Ebook Clinical surgery pearls (2/E): Part 1

Part 1 book “Clinical surgery pearls” has contents: Toxic goiter, solitary thyroid nodule, solitary thyroid nodule, multinodular goiter, early breast cancer, advanced breast cancer, epigastric lump, right hypochondrial lump without jaundice, right hypochondrial lump without jaundice, appendicular mass,… and pther contents.

CLINICAL SURGERY PEARLS

CLINICAL SURGERY PEARLS

R Dayananda Babu MS MNAMS

Professor and Head

Department of Surgery Sree Gokulam Medical College and Research Foundation

Venjaramoodu, Thiruvananthapuram, Kerala, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

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SECOND EDITION

Foreword

Mathew Varghese

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© 2013, Jaypee Brothers Medical Publishers

All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the author Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.

Clinical Surgery Pearls

Email: joe.rusko@jaypeebrothers.com

My late parents for their love and affection –

Mr Raghavan and Mrs Mallakshy

My only sister – late Ms Damayanthy

My wife – Professor (Dr) Geetha Bhai and

to my beloved son Deepak D Babu for their moral support

My teachers for their wisdom

My patients for their trust and support

My students for their assistance

Professor R Dayananda Babu is known to me for the past forty years I have great admiration for his wealth

of knowledge in the subject of surgery

He has written the book Clinical Surgery Pearls with careful and persistent effort The overriding goal has

been the mobilization of information relative to the science and skills of surgery In addition to defining the frontiers of surgical knowledge, it affords the student to assimilate the fundamentals in an easy way This book will be an enormous help to those who are studying surgery at both undergraduate and postgraduate levels

I wish the book a great success

Professor (Dr) Mathew Varghese

MS FRCS Ed

Emeritus Professor of Surgery Government Medical College Kottayam, Kerala, India

Foreword

Preface to the Second Edition

The first edition of this book was published in 2010 It is gratifying to note the wide acceptance of this book as an exam cracker by undergraduates and postgraduates alike; and, therefore, I was forced to bring out the second edition within 2 years of the initial publication I am happy to note that now this book is recommended by many universities

There is no need to stress the importance of refreshing a book like this I was forced to spend many hours

in rectifying the errors which have crept up in the first edition The old chapters have been thoroughly revised and updated The new American Joint Committee on Cancer (AJCC), 7th edition, has been used for staging and management, instead of the 6th edition of AJCC as used in the first edition At the end of some

of the important cases, colored boxes have been used under the title “What is new—For postgraduates, the unique unorthodox style, the student-oriented approach and the question-answer format are still retained.”

I am grateful to Professor John S Kurian, who is Professor of Surgery at Government Medical College, Kottayam, Kerala, India, for the effort he has taken to find out the errors and for coming up with suggestions for improvement I also thank Dr Deepak George, for his valuable suggestions for improvement of many

of the chapters

I also thank the publisher M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for bringing out a high-quality second edition book quickly

R Dayananda Babu

Preface to the First Edition

This book is the final result of my continuous teaching and learning process with my undergraduate and postgraduate students in surgery Whenever I interact with my students, I realize their problems and deficiencies and find out the solutions, so that it reaches them Whenever I read a chapter, a series of questions will come to my mind and then I will try to answer those questions That is exactly the reason why this book is in question-answer format The flow charts and tables in this book are evolved in the classrooms and bedside teaching area

Whenever I read a topic, I try to define the condition I feel that when you define something, half the problem is solved; and, therefore, the first chapter is devoted to definitions There are more than 100 definitions in this book

Another important aspect of any learning process is to find out the concepts behind the disease process and management These concepts are converted to an easily digestible capsule form in this book for the students As an examiner at undergraduate and postgraduate levels, I realized that most of the time the students miss many important clinical points during case presentation, not because they do not know them but because they do not have a checklist Therefore, I have given the checklist for all clinical cases The questions for the postgraduate (PG) students are marked as PG in brackets so that the undergraduate students can skip them if they feel so

More than 50 clinical cases are discussed in this book (both long ones and short ones) Each case starts with a clinical capsule and questions are formulated based on the clinical capsule There is a separate chapter for radiology and imaging and about 32 skiagrams are discussed Important tables and charts are included as a separate chapter for ready reference

This is a clinical book of definitions, checklists, tables, flow charts, questions and answers All my classes

are distilled into a book and the title is Clinical Surgery Pearls The preparation of this book took seven long

years of hard work, and I completed this book single handedly All the clinical photographs are taken by

me with a small Kodak digital camera The highlighted boxes and charts in this book will make it easily readable I am sure, the unique style and the student-oriented approach will make the learning process

a pleasant experience

R Dayananda Babu

I am grateful to:

• All my patients, for permitting me to take clinical photographs

• My favorite student Dr Suraj Rajan, who has drawn the medical illustrations in Adobe photoshop and who is now working in the US He also read the first “raw copy” and gave suggestions from the “student point of view”, which is incorporated as student review I am short of words to thank him

• All my Professors and teachers in surgery I remember my great teachers like Professor CKP Menon, Professor KJ Jacob, Professor Mathew Varghese, Professor Balsalam, Professor Mohankumar, Professor

KY Roy and Professor CK Bahuleyan

• My wife Dr Geetha Bhai, who helped me in proofreading and editing this book and without her help this could not have been possible

