Surgery

Intestinal obstruction symptoms and bowel obstruction treatment

2011-05-11T13:56:00.000-07:00

LISTEN YOUR ABDOMEN......

MALFUNCTIONING OF THE BODY THEREBY BLOCKING THE INTESTINE

Undergo HOW to prevent and Treat ?

INTESTINAL OBSTRUCTION

The mall-functioning of the body thereby blocking the gut and preventing the movement of product of digestion. Its a mechanical or useful impediment of the gut ,veto the normal transit of the products of digestion. it can become at some level distal to the duodenum of the small gut an is a medical emergency. Although many cases are not treated surgically , is a surgical problem.

CLASSIFICATION

ACUTE OBSTRUCTION : Occurs in small intestine.
CHRONIC OBSTRUCTION : Occur in large intestine.
ACUTE-ON-CHRONIC OBSTRUCTION : Spreads from large gut to involved small intestine.

ETIOLOGY

DYNAMIC OBSTRUCTION

Here an obstructive agent is present.

LUMINAL OBSTRUCTIONFecal impaction

Gall stone ileus
worms eg ascariasis.

INTRINSIC LESION OF BOWL WALL

Inflammatory stricture
Malignant stricture
Intussusception

EXTRINSIC COMPRESSION

Adhesions
Hernias
Volvulus

ADYNAMIC OBSTRUCTION

Here's no obstructive agent is present.

PARALYTIC ILEUS

Postoperative
Peritonitis
Reflex
Uremia
Hpokalemia

MESENTRIC VASCULAR OCCLUSION

Embolism
Thrombosis

SIGNS AND SYMPTOMS

Based on the extent of impediment involved, viscus impediment can result into abdominal pain, abdominal distension, vomiting and regurgitation. (This a information where half-digested concern is remove from the gut into the stomach by contraction and muscle movement, forcefully expelled through the oesophagus and finally outside from the mouth. This is not actually faecal concern that is vomited, but it smells similar). The information of viscus impediment haw be worsen by extraction and electrolyte abnormalities (acid-base imbalance) cod to vomiting. In diminutive gut obstruction, the discompose are cramping and consistent in nature. The discompose is more central and mid-abdominal. Constipation comes after vomiting. In case of large viscus impediment , the discompose is felt in the lower conception of the abdomen. Constipation occurs first and regurgitation haw be irregular.

INVESTIGATIONS

Test that shows obstruction

Barium enema
Abdominal CT scan
Upper GI and small bowl series
Abdominal film

The field diagnostic tools are blood test, X-rays of the abdomen, CT scanning (computer tomography) and or ultra-sound. In a case of identifying mass, biopsy haw be employed to determine the nature of the mass. Radio logically viscus impediment shows viscus distension and the presence of multiple gas-fluid levels. Contrast enema, diminutive gut series or CT construe can be used to define the level of obstruction, as in either partial or complete and helping to know the cause of the obstruction. In colonoscopy,small gut are diagonalised using ingested camera,while endoscopy is an instrument used to get medical information from inside the embody and laparoscopy is a form of new technique aimed at carrying out abdominal activeness through diminutive incision.unlike the usual large surgical procedure.

TREATMENT

GASTRODUODENAL OR GASROINTESTINAL SUCTION DRAINAGE

REPLACEMENT OF FLUID AND ELECTROLYTES

RELIEF OF OBSTRUCYION BY OPERATION

ANTIBIOTICS

The treatment for diminutive viscus impediment is both non-surgical called conservative and surgical. Non-surgical treatment involves a nasogastric tub, correction of extraction and electrolyte abnormalities. For patients with cut pain, Opioid discompose reliever haw be used. Antiemetics haw be administered to regurgitation patient. Intestinal Obstruction in Children Intestinal atresia is the main causes of fetal and neonatal viscus obstruction. This is characterised by narrowing or absence of a conception of the intestine. The atresia are usually discovered before birth via Sonagram and treated with using laporotomy after if the area infected is small, surgeon haw be able to remove the damaged conception and the gut is joined back together. In a information where the narrowing is longer and the area is damaged, a temporary stoma haw be placed.

SURGERY

The surgery is performed while you are under general anaesthesia. This means you are unconscious and pain-free .A cut is prefabricated in your abdomen. The disease conception of the super bowl is distant and the digit healthy ends of bowl are seamed back together ( resected ).The cut is winking , if the entire colon and rectum is distant , it is titled a proctocolectomy. A bowl resection haw be performed as a traditional 'open' machine or as a minimally invasive laproscopic procedure.

PREVENTION

It depends on the cause,treatment of conditions ( such as tumor and hernias ) that are attendant to obstruction,may reduce the risk.some causes of obstruction are not preventable.

EXPECTATION

The outcome varies with the cause of obstruction.

Chronic cholecystitis treatment

2011-05-11T13:34:00.000-07:00

ITS A LONG STANDING SWELLING AND IRRITATION OF GALL BLADDER

TREATMENT
NON SURGICAL TREATMENT
Analgesics may be given for pain .Severe pain require opiates ,which is given along with hyoscine butylbromide ( to counteract spasm of sphincter of Oddi ).Ptient should be put on low-fat diet until cholecystectomy.
MEDICAL DISSOLUTION OF GALL STONES
Gall stone can be dissolved as long as they are radiolucent and gall bladder is functioning.Some drugs can work such as bile acids ,chenodeoxycholic acid .Ursodeoxycholic acid .
EXTRACORPOREAL LITHOTRIPSY
Extracorporeal shock wave lithotripsy can disrupt gall stones and allow debris to pass into bile duct and beyond. It is suitable for patients with 1-3 stones in a functioning gall bladder.
SURGICAL TREATMENT
Prophylactic antibiotics e.g. 2nd generation cephalosporin should be given.Premedications.provision is made for peroperative cholangiography.

LAPAROTOMY
Give incision in right paramedian or right subcostal incision ( Kocher's incision ) and examine all abdominal organs .inclding gall bladder.

CHOLECYSTECTOMY
Isolate the gall bladder area with packs .Aspirate the gall bladder if it greatly distend through fundus via trocar and cannula attached to a suction apparatus.Grasp the neck of gall bladder with sponge-holding forceps.Display the junction of cystic ,common hepatic and bile ducts via dissection and identify cystic artery and its relation to common hepatic duct .Cholangiography is performed ,to confirm the anatomy of biliary tree and to check for stones in main duct .Ligate the cystic duct and then divide it .Dissect the gall bladder from its bed ,rom below and upwards .dividing the peritoneum on gall bladder. Secure hemostasis and close the abdominal wall.Drainage is not mandatory ,if used ,it should be a 3mm closed suction drain.

WITH SEVERE INFLAMMATION IN CALOT'S TRIANGLE
Open the gall bladder ,extractall stones and bile ,and excise as much of wall of gall ladder as possible.Cystic duct opening is closed by cargut suture from within .An alternative is cholecystostomt.

OTHER SURGICAL TECHNIQUES
CHOLECYSTOSTOMY
PERCUTANEOUS CHOLECYSTOLITHOTOMY
LAPAROSCOPIC CHOLECYSTECTOMY
MINICHOLECYSTECTOMY …..... read more

Gall bladder disease symptoms or chronic cholecystitis

2011-05-11T13:21:00.000-07:00

PROLONG FASTING AND OLDER AGE WITH GALL STONES

CAN PRECIPITATE GALL BLADDER DISEASE SYMPTOMS

CHRONIC CHOLECYSTITIS is invariably associated with gall stones.It may develop after repeated episodes of acute cholecystitis but more often develop insidiously without any precedind clinically evident acute attacks .The gall bladder wall becomes thickened by fibrosis and relatively indistensible .The gall bladder wall is infiltrated with chronic inflammatory cells ,lymphocytes ,plasma cells and macrophages.Glandular outpouchings are formed by the lining of the mucosa and are known as Aschoff - Rokitansky sinuses. If obstructive jaundice occurs ,it is due to a stone impacted in the common bile duct.

The gall bladder does not usually distend ,as the wall is relatively rigid due to fibrosis consequent on the associated chronic cholecystitis.Mucocele ,this ocurrs when a stone impacts in the neck of the gall bladder in the absence of infection in the bile.The bile is absorbed from the gall bladder,and mucus is secretedinto it from the mucus secreting cells of the epithelium.The lack of inflammation in the wall allowsthe gall bladder to distend to several times its normal size.The gall bladder is usually palpable below the costal margin.The wall of a mucocele is usually very thin and is easily ruptured at surgery.cholestrolosis ,this is a condition where lipid laden macrophages accumulate in the gall bladder mucosa to produce yellowish flecks in a reddish mucosa ,appearing like the surface of a strawberry - hence the alternative name " strawberry gall bladder " .This is often a symptomless condition but may accompany or pedispose to cholestrole stones.

SYMPTOMS AND SIGNS

May be asymptomatic for years,may progress to symptomatic gall bladder disease or to acute cholecystitis ,or present with complications.PAIN in right hypochondrium ,radiate between shoulder blades is frequent .it can occur after eating but not so closely related as peptic ulcer.It begins gradually 15 - 30 minutes after meal and last for 30 -90 minutes ,its duration is several hours ,but it must be less than 12 hours.severity is varying from mild to excruciating .it can precipitated by taking fatty foods,and relieved by analgesic drugs ,associated with nausea and vomiting .

FLATULENT DYSPEPSIA it is a feeling of fullness after food associated wih belching and heartburn.It is brought on by a large or a fatty meal.

TENDERNESS present in the right hypochondrium ,just below the tip of 9th rib where edge of rectus abdominus muscle crosses the costal margin ( gall blader point ) .

MURPHY's SIGN may be positive .This is elicited by asking the patient to breathe in whilst gently pressing the gall bladder point with your thumb pointing towards feet , Patient will experience pain and catch her breath just before the zenith of inspiration.

DIAGNOSTIC INVESTIGATIONS

PLAIN X-RAY ABDOMEN show radio opaque gall stones.

ORAL CHOLECYSTOGRAPHY ( OCG ) presence of gall stones can be detected ( filling defects )

ULTRASONOGRAPHY demonstrates gall stones , as well as biliary calculi and dilatation of biliary tree.

CT SCAN useful for patients in whom U/S is difficult e,g. obese or those with excessive bowel gas.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY ( PTC ) or PEROPERATIVE
CHOLANGIOGRAPHY to detect associated duct stones....... read more

Peritonitis treatment

2011-05-11T10:37:00.000-07:00

First make diagnosis for appropriate treatment

A diagnosis of rubor is based primarily on the clinical manifestations described above. If rubor is strongly suspected, then surgery is performed without further retard for another investigations. Leukocytosis, hypokalemia, hypernatremia and acidosis haw be present, but they are not specific findings. Abdominal X-rays haw expose dilated, edematous intestines, though such X-rays are mainly multipurpose to countenance for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under think and is likely to expand in the future. Computed tomography (CT or CAT scanning) haw be multipurpose in differentiating causes of abdominal pain. If reasonable uncertainty ease persists, an exploratory peritoneal lavage or laparoscopy haw be performed. In patients with ascites, a diagnosis of rubor is prefabricated via paracentesis (abdominal tap) more than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram bactericide and culture of the peritoneal fluid can watch the microrganism responsible and watch their sensibility to antimicrobial agents.

GENERAL CARE OF PATIENT

INTRAVENOUS FLUIDS restoration of ECF volume. rebuke of ECF electrolyte balance.correction of ECF protien depletion.Hyperalimentation ( IV intake ) , if patient's recovery is delayed for more than 7 - 10 life .

NASOGASTRIC ASPIRATION intermittent aspiration is maintained ,until paralytic ileus has recovered.If the cavum is soft and non-tender and bowel-sounds return ,oral intake haw be progressively introduced.

