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HOWTOIISETHISBOOK

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QUESTION BAI\K
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HERiIIA
. Abdanipl henh . ehurgplaled hornh . O$lirlrle, fu, fomad ffi . Umbliod ]renb ' lrrcieione!, rurrsrl htn'ra. &rrgl abdomen
(Xhc lgps of hotrrkt fwso|e. Kry lo oaeee. Queglirr Bark,
fake gour

a 5

I I

ACTIIE ABDOMETI
ra

' '

to t2

T'
8l 8tl a4 85

nole

. .

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8ub-Phrcnb abeoese
Speoifio !g

OESOPHAGUE: . Dbphtqtnslio hsnkr . OERI) . Eeophqed oarcirqra . Pct Obdd oe(ir(ma. . .

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t
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virqr'e

e.

r8 r9 20 2t
,42

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89 90 9t u2 93 94
Take

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r8

ETOAMCH:

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24
2A
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gor
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2e 30 g2

gMALL, IARGE INTESIINE

.
lnlestiral

&
fake

ltauma

lol
lO4

35

LIVER, PH, 8IILEE]II . Livc lranma . Livc hf,ootirne . Pgqgrtb live Seoc . BeiEI live fumom . HepalooCular oaohonra . Lfuc melaetaslg . Palal hgpctersbn . Ruplure epleer . eplenomqgdg , Migoellarreons lopbg . fure'lt, KeUe lo oases, (heslbn
gour nolee

& 4 45 4
47

4t

49 53

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55 5e

GB, PANCREAS . Oallbladdc clonc . Managerneil of oholeogsfif'n . Managenal of obgtruotive jaundoe

. . . .
Panorcalllis
Mleodlaneoue topbe Carohroma of Panoreas fuec'le, KeUe fo oaeee,

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gour nolee

lOs
IOG

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116

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General scheme Hernia "V\rQ" Oblique vs. Direcl vs. Fernoral hernia Urnbilical hernia Complicalions of hernia Sirangfulated hernia Other lgpes of hernia

SCHEMEFORM
Definilion . Palholo$cal . Clinical Eliologg : . Congenilal or acquired . Predisposing factors Pathologg . Sac . Conlenl . Defecl

lJFq-{wN5 t $f IJPhR'l

?AEY

t1

INCIDENCE:

Mosl cornmon hernias are: - lnguinal hernia (lst) - lncisional hernia (2nd)
Ep'gastric hernia Fernoral hernia Mosl cornmon slraneulaled hernia is lnguinal hernia Most Liable hernia for slrangulalion is Femoral hernia

{. *

rgpe :

Neck of hernia sac:

N. Narrow
:

Clinical piclure

. . .

Precipilatingfaclors
Case (READ) Complicalions

Para-umbilicalhernia lll-defined lncisional hernia

:

Fernoral hernia

.DD

lnvesligalions
Pre-operalive, for precipitating faclors

Treatmenl D Trealmeni of Precipilating faclors F Surgerg

lf complicaled: TTI. of lhe

cause

EXPANSILE IMPULSE ON COUGH

E-whu?
SAC is continous wilh When Hernia doesn't

Slrangulated, Fattg hernia of linea alba,

Other sacs wilh exoansile

MMrffiTiffillr
DEFTNtrtoN
,
Patholoqicallu: Prolrusion of a VISCOUS within a peritoneal SAC through a DEFECT in abdorninal wall Clinicallg: Painless swelling characterized bg "READ" Reducible, expansile impulse on cough, on analomical site of hernia, with a defect

rr_ r! - ? - ? ^t^.-^ , !'reolsPoslng Factors

precipiran ng

CONGENITAL... Congenilal lngluinal , Congenilal Umbilical hernia ICdfiEEo>lNctslot{RL, Paialgtic lortt Grid iron incision, "+r", Kocker incision), Defeclive lgpe

Facrors

: il::il"1T;il:1'ro#ili;;;,,1f1:l#fl';u"l'13; :H.,Y,
Defect
$lac

. . . .

Conlenl
Coverings

CrrNtcALHC,TURE
Sgmptoms
PAINLESS SWELIING Characlerized bg "READ" , Reducible, or gives historg of reducibilitg . givin! expansile impulse on cough, . On analomicalsile of

General O/E
signs of mesenchgmal weakness
T T

LOCAL OlE
r) lnguino-scrofal, Parcumbilical swelling 2) Expansile impulse on cough 3) Descenl.. 4) Reducible

PPT faclors

complications

hernia,

wilh a defecl

CoMnrtCknollS& DD
I
I I

Hernia is a clinical diagnosis lnvesligalions for the precipitating! factors & Preoperativelg (CXR, CBC, FBg, U/S, LFTs, KFIs)

TTT

of

PPT faclors

Surgical Treatmenl For unbomolicated cases

TTT of Complicalions

t6

' .

DEFINIIION: Failure, of whole or parl of hernia conlenls lo return lo abdomen

ETIOLOGY:

MOST COMMON CAUSE: Adhesions belween sac, Conlenls

Other causes: Adhesions belween contenls, Overcrowding of conlenls, Narrow Neck, Bliding Hernia, Ornentum in sac (mag lead lo sfrangulalion)

. ,

DEFINITION: Occlusion CLINICAL PICTURE:

of iniestinal lumen wilhout inlerference with blood supplg

Abdominal colic, projeclile vomiting, absolule conslipation, distension Hernia sac is Tender, Sofi, Oiving weak expansile impulse on cough

ETIOLOGY:

lnflarnrnalion of Bac) due lo lruss lnflarnrnalion of Conlenl) append:citis, Meckel's diverliculilis

CLINICAL PICTURE: FAHM, Pain

al sile of swelling O/E: hernia is red, hol , lender, giving expansile impulse on cough

ITT

lf due lo lruss) lf due to

Rernove lruss, give NSAlDs, Eleclive repair

, Hernia repair

opening of sac, onlg fluid passes lo sac CLINICAL PICTURE: Cgstic, Translucenl, lnguino-scrolal swelling TTT: Excision

Hgdrocoele occurs in INGUINAL, FEMOMT hernia ... But NEVER occurs in epigaslric & umbilical hernia

Ruplure of hernia sac r Torsion of the omentum T gliding

I

ilPq4w$

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HERD'In
DEFINTTPN
. . , . .
/ / //
lnlerference with blood supplg of conlenls leading to gangrene wilhin 4-6 hours

INCDENCE

Most cornrnon cause of inlestinal obslruclion Mosl common hernia to be siranlulaled)lnguina! hernia Mosi Liable hernia lo be slrangulated) Femoral hernia Most cornrnon conlents to be slrangulated) Srnall inlesline.. Omenlum
Sharp edge of defecl Narrow neck in relation to large contenl lrreducibilitg ) Obstruclion ) lnflarnmation

/ Conslriclion) Bands of adhesions, defecl / Obslruciion of vein, arterg ... tllrJ r pJ r rrr-ro /( Sac) Dislended & Loses its lusler ,( Covering) lnflamed

AuNrAArHctTt RE
gYMPIOMg

Historg of painless swelling which becomes painful (Colic & $tabbiag) EI Piclure of inteslinal obstruclion) Abdornina! colic + Projeclile vomiting! + absolule conslipation *Distension

GENEML EXAMINATION

fl

EI

Badgleneral condilion Shock

LOCAL M Swelling with M lrreducible,

PRE.OPERATIVE
RESUBCIIATION RYLE, LINE, CAII{ETER, FLUID, MONITOR

INTRA.OPERATIVE

POST.OPERAIIVE

g
V

General aneslhesia Viable vs. Non-viable

g g
V V

Sedation
NPO

inlestine @ Deal with conlents V Herniolomg , Herniorrhaphg Closure

Rgle suction {luids Anlibiolics Drains

lV

5UPI4-100..15

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PFE-OPERTTTVE
RYLE. LINE, CATHETER, MONITOR RYLE: Prevenl vomiting Prevent Aspiralion Prevent posloperalive paralgtic ileus Asses amounl of fluid loss Aspirale loxins
@

INTRA-oPERATN/E
g
V
General anesthesia Wide exploralorg incision Open lhe sac, evacuate il from loxic fluid before division of conslriclion ring, grasp the intestinal loop & exarnine it (Viable vs. Non-Viable) Then Deal with conlents :

FC!r_OFERATN/E

. . .

g
V V

9edation
NPO Ryle euction + lVfluide

g
V

Antibiotice
Drains

EXCTSTON

CANNULA

. . r

lV fluids Blood lransfusion Pre-operative medications "morphia & Antibiotics"

Reduction of hernia

V V

CATHETER

Deleclion of urine oulpuVhour MONITORING of Vilal data . Pulse, BP, lemperalure . Urine outpul

RESECTION & ANASTOMOSIS

V lntra-operalive Iavage lhen Reseclion & Anastornosis

Exleriorization of both ends from olher incision & Anastornosis is done later after lmprovemenl of general condilion (Low residue diel + enema + flaggl * neomgcin)

1J?4-T0or..l5: qT

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Definilion

. .

Palholo{icallq: Protrusion of a VISCOUS within a peritoneal 9AC through a

abdominalwall

DEFECT in

lncidence

. .
.

Clinicallv: Painless swelling charcclefized bg "READ" Reducible, expansile impulse on couAh, on anatomical site of hernia, with a defecl . 3rd common Old age Young age . Female, 20-40 grs. Voung age, Mate . RT side > LT side RIGHT > LEFT
Weakness of lower

Elioloqq
Predisposing

. qglgfeL un-oblilerated
processes vaginalis

lnjurg lo
!lioinguinal N.B. Paralgsis in

faclors
Precipilating

faclors

Acquired: weak abdominalwall, 4 lnlra-abdominal Pressure

abdominalwall 4lrrtra-abdominal
PreSrSure

'us
2)

. Rarelg Cong. NAMTH's H.

associated with Maloaone buloe

Palholoqu :
Defeqt

conjoint lendon
Through medial

U 4 lnlrabdominal

Pr.

Weakabdominalwall

Comes from lhe lrrlernal ri4g laleral to inferior Epigastric arterg

Bulges lhrough

laleral parl of
Hasselbach's

part

of

Ihrough femoral ri4g (Below medial part of

inguinal ligament) Passes dowrrurards.

Hasselbach's

lrianole
8ac Conlenls
ooverings

irianole
Mag descend

inside lhe cord coverings, Anteromedial to vas deferens & vessels 9mall intesiine, omentum

NEVER descends

lo scrotum

lo scroium

Hlll,t7ll

S{|lllalrll

l) lrrlernal spermalic fascia 2) Cremasteric fascia

3) Exlernal oblique
apponeurosis

$mal! intestine, omenlum l) Fascia Fascia lransversalis lransversalis 2) Exlernal

Oblique apponeurosis 3) 0uperficial
2) Conjoirrt

fonrards, upwards then lalerallq

l)

Femoral sheath

3) External
spermalio Ms.

tendon
3) Buperficial

2) Cribriform fascia 3) superficia! Fascia 4) SC far 5) 9kin

4) Camper, scarpa
fascia

4) Darlos Ms. 5) Skin

fascia*
Bkin

fascia+ $kin

5l
Clinical Diclure
General

Skin

Local

SWELLING

2) Gives expansile impulse on cough 2l ................ 3) Descend) Downwards. fonrards 3) Forurards 4) Backwards & mediallg

SumDloms) Painless swellinq charaslerized bu "READ" giqns of meserchqmal weakness, PPT faclors & complicaliors r) lnguinal or inguino-scrolal

Direclion of descerrt
Downwards Forwards Upwards &Laleral

t) il
ComDlicalions

Reducible)upwards, backwards,
laterallg

s)

NEGATTVE

lnterna! rinQ lesl

See soheme

& lnvesti{ations...

frealment III of PPI

Surgical Complic.

g g

Herniolomg lndications
:

congenilalOlH

V
@

Herniorrhaphg l) Adulls & elderlg

Herniorrhaphg shouldice, marcg rePair Hernioplaslg bg mesh Herniotomg is nol usuallg

needed. lf patierrt isn'i fit for surgerg) Truss

g g g
@

Low approach

2) 3)

lnfection Concomifanl bowe! resection

"Lockwood" lnguinalapp "Lotheissen" Pre-periloneal "McEvedg"

Laparoscopic

Tgpe6: Marcg, Bassini, thouldice

Hernioplaslg(Grafting): Prolene, Mersalin, PTFE mesh

Truss is

figtucAHffi
Definiiion lncidence Etiologg

?^qYt1

. .

Pathologicallg........
Clinicallq

Since birth Failure of ALt or part of midgut lo relurn lo the

abdomen

. Weeks-monlhs after birth

Weak Umbilical scar

.qEEJ&-EE@E
. 4lnlra-abdomina! pressurc (Chronic
coughing, Obesitg) . Weak anlerior abdominal wall

PalholoEu : Defeci
AT ANTERIOR

. <Scm
(exomphalous minor)

t@!E
umbilicus

ABDOMINAL
WALL

. >Scm
(exomphalous maior) Periloneum . !rrtesiine . Meckel's diverliculurn . Ang olher abdominal viscera Periloneum

'r",o,n

umbilicus (less common)

9ac Conlenls

adhesiorrs, Narrour neck

. Omerrtum . Bmall lrrtesline

. Omenlum . Bmall lrrleetine

I

Coverings

Amniolic membrane
Wharton jellg (onlg in Exomphalous minor)

$trelched umbilicalscar,
exlra-peritoneal

Bkin ,9C lissue, Exlra-peritonea! fal

fat
Clinical piclure: Bqmp,loms: Painless swellinA characlerized bq "READ" 9'rgns: Other associaled Phimosis Sigrs of mesenchgmalweakness, PPT
anomalies

faslors, Complicat'ors
Slraqgulaiion

Complicalions

Rupture of sac, infeclion of intesline

. *rroorsrs ao"*1,11:::r:?Iil:J'
. g g
@

Trealmerrt

. ' .

'!llDds!!slry!!@ V
.
accommodate conlenf: Primarg olosure undet moderate lension lf can'l aooommodale confenls: Skin flap closure

Reassurarrce

TTT

ofPPT 0urgical ....

& follow up EI TTT. of PPI

umbilical hernia except if secondarg ascites Maq be Treal lntertrigo if present 9urgical repair :

lo

Complications

EI

factors Burgcal correclion

>2grs. Old,

2)

l)

Analomical repair
Mago's repair

if hernia is lage )Post-op. Venlilator Truss is # ($tranlulalion)

B@EllM
closure

slaged

(lf large defect.

slranoulafionl

Defecl
Bac Corrterrt Cover Complica

Small (<Scml
Bmall

Laroe

l>Scml

Large

loop of small inlesline

Meckels' diverticulum Lauer of amniolic membrane + Wharion's iellu Errta4gling of a loop of inlesline durirg ligature
Reduce

Ang abdominalviscera (e.g. UVER, Bowel) Lauer of amniotic membrane ONLY Rupture of sac &coverings) peritonitis
URGENT 9URGERY lcover wilh sunlhelic materiall

lions
TIT

corrterrt) excise sac) ReDair defecl

5UP.4-T00N5 : qT

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Definilion
lncidence Etiologg

Hernia al a site of previous abdominal incision Develops immedialelg or earlu Posl-Operalive

Disruption of abdomina! incision aboul 10-15 % within I uear of Ooeralion

/ /

PRE-OPEMTIVE / Weak abdomina! Ms. ,/ Obesitg z/ Chronic cough / Chronic conslipation

BPH

/ /{ / /

INTRA-OPERTATIVE A Trauma

@ POST-OPERATIVE

Bad hemoslasis Too loose, too t'rghl repair

Chronic debilitating
disease

Muscle Cutling
Closure with absorbable sulures

/ / / / /

Wound infeclion Vomiling, coughing Earlg relurn lo work Persislenl PPT faciors Paralgtic ileus

z/
@

(Ex: Calgul)

V V
Clinical uiclure Sgmptoms General si(ns Local s'rgns
:

lncomplete removal of sac

Missed sac Displacemenl proslhesis Prosthesis of inadequale
size

g g

Swollen abdomen Abdominal sepsis

. . g

Hisloru of elioloqu & Tuoe of oDeralion. liminq, Dosl-oDeralive Deriod Obesitu, anemia, chesl Droblems, BPH ....eic
BCAR:

g /
M

/ /

Yertical,lransverse Healing (lrg or 2rg)

EI Sero-sanguinous

HERNIA:

g >l week afler g

Operation Pt. feels as wau

discharge

z/ Reducible, Expansile impulse on cough

if

lnlertfigo
ABDOMEN:

something is giving

HSM, Ascites Complicalions... as before !nvestigations

/ /

Duaricaiion of recli

Trealment TTT of PPI Surgical ....

Complicalions

g g
@
Hernioplaslg to
avoid disseclion

LAB)C/g , CBC RADIO) US,CT,X-rau

Suqgicalrepair :

PRE-OPERATIVE

l) Analomical repair 2) Man'rgoi repair 3) Cattell's repair 4) fension free Hernioplaslg l)

lf
large hernia :

lhrough scar lissue

4Cover wound with slerile lowel & warm saline ZIRgle, line, catheter, Abs
INTM-OPERATIVE V lnlestinal Loops are washed wilh saline g Closure wilh fension

skin preparation (TTT of intertrigo) 2) Post-op. venlilalor

sulure

3) Gradual pneumo-Peritoneum

Abdominal binder

1JR4-T00N5 :

qr ilP4%l

?hq7 I I

.......... (= inlestine ) 2)Omenlocele= epiplocele .......... (- omenlum )

3) Epigaslric hernia 4) lncisional hernia 5) Lumber hernia 6) Spigelian hernia 7) Litfre's hernia .......... (= Mecke!'s diverticulum ) 8)Amian hernia .......... (= appendix ) 9) Richter's hernia (Gangrene wilhoul obstruction) lO) Magd!' hernia - W-hernia .......... (Gangrenous loop inside lhe abdomen) ll) Sliding hernia .... (Urinarg bladder, caecum, colon passinglhrough lhe defecl) 12) lncarcerated hernia (lntestina! Iurnen obstrucled from inside bg fecolith.) 13) Panlaloon hernia

l) Enterocele

Dual hernia ,.....(OlH + DIH on the same side)

\*

flJK4-T?N5 qT il?4W
lurnbar trianglle 2. Etiologg Congenilal or assoc. with ms. Weakness 3. Laqge, wide neck, reducible, +ve impulse on cough 4. TTT: surgerg or corsei

?AqV I w

l. ln superior or inferior

4. Old fernale With Defect in the semi-lunar line at Ievel of arcuale line 5. Lies benealh an inlacl exlernal obligue aponeuorosis 6. C/O : localized local pain wilhoul bulge 7. Narrow neck -, Iiable lo strangulalion --+TTT : analomical repair 8. lnvestigations : -'US, CT

\:
i

I,

tl

t.--!
'a#

- Conient is a part of lhe circurnflex of a bowel)

Causes strangulalion

Mlhout obslruction

. Pt. with long slanding OIH . Partiallg irreducible

. Visceral periloneum forms a parl of lhe sac . Sure diagnosis is inlra-operative . If bladder is sliding ) Double micluralion

, Separaled from Umbilicus bg an inlerval . Mag be multiple . Pl. mag complain of DYSPEPSIA (D.D. peptic ulcer) . Mag start as " faltg hernia of linea alba " (no
impulse on cough,no sac)
Fattg hernia of Linea alba lrreducible 2) No impulse on cough

--

I
I

rna
I

D.D. Lipoma

l)

l)

Reducible or Hislorg Of irreducibiliig

3)

Pairrful

2) +ve expansile impulse on cough 3) Painless

(lf contain
Grealer

(incarceralion of fat)

omentum) Dgspepsia)

'

Females, C/O: - Pain and tenderness over medial side of th'rgh - Pain ton doing exlension, adduclion or medial rotation of hip

. Complicalions)referral to KNEE

- Absent adduclor reflex in thigh

ilP+-Trrf{5 | qT il?q%l ? AqY t h

. Conlralateral inguinal exploration will be required in high percentage of infants & children with
inguinal hernias. lnfanl inguinal hernias are associated wilh prematuritg, male, sex, incarceralion & right sidedness. The rnosl frequent cause of recurrence of indirecl inguinal hernia is low lgation of lhe sac. At the lime of repair epilaslric hernias, a careful search for other defects should be perforrned.

.
.
.

Young adull male complaini4g of painless rnass in the inguinal region reaching lhe scrolum, reducible and gives expansile impulse on cough.

Oblqle rrtglna/ llertm

Young! adult male complaining

of painful swelling in the inguinal region thal was painless.

The pain is stabbing and the swelling become tense and give no expansile irnpulse on cough.

Stratglatd

ob/,qt, ntgfual hernh

African babg I monlh old, presents wilh painless swelling al umbilicus that gives expansile impulse on cough.

lfifdiltle M/brlhal lrerum

4. Mulliparous female presenls wilh painless swelling separated from ihe umbilicus bg interval
.There is also dgspepsia and hearl burn.

EVrgastnb ltertb

(A faffy

lernn of lrhu a/ba

5.

