Surgery

trauma
INITIAL ASSESSMENT AND MANAGEMENT
The mainstay of the initial approach to the injured patient is the ATLS course. Since
its development in 1980, the ATLS course has provided a structured, standardized
approach to the injured patient that is based on the concept of rapidly identifying
and addressing life-threatening conditions during the initial assessment of the
patient.
ATLS conveys three important concepts that greatly enhance the ability to manage
injured patients, regardless of where care is provided:
1. Treat the greatest threat to life first.
2. The lack of a definitive diagnosis should not delay the application of an indicated
urgent treatment.
3. An initial, detailed history is not essential to begin the evaluation of a patient with
acute injuries.
Primary survey (the ABCs)
A. Airway:
▪ The first step in the evaluation of trauma is airway assessment and protection :
- An airway is considered protected if the patient is conscious and speaking in a
normal tone of voice.
- An airway is considered unprotected if there is an expanding hematoma or
subcutaneous emphysema in the neck, noisy or “gurgly” breathing, or a Glasgow
Coma Scale
▪ An airway should be secured before the situation becomes critical :
. In the field: an airway can be secured by intubation or cricothyroidotomy
Contraindications for Endotracheal airway
Total upper airway obstruction.
Total loss of facial/oropharyngeal landmarks.
Inability to open the mouth (eg, scleroderma or surgical wiring).
cricothyroidotomy
Intubation is not possible via the oral or nasal route:
Severe maxillofacial trauma.
Oedema of throat tissues preventing visualisation of the cords (eg, angioneurotic
oedema, anaphylaxis, burns, smoke inhalation).
Severe oropharyngeal/tracheobronchial haemorrhage.
Foreign body in upper airway.
Lack of equipment for endotracheal intubation.
Technical failure of intubation.
. In the presence of a cervical spine injury:
- Orotracheal intubation can still be done as long as the head is secured and in-line
stabilization is maintained during the procedure.
- Another option in that setting is nasotracheal intubation over a fiberoptic
bronchoscope.
. If severe maxillofacial injuries preclude the use of intubation or intubation is
unsuccessful, cricothyroidotomy may become necessary.
. In the pediatric patient population (age <12): Tracheostomy is preferred over
cricothyroidotomy due to the high risk of airway stenosis (subglottic stenosis)
A man arrives at the ER after a car accident. Paramedics on the way tried twice to
intubate the patient without success. On arrival saturation is measured 82% with
laryngeal mask, blood pressure 110/60, pulse 110, GCS 7. In addition, multiple
fractures in the face are seen. What is the appropriate next step?
When all attempts to access a definite airway have failed, a Crycothyroidotomy
should be performed.

❖ N.B: 1. Right mainstem bronchus intubation is a relatively common complication

of endotracheal intubation. ▪ It causes asymmetric chest expansion during
inspiration and markedly decreased or absent breath sounds on the left side on
auscultation.
▪ The ideal location of the distal tip of the endotracheal tube (ETT) is 2-6 cm above
the carina. ▪ Because the right mainstem bronchus diverges from the trachea at a
relatively non-acute angle, an ETT advanced too far will preferentially enter into the
right main bronchus.
▪ This results in overinflation of the right lung, underventilation of the left lung, and
asymmetric chest expansion. Auscultation will show markedly decreased or absent
breath sounds. Chest x-ray confirms the diagnosis.
▪ Repositioning the endotracheal tube by pulling back slightly will move the tip
between the carina and vocal cords and solve the problem.

Which of the following is the most appropriate method to evaluate the cervical
spine in an alert, unintoxicated, neurologically normal patient, without distracting
injuries after a motor vehicle crash?
Clinical exam to assess midline tenderness and range of motion
B. Breathing:
▪ Breath sounds indicate satisfactory ventilation:
- Absence or decrease of breath sounds may indicate a pneumothorax and/or
hemothorax and necessitate chest tube placement.
▪ Pulse oximetry indicates satisfactory oxygenation:
- Hypoxia may be secondary to airway compromise, pulmonary contusion, or
neurological injury impairing respiratory drive and necessitate intubation.

❖ N.B: ▪ Positive pressure mechanical ventilation causes an acute increase in

intrathoracic pressure, which, in a severely hypovolemic patient with low central
venous pressure, can collapse venous capacitance vessels (inferior vena cava) and
cut off venous return.
▪ This sudden loss of right ventricular preload can cause acute circulatory failure and
sudden cardiac death (SCD). ▪ In addition, sedatives used prior to intubation cause
relaxation of venous capacitance vessels and can also contribute to decreased
venous return.

C. Circulation :
▪ Clinical signs of shock include the following:
- Low BP (100 bpm).
- Tachycardia (heart rate >100 bpm).
- Low urinary output (<0.5 ml/kg/h).
▪ Patients in shock will be pale, cold, shivering, sweating, thirsty, and apprehensive.

▪ In the trauma setting:

- In the trauma setting, shock is either hypovolemic (secondary to hemorrhage and
the most common scenario) or cardiogenic (secondary to pericardial tamponade or
tension pneumothorax due to chest trauma).
- Hemorrhagic shock tends to cause collapsed neck veins due to low central venous
pressure (CVP), while cardiogenic shock tends to cause elevated CVP with jugular
venous distention.
Both processes may occur simultaneously. - In pericardial tamponade, there is
typically no respiratory distress, while in tension pneumothorax there is significant
dyspnea, loss of unilateral breath sounds, and tracheal deviation.
Secondary Survey (A review from head to toe)
A. Head Trauma:
Open fractures require wound closure. If comminuted or depressed, treat in the OR
to evaluate for any damage to the underlying brain tissue.
- Penetrating head trauma as a rule requires surgical intervention and repair of the
damage.
- Anyone with head trauma who has become unconscious gets a CT scan to look for
intracranial hematomas → If negative and neurologically intact, they can go home if
the family will awaken them frequently during the next 24 hours to make sure they
are not going into coma.
- Signs of a fracture affecting the base of the skull include raccoon eyes, rhinorrhea,
otorrhea or ecchymosis behind the ear (Battle’s sign) → CT scan of the head is
required to rule out intracranial bleeding and should be extended to include the
neck to evaluate for a cervical spinal injury → Expectant management is the rule and
antibiotics are not usually indicated.
▪ Intervention for loweing Intracranial pressure:
Head injuries are associated with high degrees of morbidity and mortality. Falls are
the most common cause of head injuries.
The treatment of intracranial bleeding is by craniotomy and drainage of the
hematoma. Craniectomy would help in case of high intracranial pressure.
Non-surgical treatment of head injury and increased ICP includes:
Elevation of the head, by elevating the head of the bed (reduces the pressure due to
gravity).
Hyperventilation (decreases the pCO2 to values of 30-35 mmHg and helps inducing
vasoconstriction at the optimal level for reducing the intracranial blood pressure
while maintaining adequate brain perfusion).
Sedation and pain control.
Hyperosmolar therapy with mannitol or hypertonic saline which helps reducing the
intracranial edema.
Inducing paralysis and administrating barbiturates in case the other therapies are
unsuccessful.

▪ Diffuse axonal injury:

- CT scan characteristically shows numerous minute punctate hemorrhages with
blurring of grey white interface. However, MRI is more sensitive than CT scan for
diagnosing diffuse axonal injury.
1. Glasgow coma scale (GCS): ▪ All trauma patients should be triaged using the
Glasgow coma scale (GCS), which can predict the severity and prognosis of coma,
during the primary survey. ▪ Maximum score 15 points (full consciousness);
minimum score 3 points (coma or death). ▪ Mild head injury: GCS score 13-15,
Moderate head injury: GCS score 9-12, Severe head injury: GCS score ≤ 8
(Indication for endotracheal intubation)
B. Neck Trauma:
Bleeding in the neck is first treated with direct pressure on the wound until
exploration is performed in the operating room.
Unstable patients are immediately taken to the operating room for exploration.
Stable patients require assessment by initial physical examination and imaging
(CTA).
Penetrating neck injuries are categorized by location:
Zone I - from the thorax to the cricoid cartilage, contains large vascular structures,
the trachea and the esophagus.
Zone II - from the cricoid cartilage to the mandibular angle and contains the carotid
and arterial artery, the jugular vein and structures of the respiratory and digestive
system. The easiest location for surgical treatment.
Zone III - between the angle of the mandible and the base of the skull, contains
blood vessels that are surgically difficult to reveal.
Traditionally, Zone II injuries have been managed directly by exploration in the
operating room. Today, however, only patients with evidence of active bleeding or
with damage to the structures of the respiratory or gastrointestinal tract require
surgical intervention.
there are voice changes and air bubbles from the wound, meaning there is evidence of
respiratory tract injury. Therefore, urgent exploration in the operating room is required.

A patient with a seat belt mark on the neck is at high risk of having an injury to the cervical
blood vessels and the best way to assess such an injury is with CTA of the neck.
D. Chest Trauma:
▪ Severe blunt trauma to the chest may cause obvious injuries such as rib fractures
with a flail chest or sucking chest wound, as well as less apparent injuries such as
pulmonary contusion, blunt cardiac injury, diaphragmatic injury, and aortic injury.
Rib fractures:
- Up to half of rib fractures will not be evident on initial chest x-ray; therefore, the
diagnosis should be highly suspected in all patients with localized chest wall
tenderness following trauma.
- Rib fractures are typically associated with significant pain, which causes
hypoventilation that may lead to atelectasis and pneumonia.
- Maintaining adequate ventilation is the main goal of rib fracture management .
DX- CXR

TX-epidural infusion is the preferred method of pain control. Pain control (analgesics),
intercostal nerve block
Pneumothorax
Accumulation of air in the pleural space. - Unilateral chest pain and dyspnea, ↓
tactile fremitus, hyperresonance, diminished breath sounds, all on the affected side.
DX: upright –chest X-ray (absence of Lung markings, lung collapse).
TX. • immediate needle decompression and chest tube placement.
Flail chest: - Flail chest is usually caused by blunt thoracic trauma (steering wheel
hitting the chest in a motor vehicle collision) and describes what occurs when ≥3
adjacent ribs fracture in ≥2 places.
- The fractured portion of the rib cage (flail segment) separates from the rest of the
chest wall and moves in a paradoxical motion on respiration.

Pain control, chest physiotherapy, and close observation

Pulmonary contusion: - Pulmonary contusion results in intraalveolar hemorrhage
and edema and complicates 25%-35% of cases of blunt thoracic trauma (BTT).
- Characteristic features include tachypnea, tachycardia, and hypoxia with rales and
decreased breath sounds, all of which develop.
Blunt cardiac injury:
- Blunt cardiac injury should be suspected with the presence of sternal fractures.
ECG monitoring will detect any abnormalities (arrythmia).
- An urgent echocardiogram should be obtained in patients with blunt chest trauma
and signs of acute heart failure or shock

▪ Traumatic rupture of the diaphragm:

- Blunt abdominal trauma can cause a sudden increase in intraabdominal pressure
that overcomes the muscular strength of the diaphragm and leads to large radial
tears in the muscle.
- The resultant diaphragmatic rupture allows leakage of intraabdominal contents
into the chest, causing compression of the lungs and mediastinal deviation.
- Diaphragmatic rupture is more common on the left side because the right side
tends to be protected by the liver.
- Patients can acutely present with respiratory distress, but some patients with
smaller ruptures can have a delayed presentation with nausea and vomiting.
- Chest x-ray showing a nasogastric tube in the pulmonary cavity is diagnostic.
In case there is a suspicion for rupture following imaging, surgical exploration is
required. However, if the patient does not have another indication for laparotomy- a
laparoscopy or a thoracoscopy should be performed.
▪ Traumatic rupture of the aorta is the ultimate “hidden injury ”:
- For patients involved in motor vehicle accidents or falls from > 10 feet (3 m),
physicians must have a high suspicion for blunt aortic injury.
- Traumatic rupture of the aorta most commonly occurs at the junction of the arch
and the descending aorta (aortic isthmus) where the relatively mobile aorta is
tethered by the ligamentum arteriosum.
- Suspicion should be triggered by one of the following:
o Mechanism of injury.
o Widened mediastinum on chest x-ray.
o Presence of atypical fractures such as the first rib, scapula, or sternum, which
requires great force to fracture.
- Chest x-ray is the initial screening test and widening of the mediastinum is the most
sensitive finding. The diagnosis can be confirmed via CT angiogram.
- Management of patients with established aortic injury includes antihypertensive
therapy where appropriate and immediate operative repair.

Traumatic rupture of the trachea or major bronchus:

- Traumatic rupture of the trachea or major bronchus is suggested by developing
subcutaneous emphysema in the upper chest and lower neck, or by a large “air leak”
from a chest tube.
- Chest x-ray and CT scan confirm the presence of air outside the bronchopulmonary
tree, and fiberoptic bronchoscopy is necessary to identify the injury and allow
intubation past the injury to secure an airway.
- Surgical repair is indicated.
• Tx. • Pericardiocentesis • Cardiac window • Avoid diuretics .
• Penetrating trauma (stab wound) → sternotomy.

Fat embolism:
- Fat embolism may also produce respiratory distress in a trauma patient who may
not have necessarily suffered chest trauma.
- The typical setting is the following: o The development of the classic triad
respiratory distress, diffuse neurological impairment (confusion), and an upper body
petechial rash (due to thrombocytopenia) within days of severe long bone fractures
is characteristic of the fat embolism syndrome.
o Diagnosis can be confirmed by presence of fat droplets in urine or presence of
intra-arterial fat globules on fundoscopy. Serial x-ray shows increasing diffuse
bilateral pulmonary infiltrates within 24-48 hours of onset of clinical findings.
o The mainstay of therapy is respiratory support. Use of heparin, steroids, and low
molecular weight dextran is controversial.
Hemothorax:
- Hemothorax happens the same way but the affected side will be dull to percussion
due to blood accumulation in the pleural space.
- After blunt chest trauma, hemorrhagic shock associated with decreased breath
sounds and dullness to percussion over one hemithorax and contralateral tracheal
deviation is most likely due to a large ipsilateral hemothorax.
immediate thoracotomy is indicated for more than
Over 1500mm of blood after insertion of a chest tube.
Drainage of over 300 ml/hour, during 3 consecutive hours or 200 ml/hour after 2-4
hours (according to ATLS).
Large air leak and pneumothorax that is not controlled by a chest tube.
Appearance of the GI content in the chest tube.

• Hemodynamically stable: chest tube insertion in constant rate of no more than 300
mL/ hr over several hours.
Abdominal Trauma:
▪ For the sake of evaluation and management, abdominal trauma is divided into
penetrating and blunt trauma based on the mechanism of injury.
▪ Penetrating trauma is further differentiated into gunshot wounds and stab wounds.
▪ Any penetrating injury in the thorax below the 4th intercostal space (level of the
nipples) has potential to also involve the abdomen through the diaphragm and is
assumed to involve both compartments until proven otherwise.
▪ Gunshot wounds: - Gunshot wounds to the abdomen require exploratory
laparotomy for evaluation and possible repair of intra-abdominal injuries (almost
always penetrate peritoneum → cause intraperitoneal organ injury), not to “remove
the bullet”.
▪ Stab wounds: - Following completion of the primary survey, the evaluation of
patients with penetrating abdominal trauma (PAT) should focus on identifying
potentially life-threatening indications for urgent exploratory laparotomy to prevent
sepsis or exsanguinating hemorrhage.

