🔻Radiation of pain:
-It is the extension of the pain to another site while the initial pain persists.
-Radiating pain is of same character of original site.
-For example, penetration of duodenal ulcer posteriorly causes pain both in epigastrium and back.
-Pain of pancreatitis radiates to back.
#Surgery
-It is the extension of the pain to another site while the initial pain persists.
-Radiating pain is of same character of original site.
-For example, penetration of duodenal ulcer posteriorly causes pain both in epigastrium and back.
-Pain of pancreatitis radiates to back.
#Surgery
🔻Referred pain:
-It is pain that is felt at a distance from its source. It's not felt at the site of the disease.
-For example, inflammation of the diaphragm causes a pain experienced only at the tip of the shoulder.
-Hip joint pathology may cause referred pain in knee joint.
-Referred pain in the epigastrium from the heart; referred pain in the abdomen from pleura; referred pain over the testis from the ureter..etc
-Referred pain is caused by the inability of the central nervous system to distinguish between visceral and somatic sensory impulses.
#Surgery
-It is pain that is felt at a distance from its source. It's not felt at the site of the disease.
-For example, inflammation of the diaphragm causes a pain experienced only at the tip of the shoulder.
-Hip joint pathology may cause referred pain in knee joint.
-Referred pain in the epigastrium from the heart; referred pain in the abdomen from pleura; referred pain over the testis from the ureter..etc
-Referred pain is caused by the inability of the central nervous system to distinguish between visceral and somatic sensory impulses.
#Surgery
🔻Shifting/migration of pain:
-Origin of pain is in one site; later pain shifts to another site and pain at original site disappears.
-Pain when begins in viscera, is felt at the same somatic segmental area in the body; but once parietal layer is involved by inflammation/ pathology pain is felt at the anatomical site.
-Common example is that of acute appendicitis.
#Surgery
-Origin of pain is in one site; later pain shifts to another site and pain at original site disappears.
-Pain when begins in viscera, is felt at the same somatic segmental area in the body; but once parietal layer is involved by inflammation/ pathology pain is felt at the anatomical site.
-Common example is that of acute appendicitis.
#Surgery
-The normal appendix may not be visualized on US.
-The diameter of the appendix is usually less than 6 mm. When visible, the normal appendix compresses when pressure is applied with the transducer.
-The inflamed appendix is noncompressible (using a technique called graded compression).
#Surgery
-The diameter of the appendix is usually less than 6 mm. When visible, the normal appendix compresses when pressure is applied with the transducer.
-The inflamed appendix is noncompressible (using a technique called graded compression).
#Surgery
Pericardial tamponade
-Becks triad
•Hypotension
•Engorged neck veins (elevated JVP)
•Muffled heart sounds.
-Acue tamponade 👉🏼100 cc of blood
-Chronic tamponade 👉🏼700-1000 cc of blood.
(Chronic tamponade occurs in pericarditis due to TB, renal failure, liver failure, heart failure, tumor).
#Surgery
-Becks triad
•Hypotension
•Engorged neck veins (elevated JVP)
•Muffled heart sounds.
-Acue tamponade 👉🏼100 cc of blood
-Chronic tamponade 👉🏼700-1000 cc of blood.
(Chronic tamponade occurs in pericarditis due to TB, renal failure, liver failure, heart failure, tumor).
#Surgery
In Tension Pneumothorax:
Needle puncture or needle decompression (wide bore needle): in the 2nd intercostal space at the level of mid-clavicular line, converting it into open pneumothorax allowing air to escape into atmosphere thus temporarily relief the tension pneumothorax.
#Surgery
Needle puncture or needle decompression (wide bore needle): in the 2nd intercostal space at the level of mid-clavicular line, converting it into open pneumothorax allowing air to escape into atmosphere thus temporarily relief the tension pneumothorax.
#Surgery
You must be able to identify the visceral pleural line(Fig.10-1) to make the definitive diagnosis of a pneumothorax!
-Visualization of the visceral pleural line—a must for the diagnosis.
#Surgery
-Visualization of the visceral pleural line—a must for the diagnosis.
#Surgery
Recognizing acute cholecystitis on US:
-The presence of gallstones, possibly impacted in the neck of the gallbladder or cystic duct) (Fig. 21-5)
-Thickening of the gallbladder wall (>3 mm) (see Fig. 21-5, A)
-Pericholecystic fluid (fluid around the gallbladder) (see Fig. 21-5, B)
- A positive sonographic Murphy sign (A positive Murphy sign in this case is pain that is elicited by compression of the gallbladder with the US probe).
•In the presence of gallstones and gallbladder wall thickening, US has a positive predictive value for acute cholecystitis as high as 94%.
