tag:blogger.com,1999:blog-4521769584331247852024-03-20T19:24:41.723-07:00Surgicomaniaonly for nerds....fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.comBlogger35125tag:blogger.com,1999:blog-452176958433124785.post-74837505150446677152011-09-30T20:33:00.001-07:002011-09-30T20:33:28.669-07:00Time for a changeDecided to stop posting in Madicine@ and Surgicomania.<br />
Notice that there's not much of HO in East Malaysia who blogs.<br />
Many medical students or potential ones may be curious about life as a HO in Sabah and Sarawak.<br />
<br />
Starting another blog. <a href="http://fusionclk.blogspot.com/">Days of my life....</a><br />
<br />
Thanks for the comments in the clinical cases that I've posted.<br />
Didn't know that there's actually someone out there who knew the existence of this blog.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com7tag:blogger.com,1999:blog-452176958433124785.post-66753080000194568932010-08-23T09:13:00.000-07:002010-08-23T09:13:00.007-07:00Briefly about Pancreatic PseudocystPancreatic pseudocyst is defined as single/multiple fluid collection with high amylase content, surrounded by fibrous or granulation tissue within the lesser sac.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://www.med.illinois.edu/m34/clerkships/surgery/student/other/path/slides/Pancreatic%20pseudocyst%20at%20laparotomy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="261" src="https://www.med.illinois.edu/m34/clerkships/surgery/student/other/path/slides/Pancreatic%20pseudocyst%20at%20laparotomy.jpg" width="400" /></a></div><br />
It usually occurs around 4 weeks after an acute attack of pancreatitis, where patient complains of epigastric fullness, pain, nausea and vomiting.<br />
If it's infected, there may be fever, rigors and sweating.<br />
<br />
However, pseudocyst can be also caused by chronic pancreatitis or any pancreatic trauma.<br />
<br />
<b>Abdominal examination</b><br />
<br />
Firm, <b></b>tender epigastric mass is felt, with indistinct lower edge, and inability to get above the swelling.<br />
It moves slightly with respiration.<br />
Percussion reveals resonant note since the pseudocyst is covered by stomach.<br />
However, it's not possible to demonstrate fluctuation and fluid thrill.<br />
<br />
<b>Investigations</b><br />
<br />
Pancreatic pseudocyst must be differentiated from acute fluid collection and pancreatic abscess.<br />
<b></b>Usually just based on the clinical scenario and USG abdomen (or sometimes CT), one will be able to distinguish these conditions.<br />
<br />
However, one must not forget that a cystic neoplasm may mimic as a chronic pseudocyst.<br />
To differentiate, one needs to perform aspiration of the swelling under EUS guidance (EUS = endoscopic ultrasound).<br />
<br />
Then, sent the aspirate for amylase level, cytology and CEA level.<br />
Typically, if it's a chronic pseudocyst - high amylase level, with leucocytes and CEA < 400 ng/ml.<br />
However, in case of mucinous neoplasm - CEA > 400 ng/ml.<br />
<br />
<b>Complications</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_au5dJPQRwPc/THKcxpzRgDI/AAAAAAAAAcQ/iy-Ys0rfD9o/s1600/Untitled.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://4.bp.blogspot.com/_au5dJPQRwPc/THKcxpzRgDI/AAAAAAAAAcQ/iy-Ys0rfD9o/s400/Untitled.jpg" width="400" /></a></div><br />
<b>Treatment</b><br />
<br />
Treatment consist of drainage of the pseudocyst.<br />
There are 3 approaches towards the drainage :<br />
<br />
1) Percutaneous transgastric cystogastrostomy under imaging guidance, then by placing a double pigtail catheter, one end within the cystic cavity, another within the gastric lumen for drainage.<br />
Chance of recurrence : not more than 15 % <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.hopkins-gi.org/Upload/200802291654_10407_000.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="http://www.hopkins-gi.org/Upload/200802291654_10407_000.jpg" width="400" /></a></div><br />
2) Endoscopic method under EUS guidance : By puncturing the wall of stomach/duodenum to gain access into the pseudocyst cavity, then insertion of a drainage tube one end within the cystic cavity, another within the gastric lumen for drainage.<br />
<br />
3) Surgical method by internal drainage into gastric/jejunal lumen. Rate of recurrence is not more than 5%.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com3tag:blogger.com,1999:blog-452176958433124785.post-84875674997217747742010-07-21T09:07:00.000-07:002010-07-21T09:07:16.974-07:00Colonic diverticular disease<b>Introduction</b><br />
<br />
Colonic diverticular disease is very common in developed nations, which is related to their diet containing low dietary fibers.<br />
<b></b>It is estimated that in developed countries, there are about 60% of the population aged > 70 years old are affected by diverticular disease. But this condition is rare before 35 years old.<br />
Incidence is more common among females.<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/15808.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/15808.jpg" width="400" /></a></div><br />
Though the entire colon may be affected, but the commonest site is the sigmoid colon, probably after intake of low residual diet, the intramural pressure over sigmoid colon is the highest.<br />
<br />
Pulsion of diverticulae emerged in between the mesenteric and anti-mesenteric taenia, through the circular muscles, at points where the blood vessels penetrates through it.<br />
<br />
Hence, diverticular disease will never occur in the rectum.<br />
This is due to it's different arrangement of blood vessel, and it's longitudinal smooth muscle covers the entire circumference of the rectum.<br />
<br />
Sometimes, a caecal diverticula may be obstructed by a faecolith or by inflammatory processes.<br />
Hence resulting in acute appendicitis (mimics simple acute appendicitis)<br />
<br />
<b>Clinical features</b><br />
<br />
Colonic diverticular disease are mostly asymptommatic.<br />
Most of the cases are detected during investigation of other GI diseases, where diverticular disease are found incidentally.<br />
<br />
Occasionally, patient may present with intermittent lower abdominal/LIF pain and tenderness.<br />
Other symptoms include minor rectal bleeding, defecation urgency, altered bowel habits, etc.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.health.com/health/static/hw/media/medical/hw/h9991106.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.health.com/health/static/hw/media/medical/hw/h9991106.jpg" width="393" /></a></div><br />
Barium enema shows intestinal smooth muscular hypertrophy with multiple diverticula.<br />
<br />
<b>Complications</b><br />
<br />
<b>1) Perforation</b><br />
<b> </b><br />
Purulent peritonitis<br />
Fecal peritonitis<br />
<br />
<b>2) Inflammation</b> <br />
<br />
Pericolic abscess<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.uphs.upenn.edu/surgery/graphics/images/diverticulitis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="372" src="http://www.uphs.upenn.edu/surgery/graphics/images/diverticulitis.jpg" width="400" /></a></div><br />
Peridiverticulitis<br />
<br />
<b>3) Fistula formation</b><br />
<br />
Colovaginal<br />
<b> </b>Colovesical<br />
Colocolonic<br />
Colocutaneous<br />
<br />
<b>4) Intestinal obstruction</b><br />
<br />
Colonic fibrous fistula<br />
<b> </b>Inflammatory mass, fistula<br />
Adherent loops of small bowel<br />
<br />
<b>5) Bleeding</b><br />
<br />
Chronic intermittent bleeding<br />
<b> </b>Massive lower GI bleeding<br />
<br />
<b>Acute diverticulitis</b><br />
<br />
<b>1) History</b><br />
<br />
Initially, patient may complains of intermittent lower abdominal pain.<br />
Later, the pain is shifted to the left iliac fossa, which gradually becomes more constant, dull aching in nature.<br />
If there's intestinal obstruction, the pain can be colicky in nature as well.<br />
<br />
Often, there is lost of appetite, and nausea (rarely vomiting).<br />
If the colonic vault is close to the bladder, it is not uncommon for the patient to have bladder symptoms (frequency, dysuria)<br />
<br />
<b>2) On examination</b><br />
<br />
Patient appears in obvious distress, with fever and tachycardia.<br />
Over the left iliac fossa, there is significant tenderness and guarding.<br />
Occasionally, a tender, sausage-shaped mass may be palpable over the left iliac fossa.<br />
<br />
Reverse Rovsing's sign is +ve : RIF is pressed, and pain is felt over LIF.<br />
If there's intestinal obstruction or generalised peritonitis, abdomen is distended, with rebound tenderness, while on auscultation, bowel sounds is hyperactive (obstruction), or reduced (paralytic ileus - peritonitis).<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://radiology.healthcommunities.com/rad/Images/75_27_70008_01.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://radiology.healthcommunities.com/rad/Images/75_27_70008_01.jpg" width="400" /></a></div><br />
Acute diverticulitis can be confirmed by Barium enema.<br />
However, it is better to have it done 4-6 weeks later after infection has subsided.<br />
<br />
<b>Management</b><br />
<br />
Nil by mouth<br />
Bed rest<br />
IV fluids<br />
Antibiotics (Cephalosporins, Metronidazole)<br />
<br />
If doesn't resolve, suspect pericolic abscess formation.<br />
May requires incision and drainage of abscess, surgical resection, peritoneal toilet.<b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-77629503339331305142010-05-07T05:15:00.000-07:002010-05-08T02:35:36.079-07:00Acute Pancreatitis and CA pancreas<b>Introduction</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.aafp.org/afp/20000701/164_f1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="327" src="http://www.aafp.org/afp/20000701/164_f1.jpg" width="400" /></a></div><br />
Defined as activation of the pancreatic enzyme resulting in autolysis of the gland.<b><br />
</b><br />
It is important to investigate for the possible causes of Acute pancreatitis before labeling it as 'idiopathic'.<br />
Possible aetiology of Acute pancreatitis :<br />
<br />
Gall stones<br />
Alcoholism<br />
Post ERCP<br />
Abdominal trauma<br />
Complication of cardiothoracic, biliary and abdominal surgery<br />
Hypercalcemia<br />
Hyperparathyroidism<br />
Pancreatic Divisum<br />
Autoimmune pancreatitis<br />
Scorpion bite<br />
Drugs : Corticosteroids, Azathioprine, Thiazide diuretics<br />
Mumps, Cocksakie viral infection<br />
Idiopathic<br />
<br />
<b>History</b><br />
<br />
Both males and females are equally affected.<br />
<b></b>Age of onset is around 4th - 5th decade of life.<br />
History of any gall stone diseases, or alcoholism is important (2 most important cause)<br />
Though rare, but ask for recent contact with children with mumps or cocksakie infection.<br />
<br />
Symptoms are usually triggered after consumption of large meal or alcohol.<br />
Patient usually complains of sudden onset of severe, continuous epigastric pain, which typically radiates to the back, relieved by bending forwards.<br />
It's accompanied by excessive vomiting and retching, with persistent nausea in between.<br />
Breathing and movements exacerbates the pain.<br />
<br />
<b>General examination</b><br />
<br />
Patient appears ill, with shallow breathing.<br />
<b> </b>If the patient looks pale, diaphoretic, it is likely that it has complicated as a hypovolemic shock.<br />
There might be mildly tinged jaundice if the pancreatitis is caused by gall stones.<br />
Even 2-3 days after the illness, the mild tinged jaundice can be caused by compression of biliary duct by edematous head of pancreas.<br />
Shock features of tachycardia, hypotension.<br />
Low grade fever may or may not present.<br />
<br />
<b>Abdominal examination</b><br />
<br />
In acute pancreatitis, the complains of the patient may indicate severe pain, but there is usually minimal findings<b> </b><br />
during abdominal examination.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-776871-863.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-776871-863.jpg" width="400" /></a></div> <b>Cullen's sign</b> <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://upload.wikimedia.org/wikipedia/commons/5/5d/Hemorrhagic_pancreatitis_-_Grey_Turner%27s_sign.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="208" src="http://upload.wikimedia.org/wikipedia/commons/5/5d/Hemorrhagic_pancreatitis_-_Grey_Turner%27s_sign.jpg" width="400" /></a></div> <b>Grey Turner's sign</b><br />
<br />
On inspection, if there's haemorrhagic pancreatits, there might be bruising (bluish purplish) discolouration over around the umbilicus (Cullen's sign) or left flank (Grey Turner's sign).<br />
However, these signs are rarely seen nowadays.<br />
<br />
The abdomen may not rise and fall with respiration, since the musculature is tightly contracted, and during onset of paralytic ileus.<br />
<br />
Often there is accumulation of inflammatory exudates within the lesser sac, which eventually forms pseudocyst, suggested by epigastric fullness (distension), dullness during percussion over it.<br />
<br />
Shifting dullness may be present, bowel sound may be reduced if there is pancreatic ascites.<br />
<br />
<b>Invesitgations</b><br />
<br />
Acute pancreatitis is usually diagnosed by typical clinical presentation and laboratory investigation that reveals elevated serum amylase level. Serum amylase of 3-4 times greater than the normal level is suggestive of pancreatitis.<br />
<b> </b>However, if serum lipase assay is available, it is more sensitive and specific.<br />
Note that normal serum amylase level doesn't rule out Acute pancreatitis, and the level poorly correlates with the severity.<br />
<br />
Both Ranson's and Glasgow's criteria is used to grade the severity of Acute pancreatitis.<br />
If 3 or more factors are present in the patient, it indicates severe pancreatitis.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_au5dJPQRwPc/S-P-kGK92qI/AAAAAAAAAaU/gTD-6jwxevk/s1600/kl.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="301" src="http://3.bp.blogspot.com/_au5dJPQRwPc/S-P-kGK92qI/AAAAAAAAAaU/gTD-6jwxevk/s400/kl.jpg" width="400" /></a></div><b>Imaging studies</b><br />
<b> </b><br />
Chest X ray, and plain abdominal X ray is not very helpful in the diagnosis of Acute pancreatitis<br />
During early stages, if abdominal X ray is taken, non-specific signs such as Sentinel loop, Renal Halo sign or Colon cut off sign may be present.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_ywqDbJp_e98/SBrimhNYwhI/AAAAAAAAAJ8/y7hz4kmzRqU/s1600/DSC00041.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/_ywqDbJp_e98/SBrimhNYwhI/AAAAAAAAAJ8/y7hz4kmzRqU/s320/DSC00041.JPG" width="240" /></a></div> <b>Sentinel loop</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_fBQVVpFhTQs/SQXYzQSTs9I/AAAAAAAAAVQ/HWdj2ZKqA04/s1600/colon+cutoff-xr.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/_fBQVVpFhTQs/SQXYzQSTs9I/AAAAAAAAAVQ/HWdj2ZKqA04/s320/colon+cutoff-xr.jpg" /></a></div> <b>Colon cut-off sign</b><br />
<br />
Chest X ray may reveal pleural effusion, or if there is diffuse alveolar infiltrates, indicates ARDS.<br />
<br />
Though Abdominal USG is non-diagnostic for Acute pancreatitis, but it must be done within 24 hours of presentation.<br />
This is to rule out Acute cholecystitis as a differential diagnosis, to check whether the bile duct is dilated and to reveal any stones within the CBD (gall stone as a cause of Pancreatitis)<br />
<br />
CT abdomen is not indicated in every patient.<br />
Only when :<br />
<br />
1) Diagnostic uncertainty<br />
2) Severe pancreatitis<br />
3) Clinical deterioration, with multi-organ failure, sepsis<br />
4) Local complications occurs<br />
<br />
<b>Complications</b> <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/_au5dJPQRwPc/S-QCAADeuuI/AAAAAAAAAac/uH6aGUr--CU/s1600/Untitled.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="206" src="http://1.bp.blogspot.com/_au5dJPQRwPc/S-QCAADeuuI/AAAAAAAAAac/uH6aGUr--CU/s400/Untitled.jpg" width="400" /></a></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://www.med.illinois.edu/m34/clerkships/surgery/student/other/path/slides/Pancreatic%20pseudocyst%20at%20laparotomy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="209" src="https://www.med.illinois.edu/m34/clerkships/surgery/student/other/path/slides/Pancreatic%20pseudocyst%20at%20laparotomy.jpg" width="320" /></a></div><b> Pancreatic pseudocyst</b><br />
<br />
<b>Management</b><br />
<br />
<b>a) Conservative</b><br />
<b> </b><b> </b><br />
1) Gain IV access and rapid fluid resuscitation.<br />
<b> </b>2) Give analgesics (usually IM pethidine is given)<br />
3) Nil by mouth<br />
4) Insertion of NG tube to relieve vomiting<br />
5) Enteral feeding - nasojejunal tube (to maintain adequate nutrition)<br />
6) Urinary catheterization is done<br />
7) Monitor pulse, BP, urine output and CVP<br />
8) Give antibiotics to prevent secondary infection<br />
<br />
<b>b) Endoscopic </b><br />
<br />
If gall stone is strongly suspected as the cause of pancreatitis, the stones should be removed by basket (dormia) through endoscopic sphincterotomy.<br />
If there is severe pancreatitis, or cholangitis occurs, both sphinterotomy and ERCP is done.<br />
<br />
<b>c) Surgery</b><br />
<br />
Only indicated if : clinical deterioration during conservative management, unsure diagnosis, local complication occurs.<b> </b><br />
<br />
<b>Adenocarcinoma of Pancreas</b><br />
<br />
More common in males.<br />
Age of presentation - 55-75 years old<br />
85% of CA pancreas involves the head of pancreas, where the prognosis is usually poor.<br />
Patients usually dies within 1 year of diagnosis (5 year survival is exceptional)<br />
Upon presentation, most have progressed to a surgically incurable stage.<br />
Though uncommon, but tumour arising from the distal CBD, duodenum and ampulla has a better outlook.<br />
Currently, the risk factor of developing CA pancreas is thought to be :<br />
<br />
Cigarette smoking<br />
High fat and protein diet<br />
<br />
<b>Clinical features</b><br />
<br />
Any elderly patient presents with painless jaundice, always suspect the possibility of Pancreatic cancer.<br />
<b> </b>Typical symptoms are usually : Abdominal pain, jaundice and weight loss.<br />
<br />
Jaundice is usually obstructive in nature, suggested by the classical triad of pruritus, clay-coloured stool and tea-coloured urine.<br />
There might be steatorrhoea.<br />
Abdominal pain - constant, dull aching, discomfort, over the epigastric region<br />
Sought for symptoms of metastases<br />
<br />
On examination, the gall bladder may be palpable, as accordance to the Curviosier's law, which states that,<br />
<br />
<i>"For patients presenting with clinically evident jaundice, and on examination the gall bladder is palpable, the cause is more likely to be due to Carcinoma of the Head of Pancreas"</i>.<br />
<br />
Look for scleral icterus, hepatomegaly, etc.<br />
<br />
<b>Investigations</b><br />
<br />
If stool occult blood test is positive, suggestive of a ampullary tumour.<br />
<b> </b>Abdominal USG - usually done to look for liver metastases, or any mass lesion over the pancreas, and dilated bile ducts<br />
CT abdomen - extent of metastases<br />
To confirm the nature of obstruction, MRCP is preferred over ERCP since the former is less invasive.<br />
<br />
<b>Surgery of choice : Whipple's procedure</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.aafp.org/afp/2007/1201/afp20071201p1679-f3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="385" src="http://www.aafp.org/afp/2007/1201/afp20071201p1679-f3.jpg" width="400" /></a></div>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com7tag:blogger.com,1999:blog-452176958433124785.post-6613583861848565452010-05-06T09:25:00.000-07:002010-05-06T09:38:38.041-07:00Peptic ulcer disease and Gastric CarcinomaBoth duodenal ulcers and benign gastric ulcers are believed to be related to mucosal infection by H.pylori.<br />
Peptic ulcer disease are mainly classified as complicated and uncomplicated.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.resourcing.uk.com/media/6839/peptic_ulcer.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="257" src="http://www.resourcing.uk.com/media/6839/peptic_ulcer.jpg" width="400" /></a></div><br />
<b>Benign gastric ulcer/duodenal ulcer</b><br />
<br />
Age of presentation ranges from 20-60 years old, which is of course, more common among young adults.<br />
Incidence is higher in males. <br />
<br />
Most patients during acute presentation will present with epigastric discomfort or pain.<br />
<b> </b>The intensity ranges from mild dyspepsia (related to food intake, sensation of indigestion), to severe epigastric pain, which often forces the patient to lie down still.<br />
<br />
However, as the course of illness goes chronic, pain is rarely severe.<br />
A characteristic feature is night pain, which is a dull, boring ache often wakes patients from sleep.<br />
This is due to the increased gastric acidity at night, and there is lack of food to buffer against it.<br />
The pain either radiates to the back, or towards the RHC (depends on the position of the ulcer : posterior part of stomach, duodenum) <br />
<br />
Patient may complain of heart burn, excessive salivation (water/acid brash) related to food intake.<br />
In duodenal ulcer, food intake relieves the symptoms. Hence, patient rarely losses appetite.<br />
In gastric ulcer, food intake aggravates the pain and often patient is apprehensive towards food.<br />
Hence, history of appetite and weight loss is more common in them.<br />
Vomiting relieves the pain in gastric ulcer. <br />
<br />
The symptoms exhibit another characteristic, which is periodicity.<br />
As the symptoms persisted for a few weeks, then it may be followed by a period of remission for weeks to months, only to recur after that.<br />
<br />
Hemetemesis and malena must be asked in the history as well.<br />
<br />
History of drug intake is important, eg : NSAIDs, steroids, salicylates<br />
Other risk factors : Period of stress, cigarette smoking<br />
<br />
Often, in examination, apart from abdominal tenderness (guarding if severe), and pallor if there's chronic silent bleeding, there is usually no other significant findings in examination.<br />
<br />
<b>Investigation</b><br />
<br />
Full blood count and iron studies may reveals iron deficiency anemia<b>.</b><br />
<b> </b>Other blood investigations - hypokalemia, increased hematocrit as a result of vomiting.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_D-D6QiTlKiw/SwuzuHbBe5I/AAAAAAAACQc/H1blcNPUrjc/s1600/OGDS.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/_D-D6QiTlKiw/SwuzuHbBe5I/AAAAAAAACQc/H1blcNPUrjc/s320/OGDS.gif" width="209" /></a></div><br />
The choice of imaging in peptic ulcer disease is oesophago-gastroduodenoscopy (OGDS).<br />
Not only it allows visualization of the lesion, it allows mucosal specimens to be biopsied.<br />
Usually biopsy is taken from the gastric antrum, and the specimen is subjected to CLO test.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.marvistavet.com/assets/images/CLO_test.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="68" src="http://www.marvistavet.com/assets/images/CLO_test.gif" width="400" /></a></div><br />
