*

Mini Osce
Done By: Dr. Ayman Hajeer
*

*Spot diagnosis ?
* indications ?
*Complications ?
Done By: Dr. Ayman Hajeer
* Ileostomy

* End ileostomy : usually after proctocolectomy (typically for UC )

* Loop ileostomy : temporarily to protect distal anastamosis

* Complications
 early :
- hemorrhage at stoma site
- stoma ischemia
- high output
- obstruction secondary to adhesions
- stoma retraction
 delayed :
- obstruction
- dermatitis around stoma
- stoma prolapse
- parastomal hernia
- fistulae
- Psychological problems
Done By: Dr. Ayman Hajeer
 Ileostomy Colostomy

Spout Flush

Liquid Solid

Electrolyte disturbance Less likely

Rif Lif+ruq
Know the
difference between
Ileostomy and
colostomy
Done By: Dr. Ayman Hajeer
 *
* A 39-year-old African American
female went to the emergency
department with a chief complaint
of chest pain and shortness of
breath. These complaints were of
sudden onset and started while she
was typing on her computer. She
complained of squeezing, pressure-
like sensation in her midsternal area
and over her right side. She rated
her pain as a 10 on a scale of 1/10.

 diagnosis ?
 how to diagnose this condition ?
 management ?

Done By: Dr. Ayman Hajeer

*right tension pneumothorax
There are completely absent lung markings on the right,
with the right lung collapsed and pushed across into the
left hemithorax, along with the mediastinal contents.

*History and physical examination remain the keys to

making the diagnosis of pneumothorax
( don’t wait for CXR to confirm the Dx. Start ttt
imediately )

*Emergency !!
 emergent chest decompression
with needle thoracostomy
**A 14-16G intravenous cannula is inserted into the second
rib space in the mid-clavicular line.
Done By: Dr. Ayman Hajeer
 *
- Spot diagnosis ?
- Causes ?
- Management ?
- What is the type of the
abdominal X-ray you
will order for , in order
to diagnose such case?

Done By: Dr. Ayman Hajeer

Small bowel obstruction

- Centrally located multiple

dilated loops of gas filled bowel
- Valvulae conniventes are
visible - confirming this is small
bowel
-Evidence of previous surgery -
note the anastomosis site this
suggests adhesions is the likely
cause of obstruction (confirmed
at surgery)

** Dilated small bowel >3cm is

considered abnormal

** The X-ray features of post-

operative ileus are often
indistinguishable from those of
small bowel obstruction.

Done By: Dr. Ayman Hajeer

Key points
- Dilatation of the caecum >9cm is abnormal
- Dilatation of any other part of the colon >6cm is abnormal
- Abdominal X-ray may demonstrate the level of obstruction
- Abdominal X-ray cannot reliably differentiate mechanical obstruction from pseudo
obstruction

Large bowel
obstruction
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
*
* Spot diagnosis ??
* Causes for this condition ?

Done By: Dr. Ayman Hajeer

 * Free air under diaphragm

* Possible causes :
- post op ( laparatomy , laprascopy )
- perforated viscus
- gas producing bacteria
- Penetrating trauma
- Peritoneal dialysis

Done By: Dr. Ayman Hajeer

 *
* Spot diagnosis ?

Done By: Dr. Ayman Hajeer

 * The apple core sign  stenosing
annular colorectal carcinoma.

Done By: Dr. Ayman Hajeer

 *
* A 65 year old man
underwent colonoscopy
for lower GI bleeding .
( see the picture )

- spot diagnosis
- risk factors
- complications

Done By: Dr. Ayman Hajeer

* Diverticulosis

* - old age
- low dietary fiber intake
- Physical inactivity
- female gender

* - diverticulitis
- perforation
- hemorrhage
- fistulae
- abscess
- post infective strictures

Done By: Dr. Ayman Hajeer

*
* A 51 year oldman presented to the ER C/O yelowish
discolaration of his eyes and skin and RUQ abdominal pain .
You did several blood tests and imaging studies for him . “see
next slide”

