Faculty of Medicine

University of Khartoum
Batch 89 - Qayasir

SURGERY SHEET

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‫‪Preface‬‬

‫‪- These Notes are gathered from different sources by Hazim‬‬

‫‪Eldirdiri, Qayasir 89 Batch (2018):‬‬
‫‪o Al-Kasr Al-aini Surgery Book, 8th Edition‬‬
‫‪o Ellis Lecture Notes of General Surgery, 13th Edition‬‬
‫‪o Surgical Club Sheet – Qasawir – UofK‬‬
‫‪o Churchill’s Pocketbook of Surgery, 4th Edition‬‬
‫‪o Clinical Rounds and Mr. Suliman Hussein and Dr. Adil‬‬
‫‪ibrahim Tutroials during 6th Year‬‬

‫‪- Any mistakes in this notes, are not intentional‬‬

‫‪* -‬تنبيه مهم‪ :‬بأي حال من األحوال‪ ،‬ال يعتبر هذا الشيت بديال عن المراجع األساسية للمادة‬
‫والمحاضرات‪ .‬رجاء أال يستخدم كمرجع أساسي‪ ،‬بل كمادة للمراجعة بعد المذاكرة من المرجع أو‬
‫المحاضرة‪،‬‬
‫كتبه‪ :‬حازم الدرديري‬

‫‪ -‬كتابة وورد‪ :‬حازم الدرديري – ساجدة صالح ‪ -‬أحمد ابو شمال ‪ -‬محمد دلدوم ‪ -‬هيثم محمد قرشي ‪-‬‬
‫إسراء حمزة ‪ -‬شهد اسماعيل ‪ -‬تسابيح ابراهيم ‪ -‬اية الطيب ‪ -‬إيمان المرضي ‪ -‬آالء اسماعيل ‪-‬‬
‫الشيماء شهاب ‪ -‬سارة موسى ‪ -‬سهى سيد احمد ‪ -‬هبة فاروق‬

‫‪ -‬راجعه‪ :‬مروة محمد الرشيد – علي سيف الدين – ساجدة صالح – لينا يحيى‬

‫‪ -‬تنسيق‪ :‬حازم الدرديري – ساجدة صالح‬

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 Contents
Esophagus ..................................................................................................................................................... 6

Stomach ...................................................................................................................................................... 10

Intestinal Obstruction ................................................................................................................................ 14

Small and large bowel ................................................................................................................................. 20

Colorectal cancer......................................................................................................................................... 25

Stoma .......................................................................................................................................................... 28

Rectum ........................................................................................................................................................ 30

Anal canal ................................................................................................................................................... 32

Lower GI Bleeding ....................................................................................................................................... 37

Upper GI Bleeding ....................................................................................................................................... 39

Appendicitis ................................................................................................................................................. 42

Peritonitis ................................................................................................................................................... 47

Pancreas ...................................................................................................................................................... 50

Biliary disease and jaundice ....................................................................................................................... 58

Obstructive jaundice .................................................................................................................................. 63

Breast .......................................................................................................................................................... 69
Thyroid ........................................................................................................................................................ 84
Scrotum....................................................................................................................................................... 96

Hernia ....................................................................................................................................................... 102

Urology ..................................................................................................................................................... 108
Pediatric surgery ...................................................................................................................................... 128
Vascular Surgery ....................................................................................................................................... 135
FLUIDS AND ELECTROLYTES ..................................................................................................................... 149
Preoperative & Postoperative Care ......................................................................................................... 154
BLOOD TRANSFUSION .............................................................................................................................. 160
Shock ......................................................................................................................................................... 161
Trauma...................................................................................................................................................... 166
CHEST TRAUMA ........................................................................................................................................ 168
Abdominal trauma ................................................................................................................................... 173

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Neurosurgery & Head Injuries ................................................................................................................. 178
Cleft lip and palate ........................................................................................ Error! Bookmark not defined.

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 Esophagus

1) Boerhaave syndrome:

- perforation of esophagus → mediastinitis

- Following severe vomiting, trauma or iatrogenic “eg.Endoscopy”.

- Dx: Chest X ray/CT “better gastrographin swallow”

- Emergency TX by repair.
2) Mallory Weiss syndrome:

- Forceful vomiting followed by hematemesis→ Alcoholic/ hyperemesis gravidarum.

- Tx : antiemetics
3) GERD:

- Episodic relaxation of LES. “risk factor: hiatus hernia; sliding and rolling types”

- C/F: Typical: Heartburn, epigastric pain, regurgitation, reflux, water brush.

Atypical: chest pain/ wheeze/ cough

- Inv. : -Endoscopy to confirm + biopsy

-24 hr pH monitoring “pH <4 in multiple episodes” → Gold Standard Test
-Barium swallow & meal to detect hiatus hernia

- Mx: 1- life style modification weight loss- elevate bed- stop smoking, alcohol and
coffee.
2- Drugs: PPI (omeprazole), prokinetics.
3- Surgery: Nissen’s fundoplication (360⁰ complete wrap)
- Complications of GERD:
i. ulceration (reflux esophagitis)
ii. Stricture (dysphagia & odynophagia)
iii. Iron deficiency anemia
iv. Barrett’s esophagus (metaplasia; precancerous to squamous cell CA)
Metaplasia “follow up annually → low grade dysplasia “local ablation or diathermy” →
high grade dysplasia “resection; oesophagectomy”

 Esophageal Achalasia:
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 - Failure of relaxation of lower esophageal sphincter due to absent myenteric plexus.
- C/F: Dysphagia: progressive, fluid then solids then absolute. “dysphagia for many years”
Wasting, odynophagia, chest pain.
NB: Progression of dysphagia doesn’t differentiate; it is better to judge by the time
period of the dysphagia.
- Invx:
1- Barium Swallow showing proximal dilatation and smooth distal tapering “Rat-Tail
Appearance” or “Bird-peak appearance”
2- Manometry showing Absent Peristalsis; and Increased LES resting tone
3- Upper GI Endoscopy: variable degrees of esophageal dilatation with food residues;
failure to pass with Biopsy to exclude malignancy

- Mx: There are 4 modalities

1- Medical with CCB; Botulinium Toxin and Nitrates
2- Serial Endoscopic Pneumatic Dilatation
3- Endoscopic Per oral Myotomy (POEM) >>>>>> BEST
4- Surgical laparoscopic Heller’s Cardiomyotomy with Partial fundoplication

* Complications: perforation,
* Pseudoachalsia: same in barium, but its cancer.
* Nut cracker esophagus: Diffuse spasm
Ttt: Heller’s myotomy + fundoplication

 Esophageal cancer:

SCC (Most common) Adenocarcinoma

Upper 2/3 Lower 1/3

Risk factor: Achalasia Risk factor: GERD, Barrette

Risk factors and causes: Smoking, alcohol, smoked food (nitrates), hot drinks, achalasia,
Plummer Vinson syndrome.
C/F: Mostly no visible signs

- Dysphagia (Painless & Progressive) → solid followed by liquids → absolute.

- odynophagia, severe wt loss, anorexia, dehydration

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 - + Symptoms of mets: local (trachea, lung, heart),
 LN (St. Mary Joseph Nodule) liver.
Invx. : 1- Barium swallow → shouldering “Remember; it is not done as a routine; only in
exam – endoscopy is a must”
2- Endoscopy → showing mass and for biopsy
3- If confirmed → CT scan for staging “TNM” chest, abdomen, and back. And assessing
for operation... Also Endoscopic US is used for staging.
*NB: General Invx for the general condition of the pt:
Hb (anaemia), WBC, ESR (high).

-U&E->problem of dehydration, hyponatremia and hypokalaemia.

-LFT->mainly the albumin (for anastomosis, and performance of the pt).

-> (in surgery, the 2 most important are potassium and albumin).

-RBS->asymptomatic diabetic.

-Hepatitis screen->for the sake of the staff and you as well.

Mx: Dependent on Acute or not; Curative or Palliative; Operable or not

1- Resuscitation
2- feeding jejunostomy tube (↑BMI) / Total parenteral nutrition “initially you have to
determine BMI for fitness of patient”
3- After staging by CT and EUS,
 If operable: surgery: OSPE! See Pics
o 1- Iver Lewis (lower 1/3 tumors; 2 incision (laparotomy + rt. thoracotomy)
o 2- McKowen’s operation (upper 2/3; 3 stages (midline laparotomy + rt.
Thoracotomy + central cervical).
o 3- Trans-hiatal
{Stomach becomes esophagus in these surgeries}
4- Highly selective Vagotomy (to prevent acid)
- 5yrs survival is 25%.
- Post-surgery we do Epidural Analgesia to relieve pain
- Complications: leak/ thoracic duct/RLN injury/ cardiac/ resp.

- Palliative options:
Most esophageal cancers pts. Present at this stage
Options:
 Self-expanding metallic Stenting [BEST]

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  Percutaneous endoscopic gastrostomy [PEG tube]
 Feeding Jejunostomy [immediate measure for total dysphagia]; done till patient fit for
other palliative option
 Chemotherapy
 Radiotherapy
You will be asked about the best option and why!

 Dysphagia causes in esophagus:

- Extra luminal: Retrosternal goiter, LN, tumor
- Intramural: cancer, achalasia , stricture
- Intraluminal: Zenker’s diverticulum, Plummer Vinson syndrome, Foreign body

Dysphagia is common in OSCE history; see Surgery OSCE sheet

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 Stomach
- H. pylori: peptic ulcer/ gastric carcinoma/ gastric MALToma/ chronic gastritis type B (type A =
pernicious anemia) Type A is associated with gastric carcinoma —> so ulcer+
 Peptic ulcer: achlorohydria suspect malignancy and take biopsy
- Commonly: lesser curvature of stomach, 1st part of duodenum
- Others: lower esophagus, jejunum (gastro-jejunostomy), Ileum (Meckel’s diverticulum)
Gastric: defective protective mechanisms (NSAIDS/smoking)
Duodenal: ↑HCL/ H.pylori in 90%. Blood group O peptic ulcer
Blood group A gastric cancer
N.B: - Gastrinoma: ↑HCL -> multiple, resistant, distal, recurrent ulcers
- Stress ulcers: Curling (burn), Cushing (↑ICP)
Clinical features:
- Duodenal: elderly, hunger pain, relieved by food
(Anterior ulcer: perforates/ post. ulcer: bleed; UGIB)
- Gastric: young, pain upon meal
- Nausea, vomiting, hematemesis, IDA, Acquired pyloric stenosis

Dx: 1\ Urea breathe test 2\ Endoscopy &biopsy (diagnostic)

3\ stool antigens
Mx: Life style modification + Eradication therapy + follow up after 6 wks.
Surgery: (if intolerable/ or complicated)
- If Gastric: Billroth gastrectomy [1&2]
- If Duodenal: -Truncal vagotomy + pyloroplasty
-Highly selective vagotomy (spare nerve of Latarjet)
Complications of gastrectomy:
- Diarrhea
- Dumping syndrome (fainting, vertigo, sweating, hypotension “early”, & hypoglycemia
“late”) give somatostatin. Don’t treat immediately (after 2 month) cause may
- Early satiety resolve spontaneously
- Iron deficiency anemia
- Recurrent ulcers
- Cancer
- Gall stones “due to vagotomy” Cutting hepatic branch

*gastric ulcers: Antrectomy+ Roux-en-y gastroenterostomy

 Pyloric Stenosis: Due to obstruction, complication of ulcer; healing by fibrosis.

C/F: (Gastric outlet obstruction)

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 - Non bilious projectile vomiting
- metabolic alkalosis , hypochloremia, hypokalemia & paradoxical aciduria
- dehydration, wasting
Metabolic abnormality: hypochloremic hypokalemic metabolic Alkalosis. (Kidneys excrete
NaHCO3 to compensate alkalosis, then H+ gets diluted...)
(Fibrosed healed peptic ulcer: 1\ abnormal distention 2\ visible peristalsis from Lt to RT 3\
succession splash 4\Hypertrophied Abdomen)
O/E: Very important
- Abd. Distention + visible peristalsis [children] + splash sound 2-3 hrs postprandial on
auscultation
Invx: 1\ Endoscopy 2\ Barium meal
Others: ABG, U&E, urinalysis, LFT, CBC, CT scan
Mx: NG tube, suction and give fluids, electrolyte balance
Surgery:
- Pyloroplasty/ [antrectomy + Roux-en-y gastrectomy]
- Gastrojejunostomy + vagotomy

 Perforated peptic ulcer: [DDx: is Acute Pancreatitis] Acid burning (chemical peritonitis)
- C/F: Sudden severe sharp stabbing epigastric pain for few hrs, & vomiting.
The pain disappears
- The pain disappears, then generalized gradual epigastric pain. by dilution (secretions)
- Why? Sudden pain due to perforation => chemical peritonitis by HCL. Then dilution
“disappearance of pain”. Then bacterial peritonitis “sepsis and death”
- If pt presents late, pain may be at RT iliac fossa & generalized peritonitis.
Bowl sound silent because of paralytic ileus (peritoneal irritation)
Examination: board-like rigid abdomen/ tenderness/ diminished liver dullness/ PR: pelvic
tenderness
Invx: i- Erect CXR with Abdominal View: air below RT side of diaphragm
Ii- CT scan (best)
Iii- Serum amylase-> to exclude acute pancreatitis
 D.D of air under diaphragm:

- Perforated viscous (perforated peptic ulcer)

- Post-operative (laparoscopy)

- Sub-phrenic abscess

- External trauma

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 D.D of perforated peptic ulcer is acute abdomen:

- Perforated appendicitis

- Acute cholecystitis

- Acute pancreatitis
Mx: Stabilize and resuscitate:
1) Admission, O2 to correct saturation & RR; & ventilation if severe .
2) 2 Wide bore cannula for Blood baseline investigations (CBC, RBG, LFT,
3) coagulation profile & blood cross-matching)
4) -IV fluids & correction of electrolytes, urinary catheter for monitoring ,
5) -NPO, Nasojejunal tube for nutrition.
6) -IV antibiotics (Meropenem)
7) -IV Analgesia (Pethidine)
8) - IV PPI to guard from ulcer.
Definitive:
** Emergency open laparotomy; Suction by lavage of peritoneal cavity Then suturing + omental
patch (If in stomach: biopsy) followed by medical management of peptic ulcer
- Injectable PPI after surgery
- Upper endoscopy after 6 wks
*other complication-> Hematemesis

 Gastric Carcinoma:
- Very poor prognosis – Japan - high socioeconomic status - chronic gastritis (A) - blood
group A – smoked food (nitrates) – Alcohol – adenomatous polyposis of stomach.
- C/F: early satiety + epigastric pain + ALARMED symptoms
- ** spreads to : 1) Virchow’s node 2) sister Mary Joseph nodule 3)migratory
thrombophlebitis & Liver mets
- Types: - Ulcer - Polyp - Diffused ( Linitis plastic )
- Endoscopic signs of bleeding: (if Hg<9 = blood transfusion)
1. Oozing blood
2. Fresh clot
3. Visible vessel at base of ulcer
- Ttt: if early:
 Distal: Billroth type II
 Proximal: total gastrectomy + radical lymphadenectomy + esophago-
jejunostomy
 Roux-en-y operation
If late: palliative care-> 1.Stent 2.Gastro-jejunostomy
 N.B: if female, mets to ovary [Knuckenberg’s syndrome] by trans-celomic metastasis.
(Ovarian mass).

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  N.B: Zollinger-Ellison syndrome: Tumor in pancreas causing peptic ulcer in stomach &
multiple ulcers – MEN 1.
Remove CA pancreas.

SO:
 Gastric Outlet Obstruction:
- Dx: DDx:
1) Fibrosed healed peptic ulcer
2) CA stomach
3) CA head of pancreas
4) Chronic pancreatitis
5) Invasion by malignant nodes
6) Gastroparesis
C/F: Vomiting following meals by 4-6 hours; offensive and large amount. Along with the
causative history.

- Hx: long hx of peptic ulcer → benign

Short hx & painless: CA stomach
- Gross dilation of stomach → benign
Palpable stomach mass → malignant

O/E:
 Visible peristalsis from lt. hypochondrium to umbilicus
 Palpable stomach
 Succession; Splash
Then findings O/E of the cause

Invx in the blood:

1- CBC for anemia
2- Urea & Electrolytes: High urea & Hypokalemia, hyponatremia & hypoCl
3- LFT: Albumin
4- Arterial Blood Gas: for metabolic Alkalosis

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 Intestinal Obstruction
Restriction of normal passage of intestinal content
Mechanical .v.s Paralytic

Mechanical Intestinal Obstruction Approach:

 Know source of Colic? * Cardinal Sympts. Of Small and large bowel obstruction
C\F:
1) On\off abd. Colicky pain 2) vomiting 3) absolute constipation 4) abdominal distention
N.B. any tube obstructed→ proximal dilated, distal collapsed

So when approached answer the following:

1. Is it obstruction or not? 2. Simple or Strangulated? by markers
3. Proximal or distal obstruction? Order of sx.
4. Possible Cause?
5. Initial Invx.?
6. Further Invx. & Management?

Order of symptoms:
- In small intestines: 1. early vomiting 2. Pain around umbilicus 3. Late constipation 4.
Small distention
- In large intestine: 1.early constipation 2. Big distention 3. Pain “lower abdomen” 4. Late
vomiting
N.b: if vomiting is large amount and with fluid deficit >> think about is it GOO or not?
O/E:
- Vitals for signs of dehydration and shock PR is important
- Distention (small :small bowel/ big: large bowel)
- Pain, dehydration (3rd space loss-> hypovolemic shock)
- Tender abdomen
- Hyper-resonance of abdomen “tympanic”
- Exaggerated bowel sounds on auscultation -> 10 per min Normal 3-5
- Guarding and Rigidity Exaggerated at start then will be decreased
N.B. do PR; empty rectum -> mechanical or absent
*Absolute constipation: no stool, no flatulence
*If Richter’s hernia, gall stone ileus or CA-> no absolute constipation
Causes strangulation not obstruction (small hernia)
N.B: Markers of strangulations: >> Indication for immediate surgery
- Change in pain character from colicky to continuous
- ↑ Pulse, ↑ Temp, ↑ (Inflammatory markers: CRP, Leukocytosis)
- Bowel Sounds Decrease or become Absen
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 Causes:
Adhesions and hernia in Tumors and volvulus in
- Extraluminal (AHIV): small bowel large bowel
Adhesions (most common cause), Hernia “2nd most common”, intussusception, volvulus.
- Intramural: tumor “benign, malignant, lymphoma”, stricture “post-operative, Chron’s,
TB , radiation”
- Intraluminal: gall stones “gall stones ileus”, worms “ascaris”, forign bodies

**Adhesions & hernia are the 2 most common causes.

1) Adhesions: single band (serious; needs surgery), or complete fibrous tissue
Caused by: post-operative (previous surgery), peritonitis
2) Hernia:
- External: inguinal, femoral, umbilical,
- Internal: retrocecal recess/ epigloit foramen to lesser sac (CT or intraoperative)
3) Intussusception:
- Bowel inside each other, proximal inside the distal bowel -> excessive peristalsis due
to a lead point (LN “commonest in winter, children with URTI”, appendix, Meckel’s
diverticulum).
- It’s common in children, if adult think of tumor.

- If lead point is appendix → ileoceacal intussusception ileocolic

If Meckel’s → ileo-ileal intussusception Sausage shape mass
If tumor → -> colo-colic
Current gelly stool in intassusseption
- It can be ileo-ileo-colic/ gastro-colo-colic
- Apex intussusception [reversible rectal prolapse] -> children’ poor prognosis, chronic.
N.B: narrowest area from ileum is >> 2 feet from ileoceacal junction; gall ileus adhesions of
gallbladder with intensive inflammation leading to cholecystoenteric fistula
4) Volvulus: twisting of bowel around mesentery
- Can obstruct blood supply-> ischemia Risks of volvulus (constipation &
- Due to : 1\ chronic constipation (in elderly) long mesentry)
2\ redundant mesentery
- 90% in sigmoid colon (mobile, long, redundant)
- A disease of elderly Recurrent attack of obstruction
- Dx by X-ray; inverted “U” sign.

**young: Adhesions/hernia, elderly: volvulus

C/F of intussusception: important in Pediatric Surgery Intussuseption sign in X-Ray (Clow sign)
Contrast enters the proximal part

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 - Child, colicky abdominal pain (episodic screaming attacks), drawing legs to abdomen.
- Blood & mucous in stool (cherry jelly stool) → bad sign
- One side is empty, other side is bulging or mass (sausage shape)
- Dx by abd. US → target sign.
- Apex intussusception can be found

C/F of volvulus:
- Elderly, recurrent attacks of large bowel obstruction. Anti-clockwise

 Complications of intestinal obstruction:

1) Hypovolemic shock 2) Strangulation & ischemia
3) Electrolyte imbalance & renal failure (↓K+ refractory)
Dx and Invx:
1- General investigations: CBC and Bleeding Profile, LFTs, RFTs, U&E, RBG
2- Abd X ray (erect & supine): See Pics N.b: Supine is the important one
N.B: normally in X-ray there is Air-fluid level in Stomach, 1st part of duodenum and cecum.
- Erect: - Multiple air-fluid level > 3 levels
- In small bowel obs: central Erect X-ray is not routinely done
- In large bowel obs.: peripheral
- Supine: Haustrae in large bowel obs.
Jujenum - Volvulae conniventes in small bowel obs.
- Cecum dilated in large obs, collapsed in small.
- If volvulus; inverted U sign [coffee bean sign]
- X ray not useful in intussusception

3- Abd. US:
- For intussusception -> target sign
 In X ray, opacity in Rt iliac fossa, central level, air in biliary tree -> cholecysto-enteric
fistula
 Rigler’s triad of gall stone ileus : opacity “gall stone outside biliary tree”, small bowel
obstruction, pneumobilia Rigler’s sign is when wall of intestine visible in both
sides when there’s air outside
4- CT abdomen: closed loop obstruction
Competent In incompetent valve with large bowel obstruction.
- Risk of perforation -> emergency
(Collapse- dilation- collapse)
5. Gastrographin water soluble studies: to see if complete or partial obstruction?

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Indications of conservative treatment in intestinal obstruction:
1. Distinction between paralytic ileus & mechanical is hard
2. Repeated obstruction due to massive adhesions
3. Chronic large bowel obstruction

Mx:
1. Resuscitation: Admission & NPO & Monitor vitals with vital chart. & NG tube for suction
2. Insert 2 wide bore cannula for blood investigations (Blood grouping & Crossmatching
&Coagulation profile; CBC, LFTs)
3. IV Fluids, correction of electrolytes & Urinary catheterization for output monitoring
4. IV analgesia; IV antibiotics Cephalosporins & Metronidazole
5. After resuscitation; do Investigations to know the cause & treat
NGT: mandatory for suction:
i) Can relieve obstruction (adhesions)
ii) Suction prevents aspiration

 If adhesions: conservative -> follow up, if no improvement in 3 days “2wks in ICU” ->
surgery (Adhesiolysis) Only the adhesion that cause the obst not all
 If intussusception: remove it, see if dead or not
[MBC PPC: 1. Mobility “peristalsis” 2.Bleeding 3.Color
*Pressuring *Peritoneum *Consistency]
If dead: resection & anastomosis
If healthy: leave it/ warm gauze & repeat after 10 min, if still in doubt -> resection
If elderly: resection & anastomosis
 If volvulus -> untwisting, sigmoidopexy (risk of recurrence)
Or Sigmoidectomy & colostomy.
 If gallstone ileus: enterostomy(emergency) and fistula (elective)
N.B. pt should be fasting after surgery, until return of bowel sounds
N.B. paralytic ileus: symptoms of intestinal obs after surgery -> non mechanical
obstruction (fully dilated bowel & full rectum) -> conservative Mx
- If in large bowel -> pseudo obstruction [Oblief syndrome]
- PR: rectum collapsed-> mechanical, rectum full-> non mechanical obstruction.

(N.B: Pexy>> Fixation; Ectomy >> removal; omy>>> open)

 Mesenteric ischemia:
- Presents as intestinal obstruction (SMA), acute abdomen.
- Acute: irregular pulse (AF)-> thromboembolism ,

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 -
All midgut pt C/F of severe periumblical continuous pain, very tender abdomen,
distention, constipation & vomiting.
- DX: - Duplex - Emergency CT abdomen - Mesenteric angiography
- Mx: Resuscitation + lots of IV fluids + Heparin. Then Embolectomy & resect dead part.
- Complication:
 Entero-cutaneous fistula
After resection  short bowel syndrome (malabsorption for few months-> die) Mx -> TPN by central
line
 N.B small intestine is 4-6 m long, resection should leave ≥1 meter .less is incompatible.

 TPN complications:
- Line ( sepsis/ bleeding/ hemothorax/pneumothorax)
- Solution ( hypoglycemia with sudden removal of TPN)
- Gall stone formation
- thrombosis
 If chronic→ pain with exertion (post prandial angina) intestinal claudication.

Paralytic Ileus: *Functional Int. Obstruction

Atonic bowel; all C/O of intestinal obstruction except Pain
Causes:
1. Following surgery / Post-peritonism (resolves in 3-5days) (m.c.c)
2. Sepsis
3. Biochemical: (Severe Hypokalemia/ Uremia / Diabetic Coma)
4. Drugs (anticholinergics, opiates)
5. Spinal injury Oglive (pseudo obstruction) large bowel
 Clinically:

- Intestinal obstruction but no pain

- Important to differentiate from mechanical obstruction:

 It rarely last more than 5 days
 absence of pain relatively
 absence of bowel sound

- Absolutely silent abdomen is diagnostic

- Abdominal X-ray: presence of gas through small and large bowel

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 Management: Conservative

- NPO

- NG Tube for suction

- IV Fluid

- IV antibiotics, Analgesia, catheter

- If it is stubborn, give Metaclopramide + Erythromycin to increase motility

 Prevention:

- Preoperative correction of electrolytes

- Gentle handling of bowel during operations

- Regular Gastric aspiration

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 Small and large bowel

Notes:

Embryological origin:

Foregut: Stomach, Duodenum until ampulla of vater / Supplied by celiac artery / Epigastric Pain

Midgut: 2nd part of duodenum till distal transverse colon / Supplied by Sup. Mesenteric / Periumblical
pain

Hindgut: Colon, rectum and upper anal canal / Supplied by Inf. Mesenteric a / Hypo gastric Pain

Layers: Mucosa / Submucosa / Muscualris / Serosa

Intraperitoneal Organs:- Stomach, Spleen, Liver, Duodenum bulb, jejunum, ileum, Transverse Colon,
Sigmoid Colon.

Retroperitoneal organs: - Duodenum, cecum, Asc. Colon, Desc. Colon, Pancreas, Kidneys

Colon is 5-6 inches long; divided into right and Left Colon

Right Colon: Cecum, ascending, Hepatic Flexure, and Proximal Transverse Colon

Left Colon: Distal Transverse, Splenic Flexure, Descending, Sigmoid colon, rectosigmoid

Rectum: 12-15 cm in length / Upper and Lower Parts /

Invx of Large Bowel: CT abdomen / CT Angiography / Barium Enema /

Anoscope: 10 cm long / Proctoscope: 13 cm / Sigmoidoscope: 30 – 60 cm / Colonoscope: 120-150 cm

 Carcinoid tumor:

- Benign tumor arises from enterochromaffin cells.

- Terminal ileum & appendix ( most common site ) yellowish mass

- Produce serotonin (hot flushes, diarrhea ‘’ carcinoid syndrome’’, bronchospasm, wheeze).

- Mets : liver & lung

- TX: <1 cm local resections.

>1cm extensive resection [right hemicolectomy + or- liver mets].
Dx:
1- CT-Abd. 2- 5-HIAA in urine.
Hydroxy Indol Acetic acid
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  IBD :

- Chronic/ relapse & remission disease/ young male

- Crohn’s/s disease and ulcerative colitis.

- Cancer in UC  prophylactic colectomy

Crohn’s disease UC
Mouth to anus Ulcers in mucosa
Rectal sparing Abscess in submucosa bloody mucoid
diarrhea and tenesmus
Anal
Strictures and fistulae
Mouth to anus ‘’ apthous ulcer /
dysphagia / ulcers in small bowel’’
RIF mass

Complication of IBD
1- Medical: iritis/ scleritis/ uveitis EN/ pyoderma gangreonosam PSC/AIH ankylosing
spondylitis
2- Surgical:

- UC: 1- perforation. 2- Massive rectal bleeding. 3- Cancer (CCa if low grade / local
ablation if high grade).

- 4- Malabsorption. 5- RIF abd. Mass. 6- intestinal obstruction. 7- Toxic mega colon

(severe colon inflammation & dilation (serial x-ray monitoring) conservative Mx or
surgery.
Dx:

- General: CBC/ Protein/ CRP.

- Specific: 1- barium enema (lead pipe sign).

2- PR/ sigmoidoscopy/ colonoscopy biopsy if cancer suspected.
Tx:

- Medical [ aminosalycates  methalazine/ sulphasalazine] + steroid

- If emergency methylprednisolone inj.

- If fistula infliximab injection.

- If medical failed surgical

| P a g e 21
 - Total colectomy & ileorectal anastomosis or & ileostomy & rectal stump

- If rectum  total procto-colectomy + ileoanal anastamosis ( widen ileum)

N.B: most common site for left side intestinal obstruction: colon 21%, sigmoid 17 %, splenic
flexure 15%.

 Angiodysplasia:

- Capillary Hemangioma in bowel wall.

- Usually in ascending colon.

- Sub mucosal lesion > massive rectal bleeding.

- Missed in colonoscopy.
Dx: by 1- CT-Abd. With contrast. 2- Mesenteric angiography.
TX: Laser/ diathermy/ cautery, if massive bleeding resection.

Most common cause of rectal bleeding in elderly is

 Diverticular disease: Diverticular disease
Diverticulum terminology (From Ellis)
True diverticulum: An outpouching covered by all the layers of the bowel wall (e.g.
Meckel’s diverticulum, jejunal diverticulum
False diverticulum: Lacking the normal muscle coat of the bowel (e.g. colonic diverticula)
Diverticula: Plural of diverticulum
Diverticulosis: The presence of (usually colonic) diverticula
Diverticular disease: Complicated diverticulosis
Diverticulitis: Inflammation of a diverticulum

True: Congenital: Single/ small int [ileum]/ full thickness. (Meckel’s diverticulum).
False: Acquired: Multiple/ colon/only mucosal herniation. (Diverticulosis). Mainly sigmoid colon
left iliac fossa.
Meckel`s diverticulum is antimescentric.

| P a g e 22
Meckel`s has rule of 2:

- 2% of pop. _2 inch in length. _ 2 feet from ileoceacal valve.

- 2 types of tissue: ectopic gastric/ pancreatic.

- 2 complication: inflammation, perforation/ rectal bleeding. + Obstruction

- It is D.Dx of acute appendicitis:

-
Meckel’s diverticulitis: periumblical pain, shifting to RIF, perforation, massive bleeding in
children.
Massive rectal bleeding:

- Adult’s  diverticulosis. There is dudenal & Jujenal diverticula

-Children  Meckel’s diverticulum
Also cause:

-Intussception & intestinal obstruction by adhesive band.

Dx of Meckel’s Diverticulum:

- Meckel`s techitium T99 scan

Tx:

- Wedge excision & bowel anastomosis

- If found incidentally  only if wide base > 2 cm or longer than 5 cm  resect.

 Diverticulosis:

- Multiple/ mucosal/ large bowel. In sigmoid colon 90% / jejunum malabsorption.

Acute Diverticulitis:
If inflammation &symptomatic  diverticulitis (acute abdomen) severe LIF abd. Pain +
tenderness + guarding + rigidity. + Sigmoid colon mass  Hence Named >> left sided
appendicitis.

