Ebook Nutshell series for general surgery: Part 2

(BQ) Part 2 book Nutshell series for general surgery presents the following contents: Intestinal system, hepatobiliary and pancreatic system, urological surgery, liver, liver differentiating feature between, burns and cosmetic surgery, cardiothoracic surgery,...

○ In small bowel—Duodenum is m/c site, m/c on

mesen-tric side, false diverticula

○ Most sensitive test—Enteroclysis

○ Peutz-Jeghers syndrome: Hamartomatous polyps in jejunum* and other part, pigmentation of lips, tumors

of ovary, breast, endometrium, pancreas

○ Cronkhite canada syndrome: Juvenile polyps are

noted along with alopecia, cutaneous pigmentation, atrophy of nails and toe nail

COLONIC CANCER Risk factors

○ Previous history of colon cancer: Increased risk for recurrent cancer

○ Ulcerative colitis: 10%–20% after 20 year

○ Radiation: Associated with a mucinous histology and poor prognosis

○ Ureterosigmoidostomy: 100–200 times increased risk at or

adjacent to the ureterocolonic anastomosis

Contd

○ sion colostomy is done

SMALL BOWEL TUMORS

SMALL BOWEL CARCINOIDS

○ Primary: Usually small

○ Secondary: Those metastasized produces many symptoms together known as carcinoid syndrome

 Most common site is ileum*, 2nd common is rectum, 3rd common site is lungs Being the most common site

previ-ously appendix is now pushed to 4th place.

• Terminal ileum: Right hemicolectomy

• Liver mets: Resection, hepatic artery ligation or embolization or radiofrequency ablation (R�A)

INFLAMMATORY BOWEL DISEASE (IBD)

that resemble polyps, but are actually

pseudopolyps

○ Histologically, the typical early lesion consists of an infiltration of inflamma-tory cells, primarily polymorphonuclear leukocytes, into the crypts at the base of

the mucosa, forming crypt abscesses

Contd

INFLAMMATORY BOWEL DISEASE (IBD)

○ Serpiginous network of linear

Location ○ Colon only • Anywhere in the alimentary tract

Anatomic distribution ○ Continuous, beginning distally • Asymmetrical skip lesions

Rectal involvement ○ > 90% • Occasionally

Diarrhea/gross bleeding ○ Severe, often bloody with mucus • Less severe, infrequent bleeding

Strictures and obstructions ○ Uncommon • Common

Extraintestinal manifestations ○ Common • Common

Recurrence after surgery ○ If retained rectal mucosa • Yes

Mucosal involvement ○ Contiguous • Discontinuous

Surrounding mucosa ○ Abnormal • Relatively normal

Longitudinal ulcers (serpiginous) ○ Rare • Common

Rectal involvement ○ > 90% • Sparing common

Radiographic features

Terminal ileum abnormalities ○ Rare • Yes

Contd

LOCAL COMPLICATIONS OF IBD

TREATMENT FOR IBD

○ Conservative

○ Surgical—Elective and emergency

○ Indications for surgery

○ Remember UC can be cured by resection of affected segment, but CD needs only palliative care

1 Ulcerative

2 Hyperplastic 1 Primary infection: Mycobacterium bovis, infected milk—hyperplastic (TB)2 Secondary infection: Swallowing tubercle bacilli—ulcerative type TB—M/c form of

intestinal (TB)

1 Cause ○ M bovine primary ingestion  Secondary to swallowing infected sputum

2 M/c site ○ Ileocecal valve  Longer parts of terminal ileum

3 Presentation ○ As obstruction  As transverse ulcers

5 Barium meal ○ Pulled up cecum, ileocecal angle becomes obtuse  Absence of filling of lower ileum

6 Treatment ○ Augmentation therapy (ATT) + surgery if obstructed  ATT + surgery if perforated

7 Complications ○ Obstruction  Perforation, fistula

Contd

7 Increased gastrin secretion: due to reduced hormonal inhibition

Risk factors for short gut syndrome

Megacolon Toxic megacolon

 Cope’s psoas test: Retrocecal appendicitis on extension of

hip produces pain due to irritation over psoas major  Cope’s obturator test: Pelvic appendicitis, flexion and

fedial rotation produces pain

Contd Contd

ENTEROCUTANEOUS FISTULA

ACUTE APPENDICITIS Alvarado scoring

○ lowed

per-the omentum and small bowels usually surround the inflammed appendix and prevent spread

