Ebook Surgical diseases: Part 1

(BQ) Part 1 book “Surgical diseases” has contents: General surgery, jaw and oral cavity, neck and salivary glands, thyroid, parathyroid and adrenals, breast, acute abdomen, peritoneum and retroperitoneum.

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Sriram Bhat M MS (General Surgery)

Associate Professor in Surgery

Kasturba Medical College

MangaloreKarnataka, Indiae-mail: meera_sriram2003@yahoo.com

JAYPEE BROTHERS

MEDICAL PUBLISHERS (P) LTD

New Delhi

Kochi 682 018, Ph: +91-0484-4036109 e-mail: jaypeekochi@rediffmail.com

• 1A Indian Mirror Street, Wellington Square

Kolkata 700 013, Phones: +91-33-22456075, +91-33-22451926

Fax: +91-33-22456075 e-mail: jpbcal@dataone.in

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Jaypee Gold Standard Mini Atlas Series: Surgical Diseases

© 2007, Jaypee Brothers

All rights reserved No part of this publication and photo CD ROM should be reproduced, stored in

a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher This book has been published in good faith that the material provided by author is original Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s) In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2007

ISBN 81-8061-981-8

Typeset at JPBMP typesetting unit

surgical disorders with a brief summary of the salient pointsabout the condition The belief that, a photograph is worth

a thousand words, is exemplified in the work of his, which

is short yet informative, brief yet complete, designedspecially to leave a long lasting imprint in the readers mind

I am sure this book will create a niche of its own inthe armory—both of a student in the process of learningand a practitioner who still has the zeal to learn

I am proud of the fact that a student of mine hasreached such heights of excellence and I feel privileged

to be given the honor of penning the foreword for thisunique book

I wish him success in all his endeavors which I am surewill be an inspiration for every young aspiring surgeon

Thangam Verghese Joshua MS Mch.

Head, Department of Surgery,Kasturba Medical College,Mangalore 575001

for a quick glance Each picture has been provided with

a short summary but for further reading concerned book has to be referred

text-I thank all my patients for their kind co-operation whichenabled me to bring out this book I also thank all myteachers, colleagues, friends, students and my wife

Dr Meera Sriram for their help to bring out this book

in time I hope this book will be of help to many studentsand practitioners Any criticism and suggestions are well-accepted

Sriram Bhat M

8 Liver and Gallbladder 165

9 Pancreas and Spleen 179

10 Abdominal Wall and Hernia 191

11 Oesophagus and Stomach 209

12 Intestine 229

13 Rectum and Anal Canal 241

14 Thoracic and Neurosurgery and Urology 255

Index 289

which is granulating.

Acute paronychia is the most common hand infectioncaused by Staphylococcus aureus and or Streptococcuspyogenes Severe infection can cause suppuration aroundand under the nail leading to hang nail or floating nail.Throbbing pain, severe tenderness with visible pus are thefeatures It needs antibiotics and drainage for fast recovery.Chronic paronychia is due to fungal infection which oftencauses destruction of nail, itching and recurrent pain

Figure 1.2A shows typical abdominal wall abscess, which

is well localized An abscess is a localized collection of puslined by granulation tissue covered by pyogenic membrane[containing pus in loculi] All abscesses should be confirmed

FIGURE 1.2C: Cold abscess loin

regularly.

FIGURE 1.3: Callous ulcer

A callous ulcer is an ulcer without any signs of healing andwithout any granulation tissue It is due to callous attitude

of the patient It may be due to nutritional deficiency,ischemia, venous hypertension, diabetes or immuno-suppression It lasts for many months Floor contains paleunhealthy granulation tissue without any tendency to heal

antibiotics should be started after doing culture andsensitivity of discharge from the ulcer bed Slough should

be excised from the ulcer bed Split skin graft is used tocover the raw area An ulcer can be spreading, healing orcallous It can be specific, nonspecific or malignant Edge

of an ulcer can be sloping, punched out, undermined, raisedand beaded or everted

FIGURE 1.6: Necrotizing fasciitis

Figures 1.5 and 1.6 shows necrotizing fasciitis of foot, legand thigh It is spreading inflammation of the skin, deepfascia and soft tissues with extensive destruction due toStreptococcus pyogenes infection commonly but often due

to mixed infections Muscle is not involved It is common inlimbs, lower abdomen, groin and perineum Type I is due to

FIGURE 1.7B Cellulitis leg

Cellulitis is spreading inflammation of the subcutaneoustissues and fascial planes It is commonly due to Strepto-coccus pyogenes organism but can occur due to otherorganisms like gram negative organisms etc Diffuse swellingwith redness, shiny, stretched warm area with pain andtenderness are the features It can cause abscess, bacte-remia, septicemia, pyemia or local gangrene Orbital cellulitis,Ludwig’s angina are special types of cellulitis It is morecommon in diabetics Elevation of the limb, glycerine dressing,and antibiotics like penicillins or cephalosporins are thetreatment During active phase of the disease skin may getnecrosed leaving a raw area which when granulates wellneeds split skin graft to cover