• All my postgraduate and undergraduate students in surgery

• Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India

Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-• Mr PM Sebastian (Branch Manager, Jaypee Brothers, Kochi) and Mr Arun Kumar (Senior Sales Executive, Jaypee Brothers, Kochi) and all the staff of Kochi Branch for bringing out this book in time

• Finally, Mr Subramanian, for spending time with me and doing the DTP work of this book

SECTION 1: Definitions

Definitions 3

SECTION 2: Long Cases Case 01: Toxic Goiter 21

Case 02: Solitary Thyroid Nodule (STN-Nontoxic) 45

Case 03: Papillary Carcinoma Thyroid with Lymph Node Metastases 52

Case 04: Multinodular Goiter 68

Case 05: Early Breast Cancer 74

Case 06: Advanced Breast Cancer 95

Case 07: Epigastric Lump 106

Case 08: Right Hypochondrial Lump without Jaundice 119

Case 09: Right Iliac Fossa Mass (Suspected Ileocecal Tuberculosis) 128

Case 10: Suspected Carcinoma of the Cecum 134

Case 11: Appendicular Mass 146

Case 12: Obstructive Jaundice 152

Case 13: Varicose Veins 168

Case 14: Peripheral Occlusive Vascular Disease 188

Case 15: Lymphoma 207

Case 16: Renal Swelling 224

Case 17: Pseudocyst of Pancreas 235

Case 18: Retroperitoneal Tumor 241

Case 19: Testicular Malignancy 248

Case 20: Portal Hypertension 261

Case 21: Mesenteric Cyst 278

Contents

SECTION 3: Short Cases

Case 22: Non-thyroid Neck Swelling 285

Case 23: Tuberculous Cervical Lymph Node 288

Case 24: Cervical Metastatic Lymph Node and Neck Dissections 296

Case 25: Carcinoma Tongue with Submandibular Lymph Node 308

Case 26: Carcinoma of Gingivobuccal Complex (Indian Oral Cancer) 319

Case 27: Parotid Swelling 324

Case 28: Submandibular Sialadenitis 335

Case 29: Ranula, Plunging Ranula, Sublingual Dermoid and Mucous Cyst 340

Case 30: Thyroglossal Cyst, Lingual Thyroid, Ectopic Thyroid, Subhyoid Bursa and Carcinoma Arising in Thyroglossal Cyst 343

Case 31: Branchial Cyst, Branchial Fistula, Cystic Hygroma 349

Case 32: Soft Tissue Sarcoma 355

Case 33: Neurofibroma, von Recklinghausen’s Disease 364

Case 34: Lipoma (Universal Tumor) 370

Case 35: Sebaceous Cyst/Epidermoid Cyst/Wen/Dermoid Cyst 373

Case 36: Ulcer 378

Case 37: Malignant Melanoma 388

Case 38: Basal Cell Carcinoma/Rodent Ulcer 402

Case 39: Squamous Cell Carcinoma—SCC (Epithelioma) 407

Case 40: Carcinoma Penis 414

Case 41: Congenital Arteriovenous Fistula/Hemangioma/Compressible Swelling 422

Case 42: Unilateral Lower Limb Edema 432

Case 43: Hydrocele of Tunica Vaginalis Sac (Epididymal Cyst, Spermatocele, Varicocele, Hematocele, Chylocele, etc.) 441

Case 44: Inguinal Hernia/Femoral Hernia 450

Case 45: Incisional Hernia (Ventral Hernia, Postoperative Hernia) 469

Case 46: Epigastric Hernia (Fatty Hernia of the Linea Alba) 474

Case 47: Paraumbilical Hernia, Umbilical Hernia in Adults and Children 477

Case 48: Desmoid Tumor, Interparietal Hernia (Interstitial) and Spigelian Hernia 483

Case 49: Gynecomastia/Male Breast Carcinoma 486

Case 50: Fibroadenoma/Cystosarcoma/Breast Cyst/Fibroadenosis/Fibrocystic Disease/ Mastalgia/Mastopathy/Chronic Mastitis 494

SECTION 4: Radiology and Imaging

Radiology Questions and Answers 503

SECTION 5: Important Tables and Charts General 559

Trauma 567

Burns 574

Neck 578

Breast 579

Abdomen 583

Vascular 594

Limbs 599

Anorectal 604

Index .607

1 Take up one idea

Make that one idea your life

Think of it, dream of it, live on it

Let the brain, muscle, nerves and every part of your body be full of that idea

Leave the other ideas alone.

Second, it is violently opposed

Third, it is accepted as being self-evident.

—Schopenhauer

5 The world is not divided into the rich and poor, the successes and failures,

but into learners and non-learners.

—Benjamin Barber

Sayings of the Great

S e c t i o n 1

Definitions

b Arteriosclerotic lesion in older individuals

– Superior mesenteric artery:

Mesenteric apoplexy (spontan -

eous rupture)

– Right colic artery

– Branches of celiac

c Hemorrhage from congenital aneurysm in

young patients — bleeding from splenic artery

aneurysm in pregnancy.