ANTIBIOTICS paraenteral Polycillin ,gentamycin ,and antiprotozoal haw be given.

ANALGESICS narcotic analgesics haw be presented ,e.g dextropropoxyphene ,nalbuphine and diminutive dose continuing for 48 hours.

FLUID BALANCE CHARTING

VITAL SIGN MONITORING

NEUTRALIZATION OF LOCAL SOURCE
BY SURGERY this is indicated in cut appendicitis , cut diverticulitis ,perforated peptic lesion ,perforated or unhealthy cholecystitis.
BY CONSERVATIVE TREATMENT this is done in rubor due to pancreatic salpingitis , or in case of primary rubor of streptococcal or pneumococcal lineage .

PERITONEAL LAVAGE if surgery has been undertaken ,then whole peritoneal cavity should be explored with sucker and mopped dry .Through improvement of peritoneal cavity can be achieved by work with upto 10 litres of armed normal saline.Last some litres should contain a broad-spectrum antibiotic ( e.g antibacterial ).

COMPLICATIONS OF PERITONITIS these may be either systemic or local.

Local complications allow :intraperitoneal abcess e.g subphrenic and pelvic ,Wound infection ,Anastomotic breakdown ,Fistula formaton ,adhesions .
Systemic complications allow : hypovolemic damper ,septic damper ,adult respiratory disress syndrome ,disseminated intravascular coagulation ,immunological unfortunate ,multiorgan unfortunate .

PROGNOSIS

The coverall mortality in generalized rubor ,especially if it is unhealthful ,is broad .Factor affecting mortality allow :
Age __ old patients with soiled rubor hit an exceptionally broad mortality.
causation __ unhealthful causes hit a higher mortality than chemical.
Duration of symptoms.
Degree of bacterial contamination.
Concomitant disease processes e.g cardiac ,renal , and hepatic organ failure.......read more

Acute peritonitis and peritonitis symptoms

2011-05-11T10:15:00.000-07:00

A SERIOUS CONDITION IN WHICH THE INSIDE WALL OF THE BODY BECOMES SWOLLEN AND INFECTED

ACUTE PERITONITIS

Peritonitis is an inflammatory or suppurative response of the peritoneal lining to direct irritation.It haw be decentralised or unspecialised bacterial or chemical.Localized peritonitis is due to transmural inflammation of aviscus ,e.g. accent appendicitis ,acute cholecystitis .acute diverticulitis .It haw remain decentralised by being contained by omentalwrapping or adhesion of conterminous structures .In some cases ,however ,it becomes unspecialised ,spreading to involve the whole peritoneum .Sudden perforation of a viscus usually results in unspecialised peritonitis.

In this case , the patient is usually seriosly ill .Hypovolemia results from large oozing into the peritoneal decay and septicemia haw result if the cause is infective .eg faecal peritonitis due to perforated diverticulitis.Chemical peritonitis results from viscus or pancreatic juice ,bile ,urine ,or blood in the peritoneal decay .Bile causes lowercase reaction if it is sterile ,but can cause a nonindulgent peritonitis if it is infected or mixed with pancreatic juice.Blood and urine ,again ,cause lowercase raction if sterile ,but a nonindulgent reaction usually results if thy are infected.

CAUSES OF PERITONITIS

It haw be ACUTE OR CHRONIC

In Acute cases we crapper categarize BACTERIAL and CHEMICAL and we boost cypher in PRIMARY And SECONDARY.

Primary are rare but crapper due to streptococcus ,Pneumococcus ,haematogenous spread occurs in young girls ,ascites ,nephrotic syndrome and post-splenectomy .

Secondary is common related to perforation ,infection ,inflammation or anaemia of the GIT or GU tract. In chemical culprits are Gastric juice e.g cut gastric ulcer.
Pancreatic juice e.g accent pancreatitis .
Bile e.g cut gall bladder.
Blood e.g damaged spleen.
Urine e.g intraperitoneal break of the bladder.

In CHRONIC cases allow Tuberculosis and Starch ( medicine activity )

CLINICAL FEATURES

Most patients with rubor module hit abdominal pain and a fever. Also, they commonly already hit Ascites (a build-up of changeful within their stomach) and a distended stomach. Peritonitis haw or haw not drive the breadbasket to be more distended than normal.

Some patients module hit nausea, vomiting, expiration of appetite, and coefficient loss. Which of these symptoms are inform depends on the drive of the problem. Many patients with Ascites also hit liver problems. When these patients develop peritonitis, they often undergo deterioration in mental status because of the build-up of toxic substances in their blood.

Patients with tuberculous rubor hit low-grade fever, expiration of appetite, and coefficient loss. Often, their Ascites module develop slowly.

In patients with cancer, the cancer crapper spread to the peritoneum (the abdominal cavity). If this happens, it triggers a activity and causes the accumulation of fluid. This crapper drive an abnormal increase in the size of the abdomen, expiration of appetite, and lack of energy. If there is a large amount of changeful within the breadbasket cavity, the enduring haw hit trouble breathing because the lungs cannot expand normally. Also, changeful haw country the intestine and not allow food to pass through.Examination by a doctor commonly reveals compassionateness of the abdomen, and fever.

DIAGNOSTIC INVESTIGATIONS

How to listen your body in crisis with Volvulus ?

2011-05-11T06:29:00.000-07:00

VOLVULUS ( Twisting of intestine )

VOLVULUS refers to the winding of a assets of the intestine around itself or a stalk of mesentery tissue to cause an obstruction. Volvulus occurs most ofttimes in the colon, although the breadbasket and small bowel crapper also twist. The conception of the digestive grouping above the volvulus continues to function and haw swell as it fills with digested food, fluid, and gas. A condition called strangulation develops if the mesentry of the bowel is twisted so tightly that murder line is cut off and the tissue dies. This condition is called gangrene.

VOLVULUS IS A SURGICAL EMERGENCY because gangrene crapper amend quickly, cause a mess in the wall of the bowel (perforation), and become life-threatening.

ITS AXIAL ROTATION HAS DIFFERENT TYPES

Volvulus Neonatorum

Volvulus of Small Intestine

Volvulus of Cecum

Volvulus of Sigmoid Colon

VOLVULUS NEONATORUM an intestinal obstruction in a new born resulting from a twisting of the bowl caused by malrotation or nonfixation of the colon .Floating of cecum , together with whole of small intestine which has a narrow attachment ,revolves.

Arrested rotation , in which cecum remains in left hypochondrium ,and a peritoneal band is found running from cecum to right side of abdomen and then across the 2nd part of duodenum ( transduodenal band of Ladd )

In the clinical fearures ,there is some symptoms of Repeated vomiting , which will be bile stained .can also cause abdominal distension .

It can cause some signs of Dehydration and abdominal distension.
Few diagnostic test ,that shows or revealed a diseased portion.For this reason we can do PLAIN ABDOMINAL X-RAY it reveal stomach and upper part of duodenum are greatly distended ith air ,so called 'double stomach.

This condition needs immediate surgery included :

Early Laprotomy
Whole of the midgut is delivered on to the surface .
Untwisting is done in opposite direction .
Transduodenal band of Ladd is divided .
Abdomen is closed in layers .

VOLVULUS OF CECUM nearly always occur in a clockwise direction. First twist obstructs the ascending colon ,if a 2nd twist occurs ,it obstructs the ileum also .Axial torsion, the most common form of volvulus, occurs with the development of a twist of 180-360^o; along the longitudinal axis of the ascending colon. This form has a high mortality rate because the obstructive process is associated with vascular compromise, which can lead to gangrene and perforation, often on the antimesenteric border, where the ischemic changes may be most pronounced.

Nonspecific abdominal symptoms occasionally occur with abnormalities of fixation. Traction on the superior mesenteric artery with partial compression of the duodenum, gallbladder, pylorus, or kidneys has been implicated. The most important complication of the abnormalities of fixation is a volvulus of the right side of the colon and/or cecum.

The common presentation of a cecal volvulus is an acute abdomen, with colicky abdominal pain of sudden onset. Most cases of cecal volvulus reportedly occur in patients with a mobile, defectively fixed right colon while they are asleep. Normal movement of the patient from side to side during sleep may result in displacement of the right colon to an ectopic or abnormal location. When gaseous distention occurs, the displaced right colon is trapped, resulting in symptomatic acute volvulus.

The diagnosis is mostly based on plain abdominal radiographic findings aided by those of single-contrast barium enema examination. CT is useful in identifying signs of ischemia, which include mural thickening, infiltration of the mesenteric fat, and pneumatosis intestinalis. Treatment is surgical, but reduction of the volvulus has been reported after barium enema examination.colonoscopy may be considered for the purpose of decompression. Simple abdominal radiographs had a low diagnostic accuracy but revealed bowel obstruction.

TREATMENT

Laprotomy should be done ,Deflate the ballooned cecum by insertion of a needle .Untwisting is accomplished in opposite direction ,ie anticlockwise . Cecostomy is performed , which relieves the distension , and fixes the organ to abdominal wall ( preventing recurrence ) ,If cecum is gangrenous ,right hemicolectomy is performed .Abdominal wound is closed .

VOLVULUS OF SIGMOID COLON

This is the terminal section of the colon. Two body differences can increase the risk of colon volvulus. One is an elongated or movable colon colon that is unengaged to the left sidewall of the abdomen. Another is a narrow mesentery that allows winding at its base. Sigmoid volvulus, however, can occur modify without an body abnormality.

This type of twisting in the sigmoid can occur due to Band or Adhesions ( peridiverticulitis ) ,Overloaded pelvic colon ,Long pelvic mesocolon .Narrow attachment of pelvic mesocolon.

Loop may rotate half a turn , in which event spontaneous rectification sometimes occur .After the loop has rotated 1 1/2 turns ,veins involved in torsion are compressed ,and loop becomes greatly congested .if it rotates more than 1 1/2 turns ,blood supply is cut off entirely and loop becomes gangrenous .Rotation nearly always occur in anticlockwise direction .

In clinical fearures ,it can shows the sumptoms of sudden severe abdominal pain ,often coming on while the patient is straining at stool .Abdominal distension ,hiccough and retching occur early ,Vomiting occur late ,absolute constipation .

some sgns of abdominal distension ,abdominal guarding and tenderness

DIAGNOSTIC INVESTIGATION

PLAIN ABDOMINAL X-RAY
A connatural stark abdominal x-ray will demonstrate a huge air filled distended bowel like the appearance of an inverted U, with the convexity of the U covering the right upper abdominal quadrant. This appearance has been described as the kidney noodle shape, coffee noodle shape, bent inner plaything shape, ace of spades or ‘Omega loop Sign’. You can wager an example down in the inventiveness section.

BARIUM ENEMA

With a water solvable metal enema, the distention in the sigmoid colon can be demonstrated to be cod to a twist, as it will show an Atlantic of rank obstruction with some twisting in the so called shuttle beak or shuttle of beast sign.

TREATMENT

DEFLATION AT SIGMOIDOSCOPY

Sigmoidoscopy is carried out and when obstruction is reached an attempt is made to coax a soft rectal tube into twisted gut .This will immediately deflate the gut and operation can be delayed for a few days until the patient is more fit.

OPERATION

Laparotomy is performed ( immediately if dilation is not successful ) .Untwist the gas filled viscus in aclockwise direction .Simultaneously ,a rectal tube is passed to deflate the colon .Resection and end-to-end anastomosis is carried out .Abdominal wound is closed.

Colostomy is an artificial opening to divert faeces and flatus.