FIGURE 1.9: Ischemic ulcer foot

Ischemic ulcers are common in lower limb but can occur inupper limb in finger tips It is due to poor blood supply It isobserved in TAO, atherosclerosis, diabetic patients Limbcan become gangrenous eventually Healing is poorlyobserved due to poor blood supply There is unhealthy andpale granulation tissue on the floor with slough Doppler studyconfirms the diagnosis Patient commonly needs amputation.Level of amputation is decided by skin temperature andDoppler study Diabetes should be controlled using insulin

and tender with signs of toxemia Tender regional lymphnodes are palpable It is commonly due to streptococcalorganisms Erysipelas is streptococcal induced cutaneouslymphangitis with cellulitis of the area Erysipelas can occur

in ear lobule but cellulitis cannot occur because skin of earlobule is adherent to subcutaneous tissue Treatment ofcellulitis is antibiotics, elevation of the limb Lymphangitis

is common in filariasis and in lymphedematous limb/part.Recurrent lymphangitis aggravates the lymphedema

FIGURE 1.11: Bedsore sacrum

It is a large bedsore over the sacrum in a bedridden patient.Size of the bedsore is extensive and slough over the floor

is typical Bedsore is also called as decubitus ulcer orpressure sores It is a trophic ulcer with bone as its base It

is nonmobile, deep and punched out It is common in oldage, diabetic, paraplegic, bedridden patient, tetanus, headinjury patients It is common over sacrum, occiput, heel,scapula and ischium Management is by regular change ofpositions, using water bed, ripple bed, proper excretadisposal, avoidance of moisture, good nutrition, good nursingcare, regular excision of slough and covering the defectusing rotation flaps

FIGURE 1.12: Ear infection in HIV patient

Photo shows ear infection in a HIV patient Note the extensiveinvolvement of the ear Cartilage infection is common herewhich is difficult to manage as cartilage has got poor bloodsupply Anaerobic infection is common in ear It should betreated with antibiotics [metronidazole], proper cleaning andwash/irrigation of the ear to prevent further destruction Whenthere is extensive cartilage loss it can be reconstructedusing flaps, prosthesis etc Ear infection is very difficult tomanage and is cosmetically challenging

FIGURE 1.13: Tuberculous ulcer foot

Tuberculous ulcer over the medial malleolus Underminededge is obvious As disease progresses in the deeper planefaster than in the skin, ulcer edge is undermined Anklejoint should be examined for the possibility of having jointtuberculosis Inguinal lymph nodes should be examined.Chest should also be examined for tuberculous focus.Investigations are chest X-ray, X-ray ankle joint, ESR,discharge study for AFB and often edge biopsy for epithelioidcells Treatment is by anti-tuberculous drugs

histolyticum organisms which are exotoxin releasing grampositive, spore bearing organisms Toxemia, extensivenecrosis of muscles, foaming liver and liver failure, renalfailure, crepitus over the skin, khaki colored skin are thetypical features of gas gangrene (malignant edema).Treatment includes liberal debridement, penicillins asantibiotics, fresh blood transfusion, anti gas gangrenepolyvalent serum, supportive measures and oftenamputation as life saving procedure.

irritation, infection and formation of unhealthy granulationtissue at the fold Great toe is commonly involved Bothmedial and lateral margins of the nail can cause ingrowing.Often it is bilateral Treatment is excision of outer part of thenail with its root so as to prevent its recurrence.

FIGURE 1.16: Madura foot

It is a chronic granulomatous condition caused by Nocardiamadurae, Nocardia brasiliensis, Nocardia asteroides.Organism enters the foot when walked with bare foot andevokes granulomatous inflammation which eventually leadsinto multiple discharging sinuses Limb significantly becomesdisabled Condition mimics tuberculous osteomyelitis,chronic osteomyelitis It needs long term therapy withpenicillins, dapsone, iodides, antifungals

features of chronic osteomyelitis

It shows sequestrum, new bone formation and radiolucentzone around the sequestrum Sequestrum should be formedbefore surgical intervention Sequestrum can be feathery{tuberculous}, ivory {syphilis}, granular {typhoid}, ring {stump}

or black Discharging sinus with bone pieces coming outare the features Treatment is sequestrectomy andsaucerization

FIGURE 1.18: Pott’s puffy tumor

It is scalp infection, scalp edema and subperiosteal pusformation, commonly observed in frontal region It can bedue to trauma or due to frontal sinusitis Pain, warm, tenderswelling with toxicity are the features It may cause frontalbone osteomyelitis or can spread intracranially