Chronic Diverticular disease: D.Dx Colorectal Ca

C/F: 1. Change in bowel habits 2. Large bowel obstruction 3. Blood and mucus per
rectum 4. Massive Rectal bleeding (Elderly, bright red, hypertensive pt)

O/E: LIF Tenderness + thickened mass in sigmoid colon side felt on PR

| P a g e 23
Comp:

- Acute: 1- perforation. 2- Fecal peritonitis (laparotomy & peritoneal lavage) resect &
colostomy + Hartmann’s.

- Chronic : 3- fistula  perianal MRI is the inv of choice in perinatal fistula

{Fistula in ano}
Colovesical fistula  fecaluria and pneumatourea.

4- Massive rectal bleeding in adults (m.c.c)

5- Intestinal obstruction.
N.B: saint`s triad: Diverticulitis+ cholecystitis + GERD [esp. hernia]
Gallstones Hiatus hernia
Invx:
- CT Abdomen: Best in Acute stage; shows thickened colonic wall
- Sigmoidoscopy, Colonoscopy
- Barium enema (Double Contrast): Saw teeth Appearance (Contraindicated in acute
Diverticulitis)
- CT Colonography (Angiography): Globular outpouchings giving signet ring appearance >>
BEST invx. In Acute stage

- Mx:
o Diverticulosis: conservative (High fiber diet/ Antispasmodics)
o Acute: Conservative until inflammation subside.
o Pericolic Abscess: Percutaneous Drainage
o Acute complicated by Peritonitis: Laparatomy, Resection of perforated colon by
Haartman’s Procedure and Lavage.
o Chronic: Colectomy
o Bleeding: Resuscitation and Angiography to determine side for urgent colectomy

 DDx of LIF pain :-

1- Diverticulitis
2- Supra mesenteric
3- Aortic aneurysm

| P a g e 24
 Colorectal cancer
- Can arise anywhere colon, rectum, anal.

- 5 year survival is 50%

 Risk factors:
Hereditary: Majority in proximal, not more malignant than acquired, 80%
44 mean age
- Polyposis adenomatous/ inflammatory/ hamar / hyperplastic

- Non-polyposis BRCA gene / APC/ P53

Linch syndrome (not from
adenomatous polyps)
Acquired: diet (low fiber) / smoking/ alcohol.
APC [adenoma- carcinoma sequence]
Adenomatous polyp’s villous, tubular, tubulovilous.

- If hereditary > 100, young pt. defect in APC gene chr.5

- FAP AD prophylactic colectomy

 Pathology:

- m.c on Lt side 75%  annular constricting Ca Obstruction and change b habits

- Rt side ulcer Bleeding + IDA

- Ca is tubular / cauliflower / villi/ adenocarcinoma

Cauliflower Least malignant (villous most malignant)
C/F: depends on site of cancer {Lt Side obstructive symptoms} {Rt. Sided ulcerating symptoms)

1- Lt side : change in bowel habit / Spurious Diarrhea / Large bowel obstruction / bleeding
(minimal, fresh, mixed with stool) / Left sided Mass

2- Rt side (vague): Anemia, cachexia, ulcer, melena, recurrent RIF Pain, RIF mass / Iron Def.
Anemia in elderly + perforation

C/F of ca  weight loss / anorexia/ cachexia + S/S of mets

O/E:

- General: anemia/ LN`s( Virchow's ) / jaundice (liver mets)

- Abdomen: distention / ascites/ palpable liver mass (RIF/LIF)

- Rectum: PR: felt mass if tumor low lying or LNs or blood in finger

| P a g e 25
 - D.Dx: diverticular disease - UC – dysentery

 Spread:

- Local: caecal small bowel.

Transverse colon  stomach/ liver (gastro colic fistula/ Colovesical fistula ‘’
colouric pneumonia’)
Des & Asc. colon  ureter`s Obs.
Sigmoid bladder

- Lymphatic : aortic LNs

- Blood : liver

- Staging : TNM & Duke`s classification

Dukes: 5 yr. survival:
1- A: confirmed to wall. 90%
2- B: invade the wall. 70%
3- C: spread to LN`s. 40%
4- D: blood mets. 5-10%
A & B for surgery.
C & D advanced palliative & adjuvant chemotherapy.
 Invx:

- General to assess pt. condition CBC: Microcytic anemia / stool general  occult
blood / LFTs /RFTs /

- Specific:
1- PR & sigmoidoscopy & colonoscopy  take biopsy.
2- Tumor marker: CEA (Not specific)
3- barium enema: apple core sign [ Fixed irregular filling defect ]
4- CT for staging (liver) / if C/P is obstruction do X-ray Abdomen + General invx.
N.B:

- Synchronous tumor: 5% multiple tumors different places

- Metachronus tumour : tumor arise after surgery 5% , In follow up

- Aim of tx is cure in duke`s A & B

N.B: left side  obstructive, RT side  ulceratory

| P a g e 26
  Mx: Depends if Curable or not
Surgery {pre- surgery- post- follow up}
1- bowel`s preparations :

- Mechanical: phosphate enema.

- Chemical: laxative tabs, 2-3 days fluids before surgery , 6 hrs NPO, antibiotics{
metronidazole, neomycin}

- N.B: if tumor is causing obstruction  emergency [ wash bowel with saline on table
lavage}
Pre:
1- Admit. 2- NPO. 3- IV fluids. 4- Lactulose. 5- Phosphate enema. 6- Metro + neomycin. 7- SC
heparin + stacking
Operation: Curable

- Firstly inspect liver, peritoneum & tumor for mets.

- Rt side cancer right hemicolectomy + ileocolic anastomosis

- If transverse colon  Transverse Colectomy + end to end anastomosis.

- If Lt colon left hemicolectomy + anastomosis if elective or + Haartman`s if emergency

- Sigmoid > Sigmoid colectomy + Primary anastamosis

 Haartman’s: Resection + End Stoma + Rectum overswen / Done in
Diverticular; Cancer and Rectal Cancer
If Inoperable:
o Palliative resection is preferred to decrease risk of obstruction and bleeding
(Resection if liver mets (young/ one lobe/ < 4 mm & 8 in size = partial
hepatictomy + chemo.)

- If irresectable;
o Right Colon: Side to side Ileotransverse Anastamosis (Bypass)
o Rest of Colon: Proximal Colostomy (i.e: Sigmoid tumor > Transverse colostomy is
done)

- Chemo with 5- fluorouracil + poliric acid

Follow-up:

- PR/ CEA  colonoscopy every 6 month for 1 yr., & annually.

Carcino embryonic antigen tumor marker for
colorectal cancer followup

| P a g e 27
 Stoma
- Artificial opening between bowel and skin
- Temporary [loop] or permanent [End]
- Gastrostomy jejunostomy ileostomy colostomy
Ileostomy: Used in Proctocolectomy for UC or FAP
Colostomy: Indications:
Temporary: 1. Large bowel obstruction (i.e Ca Colon & Hirschsprung ); 2. Colonic Injury
3. Rectal anastamosis
Permanent:
1. After Abdomino-perineal resection of rectal cancer 2. Irresectable Colorectal cancer.
3. Incurable anal incontinence 4. High anal fistulae

N. B: Colostomy is done in sigmoid and transverse only → Ascending and descending Are
retroperitoneal organs that are fixed

 Uses :*FLED
1- Feeding ‘’gastro, jejuno” 2- Lavage “cecostomy” 3- Evisceration 4- diversion: relieve
obstruction / bypass stricture

 Types of stoma : LEDD loop/ End / Divided / Double - barrel

1- Loop [no need for complete diversion/ usually temporary / transverse colon )
2- End {Hartman’s} (may be permanent or temp.
3- divided
4- double - barrel (sigmoid volvulus}

Ileostomy Colostomy
Location (not specific) Right iliac fossa (RIF) LIF
Contents Secretions Well-formed feces (smell)
surroundings Excoriation and skin changes No skin changes
around
Edge Spouted At level of skin

 Complications : (Know about Colostomy care)

1- Prolapse 2- Retraction 3- Necrosis
4- Stenosis 5- parastomal hernia 6- diarrhea or fistula
7- Psychological
 Management : Refashioning of stoma

| P a g e 28
 Intestinal fistula
Internal:
- Pneumtourea / choluria: colovasical fistula.
- Vomiting feces: gastrocolic fistula.
- Cholecystoenteric fistula: intestinal obstruction.
- Normal abdominal X-ray. Invx (barium and CT)
- High outlet >1 liter.
External: Ebethelial connection fails to
- Enterocutaneous fistula heal spontanously
- Low output < 1liter. High output > 1 liter
Causes: Heal spontaneously if no distal obst
1- Inflammatory: peritonitis, Chron’s, TB, radiation, mesenteric ischemia.
2- surgery Most common cause
3- Cancer
4- Obstruction
Mx:
SNAP:
- Sepsis control  broad spectrum antibiotic IV antibiotics 
- Nutrition  oral / TPN
- Anatomy  MRI
- Plan 60% definitive is conservative , 40% surgery

| P a g e 29
Rectum
Rectal prolapse:-
Partial prolapse:- full thickness:-
In children. Old , female , Recurrent in pregnancy
Mucosal prolapse
+ Gastroenteritis. Due to diarrhea
Rx: reduction gradually Rx: surgery(rectopexy fixation of rectum)
Teach mother
Operations (Thirish, ripstein, Delorme
Treat underlying cause

N.B: in children (Thiersch operation narrowing of canal)

Or (Rectopexy>>fixation to the sacrum)

 Rectal cancer:-
RFs:- Ant facia denonvnan
Mucous discharge secreats K+
Post facia wielder
1-dietary. 2-alcohol. 3-villous adenoma
CFs :-( rectal presentation)
1-rectal bleeding mixed with stool. (Blood clots coating the stool) 2-tenesmus
3-change in bowel habits. 4-pain *usually painless Early mornings no diarrhea
N.B: tenesmus  painful defecation + sense of incomplete voiding (spurious diarrhea
Invx:-
1- Examination: General → pallor , jaundice
- Abdominal
- PR→ hemorrhoid ( hidden ‘’don’t exclude , LN palpable , mass, blood
2- PR→ proctoscope → sigmoidoscope → colonoscope.
2- Proctoscope (4cm):-
- Uses:- Diagnostic: polyps, hemorrhoids, biopsy
Therapeutic: hemmorhoidectomy, polypectomy.
3- sigmoidoscopy
4- colonoscopy
 Spread:-
- Local → uterus, bladder, ureter
- LNs → para rectal, inferior mesenteric, para aortic.
- Blood → liver
 Staging:- TNM or DUKE's Staging by CT or MRI but MRI better in rectal area
- Duke : A : confined to wall Incidence 15

| P a g e 31
  B : invaded the wall Incidence 35
 C : invaded LNs Incidence 50
 D : metastasis
- A+B surgery (early )
- C+D palliative (late )
 Mx: according to stage:-
- Early > surgery
- Late > palliative with neoadjuvant
*surgery depends on distance from anal canal and tumor:-
1- >5 cm high rectal → anterior resection & anastomosis
2- <5 cm low rectal → APR (abdominoperotoneal resection) + permanent colostomy
3- Advanced  5flurouracil + folinic acid chemotherapy
Surgical complications:-
1- Urinary tract injuries 2- stoma complications 3- sexual dysfunction
Follow up:-
- PR, colonoscopy, CEA
- Every 3 months in first year
- Every 6 months in second year
- Annually up to 10 years
- Metachronus Lesion vision

| P a g e 31
 Anal canal
Surgical Anatomy:
- The muscle junction between the anus and rectum can be felt as a ridge, anorectal ring
- Dentate line: tortious line separates the upper part from the lower part of the anal canal
- Upper Anal Canal: Columnar Epithelium / Autonomic / Inferior Mesenteric Artery /
Portal Drainage
- Lower Anal Canal: Squamous Epithelium / Somatic / Internal Iliac artery / Systemic
drainage

2 Sphincters (Internal and External)

The internal sphincter:
a. circular muscle part:
 Thickened continuation of the circular muscle coat of the rectum. Pearly white in color.
 Spasm play a major role in anal fissures.

b. Longitudinal muscle:
 Fan out to be inserted into peri-anal skin.
 Provide pathway for spread of peri-anal infection.
 Mark out tight compartments responsible for the intense pressure and pain of peri-anal
infections.

- External sphincter:

 Somatic, voluntary muscles.

 Deep, superficial and subcutaneous parts.
 Pink in color.
 Has two parts inner circular and longitudinal, the circular muscles downwards part
become more condensed its importance come in fissure in ano because the spasm of
this muscle is responsible for anal fissure and its tttx is relaxation of this part of the
internal sphincter this part is the one we cut in lateral sphinctrotomy.

D.Dx of Painful Anorectal Conditions:

1. Fissure in ano.
2. Peri-anal abscess.
3. Strangulated, thrombosed, infected piles (piles don’t present with pain unless they are
complicated)
4. Peri-anal hematoma.
5. Proctalgia fugax.
6. Rectal cancers can present with pain if they are extending to the anus or indirectly if it
presented with hemorrhoids and they got complicated but its not common for cancer to
present with pain.

| P a g e 32
  Anal fissure:-
Def.: -longitudinal split in anal mucosa caused by hard stool & constipation commonly in young
females. (Hard stool and post pregnancy are RFs)
- Posteriorly mid line. (90%)
CFs:-
- Acute: fresh rectal bleeding after defecation + severe pain after defecation for 2-3 hrs
Patient avoid going to defecate » more constipation
- Chronic : anal spasm
Skin tag (sentinel pile)
* No PR » examine under anesthesia

Mx:-
1- Conservative : high fiber diet /water/ laxatives
- GTN ointment & CCB → relax anal spasm
- Botulinium toxin injection
- For 6 wks » follow up » 6 wks » surgery
2- Surgery : fissurectomy ( lateral anal Sphincterotomy (internal or external))
N.B: the best palliation for colon and rectal cancer is the resection of the primary tumour.
Neoadjuvant therapy is indicated in all rectal CA, but in advanced colon CA.

 Hemorrhoids ( piles ) :-
- Dilated anal Cushing’s →3 o’clock, 7 o'clock and 11 o'clock.
- 3,7,11 → TRUE → primary
- In between 3,7 , 11 → secondary
- FALSE → perianal hematoma( thrombosed external pile )
Causes:-
- idiopathic , constipation (Straining during defecation) (main cause) , portal HTN ,
- Secondary to: 1. Ca Rectum (Always exclude it when doing PR)/ 2. Pregnancy / 3.
Straining at micturition / 4. Chronic Constipation

CFs: - Mostly Asymptomatic

- painless rectal bleeding after defecation ( toilet paper bleed )
- pruritus and mucous with stool
- N.B : if strangulated → painful
Grades:-
1°: confined, bleed only, don't prolapse.
2°: prolapse on defecation, return spontaneously.

| P a g e 33
3°: prolapse + reduced manually (discomfort, and discharge leading to pruritus)
4°: prolapsed permanently

EXAMINATION: General, abdominal, PR → proctoscope, sigmoidoscopy, colonoscopy

May be complicated by profuse bleeding or Iron Def Anemia or Strangulation or Thrombosis

Strangulation happens with 2nd degree piles; Cause severe pain if not reduced within 1-2 hours
it causes thrombosis

Complications:-
-Anemia, thrombosis (external pile)

Mx:- for symptomatic only

1° + 2° → conservative → - Sclerotherapy (1° + early 2 °) Na tetradecile sulphate used in sclerotherapy
- Band ligation (late 2 ° + 3 °)
2+  sclerotherapy and …….. Hemmorhoidectomy.
3° + 4° → hemmorhoidectomy Don’t take them all at once (can cause anal stenosis)

Surgical complications:-
- Early: infection, acute retention of urine, post op hemorrhage :- reactionary 
diathermy + gauze packing / Secondary  blood transfusion + NS washout)
- Late (secondary haemorrhage, anal stenosis in extensive surgeries , anal fissure,
incontinence)
- N.B : post op care : set 2 bath ,, laxatives ,, analgesia ,, PR in 4 wks

N.B: hemmorhoidectomy is replaced by:-

1- stapled hemmoroidpexy
2- hemorrhoids artery ligation

 Thrombosed external pile ( perianal hematoma ) :-

- Thrombosis in inferior rectal venous plexus.
- RF :- hard stool
- acute: sudden pain after defecation , worse by sitting, moving or defecation
- O/E : tense , smooth lump on anal verge
- subsidies in few days or rupture
Mx:-
- if acute : evacuation under GA & excision
- If ruptured: conservative » hot paths, Lasix.

| P a g e 34
Anal abscess + anal fistula:-
1- subcutaneous ( peri anal )
2- submucosal » tender PR
3- ischio rectal » febrile , Deep anal pain , discharge , itching
4- peri rectal ( supra levator ) » febrile , deep anal pain , discharge , itching
5- Intersphencteric abscess
Perianal is most of the cases / mostly caused by E.Coli / usually starts as infection / 40%
coincide with fistula in ano

* Contents: hard + fluctuant + tender + hot + red + pus

Perianal Abscess: Fever + Pain + Indurated tender mass with pointing tip O/E

* N.B: abscess cause fistula in: - T.B - Chron’s - CA. - radiation

Mx:-
- Abscess : Antibiotics + drainage by cruciate incision under GA followed by wound
dressing
- ( to prevent rupture and formation of fistula )

 Fistula in ano :-
Part's classification:-
1- trans sphincteric fistula » low anal
2- inter sphincteric » low anal
3- supra sphincteric » high anal
4- extra sphincteric » high anal
- submucosal & sub cutaneous » superficial
- N.B: fistula is the result of untreated abscess. Can be after drainage too
C/F:- perianal itching, irritation and seropurulent discharge + opening near anus
Invx:-
- Dye with x-ray » fistulogram
- MRI » dx the tract
- Sigmoidoscopy » sphincteric location
TX:-
1- High anal » fistuloectomy (excision + .....) If crosses the sphincter insert seton to heal by fibrosis
Low anal » fistulotomy (open & heal by granulation)
2- SNAP
N.B: Anal Cancer: - homosexual, warts, HPV/ Painful.
Rx:- Radiotherapy / Surgery : APR + end colostomy

| P a g e 35
So; When approaching Painful anorectal conditions:
D.Dx: Fissure in ano. / Peri-anal abscess / thrombosed infected piles /Peri-anal
hematoma. (Less likely: Rectal cancers)
History: Swinging fever & throbbing pain for perianal abscess
- Chronic Constipation & blood streaks in stool; pruritus in ano for anal fissure
- Recent history; increasing with cough, movement and sitting for infected hematoma
- History of toilet paper bleeding per rectum after defecation for thrombosed pile.

O/E: for tender mass / sentinel pile and skin tag with tight anal sphincter / red indurated mass /
purple bluish cystic mass (Respectively)

| P a g e 36
 Lower GI Bleeding
- Bleeding per rectum coming from distal to duodenojejunal flexure (N.B: Ligament of
treitzand in duodenum separates upper and Lower GI)
- 2/3 of GI Bleeding is Upper and 1/3 is Lower
- Only 15% of Lower GIB present with hemodynamic instability; and 80% Respond to
resuscitation
-
Classification:
i- Massive bleeding: acute associated with haemodynamic instability.
ii- Mild to moderate.
iii- Occult bleeding: chronic problem, and present anaemia or even anaemic heart
failure.
 Iron deficiency anaemia (low MCV), almost always due to LGITB or UGITB in males, but
exclude gynaecological problems first in females.

*acute bleeding: bleeding for less than 3 days duration, associated with instability of vital signs,
anaemia or need for blood transfusion.

D.Dx of Lower GIT Bleeding:

1. Anal Condition >> Most common: Hemorrhoid / Anal Fissure
2. Colorectal: Inflammatory (Dysentery, Colitis, UC) / Ischemic Colitis / Diverticular
disease / Cancer / Angiodysplasia
3. General conditions: Thrombocytopenia / Leukemia
4. Upper GI Bleeding Exclude it first by upper endoscopy or NG tube

Hemorrhoids is the commonest cause

D.Dx of Massive Lower GI Bleeding: (Treated as emergency)

1. Diverticular Disease 2. Angiodysplasia 3. Ulcerative Colitis 4. Ischemic
Colitis 5. Massive bleeding from UGIB

In history Analyze nature of Bleeding; e.g:

- Amount
- Color: bright red: anorectal bleeding. / Dark: sigmoid colon / Melena: caecum or small
bowel.
-relation to defecation:
i. mixed with motion (indicating mucosal pathology)
ii. Separate (healthy mucosa) can be before or after.

Check Anal, and abdominal symptoms and mets symptoms

Examine abdomen for Masses, Anemia and PR
Then Proctoscopy

| P a g e 37
So Invx of Lower GI Bleeding:
1. Check UGIB by NG Tube or upper endoscopy
2. Exclude Generalized bleeding tendency by CBC, and Bleeding Profile
3. Stool Analysis for bilharziasis or amebiasis
4. Proctoscopy; reveal internal hemorrhoids
5. Sigmoidoscopy / colonoscopy
6. T99 Scan can identify site of bleeding
7. Angiography: When colonoscopy is contraindicated (e.g Massive Bleeding)
8. Double contrast barium enema
9. CT abdomen
10. Laparotomy (only if all not available)

N.B: Massive Bleeding (Blood Loss >2.5 L over 48 hours)

Management:
- If Massive >> Resuscitate (80% bleeding stops)
If continued> colonoscopy or Angiography > Localize Bleeding and give vasopressin or
diathermy > If failed > Surgery

| P a g e 38
 Upper GI Bleeding
 GI Bleeding:
- Hematemesis
 Causes
1- Esophageal varices, due to portal HTN (mostly due to periportal fibrosis 2ndry to
Schistosoma)
2- Bleeding PUD
3- Gastroduodenal erosions
4- CA stomach
5- Malory Weiss tear

Hx: nature of bleeding, frequency & amount, hypovolemia

& hx of (PUD, schistosoma, portal HTN, NSAIDs, &HTN).
O/E: vitals/ abdomen/ chronic liver stigmata/ portal HTN

Management of UGIB:
1) Admission
2) Resuscitation (airway patency, O2)
 Insert 2 wide bore cannula, draw blood for baseline investigations “CBC, blood grouping
& cross matching, coagulation p, LFT, RFT,U&E”
 NG tube for suction & aspiration of blood
 Assess for blood transfusion; 2L of IV fluids “Ringer lactate” & correction of electrolytes
 Monitor fluids by urinary catheter for UOP
 IV analgesics, IV PPI
 Terlipressin or Octreotide
 If not stopped; 3 ways Sangestaken Blackmore tube, or better Minnesota (4ways)
Then emergency endoscopy:
If Varices: Band ligation/ injection sclerotherapy.
Ulcer: injection of Adrenaline/ Diathermy /LASER photocoagulation
 TIPPS -> hepatic encephalopathy [Portocaval shunting]
 Hassab’s operation [splenectomy + devascularsation of stomach & esophagus + highly
selective vagotomy]

*Prophylaxis: - Non bleeder: B blocker

- Bleeder: band ligation & B blocker

N.B: Portal Hypertension Shunt Operations:

1. Shunt Operations: Portocaval / Proximal Spleno-renal shunt + Splenectomy / Mesocaval
2. Porto-Azygos Disconnection Operation: Hassab Operation / Oesophageal transection
3. Definitive is Liver Transplant

| P a g e 39
 N.B: - 60% Stop within Initial Resuscitation
- NG Tube (suction of blood to determine the amount lost, to prevent blood degradation
“Ammonia” & prevent aspiration) Very important
- 3 ways- singestakean Blackmore tube
* ( 3 ways for : esophageal balloon, gastric balloon, suction)
* Deflate every 2 hrs
* Complications: Aspiration, rupture of esophagus, & pressure necrosis.
- Terlipressin-> Contraindicated in HTN & IHD due to generalized vasoconstriction -> give
Octreotide.
- Initial Fluid Always If Blood is found it is better; if not Plasma; if not colloids and
Crystalloids

N.B: Predictors of rebleeding after endoscopy:

- Adherent Clot - Spurting Vessel - Visible vessel at the base of ulcer

UGIB Bleeding PUD >>>

Resuscitate and Adrenaline

Inj / Diathermy
Varices

Bleeder Non Bleeder

Chronic Acute (emergency)

B-Blockers

Resuscitate
Prophylaxis:
- Serial Band Ligation If Failed
Or – Sclerotherapy
Sangestaken Tube / Drugs
+ Drugs
If Failed

Emergency Endoscopy For

Band Ligation /
Sclerotherapy

04
 DDx of painful epigastric pain :-
1- Perforated PUD  relief  erect CXR
2- Acute pancreatitis  back  serum amylase / CT
 DDx of peri umbilical pain :- 3- cholicytitis
1- Early appendicitis
2- Small bowel obstruction ( colicky )
3- Mesenteric ischemia ( continuous )
 DDx of RIF pain :-
1- Appendicitis
2- Ureteric colic
3- Gyn.
4- Meckel's diverticulum
 DDx of RIF mass :-
1- Appendicular mass
2- CA cecum
3- Crohn's
4- Ovarian cyst
5- T.B
6- Undescended testes
7- Psoas abscess
8- Kidney

| P a g e 41
 Appendicitis
- Appendix is a mid-gut organ

- Most common emergency

- males
 Locations:

- Most common site is Retro-cecally.

- Other locations: Pelvic appendix, Pre-ileal, subhepatic appendix.

 Causes:

- Obstruction or bacteria

- obstruction of lumen of appendix:

1. Lymphatic tissue hyperplasia
2. Fecolith
3. Worms
4. Carcinoma cecum  > 40 yrs.

N.B. veins compression → edema → inflammation → compression to appendicular

artery → gangrene → perforation of the tip commonly [in Fecolith the base perforates]
 Clinical features:
History:
1. colicky periumblical pain
2. shifting to Right Iliac Fossa
3. Nausea, vomiting, anorexia Vomiting due to reflux pyloric spasm
4. Fever,
5. Diarrhea , urinary symptoms and tenderness in PR in pelvic appendix
Examination:
In McBurney point (1/3 from ASIS
1. Right iliac fossa tenderness " most specific sign" towards umbalicusj
2. Rebound tenderness " pain upon releasing the palpating hand pushing the
abdomen"
3. voluntary guarding/ involuntary rigidity " board like"
4. Rovsing's sign: Rebound pressure on LIF causes pain in RIF Reversed tenderness
5. Psoas sign: pain by extending hip and knee, or flexing hip against resistance →
Retro-cecal appendix
6. Obturator's sign: pain on internal rotation of leg with hip and knee flexed →
pelvic appendix
| P a g e 42
7- Point sign (pt point the macperny sign
 7. Coated tongue swelling mouth
N.B. McBurney point: 1/3 from ASIS to umbilicus = point of maximum tenderness
[cough sign... pointing sign]

 Differential diagnosis of appendicitis:

1. Meckel's diverticulitis (in children)
2. Ureteric colic
3. Gynecological conditions: Ectopic pregnancy, ovarian cyst or PID "salpingitis"
4. Infection: Yersinia, Mesenteric lymphadenitis
5. Carcinoma of cecum "Male, older than 40 years"
Course is: Anorexia → Pain → vomiting
 Investigations:
1. WBC count: > 10.000. If WBC > 18.000/mm3 means there is a complication.
2. CRP
3. Urine analysis: sterile pyuria, to rule out UTI.
4. If female: pregnancy test" serum B-HCG" and Ultra sound
5. If old patient: Colonoscopy
6. CT abdomen
7. Plain Abdominal X-Ray: Fecolith
 Alvarado scores for appendicitis:
History Shifting of Pain 1 point
Nausea and vomiting 1 point
Anorexia 1 point
Examination Tenderness in RIF 2 point
Rebound Tenderness 1 point
Fever 1 point
Investigation Neutrophilia 2 point
Leukocytosis shift to left 1 point
Immature neutrophils in blood film (BM hyperactive)
 Interpretation:

- 8 → for appendectomy

- 4-8 → do more investigations

- < 4 →revise diagnosis and admit the patient

N.B. If Female OR atypical age OR > 48 hrs of presentation: do more investigations
"US/CT scan"
 Management of appendicitis:
1. Admission

| P a g e 43
 2. NPO
3. Fluid/ Analgesia/ Antibiotics
4. NG tube & Catheter
5. Surgery: Appendectomy
ON table, after anaesthetizing the patient the first thing you do is palpating the
abdomen for appendicular mass
 Management of appendicular mass:

- Discharge the patient and put him on antibiotics for 6 weeks, if regressed do
interval appendectomy. If not regressed: diagnosis is appendicular abscess:
managed by Extra-peritoneal drainage under US guide + antibiotics

- If normal abdominal examination, do incision on McBurney point.

- Transverse→ Lans incision " better in healing"

- Vertical →Grid ion incision " good if other differential diagnoses are
suspected - It can be extended to Morrison incision"

- appendicectomy can be done laproscopically "outside"

 Complications of appendicitis:
1. Perforation and peritonitis
2. appendicular mass and appendicular abscess
3. Liver abscess, present by jaundice
 Complications of surgery:
Early:
1. Wound Infection
2. Fecal fistula
3. Pelvic collection
4. Paralytic ileus
Late:
1. Incisional hernia
2. Adhesions. ( In females it leads to obstruction of Fallopian tube and ectopic
pregnancy)
3. Inguinal hernia by injury to ilioinguinal nerve ( In Grid ion incision)
Notes:

- If vomiting precedes the pain, question your diagnosis.

- Perforation is more common in children due to shortage of omentum

- appendicular mass: Observe for 48 hrs

| P a g e 44
 - In elderly; do colonoscopy before operating on appendicular mass

- Non resolving mass is for further evaluation

- Shifting pain is due to visceral pain first then somatic pain, due to embryological
origin

- Mr. Suleiman  rule out ectopic pregnancy firstly (in term of seriousness) then
appendicitis.
 Differential diagnosis of appendicitis:
In children: 1. Mesenteric adenitis Gastritis, lobar pneumonia (Rt lower)
2. Meckel's diverticulitis
In Females: 1. Ectopic pregnancy
2. PID [salpingitis] In adults:
Mite schmares, - regional elitis
Pyelonephritis 3. Ruptured ovarian cyst
- PUD
In All patients: 1. Chron's Ileitis - ureteric colic Leaked AAA
2. Ca cecum - torsion of testes
3. Ureteric colic
N.B. Positive urinalysis doesn't exclude diagnosis.
Antibiotics continued for 24hrs post operatively
If perforated → broad spectrum IV antibiotics
 Risk of perforation:

- 25% in the first 24 hrs

- 50% in the first 36 hrs

- 75% in the first 48 hrs

Alvarado Score

No Mass

= Mass
Surgery and follow up
Abscess
Female, Old, Atypical Age of
C/P = Further Invx. =

Drain and antibiotics

No Abscess
| P a g e 45
 Old patient = Colonoscopy

Female = US / CT

Notes on Approaching pt of appendicitis:

You have to exclude ectopic pregnancy first, in terms of seriousness:
In female with RIF pain;
 History Taking:

- Analyze pain (Appendicitis shifting pain + N&V + anorexia)

- gyne History (Amenorrhea / Vaginal Bleeding)

- GIT symptoms

- Urinary symptoms (hx. Of passing stones, hematuria)

- Past history
Physical examination.