Patienl with posloperative scar (especiallg midline and sub coslal incisions) presenls wilh painless swelling relaled to this scar, reducible & gives expansile impulse on cough.

lttcrsrbtal hmih

Complicalion of oblique inguinal hernia

(r,lvt

alans,2@5 - r44rar,l/,2ob - Ay'tar f, Zffi)

G4z/rar 1r1,

Complicalions of hernia 2@/ - ,4y'rar f, 2@4,2M) Complicalions of umbilical hernia CIassi{icalion of inguinal hernia

Diagnosis and rnanagemenl of slrangulaled hernia

?hqv I w

l/alaet Sdfwat /UflBah lu

:thama atiwr-.;ilt1

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Diaphragmatic hernia
GERD

Esophageal carcinoma Motilitg disorders of Esophagus Traurnatic lesions of Esophagus

c{.lR44c0.l5 | qT

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?IQY

IV

HERNlA
GoNGENrrAt
HERhhA
M Mosf common inlernal hernia M Mosl common in lnfants M Due

lo persistence of pleura-periloneal

canals M Leff eide , Posferior CLINICAL PICTURE: Neurborn with Dgspnea, cganosie afler bi?th ... with NO heart diseases

MThrough opening of lnlernal mammarg arlerg MR'Ehf side, Anlerior

CTINICAL PICIURE:

MTrue hernia .... Ihnough Hiatus & Greafer ourvalure of slomach herniafed

MHernia of cardia.... fhrough esophegeal hiatus in diaphragm .. inlo Posterior Mediaslinum

MREFTUX

.....

Gaslro-esophegeal junotion is

Recurrenl Respiralorg infeolion, cough, vomiling MAdult ) lnteeiinal obslruotion

EI

Child

lo Posferior Mediasfinum ...lnlo posterior Mediaslinum

EINO REFLUX... Normal relalion of cardio-esophegeal Junction lo
diaphragm
CLINICAT PICIURE:

displaced inlo chest

MEliologg: UNKOWN but mag be due fo.. t) thorl esophegous

olE:
Msoaphoid abdomen
EIlpsi-lafenal chest (Vair entrg,

INVESIIGATIONE:

2) f lntra-abdominal 3) Wide Hiatus

Pressure

EJX-tag ) Air fluid level behind Slemum

flntestinal Sounde )
INVESTIGAIIONS: MBest : Gaslrographin M Plain

IREAIMENI)

SURGICAL

M Trans-abdominal approach

meal)

sfomach,

MReduclion & Closure

lntestinal loops in chesl cavitg x-rag) gas shadow of sfomach

lf small) Asgmplomafic M lf Large) Ptessure manifeslalions .Eggphggg. Dgsphagia .@g]1 Post-prandial pain, palpitafion .PEqlg-lL. Hiccough
M

Clinical picture: Palienl: Obese Female > 40 gears g Sgmploms of GERD

V g

. .

Complicalions:
Aspiration Pneumonia * anemia Barret'e esophagus * Sfricture Part of ... SAINT'S fRIAD HIAIUS HERNIA + DIVER,TICUI.AR. DIS
+ Chr. CALCULAR CHOLECYSI|TI8

in chest oavilg , shi$ of mediaslinum

MABG)

Hgpoxia. Hgpercapnea. acidosis

MAnlenalal: polghgdraminos , U/8 & Eoho)Bowel in chesf

IREAIMENT )SURGICAL III M Pre-operalive : NGI, Mech. venfilation, inhaled NO
M lnlra-operafive: reduclion
EI

COMPIICAIIONE: R.upture, Slrangulalion. Gangrene INVESIIGAIIONB: M Barium Meal in Trendlenberg's posilion: .Hernialion of stomach into chest . Gastro-esophageal junclion in place g Plain x-rag TREATMENT )SURGICAL TII

lnvesligations:
M lnvestigalions of GERD El Barium srirallow. meal in trendlenberg posilion . Reflux of barium from slomach lo esophagus . Parl of slomach is found in chesl

& Closure

SURGICAT IREAIMENT

Post-operalive: Venlilalorg supporl

l) 2) 3)

Reftact stomach Downwards

Excision of hernia sac Repair of hernia defecf

Trcalment

g fII g

of GERD) Life sfgle modifioafion,

Drug therapg,

Surgical ITT (lf Complioatione, Saint's lriad are found)

5J?4--{w.t5, qT il?4ry

?IQY

IW

NORMAL ANTI.REFLUX MECHANISM

g
Angle of Hiss )Valvular effecl

ETIOLOGY OF GERD
Mosl imporlant )Sliding hiatus hernia lnfants )Decreased Gaslrin Adults )Smoking, alcohol, Obesitg
Scleroderrna

g
@

lntra-abdominal

Pr.

)close

Esophagus

fl
V

Rosel-te shaped mucosa

Pinchcock effecl of Hialus of Esophagus Conlinuous release of Acelgl Choline from lower end

g
@

2rg lo pgloric stenosis

of esophagus

SYMPTOMS
Heart burn
:

SIGNS

. Relrosiernal burning pain ' A bU heavg meals, lging flat . V bU slanding uprighr
V V
Regurgilation

V g V

Bad nuilrinionalstate Bad Chest condition

Anemia

a Dgsphagia: . . . .

( esophageal Spasm .....siriclure

9gmploms of Complications Aspiralion Pneumonia

anemia
O m ep r azol

Barrel's esophagus) Pre-cancerous ...... Slriclure (Schatzki's ring) Bleeding from ulcer

e wil,h

oll ow up

g CIO:Dysphagia 24 hours ambulalorg PH monitoring (BESI) (PH<4 .... For >3o min ...... in 24 hours) --M lI:.{t|?-?:?y:-{9'Esophageal manometrg) LOW LOS pressure, perislalsis ...
(weak peristalsis) partial wrap , Good perisfalsis) Iotal wtap)

INVESTIGATIONS

Reversible et riclure due

to

refl ux

g g

Stricture wilh NO proximal esophagitis Bariurn swallow, meal in lrendlenbergs posilion V For complications CBC) Microcglic, hgpochromic anemia
Upper Gl endoscopu

+ Biopsg)

TREATMENT OF GERD
UFE SE/TE
V V V
Lose weight

Mpdau
PROKINETICS
VGaslric aciditq :
Omeprazole

soFq0ar
TUTATR,NDO_

Small frequeni meals Avoid lea, coffee,

PUCffioN
'NlSSlEl.l"

spirils, smoking, lging flal after meals Sleep with extra-pillows

ElcffioN
@ g
lf
Poor
$

PAIIf,IAt, R,NDO-

( Reverse barrei's
esophagus
) :

g lf Good perislalisis V SE: GAS BLOAT

peristalisis
Less SE
$)

Resulalino motilitq
Meloclopramide

(NO GAS BLOAT

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I t1

!NCIDENCE
V4% ol
GIT lumors

PATHOTOGY

@Male, Old age 45-6O gears

PREDISPOSING FACTORS
M$picg food, smoki4g, spirits EIBarrel's esophagus
ElTglosis A ElPlummer Vinson
$

g eile: LOWER IHTRD lS INCREASTNG V MacroscoDic: proliferalive, infilf, Ulcerafive g MicroscoDic: Adenocarcinoma (lowerl/3)
> SCC

lupper AO)
Earlg bg Lgmphatics

Bpread:

. . .

Mosl dangerous is DIRECI spread

Blood spread is rare & Late

MPapilloma, Adenoma

SYMPTOMS
MProgressive dgsphaga to

SIGNS
MCachexia EIChest infection EISigns of melastasis

COMPLICATIONS
MMediastinilis
ElHematemesis

Solids> Fluids EINB : $wallowing mag be easier El(sloughing of a part of lumor) EI Regurgitalion, 4 9alivation Mloss of Apetitie+ Halislosis

MParalgsis of diaphragm
M Pulmonarg complicaiions

)LNs

enlargement

INVESTIGATIONS

. ENDOSCOPY + Biopsg + cgiologg ' Bariurn Swallow ) Rat lail appearance, Shouldering, irregular filling defect MFOR STAGING . Endo-luminal U/S ..........show exlenl of tumor & asses operabililg . Chesl x-rau, U/g , CT scan, Bone scan
EIPRE-OPEMTIVE

MFOR DIAGNOSIS

CBC, LFT, KFT, Serum electrolgles, serurn proteins

IREATMENT OF ESOPHAGEAL CANCER

i opEnnBLE 40%
PRE-OPERATIVE
M Nutritional

INOPERABLE
MEndoscopic Laser M9elf-expanding Metal stent MRadio, Chemo-lherapg (5 FU)

Hgperalimenation

MRespiralorg

TTT

of chest irrfieclion,

Respiralorg Excercise MHematological Correclion of Hb, Albumin

OPERATIVE
TMNSHIATAT OESOPHAGECTOMY

&

SIOMACH PULL UP

(Nowadags, Mdeo assisled Iechnique is used)

Fosrffi
ETIOLOGY

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?n

g g

& PAIHOLOGY:

trr*AT

Alt YA, ra*ne er?

rlgrlhlq r'fi f,llte 1to gl,all/ort

,,rY nU,C!

lop of Site: Phargngeal mucosa

On

Squamous cell carcinoma

CLINICAT PICTURE: g C/O: Pain in throat referred lo Ear,

V INSPECTION: V PALPATION:

cartilage (loss of Largngeal click)

INVE8T!GAIIONS: g FOR DIAGNOSIS: Phargngoscopg, endoscopg + Biopsg

V g

FOR 9TAGING: CT, CXR, Bone scan PRE-OPERATIVE: CBC, KFT, LFT

IREAIMENT:

OPEMBLE : Total largngo-pharg4geclorng wilh Stornach pull up 2) Block dissection of LNs 3) Permenanl Tracheoslomg 4) Esophageal replacemenl INOPEMBLE: Radiotherapg

l)

ETIOLOGY

Deficiencg of IRON, VITAMIN B complex Site: Upper end of esophagus CLINICAL PICIURE : Palienl: Posl-menopausal Female Sgrnploms Relro-slernal pain, Dgspha$a Signs : Koilongchia, Atrophic changes, Splenomegalg Cornplications : Pre-cancerous "POr-CRtCOt D CARCTNOMA" IttlvEgTlGAIlONS: @ CBC )Microcgtic hgpochromic anemia Gaslric funclion tests) Achlorohgdria TREAIMENI: lron, Vilamin B, Dilalalion wilh an endoscope

fl

&

PATHOLOGY:

Hern Ihrough fl
g
Pulsion diverticulae

osa .... ...belween

Thgrophargngeus Ms., Cricophargngeus Ms.

g g

g g

CLINICAL PICIURE: Palient: OLD male SWELLING: wiih eating, Cornpressible,

g V

leading lo regurgilation of undigested food COMPLICATIONS Carcinorna lO.3 %)

g g g

INVESTIGATIONB:

BARIUM gWAttOW Endoscopg ...... Perforalion

TREATMENT:

MSmall

Repeated dilatation

M Old Patient, HRG) Laser pholocoagulalion

ffiOFT}IECAFDIA

DlsoffioF
ffiSPASM
EIIOLOGY:

1,JW4-TW+5

l qt il?4%\

?NqY

?-t

DIFI{,SIE,

MFailure of relaxalion of cardia .... Abserrt lrg peristalsis MTheories: ldiopathic, Chaga's dis.. Posi-vagdomg
achalasia, Aulo-immune ElMacroscopic Diclure : . Upper segment) Hgperlrophied, disorganized peristalsis , dilated & elongaled (sausage shaped) . Lower segmerrl) Normal, failure o[ relaxation, $pastic

ffi ffi
Peristaltic waves,

High amplitude NON-perislaltic waves

Amplilude

CLINICAL PICTURE

g .

MicroscoDic piciure : . Degeneralion of Auerbach's Plexus

Slress, Neurosis, Esophageal lschemia

Abnormal GERD resistarrt tu

TfI

CLINICAL PICIURE

9YMPTOMS:
PT

glGNg
@Bad nuiritional slale

RETRO-STER.NAL PAIN

INVESTIGATIONg EI Esophageal manometrg

Obese Female

> 4O uears

DD: I$CHEMIC HEARI DISEASE

@Bad moulh odour (Halitosis) M Regurgilation& Relro-slernal pain

ElDehgdralion EIChest infeclion

INVESIIGATIONg
M Esophageal

Peristaliic waves

4Amplitude 2OO mmHg

as DES

manomelrg) Non-perisfallio waves,

TREATMENT
Esophageal Mgotomg wifh preservalion of LOS

fAmplitude l4-2OO mmHg MBarium swallow:

COMPLICATIONS
MAspiration pneumonia, Diveriiculae, Malnulrilion MMATIGNANT CHANGES : 3 To aller 20 Years , discovered late

.CUR.LING,@
TREAIMENT
Mgotomg wilh preservation of LOS MEsophago-gasireclomg & Slomaoh pull -up
M Esophageal

Segmenlal spaems

Esophago-gastreclomg

& Slomach pull -up

INVESIIGAIIONS
MEsophaeeal

Manomelrv) Pressure in high Pr. zone >25 mmHg

MBarium swallow: Above diaphragm, Delaged sigmoid esophageal, parroi's peak appearance MEsophaQoscopq + Biopsv: Narrow eccenlric cardiac orifice MFor complications : CBC) anemia, leucocp;losis

IREAIMENI
MMedical sphinclerolomg: lso-sorbide binilrate, CCBs, Bolulinum loxin MForcible dilatation bg High Pneumaiic Pressure Balloon M8urgerg: Esophago-mgotomg : Modified Heller's operalion with Left Thoracolomg

?l,tqY

t ?:L

Fru&={uffi
EIIOLOGY:

tvlArr.oFy

tElss $

CLINICAT PICTURE
MOld alcoholic male preserrled-bg Hemalemesis after sevene vomiling MTrealmerrt :

g g
a)

M
ACCIDENTAT IATROGENIC

EIIOLOGY, PATHOLOGY
Mlngeetion of Alkalies ) liquefaclive necrosis MAcids ) Coagulative necrosis

MOSI COMMON SITE

3-5 om above Cardia, Lefr posterior aspecl b) Ai level of Azggous vein

CLINICAL PICTURE
MHistorg of i4gestion of causalic materia! MGenera! ) Toxicitg, high fever, thock EILocal ) Burns, chesl pain MComplicalions: r) anli-shock. anlacids, H, Blockers

CTINICAL PICTURE g Old alcoholic Male wilh severe Vomifing g Dgsphagia, Dgspnea, Chest pain, Mediaslinal
emphgsema

INVESTIGATIONg g Esophagogram " Gastrographin Swallow"

, ' ' .

Shock Largqgeal edema, chesl irrfeclion

2) Endoscopic Pholocoagulalions 3l Suluring 4l Embolization

Malignancglransformalion Perforation ) mediaslinitis

Plain x-rag, Thoracocentesis

TREATMENT
EMMERGENCY ITT
@ ABC

TREATMENT
CERVICAT PER,FORATION THR,OACIC PERFORATION

measures... Give palient milk to dilule corrosive

M M

Repeated dilatation

Surgerg :

M Nlt bg mouth M lV hgper-alimination M Drainage of

lf

Earlg : $ulure perforalion, chesl

drainage

g g # GASTRIC LAVAGE
- Barium

effecl Anti-shhook. Antibiotics Sleroids) decrease striclure, edema

Irans-hiatal Blurrt Esophageclomu +

Esophageal replacement

g
V

Exlravasaled fluid

If

LATE :

Arrtibiotics Surgical closure of perforalion

esophageclomg & Blomach pull up

g # ORAI INTAKE for l-2 weeks g URGENI INVE9TIGATION9 :

ewallow.. Gaslrograffin
- Endoscopg

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?NaY

t Lj

Diaphragrnatic hernia
CERD

Esophagea! carcinorna Motilitg disorders of Esophagus Traurnalic lesions of Esophagus

qT

lGoNArAt \oMrnNd*-rooN5'
CHPS
DEFINIIION: ETIOTOGY:
UNKOWN

*4w

?ltaV

IU

Thicknegs of pglorus

> 8mm ........

(Normal: 4mm)

...

mag be due to Hgpertrophg of pglorus, Achalasia of pglorus

AGE:

CTINICAL PICTUR,E: M WPE OF PATIENT:

Soon after birth

ETIOLOGY:

Failure lo thrive GENERAL SIGNS: We'rght Ioss, Bad chesl !oca!S!qns: Visible peristalsis + palpared d uring nursing)

;,'ii"ffi[ffi

V g

True Alresia False Alresia due lo: & Annular pancreas * Band of Laad) Volvulus neonalorum

EIE@[ls|
3)

*EITTE@
t^ I i

{Jl,L superior mesenieric

Jl

duodenumJl
Dehgdration. Telang, Chesl infection, Aspiration pneumonia

r.ft Jeilo g

INVE9IIGATIONS:

V U/S ..... thicke

Gaslrograffin:

r) Chronic PU 2) Chronic Cholecgstilis 3) Chronic Appendicitis

)ou,

a) V Na, K, Cl, Ca, H* b) 4 lotal aciditg (SIOMACH), Paradoxic Aciduria(URINE)

CORRECTION BY SALINE: NaCl (urrtil urine is normal))K0l

Electrolgles:

INVESIIGATIONS:

Treatmerrl:

flx-rag>@
@ R&M> Duodeno-jejunostomg

IREAIMENI:

ilR+*Twr5 | q

ilww

?rcY

t ?5

Etiologg

& Palhologg:
licb+kLa>9 C-ry1 Aughf il^j.61"6o"[c9-al*iiJl gew

Oy+A+Jl U+^"lr.."JtrqSjo'r.otf

*?Jb

MULTIPLE EROSIONS

TRUE STRESS ULCER

@ @

V
MSITE: Bodg & fundus of slornnach MMultiple, shallow, punshed oul MVarg in size frorn lrnm lo lcrn EIUsuallg limited io mucosa, sub-rnucosa

ICU palienls 9evere lrauma Major burns Endotoxic shock

Mulliple erosions lhat if Not recognized & Trealed)

ACUTE HEMORRHAGIC GASTRITIg

Clinical picture:

fl fl

C/O> Historg of the cause lhen Hemalemesis , melena, Epigaslric

OlE

pain

>

EpigastricTenderness ....
(NO REBOUND TENDERNESS as palhologg is limited to mucosa)

)
Treatmenl:

Visualize Ulcer

&

Conges{ed Mucosa

Rgle, line, catheler, lV fluids, rnonilor of vital dala 2) Gastric lavage bg Cold saline, Analacids 3) lV Cimetidine or Omeprazole, lf failed) lV Vassopressin

l)

V V
leave a small parl of fundus

lo

Generous Gaslreclorng, anaslomose wilh lhe inlesline

AHFoNKTffi@
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'Ho

ETIOLOGY: g Mosl common ) Oenetic Blood group "O", "A" lrrilant food, Srnoking, Drugs (NSAlDs)

V fl fl
g

c"b

e[]

tVaga!

tone

d\nritl>r

Endocrine diseases ) ZE$ , Chernical, rnechanical, Trauma .....

(Ulcer on lesser curvalure)

PATHOLOGY, CLINICAL PICTURE:

l"t inch of l"t

o J o f
F o.

CD

Round or Oval

lnduraied Sloping ) Punched out later

CLINICAL PICTURE Male,25-4O gears, Blood GrouD "O",+ve

Male, 4O Uears,

t ' ' ,

Q- 2&l/2 hours afler meals Noclurnal pain rlz bg eatin!, Buffers Periodic ... "sDrine. aulurnn"

.lmmediaielg or 30 rninules after meals '..1, bU vomitin!

Palienl can Iocalize sile of the pain with I

COMPLICATIONS: Perforalion
Bleeding

Fibrous Conlraclure (pqloric slenosis, Hourglass slornach) Resistance

Recurrence Maliqnancu in GU

INVE$TIGATIONS: BESI >

V
V

(in GU

+ 4 puch Biopsg)

Barium Meal Ulcer niche + Trifoliale IF PYLORIC STENOSIS) GU) Ulcer Niche + Ulcer craler IF FIBROUS CONTRACTURE For Complicalions: . Bleeding) CBC (Anemia) , Benzidine lest . Recurrence .... (e.g. ZE$ ) Gastrin level in blood, Octeriotide lest, CT)

. .

DU)

cilP.{4,-Tcrr{5 |

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ffiOFFED'NSO'.GR'
TITOF
AAOSEE
g
V
zEs ....... Hgperparathgroidism

OF

OTCER
g g g g
LIFE SWIE MODIFICATIONS

CoMffi
M

TITOF

Resl Small frequenl meals Avoid irrilanl foods Avoid irrilanl drugs Avoid srnoking!, alcohol,

V Perforalion V Bleeding
Fibrous conlraclure Recurrence

(:

TTT

of cause)

Malignancg ......