- spot diagnosis
- causes
- complication
- management

Done By: Dr. Ayman Hajeer

Done By: Dr. Ayman Hajeer
* Porcelain gallbladder
“characterized by intramural calcification of the
gallbladder wall , the term "porcelain gallbladder" is used
to describe the bluish discoloration and brittle
consistency of the gallbladder wall seen in this condition”
* Causes :
- chronic cholecystitis
- excessive gallstones ( an obese female in her 40’s )

* Complications :
- gallbladder carcinoma (adenocarcinoma)

* cholecystectomy

Done By: Dr. Ayman Hajeer

 *
*Spot diagnosis
?
*Most common
(imp.) cause ?
*Management ?

Done By: Dr. Ayman Hajeer

* Bloody nipple discharge

* Intraductal papilloma

* Triple assesment
- history + physical examination
-imaging studies
- tissue biposy

Done By: Dr. Ayman Hajeer

*
* 48 year old female
presented to the
outpatient clinic , C/O a
lump in her right breast

* Spot diagnosis
* Radiological features
suggestive of malignancy
* What do we mean by
BIRAD 5 ??

Done By: Dr. Ayman Hajeer

* cancer in the right breast , and also an unsuspected cancer in the
opposite breast

* 1.mass
2. with density greater than that of the normal breast tissue.
3. irregular, indistinct, speculations
4. calcifications
5. asymmetry , irregularity , architectural distortion
6. skin thickening , nipple retractions and changes
7. axillary adenopathy,

Done By: Dr. Ayman Hajeer

*

* a widely accepted risk assessment and quality assurance tool

in mammography, ultrasound or MRI. Part of the initial
implementation was to make the reporting of mammograms
more standardized and comprehensible to the non-radiologist
reading the report.
* The BI-RADS lexicon offers a number of strengths, including
the application of a standardized common language to
facilitate communication between radiologists, referring
physicians, and patients. The system also clarifies the
reporting of mammography results and will support the
completion of quality improvement activities and clinical
research.
Done By: Dr. Ayman Hajeer
Done By: Dr. Ayman Hajeer
Case 10

*What is your diagnosis ?

* and how would you approach such
patient ?

Done By: Dr. Ayman Hajeer

 * surgical complication and emergency in which
a wound ruptures along a surgical suture.

* Risk factors :
age, diabetes, obesity , poor surgical techniques
, subacute infection , smoking , previous
scarring , cancer , chronic use of steroids ,
increased stress to the wound area as a result
of strenuous exercise, heavy lifting, coughing .

*Abdominal Wound
Dehiscence
Done By: Dr. Ayman Hajeer
*
* It’s an emergency ! Take the patient to the OR right away for primary
closure ! “Treat as a new wound “
* Reassure your patient !
* While your patient waits to be transported to the OR, keep the wound
and organs covered with wet dressings
* Each time you moisten the dressings, inspect exposed viscera for signs
of ischemia or necrosis
* Don't try to push protruding viscera back into the abdomen.
* keep the patient in bed in a low Fowler's position—about 15 – 45
degrees. Flex the knees to reduce tension in the wound area.
* V/S , IV fluids , antibiotcs , NG tube
* Surgical debridement
* appropriate surgical technique and sutures.
* closely monitore the patient to prevent dehiscence from reccurring
* Frequent dressing
Done By: Dr. Ayman Hajeer
*

* Name the triangle of the neck in

which the lesion is situated:
__________________________

* Give two differential diagnoses for the

lump:
__________________________
__________________________

Done By: Dr. Ayman Hajeer

* Anterior triangle

* - lymph node
- lipoma
- Sialadenitis

Done By: Dr. Ayman Hajeer

Case 12

* What is the diagnosis:

___________________________
* Give two other complications of the
same pathology:
___________________________
___________________________

Done By: Dr. Ayman Hajeer

 * Bleeding per rectum due to hemorroids
“thrombosed “

* infection
bleeding
thrombosis

Done By: Dr. Ayman Hajeer

 Case 13

* Identify the lesion:

__________________________

* Give two symptoms which might be

associated with the condition:
__________________________
__________________________

Done By: Dr. Ayman Hajeer

 * Ischemic (arterial ulcer)

* -Claudication
- rest pain
- 6 p’s

Done By: Dr. Ayman Hajeer

*
* Name this sign ?
* What is the diagnosis

Done By: Dr. Ayman Hajeer

 *Double bubble sign

*Duodenal atresia

Done By: Dr. Ayman Hajeer

*
* Spot diagnosis ?
* How many weeks you need
to have such finding after
the 1st insult ?
* how we could
differentiate between the
acute and the chronic
form of this condition
radiologically ?

