SURGERY

I. ESHOPHAGUS
MALLORY-WEISS SYNDROME
• A longitudinal mucosal tear (not perforation) in the gastric mucosa, usually induced by repetitive and
forceful vomiting and retching
• Located immediately below the squamo-columnar junction in 90% cases; 10% in the oesophagus
• Common in men, alcoholics
• Presents with hematemesis, but bleeding is usually not severe
• Associated with – hiatus hernia, NSAID abuse
• For persistent bleeding- endoscopic electro coagulation
• Surgery: stomach opened by longitudinal gastrostomy, lesion located and under-running sutures

BOERHAAVE SYNDROME
• Barotrauma/ Spontaneous perforation
• When a person vomits against a closed glottis which may cause full thickness oesophageal rupture.
• Commonest site: lower 1/3rd
• Most serious type of perforation because large volume of material is released under pressure
• Sudden onset of symptoms, severe chest and abdominal pain, subcutaneous emphysema, shock
• Hamman's sign: crunching effect of the chest
• Mackler's triad: vomiting, chest pain, subcutaneous emphysema
• Barotrauma has also been described when the patient strains against a closed glottis: defecation, labour,
weight-lifting
• DD: MI, peptic ulcer perforation or pancreatitis
• Chest X-ray is often confirmatory - air in the mediastinum, pleura or peritoneum [V sign of Nacleiro]

BARRETT'S ESOPHAGUS
• Metaplasia of distal mucosa (lower 3rd) of esophagus from normal squamous to columnar epithelium.
• Types: long segment Barrett's or classic Barrett's (> 3 cm metaplasia) and short segment Barrett's.
• Hallmark is the presence of mucus secreting goblet cells.
• More common in men.
• Complication of long standing GERD
• 10% patients with GERD develop Barrett esophagus.
• Single most important complication is the development of adenocarcinoma
• Treatment: for low grade dysplasia – photodynamic therapy, endoscopic mucosal resection.
• For high grade dysplasia – near total Oesophagectomy

GASTRO-OESOPHAGEAL REFLEX DISEASE (GORD)

Lower Oesophageal Sphincter (LOS)
• Comprises the last 4cm of the esophagus.
• A physiological entity rather than an anatomical entity.
• Episodes of physiological reflux occur during postprandial transient lower oesophageal sphincter relaxations
(TLOSRs)

LOS relaxed by LOS tone increased by

• Drugs (nitrates, Anticholinergics, PGE2, barbiturates, CCB, • Drugs (Antacids, cholinergic,
Caffeine, theophylline, diazepam, dopamine) domperidone, metoclopramide, PGF2)
• Others – Peppermint, Chocolates, Coffee, Alcohol, Smoking, • Supine posture
Fat
Factors contributing to high intraluminal pressure in LOS
• Intrinsic musculature of distal esophagus
• Sling fibres of cardia
• Crura of the diaphragm
• Intra-abdominal pressure(most important factor)

Symptoms
• Triad of retrosternal burning pain(heart burn or pyrosis), epigastric pain and regurgitation
• Often associated with Type 1(Sliding) Hiatal hernia (Loss of intra-abdominal length of oesophagus)
• Patients with nocturnal reflux and those who reflux food to the mouth have severe GORD
• Dysphagia is usually a sign that a stricture has occurred

GORD in children
• During the first year, infants normally have some degree of reflux/vomiting, due to incompetent LES
• This physiologic vomiting resolves spontaneously after 6 – 12 months
• A history of repeated episodes of vomiting that interferes with growth and development (failure to thrive)
or the presence of apparent life-threatening events is required for the diagnosis of GERD
• Failure to thrive and pulmonary problems due to aspiration of gastric contents - common in infants Srictures
and esophagitis - common in older children and adolescents.

Investigations
• Most appropriate examination is endoscopy with biopsy
• Barium swallow and meal examination gives best appreciation of gastro-oesophageal anatomy

Manometry
• Normal LOS pressure is b/w 12 – 30 mm Hg
• Information about LES like total length, intra-abdominal length, location of sphincter relative to nares

24 hour pH monitoring
• Gold standard for diagnosing & quantifying acid reflux in 24 hour pH test
• Abstain from proton pump inhibitors for 1 week before the test

Scintigraphy
• Evaluate esophageal clearance & reflux
• Used for detecting motility disorder & GORD

Medical treatment: 8 weeks of PPIs

Endoluminal therapies
• Plexiglass microspheres (PMMA)
• Enteryx injection(estrinyl vinyl alcohol)
• Endoscopic full thickness plication

Surgeries
• Nissen (total) fundoplication

Most durable repair in terms of long-term reflux control

More short term dysphagia

Gas bloat syndrome in which belching is impossible (due to over competent cardia)
• Partial fundoplication (Toupet-posterior; Dor, Watson-anterior) has slightly high long-term failure rate
• Hill's operation, Boerema operation
 • Placing Angelchik prosthesis in the lower end of esophagus prevents reflux

Schatzki's ring
• Circular ring at the squamocolumnar junction of esophagus
• Strongly associated with reflux disease
• Mostly asymptomatic

MOTILITY DISORDERS
ACHALASIA CARDIA
• Motor disorder of esophagus where the LES does not relax normally while swallowing
• Esophagus undergoes non peristaltic contractions
• Due to loss of ganglions in the Auerbach's myenteric plexus
• Histology reveals reduction in the number of ganglion cells – mainly inhibitory neurons
• Associated with stress, vitamin B1 deficiency, Chaga's disease(Trypanosoma cruzi)
• Premalignant condition for esophageal carcinoma
• Pseudo achalasia – produced by adenocarcinoma of cardia (sometimes ca of bronchus & pancreas)

Clinical features
• Common in females
• Progressive dysphagia to both solids and liquids (liquids > solids), pain, regurgitation, aspiration

Diagnosis
• Plain X-ray abdomen erect: absence of gastric air bubble
• X-ray chest lateral view: Retro-cardiac air-fluid level
• Barium swallow

Uniformly dilated proximal esophagus with a smooth tapering segment below - Birds beak or Pencil tip
deformity or Cucumber esophagus

Sigmoid esophagus or mega esophagus

An air fluid level in the mediastinum in upright position

Hurst phenomenon – temporary transit through the cardia when the hydrostatic pressure barium
column is more than the pressure of the esophageal sphincter
• Manometry

Incomplete relaxation of LES

Elevated LES pressure

Loss of peristaltic wave in esophageal body

Increased intra esophageal baseline pressure
• CCK test – Cholecystokinin normally causes relaxation of LES, paradoxically causes contraction

Treatment
• Modified Heller's myotomy is the treatment of choice
• Fundoplication is usually done along with this procedure to prevent reflux (Heller-Dor's operation)
• Pneumatic dilatation
• Botulinum toxin – has to be repeated every few months, repeated injections cause fibrosis
• Drugs – calcium channel blockers, nitrates

 Rat tail appearance and Apple core lesion - Esophageal carcinoma

DIFFUSE ESOPHAGEAL SPASM

• Incoordinate, repetitive, simultaneous high amplitude contractions of esophagus
 • Pathology: motor abnormality of the esophageal body; most notable in the lower two thirds
• Marked hypertrophy of circular muscles
• Presents with dysphagia, chest pain
• Patients will complain of a squeezing pressure in the chest that may radiate to the jaw, arms, and upper
back
• Barium swallow – corkscrew or rosary- bead esophagus or pseudodiverticular appearance or segmental
spasm
• LES – normal resting pressure and normal relaxation on swallowing
• Severe symptoms – extended esophageal myotomy upto the aortic arch

NUT CRACKER ESOPHAGUS

• Hypermotility disorder a.k.a supersqueeze esophagus
• Hypertensive peristalsis or high-amplitude peristaltic contractions
• Most common and most painful esophageal hypermotility disorder
• Chest pain and dysphagia are typical symptoms.

Characteristics of the primary esophageal motility disorders

Achalasia Diffuse esophageal spasm
• Incomplete LES relaxation (< 75% • Simultaneous (nonperistaltic contractions) (>20% of wet
relaxation) swallows)
• Aperistalsis in the esophageal body • Spontaneous, repetitive and multipeaked contractions
• Elevated LES pressure < 26 mmHg • Intermittent normal peristalsis
• Lack of a gastric air bubble • Contractions may be of increased amplitude and duration
• LES – normal resting pressure and normal relaxation

Nut cracker esophagus Hypertensive lower esophageal sphincter

• High amplituted peristaltic contractions • Elevated LES pressure (>26 mmHg)
• Mean peristaltic amplitude (10 wet swallows) in • Normal LES relaxation
distal esophagus >180 mmHg • Normal peristalsis in the esophageal body
• Increased mean duration of contractions (>7.0 s)
• Normal peristaltic sequence

DYSPHAGIA
Intermittent dysphagia Progressive dysphagia
• Diffuse esophageal spasm • Carcinoma esophagus
• Pharyngeal diverticulum • Stricture
• Schatzki's ring • Achalasia
• Esophagitis

ESOPHAGEAL CARCINOMA
Predisposing factors for both Squamous Cell Carcinoma and Adenocarcinoma
• Excess alcohol
• Smoking

Predisposing factors for Adenocarcinoma

• Barrett esophagus - single most important risk factor
• Bisphosphonates increase the risk in patients with Barrett esophagus
• H pylori infection
 • Obesity

Predisposing factors for Squamous Cell Carcinoma

• HPV infections Mucosal damage Premalignant lesions
• Excess nitrates in drinking water • Hot beverages • Tylosis Palmaris et plantaris
• Opium smoking • Lye ingestion (40-60 % develop cancers)
• Fungal toxins in pickled • Radiation • Achalasia cardia (30%)
vegetables • Corrosives • Esophageal web (20%),
• Deficiency: Vit A, Molybdenum, • Bulimia strictures and diverticula
Zinc • Plummer Vinson syndrome
• Head and neck cancer (10%)
• Celiac sprue

Squamous cell carcinoma Adenocarcinoma

• Most common type world wide • More common in whites
• More common in blacks • Most common in Western countries
• Most common in China, Southeast Asia • Male to female ratio –15:1
• Male to female ratio – 3:1

Site
• Overall, MC site – middle 3rd
• Squamous cell carcinoma – upper 2/3rd
• Adenocarcinoma – lower 1/3rd

Clinical features
• Progressive Dysphagia (initially for solids, later for semisolids and liquids) - most common symptom
• Short term weight loss is also a common symptom
• By the time these symptoms develop, the disease is usually incurable, since difficulty in swallowing does not
occur until >60% of the esophageal circumference is infiltrated with cancer
• Advanced malignancy: RLN paralysis, Horner's syndrome, chronic spinal pain and diaphragmatic paralysis

Investigations
• Barium swallow – Shouldering sign and irregular filling defect
• Fluoroscopy – rat tail appearance
• Endoscopic ultrasound (Endosonogram) – most accurate for T staging

TNM staging

Tis: high grade dysplasia N0: no regional LN metastasis

T1: tumor invading lamina propria or submucosa N1: regional LN metastasis
T2: tumor invading muscularis propria Nx: LN status cannot be assessed
T3: tumor beyond muscularis propria
T4: tumor invading adjacent structures
Tx: primary tumor cannot be assessed
M0: no distant metastasis
M1(a): coeliac node involved (for distal oesophageal tumors) & supraclavicular node (for proximal tumors)
M1(b): coeliac or supraclavicular node involved if not remote from tumor site
Mx: distant metastasis cannot assessed
Management
• Poor prognosis
• Radical oesophagectomy is the most important aspect of curative treatment
• Cervical oesophagus (usually SCC): oesophagectomy (proximal 10cm and distal 5cm resection from the
macroscopic tumor) followed by radiotherapy
• Thoracic oesophagus – McKeown's 3 stage en block oesophagectomy
• Lower oesophagus and cardia – en block resection (best) or Transhiatal Oesophagectomy

Palliative treatment
• SEMS- self expanding metallic stents
• Endoscopic laser treatment
• Photodynamic therapy(PDT) or Chemoradiotherapy for early ca and those unfit or unwilling for surgery
• Brachytherapy
• Argon plasma coagulation

Esophageal substitutes
• Stomach is the conduit of choice.
• For longer segments, a supercharged jejunal (pedicle flap with an additional microvascular anastomosis) and
colonic interposition are both good alternatives

Esophageal cancers have poor prognosis because

• Lack of serosal layer in esophagus favors local extension
• More lymph vessels in submucosa than capillaries – fast spread
• Lymph flow in submucosal plexus runs longitudinally – primary tumor can extend for a considerable length
both superiorly and inferiorly

 Cervical oesophagus – direct spread to lymph nodes and there are less lymphatics in submucosa (better
prognosis)
 Dohlman procedure - Zenker's diverticulum
 Most common cause of esophageal perforation – iatrogenic (diagnostic or therapeutic procedures)
 Most common site esophageal perforation – cervical esophagus just above the upper sphincter
 Most common benign esophageal tumor – leiomyoma or stromal tumor
 II. STOMACH & SMALL INTESTINE
INFANTILE (IDIOPATHIC/BENIGN) HYPERTROPHIC PYLORIC STENOSIS
• Not congenital (symptoms are not present at birth)
• More common in boys (4:1)
• Pylorus thickened, elongated and lumen narrowed due to hypertrophy of circular muscle
• Increased incidence in 0 and B groups
• Increased risk in Turner syndrome and Trisomy 18
• Erythromycin or azithromycin exposure, in the first 2 weeks of life - increased incidence

Clinical features
• The classical presentation is non-bilious, projectile vomiting between 2 - 8 weeks of age
• Persistent vomiting  dehydration, malnutrition, hypokalemic, hypochloraemic alkalosis and paradoxical
aciduria
• Visible gastric peristaltic waves moving from left to right across the upper abdomen
• Palpation of the pyloric tumor (olive-shaped) in the epigastrium or right upper quadrant is pathognomic
• X-ray after barium meal shows string sign or double neck sign and shoulder sign
• Diagnosis confirmed by USG

Persistent pyloric muscle thickness more than 3 to 4 mm

Pyloric canal length more than 15 to 18 mm in the presence of functional gastric outlet obstruction

Pyloric thickness (serosa to serosa) of 15 mm or greater

Target sign on transverse images of the pylorus

Failure of the channel to open during a minimum of 15 minutes of scanning

Retrograde or hyperperistaltic contractions

Antral nipple sign (prolapse of redundant mucosa into the antrum, which creates a pseudomass)

Double-track sign (redundant mucosa in the narrowed lumen, which creates 2 mucosal outlines)
• Ramstedt's operation (pyloromyotomy) is the treatment of choice. The hypertrophied circular muscle fibres
are cut longitudinally without damaging the mucosa

GASTRITIS
Autoimmune (Type A) gastritis H. pylori (Type B) gastritis (90%)
• Associations - Autoimmune disease; thyroiditis, • Associations - Low socioeconomic status,
diabetes mellitus, Graves disease poverty, residence in rural areas
• Antrum not affected • Most commonly affects the antrum
• Antibodies to parietal cells components (H+,K+- • (Normal or) Increased acid production 
ATPase, or proton pump, intrinsic factor)  peptic ulcer disease
Hypochlorhydria  G cell hyperplasia  • CagA expressing strains  effectively
hypergastrinemia colonize the gastric body  Multifocal
• Intrinsic factor deficiency  pernicious anemia atrophic gastritis  decreased acid
• Microadenoma of enterochromaffin like (ECL)  production, Intestinal metaplasia  gastric
gastric adenocarcinoma, carcinoid adenocarcinoma, MALToma
• Reduced serum pepsinogen I concentration • Hypergastrinemia uncommon
Histology Histology
• Inflammatory infiltrates - Lymphocytes, • Intraepithelial neutrophils and subepithelial
Macrophages plasma cells are characteristic
• Diffuse mucosal damage of the oxyntic (acid- • Typically a patchy process
producing) mucosa within the body and fundus
H pylori
• H. pylori infection usually occurs in childhood, and spontaneous remission is rare
• When H pylori is eradicated as part of ulcer treatment, ulcer recurrence is extremely rare.
• H pylori can only live in gastric epithelium, duodenum is not colonized, unless gastric metaplasia occurs
• H pylori concentrated within the superficial mucus over epithelial cells (no invasion)
• Gastric antrum is the commonest site of colonization
• H pylori is generally not found in the region of intestinal metaplasia

H.pylori causes
• Atrophic gastritis
• Type B gastritis
• Intestinal metaplasia
• Dysplasia
• Adenocarcinoma

Eosinophilic gastritis Lymphocytic gastritis Reflux gastritis

• Eosinophil infiltration in any layer of • More common in women • Caused by enterogastric
stomach - antral or pyloric region 40% associated - celiac reflux after gastric
• Peripheral eosinophilia disease surgery
• Raised serum IgE levels • Affects entire stomach • Occasionally after
• Most common allergen – cow's milk and • Endoscopy – varioliform • Cholecystectomy
soy protein appearance • Bile-chelating agents &
• Associated – immune disease, parasites, • Increase in the number of prokinetic drugs are
H.pylori intraepithelial T cells useful in treatment

 Erosive gastritis – NSAIDs and alcohol

 Granulomatous gastritis – Crohn's disease and TB
 Phlegmonous gastritis – bacterial infection, usually an agonal event
 AIDS gastritis is secondary to infection with Cryptosporidium

PEPTIC ULCER (GASTRIC AND DUODENAL ULCER)

GASTRIC ULCER DUODENAL ULCER
Etiology • Stress, anxiety – 'hurry, worry, curry'
• H. pylori (70%) • H. pylori (90%)
• Altered mucosal barrier function (NSAID) • NSAIDs, steroids
• Smoking, Alcohol • Blood group O+ve
• Type B gastritis • Endocrine: Zollinger-Ellison syndrome, MEN-I
• Lower socioeconomic group Cushing's syndrome, hyperparathyroidism
• Either normochlorhydria or ,I,chlorhydria • Alcohol, smoking, vitamin deficiency
• Cirrhosis • Chronic pancreatitis, Cirrhosis
MC Site: lesser curvature along the incisura angularis MC site: 1st part of Duodenum (overall me site for
peptic
Clinical features • More common in males
• Equal in both sexes • Pain is more before food, in early morning,
• Pain in the epigastrium after taking food; decreases after food (hunger pain)
relieved by vomiting • Pain common during night
• Pain is uncommon during night • Melena common
• Hematemesis common • Appetite good, eats more frequently and there is
 • Appetite good, but hesitant to eat as eating weight gain
induces pain • Once stenosis develops, loss of weight
• that results in loss of weight
Barium meal X ray features
• Niche on lesser curve with notch on greater • Deformed or absent duodenal cap (because of
curve spasm)
• Regular/round margin of ulcer crater – stomach • Appearance of trifoliate duodenum due to
spoke wheel pattern secondary duodenal diverticula
• Overhanging mucosa at the margins of a benign
gastric ulcer projects inwards towards the ulcer –
Hamptom's line
• Converging mucosal folds at the base of the
ulcer
Complications • Bleeding – MC complication, on posterior wall,
• Hour glass contracture - exclusively in women gastroduodenal artery is the artery of bleed
due to cicatricial contracture of lesser curve • MC site of bleeding from peptic ulcer – First part
ulcer which leads to loss of periodicity, of duodenum
persistent pain and vomiting • Perforation – more on anterior wall, if posterior
• Tea pot stomach (hand bag stomach) – –into pancreas
cicatrisation and shortening of the lesser • Gastric Outlet Obstruction due to pyloric
curvature stenosis– least common
• Bleeding (splenic A; rarely left gastric A) • Duodenal ulcer will never turn malignant
• Perforation (into lesser sac)
• Malignant transformation to adeno Ca. in 2-5%

 Peptic ulcers never occur in association with pernicious anaemia (no acid and pepsin-secreting parietal and
chief cells respectively)

Types of gastric ulcer

• I – near the incisura on lesser curvature
• II – associated with active or quiescent duodenal ulcer
• III – Prepyloric region
• IV – Near gastro-esophageal junction

Most important factors causing peptic ulcer

• H pylori infection
• NSAID use

Benign gastric ulcer Malignant gastric ulcer

• Converging mucosal folds upto the margin • Effacing mucosal folds
• 95% on the lesser curve • Greater curvature
• Regular margins • Irregular margins
• Granulation tissue in the floor • Necrotic slough in the floor
• Edge not everted; punched or sloping • Everted edge
• Rugae in the surrounding area are normal • Nodules, ulcers, irregularities in surrounding area

 Cushing ulcer – due to intracranial injury/increased ICP/after neurosurgical operations

 Curling ulcer – after burn injury (>35%); in the body and fundus; not in antrum and duodenum
 Cameron ulcers – linear gastric erosions in hiatal hernias
  Kissing ulcers – both anterior and posterior duodenal ulcers are present

Medical treatment: Proton pump inhibitors or H2 blockers; H.pylori eradication

Surgeries for Duodenal ulcer

• Highly Selective Vagotomy or Parietal cell Vagotomy or Proximal gastric Vagotomy

Procedure of choice

Nerves of Latarjet are preserved (and hence gastric motility)

Lowest mortality rate and side effects

Minimal chances of dumping syndrome
• Gastrectomy – highest mortality
• Vagotomy and Antrectomy – lowest recurrence & highest morbidity
• Gastroenterostomy alone – highest recurrence
• Billroth II gastrectomy

 Duodenal blow out following Billroth II gastrectomy occurs on 4th day (2-7days)

Surgery for gastric ulcer

• Partial gastrectomy with Billroth I gastroduodenal anastomosis
• Type IV ulcer – subtotal gastrectomy

Sequelae of peptic ulcer surgery

• Recurrent ulceration
• Small stomach syndrome

Follows most ulcer operations, does not occur following Highly selective vagotomy

Due to loss of receptive relaxation

Gets better with time

Revisional surgery is not necessary
• Bile vomiting (Afferent loop syndrome)

Following gastrectomy, best treatment is Roux-en-Y diversion

In patients with gastroenterostomy, small Pyloroplasty may be performed
• Dumping syndrome (Post cibal syndrome)

More common after partial gastrectomy with the Billroth II reconstruction.

Much less common following the Billroth I gastrectomy or after vagotomy and drainage procedures
• Efferent loop obstruction

More than 50% of cases occur within the first postoperative month
• Alkaline reflux gastritis

Although the diagnosis can be made by taking a careful history HIDA scans usually demonstrate biliary
secretion into the stomach and even into the esophagus.

Most patients had gastric resection and Billroth II anastomosis
• Post vagotomy diarrhea

Patient managed as for early dumping

Octreotide not effective

Early dumping Late dumping

 • More severe • Less severe
• Abdominal and vasomotor symptoms • Reactive hypoglycemia
• Immediately after meals • 2-3 hrs after meal
• Aggravated by more food • Aggravated by exercise
• Precipitating factor - carbohydrate rich food • Tremors, faintness and prostration
• Epigastric fullness, sweating, diarrhea, hypotension • Symptoms relieved by sugar intake
• Diagnosed by rise in PCV when the symptoms are present • Octreotide is also very effective
• Symptoms improves on lying down or saline infusion
• Dietary manipulation is the best treatment: small, dry
meals
• Octreotide given s.c. before meals is beneficial

• Malignant transformation

Gastrectomy or Vagotomy and drainage are independent risk factors for gastric cancer

No association of Highly selective vagotomy with gastric cancer
• Nutritional consequences

Weight loss after gastrectomy

Iron deficiency anemia after gastrectomy/vagotomy and drainage

Vitamin B12 deficiency after total gastrectomy

Osteoporosis after gastrectomy and mainly in women
• Gallstones: Strongly associated with truncal vagotomy

 Gastric ulcers > 1cm should always be regarded as being malignant. Minimum 10 well targeted biopsies
should be taken for excluding malignancy

Stomal ulcers
• Ulcer in the anastomotic site of GJ/GD
• Overall incidence is 10% after surgery
• Most commonly after gastrojejunostomy alone (40%)
• Usually seen on the jejunal side of the stoma
• Pyloric channel ulcers are similar to duodenal ulcers
• Pre-pyloric and pyloric ulcers may be malignant
• Medical: PPIs; if refractory completion vagotomy

Stress ulcer/gastritis
• Develop in 25% to100% of ICU patients within 24 to 48 hours of admission
• Clinically significant bleeding manifests in only 5% to10% of patients
• Caused by a reduction in the blood supply to superficial mucosa of the stomach due to intense
physiological stress
• Risk factors: mechanical ventilation > 48 hours, ARDS, coagulopathy, significant burns, head injury
• Sometimes follows cardiopulmonary bypass

PERFORATED PEPTIC ULCER

• Mostly seen in elderly females
• Patient with a history of peptic ulceration, develops sudden-onset, severe, generalized abdominal pain as a
result of irritant effect of gastric acid on the peritoneum
• Abdomen exhibits a board like rigidity and does not move with respiration
• Tenderness and rebound tenderness (Blumberg sign) is seen all over the abdomen
 • Most common site of perforation is the anterior aspect of duodenum
• Gastric ulcers perforate into the lesser sac, which is difficult to diagnose
• Erect chest x-ray - ideal first test; as little as 10-20 mL of free air (swallowed air) be detected under the
diaphragm
• CT scan is more accurate

X-ray signs in duodenal ulcer perforation

• Cupola sign – crescent shaped radiolucency under the diaphragm
• Rigler's sign – visualization of both aspects of bowel wall being outlined by gas on either side
• Inverted V sign – gas on either side of falciform ligament
• Football sign – collection of gas in the centre of abdomen like a food ball
• Triangle sign – gas between bowel loops

Surgery
• Emergency laparotomy. Perforation is identified and closed with interrupted sutures
• Surgical options

Most commonly performed procedure: Simple patch closure - Omental patch is placed and fixed with
loose sutures (Rosoe Graham operation) - in patients with hemodynamic instability and/ or exudative
peritonitis signifying a perforation E124 hours old

Patch closure + Highly selective vagotomy - In stable patients without longstanding perforation

Patch closure and Vagotomy + Drainage

Pneumoperitoneum Pseudopneumoperitoneum
• Hollow viscus perforation • Distended viscus
• Postoperative abdomen • Chilaiditi's syndrome [interposition of colon with gas between liver
• Laparoscopy and diaphragm]
• Diagnostic procedures • Subphrenic abscess, Uneven diaphragm, Sub diaphragmatic fat
involving female genital tract • Subpulmonary pneumothorax, Curvilinear pulmonary collapse
• Peritoneal dialysis • Intramural gas in pneumatosis intestinalis

GASTRIC OUTLET OBSTRUCTION

• Most common cause – gastric cancer
• When GOO is due to peptic ulcer disease, the stenosis is found in the first part of duodenum
• The patient commonly complains of losing weight, and appears unwell and dehydrated
• In the vomitus, often it is possible to recognise foodstuff taken several days previously
• Metabolic abnormality - hypochloraemic alkalosis is usually only seen with peptic ulcer disease
• Paradoxical aciduria and hypokalemia

UPPER GI BLEEDING
Common causes
• Peptic ulcer (esophageal, gastric and duodenal) 60% is the most common cause
• Erosions (esophageal, gastric and duodenal) 26%
• Esophageal varices (4%)
• Mallory Weiss tears (4%)
• Vascular lesions(Dieulafoy's disease)
IOC: upper GI endoscopy
Capsule endoscopy
• Useful role in those patients with evidence of chronic gastrointestinal blood loss where no evidence of
ulceration can be found with more conventional endoscopic assessment
• Should not be undertaken where there is a risk of stricture, because of the possibility of the capsule
becoming stuck in the narrow segment

MANAGEMENT OF BLEEDING VARICES

General measures
• Blood volume should be replaced with colloids, plasma expanders and blood transfusions.
• Hypervolemia should be avoided since this may increase portal pressure and exacerbate the bleeding.
• Blood resuscitation should be performed carefully to reach a hemoglobin level of approximately 8 g/dL
• Vitamin K, FFP and platelet transfusion
• Use of recombinant factor Vila has not been shown to be more beneficial
• Treatment with a splanchnic vasoconstrictor should be started.
• Administration of a prophylactic antibiotic is recommended
• Gastric lavage with saline via NG tube is helpful to determine the extent of bleeding
• Room temperature saline is most physiologic; iced saline lavage is not more efficacious
• After haemodynamic stabilization an upper gastrointestinal endoscopy should be performed

Sengstaken-Blakemore tube
• Inserted to provide temporary hemostasis (if the rate of blood loss prohibits endoscopic evaluation)
• Gastric balloon inflated with 300ml air and retracted to gastric fundus
• Oesophageal balloon inflated to a pressure of 40mmHg
• The balloons should be temporarily deflated after 12 hours to prevent pressure necrosis

Pharmacotherapy
• IV infusion of somatostatin analogue octreotide
• Glypressin (Terlipressin) has longer half-life and fewer side effects
• Propranolol/nadolol is not effective at acute bleeding. Used in prophylaxis
• Somatostatin analogues are more effective than vasopressin in acute bleedings

Endoscopic treatment
• Techniques

Endoscopic banding (gold standard treatment)

Endoscopic sclerotherapy
• Sclerosants: ethanolamine oleate, sodium morrhuate, sodium tetradecyl sulphate, polidocanol
• Chance of rebleeding is high compared to banding
• Complications: esophageal ulceration, perforation, pleural effusion, pulmonary edema, mediastinitis
• Standard treatment: vasoconstrictor + endoscopic therapy.

Transjugular intrahepatic portosystemic stent shunts (TIPSS)

• Inserted under LA, analgesia and sedation using fluoroscopic guidance and USG
• Stent placed between hepatic venule and portal venule
• For treatment of variceal haemorrhage that has not responded to drug treatment and endoscopic therapy
• The main early complication is perforation of liver capsule, which can be associated with fatal
intraperitoneal hemorrhage
• Post-Shunt encephalopathy occurs in 40% patients
 • The main contraindication to TIPSS is portal vein occlusion
• The main long term complication is stenosis of the shunt

Surgical shunts
• The main current indication is a patient with Child's grade A (compensated) cirrhosis in whom the initial
bleed has been controlled by sclerotherapy
• Effective methods of preventing rebleed
• Selective shunts have a lower incidence of Portal systemic encephalopathy (PSE)

Non selective shunts Selective shunts

• Porta-caval shunt • Distal spleno-renal shunt (Warren's shunt)
• Mesenterico-caval/renal shunt • Inokuchi shunt — shunt between IVC and left
• Proximal spleno-renal shunt (Linton's shunt) • gastric vein

Forrest Classification for Endoscopic findings and Rebleeding risks in Peptic Ulcer Disease
Grade Description Rebleeding risk
la Active pulsatile bleeding High
lb Active non-pulsatile bleeding High
Ila Non bleeding visible vessel High
Ilb Adherent clot Intermediate
Ilc Ulcer with black spot Low
III Clean, non-bleeding ulcer bed Low

 Ulcers larger than 2 cm, posterior duodenal ulcers, and gastric ulcers - significantly higher risk of rebleeding

Bleeding peptic ulcers

• Most common site of bleeding from a peptic ulcer is duodenum
• Proton pump inhibitors — reduces the risk of rebleeding and the need of surgical intervention

Endoscopic management
• Epinephrine injection (1 : 10,000) to all four quadrants of the lesion in combination with
• Electrocoagulation for bleeding ulcers and Argon Plasma Coagulation for superficial lesions
• Hemoclips — can be effective particularly effective when dealing with a spurting vessel

Indications for surgery

• Hemodynamic instability despite vigorous resuscitation (>6 U transfusion)
• Failure of endoscopic techniques to arrest hemorrhage
• Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic
hemostasis)
• Shock associated with recurrent hemorrhage
• Continued slow bleeding with a transfusion requirement >3 U /day

 10% of patients with bleeding ulcers require surgical intervention

ISOLATED GASTRIC VARICES

• Usually associated with portal hyper-tension or splenic vein thrombosis
• Risk of massive UGI bleeding
• Endoscopic sclerotherapy or varix ligation is less successful than in esophageal varices
 • Treatment

Nonsegmental portal hypertension: Transjugular intrahepatic portosystemic shunt

Splenic vein thrombosis and left-sided (sinistral) or segmental portal hypertension - splenectomy

DIEULAFOY'S DISEASE
• Congenital AV malformation with large tortuous submucosal artery
• Lesion is covered by normal mucosa and when not bleeding, it is invisible
• Occurs in proximal stomach within 6cm of OG junction and 80% along the lesser curve
• Rupture of unusually large vessels (1 to 3 mm) found in the gastric submucosa.
• Vasculitis and atheroma are absent in the vessel
• Presents with sudden massive painless UGI bleeding which is most difficult to treat
• Treatment: endoscopic sclerosant injection, if it fails then angiographic coil embolization
• If identified at operation, then only a local excision is necessary

GASTRIC ANTRAL VASCULAR ECTASIA (GAVE)

• Water melon stomach or Tiger stripe stomach
• Usually affects elderly women
• Dilated mucosal blood vessels in the lamina propria that often contain thrombi
• Antrum – commonly involved
• Most have associated connective tissue disorder or chronic liver disease
• IOC - endoscopy
• Non-surgical treatments: Argon plasma coagulator, estrogen and progesterone or Nd:YAG laser
• Antrectomy may be required to control blood loss but carries increased morbidity

Portal hypertensive gastropathy

• Usually affects proximal stomach
• Unlike variceal hemorrhage, bleeding from portal hypertensive gastropathy is not amenable to endoscopic
treatment because of the diffuse nature of the mucosal abnormalities.
• The underlying pathology involves elevated portal venous pressures, so pharmacologic therapy aimed at
reducing portal venous pressure is indicated.
• If pharmacologic therapy fails to control acute bleeding, TIPS should be considered.