In the absence of the conditions aboven

(indication for urgent exploratory laparotomy), local wound exploration may be
performed in the ED to assess whether or not the anterior rectus fascia has been
penetrated (determine if there is penetration into the peritoneal space):
o If the fascia is not violated → the intra-abdominal cavity likely has not been
penetrated and no further intervention is necessary.
o If the fascia has been violated → surgical exploration is indicated to evaluate for
bowel or vascular injury
Blunt abdominal trauma = FAST scan
• -FAST shows blood in the peritoneum and the patient is unstable → laparotomy
(not laparoscopy).
• -FAST shows blood in the peritoneum and the patient is stable → CT after FAST
• -FAST is limited/equivocal and the patient is unstable → DPL , and then,
laparotomy.
• The most frequently injured solid organ in penetrating trauma is the liver.
• The most frequently injured solid organs in blunt trauma are the liver and spleen.
If surgical exploration is indicated for penetrating or blunt trauma, certain principles
must be employed:
1. Prolonged surgical time and ongoing bleeding can lead to the “triad of death” →
hypothermia, coagulopathy, and acidosis
Specific means of preventing the initiation of the lethal triad are as follows:
Aggressively warming trauma patients
Concept of hemostatic resuscitation and permissive hypotension
Massive transfusion protocols and transfusion of blood products in specific ratios (ie:
packed red blood cells, fresh frozen plasma and platelets in a ratio of 1:1:1)
2.

The term Damage Control was coined by Rotondo and associates in order to
describe the approach in treating a trauma patient which deteriorates to death, and
its principles are:
Stopping the bleeding quickly in order to achieve hemostasis- by packing.
Hollow organs- primary repair or resection without anastomosis in order to reduce
the time of the operation.
Temporary closure of the thoracic cavity or the abdomen- usually by vacuum closure
in order to prevent the creation of elevated intra-abdominal pressure, and to control
the drainage of fluids.
Continuing resuscitation and stabilization of the patient in the ICU.
Returning to the operation room when the patient does not have acidosis,
hypothermia or coagulopathy.
▪ Ruptured spleen:
- The most common intra-abdominal organ Injuries due to BAT are hepatic and
splenic lacerations.
- Splenic injury is most likely in the setting of abdominal pain, tachycardia and left
chest wall and shoulder pain without evidence of abnormalities of the shoulder
(likely referred pain due to phrenic nerve irritation from splenic hemorrhage) .
• Unstable + nonresponsive fluids = laparotomy
• Unstable + responsive to fluids = CT
The treatment of splenic injuries depends on the patient's hemodynamic statust and
on the degree of bleeding control.
In cases of unstable patients with abdominal free fluid on FAST, surgery is indicaded.
In most cases, the bleeding would originate from the spleen, therefore it needs to be
removed.
In cases of stable patients who have no active bleeding from the spleen (seen on a
CT scan), an angiography should be considered, and if necessary, embolization.
In cases of stable patients with no evidence of active bleeding from the spleen,
admission and observation should be considered (preferably in the ICU, where the
observation is more intensive).
Surgical treatment should be considered for patients with a severe degree of injury,
and for elderly patients in which the failure rates of conservative treatment are
higher.
In case a splenectomy was performed, the patient should be vaccinated against
encapsulated bacteria (Streptococcus pneumoniae, Neisseria meningitidis and
Hemophilus influenzae).

A 5-year-old boy fell from the second floor of a building. He is hemodynamically

stable. CT reveals splenic rupture of grade V. Which of the following is the best
treatment option now?
Splenic injuries are very common in children and usually treated non -surgically,
unless the patient is hemodynamically unstable. <12 age
The indication for angioembolization treatment is not as clear in children as it is in
adults.Observation at ICU

The most common organism that causes infection after splenectomy is

Streptococcus pneumonia which is responsible for 50-90% of cases.
In case of evidence of active bleeding on CT, in a hemodynamically stable patient,
angiography with embolization can be performed.

▪ For penetrating trauma: operative management

▪ For blunt trauma: observation if the patient is stable with no peritoneal signs and
can be assessed by CT , repeat CT after 2-3 days to check the injury
• Operative management is needed for hemodynamically unstable patient usually
from stage III liver laceration or higher
. Duodenal hematomas
are more commonly seen in pediatric patients and most often occur following blunt
abdominal trauma.
▪ They are more commonly seen in children due to a number of anatomic
differences, including thinner abdominal wall musculature, less abdominal adipose
tissue and more pliable ribs (which absorb less force than the stiffer ribs of adults).
▪ DH commonly occurs when a blunt force rapidly compresses the duodenum against
the vertebral column. Following trauma, blood collects between the submucosal and
muscular layers of the duodenum causing partial or complete obstruction.
▪ Patients classically present 24-36 hours after the initial event with epigastric pain
and vomiting due to failure to pass gastric contents beyond the obstructing
hematoma.
▪ Diagnosis is confirmed with CT imaging of the abdomen. ▪ Most DHs will resolve in
1-2 weeks.
▪ Management involves decompression by nasogastric tube and, in many patients,
parenteral nutrition. ▪ Surgery or percutaneous drainage may be considered to
evacuate the hematoma if nonoperative management fails.
1-SMA injury requires its repair by primary anastomosis or placement of a venous
graft. Ligation of the SMA would result in impaired blood supply to the intestines.
The main branches of the SMA are right colic, middle colic, inferior
pancreaticoduodenal and ileocolic.
2-The term “acute abdomen” is used to describe a typical clinical presentation that
usually requires surgical treatment. In the absence of peritoneal signs and in setting
of acidosis and increased lactate levels, CT should be done. However, if peritoneal
signs are present, abdominal X RAY is done
3-Which of the following is correct with regards to diagnostic laparoscopy for
suspected acute abdomen?The main advantage is high diagnostic rate (over 80%)
Pelvic fractures
most often occur in patients with multiple trauma caused by impact injuries such as
car accidents. Pelvic fractures are associated with vascular injuries and may lead to
extensive intraperitoneal and retroperitoneal bleeding, that may result in
hemorrhagic shock or death.
Pelvic fractures are typically identified on initial pelvic radiography. Those that
demonstrate an increase in pelvic volume must be quickly compressed with a pelvis
sheet or binder wrapped around the hips to reduce the space available for
hematoma development. This action addresses venous bleeding. However,
continued hemodynamic deterioration suggests an arterial source.
Following wrapping of the hips, FAST examination is obtained. If negative, and the
patient is responsive to fluid resuscitation, abdominal\pelvic CT is done.
If the CT identifies a pelvic hematoma with active extravasation or if the patient is
not reacting positively to fluids, pelvic angiography with embolization is indicated.
Recently, several studies suggested that extraperitoneal packing of the pelvis may
substitute embolization, particularly if endovascular therapy is not instantly
available. However,
if the CT detects a pelvic hematoma without extravasation, external fixation of the
pelvic fracture may be done as needed.
On the other hand, if FAST is positive, exploratory laparotomy is carried.
Urologic Injury:
▪ The hallmark of urologic injury is blood in the urine of someone who has sustained
penetrating or blunt abdominal trauma. Gross hematuria in that setting must be
investigated with appropriate studies.
▪ Penetrating urologic injuries as a rule are surgically explored and repaired.
▪ Blunt urologic injuries may affect the kidney, in which case the associated injuries
tend to be lower rib fractures. If they affect the bladder or urethra, the usual
associated injury is pelvic fracture.
Urethral injuries:
- Urethral injuries most commonly occur in men because of their longer urethral
length and are divided into anterior and posterior urethral injuries.
- Injury to the posterior urethra is associated with pelvic fractures, and the anterior
urethra is most commonly damaged in straddle injuries.
- The posterior urethra is located above the bulb of the penis, and the anterior
urethra lies within the bulb and the remainder of the corpus spongiosum.
Sx. Flank or groin pain. • Blood at the urethral meatus. • Ecchymoses on perineum
and/or genitalia. • Evidence o pelvic fracture. • Rectal bleeding. • A “high-riding” or
superiorly displaced prostate. •
Dx. • Retrograde urethrogram (before foley catheter placement)
Tx. • Ureteral injuries require repair for which there are many described techniques,
ranging from primary repair to nephrectomy.
Bladder Rupture
Bladder injuries can occur in either sex, are usually associated with pelvic fracture,
and are diagnosed by retrograde cystogram or CT cystography.
- Bladder rupture after blunt trauma is due to a sudden increase in intravesical
pressure and most likely occurs following a blow to the lower abdomen when the
bladder is full and distended.
- Extraperitoneal bladder injury (EPBI): o Extraperitoneal bladder injury (EPBI) which
may consist of either contusion or rupture of the neck, anterior wall, or anterolateral
wall of the bladder. o In the case of rupture, extravasation of urine into adjacent
tissues causes localized pain in the lower abdomen and pelvis. o Pelvic fracture is
almost always present in EPBI, and sometimes a bony fragment can directly puncture
and rupture the bladder. o Gross hematuria is also usually present, and urinary
retention (evidenced by suprapubic fullness) may occur, especially in the case of
injury to the bladder neck.
- lntraperitoneal bladder rupture: o lntraperitoneal bladder rupture describes
rupture of the dome of the bladder; the dome is composed of the superior and
lateral bladder walls. o The superior and lateral surfaces of the bladder compose the
dome of the bladder and are bordered by the peritoneal cavity. o Rupture of this
area results in intraperitoneal urine leakage and typically presents with signs of
chemical peritonitis (diffuse abdominal tenderness, guarding, rebound). o Pelvic
fracture is often present but less commonly than in EPBI.
• Treatment of bladder rupture depends on location:
1- If retroperitoneal : decompression with foley catheter after it cystoscopy to check
healing
2- Peritoneal: suturing of bladder with two layers of absorbable thread
• Trauma patient with hematuria on urinalysis or catheter requires further
evaluation by abdominal CT with contrast.

- Indications for urethrogram include: o Blood at the meatus. o Hematuria. o Dysuria.

o Urinary retention.
A 41-year-old man is injured after driving a motorcycle and hitting an electric pole.
Upon arrival to the trauma unit he is hemodynamically stable and complains of
lower abdominal pain. CT reveals extraperitoneal leakage of contrast from the
urinary bladder. Which of the following is the best treatment option?
Urinary catheter The patient in the question presents with bladder rupture which
results in leakage into the retroperitoneum.
 Shock
• Condition of severe impairment of tissue perfusion → cellular injury and
dysfunction. • Rapid recognition and treatment are essential to prevent irreversible
organ damage and death.

• Dx.
• Fever and a possible site of infection suggest septic shock.
Trauma, GI bleeding, vomiting, or diarrhea suggests hypovolemic shock.
History of MI, angina, or heart disease suggests cardiogenic shock. If JVD is present,
this suggests cardiogenic shock.
If spinal cord injury or neurologic deficits are present, neurogenic shock likely.
• Draw blood: CBC, electrolytes, renal function, PT/PTT. • ECG, CXR.
• Tx.
• ABCs (airway, breathing, and circulation) should be addressed for all patients in
shock.
• Establish two large-bore venous catheters, a central line, and an arterial line.
• A fluid bolus (multiple liters of normal saline or lactated Ringer solution) should be
given in most cases.
• Vasopressors (dopamine, norepinephrine or phenylephrine) may be given if the
patient remains hypotensive despite fluids.
Hypovolemic Shock
Hypovolemic shock is the most common form of shock and may occur due to
trauma, gastrointestinal bleeding, diarrhea, fistulas, vomiting, burns and more. The
most serious form of hypovolemic shock is hemorrhagic shock due to blood loss.
• The physical loss of either
– Blood – due to hemorrhage
– Plasma – due to burns
• This patient will present with: ▪ Decreased Blood Pressure ▪ Increased Heart rate
first sign ▪ Increased anxiety ▪ Increased respiratory rate ▪ Decreased urine output
Class I is associated with normal vital parameters and the patient may be slightly
anxious. It represents 0-15% of blood loss.
Class II is associated with mild anxiety, tachycardia, respiratory rate of 20-30/min,
urine output of 20-30 ml/hr, and decreased pulse pressure. It represents 15-30% of
blood loss.
Class III is associated with anxiety or confusion, pulse of >120/min, decreased blood
pressure and pulse pressure, respiratory rate of 30-40/min, and urine output of 5-15
ml/hr. It represents 30-40% of blood loss. The vital signs of the patient in the
question fit to this class.
Class IV is associated with confusion or lethargy, pulse of >140/min, decreased blood
pressure, respiratory rate of >35/min, and no significant amount of urine production.
It represents blood loss of >40%.
Treatment for all shock states starts with fluid resuscitation and includes
administering intravenous crystalloids, blood, and blood products.
The most important blood test in trauma is arterial blood gases. Its results are
immediate and allow an assessment of lactic acid levels, which helps guide
treatment.
Cardiogenic Shock
Inadequate contractility of the heart due to
– MI – Blunt trauma to the heart – Dysarrhythmias – Cardiac Failure
Rare in Trauma cases This patient does not necessarily need fluids
Extrinsic causes are unrelated to the heart pump itself and include tension
pneumothorax, hemothorax, or cardiac tamponade.
Intrinsic causes refer to pump failure and include infarct, cardiac failure, contusion,
or cardiac laceration.
• Sx: hypotension, tachycardia , JUGULAR VEIN DISTENSION , pale cool skin.
• Tx. • Dobutamine , dopamine.
Neurogenic Shock
• Neurogenic shock presents with hypotension and the patient comes with the
symptoms of warm extremities.
Warm, well-perfused skin , Urine output low or normal , Bradycardia and
hypotension
• Treatment of neurogenic shock : crystalloids and vasopressors.

• Tx. • Initially, IV antibiotics (broad spectrum) at maximum dosages.

• Vasopressors (Norepinephrine, dopamine, phenylephrine) may be used if
hypotension persists despite aggressive IV fluid resuscitation.
Surgery

Preoperative evaluation

Cardiac Risk assessment:

• Patients >40 years old with no cardiac history > Obtain EKG→ if normal , no other
workup needed.
• For patients with any age ,with cardiac history > obtain EKG , echocardiogram ,
stress test.

The worst finding predicting high cardiac risk is jugular vein distension/EF which
indicate CHF

The next worst predictor is MI

Risk factors for more than 5% risk of cardiac complication following surgery : aortic
surgery ,peripheral artery surgery

Pulmonary Risk assessment:

ASA class greater than II (4.9)
Emergency surgery (2.2)
Age >60 (2.1)
surgery lasting longer than 3 hours (2.1).
COPD (1.8) least significant one

Smoking ,obesity and asthma are not considered to be significant risk factors for
developing postoperative pulmonary
complication

Goals to reduce risk : stop smoking at least 8 weeks preoperatively

Ways to decrease complications (before surgery):
• Incentive spirometry.
• Early postoperation ambulation.
• Chest physical therapy.
• DVT prophylaxis (clexane (enoxaparin) sequential compression device (SCD).

The preoperative testing of a healthy patient above 70 years of age include ECG,
CBC + platelets, electrolytes, BUN/creatinine and glucose levels.

Hepatic Risk
• Predictor of operative mortality in patients with liver disease:
• Encephalopathy
• Ascites
• Low serum albumin < 3
• Elevated prothrombin time (INR). > 16 sec
• Elevated billirubin. > 2mg

Metabolic Risk
• DKA , Diabetic coma is an absolute contraindication to surgery

Nutritional Risk
• Severe nutritional depletion is identified by :
• Loss of >10% of body weight within 6 months.
• Serum albumin < 3
• serum transferrin level < 200mg/dl
Preoperative cognitive status

More than one-third of patients above the age of 70 have some degree of cognitive
impairment or dementia. Therefore, the most important preoperative assessment in
this patient is a cognitive assessment can be assessed using the Mini-Cog exam

The most significant risk factor for developing delirium is : Dementia

Patients known to have alcohol use disorders should have perioperative thiamine
(vitamin B1) and multivitamins

Thyroid evaluation

Thyroid function panel; in particular, thyroid stimulating hormone (TSH) level is

measured. Evidence of hyperthyroidism (very low TSH level) is addressed
preoperatively, and surgery is deferred until a euthyroid state has been achieved .