• McBurney’s grid iron incision

it involves leave it as such

MUCOCELES Histological types ○ Intraluminal accumulation of mucoid substance

○ pendicectomy is enough

Contd

INTESTINAL OBSTRUCTION Intusussception

Barium enema—Claw-sign, coiled- Ultrasound—Target sign, pseudo- kidney sign and Bulls eye sign

 X-ray plain—Target sign (soft tissue mass with concentric area of lucency due to mesentric fat)

• Hydrostatic reduction by contrast agent or air enema is diagnostic and therapeutic

• cated in peritonitis and hemody-namic instability

○ Air fluid levels do not form in spite of complete small bowel obstruction

be-cause enteric contents are viscous and thick

○ Normal fluid levels ; 3–5 each < 2.5 cm is normal

○ Fluid levels > 5 indicates small bowel obstruction

○ Step ladder pattern: Small bowel obstruction

PARALYTIC ILEUS (INORGANIC CAUSE)

○ Other clinical points in favor of paralytic ileus 1.Diminished bowel sounds

2 No pain in abdomen

Management

○ Usually resolve in 3–5 days

○ Treat the cause ○ If prolonged beyond 5–7 days intervention needed laparoto- If prolonged beyond 5–7 days intervention needed laparoto-my to r/o hidden cause

laparoto-LARGE BOWEL OBSTRUCTIONS

○ Definitive treatment is—sigmoid colectomy

SALIENT POINTS IN LARGE BOWEL OBSTRUCTION

ACUTE MESENTERIC ISCHEMIA

 If peritoneal signs are present—urgent laparotomy needed

 If peritoneal signs

PSEUDO-OBSTRUCTIONS Etiological classification

RECTUM AND ANUS CANCER RECTUM

○ Best investigation for local spread—Transrectal USG

○ srectal MRI

 Complete excision of rectum and anus along with permanent colostomy

 Also known as Mile’s procedure

Anatomy of rectum  �or tumors involving upper 1/3rd anterior resection and for

tumors involving middle 1/3rd low anterior resection

fined to rectum having peritoneal reflection and low anterior resection for tumors in rectum without peritoneal reflection

 In other words… anterior resection is done for tumors con-With the advent invention of staplers low anterior resection has become easier

Recent theories state that hemorrhoids are normal anatomical struc-○ Three hemorrhoidal cushions are there at 3, 7, 11 O’clock position

Contd Contd

HEMORRHOIDS Treatment

 Injection tion of 5% phenol in arachis oil or almond oil, may be advised using Gabriel syringe

sclerotherapy, the submucosal injec- The open technique is most commonly used in

the UK and is known as the Milligan–Morgan operation: Named after the surgeons who

Contd

NORMAL FECAL CONTINENCE REQUIRE

○ Anorectal ring (puborectalis, deep external sphincter, internal sphincter) is very important for continence

ANORECTAL ABSCESS

○ Usually produces a painful, throbbing swelling in

the anal region.

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

• Bascom’s procedure involves an incision lateral

to the midline to gain access to the sinus cavity, which is rid of hair and granulation tissue

• Psychosis

• Diabetes

Contd

PRURITUS ANI Treatment

tula opens into the posterior vestibule (not the vagina)

Contd

SOLITARY RECTAL ULCER

No visible intra-abdominal injury is present, but in-citation

 It is due splanchnic reperfusion after massive resus-• Chronic ACS:

ence of cirrhosis and ascites, often in the later stages of the disease

4 Increased pulmonary artery pressure

o Increased intra- cranial pressure

nificantly increased risk when more than 3 L are infused

 Large-volume resuscitation: The literature shows a sig- Large areas of full thickness burns:

