Concise Surgery

• Road traffic accidents, burn, surgical operations, heat stroke, surgery,
anaesthesia and all medical illnesses are examples of stress.

• Response of the normal body to stress occurs in two ways:
1- Neural pathway. 2- Hormonal pathway.
1- The neural response:

The neural response occurs through the sympathetic and parasympathetic
systems: e.g. Pain is carried by the peripheral sensory nerves through the
spinothalamic tracts to the brain. The cerebrum part of the limbic system is activated
(the reticular-activating system). This stimulates the sympathetic system
(sympathetic chain ganglia + fibres) that release norepinephrine.
Actions of the activated sympathetic system:
1- Sympathetic fibres supplying the arteries release norepinephrine that leads
to vasoconstriction. Vasoconstriction increases the peripheral resistance.
The blood pressure = the stroke volume X peripheral resistance. Therefore, as
vasoconstriction increases the peripheral resistance raises the blood pressure.
This is how the body responds to defend itself against hypotension.
2- The sympathetic stimulus passes through the sympathetic chain to the adrenal
medulla which secretes adrenaline and postganglionic membranes that secrete
norepinephrine. These hormones are released into the circulation and when they
reach the heart they lead to increases the heart rate. Also they increase the
generalized vasoconstriction and rise in blood pressure in an attempt to prevent
hypotension.
3- The skin temperature and the reddish colour of the skin and mucos
membranes are due to blood in blood vessels. Therefore when
vasoconstriction occur the skin and mucous membranes become pale and
cold.
1
3- In the skin the sweat glands are supplied by the sympathetic system.
Therefore sympathetic stimulation leads to sweating.
The early clinical features of severe stress (e.g. multiple injuries) are:
1- Tachycardia 2- Sweating 3- Pallor 4- Cold skin.
This is how the body tries to defend itself against hypotension. If this defense
fails the patient goes in shock.
BP: The normal systolic pressure is >100mmHg.
The normal diastolic pressure is 60-90mmHg.
Hypotension (shock) is diagnosed if the systolic pressure is less than
100mmHg. This is the time to give intravenous fluids to correct any
hypovolaemia resulting from loss of blood (as in trauma), plasma (as in burn)
or water (as in diarrhoea and vomiting). If intravenous fluids are not given
early the patient’s responses may become exhausted and he/she develops
hypotension.
If the diastolic blood pressure is more than 90mmHg then hypertension is
diagnosed, but if diastolic blood pressure is less than 30mmHg poor
perfusion of the cardiac muscle occur because the coronary arteries fill
during diastole. Therefore, poor filling of coronary arteries in severe
hypotension leads to myocardial insufficiency.
So, we need the diastolic pressure to fill the coronary arteries for cardiac
perfusion and we need the systolic pressure for perfusion of the rest of the
peripheral body tissues.
Adrenaline and norepinephrine cause generalized vasoconstriction but it
also lead to coronary vasodilatation.
Elderly people have arterial sclerosis and any stress e.g. due to
postoperative pain → vasoconstriction → poor peripheral tissue perfusion and
early shock. So they should avoid all types of stress.
Stress → Sympathetic stimulation →vasoconstriction→ cold extremities,
because the blood carries blood and heat.
2
Also stress →stimulation of the sweat glands →sweating. Therefore the early signs
of impending shock occur during the period of compensation by the sympathetic
stimulation to guard against the blood pressure falls are:
1- tachycardia 2-palor 3- cold clammy (sweaty) skin.
If the compensatory mechanism fails blood pressure will drop to less than
90mmHg and shock ensues.
Shock:
Definition: Inadequate tissues perfusion.
It occurs when the systolic blood pressure is < 90mmHg.
If the systolic pressure is < 70mmHg, vasoconstriction of the renal afferent
arteriole occurs resulting in acute renal failure (acute tubular necrosis).
If the diastolic pressure is <30mmHg → decreased blood supply to the heart
and brain.
If BP remained low for long time the oxygen reaching tissues will be low
therefore metabolism in tissues become anaerobic metabolism resulting in lactic
acid and keto acid production. The liberation and accumulation of these acids
leads to metabolic acidosis.
• The normal range of the arterial partial pressure of oxygen is more
than 95mmHg (PO2=>95mmHg) and the normal arterial blood
saturation of oxygen is >95% (Sat O2 =>95%)
• The normal range of the PH of the arterial blood is 7.34 - 7.43
PH less than 7.34 means acidosis which will be compensated by the lungs
through increasing the respiratory rate to wash out carbon dioxide.
Carbonic acid (H2CO3)  H2O + CO2
Hypotension leads to metabolic acidosis → depressing of the myocardium. If PH
is < 7.2 cardiac arrest may occur.
The acid base status of the blood can be detected by taking arterial blood
gases (ABG) from radial or femoral arteries for analysis.
3
7.2 Acidosis 7.34 - 7.43 alkalosis 7.5
Metabolic changes in stress:

In the shocked patient ↑ adrenaline → glycogenolysis (Break down of liver
glycogen to maintain the blood glucose level) → ↑ blood glucose. Therefore this
break down is catabolism.
2-Hormonal response to stress:

Loss of blood (as in bleeding), loss of plasma (as in burn), or loss of
water (as in excessive diarrhoea, vomiting or excessive sweating of heat stroke)
leads to decrease of blood volume. Hypovolaemia → hypothalamus → hormone
releasing factors → pituitary → releasing or stimulating hormones → Secretion
of Adrenocorticotropin hormone (ACTH) and anti-diuretic hormone (ADH).
Body responses to correct hypotension:
1- Release of ADH: ADH acts on distal renal convoluted tubules and
collecting system → reabsorption of water → ↑ blood volume to correct
hypovolemia.
2- Hypotension affect the kidneys → stimulate the macula densa and the
juxtaglomerular apparatus → renin release → angiotensinogen
production→ angiotensin I → angiotensin II → Supra-renal cortex
(adrenal cortex)  Aldosterone secretion.
a)- Angiotensin II is a potent hypertensive agent that raises the blood pressure.
b)- Aldosterone secreted from the suprarenal cortex leads to active reabsorption of
sodium from the convoluted tubules of the kidney. Water passively follows sodium
reabsorption. Sodium and water reabsorption helps to compensate in correcting the
hypovolemia and hypotension.
4
Action of ACTH:
ACTH stimulates the release of cortisol from the adrenal cortex.
Cortisol increases the catabolism pathway and leads to gluconeogenesis i.e.
increases blood sugar (glucose) by break-down of fat for energy and breaking
proteins to liberate glucogenic amino acids which are converted to glucose.
(catabolism of fat excess acetyl-CoA which is converted to acetoacetyl-CoA
then in the liver to acetoacetic acid and its derivatives acetone and ß-
hydroxybutyric acid = ketone bodies)
Baroreceptors in the arch of the aorta, in the carotid sinus and cardiac
chambers are stimulated by reduction in blood pressure.
Cardiac Out = Heart rate X Stroke volume.
BP = Cardiac output X Peripheral resistance.
Types of shock:
1- Hypovolemic shock. 2- Septic shock.
3- Cardiogenic shock. . 4- Anaphylactic shock.
5- Neurogenic shock. . 6- Adrenal shock.
Note: The hypotensive patient should be catheterized to measure the urine
output. In the basal metabolic state, the minimum volume of urine which gets
rid of the toxins of metabolism is 500ml. If the urine out put is less than 500ml
then urea will raise and lactic acid and ketone bodies of metabolism will raise
leading to uraemia and metabolic acidosis.
The adequate urine output is 1ml/kg body weight/hour.
Oliguria: urine output/ day = 700 -500 ml.
Anuria: urine output/day = 400 ml.
Self assessment
5
:Body response to stress
:Stimulation of the sympathetic system results in -1

.a- Vasoconstriction to increase the blood pressure
.b- Pallor in presence or absence of anaemia
.c- Cold temperature of the skin because of vasoconstriction
.d- Stimulation of the sweat glands leading to sweating
.e- All the above are correct
:Answer
e) - All the answers are correct responses of the stimulation of ) - 1
the sympathetic system which lead to vasoconstriction all over the
body except in the coronary arteries where adrenaline leads to
vasodilatation. The benefit of this is to increase the peripheral
resistance in an attempt to raise the blood pressure. However,
because the blood carries temperature vasoconstriction leads to
peripheral cold and pale limbs. The sympathetic system also
.stimulates the sweat glands
:Stimulation of the sympathetic system results in -2

.a- Increase release of adrenaline and nor-adrenaline
.b- Breakdown of liver glycogen to raise the blood glucose
.c- Vasodilatation of coronary arteries
.d- All the above are correct
.e- Only (a) and (b) are correct
:Answer
2 - (d) – Adrenaline leads to catabolism and increases the blood
glucose level by breaking down glycogen.
3 - In stress the pituitary gland secrets:

a- Anti-diuretic hormone for water reabsorption in renal tubules
.b- Adrenocorticotropin to stimulate the adrenal cortex
.c- Thyrotoxicosis due to thyroid stimulating hormone
:Answer
6
e) - Although in the normal state the pituitary gland liberates )–3
TSH but in stress it does not cause thyrotoxicosis. However, if a
thyrotoxic patient is subjected to severe stress like in trauma, he may
.develop thyroid crisis
:Cortisol liberated from supra-renal cortex in stress leads to-4

.a- Formation of glucose from proteins
.b- Break down of fat for energy
.c- Reduces immunity in the multiple injured patients
.d- An anti-insulin effect to help rising the blood glucose
:Answer
.e) – All of these are actions of cortisol ) –4
:Aldosterone secretion -5
.a- Results from stimulation of the adrenal cortex
.b- Leads to activation of the rennin-angiotensin system
.c- Leads to re absorption of sodium at the renal tubules
.d- Helps to elevate the blood pressure and blood volume
:Answer
e) – Adrenocorticotropin from the pituitary stimulates the ) – 5
adrenal cortex to liberate aldosterone. Aldosterone leads to active
reabsorption of sodium from the renal tubules. Also aldosterone
leads to activation of the rennin angiotensin system so that
angiotensin II and aldosterone is liberated to help raising the blood
.pressure
:In stress -6
.a- Anti-diuretic hormone increases the intra-vascular volume
.b- Sodium reabsorption helps to increase the blood volume
.c- Angiotensin II is a potent vasoconstrictor
:Answer
d) – All these are correct responses to increase and maintain ) – 6
.the blood volume and blood pressure
7
:In severe stress - 7
.a- Oliguria is urine output of 700ml/24 hours
.b- Oliguria is urine output of 500ml/24
.c- Anuria is urine output of 400 ml/24 hours
.d- Anuria is complete failure of secretion of urine
.e- Only (a) and (c) are correct
e) – Oliguria is alarming before the patient goes into renal )– 7

failure. The minimum urine output to excrete the toxins of metabolism
is 500ml/day. So, the correct definition of oliguria is urine out put
700 ml/24hours and anuria is urine out put of 400ml/24 hours.
. .Remember it is anuria and not unuria
:In reading the blood pressure -8

.a- Systolic BP <100mmHg means shock
b- Systolic BP <70mmHg leads to acute renal failure
.c- Diastolic BP < 30 mmHg reduces coronary perfusion
.c- Only (a) and (c) are correct
:Answer
:d) – all are correct answers ) – 8
A 36 year old driver was involved in a road traffic accident. -9

He sustained fracture of the left femur and fracture of the ninth,
tenth and eleventh ribs on the left side. He was conscious and
.oriented but was restless
?a)Which of the following signs is expected to be found)
.a- Pulse 72/min regular with good volume
.b- Respiratory 14/min deep and regular
.c- Blood pressure 120/80 mmHg
.d- Pale with cold sweaty skin
.e- Temperature 38oC
:Answer
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d)- It is clear that this patient has hypovolaemia from fracture )– 9
femur and possibly ruptured spleen. So, the only sign of shock is pale,
.cold and sweaty skin
b)After insertion of Foley's urinary catheter, his urine output)

was 10 ml in the first hour. This could be explained by the fact
:that
.a- He had hypovolaemia and hypotension due to bleeding
.b- Pain from fracture of bones led to renal shut down
.c- Being a driver he is dehydrated
.d- In response to stress of trauma ADH reduced the urine
.e- Only (a) and (d) are correct
:Answer
e) – 10 ml / hour means 240 ml urine/24 hours i.e. anurea. ) - 10
Pain does not lead to anuria and being a driver does not necessarily
.means he is dehydrated
c)The explanation of his restlessness is)

.a- Reduced brain glucose
.b- Reduced brain oxygenation
.c- Acute retention of urine
.d- Confusion due to uraemia
.e- Frightened from fracture ribs
:Answer
b) – He has fracture ribs and possible haemo-pneumothorax ) – 11
with reduction in his oxygen level. Also his hypovolaemia reduces the
brain perfusion leading to reduction of brain oxygenation.
Hypoxaemia and pain from any cause retention or fracture leads to
restlessness and irritability. It is expected that in stress adrenaline
.increases the blood glucose
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About 70% of the body weight in an adult person is water. The total body
water is more in children than in elderly patients. Total body water in a 70 kg
body weight adult is about 42 Litres.
The intra-cellular fluid (I.C.F) = 28 Litres = 2/3 of total body fluids.
The extra-cellular fluid (E.C.F) = (intravascular fluid + interstitial fluid) = 14
Litres.
The blood volume = 5 Litres.
Water loss:
The normal body losses are:
Urine = 1500 ml.
Sweating = 500 ml. (Sweating varies with climate from 30-1600ml).
Respiration = 500 ml.
Faeces = 200 ml
Total loss =about 2700-3500 ml/24 hours.
Therefore, if an adult person is kept fasting in hospital (NPO = Nothing Per
Orem). Then he or she should be given about 3 litres of fluids (2.5 litres
glucose 5% + 500ml normal saline) every 24 hours i.e. 1 litre every 8 hours.
If the patient has further losses of fluids as in vomiting, diarrhoea, losses in
drains and nasogastric tubes (NGT), or excessive sweating, the volume of
these losses (out put) should be replaced by crystalloid fluids (in put) and the
balance of input output chart should be maintained.
?What is the first symptom of water loss
Thirst is the first symptom. When there is loss of water, there is an increase of
blood concentration → increase osmotic pressure and reduction of the blood
volume → baroreceptors in the arch of aorta and carotid sinus and osmotic
receptors in the hypothalamus. These receptors detect these changes and send a
signs to the cerebral cortex to be explained as thirst and send impulses to the
pituitary gland to secrete ADH to reduce the loss of water in the urine.
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Causes of water loss:
1- Cancer oesophagus leading to absolute dysphagia.
2- Coma because of failure of in take of water
3- Excessive sweating in heat stroke.
4- Diarrhoea and vomiting.
5- In intestinal obstruction: Water is not absorbed in the obstructed
lumen {fluid volume is 8 litres. 4L above the pylorus (saliva1500ml +
gastric juice 2500ml) and 4L below the pylorus (bile 600ml +
pancreatic juice 400ml + succus entericus 3000ml)}. These fluids are
rich in enzymes and electrolytes and can not be absorbed in intestinal
obstruction.
We use dextrose 5% in water because it is isotonic ( i.e. iso-osmotic has equal

osmotic pressure to plasma) and therefore it neither goes in side the blood cells
to cause haemolysis nor does it withdraw water from the blood cell. Yet,
dextrose 5% in water is not used as a source of nutrition because it contain only
50 gram of glucose in 1 litre
(1000x 5) = 50 grams glucose.
100
Every 1 gram glucose releases 4 Kcal of energy. Therefore, 1 litre of glucose
releases 50 X 4 = 200Kcal but the daily requirement for the adult person is
2500-3000 Kcal.
Normal saline (0.9%gm of sodium chloride): This means that:

100 ml of water contain 0.9 gm of NaCL.
1000ml = 1 Litre contain 9g of NaCL = 150 mmol/ Litre
i.e. (150 mmol/L Na+ and 150 mmol/L CL-).
The normal level of Na in the Extracellular fluid (ECF) = 135 -145
mmol/L
Daily requirement of Na+ =1 mmol/kg/day. So a70 Kg body weight patient
needs 70mmol/day i.e. only 1/2 litre of normal saline per day.
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Therefore, the daily requirement is 500 ml (one pint) of normal saline in winter
when there is no excessive sweating but this could be increased to one litre or
more of normal saline if there is excessive sweating in summer or in
replacement for extracellular fluid loss in drains, vomiting, diarrhoea, and urine.
For all these reasons when an adult patient is admitted to the hospital and kept
fasting at least 3 litres of i.v. fluids should be prescribed for him. One Litre
Normal Saline + 2 Litters dextrose 5% to cover the fluid and sodium required in
the normal state.
In the elderly patients normal saline should not exceed 1/2 litre per day.
Patients who have cardiac or renal diseases should have less i.v. fluid and less
sodium per day to avoid water overload.
Patient with excessive sweating, heat stroke, diarrhoea, intestinal fistula,
intestinal obstruction, vomiting, drain, diabetic ketoacidosis, need to calculate
the amount of fluid loss and compensate it by adding the same quantity to the
daily requirement in the form of normal saline.
Patients with chronic liver disease particularly cases of portal hypertension
usually do not break down their normal aldosterone, so their aldosterone
accumulates and they develop secondary hyperaldosteronism because of the
poor breakdown of Aldosterone by the chronically diseased liver. These high
levels of aldosterone → Na+ retention and hence water retention that may lead to
ascites and lower limbs oedema. So don't give portal hypertension patients
normal saline unless they are in shock.
Sodium
Causes of Hypernatremia (↑ Na+):
1- Iatrogenic: (medical mistakes) especially in children and old patients
when they are given large volumes of normal saline.
2- Hyperaldosteronism:
Primary hyperaldosteronism (Conn's disease) due to
aldosterone secreting tumour in the adrenal cortex.
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Secondary hyperaldosteronism: Due to chronic liver disease (Cirrhosis and
periportal fibrosis).
Causes of hyponatremia (↓ Na+):

1- Recurrent vomiting associated with pyloric stenosis and intestinal
obstruction leads to loss of water and hydrochloric acid (H2O+HCl) in the
vomitus. Normally the Ph of the blood is neutral (7.34 - 7.43). If acid is lost,
then the amount of alkaline material is relatively raised. Therefore, in recurrent
vomiting alkalosis occurs. Because the cause is the gastrointestinal system
problem and not respiratory disease, it is called metabolic alkalosis.
For the body to minimize alkalosis the kidneys compensate by secreting
alkaline urine in the form of sodium bicarbonate (Na2HCO3) to reduce the
level of alkalies in the blood. This is called compensated metabolic alkalosis. It
results in loss of Na through the urine. Therefore, in recurrent vomiting the
patient losses H2O, H+ and CL- in the vomitus and Na+ and HCO3- in the urine.
In the normal state 2/3 of potassium excretion occurs through the urine and 1/3
through the faeces. In alkalosis potassium shifts from the ECF and enters the
cells. Therefore, the level of K+ in the blood becomes low (Hypokalemia).
When the serum level of sodium (the main extracellular fluid cation Na+) is
critically low the kidney excrete instead another cation which is hydrogen (H+)
i.e. replaced by H+ in the form of ammonium chloride (NH3CL + H+ = NH4CL)
in the urine making the urine acid again in spite of state of alkalosis due to
vomiting of acid. This is called paradoxical acid urea i.e. while the patient is
vomiting acid he is secreting acid in the urine in stead of secreting alkaline
urine. This is actually what happens in pyloric stenosis.
2-Diarrhoea: Diarrhoea results in loss of water (Dehydration) and the rapid

transit through the intestine leads to loss of bile, pancreatic juice and the small
intestinal juice (Succus entericus). All these are alkaline fluids rich in proteins
and electrolytes namely Na and K. Loss of these alkaline fluids tip the balance
13
of the Ph towards the acid side and leads to metabolic acidosis with
hyponatremia, hypokalaemia and hypoproteinemia.
The clinical features of hyponatremia are fatigue, muscle weakness and
hypotension.
3- Recovery phase of acute renal failure: In the recovery phase of

acute renal failure the kidney goes in a phase of diuresis (polyuria)
in which Na and K are lost and if the patient is not given the
appropriate replacement he will develop hyponatremia and
hypokalemia.
4- Diuretics: Patients on diuretics tend to loose Na and K in urine.
5- Prolonged administration of glucose 5% only in a fasting patient: In
these cases there are normal daily losses of Na and if the daily Na requirements
are not given the patient will develop hyponatremia.
Potassium:
Potassium is the main intracellular fluid (I.C.F) cation. Normal extra cellular
fluid (E.C.F) K+ = 3.5 -5.3 mmol/Litre. The daily requirement of K+: 1
mmol/kg body weight/day. i.e. in the adult 60-80-mmol/liter/day.
Causes of hyperkalemia (K+):

1- Renal failure.
2- Injudicious iatrogenic infusion of KCL.
3- Transfusion of old blood (acidosis + haemolysis)
4- All other causes of metabolic acidosis.
Hyperkalemia leads to ECG changes in the form of tall T-wave. Clinically it

causes severe muscular weakness, flaccid paralysis, loss of tendon jerks,
arrhythmia and cardiac arrest in diastole.
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Treatment of hyperkalemia:
1-Insulin (10 units) + glucose (10%) help to get K+ into the
intracellular compartment.
2-Calcium gluconate i.v. improves myocardial contractility and helps
to protect the heart against arrhythmia.
3-Sodium bicarbonate (NaHCO3) helps to correct acidosis and pushes
K into the cells.
4-Haemodialysis helps to remove the excess potassium.
5-Resonium (chelating agent) given by mouth or rectal enema.
Causes of hypokalemia:
1- Diuretics as furosemide.
2- Diarrhoea.
3- Hyperaldosteronism.
4- Recurrent vomiting (during the compensatory mechanism for metabolic
alkalosis).
5- Intestinal fistula.
6-Jaundice (metabolic alkalosis in which K+ moves inside the cells)
7- High upper GIT obstruction leading to recurrent vomiting.
8- Insulin therapy moves K and glucose inside the cells.
9- Villous adenoma of the rectum leads to excessive mucus per rectum.
In obstructive jaundice:
The accumulation of the alkaline bile in all tissue fluids results in
metabolic alkalosis. In alkalosis K+ shifts inside the cells, so K+ in
extracellular fluids becomes low (Hypokalemia).
Clinically hypokalemia causes tiredness, muscular weakness,
tingling of fingers, apathy, paralysis, coma, and muscle cramps.
ECG changes: Flat T-wave with possible depression of S-T segment.
15
Treatment: Correction of the K+ level by slow-k tablets or slow
infusion of potassium chloride in i.v. fluids (do not exceed 120
mmol/24 hours) followed by daily estimation of serum electrolytes.
Never ever give potassium directly intravenously. If potassium is
given directly intravenously it leads to immediate death (cardiac
arrest in diastole).
Metabolic acidosis:
Causes of metabolic acidosis:
1- Diabetic ketoacidosis. 2- Renal failure.
3- All causes of chronic diarrhoea (loss of alkaline intestinal contents).
4- Prolong hypotension and all types of shock → poor tissue perfusion
→ poor tissue oxygenation →anaerobic metabolism →metabolic
acidosis.
The clinical features of metabolic acidosis:
The clinical features of metabolic acidosis depend on the cause but
generally acidosis is compensated by rapid deep breathing (Kussmaul
respiration) to eliminate carbon dioxide.
In diabetic ketoacidosis accumulation of the acids of the ketone
bodies (gluconeogenesis and the increased blood sugar (glucose) because of the
lack of insulin and the break-down of fat for energy and breaking proteins to
liberate glucogenic amino acids which are converted to glucose. Catabolism of
fat excess acetyl-CoA which is converted to acetoacetyl-CoA then in the liver
to acetoacetic acid and its derivatives acetone and ß- hydroxybutyric acid =
ketone bodies. All that leads to metabolic acidosis. Lactic acidosis by itself may
lead to coma. However, the hyperosmolarity may by itself reduce the level of
consciousness and precipitate coma (hyperosmolar coma in type II diabetes
mellitus).
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Treatment of metabolic acidosis:
Treatment of metabolic acidosis is the treatment of the cause and restoration of
adequate tissue perfusion and oxygenation by correction of the hypovolaemia or
correction of the cause of local impairment of blood supply (Limb ischemia).
Sodium bicarbonate solution (0.5 mmol NaHCO3 / kg body weight) can be

given.
Respiratory acidosis:
Respiratory acidosis is caused by obstructive lung disease as chronic
bronchitis and emphysema. However, severe chest trauma with flail chest, lung
contusion and tension pneumothorax may lead to respiratory acidosis.
Clinically the patient has rapid deep acidotic breathing (air hunger). So
compensation occurs through the kidneys by reabsorption of sodium
bicarbonate and secretion of H in the form of ammonium chloride.
2Na + H2CO3 → Na2HCO3 + H+
NH3Cl + H+ →NH4Cl (ammonium chloride).
Normally PCO2 in arterial blood < 40 mmHg. It is measured by arterial blood
gas analysis. HCO3 in arterial blood is 21mmHg.
*****************************
Self assessment
Body Fluids, electrolytes and acid base balance
1- The normal daily water losses include:

a- Urine out put not less than 1500ml.
b- 500ml in respiration.
c- 200 ml water in stools.
d- 500ml or more in sweating.
e- All the above (2700ml or more) are correct.
Answer:
1 – (e) – All these figures are correct, however we have to put in mind that the
volume of water differs according to climate, body surface area, presence or
17
absence of fever, evaporation from peritoneal cavity during laparotomy, age of
the patients and the status of the renal and cardiac functions.
2- The following is correct for sodium correction:

a- The normal dietary requirement is 50-200mmol/day Sodium.
b- Excess dietary sodium is filtered through the kidneys.
c- One liter of normal saline contains 150mmol sodium.
d- 2 liters of dextrose 5% +1litre NaCl is the daily requirement
e- All the above are correct in correction of sodium.
Answer:
2- -(e) – All these answers are correct. Roughly the daily requirement of
sodium is 1mmol/kgwt/day; however, this should be reduced in elderly patients
with potentially ischaemic heart disease and in hypertensive patients and it
should be increased if there is excessive sweating, diarrhoea, recurrent
vomiting and polyuria.
3- The normal regulation of potassium include:

a- The daily requirement is 1 mg/kg body weight.
b- Two thirds of the daily losses occur in urine.
c- Diarrhoea causes hypokalaemia by direct loss.
d- Metabolic alkalosis causes hypokalaemia.
e- All the above are correct.
Answer:
3 – (e) – All the answers are correct. The commonest causes of
metabolic alkalosis encountered by the surgeon are recurrent vomiting
due to gastric outlet obstruction (benign or malignant), intestinal
obstruction and jaundice
4- Extracellular fluid loss occurs in:
.a- Vomiting
.b- Diarrhoea
.c- Loss from drains
.d- Loss from fistulae
Answer:
e) – All theses losses are extracellular fluid losses including bile coming ) –4
through a drain or a T-tube, pancreatic fistula, Taping of ascites and drainage
of pleural fluid. They should be replaced volume by volume with normal saline
.with addition of potassium chloride
5- Stretch receptors in the heart and large blood vessels:
.a- Can detect changes in blood volume
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.b- Can detect changes in blood pressure
.c- Control renal excretion of water
.d- Control renal excretion of sodium
:Answer
e) – All the answers are correct and this is actually the mechanism of ) – 5
.controlling the blood volume and blood pressure
6- Blood pressure is controlled by:

.a- Stretch receptors that stimulate the sympathetic system
.b- Intra-renal stretch receptors in the juxtaglomerular apparatus
.c- The rennin containing cells in the afferent renal arteriole
.d- The macula densa in distal convoluted tubule regulates sodium
:Answer
e) – All these answers are correct. This is the mechanism to regulate the ) – 6
.blood pressure if the body is subjected to any cause of hypotension
:Hypovolemia and/or hypotension lead to -7

.a- Direct release of aldosterone to reabsorb sodium
.b- Release of renin to form angiotensin II
c- Angiotensin II to stimulates release of aldosterone
.d- Release of ADH to reabsorb water
:Answer
.e) – All the answers are correct ) – 7
:The following conditions lead to pure water loss-8

.a- Coma
.b- Absolute dysphagia
.c- Heat stroke
:Answer
e) – Coma and absolute dysphagia lead to pure water loss because of ) – 8
inability to drink while water is lost through insensible perspiration, faeces,
respiration , and urine. However, in heat stroke there is excessive loss of sweat
.which is rich in sodium chloride
:In pure water loss -9

.a- There is gradual rise in osmolarity of body fluids
.b- There is gradual rise in serum sodium concentration
(c- The best corrected is by glucose in fifth saline (30-75mmolNa+/L
.d- Fast fluid correction may lead to coma and convulsions
19
:Answer
All the above are correct. Therefore in children and in cases of absolute -9
.dysphagia it is better to start gradual rehydration
:Post operative hyponatraemia -10

.a- Is due to water retention after the stress of surgery
.b- Is due to loss of potassium in urine after surgery
.c- Sodium replacement may lead to water overload
.d- Is commonly associated with extracellular fluid loss
:Answer
e) – All are correct. This is why postoperative hyponatraemia is also ) – 10
called dilutional hyponatraemia and is commonly encountered in jaundiced
.patients
:The earliest feature of dehydration is -11

.a- Collapsed veins
.b- Oliguria
.c- Sunken eyeballs
.d- Thirst
.e- Dry tongue
:Answer
d) – All are symptoms and signs of dehydration but the first feature of ) – 11
dehydration is feeling of thirst. However, the distressing feeling of thirst can be
.reduced or abolished by moistening the tongue with apiece of ice or wet gauze
:The best laboratory indication of dehydration is -12

.a- Elevated haematocrit
.b- High haemoglobin level
.c- High blood urea level
.d- High serum sodium level
.e- High osmolarity
:Answer
a) – Although all are correct, haematocrit is the best because it is ) – 12
elevated before significant raise of blood urea, haemoglobin, osmolarity, and
sodium to levels above the normal range. It is also the best answer because it is
.the simplest test to do and has the least cost
:Over infusion of normal saline leads to -13

.a- Dyspnoea
20
.b- Crepitations in the lung
.c- Raised jugular venous pressure
.d- Lower limb oedema
:Answer
e) – All are correct and sodium over load leads to the same features of ) – 13
.left and right ventricular failure
:Sodium retention is a feature of -14

.a- Ischaemic heart disease
.b- Renal impairment
.c- Chronic liver disease
.d- Chronic respiratory diseases
:Answer
e) – All are correct so, "NaCL" great care should be taken when NaCL ) – 14
is prescribed in these conditions. It may lead to water retention, water over
.load and pulmonary oedema
:Low level of serum potassium is found in -15

.a- Pyloric stenosis
.b- Intestinal obstruction
.c- Diarrhoeal diseases
.d- Obstructive jaundice
:Answer
e) – All are correct because all lead to metabolic alkalosis and in ) – 15
metabolic alkalosis potassium shifts from the extracellular fluid to inside the
cells and we are measuring the serum potassium and not the intracellular
.potassium
.The following is correct in metabolic alkalosis -16

.a- Metabolic alkalosis leads to hypokalaemia
.b- Repeated vomiting cause metabolic alkalosis
.c- Obstructive jaundice leads to metabolic alkalosis
.d- In hypokalaemia H+ is excreted and HCO3 is reabsorbed
:Answer
e) – All are correct because this is the mechanism to keep the body in ) – 16
.state of compensated metabolic alkalosis
:Hypokalaemia is very serious because -17

.a- It causes muscle weakness
21
.b- It causes ventricular dysrhythmias
.c- It complicates villous adenoma of the rectum
.d- It can be corrected but with slow K+ infusions
.e- It induces metabolic alkalosis
:Answer
b) - although all these are true in hypokalaemia the most serious effect ) – 17
of hypokalaemia is ventricular dysrhythmias and the heart may stop in
.diastole
:The disturbance in acid base balance is due to -18

.a- Deep rapid or slow shallow breathing
.b- Impaired renal function
.c- Excessive loss of gastrointestinal fluid
.d- Hypotension
:Answer
e) – all these are correct. Deep rapid respiration as in hysteria leads to ) - 18
respiratory alkalosis while slow shallow breathing leads to respiratory
acidosis. Renal failure leads to metabolic acidosis and the body tends to
compensate by Kussmaul's respiration to reduce the carbon dioxide level.
Excessive vomiting result in metabolic alkalosis while losses of alkaline fluids
below the pylorus in the form of intestinal or biliary fistula or diarrhoea leads
.metabolic alkalosis
:The causes of metabolic acidosis include -19

.a- Loss of alkaline intestinal fluid in diarrhoea
.b- Tissue hypoxia due to cardiac arrest
.c- Hypotension from any cause
.d- Acute or chronic renal failure
:Answer
e) – all are correct. Loss of alkaline fluids in diarrhoea shifts the normal ) – 19
PH (7.34-7.43) towards acidosis. In cardiac arrest, hypotension and renal
failure and diabetic keto acidosis there is accumulation of the waste products
.(of metabolism (lactic acid and keto acids and ammonium chloride
:In metabolic acidosis -20
22
a- The blood PH is less than 7.34
.(b- Low HCO3 (less than 21mg/dl
.c- Compensatory low CO2 in blood
.d- Increased excretion of H+ in urine
:Answer
e) – All are correct. CO2 is lost by deep rapid breathing (Kussmaul’s ) – 20
. +respiration) and acid urine is formed to eliminate H
:Metabolic acidosis is best treated by -21

.a- Treatment of the cause
.b- Correction of hypotension
.c- Infusion of bicarbonate solution
:Answer
e) – Only (a) and (b) are correct because although bicarbonate correct ) – 21
acidosis but for a very short period and then it dissolve in water to liberate
CO2 which in turn dissolves in water to form carbonic acid. So the best
.treatment of acidosis is to treat the cause and correct hypotension
:Causes of metabolic alkalosis include -22
.a- Recurrent vomiting in pyloric stenosis
.b- Excessive intake of alkalies in duodenal ulcer
.c- Hypokalaemia
.d- Jaundice
:Answer
e) – All the answers are correct. Hypokalaemia is always associated ) – 22
with alkalosis as a cause and a result of hypokalaemia. Excessive intake of
.antacids in duodenal ulcer may result in Milk-alkali syndrome
:In metabolic alkalosis -23

a- The PH of the blood is more than 7.43
.b- There is compensatory high arterial CO2
.(c- The level of serum HCO3 is high (more than 28mg/dl
.d- The urine becomes alkaline
:Answer
e) – All the answers are correct. Metabolic alkalosis is always ) – 23
associated with loss of alkaline urine containing sodium bicarbonate in an
attempt to reduce the alkaline level in the blood i.e. to be in compensated
.rather than frank alkalosis
:Treatment of metabolic alkalosis is -24

.a- Infusion of normal saline
23
.b- Correction of hypokalaemia
.c- Treatment of the cause
:Answer
d) – All the answers are correct. Loss of sodium bicarbonate results in ) – 24
.hyponatraemia. In alkalosis potassium tend to shift in side the cells
:Treatment of hyperkalaemia includes -25

.a- Infusion of 10% glucose and insulin
.b- Calcium gluconate infusion
.c- Emergency haemodialysis
.d- Calcium resonium by mouth or rectum
:Answer
e) – All the answers are correct. Insulin helps glucose to enter the cells. ) – 25
Glucose carries with it potassium to reduces the extracellular fluid potassium
level. Calcium leads to cardiac muscle contraction therefore protect the
cardiac muscle from stopping during diastole which is the end result of the
effect of hyperkalaemia. Calcium resin taken by mouth or as colonic enema is a
chelating agent for potassium which is eliminated with diarrhoea. K+ level
more than 6.5mmol/l when not responding to previous measures is an
.indication for emergency dialysis
:Dextrose 5% in water solution is used because -26