CLO test consists of inoculating the specimen into a medium containing urea.<br />
Hence, if the specimen contains H.pylori, which produces urease.<br />
The enzyme reacts with urea, and produces ammonia, which changes the medium from yellow to pink/red colour.<br />
That confirms the positive status of H.pylori in the patient.<br />
<br />
<b>Management</b><br />
<br />
Due to the finding of Peptic ulcer disease is related to H.pylori infection, the management of uncomplicated peptic ulcer disease is mainly medical.<br />
<b> </b>First of all, avoid smoking, alcohol, and NSAIDs.<br />
<br />
However, if the patient requires long courses of NSAIDs, and his/her H.pylori status is -ve, a least damaging agent should be used, such as ibuprofen.<br />
<br />
Anti-secretory agents such as proton pump inhibitors, H2 blockers are used.<br />
To supplement these agents, drugs like sucralfate, bismuth compounds, prostaglandin analogues are used.<br />
<br />
<b>Eradication of H.pylori</b><br />
<br />
Regardless whether it's a duodenal ulcer/gastric ulcer, once the patient is H.pylori positive, eradication regime of H.pylori is employed.<br />
Usually consist of 1 proton pump inhibitor and 1 or more antibiotics.<br />
In case of duodenal ulcer, if the patient is compliant to the medication, the success rate of remission is about 90%.<br />
Without the eradication regime, the chances of relapse within 1 year is about 80%.<br />
Any persistence of symptoms, a urea breath test (non-invasive) should be done to reassess the H.pylori status in the patient.<br />
However, it must be done 4 weeks after completion of the eradication regime.<br />
Or else, the therapy merely suppresses the bacteria, and may lead to a false negative test result.<br />
<br />
However, in gastric ulcer, biopsy need to be taken before making a diagnosis of benign gastric ulcer.<br />
Then if found benign, eradication therapy is given to all patients with +ve status of H.pylori.<br />
Surveillance of the lesion need to be done until the ulcer heals.<br />
Any persistence of symptoms, further biopsy must be taken.<br />
<br />
<b>Perforated peptic ulcer</b><br />
<br />
Occasionally, the gastric juices erodes through the gastric/duodenal<b> </b>wall to the extent that only covering left is the visceral peritoneum. The gastric juices collects within the peritoneal cavity, leading to chemical peritonitis.<br />
Eventually, there'll be secondary bacterial infection, leading to spontaneous bacterial peritonitis.<br />
<br />
<b>History</b><br />
<br />
Age of presentation : Usually 40-60 years old<b> </b><br />
History of drug intake : NSAIDs, Steroids, Salicylates<br />
Symptoms :<br />
<br />
Sudden onset of severe, continuous abdominal pain which initially confines to the epigastrium.<br />
It rapidly increases in it's intensity, and eventually the pain becomes generalized.<br />
Breathing, movements aggravates the abdominal pain.<br />
<br />
Also ask for previous peptic ulcer disease, or history of dyspepsia. <br />
<br />
<b>General Examination :</b><br />
<br />
Patient usually lies still on bed, breaths shallowly, and is in a state of distress.<br />
Temperature is usually normal, there might be tachycardia.<br />
<br />
<b>On abdominal examination :</b><br />
<br />
On inspection, the abdomen doesn't rise and fall with respiration.<br />
This is due to the tight contraction of the abdominal musculature.<br />
<br />
On palpation, abdominal tenderness and guarding initially confines towards the epigastrium.<br />
Later, if the peritonitis becomes generalized, the entire abdomen is tender, and there is intense guarding.<br />
This results in the abdomen being described of having board-like rigidity.<br />
It is impossible to palpate for the abdominal viscus since the muscles are tightly contracted.<br />
<br />
On percussion, there may be obliteration/diminished liver dullness (due to the air escaped from the perforated viscus into the peritoneal cavity.<br />
Shifting dullness may be +ve.<br />
<br />
On auscultation, bowel sound may be reduced, which indicates generalised peritonitis.<br />
<br />
<b>Note : </b>4-6 hours later, due to the dilution of the accumulated gastric juices within the peritoneal cavity, the patient's symptoms and signs subsides, and the patient actually thought that his/her condition is improving. This is mainly due to the onset of hypovolemic shock, which may be indicated by the presence of increasing abdominal distension, tachycardia, signs of dehydration and etc.<br />
<br />
<b>Investigation</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.medicine.cu.edu.eg/english/students/study/x_ray_surgery/xray/osophagus_stomach/164_pneumoperitoneum.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.medicine.cu.edu.eg/english/students/study/x_ray_surgery/xray/osophagus_stomach/164_pneumoperitoneum.jpg" width="342" /></a></div><br />
In 60% of the patients, the CXR reveals air-filled under the diagphram.<br />
However, absent of this finding does not exclude perforation.<br />
Lateral Chest X-ray may be useful in case an erect CXR is not feasible (patient may be in the state of shock, disability)<br />
In laboratory investigation, there is usually some degree of elevated serum amylase level.<br />
However, 3-4 folds elevated serum amylase level is more suggestive of pancreatitis.<br />
<br />
<b>Management</b><br />
<br />
1) Give fluid resuscitation<b> </b><br />
2) Analgesic for relief of pain<br />
3) IV unasyn and flagyl<br />
4) Anti-emetics are given<br />
5) Insertion of NG tube, and catheterize the patient (monitoring of urine output)<br />
<br />
Only after the patient is stable, surgical intervention is done.<br />
In case of a perforated duodenal ulcer, usually simple closure is performed by using an omental patch.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://i306.photobucket.com/albums/nn261/ayutiyus/omentalpatchrepair.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://i306.photobucket.com/albums/nn261/ayutiyus/omentalpatchrepair.jpg" width="400" /></a></div><br />
However, if it's a perforated gastric ulcer, a biopsy need to be taken first (to rule out malignancy)<br />
Then, close the perforation by either simple closure or local excision.<br />
During post-op period, IV gastric anti-secretory agent is given.<br />
<br />
<b>Pyloric stenosis</b><br />
<br />
First of all, lets take a look at some causes of gastric outlet obstruction :<br />
<br />
Peptic ulcer disease<br />
Malignancy (Stomach, pancreas and lymphoma) <br />
Crohn's disease of duodenum <br />
Inflammation of surrounding structures<br />
<b> </b>Gastroparesis (autonomic neuropathy)<br />
Adult hypertrophic pyloric stenosis<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/__aynJuNxKuk/SpyEN95Yy-I/AAAAAAAAAFI/6d8MUkwjBdI/s1600/img_main.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://2.bp.blogspot.com/__aynJuNxKuk/SpyEN95Yy-I/AAAAAAAAAFI/6d8MUkwjBdI/s400/img_main.gif" width="382" /></a></div>Patients with long standing peptic ulcer disease may develop pyloric stenosis due to healing of the ulcer via fibrosis at the level of the antrum.<br />
Usually, the complaints are :<br />
<br />
Early satiety<br />
Sensation of fullness, constant epigastric discomfort/pain<br />
History of weight loss <br />
Projectile vomiting is classical, which consists of non-bilious, undigested food particles.<br />
It usually occurs when the patient is lying down, and following the vomiting, it relieves the sensation of fullness.<br />
<br />
On examination, the usual findings includes :<br />
<br />
On inspection - epigastric distension, visible peristalsis<br />
On palpation - succussion splash ('splashing' sound heard while the abdomen is shaked right-left-right)<br />
<br />
Investigation of choice is by OGDS, to determine the nature of obstruction (notice that the symptoms mimics malignancy)<br />
<br />
Note that not all patients requires surgical intervention.<br />
A course of PPI can be given first, in hope that when the ulcer heals, the stenosis is resolved.<br />
However, if not reponsive, surgical options includes :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://catalog.nucleusinc.com/imagescooked/11627W.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://catalog.nucleusinc.com/imagescooked/11627W.jpg" width="300" /></a></div><br />
Pyloroplasty or Gastrojejunostomy<br />
<br />
<b>Gastric carcinoma</b><br />
<br />
One of the most common cause of death in men.<br />
<b> </b>Pernicious anemia, gastric polyps and chronic gastric ulcers are known pre-malignant conditions.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.pathology.vcu.edu/education/gi/GastricAdenocarcinomaLinitisPlasticType.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="266" src="http://www.pathology.vcu.edu/education/gi/GastricAdenocarcinomaLinitisPlasticType.jpg" width="400" /></a></div><b>Risk factors :</b><br />
<br />
1) Diet<br />
<br />
High intake of salt, nitrosamines (usually present in preservatives)<br />
Gastric CA is more prevalent in countries which malnutrition is a problem.<br />
High intake of vitamin C and E seems to be protective.<br />
<br />
2) History of surgery : Gastroenterostomy<br />
3) Type A blood group<br />
4) Atrophic gastritis secondary to Pernicious anemia<br />
5) Chronic gastric ulcer<br />
6) Gastric polyps<br />
<br />
<b>History</b><br />
<br />
<b> </b>Age of onset : around 50-70 years of age<br />
Male predominance<br />
Any individual above 45 years of age, presenting with symptoms of dyspepsia, no matter how vague is it, should be investigated.<br />
The epigastric discomfort may not be always associated with food intake.<br />
Patient with long standing history of peptic ulcer disease may notice the change in the character of pain.<br />
Usually it's the periodicity of pain becoming more constant.<br />
There's usually complains of early satiety as well.<br />
<br />
Another prominent symptom of Gastric CA is significant loss in appetite, which results in loss of weight.<br />
Patient can lose around 10-20 kg of weight within 1-2 months.<br />
<br />
If the tumour is present at the region of gastric cardia, patient may report of progressively worsening dysphagia, and eventually it may be worse enough to cause regurgitation of food contents.<br />
<br />
If the tumour is present over the gastric outlet, there may be symptoms of gastric outlet obstruction.<br />
<br />
Next is to sought the history of the risk factors mentioned above.<br />
And please elicit history suggestive of metastases to the lung, liver, bones, and brain.<br />
<br />
<b>Examination</b><br />
<br />
On general examination, the significant findings includes pallor, cachexia and probably jaundice.<br />
Severe wasting is most noticeable over the hands and face.<br />
Presence of jaundice (usually scleral icterus) indicates liver metastases.<br />
Please look for evidence of an enlarged Virchow's node (left supraclavicular node) <br />
<br />
On abdominal examination :<br />
<br />
Inspection : abdomen is usually scaphoid, due to the severe wasting. Paradoxically, the abdomen may be distended due to malignant ascites.<br />
<br />
Palpation : usually reveals deep tenderness over the epigastric region. In thin patients, deep palpation on full inspiration sometimes reveals a hard, irregular mass. Liver may be palpable, which is hard in consistency, knobbly in surface, non-tender.<br />
<br />
Percussion : shifting dullness is +ve if there is malignant ascites<br />
<br />
On systemic examination : evidence of metastases (pleural effusion, bony tenderness)fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-49068769592235879462010-05-05T10:02:00.000-07:002010-05-05T10:02:02.153-07:00Gall Stones<b>Pathophysiology</b><br />
<div class="separator" style="clear: both; text-align: center;"><b> </b><a href="http://www.pyroenergen.com/articles08/images/gallstones2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.pyroenergen.com/articles08/images/gallstones2.jpg" width="343" /></a></div><br />
Mostly cholesterol stones (80%), pigment stones or mixed stones.<br />
Whether cholesterol remains as solution within bile depends on it's concentration, and the levels of phospholipids and bile acids within.<br />
If the bile is supersaturated by cholesterol, and/or levels of phospholipids and bile acids is low, this promotes formation of cholesterol crystals.<br />
These cholesterol crystals are toxic towards the gall bladder musculature, and hence damages it.<br />
This results in gall bladder hypomotility, and enhances the nucleation of theses gall bladder crystals.<br />
Eventually, gall stones are formed.<br />
<br />
As for pigment stones, there are 2 types, namely black and brown stones.<br />
Black stones are sterile stones, usually caused by extensive hemolysis leading to unconjugated hyperbilirubinemia. Eg, seen in Hereditary Spherocytosis, Sickle-cell disease.<br />
Whilst brown stones are non-sterile stones, mainly caused by infection.<br />
Eg, certain bacteria (E.coli) produces B-glucoronidase, which converts conjugated bilirubin back to unconjugated bilirubin.<br />
Also associated with parasitic worm infestation, eg : Ascariasis, Clonorchis sinensis<br />
<br />
<b>Complications</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.netterimages.com/images/vpv/000/000/030/30567-0550x0475.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.netterimages.com/images/vpv/000/000/030/30567-0550x0475.jpg" width="345" /></a></div><br />
<b>1) Gall bladder</b><br />
<br />
Biliary colic<br />
Acute cholecystitis<br />
Chronic cholecystitis<br />
Empyema<br />
Mucocele<br />
Perforation<br />
<br />
<b>2) Biliary tract</b><br />
<br />
Biliary tract obstruction<br />
Acute pancreatitis<br />
Ascending cholangitis<br />
<br />
<b>3) Intestine </b><br />
<br />
Gall stone ileus<br />
<br />
<b>Acute cholecystitis</b><br />
<br />
Usually caused by obstruction of cystic duct by gall stones, leading to gall bladder distension, chemical inflammation, and eventual bacterial infection.<br />
<b> </b><br />
<b>History</b><br />
<br />
Age : Typically 30-60 years old. Presentation in younger patients, may be due to Congenital hemolytic anemia<br />
Gender : Females are more commonly affected<br />
Symptoms :<br />
<br />
Fever<br />
Sudden onset of severe, continuous RHC pain<br />
Radiates to the back (close to the inferior angle of right scapula) <br />
Associated with nausea and vomiting<br />
Duration of pain usually exceeds 3-6 hours<br />
Pain aggravated by movements and breathing<br />
May have previous h/o of flatulent dyspepsia or biliary colic<br />
<br />
On general examination :<br />
<br />
Patient appears ill<br />
Lying still on bed, breathing shallowly <br />
Tachycardia +ve, Pyrexia +ve <br />
During initial stages of inflammation - RHC fullness (known as Zackary-cope's sign)<br />
RHC tenderness, guarding/rigidity, +ve Murphy's sign<br />
Before the onset of guarding, during the early stages the gall bladder may be palpable<br />
If the inflammation persisted for a few days, with subsequent subside of symptoms, an inflammatory mass may be palpable (empyema)<br />
Boas Sign +ve<br />
<br />
<b>Biliary colic</b><br />
<br />
Before proceeding to investigations of Acute cholecystitis, briefly about biliary colic.<br />
It's actually a misnomer, caused by spasm of gall bladder musculature, trying to force the stone down the cystic duct. <br />
Since it's a visceral pain, pain is usually felt over the epigastrium (foregut)<br />
The pain is typically aggravated by intake of oily food.<br />
Since after ingesting oily food, as it passes through the 2nd part of duodenum, it stimulates the production of cholecystikinin from the duodenal mucosa.<br />
It causes contraction of the gall bladder musculature over the stones, hence causing pain.<br />
Duration of pain typically lasted < 3 hours.<br />
However, in practice, patient usually localizes their pain poorly (c/c usually diffuse upper abdominal pain)<br />
It's a pseudocolic, since there's no complete relief of pain in between periods of excruciating exacerbations.<br />
There might be nausea and vomiting.<br />
On examination, there may be tachycardia, but fever is absent.<br />
On abdominal examination, other than tenderness, guarding, usually there's no other signs.<br />
<br />
Hence, there's a frequent overlap in between the clinical features of biliary colic and acute cholecystitis.<br />
Here the table showing their difference :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/_au5dJPQRwPc/S-GbaAmNKlI/AAAAAAAAAaM/4EmPuyzDMsk/s1600/Untitled.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="92" src="http://1.bp.blogspot.com/_au5dJPQRwPc/S-GbaAmNKlI/AAAAAAAAAaM/4EmPuyzDMsk/s400/Untitled.jpg" width="400" /></a></div><b>Investigations</b><br />
<br />
Full blood count - reveals leucocytosis<br />
Abdominal X ray - not useful, only 10-15% of the calculus is visible through plain abdominal X ray<br />
USG abdomen - visualisation of gall bladder wall, contents, biliary tree<br />
<br />
<b>Management</b><br />
<br />
As for asymptommatic gall stones, which is usually detected incidentally, the best option is to observe (no further intervention)<br />
However, prophylactic cholecystectomy will be indicated in :<br />
<br />
a) Non-functioning gall bladder<br />
b) Gall bladder with calcified/thickened wall<br />
c) Diabetic patients (prevent Emphysematous Cholecystitis)<br />
d) Multiple small stones (risk of stones rolling into CBD)<br />
e) Congenital hemolytic anemia<br />
<br />
During acute presentation, > 90% of the cases, symptoms subsides with conservative management :<br />
<br />
1) Nil by mouth<br />
2) Administration of analgesics<br />
3) Administration of antibiotics (Unasyn + Flagyl)<br />
4) Gain IV access, give IV fluids <br />
5) Monitoring of vital signs<br />
6) If symptoms subsided, initially oral fluid intake is allowed, then followed by fat-free diet, and lastly regular diet<br />
7) USG - to evaluate whether there's any local complications<br />
8) Plan for cholecystectomy<br />
<br />
<b>Pre-operative investigations</b><br />
<br />
1) Informed consent<br />
2) Full blood count<br />
3) BUSE/Creatinine<br />
4) Liver function test<br />
5) ECG, Chest X ray (if medically indicated)<br />
6) Antibiotic prophylaxis<br />
7) DVT prophylaxis<br />
<br />
Cholecystectomy can be done via laproscopic approach or laparotomy.<br />
<br />
<b>Gall stone ileus</b><br />
<br />
Small bowel obstruction caused by gall stone impaction at the distal ileum<br />
Usually seen in females, age > 60 years old<b>, </b>with h/o of recurrent cholecystitis<br />
Erosion of the stones through the duodenum, eventually forming a fistula with the distal ileum<br />
Presentation is similar to any other small bowel obstruction<br />
Plain abdominal X ray reveals multiple air-fluid levels, and there might be aerobilia (gas within biliary tree)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.ganfyd.org/images/thumb/f/fa/Aerobilia.jpg/180px-Aerobilia.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="248" src="http://www.ganfyd.org/images/thumb/f/fa/Aerobilia.jpg/180px-Aerobilia.jpg" width="320" /></a></div>Soft stones can be crushed<br />
Hard stones requires enterotomy<br />
<br />
<b>Mirizzi's syndrome</b><br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.rcsed.ac.uk/journal/svol1_5/105020.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.rcsed.ac.uk/journal/svol1_5/105020.gif" width="307" /></a></div>A complication of cholecystitis<b> </b><br />
Gall stone impaction occurs at cystic duct.<br />
There's impingement of the gall stone over the common hepatic duct, which eventually results in formation of a fistula in between the gall bladder and the bile duct.<br />
An exception towards the Curvoisier's law.<br />
<br />
<b>Complications : Post-cholecystectomy</b><br />
<br />
<b>1) Haemorrhage </b><br />
<br />
Usually the source is from cystic artery.<br />
One should suspect possibility of haemorrhage if the patient complains of persistent abdominal pain, or features of hypovolemic shock during post-operative period<br />
<br />
<b>2) Infection</b><br />
<br />
Drastically reduced after administration of prophylactic antibiotics before cholecystectomy.<br />
<b> </b><br />
<b>3) Leakage of bile</b><br />
<br />
Usually due to disrupted ligature, or accidental removal of any accessory ducts.<br />
Patient usually complains of persistent abdominal pain.<br />
If there's no biliary ascites -> ERCP<br />
If there's biliary ascites -> Laparotomy<br />
<br />
<b>4) Post-cholecystectomy syndrome</b><br />
<b>5) Biliary stricture</b><br />
<b> 6) Retained stone</b><br />
<br />
Usually found during T-tube cholangiogram<br />
<b></b>Any procedure done to explore the common bile duct requires insertion of T-tube.<br />
This is to prevent biliary stasis due to formation of stricture.<br />
The opening of bile duct is sutured to the T-tube, which the long limb is brought out through an abdominal stab incision.<br />
Any bile is collected through a bag.<br />
7-10 days later, T-tube cholangiogram is done (iodine as contrast material)<br />
If there's free flow of contrast material into the duodenum, and there's no residual stone -> remove the T-tube<br />
If there's residual stone :<br />
<br />
Stone is small - try using normal saline to irrigate the duct via the T tube (stone eventually migrates to the duodenum)<br />
Stone is large - delayed removal after 4-6 weeks, via radiographically guided removal using dormia basketfusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-29987371486189371132010-01-05T07:10:00.000-08:002010-01-05T07:10:13.816-08:00Intercostal drainage<b>Indications for intercostal drain :</b><br />
<br />
a) Pneumothorax<br />
b) Traumatic haemopneumothorax<br />
c) Malignant pleural effusion<br />
d) Empyema thoracis / Complicated parapneumonic effusion<br />
e) Post-operative drainage : esophagectomy, cardiac surgery, thoracotomy<br />
<br />
<b>Equipments :</b><br />
<br />
Intercostal tube or Chest tube (Size for pneumothorax : 36-40 Fr, hemothorax : 22-24 Fr)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.goharshafa.com/images/product_img/chest_tube_lrg.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="http://www.goharshafa.com/images/product_img/chest_tube_lrg.jpg" width="320" /></a><br />
</div><br />
Connecting tubes and compatible connectors<br />
Underwater seal drainage bottle containing water upto mark <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.saddleback.edu/alfa/N176/images/ChestTubeSystem2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.saddleback.edu/alfa/N176/images/ChestTubeSystem2.jpg" width="235" /></a><br />
</div>Line clamp<br />
11 blade scalpel<br />
Instruments for blunt dissection<br />
Blue and Green needle<br />
2 or 3/0 silk in a large hand-held needle<br />
10ml syringe<br />
20ml of 1% lidocaine<br />
Normal saline<br />
Sterile gloves<br />
Sterile drapes<br />
Sterile gauze<br />