Gastritis Cystica
• Reactive epithelial proliferation associated with entrapment of epithelial-lined cysts
• In submucosa of stomach – gastritis cystica polyposa
• Associated with chronic gastritis and partial gastrectomy
• In deeper layers of gastric wall – gastritis cystica profunda

GASTRIC VOLVULUS
• Organo-axial (horizontal) in the elderly
• Mesenterico-axial (vertical) in the children
• Borchardt's triad

Acute epigastric pain

Violent ineffective vomiting

Inability to pass a nasogastric tube

MENETRIER'S DISEASE
• Gross hypertrophy of gastric mucosal folds, mucus production and hypochlorhydria
 • No inflammation
• Caused by excessive secretion of TGFα
• Present with hypoproteinemia and anemia
• Increased risk of gastric adenocarcinoma
• Treatment – gastrectomy

GASTRIC CANCER
• Second most common cause of cancer death
• More common in males

Risk factors Genetic and familial Premalignant lesions

• Smoking, alcohol • E cadherin gene • Chronic Atrophic gastritis – most
• Spicy foods, high salt diet mutation – common precursor lesion
• Smoked meat or fish • CDH1 (90% risk) • Adenomatous polyps (FAP)
• EBV, H. pylori • TP53 mutation • Hyperplastic polyps
• Low animal fat and proteins • BRCA1 mutation • Chronic gastric ulcer
• High nitrate consumption • APC gene mutation • Pernicious anemia
• High complex carbohydrate • β-catenin mutation • Intestinal metaplasia (H.pylori)
• Lack of fresh fruits, vegetables • BAX mutation • Menetrier's disease
• Deficiency of antioxidant • CDKN2A mutation • Stomach remnant(stump
vitamins • Blood group A carcinoma) after Billroth II GJ or
• Rubber and coal workers • HNPCC Vagotomy GJ
• Low socioeconomic status • Li Fraumeni syndrome

 Proximal gastric cancers: (Not associated with H pylori) higher social status, young people, type A gastritis
 Distal gastric cancers: low social status, old people, type B gastritis
 Most common site is the gastric antrum (prepyloric and pyloric regions) 65%
 Incidence near the oesophago-gastric junction is increasing (Proximal shift)

Factors that decrease the risk of gastric cancer

• Fresh fruits and vegetables
• Diet rich in vitamin C and E
• Aspirin
• History of duodenal ulcer

Lauren's (DIO) Classification

Intestinal type Diffuse type
• Environmental; Common in H pylori induced • Familial
• Gastric atrophy, intestinal metaplasia • Blood group A
• Men > women • Women > men
• Increasing incidence with age • Younger age group
• Gland formation, Well differentiated • Signet ring cells, Poorly differentiated
• Hematogenous spread • Transmural (early gastric wall penetration)
• Microsatellite instability • lymphatic spread
• APC gene mutations; p53, p16 inactivation • Decreased E-cadherin; p53, p16 inactivation
• Types: Polypoidal, superficial, excavated • Linitis plastica
• Favorable prognosis • Poor prognosis
Depending Depending on the depth of invasion
Early gastric cancer Advanced gastric cancer
• Involvement of mucosa and/or submucosa only, with • Involvement of muscularis and/serosa with or
or without lymph node involvement (T1 + any N) without lymph node involvement
• Overall cure rate with gastric resection and
lymphadenectomy – 95%

Siewert classification – for OG junction carcinoma

Type 1 Carcinoma in Barrett's ca esophagus/true Treatment: Total esophagectomy with gastric pull
esophageal ca extending to GE junction through to neck
Type 2 Tumor within 2cm of squamocolumnar jn. Total gastrectomy with Roux-en-Y esophago-jejunostomy
Type 3 Tumor in subcardial region Total gastrectomy with Roux-en-Y esophago-jejunal
anastomosis

Metastasis
• Virchow's node – enlarged left supraclavicular nodes(Troisier's sign)
• Lymph node groups

Group I: perigastric nodes

Group II: along the root of major vessels

Group III: at the root of SMA and hepatoduodenal ligament

Group IV: distant lymph nodes
• Blood borne metastasis mostly to liver
• Transperitoneal spread – best identified by laparoscopy

Sister Mary Joseph's node (umbilical secondaries)

Blummer's shelf (rectal secondaries)

Krukenberg's tumor - ovaries (commonly in colloid carcinoma of stomach)

Clinical features
• Vague epigastric discomfort after food (earliest symptom)
• Pain – non radiating, unresolved by food particles
• Weight loss (most common symptom), anorexia, fatigue, vomiting
• Melena, Hematemesis
• Proximal Tumors – dysphagia
• Distal tumors – Gastric outlet obstruction

TNM staging
T: Primary tumor N: Lymph nodes M: Metastasis
T0: no evidence of primary tumor N0: no regional lymph nodes M0: no distant
Tis: carcinoma in situ N1: perigastric nodes within 3cm of tumor (1-6 metastasis
T1: invasion of lamina propria nodes) M1: distant
submucosa N2: perigastric nodes more than 3cm or involvement metastasis
T2: inv. of muscularis propria/subserosa of left gastric, splenic, celiac or hepatic nodes (7-15 present
T3: penetration of serosa nodes)
T4: invasion of adjacent structures N3: > 15 nodes

Linitis plastica (Scirrhous carcinoma / Brinton's disease/ leather bottle stomach)

• Type IV gastric carcinoma [poorly differentiated mucin-producing carcinoma cells that infiltrates the
muscle wall]
 • Aggressive diffuse type with proliferation of fibrous tissue of submucosa which is thickened (Mother of Pearl
appearance)
• Mucosa appears normal
• Barium meal: small sized stomach
• Poor prognosis
• Total gastrectomy with OJ anastomosis is the treatment

Colloid carcinoma of stomach

• Common in women
• Poor prognosis

Investigations
• Endoscopy and biopsy is the investigation of choice
• 6-8 biopsies taken
• PET-CT is most useful for detecting distant metastasis and to detect recurrent gastric cancer
• Laparoscopy US is very sensitive to see nodes and liver metastasis

Endoscopic ultrasound
• 90% accuracy in detecting T staging and 80% in nodal staging

Barium meal findings in CA stomach

• Irregular filling defect
• Loss of rugosity
• Delayed emptying
• Dilation of stomach in carcinoma pylorus
• Decreased stomach capacity in Linitis plastica
• Margin of lesion projects outward from the ulcer/lesion into the gastric lumen – Carmann's meniscus sign

 Tetracycline fluorescence test: gastric cancer cells take up tetracycline given orally which appears yellow
under UV light
 CA 72-4 is an important tumor marker to evaluate the relapse

Paraneoplastic syndromes
• Trousseau syndrome (migratory thrombophlebitis)
• Acanthosis nigricans (hyper pigmentation of axilla and groin)
• Diffuse Seborrheic keratoses (Leser-Trelat sign)

Treatment
• Surgical resection of the stomach is only curative treatment
• Tumors < 2cm, elevated, well differentiated, without nodal disease: Endoscopic mucosa! resection(EMR)
• Growth in the body, proximal stomach, Linitis plastica - Total radical Gastrectomy with OG anastomosis
• Growth in pylorus - lower radical gastrectomy with proximal 5cm clearance, nodal clearance, removal of
greater and lesser omentum and later, Billroth II anastomosis.
• Operable patients should undergo a course of Neo-adjuvant chemotherapy: epirubicin + cis-platinum + 5-
FU infusion or oral capecitabine
• Radiotherapy — Gastric cancer are relatively radio resistant
Prophylactic total gastrectomy is advised for those having
• E cadherin gene mutation (90% risk)
• Deletion/inactivation of p53
• Over expression of COX-2

Signs of inoperability
• Ascites, Liver secondaries, Para-aortic lymph nodes
• Adherent to pancreas, colon or mesocolon
• Blummer shelf, Left supraclavicular nodes, Sister Mary Joseph nodule, Irish node (Left axillary node
secondaries)
• Palpable mass is incurable but resectable surgically

GASTROINTESTINAL STROMAL TUMORS (GIST)

• Most common mesenchymal tumor of the abdomen
• Commonly occur in stomach (mc site) and duodenum
• Arise from the interstitial cells of Cajal or pacemaker cells
• Carney triad (non hereditary syndrome of young females)

Gastric GIST

Paraganglioma

Pulmonary chondroma
• Bleeding is the most common presentation (Endoscopy — appearance of cervix)
• Diagnosis of malignancy is by greater mitotic figures
• If mucosa is not ulcerated — biopsy on a biopsy is needed
• Immunohistochemistry is mandatory for diagnosis. C-kit gene amplification — tumor marker
• Size and mitotic index are the best predictors of metastasis
• Peritoneal and liver metastases are most common
• Lymphatic spread extremely rare
• 80% tumors respond to Imatinib(tyrosine kinase antagonist)
• Treatment of choice — Resection

LYMPHOMA
• Most common site of extranodal lymphoma — Stomach
• Most common type — extranodal marginal zone B-cell lymphomas
• Otherwise called Mucosa associated lymphoid tissue or MALTomas
• Usually arise at the site of chronic inflammation
• Most common cause of pro-lymphomatous inflammation — H pylori
• H pylori eradication results in durable remissions and low rates of recurrence
• Translocations: t(11; 18) — most common; others — t(1;14), t(14;18)
• Diagnostic histologic features

Lympho-epithelial lesions

Monocytoid change

BARIATRIC SURGERY
Surgical treatment performed for morbid obesity
Eligibility criteria
• BMI >40
• BMI >35 with an associated medical comorbidity worsened by obesity
• Failed attempt at other weight loss treatments
 • Psychologically stable without alcohol dependence and illegal drug abuse

Relative Contraindications
• Class IV disease according to American society of anesthesiology
• Psychological instability
• Inability or unwillingness of the patient to change lifestyle post-operatively
• Drug, alcohol or substance addiction
• Non ambulatory status
• Patient's view of surgery as a 'magic bullet'
• Unsupportive home environment

Surgery MOA
Vertical Banded Gastroplasty* Restrictive
(not practiced now-a-days)
Adjustable Gastric Banding Restrictive
Roux en Y Gastric bypass Largely restrictive / Partly malabsorptive
Bilio-pancreatic diversion Largely malabsorptive / Partly restrictive
Duodenal switch Largely malabsorptive / Partly restrictive
• Sleeve gastrectomy is a part of the above preformed surgeries

DUODENAL ATRESIA
• Complete atresia of the second part of duodenum at the level of ampulla of Vater.
• Preampullary type – non bilious vomiting
• Post Ampullary type (Most common) – bilious vomiting

Associated anomalies
• Prematurity
• Down syndrome
• Incomplete rotation of the gut
• Congenital heart diseases
• Annular pancreas
• Anorectal malformations
• Biliary atresia

Diagnosis and treatment

• Prenatal: Maternal polyhydramnios and USG shows double-bubble appearance
• Plain X-ray is diagnostic which shows double-bubble sign with absence of air in the distal part
• Surgery – Duodeno-duodenostomy; Kimura's diamond shaped anastomosis

INTESTINAL ATRESIA
• Jejunoileal atresia is the most common GI atresia
• Atresias occur more frequently in the proximal jejunum than in the ileum
• Thought to occur as a result of an intrauterine mesenteric vascular occlusion
• Often associated with malrotation, gastroschisis, volvulus-20% (SRB 4TH Ed P-990)

Classification
• Type I, a mucosal atresia with intact muscularis
• Type II, with an atretic cord between two blind ends of bowel with intact mesentery
 • Type IIla, a complete separation of the blind ends of the bowel by a V-shaped mesenteric gap
• Type lllb, an apple peel or Christmas tree deformity with a large mesenteric gap
• Type IV, there are multiple atresias, with a string of sausage or string of beads appearance

MECKEL'S DIVERTICULUM
• Most common congenital anomaly of the GIT
• True diverticulum (contains all the 3 layers of intestine)
• Situated at the anti-mesenteric border of small intestine
• Represents the patent intestinal end of the Vitellointestinal duct
• Contains heterotopic mucosa (mc-gastric mucosa)
• Rule of 2: 2% incidence; 2 inches (5 cm) in length; 2 feet proximal to ileo-caecal valve, 2 times common in
males, 50% symptomatic by age 2 years
• Meckel's diverticulum should be looked for when a normal appendix is found at surgery for suspected
appendicitis
• Littre's hernia – when the content of an inguinal or femoral hernia is Meckel's diverticulum
• Symptoms

Painless rectal bleeding or melena — most common presentation (most likely cause in a child
presenting with rectal bleeding and anemia)

Intussusception

Meckel's diverticulitis

Chronic peptic ulceration

Intestinal obstruction
• Technetium-99m scanning is useful in identifying Meckel's diverticulum as a source of GI bleeding, is most
accurate
• Treatment: Resection of diverticulum or the segment of intestine containing diverticulum
• If silent Meckel's diverticulum is found during the course of an operation, it can be left alone provided it is
wide mouthed and not thickened.

FOREIGN BODIES
• Ingestion of batteries rarely leads to problems, but symptoms can arise from leakage of alkali or heavy metal
(mercury) from battery degradation in the gastrointestinal tract
• Removal of battery needed when

Patients experience symptoms such as vomiting or abdominal pain

Large-diameter battery (>20 mm in diameter) remains in the stomach for longer than 48 hr

Lithium battery is ingested
• Batteries larger than 15 mm that do not pass the pylorus within 48 hr are less likely to pass spontaneously
and generally require removal
• In children younger than 6 yr of age, batteries larger than 15 mm are not likely to pass spontaneously and
should be removed endoscopically
• Batteries beyond the duodenum pass per rectum in 85% within 72 hr

SHORT BOWEL SYNROME

• After bowel resection, the remnant small intestine displays evidence of epithelial cellular hyperplasia, villi
lengthening,
• increase in intestinal absorptive surface area and and digestive and absorptive functions improve.
• Short bowel syndrome: presence of less than 200 cm of residual small bowel in adult patients.
• Resection of less than 50% of the small intestine is generally well tolerated.
• Clinically significant malabsorption occurs when greater than 50% to 80% has been resected.
 • In adults with intact and functional colon - lifelong TPN dependence is likely to persist if there is less than 60
cm of residual small intestine
• Resection of jejunum is better tolerated than resection of ileum, as the capacity for bile salt and vitamin
B12 absorption is specific to the ileum
• Malabsorption after massive small bowel resection is exacerbated by a characteristic hypergastrinemia-
associated gastric acid hypersecretion that persists for 1 to 2 years postoperatively

Risk factors for development of short bowel syndrome after massive small bowel resection
• Small bowel length ?200 cm
• Absence of ileocecal valve
• Absence of colon
• Diseased remaining bowel (e.g., Crohn's disease)
• Ileal resection

RADIATION ENTERITIS
• Increased risk of enteritis: previous history of laparotomy, preexisting vascular disease, hypertension,
diabetes
• Chemotherapeutic agents: 5-fluorouracil, doxorubicin, dactinomycin, methotrexate, also contribute to the
development of enteritis
• Radiation damage tends to be acute and self-limiting, with symptoms consisting mainly of diarrhea,
abdominal pain, and malabsorption
• Serious late complications are unusual if the total radiation dosage is less than 4000 cGy
• Sucralfate - prevents the diarrhea associated with abdominal radiation
• Superoxide dismutase - reduces complications.
• The most effective radioprotectant agent — amifostine

Surgical management
• Obstruction due to rigid, fixed intestinal loops in the pelvis — bypass procedure
• Perforation — resection and anastomosis

SMALL BOWEL PERFORATION

• Most common cause before 1980: duodenal ulcer perforation due to peptic ulcer
• Most common cause now-a-days: iatrogenic injury incurred during GI endoscopy
• Most common among iatrogenic injuries: duodenal perforation during ERCP with endoscopic
sphincterotomy

 The angle of His: where the fundus meets the left side of the GE junction
 Minimum amount of intestinal bleeding to cause melena: 50 –100 ml in the stomach
 III. APPENDIX, LARGE INTESTINES, RECTUM & ANAL CANAL, INTESTINAL
OBSTRUCTION, CARCINOID TUMORS
APPENDIX
Positions of appendix
• Retrocaecal – 74%
• Pelvic – 21%
• Paracaecal – 2%
• Subcaecal – 1.5%
• Preileal –1%
• Postileal – 0.5%

ACUTE APPENDICITIS
• Young males, low dietary fibre, family history, purgative abuse, faecolith
• E.coli is the most common organism; enterococci rd most common
• Oxyuris vermicularis (pinworm) can proliferate in the appendix and occlude the lumen
• Appendicitis is less common after 30 years of age (as the lymphatic tissue in the submucosa decreases with
age)

Pseudoappendicitis
• Appendicitis due to acute ileitis following Yersinia infection
• Crohn's disease

Clinical features
• Pain is the earliest feature, which is frequently first noticed at the periumbilical region
• Soon the pain shifts to the RIF and changes in character
• Murphy's triad – pain, followed by vomiting and then fever
• Pointing sign – the patient is asked to point where the pain started and where it moved
• Rovsing's sign – pressure in LIF causes pain in RIF
• Psoas sign – the inflamed appendix lies on the psoas muscle and the patient lies with the right hip flexed for
pain relief
• Cope's Psoas test – hyperextension of hip causes pain in RIF in retrocaecal appendix
• Obturator test – flexion and internal rotation of hip causes pain in the hypogastrium in pelvic appendix
• Mac Burney's sign – guarding and maximum tenderness in the McBurney's point
• Blumberg (release) sign – rebound tenderness in right iliac fossa
• Balswing's test – in retrocaecal appendix, when legs are lifted off the bed with knee extended, patient
complains pain while pressing over flanks
• Hyperesthesia in Sherren's triangle – lines joining ASIS, pubic symphysis and umbilicus
• Pneumoperitoneum is not common in appendicular perforation
• Pelvic appendix causes early diarrhea
• Post Heal appendicitis is most difficult to diagnose
• Appendicitis is the most common extra-uterine acute abdominal condition in pregnancy. Pain in the right
lower quadrant is the cardinal feature in pregnancy

Alvardo score
Symptoms Score Signs Score Laboratory Score
 Migratory RIF pain 1 RIF tenderness 2 Leucocytosis 2
Anorexia 1 Rebound tenderness 1 Shift to left 1
Nausea and Vomiting 1 Elevated temperature 1
• A score of 7 or more is strongly predictive of acute appendicitis

Risk factors for perforation of appendix

• Extremes of age
• Immunosuppression
• Diabetes mellitus
• Fecolith obstruction
• Pelvic appendix
• Previous abdominal surgery

 Contrast-Enhanced CT (CECT) – investigation of choice specially in unclassical cases

Sonographic criteria for appendicitis

• Appendix of size > 6 mm (SABISTON > 7mm) AP diameter
• Thick walled non continuous lumina! structure
• Blind ending tubular structure
• Noncompressible
• Aperistaltic
• Appendicolith
• Interruption of submucosal continuity
• Periappendicular fluid
• Target appearance

Surgery
• Appendicectomy: Gridiron's incision(McBurney's incision) or Lanz crease incision
• Appendicular mass is conservatively treated with Oschner Sherren's regime
• Majority of patients will not develop recurrence and it is no longer advisable to remove the appendix after
an interval of 6-8 weeks
• In children surgery is the only treatment of choice

COLON & RECTUM

HIRSCHSPRUNG'S DISEASE/CONGENITAL MEGACOLON

• Absent ganglion cells in Auerbach's (myenteric) & Meissner's (submucosal) neural plexus due to failure of
migration of vagal neural crest cells into the developing gut and hypertrophy of associated nerve trunks
• The affected gut is tonically contracted causing functional bowel obstruction
• Aganglionosis involves

Rectum and sigmoid colon (short segment HD) in 75%

Proximal colon (long segment) in 15 %

Entire colon and a portion of terminal ileum (total colonic aganglionosis) in 10 %
• A transition zone exists between the dilated, proximal, normally innervated bowel and the narrow, distal
aganglionic segment

Clinical features
• Male to female ratio 4:1
• Associated with Down syndrome
 • Typically presents in the neonatal period with

Failure to pass meconium within 24 hours of life

Progressive abdominal distension

Bilious vomiting
• On rectal examination, forceful expulsion of foul-smelling liquid feces is typically observed and represents
the accumulation of stool
• under pressure in an obstructed distal colon Diarrhea- if enterocolitis sets in
• May present at an older age with a history of poor feeding, chronic abdominal distention, and significant
constipation.
• Enterocolitis is the most common cause of death in patients with uncorrected Hirschsprung's disease

Diagnosis
• Gold standard: full thickness rectal biopsy (absence of ganglion cells)
• In the newborn period, this is performed at the bedside using a special suction rectal biopsy instrument
• Barium enema – abnormal segment is contracted, normal segment is dilated
• Anorectal manometry – absence of anorectal reflex which is diagnostic

Treatment
• Swenson procedure– aganglionic bowel is removed & coloanal anastomosis is done
• Duhamel – normal ganglionated colon pulled behind the abnormal segment & stapled
• Soave – endorectal mucosal dissection within the aganglionic distal rectum followed by pull through of
normal segment & coloanal anastomosis.

Acquired megacolon:
• Chagas disease
• Ulcerative colitis
• Visceral myopathy
• Psychosomatic disorders

DIVERTICUOSIS
• Diverticulosis refers to the presence of diverticula without inflammation.
• Diverticular disease is a clinical term used to describe the presence of symptomatic diverticula
• False diverticula (mucosa and muscularis mucosa have herniated through thecolonic wall) between the
teniae coli, atvpoints where the main blood vessels penetrate the colonic wall
• True diverticula, which comprise all layers of the bowel wall, are rare and are usually congenital in origin
• The sigmoid colon is the most common site of diverticulosis
• But in South-East Asia, right-sided diverticular disease is more common

Complications
• Diverticulitis: Refers to inflammation and infection associated with diverticula. Left sided lower abdominal
pain, loose stools, low grade fever, tenderness and sometimes mass palpablee in the left iliac fossa (left
sided appendicitis)
• Perforation: most often contained leading to pericolic abscess formation
• Peritonitis, Intestinal obstruction, Haemorrhage
• Fistula formation: Colovesical fistulas are most common

Hinchey classification of complicated diverticulitis

• Grade I: Mesenteric or pericolic abscess
 • Grade II: Pelvic abscess
• Grade Purulent peritonitis
• Grade IV: Faecal peritonitis

Management
• High-fibre diet and bulk-forming laxatives
• Acute diverticulitis is treated by intravenous antibiotics
• Abscess < 5 cm - likely to settle with antibiotics; > 5cm – likely to require intervention.

Urgent or emergent laparotomy

• Abscess is inaccessible to percutaneous drainage
• Patient's condition deteriorates or fails to improve
• Patient presents with free intra-abdominal air
• Peritonitis
• Hartmann's procedure - safest option in emergency surgery
• Primary anastomosis – for young and fit patiients without gross contamination or overwhelming sepsis
Elective resection: Recurrent attacks, Fistulae

INFLAMMATORY BOWEL DISEASE

• Peak age of presentation 15-30 years and 60-80 years
• Females > males

CROHN'S DISEASE/ REGIONAL ENTERITIS GRANULOMATOUS ULCERATIVE COLITIS

COLITIS / TERMINAL ILEITIS
Can affect any part of GIT, but me sites – terminal ileum, Limited to colon and rectum
ileocecal valve, and cecum
HLA-DR1/DQw5 HLA-DR2, HLA DR103
• Smoking is a strong risk factor • Non-smokers, ex-smokers - higher risk
• OCPs and Appendicectomy increase risk • Appendicectomy before 20 years protects
against UC
Morphology
Skip lesions Continuous lesions
Thick bowel wall Thin bowel wall
Strictures common Rare
Transmural inflammation Limited to mucosa
Non caseating granulomas (35%) No granulomas
Moderate pseudopolyps Marked number of Pseudopolyps (tips fuse to
form mucosal bridges)
Deep, knife-like ulcers Superficial broad-based ulcers
Fibrosis, serositis – marked Mild to none
Perianal disease - painful skin tags, anal fissures, perianal Absent
abscesses, fistulas
Rectum mostly spared Rectum always involved
 • Earliest lesions - aphthoid ulcers • Rectum always involved and disease
• Crypt abscesses extends proximally (pancolitis and
• Mesenteric fat wraps bowel surface (creeping fat) backwash ileitis)
• Paneth cell metaplasia in the left colon • Crypt abscess
• Distortion of mucosa! architecture
• Cutaneous granulomas - metastatic Crohn disease
Clinical features
Intermittent mild diarrhea, fever, abdominal pain (MC) Relapsing disorder with attacks of bloody diarrhea
Right lower quadrant mass, weight loss, anemia (usually nocturnal/postprandial), cramps, fecal
Sometimes mimics appendicitis or bowel perforation urgency
Anal complaints (fissure, fistula, abscess) - frequent Infrequent
Less incidence of perforation Increased incidence of perforation
Fat/vitamin malabsorption present Absent
Malignant potential + with colon involvement Malignant potential (UC > CD)
Recurrence after surgery common Rare
Toxic megacolon – not common Toxic megacolon seen (diameter > 6 cm)
Investigations
70% ASCA +ve (anti Saccharomyces cerevisiae Ab) 75% pANCA positive
10% pANCA positive 10% ASCA +ve
Barium meal follow through or small bowel enema Barium enema
• Straightening of valvulae conniventes • Loss of haustrations
• Multiple defects (cobblestone appearance). • Narrow contracted colon (hose pipe colon)
• Cicatrisation & narrowing of ileum (string sign of • Mucosal changes caused by granularity
Kantor) • Chronic - narrow contracted colon
• Rose thorn appearance of the bowel wall.
• Antibodies to E. coli outer membrane porin protein C • Fecal lactoferrin - marker for intestinal
(OmpC) , Antibody to 12„Antiflagellin (anti-CBir1) inflammation
• CT enterography - first-line test for the evaluation of • Fecal calprotectin - correlate with, predict
suspected CD and its complications relapses, detect pouchitis
Treatment
• 5-ASA agents (mesalamine) not used now • Mild to moderate distal colitis – topical
• Mild to moderate disease involving terminial ileum or mesalamine is the drug of choice
ascending colon– Budesonide • Mild to moderate disease extending above
• Severe disease involving proximal small intestine or the sigmoid colon
distal colon – Prednisone
Oral 5-ASA agents
• Immunomodulators (Azathioprine, mercaptopurine,
No response – add prednisone
methotrexate) and for maintenance of remission or
No response- immunomodulators
• induction of remission along with steroids in severe • Severe colitis
disease • IV Methyiprednisolone
• Anti-TNF therapy (Infliximab, adalimumab,
No response - Infliximab
certolizumab)
No response - Cyclosporine
-first-line agents to induce remission in moderate to
No response - Surgery
severe disease and to maintain remission • Fulminant colitis & Toxic megacolon not
• Anti-integrins: Natalizumab (anti-a4 integrin) – if no improving in 48-72 hours  surgery–Total
response to anti-TNF agents proctocolectomy

Extraintestinal manifestations
• Rheumatologic
 • Inflammatory arthropathy is the most common extraintestinal manifestation
• Peripheral arthritis (CD > UC) – asymmetric, polyarticular, migratory, mostly affects large joints of the upper
and lower extremities, worsens with exacerbations of bowel activity
• Ankylosing spondylitis (CD > UC) - not related to bowel activity, does not remit with glucocorticoids or
colectomy, most often affects the spine and pelvis
• Sacroileitis (CD=UC) – does not correlate with bowel activity

Dermatologic
• Erythema nodosum (CD > UC) - attacks correlate with bowel activity; skin lesions develop after the onset of
bowel symptoms
• Pyoderma gangrenosum (UC>CD) - may occur before the onset of bowel symptoms, course independent of
the bowel disease, respond poorly to
• Aphthous stomatitis and "cobblestone" lesions of the buccal mucosa (CD > UC)
• Pyoderma vegetans, pyostomatitis vegetans, Sweet syndrome (neutrophilic dermatosis)

Other Extraintestinal manifestations

• Primary sclerosing cholangitis (UC > CD)
• Nephrolithiasis (CD)
• Secondary amyloidosis (CD>UC)
• Uveitis, episcleritis

 In UC - Arthritis, ankylosing spondylitis, erythema nodosum, and pyoderma gangrenosum typically improve
or completely resolve after colectomy
 Colectomy has no effect on PSC
 In some centres, for Ulcerative colitis, an instant enema is used with a water soluble medium for contrast
instead of barium and no bowel preparation to avoid aggravating any underlying colitis

Indications for surgery in Crohn's disease

• Intractable to medical therapy
• Intra-abdominal abscess
• Massive bleeding
• Refractory internal or perianal fistulas Intestinal obstruction

Colitis associated Neoplasia

• Depends on - Duration and extent of disease; severity and frequency of inflammation
• Patients are enrolled in surveillance programs approximately 8 years after diagnosis of IBD
• Patients with IBD and primary sclerosing cholangitis (greater risk) – enrolled at the time of diagnosis
• Advanced endoscopic imaging techniques - chromoendoscopy and confocal endoscopy are used

COLO-RECTAL CANCER
Increased risk Protective effect
 • Animal fat (red meat); Saturated fat • Ulcerative colitis • Aspirin
• Alcohol, Smoking, Obesity • Crohn's disease • NSAIDs
• High calorie diet, low fibre diet • Streptococcus bovis • Folic acid
Genetic bacteremia • Oral calcium
• HNPCC (Lynch syndrome) • Ureterosigmoidostomy • Estrogen replacement
• Familial Adenomatous Polyposis • Acromegaly therapy
• Gardner syndrome • Pelvic radiation (mucinous • Selenium
• Turcot syndrome type) • Zinc
• Peutz-Jeghers syndrome • Cholecystectomy and ileal • Vitamins A, C, E
• Juvenile polyposis • resection (↑ bile salts) • High fibre diet
• Size - most important characterist.c that correlates with risk of malignancy in colonic adenomas

Molecular pathogenesis
• APC/β catenin pathway (Adenoma-Carcinoma sequence): Loss of APC tumor suppressor gene results in
increased β-catenin activity leading to increased intestinal epithelial proliferation
• Microsatellite instability pathway: mutations in MSH2 and MLH1 genes which are DNA mismatch repair
genes

Types
• Annular(stenosing) type – common in left side
• Ulcerative and proliferative type – common in right side

Clinical features
Right colon tumors Left sided growth
• Growth: fungative, ulcerative, • Growth: obstructive, annular lesions producing napkin ring
polypoid or cauliflower like constriction
• Infiltration absent • Infiltration present
• Iron ↓ anemia due to chronic blood • Rectal bleeding, Colicky pain
loss • Altered bowel habits (alternating diarrhea and
• Palpable mass in the RIF, which is not constipation)
moving with respiration • Abdominal distension due to subacute/chronic obstruction
• Spurious(early morning) diarrhea • Tenesmus

Stagin
Modified Duke's staging Astler-Coller's staging
A Growth limited to rectal wall A Intramucosal
B Growth extending to extra rectal tissues but no B1 Involvement up to muscularis propria
lymph node spread B2 Spread through the wall of peritoneum
B1: invading muscularis mucosa C1 B1+ Lymph nodes
B2: invading serosa C2 B2 + Lymph nodes
C Lymph node secondaries D Distant spread
D Distant spread to liver, lungs, bone and brain

The two most important prognostic factors

• Depth of invasion
• Lymph node status
Investigations
• Barium enema: apple core lesion in left sided carcinoma
• Colonoscopy and biopsy: is the investigation of choice
• CEA: normal level <2.5ng/ml; >5ng/m1 significant

Low sensitivity (also ↑ in pancreatitis, hepatitis, obstructive jaundice, BPH)

Pre-op levels >7.5ng/ml indicates poor prognosis

If post-op levels do not fall, indicates incomplete resection or occult metastasis

Increase in CEA during follow up
o Slow rise – loco regional disease
o Rapid rise – metastasis

Treatment
• Bowel preparation is not safe for right sided colonic surgery. The me method used is dietary restriction to
fluids only for 48 hrs before surgery
• Carcinoma of the caecum or ascending colon: right hemicolectomy
• Carcinomas of the transverse colon and splenic flexure: extended right hemicolectomy
• Carcinomas of descending and sigmoid colon: left hemicolectomy
• Right sided tumors presenting as obstruction: right hemicolectomy
• Left sided tumors presenting as obstruction

Hartmann's procedure or resection and anastomosis

If facilities available an expanding metal stent followed by resection and anastamosis
• A second look operation is most often helpful in colonic carcinoma to resect residual or recurrent tumors
(Owen Wangensteen's second look surgery)
• Hepatic metastases: hepatic resection is usually performed as a staged procedure after recovery (12 weeks)
from colonic resection
• The criteria for resection is < 3 lesions in one lobe of liver
• Chemotherapy

5-FU + (folinic acid)Leucovorin + Irinotecan (topoisomerase-1 inhibitor) improves survival in patients
with metastatic disease(FOLFIRI regimen)

5-FU + (folinic acid)Leucovorin + Oxiplatin (FOLFOX regimen) is equally effective

Indications for large bowel preparation

• Carcinoma colon (especially left sided) • FAP
• Anorectal malformations • Diverticulitis
• Megacolon, Carcinoma rectum • High pelvirectal fistulas
• Surgery for ulcerative colitis • Before colonoscopy

RECTAL PROLAPSE
• Women > 50 yrs
• Young men with h/o psychiatric disease, medications for constipation
• In children, the prolapse is usually mucosal and treated conservatively
• In adults, prolapse is often full thickness and associated with incontinence
• Partial prolapse – only mucosa and submucosa descends not more than 3.75cm

Treatment for partial prolapse

• Submucosal injection of 5% phenol in almond oil or ethanolamine oleate or tetracycline given into the apex
of prolapse and supported by Thiersch wiring (temporary)
 • Goodsall's operation

Treatment for complete prolapsed

• Perineal approach

To avoid possible damage to pelvic autonomic nerves in abdominal approach which may result in sexual
dysfunction, perineal approach is preferred in young men

Also in elderly and very frail patients

Delorme's operation [most preferred], Thiersch operation, Altemeier's procedure
• Abdominal approach

For complete prolapse in patients with good health

Well's operation

Ripsteins operation [sling operation]

Rectopexy

Solitary rectal ulcer

• Ulcer on the anterior wall of rectum
• May heal leaving a polypoid appearance
• Due to the combination of internal intussusception or anterior rectal wall prolapse and increased
intrarectal pressure
• This combination of factors is usually caused by chronic straining due to constipation
• Benign condition but difficult to treat
• Treatment – intrarectal stapling or abdominal rectopexy

RECTAL CARCINOMA
Spread
• Local spread occurs circumferentially rather than in a longitudinal direction
• Lymphatic spread mainly occurs in the upward direction via the superior rectal vessels to the para-aortic
nodes
• Principle sites of blood borne metastasis are liver (34%), lungs (22%) and adrenals (11%)

Symptoms
• Bleeding is the earliest and most common symptom
• Tenesmus
• Sense of incomplete evacuation (very important early symptom)
• The patient will try to empty the rectum several times a day (spurious diarrhea), often with the passage of
flatus and a little blood-stained mucus (bloody-slime)
• Alteration in bowel habits
• Growth in the ampulla of the rectum - Early morning bloody diarrhea
• Annular carcinoma at the recto sigmoid junction - increasing constipation

Diagnosis
• 90% of rectal growths can be felt by per-rectal examination
• Investigation of choice – rigid sigmoidoscopy and biopsy
• To assess local spread – TRUS (Endoluminal ultrasound)
• For local staging and assessment of proposed circumferential resection margin – MRI (CT is not accurate in
local staging)
• CT chest and abdomen or PET – to exclude distant metastasis
Surgeries
• Pre-operative neo-adjuvant radiotherapy in resectable rectal cancer reduces the incidence of local
recurrence
• Adjuvant chemotherapy improves survival in node-positive cases
• Anterior(low) resection: sphincter saving procedure

Proximal 2/3rd of rectum (lesions 6cms above the dentate line/2 or more cms above anal canal)

Well differentiated tumor

<4 cm size tumor

T1/T2, NO tumors
• Recto sigmoid tumors and upper third rectal tumors : High anterior resection (rectum and mesorectum are
taken to a margin 5cm distal to the tumor and colorectal anastomosis is performed)
• Tumors in the middle and lower thirds of rectum: complete removal of rectum and mesorectum (TME-
total mesorectal excision)
• Abdomino perinea! resection(Mike's procedure) when sphincter saving procedure is not possible
• Hartmann's procedure – for elderly and unstable patients who cannot withstand long procedure of APR
• It is imperative that a colonoscopy is always performed either before(for synchronous tumors) or within a
few months (for metachronous tumors) of surgical resection for tumor detection

ANAL FISSURE (FISSURE-IN-ANO)

• A longitudinal split in the distal anal canal; extends from the anal verge proximally towards dentate line
• Posterior fissures (most common) – passage of hard stool
• Anterior fissures – more common in women following vaginal delivery
• Fissure away from midline - Crohn's disease, tuberculosis, STDs, HIV, Kaposi's sarcoma, squamous cell
carcinoma
• Severe anal pain associated with defaecation
• Stools are hard, pellet like and there is a drop or streaks of fresh (bright red) blood
• Mucus discharge
• Sentinel pile – tag of skin at the outer end of chronic fissures
• Per-rectal examination with lignocaine jelly – can demonstrate sphincter spasm
• Proctoscopy is contraindicated

Treatment
• Conservative: stool softeners, high fibre diet, mild laxatives, sitz bath
• Pharmacological

Topical Lignocaine gel

Topical 0.2% Glyceryl trinitrate – releases NO and relaxes internal sphincter (head ache is a
complication)

Oral Nifedipine

Injection Botulinum A toxin
• Surgery

Lateral sphincterotomy – gold standard

Fissurectomy and local advancement flap – for chronic, non-healing fissure

ANAL FISTULA (FISTULA-IN-ANO)

• An abnormal communication between anal canal and recto with exterior
• Even though multiple openings are seen in perianal skin – the internal opening is always single
• Causes: persistent anal gland infection, TB, Crohn's disease, lymphogranuloma venereum, actinomycosis,
rectal duplication, foreign body and malignancy
• More common in men
 • Usual presentation – intermittent purulent discharge (may be bloody) and pain (which increases until
temporary relief occurs when the pus discharges)
• A previous episode of acute anorectal sepsis that settled (incompletely) spontaneously or with antibiotics,
or which was surgically drained

Parks classification
• Inter-sphincteric (45%) – do not cross external sphincter
• Trans-sphincteric (40%) - have a primary track that crosses both internal and external sphincters, which then
passes through the ischiorectal fossa to reach the skin of the buttock
• Supra-sphincteric – rare; internal opening above anorectal bundle; usually result from pelvic disease or
trauma
Goodsall's rule (used to indicate the likely position of the internal opening according to the position of the external
opening)
• Fistula with external opening in the anterior half of the anus within 3.75 cm – direct type
• Fistula with external opening in the posterior half of the anus– indirect, curved or horseshoe type

Investigations
• Endoanal ultrasound with hydrogen peroxide - to delineate fistulae
• MRI - Gold standard for fistula imaging
• Fistulography and CT - useful techniques if an extrasphincteric fistula is suspected.

