Surgery 2 notes compiled

Hernia :

Omentocele/Epiplocoele = Having omentum

Enterocoele = Having intestine
Ritcher hernia = circumference of intestine
Amyand = Appendix
Littre = Meckel's diverticulum
Maydl = W shaped loop of small bowel

First portion of intestine difficult to reduce

Last portion of omentum difficult to reduce

Irreduciblity without any other signs is almost diagnostic of omentocoele

Obstructed hernia gradual abdominal pain and less tenderness

Strangulated hernia sudden abdominal pain and more tenderness and nausea vomitting

Strangulated hernia more common in femoral hernia due to narrow neck and rigid
surrounding structures

Gangrene starts 5-6 hours after strangulation first at construction part then anti
mesenteric border, first venous flow blocked then arterial.

Inguinal Hernia :

Superficial Ring is triangular and 1.25 cm above pubic tubercle made of external oblique
muscle.
Deep ring : U shaped, 1.25cm above inguinal ligament and made of transversalis fascia.

Inguinal canal is 3.75cm long down and medial directed, has spermatic cord in males
and round ligament of uterus in females

MDLI
Medial to epigastric vessels Direct hernia
Lateral to epigastric vessels Indirect hernia

Indirect hernia most common , specifically in young

14% bilateral
20 times more common in males

Indirect Inguinal Hernia :

Infants, adults and young adults = Herniotomy
Adults = Hernio raphy ( herniotomy + posterior wall repair)

Herniotomy is done 1.25 cm aboveedial 2/3rd of inguinal ligament

Ilioinguinal nerbes is identified and preserved first after cutting external oblique.

Tx :
Bassini rep

Strangulated inguinal hernia = 4% occurence , 5 times more common in women and

ovary most common content in girls otherwise intestine is most common content

Ilioinguinal damage= cremasteric reflex lost , loss of sensation on ipsilateral penis ,

scrotum and upper thigh
Genital branch of Genitofemoral =
Femoral branch of Genitofemoral =

Femoral Hernia:
Medial to femoral sheath , 1.25 cm long and wide at base , contents include connective
tissue , deep inguinal lymph nodes and nodes of Cloquet
20% in women(older) and 5% in Men(young) , twice common on the right , 20% bilateral
and 40% strangulated at presentation. Rare before puberty

Saphena varix = differential , disappears on laying flat and positive cough impulse and
fluid thrill
Tx
Lockwood = oblique incision , for elective , non strangulation
Mc Evedy = vertical hernia, for emergency and strangulation and bilateral hernia
Lothessein / Inguinal Incision = for elective or emergency without strangulation.

Umbilical Hernia :
In premature black infants (10%)
Conservative = less than 2 year
Surgery = in more than 2 year and symptomatic

In adults :
Herniorrhaphy if less than 2cm Mayo repair ( double breasting, transverse incision used
, non - absorbable mattress suture used)

Mesh repair if more than 2cm , Onlay repair , quickest in peritoneal space and securest
in retro muscular plane , subcutaneous space is most prone to infection.

Epigastric Hernia :
Along linea alba between umbilicus and xiphisternum, either fatty hernia or true
epigastric hernia ( having peritoneum) , multiple, very painful like peptic ulcer, in healthy
fit male ( 25-40 years)

Spigelian Hernia :
Below umbilicus , above arcuate line, through aponeurosis of transversus muscle

Lumbar Hernia :
Incisional, two triangles inferior Petit ( most common ) and Superior is Grynfelt

Incisional hernia :
In Vertical incision with week one layered suture.
May be diffuse or multiple, obstructed but rarely strangulated . Skin excoriation may be
present.
Anatomical repair for small and Mesh (sublay) for larger.

Burst abdomen :
Wound dehiscence, serosanguinous pink discharge , pain and shock absent
Tx
Monofilament nylon sutures used, anterior 2/3rd circumference of abdomen covered
with adhesive plaster and antibiotics required.

Rectus Sheath Hematoma :

From trauma , inferior epigastric artery tearing. At an arcuate line because posterior
sheath is lacking.
Seen in thin elderly women, pregnant women or athletic young men
Fothergill sign : pain on rectus flexion

Vitellointestinal Duct :
Should disappear 5-6th week in utero . In remain
Umbilical sinus = only umbilical part patent
Umbilical Fistula = both ileal and umbilical part patent, persistent foul smelly pus
discharge from umbilicus.
Meckel = ileal portion patent and diverticulum formed.

Obturator Hernia :
6 times more in women , 60 years or older.
Howship Romberg sign = more prominent on hip flexion , abduction , and outward
rotation
Pain along medial part of knee due to geniculate branch of obturator nerve
OBturator fascia is cut parallel to the obturator vessels and nerve.

Desmoid Tumor :
Aggressive fibromatosis, benign , locally aggressive, 80% in women. May be associated
with FAP / Gardner syndrome.
Initially slow growing then myxomatous changes and becomes fast growing
May cause hydronephrosis
Tx : Wide excision with 2.5 cm healthy margin , moderately radio sensitive

PERITONITIS

ACUTE INFLAMMATION OF PERITONEUM

BACTERIAL PERITONITIS CAUSES

GI SOURCES
ENDOTOXIN MEDIATED ...GRAM NEGATIVE RODS E COLI ENTEROCOCCI
EXOTOXIN MEDIATED .....CLOSTRIDIUM
BACTEROIDES..... GRAM NEGATIVE NON SPORING

NON GI SOURCES
PID ... CHLAMYDIA GONOCOCCUS
SBP....STREPTOCOCCI STAPHYLOCOCCI
MYCOBACTERIAL ..... TB

LOCALIZED PERITONITIS

RISK FACTORS:
ADHESION
SLOW PERISTALSIS
SURGICAL DRAIN
GREATER OMENTUM
ANATOMICAL DIVISION

SIGN SYMPTOMS
MALAISE ANOREXIA NAUSEA
PYREXIA VOMITING
PATHOGNOMONIC SIGN: GUARDING RIGIDITY REBOUND TENDERNESS
SHOULDER TIP PAIN(C5 DERMATOME) PHRENIC NERVE ..INFLAMMATION
UNDER DIAPHRAGM

GENERALIZED PERITONITIS

SEVERE ABDOMINAL PAIN AGGRAVATED WITH MOVEMENT AND DEEP

RESPIRATION
GUARDING RIGIDITY OF ABDOMINAL WALL
ANOREXIA FEVER MALAISE
TENDERNESS OVER DRE OR VE
TACHYCARDIA
ABSENT OR REDUCED BOWEL SOUND
SEPTIC SHOCK
CIRCULATORY FAILURE( COLD CLAMMY SKIN SUNKEN EYES DRY TONGUE
THREADY IRREGULAR PULSE DRAWN N ANXIOUS (HIPPOCRATES FACIES)

INVESTIGATION

[Link] RADIOGRAPH
SUPINE ABDOMINAL X RAY (DILATED GAS FILLED LOOP CONSISTENTLY WITH
PARALYTIC ILEUS )
ERECT CHEST X RAY .(. GAS UNDER DIAPHRAGM)
LATERAL DECUBITUS FILM (GAS BENEATH ABDOMINAL WALL)

[Link] FLUID ASPIRATION

BILE STAINED FLUID ( PERFORATED PEPTIC ULCER)
BILE STAINED FLUID (PERFORATED GALLBLADDER)
PUS IN FLUID (BACTERIAL PERITONITIS)
BLOOD IN FLUID (INTRAPERITONEAL BLEEDING)

MANAGEMENT:

[Link] CARE
[Link] MANAGEMENT (ACUTE APPENDICITIS ,PEPTIC ULCER DISEASE
DIVERTICULAR DISEASE PERFORATED TUMORS)
[Link] OPERATIVE MANAGEMENT (PANCREATITIS ,SALPINGITIS ,PRIMARY
BACTERIAL PERITONITIS )
[Link] LAVAGE (WITH NORMAL SALINE ANTISEPTIC + ANTIBIOTIC
(TETRACYCLINE)) IF LARGE VOLUME AT LEAST 3L

COMPLICATION

SYSTEMIC :
SHOCK
PNEUMONIA
RESPIRATORY FAILURE
RENAL FAILURE
BONE MARROW SUPPRESSION
MULTIORGAN FAILURE

ABDOMINAL COMPLICATION
ADHESION
PARALYTIC ILEUS
RESIDUAL
PORTAL PYEMIA
LIVER ABSCESS .

PELVIC ABSCESS

MC INTERAPERITONIAL ABCESS
CAUSES: APPENDIX FALLOPIAN TUBE DIFFUSE PERITONITIS COLORECTAL
SURGERY

SIGN:
PELVIC PAIN DIARRHEA PASSAGE OF MUCUS IN STOOL
RECTAL EXAMINATION BULGING OF RECTAL WALL

MANAGEMENT:
[Link] TRAN VAGINAL DRAINAGE
[Link] TRANSRECTAL DRAINAGE
SUBPHRENIC ABSCESS

SPECIALIZED FORM OF PERITONITIS

SPONTANEOUS BACTERIAL PERITONITIS

BACTERIAL INFECTION OF ASCITES FROM ANY CAUSE

CAUSE: CIRRHOSIS

CF: ASCITES WORSENING DISTENSION ABDOMINAL PAIN

FEVER TACHYCARDIA TACHYPNEA LEUKOCYTOSIS

BEST INITIAL TEST... PERITONEAL ASPIRATION WBCS GREATER THAN 250

CULTURES POSITIVE FOR GNR E .I GPC STREPTOCOCCI STAPHYLOCOCCI

TX :ANTIBIOTICS

[Link] PERITONITIS
CAUSE: NEPHROTIC SYNDROME CIRRHOSIS MIDDLE EAR INFECTION
RESPIRATORY INFECTION

CF: SUDDEN ONSET PAIN LOCALIZED TO LOWER HALF OF ABDOMEN (EARLY

SYMPTOM)
PYREXIA
VOMITING
PROFUSE DIARRHEA
INCREASED MICTURITION

DX: ODORLESS STICKY EXUDATE

TX: ANTIBIOTIC ,SURGERY (SPE) ,ASCITES (PERITONEAL TAPE)

[Link] PERITONITIS

CF : ABDOMINAL PAIN FEVER NIGHT SWEAT LOSS OF WEIGHT ASCITE

ABDOMINAL MASS
4 TYPES
[Link] FORM
PERITONEUM WITH TUBERCLES
PAIN ABSENT
VEIN DILATED
ABDOMINAL PALPATE TRANSVERSE ABDOMINAL MASS
ASCITIC FLUID : PALE YELLOW RICH IN LYMPHOCYTE EXADUATE

[Link] FORM
LOCALIZED INTRA ABDOMINAL SWELLING
INTESTINAL OBSTRUCTION

[Link] /PLASTIC FORM

WIDESPREAD ADHESION

[Link] FORM:
Rare

TX ANTI TUBERCULOUS DRUGS

NEOPLASM OF PERITONEUM

[Link] PERITONEI
METASTATIC DISEASE OF PERITONEUM
SPREAD FROM: STOMACH COLON OVARY BREAST BRONCHUS

3 FORMS DISCRETE(MC) PLAQUES DIFFUSE

FROZEN PELVIS( DIFFUSE FORM)

TUBERCULOSIS ( DISCRETE)

MANAGEMENT:
UNDERLYING CAUSE TREATMENT
CRYOREDUCTIVE SURGERY
INTRAPERITONEAL CHEMOTHERAPY
HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY (HIPC)

2 PSEUDOMYXOMA PERITONEI
CAUSE: MUCINOUS CYSTIC TUMOR OF APPENDIX OR OVARY
DX : US OR CT SCAN

MANAGEMENT:
APPENDECTOMY

IF TUMOR LOW GRADE DO COLONOSCOPY EVERY 5 YEARS

IF HIGH GRADE RIGHT HEMICOLECTOMY PERITONECTOMY OMENTECTOMY
SALPHINGOOPHERCTOMY INTRAPERITONEAL CHEMOTHERAPY

MESENTERIC ADENITIS

[Link] NON SPECIFIC MESENTERIC ADENITIS

YERSINIA INFECTION ..DENTS SIGN LYMPHADENOPATHY OF ILEUM

TYPHOID FEVER ..DUMBBELL SIGN
PSEUDOAPPENDICITIS ..YERSINIA

MC SITE : ILEOCECAL LYMPH NODES

CF: SHORT ATTACKS OF CENTRAL ABDOMINAL PAIN LASTING FROM 20-30
MINUTES
NODES ENLARGED N RED
PYREXIA
VOMITING
SHIFTING TENDERNESS
LEUKOCYTOSIS

TX : BED REST ANALGESIA APPENDICITIS( APPECTOMY OR DIAGNOSTIC

LAPAROSCOPICALLY)

[Link] MESENTERIC ADENITIS

LESS COMMON
COMMON IN CHILDREN
CENTRAL ABDOMINAL PAIN CONSTANT
INTESTINAL OBSTRUCTION

DX ABDOMINAL X RAY ...CALCIFIED LYMPH NODES MANTOUX TEST CHEST X

RAY
TX ANTI TB DRUGS
LOCAL ABSCESS DRAINAGE

MESENTERIC PATHOLOGIES

[Link] CYST
5 TYPES
CHYLOLYMPHATIC
SIMPLE (MESOTHELIAL)
ENTEROGENOUS
UROGENITAL REMNANT
DERMOID (TERATOMUS CYST)

CHYLOLYMPHATIC(MC TYPE)
OWN BLOOD SUPPLY
THIN LINED FLAT ENDOTHELIUM
TX ENUCLEATION

ENTEROGENOUS TYPE
NO OWN BLOOD SUPPLY
THICK LINED WITH CILIATED MUCOUS MEMBRANE
TX: RESECTION OF INTESTINAL PART

TILLAUX TRIAD: SOFT FLUCTUANT SWELLING AROUND UMBILICUS MOVES

FREELY AROUND UMBILICUS ZONE OF RESSONUNCE
TILLAUX SIGN : SWELLING MOVES FREELY IN A PLAN RIGHT ANGLES TO THE
ATTACHMENT AROUND MESENTERY

MESENTERIC INJURY
SEVERE ABDOMINAL CONTUSION MOTOR VEHICLE ACCIDENT
SEAT BELT SIGN
BUCKET HANDLE INJURY

2 FORM
TRANSVERSE LACERATION
SEVERE BLOOD SUPPLY OF SEGMENT IMPAIRED
SURGICAL RESECTION OF INTESTINE
VERTICAL LACERATION
LESS SEVERE BLOOD SUPPLY NOT IMPAIRED
SIMPLE SUTURING OF TEAR

RETROPERITONEAL PATHOLOGIES

FIBROSIS (MC CAUSE :IDIOPATHIC DISEASE ORMAND DISEASE)

SARCOMAS:
3 TYPES. LIPOSARCOMA(MC) LEIOMYOSARCOMA MALIGNANT FIBROUS
HISTIOCYTOMA
DX CT + MRI
TX: SURGICAL EXCISION

LIVER

FOREGUT STRUCTURE ... SUPPLY BY CELIAC ARTERY

1.7KG (LARGEST GLAND) ,FALCIFORM LIGAMENT (REMNANT IF FETAL
UMBILICAL VEIN) DIVIDE LIVER INTO 2 LOBES RIGHT N LEFT , RIGHT LOBE
CONTAIN QUADRATE AND CAUDATE LOBE

PORTA HEPATIS: (HILUM OF LIVER)

COMMON HEPATIC DUCT
HEPATIC ARTERY
PORTAL VEIN
SYMPATHETIC NERVE FIBER
PARASYMPATHETIC NERVE FIBER
LYMPHATIC VESSELS

BLOOD SUPPLY
HEPATIC ARTERY 20 PERCENT
PORTAL VEIN 80 PERCENT

CANTLIE LINE: FUNCTIONALLY DIVIDE THE LIVER INTO RIGHT AND LEFT LIVER

COUINAUD'S LIVER SEGMENTS:

SEGMENT 1 CAUDATE LOBE
SEGMENT 2-4 LEFT LOBE
SEGMENT 5-8 RIGHT LOBE
INVESTIGATION

ALT(CYTOSOL) INCREASE IN LIVER CELL NECROSIS ...VIRAL HEPATITIS

AST(MITOCHONDRIA) ..INCREASED IN ALCOHOLIC HEPATITIS
ALP GGT INCREASE= CHOLESTATIC JAUNDICE
ALP INCREASE GGT NORMAL= BONE (PAGET DISEASE)

ULTRASOUND( FIRST LINE INVESTIGATION) GALLSTONE BILE DUCT DILATION

MASSES

CT SCAN ( BEST MODALITY) :

EARLY ARTERIAL ENHANCEMENT= PRIMARY LIVER CANCER
LESION WITH RIM ENHANCEMENT= { INFLAMMATORY LIVER LESION}
DELAYED VENOUS ENHANCEMENT = HEMANGIOMA

MRI MRCP ( CHOLANGIOCARCINOMA/ KLATSKIN TUMOR)

ERCP IF IT FAILED PTC
ANGIOGRAPHY (TUMOR VESSEL GROWTH )
FDF PET SCAN( DIFFERENTIATE BETWEEN BENIGN AND INFLAMMATORY
CONDITION)

ACUTE LIVER FAILURE

SUDDEN LOSS OF LIVER FUNCTION LEADS TO HEPATIC ENCEPHALOPATHY
HYPERACUTE LESS THAN 7 DAYS VIRAL PARACETAMOL
ACUTE 8-28 DAY (CRYPTOGENIC DRUGS)
SUB ACUTE. 29 DAY-12 WEEK (CRYPTOGENIC DRUGS)

MC CAUSE: VIRAL HEPATITIS

MC DRUG: PARACETAMOL
MC TOXIN: AMANITA PHALLOIDES

HEPATOMEGALY + SUDDEN ASCITES= BUDD CHIARI SYNDROME

MANAGEMENT:
IV N ACETYL CYSTEINE( INCREASE CEREBRAL BLOOD FLOW).
ADMIT IN ICU N GIVE SUPPORTIVE THERAPY
CHRONIC LIVER DISEASE

IRREVERSIBLE LIVER DIFFUSE FIBROSIS WITH FORMATION OF REGENERATIVE

NODULES
DECOMPENSATED WHEN IT OCCURS WITH JAUNDICE VARICEAL HEMORRHAGE
ASCITES AND ENCEPHALOPATHY
MC CAUSE OF PORTAL HYPERTENSION

MC CAUSE WORLDWIDE: HEPATITIS B N C

MC CAUSE IN WEST: ALCOHOLIC

LIVER :
INITIALLY ENLARGED FIRM PALPABLE
EVENTUALLY SHRUNKEN N NODULAR

INVESTIGATION :
LIVER FUNCTION
BILURIBBIN ALBUMIN PROTHROMBIN TIME FOR CLD PATIENT .
CHILD PUGH CLASSIFICATION 5 COMPONENTS( ASCITES ENCEPHALOPATHY
BILIRUBIN ALBUMIN PT)
CHILD A LESS THAN 7 SCORE
CHILD B 7-10
CHILD C MORE THAN 10

PORTAL HYPERTENSION

HVPG PRESSURE DIFFERENCE OF PORTAL VEIN AND IVC

HVPG GREATER THAN 6 PORTAL HTN
HPVG GREATER THAN 10 PORTAL HTM CLINICALLY APPEAR AT RISK OF
VARICES
HVPG GREATER THAN 12 PATIENT AT RISK OF BLEEDING ASCITES

MC CAUSE: CHRONIC LIVER DISEASE

CLINICAL FEATURE:
SPLENOMEGALY : CARDINAL SIGN
ASCITES FETOR HEPATICUS
CRUVEILHIER BAUMGARTEN SYNDROME : VENOUS HUM ON AUSCULTATION BY
DISTENTION LARA UMBILICAL VEIN
ASCITES
ACCUMULATION OF EXCESS FLUIDS MORE THAN 500ML

SIGN:
ABDOMINAL DISTENSION
FLUID THRILL AND SHIFTING DULLNESS

CAUSES:
SINUSOIDAL HYPERTENSION
HYPOALBUMINEMIA
SPLANCHNIC VASODILATION
SECONDARY HYPERALDOSTERONISM

MANAGEMENT:
WATER N SALT RESTRICTION
DIURETICS( SPIRO LACTONE - DOC)
REFRACTORY ASCITES :
LARGE VOLUME PARACENTESIS
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT TIPSS
SURGICAL SHUNTS
PERITONEOVENOUS SHUNTING ...LEVEEN SHUNT
LIVER TRANSPLANTATION

PORTAL HTN ASSOCIATED ASCITES: SAAG GREATER THAN

1.1G/DL(TRANSUDATIVE FLUID)
CIRRHOSIS ACUTE HEPATITIS LIVER MALIGNANCY ,RIGHT SIDED HF, BUDD
CHIARI SYNDROME,SPLENIC VEIN THROMBOSIS, SCHISTOSOMIASIS
NON PORTAL HTN ASSOCIATED ASCITES: SAAG LESS THAN 1.1G/DL EXUDATIVE
FLUID
PERITONITIS, PERITONEAL CARCINOMATOSIS
PANCREATITIS,VASCULITIS,HYPOALBUMINEMIA,MEIGS
SYNDROME,HYPOTHYROIDISM

ESOPHAGEAL VARICES
BLEEDING MOST COMMONLY OCCUR FROM LOWER ESOPHAGUS
IMPORTANT SITE OF PORTOSYSTEMIC SHUNT
ESOPHAGEAL ,GASTRIC VARICES,ANORECTAL VARICES, CAPUT MEDUSAE
(UMBILICUS)

MANAGEMENT
DOC FOR PORTAL HYPERTENSION : TERLIPRESSIN
BAND LIGATION:
ESOPHAGEAL VARICES: BAND LIGATION TO STOP BLEEDING TO PREVENT
ULCER FORMATION GIVE PPI ALONG THIS PROCEDURE

INJECTION SCLEROTHERAPY:
SCLEROSING AGENT (POLIDOCANOL) INCREASE RISK OF PERFORATION N
STRICTURE

PHARMACOLOGICAL AGENT: VASOCONSTRICTOR: TERLIPRESSIN

OCTREOTIDE,VASOPRESSIN
PRIMARY PREVENTION OF BLEEDING : PROPRANOLOL

BALLOON TAMPONADE:
INDICATION: IF ENDOSCOPIC N PHARMACOLOGICAL METHOD FAILS
TUBE: SENGSTAKEN BLAKEMORE TUBE (2 BALLOON 1 STOMACH(300ML) 1
ESOPHAGUS(LESS THAN 40 MMHG)
COMPLICATION: ESOPHAGEAL PERFORATION ASPIRATION PNEUMONIA

TIPSS
INDICATION:
ACTIVE VARICEAL BLEEDING,RECURRENT EV BLEEDING ,ISOLATED GASTRIC
VARICES ,HIGH RISK SURGICAL PATIENT ,CHILD PUGH CLASS A N B
METHOD: STENT BETWEEN PORTAL AND HEPATIC VEIN WITH IN LIVER TO
REDUCE PORTAL PRESSURE
MC CONTRAINDICATION: PORTAL VEIN THROMBOSIS
COMPLICATION:
LIVER CAPSULE PERFORATION (EARLY MOST COMMON)
POST SHUNT ENCEPHALOPATHY
STENOSIS OF THE SHUNT

SURGICAL SHUNTS
NON SELECTIVE SHUNT(HIGH INCIDENCE OF HEPATIC ENCEPHALOPATHY)
END TO SIDE PORTACAVAL SHUNT
CENTRAL SPLENORENAL SHUNT
SIDE TO SIDE PORTACAVAL SHUNT
SELECTIVE SHUNT (LOW INCIDENCE OF ENCEPHALOPATHY)
DISTAL SPLENORENAL(WARREN SHUNT)
MESOCAVAL SHUNT
SARFEH SHUNT(H GRAFT)

SPLENECTOMY AND GASTROESOPHAGEAL DEVASCULARIZATION

LIVER TRANSPLANTATION

BUDD CHIARI SYNDROME

HEPATIC VEIN OUTFLOW OBSTRUCTION

DX HEPATIC VENOGRAPHY( CONFIRMATORY TREATMENT)

CT SCAN LARGE CONGESTED LIVER (EARLY STAGE)