FIGURE 1.19: Pyogenic granuloma nostril left sided

Pyogenic granuloma is common in face, scalp and fingers.Minor trauma causes infection followed by formation andprotrusion of unhealthy granulation tissue as a friable, tenderred swelling which bleeds on touch Treatment is excision

FIGURE 1.20: Scalp wound with large slough in the center

Extensive scalp injury causing slough formation over thecenter which is adherent to the periosteum Slough isadherent to the periosteum and often outer table will benonviable In such occasion, after excising slough, multiplesmall drill holes are made over the outer table to allow bloodsupply to come from the diploë which will eventually lead tothe formation of healthy granulation tissue Later skin graft

or flap is used to cover the defect

FIGURE 1.21: Abdominal fecal fistula

Fecal fistula commonly occurs after ileal/colonic surgeriesfor acute abdomen like lower GI perforations, malignancy,intestinal obstruction, volvulus, tuberculous intestine It isusually treated conservatively by good nutrition {enteral/total parenteral}, care of wound, antibiotics, electrolytemanagement Usually fistula closes in few weeks providedthere is no distal obstruction or residual disease or sepsis

FIGURE 1:22: Bilateral TAO

Thromboangiitis obliterans is seen in male smokers as ahypersensitive reaction to carbon monoxide and nicotine Itcauses vasospasm, hyperplasia, thrombosis and blockage

of the medium sized vessels Claudication, rest pain,ulceration, gangrene of toes and foot/leg and absence ofdistal pulsations are the typical presentations Conditionoccurs in young individuals and is confirmed by duplex scan,angiogram or arterial biopsy Treatment is completecessation of smoking, vasodilators, antiplatelet drugs,lumbar sympathectomy, omentoplasty, profundaplasty oroften amputation

Figure 1.23 A shows diabetic gangrene of the lateral fourtoes with distal part of the foot Note the blackish dis-coloration Great toe is spared It needs amputation aftercontrol of diabetes Figure 1.23 B shows gangrene of greatand little toes Arterial Doppler is required to find out theblock, its site, extent and severity.

FIGURE 1.24: Arterial graft

On table use of synthetic arterial dacron graft as femoral bypass for aortoiliac block Arterial grafts aresynthetic or natural Natural internal mammary graft is idealone Long saphenous vein and umbilical vein are also used.Synthetic grafts are woven/knitted graft or PTFE (polytetra-fluoroethylene) graft Graft can cause leak, thrombosis, re-block as complications

aorto-FIGURE 1.25A: Aortic aneurysm

Figure shows aortic aneurysm from the arch of aorta whichhas eroded into the sternum presenting as pulsatile swelling

It is an aortic aneurysm with impending rupture It has gotpoor prognosis Emergency surgery is needed to save thelife of the patient It has got high operative mortality also

FIGURE 1.25B: X-ray of aortic aneurysm of thoracic aorta

Note the extensive involvement of thoracic aorta which isextending into the abdominal aorta Such cases are difficult

to operate U/S, Doppler and CT angiogram confirms thediagnosis as well as give the detail about the aneurysm.This patient had a massive rupture in a month and died

FIGURE 1.25C: CT of right arch aortic aneurysm with thrombus

Persistent entire right developmental dorsal aorta andinvoluted distal part of left dorsal aorta {Normally right dorsalaorta involutes} Right arch aorta arising from ascendingaorta passes backwards to the right of trachea andoesophagus to join upper descending aorta Aneurysm hasdeveloped in this anomalous right arch aorta with thrombus

in the aneurysm

in wrist but often done in brachial (elbow) region and femoralregion This A-V fistula can get infected, can get blocked oroften can cause torrential bleeding Creation of AV fistula isdone under local anaesthesia.

FIGURE 1.26B: AV fistula done for CRF became fistulous

aneurysm in the elbow

Figure shows aneurysm in an A-V fistula which is pulsatile,warm, and tender with continuous thrill on palpation andbruit on auscultation Skin changes over the summit signifysepsis/thrombosis/impending rupture

FIGURE 1.27A: Haemangioma FIGURE 1.27B: Haemangioma

FIGURE 1.28A: Congenital AV malformation

Congenital arterio-venous malformation of the middle fingershowing local gigantism Typical increase in length and girth

of the part with continuous thrill and bruit, warmness andoften with bone erosion are the features Even minor traumacauses torrential bleeding It may cause hyperdynamiccirculation and cardiac failure especially when it is extensive.X-ray of the part, Doppler and angiogram are needed

Figure shows congenital AV malformation in cerebral cortex.

It may cause bleeding and CVA It is treated by therapeuticembolization or by clipping

FIGURE 1.28B: MRI of congenital A-V

malformation of brain