- Vaginal and PR examination: Cervical Excitation Test will confirm Gyn. Causes

- Examine Abdomen for Appendicitis signs + Costovertebral angle tenderness in UTI

& Palpable Kidneys)

| P a g e 46
 Peritonitis
Causes are:
1. Perforated viscous: PUD, GB, Appendix, bladder, small bowel, large bowel " large
bowel = fecal peritonitis"
2. Trauma
3. PID "pelvic inflammatory disease"
4. Primary from hematological spread
 Organisms:

- E-coli → Large bowel

- Streptococci → Trauma

- Gonorrhea → PID
 On Examination

- General look: Pt. lie still, looks ill, toxic,

- Inspecting abdomen: distended abdomen, not moving with respiration

- Superficial palpation: tenderness, guarding and rigidity,

- Deep palpation: rebound phenomena is positive,

- Percussion: Tympanic abdomen and

- Auscultation: absent bowel sound

 Investigations:

- Erect CXR

- US

- CT scan
 Management:

- Resuscitate and peritoneal lavage

- Antibiotics and treat underlying cause

| P a g e 47
 Complications:
1. ARDS
2. Renal failure
3. Sepsis
4. abscess
5. Fistula
6. Adhesive intestinal obstruction
7. MOF “Multi organ failure? PAGE 51

| P a g e 48
| P a g e 49
Pancreas
- Retroperitoneal organ

- head, body, tail

- (pancreatic duct - accessory duct) + (common bile duct)  ampulla of Vater &
sphincter of Oddi

- Arterial Supply by Splenic Artery Branches

- Exocrine Fx: Pancreatic enzymes  2nd part of the duodenum; (Lipase, Amylase
& Protelytic enzymes) + Stimulate hormones and Vagus

- Endocrine: Glucagon, Insulin, Somatostatin, Polypeptide

Acute Pancreatitis / Chronic Pancreatitis / Ca Pancreas / Pseudocyst

Acute pancreatitis:

- epigastric pain  acute abdomen

 Causes ( I GET SMASHED):

1-Iatrogenic (ERCP)
2- Gallstones (50%)
The most common
3- Ethanol (alcohol)
causes
4- Trauma
5- Surgery + ERCP ‘’ bad prognosis ‘’
6- Metabolic ( ↑Ca / ↑lipid /↓temp)
7- Autoimmune
8- Scorpion and snake bite
9- Hypothermia
10- Enflammatory ( mumps, Coxackie, CMV)
11- Drugs Na valproate
 If a patient presented with jaundice 
- good prognosis (stones)
- middle age & elderly
- < 40  young  alcohol

| P a g e 51
  C/F:
- sudden severe epigastric pain, progressive (DDx: perforated PUD  sudden
but relieved)
- radiate to the back / Following heavy meal or ingestion of alcohol
- relieved by leaning forward
- associated with nausea and vomiting

 O/E:
- ill patient
- lie still
- fever / tachycardia / shallow breathing
 Abdomen examination:
- Mild Tenderness
- Jaundice
Gall stone
- Ascites
- Cullen’s sign
- Grey turner’s sign Trauma + necrotizing fox sign under inguinale line

- If after 2-3 weeks of acute episode, upper abdominal swelling

appeared >> Pancreatic Pseudocyst
 N.B: pancreatitis is either:
1- mild edematous or
2- severe necrotizing hemorrhagic: characterized by;
3- sterile
necrotizing Grey Turner’s (flanks hemorrhage) & Cullen’s sign
(periumblical hemorrhages)

 Complications:
1- Systemic: 2- Local:
a. ARDS { RF-1} a. pancreatic necrosis
b. acute renal failure b. pancreatic abscess
c. sepsis c. pseudo-cystFluid collection in lesser sac
Hypocalcemia (between stomach and p
(sabonification, d. multi organ failure d. ascites + pleuritic effusion
Sepsis e. hypocalcemia ( after 2 days)

 N.B => necrosis

- Dx by IV contrast CT abdomen
- Tx : if :
1- sterile  medical
2- infected  US guided FNA
3- shocked  operative debridement [necrostomy]

| P a g e 51
  Abscess is for drainage  DDx of ↑serum amylase:
 Most common complication => ARDS 1- acute pancreatitis
 Most serious complication => NECROSIS 2- perforated PUD
3- mesenteric ischemia
 Investigations: 4- ovarian tumor/ectopic
- to confirm Dx / assess severity 5- testicular torsion
- Enzymes ( amylase ) / US / CT/ ERCP / MRCP/ EUS 6- renal failure
 To assess condition: CBC, LFT, RFT, ABG, U/E 7- DKA
 To confirm: US, amylase, and CT abd.
 Erect CXR exclude ARDS + perforated PUD

1- Serum amylase/lipase: > 10,000 [5 folds]

2- Erect CXR with abdomen view : exclude air under RT diaphragm  perforated
PUD
3- CT abdomen: Diagnostic; showing peripancreatic edema and Intraperitoneal
fluid (To detect necrosis CT is done 48 hrs after attack)
4- ERCP  if jaundiced [stone] diagnostic and therapeutic
5- Abdominal X-ray:
- Colon cut-off sign
- Sentinel loop sign (gas in jejunum)
- If the patient presents late  calcification DD perforated
peptic ,cholycstitis.
 Ranson- Abatehi –Glasgow scoring : for severity
PANCREASE
- PO2 < 8.0 KPa
- Age >55 years
- Neutrophils > 10,000/mm3
- Calcium < 20 mmol
- R urea > 60
- Enzymes [LDH] > 600
- Albumin < 2.5
- Sugar > 10 mmol
 If ≥ 3 +ve  severe pancreatitis  admit to ICU

Severity of Pancreatic Inflammation ranges from mild oedema, to hemorrhagic

pancreatitis and severe necrotizing pancreatitis

| P a g e 52
  Mx. Acute pancreatitis is conservative management; unless surgery is indicated
1- Admission  ICU/ Maintain airway patency and Give O2
2- NPO
3- IV fluids, correction of electrolytes, monitor output by urinary catheterization
4- NG tube (Nasojejunal tube)
5- Broad spectrum IV antibiotics (Meropenem/ Imipenem)
6- Analgesia (pethidine)
7- O2 and ventilation
8- PPI  to guard against ulcer

N.B: Relieve Pain by pethidine; is a vital step in the beginning

 Role of surgery depends on the presence of complications; indications of surgical

treatment:
- Doubtful diagnosis - Drainage of Abscess - Persistent Pseudocyst

N.b: hypocalcemia  Ca + omental fat  saponification, ↓ MG + ↓albumin.

Pancreatic Pseudo-cyst:
DD acitis, pancreatic psudoscyst.
- Fluid collection in the lesser sac, rich in amylase

- Complicate 10% of acute pancreatitis; 2-3 weeks after acute attack. Also
Pancreatic trauma cause it

- Could be complicated by Infection, hemorrhage & Rupture.

- C/F: if small Painless / Sudden increase in abdominal swelling

- early satiety + mass after eating

- Diagnosed by Abdominal US & CT-Abdomen

 Mx:
- conservative for 6 weeks
- if not  drainage percutaneous or open surgery [cysto- gastrostomy]
Cysto-gastrostomy  Ascites  pleural effusion

| P a g e 53
Chronic pancreatitis:
 RF:
1- Alcoholism
2- cystic fibrosis + pressure atrophy  fibrosis
3- after acute
4- Stone in CBD
 C/F:
1- epigastric pain radiates to the back, relieved by leaning forward [Analgesic
Abuse]
2- mal-absorption  steatorrhea [fatty bulky offensive stool] stop the exocrine
function first.
3- Diabetes if extensive (1/3 pts)
 exocrine failure [pain, steatorrhea] then endocrine [newly onset DM]

 Investigations:
1- Amylase :  , ↑ / No Significant lab test
2- CT abdomen => best; showing pancreatic enlargement and ass. Biliary
pathology
3- ERCP /MRCP “Chain of Lakes appearance”
4- Stool analysis: enzyme deficiency ‘Absent stool elastase’

 Mx: conservative
1- Analgesia (controlled)
2- oral pancreatic enzymes
3- insulin injection
4- pancreas transplantation

Surgery if persistent uncontrolled pain or complicated:

 If localized:
- head => pancreato-duodenectomy “Whipple”
- tail => distal pancreatectomy
 If dilated pancreato-jejunestomy

 Complications of chronic pancreatitis:

- Malabsorption / DM
- Narcotic addiction
- Splenic venous thrombosis  gastric varices  splenectomy
- Left sided pleural effusion
 Malabsorption + DM  + Hx of abd. Pain
1- General condition
2- CT abdomen

| P a g e 54
Pancreatic cancer:
 R/F:
1- Old (55-70 yrs)
2- African
3- Smoker
4- DM
5- Alcohol
6- Chronic pancreatitis precancerous

 Pathology: ductal Ca / cystic Ca (female)

 Sites:
- Tail 33%
- Body 33%
- Head 60% ‘’ Most common’’
> Very Poor Prognosis, 5-yrs-survival is 5%.

Spread:
 Local:
- Common Bile Duct causing obstructive Jauncice
- Stomach [GOO]
- Colon and small intestine
- Spleen
 LN:
- Para-hepaticus / Spleen /Para-aortic /Celiac
 Blood  liver & lungs

 If on the head of the pancreas:

 C/F 
- progressive painless obstructive jaundice + pruritus + Courvoisier law
- constitutional symptoms: weight loss/ anorexia / diarrhea
- then: late  painful [radiate to the back ,relieved by leaning] + recent onset
DM
 Abdominal mass could be:
 O/E Tumor/ liver/palpable gall bladder globular
- pale, cachexic, jaundiced
- Virchow’s node  Courvoisier law  If the gall bladder is
- Migratory thrombophlebitis dd Ca palpable in the presence of jaundice, the
- abdominal mass stomach jaundice is unlikely to be due to stone’’
 Exceptions: - Stone impacted in hartmann’s
in Body and Tail  Late symptoms +
pouch (mucocele)
Splenomegaly in 10%
 Insitu stone in CBD

| P a g e 55
  Investigations: Abdominal US is always initial invx. Whenever obstructive
jaundice is suspected

1- tumor marker: CA 19-9 & CEA

2- routine jaundice: CBC, clotting, LFT [↑bilirubin, ALP], RFT
3- US; biliary duct dilation & no stones
4- CT scan [staging]
5- ERCP & MRCP [biopsy +stent]
 Staging by CT:
- Early
- Advanced
N.B: US and CT for staging.

Painless progressive jaundice + migratory thrombophlebitis.

 Surgery: Depends on whether curable or not/ and Fitness to surgery
 Preoperative Preparation of Jaundiced patients is very important

 If early: Whipple operation

- [pancreaticoduodenectomy] + connect (pancreato-jejuno + choledoco-
jejuno, entero-jejuno)
- Complications: 1- delayed gastric empting 2- anastomotic leak.

 If late [jaundice + GOO]  palliative:

 For jaundice:
- Vit. K  bleeding
- IV fluids  Hepatorenal
- Laxative encephalopathy
- Antibiotics  asc. Infection

 For gastric outlet obstruction:

1) Triple bypass surgery;
a. Gastro-jejunostomy
b. Choledoco-jejunostomy
c. Jejuno-jejunostomy
2) ERCP stent
3) PTC drainage
4) Celiac plexus block => pain

| P a g e 56
Endocrine tumors:
1) Insulinoma (m.c)
- Whipple triad;
1- Hypoglycemia S/S with fasting
2- ↓RBG
3- Symptoms disappear with glucose
- Associated with MEN-1
- No DM  CT abd tumor
- Resection
2) Gastrinoma:
- MEN
- Zollinger Ellison Syndrome
3) VIPoma: WDHA;
- Watery Diarrhea
- Hypokalemia
- Achlorohydria
4) Glucagonoma:
- ↑Sugar (DM)
- Skin rash (necrotizing erythema)
5) Somatostatinoma
- Gallstone stasis
- DM +gall stones+

| P a g e 57
 Biliary disease and jaundice

2 hepatic ducts ‘’Common hepatic duct ’’ + cystic duct →

common bile duct  Ampulla of vater → 2nd part of duodenum

Congenital: biliary atresia, Choleducal cyst

Bile → cholesterol / lecithin / bile salts water
Emulsification and degradation of fats {entero hepatic
circulation}
Gall bladder contracts after fatty meals by cholecystokinin

 Gall stones types : cholesterol 5 Fs, Pigment ( hemolytic

anemia), Mixed 75%

-
Gall stones either ( pathologically) silent or
choledocholethiasis ( CBD → Jaundice)
 Impact :
 Hartman's pouch
 Cystic duct
 Empyer.
 Gallstones ileus ( int. Obstruction)

RFs of Stasis of Bile are (Female, Post Vagotomy, DM, Obesity, TP

 Clinically Gallstones; Possible Scenarios of GB Complications: “

o Obstruction of Cystic Duct: Mucocele / if infected: Acute Calcular
Cholecystitis
o Chronic Calcular Cholecystitis
o Carcinoma of Gall bladder
 Migration:
o To CBD: Obstructive Jaundice / Cholangitis / acute Pancreatitis
o To Duodenum: Gallstone ileus

| P a g e 58
 So C/F of Gallstones; other than incidental discovery:

- Recurrent biliary pain; similar to acute cholecystitis pain but less duration
o (O/E: Right hypochondrial tenderness / Murphy sign)

- Biliary dyspepsia

- Reflex symptoms

N.B: Murphy sign: (Palpation of GB while patient taking deep breath; will cause the
patient to catch his breath)

Abdominal US is the invx. Of choice

Management is Cholecystectomy

Acute cholecystitis:

- Either calculus (95%) or acalculus (either due to infections {typhoid, ascaris},

burn or surgery.
N.B contracts post - meal by cholecystokinin against obstruction
Fate of Acute cholecystitis: Resolution / Gangrene / Empyema / Chronic
Calcular

| P a g e 59
Acute cholecystitis C/F: Acute abdomen

- Severe Rt hypochondrial pain radiating to tip of scapula,

- DDx of colic :
relieved by analgesia , and increased by fatty meal - Stone

- Fever + N/V - Ureteric colic /

bladder colic
O/E: pt looks Ill febrile, tachycardic - Int. Obstruction
- Tenderness, Rebound tenderness and guarding & rigidity - Appendicitis

- Murphy's sign - Gyn. Causes

- Boa's sign : hypertheasia of scapula tip

- Zachary copes sign : fullness in rt hypochondrium

- If perforated peritonitis

 Inv. :
1- general to assess condition: CBC (↑ TWBCs) - ESR ↑- CRP ↑ - blood culture
2- US : Hyper echoic masses with acoustic shadow
3- Gallbladder thickness
4- HIDA scan : no visible gallbladder
N.b: CT and MRCP  if chronic or obs.jaundice
 Management : Either Early Surgical Cholecystectomy within 3 days or
Conservative followed by elective surgery

- Conservative by : NPO /IV fluids / analgesia /Antibiotics

+ Elective cholecystectomy in 4-6 weeks
 Complications :
1- Empyema of GB: Drainage + emergency cholecystectomy
2- Biliary peritonitis: when it perforates
4- Emphysematous GB (Dilation)

 Chronic cholecystitis :

- Recurrent attacks, less severe

- Acute chronic → analgesia

- RFs : female, fertile, forty (40s), fatty, flatulence

| P a g e 61
 - DDx: chronic dyspepsia causes

- Management : cholecystectomy

- Or obstruction of CBD → Obstructive jaundice

N. B: Cholecystectomy → removal of GB either laparoscopic or open surgery

Laparoscopic: intubation of cystic duct + MRCP + ERCP Cholangiogram
Injury - difficult
CI to laparoscopic cholecystectomy:
1-pregnancy 2- ascites 3-int. Obstruction 4- non-virgin abdomen
The last 2 cause’s → abdominal distension

Open cholecystectomy is: 2 cm below RT costal margin [coher’s, incision]

 Complications :

- Scars, bleeding, wound infection, adhesions, cosmetic, pain , prolonged

hospital stay

-CBD in case of failed ERCP : exploration of CBD [ERCP] Followed by removal

of stone, and T-tube insertion, and removal after 10 days with
Cholangiogram
 Complications of cholecystectomy :
1- General 2- leakage of bile 3- sclerosing cholangitis 4- jaundice [retained
stones]

Ascending cholangitis:
- Occurs in obstructive jaundice
- E. Coli
- Post ERCP Biliary reconstruction
- C/F : Charcot's triad
 Pain in Rt hypochondrium
 High intermittent fever +Rigors
 Jaundice
Hypotension and mental confusion (pentad phenomenon)
- TX. With I. V Antibiotics + sepsis control
- Risk of: liver abscess, Septicemia
- If no response within 24-48 hours; Emergency decompression by ERCP or T-Tube
drainage of CBD

| P a g e 61
Biliary stricture:

- Cholangiocarcinoma - Asc. Cholangitis

- Trauma - PSC

- Post ERCP - Cholecystitis

Diagnosed by ERCP / MRCP:

Tx by dilation or ERCP stent insertion [ Raux. En hepatojejunostomy]

 Cholangiocarcinoma

- Bile ducts C, Female> 50 yrs

- Association: IBD (UC → sclerosing cholangitis)

- Occur at confluence of :
1- Rt and Lt hepatic ducts
2- common hepatic with cystic duct

- Adenocarcinoma

- Obstructive jaundice.

- C/F: painless, progressive jaundice (obstructive S/Sx)

 Epigastric pain
 Constitutional S/S of malignancy
 Hepatomegaly
 GB not palpable

- Investigations:
1- MRCP or PTC
2- US /CT guided biopsy
3- ERCP  Obsolete (not seen)

- Treatment :
 Palliative PTC stenting or Whipple
 Poor prognosis

| P a g e 62
 Obstructive jaundice
- Yellowish discoloration of sclera, dark urine, pale stool and itching.

 Causes : Either classified according to site / or according to benign or malignant

- Within lumen : gall stones

- In the wall : structure, constrictive atresia, Cholangiocarcinoma

- External compression: chronic Pancreatitis, Ca head of pancreas,

periampullary Ca.
Or 3Ss: 1) Stones,
2) Stricture: benign (ascending cholangitis, trauma)

- Malignant : Cholangiocarcinoma
3) Space occupying lesion: Ca head of pancreas, periampullary Ca

Eti. Malignancy:
1- Ca head pancreas
2- Cholangiocarcinoma
3- periampullary Ca
4- adenocarcinoma of 2nd part of duodenum
5- 2ndaries from porta hepatis
6- HCC
Benign Etiologies:
1- Gallstones in CBD “Most common cause”
2- CBD stricture : following ERCP, following surgery [ cholecystectomy], chronic
pancreatitis

- 2 m.c : stones + Ca head of pancreas

Dx is by Hx, Ex and invx.
Important in Hx: complications and sequelae of obstructive jaundice:
1. Ascending Cholangitis: Charcot’s triad; could be complicated by septicemia, liver
failure, and liver abscess
2. Bleeding tendency (Vit. K)
3. Dehydration and Hepatorenal syndrome
4. Hepatic Failure “Hepatic Encephalopathy”

3&4 very poor outcome

| P a g e 63
Approach to Obstructive Jaundice: 1. Hx 2. Ex 3. Invx. 4. Mx
1. Focused Hx of obs. Jaundice:
PD Name, Age, Occupation, Residence, Marital Status
HPI Onset?
(ODIPARA) How it was discovered? Noticed it or someone else?
Duration?
Progression since start? Continuous, Intermittent or Progressive?
Intensity:
Agg. & Relieving Factors: Fatty Meals with stones
Associations:
- To confirm Obs Jaundice:
o Dark Urine / Pale Stool / Pruritus / Steatorrhea
- Identify the cause:
o Stones: Pain? +/- Fever with rigor
o Ca Pancreas: Constitutional (Weight Loss, Anorexia, N&V) /
Recurrent Onset DM / Backpain / Thrombophlebitis
o Periampullary: Melena
- Other GI Symptoms: Dyspepsia/ Change in Bowel habits /
Anemia
SR: Morning Headache, Sleep-wake disturbance
Complications Weight Loss
Cough & Hemoptysis
Bleeding from any site?
Urine Amount, frequency & color
Backache
PMH: - Jaundice - Hx of Stones - DM / HTN
- Past ERCP - Past Endoscopy - Hemolytic Anemia - Blood
Transfusion
FH - Malignancy - Stones - Similar Condition
DH - Current & chronic medications - Contraceptives - Allergies
- Amoclan
SH - Alcohol - Smoking - Insurance - Impact on daily activity &
Mobility

N.B: Clinical Associations: Prof Shakir zain

i- Pain:
 Silent jaundice in malignancy. * Gradual obstruction
 Biliary colic in stone disease, followed by jaundice. - If silent and intermittent
think of carcinoma of ampulla of vater
 Persistent dull aching pain in malignancy. Increase by night, prevent patient
from sleep [pt is not distracted at night] the pain is due to invasion and

| P a g e 64
 infiltration > usually with malignancy it silent jaundice then with progression of
disease invasion and filtration the patient develops this pain

ii. Course of Jaundice

 Painful intermittent in stone disease. Between attacks the patient is free of
jaundice
 silent progressive in malignant obstruction
 Painless intermittent in ampulary tumors. Central necrosis of the tumor and this
makes a channel for bile flow > this occurs in only 50% of cases of ampullary
carcinoma

2. O/E:
- General look
- Vitals , BP [hypotension → sepsis]
- Eye [ yellowish or not] /Anemia / Left supraclavicular LN.
- Chest → signs of hepatic encephalopathy
- Anemia +LN→ malignancy
- Abdomen → inspect → distention, moves with respiration, pigmentation,
scars, dilated veins
- From back of bed :
o Ask to inspirate deeply
o Palpable GB.
- Superficial Palp. → tenderness [ +ve → for Pancreatitis]
- Check for Palpable GB [ 9th ICS]
- Deep palpation: mass, hepatomegaly, Para aortic LN (not found).
- Percussion → for ascites
- DRE : for Plummer rectal nodule
- Scrotum
- LL→ for edema
- nutritional status

3. Investigations: Always remember Abdominal US is the most important initial

screening test for Obstructive Jaundice + Routine Jaundice Invx.

1- Exclusion of pre and hepatic causes: reticulocyte count, CBC, bilirubin levels.
2- General condition: CBC, coagulation profile, RFT, LFT, U & E.
3- liver: LFT and ALP levels, synthetic function, bilirubin
4- bile duct obstruction confirmation: ALP, US, MRCP or PTC, ERCP, CT

- Confirm and identify the cause

| P a g e 65
Inv.:
1- General : 1/ CBC : low Hb → malignancy
 TWBCs ↑ → asc. Cholangitis following obstruction.
 If ↓ rapidly → 2ndary biliary cirrhosis
 Platelet → thrombocytopenia
2/ ESR → ↑↑↑ [advanced Ca]
2- LFT :
 Serum albumin( <3-2 IU)
 Bilirubin → > 20, 30mg ↑↑↑ (indicates malignancy)
 ALP → 380 → malignancy

3- Coagulation profile: PT, PTT, INR →assess Bleeding Tendency

4- U/ analysis : Absence of urobilinogen , Bilirubin ++ , Sugar and acetone
5- RFT: creatinine clearance (Reflects kidney circulation > if <20 severe) , Serum
creatinine , Blood urea.
6- RBG
7- If elderly : ECG / CXR

 Specific :
1- Abdominal US; show dilated CBD, and may show the cause if stones “acoustic
shadow” (Used for follow up)
2- Abd. CT IV / oral contrast {pancreas}

Definitive inv. (Invasive Biliary procedures):

1- MRCP “Magnetic Resonance Cholangiopancreatography” Diagnostic Only
2- PTC “Percutaneous Transhepatic Cholangiography” : Diagnostic and Therapeutic
3- ERCP “Endoscopic Retrograde Cholangiopancreatography”: Diagnostic and
therapeutic

N.B: MRCP is superior in diagnostic value; ERCP and PTC are reserved for
Therapeutic uses

| P a g e 66
Notes on imaging invx. Of jaundice:
- Abdominal US: - Best initial – detect GB stones – detect thickness of GB wall –
visualize dilation of extra and intrahepatic biliary ducts

- ERCP: uses and complications:

1- diagnostic:

- Filling defect in bile duct + dilatation (gall stones)

- Detect Ca head of pancreas + biopsy

- Detect missed calculi in CBD post cholecystectomy

- Detection of injuries in biliary system

2- Therapeutic:

- Bile duct stone: Sphincterotomy followed by dormia basket extraction of stone

and Plan for elective cholecystectomy

- Insertion of stent for Ca head of pancreas obstruction drainage

Complications of ERCP:
1- Cholangitis and Septicemia in 4- Bleeding “Sup. Pancreatic
failed drainage duodenal artery”
2- injury and perforation 5- Failure
3- Pancreatitis

If failed ERCP (10-15%)→ Open Surgery

1. Operative Cholangiography
2. Cholecystectomy
3. Exploration of CBD, extraction of stones and T-Tube drainage
4. T-Tube Cholangiogram to check and ensure absence of residual stones
5. Removal of T-Tube on the 12th day

- PTC: Pre-requisites: Normal Coagulation and dilated intrahepatic biliary radicles on US

- Used to diagnose high obstruction of bile ducts – Biliary drainage in case of
failure of ERCP
Complications: - Bleeding from Liver Tear - Cholangitis and septicemia - Biliary leak
into peritoneal cavity “Peritonitis”

N.B: MRCP has preceded ERCP & PTC and better the diagnostic role in Obstructive Jaundice

| P a g e 67
4. Management: Manage Jaundice; protect against complications or manage them;
then Manage Cause “Relative Emergency”
 Pre. Operative preparation and management of obs. Jaundice :
- Admission & Vitals chart
- NPO; NG Tube for suction, and feeding gastrostomy or TPN
- IV Fluids, correction of electrolytes & Urinary catheterization for output
- Monitor; and correction of anemia
- IV Broad spectrum Antibiotics (2nd Gen Cephalosporins + Metro)
- 2 wide bore cannula for blood investigations (Blood grouping & Crossmatching
- &Coagulation profile; CBC, RBG, LFTs, RFTs)
- IV analgesia (Pethidine)
- IM 10mg of Vitamin K; FFP (4-6 units) if PTT prolonged, Blood transfusion for
anemic
- Rectal Lactulose & Bowel enema to wash bowel
- IV PPI to guard from peptic ulcers

N.B:
- Hepatorenal syndrome; prevented by adequate preoperative dextrose infusion
& high urine flow by mannitol
- Bleeding; prevented by IM injection of 10mg Vit. K preoperatively
- Infections: Acute Ascending cholangitis & liver abscess; prevented by broad
spectrum antibiotic prophylaxis
- Hepatic failure prevented by rectal lactulose & bowel enema

-Specific :
 If CBD gallstone:
1. ERCP Sphincterotomy and extraction by dormia basket, followed by
laparoscopic Cholecystectomy after 6 wks
2. Laparoscopic Cholecystectomy & Laparoscopic Exploration of CBD and
insertion of T-tube for 10 days.
3. open Exploration and Cholecystectomy

- if benign stricture: hepatojejunostomy

- If pancreatic Ca head: early (curable) whipple procedure, or unresectable :

3 options of palliation:
1- endoscopically ERCP stenting
2- triple bypass surgery :
 Choledoco jejunestomy / Gastro jejunestomy /Entero- enterostomy
3- PTC drainage
For periampullary carcinoma: head of pancreas; duodenal & lower CBD excision

| P a g e 68
 Breast
 anatomy :
- Arterial supply:
 Internal mammary artery
 Lateral thoracic artery
 Intercostal arteries
- venous drainage :
 Axillary vein
 Mammary vein
 Intercostal vein
* Through Vertebral venous plexus → bone mets

- lymph nodes : Very important for staging

 Anterior (pectoral)
 Posterior (subcapsular)
 Lateral (along axillary vein)
 Central (behind pectoralis minor)
 Apical (above pectoralis minor)
 physiology:

- Estrogen (+ GH +steroids) : duct proliferation

- Progesterone : lobular formation

- Prolactin : alveolar formation

Disorders:
1. Congenital 5. Cyst
2. Traumatic 6. Nipple
3. Inflammatory 7. Benign tumors
4. Fibrocystic 8. Cancer
1. Congenital

- Athelia - Polythelia

- Amazia - Polymazia

- Accessory breast

| P a g e 69
2. Traumatic: (Hematoma * Fat Necrosis)

- Hematoma: no external bruising; may resemble mass of CA; do biopsy

- Traumatic Fat necrosis: Following trauma, hard, fixed, cyst, and chalky, white
appearance.

- " Do triple assessment "

3. Inflammatory:
I) Acute mastitis + breast abscess :

- RF : engorgement of breast by milk + presence of nipple cracks + poor

hygiene

- Staph aureus from baby's mouth

- S/s according to stage :

 Acute mastitis : pain, fever, redness, tenderness, swelling
 Acute breast abscess: throbbing pain, swinging fever, localized
tenderness, pitting edema.
 5days of local inflammatory signs +/- 2 days systemic s/s despite
antibiotics.

- Mx. :
 Acute mastitis: proper antibiotics (Flucloxacillin) , Switch to the normal
breast for breast feeding
 Abscess : drainage under General Anesthesia + proper antibiotics ,
elevation and milk expression , biopsy to exclude inflammatory CA

- NB. Non lactating mastitis: follows duct ectasia, most common organism
is anaerobes (TX: metronidazole).

II) Mammary duct ectasia

- Idiopathic periductal inflammation and dilatation of ducts and stasis of

secretions.

- Clinical presentation :
 asymptomatic
 nipple discharge (any type of discharge) (Single or Multiple Ducts)
 acute inflammation (non-lactating mastitis)
 nipple retraction ( due to shortening of ducts)(slit like)

| P a g e 71
  chronic inflammation : abscess near areola + hard +dimpling +nipple
retraction)

- plasma cell mastitis

- Tx. : microdocectomy + hansfield operation (incisional biopsy)

Chronic pyogenic abscess:

- Improper tx, antibiotics, drainage

- More pain+ low fever

- Tx : excision

4. Fibrocystic disease: Most frequent disorder of Breast

Fibroadenosis:
- Idiopathic, * occur 20- 50 yrs ( puberty ages )

- ANDI “Aberrations of Normal Development and involution)

- UOQ most common site and bilateral

Patho.

- Adenosis (glandular hyperplasia).

- Epitheliosis (ductal hyperplasia → atypical→ precancerous).

- Sclerosing adenosis ( fibrosis)

- Cyst formation
Clinical Features:

- Asymptomatic

- cyclical mastalgia ( breast pain with period + nodularity )

- accidental lump

- painful small lump

- nipple discharge (clear, yellow)

Inv.: triple assessment & exclusion of CA

*35-55, painful lump, firm, indistinct surface and no lymph nodes

| P a g e 71
Mx:
1. aspirate cysts :

- Confirm benign : on aspiration :

 No blood content, not filled in 2 weeks, no residual lump.
 If not: Fancy & biopsy.
2. for mastalgia :

- Explain & reassure the pt,

- Supporting Bra

- Caffeine

- Bromocriptine

- Danazole ( estrogen analogue )

- Breast self-examination monthly & consider prophylactic mastectomy

5. Breast cysts

- Acinar ( ducts) or interacinar

- Acinar: retention cysts , Galactocele, intracystic CA

- Interacinar: dermoid cyst, lymph cyst, blood, sebaceous.

- Tx. :Aspiration + excision

6. Nipple discharge
Hx.
1) Nature?
 Purulent → abscess
 Serous → pregnancy, OCP, fibrocystic, duct ectasia.
 Yellow, green, black, blue → duct ectasia (m.c), fibrocystic disease.
 Bloody → ductal papilloma ( bilateral, m.c) Ductal CA(unilateral), duct
ectasia
 Milky → lactation, Prolactinoma, hypothyroidism, OCP, Galactocele.
2) lump presence
3) Bilateral or unilateral?
4) Single duct or all?
5) OCP? Pregnancy?
6) Headache, increased ICP, infertility, hypothyroidism?
7) symptoms of CA
8) constitutional symptoms

| P a g e 72
Examination: lump
Inv.: triple assessment, Cytology for the discharge
Mx. according to the cause
+ Microdocectomy
+ Hansfield operation (total duct excision)
*Most common cause of nipple discharge is duct ectasia

7. Benign breast tumors (papilloma, phylloid, fibroadenoma)

I) Ductal papilloma : MOST COMMON CAUSE OF BLOODY NIPPLE DISCHARGE

- One of main ducts near nipple in young female

- C/F :
1/ bloody discharge from single duct.
2/ bilateral
3/ retention cyst

- No mass usually

- Inv. Triple assessment , ductography

- Tx. Microdochectomy.
II) Phylloydes tumor :

- Highly cellular, rarely malignant, large size & skin ulcers, but Never attached.

