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SurgeryNotesDr.YasserAlDuraziNotes+GSnotes

Thyroid:..................................................................................................................................2

Acuteabdomen:.....................................................................................................................9

HepatobiliarySystem:...........................................................................................................11

Pancreatitis:..........................................................................................................................17

ColonCancerandPolyps:......................................................................................................21

Anus:.....................................................................................................................................25

Upper&LowerGIBleeding:..................................................................................................26

Hernia:1...............................................................................................................................29

BreastCancer:.......................................................................................................................34

Carcinoidtumor:...................................................................................................................37

DiabeticFootandUlcers:.......................................................................................................38

Appendicitis:.........................................................................................................................39

Cellulitis:...............................................................................................................................40

SalivaryGlands:.....................................................................................................................41

Sutures:.................................................................................................................................42

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Thyroid:Thyroidhistory/midlineneckswelling.

• Whendidyoufirstnoticethemass?• Progressionofthemass?• Anyotherswellings?• Anyassociatedsymptoms(askaboutcompressionsymptomsdyspnea,dysphagia,etc)

andpain?• Askabouthypothyroidandhyperthyroidsymptoms• Familyhistoryofthyroiddiseases(thyroidcancer,Hashimoto’sandGraves’disease)• Radiationexposure• Anymedications?• Askaboutfever,nightsweatsandweightlosstoexcludeotherddx

Thyroidexamination:NeckInspection:

• Askthepatienttoswallowandprotrudethetongue,askthepatienttheraisehandsovertheheadandmaintainit2-3minutes(withretrosternalmasstherewillobstructiontotheSVC)“Pemberton’ssign”

Palpation:• Palpatethetracheaforanydeviation• Palpatethemass(describeit)• Palpatethelymphnodes

AuscultationforbruitswiththeBELL!PercussionforretrosternalthyroidEyes:

• Lidlag• Exophthalmos• Extraocularmovement

Hands:• Inspectforacropachy/palmarerythema• Palpatethepulse,feelforwarmthandsweating• Askthepatienttoclosehiseyesandextendhisarmsandputapapertolookfor

tremors• Lookforproximalmuscleweakness“Graves”

Lowerlimbs:• Lookforpretibialmyxedema• Reflexes

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NEVERorderthyroidscananduptakeforpatientswithhypothyroidismJItsonlydoneforpatientswithhyperthyroidism!ThyroperoxidaseantibodiesarefoundinpatientswithHashimoto’sdiseaseYouexaminedathyroidnodulewhatdoyoudonext?

• CheckTSH• Doultrasound• FNA

Next?CTiftherewereanyobstructivesymptomsWhatarethecausesofthyrotoxicosis?

• Grave’s• Toxicmultinodulargoiter• Thyroiditis• Exogenousthyroxine• StrumaOvarii

Howtodescribetheswelling?

• Site,size,shape,consistency,mobility,tenderness,anypulsationsandskinchanges.

Approachtoathyroidnodule:• 10-15%ofthyroidnodulesaremalignant• 1cmnodulewithnoevidenceofmalignancynoFNA• >1.5cmbiopsy

ResultsofFNAC:

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Thyroidhormonesynthesis:

WhatcausesexophthalmosinGraves’disease?

• Accumulationofhydrophilicglycosaminoglycans(hyaluronicacidandchondroitinsulfate)

• InfiltrationoftheretroorbitalspacebyTcells• Inflammatoryedemaandswellingoftheextraocularmuscles• Fattyinfiltration

HowtodiagnoseGraves’disease?

• Clinical;exophthalmos(50%),hyperthyroidism,pretibialmyxedema(10-15%)andthyroidbruits(50-90%)

• TSHand+antibodies(TSI)• Increaseduptake

TreatmentoptionsinGraves’:Medical:

• PTU,methimazole(inhibitthyroidperoxidase)(PTUinpregnancy)• Betablockersforsymptomaticrelief• Sideeffects:agranulocytosisandhepatitis

Radioiodineablativetherapy:• AblationwithI131• Drawbacks:exacerbationofexophthalmos

Surgery:• Forpatientswithfailedmedicaltherapy• Poorcandidatesforradioablation(pregnancy,youngpatientsandpatientswithlarge

goiters)• Compressivesymptoms• Cosmetic• Suspicionofmalignancy

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Toxicmultinodulargoiter:

• Nodularuptakewiththyroidscan• SubtotalthyroidectomyRx;radioablation

hasahighrateoffailure• Forasolitarynodule:lobectomy

Secondarycausesofthyrotoxicosis:

• Pituitarytumors• Straumaovarii• Paraneoplasticsyndrome• Drugs:amiodarone

Whatisyourdifferentialdiagnosisforneckswellings?

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ThyroidCancerThemostcommontypeofthyroidcancerisPapillary85%ofallthyroidcancers

Type % Riskfactors Agegroup

Signsandsymptoms

Diagnosis Metastasis Treatment

Papillary 85% RadiationTumormarkerTG

30-40 Painless,dysphagia,dyspnea,hoarness,

FNA/CTandMRI(psommomabodies)

Lymphatic TotalthyroidectomyI131ablationforanyremnantthyroidtissue

Follicular 5-20%secondmostcommon

Dysmorphogenesis 40-50 Painlessmass FNAisuselessweneedtodoalobectomytoknowifitsbenignormalignant

Hematogenous TotalthyroidectomyI131ablationforanyremnantthyroidtissue

Medullary 5-10% MENIITumormarkercalcitonin

50-60 Painfulmass,palpableLN,dysphonia,dysphagia(PAINFUL)DIARRHEA

FNA,amyloidandcheckforcalcitonin

Lymphaticandlocaltotracheaandesophagus

Sporadic:totalthyroidectomyFamilial:TEwithcentralnecknodedissectiondon’tdoI131andfollowuptopatientcalcitonin

Anaplastic(undifferentiated)

1-5% Priorthyroidcancerandiodinedeficiney

60-70 Rapidenlargement,neckpain,hardfixed!

FNA Localspreadaggressive

Debulkingofthyroidandadjacentandtracheostomystructuresanddoxorubicinchemo!

MEN I Parathyroid tumor Pituitary adenomas Pancreatic endocrine (ZES, Insulinomas, VIPomas, glucagonoma) 3P

MEN IIa Pheochromocytoma, Parathyroid hyperplasia, Medullary thyroid cancer, Cutaneous lichen amyloidosis

MEN IIb Medullary thyroid cancer Pheochromocytoma Neuromas/Ganglioneuromas

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Whatarethecomplicationsofthyroidsurgery?Thyroidectomy:

• Recurrentlaryngealnerveinjuryresultinginhoarsenessandiftheinjurywasbilateralitwillresultinairwayobstruction

• Superiorlaryngealnerveinjuryresultinginmonotonicvoice• Hypocalcemiacanbetransientcausedbythemanipulationoftheparathyroidglandsor

permanenthypocalcemiacausedaccidentalremovaloftheparathyroidglands;firstsignofhypocalcemiawillbeparesthesiaofface.Teststodochvosteksignbytappingonthestyloidmastoidforamenwhichwillresultinfacialmusclestwitching.Trouseausign;inflatetheBPcuffupto200mmHgthiswillelicitmusclespasmofthehand.Topreventthetransienthypocalcemia,giveCagluconateafterthesurgery.

