FMG MARATHON

INTUSSUSCEPTION

• Telescoping of one segment of bowel into another

• More common in children of age 4-10 months
• MC type - ILEOCOLIC
• MC type in adults - COLOCOLIC
PARTS OF INTUSSUSCEPTION

• Intussusceptum- incoming segment

• Intussuscepiens- receiving segment
• Neck- narrowest part of intussusception
• Apex - most prone to gangrene
• Middle layer is most prone to gangrene because it is sandwiched between
outer and inner layer and has two acute bends
• MC lead point is Meckel's diverticulum › Polyps
• MC tumor responsible for intussusception in children – Lymphoma
• MC tumor responsible for intussusception in adults – Villous Adenoma
CLINICAL FEATURES

• At time of attack
o Child cries a lot, pulls legs towards abdomen
o Colicky pain
o Bilious vomiting (Multiple episodes)
• In between attacks, patient is asymptomatic
• After many attacks
o Passage of small amount of stools mixed with blood (Red current jelly
appearance)
ON EXAMINATION

• Sausage shaped mass in right lumbar region

• Empty right iliac fossa known as Sign of dance
INVESTIGATION

• Diagnostic + therapeutic - Enema (air › barium)

TREATMENT

• Air enema (Enema creates pressure by which there will be reduction of bowel
back to normal)
• For Recurrence - Air enema is repeated.
• If recurrence occurs for the third time - indication for surgery (Ileocolectomy +
Ileo- transverse anastomosis)
RADIOLOGICAL SIGNS
SIGMOID VOLVULUS

• MC Site of volvulus
• Volvulus can be both
o Anti- clockwise (MC)
o Clockwise
• Mandatory factors for volvulus
o Constipation
o Long narrow mesentery
CLINICAL FEATURES

• It is a type of Closed loop obstruction - Has signs & symptoms of LBO

o Colicky pain in lower abdomen
o Abdominal Distention
o Absolute constipation / obstipation
INVESTIGATIONS

• On X-ray
o Coffee Bean sign
o Bent Inner Tube sign
o OMEGA sign
INVESTIGATIONS

• On Barium enema
o Bird beak sign
o Ace of spade sign
o Bird of prey sign
TREATMENT

• TOC- Colonoscopic Detorsion

↓ followed by
Elective sigmoid colectomy (After 72 hrs)
CECAL VOLVULUS

• Misnomer - Cecocolic volvulus

• Has involvement of part of ileum,
cecum # Ascending colon
• Mainly clockwise
PREDISPOSING FACTORS

• Multipara patients (due to release of relaxin)

• H/O previous surgery (ligaments are divided)
• Malrotation (abnormal location of cecum which is free)
• Distal obstructing lesion (proximal part of colon distention leading to torsion)
CLINICAL FEATURES

• Has signs and symptoms of SBO (Because Twisting is at the level of ileum)
o Colicky pain
o Bilious vomiting
o Absolute constipation
INVESTIGATIONS

• IOC- Abdominal X-ray

• Findings
o Kidney bean sign
o Comma shaped cecum
TREATMENT

• leocolectomy + lleo-transverse anastomosis

INCISIONS

• Mc Burney's incision
o Incision centered on Mc Burney's point # perpendicular to umbilical ASIS
line.
o Aka Gridiron incision
o Aka Mc Arthur incision
o This is a muscle splitting incision
• Rutherford- Morrison incision
o In retrocecal appendicitis (appendix difficult to be visualized) extend the MC
Burney incision, upward $ laterally by cutting conjoint tendon.
o This incision is Muscle Cutting incision
o Preferred for retrocecal appendix.
• Lanz incision
o This incision is a muscle splitting incision placed transversely2cm below
umbilicus on the line joining midpoint of clavicle to midpoint of inguinal
ligament
o Aka modified Mc Burney's incision
o Aka Rocky Davis incision
o Aka Bikini incision
o Transverse skin crease incision
o Preferred nowadays
q Better exposure
q Easier extension
ABDOMINAL WALL DEFECTS

Omphalocele
• Intestine fails return to the
intra-abdominal cavity
• Covered by 2 layers
o Amnion
o Peritoneum
GASTROSCHISIS