TX: SHUNTS(TIPSS POSTCAVAL SHUNT),LIVER TRANSPLANTATION

TUMORS AND CYST OF LIVER

MC BENIGN : HEMANGIOMA
MC MALIGNANT : HCC

[Link] :
KASABACH MERRITT SYNDROME (CONSUMPTIVE COAGULOPATHY CAUSED BY
SEQUESTRATION OF PLATELETS AND CLOTTING FACTORS IN GIANT
HEMANGIOMA)
DX:RADIOLABELED RBCS SCAN( HEMANGIOMA)
ULTRASOUND
CONTRAST ENHANCED CT SCAN
DELAYED ENHANCEMENT,CENTRAL ARTERIALIZATION
TX: ASYMPTOMATIC ( OBSERVATION) SYMPTOMATIC( EXCISION ENUCLEATION
)

[Link] ADENOMA
ASSOCIATED WITH OCPS
HOMOGENOUS MASS NO CENTRAL VEIN NO BILE DUCTULES
DX: ULTRASOUND
SULFUR COLLOID SCAN(KUPFFER CELL): NO UPTAKE
CONTRAST ENHANCED CT SCAN
EARLY ENHANCEMENT ,WELL DEVELOPED PERIPHERAL ARTERIALIZATION
RISK OF HCC
TX
ADENOMA LESS THAN 5 CM OBSERVE /CEASE OCP
ADENOMA GREATER THAN 5CM SURGICAL RESECTION

[Link] NODULAR HYPERPLASIA :

HOMOGENOUS MASS NO CENTRAL VEIN HAVE BILE DUCTULES
SULPHUR COLLOID POSITIVE FOR KUPFFER CELL
NOT A PRECANCEROUS LESION

[Link] CARCINOMA

MC CAUSE: HEPATITIS B & C

TOXIN: AFLATOXIN

CLINICAL FEATURE: WEIGHT LOSS ABDOMINAL PAIN FATIGUE SPONTANEOUS

RUPTURE , CLD SYMPTOMS

DX: US ABDOMEN ( HYPOECHOIC SOLID APPEARING LESION)

CONTRAST ENHANCED CT SCAN , MRI(MOSAIC PATTERN),CT SCAN CHEST ,
BONE SCAN

MANAGEMENT :
SURGERY (TOTAL/PARTIAL HEPATECTOMY ) PARTIAL FOR NON CIRRHOTIC
TOTAL+ lIVER TRANSPLANT IN CIRRHOSIS

ABLATIVE TECHNIQUE :
TRANS ARTERIAL EMBOLIZATION
TRANS ARTERIAL CHEMO EMBOLIZATION
PERCUTANEOUS ETHANOL INJECTION
THERMAL ABLATION

OBSTRUCTIVE JAUNDICE

PAINLESS PROGRESSIVE JAUNDICE WITH PALPABLE GALLBLADDER=

PANCREATIC CA

PAINLESS PROGRESSIVE JAUNDICE WITH NO PALPABLE GALLBLADDER =

KLATSKIN TUMOR(CHOLANGIOCARCINOMA)
PAINLESS INTERMENTENT JAUNDICE +- PALPABLE GALLBLADDER =
CHOLEDOCHOLITHIASIS CHOLELITHESIS

PAINFUL INTERMITTENT JAUNDICE WITH NO PALPABLE GALLBLADDER =

CHOLEDOCHOLITHIASIS

PAINFUL JAUNDICE WITH PALPABLE GALLBLADDER = DOUBLE IMPACTION OF

STONE

CHARCOT TRIAD( FEVER JAUNDICE RUQ PAIN)= ASCENDING CHOLANGITIS

SURGICAL MANAGEMENT:
CA OF PANCREASES: WHIPPLE PROCEDURE
CHOLEDOCHOLTHESIS: CHOLEDOCTOMY
BILIARY ATRESIA : KASAI PROCEDURE

ENDOSCOPIC PROCEDURE:
ERCP( SPHINCTERECTOMY /STENT INSERTION)
PTC( STENT INSERTION)

ESOPHAGUS

ESOPHAGEAL CONSTRICTION

CRICOPHARYNGEAL CONSTRICTION 15 CM FROM INCISOR TEETH

AORTIC N BRONCHIAL CONSTRICTION 25 CM FROM INCISOR TEETH
DIAPHRAGMATIC AND SPHINCTER CONSTRICTION 40 CM FROM INCISOR
TEETH

ESOPHAGEAL ANATOMY

UPPER 1/3
STRIATED MUSCLE INFERIOR THYROID ARTERY + VEIN DEEP CERVICAL
NODES PARATRACHEAL NODES

MIDDLE 1/3
SKELETAL + SMOOTH ESOPHAGEAL ARTERY AZYGOUS ON RIGHT
HEMIAZYGOUS ON LEFT MEDIASTINAL LYMPH NODES THORACIC DUCT
LOWER 1/3
SMOOTH LEFT N PAIRED PHRENIC ARTERY LEFT GASTRIC NODES CELIAC
NODES

INVESTIGATION OF CHOICE
PLAIN RADIOGRAPH ...FOREIGN BODY OBSTRUCTION
ENDOSCOPY... MOST ESOPHAGEAL CONDITION
CT SCAN ... ESOPHAGEAL NEOPLASM PERFORATION
24 HOUR PH MONITORING ... GERD
MANOMETRY ... ESOPHAGEAL MOTILITY DISORDER
ENDOSONOGRAPHY .. ENDOSCOPIC ULTRASONOGRAPHY

ESOPHAGEAL PERFORATION

MC CAUSE: IATROGENIC /INSTRUMENTAL

BAROTRAUMA(BOERHAAVE SYNDROME) ESOPHAGEAL PERFORATION DUE TO

INCREASE PRESSURE IN ESOPHAGUS

CERVICAL PERFORATION NECK PAIN+ STIFFNESS

THORACIC PERFORATION RETROSTERNAL CHEST PAIN SHORTNESS OF
BREATH
ABDOMINAL PERFORATION EPIGASTRIC PAIN RIGIDITY

INVESTIGATION:
INITIAL CHEST X RAY AIR IN MEDIASTINUM PNEUMOTHORAX
PNEUMOPERITONEUM
MOST ACCURATE CT SCAN
CONTRAST ESOPHAGOGRAPHY (BARIUM ) FOR THORACIC + GASTROGRAFIN
(WATER SOLUBLE ) IN ABDOMEN

SURGICAL APPROACHES

UPPER 2/3 RIGHT POSTEROLATERAL THORACOTOMY

LOWER 1/3 LEFT POSTEROLATERAL THORACOTOMY
GASTROESOPHAGEAL JUNCTION UPPER MIDLINE ABDOMINAL INCISION LEFT
THORACOTOMY

[Link] REPAIR
EARLY PRESENTATION WITHIN 24 HOUR MINIMAL MEDIASTINAL PLEURAL
CONTAMINATION

[Link] DRAINAGE WITH CONTRAST FISTULA ENTERAL FEEDING

DELAYED PRESENTATION AFTER 24 HOUR
WIDESPREAD MEDIASTINUM PLEURAL CONTAMINATION
T TUBE PLACEMENT INTO ESOPHAGUS WITH DRAIN AND JEJUNOSTOMY

GASTROESOPHAGEAL REFLUX DISEASE(GERD)

REFLUX ESOPHAGITIS
TRANSIENT LES RELAXATION /INCOMPETENT RELAXATION
TRAID: RETROSTERNAL BURNING PAIN,EPIGASTRIC PAIN RADIATE TO
BACK,REGURGITATION
WATER BASH
PAIN INCREASE BY BENDING STRAINING LYING DOWN

DX:
ENDOSCOPY (INVESTIGATION OF FIRST CHOICE)
24 HOUR HOUR PH MONITORING (GOLD STANDARD).
POSITIVE TEST:GREATER THAN 6 PERCENT OF THE TIME WITH PH OF LESS
THAN 4
MEDICATION STOP BEFORE THIS TEST
H2 BLOCKER 3 WEEK BEFORE TEST
PP1 1 WEEK BEFORE

TX:
LIFESTYLE MODIFICATION
PPI DRUG OF CHOICE GIVEN FOR 8 WEEKS ONLY ALSO USED IN TREATMENT
OF REFLUX INDUCED STRICTURE

SURGICAL TYPES
COMPLETE FUNDOPLICATION (360 DEGREE )OR NISSEN FUNDOPLICATION
GAS BUBBLE SYNDROME
PARTIAL FUNDOPLICATION :

HILLS PROCEDURE
PARTIAL GASTRECTOMY WITH ROUX EN Y CONSTRUCTION
LAPAROSCOPIC FUNDOPLICATION
HIATAL HERNIA

SLIDING HERNIA (TYPE1)

MOST COMMON
ASSOCIATED WITH GERD .
GE JUNCTION IS NOT MAINTAINED IN ABDOMINAL CAVITY MIGRATED TO
MEDIASTINUM

ROLLING HERNIA (TYPE 2)

PARAESOPHAGEAL TYPE
CARDIA GE JUNCTION IN NORMAL POSITION
VISCERA IN CHEST CAVITY

TYPE 3 (MIXED)
BOTH TYPE 1+2

TYPE 4 SPLEEN or COLON

TYPE 1+3 REFLUX SYMPTOM

TYPE 2 NON REFLUX SYMPTOMS

CAMERON ULCER ISCHEMIC LONGITUDINAL ULCER OF HERNIATED GASTRIC

POUCH
ROLLING HIATAL HERNIA CHEST X RAY GAS BUBBLE WITH AIR FLUID LEVEL IN
CHEST AND IN ABDOMEN
UPPER BARIUM GI STUDY BEST METHOD OF DIAGNOSIS

BARRETT ESOPHAGUS
SQUAMOUS EPITHELIUM CHANGE TO COLUMNAR EPITHELIUM (INTESTINAL
METAPLASIA)

TYPES:
1. CLASSIC BERET MORE THAN 3 CM OF COLUMNAR EPITHELIUM
SHORT SEGMENT BARRETT LESS THAN 3 CM OF COLUMNAR EPITHELIUM
CARDIAC METAPLASIA INTESTINAL METAPLASIA

DX: ENDOSCOPY

TX:
ESOPHAGECTOMY (IF ADENOCARCINOMA)
PHOTODYNAMIC THERAPY
ARGON BEAM PLASMA COAGULATION
ENDOSCOPIC MUCOSAL RESECTION

ESOPHAGEAL CARCINOMA
6 MOST COMMON CANCER
[Link]
LOWER THIRD ESOPHAGUS
GERD AND BARRETT'S ESOPHAGUS

[Link] CELL CARCINOMA

UPPER 2/3 OF ESOPHAGUS
SMOKING TOBACCO ACHALASIA PLUMMER VINSON SYNDROME

CLINICAL FEATURE
PROGRESSIVE DYSPHAGIA
REGURGITATION ODYNOPHAGIA
ANOREXIA WEIGHT LOSS

TUMOR SPREAD:
LOCAL RAPID DUE TO LACK OF SEROSA LATERALLY LONGITUDINALLY

LYMPHATIC OCCURS IN CAUDAL DIRECTION MEDIASTINUM CELIAC GASTRIC

HEMATOGENOUS LIVER LUNGS BONES BRAIN

BEST INITIAL INVESTIGATION:

ENDOSCOPY WITH BIOPSY FIRST LINE
CYTOLOGY AND HISTOLOGY

FIT FOR SURGERY - WORKUP FOR STAGING

IF UNFIT FOR SURGERY -- PALLIATIVE CARE

STAGE WORKUP :
CT SCAN INVESTIGATION OF CHOICE
LAPAROSCOPIC PERITONEAL SPREAD
ENDOSCOPIC ULTRASOUND IF TUMOR IN WALL
PET SCAN IF DISSEMINATED DISEASE
BRONCHOSCOPY IF TRACHEAL INVOLVE
T1 MUCOSA MUSCULARIS MUCOSA SUBMUCOSA
T2 TUMOR IN MUSCULARIS PROPRIA
T3 TUMOR IN ADVENTITIA
T4 TUMOR IN ADJUVANT STRUCTURE

MANAGEMENT
MOST IMPORTANT CURATIVE TREATMENT : RADICAL ESOPHAGECTOMY
IDEAL RESECTION MARGIN ARE 10 CM PROXIMAL TO MACROSCOPIC TUMOR 5
CM DISTAL TO MACROSCOPIC TUMOR

EARLY ESOPHAGEAL CANCER JUST SURGERY

MULTIMODAL THERAPY IN ADVANCED ESOPHAGEAL CANCER

SURGICAL APPROACHES

IVOR LEWIS OPERATION:

2 STAGE OPERATION
1 LAPAROTOMY TO CONSTRUCT GASTRIC TUBE
2 RIGHT THORACOTOMY TO EXCISE TUMOR N CREATE ESOPHAGOGASTRIC
ANASTOMOSIS

MCKEOWN OPERATION
3 STAGE OPERATION
FIRST 2 SAME AS ABOVE
3 CERVICAL INCISION TO COMPLETE PERMIT LYMPHADENECTOMY
SQUAMOUS CELL CANCER UPPER ESOPHAGUS

TRANSHIATAL RESECTION
ABDOMEN + CERVICAL INCISION
ADENOCARCINOMA OF LOWER ESOPHAGUS

CHEMOTHERAPY
FLUOROURACIL
ETOPOSIDE
CISPLATIN

EXPANDING METAL STENT ...MALIGNANT TRACHEOESOPHAGEAL FISTULA

COMPLICATION: RESPIRATORY COMPLICATION (MC EARLY ) BENIGN
ANASTOMOTIC STRICTURE (MC LATE)

ACHALASIA

DEFINITION:
FAILURE OF LOWER ESOPHAGEAL SPHINCTER TO RELAX
,APPRESTALSIS,INCREASING RESTING TONE OF LES

LOSS OF GANGLION IN MYENTERIC PLEXUSES = LOSS OF MOTILITY

LOSS OF NO= INCOMPETENT RELAXATION OF LES

CHAGAS DISEASE TRYPANOSOMA CRUZI MEGAESOPHAGUS MEGACOLON

MEGA HEART

PSEUDOACHALASIA DUE TO ADENOCARCINOMA OF CARDIA PANCREATIC

CANCER BRONCHOGENIC CANCER

CLINICAL FEATURE :
DYSPHAGIA FOR LIQUID N SOLID BOTH
NOCTURNAL REGURGITATION
RESPIRATORY INFECTION

DIAGNOSIS:
BARIUM SWALLOW TEST :
BEARD BEAK APPEARANCE
RAT TAIL APPEARANCE
PENCIL TIP APPEARANCE
GASTRIC BUBBLE ABSENT

ESOPHAGEAL MANOMETRY: GOLD STANDARD

VIGOROUS ACHALASIA : EARLY STAGE INFLAMMATORY NEURAL FIBROSIS

NORMAL GANGLION CELLS

TREATMENT:
PNEUMATIC DILATATION (COMPLICATION: PERFORATION)
HELLER'S MYOTOMY + DOR FUNDOPLICATION (COMPLICATION: GERD)
MEDICATION: BOTOX INJECTION , CALCIUM CHANNEL BLOCKER
DIFFUSE ESOPHAGEAL SPASM:

HYPERMOTILITY DISORDER,UNCOORDINATED CONTRACTION OF ESOPHAGUS

CAUSING DYSPHAGIA CHEST PAIN
BARIUM SWALLOW CORKSCREW APPEARANCE
NORMAL DES TONE ,CONTRACTION WAVES
ORAL CALCIUM CHANNEL BLOCKER
LONG ACTING NITROUS OXIDE
PNEUMATIC DILATATION
MYOTOMY

NUTCRACKER ESOPHAGUS ( DIFFUSE ESOPHAGEAL SPASM)

ZENKER'S DIVERTICULUM
DYSPHAGIA SMALL ( PHARYNGEAL) LARGE( ESOPHAGEAL)
REGURGITATION OF FOOD
HALITOSIS
ASPIRATION OF FOOD
GURGLING SOUND
NECK SWELLING

TREATMENT
ENDOSCOPIC STAPLED PHARYNGOPLASTY
SURGERY (DIVERTICULECTOMY + MYOTOMY)

TRACTION DIVERTICULUM
MIDDLE ESOPHAGUS
TB HISTOPLASMA

EPIPHRENIC DIVERTICULUM
LOWER ESOPHAGUS

ESOPHAGEAL INFECTION:
CANDIDA: CURDY WHITE PLAQUE
CMV :LINEAR ULCER
HSV: PUNCHED OUT ULCER
SPLEEN

MEASUREMENT:10×7×3 cm
LOCATION: LEFT HEMIDIAPHRAGM AT 10 RIB
ARTERY : SPLENIC ARTERY .. CELIAC TRUNK
VENOUS DRAINAGE: SPLENIC VEIN + SMV CONVERTS TO PORTAL VEIN
CONTAINS 2 COMPONENTS:
RED PULP 85 PERCENT ...RBCS
WHITE PULP 15 PERCENT... LYMPHOCYTES + MACROPHAGE

SPLENUNCULI
SINGLE OR MULTIPLE ACCESSORY SPLEEN
LOCATION : NEAR HILUM
TX: SPLENECTOMY

SPLENIC ARTERY ANEURYSM

MC VISCERAL ANEURYSM
LOCATION: MAIN ARTERIAL TRUNK
HIGH RISK OF RUPTURE IN PREGNANCY IN 3RD TRIMESTER
ELDERLY PATIENT...ARTERIAL CALCIFICATION ..OBSERVATION
REPAIR INDICATION: SYMPTOMATIC PATIENT PREGNANT ,WOMEN OF CHILD
BEARING AGE ANEURYSM GREATER THAN 3-4 CM

TX: COVERED STENT (TOC)

IMMUNE THROMBOCYTOPENIC PURPURA ITP

ANTIBODY AGAINST PLATELET MEMBRANE GLYCOPROTEIN
CAUSE OF DEATH: INTRACEREBRAL HEMORRHAGE

ACUTE ITP :
CHILDREN ,AFTER ACUTE INFECTION ,RESOLVE WITHIN 2 MONTHS

CHRONIC ITP:
ADULTS ,UNKNOWN CAUSE, PERSIST MORE THAN 6 MONTHS
DX:
PLATELET COUNT DECREASE
BONE MARROW PLATELETS PRODUCING MEGAKARYOCYTE
TREATMENT:
STEROIDS
SPLENECTOMY

HEREDITARY SPHEROCYTOSIS

MEMBRANE DEFECT INCREASE FRAGILITY ...SPECTRIN ANKYRIN BAND 3 BAND

4

CP:
JAUNDICE
GALLSTONE PIGMENTED
SPLENOMEGALY
HEPATOMEGALY
CHRONIC LEG ULCER

.DX:
FRAGILITY TEST
RADIOACTIVE CHROMIUM SCAN

TX:
SPLENECTOMY AFTER 6 YEAR OF LIFE

SPLENECTOMY

INDICATION:
TRAUMA, PORTAL HTN, ONCOLOGICAL, HEMATOLOGICAL

PREOPERATIVE VACCINATION:
BEFORE 2 WEEK IN ELECTIVE SURGERY
PNEUMOCOCCAL VACCINE
MENINGOCOCCAL VACCINE
HAEMOPHILUS INFLUENZAE
INFLUENZAE

INCISION: UPPER MIDLINE SUBCOSTAL THORACOABDOMINAL

COMPLICATION:
INTRAOPERATIVE HEMORRHAGE
GASTRIC COLONIC PERFORATION
POSTOPERATIVE HEMATOMA
THROMBOCYTOSIS

OVERWHELMING POST SPLENECTOMY SEPSIS OPSS

AGENTS: [Link] [Link],[Link]

ELECTIVE SPLENECTOMY 2 WEEK BEFORE SURGERY

EMERGENT SPLENECTOMY 2 WEEK AFTER SURGERY
SPLENECTOMY LESS THAN 5 YEAR DAILY PENICILLIN UNTIL AGE 10 YEAR
SPLENECTOMY GREATER THAN 5 YEAR DAILY PENICILLIN UNTIL AGE 16 YEAR

MC BENIGN TUMOR: HEMANGIOMA

MC MALIGNANT TUMOR: LYMPHOMA

PANCREAS

RETROPERITONEAL ORGAN 80G

PARTS: HEAD UNCINATE PROCESS NECK BODY TAIL
NECK NEAR ITS UPPER BORDER SPLENIC AND SMV MEET TO FORM PORTAL
VEIN

GLAND COMPOSITION:
EXOCRINE 80-90 PERCENT
PANCREATIC ACINI DIGESTIVE ENZYME ALKALINE PH

ENDOCRINE 5-10 PERCENT

ISLET OF LANGERHANS CONTAIN 4 CELLS
B CELL 75 INSULIN INNER CORE
A CELL 20 GLUCAGON OUTER CORE
D CELL 4 SOMATOSTATIN INTERMIXED
P CELL 1 POLYPEPTIDE

MAIN PANCREATIC DUCT (DUCT OF WIRSUNG) FORMED FROM VENTRAL AND

DISTAL PORTION OF DORSAL DUCT OPEN AT MAJOR DUODENAL PAPILLA (2ND
DUODENUM)
ACCESSORY PANCREATIC DUCT ( DUCT OF SANTORINI) PROXIMAL PORTION
OF DORSAL DUCT

ARTERIES:
SUPERIOR (CT) AND INFERIOR (SMA) PANCREATICODUODENAL ARTERY TO
HEAD AND UNCINATE PROCESS
DORSAL PANCREATIC ARTERY, INFERIOR PANCREATIC ARTERY, PANCREATICA
MAGNA ARTERY CAUDAL PANCREATIC ARTERY TO BODY NECK TAIL

PANCREATIC INVESTIGATION

[Link] AMYLASE ELEVATED

T TORSION OF INTRA ABDOMINAL VISCUS
U UPPER GI PERFORATION
M MESENTERIC INFARCTION
E ECTOPIC PREGNANCY
R RETROPERITONEAL FIBROSIS
S SALIVARY GLAND INFLAMMATION

[Link] FUNCTION TEST

SECRETIN STIMULATION TEST
SECRETIN INCREASE BICARBONATE RICH FLUID ( EXOCRINE GLAND)

LUNDH TEST
AFTER LIQUID MEAL TRYPSIN MEASUREMENT FROM DUODENAL ASPIRATION

NBT PABA TEST

PANCREATIC ENZYME DEGRADE ITS N ITS END PRODUCT EXCRETE FROM
STOOL AND URINE

FECAL ELASTASE TEST:

MEASUREMENT OF FECAL ELASTASE IN STOOL
GREATER THAN 200 NORMAL
100-200 MILD TO MODERATE INSUFFICIENCY
LESS THAN 100 SEVERE INSUFFICIENCY

.3. ULTRASONOGRAPHY
IOC : PATIENT WITH JAUNDICE ( STONE MASS DILATATION METASTASIS)
[Link] SCAN:
BEST TEST FOR MOST PATHOLOGIES
UNENHANCED FOR CALCIFICATION
ENHANCED FOR PANCREATIC CANCER TUMORS INFLAMATORY LESION

[Link] & ERCP:

MRCP : NON INVASIVE ONLY DIAGNOSTIC
ERCP: INVASIVE DIAGNOSTICs THERAPEUTICS

DOUBLE DUCT SIGN MALIGNANT STRICTURE IS PRESENT IN COMMON BILE

DUCT AS WELL AS MAIN PANCREATIC DUCT

[Link] ULTRASOUND:
SMALL TUMORS,PANCREATIC TUMOR TO MAJOR VESSELS NEUROENDOCRINE
TUMOR

ANNULAR PANCREAS
FAILURE OF CLOCKWISE ROTATION OF VENTRAL PANCREATIC DUCT
CIRCUMFERENTIAL PANCREATIC TISSUE AT 2 ND PART OF DUODENUM

EARLY PRESENTATION: (DUODENAL OBSTRUCTION)

DEUDENODEUDENOSTOMY DEUDENOJEUJENOSTOMY
DELAYED PRESENTATION :(PANCREATITIS) RESECTION OF HEAD OF
PANCREAS

PANCREATIC DIVISUM

FAILURE OF FUSION OF VENTRAL AND DORSAL DUCT

MAJOR PANCREATIC DUCT FROM DORSAL DUCT OPEN TO MINOR PAPILLA
MINOR PANCREATIC DUCT FROM VENTRAL DUCT OPEN TO MAJOR PAPILLA

