15.surgery Final PDF

SURGERY
INDEX
S. No. Topics Pg. Nos.
1 BREAST CARCINOMA 1-9

2 THYROID CARCINOMA 9-13
3 PROSTATE CARCINOMA AND BPH 14-16
4 SALIVARY TUMORS 17-18
5 B COLORECTAL POLYPS 18-19
6 CARCINOMA COLON 19-22
7 GALL STONE 22-25
8 PEPTIC ULCER 25-29
9 TESTICULAR CARCINOMA 30-32
10 IBD 32-36
11 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS 36-37
12 GASTRIC CARCINOMA 37-38
13 SPLENECTOMY 39
14 HERNIA 39-44
15 HEPATOCELLULAR CARCINOMA 44-46
16 PANCREATITIS 46-48
17 RENAL CELL CARCINOMA 49
18 RENAL STONE 50-52
19 ESOPHAGEAL CARCINOMA 53-54
20 INTESTINAL OBSTRUCTION 54-56
21 THROMBANGITIS OBLITERANS 56-57
22 BURNS 58-62
23 GRAFTING 63-65
24 CBD STONE 65-66
25 SHOCK 66-70
26 BLUNT INJURY ABDOMEN 70-77
27 HIRSCHSPRUNG’S DISEASE 77-78
28 BLADDER CANCER 78-79
29 MELANOMA 79-80
30 PANCREATIC CARCINOMA 81
31 APPENDICITIS 82-83
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SURGERY
INDEX
S. No. Topics Pg. Nos.
32 URETHRAL RUPTURE 83-85

33 ACHALASIA 85-87
34 CARCINOMA TONGUE 88
35 DUCT PAPILLOMA 88-90
36 ANAL CARCINOMA 91-92
37 DIAPHRAGMATIC HERNIA 92-93
38 TOTAL PARENTERAL NUTRITION 93
39 LIVER ABSCESS 94
40 MECKELS DIVERTICULUM 95
41 VARICOSE VEINS 95-96
42 CARCINOID 96-97
43 HYPOSPADIAS 97
44 INSULINOMA 98-99
45 MEDIASTINAL TUMOR 99-100
46 TRANSPLANTATION 100-107
47 BASAL CELL CARCINOMA 108
48 HEMORRHOIDS 108-109
49 PARATHYROID ADENOMA 109
50 AORTIC ANUERYSM 110-112
51 INTUSUSSCEPTION 112-113
52 POSTERIOR URETHRAL VALVE 113
53 VOLVULUS 114
54 CLEFT LIP 115
55 DIVERTICULOSIS 115-116
56 ISCHEMIC BOWEL DISEASE 116-117
57 ZENKER DIVERTICULUM 118
58 ANNULAR PANCREAS 118
59 CARCINOMA GALLBLADDER 119
60 SALIVARY CALCULUS 119
61 CYSTIC HYGROMA 120
62 MECONIUM ILEUS 120
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TOPIC - 1 BREAST CARCINOMA n Infiltrating Ductal Carcinoma
m Most common invasive breast cancer (80% of
n Premalignant Lesions of breast cases). (MCQ)

m Most common in perimenopausal and postmenopausal
n DCIS
m Cell of origin -Inner layer of epithelial cells
women. (MCQ)
m Ductal cells invade stroma in various histologic
in major ducts
m Definition- Proliferation of ductal cells that spread
forms described as scirrhous, medullary,
through the ductal system but lack the ability to comedo, colloid, papillary, or tubular.
m Metastatic to axilla, bones, lungs, liver, brain.
invade the basement membrane
m Age- > 2 of cases occur after menopause
Infiltrating Lobular Carcinoma
n
m Second most common type of invasive breast
(MCQ)
m Sometimes presents with palpable mass
cancer (10% of cases)
m Originates from terminal duct cells (MCQ)
m Diagnosis – (MCQ)
m like LCIS, has a high likelihood of being bilateral
n Clustered micro calcifications on
mammogram (MCQ)
m Presents as an ill-defined thickening of the
n malignant epithelial cells in breast duct on
biopsy breast
m Like LCIS, lacks microcalcifications (MCQ)
m Lymphatic invasion - < 1%
m often multicentric (MCQ)
m Risk of invasive cancer –
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m Tends to metastasize to the axilla, meninges, and
n Increased risk in ipsilateral breast (MCQ)
n usually same quadrant; (MCQ)
serosal surfaces
n infiltrating ductal carcinoma most common
Paget’s Disease (of the Nipple)
n
m 2% of all invasive breast cancers
histologic type (MCQ)
m Usually associated with underlying LCIS or
n comedo type has the worst prognosis (MCQ)
m Treatment (MCQ)
ductal carcinoma extending within the epithelium
n If small (<2cm): Lumpectomy with either
of main excretory ducts to skin of nipple and
close follow-up or radiation areola (MCQ)
m Presentation:
n If large (>2cm): Lumpectomy with 1-cm
BREAST CARCINOMA
n Tender, itchy nipple with or without a bloody
margins and radiation
n If breast diffusely involved: Simple mastectomy
discharge with or without a subareolar
n LCIS
palpable mass (MCQ)
m Treatment: Usually requires a modified radical
m Cell of origin -Cells of terminal duct–lobular unit
(MCQ) mastectomy (MCQ)
Inflammatory Carcinoma
m Definition- A multifocal proliferation of acinar and
n
m Two to 3% of all invasive breast cancers.
terminal ductal cells
m Most lethal breast cancer.
m Age- Vast majority of cases occur prior to
m Vascular and lymphatic invasion commonly
menopause
m Never presents with Palpable mass (MCQ)
seen at pathologic evaluation.
m Frequently presents as er ythema, “peau
m Diagnosis - Typically a clinically occult lesion;
undetectable by mammogram and incidental on d’orange,” and nipple retraction. (MCQ)
m Treatment:
biopsy
n Consists of chemotherapy followed by surgery
m Lymphatic invasion - Rare
m Risk of invasive cancer – (MCQ)
and/or radiation, depending on response to
n Equally increased risk in either breast
chemotherapy. (MCQ)
n infiltrating ductal carcinoma also most common
BREAST CANCER
n
m One in eight women will develop breast cancer
histologic type (you might have not expected this
when asked in MD Entrance) in their lifetime.
m Incidence increases with increasing age.
n associated with simultaneous LCIS in the
m One percent of breast cancers occur in men.
contralateral breast in over 1D 2 of cases
m Risk Factors (MCQ)
m Treatment – (MCQ)
n Early menarche (< 12) (MCQ)
n None
n Late menopause (>55) (MCQ)
n bilateral mastectomy an option if patient is
n Nulliparity or first pregnancy >30 years
high risk
n Old age n Li–Fraumeni syndrome results from a p53
n History of breast cancer in mother or sister mutation.
n especially if bilateral or premenopausal m BRCA1 (MCQ)
n Genetic predisposition n On 17q21, also associated with ovarian cancer.
l BRCA1 or BRCA2 positive m BRCA2 (MCQ)
l Li–Fraumeni syndrome n On chromosome 13
n Prior personal history of breast cancer n not associated with ovarian cancer.
n Previous breast biopsy m Somatic mutation of p53 in 50% and of Rb in
n DCIS or LCIS 20% of breast cancers.
n Atypical ductal or lobular hyperplasia n Screening Recommendations (from the American
n Postmenopausal estrogen replacement Cancer Society)
(unopposed by progesterone) (MCQ) m Screening reduces mortality by 30–40%.
n Radiation exposure m Begin monthly breast self-examinations at age
n Breast Cancer in Pregnant and Lactating Women 20. (MCQ)
m 3 breast cancers are diagnosed per 10,000 m First screening mammogram at age 35. (MCQ)
pregnancies. m Annual mammograms after age 50.
m A FNA should be performed. n Diagnostic Options
m If it identifies a solid mass, then it should be m Mammography
followed by biopsy. n Identifies 5 cancers/1,000 women.
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m Mammography is possible as long as proper shielding n Sensitivity 85–90%.

is used. n False positive 10%, false negative 6–8%.
m Radiation is not advisable for the pregnant n If cancer is first detected by mammogram, 80%
woman. (MCQ) have negative lymph nodes (vs. 45% when
m For stage I or II cancer, a modified radical detected clinically). (MCQ)
mastectomy should be done rather than a n Suspicious Findings (MCQ)
lumpectomy with axillary node dissection and l Stellate, speculated mass with associated
postoperative radiation. (MCQ) microcalcifications
m If lymph nodes are positive, delay chemotherapy n Reporting Mammogram Results
BREAST CARCINOMA
until the second trimester. (MCQ) l I: No abnormality

m Suppress lactation after delivery. l II: Benign abnormality
n Breast Cancer in Males l III: Probably benign finding
m Predisposing factors: (MCQ) l IV: Suspicious for cancer
n Klinefelter’s syndrome l V: Highly suspicious for cancer
n estrogen therapy m Ultrasound
n elevated endogenous estrogen n Advantages
n previous irradiation l No ionizing radiation
n trauma. l Good for identifying cystic disease and can
m Infiltrating ductal carcinoma most common also assist in therapeutic aspiration
histologic type (men lack breast lobules). (MCQ) l Results easily reproducible
m Diagnosis tends to be late, when the patient n Disadvantages (MCQ)
presents with a mass, nipple retraction, and skin l Resolution inferior to mammogram
changes. l Will not identify lesions?< 1 cm
m Stage by stage, survival is the same as it is in m FNA (Aspiration of Tumor Cells with Small-
women. Gauge Needle)
m However, more men are diagnosed at a later stage. n Advantages
m Treatment for early-stage cancer involves a l Low morbidity
modified radical mastectomy and l Cheap
postoperative radiation. (MCQ) l Only 1–2% false-positive rate
n Genetic Predisposition n Disadvantages (MCQ)
m Five to 10% of breast cancers are associated with l False-negative rate up to 10%
an inherited mutation. l Requires a skilled pathologist
m p53 l May miss deep masses
n A tumor suppressor gene m Needle Localization Biopsy

n Locates occult cancer in > 90% m N1: Movable ipsilateral axillary nodes
m Core Biopsy m N2: Fixed ipsilateral axillary nodes
n Has chance of sampling error m N3: Ipsilateral internal mammary nodes
m Stereotactic Core Biopsy m Mx: Cannot assess mets
n Advantages m M0: No mets
l Fewer complications compared to needle m M1: Distant mets or supraclavicular nodes
localization biopsy n Staging System for Breast Cancer and 5-Year Survival
l Less chance of sampling error than core Rates
biopsy alone m Stage 0 -DCIS or LCIS (MCQ)
l No breast deformity m Stage I- (MCQ)
n Treatment Decisions n Invasive carcinoma < 2 cm in size (including
m Types of Operations carcinoma in situ with microinvasion) without
n Radical mastectomy (MCQ) nodal involvement and no distant
l Resection of all breast tissue, axillary nodes, and metastases.
pectoralis major and minor muscles (rarely m Stage II- (MCQ)
preferred) n Invasive carcinoma <5 cm in size with
n Modified radical mastectomy: (MCQ) involved but movable axillary nodes and no distant
l Same as radical mastectomy except metastases
pectoralis muscles left intact n a tumor > 5 cm without nodal involvement
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n Simple mastectomy: (MCQ) or distant metastases
l Same as radical mastectomy except pectoralis m Stage III – (MCQ)
muscles left intact and no axillary node dissection n Breast cancers >5 cm in size with nodal
n Lumpectomy and axillary node dissection: involvement
(MCQ) n any breast cancer with fixed axillary nodes
l Resection of mass with rim of normal tissue and n any breast cancer with involvement of the
axillary node dissection—good cosmetic result ipsilateral internal mammary lymph nodes
n Sentinel node biopsy: (MCQ) n any breast cancer with skin involvement,
l Recently developed alternative to complete pectoral and chest wall fixation, edema
BREAST CARCINOMA
axillary node dissection: n clinical inflammatory carcinoma, if distant
l Based on the principle that metastatic metastases are absent
tumor cells migrate in an orderly fashion to m Stage IV – (MCQ)
first draining lymph node(s). n Any form of breast cancer with distant
l Lymph nodes are identified on preoperative metastases (including ipsilateral supraclavicular
scintigraphy and blue dye is injected in the lymph nodes)
periareolar area. n Hormone Receptor Status and Response to
l Axilla is opened and inspected for blue Therapy
and/or “hot” nodes identified by a gamma m Hormone Receptor Status vs Response to Therapy
probe. (MCQ) n ER+/PR+ - 80%
l When sentinel node(s) is positive, an axillary n ER/PR+ - 45%
dissection is completed. n ER+/PR 35%
l When sentinel node(s) is negative, axillary n ER/PR 10%
dissection is not performed unless axillary n Hormonal Therapy: Tamoxifen
lymphadenopathy identified. m Selective estrogen receptor modulator
n TNM System for Breast Cancer (MCQ) (MCQ)
m Tx: Cannot assess primary tumor n blocks the uptake of estrogen by target
m T0: No evidence of primary tumor tissues
m T1: < 2 cm m Side effects: (MCQ)
m T2: < 5 cm n Hot flashes, irregular menses
m T3: >5 cm n thromboembolism,
m T4: Any size, with direct extension to chest wall n increased risk for endometrial cancer
or with skin edema or ulceration m Survival benefit for pre- and postmenopausal
m Nx: Cannot assess lymph nodes women, but benefit greater for ER+patients
m N0: No nodal mets

m May get additional benefit by combining m Benign cysts should not be bloody. A bloody
tamoxifen with chemotherapy aspirate usually indicates malignancy.
n Recurrence m Five to 10% of palpable masses have a negative
m 5–10% local recurrence at 10 years mammogram (MCQ)
m Metastases in < 10% of cases m Mammography is more useful if age ??30 because
m Local chest wall recurrence most common the large proportion of fibrous tissue in younger
within 2 to 3 years, if at all women’s breasts make mammograms more
§ Metastasis difficult to interpret.
m Median survival 2 years. m Recommended chemotherapy for breast cancer
m Palliative therapy indicated. is (MCQ)
m Doxorubicin in this setting has a response rate n CAF (cyclophosphamide, adriamycin, 5-FU)
of 50% with a 1-year survival of 60%. n CMF (methotrexate instead of adriamycin).
n Clinical Pearls: m Prognosis depends more on stage than on histologic
m Tumors with high tendency to metastise to Bone type of breast cancer.
– Thyroid ,Renal ,Lung ,Prostate ,Breast m Lumpectomy with postoperative radiation is
m Twenty percent of infiltrating lobular breast a viable treatment option only in stages I and II
carcinoma have simultaneous contralateral breast (MCQ)
cancer. (MCQ)
m Typical Clinical scenario: n Tumours suitable for breast conservation
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n A 70- year-old female presents with a pruritic, m Small single tumours in a large breast
scaly rash of her nipple–areolar complex m Peripheral location
and a bloody nipple discharge. m No local advancement or extensive nodal
n Diagnosis : Paget’s disease. (MCQ) involvement
n Biopsy and pathologic exam required to n For tumours that are suitable for breast conservation
confirm diagnosis. there is no difference in local recurrence or overall
m Typical Clinical scenario: survival when BCS + radiotherapy is compared
n A 49- year-old female presents with to mastectomy (MCQ)
enlargement of her left breast with nipple n Aims of axillary surgery
BREAST CARCINOMA
retraction, erythema, war mth, and n 30-40% of patients with early breast cancer have
induration. (MCQ) nodal involvement
n Diagnosis : Inflammatory breast carcinoma. n The aims of axillary surgery is to:
m Fibrocystic changes of the breast alone is not l To eradicate local disease
a risk factor for breast cancer. (MCQ) l To determine prognosis to guide adjuvant
m Despite all known risk factors, most women with therapy
breast cancer (75%) present without any n Clinical evaluation of the axilla is unreliable
identifiable risk factors. (30% false positive, 30% false negative)
m Termination of pregnancy is not part of the n No reliable imaging techniques available
treatment plan for breast cancer and does not n Surgical evaluation important and should be
improve survival. considered for all patients with invasive cancer
m Males with breast cancer often have direct n Levels of axillary clearance are assessed relative
extension to the chest wall at diagnosis. to pectoralis minor (MCQ)
m Genetic syndromes associated with breast cancer: n Level 1 -below pectoralis minor
n Autosomal dominant: (MCQ) n Level 2 –upto upper border of pectoralis
l Li–Fraumeni minor
l Muir–Torre n Level 3 – to the outer border of the 1st rib
l BRCA1and BRCA2 n Axillary samplings removes at least four nodes
l Cowden’s syndrome (MCQ)
l Peutz–Jeghers syndrome n Pre-operative axillary ultrasound and biopsy may
n Autosomal recessive:( (MCQ) allow a tailored approach tthe axilla
l Ataxia–telangiectasia n Clinical points in favour of axillary clearance (MCQ)
m Start yearly mammograms 10 years before the age at n Axillary clearance both stages and treats the
which first-degree relative was diagnosed with axilla
breast cancer. (MCQ)
n Sampling potentially misses nodes and under n EGF receptors are negatively correlated
stages the axilla with ER and poorer prognosis (MCQ)
n Surgical clearance possibly gains better local n Oncogenes
control n Tumours that express C-erb-B2 oncogene
n Avoids complications of axillary radiotherapy likely to be: (MCQ)
n Avoids morbidity of axillary recurrence l Resistant to CMF chemotherapy
n Clinical points in favour of axillary sampling(MCQ) l Resistant to hormonal therapy
n Only stages the axilla l Respond to anthracycline
n Must be followed by axillary radiotherapy l Respond to taxols
n The 60% of patients with node negative n Proteases
disease have unnecessary surgery n Urokinase and cathepsin D found in breast
n Radical lymphadenectomy in other cancers cancer (MCQ)
(e.g. melanoma) produces disappointing results n Presence confers a poorer prognosis
n Avoids morbidity of axillary surgery n Nottingham Prognostic Index (NPI) (MCQ)
n The combination of axillary clearance and
radiotherapy is to be avoided The Nottingham Prognostic Index
n Produces unacceptable rate of lymphedema Factor
n Chronological prognostic factors Involved Nodes Tumour Grade Score per factor
n Age 0 1 1
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l Younger women have poorer prognosis of 1-3 2 2
equivalent stage >3 3 3
n Tumour size
• NPI = 0.2 x size (cm) + Lymph node stage + Tumour grade
l Diameter of tumour correlates directly with
survival n Post-operative adjuvant chemotherapy
n Lymph node status m Most commonly used regimen = CMF (MCQ)
l Single best prognostic factor (MCQ) n Cyclophosphamide, Methotrexate, 5
l Direct correlation between number and level Flurouracil
of nodes involved and survival m Given as six cycles at monthly intervals
BREAST CARCINOMA
n Metastases m No evidence that more than 6 months
l Distant metastases worsen survival treatment is of benefit
n Some histological types associated with improved m Greatest benefit seen in premenopausal women
prognosis: (MCQ) m High -dose chemotherapy with stem cell
n Tubular,Cribriform, Mucinous, Papillary, Micro-invasive rescue produces no overall survival benefit
n Hormone and growth factor receptors (MCQ)
n ER positivity predicts for response to
endocrine manipulation (MCQ)

Chemotherapeutic options in breast cancer
Nodal state Treatment
Premonepausal Node positive Combination chemotherapy
Node negative Adjuvant therapy is not generally recommended; for high risk patients
chemotherapy should be considered
Postmenopausal Node positive ER positive - Tamoxifen
ER negative - Combination chemotherapy should be considered
Node negative No indication for routine adjuvant therapy; for high risk patients chemotherapy shoud be
considered
n Primary (neoadjuvant) chemotherapy l May be superior to tamoxifen(MCQ)

n Chemotherapy prior to surgery for large or n Locally advanced breast cancer
locally advanced tumours (MCQ) n Regarded as a tumour that is not surgically
n Shrinks tumour often allowing breast resectable
conserving surgery rather than mastectomy n Clinical features include:
n 70% tumours show a clinical response l Skin ulceration
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n In 20–30% this is response is complete l Dermal infiltration

n Surgery required even in those with complete l Erythema over the tumour
clinical response l Satellite nodules
n 80% of these patients still have histological evidence l Peau d ‘orange
of tumour l Fixation to chest wall,serratus anterior or
n Primary systemic therapy has not to date been intercostal muscles
shown to improve survival l Fixed axillary nodes
n Endocrine therapy in breast cancer n Strictly speaking, LABC includes: T3+N1 – 3
n Tamoxifen(MCQ) or T4+N0 – 3 or any T+N2 – 3 (i.e. Stage
BREAST CARCINOMA
l Tamoxifen is an oral anti-oestrogen III A/B disease) (MCQ)

l Effective in both the adjuvant setting and n Management
in advanced disease l If oestrogen receptor-positive usually
l 20 mg per day is as effective as higher doses treated with primary hormonal(MCQ)
l 5 years treatment is better than 2 years l If oestrogen receptor-negative
l Risk of contralateral breast cancer reduced chemotherapy may be useful (MCQ)
by 40% l Radiotherapy may be useful in local control
l Greater benefit seen in oestrogen receptor of disease
rich tumours(MCQ) l If adequate response a salvage mastectomy
l Benefit still seen in oestrogen receptor can be consider
negative tumours n Who gets chemotherapy?
l Benefit observed in both pre and post n Pre menopausal: (MCQ)
menopausal women(MCQ) l 4 ER/PR Negative
l Risks of Tamoxifen use(MCQ) l 4 T>1cm
„ 3 ↑Uterine adenocarcinoma, sarcoma l 4 Any N, including micro (SN+)
„ 3 ↑Cataracts n Post menopausal (up to 90% are ER/
„ 3 ↑DVT, PE PR+get tamoxifen): (MCQ)
„ 3 ↓osteoporosis l 4 ER/PR Negative
„ 3 No change in incidence of heart disease l T > 2 cm e” 4 nodes OR matted nodes
n Aromatase inhibitors (regardless of ER/PR)
l Reduced the peripheral conversion of l (Hence, ER/PR+, < 3 unmatted nodes
androgens to oestrogens no chemo)
l Only effective in post menopausal n Who gets axillary radiation? (MCQ)
women(MCQ)

n (In general, want to avoid axillary radiation TOPIC - 2 THYROID CARCINOMA
following dissection)
n 4 Positive(+) supraclavicular node
n Benign thyroid tumours
n 4 matted nodes (extracapsular extension)
m Most are follicular adenomas (MCQ)
n 4 > 4 nodes
m All papillary tumours should be considered
n Who gets breast irradiation? (MCQ) malignant
n 4 any segmental resection for invasive or
n Follicular adenoma
DCIS m Of all follicular lesions - 80% benign and 20%
n 4 inf lammatory disease (T4/skin malignant (MCQ)
involvement); some T3 m They are smooth and discrete lesions with
n Chemotherapy/Hormonal* Treatment: glandular or acinar pattern
n Premenopausal(MCQ)
m They are encapsulated and usually 2-4 cm in
n 4 chemo for almost any tumor > 1 cm
diameter
(regardless of nodal status) m Adenomas can not be differentiated from
n 4 cytoxan & adriamycin
carcinoma on FNA cytology
n 4 add taxane if node positive
m Requires histological assessment of capsular
n 4 tamoxifen if ER/PR positive
invasion (MCQ)
n 5 arimidex and aromatase inhibitors not
n Toxic adenoma
effective in premenopausal since can’t m Account for 5% of cases of thyrotoxicosis
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compete with estrogen produced m Female : Male ratio is approximately 9:1(MCQ)
n Postmenopausal(MCQ)
m Presentation
l 5 tamoxifen or arimidex if node negative
n 54% with a nodule(MCQ)
and ER/PR+ n 37% with thyrotoxicosis
l 5 Chemo if poorly differentiated and > 1
n 95% of toxic adenomas are benign(MCQ)
cm (even if node negative) m Thyrotoxicosis not usually associated with eye
l 5 cytoxan & adriamycin ± taxane if node
signs (MCQ)
positive m A hot nodule on scintigraphy with suppression
l 5 tamoxifen or adriamycin if elderly, node
of normal thyroid uptake (MCQ)
THYROID CARCINOMA
positive, and ER/PR+ m Treatment is by thyroid lobectomy (MCQ)
m Require post operative thyroxine until
suppressed gland returns to normal (MCQ)
n Malignant thyroid tumours
m Differentiated thyroid cancer accounts for 80%
of thyroid neoplasms
m Female : male ratio is approximately 4:1(MCQ)
m Usually presents as solitary thyroid nodule in
young or middle age adult
m Nodule more likely to be malignant in man or
child
n Papillary and mixed tumours
m 50% tumours are less than 2 cm diameter at
presentation(MCQ)
m Tumours < 1 cm diameter regarded as minimal
or micropapillary lesions(MCQ)
m Characteristic histological features(MCQ)
n Psammoma bodies
n ‘orphan Annie’ nuclei
m 30 - 50% are multicentric with simultaneous
tumour in contralateral lobe
m Early spread occurs to regional lymph nodes
m ‘Lateral aberrant thyroid’ almost always
metastatic papillary carcinoma (MCQ)

m Thyroid lobectomy adequate for minimal m May allow detection of recurrence without
lesions (MCQ) inconvenience of scintigraphy
m Total thyroidectomy is otherwise surgery of n Total thyroidectomy versus. thyroid lobectomy
choice (MCQ) for differentiated tumours
m Many tumours are TSH dependent m Points in favour for total thyroidectomy
m TSH suppression with post-operative thyroxine (MCQ)
appropriate n Multifocal disease occurs in opposite lobe in
m Post operative Thyroxine reduces recurrence and 50% cases
improves survival n Total thyroidectomy reduces risk of local
m 80% nodes have microscopic involvement recurrence
(MCQ) n Ablation with radioiodine is facilitated
m The role of prophylactic lymph node dissection n Serum thyroglobulin can be used as a tumour
at time of initial surgery is unclear marker for progression or recurrence
m Lymph node dissection does not improve n In experienced hands, morbidity of total
survival (MCQ) thyroidectomy is low
m Alternative is to sample the lymph nodes. m Points in favour for thyroid lobectomy
n If no evidence of nodal metastases – no (MCQ)
further surgery n Many patients do not require radioiodine
n If nodal metastases present - modified neck n Progression to undifferentiated carcinoma is
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dissection rare
n Follicular tumours n Significance of micro-foci in contralateral
m Can not differentiate follicular adenoma and lobe is uncertain
carcinoma on FNA cytology (MCQ) n No evidence that more extensive procedure
m Treatment of all follicular neoplasms is thyroid is associated with better prognosis
lobectomy with frozen section (MCQ) n Higher incidence of hypoparathyroidism after
n If frozen section confirms carcinoma - Total total thyroidectomy
thyroidectomy n Anaplastic carcinoma
n If frozen section confirms adenoma – No further m Accounts for less than 5% thyroid malignancies
THYROID CARCINOMA
surgery required m Occurs in elderly

m Total thyroidectomy allow detection of m usually an aggressive tumour (MCQ)
metastases using 123I Scanning during follow m Local infiltration causes dyspnoea, hoarseness
up(MCQ) and dysphagia
m All patients require suppressive thyroxine m Thyroidectomy seldom feasible
therapy m Incision biopsy should be avoided as it often
causes uncontrollable local spread (MCQ)
Papillary tumours Follicular tumours m Radiotherapy and chemotherapy important
Multifocal Solitary modes of treatment(MCQ)

m Death usually occurs within 6 months
Unencapsulated Encapsulated
n Thyroid lymphoma
Lymphatic spread Haematogenous spread m Accounts for 2% of thyroid malignancies
Metastasises to Metastasises to lung, m Often arises with Hashimoto’s thyroiditis or
regional nodes bone and brain non-Hodgkin’s B-cell lymphoma(MCQ)
m Presents as a goitre in association with generalised
n Follow up of thyroid carcinoma
lymphoma
m Annual I scanning to detect asymptomatic
123
m Diagnosis can often be made by FNA cytology
recurrence
m Radiotherapy is treatment of choice(MCQ)
m Treatment of such recurrence can still be
m Prognosis is good - often >85% 5 year survival
curative
n Medullary carcinoma of the thyroid
m Need to be off T4 for at least one month with
m Accounts for 8% of thyroid neoplasms
conversion to T3
m Arises from para-follicular C-cells(MCQ)
m Serum Thyroglobulin - increasing levels often
m 20% of cases are familial
first sign of recurrence (MCQ)
m Autosomal dominant inheritance with almost
complete penetrance
m Can occur as part of MEN IIa and MEN IIb m Wound Complications
syndromes (MCQ) n Sepsis
m 80% of cases are sporadic n Hypertrophic scarring
m Sporadic cases usually unilateral (MCQ) m Respiratory Obstruction
m 50% have lymph nodes at presentation n Laryngeal mucosal oedema
m Familial cases often multifocal and bilateral n Clot deep to strap muscles
m Tumours metastasise to nodes and via blood n Bilateral incomplete recurrent laryngeal nerve
to bone, liver and lung palsies
m They produce calcitonin, calcitonin gene n Tracheomalacia
related peptide and CEA m Nerve Damage
m Total thyroidectomy is treatment of choice n Recurrent laryngeal nerve palsy
(MCQ) l Incomplete-Cord moves to midline
m Calcitonin can be used in follow up for the l Complete-Cord in cadaveric position
presence of metastatic disease (MCQ) n Pre operative cord inspection is essential
n Complications of thyroidectomy n 3% population have asymptomatic recurrent
m Haemorrhage laryngeal nerve palsy
m Hypocalcaemia
m Pneumothorax
m Air Embolism
SURGERY
m Recurrent hyperthyroidism
m Hypothyroidism
Clinical Pearls for MD Entrance Exam :
Papillary Follicular Medullary Anaplastic

Percent 80-85 5-10 5-10 1
75% of pediatric
thyroid cancer
THYROID CARCINOMA
Risk factors Radiation Dyshormonogenesis Associated with n Prior diagnosis of
multiple endocrine well-differentiated
neoplasia (MEN) thyroid cancer
in 30-40% n Iodine deficiency
Age group 30-40 50s 50-60 60-70

Sex (F/M) 2/1 3/1 1.5/1 1.5/1
Signs and n Painless
mass n Painless mass n Painful mass n Rapidly enlarging
symptoms n Dysphagia n Rarely n Palpable lymph neck mass
n Duspnea hyperfunctional node (LN) n Neck pain
n Hoarseness (15-20%) n Dysphonia
n Euthyroid n Dysphagia n Dysphagia
n Dyspnea n Hard, fixed LN
n Hoarseness
Diagnosis n Fine-needle n FNA n FNA n FNA

aspiration (FNA) n CT or MRI (to n Presence of
assess local amyloid is
n Computed invasion) diagnostic
tomography n Check
(CT) or magnetic immunohisto
resonance chemistry for
imaging (MRI) (to
assess local invasion)

Gross n Intrathyroidal n Encapsulated n Unilateral n Macroinvasion
characteristic n Partially tumor n Mild-upper lobes n Clinically + LN
encapsulated n Solitary n Familial tumors
n Likely to be more likely
multifocal multicentric and
n Hard
n White
n Areas of necrosis
n Cystic changes
Histologic n Papillary n Solitary n Cell of origin: C n Sheets of

characteristics projections n Encapsulated (90%) cells heterogeneous
n Pale, abundant n Sheets of cells cells
cytoplasm n Amyloid
n Psammoma n Collagen
bodies
n Orphan Annie eyes
Metastases Lymphatic Hematogenous n Lymphatic n Aggressive local

(local neck and disease
mediastinal n 50% have
SURGERY
nodes) synchronous
n Local (into trachea pulmonary mets at
and esophagus) diagnosis
Treatment n Minimal ca: n Minimal ca: n Sporadic MTC n Debulking
Lobectomy and Lobectomy and Total resection of
isthmectomy isthmectomy thyroidectomy thyroid and
n Other: Total or n Other: Total or and central neck invaded structures
near-total near-total node dissection n External radiation
THYROID CARCINOMA
thyroidectomy thyroidectomy (modified radical theraphy (XRT)

neck dissection
for + LN)

n the majority of hot nodules are benign, and n May see amyloid on pathology
approximately 5% of cold nodules are malignant. n ↑ serum calcitonin (can use serum calcitonin
(MCQ) levels to monitor for recurrence) (MCQ)
n Thyroid ultrasound is used to determine whether n Originates from parafollicular C cells, which
a nodule is solid or cystic to assess nodule size produce calcitonin and hence do not
or to identify impalpable nodules. concentrate iodine. (MCQ)
n Solid nodules are more likely to be cancerous than n Anaplastic:
are cystic lesions. (MCQ) n Only operation that should be considered is
n For patients suspected of having medullary cancer tracheostomy.
based on family history, serum calcitonin levels n Minimal role for palliative resection
should be checked after a calcium-pentagastrin n Medical management (MCQ)
infusion test. l Thyroid hormone suppression
n An elevated calcitonin level defines a positive l Radioactive iodine ablation (RIA)
result and obviates the need for FNA. (MCQ) „ T3 [half life 3-4 days] vs. T4 [half life 4 weeks]
n One option for lesions deemed benign on FNA „ Hence use T3 replacement post op before
is hormone suppression: (MCQ) RIA
n if regresses then follow m Thyroglobulin can only serve as a tumor marker
n If grows remove when the following 2 conditions are met: (MCQ)
n if same repeat FNA n The tumor is well differentiated (since it’s
SURGERY
n Surgical management (MCQ) produced by follicular cells)
n Lobectomy: n The patient has had a total thyroidectomy
l unclear path (go back for completion, if m Lymph nodes
necessary) n For differentiated cancer: no role for
n Lobectomy + isthmusectomy: prophylactic LND (MCQ)
l papillary < 1 cm, benign unilateral lesions n only for palpable or FNA+ nodes ——
or suspicious lesions “Regional dissection” (MCQ)
n Total thyroidectomy (followed by RAI): l Radical dissection takes levels I – VI +
l papillary > 1 cm, follicular, Hurthle, jugular + CNXI
THYROID CARCINOMA
medullary l Modified Radical dissection
n IF planning post op RAI (MCQ) „ takes levels II – VII
l must do total thyroidectomy, regardless „ spares IJV, SCM, spinal accessory nerve
of size (RAI only useful in well XI (MCQ)
differentiated cancers not MTC) n Levels most at risk are II – VI
n Medullary is the only histology where you do m Prognosis (for well differentiated thyroid cancer):
central dissection (level VI and VII) n Age
prophylactically (in addition to total thyroidectomy) n grade/mets
and modified radical neck dissection (levels II – V) n extent
on affected side (MCQ) n size
n Performing a total thyroidectomy allows use n TNM
of thyroglobulin for recurrence monitoring m However, age, grade (histology), size most
and use of RAI for microscopic disease (MCQ) important (MCQ)
n Medullary Thyroid Cancer: m Age (> 45, or < 14) is single greatest factor
n 20% of those with MTC have MEN II deciding prognosis (MCQ)
n 100% of those with MEN II have MTC m Superior laryngeal nerve (both sensory and
n MEN II associated MTC tends to be motor) (MCQ)
l bilateral, younger, worse prognosis n External branch:
(MCQ) l motor to cricothyroid
l RET proto oncogene (MCQ) l injury lose projection, high pitch tone
l Aggressiveness is as follows: l provides sensory to supraglottis
„ MEN IIB [perform thyroidectomy by 6 m Recurrent laryngeal nerve:
months old] > MEN IIA [perform n innervates all of larynx except cricothyroid
thyroidectomy by 5 years old] > FMTC n bilateral injury causes airway occlusion
(MCQ) m Always assess cord function before any operation
Join free today www.news4medico.com on thyroid to document RLN function

13
TOPIC - 3 m Imaging studies:
PROSTATE CARCINOMA AND BPH n Transrectal sonography
l a sensitive test to detect prostate cancer.
l Carcinomas appear as hypoechoic densities
n Prostate Cancer
m Only about one third of the cases identified at
in the peripheral zone. (MCQ)
n MRI or CT may also be helpful in defining the
autopsy were manifested clinically.
m Rare before age 50 (
extent of the tumor
n but is used with less frequency.
m Classification
n Ninety-five percent are adenocarcinoma,
m Biopsy:
n Essential in establishing the diagnosis of
which has a predilection to start in the
periphery. (MCQ) prostate cancer
n It should be done when (MCQ)
n Generally multifocal. (MCQ)
l an abnormality is detected on rectal exam
m Signs and symptoms
l elevation of PSA level
n Most patients are asymptomatic at the time
l when lower urinary symptoms occur in
of diagnosis
n about 80% of patients have stage C or D
men without known causes of obstruction.
disease at the time of diagnosis. (MCQ) m Staging
n Metastatic spread occurs via:
n In symptomatic patients, common complaints
l Direct extension
include: (MCQ)
SURGERY
l Lymphatics
l Dysuria
l Hematogenous
l Difficulty in voiding
n Direct extension can occur upward into the
l Urinary frequency
l Urinary retention
seminal vesicles and bladder flnor.
n Lymphatic spread is to obturator, internal
l Back or hip pain
l Hematuria
iliac, common iliac, pre-
n sacral, and periaortic nodes. (MCQ)
n Symptoms in advanced disease may include
n Hematogenous spread occurs to bone more
l spinal cord compression
l deep venous thrombosis
frequently than viscera.
PROSTATE CARCINOMA AND BPH
n Whitmore Standard staging scheme

l pulmonary emboli
l Stage A (MCQ)
l myelophthisis.
„ Cancer not detectable by physical exam
m Diagnosis
n The most important physical exam is the
but incidentally on surgical specimen.
l Stage B(MCQ)
digital rectal exam(MCQ)
„ Palpable but confined to the prostate.
n The carcinoma begins most often on the
® B1: Involves only a single nodule
posterior surfaces of the lateral lobes where
it can be easily palpated on digital exam surrounded by normal tissue.
® B2: Involves the gland more diffusely.
(MCQ)
l Stage C: (MCQ)
n Carcinoma is usually hard, nodular, and
„ Palpable tumor extends beyond the prostate but
irregular
n The typical middle raphe of the prostate may
no distant metastasis.
l Stage D:
be obscured by either a malignant or a benign process.
„ Distant metastases are present.
(MCQ)
® D1: To pelvic nodes only
n prostate-specific antigen (PSA)
® D2: Widespread metastasis
l most sensitive test for early detection of
prostatic cancer. m Bony metastasis can contain both osteoblastic
l Following diagnosis, PSA is used to follow
and osteolytic components (MCQ)
progression of disease and response to m Pelvis and lumbar vertebrae are most commonly
treatment(MCQ) affected(MCQ)
l However, the PSA is not a specific
m Skeletal survey has a low sensitivity for detecting
test(MCQ) bony metastasis
l PSA can be elevated in prostatic hyperplasia
m Radionuclide bone scan
n has a much higher sensitivity
or prostatitis.

n also useful in monitoring progression and response l the current trend is to treat advanced
to therapy. disease with combination androgen
m To assess lymph node involvement ablation therapy. (MCQ)
n either lymphangiography or pelvic CT can m Clinical Pearls :
be employed. n Complications of radiation therapy for prostate
n Alternatively, operative staging may be cancer:

employed. l Acute proctitis
m Treatment l Urethritis
n Radical prostatectomy: l Rectal strictures and fistula
l Most clearly indicated in Stage B disease l Impotence (30–50%)
(MCQ) n Tumors are histologically graded using the
l In men with 1- to 2-cm nodules involving only Gleason scoring with scores from 2 (well
one lobe of the prostate, this group has differentiated) to 10 (poorly differentiated).
the highest cure rate. (MCQ) Tumor grade correlates with prognosis. (MCQ)
l Not indicated in most Stage A1 disease since m The vast majority of prostate cancer (-95%) is
the disease is usually cured definitively by adenocarcinoma. (MCQ)

the simple prostatectomy at which the m Arise in the posterior part of the gland(MCQ)
diagnosis is made. (MCQ) m Pattern of spread is via lymphatics to iliac and
l For locally advanced disease, the periaortic nodes and via the circulation to bone,
SURGERY
effectiveness of surgery is uncertain. lung, and liver.
l With the renewed interest in androgen m The treatment options for localized disease
ablation therapy, there may be a role for (stage TI-T2) include (MCQ)
radical prostatectomy in advanced n radical prostatectomy
disease. n external-beam radiotherapy
l There is a definite role for surgery in n interstitial irradiation with implants.
reducing morbidity such as (MCQ) m For local spread (T3-T4), the treatment is
„ bladder outlet obstruction (MCQ)

„ hematuria, n external-beam radiotherapy with the addition

„ ureteral obstruction. of hormonal therapy for more advanced cases.
n Radiation: (MCQ) m Treatment for metastatic disease is hormonal
l For Stage A and B disease: 50% survival ablation, as most prostate cancers are androgen
in 10 years sensitive. (MCQ)
l For Stage C disease: 30% survival in 10 m Bilateral surgical orchiectomy is the gold
years standard for ablating testosterone

l For stage D disease: 55% survival in 5 years production(MCQ)
n Androgen deprivation: m Serum prostate specific antigen (PSA)
l Since growth of the normal prostate is n Kallikrein-like protein produced by prostatic
dependent on testicular androgens, deprivation epithelial cells

of androgens would arrest the development n 4 ng/ml is the upper limit of normal (MCQ)
of prostate cancer. n >10 ng/ml is highly suggestive of prostatic
l Androgen deprivation can be achieved via: carcinoma(MCQ)

„ Surgical castration n Can be significantly raised in BPH
® bilateral orchiectomy results in 90% n useful marker for monitoring response to
reduction in testosterone (MCQ) treatment

„ LHRH analogue therapy m Androgen depletion can be achieved by:
„ Estrogen administration n Bilateral subcapsular orchidectomy
„ To achieve androgen depletion beyond n LHRHagonists-goseraline
the level of surgical castration, n Anti-androgens-cyproteroneacetate,flutamide
adrenalectomy is needed. n Oestrogens-stilbeostrol
o This can be achieved by antiandrogen n The prostate enlarges during puberty when it
drugs (e.g., flutamide). undergoes androgen- mediated growth.
n It remains stable in size until about the fifth or
sixth decade, when its size increases again.(MCQ)
n Pathophysiology l Infection
m Hyperplasia begins in the periuretheral area, then l Clot retention
progresses to the remainder of the gland.(MCQ) l Epididymo-orchitis
m most common initial symptoms are those of l Incontinence
obstructive in nature. o Intermediate
m Histologically, the hyperplastic tissue is comprised l Secondary haemorrhage
of glandular epithelium, stroma, and smooth l Retrograde ejaculation
muscle. .(MCQ) l Erectile dysfunction
m As hyperplasia increases with increasing o Late
obstruction, frank obstruction can occur l Bladder neck stenosis
m frank obstruction may be precipitated by l Urethral stricture
n infection m The size of the gland has no relationship to
n anticholinergic drugs symptomatology. .(MCQ)
n alcohol. n A small gland may produce a high degree of
n Signs and symptoms outflow obstruction, whereas a large gland
m Early symptoms: .(MCQ) may produce no symptoms at all
n Hesitancy in initiating voiding m Urinary flow rate is assessed by measuring the
n Postvoid dribbling volume of urine voided during a 5-second period
n Sensation of incomplete emptying n produces smooth muscle relaxation of both
SURGERY
m As the amount of residual urine increase: . prostate and bladder neck

(MCQ) n infrequent side effect of alpha- antagonists
n Nocturia (e.g., terazosin) is postural hypotension (2-8%)..
n Overflow incontinence (MCQ)
m Palpable bladder m Prostatic hyperplasia can also be treated with 5-
m Frank obstruction alpha reductase inhibitors (e.g., finasteride)
n Diagnosis n block the conversion of testosterone to DHT
m Clinical history without lowering serum levels of
m Digital rectal exam—in hyperplasia, the prostate circulation testosterone.
will be smooth, firm, n However, the effectiveness of 5-alpha reduc-

m but enlarged. .(MCQ) tase inhibitors is less than half that seen with
m Measurement of postvoid residual urine alpha blockers. (MCQ)
volume. m The indications for surgery are. (MCQ)
n Management n postvoid residual volume greater than 100mL.
m Many patients without treatment show no (MCQ)
progression of symptoms. n acute urinary retention
m In patients with advanced symptoms, several n chronic urinary retention with overflow
options exist. dribbling. (MCQ)
m Medical: n gross hematuria on more than one occasion
n LHRH analogues shrink prostatic hyperplasia. n recurrent urinary tract infections.
(MCQ) n patient request for restoration of normal
n Alpha-adrenergic antagonists decrease urethral voiding pattern because of excessive nocturia
resistance.. (MCQ) or dribbling.
m Surgical:
n Transurethral prostatectomy (TURP) is
usually the procedure of choice. .(MCQ)
n Open prostatectomy
Clinical pearls
m Complications following TURP
n Early
l Primary haemorrhage
l Extravasation
l Fluid absorption (TUR syndrome)

