ABHIRAM SAVVY

SURGERY PAKKA PASS

GENERAL SURGERY
1. Wound and wound healing – 2
2. Ulcer – 6
3. Infectious diseases – 12
4. Swellings – 22
5. Electrolytes & Nutrition – 27
6. Shock – 32
7. Haemorrhage & Blood transfusion - 37
8. Burns – 40
9. Hand Infection – 45
10. Arterial diseases – 47
11. Vascular diseases - 58
12. Venous disease – 60
13. Lymphatic – 65
14. Skin tumours - 68

SYSTEMIC SURGERY
1. Facio-Maxillary diseases - 73
2. Oral cavity – 75
3. Salivary glands – 79
4. Neck - 83
5. Thyroid – 87
6. Parathyroid & Adrenals – 95
7. Breast – 96
8. Peritonitis – 105
9. Liver – 113
10. Gall bladder – 123
11. Spleen – 135
12. Pancreas – 139
13. Retroperitoneal tumour – 146
14. Abdominal wall & Umbilicus – 151
15. Hernia – 153
16. Esophagus – 164
17. Stomach – 174
18. Small intestine – 184
19. Large intestine – 192
20. Intestinal obstruction – 196
21. Appendix – 204
22. Rectum & Anus – 207
23. Kidney & Ureter – 217
24. Urinary bladder – 228
25. Prostate - 231
26. Urethra - 234
27. Penis - 236
28. Scrotum - 238
29. Testis - 241
30. Neurosurgery – 245
31. Thorax – 249
32. Anesthesia & Adjuvant therapy - 254
33. Operative procedures - 261

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WOUND AND WOUND HEALING

HEMATOMA
• Localised collection of blood after blood trauma or after surgery
• Collected blood gets clotted in few minutes to hours → letter eventually liquefied to form a discoloured
fluid
• Location
o Subcutaneous
o Intramuscular
o Subfascial
o Intra-articular
• Large hematomas gets infected and forms abscess → needs drainage under General or regional
anaesthesia
• Small hematomas usually get absorbed (scalp hematoma)
• Complications
o Pressure effects
o Abscess formation
o Cosmetic problems
• Treatment → incision and drainage
• Applied concept
o Spontaneous hematomas occur in individuals
▪ Coagulating disorders
▪ Anticoagulant drug therapy

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PHASES OF WOUND HEALING

A. Inflammatory phase (exudative phase)
• Begins immediately and lasts for 72 hours
• Pathogenesis
• Initial arteriolar vasoconstriction → platelet aggregation → thrombus formation
• Later vasodilation and increased vascular permeability develops
• It it happens in the sequence of
• hemostasis → coagulation → chemotaxis
• All these causes features of acute inflammation
• Rubor
• Calor
• Tumor
• Dolor
• Loss of function
B. Proliferative phase
• It begins from third day and lasts for 3-6 weeks
• Formation of granulation tissue and repair of the wound
• Granulation tissue contains fibroblasts, collagen, neocapillaries
• It happens in the sequence
• Initial angiogenesis (due to VEGF) → fibroplasia (formation of collagen → re-epithelization
C. Remodeling phase (maturation phase)
• Begins at 6 weeks and lasts for 6 months to 2 years
• Maturation of collagen by crosslinking
• Realignment of collagen fibres along the line of tension
• Type 3 collagen is replaced by type 1 collagen
• Scar strength
• 1 week – 3%
• 3 weeks – 20%
• 12 weeks – 80%

FACTORS AFFECTING WOUND HEALING

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CRUSH SYNDROME
• Due to crushing of muscles causing extravasation of blood and release of myohemoglobin into circulation
• Leads to acute tubular necrosis and acute renal failure
• Causes
o Earthquake
o RTA
o Mining accident
o Industrial accident
• Pathogenesis
o Crush increases tension in muscle compartment → impedes the circulation → ischaemic damage →
release of myohemoglobin and toxic proteins → damage to kidney
• Clinical features
o Urine discoloration
o Patient becomes restless
o Uraemia
• Effects of crush injury
o Renal failure
o Toxemia
o Septicemia
o Gas gangrene
o Extensive tissue loss
• Treatment
o Fasciotomy
▪ Multiple parallel deep incisions to relieve tension
o Rheomacrodex and mannitol
▪ Given to improve urine output
o Urine Alkalinisation using sodium citrate and sodium bicarbonate
▪ Increase the solubility of acid hematin and promotes excretion
o Hemodialysis, antibiotics, correction of severe hyperkalemia

HYPERTROPHIC SCAR
• Excessive formation of abnormal scar tissue containing type 3 collagen
• Often raised but confined within the margin of original wound
• Usually its growth stops in 6 months and regress spontaneously
• Features
o Occurs anywhere in the body
o Not genetically predisposed
o Growth limits up to 6 months
o It will not extend beyond The originals scar margin
o Response variable for steroid injection
• Complications
o Often scar breaks causes infection, pain
o After repeated breakdown → turns into Marjolins ulcer
• Treatment
o Pressure garments
o Excision of scar and closure
o Triamcinolone injection

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KELOID
• Excessive abnormally stretched collagen tissue bundles extending beyond the original scar margin
• Features
o MC in blacks
o MC in females
o Genetically predisposed
o Defect in maturation and stabilization of collagen fibrils
o Keloid may continue to grow even after 6 months
o Recurrence after excision >50%
• Associated with disorders like
o Ehlers-Danlos syndrome
o Scleroderma
• Contents of keloid
o Proliferating immature fibroblasts
o Proliferating immature blood vessels
o Type 3 collagen stroma
• Site
o Sternum
o Upper arm
o Chest wall
o Lower neck
• Differential diagnosis → Hypertrophic scar
• Treatment
o Intra-keloidal triamcinolone (reduces fibroblast proliferation and collagen synthesis)
• Silicone gel sheeting
• Nd-YAG laser
• Vitamin E / palm oil massage
• Excision and skin grafting

COMPARTMENT SYNDROME
• Syndrome due to increased intra-compartmental pressure within a limited space area
• Causes
o Tight dressings/plaster cast
o Lying on one limb in comatose patients
o Trauma like Fractures, ischemic injury, hematoma, burn injury etc
o Gun shot
o Snake bite
• Features
o Compromises circulation
o Compromises function of muscles and nerves
o Muscle ischemia > 4 hours causes muscle death and myoglobinuria
o Nerve ischemia > 8 hours causes irreversible nerve damage
o Diagnostic sign →persistent severe pain which aggravates by passive muscle stretching
• Symptoms
o Pallor, Pulselessness
o Pain, Paraesthesia
o Diffuse swelling, Cold limb
o Upon progression →gangrene for chronic ischemic contracture

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• Complications
o Infection, Septicaemia
o Renal failure
o Gangrene, Ischemic contracture
• Treatment
o Compartment pressure measured by placing fine catheter in the compartment → if > 30 mmHg
→ Fasciotomy
o Fasciotomy
▪ Adequately lengthy incision through deep fascia → done until underneath muscle bulges
out properly
o Antibiotics, hyperbaric oxygen
o Mannitol → diuresis

ULCER
• Is a break in the continuity of the covering epithelium due to molecular death
• Parts of an ulcer
1. Margin
▪ Regular or irregular
▪ Rounded or oval
2. Floor - contains discharge, granulation tissue
3. Base – upon which ulcer rests (soft tissue or bone)
4. Edge
▪ Sloping edge – seen in healing ulcer
▪ Undermined edge – seen in tuberculous ulcer
▪ Punched out edge – Seen in syphilitic (granulomatous) ulcer
▪ Raised and beaded edge – Rodent ulcer (BBC)
▪ Everted edge (rolled our edge) – Seen in carcinomatous ulcer

Induration of an ulcer
• Induration is a palpatory sign which means there is a specific type of hardness in the diseased tissue
• Observed in long standing ulcer with underlying fibrosis
• Outermost part of the indurated area is the point from where clearance of Wide Excision is planned

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Stages of ulcer healing

A. Stage of extension
a. Ulcer floor covered with purulent discharge
b. Inflamed edge
B. Stage of transition
a. Floor shows healthy granulation tissue
b. Serous discharge
C. Stage of repair
a. Fibrosis
b. Collagen deposition
c. Scar formation
Clinical classification
1. Spreading ulcer
• Edge – inflamed, irregular, oedematous
• Acute painful ulcer
• Floor
• does not contain healthy granulation tissue
• granulation tissue may be absent
• Has profuse purulent discharge
• Regional lymph nodes are enlarged and tender due to inflammation
2. Healing ulcer
• Sloping edge, with healthy pink granulation tissue
• Floor – Scanty/minimum serous discharge
• Surrounding areas does not show any signs of inflammation or induration
• 3 zones are observed
1. Innermost red zone - healthy granulation tissue
2. Middle bluish zone – growing epithelium
3. Outer whitish zone - fibrosis and scar formation
3. Non-healing ulcer
• It is a chronic ulcer depending on the cause
• Edge
• Punched out - trophic ulcer
• Undermined - tuberculous
• Rolled out - carcinomatous ulcer
• Beaded - rodent ulcer
• Floor
• Contents and healthy granulation tissue and purulent/bloody discharge
4. Callus (stationary) ulcer
• Chronic non-healing ulcer
• Edge - indurated
• Floor
• Unhealthy, white granulation tissue
• Scanty serous discharge
• Ulcer does not show any tendency to heal

Based on duration classification

1. Acute ulcer - <2 weeks
2. Chronic ulcer >2 weeks

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Pathological classification
1. Specific ulcer
• Tuberculous
• Syphilitic
• Actinomycosis
• Meleney’s ulcer
2. Malignant ulcer
• Carcinomatous
• Rodent ulcer (BBC)
• Melanotic ulcer
3. Non specific ulcer
• Traumatic ulcer
• Arterial ulcer – atherosclerosis, TAO
• Venous ulcer - gravitational ulcer, post-phlebitic ulcer
• Trophic ulcer/ pressure sore
• Infective ulcer
• Cortisol ulcers
• Bazin’s ulcer
• Diabetic ulcer
• Martorell’s hypertensive ulcer – seen in calf
• Frostbite (cryopathic ulcer)
• Ulcers due to leukaemia, polycythemia, jaundice etc
Wagner’s grading of ulcer
Grade 0 Pre ulcerative lesion/ healed ulcer
Grade 1 Superficial ulcer
Grade 2 Ulcer exposing soft tissues or bone
Great 3 Abscess formation/ osteomyelitis
Grade 4 Gangrene of a part of the Area/limb
Grade 5 Gangrene of entire Area/limb

Different types of discharges in ulcer

• Serous - healing ulcer
• Purulent - infective ulcer
• Bloody - malignant ulcer, healing ulcer with healthy granulation tissue
• Seropurulent
• Serosanguinous – serous and blood
• Serious with Sulphur granules – actinomycosis
• Yellowish discharge – tuberculous ulcer

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Granulation tissue
Proliferation of new capillaries and fibroblasts with fibrin cover over it

Types
A. Healthy granulation tissue
• Occurs in healing ulcer
• Sloping edges
• Serous discharge
• 5P
• Pink
• Punctate hemorrhage
• Pulsefull
• Painless
• Pin-head granulation
B. Unhealthy granulation tissue
• Pale with purulent discharge
• Edge is inflamed and oedematous
• It is a spreading ulcer
C. Unhealthy Pale, Flat granulation tissue
• Seen in chronic non healing ulcer (callous ulcer)
D. Exuberant granulation tissue (proud flesh)
• Granulation tissue protrudes out of the sinus opening or ulcer bed
• Associated with retained foreign body in the sinus cavity
E. Pyogenic granuloma
• Protruding granulation tissue
• Presenting as a well localised, red swelling which bleeds on touching

Investigations
• Study of discharge
o Culture and sensitivity
o AFB study
• Wedge biopsy
o Biopsy taken from edge – contains multiplying cells
o Biopsy taken from two sites
o Not taken from centre – as it contains necrosed tissue
• X-ray
o To look for periostitis/ osteomyelitis
• CXR, Mantaux test – in case of TB ssuspicion

Management of an ulcer
• Debridement
o Removal of devitalized tissue
o Acriflavine – irritant, desloughs and promotes granulation tissue formation
o Maggots if present removed using Turpentine solution
o Hydrogen peroxide is used to clean the ulcer
o Use of povidone iodine it is controversial in ulcer cleaning – not suitable for open wound, mainly
used to clean surgical field prior to Incision
• Removal of exuberant granulation tissue

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• Ulcer dressing
o Semipermeable polyurethane films
o Hydrocolloids
o Hydrogels
o Hydroactives
o Impregnates
• Vacuum assisted closure (VAC) therapy
o Creation of negative pressure, continuous or intermittent over the Wound surface
o Causes reduced fluid in interstitial spaces, reduces edema, promotes formation of healthy
granulation tissue
o Sterile foam is placed over the Ulcer bed → tube train it is kept within it → suction is maintained
initially continuously later intermittently
• Maggot debridement therapy
o Used as biotherapy by placing cultured live disinfected maggots
o The act by dissolving and engulfing dead necrotic tissues
o They can indicate many bacterias including MRSA
• Amnion → promote re-epithelialization
• Chorion → promote granulation tissue formation
• Once ulcer granulates, defect is closed with secondary suturing, skin graft or flaps

TROPHIC ULCER (pressure sore/dendritic ulcer)

• Tissue necrosis and ulceration due to prolonged pressure
Pathogenesis
External pressure >30mmHg →Blood flow to the skin stops → tissue hypoxia → necrosis and ulceration
It is due to -
• Defective blood supply
• Neurological deficit
• Anemia
• Pressure injury
• MC seen in orthopaedic, coma, stroke patients)
Sites
• Ischial tuberosity
• Sacrum
• Heel
• Heads of metatarsals
• Botox
• Shoulder
• Occiput
Features
• Painless, non-mobile, punched out ulcer
• As it occurs in neurological deficit patients → it is also called Neurogenic/Neuropathic ulcer
Investigations
• Study of discharge
• Blood sugar level test
• Wedge biopsy
• X-ray of the part and spine

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Treatment
• Cause should be treated - correction of diabetes and anemia
• Nutritional supplementation
• VAC therapy
• Once ulcer granulates, defects closed with flap or skin graft
• Proper care
o Change in position once every 2 hours
o Use of of water bed/ air bed
o Keeping skin dry and clean

DIABETIC ULCER
Etiopathogenesis
• Increased glucose in the tissue precipitates infection
• Diabetic microangiopathy affects microcirculation
• Increased glycosylated tissue protein decrease oxygen utilisation
Sites
• Foot-plantar aspect
• Leg
• Back
• Scortum
• Perineum
Investigations
• Blood sugar estimation
• Urine ketone bodies
• Discharge - culture and sensitivity
• X-ray the part to see osteomyelitis
• Arterial Doppler of the limb
Management
• Control of diabetes using insulin
• Regular cleaning, debridement, dressing
• Once granulates, ulcer is covered with skin graft or flaps
• Revascularization procedure – endarterectomy or balloon angioplasty or arterial bypass graft
• Toe/foot/leg amputation
• Microcellular rubber (MCR) to prevent injuries (care of foot)

MARJOLIN'S ULCER
• Aggressive ulcerating squamous cell carcinoma presenting in an area of ppreviously
o Traumatized
o chronically inflamed
o scarred skin.
• They are commonly present in the context of chronic wounds including
o burn injuries
o varicose veins
o venous ulcers
o ulcers from osteomyelitis
o post radiotherapy scars

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INFECTIOUS DISEASES
TETANUS
Causative organism
• Clostridium tetani
Infective agent – Spore
Source of infection
• Soil
• Manure
• Dust
Mode of transmission – spores gain entry via
• Wounds
• Pricks
• Injuries
Incubation period
• Time between entry of spore and appearance of first symptom
• 7-10 days
• Shorter incubation period → worse prognosis
Period of onset
• Time between appearance of first symptom and appearance of first sign
Pathogenesis
• Spores enter Wound → germinate in anaerobic environment → release of bacteria → release of Exotoxins
• Two types of Exotoxins
1. Tetanolysin – Haemolysis
2. Tetanoplasmin – blocks Cholinesterase enzyme at Anterior horn cells → increase ACh in synapses
→ Hyperexcitability and reflex spasm along with tonic-clonic sizure
• Once toxin is fixed in nerve tissue, it cannot be neutralized by antitoxin
Symptoms due to nerve involvement
• Trigeminal – Trismus
• Facial – Risus Sardonicus (smiling facies)
▪ Rigid smile due to spasm of facial muscles - zygomatic major
▪ Looks like patient is smiling
• Vestibulocochlear – Hyperacusis
• Vagus and Hypoglossal – Dysphagia
• Respiratory muscle spasm - respiratory failure → death
Different postures in tetanus
• Opisthotonus – backward bending →posterior muscles are acting more
• Orthotonus - straight posture → both back and front muscles are acting equally
• Emprosthotonus – forward bending - anterior muscles are acting more
• Pleurothotonus – lateral bending → lateral muscles acting more

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Complications of tetanus
• Bone fracture
• Respiratory failure
• Carditis → life threatening
• DVR
• Repeated conversions can lead to coma

Differential diagnosis
• Strychnine poisoning (patient is normal in between seizures)
• Metabolic causes like hypocalcemia, hypomagnesemia, hypoglycemia
• Convulsive disorders

Management
• Isolation
o Dark quiet room
o With supportive critical care facilities
• Eliminating the source of toxin
o Penicillin, clindamycin, erythromycin
o Useful if given within 6 hours after infection
• Neutralizing circulating toxins
o Human tetanus immunoglobulin
• Control of muscle spasm
o Benzodiazepines
o Phenobarbitone
• Control of autonomic dysfunction
o Fluid therapy
o Morphine
o Anticholinergics (Atropine)
o Alpha 2 agonists
o Magnesium sulphate → presynaptic neuromuscular broker, anticonvulsant, vasodilator
• Wound management
o Wound debridement
o Pus drainage
• Active immunization using Tetanus toxoid

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PYOGENIC ABSCESS
• Localised collection of pus in a cavity lined by granulation tissue and covered by pyogenic membrane
• It contains Pus, which is made of
o Dead WBC’s
o Multiplying bacteria
o Toxins
o Necrotic material
Bacteria causing abscess
• S.aureus
• S.pyogenes
• E.coli
• Pseudomonas
• Klebsiella
Factors precipitating abscess formation
• Nutritional deficiency
• Diabetes
• HIV
• Immunosuppression
• Trauma, RTA
Clinical Features
• Fever with chills and rigors
• Localised smooth, fluctuant swelling
• Throbbing pain upon touch
• Brawny induration
• Active ongoing features of inflammation (Rubor, dolor, calor, tumor, functiolaesa)
Differential diagnosis
• Aneurysm
• Soft tissue tumor
• Hematoma
• Cold abscess
Management
• Hilton’s method of abscess drainage
o Method used to drain abscess in Neck, Axilla, Parotid by using Lister Sinus forceps
o Under General or regional anaesthesia → cleaning and draping → aspiration of pus
o Skin is incised parallel to neurovascular bundle
o Pyogenic membrane opened using Lister Sinus forceps
o Abscess cavity is clear of pus and washed with saline
o Wound is not closed, allowed to granulate and heal
o Pus →culture and sensitivity
o Antibiotics and treatment of the cause

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CARBUNCLE (charcoal like)

• Infective gangrene of skin and subcutaneous tissue
• Causative agent – S.aureus
• Site
o Nape of the neck and back
o Shoulder
o Cheek
o Hand
• Risk factors
o Diabetes
o Age > 40 years
o Males
• Pathogenesis
o Infection → development of small vesicles → red indurated skin with discharge in pus → vesicles
fuse together to form a central necrotic ulcer (Ash-grey Slough) → skin becomes black due to
blockage of cutaneous vessels → disease spreads to adjacent skin rapidly
Investigation
• Urine sugar and urine ketone bodies
• Blood sugar
• Discharge - culture and sensitivity
Treatment
• Control of diabetes
• Antibiotics depending upon sensitivity
• Drainage and debridement
• Once wound granulates, skin grafting is done

POTT’S PUFFY TUMOR

• Diffuse external swelling in scalp due to subperiosteal pus and scalp edema
• Misnomer – not a tumor
• Site – frontal region
• Causes
o Chronic fungal sinusitis
o Trauma
• Clinical features
o Pain and boggy swelling in frontal region
o Pitting scalp edema
Investigation
• ESR – raised
• TLC – raised
• X-ray skull
Complications
• Osteomyelitis of frontal bone
• Intracranial spread of abscess
• Cortical vein thrombosis
Treatment
• Antibiotics
• Drainage under general anaesthesia
• Extension into cranial cavity → neurosurgical decompression using Dandy brain cannula

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GAS GANGRENE
• Infective gangrene is caused by clostridial organisms a.k.a Malignant edema
Causative agents
• C. Perfringens (welchi)
• C . Septicum
• C. Histolyticum
Source of infection
• Soil
• Dust
• Manure
• Intestine (auto-infection)
Infective agent – spores
Mode of transmission – infection of
• Wounds
• Injuries
• Pricks

Exotoxins
• Lecithinase - Extensive myocytis and Necrosis
• Hemolysin
• Hyaluronidase – rapid spread of gas gangrene
• Proteinase
Clinical features
• Fever, tachycardia
• Features of toxemia
• Wound with foul smelling discharge (decaying apple odour)
• Crepitus felt
• Jaundice – liver involvement
• Renal failure
Complications
• Septicemia
• Circulatory failure
• DIC
• Death

Investigations
• X-ray - gas in muscle plane or under the skin
• LFT, PO2, PCO2
• CT scan – useful in chest or abdominal wounds
• Gram stain - gram positive bacilli
• Robertson cooked meat media – turn pink with sour smell

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Prevention of gas gangrene

• Proper debridement of devitalised Crushed wounds
• Devitalised wound should not be closed
• Adequate cleansing with H2O2
• Penicillin as prophylaxis
Treatment
• Penicillin – useful if given within 6 hours of infection
• Antiserum
• Hyperbaric oxygen
• Department of devitalized tissue
• Severe case – amputation (stump should not be closed) -Guillotine application

NECROTISING FASCIITIS
▪ Splitting inflammation of skin, deep fascia, soft tissue with extensive destruction and toxemia
▪ Muscles are usually not involved in necrotising fasciitis
▪ Causative agent
o S pyogenes
o MRSA
▪ Risk factors
o Old age
o Smoking
o Diabetes
o Obesity
o Immunosuppression
▪ Site
o Limbs
o Lower abdomen
o Groin
o Perineum
▪ Clinical features
o Fever, Erythema, Edema
o Blisters and bullae formation
o Hyperesthesia, Crepitus, Tissue necrosis, Haemorrhagic bullae
▪ Management
o IV fluids, Blood transfusion
o Broad spectrum Antibiotics
▪ 3rd Gen Cephalosporin
▪ Aminoglycosides
o Pus culture
o Control of diabetes
o Hyperbaric oxygen therapy
o Radical an excision of gangrenous skin
o VAC therapy

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MADURA FOOT (mycetoma pedis)

• Chronic granulomatous condition of foot
• Involves subcutaneous and deeper tissues
• Causes multiple discharging sinuses
Causative agent
• Bacterial
o Actinomyces
o Nocardia
• Fungal
o Madurella mycetoma
o Madurella gross
Pathogenesis

Clinical features
• Multiple discharging sinuses
• Discharge contains granules (black, red, yellow)
• Regional lymph nodes are not involved
• Secondary bacterial infection
• Osteomyelitis
Investigations
• Discharge microscopy → branching filaments appearance of organism
• Culture – SBD agar
• X-ray foot – to look for osteomyelitis
• FNAC and Biopsy – confirmation of eumycetoma or actinomycetoma
• MRI – Dot in circle sign
Treatment
• Medical
o Actinomycetoma
▪ Streptomycin
▪ Cotrimoxazole
o Eumycetoma
▪ Ketoconazole
▪ Voriconazole
• Surgical
o Wide surgical excision
o Amputation in severe refractory cases

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AIDS
• Confirm HIV infection with CD4 T-cell count 200 cells/mm³ with symptoms
Classification
STAGE 1 • Asymptomatic
• Lymphadenopathy > 6 months
STAGE 2 • Unexplained weight loss <10% TBW
• Recurrent Respiratory infections
o Sinusitis
o Bronchitis
o Pharyngitis
• Recurrent Dermatological conditions
o Chelitis
o Oral ulcer
o Herpes zoster Flares
STAGE 3 • Unexplained weight loss > 10% TWB
• Unexplained diarrhoea
• Pneumonia
• Meningitis
• Oral candidiasis
• Hairy leukoplakia
• Necrotising stomatitis, gingivitis
STAGE 4 • HIV wasting syndrome
• Opportunistic fungal infections
o Pneumocystis pneumonia
o Cryptococcosis
o Zygomycosis
o Histoplasmosis
• Opportunistic bacterial infection
o NTM Infection
o Miliary tuberculosis
• opportunistic viral infection
o Cytomegalovirus
o Herpes simplex virus
o Epstein barr virus
• Opportunistic parasitic infection
o Toxoplasmosis
o Cryptosporidiosis
o Isosporiosis
• HIV induced cancer
o Kaposi sarcoma
o Non-Hodgkin’s lymphoma
o Cervical cancer
• Miscellaneous
o HIV encephalopathy
o HIV cardiomyopathy
o HIV nephropathy

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Mode of transmission
o Sexual intercourse - vaginal or anal
o Needle pricks
o Vertical transmission – transplacental, breast milk
o Organ transplantation
o Blood transfusion
Pathogenesis
o HIV envelope glycoprotein binds to surface molecules CD4 (CXCR-4 and CCR-5) on T-cell, Monocytes,
Macrophages, Dendritic cells → HIV enters these cells and replicate using Reverse transcriptase enzyme
o HIV suppresses T-cell function → indirect suppression of B-cells → immunosuppression

Investigations
o ELISA – screening test
o Western blot test – diagnostic test
o Rt-PCR
o CD-4 count
o >500/mm³ - Asymptomatic
o 200-500/mm³ - Kaposi sarcoma, Candidiasis, M.tuberculosis infection
o 50-200/mm³ - Pneumocystis, Toxoplasmosis
o <50 mm³ - Cytomegalovirus, NTM Infection
Treatment
• Antiviral therapy
o NRTI – Lamivudine, Didanosine, Abacavir
o NNRTI – Nevirapine, Delavirdine, Efavirenz
o NtRTI – Tenofovir
o PI – Ritonavir, Indinavir, Amprenavir
o II – Raltegravir
o FI – Maraviroc, Enfluvirtide
• Treatment of opportunistic infections
• Treatment of tumors
• Anti-CD3 or Anti-IL² after HAART
• Psychotherapy and counselling

Precautions around HIV patient

• Careful handling of needles, blades
• Wearing double gloves
• Head mask, apron, goggles
• Proper disposal of needles
• Spilled body fluids should be wiped with Sodium hypochlorite and Glutaraldehyde
• OT should be fumigated after surgery to HIV patient

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ERYSIPELAS
• Acute spreading inflammation of outer dermis and superficial lymphatics
• Causative agent – Streptococcus pyogenes
• Clinical features
o Welding marketed skin rash ( Rose pink rash )
o Cutaneous lymphangitis
o Skin vesicles → eventually rupture → serous discharge
o Milian’s ear sign
▪ Clinical sign used to differentiate erysipelas and cellulitis
▪ Skin of Ear lobule is adherent to subcutaneous tissue → cellulitis cannot occur
▪ Erysipelas being cutaneous condition can spread into ear lobule
• Complications
o Septicemia
o Localised cutaneous gangrene
o Necrotising fasciitis
o Glomerulonephritis
• Treatment
o Penicillin
o Clindamycin
o Roxithromycin

PYOGENIC GRANULOMA
▪ Infection of minor trauma →leads to formation of unhealthy granulation tissue which protrudes through
the wound
▪ a.k.a Acquired lobular capillary hemangioma
Features
▪ Single, well defined, firm Nodule
Site
▪ Face
▪ Scalp
▪ Fingers
▪ Toes
Differential diagnosis
▪ Hemangioma
▪ Papilloma
▪ Melanoma
Treatment
▪ Excision
▪ Laser surgery

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SWELLINGS
LIPOMA (a.k.a Universal tumor or Ubiquitous tumor, prevalence 2/100 people)
• Benign neoplasm arising from yellow fat
• Made of Mature adipocytes → but the fat in lipoma is considered unavailable for general metabolism
• Site - Occurs anywhere in the body except brain
• Subcutaneous, Subfascial
• Intermuscular, Intramuscular
• Parosteal, Sub-synovial, Interosseous, Sub-periosteal
• Subserosal, submucosal (GI tract)
• Extradural (never Intradural)
• Intra-glandular (breast, pancreas, kidney
• Types
• Localised (encapsulated)
• Diffuse (non-encapsulated)
• Multiple lipomas associated with
• MEN syndrome
• Banayan-Zonana syndrome
• Adiposa dolorosa (Dercum’s disease)
o Multiple lipomatosis
o Seen in Females, Epileptics, Psychiatric patients
o Site – Trunk and Gridles
• Hibernoma - benign tumor arising from brown fat
• Lipomas’s with non-adipose components
• Fibrous component – fibrolipoma
• Telangiectasis – Naevolipoma
• Nerve tissue – Neurolipoma
• Vessels – Angiolipoma
• Cartilage – Chondrolipoma
• Muscle – Myolipoma
• Malignant transformation of lipoma never happens
▪ Liposarcoma arises from primitive mesenchymal cells (not from mature fat cells)
• Clinical features
• Localised lobular, non-tender, non-tansilluminate swelling
• Pseudofluctuation - Often feels like Fluctuant but actually not (because fat in body temperature
remains soft)
• Mobile, Slip sign – edges of lipoma slips between palpating fingers
• Pain – due to neural element or compression of nerves
• Differential diagnosis
• Neurofibroma – moves horizontally but not longitudinally along the line of the nerve
• Cystic swelling
• Liposarcoma – infiltrate deeper plane, immobile
• Investigations
• USG, CT, MRI – for deep/intracavitary lipoma
• FNAC
• Complications
• Myxomatous changes
• Saponification – calcification
• Treatment → Excision under local or general anaesthesi

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CYST – collection of fluid in a sac lined by epithelium or endothelium

Types
• True – lined by epithelium or endothelium
• False – does not have epithelial lining
o Pseudocyst of pancreas
o Apoplectic cyst in brain as a result of ischemia
Classification
1. Congenital cyst
o Dermoids
▪ Sequestration dermoid
▪ Tubulodermoids
• Thyroglossal cyst
• Urachal cyst
o Embryonic remanent cyst
▪ Mesonephric duct cyst
▪ Vitellointestinal duct cyst
2. Acquired
o Retention cyst
▪ Bartholin's cyst
▪ Parotid cyst
▪ Epididymis cyst
▪ Breast, Sebaceous cyst
o Distension cyst
▪ Lymph cyst
▪ Ovarian cyst
o Excudation cyst → Bursa, Hydrocele
o Implantation dermoid
3. Cystic tumors → Ovarian Cystadenoma
4. Traumatic cyst
5. Degenerative cyst
6. Parasitic cyst → Hydatid cyst, Cysticercosis, Trichinosis
Clinical features
• Smooth, fluctuant, non-tender swelling
• Single or multiple
• Presentation varies depending upon site
Complications of cysts
• Compression of adjacent structures
• Infection
• Tarzan – Ovarian cyst
• Calcification – Hydatid cyst, Cysticercosis
• Cachexia

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DERMOIDS
• Congenitally acquired cyst
Types
1. Sequestration dermoid
• Sequestration of epithelium at line of embryonic fusion
• Sites
• Forehead, neck, postauricular
• Sublingual dermoid
• Angular dermoid
• External angular dermoid – over external angular prices of Frontal bone
• Internal angular dermoid – over Root of nose
• Dermoids occurring in skull main extend into cranial cavity or orbital cavity
• Clinical features
• Painless swelling in the line of embryonic fusion
• Presents in 2nd and 3rd decade
• Paget’s test positive – swelling is fixed with two fingers and summit yields fluid sensation
• Resorption and indentation of bone beneath
• Investigations
• X-ray Skull
• CT skull
• Complications
• Infection, Haemorrhage, Rupture
• Ulceration, Calcification
• Treatment
• Excision under general anaesthesia
• Often raising of cranial osteocutaneous flaps required
2. Tubulodermoids
• Arises from embryonic Tubular structure
• Types
• Thyroglossal cyst
• Ependymal cyst
• Urachal cyst
• Post-anal dermoid
• Remanent of neuroenteric canal
• Located in front of sacrum and coccyx
• Rectal examination – reveals cyst
• Treatment – complete Excision, Coccyx may need to be removed for easy access
3. Teratomatous dermoid
• Arises from all 3 germinal layers – ecto, meso, endoderm
• Site
• Ovary
• Testis
• Retroperitoneum
• Mediastinum
• Contents
• Hair, Teeth, Cartilage, Sebum

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SEBACEOUS CYST
• Is a Retention cyst, due to blockage of the duct of sebaceous gland
• Site
• Face
• Scalp
• Scortum
• Not seen in Palm and soles ( no Sebaceous glands)
• Demodex folliculorum
• Putty like consistency, with a parasite in the wall of sebaceous cyst
• Clinical features
• Painless, smooth, non-tender swelling
• Positive Paget’s test
• Hair loss over the surface – due to constant pressure over the root
• Complications
• Infections and abscess formation
• Cock’s peculiar tumor – sebaceous cyst ulcerates leading to formation of painful discharging mass
• Sebaceous horn – hardening of slowly discharged sebum through the punctum
• Treatment
• Dissection method – Excision including the skin adjacent to punctum by elliptical incision
• Abscess → initial drainage and later excision

CAFE-au-LAIT-SPOTS
• Coffee coloured pigment red spots in skin
• It signifies common neuroectodermal origin of nerve sheath cells and melanocytes
• Sites
o Back
o Abdomen
o Thigh
• Seen in
o Generalised neurofibromatosis (Von Recklinghausen’s disease)
o McCune Albright Syndrome

GANGLION
• Cystic swelling occurring in relation to tendon sheath/ synovial sheath/ joint capsule
• Sites
o Dorsum of wrist (near Scaphoid-Lunate articulation)
o Around ankle joint
• Pathogenesis
o Cystic degeneration of tendon sheath
o Leakage of synovial fluid through joint capsule
• Clinical features
o Smooth, Non-tender swelling
o Transilluminant
o Paget’s test positive
• Treatment
o Aspiration and sclerosant injection
o Excision done under local anaesthesia

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GLOMUS TUMOR (glomangioma)

• Arises from Sucquet-Hoyer canal → site where tortuous Arteriole communicates directly with Venule and
is covered by network of small nerves (painful)
• Contents (angiomyoneuroma)
o Blood spaces
o Muscle fibres derived from arteriolar wall
o Cuboidal glomus cells
• Features
o Severe burning sensation and pain
o MC site – Nail bed (subungual region)
o Reddish hue spot, does not blanch on percussion
• Treatment – Excision

BACKER’S CYST
• Cystic swelling containing gel like fluid in lower midline of popliteal fossa
• It is a Pulsion/Pressure diverticula of synovial membrane through an opening in joint capsule
• Clinical features
o Smooth, Tender swelling located below the joint line
o On flexion – swelling disappears
o On extension - swelling increases in size
o Pain and tenderness in knee joint
o Effusion with positive patellar sign
o X-ray shows arthritis changes
• Complication
o Rupture → sudden pain mimicking DVT
• Management
o Treatment of arthritis
o Baker’s cyst is excised in prone position under general anaesthesia

TRANSILLUMINANT SWELLINGS
• Hydrocoele
• Ranula
• Epididymal cyst
• Meningocoele
• Cystic hygroma
• Lymph cyst

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ELECTROLYTE AND NUTRITION

INDICATIONS OF NUTRITIONAL SUPPORT
• Preoperative nutritional depletion
• Postoperative complications – ileus, fistula
• Intestinal fistula
• Anorexia nervosa
• Intractable vomit
• Trauma – multiple fractures, faciomaxillary injuries, Head and neck injuries
• Massive bowel resection causing small bowel syndrome

TOTAL PARENTERAL NUTRITION - TPN

• All required nutritions are given through intra-venous route
• Given through
o Central catheter
o Subclavian/ internal jugular vein
o Peripheral vein (peripherally inserted Central venous catheter - PICC)
• Indications
o Failure or contraindication of enteral nutrition
o High output abdominal fistula
o Major abdominal surgeries liver, pancreas
o Multiple trauma
o Short bowel syndrome
o Massive GI bleeding
o Hyperemesis gravidarum
o High risk of aspiration
o Multiorgan failure, severe burns

Goals of TPN
• Prevents adverse effects of catabolism
• Increase protein synthesis
• Prevent weight loss
• Support metabolism
• Improve immune function
• Maintain glycogen reserve for energy
• Maintain acid, base and electrolyte metabolism

Complications
• Technical
o Air embolism
o Catheter displacement
o Thrombosis
• Biochemical
o Electrolyte imbalance
o Hyperosmolarity
• Others
o Dermatitis
o Staphylococcal infection

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Contraindications of TPN
• Cardiac failure
• Blood dyscrasias
• Altered fat metabolism

HYPONATREMIA
• Na levels <135mE/L
• Severe hyponatremia <100mE/L
Types
• Acute - presents with neurological manifestations
• Chronic – leads to
o Pontine myelinolysis
o Behavioural changes
o Progressive weakness
o Cranial nerve palsies
• Hypervolemic hyponatremia
o Rapid absorption of fluid into intravascular compartment
o Leads to pulmonary and cerebral edema (decreased osmolality causes ECF movement into Cells)
o Corrected by
▪ Fluid restriction
▪ Hypertonic saline
▪ Loop diuretics
o Overcorrection or Rapid correction of condition can cause irreversible pontine myelinolysis
• Hypovolemic hyponatremia
o Loss of fluid electrolytes
▪ Diarrhoea
▪ Vomiting
o Treatment – isotonic normal saline
• Normovolaemic hyponatremia
o Causes
▪ Syndrome of inappropriate ADH secretion (SIADH)
▪ Renal failure
o Treatment → vasopressin antagonist = demeclocycline
• Pseudohyponatremia
o Plasma osmolality is maintained not only by sodium but also solutes like glucose, plasma proteins,
urea
o Pathology increasing the concentration of the solutes, proportionately decreases concentration of
sodium
Clinical features
• Dry tongue, sunken eyes, dry wrinkled skin
• Hypotension, dark scanty urine
• Irritability, disorientation, convulsions
• Chronic hyponatremia → hypothermia, reduced tendon reflex

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HYPERNATREMIA
• Serum sodium level >145mEq/L
• Excess infusion of normal saline causes overload in circulating salt and water
• Causes
o Renal dysfunction
o NSAID induced
o Central Diabetes insipidus
o Decreased fluid intake
o Osmotic diuresis
o Corticosteroids
• Types
o Euvolemic hypernatremia
▪ Failure of water intake
• Comatose
• Bedridden people
• Post operative patients
▪ High fever → extrarenal loss of water
▪ Diabetes insipidus
o Hypovolemic hypernatremia
▪ Among loss of water and sodium, more water is lost than sodium
• Vomiting
• Diarrhoea
• Excess sweating
• Osmotic diuresis by mannitol
o Hypervolemic hypernatremia
▪ Among gain of water and sodium, more sodium is gained than water
• Sodium bicarbonate/hypertonic saline infusion
Clinical features
• Pitting edema
• Facial puffiness
• Increased urination
• Dilated veins
• Pulmonary edema
Management
• Sodium restriction
• Treatment of pulmonary edema
• Hyponatremia should be corrected slowly as follows
o Initial infusion of normal saline
o Followed by infusion of half strength saline (0.45%)
o Followed by infusion of 5% dextrose
o Gradual controlled correction is done → otherwise cerebral edema and hyperglycemia can
develop

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HYPOKALEMIA
• Serum potassium level <3.5 mEq/L
Types
• Sudden hypokalemia
o Diabetic coma treated by insulin
• Gradual hypokalemia
o Diarrhoea
o Pyloric stenosis
o Drugs like Beta agonists
o Metabolic alkalosis
Clinical features
• Slurred speech
• Muscle hypotonia – physical sign
• Paralytic ileus, Depressed reflexes
• Cardiac arrhythmia (QT prolongation, ST depression, T inversion, prominent U wave)
• Hypokalemic Alkalosis
Treatment
• Oral or IV KCl infusion

HYPERKALEMIA
• Serum potassium > 6 mEq/L
• Causes
o Renal failure
o Rapid infusion of potassium
o Diabetic ketoacidosis
o Insulin deficiency
o Metabolic acidosis
o Tissue destruction, burns, crush injury, tumor necrosis
o Potassium sparing diuretics
• Management
o ECG – peak T wave
o IV glucose and insulin
o IV calcium gluconate (cardioprotection)
o Loop diuretics
o Continuous ECG monitoring

METABOLIC ALKALOSIS
o Serum bicarbonate >27mmol/L, It is due to base excess
o Causes
o Repeated vomiting (seen in pyloric stenosis) → hypokalemic alkalosis
o Excess alkali injection e.g Antacids
o Cortisol excess (Drug or Cushing’s syndrome)
o Features
o Cheyne stokes breathing with period of apnoea of 5-30 secs
o Tetany due to alkalosis
o Treatment
o IV potassium infusion
o pH >7.7 is life threatening, immediate correction by IV ammonium chloride

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METABOLIC ACIDOSIS
o Serum bicarbonate < 21 mmol/L
o It is due to Excess acid or base deficit
Causes
o Increase in fixed acid
o Diabetic ketoacidosis, Starvation, Hypoxia
o Excessive exercise
o Intestinal strangulation – here Anion gap also increased
o Loss of base
o Diarrhoea
o Intestinal fistula
o Uretero-sigmoidostomy = hyperchloremic-hypokalemic acidosis
Clinical features
o Kussmaul’s breathing – Rapid, deep, noisy breathing
o Tachycardia, cardiac arrhythmia
o Anorexia
o pH <7.2 is life threatening
Treatment
o Correction of hypoxia
o IV sodium bicarbonate infusion
o Treatment of lactic acidosis
o Treatment of diabetic ketoacidosis

GASTROSTOMY
o Procedure where tube is passed into the stomach per abdominally for purpose of enteral feeding
o Indications
o Severe malnutrition
o Major surgeries
o Major trauma
o Contraindications
o Previous gastric surgeries
o Intestinal obstruction
o Problems in gastrostomy tube
o Leakage
o Infection
o Displacement, blockage of the tube

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SHOCK
• State of cellular and tissue hypoxia with Circulatory failure and poor perfusion and
o reduced oxygen delivery or
o poor oxygen utilisation or
o Increased oxygen consumption
Causes
1. Hypovolemic shock
• Reduction in total blood volume
• Hemorrhage
• Severe burns
• Vomiting and diarrhoea
2. Cardiac shock
• Acute MI
• Acute carditis
• Acute pulmonary embolism
• Drug induced
• Cardiac tamponade
• Trauma to heart
3. Septic shock
• Bacterial infection with release of toxins into circulatory system
4. Neurogenic / Vasovagal shock
• Sudden anxious stimuli causing severe splanchnic vessels vasodilation
• Patient goes into cardiac arrest or recovers spontaneously
• Spinal cord injury/anaesthesia can cause neurogenic shock
5. Anaphylactic shock
• Type 1 hypersensitivity reaction
6. Respiratory causes
• Atelectasis
• Thoracic injury
• Tension pneumothorax
7. Other causes
• Acute adrenal insufficiency (Addison’s disease)
• Myxedema

Pathophysiology of shock
Any cause of shock

Low cardiac output

Decreased renal blood flow

Decreased GFR → Decreased urine output

Activation of RAAS → Ag-2 and Aldosterone mediated Vasoconstriction and Salt/Water retention respectively

ADH is released

Further retention of water

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Persistence of shock → further decrease in cardiac output

Hypoxia → metabolic acidosis

Release of cardiac depressants

Cardiac failure

Hypoxia →anaerobic metabolism

Lactic acidosis

Cell wall damage

Na and Ca enter the cell

K leaks out of the cell

Hyperkalaemia, Hyponatremia, Hypocalcemia

Intracellular lysosome breakdown → release of proteolytic enzymes

SICK CELL SYNDROME

Platelets are activated forming small clots at many sites

Disseminated intravascular coagulation (consumption coagulopathy)

Further bleeding

Stages of shock

Factors like Infection, trauma, burns, haemorrhage, hypovolemia

Hypoxia and its effects

SIRS (systemic inflammatory response syndrome)

• Due to Vasodilation, increased vascular permeability, Thrombosis, leucocyte migration

Leads micro-vascular occlusion, cellular dysfunction, DIC, Sick cell syndrome

MODS (multiorgan dysfunction syndrome) → of lungs, kidney, liver, brain (Irreversible shock)

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Effects of shock
• Heart
o Low cardiac output → hypertension → reflex tachycardia
o Persistent shock → hypoxia → release of cardiac depressants → cardiac failure
• Lung
o Interstitial edema → decreased gas exchange → tachypnea → ARDS
• Metabolic
o Hypoxia induced lactic acidosis
o ADH induced water retention
• Cellular changes
o Lysosomal enzymes mediated destruction of cell (Sick cell syndrome)
• Brain
o Decreased blood perfusion → loss of consciousness
o Brain is the last organ to get under perfused in shock
• Kidney
o Decreased GFR → Decreased urine output → RAAS mediated salt and water retention
• Blood
o Disseminated intravascular coagulation (consumption coagulopathy) → internal bleeding