Done By: Dr. Ayman Hajeer

 * Pancreatic cyst

* 4 weeks

* Calcifications

Done By: Dr. Ayman Hajeer

 Case 16

* Identify this type of image:

___________________________

* Give two radiological findings:

___________________________
___________________________

* What is your diagnosis?

___________________________

* Mangement
Done By: Dr. Ayman Hajeer
?
 * MRCP

* CBD stone shadow, CBD dilation

* Ascending cholangitis

* Immediate decompression of the biliary tree

antibiotics !

Done By: Dr. Ayman Hajeer

 *
* Spot diagnosis (sign) ?

* Underlying problem
(disease ) ?

Done By: Dr. Ayman Hajeer

* Grey Turner’s sign

* Pancreatitis
- sign of retroperitoneal
hemorrhage
- cullen’s and turner’s signs
may be indicative of
pancreatic necrosis with
retroperitoneal or
intraabdominal bleeding

Done By: Dr. Ayman Hajeer

*

* Spot diagnosis ?
* Pathophysiology of this condition ?
* Management ?

Done By: Dr. Ayman Hajeer

* Achalasia

* The disordered esophageal motility of achalasia appears to be

due primarily to the degeneration and loss of ganglion cells
within the esophageal wall, a process that preferentially affects
inhibitory neurons. Loss of inhibitory neurons in the LES
causes basal sphincter pressures to rise, and renders the
sphincter incapable of normal relaxation

Done By: Dr. Ayman Hajeer

Done By: Dr. Ayman Hajeer
*

* The followings are pictures

of colonoscopy for 40 year
old male pt .

Spot diagnosis ?
 inheritance
 mangement ?

Done By: Dr. Ayman Hajeer

 * familial adenomatous polyposis

* the inheritance pattern is autosomal dominant,

with a faulty adenomatous polyposis coli (APC)
gene

* Colectomy

Done By: Dr. Ayman Hajeer

 *
45 y/o Asian male who works as a
shepherd ,presented to the ER
complaining of acute
exacerbation of right upper
quadrant pain for three days
duration associatd with nausea ,
vomiting , fever and jaundice .
On examination, there was right
upper quadrant tenderness and
hepatomegaly.

** spot diagnosis ?
** causative organ ?
** most common site
for this disease ?
** management ?
Done By: Dr. Ayman Hajeer
Laboratory analyses revealed
the following results:
Leukocytosis with eosinophilia
total bilirrubin - 2.3mg/dL
conjugated bilirrubin – 1.4
mg/dL
glutamyltransferase -400U/L,
alkaline phosphatase - 315
U/L.
 * Charcot’s triad of cholangitisdue to hydatid
cyst that had ruptured into the biliary tree
* Echonococcus granulosus , multilocularis ,
vogeli , oligarthus
* Liver , lungs ,any other organ …

Done By: Dr. Ayman Hajeer

 *
 leave inactive and asymptomatic cysts alone , monitor size by US

 Active cysts should first be treated by a full course of albendazole

 Surgical treatment ( PAIR )

puncture , aspration , injection , reaspiration .
After adequate drug treatment with albendazol (or paraziquantel )
-During operation , scolicidal agents such as
hypertonic saline , ethanol povidone iodine
 other procedures : pericystectomy with omentoplasty , hepatic
segmentectomy .

-Avoid peritoneal contamination !! So continue ttt with albendazole post

op , and add paraziquentel preop.

Done By: Dr. Ayman Hajeer

 *

Done By: Dr. Ayman Hajeer