+
MEDICAL THERAPY

Triple therapg for

l0

dags :

Orneprazole

*
+

Metronidazole

+Clarithrorngcin
Conlinue wilh omeprazole for 6-8 weeks

J FEFErqTEDIDCCOF/

HEAUNq

NOr}GAUNq

I
Slop the morning dose

g(,
+
GASTRECTOMY

DO
Conlinue rnedical lrealment for anolher 6 monlhs

Nfi
HEAt${q
+

lf

healing

... slop drugs afler 2 months

VAOOTOMY

&

PYTOROPTASTY

Highlg seleclive

vagolomu Seromgolomg

1,JK4-T[0N5 :

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?llaV

t 'lB

f aI! th{.iJ

TFTTNQAt

Trunk

ofAnl. & Post

Vagus

qtr ill

f
I I

o=t!

Frrlid

t siliiJl

q!

f ULldlg.rao

o!

Hepatic Br. Celiac Br. Crow's Foot

Podrior vaes

Coa{ebrecfi--_
Psorlor ot trtarl.r

Hepatic Br. . Gall slones (dgskinesia of sphincter of oddi ) Coeliac Br.: . Dislension of Slomach . Repealed episodes of

Pgloroplaslg (Mickulicz lechnique) Gastro-Jejunoslomg : r) 2)

rrr'urtv']fi!@,
Ctow's fool : . Loss of innervalion of pglorus Olhers
Crow's fool
lncornplete Drocedure) Recurrence Loss of innerva{ion of pglorus

3)

Ani. & Posl. Nerve of Lallerjet

tsranches innervatin{ bodg of Slomach stopping al lncisura (spare Br. Of pglorus)

Pgloroplastg) Diarrhea,
dumping

Jl r6i,Hg Ant. & Posl. Nerve of

Lallerjel

Jl Chili

g CLt o UD}r

rrru-i

Necrosis of Lesser ts {l Curvalure in O.5 T" Pglorplaslg lJgti-ro Conlra-indicalions : Diarrhea Uir=t-sr 0i! . PU * Gastric oullet $ . PU in Fundus . Cigarelle chain smoking . Perforated PU Resolulion No Necrosis on Lesser Curvature
Ufu.o U,t.s

+i

Pglorus

$erosa

&

Musculosa

1fri4'T00f'r5 : 4f WeqWl

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CoMffiG
PAI{NAL,

Co.nffi
V

g g

Complications of anesthesia Primarg Hemorrhage

lnjurg: EI Hemorrhage . Pancreas)Pancreaiitis M Leakage from anastomosis . CBD) Obslruclive Jaundice M Duodenal stump blow-oul

M Post-gaslreclorng

Spleen)

Bleeding

lnfeclion
Dumping, Btind loop

M Paralgtic ileus M Acute Gaslric dilatation M Sub-phrenic collection

EI Pulmonarg cornplicalions

' , '

Nuitrilional $ Afferenl Loop Posl-cibal

$

"DUMPING
SYNDROME"

EI Recurrence

M Gastro-jejuno-colic
{islula

M Biliarg reflux M Slone of GB

EI 4 Risk of cancer

ilPq%\

?*rfr

t zfr

(,F PED,flCOI'CER

A&'IEPERI M 90 % inlf,: ulcers

V

g g

"N\qJU Clinical picture : l) 9tage of chemical peritonilis ) Acule pain in Epigastriurn 2) Quiescenl stage ) PainV and palienl APPARENILY improves 3) Septic perilonilis ) Generalized perilonitis + foxemia
:

PDF :

tuo!

Fluid from perforaiion runs on the para-Colic gutler io lhe caecum

r;> os$i qxo\ .... r\nl$

o.p qDJ q

6u\r\,\iuUi

o$re p

e)

M lnvesligalions

* * *

: [JuJlr-s pF iirrEi

Plain x-rav abdomen ERECT) air under diaphragm

Ug, CT ) Fluid in periloneum Aspiration tesl) Bile slained alkaline fluid

**

NB: Serum amglase rnag be elevaled (8OO somogi)

For Cornplicaiions) CBC, KFI, Electrolgtes

Resuscitalion

& Monilorint> Rgle, line, carher, {tuids,

I

monitoring ...

EMMERGENCY OPERATION: PERITONEAL TOILET

ACC. to general condilion

Vagotomg
& Drainage

+ Do
)

d(,
Parlial gastrectomg

gimple closure bg Omenlal palch (Graham's method) + Biopsg if GU

Then Draining lhe Periloneum, Good Posl-operativ e care

SUB.ACUTE PERFOMTION
M
EI
Perforalion afler 48 hours from Aclivitg)Mass U/S EI lnvestigalions
TTT:

CHRONIC PERFOMTION
Pt. with PU who refused

surgerg)

/ Consewe unlil mass subsides then surgical TTT / ll abscess: Drainage)conserve unlil mass
subsides) surgical
TTT.

Pain becomes persislenl & radiating to back TTT: DU> Vagolomu, Gaslreclomg Pgloroplasfg..GU

corirucffioNs
V 3 calegories :

oF PEF,rlc otcER

"Ie+='Tcr/,r5|$

lJWW'l ?Wt 7l

ELEEDINq FED4IC O'.CR,

) )

granulalion lissue 2) Moderale bleeding gmall vessel 3) gevere bleeding Gaslro-duodenal Arlerg M Clinical piclure : C/O> Historg of Ulcer followed bg Hematemesis, Melena, BPR O/E> $hock, Anemia, Epigastric lenderness EI lnvesligalions : Urgent Gl Endoscopu after resuscilalion tf failed> Angographg Laboratorg> CBC, KFT, LFT, Electrolgtes

l) Mild bleeding )

. . . . .

R&M)

Rgle, line, calher, fluids, monitoring ...

I

URGENT ENDOSCOPY
(Laser coagulalion, lhermal coagulaiion, lnjection of alcohol )

. . '

lV omePrazole Anlacids NG lavage bg cold saline

+

SURGICAL TTT (Bteeding >2L, Failure of TTT)

' DU) Vagoiomg, Pgloroplaslg, under runningf .

sulures for hemoslasis, Gaslroduodenal arterg mag require ligation GU) Gaslreclomg

?ltqY

| 1L

Do : FrI.ontCs;rED{oSlS
[grJ.jr$ lJ, g6J CHP9JI n ! rir g Ligrb lr.fJ DU er ir [15 ulg ii.aii U!#ldt{ ce iifii a41 ..ii.ilorll Ufulog {+r.rUl g Gr.H loJ eU.l+l g ti:g-ii.o. i^f .ol
lyLurJl

C(l: Hffis;rcliACll
+ rolroiillhirc: ZES, Hgperparalhgroidism + r-rl+lo,c illUio: Criminal N. of Grassi, inadequaie t
gastrectomg, drainage tUgri,llLrfto: NgAlDg, Corticosleroids
ZE

pgfl [f

i+e.l+l

*il

..

EI Most importanl investigalion is lo

gA}$EAt

ENDGCOF/

'ffi*
EI Dtlatation

&ercpSy
M
Exclude

* * * *

Sgndrome) Gaslrin Hgperparalhgroidism) Calcium, Phosphorus H. Plgori )C,o Brealh tesl,

Gastric Funciion

lesls)N
fu

malignancg

Ug

a.ag lai lor EIll AiIJodl

Delaged ernptging

PREOP

g g

TTI of Chesl infeclion Fluid & Electrolgtes imbalance @ Blood lransfusion Diet g Gastric lavage

Micro-aerophilic, Spiral, Flagellated Mosi common Baclerial infeclion in humans on Skirrow's medium Anfibodies in serum c) Carbon (C,o) Breath tesl: t.COz Treatmenl: TRIPLE IHERAPY Omeprazole, melronidazole,Clarilhromgcin

fl
OFCRAflON

al Gaslric biopsg )Culture

b)

EI Truncal vagotomu

Gastro-jeujenoslomg

ilP+TCr,r5 | qT ilRfuR'l

?Wt

. .

INCIDENCE: V 2d rnosl cornrnon lurnor Age & Sex Male, 45 gears PREDISPOSING FACTORB: EI chronic lesions) H.Pglori, Arrophic Gastrifis, Benign lumor M Chronic irrilation Spicg food, Spirils, gmoking M Heredilarg : Familg historg, Falal, pernicious Anemia Blood group "A,,, Bad prognosis PATHOLOGY: glTE Most cornrnon sile is LOWER l/g ... @O%)

fl

MACROBCOPIC :

INFILTRATING

l)

ADENOCARCTNOMA

(9s%)

2) Squamous cell carcinorna 3) Anaplaslic carcinorna

JAPANESE CI.ASSI FICATTON :

. Lirniled to rnucosa, submucosa . lnvolves muscularis rnucosa . 5 gears survival > 90% . 5 gears survival ) lO% . Diagnosed bg ..
"SCREENING PROGRAMMES"

SPREAD: Direct Duodenurn, Esophalus Liver "BLBL" Blood Lgmphalic latelg Virchow LNs+ +

. . . .

) )

Transcelomic: Krukenberg's lumor (Ovaries) 2) Blumer's Shelf (douglas pouch)

l)

qT

ilFqwl

?l,tY t T*

WPE OF PATIENT: Male, 45 gears cLlNlcAL PlcTuRE

....... 5 GROUPS ......

of appelite &
Loss
DD:

. . .

Unexplained

dgspepsia to Meal >2 weeks Resistant to TTT. Pain becomes persislent.

weight

. . . .

Dgsphagia,

Liver

Cancer slomach Cancer colon Cancer Panc. Hepatoma

Vomiting

melaslasis

INVESTIGATIONg

. '.

DIAGNOBIS : Upper Gl endoscopu & Biopsg Barium Meal: l) lrregular {illing defect, Ulcer niche oul of Ulcer-bearing area, Linitis plaslica. 2l ln Trendlenberg's position ) shows Fundus containing lrregular filling defecl 3) Post -evacualion ) Carmen meniscus sign SIAGING Endo-Luminal U/S, Abdominal U/S, CT scan rUMOR MARKERg (CEA, CA t9-9, CA72-4) FOLIOW Up PRE-OPERATIVE CBC, KFT, LFT, Electrolgles

. .

>

TREATMENI

OPERABLE
TOIAL Radical Gaslreclomg (Japanese School)

. Adenocarcinorna) Radio, chemolherapg tnsensilive . lf Resectable ) Pallialive Parlial Gaslreclomg . lf lrreseclable )Palliative Gaslro-jejunoslomg, Celeslin lube

!N-OPERBLE

bg Esophago-jejunostomg bU Roux-en-Y MIDDLE l/3: fotal Radical Gaslreclorng, Esophago-jejunostomg bg Roux-en-Y LOWER l/3: Lower Radical partial Gaslreclorng, Anaslomosis bg Polga or Polga wilh valve

ilK4-T00.,15 : qT 5U?4Wl
The normal pressure of the LOS is

?Aqv

t 15

3O-4Ocm H2O Nissen ,Belsg ,Hi!! operations all are effeclive for TTT of GE reflux Surgerg is the best line for TTT of ulceralive carcinoma at cardia of esophagus. ln diaphragrnalic inllamrnalion, pain is referred to C3 - C5.

* *

t
t
* * *

n
n

Congenital alresia of duodenum usuallg involves neighborhood of ampulla of vater Gaslrin secreling G cells are present in pgloric anlrum Regardingthe location of gastric ulcers: A- tgpe I :ulcer alonglhe lesser curvature B-tgpe 2 :2 ulcerc present -one gaslric ,one duodenal C-tgpe3: pre pgloric ulcer D-tgpe 4: proximal gastro-oesphageal ulcer lncidence of recurrenl ulcer is lhe highesl with Gastro-enleroslomg Deterioralion of palients afler gaslro-jejuno-colic fislula is due lo Jejunal conlamination bg colon contenl Gastro-jejuno-colic fistula is besl diagnosed bg Barium ehema Diffuse B cell lgmphoma is the commonesl varielg of gastric lgmphoma followed bg
MALT

* Slomach is the mosl cornmon sile for lgmphoma in the GIT , Mosl of MALT lgmphoma are low grade malignancg * GIBT:

l-

Are known previouslg as leiorngorna and leomgosarcorna

2- Ori$nate from interslitial cell of Cajal, Stomach is the mosl common sile for it is appearance {5O-7O%llollowed bg small bowel lhen Esophagus
,colon and reclurn 3- Surgerg is lhe de{initive therapg for it and the onlg effective Non-surlica! therapg for il is lmatinib mesglate Krukenberg lumor of ovarg is comrnon with colloid carcinoma of the slomach Lealher bottle stomach occurs due lo Scirrhous form of cancer stomach The land mark dislinguishing pgloric cana! from Id parl duodenum is veins of Mago Barialric surgeru could be appropriale for pal'rent wiih a BMI of 35 to 40 with no co morbidities or BMI of 30 to 35 with s'gni{icanl co morbidities such as DM There arc 3 major tgpes of weight loss surgeries being done for morbid obesitg : - Reslriclive barialric procedure which includes l. Adjustable gaslric bands 2. Vefiical band lastroplastg - Malabsorbiive weight loss procedure l. Biliopancreafic diversion 2. Duodenal swilch - Mainlg Reslrive Mildlg Malabsorblive bariataric procedure l. Roeux en Y gaslric bgpass

N.

a
{.

ilR{ii_{wr5 | qT ilRqW

?[QY

t ry,

l.

Mostlg obese fernale more lhan 4O gears old presenls with relroslernal chest pain simulating anginal pain increases wilh fattg food and lging flal , decrease bg standing uprighf.

qfRD,
Old male complaining of conlinuous rapidlg progressive dgspha$a more lo solid lhan fluids and regurgitation.

6artcer molhalils, Old male cornplaining of dgsphagia and'swelling in the neck, when he compresses this swelling regurgitation of undigested food occurs.

Pharytgul prch,

4.

Male or female middle aged complaining of dgsphagia lo {luids more lhan solids gradua! onsel inlerrnitlenl course of long duralion and poslural regurgitaiion of alkaline foul smelling fluid.

of

Acha/asa of the esolhailts. 5. Male or fernale presenls

with sudden onsel of severe dgsphagia, sever chesl pain, mediaslinal emphgsema and dgspnea.

f s oVhagal ledorattotl,

l.

Male or fernale with historg of smoking, spicg food (or ang PDF) presents with sudden severe epigastric pain and hemalemesis.

eros4/e gastntb. 2. Male 25-40 gears good health complaining of burning or stabbing pain 2-3 hours afler meals above the umbilicus relieved bg eating.

Aute

6hrotb fu&rtal tlcer

3. -Male 35-45 gears usuallg lhin complaining of burning or stabbing abdominal pain irnmediatelu or l\2 lo I hour afler meals in midline or just to the lefl relived bg fasting or vomifing.

6hrortb gstnb rtlcer 4. Old male with unexplained dgspepsia resislanl for lreatmenl for more lhan 2 weeks. 6atcer stonaclt

lLlP.q4Wt5 | $ ilEtq$l

?NqY

tn

Cancer esophagus Aetiopathologg, prognosis, ClP, I nvesligations, lreatrnenl

Kasn

2@7.

Kasn

zil

A mother brings her --- gears old child lo the ER with historg of corrosive inlestion: Describe lhe first aid , sequelae and de{initive rnanagemenl
Kasn

2M zffi

GERD:ClP &manalernenl
,4rh slrans'

2@/.

,4dtar

f,2M

Achalasia of the cardia

,4ltar f'

Cornplicalions of chronic DU, PU, surgical TTT, Clinica! piciure, Manalfernent

,4Zrar

f,2M.2@5

rlrl.2AO.2d, Ay'rar f,2M,Alur )A Zob

- Alrar
Ay'rar

Cancer slornach: Presenlation, Cases, Diagnosis, frealmenl

fizo@-

Kasn

2M.

,4y'rar rlrL

2oo5, tasn

zM

CHPS

AZrar

f,2ffi - Ailar ril,2w,'luh sltatts' 2@ -Kasr' 2M

Au sfiams,2M

Pgloric Obslruclion in adull "CfP, lnvesiigalions, cornplications

& Treatrnenl"

il?t4*ToOtr5:

{ilRhW

?tQYt

qA

POHIAL

PiI

/lbhae/ d'afWf

1e4-fi0)5 : qT ilRh6\ ?ltY t 40

Liver lraurna Liver lnfeclions Pgogenic Iiver abscess Benign Liver lurnors Hepalocellular carcinorna Liver Metastasis

il?4'Twr5

| qT

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t +t

Predisposing Faclors

2'd MOST COMMON SOLID

ABDOMINAL ORGAN TO BE INJURED (SPLEEN tg THE t8r)

M M

Liver enlargemenl: This rnakes il more liable to trauma. Diseases of the Liver: which make it sofl.

Etiologg 'Open:
Gun-shot wounds. Punclure due to stabbing.
Closed:

Direct traurna: e.!. molor car accidenl & falling from a he'rght. lndirecl lraurna: fraclure ribs. Sponlaneous ruplure: with pathological liver. . ktgqen!c:-e.g. PTC or liver biopsg.

Pathologg

Tgpes of ruptured liver:

. , . . . ' .

Sub-capsularhematoma. Superficial tear(s). Deep tear(s).

Avulsion of a pole of the liver. Complele depulping of the liver. lnjurg of a vascular pedicle) The most difficult injurg is main hepalic veins
Hemobilia.

Complicalions

l. (lrrternal or exlernal) 2. lnfarclion of liver tissues due to occlusion of liver blood supplg bg hematoma or abscess. 3. Billiarg leakage ) billiarg perilonilis 4. Associaled abdominal or thoracic injuries.
Clinical Picture M Hlstorg of trauma lo the upper abdornen or lower chesl followed bg abdominal pain. EI General Signs (picture of hgpovolernic shock)

l)

Rapid weak pulse, hgpolension

& subnormal iemperature.

2) M

Cold extremities

& pallor.

Local Exarninalion - lnspeclion) Bruises in lhe Rl. Hgpochondrium, Fraclure of the Rl. lower ribs, R'rgiditg. - Palpalion) Tenderness & guarding in the Rt. Hgpochondrium, Rebound tenderness. - Percussion) shifting dullness. - Auscullation) U intestinal sounds. - DRE) Fullness in the reclo-vesical pouch & Douglas pouch.

INVESTIGATIONS:
free blood & hemaloma, palhological tgpes and injuries lo olher organs. Plain X- rag:

M M M

Fraclure ribs, Elevated Rl. copula of the diaphragm, Obliterated psoas shadow, MuHiple fluid levels. M Beleclive hepalic angiographu

Diagnoslic periloneallavage (DPL) ... (lf lhere's NO time for oiher invesligalions) Laboralorg invesl'rgations) KFTs, LFTS, FBS, eleclrolgles,CB0.

ilK4400N5: qT 5U?4Wl
Trealmen{

%tav

t *L

Managlernenl g

of

-traurn alized palienl (ATLS)

V Pre-hospilal managemenl .... ABCD

Hospilal manalemenl

. .

Primarg surveu: ABCD Secondarg surveu: !- Head to loe examinalion. .l Resuscitation & moniloring. i'r AMPLE Historg. I lnvestigalions Blood transfusion and morphia Adequale exposure of the abdomen Sgslemalic exploralion of lhe abdomenDealing with differenl tgpes of injurg The breeding area PRINGLE'S MANEUVER + fresh frozen

Preoperalive Preparalion

.
' ' .

V lmmediale Laparoiomg

'

o'':"iHfi:[T:"-ffj'if*"

"'l""fi i,;fi 1"ff:'i:#xT:l:il1'j:l**5 j*Jfii:?t'ffi i#;J':T'::"ul

'
N.B.
ProPhglaclicanlibiolics.

l)
2)

lf hemo-dgnamicallg stable pafienls, Blunt lrauma)

CONSERVATIVE TTT

Close observalion of vita! dala, Hb\4 hours and dailg U\S. Penetualing injuries Exploralion

Prognosis

M Mortalitg rate of liver injurg >15 - 20 %. M if three organs are injured> 70%

1JR44wr5 : tlT cJJPgW\

H,DANdoISEASE
ORGANISM : ORGANISM :

Echinococcusgranulosus Echinocoocus Mulli-locularis

Human is an accidental inlermediale host Catu & dogs are de{initive hosts

Entamoeba hislolgtica

PATHOTOGY:

HOST$ :

glTE...Rigl* !obe, Postero-sup. segmenl NUMBER.... Solitarg

Amoebic

EI

hepalitis) Amoebic Abscess:

PATHOLOGY: EI slTE: ... Right lobe V NUMBER.... Solilarg

' . '

Not a true abscess Amoeba exists in wal! Conlains ANCHO\IY SAUCE

I)

TAYERS OF CY$T: Advenlitia (PERICY0T)

2)

Laminaled membrane Separafed fiom advenfilia bg line of cleavage (ECTOCY9T)

Germinal lager (ENDOCYST)..(gcolices, broad
Capsule, Daughter cgsts)

3)

CTINICAL PICTURE: .. Like acute cholecgstilis .. EI Tgpe of patient ... YOUNG MALE .... V C.P.: MAJOR PAIN + MlNlMuM FEVER EI Attack of desenlerg MAY NOT be oblained

4) Hgdarid fluid ... HIGHLY ALLERGIC

CIINICAL PICTUR,E: M Tgpe of patient ... Lrg-t+tit ....