TOPIC - 4 SALIVARY TUMORS m Pain is suggestive of malignancy but is not a
reliable symptom
m Facial nerve palsy is highly suspicious of a
n Salivary Gland Tumors
malignant tumour
m No specific risk factors or environmental carcinogens
m Pleomorphic adenoma
have been identified.
n Accounts for 75% of parotid and 50%
m Parotid tumors are the most common. (MCQ)
submandibular tumours (MCQ)
m Most parotid tumors are benign(MCQ)
n Believed to have both epithelial and mesothelial
m half of submandibular and sublingual gland
elements
tumors, and most minor salivary gland tumors,
n Now appears to arise from ductal
are malignant. (MCQ)
myoepithelial cells (MCQ)
m Have a tendency to recur after resection.
n Male : female ratio approximately equal
m All parotid gland tumors can affect the facial
(MCQ)
nerve and cause a unilateral facial palsy.
n Requires excision with 5-10 mm margin as
m Tumor types
local implantation of cells can lead to recurrence
n Pleomorphic adenoma:
m Warthin’s tumour
l Most frequent tumor(MCQ)
n Also known as an adenolymphoma
l Most commonly affects the parotid(MCQ)
n Usually occurs in elderly patients
l can be found in the submandibular or minor
n Male: female ratio is approximately 4 : 1
glands
SURGERY
n 10% of tumours are bilateral
l Benign but recurs; rarely undergoes malignant
n Do not undergo malignant change (MCQ)
transformation
m Malignant salivary tumours
n Warthin’s tumor:
n Also develop distant metastases to the lung
l Papillary cystadenoma lymphomatosum
n Cannon-ball metastases may be present for
l Benign and affects the parotid gland
years without symptoms (MCQ)
n Oncocytoma:
m Enucleation of benign tumours often results in
l Benign
local recurrence
l Affects the parotid
m As salivary gland size↑ increases [sublingual
l Elderly
(60%), (MCQ)submandibular (50%), parotid
SALIVARY TUMORS
n Mucoepidermoid carcinoma:
(20%)] incidence of malignant disease ↓ decreases
l Can vary from benign to highly malignant
m Mucoepidermoid carcinoma:
l Affects the parotid
n Most common malignant salivary tumor
n Adenoid cystic carcinoma:
overall (MCQ)
l Malignant but slow growing
m Adenoid cystic carcinoma:
l late metastasis
n Most common malignant salivary tumor of
l Commonly affects the minor salivary
submandibular/minor glands. (MCQ)
glands(MCQ)
n Overall: poor prognosis
l Has a tendency to recur along the nerve
m Pleomorphic adenoma a ≡ mixed parotid
tracks and cause severe pain
tumor
m TREATMENT
n Most common benign tumor (40 – 70% of
n Benign tumors treated with surgical incision.
all salivary gland tumors)
n Invasive tumors with surgery and radiation.
n Do NOT enucleate (or will recur) (MCQ)
n Neutron radiation is particularly effective.
n needs superficial parotidectomy (spare CN
n Watch for frequent recurrences.
VII). (MCQ)
n Determine status of facial nerve before and
n If malignant take whole gland + CN VII;
after surgery.
(MCQ)
n Chemotherapy with doxorubicin or cisplatin
n If high grade (anaplastic)need neck dissection
for metastatic disease.
(MCQ)
n Clinical Pearls
m Warthin’s tumor (adenolymphoma)
m Open biopsy is contraindicated (MCQ)
n Second most common benign salivary tumor
m Fine needle aspiration cytology may confirm
n male predominance (MCQ)
diagnosis (MCQ)
n 10% bilateral
n Has a poor sensitivity but a high specificity

n 70% of bilateral parotid tumors are Warthin’s TOPIC - 5 B COLORECTAL POLYPS
tumor;
n Rx- superficial parotidectomy(MCQ)
n Colorectal Polyps
m Frey’s Syndrome: m Morphology
n late complication of parotidectomy (MCQ)
n Broadly divided into sessile (f lat) and
n occurs ≈ 50% when facial nerve is preserved
pedunculated (on a stalk).
n profuse perspiration over cheek following
m Histologic types
salivary stimulation. (MCQ) n Inflammatory (pseudopolyp): (MCQ)
n Intracutaneous injection of Botox A ≈ 100%
l Seen in UC
effective in treatment, but responses may be n Lymphoid:
short lived (can be repeated). (MCQ) l Mucosal bumps containing intramucosal
n Usually self limiting.
lymphoid tissue;
m Ipsilateral drooling following submandibular l no malignant potential (MCQ)
gland resection n Hyperplastic:
n likely injury to marginal mandibular nerve
l Overgrowth of normal tissue
(MCQ) l no malignant potential(MCQ)
m Radical neck dissection: takes CN XI, SCM, IJ, n Adenomatous:
submandibular gland; most morbid is CN XI l Premalignant
(MCQ) l classified (in order of increasing malignant
SURGERY
potential) as
„ tubular (75%),(MCQ)
„ tubulovillous (15%)
„ villous (10%)
n Hamartomatous:
l Normal tissue arranged in abnormal
configuration
l juvenile polyps, Peutz–Jeghers
polyps(MCQ)
B COLORECTAL POLYPS

n Asymptomatic (most common) (MCQ)
n Melena
n Hematochezia
n Mucus
n Change in bowel habits
m Diagnosis
n Flexible endoscopy (sigmoidoscopy or
colonoscopy)
m Treatment
n Attempt colonoscopic resection if: (MCQ)
l Pedunculated, well or moderately well
differentiated
l no venous or lymphatic invasion
l invades only into stalk
l margins negative.
m Otherwise, a segmental colon resection is
indicated. (MCQ)
m Malignant potential of a polyp is determined by:
size, histologic type, and epithelial dysplasia.
n SIZE and RISK of CA (MCQ)
l < 1 cm -1–3%
l 1–2 cm - 10%
l > 2 cm -40%
n HISTOLOGY and RISK of CA(MCQ)
l Tubular -5% l Lynch syndrome II: (MCQ)
l Tubulovillous -20% „ Same as Lynch I but additional risk for
l Villous -40% extracolonic adenocarcinomas of the
n ATYPIA and RISK of CA(MCQ) uterus, ovary, cervix, and breast
l Mild -5%
l Moderate -20% TOPIC - 6 CARCINOMA COLON
l Severe -35%
m Polyposis syndromes of the bowel. n Colon cancer
n Familial polyposis coli (FAP) m Incidence increases with increasing age starting at
l Autosomal dominant (MCQ) age 40 and peaks at 60 to 79 years of age.
l Polyps develop between the second and (MCQ)
fourth decades m Risk factors
l colon cancer inevitable without n Age>50
prophylactic colectomy n Personal history of resected colon cancer or
l Caused by abnormal gene on chromosome adenomas
5(MCQ) n Family history of colon cancer or adenomas
l Indication for operation:Polyps n Low-fiber, high-fat diet(MCQ)
l Operations n Inherited colorectal cancer syndrome (familial
„ Proctocolectomy with Brooke’s ileostomy adenomatous polyposis[FAP] (MCQ)
SURGERY
„ Proctocolectomy with continent n hereditary nonpolyposis colon cancer
ileostomy [HNPCC]) (MCQ)
„ Colectomy with ileorectal anastomosis n Long-standing UC or Crohn’s disease(MCQ)
„ Proctocolectomy with ileal pouch—anal m Adenoma–Carcinoma sequence
anastomosis n Normal → hyperproliferative → early
n Gardner’s syndrome adenoma → intermediate adenoma → late
l Autosomal dominant (MCQ) adenoma → carcinoma (→ metastatic disease)
l Innumerable polyps with associated l APC loss or mutation(MCQ)
osteomas, epider mal cysts, and l Loss of DNA methylation (MCQ)
CARCINOMA COLON
fibromatosis (MCQ) l Ras mutation
l colon cancer inevitable without surgery l Loss of DCC gene (MCQ)
n Turcot’s syndrome l Loss of p53
l Autosomal recessive (MCQ) m Signs and symptoms
l Multiple adenomatous colonic polyps with n Typically asymptomatic for a long period of
CNS tumors (especially gliomas) (MCQ) time
n Cronkite–Canada syndrome n Right-sided cancers: (MCQ)
l GI polyposis with alopecia, nail dystrophy, l Occult bleeding with melena, anemia, and
and hyperpigmentation (MCQ) weakness
l minimal malignant potential (MCQ) n Left-sided cancers: (MCQ)
n Peutz–Jeghers syndrome l Rectal bleeding, obstructive symptoms
l Autosomal dominant (MCQ) l change in bowel habits and/or stool caliber
l Hamartomatous polyps of the entire GI n Both: Weight loss, anorexia
tract m Diagnosis
l melanotic pigmentation of face, lips, oral n Colon cancer:
mucosa, and palms (MCQ) l Flexible sigmoidoscopy or colonoscopy
l increased risk for cancer of the pancreas, (need to evaluate entire colon and rectum to
breast, lung, ovary, and uterus (MCQ) look for synchronous lesions), barium enema
n Hereditary nonpolyposis colon cancer n Rectal cancer:
syndrome (HNPCC or Lynch syndrome) l Digital rectal exam, proctoscopy/
l Autosomal dominant (MCQ) colonoscopy
l Lynch syndrome I: (MCQ) l barium enema
„ Patients without multiple polyps who
develop predominantly right-sided
colon cancer
l To assess depth of local tumor invasion and „ Ligation of ileocolic, right colic,and right
local lymph node status. -transrectal ultrasound branch of middle colic arteries
(TRUS), CT, MRI n Right colon
m Treatment l Right hemicolectomy
n Surgical resection n Proximal/mid- transverse colon
l Goal is to remove primary tumor along with l Extended right hemicolectomy(MCQ)
lymphatics draining involved bowel. „ Resection as above plus remainder of transverse
l Involves at least a 2-cm margin both colon and splenic flexure
proximally and distally (traditionally requires „ Ligation of ileo colic,right colic,and middle colic
a 5-cm margin). (MCQ) artery
l In rectal cancer, the circumferential radial n Splenic flexure and left colon
margin (CRM) is crucial to local recurrence. l Left hemicolectomy: (MCQ)
(MCQ) „ Resection through descending colon
l Local recurrence to be 55% in patients with a „ Ligation of left colic artery
positive CRM, 28% with a margin <1 mm, n Sigmoid or rectosigmoid colon
and 10% with a margin >1 mm. (MCQ) l Sigmoid colectomy: (MCQ)
n Adjuvant treatment: „ Ligation of inferior mesenteric artery
l Dukes C colon cancer: (MCQ) (IMA) distal to take off of left colic artery
„ 5-FU and levamisol including sigmoidal and superior rectal arteries
SURGERY
„ 5-FU and leucovorin n Proximal rectum

l Fixed rectal cancer: Preop XRT(MCQ) l Low anterior resection (LAR):
l Rectal cancer that is transmural or has „ Indication - Tumors > 4cm from anal
positive nodes: (MCQ) verge (with distal in trans mural spread
„ Pelvic radiation,using 5-FU as a radiosensitizer < 2 cm) (MCQ)
m Staging and prognosis „ Must be able to get 2-cm margin (MCQ)
n Dukes System(MCQ) „ Includes total meso rectum
l A: Limited to wall excision(MCQ)
l B: Through wall of bowel but not to lymph „ Involves complete mobilization of
CARCINOMA COLON
nodes rectum,with division of lateral ligaments,

l C: Metastatic to regional lymph nodes posterior mobilization through Waldeyer’s fascia to
l D: Distant mets tip of coccyx, dissection between rectum and vagina
n TNM system (MCQ) or prostate (MCQ)
l T1: Invasion of submucosa „ Complications: (MCQ)
l T2: Invasion of muscularis propria ® Incontinence,urinary dysfunction
l T3: Invasion of subserosa, or ® sexual dysfunction
nonperitonealized pericolic or perirectal ® anastomotic leak (5–10%)
tissues ® stricture (5–20%)
l T4: Invasion of visceral peritoneum or direct n Distal rectum
invasion of other organs l Abdominal–perineal resection (APR):
l N0: No nodal disease „ Tumors not fitting criteria for LAR
l N1: 1 to 3 pericolic or perirectal lymph nodes (MCQ)
l N2: 4 or more pericolic or perirectal lymph „ Involves creation of endostomy,with
nodes resection of rectum,total mesorectal
l N3: Involvement of any lymph node along excision (TME), and closure of anus
the course of a named vessel M0: No evidence (MCQ)
of distant mets „ Complications:
l M1: Distant mets ® Stenosis
m Operative management of CRC based on tumor ® retraction or prolapse of ostomy,
location. ® perineal wound infection
n Cecum n Obstructing cancer: (MCQ)
l Right hemicolectomy: (MCQ) l Attempt to decompress
„ Resection of terminal ileum, cecum, n Perforated cancer: (MCQ)
ascending and proximal transverse colon l Remove disease and perforated segments

n Synchronous or metachronous lesions ,or l T1N0M0/T2N0M1 (74%)
proximal perforation with distal ca: (MCQ) n Stage II:
l Subtotal colectomy with ileosigmoid or l T3N0M0/T4N0M0 (63%)
ileorectal anastomosis n Stage III:
n Very distal rectal tumor and /or patient not l anyTN1M0/anyTN2-3M0 (46%)
stable for big operation: (MCQ) n Stage IV:
l Transanal excision of tumor l any T any N M1 (5%)
l endoscopic microsurgery, m Rectal cancer:
l endocavitary radiation n 5-year survival I: 72%( II: 54% III: 39% IV:
Rare
n Recommended Cancer Screening Measure(s)/ m Local recurrence after resection with intent to
Treatment cure is 5–30%, with total mesorectal excision,
m Digital rectal examination - Every year after 3.5%. (MCQ)
40 (MCQ) n Recurrence may require pelvic exenteration.
m Fecal occult blood test -Every year after n 40% are rectal and 60% are colonic
50(MCQ) tumours(MCQ)
m Flexible sigmoidoscopy (MCQ) n Familial colo rectal cancer(20%) (MCQ)
n Every 5 years after 50, with fecal occult blood m First or second degree relatives with cancer but criteria
test (FOBT) for HNPCC not fulfilled
SURGERY
m Colonoscopy (MCQ) m One first-degree relative increases risk by 2.3
n Every 10 years m Two or more first degree relatives increases risk
m Persons at high risk for colon cancer (FAP, by 4.3
HNPCC, UC, high-risk adenomatous polyps) m Index case <45 years increases risk by 3.9
(MCQ) m Family history of colorectal adenoma increases
n Regular endoscopic screening by a specialist risk by 2.0
m Follow-up after resection of colorectal n Any surgical resection requires 5 cm proximal and
carcinoma (CRC) (MCQ) 2 cm distal clearance for colonic lesions (MCQ)
n Perioperative colonoscopy to remove any n 1 cm distal clearance of rectal lesions adequate if
CARCINOMA COLON
synchronous cancer mesorectum resected(MCQ)
n Colonoscopy 1 year post op and yearly n Radial margin should be histopathologically free of
thereafter to look for metachronous lesions tumour if possible (MCQ)
n Colonoscopy 3 years after one negative test n Lymph node resection should be performed to
n Colonoscopy every 5 years once a 3-year test the origin of the feeding vessel
is negative n En Bloc resection of adherent tumours should be
n Clinical Pearls performed (MCQ)
m At diagnosis of CRC: (MCQ) n The value of a ‘no-touch’ techniques remains
n 10% in situ disease unproven
n One third local disease n Adjuvant radiotherapy
n One third regional disease m In patients with rectal cancer ,50% undergoing
n 20% metastatic disease curative resection develop local recurrence
m Microcytic anemia in an elderly male or (MCQ)
postmenopausal woman is colon cancer until m Median survival with local recurrence is less than
proven otherwise. (MCQ) one year
m Rule out metastases from colorectal cancer with m Risk factors for local recurrence include:
CXR, CT of abdomen and pelvis, and liver n Local extent of tumour
function tests. n Nodal involvement
m Measure carcioembryonic antigen (CEA) to n Circumferential margin status
establish a baseline level. m Risk of local recurrence can be reduced by
m The “apple core” filling defect in the descending radiotherapy
colon on barium enema is classic for left-sided m Can be given either preoperatively or
colon cancer. (MCQ) postoperatively
m CRC 5-year survival by stage: m Preoperative radiotherapy given as short course
n Stage I: immediately prior to surgery (MCQ)
n Reduces local recurrence TOPIC - 7 GALL STONE
n Increases time to recurrence
n Increases 5-year survival
n Gallstones
m Combination chemotherapy and radiotherapy
m Prevalence increases with advancing age
may produce better outcome m 10-20% become symptomatic (MCQ)
n Adjuvant chemotherapy m Over 10% of those with stones in the
m Improves survival in Duke’s C tumors (MCQ)
gallbladder have stones in the common bile
m Not required in Duke’s A tumours which already
duct (MCQ)
have a good prognosis m Pathophysiology
m Role in Duke’s B tumours remains to be defined
n Three types of stones
(MCQ) l Cholesterol stones(15%)
m Results of QUASAR (Quick and Simple and
l Mixed stones (80%) (MCQ)
Reliable) study to date have shown: l Pigment stones(5%)
n 5FU and Folinic acid is effective as adjuvant
n 10% of gallstones are radio-opaque (MCQ)
therapy n Bile acids act as a detergent keeping
n High dose folinic acid rescue confers no
cholesterol in solution
additional benefit n Bile acids, lecithin and cholesterol result in
n The use of levimasole confers no additional benefit
the formation of micelles
n Treatment n Bile is often supersaturated with cholesterol
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m Stage I,II colon: Surgery alone (current trials

n Biliary infection, stasis and changes in
looking into adjuvant chemo for II) (MCQ) gallbladder function can precipitate stone
m Stage III colon: Surgery + Chemo (FL ± what
formation
other trials throw in) (MCQ) n Bile is infected in 30% of patients with
m Stage II, III rectal: Surgery + Chemo/XRT
gallstones
(adjuvant) (MCQ) n Gram-negative organisms are the most common
m Stage IV: (MCQ)
isolated (MCQ)
n 5FU/Leukovorin (FL)
m Clinical presentations
n Oxaliplatin
n Acute cholecystitis
n CPT 11(Irinotechan)
n Empyema of the gallbladder
n Avastin
GALL STONE
n Mucocele of the gallbladder

n IFL (Saltz regimen) + Avastin (MCQ) n Biliary colic
m increased median survival to 20.3 months from
n ‘Flatulent dyspepsia’
15.6 months (IFL alone); n Mirrizi’s syndrome
m But no increase in 5-year survival
n Obstructive jaundice
m (no regimen has impacted this in nearly 20
n Pancreatitis
years) n Acute cholangitis
n Post Resection Follow - Up (Debatable) m Acute cholecystitis
m CEA - q3 months
n 90% cases result from obstruction the cystic
m Colonoscopy - q1–3years
duct by a stone
m Serial CT - q6 months
n Increased pressure within the gallbladder
m Liver enzymes - q2 – 3 months (LDH is most
results in an acute inflammatory response
important) n Most common organisms are E. coli,
m CXR -q6 months
Klebsiella and strep. Faecalis (MCQ)
n CT will miss nearly 40% of recurrences n Clinical features
m 60 – 90% of these missed lesions will be intra -
l Constant pain (usually greater than 12 hours
abdominal duration) in right upper quadrant
n FDG-PET is 89% sensitive when other modalities l Fever, tachycardia
are negative, so algorithm is: (MCQ) l Tenderness in right upper quadrant
l Murphy’s sign - guarding in right upper
quadrant on deep inspiration (MCQ)
m Investigation
n Ultrasound is the initial investigation of
choice (MCQ)
n Diagnostic features on ultrasound include: n Shown tbe equally as effective as open
l Presence of gallstones cholecystectomy in controlled trials
l Distended thick-walled gallbladder n Pre-operative ERCP indicated if: (MCQ)
l Pericholecystic fluid l Recent jaundice
n Murphy’s sign demonstrated with ultrasound l Abnormal liver function tests
probe l Significantly dilated common bile duct
l If diagnostic doubt a HIDA scan may be l Ultrasonic suspicion of bile duct stones
useful (MCQ) n Technique
l Will show failure of isotope l CO2 pneumo-peritoneum induced using
(hydroxyiminodiacetic acid) uptake by either Veress needle or open technique
gallbladder (MCQ)
m Complications of acute cholecystitis (MCQ) l Open (Hasson) technique is believed be
n Gangrenous cholecystitis safer
n Gallbladder perforation l Over half of bowel injuries are caused by Veress
n Cholecystoenteric fistula needles or trocars
n Gallstone ileus l Abdominal pressure set to 12-15 mm Hg
m Management l High intra-abdominal pressure can:
n Initial management is usually conservative „ Reduce pulmonary compliance
n Patient is fasted, given intravenous fluids and „ Decrease venous return
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opiate analgesia „ Higher end-tidal CO2 levels
n Intravenous antibiotics (e.g. second generation l Surgery usually performed using four
cephalosporin) should be given to prevent standard ports (2 x10 mm & 2 x 5 mm)
secondary infection l Patient positioned with head up tilt and
n 80% patients improve with conservative rolled tthe left
treatment l Calot’s triangle dissected using a retrograde
n If fit, should be considered for a laparoscopic technique (MCQ)
cholecystectomy (MCQ) l Cystic duct and artery identified
n Timing of surgery l Ligated with clips or endo-loops
l early surgery (<72 hours) is safe l About 50% surgeons routinely use intra-
l It has a lower conversion rate operative cholangiography
GALL STONE
l It avoids the complications of conservative l Cholangiography allows: (MCQ)
treatment failure „ Definition of biliary anatomy
l If patient unfit for surgery, percutaneous „ Identification of unsuspected CBD
cholecystotomy my be beneficial stones(~10%patients)
n Particularly useful in acalculus cholecystitis n Outcome
n Treatment of gallbladder stones l Conversion rates typically about 5%
m Open cholecystectomy l Laparoscopic cholecystectomy associated
l Specific complications with:
„ Bile duct damage l Reduced analgesic requirements
„ Retained stones l Reduced postoperative stay
„ Bile leak l Bile duct injury
l General complications „ Occurs in between 0.1% and 0.5% of
„ Wound dehiscence patients
„ Pulmonary atelectasis „ For most injuries hepaticojejunostomy is
m ‘mini’ cholecystectomy is done through a 5 cm the treatment of choice (MCQ)
transverse incision (MCQ) „ Long-term risk include stricture
m Dissolution therapies formation and cirrhosis
l High complication rate n Laparoscopic surgery in acute cholecystitis
l Poor long-term results „ In those with acute cholecystitis ,
m Extra-corporeal shock wave lithotripsy operation has usually been deferred 6-8
l Poor stone clearance weeks (MCQ)
m Laparoscopic Cholecystectomy „ Recently shown that early laparoscopic
cholecystectomy is safe
m Emphysematous Cholecystitis „ Ultrasound: (MCQ)
l Severe variant of cholecystitis caused by gas- ® Useful to confirm cholelithiasis; may also
forming bacteria identify the fistula
l Relatively rare „ Upper and lower GI series: Other
l Often results in perforation of the diagnostic options that are usually
gallbladder unnecessary
l high mortality and morbidity l Treatment
l Typically affects elderly diabetic men „ Exploratory laparotomy, removal of the
m Acalculous Cholecystitis gallstone, and possible small bowel re-
l Acute cholecystitis without evidence of section with or without
gallstones; thought to be due to biliary stasis. cholecystectomy and fistula repair
l Ten percent of cases of acute cholecystitis. „ Typical clinical scenario of Gall stone ileus:
l Risk factors (MCQ) (MCQ)
„ intensive care unit (ICU) patients with ® A 78- year-old female with a past history
multiorgan system failure of cholelithiasis presents complaining of
„ trauma (especially after major surgery) RUQ pain that radiates to her back,
„ burns, sepsis with nausea, vomiting, and abdominal
„ TPN distention. Abdominal plain films show
l Diagnosis air in the biliary tree and a “‘stepladder”
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„ Leukocytosis, with or without increased appearance of the small bowel.

ALP, LFTs, amylase, and total bilirubin ® Think: The history is consistent with both
l Ultrasound: cholelithiasis and small bowel
„ Biliary sludge and inflammation; can obstruction, and findings on abdominal
also be used to detect complications (e.g., radiograph are suggestive of gallstone
gangrene, empyema, or perforation of the ileus.
gallbladder) Clinical Pearls :
l HIDA scan: To confirm diagnosis m By definitions: stones in CBD > 2 years after
l Treatment cholecystectomy are primary CBD stones
„ Urgent cholecystectomy (MCQ) (pigmented, related to biliary stasis and infection),
„ percutaneous cholecystectomy is an rather than cholesterol stones; need
GALL STONE
option in p tients with high surgical risk sphincterotomy and (extraction (MCQ)
(MCQ) m Three most sensitive signs of cholecystitis: (MCQ)
m GALLSTONE ILEUS l Sonographic Murphy’s sign
l Small bowel obstruction caused by a gallstone l Wall thickening > 4 mm
l the ileocecal valve is the most common site l Pericholecystic fluid
of obstruction. (MCQ) m Postop lap chole patient not doing well, think:
l Most often a large stone has eroded a hole (MCQ)
through the gallbladder wall to the duodenum, l 5 Viscous injury (e.g. duodenum)
causing a cholecystenteric fistula l 5 Duct injury
l A gallstone escapes through this hole into l 5 Bile leak
the GI tract and eventually gets stuck in the l 5 Retained CBD stone
ileum, causing small bowel obstruction. l 5 Cystic duct stump leak
l Most common in women over 70. m Management of gallstone ileus: (MCQ)
l Symptoms of acute cholecystitis followed by l Remove stone (via enterotomy proximal at
signs of small bowel obstruction (nausea, site of obstruction)
vomiting, abdominal distention, RUQ pain). l Run entire bowel
(MCQ) l In acute setting, especially elderly, reserve
l Diagnosis cholecystectomy for later (risk of recurrence
„ Abdominal plain films— pathognomonic ≈ 5 – 10%) & repair biliary enteric fistula
features (MCQ) m Blood supply to supraduodenal bile duct arises
® Pneumobilia from RHA and branches of GDA
® dilated small bowel (retroduodenal artery) and lie longitudinally
® a large gallstone in the RLQ at the 3 and 9 o’clock positions
m 5 Stones associated with ileal disease/resection l Has sickle cell anemia
and TPN use are pigmented stones, not l Hasa stone >2 to 3 cm
cholesterol stones (are composed of calcium l Is a pediatric patient
bilirubinate) (MCQ) m Symptomatic cholelithiasis requires
m 5 Primary common duct stones (those in duct cholecystectomy.
> 2 years after cholecystectomy) are pigmented m Medical treatment of cholelithiasis involves
and related to biliary stasis and infection, not chenodeoxycholic acid or ursodeoxycholic
cholesterol (MCQ) acid, drugs that can be used to dissolve cholesterol
m 5 Natural History of Asymptomatic Gallstones: stones. These are not effective as surgical
l Symptoms develop in about 1 – 3% of management.
patients per year.
l Hence, observe asymptomatic stones.
m Complicated gallstone disease develops in about TOPIC - 8 PEPTIC ULCER
3 – 5% of symptomatic patients per year.
m Intraoperative cholangiography is not considered n Stomach - Blood Supply (Basic MCQ in every
adequate unless the following are visualized: MD Entrance)
(MCQ) m Greater curvature: Right and left gastroepiploic
l Both right and left hepatic ducts (if notbe arteries
concerned about duct transaction) m Lesser curvature: Right and left gastric arteries
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l CBD without filling defect m Pylorus: Gastroduodenal artery
l Free flow of contrast into duodenum (try m Fundus: Short gastric arteries
glucagon if not seeing) n Stomach – Innervation (MCQ)
m Concentrates bile by active absorption of Na+, m Anterior gastric wall: Left vagus nerve
Cl (H2O follows) m Posterior gastric wall: Right vagus nerve
m cholecystectomy works by eliminating reservoir m Sympathetic afferents from level T5 (below
forces a more continuous source of bile and nipple line) to T10 (umbilicus) are responsible
eliminates chance for “sludge” and stone for sensation of gastroduodenal pain.
formation. n Peptic ulcer disease
m 70% of patients with EF < 30% (normal is > m PUD consists of duodenal ulcers (DUs) and
35%) on CCK HIDA benefit from
PEPTIC ULCER
gastric ulcers (GUs).
cholecystectomy, although this may still be m Two times more common in men.
controversial m Incidence increases with age.
m HIDA scan (most sensitive) (MCQ) m Smoking and EtOH increase risk.
l A radionu- cleotide scan in which m Pathophysiology
Technetium-99m labeled iminodiacetic n Parietal cells secrete HCl into the gastric
acid is injected intravenously into hepatocytes. lumen and bicarbonate into the gastric venous
l A normal gallbladder would be visualized circulation (alkaline tide) and into the protective
within 1 hour. gastric mucous gel.
m Gall stone are often incidental, as most patients n A proton pump exchanges potassium in the
are asymptomatic. gastric lumen for protons.
m Abdominal plain films pick up 15% of n The parietal cells are stimulated by gastrin,
gallstones. the vagus nerve, and histamine.
m Ultrasound for Gall stones: n Gastrin release (MCQ)
l Procedure of choice; l stimulated by gastrin-releasing peptide
l classic findings include an l inhibited by somatostatin.
„ acoustic shadow (“headlight”) n Histamine receptors on parietal cells also
„ gravity-dependent movement of stimulate HCl secretion.
gallstones with patient repositioning n Gastric bicarbonate secretion into the mucous
m Asymptomatic cholelithiasis does not require gel is inhibited (MCQ)
cholecystectomy unless the patient: (MCQ) l NSAIDs
l Has a porcelain gallbladder (which has an l Acetazolamide
increased incidence of carcinoma) l Alpha blockers,
l Alcohol.

n Gel thickness is increased by prostaglandin E l H. pylori:
(PGE) and reduced by steroids and NSAIDs. „ Endoscopy with biopsy—allows C&S
m Complications for H. pylori
n Bleeding: 20% incidence „ organism is notoriously hard to
n Perforation: (MCQ) culture(MCQ)
l Incidence: 7%. „ multiple specimens required during
l Posterior perforation of a duodenal ulcer biopsy
will cause pain that radiates to the back and l Serology:
can cause pancreatitis or cause GI bleeding. „ Anti-H. pylori immunoglobulin G
l A chest or abdominal film will not show (IgG) indicates current or prior infection.
free air because the posterior duodenum l Urease breath test:
is retroperitoneal. „ C13/14 labeled urea is ingested. (MCQ)
l Anterior perforation will show free air „ If gastric urease is present, the carbon
under the diaphragm in 70% of cases. isotope can be detected as CO2 isotopes
n Gastric outlet obstruction, due to scarring in the breath.
and edema. n ZE:
n DUODENAL ULCER (DU)) l A fasting serum gastrin level ??1,000 pg/
m Pathophysiology - Increased acid production. mL is pathognomonic for gastrinoma.
(MCQ) (MCQ)
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m Etiology l Secretin stimulation test: (MCQ)

n Helicobacter pylori: (MCQ) „ Secretin, a gastrin inhibitor, is delivered
l A bacterium that produces urease, parenterally (usually with Ca2+) and its
l breaks down the protective mucous lining of effect on gastrin secretion is measured.
the stomach „ In ZE syndrome, there is a paradoxical
l 10% to 20% of persons with H. pylori astronomic rise in serum gastrin.
develop PUD. l Over 90% of patients with ZE have PUD.
n NSAIDs/steroids: (MCQ) n H. pylori may colonize 90% of the
l Inhibit production of PGE, which population— infection does not necessitate
stimulates mucosal barrier production. disease. (MCQ)
n Zollinger–Ellison (ZE) syndrome: (MCQ) n Most common location for DU: Posterior duodenal
PEPTIC ULCER
l A gastrin-secreting tumor in or near the wall within 2 cm of pylorus treatment(MCQ)

pancreas. m Medical Management
l 0.1–1% of patients with ulcer. n Discontinue NSAIDs, steroids, smoking.
l 20% of ZE patients have associated multiple n Proton pump inhibitors (omeprazole,
endocrine neoplasia 1(MEN-1). (MCQ) lansoprazole, pantoprazole):
l Two thirds are malignant. (MCQ) n 90% cure rate after 4 weeks. (MCQ)
l Diarrhea is common. n Eradication of H. pylori: (MCQ)
l Can see jejunal ulcers(MCQ) l Proton pump inhibitor, clarithromycin,
m Clinical features and amoxicillin/metronidazole x 14 days
n Burning gnawing epigastric pain that occurs „ < 90% cure rate
with an empty stomach: l Bismuth, metronidazole, tetracycline x 14
n Pain is relieved within 30 minutes by food. days:
n Nighttime awakening (when stomach „ < 85% cure rate
empties) (MCQ) l H2 blockers (cimetidine, ranitidine,
n Nausea, vomiting. famotidine, nizatidine):
n Associated with blood type O. (MCQ) „ 85–95% cure rate after 8 weeks.
m Diagnosis – l Prostaglandin analogues (e.g.,
n DU misoprostol) work because of their anti-
l Via endoscopy secretory effect
„ Most symptomatic cases of DU are easily l Not as efficacious as H2 blockers, so no
diagnosed clinically longer recommended.
„ If patient responds to DU therapy, there n Antacids:
is no need to do the biopsy. (MCQ)
l Over the counter, good for occasional use m Causes
for all causes of dyspepsia, but better drugs n NSAIDs and steroids inhibit production of
are available for active ulcer disease. PGE.
m Surgical Management n PGE stimulates production of the gastric
n Since the advent of highly effective medical mucosal barrier.
therapy, elective surgery for PUD is quite rare. n H. pylori produces urease, which breaks down
n Surgery is indicated (MCQ) the gastric mucosal barrier.
l when ulcer is refractory to 12 weeks of m Classification (MCQ)
medical treatment n Type I: Ulcer in lesser curvature at incisura
l if hemorrhage, obstruction, or angularis
perforation is present. n Type II: Simultaneous gastric and duodenal
n Truncal vagotomy and selective vagotomy ulcer
(MCQ) n Type III: Prepyloric ulcer
l not commonly performed anymore due to n Type IV: Ulcer in gastric cardia
associated morbidity (high rate of dumping m Signs and symptoms
syndrome) despite good protection against n Burning, gnawing epigastric pain that occurs
recurrence. with anything in the stomach: Pain is worst 30
n Procedure of choice is highly selective minutes after food.
vagotomy (parietal cell vagotomy, proximal n Anorexia/weight loss
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gastric vagotomy) (MCQ) n Vomiting
l Individual branches of the anterior and n Associated with blood type A (MCQ)
posterior ner ves of Latarjet in the m Diagnosis
gastrohepatic ligament going to the lesser n Via endoscopy.
curvature of the stomach are divided from a n Three percent of GUs are associated with
point 6 cm proximal from the pylorus to a gastric cancer so all GU are biopsied. (MCQ)
point 6 cm proximal to the m Treatment
esophagogastric junction. n Medical options same as for duodenal ulcers
l The terminal branches to the pylorus and n Surgical options: (MCQ)
antrum are spared, preserving pyloroantral l Antrectomy for types I and II
function and thus obviating the need for l Highly selective vagotomy for type III
PEPTIC ULCER
gastric drainage. l Subtotal gastrectomy followed by Roux-
l Preferred due to its lowest rate of dumping; en-Y esophagogastrojejunostomy for
however, it does have the highest rate of type IV
recurrence. m Special Gastric Ulcers
n Recurrence depends on site of ulcer n Curling’s ulcers: (MCQ)
preop(MCQ) l Gastric stress ulcers in patients with severe
l Prepyloric ulcers have the highest burns
recurrence rate at 30%. n Cushing’s ulcers: (MCQ)
n Laparoscopic option: l Gastric stress ulcer related to severe CNS
l A posterior truncal vagotomy coupled with damage
an anterior seromyotomy is being done m Postgastrectomy syndromes
laparoscopically in select centers. n Dumping Syndrome (MCQ)
n For ZE: l Complication of gastric surgery thought to
l The tumor is resected. result from unregulated movement of
l Occasionally, when focus of tumor cannot gastric contents from stomach to small
be found, a total gastrectomy may be intestine. (MCQ)
considered in severe cases. l Signs and symptoms
n GASTRIC ULCER (GU) „ Typically occur 5 to 15 minutes (early
m Decreased protection against acid(MCQ) dumping syndrome) or 2 to 4 hours (late
m Normal or low acid production(MCQ) dumping syndrome) after eating: (MCQ)
m Can be caused by reflux of duodenal contents ® Nausea, vomiting
(pyloric sphincter dysfunction) and decreased ® Diarrhea
mucus and bicarbonate production ® Belching

® Tachycardia, palpitations n Pain usually worsened with food and relieved
® Diaphoresis, flushing by antacids.
® Dizziness, syncope n Vomiting may relieve the pain after eating.
l Treatment m Diagnosis is made by endoscopy.
„ Avoid high-sugar food or excessive m Treatment
water intake. n Halt NSAIDs.
„ Severe cases (1%) that do not respond to n Triple therapy to eradicate H. pylori if present.
dietary modifications can be treated with n Halt cigarettes and alcohol.
octreotide. (MCQ) n H2 blockers (e.g., cimetidine, ranitidine),
n Postvagotomy Diarrhea sucralfate, or misoprostol.
l Seen mostly after truncal vagotomy. n Over-the-counter antacids.
(MCQ) m Complications
l Usually self-limited. (MCQ) n Chronic gastritis leads to:
l Treated symptomatically with kaolin–pectin, l Gastric atrophy
loperamide, or diphenoxylate as needed. l Gastric metaplasia
l Refractory cases may respond to l Pernicious anemia (MCQ)
cholestyramine. (MCQ) „ decreased production of intrinsic factor
n Alkaline Reflux Gastritis from gastric parietal cells due to idiopathic
l Diagnosis of exclusion after recurrent ulcer atrophy of the gastric mucosa and
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has been ruled out. subsequent malabsorption of vitamin

l Presents with chronic abdominal pain and B12
bilous vomiting. GASTRIC OUTLET OBSTRUCTION
l Medical treatment is difficult. m Common causes
l Surgical management: (MCQ) n Malignant tumors of stomach and head of
„ Roux-en-Y gastrojejunostomy with pancreas.
Roux limb at least 45 to 50 cm long. n Obstructing gastric or duodenal ulcers.
„ Recurrence still reported with this n Usually with duodenal ulcer.
procedure. n Chronic ulcer causes secondary edema or
n Afferent Loop Syndrome scarring, which occludes lumen.
l Obstruction of afferent limb following m SYMPTOMS
PEPTIC ULCER
gastrojejunostomy (Bilroth II) (MCQ) n Early(MCQ)

l Two thirds present in first postoperative l Early satiety ,Gastric reflux ,Weight loss ,
week(MCQ) Abdominal distention
l Signs and symptoms n Late(MCQ)
„ Right upper quadrant (RUQ) pain l Vomiting ,Dehydration , Metabolic
following a meal alkalosis (due to secondary
„ Bilous vomiting hyperaldosteronism due to repeated vomiting
„ Steatorrhea induced dehydration)
„ Anemia m Diagnosis - Endsocopy or barium swallow x-ray.
l Diagnosis m Treatment
„ Afferent loop will be devoid of contrast n Endoscopic balloon dilatation(MCQ)
on the upper gastrointestinal (UGI) n Surgical resection:
series. (MCQ) l Truncal vagotomy and pyloroplasty after
l Treatment(MCQ) 7 days of nasogastric decompression and
„ Endoscopic balloon dilatation antisecretory treatment(MCQ)
„ Surgical revision n Clinical Pearls
n Gastritis m Typical Clinical scenario of Gastric Perforation:
m Increased acid: Smoking, alcohol, stress (MCQ)
m Decreased mucosal barrier: NSAIDs, steroids n A patient with known PUD presents with
m Direct irritant: Pancreatic and biliary reflux, sudden onset of severe epigastric pain.
infection Physical exam reveals guarding and rebound
m Signs and symptoms tenderness.
n Burning or gnawing pain.

m Typical Clinical scenario of Gastric outlet Sensitivity and specificity of H. pylori diagnostic tests
obstruction.: (MCQ)
n A 56- year-old woman presents due to 3
Test Sensitivity Specificity
months of early satiety, weight loss, and (%) (%)
non-bilious vomiting Rapid urease 90 90-95
n Over 90% of patients with ZE have PUD.
Culture 80 100
m Typical Clinical scenario of Duodenal ulcer..
Microscopy 90 90
(MCQ) Carbon breath test 95 95
n A 38- year-old female presents with burning
Serology 98 100
epigastric pain that is improved after eating a
meal.
m Billroth I gastrectomy (MCQ)
m Most common location for DU: Posterior
l Originally described for the resection of
duodenal wall within 2 cm of pylorus (MCQ)
distal gastric cancers
m Complications of surgery for peptic ulcer
l Still used in gastric cancers if radical
disease:
gastrectomy is inappropriate
n Dumping syndrome
l Later applied in the treatment of benign
n Afferent loop syndrome
gastric ulcers
n Postvagotomy diarrhea
l Indications :
n Duodenal stump leak
l if ulcer situated high on the lesser curve
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n Efferent loop obstruction
l bleeding ulcer that requires resection
n Marginal ulcer
l Less effective than Polya Gastrectomy for
n Alkaline reflux gastritis
duodenal ulcers
n Chronic gastroparesis
m Billroth II / Polya gastrectomy(MCQ)
n Post gastrectomy stump cancer
n Initially described for duodenal ulceration but
m Gastric ulcers can even occur with achlorhydria.
rarely performed today
(MCQ)
n Some form of vagotomy is the surgical treatment
m Smoking is a risk factor for GU. (MCQ)
of choice for uncomplicated DU
m Most common location for GU: Lesser
n Occasionally used below a high gastric ulcer
curvature(MCQ)
n Ulcer invariably heals after surgery
m Typical Clinical scenario Gastric ulcer.:
PEPTIC ULCER
n Useful in recurrent ulceration following
(MCQ)
previous vagotomy
n A 52- year-old male smoker working as
Marketing Head of a Multinational company
presents with weight loss and epigastric pain
exacerbated by eating.
m Typical Clinical scenario of Afferent loop
syndrome.: (MCQ)
n A 62- year-old woman who is 7 days postop
from a gastrojejunostomy for PUD presents
with postprandial RUQ pain and nausea. She
reports that vomiting relieves her suffering
m Cimetidine is a p450 inhibitor, and therefore
prolongs the action of drugs cleared by this system.
n Helicobacter pylori
m 90% patients with duodenal ulceration
m 70% patients with gastric ulceration
m 60% patients with gastric cancer

TOPIC - 9 TESTICULAR CARCINOMA l Gonadoblastomas (germinal cell ??stromal
cell):
n Testicular cancer m seminomas vs nonseminomas
m The most common malignancy to affect young n Relative radioresponsiveness of seminomas
men.(MCQ) compared with the radioresistance of

m There is a peak frequency in early childhood nonseminomas. (MCQ)
m a larger peak incidence between 20 and 35 years n Pure seminomas: (MCQ)
of age. (MCQ) l Radiation therapy (XRT) is the mainstay
m Uncommon after age 40. of treatment.

m Risk factors n Nonseminomas: (MCQ)
n Men with cryptorchid (undescended) testes l Retroperitoneal lymph node dissection ±
(MCQ) chemotherapy.
n intra-abdominal testes with the highest risk. m Staging evaluation
n Both the affected testis and the normally n To determine whether the cancer is:
descended testis are at risk l Localized to the testis
n History of mumps orchitis. l Regional lymphatics
n Inguinal hernia in childhood. (MCQ) l Widely metastasized
n Testicular cancer in the contralateral testis. n For pure seminomas: (MCQ)
n Klinefelter’s syndrome(MCQ) l Abdominal and pelvic CT scan to

SURGERY
m Signs and symptoms determine the presence of adenopathy or

n Symptoms are varied and may range from visceral involvement
asymptomatic nodule to symptoms of l Chest x-ray (CXR) ± chest CT
massive metastasis: l Biologic markers—AFP and HCG
n Asymptomatic nodule or presence of mass. n If AFP is elevated, the patient should be
l Swelling. treated as having nonseminomas. (MCQ)

l Sensation of heaviness. n If HCG is elevated, a search should be made
l Most are painless but may be painful if there for syncytiotrophoblastic giant cells.
is hemorrhage into the tumor. Otherwise, there may be an occult foci of
TESTICULAR CARCINOMA
n Back or abdominal pain secondary to nonseminomatous component producing the

retroperitoneal adenopathy. HCG. (MCQ)
n Weight loss. n If the workup does not reveal metastatic
n Dyspnea secondary to pulmonary metastasis. disease, serum HCG level should be followed
n Gynecomastia. after orchiectomy. (MCQ)
m Diagnosis l If it does not decline as predicted, the
n Testicular sonogram presence of occult metastatic cancer

n Magnetic resonance imaging (MRI) should be considered.
n Tumor markers—alpha fetoprotein (AFP) n Nonseminomas:
and human chorionic gonadotropin (HCG) n The staging workup for nonseminomas is similar
m Classification and pathology to that described for seminomas. (MCQ)

n Most widely used classification is the l Stage I:
Mostofi and is based on the cell type from „ No clinical, radiographic, or marker
which the tumor is derived, germinal or evidence of tumor presence beyond the
stromal. (MCQ) confines of the testis.
l Germinal cell tumors comprise 95% of all l Stage II:
testicular tumors: „ Early:
„ Seminomas (pure single-cell tumors) ® Nonpalpable, small, retroperitoneal
„ Nonseminomas adenopathy on CT scan (<4 to 5 cm).