Postpone surgery until the gland is better controlled

Severe hypothyroidism needs to be corrected before elective operation

Refeeding Syndome

Occur in the setting of hypophosphatemia typically due to chronic malnutrition

(alcohol use) the reintroduction of carbohydrate (5% dextrose) in patients with
chronic hypophosphatemia leads to increased insulin secretion > this stimulate
intracellular shift of electrolytes (hypokalemia,hypomagnesemia,hypophosphatemia)
Manifestations : muscle weakness,Arrhythmia,CHF

Antibiotics prophylaxis

• A single preoperative parenteral dose of antibiotic effective against aerobes and

anaerobes , no longer than 1 hours before the incision reduces the risk of
postoperative infectious complications.

In general : cefazolin
GIT surgery : cefazolin and metronidazole
Urologic surgery : ciprofloxacin
Drugs To stop before surgery:
• Aspirin : stop 3-4 days before surgery.
• Clopidogrel (plavix) : avoid for 7 days.
• Warfarin (coumadin) : stop 5 days prior to surgery and cover with LMWH
• Antihypertension : continue beta blockers, stop diuretics in the morning of surgery
• Anti-thyroid drugs: stop in the morning of surgery.
• Thyroid drugs (levothyroxine) : give in the morning of surgery.
• Oral hypoglycemic : stop on day of surgery.
• Insulin: short acting insulin should be discountinued and long acting insulin give
half of usual dose on morning of surgery.

NB : patients on warfarin who require urgent surgery with high risk bleeding should
receive prothrombin complex concentrate /fresh frozen plasma(if immediate
surgery) and IV vitamin K (if after 1 day surgery)

Splenectomy

• Patients undergo splenectomy : should be vaccinated against encapsulated

bacteria ( H.influenza , N.Meningitidis, S.pneumonia)
• Elective splenectomy → vaccinate 2 weeks before surgery.
• Emergency splenectomy → immediately after splenectomy.
• To check for spleen hypofunction (asplenic patient) → perform peripheral blood
smear , look for howel-jolly bodies.
• Normally the spleen should remove howell jolly bodies from the RBCs.
• In asplenic patients – howell jolly body persists – indicates hyposplenism.
Preoperative steroids administration

Patients who have taken more than 5 mg of prednisone (or equivalent) per day for
more than 3 weeks within the past year are considered at risk when undergoing
major surgery
Postoperative Complications:

• Fever:

Malignant Hyperthermia:
• May have a family history.
• Develops shortly after the onset of anesthetic (halothane or succinylcholine ).
• Temperature >104 F. , Rigor , myoglobinuria ( bloody urine ).
• Metabolic Acidosis.
• Hypercalcemia.
• Tx : Stop the procedure, give IV dantrolene , 100% oxygen , correct acidosis,
cooling blankets.

1 st day fever ;
• Atelectasis, perform CXR , improve ventilation (incentive spirometry).

Day 2 fever;
• Pneumonia , CXR , sputum culture, antibiotics.

Day 3-5 fever:

• UTI (urinary tract infection) , urinalysis, urine culture, antibiotics.

The most common cause of nosocomial infection postoperatively is UTI

Day 6 fever :
• Deep thrombophlebitis , perform Duplex , heparin , warfarin.

Day 7 – 9 fever:
• Wound infection , erythema, warm, tender, Tx, antibiotics, open and drain if
abscess present.

Day 10-15 fever ;

• Deep abscess, CT , percutaneous darinage.

Urinary retention;

• Extremely common, especially in surgery in lower abdomen, pelvis, perineum ,

groin.
• Patient feel the need of void , but cant do it.
• Bladder catheter should be done at 6 hours postoperation if no spontaneous
voiding occur.
• Indwelling (Foley) catheter is indicated in the 2nd consecutive catheterization.
Paralytic ileus:

• Hypokalemia can be a cause, (check K).

• Obstruction of the intestine due to paralysis of the intestinal mucosa.
• Sx : Absent bowel sound, obstipation, constipation , abdominal distension.
Tx : conservative therapy

Ureteral injury

Flank pain ,fever,leukocytosis,hydronephrosis

Colorectal surgery is the most common cause of iatrogenic ureteral injuries
Dx : IV pyelogram

Contraindications of enteral nutrition after surgery is : Ileus

Complications of total parenteral nutrition (TPN)

Mechanical : thrombosis
Metabolic : hyperglycemia ,hepatic dysfunction/steatosis
Infectious : sepsis

Metabolic complications following gastrectomy

Iron deficiency anemia , vitamin B12 deficiency

Wound healing

Stages

1: Hemostasis (5-10 min - platelets)

2: inflammatory (within 3 days )
First 2 days after injury > Neutrophils
3-4 days > Macrophages

3: proliferative (from 4 to 21 days ) At the proliferation stage there is angiogenesis

and epithelialization

4: maturation (from 21 days to 2 years )

Factors that inhibits wound healing : infection (the most common) ,DM ,radiation ,
smoking,malnutrition,steroids,vitamin C\A deficiency

Wound dehiscence
occurs in 1% -3% of patients undergoing abdominal surgery. Most often develop 7 to
10 days postoperatively. In 25% of cases, sudden drainage of a large amount of clear
fluid (or light pink color) occurs before the onset of separation.

Risk factors for wound dehiscence

Infection ,steroids,morbid obesity,advanced age

Management of wound dehiscence

Small dehiscence : conservative with saline-moistened gauze dressing and an

abdominal binder

In case of evisceration : operation

Wound classifications

Clean : A wound that is not infected ( breast ,hernia) (2% risk of infection)

Clean-contaminated : occurs from the surgical entry of the reproductive, urinary,

respiratory, or gastrointestinal system without leakage (5% risk of infection)

Contaminated : a wound with bacteria present resulting from trauma, a break in

sterile technique during surgery or leakage of bowel contents or other bacteria-
laden material during surgery (15% risk of infection)

Dirty : an infected wound (35% risk of infection)

Types of wound closure

Primary intention ( the edges of the wound are brought together and sealed
immediately with simple suturing)
Secondary intention ( leaving the wound open- contraction of the wound )
Tertiary intention ( contraction ,connective tissue repair )

Surgical site infection

Surgical site infection is the most common nosocomial infection among patients
undergoing surgery. It is defined as an infection that occur within 30 days of a
surgical procedure at the site of surgical intervention.

Factors which increase the risk of surgical site infections include :

extremes of age, diabetes, obesity, hypothermia, hypoxemia, hypocholesterolemia,
recent surgery, coexisting infection, chronic inflammation and corticosteroids
therapy. PROLONGED PREOPERATIVE HOSPITALIZATION
PROLONGED OPERATIVE TIME

Management of surgical site infection

First step include removing staples ,manual pus drainage and assessment of infection
severity

In case of superficial infection with no involvement of the fascia or muscle ,non-

viable tissues should be removed ,the wound should be irrigated with saline and a
damp gauze is placed over the wound

In case of cellulitis or systemic signs of infection (fever,tachycardia) > IV antibiotics

The most common isolated pathogen in surgical wound infection is : coagulase -

negative staph

Other pathogens can be involved depending on the location of the surgery:

Abdominal or chest surgery - gram-negative bacilli such as Escherichia coli and

Klebsiella spp.

Pharynx surgery, lower digestive system, female reproductive system - anaerobic

bacteria

Reducing the risk of surgical site infection

Oral antibiotics (1 hour before surgery) and mechanical bowel prepar

‫שחזורים‬

Pancreatic fistula (amylase content more than 3 times the serum amylase) : will
spontaneously close under conservative treatment (somatostatin analogue)

Allograft rejection is classified into 3 types based on the histopathological

characteristics and the predominant mediator, as well as the timing of the rejection.
The 3 types are:
Hyperacute rejection- occurs within minutes to days (<48 hours) following
transplantation. Mediated by preformed antibodies.
Acute rejection- occurs within weeks to months (<6 months) following
transplantation. Mediated by T-cells and accompanied by acquired antibody
response.
Chronic rejection- occurs during months to years (>6 months) following
transplantation. It is a fibrotic process that is considered to be secondary to T and B
cell processes, as well as nonimmune mechanisms of chronic organ damage, like
drug toxicity and cardiovascular comorbid diseases.

Acute rejection is considered to be the only rejection type which is fully reversible

Acute transplant rejection can completely resolve with appropriate treatment .

Seroma

Is a collection of liquefied fat and is the most benign complication after surgery
Present as a soft swelling in the neck which is easily mobile with gentle pressure
,require only monitoring and follow up

hematoma

appears in 1% of patients after thyroidectomy. The typical presentation is a firm

swelling in the operating bed ,require opening the surgical wound

risk factors predict high surgical mortality

age >80 , hypertension , coplex abdominal suergery , use of blood thinners

Indications for perioperative nutritional support
include:

1:Past medical history: chronic disease, severe malnutrition.

2:Involuntary weight loss of 10-15% or more of body weight within 6 months, or
more than 5% weight loss per month.
3:Expected blood loss during surgery of more than 500ml.
4:Weight under 20% IBW or BMI <18.5.
5:Failure to thrive in children
6:Albumin lower than 3 g/dL, or transferrin lower than 200 mg/dL in the absence of
an inflammatory condition, liver failure or kidney disease.
7:Anticipated that the patient will not be able to consume enough calories within 7 -
10 days of surgery. (patient after Whipple surgery, who is not expected to be able to
consume enough calories within 7-10 days of surgery due to delayed gastric
emptying.)
8:Catabolic disease - significant burns (at least 20% of the body), trauma and sepsis.

Abdominal compartement syndrome (ACS)

Indicated by an increase in respiratory pressure ,decrease in urine output and

elevated intra-abdominal pressure

ACS is caused by an increase in intra-abdominal pressure that cause organ system

dysfunction ,it occur when the intra-abdominal pressure exceeds 20mmHg

Lungs : increase in peak airway pressure (PAP)

Cardiovascular : compression of the inferior vena cava resulting in decreased venous

return (cardiac output) and increased peripheral vascular resistance

Kidneys : decrease urine output

Gastrointestinal : intestinal edema and swelling

Treatment of ACS : laparotomy

Calculator: Padua score for assessing venous thromboembolism risk in hospitalized
adult patients

Cancer: Active or treated with chemotherapy and or XRT within the last six months
(3 points)
History of venous thrombotic disease (not to include superficial thromboses) (3
points)
immobilization of at least three days duration (3 points)
Preexisting hypercoaguable state (3 points)
Trauma or surgery within one month (2 points)
Age ≥70 years old (1 point)
Heart or respiratory failure (1 point)
Stroke or acute MI (1 point)
Acute infectious disease or rheumatic disease (1 point)
Obesity with a body mass index ≥30 kg/m2 (1 point)
Intercurrent hormone replacement treatment (1 point)

0 to 3 points:Lower risk of symptomatic VTE

4 to 20 points:Higher risk of symptomatic VTE

•Low risk patients (score >>>>> no need for VTE prophylaxis

•High risk patients (score ≥4): for VTE prophylaxis is indicated >>>>LMWH
(enoxaparin ,clexan)

Maintenance fluid is calculated according to the patient body weight using the
following formula : 4 x the first 10 kg + 2 x the next 10 kg + 1 x the remaining wei ght
For example : patient weight 90 kg : 4 x 10 + 2 x 10 + 1 x 70 = 130 ml/hr

Complication of jejunoileal bypass

In the absent of the terminal ileum unabsorbed fatty acid reach the colon ,where
they combine with calcium,leaving free oxalate to be absorbed (hyperoxaluria)

-Significant bleeding in the early postoperative period > Error in surgical control of
blood vessels in the operative field

-Transfusion with FFP to replenish vitamin k dependent clotting factors should be

administrated on call to the operating room

-Hypomagnesemia > loss of deep tendon reflex

-Hypermagnesemia (<1.5) > tetany

-Hypochloremic hypokalemic metabolic alkalosis > infusion of 0.9%

Factors that predispose to fistula formation and may prevent closure can be
remembered.

The best initial study in evaluation patients with fistula is CT scan of the abdomen

Ringer lactate solution

Crystalloid ,Na,Cl,K,Ca,lactate
Obesity

Complications of surgeries

Biliopancreatic diversion

Calcium and vitamin D ,vitamin A deficiencies ,protein malnutrition are common

Laparoscopic sleeve gastrectomy

The most common complication is gastric leak

Gastric band surgery

x-ray show band slippage

Duodenal switch

Highest nutritional complication

Roux-en-Y gastric bypass (RYGB

1: The 2 most common deficiencies are iron and vitamin B12

2: bowel obstruction. Patients who have a clinical or radiographic picture of small

bowel obstruction after RYGB need a reoperation (exploratory laparoscopy). The
potential for internal hernias after this operation makes strangulation obstruction a
frequent presentation. Patients with bowel obstruction are best diagnosed by an
oral and intravenous contrast-enhanced CT scan of the abdomen to visualize the
bypassed stomach and small bowel that may be obstructed or the mesenteric twist
with volvulus of the Roux limb. These patients must be promptly treated before
retrograde distention of the biliopancreatic limb and distal part of the stomach
results in rupture of the distal gastric staple line with subsequent peritonitis
Burns

1st degree burn : Only the epidermis (red, painful, and edema) no blisters

2nd degree burn (superficial) : Epidermis and upper layers of the dermis
(pain,erythema),vesicles/Bullae

2nd degree burn (deep) : Deeper layers of the dermis (minimal pain ,mottled
skin),vesicles/bullae

3rd degree burn : All three layers have been effected (no pain,tissue necrosis)

4th degree burn : This degree of burn affects underlying SOFT TISSUE.

Local changes at the burn site

Zone of coagulation (coagulative necrosis)

Zone of stasis (decreased perfusion)
Zone of hyperemia (inflammation and increased blood flow)

Management of burns

- Most important step when a patient has been in a fire is to give 100% Oxygen as
most common cause of death in fires in CO poisoning - Then important thing is to
determine who needs to be intubated and who can be managed just with fluids

Intubate burns patients if there is

Stridor,hoarseness,wheezing,
burns inside the nasopharynx or mouth
carboxyhemoglobin >10%,

Volume of fluids replacement

Parkland formula = BW(kg) x % of burn (up to 50%) x 4 cc RL Infuse 1/2 first 8 hours
,infuse 1/2 next 16 hours

Burn care

Tetanus prophylaxis
Clean area
Topical antibiotics: silver sufladiazine or mafenide acetate for deep penetration
What is the rule of nines

Each upper limb 9%

Each lower limb 18%
Anterior and posterior trunk 18%
each Head and neck 9%
Perineum and genitalia 1%

Silver sulfadiazine (side effect) : neutropenia

Mafenide acetate (side effect) : metabolic acidosis

Silver nitrate (side effect) : hyponatremia

Burn wound infection (sepsis)

Temperature (<36 0r >38) ,HR >90,RR >20

What investigation should be done in burn patients in whom sepsis is suspected

Blood culture

Most common burn infection pathogens

Pseudomonas aeruginosa (most common) ,staphylococcus aureus

Tx : piperacillin-tazobactam and vancomycin

Reduce the risk of both noninvasive and invasive burn wound infection

Early wound excision and grafting

Burn patients feeding

Enteral nutrition is preferred It is associated with multiple clinical benefits including

Maintenance of gut integrity ,Reduced rates of sepsis ,Decreased mortality

Next step in patients who have genital burns

Uretheral catheter should be placed as soon as possible

Alkali chemical burns treatment : Large volume of water lavage

Burns with decreased capillary refill (vascular compromise) : Escharotomy

Hydrofluoric acid burns : treat with calcium gluconate

Most effective method of oxygen-> orothracheal intubation

Cricoid pressure ->Reduce risk of regurgitation / reduce risk of aspiration/ prevent additional
air from entering stomach.