Skin prep. solution<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/7048.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/7048.jpg" width="400" /></a><br />
</div><b>Procedures :</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.cssolutions.biz/Screens/ct_6.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="333" src="http://www.cssolutions.biz/Screens/ct_6.gif" width="447" /></a><br />
</div><br />
1) Explain procedure to the patient if appropriate.<br />
<b> </b>2) Connect the patient to a pulse oxymeter.<br />
3) Prop up the patient to a semi-recumbent position, with the ipsilateral limb abducted.<br />
4) Prepare the skin at the site of tube insertion (antiseptics)<br />
5) Make proper drapping over field of interest.<br />
6) Infiltrate the local anesthetic sufficiently, including the parietal pleura and the periosteum of the rib posterior to the line of incision.<br />
7) Make a transverse, 2cm incison over the 5th intercostal space, over the mid-axillary line (may extend upto the anterior axillary line)<br />
8) Proceed with blunt dissection until the pleura is visible.<br />
9) Now, gently and firmly, by using a blunt-ended clamp, puncture the pleura, and widened the hole created.<br />
10) Place one of your finger into the hole to ensure there's no adhesions.<br />
11) Insert the chest tube <b>without trochar</b> into the puncture hole created after clamping it. Guide the tube superiorly if it's a pneumothorax, and towards the base if it's a hemothorax.<br />
12) Fix the chest tube using the silk sutures.<br />
13) Connect the distal end of the tube to the underwater seal drainage bottle, and remove the clamp.<br />
<br />
<b>Potential complications :</b><br />
<br />
1) Misplacement (intra-parenchymal or subcutaneous)<br />
<b> </b>2) Damaging the surrounding structures : liver, spleen, lungs, heart, aorta, diagphram, etc<br />
3) Surgical emphysema<br />
4) Wound infection, empyema<br />
5) Painfusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-19446621190369973562009-12-30T08:14:00.000-08:002009-12-30T08:14:23.917-08:00Breast Lump<b>Anatomy of Breast</b><br />
<br />
The vertical extent of breast is from 2nd-6th ribs inclusive.<br />
The horizontal extent is from the lateral edge of sternum to the mid-axillary line.<br />
2/3rds of the breast overlies the pectoralis major muscle, whereas 1/3 of it over the serratus anterior.<br />
The lower medial quadrant is lying on the external oblique aponeurosis, which separates it from the rectus abdominis.<br />
The breast tissue is separated from the pectoralis major muscle by the pectoral fascia. It's anchored anteriorly to the skin, posteriorly to the pectoral fascia by the cooper's ligament.<br />
The outer prolongation of the gland into the axilla at the level of 3rd rib, is known as the axillary tail of spence. It enters the axilla by piercing the opening in the axillary fascia, known as the foramen of langer, and if it's enlarged, it can be mistaken as a lipoma.<br />
<br />
The breast tissue is made up of acini, which forms the lobules, and the aggregations of these lobules made up the lobes. Each of these lobes are drained by a collecting duct, and 10-15 of these ducts drains out to the surface of nipple.<br />
<br />
If there's a malignant breast lump, infiltrating the cooper's ligament, it'll lead to dimpling of the skin over breast, due to contraction of the cooper's ligament. If the tumour continues to infiltrate along these cooper's ligament, and now involving the pectoral muscle, it renders it lump non-mobile in a direction parallel to the direction of the pectoral muscle fibers, and mobile in a direction perpendicular to it.<br />
<br />
If a tumour infiltrates into the major milk ducts, a subsequent fibrosis is going to cause the nipple to be drawn inwards, and hence leading to nipple retraction.<br />
<br />
Peu'd orange, an appearance of orange skin of the skin of breast in infiltrative CA breast, is due to the tumour destruction of the cuticle lymphatics, leading to subsequent lymphostasis and edema, and hence the pits of hair follicles appears depressed from the surrounding skin.<br />
<br />
<b>Arterial supply</b><br />
<br />
Lateral thoracic artery (major), a branch of the 2nd part of axillary artery<br />
<b> </b>Perforating cutaneous branch of the interal mammary artery to the 2nd, 3rd, 4th space.<br />
Lateral branches of the 2nd, 3rd, 4th intercostal arteries<br />
<br />
<b>Venous drainage</b><br />
<br />
Intercostal veins, axillary veins and internal mammary veins<br />
<b> </b><br />
<b> Lymphatic drainage</b><br />
<br />
The primary lymphatic drainage of breast is the axillary nodes (around 20-30 of them), followed by the internal mammary nodes. Around 75% of the lymphatics of the breast is handled by the axillary nodes, and the remaining 25%, by the internal mammary nodes.<br />
<b> </b><br />
<b> </b>There are 5 groups of axillary nodes, namely the anterior, posterior, lateral, central and apical. By surgical means, they can be classified based on their position in relation with the pectoralis minor muscle.<br />
Nodes located below the lateral border the pectoralis minor -> Level I (anterior, posterior and lateral)<br />
Nodes located behind the pectoralis minor muscle -> Level II (central)<br />
Nodes located above the medial border of pectoralis minor muscle -> Level III (apical)<br />
<br />
Lymphatics from the lateral quadrant, some from the medial quadrant drains into the anterior nodes (located behind the lower border of pec. major muscle), and the posteior nodes, which then proceeds to the central nodes, and lastly the apical nodes.<br />
<br />
Lymphatics from the right axillary and internal mammary nodes drains into the right subclavian lymphatic duct, whilst lymphatics from the left axillary and internal mammary nodes drains into the thoracic duct, then into the subclavian vein. Both eventually drains into the subclavian vein.<br />
<br />
<b>Common presenting problem of the breast</b><br />
<br />
<b>1) Painless lump</b><br />
<br />
Breast cancer<br />
Fibroadenoma<br />
An area of fibroadenosis<br />
Breast cyst<br />
<br />
<b>2) Painful lump</b><br />
<br />
An area of fibroadenosis<br />
Breast cyst<br />
Periductal mastitis<br />
Breast abscess<br />
Advanced breast carcinoma<br />
<br />
<b>3) Only pain</b><br />
<br />
Cyclical mastalgia<br />
Non-cyclical mastalgia<br />
Very rarely, CA breast<br />
<br />
<b>4) Nipple changes</b><br />
<br />
Destruction<br />
Depression (retraction, inversion)<br />
Duplication<br />
Discharge<br />
Deviation<br />
Displacement<br />
<br />
<b>Remember these 6 Ds</b><br />
<br />
<b>Different causes of nipple discharge :</b><br />
<br />
<b>Fresh red (blood) -> </b>Duct papilloma<br />
<b>Pinkish</b><b> (blood + serum) -> </b>CA breast<br />
<b>Greenish/Blackish -> </b>Breast cyst<br />
<b>Creamy, pale yellowish -> </b>Duct ectasia<br />
<b>Whitish -> </b>Lactation<br />
<br />
Occasionally, paget's disease of the nipple can be confused with eczema of the breast. To differentiate it :<br />
<br />
<u><b>Paget's disease</b></u><b> <u>Eczema</u></b><br />
<br />
Unilateral Bilateral<br />
No vesicles With vesicles<br />
Doesn't itch Itches<br />
May be associated with lump No lump<br />
Nipple may not be intact Nipple is always intact<br />
Post-menopausal Post-lactational<br />
<br />
<b>How do you approach in a case of breast lump?</b><br />
<br />
It's by the tripple assessment, which includes history and examination, imaging and Biopsy<br />
<b> </b><br />
<b>1) History </b><br />
<br />
About the lump : Onset, side, site, duration, progression, initial size, current size<br />
<b> </b><br />
Any pain associated with the lump, and proceed to the details of pain<br />
<br />
Is there any skin changes? (dimpling, nodules, ulceration, peu'd orange)<br />
Ask about the onset, duration and progression <br />
<br />
Is there any nipple discharge?<br />
Ask about the onset, duration, amount, colour, foul-smelling<br />
<br />
Is there any recent nipple retraction?<br />
<br />
Is there any lumps felt in the axilla?<br />
<br />
Then, proceed to the history of risk factors :<br />
<br />
Age of menarche (<11 years old)<br />
Age of menopause (>55 years old)<br />
Age of first child birth (if <30 years old, lesser risk)<br />
Parity index (no. of children)<br />
History of breast feeding and the duration (at least 6 months)<br />
Family history of breast cancer (first degree relatives)<br />
HRT/OCP intake (controversial)<br />
Post-menopausal obesity<br />
Diet - Fatty food predilection<br />
<br />
Then, h/o of metastases :<br />
<br />
Consitutional -> h/o of weight lost, lost of appetite<br />
Respiratory -> Cough, hemoptysis, dyspnoea<br />
CNS -> Headache, vomiting, diplopia, focal neurological deficits, seizures<br />
Liver -> Jaundice<br />
Musculoskeletal -> Bone pain, pathological fractures<br />
<br />
<b>2) Examination</b><br />
<br />
<b>a) Comparison of both breasts</b><br />
<b> </b><br />
Patient is sitting up, both arms are at her side.<br />
Now observe, any discrepency of size and shape of both breasts?<br />
Is there any differences in between the nipples of both sides? <br />
Is there any visible mass?<br />
<br />
Now, ask the patient to lift up both of her arms above head<br />
Observe if there's any accentuation of dimpling or distortion of the breasts?<br />
Observe if both breast are elevated equally (if one is higher than the other, it means that the lump probably has fixed to the pec.major muscle)<br />
<br />
Now, ask the patient to bend forwards.<br />
Does both breast moves forwards equally?<br />
If one doesn't move as the patient bend forwards, possibly it has fixed to the chest wall (intercostal muscles or ribs)<br />
<br />
Now, examine the affected breast.<br />
On inspection, note :<br />
<br />
Size and shape - normal?<br />
Skin over breast - peu'd orange, ulcers, nodules, dimpling, dilated veins<br />
Nipple - retraction, discharge<br />
Visible mass - size, shape, surface<br />
Any ulcers - describe it<br />
<br />
On palpation, palpate all 4 quadrants of the breast, including the central area and the axillary tail of spence. Note if there's any lump under headings of :<br />
<br />
Number of lumps<br />
Site<br />
Size<br />
Surface<br />
Consistency<br />
Tenderness<br />
Edges<br />
Mobility and fixity<br />
<br />
First as the patient's hands are placed over her hips, try moving the lump.<br />
If it's not mobile even when the muscles are relaxed, it means that the lump has infiltrated into the chest wall (skin/intercostal muscles).<br />
If it's infiltrated into the serratus anterior, it'll be the same as infiltration to the chest wall, and noted as stage T4 in TMN staging system.<br />
To test whether it has infiltrated to serratus anterior, ask the patient to push against the wall using both hands, and if renders the lump non-mobile, it means infiltration to serratus anterior has taken place.<br />
<br />
If the tumour has already infiltrated into the pectoralis major muscle, the lump is mobile in a direction perpendicular to the muscle fibers, but not in a direction parallel to it. This can be confirmed by asking the patient to press firmly using her hands against her hips, and if the lump now is completely immobile, it means infiltration into the pectoralis major muscle has taken place.<br />
<br />
Now, try to feel for any lumps of SC nodes.<br />
Examine the axilla, and note any enlarged nodes in it's numbers, consistency, tenderness, fixity.<br />
Percuss the parasternal region for any dullness.<br />
<br />
Repeat the same procedure for the opposite breast and axilla.<br />
<br />
Now, examine the abdomen -> hepatomegaly, ascites, PR and PV done (metastatic deposits)<br />
Examine the lungs -> Chest wall tenderness, pleural effusions<br />
Check for any bony tenderness<br />
<br />
<b>3) Imaging</b><br />
<br />
For women below age of 40 years old, the imaging of choice is ultrasonography<br />
<b> </b>For women above age of 40 years old, imaging of choice is mammography<br />
<br />
<b>4) Biopsy</b><br />
<br />
FNAC<br />
TRU-cut/core-needle biopsy<br />
Incisional biopsy<br />
Excisional biopsy<br />
<br />
Further test done :<br />
<br />
1) Liver function test - elevation of ALP is suggestive of liver metastases<br />
2) Liver ultrasound - liver metastases<br />
3) Chest X ray - pleural effusions, cannon-ball secondaries, rib erosions<br />
4) CT abdomen and Bone scan (optional - not done in MUAR)<br />
<br />
<b>TMN staging of CA breast</b><br />
<br />
<b>Tis - </b>Carcinoma in situ<br />
<b>T0 - </b>No evidence of the presence of primary tumour<br />
<b>Tx - </b>Primary tumour cannot be accessed (may be after BCS/mastectomy)<br />
<b>T1 - </b>Size of tumour is < 2cm, not fixed to muslces<br />
<b>T2 - </b>Size of tumour is 2-5cm, fixed to the muscles<br />
<b>T3 - </b>Size of tumour is >5cm<br />
<b>T4a - </b>Involvement of the chest wall<br />
<b>T4b - </b>Involvement of the skin over breast<br />
<b>T4c - </b>Both T4a and T4b present<br />
<b>T4d - </b>Inflammatory carcinoma<br />
<br />
<b>N0 - </b>No evidence of nodal metastases clinically<br />
<b>N1 - </b>Ipsilateral axillary nodes palpable, mobile<br />
<b>N2 - </b>Ipsilateral axillary nodes palpable, immobile<br />
<b>N3a - </b>Both infraclavicular and axillary nodes palpable<br />
<b>N3b - </b>Both internal mammary and axillary nodes palpable<br />
<b>N3c - </b>Both axillary and supraclavicular nodes palpable<br />
<br />
<b>M0 - </b>No distant metastases<br />
<b>M1 - </b>Distant metastases present<br />
<br />
Hence, the stages are :<br />
<br />
Stage I - T1 N0 M0<br />
Stage IIA - T0 N1 M0, or T1 N1 M0, or T2 N0 M0<br />
Stage IIB - T2 N1 M0, or T3 N0 M0<br />
Stage IIIA - T0/T1/T2 N2 M0 or T3 N1/N2 M0<br />
Stage IIIB - T4 N0/N1/N2 M0<br />
Stage IIIC - Any T N3 M0<br />
Stage IV - Any T Any N, M1fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-22173852931794493292009-12-29T06:38:00.000-08:002009-12-29T06:38:28.490-08:00Thoracic Trauma<strong>Introduction</strong><br />
<br />
Thoracic trauma accounts for about 25% of all cases of trauma.<br />
Most of the thoracic injuries are life theratening, where the commonest cause of morbidity and mortality is hypoxia and haemorrhage.<br />
However, ironically upto 80% of the cases can be managed conservatively.<br />
The key to succesful management here is early physiological resuscitation and accurate diagnosis.<br />
<br />
<strong>Investigations</strong><br />
<br />
An approach towards chest injuries is the same as any other injuries in primary and secondary survey, as noted by the Advanced Trauma Life Support Protocol (ATLS). History and examination will be important, and probably the most useful tool is a chest radiography. <br />
<br />
In an unstable patient, chest radiography can be done first, provided that it didn't interfere with the process of resuscitation. An ultrasound can give useful information about the presence of hematoma together with a contusion or just contusion alone. Chest drain can be both diagnostic and therapeutic, where the benefits outweights the risks.<br />
<br />
Some pitfalls during investigations :<br />
<br />
a) Failed to identify tracheal shift<br />
b) Failed to pass NG tube due to failure to recognise diagphramatic rupture<br />
c) During hemothorax, must auscultate both anterior and posterior chest<br />
d) Failed to resuscitate the patient first before investigations are done (both should be done hand in hand)<br />
<br />
Nowadays, CT scan made an important role in the management of chest injuries.<br />
Not only it can provide details about ribs and verterbral fractures, it can pick up contusions, hematomas, pneumothoraces easily. In penetrating injuries, eg gunshot wounds, CT can even trace the track of penetration through the thorax. Though aortogram is the 'gold standard' in diagnosing disruption of thoracic aorta, CT scan yields the similar results.<br />
<br />
<strong>Immediately life threatening chest injuries :</strong><br />
<br />
<strong>a) Airway obstruction</strong><br />
<br />
The commonest cause of early preventable death in a case of thoracic injury is airway obstruction, which blood, clots, secretions, dentures, teeth or even tongue can be a source of obstruction. Rapid removal usually relieves the obstruction. <br />
<br />
Examples of injuries potentially causing airway obstruction :<br />
<br />
a) Expanding neck hematomas<br />
b) Bilateral mandibular fractures<br />
<br />
Both a and b causing pharyngeal deviation and tracheal compression<br />
<br />
c) Laryngeal injury with thyroid/cricoid cartilage fracture, and other tracheal injuries<br />
<br />
What need to be done immediately is endotracheal intubation, as early as possible.<br />
Since most of these conditions are insidious and yet progressive, and delay will render increased difficulty in inserting the ET tube.<br />
<br />
<strong>b) Tension pneumothorax</strong><br />
<br />
Tension pneumothorax occurs when "one-way" valve is created in such a way that air is collected within the pleural cavity, without any means of escape. The source of air leakage can be originating from the chest wall or lung parenchyma. This results in significant compression over the affected lung, obstruction of the great veins compromising the venous return, mediastinal shift and eventually, compression of the opposite lung.<br />
<br />
Common causes includes, penetrating chest injuries, blunt chest trauma with parenchymal injury, iatrogenic causes includes a central subclavian venepuncture or mechanical positive pressure ventilation that has gone wrong.<br />
<br />
The clinical presentation is dramatic, with a panicky patient, complaints of dyspnoea, and with distended neck veins. Clinical signs : Tracheal shift to the opposite side (late presentation), diminished lung expansion over affected side, hyperresonant note on percussion, absence breath sounds.<br />
<br />
Tension pneumothorax is a clinical diagnosis, NEVER EVER proceed to radiological investigations first.<br />
If clinical diagnosis is establish, one should use a large bore needle, puncture the anterior chest and the 2nd intercostal space, along the midclavicular line. This is followed by inserting a chest tube over the 5th intercostal space at the anterior axillary line.<br />
<br />
<strong>c) Pericardial tamponade</strong><br />
<br />
In a case of patient with shock and distended vein, pericardial tamponade must be differentiated from tension pneumothorax. Pericardial tamponade is usually caused by penetrating chest injuries, and due to the non-distensible feature of the pericardial sac, even accumulation of small volume of blood is going to cause significant mechanical obstruction which renders cardiac pump failure.<br />
<br />
The typical presentation will be : Features of hemorrhagic shock, Raised JVP and CVP, muffled heart sounds. Some pitfalls of these presentation must be remembered :<br />
<br />
i) In case where there's active bleeding from a site distant to site of pathology, the neck veins are not distended.<br />
<br />
ii) In case where the patient is having circulatory collapse, CVP will not be raised<br />
<br />
To buy time for preparing the patient for definite operative management, which is left thoracotomy and sternotomy, a needle pericardiocentesis and resuscitation can be done. Needle pericardiocentesis is NOT a substitute for surgical management, and is done with ECG guidance (related with high incidence of iatrogenic myocardial injury)<br />
<br />
<strong>d) Open pneumothorax</strong><br />
<br />
This means an opening chest wound is present, where the size of the defect is > 3cm.<br />
Every breath that is inhaled, more air will be accumulated within the affected hemithorax.<br />
This eventually causes significant hypoventilation, and eventually hypoxia.<br />
The signs and symptoms are directly proportional to the size of the defect.<br />
Initial management includes covering the chest wound is a sterile plastic occlusive dressing, which is only adhered at 3 sites, creating a flutter-wave valve, while suction is continued, where the tube is connected to an underwater seal drainage bottle.<br />
Remember, no 'sucking' chest wound should be covered completely before a controlled drainage is established.. <br />
Definite management : pulmonary debridement and closure of the wound.<br />
<br />
Some pit falls regarding this conditions :<br />
<br />
For adults, a larger tube is required (>28 FG in size)<br />
Some patients may require 2 chest drains<br />
In case where patient's condition doesn't improve despite adequate drainage, try reducing the pressure within the seal drainage bottle to 5cm H20.<br />
Early mobilisation and physiotherapy is required<br />
<br />
<strong>e) Massive hemothorax</strong><br />
<br />
Defined by : initial blood collection by chest drain of > 1500 ml or in on-going hemorrhage, > 200-300 ml/h of blood collected over a period of 2-3 hours.<br />
<br />
Massive hemothorax usually occurs due to blunt injuries, rupturing the intercostal and internal mammary vessels. Blood is hence collected within the affected hemithorax, causing significant respiratory distress. It's recognised by signs of haemorrhagic shock, flat neck veins, diminished expansion, dullness on percussion, absence of breath sounds.<br />
<br />
Initial management of massive hemothorax includes chest drain, resuscitation and sometimes, intubation. Blood from the pleural cavity must be drained as rapid and as complete as possible, in order to prevent possibility of empyema and later, fibrothorax.<br />
<br />
Pit falls regarding massive hemothorax :<br />
<br />
1) One must examine both anterior and posterior chest when the patient is lying in a supine position, since there's a chance where the affected lung 'floats' within the BLOODY thoracic cavity.<br />
If you only auscultate the anterior chest - it'll be normal<br />
<br />
2) Even after draining out about 500ml of blood, dullness still persist and radio-opacity still present -> emergency thoracotomy<br />
<br />
<strong>f) Flial chest</strong><br />
<br />
Flial chest is defined as a loss of bony continuity of a chest wall segment with the rest of thoracic cage, caused by a blunt trauma, which occurs when there's :<br />
<br />
i) 3 or more rib fractures<br />
ii) occurs in more than 2-3 places<br />
<br />
Flial chest is a clinical diagnosis, not by chest radiography.<br />
It's done by observing few respiratory cycles, where the flial segment will be drawn inwards during inspiration.<br />
<br />
Causes of hypoxia in flial chest : voluntary splinting due to pain, pulmonary contusion, defect in the mechanical movement of the rib cage<br />
<br />
Initial management : opiate analgesics, oxygen support. If a chest drain is present, intrapleural local analgesia can be given. Ventilation is reseved for patients with respiratory failure despite optimal treatment given. Surgical fixation is done in severe thoracic injury or in cases where pulmonary contusion is present.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-2073520938961250212009-12-26T07:51:00.000-08:002009-12-26T07:51:37.637-08:00A case of Acute testicular pain<b>History</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://teft.mimiandteft.com/wp-content/uploads/2007/07/kicknut.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="317" src="http://teft.mimiandteft.com/wp-content/uploads/2007/07/kicknut.jpg" width="441" /></a><br />