CF: RECURRENT ACUTE PANCREATITIS & CHRONIC PANCREATITIS

DX: MRCP ERCP OR EUS
ASYMPTOMATIC: NO TREATMENT
SYMPTOMATIC : ERCP SPHINCTEROTOMY + STENTING OF MINOR PAPILLAE
SURGICAL INTERVENTION : SPHINCTEROPLASTY
,PANCREATICOJEJUNOSTOMY,RESECTION TO PANCREATIC HEAD

CYSTIC FIBROSIS
CFTR GENE MUTATION ON CHROMOSOME 7
MC CAUSE OF CHRONIC LUNG DISEASE IN DEVELOPED COUNTRY
RESPIRATORY N PANCREATIC INSUFFICIENCY
INFERTILITY IN MEN DUE TO ABSENT VAS DEFERENS
INFERTILITY IN WOMEN DUE TO THICK CERVICAL MUCUS
SWEAT TEST : SODIUM CHLORIDE MORE THAN (90)MMOL/L

ACUTE PANCREATITIS
AUTO ACTIVATION OF PANCREATIC ENZYME TRYPSINOGEN LEADS TO AUTO
DIGESTION

MILD(INTERSTITIAL EDEMATOUS ) PANCREATITIS 80

INTERSTITIAL EDEMA ,MINIMAL ORGAN DAMAGE
SEVERE ( NECROTIZING) PANCREATITIS
PANCREATIC NECROSIS SIRS MOF
MORTALITY WITHIN 1ST WEEK MULTI ORGAN FAILURE
MORTALITY AFTER 1 WEEK SEPSIS

CAUSES:
I IDIOPATHIC
G GALLSTONE MC
E ETHANOL
T TRAUMA
S STEROID
M MUMPS
A AUTOIMMUNE
S SCORPION VENOM
H HYPERLIPIDEMIA
E ERCP
D DRUGS(AZATHIOPRINE ESTROGEN VALPROIC ACID)
.
SYMPTOMS:
CONSTANT EPIGASTRIC ABD PAIN RADIATE TO BACK SITTING FORWARD MAY
RELIEVE PAIN (CARDINAL SIGN)
NAUSEA VOMITING
SWINGING PYREXIA CHOLANGITIS
CULLEN SIGN PERIUMBILICAL ECCHYMOSIS
GREY TURNER SIGN FLANK ECCHYMOSIS
FOX SIGN INGUINAL ECCHYMOSIS
BRYANT SIGN SCROTAL ECCHYMOSIS

DIAGNOSIS:
SERUM AMYLASE : 3-4 FOLD INCREASE RETURN IN 3-5 DAYS
SERUM LIPASE LEVEL MORE SENSITIVE AND SPECIFIC TEST , ELEVATED FOR
LONG TIME

ABDOMINAL X RAY:
SENTINEL LOOP SIGN DILATED JEJUNAL LOOP
COLON CUTOFF SIGN DISTENDED COLON TO MID TRANSVERSE COLON
RENAL HALO SIGN LOSS OF RENAL SHADOW

CONTRAST ENHANCED CT IS CONFIRMATORY TEST

DIAGNOSIS: ABDOMINAL PAIN + ELEVATED SERUM AMYLASE FINDING IMAGING
ON CT MRI US

RANSON SCORING FOR ACUTE PANCREATITIS :

NON GALL STONE
ADMISSION AGE GREATER THAN 55 ,BLOOD GLUCOSE GREATER THAN 200
WBCS GREATER THAN 16000 LDH GREATER THAN 350 AST GREATER THAN 250
AFTER 48 HOURS
HEMATOCRIT FALL BY GREATER THAN 10 SERUM CALCIUM LESS THAN 8 BASE
DEFICIT GREATER THAN 4 FLUID SEQUESTRATION GREATER THAN 5 PAO2
LESS THAN 60 MMHG

GALLSTONES
ADMISSION
AGE GREATER THAN 75 ,BLOOD GLUCOSE GREATER THAN 220 WBCS
GREATER THAN 18000 LDH GREATER THAN 400 AST GREATER THAN 250
AFTER 48 HOUR
HEMATOCRIT FALL BY GREATER THAN 10 SERUM CALCIUM LESS THAN 8 BASE
DEFICIT GREATER THAN 4 FLUID SEQUESTRATION GREATER THAN 5 PAO2 NOT
AVAILABLE

SCORE GREATER THAN 3 ...SEVERE

MNEMONIC: LEGAL CHOBBS

BALTHAZAR CLASSIFICATION ON CT SCAN

PANCREATIC INFLAMMATION:
NORMAL PANCREAS 0
FOCAL OR DIFFUSE ENLARGEMENT 1
INTRINSIC PANCREATIC ALTERATION 2
SINGLE FLUID COLLECTION OR PHLEGMON 3
GREATER THAN 2 FLUID COLLECTION OR GAS 4

PANCREATIC NECROSIS
NONE 0
LESS THAN 30 2
30-50 PERCENT 4
GREATER THAN 50
.CTSI SCORE 0-3 MORTALITY 3 CTSI 4-6 MOTILITY 6 CTSI 7-10 MORTALITY 17

ATLANTA CLASSIFICATION
MILD MODERATE SEVERE ON THE BASIS OF ORGAN FAILURE OR SYSTEMIC
COMPLICATION

MANAGEMENT:
MILD PANCREATITIS : CONSERVATIVE NPO FLUIDS ANALGESIC ANTIEMETICS
NO ANTIBIOTICS
SEVERE PANCREATITIS: NOP ANALGESIC ANTIBIOTIC ANTIBIOTICS
NUTRITIONAL SUPPORTS VITALS MEASUREMENT

COMPLICATION :SHOCK DIC RENAL FAILURE HYPOCALCEMIA

HYPERGLYCEMIA HYPERLIPIDEMIA

LOCAL COMPLICATION

1 ACUTE INTERSTITIAL EDEMATOUS PANCREATITIS

LESS THAN 4 WEEK ACUTE PERI PANCREATIC COLLECTION(APFC) : NON

INFECTED WITH NO WALL NORMAL ENHANCEMENT: TX
OBSERVE(ASYMPTOMATIC,) , IMAGE GUIDED DRAINAGE (SYMPTOMATIC)

MORE THAN 4 WEEK PSEUDOCYST: WALLED OFF NON INFECTED NORMAL

ENHANCEMENT 2 TYPES(COMMUNICATING & NON COMMUNICATING
PSEUDOCYST) TX:SYMPTOMATIC PATIENT..SURGERY
PERCUTANEOUS APPROACH: TRANSGASTRIC CYSTOGASTROSTOMY DOUBLE
DRAIN (ONE IN CYST ONE IN STOMACH)
ENDOSCOPIC APPROACH : CYSTOGASTROSTOMY ,CYSTODUODENOSTOMY
SURGICAL APPROACH(STANDARD) PSEUDOCYST ADDHEAR TO STOMACH
(CYSTOGASTROSTOMY) DUODENUM (CYSTODUODENOSTOMY ) TAIL OF
PANCREAS ( PANCREATIC TAIL RESECTION)

ACUTE NECROTIZING PANCREATITIS

CT SCAN: NO ENHANCEMENT OF NECROTIC AREAS
LESS THAN 4 WEEK ACUTE NECROTIC COLLECTION( ANC) SUPERIMPOSED
BACTERIAL INFECTED
MORE THAN 4 WEEK WALLED OFF NECROSIS INFECTED
TX: STERILE PANCREATIC NECROSIS: ONLY SUPPORTIVE
INFECTED PANCREATIC NECROSIS: ANTIBIOTICS DEBRIDEMENT AND
NECROSECTOMY CLOSE DRAINAGE OPEN PACKING

CHRONIC PANCREATITIS
PERSISTENT INFLAMMATION & IRREVERSIBLE FIBROSIS WITH ATROPHY OF
PANCREAS

MC CAUSE: ALCOHOL
GENETIC MUTATION: SPINK1 PS1 GENE
.ABDOMINAL PAIN ( PRIMARY MANIFESTATION OF CHRONIC PANCREATITIS)
HEAD RIGHT SUBCOSTAL PAIN + EPIGASTRIC
BODY TAIL LEFT SUBCOSTAL PAIN + BACK PAIN
EXOCRINE + ENDOCRINE INSUFFICIENCY

DX:
ABDOMINAL X RAY: CALCIFICATION
CT SCAN: DILATED PANCREATIC DUCT
ERCP: DILATED CHAIN OF LACK
EUS: MOST ACCURATE IN EARLY, ROSEMONT CRITERIA
FUNCTION TEST: FECAL ELASTASE TEST

TX:
CELIAC AXIS BLOCK IN CASE OF INTRACTABLE PAIN
SURGERY:
ERCP: ENDOSCOPIC SPHINCTERECTOMY STONE REMOVAL ESWL WITH STONE
REMOVAL
MODIFIED PUESTOW PROCEDURE: PANCREATIC DUCT DILATION PANCREATIC
PARENCHYMA CONSERVATION,HIGH RECURRENCE RATE
FREY'S PROCEDURE: PANCREATIC DUCT DILATION PANCREATIC PARENCHYMA
REMOVED,LOW RECURRENCE RATE
WHIPPLE PROCEDURE: SINGLE STONE OR STRICTURE
BERGER PROCEDURE: NO DUCT ENLARGEMENT
NORMAL PANCREATIC DUCT: DISTAL PANCREATECTOMY (TAIL) TOTAL
PANCREATECTOMY AND ISLET AUTOTRANSPLANTATION

PANCREATIC CARCINOMA
RISK FACTOR: AGE SMOKING CHRONIC PANCREATITIS MALE GENDER
DIABETES GENETIC
PATHOLOGICAL FEATURE:
DUCTAL ADENOCARCINOMA (MC HEAD OF PANCREAS MALIGNANT)
SEROUS CYSTADENOMA (BENIGN: BUBBLE WRAP)
MUCINOUS CYSTADENOMA (PERI MENOPAUSAL MALIGNANT )

MC SITE : HEAD 60 PERCENT

CARCINOMA OF HEAD: PAINLESS OBSTRUCTIVE JAUNDICE PALPABLE

GALLBLADDER(COURVOISIER'S SIGN) ..OBSTRUCTIVE SIGN

CARCINOMA OF TAIL & BODY

LATE PRESENTATION
DIABETES WEIGHT LOSS BACK PAIN
THROMBOPHLEBITIS MIGRANS TROUSSEAU SIGN

INVESTIGATION:
ELEVATED MARKER: CA 19.9
CONTRAST ENHANCED CT SCAN
EUS: SMALL TUMOR LESS THAN 3 CM VASCULAR INVASION ,CYSTIC TUMOR
DIFFERENCE

SURGICAL MANAGEMENT:
PPPD PROCEDURE: PYLORUS PRESERVING PANCREATODUODENECTOMY:
STANDARD PROCEDURE FOR HEAD & AMPULLA

WHIPPLE PROCEDURE: TUMOR INVOLVING ANTRUM 1ST PART OF DUODENUM

DISTAL PANCREATECTOMY SPLENECTOMY: TUMOR IN BODY & TAIL

CHEMOTHERAPY: GEMCITABINE/- FLUOROURACIL

GALLBLADDER

STIMULATE: CCK
INHIBITED: SOMATOSTATIN

INTRAHEPATIC BILE DUCTS (RIGHT HEPATIC DUCT LEFT HEPATIC DUCT)

EXTRA HEPATIC DUCT
RHD + LHD TO FORM COMMON HEPATIC DUCT CYSTIC DUCT = COMMON BILE
DUCT + PANCREATIC DUCT = COMMON PANCREATICOBILIARY DUCT
OPEN AT MAJOR DUODENAL PAPILLA AT AMPULLA OF VATER

COMMON BILE DUCT PARTS:

SUPRADEUDENAL
RETRODUODENAL
INFRADUODENAL
INTRADUODENAL

INVESTIGATION OF BILIARY TRACT

[Link] RADIOGRAPH:
CALCIFICATION( PORCELAIN GALLBLADDER)
GAS( EMPHYSEMATOUS GALLBLADDER)
RADIOPAQUE GALLSTONES
STONES CONTAIN RADIOLUCENCY IN CENTRE- MERCEDES BENZ SIGN

[Link]:
BEST IMAGING MODALITY
STONE SIZE THICKNESS INFLAMMATION

[Link] SCAN (HIDA ) SCAN :

BILIARY TREE N GALL BLADDER DETAILED VISUALIZATION

[Link] SCAN:
METASTASIS

[Link]:
DIAGNOSTIC TEST
[Link]:
DIAGNOSTIC AS WELL AS THERAPEUTICS (STONE REMOVAL AND STENT
PLACEMENT)

[Link] TRANSHEPATIC CHOLANGIOGRAPHY (PTC):

UNDER FLUOROSCOPIC GUIDANCE
USED IN JAUNDICE PATIENT OF MALIGNANT STRICTURE
[Link] OPERATIVE OR INTRA OPERATIVE CHOLANGIOGRAPHY

CONGENITAL ANOMALY

[Link] TURN /MOYNIHAN HUMP: DILATED TORTUOUS RIGHT HEPATIC

ARTERY OR CYSTIC ARTERY

[Link] ATRESIA :

TYPES:
I ATRESIA OF COMMON BILE DUCT TX: DIRECT ROUX EN Y
HEPATICOJEJUNOSTOMY
II ATRESIA OF COMMON HEPATIC DUCT TX KASAI PROCEDURE
III ATRESIA OF RIGHT N LEFT HEPATIC DUCT TX KASAI PROCEDURE

PRESENTATION:
JAUNDICE WITH IN 1 WEEK
PALE STOOL DARK URINE
BILIARY RICKETS
SEVERE PRURITUS CLUBBING XANTHOMAS

TX:
KASAI SURGERY BEFORE 8 WEEK
LIVER TRANSPLANTATION IF KASAI FAILS

[Link]'S DISEASE:
CONGENITAL DILATATION OF INTRAHEPATIC DUCTS
TYPE 5 CHOLEDOCHAL CYST IN TODANI CLASSIFICATION

TYPE:
PERIPORTAL FIBROTIC TYPE:
CHILD HOOD. BILIARY STASIS,STONE FORMATION,CHOLANGITIS

SIMPLE TYPE:
AFTER CHILDHOOD ,ABDOMINAL PAIN,BILIARY SEPSIS

TX: ANTIBIOTIC FOR CHOLANGITIS

REMOVAL OF CANALICULI HEPATIC LOBECTOMY

[Link] CYST:
DILATATION OF BILE DUCTS

TODANI CLASSIFICATION
I CYSTIC DILATATION OF ENTIRE EXTRA HEPATIC BILE DUCT(MC)
II DIVERTICULUM OF COMMON BILE DUCT
III INTRADUODENAL PORTION OF CBD
IVa INTRAHEPATIC + EXTRAHEPATIC
IVb EXTRA HEPATIC ONLY
V INTRAHEPATIC ONLY( CAROLI'S DISEASE)

INCREASE RISK OF CHOLANGIOCARCINOMA

TX: RADICAL EXCISION . RECONSTRUCTION BY ROUX EN Y
HEPATICOJEJUNOSTOMY

GALLSTONES(CHOLELITHIASIS)
MC BILIARY PATHOLOGY
CAUSES:
[Link] OF SECRETED BILE DUCT
2. CONCENTRATION OF BILE IN GALLBLADDER
[Link] NUCLEATION OF CHOLESTEROL
[Link] DYSMOTILITY

TYPES:
[Link] STONES:
MC STONES 51-90 PERCENT CHOLESTEROL

[Link] STONES
INCREASE HEMOLYSIS
BLACK STONE : UNCONJ BILIRUBIN + CALCIUM PHOSPHATE + CALCIUM
BICARBONATE FOUND IN GALLBLADDER
HEMOLYTIC CONDITION , CIRRHOSIS
BROWN STONES: UNCONJ BILIRUBIN CALCIUM PALMITATE CALCIUM STEARATE
CHOLESTEROL FOUND IN BILE DUCT
BILE STASIS INFECTED BILE PARASITIC INFECTION(CLONORCHIS SINENSIS
ASCARIS)

SYMPTOMS:
ASYMPTOMATIC IN 80 PERCENT CASES
ACUTE CHOLECYSTITIS :
RIGHT UQ PAIN EPIGASTRIC PAIN RADIATE TO BACK DULL N CONSTANT ,FOOD
INTOLERANCE ,SYSTEMIC SIGNS

MURPHY SIGN RUQ TENDERNESS DURING INSPIRATION BY EXAMINER RIGHT

SUBCOSTAL PALPATION
COURVOISIER'S [Link] NON TENDER GALLBLADDER ...PANCREATIC
CA

BILIARY COLIC:
RUQ PAIN NAUSEA VOMITING BUT NO SYSTEMIC SIGN

COMPLICATION:
BILIARY COLIC
ACUTE CHOLECYSTITIS
CHRONIC CHOLECYSTITIS
EMPYEMA
MUCOCELE
PERFORATION
MIRIZZI SYNDROME JAUNDICE CAUSED BY GALLSTONES ULCERATING
THROUGH COMMON BILE DUCT RESULT IN COMPRESSION OF DUCT

INVESTIGATION OF CHOICE : ULTRASOUND

CONFIRMATORY TEST: CT SCAN

TOKYO GUIDELINE OF ACUTE CHOLECYSTITIS

A LOCAL SIGN 1. RUQ PAIN/ TENDERNESS / [Link] SIGN
B SYSTEMIC SIGN : 1 FEVER 2 ELEVATED WBCS 3 ELEVATED CRP
C IMAGING STUDY ; ACUTE CHOLECYSTITIS

SUSPECTED AC ONE ITEM FROM A ONE FROM B

DEFINITIVE DIAGNOSIS ONE ITEM FROM EACH A B & C

MANAGEMENT:
CONSERVATIVE: NPO ANTIBIOTIC ANALGESIC
OPERATION: EARLY: 7 DAY LATE: 6 WEEK COMORBIDITIES: PERCUTANEOUS
CHOLECYSTOSTOMY

CHOLECYSTECTOMY

PREOPERATIVE EQUISITS:
BASE LINE
DVT PROPHYLAXIS
ANTIBIOTICS

INDICATION:
CHOLELETHESIS
TORSION OF GALLBLADDER
DIVERTICULOSIS GALLBLADDER
TYPHOID GALLBLADDER
EMPYEMA OF GALLBLADDER

CALOT'S TRIANGLES:
LOCATION OF CYSTIC ARTERY
MEDIALLY_ COMMON HEPATIC DUCT
LATERALLY _ CYSTIC DUCT
SUPERIORLY _ INFERIOR SURFACE OF LIVER

METHOD:
[Link] CHOLECYSTECTOMY
POSITION REVERSE TRENDELENBURG
ANESTHESIA GENERAL
PORTS: 3
I 10 MM IN SUB UMBILICAL AREA FOR CAMERA
II 10 MM IN XIPHOID AREA FOR MAIN INSTRUMENTATION
III 5 MM IN RIGHT SUBCOSTAL FOR RETRACTION

[Link] CHOLECYSTECTOMY
POSITION SUPINE
ANESTHESIA GENERAL
INCISION KOCHER ,RIGHT SUBCOSTAL, RIGHT UPPER TRANSVERSE INCISION
CHOLEDOCHOLITHIASIS
STONES IN COMMON BILE DUCT

PRIMARY STONE ..CBD STONE ARISE IN BILE DUCT BROWNSTONE

SECONDARY STONE: CBD STONE PASSING FROM GALLBLADDER TO BILE DUCT
BLACK STONE
RETAINED STONE CBD STONE FOUND WITHIN 2 YEAR FOLLOWING
CHOLECYSTECTOMY

CHARCOT TRIAD: RUQ PAIN JAUNDICE FEVER

REYNOLDS PENTAD FEVER RUQ PAIN JAUNDICE MENTAL STATUS ABNORMAL
HYPOTENSION

DIAGNOSIS N TREATMENT:
WBCS GREATER THAN 15000 COMMON IN CHOLANGITIS
IMAGING STUDIES: ULTRASOUND ERCP MRCP PTC

MANAGEMENT:
ENDOSCOPIC PAPILLOTOMY WITH SPHINCTERECTOMY BY ERCP IS
PREFERRED PROCEDURE
IF STONE REMOVAL POSSIBLE USE = DORMIA BASKET
IF STONE REMOVAL NOT POSSIBLE = PLACEMENT OF A STENT
SURGERY: COLEDOCHOTOMY ( LONGITUDINAL INCISION PLACEMENT OF T
TUBE)

BILE DUCT INJURY

MC CAUSE: SURGICAL TRAUMA
STRASBERG CLASSIFICATION
A LEAK OF BILE FROM CYSTIC DUCTS
B OCCLUSION OF RIGHT HEPATIC DUCT
C TRANSECTION OF RIGHT HEPATIC DUCT
D LATERAL INJURY MAJOR BILE DUCT
E BISMUTH CLASSIFICATION
I INJURY OF COMMON HEPATIC ARTERY GREATER THAN 2CM FROM
BIFURCATION
II INJURY OF COMMON HEPATIC ARTERY LESSER THAN 2CM FROM
BIFURCATION
III HILAR CONFLUENCE OF RIGHT N LEFT DUCT INTACT
IV HILAR INVOLVEMENT OF CONFLUENCES RIGHT N LEFT HEPATIC DUCT
V INVOLVEMENT OF INTRAHEPATIC DUCT

PRIMARY SCLEROSING CHOLANGITIS

AUTOIMMUNE DISEASE
INFLAMMATION AND SCARRING OF BOTH INTRA AND EXTRAHEPATIC DUCT
ASSOCIATED WITH UC RIEDEL THYROIDITIS HYPER GAMMA GLOBULINEMIA

SECONDARY SCLEROSING CHOLANGITIS DUE TO INFECTION AND

MALIGNANCY

CLINICAL FEATURE:
OBSTRUCTIVE SIGN: RUQ PAIN FEVER JAUNDICE PRURITUS WEIGHT LOSS

LFT OBSTRUCTIVE PATTERN

ANTIBODY: ANTI SMOOTH MUSCLE ANTIBODY , P ANCA
ERCP : BEADED APPEARANCE OF DUCT
LIVER BIOPSY:
EARLY ONION SKIN CONCENTRIC PERIDUCTAL FIBROSIS
LATE PERIPORTAL FIBROSIS EVENTUALLY BILIARY CIRRHOSIS

MEDICAL TX : URSODEOXYCHOLIC ACID , CHOLESTYRAMINE , ANTIBIOTICS

,VIT K ,STEROID ,IMMUNOSUPPRESSION

SURGICAL TX: ENDOSCOPIC STENTING , SURGICAL RESECTION ,LIVER

TRANSPLANTATION

MC BENIGN TUMOR OF BILE DUCT : PAPILLARY OR ADENOMA

VERMIFORM APPENDIX

VESTIGIAL ORGAN
4 LAYERS MUCOSA SUBMUCOSA MUSCULAR SEROSAL LAYER
AT BIRTH ITS SHORT AT AGE 2 ITS BECOME A BLIND TUBULAR STRUCTURE
FROM CAECUM

POSITION 6:
RETROCECAL(MC) SUB CECAL POST ILEAL PRE ILEAL PELVIC PARA CAECAL
ARTERY: APPENDICULAR ARTERY BRANCH OF ILEOCOLIC ARTERY
COVERING : MESOAPPENDIX
LYMPHATICS: ILEOCECAL LYMPH NODES
MICROSCOPIC: 7.5-10CM ,COLUMNAR EPITHELIUM,BASE OF CRYPTS
KULCHITSKY CELLS (CARCINOID TUMOR)

APPENDIX MC SITE CARCINOID TUMOR

ACUTE APPENDICITIS
MC SURGICAL EMERGENCY,MC EXTRA UTERINE IN PREGNANCY
RISK FACTORS: FECALITH OBSTRUCTION(MC) LYMPHOID HYPERPLASIA ,BALL
OF WORN (OXYRIS VERMICULARIS),TUMOR,BACTERIAL PROLIFERATION

MC CAUSE IN CHILDREN: LYMPHOID HYPERPLASIA

MC CAUSE IN ADULT: FECALITH OBSTRUCTION

RISK FACTOR OF PERFORATION:

EXTREMES OF AGE ,DIABETES, FECALITH OBSTRUCTION, PREVIOUS
ABDOMINAL SURGERY, IMMUNOCOMPROMISED

SYMPTOMS:
PERIUMBILICAL PAIN WHICH IS VISCERAL RADIATES TO RIGHT ILIAC FOSSA
PAIN IS CONSTANT AND SEVERE
ANOREXIA
NAUSEA VOMITING
FEVER (lLOW GRADE THEN HIGH GRADES)