• Thyroidstorminpatientswithhyperthyroidism• Hypothyroidism

Woundcomplications:• Hematoma• Seroma• Infection

Generalcomplications:• Anaphylaxis• MI• Pulmonaryembolism• Atelectasis• Pneumonia• UTI

CausesofPost-Opfever:Day 1 • Atelectasis Day 3 • UTI Day 5 • Wound infection Day 7 • DVT / PE

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Youoperatedonapatientwithgravesdiseaseforthyroidectomyseveralhoursafterthesurgerythepatientdevelopeddifficultybreathing,stridorandprogressiveswellingundertheincision.Thisisawoundhematomathiswouldrequirewoundexplorationandairwaycontrol.Ifairwaycontrolisunabletobeobtainedpriortooperatingroom,thewoundshouldbeopenedatthebedside.Topreventsuchcomplicationadrainshouldbeplaced.Whatisatelectasis?Itthecollapseofthealveoli,itisthemostcommoncauseofpost-opfeverinthefirst24hours.Whatkeepsouralveoliopen?

• Positiveendexpiratorypressure(thiswillbelowresultinginthecollapse)• Surfactant

Howtotreatatelectasis?• Chestphysiotherapy• Incentivespirometry• Antibioticsbroadspectrum

Youinducedanesthesia“succinylcholine”inapatienthethendevelopedfever,musclerigidity,tachycardia,hypotension.Whatisyourdiagnosisandwhatdoyoudonext?Malignanthyperthermiawhichisanautosomaldominantdiseasecausedbyryanodinereceptordefectresultinginanimpairedreuptakeofcalciumbythesarcoplasmicreticuluminmuscles.Rx:antidotedantrolene(calciumchannelblocker),hydrateandstopanesthesia.Complications:rhabdomyolysis,death.Whatishungrybonesyndrome?Occursafterthecorrectionofhyperparathyroidism(parathyroidectomy).Increasedboneremodelingunitswillmineralizeandbalancewillbetowardssynthesisofbonesresultinginseverepostoperativehypocalcemiathatmayleadtosymptomsoftetany.

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Acuteabdomen:RLQpain:

• Appendicitis• Cecaldiverticulitis(notcommon)• Meckelsdiverticulum• Perforatedduodenalulcer(Valentino’ssign)• Gastroenteritis• Mesentericadenitis(usuallyafterupperrespiratoryinfectionmoreinkids)• Renalcolic• UTI• Crohn’sdisease(terminalileitis)• Ovariancystrupture,ovariantorsion,PIDandectopicpregnancyinfemales

LLQpain:• RenalcolicandUTI• Sigmoidvolvulus• Diverticulitis(leukocytosis,feverandLLQinoldage)• Colitis• Ovariancystrupture,ovariantorsion,PIDandectopicpregnancyinfemales

RUQpain:• Inferiorlobepneumonia• Hepatictumors,abscessandhepatitis• Biliarycolic,cholangitis,cholecystitis• Retrocaecalappendicitis

LUQpain:• Pneumonia• Splenicinfarction,abscessorrupture

Epigastricpain• Pancreatitis• Duodenal/gastriculcer• Gastritis

Diffuseabdominalpain:• Bowelobstruction(vomitingandobstipation/constipation)• Aorticaneurysm• Enteritis• Mesentericischemia

Medicalcauses:• MI• Sicklecellcrisis• Leadpoisoning• Mittelschmerz• Shingles• DKAoraddisoniancrisis

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• Porphyria

WhatinvestigationsyouwillorderinapatientwithRUQpain?• CBC• LFT• Amylaseandlipase• Urinalysis• U/S

Whichtumorsthatcanresultinjaundice?

• Hepatocellularcarcinoma• Cholangiocarcinoma• Ampullarycarcinoma• Pancreaticcancer

Whatisyourdifferentialdiagnosisforananteriorabdominalmass?• Mesenchymalcyst• Gastriccancer• Leiomyosarcoma• Gastrointestinalstromaltumor

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HepatobiliarySystem:Whatisthefunctionofgallbladder?StorageandconcentrationofbileWhatarethecomponentsofbile?Bileacids,lethicin,bilirubin,cholesteroland90%iswaterConsequencesofgallstones:

• Asymptomatic• Obstructivejaundice• Ascendingcholangitis• Pancreatitis• Biliarycolic• Cholecystitis• Gallstoneileus“pneumobilia”• Gallbladdermucocele>empyema• Mirizzisyndrome(compressiononthecommonhepaticduct)

Indicationsofcholecystectomy:• Immunocompromisedpatients(post-

transplant)• Pediatrics• Porceliangallbladder“increasedriskof

cholangiocarcinoma”• SCD/Thalassemia• Bariatricsurgery• Single2cmstone

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Disease Cholecystitis Choledocholithiasis Cholangitis Obstruction of the cystic duct by gallstone

Common bile duct obstruction by gallstone

Ascending bacterial infection of the biliary system associated with CBD obstruction

Signs and Symptoms

RUQ pain, fever, nausea, vomiting and positive Murphy’s sign

Epigastric pain, jaundice, recurrent attacks of acute pancreatitis

Charcot’s triad: fever, jaundice and RUQ pain. Reynold’s pentand: charcot’s + CNS symptoms and septic shock

Diagnosis -Labs: increased WBC -U/S: gallbladder wall >4 mm, pericholecystic fluid and stone in the gallbladder. -HIDA scan: non-filling of the gallbladder (if U/S not diagnostic)

-Labs: increased bilirubin, alk phos direct bilirubin -ERCP

-Lab: increased bilirubin, alk phos direct bilirubin -U/S: dilatation of common and intrahepatic bile ducts -ERCP -Blood culture

Treatment Cholecystectomy ERCP ERCP/PTC/T-tube Imaging

ClinicalVingnette:A30yearsoldfemalepresentedtotheA&Ewithahistoryofpainradiatingtothetipofshoulder,nauseaandvomiting,RUQtenderwithpositivemurphysign.AcutecholecystitisNextstep:

• CBCwithdifferentialdiagnosis15kWBC• Amylaseandlipase(-)• LFTandbilirubinnormal• Electrolytes

Radiology:U/Swillshowthickwalls>5mm,edema,stone,pericholecysticfluid.Rx:IVfluids,NPO,analgesia(TramadolorPethidinewithbuscopan),Antibiotics(ceftriaxoneandFlagyl)Whendoweadmitthepatientforcholecystectomy?Waituntil6weeks,askthepatienttoavoidfattyfoodetcthendoit.