</div><br />
We have a 16 years old male here presented to the ER complaining of sudden onset of right testicular pain. The pain woke him up from his sleep and has persisted over the last 3 hrs. His mother says that he has vomited once. His previous medical history includes a similar event a year ago, but on that occasion the pain subsided quickly. He is an asthmatic and uses a salbutamol inhaler.<br />
<b> </b><br />
<b>Only with h/o, what's your differential diagnosis?</b><br />
<br />
Testicular torsion?<br />
Acute epididymo-orchitis?<br />
Torsion of appendix testis?<br />
Infected hydrocele?<br />
Strangulated hernia?<br />
Testicular rupture?<br />
Haemorrhage into a tumour?<br />
<br />
<b>On examination</b><br />
<br />
The left hemi-scrotum feels normal but the right side is acutely swollen and tender on palpation. The testicle is elevated when compared to the other side and has an abnormal horizontal lie. The abdomen is soft, non tender, with intact hernial orifices. Vitals are stable, cremesteric reflex is absent.<br />
<br />
<b>So, what's your provisional diagnosis?</b><br />
<br />
In this case, testicular torsion should be ruled out unless proven otherwise. Points towards diagnosis of testicular torsion :<br />
<b> </b><br />
<b>1) Age (testicular torsion is common in age group of 10-25 yrs old)</b><br />
<b>2) Elevated, tender right testicle</b><br />
<b>3) Abnormal horizontal lie (risk factor for torsion)</b><br />
<b>4) Cremesteric reflex is absent (bear in mind that presence of this reflex doesn't rule out testicular torsion!)</b><br />
<b> </b><br />
If doppler's ultrasound is immediately available, a results showing interrupted blood supply to the testis is diagnostic.<br />
However, if the diagnosis is in doubt, PLS peform surgical exploration to confirm the diagnosis. If not, he CAN SUE YOU BECOZ you've caused him to lose his precious balls.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://radiographics.rsna.org/content/25/5/1197/F23.large.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="266" src="http://radiographics.rsna.org/content/25/5/1197/F23.large.jpg" width="400" /></a><br />
</div><br />
Remember, you've only 4-6 hours (starting from the time of onset of pain) to salvage the balls.<br />
However, if the patient presented within the first hour after onset of pain, it's sometimes possible to untwist the cord manually, which if succesful, the affected testicle is out of danger and surgery can be planned later.<br />
<br />
And, surgical correction is bilateral, since congenital defects often involves both sides.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-60219426502032226982009-12-15T08:34:00.000-08:002009-12-15T08:34:36.190-08:00Head injury - part 3<b>Management of mild head injury (GCS 14-15)</b><br />
<br />
Most of the occasions, patients with mild head injury, after history and examination, and a period of observation, will be allowed to be discharge after following criterias met :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.itim.nsw.gov.au/images/Battle_Sign_s.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://www.itim.nsw.gov.au/images/Battle_Sign_s.jpg" width="400" /></a><br />
</div> <i><b>Battle's sign</b></i><br />
<br />
a) Full GCS score (15/15)<br />
b) No focal neurological deficits<br />
c) Accompanied by a responsible adult<br />
d) Not under influence of any drugs/alcohol<br />
e) Verbal/Written advice about the injury given<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/fullsize/migrated/410/630/smj9309.14.fig2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="206" src="http://img.medscape.com/fullsize/migrated/410/630/smj9309.14.fig2.jpg" width="400" /></a><br />
</div><div style="text-align: center;"> <i><b>Racoon's Sign<br />
</b></i><br />
</div><br />
Statement e) means : Advice regarding any worsening of symptoms, such as persistent headahce not relieved by analgesia, severe vomiting, blurring of vision, diplopia, weakness/numbness of limbs have been given verbally or written.<br />
<br />
Sometimes, for patients with mild head injury, decision of whether to perform CT brain or not can be a big headahce. However, here are the NICE guidelines regarding indications of CT brain in patients with mild head injury :<br />
<br />
a) GCS is <13 at any point<br />
b) GCS is 13-14 at 2 hours time<br />
c) Evidence of focal neurological deficit<br />
d) Suspicion of open, comminuted, depressed, or basal skull fracture<br />
e) Vomiting > 1 episode<br />
f) Seizures<br />
<br />
Urgent indication<br />
<br />
a) Age > 65 years old<br />
b) Evidence of coagulopathy (liver disease, blood dyscarias, warfarin, anti-platelet medications)<br />
c) Dangerous mechanism of head injury (CT within 8 hrs)<br />
d) Antegrade amnesia > 30 mins (CT within 8 hrs)<br />
<br />
<b>Management of moderate/severe head injury</b><br />
<br />
First of all, resuscitation and primary survery.<br />
<b> </b>After stabilising cervical spine at 3 fixation point, start primary surveying.<br />
Remember that normalising the patient's oxygenation and circulation is more important than getting a CT done! This is to prevent secondary brain injury<br />
<br />
After primary survey, you've made a diagnosis of moderate/severe head injury, the next step is CT brain, to detect any intracranial hematoma, or any skull fractures, soft tissue injuries, or any mild intracerebral contusion.<br />
For intubated patients, it's recommended that you've asked for CT cervical spine.<br />
<br />
Before ariving at the hospital, some conservative management can be given for raised ICP, which includes :<br />
<br />
a) Reversed tredelenburg : Raised head upto 20-30 degrees<br />
b) Check if the cervical collar is too tight (may obstruct venous drainage from brain)<br />
c) If there's pupillary dilatation (may be due to acute raised ICP), 0.5mg/kg 20% IV mannitol can be given.<br />
<br />
<b>Medical management of severe head injury</b><br />
<br />
Severe head injury is preferably managed in a neurointensive care unit.<br />
<b> </b>ICP can be monitored by passing a catheter into the frontal horn of the lateral ventricle (2 finger breadth from the blurred hole, behind the hairline)<br />
Raise the patient's head for about 20-30 degrees<br />
<br />
Protect the patient's airway!<br />
For those with traumatic brain injury and coma, they are more prone to aspiration.<br />
Preferably intubate the patient, and provide high flow oxygen. (Prevent hypoxia)<br />
<br />
Make sure that the cervical collar is not too tight. <br />
<br />
Cerebral vasculatures are very sensitive to the PCo2 level. When there's a rise in PCo2 level, the cerebral vasculatures dilates, and elevates the ICP. In contrast, when there's a fall in PCo2 level, cerebral vasculature constricts.<br />
<br />
Hence, you must try to maintain the PCo2 level in between 4.5-5kPa.<br />
Some experienced anesthetist may induce hyperventilation in patients to cause temporary reduction in ICP by reducing the PCo2 level.<br />
<br />
Sedative given, either with or without muscle relaxant.<br />
Mannitol/Frusemide given to reduce cerebral edema.<br />
Patient is prone for hyponatremia or other electrolyte imbalance -> correct it<br />
Avoid pyrexia, as it'll cause undesirable increase in the brain metabolic activity.<br />
Barbiturates eg: thiopentone sodium is given to reduce ICP and brain metabolic rate.<br />
Prophylactic anticonvulsant given.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-44590864362093980922009-12-15T07:35:00.000-08:002009-12-15T07:35:46.182-08:00Head Injury - part 2<b>Extradural hematoma</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.pharmacology2000.com/822_1/extradural1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="312" src="http://www.pharmacology2000.com/822_1/extradural1.jpg" width="416" /></a><br />
</div><br />
This refers to collection of blood in between the skull and dura mater.<br />
More commonly seen in younger patients (children, adolescence)<br />
Extradural hematoma is always associated with skull fractures, most frequently, the temporal bone. (since pterion is the thinnest part of skull, involvement of this area causes tearing of the middle meningeal artery)<br />
Of course, involvement of the posterior fossa and frontal bone is also possible.<br />
However, the hematoma is not always arterial in origin, it may be due to a tear to the dural venous sinuses as well.<br />
<br />
Classical presentation of extradural hematoma is : (<1/3 of the cases)<br />
<br />
Lucid interval, where after initial injury, patient is conscious, alert, oriented, and only complaints of headache. Minutes or hours later, the condition worsens, with deterioration of consciousness, contralateral hemiparesis/plegia, and ipsilateral pupillary dilatation.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.catscanman.net/blog/wp-content/uploads/casebook/edh1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="448" src="http://www.catscanman.net/blog/wp-content/uploads/casebook/edh1.jpg" width="383" /></a><br />
</div><br />
<br />
Early diagnosis and treatment of subdural hematoma is VITAL.<br />
CT brain is confirmatory, where it'll appears as a lentiform, biconvex, or lense-shaped hyperdense mass in between the skull and brain, with or without midline shift.<br />
<br />
After diagnosis is confirmed, surgical evacuation of the hematoma is required, where craniotomy is performed.<br />
<br />
<b>Acute subdural hematoma (ASH)</b><br />
<b><br />
</b><br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.neuropathologyweb.org/chapter4/images4/4-3L.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="268" src="http://www.neuropathologyweb.org/chapter4/images4/4-3L.JPG" width="372" /></a><br />
</div><b><br />
</b><br />
This is actually more common, with poorer prognosis, higher mortality rate as compared to extradural hematoma.<br />
It refers to blood collection in between the dura and arachnoid mater.<br />
ASH is almost always associated with a primary brain injury.<br />
Most of the time at presentation, the patient has impaired consciousness, which rapidly deteriorates depending on the size of the hematoma.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.health-res.com/EX/08-03-19/Trauma_subdural.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="422" src="http://www.health-res.com/EX/08-03-19/Trauma_subdural.jpg" width="345" /></a><br />
</div><br />
<br />
Again, CT brain is diagnostic.<br />
It'll appears as a crescent shaped, more diffuse (with concavity towards the brain), hyperdense mass in between the brain and skull.<br />
<br />
Treatment - surgical evacuation by craniotomy<br />
<br />
<b>Chronic subdural hematoma (CSH)</b><br />
<b><br />
</b><br />
CSH often seen in elderly patients, who is on anti-platelets or anti-coagulants. It is believed to be due to tearing of the bridging veins, which causes formation of clinically inapparent, small ASH<b>. </b>Later, as it breaks down and the volume expands, it becomes symptommatic.<br />
<br />
Mostly, patients presents with headache, focal neurological deficit, impaired cognition, seizures, etc (hence, one of the d/d of CVA)<br />
<br />
CT brain intepretation :<br />
<br />
Acute blood (0-10 days) = hyperdense<br />
Subacute blood (10 days - 2 weeks) = isodense<br />
Chronic blood (>2weeks) = hypodense<br />
<br />
Treatment = creating a blurr hole and evacuate the hematomafusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-74541732490477333712009-12-14T08:28:00.000-08:002009-12-14T08:28:44.338-08:00Head injury - part 1<b>Pathophysiology</b><br />
<br />
90% of the brain metabolism requires blood-borned glucose.<br />
During normal circumstances, the cerebral autoregulation mechanism maintains the cerebral blood flow above 70mmHg, even though the Mean Arterial Pressure (MAP), varies as much as between 50mmHg - 150 mmHg.<br />
<br />
<b>*Cerebral perfusion pressure (CPP) = MAP - ICP</b> <br />
<br />
However, when there's head injury, this autoregulatory mechanism is disordered. Hence, the CPP fluctuates with MAP, and hence, brain is more vulnerable towards ischaemia.<br />
<br />
According to Monro-Kellie's hypothesis, our skull is a rigid structure, and hence will not expand. Intracranial pressure is directly proportionate to the increase in volume of the intracranial structures, including vascular components (blood in vessels), Cerebrospinal fluid (CSF), or the brain tissue itself.<br />
<br />
Initially, when there's formation of a space-occupying lesion, the rise in ICP is prevented by transient displacement of venous blood and CSF away from the brain. This decrease in volume compensates for the rise in volume due to formation of space occupying lesion.<br />
<br />
But, further rise in the volume of a brain compartment -> even a slightest increase in volume is going to cause a surge in ICP.<br />
<br />
<b>Note : ICP can be measured by passing a catheter through the frontal horn of lateral ventricle. In head injuries, ICP is monitored in btw 5-15 mmHg. Bear in mind that normal ICP is <10mmHg</b><br />
<br />
One should never forget that intracranial hypertension is the dreadliest consequence of head injury. The end-stage of<b> </b>raised ICP will be cerebral herniation, which can be :<br />
<br />
a) Herniation through the Tentorial hiatus<br />
<br />
Tentorial hiatus is an opening at the tentorium cerebelli<br />
As with central herniation, involving the midbrain, features are :<br />
<br />
-> Altered consciousness due to midbrain ischaemia<br />
-> Increased muscle tone, and eventually decorticate rigidity<br />
-> Bilateral +ve babinski's sign<br />
-> pupillary constriction, which followed by dilatation, and lastly, becomes static<br />
<br />
As for Lateral herniation, involving the temporal lobe (uncus) :<br />
<br />
-> Altered consciousness <br />
-> Contralateral hemiparesis, hemiplegia<br />
-> Compression on the 3rd nerve, initially causing ipsilateral pupillary constriction, followed by dilatation, then becomes fixed to light response. Continued rise in ICP results in involvement of the contralateral side of pupil. The sequence of changes in pupillary response is known as Hutchingson's pupil.<br />
-> Others : ptosis, eye deviated inferolaterally<br />
<br />
b) Herniation into foramen magnum<br />
<br />
If ICP continues to rise, the cerebellar tonsils will herniates into the foramen of magnum, thereby compressing the brainstem and medulla.<br />
This results in Cardiorespiratory collapse, bilateral pinpoint pupil, and flaccid quadriplegia due to lateral corticospinal tract compression.<br />
<br />
<b>Note : Signs of Raised intracranial pressure </b><br />
<br />
<b>Papilloedema (swollen optic disc)</b><br />
<b>Altered level of consciousness</b><br />
<b>Bradycardia*</b><br />
<b>Widened pulse pressure*</b><br />
<b>Decreased systolic BP*</b><br />
<b>Abnormal breathing pattern (Cheyne's-Stokes/Hyperventilation)</b><br />
<b><br />
</b><br />
<b>*Cushing's triad</b><br />
<b>DO NOT PERFORM LUMBAR PUNCTURE IN A PATIENT WITH RAISED ICP!!</b><br />
<br />
<b>Classification of Head injuries</b><br />
<br />
<b>Classification can be made via :</b><br />
<b> <br />
</b><br />
<b> a) Glasgow Coma scale</b><br />
<br />
Minor head injury = No lost of consciousness and GCS is full 15/15<br />
Mild head injury = GCS 14-15 with lost of consciousness<br />
Moderate head injury = GCS 9-13<br />
Severe head injury = GCS 3-8<br />
<br />
<b>b) Mechanism of head injury</b><br />
<br />
i) Blunt trauma<br />
<br />
<b>Direct injury (Croup injury)</b><br />
The brain substance collide against a fixed skull.<br />
Usually caused by sudden deceleration/acceleration forces<br />
Resulting in contusion, laceration and intra-cranial bleeding<br />
<br />
<b>Indirect injury (Counter-croup)</b><br />
Injury to the side opposite to the side of trauma.<br />
Hence, subdural/extradural hematoma may be seen opposite to the side blunt trauma<br />
<br />
<b>Rotational injury</b><br />
This occurs in acceleration/deceleration injury.<br />
<b> </b>Such forces creates rotational injury at the junction btw white/grey matter of brain.<br />
<br />
ii) Penetrating injury<br />
<br />
High velocity - gunshot injuries<br />
Low velocity - stab injuries<br />
In penetrating injury, there's risk of intracranial infection, due to introduction of foreign bodies<br />
<br />
<b>c) Morphological</b><br />
<br />
i) Scalp injuries<br />
<b> </b><br />
<b>Cephalhematoma</b><br />
More commonly seen in infants and children.<br />
Due to collection of blood under the periosteum, resulting in formation of a tense swelling, confined to the margins of underlying bones.<br />
It takes weeks to resolve<br />
<br />
<b>Subaponeurotic hematoma</b><br />
Blood collection in between aponeurosis and pericranium<br />
<b> </b>Formation of a fluctuant swelling involving the whole scalp<br />
Take weeks to resolve as well<br />
<br />
<b>Others : Scalp laceration, Scalding (avulsion)</b><br />
<br />
ii) Skull fractures<br />
<b> </b><br />
It can involve the vault or base, and can be open or closed.<br />
In closed fractures, there's no communication with the exterior, so do not expect a nose, ear bleed or leakage of CSF.<br />
<br />
For open vault fractures, expect visible brain substance.<br />
For open base fractures :<br />
<br />
If it's an anterior cranial fossa fracture -> Raccoon's Sign (periorbital hematoma) + subconjunctival haemorrhage with no posterior limits + CSF rhinnorhoea and nose bleeding<br />
<br />
If it's a middle cranial fossa fracture -> Battle's sign (Bruises seen over mastoid and post-auricular region, which forms within 48 hrs) CSF otorrhoea and ear bleeding<br />
<br />
Posterior cranial fossa fracture is not easily identified clinically. Most of the time, when there's occipital bone fracture, there'll be a dural venous sinus tear. Usually, there'll be hypertension, bradycardia, changes in respiration and consciousness.<br />
<br />
A closed fracutre can be depressed, communited, or linear.<br />
<br />
d) <b>Primary/Secondary</b><br />
<br />
Primary head injury occurs during time of impact, it's irreversible, and not treatable, and recovery will largely depends on the type and extent of injury. Remember that neurons once damaged, will not regenerate.<br />
Hence, most of the our treatment will be focusing on secondary head injury.<br />
<br />
Causes of Secondary head injury :<br />
<br />
1) Hypoxia, with PaO2 <8Kpa<br />
2) Hypotension, with SBP <90mmHg<br />
3) Cerebral perfusion pressure <65mmHg<br />
4) Intracranial pressure >20 mmHg<br />
5) Pyrexia<br />
6) Seizures<br />
7) Metabolic disturbances<br />
<br />
e) Intracranial hematomas<br />
<br />
<b>Extradural hematoma</b><br />
<br />
More common in children as their dura strips easily to accomodate blood clot<br />
<b> </b>Here, blood collects between the skull and dura mater<br />
Common at the frontal and temporal region, usually associated with local fractures<br />
Middle meningeal artery or dural venous sinuses are teared<br />
Classical presentation : Lucid interval<br />
Others : Headache, vomiting, lost of consciousness, hemiparesis, seizures, signs of raised ICP<br />
Diagnosis is confirmed by CT brain, which reveals a biconvex, lense-shaped hyperdense hematoma.<br />
If the hematoma is stable, conservative treatment suffice.<br />
However, if there's evidence that it's enlarging, perform blurr hole and craniotomy<br />
<br />
<b>Subdural hematoma</b><br />
<br />
More common than extradural hematoma<br />
<b> </b>Here, blood collects between the dura mater and arachnoid mater<br />
Clinical features are similar to extradural hematoma<br />
CT brain reveals a cresent shaped hematoma, which concavity directing towards the brain.<br />
Treatment - same<br />
<br />
<b>HISTORY TAKING IN HEAD INJURY</b><br />
<br />
1) How did you injure your head?<br />
<b> </b><br />
<b> </b>Basically, you're asking what's the mechanism of injury.<br />
For dangerous mechanisms, such as falling from a height, or high-speed motor vehicle accident, it may be a multisystem injury, including the spine.<br />
For head injury with lost of consciousness, but without any accidental mechanism, consider hypoglycemia, syncope, aneurysmal subarachnoid haemorrhage<br />
<br />
2) Ask about the neurological state of patient during and after injury<br />
<br />
Is there lost of consciousness?<br />
Is there seizures?<br />
Is the patient able to respond, move, or talk properly after the injury?<br />
Is there antegrade (can't recall what happened after injury) or retrograde (can't recall what happened before injury) amnesia?<br />
<br />
3) Then, What's the GCS of the patient during the scene, prior to intubation, and on arrival in hospital?<br />
<br />
4) Is there any evidence suggestive of hypoxia, or any cardiovascular instability?<br />
<br />
5) Any co-morbid medical illness?<br />
<br />
6) Is the patient taking any drugs? (esp antiplatelets or anticoagulants)<br />
<br />
7) Any ilicit drung intake or alcohol consumption<br />
<br />
TO BE CONTINUED.....<br />
<br />
<br />
<br />
<b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-9999096555072856522009-12-13T01:44:00.000-08:002009-12-13T01:48:11.205-08:00Testicular TumourJust breifly describe about this uncommon, but important condition<br />
<br />
First, we'll talk about the anatomy :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.memorialhermann.org/adam/graphics/images/en/19120.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.memorialhermann.org/adam/graphics/images/en/19120.jpg" width="400" /></a><br />
</div><br />
Testes are originally retroperitoneal organs, during intra-uterine life.<br />
Just before guys are born, our balls descends down, through the inguinal canal, and enters the scrotal sac at the perineum.<br />
As it descends, it bring along vessels, nerves, lymphatics, and it's primary drainage duct - the vas deferens<br />
All these structures are kept safely within the spermatic cord, which can be described of having :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.aafp.org/afp/990215ap/817_f2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.aafp.org/afp/990215ap/817_f2.jpg" width="275" /></a><br />
</div><br />
<br />
3 vessels : Cremesteric artery, Artery to Vas, and Testicular artery<br />
<br />
3 nerves : Autonomic nerves, Genital branch of genitofemoral nerve, and illioinguinal nerve<br />
<br />
3 structures : Lymphatics, Pampiniform venous plexus, and Vas deferens<br />
<br />
3 coverings : Cremesteric fascia, Internal and external spermatic fascia<br />
<br />
The anterior aspect of our testis is covered by a closed peritoneal sac, known as the tunica vaginalis, formed as a result of the obliteration of processus vaginalis.<br />
The posterolateral aspect, is where a single, long coiled duct located, which is the epididymis.<br />
<br />
<b>2 histopathological types of Testicular tumour :</b><br />
<br />