„ Combination tumors (MCQ)
l Tumors of gonadal stroma (1–2%): „ Advanced:
„ Leydig cell ® Retroperitoneal adenopathy >5 cm
„ Sertoli cell on CT scan or palpable retroperitoneal

„ Primitive gonadal structures adenopathy with disease limited to
lymphatic below the diaphragm. (MCQ)
l Stage III: m Clinical pearls
„ Visceral involvement of the cancer. n Seminoma
„ Conceptually, patients have either early or l 20 – 35 years old;
advanced. l Anaplastic subtype is most malignant;
„ Early disease is stage I and early stage l ‘↑βhCG in 5 to 10% of pure seminoma
II. (MCQ) patients
„ Advanced disease is advanced stage II or l 25% have occult mets in stage I
any form of stage III. l Very radiosensitive (all stages get RT)
m Treatment l Node + disease (N1 and N2) gets RT
n Operative approach: (MCQ)
l High radical inguinal orchiectomy. l Bulky node + disease > 5 cm (N3) gets
l Trans-scrotal biopsy of the testis or a trans- platinum chemo (BEP) (MCQ)
scrotal orchiectomy should not be performed „ if residual nodes, then surgery
if the diagnosis of testicular cancer is likely „ if residual nodes + for tumor, salvage
(MCQ) chemo with VIP (vinblastine,
„ Reason : ifosfamide, cisplatinum)
® the lymphatic drainage of the testes n Nonseminoma ger m cell tumors
is different from that of the scrotum (choricocarcinoma, embryonal cell, yolk sac,
® a scrotal incision in the presence of teratocarcinoma) (MCQ)
l May have ↑βhCG AND AFP
SURGERY
testicular cancer may cause local recurrence
and metastasis. l AFP not elevated in pure choriocarcinoma
n Early seminoma: (MCQ) or seminoma
l Orchiectomy +XRT. l Get LN dissection; chemo if advanced;
n Advanced seminoma: (MCQ) NOT radiation
l Combination chemotherapy followed by l Chemo is BEP: bleomycin, etoposide,
restaging. cisplatin
n Stage I nonseminoma: (MCQ) l pulmonar y fibrosis is most feared
l Orchiectomy + retroperitoneal lymph node complication due to bleomycin(MCQ)
TESTICULAR CARCINOMA
dissection (RPLND) or surveillance. m Seminomas metastasise to para-aortic nodes and
n Stage II nonseminoma: (MCQ) produce back pain
l The optimal management of this group of m Teratomas under go blood borne spread to liver,
patients is controversial. lung, bone and brain
l RPLND can be curative but have a high m Alpha-fetoprotein (áFP)
relapse rate. n Produced by yolk sac elements
l If relapse occurs, chemotherapy can be n Not produced by seminomas (MCQ)
given as adjunctive therapy. m Beta-human chorionic gonadotrophin (βHCG)
l Alternatively, chemotherapy can be given n Produced by trophoblastic elements
prior to RPLND. n Elevated levels seen in both teratomas and
n Advanced stage nonseminoma: (MCQ) seminomas (MCQ)
l Chemotherapy ±tumor reductive surgery.
n Commonly used chemotherapeutic regimens:
(MCQ)
l BEP—etoposide, bleomycin, cisplatin
l PVB—vinblastine, bleomycin, cisplatin
l VAB-6—vinblastine, bleomycin, cisplatin,
cyclophosphamide, actinomycin D
n Following appropriate therapy, patients need to
undergo continuous surveillance for at least
18 to 24 months via tumor markers and/or
radiographs for regression of disease or for
relapses. (MCQ)
n Most relapses occur within 24 months but later
relapses do occur(MCQ)
Stage Definition
I Disease confined to testis
IM Rising post-orchidectomy tumour marker
II Abdominal lymphadenopathy A Lessthan 2 cm
B 2-5 cm
C Morethan 5 cm
III Supra-diaphragmatic disease O No abdominal disease
A,B,C, Abdominal nodal disease
IV Extra-lymphatic metastases
L1 Lessthan 3 lung metastases
L2 Morethan 3 lung metastases
L3 Morethan 3 lung metastases 1 or
more greaterthan 2 cm
SURGERY
H+ Liver involvement
TOPIC - 10 IBD „but gross lower GI bleeding less

common than in ulcerative colitis
n Perianal disease in up to one third of patients
m Crohn’s disease
n Transmural inflammation of any part of the
(MCQ)
n Signs and symptoms of intestinal perforation
GI tract from mouth to anus, with affected areas
neighboring unaffected ones (MCQ) and/or fistula formation (MCQ)
l combination of localized peritonitis, fever,
n characterized by periods of clinical remission
and progression abdominal pain, tenderness, and palpable
n Unknown etiology
mass on physical exam
IBD
n Diagnosis
n postulated to be caused by infection, genetic
l Typical history of prolonged diarrhea with
defect, or autoimmune process.
n Epidemiology
abdominal pain, weight loss, and fever
l Most common surgical disease of small
with or without gross bleeding.
l Physical exam can be normal, nonspecific,
bowel (MCQ)
n Risk factors
or suggestive of Crohn’s disease with
l Urban dwelling
(MCQ)
„ perianal skin tags
„ sinus tracts
l Onset most common between 15 and 40 or
„ palpable abdominal mass.
50 and 80 years of age (bi-modal age
l Clinch diagnosis depends on suspected site
distribution) (MCQ)
of involvement. by (MCQ)
l Positive family history
„ Colonoscopy
l Smoking (MCQ)
„ esophagogastroduodenoscopy (EGD),
l Diet high in refined sugar, NSAID use, or
„ air-contrast barium enema
oral contraceptive use (MCQ)
l Radiographic evidence: (MCQ)
n Signs and symptoms
„ Nodular contour of bowel
l Diarrhea, weight loss, and fever
„ narrowed lumen, sinuses, and clefts
l Crampy abdominal pain
„ linear ulcers
l Bleeding
„ asymmetrical involvement of bowel wall
„ hemoccult + stools common
„ string sign

n Treatment n Risk factors
l Medical: (MCQ) l Urban dwelling
„ Corticosteroids, aminosalicylates l Age between 15 and 40 or 50 and 80
(sulfasalazine, 5-ASA), (bimodal age distribution)
„ immune modulators l Positive family history
® azathioprine l Diet high in refined sugar, NSAID use, or
® mercaptopurine oral contraceptive use
® cyclosporine l Nicotine decreases risk (unlike Crohn’s
„ metronidazole. disease) (MCQ)
l Surgical: (MCQ) n Signs and symptoms
„ Most patients ultimately require surgical l Two characteristic presentations:
therapy „ Insidious, recurrent abdominal pain, anorexia,
„ physicians tend to avoid sugery it as long as weight loss, and mild diarrhea
possible since „ Acute onset of bloody diarrhea
„ Crohn’s disease is not curable abdominal pain +tenesmus vomiting,
„ surgical resection of an affected area does and fever (MCQ)
not preclude future development in n Diagnosis
adjacent or distant parts of the bowel. l Endoscopy with histolopathologic evaluation
„ Indications for Surgery: of biopsies
SURGERY
® obstruction, abscess, l Barium enema:
® fistula, perforation „ “Lead pipe” appearance of colon classic
® perianal disease, or cancer. but no longer test of choice (MCQ)
„ For strictures, stricturoplasty. n Treatment
„ For fistulas, fistula resection; l Medical: Similar to Crohn’s (MCQ)
„ if patient is septic „ Mild/moderate disease: 5-ASA,
® excise grossly involved portion only corticosteroids PO or per rectum
followed by intraoperative open „ Severe disease: IV steroids
debridement. „ Proctitis: Topical steroids
„ For cancer, operate just as if the patient „ Refractory disease: Immunosuppression
did not have Crohn’s. l Surgical:
n Prognosis „ Indications: (MCQ)
l Typical course is one of intermittent ® Failure of medical therapy
IBD
exacerbations followed by periods of ® increasing risk of cancer in long-standing
remission. disease
l Ten to 20% of patients experience ® bleeding
prolonged remission after initial ® perforation
presentation. „ Procedure: Proctocolectomy (curative)
l Approximately 80% of patients ultimately (MCQ)
require surgical intervention. „ If patient is acutely ill and unstable, due to
l Resection with anastomosis has 10–15% perforation, a diverting loop colostomy
clinical recurrence rate per year. is indicated. (MCQ)
l Total colectomy with ileostomy ha s 10% ® Once stabilized, the patient may undergo
recurrence rate over 10 years in remaining a more definitive operation.
small bowel. n Prognosis
m Ulcerative colitis l Approximately 10% risk of cancer at 10 years,
n Inflammation confined to mucosal layer of and 2%/year thereafter. (MCQ)
colon that extends from the rectum proximally
in a continuous fashion. (MCQ)
n Incidence
l Highest in third and fourth decades of life
(MCQ)
l industrialized nations >>developing
nations
Ulcerative colitis vs. Crohn’s disease.
Ulcerative Colitis Crohn’s Disease
Pathology n Inflammation of the mucosa only n Inflammation involves all bowel wall
(exudate of pus, blood and mucus layers, which is what may lead to
from the “crypt abscess”) fistulas and abscess
n Always starts in rectum (up to one n Rectal sparing in 50%
third don’t progress)
Diagnosis n Continuous lesions n Skip lesions : Interspersed normal and
n Rare normal and diseased bowel
n Lead pipe colon appearance due to n Aphthous ulcers
chronic scarring and subsequent n Cobblestone appearance.
retraction and loss of haustra From submucosal thickening interspersed
with mucosal ulceration
Complications n Perforation n Abscess
n Stricture n Fistulas
n Megacolon n Obstruction
Perianal disease
SURGERY
Pathological features
Ulcerative colitis Crohn’s disease

Lesions continuous - superficial Lessions patchy - penetrating
Rectum always involved Rectum normal in 50%
Terminal ileum involved in 10% Terminal ileum involved in 30%
Granulated ulcerated mucosa Discretely ulcerated mucosa
No fissuring Cobblestone appearance with fissuring
Normal serosa Serositis common
IBD
Muscular shortening of colon Fibrous shortening

Fibrous strictures rare Strictures common
Fistulae rare 10% Enterocutaenous or intestinal fistulae in
Anal lesions in <20% Anal lesions in 75%
Anal fistulae and chronic fissures
Malignant change well recognised Possible malignant change

n Clinical Pearls n 5-Aminosalicylic acid
n Both ulcerative colitis (UC) and Crohn’s disease n Used in mild / moderate ulcerative colitis and
can present with bloody diarrhea, but bloody Crohn’s disease
diarrhea is more common in UC. (MCQ) n 5-ASA block production of prostaglandins
n Unless all the colonic and rectal mucosa is and leukotrienes
removed, the patient is still at risk for cancer. n Compounds are available to release 5-ASA at
(MCQ) site of disease activity
n Recommend colonscopy (MCQ) n Mesalazine is conjugated to prevent absorption
l after 7 years of pancolitis in small intestine (MCQ)
l after 10 years of left-sided colitis, then scope n Topical preparation may be used in those with
and biopsy every 1 to 2 years. left-sided colonic disease
n Assessment of disease severity in ulcerative colitis n Maintenance therapy
(MCQ) l of proven benefit in those with ulcerative
n Mild = More than 4 stools per day. Systemically colitis
well l Of unproven benefit in those with Crohn’s
n Moderate = Less than 4 stools per day. disease
Systemically well n Corticosteroids
n Severe = More than 6 stools per day. n Often used in those in whom 5-ASA therapy
Systemically unwell is inadequate
SURGERY
l Systemic features include tachycardia, fever, n Also used in those presenting with acute severe
anaemia, hypoalbuminaemia disease
n Endoscopic grading of ulcerative colitis (MCQ) n Can be given orally, topically or parenterally
n 0=normal n Use should be limited to acute exacerbations
n 1=loss of vascular pattern or granularity of disease
n 2=Granular mucosa with contact bleeding n Of no proven value as maintenance therapy
n 3=Spontaneous bleeding in either ulcerative colitis or Crohn’s disease
n 4=Ulceration (MCQ)
n Crohn’s disease n Immunosuppressive and immunomodulatory agents
n 50% have ileocaecal disease n Often used in those in whom steroids can not
n 25% present with colitis be tapered or discontinued
n Systemic features are more common than in n Agents used include:
ulcerative colitis l Azathioprine -effective in both ulcerative
IBD
n Extraintestinal manifestations of Crohn’s disease colitis and Crohn’s disease
(MCQ) l Methotrexate - effective in Crohn’s disease
n Associated with disease activity l Cyclosporin
l Erythema Nodosum l Inflixitab - anti-TNF-alpha therapy
l Pyoderma Gangrenosum n Surgery for inflammatory bowel disease
l Asymmetrical non-deforming arthropathy m Indications for surgery - Ulcerative colitis (MCQ)
l Anterior uveitis n 20% of patients with ulcerative colitis require
l Episcleritis surgery at some time
l Conjunctivitis n 30% of those with total colitis require
l Acute fatty liver colectomy within 5 years
l Thromboembolic disease n Emergency indications
n Unrelated to disease activity l Toxic megacolon
l Sacroilitis l Perforation
l Ankylosing spondylitis l Haemorrhage
l Hepatobiliary conditions l Severe colitis failing to respond to medical
l Primary sclerosing cholangitis treatment
l Cholangiocarcinoma n Elective indications
l Chronic active hepatitis l Chronic symptoms despite medical therapy
l Gallstones l Carcinoma or high grade dysplasia
l Amyloid m Surgical options
l Nephrolithiasis n Emergency

l Total colectomy with ileostomy and mucus TOPIC - 11
fistula CONGENITAL HYPERTROPHIC
n Elective (MCQ) PYLORIC STENOSIS
l Panproctocolectomy and Brooke ileostomy
l Panproctocolectomy and Kock continent
n Congenital Hypertrophic Pyloric Stenosis
ileostomy m Narrowing of the pyloric canal due to
l Total colectomy and ileorectal anastomosis
hypertrophy of the musculature
„ Maintains continence but proctitis persists
m Occurs 1 in 250 births
l Restorative proctocolectomy with ileal pouch
m Male-to-female ratio: 4:1 (MCQ)
„ Need adequate anal musculature
m Cause - Unknown.
„ Need for mucosectomy uncertain
„ Need for defunctioning ileostomy unresolved
n Starts third to fifth week of life(MCQ)
o Morbidity n Nonbilious vomiting: (MCQ)
l 50% develop significant complications
l Progressive
„ Small bowel obstruction(20%)
l Projectile (±)
„ Pouchitis(15%)
l Hungry after vomiting
„ Genito urinary dysfunction(6%)
n Dehydration
„ Pelvic sepsis(5%)
n Midepigastric mass (“olive”) (MCQ)
„ Fistula (5%)
n Visible peristaltic wave (left to right)
SURGERY
„ Pouch failure(6%)
hypochloremic metabolic alkalosis
„ Anal stenosis (5%)
m Diagnosis
l Larger capacity pouches reduce stool
n Ultrasound (90% sensitivity):
frequency l Elongated pyloric channel (>14 mm)
n Indications for surgery - Crohn’s disease (MCQ)
n Absolute (MCQ)
l Thickened pyloric wall (>4 mm) (MCQ)
l Perforation with generalised peritonitis
n Radiographic contrast series:
l Massive haemorrhage
l String sign—from elongated pyloric
l Carcinoma
channel (MCQ)
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS
l Fulminant or unresponsive acute severe

l Shoulder sign—bulge of pyloric muscle
colitis into the antrum(MCQ)
n Elective (MCQ)
l Double tract sign—parallel streaks of
l Chronic obstructive symptoms
barium in the narrow channel(MCQ)
l Chronic ill health or debilitating diarrhoea
m Treatment
l Intra-abdominal abscess or fistula
n Correction of fluid and electrolyte and acid–
l Complications of perianal disease
base balance
n Surgery should be as conservative as possible
n IV fluid 5% dextrose in normal saline plus
n No evidence that increased resection margins
potassium chloride 3 to 5 mEq/kg
reduce recurrence rate (MCQ) n Surgical correction: Ramstedt pyloromyotomy
(MCQ)
m Clinical Pearls :
n Children of affected parents have a 7% chance
of disease.
n 20% of male and 10% of female children
have an affected mother. (MCQ)
n Most common in first- born male. (MCQ)
n Associated malformations: malrotation, hepatic
glucuronyl transferase ability (jaundice) (MCQ)
n Mainly affects circular muscle fibres(MCQ)
n Inheritance pattern (MCQ)
l Risk to son if affected mother is 20%
l Risk to daughter if affected mother is 7%
l Risk to son if affected father is 5%

l Risk to daughter if affected father is 2% n Krukenberg’s tumor—.(MCQ)
n Ramstedt’s pyloromyotomy l metastasis to ovaries
l Transverse right upper quadrant or n Blumer’s shelf—.(MCQ)
circumumbilical incision (MCQ) l metastasis to pelvic cul-de-sac, felt on
l Longitudinal incision in pylorus down to digital rectal exam
mucosa (MCQ) n Virchow’s node—.(MCQ)
l Incision extend from duodenum onto l metastasis to lymph node palpable in left
gastric antrum supraclavicular fossa
l Avoid mucosal perforation n Sister Mary Joseph’s nodule.(MCQ)
l Feeding re-established within 12-24 hours of l metastasis to the umbilical lymph nodes
surgery (MCQ) m Diagnosis
n Upper GI endoscopy:
l Best method, .(MCQ)
l allows for biopsy
l definitive >95% sensitivity and specificity
TOPIC - 12 GASTRIC CARCINOMA n Upper GI series: .(MCQ)

l With double contrast;
n Adenocarcinoma l 80–96% sensitivity, 90% specificity (operator
m Highest incidence in age >60 years.(MCQ) dependent)
SURGERY
m Adenocarcinoma comprises 95% of malignant l excellent method in skilled hands
gastric cancer. .(MCQ) n Abdominal CT: .(MCQ)
m Male predominance. l Good for detecting distant metastases
m Risk factors.(MCQ) l also used for preop staging, but suboptimal
n Familial adenomatous polyposis n Endoscopic ultrasound:
n Chronic atrophic gastritis l Good for detecting depth of invasion
n H. pylori infection (6Ξ increased risk) .(MCQ) m Staging
n Post-partial gastrectomy (15+years) .(MCQ) n Birmingham Staging System
n Pernicious anemia n Clinico pathological system.(MCQ)
n Diet (foods high in nitrites—preserved, n Does not require detailed lymph node status
GASTRIC CARCINOMA
smoked, cured) n Stage1-Disease confined to muscularis
n Cigarette smoking propria

n Duodenal ulcer disease may be protective against n Stage 2-Muscularis and serosal involvement
gastric cancer. .(MCQ) n Stage 3-Gastric and nodal involvement
m Pathology l Stage 4 a-Residual disease
n Polyploid: 25–50%, no substantial necrosis or l Stage 4 b-Metastatic disease
ulceration m Treatment
n Ulcerative: 25–50%, sharp margins n Radical subtotal gastrectomy .(MCQ)
n Superficial spreading: l can be curative in early disease confined to
l 3–10%, the superficial layers of the stomach (less

l involves mucosa and submucosa only, than one third of all patients due to typical
l best prognosis.(MCQ) late presentation)
n Linitis plastica: n Chemotherapy: .(MCQ)
l 7–10%, l Sometimes used palliatively for nonsurgical
l involves all layers candidates

l extremely poor prognosis.(MCQ) l no role for adjuvant chemotherapy
m Signs and symptoms m Prognosis
n Early: Mostly asymptomatic. n Prognosis depends on stage of disease.
n Late: n Overall 5-year survival is still only 5–15%.
l Anorexia/weight loss, nausea, vomiting Gastric Lymphoma.(MCQ)

n
l dysphagia, melena, hematemesis m Second most common malignant gastric cancer
l pain is constant, nonradiating, m Comprise only 5% of all gastric tumors
exacerbated by food. .(MCQ) m Increased x risk with HIV.(MCQ)
l Anemia—from blood loss, pernicious m Male predominance 1.7:1.(MCQ)

m Signs and symptoms m no obvious role for extended lymphadenectomy
n Nonspecific; include abdominal discomfort, nausea, (MCQ)
vomiting, anorexia, weight loss, and hemorrhage. m 3 Chronic atrophic gastritis underlies most
m Diagnosis gastric cancer;
n Made by endoscopic biopsy, not readily m 3 other risks: adenoma > 2 cm, Type A blood,
distinguishable from adenocarcinoma by simple nitrosamines, pernicious anemia (MCQ)
inspection. Lymphoma:
n Bone marrow aspiration and gallium bone m distinguish between T cell, NHL (non MALT),
scans can diagnose metastases. and MALT
m Staging (ann arbor classification) .(MCQ) m Extranodal marginal Zone B Cell lymphoma
n Stage I: Disease limited to stomach (low grade B cell lymphoma of Mucosa
n Stage II: Spread to abdominal lymph nodes Associated Lymphoid Tissue, MALT):
n Stage III: Spread to lymph nodes above and m 3 50% of patients with gastric NHL have the
below the diaphragm indolent MALT type
n Stage IV: Disseminated lymphoma m 3 gastric MALT is frequently associated with
m TREATMENT chronic gastritis and H.pylori infection
n MALT (low grade)— .(MCQ) (MCQ)
l Treat H. pylori. m the standard treatment for MALT patients (who
n MALT (high grade) or non-MALT-.(MCQ) are H.pylori +) (MCQ)
SURGERY
l Radiation/chemo m antibiotics and follow up

l Resection reser ved for patients with m EGD 3 and 6 months later: (MCQ)
bleeding or perforation n if CR - done
m Prognosis n if PR -continue antibiotics before XRT (not
n Poor prognostic factors include: .(MCQ) surgery)
l Involvement of the lesser curvature of the n Surgery reserved for complications
stomach m Note: the thicker the lesion the less likely it
l Large tumor size will regress with eradication of H.pylori alone
l Advanced stage
m Gastric Sarcoma
GASTRIC CARCINOMA
n Equal incidence in men and women (unlike

gastric adenocarcinoma or gastric lymphoma)
n Usual age at diagnosis is 65 to 70 years
n Most are leiomyosarcomas.
n Spread is hematogenous treatment.
n Surgical resection.
m Gastrointestinal Stromal Tumor (GIST)
n Arises from interstitial cell of Cajal (intestinal
pacemaker) (MCQ)
n C kit mutation/CD117+ (MCQ)
n Gain of function tyrosine kinase
n Resect if possible;
n Imatinib mesylate for mets; (MCQ)
n role of Imatinib mesylate in adjuvant being
currently evaluated
Clinical pearls :
n Carney triad: (MCQ)
m Gastric leiomyo sarcoma
m Pulmonary chondromas
m Extra-adrenal paraganglioma
m Syndrome seen in women under 40
n Adenocarcinoma of stomach(MCQ)
m 3 Resect with 6 cm margins + draining lymph
nodes + omentum(MCQ)
TOPIC - 13 SPLENECTOMY m Pneumococcal and Haemophilus
m Perform 2 weeks prior to planned operation
n Indications for splenectomy (MCQ) (MCQ)
m Trauma
m Immediately post op for emergency cases
n Commonest organ injured in blunt abdominal
m Repeat every 5 - 10 years (MCQ)
trauma
n Associated with lower rib fractures
m Spontaneous rupture TOPIC - 14 HERNIA
n Usually seen in those with massive
splenomegaly (e.g. infectious n Hernia
mononucleosis) (MCQ) m Fifty percent are indirect inguinal hernias
n Often precipitated by minor trauma (Most common) (MCQ)

m Hypersplenism n 25% are direct inguinal, and 15% are femoral.
n Hereditary spherocytosis or elliptocytosis m The male-to-female ratio is 7:1. (MCQ)

(MCQ) m Hernia:
n Idiopathic thrombocytopenic purpura n A protrusion of a viscus through an opening
(MCQ) in the wall of a cavity in which it is contained

m Neoplasia m Groin hernia:
SPLENECTOMY
n Lymphoma or leukaemic infiltration (MCQ) n Protrusion of a peritoneal sac through the
n Splenectomy not usually required for transversalis fascia that extends over the
diagnosis myopectineal orifice
n Only required if hypersplenism resistant to m Hernia orifice:
treatment n Defect in the innermost abdominal layer of
m With other viscera (MCQ) the aponeurosis

n Total gastrectomy m Hernia sac:
n Distal pancreatectomy n Outpouch of peritoneum
m Other indications (MCQ) m Inguinal canal boundaries: (MCQ)

n Splenic cysts n Anterior wall:
n Hydatid cysts l External oblique aponeurosis
n Splenic abscesses n Posterior wall:

n Physiological effects of splenectomy (MCQ) l Transverse abdominal muscle aponeurosis
HERNIA
m Raided white cell and platelet count - peaks at l transversalis fascia
about 7 days n Medial border:

m Increased abnormal red cells in circulation l Transverse aponeurosis and transversalis fascia
m Reduced IgM and raised IgA (MCQ) n Lateral border:
m Reduced ability to opsonize encapsulated l Transverse abdominal muscle
bacteria n Inferior crus:

n Overwhelming Post Splenectomy Infection l Transverse aponeurotic fascia
(OPSI) (MCQ) n Superior crus:

m Infection due to encapsulated bacteria l A portion of the transverse aponeurosis
m 50% due to strep. Pneumoniae (MCQ) (transverse aponeurotic arch)
m Other organisms include: m Spermatic cord:
n Haemophilus influenzae n Begins at the deep ring
n Neisseria meningitidis n contains the (MCQ)
m Occurs post splenectomy in 4% patients without l vas deferens and its artery (descend to the
prophylaxis seminiferous tubules)

m Mortality of OPSI is approximately 50% l one testicular artery
m Greatest risk in first 2 years post op l two to three veins,
n Prevention of OPSI (MCQ) l lymphatics (incline superiorly to the kidney
m Antibiotic prophylaxis region)

n Penicillin or amoxycillin l autonomic nerves, and fat
n Certainly in children up to 16 years (MCQ) m Ligaments
n Immunisation (MCQ) n Inguinal ligament:

l Medial insertion— pecten pubis, attaches „ Medial border: Rectus abdominis
to the adjacent iliopubic tract and transversalis fascia. „ Lateral border: Inferior epigastric vessels
l All three strongly brace the myopectineal (lateral umbilical fold).
orifice, which separates inguinal from n Triangle of Grynfeltt (superior lumbar)
femoral herniation and constitutes the medial bounded by the (MCQ)
border of the orifice of the femoral canal. l twelfth rib superiorly
n Henle’s ligament: (MCQ) l internal oblique muscle anteriorly
l The portion of the tendon of the rectus l floor composed of fibers of the quadratus
abdominal muscle that curves laterally onto the lumborum muscle.
pecten pubis. n Triangle of Petit (inferior lumbar triangle)
n Hesselbach’s ligament: (MCQ) bounded by: (MCQ)
l Fascial condensation in the region of the l Posteriorly: Latissimus dorsi muscle
inferior epigastric vessels. l Anteriorly: External oblique muscle
m Vasculature l Inferiorly: Iliac crest
n Cremaster vessels: l The floor is composed of fibers from the
l Arise from the inferior epigastric vessels inter nal oblique and transversus
(MCQ) abdominis muscle. (MCQ)
l pass through the posterior wall of the m Inguinal hernia
inguinal canal via their own foramen. n Hernias arising above the abdominocrural
SURGERY
l Supply: Cremaster muscle and the testis crease.

tunica. n Most common site for abdominal hernias.
m Nerves n Male-to-female ratio: 25:1. (MCQ)
n Genital nerve: n Males: Indirect 2:1 direct. (MCQ)
l Travels along with the cremaster vessels to n Female: Direct is rare. (MCQ)
form a neurovascular bundle. n Incidence, strangulation, and hospitalization all
l Originates: From L1 and L2. (MCQ) increase with age.
l Motor and sensory: n Cause 15–20% of intestinal obstructions.
„ Innervates the cremaster muscle n Risk factors
„ skin of the side of the scrotum and labia. l Abdominal wall hernias occur in areas where
„ May substitute for the ilioinguinal nerve aponeurosis and fascia are devoid of
if it’s deficient. protecting support of striated muscle.
HERNIA
n Iliohypogastric and ilioinguinal intertwine. l They can be congenital or acquired by

l Originates: From T12 and L1. (MCQ) surgery or muscular atrophy.
l Sensory: To skin of groin, base of penis, l Why there is Female predisposition to
and medial upper thigh. femoral hernias ?
l Genital branch of genitofemoral nerve: „ Increased diameter of the true pelvis as
(MCQ) compared to men, proportionally widens
l Located on top of the spermatic cord in the femoral canal.
60% of people l Muscle deficiency of the internal oblique
l can be found behind or within the cremaster muscles in the groin exposes the deep ring
muscle. and floor of the inguinal canal, which are
m Femoral Canal Structures further weakened by intra-abdominal
n From lateral to medial: (MCQ) pressure.
l Nerve, Artery, Vein, Empty space, l Connective tissue destruction (transverse
Lymph nodes aponeurosis and fascia):
m Anatomical Triangles n Caused by physical stress secondary to
n Hesselbach’s triangle: l intra-abdominal pressure, smoking, aging
l The triangular area in the lower abdominal l connective tissue disease, systemic
wall. illnesses
l It is the site of direct inguinal hernia. l fracture of elastic fibers
l The boundaries of Hesselbach’s triangle l alterations in structure, quantity, and
are: (MCQ) metabolism of collagen.
„ Inferior border: Inguinal ligament l Abdominal distention

l ascites with chronic increase in intra- l Both: More common with anterior groin
abdominal pressure hernioplasty because of the nerves and
l peritoneal dialysis. spermatic cord dissection and mobilization
n Pain: Worse at the end of the day and relieved n Prognosis
at night when patient lies down (because the l Recurrence:
hernia reduces). „ Expert surgeons 1–3% in 10-year follow-
n Groin hernias do not usually cause testicular up
pain. „ Causes
n Likewise, testicular pain doesn’t usually ® excessive tension on repair
indicate the onset of a hernia. ® deficient tissue
n Herniotomy ® inadequate hernioplasty
l operation of cutting through a band of ® overlooked hernias
tissue that constricts a strangulated hernia. „ Decreased with relaxing incisions
(MCQ) „ More common with direct hernias
l This may be sufficient in young, muscular (MCQ)
individuals and in children. n Classification of inguinal hernias
n Herniorrhaphy l Direct
l involves opening the coverings, returning l Indirect
the contents to their normal place (MCQ) n Direct Inguinal Hernia
SURGERY
l obliterating the hernial sac, and closing the l A direct inguinal hernia enters the inguinal canal
opening with strong sutures. through its weakened posterior wall
l this can be considered in adults with good (MCQ)
muscular tone. l The hernia does not pass through the internal
l Lytle’s repair: (MCQ) ring. (MCQ)
„ Narrowing of the deep ring by suturing l Lies posterior to the spermatic cord (MCQ)
medial wall. l Practically never enters the scrotum
l Bassini’s repair: (MCQ) l Wide neck (almost never strangulates)
„ Suturing of conjoint tendon to the l Practically only in males
incurved part of inguinal ligament. l Common in older age groups
l Shouldice repair: (MCQ) l Common in smokers due to weakened
„ Double breasting of transversalis fascia. connective tissue
HERNIA
l Ogilvie’s repair: (MCQ) l Predisposing factors: Hard labor, cough,
„ Plication of transversalis fascia. straining, etc.
l McVay’s repair/Cooper’s repair: (MCQ) l Can lead to damage to the ilioinguinal
„ Conjoint tendon sutured to Cooper’s nerve
ligament. l Symptoms
n Laparoscopic repair: „ Dull dragging pain in the inguinal region
l decreased postop pain referred to testis.
l requires general or regional anesthesia, and „ Pain increases with hard work and
more expensive straining.
l Wound infection has been shown to n Indirect Inguinal Hernia
decrease with laparoscopic repair. l Herniation through the internal inguinal
n Indications for surgery ring traveling to the external ring.
l Generally, all hernias should be repaired l If complete, it can enter the scrotum while
unless the risks of surgery out- weigh the exiting the external ring.
benefits of the repair. l If congenital, is associated to a patent
l Exception: A hernia with a wide neck and processus vaginalis. (MCQ)
shallow sac that is expected to enlarge slowly. l Bilateral in one third of cases.
n Complications of surgery l Most common hernia in both males and females.
l Ischemic orchitis with testicular atrophy (MCQ)
l Residual neuralgia l Occurs at all ages.
l More common in males than in females.

l In the first decade of life, the right-sided n Rupture occurs in chronic ascitic cirrhosis.
hernia is more common than left (because n Emergency portal decompression is needed.
of late descent of right testis). (MCQ) m Treatment - Surgical repair: (MCQ)
m FEMORAL HERNIA n Small partial defect:
n A form of indirect hernia arising out of the l Closed by loosely placed polypropylene
femoral canal beneath the inguinal ligament suture
n It is medial to the femoral vessels n Large partial defect:
n Female-to-male ratio of 2:1. (MCQ) l Managed with a prosthesis repair
n Males affected are in a younger age group. l Mayo hernioplasty is the classical repair (not used
n Rare in children. often).
n Uncommon—around 2.5% of all groin n PEDIATRIC UMBILICAL HERNIA
hernias. m Secondary to a fascial defect in the linea alba
n Left side 1:2 right side: (MCQ) with protruding abdominal contents, covered
l Reason : Secondary to the sigmoid colon by umbilical skin and subcutaneous tissue.
tamponading the left femoral canal. m Caused by a failure of timely closure of the
n Common in elderly patients. umbilical ring, and leaves a central defect in the
n High incidence of incarceration due to linea alba.
narrow neck. m Common in infants. (MCQ)
n Anatomy m Incarceration is rare and reduction is
SURGERY
l femoral canal contraindicated. (MCQ)

„ 1.25 cm long (MCQ) m Management
„ arises from the femoral ring to the n Usually close spontaneously within 3 years if
saphenous opening. the defect < 1.0 cm
l Femoral sac originates from the femoral canal n Surgical repair indicated if: (MCQ)
through a defect on the medial side l The defect >2 cm.
(common) or the anterior (uncommon) side l Child is >3 to 5 years of age.
of the femoral sheath. (MCQ) l Protrusion is disfiguring and disturbing to
n Symptoms the child or parents.
l Dull dragging pain in the groin, with n ESOPHAGEAL HIATAL HERNIA
swelling. m A hernia in which an anatomical part (such as
l If obstructed, can cause vomiting and constipation. the stomach) protrudes through the esophageal
HERNIA
l If strangulated, can lead to severe pain and hiatus of the diaphragm

shock. m Two types:
l Swelling arises from below the inguinal n Paraesophageal hernia
ligament. n Sliding esophageal hernia
n Differential diagnosis m Sliding Esophageal Hernia (Type I)
l Inguinal hernia n The gastroesophageal junction and the
l Saphenous varix stomach herniate into the thoracic cavity.
l Enlarged femoral lymph node (MCQ)
l Lipoma n These account for more than 90% of all hiatal
l Femoral artery aneurysm hernias. (MCQ)
l Psoas abscess n Can lead to reflux and esophagitis that can
ACQUIRED UMBILICAL predispose to Barrett’s esophagus. (MCQ)
m Abdominal contents herniate through a defect in n Management can be done medically with
the umbilicus. antacids and head elevation.
m Common site of herniation, especially in n Surgery consist of wrapping of the stomach
females. fundus around the lower esophageal
m Associated factors sphincter (Nissen fundoplication). (MCQ)
n Ascites, obesity, and repeated pregnancies. m Paraesophageal Hiatal Hernia (Type II)
(MCQ) n Herniation of the stomach into the thorax by
m Complications way of the esophageal hiatus, without
n Strangulation of the colon and omentum is disruption of the gastroesophageal junction
common. (MCQ)
n Rare (<5%) n Eventration:
n High frequency of complications m Loss of integrity of the abdominal wall
n obstruction, strangulation, and hemorrhage m reduces the intra-abdominal pressure and result
n warrants prompt surgical correction in external herniation of bowel.
n Richter’s hernia: (MCQ) n Clinical Pearls :
m Only part of the intestine wall circumference n The most common hernia in females is the indirect
is in the hernia. (MCQ) inguinal hernia. (MCQ)
m May strangulate without obstruction. n Groin hernias usually present with the complaints of
m Seen commonly in femoral and obturator a bulge in the inguinal region.
hernias. (MCQ) n Hernia Calendar (MCQ)
n Littre’s hernia: m 0 to 2 years—indirect inguinal hernia
m The hernial sac contains Meckel’s diverticulum. m 2 to 20 years—hernia is uncommon
(MCQ) m 20 to 50 years— indirect inguinal hernia
m It may become inflamed. m >50 years—direct inguinal hernia
n Garengoff ’s hernia: n Valsalva’s maneuver and cough may accentuate
m The hernial sac has the appendix. (MCQ) the bulge, making it clearly visible.
m Importance is that it may form an inflamed n Hydroceles can resemble an irreducible groin hernia.
hernia. m To distinguish, transilluminate (hernias will not
n Pantaloon hernia: light up).
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m A combination of a direct and an indirect n The hernias associated with obesity are: Direct
inguinal hernia. (MCQ) inguinal, paraumbilical, and hiatal hernias.
n Maydl’s hernia: (MCQ)
m W type of intestinal loop herniates Classification of inguinal hernias (Nyhus)
m may strangulate with the gangrenous part being Type Features
inside the abdomen, or may be reduced into Type 1 Indirect hernia. Normal internal ring
the abdomen without noticing the gangrenous part. Type 2 Indirect hernia. Dilated internal ring.
n Spigelian hernia:
Posterior wall intact
m The sac passes through the spigelian or
semilunaris fascia. (MCQ) Type 3 Posterior wall defect
n Cooper’s hernia: A. Direct inguinal hernia
m Hernia that involves the femoral canal (MCQ) B. Indirect inguinal hernia. Internal ring
HERNIA
m tracts to the labia majora in females and to the dilated. Posterior wall defective
scrotum in males. (MCQ) C. Femoral hernia
n Lumbar hernias: Type 4 Recurrent hernia
m Divided into congenital, spontaneous, traumatic,
and incisional. n Herniorrhaphy can be achieved with following
m Can pass through the triangle of Grynfeltt, techniques
through the inferior lumbar triangle of Petit, m Bassini+/-TannerSlide
or previous incision. (MCQ) m Nylondarn
n Perineal hernia: m Shouldice
m Located through pelvic diaphragm, m Lichtenstein
m anterior m Other Mesh-Stoppa
n passes through labia majora m Laparoscopic
n seen in females only n Shouldice or Liechtenstein now regarded as ‘gold
m posterior standard’ as judged by low risk of recurrence
n male : enters the ischiorectal fossa; (MCQ)
n female: close to the vagina to the superficial n Complications of hernia repairs
transverse perineal muscle. m Urinary retention
n Incisional hernia: m Scrotal haematoma
m Result as a surgical complication. m Damage to the ileoinguinal nerve
m These could enlarge beyond repair. m Ischaemic orchitis
m Associated with obesity, diabetes, and infection. m Recurrent hernia
(MCQ) n Recurrent inguinal hernia
m Recurrence rate varies with herniorrhaphy TOPIC - 15
technique and duration of follow up HEPATOCELLULAR CARCINOMA
m With Bassini and darn repairs may be as high as
20% n Hepatocellular Carcinoma (Hepatoma)
m With Shouldice and Lichtenstein repairs
m Much more common in males (3?1)
recurrence rates <1% have been reported (MCQ) m Usually diagnosed in the fifth or sixth decade.
m Recurrent hernias should be repaired using a mesh
m Risk factors
technique n Hepatitis B
n Anatomy of the femoral canal n Hepatitis C
n Anterior border is the inguinal ligament
n Cirrhosis
n Posterior border is the pectineal ligament
n Aflatoxins (found in peanuts) (MCQ)
n Medial border is the lacunar ligament
n Liver flukes
n Lateral border is the femoral vein
n Hemochromatosis(MCQ)
n Three classical approaches to the femoral canal have n Alpha-1-antitrypsin deficiency(MCQ)
been described (MCQ) n Anabolic steroid use
n Low(Lockwood)
n Transinguinal (Lotheissen)
n Weight loss
n High(McEvedy)
n Weakness
n Preoperative factors predisposing to Incisional n Dull pain in the RUQ or epigastrium
SURGERY
hernia (MCQ) n Nausea, vomiting

n Increasing age
n Jaundice
n Malnutrition
n Nontender hepatomegaly
n Sepsis
n Splenomegaly (33%)(MCQ)
n Uraemia
n Ascites (50%)(MCQ)
n Jaundice
m Diagnosis
n Obesity
n Increased ALP, AST, ALT, gamma-glutamyl
n Diabetes
transferase (GGT), alpha- fetoprotein, and des-
n Steroids
gamma-carboxy prothrombin (DCP).
HEPATOCELLULAR CARCINOMA
n Spigelian hernia (MCQ)

n Occurs at the lateral edge of the rectus sheath
n Contrast CT and ultrasound can visualize the
(MCQ) tumor.
n Interparietal hernia in the line of the linea semilunaris
n CT or ultrasound-guided needle biopsy will
n Usually occurs at the level of the arcuate line
give the definitive diagnosis.
n Obturator hernia m Treatment
n Occurs in the obturator canal (MCQ)
n Surgical resection is the only cure, consisting
n Usually asymptomatic until strangulation
of either lobectomy or segmental resection
occurs n A 1-cm margin is required. (MCQ)
n May complain of pain on the medial aspect
n Transplant is also a possibility, but there often
of the thigh (MCQ) is a high recurrence rate due to the continued
n Vaginal examination may allow identification
presence of the underlying risk factor (e.g.,
of a lump in the region of the obturator hepatitis B, hepatitis C, etc.). (MCQ)
foramen m Prognosis
n Most patients die within the first 4 months
if the tumor is not resected. (MCQ)
n After resection or transplant, the 5-year survival
is approximately 25%.
n Metastatic Neoplasms
m Patients are usually asymptomatic until the
disease has become advanced and the liver begins
to fail.
m Symptoms may include fatigue, weight loss, epigastric
fullness, dull RUQ pain, ascites, jaundice, or fever.