 Penetrating or blunt trauma without identifiable injury

 Postoperative

 Packing and primary fascial closure, which increases incidence

 Sepsis

 Peritoneal dialysis

 Morbid obesity

 Cirrhosis

drome

 Meigs syn-Contd

ABDOMINAL COMPARTMENT SYNDROME

• (Realize plain abdominal radiographic studies are often useless

in identifying abdominal compartment syndrome)

• Abdominal CT scanning can reveal many subtle findings:

 Round-belly sign  Abdominal distention with an increased ratio of anteroposterior-to-transverse abdominal diameter

FMGE QUESTIONS

1 Routine management of paralytic ileus include all

of the following, except: (Sep 2009, 2007)

Management of paralytic ileus:

Bailey and Love (Page 1201, 25th edition)

2 Ideal management in an old and frail patient

pre-senting with intestinal obstruction with a mass

situ-ated 15 cm away from anal orifice: (March 2010)

• mann’s operation—proximal colostomy and distal closure Hartmann’s is a very useful procedure in emergency conditions.

But, since this patient is old and frail we go for Hart-3 Which of the following is not associated with

4 Hirschsprung disease involves, which region of

• Definitive diagnosis is by Full thickness rectal biopsy*, which will show absence of ganglion cells

both in auerbach and myenteric plexus and presence

of hypertrophied nerve trunks.

6 Which of the following is the investigation of

choice for diagnosing carcinoma colon? (Sep 2009)

7 Uncommon complication of Meckel’s

8 Acute appendicitis is characterized by all of the

pain—which is localised in the right iliac fossa.

• This classic visceral—somatic sequence of pain is

seen in more than half of patients.

• Anorexia is a constant clinical feature

• Fever: Pyrexia is always slight (37.2—37.7°C) It will

never reach beyond 38.5°C If it goes beyond that

temperature other causes like mesenteric adenitis

�istula is a feature of Crohn disease and not seen in ul-10 Which of the following statement is false?

11 Which of the following is not a commoner cause

of intestinal perforation (March 2004)

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

14 Most common site of volvulus is:

15 The commonest cause of significantly lower

gas-trointestinal bleed in a middle aged person

with-out any known precipitating factor may be due to:

16 Treatment of an incidentally detected

appendicu-lar carcinoid measuring 2.5 cm is: (March 2008)

a Right hemicolectomy

b Limites resection of the right colon

c Total colectomy

d Appendicectomy

Ans: a (Right hemicolectomy)

(Refer: Bailey and Love- Page 1217)

Carcinoid tumor of appendix:

17 A 26-year-old male presented with 4 day history

of pain in the right sided lower abdomen with quent vomiting Patients GC is fair and clinically

fre-a tender lump wfre-as felt in the right ilifre-ac fossfre-a Most appropriate management for this case would be:

18 Lateral internal sphincterotomy is useful for:

Ans: d (Anal fissure)

19 Treatment of choice for 3rd degree hemorrhoids

a Sclerotherapy

b Band ligation

c Hemorrhoidectomy

d All of the above

Ans: d (All the above)

20 All of the following are true regarding pilonidal

Ans: c (Pilonidal sinus)

22 Ideal investigation for fistula-in-ano is:

Ans c (Preserving the anal sphincter)

24 A 10-month-old infant present with acute

intesti-nal obstruction Contrast enema X-ray shows the

intussusception Likely cause is: (March 2009)

a Peyer’s patch hypertrophy

b Mekel’s diverticulum

c Mucosal polyp

d Duplication cyst

Ans: a (Peyer’s patch hypertrophy)

25 After undergoing surgery, for carcinoma of colon,

a 44-year-old patient developed single liver

metas-tasis of 2 cm What do you do next? (Sep 2008)

26 A 50-year-old male, working as a hotel cook, has

four dependent family members He has been

di-agnosed with an early stage squamous cell cancer

of anal canal He has more than 60% chances of

cure The best treatment option is: (Sep 2008)

a Abdominoperineal resection.

b Combined surgery and radiotherapy.

c Combined chemotherapy and radiotherapy.

d Chemotherapy alone.