SIGNS
POINTING SIGN:
ROVSING SIGN: DEEP PALPATION ON LEFT PAIN FELT ON RIF
PSOAS SIGN:PAIN ELICITED BY EXTENDING HIP WITH KNEES OR FLEXING HIP
JOINT(RETROCECAL APPENDIX)
OBTURATOR SIGN: PAIN ELICITED BY INTERNAL ROTATION OF LEG WITH HIP &
KNEE FLEXED (PELVIC APPENDICITIS)
HAMBURGER SIGN: ASK FOOD TO EAT BT HE DENIES

OBSTRUCTIVE V/S NONOBSTRUCTIVE TYPES

ONSET ABRUPT ,GENERALIZED ABD PAIN ,MORE ACUTE COURSE,TEMP
NORMAL URGENT SURGICAL RESECTION

SUBTYPES IMP POINTS

[Link] APPENDIX/SILENT APPENDIX: PSOAS SIGN

[Link] APPENDIX: DIARRHEA MICTURITION ABDOMINAL RIGIDITY

TENDERNESS ABSENT DRE TENDERNESS

3 POST ILEAL : PAIN AND TENDERNESS IN PERIUMBILICAL REGION NON

SHIFTED, DIARRHEA

DIFFERENTIALS DIAGNOSIS:
CHILDREN:
GASTROENTERITIS ,MESENTERIC ADENITIS, MECKEL'S DIVERTICULUM
,INTUSSUSCEPTION
ADULTS:
CROHN'S DISEASE URETERIC PAIN RIGHT SIDED PYELONEPHRITIS PEPTIC
ULCER DISEASE TORSION OF TESTIS ,PANCREATITIS
ADULT FEMALE:
MITTLE SHRIMERZ ,PELVIC INFLAMMATORY DISEASE ,ECTOPIC PREGNANCY,
ENDOMETRIOSIS

ALVARADO SCORE
MNEMONIC : MANTRELS
M MIGRATORY RIF PAIN. 1
A ANOREXIA. 1
N NAUSEA VOMITING. 1
T TENDERNESS. 1
R REBOUND TENDERNESS 2
E ELEVATED TEMPERATURE. 1
L LEUKOCYTOSIS 2
S SHIFT TO LEFT 1

REBOUND TENDERNESS AND LEUKOCYTOSIS HAS 2 ALL OTHER 1

LESS THAN 4 DIAGNOSIS UNLIKELY

5-6 OBSERVE
MORE THAN 7 APPENDECTOMY

TX: APPENDECTOMY
[Link] APPENDECTOMY
[Link] APPENDECTOMY
[Link] MANAGEMENT ( ANTIBIOTICS)
MCBURNEY'S POINT POINT BTW MEDIAL 2/3 AND LATERAL 1/3 OF LINE
BETWEEN UMBILICUS AND ASIS

INCISION:
GRIDIRON INCISION: VERTICAL (90 DEGREE) LINE AT MCBURNEY'S POINT
RUTHERFORD MORRISON INCISION: CUTTING INTERNAL OBLIQUE AND
TRANSVERSE MUSCLE OVER MCBURNEY POINT UPWARD AND LATERALLY
(PERICAECAL & RETROCECAL)1
LANZ INCISION:TRANSVERSE SKIN CREASE INCISION 2 CM BELOW UMBILICUS

PROBLEM DURING APPENDECTOMY

[Link] TUMOR
LESS THAN 2 CM= APPENDECTOMY
MORE THAN 2 CM= RIGHT HEMICOLECTOMY
[Link] ABSCESS:
BEST INITIAL: PERCUTANEOUS DRAINAGE (US-CT)
NON RESOLVING MIDLINE LAPAROTOMY
[Link] DISEASE
HEALTHY CECAL WALL= APPENDECTOMY
APPENDIX AFFECTED= IV STEROID ANTIBIOTICS
[Link] ABSCESS :
TRANSRECTAL ASPIRATION

CARCINOID TUMOR
KULTI SKY CELLS
MC SITE: APPENDIX (DISTAL 1/3)
TREATMENT:
LESS THAN 2 CM= APPENDECTOMY
MORE THAN 2 CM= RIGHT HEMICOLECTOMY

COMPLICATION:
MC EARLY COMPLICATION: WOUND INFECTION
MC LATE COMPLICATION: ADHESIVE INTESTINAL OBSTRUCTION

APPENDIX MASS
INFLAMED APPENDIX WITH ADHERENT COVERING OF OMENTUM

MANAGEMENT:
CONSERVATIVE :(OCHSNER SHERREN REGIMEN) NPO ANALGESICS
ANTIBIOTICS IV FLUIDS CT GUIDED DRAINAGE GLYCERIN SUPPOSITORY DVT
PROPHYLAXIS
SURGICAL: APPENDECTOMY

RECTUM
START FROM RECTOSIGMOID JUNCTION END AT ANORECTAL JUNCTION
PUBORECTALIS MUSCLE ENCIRCLED THE POSTERIOR AND LATERAL ASPECT
OF THIS JUNCTION ... ANORECTAL ANGLE NORMALLY 120 DEGREE

LENGTH: 12_18CM AVERAGE 15

3 LATERAL CURVATURE: HOUSTON VALVE

RECTUM 3 PARTS
UPPER : COVERED BY PERITONEAL MOBILE , SUPERIOR RECTAL ARTERY
(IMA)n VEIN (PORTAL)
MIDDLE: COVERED ON ANTERIOR AND LATERAL ASPECT MIDDLE RECTAL
ARTERY (IIA)& VEIN(IVC)
LOWER THIRD: NO PERITONEAL COVERING INFERIOR ILIAC ARTERY (IPA)n
VEIN (IVC)

LYMPH NODE: PARAAORTIC NODES (UPWARD)

DENOVILLERS FASCIA SEPARATES RECTUM FROM VAGINA

WELDEYERS FASCIA SEPARATES RECTUM FROM COCCYX SACRUM

RECTAL PROLAPSE

1. MUCOSAL PROLAPSE
PROTRUSION OF MUCOUS MEMBRANE AND SUBMUCOSA OF RECTUM
OUTSIDE ANUS
1-4 CM ONLY

RISK FACTORS:
CHILDS: DIARRHEA MC
ADULTS: HEMORRHOID MC

TREATMENT:
CHILDREN: DIGITAL POSITIONING SUBMUCOSAL SCLEROSING AGENT
INJECTION
ADULT : SUBMUCOSAL INJECTION OF 5 pERCENT PHENOL IN ALMOND OIL
,RUBBER BAND
EXCISION: UNILATERAL (EXCISE) CIRCUMFERENTIAL (STAPLING)

[Link] THICKNESS PROLAPSE(PROCIDENTIA)

PROTRUSION OF ANT WALL OF RECTUM OUTSIDE ANUS
MORE THAN 4 CM (10-15 CM IN LENGTH)
ASSOCIATED WITH WEAK PELVIC FLOOR,FECAL INCONTINENCE PATULOUS
ANAL SPHINCTER
RISK FACTOR: OLD AGE ,POST MENOPAUSAL WOMEN MULTIPAROUS,CHRONIC
DEFECATION

TX SURGERY:
PERINEAL APPROACH
[Link] OPERATION
2. THIERSCH OPERATION
[Link] PROCEDURE

ABDOMINAL APPROACH
[Link] PROCEDURE
[Link] OPERATION
[Link] OPERATION
A/E: SEXUAL DYSFUNCTION,SEVERE CONSTIPATION

PROCTITIS & ULCERS

INFLAMMATION OF RECTAL MUCOSA

CAUSES: IDIOPATHIC, RADIATION, IBD(UC &CD) , INFECTIONS

.CF: ANALPAIN BLEEDING DIARRHEA
DRE: MUCOSA WARM SMOOTH BLOOD STAINING OF FINGER

CLOSTRIDIUM DIFFICILE: PSEUDOMEMBRANOUS COLITIS + WATERY DIARRHEA

BACILLARY DYSENTERY: PURULENT PROCTITIS or MULTIPLE SMALL SHALLOW
ULCER
GONOCOCCAL: RECTAL COITUS .
LYMPHOGRANULOMA VENEURUM: HYPEREMIC MUCOSA + ENLARGED
INGUINAL LYMPH NODE.
TUBERCULOSIS PROCTITIS: SECONDARY TO TB: SUBMUCOSAL RECTAL
ABSCESS BURST AND LEAVE ULCER WITH UNDERMINED EDGES
SPIROCHETE VINCENTI BACILLUS FUSIFOR: STRAWBERRY LESION OF
RECTOSIGMOID
SCHISTOSOMIASIS MANSONI: RECTAL BILHARZIASIS

TX: STOOL SOFTENERS, SUPPOSITORIES, STEROIDS ,BED REST .

SOLITARY RECTAL ULCER

ANTERIOR RECTAL WALL 8 CM FROM ANAL VERGE
TX:BIOFEEDBACK ,INTRARECTAL STAPLING PROCEDURE ,ABDOMINAL
RECTOPEXY,RECTAL EXCISION

RECTAL CARCINOMA

MC SITE FOR COLORECTAL CARCINOMA

RECTAL CA PRESENT AS ULCER
CRC ARISES FROM ADENOMA

LOCAL SPREAD:
ANTERIOR: PROSTATE(MALE) VAGINA(FEMALE)
LATERAL : URETER
POSTERIOR SACRUM
DISTANT SPREAD:
LYMPHATICS & HEMATOGENOUS SPREAD (LIVER LUNGS ADRENALS)

1/4 INVOLVEMENT OCCUR IN 6 MONTH

CIRCUMFERENTIAL OCCUR IN 18 MONTHS

DUKES CRITERIA
A GROWTH INSIDE RECTAL WALL
B GROWTH OUTSIDE RECTAL WALL
C INVOLVEMENT OF REGIONAL LYMPH NODE
D DISTANT METASTASIS

TNM STAGING
T1 TUMOR INVASION IN SUBMUCOSA
T2 TUMOR INVADES INTO MUSCULARIS PROPRIA
T3 TUMOR IN THE SEROSA
T4 TUMOR IN PERITONEAL CAVITY
N0 NO NODAL INVOLVEMENT
N1 1-3 LYMPH NODES
N2 GREATER THAN 4 LYMPH NODE

MO NO METS
M1 DISTANT METS

HISTOLOGICAL : ADENOCARCINOMA
LOW GRADE WELL DEFINED GOOD PROGNOSIS
HIGH GRADE ANAPLASTIC TUMOR POOR PROGNOSIS

DIAGNOSIS: (BLEEDING PER RECTUM+ TENESMUS+ SPURIOUS DIARRHIA +

ALTERD BOWEL HABITs PAIN + WEIGHT LOSS)

DRE: NODULE WITH INDURATED BASE BLOOD STAINING OF FINGER ENLARGED

LYMPH NODE
COLONOSCOPY/CT COLONOSCOPY/BARIUM ENEMA:
ADENOMA= SNARE REMOVE VIA COLONOSCOPY
CARCINOMA= STAGING (CT CHEST ABDOMEN PELVIS)
HEPATIC METS (INTRAOPERATIVE US)

MANAGEMENT
SURGERY IS THE MAINSTAY OF CURATIVE TREATMENT

[Link] RESECTION:
ANAL SPHINCTER PRESERVING RESECTION OF RECTUM VIA ABDOMINAL
APPROACH
PREFERRED FOR ALL TUMORS WHOSE LOWER MARGIN IS GREATER THAN 2
CM ABOVE ANAL CANAL .
RESECTION OF RECTUM MESO RECTUM ASSOCIATED LYMPH NODE +
COLOANAL ANASTOMOSIS

[Link] ANTERIOR RESECTION:

TUMOR OF UPPER 1/3
B. LOWER ANTERIOR RESECTION:
MIDDLE & LOWER 1/3
[Link] RESECTION(APR)
ANAL SPHINCTER IS NOT PRESERVED RESECTION OF RECTUM VIA
ABDOMINAL & PERINEAL APPROACH
EXCISION OF RECTUM & ANUS
PREFERRED FOR ALL TUMORS WHOSE LOWER MARGIN IS LESS THAN 2 CM
BELOW ANAL CANAL .
TUMOR INVOLVING ANAL SPHINCTER
RESECTION OF RECTUM& ANUS+ END COLOSTOMY

[Link] ANAL EXCISION:

LOW GRADE T1 CANCER

[Link] PROCEDURE:
EXCELLENT IN OLD AND FRAIL PROCEDURE
RESECTION OF RECTUM CLOSURE OF RECTAL STUMP FORMATION OF END
COLOSTOMY

[Link] PROCEDURE (PELVIC EXENTERATION):

REMOVAL OF ALL PELVIC ORGAN WITH INTERNAL ILIAC NODES OBTURATOR
GROUP OF LYMPH NODES

COMPLICATION AR & APR

IMPOTENCE
ANASTOMOTIC LEAKAGE
MASSIVE PRESACRAL VENOUS BLEEDING
LOWER ANT RESECTION SYNDROME:( FREQUENCY URGENCY ALTERED
BOWEL HABIT)

CHEMO & RADIOTHERAPY

FLUORIC + LEUCOVORIN OXALIPLATIN
PREOPERATIVE FOR THE PERIOD OF 6 WEEK

Surgery Small and Large Intestine 1

Small Intestine :
Small bowel is average 6 metre long( 300-850 cm)
40% jejunum and 60% ileum
Small bowel Intraperitoneal
Mesentery is 15 cm long runs from DJ flexure to across right sacroiliac joint
Artery SMA and vein SMV that joins with splenic vein to form portal vein
Vagus parasympathetic and T9+10 sympathetic in superior mesenteric ganglion
Ileum has thicker mesentery withore fat , larger lymph does Payer's patches and is
below the umbilicus

Large Intestine
1.5 metres long
Colon has fat tags ( appendices epiploicae) mostly over sigmoid colon, absent
elsewhere.
Taenia Coli located at all parts , gives the large intestine it's sacculated appearance.
Arterial supply:
Ileocolic , right coloc and middle colic from SMA upto 2/3rd of transverse colon
Left colic from IMA supplies distal part
SMA and IMA communicates through Marginal artery of Desmond
Nerve supply from symphatetic plexus around SMA and IMA
Visceral Pain felt around umbilicus for proximal colon and in hypogastric region for distal
colon

Diverticulum :
Conginatal are true diverticulum like Meckel diverticulum
Acquired are false diverticulum

Duodenal diverticulum are most common

Primary occur in 2nd and 3rd part are asymptomatic and occur in old patient
Secondary is in duodenal cap due to PUD
Tx :
If asymptomatic : observe
If symptomatic and below ampulla : resection and anastomosis
If above ampulla: Choledocojejunostomy or ERCP with stenting

Jejuonal diverticulae are variable size and number and due to connective tissue
disorders, may cause accute abdomena dm malabsorption

Meckel Diverticulum:
True diverticulum, all layers and it's own blood supply
Due to remnant of ileal part of Vitelointestinal duct, located on anti mesenteric border
Rule of 2
Mostly contains pancreatic tissue causing inflammation.
Gastric tissue causes bleeding
Little's Hernia is inguinal/femoral hernia containing Meckel diverticulum
Most common presentation intestinal obstruction in adults and painless bleeding in
children
Meckel scan ( technitium 99 scan) most accurate for diagnosis.
Tx :
Observe if widemouth, asymptomatic and thin walled
If uncomplicated = Diverticulectomy

If complicated = Diverticulectomy+ Segmental Resection of Illeus.

Done when
Perforation ,neck more than 1/3rd bowel diameter or diverticulitis at it's base.

Colonic Diverticulae :
Acquired , false , due to wall weakness
Most common acquired Sigmoid colon diverticulae
Most common congenital in Ceacum, in south east Asians
60% over 60 years of age
Main morbidity due to sepsis
Asymptomatic , bleeding, pain or change in bowel habits
Most common complication is Diverticulitis
Intestinal obstruction in sigmoid colon due to fibrosis and in small intestine due to
adhesions
Fistula most commonly Colovesical .
Diagnosis : Sawtooth appearance on barium enema

Diverticulitis :
Non precancerous
Distention , flatulence and heaviness in elective presentation
Emergency cases present as left sided appendicitis
Colovesical fistula present as pneumaturia and feacaluria
May present with perforation

Hinchey classification for degree of contamination

Stage 1 = peri colic abcess
2 = pelvis abcess
3 = prulent peritonitis from abcess perforation
4 = feculent peritonitis from colon perforation

Best investigation CT Abdomen and Pelvis for accute attacks and complications.
Colonoscopy and barium enema contraindicated in accute state , should be done after 6
weeks to rule out malignancy and assess spread.
Water soluble contrast done in large bowel obstruction
Cystoscopy best test for Colovesical fistula

Tx : high fibre diet and antispasmodics for diverticulosis

Conservative for most diverticulitis
Surgery if :
In accute perforation /peritonitis
In chronic : 3 or more simple episodes , 1 perforated episode , age less than 50 and
giant diverticulum

Surgery may be 1 stage : resection and anastomosis

Or Hartman 2stage procedure ( resection, end colostomy and then reversal), done in
Obstruction, inflammation, adhesions ,perforation

Alternatively 2 stage resection , on table washing , resection and end ileostomy and
reversal.

Unlike Carcinoma Diverticulitis has longer history, more pain ,more diffuse ,
inflammatory changes and has periodic and profuse bleeding

Inflammatory Bowel Diseases :

Ulcerative Colitis :
Relapsing remitting, colon only mostly rectum , distal to proximal continuous spread with
no skip lesion. Spares anus unlike Crohn.
Smoking and appendectomy has a protective effect against UC.
In 20-40 years age , more in Caucasians , 15% in first degree relative

Multi genetic non mendelian inheritance

HLA DR2 , Th2 Helper TCells over activation ,pAnca 75% present
No NOD2 and ASCA

Only involve mucosa and submucosa, no normal region in between. Multiple small
broad based ulcers.
Backwash ileitis due to incompetent sphincter
Inflammatory cells in lamina propria, crypts , goblet cells depletion and precancerous
changes.

Watery and Bloody diarrhea is Hallmark

Proctitis : semi solid stools, urgency/tenesmus main signs and no systemic signs
Colitis : liquid stool, diarrhea main complain and systemic signs
Good prognosis of left sided only

Poor prognosis if severe first attack, more than 60 age and whole colon affected

Truelove and Wits criteria for severity

Toxic megacolon is the most common complication . ( Colon more than 6 cm diameter
on CT most accurate)
Perforation may occur in 40%
Cancer may occur in 3.5% mostly in colon, mostly in 4th decade
10 year : 1%
20 years: 10%
30 years: 20%

Colectomy improves arthritis , anemia and eye problems but not PSC and
cholangiocarcinoma

Colonoscopy done after 7-10 years of diagnosis every 1-2 years

Abdominal X ray shows severity, thumb print signs
Barium enema shows loss of haustrations
Sigmoidoscopy shows early disease , pseudopolyps indicate relapse and remitting.
Stool culture to rule out infections
Typhoid :
Most commonly in terminal ileum
Ulcer parallel to gut axis
Paralytic Ileus most common complication
Perforates in 3rd weeks, arthritis, osteomyelitis, phlebitis. , cholecystitis etc

Intestinal TB :
Most common site terminal ileum
Multiple ulcers with undermined edges transverse to the long axis of gut

Ulcerative type :
Terminal ileum mostly
Virulence greater than defense
Diarrhea and weight loss mains symptom
Tubercles on serosa, barium enema shows multiple strictures
Anti TB therapy or surgery if perforation or obstruction
Hyperplastic TB :
Mostly at Ileocecal junction
Les avirulent
Abdominal pain + intermittent diarrhea main symptom
Unlike Crohn no fistula and abscess.
Long narrow filling defect due to strictures
Anti TB therapy or surgery

Tumors Small intestine. :

Peut- Jaeger Syndrome :

AD, STK1 gene on chromosome 19 .
Hemattamous polyps and hyper pigmentation on lips, mouth and digits.
Recurrent colicky abdominal pain e to intussusception main symptom
Anemia
Small intestine tumors
Tx :
Colonoscopy every 3 years

Carcinoid tumor :
Kulchitsky cells of appendix mostly
Serotonin release
Exalted with other malignancies
Pain, diarrhea , weight loss,
carcinoid syndrome : due to hepatic Mets
Flushing , asthma, cyanosis, hepatomegaly , diarrhea

CT abdomen and Pelvis best test

Octreotide scan
Chromogranin A level : monitor recurrence & prognosis

Tx :
Resection anastomosis + lymphadenectomy and enucleation for liver Mets
Octreotide preoperatively to prevent carcinoid crisis
Aprotinin( bovine trypsin inhibitor )for bronchospasm
Alpha blocker for flushing

GIST :
Connective tissue tumor at stomach, radio resistant, imatinib and surgery
Lymphoma :
Western : Non Hodgkin lymphoma
In celiac disease T cell lymphoma
Mediterranean lymphoma in a-chain disease

Benign tumor large Intestine :

Adenomatous Polyps :
Pre cancerous true polyps
Mostly tubular
Villous adenoma cause hypokalemia, hypoalbuminemia, high risk malignancy
Colonoscopic polypectomy done

FAP:
AD, APC mutation on chromosome 5, family history 80%
Risk of colorectal cancer 100%
Most common cause of death peri ampullary duodenal tumors
If no adenoma by 30 years age not FAP
Cancer occurs 10-20 years after polyps
Men female equal affected
Large bowel mostly affected

Associated with
CHRPE
Gardner syndrome : FAP + desmoid Tumor + osteoma
Turcot syndrome: FAP + CNS tumors

Screening examination from 10-12 and genetic at 13-14

Upto 20 years no polyps then examination every 5 years upto 50 years age
Flexible sigmoidoscopy better than colonoscopy.

Same surgeries .
Total collectomy with Illeorectal anastomosis best
But 6 month sigmoidoscopy
10% cancer risk in 30 years

HNPCC / lynch syndrome :

AD , DNA mismatch repair mutation of MLH1 and MSH 2
Risk of colorectal cancer 80%
Mostly occurs at 44 years
Amsterdam criteria for diagnosis 3-2-1 rule
3 relative with HNPCC
2 successive generations
1 less than 50years
Exclusion of FAP

Colon Carcinoma :
Adenoma - carcinoma sequence APC theN KRAS, , smad4 then p53
Adenocarcinoma mostly
Annular : obstruction
Tubular : bleeding
Ulcerative : bleedinga nd invasive
Cauliflower growth : bleeding leastalignant

Most common site rectum, least descending colon

Duke and TNM staging

Rights sided tumor :

Always bleed , after 40, iron deficiency anemia , blood mixed with stool, right IF mass

Left sided :
Obstruction, blood coating on stool, tenesmus

Metastatic : jaundice, ascites , hepatomegaly, weight loss

Sigmoidoscopy
CT abdomen pelvis. For staging
Colonoscopy + biopsy best initial test
Alternative double contrast enema : apple core lesion

Surgical resection ( depending on location) and anastomosis with lymphadenectomy

Intra operative US for hepatic Mets

No biopsy
Hepatic resection after 12 weeks

Post operative chemotherapy for node positive stage 3&4 tumors

No radiotherapy

Angiodysplasia :
Idiopathic
Dilated submucosal veins leading to bleeding due to aging
5-10% after 65 age
Most common site : ascending colon and rectum
Anemia, Malena , intermittent bleeding
Heydes Syndrome : aortic stenosis + colonic angiodysplasia
Colonoscopy best initial test
Target RBC scan for less than 1ml/min bleeding
SMA & IMA Angiogram for more than 1ml/min bleeding point
Tx : Stabilization, localization, Cauterization
Or Colectomy + Illeorectal anastomosis if bleeding vessel not found

Blind-loop Syndrome / Bacterial Overgrowth syndrome :

Increase in intestinal flora after intestine bypass
In upper loops it causes malabsorption and stetorrhia
In lower loops it causes vitamin B12 anemia.
Tx : antibiotics , vitamin B 12 supplements
Surgical correction of obstruction main treatment

Enterocutaneous Fistula :
Due to previous surgery mostly
If more than 500ml/day : high output
If less than 500ml/day : low output

If from duodenum / jejunum: bile stained discharge and skin excoriation

Illeum/ Ceacum: fluid fecal matter
Distal colon: solid fecal matter

Tx :
Low output : self healing
High output : SNAP
S : sepsis control and skin care
N : nutrition
A : anatomical asseseement
P : planning surgery if conservative fails

Constipation:
Constipation means less than one stool per 3 days
It may be
Megacolon constipation :
Hirshprung

Non hirshprung megacolon and megarecrum :

Starts before 20 years

Megarecrum : fecal continence
Megacolon : abdominal distension and pain
Anus usually patulous and soiling common

Dix : abdominal X-ray, double contrast enema shows more than 6.5cm diameter
Rectal biopsy differentiates from hirshprung
Anorectal physiologic test :
Delayed first sensation
Raised maximum tolerated volume

Tx : empty rectum and surgery

Non megacolon constipation :

Due to drug ir medical conditions reducing perostalsis
May be normal or slow gut transit time

Dix : defecating proctography

Whole gut transit time measurement:
Through Radio-opaque capsule, retention if more than 80% shape after 120 hour is
abnormal
Tx :
Dietary fibres
Laxatives
Idiopathic slow transit constipation is hard to treat medically ; total colectomy and
Illeorectal anastomosis is preferred procedure.