PEEP-> can improve oxygenation by recruiting collapsed alveoli and increasing functional
residual capacity.

Hormones decreased in operation- insulin/ thyroxine

-The term massive blood transfusion is defined as a single transfusion greater than
2500 mL or 5000 mL transfused over a period of 24 hours. When large amounts of
banked blood are transfused, the recipient develops dilutional thrombocytopenia
and deficiencies in factors V and VIII. Treatment involves transfusion of FFP and
platelets.
The coagulopathy is secondary to dilutional thrombocytopenia and deficiency of
clotting factors from the massive blood transfusion.
-The preoperative testing of a healthy patient above 70 years of age include ECG,
CBC + platelets, electrolytes, BUN/creatinine and glucose levels.
-Lab tests that are considered routine in diagnosis of acute abdomen include
complete blood count, blood chemistry, liver and pancreatic function tests.
-Coumadin should be stopped 5 days prior to surgery Bridging therapy using LMWH
or heparin is recommended in patients at high risk for thromboembolic events.AF
MALIGNANCY.
-Apixaban (Eliquis) is a highly selective oral direct factor Xa inhibitor that blocks the
conversion of prothrombin to thrombin. It should be discontinued approximately 2-3
days before a surgical procedure.
-How does CO affect wound healing? Prevents the function of enzymes that are
essential for oxidative metabolism.
-Approximately 5-10% of breast cancers are inherited and two genes were .
identified - BRCA1 and BRCA2.
-Diagnostic laparoscopy was shown to have high diagnostic accuracy in patients with
acute abdominal pain, ranges between 90% and 100%.
Decreased morbidity and mortality.
Decreased length of hospital stays.
Decreased hospital costs.
-Mixed Venous Oxygen Saturation is measured in distal pulmonary arteries using a
Swan-Ganz catheter.
In patients with STEMI or non-STEMI who have undergone interventions, the
guidelines are:
-Postpone elective surgery by 14 days after balloon angioplasty.
-Reject elective non-cardiac surgery by 30 days after placing bare metal stent (BMS).
-After placement of Drug-Eluting Stent (DES) Non-cardiac elective surgery should be
postponed by 12 months due to the risks of discontinuing Dual Antiplatelet Therapy.
Endocrine System

Thyroid Gland anatomy

1:Pyramidal lobe 2:right lobe 3:isthmus 4:left lobe

Thyroid gland

Which paired nerves must be carefully identified during a thyroidectomy? Recurrent

laryngeal nerves
damage to these nerves paralyzes laryngeal Muscles and causes hoarseness if unilateral,
and airway obstruction if bilateral

Injury to external branch of superior laryngeal nerve causes voice changes, voice fatigue
and inability to sing higher ranges

The most important complication of thyroidectomy is hematoma which can obstruct the
airway
Treatment for this complication is: intubation and reopening the wound (even if this occurs
at the bedside) to drain the hematoma

Thyroid Storm

Signs of thyroid storm:

High fever
Tachycardia
Confused state/ may result to mania and coma
vomiting

Thyroid storm is life threatening condition and is caused due to bad treatment of
thyrotoxicosis

Thyrotoxicosis should be treated medically before thyroidectomy

Treatment for the thyroid storm:

1- Rapid fluid replacement

2-Antithyroid drugs (PTU)

3-Betablockers (propranolol)

4-iodine solutions

5- Steroids (prednisolone)

➢ Plasmapheresis can be given in life-threatening conditions

Thyroid Nodule

What studies can be used to evaluate a thyroid nodule?

U/S—solid or cystic nodule

Fine Needle Aspirate (FNA) cytology hot or cold nodule

What is the DIAGNOSTIC test of choice for thyroid nodule?

FNA

What is meant by a hot versus a cold nodule?

Nodule uptake of I or 99mT

Hot—Increased I uptake functioning/hyperfunctioning nodule
Cold—Decreased I uptake nonfunctioning nodule (high risk for malignancy)

In evaluating a thyroid nodule, which of the following suggest thyroid carcinoma

History?
Neck radiation
Family history (thyroid cancer, MEN-II) 3. Young age (especially children)

Signs?
Single nodule
Cold nodule
Hard, immobile

Nodule Symptoms?
Voice change (vocal cord paralysis)
Dysphagia
Discomfort (in neck)
Rapid enlargement
Thyroid nodule

FNA cytology:

If malignant/ suspect malignancy : Surgery

If Benign : Follow Up

If Non-diagnostic: Repeat

FNA Biopsy

Some types of thyroid cancer is underdiagnosed with FNA especially the

follicular type tumor

high risk malignancy such as familial history of thyroid cancer, total

thyroidectomy is recommended even if the FNA biopsy didn’t reveal
malignancy.

Thyroid nodule > 1 cm should be evaluated by FNA

FNA

Patients with unilateral compressing masses (difficult breathing) and benign

biopsy results are treated with total thyroidectomy or lobectomy. Patients
with bilateral goiter are treated with total thyroidectomy
Thyroid cancer

• 4 types:
1: Papillary thyroid ca the most common type 80%
2; Medullary thyroid ca
3: Follicular thyroid ca
4: Anaplastic thyroid ca 1-2%

• Diagnosis :
FNA ,Except, follicular type ( needs lobectomy , FNA is not adequate , needs
to evaluate capsular invasion , blood vessels, lymphatics).

Prognosis

Recommendations for total thyroidectomy

Diameter above 4 cm
Findings/nodules on both lobes
Important clinical findings such as radiation exposure in the past
Genetic mutations and family history
age >45 years
Papillary thyroid cancer

Papillary thyroid cancer is strongly associated with radiation

The risk factor for papillary thyroid cancer is greater for people who
exposed to radiation during childhood

Papillary thyroid cancer spreads lymphatically

Treatment

Total thyroidectomy (because of high rate of metastatic lymph node)

• <1cm + no clinical involved lymph nodes (L.N) + no history of head and

neck radiation→unilateral lobectomy and isthmusectomy.
• >1cm or <1cm + clinically positive L.N , or history of head or neck
radiation→total or near total thyroidectomy followed by radioablation.
• If clinically positive adenopathy is detected in the central neck :
• Therapeutic level VI ( central neck L.N dissection )should be performed at
the time of total or near total thyroidectomy.

Medullary thyroid cancer

• 4-10% of all thyroid cancer

• Malignancy of parafollicular of C-cells ( which secrete calcitonin) and are a
neural crest origin.
• 80% sporadic form.
• 20% familial (autosomal dominant , MEN2A, MEN2B , and familial
medullary thyroid cancer).
• Medullary thyroid cancer arising in MEN2A has more favorable longterm
outcome than those arising in MEN2B or sporadic forms.

Patients with medullary thyroid cancer should be examined for MEN 2

syndrome,Assessment includes:
calcium level for hyperparathyroidism
Catecholamines in urine for pheochromocytoma

Treatment

Total thyroidectomy and prophylactic resection of local lymph nodes IV

Prior to surgery pheochromocytoma should be ruled out

follicular thyroid cancer

FTC is a disease of an older population compared with PTC, with a peak

incidence between ages 40 and 60 years. It occurs more commonly in
women, with a ratio of approximately 3:1.

What are the 4 “F’s” of follicular cancer?

1: Far-away metastasis (spreads hematogenously)

2: Female (3 to 1 ratio)
3: FNA not diagnostic (need lobectomy)
4: Favorable prognosis

Associated with Painless mass

What is the most common site of distant metastasis? > Bone

What is the treatment for follicular cancer?

<4 cm without risk factors: lobectomy

>4 cm total thyroidectomy

If LN + : MODIFIED RADICAL neck dissection

Postoperative treatment: The use of radioiodine ablation and long-term monitoring

of the Tg (thyroglobulin).

Anaplastic Thyroid Cancer

What is it also known as? Undifferentiated carcinoma

•Worst , most aggressive form of thyroid carcinoma

Summary for Thyroid Cancer

Follicular cancer :

<4 cm without risk factors: lobectomy

>4 cm total thyroidectomy

If LN + : MODIFIED RADICAL neck dissection

Papillary cancer:

<1 cm without risk factors :no clear outline for surgery

>1 cm : total thyroidectomy

Medullay cancer: any size: total thyroidectomy

Parathyroid Gland

•Anatomy

Superior and inferior parathyroid glands Supplied by inferior thyroid artery

•Physiology

Parathyroid hormone (PTH)

Chief cells of parathyroid gland produce PTH.

PTH functions:

Increase bone resorption of calcium and phosphate

Increase kidney reabsorption of calcium in distal convoluted tubules

Increase serum calcium

Decrease serum phosphate (increase urinary excretion of phosphate).

PTHrP (parathyroid related peptide) :

Function like PTH and is commonly increase in malignancies (squamous cell

carcinoma of the lung, renal cell carcinoma).

Mg (magnesium ) is needed for PTH release , low Mg  no PTH release 

hypocalcemia.

Check Mg levels in patient present with hypocalcemia.

Calcitonin

Secreted from parafollicular cells (C-cells ) of thyroid gland.

Decrease bone resorption of calcium.

Increase serum calcium calcitonin release

Opposite action of PTH.

It decrease calcium level in blood and keep it in bones

Primary hyperparathyroidism

• hypersecretion of PTH → hypercalcemia.

• Causes:
Parathyroid Adenoma : most common cause
Hyperplasia of parathyroid gland
Carcinoma
• Sx. Muscle pain ,stone,bone,abdominal groan ,psychiatric overtones

preoperative localization

• technetium-99m (99m Tc) sestamibi scintigraphy (best test)

Indications for surgery in primary hyper PTH

1: age < 50
2: Serum calcium level 1mg/dl above normal range
3: Bone density ≤ -2.5
4: Creatinine clearance (GFR) <60 ml/min
5: Patient whose medical monitoring is not possible

Treatment

Treat hypercalcemia with fluid (IV Normal saline)

Solitary adenoma : Solitary parathyroidectomy
Secondary hyperparathyroidism

• Chronic kidney disease (causes hypovitaminosis D and

hyperphosphatemia) → hypocalcemia → increase parathyroid hormone.
• Dx.
Chronic kidney disease (high BUN , creatinine ,low GFR).
Low calcium ( PTH cant absorb Ca from kidney , it is not working , and no
activation of vitamin D , which takes place in kidney).
High Parathyroid hormone
Hyperphosphatemia (kidney is damaged, it cant eliminate posphate)

Tertiary hyperparathyroidism.

• chronic kidney disease → Refractory (autonomous) hyperparathyroidism -

→ increase PTH → increase calcium

• Renal osteodystrophy • renal disease → 2° and 3° hyperparathyroidism →

bone lesions

Hypoparathyroidism

• Due to injury to parathyroid glands or their blood supply (usually during

surgery).
• autoimmune destruction.
• DiGeorge syndrome.
Findings : tetany, hypocalcemia, hyperphosphatemia.
Signs of hypocalcemia:
Chvostek sign :tapping of facial nerve (tap the Cheek)→ contraction of facial
muscles. Trousseau sign: occlusion of brachial artery with BP cuff (cuff the
Triceps) → carpal spasm.
Dx.
• Low serum calcium
• Low PTH
• High phosphate
• EKG : QT prolongation
Tx.
Calcium gluconate • Vitamin D , calcium
The adrenal glands are a pair of mustard color glands that are located above
the kidney, directed medially and are retroperitoneal. They weigh about 4
grams each. In most cases, the cortex and medulla are considered two
different organs that connect during fetal development.

They are among the organs with the most profound blood supply in the
body. They receive about 200 ml/kg/minute of blood (after the kidney and
thyroid gland).

Knowing the vascular anatomy is very important for proper surgical

treatment. It is important to understand that while the gland's arterial
supply is extensive, the venous drainage lies on one solitary vein.

Arterial supply is based on 3 blood vessels:

Superior Adrenal Arteries that arise from the Inferior Phrenic Arteries.

Middle Adrenal Arteries that arise from the aorta (near the Celiac Artery).

Inferior Adrenal Arteries that arise from the renal arteries. They are
considered the most prominent and recognizable arteries.

The left adrenal vein is about 2 cm long and drains into the left renal vein
after connecting to the inferior phrenic vein.

The right adrenal vein is usually short and thick and drains directly to IVC. In
about 20% of people, it drains into the Accessory Right Hepatic Vein or into
the IVC near this vein. This should be noted during surgery to prevent
unnecessary bleeding.

Incidentally Discovered Adrenal Mass (Incidentaloma)

is an adrenal mass that is discovered incidentally during imaging of another

disease ,patients with adrenal mass > 1 cm need further evaluation that
include :

24 h urine metanephrines
Aldosteron : renin ratio
24 h urine cortisol

Imaging finding suspicious for incidentiloma are size > 4 cm and density over
20 HU

MC adrenal mass incidentally found in CT scan –> cortical adenoma

Indication for surgery (high risk of malignancy):

hormonally active (tumors secretes hormones) = active tumors.

Size >5 cm (25% risk of malignancy).

Characteristics suggestive of a benign lesion on CT scan include -

homogeneous appearance, well-defined borders, high lipid content, rapid
washout of contrast material, and low degree of vascularity.

Features that are concerning for malignancy include

-irregular or ill-defined borders, necrosis, internal calcifications or

hemorrhage, and high vascularity

-The primary cancers that most often spread to the adrenals are those of the
lung, gastrointestinal tract, breast, kidney, pancreas, and skin (melanoma).
* Insulinoma:-
Tumor of the Beta pancreatic cells which secrete insulin
SX : whipple triad (low blood glucose,symptoms of hypoglycemia ,resolution
of symptoms after normalization of glucose )
Dx. Increased insulin and C-peptide levels
Glucose < 40 mg/dl ,insulin > 60 U/dl
Tx : simple enucleation

The most common cause of of hypoglycemia is drug induced hypoglycemia

*Glucagonoma:-
Tumor of the Alpha pancreatic cells which secrete glucagon
Presentation: hyperglycemia (DM), glossitis, dermatitis

*VIPOMA:-
Vasocative intestinal peptide secretion
WDHA : watery diarrhea (despite fasting), hypokalemia, achlorhydria

*Gastrinoma:-
Tumor secreting gastrin - stimulates HCI secretion
Presentation: recurrent multiple gastric and duodenal ulcers
Dx. Gastrin level > gastric PH (<4) , if equivocal do secretin test
Stop PPI 2 weeks before the test (PPI increase gastrin level)

*Multiple Endocrine Neoplasia:-

-They are all AD
1. MEN 1 (PPP) : Parathyroid +Pituitary + Pancreas (ZES, insulinoma,
glucagonoma)
2. MEN II A : Parathyroid + MTC+ Pheochromocytoma
3. MEN II B :MTC + Pheochromocytoma + mucosal neuromas

-MEN 1 is Menin mutation

-RET Proto-oncogene test for MTC.
 *Carcinoid syndrome:-
Increased secretion of serotonin
The most common location > appendix
Presentation: flushing, diarrhea, wheezing.
Usually presents when there is metastasis to the liver.
Dx. Urinary 5HIAA , Chromogranin A in the blood

Tx. Somatostatin analogs (octreotide).