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A40-year-oldmalepresentedtotheA&Ewithahistoryofnausea,vomitingandepigastricpainradiatingtotheback.WBCwerehigh,lipaseandamylasewerehigh.U/Sshowedastoneinthegallbladderanddilatedcommonbileduct.AcutepancreatitisRx:IVhydration,NPO,analgesia“antibioticsarenotindicatedinpancreatitis”NextforthestoneintheCBDdoERCPtoremovethestonethendocholecystectomy.A60yearoldfemalepresentedtotheA&EwithahistoryofRUQpain,fever,jaundice,andherbloodpressurewas80/40.WBClevelswerehigh,increasedbilirubin,alkalinephosphataseandLFT.Ascendingcholangitiswithreynold’spentad(charcotstriad+shock+alteredmetalstatus)Rx:U/Sistheinitialstudy;dilationofthecommonandintrahepaticductsalongwithgallstones,thickedematousgallbladderwall.Definitiverx:ERCP+antibioticsPatientpresentedtoyouwithahistoryofincreasedpain,feverandpalpabletendermassbelowtheliver.Gallbladderempyema,doU/Sguideddrainagewithantibiotics.Geriatricpatientpresentedtoyouwithahistoryofvomiting,abdominaldistentionandpainwithconstipation.Patienthashistoryofpreviousgallstones.GallstoneileusInvestigations:CXR,abdominalXraysupineanderect(airinthebiliarytree)ConfirmitwithCTscanRx:laproscopicremovalofthestonewithcholecystectomy.Patientpresentedwitha3dayhistoryofRUQpainwithnausea,vomitingandpositiveMurphy’ssign.WBClevelswereslightlyelevated,U/Sshowednostones.AcalculouscholecystitisDiagnosis:HIDAscanRx:admit,NPO,Antibiotics+cholecystectomyItpresentsin10%ofcasesofcholecysitis.Riskfactors:ICUpatients,trauma,burns,sepsisandTPN.Whatarethecomplicationsoflaparoscopiccholecystectomy?

• Injurytothecommonbileduct(diagnosedwithERCP)• Injurytotheliver• Injurytothebloodvessels• Trocarsitehernia

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Whatarethecausesofperitonitis?Classification:Localized:appendicitis,diverticulitis,cholecystitis,salpingitisGeneralized:

• Chemical:perforationofstomach,smallbowelorgallbladder

• Bacterial:intra-abdominalabscess,fecalcontaminatedduetobowelperforation,trauma,surgicalspillageoranastomoticleakafterbowelsurgery

OR• Primary: spontaneous bacterial

peritonitisorsecondarytoperitonealdialysis

• Secondary:causedbyaperforatedviscus• Tertiary:complicationafterasurgery(abscess)

Whatarethecausesofairunderdiaphragm?

• Perforation• Postlaproscopic/laparotomy• Typhoid(Causingsmallbowelperforation)• Abscessunderdiaphragm(C.perfringens)• Penetrationofthediaphragm

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ObstructiveJaundice:Whatisjaundice?Yellowishdiscolorationoftheskinandmucusmembraneswithhyperbilirubinemia>3g/dLCausesofhyperbilirubinemia:

• Pre-hepatic:anycauseofhemolysis(SCD,G6PD,spherocytosis)• Hepatic:hepatitis,cirrhosis,enzymesdeficiency• Post-hepatic:obstructivejaundice

Whatarethecausesofobstructivejaundice?Proximal

• Cholangiocarcinoma• Lymphodynopathy• Cholangiocarcinoma• Sclerosingcholangitis• Gallstones• Parasite• Postsurgicalstricture

Distal• Choledocholithiasis• Pancreaticcancer• Pseudocyst• Pancreatitis

Whatiscourvoisier’ssign?Jaundicewithapalpablenon-tendergallbladderseeninpatientswithpancreaticheadcancerWhatisyourddxofpalpablegallbladder?

• Pancreaticcancer(non-tender)• Gallbladderempyema(tender)

Historytakinginpatientwithjaundice?Makesuretocoverallthepointsbelow

• Theonset,durationandprogression• Changeinstool/urinecolor• RUQpain• Itching?(patientPBChavepruritusfollowedbyjaundice)• Flulikesymptomsandfever(hepatitis)• Historyofanyhemolyticanemia• Weightlossandanorexia(cancer)• Useofanymedication• ParenteralexposuretoIVdrugsortransfusion• Tattoosandsexualhistory• Recenttravel

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Whatinvestigationyouwillorderinapatientwithjaundice?

• CBC• Liverfunctiontest

Livercellnecrosis:ALT Specific enzyme for liver necrosis

ALT>AST; viral hepatitis AST AST>ALT; indicates alcoholic hepatitis

Cholestasis:

GGT Intrahepatic or extra-heptic obstruction to bile flow

ALP Synthesized by the bile duct epithelium

• Serumalbumin,PT,BUN,ammoniaRandomtests:SerumIgM PatientswithPBCAnti-mitochondrialantibody

PBC

Anti-smoothmuscleantibody

Autoimmunehepatitis

ANA Autoimmunehepatitisa-fetoprotein HepatocellularcarcinomaOthersinvestigations:

• U/S• CTscan• Percutaneoustrans-hepaticcholangiogram(goodfor

proximalbiliarytree)• ERCP(distalpartofbileduct)• EndoscopicU/Sguidedbiopsy(forpancreaticcancer)

EndoscopicU/S

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Pancreatitis:Whatisthefunctionofthepancreas?IthasanendocrineandexocrinefunctionEndocrine:

• Insulinproducedbythebetacells• Glucagonbyalfacells• Somatostatinbydeltacells• VIP

Exocrine:• Lipase,amylase,trypsin,phospholipase,protease• Theseenzymesareallsecretedintheinactivezymogenandtheygetactivatedby

enterokinaseintheduodenum.• Iftheygotactivatedbeforethiswillresultintheauto-digestionofthepancreas

Acutepancreatitis:Itistheinflammationofthepancreascausedbyparenchymalauto-digestionbyproteolyticenzymes.Extra-abdominalsymptomsofacutepancreatitis

• Shock• ARDS• Uveitis• Pleuraleffusion

Whatarethecausesofacutepancreatitis?

• Alcohol• Gallstones• hypercalcemia,hyperlipidemia• Druginduced(Azathioprine,cimetidine,steroids,metronidazole,methyldopa,valporic

acid,sulfasalazine,TMP-SMX,thiazides)• ERCP(in5%)• Scorpionvenom(Tityustrinitatis)• Infections(CMV,EBV,Coksakivirusandmumps)• Trauma• Congenital(divisum)• Autoimmune• Idiopathic

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A40yearsoldmalepresentedtotheA&EwithahistoryofsuddenepigastricpainradiatingtotheshoulderafterafattymealDdx:

• Acutecholecystitis• Acutepancreatitis• PUD/Gastritis• InferiorwallMI• Lowerlobepneumonia

ThepatienthadhighlipaseandamylaseWhattodonext?