INTESTINAL OBSTRUCTION

[Link] OBSTRUCTION
PERISTALSIS PRESENT WORK AGAINST MECHANICAL OBSTRUCTION

INTRALUMINAL CAUSE: FOREIGN BODY. FECAL IMPACTION, BEZOAR

INTRAMURAL CAUSE: STRICTURE MALIGNANCY ETC
EXTRAMURAL CAUSE: MC(ADHESION)

2.A DYNAMIC OBSTRUCTION

PERISTALSIS MAY BE PRESENT OR ABSENT WITHOUT ANY OBSTRUCTION

CAUSES:PARALYTIC ILEUS ,PSEUDO OBSTRUCTION

PATHOPHISIOLOGY OF OBSTRUCTION

DISTAL PART: NORMAL PERISTALSIS & ABSORPTION

PROXIMAL PART: DILATED & ALTERED MOTILITY DUE TO GAS (NITROGEN &
HYDROGEN SULPHIDE)& LIQUIDS (ASSOCITED WITH ELECTROLYTE
IMBALANCE)

[Link] LOOP OBSTRUCTION

OBSTRUCTION FROM PROXIMAL & DISTAL POINTS
CAUSE: MALIGNANT STRICTURE IN RIGHT COLON WITH COMPETENT
ILEOCECAL VALVE
TREATMENT: RESECTION OF IS ISCHEMIC BOWEL FOLLOWED BY END TO END
ANASTOMOSIS

2SYMPTOMS& SIGN
ABDOMINAL PAIN(FIRST SYMPTOM ),: CENTER ON UMBLICUS(SMALL BOWEL)
LARGE BOWEL(LOWER HYPOGASTRIC REGION)

DISTENSION,VOMITING :

CONSTIPATION:
ABSOLUTE CONSTIPATION : NEITHER FEACES NOT FLATUS (OBSTIPATION)
RELATIVE CONTIPATION : ONLY FLATUS PASS NO FEACES
DOESNOT APPLY IN: RITCHER HERNIA,GALLSTONE ILEUS, MESENTRIC
VASCULAR OCCLUSION, PARTIAL OBSTRUCTION

HIGH SMALL BOWEL OBSTRUCTION: VOMITING(EARLY) CENTRAL DISTENSION

LOW SMALL BOWEL OBSTRUCTION: PAIN(EARLY) CENTRAL DISTENSION
LARGE DISTENSION: DISTENSION(EARLY) ,PERIPHERAL DISTENSION

ACUTE OBSTRUCTION: SMALL BOWEL OBSTRUCTION

CHRONIC OBSTRUCTION: LARGE BOWEL OBSTRUCTION
SUBACUTE OBSTRUCTION: INCOMPLETE OBSTRUCTION
RADIOLOGICAL FEATURE OF OBSTRUCTION

SUPINE ABDOMINAL XRAY: OBSTRUCTION

ERECT ABDOMINAL XRAY: PERFORATION

3 PHYSIOLOGICAL FLUID LEVELS: GASTRIC FUNDUS, DEUDENAL

CAP,TERMINAL ILEUM

BOWEL DIAMETER: 3 6 9
SMALL BOWEL:30MM LARGE BOWEL:60MM CAECUM :90MM

TREATMENT
CONSERVATIVE MANAGEMENT: NG DECOMPRESSION, IV FLUIDS, SODIUM &
WATER LOSS ,BROAD SPECTRUM ANTIBIOTICS

SURGICAL MANAGMENT:
MIDLINE INCISION LOOK FOR CAECUM :
CAECUM COLLAPSED: SMALL BOWEL OBSTRUCTION
CAECUM IS DILATED: LARGE BOWEL OBSTRUCTION
ADHESION: ADHENOLYSIS
VOLVOLUS: UNTWISTING
IF VIABLE: NO RESECTION IF NON VISBLE: RESECTION& END TO END
ANASTOMOSIS

STRANGULATION
OBSTRUCTION OF VASCULAR COMPROMISE ,SURGICAL EMERGENCY
COMPROMISE VENOUS FIRST THEN ARTERIAL SUPPLY
IF ARTERY IS IMPAIRED,HEMORRHAGIC INFARCT OCCURS

MC CAUSE: CLOSED LOOP OBSTRUCTION

SYMPTOMS: CONSTANT PAIN, TENDERNESS WITH RIGIDITY,SH,SUDDEN ONSET

OF SYMPTOM

TX: CONSERVATIVE + RESECTION & END TO END ANASTOMOSIS

INTUSSUSCEPTION

MC TYPE CHILDREN: ILEOCOLIC (MECKELS DIVERTICULUM)

MC TYPE IN ADULTS: COLOCOLIC (POLYP, ADENOMA, LIPOMA)
MC CAUSE: IDIOPATHIC

PARTS (3): INTUSSUSPIENS, INTUSSUSEPTUM , INTUSSUSCEPTION (APEX

,NECK)

CF: SCREAMING AND DRAWING UP OF LEG

REDCURRANT JELLY , THE SIGN OF DANCE (RIF),SAUSAGE SHAPE LUMP
CONCAVITY

DX:
PLAIN ABDOMINAL XRAY : ABSENT CECAL GAS(ILEOCOLIC)
BARIUM ENEMA: CLAW SIGN (ILEOCOLIC)
ABDOMINAL U/S: DOUGHNUT APPEARNCE

TX:
NONOPERATIVE REDUCTION(RADIOLOGICAL) USING AIR OR BARIUM ENEMA
OPERATIVE REDUCTION: TRANSVERSE RIGHT SIDED ABDOMINAL INCISION
THEN SEE TISSUE VIABILITY
NONVIABLE: RESECTION & END TO END ANASTOMOSIS
VIABLE: NO RESECTION

VOLVOLUS
TWISTING OF BOWEL AROUND ITS MESENTERY

CAECAL VOLVOLUS : TWIST CLOCK WISE, BARRIUM ENEMA'BIRD BEAK

DEFORMITY' TX: IF NON VIABLE..RIGHT HEMICOLECTOMY IF VIABLE ..
CECOPEXY
SIGMOID VOLVOLUS: TWIST ANTICLOCKWISE, MC VOLVOLUS ACUTE IN YOUNG
CHRONIC IN ELDERLY ABDOMINAL XRAY 'COFFEE BEAN SIGN OR OMEGA SIGN
TX: BEST INITIAL TEST(COLONOSCOPIC DECOMPRESSION ) THEN
SIGMOIDECTOMY OR SIGMOIDOPEXY

LAXATIVE ABUSE, PSYCHIATRIC PATIENT: SIGMOID VOLVOLUS

ADHESION
FIBROUS BAND BTWN TISSUE AND ORGAN
MC CAUSE OF INTESTINAL OBSTRUCTION
CAUSE: ISCHEMIC AREA FOREIGN MATERIAL INFECTION & INFLAMATION
TX: CONSERVATIVE MANAGEMENT(72HOURS) & SURGICAL (ADHENOLYSIS ,
NOBLES PLICATION , CHARLES PHILLIPS PLICATION , INTESTINAL INTUBATION)

INTERNAL HERNIA
HERNIATION THROUGH MESENTERIC DEFECT OR NORMAL ANATOMICAL
OPENNING

FORAMEN OF WINSLOW
PARADEDEUDENAL .(MC)
TRANS MESENTRIC
TRANS MESOCOLON
PERI CECAL (PERI APPENDICIAL)
AQUIRED (POST TRAUMATIC POST SURGICAL)

GALL STONE ILEUS

RIGLER TRAID: SMALL BOWEL OBSTRUCTION , PNEUMOBILIA , ABNORMAL

MINERAL SHADOW(CALCIFICATION) ON XRAY
TX: LAPAROTOMY

PARALYTIC ILEUS

MC CAUSE:TYHPOID, POST OPERATIVE

AFTER 72 OPERATION , NO BOWEL SOUND,NO PASSAGE OF FLAUTUS ,NO PAIN
.
TX: CONSERVATIVE MANAGMENT

PSEUDOOBSTRUCTION

CAUSES: IDIPATHIC MC DIBETIES UREMIA TRAUMA MYXEDEMA DRUGS

MC SITE: COLON
OGLIEVES SYNDROME: ACUTE COLONIC OBSTRUCTION IN ELDERS AFTER
SURGERY
.TX: TREAT UNDERLYING CAUSE ,FLUID BALANCE ,PROKINETIC MEDICATION
(NEOSTIGMINE METACLOPRAMIDE, ERTHROMYCIN)
COLON GREATER THAN 10cm COLONIC DECOMPRESSION IF IT FAILS
CECOSTOMY

MESENTRIC ISCHEMIA
MC CAUSE : SMA ARTERY EMBOLISIM (ORGIN OF MIDDLE COLIC ARTERY)

SMA EMBOLISIM MC CAUSE: LA FIBRILLATION

ACUTE ONSET OF PAIN(OUT OF PROPORTION),HEMOTO CHEZIA AND
PERITONEAL SIGN LATE
TX: EMBOLECTOMY

SMA THROMBOS MC CAUSE: ATHEROSCLEROSIS

CHRONIC OR ACUTE ON CHRONIC ABDOMINAL PAIN
TX: THROMBECTOMY (OPEN/ CATHETER) WITH STENTINGOR ANGIOPLASTY

SMV THROMBUS: HYPERCOGULABLE STATE

CRAMPY ABDOMINAL PAIN WITH DISRRHEA
TX: ANTICOGULANT ,RESECTION OF NECROSED PART

DX: CT ANGIOGRAM (CT ABDOMEN & PELVIS)

NON OCCLUSIVE MESENTRIC ISCHEMIA

MC CAUSE: LOW CARDIAC OUTPUT (HYPOVOLEMIA ,CHF

,HEMOCONCENTRATION)

WATERSHED AREAS: GRIFFITH AREA(SPLENIC FLEXURE)MC ,SUDAK AREA

(UPPER RECTUM)

3FORMS: GANGRENOUS, TRANSIENT OR STRICTURING FORMING

TX: VOLUME RESUCITATION , INC CARDIAC OUTPUT , CATHETER ASSOCIATED

NITROGLYCRINE , RESECTION OF AFFECTED BOWEL

NEWBORN INTESTINAL OBSTRUCTION

[Link] ATRESIA

DEUDENAL MC : DOUBLE BUBBLE SIGN DOWN SYNDROME TX

DEUDENODEUDENOSTOMY
JEUEJNAL: TRIPLE BUBBLE SIGN ,TXRESECTION ENT TO END ANASTOMOSIS

[Link] ILEUS:
MC CAUSE: CYSTIC FIBROSIS
MC SITE: TERMINAL ILEUM
ABDOMINAL XRAY: DILATED SMALL INSTESTINE WITH MOTTLING ,FLUID LEVEL
NOT SEEN
SWEAT CHLORIDE GREATER THAN 70
TX:
UNCOMPLICATED CASE: HYPEROSMLOR GASTROGRAFFIN ENEMA
COMPLICATED CASE: SURGERY

ANUS & ANAL CANNAL

2 SPHINCTORS:
INTERNAL ANAL SPHINCTOR .. SMOOTH MUSCLE . INVOLUNTARY ..
AUYONOMIC NERVES

EXTERNAL ANAL SPHINCTOR ... SKELETAL MUSCLE .. VOLUNTARY .. PUDENDAL

NERVE , 3 PARTS DEEP ,SUPERFICIAL,SUB CUTANEOUS

BETWEEN TWO SPHINCTOR .. HILTONS WHITE LINE (INTERSPHINCHTERIC

PLAN).. POTENTIAL ROUTE FOR PUS SPREAD

DENTATE LINE SEPERATE RECTUM TO 2 PARTS UPPER 2/3 AND LOWER 1/3
UPPER ANAL CANNAL ( VISCERAL PORTION):
UPPER 2/3 SIMPLE COLUMNAR EPITHELIUM, SUPERIOR RECTAL VEIN,
INTERNAL ILIAC NODES ,PELVIC PLEXUSES

LOWER ANAL CANNAL ( STRATIFIED SQUAMOUS EPITHELIUM),INFERIOR

RECTAL VEIN,SUPERFICIAL INGUINAL NODE,SOMATIC NERVE FIBER .

IMPERFORATE ANUS
CONGENITAL DEFECT IN WHICH ANAL OPENING IS MISSING
BELOW PUBORECTALIS: LOW IMPERFORATE
EASY TO CORRECT , CONSTIPATION
TX: ANOPLASTY

ABOVE PUBORECTALIS: HIGH IMPERFORATE

DIFFICULT TO CIRRECT ,FECAL INCONTINENCE
TX: TEMPORARY COLOSTOMY ,POSTERIOR SAGITTAL ANORECTOLLASTY
(PSAP)
BOYS: RECTOURETHRAL FISTULA MC
GIRLS: RECTOVESICULAR FISTULA MC

DX:
PRESENCE OF MECONIUM ON PERINIUM OR URINE
LATERAL PRONE RADIOGRAPHY:(INVERTOGRAM)DISTANCE BTWN RECTAL GAS
BUBBLE &ANAL AKIN

PILONIDAL SINUS(JEEP DISEASE)

SINUS IN NATAL CLEFT OVERLYING COCCYX ,LINED BY GRANUKATION TISSUE

OR HAIR
DUE TO EXCESS SITTING (LORRY DRIVER COMPUTER OPERTOR)
INTERDIGITTING PILONDINAL SINUS(HAIR DRESSERS)

CF: INTERMETINIT PAIN,SWELLING ,DISCHARGE

ACUTE : ABCESS CHRONIC: SEPSIS

TX:
ACUTE: BROAD SPECTRUM ANTIBIOTICS & DRAINAGE
CHRONIC :
[Link] OPERATION: SEMI LATERAL INCISION HEAL BY PRIMARY
INTENTION BY FLAP
[Link] OPERATION: LATERAL TO MIDLINE INCISION HEAL BY SECONDARY
INTENTION

ANAL FISSURE
LONGITUDNAL SPLIT IN ANODERM AT DISTAL ANAL CANNAL
MC SITE: POSTERIOR MIDLINE WOMEN(ANTERIOR)
PAIN ON DEFECATION RELIEVED AFTER DEFECATION .
BRIGHT RED STOOL WITH MUCOUS DISCHARGE
CHRONIC FISSURE ....HYOERTROPHIED ANAL PAPPILAE & SENTINEL TAG
EXTERNALLY

TX:
CONSERVATIVE MANAGMENT: HIGH FIBER DIET STOOL SOFTENER
,WARMS(SITZ BATH)& ANESTHETICS, DRUGS
MANNUAL DILATATION: (4-8 DIGITS FORCE FUL UNDER LOCAL OR GENERAL
ANESTHESIA A/E : INCONTINENCE)
LOCAL ANAL SPHINCTERECTOMY: EARLY COMP(HEMORRHAGE HEMATOMA)
LATE(INCONTINENCE MC)
ANAL ADVANCEMENT FLAP:

HEMORRHOIDS

ANAL CUSHIONS(ANORECTAL MUCOSA,SUB MUCOSAL TISSUE ,SUBMUCOSAL

BLOOD VESSELS)

TYPES:

INTERNAL HEMORRHOIDS: ABOVE PECTINATE LINE PAINLESS 3,7,11 O CLOCK

EXTERNAL HEMORRHOIDS: BELOW PECTINATE PAINFUL
INTERNO-EXTERNAL HEMORRHOIDECTOMY:
SECONDARY HEMORRHOIDS : CARCINOMA, ANORECTAL DEFORMITY, GRAVID
UTERUS

RISK FACTOR: SHEARING FORCES ACTING ON ANUS

CF: BRIGHT PAINLESS BLEEDING(MC) ,BLOOD NOT MIXED WITH STOOL

,MUCOSAL DISCHARGE ,PROLAPSE ,

DEGREE OF HEMORRHOIDS:
1 BLEED ONLY NO PROLAPSE
2 PROLAPSE BUT REDUCE SPONTANEOUSLY
3 PROLAPSE REDUCED MANUALLY
4 PERMENANT PROLAPSED

MANAGEMENT
CONSERVATIVE MANAGMENT: HIGH FIBER DIET SUPPOSITRIES
INJECTION SCLEROTHERAPY : 1&2 DEGREE HEMORRHOIDS ,BLEEDING MAIN
COMPLAIN
BANDING :1&2 DEGREE HEMORRHOIDS PROLAPSE MAIN COMPLAIN

HEMORRHOIDECTOMY: 3&4 DEGREE HEMORRHOIDS

TECHNIQUE:
OPEN HEMORRHOIDECTOMY
CLOSED HEMORRHOIDECTOMY
STAPLED HEMORRHOIDECTOMY

COMPLICATION:
EARLY: REACTIONARY HEMORRHAGE
LATE: SECONDARY HEMORRHAGE

THE PROSTATE

LOCATION:BETWEEN BASE OF URINARY BLADDER AND UROGENITAL

DIAPHARGM
LOBES(5): ANTERIOR POSTERIOR MEDIAN RIGHT LATERAL LEFT LATERAL LOBE

COLLECTION OF 30-50 COMPOUNDS TUBULEALVEOLAR GLANDAREANGE IN 3

ZONE
PERPHERAL ZONE ...PROSTATE CANCER
CENTRAL ZONE
TRANSITIONAL ZONE ... BPH

ARTERY: INTERNAL ILIAC ARTERY (INFERIOR VESICAL ARTERY)

VEIN: PROSTATIC VENOUS PLEXUSES
[Link] ILIAC VEIN TO IVC(PROSTATE CANCER TO HEART &LUNG)
[Link] VENOUS PLEXUSES TO CRANIAL DURAL SINUSES( VERTEBRAL
COLUMN & BRAIN)

HORMONAL CONTROL : PROSTATE(TESTOSTERON) FROM LEYDIG CELL (90)

ADRENAL GLAND (10)

PSA: MARKER OF PROSTATIC DISEASE, LIQUAFICATION OF SEMEN

1-4NG/ML= 15_20 PERCENT CANCER
4-10NG/ML= 25 PERCENT CANCER
METASTATIC DISEASE=GREATER THAN 30NG/ML
LOCALLY ADVANCED DISEASE=LESS THAN 10-15NG/DL

BPH(BENIGN PROSTATIC HYPERPLASIA)

NON MALIGNANT ENLARGEMENT OF PROSTATE

INCREASE IN STROMAL & GLANDULAR COMPONENT
MC SITE: TRANSITIONAL ZONE
AGE: OVER 50 YEARS
MC CAUSE OF BLADDER OUTFLOW OBSTRUCTION
HORMONES: ESTROGEN (PROSTATE ENLARGEMENT DUE TO INCREASE DHT
RECEPTOR) DHT (HYPERTROPHY OF PROSTATE)

CLINICAL FEATURE:
VOIDING SYMPTOMS: HESISTANCY , POOR FLOW , INTERMENTENT STREAM,
DRIBLING, SENSATION OF POOR BLADDER CONTROL
STORAGE SYMPTOMS: FREQUENCY URGENCY NOCTURIA URGENCY URGE
INCONTINENCE NOCTURNAL ENURESIS

DRE: SURFACE SMOOTH & CONVEX , PRESISTENCE OF MEDIAN SULCUS()

CONSISTENCY HOMOGENOUS , NON TENDER , RECTAL MUCOSA MOVES
FREELY OVER PROSTATE

DX: SERUM UREA & CREATNIN RENAL TRACT U/S SERUM PSA , TRANSRECTAL
ULTRASOUND , CYSTOSCOPY , URODYNAMIC STUDIES ( DECREASE URINE
FLOW RATE INCREASE VOIDING PRESSURE)

TREATMENT:
MEDICAL MANAGEMENT:
WATCH FUL WAITING= MILD SYMPTOMS
ALPHA BLOCKER: PARAZOSIN, DOXAZOCIN, TAMSULIN (LESS THAN 30G)
5 ALPHA REDUCTASE INHIBITOR: FINESTERIDE(MORE THAN 30G)

SURGICAL MANAGMENT: (PROSTATECTOMY)

TRANSURETHERAL RESECTION OF PROSTATE
RETROPUBIC PROSTATECTOMY
TRANSVESICAL PROSTATECTOMY
PERINEAL PROSTECTOMY

GOLD STAND TREATMENT: TRANSURETHERAL RESECTION OF PROSTATE(

TURP )... ASSOCIATE WITH
WATER INTOXICATION (TUR SYNDROME)...CONGESTIVE HEART
FAILURE,HYPONATREMIA & HEMOLYSIS TX: FLUID RESTRICTION PRECENTION;
ISOTONIC GLYCINE

COMPLICATION : MC RETEROGRADE EJACULATION

PROSTATIC CARCINOMA
MC CARCINOMA IN ELDER MALE
MC SITE: PERIPHERAL ZONE
MC RISK FACTOR : AGGING
LOCALLY: SEMINAL VESICLE BLADDER
HEMATOGENOUS SPREAD: LUMBER VERTEBRAE(OSTEOLYTIC-
OSTEOBLASTIC)
LYMPH NODE: OBTURATOR NODES

SYMPTOMS: ADVANCE CASES VOIDING & STORAGE SYMPTOMS PELVIC BACK

PAIN MAILAISE ANEMIA WEIGHT LOSS

DRE: SURFACE HARD NODULAR & IRREGULAR MEDIAN SULCUS OBLITERATED

CONSISTENCY HETEROGENOUS ,RECTAL MUCOSA TETHERED TO GLAND

STAGGING OF PROSTATE:
T1: CLINICALLY INAPPEARENT TUMOR NOT PALPABLE NOR VISIBLE
T2: SUSPICIOUS NODULES OR RECTAL EXAMINATION WITHIN CAPSULE
INVOLVE 1 LOBE(A) BOTH LOBE (B)
T3: TUMOR EXTEND THROUGH CAPSULE UNILATERALLY OR BILATERALLY
T4 : TUMOR THAT IS FIXED ARE METS

DX:
PSA LEVEL: GREATER THAN 10 (SUGGESTIVE) GREATER THAN 35(DIAGNOSTIC)
MRI MOST ACCURATE TEST FOR STAGGING

TX:
STAGE 1A&1B
YOUNG RADICAL PROSTECTOMY
ELDERLY = TRANURETHRAL RESECTION WITH HORMONE RESECTION

STAGE 1C&2:
YOUNG= RADICAL PROSTATECTOMY OR RADICAL RADIOTHERAPY
ELDERLY= TRANSURETHERAL RESECTION WITH OR WITHOUT HORMONE
THERAPY

STAGE 3&4:
YOUNG= ANDROGEN ABLATION
ELDERLY= ANDROGEN ABLATION
RADICAL PROSTATECTOMY(T1&T2): REMOVAL OF PROSTATE DOWN TO DISTAL
SPHINCTER MECHANISIM IN ADDITION TO SEMINAL VESICLES , BLADDER NEVK
IS RECONSTITUTED TO URETHRA

EXTERNAL BEAM RADIOTHERAPY : (T1&T2) RADIATION OF RADICAL DOSE

55-70Gy IN 20-25 FRACTION OVER 4 WEEK (PROCTITIS CYSTITIS ERECTILE
DYSFUNCTION)

MEDICAL CASTRATION - HORMONAL THERAPY: (T3&T4):