A late complication is fibrosis of the endocardium (Tricuspid valve) - carcinoid heart

disease
The Breast
Breast cancer occurs most frequently in the upper outer quadrant (UOQ).
Sentinel lymph node is the first node or group of nodes in which a primary tumor
spread to.
• The different types of invasive breast cancer:

➢Inflammatory Breast cancer

➢Infiltrating ductal carcinoma ( 75%)

➢Infiltrating lobular carcinoma ( 5%)

Nipple Discharge
• The appearance of discharge from the nipple of a nonlactating woman is a
relatively common condition and is rarely associated with an underlying carcinoma.
• In the absence of a palpable mass or a suspicious mammogram, discharge is rarely
associated with cancer.
• The most common cause of spontaneous nipple discharge from a single duct is a
solitary intraductal papilloma in one of the large subareolar ducts under the nipple.
• Subareolar duct ectasia: inflammation and dilation of large collecting ducts under
the nipple is common and usually involves discharge from multiple ducts

Galactocele
• a milk-filled cyst that is round, well circumscribed, and easily movable within the
breast.
• occurs after the cessation of lactation or when feeding frequency has curtailed
significantly.
• may occur up to 6 to 10 months after breastfeeding has ceased.
• The tumor is usually located in the central portion of the breast or under the
nipple.
• Needle aspiration produces thick creamy material that may be tinged dark green or
brown.
• TX. • needle aspiration, and withdrawal of thick milky secretion confirms the
diagnosis; • cysts that cannot be aspirated or those that become infected → surgery.
DIAGNOSIS OF BREAST DISEASE
Physical Examination
• patient in the upright sitting position with :
• Inspection for obvious masses.
• asymmetries, and skin changes.
• Inspection of nipples:
• presence of retraction, nipple inversion, or excoriation of the superficial epidermis
such as that seen with Paget’s disease. Paget disease is a condition of the nipple that
is commonly associated with an underlying breast cancer.
• dimpling of the skin or nipple retraction is a sensitive and specific sign of
underlying cancer.
•Edema of the skin produces a clinical sign known as peau d’orange (Peau d’orange
and tenderness, warmth, and swelling of the breast are the hallmarks of
inflammatory carcinoma but may be mistaken for acute mastitis.
• Palpation of the breast tissue and regional lymph nodes follows visual inspection.
Fine-Needle Aspiration Biopsy (FNA):
• Fine-needle aspiration (FNA) biopsy is a common tool used in the diagnosis of
breast masses.
• The main usefulness of FNA biopsy is differentiation of solid from cystic masses.
Core Needle Biopsy
minimally invasive procedure
• is the method of choice to sample nonpalpable, image-detected breast
abnormalities.
• This technique is also preferred for the diagnosis of palpable lesions.
• if a malignancy is detected, histologic subtype, grade, and receptor status should
be determined from the core biopsy sample.
• approximately 10% to 20% of patients with a diagnosis of DCIS on core biopsy will
be found to have some invasive carcinoma at definitive surgery..
BREAST IMAGING
• are used to detect small, nonpalpable breast abnormalities, evaluate clinical
findings, and guide diagnostic procedures.
• Mammography is the primary imaging modality for screening asymptomatic
women.
• Mammography in women > 30 years, whose breast tissue is dense

Screening Mammography
•Annual screening mammography for women older than 40 years
• Screening mammography is performed in asymptomatic women with the goal of
detecting breast cancer that is not yet clinically evident.
Ultrasonography
• Used for patients < 30 years old
• Ultrasonography is useful in determining whether a lesion detected by
mammography is solid or cystic.
Magnetic Resonance Imaging (MRI)
The sensitivity of MRI is greater than 90% for the detection of invasive cancer but
only 60% or less for the detection of DCIS. ILC
Nonpalpable Mammographic Abnormalities
• Mammographic abnormalities that cannot be detected by physical examination
include clustered microcalcifications and areas of abnormal density (e.g., masses,
architectural distortions, asymmetries) that have not produced a palpable finding •
• The Breast Imaging Reporting and Data System (BI- RADS) is used to categorize the
degree of suspicion of malignancy for a mammographic abnormality.

1-3 > annual screening

4-5 > biopsy (core needle)
6 > treat
Receptor Status
• ER (estrogen ) Receptor Status.
• PR (progesterone ) receptor status.
• human epidermal growth factor receptor pathway (HER2neu). • Trastuzumab
(Herceptin) work against HER2neu positive receptors.
• Tumors that lack expression of ER, PR and HER-2 are often called triplenegative
breast cancers.
• All receptor status positive patients should receieve :
• Postmenopasue : aromatase –inhibitors (anastrazole, letrozole, exemestane).
• Premenopause: Tamoxifen ,Raloxifen.
• HER2/neu positive → give Trastuzumab (Herceptin).
• Perform echocardiogram before and after herpectin. • Leads to cardiotoxicity .
Sentinel lymph node biopsy;
• Sentinel lymph node is the first node or group of nodes in which a primary tumor
spread to.
• SLNB : injection of radioactive substance ,blue dye , near the tumor, look for the
1st lymph node contains the radioactive substance or lymph node stained with
dye→ remove the sentinel node to check for the presence of cancer cells.
• It done in all patients at the time of lumpectomy or mastectomy.
• A negative SLNB → no need for axillary lymph node dissection.
Identification of High-Risk Patients
Age is probably the most important risk factor for breast cancer development

LCIS (Lobular Carcinoma In Situ).

• uncommon condition, found incidentally at biopsy and does not present as breast
mass or may be found as microcalcification on mammogram.
• not considered a breast cancer but rather a histologic marker for increased breast
cancer susceptibility, which is estimated at slightly less than 1%/year longitudinally.
• 3 Options are available for treatment:
• close observation
• chemoprevention with tamoxifen (for 5 years) or raloxifene -will lower the risk up
to 50%
• bilateral mastectomy (procedure of choice for those who elect surgery).
Genetic factors
• responsible for 5% to 10% of all breast cancer cases.
• but they may account for 25% of cases in women younger than 30 years.
• BRCA1 gene: • Tumor suppression gene , inherited as autosomal dominant.
• account for up to 40% of familial breast cancers
• BRCA2 gene: found in chromosome 13, account for up to 13% of familial breast
cancer.
• BRCA2 increase risk of : breast cancer in males
• Both BRCA1 (45% lifetime risk of carriers) and BRCA2 increase the risk of ovarian
cancer.
• BRCA1 mutations , more likely to have: • high grade tumors • hormone receptor–
negative • Aneuploid • increased S phase fraction.
• BRCA2 : more commonly hormone receptor–positive.
• Overall mortality rates in patients with BRCA1- or BRCA2-associated breast cancer
are similar to those in women with sporadic breast cancer.
BRCA TEST (indications)
Breast cancer diagnosed before age 50
Bilateral breast cancer
Breast and ovarian cancer in the same individual
Breast cancer in men

P53 gene mutation : breast cancer,sarcoma,brain tumor,adrenocortical carcinoma

and leukemia)
PTEN gene mutation : cowden disease/ breast cancer,thyroid cancer and female
genitourinary
Management of High-Risk Patients
Chemoprevention for Breast Cancer
• Tamoxifen (estrogen antagonist):
• Used for treatment of estrogen receptor (ER)– positive breast cancer.
• reduce the incidence of a second primary breast cancer in the contralateral breast
of women who received the drug as adjuvant therapy for a first breast cancer.
Tamoxifen use has been proven to reduce the chances of breast cancer development
in high-risk women, including women with previous breast cancer.
• Increase the risk of : • Endometrial cancer ( estrogen agonist in endometrium). •
Pulmonary Embolism and DVT.
• Raloxifene (selective ER modulator (SERM)
Prophylactic Mastectomy:
• reduce the chance of developing breast cancer in high -risk women by 90%.
• Reduce the risk of developing breast cancer in the contralateral side.
 BENIGN BREAST TUMORS AND RELATED DISEASES

New findings that can indicate malignant / pre-malignant findings (calcifications)

require a biopsy. A stereotactic biopsy means that the biopsy is done with three-
dimensional targeting of any neuroimaging device.
• Breast Cysts:
• Most cysts occurs in women >35 years.
• fluid-filled, epithelial- lined cavities that may vary in size from microscopic to large
palpable masses containing as much as 20 to 30 mL of fluid.
• Cysts are influenced by ovarian hormones, they change with the menstrual cycle.
• Dx. • Direct aspiration or ultrasound (US).
• if the mass resolves following aspiration and the cyst contents are not grossly
bloody (simple cyct), the fluid does not need to be sent for cytologic analysis.
• Bloody fluid→ biopsy.core nedel
Fibroadenoma
• benign solid tumors composed of stromal and epithelial elements.
• Fibroadenoma is the second most common tumor in the breast (after carcinoma).
• the most common tumor in women younger than 30 years.
• Associated with contraception use.
• Sx. • firm , mobile , rubbery , painless mass ,may increase in size over a period of
several months in young female.
• Dx. • ultrasonography • FNA biopsy can also be used to confirm the imaging
findings.
• Tx. • Simple cyst in ultrasound→ reassurance
• Complex cyst in ultrasound → aspirate , if bloody → biopsy. If clear → reassurance.
• Two subtypes of fibroadenoma:
• Giant fibroadenoma : >5 cm fibrodenoma.
• juvenile fibroadenoma: large fibroadenoma that occurs in adolescents and young
adults.
• Tx. • surgical removal.

Accessory mammary tissue

manifest as an asymptomatic mass that grows in size during pregnancy and remains
until after breastfeeding is completed. Follow-up is sufficient, but surgical removal
can be performed in cases of large masses, cosmetically deforming or for the
purpose of preventing recurrence in future pregnancies.
Breast Abscess and Infections
• Lactational infections (lactational mastitis):
• During lactation –bacteria enters through the nipple into the duct system.
• Symptoms : fever, leukocytosis, erythema, and tenderness.
• Staphylococcus aureus (most common cause).
• May progress to abscess.
• DX. Clinical + ultrasound
• Tx • Antibiotics (cephalexin, flucloxacillin )
• frequent emptying of the breast (continue breastfeeding) to avoid breast abscess
formation.
Breast abscess
Fever ,fluctuant,tender mass
Treatment : antibiotics + drainage (needle aspiration)

Papillomas and Papillomatosis

• Solitary intraductal papillomas :
• Most common cause of unilateral nipple discharge.
• are true polyps of epithelial-lined breast ducts.
• most often located close to the areola but may be present in peripheral locations.
• Most papillomas are smaller than 1 cm but can grow to as large as 4 or 5 cm in size.
• Papillomas are not associated with an increased risk for breast cancer.
• Papillomas located close to the nipple are often accompanied by bloody nipple
discharge.
Tx. excision
Fat Necrosis:
• no malignant potential. • Fat necrosis can mimic cancer by producing a palpable
mass or density on a mammogram that may contain calcifications.
• Fat necrosis may follow an episode of trauma to the breast.
• Sx. • Palpable breast mass after trauma
• Dx. • Ultrasound , mammography : calcification. Histologically, fat necrosis is
composed of lipid-laden macrophages, scar tissue, and chronic inflammatory cells.
• Tx. • Excision.

Fibrocystic Changes
• Usually affect women of 40-50 years old , generally lasting until menopause.
• Hormonal change in breast. • No risk for breast malignancy.
• Sx. • premenstrual bilateral cyclic mastalgia ( pain and tenderness to touch ).
• Dx. • Ultrasound • Mammography
• Tx. • FNA of mass in office , if disappear → reassurance.
• If persist → aspiration with large needle→ if bloody → biopsy .
If clear → follow up.
• NSAIDs. Danazol , mefenamic acid.

Phyllodes tumor combines stromal and epithelial cell components. The tumor can
be benign, borderline or malignant.
Phyllodes tumors are seen on mammography as round densities with smooth
borders and are indistinguishable from fibroadenomas. Ultrasonography may reveal
a discrete structure with cystic spaces.
Treatment is determined according to:
Benign - local resection of the tumor.
Borderline - wide excision with margins of at least 1 cm. The goal is to try and
prevent local recurrence.
Malignant phyllodes - wide local excision with tumor-free margins is necessary,
followed by radiation. If the tumor is large in comparison to the breast, there is room
to consider a mastectomy. After mastectomy, radiation is required if the borders are
involved or if the tumor is larger than 5 cm.
Noninvasive Breast Cancer
• LCIS (Lobular Carcinoma in situ):
• It is a a risk factor for the development of breast cancer (<1%/year risk for
development of breast cancer). • Equal risk in developing invasive carcinoma in the
future both breasts!
• DCIS (Ductal Carcinoma in situ);
• Findings on mammography in patients with DCIS include clustered calcifications
• Tx.
• mastectomy
• breast-conserving surgery with irradiation
• breast-conserving surgery alone
• Adjuvant hormonal therapy with tamoxifen is also administered in order to reduce
the risk for future local recurrence.
• Tumor less than 1 cm (low grade): Remove with 1 cm margins
• Tumor more than 1 cm: Perform lumpectomy with 1 cm margins and radiation or
total mastectomy (no axillary dissection)
• mastectomy with sentinel lymph node biopsy, which is curative for over 98% of
patients with ductal carcinoma in situ (DCIS)
• What is the role of axillary node dissection with DCIS?

➢No role !!!!!!

• Ductal carcinoma in situ is precursor for invasive carcinoma ductal carcinoma in the
same breast! ➢Remember DCIS: SAME BREAST !!

Invasive Breast Cancer

• 1) invasive lobular cancer :
• accounts for up to 10% of breast cancers,
• clinically occult and often escapes detection on mammography or physical
examination until the extent of the disease is large.
• Invasive Ductal Cancer (infiltrating ductal carcinoma):
• the most common form of breast cancer.
• 50% to 70% of invasive breast cancers.
• Palpable on physical examination at smaller size , detected on mammogram as
microcalcification.
STAGING OF BREAST CANCER
Stage 0 : DCIS OR LCIS
Stage I : invasive carcinoma <2 cm without nodal involvement
Stage II : invasive carcinoma < 5 cm with involved nodal but movable axillary nodes
or a tumor >5 cm without nodal involvement
Stage III : Breast cancer > 5 cm with nodal involvement
Stage IV : Any form of breast cancer with distant metastasis

Contraindications to breast irradiation therapy

Breast-Conserving Surgery
Lumpectomy + radiation (to reduce recurrence and improve outcome) is equal in
efficacy to modified radical mastectomy but less deforming
Indications : Multifocal disease (multiple tumors within 1 quadrant of the breast)
Contraindication : multicentric disease , radiation contraindications
Total mastectomy for treatment of DCIS
• Indications: Inability to obtain clear margins with breast- conserving surgery.
• Diffuse calcifications on mammogram that suggest extensive disease.
• Poor cosmetic result after breast- conserving surgery.
• Patient preference • large tumors relative to breast size.
• Contraindications to radiation therapy.
Postmastectomy radiation therapy
significantly improves outcome of patients in terms of local recurrence and overall
survival rates.
Adjuvant chemotherapy • Adjuvant (after surgery) chemotherapy indications:
• Lesions >1 cm.
• Positive axillary lymph nodes.
causes the tumor to shrink and therefore enable the patient to undergo a
lumpectomy rather than a mastectomy (transform inoperable tumor to
operable)
Metastases
• Metastatic disease is the principal cause of death from breast cancer.
• The most common site for distant metastases from breast cancer are
-> Liver • lungs • bones

The most important predictor of prognosis for breast cancer is : number of the
axillary lymph node involved with metastatic tumor
Inflammatory breast cancer
• neoplastic cells block lymphatic drainage → erythema, edema, and warmth of the
breast as a result of lymphatic obstruction→ Peau d’orange (skin texture resembles
orange peel ).
• constituting approximately 5% of all breast tumors.
• the most aggressive subtype of breast cancer
• Poor prognosis (50% survival at 5 years).
• There may be no mammographic abnormalities, and palpable mass in not needed
for the diagnosis.
• Axillary nodal metastases are common, and there is a significant risk for distant
metastases.
• Dx. clinical diagnosis,biopsy (The pathologic hallmark of inflammatory cancer is the
presence of tumor cells within dermal lymphatics/Thickening of the breast skin)
• TX. • neoadjuvant chemotherapy, mastectomy, and radiation therapy,
Paget’s Disease of the nipple
• 1% of breast malignancies.tumor cells in cutaneous lymphy vessels
• Sx. • nipple erythema and irritation with associated itching. may progress to
crusting and ulceration.
• Dx. • Mammography (breast imaging is often negative) and biopsy of the skin of
the nipple should be performed.
• Tx. • mastectomy with sentinel node dissection or extensive local resection of the
nipple and areola followed by radiation.