.a- It is the only source of water supply
.b- It is a good source of supply of energy
.c- It is isotonic and does not cause haemolysis
:Answer
c) - Glucose 5% in water is isotonic. Pure water infusion leads to ) – 26
haemolysis, haemoglobinuria and renal failure. 1 liter of dextrose 5% in water
contain 50 grams of glucose i.e. 200kcal so, 3 liters can liberate only 600kcal
which is very far behind the daily requirement of energy which is 2500-
.3000Kcal/day
:After major trauma or surgery the best urine out put we aim at is -27
.a- 1500 ml / 24 hours
.b- 1 ml/Kg body weight
.c- More than 700ml / 24 hours
.d- Less than 1/2ml/Kg body weight /24 hours
:Answer
.b) – The best urine out put is 1/2-1ml/kgwt/hour ) – 27
24
:In post operative fluid therapy we add to the daily requirement -28
.a- Volume of blood and fluid loss during surgery
.b- Volume of losses through drains and catheters
.c- 250 ml for every degree Centigrade rise in temperature
.d- 70-90 mmol Sodium in form of normal saline
:Answer
e) – All are correct. In fact this is how we design the postoperative fluid ) – 28
.for different patients by making a balance of the in put out put charts
A 45 year old male, heavy smoker, presented with recurrent vomiting -29
which was foul in smell containing the same food he had taken before. He
had had long history of recurrent epigastric pain that awaken him at mid
.night associated with heart burn
:a) He is expected to have)
.a- Hypocalcaemia and hypokalaemia
.b- Hypokalaemia with metabolic alkalosis
.c- Hyponatremia with metabolic acidosis
.d- Urine Ph is unlikely to be affected
.e- Renal failure with hypernatremia
:Answer
b) – This is a case of gastric out let obstruction in which hypokalaemia and ) –
metabolic alkalosis are common. Hypercalcaemia and not hypocalcaemia may
be associated with duodenal ulcer and is such a case both hypercalcaemia and
.hypokalaemia with metabolic alkalosis are expected to coexist
b) Barium meal showed deformed first part of the duodenum with little)
barium passing to the second part of the duodenum. In preparation of this
:patient for surgery the best fluid to receive is
.a- Normal saline alternating with glucose5% in water

.b- Dextrose 5% with potassium chloride
.c- Ringer's solution
.d- Hartman's solution
e- Alternating normal saline and glucose5% with KCL
:Answer
e) – Proper calculation of potassium deficit and correct replacements of K ) –
and Na are better than Ringer's solution alone which contain only 4mmolK+ / L
.and Hartman's solution which contain 4mmolK+/l plus 28mmol HCO3
25
A 36 year old male was involves in a road traffic accident. He -30
had fracture pelvis and ruptured spleen. Blood transfusion was
.started
a) The signs that you should look for to detect immediate blood)
:transfusion problems include
.a- Raise in temperature, rigors and tachycardia
.b- Pain and redness along the vein used for transfusion
.c- Loin pain or backache with or without skin rash
Answer
d) – raised temperature could be due to febrile transfusion reaction ) – 30
resulting from pyrogenes, while phlibothrombosis with red painful vein is a
local sign of mismatched blood but loin pain is a feature of severe haemolysis
.and impending renal failure from major incompatible blood transfusion
b) The patient mentioned above actually complained of pain in)
the loin and rigors. His temperature was 38.5o C and pulse was
:100/min. The most likely diagnosis is
.a- Major incompatibility reaction
.b- Simple pyrexial reaction due contaminated blood
.c- Allergic transfusion reaction
.d- Infection with serum hepatitis virus
.e- Disseminated intravascular coagulation
:Answer
a) – All these causes lead to raise in temperature, hepatitis needs incubation ) –
long period and does not occur immediately. However, loin pain with the
.previous features indicates a major incompatibility reaction
:c) The immediate actions to be taken for this patient are)
.a- Immediately stop blood and sample blood for cross matching
.b- Start normal saline and I.V. diuretic to prevent renal failure
.c- I.V. hydrocortisone and antihistamine and possibly adrenaline
.e- Only a and c are correct
:Answer
d) – Blood must be immediately stopped. Recheck the label on the blood bag ) –
(blood group and bottle number). Take sample from the bottle and another
sample from the patient to reconfirm cross matching. Start i.v. saline, diuretics,
.hydrocortisone antihistamine and adrenaline
26
[1] Skin:
• Normal flora:
1- Candida albicans.
2- Staphylococcus epidermidis (albus).
3- Occasionally Staphylococcus aureus.
In disease (Infection):
1- Staph. aureus leads to infection of the base of the hair follicles (Boil
–furuncle) and in axillae (Hydradenitis suppurativa). It also causes
subcutaneous necrosis and abscess formation (carbuncle) and infection of
nail beds (paronychia) and space and hand spaces infections. Staphylococci
result in yellowish pus.
The abscess is a collection of pus surrounded by a pyogenic membrane
composed of fibrous tissue, dead bacteria, macrophages and polymorph
leucocytes. It present clinically with throbbing pain in a tender reddish warm
swelling. If not treated it may burst through the skin (forming a sinus) or into a
body cavity (leading to empyema of the pleural cavity or peritonitis). The
proper treatment of an abscess is incision and drainage of the pus with
breakdown of its loculi and curettage of the abscess membrane.
If the abscess is not tender it is called cold abscess and in this case it is due to
mycobacterium tuberculosis.
Deep abscesses in peritoneal cavity can be drained by open surgery or
aspirated under guidance of ultrasound or CT scan. If the patient comes with
Staph infection from home the best treatment is drainage of the pus and one of
the penicillin derivatives. Resistant Staph occur in hospital (nosocomial
infections) for which Colxacillin or Flucolxacillin should be given.
27
2- Streptococcus pyogenes leads to cellulitis (infection of the subcutaneous
tissue) and result in reddish painful flat area blanching on finger pressure. It
results in pinkish pus. Cellulitis in skin over long bones may hide underneath
acute osteomyelitis.
3- B- haemolytic streptococci cause rheumatic fever and rheumatic heart
disease and is very serious particularly in skin grafts. It usually responds well to
penicillin.
4- Clostridium tetani causes tetanus. Also it is sensitive to penicillin.
5- Clostridium welchii– Cl. septicum and Cl. oedematiens causes gas
gangrene. All are sensitive to penicillin.
Treatment of Staph infection:

1- Drainage of pus and excision of dead tissues.
2- Antibiotic of choice is penicillin but if infection is gained inside the hospital
like deep post surgical sepsis Staph. aureus can be resistant to penicillin because
it has an enzyme called ß - lactamase that break the penicillin ß-lactam ring, so
we use Coloxacillin or Flucloxacillin. However, infection by Methicillin
Resistant Cocci (MRC), (Methicillin is one of the penicillin group), is a serious
infection. In resistant strains vancomycin may be required.
If the patient is hypersensitive to penicillin, erythromycin tablets 250 mg
6 hourly or Ciprofloxacin 500m orally or I.V can be given.
*Staph cocci is the commonest cause of lactation mastitis and breast abscess.
*All types of clostridia are sensitive to penicillin.
• Perineum: In the perineum in addition to Staph aureus large
bowel organisms such as E. coli, Kelbsiella pneumoniae,
Streptococcus faecalis, Proteus vulgaris, Bacteroides fragilis and
Pseudomonas spices are found. However the best treatment of
perineal wound is to have daily warm sitzbaths. The antibiotics of
choice are:
28
- Metronidazole: for Bacteroides fragilis and Cefuroxime or gentamicin for
the other gram negative bacilli. Metronidazole (Flagyl) is given in a dose of
200mg tablets or 500mg i.v. t.d.s (three times daily).
-Cefuroxime: is a second generation cephalosporin active against both
gram positive and gram negative organisms. It is given in a dose of 750mg i.v.
8 hourly.
-Gentamicin: is one of the aminoglycosides, so it is nephrotoxic and
ototoxic (causes irreversible deafness). It is given in a dose of 80 mg iv or im 8
hourly and blood urea and gentamicin blood level should be monitored
regularly.
-Ciprofloxacin: is contraindicated in children, adolescents, pregnant and
lactating ladies because it precipitates in cartilage and may affect growth. Its
dose is 250 or 500mg tablets or 200mg infusion bottles given bid (twice a day)
[2]Respiratory system:
Streptococcus pneumoniae, Pneumococcus pneumoniae, Corynebacteria
Haemophilus influenzae are the pathognomonic organisms. The antibiotic of
choice is penicillin. in the form of crystalline penicillin 1 million units i.v. 4
hourly or Procaine penicillin 1 million units i.m. after skin test because it may
cause anaphylactic shock and death. Also, Amoxicillin 500mg syrup or
capsules can be given orally 8 hourly.
[3]Oesophagus and mouth:

In the mouth there are Streptococcus faecalis, Corynebacteria species.
and occasionally Staphylococcus aureus.
Infections such as: Pharyngitis, laryngitis and tonsillitis. May be caused
.by Strept. pyogenes and Staph. aureus. Treatment is Penicillin
Nystatin (Mycostatin) oral drops for glossitis caused by moniliasis.
29
Oesophagus is usually sterile in the normal state. In disease as
immunocompromised patients it is infected by fungi (Candida albicans -
moniliasis) which causes pain and difficulty in swallowing. It is treated by
Nystatin oral suspension.
[4]Stomach:
It is usually sterile in the normal state.
In disease:
1- If PH is still acidic (1-2) infection is caused by Helicobacter pylori
gastritis and is treated with Metronidazole 200mg t.d.s for 2 weeks +
Amoxicillin 500 mg capsules 8 hourly for 2 weeks + Omeprazole tablets 20 mg
o.d. (once daily) for 6 weeks.
2- In achlorhydria as in pernicious anaemia, gastric ulcer and gastric carcinoma

the following bacteria can be isolated: E. coli, Kelbsiella pneumonic,
Streptococcus faecalis and Bacteroides fragilis.
[5]Duodenum:
Normally: sterile (due to the pancreatic proteolytic enzymes).
In disease: usually sterile.
[6]Biliary system:
Normally: Bile is sterile.
In cholangitis or cholecystitis the expected organisms are: E. coli, Kelbsiella
spp, Streptococcus faecalis.
Cefuroxime 750 mg i.v. is given prophylactic in the time of induction of
anaesthesia. In case of cholangitis treatment is continued for 5 days.
Ciprofloxacin and gentamicin are other good alternatives.
30
[7]Pancreas:
Normally: pancreatic juice is sterile.
In mild acute pancreatitis there is no need for antibiotics but in severe acute
pancreatitis it is better to cover the patient against gram negative organisms
namely E. coli, Kelbsiella spp, and Strept. faecalis with Cefuroxime, gentamicin
or ciprofloxacin or a third generation like Ceftriaxone or Ceftazidime.
Note that combination of cephalosporin + aminoglycosides are synergistic as
nephrotoxic.
[8] Small intestine:

In the normal state contain bacterial flora like lactobacillus that does
not cause disease. In disease like intestinal obstruction, strangulated hernia and
mesenteric thrombosis E. coli, Kelbsiella, Pseudomonas, and Streptococcus
faecalis may pass through the diseased mucous membrane to the blood to cause
septicaemia or become located in the lungs to cause gram negative pneumonia
or in kidneys to cause urinary tract infection. This is called bacterial
translocation.
[9]Appendix, large bowel and rectum:

Normally: The flora is E coli, Kelbsiella and Proteus vulgaris and Bacteroides
fragilis. In diseases all these bacteria can cause infection. Bacteroides fragilis is
a gram negative strictly anaerobic bacillus. Culture of Bacteroides fragilis must
be taken in special container containing CO2.
A prophylactic antibiotic immediately before appendisectomy is Metronidazole
+ Cefuroxime or gentamicin is always advised.
[10]Genital organs:
31
Pelvic inflammatory disease is due to, E. coli, Kelbsiella, Streptococcus faecalis
and Bacteroides fragilis. Vaginal infection is caused by trichomonas vaginalis
and Candida albicans. Candida is treated by Nystatin or Canistin ointment.
Trichomonus vaginalis is treated by Metronidazole. If there is urethral
discharge in the male the cause may be Gonococci (Neisseria gonorrhoea) and
is treated with penicillin. In genital infection always suspect HIV/AIDS.
[11] Urinary system:

In the normal state urine is sterile.
In urinary tract infection (UTI) we request analysis for the mid stream urine
(MSU). In UTI pus cells in the male urine are >5/HPF (Per High Power Field
i.e. when seen by the high power lens of the microscope.) and in females
>10/HPF. In urinalysis we see the reaction (PH of the urine which is normally
acidic). If urine is alkaline the organism is Proteus vulgaris. It is treated by
acidification of urine + antibiotics (Norfloxacin, Cefuroxime, Gentamicin or
Nalidixic acid. If the reaction is acid the organism is E coli, Kelbsiella spp, or
pseudomonas spp. First we take a sample for culture and sensitivity and then
start antibiotics according to the suspected cause. Later we can change to the
proper antibiotic according to the culture and sensitivity if the patient is not
responding well. When the urine is acidic in reaction infection is treated by
alkalinizing the urine with potassium citrate + Antibiotics as Norfloxacin 400
mg bid, Cefuroxime, Gentamicin, or Nitrofurantoin, or Amikacin.
In urinalysis pus cells <5/HPF in males is acceptable, and <10HPF in females is
acceptable. The difference is because of the short urethra in females can easily
get contaminated from the perineum. If there are plenty of pus cells in the urine
and no organism is isolated then the case is sterile pyuria due to tuberculosis.
In bilharzia we ask for terminal urine for urinalysis. We look for
Schistosoma hematobium ova which has a terminal spine. The treatment in this
case is Praziquantil tablets.
32
Septic shock
Septic shock occurs usually in severe burn, peritonitis, and following
manipulation of obstructed biliary, urinary or gastro-intestinal tract. Although it
may occur with gram positive infection, it is common with infection by gram
negative bacilli. Endotoxins from gram negative infection and Exotoxins from
gram positive infection (like Clostridial infections) are absorbed in the
circulation. These toxins lead to myocardial depression and destruction of the
capillary endothelium. As a result the patient has congested neck veins and
disseminated intravascular coagulation (DIC). Unlike other types of shock
the patient’s skin is warm with vasodilatation of the vein in spite of the low
blood pressure. Septic shock has high mortality rate.
Treatment of septic shock:

1- Intravenous fluids to maintain the blood pressure and urine out put.
2- Broad spectrum antibiotics (Metronidazole+ Third generation
cephalosporin Ceftriaxone or Ceftazidime).
3- Drainage of the site of infection as early as possible and excision
of dead devitalized tissues.
4- Fresh frozen plasma + heparin to stop the disseminated
intravascular coagulation (DIC).
5- Nursing in intensive care unit (ICU) with central venous pressure
line and Foley’s urinary catheter to balance the fluid intake.
6- Close monitoring of vital signs (pulse, Temperature, BP, and RR)
33
*Process of healing:
1-Inflammatory response:
Trauma leads to physical inflammation with increased capillary permeability
 protein – rich exudates rich in mediators of inflammation like 5HT (5-
hydroxytryptamine), histamine, kallikreins like interleukin and inflammatory
cells migration by chemotactic factors. Macrophages engulf wound haematoma.
Capillaries at the wound edges proliferate.
2-Proliferative phase: (3 weeks)
The epithelium is stimulated to divide and migrate from the edges while new
capillary formation starts all over in side the wound. Fibroblasts lay down
collagen synthesis with fibrils which mature into granulation tissues and later
fibrous tissue.
Sutured clean surgical wounds heal by primary intension and their sutures are
primary sutures.
Infected open wounds with loss of the skin surface are left to granulate and heal
by secondary intension. The granulation tissue is red because of vast
number of capillaries but may contain yellowish areas which are necrotic
tissue composed of dead bacteria + dead tissues + dead white blood cells.
When the wound is red i.e. granulating it can be sutured to approximate the gap
in the skin and reduce the healing time. These sutures are secondary sutures.
34
Management of wound:
1- Wounds inflicted in less than 6 hours are cleaned and sutured but
wounds of more than 6 hours duration before arrival to hospital should be
cleaned thoroughly and dressed with out sutures.
2- Prescribe antibiotic from the penicillin family if there is no allergy
to penicillin otherwise use Erythromycin if there is hypersensitivity to
penicillin.
3- The patient is asked about the status of his tetanus immunization
and treated as follows:
a- If he was immunized within less than 5 years there is no need for
further immunization.
b- If he was immunized between 5-10 years ago a booster dose of the
tetanus vaccine (Tetanus toxoid) is given with a single dose of Human
Anti-Tetanus Serum (human immunoglobulin ATS) to give passive
immunity till the booster dose works.
c- If he is immunized more than 10 years ago or not immunized at all
then give an immediate dose of the human anti-tetanus serum (ATS) and
start him on the programme of tetanus vaccination.
4- Later when the wound gap is too big but with good granulation
tissue split skin graft is advised.
5- Tendons, nerves, arteries, veins, bone and cartilage should not be
left exposed otherwise they will dry up and suffer necrosis. Skin flaps are
advised to cover these structures.
6- Strong disinfectant material like alcohol, hydrogen peroxide, and
tincture iodine should not be used in all types of wounds at all because
35
they damage cells, however, Providone iodine is found to be good for
disinfecting wounds.
*Problems of wound healing:

1) Dehiscence:
a-This occurs in wound infection when pus collect in subcutaneous
tissue and burst through the skin resulting in skin gap.
b- Dehiscence may occur in the deep layers while the skin is still
intact. This results in incisional hernia.
c- Complete separation of all layers lead to exposure of abdominal
contents is called burst abdomen. This is treated by immediate
covering of the intestine with sterile gauze soaked in normal saline to prevent
evaporation, drying up of the intestine and to reduce infection. Then the patient
should be taken to the operation room for closure with tension sutures (sutures
passing through all layers including the skin).
Causes of dehiscence:
a- Infection.
b- Suture with absorbable suture material.
c- Poor technique i.e. tight sutures that cut off the blood supply
from the healing edges resulting in necrosis and failure of
healing.
d- Increased intra-abdominal pressure by prolong illness, cough,
straining during passing urine or during defecation, carrying
heavy weight, pregnancy, malignancy, steroids,
chemotherapy and radiotherapy.
2) Keloid:
This is excessive fibrous tissue formation simulated by the sebum.
Therefore, it occurs in areas of the skin rich in sebaceous glands i.e. it does not
36
occur in palmer and planter surfaces neither in mucous membranes. Keloids are
common in dark skin people and usually absent in children below 2 years and
elderly patients. It is treated by steroid injections and pressure dressing. Big
keloids are excised from inside their edges and covered with partial thickness
(split) skin grafts.
Tetanus
Tetanus is caused by Clostridium tetani, which is an anaerobic gram
positive spore forming bacillus that has 2 exotoxins:
1- Haemolysin: This lead to haemolysis of the red blood cells
2-Tetanospasmin: This is carried along the nerves to the posterior horn
cells of the spinal cord and then to the medulla oblongata to reach the
respiratory centres. It causes severe muscle spasm and contractions.
Clinically:
1- Local tetanus: this may appear before or after complete wound
healing. If the bacteria found the suitable atmosphere i.e. anaerobic
media in the tissues, it will loose its spore and proliferate and secrete its 2
exotoxins. The patient complains of localized pain and localized muscle
spasm at the site of the wound.
2- Generalized disease: As the toxin reaches the central nervous
system more nerves become affected. Therefore, the Masseter muscles go
into spasm resulting in lock jaw while the muscles of deglutition lead to
difficulty in swallowing (dysphagia). The Buccinator muscle becomes
contracted leading to the contraction at the angles of the mouth which is
known as Risus sardonicus. The paravertebral muscles become spastic
and contracted leading to arching of the spine. All extensor muscle
contract and are easily stimulated by stimuli like light, noise touch that
initiate severe contractions and convulsions. In the severest form the
respiratory muscles become affected leading to difficulty in breathing
and then asphyxia.
37
Treatment of tetanus:
1- Local treatment by wound excision: i.e. removal of margins of the
wound and all dead tissues and leaving the wound open without suture
under cover of light dressing.
2- Benzyl penicillin 2 million units i.v. 4 hourly.
3- Nursing in a dark quiet room in isolation of other patients.
4- Human anti tetanus serum for passive immunity.
5- If the patient can not eat insert NGT for feeding and Foley's
catheter to monitor the urine out put.
6- Diazepam 10 mg i.v. and another 10 mg in i.v. fluid to control
convulsions.
7-Mechanical ventilation and full relaxation of muscles if the respiratory
muscles are affected.
8- Care of skin and care of sphincters.
Gas Gangrene
This is caused by Clostridium Welchii (perfringens), Clostridium
septicum, and Clostridium oedematiens. These are anaerobic gram positive
spore forming bacilli that have many exotoxins. The most important exotoxins
are α- toxin which breaks down the phospholipids component of the RBC
resulting in very severe haemolysis and anaemia.
Other exotoxins are collagenase and hyaluronidase and deoxyribonuclease
which produce cellulites and progressive muscle necrosis with spread of
fermented gas (H2S+ CO2) below the skin and in tissue planes. The gas results
because these bacteria are saccharolytic and proteolytic type of bacteria.
38
Clinical features:
Dirty wound with local pain, gas crepitus in surrounding tissues. The patient
looks ill, toxic very pale and hypotensive.
Treatment:
1- Correct anaemia by blood transfusion.
2- 2 million units of benzyl penicillin i.v. start (immediately)
and then 4 hourly.
3- Excision of all dead tissues. Do not apply sutures.
4- If the disease is threatening the life of the patient proceed for
emergency gluten amputation of the affected limb. If the disease is
threatening the limb only plan for limb salvage
(i.e. excision of dead tissues to save the limb).
5- Hyperbaric oxygen (oxygen under high pressure) is available
in only very few centres world wide.
6- Nurse and treat as a case of septic shock. (monitoring of pulse, BP,
Temp, RR, i.v. fluids, input out put charts)
*Wounds with gas crepitus in which the patient is not pale and does not look ill
are most likely due to other gas forming organisms like the enterobacteriacae.
In any chronic wound X-ray is mandatory to find out evidence of
osteomyelitis (irregular cortex of bone) and presence of small gas shadow
in deep tissues where gas crepitus can be missed.
IMPORTANT NOTES:
• Types of infections:
1-Specific infections: tuberculosis and syphilis.
2-Non-specific infections: other bacteria
39
• Bacteraemia: Presence of bacteria in blood. It occurs
during and immediately after manipulation of any obstructed
system being biliary, urinary or gastrointestinal tracts and after
urinary catheterization.
• Septicaemia: Presence of dividing bacteria in the blood.
• Toxaemia: This is due to the toxins of the bacteria. These
are endo or exotoxins leading to Systemic Inflammatory
Response syndrome (SIRS).
Types of surgical wounds:

1- Clean wound as in thyroidectomy, herniorrhaphy and
excision of lipoma. These wounds do not require antibiotics.
2- Clean-contaminated wound: are wounds in which a
hollow viscous was transected as in resection of stomach, small
intestine, cystic duct and ureter.
3- Contaminated wound: When there spillage of small
intestinal content, bile or urine or operation in an unprepared
large bowel or gangrenous appendix.
4- Dirty wound: as in presence of pus or foreign material as
in war injuries.
*Factors that increase susceptibility to infection:

1- Patient factors: Very young and very old, obese,
malnourished, and patients having leucopenia or
hypogammaglobulinaemia are highly susceptible to infection.
40
2- Coexisting disease: Like burns, multiple trauma,
malignancy, anaemia, diabetes, renal failure, jaundice, and
arterial insufficiency.
3- Drugs: as steroids, chemotherapy, radiotherapy and
prolonged treatment with broad spectrum antibiotics.
*Factors that delay wound healing:

1- Poor nutrition and vitamin C and zinc deficiency.
2- Ischemia leading to reduced oxygen supply.
3- Infection
41
Oral nutrition
• The best type of nutrition is the oral nutrition because:
1- Usually it contain all necessary components of nutrition which are
water, carbohydrates, protein, fat, vitamins and minerals.
2- It utilizes the normal pathway which is the elementary tract. The food is torn
into small pieces and crushed by the teeth. In the mouth it is mixed well with
saliva which contains amylase that helps in breaking down of carbohydrates. In
the stomach it is minced and mixed well and the acid of the stomach that helps
in killing contaminating bacteria. The function of the small intestine is secretion
of enzymes like the maltase, sucrase, lactase, dipeptidases, etc. and hormones
like enterogastrone. Also the small intestine absorbs the digested food and
propagates the waste to the large bowel.
3-Presence of food and bile in the intestine maintains the integrity of the
intestinal mucosal barrier against bacterial leakage into the circulation.
Need for nutrition in surgery:
Some patients who require surgery may be malnourished. Malnutrition is as
common in elderly patients as in paediatrics. Elderly patient may not take enough
food because of their disease, they can not afford to buy it, or they are too old to go
and buy or cook food, particularly when they live alone or when they are neglected
by the family.
Types of malnutrition:
1- Morbid obesity.
42
2- Under nutrition either due to protein calories malnutrition
(kwashiorkor), protein malnutrition (marasmus) or iron and vitamin
deficiency as in repeated pregnancies, and chronic gastrointestinal bleeding of
reflux oesophagitis, gastritis, or haemorrhoids, or from single vitamin
deficiency as in pernicious anaemia (B12) and (Vitamin C).
The normal requirement of nutrition is:
1-Water:
In a volume to meet the daily requirements which are:
Urine about 1500cc
Sweating varies with the climate about 30-1600cc
Water vapour in breathing about 500cc
Stools varies with type of diet about 200cc
In hot climate the daily requirement of water is about 3000-4000ml.
The daily requirement of water also varies with climate and with disease.
Larger volumes are needed in heat stroke, fever as malaria, gastroenteritis,
diabetic ketoacidosis, and sepsis. Restricted volumes are needed in renal and
heart failure. In fever add 250 ml water for every degree raise in temperature.
Therefore, to decide the volume of water - each case should be taken on its
own merits.
2-Energy:
This is found in carbohydrates and fat. I gram of glucose gives 4

kilocalories. 1 gram of fat gives 9 kilocalories. The daily requirement of energy
for the adult is 2500-3000kilocalories. In diabetes high glucose intake is not
advisable and in cases of obstructive jaundice oral fat can not be utilized. In
renal failure restrict proteins. Therefore, again to decide for the source of
energy, every case should be taken in its own merits - when supplement of
nutrition is to be given.
43
3-Protien:
Although 1 gm of protein gives 4 kcal, protein should not be given to
generate energy, on the contrary it should be given to build tissues and for
tissue repair. The daily requirement of protein is 1 gm per kg body weight. In
cases of protein deficiency and severe catabolism as in septicaemia and burn
higher doses are needed.
3- The daily requirement of vitamins and minerals should be calculated.
With consultation of food tables or any dieticians quantities of food can be easily
calculated.
Causes that prevent oral intake of nutrition:

1-Advanced cancer of the tongue or mandible.
2- Fracture maxilla or mandible.
3- Bulbar palsy.
4- Coma.
5- Carcinoma of oesophagus and stomach.
In such cases the best root for nutrition is enteral feeding. Enteral feeding is
conducted by:
1-Nasogastric or naso-duodenal tube.
2-Gastrostomy or jejunostomy feeding tube.
The Enteral feeding:

Is the next best root of nutrition because it utilizes the alimentary tract except
the mouth. Therefore, it has most of the advantages of the oral root mentioned
above.
The disadvantage of enteral feeding is:
1- Tubes passing through the nose cause discomfort and unpleasant
44
sensation to the patient.
2-Concentrated food poured directly in the duodenum or jejunum leads to
osmotic diarrhoea.
3- Contaminated food i.e. if sterilization is broken during preparation of
feeds leads to infected diarrhoea.
Parentral nutrition:
The indications of parentral nutrition are:
1-In ability to use the upper gastrointestinal tract due to carcinoma of the
oesophagus.
2-Short bowel syndrome resulting from surgical excision of large segments
of the small intestine in cases of mesenteric thrombosis, Crohn's disease etc. In
this case the small bowel is too short to maintain absorption of adequate amount
of nutrition.
3- Prolong period of paralytic ileus due to sepsis or surgery.
4- Small intestinal or pancreatic fistula.
*Total parentral nutrition is available in the following forms:
1-Concentrated glucose 10%, 25%, and 50%.
1 litre of glucose 10% contain 1000ml X 10/100 =100 gm glucose
100 X 4 = 400kcal/L
250 X 4 = 1000kcal/L
500 X 4 = 2000kcal/L
a- When concentrated glucose is given daily blood sugar must be estimated
and when the level of blood sugar is high insulin is added.
b- Also concentrated glucose is hypertonic, therefore, it should be given in a
central vein like the subclavian or internal jugular vein to prevent
thrombosis.
c- Also concentrated glucose is hyperosmolar and it causes osmotic diuresis
45
therefore, in put, out put, fluid charts should be made to maintained the
fluid and electrolyte balance.
2-Fat is available in the form of milk white emulsion of Soy been oil called
intralipid. It is available in 10% concentration giving 1100Kcal/L and 20%
intralipid giving 2200Kcal/L.
a- When intralipid is used liver function tests and prothrombin time should be
requested at least once weekly.
When intralipid is administered we should look daily for signs of fat
embolism as red skin rash and deterioration of level of consciousness.
3-Protein is available in the form of Vamin in 10% dextrose or

Aminocerel.
For better utilization of protein, It should be used for tissue repair and not for
energy. Therefore, it is advisable to be given with dextrose in a proportion of
1:12.
4- Vitamins: 1 ampoule of vitamin C and B complex is sufficient.

5-Trace elements like zinc, copper, sulphur. Magnesium etc. are available in an
ampoule called Adamel. 1 ampoule is sufficient per day.
• Principals of giving total parentral nutrition (TPN):

1- Fluids can be given separately or in mixture.
2- Fluids should be prepared and given with a strict
aseptic technique.
3- To calculate TPN: First determine the volume of
fluids you would like to give according to the disease of the
patient (burn ,diabetes, jaundice, renal or heart failure).Then
use concentrated glucose and /or intralipid according to the
disease of the patient (Diabetes, jaundice, renal failure ect.)
46
4- body weight, Hb, serum electrolytes, LFT, and PT
must be
estimated regularly.
Complications of total parentral nutrition:

1-Complications of the central lines.
a-Haemothorax
b-Pneumothorax
c-Infection septicaemia
d-Catheter embolization.
2-Complications of the TPN fluids.
a-Hyperglycaemia
b-Hypokalaemia
c-Fat embolism
d-Bleeding tendency
47
• Burn is a physical trauma due to effect of heat resulting in various degrees of
coagulation of tissue proteins.
Causes of burn:
1-Sun tan: Brown skin discolouration due to exposure to direct sun light by the
white skin people.
2-Scalds: Burn by boiling water, milk, tea etc.
3-Flames.
4-Electrical burn: Usually deep burn leading to coagulation and thrombosis of
main blood vessels ending in gangrene.
5-Chemical burn by strong acids or alkalis: Usually it is a deep burn.
6- Radiation burn: Usually it is deep and may be associated with bone marrow
depression or cancer.
Anatomy:
1-The skin is made of epidermis and dermis. In between there is a basal layer
that contain melanin secreting cells and from this basal layer the squamous
epithelium of the skin regenerate. Damage to the superficial layer of the
epidermis (the cuticle) by trauma (aberrations), burn or after taking partial
thickness skin graft is repaired with out deformities (contracture or Keloid).
48
2-The dermis contain hair follicles and sebaceous glands. The later induces
excessive fibrous tissue formation resulting in keloid formation and
contractures.
3- Subcutaneous fat: contain fat globules with minimum blood supply.
Therefore it is the site of infection.
4-Deep investing fascia: This is a tough layer of fascia that covers the muscles
and deep vessels and nerves. Burn leads to intense inflammatory reaction (Pain,
swelling, redness, hotness and loss of function).This fascia prevent expansion of
oedematous muscles. Muscles are usually found in compartments made by
tough intermuscular septa, bone and superficial fascia. The inflammatory
oedema in the muscle makes these muscles swollen and this swelling needs
bigger space. The tough wall of the compartment prevents this expansion.
Therefore, the pressure rises inside the compartment and presses on the deep
nerves and vessels leading to ischemic pain, paralysis, muscle necrosis and
distal gangrene. This is called the compartment syndrome. Pressure leads to
autolysis of the muscles and liberation of their myoglobin. Myoglobin passes to
the circulation to be filtered through the kidneys. It results in dark red urine.
Myoglobin may block the renal tubules resulting in acute renal failure.
5- Muscles are red because they are rich in capillaries. If the burn reaches the
muscles or deep to the epidermis where the vessels of the skin pass it will result
in coagulation of large number of capillaries and blood vessels resulting in
destruction of RBCs leading to anaemia. Therefore if the surface of deep burn is
10% or more the patient should receive blood till his Hb and haematocrit are
normalized.
Pathophysiology:
Burn induces major body response to stress. This is due to pain apprehension
and loss of extracellular fluid. Both the hormonal and neural pathways of the
response to stress are activated resulting in release of adrenaline, cortisol,
aldosterone and anti-diuretic hormone.
49
• Adrenaline and norepinephrine lead to generalized
vasoconstriction  increased peripheral resistance  maintained blood
pressure. Also adrenaline  break down of glycogen to release glucose
for energy.
• Cortisol gluconeogenesis. Proteins are broken down to release
glucogenic amino acids to manufacture glucose. Loss of protein thin
mucosal barrier of the alimentary tract. This thin mucosa is
susceptible to ulceration by the high levels of gastric acids liberated
during stress  stress ulceration of the mucosa of the stomach and
duodenum. Also breakdown of proteins  depression of level of
albumin and globulins. Hypoalbuminemia  low osmotic (oncotic)
pressure resulting in generalized oedema. Low globulins  low
immunoglobulin synthesis easy migration of bacteria from the bowel
to the circulation  pneumonia, abscesses, UTI and septicaemia and
endotoxic shock all by the gram negative enterobacteriacae of the
bowel (Bacterial translocation).
Interstitial oedema Hypovolaemia hypotension activation of the

renin-angiotensin system. When the systolic BP is less than 70mmHg acute
tubular necrosis occur  acute renal failure.
The function of the dead space in the upper respiratory system i.e. the nose,
nasopharynx, larynx, trachea and major bronchi is humidification of dry air,
cooling hot air and warming cold air. In flame burn the excessive inhalation
of the hot air  intense inflammatory reaction that is seen more evident
where the mucosa is lax in the larynx  laryngeal oedema that  upper
air way obstruction. Hot air reaching the alveoli  severe inflammatory
response in the form of oedema, collapse of alveoli (Burn pneumonitis) and
reduction of the O2 and CO2 exchange necessitating a use of mechanical
50
ventilator (Adult Respiratory Distress Syndrome - ARDS) which even when the
lung tissue heals by fibrosis also  reduction of gas exchange.
Burn also leads to severe psychological trauma particularly when the

exposed parts of the body like the face, neck and hands are affected.
The scar tissue of burn may go in repeated phases of ulceration and

healing i.e. become an unstable ulcer  squamous cell carcinoma
(Marjolin’s ulcer).
Criteria for Admission to hospital:

1- Burn area >15% in adults and >10% in Children.
2- Major Burn:
Criteria of major burn:

1- Burn > 25% in an adult.
2- Associated Fractures
3- Associated other illnesses like diabetes mellitus etc.
4- Burn of the face, neck, palmer surface of hands, planter surface of
feet, perineum or circumferential burn.
Treatment of Burn:
1- Maintenance of airway, breathing and circulation.
2- Assessment of the burnt surface area according to the rule of 9 or
the palmer surface equal 1% of the body surface area.
3- Calculation of the fluid requirement as follows:
1 Ration = Burnt surface area X Body weight / 2
* We give 3 rations in the first 12 hours from the time of the burn + 1/2 the
daily requirement of i.v. fluids.
51
* In the next 12 hours we give 2 rations + 1/2 the daily requirement of i.v.
fluid.
* In the third 12 hours we give one ration + 1/2 the daily requirement of i.v.
fluid.
All the fluid is either Normal Saline or Ringer's Lactate. If there is deep
Burn we add blood. Every unit of blood = 3 units of crystalloid fluid.
Foley's catheter should be inserted to calculate the input and out put aiming
at satisfactory urine out put of 1ml/kg wt/hr.
4- Start early high calorie high protein oral intake. If there is acute
gastric dilatation or paralytic ileus insert NGT and keep the patient
NPO till he opens his bowels or bowel sounds are heard.
5- Start antacids and H2 blockers to prevent stress ulcer. Alkalis 
alkalinization of the urine  dissolution of myoglobin in urine to
prevent renal failure.
6- Pethidine 1mg/kg wt i.v. 4 hourly as required to relieving pain.
7- Early physiotherapy to prevent contractures.
8- Early mobilization out of bed to prevent DVT.
9- Wound swaps every 3 days. If there is bacterial growth or fever
start antibiotics mainly penicillin if there is no hypersensitivity. Nurse
under Mosquito net to reduce contacts with flies.
10- Either keep the wounds dry and paint it with Gentian Violet or clean the
wounds with Chlorohexidine followed by normal saline. Then apply
sulfadiazine ointment (Flamazine), Sufratule gauze then cotton wool and
light bandage.
The following areas should be left exposed: The face, neck axillae
and perineum.
11-Human Anti-tetanus vaccine according to the status of immunization.
*In deep burn with skin loss advice early split skin graft to reduce the
hospitalization period.
============================
52
Self assessment
:Burn
:Aetiology of burn includes all the following except-1
.a- Scalds
.b- Sun tan
.c- Radiotherapy
.d- Heat stroke
.e- Sulfuric acid
:Answer
d) – Heat stroke is a state of severe dehydration with hypotension due to ) – 1
.excessive loss of sweat and extreme raise in temperature
:The following always causes deep burn -2

a- Scalds
.b- Electricity burn
.c- Chemical burn
.e- Only (b) and (c) are correct
:Answer
e) – Electrical burn lead to coagulation of main deep vessels resulting in ) – 2
.distal gangrene few days latter
:In burn -3
.a- Superficial burns heal with out scar tissue
.b- Partial thickness burn heals by granulation
.c- Deep burn leads to blood loss
:Answer
e) – The blood loss in deep burn is due to coagulation of millions of blood ) – 3
in billions of capillaries in red muscles. However, in extensive burn when
sepsis develop haemolysis occur leading to drop of haemoglobin. Therefore in
.burn haemoglobin and haematocrit should be measured regularly
:In burn loss of body fluids is initially due to -4

.a- Excessive heat
.b- Raised temperature
.c- Increased permeability
.d- Excessive sweating
.e- Low fluid intake
53
:Answer
c) - As part of the inflammatory response to physical trauma in general ) – 4
pain, redness, swelling, hotness, and loss of function occur. The swelling is due
.to increased permeability leading to leak of body fluids
:Burn in the respiratory system is suspected by -5

.a- Presence of burnt hair in eye brows
.b- Presence of soot in the face
.c- Presence of noisy breathing
.d- Presence difficulty in breathing
:Answer
e) – The hot air, smoke or flames lead to laryngeal oedema and strider, ) – 5
while excessive smoke in absence of oxygen lead to carbon monoxide
.poisoning
:Flame burn may lead to -6

.a- Laryngeal oedema
.b- Burn pneumonitis
.c- Hypoxia and hypercabnia
:Answer
d) – In severe burn pneumonitis the patient may requires antibiotics, ) – 6
.steroids, and probably mechanical ventilation
:In tretment of respiratory burn the following may be required -7
.a- Cricothyroidotomy
.b- Tracheostomy
.c- Mechanical ventilation
:Answer
e) – Crico-thyroidotomy is done as emergency and because tracheostomy ) – 7
is a long demanding operation requiring splitting of the thyroid isthmus, it is
.left for elective cases if mechanical ventilation is anticipated
:Severe burn may lead to -8

.a- Acute gastric dilatation
.b- Intestinal obstruction
54
.c- Stress ulcers in stomach
:Answer
d) – Burnt patient should be encouraged to take high calorie high protein ) – 8
diet as early as possible because of the severe catabolism that result from burn.
However, patients who develop GIT complications of burn as listed should
have an NGT, intravenous fluids till their bowel start to move. Prophylaxis
against stress ulcer in form of antacids, H2 blockers or proton pump inhibitors
.(Omeprazole) should be given to cases of major burn
:The burn is considered major burn if there is -9

.a- Involvement of the face, neck, or perineum
.b- Involvement of the palms or soles of the feet
.c- Associated illnesses or fractures
:Answer
d) – Also more than 25% superficial burn, 10% deep burn are considered ) – 9
.major burns and should be admitted to hospital for management
:The following patient should be admitted to the hospital -10

.a- An adult with 13 percent burn of the trunk
.b- An adult with electrical burn at both mid forearms
.c- A young adult with 9% burn and tachycardia
.d- An adult with circumferential burn in one forearm
.e- Only (b) and (d) are correct
:Answer
e) – Indications of admission include all cases of major burns, an adult ) – 10
with15% superficial burn or a child with 10% superficial burn and
.circumferential burn for fasciotomy for the fear of compartment syndrome
:In severe burn the renal function is affected by -11

.a- In adequate replacement of fluid loss
.b- Myoglobinuria in cases of compartment syndrome
.c- Late septic shock
.d- Incompatible blood transfusion
:Answer
e) – Hypotension from hypovolaemia or septic shock leads to acute ) – 11
tubular necrosis when the systolic blood pressure is sustained below 70 mmHg.
55
Myoglobins derived from autolysis of dead muscles in compartmental syndrome
.precipitate in and block the renal tubules leading to renal failure
:In burn the best relief of pain is by -12

.a- Sedation by diazepam intravenously
.b- Intramuscular Morphine injections
.c- Intravenous Pethidine in small frequent doses
.d- Sodium Diclofenac intramuscular injections
.e- Diazepam and diclofenac intramuscularly
:Answer
c - In presence of generalized vasoconstriction, intramuscular injections – 12
will not be absorbed and repeated doses lead to accumulation of the drug in the
muscle. Latter when the blood pressure is corrected the high dose of the drug in
the muscle will pass to the circulation and may lead to respiratory arrest. The
.dose of Pethidine is 1-2mg/kgwt 4-6 hourly
:Fluid therapy in burn should -13

.a- Consider the time passed from the moment of burn
.b- Dextran should be delayed till blood is taken for grouping
.c- Blood should be added in presence of deep burn
.d- Electrolytes should be corrected and daily requirement added
:Answer
e) – Dextran interferes with blood grouping therefore should not be ) – 13
.given before blood is taken for grouping and cross matching
:The danger of electrical burn is that -14

.a- It causes delayed ischemia due to coagulation of deep vessels
.b- It causes severe pain, extensive deep sepsis and fluid loss
.c- It causes severe ventricular arrhythmia
:Answer
.e) – Electrical burn should always be considered as deep burn ) – 14
:In burn early physiotherapy and ambulation are advised to -15

.a- Prevent burn contractures
.b- Prevent Keloid formation
.c- Prevent deep venous thrombosis
:Answer
56
e) – Keloid occurs in areas of skin containing sebaceous glands ) – 15
.therefore it does not occur in hands palms or mucos membranes
:Use of antibiotics in burn is indicated -16

.a- In cases of severe extensive burn
.b- After culture and sensitivity
.c- If there are signs of infection
.d- Penicillin to prevent Clostridial infections
.e- All the above are good indications
:Answer
e) – Septicemia is a major cause of death in burns, therefore regular ) – 16
swabs for culture and if there is fever blood for culture is the best way to treat
sepsis. However penicillin is a good drug to start with, yet, hospital acquired
.infection is always resistant to penicillin
:Application of gentian violet in burnt area -17

.a- Is cheep in price
.b- Allows exposed skin to dry up
.c- Reduces infection of the dry scaly skin
.d- Mosquito net should be used to keep away flies
:Answer
e) – Although Gentian violet is not the best treatment it dries the blisters. ) – 17
However dryness leads to death of cell and this need time to regenerate
.particularly in the presence of catabolism
:The dressing in burns -18

.a- Is used to keeps cells moist warm and alive
.b- Is used to reduce chances of infection
.c- Is used over skin grafts to enhance healing
.d- Should not be used in the face, axilla and perineum
:Answer
e) – Although it is costly and requires a plastic surgeon skin grafting ) – 18
reduces complications of burn, minimize the period of treatment and therefore
.reduced the overall cost of treatment
========================================================
:Practical points for the OSCE

a- Foley’s urinary catheter:
57
Uses of Foley's catheter:
1- For relieving acute retention of urine (inability to pass
urine
associated with pain and strong desire to pass urine).
2- For calculating the urine out put during and after major
operation in patients in coma and shock patients.
3- For bed ridden patients to prevent urine soiling their beds
not only to get rid of the bad smell but because wet beds lead to
maceration of the skin and lead to bed sore (infected wounds as a
result of pressure ischaemia resulting from prolonged lying on one
side of the body).
4- After operations in urinary bladder and rectum.
5- To empty the urinary bladder immediately before childbirth.
6- Immediately before procedures like peritoneal lavage and
laparoscopy (looking inside the abdomen by a scope
passed through the abdominal wall).
How to introduce the urinary catheter:
1- Inform the patient about the procedure.
2-Wear face mask, gloves.
3- Wash the groin and genitalia thoroughly with a mild antiseptic
(Chlorhexidine) to reduce chances for infection.
4- Apply sterile drapes (sheet) to isolate the genitalia.
5- Apply a lubricant (Sterile Xylocaine gel or ointment) both on the
surface of the catheter and into the urethra.
6- Hold up the penis by the middle and ring fingers and open up the
external urethral meatus by the index and thump of the same hand.
7- Gently introduce the catheter.
8- Do not push by force if resistance is encountered. Instead, request
an expert senior to do it.
9- When clear urine is obtained insert the catheter more inside to
make sure that the balloon is not in the posterior urethra.
58
10-Do not inflate the balloon till you get clear urine
11-Do not exceed the volume of inflation written on the catheter itself
otherwise the balloon will rupture and the catheter may slip out
spontaneously. There is a special valve for inflation of the balloon at the
distal end of the catheter. This balloon secures the catheter in the urinary
bladder.
12-Connect the urine bag to the catheter is to be left indwelling.
Complications of urinary catheter:
1- Injuring the urethra if pushed by force leading to false passage
formation. This may heal by fibrosis resulting in urethral stricture.
2- Bacteraemia presenting as hypotension, sweating, tachycardia and
pallor. It is due to transmigration of the bacteria in the anterior urethra
through the mucus membrane of the urethra to the blood stream. It is
treated by i.v. normal saline and gentamicin.
3- Ascending infection: Infection ascends up the lumen of the urinary
tract, by haematogenous and lymphatic spread to the urinary bladder,
ureter leading to acute pyelonephritis, and down the epididymis and
testis leading to acute epididymo-orchitis. These present as fever after 5
days or more. Acute pyelonephritis causes fever with rigors and loin
pain. The urine is turbid containing significant pus cells. Urine is taken
for culture and sensitivity and the appropriate antibiotic is immediately
started.
4- Ulcer formation in the urinary bladder or urethra itself as a result
of keeping the catheter indwelling for a long time. This may heal later
with fibrosis resulting in urethral stricture in the future.
Structured Essay Question

( 1 ) A 65 year old obese lady who was previously quite healthy has just
under gone open cholecystectomy. The operation took 1½ hours because
59
of acute inflammation and dense adhesions. The surgeon wants to keep her
fasting for 24 hours.
1- Name an antibiotic she has to receive before induction of anaesthesia and
give a reason for that.
2- Write a detailed plan for her i.v. fluid in the first 24 hours.
3- How would you be certain that the fluid you wrote is satisfactory?
4- Write the name, dose, route and frequency of the type of analgesia she
should receive.
Next morning during the ward round her temperature was 38.3° C. 5-
What is the commonest cause for the rise of her temperature and how would
you treat that?
On the third post operative day she complained of pain in her wound. The
wound was reddish tender on touch with redness that blanches on finger
pressure.
6- Write an explanation for the changes in her wound and mention how would
you treat that?
On the 5th post operative day there was wound discharge and further raise
in temperature.
7- In 3 steps mention how would you treat her at this stage?
On the 7th post operative period again her temperature showed another
rise.
8- Mention 2 possible explanations for the latest rise in temperature.
9- Mention how would you confirm and treat each of these 2 possibilities?
( 2 ) A 23-year old lady had been caught by fire in the outskirts of the
town at 6:00 am and brought to hospital at 10:00 am. She was restless, with
burn involving her face, chest, abdomen and both arms. The surface area
burnt was about 10% deep and 20% superficial burn. Her pulse 120/min
BP 90/60 temperature 37oC RR 26/min body weight 52kg.
1- Write 3 indications for her hospital admission.
60
2- What is the first action you will do in managing this patient?
3- Write down the amount and type of fluid you will give from arrival up to
6:00 pm.
4- Mention the type, dose, frequency and route for administration of analgesia
in this patient.
5- What is the expected status of her acid base balance on arrival?
Her total urine output up 6:00pm was 120 ml.
6- Is that acceptable? Give a reason for your answer.
7- If the urine output continued with the same rate what complication is she
going to develop?
8- In 7 points mention how would you treat her wounds?
After one week she was still looking weak and ill. Her body weight was
42kg.
9- In 2 points explain why she lost weight.
Unfortunately the condition of this girl deteriorated she vomited a small
amount of blood and she died on the 10Th day of admission.
10- Give a reason for haematemesis and malaena.
11- Mention 2 possible causes of her death
A 17-year old boy sustained injury to his left knee, ankle and (3)
shoulder after his motorbike turned over. At presentation to the casualty
.his wounds were not bleeding but were apparently dirty
In 4 points explain why his wounds were not actively bleeding on hospital -1
.arrival
.Mention 2 indications for cleaning and suturing his wounds -2
.In 4 points mention the steps of healing of his wounds -3
One of his wounds got infected. Its sutures were removed and left open on
.regular dressings to heal by secondary intension in 3 weeks time
.Mention 3 possible predisposing factors for infection -4
61
.Mention 3 possible reasons for his delayed healing -5
days later he was brought to the hospital because he feels pain and 10
spasm at the sites of his ankle wound but he doesn’t look ill and he was not
.pale
Mention one possible serious complication he may have developed at this -6
.stage
He was given analgesics and sent back home but his father brought him
.back after 2 days because he can not swallow his food
Mention 4 physical signs you would look for during examination of the -7
.patient
.In 9 points mention how would you treat him -8
Mr. M Shawer and Prof Ibn Ouf
Preoperative care:
1- Assess risk of surgery by (Hb%, CXR (chest X-ray), ECG, serum

electrolytes, urea).
2- Assess risk of anaesthesia (presence of another disease as heart disease,
chronic lung disease, diabetes mellitus, hypertension, liver or renal disease
etc).
3- Assess if he need blood or not (by Hb%) and general condition and type
and expected duration of surgery.
4- Informed consent.
5- Nutrition: by N.G.T in patient with cancer oesophagus.
6- Correct the dehydration and electrolytes by I.V fluids as in intestinal
obstruction, pyloric stenosis and jaundice.
7- In large bowel surgery there is a special preparation for the bowel. .
62
- As colonic wash out enema/ 3 days.
- Castor oil.
- Shave the skin.
In other pathologies check for special preparation as in the
jaundiced patient and in patients with thyrotoxicosis
8- Prophylactic antibiotics at the induction of anaesthesia.
9- Put the patient under continuous observation.
10- If the patient is obese or the operation is long consider heparin for
prophylaxis against deep venous thrombosis
During anaesthesia:
• 500 -1000 ml I.V fluids/hr. with high rate because of:
-Surgical trauma.
-Consider evaporation of fluids from surface of intestine.
-Remember a lot of fluid will go to the interstitial space in
response to the surgical trauma.
Post operative care:

• Feeding: in thyroid or breast operation, gallbladder, hernia and limb
surgery the patient can eat in the same day of operation, but in long
abdominal operations we should wait till bowel sounds are heard or the
patient opens his bowel (passes wind).
• Daily requirement of I.V fluids + same quantity which lost in drains,
NGT etc.
• Analgesics:
-Minor → paracetamol.
-Major → pethidine 1-2 mg/kg i.m.PRN (as needed) 4-6 hourly.
63
• Antibiotics if required.
• Care of skin, wound, sphincters …etc.
• Mobilization of the patient out of bed as soon as it becomes feasible.
Anatomy:
The oesophagus is a 25 cm (12 inches) long tube extending from the
cricopharyngeus muscle (oesophageal constrictor) to the cardia of the stomach.
It passes through the posterior mediastinum anterior to the vertebral bodies. The
thoracic duct passes upwards between the oesophagus and the vertebral bodies.
As the oesophagus passes down it inclines slightly to the right to pass through
the oesophageal hiatus of the diaphragm at the level of 10th dorsal vertebral
body. The lower 3 cm of the oesophagus are below the diaphragm.
The cervical part (upper third) of the oesophagus lie between the
cricopharengeus muscle and the clavicle, the middle third extend from the
clavicle to the bifurcation of the trachea while the lower third extend from the
inferior pulmonary ligament to the cardia of the stomach.
The oesophagus is made of striated muscles at the upper third and
smooth muscles at the lower 2 thirds. The mucosa of the oesophagus is lined by
squamous epithelium except in the lower 3 cm where transitional zone of
64
epithelium exist with columnar non secretary (no acid or pepsin) epithelium
covering the lower 3 cm.
Blood supply:
The arterial supply of the upper third is from the thyro-cervical trunk, the
middle third is from aortic branches and the lower third is from the left gastric
artery. The venous drainage follows the arterial supply.
Lymphatic drainage:
Lymph from the upper third drains to the deep cervical lymph nodes and lymph
from the middle third drains to the mediastinal lymph nodes (subcarinal, para-
tracheal and para-aortic lymph nodes) while lymphatic vessels of the lower
third drain in the celiac group of lymph nodes.
Nerve supply:
The nerve supply of the oesophagus is from the vagus nerve and sympathetic
chain. All along the alimentary canal there are 2 (intrinsic and extrinsic)
plexuses of nerves. These are the Auerbach's plexus and the Meissner's plexus.
In the oesophagus Meissner’s plexus is missing and Auerbach's plexus is absent
in the upper third of the oesophagus where striated muscles exist. Auerbach's
plexus helps to relax the smooth muscle of the oesophagus and its absence lead
to failure of relaxation.
Areas of narrowing of the lumen in the oesophagus:

The oesophagus has 3 areas of relative constrictions. These are:
1-The superior sphincter (The cricopharyngeus muscle)
2- Opposite the arch of the aorta and left main bronchus.
3- The lower oesophageal sphincter.
The importance of these sites is:
1-These are the sites where foreign bodies as fish bone and coins are
arrested.
65
2-They are the sites of carcinoma of the oesophagus being squamous in
the subcricoid region, upper and middle thirds of the oesophagus and adeno or
squamous carcinoma of the lower third.
3- They are the sites of strictures: Corrosives usually lead to smooth
stricture ate the upper third, and congenital oesophageal atresia usually with
tracheo-oesophageal fistula and rarely due to aberrant subclavian artery leading
to dysphagia lusoria at the middle third while reflux oesophagitis leads to
stricture at the lower third of the oesophagus.
4- They are the sites of diverticulae of the oesophagus. Diverticulae are
either pulsion (due to high intra-luminal pressure resulting from lack of
coordination of peristalsis) or traction diverticulae (due to traction by the
inflammatory process in tuberculus lymph nodes). Pulsion diverticulae occur at
the Kiland's dehiscence (the weakest area in the posterior aspect of the
cricopharyngeus muscle). This is called Zincker's diverticulum and it present
usually as swelling in one side of the neck after meals with regurgitation of the
food back into the mouth after meals.
In the lower end a pulsing diverticulum is called epiphrenic diverticulum and it
is due to downward peristalsis while the lower oesophageal sphincter is in
spasm. It usually present with dysphagia when it gets filled with food and
presses the oesophagus to the out side. Traction diverticulae occur at the middle
third.
*oesophageal diverticulum
66
Congenital oesophageal atresia
85% of oesophageal atresia occur in cases of tracheo-oesophageal fistula
(T.O.F) with blind upper pouch of the oesophagus while the lower part opens
into the trachea connecting the trachea to the stomach.
Clinical features:
1- It should be suspected in all pregnant ladies that have
polyhydramnios (hydramnios may results from inability of the foetus
to swallow the fluid of the liquor around).
2- The symptoms begins in the first few hours after birth with:
(a) Continuous salivation (drooping of saliva).
(b) Severe chocking, cough and cyanosis following the feeding
because of aspiration.
(c) The abdomen may become distended with air that enters the
lower part of the oesophagus through the fistula.
Diagnosis:
1- If a nasogastric tube (NGT) is inserted will be seen, in the plain
X-ray, coiled in the cervical oesophagus. This is sufficient for
diagnosis. Contrast x-rays for confirmation is not needed and barium
is contraindicated because of the danger of aspiration chemical
pneumonitis, but if lipiodol is available it may be used.
Management:
• Emergency surgery  surgical correction in the first day of
birth.
• Keep the baby NPO on IV fluids.
• Consult paediatric surgeon
• Prepare 250 cc blood.
• Consent.
67
• Guard against hypothermia by putting the baby in an incubator,
or cover it with warm blankets.
• 48 hours delay of surgery will result in aspiration pneumonia
which is fatal and makes anaesthesia hazardous.
**The mechanisms that prevent reflux:
1-Presence of 3 cm abdominal oesophagus: This segment is compressed
against the vertebral bodies during the rise of intra-abdominal pressure
particularly during lying down. Therefore it prevents reflux.
2-The angle of His i.e. the angle between the fundus of the stomach and the
oesophagus, acts as a shutter to close the lower end of the oesophagus during
the rise of intra-gastric pressure i.e. after meals.
3-The pinch – cock action of the fibres of the right crus of the diaphragm
hook around the lower part of the oesophagus and close it.
4-The rosette like folds of the gastric mucosa plugs the opened lower
oesophagus.
5- The lower oesophageal sphincter which is a high pressure zone in the lower
oesophagus keeping it closed.
Reflux oesophagitis
Reflux oesophagitis is regurgitation of the gastric contents into the
oesophagus. The regurgitated material could be acid (hydrochloric acid) or
alkaline (bile reflux). It is due to laxity of the lower oesophageal sphincter. This
laxity may be associated with increased intra-gastric pressure (after meals) or
increased intra-abdominal pressure (obesity, pregnancy, ascites or abdominal
tumours) or due to patulous sphincter in cases of hiatus hernia.
Reflux is a common symptom affecting about 80% of the population.
But only in 10% the reflux is severe requiring treatment.
Clinical features:
Heartburn may be associated with or without burning pain. The pain is in
the epigastrium and the retro-sternal region. It radiates to the back in between
68
the shoulder blades. The pain prevents the patient from sleeping in
contradistinction from the duodenal ulcer pain that awaken the patient at about
2:00 am. The pain of reflux oesophagitis is aggravated by spicy and sour food.
The inflamed oesophagus may become ulcerated and the ulcers bleed
and lead to anaemia. The ulcers my heal by fibrosis and this results in stricture
formation leading to difficulty in swallowing of solid food and at the same time
the stricture prevent the refluxing fluid from reaching the oesophagus i.e. reflux
symptoms are replaced with dysphagia. The inflammation and pain of
ulceration lead to reflex contraction of the longitudinal muscles of the
oesophagus leading to shortening of the oesophagus and disappearance of the
lower 3 cm of abdominal oesophagus. This further aggravates the condition.
Long standing reflux and repeated inflammation of the epithelium lead to
metaplasia (conversion of the squamous epithelium into columnar type) called
Barrett's oesophagus. Dysplasia may result leading to carcinoma.
Investigations:
1- Haem-occult blood in the stools (after 3 days of abstinence from
red meat).
2- Oesophago-gastro-duodenoscopy (OGD). With fibreoptic
endoscopy we can grade the severity of the disease as follows:
Grades of severity of reflux:
1- Normal looking mucosa of the oesophagus.
2- Diffuse or patchy redness or red linear streaks.
3- Ulceration. 4- stricture formation
69
Normal oesophagus Oesophagitis
Treatment:
1- Dietary advice:
a- Not to take spicy food and uncooked onion or garlic.
b- Not to take sour food as cheese, lemon juice, lentils.
c- Not to take hot drinks as coffee and to drink tea as warm as
possible but not when hot.
d- Not to take cold drinks as Pepsi.
e- Abandon smoking and alcohol.
f- Small frequent meals with supper at least 2 hours before going to
bed.
2- Medical treatment:
a- Antacids tablets or syrup in a titrating dose to the degree of
acidity.
70
b- H2 receptor blockers as Ranitidine 150- 300mg bid for 2
weeks then at bed time for 1 month. Or, proton pump inhibitors as
Omeprazole 20 mg bid for 1 month or Lansoprazole 30mg OD (once daily)
for 1 month.
c- Treat Helicobacter pylori if present with Metronidazole and
Amoxicillin for at least 2 weeks.
Hiatus Hernia
This is usually a congenital problem however it may be acquired. It

is of 3 types:
1- Sliding hiatus hernia type in which the oesophagus seems to
develop as congenital short oesophagus or due to spasm of the
longitudinal muscles following repeated inflammation. It is the most
common type of hiatus hernia. The abdominal oesophagus is absent,
the angle of His is widened, and the pinch- cock action of the right
crus of the diaphragm is weak.
2- Rolling hiatus hernia: in this condition part of the fundus of the
stomach herniate through the oesophageal hiatus. This type is rare but
it is serious because the herniated part may get strangulated or
ulcerated and may perforate leading to mediastinitis and empyema in
the plural cavity.
3- Mixed type i.e. sliding and rolling.
**Predisposing factors for the symptoms:

1- Increased intra-abdominal pressure.
2- Obesity.
71
*Gas of stomach above the diaphragm. The differential diagnosis is lung abscess.
Clinical features:
In the majority of patients the hernia is present with out symptoms or
the symptoms are so mild that it does not require treatment. In few
cases the symptoms of reflux oesophagitis is so severe that it is
disturbing the patient's life.
Differential diagnosis: Saint’s triad which is:
1- Duodenal ulcer. 2- Gallstone disease. 3- Diverticulitis.
Treatment:
1- Conservative treatment similar to that of reflux
oesophagitis.
2- The way the patient sleeps is as follows: Elevation of the
feet of the bed (to prevent sliding down of the patient in bed
during sleep) and elevation of the mattress at the head part of
the bed with several pillows to keep the head and chest elevated
in order to reduce the reflux of the gastric contents into the
oesophagus.
3- Reduce body weight in obese patients.
4- In case of failure of treatment surgery is advised to
construct an oesophago-gastric angle below the diaphragm in
72
the form of Nissen's fundoplication which can be done by open
surgery and by laparoscopic surgery.
Achalasia
Definition: Incomplete relaxation of lower oesophageal sphincters. This
motility disorder is due to absence of elements of Auerbach plexus although the
ganglia are present.
Pathology: Absence of Auerbach plexus leads to spasm of the Lower
Oesophageal Sphincter with dilation of the oesophagus. The condition may be
associated with vitamin B1 deficiency, trypanosomiasis, stress and emotional
upsets.
*Dilated tortuous oesophagus with smooth Bird Beak (Pencil Tip)at the lower end
Clinical picture:
1-Occurs at about 40 years of age.
2-Affect equally both males and females.
3-Dysphagia at first to the fluids, later to the solid food.
4-Loss of weight.
5-Anaemia.
6-Regurgitation of food.
7-Retrosternal discomfort
73
8-Aspiration pneumonia.
These symptoms may look like those of reflux oesophagitis.
*Investigations:
1- Barium swallow: This will show:
a- Dilated tortuous oesophagus.
b- Pencil tip (bird beak) appearance at the lower end.
c- Absent gastric fundal gas bubble.
2- Endoscopy: This shows a dilated oesophagus containing dirty

fluid and froth. If care is not exerted perforation of the oesophagus may
occur.
*Treatment:
1- Balloon dilatation using endoscope.
2-Surgical dilatation by Oesophago-cardiomyotomy
(Heller’s operation) i.e. cutting the serosa and muscles of the upper
7 cm of the stomach, cardia, and oesophagus, as high as possible, till
the mucosa bulges out. To prevent reflux, construct a new gastro-
oesophageal angle by making a rap of the fundus of the stomach
around the lower end of the oesophagus and fix it around the lower
oesophagus (Nissen's fundoplication).
3- Botulinum toxin to be injected locally via endoscope.
Complications of achalasia:
1-Aspiration pneumonia.
2-Carcinoma of the oesophagus i.e. it is a pre-malignant disease.
Differential diagnosis:
- Carcinoma of the cardia. In carcinoma dysphagia is first to
solid food then to the fluids.
- Benign stricture of reflux oesophagitis.
Oesophageal webs
74
This disease is present in females at the age group about 40
years. The common complaint is difficulty in swallowing and they feel the
food passes with difficulty at the level of the throat. Usually the patient is pale
and investigations prove that she has iron deficiency anaemia (pale smooth
tongue, angular stomatitis, Koilonychia "brittle spoon-shaped nails"). This
combination is called Plummer- Vinson’s syndrome. Barium swallow may
show oblique linear filling defects at the upper part of the oesophagus.
Endoscopy shows membranes at the level of 15-17 cm from incisors i.e. in the
cervical (upper third) of the oesophagus. Treatment is by oesophageal
dilatation. This condition is serious because it is precancerous; therefore it is
.advisable to follow up these patients and to correct their anaemia
*Lateral view and antero-posterior view of oesophageal webs

barium swallow with endoscopic view of oesophageal web*
Oesophageal cancer
This is the sixth commonest cancer world wide. It is common at old age;
.however, it is seen in patients above 30 years of age
75
:Predisposing factors
1- Premalignant conditions:
a- Achalasia.
b- Oesophageal webs.
c- Barrett’s oesophagus.
2- dietary factors:
a- Alcohol.
b- Cigarettes smoking particularly pipe smoking.
c- Vitamins deficiencies.
d- Eradication of Helicobacter pylori.
:Symptoms and signs

Difficulty in swallowing of solid food. The patient usually mention
where the food sticks to know approximately the site of the obstruction.
Dysphagia is usually progressive and fluids become difficult to swallow. The
Dysphagia may become absolute i.e. no fluid passes down. The patient
complain that he regurgitates the food and has rapid loss of weight. Physical
examination reveals an emaciated patient, dehydrated, with or with out palpable
cervical lymph nodes or enlarged nodular liver.
Regurgitation may lead to aspiration and repeated chest infection. The
malignant tumour may lead to invasion of the recurrent laryngeal nerve
resulting in horseness of voice and the tumour may invade the trachea or main
bronchus resulting in malignant tracheo -oesophageal fistula with repeated
.aspiration and chest infection
:Macroscopic appearance
1- Ulcerative type.
2- Cauliflower.
3- Annular constricting type.
:Microscopic types
Squamous cell carcinoma. This is the commonest type of cancer -1
.oesophagus
.Adenocarcinoma which is common in the lower third of the oesophagus -2
:Investigations
Barium swallow: This shows irregular filling defect or narrowing of-1
.the lumen with shouldering at the sides with a rat tail appearance
2-Endoscopy: shows the tumour and allows taking biopsy for confirmation,
also it allows oesophageal dilatation.
CT scan and chest X-ray for evidence of enlarged lymph nodes or liver-3
metastases and to see the extent of tumour invasion around the oesophagus.
If there is mediastinal widening or big hilar shadows then surgery is
.contraindicated
76
Oesophageal tumour*
:Treatment
In localized tumours where resection is possible and the patient is fit for
surgery, tumours of the middle and lower thirds are resected. Otherwise all
.patients are helped with oesophageal dilatation and chemo-radiotherapy
Survival rate is usually poor and majority of patients die within 2 years of
.diagnosis
Causes of oesophageal obstruction

1-Causes out side the oesophagus:
a- Thyroid swelling.
b- Pharyngeal pouch.
c- Aortic aneurysm.
d- Mediastinal tumours.
e- Rolling hiatus hernia.
2-Causes in the wall:
a-Stricture congenital, or due to reflux oesophagitis or corrosives.
b-Diverticulum.
c-Carcinoma of the oesophagus.
e-Cardiospasm due to achalasia or diffuse spasm.
4- Causes in the lumen as foreign bodies.
==========================
Self assessment
:The oesophagus
:In reflux oesophagitis-1
77
.a- Epigastric and retrosternal pain prevent the patient to sleep
b- Retrosternal pain radiate to the back between the shoulder blades.
.c- The differential diagnosis of reflux oesophagitis is angina pectoris
.c- Only (a) and (b) are correct
:Answer
d) – Pain of reflux oesophagitis prevents sleep in contradistinction of ) – 1
.duodenal ulcer pain which awaken the patient at 2 am
:In reflux oesophagitis -2
.a- Chronic irritation by acid leads to columnar epithelium metaplasia
.b- Long standing acid reflux leads to benign stricture formation
.c- Chronic reflux leads to longitudinal muscle spasm and shortening
.d- Stricture formation prevents reflux but result in dysphagia
.e- All the above are correct in long standing reflux oesophagitis
:Answer
e) – pain lead to longitudinal muscle spasm resulting not only in ) – 2
shortening of the oesophagus but funneling of the gastro-oesophageal junction
.with disappearance of the gastro-oesophageal angle and hence more reflux
:The following aggravates reflux oesophagitis -3

.a- Alcohol and cigarettes smoking
.b- Spicy food, cheese and lemon
.c- Lying flat after heavy meals
.d- Coffee, tea and Pepsi cola- like drinks
:Answer
e) – All these as well as very hot and very cold drinks uncooked onion, ) – 3
garlic should be avoided. Small frequent meals are advised with supper not less
than 2 hours before sleep. The patient should lie in bed with both head and
.chest raised up
.In treatment of symptomatic sliding hiatus hernia -4
.a- The patient should sleep not less than two hours after supper
.b- The patient should take small frequent meals
.c- The patient should sleep with his head and chest elevated
.d- The patient should receive treatment for H. pylori
:Answer
e) – And the patient should do his best to reduce his weight. Indications ) – 4
for surgery is severe symptoms not responding to conservative measures as
well as complications such as regurgitation resulting in aspiration pneumonia
.or chocking, ulceration and stricture formation
78
:Plummer- Vinson Syndrome is -5
.a- Iron deficiency anaemia with oesophageal webs in females
.b- Dysphagia for solid food and malnutrition in females
.c- Post-cricoid squamous cell carcinoma in females
.d- Webs at the lower end of the oesophagus in females
.e- Common in female as well as males
:Answer
a) – it is associated with iron deficiency anaemia and not malnutrition. ) – 5
.The syndrome is precancerous
:The following is correct in achalasia -6

.a- Difficulty in swallowing liquids occur first
.b- The oesophagus is dilated and tortuous in barium swallow
.c- The oesophagus is always full of fluid and food remnants
.d- The patient may have similar symptoms to reflux oesophagitis
.e- All the above are correct in achalasia of the oesophagus
:Answer
e) – Also the patient may complain of pain and regurgitation similar to ) – 6
that of reflux oesophagitis. The oesophagus has infected mucosa and ulceration
.may develop with gradual loss of blood
:In achalasia lower oesophageal cardio-spasm is due to -7

.a- Absent Meissner's plexus
.b- Absent Auerbach's plexus
.c- Hypertrophy of lower oesophageal sphincter
.d- Lower oesophageal carcinoma
.e- Lower oesophageal stricture due to acid reflux
:Answer
b) – Normally the oesophagus does not contain Meissner's plexus and ) – 7
Auerbach's plexus is present only in the lower two thirds of the oesophagus.
.Achalasia is a precancerous condition
:Barium swallow X-ray in achalasia shows -8

.a- Rat tail appearance
.b- Pencil tip appearance
.c- Soap bubble appearance
.d- Cork screw oesophagus
.e- Lower oesophageal ring
:Answer
b) – The rat- tail appearance occurs on cancer and the soap-bubble ) – 8
appearance occurs in oesophageal varices, while the cork- screw appearance
occurs in motility disorders scleroderma where there is diffuse spasm of the
oesophagus (Presbyoesophagus) but the lower oesophageal mucosal ring
.(Schatzki's ring) is situated just above the cardia
79
Omphalocele
.Congenital defects of the anterior abdominal wall
If the defect is small at the umbilical region it result in
protrusion of the small bowel at the defect (exomphalos minor ) If
the hole intestine is covered only by a thin membrane then it is
.exomphalos major
Omphalocele *
Congenital pyloric stenosis