FAIE:

EI

g C/O) Most common is

g COMPIICATIONS:
pleura, pericardium, poinls lo skin )

Chronicitg

(Peritoneum,

)Chronic pain, swelling in Hgpochondrium

@ OlE:

Bwelling, Hgdatid lhril!

INVESTIGATIONg @ U/9, CT scan) No, site, size

COMPLICATION9:

Rupilure

g M

Obslruclive jaundice Periloneum) Anaphglaclic shock Hepatic veins) Sgslemic affeoiion Malignarrl Hgdatid ... WITH E. MULITLOCU|ARI8 Calcification
Biliarg
DIAGNOSIS

, . .

tree)

@ Melronidazole lesl s lsolation from Liver, slool s $lool analgsis v Plain x-rag) elevalion of Rt. Copula of diaphragm, Rt. Sided pleural effusion
IREAIMEilT A MEDICAL> Metronidazole 8O0m{ &/d"rJ for lO daus

INVESTIGATIONS

Serologg (Complemenf fxation. hemagglulinalion Casoni-inlradermal iesl, lmmunophoresis)

- U/g ... Bile, size, Number

COMPIICATIONS) EROP(Obslructive Jaundice) TREATMENT gft.lsriLut

SURGICAL:

EI

l)
2)

Pre-operalive (MEDICAL)) Mebendazole 4OOmg x9lda1 for I monlh EI Sterilizalion of cgst bg parlial evacuation or injeclion of Colloid maleral EI OPERATIVE Enuclealion of cgsl* Omentoplasig V PO8T-OPERATIVE) Albendazole 4oo-6o0mgx3/dag for I month. TTT. Of cornplicalions

Aspiration U/S guided Undercover of melronidazole Open drainage

Fy6lg
EIIOLOGY:

lJRt4-T00.15 :

lSpta%l

?ttV t *4

2"d MOST COMMON SOLTD ABDOMINAL ORGAN TO BE

TNJURED (sPrEEN

PREDISPOSIC FACTORS

rs rHE re)

Old age, DM, lmmuno-compromized, Pre-exisling liver lesions gITE

. .

RTGHT LOBE

> left lobe

lF MULIIPLE ABSCESSES

Phlebilis, suppuralive cholangilis, Seplicemia

ORGANIBM:

G-ve aerobic rods, Slreplococci, Anaerobes MAIN ROUTES: portal pgemia, Neonalal umbilical sepsis PORTAL VEIN pgernia 2) (Mosr coMMoN) 3) BILE DUCT) 4) DIRECT DCIENSION) Sub-phrenic abscess, EmPUema lhoracis, Penelraling wound, suppuralive cholecgslilis cgst, Amoebic liver abscess, Tumor ) of Hgdalid INFECIION 5) 2rg

I)

Clinical Plslure g CP of CAUSE +

CP of ACUTE CHOLECYSIIIIB ...(fever, malaise, Rf upper quadrarrt pain)

COMPLICATIONB: EI Direcl extension lo surrounding

EI

Ruplure

INVESTIGAIION9: EI CBC> Anemia, ATLC, 1ESR

M tFt

V g
@ @

Trans-aminases, ALK. Phosphalase, Serum bilirubin, Serum Albumin U/9, CT Number, sile, size of abscesses UlS Guided aspiralion + C&S

IREATMENI:

lf multiple small abscesses) lf Large >4 cm

Broad speclrum Antibiotics

U/g guided perculaneous aspiralion 2) Open surgical drainafe. @ Trealment of cause PROGNOSIg EI Mortalitg l8-2O %

l)

insertion of Tube drain

reII[lr
PAIHOLOGY:

EFJ,ltqN lillonS
Macroscopic) Multiple soft well

ilRq4}ar5

| qT

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ffi

Palient)Fernale in Menstrual age, on OCPs.

circumscribed, gellow, fleshg iumors Microscopic) Sheels of rnature hepatocgles, Mimic nodular hgperplasia of cirrhosis C/P) Pain, swelling in the right hgpochondriurn COMPLICATIONS: Mag lurn malignanl (rare)

II
{a

INVESTIGATIONS:

Abdominal U/S , Angiographg BIOPSY Confirmalorg TREAIMENT: lf <2cm )Spontaneous regression occurs afler stopping OCPs lf large) Localized resection

. . . . .

CT "TRlPHAglC"

PATHOLOGY

....

Cavernous

CP)

Asgmplomatic

INVESTIGAIIONS: U/g) HYPER-ECHOIC

. .

A4giographu, CI wilh contrasl Small, asgrnptornatic) Follow up lf complicated) Excision

TTT:

. .

D'l t. \;
::

NOT A IRUE NEOPLASM

I D- =
::

DLr

'- til

ETIOLOGY .... Unknown bul rnag be due lo "OCPs" PAIHOLOGY) Pathognomonic "

. . .

diagnostic to differenliate belween ben'rgn adenorna or lrg rnelaslatic cancer detecls slellale scars CT $CAN

TTT:

Slop OCPs

lf

mahgnancg is suspecled) Exploralion,

& Frozen seclion is laken

5UPq-TooN5 .. qT "JJ?qV"'I

?rcv

t 4b

HEP
g lll g g g
PDF :
Hepatitis ( B>C ) Liver cirrhosis .... Aflatoxins Biliarg atresia, Alpha
Adenoma (rare)

\\flcP/tTOrNLt//

I anti-trgpsirr

deficiencg

PATHOLOGY: rvl MACRO) Mass wilh infiltrating edge+ areas of Hemorrhagb, necrosis ,'l MICRO) Adeno-carcinoma, High vascularilg (Hepatic arterg) SPREAD: g DIRECI: Slomach, Colon ... lZ LYMPH: Poria hepatis) Coeliac) Thoracic ducl) Lefl supraclavicular

BLOOD: BLBL

CLINICAL PICIURE: M WPE OF PATIENT :

EI GENERAL SIGNS : Cachexia, Jaundice,

Enlarged supraclavicular LNs

I/

LOCAL SIGNS :

INSPECTION) Enlarged PALPATION) lrregularitg, lenderness, Localized mass PERCUSSION) Ascilis AUSCULTAIION) MAAMOUN SIGN.. (Murmur) ... OCCULT PRESENTATION) "PARAMALIGNANT $".. Polgcgthemia, FUO, Hgpoglgcemia INVESTIGATIONS:

EI DIAGNOSIS
-UlS , CT scan (More specific), Alpha feto prolein -TUMOR MARKERS -HEPATIC ANGIOGRAPHY ...Ihrough Hepalic arterg) Show Characterislic fvascularitg ... 9TAGING ) Chest x-rag, CT Scan FOLLOW UP ) Carboxg prolhrombin, Alpha felo prolein (N: O-lO ng/dl).... SOOrrg/dl PRE OPERATIVE ) CBC. LFT, KFT, FBg

g g

TREATMENT

OPERAT}IE
.

HEALTHY
Liver

CIRRHOTIC
Liver

CHEMOTHERAPY MONOCLONAL Antibodies

reseclion

transplanla{ion

. Crgo-surgerg . Therrno-ablation . Perculaneous Ethanol injection

M#
ETIOLOGY:

lg-'

. . . . .

Stomach, Breast, kidneg Colo-reclal , lung Pancreas, ovarg

Melanorna

. Hepalic arterg . Lgmphatics (BREAST) . Direcl exlension

2rll Carcinoid lumor from Small inlestine, Bronchus

. . . . . , '.

PAIHOLOGY:

Mulliple, (cenlral necrosis) Adenocarcinomas 9O7" of cases Have Tumor deposils in olher organs

CLINICAT PICTURE: CP of lrg lumor + Hepalomegalg, asciles, Jaundice INVE8TIGATIONS: CBC: Anemia

LFfs: AALK. Phosphatase,

TUMOR, MARKERS

Serurn Bilirubin

U/9, CT, MRl, PEf-scan

... Number, sile,

size of rnelaslasis

TR,EAIMENI:

NON-resectable lurnors Chemolherapg 2) Monoclonal anlibodies 3) Seclorial portal vein Embolization Resec{able lumors ... Colo-rectal lurnors ... survival rate 35% MaU be up lo 60-70T, rcseclion if rnelaslasis occurs on lop of healthg liver.

l) .

r Complelelg reseclable Primarg lumor I Solilarg liver melaslasis , I <4 but Con{ined to ONE lobe I Liver is the onlg affected organ wilh melaslasis

ee
;?. +ef

rl

1e{4-Tw)5' qr

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Palhologg & Clinical picture of Porlal hgperlension Managernenl of esophageal bleeding

1JP4-1ooN5.

troFfiAtfl{psr
Porlal Vein lhrombosis Cornpression with a cgsl A-V malformations

rEroN
.

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t fl

SINoSOIDAL
I I

PRE.

Normal Pressure= TmmHg (8-12 cm H2O) Porlal HTN= >2OmmHg (25-30 cm H2O)

Bilharzial Periporlal fibrosis Congenilal Fibrosis lnfiltralion of portal lracl bg abnorrnal cells (LYMPHOMA)

Liver Cirrhosis

IVC obstruction I Right venlricular failure r Conslriclive Veno-occlusive disease Pericarditis I Tricuspid lncompelence

Sttlo0DAL

ffi-

I I

BUDD CHIARI

Triad of :
ABDOMINAL PAIN +ABCITIS +HEPATOMEGALLY
CAUDATE lobe is spared TTT: lransplantalion

PATHOLOGY OF trOFfrAt HYFEF{TF-hUSDN

. .

PORTOSYSTEMIC ANASTOMOSIS l) Belween Iower end of esophagus & fundus of slornach 2) Around umbilicus .... "CAPUT MEDUSA" 3) Belween Lower end of rectum & Anal canal ..... "ANO-RECTAL VARICES" SPLENOMEGALY Congeslive, due to RES hgperplasia, Hgpersplenism or Splenic vein Thrombosis
ASCTTIS Hgpoalbuminemia

Porlal hgpertension CONGESTIVE GASTROPATHY LIVER CELL FAILURE

Na, H2O relenlion

Wheeping liver

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*
NORMAL

Af lower end of esophagus & Fundus o{ slomach .?. Between Esophageal veins from LEFT GASTRIC V. & Esophageal veins from
AZYGOUS, HEMIAZYGOUS

* Historg of hemalemesis, melena, BPR * Cause of death ) Ruptured Varices

sPr-B.loMEgAty

* *

Anorexia, Dgspepsia
Malabsorption

Porlo-sgslemic Anaslomosis occur around fundus of stomach

A}IOREETAL

vAmces
"r *
At lower end of reclum &
Anal canal Belween Sup. Rectal veins

* t * *

Abdominal Enlargemenl & Pain Mass in LEFT hgpochondrium Preserued nolch Complicaled bg 2rg hgpersplenism ) Thrombocgtopenia

& middle, inferior recla!

HEMORROIDES.ARE USUALTY PRIMARY

V.

Around Umbilicus
Belween Para-umbilical vein & Superior, inferior ep'rglaslric veins Dila{ed veins around umbilicus
Palpable thrill
Due

* t * i'G
I
DE

lo hgpo-albuminemia

Porfal hgpertension is a localizing facfor -) Ascifis

precox fhen LL edema

Venous hum

l: Just elevation of
FOR DIAGNOSIS

mucosa bg dilated veirrs'

.GMDE ll: Elevated lortuous , veins wilh Normal mucosa inbelween i.ORROE tll: Elevated lorluous i veins wilh abnormal mucosa

Fiber-optic Upper Gl endoscopg.. deleclion & grading of esophageal varices Defeclion of portal hgperfension.. Duplex scan, Abdominal U/S (>l3mm=PH)

FOR THE CAUSE

in-between

- Urine, slool analgsis .... Bilharzial ova - S'rgmoidoscopg.... Visualize Bilharzial lesions, fake biopsg ships - Cgsloscopg... visualize Bilharzial lesions - Hepatilis markers, Liver biopsg after assessmenl of PT, PC
FOR COMPLICATIONS - KFTs: To Exclude hepalorenal failure - LFTs: (serum albumin, PT, concentrales, Serum Bilirubin, ALT, AST - Delection of Hupersplenism: CBC, BM examination, Radioaclive isotope sturlies

,.GMDE lV: Erosion, Ulceralion, j thows OHERRY RED SPOT8

(impending ruPiure)

aJJF.4-TWr5,4f apO%l

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. . .

CLINICAL PICTURE:

Variable degree of Shock, Hemalernesis, Melena, Piclure of Cause (Bilharziasis, Crirhosis) INVESTIOAIIONS: UPPER Gl Endoscopg
TREATMENT:

l)

Of Shock, of Encephalopathg, of Hemalernesis

2) lf Medical treatmeni failed ... SURGERY... 3) IREATMENT !N BETWEEN ATTACKS 4) TREATMENT OF pAgr HtgTORy OF HEMATEMESTS 5) TREATMENT OF SPLENOMEGALY ON TOp OF PORTAL HypERTENgtON

ffioF
a

ltG
5t g='lf7Atr.lPfiIlr
I

I I

!
3

=r,LTIEr,ES
BLEEDING TENDENCY
Blood
Trancfireinn

U:16o:llo

li=Uoll

r9-rk

159e

lp prJl ufu

PRESSURE THIN

O O O

Hernoslalics, Fresh blood , plasma lV Vitamin K NO Morphine

Rgle )Gaslric lavage

i.,ri [o prJl ufu Enerna / 2 hours rl.^riok pr uitgf

G) Enteral Anlibiolics (Neorngcin lgm/6 hours or
Melronidaz ole 25O mgldag)

*
*

lnjeclion Sclerolherapg
Balloon lamoonade

Oral Laclulose 10-30 mTdag loJl r-i Arnmonia Arginine - sorbilol, Flurnazenil

Uniil lnjeclion is readg or if

lhere's residual bleeding

DEVA$CULARIZATION: Hassab operalion

RECENT TRENDS: Perculaneous Trans-hepatic obliteration

varices, Trans-jugular inlra-hepalic porto-sgslemic shunl

of " IIPgg"

Liver support

Jhi

Jtff g lgjsr{

@Selemarin

r-ru,,ll aJtri
@

g J-ai

Jhrr

Ulrli=p g liug}l

OTTT. of the cause

Concenlraled gL,,;ose 2071,

@[if6rr:-'

@Proleirr res{riction @Liver suppur"l

@Proprarolr,i @ tnjection sclerolherapg

ilEq-Tw)5 | qf

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Rupture of spleen
Splenomegalg Hgpersplenism Miscellaneous lopics

1RI4-100',15 :

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t fr

EIIOLOGY

V V

CLOBED TRAUMII: Direcl, lndirecl, Spontaneous OPEN TMUMA: Gun-shols, Punclure, lalrogenic (Gastrectomg)

PATHOLOGY
9ubcapsular hematoma, superficial tears, Deep Tears, Avulsion of pole of spleen, complete depulping of spleen, lnjurg of a vascular pedicre

WPES OF RUPIURE $PLEEN:

rcla
'.
LOCAL:

@Falal MDelaged (minor trauma pass un-noticed... subcapsular hemaloma... Rupture after weeks ) MClassic tgpe

(Shock) Lucid inlerval) lnfernal

Hemorrhage)

STAGE OF SHOCK GENEML signs: rachgcardia, Hgpotension, Hgpolhermia,

urine outpul

r lnspeclion ... Ecchgmosis, Bruises, Fracture of ribs, Abdominal dislenlion E Palpalion ... R'rgiditg, Tenderness, Flebound tenderness i Percussion ... Shifting dullness 1 Auscultalion ... Vlnieslinal sounds
DRE

... Fullness in Relrovesical pouch, douglass pouch

SPECIAI gIGNg

/ /

Referred pain in Lt shoulder , hgperslhesia frorn diaphragrnalic irrilalion shifling dullness on Right side (free blood)+Fixed Dullness on Left side (Clots, hemalorna) (lale)

INVESTIGAIIONB:
(better lhan periloneallavage)) show hemalorna, free peritoneat bleeding.. U/S, Cf replaced "DIAGNOSTIC PERITONEAL LAVAGE" (used when there's no timel @ Arleriographg (diagnoslic & lherapeutic) @ Plain x-rag)Elevated left copula of diaphragm * indentation of Fundic air bubble +Oblileralion of Li psoas shadow @ LABORATORY ) CBC, KFTs, FBS, Electrolgtes TREATMENT

g g

POLYTRAUMAIIZED PAIIENT) RESUSCITATION & MONTIORING ln adulls )urgenl Iaparolomg & Spleneclomg ln children: l) Splenic preservalion... (Iotal or Pattialspleneclomg. Splenic A. tigalion, Embolizalion ) Vaccination , Posl

SUPht-400N5: qT

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BACTERIA: fgphoid,

TffiI
I I I a I

W
Porlal Huperlension
I I

! I I

Paratgphoid, TB, Pgogenic, Abscess VIRUS: IMN

SPIROCHETES: PARASITES:
$

Bilharziasis, Hgdalid ogsl, Malaria, Kala azal

Leukemia Anemia Polgcgfhemia ITP Hemolglic anemia

Hemangioma Fibro-sarcoma

t
a

Gaucher's disease Amgloidosis Rickets

I I

Feltg's disease Still's disease

N.B.

Chronic leukemia Amgloldosls

r
!

I I

ETIOLOGY: ldiopathic CLINICAL PICIURE:

I t

l) .lrWBCs ... Fever, Frequenl infeclion, Oral Ulcers 2) 'lrPla+elets ... Pelichae, Ecchgmosis
3)
URBCs ... Pallor

ETIOLOGY: Secondarg to porlal hgperlension Vasoligalion TREATMENT: Spleneclomg

INVESTIGATIONS:

CBC) Pancgtopeni a, tReliculocgtosis

BM
TREATMENf

Hgperplasia

: Spleneclomg

M
g V
g
(Hemolgsis occur al 0.6% N. Saline)
AUTOSOMAL DOMINANT

cilP4'{o}\5.. qT ilPqW

ropgg
25 7" ol

?ltY

| 55

rl rl

lncreases RBC permeabililg

lo Na, HrO

ffi(rrP)
Cause splenomegalg in cases

CLINICAL PICTURE

Trealrnenl:

@ ACUTE: Plalele{

lransfusion*

V
TREATMENT

g g

Prednisolone* lgG
CHRONIC: Conservative

lF FAILED: Spleneclorng

Snlenectomu & fuansflrsion

ANa,itA

ttr
, Elliplocglosis

EI Spherocglosis

ElThalassemia

M Hgpersplenisrn associaled anernia M Pgruvate Kinase deficiencg M Acouired auloimmune Hemolulic anemia

sPr^ED[6rlEGAty+Ly]i
Hodgkin disease, Acule leukernia, Feltg
S

g g

Hgpersplenism

V Stagng of Hodgkin
Treal Splenic cgsf, Tumors, Abscess

V All Hemolglic anemias excepl "Sickle cell anemia"

n
ETIOLOGY:

V Anaplaslic anemia V DIC

HgpersPlenisr"

cilP-4400N5: qT ilP4Eflll
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?l'80

t 0t"

nol included in child's classificalion of liver failure The Distal spleno renal shuni {Warren shunt} is a seleclive shunl thal preserves good hepalic portal perfiusion and associated wilh lowesl risk of hepatic encephalopathg Common problems occurring wilh use of balloon lamponade for conlrol of variceal bleeding are Pneumonia, Aspiration of nasophargngeal secrelion, Re-bleeding followi4g removal of the tube and Esophageal
ALT is

wa

I t

ulceration or perforalion NOT GA$TRITIS Radio-nucleolide scanning can be useful in diagnosis of FNH
Regardi4g HCC TTT: - Liver reseclion for I lesion, child A/B. - Liver lransplantalion in child C with I HCC < 5 cm. - Ablalioninsingle HCC < 2cm, child B &2- 3lumors< 3cm. Traditional chemotherapg is generallg ineffective, causes mang side effecls lhat mag severelg impair qualitg of Iife. Mechanism of aclion of ethanol when used in ablalion of liver iumors is: - Coagulalion necrosis of lissues. - Thrombosis of B.V.

lrealment. !nlrahepatic biliarg lakes wilh slone characlefize CAROLI'B DISEASE lN TTT of HCC radiofrequencg is successful in lumor <Scm About TACE {lrans arlerial chemoembolization}: - Verg effeclive in TTT of HCC, cholangiocarcinomas, Melaslalic coloreclal lumor - Cannol be used safelg given in palienls wilh compromised liver function - Palencg of portal vein should be evaluaied carefullg before il - Liver function has lo be laken into accounl while insliluling TACE CIose proximitg of HCC to bile ducl or porlal vein is a conlra-indication for Radiofrequencg Ablalion as
TTT
I I I

- V Platelel count. - For Budd Chiari $, liver lransplanialion is an effeclive

fhe mosl feared complicalion of Denver shunt is DIC Von Wllebrand faclor is sgnlhesized bg endothelial cells not bg Liver Faclor 7 has lhe shortest half-life ,5-7 hours so measuremenl of faclor 7 level are usefu! for

I I

I I

Head of pancreas is not common sile of accessorg spleen while lhe common siles are splenic hilum ,Tail of pancreas and lransverse mesocolon Mosl common sile for splenunculi is lhe Hilum of the spleen During the acule attack of ITP Bleroids, lG, Plalelel concentrate are TTf options while spleneclomg is not a mode of TTT lN ITP Platelel counis rise to adequale Ievelis in60Tolo 8O% of palients who undergo sPleneclomu Ihe following 5 causes of hemolglic anemia are amenable to spleneclomg:

Acquired auloimmune hemolgtic anemia Pgruvale kinase deficiencg. Hereditarg elliptocglosis. The MOST COMMON CAUSE of neoplaslic enlargement of spleen is TYMPHOMA

Heredilargspherocgtosis
Thalassemia

qr

aMw

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t 07

t. Palient lives in endemic area presenls wilh piclure sirnilar lo acule cholecgstilis bui wilh major pain
and minirnal fever.