HEMORRHOIDS
• External (below dentate line; covered with skin)
• Internal (above dentate line; covered with mucous membrane)

External hemorrhoids
• External haemorrhoids relate to venous channels of the inferior haemorrhoidal plexus
• They are not true haemorrhoids; Commonly termed as perianal hematoma
• Usually only recognised as a result of a complication, which is most typically a painful solitary acute
thrombosis
• They are best thought of as being external extensions of internal haemorrhoids.
• Sudden onset, olive shaped, painful blue subcutaneous swelling at the anal margin
• If the patient presents within 48 hrs, the clot may be evacuated under LA
• If untreated, in majority of the cases, resolution or fibrosis occurs
• This condition has been called 'a 5-day, painful, self-curing lesion'

Internal haemorrhoids
• Internal hemorrhoids are characteristically seen in 3, 7 and 11 o'clock positions
• Nature of bleeding is characteristically separate from the motion and is seen either on the paper on wiping
or as a fresh splash on the pan
• Pain is not commonly associated with bleeding
• Secondary internal haemorrhoids arise as a result of a specific condition (most important – anorectal
cancer)

Four degrees of hemorrhoids

First degree – bleeding only, no prolapse
Second degree – prolapse, but reduce spontaneously
Third degree – prolapse and have to be manually reduced
 Fourth degree – permanently prolapsed

Management
• Non-operative: Sitz bath
• First or second degree piles not relieved by conservative measures – sclerotherapy-using Gabriel's syringe
(submucosal injection of 5% phenol in arachis or almond oil in the apex of the pile pedicle)
• For more bulky piles – banding(Barron's bander)
• Hemorrhoidectomy – for third and fourth degree piles, fibrosed hemorrhoids
• Secondary hemorrhage occurs usually on the seventh or eighth day

 Jack knife position (prone position with buttocks elevated) – pilonidal sinus excision

MALIGNANT TUMORS OF ANUS & ANAL CANAL

ANAL MARGIN TUMORS (distal to dentate line) ANAL CANAL TUMORS
• Bowen's disease Proximal to dentate line
• Paget's disease • Epidermoid cancer
• Basal cell carcinoma • Adenocarcinoma
• Squamous cell carcinoma • Melanoma
• Verrucous carcinoma (Giant condyloma acuminatum or
Buschke-Lowenstein tumor)

SQUAMOUS CELL CARCIONOMA OF ANUS

Predisposing factors
• HPV infection (subtypes 16, 18, 31, 33)
• Anal intraepithelial neoplasia (AIN) (Bowen's disease)

Viral (HIV) induced dysplasia of perianal or intra-anal epidermis

Treatment: topical Imiquimod or oral retinoids or excision
• HIV infection
• Homosexual males
• Organ transplant recipients
• Immunosuppression

Treatment
• Chemoradiation is the primary treatment
• NIGRO regime: 5-FU (radio sensitizer) and Mitomycin C + Radiotherapy
• 80% tumors can be cured by this regimen
• Recurrence requires APR

FECAL FISTULA
• Causes

Most common cause - previous surgery Appendicectomy (after a gangrenous appendicitis)

Drainage of appendix abscess

Opening of an abscess connected with chronic diverticulitis or carcinoma colon

Necrosis of a gangrenous patch of intestine due to strangulated hernia

Radiation injury
• Low output fistula (<1 litre per day) can be expected to heal spontaneously
• Higher the fistula in the intestinal tract, more is the skin excoriation (worst in duodenal fistula)
ANORECTAL MALFORMATIONS
• Due to imperfect fusion of the post-allantoic gut with the proctodaeum
• Most common ARM in boys is imperforate anus with rectourethral fistula
• Most common ARM in females is rectovestibular fistula
• Most common associated defect – urinary tract defect
• Most common GI defect – esophageal atresia

Wingspread classification of Anorectal malformations

Low High
• Below the level of pelvic floor, (Puborectalis) • With or without a fi stula into the bladder urethra,
• Easy to diagnose and treat • uterus, vagina
• Good outcome.
• Imperforate anus • Anorectal agenesis
• Anovestibular fistula • Rectal atresia
• Anal stenosis • Cloaca (only in females) - rectum, vagina, and urinary
• Anal membrane tract meet and fuse into a single common channel

IMPERFORATE ANUS
• Divided into two main groups – high and low – depending on the level of termination of the rectum in
relation to the pelvic floor
• Presence of meconium on the perineum indicates a low defect.
• By 24 hours, the distal limit of air within the rectum, seen on a lateral prone radiograph, indicates the
distance between the rectal stump and perineum (BAILEY)

Wangenstein's invertogram (SRB)

• Usually done 6-12 hours after birth, so as to allow air to reach the rectal pouch.
• A metal coin (marker) is strapped at the presumed site of anus and X-ray is taken.
• Length between the rectal pouch and anal dimple marker is more than 2.5 cm in high anal fistula.
• In low fistula, rectal pouch is distal to the Stephen's line (Pubococcygeal line).
• In intermediate, pouch is at the level of ischial spine (Kelly's point)
• In high fistula, rectal pouch is proximal to the Stephen's line

INTESTINAL OBSTRUCTION
Proximal small bowel Distal Large bowel
• Vomiting early and small bowel
• Pain – intermittent, • Pronounced early distension
profuse colicky • Pain is mild
• Minimal distension • Central distension • Vomiting (faeculent) and dehydration
• Colicky pain • Vomiting delayed are late
• Peristalsis not seen (bilious) • Right to left peristalsis may be seen
• Little evidence of air fluid • Step ladder peristalsis • Proximal colon and caecum are
• levels in X-ray • Multiple air fluid levels distended on X-ray

• Jejunum – Concertina or ladder effect due to valvulae conniventes (Herring bone pattern)
• Fluid levels appear later than gas shadow
• Three inconstant fluid levels in adults (considered normal)

Fundus of stomach

Duodenal cap

Terminal ileum
 • Few fluid levels in the small intestine may be physiological in infants less than 1 year
• Fluid levels in non obstructive conditions (Inflammatory bowel disease, Acute pancreatitis, Intraabdominal
sepsis)

VOLVULUS
• Twisting of the bowel on its mesenteric axis causing partial or complete obstruction
• Primary volvulus

Due to congenital Malrotation of gut, abnormal mesenteric attachments or congenital bands

Examples: volvulus neonatorum, caeca! volvulus and sigmoid volvulus
• Secondary volvulus
• Rotation of a piece of bowel around an acquired adhesion or stoma
• Sigmoid colon is the most common site (anticlockwise)
• Caecum is the second most common site (clockwise)
• Compound Volvulus: Ileosigmoid knotting - ileum winds around the pelvic mesocolon

Sigmoid volvulus
Predisposing factors Clinical features Plain X-ray supine position
• Narrow attachment of • Sudden onset of severe • Coffee bean or bent inner tube sign
sigmoid mesocolon abdominal pain • Omega sign
• Long pelvic mesocolon • Obstipation • Absent gas in colon and rectum
• Overloaded pelvic colon • Distension(early feature) Barium enema – bird's beak deformity or
• Band of adhesion • Vomiting occurs late ace of spades appearance
• Peridiverticulitis • Tyre like feel of abdomen CT scan – whirl pattern

Sigmoid volvulus is common in patients of

• Chronic constipation with laxative abuse
• Psychiatric disease treated with psychotropic drugs

Volvulus neonatorum
• Secondary to intestinal Ma!rotation
• DJ flexure lies right to the midline; caecum is central creating a narrow base for small bowel mesentery
• Typically presents with bilious vomiting
• Surgery: Ladd's procedure; appendix is usually removed to avoid leaving it in an abnormal site

Caecal volvulus
• Mobile caecum - Caecal bascule
• More common in females
• Caecal volvulus is the most common cause of large bowel obstruction in pregnancy
• X-ray: gas filled ileum and occasionally a distended caecum
• Barium enema confirms diagnosis: absence of air in the caecum and a bird beak deformity

Management
• Caecal volvulus

Reduction, fixation of the caecum to the right iliac fossa (caecopexy)

If the caecum is gangrenous – right hemicolectomy
• Sigmoid volvulus

Sigmoidoscopy and insertion of flatus tube to allow decompression

Risk of recurrence is high (40% - 70%)

In young patients, an elective sigmoid colectomy is required

If decompression does not occur – laparotomy with resection of the sigmoid colon (Hartmann's
operation)

Impending gangrene – Paul-Miculicz procedure or sigmoid colectomy

INTUSSUSCEPTION
Types
• Ileo-colic (most common type in children and overall)
• Colo-colic(most common type in adults)

Parts
• Inner tube (entering tube) – intussusceptum
• Outer tube (sheathing tube) – intussuscepiens
• Invariably the proximal part invaginates into the distal part

Clinical features
• Most common cause of intestinal obstruction in infancy
• Most common during the weaning period (5-10 months)
• 90% cases idiopathic in infancy, but an URI or gastroenteritis may precede the condition
• Hyperplasia of Peyer's patches in the terminal ileum may be the initiating event
• After 2 years, lead point (Meckel's diverticulum, polyp, HSP etc) is present in one third of cases
• In adults, lead point is always present, which is usually a polyp, submucous lipoma or a tumor
• Colicky abdominal pain – initial and most common presentation
• Episodes of screaming and drawing up of the legs in a previously well male infant
• Vomiting is always present, bile stained at later stages
• Stools mixed with blood and mucus – red currant jelly stools
• A sausage shaped abdominal mass may be palpated either on the left or right side of umbilicus. Does not
move with respiration, mobile, contracts under palpating fingers, mass appears and disappears
• Emptiness in RIF (Dance sign)
• Intestinal obstruction with step ladder peristalsis

Diagnosis
Barium enema USG X-ray
• Claw sign • Target sign • Meniscus sign
• Coiled spring sign • Pseudokidney sign • Multiple air fluid levels
• Bull's eye sign • Absent caecal gas in ileocolic
• Doughnut appearance of concentric rings cases

Treatment
• Infants

Resuscitation

Non-operative reduction with enema of air or barium or warm saline (Hydrostatic reduction)

Child will pass large quantity of air and faeces; distension reduces

Successful reduction can only be accepted if there is free reflux of air or barium into the small bowel,
together with resolution of symptoms and signs in the patient
• Non operative reduction is contraindicated

Complete obstruction

Perforation

Peritonitis

Presence of a known pathological lead point

Profound shock
• Adults: surgerical resection of the involved segement and the lead point (Cope's method)

PARALYTIC ILEUS
• Failure of transmission of peristaltic waves secondary to neuromuscular failure
• Intestinal obstruction/slowing/absence of passage of luminal contents without a demonstrable mechanical
obstruction

Etiology
• Post operative

A degree of ileus usually occurs after any abdominal procedure

Self-limiting (24-72 hours)

May be prolonged in Hypoproteinemia or metabolic abnormality
• Intra-abdominal inflammation (peritonitis, abscess, retroperitoneal hemorrhage)
• Reflex ileus: following fractures of spine/ribs, retroperitoneal hemorrhage or application of a plaster jacket
• Metabolic & electrolyte derangements (uremia, hypokalemia, hyponatremia, hypo and hypomagnesemia,
diabetic coma, hypoparathyroidism, hypothyroidism)
• Drugs (opiates, psychotropic agents, anticholinergic agents, calcium channel blockers)
• Intestinal ischemia; Myocardial infarction; Ureteric colic

Clinical features
• Abdominal distension usually without colicky abdominal pain
• Nausea, vomiting, absent bowel sounds and absolute constipation
• No passage of flatus
• In the absence of gastric aspiration, effortless vomiting may occur
X-Ray: gas filled small and large bowel loops with multiple air fluid levels

Treatment
• Nasogastric decompression, IV fluids, electrolyte management
• Treat the underlying cause
• Catchpole regime: adrenergic blocking agent + cholinergic stimulant (neostigmine) used in resistant cases.

Post-operative paralytic ileus

• Following laparotomy, gastrointestinal motility temporarily decreases
• Treatment is usually supportive with maintenance of adequate hydration and electrolyte levels.
• Return of function of the intestine occurs in the following order: small bowel, large bowel and then
stomach

Wilkie's syndrome or Superior Mesenteric artery syndrome

• Obstruction of the 3rd part of duodenum due to decreased angle between the SMA and aorta
• Bilious vomiting, visible peristalsis, upper abdominal fullness are the clinical features
• Barium meal is diagnostic
• Duodeno-jejunostomy is the treatment

Ogilvie's syndrome (Colonic pseudo-obstruction)

• Colon becomes massively dilated in the absence of mechanical obstruction
• Predominantly right and transverse colon
• Due to sacral parasympathetic nerve dysfunction
 • X-ray shows colonic obstruction, with marked caecal distension
• Caecal perforation is a well-recognised complication.
• Seen in critically ill, scleroderma, SLE, Chaga's disease, multiple sclerosis, DM, hypothyroid, CRF, sepsis etc.,
• Treatment: Treat the cause, IV neostigmine, colonoscopic decompression

CARCINOID TUMOR
• GIT is the most common site of carcinoid tumors
• In GIT mc sites are Appendix [45 - 65%], ileum[25%] and rectum (SABISTON, SCHWARTZ, BAILEY, SRB,
MANIPAL)
• The most common location in GIT are small intestine (45%), rectum (20%) and appendix (17%) (CMDT)
• Distal ileum is the mc site in GIT (HARRISON)
• Jejunum and Ileum (45%) are the mc site in GIT (ROBBINS)
• Peak incidence at 6th decade
• Cause malabsorption and diarrhea by the disruption of transepithelial transport
• The most important prognostic factor for GI carcinoid tumors is location

Foregut carcinoids (bronchial, thymic, gastroduodenal, pancreatic)

• Produce low levels of serotonin
• Argentaffin-negative but argyrophilic
• Often multihormonal
• Uncommonly produce a clinical syndrome
• Occasionally secrete ACTH or 5-HTP causing an atypical carcinoid syndrome
• Those found within stomach and duodenum rarely metastasize and cured by resection
• Most sensitive screening test – serum levels of Chromogranin A

Midgut carcinoids (jejunal, deal, appendiceal, right colic)

• Produce high levels of serotonin
• Secrete tachykinins(substance P, neuropeptide K, substance K)
• Argentaffin-positive
• Most frequently cause the typical carcinoid syndrome
• Jejuna! and ilea! carcinoids are multiple and aggressive – worse outcome

Hindgut carcinoids (distal colon, rectum)

• Rarely produce serotonin, ACTH or 5-HTP
• Produce somatostatin and peptide YY
• Argentaffin-negative, often argyrophilic

Appendiceal carcinoids
• Carcinoid is the most common neoplasm of appendix
• Can occur at any age
• Distal 3rd of appendix is commonly involved
• Characteristic feature is a solid yellow tan appearance on cross section
• Shows characteristic pattern on staining with chromogranin B
• Arise from Neuroendocrine cells (Argentaffin tissue – Kulchitsky cells of the crypts of Lieberkuhn)
• Carcinoid of appendix and rectum metastasize rarely (unlike carcinoid in other parts of GIT)
• Appendicectomy is the treatment for carcinoid of appendix of size < 2 cm
• In patients with hepatic metastasis, multiple enucleations of hepatic metastasis or partial hepatectomy is
needed
 • When the tumor is >2cm; when caecal wall is involved or when lymph nodes are involved: right
hemicolectomy

Small bowel carcinoids

• One third of small bowel carcinoids are multicentric
• Grossly, these tumors are small, firm submucosal nodules that are usually yellow on cut surface
• The most common symptom is abdominal pain
• The primary is usually small, the metastases, usually in liver are larger and produce carcinoid syndrome
• Tumor size is an important factor in the frequency of metastases (metastases occur in 15-25% if the tumor
diameter is <1 cm, 58-80% if it is 1-2 cm in diameter and >75% if it is >2 cm in diameter)
• Produce dense fibrosis in the surrounding tissues which penetrate the mesentery causing obstruction

Rectal carcinoids
• Small carcinoids: local resection
• Carcinoids > 2.5cm, recurrence after local excision, fixation to perirectal tissues: resection of rectum

Carcinoid syndrome
• Occurs in 10% of carcinoid tumours
• Most commonly seen with small bowel carcinoids
• Occurs in patients who have a large volume of liver metastases (liver unable to metabolize the hormones)
or the vasoactive substances produced by the tumors enter the systemic circulation through the hepatic
vein (by passing liver metabolism)
• Rarely carcinoids of ovary, testis and retroperitoneum bypass the first pass metabolism in liver and so causes
syndrome without liver secondaries
• Flushing and diarrhea are the two most common symptoms
• Flushing — due to Tachykinin, histamine, prostaglandins
• Flushing is not due to serotonin, bradykinin
• Most manifestations are due to 5-HT (serotonin) produced by the tumors.
• Classically the flushing attacks are induced by alcohol
• Cardiac manifestations are usually on the right side
• The three most common cardiac lesions are pulmonary stenosis (90%), tricuspid insufficiency (47%), and
tricuspid stenosis (42%) (SABISTON)
• Wheezing, asthma-like symptoms and pellagra-like manifestations are other clinical manifestations
• Features due to increased fibrous tissue

Retroperitoneal fibrosis causing urethral obstruction

Peyronie's disease of the penis

Intraabdominal fibrosis

Occlusion of the mesenteric arteries or veins
• Carcinoid crisis is a life-threatening complication of the carcinoid syndrome. More common in patients who
have intense symptoms or have greatly increased urinary 5-HIAA levels (>200 mg/d).
• The treatment of carcinoid crisis is IV octreotide

Diagnosis
• Elevated urinary levels of 5-HIAA measured over 24 hours — highly specific, not sensitive
• Elevated plasma concentration of chromogranin A — not specific
• Combination of 24-hour urine 5-HIAA and serum chromogranin A levels provides the best biochemical
diagnostic accuracy
As per HARRISON
 70% of carcinoid tumors occur in bronchus, jejunoileum or colon/rectum
 Overall GIT is the most common site (64%) and second most common site Respiratory tract (28%)
 Small intestinal carcinoids are the mcc of carcinoid syndrome due to metastasis to the liver
 Diarrhea is the most common symptom of carcinoid syndrome
 Abdominal pain is the most common symptom of small bowel carcinoids
 Bleeding is the most common symptom of rectal carcinoids
 Pancreatic carcinoid metastasize most frequently
 Bronchial carcinoids are mostly asymptomatic
 Carcinoid syndrome is most frequently associated with carcinoid of ovary and testes
 Carcinoid heart disease: tricuspid insufficiency > tricuspid stenosis >pulmonary insufficiency > pulmonary
stenosis

Visualization of lower GIT

• Proctoscopy - to inspect the anus, anorectal junction and lower rectum (upto 10 cm)
• Sigmoidoscopy rigid — 18 cm
• Flexible sigmoidoscopy — 60 cm
• Colonoscopy — 160 cm
IV. INTRA-ABDOMINAL INFECTIONS, PERITONIUM, CHEST & ABDOMINAL
TRAUMA
ILEOCAECAL TUBERCULOSIS
Ulcerative type Hyperplastic type
• Secondary to Pulmonary TB, when the patient • Primary GIT TB, drinking of infected milk
swallows infected sputum • Decreased virulence & increase host defense
• Increased virulence & decrease host defense • Hyperplasia and thickening of terminal ileum
• Multiple circumferential transverse (girdle) ulcers causing narrowing and obstruction of the
with skip lesions lumen
• The serosa is studded with tubercles • Strictures and fibrosis
• Diarrhea, blood in stools, loss of appetite and weight • Presents as RIF mass
• Histology: caseating granuloma with giant cells • Can be confused with Crohn's disease (but
• Barium study — ileal(Napkin ring strictures) strictures abscess and fistula are rare )
with hypermotility • Barium study: caecum pulled upto sub-
hepatic position, obtuse ileocaecal angle

Other clinical features

• Doughy fell of the abdomen
• Localized areas of ascites
• Multiple fistula-in-ano with undermined edges and watery discharge
Ileocaecal region is the most common site of abdominal TB due to
• Stasis of luminal contents favored by ileo-caecal valve
• Abundant Peyer's patches
• Bacterial contact time with mucosa is more
• M cells in Payer's patches phagocytose bacilli & transfer to host cell

Barium study
• Earliest signs — increased transit time; hypersegmentaion (chicken intestine), flocculation of barium
• Narrow ileum with thickened incompetent ileocaecal valve — inverted umbrella sign or Fleischner sign
• Hurrying of barium due to rapid flow and lack of barium in inflamed segment — Steirlin sign
• Incompetent ileocaecal valve, ileocaecal spasm
• Obtuse ileo-caecal angle
• Ulcers and strictures in the terminal ileum and caecum - Napkin lesions
• Persistent narrow stream (string sign)
• Multiple strictures with enormous dilatation of proximal ileum (mega ileum)
• Straightening of ileocaecal junction with 'goose neck' deformity

USG features of abdominal TB

• Loculated ascites with fine septae
• Interloop ascites with alternate echogenic and echofree areas — Club-sandwich appearance
• Bowel loop radiates from its mesenteric root — Stellate sign
• Mesenteric thickness > 15 mm
• Pulled up caecum — Pseudokidney sign
• Perforation is rare in intestinal TB

Surgery
• Limited ileal resection (with 5cm margin) is the surgery of choice
 • Single stricture — stricturoplasty
• Multiple strictures, ileal perforation — resection and anastomosis
• Acute intestinal obstruction from distal ileal stricture is treated by thorough resuscitation followed by side to
• side ileotransverse bypass
• After the patient has recovered from active disease, 2nd stage definitive procedure (right hemicolectomy)
done

Surgical complications of Typhoid: During the third week of enteric fever, S.typhi and paratyphi multiply in Peyer's
patches and can give rise to the following complications
• Hemorrhage - enlarged Peyer's patches ulcerate and bleed
• Perforation of terminal ileum

Oval, vertical, single perforation situated at the antimesenteric border

Poor guarding and rigidity (due to Zenker's degeneration of abdominal wall muscles)

Plain X-ray abdomen may not reveal gas because of small sealed off perforation

CT-scan is the most useful investigation

 Perforation of the large intestine(colon) occurs in paratyphoid B infection

Thus Typhoid fever causes

• Peritonitis without guarding and rigidity
• Perforation without gas under the diaphragm
• Toxicity without tachycardia

ACUTE PERITONITIS
• Bacterial peritonitis is usually Polymicrobial
• The exception is primary peritonitis(spontaneous) – pure infection with pneumococcal (MC), Streptococcal
or Haemophilus
• E.coli is the most common organism found followed by streptococci and bacteroides
• Primary bacterial peritonitis – Pneumococci
• Secondary bacterial peritonitis – E.coli and Bacteroides
• Most common bacteria causing abscess formation in peritonitis – Bacteroides fragilis

Clinical features
• Guarding and rigidity of abdomen
• Rebound tenderness – Blumberg sign
• Hippocratic facies

Investigations
• Plain X ray erect (chest) – ground glass appearance and dilated gas-filled loops of bowel
• Serum amylase is raised to more than 4 times normal in acute peritonitis

TUBERCULOUS PERITONITIS
• Post-primary, due to activation of long standing latent focus
• Through Blood spread, diseased mesenteric LN, perforated intestine, fallopian tube

Acute
• Rare, on table diagnosis
• Straw coloured fluid escapes and tubercles seen scattered over the peritoneum and greater omentum
• Due to perforation or rupture of mesenteric LN
 • Abdomen closed without a drain with tension sutures

Chronic
• Present as abdominal pain (90%), fever, ascites, loss of wt / appetite, abdominal mass, doughy abdomen
• Peritoneum thickened with multiple tubercles

Ascitic form Fibrous form Purulent form

• Distension of abdomen • Wide spread adhesions, • Usually secondary to
• Pain often absent which cause coils of ileum tuberculous salphingitis
• Umbilical hernia commonly occurs to become matted • Cold abscesses form near
due to ↑ abdominal pressure together and distended the umbilicus
• A transverse solid mass palpated which acts as blind loop • Prolonged ATT with surgery
(rolled up greater omentum and give rise to steatorrhea to drain cold abscess
infiltrated with tubercles) • ATT is curative • Relatively poor prognosis

PSEUDOMYXOMA PERITONEI
• Occurs more frequently in women.
• The abdomen is filled with large quatities of yellow jelly
• Most cases arise from a primary appendiceal tumour with secondary implantation on to one or both ovaries
• It is often painless and there is frequently no impairment of general health.
• Does not give rise to extraperitoneal metastases
• Treatment: Removal of appendix, together with any ovarian tumour
• Recurrence is inevitable
• Occasionally, the condition responds to radioactive isotopes or intraperitoneal chemotherapy.

 Snow storm ascites – meconium peritonitis

INTRAPERITONEAL ABSCESS
Pelvic abscess
• MC site of an intraperitoneal abscess
• Diarrhea and passage of mucus in stools
• Rectal examination: bulging of anterior rectal wall
• Majority of abscesses burst into the rectum and rapid recovery follows
• In women, vaginal drainage through posterior fornix is chosen
• Rectal drainage is preferable over suprapubic drainage
• Laparotomy is never necessary

Left subphrenic space Right subphrenic space

Causes of abscess Causes of abscess
• Surgery on the stomach, tail • Perforating cholecystitis
of the pancreas, spleen or • Perforated duodenal ulcer
splenic flexure of the colon • Appendicitis
• Duodenal cap blow-out following gastrectomy
Left subhepatic space/lesser sac Right subhepatic space
• Commonest cause of infection • Deepest space of the four
is complicated acute • Commonest site of a subphrenic abscess which arises from
pancreatitis appendicitis, cholecystitis, perforated DU, following upper
abdominal surgery
Clinical features
• Pus some-where, pus no-where else, pus under the diaphragm
• Plain X-ray: elevated diaphragm (tented diaphragm)
• USG or CT is the investigation of choice
• Radiolabelled white cell scanning when other techniques have failed

RETROPERITONEAL FIBROSIS
• 70 % cases — Idiopathic (Ormond's disease)
• Other benign causes — Chronic inflammation, leakage of blood, urine or intestinal contents, aortic
aneurysms
• Drugs — chemotherapeutic agents
• Malignancy — lymphoma, carcinoma, secondaries

RETROPERITONEAL TUMORS
• Most common primary malignancy of the Retroperitoneum — Sarcoma
• Most common histologic subtypes - liposarcoma and leiomyosarcoma
• Radiation is a known risk factor; sarcomas usually occurring approximately 10 years after exposure
• Most common presentation - an asymptomatic abdominal mass
• Treatment: complete en bloc resection of the tumor and any involved adjacent organs
• The kidney is the most commonly resected organ

MESENTERIC CYSTS
• Cysts may occur in the mesentery of either the small intestine (60 per cent) or the colon (40 per cent)

Chylolymphatic cyst
• Most common type
• Most frequently in the mesentery of the ileum
• Thin wall of the cyst is composed of connective tissue lined by flat endothelium
• No efferent communication with the lymphatic system
• More often unilocular than multilocular
• Almost invariably solitary
• Blood supply independent of that of adjacent intestine.
• Treatment: enucleation

Enterogenous cyst
• Thicker wall than a chylolymphatic cyst and it is lined by mucous membrane, sometimes ciliated
• Adjacent bowel has common blood supply
• Treatment: enucleation with resection anastomosis of involved bowel segment

Urogenital remnant
• A cyst developing in the retroperitoneal space often attains very large dimensions
• Many of these cysts are believed to be derived from a remnant of the Wolffian duc

Clinical features
• Cysts occur most commonly in adults with a mean age of 45 years
• Twice as common in women as in men
• May be asymptomatic
• Most common presentation is of a painless abdominal swelling with characteristic physical signs

Fluctuant swelling near the umbilicus

Swelling moves freely in a plane at right angles to the attachment of the mesentery (Tillaux's sign) (in
contrast to the findings with omental cysts, which should be freely mobile in all directions)

There is a zone of resonance around the cyst

Management
• When symptomatic, simple mesenteric cysts are surgically excised either openly or laparoscopically
• Cyst unroofing or marsupialization is not recommended because mesenteric cysts have a high propensity to
recur after drainage alone

MESENTERIC ISCHEMIA
• Superior mesenteric vessels - visceral vessels most likely to be affected by embolization (more common) or
thrombosis.
• Occlusion at the origin of the superior mesenteric artery (SMA) is almost invariably the result of thrombosis,
whereas emboli lodge at the origin of the middle colic artery.
• Inferior mesenteric involvement - clinically silent because of a better collateral circulation.
• Irrespective of whether the occlusion is arterial or venous, haemorrhagic infarction occurs.
• The mucosa is the only layer of the intestinal wall to have little resistance to ischaemic injury

Acute ischemia
• Most important clue to an early diagnosis - sudden onset of severe abdominal pain in a patient with atrial
fibrillation or atherosclerosis
• The pain is typically central and out of proportion to physical findings.
• Persistent vomiting and defaecation occur early, with the subsequent passage of altered blood.
• Hypovolemic shock rapidly ensues.
• Abdominal tenderness may be mild initially with rigidity being a late feature.

Chronic ischemia
• Post-prandial abdominal pain - most important symptom with aversion to food and weight loss.
• Abdominal angina—recurrent colicky pain, diffuse in nature occurs with or without food intake.
• Bloody diarrhoea—feature of both acute and chronic

Investigations
• X-ray: Absence of gas in the thickened small intestine
• The most useful test when bowel ischaemia or infarction is suspected is a CT scan (BAILEY)
• Angiography - gold standard, allowing for diagnosis and therapy

TRAUMA
Advanced Trauma Life Support (ATLS) principles of resuscitation.
• A – Airway with cervical spine protection
• B – Breathing and ventilation
• C – Circulation with haemorrhage control
• D – Disability: neurological status
• E – Exposure & Environmental control

Chest injuries
• CT scan - principal and most reliable examination for major injury in thoracic trauma.
• Fractures of the ribs

Most common thoracic injury following blunt trauma

80% of patients with blunt chest injuries sustain one or more fractures.

25% of patients with penetrating chest trauma cases have rib fractures

ABDOMINAL TRAUMA
• Small bowel – most commonly injured after a penetrating injury
• DJ flexure or ileo-colic junction - most common sites involved in small bowel
• Spleen – most frequently injured in blunt injury abdomen
• Liver – most frequently injured penetrating trauma
• Kidney – most commonly injured part of urinary tract

Diagnostic Peritoneal Lavage (DPL)

• To assess the presence of blood in the abdomen
• It is useful in blunt injury abdomen
• It is not very useful in penetrating injury, bowel injury, retroperitoneal and pelvic injuries
• Nowadays replaced by FAST
• Especially useful in hypotensive, unstable patient with multiple injuries to exclude intraabdominal bleeding

Positive findings Indications Contraindications

• 10 mL of gross blood • Equivocal physical • Clear indication for
• A bloody lavage effluent examination • exploratory laparotomy
• RBC count > 100,000/mm3 • Unexplained shock or • Relative
• WBC count > 500/mm3 hypotension
Previous exploratory
• Amylase level > 19 IU/L • Altered sensorium
laparotomy
• Alkaline phosphatase > 2 IU/L • General anesthesia for
Pregnancy
• Bilirumbin > 0.01mg/L extra- abdominal
Obesity
• Detection of bile, bacteria, or food procedures
fibers • Spinal cord injury

Focused abdominal sonar for trauma (FAST)

• Focuses only 4 areas – pericardial, splenic, hepatic, pelvic
• Can be performed simultaneously with resuscitation
• Used as bedside investigation of choice for detection of intraabdominal bleeding
• Useful for detection of >100m1 free fluid
• Does not identify hollow viscus injury
• Cannot reliably exclude injury in penetrating trauma

CT scan
• Gold standard for the intraabdominal diagnosis of injury in stable patient
• If stable the best and most sensitive modality is a CT scan with iv contrast

Diagnostic laparoscopy
• Valuable screening investigation in penetrating trauma patient in stable patients

Treatment
• Liver injury – 4 Ps: Push, Pringle's maneuver (direct compression of portal triad to stop bleeding), Plug, Pack
• In children most splenic injury can be managed non-operatively
SPLENIC RUPTURE
• Occurs from direct blunt trauma
• Spontaneous rupture occurs in malaria and infectious mononucleosis

Clinical features
• Ballance's sign – dullness in the left flank which does not shift as the blood gets clotted
• Kehr's sign – clot collected under the left diaphragm irritates phrenic N and cause referred pain in left
shoulder
• Saegesser's tender point – between left sternomastoid and scalenus medius
• Latent period of Bandet – formation of subcapsular hematoma which is initially localized by greater
omentum, later giving rise to torrential bleeding

Plain X-ray abdomen

• Obliteration of splenic outline
• Obliteration of psoas shadow(most important feature)
• Indentation of fundic gas shadow
• Elevation of left side of diaphragm
• Free fluid in the abdomen between coils of intestine

Treatment
• Non operative management – in children; isolated spleen injuries; non expanding subcapsular and
intraparenchymal hematoma
• Splenorrhaphy – in clean incised wound over the surface
• Emergency splenectomy – for hilar injuries, unstable patient, multiple peritoneal sites of bleeding

Liver injuries
• Subcapsular hematoma – evacuation
• Temporary control of bleeding in severe lacerations is obtained by compression of portal vein and hepatic
artery in the gastrohepatic omentum in front of foramen of Winslow – Pringle manoeuvre
• If bleeding continues – hepatic veins are the source of bleeding

Pancreatic injuries
• More common in penetrating than blunt trauma
• Children: blunt injury more common
• Adults: penetrating injury more common
• Penetrating injury – head, body and tail are equally involved
• Blunt injury – body (or neck) is most commonly involved
• Management of pancreatic trauma is determined by

Site of parenchymal damage and

Integrity of intrapancreatic common bile duct and main pancreatic duct
• Non operative management or Closed suction drainage

Pancreatic contusions (ductal system intact)

Proximal pancreatic injuries (right of the superior mesenteric vessels)
• Distal pancreatic injuries are managed based upon ductal integrity.
• Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation

ABDOMINAL COMPARTENT SYNDROME (ACS) and INTRA-ABDOMINAL HYPERTENSION

• Normal intra-abdominal pressure: 5-7 mmHg.
 • Intra-abdominal hypertension: > 12 mmHg
• Abdominal compartment syndrome: intra-abdominal pressure > 20 mmHg associated with new organ
dysfunction or failure

Treatment:
• Supine positioning
• Judicious crystalloid resuscitation
• Drainage of intraabdominal fluid collections (paracentesis)
• Escharatomy in burns patients
• Sedation and pain control
• Ventilatory support and chemical paralysis to maximize abdominal wall relaxation
• If all the above fails – decompressive laparotomy (abdominal wall opened and fascia left open)

SYNERGISTIC SPREADING GANGRENE

• Synonym: subdermal gangrene, necrotising fasciitis
• Not caused by clostridia.
• Caused by mixed pattern of organisms: Streptoccoccus pyogenies, Staphylococci, Bacteroides spp, anaerobic
streptococci
• Abdominal wall infections are known as Meleney's synergistic hospital gangrene
• Scrotal infection - Fournier's gangrene
• Patients are almost always immunocompromised
• Untreated, it will lead to widespread gangrene and multiple system organ failure
• The subdermal spread of gangrene is always much more extensive than appears from initial examination.
• Broad-spectrum antibiotic therapy must be combined with aggressive circulatory support.
• Locally, there should be wide excision of necrotic tissue and laying open of affected areas

ABDOMINAL INCISIONS
1. Kocher: biliary or hepatic procedures
2. Midline: general access;
3. McBurney (Grid Iron): appendicectomy; muscle layers are split
rather than cut
4. Battle: appendicectomy (not used now)
5. Lanz: appendicectomy; better cosmetic result than McBurney
6. Paramedian: general access
7. Transverse: general access; almost always used in infants and
adults
8. Rutherford Morison: access to sigmoid colon and pelvis,
particularly if the midline is very scarred from previous surgery
9. Pfannenstiel: access to bladder, uterus, Fallopian tubes and
ovaries
10. McEvedy incision: not used now

 Splenenculi: single or multiple accessory spleens

 Most common site of location of accessory spleen – hilum of spleen
 Hemangioma is the most common benign tumor of the spleen
 Lymphoma is the most common cause of neoplastic enlargement of spleen
 V. LIVER, BILIARY TRACT & PANCREAS
LIVER
Imaging modality Principle indication
USG Standard first line investigation
CT (triple phase, Gold standard for liver imaging; Anatomical planning for liver surgery
multislice, spiral) The early arterial phase of contrast - detects small liver cancers
Inflammatory lesions exhibit rim enhancement
Hemangioma shows characteristic late venous enhancement
MRCP Noninvasive imaging of biliary tract
When ERCP has failed or impossible due to previous surgery
ERCP Imaging the biliary tract when endoscopic intervention is needed (endoscopic
removal of CBD stones or insertion of a palliative biliary tract stent)
PTC Biliary tract imaging when ERCP is impossible of failed
In patients with previous pancreaticoduodenectomy or Polya II gastrectomy
High strictures in CBD
Klatskin tumor
MRI or Sulphur colloid MRI using liver-specific contrast agents (gadoxetic acid - taken up by hepatocytes
liver scan or superparamagnetic iron oxide - taken up by Kupffer cells)
Sulphur colloid liver scan - Kupffer cells take up the colloid
Laparoscopic USG To detect superficial peritoneal metastasis and superficial liver metastasis
• Cholecystogram is used to study the function of gall bladder

BILIARY ATRESIA
• Extrahepatic bile ducts are occluded causing obstructive jaundice (conjugated hyper-bilirubinaemia)
• Progressive liver fibrosis in early infancy.
• It should be considered if jaundice persists after 2 weeks of age.
• Fat malabsorption can lead to a coagulopathy correctable with vitamin K.
• Abdominal USG - shows a small gall bladder and no visible bile ducts a
• Biliary radionuclide scan - shows no excretion.
• Liver biopsy - shows proliferation of small bile ducts.
• Treatment: Kasai porto-enterostomy
• Effective drainage is more likely with surgery before 8 weeks of age and may obviate the subsequent need
for liver transplantation.