<b>1) Seminoma - </b>arising from the seminiferous tubules<br />
<b> 2) Teratoma - </b>it's a malignant germ cell tumour<br />
<br />
<b>History taking</b><br />
<br />
1) Age<br />
<b> </b><br />
<b> </b>For teratoma, it's common among young men, around 20-30 yrs of age.<br />
Seminoma may be more common in individuals around 30-40 yrs of age.<br />
<br />
2) Symptoms<br />
<br />
Now, the usual scenario is : the only symptom is a scrotal swelling<br />
Since this condition is usually painless.<br />
Occasionally, there might be some amount of dragging, or dull-aching pain.<br />
Especially when the swelling increases in it's size, the patient might complaints of heaviness over the affected testicles.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.bbc.co.uk/northernireland/mindyourself/images/symptoms/testicular.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="195" src="http://www.bbc.co.uk/northernireland/mindyourself/images/symptoms/testicular.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: center;"><i><b>No, It's not painful...</b></i> <br />
</div><br />
<br />
In advanced malignancy, there might be symptoms suggesting of metastasis, eg : breathlessness, lost of appetite/weight, abdominal pain, etc<br />
<br />
<b>Examination</b><br />
<br />
1) Inspection<br />
<br />
<b> </b><br />
<b> </b>A scrotal swelling is seen, not extending into the inguinal region<br />
No expansile cough impulse seen <br />
Scrotal skin - stretched but with normal rugosity, but in advanced stage, skin may ulcerate/infected<br />
No lumps, no scars, no sinuses<br />
<br />
2) Palpation<br />
<br />
Able to get above the swelling (pure scrotal swelling la)<br />
Testis is enlarged, swollen<br />
Hard in consistency, non tender<br />
There's loss of testicular sensation, and it's feels heavier than the normal side<br />
Spermatic cord is normal<br />
Skin may not be pinchable if infiltration had taken place<br />
Non-fluctuant, non-transilluminant<br />
<br />
3) Please examine the para-aortic and supraclavicular lymph nodes<br />
4) Examine the abdomen -> any hepatomegaly? any masses?<br />
Auscultate the lungs -> any signs of metastases?<br />
<br />
<b>Investigation</b><br />
<br />
Here I'll try not to be lengthy la har....<br />
<b> </b><br />
<b> </b>1) Blood : Alpha-fetoprotein, B-HCG, and LDH (Tumour markers)<br />
2) Chest X ray (cannon-ball metastases)<br />
3) CT abdomen for staging<br />
4) Orchidectomy and sent specimen for histological analysis<br />
<br />
<b>How do we stage it?</b><br />
<br />
Stage I : Only involve the testis<br />
<b> </b>Stage II : Involving the nodes below diagphram<br />
Stage III : Involving the nodes above diagphram<br />
Stage IV : Hepatic/Pulmonary metastasis<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/_au5dJPQRwPc/SyS143XAtBI/AAAAAAAAAY4/VjuzY06xLNs/s1600-h/IMG0152A.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://2.bp.blogspot.com/_au5dJPQRwPc/SyS143XAtBI/AAAAAAAAAY4/VjuzY06xLNs/s320/IMG0152A.jpg" /></a><br />
</div><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/_au5dJPQRwPc/SyS2GkVh0-I/AAAAAAAAAZA/QqpIqT5XTGY/s1600-h/IMG0104A.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://2.bp.blogspot.com/_au5dJPQRwPc/SyS2GkVh0-I/AAAAAAAAAZA/QqpIqT5XTGY/s320/IMG0104A.jpg" /></a><br />
</div><br />
So, see how scary it is...<br />
<br />
LOVE UR BALLS, MAN!!fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-25588470164453514022009-12-08T04:02:00.000-08:002009-12-08T04:02:13.134-08:00History taking and examination of an ulcerAn ulcer is defined as a break in the continuity of the lining epithelium of tissue. Once an ulcer appears, it's usually noticed by the patients, unless it's painless, or located at non-accessible sites.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.apligraf.com/patient/images/venous_1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="297" src="http://www.apligraf.com/patient/images/venous_1.jpg" width="400" /></a><br />
</div><br />
<b>History taking</b><br />
<br />
<b>1) When do you notice the ulcer?</b><br />
<b> </b>Remember that the ulcer might have been present for long before the patient actually notices it. This is usually in case of a neuropathic ulcer.<br />
<br />
<b>2) What draws your attention to the ulcer?</b><br />
Usually is because of pain. Others includes : bleeding, discharge, may be foul-smelling.<br />
<b> </b><br />
<b> 3) How does the ulcer disturbs you?</b><br />
The commonest symptom associated with an ulcer is pain. It might be interfering with eating, walking, defecating, etc<br />
<b> </b><br />
<b> 4) Any changes to the ulcer since you've noticed it?</b><br />
Is there any increase in size, changes in shape, increased discharge, bleeding, or severity of pain?<br />
<b> </b><br />
<b>5) Is there any similar ulcers noticed elsewhere in the body?</b><br />
Asking for multiplicity.<br />
<b> </b><br />
<b>6) What do you think is the cause of ulcer?</b><br />
Most of the time the patient will get it right, and the commonest cause is trauma.<br />
<b> </b><br />
<b>Examination</b><br />
<br />
<b>1) Inspect the floor </b><br />
<b> </b><br />
The floor of an ulcer usually made up of granulation tissues or slough tissues. Sometimes, the underlying structures might been exposed, eg : bones, tendons, etc. Some characteristic contents of the floor are able to provide you a hint to your diagnosis :<br />
<br />
Solid-Brown, greyish tissue - Full thickness death of tissue<br />
Slough tissue resembles a yellow-grey wash leather - Syphilitic ulcers<br />
Unhealthy, bluish granulation tissue - Tuberculous ulcers<br />
Poor granulation tissue, with visible bones, tendons, periosteum - Ischaemic ulcer<br />
<br />
<b>2) Edge of the ulcer</b><br />
<br />
The edge is the portion in between the floor and margin of an ulcer<br />
There're 5 main types of edges for ulcer :<br />
<br />
<b>a) Slopping edge</b><br />
<br />
Usually means the ulcer is superficial/shallow and has a good chance in healing. Healthy granulation tissue usually is pinkish, means it has a good vascularity. A healing epidermis is usually seen extending from the edge, over granulation tissue, either pale/pink in colour (almost transparent)<br />
One example of such ulcer is - venous ulcer<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://www.my-varicose-veins.com/images/venousstasisulcer.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.my-varicose-veins.com/images/venousstasisulcer.jpg" width="300" /></a><br />
</div><b>b) Punch-out edge</b><br />
<br />
It means there's rapid death over full thickness of tissue with minimal attempts of the body to repair it. A classical textbook example is the Ulcers seen in tertiary syphilis. Nowadays, ulcers with punch out edges are more commonly seen in neuropathic or peripheral arterial ischaemic ulcers. (PVD)<br />
<b> </b><br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.worldortho.com/dev/images/morfeoshow/gallery_orth-4270/big/270.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="287" src="http://www.worldortho.com/dev/images/morfeoshow/gallery_orth-4270/big/270.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>c) Undermined edge</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">It means the rate of destruction of the subcutaneous tissue is more rapid than the skin, causing the edge of ulcer to be undermined. Classical example, as it's rarely seen nowadays is tuberculous ulcers. Ulcers with undermined edge is more commonly seen in bedsores, pressure sores as the subcutaneous tissues are more susceptible towards pressure.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b> <br />
<a href="http://www.jcadonline.com/wp-content/uploads/2009/10/emerfig5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="321" src="http://www.jcadonline.com/wp-content/uploads/2009/10/emerfig5.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"> <a href="http://www.manukahoneyusa.com/images/pressure-sore-on-buttock.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://www.manukahoneyusa.com/images/pressure-sore-on-buttock.jpg" width="400" /></a><br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;"><b>d) Everted edges</b><br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://wildiris3.securesites.net/cms_prod/files/course/205/WoundCare07_fig3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="392" src="http://wildiris3.securesites.net/cms_prod/files/course/205/WoundCare07_fig3.jpg" width="400" /></a><br />
</div><div class="" style="clear: both; text-align: left;">This means that over the edges of the ulcer, tissues are growing so rapid that it eventually overlaps the overlying skin. This is classically seen in Squamous cell carcinoma.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>e) Rolled edges</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><a href="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1108860-3100.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1108860-3100.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">The tissues over edges are growing slowly, which is usually pale/pink in colour, with telengiectasis seen over the pearly edges. An ulcer with rolled edges is almost diagnostic of a rodent ulcer of Basal cell carcinoma.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> 3) Depth</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Measure the depth of an ulcer by mm<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>4) Discharge</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Discharge from an ulcer can be serous, serosanginous, sanginous, or purulent.<br />
</div><div class="separator" style="clear: both; text-align: left;">Sometimes, due to the formation of a coagulation discharge scab over an ulcer, it prevents you from examining the entire structure of ulcer (might be missing some of it's features). It's advised that you remove the scab first.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>5) Base</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Feel the base of the ulcer.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Is it adherent to the underlying structure? (may be bone, periosteum, tendon in cases of osteomyelitis, malignancy)<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>6) Regional lymph nodes</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Please remember to palpate the regional lymph nodes.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>It'll be enlarged (and tender) if there's secondary metastatic deposits or any spreading infection.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>7) State of the local tissues</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Most of the ulcers over the leg is due to poor vascular/nervous supply.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Hence, it's a must that you check for it's vascularity and innervation.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-6494085557391294922009-12-07T09:25:00.000-08:002009-12-07T09:25:08.056-08:00Advanced Trauma Life Support Protocol (ATLS) - Part 1In all trauma cases, the 1st hour is also known as the golden hour, since nearly 30% of death occurs during this period of time.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.1trustedpharmacy.com/blog/wp-content/uploads/2009/07/Emergency-Medicine.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="355" src="http://www.1trustedpharmacy.com/blog/wp-content/uploads/2009/07/Emergency-Medicine.jpg" width="400" /></a><br />
</div><br />
<br />
In the ATLS Protocol, it comprises of :<br />
<br />
Primary surveilence - Management of immediately life threatening conditions<br />
Secondary surveilence<br />
Definite management<br />
<br />
<b>Primary Surveilence</b><br />
<br />
<b>1) Airway</b><br />
<b> </b><br />
<b> </b>The first thing to do in any trauma cases is to secure the airway.<br />
Stabilise the cervical spine, using the cervical collar. If not possible, place 2 bags of sand over both sides of patient's head serves the same purpose.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://traumanotes.com/wp-content/uploads/2009/08/philadelphia-cervical-collar.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="252" src="http://traumanotes.com/wp-content/uploads/2009/08/philadelphia-cervical-collar.jpg" width="400" /></a><br />
</div><br />
Examine the throat, remove any foreign bodies (dentures), blood clots, or suck out any blood/secretions that might be obstructing the airway.<br />
<br />
Next, perform jaw thrust on the patient to straighten the airway.<br />
Try inserting the nasopharyngeal/oropharyngeal airway.<br />
If not possible (airway doesn't open up) -> Endotracheal intubation<br />
One of the ways to check whether patient needs intubation is by looking for the gag reflex. If gag reflex is absent -> INTUBATE<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.ispub.com/ispub/ija/volume_7_number_2_12/perioperative_management_of_huge_goiter_with_compromized_airway/goiter-fig6.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="298" src="http://www.ispub.com/ispub/ija/volume_7_number_2_12/perioperative_management_of_huge_goiter_with_compromized_airway/goiter-fig6.jpg" width="400" /></a><br />
</div><br />
Other indications for ET intubation :<br />
<br />
1) Hypoxia (PaO2 <70mmHg, PaCO2 >45mmHg)<br />
2) Seizures<br />
3) Deteriorating consciousness<br />
<br />
If ET intubation fails, cricothyroidotomy is the next step.<br />
(Easier to perform compared to tracheostomy).<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.surgeryencyclopedia.com/images/gesu_01_img0066.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.surgeryencyclopedia.com/images/gesu_01_img0066.jpg" width="335" /></a><br />
</div><br />
<br />
Locate the cricothyroid membrane, apply horizontal stab incision over it using a scapel.<br />
Insert the scapel handle into the surgically created airway, turn it vertically.<br />
Insert a curved tracheostomy tube.<br />
<br />
Deliver high flow oxygen (14-15L/min) through nasal prongs, mask or Endotracheal tube.<br />
<br />
<b>2) Breathing</b><br />
<br />
Now that you've secure the airway, next is breathing.<br />
<b> </b>On inspection :<br />
<br />
Is there stridor? Wheezing?<br />
Count for the respiratory rate.<br />
Is there central cyanosis over the tongue?<br />
Is there usage of accesory muscles of respiration?<br />
Is there obvious wounds over the chest?<br />
Is there any asymmetry in chest movements? (pneumo/hemothorax)<br />
Is there paradoxical chest movements? (flail chest)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/_4XalECA8LI8/Sf0WtduffFI/AAAAAAAAAJE/3qj_jGVmomw/s1600/ethereal-heaven-flail-chest.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://4.bp.blogspot.com/_4XalECA8LI8/Sf0WtduffFI/AAAAAAAAAJE/3qj_jGVmomw/s320/ethereal-heaven-flail-chest.png" width="320" /></a><br />
</div><br />
On palpation :<br />
<br />
Is there tracheal deviation?<br />
Is there any palpable surgical emphysema (palpable crepitation over neck/chest)?<br />
<br />
On percussion and auscultation :<br />
<br />
Any dull/hyperresonant note on percussion?<br />
Breathing sound -> is it normal on auscultation?<br />
<br />
Now, if there's evidence of pneumothorax, hemothorax, next step is to perform chest drain, as below :<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.itim.nsw.gov.au/images/chest_tube.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://www.itim.nsw.gov.au/images/chest_tube.jpg" width="400" /></a><br />
</div><br />
1) Prop the patient in semi-reccumbent position<br />
2) Raise the ipsilateral hand above the head<br />
3) Apply incision on the skin over 5th and 6th ribs, at the anterior axillary line<br />
4) Using forceps, dissect (tunneling) the skin until the pleura is visible<br />
5) Puncture the pleura in upwards direction just above the upper border of the ribs. (To avoid neurovascular bundle of intercostal space)<br />
6) Prepare a catheter, with should be clamped first<br />
7) Insert the catheter, place the other end into a underwater drainage seal bottle. Unclamp the cathter<br />
<br />
For simple pneumothorax, tube of size 22-24 F is required.<br />
For massive hemothorax/pneumothorax, tube of size 36-40 F is required.<br />
<br />
Connect the patient to a pulse oxymeter.<br />
<br />
<b>Tension pneumothorax <br />
</b><br />
<br />
A medical emergency - any delay -> death ensues<br />
<b> </b>Symptoms -> Dyspnoea, Tachypnoea, Pleuritic chest pain, collapse<br />
Signs -> Hypotension, Raised JVP, Tracheal deviated to opposite, Hyperresonant percussion note, absent breath sounds<br />
<br />
Remember that tension pneumothorax is a clinical diagnosis, where immediate decompression is required by means of needle thoracostomy. (Don't waste time during various investigations)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.tacticalresponsegear.com/catalog/images/14needleza.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="258" src="http://www.tacticalresponsegear.com/catalog/images/14needleza.jpg" width="400" /></a><br />
</div><br />
Needle thoracostomy is performed as follows :<br />
<br />
1) Use a wide bore needle with catheter, and puncture the 2nd intercostal space on midclavicular line<br />
2) Rapid gush of air indicates tension pneumothorax<br />
3) Remove the needle, insert the catheter<br />
4) Lastly, connect the other end of catheter into a underwater sealed drainage bottle.<br />
<br />
<b>3) Circulation</b><br />
<br />
The goal in circulatory assessment is to determine whether the patient is in shock. Signs indicative of shock :<br />
<br />
a) Extremities - cool and clammy<br />
b) Prolonged capillary refilling time (normal is <2 secs)<br />
c) Thready/feeble pulse, with rate >100 bpm<br />
d) Hypotension (systolic BP <90 mmHg)<br />
e) Altered mental status<b> - </b>agitation, confusion, unconscious<br />
f) Abnormal respiration<br />
g) Reduced urine output (normal = 1ml/kg/min)<br />
<br />
One should immediately gain IV access, using in case signs of shock is present, using short and wide bore cannula of size 14-16 F<br />
Perform fluid resuscitation -> 2L of Crystalloids given (either normal saline/Ringer lactate/Hartmann's solution)<br />
<br />
<b>Don't use dextrose!</b><br />
Dextrose will be metabolised by our body, rendering the fluid hypotonic, and hence unable to maintained within the vascular compartment.<br />
In other words, they are poor plasma expanders<br />
<br />
For patients didn't respond to crystalloids, try colloids (gelufundin)<br />
Any revealed/conceal site of hemorrhage -> compression bandage is applied<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.directmedicalinc.com/images/sn66020016.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.directmedicalinc.com/images/sn66020016.jpg" width="320" /></a><br />
</div><br />
<br />
If patients condition is not improving or there's major bleed, prepare emergency O blood transfusion.<br />
For males, O +ve blood can be given.<br />
However, for females, only O -ve blood can be given for those within reproductive age group.<br />
<br />
Now sent blood for investigations :<br />
<br />
FBC, Blood grouping/Cross matching, BUSE, Coagulation profile, ABG<br />
<br />
<b>Remember to warm the blood before transfusion to prevent hypothermia. Patient should be covered with blankets as well.</b><b> <br />
</b><br />
<b> </b> <br />
If patient's condition is still not improving, use inotropics (either dobutamine, dopamine, adrenaline, nor-adrenaline)<br />
<br />
<b>Cardiac tamponade</b><br />
<br />
In cases of hemopericardium, there's compression over the cardiac chambers, causing obstructive shock, where venous return is impeded.<br />
<b> </b>Becks triad of Obstructive shock = Raised JVP, hypotension, faint/absent heart sounds<br />
Can be diagnosed rapidly using FAST (Focused Abdominal Sonography for Trauma) <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://farm4.static.flickr.com/3625/3514301565_a69df64035_o.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="318" src="http://farm4.static.flickr.com/3625/3514301565_a69df64035_o.jpg" width="400" /></a><br />
</div><br />
First, try needle cardiocentesis.<br />
Usually it's unsuccesful since blood within the pericardium is clotted.<br />
Hence, most of the time, surgical decompression is required.<br />
Mean time waiting for surgery, intropics are given.<br />
<br />
<b>Detection of bleeding</b><br />
<br />
Stop all revealed hemorrhage - scalp, skin, nose, etc<br />
<b> </b>For other concealed sites, search over the :<br />
<br />
Pleural cavity<br />
Peritoneal cavity<br />
Retroperitoneum<br />
Pericardial cavity<br />
Pelvic cavity<br />
Bone fractures<br />
<br />
<b>4) Disability</b><br />
<br />
To assess the neurological impairment on patient.<br />
Start with GCS :<br />
<br />
Lowest score 3/15, Highest score 15/15<br />
There are 3 components :<br />
<br />
<b>Eye movements</b><br />
<br />
Eye opens spontaneously -> 4<br />
<b> </b>Opens only on verbal stimulus -> 3<br />
Opens only on painful stimulus* -> 2<br />
No response -> 1<br />
<br />
*given as sternal rub, squeezing of trapezius<br />
<br />
<b>Verbal response</b><br />
<br />
Oriented, conversing -> 5<br />
<b> </b>Disoriented, conversing -> 4<br />
Inappropriate words -> 3<br />
Incoherent words -> 2<br />
No response -> 1<br />
Patient is intubated -> T<br />
<br />
<b>Motor response</b><br />
<br />
Moves according to instruction -> 6<br />
<b> </b>Localising pain -> 5<br />
Flexion withdrawal -> 4<br />
Abnormal flexion -> 3<br />
Abnormal extension -> 2<br />
No response -> 1<br />
<br />
Next, check for pupillary response towards light.<br />
In case of internal hematoma, initially there'll be constriction, followed by dilatation. If ICP is not reduced, the opposite pupil will be affected as well.<br />
<br />
Then, identify any signs of raised ICP.<br />
Finally, examine if there's any signs of 3rd, 4th, 6th nerve palsy or any obvious limb paralysis.<br />
<br />
<b>5) Exposure</b><br />
<br />
Cut off the clothes to expose other possible wounds (any lacerations, abrasions, contusions)<br />
Inspect the front and back (for the back, perform log roll)<br />
Any fractures -> splint it<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://cdn-viper.demandvideo.com/media/b8757897-8ab0-4858-9d69-db193b1677b7/jpeg/aa7797fe-9c23-4f6d-8a9a-6a300f6b0885_5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="212" src="http://cdn-viper.demandvideo.com/media/b8757897-8ab0-4858-9d69-db193b1677b7/jpeg/aa7797fe-9c23-4f6d-8a9a-6a300f6b0885_5.jpg" width="320" /></a><br />
</div><br />
<br />
Splint/immobilise any swollen/deformed areas, which can be possibly fractured, to prevent further injury, reduce pain and bleeding.<br />
Any compound fracture, sterile dressing should be applied first.<br />
<br />
<b>At the end of primary survey, these should be done :</b><br />
<b> <br />
</b><br />
<b>a) Insertion of Ryle's tube</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://product-image.tradeindia.com/00148912/b/0/Ryles-Tube.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://product-image.tradeindia.com/00148912/b/0/Ryles-Tube.jpg" width="320" /></a><br />
</div><br />