Amubb

ltw abscess.

Patient presenls with piclure similar lo acule cholecgstitis but major fever, rnalaise and righl upper quadranl pain.

Pyogetb hyer abscas,

3.

Patient wilh hislorg of liver cirrhosis presents with rapid deterioralion of health and exa*erclion of pre-existing hepalic condilion with elevalion of alpha felo-protien more than 500 ng\dl.

4.

UreVatoma) Patienl with historg of liver disease and previous injeclion sclerotherapg presenls wilh
rnassive hernalemesis and shock.

HG

Rryfure esoVhaga/ rarhes. 5. Palient with historg of lrauma to upper abdornen or lower
pain and referred pain to the left shoulder.

chesl followed bg abdominal

Rryfure s//at,

ilRq--roo*q..

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| 66

l//chaet gafwat
//)BEah - Ain shams anversltq

ilPt4-Tw\5 | qT il?4W

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tm

Gall bladder slones

Manalernenl of Cholecgstilis Managernenl of Obslruclive Jaundice

cilRq-{?1t5, 4f 1,)?4R'l

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tA

C-P

talsl...lE

n"

b;97

g'o

i"Jb

ir.olg

1g.49

,i.. =i"asr: aJ Jl! 9 o9q ixbrs & (Biliory colic) 6>. /f g^ ..-aE kJa,
h

6ls!9 qb,-r,r.a

o,r"l+ o,el9

e.-p;g

l{iL,

Anlisposmodics
..J

acL, I 2 oJ^J

JF 9 elin i.r;;Jl

Chronic cholecyslitis

f
..ll ortjH:.'i1'lJfi
qJ

..,-A.

J;r*
,

Acule cholecystilis

j X; ,* s *lktti..CFt,r4
kJL

!r^

tojf
:
aJ

(Biliory

dyspepsio) ;f f

tti!lJ^r.t.i.I"...^Jl ,st:,h Gru;1.s'ios"

JG

4/
6
obsrrucrive lounoicl

r,; oe.a,Er c,s-q^ Z;pda 9 rSgL, c9-! .-1..a J* S s!,Je1 9 elp a,ti1)

Hn'.,r"J

..

lliyt

.1" f9{

!f,

Colic in rdrium

Ascending cholongitis J9-du- , Chorcot's lriod

Jru

g.(.sl

rl shoulder

i
I

&

Back

.. pl,lYl r, par r/-s. -9 | - .'.1

Fattg meals

..t{*L r#-,,sb9J- tlar,b JSa,o Reynold's pentod

j*

Mag be accompanied bg :

. .

Nausea

& Vorniting

Reflex sgmploms (Reflex relroslernal pain)

Srohl6
ETIOTOGY:

flJ?q-.TC0.t5 t Ql SJRtaful
INCIDENCE

?ttY
gears

tW

GoMffi

g20% of females >4O M Females:Males = 3:l

Metabolic : . OBile salts/ Cholesterol fDietarg fal, Crohn's disease (interrupted entero-hepatic circulaiion),.t,Hepalic sgnlhesis (liver cirrhosis) ' lBile p'grnents.. (Hemolglic anemia) M lnfections: E.Coli, Tgphoid.. form Nidus & Change PH EI Bile stasis

M Harlman's pouch)
Biliarg colic, mucocele CBD> Obsl. Jaundice, White bile M Ampulle of vater)
EI

wlAuGNANcy

r.Wnor.l
ArlotEgrsroDooDENllt FlSn lA
. .
.
Gall etone ileus

WPES:
:taItf-ar!='

Pancreatilis

T.Hil
Inoidence components

8% choleslero!

ao%
bilirubin

&

Ca

Choleeterol +
CaCO3, Calcium bilirubinate, bile salts, bile

Female > 7O grs. Airobilia

TREATMENI:

TR.EATMENT:

oiomenls
8ze
thape
9urface
Number

Laroe

small

O.5- 2.5 cm
Faceted

OBSIRUCTIVE JAUNDICE

Prcximal

Rounded Mammilated

lrreoular

Binole, multiole
Yellow

Color Consislencg

Bmooth Multiple Yellowish Dark oreen

T/Fe t
Compressi-on

. .

Remove stone
LATER ON:

.
&

Colosiomg
IATER ON:

Cholecgslectomg

of

Cholecgs{eclomg Repair fistula

& Repair fi.slula

Hard (Floatsl
NO Nucleus + NOT laminated
RADIOLUCENT

9oft
HOMOGENOUB

Cul eeclion X-rag

Hard (sinksl NUCIEUS +

laminaled RADIO.
OPAQUE

CBD bg slone in Hartman's Pouch TREAIMENT:

. ERCP, sphincterotomg . Remove bg dormia basket . TATER ON:

CholecAstectomg

&

Repair lislula

cl&.{l:looN5: qr

il?,W\

?Wt q

s3rotGs
t
EI FOR DIAGNOSIS:

ABDOMINAL U/S (of choice) (Detects size, thickness of GB, presence of slones, diameter of CBD, intrahepalic biliarg dilatation) . Plain X-rag .. lO-15% of cases FOR COMPLICATIONB: LFTs.. NORMAL (if 4 Bilirubin, Alkaline Phosphatase

t)tr ^*
EI WAIT & WATCH EI Excepf: - Diabetic palienl - Congenital hemolgtic anernia - Palienl undergoing Barialric surgerg - Young fft patient
CHOLECYSTECTOMY

ACUIE EHOTECYSTITIS - Patienl with rnass)

,
,

Conservative TTT lhen Cholecgstectomg Palient wilhout rnass) URGENI Cholecgslectorng

Slone in CBD)

KFTs.. BUN, Crealinine

o \

ACUIE PANCREAIITIS Conservalive TfT OBSTRUCIIVE JAUNDICE - ERCP & Sphincterolorng

Revmove with Dorrnia Basket - IF SUCCEEDED: Laparoscopic cholecgsteclorn g

CB ILEUS Resuscitalion, moniloring Deal with the slone

(Crushing of stone, Milki4g lo pass iliocaecal valve, Rernoval bg enlerostomg, Reseclion & Anastornosis)

ilEq4w-t5

| qT

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t a*

oF
6F ...... female, fod
SYMPTOMS

, flalulenl, ferlile

. Sudden, severe . Colickg pain . Rigl,f upper quadranl . Referred lo Rt. thoulder . 4 bU fatlg meals E tr tr tr tr
*

Recurrenl attacks of biliarg colic+ Reflex sgmploms

LOCAL gIGNS

lnspeclion) dgidifg Palpation) guarding, lenderness, rebound

lenderness

Percussion) -VE Auscullation) decreased lntestinal sound DRE) -VE

(Hgperesfhesia belween gn,

Chronio oalcular Cholecgstilis, Hiatue hernia. Diverlicular diseaee Chronic choleogslilis, Chronio PU, Chronic appendicitie

lls

rib)

.t GB MA$S (difficult lo
LOCALLY:

Bigns of 9ainl's triad (CC,HH,DD) or Wlkie's triad (CC, PU, App.)

tr tr tr tr tr tr

Empgema, Mucocele

tr

Acule exacerbalion on lop of

chronic

Chronicitg ...... $pread of infeclion

(Cholangifis, Cholangio-hepatilis, Pancrealitis)

Perforalion) Perilonitis, lislula

Jaundice ......(Cholangitis, Mirrizi $, stone)

tr tr tr

9tones
Cardiac Iink .... Porcelain GB & cancer GB

Emphgsemalouscholecgstilis (Closlridia welchii, old diabetic pt.,

GB

INVESIIGATIONS

tr U/9.. Hgper-echoic slone, Hgpo-echoic

E

tr
E

Plain x-raq.... Radiopaque slones, gases HIDA scan ... visualizalion of CBD, noi GB Exclude lHD. Dancrealilis: ECG, Serum Amglase

tr tr tr tr tr

U/9....shrunken, fibrotic GB
Dgnamic U/9
Plain

)Delect

Function

x-rag... Radiopaque slones For complications) LFT, ERCP

Exclude saint's

triad)

Trr"F 3E
NO GB
URGENT

rE C[t(il{grsrrrrs
WITH GB MASS
IF MASS IF EMPYEMA

MASS

M Semitfing posifion M Stop oral feeding)Rgle M Anfispasmodics M Sedafives : pethidine

M Anlibiolios

: Quinolones ... # Cephalosporines

Cholecgstectomg

M Monitoring for vilal dafa

occuRs RESOLVED Cholecgsleclomu M Cholecgstoslomg lill improvemenl EI Cholecgslectomg afler 6 weeks + TTT. OF coMPLlcATloNs ...

ilK4-1wr5 | $ ilPqW

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tr tr tr tr tr tr

Jaundice.....
Urine .....dark, frolhg Stool .... offensive, clag Biliarg colic .... Fever ....charcol,s triad ltching.. (4bile salts)

EI

Jaundice ...

. .

Rl. hgpochondrium radiating to shoulder, back O with faftg meals, V with

arrli-spasmodics

tr 4 Ternp (if associated

tr tr tr
tr

with cholangitis) Bradgcardia Hgpoiension Jaundice

+
Supra-clavicular tNs entaqgemenl

tr tr tr

Gall bladder

...-

Liver ..... Spleen .....

Bhrunken enlarged. nol lender

dislended, Tender
enlarged , lender (metastasis)
Enlarged

Not felt

+ Ascilis , DRE for Krukenberg Tumor

. Bilirubin . SGOT, BGpT . Gamma GT, S-NT .PT 2) Urine

3)
Slool
BUN, CBC Abdominal U/S
ERCP, PTC

r)

LFT

O direct bilirubin No rise unless cholangio-hepatitis occur O gamma-GT, S-Nucteotidase Prolonged PT

Dark colored, frolhg

direcl biliruEirr

rlfj
Clag colored, bulkg-sensire

4)
5) 6)

4BUN, 4lTLC
Dilated intra-hep

7) 9pecial inv.

. . .

Diagnosiic and fherape Inlra-operaiiveCholedoscopg Inira-operatiye

cholangiographg

. , .

Barium meal)widenlng of

Posl-operaliveT-lube
cholangiographg

(ln peri-ampullarg carcinoma) inverted 3 shape) For slaging) CT scan ... mass in pancreas, melaslasis Follow up) Tumor markers (CEA,
POFA, PCAA)

C-curs

lJPt4-T00N5 : qT

ilPhtfl\

?thV

tw

TJT. OF
aJ,\:f.rr:O,l': Correct clolting! dgsfunclion g Vilamin K lV g Fresh Blood lransfusion Guard alfainsl LcF g f Glucose inlake g Broad specirum Anlibiolics Guard alfainst Renal failure g Hgdralion g lV mannilol g Oral bile salls

ERCP sphinclerotomg

Removal of slone bg Dormia Basket Cholecgsleclomg

g g g

Cholecgsteclomg Cholgdocholithotomg I nlra-Operalive CholedoscoPu r"r r'i ii .n t I G99 ii

/'l

M tnserlion of T-lube for lO dags then lnlraoperalive Cholan$ograPhg

ffiffiw
PREU
v
Blood

SPECIAL PROCEDURES:
M lf tmpacled slone, slriciure, lnaccessibilitg:
Choledocho-duodonoslom g (Better) Jejunoslomg - Roux en Y ) MISSED SIONE: ERCP, SPhinclerotomg, Exlraction of stone bg dormia baskel 2) T-Iube for I MONTH, CholedoscoPg 3) Dissolulion TheraPg : Saline *Heparin +Chenodeoxgcholic acid + Zglocaine

co'ret-otring dgsfunclion g Vitamin K lV

W
FOR
(OFE

V
sl'FGFF!/

l)

transir"ion Guard against LCF

sar#'

g 4 Glucose inl ke A Broad spectrum A tibiotics Guard againsl Renal failure g Hgdration g lV mannilol
V
Oral bile salts

EndoscoPic

stentingl

^-

operaiion l)

Whipple

Stenl& friPle anaslomosis

Gastro-jejunoslomg 2) Cholecgsto-jejunoslomg g) Jejuno-jejunostomg

aJJR4--TW\5 | qT

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Pancreatilis Miscellaneous pancreas conditions Carcinorna of Pancreas

Gusj illl+{ Urtlr4i4Jl

EIIOLOGY:

ETIOLOGY:

EIMost common cause is

M2nd most common: Alcoholism, ldiopafhic, ERCP, fiauma CLINICAT PICTURE:

V g

Persistenlalcoholism
Diseases of CBD .. sione, cholelithiasis

Male Patierrl, 50-60 Uears, Hislorg of Biliarg dgspepsia, alcoholism, or trauma complaining of MAJOR $YMPIOMS + MINOR glGNg C/O : Repeaied vomiling, 9evere epigastric pain radiating

CTINICAL PICTURE: ryPE OF PATIENT

@ : Male, 4O-6O gears g TRIAD OF : l) PAIN ... Epigaslric pain, radialing;lo lhe
back, Recurrent V bg leaning forwards 2) D.M. 3) MALABSORPTION ... Loss of wl.,
Weakness, slealorrhea

lo

back

o/E:

GENERAL: Fever, Tachgcardia, Signs

of MOF

(Cganosis, shock, jaundice)

LOCAL: MiH tenderness, rigidilg, Cullen sign, Greg lurner sign, Pseudo-pancrealic cgsl,

INVESTIGATIONS:

@ V

MDIOLOGICAL:

thifting dullness, Vlntesiinal sounds

COMPTICATIONB:

l) Plain X-rag abdomen ) Calcificalion 2) U/9, CT scan, ERCP) Chain of Lakes

LABOMTORY:

g V

Mosl common Complica+ion )

[@

Pseudo-pancrealic cgsl, Pancrealic abscess

INVE$TIGAT!ON8:

MFOR DIAGNOSIS:

l) Felal Elaslase level ... NEGATIVE... 2) Lundh's lest 3) Glucose lolerance lest ...DM... 4) 5 dags Collection of Fat excrelion
TREATMENT:

Serum amglase
unit/dl)

, N. IOO-3OO somogi

CONBERVATIVE:

a) Pancrealilis >IOOO somogi unit/dl b) Uafter 5 dags ) measure Urine amglase

/ //

9erum Lipase ) CT scan )Accurale for Localizalion

. . . .

FOR PAlN..$lop alcohol, Give analgesics FOR DM .. diet, insulin FOR MALAB$ORPTION :

Pancrealic exlracl, H, receplor antagonists, reslriclion of Fat up lo 25To $upplement of Fat soluble vilamins

MFOR CAUSE: ..... Abdominal U/S MFOR COMPICAIIONO: CBC. ABG. KFI,
TREATMENT... CONSERVATIVE

SURGICAL:
LFT, FBS, Serum Ca

. . . ,

l)
2) 3)

Resuscilalion, moniloring Analgesics (# Morphine), Antibiotics

NPO, NG suclion

Cutting grealer Splanchnic Nerve (lf Pancreatic tai! is a$ected) ERCP > TTT. Of slricture lf Tail is affected ) Dislal pancrealectomg

lf

Head is affecled

Whipple's Operation

4) Respiratorg supporl ... Venlilalion 5) Re-assessmenl bg ERCP

SURGICAL TTT onlg

...

if indicaled,

TTT. Of cause
:j:

MDoubtful diagnosis) Explore lhe abdomen @Lale cases) Remove Necroiic iissue delected bg

CT

Age>S5geare M Baee deficit>4mEqlL >ZOOmgVo EI Estimaled f,uid >6L MWBCe >l6,OOO/mmt ""queshalion g EI Serum Ca*2 <8mg7o
M

M FBg

ElComplicaled cases (Left sided PH)Hassab's operalion)

I

MSGOI >25,0 U70

I

MHCI .r>lO% MBUN dmg%

I
I

M
(Tumor of bela cells of islets of Langerhans)

rondS:
*ry'**#\ul
Z$q lJ gsi
ot+g

1W-Tw9

t t{T lJR{aFrl ?l,hY

t b1

DEFINITION:

.ile .-or? I tlr:

Ft "S" *tr. a.r-elirJl .i'-hiy. ;lr+Jt I S+ I e/ jr+'* t gjDM

6Jtr6lt

,si 6g0:

g V g

Colleclion of pancreatic secretions & inflammalorg exudales wiihin a lining of inflarnmalorg lissue
ETIOLOGY:

GBS

Achlorohgdria

@ Acule pancreatilis..

l) g

Hgpoglgcemia

2) O<45 mg/dl 3) lmprovemenl bg Gluoose

lnvesligalions :

g g g g

lO%

Pancreatic lrauma Posterior Peplic ulcer

2tgpes:

EITE: Lesser sac belween pancreas

&

/ /( tl /

4lnsulin 4C-pepride
Localization bg CT scan

s Diagnosis' E|EEIEU. EE@EIEM

EIEitr, q@[UIUtr,
Diarrhea, Bleeding,

a) Tlrpe t: Hgperplasia of G-cells b) Tqpe 2: turnor of pancreas

slomach
CLIiIICAL PICTURE:

g
I I

perforation lnvesligalions : Localization bg CT scan Gaslrin level

SMALL>Painless, mag be discovered bg follow up bg U/S LARGE) Discomfort, swelling (Painless, Pulsaliqg, Fixed)

I oil>l "i
@

J/t6," o\i'Ie 6.tl-xJt tt+J

tlr*

uo:r"

E!*E

f,"lt ".t;e t ) Cf scan

Diagnosis: Glucagon assau,

V TTT: n Orneprazole n Euqgerg accordi4g fo Cf Angiographg

. .
lf deiectable in Head
duodeneetomg

@!

@,EEg
)
pancreatico-

INVESTIGATIONS:

g
g

u/9, cT > Mosr AccuMTE Barium rneal) Forward

displacement of slomach in lateral view

TREATMENT:

g g

Resolve sponlaneouslg

lf persistenl >6weeks, )Gcrn)

Cgstogaslostomg (for drainage)

g g

lf deleclable in Bodg &

Pancreateclomg lf Nol deteclable

tail)

D'r"stal

Cholera resislanl lo TTT

WDAHA sgndrome

Gastreclomg

ETIOIOGY: ... UNKOWN but mag be due lo H'gh protein diet, High fat diet, Srnoking, Alcohol PATHOLOGY: .SlfE ...From ACINAR, ... Major ducl sgstem .MACRO... rnass infihrating edgest areas of Hernorrhage, Necrosis .MlCRO... Poorlg differentiated Adenocarcinoma .SPREAD: Direct, Lgmphalic, BIood, franscelomic CtINICAI PICTURE:

WNohiAOFITANffi

1JK4-T00..19: qT

il?4ry

ffiHEADoFPffi
V V
Obslructive Jaundice
Painless, Progressive, Olive green Hepatomegalg, Distended palpable GB

...

ffiED/oRTAlL
g
Thrombophlebitis migrans ... Enlarged LEFT supraclavicular LNs ... Melastatic manifeslations , Loss of We'rght COMPLICATIONS: . Obslruction) Mal'lgnanl Obstruclion Jaundice, Hemalemesis, Melena (due to left sectorial PH) . IVC obslruciion) Lower limb edema

.
. .

OCCULT MANIFESTATIONS (Usual presenlalion):

INVESTIAGTIONS

FOR DIAGNOSIS:

. . . . . . . . '

LFT .... Direct bilirubin, N. SGOT, SGPT , Prolonged PI STOOL .... Clag colored, bulkg, offensive, No slercobilinogen Direcl bilirubin URINE .... Dark colored, frothg, NO urobilinogen,

U/S: lnlrahepalic biliarg dilalation (if there's exlrahepalic biliarg obstruclion) ERCP, PTC > Biopsg, slenl BARIUM MEAL ) Wide C-curve of duodenum

V V

FOR STAG!NG: Degree of invasion ENDO9COPIC U/S Allows targeting FNAC CONTRAST ENHANCED SPIRAL CT SCAN CAl9-9 , CEA, POFA , PCAA FOLLOW UP: TUMOR MARKERS PRE-OPERATIVE:

>

of lesion

CBC, CXR, KFTs

TTT

of Cancer Pancreas
V fl
Endoscopic slenling Triple anaslomosis

g g

Pre-opera{ive preparalion for Obstr. Jaundice (see GB) SURICAL ITT: ' Whipple's operalion

PROGNOSI8

Exlrernelg Poor

... 5 gears survival rale <

5Y"

ilPq4C[lr5,6t jgphfi

?tQY

t1

. lndicalions for choledocholomg at cholecgstectorng are: - Dilated CBD. - Raised ALP (alkaline phosphatase).
bilia
I I I I

WE

Palpable slones in CBD. ERCP is easier in paiients with bile leaks because g not dilated. One of advantages of MRCP is to delineate analorng post biliarg enteric anastomosis.