- Tx. : Wide local excision

III) Fibroadenoma:

- M.C breast mass of young women 15-30 year.

- Hard in young women 20 - 30

- Soft in older 30 -50 yr.

- Patho. : micro pericanalicular fibroadenoma (hard), young

- Intracanalicular (soft) , old

- C/F :Painless lump found accidentally

- Site : anywhere

- Shape: spherical

- Size :small

- surface: smooth

| P a g e 73
 - Consistency: firm

- Skin: not attached, underlying muscle : not attached

- Mobility: not tender + very very mobile

- On mammography: well defined mas

- Mx.: Triple assessment + Surgical excision + histological confirmation

 Breast cancer

- M.c cancer in women, age 50 - 70 yrs.

Risk factors:

- Age: most important factor, >35 yrs

- gender: female

- Family hx. : BRCA 1 ( breast, ovary, colorectal CA) BRCA 2 , p35 gene

- Suspect if young female/ bilateral/ male

- Cycle related factors (high estrogen): Early menarche, late menopause,

contraceptives, HRT, nulliparity, age at first pregnancy>35 yrs.

- alcohol

- obesity

- Precancerous conditions: Ductal papilloma, fibrocystic disease.

Pathological types:
Microscopically:

- lobular (in-situ or invasive)

- Ductal( insitu or invasive)

- Mixed

- Papillary , tubular

- Medullary

- Inflammatory (worst type)

| P a g e 74
Grossly:

- UOQ most common site.

- Schirrous carcinoma (hard) commonest 75%, hard yellow, gritty.

- Eacephaloid ( soft )

- Paget's disease

- Inflammatory (worst)
Spread:
1. Locally: Skin, muscle, chest wall.
2. Lymph node spread : By penetration to axillary LN & internal mammary LN
 Prognostic sign
 Supraclavicular LN → mets
 Present as pitting edema at lower breast ( pėau dė orange)
3. Blood: Lung, bone, brain, liver.
NB. Lumbar vertebra first, ribs, femur, skull. {Due to free communication between posterior
intercostal veins and the paravertebral plexus}.
Hormone receptors:
1. Estrogen (ER +ve): 60%
2. Progesterone (PR)
3. HER2 /Neu 20%: overexpression, worst prognosis.
C/F:
● Symptoms:-
1. Painless lump ,Clinically found
2. Nipple changes: Discharge, Dimpling of skin, Deviation, Displacement, Destruction,
Retraction.
3. Skin changes : Ulceration, Tethering, Péau dé orange
● Signs:

- Breast: asymmetry, enlargement, skin dimpling, puckering, skin changes.

- Nipple changes.

- Mass ( lump ) : hard , irregular, ill defined, mobile,

- Fixed with skin, and underlying tissue.

- Axillary & supraclavicular LNs number & mobility.

● S/s of distant mets:

- Behavioral changes, fits & convulsions,

| P a g e 75
 - Hepatomegaly, jaundice, ascites,

- Spinal cord compression (most common)

- Bone pain, pathological fractures,

- Pleurisy, dyspnea, cough, hypercalcemia

- Constitutional symptoms of mets: wt loss, anorexia, fever.

*NB. Skin tethering due to invasion and shortening of ligament of cooper
*Skin fixation: direct infiltration of skin by the tumor
* DCIS → more common, rarely bilateral or multicentric / with microcalcifications, 30-50%
potential for invasion, TX as invasive
DDx if lump present:

- Carcinoma

- Fibrocystic disease

- Fibroadenoma

Cancer fibrocystic Fibroadenoma

Age >35 35-55 15-30
Pain Painless Painful (mastalgia) Painless
Surface Irregular indistinct Smooth (lobulated)
Consistency Hard firm Firm &highly mobile
LN invasion LN inv free Axilla

 TNM Staging :

- T : tumor size
 Tis : in situ
 T0 : no tumor
 T1: <2 cm
 T2 : 2 - 5 cm
 T3 : >5 cm
 T4 : regardless of size :
 A: invade the chest wall
 B: invade the skin
 C: invade both
 D: inflammatory CA & fungating

| P a g e 76
 - N : Node
 N0 - no LN invasion
 N1 - mobile ipsilateral axillary
 N2 - fixed ipsilateral axillary
 N3 - contralateral side/ edema

- M met
 M0 - no mets
 M1 - mets / supraclavicular LN

NB. ‫ مجاهد‬:

- T2 N1 M0 is the cut off = stage 2

- Less = stage 1

- More = stage 3

- Mets = stage 4

- Stage 1,2 aim of treatment is cure

- Stage 3 locally advanced

- Stage 4 palliative
UICC staging

- stage
 I T1 N0 M0 → early breast cancer
 IIa T2 N1 M0 → early breast cancer
 IIb T3 N0 M0 → early breast cancer
 IIIa T 1-3 N0-2 M0 → locally advanced
 IIIb T4 N any M0 → locally advanced
 IV T any N any M1 → mets
 Mx = no mets detected

| P a g e 77
Investigations:

- Aim: Dx carcinoma, staging, general condition of the pt, further studies.

- Triple assessment :
1. Hx & clinical examination
2. Imaging ( us & mammography)
3. Tissue pathology ( FNAc & biopsy)

- Inv. For staging : CXR , US abdomen, +ALP, MRI brain, pelvic bone scan , X-ray

- Mammography : For >35 yrs, either dense opacity , or microcalcifications ( ductal

cancer screening)

- US: For <35 yr. :

1. Differentiates solid from cystic lesion
2. benign or malignant
3. Guide biopsy
4. Screening

- MRI indicated if
1. Post op scar → implants
2. Monitor response to neoadjuvant.

- Biopsy :
1. FNAc :

- Aspirate cystic lesions

 Benign / CA (blood stained, residual mass, refill in 2 wks.
 Malignant : large pleomorphic nuclei, ill-defined cytoplasm, abnormal nuclear/
cytoplasmic ratio
2. True cut biopsy : stage, type, Lymphovascular invasion
3. Incisional biopsy
4. Excisional biopsy & frozen section.

- Screening :
1. Breast self-examination: For every female > 20 yrs monthly.
2. Imaging US if <35 , mammography if >35

- Sentinel LN: first LN of axilla which affected by CA mets, Injection of methylene blue
or sulfur & gamma camera, if +ve axillary clearance, if -ve no further excision.
Treatment of Breast Cancer:
1. Early Breast CA is curable
 Stage 1, 2a
 Either breast conservative surgery, or modified radical mastectomy.

| P a g e 78
● Breast conservative surgery:

- Wide local excision (2cm Safety margin)

- Sentinel LN Biopsy; and Axillary LN clearance if +ve

- Post op radiotherapy for 4 weeks

- Hormonal & chemotherapy

Indications:

- Small tumor ≤ 4cm

- Peripheral lesion

- In large breast
Contra indications:

- Pregnancy, in situ , multicenteric, central lesion, collagen vascular disease

Chemotherapy indications:

- +ve axillary nodes

- <70 yrs

- More than 1 cm

- HER2/ Neu +ve / ER -ve

Hormonal therapy:

- Tamoxifen : ER blocker

- Anastrazole : aromatase inhibitor, inhibit conversion of androgen to estrogen

- For HER2 Neu : monoclonal Antibody [ Herceptin ]

- [ Trastuzumab ]

Modified radical mastectomy (Patey’s operation):

- 5cm margin, 3cm depth

- Simple mastectomy + axillary clearance + breast reconstruction ( skin flap )

- Adjuvant radiotherapy if LN -ve

- Indicated if ( = BCS Contra indications )

| P a g e 79
 2. Locally advanced (stage 3):

- Neoadjuvant chemotherapy → downstage cancer

- If responded → BCS ( breast reconstruction )

- if not → modified + palliative

3. Advanced breast CA:

- Palliative ;
A. Surgery - if pain, unpleasant fungating, internal fixation for pathological fracture,
spinal cord decompression.
B. Hormonal therapy to prevent recurrence
C. Radiotherapy : locoregional for pain, ulceration , Brain mets, spine & bone , SVC
obstruction ,
BSS → Brain /Spine /SVC
D. Chemotherapy : 60 - 80 % response , targeting for mets, liver & lung mets , HER
2 Neu +ve cases ,
 Hypercalcemia with bone mets: (sx. thirst, drowsiness, constipation), Tx. IV fluids +
furosemide + prednisolone + bisphosphonate.
 brain mets : steroid + radiotherapy
 SC compression → Urgent surgical decompression + Radiotherapy
 Pleural effusion → chest drainage
 SVC obstruction : radiotherapy
NB. :
 Reconstruction → silicone implant
 Latissimus dorsi flap
 Transverse Rectus Abdominis muscle Flap (TRAM)
 Axillary clearance 5% risk for lymphedema (useless arm)
 Axillary radiotherapy 5% risk
 If Both 30%risk, so: don't do both!
Follow up: for surgery complications, recurrence and instructions

- 3monthly for first 2yrs

- 4monthly for next 3 yrs

- Annually thereafter
For
1. Detection & Tx of surgery complications :
 psychological

| P a g e 81
  arm edema { early → axillary vein thrombosis}
 Obstruction by radiotherapy
 Lymphangitis
TX: arm elevation, massage, elastic compression
2. Detect local recurrence or distant met : annually
3. Instructions :
 No pregnancy for 3 yrs
 Non hormonal contraception
 Avoid stimulation of estrogen
Reconstruction after mastectomy:

- Expanders + implants

- Tissue transfer : TRAM, latissimus dorsi flap

Prognosis:

- Depend on :
1. Type of tumor
 best → in situ , Paget
 Intermediate → invasive ductal
 Worst → inflammatory
2. T stage
3. LN number, size, location, mobility
 Assessed histologically ,
 Poor if ; Large fixed, >4 LN s, N3
4. Distant mets: poor
5. Hormone receptors ;
 PR & ES +ve → good
 HER 2/ Neu +ve → poor
6. Site of the tumor
 Medial half: poor (Inv. Of internal mammary LN)
7. Tumor proliferation by thymidine labelling & oncogene products.
8. Mitotic proliferation**
Complications of modified mastectomy:
1. Nerve injury
 Medial pectoral N.
 Intercostobrachial N.
 Lateral pectoral
 N. to serratus ant. (Long thoracic N.)
 Thoracodorsal
 N. to latissimus dorsi.

| P a g e 81
 2. Lymphedema
3. Psychological
4. Scar necrosis
5. Frozen shoulder
● NB: In axillary LN clearance, minimal 17 LN clearance.

Breast Examination (lump):

1. WIPER
 Wash hands
 Introduce self
 Permission
 Exposure ( top half )
 Reposition ( 45 degree , arm extended or arm behind head )
2. Inspection : [skin, nipple, mass ]
 Symmetry
 Swelling if visible
 Nipple areola complex
 Skin ( scar , sinus, pigmentation, sweating)
 Arm, supraclavicular
 Nipple for 4D's and retraction
 hands over head :
 Skin tethering & nipple line and retraction
 Axilla
3. Palpation
 Ask about pain
 Start with the normal side
 Fingers, start away from abnormality (UOQ , central)
 Superficial palpation for 6 quadrants
 Lump
 Site, size, surface, edge, consistency, compressible, fixation to the skin .To
underlying muscle
 Mobility in 2 planes
● Axilla:
 Hold Rt side with Rt hand, examine with left
 5 LN group : [ant. ,post ,central, apical, lateral]
 Supraclavicular
 For site, number, mobility (mobile or fixed)
● Offer areas to examine:

| P a g e 82
1. Ipsilateral supraclavicular LN from posterior and contralateral axilla and supraclavicular
LN
2. Back for tenderness
3. CNS
4. Chest for plural effusion
5. Abdomen for hepatomegaly & ascites

| P a g e 83
 Thyroid
- Goiter

- Hyper and Hypo thyroidism

- Cancers

- Thyroidectomy
 Invx of thyroid :
1/ TFTs: hyper (high T4, low TSH) / hypo (high TSH)
2/ US: - solid from cystic
- guide biopsy
- detect solitary from multinodular
(US only in solitary nodule)
3/ FNAC
 arterial supply of the thyroid :
1- superior thyroid artery ; branch from Ext. carotid
2- Inferior thyroid artery; branch from subclavian.
N.B recurrent laryngeal nerve is close (post.)
 vein supply :
1- superior thyroid vein
2- middle thyroid vein
3- inferior thyroid vein
 Tests :
1. TSH
2. fT3 and T4
3. TRM
4. Thyroid antibodies
5. Radioactive uptake Iodine scan

 thyroglossal cyst :

- from remnants of thyroid

- central thyroid swelling

- O/E : painless , cystic , moves upward with protrusion of tongue

- moves on swallowing

- Mx : surgical excision

| P a g e 84
 Goiter
1. inflammatory : thyroiditis
o subacute : de Quervain disease
o AI goiter “ Hashimoto’s “
2. simple goiter :
o simple diffuse ( physiologic )
o Simple nodular (endemic Iodine def.)
3. toxic : goiter + hyperthyroidism
4. neoplastic
goiter

Simple toxic solitray

Diffuse Diffuse nodular

Multinodular multinodular cyst

 subacute thyroiditis :

- neck pain , tender swelling , following URTI

- increased T4 / suppressed uptake

- Mx : oral steroids

 AI Hashimoto’s thyroiditis :

- m.c form of thyroiditis , common in females after menopause

- hyperthyroidism then hypothyroidism

- Anti-TPO Abs : Anti thyroglobulin Abs

- requires biopsy

- Mx: Thyroxine , surgery if large

| P a g e 85
 Simple goiter

- Increased TSH (endemic goiter, iodine def., irreversible).

- if sporadic : Pendred’s syndrome ( goiter and deafness , peroxidase def. , reversible )

Simple multinodular goiter
Complications of simple multinodular goiter:
1. tracheal obstruction by compression
2. 2ndry thyrotoxicosis in 30%
3. malignant transformation ( follicular Ca 3% )
4. cyst formation
5. hemorrhage into nodule
6. calcification
7. retrosternal extension
C/F: cosmetic / mild resp. distress
O/E: firm, smooth, painless swelling. Pt. is euthyroid

- sudden enlargement with pain and tenderness → due to hemorrhage into nodule

- Hard irregular indicates malignancy (retrosternal extension sx.)

Invx:
1. TFTs 2. Antibodies
Prevention: iodized salt tabs
* Dysphagia, hoarseness of voice and stridor: symptoms of metastasis, invasion of RLN

Retrosternal extension

- Dysphagia: worse at night, on exertion and with bending forward

- facial congestion due to venous engorgement, especially on raising arm ( pemberton

sign ) , orthopnea

- dysphagia to solids

- hoarseness of voice : pressure on one RLN

- stridor : both RLNs or tracheal compression

- O/E : insp : dilated veins and lower border of goiter can't be seen
 Palp. : enlarged thyroid gland
 Percuss. : retrosternal dullness on sternum
 Can't reach lower border of swelling
 Tracheal deviation

- Invx :

| P a g e 86
  thoracic inlet x-ray , AP and lateral views
 CT scan of the thorax : the best option

- Mx: thyroidectomy (indications of thyroidectomy!!)

Toxic goiter
1. toxic diffuse ( grave’s disease ) 75 %
2. toxic multinodular ( Plummer’s disease ) 15 %

 Grave’s disease :

- hyperthyroidism

- toxic diffuse goiter + thrill and bruit

- eye disease : exophthalmos , led retraction , led lag ± ophthalmoplegia ( dilated pupils
+ diplopia )

- thyroid acropachy / sweating

- pretibial myxedema

- fine tremors

- young female , irritable and tumors + eye disease

- Anti LATS Abs +ve , relapsing remitting pattern

* In pregnancy, radioiodine is CI, surgery after short course of Antithyroid drugs and
propranolol is the best option
* use PTU, not carbimazole.
 toxic nodular goiter : ( Plummer’s disease )

- elderly pt, gradual onset and steady course , on already diseased thyroid ( toxic
transformation of simple multinodular goiter )

- CVS Sx. , heart failure , and AF

- No eye disease
Hypothyroidism (N.B medicine):

- congenital hypothyroidism ( cretinism ) :stunted growth , puffy lips , protruded tongue ,

protuberant abdomen and mental retardation

- adult hypothyroidism (Myxedema) : females , slow deep voice , overweight and apathy
with dry coarse skin , cold intolerance ,constipation

| P a g e 87
 - low T3 , low T4 , High TSH

- Mx : Thyroxine
 Invx in toxic goiter :
1. TFTs : T4 , T3 and TSH
2. radioiodine uptake scan
3. thyroid antibodies for grave’s
 Mx of thyrotoxicosis :

- medical

- radioactive iodine

- surgical ( see later )

Medical:
1. Carbimazole
2. Propylthiouracil (PTU)
3. Propranolol
4. Iodine
 For thyrotoxicosis and pre-op Mx.
 SEs : GI upset , rash , reversible bone marrow suppression

- Toxic nodular goiter and retrosternal extension are CI of medical mx , do surgery

- radioactive iodine , given as alternative to medical therapy but serious SEs

Thyroid neoplasms
Tumors can arise from:
1) Follicular epithelial cells:
 benign:
 follicular
 malignant:
i) Differentiated :
(1) Papillary carcinoma
(2) Follicular carcinoma
(3) mixed carcinoma
ii) Undifferentiated:
 anaplastic carcinoma
2) Para follicular epithelial cells:
 Medullary carcinoma
3) Lymphoid cells:

| P a g e 88
  Malignant lymphoma

 Follicular adenoma:

- solitary nodule

- FNAC cannot differentiate between follicular adenoma and follicular carcinoma, so do

excisional biopsy.

- Mx:-
 Lobectomy + isthmusectomy
 send for histopathology
 Thyroid cancer:
PDFs
1. Irradiation
2. Genetics
3. transformation from simple nodular goiter (follicular)
4. on top of Hashimotos (lymphoma)
*N.B. Death is due to respiratory failure secondary to lung mets or airway obstruction
 Papillary carcinoma:-

- The most common type (60%) – more common in females

- Young adults & adolescence

- Slow grower

- Samoa bodies

- Late lymphatic spread

- Good prognosis (90%)

 Follicular carcinoma:-

- Commoner in female

- Middle aged (fifth decade)

- 15%

- 3% complicate endemic goiter

- Spread by blood stream to bones (skull) & lungs

-FNAC not useful

 Anaplastic carcinoma:-

- Elderly
| P a g e 89
 - Direct invasion & spread to tracheal compression

- Early lymphatic & blood spread

-Undifferentiated
 Medullary carcinoma:-

- 6%

- Arise from para follicular cells (C cells) → Secretes calcitonin

- Males = females

- Multicenteric if familial

- Alone or with MEN-II a (medullary carcinoma, hyper parathyroidism,

pheochromocytoma)

- Amyloid deposits

- spread to LNs

- Present as rapidly enlarging thyroid swelling

 Invx for thyroid cancer:-
1) TFT
2) US scan (to differentiate cystic from solid)
3) FNAC
4) Aspiration of cyst
 Characters of a benign tumor :-
a) clear aspirate
b) complete disappearance of the cyst
c) no re-accumulation of fluid
d) Free cytological Ex.
 Characters of a malignant tumor:-
a) hemorrhagic aspirate
b) residual lump
c) rapid re-accumulation
d) +ve malignant cells on cytology
5) CXR for pulmonary mets
6) Indirect laryngoscope for assessment of vocal cord mobility
If still in doubt → surgical exploration and biopsy
 Management of thyroid cancer:-

- For differentiated carcinoma → Total thyroidectomy + postoperative thyroxin to

suppress TSH +/- radiotherapy
| P a g e 91
N.B. Lobectomy can be done for:
 Small papillary
 Follicular with no invasion
 LN mx:

- If not palpable → central LN excisions

- If palpable → modified block dissection

For Mets → radioactive iodine
For medullary carcinoma: Total thyroidectomy + resection of LNs
For anaplastic carcinoma: inoperable → chemotherapy
For lymphoma: chemo & radiotherapy
 Poor prognostic features:
1) Age > 40
2) Lesion > 5 cm
3) LN involvement
4) Vascular invasion
Tumour size, LN and age at presentation determine prognosis.
 Solitary thyroid nodule :
 DDx:
1- Dominant nodule on top of multinodular goiter
2- Thyroid adenoma
3- Thyroid carcinoma
4- Thyroid cyst
5- Toxic nodular
 Finding highly suspicious of malignancy:
1- Hx. of previous irradiation
2- Young & elderly pt.
3- Recent and rapid growth
4- Pain
5- Hard, irregular, immobile mass
6- Local invasion/ LNs /mets
 Invx  Algorithm
1. TFTs
2. US
3. FNAC
4. Radio-active uptake
5. Biopsy
6. Surgery
 Isotope scan:
a. Hot  toxic, not malignant

| P a g e 91
 b. Warm functioning adenoma
c. Cold  10% malignant
*So not very useful

Thyroid nodule

clinical evaluation and

TFTs ± radioactive uptake scan

toxic nodule euthyroid

surgery US:
cystic or solid
dominant nodule
adjacent structures

cystic solid

aspirate
FNAC OR true
cut biopsy

suspicious
benign malignant
(e.g follicular)

lobectomy & total

observe
send for HP thyroidectomy

| P a g e 92
 Thyroidectomy:
 Indications:
1- Malignancy or suspicions
2- Toxic transformation of goiter
3- Local pressure symptoms
4- Venous congestion/retrosternal
5- Pt. preference [cosmetic]
 Pre-operative preparations:
1- Admission
2- Proper Hx & Ex
3- Consent
4- TFTs  render pt. euthyroid by :
- Carbimazole 300 mg
- Propranolol
- Lugol’s Iodine
5- Indirect laryngoscopy to visual vocal cords for medico-legal aspects
6- Serum calcium levels
7- Thoracic inlet X-ray AP & lateral views [for retrosternal extension]
8- General surgical inv. (CBC, blood grouping & cross matching)
*TFTs / antibodies / US / FNAC / cervical X-ray for intubation

 In surgery:
 Superior thyroid vessels, ligated close to gland avoid ELN injury
 Inferior thyroid artery & vein ligated away to avoid injury to
RLN

 Complications of thyroidectomy:  Complications:

1- Immediate: 1- Hemorrhage
a. Hemorrhage 2- Crisis
b. Thyroid crisis (↑HR, arrhythmia, ↑fever, shock)  3- Resp. obstruction (trachea-
- ICU admission malacia/ B.P RLN
- IV fluids inj./hematoma/laryngeal
- Cooling blankets and paracetamol edema)
- IV propranolol 4- Hematoma
5- Hypocalcemia
- Rectal carbimazole
6- RLN inj.
- Lugol’s Iodine
7- Wound infection
- IV hydrocortisone 8- Keloid
c. Respiratory obstruction: 9- Recurrence
- Tracheomalacia 10- Hypothyroidism

| P a g e 93
 - Partial bilateral RLN injury
2- Early (day 1-5) :
a. Hematoma:
- 6-8 hours, post op, poor ligation to the artery
- C/F : respiratory obstruction & SOB
- Immediate removal of the sutures and clot at bed side
- Laryngeal edema causing resp. obstruction
b. Hypocalcemia (day 2 – 5)
- Causes: removal or devascularization of PT gland … If late  hungry bone
syndrome [osteoporosis by ???]
- edema???
- C/F:
Circumoral numbness first sign to appear
Chovestic sign & Trousseau’s sign [carpo-pedal spasm]
- Mx: slow infusion of 10% 10 ml Ca2+ Gluconate & oral Ca2+ for 3 months
c. Recurrent laryngeal nerve injury;
1) Partial:
- Unilateral  adductors defect
- Bilateral  immediate respiratory compromise
2) Complete:
- Unilateral  hoarseness of voice
- Bilateral  Aphonia
d. Superior laryngeal nerve injury: of voice
3- Late:
a- Wound infection
b- Keloid scar
c- Recurrence
d- Thyroid insufficiency in 20 – 45%
 So follow up by Ca2+ at 6 weeks & every 6 – 12 months do TFTs

 Surgical Club
1) Hx: full systemic review
- Thyroid swelling
- Toxic features
- Malignancy Sx.
- Compression Sx.
- Retrosternal extension
And confirm by Ex.
 + full systemic review & confirm by Ex
 Invx.: TFT / US / cervical X-ray / Indirect laryngoscope / CT

| P a g e 94
 N.B:
 Huge goiter can cause displacement of carotid artery
 Complications before surgery:
- Tracheal compression
- SVC obstruction
- Bleeding into nodule
- Toxicity
- Malignant transformation
 Post-op stridor:
1- Tension hematoma
2- Trachea-malacia
3- Laryngeal edema
4- RLN injury bilateral
5- Hypocalcemia

2) If pt. presented with activity Sx.

 Ask about others:
- Wt gain / loss / appetite
- Bowel habits
- Menstrual disturbance
- Sleep cycle
 Erythema on swelling  malignancy OR inflammatory
 DDx of cystic, tender, hot multinodular mass:
1- Thyroid carcinoma
2- Subacute thyroiditis
3- Hashimoto’s thyroiditis
4- Simple multinodular goiter

| P a g e 95
 Scrotum
 Painless scrotal swelling :
 Hydrocele
 Varicocele
 Epidydimal cyst
 Painful scrotal conditions :
 Testicular torsion
 Epidydimorchitis
 Traumatic hematocele
 Strangulated inguino-crotal hernia
 Differential diagnosis of absent testis in scrotum :
1- undescended testis.
2- ectopic testis
3- vanishing testis
4- agenesis
5- retractile testis

Scrotal swelling examination:

- Can go above it ?

- Cannot → inginal hernia

- Can → pure scrotal swelling

Varicocele : Bag of worms on pt standing , disappears when lying down

Cystic : Hydrocele / epidydimal cyst
Solid → testicular tumor

Cystic :
 Can't feel the testis separately → vaginal hydrocele and confirm by transillumination
test
 Can feel the testis separately :
 Epidydimal cyst → low and can't separate from testis
 Encysted hydrocele → can move separately

| P a g e 96
 Testis and scrotum :
Tortion, infection, tumors, varicocele / epdydimal cyst / hydrocele Sajeda Salah:
 Undescended testis:

- 1%

- Rt side

- Cause sterility and spermatic cord torsion

- ↑ risk of tumors

- US and Ct Localize it

- Management : Orchidopexy before 2 years

 Testicular torsion :

- Surgical emergency

- Age 10-25 years

- C/f : Sudden severe testicular pain, Vomiting

- O/E :Tender, swollen testis and drawn up in scrotum, Elevation of testis doesn't decrease
the pain

- Differential diagnosis :
1- epididymorchitis
2- strangulated Inguinoscrotal hernia
3- hematocele [trauma]

- Investigations:
 Doppler or duplex (usually not done)
 Time > 8 hours

- Management : Immediate exploration, untwisting and if viable → Orchidopexy, if not viable

→ orchidectomy

- Complication → infertility

 Epididymorchitis :

- 2 age groups :
 Young : 2ndary to STD [N. Gonorrhea]
 Old : 2ndary to lower UTI [E. Coli], 2ndary to urinary instrumentation

| P a g e 97
- C/F :
1- acute scrotal pain
2- fever, rigors and malaise
3- frequency, dysuria

- O/E:
 Enlarged swollen tender testis and epidydimis
 Elevation of testis relieve tenderness and pain

- Investigations :
 CBC → ↑ WBCs
 Urine analysis → pus cells
 Urine culture
 Scrotal US

- Treatment :
 Bed rest and scrotal Elevation
 Antibiotics and analgesia

- Complications : abscess → drainage

Testicular Torsion
Age Usually adolescents and children
History Sometimes mild trauma
Temperature Normal or slightly elevated
Elevation of Scrotum Doesn’t alleviate pain
Urgent Urine Analysis Free
Urgent Doppler Obstructed testicular vessels
Acute epididymo-orchitis
Adults or elderly
Usually UTI Sympts.
Elevated
Partial pain relief
Sometimes pus cells
Patent testicular vessels

 Traumatic hematocele :

- History of direct trauma

- Commonly in sports injury

- Tender swollen testis

- -ve transillumination test [ DDx from hydrocele]

- Management :
 If small →conservative
 If large→ surgical removal

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 Strangulated inguinoscrotal hernia

- Hx of hernia

- Sudden localized pain, then generalized vomiting and fever

- O/E :
 Tense, shiny, tender, irreducible Inguinoscrotal swelling with - ve cough impulse
 Exaggerated bowel sounds

- Management : Urgent exploration and assessment of bowel viability (color / peristalsis /

bleeding /pulsation)

 Varicocele :

- Testicular veins originate from pampiniform plexus; 4-8 veins reduced to 2 veins
retroperiotnally. Rt. Testicular vein ends in IVC; while LT. testicular vein empties in left
renal vein

- Elongated dilated tortious veins of pampiniform plexus of veins

- 1ry or 2ndary (rare)

-
Primary Varicocele:

- Young adults, idiopathic, usually on left side :

 angle Lt spermatic vein into lt renal vein
 Left testis lower and compressible

- Complicated by subfertility

- C/F : Dragging sensation, worse in hot weather

- O/E :
 Affected side hanging lower
 When pt standing
 Dilated veins above testis feel like a bag of worms and disappears when lying down
 Compressible with +ve fluid thrill on coughing

- Investigation :
 Doppler to detect reversed flow
 Semen analysis
 Abdominal US

| P a g e 99
 - Management : Conservative, if affecting pt → ligation and division of testicular vein
2ndary Varicocele → RCC

 Epididymal cyst and spermatocele :

- Single or multiple, related to head of testis

- C/F: Painless scrotal swelling, cyst, posterior superiorly to testis , +ve transillumination
test

- Management :Conservative, if symptomtic for surgical operation

 Hydrocele :

- Primary (congenital and idiopathic)

- 2ndary

- Classes :
 Of spermatic cord :
1- encysted Hydrocele of spermatic cord
2- Hydrocele of hernial sac
 Of tonica vaginalis :
1- congenital 2- infantile 3- vaginal

- C/F :
 Pure scrotal swelling; Testis’s can't be felt separately; Fluctuant; Transilluminate,can go
above it

- Complications : Infections, Hemorrhage, Rupture, Huge expansion

- Management : Surgical excision, aspiration → recurrence and infection

- Aspiration →Done in primary hydrocele in elderly unfit patients

+/- repair hernial sac
Testicular tumors :

- Malignant → 1-2 %

- Unknown etiology

- ↑in undescended testicles

 Teratoma → 20 - 30 yrs

| P a g e 111
  Seminoma → 30 - 40 yrs
 Mixed → 20-40 yrs
 Lymphoma →→ 60-70 yrs

- C/F : painless testicular sensation with dragging sensation [ pain in 1/3 pt.].
+ symptoms of mets → backache

- Investigations :
 Tumor markers : α-fetoprotein and B- hCG
LDH and placental ALP
 Scrotal US
 CT abdomen and chest
 Sperm banking

- Management : orchidectomy
Post - surgical staging
+/- adjuvant chemoradiotherapy

| P a g e 111
 Hernia
Definition of hernia :

- Protrusion of viscus or organ from its normal content to outside abdominal wall
Intraabdominal or extra abdominal mass:

- Pt lean forward : if extra abdominal mass will bulge, if intra abdominal will disappear

- If reducible → it disappears

- If irreducible → bulge

- So reducible mass → hernia

Types :

- Inguinal hernia

- Umbilical hernia

- Incisional hernia

- Femoral hernia.

- Epigastric
 From the most common to the least common
Anatomy of inguinal canal :

- 4 cm long, passes downward and medially, deep to superficial internal to external

inguinal rings, above the inguinal ligament.