• Admit• Hydrate• NPO• NGtube• Analgesia

Lipaseismoresensitiveandspecifictoacutepancreatitisthanamylase(foundinsalivaryglands,smallbowel,ovaries,testesandskeletalmuscles)

• Highamylase/lipasedoesnotreflecttheseverityofpancreatitis• Forustodiagnoseacutepancreatitisamylaselevelsshouldbex3-4the

upperlimits• OtherlabtestisCRPafter48hrsif>150thisindicatesapoorprognosis• CTscanisthediagnostictestofchoiceinacutepancreatitis(willshowedematous

gland)Whatarethecomplicationsofacutepancreatitis?

• Pseudocyst• Pancreaticnecrosis• Pancreaticabscess• Phlegmon• Pseudoaneurysmofthesplenicartery

Whatischronicpancreatitis:Irreversibleparenchymalfibrosis,destructionandcalcificationleadingtothelossoftheendocrineandexocrinefunctionofthepancreas.Whatisthemostcausesofchronicpancreatitis?

Alcohol

Howwillpatientswithchronicpancreatitispresent?• Recurrentconstantepigatricandorbackpain• Malabsorption,steatorrhea• Type1diabetes

LEGAL&C-HOBBS

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Howtodiagnosepatientswithchronicpancreatitis?

• Fecalfatanalysis• PancreaticcalcificationonXray• ERCPorMRCPwillshowchainoflake

pattern–areasofdilatationandstenosis• CT:showsglandsenlargement/atrophy

andcalcificationsHowtotreatpatientswithchronicpancreatitis?

• non-surgical:enzymereplacementtherapy&insulin• surgical:celiacplexusblockforpainrelief/pancreaticojejunostomy

Whatarethecomplicationsofchronicpancreatitis?

• Pancreaticabscess• Pancreaticfistula• Hemorrhagicpancreatitis• Pancreaticcancer

Cases:A40yofemalepresentedwithanepigastricpainof2days’durationradiatingtothebackwithhighlipaseandamylase.Ultrasoundshowedastoneinthecommonbileduct.Thisisacaseofbiliarypancreatitis,treatthepatientjustlikethetreatmentofanypancreatitiswithERCPandlaparoscopiccholecystectomyafter6weeks.A40yofemalepresentedwithasevereepigastricpainradiatingtothebackwithnauseaandvomiting,U/Sshowedbulkyheadofpancreas.Thepatienthadseveralattacksofsuchpainbeforeshealsohasrecurrentkidneystones.CheckthepatientCa+levels,ifthelevelswerehighthencheckforthePTHlevels(hyperparathyroidism).ToconfirmhyperparathyroidismdoU/Sandsestamibiscan.Sheprobablyhadtherecurrentattacksofpancreatitisduetohypercalcemiawhichiscausedbyprimaryhyperparathyroidism.A50yearoldalcoholicmalepresentedwithsevereepigastricradiatingtothebackwithhighlipaseandamylase.NormalU/S,CTshoweddilatedheadofpancreas,Ca+normal.Youstabilizedthepatientandatnightthepatientwasverydisoriented.Deliriumtremensduetoalcoholwithdrawal.TreatthepatientwiththiaminandbenzodiazepinestopreventWernickeencephalopathywhichiscausedbythiamindeficiency.A40yearoldfemalepresentedwithepigastricpainradiatingtoback.BMIis38,U/SandCa+werenormal.Whatdoyouhavetoordernext?LipidprofileDON’TFORGETIT!

Sestamibiscan

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A40-year-oldfemalepresentedwithepigastricpainhighlipaseamylasealltestswerenegative(U/S,Ca+,lipids)YouhavetoruleoutautoimmunepancreatitiswithanendoscopicU/Sguidedbiopsy(withshowlymphocyticinfiltration)treatherwithsteroidsifyouconfirmedthediagnosis.A9yearoldmalepresentswithonandoffepigastricpainradiatingtotheback.Congenitalpancreatitis(divisum)diagnosiswithMRCPA30yearoldfemalehadahistoryofacutepancreatitis2monthsagoandnowshepresentswithamassandearlysatiety.Pancreaticpseudocyst;it’sacollectionofpancreaticfluidsurroundedbyawallwithnoepithelium.DiagnosedwithCTscan,inmostpatientsthepseudocystwillresolvespontaneouslywithin6weeksApproachtopancreaticpseuduocysts:Ifsymptomatic:doU/SorCTguidedexternaldrainageORcystgastrostomyorcystjejunostomy(Roux-en-Ycystjejunostomy)Ifasymptomatic:>6cmtreatasmentionedaboveif<5cmcanresolveonitsown*externaldrainageisnotrecommenditcancreateapancreaticcutaneousfistulaApatientpresentedwithalcoholicpancreatitisandwasshiftedtoICU,CTscanshowedpancreaticnecrosis,hisWBCcountswerehighandhehadfever.Thisisacaseofnecrotizingpancreatitis,treatthepatientwithbroadspectrumantibioticthendoaCTguidedaspirationofpancreaticfluidandsendforculture.Ifthepatientdevelopedanabscessasacomplicationofnecrotizingpancreatitiswaitfor2-3weekstoseetheareaofdemarcationandthenresecttheaffectedarea.

Acute pancreatitis Chronic pancreatitis Onset: severe epigastric pain radiating to back with nausea vomiting

Recurrent episodes of epigastric pain, weight loss, diabetes and steatorrhea

Causes: GET SMASHED Gallstones(40%), ethanol(30%), tumors, scorpion stings, mycoplasma or mumps, autoimmune, surgery or trauma, hyperlipidemia or hypercalcemia, embolic or ischemia and drugs

Alcohol (70%), pancreatic divisum

Labs: high amylase and lipase x 3-4 Low fecal elastase

Colon cutoff sign and sentinel loop

Pancreatic calcifications ERCP: chain of lakes

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Whatisthemechanismofhypotensioninpancreatitis?Inflammationandcytokinestormcauseendothelialinjuryandincreasedpermeabilityintheperipancreaticvasculature,leadingtofluidleakageintotheretroperitonealspace.Thecytokinestormalsocausesmassivevasodilation.

ColonCancerandPolyps:Whatarethetypesofcolonicpolyps?Benign:inflammatory,lymphoid,hyperplastic,hamartomatousPre-malignant:adenomatous(tubular,tubulovillousandvillous”40%riskofmalignancy”)Howwouldapatientwithcolonicpolypspresent?

• Asymptomatic• Melena/hematochezia• Mucus• Changesinbowelhabits• Largebowelobstruction

DiagnosisismadewithcolonoscopyofcRx:colonoscopicresectionWhataretheriskfactorsofcoloncancer?

• Age• FamilyhistoryofcoloncancerorFAP• Lowfiberdiet,highfatdiet• IBDespUC(riskincreases1-2%everyyearafter2yearsofthedisease)

Signsandsymptomsofcoloncancer:

Itwilldependonthelocation• Rightside:occultbleeding,melenaandanemia• Leftside:alteredbowelhabits,rectalbleeding,largebowelobstruction(patientwill

presentearlierthanrightsidedcancer)• Bothwillhaveanorexiaandweightloss

Howtodiagnosecolorectalcancer?