LHRH (GOSERILIN) HOT FLUSHES LETHARGY LOSS OF SEXUAL FUNCTION
ANTI ANDROGEN(FLUTAMINDE) GYNAECOMESTIA & NIPPLE TENDERNESS
SURGICAL CASTRATION: ORCHIDECTOMY

PROSTATIS

[Link] PROSTATITIS

MC CAUSE: E COLU
CF: FEVER RIGORS LOWER BACK PAIN PERINEAL PAIN URGENCY FREQUENCY
NOCTURIA DYSURIA
DRE: TENDER PROSTATE

TX: BED REST PAINKILLER ADEQUATE HYDRATION , ANTIBIOTICS

(TRIMETHOPRIM & SULPHAMETHAXOLE, CIPROFOLAXACIN)

[Link] ABCESS:
NO RESPONSE AFTER ANTIBIOTIC USE
DRE: HOT ENLARGED EXTREMLY TENDER PROSTATE
TX: DRAINAGE PERIURETHRAL RESECTION & PERINEAL ROUTE

[Link] PROSTATITIS :
PRESISTENT THREAD IN VOIDE URINE
PROSTATIC MASSAGE SHOW PUS CELL
CF: INTERMETINIT PAIN POSTERIOR URETHRITIS PROSTATIC PAIN
PERIGENITAL PAIN

DX: 3 GLASS TEST DRE: SOFT BOGGY TENDER PROSTATE

TX: ANTIBIOTICS
THE URINARY BLADDER

BLADDER STONES
PRIMARY STONE: STERILE URINE, ORGINATE FROM KIDNEY
SECONDARY STONE:INFECTION , OUTFLOW OBSTRUCTION , IMPAIRED
BLADDER EMPTYING

CF:
FREQUENCY(EARLY SYMPTOMS)
PAIN AT THE END OF MICTURATION TIP OF PENIS OR LABIA MAJORA
IN YOUNG BOY PULLING OD PENIS & SCREAMING AFTER MICTURATION
PAIN AGGREVATED BY MOVEMENT
TERMINAL MICTURATION
UTI

DX:
DRE OR VAGINAL EXAMINATION , ULTRASOUND PLAIN RADIOGRAPH
NEARLY ALL STONES DEALS WITH ENDOSCOPICALLY

TX:
PERURETHRAL LITHOLAPLAXY:
US LITHROTRIPSY : SMALL STONES
LASER LITHOTRIPSY: LARGE STONES

PERCUTANEOUS SUPRAPUBIC LITHOLAPAXY: IF URETHRA IS NARROW

DIVERTICULUM
BULDGING POUCHES IN BLADDER WALL

MC CAUSE: OUTFLOW OBSTRUCTION

DX: CYSTOSCOPY ULTRASOUND
COMPLICATION: RECURRENT UTI BLADDER STONES, HYDRONEPHROSIS
NEOPLASM
TX: SURGERY(COMBINED INTRAVESICAL & EXTRAVESICAL
DIVERTICULECTOMY)

SHISTOSOMIASIS
AGENT: SHISTOSOMIASIS HEMATOBIUM
SPREAD: SKIN THROUGH WATER (SWIMMERS ITCH)
INTERMITENT PAINLESS TERMINAL HEMATURIA (EARLY SYMPTOM)
BILHARAZIAL PSEUDOTUBERCULES,NODULES
SANDY PATCHES
ULCERATION
FIBROSIS .
GRANULOMA
SQUAMOUS CELL CARCINOMA

TX: PRAZIQUENTAL (20MG ) THREE DOSES 4 HOURS APART VERY EFFECTIVE

BLADDER CARCINOMA
MC: TRANSITIONAL CELL CARCINOMA
MC RISK FACTOR: CIGRETTE SMOKING
PRESENTAION: PAINLESS TERMINAL HEMATURIA CLOT URINARY RETENTION
CONSTANT PAIN IN PELVIS

TUMOR STAGING:
NON MUSCULAR INVASIVE TUMOR
PTa = NO INASION OF LAMINA PROPRIA
PT1= INASION OF LAMINA PROPRIA BUT NO MUSCLE

MUSCLE INVASIVE TUMOR :

PT2=TUMOR INVADES MUSCLE
LOCAL INVASION & DISTANT METASTASIS

NON INVASIVE CIS:

MANAGMENT:
URINE CYTOLOGY: GOOD SCREENING TEST MALIGNANT CELL
CYSTOURETHROSCOPY .MAINSTAY OF DIAGNOSIS
ULTRASOUND CT SCAN MRI IV UROGRAPHY

TX:
LOW RISK SUPERFICIAL DISEASE : TRANSURETHRAL RESECTION OF TUMOR
INTRAVESICAL CHEMOTHERAPY (MITOMYCIN C) INTRAVESICAL
IMMUNOTHERAPY

HIGH RISK SUPERFICIAL DISEASE : TRANSURETHRAL RESECTION OF TUMOR

,INTRAVESICAL (BCG) IMMUNOTHERAPY,CYSTECTOMY
MUSCLE INVASIVE TUMOR :
RADICAL CYSTECTOMY PELVIC LYMPHADENECTOMY , NEOADJUVANT
CISPLANT BASED CHEMOTHERAPY ,EXTERNAL BEAM RADIOTHERAPY IF UNFIT
FOR SURGERY

ADENOCARCINOMA...URACHAL DIVERTICULUM
SQUAMOUS CELL CARCINOMA ...SHISTOSOMA HEMATOBIUM
TRANSITIONAL CELL CARCINOMA ...SMOKING

THE KIDNEY & URETER

HORSE SHOE KIDNEY

MEDIAL SUBDIVISION OF MESONEPHRIC DUCT MEET & FUSE (MC LOWER
POLES)
KIDNEY TRAPED UNDER INFERIOR MESENTERIC ARTERY
LOCATION:4TH LUMBAR VERTEBRAE
CLININCAL FEATURE: PELVIURETERIC OBSTRUCTION ,INFECTION ,STONE
ASSOCIATION: TURNER SYNDROME
DX: RADIOLOGICAL IMAGES XRAY KUB, UROGRAM
TX: FOR COMPLICATION ONLY
ISTHMUS DIVISION(ABDOMINAL AORTIC ANEURYSUM)
PUO( PYELOURETROPLASTY)
KIDNEY STONE ( ESWL OR OPEN SURGERY)

ADULT POLYCYSTIC KIDNEY DISEASE

AD,PKD1 PKD2 GENE MUTATION

CF: BILATERALLY ENLARGED KIDNEY,DULL LOIN PAIN,HEMATURIA
,HYPERTENSION , INFECTION, UREMIA ..
ASSOCIATION: BERRY ANEURYSUM , MVP
DX: FNAC(CYTOLOGY), UROGRAPHY (BIG BIZARE BILATERAL APPEARNCE)
TX:
CONSERVATIVE :LOW PROTEIN DIET, ANTIBIOTIC ,ANTIHYPERTENSIVE
SURGERY: ROVSING PROCEDURE

CHILDHOOD POLYCYSTIC KIDNEY DISEASE:

AR, PKHD1 GENE MUTATION

CF: RENAL FAILURE(EARLY),HYPERTENSION , ANEMIA ,KIDNEY STONE
ASSOCIATION: HEPATIC FIBROSIS & PORTAL HTN
TX: CONSERVATIVE MANAGEMENT

SIMPLE RENAL CYST

SINGLE OR MULTIPLE ON UNILATERAL KIDNEY ,NORMAL KIDNEY
U/S: SMOOTH THIN WALL , HOMOGENOUS CONTENT , AVASCULARITY , FLUID

DUPLICATION OF RENAL PELVIS &URETER

ECTOPIC URETER IN WOMEN= BELOW SPHINCTOR = INCONTINENCE

ECTOPIC URETER IN MEN = ABOVE SPHINCTOR = NO INCONTINENCE ..

URETEROCELE
CYSTIC ENLARGEMENT OF INTRAMURAL URETER
CONGENITAL ATRESIA OF URETER
U/S: COBRA HEAD APPEARNCE (UROGRAPHY)
TRANSLUCUCENT(CYSTOSCOPY)
TX: ASYMPTOMATIC : NO TREATMENT
SYMPTOMATIC: ENDOSCOPIC DIATHERMY INCISION

RENAL CALCLULI

CAUSES: DEHYDRATION, INFECTION , PROLANGED IMOBLIZATION ,

HYPERPARATHYROIDISIM ,,VIT A DEFECIENCY, HYPERURECEMIA

TYPES OF STONE:
CALCIUM OXLATE(MC ADULT) CALCIUM PHOSPHATE (MC CHILDREN) :
IRREGULAR SHAPE SHALE PROJECTION, RADIOOPAQUE ALKALINE PH

MAGNESIUM AMONIUM PHOSPHATE/TRIPLE/STAGHOURN/STRUVITE STONE:

INFECTION OF PROTEUS OR STAPHYLOCOCCUS SMOOTH & DIRTY WHITE
,RADIOOPAQUE, ALKALINE PH

URIC ACID STONE: HARD SMOOTH MULTIPLE,RADIOLUCENT ACIDIC PH

CYSTEIN(WHITE)& XANTHINE(RED BRICK) STONE : ACIDIC PH

PAIN: FIXED AT HYPOCHONDRIUM (ANTERIORLY) RENAL ANGLE POSTERIORLY

,AGGREVATED WITH MOVEMENT ,RADIATES TO GRION PENIS SCROTUM OR
LABIUM
INVESTIGATION OF CHOICE: XRAY KUB (RADIOPAQUE) ,UROGRAM
(RADIOLUCENT)
NON CONTRAST ENHANCED SPIRAL CT : CONFIRMATORY FOR ACUTE
URETERIC STONE

TREATMENT:
LESS THAN 0.5CM = WILL PASS SPONTENOUSLY
STONE LESS THAN 2CM= ESWL (MC:INFECTION)
STONE GREATER THAN 2CM OR 1CM AT LOWER POLE= PERCUTANEOUS
NEPHROLITHOTOMY (PCNL) (COMP: HEMORRHAGE PERFORATION)

OPEN SURGERY:
PYELOLITHOTOMY: FOR STONE IN PELVIS
EXTENDED PYELITHOTOMY: AVOID MAJOR VESSELS
NEPHROLITHOTOMY : FOR COMPLEX CASES
PARTIAL NEPHROLITHOTOMY: LOWER CALYX WITH INFECTIVE PARENCHYMA

URETERIC STONE

OBSTRUCTION SITES:
URETEROPELVIC JUNCTION
AT POINT CROSSING THE ILAC ARTERY
JUXTAPOSITION OF VASA DEFERENCE
AT POINT ENTERING THE BLADDER
AT URETERIC ORIFICE

TX:
PAIN: STRONG ANALAGESIC
SMALL STONE: EXPECTANT TREATMENT
ENDOSCOPIC REMOVAL USING DORMIA CATCH BASKET
URETERIC MEATOTOMY: ENDOSCOPIC OPENING VIA AN INCISION USING A
DIATHERMY KNIFE
URETEROSCOPIC REMOVAL:
PUSH BANG: PUSHBAG TO KIDNEY ,JSTENT TO SECURE POSITION THEN ESWL

OPEN SURGERY:
UPPER THIRD: LOIN INCISION
MIDDLE THIRD: ILIAC FOSSA INCISION
LOWER THIRD: PFANNESTEIL INCISION

RENAL INFECTION

ECOLI & STREPTOCOCCI = ACIDIC URINE

PROTEUS & STAPHYLOCOCCI= BASIC URINE

[Link] PYELONEPHRITIS:

RISK FACTOR: UTI FEMALES PREGNANCY DIBETIES IMMUNOCOMPROMISED

,INSTRUMENT
MC ORGANISIM: [Link]

ACUTE FLANK PAIN FEVER DYSURIA ,URGENCY , FREQUENCY

TREATMENT:
ADEQUATE FLUIDS, ALKALANIZATION OF URINE BY POTASSIUM CITRATE
,NSAID ,ANTIBIOTICS

[Link] PYELONEPHRITIS : REFLUX NEPHROPATHY

MC CAUSE: VESICUURETRAL REFLEX

TUBULES AFFECTED ATROPHY & DILATION ,THYROIDIZATION OF KIDNEY

DX: VOIDING CYSTOURETHROGRAM- VUR

TX: TREAT UNDERLYING CAUSE, ANTIBIOTIC , SURGICAL(PARTIAL OR
NEPHRECTOMY ) IF UNILATERAL

[Link] TUBECULOSIS:
MC AFFECTED KIDNEY: RIGHT
FIRST SYMPTOM: URINARY FREQUENCY
MC CAUSE : STERILE PYURIA

DX: CULTURE
TX: ANTI TB THERAPIES ,SURGERY 6-12 WEEK

RENAL CELL CARCINOMA/HYPERNEPHROMA/GRAWITZ TUMOR

MC TUMOR: ADENOCARCINOMA
MUTATION:VHL GENE
TRAID: COSTOVERTEBRAL PAIN PALPABLE MASS & HEMATURIA
LEFT SIDED VERICOCELE, IMPRESSIVE SIGN
HEMATOGENOUS SPREAD: CANON BALL APPEARNCE(LUNG)
MC VEIN INVOLVED: IVC
LYMPH NODE: PARA AORTIC NODE
POLYCYTHRMIA: ELEVATE EPO
HYPER CALCEMIA : ELEVATE PTHrP
DX: ULTRASOUND CT SCAN XRAY KUB IV UROGRAPHY CBC CHEST X RAY
TX:
NEPHRECTOMY (ONLY CURATIVE TREATMENT)
INCISION: LION OR TRANS ABDOMINAL
RADICAL NEPHRECTOMY(LARGE TUMOR)
PARTIAL NEOHRECTOMY (LESS THAN 4CM)

WILMS TUMOR/NEPHROBLASTOMA
MC PRIMARY MALIGNANT IN CHILDREN
MUTATION : WT1 GENE
UNILATERAL ABDOMINAL MASS BUT DOESNOT CROSS MIDLINE

DX: CT CHEST & ABDOMEN

TX:
UNILATERAL : CHEMOTHERAPY & NEPHRECTOMY
BILATERAL TUMORS: PARTIAL NEPHRECTOMY

URETHRA & PENIS

POSTERIOR URETHRAL VALVE

MC CAUSE OF BLADDER OUTFLOW OBSTRUCTION IN YOUNG BOYS

ANTENATAL U/S: URINARY TRACT DILATATION

FLAP VALVES: URINE DOESNOT FLOW , URETHRAL CATHETER CAN PASS
IOC: VOIDING CYSTOGRAM
TX:
SUPRAPUBIC CATHETER IS INSERTED TO RELIVE BACK PRESSURE
DEFINITIVE TX: TRANSURETHRAL RESECTION OF VALVE
HYPOSPADIAS
EXTERNAL URETHRAL MEATUS ON VENTRAL SURFACE OF PENIS
MC CONGENITAL ANOMLY OF URETHRA
AVOIDE CIRCUMCISSION

TYPES:
GLANDULAR-MOST COMMON
CORONAL
PENILE & PENOSCROTAL
PERINEAL - MOST SEVERE

TX: SURGERY 9-18 MONTHS

MEATAL ADVANCEMENT & GRANULOPLASTY
MATHIEU FLAP: CORONAL HYPOSPADIAS
PEDICAL GRAFTS TUBE OR PATCHES = PROXIMAL DEFORMITY

URETHRAL STRICTURE

CAUSES: POST GONOCOCCAL (BULBAR MC) ,CONGENITAL TRAUMATIC

,INSTRUMENTAL , POST OPERATIVE

COMPLICATION: URINE RETENTION,DIVERTICULUM ,FISTULA ,ABCESS ,FISTULA

TX: DILITATION(OLD METHOD) ENDOSCOPIC URETHEROTOMY(MC)

,URETHROPLASTY

PHIMOSIS
NON RETRACTILE FORESKIN OF GLAND
CAUSE: SCARING OF FORESKIN
MC CAUSE TRUE PHIMOSIS: BALANITIS XEEOTICE OBLITERANS
TX: CIRCUMCISION

PARAPHIMOSIS
UROLOGICAL EMERGENCY ,CONSTRICTION OF GLANS PENIS
TX: REDUCE SWELLING BY ICE PACKING & REDUCTION + ANESTHESIA

CIRCUMCISION

INDICATION:
CULTURALREASON(MC) ,PHIMOSIS ,PARAPHIMOSIS ,RECURRENT BALANITIS
,PENILE TUMOR

INFANTS: PLASTIBLE DEVISE USED

ALDOSCENT & ADULT: CIRCUMFRENTIAL INCISION
.SUTURE: ABSORBLE CAT CUT SUTURE

PEYRONIE DISEASE .

CAUSE: IDIPATHIC POST TRAUMA,ASSOCIATE WITH DYUPTRINE

CONTRACTURE
FIBROMATOSIS OF TUNICA ALBUGINEA OF COPUS CAVERNOSUM

.TX: NESBITT OPERATION (STRAIGHTNING OF PENIS BY NON ABSORABLE

SUTURE)

PRIAPISIM
PAINFUL ERECTION
CAUSE: SICKLE CELL ANEMIA, LEUKEMIAS, MALIGNANCY OF CORPORA
CAVERNOSA , SPINAL CHORD DISEASE
TX:
CONSERVATIVE: ICE EJACULATION
ASPIRATION: COPORAL & IRRIGATION WITH WARM SALINE
ORAL MEDICATION: TERBUTALINE
INTRACVERNOSAL MEDICATION METAARMINOL OR ADRENALINE
SHUNTS: GLANS CAVERNOSAL SHUNT CAVERNOSAL SPONGIOSIM SHUNT ,
CAVERNOSAL SAPHENOUS SHUNT

PENILE CARCINOMA:

MC CAUSE: CHRONIC BLANOPOSTHITIS

EARLY: INFILTRATING AS LEUKOPLAKIA
LYMPH NODE: iINGUINAL NODES
DEATH: EROSION OF FEMORAL & EXTERNAL ILIAC ARTERY

TX: CIRCUMCISION RADIOTHERAPY PENILE AMPUTATION

STI

GENITAL HERPES: HSV 2

TINY PAINFUL VESICLE ERODES TO FORM SHALLOW ULCER TX: ACYCLOVIR

LYMPHOGRANULOMA VENEURUM: CHLAMYDIA TRACHOMA TIS

PAINLESS GENITAL ULCER PAINFUL INGUINAL LYMADENOPATHY(GROOVE
SIGN) TX: ANTIBIOTICS

GRANULOMA INGUINALE : KLEBSIELLA GRANULOMOTIS

PAINLESS VESICLE WITH INDURATED PAPULES TX: OXYTETRACYCLIN ,
STREPTOMYCIN .

GENITAL WART: HPV

MEN: CORNONAL SULCUS WOMEN: VULVA TX: PODOPHYLIN EXCISION

TESTIS & SCROTUM

MESONEPHRIC DUCT: EPIDIDYMIS VASA DEFERENCE & ENJECULATORU DUCT

MESODERMAL RIDGE: TESTIS
TESTIS FROM. ABDOMEN TO SCROTUM BY GUBERNACULUM
TESTIS LYMPH NODE: PARA AORTIC NODE
SCROTUM: INGUINAL NODES

ARTERY:
LEFT TESTICULAR ARTERY FROM AORTA
RIGHT TESTICULAR ARTERY FROM RIGHT RENAL ARTERY

VENOUS DRAINAGE:
LEFT TESTICULAR VEIN DRAINS TO LEFT RENAL VEIN
RIGHT TESTICULAR VEIN INTO IVC

UNDECENDED TESTIS
TESTES ABSENT ON SCROTUM AFTER 3 MONTHS
MC : RIGHT SIDES
MACROSCOPIC CHANGES: PUBERTY
MICROSCOPIC CHANGES: EARLY (LOSS OD LYDIGS SERTOLI CELLS,
DECREASE SPERMATOGENESIS
SITES: INTRAABDOMINAL INGUINAL OR SUPERFICIAL INGUINAL RING

MALIGNANCY: SEMINOMA (MC)

TX:
ORCHIDOPEXY: BEFORE 2 YEAR DARSTOUS POUCH(DAROTOUS MUSCLE &
SKIN) INCISION: DEEO INGUINAL REGION
OMBERDANNE OPERATION: NO DARSTOUS POUCH
.
RETRACTILE TESTIS: SCROTUM NORMAL
UNDESCENDED TESTIS: UNDERDEVELEOP SCROTUM

ECTOPIC TESTIS

MC SITE: SUPERFICIAL INGUINAL RING

TESTICULAR TORSION
TESTIS TWIST & INTERUPPTED BLOOD SUPPLY
SURGICAL EMERGENCY
MC CAUSE: INVERSION OF TESTIS
BELL CLAPPER TESTICLE: MC ABNORMALITY WITH TESTICULAR TORSION
,LACKS NORMAL ATTACHMENT TO TUNICA VAGINALIS ,INCREASES
TESTICULAR MOBILITY
CF: SUDDEN ONSET PAIN NAUSEA & VOMITING
SIGN: GLOBALLY TENDER HIGH IN SCROTUM TRANVERSE LIE ENLARGED
,ABSENT CREMESTRIC REFLEX (MOST RELIABLE SIGN)

PREHN SIGN:
ELEVATION REDUCE PAIN: EPIDIDMOORCHITIS
ELEVATION ELEVATE PAIN: TESTICULAR TORSION

DOPPLER U/S: ABSENT BLOOD FLOW TO AFFECTED TESTIS

SURGICAL EXPLORATION:6-8 HOURS

TESTIS VIABLE: ORCHIDOPEXY
TESTIS NON VIABLE: ORCHIDECTOMY OPPOSITE TESTIS ORCHIDOPEXY

TORSION OF TESTICULAR APPENDIGES

APPENDIX TESTIS(HYDATID OF MORGAGNI)

APPENDIX EPIDIDMITIS
PARA EPIDIDYMIS
VASA ABBRENTIA

MC: APPENTIX TESTIS

ACUTE HEMISCROTAL PAIN SUPERIOR POLE OF TESTIS
SIGN: BLUE DOT SIGN,CREMESTRIC REFLEX POSITIVE
TX: SURGICAL EXPLORATION & REMOVAL OF APPENDIGES

ACUTE EPIDIDMOORCHITIS

MC CAUSE: INSTRUMENTATION YOUNG MEN(STI)

GRADUAL ONSET PAIN & SWELLING ,FEVER
INITIAL SWOLLEN TENDER EPIDIDYMITIS .
LATER EPIDIDYMIS N TESTIS FUSE
TENDERNESS & INDURATION ARE LOCALIZED AT EPIDIYMIS AND SPERMATIC
CHORD
PREHN SIGN POSITIVE

YOUNG MEN: DOXYCYCLINE

OLDER MEN: QUINOLONES
SEPSIS: IV ANTIBIOTICS
ABCESS FORMATION: DRAINAGE

CHRONIC EPIDIDMOORCHITIS
[Link] TB : FAILURE OF ACUTE TO RESSOLVE
TX: ANTIBIOTIC FOR 4-6 WEEK IF NO RESOLUTION THEN EPIDIDYMECTOMY OR
ORCHIDECTOMY

[Link]: MC SITE: LOWER POLE SECONDARY HYDROCELE ,BEADING OF VASA DEF

TX: ANTI TB DRUGS

VARICOCELE
DILATATION OF PAMPNIFORM VENOUS PLEXUSES WITHIN SPERMATIC CHORD
ABSENT OR INCOMPETENT VALVE
MC SITE: LEFT SIDED
MC CAUSE: IDIOPATHIC (RENAL TUMOR)
SIGN: BAG OF WORMS APPEARNCE ,COUGH IMPULSE

GRADING OF VARICOCELE:
SUBCLINICAL: NOT DETECTED BY PHYSICAL EXAM FOUND ON IMAGING
I VARICOCELE ONLY PALPABLE DURING OR AFTER VALSALVA MANEUVUR
II VARICOCELE PALPABLE ON ROUTINE PHYSICAL EXAMINATIOK WITHOUT
NEED OF VALSALVA
III VARICOCELE VISIBLE TO THE EYE & PALPABLE ON EXAM .
TX:
ASYMPTOMATIC. : OBSERVATION
SYMPTOMATIC : SURGICAL LIGATION OF TESTICULAR VEIN ,EMBOLIZATION OF
TESTICULAR VEIN (TREATMENT OF CHOICE)

MC COMPLICATION: SUB FERTILITY

HYDROCELE
ABNORMAL COLLECTION PF SEROUS FLUID IN PROCESS VAGINALIS
FLUID: ALBUMIN & FIBRINOGEN
PRIMARY: DEFECTIVE ABSORPTION
SECONDARY: EXCESS PRODUCTION
COMMUNICATING: CONNECT WITH PERITONEAL CAVITY
TRANSILLUMINATION TEST: POSITIVE
TESTIS IMPALPABLE : FLUID HYDROCELE
PAINLESS SWELLING
ENCYSTIC HYDROCELE OF CHORD: SMOOTH OVAL SWELLING NEAR THE
SPERMATIC CHORD
COMPLICATION: RUPTURE , CALCIFICATION , HEMATOCELE
TREATMENT:
ASSYMPTOMATIC: CONSERVATIVE
NEEDLE ASPIRATION ...(INFECTION)
SURGERY:
CONGENITAL-- HERNIOTOMY
ACQUIRED-- JABOULEYS(HYDROCELE EVERT & SUTURED) ,LORDS OPERATION
(INTERRUPTED ABSORBLE SUTURE )

EPIDIDYMAL CYST
MC: BILATERAL
TINY BUNCH OF GRAPES
CYST IS ABOVE & BEHIND THE SUPERIOR POLE OF TESTIS
CYST BRILLIANTLY TRANSILLUMINATE
TX: EXCISION .