m Diagnosis n Focal Nodular Hyperplasia (FNH)
n Metastases will enhance on contrast CT m A benign hepatic tumor thought to arise from
n Intraoperative ultrasound with liver hepatocytes and bile ducts
palpation is the most sensitive diagnostic tool. m it has a characteristic “central scar” on
(MCQ) pathologic evaluation. (MCQ)
m Treatment m Most common in premenopausal females.
n Resection, if possible, is the treatment of (MCQ)
choice. m Usually asymptomatic
n Cavernous Hemangioma m 10% of patients present with abdominal pain and/
m A benign vascular tumor (MCQ) or a RUQ mass.
m result from abnor mal differentiation of m Usually incidental on ultrasound or CT
angioblastic tissue during fetal life m can be differentiated from hepatocellular
m usually located in the right posterior segment adenoma by a Tc-99 study.
of the liver. m Treatment - Resect if patient is symptomatic.
m Most common benign tumor of the liver(MCQ) (MCQ)
m Usually asymptomatic
m Usually discovered incidentally m Clinical Pearls
m can be detected by ultrasound, CT, magnetic n Hepatocellular adenomas present with
resonance imaging (MRI), radionuclide scan, or abdominal pain secondary to tumor rupture
SURGERY
arteriography or bleeding in approximately one third of
m do not biopsy, as hemorrhage can occur. (MCQ) patients. (MCQ)
m Surgical resection if symptomatic or in danger n Hepatocellular adenomas treated by cessation
of rupture; otherwise, observe. of OCPs rather than by resection are at risk for
n Hamartoma rupture and hemorrhage during future
m A benign focal lesion of the liver pregnancies.
m consists of normal tissue that has differentiated n Like hepatic adenomas, focal nodular
in an abnormal fashion hyperplasia is associated with long-term OCP
m multiple subtypes use. (MCQ)
HEPATOCELLULAR CARCINOMA
m depending on the types of cells involved (e.g., bile n Eighty to 90% of patients with hepatocellular
duct hamartoma, mesenchymal hamartoma, carcinoma have underlying cirrhosis(MCQ)
etc.). (MCQ) l alcoholic cirrhosis being the predominant
m Typically asymptomatic type in Western countries
m Usually discovered incidentally during radiologic l In the Far East, posthepatic cirrhosis is
imaging more common
m may require histopathologic evaluation. n A bruit can commonly be heard over a
m Treatment -Surgical excision. (MCQ) hepatocellular carcinoma due to its abundant
n Adenomas vascularity. (MCQ)
m A mass lesion of the liver n The most common hepatic malignancy is
m characterized by a benign proliferation of metastases
hepatocytes. (MCQ) n The primary is usually from colon, breast, or
m Most common in premenopausal females with lung,
a multiyear history of OCP use. (MCQ) l bronchogenic carcinoma being the most
m Risk factors (MCQ) common primary cancer. (MCQ)
n OCP use m Primary liver diseases-e.g.primary biliar y
n long-term anabolic steroid therapy cirrhosis , haemochromatosis is a risk factor
n glycogen storage disease. for HCC(MCQ)
m Signs and symptoms m Jaundice is a late feature of HCC(MCQ)
n Abdominal pain ,Abdominal mass , Bleeding m Alpha-fetoprotein
n Can also be asymptomatic l αFP is a normal fetal serum protein
m Diagnosis - Ultrasound with needle biopsy. produced by the yolk sac and liver (MCQ)
m Treatment l Progress increases in serum levels are seen in
n Cessation of OCPs 70-90% of patients with HCC
n Surgical excision(MCQ)

l Slightly increased and often fluctuating TOPIC - 16 PANCREATITIS
serum levels also seen in hepatitis and
cirrhosis n Acute Pancreatitis
l In HCC serum levels correlate with tumour
m Inflammation of the pancreas due to
size parenchymal autodigestion by proteolytic
l Rate of increase in serum levels correlate
enzyme.
with growth of tumour(MCQ) m Etiology
l Tumour resection results in a fall in serum
n Metabolic:
concentrations l Alcohol: 35–40% (MCQ)
l Serial assessment useful in measuring response
l Hyperlipidemia: Types I and IV
to treatment hypertriglyceridemia (MCQ)
m In HCC , when possible, wedge resection should l Hypercalcemia: Seen in hyper-para-
be performed, as formal hepatic lobectomy does not thyroidism (MCQ)
improve survival. (MCQ) n Mechanical:
m When colon cancer metastasizes to the liver, l Gallstones:
resection of up to three lesions has been shown l Biliary disease (40%) (MCQ)
to improve survival and should be attempted as l Trauma
long as the operative risk is not prohibitive. l post-op (e.g, ERCP]) (MCQ)
(MCQ) l Pancreatic duct obstruction (e.g., tumor,
SURGERY
m In general, liver metastases from other tumors pancreatic divisum)

should not be resected. (MCQ) l Duodenal obstruction
m In HCC, Size,stage , and histologic grade are n Vascular:
important prognostic factors l Ischemia Vasculitis(MCQ)
m HCC(MCQ) n Infectious:
l Blood supply mostly from hepatic artery
l Scorpion venom
l enhances arterial phase
l Viral infection (e.g., mumps, coxsackie B,
l iso/hypodense portal phase (can have cytomegalovirus) (MCQ)
central “scar”) n Drugs(MCQ)(Favourite MCQ in MD
m Resection of HCC - Indications : (MCQ) Entrance )
PANCREATITIS
l 4 Single lesion < 5 cm

l isoniazid, estrogens, azathioprine
l upto 3 lesions each < 3 cm
l hydrochlorothiazide, sulfonamides
l 4 Okuda I,CLIP 0–1, BCLC 0 or A
l pentamidine, didanosine
l 4 Childs A and B (not C)
l 4 No portal hypertension (clinically or PVP
n Severe, constant mid-epigastric or left upper
> 10 mmHg) quadrant (LUQ) pain, radiates to the back.
l Tumor recurrence occurs in 70% of cases at
n Pain sometimes improved when patient sits up
5 years and leans forward.
m Transplant in HCC - Indications : (MCQ) n Nausea, vomiting.
l 4 Single lesion < 5 cm
n Low-grade fever.
l up to 3 lesions each < 3 cm (Milan criteria)
n Tachypnea.
l Okuda I, CLIP 0–1, BCLC 0 or A
n Abdomen is usually tender with guarding, but
l 4 Childs B or C (not A)
no rebound.
l Fibro lamellar variant may have better
n Fluid sequestration in retroperitoneum can be
prognosis massive.
n Ninety percent have mild, self-limited disease.
n Cullen and Grey–Turner signs are indicative
of severe, hemorrhagic pancreatitis.
(MCQ)(
m Diagnosis
n Amylase:
l Secreted by the pancreas
l Also found in salivary glands, small bowel, ovaries,
testes, skeletal muscle. (MCQ)(
l May be persistently elevated in renal n Elevation in urinary amylase, amylase–
insufficiency. creatinine clearance ratio.
l A level three times the upper limit of n Radiologic features on abdominal x-ray [AXR]
normal is (MCQ) l Sentinel loop sign (MCQ)
„ 75% specific l Colon cutoff sign (MCQ)
„ 80–90% sensitive for pancreatitis. n CT scan:
l Still widely used as a marker but has false- l Diagnostic test of choice (MCQ)
negative rate of 10% and is not specific. l 90% sensitive and 100% specific
l High amylase associated with acute, not m Treatment
chronic pancreatitis. n Hydration: Maintain adequate intravascular
n Lipase: volume.
l Secreted by the pancreas to break down n Monitor electrolytes.
triglycerides. (MCQ) n Nasogastric tube: For severe disease with
l Also found in gastric and intestinal vomiting.
mucosa, and liver. n Antibiotics: If infection identified.
l A level two times the upper limit of normal n NPO.
is n Surgery indicated for:
„ 90% specific l Uncertainty of diagnosis
„ 80–90% sensitive. l Secondary infected necrosis
SURGERY
l Correction of associated biliary tract
disease
l Progressive deterioration with medical care
n Ranson’s criteria (predicts risks of mortality in pancreatitis).
PANCREATITIS
On Admission After 48 hours
Age >55 Drop in hematocrit >10%
Blood Sugar > 200 Increase in blood urea nitrogen (BUN) >5
White blood count (WBC) > 16,000 Calcium <8
Serum glutamic oxaloacetic transaminase (SGOT) > 250 PO2 < 60 mm Hg
Lactic dehydrogenase (LDH) > 700 Base deficit > 4
Fluid deficit > 6L
Number of Risk Factors Mortality
<3 1%
3 or 4 16%
5 or 6 40%
>6 70-100%

CHRONIC PANCREATITIS l salivary gland disorders.
m Etiology n A sentinel loop
l Most commonly alcohol abuse l distention and/or air–fluid levels near a site
l hyperparathyroidism, cystic fibrosis of abdominal distention.
l congenital pancreatic anomalies, l In pancreatitis, it is secondary to
hemochromatosis pancreatitis- associated ileus.
l Associated with chronic liver disease n Classical Case scenario: A 37- year-old male who
m Signs and symptoms underwent laparotomy for a gunshot wound
l Pain similar to acute pancreatitis to the abdomen 2 days ago is found to have a
l Malabsorption tender belly without rebound and is leaning forward
l Steatorrhea on his stretcher breathing at a rate of 28/min.
l Elevated blood sugars l Diagnosis :Pancreatitis.
l Polyuria n Gallstones are not a common cause of
m Diagnosis chronic pancreatitis.
l Patient history very important n Pancreatic calcifications are associated with
l Pancreatic calcifications on x-ray chronic pancreatitis.
l Chain of lakes pattern on pancreatography n Pancreatic function tests in Chronic pancreatitis
l Pseudocysts: l Direct tests-e.g.secretin-pancreozymintest,
„ Diagnosed on CT scan Lundhtest
SURGERY
„ use ultrasound for follow-up of l Indirect tests-e.g.serumtrypsin,faecal fatanalysis

pseudocysts n Treatment of Chrnic pancreatitits
m Treatment l Mass lesion can be removed by
n Nonoperative management pancreaticoduodenectomy or a Beger
l control of abdominal pain, endocrine and procedure
exocrine insufficiency l Duct obstruction can be relieved by
n Operative management: pancreaticojejunostomy or Frey
l In general for pain relief: procedure
„ Ampullary procedures l Disease confined to pancreatic tail may
„ Ductal drainage procedures (to require distal pancreatectomy
decompress the pancreatic duct) l Surgery relieves symptoms in 75% of
PANCREATITIS
„ Ablative procedures (resection of patients

portions of pancreas)
n For pseudocysts:
l Thirty percent of pseudocysts resolve on
their own with bowel rest (TPN and NPO).
l Internal drainage
„ can be after 4 weeks because pseudocyst
wall needs that time to mature
„ done via Roux-en-Y cyst-jejunostomy or
cyst-gastrostomy.
n Indications for surgery:
l Persistent pain
l Gastrointestinal or biliary obstruction
l Pseudocyst infection, hemorrhage, or rupture
l Enlarging pseudocysts
m Clinical pearls
n Cullen’s sign: Bluish discoloration of
periumbilicus
n Grey–Turner’s sign: Bluish discoloration of
flank
n High amylase levels are also seen in
l intestinal disease, perforated ulcer
l ruptured ectopic, salpingitis

TOPIC - 17 RENAL CELL CARCINOMA l Involvement of regional lymph nodes,
ipsilateral renal vein, or vena cava
n Stage IV: Distant metastasis
n Renal cell carcinoma
m Treatment
m Eighty-five percent of all primary renal
n Radical nephrectomy is the treatment of
neoplasms.
m Peak incidence between 55 and 60 years.
choice if there is no evidence of metastasis.
m Male-to-female ratio is 2:1.
(MCQ)
n There are no standard chemotherapeutic
m Risk factors
n Cigarette smoking (MCQ)
regimens or hormonal therapy for metastatic
n Exposure to cadmium (MCQ)
disease, and have been employed with limited
n Genetic defect linked to translocations between
success. (MCQ)
chromosome 3 and 8, and 3 and 11(MCQ) n Clinical pearls :
m Benign tumours of the kidney are rare
m All renal neoplasms should be regarded as
n Classic triad (seen in <10% of cases) (MCQ)
l Gross hematuria
potentially malignant
m Renal cell carcinomas arise from proximal tubule
l Flank pain
l Palpable abdominal mass
cells(MCQ)
m Alternative names include:
n The most common presenting abnormality
n Hypernephroma-Initially believed to arise
is hematuria. (MCQ)
SURGERY
n Most often diagnosed via its systemic
from adrenal gland
n Clear cell carcinoma-Histologically have small
symptoms:
l Fatigability
nuclei and abundant cytoplasm
n Grawitz tumour
l Weight loss and cachexia
m Increased incidence seen in von Hippel-Lindau
l Intermittent fever
l Anemia
syndrome (MCQ)
m Pathologically may extend into renal vein and
n Other symptoms may relate to the production
of hormones and hor mone-like substances: inferior vena cava
m Blood born spread can result in ‘cannon ball’
(MCQ)
RENAL CELL CARCINOMA

l Hypercalcemia (parathyroid hormone)
pulmonary metastases (MCQ)
m Kidney approached through either a
l Galactorrhea (prolactin)
l Cushing syndrome (glucocorticoid)
transabdominal or loin incision
m Renal vein ligated early to reduce tumour
m Diagnosis
n IVP with nephrotomography is the primary
propagation
m Lymph node dissection of no proven benefit
method for evaluating renal masses. (MCQ)
m Solitary (e.g. lung metastases) can occasionally
n It is most important to differentiate cystic
from solid lesions. be resected(MCQ)
m Radiotherapy and chemotherapy have little role
n Ultrasound has improved the ability to
differentiate a solid from a cystic lesion.
n In combination, ultrasound and IVP approach
97% accuracy in diagnosing a benign cyst.
n If the diagnosis of benign cyst is questionable
on ultrasound, a CT scan should be done.
n CT is the method of choice for diagnosis
and staging of renal cell carcinoma. (MCQ)
m Staging(MCQ)
n Stage I:
l Tumor confined within the kidney capsule
n Stage II:
l Invasion through the kidney capsule but
confined within the Gerota’s fascia
n Stage III:

TOPIC - 18 RENAL STONE „ However, its absence does not rule out
renal stones.
„ Urinary pH can aid in differentiating the
n Nephrolithiasis.
m Majority of stones form between the ages of 20
type of stone present.
„ Normal urinary pH is about 5.85.
and 50.
» If the pH is >6, one should suspect
m Male-to-female ratio of 3?1.(MCQ)
m Familial tendency in stone formation.
the presence of urea-splitting
m Tendency for recurrence:
organisms (Proteus). (MCQ)
» A low urine pH (<5) suggests uric
m 36% of patients with a first stone will have
another stone within one year(MCQ) acid stones. (MCQ)
„ WBCs or bacteria may suggest underlying
m 50% will recur within years.
m Etiology
UTI and should be aggressively treated.
l 75% of stones are composed of calcium
Laboratory studies (serum):
m
n WBC may be slightly elevated.
oxalate or a mixture of calcium oxalate
n BUN and creatinine should be measured.
and calcium phosphate.
n Uric acid, calcium, and phosphate levels
l 15% are magnesium–ammonium–
phosphate stones (struvite)— should be measured.
„ occurs exclusively in patients with UTI.
Radiographic studies:
m
n Plain abdominal film (KUB):
(MCQ)
SURGERY
„ Often standard initial study.

l Ten percent are uric acid stones.
„ Only radiopaque stones will be seen
l Less than 1% are cystine stones.
„ 60–70% specific in the diagnosis of a
m Risk factors(MCQ)
l Dietary history: Large calcium and alkali
calculus)
„ However, it is a cheap and quick test to
intake
l Prolonged immobilization
do(MCQ)
„ useful in combination with other studies.
l Residence in hot climate
n Renal ultrasound:
l History of UTI(MCQ)
„ Fast, easy, and relatively inexpensive.
l History of calculus in the past and in family
„ No IV contrast is needed.
members
„ Good for detecting hydronephrosis
RENAL STONE
l Drug ingestion (MCQ)

„ 85–95% sensitive, 100% specific
® analgesics, alkalis
„ Cannot assess renal function.
® uricosuric agents
„ Not very good for detecting small stones
® protease inhibitors(MCQ)
l Prior history of gout(MCQ)
(64% sensitivity).
„ Cannot discriminate between radiolucent
l Underlying gastrointestinal disease
® Crohn’s, ulcerative colitis(MCQ)
and opaque stones, so both types of
® Peptic ulcer disease [PUD]
stones will be seen.
„ Good way to follow known stones.
„ Good for shedding light on alternative
l Severe, abrupt onset of colicky pain
l Pain begins in the flank and may radiate
diagnoses such as (MCQ)
® abdominal aortic aneurysm
toward the groin.
® cholelithiasis,
® In male, the pain may radiate toward
n Noncontrast abdominal/pelvic CT
the testicle.
„ Fast, requires no IV contrast.
® In female, it may radiate toward the
„ Most useful to diagnose (MCQ)
labium majoris.
® small stones (95% sensitivity)
l Nausea and vomiting are almost universal
® hydronephrosis, hydroureter
with acute renal colic.
® perinephric stranding.
l Abdominal distention from an ileus.
„ However, in the absence of
l Gross hematuria.
m Diagnostic tests
hydronephrosis, it cannot reliably distinguish
l Urinalysis:
between ureteral stones and pelvic
„ Vast majority of patients (about 85%) will
calcification.
„ Cannot assess renal function.
have RBCs in the urine.
„ Useful for revealing other abdominal/ n If impaction occurs and hydronephrosis
pelvic pathology. develops, surgical decompression of the
n Intravenous pyelogram: affected kidney may be necessary to preserve
„ Clearly outlines the entire urinary system kidney function.
„ makes it easy to see hydronephrosis and n For stones unlikely to pass spontaneously:
the presence of any type of stones. „ Extracorporeal shockwave lithotripsy
„ Can assess renal function and allow for (ESWL) has been effective for stone
verification that the opposite kidney is located in the kidney with 85% success rate.
functioning properly. (MCQ)
„ Typically, if a ureteral stone exists, the „ Percutaneous nephrolithotomy(MCQ)
IVP will show a delayed nephrogram and » establishes a tract from the skin to
columnization of dye, indicating the collecting system
obstruction. (MCQ) » used when stones are too large or
„ In a nor mally functioning kidney too hard for lithotripsy
without obstruction, the entire ureter is n Bladder calculi
not visualized on a single film because n Bladder calculi are usually associated with urinary
of the peristaltic movement of dye stasis(MCQ)
through the ureter. n Urinary infections increase the risk of stone
„ IVP is generally preferred by the urologist formation
SURGERY
because of its better orientation of the n Foreign bodies (e.g. suture material) can also
stone and demonstration of its size and act as a nidus for stone formation
shape. (MCQ) n They can however form in a normal bladder
„ Disadvantages: n There is no recognised association with
® Time consuming due to need for ureteric calculi
delayed films n Most bladder calculi form in the bladder and
® requires IV contrast. are not from the upper urinary tract
n Retrograde pyelogram: n They vary in size and can be multiple
„ Most precise method of determining the n They are more common in elderly men
anatomy of the ureter and renal pelvis as n In Asia, they are seen more commonly in
diagnosing renal calculi. children
RENAL STONE
„ Done under anesthesia in the n Most stones in adults are formed of uric
cystoscopy suite where a contrast dye is acid(MCQ)
injected into the ureter via a ureteral catheter n Long-standing untreated bladder stones are
inserted into the uretheral orifice in the associated with squamous cell
bladder. carcinoma(MCQ)
„ Because of the invasive nature of the n Clinical features
procedure, this is done only when a „ Bladder calculi can be asymptomatic
precise diagnosis cannot be made by „ Common symptoms include
other means or when there is a clear need » Supra pubic pain
for an endoscopic surgical procedure. » Dysuria
m Management » Haematuria
n Analgesia with NSAIDs and/or opiates. n Surgery
n IV or PO hydration. n Indications for surgery include(MCQ)
n During passage of a stone, there are five sites „ Recurrent urinary tract infections
where the passage is likely to become arrested: „ Acute urinary retention
narrowest points of the urinary system(MCQ) „ Frank haematuria
„ Calyx of the kidney n three common approaches today are(MCQ)
„ Ureteropelvic junction „ Trans urethral cystolitholapaxy
„ Pelvic brim where the ureter arched over „ Percutaneous cystolitholapaxy
the iliac vessels „ Open suprapubic cystostomy
„ Ureterovesical junction n Extracorporeal shockwave lithotripsy is
„ Vesicle orifice relatively ineffective(MCQ)
n Complications of cystolitholapaxy include

l Infection n Check a urine dip for blood and consider
l Haemorrhage imaging.
l Bladder perforation m 10% are due to metabolic derangement(MCQ)
l Hyponatraemia n Hyperparathyroidism
n Pelviureteric junction obstruction n Vitamin D excess
m Causes of upper urinary tract obstruction n Primary hyperoxaluria
l PUJ obstruction - idiopathic, retroperitoneal m Radiation dose from IVU = 1.5 mSv(MCQ)
fibrosis, secondary to trauma or infection m Radiation does from CT scan = 4.5 mSv (MCQ)
l Extrinsic ureteric compression - e.g. m Large staghorn calculi may be asymptomatic
retrocaval ureter, AAA(MCQ) m If greater 5-10 mm in diameter and fail to pass
l Intraluminal pathology - tumour or stone spontaneously consider(MCQ)
l Intramural pathology - primary megaureter n Upper third of ureter-Extra corporeal shock
m Idiopathic PUJ obstruction wave lithotripsy (ESWL)
l PUJ obstruction is more common in men n Lower third of ureter-Ureteroscopy (USC)
l Affects left kidney more often than +lithotripsy
right(MCQ) n Middle third of ureter-Either ESWL or USC
l 10% cases are bilateral m If total obstruction occurs in the presence of
l Aetiology is unknown but important factors infected urine need urgent decompression
may be with percutaneous nephrostomy.
SURGERY
® Aberrant lower pole vessels m If large stones in renal pelvis or upper ureter
® Persistent foetal urothelial fold consider percutaneous nephrolithotomy.
m Clinical features (MCQ)
l Usually presents in adolescence or early n Particularly if stone > 3 cm in diameter or a
adult life ‘staghorn calculus’
l Presenting symptom may be loin pain - m Less than 1% patients with stones require open
worse after alcohol(MCQ) surgery - uretero- or nephrolithotomy (MCQ)
l In late cases a renal mass may be palpable
l Haematuria is an uncommon feature (MCQ)
l 10% develop UTIs and 3% renal colic
m Investigation
RENAL STONE
l Diagnosis can be confirmed by ultrasound

(MCQ)
l IVU shows a classical appearance
l Isotope renography allows assessment of
percentage of renal function
m Management
l The aims of treatment are to:
® Relieve symptoms
® Preserve renal function
l Can achieved by a pyeloplasty
® Anderson-Hymes pyeloplasty is the
commonest procedure(MCQ)
® If severe renal impairment (<20%
function)
® Nephrectomy may be required(MCQ)
Clinical Pearls :
m Typical Clinical scenario in MD Entrance Exam :
A 44- year-old man working as a Marketing
executive presents with sudden onset left-sided flank
pain that he rates a 10/10. He is writhing, unable to
stay still or find a comfortable position.
n Dignosis :Renal colic.

TOPIC - 19 ESOPHAGEAL CARCINOMA n Most patients who are symptomatic at the time
of diagnosis have advanced, widespread
n Esophageal cancer disease, with multiple metastases present to the
m In Asia, the incidence of esophageal carcinoma is
liver, lungs, pleura, and lymph nodes
n As a result of this, < 40% of patients will be
higher.
m Most cases occur in patients over the age of 50.
candidates for “curative” surgery. (MCQ)
n Even when surgery is an option, response is
m Males are affected three times more frequently
than females. poor; therefore, treatment for esophageal
m Risk factors
carcinoma is mostly palliative. (MCQ)
n Postoperative complications are common;
l Alcohol
n >20% of patients will develop fistulae or
l Tobacco
l Diets high in nitrites or nitrosamines
abscesses and respiratory complications.
n Radiation therapy can shrink the tumor,
(MCQ)
l Esophageal disorders such as
resulting in at least temporary relief from
„ Achalasia (MCQ)
obstructive symptoms. (MCQ)
n Other options include
„ chronic esophagitis (MCQ)
l endoscopic laser therapy
„ Plummer–Vinson syndrome.
l endoscopic dilatation and stent placement
l Aflatoxins
l placement of a gastrostomy or
l Trace element deficiency – molybdenum
SURGERY
(MCQ) jejunostomy tube.
l Vitamin deficiencies - vitamins A & C
n Clinical Pearls for MD Entrance Exam:
m Dysphagia does not usually develop until?? 60%
(MCQ)
l Coeliac Disease (MCQ)
of the esophageal lumen is obstructed by tumor.
l Genetic – Tylosis (MCQ)
(MCQ)
m The 5-year survival rate for esophageal carcinoma
l Gradual development of dysphagia, first
is < 5%.
m 90% are squamous cell carcinomas
for solids and later for both solids and
liquids (mechanical dysphagia). (MCQ) o Occur in the upper or middle third of the
ESOPHAGEAL CARCINOMA
l Anorexia develops as swallowing becomes
oesophagus (MCQ)
m 8% are adenocarcinomas
more painful. (MCQ)
n Occur in the lower third of the oesophagus
l Decreased PO intake results in profound
weight loss, easy fatigability, and (MCQ)
n 15% associated with Barrett’s Oesophagus
weakness.
l Physical exam early in the disease course
(MCQ)
m Adenocarcinomas are not radiosensitive and
may be entirely normal.
l With advanced disease, the patient will appear
surgery is mainstay of treatment (MCQ)
m Squamous cell carcinomas can be treated with
cachectic, and supraclavicular
lymphadenopathy may be present. (MCQ) either surgery or radiotherapy (MCQ)
m Operative approaches
m Diagnosis
n Need 10 cm proximal clearance to avoid
l Barium swallow may reveal the presence of
a mass. submucosal spread. (MCQ)
l Total gastrectomy via thoracoabdominal
l Chest x-ray may reveal hilar
lymphadenopathy. (MCQ) approach ( Adenocarcinoma)
l •Subtotal two-stage oesophagectomy
l Esophageal duodenoscopy (EGD) is
useful to both (Ivor-Lewis)
l Subtotal three-stage oesophagectomy
„ visualize the mass
„ retrieve specimens for biopsy.
(McKeown)
l Transhiatal oesophagectomy
l CT scan of the thorax is useful to
m Oesophageal intubation
„ define the extent of disease
n Open surgical intubation (Celestin or
„ thereby determine appropriate
treatment. Mousseau-Barbin tubes) now obsolete
n Endoscopic or radiological placement now
m Treatment
most commonly practised
n Atkinson tube is the most commonly placed TOPIC - 20
endoscopically INTESTINAL OBSTRUCTION
n Requires dilatation with risk of oesophageal
perforation
n Small Intestinal obstruction
n Recent increased use of self-expanding stents
m Cessation, impairment, or reversal of the
that require no pre-dilatation
physiologic transit of intestinal contents
n Complications of stents and tubes
secondary to a mechanical or functional cause.
l Oesophageal perforation
m Types
l Tube displacement or migration
n Open loop obstruction: (MCQ)
l Tube blockage due to ingrowth or
l Flow is blocked but proximal
overgrowth
decompression is possible.
m Laser therapy
n Closed loop obstruction:
n Produces good palliation in over 60% of cases
l Inflow and outflow both blocked
(MCQ)
l Seen with incarcerated hernia, torsion,
n May need to be repeated every 4 to 6 weeks
adhesions, volvulus
n Associated with oesophageal perforation in
l Requires emergent surgery
about 5% cases
m Etiology
m Lymphatics run longitudinally in esophagus
n Mechanical
straight to thoracic duct; hence small primary can
l Intraluminal (gallstone ileus, foreign body,
SURGERY
still spread aggressively via lymphatics(MCQ)

intussusception)
l T1: to lamina propria (does not breach
l Intramural (Crohn’s disease, lymphoma,
submucosa)
radiation enteritis)
l T2: to muscularis propria (does not breach
l Extrinsic (adhesion, hernia, cancer, abscess,
muscularis propria)
congenital)
l T3: Adventitia
n Functional (Paralytic Ileus)
l T4: Adjacent structures
l Hypokalemia (MCQ)
m No role for adjuvant chemo/XRT (except
l Peritonitis
adjuvant XRT for margin + to decrease local recurrence)
l Ischemia
INTESTINAL OBSTRUCTION
(MCQ)
l Medications (opiates, anticholinergics) (MCQ)
m EUS: valuable tool for staging (better than CT
l Hemoperitoneum
for T stage; good for N staging) (MCQ)
l Retroperitoneal hematoma
m Surgical Approaches
l Postoperative
n Cervical esophagus best approached via left
n Risk factors (MCQ)
neck (cervical esophagus is left of midline)
l Previous abdominal surgery (most common risk factor)
(MCQ)
l Hernia
n Thoracic esophagus best approached via
l Inflammatory bowel disease
right thoracotomy (Ivor Lewis) (MCQ)
l Diverticular disease
n Lower esophagus best approached via left
l Cholelithiasis
thoracotomy ± celiotomy
l Ingested foreign body
n Options for resection include: (MCQ)
l 2 “3 hole”
l Colicky abdominal pain
l left neck, right thoracotomy, celiotomy
l Abdominal distention
l offers complete exposure, but greatest
l High-pitched bowel sounds(MCQ)
morbidity
l Nausea
l if intrathoracic , do anastomosis
l Vomiting
o Transhiatal: (MCQ)
n Diagnosis
l no thoracotomy, cervical anastomosis
l History and physical examination give a
l very low morbidity
lot of clues to diagnosis
l but higher leak rate
l Confirm by supine and upright abdominal
x-rays:
„ Dilated loops of small intestine without
evidence of colonic distention on supine
x-ray
„ multiple air–fluid levels in a “stepladder” between simple small bowel obstruction
arrangement on upright films (MCQ) and strangulated bowel.
l CT scan sometimes helpful when x-rays are l Typical Clinical scenario: Intussusception
nondiagnostic (MCQ)
l Strangulated bowel „ A 6- year-old child presents with increasing
„ vascular supply to a segment of intestine irritability, colicky abdominal pain, and
is compromised rectal bleeding with stools that have a
„ lead to intestinal infarction currant jelly appearance. A tubular mass
„ requires immediate laparotomy is palpated in the right lower quadrant.
„ Classic signs include Upright abdominal x-ray shows air–fluid
® fever, tachycardia, leukocytosis levels with a stepladder pattern.
® constant, noncramping abdominal pain. „ Clinical diagnosis: Intussusception.
l Upright chest radiograph „ Barium enema is both diagnostic and
„ A sensitive way to detect free air under the therapeutic.
diaphragm and thus detect bowel n Large bowel obstruction
perforation. m Most commonly occurs in elderly patients
n Treatment (MCQ)
l If the patient is stable or has partial small m It is much less common than small bowel obstruction.
bowel obstruction, give a trial of nonoperative m Signs and symptoms
SURGERY
management: n Abdominal distention
„ IV hydration. n Cramping abdominal pain
„ NPO. n Nausea, vomiting
„ Nasogastric tube (NGT) n Obstipation
decompression. n High-pitched bowel sounds
„ Check upright abdominal x-ray (AXR) m Diagnosis
for dilated loops of small n Supine and upright abdominal films (MCQ)
„ bowel, air–fluid levels, gas in colon and l Distended proximal colon
rectum. l air–fluid levels,
INTESTINAL OBSTRUCTION
„ Check electrolytes, especially for l no distal rectal air.
hypokalemic, hypochloremic metabolic n Establish 8- to 12-hour history of obstipation
alkalosis. (MCQ)
l If the patient fails conser vative n passage of some gas or stool indicates partial
management - perform an exploratory small bowel obstruction, a nonoperative condition.
laparotomy –indication (MCQ) n Barium enema: May be necessary to
„ If a day passes distinguish between ileus and pseudo-
„ fever develops obstruction
„ abdomen becomes increasingly tender m Treatment
l Adhesions call for LOA (lysis of adhesions). n Correction of fluid and electrolyte abnormalities.
l Hernias should be repaired n NGT for intestinal decompression.
l if contents of hernia sac are strangulated, n Broad-spectrum IV antibiotics (e.g.,
resected. cefoxitin).
l Cancer requires en bloc resection with lymph n Relieve obstruction surgically
node sampling. l Colonic obstruction is a surgical emergency
l Crohn’s disease requires resection or since a nasogastric tube will not
stricturoplasty of affected area only(MCQ) decompress the colon
n Clinical Pearls : n PSEUDO-OBSTRUCTION (OGILVIE
l “Never let the sun rise or set on an SBO” SYNDROME))
(unless the patient is postop, has m Massive colonic dilation without evidence of
carcinomatosis, known Crohn’s disease, mechanical obstruction (MCQ)
or partial small bowel obstruction). m thought to result from an imbalance between
l There are no clinical or laborator y parasympathetic and sympathetic control of
parameters that can reliably differentiate intestinal motility. (MCQ)

m More common in older, institutionalized TOPIC - 21
patients. THROMBANGITIS OBLITERANS
m Risk factors
n Severe infection, recent surgery or trauma.
n Thromboangiitis obliterans (Buerger’s disease)
m occlusive disease of the small-and medium-
n Marked abdominal distention with mild abdominal
sized arteries (plantar, tibial, radial, etc.),
pain (MCQ)
m thrombophlebitis of the superficial or deep veins
n decreased or absent bowel sounds.
m Diagnosis (MCQ)
m Histologically, there are inflammatory changes
n Abdominal radiograph with massive colonic
distention. in the walls of arteries and veins, leading to
n Check for free air under diaphragm with
thrombosis.
m Diseases with which Buerger’s disease may be
upright chest x-ray (CXR) (MCQ)
n Exclude mechanical cause for obstruction
confused include (MCQ)
n atherosclerosis
with water-soluble contrast enema and/or
n endocarditis
colonoscopy.
n other types of vasculitis
m Treatment
n severe Raynaud’s phenomenon associated
n NGT and rectal tube for proximal and distal
decompression, respectively. with connective tissue disorders (e.g., lupus or
scleroderma)
SURGERY
n Correction of electrolyte abnormalities.

n clotting disorders of the blood
n Discontinue narcotics, anticholinergics, or other
m In the proper clinical setting, certain
offending medications.
n Turn patient frequently and mobilize from bed.
angiographic findings are diagnostic of
n Consider pharmacologic decompression with
Buerger’s. (MCQ)
n “corkscrew” appearance of arteries (MCQ)
neostigmine (a cholinesterase inhibitor). (MCQ)
l result from vascular damage
n , the patient should undergo prompt
l seen particularly in the arteries in the region
exploratory laparotomy with cecostomy or
loop colostomy –Indications (MCQ) of the wrists and ankles.
THROMBANGITIS OBLITERANS
n Collateral circulation
l If the cecal diameter is > 11 cm
l gives “tree root” or “spider leg”
l if peritoneal signs develop
m Clinical Pearls appearance (MCQ)
l Angiograms may also show occlusions
n The three most common causes of obstruction
of the large bowel (blockages) or stenosis (narrowings) in
l adenocarcinoma (65%) (MCQ)
multiple areas of both the arms and legs.
m Olin (2000) proposes the following criteria
l scarring secondary to diverticulitis (20%)
l volvulus (5%).
(MCQ)
n Typically between 20–40 years old and male
n Ogilvie syndrome is associated with any severe
n Current (or recent) history of tobacco use.
acute illness, neuroleptics, opiates, malignancy, and certain
n Presence of distal extremity ischemia
metabolic disturbances.
n In Ogilvie syndrome, pharmacologic (indicated by claudication, pain at rest, ischemic
decompression of the bowel with neostigmine ulcers or gangrene) documented by
is particularly useful because diagnosis with noninvasive vascular testing such as
contrast enema or colonoscopy can be exceedingly difficult ultrasound.
n Exclusion of other autoimmune diseases,
without bowel decontamination. (MCQ)
hypercoagulable states, and diabetes mellitus by
laboratory tests.
n Exclusion of a proximal source of emboli by
echocardiography and arteriography.
n Consistent arteriographic findings in the
clinically involved and noninvolved limbs
m Treatment
n total abstinence from smoking
l arrests, but does not reverse, the disease.
(MCQ)
n Acute case management n This condition must be distinguished from
l drugs and procedures which cause Raynaud’s syndrome, which has similar
vasodilation are effective in reducing pain features
experienced by patient. n Treatment of Raynaud’s disease consists of
l prostaglandins like Limaprost (MCQ) (MCQ)
„ vasodilators l protection from cold
„ gives relief in pain l avoidance of pulp and nailbed infection
„ do not help in changing the course of l Calcium antagonists, such as nifedipine, may
disease also have a role to play
l Epidural anesthesia and hyperbaric l electrically heated gloves can be useful in
oxygen therapy also have vasodilator effect winter
(MCQ) l Sympathectomy has been discredited in this
n Chronic cases condition.
l Lumbar sympathectomy (MCQ) n Raynaud’s syndrome
„ reduces vasoconstriction and increases n Although peripheral vasospasm may be noted
blood flow to limb in atherosclerosis, thoracic outlet
„ aids in healing syndrome, carpal tunnel syndrome, etc., the
„ gives relief from pain of ischemic ulcers term Raynaud’s syndrome is most often used
l Bypass for a peripheral arterial manifestation of a
SURGERY
„ helpful in treating limbs with poor collagen disease such as SLE or rheumatoid
perfusion secondary to this disease. arthritis(MCQ)
l Debridement-done in necrotic ulcers n The clinical features are as for Raynaud’s disease
l Amputation but they may be much more aggressive.
„ done in In gangrenous digits n Raynaud’s syndrome may also follow the use
„ Established arterial occlusions are treated of vibrating tools
as for atheromatous disease, but l In this context it is a recognised industrial
amputations may eventually be required. disease and is known as ‘vibration white
l Despite the clear presence of finger’. (MCQ)
THROMBANGITIS OBLITERANS
inflammation in this disorder, anti- n Treatment
inflammatory agents such as corticosteroids l The syndrome when secondary to collagen
have not been shown to be beneficial in healing, disease leads frequently to necrosis of digits
n Raynaud’s disease and multiple amputations (MCQ)
n idiopathic condition (MCQ) l Sympathectomy yields disappointing results
n usually occurs in young women (MCQ) and should not be used.
n affects the hands more than the feet. (MCQ) l Nifedipine, steroids and vasospastic
n There is abnormal sensitivity in the arteriolar antagonists may all have a role in treatment.
response to cold. l Patients with vibration white finger should
n The condition is recognised by the characteristic avoid vibrating tools.
sequence of blanching, dusky cyanosis and n Cervicodorsal sympathectomy
red engorgement, often accompanied by n Open cervicodorsal sympathectomy was
pain(MCQ) previously performed for
l These vessels constrict and the digits n vasospastic conditions affecting the
(usually the fingers) turn white and hands(MCQ)
become incapable of fine movements. n to treat palmar (sometimes axillar y)
l The capillaries then dilate and fill with hyperhidrosis.
slowly flowing deoxygenated blood, n The operation is now replaced by endoscopic
resulting in the digits becoming swollen transthoracic sympathectomy –Only
and dusky indication (MCQ)
l As the attack passes off, the arterioles relax, l It is suitable solely for hyperhidrosis.
oxygenated blood returns into the dilated capillaries n Lumbar sympathectomy
and the digits become red. n used to treat chronic lower limb ischaemia
n Superficial necrosis is very uncommon. in the past.
(MCQ) n Now obsolete

TOPIC - 22 BURNS m Fluid rescuscitation
n More than maintenance for all patients with >
m Criteria for Admission to a Burn Center 15% BSA burn (oral resuscitation should be
(MCQ) avoided in these patients because of likely ileus).
n Second- or third-degree burns of > 10%
(MCQ)
n Note that the following fluid requirements
body surface area (BSA) in patients under 10
or over 50 years old will be further increased in patients with fever
n Second- or third-degree burns of > 20%
or requiring intubation (increased insensible
BSA in patients of other ages loss).
n Parkland Formula
n Significant burns to face, hands, feet,
l For first 24 hours: (MCQ)
genitalia, perineum, or skin over major joints
„ Lactated Ringer’s (LR) at rate of 4 mL/
n Full-thickness burns of > 5% BSA at any
age kg/% BSA burn.
„ Give half of 24-hour requirement in first
n Significant electrical injury (including lightning)
n Significant chemical injury
8 hours from the time of burn, and the
n Lesser burn injury in conjunction with
remainder over the next 16 hours.
l In second 24-hour period, (MCQ)
inhalational injury, trauma, or preexisting
„ change fluid to D51/2NS, and give
medical conditions
n Burns in patients requiring special social,
albumin if albumin is < 1.5 or < 3.0 and
SURGERY
emotional, or rehabilitation assistance (i.e., patient is also hypotensive.

n Choosing Fluid Type
child or elder abuse)
l Colloid vs. crystalloid: (MCQ)
m Assessment of Extent and Severity of Burns
„ Use crystalloid as described above unless
n Consider only second- and third-degree
burns when stating % BSA burned. (MCQ) fluid requirement based on urine output is
n The Rule of Nines may be used to estimate
> 2 times estimated in first 12 hours;
the area burned then use colloid.
„ By 48 hours, both are equally effective
n The palm of the patient’s hand is roughly
equivalent to 1% BSA. (MCQ) at restoring intravascular volume and
n Percent BSA burned is used to determine need
cardiac output, but colloid is associated
for fluid resuscitation with more late pulmonary complications
n Who May Be Treated as Outpatient - Indications
and higher mortality.
BURNS
l Dextrose or no Dextrose: (MCQ)

(MCQ)
„ Endocrine response to burn is
l Most first-degree burns
l Superficial and intermediate second-
hyperglycemia, so euglycemic patients do
degree burns of < 10% BSA (excluding not need sugar initially.
n Pediatric Patients
most burns of face, eyes, hands, perineum)
l First 24 hours: (MCQ)
l Patients with acceptable social situations
„ Under 15 years old, estimate need as LR
amenable to providing a safe and helpful
environment at home at 3 mL/kg/%BSA, and give as in adults,
first half over 8 hours and second half
BSA. over next 16 hours.
INFANTS/CHILDREN ADULTS „ Additional need should be given as
Birth 1 5 10 15 electrolyte-free water.
Year Year Year Years+ l Second 24 hours: (MCQ)
Head/Neck 19% 17% 13% 11% 9% „ Use colloids as in adults, except for small
Arm (each) 9% 9% 9% 9% 9% children in whom D51/4NS may be

more appropriate.
Trunk (anterior) 18% 18% 18% 18% 18% „ Additional needs met with D5W
Trunk (posterior) 18% 18% 18% 18% 18% n Monitoring Fluid Status
l Resuscitation is adequate when urine output
Leg (each) 12% 15% 17% 17% 18%
is (MCQ)
Perineum 1% 1% 1% 1% 1% „ 30 to 50 cc/hr in adults
„ 1 cc/kg/hr in children < 30 kg.

l Adjust fluids when urine output is more than l After Resuscitation
33% different (in either direction) from „ Persistent hyperdynamic state:
recommended over 2 to 3 hours. „ CO increases, leading to increased renal blood
l Swan–Ganz catheter may be required to flow and increased GFR.
assess cardiac function in sicker patients. „ Elevated metabolic requirements.
l Use inotropes as needed to maintain blood „ Elevated catecholamines and glucagon.
pressure (BP). „ Decreased levels of insulin and thyroxin.
l Monitor daily weights. „ Result in catabolic state. (MCQ)
l Oliguria „ Edema (peaks at 8 to 12 hours) as fluid is
„ Usually secondary to insufficient fluid lost from intravascular compartment.
resuscitation: n Pulmonary
l Myoglobinuria l In the absence of thoracic burns or
„ Consider diuretics when concerned about inhalation injury, hypovolemia may result
myoglobinuria in rapid but shallow respirations.
„ Seen with l After resuscitation, hyperventilation
® high-voltage injury occurs with or without modest parenchymal
® associated soft-tissue mechanical dysfunction, leading to a mild respiratory
injury alkalosis
® deep burns involving muscle l Increased pulmonary vascular resistance,
SURGERY
® extensive burns with excess fluid and but no change in pulmonary capillary
still oliguric. permeability.
l If mannitol (an osmotic diuretic) is used, l With circumferential thoracic burns, the
the patient will require a CVP line because constricting eschar and edema cause a
urine output ceases to be an adequate restrictive defect and may necessitate
assessment of fluid status. escharotomy. (MCQ)
l Variations in Fluid Requirements (MCQ) n Hematologic
„ Increased l Plasma loss
® High-voltage electrical injury l Red blood cell (RBC) destruction in
® Inhalational injury proportion to extent of burn:
® Delayed resuscitation l Cell lysis secondary to heat
® Intoxicated at time of injury l Microvascular thrombosis in areas with
BURNS
„ Decreased tissue damage
® Patients > 50 years old l Early: (MCQ)
® Patients < 2 years old „ Decrease in platelets
® Patients with cardiac or pulmonary disease „ Decrease in fibrinogen
m Physiologic effect on body systems „ Increase in fibrin degradation products
n Cardiovascular l Later (MCQ)
l Pre-resuscitation „ levels return to normal and then become
„ Increased microvascular permeability elevated
secondary to release of vasoactive materials „ though antithrombin III (ATIII) and
(via arachidonic acid pathway, substance protein C are decreased
P, IL-1, IL-6, IL-8, histamine m Gastrointestinal (GI)
„ Decreased cardiac output n Most patients with > 25% TBSA will have an
„ overall hyperdynamic state with ileus that typically resolves between day 3 and
increased ejection fraction 5. (MCQ)
„ Increased hematocrit due to decreased blood n GI permeability is increased, with increased
volume, increased blood viscosity (MCQ) bacterial translocation.
„ Increased peripheral vascular resistance n Patients generally require an NG tube and GI
„ Oliguria because decreased blood volume prophylaxis with an H2 blocker.
and cardiac output (CO) lead to decreased m Endocrine
renal blood flow and decreased n Increased glucagon, cortisol, catecholamines
glomerular filtration rate (GFR) n Decreased insulin, triiodothyronine (T3)
m Immunologic (MCQ)
n Loss of skin barrier function n Fasciotomy
n > 20% BSA, cell-mediated immunity m Escharotomy may fail, especially when the
decreases in proportion to burn size n burn is from high-voltage electrical injury
n Early decrease in WBC (especially n burn is associated with soft tissue, bone, or
lymphocytes), then granulocytosis and B- vascular injury.
lymphocytosis, with T-cell activation m If compartment syndrome persists after
n Decreased IL-2,IgG, NK cells escharotomy, incision of the fascia is also
n Increased IL-6, TNF-a required.
n PMN dysfunction: m General anesthesia is required.
n Immunosuppression, increase susceptibility to n Debridement and Skin Grafting
infection m Excisional treatment is indicated for most deep
l decreased chemotaxis, second- and third- degree burns once the
l dysfunction related to size of burn patient is stabilized.
m Metabolism and Nutrition m Advantages: (MCQ)
n Hypermetabolism: n Decreased length of stay
l Increased oxygen consumption n earlier return to work
l increased CO n decreased incidence of infection
l increased minute ventilation volume n decreased complications
l increased temperature n improved survival.
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l increased urinary nitrogen m Technique: (MCQ)

n Greatly increased blood flow to wound n Full-thickness burns require debridement to the
n Catecholamine release, especially investing fascial layer using the scalpel and
norepinephrine bovie.
n Increased UUN [VC1] secondary to n Tangential excision may be used for
breakdown of muscle protein to glucose l deep partial burns of < 20% BSA
because of greatly increased need for glucose l staged excision of more extensive partial-
n Increased protein and calorie needs and full-thickness burns.
n Start PO supplementation by nasogastric tube n A Goulian knife, which takes off sequential thin
(NGT) day 3 or 4 if no oral intake, but ileus layers, can be used for partial- and some full-
resolved thickness excisions
n Total parenteral nutrition (TPN) if needed n debridement is done until uniform capillary
BURNS
n Escharotomy bleeding.
m Done in case of Circumferential burns of n Once debridement is complete, the wound is
extremities (including penis) or thorax. covered with split-thickness skin graft
m Indications: (MCQ) (STSG), full-thickness graft, or biologic
n Impairment or failure of peripheral dressing.
circulation or ventilator y exchange, m Wound closure.
manifested by cyanosis n STSG - Prerequisites (MCQ)
n Impaired capillary refill l burn is excised
n Paresthesias l there is no residual nonviable tissue
n Pain l no pooled secretions
n Elevated compartment pressure > 30 mm l surface bacterial count is <10 /cm2
5
Hg n Autograft should be 0.010 to 0.015 inches thick

n No anesthesia is needed. n Donor sites may be reharvested (after 2 to 3
m Technique: weeks when reepithelialization is complete), but
n Make an incision through the eschar and the the quality decreases each time as dermis is
superficial fascia so that the edges of the eschar thinner.
separate. n Grafts may be meshed at a ratio of 1.5:1 to
n The incision should be in the mid-lateral or increase coverage, unless burns are on face or
mid-medial area from the proximal to distal joints. (MCQ)
margin of burn, and across any involved n From which part is First Graft taken (MCQ)
joints.
n The opposite side may also need to be incised.