This is stenosis at the pyloric canal due to hypertrophy and hyperplasia of
the circular smooth muscle of the pyloric sphincter itself. This sphincter is
usually a small ring about 2mm in thickness. It becomes 3cm in length and
1.5 cm in thickness. It manifest in babies at the third to the 6th weeks after
birth. Male to female ratio is 4:1. It may be associated with gastro-
.oesophageal reflux and oesophageal atresia
80
:Symptoms
Vomiting occurs immediately after feeds. It is forceful vomiting
consisting of milk and gastric mucos but no bile. The child feeds hungry
.after vomiting and is dehydrated and constipated
:Physical examination
Child is marasmic, dehydrated, with visible peristalsis from left
hypochondrium to the right with a palpable epigastric mass beneath the
.right border of the right rectus muscle olive in size
:Investigations
HB: low
Capillary gas analysis shows metabolic alkalosis i.e. raised bicarbonates
.high pH with raised base excess
.Ultrasound: confirm presence of the mass
Barium meal if gastro-oesophageal reflux or mal-rotation of the gut is
suspected. Barium shows long pylorus with shouldering and narrow
.lumen
:Preoperative management
.Gastric lavage -1
Correction of fluid and electrolyte imbalance (Maintenance is 5% -2
dextrose in 1/2 saline + 20 mmol KCL in a rate of 100ml/kg body weight/
.24 hours) + the deficit of dehydration
:Operation
Pyloromyotomy (Ramstedt operation): The peritoneum and muscle layer
,of the pylorus is opened longitudinally allowing the mucosa to bulge out
.resulting in dilatation of the pyloric canal
:Postoperative management
.I.V. fluid 5% dextrose 1/5 the saline -1
.NPO 24 hours then remove NGT and start oral feeds -2
Peptic ulcer
:Acute peptic ulcer
This condition is related to body response to stress. It occurs in
severe stressful conditions. Therefore, it is commonly seen in severely ill
patients in intensive care units (erosive gastritis), burn (Curling’s ulcer), head
injury (Cushing's ulcer) and in severe social stress particularly in smokers and
.alcoholics
Stress leads to humeral and neural stimulation resulting in liberation
of cortisone and high gastric acids. These lead to multiple superficial erosions
in the mucosa of the stomach and duodenum presenting as melaena and/ or
haematemesis. These erosions usually do not extend beyond the muscularis
mucosae. Usually there is no pain. However, in some cases the ulcerations
81
rapidly became deep reaching the muscularis propria and in few cases perforate
into the general peritoneal cavity. However, in perforated gastric ulcer
.malignancy should first be suspected
:Chronic peptic ulcer

Benign chronic gastric ulcer is indeed very rare and such diagnosis
should be considered with great suspicion because almost all gastric ulcers seen
.in Sudan are malignant
The aetiology of gastric ulcer does not related to the action on
hydrochloric acid on the stomach. In the contrary gastric ulcer develops when
the basal and maximal gastric acid out put is markedly reduced
.((hypochlorohydria or achlorohydria
Gastric ulcer occurs in poor patients with poor mouth hygiene and the first
gastric carcinogen is Helicobacter pylori. On the other hand duodenal ulcer is
always benign. Usually it is present in the anterior or the posterior part of the
first part of the duodenum. The aetiology of acute and chronic gastric ulcers is
related to the high gastric acid out put. It occurs in patients subjected to stressful
responsibilities, smokers, alcoholics, and is also due to helicobacter pylori
Gastric ulcer Duodenal ulcer

Periodicity Present Well marked Mainly in
cold seasons
Pain Soon after meals When the stomach is
empty hunger
pain
Vomiting Relieves pain No vomiting
Bleeding haematemesis more Melaena more than
than melaena haematemesis
Appetite Good but afraid to eat Good
Diet Lives on milk and fish Pain aggravated by
sour and spicy
food
Weight Loss of weight No loss of weight
82
Gastric ulcer: Gastric folds coming Gastric ulcer: Raised edges
towards the ulcer Malignant
The high liberation of gastric acid may lead to reflux oesophagitis with
.ulceration at the lower end of the oesophagus
:Clinical features
The main complaint is epigastric pain which is aggravated by hunger,
.spicy and sour food
Physical examination may not reveal any findings except a positive
.finger pointing test just below the xiphesternum
:Investigations
Upper GIT endoscopy: Will show the ulcer and will biopsy the gastric ulcer. -1
.It is also good for follow up of healing
Barium meal: can show the ulcer crater as residual barium staying in the-2
.ulcer while the rest of the barium passes down the alimentary canal
In cases of anaemia of unknown aetiology stools should be tested for occult

(unseen) blood. If stools haem-occult blood test is positive then there is a source
of bleeding that deserve thorough investigations and carcinoma of the stomach
.or caecum should be suspected
:Treatment
Gastric ulcer is preferably treated surgically by excision of the ulcer bearing
.area for histology to prove or disprove presence of malignancy
Treatment of duodenal ulcer is by reducing the acid secretion of the stomach.
Reduction of gastric acid out put is essentially by H2 receptor blockers as
cimetidine (Tagamet) or ranitidine (Zantac) 150bid then 300 mg at night daily
for 6 weeks or by Omeprazole (proton pump inhibitor 20 mg bid for 6 weeks or
Lansoprazole 30 mg daily for 4-8 weeks in addition to treatment of H. pylori
83
(Amoxicillin 500mg 8 hourly for 2 weeks + Metronidazole 200mg t.i.d for 2
.(weeks
.Smoking delays ulcer healing, therefore, it is strongly advised to be abandoned
:Complications of duodenal ulcer

.The following complications are absolute indications for surgery
Perforation -1
.Bleeding -2
.Stenosis -3
.Penetration -4
Perforated duodenal ulcer

It is the anterior duodenal ulcer that perforates. Once perforation occurs
gastric acid secretion will be shut down and bile will leak into the general
.peritoneal cavity. Bile is irritant to the peritoneum
:Symptoms and signs

The patient presents with severe epigastric pain of sudden onset (pistol
like shot) associated with guarding and board like rigidity of the anterior
.abdominal muscles
Bile may trickle along the right paravertebral gutter to the right iliac
fossa where the pain may be felt and in this case in the right iliac fossa, so it
looks like acute appendicitis. Peritoneal fluid will be secreted to dilute the bile
therefore, after about 6 hours the pain subsides (lucid interval). This stage will
be followed by bacterial contamination that converts the case into frank
.peritonitis
:Investigations
.Chest X-ray in erect position. This shows gas under the diaphragm-1
.Hb, urea, electrolytes-2
:Treatment
Laparotomy and closing the perforation with Graham omental patch and
.cleaning the peritoneal cavity
:Prognosis
Roughly one third of patients with perforated duodenal ulcer treated
with omental patch will not develop symptoms any more and will not require
any further treatment. One third will develop symptoms which are easily
controllable by medical treatment. And the last one third will require definitive
operation for stopping acid secretions in the form of Trunkal vagotomy with
.(drainage (pyloroplasty or gastro-jejunostomy
84
Trunkal Vagotomy leads to stasis of food in the stomach, therefore, drainage by
widening the first part of the duodenum and pylorus (pyloroplasty) or gastro-
.jejunostomy is required
Bleeding duodenal ulcer

The gastro-duodenal artery lies just posterior to the first part of the
duodenum. Posterior duodenal ulcer may erode this artery and precipitate
severe bleeding. Usually there is no pain but haemorrhage in the form of severe
.melaena and haematemesis ensues
.Diagnosis is best confirmed by gastro-duodenoscopy
:Treatment
Insert wide bore venous canulae in forearm veins and take blood for -1
.grouping and cross matching of blood
In old patients early surgery is advised because the bleeding vessels are -2
rigged with diffuse arteriosclerosis and hence will not go in the physiological
vasospasm that occurs in bleeding. Therefore, bleeding might not stop.
Furthermore, elderly patients do not withstand hypovolaemia and hypotension
for long time because hypotension reduces the blood supply to the myocardium
which is potentially ischaemic in elderly patient. On the other hand, young
patients have soft vessels that may stop bleeding spontaneously by the
.physiological vasoconstriction of the bleeding vessels
:Surgery
The rationale of surgery is to stop the bleeding and to inhibit acid
secretion. Therefore, we open the first part of the duodenum longitudinally
(duodenotomy), identify the bleeding vessel and under run it with unabsorbable
suture material. Then we close the duodenum transversely to make it wider
.(pyloroplasty). After that we proceed for Trunkal Vagotomy
:Pyloric stenosis
Recurrent ulceration and healing by fibrosis result in narrowing of the
lumen of the first part of the duodenum. This is miscalled pyloric stenosis
although the narrowing is not in the pyloric canal but in the first part of the
.duodenum
:Complaint
The patient complains of indigestion, and recurrent vomiting of
.fermented food i.e. offensive vomiting
:Physical examination
This may reveal visible gastric peristalsis from left to right with
positive succussion splash i.e. hearing the sound of the retained gastric fluid on
shaking the patient trunk
:Pathophysiology
The recurrent vomiting leads to loss of acid. This may result in metabolic
alkalosis if not compensated by the kidney. The compensation is by loosing
85
alkaline urine to keep the pH of the blood in balance within normal limits (7.34-
7.43). The kidney looses sodium bicarbonate (Na2 CO3). When sodium is
reduced to critical level potassium (K+) will be lost and when potassium level is
also reduced to critical level hydrogen (H+) in the form of ammonium chloride
will be lost. At this stage the urine will become acid in spite of the patient
.vomiting acid. This is called paradoxical acid urea
:The total loses of the patient will be
In the vomitus: Dehydration due to water loss associated with loss of -1
.hydrogen ions and hypochloraemia due to loss of HCL
In urine: hyponitraemia due to loss of sodium bicarbonate and -2
.hypokalaemia due to loss of potassium
:Management
Gastro-duodenoscopy to prove the diagnosis and to exclude cancer in the -1
.antrum of the stomach in elderly patients
.Hb, urea, electrolytes, chest x-ray and ECG -2
Admission-3
.Prepare 2 units of blood-4
.Consent for surgery -5
:Preoperative management
.Correction of fluid and electrolytes -1
Surgery: Trunckal Vagotomy and drainage (Pyloroplasty or gastro- -2
.(jejunostomy
Gastric cancer
:Aetiology
:Aetiology is unknown but premalignant conditions are
.Pernicious anaemia -1
.Gastric polyps -2
.Helicobacter pylori infection -1
Tobacco juice -2
Alcohol -3
.Smoked fish -4
:Pathology
:Macroscopic appearance
.Cauliflower-like growth which ulcerate later -1
.Ulcer: irregular with raised edges -2
.Diffuse thickening of the wall of the stomach -3
:Pathological types
.Intestinal -1
.Diffuse -2
86
.Other types -3
:Microscopic types
.Adenocarcinoma
:Spread
Direct invasion of neighbouring structures like pancreas, transverse colon, -1
.left lobe of the liver and posterior abdominal wall
By lymphatic permeation or embolization to lymph nodes along the lesser or -2
greater curvature of the stomach, celiac group of lymph nodes, nodes at the
.hilum of the spleen
.Haematogenous spread to the liver -3
Transcoelomic spread to the pelvis forming a ridge in the rectovesical -4
(Doglas) pouch in males palpable on per rectal examination, or metastasizing
.into the ovaries in females called Krukenberg's tumours of the ovaries
:Clinical features
.Epigastric pain without periodicity -1
.Indigerstion and vomiting -2
.Loss of appetite and loss of weight -3
.Anaemia and weakness -4
.Any recent indigestion after the age of 40 -5
.At a late stage epigastric mass may be palpable with or without ascites
A visible and palpable lymph node may be found in the left supraclavicular
fossa (Virchow lymph node) is a sign of inoperability because the disease is too
.advanced at this stage
:Investigations
.Haemoglobin will be low -1
Gastroscopy will see and biopsy the tumour. Gastric lymphoma and -2
leiomyoma are submucosal tumours which may be missed by endoscopy in
.their early stages
Barium meal: shows a persistent filling defect with rigid wall during -3
.peristalsis
:Treatment
Is excision of the distal two thirds of the stomach for carcinoma of the antrum
with closure of the duodenum and gastro-jejunostomy (Billroth II operation).
But in cancer of the cardia and fundus the treatment is excision of the upper two
thirds of the stomach or total gastrectomy with oesophago-jejunostomy to
resume the continuity of the alimentary canal. Surgery is followed by
.chemotherapy
======================================
======================
87
Self assessment
:The stomach
:The commonest presentation of chronic gastric ulcer is -1
.a- Epigastric pain relieved by leaning forward
.b- Epigastric pain after meals relieved by vomiting
.c- Epigastric pain radiating to both hypochondria and back
.d- Epigastric pain radiating to retro-sternal region
.e- Epigastric pain that shifts to the right iliac fossa
:Answer
b) – Epigastric pain relieved by leaning forward occurs in carcinoma of ) – 1
the pancreas, while belt like pain that radiates to both hypochondria and the
back occurs in acute pancreatitis, but pain that radiates to the retrosternal
region occurs in myocardial infarction and severe reflux oesophagitis. Mild
dull pain that shifts to the right iliac fossa occurs in acute appendicitis but
severe sharp sudden on set pain could be due to perforated anterior duodenal
.ulcer
:Chronic gastric ulcer is commonly associated with -2

.a- Loss of weight in spite of good appetite
.b- Iron deficiency anaemia due to blood loss
.c- Metabolic alkalosis with hypokalaemia
.d- Carcinoma in some part of the ulcer
.e- All the above are correct in gastric ulcer
:Answer
e) – There is good appetite and patients are hungery but they refrain from ) – 2
eating because itinduces pain. Metabolic alkalosis is due to recurrent vomiting,
and iron deficiency anaemia is due to chronic blood loss and can be proved by
.haem-occult blood in the stools
:Chronic gastric ulcer is commonly associated with -3
.a- Hyperchlorohydria
.b- Hypochlorohydria
.c- Hypercalcaemia
.d- Gastrinoma
.e- Severe stress
:Answer
b) – Hypercalcaemia and gastrinoma leads to hyperchlorohydria and ) – 3
duodenal ulceration. Severe stress leads to multiple superficial acute ulcers
.that bleed or acute ulcers that penetrate deep and perforate
:Acute gastric ulcers -4

.a- Present with bleeding without epigastric pain
.b- Present with bleeding and epigastric pain
88
.c- Low production of hydrochloric acid
.d- Have elevated edges with irregular margin
.e- Are due to Helicobacter pylori
:Answer
a) – ulcers with elevated edges are always malignant ulcers. H. pylori ) –4
leads to chronic gastritis that leads to atrophic gastritis and then carcinoma.
Also H. pylori causes hyperacidity and duodenal ulcers and lower oesophageal
ulcers. Also H. pylori leads to Mucosa Associated Lymphoid Tissue
.((MALToma
:Acute gastric ulcers commonly occur in -5

.a- Patients with major burn
.b- Patients with head injury
.c- Patients with septicemia
.d- Patients in intensive care unit
:Answer
e – These are stressful conditions which the patient may develop erosive – 5
.gastritis and acute duodenal ulcers
:Acute gastric ulcers -6
.a- Are superficial ulcers in the mucosa
.b- May present first time with perforation
.c- May be associated with duodenal ulcers
:Answer
d – All these are acute ulcers occur as part of the body response to – 6
.stress
:Gastric fundal carcinoma involving the cardia present with -7
.a- Epigastric pain and difficulty in swallowing
.b- Difficulty in swallowing and vomiting
.c- Regurgitation of food with hypokalaemia
.d- Recurrent vomiting with severe haematemesis
.e- Loss of weight, anaemia and severe melaena
:Answer
a) – cancer of cardia leads to regurgitation rather than vomiting. ) – 7
.Usually cancer does not lead to severe bleeding
The aim of treatment of chronic gastric -8
:ulcer is
.a- Reduce acid out put with antacids and omeprazole
.b- Trunkal Vagotomy to abolish acid secretion
.c- Resection of part of stomach containing the ulcer
.d- Treat Helicobacter pylori with Metronidazole
.e- To treat pernicious anaemia with Iron and Folic acid
89
:Answer
c - The rationale of treating chronic gastric ulcer is to resect the ulcer – 8
bearing area because of the fear of cancer. Pernicious anaemia is an auto-
immune disease associated with megaloblastic anaemia due to vitamin B 12
.deficiency
:The treatment of bleeding duodenal ulcer in an elderly patient is -9
.a- To reduce acid secretion with antacid and ranitidine
.b- Ligation the gastro-duodenal artery and trunkal vagotomy
.c- Trunkal vagotomy and pyloroplasty
.d- Trunkal vagotomy and gastro-jejunostomy
.e- Duodenectomy with excision of head of pancreas
:Answer
b) – During closure of the duodenotomy after securing the gastro- ) – 9
duodenal artery the duodenum is closed transversely in a fashion of
.pyloroplasty to prevent stenosis
:The definitive indication of surgery in duodenal ulcer is -10
.b- Bleeding ulcer in elderly patient
.c- Perforated duodenal ulcer
:Answer
.d) – Also in penetration into the pancreas ) – 10
:Perforation of duodenal ulcer -11
.a- Occurs in the anterior duodenal ulcer
.b- Occurs in the posterior duodenal ulcer
.c- Is common after healing of kissing ulcers
.d- Is common in Zollinger- Ellison's syndrome
.e- Is common in carcinoma of the duodenum
:Answer
a) – Posterior ulcer bleeds. Healing kissing ulcers may lead to pyloric ) – 11
stenosis. In Z-E syndrome there is long standing multiple ulcerations. Cancer
.of duodenum is very rare and it leads to obstruction and not perforation
:Bleeding duodenal ulcer -12
.a- Occurs in the anterior duodenal ulcer
.b- Occurs in the posterior duodenal ulcer
.c- Is common after healing of kissing ulcers
.d- Is common in Zollinger- Ellison's syndrome
.e- Is common in carcinoma of the duodenum
:Answer
.b) – Bleeding is from the gastro-duodenal artery ) – 12
:Zollinger-Ellison's syndrome is characterized by -13
.a- Multiple duodenal and jejunal ulcers
.b- Very high basal acid out put
.c- Gastrin secreting tumour in pancreas
90
:Answer
d) – the basal acid out put at night in gastric ulcer is 10-20mequ/12 ) – 13
hours, in duodenal 40-80mequ/12hours and in Z.E. syndrome it is 100-
.300mequ/12hours
:Gastric outlet obstruction in elderly patient -14
.a- Is always due to benign pyloric stenosis
.b- Is always due to hypertrophic pyloric stenosis
.c- May be due to distal antral carcinoma
.d- Always lead to dilated J-shaped stomach
.e- Is always associated with coffee ground vomitus
:Answer
c – Hypertrophic pyloric stenosis occurs in infants however adult – 14
hypertrophic pyloric stenosis is rare. In elderly patients always think of distal
antral cancer particularly if there is coffee-ground vomitus from ulcerating
.tumours. Usually in malignancy the stomach does not dilate very much
:In benign pyloric stenosis -15
.a- Vomiting is offensive containing previous food
.b- Vomiting is effortless and does not contain bile
.c- Vomiting is projectile and does not contain blood
.d- The patient has positive succussion splash
.e- All the above are correct in pyloric stenosis
:Answer
.e) – The vomitus is frothy and it relieves the symptoms of fullness ) – 15
:In benign pyloric stenosis -16
.a- The stenosis is in the first part of the duodenum
.b- The patient may be emaciated and dehydrated
.c- The patient develops compensated metabolic alkalosis
.d- The patient may develop paradoxical acid urea
:Answer
e) - These patients may mentally be confused because of frank ) – 16
.alkalosis
A 60 year old male patient presented with epigastric pain -17
induced by in take food and relieved by dark coloured vomiting.
He is emaciated with palpable solitary lymph node in the medial
.part of the left supraclavicular region
:I)The best investigation to diagnosis this patient is)
.a- Gastroscopy
.b- Barium meal
.c- ESR
.d- Colonoscopy
.e- Ultrasound of the pancreas
91
:Answer
I– (a) – Because it superficial pathology that may be missed by barium series
.and in gastroscopy biopsies can be taken to prove the diagnosis
:II)The cause of the lymph node in the previous question is)
.a- Metastases
.b- Tuberculosis
.c- HIV/AIDS
.d- Lymphoma
.e- None specific lymph adenitis
:Answer
II– (a) – Blockage of the thoracic duct, that carries lymph from the abdomen
and right side of the chest to the junction of the internal jugular and subclavian
veins, leads to reflux back of lymph carrying malignant cells to the nearest
lymph node which lies in the left supraclavicular fossa. It is also called
.Troisier's sign
:III)In the management of the patient mentioned above)
.a- Surgery will definitely be curative
.b- Surgery will be just palliative
.c- Radiotherapy has no role in treatment
.d- Chemotherapy has no benefit
.e- Chest X-ray shows multiple metastases
:Answer
III– (b) – In advanced gastric cancer the best treatment is palliative resection
if the tumour is resectable. Radiotherapy has a role in gastric lymphoma and
all patients with gastric cancer are referred for evaluation for chemotherapy.
.Usually gastric cancer does not spread to the lungs
:Definition
Intestinal obstruction is failure of forward propagation (movement) of intestinal
:contents. It 2 types
(Mechanical obstruction (Dynamic -1
.(Paralytic ileus (Adynamic -2
92
Perforation*
Causes of the dynamic intestinal obstruction

Causes inside the lumen of the intestine (intramural) like foreign body in -1
oesophagus, Gall stone obstructing the terminal ileum, bag of ascaris worms
.obstructing the small intestinal lumen
Causes in the wall (mural) like tumours of the mucosa (adenocarcinoma -2
or carcinoid tumour), submucosal tumours like lymphoma and smooth muscle
.tumour like leiomyoma and leiomyosarcoma
Causes outside the wall (extramural) like the tough ring of the neck of -3
hernia which is the commonest cause of intestinal obstruction in developing
countries), adhesions (postoperative or inflammatory adhesions following
tuberculosis, typhoid, ruptured amoebic or appendicular abscess, and pelvic
inflammatory disease), congenital bands like the vetillo-intestinal band arising
from Meckel's diverticulum to the umbilicus and internals herniation as in
.paraduodenal fossae
*Adhesions
:Causes of Paralytic ileus

93
These are peritonitis, acute pancreatitis, hypokalaemia, retroperitoneal
haematoma, retroperitoneal surgery like operations in the kidney, spinal injury
.and thrombosis of mesenteric arteries or veins
*Strangulated hernia * Mesenteric thrombosis
*
Chrohn’s disease
94
Inguinal hernia *femoral *
hernia
:Intestinal obstruction is divided into

.Upper intestinal obstruction occurs down to the small intestine -1
.Lower intestinal obstruction i.e. in the large bowel -2
:Intestinal obstruction may be

Acute It presents with severe pain, vomiting distension and at last -1
constipation with pain as prominent feature as in obstruction of the small
.intestine or volvulus of the sigmoid colon
.Subacute due to adhesions that lead to recurrent acute obstruction -2
Acute on chronic due to acute obstruction in a patient with colonic polyp -3
.or tumour leading to intussusception or obstructing and sloughing
Chronic obstruction due to colonic tumours usually presenting with -4
.constipation, distension, vomiting and later pain
Strangulation
Simple obstruction leads to intermittent colicky pain i.e. on and off which
means only the lumen of the intestine is obstructed. When the pain becomes
continuous i.e. increasing and decreasing but continuous it means the blood
vessels are also obstructed causing ischemia of the intestine. This continuous
.pain is ischaemic pain
95
:Clinical features of acute dynamic (mechanical) obstruction*
Pain: severe, colicky in nature, intermittent associated with excessive
.vomiting, abdominal distension and absolute constipation
* :Radiological appearance
Two X-rays are important to request. The first is X-ray abdomen in erect
position for confirmation of the diagnosis. It shows multiple air-fluid levels
i.e. more than 2 air fluid levels. The gas is black on the top of a whitish fluid
.with a straight transverse line (level) in between the fluid and the gas
The second X-ray is requested to determine the site of obstruction.
Obstruction will lead to dilatation of the proximal segment of the bowel and
collapse of the distal bowel. The dilated proximal part of the intestine contains
gas which takes the shape of that part of intestine. The circular mucosal folds of
the distend jejunum appear as transverse lines extending from the anti-
mesenteric border to the mesenteric border like the teeth of the comb. They are
.called valvulae conniventes
The ileum appears broad gas in the bowel with out any special feature i.e.
.characterless
The colon is seen distended with gas and because of the longitudinal
muscles folds are seen as whitish lines extending from one border to the middle
.(of the bowel gas i.e. not reaching the other opposite border (haustrations
:Pathophysiology
.The secretions of the gastrointestinal tract are about 8 litres
:litres above the pylorus as follows 4
.Saliva 1500ml, gastric juice 2500ml
;litres are from below the pylorus. These are 4
ml bile, 500 ml pancreatic juice, and 3000 ml small intestinal 500
.(secretions (succus entericus
In intestinal obstruction these 8 litres are not absorbed. In fact some fluid
may ooz form the wall of the intestine into the lumen. This fluid with the gas in
the intestine lead to distension and part of this fluid will be vomited and the rest
will accumulate in the lumen leading to distension. Vomiting and failure of
absorption of water lead to dehydration. Peristalsis will increase to overcome
the obstruction. They will be heard as exaggerated bowel sounds during
.auscultation. In thin patients visible bowel loops may be seen during peristalsis
Excessive vomiting of the gastric acid will be compensated by secreting
alkaline urine for maintenance of the pH of the blood i.e. the state will be
compensated metabolic alkalosis by secreting sodium bicarbonate in the urine
and potassium entering into the cells in alkalosis. This, results in Na and K
.deficiency
Distension is due to accumulation of fluid and gas in the lumen of the

intestine.
96
:Causes of fluid in the intestine
.Failure of absorption of the accumulated 8 litres of fluid in the lumen -1
.Secretion of fluid from the wall of the intestine into the lumen -2
.Oral intake of fluids -3
:Causes of gas in the intestine

.The swollen gas with the oral intake of food -1
.gas produce by fermentation of bacteria -2
.Diffusion of gas from blood into the lumen of the bowel -3
Intestinal obstruction occurs at any age *

(Causes of intestinal obstruction ( in the newborn 1.2.3
.Oesophageal atresia -1
Duodenl atresia or duodenal diaphragm: In this condition vomiting and-2
not salivation occur from birth. Plain X-ray abdomen shows gas in the fundus
of the stomach and in the first part of the duodenum. No gas will be seen in the
rest f the bowel .This feature is called the double bubble sign. Clinically there
.is no palpable lump in the epigastrium as in congenital pyloric stenosis
.Treatment: duodeno-jejunostomy
.Distended stomach with absent gas in small intestine in a new born*
Atresia of the ileum: In this condition abdominal distension and bilious -3

vomiting occurs since birth. X-ray abdomen shows multiple air fluid levels.
Treatment by resection of the site of atresia and anastomosis of the rest of the
.small intestine
:Volvulus neonatorum-4
The mesentery of the small intestine extends from the tip of the left second
lumber transverse process to the left sacroiliac joint. The blood supply and
venous return of the small intestine pass in the root of the mesentery. Therefore,
Rotation of the small intestine around the root of the mesentery will lead to
kinking and twisting and obstruction of these blood vessels leading to ischemia
97
and gangrene of the small intestines. This is called Volvulus of the small
intestine. It occurs in newborns and is called volvulus neonatorum. Clinically
the newborn will be crying of sudden onset of severe pain associated with
.vomiting. The abdomen will be distended
Treatment: Laparotomy and untwisting of the intestine and division of the
.congenital band of Ladd which causes trans-duodenal obstruction
:Meconium ileus-5
Thick (viscid) meconium in cases of mucoviscidosis
fibrocystic disease of the pancreas) sticks inside the lumen of the bowel)
leading to intestinal obstruction presenting as abdominal distension and
vomiting. X-ray shows distended bowel and part of it shows mottling but the
.gas is reaching the rectum
.Treatment: Laparotomy and washing of the thick mucus down the intestine
Intussusception-6
One part of the intestine moves forward and becomes invaginated in to the
immediate adjacent part of the intestine. The cause of the forward movement is
a small polyp or hypertrophy of Payers patches. It occurs at the time of weaning
and teething i.e. in the first year. The child present with severe colicky
abdominal pain on and off. He draws his knees towards his abdomen during the
attack of pain and passes mucus stained with blood per rectum. Physical
examination shows a sausage-like mass in the line of the large bowel. This mass
may be felt per-rectum. Abdomen is distended. X-ray abdomen shows multiple
.air fluid levels
Treatment: by laparotomy and squeezing the inner bowel out. The inner
bowel is called intussusceptum and the outer bowel is the intussuscipiens. If the
.bowel is gangrenous then resection anastomosis is the treatment
:Sigmoid volvulus-7
This results from axial rotation and complete twisting of a long sigmoid colon
around its short base. The Sigmoid becomes grossly distended and reaches the
diaphragm. The patient complains of severe sudden pain starting during
straining at stools, vomiting, distension and absolute constipation. X-ray shows
.massive distension of the sigmoid colon
Treatment: Rigid sigmoidoscopy and a trial to untwist the sigmoid by
insufflation of air. If this fails, laparotomy and untwisting of the sigmoid and
fixation of the sigmoid to widen its base. If the sigmoid is gangrenous resection
and temporal colostomy should be done. If reduction succeeded prepare the
bowel with laxatives and colonic washout enemas and proceed for resection of
.the long sigmoid and anastomose the rest of the large bowel
98
Sigmoid volvulus*
Carcinoi
d tumour
Cong
enital
ano-
rectal
malfo
rmati
ons
.These are 2 types: The low type and the high type
:The low types
The covered anus: The external anal verge is covered by a thin skin but -1
the anal margins are well palpable. It is treated with incision of the covering
.skin and anal dilatation
99
The ectopic anus: The anus opens anteriorly (in the perineum in male and -2
in the vulva in females) with a small (pin hole). The treatment is to cut
.back the tract passing anteriorly
The stenosed anus: Small pin hole is seen at the external opening this is-3
.treated with anoplasty and dilatation
:High anomalies
These are usually associated with fistula communicating the upper part of the
.rectum and the vagina or urinary bladder
Ano-rectal agenesis: There is congenitally absent anal canal and lower part-1
of the rectum. The upper part of the rectum is above the pelvic diaphragm
.((levetor ani
Rectal atresia: Anal canal is normal but end blindly at the level of the-2
.pelvic floor
.Cloaca: Both rectum and urinary bladder open in a common chamber-3
Colorectal cancer
Cancer of the colon and rectum is the third commonest cancer worldwide. It is
.the second cause of death from cancer
.Low fibre diet. 2- Alcohol -1
:Smoking. 4- Genetic factors -3
Colorectal cancer is divided into hereditary and non-hereditary colorectal
cancer. The hereditary type is caused by familial polyposis coli and non-
.polyposis colorectal cancer below the age of 50
:The non-hereditary type is due to
.Ulcerative colitis -1
.Crohn's disease -2
.Villous adenoma of the rectum -3
.Dysplastic colonic polyps -4
.Sporadic colorectal cancer -5
:Familial polyposis coli
100
This is an autosomal dominant inherited disease in which more than 100 polyps
are seen in the colon and rectum. It changes to cancer at the age of 40.
Therefore in this disease family screening is mandatory and prophylactic
.colectomy is indicated
polyps*
Familial polyposis coli*
:Naked eye appearance (Macroscopic) types of colorectal cancer
Ulcerative type: Usually seen in the caecum and right side of the-1
colon. It has ulcers with elevated edges. It causes loss of blood in stools. This is
detected in stool analysis for haemoccult blood i.e. for haemoglobin in stools
provided that the patient does not take red meat for 3 days. Loss of blood leads
.to iron deficiency anaemia
.Cauliflower-2
.Tubular-3
.Annular constricting type -4
The last 2 types are commonly seen in the left side of the colon where they lead
to large bowel (Chronic obstruction) and usually present with diarrhoea
alternating with constipation. The patient also, may complain of painless blood
streaks in the surface of each piece of stools passed, This may be associated
with passage of mucus per rectum of feeling of heaviness in the rectum or
incomplete defecation if the tumour in low down in the rectum near the
sphincter. The disease, like other cancers, lead to loss of weight. It should be
.suspected in all young or old patients complaining from any bowel symptom
101
:Investigations
Haemoccult blood in stools: this can be used for screening the society for -1
.colorectal cancer
Sigmoidoscopy: The rigid sigmoidoscope which is 25 cm long or the fibre-2
optic (Flexible) sigmoidoscope can detect up to 60% of all tumours in the
.rectum and colon
.Colonoscopy: with these scopes biopsies can be taken for histopathology -3
.Barium enema: this shows filling defect -4
:Spread
.Direct invasion to the muscles and adventitia -1
Spread by lymphatic to the paracolic and epicolic and paraaortic lymph -2
.nodes
.By blood stream to the liver , lung brain and bones -3
* liver Metastases
:Duke's staging
.Stage A: Tumour confined to the wall of the bowel
.Stage B: Tumour has spread to the adventitia
.Stage C: Tumour has spread to lymph nodes
:Treatment
Excision of half the colon around the site of the tumour i.e. right or left
hemicolectomy, Transverse colectomy, sigmoidectomy, anterior resection of
the rectum or abdomino-perineal resection of the rectum in low tumours is
.indicated in operable cases
.Chemotherapy: This should follow surgical resection
.Radiotherapy: For cancer of the rectum and bone metastases
102
Stenosis of colostomy stoma Parastomal hernia
Cancer of anal canal is treated with radio-chemotherapy with or without

local resection. It has high cure rate if diagnosed before spreading to the
.inguinal lymph nodes
:Follow up
.By Ultrasound for local recurrence, nodal and liver metastases -1
Repeat colonoscopy or repeat barium enema for local recurrence of the -2
.tumour
Carcinoembryonic antigen which is a tumour marker that appear when there-3
.is local recurrence or metastases
======================================
=======================
Self assessment
:Intestinal obstruction
:Intestinal obstruction is -1
.a- Mechanical closure of the lumen of a segment of intestine
b- Inflammation of a long segment of small intestine
.c- Failure of forward propagation of intestinal contents
.d- Characterized by abdominal pain, vomiting and distension
.e- Precipitated by pre-existing hernias in all cases
:Answer
c - In Billroth II the first part of the duodenum is closed. In typhoid the – 1
patient develops diarrhoea while the whole terminal ileum is inflamed.
.Absolute constipation is an important feature of acute intestinal obstruction
103
:The commonest cause of intestinal obstruction in Africa is-2
.a- Bolus of ascaris worms
.b- Post-operative adhesions
.c- Carcinoma and lymphoma
.d- Obstruction of a pre-existing hernia
.e- Peritonitis due to perforated typhoid disease
:Answer
d) –Obstruction by ascaris is more common in India while malignancy ) – 2
.and adhesions are more common in western countries
:Small bowel obstruction is characterized by -3

.a- Pain, vomiting, distension and absolute constipation
.b- Constipation alternating with diarrhoea
.c- Upper abdominal distension and bile free vomitus
.d- Projectile effortless vomiting associated with headache
.e- Painless abdominal distension with passage of diarrhoea
:Answer
a) – Constipation alternating with diarrhoea (spurious) is common in left ) – 3
sided large bowel obstruction. Bile free vomitus occurs in gastric outlet
obstruction while effort less vomiting with headache occurs in increased
.intracranial pressure as in head injury and hydrocephalus
:Bowel ischemia is characterized by -4

.a- Continuous pain
.b- High white blood cell counts
.c- Tachycardia and late hypotension
.d- Blood in finger stall on rectal examination
:Answer
e) – Also the patient develops metabolic acidosis seen in blood gas ) – 4
.analysis as Ph < 7.34, Low bicarbonate, Low acid base excess and low CO2
:The diagnostic X-ray appearance in jejunal obstruction shows -5