Investigations
• Monitoring of
o Blood pressure
o Pulse, Heart rate
o Respiratory rate
o Urine output
o Central venous pressure (CVP)
o Pulmonary capillary wedge (PCWP)
• Estimation of
o pH
o Serum lactate level
o Blood urea, creatinine
o Prothrombin time - PT
o Activated partial thromboplastin time – aPTT
o ABG - arterial blood gas analysis

Treatment
• Acute critical care management by primary assessment and resuscitation of
o A – airway
o B – breathing, bleeding
o C - circulation
o D – disability, drugs
o E – exposure
• Fluid replacement
o Ringer lactate
o Hartmann's solution
o Plasma expander (haemaccel)
o Blood transfusion

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• Inotropic agents
o Epinephrine - Anaphylactic shock
o Norepinephrine – vasodilatory/septic shock
o Dobutamine - cardiogenic shock
• Acidosis correction
o IV sodium bicarbonate
• Steroid (hydrocortisone)
o Improves perfusion, decreases systemic inflammatory effects
• Hemodialysis
• Pain control – Morphine 4mg IV
• Ventilator and ICU care management
• MAST trouser (military anti-shock trouser)
o Provides circumferential external pressure of 40mmHg
o Wrapped around lower limbs and abdomen, inflated with required pressure
o It redistributes the existing blood and fluid towards centre

SEPTIC SHOCK
• Widespread infection and toxin release causing multiorgan failure and dangerously low blood pressure

Pathogenesis
Toxins from bacteria, fungi, virus, parasite

Inflammation, activation of macrophages, neutrophils, monocytes

Release of cytokines, free radicals

SIRS - Chemotaxis, Endothelial injury, Altered coagulation state

Reversible Hyperdynamic state (fever, tachycardia, tachypnea)

Sever circulatory failure with MODS (failure of lung, liver , kidney, heart) with DIC

Irreversible Hypodynamic Cold stage of septic shock

Stages of septic shock

• Hyperdynamic (warm) stage
o Reversible stage
o Fever, tachycardia, tachypnea
o Pyrogenic response is intact
o Treatment
▪ Appropriate antibiotic therapy
▪ Treatment of underlying cause..,
• Drainage of pus
• Laparotomy for peritonitis
▪ Ventilatory Support

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• Hypodynamic Hypovolemic stage (cold stage)

o Pyrogenic response is lost
o Patient is in decompensated stage
o Irreversible shock leading to MODS

Treatment of septic shock

• Correction of fluid and electrolyte balance
• Blood transfusion (blood perfusion is most important)
• Appropriate antibiotics
• Treatment of underlying cause
o Drainage of abscess
o Laparotomy for peritonitis
o Resection of gangrenous bowel
o Wound excision
• Norepinephrine → DOC for septic shock
• High dose steroid therapy → counteract effects off toxemia

HYPERBARIC OXYGEN
• Administration of oxygen 1 or 2 atmospheres above atmospheric pressure in a compression chamber
• It increases arterial oxygen saturation → increased Oxygen perfusion to tissues
• Indications
o Carbon monoxide poisoning
o Tetanus
o Gas gangrene
o Bedsore, Frostbite, Necrotising fasciitis
o As radiosensitizer in treatment of cancer
o Caisson’s disease
• Complications
o Cerebral gas embolism
o Tympanic membrane rupture
o Visual defects
o O2 toxicity
o Respiratory depression
• Contraindications
o Asthma/emphysema
o Pregnancy

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HEMORRHAGE AND BLOOD TRANSFUSION

COMPLICATIONS OF BLOOD TRANSFUSION
• Febrile reaction
o Due to pyrogens in blood or in the infusion set
o Fever, chills, tachycardia
• Allergic reaction
o Utricaria and allergy to antigens in donor plasma
• Acute hemolytic reaction
o Due to ABO incompatibility
o Hemoglobinemia, hemoglobinuria (smoky urine)
o Jaundice, Dyspnea
o Acute renal failure, DIC
• Transfusion-related acute injury
o Donor plasma antibodies against ‘HLA & leukocyte specific antigen’ of recipient
o Breathlessness, hypertension, saturation drop
o X-ray - bilateral diffuse lung infiltrates
• Transfusion-related-graft-versus-host disease
o Recognition and reaction against recipient tissues by Donor’s plasma antibodies
o Seen in
▪ Immunosuppressed
▪ Leukemic patients
o Features
▪ Pancytopenia
▪ Toxic epidermal necrolysis
▪ Liver dysfunction
• Congestive cardiac failure
• Transmission of infection
• Thrombophlebitis
• Air embolism
• Coagulation failure → due to dilution of clotting factors
• Severe electrolyte imbalance
• Iron overload
• Citrate toxicity → causes Bradycardia, Hypocalcaemia

MASSIVE BLOOD TRANSFUSION is when..,

• Transfusion of blood equivalent to patients blood volume in <24 hours
o Adults - 5-6 litres
o Infants – 85ml/kg body weight
• Single transfusion of blood more than 2500ml continuously
• Transfusion > 4units in one hour
• Transfusion of >50% of blood volume
Indications
• Severe trauma associated with liver, cardiac, pulmonary, pelvic injuries
• During surgical bleeding (primary hemorrhage on table)
Adverse effects
• SAME AS ABOVE

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AUTOTRANSFUSION
• a.k.a autologous blood transfusion
• Healthy individual with no infection and hematocrit >30%
• Can pre-donate blood few weeks prior to any elective surgeries
• It can be used at the time of surgery
• Autologous blood is used in
o Orthopaedic surgery
o Gynaecologic surgery
o Urologic Surgery
• Patient donates 1 unit of blood weekly
• Last donation should be 72 hours before the date of surgery

BLOOD SUBSTITUTES
• Red cell substitutes
o Perfluorocarbon
▪ Abiotic RBC substitute (synthetic oxygen carrier)
▪ Half life 7 days
▪ High affinity for oxygen
▪ Inert, colourless, biocompatible liquid
o Stroma-free hemoglobin
▪ Biomimetic hemoglobin substitute
▪ High affinity for oxygen (does not contain 2,3 DPG)
o Chelates with reverse bound Oxygen
▪ Intraoperative salvage of blood
▪ On table blood is collected, watched, filtered and transfused
• Plasma substitutes
o Human albumin
▪ 1gm of albumin binds with 14 ml of water, increases blood volume
▪ Indications
• Cirrhosis
• Burns
• Nephrotic syndrome
• Ovarian hyperstimulation syndrome
o Dextrans
▪ Used to improve plasma volume
▪ Disadvantages
• Interferes with Rouleaux formation
• Interferes with platelet function
• Causes hyperchloremic acidosis, pontine myelinolysis
▪ Gelatin (haemaccel)
▪ Hydroxyethyl starch

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HEMORRHAGE CLASSIFICATION, in relation to operating procedure

1. Primary → occurs at the time of injury or operation
2. Reactionary → occurs in < 24 hours after surgery
o Precipitating factors
▪ Coughing, Straining
▪ Rise in blood pressure
▪ Slipping of literature
▪ Clot dislodgement
o Commonly occurs after
▪ Major abdominal surgeries
▪ Circumcision
▪ Hydrocele surgery
▪ Tonsillectomy
▪ Thyroid surgery
▪ Cholecystectomy
3. Secondary → occurs in < 14 days after surgery
o Precipitating factors
▪ Infection
▪ Pressure
o Commonly occurs after
▪ Hemorrhoidectomy
▪ Inguinal block disection

INDICATIONS FOR BLOOD TRANSFUSION

• Acute blood loss >15% of total blood volume
• During Major surgeries
• Burns
• Prophylactic measure prior to surgery
• Anaemia
• Immune thrombocytopenic purpura
• Haemophilia

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 ABHIRAM SAVVY

BURNS
Burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity,
electricity, friction or contact with chemicals

Classification based on severity

• Mild (minor)
o Partial thickness burns
▪ <15% in adults
▪ <10% in children
o Full thickness burns <2%
• Moderate
o Second degree 15-25% burns
o Third degree 2 – 10% burns
o Burns not involving eyes, ears, face, hand, feet, perineum
• Major (severe)
o Second degree burns >25%
o Third degree burns >10%
o Burns involving eyes, ears, face, hand, feet, perineum
o Burns with fractures are major mechanical trauma

Classification based on thickness of skin involved - 1

• First degree
o Red and painful epidermis
o No blisters
o Heals within 7 days by epithelialization without scarring
o It shows capillary filling
• Second degree
o Red, painful, mottled area
o With blisters
o Sensation is present but No blanching
o Heals buy 14 days by epithelization
▪ Superficial second degree burn - heals with pigmentation
▪ Deep second degree burn – heals with pigmentation and scarring
• Third degree
o Painless, charred affected area
o Charred, denatured area is called ESCHAR
o Wound must heal by re-epithelialization from wound edge
• Fourth degree
o Involves underlying tissues – muscles, bone

Classification based on thickness of skin involved – 2

• Partial thickness burn
o Either first or second degree burn
o Red and painful, often with blisters
• Full thickness burns
o Third degree burns
o Charred, insensitive, involving all layers of the skin

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 ABHIRAM SAVVY

Wallace’s rule of 9 → early assessment of burns severity

Pathophysiology

Clinical features
• History of burn
• Pain, Tachycardia, Tachypnea, Fluid loss
• Features of shock
• Metabolic acidosis

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Post burn squeal or Complications

• Massive edema
o Loss of protein → decreased plasma oncotic pressure → loss of fluid from intravascular space
• Cardiac dysfunction
o Release of cardiac depressants → cardiac failure
• Renal changes
o ADH release → water retention
o Aldosterone release → sodium retention
o Toxins, myoglobin → causes acute tubular necrosis
• Pulmonary changes
o Altered ventilation-perfusion ratio
o Pulmonary edema
o ARDS
• GIT changes
o Paralytic ileus, Acute pancreatitis
o Curling's ulcer →
▪ acute gastric erosion resulting as a complication from severe burns when reduced plasma
volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa
▪ (decreased mucosal defence, not due to increased HCL)
• Electric injuries can cause fracture, convulsions
• Eschar may compress underlying vessels
• Post burn immunosuppression → severe opportunistic infections

Sepsis in burns patient

• Can occur via
o Burn focus
o Catheter site
o CVP line
• Precipitating factors
o Loss of proteins and immunoglobulins
o Loss of Physiological barrier (skin)
• Causative agents
o Streptococcus
o Staphylococcus
o Pseudomonas
o Candida

Management (first aid)

• Clothing should be removed
• Cooling the part by curling water for 20 mins
• Cleaning the path to remove dust, mud etc
• Chemoprophylaxis – Tetanus toxoid, Antibiotics, local antiseptics
• Covering with dressing
• Comforting with sedation

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Definitive Treatment
• Maintain airway, breathing, circulation (ABC)
• Endotracheal intubation if required (succinylcholine should not be used)
• Assess percentage, degree and type of burn
• Sedation and proper analgesia
• Patient placed in burn unit (Idea League air conditioned room)
• Fluid resuscitation
o Parkland regime
▪ 4ml / %burn / kg body weight / 24 hours
▪ Half volume given in initial 8 hours
▪ Rest is given in 16 hours
o Galveston regime (pediatrics)
▪ 5000 ml /m² burn + 1500 ml / m²
o Fluids given are
▪ Ringer lactate (fluid of choice)
▪ Hartmann’s fluid
▪ Plasma
▪ Blood transfusion (after 48 hours)
• Antibiotics → penicillin, cephalosporin, aminoglycoside, metronidazole
• Ryle’s tube → initially for aspiration purpose later for Enteral feeding
• Total parenteral nutrition (TPN) via CVP line for faster recovery

Local management
• Open method
o Application of 'silver sulfadiazine’ without any dressings
o Commonly done in burns of Face, Head, Neck
• Closed method
o Proper dressing done to protect the wound, to reduce pain
o Dressing at regular intervals under general anaesthesia using
▪ Paraffin gauze
▪ Hydrocolloids
▪ Fenestrated silicone sheet
▪ Vaseline impregnated gauze
▪ Biological dressings like - Amniotic membrane, Synthetic biobrane
• Tangential excision
o Tangential Excision with skin grafting done within 48 hours
o Done in patients with <25% burns
o Done in deep Dermal burn
o Dead dermis is removed till fresh bleeding occurs, later skin grafting is done
o Advantages
▪ Reduces chance of secondary infection
▪ Reduces hospital stay duration
▪ Reduces Formation of hypertrophic scar or contracture

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Wound coverage
o Once the area granulates
▪ Split Skin grafting is done
▪ For wider area MESH split skin graft is used
▪ If eschar present → escharotomy done to prevent compression of vessels
▪ {Pseudoeschar → thickened burnt skin due to repeated silver sulfadiazine application}
▪ In face and ear 'full thickness graft or flap’ is needed
▪ Cultured skin
• Sheets of skin developed by specialised culture technology
• Useful in burns >80%

{Antiseptic and soothing agents used on burns

• Silver sulfadiazine
• Sulfamylon
• Silver nitrate}

ACID BURNS
• Is a chemical burn with deep progressive tissue distruction
• Types of acids
o Inorganic acid
▪ Sulfuric acid
▪ Nitric acid
▪ HCL
▪ Hydrofluoric acid (liquefactive necrosis)
o Organic acid
▪ Carbolic acid
▪ Oxalic acid
• Mechanism of acid burn
o Causes coagulative necrosis
o Precipitates proteins and forms hard eschar crust
o The eschar crust protects underlying tissue from further burn
Treatment
• Water irrigation
• Calcium gluconate gel application at 15 mins interval
• Local or IV calcium gluconate injection
• Continuous cardiac monitoring

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HAND INFECTIONS
Causative agents
• Staphylococcus
• Streptococcus
• E. Coli
• Klebsiella
• Pseudomonas
Precipitating factors
• Diabetes
• Immunosuppression
• Trauma
• Vascular diseases
Different types of Hand Infections
• Acute paronychia
• Chronic paronychia

• Terminal pulp space infection (felon)

• Subungual infection

• Web space infection

• Midpalmar space infection
• Thenar space infection
• Deep palmar abscess

• Acute tenosynovitis
• Chronic tenosynovitis

• Lymphangitis
• Subcuticular abscess

General features of hand infection

• Fastest spreading of infection
• Edema (frog hand) over dorsum of hand due
o Lax skin
o More lymphatic network
• Loss of functions of hand like pinch, power, chuck, hook, key grips
• Severe pain and tenderness
• Axillary lymphadenopathy

Complications of hand infections

• Stiffness of digits (ankylosis)
• Deformity and disability
• Septicemia
• Osteomyelitis
• Paralysis of median nerve

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General principles of managing hand infections

• Assessment of hand grip function
o Pinch (picking a small object)
o Hook (carrying a bag)
o Power (holding a hammer)
o Key (holding a key)
o Chuck (holding a pen)
• Assessment of sensation
o Sweat test
o Two point discrimination test
• Assessment of circulation
o Allen’s test
• Antibiotic therapy
• Position of rest
o Glass holding position – wrist slightly abducted and extended, thumb and index finger away
• Elevation of hand
o Reduces edema
o Increases perfusion
o Promotes healing
• Early recognition of localised pus
• Incision and drainage of pus
• Bloodless field (using tourniquet) – to drain pus from hand
• Pus - culture and sensitivity

TERMINAL PULP SPACE INFECTION (felon)

• Index and thumb MC affected
• Etiology → finger prick
• Causative agent
o Staphylococcus
o Streptococcus
o Gram negative organisms
• Clinical Features
o Pain, tenderness, swelling in terminal phalanx
o Fever, axillary lymphadenopathy
o Severe case → collar stud abscess → Bursts eventually
• Complications
o Osteomyelitis
o Pyogenic arthritis → interphalangeal joint
o Septicemia
Investigations
• Pus - culture and sensitivity
• X-ray - to rule out osteomyelitis
Treatment
• Antibiotics and Analgesics
• Drainage of terminal pulp (oblique dip insulation)
• Osteomyelitis of terminal phalanx → amputation

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ARTERIAL DISEASES
TROMBOANGIITIS OBLITERANS (buerger's disease)
• Non atherosclerotic inflammatory disease of small and medium sized distal vessels
• Cell mediated sensitivity to typ1 and type3 collagen
• Often present as raynaud’s phenomenon with microabscesses
Etiology
o Hormonal influence
o Hypersensitivity to cigarettes
o Altered autonomic functions
o Recurrent minor feet injuries
Pathogenesis

If continuation of smoking → disease progresses into Decompensatory peripheral vascular disease called Critical
limb ischemia (pain, ischemia, gangrene)

Classification of TAO
Type 1 - upper limb (rare)
Type 2 – legs/feet
Type 3 – femoro-popliteal
Type 4 - aorto-ilio-femoral
Type 5 – generalised

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Clinical features
• MC in male smokers (smokers disease)
• MC site – lower limbs
• Intermittent claudication in foot and calf
• Recurrent superficial thrombophlebitis
• Absence of pulse distal to proximal i.e dorsalis pedis, posterior tibial, popliteal, Femoral artery
• May present as Raynaud’s phenomenon

Investigations
• Blood sugar
• Ankle brachial pressure index (ABPI)
• Arterial Doppler
• Duplex scan (Doppler + B mode US)
• Transfemoral retrograde angiogram
• If femorals not felt → Tansbrachial angiogram

Treatment
• Quit smoking
• Drugs
o Low dose aspirin – antiplatelet action
o Clopidogrel, Statins
o Cilostazole (PDE inhibitor) improves circulation (ideal drug)
o Sedatives and analgesics
o Naftidiguryl – alters tissue metabolism, useful in intermittent claudication
o Gene therapy – IM VEGF injection (promotes angiogenesis)

Care of limbs
• Buerger’s position
o Head end of bed is raised
o Foot end of bed is lowered to improve circulation
• Care of feet (chiropady)
o Avoid exposure of feet to cold temperature
o Avoid minor prick injuries to feet
o 2cm heel shoes → decrease work of calf muscle

Surgery
• Omentoplasty – revascularization of affected limb
• Profondaplasty – done for blockage in profunda femoris artery
• Lumbar sympathectomy → to cause vasodilation and increase cutaneous perfusion
• Amputation

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LIMB ISCHEMIA
Causes
• Atherosclerosis
• Acute embolism
• Arteriopathy
▪ Buerger’s disease
▪ Raynaud’s disease
▪ Takayasu disease
• Diabetes
• Scleroderma
• Physical agents – trauma, tourniquet, radiation injury
FONTAINE’S classification of limb ischemia
Stage 1 – Asymptomatic
Stage 2 – Intermittent claudication
• Well compensated – can walk > 200 meters
• Poorly compensated – walk only < 200 meters
Stage 3 – Rest pain
Stage 4 – Gangrene, Ischemic ulcer

Functional Limb Ischemia

• Blood flow is normal when legs are at rest
• Blood flow will not increase during exercise
• Muscle discomfort in the limb increases by exercise and relieved by rest within 10 mins
Critical limb ischemia
• Persistently recurring ischemic rest pain for 2 weeks
• Requires a regular analgesics for > 2 weeks
• Associated with Ulcer, Gangrene, Ankle systolic BP <50mmHg, toe systolic BP <30mmHg
• ABPI – ankle brachial pressure index (checked in supine position)
o >0.9 - normal
o 0.7 – 0.89 – mild ischemia
o 0.5 – 0.69 – moderate ischemia
o <0.5 – severe ischemia (rest pain)
o <0.3 – tissue necrosis
o Drawbacks
▪ Vessel wall calcification (diabetes)
▪ Makes vessel incompressible causing high ABPI >1.3
• Pre-gangrene
o Tissue changes indicating that blood supply is inadequate
▪ Rest pain
▪ Colour changes
▪ Edema
▪ Hyperesthesia ± Ischemic ulceration
• Gangrene
o Microscopic death of tissue in-situ with Putrefaction
▪ Dry gangrene
• Coagulative necrosis
• Due to gradual slowing of blood stream
• Clear line of demarcation between healthy and gangrenous tissue

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▪ Wet gangrene
• Liquefactive necrosis
• Due to both arterial and venous block
• Has superadded infection and putrefaction
• No clear line of demarcation
• Line of demarcation
o Junction between viable and dying tissue
o Indicated by a band of hyperemia
o Hyperesthetic region due to irritation of exposed nerve endings
• Necrosis → microscopic cell death
• Sequestrum → dead bone in-situ
• Slough → dead soft tissue in-situ

Levels of arterial obstruction

• Aorto-iliaca block
o Claudication in
• Buttocks
• Thighs
• Calves
o Absence of femoral and distal pulses
o Bruit over aorto-iliac region
o Leirche’s syndrome - impotence due to defective perfusion through internal iliac arteries →
decreased perfusion to penis → erectile dysfunction
• Iliac artery obstruction
o Claudication in thigh and calf
o Bruit over iliac artery
o Absence of femoral and distal pulses
• Femoro-popliteal obstruction
o Claudication in calf
o Palpable femoral pulse
o Absent distal pulse
• Distal obstruction
o Palpable femoral and Popliteal pulse
o Absent ankle pulse

Clinical features
• Market pallor
• Cyanosis
• Diminished hair
• Brittle nails with transverse ridges
• Ulceration, Gangrene
• Tenderness
• Temperature -. Cold

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Tests for arterial obstruction

• Delayed capillary filling
o Blanching in nails and toe pulp, on pressure
o Delayed refilling after pressure release
• Delayed venous refilling (Harvey’s sign)
o Two fingers are placed over the vein
o Finger nearest to heart moved away → to empty the vein
o Distal finger is released to observe venous refilling
• Crossed leg test (Fuchsig’s test)
o Sitting with legs crossed over
o Popliteal Fossa of 1 lakh will lie against knee of other
o Oscillatory movement of foot seen in synchronous with popliteal pulsation
o (This movement is absent with blockage of popliteal artery)
• Disappearing pulse syndrome
o Exercise the limb after feeling the pulse
o Pulse disappears due to claudication after exercise
• Buerger’s postural test
o Lying supine with raised leg
o Normal individual → plantar aspect of foot remains pink, even at 90⁰ elevation
o Limb ischemia → plantar aspect shows marked pallor
o Angle in which pallor develops → Buerger’s angle of vascular insufficiency
o If this angle is <30⁰ → severe ischemia
• Adson's test (scalene manoeuvre)
o Patient sitting on a stool, radial pulse is felt
o Ask to take deep breath (Rib cage moves upwards, narrows cervicoaxillary channel)
o And turn the face to same side (scalene anterior muscle contracts, narrow the scalene triangle)
o If radial pulse disappears or feeble → cervical rib or scalenus anticus syndrome
• Costoclavicular compression maneuver (falconer test)
o Radial pulse disappears when patient draws shoulders backwards and downwards
o Subclavian artery gets compressed between first rib and clavicle → feeble or absent radial pulse
• Hyperabduction manoeuvre (Wright test)
o Affected limb hyperabduction
o Feeble or absent radial pulse → compression of artery by pectoralis minor tendon
• Allen's test
o Check patency of radial and ulnar arteries
o Both arteries are compressed near the wrist for 1 min → palm blanched
o One of the arteries is released and colour of hand is noted
▪ Normally hand becomes pink/flushed in no time
▪ Obstruction – hand remains tale

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Investigations for arterial diseases

• Segmental pressure measurements
o Segmental BP measured at multiple levels
▪ Upper and lower thigh
▪ Upper calves and ankle
• Doppler
o To localise the site of block
• Duplex scan
o Combination of Doppler and B-mode-Ultrasound
o Localise site, extent, severity of block
o Check collateral circulation around the block
• Angiography
o Retrograde transfemoral angiography (Sledinger technique)
o Transbrachial angiography (left brachial artery)
o Transaortic angiography
• Digital subtraction angiography
o Dye is injected either to an artery or vein
o Injecting into vein is easier but large dose of dye required
o Injecting into artery is difficult but small dose of dye is sufficient
o Advantages
▪ Only vascular system is visualised
▪ Other systems are eliminated by computer subtraction
▪ Small lesions can be better observed with greater clarity
o Disadvantages → cost factor
o Complications
▪ Anaphylaxis
▪ Thrombosis
▪ Bleeding
• CT angiogram/ MRI angiogram
• Ankle-brachial pressure index

Treatment of limb ischemia

• Quit smoking, Exercise, control diabetes/hypertension
• Percutaneous transluminal balloon angioplasty (PTA)
• Bypass graft surgeries
o Different grafts used
▪ Dacron
▪ Human umbilical vein
▪ Saphenous vein
▪ Polytetrafluoroethylene – PTFE
• Thrombectomy, profondaplasty

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GANGRENE
Microscopic death of tissues in-situ with Putrefaction
Sites
• Limbs
• Appendix
• Bowel
• Testes
• Gallbladder
Causes
• Secondary to arterial occlusion due to
o Atherosclerosis
o Emboli
o Diabetes
o TAO, Raynaud’s disease
o Ergot toxicity
• Infective
o Gas gangrene
o Fournier’s Gangrene
• Trauma
• Physical → burns, frostbite, irradiation, electrical

Clinical features
• Colour changes
o Pallor
o Brownish black due to disintegration of hemoglobin
• Absence of pulse
• Loss of sensation
• Loss of function

Types
• Dry Gangrene -
• Wet Gangrene -
Line of demarcation

Investigations
• HB%, Blood sugar
• Arterial Doppler
• Angiogram (Sledinger technique)
• US abdomen – status of aorta

Treatment
• Limb saving methods
o Drugs
▪ Antibiotics
▪ Vasodilators
▪ Low dose aspirin
▪ Dipyridamole
▪ Pentoxiphylline

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o Treat the cause → diabetes, Infection etc

o Care of feet and toes
▪ Kept dry
▪ Avoid minor injuries
▪ Proper footwear (microcellular rubber footwear-MCR)
▪ Localised pus drainage
o Surgeries to improve perfusion
▪ Lumbar sympathectomy
▪ Omentoplasty
▪ Profundaplasty
▪ Femoro-popliteal thrombectomy
▪ Arterial graft bypass
• Life saving procedures
o Amputation
▪ Ray amputation
▪ Below-knee amputation (Buerger’s amputation)
▪ Above-knee amputation
▪ Modified Symes amputation

INTERMITTENT CLAUDICATION
• Crampy pain in muscles of the limb
• Due to
o Arterial occlusion
o Accumulation of metabolites like Lactic acid, Substance P
• Pain develops only when muscle is exercised
• Pain disappears within 5 minutes of rest after exercise
• BOYD’S classification of claudication
o Grade 1
▪ Pain after walking
▪ Distance at which pain develops is (Claudication distance)
▪ Continue to walk → increased blood flow → opening of collateral → pain causing
metabolites are washed away → pain subsides
o Grade 2
▪ Persistence of pain on continuing walk
▪ Can walk with effort
o Grade 3
▪ Patient has to take rest to relieve the pain

REST PAIN
• Continuous ache in calf, feet, toe
• Due to Ischemic nerve injury
• Pain increased upon lying down and foot elevation
• Pain reduces on hanging foot down
• Pain is alleviated by holding foot in hand (suppression of pain transmission)

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LUMBAR SYMPATHECTOMY
• Indications
o TAO
o Promote healing of cutaneous
o Hyperhidrosis of lower limb
o Make flaps to heal better after amputation
• Principle
o Lumbar sympathectomy → increases cutaneous blood perfusion
• Procedure
o Under General or spinal anaesthesia
o Extra-peritoneal approach → transverse incision in Loin at level of Umbilicus → divide external
and internal oblique muscles and splitting transverse abdominis → IVC on right side , Aorta on
left side are identified
o Sympathetic chain is identified over transverse processes of lumbar spines
o L2, L3, L4, L5 ganglia are removed
o L2 is identified by its larger size and more Rami
o L1 is retained on one side in bilateral cases (if both are removed it will lead to failure of
ejaculation – sterility – dry ejaculation)
• Complications
o Injury to IVC and aorta
o Dry ejaculation
o Paradoxical gangrene of opposite leg
o Injury to Bowel and ureter
• Limitation
o Its effects are only temporary (3-4 weeks)
o Long-term results are doubtful

AINHUM
• Dactylolysis spontanea
• Painful construction of base of 5th toe
• Followed by bilateral spontaneous autoamputation few years later
• Features
o MC in males
o History of running barefoot
o Fissure develops at interphalangeal joint → becomes a fibrous band → necrosis of little toe
• Treatment
o Z plasty
o Amputation

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RAYNAUD'S PHENOMENON
• Episode, localised, vasospasm of small vessels of hands and feet
• Leads temperature and colour changes
• Initial pallor (vasospasm) → blue (Venus congestion) → Red (hyperemia due to rapid blood flow)
Causes
• Working with vibrating tools
• Collagen vascular diseases – scleroderma, vasculitis
• Other causes
o Scalene syndrome
o Buerger's disease

Features
• Bilateral
• MC in young females
• Usually medial four digits and Palm are involved (thumb is spared)
• Features of pallor, cyanosis, Rubor/painful red engorgement (recovery)
• Peripheral pulses are felt (absent in upper limb TAO)
• Repeated attacks are common
Investigations
• Digital subtraction angiography (DSA)
• Arterial Doppler/Duplex scan
• Antinuclear antibody-ANA assay
• Nailfold capilloscopy – identify abnormal capillaries (differentiate b/w 1⁰ and 2⁰ RP
Treatment
• Treatment of cause
• Avoid precipitating factors
o Protect from cold
o Avoid smoking
o Avoid vibrating tools
• Vasodilators/pentoxifylline/low dose aspirin
• Localised digital sympathectomy

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DIABETIC FOOT/GANGRENE
• Ulceration associated with neuropathy / peripheral arterial disease of the lower limb in a patient with
diabetes.
MEGGIT’S classification
Grade 0 – pain only
Grade 1 – superficial ulcers
Grade 2 – deep ulcers
Grade 3 – ulcer with bone involvement
Grade 4 – forefoot gangrene
Grade 5 – full foot gangrene

Pathogenesis
• High glucose level in tissue →good culture media for bacteria
• Diabetic microangiopathy → blockade of microcirculation → hypoxia
• Diabetic neuropathy → minor injuries of foot are not noticed, Infection develops
• Diabetic atherosclerosis → reduce blood supply → gangrene
• Increased glycosylated hemoglobin → defective oxygen dissociation → hypoxia

Clinical features
• Pain
• Ulceration
• Absence of sensation
• Absence of pulsation (dorsalis pedis, posterior tibial artery)
• Abscess formation, Septicemia

Investigations
• Blood sugar, urine ketone bodies
• X-ray - to rule out osteomyelitis
• Pus - culture and sensitivity
• Doppler study
• Angiogram
• Glycosylated hemoglobin estimation
Treatment
• Antibiotics
• Drugs
o Vasodilators
o Pentoxifylline
o Dipyridamole
o Low dose aspirin
• Control of diabetes
• Surgical debridement of wound
• Amputation of gangrenous area
• Care of feet
o Avoid injuries
o Use of microcellular rubber- MCR footwear
o Keep feet clean and dry

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VASCULAR LESIONS
HEMANGIOMA
• Benign vascular endothelial tumor
• MC in girls (3:1)
• Onset → few weeks after birth
• Classification
o Capillary hemangioma
o Cavernous hemangioma
Complications
▪ Hemorrhage
▪ DIC
▪ Ulceration
▪ Infection, septicemia
Investigations
▪ Doppler, CT angiogram - to find out feeding vessel
Treatment
▪ Sclerosant therapy
▪ Ligation of feeding artery → shrinks the hemangioma
▪ Therapeutic embolization
▪ Laser ablation

Capillary hemangioma/strawberry/raspberry hemangioma

• MC site – head and neck region
• Child is normal at birth
• At 3 weeks appears as red mark → rapidly increases in size in 3 months
• Eventually intravascular thrombosis, mast cell infiltration
• Clinically compressible, warm bluish surface
• Bleeding can occur after minor trauma or ulceration
• After 1 year age → slowly disappears
• Treatment
o Allowed for spontaneous regression
o Pulsed diode laser → surgical excision and reconstruction
o Intralesional steroid therapy
o Indications for surgery
▪ Uncontrolled growth
▪ Functional impairment of vision or hearing
Cavernous hemangioma
▪ Presents at birth, size increases gradually
▪ Site
o Head and neck
o Tongue
o Limbs
o Liver
o Other internal organs
▪ Consists of multiple venous and lymphatic channels
▪ Compressible, warm bluish surface

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ARTERIOVENOUS FISTULA
▪ Abnormal communication between artery and vein
▪ Types
o Congenital → arteriovenous malformation
o Acquired → traumatic
Congenital AVM
▪ Site
o Limbs
o Lungs
o Brain - circle of Willis
o Abdominal organs
▪ Features
o Warm, girth, lengthened limb → more blood flow
o Dilated arterialized varicose veins
o Hyperdynamic circulation → increased cardiac output → congestive cardiac failure
▪ Investigations
o MR – angiogram, Doppler study
▪ Treatment
o Indications for surgery
▪ Hemorrhage, Congestive cardiac failure
▪ Functional disability
o Surgical ligation of feeding vessels
o Complete excision of the lesion
o Therapeutic embolization
o Amputation
Acquired AVF
▪ Causes
▪ Trauma
▪ Therapeutic
▪ Cimino fistula created for renal dialysis, to achieve arterialization of veins and to have
hyperdynamic circulation
▪ Features
▪ Changes at the level of fistula
▪ Aneurysmal sac (continuous thrill and machinery murmur)
▪ Changes distal to fistula
▪ Due to diversion of arterial blood, distal part becomes Ischemic
▪ High pressure of blood → arterialization of veins →varicosity
▪ Changes proximal to fistula
▪ Hyperdynamic circulation → cardiac failure
▪ Branham’s sign / Nicolandoni’s sign
• Pressure applied to artery proximal to fistula,
• Swelling gets reduced in size
• Thrill and bruit will disappear, Pulse rate and Pulse pressure becomes normal
▪ Investigations
▪ Doppler study, MR-angiogram
▪ Treatment
▪ Excision of fistula
▪ Reconstruction of artery and vein with graft

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VENOUS DISEASES
DEEP VEIN THROMBOSIS (phlebothrombosis)
• Semisolid clot in the vein, with a high tendency to develop pulmonary embolism and sudden death
• Causes
o Trauma – to leg, ankle, thigh
o Immobility
▪ Bedridden patients
▪ Long distance air/bus travel (travellers thrombosis)
o Pregnancy
o Puerperium
o OCP use
o Post-operative thrombosis
o Polycythemia
o Deficiency of Antithrombin, protein C & S
o Factor V Leiden mutation
• Sites for DVT
o Pelvic veins
▪ Internal iliac vein – PID in females
o Leg veins
▪ Ilio-femoral/ femoral vein
▪ Popliteal vein
▪ Soleal vein – MC
o Upper limb vein
▪ Axillary vein thrombosis
• Clinical features
o Fever - earliest symptom
o Tender, warm, shiny swelling calf
o Homan’s sign
▪ Dorsiflexion of foot with extended knee causes tenderness in calf
o Mose’s sign
▪ Gentle squeezing of lower part of calf is painful
▪ Squeezing should be gentle orelse it may dislodge the thrombus
o Features of Pulmonary embolism
▪ Chest pain
▪ Breathlessness
▪ Hemoptysis
o Linton’s test
▪ Application of tourniquet at saphenofemoral junction
▪ Patient is made to walk without removing the tourniquet
▪ After walk, limb is elevated → prominence of superficial veins → indicates DVT
• Differential diagnosis
o Ruptured baker's cyst
o Ruptured plantaris tendon
o Calf muscle hematoma
• Investigations
o Venous Doppler with Duplex scanning, Venogram
o Radioactive I¹²⁵ fibrinogen study
o Ventilation-perfusion scanning

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• Treatment
o Rest, bandaging the entire limbwith crepe bandage
o Anticoagulants → LMWH, Warfarin, Phenindone
o Fibrinolysis → streptokinase
o Thrombectomy using Fogarty’s catheter
o IVC filter →prevents thrombus from reaching the heart
o Palma operation
▪ In ilio-femoral thrombosis
▪ Femoral vein below the block is Anastomosed to opposite femoral vein
o May-Hunsin operation
▪ In popliteal vein thrombosis
▪ Popliteal vein below the block is anastomosed to Long saphenous vein

VARICOSE VEINS
• Permanently elongated, dilated, torturous veins causing pathological circulation
• There is reversal of blood flow through its faulty valves
• Risk factors
o Hereditary
o Female
o Prolonged standing
o Pregnancy
o Immobility
• Classification – 1
o Long saphenous vein varicosity
o Short saphenous vein varicosity
o Varicose veins due to perforator incompetence
• Classification – 2
o Thread veins/spider veins/Telangiectasis
▪ Small varices (0.5 – 1mm) in skin around Ankle
▪ Dilated red/purple network of veins
o Reticular varices (1 – 3mm)
o Varicose veins (>3mm)
▪ Dilated, tortuous, elongated superficial veins
• Etiology of varicose veins
o Primary varicosities
▪ Congenital incompetence/absence of venous valves
▪ Muscle wasting
▪ Parkes-Weber syndrome
o Secondary varicosities
▪ Recurrent thrombophlebitis
▪ Occupational prolonged standing
▪ Obstruction to venous return
• Ascites
• Pregnancy
• Chronic constipation
• Iliac vein thrombosis
▪ Tricuspid valve incompetence

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Pathogenesis (2 theories)
1. Fibrin cuff theor

2. White cell trapping theory

• Raised venous pressure → reduced capillary perfusion → trapping of WBC → inappropriate
activation of trapped WBC → release of proteolytic enzymes → endothelial damage, ulceration

Sites of varicosity occurrence

• Lower limb
• Sites of Porto-systemic anastomosis
• Vulva
• Perineum
• Pampiniform plexus of veins

Investigations
• Venous Doppler
• Duplex scan
• Plethysmography, Ambulatory venous pressure
• Varicography

Signs of varicosity
• Visible dilated veins, pain, cramps
• Pedal edema, dermatitis, ulceration
• Saphena varix - large varicosity in groin, becomes prominent on coughing
• Perthe’s test
o Affected limb is wrapped with elastic bandage
o Patient is asked to walk around and exercise
o Development of severe cramping pain → indicates DVT

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• Brodie-trendelenburg test
o Vein is emptied by elevating the limb
o Tourniquet is tied below saphenofemoral junction
o Patient is asked to stand quickly → removal of tourniquet → Rapid filling from above → indicates
saphenofemoral valve incompetence
o Or
o After standing tourniquet is not removed
o Rapid Feeling of blood from below upwards → indicates Perforator incompetence
• 3 tourniquet test
o To find the site of incompetent perforator,
o 3 tourniquets tied after Emptying the vein
▪ At saphenofemoral junction
▪ Above knee level
▪ Below knee level
o Patient made to stand → look for filling of veins by removing tourniquet from below upwards,
identify the incompetent perforator
Differential diagnosis
o AV malformation
o Orthostatic edema
o Lymphedema
o Myxedema

Treatment
• Conservative treatment
o Elastic crepe bandage
o Elevation of limb – reduces edema
o Unna boots
▪ Non-elastic compression therapy
▪ Contains zinc oxide, Calamine and glycerine
▪ Prevents further skin breakdown
o Pneumatic compression method
• Drugs
o Calcium dobesilate - improve lymph flow, reduce edema
o Diosmin - protects Venous wall and valve, anti-inflammatory action
o Toxerutin – anti-erythrocyte aggregation agent
• Sclerotherapy → injecting sclerosants (sodium tetradecyl sulphate-STDS)
o Foam sclerotherapy
o Injection sclerotherapy
o Transillumination micro-sclerotherapy
o Echo – sclerotherapy
o Catheter-directed sclerotherapy
• Surgeey
o Trendelenburg operation (Crossectomy)
o Stripping of vein
o Perforator ligation
o Stab avulsion of varicose vein and Perforator

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Varicose vein complications

o Hemorrhage – due to rupture of varicose veins
o Pigmentation – hemosiderosis
o Periostitis – thickening of tibial periosteum
o Venous ulcer
o Marjolin's ulcer
o Fibrous ankylosis – ankle joint
o Talipes equinovarus – patient walks on the tip of toes
o Calcification of the wall of varicose veins
o Recurrent thrombophlebitis
o Deep vein thrombosis

VENOUS ULCER (gravitational ulcer)

o Is a complication of varicose veins or deep vein thrombosis
Pathogenesis
Varicose veins or DVT → chronic venous hypertension around ankle → RBC diffuse into interstitial spaces
→ RBC lysis → Hemosiderin deposition → Eczema → Dermatitis → Lipodermatosclerosis → Fibrosis →
Anoxia → ulceration

Clinical features
• Site - above medial malleolus
o Due to presence of more number of perforators
o This area is called as Gaiters zone
• Non-healing, tender ulcer
• Eventually develops into Marjolin’s ulcer
• Lipodermatosclerosis
o Champagne bottle sign – prominent calf with narrow ankle
• Fibrosis causes Achilles tendon contracture
Differential diagnosis
• Diabetic ulcer
• Traumatic ulcer
• Ischemic ulcer

Investigations
• Discharge – culture and sensitivity
• X-ray – to rule out periostitis
• Wedge biopsy – to rule out Marjolin’s ulcer
Treatment
• Bisgaard method
o Measures to reduce edema and promote ulcer healing
▪ Elevation of leg
▪ Calf massage
▪ Passive and active exercise
▪ Dressing with EUSOL
• Four layer bandage technique
o High compression pressure bandaging
• Once ulcer granulates → split skin graft
• Specific treatment for Varicose veins → Trendelenburg operation, Perforator ligation

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LYMPHATICS
LYMPHEDEMA
• Lymph accumulation in extracellular and extravascular compartment
KINMONTH classification
1. Primary lymphedema
• Familial
o Congenital lymphedema - present at birth
o Lymphedema Praecox - present at puberty
o Lymphedema tarda - present in adult life
• Syndromic – Turner’s/Downs/Klinefelter
2. Secondary lymphedema
• Trauma
• Surgery – inguinal block, axillary block dissection
• Filarial lymphedema
• Advanced malignancy
• Post radiotherapy lymphedema
• Tuberculosis, Syphilis

Sites of lymphedema
o Lower limb
o Upper limb, scrotum
o Penis (Ram’s horn penis)
o Labia, Eyelid

Clinical features
o Foot swelling → tree trunk pattern leg
o Loss of normal Peri-malleolar shape
o Buffalo hump in dorsum of foot
o Squaring of toes
o Stemmer’s sign → skin over the dorsum of foot cannot be pinched due to subcutaneous Fibrosis

Complications
• Skin thickening
• Recurrent cellulitis
• Non healing ulcers
• Lymphangiosarcoma/ Stewart-Treves syndrome – multiple blue nodules often with ulceration
Differential diagnosis
• Myxedema
• Hypoproteinemia
• DVT
• Cardiac failure
• Nephrotic syndrome

Investigations
• Venous Doppler
• Lymphangiography
• Isotope-lymphoscintigraphy
• Lympho fluoroscopy

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Treatment
• Compression wraps
• Manual lymphatic drainage
• Surgery
o Excisional
▪ Charles operation
▪ Homans operation
o Anastomosis
▪ Omentoplasty
▪ Nodo-venous shunt
▪ Lympho-venous shunt
o Excision + creation of communication
▪ Thompson's operation
▪ Sistrunk operation
▪ Kondolean’s operation

HODGKIN'S LYMPHOMA
• Etiology
o Infectious mononucleosis (epstein barr virus)
o HIV virus
o Genetic monoclonal B cell disorders
• Features
o Bimodal presentation
▪ 20-30 years
▪ >50 years
o Painless progressive lymph node enlargement
o Hepatosplenomegaly
o Anemia
• Staging
o Stage 1 – confined to one group of lymph nodes
o Stage 2 - > one group of LN, on one side of diaphragm
o Stage 3 – LN involved both sides of diaphragm
o Stage 4 – extranodal involvement of Liver, Bone marrow, Spleen
• Investigations
o Hb%, ESR, Peripheral smear
o FNAC of lymph node
o Excision biopsy if Lymph node – immunohistochemistry CD15, CD30, CD45
o CXR – mediational LN involvement
o US abdomen – Abdominal LN involvement
o MRI and PET – extranodal involvement
• Treatment
o Stage 1 and 2 → Radiotherapy
o Stage 3 and 4 → Chemotherapy
o ABVD regime → Adiramycin, Bleomycin, Vinblastine, Dacarbazine

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CHYLURIA
Passage of milky White chylous urine, aggravated after fatty meal
Pathogenesis
o Obstruction of intestinal lymphatic vessel → high lymphocyte pressure → diversion of lymph intrarenal
lymphatics
Etiology
o Filariasis
o Tuberculosis
o Urinary infection
Investigations
o Urine study, Culture
o Lymphangiography
o US abdomen
Treatment
o Low fat diet
o Antibiotics
o DEC – diethylcarbamazine
o Ligation of dilated lymphatics – laparotomy

WRIST DROP
• Inability to extend the wrist
• Etiology
o Radial nerve palsy
• Investigations
o X-ray of the part
o Nerve conduction study
• Management
o Nerve suturing
o Nerve graft
o Tendon transfer

TUMOR MARKERS
• Substances that are produced by cancer cells or by normal cells in response to cancer
• Uses of tumor markers
o Screening of common cancers
o Determining therapeutic response
Example..,
• Harmones
o Calcitonin – Medullary Carcinoma of thyroid
o Human chorionic gonadotropin – Choriocarcinoma
o Vanillymandelic acid – Pheochromocytoma
• Oncofetal antigens
o Alpha-Fetoprotein – hepatocellular carcinoma
• Enzymes
o Neuron-specific enolase – Neuroblastoma
o Prostatic acid phosphatase – Prostate cancer
• CD markers
o CD 125 – Ovarian cancer

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SKIN TUMORS
PREMALIGNANT CONDITIONS OF SKIN
• Bowen’s disease
• Erythroplasia of Queyrat
• Paget’s disease of nipple
• Leukoderma
• Senile/Solar keratosis
• Radiodermatitis
• Arsenic dermatitis
• Chronic scars develop into Marjolin’s ulcer
• Albinism
• Xeroderma pigmentosa
• Chronic lupus vulgaris
• Prolonged irritation of skin by chemicals like dye, tar etc.