• Colonoscopy• Chest,abdomenandpelvisCT(Staging)• Bonescan(staging)• CEAisatumormarkerusedforfollowupaftertreatmentnotdiagnosis

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A50-year-oldmanpresentedwithahistoryofPRbleedingof2weeksPMHofhypertension.Whatwillyouask?

• Quantityofblood• Color?Darkorfresh• Timingofbleeding?beggingofstoolorattheend• Alteredbowelhabits• Weightloss,anorexia?• Signsandsymptomsofanemia?• Familyhistoryofcolorectalcancer?(askaboutalltheriskfactors)

Metastasisofcoloncancer:liver,bonesandlungsDukesstagingofcolorectalcancer

A Tumor confined to submucosa 5 years survival 90-95%

B Invasion to the muscle wall 85% C Invasion to serosa

C1: no lymph nodes spread C2: lymph nodes spread

30%

D Distant metastasis (liver, lung and bones)

<1%

Coloncancerstaging:

Stage I T1/T2 Stage II T3/T4 Stage III Any T/N1/N2 Stage Vi Any T any N M1 Screeningforcolorectalcancer:Recommendedscreeninginadultswithaveragerisk,beginningattheageof50untilage75.

• Colonoscopyevery10years• Flexiblesigmoidoscopyevery5years+FOBTevery3years• Fecaloccultbloodtestxannually

Screeninginpatientswithafirstdegreefamilymemberwithcolorectalcancer:Thesepatientsshouldbeginscreeningatageof40or10yearspriortotheonsetofcolorectalcancerinthefirstdegreerelative.Theyshouldcontinuescreeningevery5yearsafter.

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Surgerybasedontumorlocation:Cecum:

• Righthemicolectomy• Resectionoftheileum,cecumascendingcolon

andpartoftransversecolon&dividetheileocolicartery.

Ascendingcolon:• Righthemicolectomy

Hepaticflexure:• Extendedrighthemicolectomy• Resectupto2/3ofthetransversecolon&divide

theileocolic,rightcolic,rightbranchofmiddlecolicartery.

Descendingcolon:• Lefthemicolectomy&dividetheleftcolicartery

Sigmoid:• Sigmoidcolectomyanddividethesigmoid

branchesRectum:

• Upperthird:anteriorresectiondiversionileostomy(temporary)• Middlethird:lowanteriorresectionwithdiversionileostomy(temporary)• Lowerthird:abdominopernealresection(removeanus,rectumandpartofthesigmoid)

withpermanentcolostomyTumormarkersCA-15-3Estrogenandprogesteronereceptors

Breastcancer

CA-19-9 PancreaticcancerCEA Coloncancera-fetoprotein HCCFamilialadenomatouspolyposis:ItsAD,patientwillhavehundredsofpolypsitscausedbyabnormalgeneonchromosome5,APCgenerx:totalcolectomyGardnersyndrome:FAP+osteomas,epidermalcystsandfibromatosisTurcot’ssyndrome:FAP+gliomasandCNSneoplasms

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*alwaysconsidercoloncancerinoldpatientswithunexplainedmicrocyticanemia.

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Anus:Whatisafistula?Abnormalopeningandconnectionbetweentwoepithelizedhollowspaces.Whatarethetypesoffistula?

• Perianal• Enterocutaneousfistula(inIBD)• Enterovesicalfistula• Enteroentericfistula• Enterovaginalfistula• Tracheoesophygealfistula(congenital)• AVfistula

A31yomalewithhistoryofCrohndiseasepresentswithsevererectalpainthathasprogressivelyincreasedlastnight.P/Edemonstratesasmall,erythematous,welldefined,fluctuant,subcutaneousmassneartheanalorficie.Anorectalabscessisthemostlikelydiagnosis.ItisacollectionofpussurroundedbyacavitycausedbyaninfectionarisinginthecryptoglandularepitheliumliningtheanalcanalRx:incisionanddrainagewithantibioticsS.aureuscommonlycausesabscess.A25yofemalewithhistoryofIBSwithconstipationpresentswithseverepainwithpassingstool.Shenotesthatthepainissosevereandisafraidtohaveabowelmovement.Thestoolsarehardandcoveredwithbloodstreaks.ThemostlikelydiagnosisisananalfissureWhatisanalfissure?Painfultearsintheanalmucosabelowthedentatelineinducedbyconstipationorexcessivediarrhea.Patientswillpresentwithpainfuldefecation,brightredPRbleeding,lacerationon6and12o’clockposition.Patientswithchronicanalfissurewillhavehypertrophyofthesurroundingskinandsentinelpileorskintag.Whataretheoptionsfortreatinganalfissures?

• Sitzbath• TopicalnitroglycerinorCCBorinjectionofbotulinumtoxinintotheanalsphincter• Fibersupplements• Bulkingagents• Lateralinternalsphincterotomyordilationforchroniccases

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Upper&LowerGIBleeding:Rectalbleedinghistory:

• Onset• Color• Amount• Pain?• Withstoolorafter• Meds(aspirin,NSAIDS,warfarin)• Weightlossorlossofappetite• Symptomsofanemia• AskaboutIBD,diverticulosisandotherrisks

HowwillyoumanageapatientwithmassivePRbleeding?

• ABC• 2lVlines;Ringerlactate• NGT• bloodcross-match• Foleycatheter

Whatdoyoudonext?

• Endoscopy+colonoscopyWhatisalowerGIbleeding?AnybleedingdistaltotheligamentofTreitz(betweentheduodenumandjejunum)WhatarethesymptomsoflowerGIbleeding?

• Hematochezia• Melena• Anemia• Shock

WhatarethecausesoflowerGIbleeding?Rectalcauses:

• Fissures• Hemorrhoids• Solitaryrectalulcer• Analtumor• Trauma

Other:• Mostcommon:diverticulosisandvascularectasia(massivelowerGIbleeding)• Coloncancerandpolyps• Ischemiccolitis

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• IBD• Meckel’sdiverticulum• Infectiouscolitis• Smallboweltumor• Radiationenteritis• Meds:aspirin,warfarinandclopidogrel

WhatarethecausesofupperGIbleeding?

• Duodenalorgastriculcer• Acutegastritis• Esophagealvarices• Mallory-Weisstear• Gastriccancer• Boerhaave’ssyndrome• Aortoentericfistula• Dieulafoy’sulcer(submucosaldilatedlargearterioles)• GIST• AVmalformation

HowwillyoumanageapatientwithanupperGIbleeding?

• Sameasaboveplusbedsidegastroscopy• Ifvaricealbleeding;octerotide+bandligationOR

injectionofepinephrineORsclerotherapyifbleedingcontinued,considerballoon(Sengstaken-Blakemoretube)IFSTILLthepatientisbleedingthengoforesophagealdevascularizationandtransection.

Case:A70yearoldmalepresentedwithupperGIbleeding,thepatientistakingNSAIDS.HisHbwas5g/dl

• ABC,start2IVlines,bloodcross-match,transfuse1-2units(hisHbisbelow7)• Dobedsideendoscopeyousawanulcer

• Ifshallow(lowriskofrebleeding)• Clot(5-10%risk)• Visiblebloodvessel(upto50%)

• Rx:clipping,epinephrine,cauterizationThepatientrebledwhattodonext?

