerve 58 mesenteric artery syndrome 125Supraomohyoid block dissection 35Surgery in cyst 59 lymphoma 111Surgical division of prostate 193 removal of ureteric calculus 182Swellings in skin 2, 3Syphilitic glossitis 32 gumma ulcer 1

TTamoxifen 87Target cells 106Taylor procedure 106Temporal lobe 224Tension pneumothorax 25Teratomatous dermoid 3Testicular cancer 204 malignancy 205 tumors 204Testis and scrotum 204Thoracic aorta disruption 25 outlet syndrome 41 trauma 24Thoracotomy 26Thromboangitis obliterans 250Thumb print sign 131Thyroglossal cyst 46, 56 fistula 2Thyroid 59 acrobachy 61 adenoma 59 and parathyroid thymomas 227 cancers 63 carcinoma 59 disorders 56 storm 62Thyroiditis 59, 62Thyrotoxicosis 60Tillaux triad 219Time of absorption 8TNM staging of breast 84 oral cancer 35Torsion of testis 208Total conservative parotidectomy 52 extraperitoneal repair 217

tahir99 - UnitedVRG

273Index

gastrectomy 110 parenteral nutrition 5Toupet posterior fundoplication 93Toxic megacolon 125 multinodular goiter 61 nodular goiter 61Tracheobronchial injury 24Tracheoesophageal fistula 2, 95Traditional classification of hemorrhagic

shock 13Transabdominal preperitoneal mesh 217Transanal excision of cancer rectum 132Transjugular intrahepatic portal shunt 166Traumatic fat necrosis 81Treatment of complete prolapse 136 established lymph edema 251 fistula-in-ano 134 hydrocephalus 223 hypospadias 199 intraductal papilloma 80 partial prolapse 136 skin cancers 258 vesical calculus 192Triangles of neck 46Triangular cord sign 150Triple assessment of breast 79Troisier sign 156Trophic ulcer 1Trousseau sign 156True shortening of esophagus 96Trypanosoma cruzi 98Tuberculosis 1, 46 of bladder 193 of testis 209Tuberculuos sinus 1Tuberous sclerosis 183, 255Tubular carcinoma 83Tubulodermoid 2Tumor like malformations 224 localization 74 of ovary 119 of vagal body 40 thickness 259Turcot syndrome 119Types of allograft rejection 16 anal carcinoma 133 aneurysms 252 bariatric surgery 114 biliary atresia 149 casts 189 donor 188 emergency thoracotomy 26 enteral nutrition 5

flaps 238 graft 172 head injury 22 hernia 214 hydrocephalus 223 hypospadias 198 neck dissection 35 nutrition 4 of tuberculosis 124 primary lymph edema 251 renal calculus 180 skin graft 238 stockings 251 toxicosis 60 ulcer 1 urethral injuries 201 wound 8 suturing 8

UUlcer 1 of oral cavity 37Ulcerative colitis 121-123Ultimately inoperable tumors 111Umbilical calculus 218 granuloma 218Umbilicus 213Undescended testis 207Upper gastrointestinal bleeding 106, 112 limb 237 part of rectus abdominis 86Urea breath test 105Ureterocele 190Ureteroscopy 181Ureterosigmoidostomy 119Urethra 200Urethral injuries 193Uric acid stones 192Urinary bladder 190Urological injuries 27 surgery 180

VVaginal hydrocele 209Vagotomy 107Vagus nerve 92, 103Vanillymandelic acid 74Vanishing bile duct syndrome 151Varicella zoster 98Varicocele testis 207Varicose veins 244, 246

Variety of intraparietal hernia 215Vascular masses 227 surgery 244Vein of Mayo 103Venous drainage 57 grafts 232 plane 48 system 244Vigorous achalasia 97Virchow’s triad 246von Graefe’s sign 61von Hippel-Lindau syndrome 183von Recklinghausen’s disease 256

WWalls of canal 213 femoral canal 215Wardill operation 239Warthin tumor 51Water intoxication 194Watery diarrhea 125Weight loss 107Wharton submandibular duct 49Whipple procedure 156Whitaker test 188Whole blood 13Wilkie’s disease 112 syndrome 125Wilm’s tumor 185, 188Wolman’s classification 64Wunderlich’s syndrome 186

XXanthogranulomatous pyelonephritis 189

Yy loop 110

ZZenkers diverticulum 99Zollinger-Ellison syndrome 104Zona fasciculata 73 glomerulosa 73 reticularis 73Z-plasty 135, 239

INTESTINAL SYSTEM - TaiLieu.VN

Documents

Transcript of INTESTINAL SYSTEM - TaiLieu.VN