Anticholiner$c drugs and vasoconslriclors don'l increase the tone of sphincter of oddi CLONORCHIS SINENSIS mag cause cholangiocarcinoma Ben'rgn biliarg duct slriclure even a rninor one can produce liver cirrhosis over lime ,so it must be lrealed even if il is

DELIA CELLS not

The slandard supportive measures

produce somatoslalin. for palient wifh mild pancrealitis is lV fluid and eleclrolgle

lherapg onlg Serum arnglase is nol a componenl of Ranson's criteria and has no prognoslic rule in acute pancreatilis lnlerprelation of Ranson's crileria: Risk factors 3:l% morlalitg Riskfactors 3-4:157" morlalitg Risk factors 5 - 6 : 4O7" morlalilg Risk faclors >7 :1OOT"

Calcular obslructive jaundice: lnvestigations, , Pre-oPerafive PreParation, Trealrnenl (Kasn 2o// 5u shatns,2M,2@Z

Au srtans,2@Z Art sfiatts' 2@

- Ay'tar f' 2@7,2@5,-

Complications of Gall bladder stones

( Alfi s//at/s,

2@2..
Az,frar /,

zM,2@Z 2@/,2@o

D.D of obstructive jaundice, lnvestigations CBD stone: C/P, investigafions

&

,4u shams, 2@5 , Azlrrr f, 2@5,2M TTT. Art sltatts,zob

Acute cholgcgstilis: ClP, investiglations & TTT.

Au shatts,20/

IJRII--TW$ |

$ cl,Pqfl

?IW

I T.

l.

6F female (fattg, forlg or {iflg, fatlg, ferlile, {latulent) cornplaining of sudden onsel of colic in right hgpochondrium radiates to the back for less than 5 hours.

BilarV

colrb

6F female (fattg, forlg or fiflg, fa+tg, ferlile, flatulenl) complaining of sudden onset of colic in right hgpochondrium radiales to the back for rnore than 5 hours e severe nausea and mag vornilin!.

Aute calular cholaystrtrb.

Usuallg immunocomprmised patient complainin! of sudden onsel of colic in right hgpochondrium radialin! lo lhe back for > 5 hours with severe nausea and vomili4g.

Aclte il0il cabilar cholaystrtb.

4. 6F fernale (fallg, fortg or fifig, fattg, ferlile, flatulent) complaining of recurrenl atlack of biliarg
colic and Murphg s s'rgn is positive.

6hrotb cabtt/ar cholary trtrb.

6F female (fatlg, forlg or fiflg, fattg, ferlile, flaiulenl) with historg of biliarg colic complaining of gellowish discoloration of lhe ege, dark frothg urine with bulkg offensive clag colored slool e
fever.

6a/u/ar obs trnct r re 1fuidra,

Old male complaining! of gellowish discoloration of lhe ege, dark frolhg udne wilh bulku offensive clag colored stool with marked weighi loss, usuallg a febrile.
1r1

atrgrlailt obs trrctrre Jfundrca

l.

Male 5O-6O gears of age with ot withoul posilive historg to biliarg dgspepsia , excess alcohol inlake or ialrogenic lrauma cqmplains of severc epigastric pain radiating to back and repeated vorniling bul local signs are nol severe and increase serum lipase.

Acfie partautitb.
Usuallg old male or female presenls with sgmploms of peptic ulcer resislanl for trealrnent or recurrenl afler lreatmenl, wilh or wilhoul diarrhea and stealorhea.

3.

Qastnhona. Zollnger t/lrbort Sytdrone)

Old male with rapidlg progressive painless jaundice wilh or wilhout distended palpable GB.

Gailcer

ltud of patcrus.

1e4-:lwr5,6l ,J"tp4R'l

?lh7

t lC

5.1Pq400N5 : qT

ilPhWl

?f,qO

t 7*

llrclraet Safwat
llBBCh - Au shams
mivergtu

ARIFTWTS

1$ ilRqW

?*hY

t 7t"

I I

Appendicitis Arganlafinoma

ilPI{*TwN5

il?$W

?tqt t

T1

AGE& SEX GROUP Rare in children

20 -3O geaf$ Male>female

Rare in Old age

. .

Serious)BO%o perforale (!ate diagnosis) D.D. :

Lgmphadenitis

EIIOLOGY:

ORGANISM Ecoli lA5%), slaph, slrept ROUTE OF INFECTION > Direcl PR,EDI$POSING FACTORS:

' Ag Obsiruclion.. . l/3 analomical

PATHOLOGY:

Gangrene

At lip or al sile of obslruclion

G

AT

IIP

ONLY

enerulized perito niti s

Localized Perilonilis Perforalion

FAIEOF
@rrlprreffioNs
O Bacierimia O Septicemia
O Toxemia O Pgemia

1JK4-{W)5,4t "il?AR\

?tGY

| 78

CrTlS
FESOU/E
But Liable for recurrence

G,noNtc
SITE) lip of
appendix, or

al site of obslruclion
SEQUELAE:

O PAIN>2DAYS O TEMP. > 38 O D: U/S O fTT: Conservalive

Semi-sitting 2) Rgle, line, catheter, fluids 3) Monitoring 4) lV Antibiotics O Appendeclomg after 3 monlhs

S/S: O fhrobbing pain @ Heclic fever @ fachgcardia

TTT:

O O

Recurrenl

allacks of Pain,
Dgspepsia Tender R'ght

Generalized or localized

l)

perilonilis

l)

Muscle culling incision

lliac fossa
DIAGNOSIS: Bariurn Enema
TTT:

2)
3)

Exlraperiloneal drain

Antibiotics

Appendeclomg
DD:

. . . .

IBS

Amoebio colilis Chr. Calcular Cholgogsfifis Crohn's Disease

drain abscess + Oschner sherren

regimen

O Children <10 gears O Elderlg > 65 gears

ilR{4-TCr^t5 | qT ilP.^Wl
.o.rjio: orgdn
dJr,t ..

?NfiI N

"vl9 ,hzy..;JaelJlru'd lrE & C,llr.. 4"b riJlr"o,"to:<lt.ps

.,

Olc e,.4Jl 4ru J.Jay

.r.

olqtg LJ

d;l2J g -11r;^

t{arr, .=A oJb!.iJ

...\:ys+Jl+"

Acute Pain :
@

Mcburneg's poinl

=fc

Jgb upl 7l ; J -3. .1:.lt:41Pi * g{ Si9- gr.., oli,l.,9t'.i! 6l;!

_f*

Colickg

becomes in Rt. lliac fossa -O Aggravaled bg movement or COUGH

Peri-umbilical) afler 6-10 Hrs

Genreral Exam.:

* * *

Anorexia , ilausea

Vomiting Once in75To of palients

Constipalion Diarrhea mag be Earlg OR lN: O Pelvic appendicitis. O Retro-lleal Appendicitis.

Mild fever <38 @ Tachgcardia <lOO Local exam:

. Localized Tenderness . Rebound Tenderness

(Pressure On Lt. iliac fossa

Pain on Rt. lliac fossa)

thifting of gases from pelvic colon to

caecum

(Remove hand from Lt. lliac

fossa)

Pain in Rt. lliac

IN SUB.HEPATIC APPENDICITIS

irritation of parietal periloneum

IN PELVIC APPENDICITIS on inlernal rolalion of flexed IN RETRO-CAECAI WPE Pain on Exiension of IN RETRO-CAECAI TYPE Rf. LL ) Dressure on Rl. lliac fossa

Pain

O Localized lenderness O Rebound tenderness O Crossed (Rovsing's srgn ) O Crossed Rebound Tenderness (BIumberg's sign)

ffioFfficnls

"#.q-{wr5,4l il?qwl

?Wt &

Psoas sign @ minimal Pain & ri$dirg @ Ureleric colic, Hematuria

@ *ve

@ *ve Obluralor sign @ McFadden sign @ Dgsenlerg & diarrhea

@ Aooendix is felt in
DRE

. Touch lhe psoas Muscle . Caecum is prcsenl over appendix . fouch ureler . Touch oblurator inlernus Muscle . Touch UB . Touch reclum

Classic clinical @ Diarrhea followed bg constipalion (misdiagnosed as G.E.) @ No localization Generalized perilonilis @ Affeci lleo-cecal Vein )Porlal Pgemia

@ Young patient O Signs h'rgher than McBurneg's point @ Hgperesthesia al Triangle of Sherren @ Pain doesn'l DroDapale to shoulder or back

@ No Localizalion @ pain displaces upwards @ Fale:

Omenlum is elevaled

l)

lrnperforale PTL Abortion, PTL Perforale

Hgpereslhesia at lriangle of sherren

Pain is nol referred

io shoulder or back

Hgperesthesia belween 9'h, llth ribs oosleriorlu (BOAS Pain is referred to shoulder or back

oFffi(
I
@Moderale

5R'11:lCfl't5

ilRqW ' 4f

?*(fr r 8l

teucocgtosis
@Urine analgsis

(Io Exclude UII)

@U/$)diagnosis & exclude olher diseaees @CI with oral conlrasl @X-rag for perforalion @ taparoscopg: fenrales in child-bearing period

Appendicular Abscess
n
I

Diffuse

perilonifis
@ Resuscilalion

Portal pgemia

Bpec.ial Cases
Laparosoopic

&

@ Ligation

of

Monitoring @ Exploration @ Appendeclomg @ Peritonealloilel @ 3 drains : l) Pelvic 2) Hepalo-renal 3) Para-caecal

ileo-caecal vessels @ ABs @ TPIII

appendeclomg in females in child-beari4g period

PO$T.OPERATIVE:
Regular analgesics, lv fluids, Fasling lill return of inrestinat sounds, Antibiotics (3'o generalion Cephalosporins) for 5 dags.

@ @ @
@

From Arganla{in cells (Kulchitskg cells)

@
@

majoritg occur (rnetastases in 4Yo of cases) Discovercd bg rouline lnlra -operative Hislo-patholo$ca! examinarion Primarg lumor producing serolonin Deslroged in Liver No Carcinoid $ Melaslasis produce Sgmptoms due lo enlering of serolonin into circulalion

@ Trealrnenl according to size

l)

<Zcm)Appendeclomg 2l > zcrn ) Righf Hemi-colectomg

ilRfl-Tw.t5 | qT ilFqft\ ?ttY t

6?-

t Acute Perilonitis I Sub-Phrenic abscess

r TB perilonitis, Mesenieric cgst,

Acute Non-specific Lgmphadenitis

ilPq-{00N5 : qrT ilPhW

?tGY

t 81

Faclors facilitafing Localizalion of infeclion Cavitg is divided inlo 2 compartmenls (grealer sac, lesser sac)

Peristalsis

o Organisrn) Grarn-ve o Roule of infeclion: Direct

Grealer omenlum is adherenl to inflamed

spread

& Blood spread

slruclures

BAeremAu
PRIMARY (SPoNTANEOUS)

NoN gAE]BIAL
SECONDARY

O Biliarg peritonilis O Meconium

Peri{onilis

O Unkown O PPF:

cause

.lrlrnmunitg
Jtr.jJl
Liver

rri{

cirrhosis

wiih ascilis,
Chronic RF MiId FAHM, lenderness, Mild Rigiditg

O Pain O Vomiting
G) Disiension

Pain

Swelling

O Pale, dehgdraiion

Vlnlestinal sounds (Dead Fullness in Reciovesical pouch in

males

or silenf abdomen)

tr"eraE
shock Movemenf

Fever, tachgcardia, OAbdominal

&

Douglas

F"p".tionl

INVEgTIGATIONS:

@ Leukocgtosis O US & Peritoneal diagnoslic aspiralion ) lnira-abdominal fluid & ils nalure O X-rag abdomen ) indicate lhe cause, rnulliple fluid levels

Tenderness, rebound lenderness

Fr*r--l"n-l
occula

Bhifling dullness Resonanoe if obslruclion

Frrculf"fdl
FEilFullness

Jln{estinal
in

sounds (Dead or silent abdomen)

. .

Recto-vesical pouch in
males Douglas pouch in fernales

O Resuscilation & Moniloring

(D Exploralorg Laparolomg
:

lncision, loilel, idenlification of cause, Drainage, closure

1fr11,-Tmr5 $T leQfut

?l{fr t *

SSoB- Frl,IK,
@ @

Localized perilonitis Under Diaphragm Commonesl space to be affected

@ ClO : Pain & @ O/E: Scheme

*
* * *

....

, Tachgcardia, R.apid deterioralion of leneral condilion Pleural effusion(Rare): g0hest movemenl , VAir enlrg, dullness PAIPATION: Tenderness over lower ribs

l)
2) 3) 4)

Resonant (lrng) Dullness (pleural effusion) Resonant (Gas in abscess) Dullness (pus in abscess)
:

lnvesl'lgalions

& Best:
E
tr
@

*]E!
E
Elevated copula of diaphragm Pleural effusion (Homogenous opaciig obliterating Coslo-phrenic a4gle, rising to aiilla) Gas under diaphragm
ftgmSriffiE

Trealmenl : fr Analgesics, anli-pgrelics , anlibiolics B Perculaneous drainage (US or CI guided)

Open

Above, infronl: Liver, GB Posl , Behind : Upper pole of righl kidneg , right suprarena! gland , second parl of duodenum

space belween : @ diaphragm @ Right lobe of liver @ To the righl of Falciform ligamenl
Diaphragrn

teft lobe of liver, slomach,

To

spleen

lhe lefl of falciforrn

O Bursl abscess O Drainage

&

Loculi

Bursl abscess & Loculi

Drainage

TB
Cornrnonesl roule : Commonest tgpe is

11?.4-{0a.t5 1$

il?@l

?Wt ffi

rNS

CP:

Percussion : Ascilis lnvesligalions : l. CBC > Anemia, Lgmphocgtosis, ESR >lOO 2. Laparoscopg ) Visualizalion & Biopsg 3. US & Tappiag for ascitis frealment : SANATORIAL ) MEDICAL ) tf failed: SURGICAL

@ Cornmonesl

Custic swelling near umbilicus

AI\

Crossed bg band of resonance of bowel

Mobile across rool of rnesenterg

6s ..1r'i,'i6 U++t-tl n i hr r.r i? 6s g1g g rHJgr aJl+ rJg JlofiJl,., irll or?gs ErliJl oSf 6Jr r.iliiilf.;;.rr+ g ii+liJl

Suspect TB Peritonilis?

wilh Recurrenl atlacks of pain, Fever, abdominal distension, abdominal lenderness

Young! loxemic patient

@ Suspect Pelvic abscess ?

General manifeslalions

of

mucous diarrhea &

micluriiion

@ Suspecl Subphrenic abscess?

Persislenl Hectic fever following abdominal operation or an inflammalorg lesion in abdomen

lJK4:tooN5 : qT ilRh%]

?NqV

t A"

r General Scheme r Primarg inlussuscePlion r Volvulus r Adhesive !O r [Vlesenleric vascular occlusion r Paralglic ileus r Miscellaneous Topics

lffiNAto
CLINICAL PICTURE: Sgmptoms Pain,

flJiF(i-jfC[n{5: $T "il?4%A'j

?lhY

t 67

(ln Egspr) ons (ln USA)

V g
g

& absolute conslipalion

ln Colonic obslruclion : vomiling mag be delaged for l-2 dags Absolule conslipalion mag be absenl in :

O Earlg cases O lnlussusceplion O Slrangulalion wilhou{ obslruclion ( Richfer's

@ Gall slone ileus

hernia, MVO )

6=
CBC, KFT, Electrolgtes

HAIN X*AY
AEDoillElt

o/s Dislended loops * special ....

V Jejunum : Vulvulae connivenles (Mucosal folds crossing!side to the other) V lleum : Fealureless V Colon : Loss of Hausleralions

StprNe Level of obstruclion:

g g

BAFloNl ENB,rlA
lntussuscepfion : Claw srgn E.x. Sigmoid volvulus) "Ace spade
deformilg"

ilP.q4wr5 l qT ilEhWl

?f,hY

tU

FRIO
Rgle, lV Iine , Calheler , FIuid monilor

IV LINE : Replacement of Lost fluid o Antibiotics NG SUCIION: Decompress bowe! V R:sk of inhalalion during induction of aneslhesia

o o o
o

fl
V

Adhesive lO

lV drip, NC suclion lrg lnlussusceplion ) Hgdroslalic reduclion bg Barium enema Sigmoid Volvulus ) Rectal Tube

>

g
V

Exploration Delermine level of Obslruclion: - Above obslruclion: Distension - Below Obslruclion: Collapse Assessmenl of bowel viabilitg

CATHEIER,

VIAEE
Reduclion

DoOEnFt L
Cover bg hot

hlot.l-VlAEtE

Monilor urine oulpul

MONITORING Vital data

packs, Pure 02 for few minules then

re-asses

lr

Sl
/
R.esection, anasfomosis

u
-Er

-gia

-V

g g

Sedation
NPO

V V

MikulicZ Hartman Duddlg

V lV fluids 3 Liters Ringer lactafe

PNt'/lAF*/
DEFINITION:

1J?t4-{wN5 t $l

ilPhW

?NqY

| 81

g
g

!l's invagination of lnlussuscepturn inlo lhe tntussuscepiens

Mosl comrnon sile is
IDIOPATHIC

PATHOLOGY: ETIOLOGY:

Possible cause ) occurring al CLINICAI PICTURE: / IfPE OF PAIIENT: Healthg male 3-12 monlhs at the age of Weaning! / SYMPTOMS : . ATTACKS of Colickg abdominal pain ... (Crging, screamin!, Drawing legs up)> lmproved in-belween atlacks ) . VOMITING

M
V

during summer INFANT HAVING

coltcKr

PAttrt

, ABSOLUTE
per reclum

WITH PASSAGE OF BTOOD STAINED MUCUS PER,

RECTUM "R,ED CURRANT JETLY STOOL"

/ /(

. . . . ,

GENERAL: ...DEHYDRATION... LOCAL SIGNS:

INSPECTION: Visible
PALPATION:

NO CONSTIPATION

PERCUSSION: Tgmpanic resonance AUSCULTATION:MAD abdomen DRE .. MaU feel apex of inlussception) Finger is slained wilh Mucus

&

Blood

INVESTIGATIONS:

@d
@
TR,EATMENT:

ultiple fluid levels) & SUPTNE

(detects

ops)

hUR UUMPLIUAIIUNa: CBC, KFT, ELECIR

Pre-operatirc pr"prr.lion) lV fluids, Abs. NG suction, Calheter, Monitor * lf Earlg, non-complicaled ) Hgdrostatic reduction usin! barium enerna (Success) Fillin! of lerminal ileum, Caecum, Appendix) * lf Laie , Complicaled ) Surgical reduclion bg Squeeze melhod .r lf gangrenous ) Reseciion & End lo end anasiomosis aplb & lf recurrent ) slitching of ierminal ileum lo caecurn PROGNOSIS : High morlalitg in Gangrenous lesions .?. Z7oRecuwence

.r

l2rg to Polgp, lipoma, carcinoma, Meckel's div, HSP) ical reduclion & TTT of cause

ilP.q4wr5

| qT

il?4%\

?tGY

| 10

9ITES: g Mosl cornmon site

PREDISPOSING FACTORS:

g
g
@

Twistino of

Old patient, chronic, conslipalion, Namow base & long mesenlerg PAIHOLOGY: CLINICAL PICTURE:

,lOi0 qsir qru >re

p,ll\

tI>U\

Sgmptorns: t Abdominal pain, * Dislension t ABSOLUTE Constipation

Palienl : lnfanl 5-6 dags bld lnvesligations : Plain X-rag abdomen + Doppler US Trealmenl : Resuscilation & untwisling of Volvulus 2rg Iook procedure before removing of bowel (avoid Short bowel $ )

S'Ens:

DRE) Emplg Reclum COMPTICATIONS: V Shock & Toxemia, peritonitis INVE8TIGATION$: Scheme * @ Plain x-rag supine: O Ba enema: O For Complicalions) CBC, KFT, Electrolgtes TREATMENT: as scheme * * PRE.OPEMTIVE PREPARAIION: Rgle, line, catheler, fluid, monitor

.r * * .t *

IN$PECIION) Distension, Visible perislalsis PALPATION) Tense balloon of Volvulus PERCUSSION) Tgmpanic abdornen AUSCUTTAIION) MAD abdomen

CONSERVATIVE TTT:

lf earlg, non-cornplicafud

is tried, and then patienl is prepared for elective Resection of sigmoid (Success) Gush of Gases & Fluid stools)
SURGICAL TTT:

EI INCIDENCE: Most common cause of small inteslinal obslruclion is Adhesions

& Non-complicated)Colopexg lo posl abdominal wall (lf short segrnent) * lf Late & complicaled ) Mickuliz, Harlman
late

lf

EI CTINICAL PICTURE: garne as scheme* Presence of scar or Historg of previous M TREATMENT:

POST-OPEMTIVE CARE: NPO, Sedalives, analgesics, lV fluids

* lf failed >72hours, Complicated: * lf

Sur$cal interference Recurrent: Nobel's plication

McSertrecldMffi
g

1)Pq4w)5 1qT ilPqK\

?tQY

| 1l

Occlusion of Superior mesenleric arterg or one of ils branches

. * I *

(MOSr COMMON CAUSE), Arterial Thrombosis, Venous Thrombosis

CLINICAL PICTURE: WPE OF PATIENT: Elderlg (Thrombosis) or Young Adults ( Embolism) SYMPIOM$ .... ACUTE IO + 9TRANGULATION . Stabbing pain in abdomen not relieved Bg anlispasmodics, or NG suclion

. r

BPR, Vomiling!, Diarrhea OF COMPLICAIIONS ) Shock, loxemia

SIGNS:

GENERAL) Shock, Toxemia TOCAL) Guardin!, lenderness, rebound lenderness INVESTIGATIONS: Scheme + .... * Mesenleric angiographg (or duplex US) * Plain x-rau ) Multiple Fluid levels mag NOT be presenl, lntesfina! Necrosis (Late)

t *

CT scan

&

FOR COMPLICATIONS> CBC, KFT, Melabolic acidosis FOR EIIOLOGY: ... ECG, Echo, U/S

1 serum Amglase, Serum Phospha{e level,

(mag be slighflg increased in 57" of PTs)

(!V fluids, Abs, Heparin continuous infusion and slopped durin! surgerg) I

OnGErtrLAFAFcrro[y

ffi
gNous
Reseclion & Avoid Primarg anastornosis IF THERE'S DfiENSIVE GANGRENE) 2ru Look afier 48 houis

eMpulsl
Embolectomg

T{ROMBOS
Streptokinase thrombolgsis or Bgpass

Mesenleric ARTERIAL occlusion 145%), > Mesenteric EMBOLISM

ilR{1-jI00f'15 : qT

ilPhWl

?thv

t TL

DEFIN!TION Failure of neurornuscular mechanism leading to failure of peristallic waves wilh palent Lurnen ETIOLOGY: Re{lex inhibition of lnlestinal Molilitg Toxic tnhibition Peritonitis, Tgphoid Hgpokalernia, uremia, DKA Melabolic Abnormalities

of lnlesline

. . . .