2 Abscess, Cold Abscess

Abscess: It is a localized collection of pus in a

pathological space lined by granulation tissue

Cold Abscess: Soft fluctuant swelling without signs

of inflammation, which is mistaken for a cyst This

is lined by granulation tissue and caseous material

It is due to tuberculous infection and contains

tubercle bacilli It is not hot Brawny induration,

edema and tenderness are absent

3 Acute Abdomen

Any sudden spontaneous nontraumatic disorder affecting the abdomen for which urgent operation may be necessary and undue delay in diagnosis may adversely affect the outcome

4 Activities of Daily Living (ADL)

It is critical to assess the functional status of the prospective older candidate for surgery prior to scheduling an operation

The activities are:

6 Amylase

A serum amylase level four times above the normal

is indicative of acute pancreatitis

7 Ankyloglossia

Inability to protrude the tongue due to involvement

of the muscles of tongue by carcinoma The tongue

deviates to the affected side

8 Apathetic Hyperthyroidism

Asymptomatic mild hyperthyroidism occurring in

the elderly recognized only by laboratory findings

9 Arc of Riolan (Meandering Mesenteric Artery)

The left colic artery near the splenic flexure

bifurcates; one of the branches passes to the right

in the transverse mesocolon to anastomose with

a similar branch of middle colic artery to form

the Arc of Riolan This has got important role in

supplementing the marginal artery (Fig 10.1)

10 Bacteremia, Pyemia, Septicemia

Bacteremia: Circulating bacteria in the blood

without producing disease

Pyemia: Circulating infective emboli composed of

masses of organisms, vegetations and infected clots

in the bloodstream

Septicemia: Circulation of bacteria in blood

producing disease

11 Barrett’s Esophagus

It is a metaplasia of the lower esophageal mucosa

due to replacement of the squamous epithelium,

by columnar epithelium, endoscopically having

salmon pink appearance replacing the whitish squamous epithelium pathologically showing intestinal type of epithelium with goblet cells

12 Biliary Colic, Cholecystitis

The term colic is inaccurate for gallbladder It produces constant pain in most cases as a result

of obstruction to cystic duct The pain last for 1–5 hours, and rarely shorter than 1 hour duration (Right upper quadrant pain radiating to right upper back, right scapula or between the scapulas) Pain lasting beyond 24 hours suggests acute inflammation— Cholecystitis

13 Boil, Furuncle, Furunculosis, Folli culitis, Carbuncle

Folliculitis: Affection of the root of one hair follicle

alone by Staphylococcus is called folliculitis

Boil/Furuncle: Infection of the root of the hair follicle

with perifolliculitis caused by Staphylococcus is

called Boil/Furuncle

Furunculosis: Multiple boils with intervening normal

tissue is called furunculosis

Carbuncle: Infective gangrene of skin and

sub-cutaneous tissue caused by Staphylococcus

(multiple boils with involvement of intervening tissue also)

14 Breast Carcinoma—Definitions

Skin tethering and fixity: The skin tethering is due to

early involvement of ligaments of Cooper

Manifested as puckering of the skin The underlying lump can be moved independently of the skin to some extent

Skin fixity: It is because of invasion of carcinoma

along the ligaments of Cooper to the skin

The lump and the skin cannot be moved

separately

Retraction (Recent) of nipple: Extension of growth

along the lactiferous duct and subsequent fibrosis

Peau d’ Orange appearance is due to blockage

of the lymphatics draining the skin—cutaneous

lymphedema The hair follicles are more firmly

fixed to the subcutaneous tissue than the rest of

the skin The hair follicles appear to be retracted

and the between areas swell giving the orange

peel appearance

Terminal Duct Lobular Unit (TDLU): The functional

unit of the breast is the terminal duct lobular

unit All cancers of the breast and most benign

conditions arise within TDLU (Fig 5.4)

Skin Involvement: T4b

Edema (including peau d’ orange) or ulceration of the

skin of the breast or satellite skin nodules confined to

the breast Dimpling of the skin and nipple retraction

is not considered skin involvement

Inflammatory carcinoma breast: It is a

clinicopatho-logical entity characterized by diffuse erythema and

edema (peau d’ orange) of the breast without an

underlying palpable mass, involving the majority

of the skin of the breast This is due to tumor

emboli within dermal lymphatics The biopsy should

demonstrate cancer within the dermal lymphatic or

in breast parenchyma itself Neglected LABC (locally

advanced breast cancer) is not inflammatory Ca

Extensive in situ component: If more than 25% of the

main tumor mass contains in situ disease and there

is in situ cancer in the surrounding breast tissue,

the cancer is classified as having an extensive in situ component

Chest wall infiltration: Chest wall includes ribs,

intercostal muscles and serratus anterior muscle but

not the pectoral muscle

Supraclavicular nodes: These are seen in a triangle

defined by the omohyoid muscle and tendon, internal jugular vein (medial border) and the clavicle and subclavian vein (lower border) Adjacent nodes outside this triangle are considered to be lower cervical nodes (M1)

Multifocal: Tumor foci in the same quadrant are

called multifocal

Multicentric: Tumor foci in different quadrants are

called multicentric

Microinvasion: (Ti mic): Microinvasion of 0.1 cm or

less in greatest dimension

Micrometastasis: Tumor deposits greater than 0.2

mm, but not greater than 2 mm in largest dimension

having histologic evidence of malignant activity namely proliferation or stromal reaction

Isolated tumor cells: Single cell or small clusters of

cells not greater than 0.2 mm in largest dimension with no histologic evidence of malignant activity

15 Bruit

It is the sound produced by the turbulent blood flow through a stenotic arterial segment which is

transmitted distally along the course of the artery

When a bruit is heard over the peripheral vessel, stenosis is present at or proximal to that level

It is heard loudest during systole and with greater

stenosis may extend into diastole The pitch of the bruit

rises as the stenosis becomes more marked Absence

of bruit does not indicated absence of occlusion

When the vessel becomes completely occluded, the

bruit may disappear

16 Burns, Scald, Fat Burn

Burns: Injury by dry heat.