Ans: c (Nigro regimen—Chemoradiation)

27 The following is ideal for the treatment with

in-jection of sclerosing agents: (Sep 2007)

a External hemorrhoids

b Internal hemorrhoids

c Prolapsed hemorrhoids

d Strangulated hemorrhoids

Ans: b (Internal hemorrhoids)

28 In which of the following locations, carcinoid

a Esophagus

b Stomach

c Small bowel

d Appendix

Ans: c (Small bowel)

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

ul- a They may develop biliary cirrhosis

b May have raised alkaline phosphatase

c Increased risk of cholangiocarcinoma

d PSC reverts after a total colectomy

Ans: d (PSC reverts after a total colectomy)

31 Patients of rectovaginal fistula should be initially

Ans: a (Amebic abscess)

33 Not a complication of Crohn disease: (Sep 2005)

• All the above mentioned complications can occur

Ans: a (Rectal biopsy)

36 Brunners glands are seen in: (Sep 2006)

Ans: a (Increased bleeding)

38 Acute appendicitis is not characterized by:

Ans: a (Crohn disease)

40 Treatment of appendicular abscess are all, except:

43 Which of the following is a dynamic cause of

Dynamic cause means any mechanical cause for ob-• Adynamic or paralytic ileus there is no mechanical cause for obstruction

44 Enteoenteric fistula is seen in: (March 2011)

○ Common hepatic duct: 2.5 cm

○ Common bile duct: 7.5 cm and contains 4 parts

 Primary bile salts (cholate, chenodoxycholate) are synthe-investiGation

oral cholecystogram (Graham-cole test) plain X-ray

• Dye used: Iopanoic acid bp

• Mainly used for nonopaque stones • 10% gallstones are radio opaque• Porcelain GB: Calcified GB (premalignant)

limey bile iv cholangiogram usG

• Related to multiple small gallstones

• Not premalignant • Biligram meglumine ioglyca-mate* • First investigation for GB and bile

duct.

hida scan ct scan

• Tc 99m-labeled iminodiacetic acid

cholecystosis Gallbladder polyp risk of malignancy

○ Chronic inflammatory changes with

black pigment

○ MC in hemolytic states

sis, sickle cell disease

1 Hereditary spherocyto-2 Heart valves (mechanical)

○ Highest mortality*

○ Most commonly missed diagnosis

○ M/c in patients recovering from major surgery and burns, trauma*

types

 Type 1: (11%)—extrinsic compression of CHD by a large stone in Hartmann’s pouch

 Type 2: (41%)—stone has now eroded into the hepatic duct

ence

○ yl-coenzyme A (HMG Co-A) reductase in cholesterol synthesis, thus decrease cholesterol super saturation.

○ CBD stone causing cholangitis  Pain + Jaundice + Rigors ○ Charcots triad + Septic shock + Mental status changes

cholangitis Lab findings

 Best non-invasive gation—MRCP

investi-• Increased serum alkaline phosphatase

• Increased GGT

• Increased bilirubin

• Mild increase in SGOT, SGPT

• Increased WBC count

• Severe increase in SGOT, SGPT

Lap cholecystectomy with CBD explo-• Lap cholecystectomy with ERCP stone removal later

CBD exploration and T tube removal  Unexpected ductal calculi after

cholecystecto-my or routine intraoperative cholangiogram (4% to 10%)

ate postoperative ERCP retrieval

 Laparoscopic cystic duct extraction or immedi-○ Postoperative (OP) cholangiogram—day 7th POD

○ Remove T tube—10 to 14 days

○ Remove T tube on 2 weeks for diabetes and immunocompromised

Missed/retained/residual stones (< 2 years)

if t tube present if t tube absent

• Type 2—diverticulum from CBD

• Type 3 (choledochocele)—dilatation

of biliary tract within duodenum

• Type 4a—multiple dilatation of intra and extrahepatic ducts

• hepatic ducts

Type 4b—multiple dilatation of extra-• Type 5—(Caroli disease)* Multiple dilatation of intrahepatic ducts