l If the risk of mortality is anticipated to be n Perineural and lymphatic migration of
< 50%, first graft hands, feet, face, and organisms
joints. n Vasculitis with perivascular cuffing
l If the risk of mortality is anticipated to be n Intracellular viral inclusion
> 50%, graft flat surfaces first to decrease m Stages of Infection
uncovered surface area. n Colonization: Superficial, penetrating,
n Biologic dressings: proliferating
l Bilaminate; n Invasion: Microinvasion, deep invasion,
„ outer layer with pores to permit water vapor microvascular invasion
but not liquid or bacterial passage m Treatment
„ inner layer that permits ingrowth of n For invasive infection
fibrovascular tissue from wound surface. l change to Mafenide Acetate and start
l Options for Biologic Dressings systemic antibiotics. (MCQ)
l Allograft: Cadaveric (MCQ) n For pseudomonal or pediatric infections
„ Prevents wound desiccation l infuse subeschar piperacillin, and plan for
„ Promotes maturation of granulation tissue emergent operative debridement within 12
„ Limits bacterial proliferation hours.
„ Prevents exudative loss of protein and RBC n For candidal infections
„ Decreases wound pain l start antifungal creams
SURGERY
„ Increases movement l if that treatment fails, start systemic therapy
„ Decreases evaporation with amphotericin B.
„ Decreases heat loss n Aspergillus
l Xenograft: Porcine l may infect subcutaneous tissues late in the
„ Less effective course
„ More subgraft bacteria l if it crosses the fascia, amputation of the
n Biobrane: (MCQ) extremity is required.
l Synthetic collagen dermal analog, with silastic n Viral infections with HSV-1
epidermal analog l uncommon
l Partial-thickness burns l require 7 days of acyclovir 5% ointment.
l Pain is reduced m Pneumonia
l Comes off on its own when n Cause of death in over half of fatal burns.
BURNS
reepithelialization occurs n Agent is usually Staphylococcus aureus or
n INFECTION gram negatives such as E. coli and
m Signs Enterococcus.
n Degeneration of second degree to full n Onset after day 10. (MCQ)
thickness n Hematogenous pneumonia
n Focal color change to dark brown and black l occur later, around the 17th day (MCQ)
n Degeneration of wound with neoeschar l occur from a remote septic focus
formation l appears as a round infiltrate on chest x-ray
n Rapid eschar separation (CXR).
n Hemorrhagic discoloration of subeschar fat l Treatment is to remove source and treat with
n Erythematous or violaceous edematous antibiotics.
wound margin l This type is more often fatal than
n Crusted margin bronchopneumonia.
n Metastatic septic lesions in unburned tissue m Suppurative thrombophlebitis
m Biopsy Reveals n Prevent by changing peripheral IVs every 3
n Microorganisms in unburned tissue days.
n Hemorrhage in unburned tissue m Acute endocarditis
n Heightened inflammatory reaction in adjacent n Likelihood increased because of long-term
viable tissue need for IV.
n Small-vessel thrombosis or ischemic necrosis n Culprit typically S. aureus
or unburned tissue m Suppurative sinusitis
n Due to nasal intubation or long-term NGT

n Confirm with CT m The neoeschar and lack of vascularity limit
n Treat with antibiotics , Drain if treatment fails antibiotic delivery
m Burn scar cancer m Hypovolemia and hemoconcentration can lead
n Called Marjolin’s ulcer (MCQ) to an elevated hematocrit and decreased left
n Usually squamous cell carcinoma, which ventricular end diastolic volume that result in decreased
metastasizes via lymph nodes (MCQ) CO and low-flow state.
n Diagnosis made by biopsy m Burn patients are susceptible to Curling’s ulcer,
n Treatment: Wide excision of all involved which is due to lack of the normal mucosal barrier.
tissue (MCQ) m Need for escharotomy may be decreased by
m Carbon Monoxide (CO) Poisoning maintaining limb elevation and by enforcing
n In closed space burns. active motion at least 5 minutes per hour.
n Impairs tissue oxygenation by m The most common compartment requiring
n decreasing oxygen-carrying capacity of fasciotomy is the anterior tibial compartment.
blood (MCQ)
n shifting oxygen–hemoglobin dissociation curve m Limit burn excision operations to excision of <
to the left 20% BSA at one trip to the OR or to a set time
n binding myoglobin and terminal cytochrome limit of 2 hours. (MCQ)
oxidase. m Burn debridement with the Goulian knife is
n Symptoms do not correlate well with frequently accompanied by a significant amount of
SURGERY
carboxyhemoglobin levels. blood loss, which can be minimized by using topical

n Measure carboxyhemoglobin with ABG. thrombin spray and infiltration with epinephrine
(MCQ) or vasopressin.
l Treatment is hyperbaric oxygen. m Infection is more likely in patients with > 30% BSA
l Decreases half-life to 30 minutes (2 atm). burn without complete excision or grafting.
n Clinical Pearls : (MCQ)
m Typical Clinical scenarios: m Apparently infected wounds need to be examined
n A 7- year-old child presented acutely with a 14% daily and biopsied, including eschar and
total body surface area (TBSA) burn, underlying unburned tissue
including both second and third degree. It m Mafenide acetate penetrates eschar well and
looks as if he had been seated in scalding water. should therefore be used when infection is present.
Where should this child be cared for? (MCQ)
BURNS
l This patient is under 10 years old, with >

10% TBSA burned, including the perineum
and genitalia, she should be transferred to a
burn center.
n An adult male is brought with second-degree
burns of his chest and abdominal wall,
anterior right leg, and perineum. What
percentage TBSA does he have? (MCQ)
l Rule of Nines says 18% for anterior torso,
9% for anterior leg, and 1% for perineum
= 28%.
n How much fluid should a 60- kg female with
a 25% TBSA burn receive during the first 24
hours? (MCQ)
l Parkland formula. At 4 mL/kg/%, 4 ? 60 x
25 = 6,000 mL required over the next 24
hours, at a rate of 375 mL/hr for the first 8
hours, and 188 mL/hr for the next 16
hours.
m The risk of infection of burned tissue is increased
because the wound is protein rich and moist,
and is thus a good culture medium. (MCQ)
TOPIC - 23 GRAFTING
n Skin loss - flaps and grafts Definitions

n Autograft is graft from one part of body to
another in the same individual
n Allograft is graft from one individual to
another in the same species
n Xenograft is graft from one species to another
n Skin grafts
n A skin graft is an autograft
n Can be partial or full thickness depending
on the amount of dermis taken
n Partial-thickness skin grafts
n Contains epidermis and superficial part of n Axial pattern grafts
dermis (MCQ) n Receives blood supply from a direct cutaneous
n Donor site epithelium grows back from sweat arteries(MCQ)

glands and hair follicles n Examples include:
n Graft can be ‘meshed’ to increase the area that l Ilio femoral island f lap supplied by
can be covered superficial circumflex iliac artery
SURGERY
n Excess skin can be stored in fridge and reused l Lateral forehead flap supplied superficial
for up to 3 weeks(MCQ) temporal artery

n Partial-thickness grafts can not be used on l Delto pectoral island flap supplied by
infected wounds perforating branches of internal mammary

n Not suitable for covering bone, tendon or artery
cartilage(MCQ) n Survival of all flaps depends on it receiving
n Cosmetic result is often not good(MCQ) an adequate blood supply

n Full-thickness skin grafts n Depend on length of flap in relationship to
n Contains epidermis and all of dermis (MCQ) its base

n Can only be used to cover small defects n Blood supply can be improved by the use of
(MCQ) ‘delaying’ techniques
GRAFTING
n Good cosmetic results can be obtained n The flap is partially raised and replaced prior
(MCQ) to use
n Donor site needs to be closed with primary n Encourages the flap to increase its blood
suture or partial thickness graft(MCQ) supply through the pedicle

n Common donor sites include the postauricular
skin and supraclavicular fossa
n Skin flaps - Classified according to blood supply
n Random pattern grafts
l Receives blood supply from segmental
anastomotic or axial artery (MCQ)
l Examples include
„ Advancement flap
„ rotation flap

n Tube pedicle grafts Clinical Pearls :
n Frequently raised from abdomen or inner arm n With regard to tissue defects, what is the
(MCQ) reconstructive ladder?
n Parallel skin incisions allow tube of skin to m Closure techniques of increasing complexity:
be formed (MCQ) 1. Primary closure
n Skin defect is then closed 2. Skin graft
n The length of the tube should not be greater 3. Local vascularized tissue flap
than twice the base 4. Remote pedicled flap
n Long axis of tube should parallel the 5. Vascularized-free flap with microvascular
direction of the cutaneous blood anastomosis
vessels(MCQ) n What tissues will not take a skin graft?
n Good means of delaying tissue transfer over n Devitalized tissue
a long distance n Infected tissue
n Produces a good cosmetic result n Bone (granulated periosteum will)
n Myocutaneous flaps n Tendon (granulated peritenon will)
n In most parts of the body the skin receives n What are the three phases of skin graft and how
its blood supply from the underlying muscle long do they take?
(MCQ) n Serum imbibition (MCQ)
n Muscle, fascia and overlying skin can therefore l 24 hours
SURGERY
be moved as one unit l skin graft survives solely on diffusion of

n The survives on major blood vessel supplying nutrients through wound bed.
the muscle n Inosculation (MCQ)
n Examples include: l 24–72 hours
l Latissimus dorsi flap supplied by thoraco l connection of graft capillaries to wound
dorsal artery bed capillaries.
l Transverse rectus abdominis supplied by n Angiogenesis (MCQ)
superior epigastric artery(MCQ) l 72 hours
n Allow tissue transfer to poorly vascularised l ingrowth of new vessels into the skin graft from
areas(MCQ) the wound bed.
n Bone can also be transferred for osseous l What is the time frame for reliable graft
GRAFTING
reconstruction “take”? (MCQ)

n Flaps usually have no sensation(MCQ) n 5 days
n Free myocutaneous flaps n What factors will cause a skin graft to fail?
n Microvascular techniques allow the anastomosis n Fluid collection under graft (seroma, hematoma)
of arteries and veins(MCQ) n Infected wound bed
n Myocutaneous flaps can therefore be detached n Mechanical sheer forces
from blood supply n Split thickness skin graft (STSG) vs Full
n Can be transferred to other parts of thickness skin graft (FTSG) (A Very important
body(MCQ) High yield fact for MD Entrance )
n Examples include the free transverse rectus n Contraction - STSG
abdominis flap(MCQ) n Longer time to revascularization -FTSG
n Tissue expansion n Include adnexal structures—hair follicles
n Skin can be gradually stretched to accommodate and sweat glands -FTSG
a greater area n Donor must be closed primarily-FTSG
n If skin loss is anticipated it is possible to expand n Donor site heals like a second degree burn -
adjacent skin prior to operation STSG
n Tissue expanders can be placed n Can be meshed - STSG
subcutaneously in collapsed state (MCQ) n Retains native color -FTSG
n Over several weeks can be inflated with saline n What is a random flap (MCQ)
through a subcutaneous port n Skin and subcutaneous, ie, has blood supply
n Expanded skin can be used to cover defect based on subdermal plexus
and tissue expander removed n What is an axial flap(MCQ)

n Skin and subcutaneous tissue (can include TOPIC - 24 CBD STONE
muscle) that is based on a defined vascular
supply, often a named vessel. n Choledocolithiasis
n What is a flap’s pedicle? (MCQ) m Obstruction of the common bile duct by a stone.
n In flaps that have a defined vessel, it is the
m Found in
portion of the flap that contains the vessels. n 6–15% of acute calculous cholecystitis
n Used with “island flaps” where the vascular
n 1–2% of acalculous cholecystitis at surgery.
supply is dissected free from surrounding m Signs and symptoms
tissue. n Epigastric or RUQ pain and tenderness
n What is a common flap used to treat scar n Jaundice
contracture bands? n Cholangitis
n Z plasty (MCQ)
n recurrent attacks of acute pancreatitis
l Z plasty for scar contracture is made by
without other known risk factors.
incisions equal in length to the central m Diagnosis
member oriented at 60°. n Increased ALP, LFTs, and total and direct
l Use as few sutures as possible and stagger
bilirubin
to preserve blood supply. n ERCP: (MCQ)
n What is a free flap? (MCQ) l Gold standard for diagnosis of CBD stones
n Vascularized tissue flap (myocutaneous,
l also provides a therapeutic option
SURGERY
muscle, bone) in which the native blood n Endoscopic ultrasound:
supply has been disconnected and l Less sensitive than ERCP but also less invasive
reanastamosed to vessels dissected free in the l more sensitive than transabdominal
recipient wound bed. ultrasound
n What are the reconstructive options after n Transabdominal ultrasound: (MCQ)
mastectomy? (MCQ) l Highly specific but not very sensitive for CBD
n Implant after tissue expansion
stones
n TRAM (transverse rectus abdominis l Treatment
myocutaneous) flap n ERCP:
n Latissimus dorsi myocutaneous flap
l Involves endoscopic sphincterotomy with
n Free TRAM (can be muscle sparing)
retrieval of the CBD stone(s) with a
CBD STONE
basket (85–90% successful). (MCQ)
l If ERCP fails, the CBD can be opened
surgically and the stones removed.
l A T-tube is placed so bile can drain externally.
(MCQ)
l It is removed 2 to 3 weeks later on an
outpatient basis.
n Acute (Ascending) Cholangitis
n Bacterial infection of the bile ducts usually
associated with obstruction of the CBD by a
gallstone. (MCQ)
l Fever, chills
l Nausea, vomiting
l Abdominal pain with or without altered
mental status and septic shock
n Diagnosis
l Labs:
„ Leukocytosis with increased bilirubin,
ALP, and LFTs.
l Ultrasound:
„ Should be the initial study

„ dilation of common and intrahepatic bile n Intrahepatic strictures: Liver transplant.
ducts is suggestive. (MCQ)
l ERCP/percutaneous transhepatic m Prognosis
cholangiography (PTC): n Ten percent of patients develop
„ Provides a definitive diagnosis; can also cholangiocarcinoma. (MCQ)
be therapeutic. n Ten-year survival is 75%.
l Bile cultures: (MCQ)
„ Obtain to facilitate proper antibiotic
treatment TOPIC - 25 SHOCK
„ offending organisms are usually enteric
gram negatives and enterococci. n Shock
n Treatment n Inadequate perfusion and oxygen delivery to
l NPO, IV fluids, and IV antibiotics. tissues
l If patient is in shock, decompress bile duct n Tissue perfusion is determined by:
and remove obstruction immediately by l Cardiac output (CO) (and CO = Stroke
ERCP/PTC. (MCQ) volume × Heart rate)
l If unsuccessful, intraoperative l Systemic vascular resistance (SVR)
decompression with T-tube placement is n Hypovolemic Shock
indicated. (MCQ) n Decreased tissue perfusion secondary to rapid
SURGERY
l If the patient is stable, continue volume/blood loss, i.e., preload.

conservative management with definitive n CO is consequently decreased.
treatment later. n The causes include
n Sclerosing Cholangitis (MCQ) l bleeding, vomiting/diarrhea
m A chronic, progressive inflammatory process l third spacing (e.g., from bur ns or
of the biliary tree of unknown etiology that results pancreatitis).
in strictures n Signs and symptoms
m in most cases, leads to cirrhosis and liver failure. l Early on, patients will have orthostatic
m 2:1 male predominance hypotension, tachycardia, and cool skin
m median age of onset at 40 years. l As the condition progresses, they are
m Risk factors (MCQ) hypotensive, have decreased pulse
n IBD, pancreatitis, pressure, become confused, and have cold,
SHOCK
n Diabetes clammy skin due to “clamping down” of

n trauma to the common hepatic duct. peripheral vessels.
m Signs and symptoms n Classification of severity of hypovolemic shock
n Many patients are asymptomatic at the time of l Class I:
diagnosis „ Loss of < 20% of circulating blood
n symptoms can include fever, weight loss, fatigue, volume. (MCQ)
pruritus, jaundice, hepatomegaly, splenomegaly, and „ Manifestations include slight tachycardia.
hyperpigmentation. „ No change in BP or urine output.
m Diagnosis l Class II:
n ERCP/PTC reveal a “beads on a string” „ Loss of 20 to 40% of blood volume.
appearance of the bile ducts (MCQ)
n ALP is almost always elevated. (MCQ) „ Manifestations include
m Treatment ® tachycardia, tachypnea
n Balloon dilation with stent placement can ® capillary refill time > 2 seconds (MCQ)
be performed for palliative purposes, but ® orthostatasis
definitive treatment varies depending on the ® decreased pulse pressure.
location of the strictures. (MCQ) ® Agitation or confusion may be
n Extrahepatic strictures: (MCQ) present.
l Hepatoenteric anastomosis with removal l Class III:
of the extrahepatic ducts and T-tube „ Loss of > 40% of circulating blood
placement for external drainage of bile. volume. (MCQ)

„ All of the above plus lethargy and » > 10% bands
decreased urine output. „ Sepsis:
n Treatment ® Sepsis is SIRS + a known source of
l Fluids first infection. (MCQ)
l Isotonic fluids are the best volume repleters; „ Severe sepsis:
hence, use normal saline or lactated ® Severe sepsis is sepsis + organ
Ringer’s. (MCQ) dysfunction (e.g., renal failure, altered
l Replacement of blood, if hemorrhage is mental status, ARDS, etc.). (MCQ)
cause ® Hypotension is present, but it responds to
l Treat underlying cause (i.e., surgical fluid resuscitation.
correction if patient has ongoing hemorrhage). „ Septic shock:
n Distributive Shock ® Septic shock is sepsis that is refractory
n A family of shock states that are caused by to fluid resuscitation. (MCQ)
systemic vasodilation (i.e., severe decrease in n Anaphylactic shock
SVR). l Systemic type I hypersensitivity reaction
n They include causing chemically mediated angioedema
l septic shock and increased vascular permeability,
l neurogenic shock resulting in hypotension and/or airway
l anaphylactic shock. compromise. (MCQ)
SURGERY
n These patients will have warm skin from l Physical Findings
vasodilation. „ Urticaria
n Septic shock „ Swelling
l Infection that causes vessels to dilate and „ Angioedema of lips and throat
leak, causing hypotension refractory to fluid „ Wheezing
recuscitation. l Treatment
l Lab/Physical Findings „ Intubation if airway compromise
„ Fever, tachypnea „ Epinephrine
„ Metabolic acidosis, hyperglycemia „ Antihistamines (diphenhydramine)
„ Positive blood cultures (often negative, however, „ Steroids (MCQ)
particularly if drawn after antibiotics are started) n Neurogenic shock
l Treatment l CNS injury causing disruption of the
SHOCK
„ Fluids!! sympathetic system, resulting in unopposed
„ Antibiotics vagal outflow and vasodilation.
® If blood pressure unresponsive to fluids, the l It is characterized by hypotension and
following pressors are classically used: bradycardia (no sympathetic response of
norepinephrine or dopamine (high vasoconstriction and tachycardia).
dose) (MCQ) l Treatment
l The Continuum: SIRS, Sepsis, Severe „ Fluids
Sepsis, and Septic Shock „ If needed, the pressor dopamine or
„ Septic shock is the most severe dobutamine is classically used. (MCQ)
manifestation of infection in a continuum. „ Atropine and/or pacemaker for
„ Milder manifestations of infection are bradycardia
classified as SIRS, sepsis, and severe n Cardiogenic Shock
sepsis. l Pump failure, resulting in decreased CO.
„ SIRS (systemic inflammatory response l This can be caused by myocardial in-
syndrome): farction, arrhythmias, valvular defects, or
® To meet the SIRS criteria, you need two extracardiac obstruction (tampon- ade,
of the following: (MCQ) pulmonary embolism, tension
» Temp > 38°C or < 36°C pneumothorax).
» Pulse > 90/min l Wedge pressure and systemic vascular
» Respiratory rate > 20/min resistance are elevated.
» PaCO2 <32mmHg l Findings
» WBC > 12,000 or < 4,000

„ cold, clammy skin from clamping down „ Likewise, if you hemorrhage and have
of peripheral vessels. no preload, your stroke volume will
„ jugular venous distention (JVD) decrease as well.
„ dyspnea, and bilateral crackles on lung l Systemic vascular resistance (SVR)
exam „ usually divided by body surface area to
„ Chest x-ray will show bilateral pulmonary give systemic vascular resistance index
congestion. [SVRI])
l Treatment „ Normal SVRI - 1,500 to 2,400 (MCQ)
„ Left heart failure or biventricular failure: „ SVR reflects the vascular resistance across
(MCQ) the systemic circu-lation (it can be
® Diuretics thought of as afterload as well).
® Nitrates (decrease preload) „ Distributive shock causes vessels to dilate
„ Classically, the following pressors can be and leak, causing SVR to decrease.
used: „ Cardiogenic and hypovolemic shock
® Dopamine (medium dose) results in vasoconstriction, causing SVR to
® Dobutamine increase.
® Amrinone n Pressors
„ Intra-aortic balloon pump can be used m A group of vasoactive drugs that are the final
to decrease the work of the heart. (MCQ) line of defense in treating shock
SURGERY
„ Isolated right heart failure: Give fluids m Effects and side effects
(maintains preload). n Generally, pressors are used to increase CO
n Swan–Ganz catheter or SVR.
n The Swan–Ganz catheter is often used with n virtually any direct stimulation of the heart
intensive care unit (ICU) and shock patients in (β1) can cause the side effect of arrhythmias.
order to obtain information relevant to fluid m Dobutamine
and volume status. n Action: Strong stimulation β1 receptors
n It is threaded through the vena cava (superior (ionotropic/chronotropic effects on the heart) with
or inferior) ’ right atrium ’ right a mild stimulation of β2 (vasodilation)
ventricle ’ pulmonary artery. (MCQ) n Result: h CO, i SVR (MCQ)
n Measurements obtainable through the Swan– n The β2 stimulation causes the side effect of
Ganz that will allow a better understanding of hypotension. (MCQ)
SHOCK
the different types of shock. n Typical use: Cardiogenic shock (MCQ)

l Pulmonary capillary wedge pressure m Isoproterenol
(PCWP) n Similar to dobutamine.
„ normal 6 to 12 mm Hg (MCQ) n Action: Strong stimulation of β1 receptors
„ This reflects the pressures of the left (ionotropic/chronotropic effects on the heart)
ventricle (end-diastolic pressure). and β2 (vasodilation) (MCQ)
„ It can be thought of as preload. n Result: hCO, i SVR (MCQ)
„ If the pump fails, pressures in the left n Typical use: Cardiogenic shock with
ventricle increase and you will have an bradycardia
increased wedge. m Milrinone
l Cardiac output (CO) n Milrinone is technically not a pressor, but it
„ normal 4 to 8 mm Hg (MCQ) is an important drug used in the ICU. (MCQ)
„ Remember, CO = Stroke volume × n Action: Phosphodiesterase inhibitor, which
Heart rate. results in increased cyclic AMP. (MCQ)
„ The Swan–Ganz allows CO to be mea- n This has positive ionotropic effects on the
sured via the ther modilutional heart and also vasodilates. (MCQ)
technique: n Result: hCO, i SVR
„ If you have an MI and lose wall motion, n Typical use: Heart failure/cardiogenic shock
your stroke volume will be decreased and, m Dopamine
therefore, so will your CO. n Dopamine has different action depending on
the dose.
n Low Dose (1 to 3 µg/kg/min): (MCQ)

l “Renal Dose” n This is not a pressor, but it is an important
l Action: Stimulation of dopamine receptors vasoactive drug.
(dilates renal vasculature) and mild β1 n Action: Venodilation and arterial dilation
stimulation (MCQ) (MCQ)

l Typical use: Renal insufficiency (MCQ) n Result: Decrease preload and afterload
n Intermediate Dose (5 to 10 µg/kg/min): n Typical use: Low cardiac output with high
(MCQ) BP
l “Cardiac Dose” m Nitroglycerin
l Action: n has less arterial dilation, except in the coronary
„ Stimulation of dopamine receptors, arteries, which it effectively dilates.

moderate stimulation of β1 receptors n It is used for anginal pain in low doses and
(heart ionotropy/chronotropy), to reduce BP in high doses. (MCQ)

„ mild stimulation of α1 receptors n Clinical Pearls :
(vasoconstriction) n If the skin is warm, it is distributive shock.
l Result: h CO (MCQ)
l Typical use: Cardiogenic shock n If the skin is cold and clammy, it is
n High Dose (10 to 20 µg/kg/min) (MCQ) hypovolemic or cardiogenic shock.

l Action: n Of the vital organs, the first “casualty” of
„ Stimulates dopamine receptors, hypovolemic or cardiogenic shock (both “cold
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„ β1 receptors (heart ionotropy/ shocks”) is the kidneys, as blood is shunted
chronotropy) away from the constricted renal arteries.
„ strong stimulation of α1 receptors Therefore, it is crucial to monitor for renal
(vasoconstriction) failure.
l Result: hh SVR n An adequate urine output is a crucial sign that
l Typical use: Cardiogenic or septic shock the treatment is adequate.

(MCQ) n Factors that suppress the tachycardic
m Norepinephrine response to hypovolemia:

n Action: (MCQ) l Betablockers
l Strong stimulation of α1 receptors l Atheletes
(vasoconstriction) l Damage to autonomic nervous system
l moderate stimulation of β1 receptors (heart n Adequate (at minimum) urine output is 0.5 cc/
SHOCK
ionotropy/chronotropy) kg/hr. (MCQ)
n Result: h h SVR, h CO n Gram-negative bacteria are notorious for
n Typical use: Septic shock (MCQ) causing septic shock. (MCQ)

m Epinephrine n Poor prognostic signs in septic shock: DIC ,
n Action: Multiple organ failure

l Strong stimulation of β1 receptors (heart n Even when SIRS criteria are met, infection is
ionotropy/chronotropy), (MCQ) present < 50% of the time.

l strong stimulation of α1 receptors n Causes of anaphylaxis:
(vasoconstriction) l Drugs (penicillin), radiocontrast
l moderate stimulation of α 2 receptors (dilates l insect bites (honeybee, fire ant, wasps)
bronchial tree) l food (shellfish, peanut butter).
n Result:h h h h SVR,±/- h h CO, n Remember, type I hypersensitivity reactions
bronchodilation(MCQ) are immunoglobulin E (IgE) mediated and

n Typical use: Anaphylaxis, septic shock, require prior exposure.
cardiopulmonary arrest n Look for neurogenic shock following history
m Phenylephrine of spinal trauma or spinal anesthesia.

n Action: Strong stimulation of α1 receptors n Cardiogenic shock, like hypovolemic shock,
(vasoconstriction) often results in renal insult from peripheral

n Result: h hSVR(MCQ) vasoconstriction. It is crucial to monitor urine
n Typical use: Septic shock, neurogenic shock, output.
anesthesia-induced hypotension(MCQ)
m Sodium Nitroprusside
n The Swan–Ganz catheter has never been m Physical examination
proven to improve morbity or mortality in any n Seat-belt sign—(MCQ)
study. l ecchymotic area found in the distribution of
n Wedge pressure the lower anterior abdominal wall
l pressure measured equals the pulmonary l can be associated with
capillary pressure „ perforation of the bladder or bowel
l this, theoretically, represents the left atrial „ lumbar distraction fracture (Chance
pressure, and ultimately the left fracture).
ventricular end-diastolic pressure n Cullen’s sign (periumbilical ecchymosis)
(LVEDP). (MCQ) l indicative of intraperitoneal hemorrhage.
l It reflects the left ventricular pressure, which (MCQ)
will be increased with left ventricular n Grey–Turner’s sign (flank ecchymoses)
failure. (MCQ) l indicative of retroperitoneal hemorrhage.
(MCQ)
TOPIC - 26 BLUNT INJURY ABDOMEN n Kehr’s sign—
l left shoulder or neck pain secondary to splenic
n Abdominal trauma rupture.

m Penetrating abdominal injuries (PAIs) l It increases when patient is in Trendelenburg
n result from a gunshot wound (MCQ) position or with left upper quadrant
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n create damage via three mechanisms: (LUQ) palpation (caused by diaphragmatic

l Direct injury by the bullet itself irritation). (MCQ)
l Injury from fragmentation of the bullet m Diagnosis
l Indirect injury from the resultant “shock wave” n Perforation:
n PAIs resulting from a stabbing mechanism l AXR and CXR to look for free air
are limited to the direct damage of the object of n Diaphragmatic injury:
impalement. l CXR to look for
m Blunt abdominal injuries (BAIs) „ blurring of the diaphragm
n Damage by three general mechanisms of „ hemothorax,

BLUNT INJURY ABDOMEN
injury: „ bowel gas patterns above the diaphragm (at
l Injury caused by the direct blow times with a gastric tube seen in the left
l Crush injury chest).
l Deceleration injury m Focused Abdominal Sonography for Trauma
m Anatomy (FAST)
n Three openings: (MCQ) n Positive if free fluid is demonstrated in the
l T8: IVC abdomen.

l T10: Esophagus, with vagus nerves n Advantages
l T12: Aorta (also thoracic duct, azygos vein) l A rapid bedside screening study
n Abundant blood supply: Pericardiophrenic, l Noninvasive
phrenic, and intercostal arteries l Not time consuming
n Innervated by phrenic nerves l 80–95% sensitivity for intra-abdominal
n Peritoneal viscera: blood

l Liver, spleen, stomach n Disadvantages
l small bowel, sigmoid and transverse colon l Operator dependent
n Retroperitoneal viscera: l Low specificity for individual organ injury
l Majority of the duodenum (fourth part is l Four views are utilized to search for free
intraperitoneal) (MCQ) intraperitoneal fluid (presumed to be blood

l pancreas, kidneys and ureters in the trauma victim) that collects in
l ascending and descending colon dependent areas and appears as
l major vessels such as the abdominal aorta, hypoechoic areas on ultrasound
inferior vena cava, renal and splenic vessels l Morrison’s pouch (RUQ): (MCQ)
n Pelvic viscera: „ Free fluid can be visualized between the
l Bladder, urethra, ovaries and uterus in women liver and kidney.

l prostate in men, rectum, and iliac vessels l Splenorenal recess (LUQ): (MCQ)

„ Free fluid can be visualized between the m Laparoscopy (MCQ)
spleen and kidney. n Usage is increasing (mainly to identify peritoneal
l Pouch of Douglas (MCQ) penetration from gun shot/knife wound),

„ lies above the rectum especially for the stable or marginally stable
„ probe is placed in the suprapubic region patient who would otherwise require a
l Subxiphoid and parasternal views to look laparotomy
for hemopericardium. n Helpful for evaluation of diaphragm
m Diagnostic Peritoneal Lavage (DPL) n May help to decrease negative laparotomy
n Advantages (MCQ) rate

l Performed bedside n may miss hollow organ injuries
l Widely available n does not assess retroperitoneal injuries
l Highly sensitive for hemoperitoneum m Indications for Exploratory Laparotomy (MCQ)
l Rapidly performed n Abdominal trauma and hemodynamic
n Disadvantages (MCQ) instability

l Invasive n Bleeding from stomach (not to be confused
l Risk for iatrogenic injury (<1%) with nasopharyngeal bleeding)

l Low specificity (many false positives) n Evisceration
l Does not evaluate the retroperitoneum n Peritoneal irritation
n If gross blood appears (> 5 to 10 cc) the n Suspected/known diaphragmatic injury
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patient should be taken to the OR for n Free intraperitoneal or retroperitoneal air
exploratory laparotomy. n Intraperitoneal bladder rupture (diagnosed
n If the aspiration is negative, instill 15 cc/kg of by cystography)

warmed normal saline or lactated Ringer’s solution into n Positive DPL
the peritoneum through IV tubing con- nected n Surgically correctable injury diagnosed on
to the catheter. CT scan

l Let the solution stand for up to 10 minutes n Removal of impaled instrument
(if the patient is stable), then place the IV bag n Rectal perforation (diagnosed by
from which the solution came on the floor sigmoidoscopy)

for drainage via gravity. n Transabdominal missile (bullet) path (e.g., a
l A sample of the returned solution should gunshot wound to the buttock with the bullet
be sent to the lab for stat analysis. being found in the abdomen or thorax)
m CT Scanning (MCQ) n Diaphragmatic injury
n Useful for the hemodynamically stable n May result from penetrating or blunt trauma.
patient. n Left hemidiaphragm more frequently injured.
n Has a greater specificity than DPL and (MCQ)

ultrasound (US). n Signs and Symptoms
n Noninvasive l Thoracic:
n Relatively time consuming when compared „ Chest pain, dyspnea, worsening respiratory distress,
with DPL and US decreased breath sounds, rib fractures, flail chest,
n Diagnostic for specific organ injury; hemo/pneumothorax
n may miss diaphragmatic, colonic, and l Abdominal:
pancreatic injury „ Pain and tenderness
m Angiography (MCQ) n Diagnosis
n May be used to l Noninvasive:
l identify and embolize pelvic arterial „ CXR, upper GI series, barium enema, ultrasound,
bleeding secondary to pelvic fractures CT, magnetic resonance imaging (MRI) . (MCQ)
l assess blunt renal artery injuries diagnosed „ CXR findings
by CT scan. ® Initially normal in up to 50% of cases
n Otherwise limited use for abdominal trauma. ® Pneumo/hemothorax . (MCQ)
m Serial Hematocrits (MCQ) „ Delayed films: . (MCQ)
n Serial hematocrits (every 4 to 6 hours) should ® Viscera in chest
be obtained during the observation period ® obscured diaphragmatic shadow
of the hemodynamically stable patient. ® elevated diaphragm

® irregular diaphragmatic contour l Patient is stable or stabilizes after fluid
® pleural fluid resuscitation.
l Invasive: DPL, laparoscopy, thoracoscopy l There are no peritoneal signs.
n Treatment l The injury can be precisely delineated and
l OR: graded by CT scan.
„ Achieve hemostasis l There are no associated injuries requiring
„ evaluate diaphragm laparotomy.
„ repair laceration with horizontal mattress l There is no need for excessive hepatic-
sutures of 1-0 monofilament for small related blood transfusions.
defects, n Complications:
„ a running suture for larger defects. l Hemorrhage (< 5%), biloma, abscess.
n Liver injury l Repeat CTscan in 2 to 3 days to look for
m Divided into eight segments . (MCQ) expansion or resolution of injury.
n Right lobe: l Patients may resume normal activities after
l Posterolateral segments VI and VII 2 months.
l anteromedial segments V and VIII n Operative Management
n Left lobe: l Generally needed for 20% of patients with
l Anterior segments III and IV grade III or higher injuries who present with
l posterior segment II hemodynamic instability due to
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l Segment I hemorrhage.
m Hepatic veins: . (MCQ) l Laparotomy is undertaken through a long
n Middle hepatic vein joins left hepatic vein. midline incision.
n Right and left veins then drain into IVC. l The primary goal is the control of bleeding
m Portal vein with direct pressure and packing.
n formed by superior mesenteric vein and splenic vein m Specifics of trauma liver surgery include:
n accounts for 75% of hepatic blood flow. . l Pringle maneuver. . (MCQ)
(MCQ) „ Finger fracture of liver to expose
m Liver has ligamentous attachments to the damaged vessels and bile ducts.
diaphragm. l Debridement of nonviable tissue.

m DPL: l Placement of an omental pedicle (with its
n May be positive due to liver injury blood supply) at the site.
n however, not all liver injuries require an l Closed suction drainage.
operation. . (MCQ) m Major hepatic resection is indicated when the .
m CT: (MCQ)
n Will detect blood and solid organ damage l parenchyma was totally destroyed by the
n is useful for grading injury trauma
n CT is contraindicated in the unstable or l extent of injury is too great for packing
marginal patient l injury itself caused a near-resection
m Ultrasound, if accessible, should be performed l resection is the only way to control life-
initially as FAST, and may then be used for serial threatening hemorrhage.
examinations following delineation of injury m Packing the perihepatic space with a planned
on CT. reoperation in 24 to 36 hours is indicated when
m Nonoperative Management . (MCQ) the . (MCQ)
n Approximately one half of patients are l patient is severely coagulopathic
eligible l there is bilobar bleeding that cannot be
n 96% success rate controlled
m Penetrating trauma: . (MCQ) l there is a large expanding hematoma
n Operative management remains standard of l other methods to control bleeding have
care. failed
n Select patients with stab wounds may warrant l patient requires transfer to a level I trauma center.
a trial of observation after CT and/or DPL. m Complications of Liver injury : . (MCQ)
m Blunt trauma: . (MCQ) n Hemorrhage (5%):
n May attempt trial of observation if:

l Due to inadequate OR hemostasis or n May be able to use therapeutically in the
coagulopathy. stable patient (embolization of CT-identified
l If the patient remains hemodynamically injury)
stable, with corrected acidosis, hypothermia, m Definitive Treatment
and coagulopathy, consider angiogram for n Nonoperative management: Criteria: .
diagnosis and possible embolization. (MCQ)
l If the patient is unstable, a return to the l Stable
OR is indicated. l No evidence of injury to other intra-abdominal organs
n Hemobilia (1%): l No coagulopathy
l Upper GI bleed, RUQ pain l No impairment to physical exam (i.e., head injury)
l positive fecal occult blood, and jaundice. l Injury grade I or II
l Attempt angioembolization. n Course:
n Hyperpyrexia: l Bed rest (2 to 3 days)
l Self-limited to 3 to 5 days l NGT decompression
l Etiology unknown l Monitored setting
n Abscess l Serial exam
n Biliary fistula (7–10%): l Serial hematocrit
l Definition: > 50 mL/d drainage for > 14 l Resume diet once potential for laparotomy decreased
days. (when bedrest finished)
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l Will generally close spontaneously with l Follow-up CT at 3 to 5 days, or sooner if
adequate drainage. deterioration
l Prognosis: Overall, 10% mortality. l Activity restrictions for 3 months
n Spleen injury n Operative management: Indications: .
m Anatomic relations of spleen. (MCQ) (MCQ)
n diaphragm (superiorly and posterolaterally) l Signs and symptoms of ongoing
n stomach (medially and anterolaterally) hemorrhage
n left adrenal and kidney (pos- teromedially) l Failure of nonoperative management
n chest wall (laterally) l Injury ³ grade III

n phrenocolic ligament (inferiorly). n Laparotomy:
m Ligaments: l In situ inspection.
n Major l Palpation.
l Gastrosplenic and splenorenal „ Perform splenectomy if the spleen is the
n Minor primar y source of exsanguinating
l splenophrenic, presplenic fold hemorrhage.
l pancreaticosplenic, phrenicocolic, „ If not, pack the area and search for
pancreaticocolic other, more life-threatening injuries; address
m Continues to increase in size until adolescence, those first.
after which it regresses up to 30%. „ Subsequently, return to inspection of spleen.
m The spleen receives 5% of cardiac output. . „ Mobilize fully unless the only injury is a
(MCQ) minor nonbleeding one.
m CT scan: n Minor nonbleeding injury: No intervention.
o Able to define injury precisely. n Capsular bleeding and most grade II
m Ultrasound: used for initial assessment to detect injuries: . (MCQ)
hemoperitoneum l Apply direct pressure ± topical hemostatic
m DPL: . (MCQ) agent.
n Not specific for splenic injury; likely to get n Persistently bleeding grade II or III
positive result for splenic injuries that do injuries: . (MCQ)
not require operation l Suture lacerations.
m Laparoscopy: . (MCQ) n Multiple injuries: . (MCQ)
n Difficult to fully visualize and examine spleen; l Consider mesh.
difficult to evacuate blood and clots n Complex fractures: . (MCQ)
m Angiogram:

lPerform anatomic resection if possible, based l Mesentery injured, with long segment
on demarcation after segmental artery ischemic—resect or close with plan for
ligation. second look. (MCQ)
l Perform splenectomy n Complications:
m Complications: . (MCQ) l Leak
l Bleeding l Fistula
l Pulmonary complications (pneumonia, atelectasis) l Short gut syndrome (depends on amount
l Pancreatitis of bowel resected)
l Postsplenectomy thrombocytosis n Duodenum
n Mechanisms:
n Bowel injury l Three fourths of injuries result from
m Stomach, Jejunum, and Ileum penetrating trauma.
m Gastric perforation n Anatomy:
n considered “clean-contaminated” rather than n Duodenum begins at the L1 level. (MCQ)
contaminated (MCQ) l Length: 25 to 30 cm to the ligament of Treitz.
n In a normal state, free of bacteria. (MCQ)
n However, gastric juice can cause a chemical l Blood supply: Pancreaticoduodenal
peritonitis. (MCQ) arteries, branches from the celiac axis and
m Small bowel is vulnerable to injury because it the superior mesenteric artery (SMA).
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takes up a lot of space within the abdomen n Diagnosis:

m terminal ileum injuries more closely resemble l Upper GI series with water-soluble contrast.
colonic injuries in terms of contamination. l CT , DPL will miss many injuries.
(MCQ) n Treatment:
m Blunt injuries l Eighty percent of patients are able to
n “blowouts” resulting frequently from lap belts undergo a primary repair. (MCQ)
n occur near the ligament of Treitz and the l Repair may be protected with an omental
ileocecal valve. (MCQ) patch and/or gastric diversion.
n Mesentery can be significantly injured following l More complex operations: (MCQ)
blunt trauma. „ Pyloric exclusion

m CT scan has a high false-negative rate for small „ Duodenoduodenostomy
bowel injuries. „ Pancreaticoduodenectomy
m Laparotomy for gastric or small bowel injury. n Prognosis:
n Gastric injury l Complications: (MCQ)
l Pyloric injury—pyloroplasty. (MCQ) „ Dehiscence, sepsis, multiple organ
l Body injury—repair (MCQ) failure,
l if severe gastroesophageal junction „ duodenal-cutaneous fistula
injury, may need to anastomose and do a l Indications of late morbidity or mortality:
pyloroplasty (MCQ)
l Major injury—resection. (MCQ) „ Presence of pancreatic injury
n Small bowel injury: Treatment in different „ Blunt or missile mechanism
Clinical scenarios „ Size of defect > 75% of wall
l Bowel injury (small)—repair. (MCQ) „ First or second portions of duodenum
l Short segment destroyed (with one or more „ > 24-hour delay to treatment
injuries)—resection, primary anastomosis. „ Concurrent CBD injury
(MCQ) m Large Bowel
l Severe associated injuries or unstable or n Injuries generally occur via a penetrating
coagulopathic—resect; plan for second trauma
look with delayed anastomosis. (MCQ) n Diagnosis: (MCQ)
l Mesentery injured, without ischemia— l CXR may show free air.
repair. (MCQ) l CT may also show free air, but may miss
l Mesentery injured, with short segment the specific injury.
of ischemia—resection, primar y
anastomosis. (MCQ)
l In a patient with a flank injury but without m Mechanism: Largely penetrating (gunshot
clear peritoneal signs, consider a contrast wound >> stab wound).
enema. m Seventy-five percent of patients with penetrating
n If in the OR for another reason, the smell or injury to the pancreas will have associated
sight of feces is a good clue. injuries to the aorta, portal vein, or IVC.
n Treatment: m Anatomy
l Primary repair: (MCQ) n Relationships (MCQ)
„ For small or medium-sized perforations, l Posterior:
repair the perforation „ IVC, aorta, left kidney, renal vein, splenic
„ if needed, resect the affected segment, vein, splenic artery, SMA, SMV
close with primary anastomosis. l Lateral: Spleen
„ Anastomosis is contraindicated in the l Medial: Duodenum
setting of massive hemorrhage. n Ducts: (MCQ)
n Prognosis: l Main (Wirsung):
l Mortality is usually due to exsanguinations „ Traverses length of gland
from associated injuries, or from sepsis or „ slightly closer to superior edge than
multiple organ failure. inferior edge
l Complications: Abscess, suture line failure, „ ends by joining CBD and emptying into
fistula. duodenum.
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m Rectum l Accessory (Santorini):
n Two thirds extraperitoneal (MCQ) „ A branch from the pancreatic duct in
n Mechanism: 80% gunshot wound(MCQ) the neck of the pancreas
n Diagnosis: „ has its own entry into duodenum.
l DRE/guaiac: Suspicion increased by blood m Diagnosis
in stool or palpation of defect or foreign n Inspect pancreas during laparotomies
body on exam. performed for other indications.
l Rigid proctoscopy: n Check amylase (may be elevated)
„ May be done in OR if needed mandatory n CT: Look for

for patients with known trajectory of l parenchymal fracture, intraparenchymal hematoma
knife or gunshot wound across pelvis or l lesser sac fluid, fluid between splenic vein and pancreatic
transanal; (MCQ) body
„ if patient is unstable, may be delayed until l retroperitoneal hematoma or fluid.
after resuscitation. m ERCP: (MCQ)
„ X-ray to look for missiles or foreign l May be used in the stable patient if readily
bodies. available or available intraoperatively
n Treatment: l also may be used to evaluate missed injuries.
l Loop colostomy. (MCQ) m Treatment
„ Loop colostomy with distal limb closure. n Nonoperative:
l End colostomy/mucus fistula. l May follow with serial labs and exam if patient
l Extraperitoneal injuries must be diverted can be reliably examined.
via colostomy but may not need to be n Operative: (MCQ)
repaired l No ductal injury: (MCQ)
n Outcome: „ Hemostasis and external drainage.
l Death secondary to sepsis, multisystem l Distal transection, parenchymal injury
organ failure (MSOF): with ductal injury: (MCQ)
l Complications: Abscess, fistula „ Distal pancreatectomy with duct ligation.
l Colostomy may be closed in 3 to 4 months l When duodenum or pancreatic head is
m Anus devitalized(MCQ)
n Reconstruct sphincter as soon as patient is „ consider Whipple or total pancreatectomy.
stabilized. l Proximal transection/injur y with
n Divert with sigmoid colostomy. probable ductal disruption: (MCQ)
n Pancreatic injury „ If duct is spared, external drainage.