PYOGENIC LIVER ABSCESS

• The most common organisms are Streptococcus milleri and E coli (BAILEY)
• Anaerobic organisms: 40% to 60%. Most common organisms cultured - E coli and Klebsiella pneumoniae
(SABISTON)
• The most common infecting agents are gram-negative bacteria; Escherichia coli is found in 2/3rd cases
(SCHWARTZ)
• Most hepatic abscesses involve the right hemiliver

Predisposing factors
• Infections from the biliary tree are the most common identifiable cause (ascending suppurative cholangitis) -
Intrahepatic stones, Caroli's disease, Biliary ascariasis, Biliary tract surgery
• Ascending portal vein infection (pyelophlebitis) – diverticulitis, appendicitis, pancreatitis, inflammatory
bowel disease, pelvic inflammatory disease, perforated viscus, omphalitis, colorectal malignancy
• Via hepatic artery: endocarditis, pneumonia, osteomyelitis
 • Direct extension - suppurative cholecystitis, subphrenic abscess, perinephric abscess
• Treatment: IV Antibiotics and USG guided aspiration

RECURRENT PYOGENIC CHOLANGITIS

• Syn: Oriental cholangiohepatitis or hepatolithiasis
• Men and women are equally affected
• Affects at early age (20 to 40 years) and patients from lower socioeconomic classes
• Association with Clonorchis sinensis and Ascaris lumbricoides infection has been noted
• Repeated attacks of cholangitis secondary to biliary stones and strictures
• The stones are bilirubinate stones
• Fever, right upper quadrant abdominal pain, and jaundice
• Biliary obstruction is usually incomplete and therefore marked jaundice and pruritus are not common.
• Abnormal LFT
• Treatment of acute cases: percutaneous transhepatic cholangioscopic lithotomy (PTCSL)
• Definite treatment: surgery

PORTAL HYPERTENSION
• Sustained elevation of portal pressure > 5 mmHg
Pre hepatic Hepatic
• Splenic/portal vein thrombosis Pre-sinusoidal
• Periportal inflammation • Schistosomiasis
• Trauma • Congenital hepatic fibrosis
• Extrinsic compression from pancreas, stomach • Sarcoidosis
• Neonatal umbilical sepsis • Vinyl chloride
• Massive splenomegaly (Banti syndrome) Sinusoidal
Post hepatic • Cirrhosis
• Budd-Chiari syndrome • Alcoholic hepatitis
• IVC webs • Primary biliary cirrhosis
• Constrictive pericarditis • Nodular regenerative hyperplasia
• Congestive cardiac failure • Wilson's disease
• Restrictive cardiomyopathy • Hemochromatosis
• Metastasis
Post sinusoidal : Veno-occlusive disease

Sites of Porta-Systemic collateralization

• Lower end of esophagus: between left gastric and short gastric veins with azygos veins
• Umbilicus: paraumbilical vein with anterior abdominal veins
• Lower end of rectum: superior hemorrhoidal vein with middle and inferior hemorrhoidal veins
• Retroperitoneum (vein of Retzius)
• Bare area of liver

Left sided/Segmental/Sinistral portal HT

• Due to splenic vein thrombosis
• Liver normal
• Treatment: splenectomy

BUDD-CHIARI SYNDROME
• Young females
 • Venous drainage of the liver is occluded by hepatic venous thrombosis or a venous web
• Underlying disorders

Myeloproliferative disorders (Essential thrombocytosis or Polycythemia rubra vera) — 75%

Protein C or protein S deficiency or anti-thrombin C deficiency

Factor V Leiden mutation

Paroxysmal nocturnal hemoglobinuria

Chronic inflammatory diseases (Bechet's disease, Inflammatory bowel disease, Sarcoidosis, SLE)

Antiphospholipid antibody syndrome

Hyperhomocysteinemia

Oral contraceptive pills, Pregnancy and postpartum

Neoplastic encroachment of hepatic veins

Infections: amoebic and pyogenic liver abscess, aspergillosis, hydatid cysts, tuberculosis, syphilis

Constrictive pericarditis, right sided heart failure, Inferior vena cava webs

TPN
• Diagnosis suspected when CT shows a large congested liver
• Hepatic venography via transjugular approach confirms the diagnosis
• Patients presenting with acute fulminant liver failure, established cirrhosis, complications of portal
hypertension: liver transplantation is the treatment
• If cirrhosis is not established: TIPSS, portocaval shunt or mesoatrial shunt
• Patients usually need lifelong warfarin therapy

HEPATOCELLULAR CARCINOMA
• More than 85% of cases occur in countries with high rates of chronic HBV infection.
• Highest incidences of HCC are found in Asian countries (southeast China, Korea, Taiwan) and sub-Saharan
African countries
• In these areas, peak incidence is between 20 – 40 years and in 50% of cases, the tumor appears in the
absence of cirrhosis
• In Western countries, peak incidence > 60 years, and in 90% of cases, malignancy emerges after cirrhosis
becomes established
• Chronic liver diseases are the most common setting for emergence of HCC

Common/Major causes Unusual causes

• Chronic HBV or HCV • Primary biliary cirrhosis
• Chronic alcoholism • Hemochromatosis
• Non-alcoholic steatohepatitis • α 1- antitrypsin deficiency
• Aflatoxin B1 • Citrullinemia
• Metabolic syndrome • Glycogen storage diseases
Tyrosinemia (rare disease, but most • Porphyria cutanea tarda
likely gives rise to HCC) • Wilson's disease
Most common early mutational events Precursor lesions
• Activation of β-catenin • Hepatocellular adnenoma
• Inactivation of p53 • Small cell change – directly premalignant
• Large cell change – premalignant in Hepatitis B
• Dysplastic nodule

Morphology
• Cirrhosis is not required for hepatocarcinogenesis
• HCC has a strong propensity to invade vascular channels
 • Hematogenous spread most commonly to lungs
• Cholangiocarcinomas are rarely bile stained

Clinical features
• Abdominal pain is the most common symptom
• Hepatomegaly is the most common physical sign

Paraneoplastic syndromes associated with HCC

• Hypoglycemia
• Erythrocytosis
• Hypercalcemia
• Hypercholesterolemia
• Dysfibrinogenemia
• Carcinoid syndrome
• Increased thyroxin-binding globulin
• Changes in secondary sex characteristics (gynecomastia, testicular atrophy, and precocisous puberty)

Investigations
• ↑ levels of serum α-fetoprotein(AFP) (> 100 IU) seen in 50-75% cases but fails to detect small lesions
• AFP is a clinically useful marker for follow-up
• Des-y-carboxy prothrombin (DCP), a protein induced by vitamin K absence (PIVKA-2)is ↑ in 80% of HCC
patients but may also be elevated in vitamin K deficiency; always elevated after Coumadin use
• Recently staining for Glypican-3 has been used to distinguish early HCC from dysplastic nodules
• Screening – USG
• To determine tumor size and extent of portal vein invasion – Helical/Triphasic CT abdomen

Staging systems
• TNM system – not routinely followed
• Okuda system – older, simple
• Cancer of the Liver Italian Program (CLIP) – most well-validated

Treatment
• Small tumors < 2cm can be removed surgically with 1-2cm margin of unaffected liver tissue
• Extensive resections in patients with advanced cirrhosis carries high mortality due to post-op liver failure
• Extensive resections for HCC in a non-cirrhotic liver are associated with low risk of liver failure (removal of
80% of liver is compatible with life)
• Non-surgical therapy: transarterial embolization (TAE) transarterial chemoembolization (TACE)
percutaneous ethanol ablation (PEA) or radiofrequency ablation (RFA)
• Regional chemotherapy or TACE: doxorubicin and cisplatin are used along with an embolizing agent
ethiodol
• Kinase inhibitor sorafenib can prolong life in advanced stage HCC
• Bevacizumab plus Erlotinib is also effective in prolonging survival
• Radiotherapy with pure beta emitting 90Yttrium microspheres has shown encouraging results

FIBROLAMELLAR CARCINOMA
• A variant of hepatocellular carcinoma
• Young males and females (20-40yrs)
• Not associated with cirrhosis or HBV
 • Presents with large, hard scirrhous tumor with fibrous bands coursing through it
• Encapsulated
• Alpha fetoprotein not elevated
• Better prognosis

CHOLANGIOCARCINOMA
• Mucin producing adenocarcinomas that arise from bile ducts
• Types: intrahepatic, hilar or central (65%) and peripheral (30%)
• Nodular tumors arising at the bifurcation of the common bile duct are called Klatskin tumors and are often
associated with a collapsed gallbladder

Predisposing factors
• Primary sclerosing cholangitis
• Hepatolithiasis
• Fibropolycystic liver disease
• Caroli disease (bile duct ectasia)
• Alcoholic liver disease
• Choledochal cyst
• Choledocholithiasis
• HBV, HCV infection
• Thorotrast exposure(formerly used in radiography of biliary tree)
• Opisthorchis viverrini and Clonorchis sinensis infestation

Premalignant lesions
• Biliary intraepithelial neoplasia (BiIIN 1, 2,3)
• Mucinous Cystic Neoplasm
• Intraductal Papillary Biliary Neoplasia

Clinical features, diagnosis and treatment

• Typically presents with painless jaundice often with pruritis and weight loss
• CEA, CA 19-9, and CA-125 are often elevated in CCC patients and are useful for following response to therapy

LIVER METASTASES
• Surgery in the treatment of colorectal liver metastases is now well established
• The resectability rate for liver metastases from colorectal cancer is 20-30 per cent
• The role of resection of liver metastases from other primary sites has not been well defined

Caroli's disease
• Congenital, multiple, irregular dilatations of intrahepatic ducts with stenotic segments in between
• Complications: intrahepatic stone formation, bililary sepsis
• Associated with congenital hepatic fibrosis and medullary sponge kidney
• Premalignant
• Treatment:

First line therapy: biliary drainage with ERCP and PTC

Diffuse: Liver transplantation

Localized: Segmental resection
Chylous ascites
• Filariasis
• Tuberculosis
• Malignancy/Trauma of thoracic duct
• Thrombosis of subclavian vein

Ascites
• Shunts used: Le Veen shunt (peritoneal cavity to Internal jugular vein) and Denver shunt
• Diuretic resistant ascites is an indication for liver transplantation
Child's classification of he atocellular function in cirrhosis
Group A B C
Bilirubin (mg/dl) <2 2–3 >3
Albumin (g/dl) > 3.5 3 – 3.5 <3
Ascites None Easily controlled Poorly controlled
Neurological disorder None Minimal Advanced
Nutrition Excellent Good Wasting

Alpha-fetoprotein is increased in
• Hepatocellular carcinoma
• Cirrhosis
• Massive liver necrosis (with compensatory liver cell regeneration)
• Chronic hepatitis
• Normal pregnancy
• Yolk sac tumors
• Fetal distress or death
• Fetal neural tube defects(anencephaly and spina bifida)

LIVER TRANSPLANTATION
• Split liver transplantation: liver of deceased donor split into two (right lobe for an adult and left lobe is
usually used for a child)
• In adult-to-adult living donor liver transplantation, the right lobe of the liver is usually transplanted

Indications for liver transplantation

Cirrhosis (Most common Acute fulminant liver Metabolic liver Primary hepatic
indication) failure disease malignancy
• Adults • Viral • Wilson's disease • Viral induced

Alcoholic liver disease • Drug induced • Oxalosis cirrhosis

Viral hepatitis B and C • (paracetamol) • α-1-antitrypsin

Primary biliary cirrhosis deficiency

Sclerosing cholangitis
• Children: Biliary atresia
 Cholangiocarcinoma has a high recurrence rate and is not an indication for transplantation
 Other important contraindications: liver metastases, AIDS

Outcome after liver transplantation

• Best results following chronic liver disease
• Following acute liver failure

High mortality in the early post-transplant period because of multi-organ failure

Those who recover have a very good long term allograft survival
 • Following tumor: very good early outcome, but recurrence later
• Following viral hepatitis B or C: graft failure, but now it has decreased due to improved anti-viral therapy

King's college criteria for orthotopic liver transplantation in acute liver failure
Paracetamol induced Non-paracetamol induced
• pH < 7.30 irrespective of grade of • PT > 100 s OR any three of the following
encephalopathy OR • PT > 50 s
• Prothrombin time(PT) > 100 s • Age < 10 years or > 40 years
+ • Etiology: non-A, non-B, halothane or idiosyncratic drug reaction
• Serum creatinine > 300μmol/L • More than 7 days jaundice before encephalopathy
• Bilirubin > 300μmol/L

Transplantation Surgeon
Kidney Murray (1954)
Liver Starzl (1963)
Pancreas (Whole organ) Lillehei and Kelly (1966)
Heart Bernard (1967)
Lung Derom (1968)
Pancreatic Islets Sutherland and Najarin (1974)
Heart-Lung Reitz and Shumway (1981)

GALL BLADDER

BILIARY TRACT INVESTIGATIONS

Plain X-ray • Shows radio-opaque stones in 10% of patients with gallstones
• The centre of the stone may contain radiolucent gas in a triradiate or biradiate fissure
• Mercedes-Benz or Seagull sign
USG • Initial imaging modality of choice
• Can demonstrate – biliary calculi, size of the gall bladder, thickness of the gall bladder
wall, presence of inflammation around the gall bladder, size of the CBD
• Occasionally presence of stones in CBD and ca of pancreas occluding the CBD is seen
• Particularly helpful in patients with obstructive jaundice as it identifies intra and
extra-hepatic biliary dilatation and the level of obstruction
Endoscopic USG • Stones within the bile ducts(choledocholithiasis)
• Highly accurate in diagnosing and staging pancreatic and periampullary cancers
Radioisotope • To assess the function of the biliary tract
scanning • Non-visualization of gall bladder – acute cholecystitis
• Reduced/delayed visualization – chronic cholecystitis(contracted gall bladder)
• For diagnosing bile leaks and iatrogenic biliary obstruction
• Suspicion of bile leak following cholecystectomy – radioisotope scanning performed
CT • Modality of choice in staging cancers of the liver, gall bladder, bile ducts, pancreas
ERCP • Widely used
• Excellent images of ductal anatomy
• Identifies the cause and level of obstruction (stones or strictures)
• ERCP is the gold standard investigation for diagnosis of stones in the CBD and biliary
tree as it also provides therapeutic options (stone removal or stent placement)
PTC • In a jaundiced patient, if a malignant stricture at the level of the confluence of the right
and left hepatic ducts or higher is suspected, PTC is preferred to an ERCP

Indications of ERCP Relative Contraindications Therapeutic uses

• Malignancy – irregular filling defect • Acute pancreatitis • Extraction of stone from
• Chronic pancreatitis – chain of lakes • Previous gastrectomy biliary tract
appearance Complications • Nasobiliary drainage
• Congenital anomalies • Pancreatitis • Stenting of tumor in CBD or
• Stones in CBD • Duodenal injury pancreas
• Stricture of biliary tree • Cholangitis • Dilation of the biliary stricture
• Choledochal cyst • Bleeding • Endoscopic papillotomy
• Sampling of biliary and pancreatic
juices for analysis and cytology
• Brush biopsy from tumor site

GALL STONES (CHOLELITHIASIS)

Pathogenesis of cholesterol stones
Lithogenic bile Stasis
• Normal ratio of bile acids : cholesterol = 25:1 • Prolonged TPN
critical ratio < 13 : 1 • Fasting
Increased cholesterol • Pregnancy
Decreased bile salts • Drugs- octreotide, estrogen therapy
Decreased entero hepatic circulation • Burns
• Vagotomy

 When the bile is supersaturated with cholesterol or bile concentrations low, unstable unilamellar Beni
phospholipid vesicles form, from which cholesterol crystals may nucleate and stones may form
 Nucleation of cholesterol monohydrate crystals from multilamellar vesicles is a crucial step

Predisposing factors
Cholesterol stones
• Old age • Gall bladder hypomotility (TPN, fasting,
• Female sex, pregnancy pregnancy, octreotide)
• Obesity, Hyperlipidemia • Diabetes mellitus
• Rapid weight reduction • Spinal cord injury
• Drugs: OCPs, Estrogen, Clofibrate, Cholestyramine • High calorie diet, High fat diet

Pigment stones
Black pigment Brown pigment
• Insoluble bilirubin with calcium phosphate and • Calcium bilirubinate, calcium palmitate,
calcium bicarbonate calcium stearate and cholesterol
• Usually in sterile GB • Formed in biliary tree
• Small, multiple and hard • Commonly due to infection (MC-E.coli)
• Haemolytic states – hereditary spherocytosis, • Presence of stents
sickle cell disease, thalassemia, malaria • Parasites (Ascaris lumbricoides and Clonorchis
• Mechanical heart valves sinensis)
 Cirrhosis patients have a higher incidence of pigment stones
Clinical features
• 5 Fs: Flat, Fertile, Flatulent, Female, Forty
• Biliary colic with periodicity, severe within hours after meal (commonest presentation)
• Dyspepsia is a common symptom
• Cholesterol stones are mostly radio-lucent
• Pigment stones are mostly radio opaque
• No resolution of symptoms, fever and leucocytosis  Acute cholecystitis
• Centre of the stone may contain radiolucent gas which is either triradiate (Mercedes Benz sign) or biradiate
(Seagull sign)
• GB may be filled with toothpaste like material(calcium carbonate + phosphate) – limey gall bladder
• Bouveret's syndrome or gallstone ileus- a large stone may erode directly into an adjacent loop of small
bowel causing intestinal obstruction

Management
• Investigation of choice – USG
• Prophylactic cholecystectomy can be considered in

Diabetic patients

Congenital haemolytic anemia

Patients undergoing Bariatric surgery
• Conservative treatment followed by cholecystectomy (90% cases respond to conservative treatment)
• Conservative treatment abandoned if the pain and tenderness increase
• For patients with serious comorbid conditions not responding to conservative treatment – percutaneous
cholecystostomy is performed under USG control, which will rapidly relieve the symptoms. A subsequent
cholecystectomy is usually required
• If an early operation is not indicated one should wait approximately 6 weeks for the inflammation to subside
• Surgery: lap cholecystectomy or open cholecystectomy through right subcostal Kocher's incision

CHOLEDOCHOLITHIASIS or COMMON BILE DUCT STONES

• Secondary stones (formed within the gallbladder and migrate down the cystic duct) are usually cholesterol
stones
• Primary stones (formed in the bile ducts) are usually brown pigment stones
• USG: dilated common bile duct (?8 mm in diameter) in a patient with gallstones, jaundice, and biliary pain is
highly suggestive of common bile duct stones
• ERCP (gold standard): highly sensitive and specific for choledocholithiasis and can usually be therapeutic by
clearing the duct of all stones in 75% of patients during the first procedure and 90% with repeat ERCP
• MRCP is more sensitive and specific but no therapeutic option

Retained common bile duct stones

• When found within 2 years following cholecystectomy
• Best treated by ERCP

Courvoisier's law
• When a common bile duct is obstructed by a stone; gall bladder will not be palpable (chronic inflammation)
• If the CBD is obstructed in some other way(neoplasm); gall bladder will be distended and palpable

Mucocele of the gall bladder

• Due to obstruction of cystic duct by a stone in the Hartmann's pouch
• Resultin in reabsorption of the intraluminal bile salts and secretion of mucus and distension of gall bladder
 • Non-tender palpable gall bladder
• Dyspepsia
• Treatment-early cholecystectomy

Mirrizi syndrome
• Gallstone impacts in the wall causing pressure necrosis which further gets adherent to the CBD wall
• Occasionally leads to a cholecystocholedochal fistula
• Cholecystectomy; on table cholangiogram and exploration of CBD. Often needs choledochojejunostomy

 Cholecystoces: chronic inflammatory condition of the gall bladder with cholesterol deposits

ACUTE CHOLECYSTITIS
• Commonly in patients with pre-existing chronic cholecystitis but can even occur as the 1st presentation
• E.coli (mcc), Klebsiella, S.faecalis, Salmonella, Clostridium welchii

Clinical features
• Sudden onset of pain in right hypochondrium with tenderness, guarding and rigidity
• Murphy's Sign – right upper quadrant tenderness that is exacerbated during inspiration by the examiner's
right subcostal palpation
• Palpable, tender, smooth, soft gallbladder
• Boas's Sign - Area of hyperesthesia b/w 9th and 11th ribs posteriorly on the right side (definite sign)

Investigation
• USG - gold standard
• X-Ray - reveals stone in 10% of cases, gas may be seen in emphysematous GB
• Biliary radionuclide scan – no filling after 4 hrs indicates an obstructed cystic duct
• HIDA/PIPIDA scan: non visualization of GB is diagnostic

Treatment
• Initially conservative: NG aspiration, IV fluids, analgesics, antibiotics
• After 3-6 weeks elective Cholecystectomy
• Emergency cholecystectomy or Cholecystostomy

Empyema GB

Emphysematous cholecystitis

D. Perforation

Persistence and progression of symptoms

Elderly patients

Emphysematous cholecystitis Acalculus cholecystitis

• Elderly males • Highest mortality
• Diabetic and immunocompromised • Most commonly missed diagnosis
• Organism: Clostridium welchii • Particularly seen
• Gas in gall bladder
Older age
• Life threatening sepsis
Critically ill patietns
• Gangrene, perforation and peritonitis common
Burns
• Broad spectrum IVantibiotics
Trauma
• Emergency cholecystectomy needed
Prolonged TPN

Diabetes

Immunosuppression

Major surgery (coronary artery bypass)

CHOLEDOCHAL CYSTS
• Congenital dilatation of intra and/or extra-hepatic biliary system'
• Often associated with pancreatico biliary maljunction reflux of pancreatic juice into the bile duct 
enzymatic destruction of bile duct [Babbit's theory].

Types: [Todani classification]

• Type-I: fusiform dilatation of the CBD (commonest)
• Type-II: lateral saccular diverticulum of the CBD
• Type-Ill: dilatation of the intraduodenal segment of the CBD[Choledochocele]
• Type-IV: dilatation of CBD + intrahepatic biliary dilatation
• Type-V: multiple intrahepatic cysts (Caroli's disease)

Clinical features
• Jaundice, fever, abdominal pain and right upper quadrant mass on examination
• Pancreatitis is common in adults
• Increased risk of cholangiocarcinoma

Diagnosis
• USG abdomen will confirm the presence of an abnormal cyst
• MRI/MRCP will reveal the anatomy
• CT for delineating the extent of intra/Extrahepatic dilatation
Treatment of choice: Surgical excision and reconstruction

Postoperative T-tube cholangiogram

• For choledocholithiasis, after cholecystectomy, on table cholangiogram is done through cystic duct to see
any stones in the CBD
• The Choledochotomy is done to remove stones in CBD
• After choledochotomy, Kehr's T-tube is placed in the CBD for 14 days
• Then a postoperative T-tube cholangiogram is done to see for free flow or dye into the duodenum
• Then the T-tube can be removed safely

GALL BLADDER CARCINOMA

• More common in Females
• Mostly in the 7th decade of life

Risk factors
• Gall stones – most important risk factor (↑size and duration, ↑ risk)
• Porcelain Gall Bladder
• Choledochal cyst
• Chronic typhoid carriers
• Cholecystoses
• Cholesterosis of gall bladder (strawberry GB)

Clinical features
• Nonspecific – indistinguishable from benign gall bladder disease like biliary colic or cholecystitis
 • Jaundice(less common), significant weight loss in short duration
• CA 19-9 is elevated in 80%; CEA is also elevated in few cases
• Diagnosis confirmed by multidetector row CT scan

Types
• Adenocarcinoma is the me type (90%)
• The tumor is most commonly nodular and infiltrative, with thickening of the gall bladder wall

Nevin's staging
I Intramural
II Spread to muscularis
III Spread to serosa
IV Spread to cystic lymph node of Lund (the sentinel node)
V Direct spread to adjacent organs/Distant metastases

Treatment
• Stage I and II - simple cholecystectomy
• Stage III – cholecystectomy + adjacent hepatic resection (atleast 2cm depth) + regional lymphadenectomy
• Poor prognosis

BILE DUCT INJURIES

• Cholecystectomy (Lap cholecystectomy associated with higher % of injuries) [lap cholecystectomy – upper
3rd injured, open cholecystectomy – middle 3rd injured]
• Instrumentation(ERCP, Choledoscope)
• Anatomical variations
• Surgeons inexperience
• Local pathology: Acute inflammation, Shrunken gall bladder, Mirrizi syndrome, Moynihans hump

Clinical features:
• Presenting with abdominal pain, distension, cholangitis, sepsis, ileus, jaundice, excessive bile from drain -
think of bile duct injury

Investigations:
• USG- first investigation to confirm
• CT SCAN- more sensitive in confirming leaks and collections
• Biliary Scintigraphy- diagnosis leak but not the site
• ERCP- diagnosis leak but not delineates intrahepatic ductal anatomy in presence of CBD or hepatic duct
disruption
• MRCP - best to decide therapeutic approach

Management:
• Early repair not attempted. only drainage procedures carried out
• Ideal time of repair is 8 to 12 weeks to allow inflammation to subside
• Roux-en-Y -hepatico-jejunostomy

White bile
• Neither white, nor bile
• Mucus secreted by the lining of biliary tree
 • Indicates severe obstruction due to impacted stone in CBD or periampullar ca or ca head of pancreas
• On table diagnosis

PANCREAS

 Most common congenital anomaly of pancreas – Pancreas divisum

 Most common site of ectopic pancreas – stomach and duodenum

ANNULAR PANCREAS
• Due to failure of complete rotation of the ventral pancreatic bud during development, so that a ring of
pancreatic tissue surrounds the second or third part of the duodenum.
• Most often seen in association with congenital duodenal stenosis or atresia
• More prevalent in children with Down's syndrome
• Duodenal obstruction typically causes vomiting in the neonate
• The usual treatment is bypass (duodenoduodenostomy)
• The disease may occur in later life as one of the causes of pancreatitis, in which case resection of the head
of the pancreas is preferable to lesser procedures

ACUTE PANCREATITIS
• Premature activation of pancreatic enzymes within the pancreas, leading to a process of auto digestion

Drugs Recurrent acute pancreatitis Uncommon causes

without obvious etiology
• Steroids • Occult disease of the biliary • Hyperparathyroidism
• Azathioprine tree or pancreatic ducts, • Hypercalcemia
• Valproate especially microlithiasis, • Deficiency of apolipoprotein CII
• Estrogens sludge • Hereditary pancreatitis
• L-Asparaginase • Drugs
Mutations in cationic trypsinogen gene
• 6-mercaptopurine • Hypertriglyceridemia
Suffer acute pancreatitis in their teens,
• Sulfonamides • Pancreas divisum chronic pancreatitis in the next two
• Tetracycline • Pancreatic cancer decades
• Anti-retroviral • Sphincter of Oddi
40% risk of pancreatic carcinoma at 70
agents dysfunction years of age
• Thiazide diuretics • Cystic fibrosis

• Most common cause of Acute pancreatitis – Gall stones (50-70%)

• Second most common cause – Alcohol (25%)
• Acute Pancreatitis - is the most common complication after ERCP
• Most common causes in children: blunt abdominal injuries, multisystem disease (hemolytic uremic
syndrome and inflammatory bowel disease) biliary stones or microlithiasis (sludging), and drug toxicity

Assessment of severit
RANSON score GLASGOW scale
On admission On admission
• Age > 55 years • Age > 55 years
• Blood sugar> 200 mg%(10mmol/L) • Blood sugar > 200 mg%(no h/o diabetes)
• WBC count > 16000/mm3 • WBC count > 15000/mm3
• LDH > 700 Units/L • Serum urea > 16 mmol/L (no response to IV
• AST > 250 IU/L fluids)
• Arterial oxygen saturation (PaO2) < 60mmHg
 Within 48 hours • Serum calcium < 2 mmol/L
• Base deficit > 4 mmol/L • Serum albumin < 32 g/L
• Serum calcium < 2 mmol/L • LDH > 600 Units/L
• Arterial oxygen saturation(PaO2) < 60mmHg • AST/ALT > 600 IU/L
• Fluid sequestration > 6 L
• BUN rise > 5mg%

 In both systems, disease classified as severe if 3 or more factors are present

 Hypocalcemia is the worst prognostic indicator
 Patients with BMI > 30 are at a higher risk of developing complications
 Hematocrit >44% is also a marker of severe pancreatitis

Clinical features
• Acute severe, refractory, upper abdominal pain radiating to back
• Some patients may gain relief by sitting or leaning forwards
• Icterus can be caused by biliary obstruction in gallstone pancreatitis
• Grey turner's sign – bluish discolouration of the flanks
• Cullen's sign – bluish discoloration around umbilicus
• Fox sign – discoloration below inguinal ligament
• Shock, acute renal failure, ARDS, MODS
• Left sided pleural effusion

Investigations
• Diagnosis is made on the basis of clinical symptoms and raised serum amylase levels

Plain X-ray shows
o Sentinel loop
o Colon cut off sign
o Renal halo sign
o Obliteration of psoas shadow
o Localized ground glass appearance
• Serum amylase levels rise immediately and are commonly used but lacks specificity
• Serum lipase levels are more specific than serum amylase
• After three to seven days, even with continuing evidence of pancreatitis, total serum amylase values tend to
return toward normal.
• However, pancreatic isoamylase and lipase levels may remain elevated for 7 to 14 days.
• Serum lactescence (related to triglyceride metabolism) is most specific
• Serum trypsin is an accurate indicator but not commonly used
• Contrast enhanced CT is the gold standard investigation

But not necessary in all patients

When diagnosis is uncertain

When clinical deterioration or signs of sepsis or organ failure

Treatment
• Mainly conservative - fluid resuscitation, analgesics, antibiotics and anti-emetics
• No role for TPN (to rest the pancreas); for nutritional support – enteral (nasogastric) feeding
• In patients with severe acute gall stone pancreatitis and signs of ongoing biliary obstruction and cholangitis,
an urgent ERCP should be performed
• In patients with cholangitis – sphincterotomy or a biliary stent
 • Indications for surgery: deterioration despite conservative therapy, pancreatic abscess/necrosis

Complications of acute pancreatitis

Systemic – more common in the first week Local – usually develop after first week
• Cardiovascular: shock, arrhythmias • Acute fluid collection
• ARDS • Sterile pancreatic necrosis
• Renal failure • Infected pancreatic necrosis
• DIC • Pancreatic abscess
• Metabolic: hypocalcemia, hyperglycemia, • Pancreatic ascites
• hyperlipidemia • Pseudocyst
• Ileus • Pleural effusion
• CNS: visual disturbances, encephalopathy • Portal/splenic vein thrombosis
• Subcutaneous fat necrosis • Pseudoaneurysm (mc-splenic artery)

Sterile and infected pancreatic necrosis

• Sterile necrotic material should not be drained
• If the patient develops signs of sepsis, percutaneous drainage of infected fluid under CT guidance
• If sepsis worsens despite this – pancreatic necrosectomy

Pancreatic abscess
• Percutaneous drainage with widest possible drains under imaging guidance + antibiotics

Pseudocyst
• Acute pancreatitis is the most common cause (90%) followed by trauma (10%)
• Also develops after chronic pancreatitis
• 85% are located in the body or tail
• Collection of amylase-rich fluid enclosed in 'a wall of fibrous or granulation tissue
• Formation requires 4 weeks or more from the onset of acute pancreatitis
• Often single, but multiple cysts may develop
• Fluid from a pseudocyst

Low CEA level (CEA > 400ng/ml is suggestive of mucinous neoplasm)

High amylase level

Cytology reveals inflammatory cells
• Will resolve spontaneously in most instances
• Pseudocysts that are less likely to resolve

Thick walled

Larger (>6cm)

Longer duration (> 6 weeks)

Following chronic pancreatitis
• For pseudocyst causing symptoms:

Preferred: Endoscopic Internal drainage (transgastric or transduodenal)

External

Percutaneous drainage – high recurrence and hence avoided
• Pseudocysts with complications – surgical management

Purtscher's retinopathy
• Unusual complication manifested by a sudden and severe loss of vision in a patient with acute pancreatitis
• Fundus: cotton-wool spots and hemorrhages confined to an area limited by the optic disc and macula
• Believed to be due to occlusion of the posterior retinal artery with aggregated granulocytes
Pancreatic ascites
• Occurs when a disrupted pancreatic duct leads to pancreatic fluid extravasation that does not become
sequestered as a pseudocyst, but drains freely into the peritoneal cavity
• Internal pancreatic fistulae - pancreatic fluid tracks into the thorax, and a pancreatic pleural effusion occurs
• Both complications are seen more with chronic pancreatitis rather than after acute pancreatitis

CHRONIC PANCREATITIS
• High alcohol consumption is the most frequent cause of chronic pancreatitis
• In Autoimmune pancreatitis, IgG4 concentrations are elevated
• Pain (MC symptom), nausea, weight loss are common symptoms
• Loss of exocrine function leads to steatorrhea, fat-soluble vitamin malabsorption
• Jaundice, upper GI bleeding, osteopenia, and osteoporosis
• Diabetes mellitus
• Calcification is seen very well on CT but not on MRI
• ERCP is the most accurate way of elucidating anatomy of the duct and in conjunction with the whole organ
morphology, can help to determine the type of operation required

INSULINOMA
• Most common of all functioning pancreatic endocrine tumors (PET)
• Highest incidence in 4th to 6th decade
• Women are slightly more affected
• All insulinomas are located in the pancreas and tumors are equally distributed
• 90% are solitary and 90% are small ( < 2cm)
• 10% are multiple (always associated with MEN 1) and 10% are malignant

Clinical features: Abdominal discomfort, sweating, hunger, dizziness, diplopia, overeating, and obesity
Whipple's triad
• Symptoms of hypoglycemia after fasting or exercise
• Symptoms of hypoglycemia (blood sugar < 45mg %)
• Immediate relief after I.V. glucose administration

Diagnosis
• A fasting test that lasts for upto 72 hours is the most sensitive test
• Insulin, Proinsulin, C-peptide and blood glucose are measured at 1 to 2 hour intervals to demonstrate high
secretion of insulin in relation to blood glucose
• Continuous C-peptide levels demonstrate the endogenous insulin secretion and exclude factitious
hypoglycemia caused by insulin injection
• Insulin radioimmunoassay

Insulin level > 7 µU/ml

Insulin/glucose ration > 0.3

Increased circulating C-peptide

Proinsulin level >24% of total insulin signifies insulinoma

Proinsulin level >40% of total insulin signifies malignant insulinoma
• For preoperative localization: Endoscopic ultrasound(EUS) has the highest sensitivity

Treatment
• Enucleation is the treatment of choice for benign insulinomas

For superficial tumors: laparoscopic enucleation

Tumors located deep in the body or tail and those in close proximity to pancreatic duct: distal
pancreatectomy
• Diazoxide suppresses insulin secretion and offers good control of hypoglycemia
• Malignant insulinomas: aggressive resection
• When surgery cannot be applied for malignant insulinomas: Chemotherapy (Doxorubicin + Streptozocin)

 Nesidioblastosis: normal pancreatic islets replaced by diffuse hyperplasia of islet cells

GASTRINOMA/ZOLLINGER ELLISON SYNDROME

• Second most common functional pancreatic endocrine tumor (MC – Insulinoma)
• Sporadic gastrinomas (75%)

MC site: duodenum (mostly 1st part; followed by 2nd part; never in 4th part)

Tumors > 3 cm metastasize to liver
• MEN1 associated gastrinomas (25%):

MC site: duodenum

Almost always multifocal

Metastatic to the lymph nodes in 85% at presentation

Do not metastasize to liver
• Most common location (80%) - the gastrinoma triangle (Passaro) formed by connecting lines between

Junction of cystic duct with common bile duct superiorly

The junction of 2nd and 3rd part of duodenum inferiorly

The junction between the neck and body of the pancreas medially
• Most common site in pancreas – head
• Most common pancreatic endocrine syndrome seen in MEN1 patients is gastrinoma (54%), followed by
insulinoma
• Over 60% of gastrinomas are malignant
• Even malignant sporadic gastrinomas have indolent course
• Tumors found outside the triangle have worse prognosis
• More than 50% of gastrin-producing tumors are locally invasive or have already metastasized at the time
of diagnosis
• Gastrin producing tumors are histologically bland and rarely show marked anaplasia

Clinical Features
• Abdominal pain is the most common symptom
• Diarrhea (halted by nasogastric aspiration of gastric secretions is characteristic) & GORD are also common
• Most patients have a typical duodenal ulcer
• Best predictor of survival for patients with gastrinoma is the presence of liver metastases
• LN metastases are not predictive

Factors suggesting gastrinoma

• Ulcer of unusual nature – refractory/resistant to medical therapy
• Unusual number – multiple peptic ulcers
• Unusual recurrence – recurrence after vagotomy/antrectomy
• Unusual sites – jejunum
• Unusual age – young and old
• Severe esophagitis
• Ulcers in the absence of H.pylori infection or NSAID ingestion
• Ulcers associated with prominent gastric folds
Diagnosis
• Normal basal serum gastrin level is <120 pg/ml
• Serum gastrin level in ZES is typically 200 to 1000 pg/ml
• Gastric pH < 2 and fasting serum gastrin > 1000pg/ml – diagnosis of ZES is confirmed
• PPIs have to be discontinued for 1 week before gastrin determination
• Basal acid output is usually >15 mEq/hour
• Secretin test: rise above 200pg/ml over the pretreatment value is diagnostic of ZES

Localization of tumor for preoperative staging

• Somatostatin receptor scintigraphy (SRS) with radio labeled octreotide along with Endoscopic Ultrasound

Treatment
• PPIs are the drugs of choice for acid suppression
• H2 blockers, Somatostatin analogue (octreotide) are also used
• Surgical exploration for all patients without diffuse metastasis
• Pancreatic gastrinomas

Head or uncinate process: Enucleation with peripancreatic lymph node dissection

Body or tail: Enucleation or distal resection
• Duodenal gastrinomas

< 5mm: enucleated with overlying mucosa

Larger tumors: excision with full thickness excision of duodenal wall
• Systemic chemotherapy for diffuse metastatic gastrinomas: Streptozocin + 5-FU or Doxorubicin is the first
line treatment
• For metastatic lesions the following are being tried
• 111in pentetreotide

Radiofrequency or cryoablation of liver lesions

Agents that block the vascular endothelial growth receptor pathway (bevacizumab, sunitinib)

PANCREATIC CARCINOMA
Demographic, environmental risk factors Genetic factors and medical conditions
• Age (65-75 years) • Family history
• Male gender • Hereditary pancreatitis (50-70 fold increased risk)
• Black ethnicity • Chronic pancreatitis (5-15 fold increased risk)
• Smoking • Peutz Jeghers syndrome, Gardner's syndrome
• High fat diet • HNPCC
• Low fibre diet • Ataxia telangiectasia
• Obesity • Familial breast-ovarian cancer syndrome (BRCA1 and
• Occupational exposure to benzidine, BRCA2
DDT • mutations)
Molecular carcinogenesis • Familial atypical multiple-mole melanoma syndrome
• MC mutated oncogenes: KRAS • Familial adenomatous polyposis(Ampullary/duodenal ca)
• MC inactivated tumor suppressor • Li-Fraumeni syndrome
gene: p16/CDKN2A • Cystic fibrosis
• Other tumor suppressor genes • Diabetes mellitus
involved: SMAD4, p53, BRCA2 • Cirrhosis , Hemochromatosis with pancreatic calcification
 • Pancreatic Intraepithelial neoplasias (PanINs) are precursor lesions
• Most common type – Ductal adenocarcinoma
• Most common site – head of the Pancreas
• Serous cystadenomas – benign, seen in older women
• Mucinous tumors – malignant potential
• Mucinous cystic Neoplasms (MPN)

Perimenopausal women

Body and tail

Histologically contain ovarian type stroma

Malignant potential
• Intraductal papillary mucinous neoplasms (IPMNs)

Older men

Pancreatic head
• Ductal adenocarcinoma infiltrate locally, typically along nerve sheaths, along lymphatics and into blood
vessels

Symptoms
• Jaundice due to obstruction is the most common symptom that draws attention in ampullary and
pancreatic head tumors
• Ampullary carcinoma present early with biliary obstruction, relatively small at diagnosis – better prognosis
• Pruritis, dark urine and pale stools with steatorrhea
• Back pain indicates retroperitoneal infiltration
• Migratory thrombophlebitis (Trousseau's syndrome)

Carcinoma head of pancreas Periampullary carcinoma

• Pain and weight loss are early features • Pain and weight loss are late features
• Persistent and progressive jaundice • Intermittent jaundice
• No occult blood in stools • Occult blood in stools, silvery stools
• Growth not visible on endoscopy • Growth visible on endoscopy
• Prognosis bad • Better prognosis

Investigations
• Pancreatic head tumors: contrast enhanced CT
• Endoscopic ultrasound

If CT fails to detect a tumor

If tissue diagnosis is required prior to surgery

If vascular invasion needs to be confirmed

To distinguish between a pseudocyst and cystic tumors
• CA 19-9 is elevated in 80% tumors; pretreatment level has a prognostic value
• Small ampullary lesions: ERCP