Types 1&2: Cyst excision with Roux-o plasty

○ bladder has no bile)—3%

Type 2: obstruction within common hepatic duct (gall-○ Type 3: Obstruction at porta hepatis—90%

contd

eXtrahepatic biliary atresia

clinical features

○ Severe obstructive jaundice during first month of life with pale

acholic stools ○ If undiagnosed or uncorrected leads to cirrhosis in 3 to 6 month

differential diaGnosis of jaundice in infants

jaundice in newborn and infants (in india) pathology

○ Inflammatory destruction of hepatic ducts with paucity of bile ducts

Anastomosis of portal plate that contains micro- Most patients will progress ultimately to liver transplantation

 Kasai procedure actually provides some time for liver donor arrangement

prognosis after Kasai's procedure: after Kasai procedure prognosis depends on

priMary sclerosinG cholanGitis

○ Concentric periductal fibrosis around obliterated ducts (onion skin appearance)

2 Gallstones

ysplasia, hemangioma

UGI scopy—bleed-○ Investigation of choice—angiography.

Jaundice (54%)  poor prog-• Fever

• Vomiting (mechanical obstruction or malignant gastroparesis)

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

contd

contd

○ Portal vein or hepatic artery involved

○ ary biliary radicles

Bilateral involvement of second-○ Extensive duodenal involvement

treatment palliative treatment

○ Limited to mucosa: Simple cholecystectomy

○ Reaching muscle: Extended cholecystectomy

○ Perimuscular connective tissues: Extended cholecystectomy + segment 4b and 5 resection

○ Extended right hepatectomy is done for tumors extending to liver

1 Radiotherapy—role not clear

abine + cisplatin regimen

2 Chemotherapy— gemcit-cancers diagnosed in cholecystectomy specimens

bile duct cancers

risk factors pathology types clinical features

 2/3rd located at hepatic duct bifurcation (Klatskin tumors—tumors at bifurca-tion)

• dice

M/c presentation—painless jaun-• Courvoisier law exemption.

 Non-palpable GB with jaundice:

giocarcinoma at hilar level (e.g

Obstruction due to cholan-Klatskin tumors)

 Hence, palpable gallbladder suggests distal obstruction

○ CBD stone is not a risk factor.

bile duct cancers

Patient may present within days to several months depend-○ Presenting with abdominal pain, distension, cholangitis, sepsis, ileus, jaundice, excessive bile from drain—think of bile duct injury

• MRCP—best to decide therapeutic approach.

Classifications Bismuth classification: (based on location) Strasberg classification (based on patterns

bile duct injuries

Management

 Early repair not attempted Only drainage

procedures carried out  Ideal time of repair is 8 to 12 weeks to allow inflammation to subside** Roux-en-Y hepaticojejunostomy is ideal repair.

emphysematous cholecystitis chronic cholecystitis

○ Acute cholecystitis associated with infection

by gas forming organisms like Clostridium

welchii or perfringens.

○ This condition occurs most frequently in

elderly men and in patients with diabetes

mellitus

○ Can be seen on plain X-ray.

○ The condition is very aggressive, may go for

gangrene and perforation.

○ Emergency cholecystectomy must be done

○ Ongoing inflammation with recurrent episodes of biliary colic or pain from cystic duct obstruction is called chronic cholecystitis

○ About 2/3rd of the patients with gallstones will present with these repeated attacks

○ Primary symptom:

○ Biliary colicky—constant pain that builds in intensity and can radiate

tending for 1 to 5 hours It usually subsides by less than 24, if it persists beyond 24 hours think of acute cholecystitis

to the back, interscapular region or right shoulder Pain is constant ex-○ tectomy

pancreatic function test

Mimics: Acute cholecystitis, myocar-dial infarction, perforated peptic ulcer, pneumonia, etc

○ cus

Duct > 8 mm anasto-○ Frey

procedure: Head cor-ing anastomosis ○ Beger procedure: Duodenum

preserving pancreatic head resection and anastomosis

contd

Signs and symptoms of hypo-• Blood glucose < 2.8 mmol/l

• Relief of symptoms by IV glucose

 Characteristic symptom is weight gain instead of weight loss (only malignan-