Surgery 2 PDF - Medical Notes

# TARGET CEH ## PERITONEAL CAVITY - Bile, gastric juice, pancreatic juice all are peritoneal irritants. Blood is least irritant. - **DIFFUSE PERITONITIS** caused by: - perforation of a hollow viscus. - increased virulence of organism. - AIDS or steroids. - Most common cause of gene...

# TARGET CEH ## PERITONEAL CAVITY - Bile, gastric juice, pancreatic juice all are peritoneal irritants. Blood is least irritant. - **DIFFUSE PERITONITIS** caused by: - perforation of a hollow viscus. - increased virulence of organism. - AIDS or steroids. - Most common cause of generalized peritonitis in a 40 year old male is duodenal ulcer perforation. - **LOCALISED PERITONITIS** - Localised tenderness present. There will be guarding and rigidity of the abdominal wall with rebound tenderness (Blumberg sign). - Radiology-Ground glass appearance. - **Complications of Peritonitis** - Paralytic ileus. - Intestinal obstruction. - Residual abscesses following generalized peritonitis particularly pelvic abscess and subphrenic abscess. - Pelvic abscesses commonest intra-abdominal abscesses. Most common site-Pouch of Douglas. - Most common site of subphrenic abscess-Morrison/hepatorenal pouch. - **Tuberculous peritonitis** - In majority of cases, it is the secondary involvement and there is always some primary focus elsewhere in the body. - Features: straw colored fluid with tubercles scattered throughout peritoneum; fever, anorexia, weakness, weight loss; "doughy abdomen". - Mesenteric lymphadenitis- shifting tenderness differentiates this condition from acute appendicitis in which tenderness remains in the same spot. ## HERNIA - Protrusion of abdominal contents from abdominal wall through weak areas. Major weakness of abdominal wall causes increased abdominal pressure. - **Pathology**- Hernia consists of 3 parts-sac, contents of sac, coverings of sac. Sac consists of mouth, neck, body, fundus, - **PUBIC TUBERCLE**- Landmark for differentiating between femoral and inguinal hernia. In inguinal hernia, neck of the sac lie above and medial to the tubercle. In femoral hernia, the neck lies below and lateral to pubic tubercle. - **Inferior epigastric vessels**- Landmark for differentiating between direct and indirect inguinal hernia. Neck of indirect hernia lies lateral while neck of the direct hernia lies medial to these vessels. - Most common type of hernia- **Inguinal**, Extremely rare type- **Obturator hernia**. Hernia which mimics peptic ulcer. **Epigastric hernia (Fatty hernia of the Linea alba).** Most common overlooked hernia in surgery - **Pantaloon hernia**. Most common hernia in both males and females - **Indirect inguinal hernia**. Most common hernia in elderly-**direct hernia**. **Strangulation**- maximum in femoral hernia; least chances in direct inguinal hernia. Femoral hernia is more common on right side and in female. - **Richter's**- Circumference of intestine. Usually complicates femoral hernia. Associated with gangrene / perforation - **Littre's**- Meckel's diverticulum. Hernia-en-glissade. Seen exclusively in elderly males. Peculiarity- posterior wall of the hernia sac is not formed by peritoneum alone but by a viscus which lies behind peritoneum. - **Little's**- Appendix. Local tenderness is not marked, Because strangulated loop lies within abdomen - **Sliding hernia**- Urinary bladder, sigmoid colon (left side), Caecum(right side) - **Maydl's hernia**-'W' loop of bowel. All hernia that reach the stage of vascular compromise produce local signs and symptoms of intestinal obstruction EXCEPT Richter's hernia, Littre's hernia, omantocele. - Inguinal hernia is also more common right side and in males. - **Strangulated hernia**- In infancy, most common site- femoral; Most common content- Ovary. b. Gangrene develops within 6 hrs of strangulation. **Gibbon's hernia** - hernia with hydrocele. **Berger's hernia** - hernia in Pouch of Douglas, **Ogilive hernia** - hernia through defect in conjoint tendon. **Pantaloon hernia** - Double hernia direct + indirect. ## CLINICAL FEATURES | FEATURE | PARTIAL | COMPLETE | |---------------------|------------------------|-----------------------| | Prolapse of | Mucosa+submucosa | All 3 layers | | Prolapsed length | 1-4cm | >4cm | | Common in | extremes of age | Elderly, females after | | | | hysterectomy | | Associated with | Tertiary piles | Fecal incontinence in | | | | >50% | ## HEMORRHOIDS - **External / false piles** occur below the pectinate line and are therefore, very painful. They do not bleed on straining at stool. - **Internal/true/primary piles** - above dentate lines and are painless. - Primary haemorrhoids are located at rectal position 3,7 and 11 o'clock which are the most common site of internal