#Surgery
-The presence of gallstones, possibly impacted in the neck of the gallbladder or cystic duct) (Fig. 21-5)
-Thickening of the gallbladder wall (>3 mm) (see Fig. 21-5, A)
-Pericholecystic fluid (fluid around the gallbladder) (see Fig. 21-5, B)
- A positive sonographic Murphy sign (A positive Murphy sign in this case is pain that is elicited by compression of the gallbladder with the US probe).
•In the presence of gallstones and gallbladder wall thickening, US has a positive predictive value for acute cholecystitis as high as 94%.
#Surgery
Peau d’ Orange appearance:
-It is due to blockage of the lymphatics draining the skin—cutaneous lymphedema.
-The hair follicles are more firmly fixed to the subcutaneous tissue than the rest of the skin.
-The hair follicles appear to be retracted and the between areas swell giving the orange peel appearance.
#Surgery
-It is due to blockage of the lymphatics draining the skin—cutaneous lymphedema.
-The hair follicles are more firmly fixed to the subcutaneous tissue than the rest of the skin.
-The hair follicles appear to be retracted and the between areas swell giving the orange peel appearance.
#Surgery
•Why is indirect inguinal hernia more common in right side ?
Due to delayed descend of right testis , slower closure of a patent processus vaginalis on the right side compared to the left.
It's almost about one month difference.
#Surgery
Due to delayed descend of right testis , slower closure of a patent processus vaginalis on the right side compared to the left.
It's almost about one month difference.
#Surgery
•What's the difference between osteoporosis and osteomalasia ?
-In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
-In osteomalacia, the ratio of bone mineral to bone matrix is low.
#Surgery
-In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.
-In osteomalacia, the ratio of bone mineral to bone matrix is low.
#Surgery
Examination of an Incision
By inspection:
Site, side, length, direction, the healing by primary or secondary intention, relation to deep structures any signs of complication of incision as hematoma, discharge, swelling, redness..etc
-If there's dressing, comment on:
Site, side, dry or wet, clear in colour or red, yellow...
-Do not forget to say to the examiner:
"I shoud to expose the dressing".
#Surgery
By inspection:
Site, side, length, direction, the healing by primary or secondary intention, relation to deep structures any signs of complication of incision as hematoma, discharge, swelling, redness..etc
-If there's dressing, comment on:
Site, side, dry or wet, clear in colour or red, yellow...
-Do not forget to say to the examiner:
"I shoud to expose the dressing".
#Surgery
Note
When bile duct system is strictured due to a known cause it is called secondary sclerosing cholangitis, the causes can be divided into iatrogenic and non iatrogenic:
Iatrogenic causes:
1) Bile duct surgery.
2) Infusion of 5 flourodeoxyuridine in treatment of hepatic metastasis.
3) Formalin injection into a hydatid cyst.
4) Injection of alcohol into a hepatic tumour.
Non iatrogenic causes:
1) Bile duct stones leading to cholangitis.
2) Parasitic infestation of biliary system especially clonorchis sinensis infection.
3) Cholangiocarcinoma.
4) AIDS, probably because it promote infection of biliary system with CMV or cryptosporidiosis.
5) IgG4 associated cholangitis (this is a newly recognised disease associated with autoimmune pancreatitis).
#Hepatobiliary
#Surgery
When bile duct system is strictured due to a known cause it is called secondary sclerosing cholangitis, the causes can be divided into iatrogenic and non iatrogenic:
Iatrogenic causes:
1) Bile duct surgery.
2) Infusion of 5 flourodeoxyuridine in treatment of hepatic metastasis.
3) Formalin injection into a hydatid cyst.
4) Injection of alcohol into a hepatic tumour.
Non iatrogenic causes:
1) Bile duct stones leading to cholangitis.
2) Parasitic infestation of biliary system especially clonorchis sinensis infection.
3) Cholangiocarcinoma.
4) AIDS, probably because it promote infection of biliary system with CMV or cryptosporidiosis.
5) IgG4 associated cholangitis (this is a newly recognised disease associated with autoimmune pancreatitis).
#Hepatobiliary
#Surgery
Partial cholecystectomy
◼️This operation was first described in the 1950's and is considered a safe alternative to complete cholecystectomy with fairly good outcomes.
◼️The procedure entails drainage of gallbladder contents, and removal of a part of the gallbladder leaving the neck insitu, and in some cases leaving the posterior gallbladder wall insitu.
◼️The procedure is indicated in severe acute cholecystitis and gangrenous/necrotizing cholecystitis where inflammation is extensive and biliary structures are not adequately visualised.
◼️It is still considered less than ideal, as complications such as recurrence of gallstones, recurrence of biliary symptoms, and occurence of persistent biliary fistula has been reported.