SQUAMOUS CELL CARCINOMA (epithelioma)

• Arises from squamous layer of the skin
• Usually it occurs in a pre-existing predisposing lesion like
o Bowen’s disease
o Exposure to UV-B rays
o Chronic scars
o Solar or Senile keratosis
o HPV infection
o Kangri cancer – chronic contact with Hot charcoal pot over abdomen to control cold
o Kang cancer – seen on buttocks, due to sleeping oven bed to control cold
o Chimney sweep cancer – seen in scrotum, due to chronic irritation by tar
• Clinical features
o Ulceroproliferative lesion
o Raised and everted edges
o Bloody discharge from the relation
o Regional lymphadenopathy
• Variants of SCC
o Marjolin ulcer → occurs in chronic scar tissue
o Verrucous carcinoma → occurs in mucous membrane
• Histology
o Malignant Whorls of squamous cells with Keratin pearls
o BORDER’S classification
▪ Well differentiated - >75% keratin pearls
▪ Moderately differentiated – 50-75% keratin pearls
▪ Poorly differentiated – 25-50% keratin pearls
▪ Undifferentiated - <25% keratin pearls
• Differential diagnosis
o Basal cell carcinoma
o Melanoma
o Keratoacanthoma
• Investigations
o Wedge biopsy from the edge
o FNAC from lymph node, CT scan/MRI

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• Treatment
o Radiotherapy
o Chemotherapy – methotrexate, vincristine, bleomycin, cisplatin
o Wide excision clearance, followed by skin grafting or flaps
• Worse Prognostic factors in SCC
o Tumor size >2cm
o Invasion depth >6mm
o Tumor border - ill defined
o Lymphovascular invasion
o Associated immunosuppression
o Poor differentiation

MARJOLIN’S ULCER
• Well differentiated SCC occurring in chronic scars like
o Burn
o Venous ulcer
• Features
o Slow growing
o Painless, Indurated, non-tender ulcer
• Pathogenesis - chronic irritation of scar tissue
• Investigations
o Wedge biopsy from edge
o MRI
• Treatment
o Wide local excision
o In case of large ulcer – amputation

BASAL CELL CARCINOMA (rodent ulcer)

• Arises from basal layer of skin or mucocutaneous junction
• (It does not arise from mucosa)
• a.k.a tear cancer (occurs in area where tears roll down)
• Etiology
o Exposure to UV light
o Exposure to carcinogens
o Xeroderma pigmentosa
o Albinism
• MC site – Face
o Above Onghrens line (line joining angle of mouth and Ear lobule)
• It is locally malignant → erodes deeply into local tissues including bone (Rodent ulcer)
• Types
o Nodular
o Ulcerative
o Pigmented
o Geographical
o Basi-squamous
• Clinical features
o Slowly growing, non-mobile, Raised and beaded eshe’s

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• Differential diagnosis
o Squamous cell carcinoma
o Melanoma
o Keratoacanthoma
• Investigations
o Wedge biopsy from edge
o X-ray of involved part
o CT scan
• Treatment
o Radiation (radiotherapy not useful once BCC erodes bone)
o Surgery
▪ Wide excision with skin grafting
▪ Cairo surgery
▪ MOHS – microscopically oriented histographic surgery
▪ Indications of surgery
• BCC eroding cartilage or bone
• BCC close to eye
• Reccuent BCC after radiotherapy

MELANOMA
• Malignant tumor arising from epidermal melanocytes
• Risk factors
o Exposure to UV light
o Albinism
o Xeroderma pigmentosa
o Junctional naevus
o Familial dysplastic naevus syndrome
o Large congenital naevi >20cm
o Family history of melanoma
• Differential diagnosis
o Pigmented SCC
o Pigmented BCC
o Kaposi sarcoma
o Cutaneous Hemangioma
• Clinical types
o Superficial spreading
o Nodular melanoma
o Lentigo maligna melanoma
o Acral lentiginous melanoma
o Amelanotic melanoma
o Desmoplastic melanoma
• Clinical features
o A – asymmetrical
o B - border regularity – Coast of Marine sign
o C - colour variation
o D – diameter > 6cm
o E – evolving (changing progressively)
o Ulceration, bleeding, itching

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• Metastasis
o Through lymphatics
o Through Blood
• Distant spread occurs to
o Bone, Lung, Liver
• Investigations
o Excision biopsy
o FNAC of Lymph node
o US abdomen → rule out secondaries in Liver
o CXR → rule out secondaries lung (cannon ball)
o Urine study → Sentinel lymph node biopsy
o MRI / PET
• Treatment
o Handley’s wide local excision
o Melanoma on fingers → disarticulation
o Melanoma eye → enucleation
o Melanoma in pregnancy → termination of pregnancy, postpone pregnancy for 2 years

TURBAN TUMORS
1. MULTIPLE CYLINDROMA
• Multiple form pink nodules in scalp
• Locally malignant
2. Hidradenoma
• Benign sweat gland tumor
• Painless, disfiguring Cutaneous swelling
Management
• Biopsy
• Wide excision with skin grafting

KAPOSI SARCOMA
• Malignant blood vessel tumor
• Arises form – vascular smooth muscles or pericytes
• Associated with HHV8
• Types
o European KS
o African KS
o Transplant KS
o AIDS associated KS
• Clinical features
o Multiple reddish-blue nodules in skin with ulceration
o Lymph node enlargement
o Koebner phenomenon - new lesions on previously unaffected area, secondary to trauma
• Investigations – Biopsy, HIV test
• Treatment – Radiotherapy, Chemotherapy (Adiramycin, Bleomycin, Vinblastine)

SKIN GRAFTING
o Transfer of skin from one area to the required defective area (it is an Autograft)

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Types
1. Partial thickness graft (Split-thickness Skin Graft-SSG) a.k.a Thiersch graft
o Removal of full epidermis + part of dermis from donor area
o Indications
• Well granulated ulcer
• Clean wound with un-opposed edges
• After surgery to close defect created
▪ Wide excision in malignancy
▪ Mastectomy
o Limitations
• Cannot be done over bone, cartilage, tendon, joint
o Technique
• Donor area
▪ Thigh, Leg
▪ Arm, Forearm
• Knife used - HUMBY’S knife, DOWN’S blade
• Donor area is dressed and dressing is opened after 10 days
• Recipient area –
▪ Graft is placed after making window cuts in graft (prevent seroma)
▪ Graft is fixed and tie-over dressing is placed
▪ Dressing is opened on 5th day, to observe for graft take-up
▪ Mercuro chrome – applied over recipient margin to promote epithelialization
o Stages of graft intake
• Stage of plasmatic imbibition – thin layer of plasma between recipient area and graft
• Stage of inosculation – temporary linking of host area and graft
• Stage of neovascularization – new capillaries proliferate into graft from recipient area
o Disadvantages of SSG
• Graft Contracture
▪ Primary contracture
▪ SSG contracts significantly once graft is taken into donor area
▪ Thicker the graft more the primary contracture
▪ Secondary contracture
▪ Occurs after graft has been taken up during healing period, due to fibrosis
▪ Thinner the graft more the secondary contracture
• Seroma and Hematoma → prevent graft take-up
• Non-functioning of Sebaceous glands – after healing oil should be applied over the area
• Loss of hair growth, blunting of sensation
2. Full thickness graft (whole graft)
o It includes both epidermis + full dermis
o Used over face, eyelid, hands, fingers, over the joint
o It is removed using scalpel blade
o Sites of donor area
• Postauricular, Supraclavicular, Groin crease
o Advantages
• Good colour match
• No contracture
• Sensation, functions of Sebaceous glands, hair follicles are retained
o Disadvantages - Used only for small areas

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FACIOMAXILLARY DISEASES
CLEFT LIP AND CLEFT PALATE
Aetiology
• Familial
• Protein and vitamin deficiency
• Rubella infection
• Radiation
• Chromosomal abnormalities
• Drug intake during pregnancy (steroids/diazepam)
Classification
1. Cleft lip alone
2. Cleft lip and palate
3. Isolated cleft palate
• Complete – cleft palate is completely separated from Vomer and Nasal septum
• Incomplete – cleft palate is attached to Vomer and Nasal septum

Defect is often associated with other congenital anomalies of

• Cardiac
• Gastrointestinal
• Neurological
• Down’s syndrome
• Teacher Collins syndrome
• Pierre-robin syndrome
o Cleft palate
o Retrognathia
o Posteriorly displaced tongue
• Stickler syndrome
o Eye, Skeletal, Muscular, Cleft Disorders

Problems in cleft disorders

• Difficulty in sucking and swallowing
• Defective speech
• Altered dentition, Cosmetic problems
• Recurrent upper respiratory tract infection
• Chronic otitis media
LASHAL system
• Classification to explain the features
• L – lip
• A – Alveolus
• S – Soft palate
• H – Hard palate
o Complete cleft – written in Capital letters
o Incomplete cleft - written in small letters
Treatment for cleft lip
Millard criteria (rule of 10) for cleft lip repair
• 10 pound weight
• 10 weeks old
• 10 g% Haemoglobin

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Surgeries
• Unilateral cleft lip → Millard rotational advancement flap procedure
• Bilateral cleft lip → Mulliken technique
• Hard palate repair → Wardill and Von langenbeck repair
• Soft palate → Furlow technique

Timing of surgery based on DELAIRE technique and sequence

1. Cleft lip alone
• Unilateral → One surgery at 5-6 months age
• Bilateral → One surgery at 4-5 months age
2. Soft palate alone
• One surgery at 6 months age
3. Soft and hard palate
• Two operations
i. Soft palate → 6 months age
ii. Hard palate → 15-18 months
4. Cleft lip and palate
• Two operations
i. Cleft lip and Soft palate → 6 months age
ii. Hard palate → 15-18 months

Post-operative management
• Post operative speech therapy
• Training for sucking, swallowing
• Control of infection
• Dental reconstructive surgery
• Hearing support, control of otitis media
• Veloplasty, rhinoplasty, orthognathic surgery etc.

DENTIGEROUS CYST (FOLLICULAR ODONTOME)

• Unilocular cystic swelling arising from an unerupted tooth
• Lower jaw > upper jaw
• Occurs over the crown of unerupted tooth
• Seen in relation to Premolars or molars
• Clinical features
o Painless swelling in the jaw
• Differential diagnosis
o Adamantinoma
o Dental cyst
o Osteoclastoma
• Complication
o Can progress into adamantinoma
• Investigation
o Orthopantomogram – well defined tooth within the cyst
• Treatment
o If small - Excision of cyst
o If large – initial marsupialization and later Excision
o Unerupted tooth should be extracted

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EPULIS (upon Gum)

Swelling arising from mucoperiosteum of gums (gingiva)
Classification/Types
• Congenital - benign condition (newmann’s tumour) in a newborn
• Fibrous
• Granulomatous
• Pregnancy epulis - occurs during 3rd month of pregnancy
• Carcinomatous
• Myelomatous
• Fibrosarcomatous – scene in leukemic patients

ORAL CAVITY
CARCINOMA OF BUCCAL MUCOSA / CARCINOMA CHEEK
Malignancies can be
• Squamous cell carcinoma – MC
• Minor salivary gland tumors
• Melanoma
• Adenocarcinoma
• Sarcoma
• Basaloid SCC

Types
• Ulcerative
• Proliferative
• Verrucous

Etiology
• 6S
o Smoking
o Spirit
o Syphilis
o Sharp tooth
o Spices
o Sepsis
• Chewing betel nut
• Premalignant conditions (3mrk)
o Leukoplakia
o Erythroplakia
o Hyperplastic candidiasis
o Oral submucosa fibrosis
o Syphilitic glossitis
o Sediropenic dysphagia (plummer-vinson syndrome)
o Dyskeratosis congenita
o Oral lichen planus
o Discoid lupus erythematosus
• Carcinogens
o Tobacco
o Arecoline and Tannin alkaloids of areca

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Biological behaviour of carcinoma cheek

• Posterior cheek > Anterior cheek
• Spreads deeper and involves
o Buccinator
o Pterygoids
o Retromolar trigone
o Base of skull
o Pharynx
o Mandible
o Skin – ulceration, oro-cutaneous fistula formation
• Infection of the tumor area causes
o Fever
o Foul smelling
o Halitosis
Clinical features
• Ulcer - Gradually increasing in size
• Pain – if involvement of skin and bone
• Halitosis – release of mercaptan and ammonia due to necrosis of tumor
• Andy-Gump deformity
o Loss of Central part of mandible due to tumor extension
o Pouting of lower lip with drooling of saliva
• Trismus – involvement of Pterygoids
• Dysphagia – involvement of pharynx
• Submandibular and Upper deep cervical lymphadenopathy – Fixed lymph nodes
• Infiltration into
o Hypoglossal nerve – ipsilateral tongue deviation)
o Spinal accessory nerve – defective shrugging of shoulder
o Cervical sympathetic chain – Horner’s syndrome.
• Carotid blow out - compression over external carotid artery → erosion of vessel wall → bleeding from
major vessels

Investigations
• Wedge biopsy
• Taken from two sides
• Taken from the edge – as it contains active cells
• Not taken from Central area - it is area of necrosis
• Histological features
o Malignant squamous cells with epithelial pearls (keratin pearls)
• BORDERS histological grading
o Well differentiated - >75% epithelial pearls
o Moderately differentiated - 50-75% epithelial pearls
o Poorly differentiated – 25-50% epithelial pearls
o Very poorly differentiated - <25% epithelial pearls
• FNAC from lymph nodes
• CT scan - to assess the extension of tumor
• MRI - to assess the extension into soft tissues and perineural spread
• Orthopantomogram – to assess the involvement of mandible

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Treatment
• Surgery
o Trans oral approach
o Lip split incision
o Wide excision
o Patterson operation
o Neck lymph nodes block Dissection
• Mandibulectomy
o Segmental mandibulectomy
o Marginal mandibulectomy
o Mandibular rim resection
• Reconstruction after surgery
o Split skin graft
o Deltopectoral cutaneous flap
o Pectoralis major myocutaneous flap (PMMC)
o Forehead flap
o Anterolateral thigh flap
• Mandible reconstruction by
o Cortico-cancellous bone graft form iliac crest or rib cage
o Fibula graft
o Radial forearm flap with section of radius
o titanium and stainless steel plates
• Radiotherapy
o External or brachytherapy
• Chemotherapy
o Intra-arterial or intra-venous or oral
o Drugs used are
▪ Methotrexate, Vincristine
▪ Bleomycin, Cisplatin

PLUNGING RANULA (belly of frog)

• PLUNGING ranula
o Mucous retention cyst collects around the sublingual gland and penetrates the mylohyoid
diaphragm to enter the neck
o Painless dumb-bell shaped fluctuant in submandibular or submental region of neck
• Pathogenesis
o Blockage of the salivary duct → mucous retention cyst
o It is closely related to lingual nerve
• Differential diagnosis
o Lymph cyst
o Sublingual dermoid
• Investigation
o US neck
o MRI neck
• Management
o Marsupialization
o Aspiration of cyst → yellow starchy fluid
o Excision of sublingual salivary gland if needed

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LEUKOPLAKIA
• White patch or plaque involving oral mucosa
• Hyperkeratotic, persistent and adherent patch
• It is a premalignant condition
Etiology
• 6S
• Vitamin deficiency
• Tobacco chewing, areca chewing
• Chronic hypertrophic candidiasis
• Human papillomavirus

Types
• Homogeneous
• Nodular
• Speckled leukoplakia - highest rate of malignant transformation
Clinical features
• Painless and non tender
• Ulcerations are often seen
• Hairy leukoplakia → misnomer (no hairs → Syria hyperkeratosis and acanthosis lesion on tongue seen in
AIDS patients with EBV infection
Biopsy
• Rules out carcinoma
• Histologically → Parakeratosis and Dysplasia
Treatment
• Excision and Skin grafting
• CO2 laser excision
• Drugs → Isotretinoin, Beta-carotene, tocoferol

DIFFERENTIAL DIAGNOSIS FOR TONGUE ULCERS

• Painful
o Dental ulcer
o Aphthous ulcer
o Tuberculous ulcer
• Painless
o Ulcer in Lichen planus
o Syphilitic ulcer
o Malignant ulcer

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SALIVARY GLANDS
SURGICAL ANATOMY OF PAROTID GLAND
Parotid gland
• Largest salivary gland
• Situated below the acoustic meatus
• Deep cervical fascia splits and forms a capsule and encloses the gland
• Superficial layer is thickened and adherent to gland
Parts of parotid gland
• Superficial love
• Deep love
• Accessory parotid → prolongation of the gland above the parotid duct
Parotid duct (Stensen’s duct)
• Passes through the buccinator muscle
• Opens into the oral mucosa opposite to second molar tooth
Facial nerve
• Emerges from stylomastoid foramen
• Pes anserinus (goose foot) → facial nerve divides into temporofacial and cervicofacial branches → which
intern divides into many branches interconnected as pes anserinus
Blood supply
• Artery – ECA
• Vein – External jugular vein
Nerve supply
• Parasympathetic secretomotor - auriculotemporal nerve
• Sympathetic vasomotor supply - from plexus around external carotid artery
Faciovenous plane of patey
• Structures present superficial to this plane are
o Facial nerve
o Retromandibular vein
• Structures present deeper to this plane
o External carotid artery dividing into Maxillary artery and Temporal artery

Lymphatic drainage of parotid

• Drains into parotid lymph nodes → deep cervical lymph nodes

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CLASSIFICATION OF SALIVARY GLAND TUMORS

Epithelial
• Adenoma
• Pleomorphic adenoma
• Monomorphic adenoma
o Adenolymphoma (warthin’s tumor)
o Oncocytoma (oxyphil adenoma)
o Basal cell adenoma
• Carcinoma
o Mucoepidermoid carcinoma
o Acinic cell carcinoma
o Adenoid cystic carcinoma
o Adenocarcinoma
o Squamous cell carcinoma
o Carcinoma arising from pleomorphic adenoma
Non-Epithelial
• Hemangioma
• Lymphangioma
• Neurofibroma
• Neurilemmoma
Malignant lymphoma – NHL type
• Common in parotids
• Common with HIV, Sjogrens syndrome
Secondary tumors
• From head and neck
• From bronchus and skin
Lymphoepithelial tumors
• Benign
o Godwin’s tumor – benign salivary gland tumor
o Benign lymphoepithelial lesion
• Malignant
o Rare tumor occurring in parotid and submandibular glands (ESKIMOMA)

SURGICAL ANATOMY OF SUBMANDIBULAR GLAND

• J shaped salivary gland situated in the anterior part of Digastric triangle
Parts and relations
• Superficial part
o Lies in submandibular triangle between two bellies of digastric muscle
o Superficial to mylohyoid muscle
• Deep part
o Is in the floor of the mouth
o Deep to mylohyoid muscle
• Submandibular (Wharton’s) duct
o Emerges from the part of the gland
o enters the floor of the mouth, on summit of papilla beside frenulum of tongue
Artery – facial artery
Vein – Facial vein
Nerve supply – branches from submandibular ganglion

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Applied surgical anatomy

• Resting salivary flow is due to this gland
• Sialorrhoea
o Increased salivary flow often seen in
▪ Psychiatric patients
▪ Cerebral palsy
• Xerostomia
o Decreased salivary flow sign in
▪ Postmenopausal women
▪ Depression
▪ Anticholinergic drugs
▪ Radiation to head and neck region

SIALADENITIS (Salivary calculus)

• Calcium phosphate and calcium carbonate stones
• MC in submandibular gland →
o Secretion is viscous
o Contains more calcium (Radiopaque stone)
o Drainage is nondependent causing stasis
• Secretion of parotid is serous and gravity dependent and has less calcium (Radiolucent stone)
Causes
• Bacterial – MC
• Trauma
• Viral – mumps
Clinical features
• Pain, tenderness
• Double chin appearance due to spreading of edema
Investigations
• Intraoral X-ray – see Radiopaque stones
• Sialogram – see Radiolucent stones
• USG and CT
Treatment
• Sialendoscopy under US guidance – to remove stones <4mm
• Pneumatic Lithotripter – to fragment larger stones

FREY’S SYNDROME (auriculotemporal syndrome or gustatory sweating)

• Aberrant innervation of sweat glands by parasympathetic fibres which were destined for the parotid
• Instead of causing salivary secretion from the parotid decors secretion from sweat glands
Etiology
• Injury to auriculotemporal nerve → Pseudosynapsis between postganglionic parasympathetic fibres of otic
ganglion and sympathetic nerves from superior cervical ganglion)
• It occurs during
o Surgery or Accidental injuries to parotid
o Surgery or accidental injuries to temporomandibular joint

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Clinical features
• Whenever salivation is stimulated (Mastication) → Flushing, Sweating, Erythema, Hyperaesthesia in the
skin over the face innervated by auriculotemporal nerve
• Minor’s starch iodine test → iodine is applied over involved skin → allow to dry → upon application of
starch the area will become blue due to presence of sweat
Prevention
• Barrier kept between skin and parotid bed
o Sternocleidomastoid muscle flap
o Temporalis fascia flap
o Insertion of artificial membrane
Treatment
• Antiperspirants - aluminium chloride
• Denervation – jacobson’s nerve neurectomy
• Botulinum toxin injection in affected skin

PLEOMORPHIC ADENOMA
• Mixed salivary tumor
• Most common salivary neoplasm
• Parotid > submandibular > sublingual
• It is called mixed tumor because of the presence of both
o Epithelial
o Mesenchymal components
Gross
• Contains cystic spaces and cartilaginous solid tissue
Microscopy
• Epithelial cells
• Myxomatous change and cartilage/pseudocartilage

Clinical features
• 40 years
• MC in females
• MC site – tail of parotid gland
• Ear lobule is lifted
• Curtain sign positive – inability to move the gland above zygomatic bone due to deep fascia attachment
to bone
• Long standing Pleomorphic adenoma may turn into carcinoma

Investigations
• FNAC
• CT scan → local extension and spread
• MRI
• Open biopsy is contraindicated in parotid tumors due to
o Injury to facial nerve
o Parotid fistula formation

Treatment
• If only superficial lobe involvement → superficial parotidectomy
• If both lobes are involved → total conservative parotidectomy by retaining facial nerve

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WARTHIN'S TUMOR (papillary cystadenoma lymphomatosum)

• a.k.a Adenolymphoma
• Misnomer –it is not malignant, it is not lymphoma
• Benign tumor occurs Exclusively in parotid
• Occurs due to trapping of jugular lymph sacs in parotid during development period
• Involves superficial lobe of parotid gland
Clinical features
• MC in males
• MC site – lower pole of parotid (at angle of mandible)
• It is multicentric and bilateral
Microscopy
• Double layer of columnar epithelium
• Papillary projections into cystic spaces
• Lymphoid tissues in the stroma
Investigation
• FNAC
• Technetium 99 scan → produces ‘Hot Spot’
Treatment - superficial parotidectomy

NECK
CYSTIC HYGROMA
• Cystic swelling due to sequestration of a portion of ‘jugular lymph sac’ during in-utero development
• Pathology
o Contains aggregation of cysts
o Mosaic appearance – large cysts near the surface and small cysts in the deeper planes
o Each cyst contains clear lives with endothelial lining
• Clinical features
o Swelling in posterior triangle of neck (may cause labour obstruction)
o Swelling is smooth, fluctuant, brilliantly transilluminant, partially compressible
o Positive cough impulse
• Complications
o Compress Respiratory tract – dangerous sign
o Infection of the swelling – Septicaemia
o Rupture with lymph oozing
• Treatment
o Conservative neck dissection, along with excision of all lymph bearing tissues
o Preoperative injection of sclerosants like Bleomycin, PICIBANEL

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BRANCHIAL FISTULA
• Failure of fusion of 2nd and 6th branchial arch → persistence of cervical sinus
Types
• Congenital - persistent cervical sinus
• Acquired
o Branchial cyst rupture
o After drainage of infected branchial cyst
o Incomplete excision of the cyst track
• Has 2 openings
o External orifice
▪ Congenital
• In lower 1/3rd of neck at anterior border of sternocleidomastoid
▪ Acquired
• Junction of upper 2/3rd part of neck
o Internal orifice
▪ Anterior to posterior pillar of tonsil
• Treatment
o Excision of fistulous tract
o Step ladder dissection

TUBERCULOUS CERVICAL LYMPHADENOPATHY

Etiology - Mycobacterium tuberculosis
Site
• Upper deep cervical LN
• Posterior triangle LN

Stages of tuberculous lymphadenitis

• Stage 1 – lymphadenitis
• Stage 2 - Matting
• Stage 3 – Cold abscess
• Stage 4 – Collar-stud abscess
• Stage 5 – Sinus formation

Clinical types
• Acute type – in < 5 years age
• Hyperplastic type – in immunocompetent patients
• Caseation type – in immunosuppressed patients
• Atrophic type – seen on elderly patients

Clinical features
• In stage 1 and 2 – firm, non-tender, matted swelling
• In stage 3 – cold abscess – Soft, smooth, non-tender, without skin involvement
• Stage 4 – Collar-stud abscess – rupture of cold abscess – abscess adherent to skin
• Stage 5 – discharging sinus
• Involved skin – bluish hyperpigmented – Scrofuloderma
• Sinus may undergo fibrosis or calcification
• Tonsils show multiple tubercles
• Associated with pulmonary TB

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Differential diagnosis
• Lymphoma
• Lymph cyst
• Non specific lymphadenitis

Investigations
• Hematocrit, ESR, Peripheral smear
• HIV test, Mantoux test
• CXR – pulmonary TB
• US neck – node size, matting, cold abscess
• FNAC of lymph node – AFB and culture
• CT neck and chest – for lymph node status
Treatment
• Drugs
o Antitubercular drugs
▪ Isoniazid, Rifampin, Pyrazinamide, Ethambutol
• Aspiration → Z-track technique
• Hilton’s method of drainage – using Lister/Long sinus forcels
• Surgical removal
o Indications
▪ No response to drugs
▪ Persistent Sinus

COLD ABSCESS – Non tender swelling in neck

• Etiology
o Tuberculosis
o Actinomycosis
o Nodular leprosy
• Clinical features
o No signs of inflammation
o Not warm, Non-tender
o Fluctuant, Non-tansilluminating
o Non-adherent to skin
o Contains cheesy caseous material
• Investigations
o US-neck
o FNAC – culture and AFB
• Differential diagnosis
• Treatment

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CAROTID BODY TUMOR

• Tumor arising form Carotid body (located at bifurcation of common carotid artery)
• a.k.a Potato tumor, Chemodectoma, Nonchromafin Paraganglioma
• Etiopathogenesis
• Unilateral – MC, bilateral - 5%
• MC – Females
• Seen in High altitudes due to Hypoxia
• Clinical features
• Slow growing, firm neck mass
• Fontaine Sign
▪ Mobile side-side
▪ No vertical mobility
• Pulsatile swelling, Not expansile
• Compression of
▪ Carotids - carotid body syncope
▪ Esophagus, Larynx
• Cranial nerve palsy – hypoglossal, Recurrent laryngeal, Glossopharyngeal nerves
• SHAMBLIN classification
• Type 1 – Localised, Easily resectable
• Type 2 – Adherent, partially covers carotids
• Type 3 – Adherent, enclose carotids completely
• Differential diagnosis
• Carotid artery aneurysm
• Neurofibroma of Vagus – palpation of swelling → causes radycardia and dry cough
Investigations
• Duplex scan
• Contrast CT, MR angiogram
• Lyre sign – Widening/ Splaying of carotid artery seen in angiogram
• Absolute contraindication – FNAC, Biopsy, Partial excision
Treatment
• Type 1 – excision
• Type 2 – subadventitial dissection
• Type 3 – En-Bloc removal of tumor and ICA, with Saphenous vein grafting
Complications of surgery
• Bleeding
• Superior laryngeal nerve injury – decreased pitch of voice
• Recurrent laryngeal nerve injury – Hoarseness in voice

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THYROID
GOITRE – enlargement of thyroid gland
Classification
1. Simple non-toxic goitre
• Diffuse hyperplastic
▪ Physiological – puberty, pregnancy
▪ Primary iodine deficiency
▪ Secondary iodine deficiency
o Goitrogens – cabbage, soya
o Excess dietary fluoride
o Drugs – PAS, Anti-thyroid drugs
• Solitary non-toxic nodule
• Recurrent non-toxic nodule
▪ Wolff-Chaikoff effect – excess iodine intake → inhibits thyroid hormone synthesis
▪ Hokkaido goitre – iodine rich seaweeds intake – inhibits thyroid hormone synthesis
2. Toxic goitre
• Diffuse toxic – primary (Graves disease, Basedow’s disease)
• Multi-nodular – secondary (Plummer’s disease)
• Solitary toxic nodule
3. Neoplastic goitre
• Benign – Follicular adenoma, Hruthle cell adenoma
• Malignant – papillary, medullary, anaplastic, follicular thyroid
4. Thyroiditis
• Hashimoto's autoimmune thyroiditis
• De-Quervains autoimmune thyroiditis
• Reidel’s thyroiditis

MULTI NODULAR GOITRE

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Clinical features
▪ MC in Females
▪ Pizzilos method – make thyroid more prominent for examination
▪ Multiple nodules – firm, non-tender
▪ Swelling moves with deglutition
▪ Positive Kocher’s test → compression on trachea due to long standing MNG

Complications of MNG
▪ Secondary thyrotoxicosis
▪ Follicular carcinoma of thyroid
▪ Hemorrhage of nodule
▪ Tracheal obstruction
▪ Calcification
▪ Cosmetic problem

Investigations
▪ T3, T4, free T4, assay
▪ US-neck
▪ FNAC – most dominant nodule
▪ X-ray – Rim/Ring Calcification, obstruction of Trachea
▪ Radioisotope iodine scan
▪ CT/MRI - in case of retrosternal extension

Treatment
▪ Total thyroidectomy
▪ Partial thyroidectomy or Hartley Dunhill operation
▪ Post operative L-thyroxine → prevent fluctuation in TSH levels

SOLITARY THYROID NODULE

▪ Discrete nodule in thyroid gland, palpable/radiologically distinct from surrounding thyroid parenchyma
▪ Causes
o Thyroid adenoma
o Thyroid carcinoma
o Thyroid cyst

▪ Types
o Solitary non-toxic nodule
o Solitary toxic nodule

▪ Clinical features
o Single palpable nodule
o Rapid enlargement indicates malignancy
o Trail sign - tracheal deviation towards opposite side
o Hoarseness of voice
o Dysphagia
o Dyspnea/Stidor

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▪ Investigations
o TRIDAS – thyroid imaging reporting and data system
▪ Based on
• Composition
• Echogenicity
• Shape
• Size
• Margin
o US guided FNAC
o T3, T4, TSH assay
o Power Doppler – study the vascularity of the gland
▪ Treatment
o Hemithyroidectomy
o Total thyroidectomy
▪ Indications for surgery
o Malignant nodule
o Toxic nodular in young
o Nodules with obstruction
o Cosmetic reason

RETROSTERNAL GOITRE
▪ >50% gotta mass below the suprasternal notch
▪ Types
o Substernal – part of nodule palpable in lower neck
o Plunging - increased it thoracic pressure forces gland into neck
o Intrathoracic/mediastinal goitre
▪ Etiology
o Primary - arising from ectopic thyroid tissue, blood supply from mediastinal vessels
o Secondary – extension of thyroid from neck, that supply from thyroid arteries
▪ Clinical features
o Dyspnea in supine position or neck extension
o Cough and strider
o Dysphagia
o Enlargement of neck veins → due to Compression of major vessels
o Pemberton sign positive → raise arm above shoulder → Goitre compresses over SVC and Trachea
→ dilated veins over neck and dyspnea respectively
▪ Investigations
o Radioactive iodine study
o CT/MRI
o T3, T4, TSH estimation
o CXR
▪ Treatment
o Surgical removal
▪ Small mass – neck incision
▪ Large mass - median sternotomy

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THYROID STORM – condition of hyperthyroidism with fever, CNS, CVS symptoms precipitated by Infection,
surgery, trauma, amiodarone administration
▪ MC seen in inadequately prepared patient for surgery

Clinical features
▪ Tachycardia, Fibrillation, Congestive cardiac failure
▪ Hyperexcitability, irritation
▪ Hyperpyrexia, dehydration

Treatment
▪ Oxygen, IV fluids
▪ Fever - Tepid sponging, paracetamol
▪ Anti-thyroid drugs - Lugols iodine, Methimizole, Propylthiouracil
▪ Steroids (hydrocortisone) – to prevent adrenal exhaustion
▪ Hyperexcitability - Diazepam

THYROID NEOPLASM
▪ Benign
o Follicular adenoma
▪ Collidal
▪ Fetal
▪ Embryonal
▪ Hurthle cell/oxyphil
▪ Hyalinizing trabecular adenoma
▪ Malignant
o Differentiated
▪ Papillary carcinoma
▪ Follicular carcinoma
▪ Hruthle cell carcinoma
o Undifferentiated
▪ Anaplastic carcinoma
▪ Medullary carcinoma
▪ Secondaries in thyroid – from Colon, kidney, breast, melanoma

PAPILLARY CARCINOMA OF THYROID

▪ Predisposing factors
o Irradiation
o Hashimoto's thyroiditis
o Thyroglossal cyst

▪ Clinical features
o MC in females
o Soft or hard, solid or cystic
o Metastasis – lymphatic spread -MC, hematogenous
o Distant metastases – lungs > bone > liver

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▪ Investigations
o Microscopical appearance
▪ Papillary projections
▪ Psammoma bodies (concentric calcifications)
▪ Orphan Annie eye Nuclei
o FNAC
o TSH levels tend to be high → called hormone dependent tumor
o X-ray – rim/ring calcification
o MRI
▪ Treatment
o Size < 1cm – lobectomy
o Size > 1cm - total thyroidectomy
o Size > 4cm - total thyroidectomy + profile lactic bilateral central neck node dissection

ECTOPIC THYROID
▪ Presence of thyroid tissue in locations other than normal anterior neck region
▪ It lies along the course of thyroglossal tract
▪ It can be an entire gland or residual thyroid tissue

▪ Investigations
o Radioisotope scan
o CT for intrathoracic thyroid

THYROGLOSSAL CYST
▪ Swelling occurring in neck along the line of thyroglossal tract
▪ Due to failure of obliteration of thyroglossal duct
▪ Features
o Swelling in the midline, little to left
o Moves with deglutition
o Tugging sign positive – lower jaw is kept still in an open mouth → hold the cyst between thumb
and index finger → upon tongue protrusion → tugging felr
o Empty thyroid fossa

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▪ Investigations
o Radioisotope study
o Ultrasound neck
o FNAC
o T3, T4, TSH assay
▪ Complications
o Infection of cyst
o Malignancy (PCT)
▪ Treatment
o Sistrunk operation
▪ Excision of cyst and entire thyroglossal tract

COMPLICATIONS OF THYROIDECTOMY
• Hemorrhage – slipping off ligatures
• Recurrent laryngeal nerve palsy
• Hypoparathyroidism – temporary vascular spasm of parathyroid glands
• Laryngeal edema due to repeated intubation
• Tracheomalacia

THYROTOXICOSIS
• Symptom complex due to raised levels of thyroid hormones
• Types
1. Diffuse toxic goitre- primary thyrotoxicosis (Graves disease, Basedow’s disease)
2. Toxic multinodular goitre - secondary thyrotoxicosis (plummer disease)
3. Toxic Nodule/Adenoma
4. Other Rarer causes
▪ Thyrotoxicosis factitia – L-thyroxine induced
▪ De-Quervains thyroiditis, Hashimoto thyroiditis
▪ Struma ovarii
▪ Amiodarone
▪ Hydatidiform mole, Choriocarcinoma (HCG mimics TSH)
▪ Neonatal thyrotoxicosis – infant born to grave’s mom, resolves in 3 weeks ( decrease in
levels of TSH-R Antibody)

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GRAVES DISEASE
• Autoimmune disorder with antibodies against TSH receptors
• Clinical features
o CVS – palpitations, shortness of breath
o GIT - increased appetite (weight loss occurs due to increased BMR)
o Genitourinary – amenorrhea, miscarriage, infertility
o Sympathetic overactivity
▪ Irritability
▪ Hyperactivity
▪ Tremor
▪ Dysphoria
▪ Sweating
▪ Heat intolerance
o Graves dermopathy – Redding and thickening of skin,
o Graves Acropachy – Swelling of metacarpals, Pretibial myxedema
o Graves opthalmopathy –
▪ Lid retraction – sympathetic overactivity (Muller’s muscle spasm)
▪ Von-Grafe sign – Lid lag sign – lid lag upon downgaze
▪ Stellwagccs sign - absence of normal blinking – staring look
▪ Mobius sign – lack of convergence of eyeball (lymphocytic infiltration of inferior oblique)
▪ Dalrymple sign – upper eyelid retraction -> visible upper sclera
▪ Jellnek’s sign → increased pigmentation of eyelid margins
• Diagnosis
o Increased T3, T4
o Decreased TSH
o Elevated RAIU
o Increased thyroid stimulating antibodies
• Treatment
o Antithyroid drugs
▪ Methimizole
▪ Propylthiouracil
▪ Lugol’s iodine
o Radioactive iodine therapy
o Surgery
• Total thyroidectomy
• Subtotal thyroidectomy
• Hemithyroidectomy
o Indications of surgery
▪ Failure of drug therapy
▪ Contraindication for RAI
▪ Young age
▪ Graves ophthalmopathy
▪ Pregnancy (surgery done in 2nd trimester)
▪ Compressive symptoms
▪ Goitre size >80 grams

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TOXIC ADENOMA (toxic nodule)

▪ Benign functioning monoclonal thyroid tumor
▪ It is autonomous functioning tumor → TSH independent
▪ Secretes large quantities of thyroid hormones
▪ No eye signs, No Graves features
▪ Levels of T3 > T4
▪ Investigation
o Radioisotope scan – Hot nodule
o US neck
o T3, T4, TSH assay
▪ Treatment
o Antithyroid drugs
o RAI therapy

PARATHYROID AND ADRENALS

MEN SYNDROMES
Autosomal dominant inherited endocrine syndrome complex
• MEN-I (Wermer's disease)
o Parathyroid tumors
▪ Hyperparathyroidism
o Pituitary tumors
▪ Prolactinoma
▪ Acromegaly
▪ Cushing’s syndrome
o Pancreatic islet cell tumors →
▪ Gastrinoma
▪ Glucagonoma
▪ Insulinoma
▪ VIPoma
▪ Somatostatinoma
• MEN-IIa (Sipple disease)
o Medullary carcinoma thyroid
o Pheochromocytoma
o Parathyroid adenoma
o Cutaneous lichen amyloidosis
o Hrischprung’s disease
• MEN-IIb (MEN III)
o Modullary carcinoma thyroid
o Pheochromocytoma
o Mucosal and Gastrointestinal neuroma
o Marfanoid features

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Evaluation of MEN syndrome

• Family history
• Biochemical screening – Parathromone, Serum Calcium, Prolactin, Growth harmone, Insulin, Glucagon,
Calcitonin
• Genetic screening from isolated DNA from peripheral blood WBC

SESTAMIBI SCAN
• Technetium – 99m labelled scan
• Procedure in nuclear medicine which is performed to localize parathyroid adenoma
(Hyperparathyroidism)
• Adequate localization of parathyroid adenoma allows the surgeon to use a minimally invasive surgical
approach.
• Often combined with SPECT – single photon emission computerized tomography

TETANY – decrease level of calcium in blood causing its effects

• Etiology
o After thyroidectomy (decreased parathormone → hypocalcemia)
o Injury to parathyroid blood supply
o DiGeorge’s syndrome (Absent parathyroids, Thymic aplasia)
o Rickets, Osteomalacia
o Metabolic alkalosis
o Chronic renal failure
• Clinical features
o Paresthesia of neck, fingers and toes
o Carpopedal spasm
o Generalized weakness and twitching
o Stridor and breathing difficulty due to paralysis of respiratory muscles
o Trousseau sign
▪ Upon tying Tourniquet at upper arm and raising the BP
▪ Flexion of metacarpophalangeal joint
▪ Extension at interphalangeal joints
o Chevostek sign
▪ Tapping over preauricular region – twitching of facial muscles
o Prolonged QT interval
• Management
o IV calcium gluconate
o Oral calcium with vitamin D
o Magnesium sulfate supportive therapy

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BREAST
CLASSIFICATION OF BREAST TUMORS
1. Ductal carcinoma, Lobular carcinoma
2. In-situ carcinoma
a. Noninvasive
i. DCIS
• Comedo
• Cribriform
• Papillary
• Solid
ii. LCIS
b. Invasive
i. Invasive ductal
ii. Invasive lobular
iii. Tubular
iv. Scirrhous
v. Mucinous (colloid)
vi. Medullary
3. Paget's disease of nipple
4. Phyllodes, Angiosarcoma, Carcinosarcoma

CARCINOMA BREAST
• Risk factors
▪ Modifiable
▪ Nulliparous
▪ Absent breast feeding
▪ >30 years at 1 st parity
▪ Obesity
▪ Tobacco
▪ Alcohol
▪ Hormone replacement therapy
▪ Oral contraceptive pills
▪ Non-modifiable
▪ Early menarche
▪ Late menopause
▪ Familial history (BRAC 1 and 2)
▪ African-American women
▪ Radiation exposure
• Etiologiy
▪ Mutation of tumor suppressor genes
▪ BRAC 1
▪ BRAC 2
▪ HER-2 mutation
▪ Li-Fraumen’s syndrome (Tp53 mutation)
▪ Low dietary phytoestrogens
▪ Cowden’s syndrome

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• Clinical manifestations
▪ Hard, painless lump – MC, 10% cases painful lump
▪ Nipple discharge
▪ Ulceration and Fungation
▪ Axillary, Supraclavicular Lymph node enlargement
▪ Chest pain, Hemoptysis
▪ Bone pain, Pathological fractures
▪ Pleural effusion, Ascites
▪ Secondaries in Liver, ovary
▪ Cutaneous manifestations
▪ Peau d’orange – obstruction of dermal lymphatics
▪ Dimpling of skin - infiltration of ligament of cooper
▪ Nipple retraction, discharge
▪ Tethering to skin
▪ Metastasis
▪ Lymphatic spread – MC
▪ Hematogenous spread
• Staging
▪ TNM staging
▪ T1 – size < 2cm
▪ T2 – size > 2cm
▪ T3 – size > 5cm
▪ T4 – extension into chest wall or skin

▪ N1 – metastasis to ipsilateral axillary node (mobile)

▪ N2a – metastasis to ipsilateral axillary nodes (fixed)
▪ N2b – metastasis to ipsilateral internal Mammary nodes
▪ N3a – metastasis to ipsilateral infraclavicular nodes
▪ N3b – metastasis to ipsilateral internal mammary and axillary nodes
▪ N3c – metastasis to ipsilateral supraclavicular nodes

▪ M0 – no distant metastases
▪ M1 – distant metastases – ovary, opposite Brest, lungs, bone, liver, brain

• Investigations
▪ Mammography
▪ Size and location of Mass
▪ Microcalcifications - indicates malignancy
▪ FNAC
▪ Minimum of 6 aspirations done
▪ Giemsa, Papanicolaou, Eosin & Hematoxylin stains are used
▪ Corecut/Trucut biopsy
▪ Frozen section biopsy
▪ Excision biopsy
▪ Edge biopsy
▪ Oestrogen receptor study
▪ ER positive - good prognosis, Harmone therapy beneficial
▪ ER negative – poor prognosis, Harmone therapy nor beneficial

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▪ Progesterone receptor status

▪ Her-2/Neu receptors study
▪ Study of discharge from nipple
▪ Sentinel lymph node biopsy (sentinel node – first node involved from a tumor)
▪ Tumor markers – CA 15/3
▪ MRI breast, PET – scan

• Treatment
▪ Hormone therapy
▪ Useful in ER/PR positive patients
• Tamoxifen
• Letrozole
• Trastuzumab
• Lepatinib
▪ Chemotherapy
▪ CAF – cyclophosphamide, adiramycin, 5-fluorouracil
▪ CEF – cyclophosphamide, epirubicin, 5-fluorouacil
▪ CMF – cyclophosphamide, methotrexate, Cyclophosphamide
▪ TAC – taxanes, adiramycin, cyclophosphamide
▪ Radiation therapy
▪ Whole breast radiotherapy (WBRT)
▪ Accelerated partial breast irradiation (APBI)
▪ Surgery
▪ Simple mastectomy
• Prophylactic simple mastectomy
• Extended simple mastectomy
• Nipple-Areola sparing mastectomy
▪ Modified radical mastectomy
• Patey’s modification
o Pectoralis minor removed
o Level I, II, III nodes removed
• Auchincloss modification
o Pectoralis minor refracted superomedially
o Level I and II nodes removed
• Scanlon modification
o Pectoralis minor tendon divided at insertion (coracoid process)
o Level I, II, III nodes removed
• Advantages of MRM
o Structures preserved
▪ Pectoralis major
▪ Axillary vessels
▪ Cephalic queen
▪ Long thoracic nerve of BELL
▪ Thoracodorsal nerve (Nerve latissimus dorsi)
o Shoulder function is preserved
o Better cosmetic appearance (Axillary fold is preserved)