Scald: Injury by moist heat.

Fat burn: Injury by boiling oil.

17 Bursae: Bunion, Clergyman’s Knee, Golfer’s

Elbow, Students Elbow, Housemaid’s Knee,

Tennis Elbow

Bursae: These are fluid-filled cavities lined with

flattened endothelium similar to synovium Usually

seen in relation to joints When they develop over

pressure points, they are called adventitious

bursae (see examples) They prevent friction

during movement Fluctuation, fluid thrill and

transillumination are positive.

Housemaid’s knee: It is a subcutaneous bursa

between patella and skin

Clergyman’s knee: It is a subcutaneous bursa

between skin and ligamentum patella

Students elbow: It is a subcutaneous bursa between

skin and olecranon

Golfer’s elbow: It is medial epicondylitis Tender ness

can be elicited at the medial epicondyle at the

common flexor origin

Tennis elbow: It is lateral epicondylitis (Common

extensor origin at the lateral epicondyle is affected)

Bunion: It is a subcutaneous bursa between skin and

head of 1st metatarsal bone

18 Carbuncle

Read boil

19 Cellulitis, Erysipelas

Cellulitis: Spreading inflammation of subcutan­

eous and fascial tissue caused by Streptococcus

pyogenes Commences in a trivial infected wound

It has “No edge, No fluctuation, No pus and No limit”.

Morison’s aphorism: Cellulitis occurring in children is

never primary in the cellular tissue, but secondary

to an underlying bone infection.

Cellulitis of the scrotum: Always rule out extravasation

of urine

Erysipelas: It is cuticular lymphangitis

Milian’s ear sign: Facial erysipelas spreads

and involves the pinna because it is cuticular lymphangitis Subcutaneous inflammations stop short for the pinna because of close adherence of the skin to the cartilage

20 Claudication, Rest Pain

Claudication: (I limp) Claudication is the cramp

like muscle pain which appears following exercise

when there is an inadequate arterial blood flow

It must fulfil three criteria

1 It is a cramp like muscle pain (usually the calf)

2 Pain develops only when the muscle is exercised

3 The pain disappears when the exercise stops

Rest pain: It is the continuous pain caused by severe

ischemia This pain is present at rest throughout the

day and the night The pain is relieved by putting

the leg below the level of the heart

Compressibility: When the contents of a swelling can

be emptied by squeezing but the swelling reappear

spontaneously on release of pressure

Reducibility: When the contents of a swelling can

be emptied by squeezing but does not return

spontaneously This requires additional force such

as cough or effect of gravity For example, Hernia

24 Compound Palmar Ganglion

Compound palmar ganglion: It is a tuberculous

affection of ulnar bursae, with a swelling in the

hollow of the palm, extending to the lower fore-

arm Cross fluctuation can be elicited between the

palm and lower forearm

25 Constipation, Obstipation

Constipation: A bowel frequency of less than one

every 3 days (Fewer than two per week).

Obstipation: (Absolute constipation): Absence of

passage of both stool and flatus

26 Cough Impulse

Cough Impulse: Expansile impulse seen or felt over

a swelling when the patient coughs, cries or strains

27 Crepitus

Crepitus: (Grating or crackling sensation imparted

to the examining fingers) may be present when the

joint contain loose bodies May communicate with joint It is also seen in the following conditions:

• Subcutaneous emphysema (surgical emphy­

sema)—gas is present in the subcutaneous tissue.

Four types:

a Traumatic: Fracture ribs, injury to nasal fossa, breach of continuity of larynx, tracheostomy, fracture skull involving sinuses

b Infective: Gas gangrene

c Extraneous: After fluid administration, closure

of surgical wound, etc

d Complicating rupture of esophagus

Cyst: It is a pathological fluid-filled sac bound by a

wall It may be true or false, congenital or acquired.

True cyst: It is one in which the sac is lined with cells

of epithelial origin.

False cyst: It is a walled off fluid collection not lined

by epithelium False cyst may be inflammatory or

Dermoid: Cyst formation due to sequestration of

epithelium deep to the skin surface

30 Dietl’s Crises

Dietl’s crisis: This is because of intermittent hydro­

nephrosis After an attack of acute renal pain, a

swelling is found in the loin due to the

hydrone-phrosis Following the passage of large volume of

urine some hours later, the pain is relieved and the

swelling will disappear

31 Diverticulum, Diverticulosis

Diverticulum: Abnormal external projection from

a hollow viscus external to the serosa is called

diverticulum It may be true or false, congenital

or acquired Congenital is true and acquired is false

(one meaning of diverticulum is a wayside house

of ill­fame).