ERCP Barium meal X-ray

Double duct sign Rose thorn appearance in hypotonic duodenography
Scrambled egg appearance Reverse 3 sign in periampullary carcinoma
Pad sign(widened C loop of duodenum) in ca head

Management
• At the time of presentation 85% of ductal adenocarcinoma are unsuitable for resection
 • Standard resection for pancreatic head or Ampullary tumor: pylorus preserving pancreaticoduodenectomy
(PPPD or Whipple's procedure)
• Tumors of the body and tail: distal Pancreatectomy with splenectomy
• Multifocal tumor (main duct IPMN or body and tail too friable for anastomosis): total Pancreatectomy

Contraindications to surgical resection Not contraindications for surgery

• Hepatic metastases • Tumor size
• Peritoneal metastases • Continuous invasion of duodenum, stomach or colon
• LN metastasis distant from pancreatic head • LN metastases within operative field
• Encasement of superior mesenteric artery, • Minimal invasion of portal or superior mesenteric
hepatic or Coeliac artery vein

• Gemcitabine plus erlotinib, an oral HER1/EGFR tyrosine kinase inhibitor for metastatic disease

Cystadenocarcinoma
• Common in body and tail
• Epigastric pain
• Mass in epigastrium – non mobile, smooth, not moving with respiration, does not fall forward
• Jaundice not seen
• Mucinous tumors show high CEA
• Distal pancreatectomy is the treatment
• Better prognosis

Migratory thrombophiebitis or Trousseau syndrome

• Ca pancreas
• Ca lung
• Ca colon

Pancreatic surgeries
Whipple's procedure Pancreatico-duodenectomy
Child's operation Distal pancreatectomy(body and tail) with splenectomy
Peustow's operation Pancreatico-jejunostomy(Roux en Y) with splenectomy
Frey's procedure Longitudinal pancreatico-jejunostomy, spleen preserved
Duval procedure Retrograde pancreatico-jejunostomy
Beger procedure Pancreatico-jejunostomy with extensive resection of head of pancreas

Galezia triad Saint's triad Charcot's triad - Cholangitis

• Dupuytren's contracture • Hiatus hernia • Fever
• Retroperitoneal fibrosis • Gallstones • Jaundice
• Peyronie's disease of penis • Diverticulosis • Abdominal pain

Dieulafoy's triad Virchow's triad Borchardt's triad

Acute appendicitis Thrombosis Gastric Volvulus
• Hypersensitiveness of skin • Hypercoagulability • Acute epigastric pain
• Reflex muscular • Stasis • Violent vomiting
contraction • Endothelial injury • Inability to pass NG tube
• Mac Burney's tenderness
• Reynold's pentad- Charcot's triad + septic shock + altered mental status
Tillaux's triad Cushing's triad Sandblom triad
Mesenteric cyst Intracranial hypertension Hemobilia
• Soft fluctuant swelling in umbilical region • Increased BP • Jaundice
• Freely mobile perpendicular to mesentery • Decreased pulse rate • Pain
• Zone of resonance all around • Decreased respiratory • Melena
rate

Carney's triad Mackler's triad Congenital diaphragmatic hernia

• Functioning adrenal Boerhaave syndrome • Respiratory distress
paraganglioma • Vomiting • Apparent dextrocardia
• Gastric leiomyosarcoma • Chest pain • Scaphoid abdomen
• Pulmonary chondroma • Sub-cutaneous emphysema
 VI. UROLOGY
 Most common embryological abnormality of the upper urinary tract – duplication of renal pelvis

UROLITHIASIS
• 90% Idiopathic
• Most common abnormality found in standard investigation – hypercalcemia
• Calcium oxalate – most common (70%)
• Struvite stones – 15%
• Calcium phosphate - 10%

URETERIC CALCULI
• Stone in the ureter usually comes from the kidney

Ureteric colic
• Waves of agonizing loin pain referred to the groin, external genitalia and anterior surface of the thigh
• When the stone is in the intramural ureter, the pain is referred to the tip of the penis
• Strangury -painful passage of few drops of urine, when the stone is in the intramural part of the ureter

Impaction
• Five sites of anatomical narrowing where the stones may be arrested

Ureteropelvic junction

Crossing the iliac artery

Juxtaposition of vas deferens/broad ligament

Entering the bladder wall

Ureteric orifice
• When the stone gets impacted, attacks of colic give way to more consistent dull pain, often felt in the iliac
fossa
• Distension of renal pelvis because of obstruction may cause pain and discomfort in the loin
Hematuria: Every attack of renal colic is associated with microscopic hematuria

Investigations
• X ray shows radio opaque stones in the line of ureter

Near the tip of the transverse processes of lumbar vertebrae

Sacroiliac joint

Medial to ischial spine
• IVU performed at the time of pain can confirm the diagnosis
• Spiral CT is being increasingly used

Endoscopic stone removal

• Dormia basket: now replaced by ureteroscopic techniques
• Ureteric Meatotomy: impacted stones in the intramural part of the ureter
• Ureteroscopic removal: impacted stones
• Push bang: stones in the middle or upper part can be flushed back into the kidney using a ureteric catheter.
Subsequently treated with ESWL

Upper third stone Middle third stone Lower third stone

• ESWL • Uretero-Renoscopic • URS
• Stone pushed to renal pelvis and then PCNL removal (URS) • Dormia basketing
• URS (uretero-renoscopic stone removal) • Open urethrolithotomy

RENAL CALCULI – Etiology

• Dietary – vitamin A deficiency • Medullary sponge kidney
• Dehydration • Sarcoidosis, Gout
• Decreased urine citrate (normal 300-900mg/day) • Idiopathic hypercalciuria
• Infection with urea-splitting organisms (mc staphylococci • Hypervitaminosis D
and E coli) • Hypomagnesuria
• Inadequate urinary drainage and stasis • Distal renal tubular acidosis (RTA type I)
• Prolonged immobilization • Multiple myeloma
• Hyperparathyroidism (recurrent, multiple stones) • Hyperoxaluria, Cystinuria

Clinical features
• Pain, which worsens on movement, located posteriorly on renal angle
• Hematuria, Pyuria, Uremia

OXALATE STONES PHOSPHATE STONES URIC ACID STONES CYSTINE STONES

• Most common • Triple phosphate • Hard, smooth and • In patient with metabolic
• Mulberry stone or struvite stones often multiple disorders that cause cystinuria
• Irregular sharp • Smooth surface • Attractive • Only in acid urine
projections • Alkaline urine multifaceted • Hexagonal, translucent
• Bleeding • Infected urine • appearance • Pink or yellow stones that
• Radio-opaque (Proteus) • Acidic urine turn greenish on exposure to
• Envelope crystals • Staghorn calculus • Pure stones are air
in urine • Radio-opaque radiolucent • Radio-opaque
• Confirmed by CT • Very hard
• Xanthine calculi (show lamellation on cross section) and Indinavir calculi – radiolucent

Calcium oxalate dihydrate crystals - bipyramidally Cystine crystals

Struvite crystals - colorless, 3-dimensional, prism-like crystals (coffin lids) Uric acid crystsl
Investigations
• Spiral CT has become the mainstay of investigation for acute ureteric colic
• USG for locating stones for treatment by ESWL

Treatment
• Small stones <5mm pass spontaneously unless they are impacted
• The presence of upper urinary tract infection obstructed by stone is dangerous and an indication for urgent
surgical intervention

Modern methods of removal

• Extracorporeal Shock wave lithotripsy (ESWL) - When successful, stone fragments must pass down the
ureter

Indications for ESWL Contraindications Complications

• Renal calculus < 2 cm • Absolute • Ureteric colic is common
• Renal calculus 2-3cm after ii • Pregnancy • Infection
• STENT • Uncontrolled bleeding disorder • Steinstrasse (stone
• Oxalate and phosphate • Uncontrolled hypertension street)
stones fragment well to • Urinary tract obstruction distal to • Bleeding
ESWL the stones • Pancreatitis
• Harder stones, especially • Urinary tract infection with fever • Elevation of liver
cysteine stones – poor • Renal failure (Se creatinine > 3mg enzymes
fragmentation %) • Fragmentation of GB
calculi causing biliary
colic

• Percutaneous nephrolithotomy (PCNL)

Stones > 3 cm in size

Cysteine stones

Multiple stones

Stones not responding to ESWL

Complex (staghorn) staghorn stones can be given combined treatment with ESWL
• Pyelolithotomy for stones in the renal pelvis go
• Nephrolithatomy for complex calculus branching into most peripheral calyces
• Partial Nephrectomy for stones in the lowermost calyx and associated infective damage to adjacent
parenchyma
• Dietary modification

Plenty of fluids to keep their urine dilute

Lemonade and orange juice

Protein Restriction

Sodium Restriction

Moderate calcium intake in the face of calcareous nephrolithiasis

Calcium stones: decrease intake of milk products

Calcium oxalate stones: decrease intake of rhubarb, strawberries, plums, spinach and asparagus

D Uric acid stones: red meats, offal and fish which are rich in purines

Cysteine stones: eggs, meat and fish
• Drugs: bendroflumethiazide for patients suffering from idiopathic hypercalciuria

Algorithm for management of renal stones

DD for radio-opaque shadow which mimics renal stone

• Calcified mesenteric node • Ossified tip of 12th rib
• Gall stones • Calcified tuberculous lesion of the kidney
• Concretion in appendix • Calcified suprarenal gland
• Phleboliths (calcification in the walls of pelvic • Drugs (e.g: cyclopenthiazide) or foreign body in GIT
veins)

HYDRONEPHROSIS
• Aseptic dilatation of the kidney caused by obstruction to the outflow of urine
• Congenital PUJ and calculus are the commonest causes of unilateral HN
• Unilateral hydronephrosis more common in women and on the right
• Dietel's crisis (Intermittent hydronephrosis): in unilateral hydronephrosis, a swelling in the loin is associated
with acute renal pain. Some hours later the pain is relieved and the swelling disappears with passage of large
volume of urine
• USG is the least invasive means of detecting and used to diagnose PUJ obstruction in utero
 • Isotope renography - best test to establish that the dilatation of the renal collecting system is caused by
obstruction
• Obstruction is diagnosed by a combination of USG and isotope renography
• Whitaker test – a percutaneous puncture of kidney is made through the loin and fluid infused at a constant
rate with monitoring of intrapelvic pressure. An abnormal rise in pressure confirms obstruction
• Pyeloplasty

Anderson-Hynes operation when reasonable functioning parenchyma remains

V-Y pyeloplasty
• Nephrectomy when renal parenchyma is largely destroyed

Aberrant renal vessels

• Aberrant renal artery or vein in the lower pole of kidney can compress the PUJ causing hydronephrosis
• Multiple renal arteries are most common on the left.
• Renal arteries are functional end-arteries, so division of an aberrant renal artery leads to infarction of a
section of parenchyma.
• Aberrant renal veins can be divided with impunity. Treatment–ligation

PERINEPHRIC ABSCESS
• Swinging pyrexia, abdominal tenderness and fullness of loin
• Local signs present early if infection starts in the lower pole;
• Infection at the upper pole masked by lower ribs
• Characteristically no pus cells or organisms in the urine
• X-ray

The psoas shadow is obscured

Reactionary scoliosis with concavity toward the abscess

Elevation and immobility of diaphragm on the affected side

Mathe's sign: no downward displacement of kidney in erect posture (X rays are taken in one in lying
down position and another in erect position. Normally there is downward displacement of kidney in
erect posture)
• Open drainage necessary if aspiration is not possible

Psoas shadow is obliterated in

• Enlarged kidney
• Scoliosis due to inflammatory or infiltrative causes
• Tuberculous spine with cold abscess (psoas abscess)
• Splenic injury (left side shadow)
• Retroperitoneal tumors

PYELONEPHRITIS
• Acute onset fever, rigors, nausea, vomiting, and flank and/or loin pain
• Fever is the main feature distinguishing cystitis and pyelonephritis
• The fever of pyelonephritis exhibits a high, spiking picket-fence pattern
• Emphysematous pyelonephritis - occurs almost exclusively in diabetic patients
• Xanthogranulomatous pyelonephritis - chronic urinary obstruction (often by staghorn calculi)

RENAL TUBERCULOSIS
• Arise from Hematogenous spread
• Usually confined to one kidney
 • Tuberculous granulomas in a renal pyramid coalesce to form and ulcer
• Untreated lesions progress to form a tubercular abscess which may progress to pyonephrosis
• Kidney is replaced by a caseous material (putty kidney) which may calcify (cement kidney)
• X-ray may show areas of calcification (pseudocalculi)

Clinical features
• Usually occurs between 20 to 40 years of age
• Twice common in men; right kidney slightly affected more
• Urinary frequency is the earliest symptom. Progressive increase in both day-time and night-time frequency
• Sterile pyuria, Hematuria due to an ulcer at renal papilla
• Painful micturition as soon as tuberculous cystitis sets in
• Malaise, weight loss and low-grade evening pyrexia are typical
• A tuberculous kidney is oedematous and friable and more liable to damage than a normal kidney
• Tuberculous kidney is rarely palpable unless there is hydronephrosis or perinephric abscess

IVU
• Indistinct outline of renal papilla is the early sign
• Later calyceal necrosis
• Contracted bladder

Cystoscopy
• In late disease, the urothelium is studded with granulomas that cluster around the ureteric orifices
• Golf hole ureteric orifice
• Thimble bladder (bladder wall fibroses and capacity decreases)

Treatment
• ATT
• Operative treatment –to remove large foci of infection that are difficult to treat with drugs and to correct
the obstruction caused by fibrosis
• The optimum time for surgery is between 6 and 12 weeks after starting ATT
• Strictured renal pelvis – pyeloplasty
• Ureteric stenosis and Shortening – Boari operation or bowel interposition
• Nonfunctioning kidney – nephroureterectomy

RENAL TRANSPLANTATION
• Primary oxalosis: combined renal and hepatic transplantation
• Absolute contraindications for renal transplantation

preexisting malignancy(even after curative therapy transplantation should not be considered for at
least 3 years)

active infection
• Left kidney is commonly used
• The donor renal vein is anastomosed end-to-side to the external iliac vein
• The donor renal artery on a Carrel patch of donor aorta is anastomosed end-to-side to the external iliac
artery
• If the donor renal artery lacks an aortic patch (in living donor transplant) it is anastomosed end-to-side to
the recipient internal iliac artery

Organ Optimal cold storage time (hrs) Safe maximum cold storage time (hrs)
 Kidney < 24 48
Liver < 12 24
Pancreas < 10 24
Small intestine <4 8
Heart <3 6
Lung <3 8

Ureteric injuries
• Most common cause of ureteric injury is gynecological surgeries(vaginal or abdominal hysterectomy)
• Vesico ureteric junction is the most common site of ureteric injury in gynecological surgeries
• Lower ureter is most commonly involved in trauma
• Pelviureteric junction is involved in avulsion injuries
• Rupture of ureter results from a hyperextension injury of spine

URINARY BLADDER

BLADDER RUPTURE
Intraperitoneal rupture (20%) Extraperitoneal rupture (80%)
• Blunt trauma - blow or fall on a distended bladder • Fracture pelvis or surgical damage
• Sometimes due to surgical damage • Gross hematuria may be absent
• Sudden severe pain in the hypogastrium • Difficult to distinguish from rupture of
• Shock, abdominal distension, no desire to micturate membranous urethra
• Requires surgical repair • Heal with adequate urinary drainage

Investigations
• CT is ideal
• Plain X ray – ground glass appearance
• IVU may confirm a leak
• Retrograde cystogram will confirm the diagnosis

SCHISTOSOMIASIS OF THE BLADDER

• After penetration of the skin, the urticaria lasting about 5 days can occur (swimmer's itch)
• Typical early symptom is intermittent, painless, terminal hematuria
• Cystoscopy

Bilharzial pseudotubercles are the earliest specific features

Bilharzial nodules

Sandy patches

Ulceration

Fibrosis

Granulomas

Papillomas

Carcinoma

Thimble (systolic) bladder: inability of the bladder to relax and distend and inability to retain urine.
• Tuberculous cystitis
• Schistosomiasis
• Interstitial cystitis
• Radiotherapy
• Malignancy
• Previous bladder surgery
Bladder stones
• Primary bladder stone - develops in sterile urine; it often originates in the kidney. (calcium oxalate)
• Secondary stone (most common type) – develops in bladder in the presence of infection, outflow
obstruction, impaired bladder emptying or a foreign body (struvite)
• Treatment of choice: Cystoscopic fragmentation and removal

BLADDER CANCER
• More common in whites, higher socio-economic status, males, 6th and 7th decade
• 75% tumors are localized to bladder and 25% have spread to regional nodes or distant sites at the time of
diagnosis

Transitional/ Urothelial cell cancer (90%) Squamous cell cancer (10%) Adenocarcinoma (5%)
Risk factors
• Cigarette Smoking – most important • Schistosomiasis • Urachal remnants
• Chemical carcinogens: naphthylamine, (Bilharziasis) • Ectopia vesicae
benzidine, aniline • Chronic bladder • Also occurs in intestinal
• Schistosomiasis (Bilharziasis) infection urinary conduits,
• Long term use of analgesics • Irradiation • augmentations, pouches
• Drugs: Phenacetin and Chlornaphazine • Bladder diverticula and
• Long time Cyclophosphamide exposure ureterosigmoidostomies
• Pelvic irradiation
• Occupations: dye, rubber, petroleum,
leather, printing industry
Morphology
Most common site - trigone and adjacent posterolateral wall
• Papillary and exophytic lesions • Nodular and invasive
• Carcinoma in situ or Flat urothelial at the time of
carcinoma – Pagetoid spread diagnosis
• Treatment: see below • Radical cystectomy • Radical cystectomy +
pelvic
 Industrial exposure to aryl amines, particularly 2- naphthylamine - cancers appear 15 to 40 years after first
exposure

Clinical features
• Painless, gross, intermittent hematuria is the most common symptom
• Frequency, urgency and dysuria are common symptoms

Metastasis:
• Most common site of metastases – Pelvic nodes (mc-obturator)
• Most common primary to metastasize to penis – bladder cancer

Investigations
• New tests: detection of antigens such as nuclear matrix proteins (NMP22) or mini-chromosome
maintenance (MCM) in urine, which may be able to detect new or recurrent tumors
• The most common radiological sign is a filling defect
• For staging contrast-CT
• MRI can demonstrate LN metastases and muscle invasion
• Cystourethroscopy is the mainstay of diagnosis
Staging of Primary tumor
• Ta — non invasive papillary carcinoma
• Tis — Carcinoma insitu (Flat tumor)
• T1— invasion of subepithelial connective tissue
• T2a: Superficial muscularis propria invasion (inner half)
• T2b: Deep muscularis propria invasion (outer half)
• T3: extension to pelvic fat
• T4: invasion of pelvic viscera, pelvic or abdominal walls

Treatment of bladder cancer

Tis Intravesical BCG
Ta (single, low to moderate grade, not recurrent) Complete TUR
Ta (large, multifocal, high grade or recurrent )
T1. TUR + BCG or intravescial chemotherapy
T2-T4 Radical cystectomy
Neoadjuvent chemotherapy + radical cystectomy

 Beaded appearance of renal artery — fibromuscular hyperplasia

 Uraplakins — proteins present in umbrella cells on the surface of transitional epithelium
 Brunn nests — transitional cell nests that grows down the mucosa and lamina propria of bladder
 Hunner's ulcer — interstitial cystitis
 Verruca plana — HPV
 Verruca peronee — Bartonella bacilliformis
 Glitter cell — pyelonephritis (Gitter cell — CNS microglial cell)
 Thyroidization of tubules chronic pyelonephritis

URETEROSIGMOIDOSTOMY
• Procedure done for urinary diversion after radical cystectomy or as a permanent diversion
• Left ureter is implanted to the sigmoid colon, right one to the upper rectum or rectosigmoid junction
• Complications

Pyelonephritis and recurrent upper urinary tract infection.

Hypokalaemia.

Hyperchloraemic acidosis

PROSTATE

Anatomical divisions of prostate Surgical divisions of prostate

• Anterior lobe • Peripheral zone (carcinoma)
• Posterior lobe (carcinoma) • Central zone
• Median lobe (BPH) • Transition zone (BPH)
• 2 lateral lobes

TUBERCULOSIS OF PROSTATE AND SEMINAL VESICLES

• Rare and associated with renal tuberculosis
• 30 % cases have history of pulmonary tuberculosis within five years of the onset of genital tuberculosis.
• On rectal examination, the affected vesicle is found to be nodular.
• When the prostate is involved, rectal examination reveals nodules in one or both lateral lobes.
• Tuberculous prostatitis - urethral discharge, painful, sometimes blood-stained, ejaculation, mild ache in the
perineum, infertility, dysuria, abscess formation
BENIGN PROSTATIC HYPERPLASIA
• In men over 50 years of age; at 60 years 50% of males have histological evidence of BPH
• Most common cause of bladder outflow obstruction in males > 70 years
• Typically affects the submucous group of glands in the transitional zone
• Usually involves the median or lateral lobes
• The prostatic urethra is lengthened, but it is not narrowed and the normal posterior curve is exaggerated
• When only one lateral lobe is enlarged, distortion of the prostatic urethra occurs
• The bladder musculature hypertrophies and appears trabeculated
• Urinary frequency, urgency, hesitancy, nocturia, intermittent stream
• Terminal dribbling

Treatment of BPH
• Medical – α adrenergic blockers (prazosin, terazosin, tamsulosin) and 5α reductase inhibitor (finasteride)
• Surgery: Prostatectomy

Transurethral resection of prostate (TURP)

Retropubic prostatectomy (RPP) – Milin

Transvesical prostatectomy

Perineal prostatectomy (Young) – now abandoned
• Newer methods: Holmium laser to enucleate the prostatic adenoma
• Intraurethral stents - for men with retention who are grossly unfit -ASA grade IV)

Complications of prostatectomy
• Hemorrhage is a major risk following prostatectomy
• Incontinence
• Retrograde ejaculation - occurs in about 65 per cent of men after prostatectomy.
• Erectile impotence - occurs in about 5 per cent of men, usually those whose potency is waning
• Urethral stricture (Otis urethrotomy prior to TURP reduces the incidence of stricture postoperatively)
• Reoperation: after 8 years 15-18% of men with BPH will undergo repeat TURP
• Water intoxication (TUR syndrome) may lead to CCF, hyponatremia and hemolysis. Use of isotonic glycine
for performing resections and use of isotonic saline for postoperative irrigation have ↓ the incidence.
Treatment -fluid restriction
• Osteitis pubis – rare

Assessment of patients with Lower Urinary tract symptoms

• Clinical: abdominal. PR and CNS examination
• Urinary flow rate and residual volume measurement
• PSA - If rectal examination is quite normal with no suspicion of cancer, and if no change in treatment policy
would in any case result from the diagnosis of early prostate cancer, then there is little point in there routine
measurement of PSA
• Flow rate measurement
• Pressure-flow urodynamic studies
• Cystourethroscopy
• Transrectal Ultrasound

BLADDER OUTFLOW OBSTRUCITON DUE TO BLADDER NECK STENOSIS

• Syn: Marion's disease or prostatism sans prostate
• Usually occurs in men
• Due to muscle hypertrophy or dyssynergia of bladder neck muscles
CARCINOMA PROSTATE
• Most common malignant tumor in men over 65 years
• Adenocarcinoma of prostate is the most common form of cancer in men (ROBBINS)
• Carcinoma prostate usually originates from the peripheral zone, commonly in the posterior lobe
• BPH arises from the transitional zone.
• So prostatectomy for BPH does not confer protection against carcinoma prostate

Dietary products that prevent/delay prostate cancer

• Retinoids-Lycopenes(found in tomatoes)
• Selenium
• Soy products
• Vitamin D
• Isoflavonoid genistein (5a-reductase inhibitor found in many legumes)
• Cruciferous vegetables(contain isothiocyanate sulforaphane)
• Inhibitors of cholesterol biosynthesis (statin drugs).

Spread
• Locally advanced tumors tend to grow upwards to involve the seminal vesicles, the bladder neck, trigone
• Hematogenous spread is most frequently to pelvic bones (through Batson's periprostatic venous plexus)
followed by lower lumbar vertebrae(internal vertebral venous plexus)
• Prostate is the most common site of origin of skeletal metastasis (followed by breast, kidney, bronchus and
thyroid)
• Lymphatic most commonly to obturator nodes

Clinical features
• Bladder outflow obstruction (BOO)
• Pelvic pain and hematuria
• Bone pains
• Perineural invasion
• Rectal examination: Irregular induration, characteristically stony hard, with obliteration of medial sulcus

Staging
• T1a: tumor involving < 5% of the resected specimen
• T1b: tumor involving > 5% of the resected specimen
• T1c: impalpable tumors found following investigation of a raised PSA
• T2a: presents as a suspicious nodule, confined within prostate capsule, involving one lobe
• T2b: involving both lobes
• T3: tumor extends through capsule(T3a-uni/bilateral extension; T3b-seminal vesical extension)
• T4: fixed tumor involving adjacent structures other than seminal vesicles

 Gleason staging (Total Score 2 to 10) - a good indicator of prognosis and the likelihood of spread

Prostate specific antigen

• Prostate specific, but not prostate cancer specific
• Lacks specificity and sensitivity in detecting early cancers
• Normal <4ng/ml; >10ng/ml is suggestive of cancer; >35ng/mI is diagnostic of cancer
• Decrease in PSA to normal range following hormonal ablation is a good prognostic sign
 • Also increased in – BPH, prostatitis, infarct, instrumentation of prostate, after ejaculation
• Serum levels are not affected by digital examination but the performance of a prostate biopsy can increase
PSA levels up to tenfold for 8-10 weeks

Imaging
• Abdominal X-ray: characteristic sclerotic metastases in lumbar vertebrae and pelvic bones
• MRI - most accurate for local staging
• Locally extensive disease can be diagnosed with increased sensitivity by TRUS
• Bone scan – sensitive for diagnosing metastases

Treatment
• Radical prostatectomy for T1 and T2
• External beam radiotherapy has also been given for T1 and low volume T 2 disease
• Brachytherapy is gaining widespread acceptance for low grade low volume T1 disease
• Metastatic disease

Androgen ablation: LHRH agonists, androgen receptor blockage

Anti-androgen - flutamide, bicalutamide

Orchidectomy

URETHRA

URETHRAL INJURIES
Parts of urethra
• Anterior urethra – bulbar urethra and penile (spongy) urethra
• Posterior urethra – membranous urethra and prostatic urethra
• Bulbar urethra is more commonly injured than posterior urethra
• But Membranous urethra is most commonly injured in pelvic fractures

Common features
• h/o pelvic trauma
 • Blood at the meatus
• Urinary retention
• Hematuria

Rupture of bulbar urethra

• Direct blow to perineum (fall astride a projecting object)
• Cycling accidents, loose manhole covers & gymnasium accidents astride the beam account for most cases.
• Triad: Retention of urine, Bleeding from the meatus, Perinea! hematoma (butterfly shaped)
• Urine first collects in the superficial perineal pouch and then in scrotum, penis and ant. abdominal wall
• Superficial extravasation of urine
• Should be discouraged from passing urine
• Injudicious urethral catheterization may convert a partial tear into a complete transection of urethra
• Delayed Urethroplasty (after 8-12 weeks) – definitive management of complete disruptions

Rupture of membranous urethra

• Mostly due to pelvic fracture, which commonly occurs in road traffic accidents
• In prolonged labour, due to long standing pressure on the urethra by fetal head, it may rupture
• Vermooten's sign: High lying (floating prostate) on P/R
• Deep extravasation
• Urine collects in the perivesical space
• Exploration needed if there is associated rupture of bladder

Management of urethral injuries

• Retrograde urethrography should be performed
• If extravasation present - insert a suprapubic catheter
• If the patient has passed urine when first seen and there is no extravasation, the rupture, if any, is partial
and a suprapubic catheter is not usually needed.

URETHRAL STRICTURES
• Gonococcal stricture is most commonly seen in the bulbar urethra
• Balanitis xerotica obliterans

Fibrosis of the foreskin resulting in phimosis

Fibrosis and stricturing of the penile urethra.

Strictures produced are typically long and difficult to treat.
• Post-instrumentation strictures - affect any part of the urethra

TESTIS
Normal descent of testes
• 5-6 weeks - Develop in the retroperitoneum below the kidneys at around the T10 level
• 7th month – deep inguinal ring
• 8th month – inguina canal
• 9th month – superficial inguinal ring

Ectopic testis
• Lies outside its normal line of descent
• Most often in the perineum
UNDESCENDED TESTES
• Incidence: In premature infants: 30%; In full term infants: 4%; At 3 months- 2%
• Testis absent from scrotum after 3 months of age are unlikely to descent fully
• Incompletely descended testis tends to atrophy as puberty approaches
• More common on the right side(50%) and 20% cases are bilateral (cryptorchidism)
• Secondary sexual characters are normal

Etiology
• Gubernacular dysfunction
• Lack of gonadotropins [HCG]
• Lack of CGRP –calcitonin gene related peptide
• Prune Belly syndrome
• Familial

Complications
• Torsion
• Epididymo-orchitis(may mimic appendicitis)
• Sterility (in bilateral cases, especially- intraabdominal testis)
• Indirect Inguinal hernia
• Increased liability to malignant disease
• Atrophy

Treatment
• Orchidopexy is usually done before 6 months of age
• Orchidectomy: if the incompletely descended testis is atrophic, if patient is past puberty & other testis is
normal
• In bilateral cases, testis is passed into the opposite scrotum through an opening in the scrotal septum -
Ombredanne's operation
• HCG or GnRH can be given when cryptorchidism is associated with hypogenitalism and obesity

RETRACTILE TESTIS
• In some boys, any stimulation of the skin of the scrotum or thigh causes the testis to ascend and to
temporarilydisappear into the inguinal canal. This is called a retractile testis.
• Scrotum in retractile testis is normal (In true undescended testis – underdeveloped)
• When the cremaster relaxes, the testis reappears only to vanish when the scrotal skin is touched again.
• Retractile testis can be gently milked from its position in the inguinal region to the bottom of the scrotum
• This is most easily done with the child relaxed in a warm room
• Diagnosis of true incomplete descent should be made only if this is not possible.
• Retractile testes require no treatment

ACUTE EPIDIDYMO-ORCHITIS
• Most common organism Chlamydia, but gonococcal epididymitis is still prevalent
• Scrotal wall becomes red, edematous, shiny and becomes adherent to epididymis
• May follow urethral instrumentation, prostatectomy
• Epididymis and testis swell and become painful
• Acute tuberculous epididymitis – thickened vas
• Acute Epididymo-orchitis develops in 18% of men suffering from mumps, usually when the parotid swelling
is waning
 • The main complication is testicular atrophy, which may cause infertility, if it is bilateral(not usual)
• Mumps epididymitis in the absence of parotitis occurs in infants
• Other infections: Enteroviruses, Brucellosis, Lymphogranuloma venereum
• Doxycycline for Chlamydial infection, Plenty of fluids, scrotal support and analgesics

CHRONIC TUBERCULOUS EPIDIDYMO-ORCHITIS

• Lower pole first attacked (indicates that the infection is retrograde from a tuberculous focus in the seminal
vesicles)
• Firm discrete swelling of the lower pole with little pain
• Secondary hydrocele in 30% cases
• Characteristic beading of the vas as a result of subepithelial tubercles
• Cold abscess may form in neglected cases
• The body of the testis may be uninvolved for years but the contralateral epididymis often becomes diseased
• Treatment with ATT is less effective
• If resolution does not occur within 2 months, epididymectomy or orchidectomy

TORSION OF THE TESTES

For torsion to occur one of the several abnormalities must be present
• Inversion of the testis is the most common predisposing cause
• High investment of tunica vaginalis (testis hangs like clapper in bell)

Predisposing factors
• Bell-clapper deformity—poor gubernacular fixation of the testicles to the scrotal wall
• Straining at stool
• Lifting heavy weight
• Coitus
• Sometimes spontaneously during sleep

Clinical features
• Most common between 10 and 25 years of age. Few cases occur in infancy
• Most common cause of testicular pain >12 years
• Sudden agonizing pain in the groin and lower abdomen, nausea, vomiting
• Deming's sign: affected testis is positioned high because of twisting of cord and spasm of cremaster muscle
• Angell's sign; Opposite testis lies horizontally because of presence of mesorchium
• Prehn's sign: on elevation of testis

Pain decreases  epididymorchitis

Pain increases  torsion
• Doppler ultrasound scan will confirm the absence of blood supply to the affected testis. But if diagnosis is
doubt, the scrotum should be explored without delay

Epididymo-orchitis Torsion of the testes

• Cord not thickened • Cord twisted and thickened
• Dysuria and urinary infection present • Absent
• Elevation of testis reduces pain • Elevation of testis worsens pain

Treatment
• If the diagnosis of testicular torsion is possible, then surgical exploration is indicated
• Prompt exploration, untwisting and fixation is the only way to save the torted testis
 • Anatomical abnormality is bilateral and the contralateral testis should also be fixed

TORSION OF TESTICULAR APPENDAGES

• Testicular appendages

Appendix of testis (hydatid of Morgagni)

Appendix epididymis

Paradidymis (organ of Giraldes)

Vas abberans of Haller
• Majority of twisted appendages involve appendix testis
• Torsion of appendis testis - Most common cause of testicular pain in 2-10 years age group
• Shows Blue dot sign

VARICOCELE
• Dilatation and tortuosity of the Pampiniform plexus of veins and testicular veins
• Common in tall, thin, adolescent males
• Most varicoceles are on the left side
• Varicocele does not disappear on supine position
• Dragging sensation that is worse if the testis is unsupported
• Swelling at the root of the scrotum
• The scrotum on the affected side hangs lower than normal
• On palpation, when the patient is standing, the varicose plexus feels like bag of worms
• Cough impulse may be present
• In long standing cases, the affected testis is smaller due to minor degree of atrophy
• Cause increase in temperature in the scrotum which depresses spermatogenesis which is reversible
• Embolization of the testicular vein under radiographic control is the treatment of choice
• Palomo's operation (suprainguinal extraperitoneal ligation of testicular vein)

TESTICULAR TUMORS
• MC tumour of testis: Seminoma
• MC testicular tumor in infant and children upto 3 years: Yolk sac tumour
• MC testicular tumor in pre-pubertal children: Teratoma

Germ cell tumors (95%) Sex cord tumors Mixed tumors

• Seminomas Leydig cell tumor • Gonadoblastoma (Combined Germ cell
• Non seminomas Sertoli cell tumor and gonadal stromal tumor)

Teratoma Gonadoblastoma • Teratocarcinoma (embryonal carcinoma

Embryonal carcinoma with teratoma)

Choriocarcinoma
Yolk sac tumor
Predisposing factors for germ cell tumors
• Undescended testis/Cryptorchidism(Abdominal cryptorchid testis are at higher risk than inguinal cryptorchid
testis)
• Testicular ca in one sibling
• Klinefelter syndrome
• DES administration to mother during pregnancy
• Testicular feminization syndrome
• An isochromosome of the short arm of chr. 12 [i(12p)] is pathognomonic for GCT of all histologic types
Seminoma (40%)
• Peak incidence for classic form is between 35 — 45 years
• Types

Typical or classic seminoma — most common type; common in 30-40 years

Anaplastic seminoma — bad prognosis

Spermatocytic seminoma - occurs in older people (> 65 years); excellent prognosis
• Arise from seminiferous tubules
• Follows an indolent course
• Enlarged testis is smooth and firm
• Active lymphocytic infiltration in the tumor suggests a good host response and a better prognosis
• Metastasize via lymphatics, Hematogenous spread uncommon

Teratoma (32%)
• Arise from the totipotent cells of the rete testis
• Mainly hematogenous spread, less commonly lymphatic spread
• Pulmonary (cannon ball) metastasis suggests that the tumor is a teratoma
• Even a large tumor is moulded by tunica albuginea so that the overall outline of the testis is maintained
• Types

Malignant teratocarcinoma intermediate(MTI), teratocarcinoma – most common

Teratoma differentiated – dermoid cyst

Malignant teratoma anaplastic(MTA), embryonal carcinoma

Malignant teratoma Trophoblastic (MTT)
o Malignant villous cytotrophoblasts(Choriocarcinoma)
o Most malignant
o Spreads by blood stream and lymphatics early
o Produces HCG

Interstitial cell tumors

Leydig cell tumor Sertoli cell tumor
• Masculinizes • Feminizes
• Prepubertal tumor • Postpubertal tumor
• Sexual precocity • Gynecomastia, loss of libido, aspermia
• Chemo and radio resistant • Usually benign; Orchidectomy cures

Lymphatic spread
• From the right testis, initial lymph node metastasis is to the pericaval, and interaortocaval nodes
• From the left testis, initial lymph node metastasis is to the left Paraaortic nodes,
• Retroperitoneal nodes, supraclavicular nodes and mediastinal nodes may also be involved
• Inguinal nodes are involved only when the scrotal skin is involved

Clinical features
• Most common presentation – painless testicular lump
• h/o recent trauma (which calls attention to the testicular enlargement but does not initiate neoplasm)
• Few cases present with gynecomastia (mainly the teratomas)
• Some present with severe pain and acute enlargement of the testis because of haemorrhage into the
tumour
• Hurricane tumor is a malignancy that kills in a matter of weeks
• Back pain, abdominal or lumbar pain - from retroperitoneal node metastases – presenting feature in 25%
seminomas
 • Majority (2/3) of seminoma are confined to testis at the time of presentation
• Majority of non-seminomatous tumors have widespread metastasis at presentation.