- Represents oblique passage through anterior abdominal wall of vasdefernes

- Lateral 1/3 of internal oblique

- Anteriorly : skin and fascia , external oblique aponeurosis

- Posteriorly : conjoint tendon [fused common aponeurosis insertion of internal oblique

and transverse abdominus into pubic crest]

- Medially : conjoint tendon and laterally transverse fascia

- Superiorly : lower fiberz of internal oblique and transverse abdominus

- Inferiorly : inguinal ligament

- Medially : conjoint tendon

- Laterally : transversalis fascia

| P a g e 112
 - Int. Ring marked medially by Inferior epigastric artery

- External ring → lies above and medial to pubic tubercle

Canal : transmits spermatic cord and ilioinguinal nerve
{ Round ligament in females}
Spermatic cord :

- 3 nerves : ilioinguinal n.

- genitofemoral

- Sympathetic fibers
3 layers of fascia :

- External spermatic {from ext. Oblique}

- Cremastric { conjoint tendon}

- Internal spermatic { transverse fascia}

3 arteries :

- Testicular { from aorta}

- Artery of vas { external iliac}

- Cremastric { inf. Epigastric}

3 other structures:

- Vas deferns

- Pampinoform plexus of veins

- Lymphatics
Treatment :

- Reducible → contents replaced complications

- Irreducible: Adhesions if contents / healthy intestine and normal blood supply

- Strangulated → contents constricted at neck of sax, blood supply cut off and
perforation can occur
Hx :

- P/C swelling or intestinal obstruction or strangulation

- Reducible or not?

| P a g e 113
 - Site?

- of intestinal obstruction?
Risk factors :

- COPD / Lung‫ د‬chronic cough

- Causes of ↑ Intraabdominal pressure v

- Congenital defect

- Heavy load { manual workers}

- Chronic urine retention

- Past surgery

- Trauma

- Weak abdominal wall

Ex. :

- Reducible or not?!

- Site?!

- Anterior superior iliac spine

- Pubic tubercle

- Inguinal or femoral ? (if inguinal it is above and medial)

- Direct or indirect? Ring → doesn't protrude→ indirect

- Defect
Investigation :

- Clinical → US to exclude other Dx

- Pre-operative inv.
 Inguinal hernia → above and medial to pubic tubercle
 Femoral hernia → below and Lateral to pubic tubercle

| P a g e 114
 Hasselbach triangle :

- Inferior Epigastric artery

- Rectus abdominus

- Inguinal ligament
Inguinal :

- Direct :
 Pass through posterior wall of inguinal canal , medial ti inferior epigastric artery
 Acquired → protrudes when occluding internal ring.
 Strangulates rarely and doesnot extend into scrotum
 More common to recur

- Indirect :
 Most common
 Pass through internal inguinal ring , lateral to inferior epigastric artery
 Maybe congenital
 Doesnot protrude when occluding ring.
 Strangulates commonly and extend to scrotum
 Uncommon to recur
 Doesnot reduce immediately when pt lies down
 Narrow defect

- 70% right sided

Strangulated hernia :

- Seveer pain → Sx. Of intestinal obstruction.

- O/E : tender tense hernia , cannot be reduced with -ve cough impulse.

- Overlying skin become inflamed and edematous.

- Tenderness , guarding , ………….

Most common types to strangulate :

1- Femoral hernia.
2- Indirect inguinal.
3- Umbilical.
Management of inguinal hernia :
1- Congenital :
 Herniotomy at 1 year { excision of hernia sac and ligation of process vaginalis}
2- Adults:

| P a g e 115
  Herniotomy and herniorrhaphy { repair of defect }
Methods of repair of inguinal hernia :
1- Lichtenstein repair : tension free mesh.
2- Shouldice repair
3- Laparoscopic repair by mesh : for bilateral or recurrent hernias.
If surgery CI → truss
Obstructed / strangulated hernia :
Emergency surgery , resection of bowel if not viable and repair defect.
Complications of surgery:
1- Recurrence
2- Infection
3- Ilioinguinal nerve entrapment
4- Testicular ischemia
Femoral hernia

- Through femoral canal

- boundaries of femoral canal :

 anteriorly : inguinal ligament
 posteriorly : pectoral ligament
 medially: lacunar part of inguinal ligament
 laterally : femoral vein

- women { middle age }

- below and lateral to pubic tubercle

- ↑on standing and coughing

- Narrow neck → most common to strangulate

Richter's hernia :

- Femoral sac

- Part of small intestine wall herniate

- Strangulate , but no intestinal obstruction

- Cause acute peritonitis

- Management : repair by excision and closure of femoral canal

 Umbilical → congenital { exomphalus} , in pead. Surgery.
 Diaphragmatic congenital → pead. Surgery

| P a g e 116
 Paraumbilical hernia :

- Acquired hernia

- Above and below umbilicus

- Obese , multiparous, middle aged women

- Narrow defect → strangulate → omentum usually or colon and intestine

- Management :
1- Surgical excision '' may's operation''
2- Mesh repair
Epigastric hernia :

- Painfull → extraperitoneal fat

- Management : suturing defect

Incisional hernia :

- Defect on previous operation scar.

- Wide neck → rarely strangulates

- Dissection and suturing

- Most common RF is wound related

Unusual hernias:
 Obturator hernia :

- Thin , elderly women with acute intestinal obstruction

- Referred pain of obturator Nerve

- { intestinal obstruction , with pain in medial thigh in an elderly thin female}

- Richter type

- CT confirms Dx.
 Littre's hernia :

-Contains meckel's diverticulum in sac.

 Spigelian hernia:

- Passing at lateral margin of rectus sheath, through transverse abdominal and internal
oblique but beneath external oblique

| P a g e 117
  Sliding hiatal hernia:

- Stomach slides into hiatus

- anteriorly → peritoneal sac

- Posteriorlt → exta peritonial

- C/F :
1- Mechanical : cough, dyspnea, palpitations
2- Reflux : GERD symp.
3- Esophagus

- Laparoscopic repair

Urology
 Symptoms of urinary tract: Systemic, upper, and lower.
1- Systemic:
 Infection: fever, rigors, headache.
 mets: constitutional, malignancy.
 uremia: renal failure (malaise, uremic encephalopathy, bleeding)
2- Upper urinary tract symptoms:
 Pain: renal dull aching in renal angle radiates to umbilicus, or ureteric colic (colicky
pain loin to groin, as obstruction goes down, radiates to groin, testes, thigh, and
tip of the penis.

| P a g e 118
 3- Lower urinary tract symptoms:
a- Pain: Vesical (suprapubic), Prostatic (vague, referred to rectum and suprapubic),
urethral (burning), testicular (severe local radiates to RIF & LIF).
b- Micturition: LUTS
 storage problems (irritative): Frequency (Diurnal, Nocturnal), urgency, nocturia,
dysuria, urge incontinence
 Voiding (obstructive symptoms): Hesitancy, straining, sense of incomplete
voiding, drippling, urine retention.
c- Incontinence
d- Urine:
 Volume: Polyuria, oliguria <400 ml/24 hrs, anuria <200 ml
 Color and content: hematuria, pyuria, chyluria, pneumaturia, cloudy urine,
discharge, mass, hx of catheterization or trauma or schistosoma or stones.

 Investigations:
A- Lab:
1- Mid stream urine analysis: 24 hrs urine analysis (color, pH, gravity, microscopic and
biochemistry).
2- Renal function test (RFTs): Urea, BUN, creatinine, creatinine clearance, electrolytes.
3- Serum prostate specific antigen (PSA).
B- Imaging:
1- USS: abdominopelvic (morphology, obstructive uropathy, cystic & solid, calculi)
2- Plain x-ray (KUB): for radio-opaque shadows

- Intravenous urography (IVU), Cystography, Urethrography (Ascending, Micturating),

Arteriography, CT-KUB/ MRI, Cystoscopy, Urethroscopy.

Urine Retention: (SEE LATER)

 Divided into:
1- Mechanical/Neurogenic
2- OR: Acute/Chronic.
 Causes:
1- Mechanical:

- Urethral: stone, rupture, Posterior urethral valve (congenital), phimosis.

- Prostatic: BPH, or carcinoma

| P a g e 119
 - Bladder: stone, carcinoma.

-+ Fecal, paraphimosis, pregnancy.

2- Neuregenic:

-Postoperative, DM (Autonomic neuropathy), Spinal cord injury & spinal cord disease.
*According to age:

- Children: Posterior urethral valve (PUV), impacted stone, paraphimosis.

- Adults: urethral stricture, spinal cord injury.

- Elderly: CA prostate, stricture, BPH.

- generally : neurogenic, spinal cord injury, postoperatively.

 Types of Urinary retention:
1- Acute Retention: sudden painful, full bladder.
2- Chronic retention: residual urine, hesitancy.
 DDx: Anuria, ruptured Abdominal aortic aneurysm (AAA).
 Investigations:
1- To define cause: x-ray pelvis, USS, PSA, IVU.
2- To assess renal impairment: urea>7, creatinine> 150
3- Assess general condition: USS/IVU/CBC + general.
 Management:
1- Acute retention:
 Conservative: bed rest, iv analgesic, parasympathatic drug (Carbacol)
 If retention: insert two way foley catheter (*Complications: Bleeding, infection,
stricture)
 If CI: suprapubic catheter.
 +TTT underlying cause.

Urine incontinence:
- Uncontrolled escape of urine.
1- True: Ectopia vesicae/ epispadias.
2- Stress
3- Urge: with urgency, cystitis, neural cause.
4- Overflow incontinence: due to chronic retention or 2ndry to flaccid bladder results in
dribbling of urine.
5- Eneuresis.

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Hematuria: (SEE LATER)

- Frank or microscopic

- Painful or painless

- Total, terminal, initial.

- Most common causes: Stones, BPH, renal CA, Bladder CA, schistosomiasis.
Renal injuries:

- not common , Due to blunt or penetration trauma.

 Types:
1- Bruising and ecchymosis.
2- Subcapsular hematoma.
3- Lacerations.
4- Avulsion of renal artery.

*clinical features: hx of injury, pain, hematuria

*investigations: USS/IVU/CT-scan

*Mx: conservative, surgery if: persistent hematuria or progressive mass.

*Idiopathic retropeitoneal fibrosis (IRF): Urgent catheterization & ureter lysis + steroids.

Obstructive uropathy:

- Acute/Chronic, Unilateral/Bilateral, Congenital/Acquired, Complete/Partial,

Extrinsic/Intrinsic.

- Causes: according to level of obstruction:

1- Renal: stones, cong. PUJO, tumors.
2- Ureteric: lumen(stone, blood clot), wall (congenital, stricture, bilharzia, TB),
Outside(Infiltration by CA, IRF).

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 3- Bladder: Tumor in vesicoureteric junction, neurogenic bladder dysfunction.
Neck: schistosoma, tumor.
4- Prostate: BPH, carcinoma
5- Urethral: PUV, stricture.
 Pathological changes: according to site:

- Hydronephrosis, hydroureter, Thick bladder wall with diverticulum and trabeculae,

narrowed Urethra.

*N.B: acute obstructive needs urgent intervention:

1- Acute retention.
2- Calcular anuria.
3- Ligation of both ureters in surgery.

Bilateral obs: uremia and RF, if managed early it is reversible.

Complications: Stasis and infection, stone formation, rupture, renal failure and insufficiency.

Hydronephrosis:

- Dilatation of renal pelvis ans calyceal system due to obstruction.

- Causes:
1- Obstructive uropathy: bilateral when in urethra, bladder and prostate.
2- Pregnancy
3- Vesicoureteric reflux (non-obestructive).

- Clinical features: LUTS, Pain in the loin +/- swelling

- Comp: bilateral: uremia and RF.

- DDx: Hypernephroma, polycystic kidney disease, RCC.

- Invx:
1- Urine general
2- USS: size and cause
3- IVU: (retrograde pyelogram is better ), pelvic dilatation(Biconvex), loss of cupping
and clupping of calyces + delayed excretion of contrast

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 4- MAG: differentiate Obs vs Non Obs

- Management:
1- Treat the cause
2- US Guided drainage: percutaneous nephrostomy [ PCN]
3- Nephrectomy if severe.

Ureteric stricture:
- Causes: Cong (PUJO), Traumatic, inflammatory (Bilharzia/TB), Long standing tumor

- Clinical features: renal Pain, progressive hydronephrosis, recurrent UTI, Bilharzia.

- Inv.x: RFT, USS, IVU.

- Mx: surgical repair:

1- Upper two thirds (Above ischial spine) Excision & end to end anastomosis.
2- Lower third: Uretrovesical implantation, Bladder Boari`s Flap.

*N.B: Bilharziasis (lower third) and tuberculous stricture (whole and multiple) are commonest
causes.

Urinary stones:

- Males>Females, high recurrence.

- Causes:
1- Inadequate drainage and stasis and infection.
2- Dehydration.
3- Excess contents (metabolic ↑Ca+ [idiopathic/ ↑PTH), High uric acid & oxalates
4- Foreign bodies.
5- Vitamin A deficiency
6- Cystinuria

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 - Content:
1- Calcium 75%
 Oxalate, phosphate, mixed,
 Most common, radiopaque, hard, hematuria.
2- AMP (Struvite) 15%:
 Alkaline urine, radiopaque, preceded by infection
3- Uric acid: 7-9%: radiolucent
4- Cysteine.

*M.C: Ca oxalate, Largest: Struvite, Hardest: Cysteine, Radiolucent: uric acid.

*N.B : stones usually forms in pelviureteric junction/ ureter [ crossing of iliac artery] and
uretrovesical junction.

- Complications:
1- Obstruction: hydronephrosis, hydroureter, hydrocalyx.
2- Infection
3- Hematuria
4- Renal failure
5- Mtaplasia to SCC (Bladder).

- Clinical features:
 Renal and ureteric: asymptomatic, symptomatic when moves
o Renal or ureteric colic, dull aching : back, upper third: groin, middle: appendicitis,
lower: tip of penis,
o Increases with movement, nausea/vomiting, hematuria.
 Bladder: suprapubic pain, radiates to tip of penis/labia majora and on day during
micturition.
o Frequency (diurnal, nocturnal), LUTS, terminal hematuria,
 Urethra: severe pain.

- INVx:
1- Urine analysis/RFT/Metabolic screen
2- X-ray KUB
3- IVU
4- CT-KUB

*N.B: IVU; for function of kidney CT-KUB: site size density + another impacted stones.

- Management:

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 1- Pain relief: Diclofenac (normal RFT), pethidine
2- Antibiotic if infected.
3- IV fluids.

- according to site and size : renal, pelvis, ureter, bladder, urethra:

Three options:

1- Conservative
2- Interventional.
3- Open surgery.
1- Renal calculi Management:
I- Conservative: indications: (size <0.5 cm with no obstruction and no complications)
o Analgesia+ fluids& antiseptics+ alpha blockers + follow up
II- ESWL (Extracorporal shockwave lithotripsy): (Radiopaque, renal and <2cm)
*Contraindications:
1- Distal obstruction
2- Large >2cm
3- Renal failure
4- Infection
5- Stone in solitary kidney
6- Pregnancy
7- Bleeding tendency

*Complications: Hematuria, failure, embolus, ureteric obstruction.

III- Percutaneous Nephrolithotomy (PCNL):

o Indications: >2cm, cysteine, ESWL failure
o Complications: kidney bleeding, extravasation to peritoneal cavity, residual stone,
injury.
IV- Open surgery:
o Pyelolithotomy.
o Nephrolithotomy
o Pyelonephrolithotomy
o +Drainage

2- Ureteric stone Management:

- Indications: size 0.5 cm /back pressure effect/2ndry infection/persistent pain/failure of

conservative.

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 - Upper third: <1cm =ESWL, >1cm=Open surgery

- Middle third: Open surgery

- Lower third: <2cm Ureteroscopy, >2cm open surgery

*So options: Ureteroscopy, or Uretrolithotomy.

Indications:

- >1cm in upper ureter

- >2cm in lower ureter
- in middle ureter
- associated with stricture
- Failed endoscopy
3- Bladder stones:
I- Cystoscopic litholopaxy: <2cm, comp: bleeding /injury
II- Cystolithotomy: >2cm/ Multiple/ diverticulum/ very hard/ children/ crushing.

So according to site and size:

1- Conservative 2-Endoscopy(ESWL-PCNL-scopy) 3-Open lithotomy

 Renal: <0.5cm → conservative, 0.5-2cm → ESWL, >2cm → PCNL/open
 Renal pelvis and upper ureter: <0.5cm → conservative, 0.5-2cm → ESWL, >2cm [>1cm]
→ open
 Mid-ureter: > 0.5cm→ open Nephrolithotomy
 Lower ureter: <2cm → Ureteroscopy, >2cm → open surgery

*N.B: after any intervention do x-ray for any residual stone.

High recurrence so preventive measures needed:
1- High fluid intake
2- Lower calcium intake, thiazide, acidy urine
3- Lower oxalate intake (tomatoes, strawberry, tea, and chocolate)
4- lower red meat intake/alkaline urine

And treatment of UTI.

Bladder stones:

- Clinical features: suprapubic pain, frequency, terminal hematuria, cystitis.

- Causes: Primary de novo, 2ndry from the kidney.

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 - Invx: X-ray KUB, Cystoscopy (diagnostic and therapeutic).
- Mx:<2cm Cystoscopic litholopaxy or ESWL
>2cm or other indication: Cystolithotomy.

Bladder:

- Congenital
- Injury
- Stone
- Carcinoma.

*Ectopia vesicae (bladder extrophy): abdominal wall opening of the bladder, congenital and ass
with epispadias and congenital heart disease.

Mx: first 24 hrs approximation and suturing + urinary catheter.

*Bladder Trauma:
- Mostly from external source.
- Associated with pelvic fractures
- Injury: Extra peritoneal 80% most common/empty bladder, Intraperitoneal 20% most
serious, full bladder.
- Causes: Pelvic fracture (M.C.C), Blunt trauma, open injury, Iatrogenic
- Clinical features: If ruptured extra peritoneal hx of trauma + shock + Intense desire to
urinate
- O/E: swelling boggy suprapubic, DRE normal prostate, or severe hypogastric pain anuria
+ peritonism.
- Invx: 1-X-ray 2-IVU 3-USS
- Complications: Pelvic abscess, peritonitis, partial incontinence
- Management:
1- Manage shock
2- Catheterization
3- Repair
4- Antibiotic prophylaxis

Stones: see above

 *Bladder Cancer:

3 types:

1- Transitional cell CA [TCC]: smoking, rubber, cyclophosphamide.

2- Squamous cell CA [SCC]: Billharziasis, stones
3- Adenocarcinoma: remnant urachus, congenital anomalies (bladder extrophy)

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*M.C TCC

1- SCC:
- Nodular fungating type

- Direct spread

- Associated with Billharziasis due to squamous metaplasia.

- Terminal hematuria

*Clinical features: recent exaggeration of cystitis S/S, recent painful hematuria, suprapubic
pain.

*Invx: General, DRE, Urine general, RFT, CBC, IVU, USS, CT, cystoscopy and biopsy.

*Management: Radical cystectomy + urinary diversion.

2- TCC:
- Painless total hematuria: DDx TCC, RCC, TCA of pelvis and ureter

- If painful; total→ mets to plexus, clot, obstruction

- TNM classification:
I- Carcinoma in situ – Oedema
II- Non muscle invasive –superficial
III- Muscle invasive

- Investigations: Urinalysis, urine cytology, MRI/CT-scan, cystoscopy & biopsy →GS.

- Management:

Stages I&II:

1- Transurethral resection of the bladder (TURB)

+2-Intravesical immunotherapy [BCG] to prevent recurrence

+3-Chemotherapy [Mitomycin]

+Follow up for 3 yrs

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 Stage III Muscle invasive:

Palliative, Radical cystectomy or Radiotherapy or chemotherapy

+ Urinary diversion

Diversion surgery:

1- Temporary: catheter + stent + PTN

2- Permanent:
I- Ureterocolic anastomosis [ileostomy + ureterosigmoidoscopy] comp: UTI,
psychological, hypokalemia
II- Ileal pouch+ no sphincter + self-catheter

Benign Prostatic Hyperplasia:

- 50yrs , 50% of male have it

Prostate:

1- Anterior fibromuscular zone

2- peripheral zone
3- Transitional zone.

BPH: transitional zone

CA: peripheral zone

- Clinical features: depends on degree of obstruction to:

1- Asymptomatic
2- Acute urine retention [ preceded by RFs]
3- LUTS
4- Chronic urine retention
5- Renal failure
6- Hematuria
7- Vesical stone
8- VUR

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 - O/E: General (CRF), Abdomen: suprapubic mass + enlarged kidneys, DRE (the prostate
enlarged): enlarged mass smooth and firm, preserved median sulcus, rectal mucosa
moved freely over prostate, can reach upper border.

- Investigations:
1- Abdominal USS: Kidney changes and post-residual urine volume
2- Serum PSA: normal: 0-4ng/ml, > 4ng/ml→ BPH, very high CA prostate.
3- KUB/IVU
4- Transrectal USS: Biopsy [10 samples to exclude], size and pattern

- Management:
1- Medical:
 alpha blocker: Prazosin Relaxes sphincter and reduces pain
 5alpha-reductase inhibitor: Finasteride reduces size of the prostate
2- Surgical:
 Transurethral resection of the prostate (TURP)
 Open surgery: Transvesical prostatectomy, Retropubic prostatectomy (millian)

- Indications for surgery:

1- Obstructed uroflow curves.
2- Acute retention
3- Chronic retention with residual urine >200ml
4- Hematuria
5- Complication (Bladder stone)
6- Back pressure effect or frequency distressing.

- Complications of open surgery:

1- Bleeding
2- Retrograde ejaculation
3- Infection
4- Bladder neck fibrosis
5- Urethral stricture
6- Urine incontinence
7- TURP syndrome:
 Irrigation of hypotonic solution
 Hypervolemia, dilutional hyponatremia, intravascular hemolysis
 Mx: Glycine isotonic solution.

Follow up 6 years: PSA/Histology.

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 CA Prostate:

- Arise from peripheral zone mostly in aged 60 and above if <60 yrs mets from the lung.

- Clinical features: LUTS, CRF, acute urine retention, constitutional symptoms, mets (Back
pain, LL oedema, sciatica, fractures

- Increased in African Americans.

- Spread: locally (seminal vesicles), LNs (Iliac or paraortic), Blood (Bone), Lower v- /
osteoblastic

- O/E: mass, nodular, hard, can't move mucosa, can't reach upper border from it, and no
median sulcus.

- T1-T2: Early → surgery

- T3 advanced (seminal vesicles)

- Investigations:
1- PSA: > 20 ng very high, >35ng mets, >10 high suggest
2- TRUS: biopsy 15 cut
3- General investigations
4- Mets: MRI back, ALP, acid phosphatase, CXR

- Management: early radical…….

1- Radical Prostatectomy: complications (urine incontinence, sexual dysfunction)
2- Radiotherapy: palliative
3- Subcapsular orchidopexy
4- Hormonal replacement: castret if failed and resistant: Zoladex LHRH depot injection
for 3 months and PSA at 3m→ 8 ng/ml

Wait-

-Androgen antagonist.

*N.B: Frank hematuria with clots:

1- RCC 2- TCC of pelvis 3- TCC of bladder

Mx: 1- Admission and resuscitate
2- Focus hx and ex
3- Insertion of hematuria catheter (semirigid catheter) for bladder washout.

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 4- Insertion of 3 way Foley catheter to irrigate Bladder.

*N.B: FBC, LFT, coagulation in two wide cannula if blood loss: transfusion

*After washout and irrigation and investigation do APP. Invx to know cause and follow up.

*N.B: if catheter is CI do suprapubic catheter.

Urethral conditions:

1- Posterior urethral valve:

- Congenital anomaly

- Clinical features: hx of oligohydramnios, failure to pass urine, palpate bladder dull on

percussion, open to catheter

- Confirm by cystoscopy.

- Rx: valve ablation

- Complications: VUR, MCUG dx and to exclude if +ve ureter Reimplantation

2- Hypospadias:

- Ventral opening of urethral meatus

- Most common anomaly.

- Classification: Granular, coronal / Penile, penoscrotal/ perineal

- Anterior penile in 65 yrs, midpenile

- Clinical features: curved shaft+ ventral meatus, associated with inguinal hernia, UT
anomaly

- Mx; repair and no circumcision

3- Epispadias:

- Dorsum opening of meatus

- Granular, (penile, penopubic ass with incontinence), and complete

- in females bifid clitoris

- Associated with bladder extrophy

4- Phimosis and paraphimosis:

- Phimosis →Retraction of penile skin failure: acute urine retention.

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 - Mx: Circumcision

- Para: retracted and failed to go back: stricture + skin oedema + inflammation + urine
retention

- Mx: by circumcision.
Urethral trauma:

- Site of injury:
1- Membranous: pelvic fracture, abd distension, no desire to urinate, hematuria,
shock
2- Penile: urine retention, blood drops on meatus, butterfly shape bruises on
perineum ( trauma to penis)

- Dx: dye injection by:

1- Ascending cystourethrogram: urinary catheterization CI
2- PR: high riding prostate (memb.)

- Mx:
1- Suprapubic catheterization
2- Surgical repair
3- Catheter for two weeks
Urethral stricture:

- Healing by fibrosis

- depend on site
1- Membranous urethra: catheter, endoscopy, pelvic trauma, fracture
2- Bulbar urethra: STD ( gonorrhea → Hx of discharge)
3- Stones

- Clinical features: 1- LUTS (straining, dribbling)

2-Acute urine retention

3-Chronic urine retention

- Investigation: 1- Ascending cystourethrogram: narrowing

2-MCUG

- Mx:
 Direct internal visual urethrotomy

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  cystoscopy + cut fibrosis + urine catheter for two weeks

- complications recurrence do urethroplasty by graft (Best):

1- Multiple dilatation [ 100% recurrence]
2- Direct internal visual urethrotomy
3- urethroplasty with buccal mucosa graft

+follow up

*Complications of stricture:

1- CA 2-stone 3- Diverticula’s 4-Fistula 5-Extravasation

N.B: 1st→ prostatic urethra, 2nd → membranous urethra [pelvic], 3rd → bulbous /
penile urethra

Renal tumors:

- From renal parenchyma 90%: renal cell carcinoma, nephroblastoma.

- Pelvis 10%: TCC, SCC

- Hypernephroma -Grawitz’s tumor

(1) RCC: M.C tumor 75% of renal carcinoma

- males to females 2:1

- 50-70 yrs

- unilateral

- smoking doubles the risk

- Associated with von hippel landau disease VHL

- Gross: upper pole of kidney surrounded by pseudocapsule with mosaic appearance,

infiltrate the pelvis early

- Adenocarcinoma

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 - Spread: infiltrate renal pelvis, gerota’s fascia, IVC (RT), renal vein (Lt.), LNs (paraortic),
mets (bone, lung cannon balls appearance).

- Clinical features:
1- Hematuria: painless, recurrent, profuse or total hematuria.
2- Loin pain
3- Loin mass=Hard

*In 10% we see triad of painless hematuria + loin pain + loin mass.

4- Mets: pulmonary, skull

5- Constitutional symptoms
6- Secondary varicocele: old male, varicocele in left side→ RCC
7- Paraneoplasm: Renin [HTN], PTHrP [hypercalcemia], erythropoietin [polycythemia],
amyloidosis.

- Investigations: 1- USS 2-CT 3-IVU 4-Staging CXR CT-brain

- Management:
I- confined to kidney
II- confined to Gerota’s fascia
III- Involve renal vein, lymph nodes
IV- Distant mets

Radical nephrostomy + chemotherapy

(2) Wilm’s tumor (Nephroblastoma):

- 10% of childhood malignancies and 80% of genitourinary cancers in children. Associated

with neurofibromatosis.

- 3-4 years , 90% before 7 years M1:F1

- Pathology: Solitary, sharp, hemorrhagic, not invasive

- Associated anomalies: Aniridia, Hemihypertrophy, macroglossia, 30 fold risk of

neurofibromatosis, and genitourinary anomalies.

- Clinical features: Abdominal mass: smooth firm confined to one side, 1/3 → vague pain ,
microscopic hematuria, HTN: renal ischemia and increased renin

- DDx: neuroblastoma, renal swelling: hydrocele & polycystic kidney disease.

- Staging:
I- Limited to one kidney and completely excisable

| P a g e 125
 II- Beyond kidney and completely excisable
III- Residual
IV- metastasis
V- Bilateral

- Investigations:
1- General: urine catecholamine raised
2- IVU/USS/CT/CXR

- Management:
 Radical resection, if large chemotherapy + resection
 If postoperative residual radiotherapy

- Prognosis: 80% five year survival

(3) TCC of pelvis and ureter:

- Smoking

- Microscopic hematuria + renal pain + renal swelling.

- Investigation: IVU, CT-scan

- Management: Nephroureterectomy + cuff excision of the bladder (Stump)

*N.B:

- DRE for CA prostate:

I- no palpable mass
II- hard mass in one lobe obliterating the sulcus (confined)
III- Mass in prostate and tissues on either side
IV- fixed mass, bladder invasion

- Investigations in BPH:
 Frequency/volume chart
 urine flow rate: normal >15 ml/sec
 serum Hb / creatinine
 PSA free/total normal <4 >0.15
 urinalysis: infection
 USS: hydronephrosis, residual volume

*alpha reductase inhibitor effect appears after 6 months

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RCC: partial nephrectomy if: <5cm

Complete if: >5cm or in the center.

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 Pediatric surgery
Upper GI obstruction Hx of polyhydramnias, +/- vomiting (bilious/non) +/- intestinal obstruction
Fluids in neonate are half D5% + 0.45% normal saline, 120-150ml/kg/day + 10mmol K/500ml
 Vomiting: intestinal obstruction, child at birth + Hx of Polyhydramnios
DDx: 1- esophageal atresia, 2- duodenal atresia, 3- IHPS (pyloric stenosis)

1- Esophageal atresia: regurgitation not vomiting, if chocking → tracheoesophageal fistula

 Most common type: blind proximal pouch + distal TEF
Start just after birth with
 Clinical features: hx of Polyhydramnios + regurgitation + frothy saliva + chocking
the first breastfeeding & cyanosis.
 Investigations: 1- pass /NGT → arrest. 2- CXR → coiled tube + Gastric air bubble
And coiling
(fistula)
 CT and go immediately for surgery, esophogram, bronchoscopy fistula
 Mx: RT thoracotomy, ligate fistulae, divide and end to end anastomosis of
esophagus, if very ill →temporary gastrostomy. Till he is able to do thoracotomy
2- Duodenal atresia: Down’s syndrome, Hirschsprung, bilious vomiting, abdominal X-ray →
Usually the
second part
double bobble sign (DDx is Malrotation) Dilated before the stenosis and collapsed after
 Tx duodenal duodenostomy
3- Infantile hypertrophic pyloric stenosis: males > females 4:1
 Familial tendency
 2-3 weeks after birth projectile non-bilious vomiting Loss of K,Na,HCL
Test feed = tell the
mother to  O/E 1- visible peristalsis from Lt to Rt. 2- olive mass, test feed + hypokalemic
breastfeed the
child .. then you will hypochloremic metabolic alkalosis + aciduria paradoxical + succession splash (on
auscultation) Fluid sound when
see the peristalsis
moving the child

- All present with bilious vomiting except IHPS

The best
- Investigations: 1- ultrasound: >4mm. 2- Barium meal. 3- electrolytes
- Mx : preop + Fredt Ramstedt Pyloromyotomy
Normal saline with K and cloride to correct the hypokalemic hypochloremic metabolic alkalosis
4- Small bowel atresia: single or multiple, dilation and collapse (obst)
 Note: apple peel atresia (bowel distal to atresia is mesenteric reminent)
 Clinical features: bilious vomiting, distention, visible peristalsis.
 Mx :resuscitation + end to end anastomosis
 Esophagus, stomach, 1st duodenum → forgut
2nd half of the 2nd part  2nd half of duodenum and jejunum and ilium and cecum→ midgut
 Appendix and 2/3 of transverse colon and ascending colon??
5- Malrotation: of midgut
 Volvulus neonatorum

| P a g e 128
 Fibrous band
 Abn. 1- duodenojejunal junction of right of midline (Ladd band)
Cecum and appendix 2- Cecum to center obstruct first part of duodenum → distal, others → collapse
pulled superiorly
 Peritoneal band is called Ladd Band → canned duodenum to posterior
abdominal wall (1+2) + volvulus
Clinical features: 1) US abd. Mesenteric a. to v. relation
2) X-ray → double bobble sign If the ladd band obstruct the first duodenal part
3) Contrast (barium enema → Diagnostic) and gastrographin
 Mx: Ladd operation:
1) Untwisting of volvulus + return Bowel loops
2) Remove dead bowel after assessing
3) Dilate root of mesentery
4) Divide Ladd Band So dx of appendicitis will be
5) Prophylactic appendicectomy (cecum in LUQ) difficult due the abnormal
position , so remove
Failure to pass meconium: Or delayed prophylacticaly
1- Imperforate anus
2- Meconium ileus
3- Hirschsprung disease
Cystic fibrosis = thick secretion all over the body
1- Meconium ileus: with cystic fibrosis, very thick meconium, causing intestinal
obstruction.
 Clinical feature: abdominal distention, no passage of meconium, on examination
empty rectum
 Investigations: 1) x-ray → distended bowel mottled ground glass appearance
2) US
3) Enema (water soluble) + cystic fibrosis screening

 Mx: hypertonic saline or gastrographin washout of meconium, if failed or

complicated (peritonitis, perforation, obstruction → open resection, ileostomy and
anastomosis. If very distended or through x-ray
N.B. meconium peritonitis.