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FIBROADENOMA BREAST (breast mouse) - Most common benign tumor of breast

o Hyperplasia of a single lobule of the breast
o Etiopathogenesis - focal increased sensitivity to oestrogen
o Types
1. Pericanalicular/ hard type
▪ Small, fibrous tissue
▪ Easily felt due to firmness
▪ Moves freely (breast mouse)
▪ Slow growing, Painless
▪ Enucleation possible
2. Intracanalicular/ soft type
▪ Large, Glandular issue
▪ Less firm
▪ Rapid growth, Painful
▪ Enucleation impossible, Excision needed
o Clinical features
1. Freely mobile, firm swelling
2. MC site - lower part of breast
3. No discharge form nipples, No axillary LN involvement
o Investigations
o Mammography - popcorn calcification
o FNAC, Core biopsy
o Ultrasound, MRI
o Management
o Excision – removal of tumor along with capsule
o Enucleation – removal of tumor leaving capsule behind
o Incisions used
▪ Sab mammay fold incision
▪ Peri-areola incision
▪ Radial or curved incision
o Giant fibroadenoma - >5cm → enucleation via Submammary incision

ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI)

o Includes variety of benign breast disorders occurring at different reproductive periods
o Based on 3 phases of physiological changes in breast
1. Lobular development
2. Cyclical hormonal modification
3. Involution
o Types
1. In early reproductive age group (15-25 years)
▪ Fibroadenoma
▪ Stromal hypertrophy
2. In mature reproductive age group (25-40 years)
▪ Cyclical mastalgia (Fibrocystadinosis)
3. Involution age group (40-55 years)
▪ Lobular involution (fibrosis, adenosis, apocrine metaplasia)
▪ Ductal involution (periductal mastitis, mammary duct fistula, partial nipple retraction)
▪ Epithelial changes - hyperplasia and Atypia

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PHYLLODES TUMOR (CYSTOSARCOMA PHYLLODES)

o Tumor of mixed connective tissue and epithelium
o a.k.a Systemic disease of Brodie
o Types
o Benign
o Borderline
o Malignant

o Clinical features
o Age > 40 years
o Rapidly grow into a bosselated mass
o Smooth, non-tender, fluctuant swelling
o Skin over the breast is stretched, visible dilated veins

o Differential diagnosis
o Giant fibroadenoma
o Angiosarcoma
o Carcinoma breast

o Gross examination
o Massive tumor with bosselated surface
o Multiple areas of necrosis and cystic changes
o Microscopy
o Epithelial clefts resembling leaf-like structure

o Investigation
o Mammography - calcification and necrosis
o Ultrasound - cystic spaces

o Treatment
o Small phyllodes – excised along with 1cm Margin of normal breast tissue
o Large phyllodes – mastectomy with adjuvant chemotherapy

SENTINEL LYMPH NODE BIOPSY

• Sentinel node is the first node involved from a tumor
• Commonly used for
o Carcinoma breast
o Penile cancer
o Malignant melanoma
• Mechanism – if sentinal node has no tumor, it indicates no necessity for extensive LN disection
• Indications
o Done when LN are not detectable clinically or by imaging
• Contraindication
o T3/T4 tumors
o Inflammatory breat cancer
o Pregnancy

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MASTALGIA
• Pain in the breast
• Types
1. Chest wall pain
2. Cyclical
▪ Pain related to menstrual cycles
▪ Pain more during menstruation
▪ Seen in ANDI like fibrocystadenosis
▪ Treatment
• Diclofenac gel
• Evening primrose oil
• Tamoxifen
• Analgesics
3. Non-cyclical
▪ Periductal mastitis
▪ Malignancy
▪ Musculoskeletal pain
▪ Tietze syndrome _ costochondritis of 2nd costal cartilage
▪ Mondor’s syndrome – thrombophlebitis of superficial veins of breast
▪ Cervical root pain
▪ Treatment
• Identification and treatment of cause

PAGET'S DISEASE OF NIPPLE

• Superficial manifestation of an intraductal carcinoma
• Malignancies spreads from ducts to nipple
• Clinical features
▪ Hard nodule underneath areola
▪ Ulceration and destruction of Nipple
▪ Unilateral (unlike eczema – bilateral)
▪ Distinct edges
▪ Itching absent
• Differential diagnosis – Eczema
• Investigations
o Biopsy
▪ Large, clear PAGET’S cells with malignant Features
▪ Pegets cells contains intracellular mucopolysaccharides, clear halo in cytoplasm
Treatment – MRM

TRIPLE ASSESSMENT
• Clinical history and examination
• Radiological imaging US/MRI/mammography
• Cytological/Histological analysis – FNAC/ Core biopsy

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BREAST ABSCESS (inflammatory mastitis)

• Precipitating factors
o Cracked nipple, retracted nipple
o Improper cleaning of Nipple
o infection from mouth of the baby
o hematoma getting infected

• Infective agent
o Staphylococcus aureus
o Staphylococcus epidermidis
o Streptococcus

• Clinical features
o Continuous throbbing pain
o Diffuse redness, brawny induration in breast
o Purulent discharge from nipple
o Palpable Axillary LN
• Differential diagnosis
o Inflammatory carcinoma of breast
• Investigations
o CBC
o US breast – Localise the abscess
o US guided aspiration - culture and sensitivity
• Treatment
o Antibiotics
▪ Cephalosporins, Penicillin
o Drainage under general anaesthesia
• Complications
o Antibioma formation
o Sinus formation, skin necrosis
o Septicemia

ANTIBOMA
• Pus in inflammation matitis → localizes and becomes sterile with thick fibrous tissue cover
• Features
o Mastitis treated only with antibiotics, without drainage
o Painless swelling, non-tender and fixed
• Differential diagnosis – Scirrhous Carcinoma of breast
• Investigations
o FNAC, Mammography, US breast
• Treatment
o Excision with sub-mammary incision

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GYNECOMASTIA
• Enlarged breast in males
• Etiology
• Physiologic gynecomastia (excess circulating oestrogen)
▪ Neonatal period
▪ Adolescence
▪ Senescence
• Oestrogen excess states
▪ Testicular tumors
▪ Endocrine disorders
▪ Hermaphrodites
▪ Liver cirrhosis
• Androgens defecient state
▪ Hypogonadism (Klinefelter)
▪ ACTH deficency
• Testicular failure
▪ Trauma, Radiation
▪ Orchitis
▪ Undescended testis
• Drugs
▪ Furosemide
▪ Spironolactone
▪ Ketoconazole
▪ Cimetidine, Captopril
▪ Isoniazid
• Complications
• Breast cancer
• Grades of gynaecomastia
• Grade 1 – mild enlargement without skin redundancy
• Grade 2a – moderate enlargement without skin redundancy
• Grade 2b - moderate enlargement with skin redundancy
• Grade 3 – marked enlargement with skin redundancy and ptosis
• Management
• Testosterone therapy
• Danazol
• Surgical treatments - Local excision, Liposuction, Subcutaneous mastectomy

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MONDOR'S DISEASE (string phlebitis)

• Thrombophlebitis of superficial veins of breast and anterior chest wall
• Involved veins
o Lateral thoracic vein
o Thoraco-epigastric vein
o Superficial epigastric vein
• Examination
o Thrombosed cord like veins attached to skin
o Forms grooves over skin upon lifting arm
• Differential diagnosis - lymphatic permeation of carcinoma breast
• Treatment
o Warm compressions
o Brassier support
o Excision

DUCT ECTASIA (PERIDUCTAL MASTITIS)

• Dilation of breast ducts associated with periductal inflammation
• a.k.a Plasma cell mastitis
• Risk factors
o Smoking
o Multiple pregnancies
o Hyperprolactin stage
• Clinical features
o Greenish discharge from nipple
o Indurated mass under areola
o Retraction of nipple
o Secondary bacterial infection
• Differential diagnosis - carcinoma breast
• Investigations
o Discharge study, FNAC
o Mammography
• Treatment
o Quit smoking
o Hadfield operation – Cone Excision of involved major ducts

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PERITONITIS
• Inflammation of parietal and serosal layer of peritoneum
• Types
1. Primary peritonitis
▪ Etiology
• Spread of infection from lower genitals
• Cirrhotic patients with ascites (spontaneous bacterial peritonitis)
2. Secondary peritonitis
▪ Etiology
• Bowel perforation
• Appendicitis brust
• Cholecystitis
• Diverticulitis
• Valentino’s syndrome – perforated duodenal ulcer into retroperitoneum, presents
as pain in right iliac fossa mimicking appendicitis
3. Tertiary peritonitis
▪ After abdominal surgeries
• Bacteria causing peritonitis
▪ Bacteria from GIT
• Streptococcus faecalis
• Staphylococcus
• E. Coli
• Klebsiella
• Cl. Welchii
▪ Bacteria from elsewhere
• Gonococcus - from fallopian tube
• Mycobacterium - from pulmonary TB
• Chlamydia – from vaginal Infection
• Mode of transmission
▪ Perforation of GIT
▪ Penetrating trauma
▪ Surgery – Drains, Dialysis
▪ Appendicitis, Cholecystitis
▪ Via fallopian tube
▪ Septicaemia
▪ Uterine perforation
• Clinical features
▪ Sudden onset severe pain
▪ Fever, Vomiting
▪ Blumberg sign - rebound tenderness
▪ Tachycardia, Tachypnea
▪ Abdomen distension
▪ Hypocrates facies
• Sunken eyes and temples
• Pinched nose
• Tense hard skin
▪ Absent bowel sounds due to paralytic ileus
▪ Septicemia – SIRS & MODS

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Differential diagnosis
• Pancreatitis
• Intestinal obstruction
• Ruptured ectopic pregnancy
• Acute pyelonephritis
• Acute mesenteric ischemia
• Diabetic acute abdomen
Investigations
• CXR of abdomen
o Ground glass appearance
o Gas under the diaphragm
• US abdomen
o Shows fluid in abdominal cavity
• Electrolyte study, Blood culture
• Diagnostic peritoneal lavage - >500 WBC / ml suggests peritonitis
• Diagnostic laparoscopy
• CT/MRI
Treatment
• Primary assessment and resuscitation
• A – airway
• B - breathing
• C - circulation
• D – disability, drugs
• E - exposure
• F – fever, fluid, Foley’s catheter
• G – gastric tube
• H – history
• Systemic antibiotic therapy
• 3rd gen cephalosporins
• Piperacillin and tazobactam
• Meropenem, Imipenem
• Electrolyte management
• Surgical drainage
• Laparotomy
▪ Closure of perforation
▪ Resection of gangrene area
▪ Peritoneal lavage
▪ Appendectomy
• Percutaneous USG or CT guided drainage
• Proper post operative care
• ICU
• Ventilator
• Prevention of complications
▪ Respiratory infection
▪ Renal failure
▪ DVT
▪ Abdominal compartment syndrome

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SUBPHRENIC ABSCESS
• Abscess in Subphrenic spaces such as

• Etiology
o Appendicitis
o Perforated duodenal ulcer
o Cholecystitis
o Amoebic liver abscess
o Pancreatitis
o Splenectomy
o Post operative (cholecystectomy, gastrectomy, pancreatic surgery, bowel resection)
• Clinical features
o Barnard’s aphorism
▪ Pus somewhere, pus nowhere else, pus under diaphragm
o Fever with chills and rigor
o Pain and tenderness in right hypochondrium, epigastrium
o Sympathetic right sided pleural effusion due to hyperemia and congestion of diaphragm → lung
collapse/basal atelectasis
o Pain in right shoulder –> irritation of phrenic nerve
o Hoover’s sign – scoliosis towards same side in Subphrenic abscess
• Complications
o Peritonitis, Sinus formation, Septicaemia
• Differential diagnosis
o Amoebic liver abscess
o Pulmonary collapse
• Investigations
o X-ray abdomen
▪ Soft tissue shadow
▪ Elevated right diaphragm
▪ Lung collapse
▪ Reduced Right sided diaphragmatic movement
o USG abdomen
o CT abdomen
o Gallium 67 imaging
• Treatment
o Antibiotic therapy
o Percutaneous drainage – Malecot’s, Foley’s, Pigtail, Sump catheter
o Open drainage

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MESENTERIC CYST
• Causes
o Chylolymphatic – congenitally misplaced lymphatic system,
o Enterogenous – arises as diverticulum
o Urogenital remnants
o Teratomatous dermoid cyst
o Hydatid cyst of mesentery
o Traumatic hematoma and cyst formation
o Tuberculous cold abscess of mesentery
• Features
o Tillaux triad
▪ Painless abdominal swelling in umbilical region
▪ Freely mobile
▪ Zone of resonance all around
o Torsion of cyst
o Rupture of cyst
o Hemorrhage into cyst
o Infection
• Investigations
o US abdomen
o Barium meal X-ray
o CT scan
• Differential diagnosis
o Hydronephrosis
o Omental cyst
o Ovarian cyst
• Treatment
o Enucleation
o Cyst removal with resection of adjacent bowel

ILEAL TB
• Stricture type – presents with intestinal obstruction
• Complications
o Bowel adhesion
o Fibrosis
o Perforation
• Investigation
o Plain X-ray – multiple air fluid levels
• Treatment
o Anti-TB therapy
o Stricturoplasty
o Resection and anastomosis

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ABDOMINAL TUBERCULOSIS
• Type of TB that affects the gut, the peritoneum, abdominal lymph nodes, the solid organs in the
abdomen (liver, pancreas, and spleen)
• Incidence is high in HIV patients

• Types
1. Intestinal - Ileocecal region (MC)
▪ Ulcerative
▪ Hyperplastic
▪ Ulero-hyperplastic
2. Peritoneal tuberculosis
3. Tuberculous mesenteric lymphadenitis
4. Ano-recto-sigmoidal tuberculosis
5. Tuberculosis of omentum
6. Miliary TB – affecting Liver, Spleen etc
(gastric TB is Rare – HCl is acidic media)

Modes of spread
• Ingestion
o Food contaminated with TB – primary intestinal TB
o Sputum containing tubercle bacilli – secondary Intestinal TB
• Hematogenous spread from lungs
• Lymphatic spread from neck lymph nodes
• Retrograde spread from fallopian tube
• Direct spread from adjacent organs

Compilations
• Obstruction
• Malabsorption
• Blind-loop syndrome
• Cold abscess formation
• Perforation

PSEUDOMYXONA PERITONEI
• Malignant condition developing due to ruptured malignant ovarian cyst or appendix adenocarcinoma
• Peritoneum is coated with mucous secreting tumor with gel like mucous within cystic masses

• Clinical features
o Abdominal distension
o Interloop bowel adhesion
o Intestinal obstruction
o Hemorrhagic asities

• Differential diagnosis
o Peritoneal tuberculosis
o Acute pancreatitis

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• Investigations
o CT scan – bowel displacement, fluid in peritoneal cavity
• Treatment
o Appendectomy
o Removal of all mucus gel with right hemicolectomy
o Panhysterectomy with omentectomy
o Intraperitoneal chemotherapeutic agents - 5 fluorouracil, mitomycin C
o Intraperitoneal mucolytic agents – dextran, urokinase

ILIOCAECAL TB – MC site of abdominal TB because ..,

• Abundant peyer's patches
• Stasis – more contact time with mucosa
• Increased rate of fluid and electrolyte absorption
• Minimal digestive activity

Types
• Ulcerative – multiple transverse ulcers
• Hyperplastic - chronic granulomatous lesion
• Ulcero-hyperplastic

Clinical features
• Abdominal pain
• Diarrhoea
• Mass in right iliac fossa
• Intestinal obstruction

Differential diagnosis
• Carcinoma caecum
• Ameboma
• Ectopic kidney
• Crohns disease

Investigations
• CXR, Mantaux test, ELISA
• US abdomen – ascites, caecal thickening
• Plain X-ray – Intestinal Obstruction, Calcification
• Colonoscopy – rule out carcinoma
• Barium study X-ray - shows
o Conical caecum
o Obtuse ileocecal angle
o Inverted umbrella sign - narrow ileum with thickened Ileocecal valve
o Calcifications
o Ulcers and strictures
• Transabdominal peritoneoscopy - visualisation of peritoneal cavity
• Percutaneous needle peritoneal biopsy – Abraham’s needle
• Abdominal CT

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Treatment
• Antitubercular therapy – HRZE
• Steroids - to prevent interloop adhesions
• Indications for surgery
o Obstruction
o Hemorrhage
o Perforation
o Fistula formation
• Surgery
o Ileocecal resection
o Stricturoplasty
o Hemicolectomy with Ileo-tansverse colon anastomosis
o Drainage of abscess

PERITONEAL TB
• Thickening and fibrosis of peritoneal wall with multiple tubercles
• Types
o Dry – presents with thickening and fibrosis
o Wet type - presents with different forms of ascites like ..,
1. Loculated form
• Asitis gets loculated because of Fibrinous deposition
2. Fibrous form
• Widespread additions between intestine, omentum, abdominal wall
3. Purulent form
• Due to tuberculous salpingitis
• Lower Abdominal mass containing pus →abscess gets adhered to abdominal wall
and forms umbilical fistula
• Clinical features
o Abdominal distension, doughy abdomen
o Colicky abdominal pain main
o Intestinal obstruction
o Small bowel destination → Blind loop aka stagnant loop → normal bacterial flora of the
small intestine proliferates to numbers that cause significant derangement
o Recurrent fever
o Abdominal cocoon - small intestine covered with dense adhesions of peritoneum and omentum
• Investigations
o USG abdomen
o CT abdomen
o Ascitic fluid analysis → fluid culture will show M. tuberculosis
o Peritoneal biopsy
o Diagnostic laparoscopy
• Treatment
o Antitubercular drug therapy
o Surgery indicated when
1. Intestinal obstruction
2. Perforation
3. Multiple Structures

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TUBERCULOUS MESENTERIC LYMPHADENITIS

• Infection occurs through Peyer’s patches of the intestine
• M. tuberculosis gets trapped in Peyer’s patches
→ M cells in Peyer’s patches phagocytose tubercle bacilli
→ Lipoarabinomanan in TB bacilli inhibits phagolysosome formation → enters into host cell
• Clinical features
o Pain in umbilical region and right iliac fossa
o Fever, weight loss
o Tebes mesentrica – massive enlargement of Mesentric lymph nodes
o Psudomesentric cyst – caseating LN material between layers of mesentery → forms cold cyst,
mimics mesenteric cyst
o Intestine gets adhered to caseating material → Intestinal Obstruction
• Differential diagnosis
o Acute appendicitis
o Carcinoma caecum
• Investigation
o X-ray abdomen – Calcifications
o USG abdomen
o Mantoux test
• Treatment
o Anti-TB therapy
o Diagnostic Laparoscopy and abscess drainage

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LIVER
AMOEBIC LIVER ABSCESS
Causative agent - Entamoeba histolytica
Mode of infection – Feco-oral route
Pathogenesis
• Primary infects Ileocecal junction (Flask shaped ulcer) → Reaches liver via Portal and Superior Mesentric
vein – involves Right lobe of liver
• Trophozoites destroy hepatocytes by releasing histolysin → liquefaction necrosis of liver → abscess
formation (Anchovy sauce coloured)
Clinical features
• Occurs after an attack of amoebic dysentery
• Smooth, tender liver
• Right sided pleural effusion
• Mild jaundice
• Pain in right hypochondrium
Complications
• Rupture of abscess into
o Lungs → chocolate coloured sputum
o Peritoneum → peritonitis
o Intestine → amoebiasis cutie
• Septicemia and liver failure
• Articles of allopathy
• Abscess compresses hepatic veins or IVC – Budd-Chiari syndrome
Differential diagnosis
• Acute cholecystitis
• Subphrenic abscess
• Pyogenic liver abscess
Investigations
• Liver function tests – altered Bilirubin and albumin level
• Prothrombin time – elevated
• CXR – raised fixed diaphragm, pleural effusion
• USG – hypoechoic, nonhomogeneous lesion
• CT scan – size and location of abscess
• Technetium nuclear scan
o differentiates pyogenic and amoebic abscess
o Amoebic abscess doesn’t contain WBC
o Amoebic abscess shows Cold lesion (halo) with Hot rim, (Pyogenic abscess-entirely Hot)
Treatment
• Drugs
o Metronidazole
o Paromomycin
o Idoquinol
• Aspiration
o If abcess > 10cm
o Abscess extension into left lobe
o Abscess in pregnancy
• US guided wide bore needle aspiration
• US guided percutaneous drainage – using Pigtail or Malecot’s catheter

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PORTAL HYPERTENSION
• Sustained elevation of portal venous pressure > 10 mmHg (normally 5-10 mmHg)
Or
• Elevation of hepatic venous pressure gradient- HVPG > 5 mmHg
o HVPG > 5 mmHg - portal hypertension
o HVPG > 10 mmHg – Porto-systemic shunt opens
o HVPG > 12 mmHg – esophageal variceal bleeding
• Causes of portal hypertension
o Prehepatic causes
▪ Portal vein or Spleenic vein thrombosis
▪ Periportal inflammation
▪ Hypercoagulable state
o Hepatic causes
▪ Alcoholic cirrhosis
▪ Schistosomiasis
▪ Hepatitis
▪ Wilson's disease
▪ Hemochromatosis
o Posthepatic causes
▪ Budd-Chiari syndrome
▪ Congestive cardiac failure
▪ Constrictive pericarditis
• Clinical presentation
o Triad of portal hypertension
▪ Esophageal varices
▪ Splenomegaly
▪ Ascites
o Coagulopathy
o Hepatic encephalopathy
▪ Memory loss
▪ Asterixis (flapping tremor/liver flap)
o Porto-systemic shunting
▪ Kenawys sign – venous hum in epigastrium, heard louder on inspiration
▪ Sites of Porto-systemic shunting
• Lower end of oesophagus –short gastric and azygos veins - esophageal varices
• Umbilicus – Paraumbilical vein and Anterior abdominal vein → Caput medusa
• Falciform ligament
• Fissure for ligamentum venosum
• Bare area of liver
• Lower end of rectum
• Posterior abdominal wall
o Hepatorenal syndrome
▪ Decreased urine output
▪ Renal failure
o Hypersplenism
o Haemorrhoids

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• Investigations
o Hb% - anaemia due to bleeding and hypersplenism
o LFT – raised bilirubin
▪ Raised PT, Raised aPTT
o RFT – raised blood urea, serum creatinine
o USG abdomen - splenomegaly
o Contrast CT and MRI – collateral circulation and portal vein status
o MR venogram – extrahepatic portal vein thrombosis
o HVPG – gold standard
o Esophago-gastroscopy – identify bleeding varices
• Management
o General measures
▪ Correction of anaemia
▪ Nutrition supplementation
▪ Inj Vitamin K – coagulopathy correction
▪ Blood transfusion
o Specific measures
▪ Treatment of Hepatic encephalopathy
▪ Treatment of ascites
▪ Reduce portal pressure
• Surgery – Porto-systemic shunt
▪ Liver transplantation
▪ Treatment of esophageal varices

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• Endoscopic therapy
o Endoscopic variceal banding/band ligation
o Endoscopic variceal sclerotherapy using ..,
▪ Ethanolamine
▪ STDS – sodium tetradecyl sulphate
o Endoscopic gluing using tissue adhesives (Butyl cyanoacrylate)
• Shunting surgeries
o Transjugular- Intrahepatic Porto-systemic shunt
o Conventional splenorenal shunt
CAUSES OF HEMATEMESIS
• Chronic peptic ulcer
• Acute peptic ulcer
• Acute erosive gastritis (NSAID, steroid)
• Esophageal varices
• Mallory Weiss syndrome
• Carcinoma stomach
• Gastric polyp, Gastric lymphoma
• Portal gastropathy
• Bleeding disorders
• Pernicious anaemia
• Dieulafoy’s Lesion - large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes
and bleeds

SURGICAL LOBES OF LIVER

• Liver is divided into two functional right and left lobes by a line passing from left of gallbladder fossa to
the left off IVC – Cantlie’s line
• There are 8 segments
• Segments 1, 2, 3, 4 → left lobe
• Segments 5, 6, 7, 8 → right lobe

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LIVER TRAUMA/INJURY
• Most vulnerable abdominal organ for injury
o Predisposing factors
▪ Size
▪ Anterior location
▪ Thin Glisson’s capsule
o Types
▪ Penetrating trauma
▪ Blunt trauma
o Clinical features
▪ Shock (severe bleeding)
▪ Abdominal distension
▪ Oliguria
▪ Tachypnea, ARDS
▪ Hemoperitoneum
▪ Bile leak → Biliary peritonitis
o Investigations
▪ CXR – rib fractures
▪ US abdomen
▪ FAST – focused assessment with sonography for trauma
▪ CT chest and abdomen
▪ Diagnostic peritoneal lavage - >10 ml blood on initial aspiration
▪ ABG
▪ Thromboelastography (TEG) – assessing coagulation status on surgical table
o Treatment
▪ Initial recitation – ABC
▪ General measures
• Blood transfusion, FFP transfusion
• Factor VII (proconvertin) – very effective, normalizes PT time
▪ Interventional radiology – angio-embolism
▪ Specific treatment
• Pringle’s maneuver – liver wound is directly packed with mop
• Laparotomy – bucket-handle abdominal incision
▪ Tractomy – ligation of bleeding vessels individually

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PYOGENIC LIVER ABSCESS

• Etiology
1. Biliary sepsis – MC
▪ Cholangitis
▪ Carolis disease – congenital dilation of Intra-hepatic bile duct
2. Portal vein sepsis
▪ Appendicitis
▪ Pancreatitis
▪ Inflammatory bowel disease
3. Distant infections
▪ Pneumonia
▪ Upper UTI
▪ Endocarditis
▪ Septicemia
4. Superadded infections
▪ Amoebic liver abscess
▪ Hydatid cyst
• Causative agent
▪ E.coli
▪ Klebsiella, Proteus, Pseudomonas
▪ Streptococcus, Staphylococcus
• Clinical features
▪ Right hypochondriac pain
▪ Fever with rigors
▪ Jaundice
▪ Intercostal tenderness
▪ Features of toxicity
• Differential diagnosis
▪ Amoebic liver abscess
▪ Subphrenic abscess
▪ Hydatid cyst
• Investigations
▪ Blood culture
▪ US abdomen
▪ LFT
▪ US guided aspiration of pus
▪ CXR - elevated diaphragm on right side
▪ Technetium nuclear scan – Hot lesion due to presence of WBC
• Treatment
▪ Systemic antibiotics – 3rd gen cephalosporins
▪ Ultrasound guided percutaneous drainage – pigtail’s catheter – TOC

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HYDATID CYST OF LIVER

• Causative agent – Echinococcus granulosus
• Definite host – DOG
• Intermediate host – sheep, man
• Mode of transmission – Feco-oral route
• Ingested eggs → becomes larva in intestine → through portal vein → Liver –> Hydatid cyst
Pathology
• Cyst has 3 layers
• Innermost germinal layer – source of Daughter cyst, secretes Hydatid fluid
• Middle laminated layer
• Outer advential layer
• Clinical features
• Hydatid thrill – three finger test
▪ The hydatid thrill is pathognomic sign of hydatid disease.
▪ The thrill occurs when a mother cyst packed with unruptured daughter cysts is gently
percussed.
▪ Consistency of wall of the daughter cyst and tension of the fluid inside it are responsible
for making the cysts vibrate and produce the sensation of a thrill.
• Jaundice
• Anaphylaxis
• Right hypochondriac pain
• Splenomegaly, Pleural effusion
• Camellote sign – intra-biliary rupture, gas enters into cyst → partial collapse of cyst wall
• Complications
• Calcification of cyst
• Rupture into peritoneal cavity – Anaphylaxis and Shock
• Raftaar into biliary channels
• Secondary infection and septicemia
• Disseminated abdominal hydatidosis
• Differential diagnosis
• Hepatoma
• Amoebic liver abscess
• Cystic disease of liver
• Investigations
• USG → visualisation of cyst
• X-ray → shows calcification
• CT abdomen – cart-wheel appearance
• Casoni's test – intradermal Inj of purified Hydatid fluid → Erythema & Wheal formation
• PCR, ELISA
• Treatment
• Drugs
▪ Albendazole
▪ Praziquantal
▪ Main bendazole
• US guided PAIR – puncture-aspiration-injection-reaspiration
• Surgery
▪ Laparoscopic pericystectomy
▪ Liver resection

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HEPATOCELLULAR CARCINOMA / HEPATOMA

• Primary malignant tumor of liver with hepatocellular differentiation
• Risk factors
o Infection – Hep B, Hep C
o Cirrhosis
o Environmental – Aflatoxins, Pyrrolizidine
o Metabolic – hemochromatosis, Wilson's disease, alpha1-antitrypsin deficiency
• Clinical features
o Right hypochondriac pain
o Palpable mass in right hypochondrium and epigastrium
o Weight loss
o Jaundice
o Ascites, Massive spleenomegaly
o Gastrointestinal bleeding - due to portal hypertension
• Spread of tumor
o Lymphatic spread
o Hematogenous spread
o Direct infiltration
• Differential diagnosis
o Secondaries in liver
o Hepatosteatosis
o Hydatid cyst
o Amoebic liver abscess
o Cholangiocarcinoma
• Investigations
o US abdomen – hyperechoic mass, Mosaic pattern with thin halo and lateral shadow
o CT scan abdomen – size, location, portal vein invasion
o Tumor markers – Alpha-Fetoprotein
o CT angiography – Arterial pattern of tumor
• Treatment
o Non-surgical strategies
▪ Transarterial Chemotherapy
▪ Transarterial embolization
▪ External Beam radiotherapy
▪ Percutaneous ethanol/acetic acid injection
o Surgical procedures
▪ Hemi hepatectomy
▪ Total hepatectomy
▪ Liver transplantation

TRANSJUGULAR INTRAHEPATIC PORTO-SYSTEMIC SHUNT (TIPSS)

• Is a shunting operation
• Done when all other methods to control esophageal varices have failed
• Repair of uncontrolled acute bleeding and prevention of further bleeding
• Also acts as a bridge for future transplantation
• 10mm stent placed b/w Hepatic Venule and Portal Venule
• S/E → Hepatic encephalopathy, Bile leak,

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SECONDARIES IN THE LIVER

• Causes
o Abdominal cancers of
▪ Stomach
▪ Colon
▪ Kidney
▪ Pancreas
▪ Abdominal oesophagus
▪ Rectum
▪ Carcinoid
o Extra abdominal cancers of
▪ Breast
▪ Lungs
▪ Prostate
▪ Urinary bladder
▪ Melanoma
▪ Follicular carcinoma thyroid

• Classification
o Precocious
▪ Secondary cancers Presets before primary cancer is suspected
▪ Ex. Carcinoid, Colorectal cancer
o Synchronous
▪ Both primary and secondary cancers are identified at same time
▪ Ex. Stomach carcinoma
o Metachronous
▪ Secondary cancer develops much later after treatment of primary cancer
▪ Ex. Melanoma, Breast cancer

• Route of spread
o Direct → cancer of stomach, colon, gallbladder
o Hepatic artery → melanoma
o Portal vein → carcinoid tumors
o Lymphatic spread → breast and lung cancers

• Clinical features
o Multiple hard nodules
o Nodules show umbilication due to Central necrosis
o Ascites, Hypochondriac pain
o Blumer shelf – Recto-vesical secondaries
o Trousier’s sign -enlargement of Virchow's node (supraclavicular lymph node)

• Differential diagnosis
o Multicentric hepatoma
o Micronodular cirrhosis
o Polycystic liver disease
o Hydatid cyst of liver

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• Investigations
o Primary cancer identified by
▪ Gastroscopy
▪ Colonoscopy
▪ Contrast X-ray, Contrast CT
o Liver biopsy, Liver function tests
o USG abdomen - multiple hypoechoic or hyperechoic lesions
o Tumor marker – CEA (carcinoembryonic antigen)
• Treatment
o Chemotherapy – TOC
o Palliative procedures for primary cancer
▪ Stomach cancer → Gastrectomy, Gastro-jejunostomy
▪ Pancreas cancer → Triple anastomosis, ERCP stenting
o Hemihepatectomy, Liver transplant

LIVER FUNCTION TESTS

• Serum bilirubin - includes both direct and indirect bilirubin (Van-den-Bergh’s test)
• Serum albumin, globulin, A:G ratio, serum albumin indicator of chronic liver disease
• PT – normal value 12-16 seconds, if altered corrected by IM Vitamin K
• Alkaline phosphatase-ALP → indicates Secretory functions
• Aspartate aminotransferase-AST/SGOT → indicates Inflammation
• Alanine transaminase-ALT/SGPT – specific to liver
• 5-nucleotidase, Gamma glutamyl transpeptidase (GGT)
• Alpha-Fetoprotein
• Technetium 99 scan – shows uptake and excretion of bile
• Urine bile salt test (Hays test), urine bile pigments (Fouchet’s test)
o Hepatocyte function → AST, ALT
o Synthetic function → PT, Albumin, Bilirubin, Factor 5, 7
o Biliary canalicular function – ALP, 5 nucleotidase, GGT
Other investigations for liver disease
• US abdomen
• ERCP/MRI/CT/PTC. (Percutaneous transhepatic cholangiography)
• Laparoscopy
• Liver biopsy

HEPATORENAL SYNDROME
• Acute renal failure due to severe hepatic or biliary disease
• Diagnostic criteria for HRS
o Chronic or acute liver disease with advanced liver failure and portal HTN
o Serum creatinine > 1.5 mmHg
o Lack of renal function improvement after volume expansion with Albumin
o Absence of parenchyma kidney disease or US evidence of Obstructive uropathy
• CF – oliguria, azotaemia, hyponatremia
• Cause – liver disease → bile salts in renal tubles → ADH release → renal hypoperfusion and renal ischemia
• Treatment – Mannitol diuresis, Dialysis, Liver transplantatio

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GALL BLADDER
GALL STONES
• Types
• Cholesterol stones
• Mixed stones
• Pigment stones – Black and Brown
• Etio-Pathogenesis
• Lithogenic bile/ Supersaturated bile
o Bile salts and phospholipids (lecithin) keep cholesterol in Solution from (micelles)
o Admiron’s hypothesis – Cholesterol levels more than bile salts and lecithin → cholesterol
crystallization → Cholesterol monohydrate crystals
o Causes of increased cholesterol content in bile
1. Obesity
2. Cholesterol rich diet
3. Clofibrate therapy
o Causes of decreased bile salts in bile
1. Primary biliary cirrhosis
2. Alpha-hydeoxylase enzyme deficiency → rate limiting enzyme in Bile salts sythesis
3. MDR-3 mutation → defective Lecithin
• Nucleation
o Cholesterol monohydrate crystals aggregate to for macroscopic crystal
o Conditions of excess pro-nucleation factors
1. Mucin
2. Infection – E.coli, Salmonella, Ascaris, Clonorchis
o Decreased Anti-nucleating factors (Apo-lipoproteins)
• Bile stasis
o Drugs – Octreotide, OCP
o Total parenteral nutrition (TPN)
o Fasting
o Pregnancy
o Massive burns
• Increased bilirubin production
o Hemolysis
1. Hereditary spherocytosis
2. Sickle cell anaemia
3. Thalassemia
4. Malaria

Clinical features
• Biliary colic – Spasmodic pain in right hypochondrium radiating to chest and shoulders
• Tachycardia, restlessness
• Tenderness in right hypochondrium
• Pain exacerbated in supine position (sleeping at night)
• Reflex pylorospasm → vomiting
• Belching, Heartburn
• Fat intolerance

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Complications of gallstones
• In gallbladder
• Acute cholecystitis
• Chronic cholecystitis
• Gallbladder empyema
• Gallbladder mucocele
• Gallbladder perforation – peritonitis
• Gallbladder carcinoma
• In Intestine
• Cholecystoduodenal fistula → gallstone ileus and intestinal obstruction
• In Common bile duct
• Secondary CBD stones
• Cholangitis
• Pancreatitis
• Mirizzi syndrome – compression of CBD/CHD by extrinsic compression by a gallstone in cystic
duct or Hartmann’s pouch
Investigations
• US abdomen – gallstones seen with Posterior acoustic shadowing
• X-ray abdomen
o Centre of gallstone contains radiolucent gas which is
▪ Triradiate - Mercedes Benz sign
▪ Boradiate – Seagull sign
o Limeys gallbladder - opacified gallbladder → filled with paste made of CaCO3 and CaPO4
• LFT – increased bilirubin, ALT/AST, ALP
• WBC count
Treatment
• Laparoscopic cholecystectomy – gold standard
o Done by ‘Four port technique'

OBSTRUCTIVE JAUNDICE / Surgical Jaundice

• Jaundice that develops due to partial/complete biliary obstruction
• Classification
o Congenital → biliary atresia, choledochal cyst
o Inflammatory → ascending cholangitis, sclerosing cholangitis
o Obstructive → CBD stone, Biliary stricture, Parasite infestation
o Neoplastic → carcinoma of head of pancreas, cholangiocarcinoma, Klastkin tumor
o Extrinsic compression of CBD → lymph nodes
• Clinical features
o Severe jaundice (conjugated hyperbilirubinemia)
o Pruritus (back and forearm) – due to retension of bile salts → histamine release in skin
o Fever
o Right hypochondriac pain
o Palpable gallbladder
o Steatorrhoea
o Charcot’s triad → pain, jaundice, rigours (CBD stone causing Cholangitis)
o Reynauld’s pentad → Charcot’s triad + septic shock + mental changes

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• Complications
o Liver
▪ Enlarged green stained liver (hydrohepatosis)
▪ Hepatocytes degeneration
o Biliary tree
▪ Cholangitis, fibrosis
▪ Obstruction → stasis → colonization of bacteria → concomitant increased intraductal
pressure → reflux of biliary contents → bacteraemia, septicemia → septic shock
o Bowel → absence of bile impairs absorption of
▪ Fat – steatorrhoea
▪ Vit K – bleeding tendencies
▪ Vit A - visual problems
▪ Vit D – osteomalacia
▪ Vit E – peripheral neuropathy, cerebellar ataxia
• Investigations
o LFT
▪ Conjugated hyperbilirubinemia ( >1 mg%)
▪ Increasd PT
▪ Increasd ALP, GGT, 5 nucleotidase
o ERCP – endoscopic retrograde cholangiopancreatography → to visualise the site of obstruction
o MRCP - Magnetic resonance cholangiopancreatography
o Tumor markers – CA 19/9
o Endoscopic US
o Intraductal US
o CT/MR angiogram
o Urine tests - Hays test, Fouchet’s test
• Treatment
o CBD stones
▪ ERCP stone removal
▪ Cholidocholithotomy
▪ Cholidocho-jejunostomy, Cholidocho-duodenostomy
o Carcinoma of head of pancreas
▪ Whipple’s operation
▪ Triple bypass
o Biliary stricture
▪ Stenting
o Biliary atresia
▪ Kasai’s operation
o Management of pruritus
▪ Choletyramine – bile salt binding resin
▪ Antioxidants
▪ Phototherapy

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CHOLEDOCHAL CYST
• Congenital dilation of intra and extra hepatic ducts
• Babbit theory (pancreaticobiliary maljunction)
o Leads to reflux of pancreatic enzymes into bile duct
o Enzymatic destruction of bile duct, duct wall weakening, ductal dilation
• Classification
o Type 1 – extrahepatic biliary tree dilation
o Type 2 – extrahepatic biliary tree diverticulum
o Type 3 – dilation of intraduodenal part of CBD
o Type 4a – dilation of extrahepatic and intrahepatic biliary tree
o Type 4b – multiple dilations in extrahepatic bile duct
o Type 5 (Caroli’s disease) - multiple dilation of intrahepatic biliary tee
• Presentation
o MC in females
o MC age - infancy
o Classical triad
1. Right hypochondriac pain
2. Palpable abdominal lump
3. Obstructive jaundice
o Failure to thrive
• Complications
o Pancreatitis
o Gallstone and CBD stone
o Biliary cirrhosis
o Portal vein thrombosis
o Cyst rupture – peritonitis
o Cholangiocarcinoma
• Investigations
o US abdomen - unilocular cyst
o CT scan
o ERCP/ MRCP – asses ductal anatomy
o LFT
o PTC
• Treatment
o Type 1 & 2 – cyst excision with hepaticojejunostomy
o Type 3 – transduodenal sphincteroplasty
o Type 4 & 5 - liver transplantation

CALOT’S TRIANGLE
• Relations
o Inferior - cystic duct
o Medial – Common hepatic duct
o Above – Cystic artery/ Inferior surface of liver
• Component
o Lymph node of LUND
o Cystic artery

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EXTRAHEPATIC BILIARY ATRESIA

• Occlusion or destruction of extrahepatic bile ducts
• Etiology
o Infection – CMV, Rotavirus, HPV
o Congenital abnormal development of biliary system
• Types
o Type 1 – CBD atresia
o Type 2 – CBD & CHD atresia
o Type 3 – CBD & CHD & Right and left hepatic ducts atresia
• Clinical features
o Severe obstructive jaundice – neonatal period
o Steatorrhoea
o Hepatomegaly
o Splenomegaly
o Portal hypertension
o Severe pruritus
• Differential diagnosis
o Choledochal cyst
o Cholestatic jaundice
o Sclerosing cholangitis
• Diagnosis
o LFT - conjugated hyperbilirubinemia
o US abdomen – tubular echogenicity
o MRCP
o ERCP – multiple strictures in intra and extra hepatic ducts
o Percutaneous liver biopsy – onion skin periductal fibrosis
• Treatment
o Roux-en-Y jejunal anastomosis (hepaticojejunostomy)
o Hepatico-porto-jejunostomy (Kasai’s operation)
o Orthoptic liver transplantation

ORAL CHOLECYSTOGRAM
• Study function of gallbladder
• Procedure
o Fat free diet for 3 days
o Previous night six tablets of iopanoic acid taken orally
o Test day
▪ X ray abdomen in erect posture → visualise gallbladder
▪ Fatty meal is given and another X-ray is taken
• Normally - of gallbladder (stimulated by fatty meal)
• Non-opaque stone - smooth filling defect
o Contraindications
▪ Serum bilirubin > 3mg%
▪ Acute cholecystitis
▪ Vomiting

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ACUTE CHOLECYSTITIS
• Causative agent
o E.coli
o Salmonella
o Klebsiella, Proteus
o Pseudomonas
o Streptococcus faecalis
• Mode of Infection
o Hematogenous – Hepatic artery, cystic artery, Portal vein
• Classification
o Acute calculous cholecystitis
o Acute Acalculous cholecystitis
• Pathogenesis
o Stones causing Obstruction at Hartmann’s pouch or Cystic duct → Stasis of bile → bacterial
infection → inflammation
o Impacted stone may cause mucosal erosion → submucosal tissue is injured due to toxic effect of
bile → necrosis and perforation of gallbladder (usually at Hartmann’s pouch)
• Clinical features
o Sudden onset right hypochondrium pain
o Right hypochondrium tenderness
o Boas’s sign → area of hyperaesthesia between 9th and 11th ribs posteriorly on right side
o Jaundice
o Palpable tender mass in GB region
o Murphy’s sign → mid-inspiratory arrest
1. Ask patient to take and hold a deep breath while palpating the right subcostal area
2. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the
examiner’s hand
• Complications
o Perforation
o Cholecystoduodenal fistula
o Mirrizi syndrome
o Peritonitis
o Septicemia
o Cholangitis
• Investigations
o US abdomen
1. Elicit gall stone
2. Positive sonographic Murphy’s sign
o Plain X-ray abdomen – gas seen in emphysematous GB
o HIDA (Hepatobiliary iminodiacetic acid) scan – Non-visualization of GB is diagnostic
o CT – elicit perforation, impacted stone, gallbladder wall thickness
• Treatment
o Advised hospitalisation
o Conservative treatment
1. Broad spectrum antibiotics
2. Analgesics
• Cholecystectomy – right subcostal Kocher’s incision or through Laparoscopy

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ACUTE ACALCULOUS CHOLECYSTITIS

• Acute inflammation of GB without gallstones
• Causes – GB stasis and Ischemia
o Major surgeries
o Burns
o Trauma
o Long term TPN
o Gall bladder distention
o GB torsion
o Infection – leptospira, Streptococcus, Salmonella
• Presentation
o GB empyema
o GB perforation
o GB necrosis
o GB wall edema
• Investigations
o HIDA
o USG
o Cholescintigraphy – Absence of GB filliing
• Treatment – Cholecystectomy

ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY (ERCP)

• Patient is placed prone with head turned to right
• Patient under Midazolam or Propofol anesthesia
• Sphincter of Oddi is cannulated via Gastro-duodenoscope → water Soluble iodine dye is injected
• Biliary and pancreatic trees are visualised
Indications
• Malignancy – irregular filling defect
• Chronic pancreatitis – ‘chain of lakes’ appearance
• Congenital anomalies of biliary duct
• Stricture of biliary tree
Therapeutic uses
• Extraction of stone from biliary duct
• Endoscopic papillotomy
• Dilation of biliary stricture
Complications
• Pancreatitis, Cholangitis
• Duodenal injury, perforation
• Bleeding from pancreato-duodenal artery

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CHOLEDOCHOLITHIASIS
• Stones in CBD and biliary tree
• Classification
o Primary stone
▪ Biliary stasis
▪ Biliary dyskinesia
▪ Biliary stricture
▪ Choledochal cyst
▪ Sclerosing cholangitis
o Secondary Stone
▪ Stones from GB pass via Cystic duct to CBD and gets impacted
• Clinical features
o Biliary colic
o Jaundice
o Fever with chills
o Steatorrhoea
o Pruritus
o Charcots triad
▪ Intermittent pain
▪ Intermittent fever
▪ Intermittent jaundice