Examination
• Testicular sensation is often lost (sign should be elicited with care to avoid dissemination)
• Secondary hydrocele
• The epididymis becomes more difficult to feel
• The vas, prostate, seminal vesicles andrectal examination are normal

Diagnosis
• Diagnosis confirmed by USG - seminomas usually appear as a homogeneous intratesticular mass of low
echogenicity compared to normal testicular tissue
• Orchidectomy is essential to remove the primary tumor and to obtain histology
• CT and MRI are the most useful means of detecting secondaries and for monitoring response to therapy
• No FNAC
• No Scrotal approach
• No incisional biopsy

Tumor markers
• AFP – raised in non seminomatous tumors
• β-HCG and LDH raised in both seminoma and non seminomatous tumors

Treatment
• High inguinal Orchidectomy for all tumors and suspected tumors
• After orchidectomy, management depends on stage

Prognosis
• Testicular tumour with best prognosis: Yolk sac tumour
• Testicular tumour with worst prognosis: Hurricane tumour (Choriocarcinoma)

Germ Cell Tumor Staging and Treatment

Stage Extent of Disease Treatment
Seminoma Nonseminoma
IA Testis only, no vascular/lymphatic Radiation therapy RPLND or observation
invasion (T1)
IB Testis only, with vascular/lymphatic Radiation therapy RPLND
invasion (T2), or extension through
tunica albuginea (T2), or involvement
of spermatic cord (T3) or scrotum
(T4)

IIA Nodes < 2 cm Radiation therapy RPLND or chemotherapy followed by RPLND

IIB Nodes 2-5 cm Radiation therapy RPLND +/– adjuvant chemotherapy or
chemotherapy followed by RPLND
IIC Nodes > 5 cm Chemotherapy Chemotherapy, often followed by RPLND
III Distant metastases Chemotherapy Chemotherapy, often followed by surgery
(biopsy or resection)
 PENIS & SCROTUM
PHIMOSIS
• Physiological adhesions between the foreskin and the glans penis may persist until 6 years of age
• Occurs as a result of balanitis xerotica obliterans (BXO) in which the normally pliant foreskin becomes
thickened and will not retract
• Treatment is by circumcision
• Circumcision is most commonly performed for cultural reasons
• The Plastibel (Hollister) device is used for circumcision in infants
• Never use monopolar diathermy when performing circumcision

HYPOSPADIAS
• Most common congenital anomaly of urethra
• Occurs in around one in 200-300 male live births
• Characterized by

Proximally and Ventrally placed urethral meatus

Hooded foreskin

Chordee (fixed bowing of the penis)
• It is attributed to failure of complete urethral tubularisation in the fetus

Types
• Glandular – common type; no treatment required
• Corona!
• Penile and penoscrotal
• Perineal – most severe form, bifid scrotum, rarest

Treatment: Staged procedure

• At one and half years, surgical correction of chordee is done
• At 5-7 years reconstruction of urethra using prepucial skin is done
• Perianal urethrostomy for diversion of urine (Denis-Browne procedure)

Avoid circumcision in Hypospadias as prepuce may be used in procedure to correct the abnormality

EPISPADIAS
• Rare congenital anomaly,
• Usually coexists with Bladder exstrophy
• Urethra opens on the dorsum of penis, associated with upward curvature of the penis

PEYRONIE'S DISEASE
• Deformity of erect penis
• PDES inhibitors - causally related to the development of Peyronie's disease
• On palpation, hard plaques of fibrosis are felt in the tunica of corpora cavernosa
• The plaques may be calcified and causes the erect penis to bend
• Associated with

Dupuytren's contracture

Retroperitoneal fibrosis

Plantar fasciitis
• Management: Vitamin E, Potassium aminobenzoate, carnitine
• Surgeries

Nesbitt's operation

Fitzpatrick operation

Gerhard's operation

BUSCHKE LOWENSTEIN TUMOR

• Giant condyloma
• Histological pattern of verrucous carcinoma
• Locally destructive and invasive
• No evidence of lymphatic or hematologic spread
• Surgical excision is the treatment of choice
• Interferon a therapy and Nd:YAG laser therapy is also successful

CARCINOMA PENIS
• Circumcision soon after birth confers immunity against carcinoma penis

Etiology
• Chronic balanoposthitis
• Leukoplakia of glans
• Long standing genital warts
• HPV16 - most frequently detected type in primary carcinomas

Carcinoma in situ
• At glans penis: Paget's disease of penis or Erythroplasia of Queryat
• At shaft: Bowen's disease - Usually in those older than age 35 years
• Bowenoid papulosis

In sexually active young adults

Multiple, pigmented papular lesions

Related to HPV type 16

Histologically indistinguishable from Bowen's disease

Virtually never develops into invasive carcinoma

Clinical features
• In adults recent onset phimosis should raise the suspicion of carcinoma penis
• Inguinal node enlargement(60%) is the most common presentation
• Little or no pain
• Altered urinary stream
• Inguinal nodes may erode the skin and death may result from erosion of femoral or external iliac artery

Spread
• First to horizontal group of inguinal nodes and then external iliac nodes
• From glans to lymph node of Cloquet in the femoral canal
• Blood spread is rare

Investigations
• FNAC of lymph nodes (NO OPEN BIOPSY)
• Sentinel Lymph Node Biopsy (SLNB) – Cabana sentinel node is located above and medial to the junction of
saphenous and femoral veins.
 TNM STAGING
• TO: No evidence of primary tumor • NO: No regional lymph node metastasis
• Tis: Carcinoma in situ • NI: Metastasis in a single superficial, inguinal
• Ta: Non invasive verrucous carcinoma lymph node
• T1: Tumor invades subepithelial connective tissue • N2: Metastasis in multiple or bilateral
• T2: Tumor invades corpus spongiosum or superficial inguinal lymph nodes
cavernosum • N3: Metastasis in deep inguinal, iliac or pelvic
• T3: Tumor invades urethra or prostate lymph node {s), unilateral or bilateral
• T4: Tumor invades other adjacent structures

Treatment
• Ca in situ: topic 5-FU cream, CO2 laser ablation or surgical excision qiitimeork) asmirmiumin
• Radiotherapy is effective for small cancers
• Ca in situ or well differentiated tumor in young individual or <2cm tumor of glans: circumcision + RT
• Young's operation (partial amputation of penis with bilateral ileo-inguinal lymph node dissection) for glans
involvement without extending into proximal part of shaft; 2.5cm stump retained
• If shaft is involved or if it is anaplastic type — total amputation with perinea! urethrostomy
• Piersey Gold operation: total amputation + total scrotectomy + total orchidectomy
• Mohs Micrographic Surgery - likely to be equivalent to those of partial amputation for carcinoma in situ or
for small, distal, superficially invasive tumors
• Laser Ablation: stage T1 tumors, combining Nd:YAG laser ablation with tumor base biopsies to ensure
negative surgical margins

Treatment of associated enlarged Inguinal nodes —

• Delayed until at least 3 weeks after local treatment of the primary lesion
• Enlargement caused by infection will usually show signs of subsiding with antibiotic treatment.
• For palpable nodes, ultrasound-guided fine needle aspiration will confirm the diagnosis
• Block dissection of both groins should be undertaken

Condyloma acuminata (genital warts)

• Sexually transmitted
• MC site in men- under the prepuce in the corona! sulcus; MC site in women vulva
• Podophyllin 25% in spirit is often effective as topical application

HYDROCELE
• Abnormal collection of serous fluid in a part of processus vaginalis, usually the tunica
• Hydrocele fluid is rich in albumin (3-6g/dL) consistent with exudates
• Hydroceles are typically translucent and it is possible to get above the swelling
• Primary hydrocele: Testis is not palpable separately as it usually attains a large size
• Secondary hydroceles: small and lex (except filarial hydrocele) testis palpable separately
• An acute hydrocele in a young man may be due to a testicular tumor

Congenital hydrocele
• Vaginal hydrocele — sac patent only in the scrotum
• Infantile hydrocele — sac patent from scrotum upto the deep inguinal ring
• True congenital hydrocele (communicating hydrocele)

Patent processus vaginalis connects with peritoneal cavity

Hydrocele is often intermittent (may drain into the peritoneal cavity when the child is lying down)

But not reducible
• Encysted hydrocele of the cord

Sac is obliterated at inguinal canal and scrotum but patent around spermatic cord

Soft, cystic, fluctuant transilluminant swelling well above the testis

Diagnosis established by traction test — swelling is freely mobile but when traction is applied to the
testis, swelling becomes fixed
• Hydrocele-en-Bissac (bilocular hydrocele) — scrotal sac communicates with another sac underneath the
anterior abdominal wall. Diagnosed by cross fluctuation test
• Hydrocele of canal of Nuck — swelling in the inguinal region in female

Treatment of hydrocele
• Congenital hydrocele — herniotomy
• Large, thick walled sac and chylocele — Jaboulay's method (partial excision eversion of sac with placement
of the testis in a pouch prepared by dissection in the fascial planes of the scrotum)
• Small, thin walled sac containing clear fluid — Lord's plication
• For hematocele and infected hydrocele — excision of sac and orchidectomy
• Injection of sclerosants like tetracycline is effective but painful

FOURNIER'S GANGRENE
• Sudden scrotal inflammation, with rapid onset of gangrene leading to exposure of the scrotal contents.
• An obvious cause is absent in over half the cases.
• can arise following minor injuries or procedures in the perineal area, such as a bruise, scratch, urethral
dilatation, injection of haemorrhoids or opening of a periurethral abscess
• Many patients have concurrent illnesses that diminish their defences, most notably diabetes mellitus and
alcoholism.
• Infections are usually polymicrobia (aerobic and anaerobic bacteria)
• Fulminating inflammation of the subcutaneous tissues results in an obliterative arteritis of the arterioles to
the scrotal skin
• Treatment involves urgent surgical debridement of necrotic tissue in combination with intravenous
antibiotics
• Despite best therapy, mortality rates as high as 50 per cent are often reported

Corbus disease (Gangrenous balanitis)

• Affects exclusively glans penis
• Spares the penile fascia, dartos and foreskin (in contrast to Fournier's gangrene)
• Caused by anaerobic microorganisms
• Associated with poor hygiene
• May cause total necrosis of glans

Infectious causes of sterile pyuria Non infectious

• Chlamydia • Calculi
• Ureaplasma • Anatomic abnormality, VUR
• Mycobacterium TB • Polycystic disease
• Fungal infections • Interstitial nephritis

CATHETERS
Types
• Nonself-retaining catheter: Simple red rubber catheter.
 • Self-retaining catheter: Foley's catheter, Malecot's catheter, Gibbon's catheter, De-Pezzer catheter

Types of catheterization
• Indwelling catheterisation: catheter is left behind in bladder and remains

Ballon tip of catheter—Foley's catheter

Flower tip of catheter—Malecot's catheter, De- Pezzers.

Straping catheter externally—Gibbon's catheter.
• Intermittent catheterisation: A sterile catheter is introduced intermittently by the patient or by others

FOLEY'S CATHETER
• Usuallykept for 7 days.
• Size: Adults-16 F; Children-8 F or 10 F.
• F—French unit; each unit equals 0.33 mm
• 16 F means circumference of the catheter is 16 mm
• Diameter is one-third of circumference

MALECOT'S CATHETER
• Never introduced per urethrally
• Used in Suprapubic cystostomy (SPC) - when Foley's catheterization fails (after two trials)
• Can be kept for a longer duration (3 months).
• Less infection rate.
 VII. THYROID
Essential thyroid investigations
• Serum: TSH
• Free T3 and Free T4
• Thyroid autoantibodies
• FNAC of palpable discrete swellings

 Assays of total T3 and T4 are now obsolete

THYROID FUNCTION TESTS

Thyroid functional state TSH (0.3-3.3mU/L) Free T4(10-30nmol/L) Free T3(3.5-7.51.tmol/L)
Euthyroid N N N
Thyrotoxic Undetectable High High
Myxedema High Low Low
Suppressive T4 therapy Undetectable High High (often normal)
T3 toxicity Low/undetectable Normal High

IMAGING
Isotope Scanning
• Not indicated routinely - principal value is in the toxic patient with a nodule or nodularity of the thyroid
• 80% cold swellings are benign
• 5% warm swellings are malignant

Radioactive iodine
• I131- radioiodine therapy
• I123 - diagnostic studies

FNAC
• Investigation of choice in discrete thyroid swellings
• Thyroid conditions that may be diagnosed by FNAC

Colloid nodules

Thyroiditis

Papillary carcinoma

Medullary carcinoma

Anaplastic carcinoma

Lymphoma
• FNAC cannot differentiate benign follicular adenoma and follicular carcinoma

Classification of FNAC reports

FNAC report Next step
Non diagnostic Repeat FNAC
Non neoplastic Follow-up
Intermediate follicular neoplasm I231 scan  cold  surgery
I231 scan  hot  follow
Intermediate Hurthle cell neoplasm SURGICAL RESECTION
Suspicious of malignancy
Malignant
Ultrasound
• Good anatomical details
• Reveals more number of clinically irrelevant swellings
• Physical characteristics of swellings
• Guide to take biopsy
• Parathyroid adenomas
• Nodes involved in thyroid cancer
• Features suggestive of malignancy in USG

Microcalcifications

Hypervascularity

Infiltrative margin

Hypoechoic compared with surrounding parenchyma

Shape that is taller than its width on transverse view

 MC solitary thyroid nodule – Benign colloid nodule > Follicular adenoma

ENDEMIC GOITRE
• Most common cause – iodine deficiency
• Most patients are asymptomatic
• Patients often complaints of pressure sensation in the neck

HYPOTHYROIDISM
Cretinism Adult hypothyroidism
• Hoarse cry Signs Symptoms
• Macroglossia • Bradycardia • Tiredness
• Umbilical hernia • Cold extremities • Mental lethargy
• Screening by TSH and T4 • Dry skin and hair • Cold intolerance
assays in the heel prick • Periorbital puffiness • Weight gain
blood sample of • Hoarse voice • Constipation
neonates • Bradykinesia • Menorrhagia
• Delayed relaxation phase of ankle jerks • Infertility
(most useful clinical sign) • Carpel tunnel syndrome
• Wolff-Chaikoff effect – iodides inhibit the further release of hormone causing hypothyroidism (Hokkaido
goiter)

HYPERTHYROIDISM
• Primary thyrotoxicosis: Graves' disease (MCC of hyperthyroidism)
• Secondary thyrotoxicosis: Plummer disease
• Thyrotoxicosis factitia – intake of L-thyroxine more than normal
• Jod Basedow thyrotoxicosis – large doses of iodides given to a case of hyperplastic endemic goiter
• Autoimmune thyroiditis or deQuervain's thyroiditis

Diffuse toxic goiter (Graves' disease) Toxic nodular goiter.

 • Primary thyrotoxicosis • Secondary thyrotoxicosis
• Goiter appearing at the same time as hyperthyroidism • Goiter present long before
• Young women hyperthyroidism
• Eye signs (exophthalmos) • Middle and older age
• Cardiac failure rare • Rarely associated with eye signs
• Family history of autoimmune endocrine diseases • Cardiac failure common
• Diffuse vascular goiter; Whole thyroid tissue involved • Hyperthyroidism is due to
• Hypertrophy and hyperplasia due to abnormal thyroid stimulating autonomous thyroid tissue
antibodies (TSH-RAbs); long acting thyroid stimulator(LATS)

Graves' disease also known as - Basedow's disease, Exophthalmic goitre, Parry's disease, Begbie's disease,

Eye signs in thyrotoxicosis

• Stellwag's sign: staring look, absent of normal blinking, first sign to appear(mild hyperthyroidism)
• Von Graefe's sign(Lid Lag sign): inability of upper eyelid to keep pace with the eyeball (mild)
• Joffroy's sign: absence of wrinkling on forehead when the patient looks up(frowns)(moderate)
• Moebius sign: lack of convergence of eyeball(severe hyperthyroidism)
• Dalrymple's sign: upper eyelid retraction, sclera visible
• Jellinek's sign: increased pigmentation of eyelid margins
• Enroth sign: edema of eyelids and conjunctiva
• Rosenbach's sign: tremor of closed eyelids
• Gifford's sign: difficulty in everting upper eyelid in primary toxic thyroid. Differentiates exophthalmos from
other causes
• Loewi's sign: dilation of pupil with weak adrenaline solution
• Knie's sign: unequal dilation of pupil
• Cowen's sign: jerky papillary contraction to consensual light
• Kocher's sign: when clinician places his hands on patient's eyes and lifts it higher, patient's upper eyelid
springs up more quickly than eye brows
• Naffziger's sign: with patient in sitting position and neck fully extended, protruded eyeball can be visualized
• when observed from behind
• Proptosis due to infiltration of retrobulbar tissues with fluid and round cells
• Weakness of extraocular muscles(particularly inferior oblique) results in diplopia
• The most common ocular motility defect is a unilateral elevator palsy caused by the involvement of inferior
rectus; next common – failure of abduction due to involvement of medial rectus

Clinical features
Thyrotoxicosis eight times more common in women
Symptoms Signs
• Tiredness • Tachycardia (even during sleep)
• Emotional labiality • Hot, moist palms
• Heat intolerance • Thyroid goiter and bruit
• Weight loss • Muscle wasting
• Excessive appetite • Proximal limb muscle weakness
• Palpitations • Fine tremors
• Oligo/amenorrhea • Hyperactive tendon reflexes
• Pretibial myxedema
• Thyroid acropachy (clubbing of fingers and toes)
Investigations
• Serum T3 and T4 levels are very high.
• TSH is very low or undetectable.
• Sometimes, only T3 level is increased and is called as T3 toxicosis

Treatment in Thyrotoxicosis
• Radioiodine contraindicated in children because of risk of carcinoma
• Carbimazole is the drug of choice for preparation of the patient for surgery
• Propranolol is also effective for pre-operative preparation

Diffuse toxic goiter

• Age >45 years: radioiodine
• Age <45 years: surgery(subtotal thyroidectomy )

Toxic nodular goiter

• Surgery

Toxic solitary nodule

• Age > 45 years: radioiodine
• Age < 45 years: hemithyroidectomy

Recurrent Thyrotoxicosis after surgery

• Age > 45 years: Radioiodine
• Age < 45 years: Anti-thyroid drugs

Failure of antithyroid drugs or radioiodine

• Surgery or thyroid ablation with I231

Children
• Increased risk or recurrence after surgery
• Treated with anti-thyroid drugs until late teens

Cardiac patients
• Radioiodine with anti-thyroid drugs

Thyrotoxicosis in pregnancy
• Radioiodine is absolutely contraindicated during pregnancy
• Propyl thiouracil is preferred in pregnancy
• Near total thyroidectomy can be done in second trimester

THYROID CARCINOMA
Etiology
• Irradiation during childhood (particularly for papillary carcinoma)
• Malignant lymphomas develop from autoimmune thyroiditis

Risk factors for thyroid carcinoma in patients with thyroid nodule

 • History of head and neck irradiation • Family history of thyroid cancer or MEN2
• Age < 20 or > 45 years • Vocal cord paralysis/hoarse voice
• Bilateral disease • Nodule fixed to adjacent structures
• Increased nodule size(> 4cm) • Extra thyroidal extension
• New or enlarging neck mass • Suspected lymph node involvement
• Male gender • Iodine deficiency(follicular cancer)

Diagnosis
• Failure to take up radioiodine is characteristic of all thyroid carcinomas
• FNAC
• Incisional biopsy may cause seeding of cells and local recurrence and hence not advised in resectable cancers

PAPILLARY CARCINOMA (80%)

• Most common type of thyroid carcinoma
• More common in women
• Mostly in the age group 25 – 50
• Mutations in RET or BRAF gene
• Associated with previous exposure to ionizing radiation
• Histology

Nuclei: optically clear or empty appearance – groundglass or Orphan Annie eye nuclei

Crowded nuclei may demonstrate grooving

Psammoma bodies

Seldom encapsulated

Multiple foci seen

Histologic variants – follicular (most common), tall cell, diffuse sclerosing, insular, columnar
• Slowly progressive and less aggressive tumor
• Thyroglobulin is used as tumor marker
• Spread to lymph nodes is common, blood borne metastasis is unusual
• Lymph node status does not alter the prognosis
• Seen as cold masses on scintiscans
• Classic papillary carcinoma and follicular variant - Excellent prognosis
• All other subtypes – aggressive

Diffuse sclerosing variant

• Occurs in younger individuals, including children
• Extensive, diffuse fibrosis throughout the thyroid gland
• Often associated with a prominent lymphocytic infiltrate, simulating Hashimoto thyroiditis
• Lymph node metastases are present in almost all cases.
• Lack BRAF mutations, but RET/PTC translocations are found in 50% cases

Microcarcinoma (Occult carcinoma)

• Papillary cancers less than 1 cm
• Most commonly come to attention as an incidental finding in patients undergoing surgery
• Majority of such tumours never progress to become a clinically significant entity
• Have a uniformly excellent prognosis

Factors associated with worse prognosis

• Male gender
 • Age > 40 gars
• Size > 3 cm
• Tall cell variant

FOLLICULAR CARCINOMA (15%)

• More common in women
• Present at older age (40 – 60 years)
• More frequent in areas with dietary iodine deficiency (endemic goitre)
• Acquired mutations that activate RAS or the PI-3K/AKT arm of the receptor tyrosine kinase signalling
pathway
• Mutations in RAS, PIK3CA or PTEN also seen
• Macroscopically capsulated but microscopically capsular invasion seen
• Multiple foci are seldom seen
• Occurs in long standing MNG
• More aggressive tumor
• Lymph node involvement less common than papillary carcinoma
• Blood borne metastasis commonly seen (Lungs > Bones [osteolytic lesions] > CNS)
• Pulsatile secondaries are seen (also in Renal cell carcinoma)
• Mostly they are cold nodules on scinti scans, but well differentiated tumors may appear warm
• Hurthle cell carcinoma

Variant of follicular carcinoma

Older age group (60-75 years)

Secretes thyroglobulin

Abundant oxyphil cells

Spreads more commonly to regional lymph nodes

Hematogenous spread to bones

Poorer prognosis than follicular carcinoma

Factors associated with worse prognosis

• Male gender
• Age > 40 yars
• Size > 3 cm
• Poorly differentiated cell type

• Age at diagnosis — most important prognostic factor in well-differentiated thyroid cancer

Treatment of differentiated thyroid cancer

• Tumors > 2 cm with nodal involvement an/or metastases: Total thyroidectomy + node dissection +
radioiodine ablation + long term TSH suppression
• Tumors < 2 cm without nodal involvement or metastases: lobectomy
• Solitary intrathyroidal papillary microcarcinoma: no clinically involved cervical lymph nodes, no history of
head and neck radiation unilateral thyroid lobectomy and isthmusectomy
• Thyroid cancer > 1 cm or papillary cancer < 1 cm: clinically positive nodal disease, multicentricity, or a
history of head and neck radiation  total or near-total thyroidectomy, followed by radioablation
• TSH suppression: thyroxine 0.1— 0.2 mg daily for all patients after operation for differentiated thyroid
carcinoma on the basis that most tumours are TSH dependent.
MEDULLARY CARCINOMA (5%)
• Tumors of the parafollicular C cells derived from the neural crest
• 70% sporadic — solitary nodule
• Familial cases — bilateral and multicentric
• Can be a part of MEN 2A and 2B; Most aggressive form associated with MEN2B
• RET protooncogene mutation in sporadic and familial cases
• Characteristic amyloid stroma
• Lymph node spread common
• Calcitonin and CEA are secreted and are used for follow up after resection to detect recurrence
• Diarrhea is common and may be due to serotonin or prostaglandins secreted by the tumor cells
• Despite the very high levels of calcitonin found in some patients, hypocalcaemia is extremely rare
• CGRP(calcitonin gene related peptide), ACTH and VIP are also secreted by the tumor cells
• Do NOT take up RAI
• NOT hormone dependent
• Treatment: total thyroidectomy + prophylactic or therapeutic resection of central & bilateral cervical lymph
nodes

Factors associated with worse prognosis

• MEN2B (aggressive form)
• Sporadic

ANAPLASTIC CARCINOMA (10%)

• Elderly women; Most aggressive
• Spread by direct invasion, lymph nodes and blood stream
• Poor prognosis
• Berry's sign: absent carotid pulsation due to invasion of carotid sheath
• AJCC classification: All anaplastic thyroid cancers are considered stage IV; T4a — intrathyroidal anaplastic
cancer, T4b — extrathyroidal anaplastic cancer
• No treatment satisfactory
• Isthumectomy (if the tumor compress trachea ) + radiotherapy + chemotherapy may prolong survival

 Thyroid cancer at a young age (<20) or in older persons (>45) is associated with a worse prognosis.
 Thyroid cancer is twice as common in women as men, but male gender is associated with a worse prognosis.

THYROIDITIS
• Chronic lymphocytic or Hashimoto's thyroiditis or Non goitrous or Struma Lymphomatosa
• Polymorphisms in immune regulation-associated genes, including cytotoxic T lymphocyte-associated
antigen-4 (CTLA4) and protein tyrosine phosphatase-22 (PTPN22)
• Mechanism of thyroid cell death

CD8+ cytotoxic T cell-mediated cell death

Cytokine-mediated cell death

Less likely - Thyroid Abs against thyroglobulin, thyroid peroxidase (mc) or TSH- Receptor
• Family history of autoimmune disease
• MC in women at menopause
• Painless enlargement of both lobes, which are firm, rubbery, firm and tender
• Extensive mononuclear inflammatory infiltrate
• No colloid in the follicle
• Hurthle cells or Askanazy cells
 • Mild hyperthyroidism present initially but hypothyroidism is inevitable
• Occasionally predisposes to papillary CA
• Increased risk for the development of extranodal marginal zone B-cell lymphomas within the thyroid gland

Hashitoxicosis
• Transient thyrotoxicosis caused by disruption of thyroid follicles, leading to release of thyroid hormones
• Free T4 and T3 levels are elevated, TSH is diminished, and radioactive iodine uptake is decreased

Granulomatous or De Quervain's thyroiditis Riedel's thyroiditis or Ligneus thyroiditis

• Women, 40-50 years • Very rare
• Follows URI; Viral etiology • Thyroid tissue replaced by fibrous tissue
• Fever • Associated with retroperitoneal and
• Painful thyroid swelling mediastinal fibrosis
• TESR, high normal T4, no Abs • Hard and fixed goiter
• Low radio-iodine uptake • High dose steroids and thyroid replacement
• Self-limiting. After a period of hyperthyroidism, • Treatment: isthumectomy to relieve airway
eventual recovery compression. Thyroidectomy is not necessary
• Prednisolone
 Autoimmune thyroiditis is the most common cause of hypothyroidism in iodine sufficient areas of the world
 Transient hypothyroidism is seen in all types of thyroiditis EXCEPT Reidel's thyroiditis

Subacute lymphocytic (painless) thyroiditis

• Mild hyperthyroidism, goitrous enlargement of the gland, or both.
• Can occur at any age, it is most often seen in middle-aged adults and is more common in women
• Can occur during the postpartum period in up to 5% of women (postpartum thyroiditis)
• Most patients have circulating antithyroid peroxidase antibodies or family h/o other autoimmune disorders.

THYROGLOSSAL CYST
• Tubulodermoid type of cyst
• Most common site is the sub-hyoid region
• Midline swelling(except in the region of thyroid cartilage where it is pushed usually to the left side)
• Congenital but swelling presents at the age of 15-30 yrs
• Thyroglossal fistula is always acquired
• Cyst can be moved sideways but not up and down
• Moves up with the protrusion of tongue; moves with deglutition
• Rarely papillary carcinoma may develop
• Surgery – Sistrunk operation (removal of the cyst + track + central part of hyoid bone + portion of the
tongue base up to the foramen cecum

Thyroid operations
• Lobectomy = total lobectomy + isthumectomy
• Total thyroidectomy = 2 x total lobectomy + isthumectomy
• Subtotal thyroidectomy = 2 x subtotal lobectomy + isthumectomy
• Near total thyroidectomy = total lobectomy + isthumectomy + subtotal lobectomy

COMPLICATIONS OF THYROIDECTOMY
• Reactionary hemorrhage

Within 6-8 hours, due to slipping of ligatures

May cause stridor, respiratory obstruction due to tension hematoma

Re-exploration of neck under GA, control bleeding and evacuate hematoma
• RLN palsy: usually transient recovers in 3 weeks to 3 months.
• Hypoparathyroidism

Less common, usually temporary

Appears on 2-5th postoperative day

Due to vascular spasm of parathyroid glands
• Thyroid storm or Thyrotoxic crisis

Precipitated by abrupt cessation of antithyroid medications, infection, thyroid or nonthyroid surgery,
and trauma in patients with untreated thyrotoxicosis.

In patients who are not adequately prepared for thyroidectomy

Present within 12-24 hrs

Treatment: IV.Propanolol. IV hydrocortisone, carbimazole, Lugol's iodine drops, rehydration, cooling
the patient with icepacks, digoxin for AF

Thyroid storm is an acute, life-threatening emergency

The adult mortality rate is extremely high (90%).
• Hungry bone syndrome

Rapid influx of serum calcium in to bones in the immediate postoperative period may cause severe
hypocalcemia

Due to sudden drop in PTH after surgery

Treatment: IV calcium gluconate

Euthyroid sick syndrome

• Seen in severely ill patients
• Peripheral thyroid hormones may be reduced, without a compensatory increase in TSH levels
 VIII. BREAST

INVESTIGATIONS
Mammography
• The dose of radiation is 0.1cGy and therefore it is very safe
• The sensitivity increases with age as the breast becomes less dense
• In total 5% of breast cancers are missed by population based mammographic screening programmes
• Tomo-mammography is a more sensitive diagnostic modality
• Normal mammogram does not exclude the presence of carcinoma

Screening mammography – 2 views

• Craniocaudal view
• Mediolateral oblique view

Diagnostic mammography – 2 additional views

• 90° lateral view
• Spot compression view
• Accuracy 90-95%

Benign lesion Malignant lesion

• Smooth margins • Ill defined margins
• Macrocalcification • Microcalcification
• Normal breast parenchyma • Architectural distortion
• Ducts normal • Focal dilation of ducts

Ultrasound
• Useful in young women with dense breasts
• In distinguishing cystic from solid lesions
• Not useful as a screening test
• USG of axillary tissue is performed when a cancer is diagnosed and guided percutaneous biopsy of any
suspicious glands may be performed

MRI
• Can be useful to distinguish scar from recurrence in women who have had previous breast conservative
therapy for cancer (although it is not accurate within 9 months of RT because of abnormal enhancement)
• It is becoming the standard of care when a lobular cancer is diagnosed to assess for multifocality and
multicentricity and can be used to assess the extent of DCIS
• Best imaging modality for the breasts of women with implants
• Useful as a screening tool in high risk women
• Less useful than USG in the management of the axilla in both primary breast cancer and recurrent disease

Needle biopsy/cytology
• A histological specimen taken by core biopsy

Allows a definitive preoperative diagnosis

Differentiates duct carcinoma in situ from invasive carcinoma

Allows the tumor to be stained for receptor status(important before commencing neoadjuvant therapy)
Triple investigation
• Any patient presenting with breast lump or other symptoms suggestive of carcinoma, the diagnosis should
be made by a combination of

Clinical assessment

Radiological imaging

Cytological/Histological analysis

The positive predictive value of this combination should exceed 99.9%

Discharges from nipple

Discharge from single duct Discharge from more than one duct
Blood stained Serous Blood stained or serous Purulent
• Intraduct papilloma • Fibrocystic • Carcinoma • Infection
• Intraduct carcinoma disease • Ectasia Milk
• Duct ectasia • Duct ectasia • Fibrocystic disease • Lactation
• Carcinoma Black or green • Hypothyroidism
• Duct ectasia • Pituitary tumor
 MCC of spontaneous nipple discharge from a single duct -intraductal papilloma

DUCT ECTASIA/PERIDUCTAL MASTITIS

• Dilated subareolar ducts that are palpable
• More common in smokers
• Nipple discharge (of any colour), a subareolar mass, abscess, mammary duct fistula and/or slit like nipple
retraction
• Carcinoma must be excluded
• Definite treatment: excision of all of the major ducts (Hadfield's operation)

Cyclical mastalgia
• Oil of evening primrose - higher responserates in those over 40 years of age rather than younger women.
• Intractable symptoms – danazol (anti-gonadotrophin), or Bromocriptine (prolactin inhibitor)
• Rarely needed: tamoxifen (anti-estrogen), or a luteinising hormone- releasing hormone (LHRH) agonist

BENIGN BREAST DISEASE

AMAZIA
• Congenital absence of breast on one or both sides
• Associated with the absence of sternal portion of pectoralis major (Poland's syndrome)
• More common in males

POLYMAZIA
• Accessory breasts along milkline or Manchester line
• Most common site: axilla
• They may function during lactation

MASTITIS OF INFANTS
• Common in both boys and girls
• On the 3rd or 4th day of live, if an infant's breast is pressed lightly, a drop of colorless fluid may be expressed
• Few days later there is a milky secretion (witch's milk, only in full term infants); disappears during 3rd week
• True mastitis is uncommon and predominantly caused by Staph aureus
MONDOR'S DISEASE
• Thrombophlebitis of superficial veins of breast and anterior chest wall
• Only treatment is restriction of arm movements and in any case the condition subsides within a few months

Aberrations of normal development and involution (ANDI)

• Consists of essentially four features

Cyst formation

Fibrosis

Hyperplasia of epithelium lining the ducts and acini

Papillomatosis
• There may be increase in both lumpiness and tenderness before a menstrual period

TRAUMATIC FAT NECROSIS

• Usually occurs in stout, middle-aged women
• Following a blow, or indirect violence (e.g. contraction of the pectoralis major), a lump, often painless,
appears
• May mimic a carcinoma, even displaying skin tethering and nipple retraction; biopsy is required for diagnosis

FIBROADENOMA
• Aberration(Hyperplasia) of normal development(AND) of a single lobule
• Age 15-25 years
• Capsulated, smooth, firm, nontender, freely mobile(mouse in the breast)
• Popcorn calcification on mammography
• A fibroadenoma does not require excision unless there is suspicious histology on FNAC
• Giant fibroadenomas > 5cm are often rapid growing and can be enucleated using submammary incision

PHYLLODES TUMOR (SEROCYSTIC DISEASE OF BRODIE/CYSTOSARCOMA PHYLLOIDES)

• Benign tumor, sometimes malignant, rarely cystic
• Large tumor with an unevenly bosselated surface
• Usually in women > 40 yrs; but can appear in younger women
• Mobile on chest wall
• Histologically similar to fibroadenoma, but few tumors show high mitotic index
• Enucleation for benign type in young women
• Total mastectomy for massive, recurrent and malignant histology

BREAST CARCINOMA
Relative Risk of breast cancer in benign breast diseases (BAILEY)
No increased risk (RR= 1) Mild increased risk (RR 1.5-2)
• Adenosis (sclerosing or florid) • Moderate or florid hyperplasia
• Apocrine metaplasia • Sclerosing adenosis
• Micro or macro cysts • Papilloma
• Duct ectasia • Complex Sclerosing lesion (radial scar)
• Fibroadenoma without complex features • Fibroadenoma with complex features
• Mild hyperplasia Moderately increased risk (RR 4-5 )
• Fibrosis • Atypical ductal hyperplasia
• Mastitis/periductal mastitis • Atypical lobular hyperplasia
• Squamous metaplasia
 Etiological and epidemiological factors
• Western countries • High breast radiodensity
• Old age (> 77 % case above 50 yrs) • Radiation exposure
• Female gender • Early menarche (< 11 years)
• Mutations in tumor suppressor genes • Late menopause (> 55 years)

BRCA 1 (60-80% risk) • First full term pregnancy > 35 yrs

BRCA 2 (50% risk) • Nulliparous

TP53 • Ca of contralateral breast or endometrium

CHEK2 • Hereditary syndromes
• Family history of breast cancer (15-20 % have
Li Fraumeni syndrome
h/o
Cowden's syndrome
• Breast cancer among first degree relatives)
HNPCC syndrome
• High socioeconomic status
Peutz Jegher's syndrome
• Heavy alcohol
Ataxia telangiectasia
• Hormone replacement therapy

BRCA1 associated breast cancer BRCA2 associated breast BRCA 1 & BRCA 2 associated
cancer cancers
• Poorly differentiated (have • Poorly differentiated • Ovarian cancer
medullary features) • More often ER positive • Prostatic cancer
• Do not express hormone • Pancreatic cancer
receptors • Male breast cancer (more with
• (triple-negative) • BRCA2)
• Overexpress HER2/neu
 BRCA1 and BRCA2 - inherited in an autosomal dominant fashion with varying degrees of penetrance

Factors that decrease risk of breast cancer Oral contraceptive pills

• Longer duration of breast feeding • Do not increase breast cancer risk
• First full term pregnancy < 20 years (ROBBINS)
• Oophorectomy • Reduce risk of
• Tamoxifen & Aromatase inhibitors (↓risk of ER positive • Endometrial carcinoma
cancers) • Ovarian carcinoma

Not associated with breast cancer – cigarette smoking

Molecular subtypes of Invasive (Infiltrating) breast cancer

ER-positive, HER2-negative
Most common type (40 - 55%)
40-55% of cancers (Low proliferation) 10% (High proliferation)
• Majority of cancers in older women, Men • Most common type associated with
• MC type detected by mammographic screening BRCA2 mutations
• Lowest incidence of local recurrence
• Metastasize late and typically to bone
• Respond well to hormonal treatment
Metastasis to bone more common than viscera and brain

HER2-Positive ER-Negative; HER2-Negative

(ER-Positive or Negative) (basal like triple negative carcinoma)
Second most common - 20% 15% - Carcinomas with medullary features
 • Young women, non-white women • Young premenopausal women
• Half of these cancers are ER-positive. • BRCAI mutation carriers
• When present, ER expression is usually low; • Likely to present as palpable mass
• progesterone receptor expression is often • Local recurrence is common, even after
absent mastectomy
• TP53 mutation carriers (ER positive)
• Complex interchromosomal translocations,
high- level amplifications of HER2, and a high
mutational load
Can metastasize when small in size and early in the course often to viscera and brain
• Menopausal hormone therapy is associated with an increase in ER-positive cancers

LOBULAR CARCINOMA IN SITU DUCTAL CARCINOMA IN SITU (DCIS)