2- Anorectal malformation:
- VACTERL association
- imperforate anus Sphincter is existed either poor or well developed
- ± fistula (high defect or low defect)
 high defect: Rectobulbar fistula, Rectoprostatic fistula, persistent cloaca (poorly
sphincter)
 lower defect: Rectoperineal, Rectovestibular (vagina), (developed sphincters)
 Most common: Rectobulbar in males, Rectovestibular in females.

| P a g e 129
 Or delayed if there is a fistula

From the first day

- Clinical features: failure to pass meconium + abd. Distention + imperforate anus
(absent anal urge).
- Investigations: 1- lateral shot through prone radiograph (coin test), calculate
Put the child in the prone position(‫ )ساجد‬,and put a coin in the expected anus are , do
distance.
x-ray and calculate the distance to categorize it to high/lower distance
2-MRI.

- Fistulas in girls repaired electively, in boys urgently (UTI)

- Mx: resuscitate + defunctioning colostomy.
- If lower defect → anaplast +/- fistula repair.
- If high defect →posterior sagittal Anorectoplasty.

Low: Anocutaneous fistula, incision (cut back surgery), male=females.

High: males→ Rectobulbar/prostatic/ vesical
Females→ vestibular/ cloacal/ perineal
Investigations: 1- vertogram (obsolete) >1cm → high/ <1cm → low. 2- Distal logogram
Mx: 1) resuscitation. 2) Defunctioning colostomy. 3) Anorectoplasty
High→ abdominal, posterior sagittal
Low→ cruciate incision

 Hirschsprung disease: 75% in the rectum

- Aganaglionosis of large bowel, failure of migration of ganglia to distal part of bowel,
dilatation of proximal bowel, mostly in recto-sigmoid region, failure to contract and
relax.
- Associations: with down’s syndrome.
Barium enema zones = Or total absence
1-dilated (before) - Clinical features: 1) delayed meconium passage >24hrs. 2) Abdominal distention &
2-transitional (between) bilious vomiting. O/E: gush of stool on PR exam.
3-collapsed
- Investigations: 1) X-ray dilated loops 2) barium enema: 3 zones dilation 3) rectal
(aganglionic area)
biopsy: hypertrophied nerves and loss of ganglia Includes the transitional zone in colostomy
- Mx: resuscitate, temporal colostomy for 3-6 months, then pull through operation (3
staged operation: defunctioning loop colostomy+ pull through +biopsy)
- Complications: 1) fatal necrotizing enterocolitis. 2) Anastomotic leak. 3) Stricture. 4)
Decreased motility.
- Rectal biopsy findings: 1) absence of ganglia. (Submucosa, intermyentric) 2)
hypertrophied nerve endings. 3) increased neurographin A

 Necrotizing enterocolitis: Necrosis in both small and large bowl

- Associations: Preterm baby (formula milk) + Hirschsprung
- Clinical feature: ischemia + bacterial infection = abdominal distention / bilious vomiting /
bloody mucoid diarrhea + risk of septicemia.
- dx. Abdominal x-ray → pneumontasis intestinalis (gas in bowel wall).

| P a g e 131
Untreated hirschsprung : so clinically come with symptoms of hirschsprung then present with high
grade fever , bloody diarrhea, very ill, septic
 - Mx: Resuscitate, NPO/NGT suction, rectal washout, IV antibiotics, TPN. If failed or
perforated → laparotomy + (remove necrotic bowel and temporal ileostomy +
anastomosis later on).

 Congenital diaphragmatic hernia:

In the left 1) Bochdalek’s: 90%, posterolaterally bilateral. Abdominal content in chest, lung
hypoplasia, displaced apex beat, bowel sound in chest, scaphoid abdomen.
2) Morgagni’s: 10 %, central defect.
- Causes respiratory failure.Respiratory distress at birth due to hypoplasia
- Investigations: abdominal and chest X-ray
- Mx. Respiratory (not by face mask → worsens cyanosis) and circulatory support and
close defect (suture and prosthetic valve). Or mesh
- Bochdalek’s =pleuroperitoneum, posterlaterally, causes distress.
- Morgagni’s → central tendon, anterior, usually asymptomatic.
 Abdominal wall defects in children :
- Omphalocele (exomphalos)
- Gastroschisis
Omphalocele Gastroschisis

Umbilical Bowel protrusion through umbilicus Periumblical , Rt

Covered by membrane (amniotic) Not covered by a membrane
Common 2:1 Rare
Not emergency Due to the membrane Emergency
Not dehydrated dehydrated
[ NTD]
Omphalocele Mx: Dressing, till skin cover it (becomes
Mx :- umbilical hernia) then do elective hernial repair
Staged reduction
- Mx: is by staged reduction [to avoid abd. Compartment] + antiseptic cover
- N.B : both are associated with NTD and CVS anomalies [ more with omphalocele ]
- Mx. Cover with NS gauze + antiseptic + staged reduction.
 Intussusception :
- Bowel invagination into other
- M.c ileoceacal
- Intestinal obstruction Draw up
- C/F : infant , 5-10 months , with colicky abdominal pain [ crying + screaming ] + drawing
of legs + current jelly stool ( blood and mucous)
- O/E: sausage shape abdomen. , empty RT fossa, PR: for apex intussusception and blood.
- Invx : 1) abdominal US : target sign
2) Barium enema: coiled spring
- Mx. : resuscitate , reduction by pneumatic reduction or hydrostatic by enema + milking
and asses [ MBCPPC]
 Resection and deep bowel anastomosis.

| P a g e 131
US is the best option to diagnose intussusception and pyloric stenosis
 Other pead. Surgery cases:
Sacral swelling big: Spot diagnosis (OSCE case)
 sacrococyxgeal teratoma : all types of tissue , benign condition Can turns into malignant
 O/E: mass ± paraplegia + sphincteric disturbance.
More in females
DDx of neck lump in children:
Branchial cyst
(from branchial
1)Brachial cyst: ant. To sternocleidomastoid [ contains cholesterol crystals] Laterally
arch) 2)Thyroglossal cyst : with tongue protrusion Anteriorly
3) Cystic hygroma : posterior triangle , jugular lymph sac reminants

Esophageal atresia is associated with VACTERL:

 Vertebral
 Anorectal
 Cardiac
 Tracheal
 Esophageal
 Renal
 Limb anomalies

: ‫مراجعة حسن اسامة‬

1- Pic of X-ray : esophageal atresia with distal tracheoesophageal fistula

M.c type is C
- coiling of NG tube in X-ray and air in stomach
- gastric air → TEF , if not →no fistula
- excessive salivation / respiratory distress , chocking
- CXR →atelectasis + gastric air →atresia with TEF
- Confirm Dx → CXR with passing an NGT , coiling of NGT
- Anticipate antenatally : Polyhydramnios
- US
- Association with : VACTERL

Down's syndrome:
- Duodenal atresia
- Hirschsprung disease

Bilious vomiting / meconium:

1) Duodenal atresia
2) Malrotation

| P a g e 132
 2- Neonate with Down's , vomiting and abdominal distention :
- Dx. : duodenal atresia
- Invx : Definitive → barium , others →X-ray [ double bubble sign ]
- Anticipate antenatally : Polyhydramnios , US , down's Fx [ nuchal's translucency
] , PAP.A
- D.Dx : Malrotation (healthy neonate) , annular pancreas ( constrict the 2nd part
of the duodenum
- Associations : cardiac anomalies [VSD] , Hirschsprung disease
- Pathogenesis : failure of recanalization → ischemia
- Type 2 is the most common
- Down syndrome

3- Malrotation :
- Invx : UGIT contrast studies [ gastrographin / barium meal ]
- Mx. : ladd's operation + prophylactic appendectomy

4- Grunting, cyanosis, scaphoid abdomen, bowel sounds on lt. chest?

- Dx : left sided diaphragmatic hernia [ bockdaletic]
- Invx : abdominal and CXR : left side atelectasis , bowel in let side
- M.c: NPO , extracorpuscolar oxygen
- Pleuperotinium → bochdalek’s
- Central tendon → Morgagni’s
- Poor prognosis
- Displaced apex beat

5- IHPS :
- EX. Findings : 1/ olive mass in epigastric area
2/ Test feed + [visible peristalsis from left to RT side]
3/ Succession splash
- Invx : US → thickening of pylorus > 4 mm
- Mx.: Ramstedt Pyloromyotomy
- Hypokalemic hypochloremic metabolic alkalosis

Necrotizing enterocolitis:
- RF :
1. preterm
2. NSAIDs for other chronic conditions
3. Enteral feeding
4. Cow milk feeding
5. Infant of diabetic mother
6. Complication of Hirschsprung disease
- i.v: AXR → pneumontasis intestinalis [ air in wall bowel]
- Mx: NPO/ NG tube suction/ I.V abs / TPN / rectal washout
| P a g e 133
 - Indications of surgery :
1) Perforation
2) Failure of conservative management
3) Erythema of abd. Wall

 Hirschsprung disease:
- aganaglionosis of bowel , due to failure of migration of neural crest cells to myerbach
plexus
- Inv. : barium enema
Biopsy: 3
 Hypertrophy of nerve cells ending
 Absence of myenteric plexus
 Neurograffin A increased
Feeding intolerance / bilious vomiting
X-ray → multiple dilated loops of small bowel and ground glass appearance at lower abdomen?
Biliary atresia choledocal cyst
Invx HIDA scan (non-secretor), LFT /ALP
Mx. casay's operation, before 6 wks

 Intussusception :
- m.c.c of intestinal obstruction in children from 6m- 3yrs
- m.c ileocecal
- D.x : US
- Enema
- X-ray → target sign
- LN's → m. c lead point in children

Page 102

| P a g e 134
 Vascular Surgery
1- Arterial diseases. 2- Venous diseases. 3- Lymphatics.

Arterial diseases:
1- Limb ischemia
Acute

Chronic

Acute on chronic

Arteries of lower limb:

- Aorta  2 common iliac arteries  Internal iliac  External iliac  Femoral 
Popliteal  Ant. & Post. Tibial  Peroneal

A- Acute Limb Ischemia:

 Causes:
1- Arterial Embolism (90% Cardiac)  AF [Arrhythmia], MI [Mural thrombus],
CM/Left Ventricular Aneurysm/valvular
2- Thrombosis  Atherosclerosis, Hyperviscosity, AAA, Previous graft.
3- Aortic Dissection.
4- Trauma.
5- Iliofemoral DVT.
 C/F: 6Ps
- Pain.
- Paralysis/Paresis.
- Paresthesia. [Pins & Needle}
- Pulseless. *the most important*
- Pallor.
- Perishing Coldness. [Poikilothermic]
+ Poor capillary filling
* Veins empty & Guttered
* Decreased Beurger’s Angle

| P a g e 135
 * Color changes (Pale  White  Mottled)
* Absent Pulses  most important (if pulse found ) Not ischemia.
* Pain is the first symptom, can be in Groin.
 Irreversible LL ischemia:
1- Fixed color change (blue)
2- Muscle necrosis (tense calf, bulging ant. Leg and fixed planter flexion)
3- Acute Paraplegia (due to saddle embolus)
- Mottling of skin
 DDx:
1- Acute DVT.
2- Hypoperfusion.
3- Nerve compression.
4- Trauma.
5- Aortic Dissection.
 Mx and Invx: is it Acute? How far does it extend? Reversible or Not? What is the
cause?
 Invx: 1- Duplex. 2- Angiography.
- NB: Differentiate between Acute and acute on chronic (atherosclerosis , there is
claudication in chronic).
 Mx:
1- Examine Cardio and Abdomen. (Exclude other severe causes and General
investigation)
2- Morphine for pain.
3- IV fluids.
4- IV unfractionated Heparin (Loading dose 100 IU/Kg, then 18 U/Kg/hr.
o Monitor APTT [2-3 x target]
5- Cardiac care, if needed: - O2 - ECG/X-ray - Digoxin - Lasix

- Do Doppler US (Duplex).

- Emergency Embolectomy with Fogartey’s catheter, if within 6 hours

- If tissues are dead  Don’t do embolectomy  will cause Reperfusion injury.

- If confirmed Acute Limb ischemia don’t do Angiography because it will delay

diagnosis by 2-3 hours. If suspected thrombosis do it
- Embolectomy (Bilateral Arteriotomy or Transverse Arteriotomy according to site
of occlusion) using Fogartey’s catheter + Post Op Heparin.
- If thrombosis is the cause:
1- Angiography.
2- Thrombolysis (Revascularization) with streptokinase, urokinase or tPA.
3- Monitor APTT every 6 hours and complications (Anaphylaxis …….).

| P a g e 136
  Complications of Embolectomy:
1- Re-Thrombosis.
2- Dissection.
3- Distal microembolization.
4- Rupture.
5- False Aneurysm.
6- AV fistula.

B- Chronic Limb Ischemia: pain in distal muscle group (2 limbs)

 Causes:
1- Atherosclerosis [risk factors]
2- Buergers disease in males
3- Raynaud’s disease in females
 Narrowing of artery and pain in muscle groups distal occluded site.
> Calf  S. Femoral artery.
> Thigh  External iliac artery.
> Buttocks  Aortoiliac
 C/F according to Fanconi’s classification:
1- Asymptomatic
2- Intermittent claudication.
3- Rest pain.
4- Ulceration or Gangrene.
5- Absent pulse.

*Intermittent Claudication*

- Cramp pain, Induced by exercise and relieved by rest.

- Affect groups of muscles.

- Calf mostly  common femoral

- N.B.: Buttock’s claudication + impotence = Lerich’s Syndrome.

*Claudication Distance*

- Either deteriorates and narrows or improve

- Improving due to extensive collaterals.

- Always differentiate ischemic pain

Spinal claudication : pain on standing , relieved by setting down
DDx. Of intermittent claudication : 1/ arterial entrapment 2/ osteoarthritis 3/ spinal claudicaton

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 *Rest Pain*

- Agonizing burning pain, mostly in foot and toe.

- Relived by strong analgesics and elevation of the foot over edge.

- Cold limb.
 O/E:
- General: All arteries (inspection, palpation and auscultate for pulse)
- Cardio and abdominal examination
- LL:
o Trophic changes [brittle nails/skin loss/callus formation/ischemic ulcers].
o Temperature changes.
o Color change.
o Absent pulse.
+Capillary refill. +Venous Guttering. +Burgers Angle.
 N.B.: Critical Limb Ischemia:
1- Rest Pain.
2- Ulceration.
3- Gangrene.
4- ABPI < 0.3 <0.5???
 Invx:

- General examination and investigations.

- RBG - CBC - Lipid profile - Coagulation profile.

- Cardiac enzymes - RFT

- Specific:
1- Handheld Doppler Device:
 Detect pulses of ant. And post. Tibial.
 Measure ABPI (Ankle Brachial Pressure Index):
 Normal 1.0-1.2
 Mild ischemia <0.9
 Moderate <0.7
 Severe <0.5
 Critical Limb Ischemia <0.3

2- Duplex scan : Doppler US (visualize blood flow)

3- Arteriography (showing exact site of block, state of proximal artery,
degree of obstruction, presence of collaterals and distal run off vessels.

| P a g e 138
 - Conventional Angiography [Dx & Tx] ( if surgery is indicated)

- CT – Angiography (Best).

- MR – Angiography.
 Complication: injury, anaphylaxis, removal, dissection, bleeding, hematoma and
renal tox.
 Mx:

- Conservative: stabilization, control of RFs & life style medication ( stop

smoking , loose wt and exercise)

- Medical: Aspirin + clopidegrel + statins + CCB

- If failed or job dependent or critical limb, do surgery:

1- Endovascular: Percutaneous Angioplasty (PTA) + stent [ cushin balloon
catheter ]
2- Bypass grafting surgery (open surgery ) : (Saphenous v. graft, Synthetic
Dacron’s graft or PTFE)
*e.g femoropoliteal , aortofemoral

- Amputation if surgery failed. ( 3Ds: deadly , defunction, Dead) '' severe pain ''

2- Gangrene  macroscopic death of tissues due to loss of blood supply black color.
due to degradation oh HB production of iron sulphide
 5 cardinal signs:
1- Loss of pulse 2- Fixed change in color
3- Loss of heat 4- Loss of sensation 5- Loss of function
 Causes: 1) Ischemic. 2) Neuropathic [DM/leprosy]. 3)Traumatic [burns/frostbite].
4) Infective [Cl. Perfringes].
Neuropathic is the most common type in Sudan  DM
 Types:
1- Dry Gangrene [positive line of demarcation].
2- Wet Gangrene [Infection on top]
3- Gas Gangrene  Ascends 1 cm/hr. (top Emergency). Mx. : amputation below
, above knee
N.B.: if it reaches trunk  Forneal Gangrene
Most Common Cause of amputation is Diabetic Septic Food (DSF).

 Indications of Amputation:
1- Deadly (infection)
2- Dead limb (Dry Gangrene)

| P a g e 139
 3- Dead Loss (Useless/elephantiasis/Mycetoma)
 Post op. 3Ps: pain relief , physiotherapy , prosthetic.

 Complications of amputation:
1- General Surgical complications.
2- Joint contractures.
4- Psychological.
5- Immobilization complications (DVT).
6- Phantom pain.
7- Painful Neuroma  Nerve fibrosis (we should cut under tension for retraction).
8- Flap necrosis.

3- Aneurysms  Abnormal dilatation of vessel diameter [Double more than normal (2cm
in aorta)]
 Abdominal Aortic Aneurysm AAA:
- Equal to or more than 4 cm in diameter, 90% infra renal.
- Saccular / Fusiform.
- Wall atherosclerosis is the common cause.
- If asymptomatic  US Follow up every 6 months.
- If symptomatic or complicated or diameter > 5 cm or > 1 cm per year or rupture
- Mx  Open repair + Stent or grafting.
- Complications: Ruptured AA / Aortoenteric Fistula  Hematemesis.
4- AV Fistula
- Iatrogenic  Hemodialysis.
- Trauma, we will find scar.
- Congenital for example: Congenital Steel Syndrome (Subclavian Art. Stenosis
before giving Vertebral Art. … when the pt. uses his hand  Syncope).
* Dilated veins + Bruits + thrills.
- Complications:
1- Hyperdynamic circulation [Venous HTN/HF].
2- Steel Syndrome [Ischemia to distal limb].
3- Rupture (the most dangerous).
5- Diabetic Septic Food DSF
 RFs:
1- Diabetes for long period, poorly controlled and complication.
2- Food injury: (Neuropathy/Pure ischemia/Neuro ischemic/infection)
 Invx & Mx:
1- General.
2- RBG and HbA1c.
3- X-ray.

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 4- Duplex.
5- Angiography.
 Control DM.
 Determine which type in foot
1) Sensation.
2) Charcot’s joint.
3) Ulcers.
4) Ischemic 6 Ps and ABPI.
 Mx:
- Prevention
- Hospitalization.
- Rest and Elevation of foot.
- Insulin every 8 hours [Control G]
- Broad Spectrum Antibiotics and Swab for culture.
- Drainage and Debridement under GA.
- If neuropathic  Offloading + Footcare + Gabapentin + B12.
- if ischemic  assess and manage  Revascularization.
N.B.: Neck lump (pulsatile) DDs: Carotid Aneurysm / Carotid Body tumor.
PAGE 109
Venous diseases:
 Venous system:
1. Superficial veins:
- Long Saphenous v. (Anteromedial)  Femoral v. [Saphenofemoral Junction SFJ].
- Short Saphenous v. (Posterolateral)  Popliteal v. [ Saphenopopliteal Junction SPJ].
2. Deep veins
3. Perforators [communicating]
Superficial  Deep (+valves).
A- Varicose veins: Abnormally dilated Tortious elongated superficial veins.
due to valve incompetence (long standing/hereditary)  regurgitation of blood.
Primary Secondary
1D10PATH / C 2ndary to DVT/AV fistula/Pelvic
tumor/Pregnancy
Slight or Absent Painful
Distorted along short and long saphenous Haphazardly
veins Grossing groin
Minimal or absent complications Edema
Eczema
Ulceration
Lipodermatosclerosis
……………………..

| P a g e 141
  Clinical features:
1- Cosmetic disfigurement.
2- Itching.
3- Pain.
4- Aching discomfort (restless leg ) [dull heavy bursting sensation, at end of the day,
relieved by elevating legs].
5- Night cramps: Mainly with 2ndary varicose :- Swelling, pigmentation and
ulceration.
 On Examination:
1- Anatomical distribution of veins.
2- Varicosities: 1ry or 2ndary?
3- Competency of Saphenofemoral function and other communicators.
4- Condition of deep system.
5- Presence of complications.
 Saphena varix:
o Blow out in Saphenofemoral junction  cough impulse.
 Complications (mainly with 2ndary varicose veins):
1- Edema.
2- Subcutaneous bruises [Venous HTN].
3- Hemosiderin disposition ( itching , dermatitis eczema)
4- Liposclerosis.
5- Recurrent superficial thrombophlebitis.
6- Venous ulceration.
7- Rupture and bleeding.
8- Saphena varix.
N.B: Postphlebitic Syndrome after DVT  3, 4, 5, 6.
 Invx:
1- Clinical diagnosis.
2- Tourniquet and bethe's tests.
3- Duplex  Site of incompetency and accompying DVT.
 Mx:
1- Conservative: Reassurance and elastic stockings [II]
2- injection of sclerotherapy: Sodium Tetradecylsulphate.
-Risk of DVT and failure (sloughing).
-Indicated in small veins/localized/perforators.
3- Surgery: Trendelberg’s operation (Ligation of Saphenofemoral junction +
stripping)
 Complication  Nerve injury (Saphenous nerve)

| P a g e 142
  If pregnancy is the cause  Use complete elastic stockings, Toes to groin and after
delivery do surgery.
 Venous Ulcer: Medially/Painless/Surrounded by eczema and edema/red base and
takes a long time to heal.
 Mostly post-phlebitic.
 Precancerous [Mangolin ulcer + SCC]
 Mx: Elevation of foot and ulcer care + four layers of compression bandages
after ABPI measuring if No improvement take biopsy.

B- Deep Vein Thrombosis DVT:

 Hypercoagulability state, stasis and endothelial injury → Virchow’s triad.
 RFs: is Virchow’s triad plus or minus Obesity / old age / OCP.
Previous DVT / Major surgery / Trauma / Thrombophilia.
 Clinical Features: classically a triad of Pain, Tenderness and swelling unilaterally.
Plus or minus shiny skin / dilated veins / pitting edema / warm legs.
 Complications:
1- Gangrene.
2- Secondary varicose veins.
3- Venous ulcers.
4- Liposclerosis.
5- Post Phlebitic Syndrome [chronic venous insufficiency]
6- Pulmonary embolism.
 DDx: Cellulitis, Ruptured Becker’s cyst, Lymphedema, Weber Syndrome [Cong. AV
fistula], Calf hematoma.
 Diagnosis: Using Duplex and D-Dimer.
If DVT is the cause of varicosities you should treat DVT first.
 Well’s Criteria:
Hx Ex
Bedridden more or equal to 3 days Dilated veins
Paralysis Diameter more than or equal to 3 cm.
Active malignancy Pitting edema
Recent surgery Enlargement and tenderness
More than or equal to 3  High probability.
 Mx:
1- IV unfractionated Heparin loading and Maintaining doses.
2- Warfarin
3- Follow up: APTT (2x3 times) , INR (2-3 )

*Stockings*
I  Prophylaxis of DVT.

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 II  Marked varicose veins.
III  Chronic venous insufficiency or venous HTN.
IV  Lymphedema.

END 

| P a g e 144
 Diabetic Septic Foot (DSF)
- DM for long time, if short: asymptomatic +/- other micro-complications.

- Foot: wound/ulcer duo to:

 Neuropathy most common
 Ischemia most serious
 Neuroischemic

+ Septic: fever/pus due to bacterial infection

+ Ex: other problems

- Investigations:
1- RBG/HbA1c (start insulin if on oral hypoglycemic).

*Neuropathy: numbness, loss of sensation, Charcot’s joint

*Ischemia (atherosclerosis): trophic changes/callus formation/absent pulsations low ABPI< 0.9

+/-gangrene

*Neuropathic ulcers: sole

*Ischemic ulcers: lateral, painful, wide base

- Definition of diabetic foot: infection ulceration and destruction of deep tissues

associated with neurological abnormalities or PUD

- Types: ischemic, neuropathic, neuroischemic

- Edmond foster signs: Neuropathy, ischemia, swelling, deformity, callus.

- Stages of diabetic septic foot:

1- Normal foot 2-High risk foot 3-Ulcerative 4-cellulitic 5-Necrotic 6-Major
amputation
1- Normal foot: No signs
 Shoes: wide front, smooth lining, heal < 5cm
 Nails: horizontal cutting, not corners (use antiseptic)
 Control DM + stop smoking

| P a g e 145
 2- High risk foot:
 Two or more of the following signs:
 callus: shaving, if recurrent proper shoes
 Deformity: proper shoes
 Swelling: elevation + diuretics, unilateral exclude DVT, bilateral exclude HF/RF
3- Ulceration:
 Debridement + swab for C/S
 Blister: open and dressing (heal in one to two weeks).
 Nail/Thorn prick in sole (very serious!!!) clean with spirit, dress with sterile gauze
and give IV-cephalosporin.

*N.B: Causes of non-healing ulcers: Ischemia, osteomyelitis, malignant ulcer, pressure (weight
bearing).

4- Cellulitic foot:
 Infection of ulcer (yellow color/pus discharge/offensive smell)
 if severe: sepsis (fever, ill) + warm swollen leg
 Antibiotic (IV-cephalosporin) 2-3 days then orally for 10-14 days and swab for C/S.
 In debridement do x-ray for bone and remove dead. + dressing.
5- Necrotic foot (Gangrene) dry:
 reconstructive surgery
 angioplasty
 amputation
6- Major amputation:
 overwhelming life threatening sepsis
 major limb ischemia
 extensive necrosis

N.B : neuropathic → aim is offloading, neuroischemic → ain is protection of margins.

*General management: multidisciplinary team:
1- Wound: swab for c/s, debridement, intravenous antibiotics
2- Insulin + nutritional care: check HbA1c/ monitor glucose.
3- Education about post care
4- If neuropathy: offloading/ B12-gamma-globulin
Ischemia: lifestyle modification/ Aspirin & clopidogrel +/- angioplasty
5- Treatment of comorbidities.

*Prevention:

1. Glycemic control/stop smoking

2. Daily foot inspection/clean with soap and water, use moisturizer
3. Shoes inspection (support/clean/remove foreign bodies)

| P a g e 146
 4. Minor wound care
5. Avoid hot soaks, heating pads, irritating topical agents.
6. In pediatrics: correct high risk deformity.
*N.B:

- Most important factor in outcome is P.vascular Dx.

- Predictors: toe pressure/ankle pressure, percutaneous oxygen tension, signs.

- *DD of swollen deformed foot: Cellulitis & Charcot’s joint.

- Mx: Immobilize + Surgery (osteotomy, orthodesis).

50 years old salesman has diabetes for 15 year. He presented with left heel ulcer
and despite regular dressing; the ulcer didn’t heal for last 8 months.
a. Mention 3 possible causes of delayed healing?
- Ischemia
- Osteomyelitis
- Excessive Weight bearing
- Malignancy (Marjolin ulcer)

a.Mention 4 relevant points in clinical examination?

- For ischemia: absent distal Pulsations & trophic changes
- For osteomyelitis: Probe to bone test for susceptibly of osteomyelitis
- Foot wear assessment (foreign bodies, long enough, broad and deep) &
associated deformities
- Local examination of ulcer (Everted edges)
- neurological ex: 10 gram monofilament test for absent sensations & tuning fork
for vibration impairment, Motor function (tone & reflexes & deformed joints
- Color, temperature and capillary refill

b. Mention 3 Specific Investigations to do in this patient?

- For ischemia: CT-Angiography to determine the level; length of obstruction and
presence or absence of distal run off & collaterals
- For Osteomyelitis: X-Ray foot or MRI for osteomyelitis
- For excessive weight bearing: Foot Pressure studies

| P a g e 147
- For malignancy: Biopsy & send for histopathology

d. What are the specific measurements to be done in this patient?

- For ischemia; Revascularization with angioplasty or bypass.
- For osteomyelitis: Long course of Antibiotics +/- surgery
curettage/ removal of affected bone followed by antibiotics
- For excessive weight bearing; Off-loading by total contact
cast or shoes or surgery
- For malignant ulcer: Excision according to oncological
principles
- Plastic surgery consultation grafts and flaps; and O2 therapy.

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 FLUIDS AND ELECTROLYTES
FLUIDS COMPARTMENTS:

- In a 75 kg total body weight (TBW) is 60% water, which is divided into :

1- 40% is in the Intracellular fluids (ICF) where the main cation is K+.

2- 20% is in the Extracellular fluids (ECF) where the main cation is Na+, 15% of it is in
the interstitial fluid and the 5 % is in the intravascular fluids "plasma".

 So a 45 liters water is distributed as follows :

 30 L ICF

 15 L ECF [ 12 L in ISF & 3L in plasma ]

3- Third space.

NORMAL VALUES:

- Urine specific gravity 1.016

- Urine PH ≤ 5.8

- Urine output (UOP) 0.5 _ 1.0 ml∕kg ∕hr.

- Serum Na+ 135_ 145 mmol∕L

- Serum K+ 3.5 _5.0 mmol∕L

- Ca++ (corrected) 2.2 _ 2.6 mmol∕L

- Mg 1.5 _ 2.5 mmol∕L

- HCO3− 85 _ 115 mmol∕L

- Urea 2.5_ 6.7 mmol ∕L

- Creatinine 70 _ 100 mmol ∕L

| P a g e 149
DIAGNOSIS OF IMBALANCE:

1. History and examination

2. Laboratory tests

I.e from history: vomiting

GOO Metabolic Alkalosis

Small Intestinal obstruction Metabolic Acidosis

Diarrhea Metabolic Acidosis

Or

Burns loss of plasma

Sweating shrinkage of the ECF.