piles. - Secondary haemorrhoids usually occurs between the primary sites-8,9,10,1 and 4 o'clock positions. - Bleeding is the first symptom (splash in the pan). But in fissure-in-ano, where streak of blood may be seen on the stool. - Surgery is indicated for 3º + 4º piles. - **'Sentinel pile'** is not associated with haemorrhoids, but associated with fissure -in - ano. ## COMPLICATIONS - Bleeding (particularly in the first degree and early stage of second degree); thrombosis; Strangulation (especially seen in second degree); Gangrene; fibrosis, suppuration; pylephlebitis. - **COMPLICATIONS OF HEMORRHOIDECTOMY** - Early- pain, acute urinary retention, reactionary haemorrhage. - **DEGREE** - 1º bleed but do not prolapse - 2º prolapse but return back spontaneously or by digital reposition - 3º prolapsed but reducible manually - 4º permanently prolapsed ## FISSURE-IN-ANO - Occur most commonly in midline posteriorly in 6 o'clock position. - Most common cause - Constipation. - Sentinel pile - skin tag at the lower end of the ulcer. - Passage of bright streaks of blood along with stool. Pruritus ani may also occur - Best diagnosed clinically by history and visual inspection. ## FISTULA-IN-ANO - Has external opening (secondary opening) in perianal skin and an internal opening (primary opening) in anal canal or rectum - Usually originates from Perianal abscess - Rectal continence depends solely on anorectal ring (Puborectalis). - Most common symptom- Persisten seropurulent discharge. - Most common cause of multiple fistulae in India- Tuberculosis. ## GOODALL'S RULE - Fistulas with an external opening in relation to the anterior half of anus (within 1.5inches) is of **direct type** - While fistulas with external opening in relation to posterior half of anus have a curved track (more common variety). - Exception is **long anterior fistula**. ## APPENDICITIS - Most commonly seen in second and third decades of life. - Most common organism - E coli. - Organism causing appendicitis like syndrome Pasturella, Strongyloids, Yersinia pseudotuberculosis. - **Alvarado score** is used for diagnosis. Score of > 7 is strongly suggestive. ## Clinical features - - **Pain**- initial typical pain is diffuse and dull and is situated in the umbilical or lower epigastric region. Gradually, the pain is localised in **right lower quadrant.** - Anorexia, nausea. - **Murphy triad**- pain, vomiting and temperature. - **Sequence of symptom appearance**:- anorexia abdominal pain-nausea and vomiting. - **Rovsing's sign** - pain in right lower quadrant when palpation pressure is exerted in left lower quandrant (referred rebound tenderness) - **McBurney's point** - classical site of tenderness in appendicitis. The point is situated at the junction of lateral 1/3 and medial 2/3 of the line joining the anterior superior iliac apine and umbilicus. - **Ba enema**- '**Reverse 3'** on the caecum and mucosal irregularities of terminal ileum. - **ALVARADO SCORE consists of**:- - **Symptoms**- anorexia: nausea and vomiting; migratory RIF pain. - **Signs**- raised temperature: tenderness in RIF: rebound tenderness. - **Tests**- Leucocytosis; Shift to left (segmented neutrophils). ## VOLVULUS - Means rotation of a segment of bowel around its mesenteric axis. - Most common site in colon- **sigmoid colon**. - **Sigmoid volvulus** - Causes- severe chronic constipation. Uncommon to occur in a person who leads an active life and has no serious mental or physical illness. - Straight X ray of abdomen- '**bent inner tube'** or '**Omega loop sign**'. Ba enema- "**twisted bird's beak**", Sigmoid colon turns in anticlockwise direction (unlike volvulus of caecum which occurs in clockwise direction). ## THYROID AND PARATHYROID GLANDS ## ASSESSMENT OF THYROID FUNCTION - **In vitro tests** - Serum T3 and T4: TSH. - **In vivo tests** - - **TSH stimulation test** to distinguish between primary and secondary hypothyroidism. - **Thyroid scan** distinguishes between functioning (hot) and non functioning (cold) thyroid nodules. A functioning nodule is unlikely to be a carcinoma. - **Thyroid autoantibodies.