True diverticulum: Containing all the layers of the

bowel wall

False diverticulum: There is no muscle coat, but all

other layers (herniation of mucosa or submucosa

through the muscular coat)

Pulsion diverticulum: The diverticulum is pushed out

by intraluminal pressure

Traction diverticulum: Diverticulum develops as a

result of external traction

Diverticulosis: Presence of multiple false diverticulae

32 Diarrhea

Diarrhea: If stools contain more than 300 mL fluid

daily

33 Edema

Edema: It is an imbalance between capillary

filtration and lymphatic drainage (this does

not mean that all edemas are lymphedemas)

This will occur only when the lymphatic system fails to drain the tissue fluid produced by normal capillary filtration

34 Empyema

Empyema: It is collection of pus in a physiological

space

35 Erysipelas (Read Cellulitis)

Erysipelas: Spreading cuticular lymphangitis caused

by Streptococcus pyogenes It has a sharply defined

margin unlike cellulitis The vesicles contain serum Milian’s ear sign—Erysipelas can spread to the pinna

36 Erythroplakia, Leukoplakia

Erythroplakia: Any lesion of the oral mucosa that

presents as bright red velvety plaques that cannot

be characterized clinically or pathologically as any other recognizable condition

Leukoplakia: Any white patch or plaque that cannot

be characterized clinically or pathologically as any other disease

Levels of evidences: Agency for health care policy

and research grading system for evidence and recommendation

Recommendation of Strength:

A – Directly based on category I evidence

B – Directly based on category II evidence or

extrapolated recommendation from category

I evidence

C – Directly based on category III evidence or

extrapolated recommendation from category

I or II evidence

D – Directly based on category IV evidence or

extrapolated recommendation from category

I, II, or III evidence

Levels of evidences: Pragmatic grading (only three

grades)

Evidence Description

I a Evidence from meta­analysis of randomized controlled trials RCT

I b Evidence from at least one RCT

II a Evidence from at least one controlled study without randomization

II b Evidence from at least one other type of quasi­experimental study

III Evidence from nonexperimental descriptive studies, such as comparative studies and case

control studies

IV Evidence from expert committee reports or opinions or clinical experience of respected

authorities or both.

I Beyond reasonable doubt, high quality RCT,

systematic reviews, high quality synthesized

evidence

A Strong recommendations which should be followed

II On the balance of probabilities

Evidence of best practice from high quality review

of literature

B Based on evidence of effectiveness that may need interpretation in the light of other factors like local facilities, audit, etc

III Unproven in sufficient evidence upon which to

base a decision or contradictory evidence C When there is inadequate evidence

39 Fistula, Sinus

Fistula: It is a communicating tract between two

epithelial surfaces lined with granulation tissue

It may be a communication between the skin and hollow viscera or between two hollow viscerae (Internal fistula)

Sinus: Sinus is a blind track leading from the surface

down to the tissue lined by granulation tissue/ epithelium

Fistula-in-ano: The pathology of fistula-in-ano is

‘cryptoglandular infection’ (Infection of the anal glands in the crypt)

Ganglion: Cystic, myxomatous degeneration of

fibrous tissue They are not pockets of synovium

protruding from joints It may be multilocular

occasionally

Content—Viscous gelatinous material

Disappear underneath adjacent structure during

certain movements

Fluctuation is present if not tense

43 Gangrene, Necrosis, Infarction, Slough

Gangrene: Macroscopic death of tissue with

putrefaction

Necrosis: Microscopic death of tissue.

Infarction: Ischemic necrosis is called infarction.

Slough: A piece of dead tissue separated from living

tissue

44 Early Gastric Cancer

Early gastric cancer: Cancer of the stomach confined

to the mucosa and submucosa irrespective of the

nodal status

45 Gastrinoma

Gastrinoma: A basal gastric acid output more than

15 mmol/HR and a fasting gastrin level of more than

200 pg/mL is strongly supporting the diagnosis

46 Gastrinoma Triangle (Passaro’s Triangle)

Gastrinoma triangle: The three points forming the

triangle are:

1 Junction between the head and neck of the pancreas

2 Junction of cystic duct with CBD

3 Junction between 2nd and 3rd parts of the duodenum

palpableGrade III Large gland evident from a distance

WHO classification (1994) Grade 0 – No palpable or visible swelling Grade 1 – A mass in the neck that is consistent with

an enlarged thyroid that is palpable, but not visible when neck is in normal position It moves upwards

in the neck as the subject swallows

Grade 2 – A swelling in the neck that is visible when

the neck is in a normal position and is consistent

with an enlarged thyroid when neck is palpated

Hamartoma: A tumor-like formation of tissues

indigenous to the site due to developmental

aberration

Teratoma: Tumor-like proliferation of tissues, not

indigenous in origin, containing more than one

germinal layer

50 Hematemesis, Melemesis, Melena,

Hematochezia

Hematemesis: Vomiting of bright red or dark blood.