• Endoscopyagainsamerxifbleedingwasnotcontrolledwiththeabovemeasuressurgicaloptions(oversew/distalgastrectomy)

• Ifthepatientcantundergosurgerythentheotheroptionwouldbeembolizationbyinterventionradiologyofthegastroduodenalartery

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A15yearoldmalepresentstotheA&Ewithhistoryofbleedingforfewdays,hisHbwas5g/dLInvestigationstoidentifythebleedingsite?

1. Colonoscopy+PT/PTT(ifnormalthennext)2. TaggedRBCscan>0.5mL/min3. Angiography>1ml/min

Ifnormalthen:4. Capsuleendoscopy(swallowfor24hours)5. Meckl’sscan6. Retrogradeantroscopy7. Lastoption>laproscopicopening

Upper Vs Lower GI Bleeding Upper Lower Location Proximal to ligament of

Treitz Distal to ligament of Treitz

Common causes

Gastritis, PUD, varices Vascular ectasia, diverticulosis, colon cnacer, colitis, IBD, hemorrhoids

Stool Tarry, black stool (melena)

Red blood in stool (hematochezia)

NG aspirate Positive for blood Negative for blood

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Hernia:1Whatisthedefinitionofhernia?It’saprotrusionofaviscusthroughanabnormalopeninginthewallofacavityinwhichitscontained.Typesofhernia:Internal:

• Diaphragmatichernia• Brainstemherniation• Internalbowelherniation

External:• Inguinalhernia• Femoral• Obturator• Lumbar• Spigelianhernia• Umbilical• Incisional• Richter’shernia• Littershernia• Maydl’shernia• Epigastrichernia

Whatisthecardinalsignofhernia?CoughimpulseCausesofhernia:Congenital:patentprocessvaginalis,collagenvasculardisease“Ehlers-Danlossyndrome”andprematurityAcquired:chronicconstipation,chroniccough,ascites,pregnancy,liftingheavyobjects,BPH,weaknessintheabdominalwall,previoussurgery,trauma.Herniahistory:•Whendidyoufirstnoticethelump?•Askabouttheprogressionofsize?•Anyotherswellings?•Associatedsymptoms?•Askthepatientaboutthecause?Andaskabouteachriskfactorfromabove.Complicationsofhernia:•Incarceration•Strangulation•Obstruction

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Whatistheinguinalcanal?It’sa4cmfibrouscanalextendingfromthedeepringtothesuperficialringandtheboundariesare:Anterior:aponeurosisofthemedial2/3externalobliqueandlateral1/3internalobliquemusclePosterior:mediallyconjointtendonlaterallytransversalsfasciaRoof:archingfibersoftransversemuscleandinternalobliqueFloor:inguinalligamentandlacunarligamentContentsoftheinguinalcanal:

• Females:roundligamentandilioinguinalnerve• Males:spermaticcordandilioinguinalnerve

Hasselbach’striangle:

• Medially:lateraledgeoftherectusabdominis• Laterally:inferiorepigastricvessels• Inferiorly:inguinalligament

The3ruleofspermaticcord:Whatarethe3nervesinspermaticcord?• Genitalbranchofthegenitofemoral• Cremastericnerve• Sympatheticnervefibers

Whatarethe3arteries?•Testicularartery•Arterytovas•ArterytocremastericWhatarethe3veins?•Pampiniformplexus•Cremastericvein•VeinofvasWhatarethe3structurespassingintheinguinalcanal?•Lymphatics•Vasdeferens•PampniformplexusWhatistheconjointtendon?Formedbythelowerpartofthecommonaponeurosisoftheinternalobliqueandtransversesabdominismuscleanditsinsertedintothepubictubercleandcrest

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Howtodifferentiatebetweeninguinalherniaandfemoralhernia?Relationtothepubictubercle,femoralherniawillbebelowandlateralwhileinguinalherniaswillbeaboveandmedial.Whatisrichter’shernia?Whenonlypartoftheintestinewallcircumferenceintheherniaitmaystrangulatewithnoobstruction,seeninfemoralandobturatorhernia.WhatisMaydl’shernia?WtypeofintestinalloopherniatesandmystrangulatewiththegangrenouspartbeinginsidetheabdomenwithoutthenoticingofthegangrenouspartWhatarethecomplicationsafterherniasurgery?

• General:hematoma,seroma,woundinfectionanddehiscence• Specific:scrotalhematoma,injurytotesticularartery,injurytoilioinguinalnerve,

chronicpainduetoentrapmentofilioinguinalnerveandrecurrenceWhatisthedifferencebetweenherniorrhaphyandherniotomy?•Herniorrhaphyistherepairofwallwhileherniotomyistheexcisionofthesacwithnorepairofwall,itsusuallydoneinpediatricpatients.Explainhowmeshisusefulinthemanagementofhernia?•Itincreasesthefibroblastactivityandhencewillstrengthenthemuscles.Whataretypesofmesh?

• Mersilenemesh• Prolenemesh

Whataretheprinciplesofmanagementinpatientswithhernia?•Opentissuerepair“tensionrepair”:Bassini,Shouldice,MacVay(femoralhernia)•Tensionfreerepair:usingaprostheticmesh(Lichtenstein’srepair)hasleastrecurrencerate•LaproscopicrepairWhendowerepairthehernialaproscopically?Bilateralorrecurrent

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Whyarefemoralherniasmorepronetoincarceration?Bowelenteringafemoralherniapassesdownthenarrowfemoralcanalbecauseofthefemoralringwhichisveryrigid.Thusthefixedneckoffemoralherniaisatahigherriskofincarcerationthanothertypes.Whatistheringocclusiontest?Weoccludethedeepinguinalringandthenaskthepatienttocoughifthemassisnotseenmedialtothedeepringthenthisisindirecthernia(positiveocclusiontest)IFweoccludedthedeepringandexpansileimpulseoncoughisseenmedialtothedeepringthenitsdirectinguinalhernia(negativeocclusiontest)Whatisthedifferencebetweenepigastricherniaandotherhernias?ProtrusionofsubcutaneousfatintheopeningoftheherniaWhatisyourdifferentialdiagnosisforgroinswellings?

Malformation Undescended testicle, varicocele, hydrocele, hernias, saphena varix

Infectious/inflammatory Lymphadenopathy, abscess, lymphogranuloma venereum

Neoplastic Lymphoma, lipoma, metastatic cancer Traumatic Hematoma, femoral aneurysm or

pseudoaneurysm

Indirect hernia Direct hernia Pass through inguinal canal Caused by patent processus vaginalis

Bulge from the posterior wall of the inguinal canal caused by weakness of abdominal wall

Can descend into the scrotum Can not descend into the scrotum Lateral to the inferior epigastric vessels Medial to the inferior epigastric vessels The defect is not palpable The defect may be felt in the abdominal wall Common in children and young adults Common in old age + occlusion test Negative occlusion test Umbilicalhernia:Prevalentininpediatricpopulationandcommonwithcongenitalhypothyroidism.Inchildrenmostareasymptomaticandclosespontaneouslywithnointervention(indicationsforsurgery:childage>4years,defectsize>2cmindiameter,strangulationorprogressiveenlargementafter1-2yearsofage).Inadults,umbilicalherniasareassociatedwithincreasedintra-abdominalpressure(pregnancy,ascitesandweightgain).