.a- More than 3 air-fluid levels in the erect X-ray of the abdomen
.b- Distended characterless terminal ileum in the supine X-ray
.c- Multiple haustrations and valvulae conniventes
.d- Diffuse distension of small and large bowel with gas in rectum
.e- Huge distended loop of bowel extending from pelvis to diaphragm
104
:Answer
a) – In jejunal obstruction the bowel distal to the site of obstruction is ) – 5
collapsed. Diffuse distension with gas in the rectum occurs in paralytic ileus.
Huge bowel distension from the pelvis to the diaphragm occurs in volvulus of
.the sigmoid colon
:The source of gas in the obstructed bowel is -6

.a- The air swollen with food
.b- Bacterial fermentation
.c- Back diffusion from blood vessels
:Answer
.d) – The intestine interpret distension as pain ) – 6
:The volume of fluid sequestrated in intestinal lumen in obstruction is -7

.a- Two litres
.b- Four litres
.c- Six litres
.d- Eight litres
.e- Ten litres
:Answer
d) – These are gastro-intestinal secretions 4 litres above the pylorus ) – 7
( one and half litres saliva and 2.5 litres gastric secretions) and 4 litres below
.(the pylorus ( one litre bile and pancreatic juice and 3 litres succus entericus
:The source of fluid in the lumen of obstructed terminal ileum is -8

.a- 1500 ml saliva
.b- 1000 ml bile and pancreatic juice
.c- 2500 ml gastric secretions
.d- 3000 ml succus entericus
.e- 8000 ml of foregut and mid gut secretions
:Answer
e) – There fore dehydration in intestinal obstruction is due to vomitus, ) – 8
.defective absorption and sequestration of the 8 litres of fluid in the lumen
:Signs of viable bowel include -9

.a- Glistening pinkish colour
.b- Palpable pulsations and visible peristalsis
.c- Thick oedematous dark bowel
.d- Does not bleed if punctured or cut
105
:Answer
e) – However, the doubtful bowel viability may return to normal if ) – 9
covered with warm abdominal gauze with 100% oxygen supply by the
anaesthetist for 10 minutes. If still in doubt wide resection is important because
if thrombi remain in vessels the thrombus may propagate and again ischaemia
will develop at the site of anastomosis leading to anastomotic leak and
.peritonitis
:Intra-luminal causes of intestinal obstruction include -10

.a- Food bolus (piece of meat) in oesophagus
.b- Ball of ascaris worms in the terminal ileum
.c- Gallstone in terminal ileum of elderly female
.d- Hard faecal mater in bed ridden elderly patients
:Answer
e) – However in elderly patients always think of large bowel cancer and ) – 10
in dysphagia think of a cause like benign or malignant stricture. In elderly lady
remember to look for has biliary tree (pneumobilia) in the plain erect X-ray of
the abdomen due to spontaneous cholecysto-duodenal fistula. Some young
adults develop intraluminal obstruction by solid organic material containing
.(hair (Bezoars
:Causes of intestinal obstruction in the intestinal wall include -11

.a- Carcinoma or lymphoma
.b- Intussusception
.c- Mesenteric thrombosis
.d- Benign strictures or congenital atresia
:Answer
e) – Also volvulus of the small intestine, caecum or sigmoid colon, ileo- ) – 11
.caecal tuberculosis Crohn's disease and diverticulitis
:Causes of intestinal obstruction out side the intestinal wall include -12
.(a- Congenital bands (Vitillo-intestinal band and band of Ladd
.(b- Tumours (carcinoma pancreas obstructing duodenum
.c- Post operative adhesions
:Answer
106
d) – Also lymphoma, tuberculosis ( adhesive type) and internal hernias ) – 12
.in the paraduodenal fossae
:Electrolytes disturbance in intestinal obstruction include -13

.a- Dehydration with hypernatraemia
.b- Dehydration with hypokalaemia
.c- Metabolic alkalosis with hyperkalaemia
..d- Metabolic acidosis with hypocalcaemia
.e- Hypokalaemia with hypercalcaemia
:Answer
b) – Usually intestinal obstruction with excessive vomiting leads to ) – 13
metabolic alkalosis with hypokalaemia but, in mesenteric thrombosis the
.patient develops metabolic acidosis
:Congenital causes of intestinal obstruction include -14
.a- Oesophageal atresia
.b- Duodenal atresia
.(c- Primary megacolon (Hirschsprung’s disease
.d- Imperforated anus
:Answer
e) – Congenital causes could be expected during pregnancy if there is ) – 14
polyhydramnious. However other causes that present shortly after birth are
.meconium ileus and volvulus neonatorum
:Inflammatory causes of intestinal obstruction include -15

.a- Ileo-caecal tuberculosis
.b- Crohn’s disease
.c- Diverticulitis
.d- Appendicular abscess
:Answer
e) – Also in perforated typhoid and toxic megacolon of ulcerative colitis ) – 15
.the patient develops paralytic ileus
:Double bubble sign in newborn abdominal X-ray is diagnostic for -16

.a- Duodenal atresia
.b- Hypertrophic pyloric stenosis
.c- Volvulus neonatorum
.d- Meckel's diverticulum
107
.e- Meconium ileus
:Answer
a) – double bubble sign is absence of gas in the alimentary canal except ) – 16
one bubble in the fundus of the stomach and the one in the dilated first part of
.the duodenum
A newborn infant was noticed to have continuous excessive salivation. -17

It develops intense cough and becomes bluish in colour after feeds. The
:most likely diagnosis is
.a- Volvulus neonatorum
.b- Meconium ileus
.c- Duodenal atresia
.d- Oesophageal atresia
.e- Congenital heart disease
:Answer
d) – In volvulus neonatorum and meconium ileus the abdomen will be ) – 17
distended and in volvulus the baby will be crying of pain. In both conditions the
.baby feed without chocking or excessive salivation
:The best diagnostic test for the above mentioned newborn is -18
.a- X-ray abdomen in erect view
.b- Barium sallow X-ray
.c- NGT and plain X-ray
.d- Ultrasound of the abdomen
.e- CT scan of the abdomen
:Answer
c - The nasogastric tube will be found coiled in the upper oesophageal – 18
.pouch. No need for contrast study for diagnosis
:The major cause of death in the above mentioned newborn is -19

.a- Aspiration pneumonia
.b- Diarrhoea and dehydration
.c- Anaesthetic complications
.d- Other congenital abnormalities
e- Vomiting and malnutrition
:Answer
.a) – Delay in diagnosis or operation leads to fatal chest infection ) – 19
A 3-week-old male child presented with projectile vomiting that does -20
not contain bile. He appears to be hungery all the time crying for food and
:he lost weight. The Most likely diagnosis is
108
.b- Duodenal atresia
.c- Annular pancreas
.d- Volvulus neonatorum
.e- Meconium ileus
:Answer
a) – Congenital hypertrophic pyloric stenosis. Duodenal atresia, ) – 20
volvulus neonatorum and meconium ileus do not stay for 3 weeks for treatment.
In annular pancreas the condition may present clinically at any age. The
diagnosis is difficult and it requires ultrasound and possibly CT-Scan of the
.abdomen
During examination upper abdominal distension with visible -21

peristalsis passing from left hypochondrium towards the right side. The
other most important single diagnostic sign in the above mentioned baby
:is
a- Tympanitic abdomen on percussion
b- Palpable mass in the right iliac fossa
.c- Hyperactive bowel sounds
.d- Palpable mass in the epigastrium
.e- Abdominal distension
:Answer
.d) – Palpable mass in right iliac fossa occur in intussusception ) – 21
A 9-month- old boy was brought to the casualty after passing blood -22
and mucus per rectum while crying and flexing his knees to his chest. The
:most likely diagnosis is
.a- Peptic ulcer disease
.b- Intussusception
.c- Juvenile rectal polyp
.d- Typhoid fever
.e- Hirsh Sprung disease
:Answer
.b) – the rest of the possibilities do not cause severe pain ) – 22
On physical examination the abdomen of the above mentioned boy -23

was distended, tympanitic with tinkling bowel sounds. Palpation is
:expected to detect
.a- Palpable sausage like mass in the line of the colon
.b- A rounded mass that moves from right to left not up and down
.c- A mass that moves with respiration
d- Epigastric mass that transmits the pulsation of the aorta
.e- A mass that becomes more prominent on raising the trunk
:Answer
109
a) – The mass that moves from sis to side but not up and down is ) – 23
mesenteric cyst. The mass that moves with respiration is arising from the liver,
spleen or stomach. While epigastric mass that transmits aortic pulsations arise
.from the pancreas, para-aortic lymph nodes or a horse shoe kidney
Self assessment
:Acute appendicitis
:Acute appendicitis -1
.a- Is common in some families
.b- Is common with low fibres diet feeding
.c- Is rather difficult to diagnose in elderly patients
.d- Is easily missed in children below 2 years of age
:Answer
e) – Elderly are more tolerable to pain and may not show significant ) – 1
tenderness and guarding, also, suspicion of malignancy is higher in elderly
patients and this leads to delay for unnecessary investigations. However,
children below 2 years of age have short greater omentum and infection and
perforation can not be sealed so the develop peritonitis if the diagnosis is
.missed
:Central abdominal pain -2

.a- Is a referred type of pain
.b- Is carried by the 10th thoracic nerve
.c- Is due to inflammation in mid gut
:Answer
d) – later the pain becomes localized in the right iliac fossa because the ) – 2
.inflammation reaches the parietal peritoneum in the right iliac fossa
:The differential diagnosis of acute appendicitis in children includes -3

.a- Mesenteric lymph adenitis
.b- Pharyngitis and/or tonsillitis
.c- Basal pneumonia
.d- Pyelonephritis
:Answer
e) – The appendix is full of lymphoid tissue therefore it is inflamed in ) – 3
mesenteric lymph adenitis which occur in cases viraemia and upper respiratory
.tract infection
110
:The differential diagnosis of appendicitis in young females includes -4
.a- Mid-cyclic pain
.b- Ruptured ovarian follicle
.c- Salpingitis
.d- Torsion of ovarian cyst
e- All the above are correct
:Answer
e) – Also red degeneration of fibroid, and ruptured tubal pregnancy. In ) – 4
fact pain in RIF in a Female at child bearing age associated with pallor and
. .hypotension is ruptured tubal pregnancy till proved otherwise
:The differential diagnosis of appendicitis in adult males includes -5

.a- Perforated duodenal ulcer
.b- Meckel's diverticulitis
.c- Right side ureteric colic
.d- Acute cholecystitis
:Answer
e) – Ureteric colic is severe intermittent and makes the patient to roll in ) – 5
bed. In acute cholecystitis tenderness is more at the right subcostal region.
Ultrasound is helpful to reach a proper diagnosis. During surgery if the
appendix was normal the incision should be extended to do formal laparotomy
.to see the pelvic organs, terminal ileum and duodenum
:The differential diagnosis of right iliac fossa mass includes -6

.a- Appendicular mass
.b- Ileo-caecal tuberculosis
.c- Carcinoma of the caecum
.d- Pyelonephritis in a pelvic kidney
:Answer
.e) – Also Crohn's disease, Twisted ovarian cyst and Actinomycosis ) – 6
:The commonest bacteria in acute appendicitis are -7

.a- Pseudomonas aeruginosa and E. coli
.b- Klebsiella pneumoniae and Strept. faecalis
.c- Staph. Aureus and Strept. pyogenes
.d- E. coli and Clostridium perfringens
.e- Bacteroides fragilis and E. coli
:Answer
e) – Bacteroides is strictly anaerobic gram negative bacilli that respond ) – 7
.to Metronidazole
:The best prophylactic antibiotics in acute appendicitis are -8
111
.a- Gentamicin and Cefuroxime
.b- Clindamycin and Metronidazole
.c- Ampicillin and Gentamicin
.d- Metronidazole and Cefuroxime
.e- Metronidazole and penicillin
:Answer
e) – Clindamycin is also good against Bacteroides but it is famous of ) – 8
causing severe mucoid diarrhoea (Pseudomembranous colitis). It is good in
renal impairment because it is metabolized in the liver and secreted in in bile
and not in urine. Both gentamicin and Cefuroxime are good but Cefuroxime is
not nephrotoxic. Combination of both cephalosporin and aminoglycosides lead
.to early nephrotoxicity unless the renal function is carefully watched
:The following indicates that infection has reaches parietal peritoneum -9
.a- Cough increases abdominal pain
.b- Movement increases abdominal pain
.c- Pain increase after sudden release of the pressing hand
.d- Pain increases under the percussing finger
:Answer
e) – In all these methods there is movement and friction of the inflamed ) – 9
.visceral and parietal peritoneum represent indirect positive rebound test
:The commonest site of the appendix is -10

.a- Paracaecal
.b- Pelvic
.c- Retro-caecal
.d- Post-ileal
.e- Pre-ileal
:Answer
c - The commonest position of the appendix is the retrocaecal position – 10
.((74%) followed by pelvic position (21%
.The following sign localizes the retro-caecal appendix -11

.a- Rovsing's sign
.b- Psoas sign
.c- Obturator sign
.d- Positive finger pointing test in Mc Burney's point
.e- Tenderness and guarding in right iliac fossa
:Answer
b) – is positive in retrocaecal appendicitis while Obturator sign is ) – 11
positive in pelvic appendicitis' The rest of the signs are for diagnosis rather
.than determining the position of the appendix
112
:The following is correct in acute appendicitis -12
.a- Normal WBC count does not rule out acute appendicitis
.b- Puss cells in urine do not rule out acute appendicitis
.c- RBCs in the urine do not rule out acute appendicitis
.d- Tachycardia with normal temperature occurs in appendicitis
:Answer
e) – All are correct. Acute appendicitis is a clinical rather than a ) – 12
.laboratory investigation
:The most important symptom besides pain in acute appendicitis is -13

.a- Nausea
.b- Vomiting
.c- Loss of appetite
.d- Diarrhoea
.e- Fever
:Answer
c - Diarrhoea is common in retro-ileal appendicitis and in pelvic – 13
.abscess
A 28 year old lady presented to the casualty with right lower quadrant -14
.abdominal pain for 12 hours. She is a mother of 2 kids
She looks anxious, pale and cold clammy skin. Pulse 100/min BP 80/60.
:(I)The most likely diagnosis is
.a- Acute appendicitis
.b- Red degeneration of fibroid
.c- Ruptured tubal pregnancy
.d- Ruptures cyst-adenocarcinoma of the ovary
.e- Pelvic inflammatory disease
:Answer
I - c - Features of acute appendicitis with shock in a female is ruptured tubal
.pregnancy till proved otherwise
:II) For proper management of the previous patient one should)

.a- Ask about the time of the last menstrual period
.b- Request urgent pregnancy test in urine
.c- Request ultrasound of abdomen and pelvis if possible
.d- Consult obstetrician on call
:Answer
.II – (e) – These are the proper steps to be taken if tubal abortion is suspected
113
:The Following pathology could be found in the appendix-15
.a- Carcinoid tumour
.b- Mucocele of the appendix
.c- Adenocarcinoma of the appendix
.d- Tuberculus granulomas, Bilharzial ova, or worms
:Answer
e) – Appendix should always be sent for histopathology because of these ) – 15
reasons. The commonest site for Carcinoid tumour is the appendix followed by
the terminal ileum. Mucocele of the appendix should not be allowed to rupture
because it contains mucous secreting adenocarcinoma and when it ruptures it
.lead to pseudomyxoma peritonii
:Management of appendicular mass includes -16

.a- Observation of pulse, temperature, BP and pain
.b- Intravenous fluids plus antibiotics
.c- Keep the patient fasting
.d- Mark and observe the size of the mass
:Answer
e) – If the mass subsided discharge the patient to come for interval ) – 16
appendicectomy after 3 months . If fever pain and pulse increased the patient is
developing appendicular abscess and this should be drained extraperitoneally
114
Formation of bile:
Red blood cells destruction leads to release of haemoglobin. Haemoglobin
is then broken down to haem and globin. The globin is taken back to the
protein synthesis in the liver. The haem moiety changes to porphyrin. This
forms biliverdin which is carried by albumin to the liver to form
unconjugated bilirubin. This is becomes conjugated and is released into the
biliary canaliculi to the common bile duct and therefore to the intestine
where bacteria breaks it down to stercobilinogen that gives the stools the
brown colour and urobilinogen. Urobilinogen is absorbed and goes through
the circulation to all tissues. In the kidney urobilinogen is secreted in the
urine. Therefore if bile reaches the intestine i.e. when there is no obstructive
jaundice urobilinogen is found in the urine. If there is obstructive jaundice
bile will not reach the intestine and urobilinogen will be absent in the urine.
The bile constituents:
1-water.
2-Bilirubin (bile pigment).
3- Bile salts which are bile acid + Na . The essential bile acids are
Cholic acid, Deoxycholic acid and Chenodeoxycholic acid.
4-Phospholipids.
Types of gallstones:
115
1- Cholesterol stone: These usually develop in sterile bile. It is
usually solitary stone (gallstone solitaire). It is faint radio-opaque. It
develops in obese patients and those who have hypercholesterolemia.
2- Pigment stone: these are black in colour small, with different
shapes and are radiolucent. They develop in vegetarians and in patients
with haemolytic diseases like malaria and sickle cell anaemia.
3- Mixed stones: are brown, multiple, faceted, radiolucent and
develop in infected bile.
Gallstone disease
Gallstones are common in female than males. It is more common in
fatty, fertile, females 40-50 years of age suffering from flatulence.
Gall stones may remain asymptomatic in the gallbladder. However, the
symptoms and complications of gallstones increase with age.
1- Acute calcular cholecystitis: Stones in the gallbladder may cause
inflammation of the gallbladder wall which becomes thick, oedematous
leading to continuous pain on the right hypochondrium radiating to the
right shoulder aggravated with fatty meals and associated with
indigestion (Dyspepsia).
2- Chronic calcular cholecystitis:
Recurrent inflammation of the gallbladder is followed by healing by
fibrosis. Therefore the patient has recurrent attacks of indigestion, upper
abdominal pain induced by fatty meals and referred to the right shoulder,
flatulence with deep tenderness in the right hypochondrium during the
attacks but the gallbladder will not be palpable. In fact it will be small,
contracted, shrunken and fibrosed with thick wall.
Murphy's sign: This is demonstrated by the examining hand pressing at
the fundus of the gallbladder (just deep to the tip of the ninth rib) while
the patient is taking a deep breathing i.e. moving the diaphragm and the
116
liver downward against the examining hand, the patient will suddenly
stop inspiration when the inflamed gallbladder touches the hand.
Courvoisier's law: In a jaundiced patient with a palpable gallbladder the
cause is unlikely to be gallstones because in gallstones recurrent
inflammation leads to fibrotic small gallbladder.
3-Mucocele of the gallbladder:

When a stone gets impacted at the cystic duct or the neck of the
gallbladder, bile inside the gallbladder will be absorbed but the
gallbladder becomes distended with mucus which is secreted from its
columnar epithelium (the gallbladder has no goblet cells to secret mucus
as in the rest of the gastrointestinal tract). Mucocele is a type of acute
cholecystitis. The gallbladder may become palpable but the patient is not
jaundiced.
4-Empyema of the gall bladder:

In this condition the gallbladder becomes hugely distended with severe
inflammation thick oedematous wall and white bile that may or may not
contain bacteria. Some fluid may collect near the gallbladder. The
distended gallbladder may compress the common bile duct from out side.
The patient is febrile with tinge of jaundice and severe tenderness and
guarding in the right hypochondrium.
5-Gangrenous gallbladder:
In this condition the obstruction at the neck of the gall bladder leads to
severe inflammation. The gallbladder becomes distended with thick
oedematous wall. Because of the severe inflammation and the huge
distension the branches of the cystic artery reaching the fundus of the
gallbladder will not be sufficient to supply the fundus which will
consequently develop necrosis. The greater omentum (policemen of the
abdomen) will cover the fundus to seal any perforation that may occur at the
area of necrosis. So, the gall bladder will be palpable as a tender gallbladder
117
mass and the patient will suffer from severe pain, fever, tinge of jaundice
with tenderness and guarding at the right hypochondrium.
6- Perforation of the gallbladder:

a- Biliary peritonitis:
If omentum did not seal the perforation the gallbladder will perforate at
the fundus and pus and bile will contaminate the general peritoneal cavity.
The patient becomes toxic, febrile, dehydrated with distended tender
abdomen due to peritonitis resulting in paralytic ileus. This is a serious
condition because delay in prompt correct management will end up with
endotoxic shock and death.
b- Spontaneous cholecysto-duodenal fistula:
In this condition the distended gallbladder is obstructed at the neck and
the blood supply is not sufficient at the fundus that lies on the first part of
the duodenum. The adherent area between the fundus of the gallbladder and
the duodenum gradually develops a fistula (Communication between two
epithelial surfaces). The fistula helps in reducing the high pressure within
the gallbladder and hence distension and inflammation subside. Like chronic
calcular cholecystitis the patient may complain of pain due to presence of
the stone at the neck of the gallbladder. Ultrasound and plain X-ray reveals
gas in the intrahepatic biliary ducts. This gas comes from the duodenum to
the gallbladder and biliary ducts.
c- Gallstone ileus:
In this condition after developing cholecysto-duodenal fistula the stone
slips into the duodenum and pass down to be impacted at the terminal ileum
because this is the narrowest part of the small intestine. The patient is
usually an elderly female (>70 years). She present with acute intestinal
obstruction (pain, vomiting, distension and absolute constipation).
Laparotomy will reveal the cause to be gallstone impacted in the terminal
ileum.
Management of cholecystitis:
118
a-Relieve of pain by:
1-Analgesics like diclofenac sodium if the patient is not complaining
from heartburn or peptic ulcer disease.
2- Antispasmodics like hyoscine.
3- Antibiotics to be added only if there is evidence of infection i.e.
polymorphs leukocytosis and/or fever.
4- Abstinence of fatty food.
b- Investigations to prove the diagnosis:

1- Ultrasound of the abdomen we look particularly for:
a- Presence of gallstones. b- Dilatation of intra hepatic biliary duct
and common bile duct (This could be due to stones).
c- Mass in pancreas (due to pancreatitis or carcinoma of the pancreas).
Acute acalcular cholecystitis

If the most likely diagnosis is cholecystitis and gall stones were not seen
by ultrasound then there is a possibility of acalcular cholecystitis. We
have to do one of the following tests:
a- Repeat ultrasound after fatty meal if the size of the gall bladder
became small i.e. it contracts after fatty meal then the gall bladder has a
normal function and its cystic duct is patent. If it remained distended then
the cystic duct may be occluded by a small stone or a polyp.
b- Oral cholecystogram: 6-12 biloptin tablets are given at night and
the patient remains fasting till morning. The tablets will be absorbed in
the intestine, secreted in bile stored and concentrated in the gall bladder.
In the morning X-ray of the right hypochondrium is taken to look for
distended gallbladder with or without filling defects (stone or tumour).
Then fatty meal is taken and X-ray is repeated. If the gall bladder
contract i.e. became smaller in size then it is normally functioning. If it
didn't contract then it is a non-functioning gallbladder. The gall bladder
119
may not be seen opacified i.e. the contrast may not enter the gallbladder.
In this case the cause may be either the patient has vomited the tablets,
passed them in diarrhoea or the cystic duct is obstructed by stone, polyp
or tumour preventing the contrast from entering the gallbladder. Oral
cholecystogram is contraindicated in presence of jaundice because liver
will not be able to secrete the drug in bile.
c- radio-isotope study of the gallbladder called HIDA scan which
demonstrates the gallbladder and bile ducts. Any filling defect could be
seen.
d- Cholecysto-kinin provocation test: When this hormone is injected
in the patent then the patient suffers from typical gallstone colic due to
contraction of the gallbladder if it is inflamed.
It is clear that ultrasound is the best investigation because it is cheep,
repeatable, has no side effects and has high accuracy rate.
Common bile duct stones
Stones usually develop within the gallbladder and may slip into the common
bile ducts. Stones in the common bile duct may remain asymptomatic for a
time but ultimately will lead to one of the following complications:
1- Obstructive jaundice: The stone gets impacted and disimpacted in
the common bile duct. This leads to flocculating jaundice i.e. recurrent
jaundice associated with severe intermittent biliary colic that comes
suddenly in the epigastrium (because the CBD is a midline structure)
referred to the back.
2- Cholangitis: The stone in the common bile duct may predispose to
infection of the biliary ducts i.e. cholangitis. The symptoms of
cholangitis are summarised by the Charcot's Triad which is Jaundice,
pain and fever with rigors.
3- Acute pancreatitis: A small stone
may obstruct the ampulla of Vater where
both the common bile duct and pancreatic
120
duct join before opening into the duodenum. This transient obstruction of
the ampulla leads to reflux of bile into the pancreatic duct and therefore
activation of trypsinogen to trypsin that leads to severe inflammation of
the pancreas.
ERCP
Common bile duct stones:
As mentioned previously ultrasound may not detect a stone in common
bile duct but will be helpful to see the dilated common bile duct (>7mm
diameter) or presence of swollen oedematous pancreas.
ERCP (Endoscopic Retrograde Pancreatico-Cholangiogram):
If the patient has past history of jaundice ERCP has a diagnostic advantage
of showing common bile duct stone and a therapeutic role
by removing the stone.
Treatment:
The best curative treatment for gallstone disease is cholecystectomy
either by open surgical procedure or by laparoscopy. One week after
extraction of common bile duct stone by ERCP cholecystectomy should
be done because it is the diseased gallbladder that acts as a source of
gallstone formation. If ERCP failed to extract the common bile duct stone
then after cholecystectomy the common bile duct is opened
(choledochotomy) and the stone removed and the choledochotomy is
closed over a T-tune in the common bile duct. The T- tube is left for free
drainage and after 10 days T-tube cholangiogram is done to make sure
that there are no residual or missed stone in the common bile duct. The
T- tube is considered normal if:
a. There is no filling defect in the biliary ducts.
b. There is no dilatation of intra or extrahepatic biliary ducts.
c. The contrast is reaching the duodenum.
If the T-tube cholangiogram is normal then the T-tube is removed.
121
1- Well rehydration orally and supplemented with intravenous fluids.
This is to increase diuresis to wash out bile salts from renal tubules.
Deposition of bile salts in renal tubules leads to tubular necrosis and renal
failure.
2- Request blood urea nitrogen and serum creatinine to make sure that
the renal function is not impaired by the bile salts.
3- Serum electrolytes and supplement potassium chloride (KCL)
because the bile is alkaline and it is diffusing in all tissues and fluids of
the body. Therefore the patient will be in metabolic alkalosis. In
metabolic alkalosis potassium shifts in side the cell and the potassium
level becomes low in the serum. ( normal K+ 3.5-5.3 mmol/L) If the level
of potassium is <2.7 the patient may develop arrhythmia during
anaesthesia.
4- Ask for prothrombin time (PT). In obstructive jaundice bile does
not reach the small intestine and therefore the fat will not be emulsified
nor absorbed. Fat will pass in faeces in the form of steatorrhoea. Vitamin
K will not be absorbed. Synthesis of clotting factors number 10, 9, 7 and
2 (prothrombin) will be impaired and the deficiency of these factors
renders the patient liable for bleeding during surgery. The normal
prothrombin time is <15 seconds. If it is prolonged then supply Vitamin
K in injectable form.
5- Ask for haemoglobin level and prepare two units of blood after
grouping and cross matching.
6- Insert Foley's urinary catheter to calculate the urine out put.
7- Use preoperative antibiotics because any interference with
obstructed system may flare up infection and the jaundiced patient is
considered as immuno-compromised patient. Remember the bile is sterile
in the normal state but in disease the commonest organisms expected are
E. coli, Klebsiella pneumonae, Proteus vulgaris, Streptococcus faecalis
122
and Staphylococcus aureus. Therefore use a second generation
cephalosporin like Cefuroxime 750mg intravenously and can be repeated
8 hourly. Try to avoid aminoglycosides like gentamicin which is
nephrotoxic because jaundiced patients are liable for renal failure.
8- During surgery add manitol to enforce diuresis because jaundiced
patients are liable for bacteraemia and hence for hypotension during
surgery. If jaundiced patients develop hypotension they may end up with
acute tubular necrosis and renal failure particularly if systolic blood
pressure becomes lower than 70 mmHg.
9- Informed written consent for surgery.
Complications of cholecystectomy:
1-General complications:
As in any other surgery complications that may develop are
a)Complications of anaesthesia
b)Complications of surgery:
1- Bleeding: primary from slipped ligature of the cystic artery.
Reactionary bleeding is due to raise of blood pressure after recovery.
Secondary bleeding is due to infection.
2- Infection of the wound: in form of cellulitis in the third and fourth
days or subcutaneous pus after the fifth day.
3- Deep infection as subhepatic, subdiaphragmatic abscess or
generalized peritonitis.
4- Injury to the duodenum.
5- Slipped ligature of the cystic duct leading to biliary fistula or
biliary peritonitis.
6- Common bile duct injury or accidental ligation leading to post
operative bile leak of jaundice.
7- Missing stone in the common bile duct leading to post operative
biliary colic or jaundice.
======================================
=================
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Self assessment
Hepato- biliary system
:Bile is formed -1
.a- After breakdown of haem to porphyrin in bone marrow
.b- By conjugation of biliverdin by the enzyme glucorinidase
.c- In the liver and made less alkaline in gallbladder
:Answer
c - The life span of the red blood cell is 120 days. Then it is – 1
broken down in bone marrow and haemoglobin is released. The
globin is taken back to the amino acid pool in the liver and the haem
moiety is broken down and its porphyrin ring enter in formation of
biliverdin which is carried back to the liver to for bilirubin. Bile in
hepatic ducts has a Ph 8.2. It is stored and concentrated in the gall
.bladder to a Ph 7.-7.6
:Bile is formed of -2
.a- Bile acid, bile pigment, cholesterol and phospholipids
.b- Bilirubin, cholesterol, phospholipids and bile salts
.c- Bile pigment, bile salts, water and cholesterol
.d- Cholesterol, bilirubin, bile salts, water and fatty acids
.e- Bile acids, cholesterol, bilirubin and phospholipids
:Answer
d) – As bile leaves the liver it is composed of 97% water, 1-2% ) – 2
bile salts, 1% bilirubin, cholesterol, and fatty acids, The gallbladder
.reabsorbs water, NaCl and bicarbonates
.The following is correct for gallstones -3
.a- Repeated attacks of malaria may lead to pigment stones
.b- Cholesterol stones are usually formed in sterile bile
.c- Mixed stones are usually due to inflammation or infection
:Answer
d) – Cholesterol stones make up to 6% of gallstones. They are ) – 3
usually solitary, pale yellow in its pure form it is feebly translucent.
.Mixed stones constitute about 80 % of gallstones
:Acute calcular cholecystitis causes -4
124
.a- Dull aching continuous pain in right hypochondrium
.b- Colicky intermittent pain in the right hypochondrium
.c- Colicky pain in right hypochondrium with jaundice
.d- Severe pain that comes suddenly and disappears suddenly
.e- Epigastric pain that radiate to both hypochondria and back
:Answer
a) – Colicky pain in right hypochondrium is due to impaction ) – 4
and disimpaction in the Hartmann's pouch blocking the cystic duct.
Stone in CBD has colicky intermittent pain that comes suddenly and
disappears suddenly and radiate to the back. Pain like a belt is
.characteristic of acute pancreatitis
.The following may result in palpable tender gallbladder -5

.a- Mucocele of the gallbladder
.b- Empyema of the gall bladder
.c- Carcinoma of the head of pancreas
.d- Only a and b are correct
e- Only (b) and (c) are correct
:Answer
b) – mucocele occurs due to obstruction of the neck of the ) – 5
gallbladder by a solitary stone, bile is absorbed and mucus is
secreted in sterile conditions. In empyema the inflamed obstructed
gallbladder is filled with pus like cream of sterile calcium carbonate,
.cholesterol, and epithelial cells
:Causes of palpable gallbladder with jaundice include -6

.a- Carcinoma of the gallbladder
.b- Empyema of the gallbladder
.c- Carcinoma of the head of pancreas
:Answer
d) – In empyema and acute cholecystitis there is tenderness ) – 6
and guarding in the right hypochondrium associated with a tinge of
jaundice but in carcinoma of the gallbladder and head of pancreas
there is no tenderness or guarding in the right hypochondrium. In
mucocele the gallbladder may be palpable but the patient is not
.jaundiced
:In obstructive Jaundice due to common bile duct stone -7
125
.a- Indirect bilirubin and urobilinogen are absent in urine
.b- Direct bilirubin and urobilinogen are absent in urine
.c- The indirect is higher than the direct bilirubin in blood
.d- Alkaline phosphatase is slightly raised
.e- Liver enzymes are raised more than 3 times normal
:Answer
a) – In obstructive jaundice the indirect bilirubin is not water ) – 7
soluble and bile does not reach the intestine this is why both of them
are absent in the urine. Also in obstructive jaundice alkaline
phosphatase raises 3 times its normal level while liver enzymes (ALT,
AST) may get raised but slightly knowing that liver enzymes raises 10
.times their normal value
:Common bile duct stone may lead to-8

.a- Colicky pain in epigastrium radiating to the right shoulder
.b- Colicky pain in epigastrium radiating to the back
.b- Colicky pain in right hypochondrium
.c- Dull aching pain right hypochondrium
.e- Pain with sudden on set but subsides gradually
:Answer
b) – This is because the CBD is a midline structure opposite the ) – 8
vertebral column. Pain in right hypochondrium radiating to the
shoulder originate from the gallbladder. If it is colicky it is due to
obstruction at the neck of the gallbladder but if it is continuous it is
due to inflammation of the gallbladder. Sudden onset of epigastric
pain that subsides gradually may be due to perforated anterior
.duodenal ulcer
:Charcot's triad is -9
.a- Pain, jaundice and palpable gallbladder
.b- Pain, jaundice and contracted gallbladder
.c- Fever with rigors, jaundice and pain
.d- Jaundice, fever with rigors and vomiting
.e- Pain and jaundice with liver abscess
:Answer
c - It is due to cholangitis. Pain, jaundice and palpable – 9
gallbladder occurs in empyema while pain jaundice with contracted
126
gallbladder fulfills the Courvoisier's law, it is due to CBD stone.
Jaundice fever with rigors associated with nausea and vomiting is a
feature of viral hepatitis and may occur with multiple liver
.abscesses
:The following play a role in gallstone formation -10

.a- medical and surgical diseases of the terminal ileum
.b- Oestrogen of pregnancy and contraceptive pills
.c- Disturbance of the ratio of bile acids to cholesterol
.d- High levels of endogenous cholesterol
.e- All the above are correct in human beings
:Answer
e) – Bile salts are absorbed in the terminal ileum to start their ) – 10
entero-hepatic circulation. If bile salts were not absorbed they pass
to the colon to cause diarrhoea. There is a fixed ration of bile acids
to cholesterol (25: 1) in which cholesterol remains soluble therefore,
if there is reduction in bile acids or salts cholesterol will deposit
.forming stones. Hormones also make this ratio lithogenic
Complications of stones in common bile duct include -11

.a- Cholangitis
.b- Liver abscess
.c- Liver failure
.d- Acute pancreatitis
.e- All above are correct
:Answer
e) – The commonest cause of liver abscess are cholangitis and ) -11
portal pyaemia. Obstructive jaundice leads to secondary biliary
.cirrhosis and in presence of cholangitis liver failure occurs
127
1. Upper G.I. bleeding.
2. Lower G.I. bleeding
Upper G. I. Bleeding (Vomiting of blood)