Drugs )

Anticholinerlics, TCA

PATHOLOGY:

. . .

Mosl common affecled sile

TUp" of patient As lO +... SYMPTOMS Painless ,/ Vomiting is Conslipaled, mau pass

CLINICAL PICTURE:

Of 8l ) Paralglic ileus Of Slomach) Acule gaslric dilatalion Of Colon ) OOILVIE $

,/

urb,

g V V g g V

GENERAL gtCNS ) Shock + C.P. of Cause "Uremia, Hgpokalemia" INSPECTION > Dislension, Scar of previous operalion, No visible perislalsis PERCUSSION) Tgmpanic abdomen, Pseudo-shifting dullness AUSCULTATION ) Dead silenl abdomen, High Pifched Tinkling abdominal sound

z/ Auscultalion : Dead silenl

Je dN)

9)

Suspecl: . Perilonilis . Adhesive lnlesfinal Obslruclion

IVESTIGATIONS:

Multiple fluid levels Plain x-rau abdomen CBC, KFTs, Serum Electrolgles LABORATORY

>

TREATMENT:

PROPHYAXIS:

g g V

PRE-OPERAIIVE) Correclion of Eleclrolgle imbalance INTRA-OPERAIIVE) Gentle manipulalion POST-OPEMTIVE > NPO unlil inleslinal peristalsis

ACTIVE TR,EAIMENT: TIT of cause Rgle, line, fluids, Abs Sedalion bg pethidine

g V g V
g

Observalion for

of recoverg r\p qI\"s r.;d\

lgl

POST OPERATIVE CARE Sedalion NPO IV FLUIDS

wtno

Darn

V V g

M Flarus' EI V Dislension EI V Aspiralion

M
X-rag
:

ilK4-1wr5

roFrgs

| qT

il?4@

?hq7

|T

CAUSE: gudden VCOP due lo anu cause.. ex. Arrhglhmia PATIENT: A crilicallg ill palient in ICU with gudden hgpolension ClO : Acule abdomen, BPR

Treatrnent : CONSERVAIIVE

.
,

Palient with alherosclerosis

CLINICAL PICTURE:

t5-3O min afler meals

MecoXKnl lt^Eos
M
Mag be associaled

with
ted muconium

ll0%)

.V

V X-rag: scheme *
Trealmenl :

M Etiologg :

MecoXrnlHJq r
. .
colon
Thick

TTT:

Lumen: t"n-rcril From E Meconium ileus

E
Meconium plug

rGoWl
From
Etr

1ilPI+-TC0)5 : rdT flJRI1fr'J

?thV

t oyi

Wall:

$ tr
of

tr
E

Congenilal atresla Annular Hirshsprung dis (coNG. Megacolon) lmperforate anus

.... pancreas
Clinical

Outside wall:
Volvulus neonalorum EI lrreducible congenilal her.nia
Etr

i-chNrcAL
F

crruFE.

I
I

Clinicat piclure

lO

t( Vomiling r( Colickg abdom:nal Pain ,/ Absolut conslipalion / Abdominat dissension & visible perislalsis

/
1/

tffi

/ Paln X-rag abdomen erect ......& supine ..... ,/ Hirschsprung's disease ) barium enemar Rectal Biopsg / lmperlorale anus) lnverlogram lo delecl low vs. high anomalies & IVP for associated anomalies
Pre-operalive

Yolvulus neonalorum ) BPR lmpefiorale anus : l) Associaled VACIREL anomalies 2) lmpulse on crging in low anornalies 3) Presence of anal dimple Hitschsprung's disease : 24 hours Delaged passage of meconium 2) Empfg reclum 3) Grips on finger Gush of slools on wilhdrawal

piclure of the cause

l)

preparation: EI Rgle) suclion

EI Line) lV fluids, eleclrolgles M Catheter)monilor urine oulpul

Operalive M Time)

V M lf HiAh lmperforale anus) Staged operalion (rG ................) EI lf Low irnperforale anus) Simple excision , cruciale incision .....

5JP{4-Tm)5, qT il?4w
I.
Young aduH presents wiih acute severe ill-defined colickg abdominal pain slaried Peri-umbilicalthen shifted to ihe right iliac fossa wiih and rarelg without vomiting and usuallg gives historg of constipation.

?hh9

| 1b

,4ute

aVVeildbrtrb,

Male or female with persislerrl hiccough, throbbing pain, heclic fever, rapid delerioralion of the general condition wilh previous hislorg of inflammalorg Iesion in abdomen.

Sttb-Vhratb abscess.

3. Heahhg infarrt male belween 3 &12 morrths preserrls with attacks of colickg abdominal pain and
Passale of blood slained mucus per rectum.

Pnuar7 r'ttlssrcceptnn
An elderlg conslipaled male wilh repeatud episodes of abdominal pain presented with sudden severe colickg pain with marked dislenlion in flanks from lefl side lowards the umbilicus absolule constipalion and delaged vomiling. Adult patienls with hislorg o{ recenl abdominal o ggnecological operation presenls with colickg abdominal pain, absolute constipalion, vomiting.

Yolwtlls of t/te Ve/rrc

co/ot/.

Adhsrw nttstrhal obstuctrort.

6-An adult preserris mosllg 3rd dag postoperalive bg abdominal distenlion, absolule corrslipalion and repealed efforlless vomiling

Para/ftrb rlerc.

Acule lnleslinal obslruclion : ggmploms , Signs & lnvestigations

( ,4y'rar

ril' 2@5 -,4ilar

( ,4dur

f,2o(9

) )

Causes

of lnlestinal obslruclion in old age

/1zo/

Explain whg: Pt. wilh adhesive inlestinal obstruc{ion should be given a chance of conservalive fTf.
(

lnlussusception : Causes, C/P &

ilI
(
(

Kasr,2@A )

5u shatts, 2M )
,4Zrar hL

lnfantile intussusception: C/P, lnvesligations & ITT.

5u
shans,

Zo/-

ZooaS

Mechanical lnleslinal obslruclion: Managemenl

Paralglic ileus Volvulus , ManaElemenl of gigmoid volvulus

ilPt4-{00N5 : qT

ilRhW

?NqY

| 1b

ilE+Tw{f t tdf clJktaful

?lhY

IT

I I

TB

of lnlesline

lnleslina! lrauma

Mre,S
V V
DEFINITION:

tT

Persisleni palencg of proximal part of vitello-inleslinal ducl

INCIDENCE :

Mosl common cause of

g g

Especiallg if complicated with PU :: Mosl comrnon congenital anomalg in GtT .... l27o of Pop, 27o complicaled. Male>Female 2:1, 2 inches long,2 feel from ileo-caecal valve ) PATHOLOGY: of bowel wall are presenl Arises frorn Mag Conlain (e.g. gastric lissue ... liable fo PU ) CLINICAL PICTURE: Mosllg ABYMPTOMATIC, Bul mosl comrnon complaint is Bleeding COMPLICATIONS:

. I

::

'
'

ll[Eldir"'t,"{s4ll!!

Child 8-lO gears old, wifh abdominal pain, melena, or

M lntussceplion

MVolvulus

ClP ol Peritonifis perforated

if

Picture SIMILAR lo Appendicilis BUI Appendix is found NORMAT TNIRAOPERAIIVE.

STRANGUI.ATION

WTIHOUT OBgTRUCTION
D.D, SIRANGUTAT!ON

D.D. OF BPR IN A CHIID:

- Meckel's Divirticulitis*
- Tgphoid - Colonic polgp

D.D. APPENDICITIS

PU

WIIHOUI
OBSTRUCTION

- Angiomatus malformalion

g g
V

Mosl common DD is Acule appendicitis (Differentialion is intra-operalive) Meckel's diverliculum is more dangerous ... because il's easier to be perforaled, Difficult localizalion of bleeding due lo Cenlral posilion
lnvestigiations 0Jadl 1's pr iir-cLi @ Best: i[.. can demonslrale gastric rnucosa @ Angiographg : weepino Meckels's (O.5 ml/min) Trealmenl : fr SYMPTOMATIC) wedge reseciion & closure of defect

fr

ASYMPTOMATIC:

Wirh an indication for surgeru ) RESECTION NO indicalion for surlerg ) LEAVE lT ALONE

1JP4-jI00N5 ,

6f lJPhWl

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t A0

TBOF
EIIOLOGY

T
''l
2

,Ilfllrll lN/ll'l2tl:
. . . . . . ' . .
OROANISM
R.OUTE

I :l i l{l)

2:I

IrI I'l 2 :

PDF

gcobaclerium Tuberculosis 2rg lo pulmonarg TB, or lnteslinal Bad immunilu

M

Mgcobacleriurn Bovis lngeslion of lnfected Milk Relalivelu eood immunilu lleo-cecal region

PAIHOLOGY

Sile
Shape

Terrninal ileum (Peger's palches) Transverse

Number
Base

Floor
Edge

Multiple lndurated Caseous malerial Undermined, Cuanotic margin Usuallg Adull, Bad immunitg Signs of TB,.lrWT, anemia Diarrhea, colickg pain, Bloodg stool
I I

NO caseous necrosis

CLINICAL PICTURE

. . .

Patienl
General Local

Child, good immunitg .lrWT, anemia

Diarrhea, Pain, Mass in Rl. lliac fossa

I I

COMPLICATIONS

Slriclure ) lO Perloration ...?are

Slricture ) lO Fecal fistula

INVESIIGATIONS

LABORATORY:

. ' r . .

CBC

Anemia, Lgmphocgtosis

4ESR , +ve CRP +ve Tuberculin Tesl Stool Cullure on Lowenstein jehnsen media
PCR RADIOLOGICAL:

RADIOLOGICAL:

Ba meal follow-through
"Non-visualizalion of caecum, Terminal ileum"
IREAIMENT

Ba meal follow-through . Narrowing of lleum with

Elevated Caecum

$ANATORIAL TTT. SURGICAL TTT:

ANTI-TB DRUGS SURGICAL

ITI:

Resection & Anaslomosis ... (Perforalion, striclure, bleeding)

Right Hemi-coleclomg ... (Perforalion, Fecal fislula, Obsiruclion)

ACflNohtfocls g Multiple sinuses

V
dischargng pus conlaining sulphur granules
No LN spread

l@

l) Adenocarcinoma
2) Carcinoid lumor

ilK!-{w'J5

$ ilRhW

?MYt

g
g

ETIOLOGY:

Open, Closed, latrogenic TYPES OF TNJURY

BLOOD VESSELS

. .

CLINICAT PICTURE:

C/O ... Historg of lrauma, abdorninal pain GENERAT SIGNS ... Tachgcardia, fever, Hgpolension
LOCAL SIGNS:

SIGNS OF INJUR,Y

TENDERNEBB

REBOUND TENDERNESS SHIFTING DUTLNEgg DISTENSION

COMPLICATIONS:

. . . .

Peritonilis lnlernal Hemorrhage Hgpovolemic, Seplic shock Paralglic ileus

INVE8TIGATIONB:

@ DIAGNOSIS tS MAINLY CLINICAL @ LABOMTORY INVESTIGATIONS:

Leucocglosis, Hemodilution @ MDIOLOGICAL INVESTIGATIONS: . Plain X-rag abdornen ) Free air under diaphragm, Mulliple fluid levels, Fraclures . U/g , CT scan ) Hemaloma, inlra-peritoneal oolleclion

EITREATMENT:
ABCD +
LAPAROTOMY + TETANUS TOXOID

ShiAlr-INTENNE. RrG*frOoLoN
TIDY, SHARP) Resection, anaslornosis for ischernic & gangrenous parls RAGGED> Trimming of edge, suluring

ffi
>

LEFT@T,.ON

LOCAIIZED Exteriorization IF RESECTION IS INDICATED HARTMAN's . MICKULIZ

WRq-rwY

I qT

aRq%l

?thY

rW

Hirschsprung's disease Diverlicular disease Benign Coloreclal lurnors Colorectal carcinorna lnflamrnalorg bowe! disease Rectal prolapse

qr ilRhw

?ltY

tW

..@NGIFNrrAtMffi"

V 6% Farnilial
EI Associated with Down $ in lO% of
cases

"MrCMffi"
PATHOLOGY:

Absence of AuerBach's gangtia in Musculosa Meissner's plexus in Submucoasa

MicroscoPic Picture:

&

. ' .

CLINICAL PICTURE:
New born presenled with delaged passage of rneconiurn > 24 Hrs. Defecalion occurs afler inserlion of finger of molher in anus of babg DRE: Grips on {inger Gush of fetOd slool in withdrawal

COMPTICATIONS:

. .

Obslruclive loxic enlerocolitis, Acule Obstruclion Delaged Growth, Failure lo lhrive, Chesi infec{ion
BARTUM ENEMA (W|THOUT pREpARAilON OR DRE) Narrow aganglionic segmenl with marked proxima! colonic dilalation.

INVESTIGATIONS:

rp

suBMucosA)
, thows: Absence of Ganglion cells

EI.ECTTVE >,,tr)\ .,e \ae\b 5x re drYt

eUl ffi o\fiIe SWENSON'g OPEMTION
...
a$ A\rrs Grn

OESTFOCfl\'Effi
I

@ripuereD$rtilt
Co!.tsnVlirr\lE:
Nasogastric lube, lV fluids, Colonic wash wilh saline

ffiNOTREUEIED
FEUE\IED: Prepare for laler
surgerg
Urgenl Coloslomg
I SWENSON'g OPERATION At I gear age

A)P'Q-{00N5:
dv$.$at tl

ql 5WW

?rcY

I W+

Obl-

DOF
V Asgmplornalic or Discovered
during enema inserlion
INVESTIGATIONS:

MFalse, Pulsion diverticulurn M'1. in Weslern counlriee)Urban El9ile : Sigmoid colon, RECTUM

Ig NET'ER AFFECTED MNol he-carcenous

accidentallg

TREATMENT: H'gh

@)@

fiber diet& anlispasmodics

PERREC'fl.'}N
FlsnuA
GENERALIZED

V V

<48 Hrs.

LOCALIZED

DN'hilqrlo}i
g V
INVESTIGATIONS:

CANcm,
CoLoN

Recurrent Attacks of Abdominal pain + Passage of BPR Trealmenl : Coleclomg afler preparalion

>48 Hrs.

g g

rNVEsrGATroNs > qE@[ TREAIMENI: . Resl, analgesics, antipgrelics, antibiolics > lncision & U/S guided Drainage . Peritonilis) R&M, laparolomg, Peritoneal toilel, Drain, Reseclion . Fislula) Fleseclion, Repair

* t

Angiographg Sigrnoidoscopg to Exclude Carcinoma

TREATMENT:

Resuscilalion ) Angiographg ) Re$onal reseclion lf Failed) Total Colectomg * lleoReclal anaslomosis

aRq--rw)5 t rlT crRQful

?ttY

IW

fl
M Cl.Pict :

On long arm of Mag be a part

V V g V V

PAIHOLOGY:

* @[[$D 0r-loo s,or,tgrJr)> AuTogoMAL DoMINANT *@ 0lloo g ao)) AurosoMAL REcEsstvE

unlrealed cases lurn

of :

'rffi:"'r E@
s
Mulliple polgps * Melanolic pigmenlalion * Malignant polenlial 2To EEE :n childhood

CLINICAL PICTURE:

PAIIENT: Male, Pubertal age, wilh positive familg hislorg C/O: Diarrhea, BPR, Abdominal pain O/E: Bad general condilion, anemia, DRE) Polgps INVESIIGATIONS> Ba enerna, Colon TREATMENT... SURGICAI> Familg Screening should be

lleoslomg

7 tJ

Risk of malignancg depends on SIZE

.t)

or )Diarrhea, Hgpokalemia

It oo

'+lp

V V

. .

DEFINITION: Cancer colon is PROXIMAL to the point where lhe 2 anli-mesenleric Taenia Coli converge Cancer Rectum is DISTAL to this point INCIDENCE: Peak incidence d EIE, More common in Mates excepl Cancer caecum ETIOLOGY & PRESISPOSING FACTORS:

@to

5UP4-100N5: qT

il?h*l

?l,hY

t l)b

Dielarg faclors, srnoking, Alcohol, Uretero-colic anastomosis.lBD

Villous Adenomatous polup >2 cm

.FPC, Gardener's $ .LYNCH $ ... (on Rl. side, Beller prognosis lhan FPC) - TYNCH l-) Cancer colon - LYNCH ll) Cancer colon* Cancer ovarg, Endomelrial carcinoma .LE FRAUMINI $(Error in Pu")) Cancer breast, endomelrium, Colorectal cancer

PATHOLOGY:

strE :
Mosl common site i* ' 257" in Rt. Colon, Leasl affected sile is TRANSVERSE COLON is Essenrial" EETEIIIEIEE) MACROSCOPIC: Ulceralive ( , Cauliflower (least malignant, Rl. side), Annular MICROSCOPIC : Adenocarcinoma, Colloid, anaplaslic

g V
V

"

. .

SPR,EAD: DIRECT

Spread in Upwards direclion , Vq cftcle everu LYMPHATTC, BLOOD (BLBL), TMNS-PERTTONEAL

I I I I

6 months

Of PROCNO9IIC value
Begond Ms. l-ager, NO nodal involvemenl

COMPLICATIONS:
Perforalion Fistula MILD Bleeding

chrNGAr nGrn ne

G CoLoFffiAr ffi
BPR Tenesmus Bladder sgmploms e.g. Dgsuria Palpable mass bg DRE

1JRfi400N5: qT

5{.IFQW\

?ttY

tW

ulmtooroffi
ASC cotoN
Acule: Acule lO on top of Chronic Chronic:

$rrrr{ffi
$Grvloro
g
V V

Cototl
Acule:

IEFT

LETT
Gradual progressive Conslipation, dislension & Colickg abdominal pain

Acule lO on top of Chronic

Chronic:

EI Pain, mass

V g

BPR Mass

V ENDOSCOPY & BIOPSY> Colonoscopg for V g

Multicenleric lesions BARIUM ENEMA> SPIRAL CT> ln Elderlg

lffiFoRDUlg;10**=

g
V

Endoluminal U/S ) exlenl of Local infiltraiion Abdominal U/S

g g

cxR rvu

EI LFT,KFT,CBC.FBS

MTumor Markers (cEA)

ro@

il?q-{w{5 4f ilPhWl

VtaY

r tff

Etiologg

UNKNOWN.. Geographical, racial differences, energu deficiencg , alteralion mucosal Elucol-proiein.