„ If duct is damaged, external drainage and l >10 mLgross blood on initial aspiration
pancreatic duct stenting l >100,000 RBCs
m Outcome l >500 WBCs
n Primary cause of death is exsanguination from l Gram stain with bacteria or vegetable matter
commonly associated vascular injuries, or l Amylase> 20 IU/L
splenic and liver injuries. (MCQ) l Presence of bile
n Pancreatitis is also common and sometimes n Contraindications to DPL: (MCQ)
severe. l Absolute:
n Late deaths usually due to infection or multiple „ Clear indication for laparotomy
system organ failure. l Relative
n Vascular injury „ Coagulopathy
m Retroperitoneum divided into four zones „ Previous abdominal surgeries
(MCQ) „ Morbid obesity
n Zone I (middle): „ Gravid uterus
l Aorta, celiac axis, proximal SMA, proximal m CT is the most sensitive test for retroperitoneal
renal artery, SMV, IVC injury.
n Zone II (upper lateral): n Contrast use: (MCQ)
l Renal artery and vein l Non contrast to look for intraparenchymal
n Zone III (pelvic): hematomas
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l Iliac arteries and veins l PO contrast to assess location and integrity

n Zone IV (portal-retrohepatic): of upper GI tract
l Portal vein, hepatic artery, IVC l IV contrast to look for organ or vascular injury
m Renal artery injury: Flank pain and hematuria. m Diaphragmatic trauma is rarely an isolated injury.
m Survival: n Look for it especially when the following injuries
n Suprarenal aorta—35%, infrarenal aorta— are present:
46%, portal vein—50% l Head trauma
m Complication: Vasculoenteric fistula l Fractures (pelvic,rib)
n Clinical Pearls : l Thoracic aorta
m The most frequently injured solid organ l Pneumo/hemothorax

associated with penetrating trauma is the liver. l Intra-abdominal injury
(MCQ) n Do not force NGT
m The most frequently injured solid organ l diaphragmatic hernia may result in kinking
associated with blunt trauma is the spleen or unusual twisting of esophagus.
followed by the liver. (MCQ) n Use caution in placing chest tubes if viscera
m Peritonitus and guarding in a neurologically are in the chest.
intact patient obviate the need for much diagnostic workup. m Though the liver has been found to be protective
o Trauma laparotomy is indicated in this setting. against other organ injuries, for the same
m In a stable patient with neurologic reasons (size, position), it is very vulnerable to
dysfunction, whether from drugs, alcohol, head injury itself.
trauma, or baseline dementia, exam findings have a m Imaging of the liver: If contrast pool or blush
limited ability to direct care. These patients often is noted on CT and patient remains stable,
require additional diagnostic tests. consider an angiogram. (MCQ)
m DPL m Pringle maneuver:
n is especially useful in marginal or unstable n Occlusion of the portal triad manually or with
patients with equivocal ultrasounds and for an atraumatic vascular clamp. Occlusion should
patients with hollow viscus injuries. not exceed 20 minutes if feasible. (MCQ)
n DPL should be undertaken only after gastric n If the Pringle maneuver fails to stop
and urinary decompression. hemorrhage, consider an injury to the
n If pelvic fracture is suspected, a supraumbilical retrohepatic IVC. (MCQ)
approach should be used m Watch for increasing abdominal distention
n If the patient is pregnant, a suprafundal with decreasing hematocrit as potential
approach should be used. indicators of postop bleeding.
n Criteria for a positive DPL: (MCQ) n Splenic Injuries
m The spleen is the most commonly injured organ TOPIC - 27 HIRSCHSPRUNG'S DISEASE
in blunt abdominal trauma(MCQ)
m trauma is the most common reason for n Hirschsprung’s Disease (Congenital
splenectomy. (MCQ) Aganglionosis Coli)
m Causes of splenic rupture: m Congenital absence of ganglion cells in the
n Trauma
plexuses of Auerbach (myenteric) and
n Rib fractures on the left ( (especially the ninth
Meissner (submucosal) (MCQ)
and tenth ) m Results in functional intestinal obstruction
n Spontaneous rupture (associated with
m Male-to-female ratio: 4:1 (MCQ)
mononucleosis) m Types
m Transverse lacerations often stop bleeding n Rectosigmoid (75%) (MCQ)
spontaneously because they are parallel to blood n Entire colon (10%)
vessels and not likely to disrupt them. m Signs and symptoms
m 30% of patients with splenic injury will present n In neonatal period:
with hypotensive shock. l Delayed passage of meconium
m Radiographic signs of splenic injury: l Rectal examination (MCQ)
n CT:
„ An empty vault that is not dilated
l Low-density mass
„ Explosive release of feces
l intrasplenic accumulation ( of contrast
l Most ominous presentation is enterocolitis
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n US:
(MCQ)
l Perisplenic fluid, ( enlarged spleen
n Presentation later in childhood:
l irregular borders, abnormal position
l Bilous vomiting (MCQ)
l increase in size over time
l Chronic constipation (MCQ)
m Patients with a vascular blush on CT scan are l Abdominal distention
likely to fail nonoperative management. l Failure to thrive
m Patients who fail nonoperative management m Diagnosis
usually do so within 48 to 72 hours. n AXR to look for evidence of obstruction
m Indications for splenectomy: (MCQ) (MCQ)
n Source of exsanguination
n Barium enema to look for transition zone
HIRSCHSPRUNG'S DISEASE
n Pulverized organ
(may not be present until 1 to 2 weeks of
n Shock
age) (MCQ)
n Associated life- threatening injuries
n Rectal biopsy to demonstrate absence of
m Contraindications to ( splenectomy (MCQ) ganglion cells
n prolonged surgery (severe coagulopathy,
m Treatment
hypothermia) n Surgical repair:
m Duodenal hematoma l Temporary colostomy proximal to transition
n result from an MVC,
zone at diagnosis
n associated with child abuse in the pediatric
l Definitive repair when the infant is 6 to 12
population(MCQ) months old(MCQ)
n Patients present with signs and symptoms of
l Closure of colostomy - 1 to 3 months
small bowel obstruction, and require CT/ postop(MCQ)
upper GI series for diagnosis. n Cinical Pearls for MD Entrance
n Treatment is nonoperative and includes
m Hirschsprung’s disease is the most common
l NGT decompression
cause of lower intestinal obstruction in the
l total parental nutrition (TPN),
neonate. (MCQ)
l reevaluation with upper GI series after about 1
m Commences at internal sphincter and progresses
week for variable distance proximally(MCQ)
m 30% of patients with rectal injury will have an m Some appear to be due to autosomal dominant
associated injury to the bladder. inheritance(MCQ)
m Eighty percent of pancreas can be resected m Plain abdominal x-ray will confirm intestinal
without endocrine or exocrine dysfunction. (MCQ) obstruction
m Barium enema may show (MCQ)
n contracted rectum

n cone shaped transitional zone TOPIC - 28 BLADDER CANCER
n proximal dilatation
m Anorectal manometr y may show recto- n BLADDER CANCER
sphincteric inhibition ref lex on rectal m Men are affected 3 times more than women.
distension(MCQ) (MCQ)
m Rectal biopsy shows: m Peak incidence occurs between the ages of 60 and
n Absent ganglion cells in submucosa
70. (MCQ)
n Increased acetylcholinesterase cells in muscularis
m The lining of the urinary system from the renal
mucosa(MCQ) pelvis to the urethra is made up of transitional
n Increased unmyelinated nerves in bowel wall
cells. This entire lining is subject to carcinomatous
(MCQ) changes. However, the bladder is involved most
m Treatment frequently.
n Initial defunctioning stoma to relieve
m Squamous cell and adenocarcinomas have a
obstruction worse prognosis compared to transitional cell
n Bypass of affected segment - Duhamal or
carcinoma. (MCQ)
Soave bypass(MCQ) m Risk factors
n Excision of aganglionic segment - Swenson
n Environmental:
procedure(MCQ) n Cigarette smoking(MCQ)
m Treat with resection and pull through (1 stage n Workers in dye or chemical industries(MCQ)
SURGERY
vs. 2 stage); n Chronic UTI(MCQ)

n 1 stage associated with “! anastomotic (
n Recurrent nephrolithiasis(MCQ)
disruption( (MCQ) n Analgesic abuse e.g. phenacitin
m Diagnose with BE (look for sigmoid/rectum n Pelvic irradiation - for carcinoma of the cervix
ratio > 1) (MCQ) n Schistosoma haematobium associated with
m suction rectal biopsy (definitive) (MCQ) increased risk of squamous carcinoma
n Gross and microscopic hematuria are the most
common complaints. (MCQ)
BLADDER CANCER
n Dysuria.
n Urinary frequency.
n Urgency.
n Ureteral obstruction.
m Diagnosis and staging
n Urine cytology
n IVP—ureteral obstruction with hydronephrosis
or filling defect
n Cystoscopy with tumor biopsy
n Additional staging may be obtained via CT of
abdomen and pelvis and endoscopic
resection of a bladder neoplasm.
n Staging(MCQ)
l Superficial
„ Stage 0: Carcinoma in situ, mucosal
involvement
„ Stage A: Submucosal involvement
l Invasive
„ Stage B: Involvement of bladder
muscularis
„ Stage C: Involvement of perivesical fat
l Metastatic
„ Stage D1: Metastasis to lymph nodes
„ Stage D2: Metastasis to bone or other
viscera
m Treatment TOPIC - 29 MELANOMA
n Superficial carcinoma (MCQ)
l can be treated with endoscopic resection
n Malignant melanoma
with repeat cystoscopy ever y 3 to 6 m Risk factors (MCQ)
months(MCQ) n Giant melanocytic naevus
l However, 50–70% of these patients will have
n Total number of naevi
superficial recurrence within 3 years. n Dysplastic naevus syndrome
l These patients can be treated with:
n History of recurrent sunburn
„ Intravesical therapeutic agents, the most
n 10% autosomal dominant with reduced
effective of which is BCG (bacillus penetrance
Calmette–Gueìrin). (MCQ) m Clinical features
„ Laser therapy.
n Major Sign (MCQ)
n Invasive disease.
l Change in size
l Approximately 10% of those with initially
l Change in shape
superficial disease will develop invasive l Change in colour
disease. (MCQ) l Diameter >7 mm
l Mainstay of treatment is simple or radical
n Minor signs (MCQ)
cystectomy. l Inflammation
l Five-year survival is about 50% with such
l Bleeding
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treatment. l Sensory changes
l Majority of patients die of metastatic
n Early detection
disease rather than local recurrence. (MCQ) l Lesion unlikely to be a melanoma without
l In patients with metastatic disease,
at least one major sign
chemotherapy has shown good result; l Need to assess (MCQ)
however, it is short lasting. „ A=Asymmetry
l Chemotherapuetic agents used are:
„ B=Border irregularity
„ Cisplatin, Methotrexate
„ C=Colour variegation
„ Doxorubicin, Cyclophosphamide,
„ D=Diameter
Vinblastine m Pathology
m Prognosis
n 60% arise in pre-existing naevi
MELANOMA
n The survival rate of patients with metastatic
n Have initial radial and then vertical growth
disease is generally < 2 years. (MCQ) phase
n Staged according to depth of tumour invasion n Determines growth characteristics of the
m Tis - In-situ disease
tumour
m Ta - Epithelium only
n Superficial spreading melanoma (65%)
m T1 - Lamina propria invasion
l Occurs in middle age
m T2 - Superficial muscle invasion
l Female : male ratio 2:1
m T3a - Deep muscle invasion
l Commonest sites - lower leg in women and
m T3b - Perivesical fat invasion
trunk in man(MCQ)
m T4 - Prostate or contiguous muscle
l Usually slightly elevated lesion with variable
n Grade of tumour also important colour
m G1-Well differentiated
n Nodular melanoma (27%)
m G2 - Moderately well differentiated
l Aggressive tumour
m G3 - Poorly differentiated
l Occurs in younger age group
l Female : male ratio 1:2
l Early vertical growth phase
l Usually uniform colour, early ulceration and
bleeding
n Lentigo maligna melanoma (7%)
l Least malignant (MCQ)
l Usually found on face of elderly(MCQ)
l Long radial growth phase
l Presents as flat light brown macule(MCQ)

n Acral lentiginous melanoma (1%) n For these two groups lymphadenectomy
l Aggressive tumour (MCQ) provides no added survival benefit
l Occurs on soles of feet and palms of hand n Lymphadenectomy for ‘inter mediate’
l Subungual melanomas included in this thickness tumours controversial
group(MCQ) m Morbidity of lymphadenectomy (in descending
n Intransit metastases order) (MCQ)
l Uncommon. Seen in less than 2% tumours n Lymphoedema
l Appear as intracutaneous metastases or n Seroma
‘satellites’(MCQ) n ‘Functional deficit’
l Those within 2 cm of primary classified as n Wound Infection
part of it (MCQ) n Persistent pain
l Usually associated with regional m Adjuvant Therapy
lymphadenopathy (MCQ) n Patients at high risk of recurrence should be
m Lymph node metastases considered for systemic adjuvant therapy
n Commonest metastatic presentation(MCQ) n Patients include those with: (MCQ)
n Reduces survival by 50% l Primary tumour > 4mmthick
n 70 - 80% patients with regional l Resectable positive locoregional lymph
lymphadenopathy have distant disease nodes
m Tumour thickness n No standard adjuvant therapy exists
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n Tumour thickness most important prognostic l Interferon α2b has shown promising results
factor for local, distant recurrence and n Shown to increase disease-free and overall survival
survival m Isolated limb perfusion
n With regional lymphadenopathy 10-year survival n Intra-arterial chemotherapy
is less than 10% n Commonly used agents - Melphalan +/-
TNF-alpha(MCQ)
Five-year survival related to Breslow thickness (mm) n Used with hyperoxygenation
Five-year survival related to Breslow thickness (mm) n Hyperthermia at temperature of 41-42 °C
n Perfusion generally last about 1 hour
Five-year survival (%)
n Usually combined with lymphadenectomy
Lessthan 0.75 mm 95-99
n Indications (MCQ)
0.76 - 1.49mm 80-90
MELANOMA
l In transit metastases
1.5 - 3.99 mm 60-75
l Irresectable local recurrence
Morethan 4.0 mm <50
l Adjuvant therapy for poor prognosis
tumours
m Melanoma surgery
l Palliation to maintain limb function
n Resection margins
n Morbidity of Isolated limb perfusion (MCQ)
n Generally accepted resection margins based on
l Mortality (2%)
clinical appearance are: (MCQ)
l Limb oedema (most common)
l Impalpable lesions-1 cm margin
l Persistent pain
l Palpable lesion-2 cm margin
l Neuropathy
l Nodular lesion - 3 cm margin
l Venous thrombosis
m Regional lymphadenectomy
l Septicaemia & thrombocytopenia
n 20% clinically palpable nodes are histologically
negative
n 20% palpably normal nodes have occult
metastases
n Therapeutic lymph node dissection provides
regional control and prognostic information
n No improvement in survival
l For tumours less than 0.75 mm thick - 90%
cured by local excision alone (MCQ)
l For tumours more than 4.0 mm thick - 70%
have distant metastases at presentation(MCQ)

TOPIC : 30 PANCREATIC CARCINOMA n Two types:
l Serous: Benign (MCQ)
m PANCREATIC ADENOCARCINOMA n Mucinous: Generally benign but has potential
n From exocrine pancreas. to be malignant
n Male:female: 2 :1. (MCQ) n Treatment: Surgical
n Blacks > whites. m Clinical pearls
n Associated with smoking and older age. n Courvoisier’s sign: (MCQ)
n Most occur in head of pancreas. (MCQ) l Palpable nontender gallbladder (don’t
n Associated with genetic lesions. confuse with Murphy’s sign).
n Signs and symptoms (MCQ) m Whipple procedure: (MCQ)
l Weight loss n Removal of gallbladder, common bile duct
l Jaundice (due to obstruction in head) (CBD), antrum of stomach, duodenum,
l Pain radiating to back proximal jejunum and head of pancreas (en
l Phlebitis bloc); high morbidity and mortality
n Diagnosis m Pancreatic cystadenoma: Mucinous = malignant
l Elevated CA 19-9, alkaline phosphatase, potential (MCQ)
direct bilirubin. (MCQ) m Cystic Neoplasms of the Pancreas
l Initial study is an ultrasound if biliary n EUA + FNA for CEA is probably most
obstruction suspected. accurate (optimized sensitivity + specificity)
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l CT scan very useful. measure of malignancy, (MCQ)
l Percutaneous transhepatic n BUT resection almost always indicated as it
cholangiography (PTC) and endoscopic is difficult to exclude malignancy on the basis
retrograde cholangiopancreatography of biopsies (MCQ)
(ERCP) useful in periampullary lesions. n 2 Do not perform CT guided percutaneous
(MCQ) biopsy (often undiagnostic, potential to cause
l Angiography may also be useful. pancreatitis, bleeding, rupture of capsule (MCQ)
n Treatment
l Preoperative nutritional optimization. Account for < 15% of pancreatic cystic lesions
(but incidence increasing)
PANCREATIC CARCINOMA
l Preoperative inter nal biliar y
decompression with stent may be IPMN* MCN‡ Serous
considered. Gender M=F 2:1 0.8:1
l Most patients are not candidates for Age 70 50 60 - 70
Whipple procedure (pancreatico- Location Head Tail Uniform
duodenectomy). (MCQ) Ductal component Yes Rare No
l If unresectable, palliative procedure
Malignant 35% 30% Rare
considered: (MCQ) * Associated with chronic pancreatitis (and often mistaken for)
„ Relieve biliary obstruction. ‡ By definition must have underlying ovarian stroma
„ Relieve duodenal obstruction.
l Chemical splanchicectomy (pain control). n Exocrine Neoplasm of the Pancreas
(MCQ) m Four periampullary malignant neoplasms:
l Postoperative chemoradiation therapy n pancreatic ductal adenocarcinoma of the
controversial. head, neck, and uncinate process

m CYSTADENOCARCINOMA n ampullary adenocarcinoma
n Commonly females age 40 to 60 years (MCQ) n peri ampullary duodenal adenocarcinoma
n In body and tail (MCQ) n distal cholangiocarcinoma
n Malignant potential m Of these, pancreatic ductal adenocarcinoma
n < 2 % of all pancreatic exocrine tumors accounts for the most (75 – 85%) and has the
n Present with abdominal/back pain poorest prognosis (MCQ)
n Prognosis better than adenocarcinoma m Visualization of fat planes around SMV/PV are
n Treatment: Surgical resection (MCQ) predictive of resectability (MCQ)

m CYSTADENOMA m 2 Thrombosis of SMV/PV is a contraindication
n Older and middle-aged women for resection (MCQ)

n Present with vague abdominal symptoms

TOPIC - 31 APPENDICITIS n mild leukocytosis (10,000 to 18,000/mm3) with
moderate PMN predominance.
ACUTE APPENDICITIS n If WBC > 18,000/mm3, consider perforation
n Incidence parallels lymphoid development with with or without abscess. (MCQ)

the peak in early adulthood.(MCQ) m Urinalysis
n More frequent in males 1.3:1 (especially during n Several WBCs or RBCs may be found in
puberty). appendicitis secondary to ureter or bladder

n There is a second peak in the incidence of irritation from inflamed appendix. (MCQ)
appendicitis in the elderly. n Bacteriuria from catherized specimen is not
n Causes of luminal obstruction seen in appendicitis.

m Lymphoid hyperplasia n Diagnostic imaging
m Fecalith (30%) (MCQ) m Abdominal X-Ray (AXR)
m Foreign objects n Will reveal an appendicolith/fecalith < 15%
n inspissated Ba2+ from previous x-ray study of the time

n vegetable and fruit seeds m Abdominal CT with Contrast(MCQ)
m Stricture (tumor) n Sensitivity of 95–98%
m Parasites (especially Ascaris spp.) (MCQ) n Specificity of 83–90%
n Symptoms n Positive findings include:
m Abdominal pain that precedes vomiting l > 6 mm dilatation of the appendix(MCQ)

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(opposite of gastroenteritis) l Appendiceal thickening
m Pain (MCQ) l Periappendiceal streaking (densities within
n intially diffuse, over epigastrium or umbilicus perimesenteric fat)

(periumbilical) l Presence of appendicolith
n then localizes to right lower quadrant (RLQ) m Graded Compression Ultrasonography
m Fever n Sensitivity of 85%.
m Leukocytosis n Specificity of 92%.(MCQ)
n Signs n Very much operator dependent.
m Direct rebound tenderness, maximal at or near n Main positive finding is an enlarged (> 6 mm)
McBurney’s point noncompressible appendix (MCQ)

APPENDICITIS
m Rovsing’s sign: (MCQ) m Primary role is to exclude gynecologic pathology
n Pain in RLQ when palpation pressure is exerted for which it is an excellent modality.
in LLQ n False positive seen with: (MCQ)
m Iliopsoas sign: (MCQ) l Periappendix from surrounding

n Pelvic pain upon extension of the right thigh inflammation.
n presence signifies retrocecal appendicitis l Dilated fallopian tube.
m Obturator sign: (MCQ) l Insipissated stool: Looks like

n Pelvic pain upon internal rotation of the right appendicolith.
thigh l Obese patients: Appendix is
n presence signifies pelvic appendicitis noncompressible secondary to overlying fat.
m Dunphy’s sign: (MCQ) n False negatives seen with: (MCQ)
n Increased pain with coughing l Inflammation that is confined to the tip of
n Differential diagnosis the appendix.

m Gastroenteritis ,Ectopic pregnancy ,Mesenteric l Retrocecal cecum.
adenitis l Large appendix: Mistaken for small bowel.
m Meckel’s diverticulum , Intussusception l Perforation: Appendix now becomes
m Typhoid fever ,Regional enteritis compressible.

m Torsion and infarction of epiploic appendages n Treatment
m Urinary tract infection ,Ureteral stone m The definitive treatment of appendicitis is
m Pyelonephritis ,Primary peritonitis appendectomy.

m Henoch–Schonlein purpura(MCQ) m Peritoneal washout and parenteral antibiotics
n Diagnosis: labs for perforation

m Complete Blood Count (CBC) n Pregnant Patients

n Appendicitis is the most common surgical TOPIC - 32 URETHRAL RUPTURE
emergency in the pregnant patient. (MCQ)
n Most frequent in first trimester. (MCQ)
n Genitourinary trauma
n Fetal mortality increases 3–8% with early
m Signs and Symptoms
appendicitis to 30% with perforation. n Flank or groin pain
n Surgery during pregnancy carries a risk of
n Blood at the urethral meatus
premature labor of 10–15% but is standard n Ecchymoses on perineum and/or genitalia
treatment. (MCQ) n Evidence of pelvic fracture
n Appendicitis in special populations n Rectal bleeding
n Elderly Patients (MCQ)
n A “high-riding” or superiorly displaced
l Present late in the course.
prostate (MCQ)
l Perforation rate is higher (> 50%).
m Placement of Urethral Catheter
l Tend to present with atypical findings
n A Foley or Coude catheter should be placed
(report less pain, have less peritonitis). in any trauma patient with a significant
l Delayed leukocytosis.
mechanism of injury in the absence of any
n Immunocompromised Patients(MCQ)
sign of urethral injury. (MCQ)
l Examples: Patients with AIDS, those
n Partial urethral tears warrant one careful
receiving high-dose chemotherapy attempt of a urinary catheter.
l Are susceptible to CMV-related bowel
n If any resistance is met or a complete
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perforation and neutropenic colitis urethral tear is diagnosed, suprapubic
n Clinical pearls : catheter placement will be needed to establish
m Just 0.5 mL raises the appendiceal intraluminal
urinary drainage.
pressure by 60cm H2O. m Urinalysis
m The anatomic site of the tip of the appendix is
n The presence of gross hematuria indicates GU
responsible for the corresponding principal locus injury and often concomitant pelvic fracture.
of somatic phase of pain(MCQ) (MCQ)
n Long tip: Left lower quadrant (LLQ) pain
n Urinalysis should be done to document
n Retrocecal: Flank or back pain
presence or absence of microscopic
URETHRAL RUPTURE
n Pelvic:Suprapubic pain
hematuria.
n Retroileal:Testicular pain
n Microscopic hematuria is usually self-limited.
l from irritation of spermatic art and ureter
m Retrograde Urethrogram
n Malrotation:Perplexing pattern of pain
n Should be performed in any patient with
m McBurney’s point(MCQ)
suspected urethral disruption (before Foley
n One third the distance along a line from the
placement). (MCQ)
anterior superior iliac spine to the umbilicus n A preinjection KUB (kidneys, ureters,
m With mesenteric adenitis, there is usually a
bladder) film should be taken.
concurrent or antecedent history of respiratory n A 60-cc Toomey syringe (vs. a Luer-lock
tract infection. (MCQ) syringe) should be filled with the appropriate
m Approximately one third of appendixes rupture
contrast solution and placed in the urethral
prior to appendectomy. meatus.
n With the patient in the supine position, inject
20 to 60 cc contrast over 30 to 60 seconds.
n A repeat KUB is taken during the last 10 cc
of contrast injection.
n Retrograde flow of contrast from the meatus
to the bladder without extravasation
connotes urethral integrity and Foley may
then be placed. (MCQ)
m Bladder Rupture
n Intraperitoneal (MCQ)
l Usually occurs secondary to blunt trauma
to a full bladder.

l Treatment is surgical repair. (Ver y n Management of major renal lacerations are
Important MCQ) varied and depend on the
n Extraperitoneal (MCQ) l Surgeon
l Usually occurs secondar y to pelvic l hemodynamic stability of the patient
fracture. (MCQ) l extent of injur y and its coincident
l Treatment is nonsurgical management by complications (ongoing bleeding and urinary
Foley drainage. (Very Important MCQ) extravasation).
n Retrograde Cystogram m Renal Fracture (“Shattered Kidney”)
l Should be performed on patients with gross n Involves complete separation of the renal
hematuria or a pelvic fracture. (MCQ) parenchyma from the collecting system.
n Obtain preinjection KUB. n Usually leads to uncontrolled hemorrhage and
n Fill the bladder with 400 cc of the appropriate requires surgical intervention.
contrast material using gravity at a height m Clinical pearls:
of 2 ft. n Suspect GU trauma with: (MCQ)
n Obtain another KUB. l Straddle injury
n Empty the bladder (unclamp the Foley), l Penetrating injury to lower abdomen
then irrigate with saline and take another l Falls from height
KUB (“washout” film). (MCQ) l Hematuria noted on Foley insertion.
n Extravasation of contrast into the pouch of n Blood at the urethral meatus is virtually
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Douglas, paracolic gutters, and between diagnostic for urethral injury and demands early
loops of intestine is diagnostic for retrograde urethrogram before Foley
intraperitoneal rupture and requires placement(MCQ)
operative repair of the bladder. (MCQ) n Do not probe perineal lacerations as they are
n Extravasation of contrast into the often a sign of an underlying pelvic fracture and
paravesicular tissue or behind the bladder disruption of a hematoma may occur.
as seen on the ‘washout‘ film is indicative of n History of enlarged prostate, prostate
extraperitoneal bladder rupture. (MCQ) cancer, urethral stricture, self-
m Ureteral Injury catheterization, or previous urologic
URETHRAL RUPTURE
n Least common GU injury surgery may make Foley placement difficult or

n Must be surgically repaired(MCQ) can be confused with urethral disruption.
n Diagnosed at the time of IVP or CT scan (MCQ)
during the search fo renal injury m Renal injuries
m Renal Contusion n Classification
n Most common renal injury. l Class I - Renal contusion or contained
n Renal capsule remains intact. subcapsular haematoma
n IVP is usually normal l Class II - Cortical laceration without urinary
n CT scan may show evidence of edema or extravasation
micro-extravasation of contrast into the renal l Class III - Parenchymal lesion extending
parenchyma. more than 1 cm into renal substance
n Often associated with a subcapsular l Class IV - Laceration extending across
hematoma. (MCQ) cortico-medullary junction
n Management is conservative and requires l Class V - Renal fragmentation or reno-
admission to the hospital. vascular pedicle injury
n Recovery is usually complete unless there is n Management
underlying renal pathology. l 80% injuries are minor (Class I/II) and can
m Renal Laceration be managed conservatively
n Classified as (MCQ) l Early surgical intervention is required for:
l Minor - involving only the renal cortex (MCQ)
l Major - extending into the renal medulla „ Reno-vascular pedicle injury
and/or collecting system „ Pelviureteric junction disruption
n Diagnosed by CT scan or IVP. „ Shock with signs of intraperitoneal or
n Minor renal lacerations are managed retroperitoneal trauma
expectantly. m Bulbar urethral injury
n Is the commonest type of urethral TOPIC - 33 ACHALASIA
injury(MCQ)
n Usually the result of direct trauma causes by
n Achalasia
falling astride an object(MCQ) m Achalasia is the result of a primary or secondary
n Clinical features include blood from meatus
derangement of the myenteric plexus, the
and perineal bruising network of neurons involved in the coordination
n If unable to pass urine a urethral catheter
of GI motility. .(MCQ)
should not be passed m The resulting dysphagia is due to three
n Can convert a partial tear into a complete
mechanisms: .(MCQ)
urethral injury n Nonperistaltic contrations
n If catheter is required it should be inserted via
n Incomplete relaxation of the LES after
the suprapubic route swallowing
n Diagnosis can be confirmed by ascending
n Increased resting tone of the LES
urethrogram(MCQ) m Signs and symptoms
n Prophylactic antibiotics should be given
n Dysphagia for both solids and liquids.(MCQ)
n Complications include a urethral n Regurgitation of food
stricture(MCQ) n Severe halitosis (due to the decomposition of
m Membranous urethral injury stagnant food within the esophagus .(MCQ)
n Often occur in multiply injured patient and
m Diagnosis
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unless suspected can be missed n Lateral upright chest x-ray (CXR) may reveal
n 10% of men with pelvic fracture have a
l a dilated esophagus .(MCQ)
membranous urethral injury l presence of air–fluid levels in the posterior
n Tear can be either partial or complete
mediastinum. .(MCQ)
n Partial injuries present with urethral bleeding
n Barium swallow will reveal the characteristic
and perineal bruising(MCQ) distal bird’s beak sign due to the collection
n Complete injuries present with inability to pass
of contrast material in the proximal dilated
urine segment and the passage of a small amount
n On rectal examination the bladder and
of contrast through the narrowed LES.
prostate is displaced upwards(MCQ) (MCQ)
n If injury suspected a urethral catheter should
n Esophageal motility study will confirm .(MCQ)
ACHALASIA
not be passed l nonperistaltic contractions
n Diagnosis can be confirmed by ascending
l incomplete LES relaxation
urethrogram(MCQ) l increased LES tone.
n Treatment is with suprapubic catheter(MCQ)
n Esophagoscopy is indicated to rule out mass
n Urethroplasty may be required(MCQ)
lesions or strictures, and to obtain specimens
n Complications include stricture, impotence
for biopsy.
and incontinence m Treatment
n Medical management:
l Drugs that relax the LES such as nitrates
or calcium channel blockers
n Surgical management
l Esophagomyotomy with fundoplication:
„ Esophagus is exposed via transthoracic (left
thoracotomy), transabdominal, thorascopic,
or laparoscopic technique.
„ The tunica muscularis of the esophagus
is incised distally, with extension to the LES.
„ Complete division of the LES
necessitates the addition of an antireflux
procedure such as Nissen 360 O
fundoplication or partial
fundoplication. (MCQ)
l Endoscopic dilatation:
„ Lower success rate and a higher complication n Barium swallow may be entirely normal,
rate however, because the esophagus may not be in
„ Involves inserting a balloon or spasm at the time of the study.
progressively larger sized dilators. n In contrast to achalasia, the LES appears its
(MCQ) normal diameter. .(MCQ)
„ through the narrowed lumen, which causes n Esophageal manometry studies will reveal the
tearing of the esophageal smooth presence of large, uncoordinated, and
muscle and decreases the competency repetitive contractions in the lower esophagus.
of the LES. n Alternatively, manometry may appear normal
m Complications when the patient is asymptomatic.
n Risk of squamous cell carcinoma is as high n Esophagoscopy should be performed to rule
as 10% in patients with long-standing achalasia out mass lesions, strictures, or esophagitis.
(15 to 25 years). .(MCQ) m Treatment
n Patients may also develop pulmonary n Nitrates or calcium channel blockers to
complications such as .(MCQ) decrease LES pressure. .(MCQ)
l aspiration pneumonia n Surgical treatment via esophagomyotomy is not
l bronchiectasis as successful in reliev- ing symptoms as it is for
l asthma, due to reflux and aspiration. achalasia and is therefore not recommended
n DIFFUSE ESOPHAGEAL SPASM (DES) unless pain or dysphagia are severe and
SURGERY
m involves a dysfunction of the myenteric plexus. incapacitating

(MCQ)
m It may be a primary disease process
m it may occur secondary to
n reflux esophagitis
n esophageal obstruction
n collagen vascular disease
n diabetic neuropathy
m Spasm occurs in the distal two thirds of the
esophagus .(MCQ)
m caused by uncoordinated large-amplitude
ACHALASIA
contractions of smooth muscle. .(MCQ)

n Dysphagia for both solids and liquids. .
(MCQ)
n Chest pain similar to that seen in myocardial
infarction (MI)
n Acute onset of severe retrosternal pain that
may radiate to the arms, jaw, or back. The chest
pain may occur at rest, or it may follow
swallowing
n The degree of chest pain depends on the
duration and severity of the contractions.
n No regurgitation (unlike achalasia). .(MCQ)
m Diagnosis
n Barium swallow may reveal the characteristic
“corkscrew” appearance of the esophagus. .
(MCQ)
n This appearance is due to the ripples and
sacculations that are visible due to
uncoordinated esophageal contraction.

Achalasia vs. diffuse esophageal sposm.
Diffuse Esophageal
Achalasia Spasm
Signs and symptoms Weight loss, cough, diffuse Dysphagia, diffuse chest
chest pain pain
Pattern of contraction Failure of LES to relax on Swallowing-induced large wave
swallowing
Classic: Simultaneous small wave
Vigorous: Simultaneous large wave
Relieved by Nitroglycerin Nitroglycerin
X-ray findings Absence of gastric bubble, Corkscrew appearance
narrowing of terminal esophagus
that looks like a beak
Treatment Nitroglycerin, local botulinum toxin, Nitroglycerin, nifedipine
balloon dilatation, sphincter myotomy
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n Clinical pearls
m Achalasia: Failure to relax
m Gastroesophageal reflux produces a sour taste
due to the presence of hydrochloride while
achalasia does not. .(MCQ)
m Esophageal perforation is four times more likely
ACHALASIA
following dilatation compared to
esophagomyotomy.(MCQ)
m Due to the fact that DES produces cardiac-like
complaints, the diagnosis is often delayed until
an extensive cardiologic workup is performed.
m Nutcracker esophagus is another hypermotility
disorder, but involves more focal segments of
the esophagus. .(MCQ)
m Patients with DES often have other functional
intestinal disorders such as irritable bowel
syndrome and spastic colon. .(MCQ)
m Because the regurgitant does not include gastric contents,
it is not sour tasting. .(MCQ)
m Achalasia the most common disorder of
esophageal motility. .(MCQ)

TOPIC - 34 CARCINOMA TONGUE m Surgical excision may include a partial anterior
glossectomy and anterior mandibular
n Tongue cancer resection.
m T1 (< 2 cm diameter) tumour m Only very small tumours of the floor of mouth
n Up to 30% of patients have occult metastasis can be managed by simple excision.

at presentation and should undergo n SCC of the buccal mucosa
simultaneous treatment of the neck by either m excised widely, including the underlying
selective neck dissection or radiotherapy . buccinator muscle.

(MCQ) m Facial skin involvement is rare but carries a poor
n When performing surgical excision of the prognosis.

primary tumour, a 2-cm margin in all planes m Although cervical node metastasis from buccal
should be achieved to ensure a wide, complete mucosa usually occurs less readily than in tongue
excision. (MCQ) and floor of mouth cancer, a simultaneous
m Advanced tumours (T3 and T4) ipsilateral selective supraomohyoid neck
n often encroach upon the floor of the mouth and, dissection (levels I, II, III) is considered good
occasionally, the mandible. practice.
n In these circumstances a major resection of .
DUCT PAPILLOMA
the tongue and floor of the mouth and

mandible is required. . (MCQ) TOPIC - 35 DUCT PAPILLOMA
m T4 tumours of the oral tongue
n often cross the midline n Mastitis
n total glossectomy is the only option to achieve m Usual etiologic agent: Staphylococcus aureus or
adequate tumour clearance. . (MCQ) Streptococcus spp.
n When a patient undergoes simultaneous neck m Most commonly occurs during early weeks of
dissection, the resection of the primary tumour breast-feeding.(MCQ)
should preferably be in continuity with the m Focal tenderness with erythema and warmth of
neck node specimen overlying skin, fluctuant mass occasionally
n This eliminates ‘lingual’ lymph nodes [lying palpable. (MCQ)
CARCINOMA TONGUE
between the primary tumour and m Diagnosis:

submandibular (level I) nodes]; these nodes n Ultrasound can be used to localize an abscess
may contain micro-deposits of tumour, which n if abscess present, aspirate fluid for Gram stain
may lead to local recurrence. and culture.
m Reconstruction m Treatment:
n Small defects of the lateral tongue can be n Continue breast-feeding
managed by primary closure or allowed to heal by n recommend use of breast pump as an
secondary intention. alternative.
n Larger defects, e.g. T2, T3 and T4 resections, n Cellulitis: Wound care and IV antibiotics.
require formal reconstruction to encourage good (MCQ)
speech and swallowing n Abscess: Incision and drainage followed by IV
n A radial forearm flap either with skin and/or antibiotics.
fascia, utilising microvascular anastomosis, gives n Fat Necrosis
a good functional result. . (MCQ) m Firm, irregular mass of varying tenderness
n Large-volume defects including total m History of local trauma elicited in 50% of
glossectomy require more bulky flaps such as patients
the rectus abdominus free flap. . (MCQ) m Predisposing factors: Chest wall or breast
n If feasible, the preservation of one or both trauma
hypoglossal nerves is useful to encourage floor m Irregular mass without discrete borders that may
of mouth function to help relearn swallowing. or may not be tender; later, collagenous scars
n Carcinoma of the floor of the mouth predominate
m It can spread to the ventral surface of the m Often indistinguishable from carcinoma by clinical
anterior tongue or encroach upon the lower exam or mammography (MCQ)
anterior alveolus m Diagnosis and treatment:

n Excisional biopsy with pathologic evaluation the symptoms is usually sufficient unless a
for carcinoma(MCQ) persistent discrete mass is identified
n Fibroadenoma n definitive diagnosis requires aspiration or
m Fibrous stroma surrounds duct-like epithelium biopsy with pathologic evaluation. (MCQ)
and forms a benign tumor that is grossly smooth, m Symptoms thought to be of hormonal etiology
white, and well circumscribed. (MCQ) and tend to fluctuate with the menstrual cycle.
m Typically occurs in late teens to early 30s; (MCQ)
m estrogen-sensitive (increased tenderness during m Associated with a group of characteristic histologic
pregnancy). findings, each of which has a variable relative risk
m Signs and symptoms: Smooth, discrete, circular, for the development of cancer.
mobile mass. (MCQ) m Not associated with an increased risk for breast
m Diagnosis: FNA. (MCQ) cancer unless biopsy reveals lobular or ductal
m Treatment: hyperplasia with atypia. (MCQ)
n If FNA is diagnostic for fibroadenoma and m Treatment:
patient is under 30, may observe depending n For cases with a classic history or absence
on severity of symptoms and size (< 3 cm). of a persistent mass:

(MCQ) l Conservative management; options include
n If FNA is nondiagnostic, patient is over 30, (MCQ)
or is symptomatic, must excise mass. „ NSAIDs ,OCPs
SURGERY
(MCQ) „ danazol, or tamoxifen
n The mass is well encapsulated and can be „ advise patient to avoid products that
shelled out easily at surgery. contain xanthine (e.g, caffeine, tobacco, cola
n Mondor’s Disease drinks).
m Superficial thrombophlebitis of lateral thoracic n If single dominant cyst, (MCQ)
or thora- coepigastric vein. l aspirate fluid;
m Predisposing factors: (MCQ) l discard if green or cloudy but must send to
n Local trauma, surgery, infection cytology and excise cyst if bloody.

n repetitive movements of upper extremity. n Mammary Duct Ectasia (Plasma Cell Mastitis)
m Presentation: Acute pain in axilla or superior aspect m Inflammation and dilation of mammary ducts
DUCT PAPILLOMA
of lateral breast. (MCQ) m Most commonly occurs in the perimenopausal
m Physical exam: Tender cord palpated. (MCQ) years

m Diagnosis: Confirm with ultrasound. m Noncyclical breast pain with lumps under
m Treatment: nipple/areola with or without a nipple discharge

n If Clear diagnosis is done by ultrasound (MCQ)
(MCQ) m Palpable lumps under areola, possible nipple
l Salicylates, warm compresses, limit discharge
motion of affected upper extremity m Diagnosis:
l Usually resolves within 2 to 6 weeks. n Based on exam
l If persistent, surgery to divide the vein n excisional biopsy required to rule out
above and below the site of thrombosis cancer(MCQ)

or resect the affected segment. m Treatment: Excision of affected ducts
n If Ultrasound nondiagnostic or an associated n Cystosarcoma Phyllodes
mass present: (MCQ) m A variant of fibroadenoma. (MCQ)
l Excisional biopsy. m Majority are benign.
n Fibrocystic Changes m Patients tend to present later than those with

m Usually diagnosed in 20s to 40s. (MCQ) fibroadenoma (> 30 years).
m Breast swelling (often bilateral), tenderness, m Indistinguishable from fibroadenoma by ultrasound or
and/or pain. (MCQ) mammogram.
m Discrete areas of nodularity within fibrous m The distinction between the two entities can be
breast tissue. made on the basis of their histologic features

m Evaluation: (phylloides tumors have more mitotic activity).
n Serial physical examination with (MCQ)
documentation of the fluctuating nature of
m Most are benign and have a good prognosis. m Clinical scenario:
(MCQ) n A 23- year-old female from New Delhi presents
m Exam: Large, freely movable mass with with a well-circumscribed mass in her left
overlying skin changes. (MCQ) breast.
m Diagnosis: n It is mobile, nontender, and has defined
n Definitive diagnosis requires biopsy with borders on physical exam. (MCQ)
pathologic evaluation. (MCQ) n Diagnosis : Fibroadenoma until proven
m Treatment: otherwise. (MCQ)
n Smaller tumors: m Mondor’s disease most commonly develops along
l Wide local excision with at least a 1-cm the course of a single vein.
margin(MCQ) m Clinical scenario:
n Larger tumors: n A female presents complaining of acute pain
l Simple mastectomy(MCQ) in her axilla and lateral chest wall, and a
n Intraductal Papilloma tender cord is identified on physical exam.
m A benign local proliferation of ductal epithelial n Diagnosis : Mondor’s disease vs. chest wall infection.
cells. n Confirm with ultrasound.
m Unilateral serosanguineous or bloody nipple n Ten percent of all women develop clinically
discharge. (MCQ) apparent fibrocystic changes. (MCQ)
m Subareolar mass and/or spontaneous nipple m Clinical scenario:
SURGERY
discharge. (MCQ) n A 35- year-old female presents with a straw-

m Radially compress breast to determine which colored nipple discharge and bilateral breast
lactiferous duct expresses fluid; mammography. tenderness that fluctuates with her menstrual
(MCQ) cycle.
m Diagnosis: n Diagnosis : Fibrocystic changes. (MCQ)
n Definitive diagnosis by pathologic evaluation of n Consider a trial of OCPs or NSAIDs. (MCQ)
resected specimen. (MCQ) m Clinical scenario:
n Treatment: Excise affected duct. n A 48- year-old female presents with breast
n Gynecomastia pain that does not vary with her menstrual
m Definition: Development of female-like breast cycle with lumps in her nipple–areolar
DUCT PAPILLOMA
tissue in males. complex and a history of a nonbloody

m May be physiologic or pathologic. nipple discharge.
m At least 2 cm of excess subareolar breast tissue n Diagnosis : Mammary duct ectasia. (MCQ)
is required to make the diagnosis. (MCQ) m Clinical scenario:
m Treatment: n A 38- year-old female presents with a 1-month
n Treat underlying cause if specific cause history of a spontaneous unilateral bloody
identified nipple discharge.
n if normal physiology is responsible, only n Radial compression of the involved breast
surgical excision (subareolar mastectomy) results in expression of blood at the 12
may be effective. (MCQ) o’clock position. (MCQ)
n Clinical Pearls : n Diagnosis : Intraductal papilloma. (MCQ)
m Clinical scenario: m Causes of gynecomastia:
n A female presents complaining of nipple pain n Increased estrogen
during breast-feeding with focal erythema l tumors, endocrine disorders
and warmth of breast on physical exam. l liver failure, nutritional imbalances
n Dignosis : Mastitis?? breast abscess(MCQ) n Decreased testosterone
n Incise and drain if fluctuance (abscess) present. l aging, testicular failure
m Clinical scenario: l primary or secondary, renal failure
n A 29- year-old female presents with a painful n Drugs (e.g., spironolactone)
breast mass several weeks after sustaining breast
trauma by a seat belt inacar accident.
n Diagnosis : The most common cause of a
persistent breast mass after trauma is fat
necrosis. (MCQ)
TOPIC - 36 ANAL CARCINOMA l Wide local excision alone or in combination
with radiation and/or chemotherapy is
n Anal Cancer successful in 80% of cases without
m Neoplasms of the anorectal region that are abdominal–perineal resection (APR) if
classified into tumor is small and not deeply invasive.
n tumors of the perianal skin (anal margin (MCQ)
carcinomas) n Anal canal tumors:
n tumors of the anal canal. l Local excision not an option
m anal margin carcinomas l combined chemotherapy (5-FU and
n well differentiated, keratinising lesions mitomycin C) with radiation often
(MCQ) successful; (MCQ)
n They are more common in men (MCQ) l APR only if follow-up biopsy indicates
n have a good prognosis residual tumor. (MCQ)
m anal canal tumors m Prognosis
n more common in women than men(MCQ) n Anal margin tumors:
n arise above the dentate line(MCQ) l 80% overall 5-year survival
n They are usually poorly differentiated and n Anal canal tumors:
non-keratinising lesions l Epidermoid carcinoma: 50% overall 5-year
n They are more common in women survival
SURGERY
n have a worse prognosis l Malignant melanoma: 10–15% 5-year
m average age 50 to 70. survival
m Risk factors (MCQ) Clinical pearls :
n
n HPV m Two unique in situ tumors of the perianal skin
n HIV are Paget’s disease and Bowen’s disease
n Cigarette smoking l Paget’s disease of the anus is
n Multiple sexual partners adenocarcinoma in situ(MCQ)
n Anal intercourse l anal Bowen’s disease is squamous carcinoma
n Immunosuppressed state in situ. (MCQ)
ANAL CARCINOMA
m Signs and symptoms m Squamous cell cancer of anal canal:
n Often asymptomatic l Treat with modified Nigro protocol:
n can present with (MCQ)
l anal bleeding, a lump, or itching „ 5FU+mitomycin & XRT (50.4 Gr),
l an irregular nodule that is palpable or visible including patients with ( positive inguinal
externally (anal margin tumor) nodes; not surgery (80 – 85% cure rate)
l hard, ulcerating mass that occupies a portion „ APR for recurrent disease (although up (
of the anal canal (anal canal tumor). to 50% response to cisplatin in this setting
m Diagnosis Surgical biopsy with histopathologic of recurrence)
evaluation. „ Risk of metastatic disease rises, and
m Histology: survival rates fall as tumor size > 2 cm
n Anal margin tumors include(MCQ) m Tumours above the dentate line spread to the
l squamous and basal cell carcinomas pelvic lymph nodes(MCQ)
l Paget’s disease m Tumours below the dentate line spread to the
l Bowen’s disease inguinal nodes(MCQ)
n Anal canal tumors are usually m Aetiology
l epidermoid (squamous cell carcinoma or l Anal carcinoma is more common in
transitional cell/cloacogenic carcinoma homosexuals (MCQ)
l malignant melanoma. l It is also increasingly seen in those with
m Treatment genital warts
n Squamous cell carcinoma l Patients with genital warts often develop
l nigro protocol - radiation and chemo intraepithelial neoplasia
(MCQ) l Intraepithelial neoplasia appears to be
l surgery is reserved for recurrence. premalignant
n Other anal margin tumors:

l Human papilloma virus (types 16,18,31 and TOPIC - 37 DIAPHRAGMATIC HERNIA
33) is an important aetiological factor(MCQ)
m Investigation n Congenital Diaphragmatic Hernia
l Rectal EUA (Examination Under m Patent pleuroperitoneal canal through the
Anaesthesia) and biopsy is the most useful foramen of Bochdalek. (MCQ)
‘staging’ investigation(MCQ) m Signs and symptoms
l Endoanal ultrasound is often impossible
n Significant respiratory distress within first
due to pain few hours of life
m Clinical Pearls on treatment of anal carcinoma n Scaphoid abdomen (MCQ)
(A high yield issue in MD Entrance ) (MCQ) m Diagnosis
n In past , anal carcinoma was considered a
n Ultrasound (prenatally) (MCQ)
‘surgical’ disease requiring radical n CXR: (MCQ)
abdominoperineal resection l Bowel gas pattern in hemithorax
n Now most patients are managed with
l Mediastinal shift
radiotherapy m Treatment
n The role of chemotherapy is currently
n Respiratory and metabolic support
undergoing investigation n Gastric decompression
n Radiotherapy is given to tumour and inguinal
n Surgical correction
nodes n Extracorporeal membrane oxygenation
SURGERY
n Surgery is required for:

(ECMO) (MCQ)
l Tumours that fail to respond to
m Prognosis
radiotherapy n Survival rates are 50% at best.
l Large tumours causing gastrointestinal
n Predictors of mortality: (MCQ)
obstruction l Pulmonary hypoplasia
l Small anal margin tumours without
l Pulmonary hypertension
sphincter involvement m Clinical Pearls :
n Congenital diaphragmatic hernia is more
common on the left. (MCQ)
n Clinical scenario: (MCQ)
DIAPHRAGMATIC HERNIA
l A newborn presents with respirator y

distress and a scaphoid abdomen.
Diagnosis : Diaphragmatic hernia
n Positive pressure ventilation must be
delivered by endotracheal (ET) tube, never by
mask.
n Bag and mask ventilation may cause
respiratory compromise (Favorite MCQ in
AIIMS QB)
n 95% occur through the posterior foreman of
Bachdalek
n Less than 5% occur through the anterior
foreman of Morgagni
n Usually associated with gastrointestinal
malrotation (MCQ)
n Prognosis is related to the time of onset and
degree of respiratory impairment
n Surgery should be considered early after
resuscitation
n Hernial content are usually reduced via and
abdominal approach
n Hernial sac is excised and diaphragm
repaired with nonabsorbable suture or a
Gortex patch(MCQ)
n A Ladd’s procedure may be required for n Absolute indications
malrotation(MCQ) l Enterocutaneous fistulae (MCQ)
n A chest drain is usually not required (MCQ) n Relative indications (MCQ)
n Early respiratory failure is assocaited with a l Moderate or severe malnutrition
poor prognosis l Acute pancreatitis

l Abdominal sepsis
TOPIC - 38 l Prolonged ileus

l Major trauma and burns
TOTAL PARENTERAL NUTRITION
l Severe inflammatory bowel disease
m Peripheral parenteral nutrition
n Surgical nutrition
n Hyperosmotic solution
m Nutritional assessment
n Significant problem with thrombophlebitis
n Clinical assessment
(MCQ)
l Weight loss (MCQ)
n Need to change cannulas every 24- 48 hours
„ 10%=mild malnutrition
n No evidence to support it as a clinically
„ 30%=severe malnutrition
important therapy
l Body mass index
n Composition - 12g nitrogen, 2000
n Anthropometric assessment
Calories(MCQ)
„ Triceps skin fold thickness (MCQ)
m Central parenteral nutrition
„ Mid arm circumference
SURGERY
n Hyperosmolar, low pH and irritant to vessel
„ Hand grip strength
walls
n Blood indices
n Typical feed contains the following in 2.5L
l Reduced serum albumin, prealbumin or
(MCQ)
transferrin(MCQ)
n 14g nitrogen as L-aminoacids
l Lymphocyte count
n 250 g glucose
n Enteral feeding
n 500 ml 20% lipid emulsion
m Prevents intestinal mucosal atrophy
n 100 mmol sodium ,100 mmol potassium ,150
m Supports gut associated immunological shield
mmol chloride
m Attenuates hypermetabolic response to injury
TOTAL PARENTERAL NUTRITION

n 15 mmol magnesium ,13 mmol calcium ,30
and surgery
mmol phosphate
m Polymeric liquid diet
n 0.4 mmol zinc ,Water and fat soluble vitamins,
n Short peptides ,Medium chain triglycerides and
Trace elements
polysaccharides
m Complications of subclavian and jugular
n Vitamins ,Trace elements
central venous lines
m Elemental diet
n 10% of central lines develop significant
n L-amino acids ,Simple sugars
complications
n High osmolarity can cause diarrhea (MCQ)
m Problems of insertion
n Enteral feed can be taken orally or by NGT
n Failure to cannulate
m Long term feeding can be by:
n Pneumothorax ,Haemothorax
n Surgical gastrostomy,jejunostomy
n Arterial puncture ,Brachial plexus injury
n Percutaneous endoscopic gastrostomy
n Mediastinal haematoma ,Thoracic duct injury
n Needle catheter jejunostomy
m Metabolic complications of parenteral
m Complications of enteral feeding
nutrition (MCQ)
n Malposition and blockage of tube
n Hyponatraemia
n Gastrooesophageal reflux
n Hypokalaemia
n Feed intolerance
n Hyperchloraemia
m Parenteral nutrition
n Trace element and folate deficiency
n Intestinal failure = ‘A reduction in functioning
n Deranged LFTs
gut mass below the minimal necessary for
n Linoleic acid deficiency
adequate digestion and absorption of nutrients’
n Can be given by either a peripheral or central
line
m Indications for Total Parenteral Nutrition

TOPIC - 39 LIVER ABSCESS to the liver via the portal vein from intestinal
amebiasis. (MCQ)
n Liver Abscess
m Pyogenic abscess
m most commonly involves the right lobe. (MCQ)
n 25% present with jaundice
m two main subtypes are pyogenic (bacterial) and
n 30% have a pleural effusion
amebic.
n Percutaneous drainage under ultrasound
n Risk factors
guidance is the initial treatment of
n Pyogenic:
choice(MCQ)
m usually secondary to bacterial sepsis or biliary
m Amoebic liver abscess
or portal vein infection
n The liver is the commonest extraintestinal site
m can also occur from a (MCQ)
of infection
n perforated infected gallbladder
n Can present several years after intestinal infection
n cholangitis, diverticulitis
n Jaundice is uncommon(MCQ)
n liver cancer
n Complications occur in 5% patients and include:
n liver metastases
(MCQ)
m Amebic: (MCQ)
l Amoebic empyema
n homosexual men
l Hepato-bronchial fistula
n institutionalized patients
l Lung abscess
n alcoholics
l Pericarditis
Signs and symptoms
SURGERY
n
l Peritonitis
m Fever, chills, RUQ pain, jaundice, sepsis, and weight
n Latex agglutination assay positive in more
loss
than 90%(MCQ)
m amebic abscesses tend to have a more protracted
n Sigmoidoscopy, stool microscopy and rectal
course.
biopsy may identify the organism(MCQ)
n Diagnosis
n Pus is odourless and sterile on routine culture
m Leukocytosis
n Metronidazole is the antibiotic of
m Elevated liver function tests (LFTs) (MCQ)
choice(MCQ)
m Ultrasound or CTof the liver
n If ineffective chloroquine and dihydrometine
m Serology for amebic abscesses
may be considered(MCQ)
Treatment
LIVER ABSCESS
n
n Ultrasound guided aspiration may be useful
m Pyogenic:
n Surgery is only rarely required
n ultrasound or CT-guided percutaneous
drainage with IV antibiotics
n operative drainage indicated if (MCQ)
l percutaneous attempts fail
l cysts are multiple
l loculated cysts
m Amebic:
n operative drainage not indicated unless
abscesses do not resolve with IV
Metronidazole or are superinfected with
bacteria (MCQ)
m Prognosis
n Mortality is low for uncomplicated abscesses,
but complicated abscesses carry a 40%
mortality risk. (MCQ)
n Clinical Pearls :
m The most common organisms isolated from
pyogenic abscesses are Escherichia coli,
Klebsiella, and Proteus. (MCQ)
m Amebic abscesses are classically described as
“Anchovy paste” in appearance and are caused
by Entamoeba histolytica, which gains access
TOPIC - 40 MECKELS DIVERTICULUM TOPIC - 41 VARICOSE VEINS
n Meckel’s Diverticulum n Varicose veins

m History
m Persistence of the omphalomesenteric
n Cough, tap and thrill tests are inaccurate
(vitelline) duct (MCQ)
n Important to identify those with history of
m omphalomesenteric (vitelline) duct should
disappear by seventh week of gestation(MCQ) DVT or lower limb fracture
n If history of DVT need preoperative
m Arises from the antimesenteric border of ileum
(MCQ) investigation with duplex scanning
m Examination
m Contains heterotopic epithelium (gastric, colonic,
n Identify distribution of varicose veins – long
or pancreatic) (MCQ)
m A true diverticulum in that it contains all layers
saphenous (LSV) vs short saphenous (SSV)
n Confirm with tourniquet testing and hand
of bowel wall(MCQ)
n Signs and symptoms held-doppler probe (5 MHz) (MCQ)
n Recurrent varicose veins need duplex
m Usually in first 2 years:
n Intermittent painless rectal bleeding (MCQ)
ultrasound
m Indications for duplex scanning (MCQ)
n Intestinal obstruction
n Suspected short saphenous incompetence
VARICOSE VEINS
n Diverticulitis
n Recurrent varicose veins
n Diagnosis
n Complicated varicose veins (e.g. ulceration,
m Meckel’s scan (scintigraphy) has 85% sensitivity
and 95% specificity. (MCQ) lipodermatosclerosis) (MCQ)
n History of deep venous thrombosis
m Uptake can be enhanced with cimetidine,
m Indications for varicose vein surgery (MCQ)
glucagon, or gastrin.
n Most surgery is cosmetic or for minor
n Treatment
m Surgical: Diverticular resection with transverse
symptoms
n Absolute indications for surgery :
closure of the enterotomy. (MCQ)
l Lipodermatosclerosis leading to venous
n Clinical Pearls :
m Meckel’s diverticulum is the most frequent
ulceration
MECKELS DIVERTICULUM
l Recurrent superficial thrombophlebitis
congenital GI abnormality. (MCQ)
l Bleeding from ruptured varix
m Meckel’s diverticulum: (MCQ)
m LSV surgery
n 2% of population
n Trendelenberg position with 20 - 30° head
n 2 inches long
n 2 feet from the ileocecal valve
down
n Legs should be abducted 10 -15°
n Patient is usually under 2 years of age
n Saphenofemoral junction (SFJ) found 2 cm
n 2% are symptomatic
m Meckel’s diverticulum may mimic acute
below and lateral to pubic tubercle
n Essential to identify SFJ before performing
appendicitis and also act as lead point for
intussusception. flush ligation of the LSV
n Individually divide and ligate all tributaries of
m If a Meckel’s diverticulum is found within a hernia
sac, it is called a Littre’s hernia. (MCQ) the LSV (MCQ)
l Superficial circumflex iliac vein
l Superficial inferior epigastric vein
l Superficial and deep external pudendal vein
n Check that femoral vein clear of direct
branches for 1 cm above and below SFJ
n Stripping of LSV reduces risk of recurrence
n Only strip to upper calf. (MCQ)
n Stripping to ankle is associated with increased
risk of saphenous neuralgia
n Post operative care:
l Elevate foot of bed for 12 hours
l Class 2 varix stocking should be worn for at
least 2weeks
m SSV surgery TOPIC- 42 CARCINOID
n Patient prone with 20-30° head down
n Saphenopopliteal junction(SPJ) has very n Carcinoid
variable position m Malignant tumor of enterochromaffin cell
n Preoperative localisation with duplex origin,(MCQ)
ultrasound is recommended m part of APUD (amine precursor uptake and
n Identify and preserve the sural nerve decarboxylation) system.
n Need to identify the SPJ (MCQ) m Peak incidence between 50 and 70 years of age
n Stripping associated with risk fo sural nerve (MCQ)
damage m Occurs with same frequency as
n Subfascial ligation inadequate (MCQ) adenocarcinoma but has variable malig-
m Perforator surgery m nant potential:
n Perforator disease may be improved by n > 90% diagnosed in GI system (MCQ)
superficial vein surgery n 46% in appendix (but 3% metastasize) (MCQ)
n Perforator surgery (e.g. Cockett’s and n 28% in ileum (but 35% metastasize)
Todd’s procedure) associated with high n 17% in rectum
morbidity (MCQ) m 30–40% present with multiple lesions (MCQ)
n Subfascial endoscopic perforator surgery m Signs and symptoms
(SEPS) n Frequently asymptomatic. (MCQ)
SURGERY
m Sclerotherpy n Slow growing. (MCQ)

n Only suitable for below knee varicose veins n Most common symptom is abdominal
(MCQ) pain(MCQ)
n Need to exclude SFJ or SPJ incompetence n Obstruction; rectal bleeding (from rectal
n Main use in persistent or recurrent varicose carcinoid), pain, weight loss.
veins after adequate saphenous surgery n Carcinoid syndrome:
n Sclerosants (MCQ) l Occur in 10% of cases: (MCQ)
l 5% Ethanolamine oleate l Due to production of serotonin,
l 0.5% Sodium tetradecyl sulphate bradykinin, or tryptrophan by tumor and
n Complications of sclerotherapy (MCQ) exposure of products to systemic circulation
l Extravasation causing pigmentation or prior to breakdown by the liver
CARCINOID
ulceration n Characterized by
l Deep venous thrombosis l cutaneous flushing, diarrhea
m Recurrent varicose veins l valvular lesions (right > left) (MCQ)
m 15 - 25 % of varicose vein surgery is for recurrence l bronchoconstriction
m Diagnosis
n Most found incidentally during appendectomy
or surgery for intestinal obstruction
n If patient has carcinoid syndrome, increased
5-HIAA (hydroxyin- dolacetic acid) or 5-HTP
(hydroxytryptophan; indicates bronchial loca-
tion) in 24-hour urine collection clinches
diagnosis (MCQ)
n Otherwise diagnosed as any other small bowel
neoplasm
m Treatment
n Medical for symptoms of carcinoid
syndrome.
l Serotonin antagonists (e.g., cyproheptadine)
(MCQ)
l somatostatin analogues (e.g., octreotide)
(MCQ)
n Surgical:

l Appendiceal carcinoid < 2 cm: Appendectomy m Locoregional spread or metastases are rare
(MCQ) especially if tumour is less than 2cm(MCQ)

l Appendiceal carcinoid > 2 cm: Right
hemicolectomy (MCQ)
l Small intestinal carcinoid: Resect tumor with TOPIC - 43 HYPOSPADIAS
mesenteric lymph nodes. (MCQ)
l Otherwise, resect tumor and any solitary n Hypospadias
liver metastasis considered resectable. m Affects approximately 1 in 500 boys
(MCQ) m Occur due to incomplete fusion of genital
m Prognosis folds and glandular urethra (MCQ)
n Overall survival roughly 54%. m Urethra found on ventral surface of
n Five-year survival penis(MCQ)
l after palliative resection is 25% m Replaced distally fibrous chordee (MCQ)
l after curative resection is 70%. m Deformity consists of malpositioned meatus,
m Clinical Pearls chordee and abnormal foreskin
n The carcinoid syndrome develops when the m If any degree of hypospadias is present
tumor produces amines and peptides circumcision is contraindicated (MCQ)
outside of the portovenous circulation. m Types:
n Classically, appendiceal and small intestinal n 70% are glandular or coronal (MCQ)
SURGERY
carcinoids cause the carcinoid syndrome only n 10% are penile
after they have metastasized to the liver. n 20% are scrotal
(MCQ) m Perineal hypospadias is associated with intersex
n Classical Clinical Vignette in MD Entrance and anorectal anomalies (MCQ)
l A 64- year-old male presents with a history m Management
of cutaneous flushing, diarrhea, wheezing, and an n Treatment is required (MCQ)
unintentional 8 Kg weight loss(MCQ) l To improve urinary stream
„ Diagnosis : Carcinoid syndrome l To allow sexual intercourse
„ the wheezing is a clue that the lesion may n Usually performed between 2 and 4 years of
be endobronchial. age(MCQ)
„ Order a 24-hour urine 5-HIAA level to n Glandular hypospadias requires a glandular
HYPOSPADIAS
confirm the diagnosis. (MCQ) meatotomy
n Foregut tumours produce little 5HIAA - often n Coronal hypospadias requires a meatal
produce other hormones (e.g. gastrin) advancement and glanduloplasty (MAGP
n Midgut and hindgut tumours produce increased operation) (MCQ)
amounts of 5HIAA n Proximal hypospadias without a chordee can
n When metastasis to liver these tumours produce be treated by a skin flap advancement
the carcinoid syndrome (MCQ)
n Flushing affects face and neck lasting only several n If chordee present it should be excised and
minutes an island flap urethroplasty performed
n Often precipitated by alcohol or chocolate m Complications
n In octreotide scintigraphy may identify primary
111 n Complications of hypospadias surgery include:
or secondary tumour(MCQ) l Urethral fistula
n Appendiceal carcinoid tumours l Urethral stricture
m Most common tumour of the appendix(MCQ) n Epispadias
m Found in 0.5% of appendicectomy specimens m Epispadias is very rare.
m Accounts for 85% of all appendiceal m In penile epispadias, the opening on the dorsum
tumours(MCQ) is associated with upward curvature of the penis
m Usually an incidental finding found during m Epispadias usually coexists with bladder
appendicectomy exstrophy and other severe developmental
m 75% occur at the tip, 15% in the middle and defects. (MCQ)
10% at the base of the appendix(MCQ)
m 80% are less than 1 cm in diameter(MCQ)
m Only 5% are greater than 2 cm in diameter

TOPIC - 44 INSULINOMA l Fasting serum gastrin level > 500 pg/mL
(normal: < 100 pg/mL) (MCQ)
n Insulinoma n Treatment
n Most common islet cell tumor. (MCQ) l Proton pump inhibitor to alleviate
n Eighty-five percent are benign. (MCQ) symptoms(MCQ)

n Most are solitary lesions. (MCQ) l Surgical resection (difficult because lesions
n Found with equal frequency in head, body, are usually multiple)

and tail of pancreas. (MCQ) VIPoma
n
n Signs and symptoms n Overproduction of vasoactive intestinal
l “Spells” or blackouts due to hypoglycemia peptide (VIP).

l Aggressiveness, confusion, coma n Also known as Verner–Morrison syndrome
l Insulinoma is characterized by Whipple’s or WDHA syndrome: (MCQ)

triad: (MCQ) l Watery diarrhea,
„ Symptoms of hypoglycemia with l Hypokalemia
fasting l Achlorhydria.
„ Glucose < 50 n Most are malignant
„ Relief of symptoms with glucose n majority have metastasized to liver at time
n Differential diagnosis of diagnosis.

l Obesity n Signs and symptoms (MCQ)
SURGERY
l Surreptitious insulin administration l Severe watery diarrhea
l Circulating insulin antibodies l Signs of hypokalemia
l Renal insufficiency n Diagnosis
m Diagnosis l Fasting serum VIP level > 800 pg/mL
l Fasting serum insulin level > 25 uU/mL (normal: < 200 pg/mL) (MCQ)
(normal: < 15 uU/mL) (MCQ) n Treatment
n Treatment l Surgical resection, chemotherapy
l Surgical resection is usually curative. (MCQ) l Octreotide (somatostatin analogue)
l Diazoxide can improve hypoglycemic Glucagonoma

n
symptoms. n Most are malignant
n Gastrinoma n large primary tumors usually metastasize to

INSULINOMA
n Also known as Zollinger–Ellison syndrome lymph nodes and liver at the time of diagnosis.
n Second most frequent islet cell tumor n Signs and symptoms(MCQ)
n 50% found in tail of pancreas l Hyperglycemia
n Small, slow-growing, multiple l Anemia
n 60% malignant(MCQ) l Mucositis
n Tumor most commonly located in pancreatic l Weight loss
head (70%) or duodenal bulb (10%)(MCQ) l Severe dermatitis
n Signs and symptoms n Differential diagnosis (MCQ)
l Signs of peptic ulcer disease l Hepatic insufficiency
l Epigastric pain most prominent after l Severe stress
eating(MCQ) l Hypoglycemia
l Occasionally diarrhea l Starvation
n Differential diagnosis(MCQ) l Decompensated diabetes mellitus
l Achlorhydria (pernicious anemia atrophic l Renal insufficiency
gastritis) n Diagnosis
l Pharmacologic inhibition of gastric acid l Fasting serum glucagon level > 1,000 pg/
secretion mL (normal: < 200 pg/mL) (MCQ)

„ proton pump inhibitors n Treatment
„ H2-receptor blockers l Surgery and chemotherapy.
l Vagotomy with retained antrum Somatostatinoma

n
l Antral G-cell hyperplasia n Very rare tumor.
l Renal insufficiency n Tumor is large and has metastasized at the
n Diagnosis time of diagnosis.

n Signs and symptoms TOPIC - 45 MEDIASTINAL TUMOR
l Indigestion
l Diarrhea
n Primary tumours of the mediastinum
l Abdominal cramps
m Thymoma, neurogenic tumours, germ cell tumours
l Weight loss
and lymphoma are usual primary tumours of
l Glucose intolerance/diabetes
the mediastinum
l Gallstones
m Thymoma
l Hypochlorhydria
n most commonmediastinaltumour (MCQ)
n Diagnosis
n The only reliable indicator of malignancy is
l Fasting serum somatostatin level > 1,000
capsular invasion.
pg/mL (normal: < 100 pg/mL) (MCQ) n Diagnosis and treatment are best achieved by
n Treatment
complete thymectomy.
l Surgical resection, chemotherapy.
m Germ cell tumour
n Clinical Pearls : n usually found in the anterior mediastinum
m Clinical Vignette in MD Entrance:
n contain elements from all three cell types
n A 34- year-old male complains of feeling
(mesoderm, endoderm and ectoderm).
faint and confused most notably after he n They tend to present in young adults
exercises. (MCQ) n 75% are benign and cystic(MCQ)
n His symptoms improve after he has a soft
n they may cause compression of neighbouring
SURGERY
drink structures; hence, dermoid cysts are best
n Diagnosis: Insulinoma— check fasting
excised.
serum insulin level. n Malignancy is suspected if elevated levels of
n Twenty-five percent of gastrinomas are
serum alpha-fetoprotein, human chorionic
associated with multiple endocrine neoplasia gonadotrophin and carcinoembryonic
type 1 (MEN-1). antigen are detected.
m Lymphoma
n A 46- year-old male from Chattisgarh
n Seen particularly the anterior
complains of chronic epigastric pain shortly mediastinum,(MCQ)
following meals and notices needing
MEDIASTINAL TUMOR
n lead to obstruction of the superior vena
increasing doses of his anti-ulcer medication. cava.(MCQ)
(MCQ) m Mesenchymaltumours
n Diagnosis: Gastrinoma.
n Lipomas are common in the anterior
mediastinum.
n A 62 year-old male from Patna presents with a
n Thyroid Ectopic thyroid tissue (and
history of severe water y diarrhea parathyroid)
characterized by hypokalemia and n found in the anterior mediastinum but usually
achlorhydria (MCQ) the mass is an extension of a thyroid lesion.
n His most recent bout required f luid
m Neural tumours
resuscitation when admitted in Hospital n These may derive from the sympathetic nervous
n Diagnosis: VIPoma.
system or the peripheral nerve
m Necrolytic migratory erythema is the skin
n more prevalent in the posterior mediastinum.
condition associated with glucagonoma. (MCQ) (MCQ)
m Islet cell tumor cancer vaccines, use the patient’s
n They may be painful
own live cancer cells to induce remission or fight n more often discovered accidentally on routine
relapse(MCQ) chest radiography (
n They include(MCQ)
„ neuroblastoma in childhood
„ Schwannomas andneurofibromas in adults.
n Distribution of Mediastinal tumors
m Anterior mediastinum(MCQ)
l Thymoma
l Lymphoma

l Germ cell tumour l 7 days to 2 months: Two clinical exams,
n Superior mediastinum(MCQ) apnea tests, and EEGs at least 48 hours
l Lymphoma apart
l Thyroid l 2 months to 1 year: As above, but 24 hours
l Parathyroid apart
n Middle mediastinum(MCQ) l Over 1 year: Two clinical exams and apnea
l Cystic lesions tests 12 hours apart

l Lymphoma n Transplant immunology
l Mesenchymaltumours n Major histocompatibility complexes (MHCs)
n Posterior mediastinum(MCQ) present antigens to T cells and are the major

l Neurogenic tumours target of activated lymphocytes.
l Cystic lesions n MHC I :(MCQ)
l Mesenchymaltumours l Found on all nucleated cells

l Consists of heavy and light chains, and
beta-2 microglobulin
l Encodes cell surface transplant antigens
TOPIC - 46 TRANSPLANTATION
l Primary target for CD8 T cells in graft
rejection
n Transpalntation
l Gene loci: A, B, C
n Donor Qualification -Exclusions:(MCQ)
SURGERY
n MHC II (MCQ)
l Age over 70 (flexible)
l Found on hematopoietic cells
l Active sepsis
l Composed of alpha and beta chains
l History of cancer except for primary brain
l Primary target for T-helper cells
tumor or basal cell carcinoma
l Gene loci: DR, DQ, DP
l History of transmissible disease
n MHC III(MCQ)
n High risk donors :(MCQ)
l Encodes complement proteins
l Sexually active gay men
l B cells are responsible for antibody-
l History of IV, IM, or SQ recreational drug
mediated hyperacute rejection when the
use within 5 years
transplant contains an antigen that the recipient
l History of hemophilia or any other
TRANSPLANTATION
B cells have seen before.

clotting disorder requiring previous
n Tissue Typing (MCQ)
transfusion of human-derived clotting
l Determination of MHC alleles in an
factors
individual to minimize differences in
n BRAIN DEATH (A Very High yield topic in
histocompatibility.
MD Entrance)
l Of above alleles, only A, B, and DR are
n Adult Criteria :(MCQ)
used in tissue typing.
l No cerebral function: Patient is in a deep
l Of these three genes, DR is most important
coma, unresponsive to stim- uli.
to match, followed by B and then A
l No brain stem function:
n Crossmatch
„ No evidence on exam of cranial nerve
l Test for preformed cytotoxic antibody in
function
serum of potential recipient.
„ lack of reflexes (papillary, corneal, cold
l Donor lymphocytes are cultured with
water calorics, Doll’s eyes, gag).
recipient serum in the presence of
l No spontaneous breathing: Apnea test.
l complement and dye.
l Requirements:
l Lymphocyte destruction is evidenced by
„ Normothermia
uptake of dye, indicating a positive
„ No CNS depressants or neuromuscular blockers
crossmatch.
in effect
l A positive crossmatch is generally a
„ Recommendations: EEG, though not
contraindication to transplant as hyperacute
legally required; 6-hour observation
rejection is likely.
period prior to performing brain death
n Risk of Malignancy
examination
n Pediatric Criteria:(MCQ)

n Overall incidence in kidney transplant „ Minimize mismatch of MHC; usual
recipients: 6%—lymphoma, skin cancer, genital immunosuppression;
neoplasms „ monitor for organ dysfunction as signs
n PTLD (post-transplant lymphoproliferative of rejection that may otherwise be
disease): asymptomatic.
l Caused by EBV, leads ultimately to l Treatment:
monoclonal B-cell lymphoma/treatment „ Kidney—
to lower or stop immunosuppression and ® high-dose steroids
restore immunity ® OKT3 or antithymocyte globulin (ATG)
n Rejection when steroid-resistant rejection
n Hyperacute (MCQ) (SRR) after 2 days. (MCQ)
l Cause: Presensitization of recipient to ® Outcome: Ninety to 95% of
donor antigen. transplants are salvaged with treatment.
l Timing: Immediately following graft n Chronic
reperfusion. l Cause: Cumulative effect of recognition of
l Mechanism: MHC by recipient immune system
„ Antibody binds to donor tissue, initiating l Timing: Insidious onset over months and
complement mediated lysis, which has a years
procoagulant effect. l Mechanism: Recipient’s immune system
SURGERY
„ End result is thrombosis of graft. recognizes donor MHC
l Prevention: ABO typing and negative l Diagnosis: Biopsy
crossmatch prevent hyperacute rejection in l Histology: (MCQ)
> 99% of patients. „ Parenchymal replacement with fibrous
n Variant: Delayed vascular rejection. (MCQ) tissue
l Mediated by humoral immunity „ some lymphocytic infiltrate, endothelial
l Occurs when preformed antibodies at destruction
levels too low to be detected by usual assays l Prevention: None known
l Deterioration of graft function, l Treatment: None
TRANSPLANTATION
postoperative day (POD) 3 l Outcome: Graft failure/loss
l Treatment: None. l Organ preservation
l Outcome: Graft failure/loss. n Optimum and Maximum Times for Each
n Acute (MCQ) Organ (A very High yield fact for MD Entrance)
l Cause: l Heart and lungs: 4 to 6 hours; preferred
„ Normal T-cell activity (would ultimately within 5 hours
affect every allograft were it not for l Pancreas: Up to 30 hours, preferred by 10
immunosuppression). to 20 hours
„ Timing: Between POD 5 and l Liver: 24 hours, preferred 6 to 12 hours
postoperative month 6. (MCQ) l Kidney: 48 hours
l Mechanism: n Principles
„ T cells bind antigens in one of two ways l Maintenance of donor’s hemodynamic
® directly through T-cell receptor (TCR) state.
® after phagocytosis and presentation of l Minimize warm ischemia time.
donor tissue l Hypothermia:
„ result in T-cell infiltration of graft with „ Rapid cooling of organ, in situ or on table,
organ destruction. and maintenance around 4°C (slows
l Diagnosis: Generally by decreased graft metabolism).
function and by biopsy. n Organ preservation solution:
l Histology: (MCQ) l Flush blood out of organ at pressure of 60
„ Lymphocytic infiltrate and/or graft to 100 cm H2O, and of appropriate volume:
necrosis „ Liver: 2 to 3 L
„ Liver rejection also characterized by „ Kidney: 200 to 500 mL
eosinophilic infiltrate. „ Pancreas: 200 to 500 mL
l Prevention:

l Appropriate solution contains impermeable „ Infection (HIV, tuberculosis)
molecules to suppress cell swelling „ Cirrhosis (chronic active)
induced by hypother mia, and is an „ Ongoing drug use
appropriate biochemical environment. l Relative Contraindications (MCQ)
l Alternative: Perfusion „ Obesity
„ Continuous perfusion: Perfusion fluid, „ Likely to be noncompliant
similar in nature to cold storage „ Ischemic heart disease severe, without possibility of
solution, is pumped continuously through CABG or angioplasty

organ, delivering oxygen and substrates, „ Sickle cell disease
thereby allowing the continuation of n Operation

metabolism, including synthetic reactions. m Donor nephrectomy
„ Pulsatile perfusion: Allows the n Flank incision, retroperitoneal approach.
pharmacologic manipulation of the n Left kidney used preferentially because
perfusate during storage and a pretransplant renal vein is longer. (MCQ)

assessment of the donor kidney. n Use kidney with fewer arteries if multiple
„ Has been found to improve graft function renal arteries are present. (MCQ)
at 1 and 2 years n Mannitol and furosemide, and possibly
n KIDNEY TRANSPLANTATION heparin, generally given prior to

n Most common solid organ transplanted n clamping vessels.
SURGERY
n Cadaveric (MCQ) n In cadaveric donors, kidney is usually
l Ideal donor: retrieved through multiorgan procurement.

„ Young brain dead patient without other n Phentolamine is given to prevent vasospasm.
disease who remains normotensive, and n Furosemide and mannitol used here as well
in whom warm ischemia time is short for diuresis prior to removal.

l Marginal donor: m Recipient operation
„ Used now because of extreme shortage of n Relative Contraindications(MCQ)
kidneys; older patients, perhaps with l Obesity
nonrenal disease, even mild renal l Likely to be noncompliant

TRANSPLANTATION
dysfunction or prolonged war m l Ischemic heart disease severe, without
ischemia time possibility of CABG or angioplasty

n Living l Sickle cell disease
l May be related or unrelated n Anesthesia:
l Decreased warm ischemia time l Atracurium is the preferred muscle relaxant.
l Associated with less delayed graft function (MCQ)

and better outcome l Inhalational agents preferable.
l Shorter waiting period l Fluids given assuming delayed graft
l Donor mortality: 1/10,000 function.

l Donor morbidity up to 10% l Right side preferred site for transplanted
l Living donor evaluation: Rule out potential kidney because iliac artery and vein are
donors with: (MCQ) more superficial here than on the left
„ Diabetes, hypertension, malignancy, COPD, side.(MCQ)
renal disease n Anastomosis:
„ Age over 65 (flexible) l End-to-side with common or external iliac
l Genitourinary (GU) anomalies assessed by artery

(MCQ) l End- to-end with hypogastric artery
„ proteinuria > 250 mg/24 hr l Renal vein anastomosis to common or
„ creatinine clearance rate (CCr) < 80 mL/min external iliac vein or to distal IVC
„ CT of urinary tract l Ureteral anastomosis typically to bladder,
n Contraindications to kidney transplantation (A but may do ureteroureterostomy (MCQ)

very High yield topic for MD Entrance) m Postoperative care
l Absolute Contraindications (MCQ) n Routine care.
„ Cancer (other than SCC or BCC of skin) l Expect diuresis with functioning
transplant; replace lost fluid.
l Expect moderate hypertension due to „ Present with hypotension, graft
preexisting hypertension as well tenderness, and swelling
l as due to aggravation by prednisone, CsA, „ If patient stable, may confirm diagnosis
and FK-506, all of which may elevate blood with CT
pressure. „ Reoperation required for significant
n Complications Specific to Kidney bleeding
Transplantation l Wound infections
n Early complications n Late complications
l Delayed graft function: (MCQ) l Lymphocele: (MCQ)
„ Evidenced by oliguria or anuria „ Perinephric fluid collection
„ First Check fluid intake is adequate or „ Incidence 5%
not „ Due to excessive iliac dissection and
„ Doppler ultrasound indicated to assess blood failure to ligate overlying lymphatics
flow (MCQ)
„ If blood flow adequate, look for urine „ Presents with swelling over transplant and
leak or obstruction at ureterovesicular unilateral leg edema due to compression
junction (UVJ) with US or renal scan of iliac vein (MCQ)
„ Once all workup negative, diagnosis is „ creatinine increased because ureter is
delayed graft function. compressed as well
SURGERY
„ Management may include dialysis in „ Diagnosis:
postoperative period. ® Ultrasound with aspiration and/or
„ Occurs in 25% of cadaveric transplants. Doppler venous ultrasound of iliac
l Graft thrombosis: (MCQ) veins(MCQ)
„ Requires immediate reoperation to save „ Treatment:
transplant. ® If asymptomatic, may leave/otherwise
„ Diagnosis indicated by abrupt cessation must drain.
of urine output. l Ureteral stricture:
„ May assess with Doppler ultrasound. „ Rising creatinine and hydronephrosis on
TRANSPLANTATION
l Urine leak: (MCQ) ultrasound(MCQ)
„ Usually at UVJ. „ Distal stricture result of rejection or
„ Technical failure: Ureteral anastomosis ischemia(MCQ)
too loose or too tight or due „ antegrade pyelogram best diagnostic tool
„ to less than watertight bladder closure. „ Treatment: (MCQ)
„ Also due to distal ureteral sloughing ® Balloon dilatation
secondary to inadequate blood supply. ® longer ones require surgical repair
„ Ureteral length should not be excessive. l Renal artery stenosis:
l Diagnosis: „ 10% of renal transplants within first 6
„ Decreased urine output, lower abdominal months(MCQ)
pain „ Presentation: Hyper tension, f luid
„ scrotal or labial edema, rising creatinine retention
l Tests: „ Diagnosis:
„ Ultrasound with fluid aspiration and ® Angiogram, US, magnetic resonance
analysis angiography (MRA)
„ renal scan with extravasation of ® If distal to anastomosis, may be
radioisotope. secondary to rejection,
„ Treatment: Reexploration and repair. atherosclerosis, clamp or other
l Bleeding: (MCQ) iatrogenic injury.
„ May be due ® Occurs more frequently with end-to-
® bleeding of small vessels that were in end anastomoses
spasm at time of operation „ Treatment: (MCQ)
® dysfunctional platelets in a uremic ® > 80% correctible with angioplasty;
patient. ® others require surgical repair
n Donor complications:

l UTI, wound infection, pneumothorax n Intra-abdominal placement of graft—
n Outcome (MCQ)
l 5-year survival (graft) (MCQ) l pancreas in the right iliac fossa
„ Cadaveric: < 60% l kidney in the left iliac fossa.
„ Living related: 70–80%, depending on n Portal vein of pancreas graft is anastomosed
donor source to IVC or iliac vein. (MCQ)
l Common causes of death: n Arterial anastomosis is made from the
„ Cardiovascular or infectious disease, malignancy reconstructed donor iliac artery graft and
l Morbidities: (MCQ) common iliac artery. (MCQ)
„ Hepatic dysfunction, osteopenia, hyperglycemia m Drainage options
„ Causes of graft loss: n Bladder drainage: (MCQ)
„ Chronic rejection, recurrent disease (2%) l Advantage: Urinary amylase may be used
l Pediatric Transplantation as a sign of rejection.
„ Workup similar but less need for l Up to 25% may require conversion to
comorbidity evaluation enteric drainage.
„ Minimum age 1 year n Enteric drainage:
„ 1-year graft survival l Avoidance of postop GU complications
® for cadaveric—80% that affect 30% of bladder
® for living related donor—90% l drained patients
SURGERY
l Avoidance of chronic dehydration
Pancreas transplantation l No need for bicarbonate replacement
n Indications l Equal efficacy, graft survival, morbidity
m Type I insulin-dependent diabetes mellitus and n Postoperative Management

age < 45 (MCQ) n Immunosuppression: Quadruple drug
m Exclusions (MCQ) regimen: (High yield MCQ)

n Significant coronary artery disease (CAD) l ATG or OKT3/MMF, CsA or FK-506 and
n Severe peripheral vascular disease (PVD) steroids

resulting in amputations n Expect rejection:
TRANSPLANTATION
n Severe visual impairment l Treatment is high-dose steroids for 2 days.
n Untreated malignancy (MCQ)

n Active infection l If no response, treat with OKT3 or ATG;
n HIV 90% resolve.

n Timing of Operation l Signs:
m Pancreas Transplant (5%) (MCQ) „ Early decrease in exocrine function
n For the nonuremic diabetic patient with (decrease in urinary amylase).

minimal or no evident nephropathy „ Confirm with biopsy (ultrasound-guided
m Pancreas Transplant After Kidney Transplant percutaneous, or duodenal needle biopsy).