<b></b>Insert through nostrils -> known as NG tube<br />
If there's nasal bleeding + h/o of head injury -> fracture of skull base<br />
Hence, Ryle's tube is passed through the mouth -> Orogastric tube (OG tube)<br />
<br />
<b>b) Urinary catheterization</b><br />
<br />
Using a self-retaining foley's catheter perform a continuous bladder drainage.<br />
<b> </b>If not possible, perform a suprapubic cystostomy.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-82964-83818.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-82964-83818.jpg" width="400" /></a><br />
</div><br />
Bear in mind that any blood present within the urethral meatus, which may indicate urethral rupture, is one of the contraindication against catheterisation.<br />
<br />
(You might convert a partial rupture into a complete rupture by passing the tube!)<br />
<br />
Other contraindications includes -> pelvic fracture, perineal injury<br />
Monitor urine output -> to be at least 0.5ml/kg/min<br />
<br />
<b>c) Wound</b><br />
<br />
Treat any wound by dressing to prevent contamination<br />
<b> </b>Any bleeding wound should be given compressive dressing<br />
<br />
<b>d) Monitor</b><br />
<br />
Monitor patient's vital signs (BP, RR, PR, Temperature), GCS, pupillary response, and Oxygen saturation.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.daviddarling.info/images/pulse_oximeter.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="335" src="http://www.daviddarling.info/images/pulse_oximeter.jpg" width="400" /></a><br />
</div><br />
<br />
<b> </b>For an unstable patient, connect the patient to an ECG monitor and pulse oxymeter.<br />
Monitor patients vital signs every 15 minutes, until the patient is stabilised for more than 1 hour.<br />
<br />
<b>e) Investigations</b><br />
<br />
<b>Blood (</b>as mentioned above)<br />
<b>Urine - </b>FEME<br />
<b>X ray</b><br />
<br />
Lateral view of cervical spine<br />
<b> </b>Chest X ray<br />
Pelvic X rayfusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-45005165057201113992009-12-06T05:19:00.000-08:002009-12-06T05:19:01.424-08:00OGDS and ColonoscopyAs Housemen, you need to know about the indications, preparations, complications<br />
<br />
<b>Oesophagogastroduodenoscopy (OGDS)</b><br />
<br />
<a href="http://www.antonine-education.co.uk/Physics_A2/Options/Module_6/Topic_6/endoscope_2.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="223" src="http://www.antonine-education.co.uk/Physics_A2/Options/Module_6/Topic_6/endoscope_2.gif" width="400" /></a><br />
Indications :<br />
<b><br />
</b><br />
1) For investigation of :<br />
<br />
<b>Dyspepsia</b><br />
Upper GI symptoms not responsive to optimal treatment<br />
Patients >45 yrs with alarmic dyspeptic symptoms, eg :<br />
<br />
Chest pain<br />
Odynophagia<br />
Weight loss<br />
Anemia, evidence of GI bleeding<br />
Dysphagia<br />
<br />
<b>Dysphagia/Odynophagia</b><br />
<b> Unexplained iron deficiency anemia</b><br />
<b>GI bleeding (Acute/Recent/Occult)</b><br />
<b>Re-evaluation of previous upper GI bleeding</b><br />
<b>Confirmation of radiologically demonstrated lesion</b><br />
<b> Suspected portal hypertension</b><br />
<b>Surveillance of tissue/fluid sampling (Barrett's/Polyposis)</b><br />
<br />
2) Therapeutic interventions<br />
<br />
<b>On-going upper GI bleeding (variceal for eg)</b><br />
<b>Variceal treatment</b><br />
<b>Removal of selected polyps<br />
</b><br />
<b>Removal of foreign bodies</b><br />
<b>Dilatation of stenotic lesions</b><br />
<b>Placement of feeding tube <br />
</b><br />
<b>Palliative treatment for neoplasm</b><br />
<br />
Preparation :<br />
<b> <br />
</b><br />
1) Informed consent<br />
2) Patient may need to stop anti-platelet medications (aspirin, clopidogrel) 1 week prior to procedure, and diabetic medication 1 day before procedure<br />
3) Antibiotic prophylaxis for patients with :<br />
<br />
Undergoing high-risk endoscopies : Dilatation of stenotic lesions, Variceal bleeding<br />
Previous h/o of infective endocarditis, those with prosthetic heart valves<br />
<br />
4) Nil by mouth at least 6 hours prior to procedure<br />
5) Pre-procedural investigations :<br />
<br />
FBC, Blood grouping/Cross matching, Coagulation profile, UPT, urinalysis, ECG and chest X ray<br />
<br />
6) Sedative given before procedure (diazepam). Hence, ask patient not to come alone or don't drive after procedure.<br />
<br />
<b>Contraindications :</b><br />
<br />
Uncooperative patients, Medically unstable patients, risk of perforation is high<br />
<b> </b><br />
<b>Complications : </b>Bleeding, infection, perforation, cardiopulmonary problems<br />
<br />
<br />
<b>Colonoscopy</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.optavisse.com/media/images/misc/Colonoscopy%20Image.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.optavisse.com/media/images/misc/Colonoscopy%20Image.jpg" width="370" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Indications :</b><br />
</div><div class="separator" style="clear: both; text-align: left;"> <br />
</div><div class="separator" style="clear: both; text-align: left;">1) Investigation<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Unexplained iron deficiency anemia</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Altered bowel habits</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Chronic diarrhoea</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Inflammatory bowel disease</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Lower GI bleeding for patients >40 yrs of age (occult blood is included)</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">2) Therapeutic<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><b>Removal of foreign bodies</b><br />
<b>Treatment of bleeding</b><br />
<b>Excision of polyps</b><br />
<b>Decompression/Megacolon/Volvulus</b><br />
<b> </b><br />
<b>Preparations :</b><br />
<br />
1) Informed consent<br />
2) Patient may need to stop anti-platelet medications (aspirin, clopidogrel) 1 week prior to procedure, and diabetic medication 1 day before procedure<br />
3) Antibiotic prophylaxis for patients with previous h/o of infective endocarditis, those with prosthetic heart valves<br />
4) 2 days prior to procedure, avoid solid foods, take only food which are easily digestible, eg :<br />
<br />
Porridge, Noodles in clear soup, Low Fibre food<br />
<br />
5) 1 day prior to procedure, only fluids !<br />
<br />
eg, Coffee/Tea without milk, Carbonated drinks (not reddish/purplish), Strained fruit juices<br />
<br />
6) Laxatives taken 1 day prior to procedure (tablets bisacodyl)<br />
7) Night before procedure - NIL BY MOUTH<br />
8) Day of procedure - try to empty bowel before procedure<br />
9) Sedative given.<br />
<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><b> </b><br />
<br />
<br />
<b> </b><b> </b><br />
<br />
<b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com1tag:blogger.com,1999:blog-452176958433124785.post-36953089738823703032009-12-06T04:25:00.000-08:002009-12-06T04:25:24.327-08:00Scrotal swelling<b>Classifications</b><br />
<br />
<b>1) Congenital </b><br />
<b><br />
</b><br />
<a href="http://content.nejm.org/content/vol361/issue7/images/large/11f1.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="272" src="http://content.nejm.org/content/vol361/issue7/images/large/11f1.jpeg" width="400" /></a><br />
Congenital hydrocele<br />
Congenital indirect inguinal hernia<br />
<br />
<b>2) Inflammatory</b><br />
<br />
Cellulitis of scrotal skin - skin appears red, shinny, warm, tender<br />
Pyocele - pus accumulation within tunica vaginalis, fluctuates, non-transilluminant<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/fullsize/migrated/441/224/iim441224.fig.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://img.medscape.com/fullsize/migrated/441/224/iim441224.fig.jpg" width="213" /></a><br />
</div><br />
<br />
Orchitis/Epididymo-orchitis/Epididymitis - tender, non-fluctuent swelling<br />
Funiculitis - tender and thickened spermatic cord<br />
<br />
<b>3) Neoplastic</b><br />
<br />
There's no benign testicular tumours!<br />
<br />
<b>Malignant </b><br />
<br />
Primary : Seminoma, Teratoma, Leydig cell tumour, Sertoli cell tumour, Lymphoma<br />
Secondaries from other sites<br />
<br />
<b>4) Others</b><br />
<br />
Hydrocele<br />
Hydatid cyst of morgagni<br />
Epididymal cyst (smooth, uni/multi-locular swelling located behind the testis, brilliantly transilluminate)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.riversideonline.com/source/images/image_popup/ans7_spermatocele.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="380" src="http://www.riversideonline.com/source/images/image_popup/ans7_spermatocele.jpg" width="400" /></a><br />
</div><br />
<br />
Spermatocele (above and behind the upper pole of testis, poorly transilluminate)<br />
Encysted hydrocele of the cord<br />
<br />
<a href="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19472.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19472.jpg" width="400" /></a><br />
Varicocele<br />
<br />
<b>History taking</b><br />
<br />
<b>1) Onset</b><br />
<b> </b><br />
Sudden onset of scrotal swelling may be hematocele (with h/o of trauma)<br />
Acute onset can be inflammatory causes (Epididymitis, Orchitis, E-Orchitis)<br />
Insidious - usually hydrocele or testicular tumour<br />
<br />
<b>2) Progression</b><br />
<br />
Rapid progression - inflammatory swellings or hemorrhage into a cyst/hydrocele<br />
<b> </b><br />
<b> 3) Association with pain</b><br />
<br />
Inflammatory swellings are painful.<br />
Acute epididymo-orchitis must be differentiated from Testicular torsion.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.bmj.com/content/vol312/issue7034/images/large/703405.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="325" src="http://www.bmj.com/content/vol312/issue7034/images/large/703405.jpeg" width="400" /></a><br />
</div><br />
<br />
The former, as testis is elevated - pain reduces (increases support on testis)<br />
The latter, as testis is elevated - pain worsens (increases the degree of torsion)<br />
<br />
<b>4) Association with fever</b><br />
<br />
Low, moderate, high grade<br />
Intermittent, remittent, continuous<br />
Both acute epididymo-orchitis and scrotal abscess presents with fever<br />
<br />
<b>5) Urinary symptoms</b><br />
<br />
A positive h/o of UTI is important for acute epididymo-orchitis<br />
Ask for frequency and dysuria<br />
<br />
<b>On examination</b><br />
<br />
<b>1) Inspection</b><br />
<b> </b><br />
Comment whether one side or both sides are involved<br />
Check whether the swelling extends up to the inguinal region, which can be :<br />
<br />
Infantile hydrocele<br />
Inguino-scrotal hernia<br />
<br />
Ask the patient to cough, look for expansile cough impulse, which can be :<br />
<br />
Hernia, Congenital hydrocele<br />
<br />
Inspect the skin over swelling, comment on it's colour and rugosity, whether :<br />
<br />
Stretched + shinny -> inflammatory<br />
Stretched + normal rugosity -> Hydrocele, testicular tumours<br />
<br />
Inspect whether there's any skin lumps.<br />
Any scars, sinuses?<br />
<br />
<b>2) Palpation</b><br />
<br />
<b>Try to get above the swelling</b>, it means that the cord is palpable above the swelling. This is to confirm that it's a pure scrotal swelling.<br />
<b> </b><br />
<b>Comment on the position of testis</b> :<br />
<br />
Swelling is anterior to testis -> Hydrocele (but usually hydrocele will be too large for the testis to be separately palpable)<br />
Swelling is attached to the top of testis, cystic -> Hydatid cyst of morgagni<br />
Cystic swelling behind the testis, more towards the upper pole -> Epididymal cyst<br />
Swelling above and behind the upper pole of testis -> Spermatocele<br />
Cystic swelling palpable at the root of scrotum -> Encysted hydrocele of cord<br />
<br />
(Can be mistaken as direct inguinal hernia - try pulling the scrotal skin down, it'll descend and becomes less mobile)<br />
<br />
Testicular swellings can be either tumour or inflammatory<br />
Varicocele - feels like a bag of worms<br />
<br />
<b>Tenderness</b> - for any inflammatory swellings (acute pyocele, hematocele, acute epididymo-orchitis), and sometimes, very tensed cyst<br />
<br />
<b>Consistency</b><br />
Soft - Spermatocele<br />
<b> </b>Cystic - Epididymal cyst<br />
Tense - Hydrocele<br />
Firm - Acute epididymo-orchitis<br />
Hard - Testicular tumours<br />
<br />
<b>Palpate the contents of scrotum</b><br />
Feel for the cord and vas deferens.<br />
<b> </b>The vas deferens will be normal but the cord is thickened - testicular tumour<br />
Both vas deferens and cord is thickened and tender - Acute epididymo-orchitis<br />
Skin not pinchable - testicular tumours infiltrated to skin<br />
Varicocele - bag of worms while patient standing, resolves as he lies down<br />
<br />
<b>Cough impulse - </b>Felt in case of hernia, palpable thrill in varicocele<br />
<br />
<b>Fluctuation positive - </b>all swelling contains fluid<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.hakeem-sy.com/main/files/images/HydrocoeleTransillumination.preview.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.hakeem-sy.com/main/files/images/HydrocoeleTransillumination.preview.jpg" width="300" /></a><br />
</div><br />
<b> <br />
</b><br />
<b>Transillumination test</b><br />
<br />
<b>3) Examine the inguinal nodes</b><br />
<b>4) Examine the abdomen</b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com1tag:blogger.com,1999:blog-452176958433124785.post-44974573328787463882009-12-06T00:39:00.000-08:002009-12-06T00:39:16.596-08:00Common Anal Diseases<b>Briefly about anatomy of anal canal</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.prn.org/images/uploads/Palefsky-fig4-680.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.prn.org/images/uploads/Palefsky-fig4-680.gif" width="365" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;">The anal canal commences from the level where the rectum passes through the pelvic diaphragm towards the anal verge. The junction in between the anal canal and rectum is the anorectal ring/bundle which can be felt during PR examination.<br />
</div><div class="separator" style="clear: both; text-align: left;">The internal sphinchter is a circular, non-striated, involuntary muscles innervated by autonomic nerves.<br />
</div><div class="separator" style="clear: both; text-align: left;">The external sphincter is striated, voluntary muscles innervated by pudendal nerves.<br />
</div><div class="separator" style="clear: both; text-align: left;">The superior part of external sphincter fuses with the puborectalis muscle to form the anorectal bundle, for maintainance of continence.<br />
</div><div class="separator" style="clear: both; text-align: left;">The lower part of anal canal is lined by the sensitive squamous cell epithelium<br />
</div><div class="separator" style="clear: both; text-align: left;">The lymphatic drainage of the lower half of anal canal is drained into the inguinal lymph nodes<br />
</div><div class="separator" style="clear: both; text-align: left;">Blood supply - superior, middle and inferior rectal vessels.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Haemorrhoids</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><a href="http://upload.wikimedia.org/wikipedia/commons/3/30/Hemorrhoids2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="308" src="http://upload.wikimedia.org/wikipedia/commons/3/30/Hemorrhoids2.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">The anal canal contains 3 anal cushions, which serves as a gas-fluid protective barrier and closes it. When these cushions enlarge, they can prolapse, and when they're damaged, it causes bleeding.<br />
</div><div class="separator" style="clear: both; text-align: left;">Chronic hemorrhoids produces pile mass, as the processes are compressing on the perianal skin below it, produces external skin tags. <br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>How it cause bleeding?</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><a href="http://www.hemroidharry.com/blog/wp-content/uploads/2009/01/hemroidpic.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="260" src="http://www.hemroidharry.com/blog/wp-content/uploads/2009/01/hemroidpic.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">As these vascular pads becomes haemorrhoids, they assumed into a position closer to the anorectal junction.<br />
</div><div class="separator" style="clear: both; text-align: left;">During defecation, as the anal canal everts, the stools compressed against the vascular pads, scratching the mucosa over it.<br />
</div><div class="separator" style="clear: both; text-align: left;">After defecation, the vascular pads are remained scratched, and hence, blood start to trickle down.<br />
</div><div class="separator" style="clear: both; text-align: left;">If the vascular pads are unable to reduce after the anal sphincter closes, it worsens the bleeding by impairing it's venous return.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Symptoms (History)</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Usually seen in individuals > 20 yrs of age. Extremely rare in children.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Bear in mind that uncomplicated piles are not painful.<br />
</div><div class="separator" style="clear: both; text-align: left;">Hence, it usually causing painless PR bleeding, which can be mild (notice on wiping your ASS after shitting), or can be severe to the extent of splashing all over the lavatory and eventually causing iron deficiency anemia.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Due to mucus discharge from the surface of hemorrhoids, it can cause pruritus ani.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Another important symptom is sensation of prolapse after defecation, or palpable lump. This forms the basis of the classification of piles based on the severity of prolapse :<br />
</div><div class="separator" style="clear: both; text-align: left;"><b></b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Grade 1 : Only bleeding, no prolapse</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Grade 2 : Prolapse occurs, but reduces spontaneously</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Grade 3 : Doesn't reduce spontaneously (reduce manually)</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Grade 4 : Irreducible</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">However, such classification is artificial, since every hemorrhoids prolapsed during defecation, the only way where it leads to bleeding.<br />
</div><div class="separator" style="clear: both; text-align: left;">Hence, to translate it clinically :<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Grade 1</b><br />
</div><div class="separator" style="clear: both; text-align: left;">Prolapse occurs during defecation, but reduces back to it's normal position when the anal sphincter closes. Hence, no lump is noticed by the patient.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> Grade 2</b><br />
</div><div class="separator" style="clear: both; text-align: left;">The prolapse occured during defecation, reduces back spontaneously but slowly.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Only complicated piles, when it strangulates, thrombosed, becomes gangrenous, fibrosed causing pain. Also known as acute hemorrhoidal crisis.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">If the patient has any underlying coagulopathy, bleeding disorders, or taking aniticoagulants, piles may bleed massively.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Examination</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Don't ever forget that non-prolapsed/thrombosed piles can't be diagnosed by your fingers! It's indistinguishable from normal mucosa.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Hence, a sigmoidoscopy/proctoscopy is very much required.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"> <a href="http://upload.wikimedia.org/wikipedia/commons/7/72/Hemorrhoids.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="330" src="http://upload.wikimedia.org/wikipedia/commons/7/72/Hemorrhoids.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">However, 3rd/4th degree hemorrhoids, since it's visible, you may be able to make a spot diagnosis.<br />
</div><div class="separator" style="clear: both; text-align: left;">It's a bluish-purplish swelling, with diameter of 1-2cm, with soft mucosal surface, usually non-tender (unless complicated), with mucus-exuding surface.<br />
</div><div class="separator" style="clear: both; text-align: left;">If it's complicated, it'll be tense, tender, oedematous.<br />
</div><div class="separator" style="clear: both; text-align: left;">Sigmoidoscopy and proctoscopy is still required to rule out other rectal pathology.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Management</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">For acute hemorrhoidal crisis, many surgeons thought that surgical intervention at this stage may cause portal pyemia.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>But, it's not true -> if early antibiotic coverage is given.<br />
</div><div class="separator" style="clear: both; text-align: left;">Yet, many surgeons usually wait until the acute phase is over, and then only decide whether hemorrhoidectomy is required.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">During acute phase :<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Analgesics given.<br />
</div><div class="separator" style="clear: both; text-align: left;">Apply cold/warm saline bag pressure -> mass usually shrinks after 3-4 days<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">For 1st-2nd degree haemorrhoids :<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Give defecatory advice - only shit when the desire is there (don't simply shit), apply correct shitting position to minimise straining, in addition of stool softerners and bulk forming agents.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Not responsive -> Submucosal injection of 5% phenol in almond oil<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Indications of hemorrhoidectomy</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>1) 3rd-4th degree</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> 2) 2nd degree non-responsive to non-operative management</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>3) Fibrosed haemorrhoids</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Perianal hematoma</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><b></b><br />
<a href="http://upload.wikimedia.org/wikipedia/en/thumb/d/d4/Perianal_hematoma.jpg/180px-Perianal_hematoma.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="321" src="http://upload.wikimedia.org/wikipedia/en/thumb/d/d4/Perianal_hematoma.jpg/180px-Perianal_hematoma.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;">It's actually a misnomer, since it's not a true hematoma.<br />