Causes of severe bleeding (Haemorrhage):-
a. Oesophageal varices
b. Gastric varices (fundal)
c. Posterior duodenal ulcer
Causes of upper GIT bleeding
d. Carcinoma of the stomach
e. Gastric erosions
f. Mallory Weiss syndrome
g. Drugs (Aspirin (NSAID); alcohol)
h. Oesophagitis
i. Periampullary cancer
j. Zollinger-Ellison syndrome
128
Lower G. I. Bleeding
(starts from duodeno-jejenal junction down to the rectum & anal canal):-
Causes of lower GIT bleeding:-
a. All causes of upper G. I. Bleeding
b. Meckel’s diverticulum (commonest cause of massive lower G. I. Bleeding
in children)
c. Intussusception  red current jelly
d. Arterio-venous malformations
e. Small intestinal tumours (Leiomyomas)
f. Crohn’s disease
g. Typhoid fever
h.Carcinoma of caecum (ulcerative type)→occult bleeding and anaemia
i. Angiodysplasia
- affects ascending colon
-affects elderly patients >70 years
-severe haemorrhage
j. Diverticulosis
- affects descending colon
- severe haemorrhage
- pt in 40-50 years of age.
k. Ulcerative colitis
-commonly affects sigmoid and rectum
-very high frequency of bloody mucoid diarrhoea and loss of
weight.
l. Dysentery  tenesmus mucus and blood
m. Intestinal bilharziasis  tenesmus mucus and blood
n. Anal canal:
anal fissure  severe pain during defecation with bright red
blood in stools.
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Haemorrhoids  painless bright red bleeding after defecation.
Diagnosis of lower G. I. Bleeding:-
1. Blood mixed with stool → colonic cancer
2. Blood (bright red + pain) → anal fissure
3. Blood (bright red without pain) → haemorrhoids
4. Stool for occult blood if present possible cancer
5. Colonoscopy – for emergency heavy bleeding if the cause is not
identified in an elderly patient → -remove the right colon
(Angiodysplasia) in young patient
- remove the left colon (Diverticulosis)
6. Barium enema is not helpful in cases of severe bleeding.
Management of a patient with upper G. I. Bleeding

(oesophageal varices)
1. Resuscitations:
A– patency of airways should be checked by:-
•Cleaning the mouth from clots. This must be done after
wearing of gloves. If the patient can talk →patent
airways.
• Feeling for air current using the dorsum of the hand
near the patient’s mouth and nose.
• If air current is not felt → that means there is
obstruction by a clot → proceed for suction.
• If suction failed → intubation + endotracheal tube
and Ambo-bag ventilation
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B-Breathing: Checked by chest movement.
If both sides moves equally or one side moves
less or there is shallow breathing, auscultation for
air entry, if collapsed → suction by tube or
bronchoscope.
C-Circulation:
1- I.V canula → take blood sample for Hb%, blood
2- grouping and cross matching
3- Fluid replacement: Ringer lactate or normal saline.
4- Vasopressin 20 units in 200 ml normal saline over 20 minutes
and to be repeated in more diluted doses under cardiac monitor because it
causes vasoconstriction that may affect the coronary artery of the heart.
Vasopressin leads to generalized vasoconstriction and hence reduces the
arterial inflow to the splanchenic area drained by the portal system i.e.
reduces overfilling of the portal system and therefore reduces the portal
venous pressure.
5- Start with upper GIT to confirm and treat or exclude causes of
upper GIT bleeding. If oesophageal varices are found proceed for
sclerotherapy.
6- If endoscopy is not available insert Sengstaken tube. It should be
introduced through the nose, inflate the gastric balloon with 250 ml. air
and pull the tube upward to compress the fundus of the stomach against
the diaphragm– this should be felt till next morning (Balloon tamponade).
If the patient continues to produce blood per mouth then inflate the
oesophageal balloon with only 60 ml air to prevent tear of the oesophagus.
In the morning deflate the balloon and leave the tube in place. If bleeding
recurs reinflate the balloon and prepare the patient for surgery. If bleeding
stopped remove the tube next morning i.e. after 24 hours from deflation.
This is because the highest chance for rebleeding is in the 24 hours
following the initial bleeding because most of the clotting factors and
131
clotting factors were already consumed in the clotted vomited blood
(state of consumptive coagulopathy)
2. Endoscopy in the next day after removal of the tube if not
bleeding → sclerotherapy if available or ligation by rubber band
3. Surgical ligation of gastric veins and splenectomy (Hassab’s
operation) if endoscopy and sclerotherapy and ligation is not done.
The veins to be ligated during surgery :-
1.Left. gastric veins
2.right gastro-epiploic vein
3.left. Gastro-epoplic vein
4.short gastric veins
5.splenic vein and splenic artery plus splenectomy.
4. β -blockers drugs (propranolol) 40 TDS till the pulse is
decreases by one third to reduce the portal venous pressure.
5. Vit. K – injection to correct prothrombin time
6. Fresh frozen plasma (FFP) if liver cirrhosis is present because
the hepatocites are diseased in cirrhosis and the will not form clotting
factors from vit K
7. Iron replacement
Child’s Classification
This is done for selection of patient suitable to undergo
surgical treatment for oesophageal varices and to predict their
.outcome
Score 1 2 3
Bilirubin <2mg/dl 2-3mg/dl >3mg/dl
Albumin >3.5gm/dl 3-3.5mg/dl <3mg/dl
Ascites None Minimal Gross
Encephalopathy None Present Present
Nutrition Normal Loss of weight Loss of weight
132
The sum of the scores
Child’s class A = 5-7
Child’s class B = 8-9
Child’s class C = 10 or more
Class - A - surgical treatment can be done with good results

Class – B - surgical treatment can be done with poor result
Class – C - no place for surgery
Complications of oesophageal varices:-

1.Ascites
2.Encephalopathy (Hepatic precoma due to reabsorption of ammonia
splitted from the blood in the intestine by bacteria).
3.Liver cirrhosis or periportal fibrosis– jaundice
4.Liver failure
5.Upper and lower GIT haemorrhage.
133
Self assessment
134
Gastrointestinal bleeding
:The following are causes of liver cirrhosis EXCEPT-1

.a- Intestinal bilharziasis
.b- Alcohol indulgence
.c- Hepatitis B and C infection
.d- Haemochromatosis
.e- Primary biliary cirrhosis
:Answer
a) – Schistosoma mansoni leads to periportal fibrosis and not ) – 1
cirrhosis. Primary biliary cirrhosis occurs in females as an
autoimmune disease; however, longstanding biliary obstruction also
results in biliary cirrhosis. Wilson's disease which is a copper
storage disease also results in cirrhosis. Long standing congestive
.cardiac failure also leads to liver cirrhosis
:The following is known to cause massive haemorrhage – 2

.a- Gastric cancer
.b- Anterior duodenal ulcer
.c- Mallory-Weiss syndrome
.d- Posterior duodenal ulcer
.e- Oesophagitis with ulceration
:Answer
d) – Causes of massive upper gastro-intestinal haemorrhage ) – 2
include bleeding from oesophageal varices and from the gastro-
duodenal artery in posterior duodenal ulcer. Anterior duodenal
ulcers are famous of perforation and peritonitis
:The following occurs after portal hypertension bleeding -3

.a- The spleen becomes smaller in size
.b- Platelets and WBCs are reduced
.c- Ascites may develop
.d- Bleeding may recur next day
:Answer
135
e) – In presence of high portal pressure the spleen become ) –3
congested with a large volume of blood (congestive splenomegaly).
So, during haematemesis the spleen becomes less congested due to
loss of blood and hence becomes smaller or even impalpable. All the
blood elements will be lost in vomitus therefore haemoglobin,
platelets, white blood cells and proteins are reduced very much. It is
a state of consumptive coagulopathy in which all elements are
consumed in vomitus of blood. For this reason do not diagnose
.hypersplenism in the few days following haematemesis
:Benefits of Sengstaken- Blakemore tube include –4

.a- Tamponade of the gastric fundal varices
.'b- Compression of abdominal oesophagus
.c- Compression of oesophageal varices
.d- Wash of the stomach and instillation of drugs
:Answer
e) – The commonest site of bleeding in portal hypertension is ) – 4
the lower oesophageal varices because at this area the varices are so
superficial just below the basement membrane of the cells of the
mucosa. The gastric balloon when inflated with 250 cc air and pulled
it will compress the fundus of the stomach and the abdominal
oesophagus against the diaphragm. The oesophageal balloon should
not be inflated unless haematemesis continues after inflation and
traction of the gastric balloon. The oesophageal balloon should not
be inflated with more than 60 ml air otherwise the oesophagus may
get torn. The stomach should be washed of blood so that any further
new bleeding will detected from the nasogastric portion of the tube.
Drugs such as lactulose should be delivered through the nasogastric
portion of the tube to get rid of the blood from the intestine to prevent
absorption of urea and ammonia. Also lactulose inhibits growth of
bacteria that split urea and allow growth of bacteria that survive on
.starch
:At the sites of porto-systemic anastomosis -5

.a- Bleeding occurs from fundal and oesophageal varices
136
.b- Caput medusa develops radiate from the umbilicus
.c- Retroperitoneal veins become dilated and tortuous
.d- Rectal varices and haemorrhoids are not common
:Answer
e) – Caput medusa are due to re-canalization of the Tere's ) – 5
ligament (obliterated left umbilical vein in the falciform ligament
passing from the umbilicus to the liver).It carries the blood from the
portal system to the subcutaneous veins that radiate away to both
axillary veins and femoral veins. Rectal varices and piles are
communication between the superior haemorrhoidal veins
(tributaries of inferior mesenteric vein) and the middle rectal and
inferior rectal veins that pass to the internal iliac vein as part of the
.systemic circulation
:In treatment of bleeding oesophageal varices-6
.a- Vasopressin leads to arterial vasoconstriction
.b- β- Blockers (Propronalol) reduces portal pressure
.c- Normal saline should only be given in hypotension
.d- Fresh frozen plasma and vitamin K help in coagulation
:Answer
e) – In bleeding varices we would like to reduce but not to stop ) – 6
the inflow of arterial blood in the intestine to reduce the distension in
the portal veins. This is achieved by using vasopressin which causes
severe generalized vasoconstriction. Therefore a cardiac monitor is
required to watch for evidence of coronary artery spasm. β- Blockers
relax the portal veins and therefore reduce the pressure inside the
portal veins. Normal saline is used in hypotension because sodium is
retuned in the extracellular fluid (blood) keeping water with it
therefore helping to correct hypovolaemia and hence hypotension. If
the blood pressure is not low use of normal saline is contra-indicated
in chronic liver disease because of fear of salt and water retention
and development of ascites because of the secondary
hyperaldosteronism due to failure of breakdown of aldosterone by the
diseased liver. Fresh frozen plasma is helpful in cases of post
hepatitis cirrhosis where the hepatocites are diseased and can not
.utilize vitamin K to form clotting factors
137
Patients involved in Road Traffic Accident (RTA) are either pedestrians
(walking on foot), bicycle or motor cyclists, or driving cars or passengers.
.Multiple injuries also occur in fall from height
The death (Mortality) rate is very high in the first hour of the accident.
Therefore, the main aim is to treat life threatening problem first and as early as
.possible
The most important is to secure air and oxygen for the brain otherwise the
patient may end in brain death in few minutes. The first hour in management is
.called The Golden Hour to support the life of victims of trauma
On receiving the multiple injured patient we start with the
:Primary Survey as follows
:Airway -1
If the patient is talking or making sounds the airway is patent. If that is not
.the case feel for air current from the nose or mouth of the patient
If there is no air current the first thing to do is to open the mouth by Chin
Lift or Jaw Thrust and suck the secretions, blood, vomitus and remove foreign
.bodies from the larynx
If still there is no air current assume presence of cervical injury and with ON-
Line Traction Of the head and neck insert an endotracheal tube and put an
air way by its side so that the patient will not bite and therefore obstruct the
.endotracheal tube and supply oxygen by an Ambo-Bag
:Breathing-2
The first thing to do to maintain breathing is to inspect the chest and close
sucking wounds because these sucking wound act like a valve in one direction
and lead to tension pneumothorax. The danger of tension pneumothorax is
that it pushes the mediastinum to the opposite side of the chest causing lung
collapse and kinking the great vessels particularly the short Inferior Vena Cava
which will be obstructed reducing the venous return to the heart and resulting in
.cardiac arrest
The second thing to do is to auscultate the chest for air entry. If this is
absent or diminished in one side check for the trachea and apex of the heart if
they are pushed to the other side proceed for percussion of the chest if there is
hyper resonance on the affected side diagnose tension pneumothorax and insert
a Wide Bore Needle in The Second Intercostal Space Just Outside The Mid
clavicular Line to avoid injury to the great vessels. Later inset a Chest tube in
the Fifth Intercostal Space in the Mid Axillary Line and connect it to an
.Under-water Seal Bottle
138
If there is stony dullness the cause is Haemothorax proceed for insertion of
.chest tube as mentioned above
:Circulation -3
The first thing to do to maintain the circulation is to stop active external
bleeding by packing and bandaging. Then insert 2 wide bore canulae in
forearm veins, take blood for grouping and cross matching and start normal
.saline or ringer's lactate fluid. Check pulse and blood pressure
If the patient is hypotensive proceed for 4 Quadrant Needle Aspiration of
the Abdomen to check for internal bleeding as the cause of hypotension or do
Diagnostic Peritoneal Lavage by inserting a tube in the abdomen. Infusing 2
litres of saline and drain the fluid and take it for analysis for RBCs, WBCs, Bile
.and Amylase
If there is evidence of bleeding or injury to a Hollow Viscous (intestine) the
.patient is for laparotomy
:Disability-4
This means inability to move due to Coma from head injury, Spinal injury,
Peripheral nerve injury or Fracture of bone. It is tested be asking the patient
to move his limbs in order. If he can not do that pinch him and he may
.withdraw his limb because of the painful stimuli of pinching
If still he can not move his limb check for fractures. If there is fracture put the
limb in a splint (Thomas splint for fracture femur or posterior slap for other
.fractures. Splinting will reduce the pain and bleeding at the fracture site
:Exposure-5
Expose the patient and look for evidence of blood in the external urethral
meatus, perineal haematoma or tear, examine the rectum for high over-riding
prostate. All these are contraindications for insertion of Foley's urinary catheter
If there is no injury insert Foley's catheter to monitor the input ant out put of
the fluids. With Log Rolling inspect the back for injuries and for haematoma in
.the loin. Then re-cover the patient to prevent hypothermia
Head injury
More than 60% of deaths due to car accidents are due to head injury.
Therefore one of the most important responsibility of treating doctors is to
correct ventilation and hypovolaemia to prevent the permanent SECONDARY
BRAIN DAMAGE due hypoxemia.
Anatomy of the scalp:
139
S: Skin
C: Dense Connective Tissue: This prevents vasoconstriction of blood vessels.
Therefore the bleeding does not stop easily and the patient may loose
significant volume of blood.
A: Aponeurosis (galea aponeurotica)of the occipito-frontalis muscle: If the
cut end of this aponeurosis is grasped by artery forceps and reflected on the skin
it will help compress and help sealing and stopping of bleeding vessels.
L: Loose areolar tissue: This helps the galea aponeurotica to slide over the
pericranium (Periostium of the vertex – calvaria - of the skull. Allot of blood
may collect in this areolar tissue particularly in a newborn delivered by forceps.
The collected blood will expand the scalp (Caput Sucssedaneum) and the
newborn may require blood transfusion.
P: Pericranium: which is the periostium covering the external surface of the
bones of the skull.
Types of head injuries:

A- Scalp injuries:
1-Abrasions
2- Contusion.
3- Laceration.
B-Fracture of bones of skull.
C- Brain injury:
1- Diffuse axonal injury
2- Internal bleeding (Haematoma):
a-Extradural haematoma.
b- Acute subdural haematoma.
c- Chronic subdural haematoma.
d- Intra-cerebral haematoma.
Management of the scalp injuries:

140
1- This exactly like management of wounds elsewhere in the skin. However if
the periostium, bone or brain is exposed we have to excise the edges of the
wound (wound excision) and apply wide sutures without tension to prevent
tissues like periostium, bone and nerve tissue from drying up and hence
necrosis.
2- The patient should be covered with antibiotics to prevent meningitis.
3- Tetanus immunization according to the status of the patient immunization.
Skull fractures:
Like other fractures these may be:
1- Simple linear fractures.
2- Compound fractures: when the bone is exposed by wound
laceration
3- Comminuted fractures: with more than one line of fracture. The
bone may become depressed compressing the surface of the cortex of
the brain. This may lead to epilepsy. Pieces of the fractured bone or
other foreign bodies (shrapnel) may enter into the brain substance.
Management of skull fractures:
1- Linear fractures: are dangerous when they cross sites of blood
vessels causing tear in these vessels leading to extradural haematoma. In
such cases the patient should be admitted for observations. Further
management depends on development of complications like deterioration
in level of consciousness and neurological defects.
2- Compound fractures:
a- should be thoroughly cleaned and sutured to prevent
exposure of bone and brain substance.
b- Antibiotics such as penicillin, gentamicin and
chloramphnicol to prevent meningitis.
c- Epanutin to prevent epilepsy.
141
3- Comminuted fracture:
a- Great care should be taken to remove bone fragments and
shrapnel.
b- Depressed fractures should be elevated.
c- Cover with antibiotics and antiepileptic drugs.
Concussion
This is a transient loss of consciousness i.e. for few minutes after which
the level of consciousness returns back to normal.
It might not be associated with any bleeding or nervous disruption. All
patients with history of concussion should be admitted to hospital for
observation because some of these patients may have a slow collecting
intracranial haematoma and their level of consciousness may deteriorate
later on. The period of clear consciousness after concussion may be
deceptive. Therefore it is called the lucid interval.
Coup and counter coup

The brain is like a tree with a trunk which is the brain stem (mid
brain, pons and medulla oblongata). It is surrounded by the meninges (dura
mater with subdural space in which some veins pass from the sulci of the
cortex to the venous sinuses below the skull), arachanoid matter with
subarachnoid space containing cerebrospinal fluid and pia matter covering
the sulci and gyri of the brain.
Any violent movement of the head is associated with movement of the
brain and the brain substance may sustain contusion at the site of the impact
of the trauma (Coup injury) or the brain substance may hit the bone of the
skull on the opposite site resulting in contusion (Counter coup injury)
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Extradural haematoma
This occurs when the fracture line crosses a blood vessel like the middle
meningeal artery that enters the skull through the foramen spinosum and
groove the inner table of the skull at the temporal bone in its course to the
vertex and the parietal bone. Bleeding from the torn vessel collects out side
the dura mater (endocranium-Periostium) and gradually compresses the
temporal lobe of the brain where the motor area and sensory area lie.
Clinically the patient may give history of transient loss of consciousness
(concussion). This is followed by complete regaining of consciousness. As
the haematoma increases it compresses the occulomotor nerve (the third
cranial nerve that passes behind the temporal lobe in its course to the pupil.
Mild compression result in excitation of the occulomotor nerve at the site of
the trauma (ipsilateral site) resulting in papillary constriction because the
nerve carry parasympathetic fibres to the pupil. If the haematoma increases
more compression of the nerve results in paralysis of the occulomotor nerve
and the ipsilateral pupil becomes fully dilated because it remains under
action of the sympathetic nerves that follow the ophthalmic artery to the eye.
Further expansion of the haematoma will compress the cerebral
hemisphere on that side and will gradually compresses the tough tissue of
the falx cerebri to compress the other (contralateral) cerebral hemisphere
resulting in compression of the contralateral occulomotor nerve leading to
dilatation of the pupil on the other side and compression of the brain stem
(mid brain, pons and medulla oblongata) to herniate through the tentorium
cerebri. Since the brain stem contains the vital centres like the vasomotor
and respiratory centres, bradycardia, hypertension and irregular pulse occur.
Also the respiration becomes deep and rapid followed by a period of apnoea
(Chyne-Stokes breathing).
Since the skull in the adult has closed sutures, brain oedema leads to
compression of the cerebrospinal fluid containing areas like the middle and
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lateral ventricles of the cerebral hemispheres. Then compression of vein and
later arteries occur. Accumulation of carbon dioxide (CO2) leads to venous
vasodilatation and this will increase the intracranial pressure more and more.
For this reason rapid deep breathing occurs till CO2 is completely washed
out. But the drive of the respiratory centre is CO2. This is why when CO2 is
washed out by raped deep breathing respiration stops and a period of apnoea
occurs. In this period of apnoea CO2 accumulates again and it start driving
the respiratory centre leading to deep rapid breathing.
At this stage the high intracranial pressure leads to convulsions and deep
coma.
Bilateral dilated fixed pupils not reacting to light is a late sign indicating brain
stem compression and herniation that occurs before death.
Management of extradural haematoma:
1- Start examination of the multiple injured patients by examining and
maintaining air way, breathing, circulation and on assessing disability:
a- Look at the temporal regions. If there is contusion this indicate
fracture in the temporal bone, tear of the middle meningeal artery with
extravasation of blood out side the skull below the fascia of the
temporalis muscle and deeply as extradural haematoma.
b- Look for level of consciousness by asking the patient to
open his eyes and to move an arm or a leg. If he couldn't obey your
command he is probably suffering from either fracture or peripheral
or central nervous injury to that site. Apply painful stimuli and see
his response. Noting his response you will have an idea about the
level of consciousness of the patient.
c- Examine the eyes for size of both pupils and their reaction to
light.
d- Conduct a rapid neurological examination for hemiplegia. The eye
signs and neurological examination may give you a clue on the site
of brain injury (lateralization signs).
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Head injury is usually associated with high blood pressure therefore don't
assume that hypotension is due to head injury. If there is hypotension think
of internal bleeding and correct it before hypotension leads to low blood
perfusion of the brain resulting in irreversible secondary brain damage due
to hypoxia.
2-Maitain air way supply the patient with oxygen and aim at
hyperventilation by mechanical ventilator to wash out CO2 to reduce venous
vasodilatation to reduce the high intracranial pressure.
3- Insert i.v. canula in a forearm vein and give as minimal fluids as
possible adding manitol to induce osmotic diuresis to reduce the brain
oedema.
4- Request CT scan: look for the central line (Falx cerebri) if it is deviated
from the central line. Look for the lateral ventricle if is compressed.
Haematoma always is seen as radio-opaque.
5- Consult the neurosurgeon for evacuation of the haematoma through a
burr hole or craniotomy.
6- Care of the unconscious patient:
a- Care of the skin by turning the patient from side to side every 2 hours
in order to prevent bed sores and if available use air mattress.
b- Nutrition through a nasogastric tube. In order to prevent aspiration
from gastric contents always suck the tube before each meal to find out if the
previous meal has passed down or it is still in the stomach.
c- Care of sphincters by using Foley's urinary catheter or condom
catheter to prevent bed wetting that enhances maceration of the skin.
d- In put out put charts, vital signs (pulse, BP, RR and temperature) and
Glasgow Coma Scale to determine if the level of consciousness is improving
or not
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.
*Exteradural haematoma
Acute Subdural Haematoma

In this injury as the brain moves in side the skull as a result of violent
movement or trauma of the head, some of the veins passing from the cortex
to the superior sagital sinus may get torn and bleed. This bleeding
accumulates in the subdural space leading to haematoma that may compress
the temporal or parietal lobe of the brain.
The patient may present with transient loss of consciousness
(concussion) with a lucid interval and later passes in deep coma with similar
mechanism of pupilary changes, contra lateral hemiparesis or hemiplegia
and if not treated ends with brain stem herniation as mentioned in extradural
haematoma with similar effect on vasomotor and respiratory centres.
Management: As in extradural haematoma.
Chronic subdural haematoma

Has the same mechanism of injury as acute subdural haematoma but
commonly it occurs in elderly patients as a result of trivial trauma that pass
146
unnoticed and the blood collects slowly. After few days the patient may
develop change in behaviour or hemiparesis.
The corner stone for correct diagnosis is proper neurological
examination where signs of lateralization as mentioned above will be found.
CT scan will confirm the diagnosis and the chronic haematoma will be seen
as precipitated blood below a thin fluid with a level in between.
Management as mentioned in extradural haematoma.
*chronic subdural haematoma
Diffuse axonal injury

In this condition severe oedema develops without obvious localized
haematoma. It is always associated with severe loss of consciousness with
elevated blood pressure (Coma).
Intracerebral haematoma
The patient present with severe brain oedema and coma. CT scan may shoe
blood in side the cerebral hemisphere or inter ventricular haemorrhage.
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Chest injury
Like trauma elsewhere in the body trauma to the chest is either penetrating
or blunt trauma. Remember the diaphragm ascend to the fifth rib during
inspiration. Therefore, trauma below the fifth rib may lead to injury of the
diaphragm, liver and/or spleen.
Trauma to the chest is diagnosed and treated at the phase B (Breathing).
Most of chest injuries can be treated by the doctor who first sees them.
We have to identify the following immediately life-threatening injuries
during the primary survey:
d. Airway obstruction.
e. Open pneumothorax.
f. Tension pneumothorax.
g. Massive haemothorax.
h. Unstable Flail chest.
i. Cardiac tamponade.
Also, we have to identify the following potentially life-threaten injuries

during the secondary survey:
1- Pulmonary contusion.
2- Myocardial contusion.
3- Injury to the diaphragm.
4- Tracheo-broncheal injury.
5- Aortic injury.
6- Oesophageal injury.
1- Airway: because hypoxia is the most serious complication of chest

injury assessment and maintenance of the patency of the airway as
mentioned previously is extremely important.
2- Breathing: Expose the chest of the patient and:
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*First seal sucking wound. If there is open wound in the chest wall air
tend to follow the least resistant i.e. it is sucked into the pleural cavity
during inspiration therefore effective ventilation is impaired and
hypoxia results.
* Sealing of the wound should be done with gauze and the plaster
should be applied at only three sides so that during inspiration gauze
is sucked into the wound to prevent air from entering the pleural
cavity and during expiration gauze is puffed away from the chest wall
to allow air to escape out of the pleural cavity.
3- Tension pneumothorax: This occurs when there is a wound in
the lung or the chest wall acting like a one-way –valve allowing air to
accumulate in the pleural cavity during inspiration. *Accumulation of
air in the pleural space leads to collapse of the lung on that side and
further accumulation of air lead to shift of mediastinum. This results in
deviation of the trachea and apex of the heart to the opposite side and
kinking of the great vessels particularly the inferior vena cava. Kinking
of inferior vena cava reduces the venous return and may lead to cardiac
arrest. Therefore, listen to air entry. If air entry is reduced in one side
then proceed for percussion if it is hyperresonant then there is
pneumothorax. Look for tracheal deviation and displacement of the
apex of the heart. These make the diagnosis of tension pneumothorax
correct. To treat the patient insert a wide bore canula in the second
intercostals space lateral to the mid clivicular line to avoid injuring
the aorta and superior vena cava. The second step is to insert an
intercostals tube in the fifth intercostals space just anterior to the mid
axillary line. Then connect the tube to under-water seal bottle.
4- Massive haemothorax: This is defined as drainage of 1500 cc
blood immediately or drainage of 200 ml blood per hour after insertion
of a chest tube. It is diagnosed by finding a diminished air entry by
auscultation and stony dullness on percussion. *Massive haemothorax
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result from major vascular injury in the chest but rarely requires surgery
(thoracotomy) to stop the bleeding.
5- Flail chest: This is defined as presence of more than one fracture
line in one rib or more ribs anteriorly leading to an isolated segment of
the anterior chest wall to move in the opposite direction of the
movement of the chest wall.
* There is no flail if the fracture is in the posterior chest wall because the
free segment is well fixed by the strong muscles of the back and lying on
the back does not allow movement of that segment.
*The anterior fractures allow the segment to be sucked in while the chest
wall is expanding outwards during inspiration (negative intra-thoracic
pressure). So, by moving inwards it prevents full expansion of the lung at
the site of the fracture during inspiration. Also, during expiration (positive
intra-thoracic pressure) the flail segment moves outwards while the chest
wall is moving inwards. This also interferes with the recoiling of the lung
during expiration so that not enough carbon dioxide is expired. This
reversed movement is called paradoxical movement. If the flail segment
is big it interferes with mechanics of chest expansion and leads to serious
hypoxia.
Management: If the flail segment is small supply oxygen by face
mask and give adequate analgesia. If there is hypoxia insert an endo-
tracheal tube and connect it to mechanical ventilator to ensure enough
pressure and adequate oxygen delivery to the affected lung.
6- Cardiac tamponade: the pericardial sac around the heart is made

of a tough fibrous tissue that does not expand. Penetrating and blunt
trauma e.g. from steering wheel trauma to the chest of a car driver may
lead to fracture of the sternum or contusion of the heart resulting in
bleeding. Accumulation of blood in the pericardial sac reduced filling
of the ventricles during diastole. This results in low cardiac out put. The
superior vena cava will be distended with blood and the vessels of the
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neck will also be engorged. Auscultation of the heart reveals distant
faint (muffled) cardiac sounds.
Managenment: the blood can be aspirated with a wide cannula inserted
through the xiphisternum towards the pericardial sac.
The potentially fatal injuries

These should be looked for in the secondary survey. They are injuries
to 2 organs i.e. heart and lung contusion and 3 tubes i.e. aorta, major
bronchi and oesophagus.
1-Pulmonary contusion: Blunt trauma may lead to rib fractures that puncture
the lung. In young persons and particularly in children the ribs are so soft that
blunt trauma reaches the lungs and the ribs spring back without fracture.
Lung contusion result in bleeding inside the lung tissue with the
inflammatory oedema of trauma the lung becomes congested, heavy and does
not expand or recoil efficiently. In presence of inflammatory oedema of trauma
the alveolar membrane becomes thick and the exchange of oxygen and carbon
dioxide will be impaired. The result is severe hypoxia.
The appearance on X-ray is the same appearance of consolidation i.e. whitish
soft tissue shadow in the lung. The treatment if there is hypoxia is mechanical
ventilation till resolution occurs.
2- Myocardial contusion: Blunt trauma to the sternum may result in
myocardial contusion. This is suspected whenever there are irregularities in the
pulse or the ECG monitor in a patient with trauma. It is managed as acute
myocardial infarction with the assistant of the cardiologist.
3- Major bronchial injury: This is associated with massive subcutaneous
emphysema and continuous bubbling in the underwater seal bottle. It requires
bronchoscopy and thoracotomy to suture the tear in the major bronchus.
4- Aortic injury: this results in bleeding in the mediastinum leading to
widening of the mediastinum in the chest X-ray. Because the arch of the aorta
passes down and to the left of the vertebral column there will be some blood in
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the left costo-phrenic angle as well as deviation of the left main bronchus
downward. Treatment is by repair of the tear after aortic angiogram.
5- Oesophageal tear: This is more common in trauma during endoscopy
however it may occur spontaneously. There will be some fluid in the left costo-
phrenic angle with air in the mediastinum. Gastric contents or food particles
may appear in the chest tube. Treatment is thoracotomy and repair of the tear.
Fracture of ribs
The strongest rib is the first rib. Fracture of the first and second ribs may be
associated with injury to subclavian artery and vein or injury to the brachial
plexus.
The commonest rib to get fractured is the seventh rib because it has a big
circle making it the most prominent rib laterally.
Fractures of the ninth, tenth and eleventh ribs may be associated with injury
to the liver or spleen.
Fracture of ribs is common at the angle of the rib posteriorly however lateral
fractures of the ribs lie tangentially in the extreme lateral side of the rib is
difficult to be seen in the A-P X-ray.
To diagnose pneumothorax ask yourself in every chest X-ray is that a lung?
If there are vascular markings then it is a lung. If there are no vascular shadows
then it is most likely a pneumothorax. If there is pneumothorax find out a
lightly faint curved line towards the mediastinum. This will be the lateral border
of the collapsed lung.
In trauma if there is a straight air fluid level in the chest X-ray then there is
haemo-pneumothorax.
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surgical emphysema
===================================
Abdominal trauma
Like elsewhere trauma to the abdomen is either inflicted by blunt or

penetrating injuries. Remember the diaphragm rises up to the fifth rib during
expiration. Therefore any penetrating injury or blunt trauma below the nipple
may penetrate the diaphragm and injure the liver, spleen, stomach and/or the
colonic flexure.
Trauma to the abdominal wall is seen as abrasions; contusion, laceration and
the force may pass inside leading to:
1- Laceration of a solid organ (Liver, spleen, kidney or pancreas).
2- Rupture of a hollow viscous (small intestines, colon or
distended urinary bladder).
3- Laceration of a blood vessel (mesenteric blood vessel, aorta,
vena cava, or their branches).
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Since abdominal trauma leads to severe internal bleeding and hypovolaemic
shock, examination of the abdomen comes immediately after the maintenance
of airway and breathing i.e. it is part of assessment of C (circulation).
After examination and correction of A(airway) and B (breathing) the first
thing to do in assessing C (Circulation) is to stop obvious external haemorrhage
by applying pressure by gauze and bandage. Then and only then we insert 2
wide bore short canulae in forearm veins and start as a rule either normal saline
or Ringer's lactate. We insert the i.v canula at this stage because in any further
delay the patient may go into shock and veins will be difficult to find.
After securing i.v. lines then we examine the pulse and blood pressure (in
well equipped emergency rooms the patient is connected to monitors that
straight ahead read the pulse, blood pressure, respiratory rate and temperature).
After checking the pulse and blood pressure we examine the abdomen as
part of the circulation. Examination of the abdomen is by:
1- Inspection of abrasions, contusions or lacerations from the fifth
intercostals space down to the pelvis.
2- Palpation for tenderness and guarding.
3- If the patient has low blood pressure we do 4 quadrants tap i.e. we
insert a needle and aspirate in each hypochondrium and each iliac fossa.
If we obtained blood by aspiration then the patient has internal bleeding
that explains his hypotension. If we didn't obtain blood then we do
diagnostic peritoneal lavage (DPL) which is better to diagnose intra-
abdominal bleeding.
The diagnostic peritoneal lavage (DPL):

1- Put the patient in slight head down position so that the intestine
will lie near the diaphragm so that no intestine is injured during the
procedure.
2- Insert Foley's urinary catheter to empty the urinary bladder to
avoid injuring a distended urinary bladder during the procedure.
154
3- Clean the abdomen with disinfectants (Chlorohexidine followed by
alcohol or providone iodine) and apply sterile towels (drapes) around
umbilicus.
4- Inject local anaesthetic (Xylocaine 2%) below the umbilicus and
incise below the umbilicus a one centimetre long incision down the
peritoneum.
5- Insert a sterile tube down to the pelvis and infuse about 2 litres
normal saline or Ringer's lactate.
6- Gently shake the patient from side to side to mix the fluid with
blood if there is internal bleeding.
7- Put the last bottle infused below the patient so that the fluid drains
back from the abdomen in to the bottle.
8- If blood is obtained then the patient has internal bleeding and
laparotomy is to be planned for to stop bleeding.
9- If no blood is obtained look for food particles, and test for bile and
pancreatic amylase to diagnose hollow viscus injury.
Indications for diagnostic peritoneal lavage:
1- Hypotension in a multiple injured patient. (Remember hypoxia
causes hypotension and head injury causes high blood pressure).
2- Coma and quadriplegia where the patient looses sensation and can
not show tenderness or guarding).
Contra-indications for peritoneal lavage:
1- If already decision was taken for laparotomy, don't waste time in
doing DPL.
2- Advanced pregnancy or suspected portal hypertension.
Advantage of DPL over CT-scan of the abdomen:
DPL is faster, safer, more accurate to reach a decision for laparotomy or not and
can be done in all patients whether the BP is stable or not.
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Splenic injuries
1- Subcapsular haematoma.
2- Small laceration.
3- Severe laceration.
4- Avulsion from the vascular pedicle.
Treatment is splenectomy. In very few cases bleeding may stop and the blood
pressure remained stable.
Complications of splenectomy:
1- Bleeding: primary, reactionary or secondary.
2- Acute gastric dilatation and for this reason a naso-gastric tube
should be inserted during operation and should not be removed before 24
hours.
3- Subdiaphragmatic abscess.
4- Left pleural effusion with left lung basal atelectases.
5- Post splenectomy sepsis which remains as a hazard life long. For
this reason the patient after splenectomy should receive prophylaxis
against malaria and long acting penicillin (benzathine penicillin) monthly
particularly against pneumococcal infection otherwise should receive
pneumococcal vaccination.
Liver injuries
It occurs in the form of Subcapsular haematoma, minor or major
laceration. If bleeding did not stop spontaneously laparotomy and suturing
or packing of the bleeding area should be done.
Retroperitoneal haematoma
During laparotomy a retroperitoneal haematoma may be found. It is either:
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1- Central retroperitoneal haematoma due to trauma to the
aorta, inferior vena cava, or fracture of the pelvis.
2- Lateral retroperitoneal haematoma due to injury of the
kidney.
Hollow viscus injury