2011-05-11T06:09:00.000-07:00

Bowel diversion surgery for artificial opening in large bowel in order to divert faces to exterior

COLOSTOMY

In simple terms, a colostomy is when the colon is cut in half and the end directive to the stomach is brought finished the surround of the abdomen and attached to the skin. The end of the colon that leads to the rectum is closed soured and becomes dormant. In other words we can say that its a artificial opening made into large bowel in order to divert feces ( & flatus ) to exterior ,where they may be collected in an adhesive bag.

Usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. This is not an activeness to be taken lightly. It is truly quite serious and demands the close attention of both patient and doctor. A colostomy is ofttimes performed so that an incident crapper be stopped and/or the affected colon tissues crapper heal. The alternative to the colostomy is ofttimes pretty grim, death. Just be glad you are here. It is essential actualise that, with a few exceptions, you crapper look forward to having the colostomy reversed.

A colostomy is sometimes necessary for destined upbeat conditions or diseases. Some of these include cancer, diverticular disease, Crohn's disease and trauma or injury. A temporary colostomy may be necessary to allow the colon to rest and ameliorate for a period of time. A temporary colostomy may be in locate for weeks, months, or years. The temporary colostomy module eventually be closed and bowel movements module return to normal. A imperishable colostomy is usually necessary when a part of the colon staleness be distant or cannot be utilised again.

This is famous as a "Hartmann's Colostomy". There are other types of colostomy procedures, but this one is the most common.

It may be TEMPORARY or PERMANENT

TEMPORARY COLOSTOMY

A temporary colostomy haw be used when the conception of the colon (typically the lower section) needs to heal, such as after trauma or surgery. After the colon is healed, the colostomy can be reversed, backward the bowel function to normal. In a colostomy reversal, the digit ends of the colon are reconnected and the area where the stoma was created in the cavum is closed. The large gut is made, erst again, into a continuous tube between the small gut and the rectum. Bowel movements are eliminated through the rectum.

INDICATIONS to relieve a distal obstruction of sigmoid colon either by a carcinoma or diverticulitis ,vesicocolic fistula ,protection of a low colorectal anastomosis after anterior resection .To prevent fecal peritoniyis developing after traumatic injury to rectum or colon .To facilitate operative treatment of a high fistula-in-ano.

PROCEDURE

The operation usually takes between digit and four hours depending on difficulty, infection, and the severity of trauma if that is the case. Most of the reasons for a colostomy are: diverticulitis, other inflammatory bowel conditions, or cancer.

Since you are having the operation, you should discuss with your student whether or not you should hit the appendix distant at the same time, since they are going to be in there anyway. It is not a necessary organ and, if removed, it crapper never cause you problems in the future.

It is normal practice to unstoppered the cavum with an incision from meet below track distinction to meet below the sternum. This gives unstoppered admittance to the internal organs. If you have infection, the student module suction and flush out the contaminates until you are clean.

A loop of bowel ( loop colostomy ) is brought to the surface , where it is held in place by a plastic or glass rod passed through mesentry .Bowel is opened & edges of colonic incision stitched to surrounding skin margins.When firm adhesion of colostomy to abdominal wal has taken place after 7 days , then rod can be removed.

Closure of colostomy performed ,following surgical cure of distal lesion .Done when the stoma is matured ,ie after 2 months .Usually performed by an intraperitoneal technique

PERMANENT COLOSTOMY

A imperishable colostomy (sometimes also called an end colostomy) is necessary for some conditions, including most 15% of colon cancer cases. This type of surgery is commonly utilised when the rectum needs to be removed because of disease or cancer. Most of the colon may also be removed, and the remaining assets utilised to create a stoma.

INDICATIONS after excision of rectum for a carcinoma by abdominoperineal technique ,through the lateral edge of rectus sheath 6cm above & medial to bony prominence.

PROCEDURE distal end ( end colostomy ) of divided colon is brought to surface in left iliac fossa ,where it is stitched in place immediately by sutures placed between colonic margin 7 surrounding skin .A colostomy bag is applied without impinging on bony prominence of anterior superior iliac spine.

After the colostomy, squander is composed on the outside of the body with an ostomy appliance. Today’s ostomy appliances become in a variety of shapes, sizes, colors, and materials to meet the wearer’s lifestyle. The aperture and the surrounding wound (peristomal skin) will order primary care that is taught to patients post-surgery by an enterostomal therapy (ET) nurse....... read more

Colostomy products

2011-05-11T05:05:00.000-07:00

DIFFERENT TYPES OF PRODUCTS FOR COLOSTOMY

Pouch
There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special concealment that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release pedal tardily and support to decrease pedal odor. The mass is general aggregation most types of colostomy pouches

Stoma covers and caps
Stoma caps or covers crapper be placed on the aperture when the aperture is not active (draining). People with descending or colon colostomies who wet may use aperture covers or caps. The cover or cap is attached to the wound in the same artefact as a pouch.

COLOSTOMY CARE

Psychic activity of the enduring for the necessity of colostomy is a daylong first step toward his adjustment to experience with an artificial anus. Proper surgical positioning of the activity module assist tending of the bowel. Control of fecal property and peristaltic rate should ideally display degradation susceptible exclusive to habit or enemata.

The goal of the enema is to display an evacuation thorough enough to prevent soiling for a day or two. The goal of fare variations is to display a manageable volume and property of fecal stream. The framework of enemas and pick of diet can be personalised when the underlying principles are understood.

COMPLICATIONS OF COLOSTOMIES

Prolapse , Retraction ,Necrosis of distal ends , Stenosis of orifice , Colostomy of hernia , Bleeding ( usually from granulomas around the margin of colostomy ) Colostomy diarrhea ( usually an infective enteritis responds to metronidazole )

Recovery at home is mostly most six weeks, although it haw be longer for patients who are very ill before surgery or who hit complications. Activity module be limited at first, and lifting, housework, and driving are not recommended. The infirmary staff module advise you most your diet when you prototypal get home, which haw be limited to low fiber. Regular appointments with your surgeon module help ensure that your cavum and the surface around the aperture are sanative well........read more

70% adult cases of chronic pancreatitis are caused by chronic alcohol use

2011-05-11T03:20:00.000-07:00

Main culprits are heavy alcohol consumption and gallstones for chronic pancreatitis

CHRONIC PANCREATITIS

is a relapsing disorder which may arise insidiously or following repeated attacks of acute pancreatitis .The most commonest cause is chronic alcohol consumption and accompanied by a protien and fat rich diet .Other causes include cystic fibrosis ,hypercalcemia ,hyperlipidemiaand a rare familial pancreatitis .Pathological changes include parenchymal destruction ,fibrosis ,loss of acini ,calculi and duct stenosis with dilatation behind the stenosis.At operation the gland feels hard and irregular and may be mistaken for carcinoma .Calcification is often seen on plain abdominal X-ray.This is thought to be due to calcification of protien precipitates in ducts .

Pancreatic duct obstruction : due to Stricture e.g.after trauma or acute pancreatitis.Occlusion by pancreatic cancer.

Hyperparathyroidism ,cystic fibrosis ,Hereditory pancreatitis ,Infantile malnutrition ,Idiopathic ,Stenosis of ampulla of vater . In 12 % of adults ,etiology is unknown.

Initially pancreas may appear normal.Later pancreas enlarges and becomes hard due to sclerosis ,while the ducts become distorted and dilated with areas of ectasia .Calcified stones ,weighing from a few mg 200 g ,may form within ducts .Ducts become occluded with gelatinous protein-rich fluid and debris ,to form cysts.

Lesions affect a particular lobule producing ,Ductular metaplasia and hyperplasia ,Atrophy of acini ,Interlobular fibrosis .

In clinical features there is symptom of discompose in epigastrium ,which alter to left and correct hypochondrium and finished to back .boring discompose to biliary colic in character .duration about 3-4 days ,and exacerbated by beverage consumption.Vomiting ,anorexia ,Steatorrhea ,and Weight loss ( results from anorexia ,malabsorption steatorrhea and vomiting .It can cause some symptoms of diabetes mellitus ,these are late feature and includes polyuria ,polydipsia ,weight loss and imperfectness.

Signs of jaundice haw be present ( due to narrowing of retropancreatic bile duct ) A protective ,hard epigastric mass haw indicate formation of a sac . ( best way to palpate pancreas is to invoke the enduring to correct and hips and knees are flexed .Left costal margin is deeply palpated.This will evoke tendrness in accent and habitual pancreatitis ( Mallet-Guy's sign ).

DIAGNOSTIC INVESTIGATIONS

The identification of habitual pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is thoughtful excessively risky. Serum amylase and lipase may well not be elevated in cases of advanced habitual pancreatitis, but are often utilised as markers for sleuthing pancreatic inflammation in acute pancreatitis. A secretin stimulation effort is thoughtful the gold standard functional effort for identification of habitual pancreatitis but not often utilised clinically. The observation that bi-carbonate production is impaired early in habitual pancreatitis has led to the rationale of ingest of this effort in early stages of disease (sensitivity of 95%). Other ordinary tests utilised to determine habitual pancreatitis are faecal elastase measurement in stool, serum trypsinogen, Computed tomography (CT) scans, ultrasounds, EUS, MRI's, ERCP and MRCP's. Pancreatic calcification crapper often be seen on plain abdominal X-rays, as well as CT scans.

There are other non-specific laboratory studies useful in identification of habitual pancreatitis. Serum bilirubin and alkaline phosphatase crapper be elevated, indicating stricturing of the ordinary bile funiculus cod to edema, fibrosis or cancer. When the habitual pancreatitis is cod to an autoimmune process, elevations in ESR, IgG4, rheumatoid factor, ANA and antismooth hooligan antibody may be seen. The ordinary symptom of habitual pancreatits, steatorrhea, crapper be diagnosed by two assorted studies: Sudden staining of feces or soiled fruitful organic over 24hr on a 100g fruitful diet. To check for pancreatic exocrine dysfunction, the most sensitive and specific effort is the measurement of soiled elastase, which crapper be done with a azygos crap sample, and a value of inferior than 200 ug/g indicates pancreatic insufficiency.

TREATMENT

MEDICAL TREATMENT

Aimed at controlling discompose and malabsorption .Intermittent attacks treated like accent pancreatitis.Alcohol and super fatty meals must be avoided .Narcotics for severe discompose ,but subsequent addiction is common ,Patients unable to maintain adequate hydration should be hospitalized ,while those with milder symptoms crapper be managed on an ambulatory basis. Surgery haw curb discompose if there is a ductal stricture .Subtotal pancreatectomy haw also curb discompose but at the outlay of exocrine insufficiency and diabetes .Malabsorption is managed with a low fat diet and pancreatic enzymes equal ( 8 customary tablets or 3 viscus glazed tablets with meals ).Because pancreatic enzymes are inactivated by Elvis ,agents that turn Elvis creation ( e.g . omeperazole or sodium bicarbonate ) haw improve their efficacy ( but should not be presented with viscus glazed preparation ) Insulin haw be needed to curb serum glucose .

SURGICAL TREATMENT

Traditional Surgery for Chronic Pancreatitis tends to be divided into two areas - resectional and drainage procedures.New and proven transplantation options preclude the patient from decent diabetic following the surgical removal (resection) of their pancreas. This is achieved by transplanting backwards in the patients own insulin-producing beta cells.

DISTAL PANCREATOMY it consist of distal pancreatic resection up to portal vein ,and it is performed if head of pancreas is relatively normal .

PANCREATODUDENECTOMY it is performed if head of pancreas is mainly involved .

LONGITUDINAL PANCREATOJEJUNOSTOMY it is performed if pancreatic duct is grossly dilated .

COMPLICATIONS

Vitamin B6 malabsorption in 40 % of alcohol induced and all cystic fibrosis cases.Impaired glucose tolerance .Nondiabetic retinopathy due to vitamin A and/ or zinc deficiency,Gastrointestinal bleeding ,icterus ,effusion ,subcutaneous fat necrosis and bone pain occasionally occur .Increased risk for pancreatic carcinoma .Narcotic addiction common.