Breast cancer during pregnancy

• Most common cancer occurs during pregnancy.
• 3-100.000 pregnant woman.
• Diagnosis and treatment ( the same as non-pregnant woman , except that we don’t
use radiation during pregnancy, no chemotherapy in 1st trimester and no hormonal
manipulations.
• Termination of pregnancy is not necessary and don’t improve survival.
• Tx. Total mastectomy with sentinel lymph node biopsy
Radiation cannot be given at any point during the pregnancy
In pregnant women lumpectomy could be done but the radiation is done after
delivery
Male Breast Cancer
• it accounts for 0.8% of all breast cancers.
• The median age at diagnosis is 68 years.
• Outcome is similar for that in women.
• Risk factors: • increasing age • radiation exposure • factors related to
abnormalities in estrogen and androgen balance, including testicular disease,
infertility, obesity, and cirrhosis. • Klinefelter’s syndrome (47,XXY karyotype)
• Family history (BRCA2 gene mutation) (male has 2 testicles).
• . Gynecomastia is not a risk factor.
• Histologically, 90% of male breast cancers are invasive ductal carcinomas.
• 80% are ER-positive, 75% are PR-positive, and 35% overexpress HER-2.
• The remaining 10% are DCIS.
• Sx. • Breast mass • local pain and axillary adenopathy. • nipple retraction,
ulceration, bleeding, and discharge.
• Dx. • Mammography • needle core biopsy.
• TX. treatment options similar to the options for women
Treatment depend on stage and extent of the tumor
• Small tumors may be treated by local excision and irradiation or by mastectomy.
• If the underlying pectoral muscle is involved, modified radical mastectomy with
excision of the involved portion of muscle is adequate treatment and may be
combined with post- operative radiation therapy.
• Most male breast cancers are hormone receptor–positive. Adjuvant hormonal
therapy with tamoxifen
Breast Hypertrophy in men
• There are two types of breast hypertrophy in men: 1- Juvenile hypertrophy 2- Adult
hypertrophy
1- Juvenile hypertrophy

➢ Common at the age of 13

➢ Can be unilateral or bilateral

➢ Non painful, it disappears by itself The mass is smooth, firm, and

symmetrically distributed beneath the areola.
It is frequently tender, which is often the reason for seeking medical attention.

➢ Rx: Follow up only surgery may be done if: 1-the tissue grows continuously 2-
Disturbing the patient 3-Unilateral
2-Adult hypertrophy:

➢Age > 50

➢Usually unilateral

➢Related to cirrhosis , kidney failure, malnutrition, drugs such as : digoxin, estrogen,

spironolactone

➢If mother or aunt had history of breast cancer it is recommended to do genetic

follow up
Postmastectomy Breast Reconstruction
Breast reconstruction may be performed as immediate reconstruction—that is, the
same day as mastectomy—or as delayed reconstruction, months or years later.
Immediate reconstruction has the advantages of preserving the maximum amount of
breast skin for use in reconstruction, combining the recovery period for both
procedures, and avoiding a period of time without a breast mound. Immediate
reconstruction does not have a detrimental effect on long-term survival, local
recurrence rates, or detection of local recurrence. Reconstruction may be delayed in
patients who might require postmastectomy radiation therapy.
Reconstruction options include tissue expander and implant and autologous tissue
reconstructions, most often with transverse rectus abdominis muscle flaps,
latissimus dorsi flaps, or, more recently, muscle-preserving perforator abdominal
flaps

Free TRAM flap is based on blood supply from the Internal Mammary Artery. Most
recurrences of carcinoma after mastectomy will be in the skin and subcutaneous
tissue so they are easily recognizable even after reconstruction.

• What option exists to decrease the risk of breast cancer in women with BRCA?

➢ Prophylactic bilateral mastectomy

• What medication may lower the risk of developing breast cancer in LCIS?
➢Tamoxifen for 5 years will lower the risk up to 50%

• Woman came with unilateral bloody discharge of the nipple, think of intraductal
papilloma.
• An axillary mass that enlarges during pregnancy is usually accessory mammary
tissue ➢Treatment: follow up is enough

• Prophylactic mastectomy reduces the risk of having breast cancer in BRCA carrier
by 90%
• The most common breast tumor in patients younger than 30 years:
➢Fibroadenoma

• The most common cause of breast mass after breast trauma: ➢Fat necrosis

• Sealed bandaging for 4-5 days would improve the graft acceptance by:
1- preventing the movement
2- prevent hematoma and seroma
3- connecting the graft of the recipient floor
• Chronic wounds can cause cancer from the type of squamous cell carcinoma
• Keloid represents improper healing of the scar
• Proliferative scars occur due to imbalance between production and decomposition
of collagen ( more production, less decomposition)
• The best method to diagnose pigmented skin lesions such as melanoma is
excisional biopsy
• In melanoma we should inspect other lesions such as cervical, inguinal and axillary
lymph nodes

ADH (atypical ductal hyperplasia) and ALH (atypical lobular hyperplasia) are both
classified as proliferative changes with atypia. These increase 4 to 5 times the risk of
a woman's lifetime developing breast cancer compared to the general population.
When there is a family history of breast cancer and proliferative atypia, the risk of
cancer increases nine times over the normal population.
HERNIAS
 INGUINAL HERNIAS
Inguinal hernias are classified as direct or indirect.
The sac of an indirect inguinal hernia passes from the internal inguinal ring obliquely
toward the external inguinal ring and ultimately into the scrotum.
- Failure of obliteration of the processus vaginalis leads to a persistent connection
between the scrotum and the peritoneal cavity through the inguinal canal.
In contrast, the sac of a direct inguinal hernia protrudes outward and forward and is
medial to the internal inguinal ring and inferior epigastric vessels. Usually in older
men due to an acquired weakness in the transversalis fascia.
Protrudes through the inguinal (Hesselbach) triangle.
Incidence
The estimated lifetime incidence of all hernias are 5% of the world population, with
75% of them being inguinal hernias. Of the inguinal hernias, ⅔ of them will be
indirect and a ⅓ direct hernias.Femoral hernias are only approximately 3% of hernias
in the groin region.
In general, men are 25 times more affected from groin hernias than women and
indirect inguinal hernias are the most common type of hernia in men and in women .
inguinal hernias remain the most common hernia in women .
Indirect inguinal and femoral hernias occur more commonly on the right side.
• Occurs more commonly in the right side (due to delay in atrophy of the processus
vaginalis, and due to temponading effect of the sigmoid colon).
The most common incarcerated hernia is indirect inguinal hernia
The prevalence of hernias increases with age, particularly for inguinal, umbilical, and
femoral hernias.
direct (25% of cases) or indirect (50% of cases).
Indirect inguinal hernia most commonly seen in male infants and older men
Direct inguinal hernia: most commonly seen in older men
Anatomy
inguinal canal
Extends between the deep (internal) and superficial (external) ring
Roof (superior): internal obliqueand transversus abdominis muscles
Floor (inferior): inguinal ligament (shelving edge of external oblique) and lacunar
ligament (medially)
Posterior wall: transversalis fascia laterally; conjoint tendonmedially
Anterior wall: external oblique aponeurosis and internal oblique muscle laterally

Hesselbach triangle borders

Medially: rectus abdominis muscle
Laterally: inferior epigastric vessels
Inferiorly: inguinal ligament
"The DIRECT path leads through the MiDdle, the INDIRECT path goes beLow."
(DIRECT hernias lie MeDial and INDIRECT hernias lie Lateral to the inferior
epigastric vessels).

Sx
Typically manifests as an ill-defined mass in the inguinal region with the following
features:
Increases in size when coughing or straining
Decreases in size on lying supine
Inguinal pain (inguinodynia) or vague inguinal discomfort that increases with physical
activity; can also be painless
A bulge palpable on the fingertip confirms the diagnosis of an inguinal hernia

The diagnosis of an inguinal hernia is done first (clinical) with a

physical examination which will reveal a bulge in the groin when the
patient stands or performs valsalva. Approximately ⅓ of inguinal
hernias are asymptomatic and do not need surgical intervention.
Imagine First line USG
Complicated inguinal hernia
Incarcerated hernia
The herniais irreducible.
If associated with mechanical bowel obstruction sudden onset of pain, nausea,
vomiting, abdominal distension, constipation, or obstipation
Skin overlying the hernia: normal
Strangulated hernia
Sudden, severe groin pain caused by constriction and ischemia(or necrosis) of hernial
contents
Features of bowel obstructionif the herniacontains intestinal loops.
Skin overlying the hernia: warm, erythematous, tender.
Treatment of inguinal hernia
• Asymptomatic : just observation
• Symptomatic : Repair of hernia through Surgery ! It could be elective
Incarcerated or strangulated: emergent surgery !
Incarcerated hernia without strangulation: Consider manual reduction of inguinal
hernia
Successful manual reduction: close monitoring; consider surgery during the same
hospital admission
Unsuccessful manual reduction: urgent surgery
The advantage of mesh repair is decreased recurrence rates
Laparoscopic inguinal Hernia Approach

• Laparoscopic inguinal hernia approach is: ➢ 1- Less pain ➢ 2- Quicker recovery

• The anatomic view is identical in both open and laparoscopic inguinal hernia
repairs.
• Laparoscopic approach is better in patients with recurrent hernia or bilateral
hernias.
The anatomic view is identical in both open and laparoscopic inguinal hernia repairs.
No-> Laparoscopic is better vieowing
• General anesthesia is the only absolute contraindication for laparoscopic->no
Which herniorraphies is least likely to lead to recurrence : Mesh
Laparoscopic inguinal hernia repair is superior to open hernia repair in the
following cases : unilateral/bilateral inguinal hernia ,small direct inguinal hernia
6. Laparoscopic inguinal hernia repair is superior to open hernia repair in all the
cases below, except:
a. Unilateral inguinal hernia following previous open repair
b. Bilateral inguinal hernia
c. Football player with small direct inguinal hernia
d. A patient with a history of radical prostatectomy
FEMORAL HERNIAS
A femoral hernia occurs through the femoral canal, which is bounded
superiorly by the iliopubic tract, inferiorly by Cooper ligament, laterally by the
femoral vein, and medially by the junction of the iliopubic tract and Cooper ligament
(lacunar ligament). It is located medial to the femoral vein
A femoral hernia produces a mass or bulge below the inguinal ligament.
Approximately 50% of men with a femoral hernia will have an associated direct
inguinal hernia, whereas this relationship occurs in only 2% of women.
• High risk for strangulation (15-20%)
• Presented as painful bulge in the inguinal region
• Diagnosis is made by US/ CT scan
The incidence of strangulation in femoral hernias is high; therefore, all femoral
hernias should be repaired, and incarcerated femoral hernias should have the hernia
sac contents examined for viability.
In patients with a compromised bowel, the Cooper ligament approach is the
preferred technique because mesh is contraindicated.
• Treatment : immediate hernia repair ,McVay (Cooper’s ligament repair).
Incisional hernias
occur as a consequence of excessive tension and insufficient healing of a previous
incision. • Usually after previous operations
Factors that predispose to incisional hernia development include conditions that
render wound healing such as surgical site infections mc and medications like
corticosteroids and chemotherapeutic agents; and those that increase intra-
abdominal pressure such as obesity, advanced age, malnutrition, ascites and
pregnancy. Additional risks include chronic pulmonary disease and diabetes mellitus.

Treatment includes either a laparoscopic or an open surgical repair of the hernia

with or without mesh placement .It is believed that the laparoscopic approach is
superior to open surgery due to fewer postoperative complications, lower infection
rates, and decreased hernia recurrence.
Small incisional hernias (< 3 cm defect): primary repair
Larger incisional hernias: hernioplasty (mesh repair)
Umbilical
In adults usually acquired
More common in women
Small asymptomatic hernias need not be repaired
Symptomatic/large/ incarcerated/ thinning of the overlying skin/ uncontrollable
‫יי‬ascites needs to be repaired.

Umbilical
umbilical hernias in infants are congenital and are common, present in
approximately in 15% of infants. In the majority of cases, they spontaneously close
by the age of 2 years. In cases that persist after the age of 5 years surgical repair is
required.
Clinical features include a mass protruding through the umbilicus that increases in
size with crying, straining and coughing; and reduces with lying down.
Surgery is rarely indicated, only in cases in which there is no spontaneous closure by
5 years of age, very large hernias, and in cases of incarceration, strangulation or
bowel obstruction.
Epigastric
3-5% of the population has epigastric hernias.
Hernia through the linea alba above the Umbilicus
Epigastric hernias are two to three times more common in men.
From the xiphoid to the umbilicus
High risk for incarceration
Weakness of the abdominal wall due to penetrating small blood vessels
Small defects can be repaired under local anesthesia. Uncommonly, these defects
can be sizable, can contain omentum or other intra-abdominal viscera, and may
require mesh repairs.
Unusual hernias
A Spigelian hernia
is created by a defect in the Spigelian fascia, which is located between the rectus
muscle medially, and the semilunar line laterally.Located lateral to the rectus muscle
at the arcuate line.
This type of hernia is usually small (1-2cm in diameter) and appears in ages 40-70.
Usually it is difficult to diagnose (since it is located below the external oblique
muscle, it is difficult to palpate on physical examination) and the diagnosis would
necessitate CT or US.
The treatment is a surgical repair, since it has a tendency for incarceration (narrow
neck).