This is due to rupture of the small or large bowel. It causes severe abdominal
pain with guarding and board-like rigidity of the abdomen. It is discovered after
DPL when food particle, bile or amylase is found in the fluid.
Treatment is laparotomy and suturing of the tear in the small intestine and
exteriorization of the torn area in the large bowel as colostomy. Such colostomy
can be closed 3 months later.
**Indications for blood transfusion in trauma:

1- Pulse 120/min, Low BP systolic 100 or less, respiratory rate
30/min or more, anxious or irritable patient (irritability could be due to
pain, hypotension with low brain perfusion or hypoxia).
2- Blood pressure drops or remains low in spite of infusion of 2 litres
of normal saline or Ringer's lactate.
Urological trauma
Renal injuries
It is due to penetrating or blunt trauma. Types of renal injuries:
1-Subcapsular haematoma: The patient feels pain but his general condition
and blood pressure remains normal. Usually it doesn't require treatment.
2- Cortical laceration not reaching the pelvis of the kidney: This leads to
perinephric haematoma but no haematuria. The haematoma may expand in
the renal angle causing an expanding mass in the lumbar region and
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hypotension. The expanding lumbar haematoma is seen during the phase of
exposure (E) when log rolling of the patient is done to see the back.
3- Laceration of the medulla of the kidney:
This causes total haematuria with out expanding lumbar haematoma.
4-Laceration extending through the capsule and medulla of the kidney:
this leads to both haematouria and expanding lumber haematoma:
5- Avulsion of the pedicle of the kidney: this lead to expanding lumber
haematoma but no hamaturia because the avulsed ureter goes into spasm.
Management:
Generally conservative management will be successful in most of the
patients. Indications for surgery are persistent hypotension and/or expanding
lumbar haematoma.
Conservative management: By admission to hospital for close observations
of the BP and haematuria. The urine should be collected every day and the
amount of the blood is compared whether it is increasing or decreasing.
Operative management is indicated if the BP remains low or bleeding is
increasing. Emergency IVU should be done to see the other kidney whether
it is present and normally functioning or not.
Laparotomy is done through the anterior abdominal wall to control the renal
vessels first.
The tendency should be towards suturing of the tears and nephrectomy
should be done only if the life of the patient is threating by the
uncontrollable bleeding.
Injuries to the ureter

This is suspected if there is a fracture in the transverse process of a lumbar
vertebra in blunt trauma, and in difficult pelvic surgery like emergency
hysterectomy for a ruptured uterus and deep pelvic surgery for cancer like
carcinoma of the rectum. Loin pain and tenderness are the usual complaints.
158
Ultrasound will detect collection of fluid (urinoma) or hydronephrosis at
the site of injury. IVU may show the site of injury if the kidney on the same
side is functioning otherwise retrograde pyelogram will demonstrate the site
of injury.
Management:
1-If injury is discovered during surgery it can be repaired over a double J
catheter or T-tube.
2- If injury is discovered late then implantation of the upper segment of the
ureter into the dome of the urinary bladder can be done directly or using a
flab from the bladder or a loop of small bowel to connect the ureter when it
is too short to the urinary bladder.
Injuries to the urinary bladder

Aetiology: Blunt and penetrating injuries usually to the distended (full of
urine) urinary bladder.
These are 2 types:
1- Intraperitoneal rupture of the urinary bladder: sudden rupture
of the distended urinary bladder at the dome of the urinary bladder may
be due to blunt trauma, stab or bullet injury. Also it may occur as
complication of transurethral resection of urinary bladder tumours. The
leak of urine in the general peritoneal cavity leads to severe abdominal
pain and the patient may go into shock.
Abdominal examination reveals distension, tenderness and guarding. The
suprapubic area of the urinary bladder is tender but resonant on percussion.
After insertion of Foley's urinary catheter no urine will be obtained.
Ultrasound detects intraperitoneal fluid in the presence of empty urinary
bladder.
Aspiration of this fluid for analysis will show level of urea >1000mg/dl
which is the character of urine. Delay in management will lead to peritonitis.
159
Therefore early laparotomy for closure of the tear in the urinary bladder
should be done, and the bladder should be decompressed with a catheter for
10 days to allow healing without tension. The patient should be covered with
antibiotics.
2- Extraperitoneal rupture of the urinary bladder:

This is usually associated with fracture of pelvis like fracture separation
of the symphysis pubis (dislocation of this fibrous joint) or fracture of the
pubic rami. During exposure phase of examination of multiple injured
patient (E) perineal haematoma will be seen. In rectal examination severe
tenderness is found anteriorly. Foley's catheter may drain bloody urine. The
tear can be demonstrated with leak of contrast in the cystogram phase of
IVU.
Management:
laparotomy, suture the tear and drain the urinary bladder by catheter and
drain the retropubic area to prevent infection.
Urethral injury
This is the commonest type of urinary injury in male patients. The male
urethra has 3 parts namely the bulbar urethra in the shaft of the penis, the
membranous urethra passing through the pelvic diaphragm and the prostatic
urethra surrounded by the prostate.
The commonest type of trauma to the urethra is by medical
instrumentation i.e. catheterization, dilatation of urethral stricture, and
cystoscopy in the inexperienced hands.
Types of injuries:
1- Injury to the bulbar urethra: This injury occurs when a person
fall astride (with wide abducted legs) on a hard object like ladder or
metal bars in buildings, manhole etc. The bulbar urethra is compressed
and injured between the pubic bone and the hard object. The patient has
160
pain and swelling at the shaft or root of the penis. Some blood will be
seen at the external urethral meatus. The patient will be unable to pass
urine. In the presence of blood at the tip of the urethra catheterization is
contraindicated because if the tear is not involving the whole
circumference of the urethra catheterization may make it complete
circumferential tear.
Management:
Suprapubic cystostomy and few weeks later cystogram and ascending
urethrogram should be done to assess the urethra, see the site of injury
and the urethra is partially torn it will heal and will require only
dilatation. If complete transection has occurred then urethroplasty is
indicated.
2- Injury to the membranous urethra:

This injury occurs on trauma leading to fracture separation of the
symphysis pubis or fracture of the pubic rami. The membranous urethra
is torn and the prostate is pulled upwards
There is contusion or haematoma in the perineum with a drop of blood
in the external urethral meatus. As mentioned before presence of perineal
haematoma and blood at the tip of the urethra makes catheterization
contraindicated.
During rectal examination the prostate will found too high to be
examined by finger (high overriding prostate).
Management:
Suprapubic cystostomy and few weeks later cystogram and ascending
urethrogram should be done to assess the urethra, see the site of injury
and the urethra is partially torn it will heal and will require only
dilatation. If complete transection has occurred then urethroplasty is
indicated.
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Self assessment
:Trauma
:Death after trauma occurs -1

a- Only in the first few seconds due to crush of vital organs
b- Only in the first hour because of hypotension and hypoxia
c- Only after few days due to sepsis
d- All the above are correct i.e. it is trimodal
e- Only (a) and (b) are correct
:Answer
d) – All are correct, therefore the first hour after arrival to the casualty is ) – 1
.the golden hour to diagnose and treat promptly the live threatening injuries
:At the site of the accident the emphasis should be on -2

A- Maintenance of airway only
b- Control of external bleeding only
c- Proper immobilization of the patient
d- All the above are correct
e- Only (a) and (b) are correct
:Answer
d) – all are correct. Immobilization of fractures will reduce pain, ) – 2
.haemorrhage at the site of fracture haematoma, and prevents soft tissue injury
:Always assume there is cervical injury if there is -3

.a- Multisystem injuries
b- Depressed level of consciousness
.c- Blunt injury to the clavicle
.e- Only a and b are correct
:Answer
d) – this is why during maintenance of airway cervical collar should be ) – 3
applied and during insertion of endotracheal tube in-line-traction should be
applied by one person while the second person opens the mouth by chin lift or
jaw thrust, suck the secretions elevate the base of the tongue with a
laryngoscope and inserts the endotracheal tube in between the vocal cords into
.the trachea
162
:In resuscitation of the multiple injured patient the best fluid is -4
.a- Pack cells blood group O Rhesus positive
.b- Whole blood group O Rhesus negative
.c- Blood group specific whole blood
d- Sodium bicarbonate to correct metabolic acidosis
.e- Plasma expander as dextran
:Answer
c - whole blood of the same group of the patient can be used with out cross – 4
matching in emergency. Blood group O positive or negative contain anti A and
anti B in the serum , therefore if it is requested it should be pack cells although
in trauma whole blood is required to correct hypovolaemia. Remember for
rhesus negative females above 45 years of age rhesus positive can be used to
save life if RH negative blood is not available and further precautions are to be
.taken in future transfusions
:ECG monitor abnormality after trauma may be due to -5

.a- Myocardial contusion
.b- Cardiac tamponade
.c- Tension pneumothorax
.d- Hypothermia
:Answer
e) – also fracture ribs, chest pain, shivering, and thoracotomy may lead to ) – 5
.some ECG abnormalities
:Insertion of Foley's urinary catheter is contraindicated in presence of -6

.a- Blood stain in external urethral meatus
.b- Scrotal and/or perineal haematoma
.c- If perineum and rectum were not examined
:Answer
d) – Because partial injury of the urethra may coexist in these cases it is ) – 6
.better to proceed to suprapubic cystostomy
:The first X-ray to be ordered after trauma is -7

.a- Skull X-ray to exclude head injury
.b- Cervical spine antro-posterior view
.c- Cervical spine lateral view
.d- Lateral Chest for fracture of sternum
.e- Open mouth X-ray for C1 odontoid fracture
:Answer
c - Cervical spine lateral view, Chest X-ray and X-ray of the pelvis should – 7
.be ordered just after finishing the primary survey
:The first step in management of airway in trauma is -8
163
.a- Chin lift and/or jaw thrust
.b- Suction of secretions, vomitus, blood and foreign bodies
.c- Crico-thyroidotomy or tracheotomy
.d- Oxygen jet through a canula in the trachea
.e- Look for voice or air current
:Answer
e) – If the patient is breathing adequately then there is no need for further) – 8
.manipulations
.
:The earliest signs of impending hypovolaemic shock are -9
.a- Low blood pressure with thready pulse
.b- Pale worm sweaty skin with tachycardia
.c- Tachycardia with cold sweaty extremities
.d- Tachycardia with collapsing pulse
.e- Absent radial pulses with hypotension
:Answer
c - These are signs occur at the phase of the body response to stress before – 9
decompensation and hypotension occurs. Resuscitation should be started at this
stage of compensation otherwise the patient may go into shock and even
refractory shock with metabolic acidosis when it becomes extremely difficult to
.save the patient
:The first step in management of breathing in trauma is -10

.a- To administer high oxygen concentration
.b- To ventilate with Ambo bag or face mask
.c- To treat tension pneumothorax
.d- To seal open pneumothorax
:Answer
d) – All these steps are correct but the very first step is to close sucking ) – 10
wounds which work in a one way valve fashion leading to tension
pneumothorax. However all trauma patients should receive oxygen till prove
.otherwise
:The method preferred in assessment of breathing in trauma is -11

.a- Inspection of chest movement in both sides
.b- Auscultation of breath and heart sounds
.c- Palpation for subcutaneous air or bony crepitus
.d- Percussion for hyper resonance or dullness
.e- All the above are certainly correct
:Answer
.e) – All are correct. During inspection do not forget flail chest ) – 11
:The best diagnostic procedure for intra-abdominal injury is -12
164
.a- Inspection of contusions and lacerations
.b- auscultation for bowel sounds
.c- Palpation for tenderness and guarding
.d- Diagnostic peritoneal lavage
.e- Ultrasonic scanning or CT scan
:Answer
d) – DPL is accurate, has over 90% sensitivity and specificity. It should ) – 12
be done in all patients with hypotension particularly if the patient is
unconscious or quadriplegic because he does not show symptoms or signs of
intra-abdominal injury. However, It is contraindicated in cases of previous
.abdominal surgery, portal hypertension and advanced pregnancy
:The cause of death from airway problems could be -13

.a- Ignoring stridor of partially obstructed airway
.b- Delay in securing definitive airway surgically
.c- Delay in providing assisted ventilation
.d- Missing aspiration of gastric juice or blood
.e- All the above are undoubtedly correct
:Answer
e) – One should be keen not to miss all these conditions otherwise the ) – 13
patient's condition may suddenly deteriorate
:In the multiple injured patients -14

.a- Agitation suggests hypoxia
.b- Drowsiness suggests hypercarbia
.c- Cyanosis suggests anoxaemia
.d- Use of accessory muscles suggests airway obstruction
:Answer
.e) – And restlessness may be due to pain of injury or retention of urine ) – 14
:In trauma crico thyroidotomy or tracheostomy is indicated in -15

.a- Presence of central cyanosis or apnoea
.b- Failure to maintain oxygen by face mask
.c- Mechanical ventilation for more than a week
.d- In severe facial and throat injuries
.e- All the above are definitely correct
:Answer
e) – All are correct. However crico-thyroidotomy is preferred in cases of ) – 15
.emergency because it is easy and not time consuming as tracheostomy
:When tension pneumothorax is suspected the next step is -16

.a- Confirmation by chest X-ray
165
.b- Insertion of an intercostals tube
.c- Insertion of a wide bore canula in the chest
.d- Insertion of a wide bore canula in the trachea
.e- Insertion of an endotracheal tube
:Answer
c) – Diagnosis of tension pneumothorax is on clinical grounds. A wide ) – 16
bore canula should be inserted to deflate the chest through the second
intercostals space outside the midclavicular line to avoid injury to the great
.vessels
:Death in tension pneumothorax is due to-17

.a- Compression and collapse of the lung
b- Compression of the ventricles of the heart
.c- Stopping of venous return to the heart
.d- Poor movement of the diaphragm
.e- Chest pain induced by tension pneumothorax
:Answer
c - Kinking of the inferior and superior vena cava stops the venous return – 17
.and leads to cardiac arrest because of failure of filling the ventricles
:the best way to say the chest tube is functioning is -18

.a- Air bubbles in the under water seal bottle
.b- The fluid in the tube is swinging with deep breathing
.c- Air bubbles come only with cough
.d- The under water seal bottle contain blood
.e- The chest tube stops draining
:Answer
.b) Absence of bubble does not mean the tube is not functioning ) – 18
.In Chest trauma -19

.a- Fracture of first and second ribs suggests fracture of cervical spine
.b- Fracture of first and second ribs suggests major vascular injury
.c- Fracture of the 9th and 10th ribs suggest liver or splenic injury
.d- Posterior comminuted rib factures does not cause flail chest
e- All the above mentioned facts are undoubtedly correct
:Answer
e) – Posterior segmental fracture of ribs does not move because they are ) – 19
splinted by the strong paravertebral muscles and the bed of the patient so that
.they do not move outwards
:In a Chest X-ray of a patient with trauma to the chest -20

.a- Fracture of ribs may not be seen in standard chest X-ray
166
.b- Surgical emphysema may suggest fracture of ribs
.c- Pneumothorax is diagnosed by absence of vascular markings
d- Centralization is important before diagnosing tension pneumothorax
e- All the above mentioned facts are clearly correct
:Answer
e) – commonly ribs fracture at their neck posteriorly. Lateral fractures ) – 20
are tangential to the X-ray and may not be seen. Fracture separation at the
.costo-chondral junction of the rib will not be seen
In infants and children the ribs are so soft that they do not fracture while the
.force of trauma may lead to lung injury
:Fatal injuries of the chest include -21

.a- Tension pneumothorax
.b- Massive Haemothorax
.c- Cardiac tamponade
.d- Unstable flail chest
:Answer
e) – Massive haemothorax is defined as bleeding through chest tube at a ) – 21
rate of 200ml/hour or 1500 ml came out immediately after insertion of the chest
tube. Massive haemothorax may require thoracotomy to control the bleeding
vessel
Self assessment
Urology
:Pain arising at the kidney is -1

.a- Severe colicky pain at the renal angle
.b- Dull ache at the costo-vertebral angle
.c- Dull pain at the right hypochondrium
:Answer
167
d) – Severe colicky pain in the renal angle is due to stone in a ) – 1
calyx or stone at the pelvi-ureteric junction. Dull aching pain is due
to pyelonephritis or hydronephrosis. The renal pain is referred to the
.right hypochondrium
:strangury is -2
.a- Severe suprapubic pain radiating to tip of urethra
.b- Suprapubic pain and straining resulting in bloody urine
.c- Pain and intense desire resulting in only few drops of urine
.d- May result from a stone in intramural portion of the ureter
:Answer
e) It is common when the ureteric calculus is in the intramural ) – 2
.portion of the urinary bladder. It also, occur in urinary bilharziasis
:The high urinary frequency is due to -3
.a- In complete emptying of urinary bladder
.b- Irritation of the urinary bladder mucosa
.c- Fibrosis and contraction of the urinary bladder
.d- High diuresis or sphincter weakness
.e- All the above reasons cause high frequency
:Answer
e) – Nocturnal frequency occur in prostatic enlargement ) – 3
because of incomplete emptying of the urinary bladder ( residual
urine). Irritation of the trigone of the urinary bladder by vesical
stones occurs during walking leading to diurnal frequency while
irritation by infection increases the frequency day and night. Also
frequency increases in presence of bladder tumours, diabetes,
.diuretics and in anxiety
:Rectal pain referred to perineum and/or hypogastrium is -4
.a- Due to infection of prostate or seminal vesicles
.b- Due to carcinoma of the rectum near the anal sphincter
.c- Due to inflammation of a pelvic appendix
.d- Due to Pelvic abscess
.e- Due to prolapsed thrombosed piles
:Answer
a) – carcinoma in the ampulla of the rectum lead to feeling of ) – 4
incomplete defecation plus blood streaks over the surface of each
168
piece of stools while a tumour near the sphincter leads to tenismus
and if it encroached on the anal canal it causes pain during
defecation like that of anal fissure but it will be continuous pain.
Pelvic appendicitis and pelvic abscess lead to pain in hypogastrium
and diarrhoea. If thrombosed piles became infected may lead to
.portal pyaemia and liver abscess
:High frequency at night only is due to all except -5

.a- Urinary bladder calculus
.b- Benign prostatic hyperplasia
.c- Diabetes Mellitus
.d- Cystitis cystica
.e- Neurogenic bladder
:Answer
a) - Irritation of the trigone of the urinary bladder by vesical ) – 5
.stones occurs during walking leading to high diurnal frequency
:Terminal haematuria is due to -6

.a- Gonorrheal urethritis
.b- Bilharzial infection
.c- Stone in middle of the ureter
.d- Impacted stone in the Urethra
.e- Tumour at dome of urinary bladder
:Answer
b) – Causes of terminal haematuria are in the region of the ) – 6
trigone and neck of the urinary bladder while initial haematuria is
.caused by diseases of the urethra
:In haematuria -7
.a- If occurs only once should not be ignored
.b- Few RBCs in urine deserve thorough investigations
.c- Painless haematuria may be due to malignancy
.d- Some drugs may cause red urine simulating haematuria
:Answer
e) – Presence of any number of RBCs in urine should be ) – 7
.thoroughly investigated because of the fear of cancer
:In urinalysis -8
169
.a- Alkaline reaction occurs in patients taking antacids
.b- Alkaline reaction occurs in infection by Proteus vulgaris
.c- Alkaline reaction occurs in pyloric stenosis
.d- Alkalinization by potassium citrate helps to treat E coli
:Answer
e) – In result of urinalysis urine reaction should not be ) – 8
.ignored
:Blood urea more than 50mg/dl may be due to -9

.a- Impairment of more than 50% of renal function
.b- Dehydration
.c- Presence of blood in the intestine
:Answer
d) – Urea rises only when more than 50% of the renal function ) – 9
is impaired. It also increases in dehydration and is absorbed from the
.blood in the intestine
:During examination of a patient with any urological disease -10
.a- It is important to measure BP
.b- It is vital to examine the chest and the Chest X-ray
.c- The CVS and ECG should be cautiously examined
:Answer
d) – Renal disease leads to hypertension that affect the heart ) – 10
and renal failure that leads to water overload and pulmonary
.oedema
:The benefits of requesting midstream urine is -11

.a- It avoids contamination as far as possible
.b- It is without the risk of catheterization
.c- It is the best sample for Schistosomiasis
:Answer
e) – In urinary schistosomiasis the patient should be ) – 11
.instructed to give the last portion of the urine for analysis
170
:The renal impairment occurs when -12
.a- The renal plasma flow is reduced in hypertension
.b- The glomeruli are damaged in glomerulonephritis
.c- The tubules are impaired in pyelonephritis
.d- Hydronephrosis impairs plasma flow, glomeruli and tubules
:Answer
.e) – This is the pathophysiology of renal failure ) – 12
:Intravenous urography (IVU) is contraindicated in -13
.a- Blood urea >100mg/dl or Creatinine >3mg/dl
.b- Allergy to iodine
.c- Multiple myeloma
:Answer
e) – High blood urea does may give faint delayed excretion of ) – 13
contrast and precipitation of the myeloma proteins may lead to renal
.failure
:Anuria is defined as -14
.a- An excretion of less than 700 ml of urine in 24 hours
.b- An excretion of less than 500 ml of urine in 24 hours
.c- An excretion of lass than 100 ml of urine in 24 hours
.d- An excretion of no urine what so ever in 24 hours
.e- Varying specific gravity between 1.002 – 1.025
:Answer
b) – the minimum urine to excrete toxins of metabolism is ) – 14
500ml/24hrs. In renal failure the kidney fails to concentrate urine
. therefore the specific gravity becomes fixed to 1.010
:Causes of pre-renal anuria include -15
.a- All cases of hypotension with systolic BP < 70mmHg
.b- Spinal anaesthesia
.c- Compartment syndrome
.d- Incompatible blood transfusion
:Answer
e) – The commonest complication of spinal anaesthesia is ) – 15
hypotension which when very low leads to acute tubular necrosis
171
while in compartment syndrome and incompatible blood transfusion
myoglobin and haemoglobin respectively precipitate and block renal
.tubules
:In intravenous urography (IVU) there is -16

.a- Delayed renal function if nothing is seen in 6 minutes
.b- Lower ureteric obstruction if the whole ureter is seen
.c- Reflux in the ureters may be seen during micturition
.d- Post micturition films show the residual urine
.e- All of the above are correct
:Answer
e) – failure of seeing a nephrogram in 6 minutes indicate ) – 16
delayed renal function. The normal ureter should be seen in relaxing
.and segments during peristalsis
:Symptoms of acute renal failure include -17

.a- Loss of appetite with or without hiccough
.b- Recurrent vomiting with or without abdominal distension
.c- Thirst and dry skin with or without raised blood pressure
.d- Confusion with flapping tremors and irregular breathing
e- All the above are correct
:Answer
e) – because symptoms of uraemia are not specific it is )– 17
..commonly missed unless one has a high index of suspicion
:In post-renal (calcular) anuria -18

.a- Renal pain may disappear gradually
.b- Headache, sleeplessness and constipation may develop
.(c- Lassitude (fatigue- feeling ill
.d- Blood urea may reach 200mg/dl
:Answer
e) – Calcular anuria is an emergency condition which should ) – 18
be treated with retrograde catheter to by pass the obstruction or by
.percutaneous nephrostomy
:If urine is not passed few hours after surgery -19

.a- Examine the suprapubic region for full urinary bladder
172
.b- Insertion of Foley's catheter
.c- 1 liter i.v. if no urine is obtained by catheterization
.d- More fluids and diuretics to augment diuresis
:Answer
e) – The cause is either inability to pass urine (Retention) or ) – 19
.hypovolaemia due to failure of correcting losses during surgery
:Causes of post-renal anuria include -20

.a- Bilateral urinary calculi
.b- Retroperitoneal fibrosis
.c- Emergency hysterectomy
.d- Malignant pelvic tumours
:Answer
e) – All led to bilateral ureteric obstruction. Also, urinary ) – 20
bilharziasis leads to calcification and obstruction of the lower
.ureters
:In Horse-shoe kidney -21

.a- Infection is the main presenting symptom
.b- A mass may be felt in front of the vertebral column
.c- In IVU the lower calyces face medially
d- The adrenals develop separately in their normal position
:Answer
e) – Infection and stone formation is common in all abnormal ) – 21
.kidneys
:Patients with congenital polycystic kidneys present with -22

.a- Pain due to tension in a cyst or dragging of big swelling
.b- Haematuria due to rupture of a cyst in renal pelvis
.c- Infection (pyelonephritis) is the commonest presentation
.d- Hypertension with or without uraemia
173
:Answer
e) – Polycystic kidney could be part of polycystic disease ) – 22
involving the lung, liver, and pancreas. Usually patients present in
their forties with hypertension, hypertensive heart failure or
.uraemia
:Causes of unilateral hydronephrosis include -23

.a- Congenital pelvi-ureteric obstruction
.b- Tumour in the urinary bladder
.c- Stricture of the ureter
.d- Impacted stone in the ureter
:Answer
e) – Also tumour in colon, benign or malignant ureteric ) – 23
stricture (transitional cell carcinoma) lead to unilateral
.hydronephrosis
:Causes of bilateral hydronephrosis include -24
.a- Urinary bladder out let obstruction
.b- Bilateral ureteric obstruction
.c- Pelvic malignant tumours
.d- Pregnancy
:Answer
e) – Also benign or malignant prostate, urethral stricture, ) – 24
carcinoma cervix and rectal cancer lead to bilateral ureteric
.obstruction
:Causes of urinary stones are -25
.a- Dietary deficiencies as vitamin A deficiency
.b- Infection with urea-splitting bacteria
.c- In adequate urinary out flow resulting in stasis
.d- Prolonged immobilization in cases of paraplegia
:Answer
.e) – Also it occur in cases of hypercalcaemia ) –25
:The calcium oxalate stone -26

.a- Has sharp spikes that cause haematuria
174
.b- Is usually single and radio-opaque
.c- It present early with severe pain
:Answer
d) – Its surface may be dark because of precipitation of blood. ) – 26
.When it is fractured it is laminated
:The calcium ammonium magnesium phosphate stone -27

.a- Is smooth, soft, dirty white stone
.b- It develops in alkaline urine
.c- It present late with infection or renal failure
:Answer
d) – It is also radio-opaque. It is frequently seen obstructing ) – 27
both kidneys. The site with resent pain is functioning and should be
.relieved first
:The uric acid stone -28

.a- Is usually single hard stone
.b- Is a radio- opaque stone
.c- It is faceted reddish brown stone
.d- It forms staghorn calculus
.e- It has envelope –like crystals
:Answer
.c)- It is radio-lucent, usually present with severe colic ) – 28
:The renal pain is -29
.a- Located in the renal angle posteriorly
.b- May radiate to the ipsilateral hypochondrium
.c- Is aggravated by movement
:Answer
d) – Particularly stone in the pelvis of the kidney the pain is ) – 29
.aggravated by movement
:A stone in the upper part of the ureter may present with-30

175
.a- Severe intermittent colicky pain
.b- Pain that radiates from the loin to the groin
.c- Pain associated with strangury and vomiting
:Answer
e) – Strangury occurs in lower ureteric calculus when it is in ) -30
.the intramural portion of the urinary bladder
:A stone in the lower part of the ureter may present with -31
.a- Pain referred along the branches of the genitor-femoral nerve
.b- Pain and retraction of the testis
.c- Pain referred to the tip of the urethra
.d- Strangury
:Answer
e) – the pain radiate to the root of penis or clitoris and medial ) – 31
.aspect of the upper part of the thigh
:The ureteric stone should be removed urgently if -32

.a- The urine is infected
.b- Hydronephrosis is increasing
.c- When first seen is > 6mm in diameter
:Answer
.d) – should be removed to save the ipsilateral kidney ) -32
:The renal tumours -33

.a- Are found in upper or lower pole of the kidney
.b- Commonly metastasis to the bones and lungs
.c- May present with haematuria or fever
.d- May cause polycythaemia or haemoptysis
:Answer
e) – the first presentation may be haemoptysis due to canon ) -33
.balls in the lung
:The causes of urine retention in females include -34
176
.a- Retroverted gravid uterus
.b- Disseminated sclerosis
.c- Hysteria
:Answer
.d) – All are correct ) – 34
:Causes of acute retention in males include -35
.a- Injury or disease of spinal cord
b- Carcinoma of the prostate
.c- Urethral stricture
.d- Perineal surgery
:Answer
e) – Also heavy sedation reduces pain of retention ) – 35
:Complicatins of insertion of Foley's urinary catheter are -36
.a- Bactraemia
.b- False passage
.c- Ascending infection
:Answer
d) – Also rupture of urethra if the balloon is inflated in the ) – 36
.urethra i.e. before urine is obtained
:Causes of post operative retention of urine are -37

.a- Sedation
.b- Reflex spasm of urinary sphincters
.c- Latent enlargement of the prostate
:Answer
.d) – reflex spasm is due to pain from perineal surgery ) – 37
:Post catheterization ascending infection leads to -38

.a- Cystitis
.b- Prostatitis
.c- Epididymo-orchitis
177
.d- Pyelonephritis
:Answer
e) – Infection spread by lymphatics, blood stream and ) – 38
.through the lumen
:Stress incontinence due to weakness of urinary sphincters -39
.a- Is leak of urine during coughing and sneezing
.b- Is leak of urine in chronic retention of urine
.c- Is persistent leak of urine day and night
.d- Is leak of urine at night particularly in children
.e- Is leak of urine after prostatectomy
:Answer
a) – Leak of urine in chronic retention is retention with ) – 39
overflow. Persistent leak of urine occur in total incontinence in cases
of vesico-vaginal fistula and malignant vesicorectal fistula in males
while in damage to the urinary sphincters in pelvic disruption in
trauma. In children nocturnal enuresis is common. After
prostatectomy weakness or trauma to the sphincter may occur
particularly in TURP if the verumontanum which is a good landmark
.is injured
:Total incontinence is due to -40
.a- Severe epispadias
.b- Trauma to pelvic muscles and nerves
.c- Carcinoma of prostate and cervix
.d- Prolonged obstructed labor
:Answer
e) – Also acute exfoliative membranous cystitis as in cytotoxic ) – 40
chemical irrigation and tuberculus cystitis, fixation of sphincters in
cancer of cervix and prostate and meningo-myelocele, multiple
.sclerosis
:The primary urinary bladder calculus -41
178
.a- Is the stone that develop in sterile urine
.b- Often but not necessarily originate in the renal pelvis
.c- Develop in infection due to bladder out let obstruction
.e- Only a and b are correct
:Answer
e) – Stones that develop in infection particularly due to) – 41
bladder outlet obstruction as in prostate, posterior urethral valve and
bladder neck fibrosis are secondary stones. A cause of vesical stone
.should be searched for and treated
:Urinary bladder calculus present with -42
.a- Increased diurnal frequency
.b- Pain at end of micturition radiating to tip of urethra
.c- Terminal haematuria
.d- Acute retention of micturition
:Answer
e) – Also children scratch their penis frequently if they have ) –42
.vesical calculus
:Bilharziasis in the mucosa of the urinary bladder is seen as -43
. .a- Pseudo-tubercles and sandy patches
.b- Nodules and granulomas
.c- Ulceration or papilloma
.d- Squamous-cell carcinoma
.e- All the above
:Answer
e) – These can only be diagnosed by cystoscopy. Therefore if ) – 43
urinary bilharziasis is suspected clinically and the ova of schistosoma
could not be isolated the patient should be advised to undergo
cystoscopic examination of the urinary bladder for the fear of future
.squamous cell carcinoma of the bladder
:Bilharzial complications in the urinary system include -44
.a- A small contracted fibrotic urinary bladder
.b- Calcification of the urinary bladder
c- Calcification and stricture of the lower end of the ureter
.d- Bilateral hydronephrosis
179
:Answer
e) – Treatment of small contracted urinary bladder is by ileal ) – 44
conduit and treatment of hydronephrosis due to calcification of the
lower end of the ureter is ureteric implantation in the dome of the
.urinary bladder with or without submucosal tunnel to prevent reflux
Self assessment
:Vascular system
:The following is correct for an embolus -1
a- It is a foreign body moving in circulation from one site to
.the other
b- Arterial embolus is whitish because of platelets and
.atheroma
c- Amniotic fluid or membranes may lead to bleeding
.tendency
d- Fat and air embolus occur in trauma and pass to the lung
.and brain
:Answer
e) – Amniotic fluid or membranes may pass into the venous ) – 1
circulation leading to disseminated intravascular coagulation. Fat
embolism is a metabolic process in which chylomicrons aggregate
and pass to the brain resulting in deterioration in level of
180
consciousness and to the lung reducing the arterial oxygen
.saturation
:The following is correct for a thrombus -2
.a- It is dark soft clotted blood in arteries or veins
.b- Commonly it moves along the veins to the lungs
c- It is due to increase viscosity, reduced velocity or vascular
.disease
d- It is a cause of sudden death if it occludes the pulmonary
.trunk
:Answer
e) – In dehydrated elderly bed ridden patients thrombosis in ) – 2
situ in arteries or veins may occur. The cause of thrombosis is
increased viscosity, decreased velocity and blood vessel wall disease.
.These are called the Virchow's triad
:The causes of reduced blood velocity include -3

.a- Heart failure. or bundle branch block
(b- Dilated vessels (varicose veins or aneurysm
.c- Forgotten tourniquet or tight bandage or plaster
.d- Immobility in anaesthesia or in bed ridden patients
:Answer
e) – Also in acute vascular the embolus is followed by ) – 3
.propagating thrombus
:Increase blood viscosity occurs in -4
.a- Polycythaemia and leukemia
.b- Post-splenectomy thrombocytosis
.c- Dehydration and use of contraceptive pills
.d- Increased proteins, multiple myeloma and cancer
:Answer
e) – Primary polycythaemia (polycythaemia rubra vera) is a ) – 4
malignant bone marrow disease while secondary polycythaemia is
due to hypoxia from high altitudes, smoking, or chronic lung disease,
or carbon monoxide poisoning. In the 7th post splenectomy day
platelets count should be done if it is 1000,000 then start anti-
181
platelets in the form of aspirin or dipyridemole to prevent
.thrombosis
:The cardinal features of acute limb ischaemia include -5

.a- Severe pain of sudden onset
.b- The limb will be pulseless, pale and cold
.c- Parathaesia followed by paralysis
.d- Skin mottling and dry gangrene
:Answer
e) – Diagnosis of arthritis should not be relied on till the pulses ) – 5
.were examined
:The possible causes of acute limb ischaemia include -6
.a- Sudden embolus detached from heart, big arteries
.b- Trauma resulting in complete transection or thrombosis
.c- Missed tourniquet for more than 6 hours
.d- Thrombosis in an artery in an elderly patient
:Answer
e) – the source of embolus could be left atrium, mitral valve ) – 6
vegetations, site of left ventricular infarction, atheroma of the carotid
artery leading to transient ischaemic attacks or CVA, Aortic arch
plaque, aneurysm of abdominal aorta. About 80% of emboli lodge in
the lower limbs. 10% of emboli lodge in a cerebral vessel or in the
.upper limb
:The Sources of an embolus include -7
.a- Atrial thrombus in cases of atrial fibrillation
.b- Vegetations from mitral valve disease
.c- Embolus from site of ventricular infarction
.d- Atheroma from arch of aorta or abdominal aorta
:Answer
e) – Acute abdominal pain in presence of heart disease is ) – 7
.mesenteric thrombosis till proved otherwise
:In the control of anticoagulants -8
.a- APTT is used for control the dose of heparin
.b- PT and INR for control the dose of warfarin
c- Fresh frozen plasma and Vitamin K are antidotes for
182
.warfarin
.d- Aspirin is an anti-plate lets, it increases the bleeding time
:Answer
e) – Bleeding time (2-5minutes) is made prolong by ) – 8
thrombocytopenia and use of anti-platelets and in
Von Willebrand's disease while clotting (time 3-5 min) is prolonged
.with anti-coagulants and in hemophilia and Christmas disease
:Amputation of an ischaemic limb is indicated if there is -9