</div><div class="separator" style="clear: both; text-align: left;">It's caused by thrombosis of a subcutaneous veins within the anal tissue, secondary to injury of venous wall while straining on defecation.<br />
</div><div class="separator" style="clear: both; text-align: left;">The thrombosis subsequently causing inflammation and edema of the surrounding tissues.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>History</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Age </b><br />
</div><div class="separator" style="clear: both; text-align: left;">Any age, no sexual predilection<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Symptoms</b><br />
</div><div class="separator" style="clear: both; text-align: left;">Characterised by anal pain, which gradually increases in it's intensity over hours, and subsides after a few days. It causes a continuous discomfort, worsened by sitting, walking, etc.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> <br />
</b><br />
</div><div class="separator" style="clear: both; text-align: left;">It is associated with the presence of a lump in the anus, which initially small in size, and gradually enlarges when it becomes more painful.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">If the lump ruptures through the skin, or it ulcerates, it can cause PR bleeding.<br />
</div><div class="separator" style="clear: both; text-align: left;">Since it causes partial opening of the anus, as there's continuous mucus discharge, it results in pruritus ani.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Can be triggered by episodes of straining at stools while defecating.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Signs</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">The lump can be located anywhere along the anal margin.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>The skin over it appears reddish-purplish.<br />
</div><div class="separator" style="clear: both; text-align: left;">Size is usually small initially (1x1cm), with hemispherical shape, gradually enlarges in size, which becomes polypoidal.<br />
</div><div class="separator" style="clear: both; text-align: left;">With smooth surface, hard in consistency.<br />
</div><div class="separator" style="clear: both; text-align: left;">It's tender, but disproportionate to what the patient complaints of.<br />
</div><div class="separator" style="clear: both; text-align: left;">Not fix to the skin, nor it can be reduced back into the anal canal.<br />
</div><div class="separator" style="clear: both; text-align: left;">Local/regional lymph nodes are not enlarged.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Fistula in ano</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
<a href="http://meded.ucsd.edu/clinicalimg/gu_fia.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://meded.ucsd.edu/clinicalimg/gu_fia.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">A fistula is a track, lined by squamous epithelium/granulation tissues, connecting two epithelised surface, either in between 2 body cavities, or 1 body cavity - external skin surface.<br />
</div><div class="separator" style="clear: both; text-align: left;"> <br />
</div><div class="separator" style="clear: both; text-align: left;"> <br />
<a href="http://fitsweb.uchc.edu/student/selectives/Luzietti/images/anus/anorectal_fistula_1.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://fitsweb.uchc.edu/student/selectives/Luzietti/images/anus/anorectal_fistula_1.JPG" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Hence, fistula in ano is an abnormal, fistulous connection between the rectum or anal canal to the external skin. Usually caused by a ruptured intersphincteric abscess. It has an external opening on the skin, and an internal opening, which can be classified based on it's relative position to the anorectal ring :<br />
</div><div class="separator" style="clear: both; text-align: left;"> <br />
</div><div class="separator" style="clear: both; text-align: left;"><b>High level fistula</b><br />
</div><div class="separator" style="clear: both; text-align: left;">Internal opening located above the anorectal ring. As it tracks through the anorectal bundle, it causes incontinence. Different varieties of it includes :<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Extra-sphincteric, Trans-sphincteric, Inter-sphincteric<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Low level fistula</b><br />
</div><div class="separator" style="clear: both; text-align: left;">Internal opening located below anorectal ring. It doesn't cause incontinence.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Different varieties includes :<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Trans-sphincteric, Inter-sphincteric, Subcutaneous/Submucosal<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Goodsall's rule</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
<a href="http://img.medscape.com/pi/emed/ckb/general_surgery/188616-190234-3129.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="322" src="http://img.medscape.com/pi/emed/ckb/general_surgery/188616-190234-3129.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">According to goodsall's rule, any anterior fistula will have it's internal opening located along a line drawn radially, connecting the external opening to the anus.<br />
</div><div class="separator" style="clear: both; text-align: left;">Whilst any posterior fistula, regardless of it's position, will have is internal opening, located at the posteior anus, on midline position.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>History</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Patient may have h/o of perianal abscess, might have been drained or healed.<br />
</div><div class="separator" style="clear: both; text-align: left;">Commonest symptoms is watery, serous, purulent discharge from the external opening.<br />
</div><div class="separator" style="clear: both; text-align: left;">They may complaint of bubbling sensation during defecation, as stool passes through the anal canal, it forces mucous discharge from the fistula. This also prevents healing of the fistula.<br />
</div><div class="separator" style="clear: both; text-align: left;">Periodic throbbing pain can be there as pus accumulates within the tract.<br />
</div><div class="separator" style="clear: both; text-align: left;">Persistent mucous discharge causing pruritus ani.<br />
</div><div class="separator" style="clear: both; text-align: left;">Some amount of bleeding might be there. (from external opening)<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">In your history taking, also ask for symptoms of inflammatory bowel disease, any abdominal upset, systemic upset.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>On examination</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
<a href="http://www.nzma.org.nz/journal/121-1276/3116/content01.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="287" src="http://www.nzma.org.nz/journal/121-1276/3116/content01.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">You'll notice that the discharge can be either serous or pustulous.<br />
</div><div class="separator" style="clear: both; text-align: left;">The external opening is seen as tufts of granulation tissues or puckered scars.<br />
</div><div class="separator" style="clear: both; text-align: left;">Rectal examination is usually not painful.<br />
</div><div class="separator" style="clear: both; text-align: left;">The internal opening is felt as an area of induration or a nodule under the anal mucosa. Most of the time, the tract is palpable.<br />
</div><div class="separator" style="clear: both; text-align: left;">Look for any other evidence of Anal carcinoma, TB, or IBD.<br />
</div><div class="separator" style="clear: both; text-align: left;">Confirm your examination findings using sigmoidoscopy/proctoscopy.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">If the inguinal nodes are enlarged -> either due to infection of the fistulous tract, or infiltrative anal carcinoma.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Treatment : Fistulotomy, Fistulectomy</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Anal fissure</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><br />
</div><div class="separator" style="clear: both; text-align: left;">Defined as a longituidinal split in the anal skin.<br />
<a href="http://graphics8.nytimes.com/images/2007/08/01/health/adam/15770.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://graphics8.nytimes.com/images/2007/08/01/health/adam/15770.jpg" width="400" /></a><br />
</div><div class="" style="clear: both; text-align: left;">Acute tear is common, especially when there's excessive straining during defecation (hard stools?), and it usually heals rapidly. But during next defecation, as the stool stretches the anal canal, it causes the split to gape, leading to pain and bleeding. Then, it's so painful that the anal sphincter undergoes spasm.<br />
</div><div class="" style="clear: both; text-align: left;">Hence, a viscious cycle of tear-pain-spasm occurs, and produces further pain. Eventually, as the fissure becomes chronic, fibrosis occurs and a chronic ulcer is produced.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://www.netterimages.com/images/vpv/000/000/020/20075-0550x0475.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.netterimages.com/images/vpv/000/000/020/20075-0550x0475.jpg" width="345" /></a><br />
</div><div class="" style="clear: both; text-align: left;"> <b>History</b><br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">This condition can be quite common in children as they frequently passes bulky stools rapidly.<br />
</div><div class="" style="clear: both; text-align: left;">In adults, usually occurs in between 20-40 yrs of age, slightly more common in males. In females, might be seen after delivery.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">Severe anal pain on defecation is the chief complaint, which is tearing in character. Persistent, throbbing pain is there minutes or even hours after defecation. It's sometimes so painful that the patient might be apprehensive towards defecation, and ended up accumulating large volume of hard stools within the rectum. This only causes more pain during next defecation.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">Since there's spasm of anal sphincter, patient might find it difficult to pass motion. (As for laymen, constipation)<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">There's streaking of stools with blood, or the patient notices blood while wiping their ass after defecation. As with chronic fissure, there's only mild-bleeding.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">In chronic fissures, sometimes there's a sentinel-skin tag palpable at the lower end of the fissure. And due to the hypertrophy of the anal papillae, mucus discharge from the ulcer causing pruritus ani.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;"><b>Examination</b><br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="http://www.bmj.com/rrgraphics/38534.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://www.bmj.com/rrgraphics/38534.gif" width="400" /></a><br />
</div><div class="" style="clear: both; text-align: left;"><b><br />
</b><br />
</div><div class="" style="clear: both; text-align: left;">Most anal fissures are located at the posterior midline of anal skin, some at the anterior midline, rarely lateral.<br />
</div><div class="" style="clear: both; text-align: left;">Usually diagnosed by separating the anal skin, and the split is visible.<br />
</div><div class="" style="clear: both; text-align: left;">Rectal examination is usually not possible as it's too painful.<br />
</div><div class="" style="clear: both; text-align: left;">However, if it's not too painful for the patient, anal skin defect can be felt during examination, surrounded by area of induration.<br />
</div><div class="" style="clear: both; text-align: left;"><br />
</div><div class="" style="clear: both; text-align: left;">NO proctoscopy/sigmoidoscopy should be done on a conscious patient !!!<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com2tag:blogger.com,1999:blog-452176958433124785.post-7006047613444608422009-11-23T08:59:00.000-08:002009-11-23T08:59:09.390-08:00Portal Hypertension<b>Anatomy of the portal system :</b><br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://anatomytopics.files.wordpress.com/2009/01/portal-vein-system.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="339" src="http://anatomytopics.files.wordpress.com/2009/01/portal-vein-system.jpg" width="429" /></a><br />
</div><br />
The portal vein is formed behind the neck of pancreas, at the level of L2, by the superior mesenteric and splenic veins.<br />
It ascends up along the free edge of lesser omentum, behind the common bile duct.<br />
It enters the liver by dividing into two of it's tributaries.<br />
The left and right gastric veins joins to it.<br />
The inferior mesenteric veins drains into the splenic veins.<br />
Portal vein is valveless and hence, if there's a raised in pressure in between the right heart and the splanchnic circulation, portal pressure elevates.<br />
The portal vein carries about 1.5L of blood per minute, originating from :<br />
<br />
Small bowel (superior mesenteric vein)<br />
Large bowel (inferior mesenteric vein)<br />
Spleen (Splenic vein)<br />
Gastric vein<br />
<br />
<b>Pathophysiology</b><br />
<br />
Normal portal pressure is about 5-10mmHg.<br />
<b> </b>Portal hypertension occurs when the portal pressure elevates beyond 12mmHg.<br />
At this point, the collaterals at sites of porto-systemic anastomosis opens up in order to decompress the elevated pressure in the portal system.<br />
As the portal pressure elevates above 20mmHg, there's a risk of the friable, submucosal esophageal varices to rupture, causing massive hematemesis.<br />
<br />
<b>Sites of porto-systemic anastomosis :</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.coldbacon.com/mdtruth/pics/portal.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="633" src="http://www.coldbacon.com/mdtruth/pics/portal.jpg" width="403" /></a><br />
</div>1) Between left and short gastric veins (portal) and azygous veins (systemic) at the lower esophagus and stomach<br />
<br />
2) Caput medusae : Paraumbilical veins (systemic) and vein within the ligamentum teres (portal)<br />
<br />
3) Lower rectum : Superior and middle haemorrhoidal veins (portal) and inferior haemorrhoidal veins (systemic)<br />
<br />
4) Perihepatic veins of Sappey : Subdiagphramatic veins (portal) and Veins at the upper surface of right liver lobe (systemic)<br />
<br />
5) Retroperitoneal veins of Retzius : Retroperitoneal veins (systemic) and Superior + Inferior mesenteric veins (portal)<br />
<br />
<b>Causes :</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.netterimages.com/images/vpv/000/000/021/21573-0550x0475.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="444" src="http://www.netterimages.com/images/vpv/000/000/021/21573-0550x0475.jpg" width="382" /></a><br />
</div><b>a) Pre-hepatic Causes :</b><br />
<br />
Portal vein thrombosis - seen in umbilical sepsis (infants)<br />
Splenic vein thrombosis - Complication of pancreatitis, pancreatic tumour<br />
<br />
<b>b) Intrahepatic Causes :</b><br />
<br />
<b>i) Pre-sinusoidal :</b><br />
<b> </b><br />
Schistosomiasis <br />
Primary biliary cirrhosis <br />
Chronic active hepatitis<br />
Sarcoidosis<br />
<br />
<b>ii) Sinusoidal :</b><br />
<br />
Cirrhosis<br />
Cytotoxic drugs<br />
Vitamin A intoxication<br />
<br />
<b>iii) Post-sinusoidal :</b><br />
<br />
Cirrhosis<br />
<b> </b>Veno-occlusive diseases<br />
<br />
<b>c) Post-hepatic causes :</b><br />
<br />
Budd-Chiari's syndrome<br />
<b> </b>Tricuspid regurgitation<br />
Constrictive Pericarditis<br />
<br />
<b>Clinical presentation (History and Examination)</b><br />
<br />
Malnutrition<br />
<b> </b>Ascites<br />
Hematemesis and Malena<br />
Encephalopathy<br />
Caput medusae<br />
Splenomegaly<br />
Venous hum heard<br />
Look for signs and symptoms of chronic liver disease<br />
<br />
<b>How do you manage these patients?</b><br />
<br />
<b>1) Esophageal varices without prior h/o of bleeding</b><br />
<b> </b><br />
Medical management is ideal in such cases.<br />
Start Propanolol orally to reduce portal pressure, provided that there's no contraindication against B-blockers.<br />
If contraindication present, isosorbide-5-mononitrate is an alternative.<br />
Studies have shown that B-blockers reduces 45% of the risk of bleeding.<br />
<br />
<b>2) Ruptured esophageal varices presented with hematemesis</b><br />
<br />
95% of the cases - originating from the esophageal varices, 5% - gastric origin<br />
<b> </b>First, assess the rate and volume of bleeding :<br />
<br />
Take pulse and BP in standing and sitting position<br />
Gain IV ascess - Blood is withdrawn for hematocrit, coagulation profile, LFT and BUSE, blood grouping and cross matching<br />
Provide immediate fluid resuscitation (Crystalloids, colloids, or even blood transfusion)<br />
Insert CVP line - for ease of rapid transfusion later to prevent volume overload<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.gmail263.net/medscope/upload/20067191030468663.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="295" src="http://www.gmail263.net/medscope/upload/20067191030468663.jpg" width="400" /></a><br />
</div><br />
Start Vasopressin IV (Contraindicated in angina) or Somastostatin IV.<br />
Or Octreotide IV (more potent and duration of action is longer)<br />
<br />
Usually 3 days later, as the patient's condition has stabilised, start B-blocker to reduce portal pressure and prevent further bleeding.<br />
<br />
Plan for endoscopic treatment :<br />
<br />
a) Band ligation<br />
b) Sclerotherapy (Sodium Tetradecyl Sulphate - STS)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79927-81020-110844.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="202" src="http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79927-81020-110844.jpg" width="400" /></a><br />
</div><br />
If the patient is not reponsive to the above measures and still bleeding or endoscopic intervention is not available (district hospitals), a Sangstaken-Blakemore tube can be inserted to prevent bleeding to buy time for deciding what's the next step. (Shoiuld be removed after 48 hrs)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.pathology.vcu.edu/education/gi/EsophagealVarices-1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.pathology.vcu.edu/education/gi/EsophagealVarices-1.jpg" width="375" /></a><br />
</div><br />
Start oral neomycin (to reduce bowel flora -> less conversion of nitrogenous waste within bowel back to ammonia -> prevent hyperammonemia)<br />
Start lactulose (to reduce bowel transit time)<br />
Repeat every 2 weeks the sclerotherapy/band ligation until all the varices have been treated.fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com13tag:blogger.com,1999:blog-452176958433124785.post-75956697993923835642009-11-22T04:02:00.000-08:002009-11-22T04:02:03.284-08:00Rectal bleedingRectal bleeding usually indicates lower GI bleeding (below duodenojejunal junction). Bear in mind that any patient, aged >45 yrs old, with complaints of :<br />
<br />
colickly abdominal pain, PR bleeding and changes in bowel habits<br />
<br />
Colorectal CA must be considered unless proven otherwise.<br />
<br />
<b>Some causes of rectal bleeding</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.wrongdiagnosis.com/bookimages/4/fig180.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="437" src="http://www.wrongdiagnosis.com/bookimages/4/fig180.jpg" width="416" /></a><br />
</div><br />
<br />
<b>1) Anal cause</b><br />
<b> </b><br />
<b> a) Haemorrhoids</b><br />
<br />
Piles are very common.<br />
<b> </b>Uncomplicated piles are not painful.<br />
<br />
<b>b) Fissure-in-ano</b><br />
<br />
Fissure-in-ano usually causes painful defecation.<br />
<b> </b>The precipitating cause is usually constipation, hence constipation is usually worsened by the patient fear of passing motion, since it's painful.<br />
Pain usually persists for minutes or even hours after defecation.<br />
<br />
<b>c) Carcinoma</b><br />
<br />
The history of anal carcinoma is similar to that of Fissure-in-ano.<br />
<b> </b>However, it's usually seen in the elderly.<br />
<br />
<b>d) Trauma</b><br />
<br />
History of penetrating injury into the anus.<br />
<b> </b>Sexual abuse? Anal intercourse?<br />
<br />
<b>2) Colorectal causes</b><br />
<br />
<b>a) Carcinoma</b><br />
<b> </b><br />
As mentioned in previous posts<br />
<br />
<b>b) Polyps</b><br />
<br />
The history given by patient is usually the same as carcinoma<br />
<b> </b><br />
<b> c) Diverticulitis</b><br />
<br />
The difference between Diverticulitis and Carcinoma :<br />
<b> </b><br />
<b> Duration : </b>Diverticulitis = longer, Carcinoma = shorter<br />
<b>Pain : </b>Diverticulitis = usually painful, Carcinoma = painless (initial)<br />
<b>Bleeding pattern : </b>Diverticulitis = periodic, massive<br />
Carcinoma = usually smaller in amount, persistent<br />
<b>Mass per abdomen : </b>Diverticulitis = tender, Carcinoma = tenderless<br />
<b>Abdominal radiograph : </b>Diverticulitis = diffuse changes, Carcinoma = localised<br />
<br />
<b>d) Inflammatory bowel disease</b><br />
<br />
Usually presented as sudden onset of watery diarrhoea, together with brown stools, mucous, and blood. Ulcerative proctitis can presents as tenesmus<br />
<b> </b><br />
<b>e) Ischaemic colitis, angiodysplasia</b><br />
<b>f) Irradiative colitis</b><br />
<b> </b><br />
Especially common in patients with pelvic malignancies, due to irradiation<br />
<br />
<b>g) Rectal prolapse</b><br />
<br />
Patient usually complaints of something hanging out at his/her back opening besides PR bleeding<br />
<b> </b><br />
<b> 3) Small bowel</b><br />
<br />
<b>a) Meckel's diverticulum</b><br />
<br />
Consider this diagnosis in young adults with frequent painless PR bleeding<br />
<br />
<b>b) Acute mesenteric infarction</b><br />
<br />
Patient with h/o of cardiac disease (embolism), with complaints of diffuse abdominal pain, PR bleeding, collapse, with signs of shock, etc -> consider this as well<br />
<br />
<b>4) Massive Upper GI bleeding</b><br />
<br />
Due to the massive nature of the upper GI bleeding, the intestinal transit is fast, and hence instead of presenting with hematemesis, patient presents with massive PR bleeding, with shock-like features<br />
<br />
<b>5) Bleeding disorders</b><br />
<b>6) Drugs (anticoagulants)</b><br />
<b>7) Uremic bleeding </b><b> </b><b> </b><br />
<b>8) Infective causes - dysentry</b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-72175389718726551012009-11-22T01:48:00.000-08:002009-11-22T01:48:37.684-08:00An approach to a case of HematemesisHematemesis means vomiting of blood.<br />
It can be either a frank blood, or altered, coffee-ground coloured blood (altered by digestive enzyme)<br />