** ## MISCELLANEOUS OTHER TESTS - **Serum cholesterol** - elevated in hypothy roidism. - **Tendon reflexes** - Particularly ankle jerk and knee jerk: relaxation is quite slow in hypothyroidism. ## GOITRE - Denotes enlargement of thyroid gland irrespective of its cause. - Types simple and toxic goitres. ## SIMPLE GOITRE - Formed due to stimulation with increased TSH along with low level of circulating thyroid hormones. - Causes Iodine deficiency, enzyme deficiency, puberty, pregnancy, familial, goitrogens such as antithyroid drugs, cauliflower, cabbage, turnips etc. - **Types**- - **Diffuse Hyperplastic goitre** - Most patients are asymptomatic. Most common symptom swelling of neck which moves on swallowing. Dysphagia due to pressure effect. - **Nodular goitre** - usually multiple nodules present. - **Colloid goitre** - patient is euthyroid, gland is soft and smooth on palpation. ## PENDRED SYNDROME - deaf and goitrous patient since infancy. - **Complications** - secondary thyrotoxicosis; tracheal obstruction, carcinoma. ## TOXIC GOITRE | TYPE | FEATURE | |----------|----------------------| |PRIMARY | Goitre appears along with toxic symptoms Usually in young patients Nervous symptoms dominate Exophthalmos and eye-signs quite common | | SECONDARY | Goitre appears first, then toxic symptoms In older patients Cardiovascular symptoms dominate These signs are virtually never seen | - **Excess secretion of active thyroid hormones occur.** - **Causes** - Grave's disease, toxic multinodular goitre, iatrogenic, struma ovarii ## GRAVE'S DISEASE/DIFFUSE TOXIC GOITRE/PRIMARY TOXIC GOITRE. - Diffuse goitre affecting whole of functioning thyroid tissue causing hypertrophy and hyperplasia. - **Triad** - goitre, thyrotoxicosis, exophthalmos - **Pretibial myxoedema** - thickening of skin with mucin like deposit. - **Tremor of extended fingers, hyperactive tendon reflexes, tachycardia, sleeping pulse rate over 80.** ## Eye signs- - **Von graffe sign**- lagging behind of upper eyelid. - **Joffroy sign**- Absence of forehead wrinkling on looking upwards with head fixed. - **Moebius sign** - failure of convergence of eyes. - **Stellwag sign** - staring look. - **Dalrymple sign** - Retraction of upper lid causing upper sclera to be seen. ## TREATMENT - Antithyroid drugs, Radioactive iodine, surgery. - **Thyroid storm or crisis** - severe thyrotoxic reaction which appears suddenly within 3-4 days after hyperthyroidism. It occurs if a thyrotoxic patient has not been brought down to euthyroid state before operation. Features tachycardia, fever, delirium, restless. - **Difference between primary and secondary toxic goitres.** - **JODBASEDOW SYNDROME**- large doses of iodine given to hyperplastic endemic goitre may produce hyperthyroidism. ## WOLFF CHAIKOFF EFFECT - Reduction in thyroid hormone levels caused by ingestion of large amount of iodine. ## HASHIMOTO THYROIDITIS - Most common form of thyroiditis. - Cause autoimmune. - Antimicrosomal and Antithyroglobulin antibodies can be measured in patient's serum. - Pathology - Askanazy cells. ## CARCINOMA THYROID | TYPE | FEATURE | |-----------------|--------------------------------------------------------------------------| | PAPILLARY | Most common type. Lymphatic spread common. Best prognosis. | | MULTIFOCAL, | Radiation induced. May arise in thyroglossal cyst | | FOLLICULAR | Most common in females. Hematogenous spread common. Common in region of iodine deficiency, associated with endemic goitre | | MEDULLARY | Most malignant. Resembles normal thyroid | | ANAPLASTIC | Worst prognosis. Undifferentiated. | | UNCOMMON | Associated with MEN 2a and 2b Hyaline amyloid stroma | - **Orphan annie eyed Nuclei, Psammoma bodies. Multiple cold nodules, multicentric. External radiation.** ## HYPERPARATHYROIDISM - **PRIMARY HYPERPARATHYROIDISM**- etiology unknown - Familial hyperparathyroidism- usually occurs with Multiple Endocrine Neoplasia (MEN). - **MEN type 1 (Wermer syndrome)**- hyperparathyroidism+ Pancreatic tumor +Pituitary adenoma. - **MEN type 2 (Sipple syndrome)**- Medullary thyroid cancer+ pheochromo cytoma+hyperparathy roidism. ## Clinical features- - Hypercalcemia, calcification of soft tissues, bone disease, Bizarre presentations- Gastroduodenal ulcers, pancreatitis, hypertension: Increased level of serum alkaline phosphatase. ## SECONDARY AND TERTIARY HYPERPARATHYROIDISM - **Secondary hyperparathyroidism**- develops in chronic renal failure and malabsorption syndrome. - **CHRONIC PHOSPHATE RETENTION-HYPERPHOSPHATEMIA-HYPON** ## CALCEMIA-PARATHYROID HYPERPLASIA. - **Tertiary hyperparathyroidism**- due to adenomata. ## HYPOPARATHYROIDISM - Most common cause- damage to parathyroid gland during thyroid surgery. - **Clinical features** - Hypocalcemia. This is manifested by: - Numbness and tingling in the fingers, toes and circumoraloregion. - Anxiety, depression. - **Tetany** - characterised by carpopedal spasms, convulsion, laryngeal stridor. ## Physical examinations- - Chvostek's sign - abnormal contraction of facial muscles elicited by tapping on facial nerve anterior to ear. - **Trousseau's sign** - elicited by occluding blood flow to forearm for 3 minutes with sphygmomanometercuff applied to arm and raising the pressure above systolic level. It will induce carpopedal spasm ieMCP joints are flexed with extension of IP joints and adduction of thumb. ECG changes include prolonged QT intervals.