.a- Patchy skin mottling
.b- Black discoloration (dry gangrene) of the toes
.c- Clear and stable line of demarcation
.d- Blisters in the skin with swollen painful leg
.e- Lapse of 12 hours since the start of ischaemia
:Answer
c - All these are stages in acute limb ischaemia but amputation – 9
should be conducted when there is clear and stable line of
demarcation which is a red zone between the dead desiccated tissue
.and the viable tissue
:The claudication distance is -10
.a- The distance the patient can walk
.b- The distance after which the patient feels pain
.c- The distance at which the pain forces the patient to stop
.d- The distance at which the patient feels cramps in the calf
.e- The distance at which the patient feels breathless and stop
:Answer
c - All are features of intermittent claudication but the – 10
claudication distance is that forces the patient to stop because of a
cramp-like pain. After a minute or two the pain passes off. Allowing
.him to go on again
:The speed of ischaemia depends on-11

.a- The status of the heart
.b- The status of the collateral circulation
.c- Presence infection in lower limbs
183
:Answer
d) – The general health (heart failure, anaemia), the speed of ) – 11
walking, hills, and wind and ambient temperature all affect the
.claudication distance
:Signs of chronic limb ischaemia include -12

.a- When the leg is raised it become dusky pale and cold
b- When the leg is hanged down it becomes purple and
.warm
c- The leg becomes cold if exposed and warm when
.covered
.d- Presence of penetrating ulcer or gangrene in the toes
:Answer
e) – Buerger test is elevation causes pallor and dependency ) – 12
change the colour to purple. The angle of elevation at which pallor
.appears give a good idea about the severity of ischaemia
:High risk patients for lower limb ischaemia have-13
.a- Heart disease
.b- Heavy smoking for 20 years
.c- Hypertension and/or diabetes mellitus
.d- High serum cholesterol and triglycerides
:Answer
.e) – All lead to arteriosclerosis and ischaemia ) – 13
Pain in the buttock, thigh and calf in an elderly male is due -14
:to
.a- Occlusion of common iliac artery
.b- Root compression by prolapsed inter-vertebral disc
.c-Osteo-arthritis of the ipsilateral Hip and Knee
.d- Metastases from carcinoma of the prostate
:Answer
184
e) – Since the disease occurs at old age in such pain all ) – 14
possibilities should be searched well and one should avoid the bad
habit of writing analgesics like diclofenac and discarding the patient
to keep searching adamantly for the correct treatment among various
.doctors
:The following is correct in compartment syndrome -15

a- It is due to high pressure in muscles surrounded by tough
.skin
b- The high compartment pressure compresses the blood
.supply
c- Autolysis of dead muscles releases myoglobin in
.circulation
.d- Myoglobin blocks renal tubules leading to renal failure
.e- All the above are correct in compartment syndrome
:Answer
e) – Compartment syndrome occur in neglected ischaemia ) – 15
with gangrene in a muscle bulk not so peripheral in tendons, and in
.circumferential burn and in crush injuries
:The causes of compartment syndrome include -16

.a- Crush injury to a limb
.b- Circumferential burn
.c- Removal of an embolus from ischaemic limb
.d- Sudden release of a missed tourniquet
:Answer
e)- Treatment is fasciotomy, intravenous fluids, diuretics and ) -16
urinary alkalinizers with close monitoring, gradual release of missed
tourniquet, and amputation if the limb existence is threatening the
.life
:Management of acute limb ischaemia includes -17

.a- Embolectomy
.b- Artificial vascular graft
.c- Reversed vein graft
185
.d- Heparin and warfarin
.e- Aspirin as anti-platelets
:Answer
a) – Artificial (Dacron, Teflon or PTFE) and vein grafts are ) – 17
commonly used in chronic limb ischaemia. Anticoagulants apart of
streptokinase and tissue plasminogen activators and anti-platelets
.are not curative by themselves but they are adjuvant to surgery
:Treatment of compartment syndrome includes -18

.(a- Incision of skin and fascia over the muscles (fasciotomy
.b- Intravenous fluids to wash out myoglobin
.c- Alkalinization of urine by antacids and potassium citrate
.d- Correction of blood supply
:Answer
e) – close monitoring because cardiac arrest may occur from ) – 18
.acidosis and hyperkalaemia, Haemodialysis may be required
Differences between benign and malignant tumours
Benign malignant
Slow growing Generally rapidly growing
May have local pressure effect on May have local pressure effect on
surrounding tissues surrounding tissues and becomes fixed
Does not infiltrate but compress the infiltrate the surrounding (Skin or other
surrounding tissues tissues)
Has a well demarcated capsule Does not have a capsule due to local
infiltration
Does not spread Spread by lymphatics , blood stream and
transcoelomic.
186
Cells are normal, equal in shape Cells are different in shape and size. Have
and size. Have nuclei equal nuclei with different shape, size with
in shape, size and chromatin hyperchromatism and abnormal( tri-
density with normal bipolar polar) Spindle in mitosis
mitosis
Difference between carcinoma and sarcoma

Carcinoma Sarcoma
Occur in epithelium Occur in mesenchymal tissue
Generally affect old patients More common in young patients
Rapid growth Very rapid growth
Spread by lymphatic and blood Spread by blood stream
Sensitive to chemo-radiotherapy Not sensitive to chemo- or
radiotherapy
Aetiology of cancer
It is generally not known but predisposing factors are:
1-Genetic predisposition particularly in young adults as in hereditary familial
polyposis which is autosomal dominant leading to colorectal cancer.
2- Environmental factors:
a- Exposure to radiation in thyroid and skin cancer.
b- High fat and high protein diet as in colorectal cancer.
c-Smoking particularly pipe smoking as in lung, oesophageal
lip and urinary bladder cancer.
d- Alcohol as in gastric, pancreatic and colon cancer.
187
d- Infections leading to metaplasia as in Helicobacter pylori
e- Chronic inflammation as in ulcerative colitis
f- Chronic irritation as in unstable wound that breaks repeatedly after healing
as in Marjolin’s ulcer.
g-Soot as in carcinoma of scrotum in chimney sweepers.
h- Exposure to ultraviolet light as in melanoma and basal cell carcinoma
Self assessment
:Cancer prevention
Preventable precancerous conditions for oesophageal cancer -1

:include
.a- Hot alcohol consumption
b- Cigarette and pipe smoking
.c- Barrett's oesophagus
:Answer
d) – abstinence of smoking and beverage consumption prevent ) – 1
the cancer and endoscopic resection of Barrett's mucosa prevent
.transformation into cancer
Early detection and treatment of the following condition may -2

:prevent cancer
.a- Oesophageal webs
.b- Achalasia
.c- Barrett's oesophagus
:Answer
d)- Early treatment of oesophageal webs and achalasia may ) – 2
prevent cancer transformation or lead to early detection of cancer at
.a curative stage
188
:Preventable precancerous conditions of the stomach include -3
.a- Alcohol and smoking
.b- Helicobacter pylori
.c- Pernicious anaemia
:Answer
e) – Pernicious anaemia is an autoimmune disease ) – 3
characterized by absence of intrinsic factor secretion from the fundus
.of the stomach. It is rare in Sudan
Early detection and treatment of the following condition may-4

:prevent cancer
.a- Gastric polyps
.b- Mucosa associated lymphoid tissue
.c- Leiomyma
.d- Carcinoid tumour
Answer
e) – Therefore gastroscopy should be requested for any patient ) – 4
with dyspepsia particularly after the age of 40 years and one should
.drop the bad habits of prescribing omeprazole injudiciously
:Preventable precancerous diseases of the liver include -5
.a- Hepatitis B viral infection
.b- Haemochromatosis
.c- Afla toxin
.d- Alcoholic cirrhosis
:Answer
e) – Programs of hepatitis B vaccination has reduced the ) – 5
incidence of hepatoma in Hong Kong. More effort is to be exerted on
farmers to eradicate the fungus Aspergillus fumigatus that produce
Afla toxin in Ground nuts and Maize. Also abstinence from alcohol
and treatment of haemochromatosis prevents development of
.cirrhosis and hence hepato-cellular carcinoma
189
Knowing the following conditions may help in early detection -6
:of pancreatic cancer
.a- Alcoholic chronic pancreatitis
.b- Rich fat diet
.c- Adult onset of diabetes
.d- BRCA1, P19,9 and K-ras tumour markers
:Answer
e) – All these are conditions in which cancer of pancreas can ) – 6
.be suspected and looked for, for early diagnosis
Early detection of the following condition may prevent -7

:colorectal cancer
.a- Familial Polyposis Coli
.b- Dysplastic and adenomatous polyps
.c- Ulcerative colitis
.d- Villous adenoma of the rectum
:Answer
e) – These are 6 premalignant conditions. Colectomy is ) – 7
advisable before the age of 30 in ulcerative colitis and hereditary
familial polyposis coli. Polyps and villous adenoma should be
removed early. If the villous adenoma is 2 cm in diameter there is a
.high chance of malignant change in it
:The following procedures help to detect cancer early -8

.a- Haem-occult blood in stools
.b- Breast self examination
.c- Testicular self examination
.d- Cystoscopy in urinary bladder symptoms
:Answer
e) – However screening programs are costly, and they did not ) – 8
.so far decreased the mortality from cancer
190
Is a modified sweat gland composed of lobes and lobules in adipose
tissue and connective tissue. Ducts converge to form a lactiferous ducts
behind the nipple. Each duct has a lining epithelium surrounded by a
thin myoepithelial cell layer responsive to oxytocin, the hormone that
stimulates lactation.
:FIBROADENOMA
191
• The natural history of fibroadenoma:
• Over a 5 year period
o 50% increase in size
o 25% remain stable
• Risk of malignant transformation is approximately 1 in 1,000
.Treatment: Excise at any age if patient requests
( • The stroma (S) has proliferated and has little dense collagen, hence 1
the paler pink color compared to the surrounding stroma.
iant The green arrows point to the slit like ductal proliferation • G
."also called "Chinese characters
fi
:broadenoma
• Bimodal age presentation - teens & premenopausal

• More common in black
• Rapidly grow to a large size
• Present with pain, breast enlargement, nipple
displacement
• Characteristic shiny skin changes with dilated veins
PHYLLOIDES TUMOUR(2
• Occur in premenopausal women

• Vary from benign to locally aggressive
• Have cellular fibrous element
192
FIBROCYSTIC DISEASE OF THE BREAST(3
3 major findings: 1- Cyst formation of the ducts (C) 2.

2- Fibrosis of the stroma (f) 3- Apocrine metaplasia of
the epithelium of some of the ducts – hyperplasia nd
Intr
hypertrophy (arrows)
ctal adu
Papilloma of Breast
• This low power view demonstrates an intracystic proliferation.

• There is a proliferation of finger-like processes into the lumen.
• The fingers contain a fibrovascular stroma.
The lining epithelium contains duct epithelium and myoepithelial
cells
193
BREAST CYST
• 7% of women will develop a clinically palpable cyst

• Usually occurs in perimenopausal women
• May appear suddenly and are frequently painful
• Initial treatment is by simple aspiration
• Cytology should be performed if blood-stained aspirate

• Consider excision if:
Cyst recurs rapidly or repeatedly -1
Residual lump after aspiration -2
Breast infections
:Lactational breast abscess -1
• Usually due to Staph. Aureus.

• Attempt aspiration. If no pus give antibiotics
• If pus present consider incision and drainage
• Continue breast feeding from opposite breast
• No need to suppress lactation
:Non-lactational breast abscess-2
• Occur in periareolar tissue Culture yield - Bacteroides,

anaerobic strep, enterococci
• Usually manifestation of duct ectasia / periductal mastitis. It
occurs at 30- 60 year. The patient Often gives history of recurrent
breast sepsis
• Repeated aspiration is the treatment of choice with
Metronidazole and flucloxacillin
194
• Drain through small incision if non-resolving is major duct
excision
• Spontaneous discharge or surgical excision can result in
mammary fistula
BREAST ABSCESS
GYNAECOMASTIA (1
• Commonest condition affecting male breast
• Due to enlargement of both ductal and stromal tissue
• It is benign and often reversible
• Usually presents as unilateral non-tender breast enlargement
Aetiology
• Most cases are idiopathic
Physiological causes
1- Neonatal 2- Puberty 3- Senile
• Physiological causes are due to relative oestrogen excess
Pathological causes
1- Primary Testicular Failure
• Klinefelter's Syndrome
• Bilateral Cryptorchidism
• Mumps
195
2- Secondary Testicular Failure:
• Generalised hypopituitarism
3- Endocrine Tumours:
• Testicular
• Pituitary
4- Non-Endocrine Tumours:
• Bronchial carcinoma
5- Hepatic Disease:
•Cirrhosis
6- Drugs:
• Oestrogens and oestrogen agonists - digoxin, spironolactone

• Cimetidine.
Management
• Reassurance that it is a benign and self-limiting condition

• Treatment of any underlying cause
• If painful or embarrassing subcutaneous mastectomy
GYNAECOMASTIA*
196
Nipple discharge (2
Discharge can be elicited in approximately 20% of women by squeezing the

nipple. Nipple discharge can be regarded as physiological in the neonatal
period, lactation, pregnancy and hyperprolactinaemia
It can also represent duct pathology such as duct ectasia, duct papilloma and
breast cancer
-The nipple discharge can be unilateral or bilateral, from a single or multiple

ducts. It may have different colours.
(i)Galactorrhoea:
Galactorrhoea is milk secretion unrelated to breast feeding
Causes of Galactorrhoea
1- Physiological
- Mechanical stimulation
- Extremes of reproductive life
- Post lactation
- Stress
2- Pathological causes:
- Pituitary tumours
(ii)Coloured, opalescent discharge:
- Commonest cause is duct ectasia
(iii)Blood-stained discharge:
- Risk of malignancy increases with age
- 12% of breast cancers present with nipple discharge
197
- 70% of cases of blood-stained discharge have either a duct papilloma or
breast cancer
*Nipple discharge
:Management
A detailed history will often indicate the underlying cause. Breast

examination is often normal. Haemostix can be used to test for the presence
of blood. Nipple smear cytology is rarely useful. Mammography should be
performed in all women over 35 years. Ultrasound may identify retroareolar
lesions. If a lump is present it should be removed. Malignancy can not be
excluded. In young women excision of the bleeding duct is indicated. In
older women proceed for total duct excision
WHO Classification
• Epithelial
o Non-invasive
 Ductal carcinoma in situ (DCIS)
 Lobular carcinoma in situ (LCIS)
o Invasive
 Ductal (85%)
 Lobular (1%)
 Mucinous (5%)
 Papillary (<5%)
 Medullary (<5%)
198
• Mixed Connective tissue and Epithelial
• Miscellaneous
Diagnosis and assessment
•Most symptomatic cancers present as a painless lump

• Breast pain is an uncommon presentation of breast cancer
• Diagnosis is by Triple Assessment
o Clinical Evaluation – Lump and regional nodes
o Imaging (ultrasound if <35 years old or mammography if >35
years oldFine Needle Aspiration Cytology or excision for
Histopathology
• Cytology is reported as:
o C1 = Inadequate sample
o C2 = Definitely benign
o C3 = Probably benign
o C4 = Suspicious of malignancy
o C5 = Definitely malignant
Aims of breast cancer surgery
• To achieve cure if excised before metastatic spread has occurred

• To prevent unpleasant sequelae of local recurrence
Surgical options for the breast
1-Breast Conserving Surgery (BCS) + radiotherapy BCS is regarded as either

wide local excision, quadrantectomy or segmentectomy.
2-Simple mastectomy
199
a) Radical mastectomy – obsolete
b) Mastectomy + reconstruction (immediate or delayed)

3- Aims of axillary surgery:
• To eradicate local disease

• To determine prognosis to guide adjuvant therapy
• Clinical evaluation of the axilla is unreliable.
• Surgical evaluation is important and should be considered for all
patients with invasive cancer
• Levels of axillary clearance are assessed relative to pectoralis minor
• Level 1 - below pectoralis minor
• Level 2 - up to upper border of pectoralis minor
• Level 3 - to the outer border of the 1st rib
• Axillary samplings removes more than 4 nodes
• Axillary clearance produces unacceptable rate of lymphoedema
:Sentinel node biopsy

• Aims to accurately stage the axilla without the morbidity of axillary
clearance
• Technique used to identify the first nodes that tumour drains to
• Can be located following the injection of either :
• Radioisotope (Blue dye)
o Combination of isotope and blue dye
• Can be injected in peritumoural, subdermal or subareolar site
200
Prognostic factors
Chronological prognostic factors-1
• Age: Younger women have poorer prognosis.

• Tumour size: Bigger tumours have poorer prognosis.
• Lymph node status: Direct correlation between number
and level of nodes involved and survival
• Metastases: Distant metastases worsen survival
2- Biological prognostic factors "Histological grade"

o Well differentiated
o Moderately differentiated
o Poorly differentiated
Lymphatic / vascular invasion: 25% operable breast cancers have

lympho-vascular invasion. Double risk of local relapse. Higher risk of short
term systemic relapse
Biochemical measurements
• Hormone and growth factor receptors

o ER (Estrogen receptor) positivity predicts for response to
endocrine manipulation
:Chemotherapy in breast cancer
• Post-operative adjuvant chemotherapy

• Depends primarily on:
201
o Age: menopausal status
o Nodal status: positive
o Tumour grade Poor
• Combination chemotherapy more effective than single drug
• Most commonly used regimen = CMF (Cyclophosphamide,
Methotrexate, 5-Flurouracil)
• Given as six cycles at monthly intervals
• No evidence that more than 6 months treatment is of benefit
• Greatest benefit is seen in premenopausal women
:Primary (neoadjuvant) chemotherapy
• Chemotherapy prior to surgery for large or locally advanced

tumours
• Shrinks tumour often allowing breast conserving surgery rather
than mastectomy
• 70% tumours show a clinical response
• In 20–30% this is response is complete
• Surgery required even in those with complete clinical response
• 80% of these patients still have histological evidence of tumour
• Primary systemic therapy has not to date been shown to improve
survival
Endocrine therapy in breast cancer: It is just over 100 years since Beatson
described response to oophorectomy in women with advanced breast
cancer
Tamoxifen
• Tamoxifen is an oral anti-oestrogen

• Effective in both the adjuvant setting and in advanced
disease
• 20 mg per day is as effective as higher doses
• 5 years treatment is better than 2 years
• Value of treatment beyond 5 years is unknown
• Risk of contralateral breast cancer reduced by 40%
• Greater benefit seen in oestrogen receptor rich tumours
• Benefit still seen in oestrogen receptor negative tumours
202
• Benefit observed in both pre and post menopausal
women
:Locally advanced breast cancer
• Regarded as a tumour that is not surgically resectable

• Clinical features include
o Skin ulceration
o Dermal infiltration
o Erythema over the tumour
o Satellite nodules
o Peau d'orange
Fixation to chest wall, serratus anterior or intercostals
o muscles and or fixed axillary nodes.
• Radiotherapy may be useful in local control of disease

• If adequate response a salvage mastectomy can be
• Consider
203
Recurrent breast cancer:
• Commonest sites for ductal carcinoma are liver, bone and lung
====================================================
Self assessment
:The breast
:The commonest cause of blood discharge from the nipple is -1
.a- Intraductal papilloma
.b- Intraductal carcinoma
.c- Fibro-adenosis
.d- Duct ectasia
.e- Breast abscess
:Answer
a) – All may lead to bleeding per nipple however the ) – 1
.commonest cause is intraductal papilloma
:In management of nipple discharge -2
.a- If there is a lump proceed for lumpectomy
.b- If it comes from one duct remove that duct
.c- If it comes from several ducts test it for haemoglobin
d- If it contain blood request mammography for possible
.mastectomy
204
:Answer
.e) – This is the way to manage bleeding per nipple ) – 2
:the pathological changes in fibro-adenosis are composed of -3
.(a- Increase in the number of acini (adenosis
b- Hyperplasia of the epithelium lining the acini
.(Epitheliosis)
.c- Microcyst formation with fibrosis in between
.d- Papilloma formation in side the cysts and ducts
:Answer
e) – All occur as part of the evolution of the breast. Fibro-cystic ) – 3
disease of the breast is not a premalignant condition but, it occurs at
the same age of carcinoma of the breast. However, epitheliosis may
change to malignant disease. So, if there is suspicion request
mammography and look for micro-calcifications which indicate
.presence of cancer
:The fibrocystic disease of the breast -4
.a- Presents with premenstrual pain in the breast
.b- Pain in the breast is aggravated by movement of the arm
.c- It is common in nulliparous and mother of bottle babies
.d- Pain disappears after completion of menopause
:Answer
e) – Probably the breast that did not do its function (lactation) ) – 4
is more prone to develop this disease. This is in contradistinction to
carcinoma of the breast which is common in all females after the age
.of 20
:Peau d'orange -5
.a- Is lymph oedema of the skin of the breast
.b- It is due to involvement of the ligaments of Cooper
.c- It may occur in breast abscess
:Answer
e) – Peau d'orange occurs in carcinoma of the breast and ) – 5
chronic breast abscess. The pits in the peal of orange like skin are
due to sweat glands. However, Involvement of Cooper's ligaments in
.breast cancer lead to tethering of the overlying skin
205
:Paget's disease of the nipple -6
.(a- Always occur in one nipple (unilateral
.b- It occurs at menopause
.c- The nipple is destroyed and has no vesicles
.d- It does not respond to local steroids
:Answer
e) – These are correct in Paget's disease of the nipple in which ) – 6
intraductal carcinoma always coexist. However, eczema of the nipple
occurs bilaterally during lactation and it responds well to steroid
.ointments
206
Lipoma
Lipoma is a slowly growing encapsulated fat cell tumour usually benign
but intermuscular (in between the quadriceps muscles) and retroperitoneal
lipomas may become malignant liposarcoma.
Lipoma is classified according to its anatomical position i.e. Subcutaneous,
subfascial, subsynovial, retroperitoneal, intermuscular, intra-articular,
extradural, subserous and submucus lipoma.
Lipoma is usually soft with positive floctuation test.
When lipoma contain excessive fibrous tissue it is called fibrolipoma.
Multiple small painful lipomata are called Dercum's disease. If considerable
vascularity is present with cutaneous telangiectasias it is called naevolipoma.
Treatment of lipoma:
Usually there is no indication for removal of small subcutaneous lipoma
because unnecessary complications may arise like pain, bleeding ,collection of
serum and infection. However, the indications for surgery are:
1- The intermuscular and retoperitoneal lipomas should be removed because
of the fear of malignant change.
2- Disfigurement i.e. for cosmotic reasons as in big lipomas at the nape
(back) of the neck.
3- Pressure symptoms as in intrathecal subdural lipoma.
Complications of excision of subcutaneous lipoma:
1-Bleeding.
2-infection.
3-Wound dehiscence.
4-Keloid formation in susceptible patients particularly near the sternum and
shoulders.
207
5-Collection of serum (Seroma).
Cysts
A true cyst is a collection of fluid with epithelial lining but a false (pseudo) cyst
has no epithelial lining like the pseudocyst of the pancreas..
Classification of cysts:
A-Congenital cysts:
1-In the skin usually occur at the lines of development of skin folds such as the
dermoid and epidermoid cyst like the external angular dermoid
cyst at the outer angle of the eye (Sequestration cyst).
2-Cysts of embryonic remnants alike the mesenteric cysts or the
vetellointestinal cyst. cyst at the outer angle of the eye.
B- Acquired cysts:
1-Retension cysts in glandular tissue as pancreas, parotid, and
epididymis.
2-Implantation dermoid cyst occurs in figure bulb punctures and in
overlap of skin during wound closure.
3- Distension cyst as in the thyroid
4-Degeneration cyst in inflammation and tumours.
5-Parasitic cyst as hydatid cyst.
6- Neoplastic as cyst adenoma and cyst adenocarcinoma of the
pancreas and the ovary.
Complication of a cyst:
Infection, haemorrhage, calcification, pressure effect in huge pseudocysts of
pancreas and cysts of the ovary.
208
Ulcers
An ulcer is spontaneous destruction of epithelial surface.
Classification of ulcers:
1- Malignant ulcers as basal cell carcinoma (BCC) and squamous cell
carcinoma (SCC), melanoma and ulcerative tumours of the gastro-intestinal
tract.
2- Benign ulcers due to non-specific inflammation, infection and varicose
veins or vascular ischaemia (penitrating ulcers) or loss of nerve supply trophic
ulcers.
3- Specific ulcers due to tuberculosis and syphilis.
Clinical description of an ulcer:
1- The site.
2- size.
3- The margin i.e. the contour line usually irregular but rectangular
ulcers are seen in contact dermatitis and dermatitis artefacta i.e. artificial
procedures done intentionally by the patient as tattoo.
4- The edge: i.e. the shape of building of the borders of the ulcer. It is
undermined i.e. shelved like a cave in cases of tuberculosis and venous
ulcers of varicose veins that occur above the medial maleolus. Elevated
edges are seen in malignant ulcers as BCC, SCC, and malignant
melanoma. The edge is sloping in benign healing non-specific ulcers and
chronic wounds as in diabetic septic foot while it is punched out in
syphilis.
5- The floor: This is what we see in the ulcer centre. It may contain
yellowish necrotic tissue (pus cells + dead bacteria + sloughed cells) or
red granulation tissue (capillaries + Fibrils and fibroblasts) or black tissue
due to desiccation resulting from lack of blood supply.
6- Base: This is the hidden part behind the floor. It is not visible. It
may be palpable. So it is defined as indurated when the base is thick or
fixed to the underlined structures.
209
7- Blood supply: pulses should be examined as in diabetic septic foot
and in deep penetrating trophic ulcers due to atherosclerosis.
8- Lymphatics: Regional lymph nodes should be palpated to decide
the stage of malignancy and to find out if there is secondary infection
(lymphadenitis).
The groin lymph nodes are composed of vertical group in the femoral
triangle draining the lower limb and transverse group in the inguinal
region. The lateral part of the transverse group drain the buttocks and
lower part of the back while the medial group drains the perineum,
outer half of the anal canal, genitalia and infra-umbilical part of the
anterior abdominal wall.
9- Sensations : These should be tested to decide if lack of innervation, as in
diabetic neuropathy or in paraplegia, plays a role in the aetiology of the
ulcer. In diabetic neuropathy all types of nerve atrophy occur i.e. sensory
loss (light touch, temperature, and proprioception), motor and autonomic
neuropathy appearing as dry scaly skin due to absence of sweating.
10- Pain occurs in the extension and transition stages and is absent in
neuropathic ulcers .
11-General condition as paraplegia, heart failure, bed ridden, and
diabetes should be looked for.
The life –history of an ulcer:

1-Stage of extension: The floor contains necrotic tissue and exudates
2-Transitional stage: floor becomes cleaner and sloughs separate and
discharge becomes serous.
3-Stage of repair: The floor contains granulation tissue which will contract to
form a scar
Sinuses
A sinus is an abnormal tract extending from an epithelial surface blindly into
the neighbouring tissue.
210
Aetiology:
1- Acquired: Tuberculosis, osteomyelitis, Madura,Actinomycosis
2- Congenital as pre-auricular sinus or acquired as pilonidal
sinus and malignant sinuses.
The treatment of the sinus is excision of the sinus with treatment of the
underlying cause.
*Pilonidal sinus
Fistula
Fistula is an abnormal communication between two epithelial surfaces.
Aetiology:
1-Congenital: As tracheo-oesophageal fistula and vetillo-intestinal fistula.
2-Aquired: As complication of surgery in appendicular mass as faecal fistula, or
after splenectomy with injury at the tail of pancreas as pancreatic fistula and in
fistula in ano.
3- Neoplastic as entero-enteric fistula, gastro-colic fistula and rectal cancer with
malignant fistula in ano.
4- Post obstructive as urinary fistula as in urethral stricture.
5- Infection as fistula in ano.
211
6- Birth trauma as vesico –vaginal fistula.
Management of fistula:
All fistulae should close spontaneously if there is no reason to prevent their
closure.
Reasons that prevent closure of the fistula:

1- Distal obstruction as common bile duct stone distal to the fistula.
2- Epithelialization of the tract of the fistula.
3- Presence of malignant disease in the fistula.
4- Type of infection as tuberculosis or Crohn's disease.
5- Dense fibrosis in the tract.
6- Continuous irritation by the discharge.
7- Presence of foreign body in the fistula as unabsorbable suture.
Indications for surgery in treatment of fistula:

1- Failure of spontaneous closure for any of the above mentioned reasons.
2- High out put fistula with excessive fluid and electrolyte disturbance.
A- Self assessment
The most important features to suggest malignancy in an ulcer -1
:is
.a- Elevated edges
.b- Sloping edges
.c- Undermined edges
.d- Punched out edges
.e- None of the above
:Answer
a) – Elevated edges is a the most important clinical sign of ) – 1
malignant ulcer. Sloping edged occur in healing nonspecific ulcer as
in diabetic septic foot. Undermined edges occur in tuberculus and
.venous ulcers. Punched out ulcers occur in syphilitic ulcers
212
:Basal cell carcinoma -2
.a- Occur commonly in the face
.b- Is locally malignant
'.c- It erode underlying bone or cartilage
.d- It does not spread to cervical lymph nodes
Answer
e) These are the typical features of BCC which is also called ) – 2
Rodent ulcer. It occurs in the triangle between the angle of the eye,
.tragus of the ear and the angle of the mouth
:Squamous cell carcinoma of the skin -3
.a- Occur anywhere in the skin
.b- It spread by lymphatics
.c- It infiltrates and obstructs regional lymphatics
.d- It causes non-pitting lymphoedema
:Answer
e) – These are the features of SCC which is also called ) – 3
.Epithelioma
Signs of malignant change in pre-existing benign naevus -4

:include
.a- Rapid increase in size
.b- Itching
.c- Bleeding
.d- Ulceration
:Answer
e) – All are correct including change in colour, appearance of ) – 4
a hallo around the naevus. The most dangerous naevus is the
junctional type of naevus. Types of malignant melanoma include
superficial spreading melanoma, nodular melanoma and acral
.(melanoma (in limps
:Malignant melanoma -5
.a- Metastasizes to regional lymph nodes
.b- Has subcutaneous nodules
.c- Metastasizes by blood to the liver
.d- Metastasizes to bones leading to pathological fractures
213
:Answer
e) – All are correct. However in early cases the depth of ) – 5
invasion of the tumour should be determined by the pathologist in
layers of the skin (Clarke) or in millimeters of depth in tissues
.(Brislow) because these affect prognosis
.The following is correct in hair lip and cleft palate -6

.(a- It has a mode of inheritance (familial
b- Associated with other abnormalities in the head and
.vision
c- May result from intra-uterine exposure to X-ray or
.steroids
.d- May result from rubella infection or vitamin deficiency
:Answer
e) – All are correct. It may be associated with hydrocephalus or ) – 6
.some degree of mental retardation or blindness
:The effects of cleft palate include -7

.a- Difficult sucking of the breast
.b- Aspiration and chest infection
.c- Change in the tone of the voice
.d- Deformity of the teeth and nose
:Answer
e) – All are correct and these are the indications for surgical ) – 7
.correction
:The external angular dermoid cyst -8

.a- Is a sequestration cyst
.b- Lies at the outer angle of the eye
.c- May lead to erosion of the bone
.d- May become adherent to the dura mater
:Answer
e) – All are correct. It can be excised under local anaesthesia ) – 8
however, it should be anticipated that it may be adherent to the dura
.mater
214
B- Short Structured Essay Questions
.A 45- year- old female presented with difficulty in swallowing -1
a- How can you differentiate between achalasia and carcinoma of the
?oesophagus from the history only
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
.………………………………
? b-Mention 2 possible radiological findings in achalasia
……………………………………………………………………..…
..………………………………………………………………………
.
..................………………………………………………………
..........
?c-Mention 3 precancerous conditions in the oesophagus
…………………………………………………………………………
…………………………………………………………………………
..................………………………………………………………
..........
A 7 year old school boy presented with injury to his foot for 2 -2
.days
.a- In 3 steps mention how will you manage him
…………………………………………-1
...………………………………………-2
...………………………………………-3
b- 3 weeks later he presented with pain and spasm in the muscles
surrounding his old wound. Mention one cause for this localized
.pain with localized spasm
………………………………………………………………………
..........………………………………………………………………
.
..........………………………………………………………………
...
c- If not treated properly mention another 3 complications he may
.develop
215
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
C- Modified Essay Question

• A 30 year old female presented with cooking gas burn
at 9: am. She is about 50 kg body weight. She has 30%
surface area burnt including the face and palms of her
hands. She was brought to the casualty at 3:pm.
?a- Calculate her fluid requirement in the first 24 hours
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
b- At what time are you going to start the fourth ration of
.................................................................. ?fluid
..........................................................................
..........................................................................
..........................................................................
................................................
?c-Mention 3 indications for her admission to he hospital
...………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
………
d- 3 hours after admission her breathing became noisy and difficult
?What is the most likely cause of deterioration of her breathing
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
e- How would you treat her breathing
.............................................................. ?problem
..........................................................................
..........................................................................
216
............................................................ .............
....................................................
f- Mention 5 other complications she may develop during her

?treatment
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
g- Mention how can you prevent 3 of these
........................................................ ?complications
..........................................................................
..........................................................................
..........................................................................
..........................................................
217

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Concise Surgery

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• Road traffic accidents, burn, surgical operations, heat stroke, surgery,

anaesthesia and all medical illnesses are examples of stress.

1- The neural response:

Metabolic changes in stress:

2-Hormonal response to stress:

:Stimulation of the sympathetic system results in -1

:Stimulation of the sympathetic system results in -2

3 - In stress the pituitary gland secrets:

:Cortisol liberated from supra-renal cortex in stress leads to-4

e) – Oliguria is alarming before the patient goes into renal )– 7

:In reading the blood pressure -8

A 36 year old driver was involved in a road traffic accident. -9

b)After insertion of Foley's urinary catheter, his urine output)

c)The explanation of his restlessness is)

We use dextrose 5% in water because it is isotonic ( i.e. iso-osmotic has equal

Normal saline (0.9%gm of sodium chloride): This means that:

Causes of hyponatremia (↓ Na+):

2-Diarrhoea: Diarrhoea results in loss of water (Dehydration) and the rapid

3- Recovery phase of acute renal failure: In the recovery phase of

Causes of hyperkalemia (K+):

Hyperkalemia leads to ECG changes in the form of tall T-wave. Clinically it

Sodium bicarbonate solution (0.5 mmol NaHCO3 / kg body weight) can be

1- The normal daily water losses include:

2- The following is correct for sodium correction:

3- The normal regulation of potassium include:

6- Blood pressure is controlled by:

:Hypovolemia and/or hypotension lead to -7

:The following conditions lead to pure water loss-8

:In pure water loss -9

:Post operative hyponatraemia -10

:The earliest feature of dehydration is -11

:The best laboratory indication of dehydration is -12

:Over infusion of normal saline leads to -13

:Sodium retention is a feature of -14

:Low level of serum potassium is found in -15

.The following is correct in metabolic alkalosis -16

:Hypokalaemia is very serious because -17

:The disturbance in acid base balance is due to -18

:The causes of metabolic acidosis include -19

:In metabolic acidosis -20

:Metabolic acidosis is best treated by -21

:In metabolic alkalosis -23

:Treatment of metabolic alkalosis is -24

:Treatment of hyperkalaemia includes -25

:Dextrose 5% in water solution is used because -26

.a- Normal saline alternating with glucose5% in water

Treatment of Staph infection:

[3]Oesophagus and mouth:

2- In achlorhydria as in pernicious anaemia, gastric ulcer and gastric carcinoma

[8] Small intestine:

[9]Appendix, large bowel and rectum:

[11] Urinary system:

Treatment of septic shock:

*Problems of wound healing:

Types of surgical wounds:

*Factors that increase susceptibility to infection:

*Factors that delay wound healing:

The normal requirement of nutrition is:

This is found in carbohydrates and fat. I gram of glucose gives 4

3- The daily requirement of vitamins and minerals should be calculated.

Causes that prevent oral intake of nutrition:

The Enteral feeding:

3-Protein is available in the form of Vamin in 10% dextrose or

Strangulated hernia Mesenteric thrombosis