(PAK) (7%)(MCQ) l In SPK, rejection usually involves pancreas
n For the uremic diabetic patient with potentially and kidney

reversible secondary effects, with suitable l May diagnose by creatinine and renal
living related kidney donor available biopsy.

m Simultaneous Pancreas and Kidney n Complications(MCQ)
Transplants (SPK) (87%) (MCQ) l Gross hematuria
n For the diabetic uremic patient with potentially l Urinary leak
reversible secondary effects, lacking a l UTI
suitable living related kidney donor l Urethritis
n Operations l Hyperamylasemia
m Donor operation n Peripancreatic fluid collections on CT and
n Pancreatic graft is harvested en bloc with liver US(MCQ)

and 10- to 12-cm duodenal segment. (MCQ) l Drain if suspect infection
n Pancreatic blood supply is reconstructed with n Outcomes

donor iliac artery graft(MCQ) m Graft loss: Most commonly due to rejection.
m Recipient operation l 1-year patient survival > 90%.

l 1-year graft survival > 75%. l Ascites: Diuretics and/or paracentesis
m SPK has the highest graft survival and lowest m Types of Liver Transplants
technical failure rate(MCQ) n Living donor
m (compared to percutaneous transluminal n Cadaveric
angioplasty [PTA] and PAK) m Operation
m 1-year graft function rate: n Native hepatectomy
n SPK: 78 n Implantation of donor liver:
n PAK: 56 l On venovenous bypass, or using technique
n PTA: 55 in which three principal hepatic veins are
m By 5 years out, no difference in enteric and anastomosed to donor suprahepatic IVC,
bladder drained in terms of patient or graft allowing restoration of IVC flow after
survival. suprahepatic caval anastomosis
m In terms of diabetic secondary effects: (MCQ) n Reconstruction of common bile duct, end-
n Reversal of neuropathy to-end (MCQ)
n prevention of nephropathy m Postoperative Management
n improvement or stabilization of retinopathy. n Avoid vasoconstrictors, which reduce blood
n Liver Transplantation flow to liver.
n Indications(MCQ) n Diuretics as needed to mobilize fluid.
l Irreversible liver failure: (MCQ) n Tacrolimus immunosuppression. (MCQ)
SURGERY
„ Chronic (More Common) m Complications
® Cirrhosis (posthepatic, alcoholic) n Graft failure:
® Primary and secondary biliary cirrhosis l Usually secondary to primary nonfunction
® Primary sclerosing cholangitis l recurrence of disease
„ Metabolic defects l biliary or vascular complications (not
® alpha-1-antitrypsin deficiency, amyloidosis generally due to rejection).
® hemochromatosis, sarcoidosis n Rejection
® tyrosinemia, ornithine transcarbinase deficiency l occurs in first 3 months post-transplant
„ Malignancy with 50% incidence
TRANSPLANTATION
® hepatocellular carcinoma [HCC] l it is well-treated with steroids or
® cholangiocarcinoma antilymphocyte therapy (MCQ)
„ Biliary atresia l indicated by elevated LFTs particularly GGTP
„ Polycystic liver disease m SMALL BOWEL TRANSPLANTATION
„ Budd–Chiari syndrome n Indications
„ Cystic fibrosis l Adults: Short bowel syndrome, due to
„ Crigler–Najjar (MCQ)
„ Histiocytosis X „ Crohn’s disease
l Acute or Fulminant – „ mesenteric thrombosis
„ Viral or alcoholic hepatitis „ trauma
„ Wilson’s disease l Children: Short bowel syndrome, due to
„ Hepatotoxic drugs (e.g., acetaminophen (MCQ)
overdose) „ necrotizing enterocolitis
n Contraindications(MCQ) „ intestinal pseudo-obstruction,
l Multisystem organ failure „ gastroschisis, volvulus, intestinal atresia
l Severe cardiopulmonary disease n Operation
l Sepsis secondary to nonhepatic source l Isolated intestinal failure: Isolated intestinal
l Widespread cancer transplant
l Noncompliance with medical therapy l With liver failure:
l Severely impaired neurologic status „ Liver–intestine combined transplant
m Evaluation l Sometimes, multivisceral transplant:
n Preoperative control of: „ Liver, stomach, pancreas, duodenum, small
l Variceal bleeding: Transjugular intrahepatic intestine, possibly large bowel
portosystemic shunt (TIPS) when l Stoma usually placed for monitoring and
needed(MCQ) biopsies
l Postop: Early feeding l Pulmonary fibrosis, emphysema
n Complications l bronchopulmonary dysplasia
l Graft versus host disease (GVHD): l primary pulmonary hypertension (without
Prevent with immunosuppression, and/or cardiac dysfunction)
pretreatment of donor. (MCQ) l post-transplant obliterative bronchiolitis
l Rejection l Bilateral single lung for septic lung
l More difficult to treat than in other organs; disease:
newer agents may prove to be more useful „ Cystic fibrosis, bronchiectasis, COPD
than older ones (tacrolimus-based). l Heart–lung for pulmonary vascular disease
l Diagnosed by „ end-stage lung disease with cardiac
„ fever, abdominal pain, elevated white dysfunction
count, ileus, GI bleed l Lobar lung
„ positive blood cultures; „ to increase donor pool from living related
„ also by biopsy showing cryptitis, villi and cadaveric donors
shortening, mononuclear infiltrate. n Contraindications (MCQ)
n Old age (definition varies)
CARDIAC TRANSPLANTATION n Significant systemic disease, including hepatic
n Cause of disease in patients receiving transplants: or renal disease
l Cardiomyopathy (50%), CAD (38%) (MCQ) n Active infection
SURGERY
l congenital disease (6%), valvular disease (2%) n Malignancy

n Indications (MCQ) n Psychiatric illness/noncompliance
l Severe cardiac disability on maximal medical n Current smoking
therapy n CIT (cold ischemic time) up to 6 hours is tolerated.
l multiple hospitalizations for CHF, NYHA III (MCQ)
or IV, n Clinical Pearls :
l peak oxygen consumption < 15 mL/kg/min m If the patient does not qualify for organ donation,
l Symptomatic ischemia cornea, skin, bone, and heart valves may still
l recurrent ventricular arrhythmias refractory to be used. (MCQ)
TRANSPLANTATION
usual therapy, LVEF < 30% m Why HLA Matching is not good for for liver
l with unstable angina and not a candidate for transplants. (MCQ)
CABG or PTCA l HLA presents viral peptides to T cells and
l All surgical alternatives already excluded compatibility may potentiate the
n Contraindications (MCQ) inflammatory phase of viral reinfection
n Irreversible, severe, pulmonary, renal, or after transplant, thereby increasing chance
hepatic dysfunction of recurrence of original disease.
n Unstaged, or incompletely staged, cancer m Graft survival is improved with matching for
n Psychiatric illness kidney, pancreas, and heart transplants, but is
n Severe systemic disease not improved, and in fact, may be worsened for
n Age > 60 (varies from center to center) liver transplants. (MCQ)
n Matching/compatibility based on: (MCQ) m Azathioprine is not generally used in liver
n ABO compatibility transplant because it is likely to cause
n Body size hepatotoxicity. (MCQ)
n Donor weight/recipient weight m FK-506 and CsA have an additive
n Phosphoribosylamine (PRA) (if PRA > 5%, immunosuppressive effect, but the toxicity may
crossmatch is done) (MCQ) be too much.
n Complications m Some studies have found up to 40% incidence of
n The most common cause of perioperative post-transplant lymphoproliferative disorder with
death is infection (50%). (MCQ) tacrolimus, and therefore, this drug is used with
n Other common causes are pulmonar y extreme caution in children. (MCQ)
hypertension and nonspecific graft failure. m Patients who are to receive OKT3 must be pre-
LUNG TRANSPLANTATION treated with steroids.
n Types of Operations and Indications (MCQ)
l Single lung for fibrotic lung disease

m Presensitization of the recipient to a donor „ Patient is on tacrolimus, which ultimately
antigen can result from prior pregnancy, causes renal insufficiency in most patients.
transfusion, or transplant. (MCQ) Do not give anything that could potentiate
m Forty to 50% of kidney transplant recipients and its nephrotoxicity.
70–80% of pancreas transplant recipients will have „ First-line drug for pain would be
at least one episode of acute rejection. acetaminophen, standard doses of which
m Clinical scenario: a transplanted liver should be able to
l A kidney transplant recipient is seen in the ER tolerate.
for nausea and abdominal pain, fever, and m Cardiac transplant:
elevated creatinine. n Cold ischemic time (MCQ)
l Dignosis Acute rejection. (MCQ) l up to 6 hours may be tolerated
„ Diagnosis may be confirmed by l 3 to 4 is ideal
ultrasound- guided biopsy. l 2 hours maximum for patients with
„ Pulse steroid treatment is indicated. pulmonary hypertension
m Treatment of acute rejection of a kidney n Denervated (transplanted) heart has (MCQ)
transplant (with pulse steroids or OKT3 for SRR) l higher resting heart rate
is effective in 90% of cases. (MCQ) l no sinus arrhythmia or carotid reflex
m Warm ischemia time should be minimized because bradycardia.
it leads to rapid decline in ATP and therefore l increased sensitivity to catecholamines,
SURGERY
(MCQ) with increased density of adrenergic receptors
l decrease in biosynthetic reactions with loss of norepinephrine uptake
l a redistribution of electrolytes across cell l cardiac output and index remain at low
membranes, normal, with adequate but abnormal exercise
l continuation of biodegradation reactions response (increase in heart rate is usually
leading to acidosis delayed).
l ultimately loss of organ viability. l normal vasodilatation with increased
m Continuous Perfusion oxygen demand but abnormal vasodilatory
l Results in decreased delayed graft function reserve is in rejection, hypertrophy, or wall
TRANSPLANTATION
compared to simple cold storage: abnormalities.
Approximately 25% versus less than 10% n CMV (MCQ)
m Cardiovascular disease is responsible for 50% l occurs at 75–100% incidence in cardiac
of dialysis patients’ deaths, and infection accounts transplant patients
for 15–30%.(MCQ) l has been identified as trigger for graft-
m The left kidney is preferred by surgeons because related atherosclerosis
of its longer renal vein, but preoperative imaging l treated with ganciclovir and hyperimmune
studies in the potential donor can identify variants globulin
of normal anatomy (like multiple arteries) that
may make the right kidney a better choice. (MCQ)
m Alternatives to whole-organ pancreas transplant
is use of insulin pump and islet of Langerhans
transplant.
m The pancreas transplant is placed in the abdominal
cavity rather than in the retroperitoneal space
because of a lower incidence of peripancreatic
fluid collections and lymphocele.
m HLA mismatch and preservation time do not
have a significant impact on graft survival for
pancreas transplants. (MCQ)
m Clinical scenario: (MCQ)
l A 58- year-old woman who is s/p liver
transplant want analgesics for musculoskeletal
pain. What will you advise ?

TOPIC - 47 BASAL CELL CARCINOMA TOPIC - 48 HEMORRHOIDS
n Basal cell carcinoma n Haemorrhoids

m Commonest skin malignancy (MCQ) m Affect 50% of population over the age of 50
m Occurs on sun exposed skin years
m Commonest site - face above line from angle m Usually presents with: (MCQ)
of mouth tear (MCQ) n Painless bright red rectal bleeding
m Predisposing factors (MCQ) n Prolapsing perianal lump
n Xeroderma pigmentosa n Acute pain due to thrombosis
n Radiotherapy n Faecal soiling or pruritus ani
m BCC are locally invasive m Pathogenesis
m They rarely metastasise n Predisposing factors
m Clinical types of BCC l Dilatation of venous plexus
n Nodular or noduloulcerative l Distension of AV anastomoses
n Cystic ,Pigmented ,Sclerosing l Displacement of anal cushions
n Cicatrical , Superficial n 80% of patients have high resting anal
m Treatment pressure (MCQ)
n Local excision with 0.5 cm margins (MCQ) m Classification
HEMORRHOIDS
n May require full thickness graft (MCQ) n Haemorrhoids are often classified as internal or
n Radiotherapy (MCQ) external
n Mohs Surgery n Internal haemorrhoids arise above the
n Cure rate more than 95% dentate line and can be sub-classified as:
n Squamous cell carcinoma (MCQ)
m Second commonest cutaneous malignancy l First degree-bleeding only
m Commonest site - face & hands (MCQ) l Second degree-prolapse,reduce spontaneously
m Arises from keratinising cell layer(MCQ) l Third degree-prolapse,pushed back
m Predisposing factors: (MCQ) l Fourth degree-permanently prolapsed
n Solar keratoses m Treatment options
BASAL CELL CARCINOMA
n Bowen’s disease n All should have high residue diet

n Viral warts m Outpatient
m Chronic ulceration or sinuses n Treatment options for first and second degree
(=Marjolin’sUlcers) (MCQ) haemorrhoids include:
m Appear as keratotic nodule with ulcerated l Injection with 5% phenol in arachis or
centre almond oil (MCQ)
m Differential diagnosis l Rubber band ligation (RBL) (MCQ)
n Keratoacanthoma „ Randomised trial of RBL and sclerotherapy
n Basal cell carcinoma have shown
n Amelanotic melanomas ® 90% success with RBL
n Skin adnexal tumours ® 70% success with sclerotherapy
m Treatment m Inpatient
n Wide local excision +/- elective lymph node n Treatment options include: (MCQ)
dissection(MCQ) l Dilatation and banding
n Keratoacanthoma l Haemorrhoidectomy
m More common in men than women n Haemorrhoidectomy
m Rapidly growing usually over 6-8 weeks (MCQ) l usually performed as an open procedure
m Dome shaped with keratin filled crater upto 3 (Milligan-Morgan) (MCQ)
cm diameter l Haemorrhoidectomy is the treatment of
m If untreated involutes over 6 months leaving choice for 3rd degree haemorrhoids(MCQ)
irregular pitted scar l Secondary infection and postoperative pain
m Differential Diagnosis = SCC (MCQ) may be reduced with oral metronidazole
m Treatment - Excision biopsy (MCQ) l Botulinum toxin injection may also reduce
postoperative pain
l Complications include:
„ Bleeding(3%) l Reoperation has 90% success rate if
„ Urinary retention(10%) remaining gland is localized preop.
„ Anal stenosis may develop if adequate m Secondary
skin bridges are not maintained n Due to chronic renal failure or intestinal
l Other haemorrhoidectomy techniques malabsorption that causes hypocalcemia with

include closed or stapled procedures appropriate increase in PTH. (MCQ)
(MCQ) n Signs and symptoms:
l The recently described stapled technique is l Bone pain from renal osteodystrophy and
associated with: (MCQ) pruritus.

„ Reduced operating time l Patients are often asymptomatic.
„ Less postoperative pain n Diagnosis: Made by labs in asymptomatic
„ Shortened hospital stay patient

„ More rapid return to normal activity n Treatment:
l Nonsurgical:
„ In renal failure patients (MCQ)
® restrict phosphorus intake
TOPIC - 49 PARATHYROID ADENOMA ® treat with phosphorus-binding agents
® treat with calcium/vitamin D supple-
n Hyperparathyroidism mentation
m Primary
SURGERY
® Adjust dialysate to maximize calcium
n Due to overproduction of PTH, causing
and minimize aluminum.
(MCQ) l Surgical – Indications (MCQ)
l increased absorption of calcium from
„ intractable bone pain or pruritus
intestines „ pathologic fractures
l increased vitamin D3 production
„ failure of medical therapy.
l decreased renal calcium excretion, thereby
l 31D 2-gland parathyroidectomy (MCQ)
raising the serum level. m Tertiary
n Signs and symptoms: (MCQ)
n Due to autonomously functioning
l “Stones”: Kidney stones
PARATHYROID ADENOMA
parathyroid glands, resistant to negative
l “Bones”: Bone pain, pathologic fractures
feedback, for example, persistent
l “Groans”: Nausea, vomiting, constipation,
hypercalcemia following renal
pancreatitis, peptic ulcer disease transplantation. (MCQ)
l “Moans”: Lethargy, confusion, depression,
n Usually a short-lived phenomenon. (MCQ)
paranoia n If persistent, surgery is indicated (31D 2-
n Etiology:
gland parathyroidectomy).
l Solitary adenoma 85–90% (MCQ)
m Clinical pearls :
l Four-gland hyperplasia 10%
n Not all patients with hypercalcemia have
l Cancer < 1%
hyperparathyroidism.
n Preop localization:
n Hypercalcemia of malignancy (due to
l US
tumor- secreted PTH-related protein) must be
l FNA of suspicious US findings
ruled out.
l Sestamibi scan
n Malignancies commonly implicated include
n Diagnosis:
lung, breast, prostate, head, and neck (MCQ)
l Elevation of plasma PTH, with n Patients with familial hyperparathyroidism (i.e.,
inappropriately high serum calcium (MCQ) MEN) (MCQ)
n Treatment:
l have a high recurrence rate
l Solitary adenoma: Solitary parathyroidectomy
l total parathyroidectomy with forearm
(MCQ) reimplantation is indicated to facilitate
l Multiple gland hyperplasia: (MCQ)
potential reoperation.
„ Remove three glands, or all four with
n Patients with sporadic four- gland hyperplasia
reimplantation of one gland in forearm. may undergo total parathyroidectomy with
n Outcome:
reimplantation or three- gland excision.
l First operation has 98% success rate.
(MCQ)
TOPIC - 50 AORTIC ANUERYSM l Rapid expansion
l Asymptomatic more than 6 cm – exact
n Abdominal aortic aneurysms lower limit controversial (MCQ)

n An AAA is an increase in aortic diameter by Popliteal artery aneurysms
n
greater than 50% of normal (MCQ) n Defined as a popliteal artery diameter
n Usually regarded as aortic diameter of greater than 2 cm (MCQ)

greater than 3 cm diameter (MCQ) n Account for 80% of all peripheral aneurysms
n More prevalent in elderly men (MCQ) (MCQ)

n Male : female ratio is 4:1 (MCQ) n 50% are bilateral
n Risk factors (MCQ) n 50% are associated with an abdominal aortic
l Hypertension aneurysm
l Peripheral vascular disease n 50% are asymptomatic
l Family history n Symptomatic aneurysms present with features
n Natural history of :
l AAA diameter expands exponentially at n Compression of adjacent structures ( veins or
approximately 10% per year (MCQ) nerves)

l Risk of rupture increases as aneurysm n Rupture
expands n Limb ischaemia due to emboli or acute
l 5 year risk of rupture: thrombosis

SURGERY
„ 5.0 to 5.9 cm is 25% n Treatment is by proximal and distal ligation
„ 6.0 to 6.9 cm is 35% n Revascularisation of the leg with a
„ More than 7 cm is 75% femoropopliteal bypass

l Overall only 15% aneurysms ever rupture n With a symptomatic popliteal aneurysm 20% patients
l 85% of patients with a AAA die from an will undergo an amputation

unrelated cause THORACIC AORTIC ANEURYSMS
n
n Screening n Aneurysm: Ballooning defect in the vessel wall
l Who should be screened? n Dissection: Tear of the arterial intima
„ males over 65 years - especially n Types

AORTIC ANUERYSM
hypertensives l Degenerative: (MCQ)
® Single US at 65 years reduces death „ Due to abnormal collagen metabolism
from ruptured AAA by 70% in screened „ Seen with Marfan and Ehlers–Danlos
population syndromes
„ Patients with small aneurysms should l Atherosclerotic: (MCQ)
undergo regular surveillance „ Due to remodeling and dilatation of the
® Repeated ultrasound every 6 months aortic wall

n Clinical features n Anatomic classification (MCQ)
l 75% are asymptomatic l DeBakey Type I: Ascending and
l Possible symptoms include: (MCQ) descending aorta

„ Epigastric pain l DeBakey Type II: Ascending aorta only
„ Back pain l DeBakey Type III: Descending aorta only
„ Malaise and weight loss (with inflammatory l Stanford A: Ascending aorta (same as
aneurysms) DeBakey I/II)

„ Rupture presents with l Stanford B: Descending aorta (same as
„ Sudden onset abdominal pain DeBakey III)

„ Hypovolaemic shock n Ascending aorta and aortic arch aneurysms
„ Pulsatile epigastric mass are worse than descending aortic aneurysms.

l Rare presentations include (MCQ)
„ Distal embolic features n Expansion rate (MCQ)
„ Aorto-caval fistula l 0.56 cm/yr for arch aneurysms
„ Primary aorto-intestinal fistula l 0.42 cm/yr for descending aorta.
n Indication for operation n Epidemiology
l Rupture l Male-to-female ratio is 2:1. (MCQ)
l Symptomatic aneurysm l Familial clustering.

l Patients tend to be younger than those with „ Requires operator expertise
abdominal aortic aneurysm (AAA). „ Moderate ability to detect ascending and
n Signs and symptoms of expansion or arch dissections (MCQ)

rupture (MCQ) „ poor for detecting descending arch
l “Tearing” or “ripping” chest pain radiating dissection (MCQ)
to the back. n Treatment and prognosis
l Acute neurologic symptoms (syncope, l Medical
coma, convulsions, hemiplegia). „ Control hypertension with nitroprusside
l Palpable thrust may be seen in right second or labetalol.

or third intercostal space. „ Parenteral analgesia.
l Pulsating sternoclavicular joint may be l Surgical
seen (secondary to swelling at the base of the „ For ruptured aneurysms, it is the only
aorta). definitive therapy.

l Hoarseness. „ Carries very high risk of mortality.
l Stridor. „ Most patients die before reaching the
l Dysphagia. operating room.
l New aortic regurgitation murmur. „ Of those that reach the OR, less than 50%
l Hemoptysis or hematemesis. survive.
l Absent or diminished pulses. „ Elective repair is considered for (MCQ)
SURGERY
n Diagnosis ® aneurysms > 7 cm
l CXR ® when aneurysm diameter is > 2.5×
„ Widened mediastinum (MCQ) that of adjacent aorta.

„ Abnormal aortic contour „ Mortality rate is 10–15%.
„ “Calcium sign”: (MCQ) „ For degenerative aneurysms, the entire
® Reflects separation of intimal calcification aortic root must be replaced.

from the adventitial surface „ Atherosclerotic aneur ysms can be
l Contrast CT repaired (MCQ)

„ Two distinct lumens (true and false) ® via open approach
AORTIC ANUERYSM
separated by intimal flap (MCQ) » median sternotomy approach for
„ Sensitivity 85–100% ascending arch

„ Specificity 100% » posterolateral thoracotomy for
n Magnetic Resonance Imaging (MRI) descending arch
„ Excellent sensitivity and specificity ® via endovascular technique.
„ Gives info about branch vessels that CT „ Ascending and descending arch
does not aneurysms are repaired with patient under

„ No need for contrast cardiopulmonary bypass, anticoagulation, and in
„ Limited to stable patients mild-moderate hypothermia. (MCQ)
l Angiography „ Aortic arch aneurysms are repaired with
„ Requires contrast dye like CT patient in circulatory arrest and profound
„ Invasive hypothermia.
l Transesophageal Echocardiography n Complications
(TEE) l Hemorrhage
„ Presence of intimal flap separating the l Paraplegia
true from the false lumen l Stroke
„ Features of the false lumen: (MCQ) l MI
„ Larger in diameter, slower blood flow l Visceral ischemia
velocity n THORACOABDOMINAL ANEURYSMS

„ Can be used in relatively unstable n Crawford classification: (MCQ)
patients as well l Type I:
l Transthoracic Echocardiography (TTE) „ Most of descending thoracic aorta and
„ Available at bedside abdominal aorta proximal to renal

„ Noninvasive arteries
„ Suitable for unstable patients l Type II:

„ Most of descending thoracic aorta and TOPIC - 51 INTUSUSSCEPTION
abdominal aorta distal to renal arteries
l Type III: Intussusception
„ Distal one-half of descending thoracic Invagination of one portion of the bowel into
aorta and abdominal aorta proximal to itself—proximal portion usually drawn into distal
renal arteries portion by peristalsis.
l Type IV: Male-to-female ratio: 2:1 to 4:1
„ Distal one-half of descending thoracic Peak incidence - 5 to 12 months
aorta and abdominal aorta distal to renal Age range: 2 months to 5 years
arteries CAUSES
n Diagnosis Idiopathic.
l Made incidentally (routine physical exam or Viral (enterovirus in summer, rotavirus in winter).
imaging for other reasons) or on A “lead point” (or focus) is thought to be present in
postmortem exam (for ruptured ones). older children
n Treatment These lead points can be caused by:
n Elective repair undertaken after weighing risk Meckel’s diverticulum ,Polyp ,Lymphoma
vs. benefit. Henoch–Schonlein purpura ,Cystic fibrosis
n Open surgical approach is used: (MCQ) SIGNS AND SYMPTOMS
l Type I: Thoracic incision Classic triad:
SURGERY
l Types II and III: Incision from sixth Intermittent colicky abdominal pain
intercostal space into abdomen Bilious vomiting
l Type IV: Retroperitoneal incision from left Currant jelly stool
flank to umbilicus Neurologic signs:
Lethargy
Shock-like state
Seizure-like activity
Apnea
RUQ mass:
INTUSUSSCEPTION
Sausage shaped
Ill defined
Dance’s sign—absence of bowel in right lower
quadrant (RLQ)
DIAGNOSIS
AXR:
Paucity of bowel gas
Loss of visualization of the tip of liver
“Target sign”—two concentric circles of fat density
Ultrasound:
“Target” or “donut” sign—
single hypoechoic ring with hyperechoic center
“Pseudokidney” sign —
superimposed hypoechoic (edematous walls of
bowel) and hyperechoic (areas of compressed
mucosa) layers
Barium enema
Treatment
Correct dehydration
NG tube for decompression
Hydrostatic reduction
Barium enema:
Cervix-like mass
Coiled spring appearance on the evacuation film
Contraindications:
Peritonitis Perforation TOPIC - 52
Profound shock POSTERIOR URETHRAL VALVE
Air enema:
Decreased radiation
n Posterior urethral valves
Fewer complications
n These folds of urothelium cause obstruction to
RECURRENCE
the urethra of boys.
With radiologic reduction: 7–10%
n They are usually just distal to the verumontanum
With surgical reduction: 2–5%
(MCQ)
n They are flap valves and so, although urine does
Clinical Pearls :
not flow normally, a urethral catheter can be
Mostcommoncauseof acute intestinal obstruction under
passed without difficulty. (MCQ)
2 years of age.
n Dilatation of the urinary tract now commonly
Mostcommonsiteis ileocolic (90%).
leads to diagnosis by ultrasound scanning before
Intussusception and link with rotavirus vaccine led to
birth. (MCQ)
withdrawal of vaccine from the market.
n Other cases present with urinary infection in the
Intussusception:
neonatal period.
Classictriadispresentin only 20% of cases.
n Sometimes the valves are incomplete and the patient
Absenceofcurrantjelly stool does not exclude the
is symptom free until adolescence or adulthood.
diagnosis.
n Posterior urethral valves need to be detected and
SURGERY
Neurologicsignsmay delay the diagnosis.
treated as early as possible to avoid the
Barium enema for intussusception is both diagnostic
development of renal failure. (MCQ)
and therapeutic. Rule of threes:
n The valves can be difficult to see on urethroscopy
Bariumcolumnshould not exceed a height of 3 feet
because the flow of irrigant sweeps them into the
Nomorethanthree attempts
open position. (MCQ)
Only 3minutes/attempt
n If the bladder is filled with contrast medium, the
dilatation of the urethra above the valves can be
demonstrated on a voiding cystogram(MCQ)
n The bladder is hypertrophied and often shows
POSTERIOR URETHRAL VALVE

diverticula.
n Typically, there is vesicoureteric reflux into dilated
upper tracts
n Treatment
n A suprapubic catheter is inserted to relieve the
back pressure and allow the effects of renal
failure to subside before definitive treatment by
transurethral resection of the valves. (MCQ)

TOPIC - 53 VOLVULUS n Hypermobile cecum secondary to incomplete
fixation during intrauterine development (cecal
n Malrotation and Midgut Volvulus volvulus)
m Incomplete rotation of the intestine during fetal
m Signs and symptoms same as other causes of
development large bowel obstruction.
m May cause complete or partial duodenal
m Diagnosis
n Abdominal films:
obstruction (MCQ)
l Markedly dilated sigmoid colon or cecum
m Embryology
n Midgut = duodenum to mid-transverse colon.
with a “kidney bean” appearance(MCQ)
n Barium enema:
n Develops extraperitoneally and migrates
l Characteristic “bird’s beak” at areas of
intraperitoneally at 12 weeks. (MCQ)
n During this migration, the midgut rotates 270°
colonic narrowing(MCQ)
counterclockwise around the superior m Treatment
n Cecal volvulus:
mesenteric artery (SMA). (MCQ)
l Right hemicolectomy if vascular
n Problem results from abnormal fixation of
the mesentery of the bowel. compromise(MCQ)
l Cecopexy otherwise adequate (suturing the
n Acute onset of bilious vomiting
right colon to the parietal peritoneum)
n Abdominal distention ,Lethargy
(MCQ)
SURGERY
n Sigmoid volvulus
n Skin mottling ,Hypovolemia
l Sigmoidoscopy with rectal tube insertion to
n Bloody stool (late sign) (MCQ)
m Diagnosis
decompress the volvulus. (MCQ)
l Emergent laparotomy if sigmoidoscopy
n AXR:
l Presence of bowel loops overriding liver
fails or if strangulation or perforation is
l Air in stomach and in duodenum (double
suspected.
l Elective resection at a later date to prevent
bubble sign) (MCQ)
l No gas in GI tract distal to volvulus
recurrence
l 40% of cases recur after nonoperative reduction
n Upper GI series:
l Duodenal C-loop does not extend to the
left. (MCQ)
VOLVULUS
m TREATMENT
n Surgical emergency
n Reduced with counterclockwise
rotation(MCQ)
n Ladd procedure(MCQ)
n Appendectomy—because cecum will remain
in the right upper quadrant (RUQ) and
future appendicitis may have misleading
presentation (A very commonly asked
MCQ in AIPGMEE, AIIMS, PGI)
m Prognosis -Ten percent chance of recurrent
volvulus.
m Malrotation without volvulus may present with
intermittent vomiting and abdominal distention.
n Volvulus
m Rotation of a segment of intestine about its
mesenteric axis(MCQ)
m characteristically occurs in the sigmoid colon (70%
of cases) or cecum (30%).(MCQ)
m > 50% of cases occur in patients over 65(MCQ)
m Risk factors(MCQ)
n Elderly (especially institutionalized patients)

TOPIC - 54 CLEFT LIP n Cleft lip repair is usually performed between
3 and 6 months of age (MCQ)
Cleft lip and palate n Cleft palate repair is usually performed
m Can be associated with congenital heart disease
between 6 and 18 months (MCQ)
m Cleft lip / palate predominates in males
m Isolated cleft palate is more common in female
TOPIC - 55 DIVERTICULOSIS
m Aetiology
n Cleft palate may be inherited as an autosomal n Divericular disease
dominant condition with variable penetrance m Herniation of the mucosa and submucosa
n Family history in a first-degree relative increases through the muscular layers of the bowel wall at
the risk by a factor of 20 sites where arterioles penetrate, forming small
n Environmental factors include: out- pouchings or diverticula. (MCQ)
l Maternal epilepsy m Diverticula occur on the mesenteric side of the
l Drugs-steroids,diazepam,phenytoin colon. . (MCQ)

l Folic acid deficiency m > 50% over 70 years of age . (MCQ)
n Cleft lip and palate also occurs as part of m Men and women equally affected
l PierreRobinSyndrome (MCQ) m Sigmoid colon most commonly involved with
DIVERTICULOSIS
„ Cleft palate progressively decreasing frequency of involvement as one
„ Retrognathia proceeds proximally. (MCQ)
„ Posteriorly displaced tongue m Risk factors. (MCQ)
l Stickler Syndrome n Old age
l Down’s Syndrome n Low-fiber diet
l Treacher Collins’Syndrome m Signs and symptoms
m Embryology n Diverticulosis
n Cleft lip deformity is established in first 6 l 80% of patients asymptomatic.
weeks of life (MCQ) l May cause recurrent, intermittent left lower
n Possibly due to failure of fusion of maxillary quadrant (LLQ) pain and tenderness that
and medial nasal processes (MCQ) often follows a meal and is relieved by
n May be due to incomplete mesodermal flatus or defecation. . (MCQ)
ingrowth into the processes l LLQ rope-like mass sometimes palpable
CLEFT LIP
n Palatal clefts result from failure of fusion of on exam. . (MCQ)
the palatal shelves of the maxillary processes l Massive lower GI bleeding is classic
m Clinical features (notably absent in diverticulitis). . (MCQ)

n Typical distribution of cleft types is : n Diverticulitis
l Cleft lip alone (15%) l Persistent abdominal pain initially diffuse
l Cleft lip and palate (45%) in nature that often becomes localized to the
l Isolated cleft palate (40%) LLQ with development of peritoneal signs.
n Cleft lips are more common on the left (MCQ)
l Primary management of cleft lip and l LLQ and/or pelvic tenderness
palate l Ileus
n Antenatal diagnosis of cleft lip may be l Fever, anorexia, nausea, vomiting,
possible l change in bowel habits (usually

n Feeding is rarely a difficulty constipation) (MCQ)
n Breast feeding may be achieved or modified l Elevated WBC
teats for bottle feeding may be required m Diagnosis
n Major respiratory obstruction is uncommon n Diverticulosis
n The aims of surgery are: l Characteristic history and physical exam
l To achieve a normal appearance of the lip, confirmed by diverticula identified on

nose and face barium enema and/or colonoscopy.
l To allow normal facial growth n Diverticulitis
l To allow normal speech l Characteristic history and physical exam with
m Surgery elevated WBCs

l Abdominal x-ray: Ileus, distention, and/ l A peridiverticular inflammation caused by
or free intraperitoneal air(MCQ) (usually tiny) perforation of the diverticulum
l CT scan: secondary to increased pressure or
„ Pericolonic inf lammation with or obstruction by inspissated feces.
without abscess formation (MCQ) l Feces extravasate onto the serosal surface
„ barium enema and colonoscopy may but infection is usually well contained in a
induce perforation and are patient with normal immune function.
contraindicated in the acute setting but
should be obtained in follow-up(MCQ)
m Treatment TOPIC - 56 ISCHEMIC BOWEL DISEASE
n Diverticulosis:
l High-fiber diet, stool softeners. (MCQ) n Acute mesenteric ischaemia
n Mild diverticulitis: m Mesenteric vascular disease may be classified as
l Outpatient management: n acute intestinal ischaemia – with or without
„ Clear liquid diet, PO antibiotics(MCQ) occlusion
„ non-opioid analgesics with close follow- n Venous
up. n chronic arterial
„ Follow-up includes colonoscopy and n central or peripheral.
dietary recommendations once acute m The superior mesenteric vessels are the visceral
SURGERY
infection has subsided. vessels most likely to be affected by embolisation

l If outpatient therapy fails, admit for IV or thrombosis
antibiotics and IV hydration with bowel m embolisation is most common. (MCQ)
rest. m Occlusion at the origin of the superior
l Nasogastric tube (NGT) is placed when mesenteric artery (SMA) is almost invariably the
there is evidence of ileus or small bowel result of thrombosis
obstruction (SBO), with nausea and vom- m emboli lodge at the origin of the middle colic
iting. (MCQ) artery(MCQ)
n Severe diverticulitis with peritonitis and/ m Inferior mesenteric involvement is usually
ISCHEMIC BOWEL DISEASE
or perforation: clinically silent because of a better collateral

l Two-stage procedure with initial surgical circulation.
drainage and diverting colostomy followed m Possible sources for the embolisation of the
by colonic reanastomosis 2 to 3 months SMA include(MCQ)
later. (MCQ) n left atrium associated with fibrillation
l Elective resection of affected bowel may n a mural myocardial infarction
be considered in the patient who has n an atheromatous plaque from an aortic
recurrent episodes of diverticulitis aneurysm
requiring treatment. (MCQ) n mitral valve vegetation associated with
m Prognosis endocarditis.
n Seventy percent of patients have no recurrence m Primary thrombosis in artery is associated with
after one episode of uncomplicated n Atherosclerosis
diverticulitis. n thromboangitis obliterans.
n After a second episode, 50% recur. m Primary thrombosis of the superior mesenteric
m Clinical Pearls : veins may occur in (MCQ)
n Recommend colonscopy (MCQ) n factor V Leiden
l after 7 years of pancolitis n portal hypertension
l after 10 years of left-sided colitis n portal pyaemia
l then scope and biopsy every 1 to 2 years n sickle cell disease
n The diverticula of common diverticulosis are n in women taking the contraceptive pill.
false diverticula, because only the mucosa and m Irrespective of whether the occlusion is arterial or
submucosa herniated rather than all the layers venous, haemorrhagic infarction occurs.
of the bowel wall. (MCQ) m The mucosa is the only layer of the intestinal
n Pathology of diverticulitis: wall to have little resistance to ischaemic injury.
m Clinical features

n The most important clue to an early diagnosis n Mild lower abdominal pain and rectal
of acute mesenteric ischaemia is the sudden bleeding, classically after AAA repair (MCQ)
onset of severe abdominal pain in a patient n Pain more insidious in onset than small bowel
with atrial fibrillation or atherosclerosis ischemia
(MCQ) m Diagnosis
n The pain is typically central and out of all n characteristically shows “thumbprinting” on
proportion to physical findings. (MCQ) barium enema (MCQ)
n Persistent vomiting and defaecation occur n But contrast enema is contraindicated in the
early, with the subsequent passage of altered setting of suspected bowel gangrene
blood. (MCQ) m Treatment (MCQ)
n Hypovolaemic shock rapidly ensues. n If symptoms mild, observe
n Abdominal tenderness may be mild initially n if moderate (with fever and increased WBC)
with rigidity being a late feature. (MCQ) l give IV antibiotics
n Investigation will usually reveal a profound n if severe (with peritoneal signs)
neutrophil leuco- cytosis with an absence l exploratory laparatomy with colostomy.
of gas in the thickened small intestine on m Clinical Pearls : (MCQ)
abdominal radiographs. (MCQ) n Ischemic colitis often affects the splenic
n The presence of gas bubbles in the flexure.
mesenteric veins is rare but pathognomonic. n Classical Clinical Vignette in MD Entrance
SURGERY
(MCQ) l A 74-year-old male with a history of
m Treatment hypertension develops cramping lower
n embolectomy via the ileocolic artery or abdominal pain 2 days s/p AAA repair. A
revascularisation of the SMA may be few hours later he develops bloody diarrhea.
considered in early embolic cases. l Clinical diagnosis
n The majority of cases, however, are diagnosed „ Ischemic colitis should be suspected in
late. any elderly patient who develops acute
n In the young, all affected bowel should be abdominal pain followed by rectal
resected, whereas in the elderly or infirm the bleeding.
situation may be deemed incurable. „ Furthermore, the most common setting
ISCHEMIC BOWEL DISEASE

n Anti-coagulation should be implemented early for ischemic colitis is the early
in the postoperative period. postoperative period after AAA repair
n After extensive enterectomy it is usual for when impaired blood flow through the
patients to require intravenous alimentation. inferior mesenteric may put the colon at
n Ischemic colitis risk.
m Acute or chronic intestinal ischemia secondary to
decreased intestinal perfusion or
thromboembolism:
m Embolus or thrombus of the inferior
mesenteric artery
m Poor perfusion of mucosal vessels from
arteriole shunting or spasm
m Ninety percent of cases occur in patients > 60
years of age. (MCQ)
m Risk factors(MCQ)
n Old age
n s/p Abdominal aortic aneurysm (AAA)
repair
n Hypertension
n Coronary artery disease
n Diabetes
n Adhesions from previous abdominal surgery
n Underlying obstructive lesion of colon

TOPIC - 57 ZENKER DIVERTICULUM l may be treated via resection and
esophagomyotomy via a left thoracotomy
n Esophageal Diverticulum approach. (MCQ)
m Outpouching of the esophageal mucosa that
protrudes through a defect in the tunica
muscularis.(MCQ)
m May be either a true diverticulum, involving all TOPIC - 58 ANNULAR PANCREAS
three layers of the esophagus, or a false
n Annular pancreas
diverticulum, involving only the mucosa and
m This is the result of failure of complete rotation
submucosa.
of the ventral pancreatic bud during
m Characterized by its location:
development.(MCQ)
n Pharyngoesophageal (Zenker’s diverticulum)
m a ring of pancreatic tissue surrounds the second
(MCQ)
or third part of the duodenum.(MCQ)
n epiphrenic.
m It is most often seen in association with congenital
n midesophageal
duodenal stenosis or atresia .(MCQ)
ANNULAR PANCREAS
m Pulsion diverticula MCQ)

m It is more prevalent in children with Down’s
n Pharyngoesophageal and epiphrenic diverticula
syndrome.(MCQ)
n they are caused by increased esophageal pressure
m Duodenal obstruction typically causes vomiting
n they are false diverticula. MCQ)
in the neonate
m Traction diverticula
m The usual treatment is bypass (duoden-
n Midesophageal diverticula MCQ)
oduodenostomy). .(MCQ)
n and are true diverticula. (MCQ)
m The disease may occur in later life as one of the
causes of pancreatitis
n Pharyngoesophageal type is the most likely
m If it causes pancreatitis - resection of the
to be symptomatic
head of the pancreas is treatment
l Typical symptoms include
n Ectopic pancreas
„ dysphagia, halitosis (MCQ)
n can be found in the
„ regurgitation of food eaten hours to days earlier
m submucosa in parts of the stomach, duodenum
„ choking, and aspiration.
ZENKER DIVERTICULUM
or small intestine Meckel’s diverticulum.

n Midesophageal diverticula are usually
(MCQ)
asymptomatic. (MCQ)
m gall bladder,
n Epiphrenic diverticula may cause (MCQ)
m in the hilum of the spleen and within the liver.
l dysphagia and regurgitation
n Ectopic pancreas may also be found in the wall
l may be entirely asymptomatic.
of an alimentary tract duplication cyst
m Diagnosis
n Congenital cystic disease of the pancreas
n Barium swallow will reveal the presence of
n occurs as part of the von Hippel–Lindau
all types of diverticula.
syndrome .(MCQ)
m Treatment
n Treatment of Zenker’s diverticulum (MCQ)
l recommended to relieve symptoms and to
prevent complications such as aspiration
pneumonia or esophageal perforation.
l The most common procedure is a cervical
esophagomyotomy with resection of the
diverticulum. (MCQ)
n Midesophageal diverticula
l resected in the occasional incidence of a
fistulous connection between the
diverticulum and tracheobronchial tree.
(MCQ)
n Epiphrenic diverticula

TOPIC - 59 TOPIC - 60 SALIVARY CALCULUS
CARCINOMA GALLBLADDER
n Sialolithiasis
n Carcinoma Gall bladder m Of all salivary stones: 80% occur in the
m majority are adenocarcinomas.(MCQ) submandibular gland (Most common
m Extremely rare (< 1% of patients with location) (MCQ)
cholelithiasis) (MCQ) m 80% of submandibular stones are radiopaque
m incidence increases with age with a peak at 75 (MCQ)
years (MCQ) m Most parotid stones are radiolucent
m female:male ratio 3:1 (MCQ) m Presentation of a submandibular stone is pain and
m Risk factors (MCQ) swelling prior tor during meal
n porcelain gallbladder m This does however requires almost complete
n gallstones, choledochal cysts obstruction of the submandibular
n gallbladder polyps duct(MCQ)
n typhoid carriers with chronic inflammation. m In partial obstruction ,swelling may be mild with
SALIVARY CALCULUS
m Signs and symptoms (MCQ) chronic painful enlargement of the gland
n Most patients are asymptomatic until late in m If diagnostic doubt then stone can be
the course demonstrated by sialogram
n findings may include abdominal pain, nausea, m Treatment is by either removal of stone from
vomiting, weight loss, RUQ mass, duct or excision of the gland (MCQ)
hepatomegaly, or jaundice. m The stone should be removed if palpable with
m Diagnosis - Ultrasound, CT, MRI, or ERCP/ no evidence of chronic infection
PTC m The gland should be excised if the stone
m Treatment posterior or gland is chronically inflamed
n Tumor confined to gallbladder mucosa:
Cholecystectomy (MCQ)
n Tumor involving muscularis or serosa:
(MCQ)
CARCINOMA GALLBLADDER
l Radical cholecystectomy
l Wedge resection of overlying liver
l lymph node dissection
n Tumor involving liver: (MCQ)
l Consider palliative measures such as
decompression of the proximal biliary
tree or a bypass procedure of the
obstructed duodenum
Clinical Pearls :
m Courvoisier’s sign: A palpable, nontender
gallbladder often associated with cancer in the
head of the pancreas or the gallbladder. (MCQ)
m The diagnosis is made on ultrasonography and
defined by a multidetector row CT scan, with
a percutaneous biopsy confirming the histological
diagnosi
m In selected patients, laparoscopy is useful in
staging the disease, as it can detect peritoneal
or liver metastases that would preclude further
surgical resection.

TOPIC - 61 CYSTIC HYGROMA
n Cystic hygroma
m Hamartomatous lymphatic malformations
resulting in multi-cystic mass (MCQ)
m 60% are found in neck region(MCQ)
m Often present in early childhood as expanding
mass
m Contain clear fluid and transilluminate brightly
(MCQ)
m Large lesions can be diagnoses prenatally and can
result in obstructed labour (MCQ)
m Surgical excision is difficult and can result in a
poor cosmetic result
m Sclerosants my be useful (MCQ)
MECONIUM ILEUS
TOPIC - 62 MECONIUM ILEUS
n Meconium ileus
m Commonest cause of neonatal intraluminal
intestinal obstruction (MCQ)
m 80% cases are associated with cystic
fibrosis(MCQ)
m Inherited as an autosomal recessive trait
m Viscid pancreatic secretions cause autodigestion
of pancreatic acinar cells
m Resulting meconium is abnormal and putty-like
CYSTIC HYGROMA
in consistency
m Meconium becomes inspissated in the lower
ileum(MCQ)
m There is a microcolon(MCQ)
m Presents with bilious vomiting and distension
usually on first day of life (MCQ)
m Passage of meconium is delayed
m Meconium filled loops of bowel may be
palpable
m X-ray may show a ‘ground-glass’ appearance,
especially in the right upper quadrant(MCQ)
n Management
m Gastrografin enemas may be successful in 50%
of patients (MCQ)
m If unsuccessful, surgery will be required
m Limited resection and stomas may be required


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SURGERY

1 BREAST CARCINOMA 1-9

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32 URETHRAL RUPTURE 83-85

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n Premalignant Lesions of breast cases). (MCQ)

m Mammography is possible as long as proper shielding n Sensitivity 85–90%.

until the second trimester. (MCQ) l I: No abnormality

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n Primary (neoadjuvant) chemotherapy l May be superior to tamoxifen(MCQ)

n In 20–30% this is response is complete l Dermal infiltration

l Tamoxifen is an oral anti-oestrogen III A/B disease) (MCQ)

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surgery required m Occurs in elderly

Multifocal Solitary modes of treatment(MCQ)

Clinical Pearls for MD Entrance Exam :

Papillary Follicular Medullary Anaplastic

Age group 30-40 50s 50-60 60-70

Diagnosis n Fine-needle n FNA n FNA n FNA

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Histologic n Papillary n Solitary n Cell of origin: C n Sheets of

Metastases Lymphatic Hematogenous n Lymphatic n Aggressive local

thyroidectomy thyroidectomy (modified radical theraphy (XRT)

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n Whitmore Standard staging scheme

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be employed. n Complications of radiation therapy for prostate

n Alternatively, operative staging may be cancer:

n Radical prostatectomy: l Rectal strictures and fistula

l Most clearly indicated in Stage B disease l Impotence (30–50%)

(MCQ) n Tumors are histologically graded using the

the disease is usually cured definitively by adenocarcinoma. (MCQ)

diagnosis is made. (MCQ) m Pattern of spread is via lymphatics to iliac and

disease. n external-beam radiotherapy

l There is a definite role for surgery in n interstitial irradiation with implants.

„ bladder outlet obstruction (MCQ)

PROSTATE CARCINOMA AND BPH

years standard for ablating testosterone

l Since growth of the normal prostate is n Kallikrein-like protein produced by prostatic

dependent on testicular androgens, deprivation epithelial cells

of prostate cancer. n >10 ng/ml is highly suggestive of prostatic

l Androgen deprivation can be achieved via: carcinoma(MCQ)

® bilateral orchiectomy results in 90% n useful marker for monitoring response to

reduction in testosterone (MCQ) treatment

„ Estrogen administration n Bilateral subcapsular orchidectomy

„ To achieve androgen depletion beyond n LHRHagonists-goseraline

the level of surgical castration, n Anti-androgens-cyproteroneacetate,flutamide

adrenalectomy is needed. n Oestrogens-stilbeostrol

m As the amount of residual urine increase: . prostate and bladder neck

will be smooth, firm, n However, the effectiveness of 5-alpha reduc-

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m Signs and symptoms

„ 5-FU and leucovorin n Proximal rectum

nodes rectum,with division of lateral ligaments,

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m Stage I,II colon: Surgery alone (current trials

n Mucocele of the gallbladder

„ Leukocytosis, with or without increased appearance of the small bowel.