Melemesis: Vomiting of altered blood is called

melemesis Coffee ground vomitus is due to vomiting

of blood that has been in the stomach long enough

for gastric acid to convert Hb to methemoglobin

Melena: Passage of black or tarry sticky, semisolid,

stools because of the presence of altered blood It

can be produced by blood entering the bowel at any

point from mouth to cecum The black color is due

the Hematin (from Heme) 50 to 100 ml of blood

in stomach can produce melena 1 liter of blood in

stomach will produce melena for 3–5 days

Hematochezia: Passage of bright red blood from

the rectum (Colon, rectum and anus) is called hematochezia Brisk bleeding from upper intestine with rapid transit can also produce it

51 Hernia, Prolapse

Hernia: Abnormal protrusion of a viscus or part of a

viscus lined by a sac through a normal or abnormal

opening in the abdominal wall

Prolapse: Abnormal protrusion of a viscus through

a normal or abnormal opening not lined by a sac

52 Hurthle Cell Tumor

Hurthle cell tumor: Presence of more than 75%

follicular cells having oncocytic features in thyroid histology is called Hurthle cell tumor

53 Hydronephrosis, Dietl’s Crisis (Read Above)

Hydronephrosis: Aseptic dilatation of pelvicalyceal

system due to partial or intermittent obstruction

54 Hyperparathyroidism

Hyperparathyroidism: The combinations of increased

PTH levels and hypercalcemia without hypocalciuria (Hypercalciuria of more than 400 mg/24 hour is diagnostic)

55 Incontinence of Urine

Incontinence of urine: Involuntary evacuation of

urine

a Incontinence for solid feces

b Incontinence for liquid feces

c Incontinence for gas

57 Infarction

Read gangrene

58 Inguinal Canal

Inguinal canal: It is an intermuscular slit situated

between the superficial inguinal ring and deep

inguinal ring

59 Intussusception

Intussusception: Telescoping of proximal intestine

to the distal intestine

Retrograde intussusception: Telescoping of distal

intestine into the proximal intestine (e.g

jejuno-gastric intussusception) after gastrojeunostomy)

60 Jaundice

Jaundice: Yellowish discoloration of skin and

mucous membrane due to excessive circulating bile

61 Karnofsky Performance Status (KPS)

Karnofsky performance status (KPS): The KPS is

reliable independent predictor of survival of

outcome for patients with solid tumors It is a

required baseline assessment in clinical protocols

in head and neck and other cancers.

The American joint committee on cancer (AJCC) strongly recommends recording of KPS along with standard staging information (TNM) It is a method

of measuring co­morbidity It provides a uniform

objective assessment of an individuals functional

status The scale in ten point increments from zero

(Dead) to 100 (Normal, no complaints, no evidence

of disease) was devised in 1948 by David A Karnofsky.

Karnofsky Performance Status (KPS)

100 – Normal; no complaints; no evidence of disease

90 – Able to carry on normal activity; minor signs or symptoms of disease 80 – Able to carry on normal activity with effort; some signs or symptoms of disease 70 – Care for self; unable to carry on normal activity or do active work 60 – Requires occasional assistance, but is able to care for most of own needs

50 – Requires considerable assistance and frequent medical care 40 – Disabled; requires special care and assistance 30 – Severely disabled, hospitalization is indicated by although death is not imminent 20 – Very sick Hospitalization necessary Active supportive treatment is needed 10 – Moribund Fatal process rapidly progressing 0 – Dead

A Able to carry on normal activity No special care

is needed (scale 80–100)

B Unable to work, able to live at home, cares

for most personal needs; a varying amount of assistance is needed (50–70)

C Unable to take care of self; requires the

equi-valent of institutional or hospital care; disease may be progressing rapidly (scale 10–40)

62 Line of Demarcation

Line of demarcation: Zone of demarcation between

viable and gangrenous tissue indicated by a band of

hyperemia and hyperesthesia on the surface and

separation is achieved by a layer of granulation tissue.

In dry gangrene the line of demarcation appears

in a matter of days without infection and this is

called “separation by aseptic ulceration”.

In moist gangrene the line of demarcation is

more proximal than dry gangrene and the process

is called “separation by septic ulceration”.

63 Lipoma (Universal Tumor)

Lipoma: It is benign tumor from “adult fat cell“ It is

called “universal tumor” or “ubiquitous tumor” and

hence the aphorism: “when in doubt hedge on fat”.

64 Lower GI Bleed, Upper GI Bleed

Lower GI bleed: It is a bleeding from distal to the

Marginal artery of Drummond: It is the paracolic

vessel of anastomosis between the superior

mesenteric and inferior mesenteric arterial system

66 Massive Hemothorax

Massive hemothorax: When 1500 mL or more of

blood is acutely removed from the pleural space,

then it is called massive hemothorax

67 Massive Blood Transfusion

Massive blood transfusion: The term massive transfusion

implies a single transfusion greater than 2500 mL or

5000 mL transfused over a period of 24 hours

Late menopause: Menopause after 50 years.

71 Mesentery of Small Intestine — Attachment

Mesentery of small intestine—attachment: The

base of the mesentery attaches to the posterior abdominal wall to the left of the second lumbar vertebra and passes obliquely to the right and inferiorly to the right sacroiliac joint crossing 3rd part of the duodenum, aorta, IVC and right ureter

It is 6 inches (15 cm) in length Remember the small intestine has got 6 meters length (Fig 2.1).