Here's some information when your intestine is inactive or Paralytic ileus

2011-05-10T03:45:00.000-07:00

PARALYTIC ILEUS

It is a state in which intestine fails to transmit peristaltic waves and is due to failure in neuromuscular mechanism and Obstruction of the gut cod to paralysis of the viscus muscles. The paralysis does not need to be complete to cause ileus, but the viscus muscles must be so inactive that it prevents the passage of food and leads to a useful closure of the intestine.

IN POSTOPERATIVE ETIOLOGY

Ileus commonly follows some types of surgery, especially abdominal surgery ,Normal lyintestinal motility and absorption returns in about 16 hours ,However ,postoperative ileus may br prolonged , if there is Hypoproteinemia ,Latent renal failure , If gastrointestinal suction is continued beyond the point at which effective bowl sounds have returned .PERITONITIS initially as a normal response to prevent dissemination .Later bacterial toxins prevent normal activity of nerve plexuses.

It also crapper result from certain DRUGS like Uremia ( in renal failure ,following prostatectomy ) , HYPOKALEMIA, IN REFLEX ETIOLOGY Spinal injuries or ribs injuries, ,sometime Retroperitoneal haemorrhage , inflammation anywhere within the abdomen that touches the intestines, and diseases of the viscus muscles themselves and Application of the plaster jacket.

Irrespective of the cause, closure causes constipation ( no passage of flatus ,for upto 48 hours after laparotomy ), abdominal distention, ( more marked and drum like tympanitic ) and sickness and vomiting ( effortless ,large volume and with dirty fluid ) Respiratory distress. On listening to the abdomen with a stethoscope, some or no bowel sounds are heard (because the bowel is inactive) after laparotomy. Also titled disfunction ileus. Also simply titled ileus.with sign of Tachycardia ,there may be wound dehiscence .

Ileus may increase bond formation, because intestinal segments have more prolonged contact, allowing fibrous adhesions to form, and intestinal distention causes serosal injury and ischemia. Intestinal distention has been shown to drive adhesions in foals . Repeat celiotomy to decompress chronically distended small gut and vanish fibrinous adhesions is also a multipurpose method of treating ileus and reducting adhesions, and it has been related with a good outcome

DIAGNOSTIC TEST FORPARALYTIC ILEUS:

The list of diagnostic tests mentioned in various sources as used in the diagnosis of Paralytic ileus includes:

Stethoscope Examination of the abdomen : when a doctor ty o listen with a stethoscope to the abdomen there will be few or no bowel sounds ,indicating that the intestine has stopped functioning .ileus can be confirmed by X-ray of abdomen .computed tomography scans (CT scan ) or ultrasound .it may be necessary to do more invasive test msuch as barium enema or upper GI series if the obstruction is mechanical.Blood test also are useful in diagnosing paralytic ileus .barium enema used in some obstruction cases but it can cause few problems by increasing pressure or intestinal contents if used in ileus Also in doubtful cases with mechanical obsruction involving the gastrointestinal tract .

So its use is contraindicated in these typs of cases .but in some caes it should be used first .

TREATMENT OF PARALYTIC ILEUS

Always seek professional medical advice about any treatment or change in treatment plans, patients may be treated with supervised bed rest in a infirmary , and bowel rest ,where nothing is taken by representative ,and patients are feed intravaneously or finished the ingest of a nasogastric

tube .A nasogastric plaything is a plaything inserted finished the nose down to the throat and into the breadbasket.A kindred plaything can be inserted in the gut .The contents are then suctioned out .In some cases ,especially where there is a machine like obstruction ,surgery may be needed . Drug therapies that encourage intestinal motility ( ability of the gut to more spontaneously ) such as morphine or pethidine , in repeated small doses .Fluid and electrolytes balance ,especially serum K and blood urea.

PROPHYLACTIC TREATMENT

Routine nasogastric suction and withholding fluids by representative after laparotomy until normal bowel sounds returns ,and /or passage of flatus occurs .in most of the cases ileus are not preventable ,surgery to remove a tumr or other intestinal obstruction will help prevent a repetition .

Treatment for diverticular disease of colon

2011-05-09T10:55:00.001-07:00

Diverticulosis is generally discovered through one of the following examinations for appropriate treatment

Barium enema: This x-ray test involves injection of liquid material into the colon through a tube inserted in the rectum. The x-ray image shows the anatomy of the colon, and can identify if diverticula, large polyps or growths are present.

Colonoscopy: This test uses a thin, flexible tube with a light and camera to view the inside of the colon. Diverticula as well as polyps and other growths can be seen with this instrument.

CT scan: This x-ray test takes multiple cross section pictures of the body. It is not generally performed to make a diagnosis of diverticulosis, but this type of exam may identify diverticula.

Patients with diverticular disease should be counselled on the benefits of a high fibre diet. Bulking agents and laxatives could also be added until stools are soft and defaecation is painless.

Patients with acute diverticulitis are admitted to hospital for bed rest, nil by mouth (with iv fluids), analgesics, and IV antibiotics (e.g. cefuroxime and metronidazole). Patients presenting with PR bleeding are resuscitated and given blood transfusion.

Complicated disease (perforation, abscess, multiple attacks, uncontrollable bleeding) usually requires surgery to remove the diseased segment of colon. There are various surgical techniques available depending on the site of the disease, and a temporary stoma is usually needed (a "stoma bag"), although this is reversed after around 6 weeks.

CONSERVATIVE MANAGEMENT

Complicated disease (perforation, abscess, multiple attacks, uncontrollable bleeding) usually requires surgery to remove the diseased segment of colon.

There are various surgical techniques available depending on the site of the disease, and a temporary stoma is usually needed (a "stoma bag"), although this is reversed after around 6 weeks.

SURGICAL TREATMENT

INDICATIONS :Recurrent attacks -and Complications

OPERATIVE PROCEDURES

IDEAL OPERATION

This is a one stage resection ,which involves removal of affected segment 10 - 20 cm long and restoration of continuity by end-to-end anastomosis .

IN CASES OF OBSTRUCTION & INFLAMMATORY EDEMA AND ADHESIONS a preliminary transverse colostomy can be done as a first stage. In second stage of resecion is performed after 3 weeks or later when inflammation has subsided.Colostomy is closed after a further 2 weeks.
IN ACUTE PERFORATION proximal colostomy can be done ,Exteriorization , Primary resection.

HARTMANN'S OPERATION colostomy after excision with closure of defunctioned distal bowel .

Restoration of bowel continuity can be done at a later stage by means of stapling guns .

IN FISTULA resection of diseased bowel. ,closure of fistula .

IN HAEMORRAHAGE resection of bleeding segment ...... read more

Diverticular disease of colon common in western society

2011-05-09T05:24:00.000-07:00

WHERE REFINED DIETS ARE MORE COMMON THAN RICH IN FIBRE

DIVERTICULAR DISEASES OF COLON

Diverticula of colon are acquired rupture of colonic mucosa ,protruding through broadside muscle at points where murder vessels understand colonic surround .They consist of mucosa and submucosa that have cut the muscular coats . They are pulsion diverticula being pushed out by increased intraluminal push .Although they haw involve the whole of the colon .They are most ordinary in the colon

Diverticular disease is most ordinary in Western society ,where civilised diets are more ordinary than diets rich in fibre and hence the stool is inferior bulky . Patients with diverticular disease have shortened ,thickened colonic muscle which reflects work hypertrophy from years of a baritone fibre diet and resulting small hard stools .High intra-luminal pressure occur ,pushing the diverticulae out through the surround .The inclination of divertculae to form in the colon colon is explained by Laplace's law which states that the push within a tube is

inversely proportional to the radius.

PATHOGENESIS

DIVERTICULOSIS two factors are essential 1.exaggerated peristaltic contractions with abnormal elevation of intraluminal push ,and foci of muscle imperfectness in colonic surround.

DIVERTICULITIS it is the secondary land and is cod to rousing of one or more diverticula.

MICROSCOPIC FEATURES

DIVERTICULOSIS

Muscular hypertrophy in colonic segments affected by diverticular changes.saccule are found penetrating between the mesentric and lateral teniae at points where entering arterioles branch out into submucosa .Diverticulae are small ,flask like or spherical outpouchings usually 0.5 to 1 cm in diameyer .Walls of diverticula are usually thin ,made up of mucosa and submucosa enclosed within fat or an intact peritoneal covering .

DIVERTCULITIS

Inflammatory changes are present ,to produce both diverticulitis and periverticulitis and sometimes localized peritonitis .

SIGN AND SYMPTOMS OF DIVERTICULOSIS AND DIVERTICULITIS

Most patients with diverticulosis have no symptoms. Many will never know they have the condition until it is discovered during an endoscopic or radiographic (Xray) examination. While most people have no symptoms, some individuals may experience pain or discomfort in the left lower abdomen, bloating, and/or a change in bowel habits.

Other conditions such as irritable bowel syndrome and stomach ulcers cause similar problems, so the symptoms do not always mean a person has diverticulosis. People with chronic symptoms should visit their doctor or health care provider.

The most common symptom of diverticulitis is abdominal pain. The most common sign on examination is tenderness in the lower left side of the abdomen. Usually, the pain is severe and comes on suddenly, but it can also be mild and become worse over several days. The intensity of the pain can fluctuate. A person may experience cramping, nausea, vomiting, fever, chills, or a change in bowel habits...... read more

Here's another head scratcher Acute appendicitis

2011-05-09T03:58:00.000-07:00

ACUTE APPENDICITIS

Scientist theorize that appendix is a remnant of an ancient digestive tract .They believe that it might have been used by early man to digest tough leaves and bark.But it can create lot of trouble by causing Acute appendicitis.

The appendix is a worm like extension of the cecum and for this reason,has been called the Vermiform appendix.The average length of the appendix is 8-10 cm ( ranging from 2-20 cm ).The appendix appears during the fifth month of gestation and several lymphoid follicles are scattered in its mucosa.Such follicle increase in number when individuals are aged 8-20 years.

LOCATION

1.Base of appendix:

it is found attached to posteromedial surface of cecum about 2.5 cm below the ileicecal junction.

2.Body and tip of appendix:

a. Retrocecal (74 %)

b. Pelvic (21 %)

c. Paracecal (2 % )

d .Subcecal ( 1.5 % )

e. Periileal (1 %)

f. Postileal (0.5 % )

Vermiform appendix has a complete peritoneal covering, which is attached to lower layer of mesentry of small intestine to form a short mesentry of its own.the mesoappendix,but there is some variations.distal 1/3 of its may be bereft of mesoappendix.

ETIOLOGY

SEX: Males are more commen than female.

SOCIAL STATUS: Upper and middle class

DIET: One relatively rich in meat,& devoid of simple diet rich in cellulose

Familial susceptibility.

OBSTRUCTION OF LUMEN OF APPENDIX:Fecoliyh ,a stricture,a foriegn body,a rond worm.or thread worms.

DISTAL OBSTRUCTION OF COLON: Carcinoma of right colon.

Abuse of purgatives.

BACTERIA: a mixture of E coli,enterococci,non hemolytic streptococci,anaerobic streptococci,Cl welchi,& bacteroids.

PATHOLOGY

NON OBSTRUCTIVE ACUTE APPENDICITIS

Inflammation usually begins in mucosa,& less often in ymph follicles,but on reaching the loose submucosa it progresses rapidly.Organ becomes turgid and dusky red with mucosal hemmorrhages.Vascular supply of distal part of appendix is at risk.because here is the artery is inframural & liable to occlusion by in inflammation or thrombosis,this may lead to gangrene of tip.