• Splitting of abdominal wall from right side

with herniation of bowel.
• Bowel is exposed, not covered and becomes
thickened, matted and edematous
• Associated with Intestinal atresia Risk factors
STONE CRYSTALS
STONE CRYSTALS
STONE CRYSTALS
STONE CRYSTALS
STONE CRYSTALS
BLADDER RUPTURE

• 2 types
o Extra- peritoneal (responsible for 80% cases)
o Intra- peritoneal (responsible for 20% cases)
EXTRAPERITONEAL BLADDER RUPTURE

• Caused by - Road traffic accident

• RTA causes Pelvic fracture ↓ leads to Extra-peritoneal rupture of bladder and
Posterior Urethral injury
CLINICAL FEATURES

• Suprapubic pain
• Difficulty in passing urine
• Hematuria
INVESTIGATIONS

• IOC - CT cystography/ Cystogram

• Findings
o Flame sign
o Pear sign
o Tear drop bladder
MANAGEMENT

• Foley's catheterization
• Spontaneous healing within 7-10 days
INTRA PERITONEAL BLADDER RUPTURE

• External blow/ kick to full bladder may lead to intraperitoneal bladder rupture
• MC in Males
CLINICAL FEATURES

• Suprapubic pain
• Difficulty in passing urine
• Hematuria
• Peritonitis
MANAGEMENT

• Exploratory Laparotomy + Peritoneal lavage + Repair of defect + Suprapubic

catheter / Foley's catheterization
HYPERTROPHIC SCAR KELOID
 Hypertrophic Scar
Genetic • Not Familial
Race • Not race related
Sex • Females = males
Keloid
• May be familial
• More common in
Blacks > whites
• Females > males

Age • Children • 10 to 30 years

Border • Remains within the wound • Outgrows wound area

Sites • Flexor surface • Sternum

• Shoulder
• Face
Etiology • Related to tension • Unknown
Development • Within 4 weeks • 3 months to 1 year
Clinical • Raised • Pain
findings • Some pruritis • Pruritis
• Respects wound confines • Grows beyond the
wound margins
Histology • Parallel orientation of type • Thick wavy type I & III
III collagen fibers collagen in random
EDH SDH
EDH SDH
EDH SDH
TENSION PNEUMOTHORAX
PATHOLOGY

1. Collapse of Ipsilateral lung

2. Shift of Mediastinum (Due to High pressure)
3. Depressed Diaphragm
4. Decreased venous return (Due to compression SVC ¢ IVC)
• Mediastinum
o Displaced to opposite side
o Decreased venous return & compression of opposite lung
INVESTIGATION

• Diagnosed clinically
TREATMENT

• Emergency treatment - Put a large bore needle into 2nd I/C space in
Midclavicular line
Note
• According to ATLS manual 10*edition - Recent evidence supports placing large
bore needle in 5th I/C space slihtly anterior axillary line

• Definitive Rx/ TOC- ICD insertion in Triangle of safety (5th V/C: space in
Anterior-axillary line)
ABDOMINAL TRAUMA

One liner on Abdominal trauma

• Most commonly injured organ in BTA - spleen › liver
• Most commonly injured organ in penetrating trauma - liver › stomach> SI
• Most commonly injured part of bowel in BTA – Jejunum
• Most commonly injured organ in Gunshot injury - Small intestine
• Most commonly site of injury in deceleration injury -Duodenojejunal junction
• Most commonly injured structure in seat belt injury - Mesentery
• 1st inv. Done in patient of BTA – FAST
• Gold standard investigation for stable patient of BTA – CECT
FAST (Focused Assessment with Sonography for Trauma)
• It is an Emergency ultra sound i.e. performed
very fast Lin 2 - 4 minutes]
• Assess Potential sites of thoracoabdominal
injuries(4P’s)- Pericardial sac
o Perihepatic region
o Peri-splenic region
o Pelvis
• 4 traditional views in FAST
e-FAST (extended FAST)
• Has two additional views(so, has a total of 6 views)
o Right thoracic view
o Left thoracic view
THANK YOU