72 Mesentery of Sigmoid — Attachment

Mesentery of sigmoid—attachment: It is shaped like

an inverted V The apex of the V is at the bifurcation

of left common iliac artery crossing the brim The right limb descends to the third piece of the sacrum

The left limb runs along the brim of left side of pelvis (Fig 10.2)

73 Mesentery of The Transverse Colon

Mesentery of the transverse colon: It is attached to

the descending part of duodenum to the head and lower aspect of the body of the pancreas and placed horizontally to the anterior surface of the left kidney

years is very old age

76 Oral Cavity, Buccal Mucosa, Retromolar

Trigone, Trismus, Ankyloglossia

Oral cavity: Starts at skin vermilion junction of

lip anteriorly to circumvallate papillae of tongue,

posterior part of the hard palate, and anterior

pillar of tonsil posteriorly Oral cavity includes the

Buccal mucosa: Extends from the upper alveolar

ridge down to the lower alveolar ridge, and from

the commissure anteriorly to the mandibular ramus

and retromolar region posteriorly

Retromolar trigone: It is defined as the anterior

surface of the ascending ramus of the mandible It

is triangular in shape with the base being superior

behind the third upper molar tooth and the apex

inferior behind the 3rd lower molar

Trismus: (Spasmodic clenching) is inability to open

the mouth

Causes for Trismus

• Oral carcinoma—Involvement of pterygoid, masseter, temporalis and buccinator muscle

Ankyloglossia (Read above).

77 Pancreatitis, Pancreatic Necrosis, Pancreatic Abscess, Pancreatic Ascites, Pancreatic Effusion, Pseudocyst, Pancreatic Necrosis, Acute Fluid Collection

Chronic pancreatitis: It is a disease in which there is

irreversible progressive destruction of pancreatic tissue Its clinical course is characterized by dynamic progressive fibrosis of the pancreas.

Acute Pancreatitis Acute fluid collection: It is fluid collection in or near

the pancreas with ill defined wall occurring early in acute pancreatitis

Pancreatitis acute pseudocyst: It is a collection of

pancreatic juice enclosed in a wall of fibrous or

granulation tissue (Requires 4 weeks).

Pancreatic necrosis: Diffuse or focal area of non-

viable pancreatic parenchyma Associated peri- pancreatic fat necrosis is present

Infected pancreatic necrosis: Same as above with

infection

Pancreatic abscess: Circumscribed intra-abdominal

collection of pus in proximity to pancreas There is

no pancreatic necrosis

Pancreatic ascites: Chronic generalized peritoneal

enzyme rich effusion associated with pancreatic

ductal disruption

Pancreatic effusion: Encapsulated collection of fluid

in the pleural cavity

78 Papilloma (Benign Papilloma), Polyp,

Polyposis

Benign papillomas: These are hamartomas

consisting of an overgrowth of all skin layers

and its appendages having a central core and

normal sensation They are well-defined, usually,

pedunculated ranging from few millimeters to a

few centimeters in size, commonly 5 mm across

The surface may be grooved or deeply fissured

The complications of papilloma are inflammation,

bleeding ulceration, pigmentation and keratosis

Polyp: It is a morphological term and no histologic

diagnosis is implied They are masses of tissue

that project into the lumen of viscera When the

base is broader than the head, it is called sessile

When the base is narrower than head, it is called

pedunculated It may be benign or malignant,

mucosal or sub-mucosal or muscular

Polyposis: Presence of many polyps.

Paralytic ileus: Defined as a state in which there is

failure of transmission of peristaltic waves in the

intestine secondary to neuromuscular failure [in

the myenteric (Auerbach) and the submucous (Meissner) plexuses

Perfusion: Artificial passage of fluid through blood

vessel (usually veins)

Transfusion: Intravenous administration of blood or

its components

83 Prolapse—Read Hernia

Abnormal protrusion of a viscus through a normal

or abnormal opening not lined by a sac

Contd

Contd

84 Pseudo Thyrotoxicosis

Seen in critically ill patients characterized by

increased levels of T4 and decreased levels of T3 due

to failure of conversion of T4 to T3

85 Pus

Pus: It is a fluid composed of living and dead

bacteria, dead fixed and free cells (the latter

representing body’s phagocytic response) and

foreign material such as sutures, implants and

Renal angle: Angle between the 12th rib and the

edge of the erectorspinae muscle Normally this

is empty and resonant There should not be any

tenderness

Rest pain: It is the continuous pain caused by severe

ischemia This pain is present at rest throughout the

day and the night The pain is relieved by putting

the leg below the level of the heart

87 Retention of Urine

Retention of urine: Accumulation of urine in the

bladder with inability to void

Acute retention: Sudden inability to pass urine with

3 Fr = 1 mm outer diameter of catheter

Recall Shakespeare’s ‘Seven Ages of Man’ from As You Like It.

The entire World is a stageAnd all the men and women merely players;

They have their exits and their entrances;

And one man in his time plays many parts, His acts being seven ages At first the infant,Mewling and puking in the nurse’s arms

And then the whining school boy, with his satchel,And shining morning face, creeping like snail,Unwillingly to school And then the lover, Sighing like furnace, with a woeful ballad Made to his mistress’ eyebrow Then a solider, Full of strange oaths and bearded like the pard, Jealous in honor, sudden and quick in quarrel,Seeking the bubble reputation

Even in the cannon’s mouth And then the justice,

In fair round belly with good capon lin’d,With eyes severe, and beard of formal cut,Full of wise saws and modern instances;

And so he plays his part The sixth age shiftsInto the lean and slipper’d pantaloon,With spectacles on nose and pouch on side;

His youthful hose well say’d a world too wideFor his shrunk shank; and his big manly voice,Turning again towards childish treble, pipes And whistle in his sound Last scene of all,That ends this strange eventful history,

Is second childishness, and mere oblivionSans teeth, sans eyes, sans taste, sans everything

Important causes for retention of urine as per the

seven ages are:

1 The infant – Posterior urethral valve

2 The school boy – Enlarged bladder neck

(Marion’s disease)

– Obturation by stone

3 The “lover age” – Retention following acute

urethritis

4 The soldier – Urethral stricture

5 The justice – Benign enlargement of

the prostate

6 The sixth age – Carcinoma of the prostate

7 The last age – Carcinoma of the prostate

“Bashful bladder”—Cannot pass urine when another

person is in the vicinity

88 Retromolar Trigone

Read oral cavity

89 Rigidity, Guarding

Reflex contraction of the abdominal wall muscles

secondary to intraperitoneal inflammation

Rigidity: In rigidity there is contraction even at rest.