SPERMATOCELE
FLUID: BARLEY WATER APPEARNCE
LOCATION: EPIDIDYMAL HEAD
THIRD TESTIS
SMALL - NO TREATMENT
LARGE- EXCISED OR ASPIRATED

TESTICULAR TUMORS
MC: YOUNG MEN
MC: MALIGNANT
SPREAD: LYMPHATICS
MC PRESENTATION: PAINLESS TESTICULAR MASS
IRREGULAR FIRM FIXED NON TRANSILLUMENT MASS
ENLARGE SUPRACLAVICULAR NODE..PRESENTING TUMOR
MC TUMOR: SEMINOMA

SEMINOMA
MC MALIGNANT TUMOR, RADIOSENSITIVE
SPREAD LYMPHATICS : PARA AORTIC NODE
SMOOTH FIRM ENLARGE TESTIS ,LARGE ROUNDED NUCLIE WITH CLEAR
CYTOPLASM

NON SEMINOMETOUS GERM CELL TUMOR

[Link]: TOTIPOTENT CEKK ,MORE AGGRESSIVE IN ADULTS ,SPREAD

HEMATOGENOUSLY ,ELEVATE HCG AFP

2 YOLK SAC TUMOR: ENDODERMAL SINUS TUMOR RAISED AFP

[Link] CARCINOMA:
PURE: RAISED HCG NORMAL AFP
MIXED: RAISED HCG RAISED AFP

4. CHORIOCARCINOMA: MOST AGGRESSIVE TUMOR ELEVATED HCG

.
DX: CHEST XRAY: CANNON BALL APPEARNCE CT CHEST ABDOMEN PELVIS FOR
MET

STAGES:
I TESTIS ONLY
II NODES BELOW DIAPHARGM
III NODES ABOVE DIAPHARGM
IV PULMONARY & HELATIC METS
TREATMENT:
ORCHIDECTOMY (VIA INGUINAL INCISION)
HIGH RISK PATIENT: BEP CHEMOTHERAPY( BLEOMYCIN, ETOPSIDE, PLATINIUM)

INTERSTITIAL TUMORS
PRE PUBERTAL : LEYDIG CELL EXCRETE MUSCULANIZING HORMONES
POST PUBERTAL: SERTOLI CELL EXCRETE FEMINIZING HORMONE
(GYNAECOMESTIA, ASSPERMIA , LIBIDO LOSS)

SCROTAL GANGRENE OR FOURNEIR GANGRENE

SUDDEN SCROTALINFLAMATION ,RAPID ONSET GANGRENE
TX: SURGICAL EXCISION. BROAD SPECTRUM ANTIBIOTICS SKIN GRAFTING

THE BREAST

VERTICALLY:2-6TH RIB (SE: CLAVIVLE TO 7-8RIB)

LATERALLY: LATERAL STERNUM BORDER TO ANT AXILLARY LINE (SE: MIDLINE
TO LATISMUS DORSI POSTERIORLY)

NIPPLE: 4 INTERCOASTAL SOACE,ERECTILE TISSUE ,CENTRE OF

ARELA,HIGHLY STRATIFIED SQUAMOUS EPITHELIUM

AREOLA: SKIN SURROUNDING THE NIPPLE ,PREGNANCY INCREASE SIZE OF

SWEAT & SABECCOUS GLAND , MONTGOMERYS TUBERCLES

LIGAMENT OF COOPER:;DERMIS OF SKIN TO PECTORALIS FASCIA , CANCERS

IT SHORTEN, DIMPLING OF SKIN , INVERSION OF NIPPLE

THE GLAND: LOBULE MAIN UNIT , EMPTY THROUGH LACTOFEROUS DUCT

LYMPHATICS: AXILLARY & INTERNAL MANMARY LYMPH NODE

LATERAL ANTERIOR POSTERIOR CENTERAL INTRAPECTORAL & APICAL NODES

INVESTIGATION

[Link]
LOW VOLTAGE HIGH AMPERAGE XRAY, RADIATION O. 1Gy
SCREENING TOOL
MALIGNANCY: SPICULATED IRREGULAR MASS, MICRO CALCIFICATION ,
ARCHITECTURAL DISTORTION

BIRAD SCORE
0 ASSESSMENT INCOMPLETE , NEED FURTHER MANAGEMENT
I NORMAL CONTINUE ANNUAL FOLLOW UP
II BENIGN LESION NO RISK OF MALIG ,ANNUAL FOLLOW UP
III PROBABLE BENIGN,SHORT TERM(3-6 MONTH)FOLLOW UP
IV SUSPICIOUS OF BREAST CANCER BIOPSY RECOMMEND
V HIGH SUSPICIOUS OF BREAST CARCINOMA ,BIOPSY REQUIRED
VI KNOWN BIOPSY PROVEN MALIGNANCY
.
[Link]:
USEFUL IN YOUNG WOMEN,CYST& SOLID MASS DISTINGUISH, NOT A
SCREENING TOOL

[Link] RESONANCE IMAGING (MRI)

BEST IMAGING MODALITY OF IMPLANTS, USEFUL SCREENING TOOL IN HIGH
RISK WOMEN (FAMILY HISTORY),MULTICENTRIC LOBULAR CARCINOMA ,
DUCTAL CARCINOMA OS SITU
.
[Link] NEEDLE ASPIRATION CYTOLOGY
CELL DIAGNOSIS ,RAPID & VERY ACCURATE INVESTEGATION
CANNOT DISTINGUIST INVASIVE FROM INSITU DISEASE

[Link] BIOPSY:
TISSUE(HISTOLOGICAL ) ANALYSIS,DIFFERENTIATE DCIS & INVASIVE DISEASE ,
TUMOR RECEPTOR STATUS

[Link] NEEDLE BIOPSY:

MORE EXTENSIVE SAMPLE DECREASE ERROR .

[Link] ASSESMENT:
CLINICAL ASSESSMENT ,RADIOLOGICAL IMAGING & TISSUE SAMPLING

NIPPLE DISORDER

1. NIPPLE RETRACTION:
SLIT LIKE: DUCTAL ECTASIA & PERIDUCTAL MASTITIS
CIRCUMFRENTIAL RETRACTION: CARCINOMA
TX: RESOLVE SPONTANEOUSLY OR SIMPLE COSMETIC SURGERY

[Link] DISEASE OF NIPPLE:

SUPERFICIAL SKIN CHANGES(ECZEMATOUS CHANGES) UNDERLYING BREAST
CA
CAUSE: DCIS & INVASIVE BREAST CANCER
MICROSCOPY: LARGE OVOID WITH ABUNDANT CLEAR PALE STAINGING
CYTOPLASM(PAGET CELL)
UNILATERAL,OLD AGE,NO PRUITUS , NIPPLE MAY SPREAD TO AREOLA ,NO
HISTORY OF ATOPY

BENIGN BREAST DISORDER

POLAND SYNDROME: AMAZIA+ ABSENCE OF PECTORALIS MAJOR MUSCLE

.ABBERENT OF NORMAL DEVELOPMENT & INVOLUTION(ANDI):

CAUSES:CYCLIC NODULARITY & MASTALGIA ,CYSTS. FIBROADENOMA ,DUCTAL

ECTASIA, GLACTOCELE ,PUREPERAL ABCESS

FEATURES: CYST FORMATION,FIBROSIS ,HYPERPLASIA , PAPPILOMATOSIS

CF:BENIGN DISCRETE LUMP, LUMPINESS BILATERAL ,CYCLIC MASTALGIA

TX:
LUMP BREAST: REASSURANCE U/S OR MAMOGRAPHY & FOLLOW UP AFTER 6
WEEK .
MASTALGIA: REASSURANCE ,ADEQUATE SUPPORT ,EXCLUDE
CAFFINE,EVENING PRIMOSE OIL ,DANAZOL TAMOXIFIN
.
.

TIETZ DISEASE: COSTOCHONDRITIS

PAIN TENDERNESS & SWELLING OF FIRST FOUR COSTAL CARTILAGE
,AGGIRVATEVBY PHYSICAL ACTIVITY ,DEEP INSPIRATION & COUGHING
TX: HEAT PACK, ANALGESIC, ANTIINFLAMATORY ,LOCAL STEROID

DIFFUSE HYPERTROPHY:
PHYSIOLOGICALLY : PUBERTY & PREGNANCY
HORMONE: ESTROGENIC
TX: ANTIESTROGEN & REDUCTION MAMMOPLASTY

FAT NECROSIS:
MC CAUSE: TRAUMA
PAINLESS BREAST LUMP
MAMOGRAPHY: VARIABLE APPEARNCE, CALCIFICATION IS PROGRESSIVE
PERIPHERAL AND NON BRANCHING , LATER OIL CYSTS FORMATION .
TX: REASSURANCE AFTER RULING OUT MALIGNANCY

INFECTIOUS MASTITIS
MC ORGANISIM: STAPH AUREUS
MC CAUSE: BREAST FEEDING TRAUMA .
STAGES:
CELLUTIS (1ST): FEVER PAIN ERYTHEMA & TENDERNESS TX: ANTIBIOTICS
ANALGESIC LOCAL HEAT BREAST SUPPORT
ABCESS (2ND) : LOCALIZED SWELLING ,FLUCTUATION IN LATE SIGN
TX:PERCUTANEOUS ASPIRATION + ANTIBIOTIC ,OPEN SURGICAL DRAINAGE:
RADICAL INCISION ,CIRCUMAREOLAR INCISION

ANTIBIOMA
CHRONIC ABCESS OF BREAST, ANTIBIOTIC ,UNDRAINED ABCESS
LARGE STERILE BRAWNY EDEMATOUS SWELLING IT TAKES MANY WEEKS TO
RESOLVE
DIFFERNCE FROM CA: PAST HISTORY OF ACUTE ABCESS, RESISTANCE TO
FINGER IN THE CENTRE ,LYMPH NODE NOT FIXED ,HISTOLOGY

MONDORS DISEASE
THROMBOPHELEBITIS OF BREAST & ANTERIOR CHEST WALL
THROMBOSED SUBCUTENOUS CHORD USUALLY ATTACHED (PATHOGNOMOIC),
RAISING HAND THE SUBCUTENOUS GRROVE
TX: SELF RESOLVING ,NSAIDS

DUCTAL ECTASIA
DILITATION OF LACTOFEROUS DUCT
PERIDUCTAL MASTITIS: SQUAMOUS METAPLASIA WITH DRAINING ABCESS
AROUND NIPPLE
MC RISK FACTOR: SMOKING NIPPLE PIERCING
CF: NONCYCLIC BREAST PAIN, NIPPLE DISCHARGE ,SLIT LKE NIPPLE
RETRACTION, SUB AEROLAR MASS ,DUCTAL FISTULA
TX: ANTIBIOTICS( FULXACILLIN& METRONIDAZOLE)
SURGICAL (HADFEILDS OPERATION) EXCISION OF ALL MAJOR DUCTS

BREAST CYST
CAUSE:INVOLUTION OF STOMA & EPITHELIUM
TX: ASPIRATION OF CYST WITH BIOPSY TO RULE OUT MALIGNANCY

FIBROADENOMA
MC LUMP IN YOUNG WOMEN (LESS THAN 30)
HYPERPLASIA OF SINGLE LOBULE
BREAST MOUSE: DUE TO ITS HIGH MOBILITY
ESTROGEN SENSTIVE: INCREASE DURING PREGNANCY & INVOLUTE DURING
MENUPAUSE
MAMOGRAPHY: POPCORN CALCIFICATION .
GIANT FIBROADENOMA: MORE THAN 5CM
DX: ULTRASOUND ...MORE USEFUL

TX:
REASSURANCE & OBSERVATION: BENIGN APPEARNCE, U/S SHOW NO
SUSPICIOUS FEATURE ,AGE LESS THAN 40 FNAC & CORECUT FIBROADENOMA
SURGICAL EXCISION: ENLARGING MASS ,SUSPIOUS ON FNAC OR BIOPSY ,AGE
GREATER THAB 40

PHYLLODES TUMOR/ CYSTOSARCOMA OF PHYLOODES/SEROCYSTIC DISEASE

OF BRODIE
LARGE MASSIVE TUMOR UNEVEN BOSSELATED SURFACE ,MOBILE ON CHEST
WALL
DX: TRIPLE ASSESMENT
TX: BENIGN TUMOR= ENUCLEATION OR WIDE LOCAL EXCISION
MALIGNANT TUMOR= MASTECTOMY

TB OF BREAST
MULTIPLE CHRONIC ABCESS AND SINUSES ,TYPICAL BLUISH APPEARNCE OF
ATTENUATED APPEARNCE OF SKIN
DX: BACTERIOLOGICAL & HISTOGICAL EXAMINATION
TX: ANTI TB DRUGS ,MASTECTOMY

CARCINOMA OF BREAST
RISK FACTOR: AGEING,FAMILY HISTORY ,IGH ALCOHOLCONSUMPTION
,NULLIPAROUS ,OBESITY ,OCP ,HORMONE REPLACEMENT THERAPY

GENETIC RISK: BARCA1 & BARCA2 ,ATAXIC TELENGENCTESIA, LIFRAUMENI

SYNDROME(tp53) ,COWDEN SYNDROME(PTEN)

MC TYPE: INFILTRATING DUCTAL CARCINOMA

HISTOLOGICAL TYPES:
INFILTRATING DUCTAL CARCINOMA
INFILTRATING LOBULAR CARCINOMA (E-CADHERIN )
MUCINOUS CARCINOMA
MEDULLARY CARCINOMA
TUBULAR CARCINOMA

INSITU CARCINOMA:
PREMALIGNANT INTACT BASEMENT:

DCIS: COMEDO(MC) SOLID CRIBRIFORM ,PAPILLARY

LOW GRADE: LUMPECTOMY & RADIOTHERAPY NO AXILLARY LYMPH NODE
DISECTION NO SENTINEL BIOPSY
HIGH GRADE: SIMPLE MASTECTOMY & RADIOTHERAPY ,NO AXILLARY LYMPH
NODE DISECTION NO SENTINEL BIOPSY .(COMEDO ,MULTICENTERIC,LARGE
TUMOR GREATER THAN 4CM,MARGIN POSITIVE LESS THAN 1CM)

LCIS:LOSS OF E CADHERI, CLASSICAL LCIS& PLEOMPRPHIC LCIS

TX: OBSERVATION,BILATERAL MASTECTOMY, NOALND

INFLAMATORY CARCINOMA:
RARE BUT AGGRESSIVE TUMOR ,PAINFUL SWOLLEN BREAST WARM WITH
CUTANEOUS EDEMA
TX: CHEMOTHERAPY RADIOTHERAPY SALVAGE SURGERY

LYMPHATIC SPREAD: AXILLARY NODES (MC),INTERNAL MAMMORY

NODE(POSTERIOR ONE THIRD)
HEMATOGENOUS SPREAD: LUMBAR VERTEBRAE METASTASIS (LUNGS LIVER
ADRENAL ,MENINGES)

CF:
BREAST LUMP(MC SYMPTOM ,UPPER OUTER QUADRANT)
NIPPLE(CIRCUMFRENTIAL RETRACTION)
SKIN CHANGES( PEAU D ORANGE, CANCER EN CURIACCE)

TNM STAGGING:
T0 NO EVIDENCE
Tis CARCINOMA IN SITU
T1 LESS THAN 2CM
T2 2-5CM
T3 MORE THAN 5CM
T4 EXTEND TO CHEST WALL

N0 NO LYMPH NODE INVOLVEMENT

N1 MOBILE IPSILATERAL AXILLORY NODES
N2 INTERNAL MEMORY NODES OR IPSILATERAL FIXED AXILLORY NODES
N3 IPSILATERAL INTERNAL MAMMORY WITH AXILLARY NODES

M0 NO METASTASIS
M1 DISTANT METASTASIS

MANAGMENT:
EARLY: SURGERY & RADIOTHERAPY
LATE: SYSTEMIC THERAPY FOR PALLIATION

[Link] LOCAL EXCISION : BREAST CONSERVING SURGERY ,REMOVAL OF

TUMOR PLUS RIM AT LEAST 1CM OF NORMAL BREAST ,FOLLOWD BY
RADIOTHERAPY
2 RADICAL MASTECTOMY: (HALSTED MASTECTOMY) EXCISION OF BREAST +
AXILLORY LYMPH NODE 1 2 3 ,PECTORALIS MAJOR+ MINOR SURGERY ,ALL
OVER SKIN
[Link] RADICAL MASTECTOMY(PATEYS MASTECTOMY): BREAST
+AXILLORY NODES +LARGE POTION OF SKIN +PECTORALIS MINOR BUT MAJOR
REMAIN INTACT
[Link] MASTECTOMY: ONLY REMOVAL OF LYMPH NODE WITH NO
DISSECTOON OF AXILLA + AXILLARY TAIL
[Link] SURGERY : AXILLA NODE METASTASIS ,PRE & POST MENUPAUSAL
WOMEN ,SURGERY + RADIOTHERAPY

AXILLARY NODES:
I LATERAL TO PEC MINOR
II POSTERIOR TO PEC MINOR
III MEDIAL TO PEC MINOR

SENTINAL BIOPSY: TECH 99 LABELDSOLUTION

HISTOPATHOLOGY, FROZEN SECTION ,TOUCH IMPRINT CYTOLOGY, PCR .

POSITIVE: AXILLARY CLEARANCE REQUIRED

NEGATIVE: AXILLARY CLEARANCE NOT REQUIRED

BREAST RECONSTRACTION: SILICON GEL IMPLANT UNDER PECTORALIS

MAJOR
MUSCULOCUTANEOUS FLAP IF LARGE TISSE REQUIRED(LATISSMUS DORSI &
TRANSVERSE ABDOMINAL MUSCLE FLAP )

BREAST RADIOTHERAPY: 50Gy IS GIVEN 4-5 WEEK AFTER 2-4 OPERATION

CHEMOTHERAPY+HORMONE THERAPY: ADDITIVE EFFECT
[Link] CANCER+ POSITIVE NODE: CHEMOTHERAPY IN ALL PATIENT ,POST
MENUPAUSAL AROMATASE INHIBITOR
[Link] THAN 1CM WITH NEGATIVE NODE:CHEMOTHERAPY IN ALL
PATIENT,POST MENUPAUSAL AROMATASE INHIBITOR PRE MENUPAUSAL
TAMOXIFEN
[Link] THAN 1CM WITH NEGATIVE NODE:CHEMO NOT
INDICATED,PREMENUPAUSAL TAMOXIFEN & POST MENUPAUSAL AROMATASE
INHIBITOR

CHEMOTHERAPY AGENT: CMF(CYCLOPHOSPHAMIDE ,METHOTREXATE ,5

FLUROURACIL)

BIOLOGICAL AGENT:
TRANSTUZUMAB(HER 2RECEPTOR): HERCEPTIN POSITIVE TUMOR
BEVACIZUMAB : VASCULAR GROWTH FACTOR INHIBITOR
LAPTINAB: COMBINED GROWTH FACTOR RECEPTOR INHIBITOR

HORMONE THERAPY:
TAMOXIFEN: SERM USED IN PREMENUPAUSAL WOMEN IN ER PR POSITIVE .
ANASTRAZOLES: AROMATASE INHIBITOR: POST MENUPAUSAL WOMEN ER PR
POSITIVE .
GOSRELIN(LHRH AGONIST):

PROGNOSTIC FACTOR OF BREAST CANCER:

AXILLARY NODES, TUMOR SIZE , DISTANT METASTASIS ,ER & PR POSITIVE
NOTHINGHAM PROGNOSTIC INDEX: TUMOR SIZE GRADE NODAL SCORE
NPI:0.2XTUMOR SIZE + GRADE(1-3) + NODAL SCORE(1-3)
NPI LESS THAN 3.4= GOOD PROGNOSIS
NPI (3.41-5.40)= MODERATE PROGNOSIS
NPI GREAT THAN 5.40= POOR PROGNOSIS

FOLLOW UP MASTECTOMY:
PHYSICAL EXAM 3-6 MONTH FOR 3 YEARS THEN 6-12 MONTH FOR NEXT 2
YEARS ,
YEARLY OR 2-YEARLY MAMOGRAPHY .

FAMILIAL BREAST CANCER

BARCA1: CHROMOSOME 17 OVARIAN COLORECTAL CA
BARCA2:CHROMOSOME 13 MALE BREAST CA.