The aetiology of hematemesis is usually proximal to the duodenojejunal junction.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.wrongdiagnosis.com/bookimages/4/fig100b.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="http://www.wrongdiagnosis.com/bookimages/4/fig100b.jpg" width="449" /></a><br />
</div><br />
<br />
<b>Causes</b><br />
<br />
<b>1) Swallowed blood</b><br />
<b> </b><br />
Due to hemoptysis, epitaxis<br />
<br />
<b>2) Oesophageal causes</b><br />
<br />
Ruptured oesophageal varices<br />
<b> </b>Reflux oesophagitis<br />
Esophageal carcinoma<br />
<br />
<b>3) Stomach and duodenum</b><br />
<br />
Peptic ulcer disease<br />
<b> </b>Mallory-Weiss disease<br />
Acute gastric erosions <br />
Gastric carcinoma<br />
<br />
<b>4) Bleeding disorders</b><br />
<br />
Hemophilia<br />
Thrombocytopoenia<br />
Coagulopathy (due to liver disease)<br />
<br />
<b>5) Drugs</b><br />
<br />
NSAIDS<br />
Aspirin<br />
Steroids<br />
Anticoagulants<br />
<br />
<b>6) Others</b><br />
<br />
Uremia<br />
Connective tissue disorders<br />
<br />
<b>History : Important questions</b><br />
<br />
1) Is there any h/o of epitaxis, hemoptysis?<br />
<b> </b>2) Ask for h/o of chronic liver disease<br />
3) Any retrosternal burning chest pain radiating upwards or heartburn?<br />
4) Any h/o of dysphagia, odynophagia, weight lost?<br />
5) Ask for h/o of peptic ulcer disease<br />
6) Any h/o of consumption of large meal and alcohol?<br />
7) Does the hematemesis preceded by severe bouts of vomiting?<br />
8) Ask for h/o of anaemia<br />
9) Any recent h/o of acute pancreatitis? Any head injuries? (Cushing's ulcer) Or Any h/o of burns? (Curling's ulcer)<br />
10) Any h/o of bleeding disorders? In the family, is there any?<br />
11) Any h/o of drug intake?<br />
12) Ask for symptoms of uraemia<br />
<br />
<b>On examination</b><br />
<br />
1) Depends on the severity of bleeding, does the patients appears to be in shock?<br />
<b> <br />
</b><br />
Cool extremities<br />
Prolonged capillary filling time<br />
Tachycardia<br />
Hypotension<br />
Reduced skin turgosity<br />
Altered sensorium<br />
Sunken eyeballs<br />
Dry tongue<br />
Reduced urine output<br />
<br />
2) Check around the nose - is there any blood?<br />
<b> </b>3) Examine the chest for any cause of hemoptysis<br />
4) Look for pallor<br />
5) Look for signs of chronic liver disease<br />
6) Any epigastric mass, palpable Left SC nodes?<br />
7) Any epigastric tenderness?<br />
8) Any bruises? Any signs of uremia?<br />
<br />
<b>Investigations</b><br />
<br />
<b>1) Full blood count, ESR<br />
</b><br />
<b> </b><br />
<b> </b>Hb level, platelet count, any raised ESR? (connective tissue disorders)<br />
<br />
<b>2) Liver function test</b><br />
<b>3) Coagulation profile (PT and INR)</b><br />
<b>4) BUSE (Renal profile)</b><br />
<b>5) Oesophagogastroduodenoscopy (OGD)</b><br />
<b> </b><br />
<br />
<br />
<b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com1tag:blogger.com,1999:blog-452176958433124785.post-50071380877421943032009-11-21T16:54:00.000-08:002009-11-21T16:55:31.654-08:00Short cases - Lumps<b>1) Dermoid cyst</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.ghorayeb.com/files/Dermoid_Cyst_640x480.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://www.ghorayeb.com/files/Dermoid_Cyst_640x480.jpg" width="400" /></a><br />
</div>Dermoid cyst is a cyst located deep to the skin and lined by the skin.<br />
It forms either due to accident during antenatal development or even following injury, some skin is being implanted into the subcutaneous tissue.<br />
Hence, dermoid cyst can be congenital or accquired.<br />
<br />
<b>a) Congenital dermoid cyst</b><br />
<br />
<b>History</b><br />
<br />
May be noticed at birth, or years later when it gradually distends to a noticable size. The common complaints, usually by the parents is cosmetic disfigurement since it's a swelling at the neck and face. Rarely it becomes large enough to cause mechanical disability or affecting the vision.<br />
<br />
<b>On examination</b><br />
<br />
Congenital dermoid cyst is usually formed when the skin dermatome fuses.<br />
It's commonly found at the midline trunk, face and neck, outer or inner aspect of eye brow, or behind the ear.<br />
Shape is usually spherical, with diameter of 1-2cm<b>.</b><br />
Smooth surfaced.<br />
Congenital dermoid cyst over the face is usually soft.<br />
Since it usually doesn't contain clear fluid as it supposed to be (mixture of sebum, sweat and desquamated epithelial cells), it doesn't transilluminate.<br />
It fluctuates and if it's large enough, there's fluid thrill as well.<br />
Skin over the cyst is pinchable.<br />
Non-pulsatile, non-compressible, non-reducible.<br />
Local lymph nodes are not enlarged.<br />
<br />
<b>b) Accquired implantational dermoid cyst</b><br />
<br />
<b>History</b><br />
<br />
There's history of old injury, such as deep cut, stab injuries and etc.<br />
These implantational dermoid cyst is usually found over areas susceptible to repeated traumas, eg the fingers.<br />
Hence, it can be painful, or even interferes with gripping and touch.<br />
<br />
<b>Examination</b><br />
<br />
Seen over sites liable to repeated trauma - beneath skin of fingers.<br />
Size and shape - Spherical, small with diameter 0.5-1cm<br />
Smoothed surace<br />
Due to it's small size, it's almost impossible to elicit specific signs for cystic swelling, which is fluctuation and fluid thrill.<br />
It's usually hard, and the skin overlying it is usually scarred.<br />
The skin is either tethered deep to the scar or within it.<br />
It's mobile over the deeper structures, which is usually normal.<br />
Commonly confused with sebaceous cyst, but with an old scar and h/o of injury is significant for diagnosis.<br />
<br />
<b>2) Subcutaneous Abscess</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://www.lib.uiowa.edu/Hardin/md/pictures22/staph/7826_lores.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="263" src="http://www.lib.uiowa.edu/Hardin/md/pictures22/staph/7826_lores.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>History</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Throbbing pain which steadily worsens, and keeps patient awaken at night.<br />
</div><div class="separator" style="clear: both; text-align: left;">Patient usually notice a swelling at the site of pain.<br />
</div><div class="separator" style="clear: both; text-align: left;">May complaints of fever with chills and rigor.<br />
</div><div class="separator" style="clear: both; text-align: left;">It may rupture and discharging pus out of the skin before they seek medical attention.<br />
</div><div class="separator" style="clear: both; text-align: left;">The patient may have h/o of diabetes, having debilitating diseases, or even IV drug use.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Examination</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Since the buttocks and upper thigh are usual sites of injection, abscess may be formed there. And in IV drug users, over cubital fossa or groin.<br />
</div><div class="separator" style="clear: both; text-align: left;">Skin over swelling appears red and shinny.<br />
</div><div class="separator" style="clear: both; text-align: left;">Surface is not definate.<br />
</div><div class="separator" style="clear: both; text-align: left;">Usually started as a patch of induration, which later as pus collects, a spherical mass is formed.<br />
</div><div class="separator" style="clear: both; text-align: left;">There's local rise in temperature.<br />
</div><div class="separator" style="clear: both; text-align: left;">The edge is not palpable since due to the induration and the edema usually fuses with the normal tissue.<br />
</div><div class="separator" style="clear: both; text-align: left;">It's tender.<br />
</div><div class="separator" style="clear: both; text-align: left;">Initially it feels hard, when pus started to collect, it becomes soft at the centre and fluctuates.<br />
</div><div class="separator" style="clear: both; text-align: left;">Skin over swelling is not pinchable.<br />
</div><div class="separator" style="clear: both; text-align: left;">Regional lymph nodes may be enlarged and tender<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>3) Sebaceous cyst</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><b> </b><b> </b><b> </b> <br />
</div><a href="http://idisk.mac.com/mirander/Public/resources%205/sebaceous%20cyst.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://idisk.mac.com/mirander/Public/resources%205/sebaceous%20cyst.JPG" width="400" /></a><br />
<div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Our skin is kept oily and soft by secretions of sebum from sebaceous gland.<br />
</div><div class="separator" style="clear: both; text-align: left;">The mouth of the sebaceous glands are located at the hair follicles.<br />
</div><div class="separator" style="clear: both; text-align: left;">Any blockage over these mouth can result in it's distension within it's own secretion and results in formation of sebaceous cyst.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>History</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Rarely present before adolescence, since it's a slow-growing swelling.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Usually seen in young adults or middle-aged individual.<br />
</div><div class="separator" style="clear: both; text-align: left;">It's usually detected incidentally by patients as they're combing their hair, when they complained of scratched lump.<br />
</div><div class="separator" style="clear: both; text-align: left;">It can be infected, where the size suddenly increased rapidly.<br />
</div><div class="separator" style="clear: both; text-align: left;">Sebum secreted from wide punctum can be later hardened to form a sebaceous horn.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Examination</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">It's usually present at scalp, back, shoulders, and scrotum. (Never in the palm and soles since there's no sebaceous gland over these areas)<br />
</div><div class="separator" style="clear: both; text-align: left;">Skin over swelling is normal unless infected.<br />
</div><div class="separator" style="clear: both; text-align: left;">Shape - spherical, with smooth surface.<br />
</div><div class="separator" style="clear: both; text-align: left;">Temperature is not raised and is not tender unless it gets infected.<br />
</div><div class="separator" style="clear: both; text-align: left;">Edge is easily felt, well-defined.<br />
</div><div class="separator" style="clear: both; text-align: left;">Consistency - hard.<br />
</div><div class="separator" style="clear: both; text-align: left;">No fluctuations or fluid thrill.<br />
</div><div class="separator" style="clear: both; text-align: left;">As the swelling increases in size, the point of fixation will be drawn inwards and punctum is formed. Punctum is diagnostic for sebaceous cyst, but however, only one-half of such swelling presents with a punctum.<br />
</div><div class="separator" style="clear: both; text-align: left;">Skin over swelling is not pinchable.<br />
</div><div class="separator" style="clear: both; text-align: left;">Local lymph nodes are not palpable.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>4) Lipoma</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b><a href="http://top-10-list.org/wp-content/uploads/2009/07/Lipoma.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="335" src="http://top-10-list.org/wp-content/uploads/2009/07/Lipoma.jpg" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>History</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Lipoma is a slow-growing swelling, rarely regresses.<br />
</div><div class="separator" style="clear: both; text-align: left;">Occurs at any age, but relatively uncommon in children.<br />
</div><div class="separator" style="clear: both; text-align: left;">Not associated<b> </b>with any symptoms, but presents to the doctor usually because they have noticed a lump and wanted to know what it is.<br />
</div><div class="separator" style="clear: both; text-align: left;">Patients can have multiple lipoma (lipomatosis), usually over the neck and buttocks.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><b>Examination</b><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Common sites of lipoma includes the upper and lower limb, back, buttocks, neck, etc.<br />
</div><div class="separator" style="clear: both; text-align: left;"><b> </b>Size is variable, shape - hemiovoid, spherical, etc.<br />
</div><div class="separator" style="clear: both; text-align: left;">On inspection, surface appears smooth. But when the swelling is palpated carefully, especially when firm pressure is applied, it's lobulated and depression in between these lobulations is seen.<br />
</div><div class="separator" style="clear: both; text-align: left;">Edge is soft, compressible and tends to slip away from examining hands (slip sign)<br />
</div><div class="separator" style="clear: both; text-align: left;">Composition - solid fat (fat in body temperature is solid instead of fluid)<br />
</div><div class="separator" style="clear: both; text-align: left;">Consistency - soft<br />
</div><div class="separator" style="clear: both; text-align: left;">There's pseudofluctuation, since it's consistency is soft. However, one will notice that on gentle pressure,the plane of swelling over palpating fingers are not tense or not buldging out.<br />
</div><div class="separator" style="clear: both; text-align: left;">There may be pseudo-transillumination.<br />
</div><div class="separator" style="clear: both; text-align: left;">Skin over swelling is pinchable.<br />
</div><div class="separator" style="clear: both; text-align: left;">As muscle is tensed, it may either be more prominent or less (it can arise above or beneath the muscle)<br />
</div><div class="separator" style="clear: both; text-align: left;">Compressible swelling.<br />
</div><div class="separator" style="clear: both; text-align: left;">No enlargement of regional lymph nodes.<br />
</div>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com0tag:blogger.com,1999:blog-452176958433124785.post-49771990024463099652009-11-21T09:13:00.000-08:002009-11-21T09:13:54.211-08:00History taking and examination of a swellingSome key questions to be asked regarding a swelling (generally)<br />
<br />
<b>1. When do you first notice the lump?</b><br />
<br />
REMEMBER, first noticed the lump 3 months ago is not the same as first appeared 3 months ago.<br />
<br />
<b>2. How do you notice it?</b><br />
<br />
Below are the 3 commonest answers :<br />
<br />
a) It's painful<br />
b) I noticed it accidentally<br />
c) Others told me about it<br />
<br />
Generally, if the lump is painful, the commonest aetiology is inflammation.<br />
Most of the patients thought that only painful lumps are cancerous.<br />
<br />
<b>3. How does the lump disturbs you?</b><br />
<br />
Basically, the question is asking about the associated symptoms.<br />
<b> </b>It can be pain, discharge, dysphagia, dyspnoea, cosmetically disfiguring, fear of malignancy, etc.<br />
<br />
<b>4. Any changes to the lump since you first notice it?</b><br />
<br />
The commonest change is the size.<br />
Whether the lump has increased or decreased in size, or it's size fluctuates.<br />
<br />
<b>5. Has the lump ever dissapears before?</b><br />
<br />
Does the lump dissapears when the patient is lying down supine?<br />
or any other activities<br />
<br />
<b>6. Do you ever had any other lumps before this?</b><br />
<br />
Asking for multiplicity<br />
<b> </b><br />
<b> 7. What do you think is the cause?</b><br />
<br />
Particularly important if there's history of trauma<br />
<b> </b><br />
<b> On examination :</b><br />
<br />
Note the -<br />
<b> </b><br />
<b> </b>a) Position<br />
b) Colour and texture of skin over swelling<br />
c) Size<br />
d) Shape<br />
e) Surface<br />
f) Temperature<br />
g) Tenderness<br />
h) Edge - indistinct/well-defined<br />
i) Composition<br />
<br />
Calcified tissues/bone makes the swelling hard<br />
Swelling packed with cells : Firm<br />
Or it might contain fluid (lymph, blood, pus)<br />
Intravascular blood<br />
Gas<br />
<br />
j) Consistency<br />
<br />
Stony hard - not indentable at all, as hard as bone<br />
Firm - hard, but not as hard as bone<br />
Rubbery - slightly indentable, feels like rubber<br />
Spongy - indentable, but with some resillence<br />
Soft - Squashable, no resillence<br />
<br />
k) Fluctuation<br />
<br />
Palpate the swelling over 3 planes.<br />
Pressure over the 3rd plane of the swelling usually causes the other 2 planes to buldge out or tensed-up<br />
Positive fluctuation test indicates that the swelling might contains fluid<br />
<br />
l) Fluid thrill<br />
<br />
Only swelling which contains fluid transmits percussion waves.<br />
Use one of the finger to tap one end of the lump, and feel for the vibration produced at another end, using another finger from another hand.<br />
If the swelling is too large, the percussion wave might be transmitted through the wall.<br />
Hence, one should place a hand at the middle of the swelling to prevent such transmission.<br />
<br />
m) Transillumination<br />
<br />
If the swelling contains clear fluid, it transilluminate.<br />
It should be done using a small bright light source, in a dark room.<br />
Eg, hydrocele, epididymal cyst<br />
<br />
n) Pulsatility<br />
<br />
Place one finger of each hand over two ends of the swelling.<br />
If both the fingers are moving upwards and outwards -> expansile (eg, aneurysm)<br />
If both the fingers are moving only upwards (one direction) -> transmitted (a lump overlying an artery)<br />
<br />
o) Compressibility<br />
<br />
As pressure is applied to the swelling, it's compressed.<br />
But once the pressuring hand is removed, the swelling immediately reappears.<br />
<br />
p) Bruits<br />
q) Reducibility<br />
<br />
This is different from compressibility.<br />
If the swelling is reducible, it is reduced into another space.<br />
As the pressuring hand is removed, the swelling usually takes some time before reappearing, or will only reappear when there's stimulus, eg cough<br />
<br />
r) Relation with surrounding tissue<br />
<br />
Is it pinchable from the skin?<br />
When the muscle is tensed,<br />
Does it becomes more prominent, less mobile or less prominent and less easily felt?<br />
When the swelling overlies a nerve/or artery -> not mobile along it's course, but mobile across it's length<br />
<br />
s) Any palpable regional lymph nodes?<br />
t) General examination<br />
<br />
<br />
<br />
<b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com4tag:blogger.com,1999:blog-452176958433124785.post-35719960622908816262009-11-21T04:35:00.000-08:002009-11-21T04:35:07.253-08:00Urology - Q & A<b>What are the common causes of urinary tract obstruction?</b><br />
<br />
Upper UT obstruction :<br />
<b> </b><br />
Renal, ureteric calculi<br />
Pelvi-ureteric junction obstruction<br />
Retroperitoneal fibrosis (idiopathic, malignancy)<br />
Transitional cell carcinoma<br />
Congenital (Ectopic ureter, ureterocele)<br />
Infections (Schistosomiasis, TB)<br />
<br />
Lower UT obstruction :<br />
<br />
Urethral causes (stricture, tumour, stone)<br />
Prostate (BPH, CA prostate)<br />
Bladder neck (CA, stones, neurological causes, stricture)<br />
<br />
<b>What are the clinical features of acute urinary retention?</b><br />
<br />
Patient usually complains of suprapubic pain, unable to pass urine<br />
<b> </b>Well aware that there's bladder distension<br />
On examination, bladder is palpable with the following features :<br />
<br />
An ovoid mass originating from the pelvis<br />
Can't get below the swelling<br />
Tense, tender, smooth surface<br />
Gentle pressure increases desire to micturate<br />
Immobile <br />
Percussion - dull<br />
Positive fluid thrill<br />
<br />
Sometimes, the bladder can be extending up to the umbilicus<br />
(in cases of acute on chronic urinary retention)<br />
<br />
<b>What are the clinical features of chronic urinary retention?</b><br />
<br />
Bear in mind that there're 2 types of chronic UR :<br />
<br />
a) High pressure type<br />
<br />
Associated with chronic bladder outflow obstruction<br />
Can progress to hydroureter and hydronephrosis and eventually, obstructive renal failure<br />
<br />
b) Low pressure type<br />
<br />
Associated with bladder atony<br />
Doesn't progress towards renal failure<br />
<br />
Symptom-wise, patient is usually unaware that there's bladder distension<br />
Usually, such condition is painless<br />
However, there's both obstructive and irritative symptoms of micturition (as in BPH)<br />
And, there's overflow incontinence :<br />
<br />
The patient can pass an apparently normal volume of urine<br />
However, whenever there's raised intra-abdominal pressure, there's dribbling of urine<br />
<br />
On examination :<br />
<br />
Bladder is usually palpable, upto the umbilicus<br />
Non-tender, not tense<br />
Gentle pressure may not be associated with any increased desire in micturition<br />
Dull note on percussion, +ve fluid thrill<br />
<br />
<b>Briefly discuss about the clinical significance of urodynamic studies</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://img.medscape.com/fullsize/migrated/467/796/un467796.fig1.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="381" src="http://img.medscape.com/fullsize/migrated/467/796/un467796.fig1.gif" width="400" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">The maximum urinary flow rate can be determined by urodynamic studies.<br />
</div><div class="separator" style="clear: both; text-align: left;">In men, it's 15-30 ml/sec; in females, it's 20-40 ml/sec.<br />
</div><div class="separator" style="clear: both; text-align: left;">A graph of urinary flow rate versus time can be plotted, in which different pattern of curves usually indicates different causes of obstruction.<br />
</div><div class="separator" style="clear: both; text-align: left;">A normal urinary flow : Rises to the peak rapidly, and rapidly drops down to the baseline (as shown above)<br />
</div><div class="separator" style="clear: both; text-align: left;">In bladder outflow obstruction, there's prolonged rise to poor maximum flow rate and periods of prolonged variability in flow rate<br />
</div><div class="separator" style="clear: both; text-align: left;">In urethral obstruction, there's a stable, plateu-shaped curve, with prolonged flow rate.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"> <a href="http://www.netterimages.com/images/vpv/000/000/001/1725-0550x0475.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://www.netterimages.com/images/vpv/000/000/001/1725-0550x0475.jpg" width="345" /></a><br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Together with cystometry, the bladder capacity, capacity during desire to micturate, pressure on the detrusor muscle in full bladder, residual urine volume can be determined.<br />
</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><b> </b>fusionclkhttp://www.blogger.com/profile/01230652937368158205noreply@blogger.com1