Inflammation may progress sufficiently slowly for protective barriers to form ,& the resulting peritonitis is localized .It can terminate in one of the following ways:

Resoluton

Ulceration

Suppuration

Fibrosis

Gangrene

OBSTRUCTIVE ACUTE APPENDICITIS

Products of inflammation becomes pent up,so that it proceeds more rapidly & more certainly to gangrene or perforation.Often within 12-18 hrs,appendix distal to obstruction become gangrenous.Perforation occurs most often at the site of an impacted fecolith before protective adhesions have had time to form-Escaping purulent & gaseous contents are under high pressure ,& early widespread peritonitis is liable to ensue -Subphrenic & pelvic abcesses are a later sequel if patient survives the initial peritonitis.

CLINICAL FEATURES

Age incidence : Increasingly common during childhood & adolescence ,maximum incidence is between 20 & 30 years.

NON-OBSTRUCTIVE ACUTE APPENDICITIS

SYMPTOMS

Abdominal pain which shift : Initially there is constant, vague pain around umblicus,in epigastrium,or it may be generalized.After a few hours pain become intense .& shift to the point where inflammed appendix irritates partial peritoneum ( usually in right iliac fossa ).

Gastric function Upset : Anorexia, nausea, infrequent vomiting & stops as soon as stomach is empty.Usually constipation is present ,but occasionally diarrhea occur.

SIGNS

GENERAL SIGNS : Pyrexia ( 99 - 100 F )

Tachycardia ( 80 - 90 per min )

Tongue ( white & furred )

A special fetor oris

LOCAL SIGNS

Localized tenderness after the pain shifts, either at McBurney's point or elsewhere ( determined by the site of appendix ).

Muscle guarding & rigidity in right iliac fossa .

Rebound tenderness at McBurney's point in right iliac fossa.

Pressure on left iliac fossa may cause pain in right iliac fossa.

Release of pressure on left iliac fossa may cause pain in right iliac fossa.

Last three manoeuvres cause pain because they move the inflamed appendix.

OBSTRUCTIVE ACUTE APPENDICITIS

Sequence of clinical events occurs much more quickly:

Onset is abrupt .& there may be severe generalized abdominal colic from start.However ,the pain shifts in the usuall way.

Vomiting is common

Temperature can be normal

Local signs are as mentioned above.

INVESTIGATIONS

Appendicitis is essentially a clinical diagnosis.

The following may be useful.

Urine analysis may exclude urinary tract infection.
Pregnancy test to exclude ectopic pregnancy.
Abdominal x-ray is of little value.
A normal white cell count does not exclude appendicitis.
Ultrasound may be helpful in the assesment of an appendix mass or abcess.
Ultrasound adds little to the clinical diagnosis of acute appendicitis.
Scoring system and computer-aided diagnosis may be helpful.
Meta analysis suggest the following to be useful predictor of appendicitis in patients with abdominal pain.

Raised inflammatory markers '

Clinical signs of peritoneal irritation.

Migration of abdominal pain.

Treatment for acute appendicitis

2011-05-09T03:48:00.000-07:00

THE APPENDIX DOES NOT APPEAR TO HAVE ANY FUNCTION IN THE HUMAN BODY ...SO HOW CAN WE PANIC THROUGH NON FUNCTION ORGAN ???

TREATMENT

INDICATION FOR SURGICAL CONSULTATION AND SURGERY
A surgeon should evaluate any patient with classic migrating abdominal tenderness. Because only a little more than half of patients with appendicitis present with a classic history and physical findings, acute appendicitis should be on the list of possible diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients with focal RLQ tenderness or progressively worsening abdominal pain.
To minimize the time between show and appendectomy, obtain surgical conference prior to performing additional diagnostic studies, such as CT scan, ultrasound, and technetium (Tc)-labeled WBC scan.3

Indications for operation
Any patient with suspected appendicitis who has
(1) persistent discompose and becomes febrile,
(2) an increasing WBC count, or
(3) worsening clinical examination findings should undergo extirpation or at least diagnostic laparoscopy. In patients with an atypical presentation, the most important determination for extirpation is serial physical examinations. The WBC count often does not process after the patient is admitted and hydrated; therefore, any patient sent home from the emergency department should undergo a follow-up evaluation the incoming day.3

APPENDICECTOMY
Open by giving INCISION

Grid-iron incision.
Paramedian incision.
Rutherford Morison's incision.

REMOVAL OF APPENDIX
A retractor is placed under the medial side of peritoneum & abdominal wall is lifted up.Any pus or serous exudate is removed with a sucker & a pack is inserted into wound on medial side.Using a a swab,cecum is withdrawn.A finger may be inserted into wound to aid delivery of appendix.Cecum is grasped by an assistant. Atissue -holding forceps is applied around the appendix in such a way as to encircle the organ & yet not damage it .Base of mesoappendix is clamped in a hemostat,tied & severed.when mesoappendix is broad,procedure must be repeated with a 2nd or a 3rd hemostat.Appendix ,now completely freed,is crushed near its junction with cecum in a hemostat,which is removed & reapplied just distal to crushed portion.A catgut ligature is tied around crushed portion close to cecum,& an atraumatic catgut purse-string suture is inserted into cecum about 1.25 cm frombase & is left untied until appendix has been amputated with a scalpal below hemostat.Stump is invaginated while purse -string suture is tied,thus burying the appendix stump.

PERITONEAL LAVAGE
Peritoneum is washed out with antibiotic laden irrigating fluids.

ANTIBIOTICS
Prophylactic antibiotics active against aerobic & an aerobics organism are given in 2 doses ( one at the time of surgery & next 8-12 hours later )

DRAINAGE OF PERITONEAL CAVITY
Unnecessary, provided adequate peritoneal lavage has been done.However ,performed if there is considerable purulent fluid in retrocecal space or pelvis, or if there is persistent oozing.

DRAINAGE OF PARIETES
Indicated if there is any soiling of wound ,especially in obese & in children.

COMPLICATIONS OF APPENDICECTOMY

EARLY

ILeus
Wound sepsis
Residual abscess
Intestinal obstruction from adhesins
Fecal fistula
Pyelophlebitis
Postoperative thrombosis & embolism
Actinomycosis
Pulmonary complications (pulmonary collapse or pneumonia )

LATE

Intestinal obstruction from adhesions
Incisional hernia
Right inguinal hernia following grid iron incision
Sterility in female from frozen pelvis.

Intestinal tuberculosis is significantly increasing in developed countries with HIV

2011-05-09T03:20:00.000-07:00

INTESTINAL TUBERCULOSIS Is a Major Health Problem in Many Underdeveloped Countries

BUT

A Recent Significantly Increase In Developed Countries In Association With HIV Infection

TUBERCULOSIS OF INTESTINE

Some bacterial infections are surgically important include INTESTINAL TUBERCULOSIS usually seen in the uk as ileocecal tuberculosis and present with thickening and narrowing of the terminal ileum.It may be indistinguishable from crohn's disease on naked eye examinaton.although pale tubercle may be seen on the serosa in tuberculosis.Complications include adhesive obstruction ,perforation and malabsorption due to widespread mucosal involvement or lymphatic blockage.

INTESTINAL TUBERCULOSIS is a field health problem in some underdeveloped countries. A recent momentous increase has occurred in matured countries, especially in connexion with HIV infection. Autopsies of patients with pulmonary TB before the epoch of effective treatment demonstrated viscus involvement in 55-90% of mortal cases. The previously noted regular connexion between pulmonary TB and viscus TB no longer prevails, and only a minority of patients (<50%) with abdominal TB now hit deviant dresser radiographic findings. However, approximately 20-25% of patients with GI TB hit pulmonary TB. Any conception of the GI system haw be infected, although the ileum and colon are common sites.

Pathologically GI TB is characterized by inflammation and fibrosis of the bowel surround and the regional lymph nodes. Mucosal ulceration results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this initiate of the disease, the changes are reversible and healing without scarring is possible. As the disease progresses, the ulceration becomes confluent, and comprehensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral mass lesions. Strictures and fistulae formation may occur.

We can categarize Intesinal Tuberculosis into Three TYPES on gross pathologic examination

ULCERATIVE modify of TB is seen in approximately 60% of patients. Multiple ostensible ulcers are largely confined to the epithelial surface. This is considered a highly active modify of the disease, with the daylong axis of the ulcers rectangular to the daylong axis of the bowel.

HYPERTROPHIC modify is seen in approximately 10% of patients and consists of thickening of the bowel wall with scarring; fibrosis; and a rigid, masslike appearance that mimics that of a carcinoma.

ULCEROHYPERTROPHIC modify is a subtype seen in 30% of patients. These patients hit a compounding of features of the ulcerative and hypertrophic forms.

Clinical features of viscus TB include abdominal pain, weight loss, anemia, and feverishness with night sweats. Patients may present with symptoms of obstruction, correct iliac fossa pain, or a palpable mass in the correct iliac fossa. Hemorrhage and perforation are constituted complications
of viscus TB, although free perforation is less frequent than in doc disease. The diagnosis of purging tuberculosis requires a broad index of suspicion. In cases where the information available does not reveal a definite differentiation between colonic tuberculosis and Crohn's disease.

Intestinal tuberculosis is a thin disease in western countries, affecting mainly immigrants and immunocompromised patients. Intestinal tuberculosis is a diagnostic challenge, especially when active pulmonary infection is absent. It may mimic many other abdominal diseases.

The most common place of GI TB is the ileocecal region, if the area can be reached with a flexible endoscope. A rapid diagnosis can be achieved if smudge or culture results are positive or if caseating granulomas are seen in biopsy samples. In countries where GI TB is endemic, a therapeutic trial of antituberculosis treatment haw be justified if the clinical picture is compatible with TB.

TREARMENT OF INTESTINAL TUBERCULOSIS

A course of chemotherapy

Surgery is required in cases of complicated obstruction in HYPERPLASTIC TUBERCULOSIS - Right hemicolectomy with removal of diseased segment of ileum or defunctioning ileocolostomy .

Surgery is required in cases of Stricture causing intestinal obstruction or in perforation in ULCERATIVE TUBERCULOSIS

Acute pancreatitis

2011-04-30T11:04:00.000-07:00

ACUTE PACREATITIS

Its an acute inflammatory process caused by the effects of enzymes released from the pancreatic acini . There are numerous aetiological factors .

The pancreas is a super gland behind the breadbasket and close to the duodenum—the first part of the diminutive intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube titled the pancreatic duct. Pancreatic enzymes join with bile—a liquefied produced in the liver and stored in the gallbladder—to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

PATHOGENESIS of acute pancreatitis is obscureb,but two main mechanism may be involved

1.DUCT OBSTRUCTION __ this may lead to reflux of bile into the pancreatic ducts causing injury .Alternatively increased intraductal pressure may damage the pancreatic acini ,leading to leakage of pancreatic enzymes which may further damage the pancrease .

2.DIRECT ACINAR DAMAGE __ this may be caused by viruses ,bateria ,drugs or trauma .

The appearance of the pancrease in acute pancreatitis may be explained by release of pancreatic enzymes. Protease release causes widespread destruction of the pancrease and increases further enzyme release ,with consequent further damage.Release of lipase causing fat necrosis resulting in characteristic yellowish-white flecks on the pancrease ,mesentry and omentum .Often with calcium deposition.Other enzymes ,e.g. elastase ,destroy blood vessels ,leading to haemmorrhage within the pancrease and haemmorrhagic exudate into the peritoneum .Haemmorrhage may be extensive ,leading to acute haemmorrhagic pancreatitis.