TX: PROPHYLACTICALLY MASTECTOMY OR TAMOXIFEN FOR 5 YEAR

PREGNANCY & BREAST CANCER

TX:
MODIFIED RADICAL MASTECTOMY (PATEY OPERATION)
RADIOTHERAPY CONTAINDICATED
CHEMOTHERAPY AVOIDED IN 1ST TRIMESTER ONLY
BREAST FEEDING AVOIDED IN CHEMOTHERAPY
TERATOGENIC HORMONE THERAPY IS NOT REQUIRED

MALE BREAST
GYNAECOMESTIA
BENIGN GLANDULAR PROLIFERATION OF TISSUE ,BILATERAL ENLARGEMENT
PSEUDOGYNAECOMASTIA: EXCESS FAT ACCUMULATION

PEAK(3): 1ST INFANCY 2ND PUBERTY 3RD MIDDLE AGE

CAUSES: IDIOPATHIC, CIRRHOSIS, CHRONIC KIDNEYDISEASE

,HYPERTHYROIDISM ,TESTICULAR NEOPLASM ,KLEIN FEILTER ,STEROIDS

TX: REASSURANCE & SUBCUTENOUS MASTECTOMY PRESERVING NIPPLE

AREOLA
CARCINOMA OF MALE BREAST
MC PRESENTATION:LUMP
MC TYPE: INFILTRATING DUCTAL CARCINOMA
MC FAMILIAL CAUSE: BARCA2 MUTATION
MC CAUSE: INCREASE ESTROGEN (KLEIN FILTER CIRRHOSIS OBESITY
MARJUANA ABUSE)

TX: RADICAL MASTECTOMY ,CHEMOTHERAPY ,RADIOTHERAPY ,HORMONAL

THERAPY

THYROID GLAND

EMBRYOLOGY: DIVERTICULUM FROM FLOOR OF EMBRYONIC PHARYNX

THYROGLOSSAL DUCT REMANANT: FORAMEN CAECUM
WEIGHT:20-25G
FUNCTIONING UNIT: THYROID LOBULE(24-40 FOLLICLES)
ARTERY: SUPERIOR THYROID ARTERY (ECA) INFERIOR THYROID ARTERY (SCA)
THYROID IMA ARTERY FROM AORTA (BCA OR CCA)
VEINS: SUPERIOR & MIDDLE THYROID VEIN INTO INTERNAL JUGLAR NERVE,
INFERIOR THYROID ARTERY DRAINS TO BRACHIOCEOHALIC VEIN

NERVES:
SUPERIOR LARYNGEAL NEEVE: CRICOTHYROID: SUPERIOR THYROID ARTERY
.. EASY VOICE FATIGIBILITY
RECURRENT LARYNGEAL NERVE : INFERIOR THYROID ARTERY: UNILATERAL
..HORSENESS, BILATERAL ... AIRWAY OBSTRUCTION

LIGAMENT OF BERRY: POSTERIOR SUSPENSORY LIGAMENT: THYROID TO

TRACHEA ,ENTRY POINT TO RLN ,RISK OF NERVE INJURY AT THIS POINT

TUBERCLES OF ZUCKERKANDI: POSTEROLATERAL THYROID GLAND ,PART

LEFT AFTER SUB TOTAL THYROIDECTOMY

HORMONES: COLLOIDES TRIIODOTHYRONINE(T3) ,THYROXIN (T4)

INVESTEGATION

[Link] FUNCTION TEST(TFT):

T4 IS 5 FOLD LESS ACTIVE THAN T3
T4 IS USEFUL FOR DIAGNOSIS

[Link] OF TSH:
DECREASE T3& T4= INCREASE TSH
INCREASE T3&T4= DECREASE TSH

[Link]:
ANTITHYROID PEROXIDASE(TPO) ANTBODIES AGAINST THYROGLOBULIN
GREATER IN HASHIMOTO THYROIDITIS

[Link] SCANNING:
HOT NODULE : INCREASE UPTAKE BENIGN(20)
COLD NODULE: DECREASE UPTAKE MALIGNANT (80)

[Link] NEEDLE ASPIRATION CYTOLOGY(FNAC):

INVESTEGATION OF CHOICE FOR THYROID NODULE
Thy1 NON DIAGNOSTIC
Thy2. NON NEOPLASTIC
Thy3. FOLLICULAR
Thy4. SUSPICOUS MALIGNANCY
Thy5. MALIGNANT

HYPOTHYROIDISIM

MC CAUSE: IODINE DEFECIENCY

PANDREDS SYNDROME: DYSHARMONEGENESIS DUE TO TPO DEFECIENCY

(GOITER)+ SENSINEURNAL DEAFNESS DUE TO LABRIYNTH ABNORMALITY

AUTOIMMUNE TYHROIDITIS:
GOITROUS: PRIMARY MYXEDEMA
NON GOITROUS:HASHIMOTO THYROIDITIS

[Link]/INFANTILE HYPOTHYROIDISM :
MC CAUSE: IODINE DEFECIENCY (ENDEMIC) INBORN ERROR(SPORADIC)
HORSE CRY, MACROGLOSSIA, UMBLICAL HERNIA ,MENTAL RETARDATION
,SHORT STATURE

[Link] HYPOTHYROIDISIM/MYXEDEMA :
BRADYCARDIA,DRY SKIN& HAIR PERIORBITAL PUFFINESS COLD INTOLERANCE
WEIGHT GAIN
MOST USEFUL CLINICAL SIGN: DELAYED RELAXATION OF ANKLE JERK
DX: DECREASE T3&T4 RAISED TSH
TX:ORALTHYROXINE(0.1-0.2MG) ,TRIODOTHYRONIN 20MICROGRAM

[Link](SEVERE HYPOTHYROIDISIM):
HYPOTHERMIA,HYPOTENSION,HYPOGLYCEMIA, HYPONATREMIA ,MALAR
FLUSH MENTAL STATUS ALTER
TX: IV BOLUS ORAL BOLUS 500MG T4 OR 10MICROGRAM T3 4-6 HOURS ,BROAD
SPECTRUM ANTIBIOTICS ,HYDROCORTISONE , SLOW REWARMING

THYROID ENLARGEMENT

[Link] SIMPLE GOITER :

NON TOXIC(,EUTHYROID ) CAUSE: IODINE DEFICIENCY ,GOITROGEN

DIFFUSE HYPERPLASTIC GOITER: FIRST STAGE, ALL GLOBULES ARE

COMPOSED OF ACTIVE FOLLICLE
COLLOID GOITER: LATE STAGE, FOLLICLES INACTIVE & FULL OF COLLOID
NODULAR GOITER: REPETITIVE& FLUCTUATING STIMULATION OF THYROID
(ACTIVE & INACTIVE FOLLICLE BOTH)

TX: INTRODUCTION OF IODIZED SALT IN ENDEMIC AREAS ,THYROXINE (0.15-0

.2MG), SURGERY

MULTINODULAR GOITER
DSG PROGRESS TO MULTINODULAR FOCAL HYPERPLASIA
CF: PATIENT IS EUTHYROID WITH PAINLESS GOITER ,PALPABLE NODULE
SMOOTH & FIRM ,CALCIFICATION ,HEMORRHAGE
TX: TFT: EUTHYROID ,FNAC OF DOMINANT FOLLICLE

SURGERY:
[Link] THYROIDECTOMY:2 LOBECTOMY + ISTHUMESECTOMY (PREFERRED IN
YOUNG)
[Link] THYROIDECTOMY: PARTIAL RESECTION OF EACH LOBE OF
THYROID (8G REMANANT IN EACH)
[Link] TOTAL THYROIDECTOMY: LOBECTOMY+ ISTHMUSECTOMY + SUBTOTAL
LOBECTOMY .
[Link] LOBECTOMY: ASSYMETRIC GOITER
[Link] THYROID SWELLING:

ISOLATED SWELLING: DISCRETE NODULE IN ONE LOBE WITH NO

ABNORMALITY ELSE WHERE(70)
DOMINANT SWELLING: DISCRETE NODULE WITH EVIDENCE OF ABNORMALITY
ELSEWHERE IN GLAND (30)

AGE:LESS THAN 20 MORE THAN 50 , INCREASE RISK OF NEOPLASIA

DX: TFT: BEST INITIAL TEST

HYPERTHROIDISIM: NO FNAC DO ISOTOPE IF UPTAKE HIGH HOT NODULE , IF
UPTAKE IS LOW COLD NODULE .
NORMAL: DO FNAC

TX: SURGERY ( NEOPLASIA RISK)

[Link] GOITER :
LOWER POLE OF NODULAR GOIDER
DYSPNEA DYSPHAGIA ,ENGORGEMENT OF FASCIAL ,NECK & SUPERFICIAL
CHEST WALL VEINS
INVESTIGATION OF CHOICE: CTSCAN
TX: SURGICAL RESECTION

THYROTOXICOSIS
MC CAUSE: GRAVES DISEASE
PRIMARY THYROTOXICOSIS:(GRAVES DISEASE)
DIFFUSE & VASCULAR GOITER , HYPERTHYROIDISIM SEVERE, EYE SIGN
COMMON

SECONDARY THYROTOXICOSIS: (TOXIC NODULAR GOITER):

NODULAR GOITER ,HYPERTHYROIDISIM LESS CARDIAC FAILURE IS COMMON

CLINICAL FEATURE: HEATINTOLERANCE ,WEIGHT LOSS, PALPITATION

,TRACHYCARDIA ,EXOPTHALMOS ,LID LAG ,LID RETRACTION ,MYOPATHY
,OERITIBIAL MYXEDEMA

[Link] DISEASE:
AUTOIMMUNE (TYPE 2 HS REACTION) TYROID STIMULATING HORMONE
RECEPTOR ANTIBODIES TSH-ABS
TRAID: DIFFUSE GOITER , EXOPTHALMOS , OERITIBIAL MYXEDEMA
THYROID EYE INVOLVEMENT: INFERIOR RECTUS , MEDIAL RECTUS , SUPERIOR
RECTUS
DX:
TFT: HYPERTHYROIDISIM (ELEVATE T3&T4 ,DECREASE TSH).
RAIU: BILATERAL DIFFUSE UPTAKE
TASHABS: POSITIVE

MANAGMENT:

[Link] DRUGS:
INHIBIT THYROID PEROXIDASE ENZYME PTU ASLO INHIBIT DEIODINASE
ENZYME
PTU SAFE IN PREGNANCY & LACTATION
CARBAMIZOLE:30-40MG DAILY IN DIVIDING DOSES
METHIMAZOLE: 30-60MG DAILY IN DIVIDED DOSE
PTU: 400-600MG DAILY IN DIVIDED DOSE
A/E: HYPERSENSITIVITY,AGRANULOCYTOSIS

[Link] IODINE:
SINGLE DESTROY & DESTROY THYROID CELLS
TREATMENT OF CHOICE: GRAVES DISEASE
CONTRAINDICATION: GRAVES OPTHALMOSCOPY, PREGNANCY
PREEQUISITS: EUTHYROID BEFORE TREATMENT

[Link]
TREATMENT OF CHOICE: LARGE GOITER,MULTINODULAR GOITER & SOLITARY
NODULE

[Link] OPTHALMOSCOPY TX: MASSIVE DOSE OF PERDINSOLONE

THYROIDECTOMY

PREOPERATIVE':
PATIENT MUST BE EUTHYROID BY CARBIMAZOLE: 30-40MG PER DAY DRUG OF
CHOICE ,8 WEEK WAIT FOR SURGERY
BETA BLOCKER: 40MG TWICE A DAY 1 WEEK WAIT FOR SURGERY
IODINE 60MG 10 DAYS BEFORE SURGERY TO DECREASE VASCULARITY

INCISION: TRANSVERSE INCISION 2CM ABOVE STERNAL NOTCH

PARATHYROID IS SUPPLIED BY INFERIOR THYROID ARTERY

SURGERY INDICATION: RECURRENT SWELLING, TOXIC ADENOMA ,PRESSURE

SYMPTOMS ,COSMESIS ,PATIENT WISH

COMPLICATION:
MC : BLEEDING (EXPANDING NECK HENATOMA)
DEEP TENSION HEMOTOMA(LARYNGEAL EDEMA)
NERVE DAMAGE: UNILATERAL RLN (HORSENESS) BILATERAL RLN (AIRWAY
OBSTRUCTION)
HYPOTHYROIDISIM
HYPOCALCEMIA

THYROID STORM
ACUTE EXCERBATION OF HYPERTHYROIDISIM
DEHYDRATION + TRACHYCARDIA + HYPERPYREXIA + RESTLENESS + VOMITING
+ DIARRHEA. + ATRIAL FIBRILLATION
TX : PROPANALOL PROPYLTHYOURACIL POTASSIUM IODIDE IV FLUIDS
,DIURETIC & DIGOXIN

THYROID CARCINOMA
[Link] THYROID CARCINOMA:
MC THYROID CANCER
MC CAUSE: NECK IRRADIATION
SPREAD: LYMPHATIC
DX: INCISIONAL BIOPSY & PATHOLOGY (PSAMOMA BODIES + ORPHAN ANNIE
EYE NUCLIE)
INVESTEGATION OF CHOICE: FNAC
TREATMENT:
TUMOR LESS THAN 1CM = LOBECTOMY
TUMOR GREATER THAN 1CM= TOTAL THYROIDECTOMY
+POSITIVE CERVICAL NODES& EXTRANODAL INVOLVEMENT= TOTAL
THYROIDECTOMY + IPSILATERAL MODIFIED RADICAL NECK DISCETION
RADIOIODINE:4-6 WEEK AFTER TOTAL THYROIDECTOMY
THYROXINE :AFTER OPERATION

[Link] THYROID CARCINOMA:

MC CAUSE: IODINE DEFICIENCY
SPREAD: HEMATOGENOUS TO BONES
INVESTEGATION OF CHOICE: FNAC (FOLLICULAR CELL)
FOLLICULAR ADENOMA = LOBECTOMY
THYROID HYPERPLASIA= LOBECTOMY
FOLLICULAR CARCINOMA= TOTAL THYROIDECTOMY
IF POSITIVE NODES= TOTAL THYROIDECTOMY+ IPSILATERAL LYMPHNODE
DISCECTION

[Link] THYROID CARCINOMA :

TUMOR OF PARA FOLLICULAR CELL (c CELLS) CALCITONIN
SPREAD: LYMPHATIC & HEMATOGENOUS
SERUM CALCITONIN IS THE MARKER OF THIS TUMOR
CEA IS ALSO USED AS SCREENING FOR MEDULLAR CANCER
DIARRHEA & FLUSHING PRESENT DUE TO SERONOTONIN & PROSTAGLANDIN
TX: EXCLUDE MEN SYNDROME FIRST THEN TOTAL THYROIDECTOMY +
CENTRAL BILATERAL CERVICAL LYMPHADENOPATHY

[Link] THYROID CARCINOMA:

MOST AGGRESSIVE TUMOR .
FIXED HARD MASS TRACHEAL COMPRESSION HORSENESS DYSPNEA
DYSPHAGIA
TX: DEBULKING SURGERY ,PALLIATIVE EXTERNAL BEAM RADIOTHERAPY ,
TRACHEOSTOMY FOR TRACHEAL INVOLVEMENT

[Link] LYMPHOMA
MC : NON HODGKIN LYMPHOMA
CAUSE: HASHIMOTO THYROIDITIS
TX: RADIATION & CHEMOTHERAPY

THYROIDITIS
[Link] LYMPHOCYTIC THYROIDITIS /HASHIMOTO THYROIDITIS
/AUTOIMMUNE THYROIDITIS:
ANTI THYROID PEROXIDASE ANTIBODY POSITIVE
ANTI THYROGLOBULIN ANTIBODY POSITIVE
MC PRESENTATION: GOITER BOSSELATED FEEL
MC CAUSE : HYPOTHYROIDISIM IN DEVELOPED COUNTRY
INVESTEGATION OF CHOICE: FNAC
TX: THYROXINE & SURGERY(IF COMPRESSIVE SYMPTOM)
[Link] THYROIDITIS/SUBACUTE THYROIDITIS /DEQUERIAN
THYROIDITIS:

MC CAUSE: VIRAL INFECTIOM

MC PRESENTATION: PAINFUL TENDER THYROIDITIS
TX: NSAID STEROID THYROXINE

[Link] THYROIDITIS:
REPLACEMENT OF THYROID CELLULAR FIBROSIS
ASSOCIATION: RETROPERITONEAL & MEDIASTAINAL FIBROSIS .
TX: HIGH DOSE STEROID & THYROXINE REPLACEMENT

PARATHYROID

PARATHYROID ANATOMY

SUPERIOR PARATHYROID GLAND: 4TH PHARNGEAL POUNCH ,ABOVE INFERIOR

THYROID ARTERY , LATERAL TO RLN

INFERIOR PARATHYROID GLAND ,BELOW INFERIOR THYROID ARTERY &

MEDIAL TO RLN & THYMUS:3RD PHARNGEAL POUCH DEFECT: DIGEORGE
SYNDROME

ARTERY: INFERIOR THYROID ARTERY

WEIGHT: 50MG
RELEASE: PTH HORMONES (INCREASE CALCIUM & DECREASE PHOSPHATE)
[Link] OSTEOCLAST ACTIVITY
2 .INCREASE CALCIUM EXCRETE FROM URINE
[Link] VIT D ACTIVATION
4. INCREASE RENAL PHOSPHATE EXCRETION

PRIMARY HYPERPARATHYROISIM:

MC CAUSE: PARATHYROID ADENOMA CARCINOMA, HYPERPLASIA

ASSOCIATION: MEN 1 & MEN 2A
RENAL STONES PAINFUL BONES ABDOMNIAL GROANS PSYCHIC MOANS
DX:
PTH ELEVATED CALCIUM ELEVATED PHOSPHATE DECREASE URINE CALCIUM
INCREASE
NORMAL VIT D LEVEL
HIGH FREQUENCY NECM U/S
SESTAMIBI RADIOISOTOPE SCANING: LOCALIZED ADENOMAS , FOCUSED
APPROACH

TX: SURGERY (PARATHYROIDECTOMY)

INDICATION: TSCORE LESS THAN 2.5, OSTEOPROTIC FRACTURE HX HIGH

SERUM & URINE CALCIUM , DECREASE GFR ,NEPHROLITHIASIS AGE GREATER
THAN 50

TYPES:
TOTAL PARATHYROIDECTOMY : REMOVAL OF ALL 4 PTH GLAND +
AUTOIMPLANTATION IN FOREARM
SUB TOTAL PARATHYROIDECTOMY: REMOVAL OF 3&1/2 GLAND

COMPLICATION: HYPOCALCEMIA

FAMILIAL HYPOCALCIURIC HYPERCALCEMIA

AD, MUTATION AT CELL MEBRANE CALCIUM RECEPTOR
ELEVATED SERUM CALCIUM NO URINE CALCIUM EXCRETE
TX: NO JUST OBSERVATION

HYPERCALCEMIC CRISIS
CALCIUM LEVEL MORE THAN 14MG/DL

DROWSINESS , DEHYDRATION , VOMITING , RENAL FAILURE , ECG CHANGES

(PROLANGED PR INTERVAL & SHORT QT INTERVAL) , AREYTHMIAS
TX: AGGRESIVE HYDRTATION WITH IV FLUIDS ,LOOPD DIURETICS ,
BISPHOSPHONATES ,CALCINTONIN

SECONDARY HYPERTHYROIDISIM
MC CAUSE: CKD

CALCIPHYLAXIS: CALCIFIC UREMIC ARTERIOLOPATHY : CALCIUM

ACCUMULATES IN ARTERIOLES TX: URGENT PARATHYROIDECTOMY

DX: INC PTH DEC CA INC PO4

TX: RENAL TRANSPLANTATION ..ONLY DEFINITIVE MANAGEMENT
BEFORE RENAL TRANSPLANT ..BRIDGING TREATMENT (MEDICAL ,TOTAL &
SUBTOTAL PARATHYROIDECTOMY)

TERTIARY HYPERPARATHYROISIM
MC CAUSE: END STAGE RENAL DISEASE
DX: INC PTH INC CA INC PO4
SURGERY: SUBTOTAL PREFERRED TOTAL PARATHYROIDECTOMY

PRESISTENT HYPERPARATHYROISIM
WITH IN 6 WEEK PARATHYROID SURGERY
MC CAUSE: MISSED ADENOMA

RECURRENT HYPERPARATHYROISIM
HYPERCALCEMIA GREATER THAN 6 MONTH WITH INTERVENING
NORMOCALCEMIC PERIOD
MC CAUSE: MISSED PATHOLOGY DURING FIRST OPERATION

PARATHYROID CARCINOMA
MC CAUSE OF PRIMARY HYPERPARATHYROISIM
INC CALCIUM INC PTH INC ALP
RISK FACTOR: NECK RADIATION
METASTASIS: LUNG MC
TX: SURGERY(EN BLOC RESECTION : PARATHYROIDECTOMY & IPSILATERAL
THYROIDECTOMY)

ENDOCRINE DISORDER

ADRENAL GLAND

LOCATION: SUPERIOR POLE OF KIDNEY ,RETROPERITONIUM

COVERING: GEROTAS FASCIA
OUTER PART: CORTEX,MESODERM 3 ZONES
GLOMERULOSA: ALDOSTERON
FASCICULATA: CORTICOSTEROID
RETICULARIS: ANDROGEN ESTROGEN

INNER PART: MEDULLA NEURAL CREST CELL , PRODUCES CATECHOLAMINE

(DOP,NE,EPINEPHRINE)
ARTERY: SUPERIOR INFERIOR PHRENIC ARTERY MIDDLE AORTA INFERIOR
RENAL ARTERY
VEINS: RIGHT TO IVC, LEFT TO LRV

ADRENAL INCIDENTELOMAS
NON FUNCTIONING ADENOMAS OF ADRENAL GLAND
MC CAUSE: METASTASIS (LUNG CANCER MC), BREAST MELANOMA RCC
TX:
NODULE NON FUNCTIONING ...OBSERVE & FOLLOW UP WITH CT MRI
NODULE LESS THAN 4CM BUT ENLARGING...ADRENALECTOMY
NODULE GREATER THAN 4CM ,FUNCTIONING ..ADRENELECTOMY

PHEOCHROMOCYTOMA (ADRENAL PARAGANGLIOMAS)

MC SITE: ADRENAL MEDULLA

MC HORMONE: CATECHOLAMINES
10 PERCENT TUMOR: FAMILIAL EXTRAADRENAL MALIGNANT BILATERAL
CHILDREN
CF: HYPERTENSION,HEADACHE ,SWEATING , PALPITATION , PALLOR ,WEIGHT
LOSS ,HYPERGLYCEMIA
DX:
24 HOUR URINE COLLECTION(INC MET& NORMET) MOST ACCURATE
CT/MRI FOR LOCALIZATION FOR ADRENAL TUMOR
MIGB FOR LOCALIZATION OF EXTRAADRENAL TUMOR
TX:
PRE OPERATIVE: MEDICINE ALPHA BLOCKER (PHENOXYBENZAMINE) THEN
BETA BLOCKER (PROPANALOL)
SURGERY:
LESS THAN 8MM = LAPROSCOPIC ADRENALECTOMY
MORE THAN 8MM= OPEN ADRENALECTOMY
ADRENAL VEIN LIGATE FIRST

MULTIPLE ENDOCRINE NEOPLASIA(MEN):

[Link] 1 (WERNER'S SYNDROME)

MUTATION: MENIN CHROMOSOME 11
3P : PRIMARY HYPERPARATHYROIDISIM , PITUATORY ADENOMA , PANCREATIC
& DEUDENAL TUMOR

[Link] 2 SYNDROME
MUTATION: RET PROTOONCO GENE ON CHROMOSOME 10

MEN 2A (SIPPLE SYNDROME)

2P1M: PRIMARY HYPERPARATHYROIDISIM , PHEOCHROMOCYTOMA
,MEDULLARY THYROID CARCINOMA

MEN 2B:
1P2M: MARFINOID HABITUS ,NEUROMAS , PHEOCHROMOCYTOMA ,
MEDULLARY THYROID CARCINOMA

PANCREATIC ENDOCRINE SYNDROME

[Link]:(MC) WHIPPLE TRAID( FASTING HYPOGLYCEMIA , SYMPTOMS ,

RESOLVE AFTER GLUCOSE) LAB FINDING: ELEVATED C LEVELS
SCREENING TEST: HYPOGLYCEMIA & PLASMA INSULIN AFTER 72 HOURS ,
SUPPRESSIVE TEST: GIVE INSULIN & MEASURE C PEPTIDE KEVELS
SURGERY: TUMOR ENNUCLEATION & CHEMOTHERAPY (DOXRUBACIN &
STREPTOZOTACIN, OCTREOTIDES)

[Link](ZOLLINGER ELLISON SYNDROME): RECURRECT PUD

ASSOCIATED WITH MEN 1
SITE: GASTRINOMA TRIANGLE OF PSARU(JUNCTION OF FIRST & SECOND PART
OF DEUDENUM , JUNCTION OF HEAD & NECK PANCREASE ,JUNCTION OF
CYSTIC DUCT & COMMON BILE DUCT)
PANCREATIC: GREATER THAN 1CM (HEAD MC)
DEUDENUM : LESS THAN 0.5CM (1&2 PART)
DX: GASTRIN LEVEL ,SECRETIN TEST ,ENDOSCOPIC U/S CT+ SOMATOSTATIN
RECEPTOR SCINTIGRAPHY
TX: MEDICAL MANAGEMENT: OCTREOTIDES PPI STREPTOSOCIN ,DOXRUBACIN
,5FLUROURACIL
PANCREATIC: ENNUCLEATION WITH PERILYMPH NODE DISECTION DEUDENAL
LESS THAN 0.5 = ENUCLEATION ,MORE THAN 0.5= EXCISION WITH FULL
THICKNESS ,REMOVAL OF BLADDER

3 .NON FUNCTIONAL TUMOR: OBSTRUCTIVE JAUNDICE ,WEIGHT LOSS &

PANCREATITIS
PANCREATIC: LESS THAN 5CM HYPODENSE NO CALCIFICATION
CHROMOGRANIN A NEGATIVE
Nf PENT:MORE THAN 5CM HYPERDENSE CALCIFICATION CHROMOGRANIN
POSITIVE
DX: U/S CT SOMATOSTATIN RECEPTOR SCINTIGRAPHY
MEDICAL TX: STREPTOSOCIN + OCTEROTIDE+ INTERFERON
SURGICAL TX: PANCREATODEUDENECTOMY

[Link](VERNER MORRISON SYNDROME): WATERY DISRRHEA

HYPOTENSION HYPOKALEMIA ,ACHLORYDIA (WDHA)

[Link]: DIARRHEA, DIABETES ,DERMATITIS (NECROLYTIC

MIGRATORY ERYTHEMA)

[Link]: CHOLELETHESIS DIARRHEA & NEUROFIBROMATOSIS

[Link] TUMOR: FLUSHING SWEATING DIARRHEA

[Link]: CUSHING SYNDROME

[Link]: ACROMEGALY

Notes by Dr Ahmed zaheer

Batch 2025