Guarding: In guarding it is secondary to provocation

from the examining hand of the physician

90 Run in, Distal Run off

Distal run off: Patency of the main vessel beyond an

arterial occlusion seen in angiogram

Run in: Patency of the main vessel proximal to the

site of occlusion in angiogram

91 Scoliosis

Scoliosis: Rotatolateral deformity of the spine.

92 Screening, Surveillance

Screening: It is defined as testing a group of people

considered to be at normal risk for a disease, to

discover those at increased risk

Surveillance: It is defined as testing of a group

known to be at increased risk for a disease.

Tension pneumothorax: Presence of air in the pleural

cavity with signs of mediastinal shift like: Tracheal shift or and Shift of Apex beat

Differences between simple pneumothorax and

tension pneumothorax

Tracheal position Normal Displaced

Percussion note Normal Increased

Jugular pressure Normal Elevated (unless

Breath sounds Normal Decreased

A tension pneumothorax impairs venous return

by caval distortion from mediastinal shift and raised

intrathoracic pressure with compression of the

97 Third Day Fever

Third day fever: If a patient is developing fever on the

third postoperative day of surgery, suspect septic

foci in the IV cannula

98 Tubercle, Caseous Material, Tuberculous Pus

Tubercle: Microscopically consists of an area of

caseation surrounded by:

a Giant cells (having 20 or more peripherally

arranged nuclei)

b Zone of epithelioid cells around giant cells

c Zone of inflammatory cells—lymphocytes and

plasma cells

Tubercle is visible to the naked eye towards the

end of second week

Caseous material: It is a dry, granular and cheese

like material (Granular structureless material microscopically)

Tuberculous pus: Softening and liquefaction of the

caseous material result in a thick creamy fluid called

tuberculous pus Liquefaction is associated with

multiplication of bacteria It is highly infective

It contains fatty debris in serous fluid with a few

necrotic cells (It is usually sterile).

99 Ulcer

Ulcer: Abnormal breach in the continuity of the skin or

mucous membrane due to molecular death of tissue

100 Upper GI Bleed

Read Lower GI

101 Varicose Vein

Varicose vein: (WHO Definition) Abnormally dilated

saccular or cylindrical superficial veins which can be circumscribed or segmental

102 Volvulus

Volvulus: Axial rotation of a portion of bowel about

its mesentery Volvulus can occur in the cecum, sigmoidcolon and in the stomach

In the stomach, there are two types of volvulus

• Organoaxial—rotation of stomach in horizontal direction (common)

• Mesenteroaxial—rotation of the stomach in the vertical direction

103 WEIGHT LOSS

Weight loss: Loss of more than 10% body weight

over a period of 6 month

S e c t i o n 2

Long Cases

Case Capsule

A 30-year-old female patient with a thin build has

presented with diffuse enlargement of the thyroid

and palpitation of 6 months duration She complains

of increased appetite and loss of weight She is

apparently irritable and says, she is intolerant to

hot weather with excessive sweating She has a

preference for cold weather She also complains of

insomnia and loss of concentration ability She has

diarrhea in addition She is married and has a baby of

6 months old She complains of amenorrhea for the

last 3 months On examination, patient is agitated and

nervous Examination of the palms revealed that they

are moist and sweaty She has tachycardia, fine and

fast tremor and protruded eyeballs There is visible

diffuse enlargement of the thyroid On auscultation,

there is a systolic bruit heard in the upper pole of the

thyroid The carotids are felt in the normal position The

trachea is central There is no evidence of retrosternal

extension The cervical lymph nodes are not enlarged

In all goiters or swelling in the neck assess the

following:

1 What is the anatomical diagnosis—by assessing

the plane—deep to the deep fascia and deep to

• Intolerance to hot/cold temperature

• Increased appetite with loss of weight

(Hyper-thyroidism)

• Gain in weight (Hypothyroidism)

• Change in menstrual cycle

• Bowel habit—diarrhea (hyper), constipation

Checklist for examination of thyroid

• Always check the pulse for tachycardia before examining the thyroid

• Look for tremor of hands and tongue before examining the thyroid

• Ask the patient to take a sip of water and to hold it in his/her mouth Then ask the patient to swallow (goiter

prominent, contract the sternomastoid muscle against resistance and see whether it becomes less prominent

• Do Pemberton’s test for retrosternal extension

• Percuss the manubrium sterni for dullness (seen in retrosternal extension)

• Assess the behavior of the patient (agitated in toxic, lethargic in hypothyroidism)

• Ask the patient to rise from squatting position without using hands for support (proximal myopathy in hyperthyroidism)

• Test the biceps reflex and look for slow relaxing reflex suggestive of hypothyroidism.

Final checklist for clinical examination of thyroid