BIOCHEMICAL CHANGES increased serum amylase. Amylase is released from the damaged acini and enters the blood stream .The serum amylase is released in the acute phase ( 24 - 48 h) but later falls to normal .Occasionally with acute haemmorrhagic pancreatitis the destruction of pancreatic acini is so swift and complete that the serum amylase may not be raised by th time the patient reaches hospital. Hypocalcaemia ,this arises become of deposition of calcium in areas of fat necrosis .Hyperglycemia ,this occurs because of associated damage to the pancreatic islets .Abnomal liver function tests may occur , especially raised bilirubin and alkaline phosphatase due to mild obstruction of the bile ducts by oedema .

Sudden, unceasing discompose in the upper part of the abdomen is a hallmark of acute pancreatitis, though other medical conditions crapper also cause this type of pain. The discompose may wrap around your upper body and involve the back in a band-like pattern. The discompose typically lasts days and is ofttimes relieved by leaning forward. Some grouping hit only slight abdominal tenderness and in 5 to 10 percent of people, there is no discompose at all.

In grouping with gallstone pancreatitis, gallbladder discompose may become before pancreatic pain. Gallbladder discompose (referred to as biliary colic) occurs in the right upper abdomen, extending to the back and right shoulder. The discompose gradually increases in intensity, is constant, and may be attended by sickness and vomiting. Gallbladder discompose ofttimes follows a meal.

In grouping with alcoholic pancreatitis, the symptoms of acute pancreatitis ofttimes become digit to three days after an alcohol binge or after stopping drinking. Pain is attended by sickness and regurgitation in most people. In severe cases, the initial symptom may be shock or coma.

Other conditions that have been linked to pancreatitis are:

Damage to the ducts or pancreas during surgery
High murder levels of a fat titled triglycerides (hypertriglyceridemia)
Injury to the pancreas from an accident
Blockage of the pancreatic duct or common bile duct, the tubes that pipage enzymes from the pancreas

Diagnosing accent pancreatitis is often difficult because of the deep location of the pancreas. The student will likely visit one or more of the mass tests:

•Abdominal ultrasound. Sound waves are dispatched toward the pancreas finished a handheld device that a technician glides over the abdomen. The good waves bounce soured the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture—called a sonogram—on a recording monitor. If gallstones are causing inflammation, the good waves will also bounce soured them, showing their location.

•Computerized picturing (CT) scan. The CT construe is a noninvasive x ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The effort may exhibit gallstones and the extent of alteration to the pancreas.

•Endoscopic ultrasound (EUS). After spraying a solution to numb the patient’s throat, the student inserts an endoscope—a thin, flexible, aflame tube—down the throat, finished the stomach, and into the small intestine. The student turns on an ultrasound adhesion to the scope that produces good waves to create seeable images of the pancreas and bile ducts.

•Magnetic kinship cholangiopancreatography (MRCP). MRCP uses attractable kinship imaging, a noninvasive effort that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like plaything for the test. The technician injects dye into the patient’s veins that helps exhibit the pancreas, gallbladder, and pancreatic and bile ducts.

Treatment of pancreatitis

Treating pancreatitis

2011-04-30T11:03:00.000-07:00

IT OCCURS SUDDENLY AND SUBSIDE IN FEW DAYS IF TREATS PROPERLY.

EACH YEAR ABOUT 210,000 PEOPLE IN THE US ARE ADMITTED TO THE HOSPITAL WITH ACUTE PANCREATITIS.

TREATMENT

The goals of communication of accent pancreatitis are to alleviate pancreatic inflammation and to correct the inexplicit cause. Treatment commonly requires hospitalisation for at small a few days."Treatment of accent pancreatitis"

BED REST
SUPPORTIVE INTRAVENOUS THERAPY restore adequate blood volume as soon as possible e.g by physiological saline .A careful fluid balance chart should be kept ,with appropiate allowance made for insensible loss .Daily serum electrolyte estimations are made ,together with acid-base studies.Full water replacement is given by intravenous route .Calories are given as glucose .Na ,K ,and Cl are given in appropriate amounts .ca deficiency, if develops , is treated by Ca gluconate IV

NASOGASTRIC ASPIRATION continuous suction removes gastric HCl from entering duodenum,that suppressing hormonal stimulation of exocrine secretions of pancrease .It also brings relief from persistent nausea and vomiting.

PAIN RELIEF
Originally it was thought that analgesia should not be provided by morphine because it haw drive symptom of the musculus of Oddi and exacerbate the pain, so the drug of choice was meperidine. However, due to lack of effectualness and risk of toxicity of meperidine, more recent studies hit institute morphine the analgesic of choice. Meperidine haw ease be utilised by some practitioners in more secondary cases, or where morphine is contraindicated.

PROPHYLACTIC ANTIBIOTICS given as a prophylactic against infection of necrotic retroperitoneal tissue ,and also against bronchopneumonia .A broad spectrum antibiotic ,e.g. cefoperazone should be given for 3-5 days.

EDOSCOPIC SPHINCTEROTOMY gallstone pancreatitis will be improved ,if a stone is obstructing the ampulla of vater .

Surgical options for pussy necrosis include:

Minimally intrusive management - necrosectomy through small incision in wound (left flank) or breadbasket
Conventional management - necrosectomy with ultimate drainage
Closed management - necrosectomy with closed continuous postoperative lavage
Open management - necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)

COMPLICATIONS include : Pancreatic Pseudocyst __ this is a localized collection of fluid in the lesser sac of peritoneum. Pancreatic Abscess , Stress induced gastric erosion with haemate mesis or melena .Acute renal failure ,Toxic psychosis ,Multiple organ failure ,chronic pancreatitis .

PROGNOSIS the overall mortality is between 10 % and 20 % .With severe haemmorrhagic pancreatitis the mortality rate reaches 50 % .The usual cause of mortality is multiple organ failure .

Acute pancreatitis
Sign and symptoms
Causes
Patophysiology
Diagnosis

Cholecystitis acute

2011-04-30T10:32:00.000-07:00

INCIDENCE RATE APPROXIMATELY SAME IN WORLDWIDE

5 TO !0 % MORTALITY OCCURS IN PATIENTS OLDER THAN 60 YEARS.

ACUTE CHOLECYSTITIS : is an inflammation of the gall bladder ,and is usually associated with stones. Occasionally it occurs without stones,i.e. acalculous cholecystitis.The later may be due to infection with E coli .Clostridia,or rarely Salmonella typhi. Acalculous cholecystitis may occur after prolonged starvation or total parenteral nutrition. Stasis is probably a contributing factor in the latter conditions .

The gall bladder becomes oedematous ,with mucosal ulceration ,and a fibrinopurulent exudate .Acute inflammatory cells infiltrate the wall . Even in the presence of thrombosis of the cystic artery ,gangrene is rare ,as the gall bladder gains a blood supply directly from the liver via the gall bladder bed .However ,gangrene does occasionally occur with perforation of the gall bladder ,resulting in generalised bile peritonitis or a localised abscess depending on whether the gall bladder has been walled off by adhesions or not .An empyema of the gall bladder may also result, suppuration occuring within the gall bladder and the gall bladder becoming distended with pus. Occasionally the gall bladder may fistulate into the duodenum.

Factors that haw initiate the inflammatory process include the manufacture of inflammatory mediators (eg, lysolecithin and prostaglandins); an increase in intraluminal pressure in association with compromise of the murder supply; and chemical botheration by bile acids.

90 % calculous and 10 % acalculous, Acalculous cholecystitis associated with higher complication rate and associated with acute illness ( i.e. burns ,trauma, major surgery ) ,fasting ,hyperalimentation leading to gall bladder stasis ,vasculitis ,carcinoma of gall bladder or common bile duct ,some gall bladder infections ( Leptospira ,Streptococcus,Parasitic ,etc.) but in >50% of cases an underlying explanation is not found.

In patients who hit emphysematous cholecystitis, ischemia of the gall bladder surround is followed by infection with gas-forming organisms that display pedal in the bladder lumen, in the gall bladder wall, or both. In 30-50% of patients, preexisting diabetes mellitus is present; the male-to-female ratio is 5:1.1 Gas haw be confined to the gall bladder; however, in 20% of cases, pedal is also seen in the rest of biliary tree. Gallstones are not inform in 30-50% of cases, and the mortality rate is 15%.1 There is a predisposition for gangrene formation and perforation, but clinical symptoms are mild; much symptoms can be deceptive. Emphysematous cholecystitis haw occur after chemoembolization performed as palliation for hepatocellular carcinoma; after fat embolism during aortography; and after gall bladder hypoperfusion during viscus resuscitation.

CLINICAL FINDINGS

Acute cholecystitis usually occurs with correct upper quadrant discompose and tenderness. The abdominal discompose increases with time. The place of discompose is usually the correct subcostal region, though the discompose haw begin in the epigastrium or the mitt upper quadrant and then shift to the correct subcostal region to the area of the gallbladder inflammation. Referred discompose to the correct shoulder or the interscapular region haw be experienced. Approximately greater than half of patients hit had preceding attacks of similar discompose that spontaneously resolved. Anorexia, nausea, and vomiting haw occur, but vomiting is seldom severe. Most patients are symptom and hit no leukocytosis.

When feverishness occurs, the patient's temperature is seldom higher than 38°C. Chills are unusual; their proximity suggests a case of complicated cholecystitis (abscess or associated cholangitis).

In some patients with acute cholecystitis hit mild jaundice, which haw be related to ordinary hepatic edema, bile duct edema, or both, or to the proximity of calculi within the common bile duct.1 In most patients, improvement occurs within 24 hours after hospitalization, and signs and symptoms gradually subside. Persistent pain, feverishness and leukocytosis, chills, and more nonindulgent localized or generalized compassionateness haw indicate complicated disease, much as abscess manufacture or GB perforation. The utilization of empyema of the GB haw display systemic toxicity, and it haw be predictive of GB perforation.

Acute acalculous cholecystitis is difficult to diagnose clinically. It often occurs in children and in patients who are critically ill or who hit fresh undergone pronounce from nonindulgent trauma, burns, or surgery. Predisposing factors allow prolonged fasting, immobility, and hemodynamic instability. Often, these patients cannot impart pain; however, fever, jaundice, vomiting, abdominal tenderness, leukocytosis, and hyperbilirubinemia are highly suggestive findings.

In approximately 1/3rd of patients, a distended, tender gall bladder haw be palpable as a distinct mass. This is an important clinical finding and haw confirm the diagnosis.

LABORATORY TEST Shows mild leukocytosis ,serum bilirubin alkaline phosphatase and AST may be mildly elevated.

DIAGNOSTIC INVESTIGATIONS

CHEST AND PLAIN ABDOMINAL X-RAYS it can help to exclude other causes ,and show radio-opaque stones .

ORAL CHOLECYSTOGRAPHY it is unreliable during acute attack , and is postponed until patients has recovered.

ULTRASONOGRAPHY confirm the diagnosis.

RADIOISOTOPE SCANNING confirm the diagnosis .

TREATMENT

CONSERVATIVE TREATMENR FOLLOWED BY CHOLECYSTECTOMY

No oral intake ,nasogastric suction .IV fluids and electrolytes ,analgesia ( mepridine or NSAIDS ). and antibiotics ( ureidopenicillins ,ampicillin sulbactam ,third generation cephalosporins ,anaerobic coverage should be added if gangerous or emphysematous cholecystitis is suspected , consider combination with aminoglycosides in diabetic patient or others with signs of gram-negative sepsis.Acute symptoms will resolve in 70% of patients.

SURGERY Optimal timing of surgery depends on patients stabilization and should be performed as soon as feasible. Urgent cholecystectomy is appropriate in most patients with a suspected or confirmed complication. Delayed surgery is reserved for patients with high risk of emergent surgery and where the diagnosis is in doubt.

Recurrent symptoms are common in patients with acute cholecystitis who are treated expectantly; most patients need elective cholecystectomy.