Auto-immune, Herediiarg,Genelic Faclors

of .Mosl common) .2nd mosl common) Colon . Mau affect anu Darl of GIT
Apthous ulcer +

Sile

Macro.

. .
I I

.Mosl common) .Rarelg) Terminal ileum .lf ileo-caecal valve) Back wash ileilis

Micro.

Mucosal edema +ulceralion NO skip lesions .lnflammation Of MUCO$A, 9UBMUCOSA

. (edematous mucosa
surrounded bq ulcers I
Female. male Waterg diarrhea, dehgdralion, abdominal pain

. . .

+ 9kip Iesions
Serosal affeclion Non-caseatingGranuloma

Trans-mural.... Affecling whole lhickness Male

Patient

c/o.
o/E
Comp.

. .

Female

... 2d-4h

decade

Acule) as acute appendicilis, but lhere's

historg of diarrhea.

lnvest.

tr Ege) Uveitis tr tr Joinl) Arthritis tr Liver) Gallstones tr Skin) Pgoderma llangrenosa EI Mal-absorption tr Liver) cirrhosis, sclerosing cholangitis tr Massive BPR tr Toxic Megacolon tr Malignancg colon..Mullicenteric, Aggressive tr Cancer A Massive HemorrhaQe & BPR ,/ Best is ,/ Besl is // Barium Enema : /f Barium enema : l) Cobblesione
Granular mucosa Pseudo-polgps CBC> anemia, ,1. TLC

Chronic) Rectal bleedine, pain, diarrhea

2) 3)

// /
K*

9tring s'rgn of Kantor CBC) anemia, 4\EgR, CPR Hgpo-proleinemia, VCa, VMg, OZn

2)

/
TTT :

Hupo-proteinemia,

Medicallrealrnerrl :

g g

Resl

Medicallr6alnpnl : g Diet ... prolein, CHO diel, vilamins

EI

Diet .... Prolein, Vilamins, iron Anti-inflammatorg: l) During atlack) sleroids enema

M
EI

Antispasmodics

Corticosieroids & Sulfasalazine,

2) ln belween) Sulphasalazine

Metronidazole euqgical lrealnrent:

euryical fisalmerrt: g Pan-proclo-choleclomg

Laparolomg) DD from appendicilis

permanenl ileostomg (ileal reservoir)

lrnune fhempg : g lrrterfieron

"ilRq4wr5 | qT ilP4W

?MYtw

DEFINIIION
ETIOLOGY

l.

Prolapse of reclal mucosa Loss of weight (loss of supporting para-recla!

fal) 2. Prolonged diarrhea or whooping

cough
(Due to excessive straini4g). 3. Advanced cases of hemorrhoids (grade lll, lV). 4. BPH due lo continuous straini4g. 5. Sphincteric along in the elderlg. 6. latrogenic injurg of anoreclal sphincler during a {istula

Prolapse of whole thickness of the reclal wall More common in females, while in Eggpt more in goun! males (due to bilharzial colil'rs). l. Repeated diarrhea ) excessive stra4gulation. 2. C.T. disease (Due io defective collagen sgnlhesis) 3. Abnormal rnobilitg of the mesoreclum leadi4g to lack of fxation belween lhe reclum and sacrum. 4. ln EgUp{, Bilharzial proctitis and colitis ) corrtinuous lenesmus )slrangulalion

ooeration.
PATHOLOGY

Length

(
3-

5cm

>5cm
lUlceration and

fhiokness
COMPLICATIONS

Mucosa onlg

lrreducibilitg. 5- Feca! inconlinence.

. .
Earlg:

infeclion.

Whole reclallhickness 2-Bleeding.

4-$lra4gulation and liargrene. 6- Discharge, prurilus.

CLINICAL

l. 2. 3.

gomelhino prolrudino from lhe anus al defecalion: Lale:

PICIURE SumDloms:

il reduoes sporrlaneouslg. il requires manual reposilioning.

Piclure of comDlicaiions. Mucous dischar(e.

Sions:

lrspeclion: Prolapse is besl seen in squatting or laleral position and slraining. Palpalion: For ihickness of prolapse and tone of the sphinclerc, Prolapse, anal sphincter, pelvic floor, PR

l.
INVESTIGATIONS

2.

Anorectal manomeler, EMG o[ reola! sphinclers. gigmoidoscopg or barium enema) exclude polgps, masses or ang underlging cause.

TREAIMENI

Children

l.

Correclion of

cause 2.Digt+al

reposition
failed

Adults: Correction of cause 2. sphincter exercises 3. Excision of the

l.

There are various surllical procedure

if

prolapsed mucosa

3. Submucous injeclion of absolule alcohol

or phenol in almond oil

include: I- Rectopexg:(laDarosooDicl fhe reclum is mobilized and pulled up, then fixed lo a mesh allached to presacral (Waldegr's) fascia and puboreclalis muscle bg sulures.

induces {ibrosis

4. fhiersch

operat'ron (perianal oirclage)

fhe anal orifice is narrowed bg passing a non absorbable qulure around il. The wire is t'gtrtened while lhe assistanl's fiqger is inside lhe anus. 5. Banding or excision of redundani mucosa.

2- Excision of the redant recium , either through an abdominal or perineal approach or lransanal approach called. Delorme's operalion.
3. Thierech operalion
N.B. coniinence improve after surgerg in onlg half of the patierrts. 4. Perineal rectosiQmoideclomq.

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. Carcinoid tumor is the 2nd most common malignant iurnor of Srnall inlesline . Carcinoid lumors most likelg lo produce carcinoid
. Aboul 40% ol coloreclal tumors present as surgical
sgndrome before rnelaslasis originate frorn bronchus.

?fifi t

\l

arises from the anli-rnesenlric border inlesline , Meconium ileus inheriied as AR not AD . The primarg eliologg of jejunal and ileal alresia is vascular accidenl . Burn, Fracture, hernatoma, Small bowel obsiruclion are examples of lhird space sequeslralion

. Meckle's Diverticulum

emeqgencies.

l.
2.

l-Child patieni presenis with bleeding per rectum &

angiograph g shows extravasalions

hlakefs

direfirctr/lrtt.

Adulf pafienl wilh bad general condilion presenls wiih night fever and sweel, loss of weight and appelile, diarrhea .colickg lower abdominal pain. & fetid bloodg slool. CBC shows anemia, lgmphocgtosis and verg high EsR.

l//ceratrw 7B of t/re ntretrne )

4i',.

Mickel's diverticulum : Palhologg & management

( Aitt,sllarfls'

2@5 )

Hirschprung's disease
(Au sltans,2@3 )

Management of reclal prolapse

(

Ailar rlrl,zok )
( Kasn

Explain whg: Pt. wilh cancet caecum not usuallg have inteslinal obstruclion

2M

Management of cancer colon

(

l&ar,,lt1,2ob )

Cancer sigmoid: C/P, lnvestigations and TTT.

(An shatrs,2Ob )

Cancer reclum: C/P

(

Ailar

f,2M

Diverlicular disease of the colon: Nalural historg, Complications

&

TTT.

Kasn2@a. fusn2d/)

Faclors predisposing! to rnalignancg in Ulcerative colilis

(

Kasr2@8 )

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DEFINIIION

. . . .

of rectum lo pass lhrough pelvic floor, io pelvic floor M:F = 2:l Associaled with Fislulous
Failure

. ' .

of reclum to pass through pelvic floor, [l!l[! lo pelvic floor M:F = l:2 Noi associaled with other
Failure anomalies

comrnunicalion with Posterior urethra in males, Vagina in Females Associated with Congenital anomalies

l)

Blind pouoh
ABOVE lhe

Blind pouch
ABOVE fhe

Anal canal is covered bg Okin bar, anus usuallg opens inlo an ectopic sile anlerior lo lhe normal posilion

pelvic floor 2) Fistulous comm. Wifh UB, urelhra,

pelvic floor

Membrane al Dentate line Bulging (due to relained meconium)

CLINICAL PICTURE

Exarnine Anus , ils size, sile, presence of Anal dimple

EI LOW ANOMALIES) lmpulse on Crging al sile of anus EI RECTAL ATRESIA) Thermorneler CANNOT be inlroduced inlo EI ECTOPIC ANUS) SC fistulous lrack full of meconium

anus for >lcrn

INVESTIGATIONS

lhere'rc evidences of inleslinal obslruciion PIAIN X-RAY "INVERTOGRAM" ...24 hours after birth: M HIGH ANOMLIES: (+ lnvesl'rgations for congenital anornalies) . Dislance between Coin & distalgas- shadow )lcm . Bowel lerminales PROXIMAL to Pubo-sacral line
Dislance belween Coin & dislalgas- shadow (lcm Bowel lerminales DISIAL lo Pubo-sacral line V Triple catheter tesl for reclal alresia Triple Mernbranous Anus g IVP > For urinarg anomalies, Fislulas calheler lesl

EI LOW ANOMALIES:

. .

V
TR.EATMENT

Urine analusis

Fistula

STAGED SURGERY:

l)

2) 3)

femporarg coloslomg Ano-reclal Pull through Closure of Colostomg (Post Sagiltal operalion)

EI COVERED ANUS) Skin Excision EI MEMBMNOU9 ANUS:

. .

Cruciale incision of
membrane

Trimming of edge

TIT. OF ASSOCIAIED ANOMALIES

TTI)

Cut-Back operafion (Anq-plastg)

f..f

-, g-\

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PILONIDALSTffi
DEFINITION:

Disease of skin covering sacrum NOT an anal disease

Young!

INCIDENCE:

adull rnale wilh Dark, dense. Hair

ETIOLOGY: Unknown cause . Theories : Congenital 2) Acquired PATHOLOGY:

l)

)lnfection of

Cong!

er pubertg

Loose hair lheorg,

EI SIIE
Other sites) Axilla, Umbilicus, lnter-digital, Supra-slernal nolch CtINICAI PICTURE: Asgrnplomatic but rna be presenled b9... I (conlaining! hair), Local discomfori 'lf abscess is formed lhrobbing pain, redness, lenderness, Pus oozing frorn sinus DIFFERENTIAT DIAGNOSIS: M Peri-anal abscess M Anal fisiuta

HT.ONDATAESAESS
* * * *
Rest, Analgesics, Analgesics, Antipgeritcs Drainage Removal of hair Wound is left lo open bg granulation tissue

Snl0S

LAYING OUT OF IHE CAVIW & SIDE TRACKS

Laging out lhe cavilg

D.
:n Wde excision of the 91 Laging out the cavilg skin & subculaneous & side tracks lissue down to H Curettage periosteum of sacrum fr Packing & Leave wound open to heal bg 2rg intention
SHAPED FLAP

and side lracks Wound is left open (heal bg 2rg intention) Phenol cauterizalion rnag be applied

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?lAY

DEFINITION:

Elongated ulcer in lhe lon! axis of lower anal canal Middle aged patient... (M=F)

INCIDENCE:

ETIOLOGY:
NO DEFINITIVE CAUSE (majorilg of cases) Hard stool MIDLINE POSTERIOR FISSURE tgo%)...lhe most ischemic area Repeated deliveries MIDLINE ANTERIOR FISSURE (lO%) DEFINITIVE CAUSES (rninorilg of cases) IBD (Crohn's disease MULIIPLE FISSURE9)

. .

. . .

SfDs latrogenic

Large enema, endoscope, Posl hernorroideclomg,

AhIAtFISSORE

CqnoNtc
I

. . . .

sup
Pain (MAIN PATHoLoOlcAt Spasrn of Sphincter VBlood flow VHealing
AGENT)

As before

. . r

+ ... 2rg PATHOLOGICAL CHAMCTER8

indurated, ihick, fibrotic Upperend)Analpapillae Lower end ) SENTINEI PILE

Margin)

SYMPTOMS:

Followi

a{"tacks

of
Slreak of blood on
surfiace

. . . .

tharp Ai anus, radialing to coccgx Btarts al defecalion Lasls for I hour

aFter defecation

Palient postpone defecation due lo severe pain

of

Purulenl if abscess is formed

. ' .

Burning

micturilion
Dgsmenorrhea Pain alorg

stool

th'ghs

SIGNS OF ACUTE ANAL FISSURE

. .

gtGNg OF CHRONIC ANAL FISSURE

INSPECTION) Fissure, senlinel pile, fibrosed sphincler DRE) Bullon Hole induralion of fissure

DRE) Beiler to be avoided "Painful"

COMPIICATION$) Acquired Megacolon, Fislula

INVESTIGATIONS: lT'g A CLINICAI DIAGNOSIS

TR,EATMENT:

Life stgle rnodificalion .lF NOT VERY FIBROBED: Laleral sphinctereclomg (Diet, laxatives, Warm toilet ) , Medical )Chemical sphinctereclomg .lF VERY FIBROSED: Fissureclorng x Side effecls: Fecal lncontinence (LocalAnesthesia, Glgcergl Nitrale, steroids) . Surgerg )Lateral Sphinctereclomg

TREATMENT: BURGICAL

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DEFINITION: Dilated torlous superior hemorrhoidal plexus of veins

g g
V

Congenital mesenchgmal weakness

Morphological Anatomical Factors

(Superior Reclal vein radicals) Exacerbation with slraining, diarrhea, desenlerg

V Pregnancg V Rectal carcinoma V Porlal hgperlension

PIT.ES

UErlair

til

t=pLtuo 1=,lr J+lJ

BLEEDING
@
@

PROLAPSE

PRUR!TIS
ANI

PAIN
(rr comeucATED)

Painless

At end of defecalion @ Bright red @ Separate from stools

$qlE
EXCLUDE CONGENIIAL

g
V

lnspeclion:
4fh degree Prolapse @ 2nd,3rd degree> Wth slraining!
@

@Bleed:ag per rcctum @Thrombosis

MESENCHYMAL
WEAKNESS & CAUSES IF PRESENT

DRE: @ Thrombosed Piles , @ Exclude Cancer reclum

@Fibrcsis @ 9lrangulafion @ Ulceralion & Oanglrene @ Euppuralion @ Portal Pgemia @ Partial reclal prolapee

V Procloscope is done for diagnosis of ld degree piles + exclusion of Cancer reclum

fl
V

Pelvi-abdominal U/S) Hepatic Peri-portal fibrosis, Pelvic Masses lnvesligalions for the cause if suspected

ArrNGAT DEGIFEES OF HITS:

l't
DEGFEE

2"d peGnee

Bpftsriru[ii

GiJl rl.tr iirlg

3'd oeGnee d r?J,!.| gl !.n ll

4th DECFE

1',U Uiro.ri-Fo

re

Ur49l PR

rJl g

c[rNtcArDlAghloe3rs
Prolapsed onlg during defecalion, sponianeous

reduclion

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ffioF
SECoNDAFY

lt.trEFNAtPlr-Esl

I$,2n4 degrees
V
Conservalive treatmenl: ' High fiber diet . Laxalives . Decongeslanlssuppositorg lnjeclion sclerolherapu bU Phenol O.5% in almond Oil SE: pain, abscess Rubber band ligation ) (2'd degree) Selective hemorrhoidal arterg ligation, Pholocoagulalion

Nol relieved wilhin l-2 hrs

g V V
g

t=!

rii

Surgical inlerven{ion

Ut|]tu-lf ullrlo4 tshirJtr Decongeslive lherapu: lherapg: (glgcerine, lanic acid) + Anlibiotics

3'd,4th degrees
HEMMOROIDECTOMY

*antibiotic

Indications:

. . . .

3'd, 4'h degrees Failure of conservalive TTT 2d degree Fibrosis

Anlibiolics, anlicoagulants , evacualion of lhrombus

Antibiolics
Liga{ion of superior rectal veins

of

Inlerno-externalpiles

Complicalions of surgerg : . Pain, urine relenlion

. .

Anal striclure Secondarg Hemorrhage

STAPLED HEMMOROIDECTOMY

DEFINITIoN; Granulomatous lrack opening inlernallg & externallg ETIoLOGY: lnfeclion of analgland ) ANAL ABscEss) Fistula

RElArloN

ro

ANORECTAt RING

CoonSe oF FSn LoOSrRACt<

chrASStnCl(nol.l

ROIE
I
Relationship bet. External Opening & lmaginarg line

beiween lschial tuberosilies

FGgr. To

. .

1:RAD.IS\,hSE mANSVERSE A}TAL UNE ANALUNE

Curved

Common internal opening in midline posterior

. .

Straighi Separate internal openint

sH{tctERlc 70%
Belween iniernal anal sphincler & exlernal

TRA.IS.SH{lcIEHC
SOFRA-SF+|rctrERtC EXTRA-SFHlcIERlC
"Lorrg

anterior"
fistu

Anterior
Secondary openrng Prlmary opening

crypt

lnflammalorg : Crohn's , UC .... Barium enema Neoplasma: Colloid carcinoma .... Cotonoscopg & endoscopg Organism : TB, actinomgcosis, 8.... CXR

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CLINICAL PICTURE: EI SYMPTOMS:

?l,tY

t ltl

. HistorU of peri-anal abscess (pain & swelling) Followed bg Blood purulenl discharge . Pruritis Ani
SIGNS:

. INSPECTION) Exlernal opening!seen as small skin elevation (lf bilateral) lschioreclal abscess) . PALPATION ) lnternal opening mag be felt . PROBE D(AMINATION ... done pre-operalivelg under anesthesia
EI
FOR DIAGNOSIS:

INVESIIGATIONS:

. . .

lnlernal opening! Procloscopg Show the lrack Endoluminal U/S , MRI Fislulograrn ... rarelg done

) )

FOR THE CAUSE:

. . .

Colonoscopg & Biopsg searching for the cause.. Crohn's dis. BA enema Chesl x-rag Tuberculosis

I.AY OPEN

Fislulolomg

OPPERPAtr
fr Senlon wire fr Fibrin glue lf Failed:
PROXIMAL COLOSTOMY

'OtAhR.PAlr LAY OPEN

FislulotomU!

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AD.lo
DEFINITION

M lrg infeclion
sphincter.
ETIOLOGY:

of the anal gland which is present belween internal & exiernal anal

. . '

ORGANISM) E.Coli
ROUTE OF INFECTION

PDF

Direct

Bad

leneral condilion, bad hggiene

spread:

TYPEB:

EI PRTMAR"

*x-:a;fifui.i',til}s
To supralevalor space

supralevalor abscess.

EI SECONDARY to:

. .
CLAS8IFICATION:

: #"m*::*?H":l:r:

Anorectal carcinoma. lrrfeclion of a perianal hemaloma, lhrombosed piles or anal fissure.

Belween the upper

surfaoe of levator ani o lnfection of perianal o Lalera! extension o lnfected piles afler injeclion o lnward spread of inlrasphincteric
abscees.

hemaloma. Downward spread

of irrtercphincteric

ll is actuallg a pefuic abscess secondarg to

appendicitis, salpirgitis or diverticulitis

of

irrlersphinoleric
abscess

abscess LgmPhalic or

blood-borne

CLINICAL PICIURE:

Throbbing pain
COMPLICATIONS:

...f

bg defecation

Redness, holness,lenderness

...in PERIANAL tuoe...

EI FISIULA cornmon with Ecoli INVESTIGAIION9: EI CBC) Leucocgiois U/g) Pus collection in pelvi-recla! abscess M !f fistula occurs) Fislulogram TREATMENI: EI Drainage of abscess (Cruciate incision with trirnming of edges under GA) EI ITT of cause (if associated fissure) lateral sphinclerotomg) EI ITT of complications TTT of ftslula (see before)

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Superior haemorrhoida! arterg is the major arlerial supplg to
anal cana!
The inlernal sphincler muscle lager

of reclum is derived from circular

Puboreclalis is the most imporlanl muscle lo preserve fecal conlinence Weight loss in palient with reclal cancer is suQgeslive of Hepalic metaslasis
Tgpes of Piles: lnternal, Exlernal, lntero-exiernal (MOST COMMON)
MOTHER PILE: occurs at 3,7,11 posilions from SUPERIOR RECTAL VEIN DAUGHTER PILE: occurs in belween.

l.

Young! adult male with dark dense hair presents with foul

smelling discharge from local discomforl.

jusl above midline of anus wilh

2.

PrlonAal altlila Middle aged male or female with historg of conslipation complaing of sharp agonizing pain localized to the anus radiating io the coccgx and genltalia slarls at defecalion and lasls I hour after it and slighr streak of bright red
blood on lhe surface of the stool.

Artal flbsre.
3. Young! adult with hislorg of conslipation (or anu generalized weak mesenchgrne as hernia, W, etc..) presenling with painless passage of bright blood per rectum lhal are separaled frorn the stool with local discharge and purilies and mag somelhing protruding from anus.

/ry Vla
with hislorg of conslipalion presents with sudden severe pain and tense lender bluish swelling around the anus.{ Peri-anal hemaloma.} 5. Young! male with historg of hectic fever and lhrobbing pain presents with purulent discharge and local sourness and purilies ani.
Young! adult

Anal

fbtnla

Peri-analsuppuralion
Peri Ana! fistula

Acule Fissure