• Originates from the terminal duct lobular units • Predominantly seen in the female breast,
• Develops only in the female breast • Accounts for 5% of male breast cancers
• Signs: none • Signs: mass, pain, nipple discharge
• No calcifications • Mammography: microcalcifications
• Less likely to be detected by mammography • Almost always detected by mammography
• Bilateral and multicentric • Poorly differentiate
• Average age at diagnosis 45 years • Average age at diagnosis: > 60 years
• Pagetoid spread, does not involve nipple • ER-negative, and overexpress HER2
• Always expresses ER and PR. • Invasive cancers - observed in the ipsilateral
• Overexpression of HER2 is not observed breast, usually in the same quadrant
• Lack of E-cadherin Types
• Invasive cancer may develop in either breast, • Comedocarcinoma
regardless of the initial focus of LCIS; up to 65% • Non comedo DCIS
of subsequent invasive cancers are ductal • Paget's disease of nipple – superficial
carcinoma manifestation of underlying ductal carcinoma
• Infiltrating ductal ca – worst prognosis

INVASIVE DUCTAL CARCINOMA

• Invasive ductal carcinoma with productive fibrosis (scirrhous, simplex, NST) - 80% of breast cancer
• Tend to grow as a more cohesive mass; form discrete abnormalities on mammograms
• Often palpable as a discrete lump in the breast at a smaller size compared with lobular cancers

INFLAMMATORY CARCINOMA/LACTATING CARCINOMA/MASTITIS CARCINOMATOSIS

• Common in lactating women, pregnancy
• Most malignant form of breast cancer
• Comes under stage IIIb(T4d)
• Presents with painful, swollen breast, peau d' orange skin and warmth
• Involves atleast 1/3rd of the breast and may mimic a breast abscess
• Diffuse infiltration of tumor, no distinct tumor mass
• Biopsy shows tumor cells within Iymphatics(hall mark)
• Rapidly fatal
• Treatment: Aggressive chemotherapy + salvage surgery + radiotherapy

PAGET'S DISEASE OF THE NIPPLE

• Presents as an eczema-like condition of the nipple and areola, which persists despite local treatment
 • Eczema begin on the areola: Paget's disease originates on the nipple and secondarily involves the areola
• The nipple is eroded slowly and eventually disappears
• Histology: Paget cells - large, ovoid vacuolated cells which do not invade the dermal basement membrane -
thereforecategorized as carcinoma in situ
• There is often an underlying intraductal carcinoma
• May be accompanied by a palpable mass in just over 50% of patients
• May be confused with superficial spreading melanoma
• Melanoma: S-100 antigen immunostaining: melanoma
• Paget's disease: carcinoembryonic antigen immunostaining

 Most common breast carcinoma - Infiltrative Ductal carcinoma

 Most common subtype – No special subtype (NOS)
 Best prognosis/Least aggressive – Tubular >Colloid (Mucinous)
 Worst prognosis – Infiltrating Ductal Carcinoma NOS
 Medullary carcinoma – marked lymphocytic reaction
 Disease of Relcus: rare intracystic papilliferous carcinoma of breast

The spread of breast cancer

Lymphatic metastasis Blood stream
• Primarily to axillary and the internal mammary • Bones are the most common site of
nodes (tumors of the posterior 1/3rd of the breast) metastases(osteolytic metastasis)
• Axillary LN status is the single most important • Lumbar vertebrae are me followed by femur,
prognostic factor thoracic vertebrae, ribs and skull
• Interpectoral nodes (Rotter's nodes) • Lungs, liver, adrenals and brain

Sentinel node
• Also called Guiliano's glands (discovered by Alexandra Guiliano)
• First node receiving lymphatic drainage from the cancer site
• Reduces unwanted LN dissection and thereby decreasing incidence of Lymphedema
• Sentinel node is localized postoperatively by injection of patent blue dye and radioisotope-labelled albumin
• The recommended site of injection is in the Subdermal plexus around the nipple
• In patients where there is no involvement of sentinel node, further axillary dissection can be avoided
• May have a role in prognosis as it detect micro metastasis that results in change in staging and treatment
• Sentinel node biopsy is also done in malignant melanoma, carcinoma colon and carcinoma penis

Clinical features
• Most common site is the upper outer quadrant
• Cancer-en-curaisse – involvement of chest wall
• Peau d' orange skin

Cutaneous lymphatic edema

Infiltrated skin tethered by sweat glands giving orange skin appearance

Staging: Tumor size is the second most important prognostic factor

T0 No clinical evidence of tumor
Tis Carcinoma in situ
T1 Tumor < 2cm
T2 2-5cm
T3 >5cm
 T4 Tumor of any size with extension to chest wall or skin or both
• T4a Extension to chest wall
• T4b Peau d' orange or ulceration of skin
• T4c Both 4a and 4b
• T4d Inflammatory carcinoma

N0 No regional lymph node metastasis

N1 Ipsilateral axillary nodes, mobile
N2
• N2a Ipsilateral axillary nodes, fixed
• N2b Ipsilateral internal mammary node but not axillary node
N3
• N3a Ipsilateral infraclavicular lymph node
• N3b Ipsilateral internal mammary and ipsilateral axillary node
• N3c Ipsilateral supraclavicular node

Prognostic factors
• Most important: Tumor staging

Lymph node status (1st)

Tumor size (2nd)
• Histological grade of the tumor
• Hormone receptor status
• Measures of tumor proliferation (e.g. S-phase fraction)

Van Nuys system – for DCIS

• Criteria

Age

Type of DCIS and presence of microcalcification

Extent of resection margin

Size of disease
• Patients with high score – Excision followed by Radiotherapy
• Patients with low score – Complete excision only

Surgeries for breast cancer

• Tylectomy – excision of lump
• Simple mastectomy - Palpable extent of breast + overlying skin
• Total mastectomy – removes all breast tissue, nipple-areola complex (NAC) and skin
• Subcutaneous - Palpable extent of breast (WITHOUT overlying skin)
• Extended simple mastectomy – simple mastectomy + removal of level I axillary nodes
• Halstead's radical mastectomy – entire breast tissue + removal of level I, II and III axillary nodes + pectoralis
major and minor muscles + overlying skin
• Extended Radical (Urbon) = Halsted's + Internal mammary LN
• Extended Radical (Dahl-Iverson) mastectomy = Halsted's + Internal mammary LN + Supraclavicular LN
• Super Radical mastectomy = Halsted's + Internal mammary LN + Supraclavicular LN + Mediastinal IN
• Toilet mastectomy = only affected part (palliative/debulking)
• Modified radical mastectomy – entire breast tissue + NAC + skin + ALN (level I + II ± Ill)

Patey's = P. minor removed

Scanlon's = P. minor divided

Auchincloss = P. minor only retracted (not removed)
 • Structures preserved in Halstead's radical mastectomy

A – Axillary vein

B – Bell's nerve (Long thoracic nerve to serratus anterior)

C – Cephalic vein

Complications of mastectomy and axillary node dissection

• Seromas beneath the skin flaps or in the axilla - most frequent complication
• MC early post-op complication – Skin flap necrosis
• Lymphedema occurs in 20%
• Stewart-Treves syndrome – lymphangiosarcoma occurring due to long standing lymphedema secondary to
MRM

Breast conservative surgery

• Removing tumor plus a rim of atleast 1cm of normal breast tissue, adjuvant radiotherapy ± assessment of
axillary LN status
• Surgical precedures: wide local excision, lumpectomy, quadrantectomy
• Currently the TOC for women with DCIS, Stage I and Stage II invasive breast cancer

Indications Contraindications
• Lump < 4cm • Tumor margin +ve after breast conservative surgery
• Clinically negative axillary nodes • Poorly differentiated tumor
• Mammographically detected lesion • Multicentric tumor
• Well differentiated tumor • Earlier breast irradiation
• Adequate size breast to allow proper • Tumor/Breast size ratio is more
radiotherapy • Tumor beneath nipple
• Feasibility of axillary dissection and RT to • Extensive intraductal carcinoma
intact breast • Pregnancy
 NOT a contraindication for Breast Conservative Surgery – Age, Bilaterality, positive family history

• QUART therapy

Quadrantectomy (removing entire segment of breast that contains the tumor)

Axillary dissection of level I and II nodes

Post-operative RT to breast

Treatment of breast carcinoma

• DCIS – simple mastectomy
• LCIS – observation with tamoxifen
• Stage I and II – MRM
• Radiotherapy

T3 tumor > 5cm

Positive margins/ close margins < 2cm

After conservative surgery/quadrantectomy

Inflammatory carcinoma

Metastases to 4 or more lymph nodes

High risk group
• Hormone therapy:

Reduces local recurrence

After breast conservative surgery for women having
o High risk-node negative
 o Receptor positive tumors
o Bone or soft tissue metastases only
o Limited or asymptomatic visceral metastases

Premenopausal women Post-menopausal women

• Tamoxifen (antiestrogen) • Aromatase inhibitor (anastrozole, letrozole,
• Ovarian ablation by surgery, Goserelin- exemestane)
an LHRH agonist (medical • Tamoxifen
oophorectomy). • Androgens
• Fluoxymestrone (androgen) • Progestogens
• Medroxyprogesterone (progestogen) • Aminoglutethamide (Medical adrenalectomy)

• Monoclonal antibodies

Transtuzumab (herceptin) – active against tumors containing the growth factor receptor c-erbB2

Bevacizumab – VGFR inhibitor

Lapitinab – combined growth factor receptor inhibitor
• Systemic Chemotherapy

Hormone receptor negative

Hormone refractory (after 3 cycles)

Symptomatic visceral metastases
• Chemotherapy regimes

CMF (cyclophosphamide, methotrexate, 5-fluorouracil)

Modern regimes include CMF + anthracycline(doxorubicin or epirubicin) + taxanes

CAF (cyclophosphamide, Adriamycin, 5-FU)

MMM (methotrexate, mitomycin-C, mitoxantrone)

 CA 15/3 is a tumor marker and used during follow up period

Prognosis
Favorable prognosis Unfavorable prognosis
• Tubular, colloid, papillary • Scirrhous type
types • Aneuploidy
• Positive hormone receptors • High expression of HER-2/neu, cathepsin D and EGFR
• Diploidy • Worst prognosis: Inflammatory ca > Infiltrating ductal ca
• Elastic fibres in histology

Breast reconstruction
• Easiest is using silicone gel implant under pectoralis major muscle
• If the skin at the mastectomy site is poor or large volume of tissue is required then a musculocutaneous flap
is
constructed from either the latissimus dorsi(the LD flap) or the transverses abdominis muscle(TRAM flap)
• TRAM flap is most commonly used, gives excellent cosmetic results but lengthy procedure

Chemoprevention of breast cancer

Tamoxifen Raloxifene
 • Estrogen antagonist with proven benefit for the • Selective ER modulator (SERM)
treatment of ER positive breast cancer • Reduces risk of second primary breast cancer in
• Reduces risk of second primary breast cancer in the contralateral breast
the contralateral breast • No increase in uterine cancer
• Increased risk of Endometrial cancer, • Less DVT and Pulmonary embolism when
pulmonary embolism, Deep vein thrombosis compared to tamoxifen

Male breast cancer

• Risk factors: increasing age, radiation exposure, obesity, and cirrhosis. family history, Klinefelter syndrome
(strongest association), BRCA1/2 mutation, feminization (estrogen exposure)
• Gynaecomastia is NOT a risk factor.
•
• Peak incidence in the sixth decade of life
• Commonly associated with BRCA2 mutations
• Infiltrating ductal carcinoma is the most common type
• Tumor stage is the important prognostic factor
• 80% cases are ER positive
• Treatment: MRM
 IX. ABDOMINAL WALL & HERNIA

EXOMPHALOS/OMPHALOCEL
• Umbilical hernia of newborn
• Failure of all or part of midgut to return to the abdominal cavity
• Abdominal wall muscle is normally developed, but peritoneal layer is hypoplastic
• Covered by

Amniotic membrane (outer)

Wharton's jelly (middle)

Peritoneum (inner)
• Exomphalos minor

Defect < 5cm

Umbilical cord attached to the summit of sac

Treatment – twisting the cord and ligature of sac
• Exomphalos major

Usually the abdominal musculature will be absent

Umbilical cord attached to the inferior aspect of the sac

Sac contains intestines and abdominal viscera

Many children are still born

High mortality

Immediate surgery required before rupture of sac

GASTROSCHISIS/BELLY CLEFT
• Defect of the anterior abdominal wall just lateral (usually right side) to the umbilicus
• Common in premature babies
• Umbilicus is normal
• Non rotation and intestinal atresia are common associations
• Necrotizing enterocolitis and paralytic ileus are common in such infants

HERNIA
• Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity which contains
it.
Classification
• Reducible – reduces by itself or by surgeon
• Irreducible – contents does not reduce back into abdomen
• Obstructed – Irreducibility + obstruction
• Incarcerated – portion of colon is the content & is blocked with feces
• Strangulated – Irreducibility + obstruction + arrest of blood supply

INGUINAL HERNIA
Mechanism preventing hernia
• Obliquity of the inguinal canal
• Shutter mechanism of the arched fibres
• Sphincter action of the transversus abdominis & internal oblique muscles at deep ring
• Ball Valve action of the cremaster
• Strong fibres of internal oblique in front of the deep ring
• Strong conjoint tendon in front of Hesselbach's triangle
Types
• Bubonocele - limited to the inguinal canal till the superficial inguinal ring
• Funicular - Process vaginalis ends just above the epididymis
• Complete / Vaginal / Scrotal – to the bottom of the scrotum

Indirect hernia Direct hernia

Age Any age Common in old age
Defect Deep inguinal ring Posterior wall of inguinal canal
Shape Pyriform/oval Globular/round
Descent To the bottom of scrotum – complete Rarely descents to the bottom of scrotum
Neck Narrow Wide
Relation of sac Lateral to inferior epigastric artery Medial to inferior epigastric artery
Anterolateral (or medial) to spermatic Posteriomedial to spermatic cord
Zieman's test Cough impulse on index finger Cough impulse on middle finger
Invagination test Tip of finger Pulp of finger
Ring occlusion Does not bulge Bulge medial to occluding finger
Coverings (from • Extraperitoneal tissue • Extraperitoneal tissue
inside out) • Internal spermatic fascia • Fascia transversalis
• Cremasteric fascia • Conjoint tendon
• External spermatic fascia • External spermatic fascia
• Skin • Skin

• Two classical signs of uncomplicated hernia – impulse on cough & reducibility

• Taxis – flexion, adduction & internal rotation to relax the pillars of superficial ring

Inguinal hernia in children

• Almost always indirect hernia (results from patent processus vaginalis)
• More common in boys
• Failure of obliteration of processus vaginalis also results in – hydrocele (communicating and non-
communicating) hydrocele of spermatic cord and hydrocele of tunica vaginalis
• The processus vaginalis remains patent in 80% of new born infants
• At 2 years – 40-50% are open
• In adults – 25% are persistently patent
• Hernias: 60% on the right side; 30 % left side; 10% bilateral

Treatment
• Early surgical repair in premature infants – since high risk of incarceration
• Infants diagnosed after hospital discharge - elective hernia repair beyond 52 weeks
• Incarcerated inguinal hernia (with no signs of peritonitis) – manual reduction (taxis) - successful in 70% caes.
Once reduced, hernia repair is performed at 24 to 48 hours, when local tissue edema resolves.
• A nonreducible incarcerated hernia – immediate surgery

DD of Inguinoscrotal Swelling DD of the groin swelling

 • Encysted hydrocele of the cord • Femoral hernia
• Varicocele • Saphena Varix
• Lymph varix or lymphangiectasis • Enlarged lymph nodes
• Funiculitis • Psoas abscess
• Diffuse lipoma of the cord • Enlarged psoas bursa
• Inflammatory thickening of the cord • Undescended & ectopic testis
• Malignant extension of the testis • Lipoma
• Torsion of the testis • Hydrocele of a femoral hernial sac
• Retractile testis • Femoral aneurysm
• Vaginal hydrocele is a scrotal swelling

Treatment – always surgical

Infants & children: Herniotomy Herniorrhaphy is also useful in adults
Adults; Hernioplasty (Mesh repair - • Shouldice's repair (low recurrence- 3%) - most effective tissue-
Lichenstein, Rives, Stoppa, TEP, TAPP) based repair when mesh is unavailable or contraindicated
Lichenstein tension-free repair – most • Halstead's repair
commonly performed procedure; least • Andrew's repair
recurrence (0.2%) • Modified Bassini (high recurrence)

Triangle of doom
• An inverted V shaped area - where it is extremely dangerous to place staples or sutures during
• laparoscopic hernia repair
• It is not a triangle – only two boundaries
• Apex – deep inguinal ring
• Lateral – gonadal vessels
• Medial - vas deferens male, or round ligament in female
• Contents - External iliac artery, external iliac vein, deep circumflex iliac vein, genital branch of genitofemoral
nerve, femoral nerve

Triangle of pain
• Inferomedial: Gonadal vessels
• Superolateral: Iliopubic tract
• Contents: Lateral femoral cutaneous nerve, anterior femoral cutaneous nerve, femoral branch of
genitofemoral nerve, femoral nerve

Strangulated hernia
• Indirect hernias strangulate more commonly than direct hernias(direct hernias have wide neck of the sac)
• Constricting agent – neck of the sac (most common), the external inguinal ring in children and adhesions
within the sac
• Contents – small intestine is mostly involved, next – omentum
• In strangulated hernia in female infants, the most common content is ovary
• Treatment – emergency operation
• For strangulated hernia - Open the sac at the fundus
• While releasing constriction of the sac at deep ring, inferior epigastric artery might get injured

Dangers of conservative management [vigorous manipulation-taxis]:

• Contusion or rupture of intestinal wall
 • Reduction en masse: sac together with its contents is pushed forcibly back into the abdomen. As the bowel is
still strangulated by the neck of the sac, the symptoms are no way relieved.
• Sac may rupture & the contents may be reduced extra peritoneally.

Sliding Hernia (Hernia-en-Glissae)

• Slipping of posterior peritoneum along with retroperitoneal viscus
• Posterior wall of sac is formed by caecum on the right side and sigmoid colon on the left side
• If caecum and appendix are the contents of hernia sac – it is not sliding hernia
• Always occurs in long standing cases of inguinal hernia
• Not completely reducible

Sportsman's hernia
• Seen in young men who play rugby or foot ball
• Presents with severe pain in the groin radiating to scrotum and upper thigh
• Tenderness over inguinal canal
• Usually no hernia can be felt; only occasionally can a true inguinal hernia be found
• In most cases, the pain is due to an orthopedic injury, such as adductor strain or pubic symphysis diastasis.
• Pain can be due to muscle tearing (Gilmore's groin)

FEMORAL HERNIA
• Comes through femoral ring, travels through femoral canal & comes out through saphenous opening (neck)
• High risk of strangulation due to narrow neck
• Occurs medial to femoral vein

Femoral ring Femoral hernia turns upwards because of

• Anteriorly by inguinal ligament • Firm unyielding falciform process
• Posteriorly by pectineus muscle • Attachment of fascia scarpa to fascia lata
• Medially by lacunar ligament • Repeated flexion of the thigh
• Laterally by septum separating it from femoral vein

Gaur sign: in femoral hernia distension of superficial epigastric and circumflex iliac veins due to pressure of hernia
sac Treatment
• High operation or McEvedy's operation
• Inguinal operation or Lotheissen's operation
• Low operation of Lockwood

Rare types of femoral hernia

• Narath's or Teale's or Prevascular hernia

Hernia behind the femoral vessels (some books say it lies in front of femoral vessels)

Caused by lateral displacement of psoas muschle in congenital dislocation of hip

Wide neck – less chances of strangulation
• Callison-Cloquet's hernia – through pectineus muscle & its fascia
• Hesselbach's Hernia – lateral to femoral artery
• Serofini's hernia – behind femoral vessels
• Teals hernia – in front of femoral vessels
• Laugier's Hernia – through the lacunar ligament, always strangulated
• Beclard's hernia – through saphenous opening
UMBLICAL HERNIA
• Hernia through the weak umbilical scar
• More in males than females
• Strangulation is rare
• Spontaneously cured within 12 – 18 months, & surgery if still not reduced

Paraumbilical hernia:
• Through the linea alba just above or below the umbilicus
• Women are more common affected (M:F = 5:1)
• Omentum gets adhered to the sac, sac is seldom reducible.
• Mayo's Operation is done

EPIGASTRIC HERNIA / FATTY HERNIA OF LINEA ALBA

• Hernia protruding in midline through the interlacing fibres of linea alba b/w umbilicus & xiphisternum
• Occurs where linea alba is pierced by small blood vessels
• Narrow neck of the sac
• Surgery justified only if hernia is giving rise to symptoms

INCISIONAL HERNIA / VENTAL HERNIA / POSTOPERATIVE HERNIA

• Occurs through an acquired scar
• More common in females
• Type I: upper abdomen or in the midline. Risk of strangulation is negligible
• Type II: Lateral part of the abdomen. Risk of strangulation is very high
• Mesh repair is the treatment of choice
• Defect < 3cm: Cattell's operation

OBTURATOR HERNIA
• More common in females (obturator foramen is wider ad triangular)
• Most common presentation – acute intestinal obstruction with strangulation
• Causes more pain than any other type of hernia
• Pain radiates along the obturator nerve and may be referred to the knee via its geniculate branch –
HowshipRomberg sign

LUMBAR HERNIA
• Through inferior lumbar triangle of Petit
o Inferiorly – iliac crest
o Laterally – external oblique
o Medially – latissimus dorsi
• Through superior lumbar triangle of Grynfeltt
o Above – 12th rib
o Laterally – internal oblique
o Medially –Sacrospinalis

 Most common hernia – Indirect inguinal hernia

 Most common hernia in males - Indirect inguinal hernia
 Most common hernia in females - Indirect inguinal hernia
 Femoral hernia is more common in females
 Inguinal hernia – above & medial to Pubic tubercle
 Femoral hernia – below & lateral to Pubic tubercle
 • Pantaloon hernia — direct & indirect hernia on • Holthouse's hernia — inguinal hernia that has turned
the same side outwards in to the groin
• Phantom hernia — hernia following paralysis of • Hernia without neck (mouth larger than neck)
the muscles of the lumbar region • direct hernia, incisional hernia
• Gibbon's hernia — hernia with hydrocele • Hernia without sac — epigastric hernia(protrusion of
• Berger's hernia — hernia in the pouch of extraperitoneal pad of fat)
Douglas • Obturator Hernia —through the obturator foramen
• Romberg hernia — saddle hernia • Gluteal Hernia — through the greater sciatic foramen
• Grynfelt's hernia — upper lumbar triangle • Sciatic Hernia — through the lesser sciatic foramen
hernia • Perinea! Hernia — through the pelvic floor
• Petit's hernia — lower lumbar triangle hernia • Spigelian Hernia — interparietal hernia at the level of
• Mery's hernia — perineal hernia arcuate line through the Spigelian point
• Barth's hernia — hernia between abdominal
wall and persistent vitello-intestinal duct

• Ogilvie Hernia — Small rigid circular orifice in the conjoint tendon just lateral to its insertion with rectus
sheath
• Richter's Hernia
o Only a circumference of anti-mesenteric wall of the bowel becomes strangulated
o Strangulation can occur without the presence of intestinal obstruction
• Littre's hernia — Meckel's diverticulum as a content of hernia
• Interstitial Hernia — b/w the muscle layers of abdominal wall
o Preperitoneal / intraparietal — b/w peritoneum & fascia transversalis
o Interparietal — b/w internal oblique muscle & external oblique aponeurosis
o Extraparietal — outside external oblique aponeurosis
• Amyand's hernia — appendix as a content of hernia
• Maydl's Hernia (Hernia-en-W / retrograde hernia) — Two loops of bowel remain in the sac with the
connecting loop inside the abdomen. Connecting loop goes in for strangulatio

Nerves injured in hernia operation

llio-inguinal nerve Ilio-hypogastric nerve Genitofemoral nerve

• Proximal & medial • Lat cutaneous — posterolateral • Genital branch — cremaster, scrotal
thigh • gluteal skin skin
• Root of penis • Ant cutaneous — suprapubic • Femoral branch — upper part of
• Upper part of scrotum region femoral triangle

UMBILICAL ADENOMA (RASPBERRY TUMOR)

• It is commonly seen in infants.
• It is due to partially obliterated vitellointestinal duct towards umbilical end
• Causing prolapse of the mucosa giving rise to umbilical adenoma
• Not a tumor
 X. ORAL CAVITY, SALIVARY GLANDS & NECK SWELLINGS
ORAL CAVITY
Premalignant lesions of oral cavity
High risk Medium risk Equivocal risk
• Leukoplakia • Oral submucosal fibrosis • Oral lichen planus
• Erythroplakia • Syphilitic glossitis • Dyskeratosis congenita
• Chronic hyperplastic candidiasis • Sideropenic dysphagia • Discoid lupus erythematosus
• Cheek is the MC site of oral cavity cancer in India

TNM Staging of oral cancer

Primary tumour (T) Regional lymph nodes (N)
TX: Primary tumour can't be assessed NX: Regional lymph nodes cannot be assessed
T0: No evidence of primary tumour N0: No regional lymph node metastasis
Tis: Carcinoma in situ N1: Metastasis in a single ipsilateral lymph node <3 cm in greatest
T1 Tumour <2 cm in greatest dimension
dimension N2a: Metastasis in a single ipsilateral lymph node >3 cm but not > 6 cm
T2 Tumour >2 but <4 cm N2b: Metastasis in multiple ipsilateral lymph nodes, none >6 cm in greatest
T3: Tumour >4 cm but <6 cm dimension
T4: Tumour invades adjacent N2c: Metastasis in bilateral or contralateral lymph nodes, none >6 cm in
structures, e.g. mandible, skin greatest dimension
N3: Metastasis in any lymph node >6 cm

Clinical features of oral cancer

• Initial symptoms include sore throat, bleeding, dysphagia and odynophagia, referred otalgia, and voice
changes, including a muffled quality or hot potato voice
• Trismus indicates advanced disease - results from involvement of the pterygoid musculature.

Hard palate carcinoma:

• Strongly associated with reverse smoking and with conventional chutta smoking

Dental (radicular) cyst

• MC odontogenic cyst
• Arises from the root of chronically infected dead erupted tooth

Dentigerous cyst (Follicular odontome)

• It occurs over the crown of unerupted tooth.
• MC in mandibular 3rd molars

Ameloblastoma/Adamantinoma/Eve's disease
• Arises from the dental epithelium
• Most commonly in mandible
• Occasionally seen in the base of skull in relation to Rathke's pouch or in Tibia
• Variant of basal cell carcinoma
• Locally malignant
• Can occur in a pre-existing dentigerous cyst
• Egg shell crackling on palpation
• Lymph nodes not involved
 • OPG shows honey comb appearance
• Segmental resection or Hemimandibulectomy is the treatment

Epulis
• Painless swelling arising from the mucoperiosteum of gum
• Precipitating factors – tooth caries, dentures, poor hygiene
• Fibrous epulis is the commonest type
• Giant cell epulis is the osteoclastoma of the jaw
• Pregnancy epulis(gingivitis gravidorum)usually in the 3rd month, resolves spontaneously
• Few may undergo sarcomatous change

Gorlin's cyst
• Calcifying cystic odontogenic tumor
• Epithelial proliferation and continuous growth into large ghost cells
• Radiographic features - "salt and pepper" appearance
 Gorlin's syndrome – nevoid basal cell carcinoma

Giant cell reparative granuloma (Jaffe's tumour)

• Swelling due to haemorrhage within the bone marrow.
• Common in women
• Causes painless enlargement of jaw
• Treatment: calcitonin (100 units/0.5 mg subcutaneously daily for 12 months) or surgical curettage.

SALIVARY GLANDS
• Sialosis: enlargement of salivary glands due to fatty infiltration
• Sialectasis: aseptic dilation of salivary ductules causing grape like dilations
• Sialolithiasis: most common in submandibular salivary gland
• Lazy S incision: parotidectomy
• Stafne bone cyst: most common ectopic salivary gland tissue

Important anatomical relationships of the submandibular glands (liable to injury during excision of the gland)
• Lingual nerve
• Hypoglossal nerve
• Anterior facial vein
• Facial artery
• Marginal mandibular branch of the facial nerve

Salivary Gland Tumors

• Parotid is the me site (65-80%)of salivary gland tumors
• Most common site of minor salivary gland tumors – palate
• Most major salivary gland tumors are benign
• 90% minor salivary gland tumors are malignant
• Adenoid cystic carcinoma – perinerual spread, neural invasion, distant metastasis
• Most common carcinoma – mucoepidermoid carcinoma

Parotid gland
• 90% tumors are benign
• Most tumors arise from superficial lobe
 • Most common tumor – pleomorphic adenoma
• 2nd most common tumor – Warthin's tumor
• Most common malignant tumor – mucoepidermoid carcinoma
• Most common tumor in children – hemangioma

Pleomorphic Adenoma
• Benign tumor; can turn malignant
• Mixture of epithelial, myoepithelial cells, cartilages(mixed tumor)
• Radiation exposure increases risk
• Raised ear lobule
• Cannot be moved above the zygomatic bone – curtain sign
• Treatment – superficial parotidectomy

Warthin's Tumor (Papillary Cystadenoma Lymphomatosum or Adenolymphoma)

• Not malignant, not a lymphoma
• It arises almost exclusively in the parotid gland (the only tumor virtually restricted to the parotid)
• Common in males in their 5th to 7th decades (all other parotid tumors common in females)
• 10% are multifocal and 10% bilateral.
• Smokers have eight times increased risk
• Never turns malignant
• Histology: narrow cystic or cleftlike spaces lined by a double layer of neoplastic epithelial cells resting on a
dense lymphoid stroma
• 99m Tc-pertechnate scan – hot spots
• Treatment – superficial parotidectomy

Frey's syndrome (Baillarger's syndrome, Dupuy's syndrome, Gustatory sweating)

• Injury to auriculotemporal nerve wherein post-ganglionic parasympathetic fibres from the otic ganglion
become united to sympathetic nerves from superior cervical ganglion (Pseudosynapsis)
• As a result of severance and inappropriate regeneration, there is "Gustatory Sweating" or sweating in the
anticipation of eating, instead of the normal salivatory response
• Treatment – Jacobson's neurectomy; botulinum toxin; aluminium chloride(antiperspirants)

Hyperhidrosis
• Excessive sweating of palms, soles of the feet, axillae and groin
• Anti-perspirants or periodic local injections of botulinum toxin A
• Resistant cases are treated by endoscopic cervical sympathectomy

NECK SWELLINGS
Swellings in the submandibular triangle Swellings in the carotid Swellings in posterior triangle
• Enlarged submandibular lymph triangle
• Branchial cyst • Solid: metastasis in lymph
nodes • Lymph nodes (cold nodes,
• Submandibular salivary gland abscess) • TB, lymphoma, lipoma, cervical
enlargement • Carotid artery aneurysm rib, Pancoast's tumor
• Plunging ranula • Thyroid enlargement • Cystic: lymphangioma,
• Ludwig's angina • Carotid body tumor hemangioma, cold abscess
• Laryngocele • Pulsatile: aneurysms of
• Sternomastoid tumor subclavian or vertebral artery
RANULA
• Mucous extravasation cyst that arises from a sublingual gland
• Cystic swelling in the floor of the mouth resembling a frog's belly
• Brilliantly translucent swelling
• Unilateral, smooth, dome shape, fluctuating and painless swelling
• Can resolve spontaneously; sometimes surgical excision of the cyst and the affected sublingual gland
needed
• Incision and drainage usually results in recurrence.

PLUNGING RANULA
• Rare form of mucous retention cyst that can arise from both sublingual and submandibular salivary glands.
• Soft, fluctuant, painless, dumb-bell-shaped swelling in the submandibular or submental region of the neck
• Diagnosis: ultrasound or magnetic resonance imaging (MRI) examination
• Excision is usually performed via a cervical approach removing the cyst and both the submandibular &
sublingual glands
• Smaller plunging ranulas: transoral sublingual gland excision, with or without marsupialisation

CYSTIC HYGROMA (CAVERNOUS LYMPHANGIOMA/HYDROCELE OF THE NECK)

• Cystic swelling due to sequestration of a portion of jugular lymph sac from the lymphatic system in utero
• Usually present in the neonate or in early infancy
• Occasionally may present at birth and be so large to cause obstructed labor (BAILEY)
• 50% of them present at birth (SABISTON)
• Most common site – posterior triangle of neck
• Less common sites - cheek, axilla, groin and mediastinum
• Cysts are filled with clear lymph and lined by a single layer of epithelium with a mosaic appearance (BAILEY)
• Multiloculated cystic spaces lined by endothelial cells (SABISTON, SCHWARTZ)
• Swelling is smooth, soft, fluctuant and increases in size when the child coughs or cries
• The characteristic that distinguishes it from all other neck swellings - brilliantly transilluminant
• Injection of a sclerosing agent (e.g picibanil[OK-432], bleomycin) may reduce the size of the cyst
• Definite treatment: surgical excision

CAROTID BODY TUMOR (Chemodectoma or potato tumor)

• Most common paraganglioma(non-chromaffin) of head and neck
• Seen at the bifurcation of carotid artery; Arises from adventitia of the artery
• Higher incidence in people living in high altitudes and those with cyanotic heart disease(hypoxia)
• Commonly occurs in 5th decade;
• Higher incidence in females
• Presents as a slow growing painless neck mass, pulsatile, mobile from side to side but not up and down
• Benign or locally malignant, 20% cases can spread to lung and lymph nodes
• Tumor may extend into cranial cavity along the internal carotid artery as dumbbell tumor
• FNAC and biopsy are contraindicated
• Angiogram: widening/ splaying of carotid artery with tumor blush – Lyre sign
• Surgery is mainstay for management

Dumbbell tumors
• Parotid tumor
• Carotid body tumor
• Spinal cord tumor
STERNOMASTOID TUMOR
• Not a tumor — misnomer
• Injury to the sternomastoid during birth causes rupture of few fibres and hematoma
• Later healing occurs with fibrosis resulting in a swelling in the middle of sternomastoid muscle
• Tender and mobile sideways
• Medial and lateral borders are distinct, but superior and inferior borders are continuous with the muscle
• Many cases are associated with Torticollis
• Treatment — physiotherapy or surgery

COLD ABSCESS
• Most common cause — tuberculosis
• Other causes — leprosy, actinomycosis, Madura foot
• Stages of Cervical tuberculous lymphadenitis

Lymphadenitis

Matting (characteristic of TB)

Cold abscess (no local rise in temperature, no tenderness, no redness, soft cystic fluctuant swelling,
transillumination negative; on sternocleidomastoid contraction — it becomes less prominent since it is
deep to deep cervical fascia)

Collar stud abscess — cross fluctuation may be positive

Sinus
• Treatment: nondependent aspiration using a wide bore needle (incision and drainage - contraindicated)
 XI. VASCULAR SURGERY
ARTERIAL DISEASES

THROMBOANGITIS OBLITERANS or BUERGER DISEASE

• Exclusively in males
• Age 20 - 40 yrs
• Strongly associated with history of heavy smoking
• Absence of atheromas
• Segmental inflammation of arteries(panangiitis) involving adjacent veins and nerves
• Involvement of small and medium sized arteries of the upper and lower extremities.
• Triad of claudication, Raynaud's phenomenon and migratory superficial thrombophlebitis

Treatment
• Smoking cessation
• Pentoxyphylline, Nifedipine
• Lumbar Sympathectomy
• Omentoplasty, profundaplasty
• Amputation

Lumbar sympathectomy
• Pre-ganglionic sympathectomy
• Sympathetic trunk divided below Ll and removed upto L4
• Vasospasm of lower limb vessels is reduced
• Rest pain improves
• Minor ulcers heal due to vasodilation

Indications for lumbar sympathectomy

• Buerger's disease
• Arterial embolism
• Frost bite
• Atherosclerotic ischemia of a limb
• Plantar hyperhydrosis

 Claudication is not an indication for sympathectomy; rest pain is an indication

 Cervical sympathectomy – Palmar hyperhidrosis
 Cervical sympathectomy – Raynaud's disease

Ankle-Brachial Pressure index (ABPI)

• Ratio of systolic pressure at the ankle to that in the arm.
• Numerator: highest pressure in the dorsalis pedis, posterior tibial or peroneal artery
• Denominator: highest brachial systolic pressure
• Normal Resting ABPI 1.0
• Claudication: < 0.9
• Rest pain: < 0.5
• Imminent necrosis < 0.3
ACUTE LIMB ISCHEMIA
• Patient has no history of claudication and has a source of emboli, who suddenly develops severe pain or
numbness of the limb, which becomes cold and mottled.
• lschaemia beyond 6 hours is usually irreversible and results in limb loss.
• The leg is often affected, with pain, pallor, paralysis, loss of pulsation and paraesthesia (or anaesthesia)
• The limb is cold and the toes cannot be moved, which contrasts with venous occlusion when muscle function
is not affected.
• Movement becomes progressively more difficult and sensation is lost.
• Pulses are absent distally, but the femoral pulse may be palpable, even thrusting, as distal occlusion results
in forceful expansion of the artery with each pressure wave despite the lack of flow.
• A similar picture will occur in the arm with a brachial embolus

Treatment
• Immediate administration of 5000 U of heparin intravenously can reduce this extension and maintain
patency of the surrounding (particularly the distal) vessels until the embolus can be treated
• Embolectomy (with the help of Fogarty balloon catheter) is the definite treatment

Choice of Conduit for Infrainguinal Bypass Grafting

• Autogenous Vein - superior to prosthetic conduits for all infrainguinal bypasses (ipsilateral great saphenous
vein, contralateral great saphenous vein, small saphenous vein, arm vein)
• Cryopreserved cadaveric arteries and veins
• Human umbilical vein
• PTFE or Dacron is the best option for above-knee bypass (if vein is unavailable)