A sliding hernia
is defined as a hernia in which part of the hernial sac is composed of visceral
peritoneum of an internal organ. Usually, sliding hernias are indirect inguinal hernias
and the organs most commonly involved are the urinary bladder and the colon.
The repair of a sliding hernia may be difficult and even dangerous if the surgeon
does not recognize the visceral peritoneum composing the hernial sac.
Obturator Hernia (females more than males)
The obturator canal is formed by the union of the pubic bone and ischium.
Weakening of the obturator membrane may result in enlargement of the canal and
formation of a hernia sac, which can lead to intestinal incarceration and
strangulation. The patient can present with evidence of compression of the
obturator nerve, which causes pain in the anteromedial aspect of the thigh
(Howship-Romberg sign) that is relieved by thigh flexion.
. Almost 50% of patients with obturator hernia present with complete or partial
bowel obstruction. An abdominal CT scan can establish the diagnosis, if necessary.
open or laparoscopic, is preferred. The obturator foramen is repaired with prosthetic
mesh, with care taken to avoid injury to the obturator nerve and vessels. Patients
with compromised bowel usually require laparotomy.
Littre hernia
Hernia involving a Meckel’s diverticulum
Amyand hernia
• Out Protrusion of the appendix
Lumbar hernia
• Occur in the lumbar region of the posterior abdominal wall
• Usually after abdominal wall trauma or surgery.
• Grynfeltt triangle (bounded by 12th rib, paraspinal muscles, internal oblique
muscle)
• Petit triangle (bounded by the iliac crest, latissimus dorsi muscle, external oblique
muscle.)
Sciatic hernia
• Arise from the greater sciatic foramen
• Asymptomatic until intestinal obstruction occur
• Usually in elderly patients
Prastomal hernia
• The highest after colostomy (50%)
• Strangulation is rare
• Richter hernia > Incarcerated or strangulated hernia involving only one sidewall of
the bowel resulting in gangrenous bowel and perforation within the abdomen
without signs of obstruction
Infringement of the antimesenteric wall of the intestine in the hernia
ESOPHAGEAL HIATAL HERNIAS

• Define type I and type II hiatal hernias?

➢ Type I: sliding
➢ Type II: paraesophageal

• What are the symptoms?

➢ Most patients are asymptomatic, but the condition can cause reflux, dysphagia

What is the surgical treatment?

➢ Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus
around the LES and suturing it in place

Paraesophageal Hiatal Hernia

• Herniation of all or part of the stomach through the esophageal hiatus into the
thorax without displacement of the gastroesophageal junction
• Also known as type II hiatal hernia
• Symptoms:
➢ Derived from mechanical obstruction
➢dysphagia
➢without reflux

The complications: Hemorrhage, incarceration, obstruction, and strangulation

• The treatment: Surgical

• What is a type III hiatal hernia? Combined type I and type II

What is the appropriate treatment for a patient with type 3 ( mixed ) hiatal hernia
and iron deficiency anemia ? Repairing of the hiatal hernia and fundoplication

Ischemic orchitis
is a possible complication following a hernia-repair surgery.
This condition is caused by thrombosis of the small veins in the Pampiniform plexus
in the vas deferens. As a result, venous congestion is developing in the testicle,
which becomes distended and tender in approximately 2.5 days after the surgery.
the diagnosis of testicular ischemia is clinically established and confirmed by color or
power Doppler USG
The treatment includes analgesics and anti-inflammatory drugs such as NSAIDs.
Usually there is no indication for orchidectomy.
Incarcerated and strangulated hernia
can result in small bowel obstruction

• Treatment: ➢ In this case the repair will be by groin exploration

➢ If groin exploration fails we go to exploratory laparotomy

Surgical Site Infection

The risk for surgical site infection is estimated to be 1% to 2% after open inguinal
hernia repair and slightly less with laparoscopic repairs.
These are clean operations, and the risk for infection is primarily influenced by
associated patient diseases. Most would agree that there is no need to use routine
antimicrobial prophylaxis for hernia repair.
score of 3 or more, receive perioperative antimicrobial prophylaxis with cefazolin, 1
to 2 g, given intravenously 30 to 60 minutes before the incision. Clindamycin, 600 mg
intravenously, can be used for patients allergic to penicillin. Only a single dose of
antibiotic is necessary.
Rectus sheath hematoma
• The causes:
1. Anticoagulant (1st most common)
2. trauma or injury (2nd most common)
3. cough and pregnancy.
• The Signs:

➢ Cullen sign :periumbilical ecchymosis

➢ Grey turner sign :blue discoloration in the flanks

• Diagnosis : ➢ Ultrasound or CT

• Treatment: ➢ rest and analgesia ➢ angio-embolization if increased . ➢ In severe

cases surgery by evacuating the hematoma.

The treatment for an incarcerated inguinal hernia is surgical, by opening the inguinal
canal.
Which blood vessel may be injured in an inguinal hernia repair?
A. Inferior epigastric vessels B. Obturator artery C. Internal iliac artery A. Lateral
femoral vein . All Answers are Right
• Why should hernias be repaired?

➢ To avoid complications of incarceration/strangulation, bowel necrosis, SBO (small

bowel obstruction)
Small Vs. Large Hernia • What is more dangerous: a small or large hernia defect?
➢Small defect is more dangerous because a tight defect is more likely to strangulate

• Hesselbach’s hernia: Hernia under inguinal ligament lateral to femoral vessels

Patient 70 years with atrial fibrillation on Plavix he has incarcerated hernia at first
then the mass is gone? What to do?

➢ Clopidogrel ( Plavix) is associated with increased risk of bleeding before surgery

• Treatment Plan:

➢ 1- Clopidogrel should be discontinued 7-10 days before surgery

➢ 2- Do surgery to reduce the risk of recurrence

 Hepatobiliary Diseases

• Type I cells found on (duodenum, jejunum) ------ secrets CCK (Cholecystokinin ) ,

CCK functions:
• increase pancreatic secretion
• increase gallbladder contraction
• decrease gastric emptying
• increase sphincter of Oddi relaxation .
• CCK stimulated by by fatty acids (fatty foods), amino acids
▪ Biliary colic:
- Biliary colic occurs when a stone temporarily occludes the cystic duct.
- This causes colicky pain in the right upper quadrant radiating to the right shoulder
and back, often triggered by ingestion of fatty food, accompanied by nausea and
vomiting, but without signs of peritoneal irritation or systemic signs of inflammatory
process.
- Biliary colic occurs due to increased intra-gallbladder pressure that is created when
the gallbladder contracts against an obstructed cystic duct.
- The episode is self-limited (10, 20, maybe 30 minutes), or easily aborted by
anticholinergics.
- U/S establishes diagnosis of gallstones and elective laparoscopic cholecystectomy is
indicated.

Gallstones (cholelithiasis) Stones in the gallbladder

• 2 types of stones:
Cholesterol stones (radiolucent with 10–20% opaque due to calcifications)—80% of
stones.
Associated with: obesity/ Crohn disease /advanced age
estrogen therapy /Multiparity
rapid weight loss/ Native American origin
Pigment stones; (black = radiopaque) (brown = radiolucent, infection)
Associated with: Crohn disease /chronic hemolysis (SCA) /alcoholic cirrhosis
/advanced age /biliary infections total parenteral nutrition (TPN)
Sx.
• Most patients are asymptomatic.
• RUQ (right upper quadrant pain).
• RUQ pain worse after fatty food. • Nausea / vomiting.
• This is called biliary colic , which is resolved in 1 hour.
Dx. • Ultrasound : stone with shadow.

Tx of gallstones.
• Symptomatic patients ? Laparoscopic cholecystectomy.
• Asymptomatic patients ? Needs No Treatment , Except :-
• Porcelain gallbladder (calcified gallbladder which increase the risk of
adenocarcinoma).
• Sickle cell anemia \Immunocompromised
• Stone size >2.5cm\ gallbladder >10mm
• Pediatric patients
Acute cholecystitis • Inflammation of gallbladder wall , can be acute or chronic.
• Calculous cholecystitis ( with stone ): • most common type • due to gallstone
impaction in the cystic duct resulting in inflammation and gallbladder wall
thickening. • can produce 2° infection.
• Acalculous cholecystitis ( without gallstone ) ; due to gallbladder stasis,
hypoperfusion, or infection (CMV). seen in critically ill patients ( ICU patients , burn ,
trauma …)
Sx
• RUQ pain.
• Murphy sign: inspiratory arrest on RUQ palpation due to pain
• Pain may radiate to right shoulder (due to irritation of phrenic nerve).
• Pain > 1 hour.
• Fever • +/- vomiting
Dx.
• 1 st ultrasound
• cholescintigraphy (HIDA scan) : dx test of choice. • Failure to visualize gallbladder
on HIDA scan suggests obstruction.

Tx. CHOLECYSTITIS • In the case of septic shock caused by infection from gallbladder,
the treatment should be with cholecystectomy!
• NPO • IV antibiotics • Analgesics
• Laparoscopic Cholecystectomy within 24-48 hours.
• In severe ill patients who cant undergo surgery ( COPD , MI , renal failure … ) Tube
Cholecyststomy (percutaneous drainage of the gallbladder).
Gallstone ileus

cholecystoenteric fistula between gallbladder and GI tract -------stone enters GI

lumen--- ------obstructs at ileocecal valve (narrowest point);
• can see air in biliary tree (pneumobilia).
• Pneumobilia= air in biliary tree = gallstone ileus.
• Usually seen in long-standing untreated gallstone. • Usually in women > 70 years
old.
Sx: • Intestinal obstruction symptoms. • History of long-standing gallstones.
Dx. • Abdominal X-ray : pneumobilia
CT • Ultrasound : gallstone
Tx: • Laparotomy with Ileotomy and extraction of stones.

Emphysematous cholecystitis
• Severe form caused by gas-forming bacteria ( usually clostrium prefrenges)
• Also called as clostridial cholecystitis. • Mainly seen in elderly diabetic men
• Results in perforation of gallbladder.
• Tx. • Cholecystectomy.
Porcelain gallbladder
• Calcified gallbladder due to chronic cholecystitis;
• usually found incidentally on imaging
• prophylactic cholecystectomy due to high rates of gallbladder cancer (mostly
adenocarcinoma).
• It should be resected even if found in asymptomatic patients.
Ascending cholangitis

• Obstruction of CBD ( common bile duct ) ----- E.coli bacteria caused suppurative
infection in biliary tree.
• Sx: • Charcoat Triad : • RUQ pain • Fever • Jaundice
• Reynold pentad = Charcoat Triad + confusion and shock
Hypotension ( septic shock) • Confusion

Dx. • Lab :
• leukocytosis • Increased ALP (alkaline phosphatase) • Increased direct billirubin
• ERCP (endoscopic –Retrograde –cholangio-pancreaticography) Dx method of
choice ( can be also therapeutic).
Tx. • NPO , IV fluid , Antibiotics
• If failed ? • ERCP
• If failed ? • Intraoperative decompression and T-tube placement.

Polyps in Gallbladder
• Asymptomatic polyps smaller than 1 cm without risk factors of malignancy should
be managed through U/S surveillance
• Symptomatic polyps in gallbladder require laparoscopic resection
Bile Duct Injury
• Patients with bile duct injury after cholecystectomy present with jaundice.
• Elevated Alkaline phosphatase levels and bile leakage from injured duct
• In case of bile duct injury during cholecystectomy surgery, the laproscopic surgery
should be transformed to open surgery ( laprotomy)
• Treatment:
1. Intravenous antibiotics
2. Drainage of periportal fluid collections
3. Cholangiography followed by stenting
4. dilation or surgical reconstruction of biliary tree.
Gallstone Pancreatitis
As a stone may pass through the common bile duct and into the duodenum, it
traverses the ampulla. In the process, it may cause secondary injury to the pancreas.
A generally accepted pathophysiologic mechanism involves temporary elevation of
pancreatic ductal pressures, causing a secondary inflammation of the pancreatic
parenchyma. Even a temporary elevation of intraluminal pressure can cause
significant injury to the pancreas. As opposed to the gallbladder, in which relief of
the obstruction is accompanied by pain resolution, the symptoms in pancreatitis
continue in spite of passage of the stone., ultrasound will help identify gallstones and
may show choledocholithiasis or a dilated bile duct. The offending stone usually
passes spontaneously but may still cause severe pancreatitis. In most cases of
gallstone pancreatitis, the pancreatitis is self-limited. If, by clinical assessment, the
pancreatitis is severe, early ERCP to remove a stone that may not have passed is
indicated and has been shown to reduce the morbidity of the episode of
pancreatitis. To prevent a future episode of gallstone pancreatitis, a laparoscopic
cholecystectomy is warranted; this is generally recommended during the same
hospitalization, just before discharge.
ERCP is indicated in cases where additionally to pancreatitis there is an obstruction
of the common bile duct by a stone
TUMORS OF THE LIVER

• What is the most common liver cancer? ➢ Metastatic disease outnumbers

primary tumors

• What is the most common primary malignant liver tumor? ➢ Hepatocellular

carcinoma (hepatoma)

• What is the most common primary benign liver tumor? ➢ Hemangioma

• What is Courvoisier’s gallbladder? ➢Palpable, nontender painless gallbladder

(unlike gallstone disease) associated with cancer of the head of the pancreas.

Recommendations to cirrhotic patients include the following:

- Child’s A and B: treat ascites and coagulopathy and proceed to surgery.
- Child’s C: delay surgery until the patient’s Child’s class is improved or cancel surgery
altogether and opt conservative management instead

The MELD index reflects the likelihood of mortality within 3 months, reflects the
severity of liver disease and is based on a formula that includes bilirubin, creatinine
levels and INR.
MELD = 3.78 × ln [serum bilirubin (mg / dL)] + 11.2 × ln [INR] + 9.57 × ln [serum
creatinine (mg / dL)] + 6.43
HEMOBILIA
Blood draining via the common bile duct into the duodenum
• What is the diagnostic triad? Triad:
1. RUQ pain 2. upper GI bleeding 3. Jaundice
• The most common cause of haemobilia is Iatrogenic injury
• How is the diagnosis made? Upper endoscopy (blood out of the ampulla of Vater)
• What is the treatment? embolization of the bleeding vessel

TUMORS OF THE LIVER

• What is the most common liver cancer?
➢ Metastatic disease outnumbers primary tumors
• What is the most common primary malignant liver tumor?
➢ Hepatocellular carcinoma (hepatoma)
• What is the most common primary benign liver tumor?
➢ Hemangioma

Hepatocellular Carcinoma
• What is it?
➢ Most common primary malignancy of the liver
• By what name is it also known?
➢ Hepatoma
• What is its incidence?
➢ Accounts for 80% of all primary malignant liver tumors
• What are the associated risk factors?
➢ Hepatitis B virus, cirrhosis, alfa toxin
• What tests should be ordered?
➢ Ultrasound, CT scan, angiography, tumor marker elevation
• What is the tumor marker?
➢ Elevated alfa–fetoprotein
• What is the most common site of metastasis?
➢Lungs
• Treatment:
Patients with advanced cirrhosis (Child class B and C) and early-stage HCC should be
considered for transplantation,
whereas those with Child class A cirrhosis : resection
CARCINOMA OF THE GALLBLADDER
Klatskin Tumor
• Cholangiocarcinoma that happens at the bifurcation region of the biliary tree is
called klatskin tumor
• Clinical features: Painless Jaundice
• In klatskin tumor it is common for the intrahepatic bile ducts to be severely dilated,
while the extrahepatic ducts are normal
Gallbladder cancer after cholecystectomy
The treatment depend on the depth of the cancer
T1a lesions : in which the carcinoma penetrates the lamina propria but does not
invade the muscle layer, cholecystectomy should suffice for therapy
T1b : penetrating the muscularis but not the deeper connective tissue or serosa >
cholecystectomy is sufficient as long as the margins are negative
T1b lesions and perineural, lymphatic, or vascular invasion > radical cholecystectomy
that includes the lymph nodes which drain the gallbladder (periportal,
hepatoduodenal, right celiac, etc.), resection of the cystic duct and sometimes the
CBD (with creation of Roux-en-Y); and resection of 2 cm of the liver bed (of course
the gallbladder has already been resected). In addition, resection of the portal areas
is required
CHOLANGIOCARCINOMA
• What is the management of proximal bile duct cholangiocarcinoma?
➢Resection with Roux-en-Y
➢unilateral hepatic lobectomy in some cases
• What is the management of distal common bile duct of cholangiocarcinoma?
➢Whipple procedure
ABSCESSES OF THE LIVER
• What is a liver abscess?
➢ Abscess (collection of pus) in the liver Parenchyma
• What are the types of liver abscess?
1.Pyogenic (bacterial) 2. parasitic (amebic)
• What is the most common location of abscess in the liver?
➢ Right lobe

Amebic Liver Abscess

Casused by Entamoeba histolytica , is endemic in Mexico, India, Africa, and parts of
Central and South America.
Transmission usually occur via the fecal-oral rout (contaminated water)
Presentations : present as single liver lesion ,abdominal pain ,fever and
hepatomegaly (jaundice is less common)
Treatment :
Antimicrobial agents : Metronidazole 750 mg orally
Aspiration is recommended in cases of diagnostic uncertainty, failure to respond to
antimicrobial therapy in 3-5 days, or in abscesses at high risk for rupture (such as
abscesses >5 cm in diameter or those located in the left liver).
Percutaneous drainage and laparotomy are reserved for peritoneal ruptures which
is the most common complication associated with these abscesses.
Pyogenic liver abscess
Caused by bacteria E.coli,klebseilla , present as multiple liver lesions
Treatment : antibiotics and drainage
. Pyogenic abscess
Pyogenic liver abscess classically presents with fever, chills, jaundice, right upper
quadrant pain, and tenderness on palpation. Ultrasound demonstrates a
hypoechogenic lesion.multiple

. Amebic abscess
Like a pyogenic abscess, common symptoms are fever, chills, right upper quadrant
pain, and tenderness. An amebic abscess is caused by Entamoeba hystolitica and is
typically described as an anchovy sauce lesion due to liquefaction necrosis of the
liver. Early abscesses are not well defined on imaging. Only chronic abscesses may
develop a fibrous capsule and calcifications. Patients with this disease usually have
a history of travel to an area endemic for amebiasis.
Hydatid Liver Cyst
a 47 years old male presents to the ER with several weeks of upper abdominal pain and
early satiety. No fever or weight loss, epigastric fullness on examination. Ultrasound and
CT scans demonstrate a left liver lobe 7 cm mass with several cysts inside and peripheral
calcification. What is the most likely diagnosis?