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Epigastrichernia:Thisisusuallyasmallprotrusionthroughthelineaalbaintheupperpartoftheabdomen.Oftentheherniaconsistsofextraperitonealfatonlybutitmaycontaintheomentumorsmallbowel.Thistypeofherniacanbeextremelypainfulbecauseofthetrappingandischemiaoftheextraperitonealfat.Rx:simplesutureofthedefectwithnon-absorbablesutures.Clinicalvignettes.You’vedoneasurgeryona70yearoldmaleinthemorningandatnighthecomplainedofpaininthesuprapubicarea.Whatdoyoususpect.Urinaryretention,canbesecondarytoBPHRx:catheterPatientcametoyourclinicweeksaftersurgicalrepairofherniacomplainingoflossofsensationinthemedialthighandlateralscrotum.InjurytotheilioingunialnervePost-surgicalpatientcamewithchronicpainafterherniarepair.Entrapmentoftheilioingunialnerve“chronicpainsyndrome”Rx:cutthenerveA30-year-oldmalepatientcomplainedofseveretesticularpainafterherniarepairwhatdoyoususpect?Injurytothetesticularartery,doduplexultrasoundtoconfirmyourdiagnosisifnoperfusionwasdetecteddoorchiectomytosavetheothertesticlebecauseantibodiescanbeformedagainstitiftheaffectedtesticlewasnotremoved.

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BreastCancer:Whataresymptomsofapatientwithbreastcancer?

• Pain• Swelling• Nippledischarge• Skinchanges• Dimpling/nippleretraction• AsymptomaticThemostcommonpresentationofbreastcancerisapainlesslump

Whendowestartscreeningforbreastcancer?• Breastselfexaminationattheageof20shouldbepreformedmonthlydaysfollowing

themenstrualcycle• Clinicalorphysicianbreastexamination• Screeningmammography>attheageof40annually(craniocaudalandmediolateral)

Whataretheabnormalfindingsinamammogram?

• Stellate,massandmicrocalcifications

Whentoscreeninahighriskpatient?5yearsearlierfromthediagnosisofafamilymemberA30yearoldpatientpresentedbreastpain.Whatquestionsyouwillask?

• Relationofpaintomenstrualcycle• Allthecharactersofpain• Anydischarge• Askaboutriskfactorsofbreastcancer

Anypatientpresentingwithabreastmassdothetripleassessment:

• History/physicalexamination• MamoorU/S• FNA

Whatisyourddxofbreastpain?

• Fibrocysticdisease• Inflammatorybreastcancer• Advancedbreastcancer• Mastitis• Breastabscess• Fatnecrosis

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Whatisyouddxofabreastlump?• Fibroadenoma(mobile,smoothandcircular)• Fibrocysticdisease(tender,bilateralandfluctuatewithmenstrualcycle)• Abscess• Galactocele• Cancer• Chronicgranulomatousmastitis

Ddxofbloodynippledischarge?

• Intraductalpapilloma• Paget’sdisease• Fibrocysticdisease• Intraductalcarcinoma

Yellow/green:• Abscess• Fibrocyticdisease• Ductectasia• Galactocele

White/milky:• Hyperprolactinemia

Whataretheskinchangesseeninbreastcancer?

• Dimpling• Peaud’orange• Rednessofskin• Fungatinglesion(T4)

Whatarethegenesrelatedtobreastcancer?

• BRCA1andBRCA2• K-167• B10andB51

Only5-10%ofallbreastcancersareassociatedwithaninheritedmutationWhataretheriskfactorsofbreastcancer?

• Age• Earlymenarcheandlatemenopause• Nulliparityorfirstpregnancy>30• Obesity• Atypicalhyperplasia• OCPorHRT• Smoking• Gender• Geneticpredisposition

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FNACresultsinbreastcancer:• C1:inadequate• C2:benign• C3:atypical• C4:suspicious• C5:malignant

Wheredoesbreastcancermetastasize?

• 2B2L• brain,bone,liver,lungsandadrenals.

Staging:

• CTabdomenandchest• Bonescan

Treatment:

StageI,II:simplemastectomy+chemotherapyORlumpectomywithradiation+chemoStageIII:mastectomywithaxillarylymphnodedissectionStageIV:systemicandpalliativetreatment

Complicationsofaxillarylymphnodedissection:• Injurytolongthoracicnerve(wingedscapula)• Lossofsensation• Seroma

TNMclassificationofbreastcancer:T0:Notumor N0:noregionallymphnodesmetastasis M0:nodistantmetastasisTIS:CIS N1:metastasistolevelI,IIaxillaryLN

ipsilateralmovableM1:distantmetastasis

T1:<2cm N2:metastasistoipsilateralLNfixedlevelIandII

T2:2-5cm N3:metastasisipsilateralinfraclavicularLNorsupraclavicularLNT3:>5cm

T4:metastasisWhatismondor’sdisease?Itssuperficialthrombophlebitisoflateralthoracicveinthepatientwillpresentwithacutepainintheaxillaorsuperioraspectoflateralbreast.Confirmthediagnosiswithanultrasound.

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Sentineallymphnodebiopsy:Weinjectaradioactivesubstanceandbluedyetolocatethepositionofthesentinellymphnodes.Weuseadevicethatdetectsradioactivitytofindthesentinealnode,onceitslocatedwemakeasmallincisionandremovethenode.Itsthensendtopathologyifmalignantcellsifsentinealnodeispositiveaxillarydissectioniscompletedifsentinealnodeisnegativeaxillarydissectionisnotperformed.Whatisthetumormarkerofbreastcancer?CA-125andCA-15-3(notspecific)Whatisyourtreatmentforfibrocysticdisease?Initial:NSAIDS,vitaminEandwarmcompressionandavoidcaffeineandtobaccoNext:primroseoil(3-6months)Severe:danazoleandtamoxifenWhatisthetreatmentforfibroadenoma?Observeifasymptomaticsize<2cm.If>2msurgicalexcision.Apatientwithhadnolumpnopaintheyonlyfoundmicrocalcificationsshefoundtohavewhattodonext?Takeastereotacticbreastbiopsyandsendforpathology

Carcinoidtumor:ItsisamalignanttumoroftheenterochromaffincellsthatmostcommonlyoccurintheappendixfollowedbythesmallintestinesandrectumSignsandsymptoms:

Ø SlowgrowingsousuallyasymptomaticatfirstandusuallyfoundincidentallyØ Symptomatic:vagueabdominalpainisthemostcommonsymptomØ Intermittedobstructionin25%ofpatientsØ Rectalbleeding(rectalcarcinods),painandweightloss