◼️The above figure is an ERCP after partial cholecystectomy, showing recurrence of biliary stones in the common bile duct which appear as filling defects (white arrow) and the remnant of the cystic duct (Black arrow)
#Hepatobiliary
#Surgery
◼️This operation was first described in the 1950's and is considered a safe alternative to complete cholecystectomy with fairly good outcomes.
◼️The procedure entails drainage of gallbladder contents, and removal of a part of the gallbladder leaving the neck insitu, and in some cases leaving the posterior gallbladder wall insitu.
◼️The procedure is indicated in severe acute cholecystitis and gangrenous/necrotizing cholecystitis where inflammation is extensive and biliary structures are not adequately visualised.
◼️It is still considered less than ideal, as complications such as recurrence of gallstones, recurrence of biliary symptoms, and occurence of persistent biliary fistula has been reported.
◼️The above figure is an ERCP after partial cholecystectomy, showing recurrence of biliary stones in the common bile duct which appear as filling defects (white arrow) and the remnant of the cystic duct (Black arrow)
#Hepatobiliary
#Surgery
Gallbladder cancer
◼️Very rare disease, but with striking geographical variation, in north of india it is so common that it represent 9.1% of all biliary tract diseases.
◼️It usually appear as infiltrative growth leading to thickening of bladder wall, usually the entire gallbladder is involved (see figure above), it may be difficult to differentiate it from chronic cholecystitis.
◼️In most cases, there is gallstones, it appears that gallstones predispose to this condition, among those with stones, about 0.3% have gallbladder cancer, in Porcelain gallbladder where the wall is calcified risk is 25%.
◼️Clinically it present just like cholecystitis or biliary colic, late features include jaundice and weight loss.
◼️The tumour invade directly the liver, and also through lymphatic channels that connect subserosal lymph vessels of the gallbladder with subcapsular lymphatics in liver.
◼️In 80% CA 19-9 (Sialyl lewis a antigen) is elevated, prognosis is very poor, 95% dead in 1 year.
#Hepatobiliary
#Surgery
◼️Very rare disease, but with striking geographical variation, in north of india it is so common that it represent 9.1% of all biliary tract diseases.
◼️It usually appear as infiltrative growth leading to thickening of bladder wall, usually the entire gallbladder is involved (see figure above), it may be difficult to differentiate it from chronic cholecystitis.
◼️In most cases, there is gallstones, it appears that gallstones predispose to this condition, among those with stones, about 0.3% have gallbladder cancer, in Porcelain gallbladder where the wall is calcified risk is 25%.
◼️Clinically it present just like cholecystitis or biliary colic, late features include jaundice and weight loss.
◼️The tumour invade directly the liver, and also through lymphatic channels that connect subserosal lymph vessels of the gallbladder with subcapsular lymphatics in liver.
◼️In 80% CA 19-9 (Sialyl lewis a antigen) is elevated, prognosis is very poor, 95% dead in 1 year.
#Hepatobiliary
#Surgery
Bile duct injury
◼️This can occur due to many errors in the surgical technique of cholecystectomy and less commonly other operations, one error is the blind clamping of a bleeding source which may come from cystic artery, accessory cystic artery or injured right hepatic artery, to avoid this, insert your finger in the foramen of winslow and pinch the free edge of lesser omentum to occlude the hepatic artery and stop the bleeding to allow identification of the bleeding source, this is called Hogarth Pringle's maneuver.
◼️Another error is during fundus first procedure, in which the gallbladder is freed by dissection started from the fundus, excessive traction on the gallbladder can tent the bile duct which may be clamped as it is mistaken for the cystic duct (see figure above).
◼️Lack of knowledge about congenital anomalies of the biliary system and failure to define the anatomy of Calot's triangle due to excessive inflammation are also risk factors for bile duct injury.
#Hepatobiliary
#Surgery
◼️This can occur due to many errors in the surgical technique of cholecystectomy and less commonly other operations, one error is the blind clamping of a bleeding source which may come from cystic artery, accessory cystic artery or injured right hepatic artery, to avoid this, insert your finger in the foramen of winslow and pinch the free edge of lesser omentum to occlude the hepatic artery and stop the bleeding to allow identification of the bleeding source, this is called Hogarth Pringle's maneuver.
◼️Another error is during fundus first procedure, in which the gallbladder is freed by dissection started from the fundus, excessive traction on the gallbladder can tent the bile duct which may be clamped as it is mistaken for the cystic duct (see figure above).
◼️Lack of knowledge about congenital anomalies of the biliary system and failure to define the anatomy of Calot's triangle due to excessive inflammation are also risk factors for bile duct injury.
#Hepatobiliary
#Surgery