• Complications
o Biliary cirrhosis
o White bile (pus)
o Liver dysfunction
o Pancreatitis
• Differential diagnosis
o Carcinoma of head of pancreas
o Carcinoma of biliary tree
• Investigations
o US abdomen – shows gallstones
o CT scan – location of stone, ductal stricture
o MRCP – biliary tree anatomy and pathology
o ERCP – identifies pathology, site of block
o LFT – increasd bilirubin, ALP, PT
• Treatment
o Vit K Inj or FFP infusion to correct PT
o Correct dehydration
o IV mannitol to prevent Hepatorenal syndrome
o ERCP – endoscopic papillotomy (sphincterotomy), stone fragmentation and extraction
o Transduodenal sphincteroplasty
o Choledocho-jenunostomy

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PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY – PTC

▪ Indications
o Failure of ERCP
o Higher biliary stricture
o Klastkin tumor
o Stenting in tumors
▪ Done in case of severe obstructive jaundice, after control of bleeding tendency by injection of Vit K or FFP
▪ Prerequisites
o Normal Prothrombin time
o Last and final inevitable method of examination
o Antibiotics and Vit K or FFP given prior to PTC
▪ Complications
o Bleeding
o Biliary leak
o Biliary peritonitis

HIDA – Hippuran Iminodiacetic acid

▪ Radioisotope scan study
▪ Radioisotope used are
o I¹³¹ Rose Bengal
o Tc⁹⁹ Iminodiacetic acid
▪ Asses the function of GB and Cystic duct patency
▪ Used to diagnose
o Acute cholecystitis
o Biliary atresia

SAINTS TRIAD
▪ Gallstones
▪ Diverticulosis of Colon
▪ Hiatus hernia

MUCOCELE OF GB (hydrops GB)

▪ Overdistension of GB containing mucous or clear fluid
▪ Etiology
o Cystic duct Obstruction due to
▪ Stone
▪ Polyp
▪ Carcinoma
▪ Congenital narrowing of cystic duct
▪ Parasitic block (Ascaris)
▪ Features
o Dyspepsia
o Painless swelling in Right Hypochondrium
o Palpable GB
▪ Differential diagnosis
o Choledochal cyst
o Hydatid cyst
o Mesentric cyst

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▪ Complications
o GB empyema
o GB perforation
o Biliary peritonitis
▪ Investigations
o US abdomen – anteroposterior diameter > 5cm
o LFT
o CT scan
o MRCP
▪ Treatment
o Cholecystectomy

GALLSTONES ILEUS

Features
▪ Pain abdomen
▪ Tumbling Obstruction - Recurrent episodic obstruction due to moving stone bolus
▪ Perforation of ileum – peritonitis
Investigations
▪ Plain X-ray – shows air in Biliary tract (pneumobilia)
▪ US abdomen
▪ CT scan
Treatment
▪ Laparotomy, Enterotomy, removal of gallstones and closure of Enterotomy
▪ Cholecystectomy
▪ Correction of Fistula using T-tube drainage

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COURVOISER’S LAW/SIGN
1. If obstruction is due to stone in CBD, GB will not be palpable
o Reason
▪ Stone in bile duct would have come from a cholecystitis GB
▪ So GB wall will be thickened and non-distensible
2. If obstruction is due to malignancy in CBD, GB will be palpable
o Reason
▪ GB will be normal, so it gets distented once CBD is oobstructed
Exceptions
• Double impacted stone (one in CBD & one in Cystic duct)
• Large stone in Hartmann’s pouch
• Empyema if GB with CBD stone

LAPAROSCOPIC CHOLECYSTECTOMY
• Gold standard method to remove GB
• Position
o Supine head up
o General anaesthesia
o Nasogastric tube and Foley’s catheter is placed
• Ports
o 10mm port in umbilicus to pass 10mm telescope
o 10mm port in midline epigastrium as working channel
o Two 5mm ports in mid-clavicular line and Anterior Axillary line in Subcostal region
• Complications
o Bile duct injury – bile leak
o Cholangitis
o Subphrenic abscess
o Injury into colon, duodenum, mesentery
• Contraindications
o End stage cirrhosis
o Portal hypertension
o Cholangitis – Cholecystectomy done after control of cholangitis
o CBD stone – Cholecystectomy done after stone extraction by ERCP

SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) in cholecystectomy

• Minimally invasive Surgery
• Operation through a single umbilical entry port
• Procedure – 2.5 cm vertical umbilical incision - 10mm telescope & two 5mm instruments can be passed
• Advantages – no visible scar, faster recovery
• Complications – umbilical hernia

MURPHY’S SIGN
▪ elicited in patients with acute cholecystitis
▪ asking the patient to take in and hold a deep breath while palpating the right subcostal area.
▪ If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand,
Murphy’s sign is positive
▪ Sonographic Murphy’s sign – eliciting same sign using sonographic transducer

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SPLEEN
SURGICAL ANATOMY OF SPLEEN
• Wedge shaped organ
• Present in left hypochondriac region
• Weight – 150 grams
• L*B*T – 12*6*3 cm
• Ligaments of spleen
o Linorenal ligament – encloses splenic vessel and pancreas tail
o Gastrosplenic ligament – contains short gastric vessels
• Blood supply
o Splenic artery – branch of celiac artery
o Splenic vein – joins with SMV to form Portal vein
• Spleen Functions
o Mechanical filtration
▪ Remove senescent erythrocytes
▪ Clears pathogen that reside in RBC (Malaria, Bartonella)
▪ Culling – Transfer iron into plasma from degraded hemoglobin
o Immune functions
▪ Synthesis of IgM, Properdin, Tuftin
o Pitting
▪ Removal of Particulate inclusions in RBC like
• Heinz bodies
• Howell jolly bodies
• Pappenheimer bodies
• (These inclusions are seen in post-splenectomy patients, but will stay absent in
Splenunculi even after splenectomy)
o Reservoir function
▪ Contains 2% of total blood volume
▪ Contains 8% of red cell mass
• Splenunculi
o Single or multiple accessory spleens
o Sites
▪ Hilum of spleen
▪ Tail of pancreas
▪ Splenic ligamen8
▪ Mesocolon, Greater omentum
▪ Left ovary
▪ Left testis
o After splenectomy, they undergo hyperplasia
o Splenunculi patients show absence of RBC inclusions post-splenectomy
o All accessory Spleens should be removed during splenectomy, inorder to prevent the recurrence of
the disease for which splenectomy will be performed

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SPLENIC INJURY / RUPTURED SPLEEN

• Spleen can rupture as a result of
o Trauma
o Atraumatic rupture → infectious mononucleosis, pregnancy, infection
o Spontaneous rupture → reflex spasm of splenic vein
• Causes
o RTA
o Blunt injury or Penetrating Injury
o Left lower rib fracture
o Spontaneous Rupture due to malaria
• Type
o Splenic subcapsular hematoma
o Clean incised wound → treated with splenorrhaphy
o Lacerated wound
o Splenic hilar injury → torrential hemorrhage → death
o Splenic Injury associated with injury to
▪ Left lobe of liver
▪ Tail of pancreas
▪ Left kidney
▪ Left Colon
▪ Left lower ribs
• Clinical features
o Elevated left hemi-diaphragm
o Left lower lobe atelectasis
o Pleural effusion
o Balance sign – unilateral dullness of left flank without shifting (collected blood gets clotted)
o Kehrs sign – referred pain to tip of left shoulder, irritation of diaphragm due to blood clot
o Latent period of Bandet – initial clot seals the bleeding, later dislodges → torrential bleeding
o Splenosis → autotransplantation of spleen fragments within peritoneal cavity following rupture
• Complications
o Blood loss
o DIC
o Splenic artery pseudoaneurysm
o Sepsis
o Splenic arterovenous fistula
• Investigations
o FAST – focused abdominal sonar for trauma
o Hb%, Packed cell volume
o Plain X-ray abdomen
▪ Obliteration of splenic shadow
▪ Obliteration of psoas shadow
▪ Elevation of left hemidiaphragm
▪ Fracture of lower ribs
o CT scan
o Diagnostic peritoneal lavage
▪ > 10 ml blood
▪ > 100,000 RBC/mm³
▪ >500 WBC/mm³

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o Treatment
▪ Initial management (resuscitation}
• ABCD
• Central venous line
• Fluids and crystalloids therapy
• Blood transfusion
▪ Non operative management – angiographic selective embolization
• Isolated splenic injury (no other associated injuries)
• Hemodynamically stable patients
▪ Surgical management
• Splenectomy
o Complications
▪ OPSI
▪ DIC
▪ Left-sided atelectasis
▪ Left sided pleural effusion
▪ Pancreatitis
• Splenorrhaphy
o In case of Clean incised wound
o Suturing of wound with placement of Gelfoam & Thrombin
o Absorbable mesh wraped over the wound
o Advantages
▪ Avoids OPSI - Overwhelming postsplenectomy infection
▪ Avoid dead space in abdomen

SPLENOMEGALY
• Causes
o Infection – TB, infectious mononucleosis, Malaria, Typhoid, Kala-azar
o Blood disease – CML, Hereditary spherocytosis, ITP, Hemolytic anemia
o Metabolic – Gaucher’s disease, Amyloidosis, Porphyria
o Portal hypertension
o Malignancy – Splenic sarcoma, Hodgkin’s lymphoma
• Clinical features
o Mass in left hypochondrium
o Moves with respiration
o Hook sign – inability to hook under left costal margin
o Mass directed towards Right iliac fossa
• Differential diagnosis
o Kidney mass, Left adrenal mass
o Retroperitoneal mass, Left Colon mass

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SPLENECTOMY
Indications
• Splenic trauma
• Neoplasms – CML, primary splenic tumor
• As a part of other surgery
o Gastrectomy
o Pancreatectomy
• Hematological conditions
o Anaemia
▪ Intracellular defects
• Hereditary spherocytosis
• G6PD deficiency
• Thalassemia
• Sickle cell anaemia
▪ Extracellular defects
• Autoimmune hemolytic anaemia
• ITP - idiopathic thrombocytopenic purpura
• TTP - thrombotic thrombocytopenic purpura
o Symptomatic Hypersplenism
o Myelofibrosis
o Other causes
▪ Gaucher's disease
▪ Felty’s syndrome – RA + leucopenia + splenomegaly
▪ Schistosomiasis
• Complications
o Immediate
▪ Hemorrhage – from short gastric vessels
▪ Gastric dilation
▪ Hematemesis – Gastric mucosal congestion after short gastric vessels ligation
o Intermediate
▪ Left basal atelectasis
▪ Left pleural effusion
▪ Pancreatitis, Pancreatic fistula
▪ Left subphrenic abscess
o Delayed
▪ Thromboembolic episodes – due to thrombocytosis after splenectomy
▪ Portal vein thrombosis
▪ OPSI

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OVERWHELMING POSTSPLENECTOMY INFECTION

• Reduction of IgM, Properdin, Tuftin
• Defective phagocytosis of encapsulated bacteria
• Infection by
o Streptococcus pneumoniae
o Haemophilus influenzae B
o N. Meningitides
o Group A streptococci
o Malaria, Babesia
• Clinical features
o Fever, Chills, Sore throat
o Hypotension, Shock, DIC
o Respiratory distress, Coma, Death
• Prevention
o Vaccination
▪ Pneumococcal vaccine
▪ HiB vaccine
▪ Meningococcal vaccine
o Antimalarial prophylaxis
• Treatment
o Antibiotics – 3rd gen cephalosporins
o Ventilatory support
o Immunoglobulin
o TPN

HYPERSPLENISM
▪ Overactivity of spleen resulting in pancytopenia and hypercellular bone marrow
▪ Causes
o Primary hypersplenism
o Portal hypertension
o Infection – Malaria, TB, Kala-azar
o Myeloproliferative disorders
▪ Clinical features
o Transfusion dependent anaemia
o Recurrent infection
o Spontaneous bleeding episodes – epistaxis, bleeding gums
▪ Investigation
o Peripheral blood smear, Bone marrow aspiration
o LFT
o US abdomen
▪ Treatment
o Splenic artery embolization
o Splenectomy

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PANCREAS
ACUTE PANCREATITIS
Etiology
• G - Gallstones
• E - Ethanol
• T - Trauma
• S – Steroids
• M - Mumps
• A – Autoimmune (SLE, PAN)
• S – Scorpion sting
• H – Hyperlipidemia, Hypercalcaemia
• E - ERCP
• D – Drugs (Valporate, Azathioprine, Thiazide diuretics)
• I – Infections (CMV, Echovirus, Ascaris, Clonorchis)
Pathogenesis
• Pancreatic injury – release of inflammatory mediators like TNF-alpha, IL-1 → this further stimulates
the release of cytokines like IL-2,6,8,10, Bradykinin, PAF → SIRS and MODS
Symptoms
• Nausea
• Vomiting
• Hiccough
• Retching
• Oliguria
• Mohammed Prayer sign - sudden abdominal pain, with partial relief on leaning forward
Signs
• Tachypnea
• Hypotension
• Tachycardia
• Facial flushing
• Gery-Turners sign – hemorrhagic pigmentation around flanks
• Cullen’s sign – pigmention around umbilicus
• Fox sign – inguinal ecchymosis
Complications
• Pancreatic necrosis → Walled of Necrosis (WON)
• Fat necrosis
• Acute fluid collection/sequestration
• Pancreatic pseudocyst
• Acute tubular necrosis
• Disseminated intravascular coagulation
• Respiratory failure - ARDS
• Hematemesis/Malaena due to duodenal necrosis
• Abdominal compartment syndrome
• Splenic vein thrombosis
Differential diagnosis
• Perforated duodenal ulcer
• Ectopic pregnancy
• Diabetic ketoacidosis
• Intestinal obstruction

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Investigation
• Serum amylase – 3 fold increase
• Serum lipase – most sensitive
• Serum trypsin
• Blood glucose – Hyperglycemia
• Serum calcium – Hypocalcaemia (calcium is utilized during saponification of fat around injured pancreas)
• US abdomen
• Spiral CT
• CXR -. Pleural effusion, ARDS
• Abdominal plain X-ray
o Colon cut off sign – transverse colon distension, descending colon collapse
o Renal halo
o Obliteration of psoas shadow
o Localized ground glass appearance
Management of acute pancreatitis
• Admission into ICU
• Analgesics – Metamizole, Buprenorphine
• Fluid therapy – Ringer lactate
• Supplement Oxygen
• Monitoring of Urine output and Blood gas analysis
• Monitoring –
o LFT
o RFT
o Coagulation profile
o Serum calcium
o Blood glucose
• Antibiotics – in case of cholangitis
• Enteral feeding for nutrition
• Gall stone Pancreatitis – ERCP within 72 hours with CBD stenting
• Laparotomy-necrosectomy
• Continuous closed peritoneal lavage

RANSON CRITERIA IN ACUTE PANCREATITIS AND ITS SIGNIFICANCE

Criteria in gallstone pancreatitis Criteria in non-gallstone
Score >3 suggest severe AP Pancreatitis
On admission → On admission →
• Age > 70 years • Age > 55 years
• Blood sugar > 220 mg% • Blood sugar > 200 mg%
• LDH > 400 IU/L • LDH > 350 IU/L
• AST > 250 IU/ 100ml • AST > 250 IU/ 100ml
Within 48 hours → Within 48 hours →
• Hematocrit drop > 10% • Hematocrit drop > 10%
• BUN rise > 2 mg% • BUN rise > 5 mg%
• Serum Calcium < 8mg% • Serum Calcium < 8mg%
• Fluid sequestration > 4L • Fluid sequestration > 6 L

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CHRONIC PANCREATITIS
Etiology
• Alcohol
• Tropical pancreatitis
• Obstructive pancreatitis
• Autoimmune pancreatitis
• Hyperlipidemia
• Hyperparathyroidism
• Trauma
• Cystic fibrosis
Pathogenesis
• Oxidative stress hypothesis
o Chronic reflux of bile with Reactive products of hepatic function → Pancreas damage
• Toxic metabolite theory
o Alcohol directly damages Pancreatic acinar cells → fatty degeneration and necrosis
• Stone and duct obstruction theory
o Alcohol increases lithogenicity of Pancreatic juice → stone formation and duct obstruction
Spectrum of chronic pancreatitis
• Early → inflammation and pancreatic edema
• Moderate → early fibrosis, exocrine dysfunction
• Late → severe fibrosis, loss of secretary function, Diabetes mellitus
Clinical features
• Abdominal pain
• Exocrine dysfunction
o Diarrhoea
o Malabsorption
o Steatorrhea
• Endocrine disruption
o Brittle diabetes
▪ Insulin deficiency → Diabetes mellitus
▪ Glucagon deficiency
• Mass per abdomen, tender, just above umbilicus
• Mallet-Guys sign
o Right knee-chest position → palpation of left hypochondrium → tenderness
• Classical triad of chronic pancreatitis
o Pancreatic calcification
o Steatorrhea
o Diabetes mellitus
Complications
• Pancreatic pseudocyst
• Pancreatic ascites
• Pancreatic fistula
• Carcinoma pancreas
• Portal vein thrombosis
• Left side pleural effusion
Differential diagnosis
• Carcinoma of head of pancreas
• Retroperitoneal tumor

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Investigations
• Blood glucose
• LFT
• Stool examination
o Fecal elastase < 200 ug / g
o Steatorrhea > 7 grams/ day
• Secretin cholecystokinin test – assess pancreatic function
• Pancreolauryl test
• ERCP – chain of lake appearance
• CT abdomen – pseudocyst, calcification, duct stones
• EUS (endosonography) → malignancy, duct status, CBD status

Treatment
• Conservative
o Avoid alcohol
o Low fat diet
o Analgesics
o Pancreatic enzyme replacement therapy
o Control of diabetes using insulin
• Surgery
o Indications
▪ Severe malabsorption
▪ Suspicion of malignant transformation
▪ Biliary obstruction (Wardsworth syndrome)
▪ Pancreatic pseudocyst
▪ Pancreatic ductal dilation > 7cm
o Drainage procedure
▪ Modified Puestow procedure
o Resection + drainage procedure
▪ Whipples procedure
▪ Duodenum preserving, Pancreatic head resection (DPPHR)
• Bergers procedure
• Freys procedure
• Bern’s procedure
o Total pancreatectomy

PANCREATIC FUNCTION TESTS

▪ Serum amylase
▪ Amylase creatinine clearance ratio
▪ Serum lipase – more specific than amylase
▪ Serum lactesence
▪ Serum trypsin
▪ Trypsinogen activation polypeptide (TAP) assay
▪ Phospholipase A2
▪ Blood glucose
▪ Serum calcium
▪ LDH levels

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PANCREATIC PSEUDOCYST
▪ Localised collection of sequestered pancreatic fluid
▪ Occurs within 3 weeks after an attack of acute pancreatitis
▪ Initially cyst wall is thin (unformed) later gets fibrosed and thickened (formed/mature)
▪ Site – Lesser sac
▪ Types
o Communicating pseudocyst
o Non communicating pseudocyst
▪ Clinical features
o Epigastric swelling
o Does not move with respiration
o Pulsation confirmed by knee-chest position
o Baid test – pseudocyst pushes stomach front,Ryle’s tube passed will be felt per abdominally
▪ Differential diagnosis
o Aortic aneurysm
o Retroperitoneal cyst
o Cystadenocarcinoma of pancreas
o Hydatid cyst of liver
▪ Complications
o Rapture
o Infection
o Duodenal obstruction
o Portal vein thrombosis
o CBD block - Cholestasis
▪ Investigations
o US abdomen – size and thickness of pseudocyst
o CT scan – shape, number, wall thickness of pseudocyst
o ERCP – visualise Communications
o EUS guided aspiration and analysis of fluid
▪ Increased amylase
▪ Normal CEA (increased CEA – indicates mucinous neoplasm)
▪ Treatment
o Surgical drainage
▪ Indications
• Size > 6cm
• Infected pseudocyst
• Multiple cysts
• Communicating cyst
▪ Cystogastrostomy (Juraz operation)
▪ Cystoduodenostomy
▪ Cystojejunostomy – best method

REVERSE 3 SIGN
▪ a.k.a Fostburgs inverted 3 sign
▪ Seen in caseen in barium studies of the upper GI tract
▪ Seen in barium studies of the upper GI tract
▪ Broadening of the duodenal loop with a ‘puckering’ around the ampulla of Vater,

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INSULINOMA
▪ Endocrine pancreatic tumor arising from B-islet cells of Pancreas
Clinical features
▪ Abdominal discomfort
▪ Trembling, Sweating
▪ Hunger, Dizziness
▪ Diplopia
▪ Hallucination, Epilepsy
▪ Weight gain due to overeating
▪ Whipple’s triad
1. Hypoglycemic attack in fasting state
2. Blood glucose < 14 mg% during hypoglycemic attack
3. Symptoms relieved by administering glucose
Differential diagnosis
▪ Nesidioblastosis
▪ Non-insulinoma pancreatogenous hypoglycemia
Investigations
▪ Insulin radioimmunoassay
o Insulin level > 7 uU/ml
o Insulin : glucose ratio > 0.3
o Proinsulin > insulin
o Elevated C-peptide level
o Blood glucose < 40 mg%
▪ Insulin provocation test using
o Calcium gluconate
o Tolbutamide
▪ MRI – localised tumor
▪ CECT – localizes hypervascular lesions
▪ EUS
Treatment
▪ Drugs
o Octreotide – decrease insulin secretion
o Calcium channel blockers
o Beta blockers, Steroids to control Hypovolemia
▪ Surgery
o Enucleation of head – TOC
o Distal pancreatectomy

ANNULAR PANCREAS
• Failure of complete rotation of ventral bud of pancreas
• Ring of pancreatic tissue encircles 2nd part of duodenum → Obstruction
• Clinical features
o Distension of upper abdomen
o Bilious Vomiting
o Visible gastric peristalsis
• Investigations –X-ray -> double bubble appearance, Barium meal → Obstruction at duodenum 2nd part
• Treatment → Duodeno-jejunostomy
[Ring of pancreatic tissue not resected –> it contains a duct that joins the main pancreatic duct]

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WHIPPLE PROCEDURE
• Radical Panceeatico-duodenectomy
• Indications
o Carcinoma of pancreatic head
o Periampullary pancreatic cancer
o Distal CBD cancer
o Duodenal cancer
• During the procedure Gastroduodenal artery (GDA) branch of Common hepatic artery is ligated
• Surgery is used to remove
o Pancreas head
o Duodenum
o Portion of Jejunum
o Distal CBD
• After surgery during reconstruction – Triple anastomosis is done
o Choledocho-jenunostomy
o Panceeatico-jejunostomy
o Gastro-jejunostomy
• Complications
o Delayed gastric emptying
o Pancreatic fistula
o Bile leak
o Infection ( wound infection, cholangitis )

ZOLLINGER-ELLISON SYNDROME
• Endocrine pancreatic tumor
o Type 1 – G cell hyperplasia with hypergastrinemia and Chronic peptic ulceration
o Type 2 – Gastrinomas
Clinical features
• Hypersecretion of gastric acid
• Severe peptic refractory ulceration
• Bleeding and perforation of ulcer
Investigations
• Fasting gastrin > 1000 Pg/ml
• Somatostatin receptor scintigraphy - locate the site of tumor
• Gastrin provocation test – using Calcium
• Secretin provocation test
• MRI, CT scan
Treatment
• Enucleation of tumor
• Distal pancreatectomy, Subtotal pancreatectomy
• Pancreatico-duodenectomy

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PANCREATIC DIVISUM
• Failure of fusion of ventral and dorsal pancreatic ducts
• Leads to
o Drainage of dorsal pancreas through Ducts of Santorini (minor papilla)
o Drainage of ventral pancreas through Duct of Wirsung (major papilla of Vater)
• This causes Major pancreatic secretion drain into minor papilla → causing partial obstruction →
precipitating pancreatitis

RETROPERITONEAL TUMOUR
• Aetiology
o Radiation
o Chemicals – Thorium dioxide
o Familial Gardner’s syndrome
o Li Fraumeni syndrome
o Familial Retinoblastoma
• Features
o Tumor arises from
▪ Fat
▪ Areolar tissue
▪ Vessels
▪ Nerves
▪ Skeletal and Smooth muscle
▪ Lymph node
▪ Lymphatic system
o Presentations
▪ Mass per abdomen
▪ Pelvic mass
▪ Abdominal pain and discomfort
▪ Anorexia, Fatigue, Weight loss
▪ Back pain – compression over lumbar nerves
▪ GI bleeding
▪ Varicose veins – compression of iliac vein
o Investigations
▪ CT abdomen/Pelvis/Chest
▪ CT guided core biopsy
▪ Retroperitoneoscopy
▪ Tumor markers – AFP, HCG
o Treatment
▪ Complete en-block excision
▪ Limited resection
▪ Debulking
▪ Postoperative Chemotherapy and Radiotherapy
o Prognosis depends on
▪ Tumor grade
▪ Tumor size
▪ Distant spread
▪ Resectability - invasion into organs, veins, nervres

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DIFFERENTIAL DIAGNOSIS OF MASS per ABDOMEN

MASS IN RIGHT HYPOCHONDRIUM
• Palpable liver
o Moves with respiration
o Dull on percussion
o Fingers cannot be insinuated under right costal margin
o Conditions
▪ Soft, Non-tender
• Hydrohepatosis
• Congestive cardiac failure
• Hydatid cyst
▪ Soft, tender
• Amoebic liver abscess
▪ Hard mass
• Hepatoma
• Solitary secondary in liver
▪ Hard, multinodular
• Multiple secondaries in liver
• Micronodular cirrhosis
• Palpable Gallbladder
o Moves with respiration
o Dull on percussion
o Located below right costal margin just right side of right rectus muscle
o Conditions
▪ Soft, Non-tender
• Mucocele GB
• Enlarged GB in CBD obstruction due to pancreatic head/ Periampullary Cancer
▪ Tender
• Empyema GB
▪ Hard GB
• Carcinoma GB
• Other mass
o Upper pole kidney mass
o Pericholecystic inflammatory mass

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MARS IN EPIGASTRIUM
• Palpable left lobe of liver
o Moves with respiration
o Dullness on percussion
▪ Hepatoma
▪ Amoebic liver abscess of left lobe
▪ Hydatid cyst of left lobe
▪ Left lobe secondary
• Stomach mass
o Moves with respiration
o Resonant on percussion
o Mass in esophagogastric junction causes Dysphagia
o Carcinoma stomach - nodular and hard
o Leiomyoma stomach – smooth and hard
• Pseudocyst of pancreas
o Does not move with respiration
o Has transmitted pulsation, elicited in knee-elbow position
o Resonant on percussion
o Baid test – as stomach is pushed front, Ryle’s tube when passed, can be palpated per abdominally
• Cystadenocarcinoma of pancreas
o Does not move with respiration
o Resonant on percussion
o Patient complaints of back pain – due to compression of lumbar nerves
• Carcinoma of Transverse colon
o Does not move with respiration
o Caecum will dilated and palpable
o Resonant on percussion
• Para-aortic lymph node mass
o Does not move with respiration
o Mass may be due to TB, Secondaries, Lymphoma
• Aortic aneurysm
o Soft, pulsatile mass ( elicited in knee-elbow position )
o Does not move with respiration
o Resonant on percussion

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MASS IN LEFT HYPOCHONDRIUM

• Enlarged spleen
o Enlarges towards the right iliac fossa
o Moves with respiration
o Hook sign positive – fingers cannot be insinuated under left costal margin
o Dull on percussion
• Left-sided colonic mass
• Left kidney upper pole mas
• Left side adrenal mass
• Mass arising from tail of pancreas

MASS IN LUMBAR REGION

• Palpable Kidney mass
o Moves with respiration
o Bimanually palpable
o Renal angle dull on percussion
o Does not cross the midline
o Conditions
▪ Hydronephrosis
▪ Pyonephrosis
▪ Polycystic kidney
▪ Renal cell carcinoma
• Ascending colon mass on right side/Descending colon mass on left side
o History of altered Bowel habits
o Does not move with respiration
o Renal angle is resonant
o Proximal dilated bowel may be palpable

MASS IN UMBILICAL REGION

• Mesenteric cyst
o Tillaux triad
▪ Intra-abdominal umbilical mass
▪ Resonant on percussion
▪ Intestinal obstruction, Volvulus
• Omental cyst
o Moves with respiration
o Dull on percussion
• Small bowel swelling
o Small bowel neoplasms
o Intussusception
▪ Does not move with respiration
▪ Contracts under palpating fingers
▪ Red currant jelly stools

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MASS IN RIGHT ILIAC FOSSA

• Appendicular mass
o Tender mass
o Resonant on percussion
o Does not move with respiration
o Well localized mass with distinct borders
• Appendicular abscess
o Tender mass
o Dull on percussion
o Indistinct borders
• Carcinoma ceacum
o Hard, nodular mass
o Does not move with respiration
o Resonant on percussion
o Features of intestinal obstruction
• Ileocaecal TB
o Non-tender mass
o Does not move with respiration
o Caecum put into lumbar region due to fibrosis
• Ameboma
o Tender mass
o Well defined mass with district borders
o History of dysentery
• Psoas abscess
o Psoas spasm (flexion of hip joint)
o Spine shows gibbus, tenderness, paraspinal spasm

MASS IN LEFT ILIAC FOSSA

• Carcinoma sigmoid colon
• Ovarian masses
• Psoas abscess
• Ectopic kidney
• Undescended testis
• Lymph node mass

MASS IN HYPOGASTRIUM
• Bladder mass
o Dull on percussion
o Mass reduces after emptying
o Felt on per-rectal examination
• Uterine mass
o Felt on pervaginal examination
• Ovarian mass
o Lower abdomen mass felt P/R and P/V
o Fatty hernia of Linea alba

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ABDOMINAL WALL AND UMBILICUS

BRUST ABDOMEN – Acute wound failure/Abdominal wound dehiscence
• Disruption of laparotomy wound, occurring usually between 5th and 8th postoperative day
• Postoperative separation of Abdominal musculo-aponeurotic layers
• Clinical features
o Sudden feeling of giving away of wound
o Pinkish serosanguinous discharge from the wound
o Omentum Or coils of intestine are forced out of the wound
o Factors related to burst abdomen
▪ Choice of suture material used
▪ Method of closure (tension free suturing is most important)
▪ Vertical wounds are more likely to disrupt
▪ Severe cough, vomiting, distension in postoperative period
▪ Poor general condition of the patient – Anemia, Jaundice, Hypoproteinemia, Obesity
▪ Ascites
• Treatment
o Primary deep fascia closure
o Topical negative pressure(vaccum) closure
o Delayed skin closure or skin graft over dehiscence
o Prevention of abdominal compartment syndrome
o Nutrition supplementation
o Antibiotics

DESMOID TUMOR – recurrent fibroma of pegets

• Tumor arising from musculo-aponeurotic layer of abdomen, below the level of umbilicus
• Unencapsulated, Hard, Aggressive Fibromatosis
• Etiology
o 80% occurs in females
o Old abdominal operations scars
o OCP use
o Familiar polyposis colon
o Osteoma
o Gardner’s syndrome
• Clinical features
o Slow growth
o No metastasis
o No sarcomatous change
o Seen below umbilicus
• Investigations
o Barium enema
o X-ray
o US abdomen
o MRI
o Biopsy - multinucleated plasmodial giant cells
• Treatment
o Wide excision of tumor with placement of mesh
o Chemotherapy

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UMBILICAL ADENOMA (RASPBERRY TUMOR)

• Due to partially obliterated vitellointestinal duct → causing prolapse of mucosa
• Commonly seen in infants
Clinical features
• Protruding red swelling
• Bleeds on touch
• Often gets infected, discharge of pus
Treatment
• Umbilectomy
• If patent vitellointestinal duct/Merkel’s diverticulum – section along with Bowel segment

EXOMPHALOS (OMPHALOCELE)
• Failure of all or a part of gut to return to the coelomic cavity during early fetal life
• Sac covering the content it is very thin and consists of
o Outer amniotic membrane
o Middle Wharton’s jelly
o Inner peritoneal layer
• Omphalocele is associated with
o Congenital cardiac anomaly
o Congenital genitourinary anomaly
o Beckwith Weidman syndrome – (EMG) exomphalos, macroglossia, gigantism
• Types
o Exomphalos minor
▪ Small sac
▪ Defect < 5cm
▪ Content – small bowel only
▪ Primary closure is possible
o Exomphalos major
▪ Large sac
▪ Defect > 5cm
▪ Content – Liver, Small and large bowel
▪ Primary closure is not possible
• Management
o Vitamin K injection
o TPN
o Sepsis control with antibiotics
o Evaluation of other anomalies
o Prevention of hypothermia
o Wrapping the content with sterile bag
o Correction of dehydration
o Surgical procedure – release incision and closure

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HERNIA
• Etiology
• Straining
• Lifting heavy weight
• Chronic cough (TB, Chronic bronchitis, asthma, emphysema)
• Chronic constipation
• Urinary causes
▪ BPH
▪ Stricture utethra
▪ Phimosis
• Obesity
• Pregnancy and pelvic anatomy (specially femoral hernia in females)
• Smoking
• Ascites
• Appendectomy through Mcburney Incision → ilioinguinal nerve injury → right side direct IH
• Indirect IH – remains of processes vaginalis
• Familial collagen disorder – Prune belly syndrome
• Collagen deficiency state – Metastatic emphysema of Read
• Parts of hernia
• SAC – diverticula of peritoneum consisting
o Mouth
o Neck – narrow in Indirect hernia, Wide in direct hernia
o Body
o Fundus
▪ Hernia without neck
• Hernia with larger mouth lack neck
• Ex. Direct hernia, Incisional hernia
▪ Hernia without sac
• Epigastric hernia - protrusion of extraperitoneal fat pad
• Coverings of the sac
▪ Layers of abdominal wall
• Contents of sac
▪ Omentum – Omentocele
▪ Intestine – Enterocele
▪ Richter’s hernia – Portion of bowel wall
▪ Urinary bladder – Cystocele
▪ Ovary, often with fallopian tube
▪ Meckel’s diverticulum – Littre’s hernia
▪ Appendix – Amyand’s hernia
Classification of hernia (Clinical)
1. Reducible hernia
• Hernia gets reduced on its own or by patient/surgeon
• Expansile impulse on coughing present
2. Irreducible hernia
• Contents of hernia cannot be returned to the abdomen due to ..,
i. Narrow neck
ii. Adhesions
iii. More content inside the sac

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3. Obstructed hernia
• Irreducible hernia with obstruction
• Blood supply to the contents is not interfered
• But eventually leads to strangulation
4. Inflamed hernia
• Inflammation of the contents of sac, Example.,
i. Appendicitis
ii. Salpingitis
• Overlying skin is red and oedematous
5. Strangulated hernia
• Irreducible hernia with obstruction of blood flow
• Tense, Tender swelling
• No impulse on coughing
• Commonly seen in → Indirect IH and Femoral hernia
6. Occult hernia
• Hernia swelling is clinically not detectable
• But presents with growing pain
• May not be expansile on impulse of coughing

Classification based on sites (LOUIS-FEDSS)

1. Lumbar
2. Obturator – via obturator foramen, Hannington-Kiff sign - Obturator nerve compression -> Absent Obturator reflex
3. Umbilical
4. Inguinal
5. Spigelian – hernia through spigelian fascia
6. Femoral
7. Epigastric
8. Diaphragmatic
9. Sliding – posterior wall of the sac formed by Colon or Bladder
10. Sportsman’s – Gilmore’s groin –due to Adductor strain, tenderness over inguinal region

INGUINAL HERNIA
• Surgical anatomy of inguinal canal
o Superficial inguinal ring / External ring
▪ Triangular Opening in External oblique aponeurosis
▪ 1.25 cm above the pubic tubercle
o Deep inguinal ring/ Internal ring
▪ U-shaped condensation of Transversalis fascia
▪ Lies 1.25 cm above mid-inguinal point (halfway b/w ASIS and Pubic symphysis
o Inguinal canal
▪ 4cm long
▪ Situated above medial ½ of Inguinal ligament
▪ In females called as canal of Nick
• Contents of Inguinal canal
o Ilioinguinal nerve
o Iliohypogastric nerve
o Spermatic cord in males
o Round ligament in females

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• Contents of spermatic cord

o Vas deferens
o Arteries – testicular, cremastric, artery to vas
o Veins – pampiniform plexus of veins
o Lymphatics of testis
o Sympathetic plexus around vas deferens
o Genital branch of Genito-femoral nerve
o Remains of processes vaginalis

• Defence mechanisms of inguinal hernia

o Obliquity of inguinal canal
o Arching of conjoint tendon
o Shutter mechanism – of Internal Oblique
o Ball-Valve mechanism - cremasteric muscle contraction, plugs the superficial ring
o Slit-Valve mechanism – External Oblique muscle contracts intercrural fibres of Superficial ring

Classification of inguinal hernia

• Anatomical classification
o Direct hernia
▪ Occurs through posterior wall of inguinal canal (Hesselbach’s triangle)
▪ Medial to inferior epigastric artery
o Indirect hernia
▪ Occurs through internal ring
▪ Lateral to inferior epigastric artery
• Classification based on Extent
o Incomplete
▪ Bubonocele – sac confined to inguinal canal
▪ Funicular – sac crosses External ring, does not reach bottom of scrotum
o Complete
▪ Sac descends to bottom of scrotum

Indirect inguinal hernia

• More common in younger age group
• 65% of all inguinal hernia are indirect
• Types
o Incomplete – Bubonocele, Funicular
o Complete (Scrotal)
Direct inguinal hernia
• 35% of all inguinal hernia are Direct
• More common in elder age group
• Occurs through Hesselbach’s traingle
o Hesselbach’s triangle
▪ Weak spot in anterior abdominal wall → Through which direct hernia occurs
▪ Medial – lateral border of rectus abdominis
▪ Lateral – inferior epigastric vessels
▪ Below – medial part of inguinal ligament
▪ Floor – Fascia Transversals

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Clinical examinations
▪ Internal ring occlusion test
o After reducing the contents, in lying down position
o Internal ring is occulded using thumb
o Patient asked to cough → swelling appears medial to thumb → direct hernia
o If Swelling does not appear → upon releasing the thumb, swelling appears during coughing →
indirect hernia confirmed in standing position
• Ring invagination test
o After reducing the contents of hernia
o Little finger/Index finger is invaginated from bottom of the scrotum → to External ring
o Impulse on coughing is felt at the tip of the invaginated finger
• Zeiman’s test
o Index finger placed on Internal ring
o Middle finger placed on External ring
o Ring finger placed on Saphenous opening
o If Impulse on coughing is felt on index finger → Indirect hernia
• Head or leg rising test
o Done to look for abdominal wall muscle tone and Malgaigne bulgings
o Valsalva maneuver is used to check the tone of abdominal wall muscles
• Per-rectal examination
• Inguinal hernia in females
o Increase the thickness of labia majora on palpation, when compared to contralateral side
• Palpation of bulbar urethra for stricture

Differential diagnosis
• Undescended testis
• Cord lipoma
• Inguinal lymph node enlargement
• Hydrocele of ‘Canal of Nuck’ in females
• Femoral hernia

Rules of hernia examination

• Always examine opposite side
• Always perform per rectal examination
• Always examine the urethra
• Always check abdominal muscle tone

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Investigation
• CXR – rule out chronic bronchitis
• US abdomen – rule out BPH, Ascites
• Tests relevant to other precipitating factors
Treatment
• Precipitating causes should be treated first like..,
o Asthma, TB, Bronchitis, Chronic cough
o Enlarged Prostate (TURP – transurethral resection of prostate)

• Surgery for hernia

Anatomical repairs / Mesh repair / Hernioplasty Laparoscopic repair
Herniorrhaphy
• Modified Bassini • Lichtenstein's TEP – total extraperitoneal repair
• Mac Vay • Gilbert’s plug repair TAPP – trans-abdominal pre-peritoneal mesh
• Maloney Darning • PHS – prolene
• Shouldice hernia system
• Stoppa GPVRS

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Hernioplasty / Mesh repair

▪ Strengthening of posterior inguinal wall using a supportive materials like
o Synthetic
▪ Prolene mesh
▪ Dacron mesh
▪ Morlex mesh
o Biological
▪ Tensor fascia Lata
▪ Temporalis fascia and skin
▪ Indications
o Direct hernia
o Recurrent hernia
o Re-recurrent hernia
o Incisional hernia
o Sliding hernia
▪ Hernioplasty complications
o Infection
o Mesh extrusion
o Foreign body reaction
o Mesh inguinodynia → causing hyperesthesia and pain along ilioinguinal or iliohypogastric nerve
o Mesh erosion into bladder, vessels, bowel
• Lichtenstein Hernioplasty
o PROLENE MESH used to bridge the gap between inguinal Ligament and Conjoint tendon
• Stoppa’s surgery
o Done for bilateral direct hernia
o a.k.a GPVRS – giant prosthetic visceral reinforcement surgery
o Modified pfannensteil incision made in lower abdomen →
o huge mesh is placed between peritoneum and fascia transversalis

Herniorrhaphy steps
o Herniotomy - excision of sac at neck level
o LYTLE’S REPAIR - Narrowing of internal ring with 2’0 prolene
o Approximation of Conjoint tendon with Inguinal ligament using 1’ Polypropylene material
• Shouldice technique
o Best among all anatomical repairs/herniorrhaphy
o Least recurrence among herniorrhaphy
o It gives additional strength to posterior wall by Double breasting the Transversalis fascia
• Complications of Hernia surgery
• Surgical site infection
• Nerve injuries
o In laparoscopic repairs
▪ Lateral cutaneous nerve of thigh
▪ Genitofemoral nerve
o Open hernia repair
▪ Ilioinguinal nerve
▪ Genital branch of GF nerve
▪ Iliohypogastric nerve
• Ischemic orchitis – testicular artery injury, Injury to vas deferens

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Complications of hernia
1. Irreducibility
▪ Adhesion
▪ Edema
▪ Sliding hernia
▪ Impacted hernia
▪ Narrow neck
2. Obstruction
3. Incarceration - portion of colon occupying hernia sac is blocked with graces
4. Strangulation
5. Rupture of sac
▪ Trauma
▪ Pressure necrosis of overlying skin
6. Fistula formation – Richter’s hernia

STRANGULATED HERNIA
▪ Obstruction + Irreducibility + Arrest of blood supply
▪ Pathogenesis

▪ Bacteria in strangulated hernia

o E.coli
o Klebsiella
o Anaerobic bacteria

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▪ Causes of strangulation
o Narrow neck
o Adhesion
o Irreducibility
o Large hernia
▪ Richter’s hernia
o Portion of bowel wall gets strangulated
o Typically constipation does not occur until paralytic ileus supervenes
o Clinical features
▪ Diarrhoea
▪ Toxicity mimicking gastroenteritis
▪ Maydl’s hernia ( Hernia-in-W)
o Loop of bowel in the form of ‘W' lies in the hernial sac
o Centre portion of the W-sac get strangulated and lies within Abdominal cavity

o Strangulation is often missed during surgery → May lead to gangrene and peritonitis

▪ Clinical features of strangulated hernia

o Colicky abdominal pain → later pain disappears due to gangrene
o Sudden increase in size of hernia – Rebound tenderness and Tense
o Features of toxicity and dehydration
o Abdominal distension
o Electrolyte in balance

▪ Taxis
o In irreducible hernia → reduction is tried by elevation, sedation and taxis
o Taxis – flexion -> medial rotation of hip → reduction of hernia is tried
o Taxis is dangerous in obstructed hernia, strangulated hernia and Femoral hernia
o Reduction may mask the gangrenous bowel in the sac
o Inner gangrenous loop of Madyl’s hernia may be missed

▪ In strangulated omentum
o Signs of obstruction or not seen (vomiting, constipation)
o Omentum becomes congested, oedematous, black in colour
o Secretes toxins upon secondary bacterial infection

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▪ Strangulation without obstruction seen in

o Richter’s hernia
o Omentocele
▪ Investigations
o Plain X-ray abdomen – multiple air-fluid levels
o Serum electrolytes
o Blood urea and serum creatinine
o US abdomen

▪ Treatment of strangulated hernia

o Emergency surgery
▪ Groin Incision → Sac is exposed → Sac is open without spillage of fluid → viability of
Bowel is checked (colour, peristalsis, pulsation) → If gangrenous, resection and anastomosis
is done

PANTALOON HERNIA (double hernia, saddle hernia, Romberg hernia)

▪ Both direct and indirect inguinal sacs are present
▪ Clinically presents as direct hernia
▪ Present on either side of inferior epigastric artery
▪ Both medial and lateral sacs straddle the Inferior epigastric artery
▪ During surgery – indirect sac may be missed → Retained indirect sac

FEMORAL HERNIA
o Femoral canal
o Medial most compartment of femoral sheath
o Extends from Femoral ring above to Saphenous opening below
o 1.25cm long and 1.25cm wide
o Contents
▪ Fat
▪ Lymphatics
▪ Lymph node of Cloquet
o Etiology
o Wide femoral canal
o Multiple pregnancies
o Pathology
o Through Femoral canal → hernial sac descends vertically downwards upto saphenous ring →
escapes out into loose areolar tissue and expands like a Retort
o Because of its narrow neck → more prone for obstruction and strangulation
o Clinical features
o More common in females
o Swelling in the groin, below and lateral to pubic tubercle
o Impulse on coughing
o Grugling sound during reduction
o If obstruction and strangulation → painful, tender, irreducible swelling without impulse
o Gaur sign - distension of superficial epigastric veins due to pressure by the hernial sac