Carcinoidsyndromeonlyfoundin10%oftotalpatientswithacarcinoidtumorØ Duetotheproductionofserotonin,bradykininortryptophanbythetumorand

exposureofthebodytotheseproductsØ Cutaneousflushing,sweating,waterydiarrhea,wheezing,dypnea.(niacin

deficiency)Diagnosis:

Ø Mostarefoundincidentallywithradiographicstudies,appendectomyorsurgeryforintestinalobstruction

Ø Ifthepatienthadcarcinoidtumor- 5HIAA(hydroxyindolaceticacid)in24hoururinecollection- plasmachormogranin- pentagastrin(inpatientswithhigh5HAAtherewillbemorecutaneousflushing)

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Treatment:-Medical:serotoninantagonistsorsomatostaticanalogs(octerotide)forsymptomsofcarcinoidsyndromeSurgery:-appendixcarcinoid<2cmappendectomy-baseofappendixcarcinoidb>2mrighthemicolectomy-smallintestinescarcinoid;resectthetumorwithmesentericlymphnodes

DiabeticFootandUlcers:Ulcerhistorytaking:

• Onset• Progression• Firsttimeornot?• Pain• Dischargeorfoulsmell• Historyofanytraumaorinsectbite• Claudication/restpain• Askabout(diabetes,HT,dyslipidemiaand

smoking)• Occupation

Diabeticfootcanbesecondaryto:

• Neuropathy(presentoverpressurearea,painless)• Ischemia(tipoftoes,painful)• Infection(pusanddischarge,+/-fever)

Examinationofanulcer:• Inspect:site,size,depth,edge,margins,base,discharge,changesin

thesurroundingskin• Inspectionofthefoot:cracksordryness“secondarytoautonomic

neuropathy”,lookbetweenthetoesforfungalinfection,anysignsofcellulitis,Charcotfootdeformity.

• Palpation:sensation,capillaryrefilltime,peripheralpulses,temperature,lookforvascularangle.Monofilamenttest:usedtoassessfordiabeticfootneuropathy.Apositivetestwhenthemonofilamentisbent(10mgforce)indicatesthepresenceofneuropathy.

Investigations:Blood:CBC,glucoselevel,HbA1C,urea,electrolytes,Cr,serumlipidsandbloodcultureifpatientsepticFootinvestigations:woundcultureifitsinfected,footxrayifosteomyelitisorcharcotfootissuspectedIschemiaspecificinvestigations:ABI,arterialduplex,angiogram

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Appendicitis:Randominfo:

• Weonlygiveoneprophylacticdoseofantibioticsbeforesurgeryinappendicitis• Ifpatienthadperforated,abscessorgangrenousappendicitiswegiveantibioticsfor5

days(ceftriaxone+metronidazole)• PatientsmightcomplainofRLQpainlastingformorethan5dayswithvomitinganda

RLQmassthinkaboutappendicularmass,insuchpatientswedon’toperateRx:IVantibiotics.Iftheylatercomplainedofrecurrentpain,wegoforappendectomyotherwiseitsnotrecommended

• ifapatientcomplainedofhighfever,RLQpainandatendermass(appendicularabscess)diagnosis:CTRx:surgicaldrainage

Examination in appendicitis Sign Finding Peritoneal signs Rebound tenderness: acute increase in pain

after removing the hand from applying pressure Involuntary guarding: tensing of abdominal wall muscles during the palpation of abdomen Rigidity: persistent tension of the abdominal wall muscles

Peritoneal irritation

Psoas sign RLQ pain with extension of right thigh Abscess adjacent to psoas or retrocecal appendix

Obturator sign RLQ pain with internal rotation of right thigh Pelvic appendix or abscess Rovsing’s sign RLW pain with LLQ palpation Acute appendicitis Rectal tenderness Right pelvic pain during rectal examination Pelvic appendix or abscess

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Cellulitis:AcuteinfectionoftheskininvolvingthedermisandsubcutaneoustissueCauses:S.aureus,b-hemolyticstreptococciRiskfactors:trauma,recentsurgery,PVD,lymphedema,diabetes,crackedskininfeet/toes(tineapedis)Clinicalfeatures:pain,edema,erythemawithindistinctborders+/-regionallymphadenopathy.Fever,chillsandmalaise.Canleadtoascendinglymphangitis(redstreaking)Investigations:CBC,bloodcultureiffebrile,skinswabonlyifopenwoundwithnopusTreatment:

• Antibiotics:cephalexin/ifextensiveerythemaorsystemicsymptomsIVcefazolin• MRSA(anti-MRSA)J• Limbelevationandresttoreduceswelling

Admissioncriteria:• Immunosuppression• Intoleranceoforalantibiotics• Lackofresponseafter72hoursoforaltherapy• Noncompliantwithmedications• ShockorDIC• Signsandsymptomsofsepsis• TotalWBC<1K

ClassI ClassII ClassIII ClassIV-No systemic signs and symptoms -No comorbidities Within a 48-72 hrs will response to therapy Outpatient treatment take a swab of the exudate antibiotics: dicloxacillin oral for 7-10 days OR clindamycin for penicillin allergy if MRSA: clindamycin/TMP-SMX

-Mild-moderate systemic signs and symptoms -Stable comorbidity -Failure of response within 48-72 hrs oral =consider for outpatient IV antibiotics

-Significant symptoms -Unstable comorbidities (poor diabetes/immunosuppression or PAD) -Limb threatening infection = Inpatients with IV or oral antibiotics

• Flucloxacillin or cefazolin • MRSA vanco/linezolid or

tacoplanin

• Severe sepsis • Necrotizing fasciitis

= Inpatients with IV or oral antibiotics • Flucloxacillin or cefazolin • MRSA vanco/linezolid or

tacoplanin

Differential diagnosis of cellulitis • Eczema • Edema • DVT • Chronic venous

insufficiency • Vasculitis

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SalivaryGlands:ReadtheanatomyandsalivaryglandtumorsSalivaryglandstonesThesubmandibularglandsandductsaremostcommonlyinvolvedand they can obstruct the salivary outflow and predispose toinfectiontheactualetiologyisunknownbuthasbeenstatedthatits caused by themore viscous secretion of the gland and theelongation of the gland the stone can be found anywhere inwharton’sduct.Clinical features: swelling andpain at timeof salivation beforeeating.The patient can also present with an acute bacterial infection(secondaryinfectioncausedbytheobstruction)Diagnosis:plainX-rayorU/SRx:surgicalremovalAcute bacterial sialadenitis: infection of the parotid gland caused by poor oral hygiene ordehydration resulting in painful unilateral swelling and limitedmouth opening (trismus) theparotidglandcanalsooozeRx:antibioticsandsurgicalremovaloftheabscessifpresent.

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Sutures:Howlongdowekeepthesutureforthefollowingcases?Midlinelaparotomy:~10days(indiabeticsandimmunocompromisedisupto14days)Cutwoundinfaceorneck:5-7daysLowerlimbs:14days

*KnowthecompositionandtypesofIVfluids