Percutaneous cholecystostomy is a minimally invasive procedure that can goodness patients with serious comorbidity who are at broad venture from major surgery. Percutaneous cholecystostomy can be performed at the bedside low local drug and is suitable for patients in qualifier care units and those with burns. It is the expressed treatment in patients with acalculous cholecystitis , or it may be used as a temporising measure—to pipage pussy bile and retard the requirement for expressed treatment.

Treatments for ulcerative colitis

2011-04-30T09:56:00.000-07:00

TREATMENT

Both medications and surgery have been used to treat ulcerative colitis. However, surgery is reserved for those with severe rousing and life-threatening complications. There is no medication that can cure ulcerative colitis. Patients with ulcerative redness will typically undergo periods of relapse (worsening of inflammation) followed by periods of remission (resolution of inflammation) lasting months to years.

During relapses, symptoms of abdominal pain, diarrhea, and rectal injury worsen. During remissions, these symptoms subside. Remissions usually occur because of communication with medications or surgery, but occasionally they occur spontaneously, that is, without some treatment.

Medications treating ulcerative redness allow 1) anti-inflammatory agents such as 5-ASA compounds, systemic corticosteroids, topical corticosteroids, and 2) immunomodulators.

Anti-inflammatory medications that modification intestinal rousing are analogous to arthritis medications that modification render rousing (arthritis). The anti-inflammatory medications that are used in the communication of ulcerative redness are:

Immunomodulators are medications that suppress the body's insusceptible system either by reaction the cells that are responsible for immunity, or by interfering with proteins that are important in promoting inflammation. Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative redness who do not move adequately to anti-inflammatory agents. Examples of immunomodulators allow 6-mercaptopurine (6-MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), cyclosporine (Gengraf, Neoral).

SURGERY

If fasting and lifestyle changes, drug therapy or other treatments don't assuage your signs and symptoms, your doctor may propose surgery.
Surgery can often decimate ulcerative colitis. But that usually means removing your whole colon and rectum (proctocolectomy). In the past, after this surgery you would dress a small bag over an opening in your cavum (ileostomy) to collect stool. But a procedure titled ileoanal anastomosis eliminates the need to dress a bag. Instead, your doc constructs a pouch from the modify of your small intestine. The pouch is then attached directly to your anus. This allows you to expel squander more normally, although you may hit more-frequent viscus movements that are soft or watery because you no individual hit your colon to absorb water.

If you hit surgery, communicate your doctor whether an ileostomy or an ileoanal pouch is correct for you. Between 25 and 40 proportionality of people with ulcerative colitis eventually need surgery.

COMPLICATIONS

These include toxic dilatation .haemmorrhage ,stricture and perforation .Carcinomas may occur ,the overall incidence being around 2% .However ,in patients who have had the disease for over 25 years this rises to 10 %.Factors associated with higher risk inclde onset in childhood , a severe first attack ,total colonic involvement ,and contineuos rather that intermittent symptoms .Extracolonic complications include seronegative arthritis ( sacroilitis ,ankylosing spondylitis) sclerosing cholangitis ,cirrhosis ,pericholangitis ,iritis uveitis ,episcleritis erythema nodosum ,pyodera gangrenosum ,and apthous stomatitis .Rarely , systemic amloidosis may occur.

ULCERATIVE COLITIS

CAUSES

SYMPTOMS

DIAGNOSIS

TREATMENT

SURGERY

COMPLICATIONS

Ulcerative colitis diagnosis

2011-04-30T09:55:00.000-07:00

DIAGNOSTIC INVESTIGATIONS

Many tests are utilised to diagnose ulcerative colitis. A fleshly communicating and medical history are usually the first step.Blood tests haw be done to check for anemia, which could indicate injury in the colon or rectum, or they haw uncover a high white murder radiophone count, which is a sign of rousing somewhere in the body

A crap distribution can also reveal white murder cells, whose presence indicates ulcerative redness or inflammatory disease. In addition, a crap distribution allows the student to detect injury or infection in the colon or rectum caused by bacteria, a virus, or parasites.

A colonoscopy or endoscopy are the most accurate methods for making a diagnosis of ulcerative redness and ruling-out another doable conditions, much as Crohn’s disease, diverticular disease, or cancer. For both tests, the student inserts an endoscope—a long, flexible, aflame tube adjoining to a computer and TV monitor—into the arsehole to wager the exclusive of the colon and rectum. The student will be healthy to wager some inflammation, bleeding, or ulcers on the colon wall. During the exam, the student haw do a biopsy, which involves attractive a distribution of tissue from the covering of the colon to view with a microscope.

Sometimes x rays much as a barium enema or CT scans are also utilised to diagnose ulcerative redness or its complications.

ULCERATIVE COLITIS

CAUSES

SYMPTOMS

TREATMENT

SURGERY

COMPLICATIONS

Disease ulcerative colitis

2011-04-30T09:36:00.000-07:00

AROUND 100,000 HAVE THIS DISASE IN UK

CURRENT HYPOTHESIS ,

HIGHER CONCORDANCE RATE IN MONOZYGOTIC TWINS

ULCERATIVE COLITIS

Ulcerative colitis is a inflammatory disease which involves the whole part of the colon .The inflammation is initially confined to the mucosa and nearly always involves the rectum .extending to involve the distal or whole colon.In severe cases the inflammation may extend into the muscle coats .Acute complications include toxic dilatation , haemorrhage and perforation .

AETIOLOGY

The cause of ulcerative colitis is not known.Current hypotheses includes immunological ,dietary and genetic factors .Familial clustering occurs . There is an association with HLA-DR2.Other evidence of a genetic role includes a higher concordance rate in monozygotic twins ,and increased prevalence in certain ethnic groups and an association with disease that are known to have a genetic predisposition .e.g ankylosing spondylitis and sclerosing cholangitis . Immunological mechanism may be important .Under normal circumtances the mucosal immune system is tolernt of luminal forign antigens and this is dependent upon the relationship between colonic epithelium and suppressor T cells .

Changes in epithelial cell antigen presentation consequent upon an acquired expression of class II major histocompatibility mlecules activate helper T lymphocytes and induce a sustained mucosal immune reaction .Antigens from gut flora may be responsible for this .This may explain the well-known triggering of ulcerative colitis by enteric infections. Dietary factors may also provide a triggering factor.

MORPHOLOGY ulcerative colitis is a diffuse inflammatory disease confined initially to the mucosa.Unlike Crohn's disease it is confined to the large intestine and is continuous in its distribution.In some cases it is confined to the rectum ( proctitis ) ,or to the rectosigmoid (distal proctitis ).

Abcesses form in the crypts of Lieberkuhn ,penetrate the superficial mucosa ,spread horizontally and cause the overlying mucosa to slough.The margins of the ulcers are raised as mucosal tags that project into the lumen ( inflammatory pseudopolyps ) Except in the most seere forms the muscle layers are spared .Occasionally the last few centimeters o the terminal ileum is ulcerated ,i.e the so called condition of 'backwash ' ileitis .

CLINICAL FEATURES More common in women ,aged 3rd ,4th and 2nd decade ,in that order .

SYMPTOMS

IN CHRONIC TYPE initially watery diarrhea occuring day and night ,in a person of previously normal bowel habit.Later a rectal discharge of mucus ,sometimes blood stained and purulent is very common .Severe bloody diarrhea upto 20 times daily may occur .pain is unusual ,initially,relases and remissions.

IN ACUTE FULMINATING TYPE

Incessant diarrhea containing blood ,mucus and pus .fever Abdominal distension ( due to toxic dilatation of colon ) ,Abdominal pain

SIGNS

IN CHRONIC TYPE depending upon severity of attacks dehydration ,Anemia

IN ACUTE FULMINATING TYPE pyrexia ,100-102 F .dehydration ,anemia and abdominal distension.

ULCERATIVE COLITIS

CAUSES

SYMPTOMS

DIAGNOSIS

TREATMENT

SURGERY

COMPLICATIONS

Gall stones(cholelithiasis)-Gall bladder problems common in women eat high fibre diet for prevention

2011-04-30T06:56:00.000-07:00

PATHOLOGICAL CONDITIONS OF THE GALL BLADDER ARE COMMON SURGICAL PROBLEMS....

GALL STONES ( CHOLELITHIASIS )

In medicine, gallstones (choleliths) are crystalline bodies formed within the embody by increment or concretion of normal or deviant bile components.In 80% of patients gall stones are composed predominantly of cholesterol with smaller amounts of calcium salts and bile pigments . They are referred to as mixed stones , are usually multiple with a faceted surface , and have a characteristic laminated surface on cross section. Only about 10 % of them contain sufficient calcium to be visible on a plain X-ray .Pure cholestrol stones form less than 10% of stones .They are usually solitary ( the cholestrol " solitaire " ) up to 5 cm in diameter ,and have a characteristic radial arrangement of crystals on cross section . Cholestrol stones usually form in bile which is supersaturated with cholestrol. When bile contains more cholestrol than can be solublised in the bile- acid -lecithin micelles ,crystals of cholestrol form in the bile .

The greater the concentration of bile acids and lecithin in bile ,the greater is the amount of cholestrol that can be contained in the mixed micelles .Lecithin is important because lecithin - cholestrol mixed micelles can solubilise more cholestrol than can micelles of bile acids alone .Following Crohn's disease of the terminal ileum or ileal resection thebile salt pool is reduced because of lack of absorption of bile salts ,and the liver can not make good the losses .

Such patients are prone to cholestrol stones. Oestrogen increases the hepatic synthesis of cholestrol ,and this may explain why females of child - bearing age have a higher incidence of cholestrol stones . A high animal fat ,low fibre diet is also associated with cholestrol stones because of excretion in bile of the excess cholestrol absobed from the gut.Clofibrate , a cholestrol-lowering agent ,has been implicated in cholestrol stone formation ,because it increases excretion of cholestrol in the bile . Decreased gall bladder motility probably plays a rle in aetiology of gall stones .

Cholestrol and other substances which form the nuclei for gall stone formation must remain in the gall bladder long enough for crystal growth to occur .Stasis occurs during pregnancy due to the smooth muscle relaxing effect of progesterone.Motility of the gall bladder is also decreased during starvation and total parenteral nutrition , due to decreased stimulation of the gall bladder by CCK.Stones may also form after vagotomy ,because of lack of vagal potentiation of CCK.Bile pigment stones account for about 10 % of stones in the UK.The major constituent is the calcium salt of unconjugated bilirubin.

They are associated with chronic haemolytic disease where there is breakdown of red cells with release of excessive bilirubin.Pure pigment stones occur in sickle cell disease , thalassaemia and hereditary spherocytosis .Pigment stones are found in the Far East ,where they are associated with biliary tract infection with E.coli and Bacteroides fragilis ,These organism produce beta-glucuronidase which splits bilirubin diglucuronide and releses free bilirubin.The latter combines with calcium to form the relatively insoluble calcium bilirubinate.

PATHOLOGICAL CONSEQUENCES OF GALL STONES ARE :

Inflammation of the gall bladder ,acute cholecystitis ,chronic cholecystitis ,acute on chronic cholecystitis
obstructive jaundice due to impaction of a stone at the lower end of the common bile duct : secondary biliary cirrhosis may result .
ascending cholengitis
empyema of the gall bladder.
mucocele
gall stone ileus __ a fistula occurs between the gall bladder and duodenum ,and a large stone enters the small bowel ,causing obstruction .usually at the terminal ileum .
pancreatitis ,usually associated with multiple small stones .
carcinoma of gall bladder .
perforation of the gall bladder .

Medicines titled chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given in preventive form to dissolve cholesterin gallstones. However, they may take 2 eld or longer to work, and the stones may return after communication ends.