On EX.:

1. Jugular venous pressure ( most sensitive and accurate )

2. Tissue turgor.

3. Pulse (tachycardia and hypotension).

4. Rapid shallow breathing depending on amount of loss of the ECF.

5. Edema and rales.

6. Electrolytes (Na / K/ HCL / Blood PH).

A. WATER :
- Daily requirement : 2-3 L/d

- Dextrose 5% 4-6 pints per day

 Water depletion: thirst, oliguria and hypernatremia.
 Water excess: high volume of all fluids, nausea, vomiting and convulsion.

| P a g e 151
B. Sodium : "CNS problem"
- Main cation in the ECF

- Serum level : 135-145 mmol /L

- Daily requirement : 80- 150 mmol/L

- In a form of 0.9% normal saline: 1 pint has 77 mmol Na+ so we give 2 pints.
 HYPONATREMIA: abnormal GI loss > ECF loss >kidney and excessive urine loss.
Diuretic use and fluid overload "this is the most common cause in surgical pts"
C/O 3Cs Convulsion, confusion & coma, EX collapsed neck veins, tachycardia, low BP,
oliguria and high HCL.
TX Normal saline or ringer lactate or hypertonic saline (1.8%)
*over correction leads to heart failure and central pontine myelinolysis.
 HYPERNATRIEMIA:
C/O: high ICP, 3Cs; Convulsion, confusion & coma.
TX restrict Na ± diuretics
C. potassium : "cardiac problems"
- Main cation in ICF

- Serum level :3.5-4.5 mmol/ L

- Daily requirement : 60-80mmol/L

- In a form of KCL ampules of 20 mmol/L , replacement of potassium follows the rule

of 4:
1. UOP ≥ 40 ml/kg/hr. 2. K+ level not more ˃ 4 mmol/L. 3. Drip given over 4 hrs 4.
Max. Given in a single drip equals 40 mmol which is 2 pints.

 HYPERKALEMIA:
Causes: cell lysis, crush injury, excessive transfusion and congenital renal failure.
C/O: malaise, weakness, and arrythmia and ECF changes.
TX "AN EMERGENCY"
1. Calcium gluconate [membrane stabilizer]
2. Insulin with glucose
3. Neb. Salbutamol
4. ± NaHCO3
5. Dialysis "optimum"

| P a g e 151
  HYPOKALEMIA:
C/O: weakness and paralytic ileus (non mechanical intestinal obstruction, no pain&
no bowel sounds).
TX: KCL ampules in normal saline.
D. CALCIUM :
 Hyperkalemia; most common cause overall is primary hyperparathyroidism.
Most common cause in surgery is malignancy.
TX: Bisphosphonate
 Hypocalcemia:
Symptoms and signs:
Muscle Tetany, laryngeal spasm, circumoral numbness, finger parasthesia, Chvostek’s
sign, trousseau sign.
TX: calcium gluconate.

E.MAGNISIUM:
 High > as hyperkalemia.
 Low > MG So4- .

Types of fluids:
 Crystalloids: normal saline [NS], 5% dextrose [D5], ringer lactate [RL] and dextrose with
saline [DNS].
 Colloids > “plasma expanders “: Albumin, Hemagel, Dextran and plasma protein fraction.
[Disadvantages: ↑ anaphylactic, not cost effective, same efficacy as crystalloids].

4 D5% + 2 NS + 3 K+Ampulles
Maintenance:

- Pre operatively and post operatively : [1L = 2 pints]

 D5 % 2 PINTS + 1 KCL Ampules
 NS 0.9% 2 PINTS +1 KCL Ampules
 D5 % 2 PINTS + 1 KCL Ampules

- Patient will have 6 pints of fluids in 24hr ie 2 drips every 8 hrs.

Losses:

- Ringer lactate (best), except in the case of: vomiting and NG suction> there is
metabolic alkalosis→ give NS + K supplements.

| P a g e 152
 -
Emergency →ringer locate / NS /colloids.
Assessment of dehydration:
- Clinical / biochemical / UOP "most reliable ˂ 0.5 ml/kg/hr /↑urea & creatinine / ↑ Na

**Total potassium deficit :

( potassium deficit ) + ( daily requirement of potassium)

Deficit = ( normal value of potassium – patient’s(pt.) value of potassium ) x

bodyweight x 0.4

Daily requirement = 1 x bodyweight in kg

POST OPERATIVE INSTRUCTIONS:

1. NPO 2. NG tube insertion 3. IV Fluids 4. Monitor the vital signs 5. Fluids intake and
output charts. 6. Medications.

 K+ replacement on day 3 postop. :

Using the equation above ↑ slow infusion over 24 hours.

COMPOSIOTION OF SOME FLUIDS:

HCO3 CL K Na Fluids
28 109 ④ 135 Ringer lactate
0 109 0 154 Normal saline
0 (water & glucose) 0 0 0 5% dextrose
14 50 2 75 Whole blood
Cannulas:

Purple: 26 Yellow : 24 Blue : 22 Pink : 20 Green : 18 Grey : 16

[neonates] [pediatrics]

Investigations:

- CXR / RBG /CBC & coagulation profile / Blood grouping & cross matching / RFT / LFT / U&E

 Na deficit : [ normal Na value – observed value ] x bodyweight x 0.6 → Ex. : Pt. Na is 120,
he’s 60 kg, Deficit = [140-120]x60x0.6 =720 mcq of Na. we give ½ of deficit in 12 hrs .

| P a g e 153
 Preoperative & Postoperative Care

Preoperative assessment: [10 steps]

1. Full Hx and Ex (take note of; drugs, anaseathsia, MI, co-morbidities and repertory
surgical examination).

2. Investigation according to ASA score[American Society of Anesthesiologists] :

 Class I A: normal healthy patient.

 Class II A: patient with mild systemic disease that does not limit functional activity.

 Class III A: patient with severe systemic disease that limits functional activity.

 Class IV A: patient with severe systemic disease that poses a constant threat to life.

 Class V A: moribund patient who is not expected to survive for longer than 24 h,
either with or without surgery.

If : young : CBC + U&E Old : CXR,LFT,RFT,ECG,ECHO,EBG & coagulation.

3. Correction of HB [minimal elective is 10mg/dl and emergency up to 7] and medical

disorder.

4. Blood preparation according to [type of surgery, pt. condition and emergency],

minimum 2 units, and max. 4-8 units.

5. Mark the site of surgery.

6. Shaving [best time is on table ]

7. Fasting: 4 hrs for fluids & 8 hrs for solids, if emergency: Ng tube & suction + prokinetic
drugs ‘Metaclopramide or erythromycin ’↑gastric emptying rate.

8. List order: 1st pts with latex allergy, 2nd DM pts, 3rd cardiac pts, and last pt on the list
are those with infections [Diabetic Septic Foot DSF/MRSA].

9. Consent verbal or written.

10. Transfer to the theater.

| P a g e 154
Specific preparations:

 Obstructive jaundice :
 Vitamin K IM 10 mg /day for 2 weeks.

 Gentamycin and cephalosporin.

 IV Fluids and mannitol.

 Blood.

 PPI.

 Lactulose and bowel enemas.

 Thyroid surgery :
 Pt. euthyroid on TFTs.

 Serum baseline ca++.

 Indirect laryngoscopy [IDL] for medicolegal reasons.

 Thoracic inlet & (lateral for compression & AP for deviation) CXR.

 B. blockers “BB" & Tracheostomy tube (anticipate tracheomalacia).

 Bowel preparations: "large bowel"

 Mechanical :bowel sulphate enemas

 Chemical: laxative [Na phosphate, polyethylene glycol], PPIs and Antibiotics

[metronidazole + ceftriaxone].

 + Carbs rich fluid 2 hrs post op.

 Patents on steroids:
 Stop the oral & give high dose injectable doses before and after.

 Complications: 1.delay wound healings. 2. Wound infections. 3. Mask the sx of

postoperative complication.

 Epilepsy pts:
| P a g e 155
  Switch to injectable forms, if on Na valproate change to phenobarbital or
phenytoin.

 Pts on anticoagulants:
Mechanical valve

 Warfarin: is ANTI vit K [1972 + protein C]: stop the warfarin 3-4 day’s pre op. &
give low molecular weight heparin (LMWH), INR: 2-3.

Antidote: vit k, Prothrombin complex factors, FFP.

Complication: haemorrhage, teratogenic, skin necrosis (↓ protein C leads to temporal

hyper coagulants state leads thrombosis of the skin vessels lead to necrosis).

 Heparin: if on it stop 5-7 days pre op. →LMWH (best) & [unfractionated
heparin: short acting, ↑heparin induced thrombocytopenia, need monitoring by
APTT], antidote: protamine sulphate.

Complication: Bleeding, Osteoporosis and heparin induced thrombocytopenia.

 Continue heparin till the patient can take orally then give warfarin and stop heparin
after 2-3 days

 12 hrs before & 12 hrs after: stop heparin.

 On Aspirin :
 Stopped 7 days pre op.

 DVT / PE prophylaxis :
 Low risk 10%: young, fit patient for minor surgery→ early mobilization.

 Moderate risk: female, obese →early mobilization + TED stockings.

 High risk: 1.LMWH 5000IU before surgery. 2. Early mobilization. 3. TED stockings.
4. Intraoperative Intermittent pneumatic calf compression.

 Anemia: as above ↑.

 Chest physiotherapy & bronchodilation:

 Before surgery for smokers & respiratory problem.

| P a g e 156
 Antihypertensive :
 Continue until time of operation.*24hour preop?!

 Diabetic patients:
 Depend on the type of surgery(minor or major)& pts drugs (diet, oral
hypoglycemic agents[OHA]or insulin)

1. NPO.

2. 2. RBG 2hourly aiming for 5mmol/L.

3. 3.RFT

 If major surgery: on OHA :

1. Stop OHA 2 days before

2. Give short acting insulin every 4 hours.

3. Ommit the morning dose & post operatively return to OHA (best is the sliding scale).

 In case of emergency:

1. Glucose. 2. Short acting insulin. 3.10% KCL to prevent hypokalemia.

 Antibiotics :
 According to NICE :

1. Clean: (˂2%) NO NEED ie. Thyroid, hernia w/o mesh and varicocele.

*clean with antibiotics: hernia with mesh, bone surgery, vascular and heart valve.

2. Clean contaminated: (2-8%) ie. Biliary tract, urinary tract, appendicitis.

→Single dose 2 hours pre op or at table with induction of anaesthesia if tourniquets

before anaesthesia.

3. Contaminated : (8-20%) ie bowel surgery

→single dose before & 2 doses after.

4. Dirty: (˃20%) ie DSF, gas gangrene, peritonitis.

| P a g e 157
 →at least 5 days after & swab for culture and sensitivity.

 Bowel surgery: metronidazole & ceftriaxone.

 Head & neck: clindamycin & vancomycin.

 Sterilization: autoclave & Disinfection: iodine.

POST OPERATIVE COMPLICATIONS:

1. Hemorrhage :

 Primary →intraoperative

 Secondary → 1st 24 hours

 Reactionary → due to surgery

2. Wound complications :

I. Infection: pt : malnutrition / immune compromised / DM /hematoma *

signs: pus & pyrexia

→evacuate the pus & drain & antibiotics & dressing.

II. Poor wound healing.

III. Wound dehiscence.

IV. Burst abdomen: day 10 emergency, proceeded by pink effusion →reclose by

deep tendon suture.

V. Incisional hernia.

VI. Anastamosis breakdown.

VII. Hematoma.

3. Cardiovascular complications.

4. Lung :

I. Atelectasis: due to retain of mucus in bronchial tree→ collapse of alveoli

C/O: first day pyrexia [day 2-5] + respiratory signs [↑HR/ ↑RR/↓air
entry/dull on percussion] → do CXR/ABG/ Sputum.

| P a g e 158
 TX chest physiotherapy + analgesia + nebulized bronchodilators.
II. Mendelsohn syndrome: aspiration pneumonia from Antral secretions.
Prevented by:
Elective →NPO
Emergency →NG tube & suction
Crush →cricoid compression
TX intubation, suction, saline lavage, antibiotic and oxygen.
III. Pneumonia
IV. Pulmonary edema
V. Pulmonary embolism: 4-10 days post op. → sudden collapse, pyrexia,
hypotension, pleuritic chest pain.
VI. * Paralytic ileus: causes: pelvic + spine fracture, hypokalemia, drugs and
retroperitoneal hemorrhage.
If persists for more than 48 hours postoperatively has other cause.
TX NG tube & suction repetitively, hydration and correct the hypokalemia.
Post-operative pyrexia:

- Causes:

 Day 2 → atelectasis.

 Day 3-5→ wound infection

 Day 5 →chest infection / UTI /Thrombophlebitis

 ˃ 5 days → 1. wound infection

4. Anastomotic leak
5. Intracavity coinfection
6. Abscess

7. VTE

*[infected cannula, DVT, transfusion reaction & drug reaction]

*day 5 pyrexia 5 Ws→ wind: 1. Atelectasis 2.wound infection 3. VTE 4.UTI 5.

| P a g e 159
 BLOOD TRANSFUSION
Complications:

1. Immunologic complications:

I. Acute hemolytic reaction: fever, tachycardia and hypotension.

 TX stop infusion, cross match, IV Ringer Lactate, hydrocortisone, mannitol

and IV NaHCO3.

II. Pyogenic infection

III. Purpura

IV. Allergic reaction

2. Congestive heart failure

3. Transfusion related acute lung injury (TRALI)

4. Hyperkalemia

5. Hypocalcemia: citrate toxicity → ca gluconate

6. Air embolism.

↑K+ /↑ Mg+ / ↑PO4-/ ↓Ca++

Massive blood transfusion:

 ˃2500 ml [˃2 at once].

 ˃5000 ml [˃10 units at once].

[↑K +, ↓ Ca++, ↓ temperature & coagulation profile]

DIC:
- Wide spread activation of coagulation →to decrease fibrinogen →wide spread bleeding.

- Causes: 1. Septicaemia 2. Severe shock 3. ABO incompatibility. 4. Malignancy.

- Invx. ↑ platelets ,↑ APTT, ↑PT, ↑d dimer & ↓fibrinogen .

- TX: 1. Treat the cause 2.FFP + cryoprecipitate 3. Platelet 3. +/_ heparin [if there is
thrombosis].

| P a g e 161
 Shock
- Generalized inadequate tissue perfusion

- Compensatory mechanisms:-

1. Sympathetic – vasoconstriction – cold peripheries

2. Renin – fluid retention – decreases urine output

+exocrine effect

Types of shock:

 Hypovolemic

 Hemorrhagic

 Non- hemorrhagic

 Cardiogenic (Obstructive)

 Distributive

 Anaphylactic

 Septic

 Hypovolemic shock:-

1. Loss of blood

2. Loss of rich fluid

3. Loss of plasma – burn

Stages of shock:

| P a g e 161
 - Stage 4 _ MOF, coma &anuria

 Stage 1 → crystalloid
IV III II I
 Stage2 → crystalloids +/ >2000 1500- 750-1500 < 750 Blood
blood 2000 loss
>40 30-40 15-30 < 15 %
 Stage3 → crystalloid + EBV
blood >140 >120 >100 <100 pulse

 Stage 4 → rapid fluid + Un Resp? decreased decreased normal BP

blood + surgery
>35 30-40 20-30 14-20 RR

Neg 5-15 20-30 > 30 UOP

Lethargic confused anxious normal CNS

- N.B colloid may have anaphylactic reaction & don’t replace interstitial compartment &
no blood? After the initial 2 hrs. of fluid
* Don’t use vasopressors, unless Septic or cardiogenic
* Delayed capillary refill >2 sec
Management of hypovolemic shock:
1. ABC ( if traumatic manage as trauma )
2. 2 wide bore cannula [16, 18]
& give: Adult_ 2 L of Ringer lactate
Peads _ or 20 ml/Kg Bolus dose running & Assess
3. Active bleeding
Don’t treat hypotension
Target 90 – 100 SBP
[Stop bleeding _ treat hypotension]
Take sample for baseline investigation [CBC, Blood group &cross matching, RFT, U&E,
RBG]
4. O- blood , until cross matching
5. Monitor _ Pulse , BP , RR , UOP
?
 Central venous pressure _ pulmonary alveolar pressure? best ever
 N.B Urine output is the most practical method done to monitor?

- N.B Lines , if not

| P a g e 162
  Best _ central venous line from internal jugular vein
 If not , cubical _ (avoid dominant hand and LL )
 If not accessible
 Venous cut in the saphenous vein
 Interosseous sly in paeds

- If not responsive : Management of distributive shock (Symptoms of shock + urticarial

laryngeal edema )

- Drugs :
1- adrenaline
2- Dobutamine
3- Dopamine
4- Hydrocortisone
 Management of distributive shock :
1. ABCS
2. Remove cause
3. IV fluids _ Ringer lactate
4. IM Adrenaline 8? ml
5. Iv 10 mg of chlormphinamine?
(Anti histamine)
6. IV 100 mg of Hydrocortisone
 Neurogenic shock:

- Bradycardia
If not – trauma – self limiting

- Ttt:
1. ABC – morphine
2. Maintain spinal mobilization
3. Vasopressors [maintain BP]
4. Atropine if significant bradycardia

 Septic shock

- Part of SIRS
 Uncommon in trauma
 Not responsive to resuscitation
 E-coli , Klebsiella , Pseudomonas

- c/f :Source of infection + hot &flushed pt , bounding pulse & signs of shock

| P a g e 163
 - management :
1. ABC [restore volume, monitor CNP?, UOP ]
2. Full sepsis screen
(CBC, U&E, LFT, Clotting screen, ABG, Serum lactate, urine?
Blood / urine / sputum culture)
3. IV antibiotic
4. If abscess _ drain or / DPL
5. Ventilation
6. Inotropes [ ? , Dobutamine ]

 Cardiogenic shock

- Tension pneumothorax , most common

- Traumatic cause

- Investigation : CXR / CBC/ U&E / cardiac markers / D-dimer/ ABG/ECG

- Management
1. ABC : High flow oxygen + IV access
2. Cardiac bed
3. Morphing for pain
4. Mx if MI / MOND? if pulmonary edema
5. Correct arrhythmia
6. Correct electrolyte imbalance
7. Cardiac & CVP monitoring
8. Treat the cause

Notes about shock

- In any trauma consider hemorrhagic , hypovolemic shock

- Warm periphery think of - distributive [septic / anaphylactic ]

- Increase venous Pressure [increase JVP ] think of _ Cardiogenic Shock

- Shock → increase in lactic acid → Acidosis

- Vomiting → metabolic alkalosis , Or in small bowel obstruction → Acidosis

- Hypothermia can interfere with resuscitation so cover pt. & warm up fluids

| P a g e 164
 - Don’t forget analgesia

- UOP is the best to monitor (0.5-1.0 ml /KG / Hr?

Mr. Omer AL-Farooq:

- Initial management, in any patient of shock :

1. Preparation
2. Primary survey
3. Resuscitation
4. Adjuvant of 1ry survey
5. Secondary survey
6. Adjuvant of 2ndry survey

- UOP : Adult 0.5 ml / kg /hr

Peads 1 ml/kg/ hr

| P a g e 165
 Trauma
- Objectives :
 General principles & ATLS
 Head
 Chest
 Abdomen

- M.C.C of deaths in ages 10-40.

- RTA is the M.C.C of trauma

- Classified into
 Blunt injury
 Penetrating injury
Or
 First peak: Kills in sec e.g laceration in brain , SC , heart
 Second peak: Trauma that kills in Mins to Hrs
 ATOM FC : Airway obstruction/ Tension pneumothorax/Open chest wound /
Massive hemothorax/ Flail chest / cardiac tamponade
+ Splenic rupture
+Sub/epidural hematoma?
+pelvic fracture
 Third peak : Days to weeks (Sepsis & MOF)
Content of trauma:-
1. Preparation
2. Triage
3. Primary survey [ ABCDE ]
4. Resuscitation
5. Adjuvant of 1ry survey
6. Secondary survey
7. Adjuvant of 2ndry survey
8. Monitoring & treat the cause

1) preparation : Notify hospital & set equipment & team

2) Triage :
 Red critical Top priority

| P a g e 166
  Yellow urgent 2nd priority
 Green Delay 3rd priority
 Black Dead
3) Primary survey : ABCDE & resuscitation
i. Airway patency & cervical spine
 Check and remove FB
 Modified jaw thrust , head tilt chin lift
 Stabilize cervical spine , with collar if available
 Intubation
 Best Endotracheal tube
 Or oropharngeal /Nasopharyngeal
ii. Breathing
 Look , listen and feel
 Percussion : Dull Hemothorax
Resonant Pneumothorax
 Insert a chest tube
 High flow O2 if needed
iii. Circulation
 If bleeding , control by direct pressure or intervention
 Insert 2 wide bore cannula 16, 18
 2 L of Ringer lactate & draw blood for investigation ( test for pregnancy )
 Accesses and management of shock
 Accesses and management of wounds
iv. Disability: AVPU and GCS
 Alert
 Respond to Vocal stimuli
 Responds to Painful stimuli
 Unresponsive
v. Exposure & environment
 Control body temperature
 IV fluid warm
 Warm environment
Note: Indication for definitive airway:
1. Unconscious
2. Severe fracture
3. Risk of aspiration
4. Risk of obstruction
5. Inhalational injury

| P a g e 167
 6. Apnea
7. Inadequate Respiratory effort
8. Severe closed head injury

4) Adjuvant of 1ry survey :

1- ECG
2- Urinary catheter
3- Monitoring by ABG /Pulse oximetery /BP
4- X-Ray : Lifesaving X-ray should be done :
 cervical lateral spine
 CXR
 Pelvic X –Ray
*In Abd → FAST
N.B any complication in 1ry survey, treated in primary survey before moving to
secondary survey.
5) Secondary survey:
 History [ AMPLE]
 Head to toe assessment
 Complete neurologic exam by GCS
 Assesse for fracture
 Reconstructive surgery
*History AMPLE: Allergy, medication, past illness & pregnancy, last meal, events & environment
related to injury
6) Adjuvant of secondary survey :
 Full Invx needed [ MRI /CT/X-Ray ]
 Procedures
7) Reevaluation & monitoring & treatment of cause

Note Triad of death in intestinal trauma: Hypothermia, acidosis, coagulopathy

CHEST TRAUMA
- 20-25% of trauma deaths

- Causes
 Blunt injury  Inhalational  Aspiration
 Penetrating injury of Fib
 Crush injury  Iatrogenic

| P a g e 168
 - Causes of death in chest trauma:
 Early : Disruption of great vessel
 Late : massive internal bleeding
Cardiac tamponade
Pneumothorax undiagnosed

- When to suspect chest trauma :

 O/E ^RR /pain/hemoptysis/abnormal breathing / chest wall deformity /
contusion/ distended neck veins /hypotension unexplained /absent
breathing

- Management by 1ry survey & exclude Dx?

 Airway obstruction
 Tension Pneumothorax
 Open chest wound
 Massive hemothorax
 Flail chest
 Cardiac tamponade

 Pneumothorax

- Accumulation of air in pleural space

1- Tension pneumothorax 2- open pneumothorax
 Tension Pneumothorax:

- One way valve progressive accumulation of air into pleura

- Respiratory comprise by lung collapse

- Mediastinal shift

- Causing hemodynamic compromise (cause of death)

- C/F 3 of :
1) Respiratory distress
2) Asymmetric chest wall motion
3) Distended neck veins
4) Shifted trachea
5) Silent chest

- O/E Resonant on percussion , decrease TVF & decrease air entry

- HX

| P a g e 169
 - Management: 1 immediate decompression by large bore needle in 2nd CS
mid clavicular line & 2 chest tube with under water seal in 5th intercostal
space mid axillary line
 Open chest wound :

- Wound > 3cm in chest

- Suck air pneumothorax

-Mx by flatter valve by plaster

 Massive hemothorax

- Pleural cavity holds up to 3 L of blood

- 200 ml – 1L seen on CXR

- 90% from internal mammary a. Or intercostal a.

- 10 % from pulmonary vessel mostly hemothorax

- C/F: Same as pneumothorax , but Dull on percussion

- MX decompression by chest tube in 5th ICS Mid axillary line

 If
1L of blood drained immediately
400 m of blood every hour
Major organ injury suspected
 Operative intervention

 Localized rip fracture:

- Pain + tenderness crepitus &deformity

- Shallow breathing + inability to cough?

- 1st to 3rd rib Vascular injuries

- 9th to 11th rib Abdominal injury

- Management: Pain relief , pulmonary toilet ,observe & physiotherapy

 Flail chest :

- Segment of the chest lost its continuity with the rest of the thoracic cage

- 2 fractures per rib for at least 2 ribs

- Separate chest in respiration

| P a g e 171
 - Dyspnea chest pain paradoxical chest movement Impaired air entry and
movement

- In CXR : Segmental rib fracture in multiple fractures

Panel mainly in and out with respiration

- Management:
 ICU admission & monitoring
 Analgesia “INTERCOSTAL NERVE BLOCK”
 PPV & Respiratory support
 Fixation by K wire
 Cardiac Tamponade

- Blood in the pericardial space

- Beck’s trait: [Hypotension / raised JVP /Muffled heart sound] only in minority
of pts

- Just shock & raised JVP

- Management : Pericardiocentesis , From the xiphoid process by 45degree

toward left shoulder under ECG monitoring
 Diaphragmatic Rupture

- Blunt to chest or abdomen

- Penetrating trauma to lower chest

- C/F: Tension pneumothorax

 Occurs n left hemidiaphragm?
 Associated with splenic rupture , stomach& liver injury

- O/E : Bowel sound inside chest

- Dx: CXR

- Tx: Thoracotomy & operative repair & antibiotic

 Chest tube insertion:

- Drains pleural content & prevent pleural collection? after thoracotomy

- shouldn’t be clamped , unless when removed or changing bottle

- When to remove?
1) No leaking air or fluid
2) Inflated lung
3) Clear hemothorax on CXR

| P a g e 171
 4) No excessive bubbling
5) Fluid level <200 ml /day & declining

- Complication
 Acute : Hemothorax, Lung laceration, Diaphragmatic rupture, Bowel injury
 Late : Blockage by clot , Retained hemothorax , Post removal pneumothorax
, Empyema

-Inserted in the 5th ICS mid axillary line

 Emergency thoracotomy:

- Indication :
1) Cardiac tamponade
2) Vascular injury
3) Major air leak
4) Radiologic evidence of bronchial injury
5) Esophageal injury
6) Chest tube output > 25 ml/hr, Or 1500 ml at immediate evacuation
 RDS

- Dyspnea

- use of accessory muscle

- No speaking

- Decrease in O2 sat %

| P a g e 172
 Abdominal trauma
- Blunt injury Or Penetrating injury

-Abdominal organs :
o Intra or
o retro peritoneal [Kidney & ureters, 2nd & 3rd duodenum , Pancreas,
Cecum & Ascending colon, 2/3 descending colon, Lower rectum, Aorta
& IVC ]
 Penetrating trauma:

- Any organ at Risk

- Most common is liver & small bowel

- Mx: is according to ANS [ primary & secondary survey ]

- Exact indication of laparotomy [ see later ]

 Blunt trauma:

- RTA , falls M.C is liver & spleen

- Mx by 1ry survey & adjuvant FAST/DPL/CT/CXR/AXR

How to determine abdominal or pelvic injury?
 History
 Physical ex [ Insp/palp/per/Ausc]
 Adjuvant of 1ry survey
N.B Factors compromising exam
 Alcohol
 Brain injury & SC injury
 Pelvic injury
 N.B Adjuvant of 1ry survey in abdominal trauma :
1. Urinary catheter: Monitor UOP , Dx decompress before DPL, Diagnose
urethral injury
2. Gastric tube: Relieve distress & decompress before DPL
3. Blood & urine Invx: Blood grouping & cross matching & coagulation
profile, Pregnancy , alcohol, hematuria
4. X Ray studies
 Blunt → AP chest /AP Pelvis
 Penetrating → AP chest / AP Abdomen
5. Contrast studies
 Ct / Urethrogram
 Diagnostic studies [ FAST/DPL / CT]

| P a g e 173
 - So Adjuvant are , urinary & gastric catheter / monitoring by ABG & blood
Invest / X-Ray / Diagnostic studies
 For Blunt Trauma :-
[DPL/FAST/CT]+CXR+AXR
i. DPL:
- Highly sensitive/Detect Bowel
- Invasive / misses diaphragm &retroperitoneal organ
- Indication: unstable blunt injury / Penetrating
- Gen. → became obsolete
ii. FAST:
- Rapid/ sensitive /Repeatable
- Bowel / Diaphragm / pancreas
- Detect free fluid Intraperitoneal
iii. CT Scan :
- With contrast
- Most specific [GS]?
- Must be stable
So FAST +CT scan
 For Penetrating Trauma :-
- If hemodynamically stable:
 Lower chest _ Serial exams, Thoracoscopy? & Laparoscopy
 Ant. Abdomen _ wound exploration& DPL
 Back & Flank _ CT scan , DPL
 Indication of laparotomy:-
1) All gunshot wounds [GSW]
2) Hemodynamically stable
3) Peritonitis
4) Air under diaphragm on AXR
5) Positive CT scan +/ FAST
6) Evisceration
N.B. +ve FAST alone is not an indication for Laparotomy
[FAST Focused Assessment with sonography for trauma]
 Specific Abdominal trauma management :
- Stomach Injury :
 By penetrating trauma
 Dx: CXR + Erect Abd. XR , Blood in Ng tube
 Mx: Laparotomy & Repair
- Pancreas Injury:
 By Blunt / Penetrating
 Present as pancreatitis _ with acute hemorrhagic pancreatitis

| P a g e 174
  Dx _ CT / increase Amylase
 Mx _ conservative
- Liver Injury:
 Blunt & penetrating
 M.C Intrabdominal injured organ
 Dx: CT scan
 Mx: if unstable→ laparotomy
 Indication for non –operative Mx :
1) Stable Pt
2) No increase in pain
3) < 4 units transfused blood
4) < 500 ml blood in Abdomen on Ct scan
 Operative :
 Packing
 Diathermy for sup? .tears
 Suture for deep tears
 Resection
- Splenic Injury
 (related to stomach/ left kidney/ colon )
 Intraperitoneal organ
 9,10,11th ribs
 ? ligament / gastro splenic
 Blood – splenic artery
- Rupture of Spleen :-
 Pdf: Splenomegaly , Diseased spleen
 Types of trauma :-
1. Blunt Abd. /Lower thoracic cage
2. Penetrating trauma [ stab / GSW ]
3. Operative trauma
 Types:
I. Sub capsular Hematoma
II. Small laceration [ superficial tear ]
III. Deep tear &
IV. Avulsion of one pole of spleen
V. Complete shattered spleen
VI. Injury to vascular pedicle
 Complication to splenic Rupture:
1. Internal bleeding _ hypovolemic shock
2. Associated with other Abd. injuries
3. Splenic cyst following peri splenic hematoma
 C/F : Fatal, Classical rupture, Delayed rupture

| P a g e 175
 1) Fatal: Massie hemorrhage → shock & death
2) Classical rupture:
o Commonest presentation
o Hypovolemic shock [ increase pulse , decreases BP ,air hunger ]
 O/E : Tenderness & rigidity in left hypo chondrium spreading to abdomen + /
shifting dullness
+/ special signs:
 Balance sign : Shifting dullness on rt. Side & fixed dullness on left side
RT [free fluid] Lt. [blood clot]
 Keher’s sign : Referred pain in left shoulder + / pressing on left hypo
chondrium
 Cullen sign’s: Bluish discoloration around umbilicus
3) Delayed rupture :
o Shock → long lucid interval → 2 wks
o C/O shock due to:
 Rupture sub capsular hematoma
 Greater omentum
 Clots
 Management: according to ATLS
 In Invx:
o US / CT scan /DPL
o X ray Abdomen: Psoas shadow / fracture rib /elevated lt. diaphragm
 So Mx : Primary survey & it’s adjuvant
 Stable pts 90 %: Conservative & monitoring / IV fluids / Bed rest &
follow up
 Unstable pts: Laparotomy → either Preserve the spleen or
splenectomy
Indication for non –operative Mx:

- Hemodynamically stable pt.