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o Differential diagnosis
o Inguinal hernia
o Enlarged Cloquet LN
o Lipoma
o Femoral aneurysm
o Saphena varix – enlarged terminal portion of long saphenous vein
o Psoas abscess – psoas spasm with flexed hip
o Hematoma in the region
o Treatment
o Lockwood-low operation
o Mc-Evedy-high approach operation
o Lothiesssen’s operation
o Henry’s procedure
o Laparoscopic mesh repair – TEP/TAPP

VENTRAL HERNIA
o Anterior abdominal wall hernia except inguinal and femoral
o Includes lumbar hernias though it is dorsolateral
o Types
▪ Umbilical or Paraumbilical
▪ Epigastric
▪ Incisional
▪ Spigelian
▪ Lumbar
▪ Traumatic

UMBILICAL HERNIA
o Develops due to either absence of umbilical fascia or incomplete closure of umbilical defect
o Upper part of umbilical cicatrix is weakest site - hernia occurs
Clinical features
o Congenital – newborn and infants (male)
o Acquired – adult (females)
o Herniation through weak umbilical scar
o Associated with
o Down syndrome
o Beckwith Weidman syndrome
o Ascites
o Defect can be felt with finger during crying
Treatment
• Indications for surgery
o Is persists even after age 2 years
o Defect is > 2cm in size
o Acquired umbilical hernia
• Primary closure of defect
• Mayo’s operation
• Sublay mesh repair
• Umbilectomy
• Laparoscopic umbilical hernia repair

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PARAUMBILICAL HERNIA
• Protrusion or herniation through Linea alba
• Just above or below the umbilicus
• Predisposing factors
o Obesity
o Multiple pregnancy
o Flabby abdominal wall
• Features
o Relatively large size
o Neck is narrow – risk of Adhesion, Irreducibility, Obstruction
o Contents
▪ Omentum
▪ Small bowel
▪ Large bowel
o Intestinal colic
• Treatment
o Umbilectomy
o Mayo’s operation
o Panniculectomy (lipectomy)
o Post-operative weight reduction

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ESOPHAGUS
GASTRO-OESOPHAGEAL REFLUX DISEASE
• Pathological reflux from stomach into lower oesophagus
• Etiology
o Anatomical factors
1. Obesity
2. Altered 'sling mechanism’ of gastric musculature
3. Altered ‘phreno-esophageal’ ligament
4. Altered Obliquity of esophago-gastric junction
5. Decreased length of intra-abdominal part of esopagus
o Physiological factors
1. Reduced 'lower esophageal sphincter' pressure
• Anticholinergics
• CCB
• Diazepam
• Alcohol and smoking
• Caffeine and Theophylline
2. Altered transient relaxation period in LES
3. Reduced esophageal clearance mechanism
4. Delayed gastric emptying – Gastroparesis, Medication, Diabetes
5. Gastric distension
6. Gastric acid hypersecretion
• Pathogenesis
o Gastric fundus distention → exposure of LES to gastric acid → esophagitis → increased stimulus to
swallow saliva to neutralize esophagitis → further fundal distinction → Sphincter gets stretched
into fundus → erosion, ulceration, mucosal metaplasia
• Clinical features
o Classic triad
1. Heart burn (pyrosis) → pain more in supine position
2. Regurgitation
3. Epigastric pain (radiating to back)
o Fatty dyspepsia
o Odynophagia (painful swallowing)
o Laryngeal symptoms - hoarseness of voice
o Hematemesis
o Recurrent pneumonia
o Water brash – reflux of acid or bile into mouth in GERD
• Complications
o Esophageal
• Esophagitis
• Stricture
• Barrett’s oesophagus
• Adenocarcinoma
o Extra-esophageal
• Laryngo-pharyngeal reflux
• Nocturnal asthma
• Recurrent pneumonia

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• Differential diagnosis
o Achalasia cardia
o Cardiac angina
o Peptic ulcer
o Gall stones
o Carcinoma oesophagus
o Pancreatic diseases

• Investigations
o Ambulatory 24 hour pH monitoring –
• Probe placed 5 cm above OG junction
• PPI stopped 3 weeks before this test
o Esophageal manometry – identify associated motility disorders
o Impedance manometry – identify type and nature of reflux
o Barium swallow study
o Video Esophagography
o Endoscopy - for strictures, shortening, hiatus hernia
o Mucosal biopsy - confirm metaplastic transformation
• Treatment
o Lifestyle changes
• Weight loss
• Avoid caffeine
• Quit alcohol and smoking
• Small frequent meals
o Drugs
• H2 antagonist – cimetidine, ranitidine, famotidine
• PPI – rabeprazole, lansoprazole, pantoprazole
• Prokinetcs – metoclopramide, domperidone, cisapride, mosapride
o Endoluminal Therapy
• Endoluminal suturing
• Gatekeeper reflux repair system
• Endoscopic full-thickness plication
• Enteryx injection technique – endoscopic injection of synthetic implant ->
enhance LES strength
o Surgery
• Indications
o Failure of drug treatment
o Sliding hernia
o Barrett’s ulcer
• Fundoplication -> fundus is wrapped around the esophagus and sutured
o Nissens posterior total fundoplication – 360 degree wrap
o Toupet posterior fundoplication – 270 degree wrap
o Dor anterior fundoplication – 180 degree wrap
o Watson Anterior fundoplication – 90 degree wrap
o COLLIS GASTROPLASTY

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CAUSES OF DYSPHAGIA
Extraluminal pathology Pathology in wall of oesophagus Pathology in the lumen
• Aortic aneurysm • Carcinoma oesophagus • Foreign body in oesophagus
• Rolling hiatus hernia • GERD
• Thyroid enlargement • Achalasia cardia
• Mediastinal LN swelling • Plummer Vinson syndrome
• Esophageal diverticulum
• Retropharyngeal abscess
• Quincy

CARCINOMA OESOPHAGUS
Etiology
Squamous cell carcinoma Adenocarcinoma
• Alcohol • Barrett’s oesophagus
• Tobacco • Obesity
• Carcinogens – Nitrosamine • Scleroderma
• Chronic achalasia • H igh protein and fat diet
• Vitamin A&C deficiency • Smoking
• HPV
• P-V syndrome
• Celiac spire
• Mycotoxins

Pathology
• MC in middle 1/3
• Lower 3cm of esophagus is lined by columnar cells – Adenocarcinoma MC here
• Gross types
o Annular
o Ulcerative
o Fungating
o Polypoid
o Varicoid
Spread
• Direct
o Lack of serosa layer in oesophagus favours local extension
o Involves bronchus, aorta, Left Recurrent laryngeal nerve
o Broncho-esophageal, Tracheo-esophageal, Esophago-aortic fistulas can occur in the affected area
• Lymphatic spread by
▪ Lymphatic permeation
▪ Lymphatic embolization
o Ivolves
▪ Supraclavicular LN
▪ Paraesophageal LN
▪ Tracheobronchial LN
▪ Subdiaphragmatic LN
▪ Celiac LN
• Hematogenous – liver, lungs, brain, bone marrow

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Clinical features
• Dysphagia
• Regurgitation
• Severe loss of weight
• Hoarseness in voice – RLN involvement
• Horner's syndrome
• Diplomatic paralysis
• Bronchopneumonia
• Malena
• Left supraclavicular LN enlargement
• Substernal pain or Abdominal pain

Investigations
• Barium swallow – shouldering sign & irregular filling defect
• Fluoroscopy – rat tail lesion
• Endoscopic Biopsy
• CXR – aspiration pneumonia
• CT scan - local extension and infiltration
• PET scan – diagnosed distant metastasis
• Esophageal endosonography - involvement of layers of esophagus, nodes, liver lobe
• Endoscopic esophageal staining with Iodine – carcinomatous area remains Pale

Treatment
• Chemotherapy – Paclitaxel, Etoposide, Bleomyci
• Trans-thoracic esophagectomy
o Ivor-Lewis 2-stage procedure
▪ Subtotal esophagectomy
▪ 2 Incisions – Abdominal and Thoracic = 2 regional nodes are removed
▪ Intrathoracic anastomosis
o McKeown 3-stage procedure
▪ Total esophagectomy
▪ 3 Incisions – Abdominal, Thoracic and Cervical = 3 regional nodes removed
▪ Neck Anastomosis
• Trans-hiatal esophagectomy (ORRINGERS OPERATION)
o 2 Incisions – Neck and Abdominal
o Neck Anastomosis
• Palliative Gastrostomy

REFLUX ESOPHAGITIS
• Site – Lower esophagus
• Causes -
Acute Chrone
• Burns • Sliding hernia
• Trauma • Post Gastric surgery
• Infection
• Peptic ulcer

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HIATUS HERNIA
Condition in which part of the stomach pushed up through the diaphragm esophageal hiatus
• Type 1 - Sliding hernia
• Type 2 – Paraesophageal (Rolling) hernia
• Type 3 – Mixed both Type 1 & 2
• Type 4 – Along with stomach organs like pancreas, spleen, small bowel migrate into mediastinum

Angle of HIS – angle b/w esophagus and left side of stomach

ROLLING HERNIA
• Part of the stomach pushes (protrudes) up through the hole in the diaphragm next to the oesophagus
• Other organs from the abdomen can also protrude through the hole
• Angle of HIS maintained
SLIDING HERNIA
• Stomach & lower part of esophagus slide up into mediastinum through the diaphragm esophageal hiatus
• Angle of HIS not maintained

Clinical features
• Abdominal pain
• Chest pain
• Hiccough
• Regurgitation
• Dysphagia
• Cardiac arrhythmias

Complications
• Gangrene of stomach
• Esophagitis
• Barrett’s esophagus
• Aspiration pneumonia
• Cameron ulcer – Ischemic ulcer in herniated part of stomach

Investigations
• Plain X-ray = Retrocardiac air-fluid level
• Barium meal study
• CT scan

Treatment
• Excision of sac and repair of defect
• If gangrenous, gastrectomy is required

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BARRETT'S OESOPHAGUS
• Metaplasia of normal squamous epithelium to Intestinal columnar epithelium in response to GERD
• Types
o Long segment Barrett’s esophagus – metaplasia > 3cm
o Short segment Barrett's esophagus – metaplasia < 3cm
o Cardiac metaplasia - metaplasia at OG junction
• Clinical features
o Features of GERD
o Hematemesis
o Dysphagia
• Complications
o Ulceration
o Stricture
o Perforation
o Adenocarcinoma
• Investigations
o Seattle Biopsy – biopsy of entire length of Barret’s esophagus at 1cm interval
o Hallmark of Intestinal metaplasia – Intestinal Goblet cells
o Endoscopy - proximal displacement of squamocolumnar junction
• Treatment
o High dose PPI for 3-6 months
o Excision and repair of defect
o If presence of high-grade dysplasia – Subtotal esophagectomy or Laser ablation

CONTRAST STUDY OF ESOPHAGUS

o Types and Indications
o Barium swallow
▪ Achalasia cardia - bird beak appearance
▪ Benign stricture
▪ Carcinoma - rat tail appearance
▪ Diffuse esophageal spasm - corkscrew appearance
▪ Pharyngeal pouch
▪ GERD
o Water-soluble contrast radiograph - Gastrografin
▪ Suspected esophageal perforation
▪ Leaking esophageal anastomosis

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ACHALASIA CARDIA (Cardiospasm)

o Motor disorder of esophageal smooth muscle
o LES does not relax normally with swallowing
o Esophagus undergoes non-peristaltic contraction
Etiology
o Degeneration of Auerbach’s myenteric plexus
o Stress
o Vitamin B1 deficiency
o Chaga’s disease – Trypanosoma cruzi
o Varicella zoster
Pathology
o Degeneration of Auerbach’s myenteric plexus → dilation of affected part of esophagus
Clinical features
o Triad of
1. Dysphagia
2. Regurgitation
3. Weight loss
o Heart burn
o Lung abscess
o Odynophagia
o Vigorous achalasia - achalasia with diffuse esophageal spasm
Differential diagnosis
o Carcinoma is of ages
o Stricture esophagus
o Scleroderma
Investigation
o Barium swallow
o Bird beak appearance
o Dilation of proximal esophagus - cucumber oesophagus
o Megaesophagus/Sigmoid esophagus
o CXR
o Patches of pneumonia
o Absence of fundic gas bubble
o Esophageal manometry
o Esophagoscopy
Treatment
o Drugs
o CCB, Sublingual nitroglycerin
o Pneumatic dilation
o Botox injection
o Modified Heller’s cardiomyotomy with Toupet fundoplication
o POEM – per oral Endoscopic Myotomy
o Esophagectomy – in case of Sigmoid esophagus

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PLUMMER VINSON SYNDROME ( Paterson Kelly syndrome )

• Condition that can occur in people with chronic iron deficiency anemia.
• Premalignant condition Characterized by
o Iron deficiency anaemia
o Dysphagia – Cervical esophageal web/ post cricoid web
o Atrophic glossitis
o Koilonychia
• Can lead to
o SCC oesophagus
o Oral cancer
o Hypopharynx cancer
• Investigations
o Esophagoscopy
o Biopsy
• Treatment
o Oral iron
o Blood transfusion
o Dilation and laser lysis of web

TRACHEOESOPHAGEAL FISTULA
• Abnormal connection in one or more places between the esophagus and Trachea
• Types
o Type A: isolated oesophageal atresia
o Type B: proximal fistula with distal atresia
o Type C: proximal atresia with distal fistula – MC
o Type D: double fistula with intervening atresia
o Type E: isolated fistula (H-type)

• Clinical features
o Neonate regurgitates all feeds
o Saliva pours continuously from mouth
o Repeated coughing
o Cyanosis
o TEF – MC associated with Polyhydramnios and Downs syndrome
o Associated with VACTREL anomalies
▪ V – Vertebral defects
▪ A – Anal atresia
▪ C – Cardiac defects (PDA/VSD)
▪ TE – Tracheo-esophageal fistula
▪ R – Radial hypoplasia, Renal agenesis

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• Investigations
o Obstruction detected by passing Nasogastric tube
o Contrast study
o CXR
o Echocardiography
• Treatment
o Fistula is resected
o Ends are anastomosed
o If length is inadequate, Colon or Gastric transposition is done

SCHATZKI RING
• Semicircular protrusion of lower esophageal mucosa located at OG junction
• Features
o Involves only mucosa and submucosa
o Presents with dysphagia and reflux
o Episodic aphagia – food bolus gets impacted → emergency esophagoscopy to remove food
• Treatment
o Intermediate esophageal bougienage
o Anti-reflux drugs

MALLORY WEISS TEAR

• Mucosal tear of OG junction following a bout of sudden Vomiting after heavy drinking
• Tear occurs in
o Cardia
o Lower esophagus
• There is limited to mucosa and submucosa ( No perforation )
• Clinical features
o Severe vomiting
o Hematemesis
o After heavy alcohol consumption
o Features of shock
• Differential diagnosis
o Bleeding peptic ulcer
o Carcinoma stomach
o Esophageal varices
• Investigation
o Gastroscopy
• Treatment
o Blood transfusion
o Haemostatic agent – Vasopressin
o Endoscopic electrocoagulation
o Angiographic embolization
o Laparoscopic sewing of tear

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STOMACH
PEPTIC ULCER DISEASE
• Multiple erosions due to disruption of mucosal barrier
• MC sites
o First 2.5cm of Duodenum – Duodenal ulcer
o Lesser curvature (incisura angularis) of stomach – Gastric ulcer
• Modified Johnson classification of peptic ulcer
o Type 1 – Lesser curvature ulcer
o Type 2 – Combined Gastric and Duodenal ulcer
o Type 3 – Pre-pyloric ulcer
o Type 4 – Proximal stomach (2cm below OG junction)
o Type 5 – NSAID induced ulcer (any location)
• Type 2 & 3 have increased HCL production, others have normal or low acid production
• Blood group O → More prone to Peptic ulcer
• Blood group A → More prone to Carcinoma Stomach
Gastric ulcer
• Etiology (imbalance between protective and damaging factors of gastric mucosa)
o Atrophic gastritis
o Duodenogastric bile reflux
o Smoking, Alcohol, NSAID, Steroid
o H.pylori infection
o Gastric stasis
o Altered mucosal Barrier mechanism
• Acute ulcer – confined to mucosa and submucosa
• Chronic ulcer – penetrates muscularis layer of stomach

• Clinical features
o Epigastric pain after taking food
o Pain relieved by vomiting
o Hematemesis more common than Malaena
o Good appetite, but hesitant to eat, as food induces pain
• Differential diagnosis
o Hiatus hernia
o Cholecystitis
o Chronic pancreatitis
o Dyspepsia
o Carcinoma stomach

• Complications of gastric ulcer

o Hour glass deformity
▪ Cicatricial contracture of lesser curvature ulcer
▪ Stomach gets divided into two compartments
o Teapot deformity
▪ Cicatricial shortening of lesser curvature
o Perforation
o Bleeding
o Penetration - posteriorly into pancreas, anteriorly into liver
o Malignant transformation (adenocarcinoma)

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• Investigations
o Barium meal X-ray
▪ Niche on lesser curvature
▪ Notch on greater curvature
▪ Elevated ulcer edge
▪ Spoke wheel pattern – Round margin ulcer
▪ Mucosa folds towards the base of ulcer
o Gastroscopy
o US abdomen
• Treatment
o Medical treatment
▪ H2 blockers – Famotidine
▪ PPI
▪ Anti-H.pylori regimen for 14 days (LAC) – Lansoprazole, Amoxicillin, Clarithromycin
▪ In refractory cases Bismuth Subsalicylate is used
o Surgical treatment
▪ Indications
• Perforation
• Bleeding
• Gastric Outlet syndrome
▪ Gastrectomy
▪ Truncal Vagotomy
Duodenal ulcer
• Etiology
• Stress (Type A personality)
• Anxiety
• NSAID, Steroid
• H.pylori infection
• Endocrine causes – Zollinger-Ellison syndrome, MEN syndrome, Hyperparathyroidism
• Alcohol, Smoking, Vitamin deficiency
• Clinical features
• Epigastric pain relieved by eating food
• Heart burn
• Melena more common than hematemesis
• Kissing ulcer – two opposing ulcers one in anterior another in posterior surface of Duodenum
• Anterior ulcer – perforates commonly
• Posterior ulcer – bleeds or penetrates commonly
• Complications of duodenal ulcer
• Pyloric stenosis – scarring and cicatrisation of Duodenum 1st part
• Bleeding
• Perforation
• Perforation to pancreas
• Intractability – ulcer that has not healed after 8 weeks of Full-dose treatment
• Differential diagnosis
• Hiatus hernia
• Cholecystitis
• Chronic pancreatitis, Esophagitis
• Carcinoma stomach

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• Investigations
• Barium meal X-Ray
▪ Absence of duodenal cap (because of spasm)
▪ Trifoliate duodenum
• Gastroscopy
▪ Reveals type, location of ulcer
▪ Biopsy taken to test for H.pylori
• Treatment
• Medical treatment
▪ H2 blockers – Famotidine
▪ PPI
▪ Antacids - aluminium hydroxide and magnesium trisilicate
▪ Sucralfate
▪ Anti-H.pylori regimen – LAC ± Bismuth Subsalicylate
▪ Misoprostol – Pg agonist → increases mucous and bicarbonate secretion, decreases acid
secretion
• Surgical treatment
▪ Gastrojejunostomy
▪ Heinke Mickulicz Pyloroplasty
▪ High Selective Vagotomy
• Only gastric branches are cut
• Preserving the latarjet nerve (crows foot) supplying pylorus
• Advantages
o Drainage procedure not required because pyloric function is preserved
o Nerve supply to gallbladder and liver are not disturbed
o No diarrhoea (unlike Truncal vagotomy)
• Disadvantages
o High incidence of recurrence

Curling’s ulcer
• Acute ulcers which develop after major burns
• Observed in body and fundus
• Not seen in Antrum and Duodenum
• Features
o Epigastric pain
o Vomiting / Hematemesis

Cushing’s ulcer
• Acute ulcers which develop after cerebral trauma or neurosurgical operation
• Deep single ulcer, tendency to perforate
• Can occur in esophagus and duodenum also

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COMPLICATIONS OF GASTRIC SURGERY

• Hemorrhage
• Duodenal blow-out
• Stomal obstruction
• Biliary fistula
• Gastrojejunocolic fistula
• Injury to CBD
• Stomal ulcer
• Dumping syndrome
• Nutritional disturbance
o Hypocalcemia
o Osteomalacia
o Anaemia (iron, Vit B12 deficiency)
• Alkaline gastritis
• Gallstone formation
• Afferent loop syndrome
• Efferent loop syndrome

CARCINOMA STOMACH
• Etiology
o Lifestyle factors
▪ Smoking, Alcohol
▪ Consumption of red meat
▪ Diet with low Vitamin A&C
▪ Smoked foods
▪ Nitrosamines
▪ Occupational exposure to rubber / coal
o Genetic and familial factors
▪ E-cadherin mutation
▪ APC gene mutation
▪ Tp53 mutation
▪ Blood group A
o Precancerous lesions
▪ H.pylori infection
▪ Chronic gastric ulcer
▪ Achlorhydria
▪ Pernicious anaemia
▪ Menetrier’s disease - protein losing enteropathy with gastric mucosal hypertrophy
• Sites of occurrence
o Prepyloric and pyloric region – MC
o Body
o Fundus, OG junction
• Borrman’s Classification
o Type 1 - Polypoid
o Type 2 – Ulceroproliferative
o Type 3 – Ulcerative
o Type 4 – Diffuse Linitis Plastica

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• Metastasis
o Direct
▪ Invasion to adjacent structures like..,
• Pancreas
• Colon
• Mesocolon
• Liver
o Lymphatic spread
▪ Lymphatic permeation
▪ Lymphatic embolization
• Spreads to..,
o Subpyloric LN
o Gastric LN
o Splenic LN
o Celiac LN
o Aortic LN
o Left supraclavicular LN – Virchow’s node (Troisier’s sign)
o Hematogenous spread
▪ Liver – multiple secondary Nodules with umbilication due to Central necrosis
▪ Lungs
▪ Bone marrow
o Transperitoneal spread
▪ Krukenberg’s tumor
▪ Blumer shelf (Rectal Secondaries)
▪ Sister Mary Joseph’s nodule (secondary around umbilicus)
• Clinical features
o Iron deficiency anaemia
o Epigastric pain
o Visible gastric peristalsis – positive
o Auscultopercussion test – positive
o Succussion splash – positive
o Troisier’s sign – positive
o Rectal Secondaries (Blumer shelf)
o Trousseau sign – positive (migrating thrombophlebitis)
o Hematemesis
o Sister Mary Joseph nodule
o Krukenberg’s tumor
• Linitis plastica (leather-bottle stomach)
o Aggressive diffuse type of carcinoma stomach
o Proliferation of fibrous tissue involving submucosa of stomach (Mother of pearl appearance)
o Mucosal looks normal
o Clinical features
▪ Loss of appetite and weight
▪ Palpable mass from body of stomach
o Investigations
▪ Barium meal study – small sized stomach
▪ Endosonography
o Treatment – Total gastrectomy with Esophago-jejunal Anastomosis

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• Investigations
o Hb%, Hematocrit
o Barium meal study
▪ Irregular filling defect
▪ Loss of rugosity
▪ Delayed emptying
▪ Small sized stomach – Linitis plastica
o Gastroscopy with biopsy → 10 targeted biopsy
o Endosonography
o US abdomen – Liver secondaries, Ascites, Ovary status
o CT scan
o LFT
o FNAC - left supraclavicular lymph node
o Tetracycline fluorescence test
▪ Gastric cancer cells take up tetracycline, under UV light gives yellow fluorescence
• Treatment
o Growth in pylorus - lower radical gastrectomy
o Growth in OG junction - upper radical gastrectomy
o Linitis plastica - Total gastrectomy with Esophago-jejunal Anastomosis
o Endoscopic mucosal resection
o Photodynamic therapy
o Chemotherapy – FAM = 5 fluorouracil, adiramycin, mitomycin C
o Radiotherapy
• Palliative procedures for carcinoma stomach
o Palliative partial gastrectomy
o Laser recanalization
o Palliative anterior Gastro-jejunostomy

BLOOD SUPPLY AND LYMPHATICS OF STOMACH

• Arterial supply
o Left gastric artery
o Right gastric artery
o Left gastroepiploic artery
o Right gastroepiploic artery
o Gastroduodenal artery
o Short gastric arteries
• Venous drainage
o Right and left gastric veins → drain into portal vein
o Right gastroepiploic vein → drain into SMV
o Left gastroepiploic and Short gastric veins → drain into Splenic vein
o Pre-pyloric vein of Mayo (distinguishes pyloric canal from Duodenum first part)
• Lymphatic drainage
o Celiac group
o Splenic group
o Gastroepiploic group
o Subpyloric group
o Omental group
o Gastric group

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GASTROSCOPY
• Visualisation of interior of esophagus, stomach, duodenum
• Uses
o Diagnosing pathology
▪ Gastric ulcer, Duodenal ulcer
▪ Carcinoma stomach
▪ Esophagitis, Esophageal varices
▪ To take Biopsy
o Therapeutic procedures such as
▪ ERCP
▪ Variceal injection/ligation/gluing
▪ Polyp removal
▪ Submucosal resection
▪ Percutaneous gastrostomy
▪ Stenting of pseudocyst of pancreas
• Procedure
o Done following 8 hours of fasting
o Lignocaine spray into oral cavity
o Gastroscope pass down the oesophagus into stomach → Air is inflated
o Different parts of stomach are visualised, Fundus visualised by retropulsion
o Scope is passed through pylorus, to visualise 1 st and 2nd part of duodenum
o Biopsy is taken
• Complications
o Bleeding, Aspiration, Perforation

HELICOBACTER PYLORI - Gram negative bacteria

• Involved in the pathogenesis of
o Duodenal ulcer
o Gastric ulcer
o Type B Gastritis
o Gastric cancer
o Gastric MALTOMA (mucosa-associated lymphoid tissue lymphoma)
• Pathogenesis
o Virulence factor
▪ Urease
▪ Dehydrogenase
▪ Endopeptidases
▪ Hemolysin
▪ Vac A toxin – Vacuolizing cytotoxin
▪ Cag A – Cytotoxin associated gene A
• Laboratory diagnosis
o Rapid urease test
o C13-C14 breath test
o Biopsy and culture. ELISA, PCR
o Stains used in identification - Warthin Starry silver stain, Acridine orange
• Treatment
o LAC – Lansoprazole, Amoxicillin, Clarithromycin
o Refractory cases – Bismuth Subsalicylate

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CONGENITAL HYPERTROPHIC PYLORIC STENOSIS

• Hypertrophy of circular musculature of pyloric antrum
• Primary failure of pylorus to relax
• Normal duodenum
• Risk factors
o Risk increases if neonate is exposed to Erythromycin or Azithromycin in first 2 weeks of life
• Clinical features
o Projectile and Non-bilious vomiting
o Visible gastric peristalsis
o Palpable lump of hypertrophied pylorus
▪ Olive-like mass – in right hypochondrium
▪ Moves with respiration
▪ Impaired resonance on percussion
o Electrolyte imbalance - hypokalemic alkalosis
• Investigations
o Clinical examination
o US abdomen – Doughnut sign
o Barium meal X-ray – shows obstruction
o Contrast study – String sign or Railroad/Double track sign
• Differential diagnosis
o Duodenal atresia (presence of bilious vomit)
o High Intestinal obstruction (volvulus neonatorum)
• Treatment
o Correction of dehydration and electrolyte imbalance
o Ramstedt’s operation
o Laparoscopic pyloromyotomy
o Balloon dilation

UPPER GI bleeding / HEMATEMESIS

• Causes
1. Chronic duodenal ulcer
2. Gastric ulcer
3. Stomal ulcer
4. Erosive gastritis
5. Gastric polyp
6. Dieulafoy’s lesion – gastric AVM covered by apparently normal mucosa
7. Esophageal varices
8. Mallory Weiss tear
9. Carcinoma stomach
10. Carcinoma oesophagus
11. Leiomyoma stomach
12. Gastric lymphoma

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PYLORIC STENOSIS / GASTRIC OUTLET OBSTRUCTION

• Chronic duodenal ulcer undergo scarring and cicatrisation → causing total obstruction of the pylorus →
leading to enormous dilation of stomach
• Clinical features
o Epigastric pain
o Feeling of fullness
o Large quantity vomiting – contains food consumed on previous day
o Visible gastric peristalsis - elicited by drinking a cup of water
o Auscultopercussion test – shows dilated stomach
o Electrolyte imbalance – Alkalosis with
▪ Hypokalemic
▪ Hypomagnesemic
▪ Hyponatremic
▪ Hypocalcemic
▪ It causes paradoxical aciduria & Cheyne Stokes breathing
• Differential diagnosis
o Carcinoma pylorus
o Pyloric mucosal diaphragm
• Investigations
o Barium meal study
▪ Absence of duodenal cap
▪ Dilated stomach - greater curvature is below the level of iliac crest
▪ Mottled stomach
▪ Barium will not pass into duodenum
o Electrolyte study, Gastroscopy
• Treatment
o Correction of dehydration and electrolytes, TPN support
o Surgery
▪ HSV with Gastro-jejunostomy
▪ Truncal Vagotomy with Gastro-jejunostomy

TRICHPBEZOAR
• Hair-ball seen in stomach of females with psychiatric illness, who swallow hair regularly
• If hair-ball extend to duodenum and jejunum it is called Rapunzel syndrome
• Clinical features
o Epigastric pain
o Hematemesis
o Loss of appetite
o Gastritis
o Perforation
o Epigastric mass
• Investigations
o Barium meal study
o Endoscopy
o CT scan
• Treatment
o Gastrostomy and removal of hair-ball
o Psychiatric counselling

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DUMPING SYNDROME (Postcibal Syndrome) → complication of gastric surgery

• Early dumping
▪ Pathogenesis
• After meals → small bowel gets filled with food → osmotic overload leads to
sequestration of fluid from circulation into GIT → vasomotor symptoms due to
Hypovolemia
• Occurs immediately after having food
▪ Clinical features
• Sweating
• Hypertension
• Tachycardia
• Colicky pain
• Diarrhoea
▪ Investigations
• PCV – increased packed cell volume
▪ Treatment
• Small, more frequent diet
• Octreotide before meal
• Roux-en-Y reconstruction
• Late dumping
▪ Pathogenesis
• After meals → carbohydrate load causes rise in plasma glucose → increased insulin
release → reactive hypoglycemia
▪ Clinical features
• Tremor
• Fainting
• Nausea
▪ Investigations
• Estimation of blood glucose
▪ Treatment
• Same as of Early dumping

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GASTROINTESTINAL STROMAL TUMORS – GIST

o MC site – stomach > small bowel > rectum
o Etiology
o Tyrosine kinase mutation
o PDGF mutation
o C-KIT mutation
o Clinical features
o Abdominal pain
o GI bleeding
o Mass per abdomen
o Weight loss
o Utricaria
o Hyperpigmentation
o Carney’s triad
1. Extra-adrenal paraganglioma
2. Pulmonary chondroma
3. Gastric GIST
o Metastasis
o Liver
o Peritoneum – Ascites
o Treatment
o CT scan – ulceration, calcification, cystic areas
o Tumor markers
o Endosonography guided FNAC
o Treatment
o Surgical resection without rupture
o Imatinib – TK inhibitor used for unresectable GIST
o Chemotherapy – Doxorubicin + Ifosfamide
o Worse prognosis
o Size > 5cm
o Male sex
o High mitotic activity - >15 mitoses/ 30 High power field
o Liver metastases
o Ruptured GIST
o C-KIT mutation

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SMALL INTESTINE
MECKEL'S DIVERTICULUM
• Congenital diverticulum arising from the terminal ileum, is part of unobliterated proximal portion of
vitellointestinal duct
• Contains Ectopic Mucosa – Gastric > Colonic > Pancreatic
• Rule of 2
o Prevalence 2%
o Length 2 inch
o Located 2 feet proximal to iliocecal valve
o Presents in <2 years of age
• Clinical features
o Severe hemorrhage (maroon coloured blood)
o Intestinal obstruction – Adhesions and Intussusception
o Perforation
o Diverticulitis - mimics acute appendicitis
o Littre’s hernia - meckel's diverticulum in hernial sac
o Carcinoid or GIST can occur Meckel’s diverticulum
• Diagnosis
o Technetium-99 radioisotope scan
o X-ray abdomen – obstruction, perforation
o Small bowel enema/Enteroclysis under fluoroscopy
o Laparoscopy
• Treatment
o Indications for surgery
▪ Presence of Adhesion, Intussusception
▪ Symptomatic patients
▪ If found in < 2 years age
o Meckellian diverticulectomy with closure of enterotomy

BLIND LOOP SYNDROME – stagnant loop syndrome

• Normal bacterial flora of the small intestine proliferates to numbers that cause significant derangement
to the normal physiological processes of digestion and absorption.
• Etiology
o Surgical operations of the abdomen
o Inflammatory bowel disease
o Scleroderma
o Jejunoileal diverticula
• Pathogenesis
o Factors that contribute to overgrowth of bacteria
▪ Achlorhydria
▪ Dysmotility
▪ Fistulae, and strictures
▪ Paralytic ileus
▪ Opioid therapy – decreases gastric motility
• Clinical features
o vitamin B12 deficiency
o fat malabsorption and steatorrhea
o fat-soluble vitamin deficiencies

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• Diagnosis
o Physical examination reveal a mass or distention of the abdomen
o Abdominal x-ray
o Abdominal CT scan
o Contrast enema study
• Treatment
o Drug therapy
▪ Tetracycline
▪ Rifaximin
▪ Metronidazole
o Surgical fixation of causes of bowel obstruction like
▪ Stricture
▪ Fistula
▪ Diverticula

PEUTZ – JEGHERS SYNDROME

• Autosomal dominant genetic disorder characterized by benign hamartomatous polyps in GIT and
hyperpigmented macules on the lips and oral mucosa (melanosis)
• Clinical features
o Brown black pigments in
▪ Face
▪ Cheek
▪ Forearm
▪ Palm, Sole, Digits
▪ Perianal region
o Harmatoma in Jejunum and Ileum
o Intussusception
o Bleeding
• Complications
o Predisposes to cancer of
▪ Small intestine
▪ Stomach
▪ Pancreas
▪ Ovary
▪ Breast
• Investigations
o Small bowel enema
o Capsule endoscopy
o CT scan
o MRI
• Treatment
o No definite cure
o Segment causing complication can be resected

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CARCINOID TUMOUR
• Neuroendocrine tumors arising from enterochromaffin cells
• These cells are capable of APUD (Amine precursor uptake and decarboxylation) and secrete vasoactive
peptides like..,
o Amines
• 5 Hydroxy-tryptamine (5 HT)
• 5 Hydroxy-indole-acetic acid (5 HIAA)
• 5 Hydroxy-tryptophan (5 HTP)
• Histamine
• Dopamine
o Tachykinins
• Kallikrein
• Substance P
• Neuropeptide K
o Peptides
• Chromogranins
• Pancreatic polypeptide
• HCG
• Neurotensin
o Prostaglandins
• Regardless of their primary site, all carcinoids share Histological, Immunohistochemical, Ultrasound
similarity

• Sites
o Appendix
o Ileum
o Rectum
o Others (Pancreas, Biliary tract, Lungs, Testis)

• Chemical features
o Abdominal pain
o Intestinal obstruction
o Bleeding per rectum
o Liver secondaries → Carcinoid syndrome → release of 5 HT, prostaglandins, Histamine → causing
flushing, diarrhoea, cyanosis, asthma attack
o Attacks can be induced by alcohol

• Investigations
o Urine – increased 5 HIAA
o Indium-111 labelled Octreotide scintigraphy – detect the tumor
o CT scan
o PET scan
o Tumor marker - Serum Chromogranin A
• Treatment
o Medical treatment
▪ Long acting somatostatin analogue – Octreotide, Pasireotide
▪ Angiogenesis inhibitor – Bevacizumab
▪ Tyrosine kinase inhibitor - Sunitinib

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o Surgical treatment
▪ Appendix
• Lesion < 2cm - Appendectomy
• Lesion > 2cm Right hemicolectomy
▪ Gastroduodenum
• < 1cm - Endoscopic resection
• > 1cm - Subtotal gastrectomy
▪ Small bowel lesion
• < 1cm – Segmental resection
• > 1cm – Radical resection
▪ Rectal lesion
• < 1cm – Endoscopic resection
• > 1cm - Wide Excision

CARCINOID SYNDROME
• Carcinoid secondaries in Liver causes Carcinoid syndrome
• Carcinoid of Ovary, Testis, Retroperitoneum bypass Fisrt pass metabolism in liver and causes Carcinoid
syndrome without liver secondaries
• Syndrome due to release of vasoactive peptides by carcinoid tumor such as
o 5 HT
o 5 HTP
o Histamine
o Dopamine
o Bradykinin
o Prostaglandins
o Kallikrein
o Substance P
• Presentation
o Vasomotor
▪ Hypotension
▪ Flushing
▪ Edema face
o GIT
▪ Diarrhoea
▪ Hepatomegaly
o Cardiac
▪ Pulmonary stenosis
▪ Tricuspid stenosis
o Lungs
▪ Bronchospasm (asthma)
o Diversion of dietary tryptophan → Pallegra
• Symptoms are precipitated by intake of alcohol, cheese, chocolate and red wine
• Carcinoid crisis – severe bronchospasm and circulatory collapse
• Investigations
o Assessment of 5-HIAA
o IV Octreotide infusion
o Management of circulatory failure

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• Treatment of hepatic secondaries

o Embolization
o Chemotherapy
o TACE - transarterial chemoembolization
o Radioablation

INFLAMMATORY BOWEL DISEASE

• Results from inappropriate mucosal immune responses to normal gut flora
• Epidemiology
• MC in females
• MC in developed countries
• Hygiene hypothesis - reduced mucosal immune response caused by reduced frequency of normal
enteric infection due to improved food storage/quality
• It comprises two disorders
▪ Crohn’s disease (regional enteritis)
• Transmural inflammation is seen
▪ Ulcerative colitis
• Inflammation confined to mucosa and submucosa
• Pathogenesis
▪ IBD results due to
• Host interactions with Gastrointestinal flora
• Intestinal epithelial dysfunction
• Aberrant mucosal immunity

CROHNS DISEASE
• Chronic, transmural, noncaseating granulomatous inflammation of Intestine
• Sites
o Terminal Ileum – MC
o Esophagus, Stomach, Duodenum, Jejunum
o Colon
• Rectum is spared
• Etiology
o Infectious – Mycobacterium paratuberculosis
o Immunological – associated with HLA-DR 1
o Environmental
o Smoking
o Diet and Food allergy
o Bacterial dysbiosis – aggressive T cell response to specific components of intestinal microbes
• Pathology
o Multiple areas of Transmural inflammation (Skip lesions)

o Granuloma formation with serpentine ulcers

o Sparing of interspersed mucosa (cobblestone appearance)

o Thickening of Bowel wall (String sign of Kantor)

o Formation of Stricture, Fissure, Fistula

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• Clinical features
o Diarrhoea, Abdominal pain
o Malabsorption and malnutrition
o Loss of albumin (protein losing enteropathy)
o Iron deficiency anaemia
o B12 deficiency anemia
o Extraintestinal manifestations
▪ Skin – Erythema Nodosa
▪ Eye – Uveitis
▪ Joints – Arthritis, Ankylosing spondylitis
▪ Kidney – Nephrotic syndrome
▪ Sclerosing cholangitis
▪ Gallstones
▪ Amyloidosis
▪ Blood – Anemia
• Complications
o Stricture
o Fistula formation
o Intestinal obstruction
o Colonic Adenocarcinoma
• Differential diagnosis
o Radiation enteritis
o Ulcerative colitis
o Intestinal TB, Salmonella, Shigella
o Carcinoma Ceacum
o Ectopic kidney

• Investigations
o Plain X-ray
o US abdomen
o Barium meal study
▪ Terminal ileum stenosis (string sign of Kantor)
o CT scan
o Colonoscopy
▪ Serpentine ulcers
▪ Skip lesions
▪ Cobblestone appearance
o Capsule endoscopy
o MRI Enteroclysis – demonstrate fistula
o Screening test – presence of ASCA) anti-saccharomyces cerevisiae antibody

• Treatment
o Medical treatment
▪ TPN
▪ Drugs
• Steroids – induces remission
• Azathioprine – immunosuppression
• Infliximab – monoclonal antibody

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o Surgical treatment
▪ Indications
• Failure of drug therapy
• Intestinal obstruction
• Fistula formation
• Bleeding
• Perforation
▪ Ileocaecal resection
▪ Right hemicolectomy
▪ Total colectomy and ileorectal anastomosis

ULCERATIVE COLITIS
• Inflammatory condition of rectum and colon
• Starts in the rectum, spreads proximally to Colon (pancolitis) and ileum (back wash ileitis)
• Etiological factors
• Red meat
• Immunological – associated with HLA-DR 2
• Allergy to dietary factors
• Excess reactive oxidative metabolism
• Stress
• Defective mucin production in colonic mucosa
• Appendectomy and smoking protective against ulcerative colitis
• Pathology
• Mucosal and submucosal inflammation

• Extensive ulceration (No skip lesions)

• Stricture of colon

• Permanently contracted colon (lead pipe appearance)

• Epithelial thickening between the ulcers (Pseudopolyposis)

• Clinical features
• Bloody mucoid diarrhoea
• Colicky pain
• Abdominal distance
• Severe malnutrition and hypoproteinemia
• Extraintestinal manifestations
▪ Uveitis
▪ Ankylosing spondylitis
▪ Sclerosing cholangitis
• Complications
• Pseudopolyposis
• Colonic adenocarcinoma
• Stricture
• Massive hemorrhage
• Toxic megacolon

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• Differential diagnosis
• Crohn’s disease
• Bacillary dysentery
• Carcinoma colon
• Infectious colitis – Campylobacter jejuni
• Investigations
• Plain X-ray
▪ Obstruction
▪ Toxic megacolon
▪ Perforation
• Barium enema
▪ Lead pipe appearance
• Sigmoidoscopy and biopsy
• Colonoscopy
• Treatment
• TPN
• Correction of anaemia
• Drugs
▪ Steroids – induces remission
▪ Azathioprine – immunosuppression
▪ Infliximab – monoclonal antibody
▪ Mesalamine – anti inflammatory
• Surgery
▪ Total proctocolectomy with ileo-anal Anastomosis
▪ Total proctectomy with ileostomy

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LARGE INTESTINE
CARCINOMA COLON
Etiology
• Diet
o Red meat and saturated fat
o Dietary deficiency of vitamin A, C, E
o Low fibre diet
o Zinc deficiency
• Genetic
o Familial adenomatous polyposis
o Gardner’s syndrome
o Turcot’s syndrome
• Ulcerative colitis
• Alcohol and tobacco
• Radiation
Pathogenesis
• Multi-hit genetic mechanism
o SMAD mutation – TGF signalling -> remote cell cycle progression
o Telomerase reactivation - Prevents cellular senescence
o Microsatellite instability – Increased proliferation and decreased apoptosis
o APC mutation – accumulation of B-catenin -> promotes proliferation
o P53 mutation – increased proliferation and decreased apoptosis
Types
• Annular
• Tubular
• Ulcerative
• Fungating
Spread
• Direct spread
o Locally invasion into bladder, obstruct ureter -> hydronephrosis
o Ovary, Uterus
• Lymphatic spread
• Hematogenous spread → Liver, Lungs, Brain
Clinical features
• Abdominal pain
• Hematochezia
• Anaemia
• Intestinal obstruction
• Mass per abdomen
o Hard, Non-tender
o Does not move with respiration
o Resonant on percussion
Complications
• Intestinal obstruction
• Invasion into ureter
• Perforation and peritonitis
• Closed loop obstruction - segment of bowel is obstructed at two areas, resulting in progressive
accumulation of fluid and gas

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Differential diagnosis
• Ovarian tumor
• Peritoneal tumor
• Ameboma
• Ectopic kidney
DUKE’s Staging
• Stage A – confined to mucosa and submucosa
• Stage B - extends to muscularis propria without LN involvement
• Stage C – LN are involved
Investigations
• Barium enema
o Irregular filling defect
o ‘Apple core Lesion'
• Colonoscopy and biopsy
• CT colonoscopy
• US abdomen – to see secondaries
• Tumor markers – Carcinoembryonic antigen (CEA)
Treatment
• Right sided growth
o Right radical hemicolectomy with Ileo-tansverse anastomosis
• Transverse: growth
o Extended right hemicolectomy
o With terminal ileum and descending colon anastomosis
• Left-sided growth
o Left radical hemicolectomy
▪ Left half of Transverse colon and descending colon is removed
• Chemotherapy
o 5 fluorouracil with leucovorin
o IROX regime – Irniotican and Oxaliplatin
• Radiotherapy

(amoebic granuloma)
• Entamoeba histolytica causes Amoebic Typhlitis (inflammation of caecum) →
• Pain and tenderness in right iliac fossa along with mass mimicking carcinoma caecum
• Differential diagnosis
o Appendicular mass
o Carcinoma colon
o Ileocaecal TB
• Treatment
o Metronidazole
o Paromomycin
o Iodoquinol

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HRISCHPRUNG’S DISEASE (CONGENITAL MEGACOLON)

• Congenital absence of ganglion cells (Auerbach’s and Meissner’s plexus) in distal colon
• Affected area is narrow, spasmodic, non-relaxing
• Types
1. Ultra short segment – anal canal and terminal rectum is Aganglionic
2. Short segment - anal canal and complete rectum is Aganglionic
3. Long segment - anal canal, rectum and part of colon is Aganglionic
4. Total colonic - anal canal, rectum and full length of column is Aganglionic
• It has 3 zones
1. Distal immobile spastic zone – aganglionic zone
2. Middle transition zone/ zone of cone – sparse number of ganglions
3. Proximal dilated zone – normal ganglionic area
• Clinical features
▪ Associated with down syndrome
▪ Child fails to pass meconium
▪ Upon introducing finger into rectum, child passes toothpaste-like stool
▪ Abdominal distension
▪ Malnutrition
▪ Constipation
▪ Rectal examination shows → tight sphincter with empty rectum
• Complications
▪ Enterocolitis
▪ Perforation
▪ Peritonitis
• Differential Diagnosis
▪ Total neuronal dysplasia
▪ Acquired megacolon
▪ Anorectal malformation
▪ Meconium plug syndrome
• Diagnosis
▪ Plain X-ray - intestinal obstruction
▪ Biopsy
▪ Barium enema
• Look for the extent of disease and 3 zones
• Foley’s catheter should not be used to give enema in HD
▪ Anorectalmanometry – absence of rectoanal reflex
• Treatment
▪ Initial colostomy
▪ Nutritional supplementation
▪ Once child reaches 10kg weight, definitely procedure is done
• Excision of a ganglionic segment
• Maintenance of continuity by coloanal astomosis
• Closure of colostomy
▪ Anorectal myectomy
▪ Modified Duhamel operation

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GARDNER’S SYNDROME
• Gardner syndrome is a form of familial adenomatous polyposis (FAP)
• characterized by multiple colorectal polyps and various types of tumors
• Gardner syndrome Patient have a high risk of developing colorectal cancer at an early age.