RAYNAUD'S DISEASE
Raynaud's phenomenon
• Cold and emotional stimuli may trigger the characteristic sequence of digital pallor due to vasospasm,
cyanosis due to deoxygenated blood and rubor due to reactive hyperemia

Primary Raynaud's phenomenon or Raynaud's disease

• Young women, familial
• Involves upper limbs, toes, ears
• Normal peripheral pulses
• Does not progress to ulceration of infarction and significant pain is unusual
• Advised to avoid cold exposure, no other investigation necessary
• Sympathectomy not indicated

Secondary Raynaud's phenomenon or Raynaud's syndrome

• Associated with systemic sclerosis or CREST syndrome
• Fixed obstruction of digital arteries, fingertip ulceration and necrosis
• Sympathectomy useful

Chemical sympathectomy: 5ml phenol in water or absolute alcohol injected lateral to vertebral bodies of L2 and L4
Indications for cervico-thoracic pre-ganglionic sympathectomy
 Cervical rib
 Raynaud's phenomenon
 Hyperhydrosis
 Acrocyanosis
 Causalgia
  Sudeck's osteodystrophy

VENOUS DISEASES

ARICOSE VEINS
Primary Secondary
• Congenital absence or incompetence of valves • Recurrent thrombophlebitis
• Inheritance with FOXC2 gene • Occupational – prolonged standing
• Klippel-Trenuanay syndrome • Obstruction to venous return – abdominal

Congenital AV fistula tumors, retroperitoneal fibrosis

Cutaneous hemangiomas • Pregnancy

Hypertrophy of involved limb • Iliac vein thrombosis

Absence of deep venous system

Clinical features
• Lipodermatosclerosis(brawny induration) pigmentation, thickening, chronic inflammation and induration of
skin in calf muscle and around ankle

Brodie-Trendelenburg test
• To assess the competence of SFJ
• Patient lies flat, elevate the leg and gently empty the veins, palpate the SFJ and ask the patient to stand
whilst maintaining pressure
• If the veins do not refill  SFJ is incompetent
• If the veins do refill  SFJ may or may not be incompetent, presence of distal incompetent perforators

Cough impulse (Morrisey's test)

• Locate the saphenofemoral junction(2-4cm inferolateral to pubic tubercle) and ask the pt to cough
• Impulse or fluid thrill felt indicates saphenofemoral incompetence

Modified Perthes Test:

• Ask the pt to stand and tourniquet is applied at SF junction and ask to walk
• Superficial veins become prominent – indicate deep vein thrombosis

Three tourniquet test

• To find the site of incompeter“: perforator
• Tourniquets at SFJ, above knee level, below knee level

Fegan's test:
• Detect the perforators

Investigations:
• Duplex Ultrasound imaging – gold standard
• Doppler examination – only when duplex is not available
• Phlebography – not needed in primary venous insufficiency. Only performed as preoperative adjuncts when
deep venous reconstruction is being planned
• Ascending phlebography – differentiates primary from secondary insufficiency
• Descending phlebography - identifies specific valvular incompetence suspected on B mode scanning.
Medical treatment
• Calcium dobesilate
• Diosmin
• Hesperidin
• Toxerutin

Surgical management:
• Trendelenburg's operation (juxta femoral flush ligation + stripping the varicose vein) for SFJ incompetency
• Subfacial ligation of Cockett and Dodd :perforator incompetence with SF competency
• VNUS closure(ablation catheter introduced into the SF junction and slowly with drawn )
• TRIVEX – veins identified by subcutaneous illumination; injection of fluid & superficial veins are sucked
• Endo venous laser ablation(EVLA)
• Sclerotherapy

Sclerotherapy- indications Contraindications Sclerosants used

• Uncomplicated perforator • SFJ incompetence • Ethanolamine oleate
incompetence • DVT • Sodium tetradecyl sulfate
• Smaller varices • Huge varicosities • Sodium morrhuate
• Recurrent varices • Peripheral arterial diseases • Polidocanol
• Isolated varicosities • Immobility • Hypertrophic saline
• Aged/unfit patients

DEEP VEIN THROMBOSIS

Signs
• Phlegmasia alba dolens – painful white leg
• Phlegmasia cerulean dolens – painful red leg
• Homan's sign – calf tenderness on forced ankle dorsiflexion
• Mose's sign– calf tenderness on direct pressure
• Neuhof's sign – thickening and deep tenderness while palpating deep in calf muscles

Risk factors for DVT

• Old age • Deficiency of anti-thrombin III, • Sepsis
• Obesity protein C and S, anti- • Nephrotic syndrome
• Varicose veins phospholipid antibody • IBD
• Immobility syndrome • Polycythemia
• Pregnancy, puerperium • Lower limb or pelvic surgery • PNH
• High dose estrogen therapy • Malignancy • Homocystinemia
• Previous DVT • MI • Paraproteinemias

• Most common site of DVT– calf veins

• Duplex USG used in diagnosis

LYMPH EDEMA
Congenital lymphedema (Milroy disease)-Evident at birth
Lymphedema praecox (Meige disease)
• Most common form; Common in women
• Clinically evident after birth and before age 35 year(most often at puberty)
Lymphedema cutanea tarda-Does not become clinically evident until age 35 years or older.
Secondary lymphedema-MC cause- filariasis

Types of surgery
Excisional Physiological Excision with bypass Limb reduction surgeries
• Charles • O' Brien's lymphovenous • Swiss role operation – • Sistrunk's
• Homan's shunt excision with bypass • Homan's
• Neibulowitz nodovenous lymphatic transposition • Thompson's
shunt • Kondolean's
• Omentoplasty
• Ileal mucosal patch

LYMPHANGIOSARCOMA
• Postmastectomy (Stewart–Treves' syndrome) – after 10 years
• Long standing lymphedema due to other causes – after 20 years
• Most common site in upper extremities
• Amputation offers the best chance of survival
• Very poor prognosis
 XII. BURNS

First degree burns Second degree - superficial Second degree - deep Third degree
Epidermis only Epidermis and superficial Epidermis and upto Epidermis and entire
dermis reticular dermis dermis
Skin appendages intact Most skin appendages All skin appendages
destroyed destroyed

Dry, Erythematous, Erythema, blisters, moist, Pale, mottled, dry, less White, charred or tan, dry
Blanches with pressure elastic elastic, less blanching and leathery eschar, no
Blanches with pressure blanching
Sensation intact, mild to Sensation intact, severe pain Sensation decreased, Anesthetic
moderate pain less painful
Heals in 3-6 days Heals in 1-3 weeks, scarring Healing > 3 weeks with Need skin grafting, severe
without scarring minimal scarring & contractures scarring and contractures

• Fourth-degree burns involve other organs beneath the skin, such as muscle, bone, and brain
• Accurate determination of burn depth - multisensor laser Doppler flowmeter
• Infection remains a common cause of death in burn patients and is responsible for 75% of all deaths
• Exposure method of treatment is used in burns of head and neck
• Acute gastric dilation following burns occurs in 2-4 days
• As the burns size approaches 10-15% of total body surface area, loss of intravascular fluid can cause a level
of circulatory shock.
• Curling's ulcer in burns > 35%

Electrical burns
• Low-voltage injuries cause cause cardiac arrest through pacing interruption without significant direct
myocardial damage
• High-voltage injuries
• Cause direct damage to myocardium without pacing interruption
• Damage to the underlying muscles in the affected limb  compartment syndrome.
• Release of the myoglobins will cause myoglobinuria and subsequent renal dysfunction
• Therefore, during resuscitation, maintain a high urine output of up to 2 mL/kg body weight per hour
• Severe acidosis is common
• Limbs may need fasciotomies or amputation

The criteria for acute admission to a burns unit.

• Suspected airway or inhalational injury
• Any burn likely to require fluid resuscitation
• Any burn likely to require surgery
• Patients with burns of any significance to the hands, face, feet or perineum
• Patients whose psychiatric or social background makes it inadvisable to send them home
• Any suspicion of non-accidental injury
• Any burn in a patient at the extremes of age
• High-tension electrical burns and concentrated hydrofluoric acid burns

FLUID REPLACEMENT IN BURNS

 • IV fluid resuscitation is needed for any child with > 10% burns and adult > 15 % burns

Crystalloid resuscitation
• Most widely used - Parkland formula = total % body surface area X body weight (kg) X 4 = Volume (ml)
• Half the volume given in first 8 hrs, rest in 16 hrs
• Ringer's lactate is the most commonly used crystalloid
• E.g: for a 60 kg adult with 40% burns, total fluid = 40 x 60 x 4 = 9.6 L total. 4.8 L given in the first 8 hours and
4.8 L in the next 16 hours
• In children, maintenance fluid must also be given – usually DNS

100 mL/kg for 24 hours for the first 10 kg;

50 mL/kg for the next 10 kg;

20 mL/kg for 24 hours for each kilogram over 20 kg body weight.

Colloid resuscitation
• Muir & Barclay formula: 0.5 x % body surface area burnt x weight = one portion
• First 12 hours – 3 portions; next 12 hours – 2 portions; next 12 hours – 1 portion
• One portion to be given in each period.

TREATMENT OF BURNS WOUND

Escharotomy
• Circumferential full-thickness burns to the limbs require emergency surgery
• The tourniquet effect of this injury is easily treated by incising the whole length of full-thickness burns.
• This should be done in the mid-axial line, avoiding major nerves
• Escharotomy can cause a large amount of blood loss; adequate blood should be available for transfusion if
required

Most common dressings for full-thickness and contaminated wounds

• 1% silver sulphadiazine cream - effective against Pseudomonas aeruginosa and methicillin-resistant
Staphylococcus aureus
• 0.5% silver nitrate solution - effective against Pseudomonas aeruginosa but not against some gram negative
aerobes
• Mafenide acetate cream - associated with
• metabolic acidosis
• Serum nitrate, silver sulphadiazine and cerium nitrate

Surgical treatment of deep burns

• Deep dermal burns need tangential shaving and split-skin grafting
• All full thickness burns except those < 4cm2 need surgery
• Topical adrenaline reduces bleeding
• Stable cover (sking graft, synthetic dermis or homograft), permanent or temporary, should be applied at
once to reduce burn load
 XIII. BURNS
NEUROSURGERY
HEAD INJUR
Primary brain injury Secondary brain injury
Primary brain injury • Sometimes after the moment of impact
• Occurs at the time of impact • Preventable
• Examples • Principle causes

Brainstem and hemispheric
Hypoxia(PO2 <8kPa)
contusions
Hypotension (systolic BP < 90mnnHg)

Diffuse axonal injury
Raised ICP (> 20mmHg)

Cortical lacerations
Reduced cerebral perfusion pressure (< 65mmHg)

Pyrexia

National Institute for Health and Clinical Excellence (NICE) guidelines for computed tomography (CT) in head injury.
• GCS < 13 at any point
• GCS 13 or 14 at 2 hours
• Focal neurological deficit
• Suspected open, depressed or basal skull fracture
• More than one episode of vomiting
• Any patient with a mild head injury over the age of 65 years or with a coagulopathy, for instance warfarin
use, should be scanned urgently
• Dangerous mechanism or injury or antegrade amnesia >30 minutes warrants CT within 8 hours

EXTRADURAL HEMATOMA
• Nearly always associated with a skull fracture
• The me site is temporal (as the pterion is the thinnest part of the skull and overlies the middle meningeal
artery)
• More common in young males
• Classical presentation(in less than one-third patients)

Initial injury followed by a lucid interval (patient fully alert and oriented with no focal deficit)

After minutes or hours, rapid deterioration occurs, with contralateral hemiparesis, reduced conscious
level and ipsilateral dilated pupil due to brain compression and herniation
• CT scan: lentiform(lens-shaped or biconvex) hyperdense lesion between the skull and the brain
• Treatment: Immediate surgical evacuation via a craniotomy

ACUTE SUBDURAL HEMATOMA

• Nearly always associated with primary brain injury
• CT: hyperdense lesion which is diffuse and concave
• Treatment: evacuation via craniotomy
• Small hematomas with little mass effects – conservative management

SUBARACHNOID HEMORRHAGE
• Aneurysms are the mcc of spontaneous SAH
• Trauma is the mcc of SAH overall
• Traumatic SAH is managed conservatively
CHRONIC SUBDURAL HEMATOMA
• Usually occurs in the elderly; more common in those on anti-coagulant or anti-platelet agents
• Usually (but not always) there is a history of minor head injury weeks or months before presentation
• CT appearance

Acute blood (0-10 days) is hyperdense

Subacute blood (10 days to 2 weeks ) is isodense

Chronic blood (> 2 weeks) is hypodense
• Treatment: evacuation via burr holes rather than craniotomy

GENERAL SURGERY

SUTURE MATERIALS
Non-absorbable suture materials
Suture material Raw material Tissue reaction Remarks
Silk Natural protein Moderate to Ligation and suturing when long-term tissue
Raw silk from silkworm high support is necessary
Not to use with Vascular prostheses
Linen Long staple flax fibres Moderate No longer in common use
Surgical steel An alloy of iron, nickel and Minimal In conjunction with prosthesis of different
chromium metal
Nylon Polyamide polymer Low General surgical use
Polyester Polyethylene terephthalate Low Cardiovascular, ophthalmic, plastic and
general surgery
Polybutester Polybutylene terephthalate Low Particularly favoured for use in plastic
and polytetramethylene surgery
ether glycol
Polypropylene Polymer of propylene Low

Absorbable suture materials

Suture material Raw material Absorption Tissue Remarks
rate reaction
Plain Catgut Collagen from 7-10 days High Ligate superficial vessels, suture
healthy sheep or cattle subcutaneous tissues
Chromic catgut Catgut tanned with 90 days Moderate
chromium salts
Polyglactin Copolymer of lactide 60 — 90 Mild Gut anastomoses, vascular ligatures.
(Coated vicryl) and glycolide; coated days Has become the 'workhorse' suture for
with polyglactin and Many applications in most general
calcium stearate surgical practices

Polyglyconate Copolymer of glycolic 180 days Mild

acid and trimethylene
carbonate
Polyglycolic Polymer of Polyglycolic 60 — 90 Minimal
acid acid days
Polydiaxone Polyester polymer 180 days Mild Not for use in association with heart
valves or synthetic grafts,
Polyglycaprone Copolymer of glycolite 90 —120 Mild Subcuticular in skin, ligation,
(Monocryl) and caprolactone days gastrointestinal and muscle surgery
Numbering of suture material
• 2-thick : for pedicle ligation
• 2-zero: bowel suturing
• 5-zero: vascular anastomosis
• 9-zero: requires operating microscope

Suturing techniques
BOWEL ANASTAMOSES
• Only bowel of similar diameter is brought together to form an end-to-end anastomosis
• Major size discrepancy: side-to-side or end-to-side anastomosis
• Minor size discrepancy: Cheatle split (making a cut into the antimesenteric border) may help to enlarge the
lumen of distal, collapsed bowel
• Ensure the anastomosis is under no tension
• The suture materials should be of 2/0-3/0 size and made of an absorbable polymer

DRAINS & timing of removal

Purpose of drain & Example Time of removal
To cover peri-operative bleeding. After 24 hours
E.g.Thyroidectomy
To drain serous collections. E.g. Mastectomy After 5 days
For infection. E.g.Abscess I&D Until the infection is subsiding or the drainage is minimal
To cover cold-rectal anastamoses 5 — 7 days
Common bile duct T-tubes After 10 days

LIGASURE TISSUE FUSION TECHNOLOGY

• Vessel sealing system that is used in both open and laparoscopic surgery
• Ligasure can seal vessels of up to 7 mm diameter, with an average seal time of 2-4 seconds

HARMONIC SCALPEL
• The harmonic scalpel is an instrument that uses ultrasound technology to cut tissues while simultaneously
sealing them
• During use, the scalpel vibrates in the 20 000-50 000 Hz range and cuts through tissues, effecting
haemostasis by sealing vessels and tissues by means of protein denaturation caused by vibration rather than
heat
• Patients experience less swelling, bleeding and bruising after the use of the harmonic scalpel
LEG ULCERS
• Venous disease: superficial incompetence; deep venous damage (post-thrombotic) — most common (70%)
• Arterial ischaemic ulcers (20%)

Venous ulcers
• 50% due to varicose veins; 50% due to post-phlebitic limb (previous DVT)
• It is common around ankle (gaiter's zone)
• Initially painful; but once chronicity develops it becomes painless.
• Vertically oval, commonly located on the medial side; never above the middle third of the leg

Tropical ulcer (Phagedenic ulcer)

• Occurs in tropical countries
• Malnutrition, Poor immunity and insect bite are precipitating factors
• Caused by Vincent's organisms(Borellia vincenti, fusiformis, bacteroides)

Trophic ulcer — pressure sore [Neurogenic/ neuropathic ulcer]:

• d/t impaired nutrition, defective blood supply & neurological deficit
• More prominent b/w bony prominence & an external surface.
• Eg: bed sores
Diabetic ulcer — great toe or metatarsophalangeal areas are most common Three main components:
• Peripheral neuropathy (motor, sensory, and autonomic)
• Peripheral vascular disease
• Immunodeficiency

Ulcer edges
• Sloping edge - healing ulcer
• Undermined - tuberculosis
• Punched out - syphilis (thin base, wash leather slough) or trophic ulcer or peptic ulcer
• Raised and beaded - basal cell carcinoma
• Everted [rolled out] - squamous cell carcinoma

 Martorelle's ulcer — hypertensive patients with atherosclerosis

 Buruli ulcer(bairnsdale ulcer) — Mycobacterium ulcerans
 Meleney's ulcer — postoperative synergistic gangrene
 Bazin's ulcer — localized fat necrosis
 Marjolin's ulcer — chronic unresponsive ulcer developing to squamous cell carcinoma

PRESSURE SORES (bed sores, pressure ulcers and decubitus ulcers)

• Defined as tissue Defined as tissue necrosis with ulceration due to prolonged pressure.
• Occur in approximately 5 per cent of all hospitalized patients
• There is a higher incidence in paraplegic patients, in the elderly and in the severely ill patient
• MC sites (in descending order): ischium, greater trochanter, sacrum, heel, malleolus (lateral>medial), occiput
• If external pressure exceeds the capillary occlusive pressure (over 30 mmHg), blood flow to the skin ceases
leading to tissue anoxia, necrosis and ulceration
• Prevention is obviously the best treatment

Good skin care,

Special pressure dispersion cushions or foams

Use of low air loss and air-fluidised beds

Bed-bound patient should be turned at least every 2 hours

Wheelchair-bound patient being taught to lift themselves off their seat for 10 seconds every 10
minutes.

SURGICAL WOUNDS
Clean wound Clean contaminated Contaminated wound Dirty infected wound
Respiratory, GI, or Respiratory, GI, or Open fresh traumatic Open traumatic dirty
genitourinary tract not genitourinary tract wounds; uncontrolled wounds; traumatic
entered entered but minimal spillage from an perforated viscus; pus in
contamination unprepared viscus the operating field
• Infection rate <2% Infection rate 10% Infection rate 15-30% Infection rate 40-70%
• Herniorrhaphy • Appendicectomy • Acute abdomen • Abscess drainage
• Surgeries of brain, • Gastrectomy • Rupture of • Pyocele
heart, blood vessels, • Cholecystectomy appendix • Empyema gall bladder
joints, transplant. • Hysterectomy • Resection of • Fecal peritonitis
unprepared bowel • Resection of gangrene

Prevention of surgical site wounds

• Maintaining positive pressure at a temperature 20 - 22°C
• Pre-operative hair removal (clipping) should be done immediately before an operation
• Patient's skin is prepared by iodophors (povidone iodine 10%)
• Surgeon and team should scrub atleast for 3-5 minutes with 4% chlorhexidine
• Gloves should be changed after 3 hours if surgery lasts for more than 3 hours
• Blood sugar level < 150 mg/dL in the preoperative period is recommended

WOUND HEALING
Primary Intention: Secondary Intention:
• When wound edges are apposed • The wound is allowed to granulate
• Little tissue loss • Granulation results in a broader scar
• Minimal scarring occurs • Healing process slow due to infection
• Most surgical incised wounds heal by first • Wound care must be performed daily to
intention encourage
• Wound closure is performed with sutures, • wound debris removal to allow granulation
staples, or adhesive at the time of initial tissue formation
evaluation • Examples: gingivectomy, gingivoplasty, tooth
• Examples: well repaired lacerations, well extraction sockets, poorly reduced fractures.
reduced bone fractures, healing after flap
surgery.

Tertiary Intention (Delayed primary closure):

• The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure.
• The wound is purposely left open
• Examples: healing of wounds by use of tissue grafts

OPERATIVE TREATMENT OF WOUNDS:

• Direct suturing - clean incised wounds of less than 6 hours duration.
• Excisions of the wounds - lacerated and contaminated wounds. After excision and cleaning, immediate
direct primary suturing is advisable. If the lacerated wound is not healthy or not clean. It is better to leave it
opened for dressing. After cleaning delayed primarily suturing is required. If graft needed, tidy wound –
primary grafting; untidy - secondary grafting
 • Debridement of the wound - infected wounds and wounds of more than 24 hours duration.
• The aim is to encourage healing by secondary intention. We leave the wound clean and opened; to provoke
growth of healthy granulation tissues. Secondary suturing or skin graft is performed

Surgical infections
• Surgical infections are most commonly due to Bacteroides fragilis (Sabiston)
• Usually acquired from the bacterial flora of the patient himself

GRAFTS
• Tissues that are transferred without their blood supply
• Therefore have to revascularise once they are in a new site
• Nerve grafts - usually taken from the rural nerve
• Tendon grafts - sually taken from the palmaris longus or plantaris tendon

Split thickness graft (Thiersch graft) Full thickness graft (Wolfes graft) Composite skin grafts
• Easy survival (uptake easy) • Reduced survival (difficult uptake) • Often taken from the
• Large graft can be taken • Only small grafts can be taken ear margin
• Limited durability and will • Minimal contraction • Useful for rebuilding
contract • Suitable for cosmetic surgeries on missing elements of
• Valuable temporary wound face, eyelid, hands, fingers nose, eyelids and
closure before better cosmetic • Common donor sites - Post- fingertips
correction auricular, Supraclavicular, Groin

FLAPS
• Flaps are tissues that are transferred with a blood supply
• They therefore have the advantage of bringing vascularity to the new area.
• Random flaps

Rectangular flap with length to width ratios 1 : 1 or less than 1.5 : 1

Vascular basis – subdermal plexus of blood vessels (no known blood vessel)

Typically used to reconstruct relatively small, full-thickness defects

Unlike axial flaps, limited by their geometry
• Axial flaps - longer flaps, based on known blood vessels supplying the skin.
• Pedicled/islanded flaps. The axial blood supply of these flaps means that they can be swung round on a stalk
or even fully 'islanded' so that the business end of the skin being transferred can have the pedicle buried
• Free flaps. The blood supply has been isolated, disconnected and then reconnected using microsurgery at
the new site
• Composite flaps. Various tissues are transferred together, often skin with bone or muscle (osseocutaneous
or myocutaneous). Muscle flaps are more malleable to conform to wounds with irregular three-dimensional
contours. They are superior in wounds compromised by irradiation or infection
• Perforator flaps. New subgroup of axial flaps in which tissues are isolated on small perforating vessels that
run from more major blood vessels to supply the surface

Preferred flaps
• Mandibular reconstruction, – Pectoralis major myocutaneous flap
• Breast reconstruction – latissimus dorsi or transverse abdominis myocutaneous flap

HYPERTROPHIC SCAR KELOID

 • Develop within 4 weeks after trauma • Occur 3 months to years after the initial insult
• Proliferation of mature fibroblasts • Proliferation of immature fibroblasts
• No proliferation of blood vessels • Proliferation of immature blood vessels
• Does not become worse after 12 weeks • Proliferation continues after 12 weeks
• Young individuals • Females, negroes, family history, tuberculosis
• Scars crossing Langer's lines patients, incision across Langer's line
• Does not extend beyond the boundary of original • Encroachment of surrounding tissues by claw
wound like process
• No claw like process • Itching and blanching
• No itching • Slightly warm and slightly tender
• Sites: anywhere on the body, common in flexor • Sites: Chest wall, upper arm, lower neck, ear
surfaces • Occasionally malignant change (Marjolin's
• Gradually regress after 6 months ulcer)
• Does not recur after excision • Recurrence after excision common

Treatment of Keloid
• No single therapeutic modality has been determined experimentally to be most effective for treating keloid
• The most important thing to consider in the management of keloid scar formation is prevention
• Pre or post-operative radiation therapy to the wound is a useful form of prevention
• Silicone gel sheets and silicone occlusive dressings have been used with varied success
• Mechanical compression dressings have long been known to be effective, especially with ear lobe keloids.
The recommended level of pressure is 25 mm Hg, but good results have been observed with pressures as
low as 5- 15 mm Hg
• Intralesional steroid (triamcinolone) injection

Mainstay and relatively effective first-line therapy

Injection of triamcinolone into the fresh site of scar excision at 4 to 6 week intervals until the scar
flattens and discomfort is controlled.

The steroid should be injected into the papillary dermis (where collagenase is produced)

Effects of corticosteroid injections alone show a 5-year response rate of 50-100% & recurrence rates of
950%.

When surgical excision is combined with steroid injection, the response rate increases to 85-100%
• Cryotherapy + intralesional steroids – good response
• Interferon alpha 2b and Interferon gamma – newest modality– 50% reduction in size
• Others – laser therapy, 5-FU, imiquimod, bleomycin, tacrolimus, Flurandrenolide tape etc.,

Cysts
Congenital Acquired
• Dermoid cyst Retention cysts Distension cysts Exudation cyst
• Thyroglossal cyst • Sebaceous cyst • Ovarian cyst • Hydrocele
• Urachal cyst • Bartholin cyst • Lymph cyst
• Parotid cyst • Colloid goiter
• Breast cyst
• Plunging ranula

Brilliantly transilluminant swellings Cross fluctuant swellings

• Ranula • Meningocele • Plunging ranula • Psoas abscess
• Primary hydrocele • Epididymal cyst • Bilocular hydrocele • Compound ganglion of
• Cystic hygroma palm
Cystic swellings
SEBACEOUS CYSTS (epidermal cysts, epidermoid cyst or wen)
• Retention cyst
• Lined by true stratified squamous epithelium
• Derived from the infundibulum of the hair follicle or traumatic inclusion
• Often found on hairy areas of the body, such as the scalp, trunk and face.
• Fixed to the skin
• Usually have a central punctum that is often indentable
• A misnomer as the cysts are not of sebaceous origin and the pearly white material within them is not sebum
but contains keratin(desquamated epithelial cells)
• Infected, ulcerated forming a painful fungating mass with discharge – Cock's peculiar tumor
• Demodex follicularum- a parasite found in sebaceous cyst
• Gardner's syndrome- associated with multiple sebaceous cysts
• Strawberry scrotum – multiple sebaceous cysts of scrotum

 Turban tumor-cylindroma of scalp, rare tumor of scalp

DERMOID
Congenital/Sequestration dermoid
• Along line of embryonic fusion
• Eyebrow (lateral border) - most frequent site (External angular dermoid)
• Bony defect/depression – pathognomic
• Manifests in childhood or adolescence
• Contain squamous epithelium, hair follicles, sebaceous glands
• Commonly asymptomatic but can become inflamed and infected

Implantation dermoid
• Common in women, tailors, agriculturists who sustain repeated minor injuries
• M/c in fingers , toes, foot
Tubulo dermoids - thyroglossal cyst, post anal dermoid, ependymal dermoid
Teratomatous dermoid: Contains elements of all germinal layers – hair, teeth, cartilage

ACUTE PARONYCHIA
• Nail bed infection is the commonest hand infection
• Most common organism: Staphylococcus aureus
• Occurs in the subcuticular area under the eponychium
• Tracks around the skin margin and spreads under the nail causing hang nail or floating nail
• Treatment: incision and drainage, antibiotics & partial nail removal

CHRONIC PARONYCHIA
• Usually a fungal infection, mostly Candida albicans
• In those whose hands are frequently immersed
• Treatment – long term antifungal therapy

TERMINAL PULP SPACE INFECTION (FELON)

• An abscess between the specialised fingertip septae in the distal pulp
• Staphylococcus is the most common organism
• TOC – incision and drainage under digital block by Volar longitudinal incision
 • If pus not released early – thrombosis of digital artery (end artery) occurs resulting in osteomyelitis and
necrosis of terminal phalanx
• Formation of collar stud abscess

Causes of collar stud abscess

• Felon
• Tuberculous cold abscess
• Deep palmar space infection m
ORF: contagious pustular dermatitis of the hand due to parapox infection
Spina ventosa: tuberculous dactylitis

AINHUM
• A fissure develops at the interphalangeal joint which becomes a fibrous band, that encircles the digit causing
necrosis (Gangrene of toe)
• Commonly affects males
• Fifth toe is commonly affected
• Treatment: Early "Z" plasty; later - Amputation often required
• Most often autoamputation occurs

LUNG SEQUESTRATION
• Normally developed bronchioles and alveoli
• Supplied by systemic rather than pulmonary arteries(thoracic or abdominal aorta)
• Commonly in lower lobes

Intralobar sequestration Extralobar sequestration

• Drain through pulmonary veins • Drain to azygos veins
• In communication with airway • No communication with lungs
• Prone to infection • Asymptomatic
• Treatment – lobectomy • Treatment - excision

BRONCHOPLEURAL FISTULA
• latrogenic: lung biopsy, thoracocentesis, radiation therapy, pneumonectomy, lobectomy
• Post pneumonectomy ventilation for > 24 hours increases the risk
• Commonly manifests 7 – 15 days following lung resection
• Clinical features: cough, respiratory distress, empyema, persistent postoperative air leak

• X-ray

Changes in the air-fluid pattern

New or increasing air-fluid level

Disappearance of pleural fluid (if there is no chest tube)

Steady increase in intrapleural air space

Development of tension pneumothorax
• Fibreoptic bronchoscopy and selective bronchography – to localize the site

Complications of pleural biopsy

• Pneumothorax
• Prolonged air leak
• Subcutaneous emphysema
 • Empyema
• Chest wall metastasis from mesothelioma
• Fever, chills

SUBCLAVIAN STEAL SYNDROME

• Obstruction of first part of subclavian artery
• Vertebral artery provides collateral circulation to the arm by reversing the blood flow
• This causes cerebral ischemia with syncopal attacks, visual disturbances, diminished BP in the affected limb
• Symptoms are aggravated by arm exercise
• Javid test: compression of carotid artery makes ipsilateral radial pulse feeble

AMPUTATIONS
• Ray amputation – amputation of toe with head of metatarsal or metacarpals
• Gillies's amputation - trans metatarsal
• Lisfranc's amputation – tarso metatarsal amputation
• Chopart's amputation – midtarsal amputation
• Syme's amputation

Removal of foot with Calcaneum and cutting of tibia and fibula just above the ankle joint with retaining
heel flap

Elephant boot is used for limb after Syme's amputation

Mainly used for crush injury, infections

Not done for: peripheral artery disease, peripheral artery disease
• Pirogroffs amputation – provides longer stump than Syme's amputation
• Below-Knee (Burgess) amputation

Long posterior flap

Better prosthesis placement with greater range of movements without limp

Stump length is 14 – 17 cm from the knee joint

Minimum length required for prosthesis is 8cm
• Hip disarticulation

Done whenever it is not possible to save the minimum 10cm length of the femur
• Above knee amputation

Equal anterior and posterior flaps

Ideally required length of femur stump is 25cm from the tip of the trochanter

HEMORRHAGE
• Revealed haemorrhage or external haemorrhage: e.g exsanguination from an open arterial wound or from
massive haematemesis from a duodenal ulcer.
• Concealed haemorrhage: e.g. occult gastrointestinal bleeding or ruptured aortic aneurysm
• Primary haemorrhage - immediately due to an injury (or surgery).
• Reactionary haemorrhage – delayed haemorrhage (within 24 hours) and is usually due to

D Dislodgement of clot by resuscitation.

Normalisation of blood pressure

Vasodilatation.

Technical failure, such as slippage of a ligature.
• Secondary haemorrhage - occurs 7-14 days after injury

Due to sloughing of the wall of a vessel.

Precipitated by - infection, pressure necrosis (such as from a drain) or malignancy
  Direct pressure should be placed over the site of external haemorrhage as an immediate resuscitative
measure

MISCELLANEOUS
NATURAL RESPONSE TO INJURY includes
• Immobility/rest
• Anorexia
• Catabolism

The metabolic response to injury in human beings is divided into ebb and flow phases
Ebb phase Flow phase
• Begins at the time of injury and lasts for 24 – 48 hrs • Initial catabolic phase for 3 – 10 days:
• May be attenuated by proper resuscitation but not
Increased production of catecholamines,
completely abolished cortisol, insulin and glucagon
• Characterized by
Significant weight loss

Hypovolemia
Insulin resistance - poor glycemic control

Decreased Basal Metabolic Rate
Risk of infection and CVS complications

Reduced cardiac output • Anabolic phase which may last for weeks

Hypothermia • Characterized by

Lactic acidosis
Tissue edema
• Predominant hormones regulating
Increased basal metabolic rate

Catecholamines
Increased cardiac output

Cortisol
Increased temperature

Aldosterone
Leucocytosis

Increased oxygen consumption

Increased gluconeogenesis

Hormone levels after injury

Levels rise following injury Levels fall following injury
• ACTH • Insulin
• Growth Hormone • Thyroid hormones
• Glucagon • Testosterone
• Cortisol
• Adrenaline

RUSH SYNDROME
• Prolonged crushing of muscle leads to a reperfusion injury when the casualty is rescued
• The myoglobinuria leads to renal failure from tubular obstruction and acute tubular necrosis
• Aggressive volume-loading of patients, preferably before extrication, is the best treatment
• Alkalinisation of the urine increases the solubility of acid haematin in urine and aids its excretion
• Do not perform late fasciotomy (where entrapment has occurred over 12 hours)  likely to cause a massive
release of myoglobin

LAPAROSCOPY
• Usually under GA
• Pneumoperitoneum created with CO2 upto a pressure of 15mmHg
• CO2 causes hypercarbia, acidosis and hypoxia
• Pneumoperitoneum causes pressure on IVC and decreases venous return and cardiac output
• Electrosurgical injuries during laparoscopy - majority occur following the use of monopolar diathermy
 • Abdominal wall vessels most commonly injured – superficial inferior epigastric vessels

Arrhythmias in laparoscopy
• Incidence 47%
• Most common- bradycardia
• Common causes - hypercarbia, hypoxia from hypoventilation, ↑ intraabd. pressure, peritoneal distension
• Laparoscopy is done always under GA. There won't be any pain in GA

Post-operative nausea and vomiting (PONV)

• Can precipitate bleeding and dehiscence of wounds by dislodging the clots and bursting suture lines
• In neurosurgical patients, it may precipitate raised intracranial pressure with disastrous effects.
• Women, non-smokers or those who have a past history of PONV, motion sickness or migraine – higher risk
• Volatile anaesthetic agents, opioids and nitrous oxide – high risk.
• Common following laparoscopic and squint surgeries
• Adequate treatment of pain, anxiety, hypotension and dehydration will minimise the risk
• Propofol for induction of anesthesia - reduces incidence.
• At least one antiemetic should be given on a regular basis in the high risk group and second one given when
needed

Perioperative and intraoperative care

Tourniquet pressure in adults: upper limb – 200 to 250 mmHg; lower limb – 300 to 350 mmHg
Temperature inside theatres: ideal for surgeons is between 19 and 20°C, but.to prevent hypothermia 24 to 26°C
Relative humidity should be capable of adjustment in the range 40 – 60%
Light source should be capable of producing a minimum of 40000 lux at the incision site
The minimum standard number of airflow changes allowed in operating theatres in UK is 17 per hour
Laminar flow will provide 100-300 air changes per hour

A proactive approach to prevent unnecessary aspects of the surgical stress response

• Minimal access technique
• Blockade of afferent painful stimuli (e.g. epidural analgesia)
• Minimal periods of starvation
• Early mobilization

ORGAN DONATION
• Chronological age of the donor is less important than the physiological function of the organs
• In donation after circulatory death (DCD) donors there is an inevitable period of warm ischaemia (up to 45
minutes is acceptable) between the diagnosis of death (cardiorespiratory arrest) and cold perfusion of the
organs.

Contraindications for organ donation

• Creutzfeldt–Jakob disease
• HIV infection
• Malignancy within the past 5 years (except primary CNS tumors, non-melanotic tumours of the skin and
carcinoma in situ of the uterine cervix)
• Hepatitis B infection
• Active systemic sepsis
TOTAL PARENTERAL NUTRITION
• Most common complications: fluid overload and hyperglycemia
Metabolic complications
Related to Nutrient Related to over feeding
deficiency Excess glucose Excess fat Excess amino acids
• Hypoglycemia • Hyperglycemia • Hypercholesterolemia • Hyperchloremic
• Hypocalcemia • Hyperosmolar • Formation of metabolic acidosis
• Hypophosphataemia dehydration lipoprotein X • Hypercalcemia
• Hypomagnesaemia • Hepatic steatosis • Hypertriglyceridemia • Aminoacidemia
(Refeeding syndrome) • Hypercapnea • Hypersensitivity • Uremia
• EFA deficiency • ↑ symp. activity reactions
• Trace mineral ↓ • Fluid retention
• Hypokalemia

Chyluria
• Filariasis is the most common cause
• Other causes: ascariasis, malaria, tumor and tuberculosis
• Painless passage of milky white urine, particularly after a fatty meal
• Diagnosis: IVU or lymphangiography
• Treatment: low-fat, high protein diet, plenty of oral fluids, laparotomy and ligation of dilated lymphatics

NOBEL LAUREATES
Alexis Carrel Works on vascular suture and the transplantation of blood vessels and organs
Joe Murray First kidney transplantation
Warren and Discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer
Theodor Kocher Thyroid disease
Werner Forssmann Cardiac catheterization
Charles Huggins Oncology

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