- <2 L unit blood loss

- No increase in spleen hematoma in CT or US

- No decrease in serial HB

- No decrease in clinical symptoms

- No sign of other injury

- No deep or avulsion of hilum

Surgical options:
1. Splenectomy
2. suture

| P a g e 176
 3. Partial splenectomy
4. Mesh compression
5. Embolization

 If Splenectomy & child → give _ pneumococcal vaccine

Complication of splenectomy:
1. General surgical compression
2. Acute gastric dilation
3. Portal vein thrombosis
4. Pancreatic fistula?
5. Sub phrenic hematoma / abscess
6. Thrombocytopenia?
7. Post splenectomy infection
 N.B: Pt. stabbed in left abdomen & there is evisceration → Laparotomy
 US with free fluid in peritoneum → Laparotomy
N.B: Signs of urethral injury:

- Fractured ramus

- Acute urine retention

- Urethral bleeding

- Perineal ecchymosis

- High riding prostate

| P a g e 177
 Neurosurgery & Head Injuries
- Scalp-skull injury-intracranial injury-hydrocephalus-neural tube defects.
 Scalp:
1- Skin. 2- Superficial fascia [connective tissue]. 3- Occiptofrontal muscle. 4-
Loose connective tissue. 5- Pericranium.
N.B: stop bleeding by applying pressure.
 Scalp wounds:
- Contusion/ hematoma /incised wound.
- Heavy bleeding/ sharp object.
- Investigations: skull X-Ray.
- Management: closure in 2 layers.
 Scalp hematoma:
- Management: Aspiration & pressure bandage.

 Brain Injury:
- Types:
 Primary: immediate trauma →contusion /diffuse skin injury.
 Secondary: From complications [hypoxia/ edema / infection/ cerebral
bleeding]
 Skull fractures: [vault & base]:
- Open or closed
- Types:
1- Linear fracture.
2- Depressed fracture.
3- Compound comminuted fracture.
4- Fracture base of skull.
Depressed fracture:
- Skull X-ray.
- Complications: 1- Dural tears. 2- Infections. 3- Epilepsy. 4- Cosmetic
deformity.
- Management: Cranioplasty & elevation.
Compound fracture:
- Management: Remove bony fragments, debridement, closure &
prophylactic antibiotics.
- Complications:
1- Cerebral abscess. 2- Epilepsy.
Fracture base of skull:
- Blunt trauma [fall from height] leading to:
1- Escape of cerebral content [CSF]. 2- Injury of CNS & brain.
 Anterior fossa:
1- Epistaxis.
2- Periorbital ecchymosis [Raccoon’s eyes].
3- Subconjuctival hemorrhage.

| P a g e 178
 4- CSF rhinorrhea.
5- Cranial nerves [1st - 5th].
 Middle fossa:
1- Ear bleeding ± epistaxis.
2- CSF Otorrhoea.
3- epimastoid bruising and ear bruising [battle sign]
4- cranial nerves injury:
 7th: 2 types of Injury: 1- early: resolve. 2-late: permanent.
 8th.
 Posterior fossa:
1- Occipital boggy swelling.
2- Cranial nerves 9th, 10th, 11th.
 Management of fracture base of skull:
- Investigations: CT scan
1- Resuscitation & assessment of head injury.
2- Head elevation 30 degrees.
3- Prophylactic antibiotics.
4- Mannitol 20% and hyperventilation.
5- Treatment of associated brain injury.
Notes:

- CSF leakage “usually “resolves in 7-10 days.

- If there is leakage of blood & CSF there will be [Halo] sign “spreading
yellowish ring around central staining of blood’ indicates CSF presence.

- NO packing of nose or ears if CSF leakage is suspected.

Intracranial Injury: mechanism, types, assessment & management [extradural-

subdural-intracranial-subarachnoid hemorrhage].
Mechanism of injury:
 Primary sequel:
1- concussion:
 Temporary loss of consciousness -rapid weak pulse – shallow
breathing.
 Outcome: complete recovery.
2- contusion:
 Prolonged loss of consciousness- physical findings of focal neurologic
deficit.
 Headache & confusion after recovery.
3- Diffuse axonal injury:
 Prolonged loss of consciousness.
 Cushing triad [ ↑BP - ↓Pulse - ↓RR ]
 DE cerebrate positioning.
 Secondary sequels:

| P a g e 179
 1- Cerebral edema.
2- Intracranial bleeding.
3- ↓ cerebral perfusion.
4- Herniation.
5- Brain stem injury.
6- Infection.
7- CSF rhinorrhea
 Herniation:

- Caused by increased intracranial pressure.

- Types:
 Tentorial herniation: 1-fixed dilated ipsilateral pupil. 2-contralateral
hemiparesis.
 Magnum herniation: 1-Bradycardia. 2-↑BP. 3-↓RR & shallow
breathing. [Cushing triad].
Notes:
 ↑ Pco2, ↓BP, hypotonic fluids & ↑ Temperature increase cerebral injury.
 Intracranial pressure:
 Normal [5-15] mmHg, increased when ≥20 mmHg.
 Causes of increased ICP:
1- Head injury. 2-Heamorhage. 3-tumors. 4-infections. 5-cerebral
edema.
 Symptoms & signs: Headache, drowsiness, blurred vision, nausea &
vomiting, papilledema & Cushing triad [↑BP - ↓Pulse - ↓RR] due to
tentorial herniation.
 Management of raised intra cranial pressure:
1- Monitor consciousness & O2.
2- Avoid fluid overload.
3- Head elevation 20 degrees & hyperventilation.
4- Mannitol.
In some cases: dexamethasone.
[No lumbar puncture]
1- Acute extradural hematoma:

- Between Dura & bone.

- Usually low speed injury

- Associated with or without fracture

- Arterial bleeding, usually middle meningeal artery.

- Clinical feature:
1- Concussion: instant loss of consciousness. Followed by,
2- Recovery: lucid interval. Followed by,

| P a g e 181
 3- Compression: headache, decreased level of consciousness, ↓Pulse -
↑BP - ↓RR & irregular.
+ Fixed ipsilateral pupil- contralateral hemiparesis.
Note: classical presentation of lucid interval happen in 1/3 of cases.

- Imaging: CT scan
 Biconvex lens hyperdense lesion.
 Midline shift & ventricular collapse.

- Management:
 Resuscitation & stabilization
 Mannitol, head elevation & hyperventilation.
Immediate evacuation by craniotomy.

Subdural hematoma
< 1 week: acute. 1-3 weeks: sub-acute. >3weeks: chronic
2- Acute subdural hematoma:

- Following severe trauma [RTA, fall from height].

- Cortical venous bleeding.

- Associated with severe brain damage, No lucid interval.

- Commonly bilateral.

- Mortality up to 50%

- Clinical features: Severe head injury, rapid deterioration, signs of ↑

intracranial pressure, localizing signs & pupillary inequity.

- On CT scan: Crescentic hyperdense lesion.

- Management:
 Resuscitation & stabilization
 Mannitol, head elevation & hyperventilation.
Emergency craniotomy with large flab & evacuation
Post-operative monitoring.

Sub-acute subdural hematoma

Evacuation 2 Burr holes.
3- Chronic subdural hematoma:

- Elderly patient - history of low trauma 4-8 weeks before, often

forgotten.

- Clinical feature: Gradual evolution of headache, cognitive delay, ataxia,

impaired conscious levels & personality changes.

| P a g e 181
 - On examination: Bilateral extensor planter response.

- CT scan: Hypo or is Odense lesion.

- Management: Dexamethasone 4mg + Burr hole drainage.

4- Intracerebral hemorrhage:

- Primary or secondary.

- Hypertension is a risk factor.

- Management: Craniotomy & prophylactic antibiotics.

- Complications: 1- meningitis. 2-cerebral hypoxia.

 Assessment of head injury:

1- History: Pre injury state, mechanism of injury, consciousness state, amnesia
& its length, medications [anticoagulants, alcohol, anti-hypertensive].
2- Primary survey: ABCDE
1) Maintain Airways patency & stabilize cervical spine.
2) ensure adequate Breathing& O2
3) Maintain Circulation & control fluids.
4) Rapid examination to exclude other trauma.
5) Disability:
 Assess level of consciousness by GCS.
Mild GCS [13-15] - moderate [9-12] - severe < 9.
 Check pupil size & response.
 Check pulse, respiration & BP.
 Check focal neurologic deficit by CNS examination.
 Check for signs of fractures & CSF leakage.
 Assess amnesia.
 Check random blood glucose for hypoglycemia.
3- Secondary survey:
 Complete examination of head.
 Check all cranial nerves.
 Eyes.
 Limb movement.
 Back tenderness.
 Anal wink by digital rectal examination [DRE]. & check for priapism.
GCS:

- Out of 15 [eye 4, verbal 5, motor 6]

1- Eyes open:
 Spontaneously 4

| P a g e 182
  To verbal command 3
 To painful stimulus 2
 Don’t open 1
2- verbal:
 Normally oriented 5
 Confused 4
 Inappropriate / words only 3
 Sounds only 2
 No sounds 1
 Intubated T
3- Motor:
 Obey commands 6
 Localizes pain 5
 Withdrawal / flexion 4
 Abnormal flexion 3
 Extension 2
 No motor response 1
Minor injury GCS 15, moderate to severe injury GCS <13.

 Management of head injury

- Minor injury:
 Does patient need CT scan? Does he need admission?
 Monitor for 24 hours.
 GCS/pulse/BP/respiratory rate & type / pupils. Hourly.

- Major injury: GCS< 13:

 Monitor vital signs and ABCs
 Assisted ventilation.
 I.V fluid and & Nasogastric suction.
 Avoid fluid overload & maintain electrolyte balance.
 Control increased ICP by I.V mannitol, head elevation &
hyperventilation.
 Prophylactic antibiotics.

Complications:
1- Epilepsy.
2- Post-concussion syndrome.
3- Infections & empyema.
4- Secondary trauma complications.

Hospital admission criteria:

| P a g e 183
 - Confusion – skull fracture – neurologic signs –difficulty assessing patient.

Hydrocephalus:

- Abnormal accumulation of excess CSF within ventricles ± subarachnoid

space.

 Normal CSF circulation:

- Choroid plexus in lateral ventricles → foramen of Monroe → 3rd ventricle

→ Aqueduct of Sylvius →4th ventricle → foramina of Magendie & Luschka.
→ sub arachnoid space.
 Congenital hydrocephalus:
1- non communicating hydrocephalus [obstructive]:
I. Aqueduct stenosis [most common].
II. Arnold Chiari malformation. Associated with meningomyelocele.
III. Dandy walker syndrome. Cystic dilation of 4th ventricle.
IV. Cerebral malformations.
V. Tumors.
2- communicating hydrocephalus
 Clinical features:

- Developmental delay, large head, frontal bossing, prominent scalp veins,

sunken eyes.

- Sutures are separated.

- Crack pot sign on percussion of skull.

- +ve transillumination test.

 Investigations:

- Skull X-ray: sutures separation.

- USS.

-CT/MRI confirm the cause.

 Management:

- Multidisciplinary team.

- Folic acid supplementation.

- Ventriculo peritoneal shunting.

| P a g e 184
 Complications of shunts:
1- Infections. 2- Obstruction.

 Acquired hydrocephalus:

- Presents with increased ICP symptoms.

- If chronic or normal pressure type presents with gait disorder & urinary
incontinence.

- Causes: Meningitis / trauma / infections / tumors.

- Investigations: CT / MRI / CSF pressure monitoring.

- Management: Ventriculo peritoneal shunting.

Spina Bifida:

- Incomplete union of vertebral column at gestational age [6-8 weeks].

- Types: Spina bifida occulta.

Spina bifida cystica.
Spina bifida aperta.

- Differential diagnose: sacrococcageal teratoma.

- Antenatal diagnose: US & amniotic fluid analysis: ↑ alpha fetoprotein.

- Affect lumbar & sacral spine.

- Associated with hydrocephalus.

1- Spina bifida occulta :
 No herniation of neural tube
 Associated with: Hairy nevi & bluish discoloration.
2- Spina bifida cystica:
 Meningocele.
 Meningomyelocele.
 Associate with: hydrocephalus – Arnold Chiari malformation – VACTERL
association.

- Meningocele: Meninges herniate through bony defect & covered by skin.

- Myelomeningocele: Exposed neural tissues& no coverage by skin.

- Clinical features:

| P a g e 185
 1- Sphincteric disturbance [urine & bowl incontinence].
2- Paraplegia.
3- ↑ Risk of meningitis.
Paraplegia with Myelomeningocele.
Hairy naevi & pigmentation with Meningocele.

- Investigations: US → MRI.

- Management:
1- Closure of defect.
2- Immediate shunting of hydrocephalus.
3- Associated defects care.
4- Folic acid supplementation.

| P a g e 186
 Plastic surgery
1) Neurofibromatosis:
- Has 2 types : type 1 and 2
- AD → chromosome 17
- Multiple lumps → neurofibromas
 NF-1
1- Multiple neurofibromas.
2- Iris lisch nodules { hamartomas}
3- Café' au lait spots
4- ↑ blood pressure , due to rental artery stenosis and pheochromocytoma
- Neurofibromas are precancerous conditions of neurofibrosarcoma.
 NF-2 :
- Vestibular schwanoma + acoustic neuroma
- Orthopedic associations : scoliosis and pseudoartharosis of tibia
- Highly recurrent.
2) Scars :
1- Hypertrophic :
- Settle after 6 month.
- Confined to wound margin.
- Same tissue , predisposing factor is trauma
- Mx: compression theory.
2- Keloid scars:
- Within 6 month
- Can develop spontaneously
- Hormonal, ↑ in black race.
- Most commonly in → chest / neck / shoulder
- Extend beyond wound margin
- ↑ collagen secretion
- Don't resolve, ↑ risk of recurrence.
- Mx.:
 Small : injection of steroid
 Large : surgery + steroid injection
Surgery + radiation (best, 30% recurrence)
3) Skin infections :
1- Impetigo: Staph, Honey colored vesicles, highly infectious.
2- Cellulitis :
- Strept, tenderness, pain, swelling, hotness and redness.
- DDx: DVT
- Invx:
- Aspiration → exclude abscess.
- X-ray → exclude osteomyelitis.

| P a g e 187
 - Mx. IV penicillin , leg elevation and monitor leg circumference.
3- Necrotizing fasciitis:
- Polymicrobial synergistic infection
- Crepitus and spreading infection in immunocompromised pts.
- Antibiotics + proper debridement.
4- Paronychia: infection below nails, managed by :elliptical incision and
excision
5- Hidradenitis suppurativa :
- Apocrine sweat gland " axilla and groin"
- Pus and discharge sinus
- Drainage and antibiotics

Ulcers:
- BEDD mnemonic for ulcer examination (Base of ulcer, Edge of ulcer,
Discharge, Describe which structure is occupying the base of the ulcer)

- Causes :
1- Arterial →lateral malleolus.
2- Venous → medial malleolus
3- Neuropathic → sole of foot.
4- Malignancy → non healing ulcer.
5- Traumatic
- Edge and floor and discharge :
- Edge :
 Slopping →venous
 Punched → out syphilis and ischemia
 Undermined → TB
 Everted → SCC
 Rolled→ BCC
- Discharge: serous / serosanguinous/ purulent / blood.
OSCE:
Skin:

Malignancy

Skin Tumor:
- Benign lumps.
- Precancerous

| P a g e 188
 - Malignant
 Benign:
1- Hemangioma :
- From blood epithelium.
- Congenital , 60% in head
- Compressible lump.
- Surgery if : psychological , near face, bleeding
- Examples: strawberry Hemangioma, port win stain {if with SCN→ sturge
weber syndrome
2- Sebaceous cyst :
- From sebaceous gland.
- Hairy areas { scalp and axilla }
- Single or multiple { Gardner's syndrome }
- O/E: small cyst, well defined, attached to skin, punctum is present 50%,
cross fluctuation test.
- Complication :
1- Infection ( (m.c) complication '' antibiotics + drainage'')
2- Sebaceous horn
3- Ulceration
4- Local alopecia
- Mx. : elliptical incision + excision , under local anesthesia , if large general
anesthesia
3- Dermoid cyst :
- Types :
1- Congenital → Sequestration,
 Most commonly :
o External angular dermoid (near face, eye)
o Midline dermoid ( Nasal, neck)
2- Acquired → Implantation
Fingers, due to trauma

 In congenital dermoid :

- Skull x-ray or CT brain before surgery to exclude dural involvement. [ i.e.

Meningocele]

- On examination : Cystic mass, cross fluctuate, NOT attached to skin

- Mx: Surgical excision.

4- Lipoma :

- Originate from subcutaneous fat

- Very slow grower.

| P a g e 189
 - Could be :
o Solitary
o Multiple lipomas
o Diffuse lipomas deposits [ painful, called Dercum’s disease]

- Solitary lipoma, Types :

I. Subcutaneous lipoma :
 Most common
 Usually in the trunk
 Painless, non-tender mass
 Soft, lobulated (this is very characteristic of lipomas),
mobile with slippery edge, and not attached to skin.
II. Subperiosteal
III. Subfascial
IV. Intermuscular
V. Retroperitoneal : Turn into malignancy [ liposarcoma ]

- Management: Cosmetic excision.

 N.B : Dangerous lipomas :

o Submuscular
o Spinal → Paralysis
o Submucousal.

5- Ganglion :

- Cystic swelling arising from tendon sheath, containing synvioum.

- Most commonly in the wrist.

- Complications: infection, recurrence.

- On examination :
 Soft, smooth mass on the dorsum of the hand.
 +ve transillumination test.
 +ve cross fluctuation.

- Management :
 Aspiration: risk of recurrence
 Excision with bloodless field under tourniquet.

6- Nevi (Moles)

- Nevi : benign tumors of melanocytes

- Types :

| P a g e 191
  Lentigo
 Intradermal
 Junctional
 Compound → Precancerous, forms giant hairy pigmented nevi.

- Indications of surgery :
 Cosmetic
 Repeated trauma
 Suspicion of malignant transformation.

 N.B : Precancerous skin lesions :

o Squamous keratosis => Squamous cell carcinoma
o Bowen’s disease.
o Xeroderma pigmentosa
o Giant hairy pigmented Nevi.

Malignant skin tumors

Most common.
1. BCC
Best prognosis

2. SCC

Least comm.
Worst prognosis.

3. MM
1- Basal cell carcinoma :
 Most common malignant skin tumor
 Local
 More common in males
 More common in ages > 60 years.

 Risk factors :

- Prolonged exposure to Ultraviolet radiation

- Albinism and Xeroderma pigmentosa

- Immunosuppression

- Ionizing radiation.

| P a g e 191
 Clinical features :

- 90% occur in the face (cheek)

- Very slow grower.

- Starts as nodule => develops into ulcer (Rodent ulcer) => invades locally

 Rodent ulcer: Rolled edge, and invade locally.

 No spread to LN or blood.
 Management:

- Very radiosensitive.

- Radiotherapy

- Wide local excision with 0.5 cm safety margin.

- Chemotherapy.

- Cure rate: 100%, best prognosis.

2. Squamous cell carcinoma:

 Risk factors :

- Same as for BCC, in addition to Marjolin’s ulcer

 Clinical features :

- Rapidly growing tumor

- Usually in the hairy areas => scalp and forehead.

- Everted fungating ulcer.

- Arise on top of non-healing ulcer. [Marjolin’s ulcer], usually in the leg.

- Spread : locally & LN, RARELY to the blood

 Management :
I. Wide local excision with 2 cm safety margin
II. Radiotherapy (Head and neck)
Imaging on see;
 X-ray for osteolytic lesions.
 US for paraortic LN.
 CT scan.
3. Malignant melanoma (MM) :
- Predisposing Factors :
 UV radiation
 Skin type 1& 2

| P a g e 192
  Geographic
 Light eye & hair color
 Male
 Premalignant navus
 Genetics

- Types (according to growth , site , prognosis )

1) Superficial spreading melanoma :
 Horizontal gradual spread with good prognosis.
 Most common type.
2) Nodular melanoma :
 Vertical rapid spread with mets, it has poor prognosis.
3) Lentigo malignant melanoma
 In situ “Hutchinson “face.
4) Subanagual melanoma
5) Acral Lentiginous melanoma:
 Sole of foot, most common type in Sudan, poor prognosis.
History:
- Age.
- Onset.
- Major Sx & signs of malignant changes:
A → Asymmetry (raised).
B → Border irregularity.
C → Color change (darker).
D → Dimensions > 5 mm
E → Ulcer & bleeding
O/E:
- Ulceration ( local )
- Satellite lesions
- Intransient lesions
- Regional LNs: No. & mobility ( imp in staging & prognosis )

 Inspect all skin for mets

 Palpate liver / auscultate chest
 Tender bones

 Very imp signs of malignant transformation :

- Size ↑or irregular
- Pigment
- Satellite nodules
- Ulceration & bleeding
- Intransient lesions

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 - Regional LNs
 Spread :
- Local
- LNs.
- Mets: lung and
 Investigations :
- CXR
- USS >> liver & groin.
- LFT >> ALP & LDH
- CT ( if needed )
- Biopsy :
1) Excisional biopsy
 If the lesion is : 1/ < 1.5 cm
2/ Low risk lesion
 Problem is that it depends on T staging & it’s not known
2) Incisional biopsy
 If the lesion is > 1.5 cm or if it is in a disfiguring area.
 Send for histopathology for staging
 Breslow → depth
 Clarke’s → thickness
 Stage → TNM

- T → Breslow & Clark

- N → LNs

- M → mets
Clarke’s:
I) Epidermis
II) Papillary dermis
III) Junctional ( between papillary & reticular )
IV) Reticular dermis
V) Subcutaneous tissue
Breslow: (safety margin)
 T1 ( < 1 mm) (safety margin 1 cm )
 T2 ( 1-2 mm) (safety margin 2 cm )
 T3 ( 2-4 mm) (safety margin 2 cm )
 T4 ( >4 mm ) (safety margin 3 cm )
 Tx :
1. Wide local excision ( + safety margin according to Breslow )
< 1 mm (safety margin 1 cm)
1-4 mm (safety margin 2 cm)
>4mm (safety margin 3 cm)

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 2. LNs clearance
- If involved : Lymphadenectomy
- If NOT involved : elective dissection or sentinel LN biopsy
3. Adjuvant chemotherapy or immunotherapy or BCG vaccine
Very poor prognosis → Breslow 4 → survival 5 %

Burns:
 Causes :
1. Flame
2. Electrical
3. Chemical
4. Sunburn ‘
5. Friction
6. Scalds ( caused by hot fluids )
 Pathogenesis & effects of burns :
1. Hypovolemia → reflex tachycardia & splanchnic vasoconstriction (bowel
ulceration & reperfusion).
2. Loss of plasma → ↑HCT ( HCT used to monitor fluid intake )
3. Edema : Respiratory → cricothyroidectomy
Limbs → escharotomy
4. Not deficit : Metabolic acidosis , renal impairment , shock
 Priorities :
 Remove source of heat.
 Rescue pt.
 Lower time of contact.
 Lower risk of inhalational injury.
 Effects of burns :
1) Inhalational injury.
 Airway & lung injury → chemical Alveolitis.
 C/O → respiratory Sxs (Stridor , SOB )
2) CO poisoning.
3) Circumferential chest scar: Limits chest movement.
4) Shock: Hypovolemic, neurogenic or septic.
5) Limb ischemia → circumferential injury.
6) Metabolic derangement (catabolic state).
7) Stress GIT ulcers.
8) Acute kidney injury.
9) Paralytic ileus.
10) Wound infection.

 A&E Mx :

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 1. Stop further damage.
2. Airway breathing & circulation.
3. Monitoring & resuscitation.
4. Fluids.
5. Wound mx.
6. Monitor.
 Inhalational injury:
- Signs: Hoarse voice/ brassy cough/ oromucosal edema.
- Suspect when :
1) Closed space (house fire/ kitchen).
2) Unconscious patient.
3) Head and neck. 4) Nasal. 5) Oral. 6) Mucosal.

- Diagnosis:
1- symptoms(respiratory distress)and wheezes
2- bronchoscope
3- ABG/CXR/ECG.

- Management:
1) Remove from burn area.
2) ABCs: maintain airway patency, endotracheal tube, and tracheostomy
and give 100% Oxygen circulationlater.
3) Antibiotics, steroids, bronchodilator.
4) Morphine for pain.
5) Tetanus prophylaxis.
6) Proton pump inhibitor to guard from ulcers.
7) IV fluids and monitor urine output (30-50ml/kg/hr) +_ wound
management
*Resuscitation burn= 0.15% of +BSA of adults and 0.10% of + BSA of child. (BSA;
Body Surface Area)
 FLUID RESUSCITATION:

- % of burn= rule of 9

- 1 leg → 18% → both 36%

- Trunk ant. → 18% trunk post. → 18% both36%

- Arm 9% both 18%

- Face 9% perineum 1%
 TYPE OF FORMULAS:
1) Parkland→ Crystalloid: wt x %of burn x 4) over 24hrs → 1/2 in first 8 hrs from
injury and 1/2 in 16 hrs.
2) Muris and Barclay → colloid
 I ration= (Weight x % of burn /2)

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  Over 36 hrs, 6 rations.
 3 ration in first 12 hrs.
 2 rations in next 12 hrs.
 1 ration in next 12 hrs.
*last ration could be blood.
Types of fluid given:
1) FFP. 2) Human albumin solution. 3) Plasma protein fraction. 4) Ringer lactate.
Maintenance:

- Feeding and dextran saline oral :

 adults 40 ml/kg/24hrs
 children:
 100 ml/kg/24hrs for first 10kg
 50ml/kg/24hrs for 2nd 10 kg
 20 ml/kg/24hrs for rest of kgs
 Nutritional supplement:

- Increased calories and proteins

 Adults: 20 kcal/kg + 70 kcal for every 1% of burn OR 1gm/kg + 3 gm
for 1% burn protein.
 Child :60 gm /kg + 3gm for 1% of burn
 Burn wound management;

- Grade 1:superficial partial thickness (red/burn)

- Grade 2: deep partial thickness(white)

- Grade 3: full thickness burn ( fat, muscle, blood)

1- blister containing fluid, no discoloration, normal sensation, heal by 2
weeks
2- heal by painful scar
3- heal with ugly scar keloid

- contraction near joint

Partial thickness Full thickness
m.c thermal m.c electrical
Painful erythema, blister Painless, thrombosed vein, white
<3 wks to heal >3 wks to heal
No scars or contraction Scars and contraction  comatosed pt
Mx of full thickness: excision and
grafting + mesh and pressure garment

 Wound management:
1) Escharotomy and Fasciotomy for circumferential wound, wash and
2) clean wound with antiseptic and antibiotic
3) if deep, debridement until healthy tissue, and take swab

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 4) dressing : 1- antiseptic Flumanizine (silver sulfadiazine) cream
2- Mebo
3- Vaseline gauze
4- Cotton gauze and bandage.
 + Or – NG tube / + or – tetanus immunization then refer to burn unit.
 Monitoring in 24 hr by: 1) vital signs. 2) ABG every 6 hrs. 3) Urine
output. 4) Chest movement and CXR 5) RFT and U& E.
 Acute complications of burn:
1) Shock. 2) Compartment syndrome. 3) resp. failure. 4) Infection. 5)
Septic shock. 6) Electrolyte disturbance.
Long term complications:
1) Contractures. 2) Deformities. 3) Joint stiffness. 4) Pigmentory change.
5) Marjolin ulcers.
 Criteria for admission:
1) Resuscitation burn. 2) Airway and lung injury. 3) Head and neck burn.
4) Hand 5) hand and foot 6) perineal 7) electrical 8) scalds 9)
hydrochloric acid.

Wounds
 Components of wounds healing :
1. Wound contraction.
2. Granulation tissues.
3. Epithelialization.
 Stages of wound healing :
1. Hemostasis.
2. Proliferation
3. Remodeling.
 Types of wound healing :
1. By primary intention (immediate/good scar)
2. By secondary intention (ugly scar).
3. By tertiary intention (contaminated wound).

- Age, nutritional status, drugs, wound vascularity, localization, irradiation,

mobility, tension, infection and adhesions are all factors that affect wound
healing.

 Complication of wound healing :

1. Wound dehiscence.
2. Hypertrophic scar
3. Keloid scar.
4. Contracture.
5. Infection.

- Closed wound : Contusion , hematoma

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 - Open wound :
 Abrasion
 Incised wound.
 Laceration.
 Penetration.
 Bites.
 Management of open wound :
1. Primary surgery (if part of Trauma)
2. History of time and cause of injury.
3. Tetanus prophylaxis.
4. Antibiotics prophylaxis.
5. Stop bleeding and remove foreign body and dressing.
6. X-rays if fracture suspected.
 Intraoperative Wound management:
1. Clean, saline irrigation, remove foreign body and sterilize by antiseptic.
2. Repair: major artery, vein, nerve or tendon.
3. Muscles: mattress suturing.
4. Skin: clean and early → primary closure.
Contaminated or late → delayed primary closure.
Laceration → Debridement to leave healthy vascularized tissues.
 Contaminated wound :
1. Don't do nerve repair.
2. No tendon repair.
3. No close deep fascia.
4. No close of skin.
 Tissues transfer
 Large defect → Graft or Flap.
 Indications of tissue transfer :
 Anatomical defect.
 Loss of function.
 Ischemia.
 Cosmetics.
 Correction of deformity.
 Graft : Skin

-Defect in well vascularized tissues.

1- Full sickness graft: 1- for all dermis and epidermis 2- for hand and feet.
2- Partial thickness graft: 1- Epidermis + Part of the dermis. 2- Limited donor
sites and contracts.
 Flaps :

- Contains skin + other layers ( muscle , bone, fascia )

- Types :

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 1. Axial flap.
2. Myocutaneous.
3. Myofascio-osteo-cutaneous.
4. Skin flap.
5. Rotation.

- Axial flab types:

1. Local (Axial with blood source) → latissimus dorsi.
2. Regional → forehead to nose.
3. Distal → groin to hand.
4. TRAM → transverse rectus abdominus myocutanous flap.

Cleft lip and palate

 Cleft lip :
- Etiology :
1- genetic 2- consanguinity or natal exposure to alcohol / Rubella.
- Diagnosis :
 Abnormal fusion between median and frontonasal process and lateral
maxillary process.
- Unilateral 70% usually left side or bilateral
- Complete or incomplete
- Simple or with cleft palate 50%
- Doesnot interfere with suckling
- Poor teeth growth

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 - Associated with cleft palate , coloboma and microophthalia
- Management:
 Surgical repair at 3-6 months
 Infant 10 pounds in wt and Hb 10%
 Surgery is cosmotic

 Cleft palate:

- Unilateral soft palate or extends to hard palate.

- Complete or incomplete /submucosal

- Bilateral softa and hard palate.

- Problems:
1- interfere with suckling.
2- food reflux → aspiration pneumonia.
3- otitis media
4- speech defects and hearing loss
5- abnormal teething

- Management: Surgical repair at 12-18 months

Note :

- Multidisciplinary team , parents should be counselled

- Bottle or spoon feeding

- speech and hearing support

- Surgical options

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Cleft lip and palate
 Cleft lip :
- Etiology :
2- genetic 2- consanguinity or natal exposure to alcohol / Rubella.
- Diagnosis :
 Abnormal fusion between median and frontonasal process and lateral
maxillary process.
- Unilateral 70% usually left side or bilateral
- Complete or incomplete
- Simple or with cleft palate 50%
- Doesnot interfere with suckling
- Poor teeth growth
- Associated with cleft palate , coloboma and microophthalia
- Management:
 Surgical repair at 3-6 months
 Infant 10 pounds in wt and Hb 10%
 Surgery is cosmotic

 Cleft palate:

- Unilateral soft palate or extends to hard palate.

- Complete or incomplete /submucosal

- Bilateral softa and hard palate.

- Problems:
6- interfere with suckling.
7- food reflux → aspiration pneumonia.
8- otitis media
9- speech defects and hearing loss
10- abnormal teething

- Management: Surgical repair at 12-18 months

Note :

- Multidisciplinary team , parents should be counselled

- Bottle or spoon feeding

- speech and hearing support

- Surgical options

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