BARIUM ENEMA
• Contrast X-ray done to visualise large bowel
• Indications
o Carcinoma colon – irregular filling defect
o Ileocecal TB – obtuse ileocaecal angle, incompetent ileocecal valve
o Ulcerative colitis – lead pipe appearance
o Crohn’s disease – string sign of Kantor
o Congenital megacolon – Narrow zone, Zone of cone, Dilated zone
o Diaphragmatic hernia – Colonic Shadow in left thoracic cavity
o Gastrojejunocolic fistula – leak into stomach from colon
• Procedure
o Laxative is given previous evening
o Enema (one litre of barium sulphate solution) infused into colorectum per anally
o X-ray is taken
o Patient is asked to evacuate the barium
o Post evacuation film is taken
o After that, air is inflated into colon
o Air gives better contrast to visualise thin mucosa of colon (air-contrast barium enema)

STOMA
• Artificial opening to the exterior, done to drain contents of bowel or ureter
• Done for diversion of urine of fecal matter
• Types
o Ileostomy
▪ terminal 5 cm ileum projected out onto skin, drain semi-fluid fecal matter
o Colostomy
o Cutaneous ureterostomy
o Ileal urinary conduit
o Vesicostomy

Colostomy
• Artificial opening in colon to exterior (skin) to divert faeces and flatus
• Types
o Temporary
▪ Done in condition, wherein diversion is required to facilitate healing in Distal colon or
Rectum
▪ Site
• Right hypochondrium
• Left iliac fossa
▪ Types
• Loop colostomy
• Double barrel colostomy

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▪ Indications
• Congenital megacolon
• Anorectal malformation
• Sigmoid volvulus
o Permanent colostomy
▪ End colostomy placed in left iliac fossa (6 cm above and medial to ASIS)
▪ Indications
• Abdomino-perineal resection
• Carcinoma anal canal
• After Hartmann’s operation
• Complications
o Skin excoriation
o Mucosal prolapse
o Infection
o Bleeding
o Herniation of abdominal contents

INTESTINAL OBSTRUCTION
Classification
• Acute – common in small bowel
• Chronic – common in large bowel
• Closed loop obstruction
Etiology (small bowel obstruction)
• Adhesion
• Malignancy
• Hernia
• Crohn’s disease
Etiology (large bowel obstruction)
• Colorectal cancer
• Volvulus
• Anorectal malformation

Pathogenesis of Bowel Obstruction

Intestinal obstruction

Increased peristalsis

Obstruction not relieved

Peristalsis ceases

Flaccid, Paralysed, Dilated bowel

Collection of fluid and air proximal to obstruction

Infection (E.coli, Klebsiella, Anaerobes)

Toxemia

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Dilation of bowel wall

Intraluminal pressure exceeds venous pressure

Impaired venous return

Congestion, edema of bowel wall

Arterial supply decreases

Gangrene → Perforation → Peritonitis

In Closed loop obstruction

• Obstruction in large bowel, with ileocaecal valve incompetence

• Pressure increases in caecum

• Stercoral ulcer in caecum

• Gangrene → Perforation → Peritonitis

Closed loop obstruction can also occur when bowel is Obstructed at both proximal and distal parts of the loop
of bowel
• Etiology
o External hernia
o Internal hernia
o Volvulus

Changes in intestinal obstruction

• Proximal to obstruction
o Distension of bowel
• Distal to obstruction
o Initial emptying, later collapse and contracted state
• At level of obstruction
o Strangulation
o Perforation
o Peritonitis
Clinical features
• Colicky abdominal pain
• Vomiting
• Visible intestinal peristalsis
• Constipation
• Toxemia and septicemia
• Abdominal tenderness
• Bowel sounds
o High pitched metallic sounds
o Eventually upon gangrene sounds not heard

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Complications
• Peritonitis
• Septic shock

Differential diagnosis
• Paralytic obstruction
• Ascites
Investigations
• Plain X-ray
o Multiple air fluid levels
o Dilated loop of bowel > 3cm
• CT scan - intestinal obstruction
• Barium enema
• US abdomen – dilated bowel
Treatment
• Nasogastric aspiration – to reduce toxic effects
• Immediate laparotomy
• Small bowel decompression – Salvage decompressor
• Right sided colonic obstruction
o Right hemicolectomy with Ileo-tansverse anastomosis
• Left-sided colonic obstruction
o Left hemicolectomy with Colo-colic anastomosis

VOLVULUS
• Twist (rotation) in the axis of the loop of bowel either Clockwise or Anticlockwise
• 15% of large bowel obstruction is due to volvulus
• Types
o Caecal volvulus (clockwise)
o Sigmoid volvulus (anticlockwise)

SIGMOID VOLVULUS – anticlockwise

• Predisposing factors
o Adhesion
o Peridiverticulitis
o Long pelvic mesocolon
o Overloaded pelvic mesocolon
• Associated with
o Parkinson's disease
o Scleroderma
o Multiple sclerosis
o Anticholinergic drugs
• Clinical features
o Left sided abdominal pain
o Absolute constipation (no feces, no flatus)
o Enormous Abdominal distension
o Late onset vomiting
o Features of Peritonitis

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• Complications
o Perforation, Peritonitis
o Septicemia
• Differential diagnosis
o Fecal impaction
o Rectosigmoid carcinoma
o Ogilvie’s Syndrome
▪ Acute colonic pseudo-obstruction
▪ Due to impaired sacral parasympathetic nerve
▪ Etiology
• Trauma
• Retroperitoneal irritation
• Hypokalemia
• Myxoedema
• Uremia
• Investigations
o Plain X-ray
▪ Omega sign
• Distented colon loop arise out of pelvis and extends till diaphragm
▪ Coffee bean sign
• Closed loop of the sigmoid colon distends with gas
• Medial wall of the dilated bowel form the cleft of the coffee bean
• Lateral wall of the dilated bowel form the outer walls of the bean
o Contrast enema
▪ Bird’s beak sign – upper end of barium column tapers into spirally twisted Sigmoid colon
o CT scan
• Treatment
o Sigmoidopexy
▪ Manual derotation
▪ Fixing the colon to lateral wall of abdomen
o Paul-Mikulicz operation
▪ Gangrenous area resected
▪ Proximal cut end is made colostomy
▪ Distal cut end is closed
o Hartmann’s operation

INTUSSUSCEPTION
• Telescoping or invagination of one segment of bowel into adjacent segment
• Types
o Antegrade
o Retrograde
• Etiology
o Diet change during weaning causing inflammation of Peyer’s patches
o Upper respiratory tract viral infection
o Intestinal polyps
o Submucous lipoma
o Meckel’s diverticulum
o Leiomyoma intestine

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• Pathology
o Apex – part which advances
o Intussuscipiens – part which receives (outer sheath)
o Intussusception – Tubes which advance (middle and inner sheath)

• Clinical features
o Abdominal colicky pain
o Red currant jelly stools
o It is recurring, when it gets reduced, child becomes asymptomatic
o Empty right iliac fossa – Sign of Dance
o Palpable mass
▪ Sausage shaped mass
▪ Does not move with respiration
▪ Resonant on percussion
▪ Mars appears and disappears
• Complications
o Intestinal obstruction
o Perforation
o Peritonitis
• Investigations
o Barium enema
▪ Claw sign
▪ Coiled spring sign
o US abdomen
▪ Bull’s eye sign / Target sign
▪ Pseudokidney sign
o X-ray plain – multiple air-fluid level
o CT abdomen
• Treatment
o Ryle's tube aspiration
o Reduction by hydrostatic pressure – using warm saline
o Surgery
▪ Cope’s method
• Milking out the distal part manually
▪ If intussusception > 48 hours → Ileocolic resection

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PARALYTIC ILEUS (Adynamic intestinal obstruction)

• Failure of transmission of peristaltic waves secondary to neuromuscular failure
• Etiology
o Post operative
o Infections
o Hypothyroidism
o Myocardial infarction
o Retroperitoneal hemorrhage
o Spinal cord injury
o Mesenteric ischemia
o Electrolyte imbalance
▪ Uremia
▪ Hypokalemia
▪ Hyponatremia
• Clinical features
o No passage of flatus
o No bowel sounds
o Large volume vomiting
o Marked abdominal distention
o Dull abdominal pain
o Features of electrolyte imbalance
• Investigations
o Serum electrolyte estimation
o Plain X-ray
o US abdomen
• Treatment
o Nasogastric aspiration
o Electronic management
o Catheterization and urine output measurement
o (Do not stimulate the peristalsis) - most often, patient recovers in 3 – 6 days
o In prolonged life-threatening paralytic ileus
▪ Laparotomy and bowel decompression with Savage’s decompressor
o Catchpole regime
▪ Adrenergic blocker with Cholinergic stimulant
▪ Used rarely in resistant cases

LADD’S BAND
• Incomplete type of maal rotation
• fibrous stalks of peritoneal tissue that attach the cecum to the posterior abdominal wall compressing the
2nd part of duodenum
• Associated with
o Prune belly syndrome
o Duodenal atresia
• Clinical features
o Small bowel volvulus
o Features of strangulation, perforation, peritonitis

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• Investigation
o Plain X-ray
o Barium meal study
• Treatment
o Laparotomy – Ladd’s band is divided and large bowel is repositioned
o Complementary appendectomy is also done – Ladd’s operation

MECONIUM ILEUS
• Neonatal Cystic fibrosis disease of pancreas, wherein thick meconium gets collected in terminal ileum
• Further inspissation forms a firm bolus leading to obstruction of ileum
• Associated with
o Exocrine pancreatic insufficiency
o Respiratory dysfunction
o Ileal obstruction
• Clinical features
o Hypertrophied and dilation of proximal ileum
o Distal ilium and Colon are narrow and contracted
o Volvulus formation
o Gangrene
o Perforation
• Investigation
o Plain X-ray
▪ Multiple air fluid levels
▪ Soap bubble appearance
• Treatment
o Bishop koop operation
▪ Proximal dilated segment of ileum is resected
▪ Resected end is anastomosed to distal collapsed ileum
▪ End of distal ileum is brought out as iliostomy
▪ Through ileostomy Acetyl Cysteine given regularly to dissolve meconium pellets

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APPENDIX
ACUTE APPENDICITIS
Etiology
• Low fibre diet
• Viral infection
• Family history
• Obstruction of appendix lumen
1. Fecolith
2. Stricture
3. Foreign body
4. Round worn
• Crohn’s disease
• Infections
1. E.coli
2. Streptococcus
3. Cl.welchi
Pathogenesis
Luminal obstruction/Round worm/Crohn’s disease

Collection of mucus and inflammatory fluid

Increases intraluminal pressure

Blockage of Lymphatics and Venous drainage

Increased edema of mucosa

Mucosal ulceration and ischemia

Bacterial Translocation

Acute appendicitis

Thrombosis of appendicular artery

Ischemia and Gangrene of appendix → Perforation → Peritonitis

• Types
• Acute non-obstructive appendicitis
• Acute Obstructive appendicitis
• Recurrent appendicitis
• Subacute appendicitis
• Stump appendicitis → retained stump of appendix after laproscopic appendectomy

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• Clinical features
• Murphy’s triad
• Pain
• Vomiting
• Fever
• Constipation
• Increased urinary frequency → inflammed appendix irritates bladder
• (Rebound tenderness - pain upon removal of pressure rather than application of pressure to
the abdomen)
• Signs in acute appendicitis
1. Rovsing sign
• Palpation of left iliac fossa produces pain in right iliac fossa by shift of bowel
2. Ten Horn sign
• Traction on right testicle -> Pain in RIF
3. Aaron sign
• Pressure on Mcburney point -> Pain in Epigastrium
4. Bastedes sign
• Rectal air insufflation -> Pain and tenderness in RIF
5. Dunphy sign
• Coughing -> pain in RIF
6. Sharans triangle hyperesthesia
• Due to irritation of lower abdominal nerves
• Triangle formed by
• ASIS
• Umbilicus
• Pubic symphysis
7. Blumberg sign
• Rebound tenderness
8. Baldwing test
• Legs lifted off the bed with extended knee → Flank pain
9. Cope’s psoas test
• Hyperextension of right hip -> Pain in RIF -> due to irritation of Psoas muscle
10. Obturator test
• Internal rotation of right hip -> Pain in RIF -> due to irritation of Obturator internus muscle
• Complications
• Perforation
• Appendicular mass
• Appendicular abscess
• Differential diagnosis
• Acute cholecystitis
• Acute pancreatitis
• Nichols diverticulitis
• Salpingitis
• Ovarian torsion
• Perforated peptic ulcer
• D/D in Children
• Intussusception
• Worm infestation

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• Investigations
• TLC – increased
• Plain X-ray
• Lumbar scoliosis towards right due to psoas spasm
• Extraluminal gas in RIF
• Fecolith in RIF
• US abdomen
• To rule out other appendicitis mimicking causes
• Laproscopy
• ALVARADO SCORING
• M – Migratory pain - 1
• A – Anorexia - 1
• N – Nausea & Vomiting - 1
• T – Tenderness – (2)
• R – Rebound tenderness - 1
• E – Elevated temperature - 1
• L – Leucocytosis – (2)
• S – Shift to left (immature - 1 WBC), Segmented neutrophils – 1
• (Total score = 10)
• Score > 7 strongly suggestive of appendicitis
• Contrast CT scan
• Dilated appendix
• Thickened wall
• Periappendicular fluid collection
Treatment
Mcburney point – junction of lateral 1/3 and medial 2/3 of ASIS-umbilical line
• Surgical-Appendicectomy
1. Gridiron incision
• Incision perpendicular to Right ASIS-umbilical line at Mcburney point
2. Rutherford morison's muscle cutting Incision
• Muscles are cut upwards and laterally
3. Lanz crease Incision at Mcburney point
• Cosmetically better
4. Right lower paramedian incision
5. Laparoscopic approach
• Complications of Appendicectomy
• Paralytic ileus
• Hemorrhage – slipping of ligature of appendicular artery
• Right inguinal hernia
• Wound Infection

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APPENDICULAR MASS (P eriappendicular phlegmon)

• Localisation of infection occurring 3-5 days after attack of acute appendicitis
• Inflamed appendix, greater omentum, dilated ilium, edematous caecum forms a mass in RIF
• Characteristics of mass
o Tender, Firm, Well-localized
o Does not move with respiration
o Resonant on percussion
o Fever and features of toxicity
• Differential diagnosis
o Carcinoma caecum
o Crohn’s disease
o Twisted ovary
o Ileocecal TB
• Investigations
o TLC – increased
o US abdomen – confirms mass
• Treatment
o Ochsner-Sherren Regimen
▪ Includes observation
• Temperature, BP, Pulse chart
• Marking the mass to identify progression/regression
• Antibiotics
o Ampicillin
o Metronidazole
o Gentamicin
• IV fluids
• Analgesics
• Initial Nasogastric aspiration
o Patient usually show response in < 72 hours
▪ Mass reduces in size
▪ Temperature becomes normal
▪ Pulse and BP normalizes
▪ Appetite is regained
o Patient is discharged and advised for interval appendicectomy after 6
weeks
▪ Criteria for discontinuation of OS regimen
• Patient becomes more toxic (Tachycardia, Fever)
• Increased size of mass
• Abscess formation in mass
• Excruciating pain abdomen (Onset of Peritonitis)
o These patients need immediate laparotomy

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RECTUM AND ANUS

CARCINOMA RECTUM
• Any tumor within 15 cm proximal to anal margin is called Rectal tumor/cancer
• Usually originates from preexisting adenoma or papilloma
• Etiology
• Low fibre diet
• Red meat
• Alcohol, Smoking
• Saturated fatty acid
• Ulcerative colitis
• HNPCC
• Familial history
• Villous adenoma
• Pathogenesis
• Chromosomal instability
• Microsatellite instability

• Gross types
• Ulcerative
• Annular
• Diffuse
• Spread
• Local spread – circumferential invasion into
▪ Prostate
▪ Bladder, Ureter
▪ Seminal vesicle (male)
▪ Uterus and vagina (female)
▪ Sacrum and sacral plexus
• Hematogenous spread
▪ Liver > Lungs

• Clinical Features
• Bleeding per rectum – mimics haemorrhoids
• Spurious diarrhoea – Early morning
▪ Overnight mucus accumulation in rectum causing Urgency & Defecation
• Tenesmus
▪ Painful incomplete defecation with bleeding
• Bloody slime
▪ Mucus with blood in stool
• Urinary symptoms due to infiltration of bladder and prostate
• Back pain due to invention into sacral plexus

• Differential diagnosis
• Inflammatory stricture
• Carcinoid
• Amoebic granuloma
• Solitary ulcer syndrome

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• Investigations
• Proctoscopy, Sigmoidoscopy
• Biopsy using Yeoman’s Forceps
• Barium enema
• Colonoscopy
• US abdomen – Secondaries in liver, Ascites
• CT scan
• Transrectal ultrasound (TRUS)
• Endorectal coil MRI
• Fluorine – 18 PET scan
• Treatment
• Chemotherapy
▪ 5-FU with Leucovorin
▪ Capecitabin
▪ Oxaliplatin
▪ Bevacizumab
▪ Cetuximab
• Surgery
• Abdomino-perineal resection (APR)
• Low Anterior resection (LAR)
• Total mesorectal excision (TME)
• Pelvic evisceration (Brunschwig operation)
▪ Removal of rectum with tumor, all LN, Urinary bladder, Fat, Fascia, Uterus, Vagina,
with Colostomy and Urinary diversion
• Laparoscopic APR
• Palliative Colostomy

PROCTALGIA FUGAX
• Sudden severe recurring pain in rectum with segmental pubococcygeal spasm
• Etiology
o Stress
o Straining
• Features
o Common at night
o Unbearable pain starts suddenly and subsides in few minutes
o Constipation
• Treatment
o Cutting of Puborectalis
▪ Complication of procedure – Fecal incontinence

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RECTAL PROLAPSE
• Circumferential descent of rectum through the anal canal
• Types
o Partial
o Complete
o Hidden/Concealed
• Etiology
o Sliding hernia of pouch of Douglas
o Procidentia -> full thickness rectal intussusception
o Decreased Sacral curvature
o Decreased anal canal tone
o Chronic constipation
o Decreased ischiorectal fossa fat
o Pudendal nerve damage
o Increased intra-abdominal pressure
▪ Chronic cough
▪ Stricture Urethra

Partial rectal prolapse

o Only Mucosa and submucosa of rectum descends not more than 4 cm
o No descent of Muscular layer
o Features
▪ Mass per anum
▪ Pink in colour and circumferential
▪ (Difference from piles – piles are not circumferential and are blue in colour)
o Treatment
▪ Digital repositioning
▪ Correction of constipation
▪ Submucosal Inj of 5% Phenol in almond oil into apex of prolapse
▪ Thiersch wring
▪ Goodsall’s operation – Excision of prolapsed mucosa
▪ Stapled Transanal rectal resection surgery (STARR)
Complete rectal prolapse (PROCIDENTIA)
o Due to weakened Levator Ami
o Often associated with uterine prolapse
o Decent > 4 cm
o Contains all layers of rectum (including muscular layer)
o Features
▪ Circumferential mass per anum
▪ Red in colour
▪ Reducible and painless
▪ If incarcerated or infected -> painful
▪ Fecal incontinence
▪ Bleeding, Sepsis
o Differential diagnosis
▪ Recto sigmoid intussusception
▪ 3rd degree piles
▪ Large rectal polyp

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o Investigations
▪ Defecography
▪ Sigmoidoscopy
▪ Anal manometry
▪ Pudendal nerve latency
▪ Electromyography of Puborectalis muscle
o Procedure for repair of rectal prolapse
▪ Abdominal operations
• Laparoscopic posterior mesh rectopexy (LPMR)
• Laparoscopic resection rectopexy (LRR)
• Well’s operation – Polypropylene mesh
▪ Perineal operations
• Delrome’s operation (Mucosal sleeve resection and plication)
• Perineal Rectosigmoidectomy
o Complications of surgery
▪ Injury to hypogastric nerve – causing impotence
▪ Bladder dysfunction
▪ Recurrence of prolapse
▪ Infection

IMPERFORATE ANUS
• Imperforate anus is a congenital abnormality characterized by the absence or abnormal localization of the
anus.
• Rectum may be connected to the Vestibule (females) or bladder/urethra (males) by a Fistula
• Associated with VACTREL anamoly
• Vertebral defects
• Anal atresia
• Cardiac defects
• Tracheo-esophageal fistula
• Renal anomalies
• Limb abnormalities
• Depending on level of rectal termination in relation to Pelvic floor
• High Imperforate anus
• Low imperforate anus
• Investigations
• Invertogram
▪ Done 6 hours after birth
▪ Baby up-side-down X-ray shows Air in distal rectum
• Treatment
• Low Fistula
▪ Anoplasty
▪ Ano-vestibuloplasty
• High Fistula
▪ Posterior sagittal anorectoplasty (PSARP)

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PILONIDAL SINUS
• Sinus in the natal cleft near coccyx
• Contains hair and unhealthy diseased granulation tissue
• Commonly seen in Jeep drivers a.k.a Jeepers bottom
• Features
o Serosanguinous purulent discharge
o Throbbing pain
o Tender swelling in midline (primary sinus)
o Tender swelling laterally on either sides (Secondary sinus)
o Tuft of hairs seen in opening of sinus

• Pathology

• Complications
o Infection
o Abscess formation
o Necrotising fasciitis
o Osteomyelitis

• Treatment
o Jack+Knife procedure
o Excision of all sinuses and closure by skin grafting
▪ Z-plasty
▪ Karydaki procedure
▪ Limberg procedure

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HEMORRHOIDS
• Masses of prolapsed cushions of submucosal vessels of rectum
• Etiology
o Hereditary
o Straining
o Constipation
o Hard stools
o Over purgation
o Low fibre diet
o Portal hypertension
o During pregnancy – increase progesterone -> venous dilation -> venous congestion
o Disruption of suspensory tissues, which holds vein plexus in position

• Types
o Internal – above dentate line, covered with mucous membrane
o External – below dentate line, covered with skin
o Interno-external

• Classification
o 1st degree piles – bleeding internal piles
o 2nd degree piles – piles prolapse during defecation, return back spontaneously
o 3rd degree piles – piles prolapse during defecation, return only upon manual help
o 4th degree piles – permanently prolapsed piles

• Features
o Bleeding – bright red
o Mass per annum
o Mucoid discharge
o Pain, Pruritus
o Per rectal examination -> thrombosed piles

• Complications
o Profuse hemorrhage
o Strangulation
o Thrombosis
o Ulceration, Gangrene

• Differential diagnosis
o Rectal prolapse
o Perianal warts

• Investigations
o Hematocrit
o Colonoscopy
o Proctoscopy
▪ Number and degree of piles
▪ Surface and appearance of piles

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• Treatment
o High fibre diet
o Stool softener
o Sclerotherapy – 5% phenol in almond oil
o Surgery
▪ Milligan Morgan Open hemorrhoidectomy
▪ Ferguson Closed hemorrhoidectomy
▪ Longo’s Stapled hemorrhoidectomy
▪ THD – Trans Anal Hemorrhoidal Dearterialization
▪ HALO – Haemorrhoidal Artery Ligation Operation
▪ Cryosurgery - using liquid nitrogen
▪ Laser therapy – 3rd degree piles
• Nd-YAG laser
• Carbon dioxide laser
FISSURE IN ANO
• It is an ulcer in the longitudinal axis of lower anal canal
• Etiology
o Hard fecal matter -> tear anal valve -> posterior anal fissure
o Lack of support to pelvic floor -> anterior anal fissure
o Diarrhoea
o Ulcerative colitis
o Local trauma
o TB, STD
• Types
o Acute anal fissure
▪ Deep tear in lower anal skin
▪ Severe anal sphincter spasm
▪ Without edema and inflammation
o Chronic anal fissure
▪ Inflamed indurated margin
▪ Ulcer at its inferior margin has an edematous skin tag, acting like a guard – Sentinel pile
• Features
o Pain
o Constipation
o Bleeding, Discharge
o Per rectal examination and Proctoscopy not possible in acute anal fissure
• Complications
o Abscess formation
o Fistula formation
• Treatment
o General measures
▪ Adequate fluid intake
▪ Fibre rich diet
▪ Stool softeners (Lactulose)
o Surgical procedure
▪ Chemical Sphincterotomy – Nitrates -> increase blood flow and heal the fissure
▪ Lateral Sphincterotomy – TOC
▪ Dorsal fissurectomy with Sphincterotomy

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ANORECTAL ABSCESS
• Abscess due to infection of anal glands in relation to Crypts
• a.k.a Cryptoglandular disease
• Etiology
o Infection
▪ E.coli
▪ Staphylococcus
▪ Streptococcus
• Risk factors
o Diabetes
o Immunosuppression
• Investigation
o MRI – IOC
o Anal US
o Proctosigmoidoscopy
• Classification
o Perianal
o Ischiorectal
o Submucous
o Pelvirectal
o Fissure-in-Ano abscess
• Perianal abscess
o Suppuration of anal gland or Thrombosed piles
o Features
▪ Severe perianal pain
▪ Tender swelling
o Treatment
▪ Sitz bath
▪ Antibiotics
• Ischiorectal abscess
o Abscess in ischiorectal fossa
o Fat in the fossa more prone to infection
o Fossa communicates with opposite side → Horse show abscess
o Features
▪ Tender, Brawny swelling
▪ Swelling not well-localised
o Treatment
▪ Cruciate Incision and pus drainage

SIGMOIDOSCOPY
• Used to visualise rectum and sigmoid colon
• Take biopsies from suspected lesions
• To do therapeutic procedures (Polypectomy, bleeding control)
• Two types
o Rigid
o Flexible

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FISTULA-IN-ANO
• Fistula tract lined by granulation tissue connecting perianal skin superficially to..,
o Anal canal
o Anorectum
o Rectum
• PARKLAND CLASSIFICATION of fistula-in-ano
o Type 1 – Inter-sphincteric
o Type 2 – Trans-sphincteric
o Type 3 - Supra-sphincteric
o Type 4 – Extra-sphincteric
• Types
o Low Fistula – open into anal canal below the internal ring
o High Fistula – open into anal canal above the internal ring
• Goodsall’s rule
o Anteriorly located fistulas drain directly individually into anal canal
o Posteriorly located fistulas join and form Horse-shoe tract and drain into anal canal
o Exception
▪ Posterior fistula > 3.5 cm away from anal verge
• Investigations
o MR – fistulogram
• Treatment
o Fistulectomy
o Fistulotomy
o Seton technique
▪ For high fistula
▪ Silk or Lenin ligature is passed across the fistula and left in place
▪ This allows fistula to granulate and heal

PROCTOSCOPY
• Types
o Illuminating
o Non-illuminating
• Indications
o Diagnostic
▪ Piles
▪ Fissure-in-Ano
▪ Anal strictures
o Therapeutic
▪ Injection therapy for piles
▪ Cryotherapy for piles
▪ Biopsy for Carcinoma rectum/anorectum

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COLONOSCOPY
• Used to visualise rectum, Sigmoid colon and upto caecum
• Indications
o Bleeding per rectum
o To take biopsies at different levels
o Identify Ulcerative colitis
o To remove polyps
o For therapy
▪ Colonoscopic polypectomy
▪ Dilation of colon stricture

SOLITARY RECTAL ULCER

• Thickening and Disorganisation of Muscularis mucosa with superficial ulceration
• Etiology
o Intussusception
o Anterior rectal wall prolapse
o Increased intra-rectal pressure
• Features
o Constipation
o Bleeding
o Mucus discharge
o Mucosal prolapse
• Investigations
o Defecography – nonrelaxing persistent Puborectalis impression waves
o Proctoscopy - Rectal intussusception or Rectal wall prolapse
• Treatment
o High fibre diet
o Treatment of prolapse
o Biofeedback exercises
o Surgery only in refractory cases

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KIDNEY
RENAL TUBERCULOSIS
• Hematogenous spread of tubercle bacilli to glomerulus -> causing caseating granuloma with Langhan
giant cell and eptheloid cells
• Pathological types
o Tuberculous papillary ulcer
o Tuberculous hydronephrosis
o Tuberculous perinephric abscess
o Tuberculous cavernous form
o Calcified tuberculous area (mimics Calculi a.k.a Pseudocalculi)
o Caseous kidney
o Miliary tuberculosis
o Tuberculous bacilluria causes
▪ Tuberculous ureteritis
▪ Tuberculous cystitis (Thimble bladder)
▪ Tuberculous prostatitis
▪ Tuberculous epididymitis
• Clinical features
o Sterile pyuria
o Painful micturation
o Hematuria
o Acute pyelonephritis
o Enlarged prostate
o Thickened vas deferens
o Recurrent urinary tract infection
• Investigations
o Mantoux test – positive
o CXR
o US abdomen
o 3 consecutive early morning urine sample (EMUS) – ZN staining and LJ media culture
o Plain X-ray – calcification in Kidney
o CT scan
o Cystoscopic
▪ Multiple tubercles
▪ Bladder spasm
▪ Golf-hole ureter orifice
o Intravenous urogenital (IVU)
▪ Hydrocalyx
▪ Stricture ureter

• Treatment
o Anti-TB therapy
▪ HRZE
o After 6 weeks of drug therapy -> Hanley’s Renal Cavernostomy
o Hydronephrosis -> Nephrostomy
o Thimble bladder -> Hydraulic Dilation
o Ureteric stricture -> Stenting
o Extensive disease -> Nephro-ureterectomy

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HYDRONEPHROSIS
• Aseptic dilation of pelvicalyceal System due to partial obstruction of urine outflow
Etiology
• Unilateral
o Extramural
▪ Aberrant renal vessels
▪ Compression by carcinoma
▪ Retracaval ureter
o Intramural
▪ Congenital PUJ (pelvi-ureteral junction) obstruction
▪ Ureterocele
▪ Neoplasm of ureter
▪ Narrow ureteric orifice
▪ Stricture ureter following stone removal
o Intraluminal
▪ Stone in Renal pelvis or ureter
▪ Sloughed papilla in Papillary necrosis
• Bilateral
o Congenital
▪ Congenital stricture of external urethral meatus
▪ Congenital posterior urethral valve
o Acquired
▪ BPH
▪ Carcinoma prostate
▪ Phimosis
▪ Bladder carcinoma
Pathology
• Pressure burden on Renal Calyces and Renal parenchyma → Parenchymal thinning and Dilation
Clinical features
• Unilateral cases
o Dull aching loin in pain
o Mass in loin, moves with respiration
o Attack of acute renal colic
o Dysuria, Hematuria
o Dietl’s crisis
▪ After an acute attack of renal colic -> loin swelling appears -> later swelling disappears
with passage of large volume of Urine
• Bilateral cases
▪ Loin pain
▪ Features of bladder obstruction
• Frequency
• Hesitancy
• Poor stream
Complications
• Pyonephrosis
• Perinephric abscess
• Renal failure

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Investigations
• Blood urea & Serum kreatinin
• Urine microscopy
• US abdomen
• IVU – assess the functioning of diseased and normal kidney
• CT scan
• Isotope renography
• Whitaker test – fine needle is passed into renal pelvis through loin -> perfusion of pelvis with saline ->
persistent increase in pressure indicates HN
Treatment
• Treatment of the cause – stones, congenital anomaly, BPH, aberrant renal vessels, stricture Urethra
• Anderson-Hyne’s operation (dismembered pyeloplasty)
• Foley’s Y-V plasty (non-dismembered pyeloplasty)
• Laparoscopic pyeloplasty
• Refractory case – Nephrectomy

POLYCYSTIC KIDNEY DISEASE

▪ Adult PCKD is inherited autosomal dominant disease
▪ Cyst formation occurs at junction of Distal convoluted tubule and Collecting duct
▪ Associations
o Polycystic disease of liver, pancreas, lungs
o Berry aneurysm in circle of Willi’s
▪ Clinical features
o MC in females
o 3rd decade
o Bilateral palpable renal mass
o Loin pain
o Hematuria
o Infection
o Hypertension
o Uremia
▪ Differential diagnosis
o RCC
o Hydronephrosis
o Solitary Renal cyst
▪ Investigations
o US abdomen – confirms presence of cyst
o IVU – Spider leg pattern
o Blood urea and Serum creatinine
▪ Treatment
o US guided aspiration
o Laparoscopic aspiration
o Rovsing operation
▪ kidney is exposed -> cyst is opened -> fluid is evacuated -> cut edge is marsupialised

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RENAL CALCULUS
Etiology
• Vitamin A deficiency -> desquamation of epithelium which acts as nidus for stone formation
• Hot climate -> increase urinary solutes -> chelation of solute with calcium
• Decrease citrate in urine (citrate maintains calcium phosphate/carbonate in Soluble state
• Infection in kidney -> Proteus, E.coli
• Hypercalciuria
• Hyperoxaluria
• Hyperuricosuria
• Cystinuria
• Stasis due to obstruction of urine flow
• Renal tubular acidosis
• Randall’s plaque theory
o Soft tissue calcification, found in deep renal medulla, act as a nucleating element for renal calculi
• Drugs
o Acetazolamide
o Loop diuretics
o Ciprofloxacin
Stages of stone formation
1. Supersaturation
2. Nucleus formation
3. Crystallization
4. Aggregation
5. Matrix formation
6. Stone
Types
Stones in acidic urine
• Calcium oxalate stones
o Dumbbell shaped
• Uric acid stones
o Hyperuricosuric conditions
• Cysteine stones
o Due to defective absorption of cysteine from renal tubules
o Appear in acidic urine
Stones in alkaline urine
• Triple phosphate stone (Calcium, Ammonia, Magnesium phosphate)
o Staghorn calculi
o Seen in alkaline urine
o Seen in Proteus infection (splits urea to ammonia)
• Calcium phosphate stone
Xanthine stone
• Due to deficiency of xanthine oxidase
• Radiolucent stone
Clinical features
• Renal colic – over Renal angle, hypochondrium and lumbar region, often radiate to groin
• Haematuria, Pyuria
• Fever
• Tenderness in renal angle

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Investigations
• Blood – ESR, Calcium, Phosphate, Creatinine, Uric acid
• Urine – Calcium, Urate, Cysteine
• Plain X-ray KUB – radiopaque Stone
• IVU - renal function
• US abdomen – detect radiolucent stone, changes in Renal parenchyma
• CT scan
Treatment
• ESWL (Extra-corporeal Shock Wave Lithotripsy)
o Stone 4-5 mm in diameter
• Percutaneous Nephrolithotomy
o Stone > 2.5 cm
o Multiple stones
o Stones not responding to ESWL
• Surgery
o Indications
▪ Large stone
▪ Infected urine
▪ Stone causing complete obstruction
▪ Stone is obstructing solitary kidney
o Pyelolithotomy
o Nephrolithotomy
o Partial nephrectomy
o Bench surgery – kidney is temporarily removed, cooled by ice packs, stones are searched and
removed completely

CAUSES OF HEMATURIA

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RENAL CELL CARCINOMA (GTAWITZ TUMOR, Hypernephroma)

• Adenocarcinoma arising from Renal tubular cell
• Etiology
o Cigarette smoking
o Obesity
o Polycystic kidney disease
o Tuberous sclerosis
o Carcinogens -> Asbestos, Lead, Cadmium
o Von-Hippel-Lindau syndrome
o Brit-Hogg-Dube syndrome
• RCC types
o Clear cell Ca
o Papillary Ca
o Medullary Ca
o Chromophobe Ca
o Collecting duct of Bellini Ca
• Spread
o Local extension
▪ Perinephric pad of fat, Renal pelvis
o Hematogenous spread
▪ RCC enters Renal vein -> Proliferating Tumor thrombus -> extends into IVC -> later it
gets detached (Cannon-ball Secondaries)
▪ Lung, Liver, Brain, Bone, Adrenals
o Lymphatic spread
▪ Hilar lymph nodes
▪ Para-aortic lymph nodes
• Clinical features
o Hematuria, Flank pain
o Palpable Renal mass
o Left sided Varicocele, in Left RCC, tumor in renal vein blocks the Left testicular vein opening
o Stuffers syndrome
▪ Non-metastatic reversible liver dysfunction, gets corrected after nephrectomy
o Due to secondaries
▪ Pathological fractures
▪ Persistent cough and hemoptysis
• Differential diagnosis
o Polycystic kidney disease
o Solitary cyst of kidney
o Adrenal tumor
o Retroperitoneal tumor
o Investigations
o Urine microscopy for RBC’s
o IVU – Mass and irregular filling defect
o US abdomen – size, extension, LN involvement, Renal vein Status
o CT scan – tumor thrombus in Renal vein and IVC
o CXR – calcified cannon-ball secondaries
o Inferior Vena Cavagram – extension of tumor through renal vein into IVC
o MR angiogram

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o Treatment
o Localised RCC
▪ < 4cm = partial nephrectomy
▪ > 4cm = radical nephrectomy
• Structures removed in radical nephrectomy
o Kidney and surrounding Gerota's fascia
o Ipsilateral adrenal gland
o Renal hilar lymph nodes
o Proximal half of ureter
o Advanced RCC
▪ Nephron sparing Nephrectomy
▪ Chemotherapy
▪ Radiotherapy

INTRAVENOUS UROGRAM/PYELOGRAM
o PROCEDURE
o Overnight fasting for 8 hours
o Laxatives are given to reduce bowel shadow
o Plain X-ray kUB taken
o 1ml test dose of sodium diatrizoate (urograffin) or meglumine iothalamate is injected IV
o If no hypersensitivity occurs, Full dose of 1ml/Kg body weight is given
o X-ray taken at 5 mins, 15 mins, 20 mins, shows the secretary function of kidney
o Film taken after 72 hours, shows bladder pathology as well as Residual urine
o Indications
o Hydronephrosis – Clubbing of Calyces
o RCC – Irregular filling defect
o Renal trauma
o Congenital anomalies
▪ Horseshoe kidney
▪ Duplex kidney
▪ Ureterocele – Cobra head appearance
▪ Polycystic kidney disease – Spider leg pattern
o Contraindications
o Iodine sensitivity
o Toxic thyroid

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CYSTOSCOPY
▪ Uses
o To examine
▪ Urethra
▪ Bladder
▪ Uretric orifice
o To visualise bladder fistula
o Therapeutic
▪ Urethrotomy
▪ TURP
▪ Bladder tumor resection
▪ Bladder stone removal (cystolithotripsy)
▪ Ureteric catheterization
▪ Types of cystoscope
o Rigid
o Flexible
▪ Contraindications
o Acute cystitis
o Prostatitis

URETROCELE
▪ Cystic enlargement of intramural portion of ureter
▪ Etiology -> congenital atresia of ureteric orifice
▪ Complications
o Stone formation
o Recurrent infection
o Hydronephrosis
▪ Classification of Uretrocele
o Stenotic
o Sphincteric
o Sphinctero-Stenotic
▪ Investigations
o IVU – Cobra head appearance
o Cystoscopy – Translucent cyst surrounding Ureteric orifice
▪ Treatment
o Cystoscopic ureteric meatotomy

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URETERIC CALCULI
▪ Sites

▪ Clinical features
o Ureteric colic radiating from loin to groin (referred along Genito-femoral nerve)
o Mimics appendicitis
o Hematuria, Dysuria
o Tenderness in renal angle
▪ Complications
o Obstruction
o Hydronephrosis
o Infection
o Impaction
▪ Differential diagnosis
o Appendicitis
o Ovarian cyst
o Ruptured ectopic gestation
▪ Investigations
o Urine microscopy
o Plain X-ray KUB – radio opaque stones
o IVU - hydronephrosis and hydroureter ureter
o CT scan
o US abdomen
o Blood urea and Serum creatinine, Calcium
▪ Treatment
o Drink plenty of water
o Diuretics – Furosemide
o Surgical intervention
▪ Stone > 5mm
▪ Deteriorating kidney function
▪ Co-existing infection
▪ Impacted stone

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o Approaches for ureteric stone removal

(URS – Uertreo-renoscopic stone removal)

WILMS TUMOR (NEPHROBLASTOMA)

▪ Arises from embryonic connective tissue
▪ Located at one of the poles of Kidney
▪ Presents within first 4 years of life
▪ Metastasis
▪ Haematogenous
▪ Liver, Lung, Bone
▪ Features
▪ Mass abdomen
▪ Hard loin mass
▪ Moves with respiration
▪ Bimanually palpable
▪ Does not cross the midline
▪ Fever - due to tumour necrosis
▪ Hematuria - signifies rupture of tumor
▪ Hypertension
▪ Associated with
▪ Glaucoma
▪ Aniridia
▪ Beckwith Weidman syndrome
▪ Staging
▪ Stage 1 – disease confined to kidney
▪ Stage 2 – extends beyond kidney
▪ Stage 3 - lymph node metastasis
▪ Stage 4 – haematogenous metastasis
▪ Stage 5 – bilateral disease

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▪ Differential diagnosis
▪ Adrenal tumor
▪ Retroperitoneal tumor
▪ Renal cyst
▪ Polycystic kidney disease
▪ Investigations
▪ US abdomen
▪ CT scan
▪ IVU
▪ Renal angiography
▪ X-ray abdomen = Eggshell peripheral calcification
▪ Management
▪ Unilateral cases
▪ Nephrectomy and Postoperative Radiotherapy
▪ Bilateral cases
▪ Nephron sparing surgery (partial nephrectomy) on one side
▪ Nephrectomy on another side
▪ Chemotherapy
▪ Actinomycin D
▪ Vincristine
▪ Doxorubicin

RETROGRADE PYELOGRAPHY
▪ Indications
o Failure to identify pathology by IVU
o Urinary tuberculosis
o Urothelial tumors from Renal pelvis
▪ Procedure
o Under general anaesthesia
o Cystoscope is passed through Urethra
o Ureteric orifice is visualised
o Ureteric catheter is passed
o Dye sodium diatrizoate is injected
o Patient is put 15 degree Head-Down position, allowing the dye to reach Upper urinary system
o X-ray is taken

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URINARY BLADDER
VESICAL CALCULUS
• Etiology
o Infection
o Hypercalciuria
o Hyperoxaluria
o Cystinuria
o Neurogenic bladder
o Schistosomiasis
o Urine outflow obstruction
▪ BPH
▪ Urethral stricture
• Types
1. Primary vesical calculus
▪ Occurs in sterile urine
▪ Comes form kidney via ureter into the bladder and enlarges in bladder
▪ MC – Oxalate stones (hard with spike on surface – mulberry stone) causes Hematuria
2. Secondary vesical calculus
▪ Occurs in presence of infection
▪ MC – Struvite stones
3. Uric acid stones
4. Cystine stones

• Clinical features
▪ Pain
• More during day time, as the stone moves and irritates the Trigone of bladder
• Pain radiating to tip of penis on labia
▪ Hematuria
▪ Interruption of urinary stream
▪ Urine retention
▪ Burning micturition

• Investigations
▪ Urine microscopy
▪ Urine culture and sensitivity
▪ Plain X-ray KUB – radio opaque stones
▪ Large stones Palpable by Per-rectal or Per-vaginal examination
▪ Cystoscopy – radiolucent stones
▪ US abdomen
▪ IVU - assess kidney function
• Treatment
1. Cystoscopic Litholapaxy
2. Suprapubic open Cystolithotomy
3. Suprapubic Percutaneous Litholapaxy

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TRANSITIONAL CELL CARCINOMA

• Etiology
o Cigarette smoking
o Chemical carcinogens
1. Naphthylamine
2. Benzidine
3. Chloro-aniline
4. Chloro-toluidene
o Cyclophosphamide therapy
o Schistosoma haematobium infection
o Pelvic irradiation

• Classification
1. Superficial bladder tumor
2. Muscle invasive TCC
3. Carcinoma in-situ

• Staging
o Stage 1 – confined to sub-epithilial tissue
o Stage 2 – partial muscle infiltration
o Stage 3 - full-thickness muscle infiltration
o Stage 4 – infiltrating adjacent organs (Prostate, Pelvic wall)