• Zoonotic parasitic disease endemic in middle east

• The common carriers are dogs which hold the echinococcal eggs in their feces
-diagnosed with a combination of imaging and serology -Eggshell calcification of
liver cyst on CT is highly suggestive of hydatid cyst.
• Hydatid cyst may have daughter cysts with septa and calcifications of the cyst wall
• The treatment: for echinococcal cyst is surgical
• When preparing for surgery epinephrine should be available .
• Rupture or tearing of the cyst during surgery can cause anaphylaxis and seeding
the parasite in other place
Pancreatic necrosis
Pancreatic necrosis is a complication from
acute pancreatitis
Diagnosis : CT

On CT : Hypo-perfused areas due to ischemia ➢

and necrosis
Treatment: Carbapenem is the drug of choice
A 58-year-old man with a history of alcohol abuse, is admitted to the emergency
room with an acute pancreatitis. CT shows hypoperfused lesions, and FNA shows
gram-negative bacilli. Which of the following is the best antibiotic treatment?
Carbapenem

it is the removal of head of pancreas, duodenum and gallbladder.

Connections:
-The pancreatic duct to jejunum
-The bile duct to jejunum
-The stomach to jejunum
Annular Pancreas
What is an annular pancreas? •
Pancreas encircling the duodenum
What is pancreatic divisim? •
Failure of the two pancreatic ducts to fuse
Chronic pancreatitis
is most commonly caused due to alcoholism
Clinical manifestations include epigastric pain, nausea, vomiting, steatorrhea and
weight loss.
Complications Pancreatic pseudo cysts occur in up to 40% of patients.Duodenal
obstruction occurs in about 1.2% of patients with chronic pancreatitis.
Serous cystic neoplasm (SCN)
occur usually in the head of the pancreas and in patients of 60-70 years of age.
The common presentation is with dull abdominal pain, weight loss and obstructive
jaundice.
These cysts are usually large and well-circumscribed. Microscopically, they consist of
multiple small cysts, filled with glycogen, with many loculations. The fluid does not
contain mucin, and has low levels of amylase and CEA.
In 10-20% of cases, CT may show central calcifications with radial septae, giving a
sunburst appearance.
Although these cysts are considered to be benign, they should be excised in cases
where the diagnosis is not certain, or when there are symptoms. Patients with a cyst
larger than 4 cm, are usually symptomatic, and those cysts grow faster than smaller
cysts (below 4 cm), therefore should be excised.
In case of a small (<4cm), asymptomatic pancreatic cyst, with no suspicion for
malignancy- only observation and follow-up is indicated.
Pancreatic pseudocysts
• CT or MRI • Endoscopic ultrasound (EUS ) with FNA for patients with unclear Dx.

• High amylase • Absence of mucin • Low CEA

• Tx

Asymptomatic + size 4cm / located in tail and no evidence of pancreatic duct obstruction or
communication with main pancreatic duct > observation (spontaneously regression in up to
70% of pts)Symptomatic/ >4cm : drainage via the stomach (endoscopic cystgastrostomy or
percutaneous drainage.
Pancreatic cancer

Tumors based on Location Signs and symptoms based on location:

• Head of the pancreas ➢ Painless jaundice from obstruction

• Body or tail ➢ Weight loss and pain
• Which tumor markers are associated with pancreatic cancer
➢ CA-19-9 (Carbohydrate Antigen 19-9)
• What metastatic lymph nodes in gastric cancer can be found with
metastatic pancreatic cancer
➢ Virchow’s node
➢ Sister Mary Joseph’s nodule

BRCA 2 mutation carriers have increased risk of pancreatic cancer 10

times more

CT is could be a choice however it can’t detect the small lesions

EUS is becoming widely used for the evaluation of suspected pancreatic
disease. Perhaps its most important ability is to provide tissue diagnosis
of suspected tumors through the use of FNA before initiation of systemic
therapy

Treatment based on location:

• Head of the pancreas ➢ Whipple procedure

• Body or tail ➢ Distal resection

• tumors involving critical peripancreatic arteries are T4 lesions and are

unresectable > chemoradiation therapy

Palliation of biliary obstruction is commonly required for patients who

are not candidates for surgical resection. ERCP with stent placement
provides excellent palliation of jaundice,
1-Dumping syndrome is a part of Postgastrectomy Syndromes. This syndrome may
develop after any gastric surgery, but are more common following a partial
gastrectomy with Billroth II reconstruction.

2-The treatment for duodenal perforation due to an ulcer, is suturing and

omentopexy. Additional vagotomy should be considered.
3-The most important risk factors for malignancy of GISTs are tumor size > 10cm and
more than 5 mitoses per high-power field (HPF).
Hemorrhoids
• Internal hemorrhoids: present with painless bleeding and prolapse
• External hemorrhoids: present with pain on defecation
Anal fissure
• sphincterotomy which is incision of the internal anal sphincter muscle is done
which can lead to stool incontinence.
Appendicitis
• Delayed presentation of appendicitis is treated conservatively with:

➢ fluid administration ➢broad spectrum antibiotics

• Percutaneous drainage is done in the case of abscess

Perforated Appendix
• The most common bacteria in case of perforated appendix are E. coli and
Bacteroides fragilis anaerobic.

• Treatment: ➢ Antibiotics for gram negative bacteria and anaerobes

• The main reason of necrosis of appendix is disruption of venous drainage

• The most common location of the base of the appendix is the merge of three
taeniae coli.
Apindicitis in patients >60 years of age
Consider diagnostic laparoscopy if imagimg finding are inconclusive
Consider colonoscopy after treatment of acute appendicitis to rule out early colon
malignancy
Appendiceal Abscess
Description: a localized collection of pus and necrotic tissue that forms around an
inflamed appendix, which typically follows an untreated perforated appendix
Clinical features: manifests as a tender mass in the RLQ in an acutely ill patient (i.e.,
high-grade fever, possible paralytic ileus, leukocytosis, signs of sepsis)
Diagnosis: Confirmed by CT scan.
Treatment
Abscess < 4 cm: antibiotic therapy alone is usually sufficient.
Abscess > 4 cm: image-guided percutaneous drainage or surgical drainage
Emergency surgery is indicated if percutaneous drainage is not feasible.
Think o an abscess in a patient who presents with the clinical picture o a c t s a RLQ
mass.
Gastrointestinal bleeding
Gastrointestinal bleeding (GIB) is divided into upper (from the esophagus, stomach
or duodenum), lower (colon), small intestinal or obscure (unknown source). Upper
GIB is more common than lower.

GIB could be overt (as hematemesis, melena, or hematochezia) or occult (as

symptomatic anemia, laboratory abnormalities or positive fecal occult test).

The most common cause for acute lower GI hemorrhage in adults is diverticulosis,
followed by:

Vascular ectasia- especially in patients older than 70 years

Neoplasms- mainly adenocarcinoma

Colitis- ischemic, infectious, inflammatory bowel disease (Crohn’s or ulcerative

colitis), NSAID-induces, ulcers

Post-polypectomy bleeding

Radiation colitis or proctitis

Rare causes for lower GIB include solitary rectal ulcer syndrome, trauma, varices
(most commonly rectal), lymphoid nodular hyperplasia, vasculitis, and aorto-colic
fistulas.

The most common causes for significant lower GIB in children and adolescents, are
inflammatory bowel disease and juvenile polyps.

Hemorrhoids and anal fissures may cause a minor bleeding and inconvenience but
severe bleeding as described is less likely.
Upper GI Bleeding : Bleeding proximal to the ligament of Treitz

The most common cause of upper GI bleeding is peptic ulcer disease

even in patients with portal hypertension (liver cirrhosis)

Management of upper gastrointestinal bleeding

Patients presenting with massive hemorrhage and hemodynamic
instability despite vigorous resuscitation should undergo an emergency
laparotomy

Treatment for variceal bleeding begins with gastroscopy and ligation or

sclerotherapy. If these operations are insufficient, bleeding should be stopp ed
by a tampon (Sengstaken-Blackmore or Minnesota tube). you can perform
definitive actions (TIPS, Shunt) afterwards.
The risk for bleeding and ulceration associated with NSAIDs

Is proportional to the daily dosage of NSAIDs.

Increases with age older than 60 years

Increases in patients having a prior GI event

Increases with concurrent use of steroids or anticoagulants.

The most common cause of small intestinal bleeding in patients under

the age of 30 is a Meckel diverticulum.
Meckel diverticula can contain ectopic gastric mucosa, acid secretion can
cause small-bowel ulcerations
Diagnosis: Technician mapping (99m)
Treatment :Segmental resection of the intestine with the finding
inside it

A 60-year-old male is brought to the ER after several episodes of bloody stool. On

admission – pale, diaphoretic, systolic blood pressure 80 mmHg, pulse 122/min. Abdomen
is soft, non-tender, with fresh blood on rectal examination. Which of the following will be
the first step after blood products and fluids? a. Nasogastric tube

b. CT angio c. Rectoscopy d. Urgent colonoscopy

When a patient presents with fresh rectal bleeding, the patient

should be stabilized and rule out bleeding from the upper
digestive tract. If the patient is hemodynamically stable,
gastroscopy should be performed.
Lower GIT bleeding

The most common cause of gross lower gastrointestinal bleeding in

adults is Diverticulosis

Algorithm for lower GI bleeding

One needs to make sure that the bleeding does not come from the
upper GI and therefore a nasogastric tube which is easy to perform
in the emergency room is the most appropriate next step.

Patients with hematochezia and hemodynamic unstable should

complete an upper endoscopy to rule out upper GI bleeding
if the source of bleeding is not identified and they remain unstable
angiography should be the next step
in stable patients > colon preparation followed by colonoscopy

When the source of GI bleeding is not detected in endoscopy (instable

patient) a video capsule is the most convenient way to detect bleeding
in the small intestine

In case of perforation after colonoscopy with hemodynamic unstable

,laparotomy is needed
Colonic massive bleeding

Diverticulosis and angiodysplasia are responsible for most cases of

massive colonic bleeding
Almost all cases of colonic angiodysplasia are located in the cecum and
right colon.
In contrast to diverticular disease, bleeding from angiodysplasia is
venous and not as severe

Angiodysplasia
diagnosis : colonoscopy , angiography
treatment : angioembolization
ALGORITHMS IN THE ACUTE ABDOMEN

A 73-year-old male arrives to the ER with vomiting, acute abdominal pain, and suspected
acute abdomen on physical examination. Labs - lactic acidosis. Which of the following is
the next step at the ER?

Abdominal CT .

Supine and upright or left lateral decubitus abdominal X-ray .

Abdominal ultrasound .

Abdominal angiography .

-> Which of the following causes fever as a result of infection alone? Diverticulitis
A 75-year-old woman following trauma and a head injury was intubated in the
field by Magen David Adom; during lung auscultation air entrance was equal
bilaterally. On admission to the emergency room: GCS 6, blood pressure 110\70,
pulse 90, saturation 85%, with decreased air sounds on the left side. What is the
appropriate next step in management? Confirm endotracheal tube position
The initial assessment, termed the primary survey, of any trauma patient follows the
ABCDE mnemonic. The first step is A, airway assessment. In a ventilated patient, the
position of the endotracheal tube is evaluated.
Surgeries of CRC
Cecum: Right hemicolectomy
Right colon: Right Hemicolectom
Proximal mid transverse colon: Extended right hemicolectomy
Splenic flexure and left colon: Left hemicolectomy
Sigmoid or recto-msigmoid colon: Sigmoid colectomy
Proximal rectum: Low anterior resection( LAR) for tumor > 4 cm from anal
verge
Distal rectum: Abdominal perineal resection (APR) for tumors <2 cm from
anorectal ring
APR is known as Mile Operation
TEM-> Trans-anal endoscopic microsurgery
Rectal cancer
Treatment:
Stage I rectal cancer:

➢ is resection of tumor with mesorectum (low anterior resection or abdominal

perineal resection)
Stage II or higher rectal cancers:
should be treated with neoadjuvant chemoradiation
Surgery either low anterior resection or abdominal perineal resection
Low anterior resection: appropriate for curative resection of middle rectum
tumor and sphincter preservation
Rectal Squamous cell carcinoma
• The treatment of rectal SCC :

➢Nigro Protocol including chemotherapy and radiation

➢If there is no response, APR should be performed

NB
1-PARENTERAL FEEDING is associated with COMPLICATIONS arising from LINE
INSERTION AND INFECTION,
including PNEUMOTHORAX, hematoma, BACTEREMIA, endocarditis, DAMAGE TO
VESSELS and other structures, AIR EMBOLISM, and thrombosis. In contrast to EN,
TPN has been associated with increased rates of bacterial translocation. No
peritonitis.
2-A 42-year-old male has ulcerative colitis for 10 years. Which of the following is not
a definitive surgical treatment?
A Total proctocolectomy with ileoctomy
B Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)
C Total protocolectomy with ileal reservoir (kock pouch)
D Subtotal abdominal colectomy
3-What is active heating in trauma?Using a heating lamp
4-ringer lactate is not used for hyperkalemia
5-Postoperative urinary retention presents with inability to urinate within 6 to 8
hours following surgery, lower abdominal fullness, suprapubic pain and discomfort,
and a palpable bladder. Treatment includes urinary catheterization.
6-Succinylcholine, a depolarizing neuromuscular blocking agent, is associated with
hyperkalemia in patients with burns, paraplegia, quadriplegia, and massive trauma.