Rarely, chemicals are passed into the gallbladder finished a catheter. The chemical apace dissolves cholesterin stones. This communication is not used rattling often, because it is difficult to perform, the chemicals can be toxic, and the gallstones may return.

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients staleness be indicated to surgery. The lack of a gall bladder does not seem to have any perverse consequences in some people. However, there is a momentous assets of the population — between 5 and 40% — who amend a information called postcholecystectomy syndrome which haw drive gastrointestinal painfulness and persistent discompose in the upper right abdomen. In addition, as some as 20% of patients amend chronic diarrhea.

Electrohydraulic damper wave lithotripsy (ESWL) of the gallbladder has also been utilised for selected patients who cannot have surgery. Because gallstones often become backwards in many patients, this treatment is not utilised very often any more.

Test for appendicitis -Pinch-an-inch test

2011-04-30T06:40:00.000-07:00

PINCH-AN-INCH TEST FOR APPENDICITIS

Its a prospective comparative assesment of two physical exam technique for evaluating patients with doubtable appendicitis.Rebound tenderness is a widely acclimated assay address for patients with doubtable appendicitis.but it can be absolutely uncomfortable.an another analysis for peritonitis is termed THE PINCH-AN-INCH TEST.

This address call two patients who presented with balmy belly affliction who subsequently were begin to accept appendicitis.In both patients classic peritoneal signs were absent but the compression an inch analysis was positive.the accomplished physicians bedside analytic assay remains the most critical component for rapidly anecdotic peritonitis.Although rebound tenderness is a broadly acclimated examination.It is afflictive and may be inaccurate.

To perform the pinch-an-inch test,a bend of belly derma over McBurney's point is grasped and animated abroad from the peritoneum.The derma is recoil back briskly against the peritoneum.If the patient has added affliction if the derma bend strikes the peritoneum, the analysis is absolute and peritonitis apparently is present.

As an added feature,if the affliction seems boundless just during the antecedent compression phase,the patient may accept a actual low affliction threshold,a factor that can be taken into account when deciding if the patient has a surgical abdomen.We anecdotally accept begin the analysis to be appreciably accessible for the appraisal of appendicitis.

Delayed analysis of acute appendicitis can advance to cogent morbidity.However recent technological advances in radiological imaging, the alert analysis of acute appendicitis can be difficult.Indeed,some experts accept that overreliance on imaging at the amount of the bedside assay may in fact access appendicitis accompanying morbitity.Arguably,both of these patients ability accept been bigger served by undergoing surgery directly without the delay of of CT imaging.Therefore analysis efforts should be directed against developing and acceptance bigger bedside assesment of peritonitis.

One important admonition to clinicians is the actuality that patients with appendicitis may in fact accept hyperesthesia over McBurney's point,and an boundless affliction acknowledgment to he compression appearance should not be absolved out of the hand.

The technique potencially allows for a added objective and reproducible physical assay than rebound tenderness which requires the examiners abjure his easily rapidly abundant to break advanced of the accustomed natural recoil of the belly wall.Rebound tenderness as well requires that the physicians does not added abase his easily in a form of backswing.Pinch an inch in contrasr allows for a added accelerated and reproducible absolution of tension.

In an accomplishment to advance patient's abundance during the belly assay we developed an alternating address for detecting peritonitis.we appellation this pinch-an-inch,we accept that compression an inch after-effects in less affliction than rebound tenderness.while not compromising effectiveness.

We achievement that our pinch-an-inch assay address may eventually action a added adequate and authentic another to classic rebound tenderness.Toward this effort,we will conduct a -to-be abstraction to appraise its accurateness and about abundance in diagnosing appendicitis.
several studies have shown it to be quite accurate in the evaluation of the appendicitis so its use should not be stoped.

Intestinal pain - Acute intussusception if you avoid can lead to death

2011-04-30T06:01:00.000-07:00

What Could Happen If You Avoid The TREATMENT ?

IT Will Get So Extreme.........Lead To DEATH

ACUTE INTUSSUSCEPTION :

INTUSSUSCEPTION is an invagination of size of intestine ( intussuscepiens ) into the immediate portion of bowl ( intussusceptum ) and most of cases occur in children during the first 5 decades of life. This can often result in an obstructio .The part that prolapse into the other is called the INTUSSUSCEPTUM and the part that recieves it is called INTUSSUSCEPIENS.

In some of children with intussuscetion , an anatomic predisposing condition . Such as Meckle's diverticulum , Burkitt lymphoma, or hamartomatous polyps ,can be found .And in most of the cases are associated with hyperplastic lymphoid tissue.suggesting an infectious causes ,which is not confirmed in most of the cases.By using serology and virus isolation from fecal and pharyngeal swabs.Adeno virus , Rotavirus ,Enterovirus , Human herpes virus ,Cytomegalovirus and Epstien-barr-virus.some bacterial agents can also involved in this condition include Yersinia ,enterocolitis and salmonella typhimurium and candida albican .

TYPES

Ileocolic ( 77 % )

Ileoileocolic ( 12 % )

Ileoileal (5 % )

Colocolic ( 2 % )

Multiple (! % )

Retrograde ( 0.2 % )

Others ( 2.8 % ) .

CLINICAL FEATURES :

SYMPTOMS

Sudden paroxymsm of abdominal pain ,with drawing up of legs and screaming :each attack lasts a few minutes and recur about every 15 minutes.
Facial pallor
Vomiting
Listleness and somewhat drawn between the attacks .
Stool : intially normal later blood and mucus are evacuated called "red currant jelly stool "
when not relieved upto 24-36 hours

a . Pain becomes contineous

b. Abdomen distends

c. Vomiting becomes copious

d. Absolute intestinal obstruction follows

SIGNS

A lump is felt ,which may harden on palpation .
PR examination : if intussuscetion has travelled far enough ,its apex ( a conical ) mass will be felt .
When not relieved ,upto 24 - 36 hours

a . Dehydration

b . Abdominal distension

c . Abdominal guarding , tenderness and rebound tenderness if gangrene has occured.

DIAGNOSTIC INVESTIGATIONS :

INTUSSUSCEPTION is often suspected based on history and physical examination , including observation of Dance's sign .Per rectal examination is particularly helpful in children as part of thintussusceptum may be felt by the finger .A definite diagnosis often requires confirmation by diagnostis imaging modalities .

ULTRASOUND is today considered the imaging advanced technology of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation.A target like mass ,usually around 3 cm in diameter confirm the diagnosis.

PLAIN ABDOMINAL X-RAY
Revealed increased gas shadow in small intestine and at times absence of cecal gas shadow .

X-RAY WITH BARIUM ENEMA :
Reveal characteristic " claw sign " in ileocolic intussusception .

TREATMENT :

The condition is not usually immediately life threatning.The intussusception can be treated with either a barium or water soluble contrast enema or an air contrast enema .which both confirms the diagnosis of intussusception, and inmost cases successfully reduce it . The success rate is over 80% .Therefore approximately 5 - 10 % of these recur within 24 hours .If it cannot be reduced by an enema or if the intestine is damaged , then surgical reduction is necessary.

PRELIMINARY TREATMENT

Gastric aspiration should be carried out and contiued during and after operation.
Give IV dextrose - saline solution.

REDUCTION OF INTUSSUSCEPTION
REDUCTION BY HYDROSTATIC PRESSURE

OPERATIVE REDUCTION :

Abdomen is opened through a right lower paramedian incision .First part of reduction is accomplished by squeezing lower part of sausag like mass ,and little intussusception is reduced.Last part is most difficult to reduce and should br withdrawn and gently compressed in a warm saline soaked pack,to

lessen the edema.
After reduction if a specific cause is revealed appropriate treatment is carried out ,eg Meckle's diverticulum.

PROGNOSIS :

The outlook for intussusception is excellent .when treated immediately .but when untreated it can lead to death within 2-5 days .Quick treatment can avoid this surgery .Prolonged intussusception can lead to ischemia and necrosis and it requires surgical resection.

AFTER TREATMENT

Gastric aspiration should be continued for 12-24 hours
Dextrose-saline is given IV or SC with hyaluronidase.
On 2nd day ,gastric tube is removed and sips of water are given.
Few hours later ,feeding is commenced with mother's milk ( if infant is still being breast-fed ).

COMPLICATIONS:

Intestinal obstruction
Gangrene

Biliary stricture

2011-04-30T05:32:00.000-07:00

IT CAN OCCUR AS A RESULT OF A TECHNICAL MISHAP......

DURING CHOLECYSTECTOMY IF IGNORED CAN DRIVE LIFE- THREATENING COMPLICATIONS

STRICTURE OF BILE DUCT

A bile duct stricture is caused by narrowing of the bile duct. The narrowing bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood feat obstructive jaundice ,it crapper cause through Surgical trauma ( postoperative ) ,Stones ,Primary sclerosing cholangitis ,Carcinoma of bile funiculus Carcinoma of head of pancreas.

Bile duct pathology (biliary stricture) is an uncommon but hard clinical condition that requires a integrated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma , Bile duct strictures (biliary strictures) may be well but, if ignored, can drive life-threatening complications, such as ascending cholangitis, liver abscess, and secondary biliary cirrhosis

POSTOPERATIVE STRICTURE it is the result of a preventable non achievement in technique , during the performance of cholecystectomy ;Blind plunge application of a hemostat to a bleeding cystic or accessory cystic artery ,or to right hepatic artery.Should cholecystectomy be performed by dissecting from fundus ,too such traction applied to freed gall sac may so tent the bile funiculus that some forceps witting for cystic funiculus apprehension angulated main channel .Failure to identify anatomy in Calot's polygon when there is such inflammation .Common hepatic funiculus is tied instead of cystic duct.Ignorance of anatomical anomalies o bile ducts.Laceration of bile patch explration for stones.Injury to bile funiculus during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE

Bile funiculus injuries may be rcognized at the instance of surgery .

Postoperatively by profuse and persistent discharge of bile if evacuation has been provided.Bile peritonitis if evacuation

has not been provided.Deepening obstructive jaundice.

In the absence of symptoms of the primary disease, most patients with bile funiculus strictures (biliary strictures) rest asymptomatic until the lumen of the bile funiculus is sufficiently narrowed to drive position to the flow of bile. Occasionally, patients may hit intermittent episodes of right upper line pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often inform with features of obstructive jaundice. On occasion, a patient may inform dramatically with sepsis and hypotension due to ascending cholangitis.

Cholangitis occurs in the proximity of partial or complete obstruction of the common bile funiculus , with accumulated intraluminal pressures, bacterial infection of the bile with procreation of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can apace embellish a life-threatening condition. Clinical show varies, with the Charcot set of fever and chills, jaundice, and right upper line abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also hit altered mental position and hypotension (ie, Reynold pentad). In the epilepsy of previous instrumentation, cholangitis is uncommon with malignant strictures.

Tests that shows stricture in the bile duct: ERCP (endoscopic retrograde cholangiopancreatography) , PTC (percutaneous transhepatic cholangiogram) ,MRCP (magnetic kinship cholangiopancreatography)

Blood tests that indicate deviant function of biliary system:

Bilirubin level is higher than normal
ALP (alkaline phosphatase) is higher than normal

TREATMENT

PREOPERATIVE TREATMENT temporary external biliary drainage ,by passing a cather percutaneously into an intrahepatic duct ,or by passing a cather through stricture at ERCP and left to drain through mouth.

OPERATIONS

Roux-en-Y choledochojejunostomy

Cholecystojejunostomy

Choledochoduodenostomy

Insertion of a stent

COMPLICATIONS

Recurrent inflammation of the biliary duct and stricture can occur in whatever patients. Patients are at risk for infection developing above the stricture. Long-standing strictures can advance to cirrhosis.

Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.