• Clinical features
o Painless hematuria
o Hydronephrosis (tumor obstructs ureteric orifice)
o If pain in groin (suggests Extra-vesical spread)

• Investigation
o Urine microscopy
o Hb%, Blood urea, Serum creatinine
o IVU - irregular filling defect
o Cystoscopy and biopsy
o Bimanual palpation under G/A for staging the tumor
o CT scan – evaluate the extension

• Treatment
o Noninvasive tumor
1. Endoscopic resection
2. Intravesical chemotherapy using BCG
3. Systemic chemotherapy
o Invasive tumor
1. Curative interstitial radiotherapy
2. Radical cystectomy

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BLADDER DIVERTICULA
• Intravesical pressure > 150 cm of water → Hypertrophy of bladder mucosa → saccule formation →
diverticulum
• Diverticula classification
o Acquired
▪ Pulsion diverticulum occurs due to intravesical pressure
▪ Traction diverticulum occurs due to traction into Hernial sac
o Congenital – due to remnant urachus
• Complications
o Recurrent infections
o Obstructive uropathy
o Bladder stone formation
o Malignant transformation
• Investigation
o Urine culture and sensitivity
o Cystogram
o IVU
o US abdomen
o CT scan
• Treatment
o Removal of Diverticula through Open Surgery
o Suprapubic transverse extraperitoneal open approach

BLADDER RUPTURE
• Types
o Intraperitoneal rupture
▪ Due to Blow, Kick, Fall
o Extraperitoneal rupture
▪ RTA
▪ Stabs
▪ Endoscopic trauma
▪ Trauma due to instrumentation
• Clinical features
o Sudden suprapubic pain
o Shock and syncope
o Urine leaks into abdomen -> abdominal distension
o Peritonitis
o Tenderness and Rebound Tenderness
• Investigations
o Plain X-ray - ground glass appearance
o Peritoneal tap – confirms presence of urine
o Cystogram - visualise tear in the bladder
o CT scan
• Treatment
o Emergency laparotomy
▪ Bladder tear sutured using Vicryl
▪ Prevesical and Peritoneal cavity are drained

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PROSTATE
BENIGN PROSTATIC HYPERPLASIA
• Etiopathogenesis
o Involuntary hyperplasia due to disturbance in quantity of circulating androgens and estrogens
o BPH involves Median and Lateral lobes of prostate
o Hypothalamus -> Pulsatile release of LHRH -> release of LH from pituitary -> stimulates Leydig
cells in testes -> Testosterone release → coverted into DTH by 5a-reductase enzyme

o Action of DTH on Prostate

▪ Increased proliferation of Stromal cells
▪ Decreased senescence of Epithelial cells
• Clinical features
o Lower urinary tract symptoms (LUTS)
▪ Symptoms of voiding
• Hesitancy
• Poor outflow
• Dribbling
• Intermittent stream
• Residual urine
▪ Symptoms of storage
• Frequency
• Urge incontinence
• Nocturnal incontinence
o Hydronephrosis
o Hematuria
o Suprapubic tenderness
o Cystitis, Urethritis
o Stone formation
o Prostatism → combination of symptoms like
▪ Frequency
▪ Poor stream
▪ Delay in starting micturation
▪ Dysuria

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• Differential diagnosis
o Bladder tumor
o Neurogenic bladder
o Ureteral stricture

• Investigations
o Per-rectal examination - enlarged prostate (done when bladder is empty)
o Urine microscopy
o Blood urea and Serum creatinine
o US abdomen – Residual urine
o Urodynamics
▪ Urine flow rate < 10ml
▪ Voiding pressure > 80 mmHg
o Transrectal ultrasound (TRUS)
o Tumor markers – Acid phosphatase and Prostate Specific Antigen

• Treatment
o Ureteral catheterization
o Suprapubic cystostomy
o Transurethral balloon dilation of prostate
o TRANSURETHRAL RESECTION OF PROSTATE (TRUP)
▪ Indications
• Prostatism
• Acute retention of urine
• Residual urine > 200ml
• Complications like hydroureter, Hydronephrosis, Stone formation, infection
▪ Procedure
• Indirect prostate identified using Cystoscope
• Reception is done using high frequency diathermy current
• After surgery, continuous bladder irrigation done using Foley’s three way catheter
• Catheter removed after 72 hours
▪ Advantages
• No Suprapubic Incision
• Faster recovery and early discharge
▪ Complications of TURP
• TURP syndrome – Water intoxication with Congestive cardiac failure
• Hypernatremia
• Erectile dysfunction
• Retrograde ejaculation
• Importance
• Incontinence
• Infection
o Suprapubic Transvesical Prostatectomy
o Retropubic Prostatectomy

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PROSTATE SPECIFIC ANTIGEN

o Is a protease
o Produced from prosthetic epithelium
o Secreted in semen to liquefy seminal coagulum
o Normally 4 ng/ml of plasma, levels > 10 ng/ml is significant
o Elevated in
o Prostate cancer
o Benign prostatic hyperplasia
o Prostatitis
CARCINOMA PROSTATE
o MC malignant tumor in men > 65 years
o Occurs in posterior lobe of prostate
o Prostatectomy for BPH does not confer protection against Prostate cancer development
o Staging
o Stage 1 - confined to prostate
o Stage 2 - involves capsule
o Stage 3 - involves seminal vesicle
o Stage 4 – extension into adjacent tissues
o Metastasis
o Local spread
▪ Seminal vesicles
▪ Bladder
▪ Ureter
o Hematogenous spread
▪ Lumbar spine (MC)
▪ Femur head
▪ Pelvis
▪ Ribs
o Lymphatic spread
▪ Obturator lymph nodes
▪ Retroperitoneal lymph nodes
o Clinical features
o Bladder outlet obstruction
o Hematuria, Frequency
o Pelvic pain, Back pain – features of secondaries
o P/R examination – hard, nodular, enlarged prostate
o Investigations
o Hb%
o PSA - >10 ng/ml
o Increased Acid phosphatase
o Blood urea, Serum creatinine
o Transrectal ultrasound (TRUS)
o Plain X-ray KUB – Dense sclerotic secondaries
o Treatment
o TRUP + Bilateral Orchidectomy + Extension Radiotherapy + Flutamide
o Tumor vaccines = Sepuleucel-T

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URETHRA
STRICTURE URETHRA
• Classification – Aetiological
o Congenital
o Inflammatory
▪ Post gonococcal
▪ Tuberculosis
▪ Ureteritis
o Traumatic
o Post-instrumentation
▪ Catheter
▪ Dilator
▪ Cystoscope
o Post-operative
▪ Prostate surgery
▪ Urethrostomy
• Clinical features
o Poor urinary stream
o Incomplete emptying
o Urine retention
o Burning micturition
o Stone formation
o Suprapubic tenderness
o Thickening in bulbar urethra (felt clinically by lifting the scrotum in the midline perineum)
• Investigations
o Urine microscopy and culture
o Blood urea and Serum creatinine
o IVU - kidney function
o US abdomen
o Ascending urethrogram – site, type, extent, of stricture
o Urodynamic study
o Urethriscopy
• Treatment
o Intermittent dilation using
▪ Lister’s dilator
▪ Clutton’s dilator
o Cystoscopic stricturotomy
o External urethrotomy

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HYPOSPADIAS
• Urethra opens on ventral surface of penis, Proximal to tip of glans penis
• Classification
o Glanular
o Coronal
o Penile
o Penoscrotal
o Parineal – a/s with B/l undescended testes

• Clinical features
o Absence of urethra and Corpus spongiosum distal to abnormal orifice
o Ventrally curved penis (Chordee)
o Urine soakage on scrotum with dermatitis and infection
o Associated with Cryptorchidism
• Complications
o Difficulty in directing the urinary stream
o Because of Chordee, erection is painful and difficult
• Management
o Surgery done at 6-12 months age
o Dennis Browne surgery
o Meatal Advancement and Glandular incorporation (MAGPI)
o In Hypospadias, circumcision is contraindicated as prepuce skin is required for future
urethroplasty

ACUTE RETENTION OF URINE

• Sudden inability to pass urine
• Leads to painful distension of bladder
• Causes
o Urethral trauma
o Anesthesia
o Perineal surgery
o Stone in urethra
o Urethral stricture
o Postoperative retension
o Drugs
▪ Anticholinergics
▪ Antihistamines
▪ Antidepressants
• Investigations
o US abdomen
o Blood urea and Serum creatinine
o Urine microscopy
• Treatment
o Urine catheterization (Foley’s catheter)
o Suprapubic cystostomy (using Malecot’s catheter)
o Evaluation and treatment of cause

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PENIS
CARCINOMA PENIS
• Premalignant conditions of penis
o Chronic balanoposthitis
o Phimosis
o Sexually transmitted diseases
o Leukoplakia
o Genital warts
o Paget’s disease of penis
o Erythroplasia of Queyrat
o Bowenoid papule
o Condyloma acuminata (HPV)
o Buschke Lowenstein tumor
o Balanitis xerotica obliterans
• Clinical features
o Recent onset phimosis
o Foul smelling discharge
o Altered urinary stream
o Function and induration
o Inguinal LN enlargement
• Investigations
o Wedge biopsy
▪ Squamous cell carcinoma with epithelial pearls
▪ BORDERS GRADING
• 75% Epithelial Pearls – Very Well Differentiated
• 50 – 75% Epithelial Pearls – Well Differentiated
• 25 – 50% Epithelial Pearls – Moderately Differentiated
• < 25% Epithelial Pearls – Undifferentiated
o FNAC of lymph nodes
o US abdomen – involvement of External Iliac Lymph Nodes
o Sentinel node biopsy
▪ Cabana Sentinel node (Above and Medial to junction of Saphenous and Femoral vein)
• Treatment
o Growth only on glans
▪ Young’s operation
• Partial Amputation of penis
• Bilateral Ilioinguinal lymph node block dissection
o Growth involving body of penis
▪ Total Amputation
▪ Perineal urethrostomy

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PHIMOSIS
• Inability to retract the Prepuce of the glans
• Causes
o Congenital
▪ Pinhole meatus and ballooning of prepuce Occurs when child urinates
o Balanitis (inflammation of glans)
o Balanoposthitis (inflammation of glans, prepuce, sac) – common in diabetics
• Predisposes to
o Recurrent infection
o Smegma collection
o Carcinoma penis
o Paraphimosis
o Prepucial calculi
o Urine retention
• Treatment
o Circumcision

PARAPHIMOSIS
• Inability to take back the retracted prepucial skin over the glans is called paraphimosis
• Causes ring like constriction at the Corona of glans
• Features
o Swollen oedematous glands
o Severe pain and tenderness
o Risk of necrosis or gangrene
• Treatment
o Initial Dorsal slit – is made to relieve the compression
o Circumcision done after 3 weeks
o Hyaluronidase injection into constriction ring -> reduces edema -> allow prepuce back over glans

CIRCUMCISION
• Indications
o Religious
o Phimosis
o Paraphimosis
o Balanitis
o Balanoposthitis
o Early carcinoma of prepuce
o Certain sexually transmitted disease. Ex. Herpes
• Complications
o Retractionary hemorrhage – due to slipping of ligature
o Infection
o Chordee - due to removal of excess skin on ventral aspect
o Priapism

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PEYRONIE’S DISEASE (penile fibromatosis)

• Development of fibrous tissue plaque on the covering of Corpus cavernosum and later involves its full
extent resulting in induration of Corpus
• Etiology
o Microhemorrhages converting into secondary fibrosus
• Associated with
o Dupuytren's contracture
o Retroperitoneal fibrosis
o Plantar fibromatosis
• Clinical features
o Penile deformity
o Penile plaques
o Penile shortening
o Erectile dysfunction
o Pain on erection
• Treatment
o Drugs
▪ Steroids
▪ Vitamin E
▪ Intralesional injection of Verapamil
o Surgery
▪ Corporotomy -> Excision of fibrous plaque -> covered with Tunica vaginalis flap

SCROTUM
FOURNIER’S GANGRENE
• Vascular gangrene of infective origin caused by
o Hemolytic Streptococcus
o Staphylococcus
o E.coli
o Cl.welchi
o Bacteroides
• Fulminant inflammation of scrotal skin -> resulting in Obliterative Arteritis of arterioles in scrotal skin ->
leading to Cutaneous Gangrene
• Risk factors
o Diabetes
o Old age
o Malnourishment
o Immunosuppression
• Clinical features
o Sudden pain in scrotum
o Rapidly spreading Cellulitis, extending often to Anterior Abdominal Wall
o Extensive skin sloughing
o Testis exposed
• Treatment
o Antibiotics
o Excision of all Slough -> after wound granulates -> skin grafting done
o Orchidectomy Not done if Testis is normal
o Testis can be placed in a pouch in medial aspect of thigh

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HYDROCELE - Collection of fluid between two layers of Tunica Vaginalis of testis

• Etiology
o Defective absorption of fluid by tunica vaginalis
o Excessive production of fluid
o Interference with drainage of fluid by lymphatics
• Types
o Primary hydrocele
▪ Abnormal accumulation of serous fluid within Tunica Vaginalis
o Infantile hydrocele
▪ Fluid collects within Tunica Vaginalis and Procesus Vaginalis
▪ But does not communicate with peritoneal cavity
o Congenital hydrocele
▪ Processus vaginalis communicates with Peritoneal cavity through a small orifice
▪ Fluid accumulates when standing, Disappears gradually upon lying down
o Encysted Hydrocele of cord
▪ Central portion of hydrocele is present, upper and lower parts are absent
▪ Fluid accumulation in Persistent central part
o Bolocular hydrocele (Hydrocele-en-bisac)
▪ Hydrocele has got two inter-communicating Sacs
▪ One above and One below the neck of scrotum
▪ Upper sac is lies superficial to inguinal canal and it is Cross-fluctuant
o Hydrocoele of Hernial sac
▪ Fluid collect in hernial sac and forms hydrocele
o Secondary hydrocele
▪ Infection
• Filariasis
• TB
• Syphilis
▪ Injuries
• Trauma
• Post-herniorrhaphy
▪ Tumor
• Features
o Hydrocele is Amber coloured
o Shows Transillumination
• Complications
o Infection
o Pyocele
o Hematocele
o Atrophy of testis
• Differential diagnosis
o Spermatocele
o Inguinal hernia
o Epididymal cyst
• Treatment
o Subtotal excision of sac
o Evacuation and Eversion of sac
o Lord’s plication

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PYOCELE
• Collection of pus between the two layers of Tunica vaginalis
• Features
o Fever
o Tender swelling in the scrotum
o Scrotal wall edema
• Complications
o Infective thrombosis of testicular vessels
o Testicular gangrene
• Treatment
o Antibiotics
o Immediate Scrotal exploration and Pus evacuation
o If Testis is not viable -> Orchidectomy

VARICOCELE - Dilation and tortuosity of a Pampiniform plexus of veins

• Etiology
o Incompetent valve at junction of Left Testicular Vein & Left Renal Vein
o Perpendicular entry of Left Testicular Vein into Left Renal Vein
o Left side RCC – tumor proliferates in Renal vein and blocks the entry of Left Testicular Vein
• Features
o Varicocele increases temperature in scrotum
o Depresses Spermatogenesis
o Causes Reversible Infertility
o On palpation – Bag of worms feeling
o It gets reduced on lying down (except in RCC)
o BOW sign
▪ Varicocele reduces in size when patient bows
▪ Bowing reduces blood flow to Testicular vein
• Differential diagnosis
o Hydrocele
o Inguinal hernia
• Investigations
o Venous Doppler
o US abdomen
o Semen analysis
• Treatment
o Indications
▪ Pain
▪ Oligospermia
o Palomo operation –> Supra-inguinal Extra-peritoneal ligation of Testicular Vein
o Inguinal approach

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EPIDIDYMAL CYST
• Due to cystic degeneration of
o Paradidymis
o Appendix of epididymis
o Vas aberrant
• Clinical features
o Bilateral
o Multiloculated (bunch of tiny grapes)
o Cyst situated behind the testis
• Differential diagnosis
o Encysted hydrocele of cord
o Spermatocele
• Investigation
o Transillumination – Chinese Lantern pattern (due to presence of numerous septae)
• Treatment
• Avoid excision as much as possible, as it causes infertility

TESTIS
UNDESCENDED TESTIS
• Results from arrest of descent of testis in its pathway to the scrotum
• Bilateral undescended testis is called Cryptorchidism
• Etiology
o Gubernacular dysfunction
o Lack of gonadotropin (HCG)
o Lack of Calcitonin Gene-related Peptide (CGRP)
▪ Produced by Genito-femoral nerve responsible for Testis descent
o Prune belly syndrome
o Retroperitoneal adhesions
o Short Vas diferens
o Short testicular vessels

• Sites of arrest of descent

o Just above Deep inguinal ring
o In the Inguinal canal
o In Superficial Inguina pouch

• Complications
o Torsion
o Epididymo-Orchitis
o Sterility
o Trauma
o Inguinal hernia
o Seminoma

• Differential diagnosis
o Retractile testis

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• Investigation
o US abdomen
o Assessment of FSH, HCG
o CT scan
o Gonadal venogram
o Laparoscopy
• Treatment
o Mobilization of cord
o Repair of associated hernia
o Adequate scrotal fixation without tension
▪ Ombredanne operation
• Fixation of testis into scrotum using Non-absorbable sutures (Prolene)
RETRACTILE TESTIS
• Over action of Cremaster, Testis is pulled upto level of External ring
• Often mistaken with Undescended testis
• Both Scrotum and Testis is normally developed
• Management
o Orr Chair test
▪ Child is made to sit on chair
▪ With feet kept on the chair
▪ Knees fully flexed and brought over to Chest wall -> causes pressure on inguinal canal ->
pushes the retractile testis downward into scrotum
o Hormone therapy (HCG)

TORSION TESTIS
• Emergency condition wherein testis twists in its axis compromising its blood supply
• Predisposing factors
o Bell-Clapper deformity
▪ Testis lacks normal attachments and hang horizontally
o Heavy straining precipitates Vigorous Cremastric Contraction -> Testis torsion
• Right testis rotates Clockwise
• Left testis rotates Anti-Clockwise

• Clinical features
o Sudden onset of pain in groin
o Vomiting due to pylorospasm
o Deming’s sign
▪ Affected testis positioned high because of Twisting of cord and Cremastric muscle spasm
o Angell’s sign
▪ Opposite testis lies horizontally because of presence of Mesorchium
o Prehn’s sign – On elevation of testis by palm
▪ Pain Increase – In torsion
▪ Pain decrease – In Epididymo-Orchitis

• Differential diagnosis
o Strangulated inguinal hernia
o Acute Epididymo-Orchitis
o Torsion of Appendage of testis

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• Investigation
o US abdomen
o Doppler study – look for testicular artery pulsation
• Treatment
o Manual torsion tried in 1st hour of torsion
o Surgery must be done within 4 hours
o Orchidopexy
▪ Both affected and unaffected testis should undergo Orchidopexy

TESTICULAR TUMORS
• Etiology
o Cryptorchidism
o Klinefelter syndrome
o Testicular atrophy
• Classification
1. Germ cell tumors
• Seminoma
• Non-Seminoma
o Embryonal Carcinoma
o Choriocarcinoma
o Yolk sac tumor
o Teratoma
2. Non-germ cell tumors
• Leydig cell tumor
• Granulosa cell tumor
• Sertoli cell tumor
3. Others – Carcinoid, Lymphoma

SEMINOMA TESTIS
• Gross
o Lobulated mass compressing adjacent testicular tissue
• Microscopy
o Malignant cells resembling spermatocytes
o Contain clear cytoplasm with large nucleus
• Types
o Typical
o Anaplastic
o Spermatocytic

TERATOMA
Originates from Totipotent cells
• Gross
o Irregular, cut section shows cystic spaces with areas of haemorrhage
o Presence of Hair, Cartilage, bone etc

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Spread of Testicular tumor

• Local
o Epididymis, Cord, Tunica albuginea, Scrotum
• Lymphatic
o Inguinal nodes
o Para-aortic nodes
o Mediastinal nodes
• Hematogenous
o Lungs, Liver, Bone, Brain, Kidney
Clinical features
• Enlargement of testis
• Pain in testis
• Secondary hydrocele
• Hypertrophied Cremaster
• Bone pain and pathological fractures – indicate metastasis
Differential diagnosis
• Acute Epididymo-Orchitis
• Syphilitic Orchitis

Sign of Vas :
• To differentiate tumor and infection
• In testicular tumors Vas deferens is normal
• In infection Vas deferens is thickened, beaded, tender

Staging of Testicular tumor

• Stage 1 – Lesion confined to testis
• Stage 2 – Nodes below diaphragm involved
• Stage 3 - Nodes above diaphragm involved
• Stage 4 – Distant spread

Investigation
• Tumor markers
o HCG
o AFP
o LDH
• CXR – lung secondaries
• US abdomen – para-aortic lymph node involvement
• CT scan – Liver secondaries
• US Scrotum

Treatment
• Seminomatous tumor
o Radiotherapy
o Chemotherapy
• Non-Seminomatous tumor
o Orchidectomy
o RPRLND - retroperitoneal radical lymph node dissection

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ACUTE EPIDIDYMO-ORCHITIS - Inflammation of epididymis and testis

• Etiology
o Infection
▪ Viral – Mumps, EBV
▪ Parasite – Filaria, Schistosomiasis
▪ Bacteria – TB, Leprosy, Brucellosis, Syphilis
o Features
▪ Testis pain, radiating to groin
▪ Fever
▪ Tenderness in testis
▪ Secondary hydrocele
▪ Thickened epididymis
▪ Vas deferens thickened, beaded
o Treatment – Analgesics, Antimicrobial therapy

NEUROSURGERY - INTRACRANIAL HEMORRHAGE

Extradural Subdural Subarachnoid Intracerebral

Location B/w Skull & Dura B/w Dura & Arachnoid B/w Arachnoid & Pia Within Brain
parenchyma
Etiology Trauma Taruma Spontaneous Hypertension
Trauma Trauma
MC vessel involved Middle meningeal Artery Bridging veins Arterial aneurysm Branches of Middle
cerebral artery

EXTRADURAL hematoma
Pathology
Direct blow to head

Fracture of temporal bone

Rapture of middle meningeal

Bleeding between Skull & Dura Mater

Hematoma formation

Hematoma compresses brain

Increased intracranial tension

Coning of Uncus through Tentorial hiatus

Shift of midbrain towards opposite side

Contralateral corticospinal tract Injury by sharp edges of Tentorial Cerebellum

KERNOHAN’S NOTCH EFFECT (on same side of hematoma)

• Hemiparesis
• Pupillary changes

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Lucid interval
• State of consciousness between two periods of unconsciousness
• Immediately after injury there is transient loss of consciousness
• Patient soon becomes normal
• After 6-12 hours , patient’s condition deteriorates
• This is the time taken to develop Increased ICP and it’s effects

Clinical features
• Lucid interval
• Hemiparesis on same side of injury
• Hutchinsonian pupil
o Initial pupillary constriction (irritation of Oculomotor nerve by Uncal herniation)
o Later pupillary dilation (constrictor Paralysis, due to persistent compression on Oculomotor N)
o Burr hole decompression done on the side of Hutchinsonian pupil
• Cushing’s triad
o Bradycardia
o Hypertension
o Respiratory irregularities
Investigations
• X-ray skull = Temporal bone Fracture
• CT head = biconvex hematoma
Treatment
• Immediate craniotomy and evacuation of clot
• Anticonvulsants

SUBDURAL hematoma
Etiology
• Trauma
• Acceleration/deceleration injury
• Shaken baby syndromel
Pathology
Traumatic acceleration deceleration head injury

Differential movement of brain relative to Skull

Results in stretching and tearing of Bridging Veins

Types
• Acute SDH - occurs immediately
• Sub-acute SDH – Occurs after 2 weeks
• Chronic SDH – Occurs after 3 – 6 weeks

Clinical features
• Increased ICP
• Confusion, Disorientation
• Convulsions
• Hypertension, Bradycardia

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Differential diagnosis
• Electrolyte imbalance
• Intracranial space occupying lesion

Investigations
• CT scan
o Concavo-Covex hematoma
• Serum electrolytes

Treatment
• Craniotomy and evacuation of clot
• Anticonvulsants

SUBARACHNOID hematoma
Etiology
• Intracranial aneurysm
• Hypertension
• Blood dyscrasias
• Anticoagulant therapy
• Arteriovenous malformations
Types
• Spontaneous
o Rupture of berry aneurysm
o Rupture of Hypertensive aneurysm
• Traumatic
o Rupture of vertebral artery

Clinical features
• Thunderclap headache – Sudden onset severe headache with vomiting
• Features of increased ICP
• Hemiplegia, Dysphasia
• Sudden loss of consciousness
• Eye Changes – Ptosis, Dilated Pupil

Differential diagnosis
• Meningitis
• Increased ICP due to Malignancy, Infection

Investigations
• Lumbar puncture - to differentiate from meningitis
• CT scan
• Carotid angiogram

Treatment
• Coiling and Clipping the aneurysm
• Excision of vascular malformations
• Craniotomy and evacuation of clot

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GLASSGOW COMA SCALE

• provides a practical method for assessment of impairment of conscious level in response to defined stimuli
Eye opening Verbal response Motor response
Spontaneous 4 Oriented 5 Obeys command 6
To speech 3 Confused 4 Localises pain 5
To pain 2 Inappropriate 3 Flexion to pain 4
None 1 Incomprehensible 2 Abnormal flexion 3
None 1 Extension to pain 2
None 1
Total score = 15
Mild head injury = 13-15
Moderate head injury = 9-12
Severe head injury < 8

MEANINGOCELE
• Herniation of meninges through a weak point of spine where bony fusion has not taken place effectively
• Features
o Present since birth
o Soft, fluctuant, transilluminating swelling
o Expansile impulse upon coughing or crying
• Location
o Lumbosacral area
o Occipitocervical area
• Complications
o Ulceration
o Hemorrhage
• Investigations
o CT head
o MRI spine
• Treatment
o Excision as early as possible
o Closure of defect by plication
o Approximation of muscles

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THORAX
FLAIL CHEST
• Fracture of two or more consecutive ribs
• With each rib having two or more fracture sites
• Such segment is called as Flial segment
• Pathophysiology
o Flail segment moves in opposite direction to that of adjacent normal thoracic cage
o During inspiration flying segment moves inward
o During expiration soil segment moves outward
• Derangements
o Paradoxical respiration
▪ Reduction in ventilatory lung surface
o Mediastinal flutter
▪ Mediastinal movement causing kinking of great vessels
• Types
o Anterior
▪ Near Costo-chondral junction
o Lateral
▪ In Rib shafts
o Posterior
▪ Near Costo-Transverse junction
• Problems
o Cardiac arrest
o Respiratory failure
o Haemothorax
o Infection
o ARDS
• Investigation
o CXR – identify the fracture segment
o Arterial PO2 & PCO2
• Treatment
o First aid
▪ Paradoxical movement of Flial segment, prevented by applying pressure using hand/cloth
o Intercostal tube drainage
o Applying clips to fracture ribs
o Antibiotic therapy
o Ventilatory support with IPPV (intermittent positive pressure ventilation)

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TENSION PNEUMOTHORAX
• Underlying lung injury, upon inspiration, air gets pumped into pleural cavity via valvular opening in
visceral pleura
• Air continuously collects in pleural cavity → Lung collapse → Mediastinum shifts to opposite side →
further decrease inline function
• Increase in Pleural pressure → reduced venous return → decreased atrial and ventricular filling →
decreased Cardiac output and Cardiac function
• Clinical features
o Tachypnea, Tachycardia
o Decreased breath sounds
o Resonant on percussion
o Severe mediastinal/tracheal shift
o Cyanosis and hypertension
o Distended neck veins
• Management
o Thoracocentesis - Wide bore needle immediately placed in 2nd intercostal space in Mid-clavicular
line, Sterile Glove is kept at the Blunt end of the needle, to prevent Inward sucking of air
o Nasal oxygen
o Later an Inter-Costal Tube (ICT) is passed
o IPPV

HEMOTHORAX
• Blood in pleural cavity
• Etiology
o Trauma
o Leaking aneurysm
o Tumors of lung, Mediastinum
o Post operative – Pulmonary, Cardiac, Oesophageal surgeries
o Leak from CVP monitor line
• Clinical features
o Pain in chest
o Tenderness
o Difficulty in breathing
o Dullness on percussion
o Decreased breath sounds
o Infection – blood acts as a culture media for bacteria
• Complications
o ARDS
o Respiratory failure
• Investigations
o CXR
o Pleural tap (Aspiration) – Site = posteriorly at tip of scapula at 7th intercostal space
o Chest CT scan
• Treatment
o ICT placement in Mid-axillary line in 6th intercostal space
o Antibiotic therapy
o Bronchodilators
o Thoracotomy

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EMPYEMA THORACIS
• Collection of Pus in pleural cavity
• Etiology
o Empyema is never primary
o Secondary causes are
▪ From chest wall – Wound, Osteomyelitis of Ribs
▪ From lung – Pneumonia, Tuberculosis, Bronchiectasis
▪ Post operative – After Thoracotomy
▪ From esophagus – Perforation, Carcinoma
▪ Below Diaphragm – Subphrenic abscess
• Pathology
o Initial collection of serous fluid → eventually becomes purulent → intrapleural clotting of pus with
pleural thickening (matured empyema)
o Leads to Rigid, Contracted immobile chest with Functionless Lung → Frozen chest
o If Pus operates through intercostal space → Empyema Necessitans
• Bacterias associated with empyema
o Staphylococcus
o Streptococcus
o Pneumococcus
o Pseudomonas
o E.coli
• Clinical features
o Pain in the chest
o Tenderness, Fever
o Features of toxicity
o Difficulty in breathing
o Dullness on percussion
o Absence of breath sounds
o Decreased chest wall movement
• Complications
o Frozen chest
o Empyema necessitans
o Osteomyelitis of vertebra
o Pericarditis
o Mediastinitis
o Bronchopleural fistula
• Investigations
o CXR
o Blood – ESR, Peripheral smear
o Diagnostic aspiration
o Pus culture and sensitivity
o Bronchoscopy
o CT scan, MRI
• Treatment
o Stage 1 – Antibiotics, Repeated Aspiration, Intercostal Tube Drainage
o Stage 2 - Rib resection (Eloiser’s method), Respiratory physiotherapy
o Stage 3 – Decortication (Thickened Pleural Sac is stripped from lung by Thoracotomy approach)

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EMPYEMA NECESSITANS
• Complication of empyema thoracis
• Empyema perforators through chest wall presenting as subcutaneous collection of pus
• Etiology
o Neglected Empyema thoracis
o Incomplete aspiration of pus
• Clinical features
o Bulge in intercostal space – Impulse on coughing
o Restricted movement of chest wall – Tenderness
o Dullness on percussion
o Decreased breath sounds
• Investigations
o CXR
o TLC – increased
o ESR
• Treatment
o Antibiotic / Antitubercular therapy
o Empyema drainage by ICT
o Pus Culture and Sensitivity

SURGICAL EMPHYSEMA
• Collection of gas/air in subcutaneous or fascial planes
• Causes
o Lung injury
o Tracheal injury
o Chest wall injury
o After laparoscopic procedure
• Types
o Localised – observed at the site of trauma
o Generalized
▪ Extensive distribution involving Chest wall, Neck, Face, Eyelids etc
• Injury to Bronchus, Oesophagus and Mediastinum
o Features
▪ Pain
▪ Diffuse swelling of subcutaneous region
▪ Palpable Crepitus – diagnostic
o Investigation
▪ X-ray chest and neck
o Treatment
▪ Treat the cause
▪ ICT placement

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PANCOAST TUMOR (superior sulcus tumor)

• Peripheral lung carcinoma arising from apex of the lung
• Features
o It invades
▪ Brachial plexus
▪ Sympathetic chain
▪ Upper ribs and vertebra
o Presents with Intractable pain in
▪ Upper chest
▪ Arm
• Presentations
o Pancoast syndrome
▪ Lower brachial plexus palsy
▪ Horner's syndrome
▪ Rib erosion
▪ Apical shadow
o Horner's syndrome (oculo-sympathetic palsy)
▪ Miosis
▪ Enopthalmos
▪ Anhydrosis
▪ Ptosis
▪ Loss of Spino-ciliary reflex
• Investigations
o CXR
o CT scan
o Bronchoscopy and Biopsy
o CT guided biopsy
o MRI - better visualisation of involved structures
• Treatment
o Lobectomy/Pneumonectomy
o Radiotherapy
o Chemotherapy – Methotrexate

CARDIOPULMONARY BYPASS
• Functions of heart and lungs are temporarily replaced by Heart-Lung Machine
• Heart-Lung Machine acts as pump and oxygenator
• Heart is exposed through a midline sternotomy
• Venous blood from SVC & IVC diverted into the HL-machine
• From HL-machine oxygenated blood is passed to Ascending Aorta
• Bypass of blood from Heart and Lungs
• Blood should be heparinized to prevent clotting in the machine
• Temperature is lowered over the heart by pouring Cold saline and Ventilation is Discontinued
• Once procedure on heart is completed, Air in heart chambers is removed
• Coronary perfusion is restored
• Heart is made to beat spontaneously using DC shock
• Function of HL-machine is gradually lowered and Heart is allowed to take back it’s function
• Correction of Hypocalcaemia and Acidosis
• Protamine sulphate is used to reverse effect of Heparin

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CABG
• Indications
o Triple vessel stenosis
o Left main stem stenosis
o Chronic stable angina
o Angina with persistent chest pain
o Block > 70%
• Grafts used
o Veins
▪ Long saphenous vein
▪ Short saphenous vein
▪ Cephalic vein
o Artery
▪ Internal mammary vein
▪ Radial artery (only if Ulnar artery is patent)
• Technique
o Done under Cardiopulmonary bypass
• Complications
o Graft thrombosis
o Atherosclerosis of graft

ANAESTHESIA & ADJUVANT THERAPY

BRACHYTHERAPY
• Radiation given with a source close to the tumor
• It is a curative radiotherapy
• Radiation material placed in a cavity called (intra-cavitary RT)
• Given using
o Iridium-192
o Caesium-137
• Indications
o Oral cavity carcinoma
o Penile cancer
o Breast cancer
o Cervical cancer
o Bladder carcinoma
• Advantages
o Gives localised effect with sparing of adjacent tissues

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REGIONAL ANAESTHESIA
• Regional anesthesia makes a specific part of the body numb to relieve pain or allow surgical procedures to
be done.
• Types of regional anesthesia include
o Spinal anesthesia (also called subarachnoid block)
o Epidural anesthesia
o Nerve blocks
• Mode of action
o Temporary block of conduction of action potential through nerves
• Advantages
o General anaesthesia is avoided
o Consciousness is retained
o Patient can have food earlier after surgery
o Technically simpler
• Drugs used
o Cocaine
o Procaine
o Lignocaine
o Prilocaine
o Bupivacaine
o Ropivacaine

Spinal anaesthesia
• Injection of local anaesthetic into subarachnoid space
• It causes
o Loss of sympathetic tone
o Loss of sensation
o Loss of motor function
• Position
o Lateral decubitus position, with Head, Knee, Hips fully flexed → to Open inter-laminar spaces
• Advantages
o Economical
o Hypertension reduces the bleeding
o Respiratory complications are less
• Disadvantages
o CSF leak
o Meningism
o Infection, Paraplegia(rare)
• Contraindications
o Cardiac patients
o Increased ICP – May precipitate Coming
o Sepsis
o Kyphosis, Scoliosis

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Epidural anaesthesia
• Injection of anaesthesia in
o Potential space between Dura (Anteriorly) and Ligamentum Flavum (Posteriorly)
o This place has got negative pressure
o It extends from Foramen Magnum to Sacral Hiatus
• Advantages → used for continuous repeated prolonged anaesthesia
NERVE BLOCK
• Method of producing anesthesia
• Nerve blocks can be
o Surgical
▪ Cutting or destroying specific nerves to prevent them from conducting impulses
▪ Surgical nerve blocks may be permanent.
o Nonsurgical
▪ Injection of an anesthetic around a specific nerve or a bundle of nerves.
▪ Anesthetic prevents the nerve impulses from reaching the (CNS)
▪ Lasts for 12 to 36 hours depending on the type of anesthetic used
• Indications
o Pain from labor and childbirth
o Cancer-related pain
o Arthritis pain
o Low back pain or sciatica
o Migraine
o Chronic regional pain syndrome
o Neck pain caused by herniated disks
o Phantom pain after an amputation
o Pain from spasms in the blood vessels
o Excessive sweating (hyperhidrosis)
o Raynaud’s syndrome
• Examples
o Inferior dental nerve block – Tooth extraction
o Intercostal block
o Median and Ulnar nerve block
o Brachial plexus block
o Sciatic nerve block
o Femoral nerve block

KETAMINE
• Used to induce Disassociative anesthesia
• Disassociative anaesthesia – form of anesthesia characterized by
o Catalepsy
o Catatonia
o Analgesia
o Amnesia
• Side effects
o Hypertension
o Laryngospasm
o Apnoea

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Xylocaine
• a.k.a Lidocaine / Lignocaine
• Is a local anaesthetic drug also an Anti-Arrhythmic drug
• Pharmacokinetics
o Metabolized by liver
o Excreted by kidney
• Dose – 4mg/kg lasts for 90 minutes
• Can be used with or without Epinephrine
• Xylocaine with epinephrine has longer duration of action (relatively bloodless field)
o Not given with Epinephrine at places of end arteries
▪ Glans penis
▪ Ear lobule
▪ Nose tip
▪ Fingers
▪ Toes
• Side effects
o Postural hypotension
o Tinnitus
o Headache
o Circumoral anaesthesia
• Uses
o Topical
o Infiltration block
o Field block
o Nerve block
o Epidural
o Spinal
o Intravenous regional anaesthesia (Bier’s block)
▪ Indications
• Upper Limb surgeries
• Lower Limb surgeries
▪ Duration of anesthesia
• 2 hours
▪ Side effects
• Hyortension
• Convulsions
▪ Procedure
▪ Limb occluded with tourniquet
▪ Pressure in the tourniquet must be 30 mmHg more than Systolic BP of patient
▪ Xylocaine is injected into the vein
▪ Xylocaine with adrenaline should not be used

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ADVANCED IMAGING METHODS

DOPPLER SCAN
• It is based on Doppler effect:
o Change in perceived frequency of sound emitted by a moving source
o Therefore used to measure blood flow
• Duplex scan
o Combination of Doppler and ultrasound imaging
• Types of Doppler scan
o Continuous waves
o Pulsed waves
• Uses
o Study cardiovascular system
o Study vascularity of tumors
o Study velocity of blood flow in arterial diseases
o Identify Deep Vein Thrombosis, Varicose veins
o Study grade of Varicocele on males
• Advantages
o It has replaced Venogarm & Angiogram
o It is a non-invasive technique

CT SCAN (computerized tomography)

• Contrast agents
o Ionic
▪ Sodium diatrizoate
▪ Magnesium iothalamate
o Non-ionic
▪ Iohexol
▪ Iopamito
• Indications
o Trauma
▪ Head injury
▪ Chest injury
▪ Abdomen trauma
o Neoplasms
▪ Location, size, extent and operability of tumor
o Inflammatory conditions
▪ Psoas abscess
▪ Pseudocyst of pancreas
• Advantages
o 1-2 mm sized sections are possible
o Amount of radiation exposure is less
o Small lesions are also detected
o CT guided biopsy
• Disadvantages
o Cost factor
o Interpretation requires experienced radiologists
o Artefacts can be present

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• HRCT
o CT technique used to obtain high quality images of Thin section
• Findings
o Extradural hematoma – biconvex lesion
o Subdural hematoma – concavo-convex lesion
o Smooth margins - benign condition
o Irregular margins - malignant condition

MAGNETIC RESONANCE IMAGING

• Types
o Plain MRI
o Contrast MRI (IV Gadolinium)
• T1 image
o Find out normal anatomical details
o Fluid (CSF) looks black
• T2 image
o Assess pathological processes
o Fluid it looks white
• Uses
o Pathologies of
▪ Intracranial
▪ Spinal
▪ Musculoskeletal
▪ Joints
o MR angiogram
o Cardiac MRI
o Breast MRI
o MRCP – Magnetic Resonance cholangio-pancreatography
o MR spectroscopy
• Advantages
o Artefacts are not common
o Most sensitive and specific than CT scan
• Disadvantages
o Cost factor
o Poor patient compliance
o Claustrophobia
o Not ideal in emergency, as it is time consuming
• Contraindications
o Patients with
▪ Prosthesis
▪ Metallic foreign
▪ Pacemakers
▪ Cochlear implants
▪ Cranial aneurysm clips

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POSITRON EMISSION TOMOGRAPHY (PET scan)

• Non-invasive diagnostic method to assess the biochemical and physiological status of a tissue
• Used in complementary with CT scan and MRI
• Uses
o Assess myocardial perfusion and viability
o To localise epilepsy
o Cancer imaging
▪ Lung cancer
▪ Thyroid cancer
▪ Head and neck cancer
▪ Melanoma
▪ Breast cancer
• Advantage → Very Specific
• Disadvantage → Very Expensive and Limited Availability

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OPERATIVE PROCEDURE
ABDOMINAL INCISIONS
• Principles
o Incision should be long enough for good exposure
o Splitting the muscle is better than cutting (accept Rectus muscle)
o Avoid cutting nerves and vessels
o Retract Muscle and Organs towards Neurovascular Supply
o Insert drainage tube through a separate Incision
o Transverse incision are better than vertical incisions
o Close the wound layer by layer
• Complications
o Wound infection
o Burst abdomen
o Fistula formation
o Incisional hernia
• Types of Abdominal Incision

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VASECTOMY
• Surgical procedure for male sterilization or permanent contraception.
• vasa deferentia are cut and tied / sealed, to prevent sperm from entering into the urethra
• Indications
o Family planning
o After prostatectomy, vasectomy done to prevent retrograde infection of testis
• Types
o Scalpel technique
o No Scalpel technique
• Advice
o Abstinence from sex or use of contraception for 3 months
• Complications
o Hematoma
o Hematocele
o Pyocele
o Infection
o Sperm granuloma
o Recanalization

TRACHEOSTOMY
• Types
o Emergency tracheostomy
o Elective tracheostomy
• Indications
o Head and neck injuries
o Tetanus
o Tracheomalacia after thyroidectomy
o Laryngeal edema/spasm
• Tracheostomy Incisions
o Vertical midline
▪ Extends from Cricoid cartilage to Sternal notch
o Transfer Incision
▪ 5 cm transverse incision
▪ Done 1 inch above Sternal notch
• Complications
o Tracheal stenosis
o Bleeding
o Aspiration
o Pneumothorax
o Surgical emphysema in neck
o Tracheostomy dependency

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LAPAROSCOPY
• Operation performed in the abdomen or pelvis by small incisions (0.5–1.5 cm) with the aid of a camera
• Laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen
• Instruments used
o Zero degree laparoscope
o Cold light source (xenon lamp)
o Camera
o Video monitor
o CO2 insufflator
o Veress needle
o Long fine dissectors
o Clip applicators
o Needle holders
o Endostaplers
o Suction – Irrigation apparatus
o Trocars
• Preparation - Always under General anesthesia
• Technique
o Pressure bandages applied to both legs to improve venous return
o Head end of the table is lowered, to have easier access
o Pneumoperitoneum created using Veress needle through Umbilical incision
o Glasses used to create pneumoperitoneum
▪ Nitrous oxide
▪ Helium
▪ Argon
▪ CO2 → MC
• It suppresses combustion
• Easily absorbed by tissues
• High diffusion coefficient
• Quickly released via respiration
o Pneumoperitoneum is created up to a pressure of 15 mmHg
o Laparoscope inserted through the umbilical port (10mm)
o Abdominal and Pelvic organs are evaluated for pathology
• Physiological changes due to pneumoperitoneum
o CO2 causes Hypercarbia, Acidosis & Hypoxia
o Pressure gets exerted on IVC → decreases venous centre
o Compromises respiratory function by compressing Diaphragm
• Complications of Laparoscopy
o CO2 Narcosis
o Sepsis - Subphrenic abscess, Pelvic abcess
o IVC compression
o Organ injury during insertion of ports
o Subcutaneous emphysema and Pneumomediastinum
o Gas emboli
o Post-operative shoulder pain, due to irritation of diaphragm
o Cardiac dysfunction due to decreased venous return
o Abdominal wall hernia
o Wound infection

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• Contraindications
o Peritonitis
o Bleeding disorders
o Morbid obesity
o Third trimester of pregnancy
o Portal hypertension
o Cardiac diseases
• Basic laparoscopic surgery
o Laparoscopic cholecystectomy
o Laparoscopic appendectomy
• Advanced laparoscopic surgery
o Requires expertise in Intracorporeal and Extracorporeal Knotting
▪ Laparoscopic hernia repair
▪ Laparoscopic splenectomy
▪ Laparoscopic fundoplication
▪ Laparoscopic Nissen's fundoplication
▪ Laparoscopic colectomy
▪ Laparoscopic hysterectomy
▪ Laparoscopic vagotomy
▪ Laparoscopic gastrojejunostomy
▪ Laparoscopic paediatric surgeries
o Diagnostic Laparoscopy
▪ Indications
• Ovarian disease
• Tubal pregnancy
• Staging of malignancy
• Biopsy from tumors
▪ Advantages
• Laparotomy is avoided
• Once diagnosed, therapeutic procedure can be carried out in the same sitting

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