•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
Limey bile
◼️Also known as milk of calcium bile, is an uncommon finding in which the bile inside the gallbladder is very rich in calcium carbonate and calcium phosphate.
◼️The bile has a consistency of a toothpaste, and tends to develop stones very easily, this condition is of unknown pathogenesis but is related to slow gradual obstruction to bile flow such as chronic pancreatitis or pancreatic cancer.
◼️As in the above figure, a plain radiograph of abdomen shows radio-opaque material within the gallbladder often with multiple stones.
#Hepatobiliary
#Surgery
◼️Also known as milk of calcium bile, is an uncommon finding in which the bile inside the gallbladder is very rich in calcium carbonate and calcium phosphate.
◼️The bile has a consistency of a toothpaste, and tends to develop stones very easily, this condition is of unknown pathogenesis but is related to slow gradual obstruction to bile flow such as chronic pancreatitis or pancreatic cancer.
◼️As in the above figure, a plain radiograph of abdomen shows radio-opaque material within the gallbladder often with multiple stones.
#Hepatobiliary
#Surgery
Ascending cholangitis caused by Clostridium perfringens
◼️Ascending cholangitis is caused by infected static bile within the biliary passages.
◼️It is famously recognized by the Charcot's triad (Fever, Pain and Jaundice).
◼️C.perfringens (previously known as C.Welchii) are gram positive anaerobic spore forming bacilli (see fig above), Septicemia caused by this bacteria most commonly arise in the context of ascending cholangitis.
◼️The special feature about this, is that this bacteria produces an enzyme known as Lecithinase, which when produced in the blood can cause a severe degree of hemolysis secondary to disruption of red cell membrane.
◼️So in such event, the intravascular disruption of RBC, releases free hemoglobin that precipitate in the renal tubules causing acute renal failure.
N.B, mortality rate of this condition is very high, atleast 60%.
#Hepatobiliary
#Surgery
◼️Ascending cholangitis is caused by infected static bile within the biliary passages.
◼️It is famously recognized by the Charcot's triad (Fever, Pain and Jaundice).
◼️C.perfringens (previously known as C.Welchii) are gram positive anaerobic spore forming bacilli (see fig above), Septicemia caused by this bacteria most commonly arise in the context of ascending cholangitis.
◼️The special feature about this, is that this bacteria produces an enzyme known as Lecithinase, which when produced in the blood can cause a severe degree of hemolysis secondary to disruption of red cell membrane.
◼️So in such event, the intravascular disruption of RBC, releases free hemoglobin that precipitate in the renal tubules causing acute renal failure.
N.B, mortality rate of this condition is very high, atleast 60%.
#Hepatobiliary
#Surgery
Biliary dyskinesia, is a condition in which the sphincter of oddi fails to relax on fatty meals, the gallbladder contract against a closed sphincter which will cause pain in the right hypochondrium, cholecystectomy appears to worsen the condition, surest investigation is manometric studies, treatment is sphincterotomy.
#Hepatobiliary
#Surgery
#Hepatobiliary
#Surgery
Side topic... Caroli disease
This can be inherited as autosomal dominant or recessive, the disease is rare and is charactarized by abnormal cystic dilatation of intrahepatic bile ducts, resulting in bile stasis with subsequent cholangitis, choledocholithiasis and jaundice,, additionally those with caroli disease are 100 times at risk for cholangiocarcinoma
#Hepatobiliary
#Surgery
This can be inherited as autosomal dominant or recessive, the disease is rare and is charactarized by abnormal cystic dilatation of intrahepatic bile ducts, resulting in bile stasis with subsequent cholangitis, choledocholithiasis and jaundice,, additionally those with caroli disease are 100 times at risk for cholangiocarcinoma
#Hepatobiliary
#Surgery
Rule in suture of wounds
Any wound covered by dressing should be covered by suitable antibiotics، and if the wound is not covered by dressing and no AB is prescribed then should be cleaned by povidine- iodine at least tow time per day
Any wound covered by dressing should be covered by suitable antibiotics، and if the wound is not covered by dressing and no AB is prescribed then should be cleaned by povidine- iodine at least tow time per day
How to differentiate between sub-hepatic acute appendicitis and acute cholycycstis?
-By tow things
1-Type of the patient:
-In acute appendicitis : the patient is young , thin.
-In acute cholycystitis: female , fatty , fertile, fory, fair.
2-Hyperesthesia:
-In appendicitis: hyperesthesia in the tringle of sherrene.
-In cholycytisits : hyperesthesia in the on the back( boas's sign).
#Appendix
#Surgery
-By tow things
1-Type of the patient:
-In acute appendicitis : the patient is young , thin.
-In acute cholycystitis: female , fatty , fertile, fory, fair.
2-Hyperesthesia:
-In appendicitis: hyperesthesia in the tringle of sherrene.
-In cholycytisits : hyperesthesia in the on the back( boas's sign).
#Appendix
#Surgery
How to differentiate between acute appendicitis and mesenteric lymph adenitis ?
-In mesenteric lymph adenitis the patient has shifting tenderness ( the patient hasPain localize tothe RIF, When he terns to the other side the pain shift with the direction of the movement) also the patient may have tonsillitis.
#Appendix
#Surgery
-In mesenteric lymph adenitis the patient has shifting tenderness ( the patient hasPain localize tothe RIF, When he terns to the other side the pain shift with the direction of the movement) also the patient may have tonsillitis.
#Appendix
#Surgery
-Analgesics is contraindicated if acute appendicitis is suspected to avoid masking of diagnosis.
#Surgery
#Surgery
Differential Diagnosis for Epigastric Abdominal Pain:
1- Gastroenteritis:-
History and physical:-
Nausea, extensive vomiting, diarrhea, myalgia, fever, mild abdominal tenderness
2-Acute gastritis:-
History and physical:-
Burning/gnawing epigastric pain, NSAID use, mild abdominal tenderness
3-Acute cholecystitis:-
History and physical:-
Right upper quadrant/epigastric pain radiating to around the right back, nausea, vomiting, fever, Murphy’s sign
4-Peptic ulcer disease (PUD)
History and physical:-
Intermittent burning epigastric pain that is better (duodenal ulcer) or worse (gastric ulcer) with food intake, nausea, Helicobacter pylori infection, NSAID use, steroids
5-Perforated ulcer :-
History and physical:-
Initial epigastric pain, followed by diffuse tenderness, abdominal rigidity, rebound tenderness
6-Pancreatitis:-
History and physical:-
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, alcohol abuse
7-Appendicitis:-
History and physical:-
Periumbilical pain migrating toward the right lower quadrant (McBurney’s point), associated with nausea, vomiting, anorexia, fever, Rovsing’s sign, psoas sign
8-Small bowel obstruction :-
History and physical:-
Adhesions, hernia, neoplasms, dilated loops of bowel with air fluid levels, absence of distal colonic gas on plain radiograph
9-Mesenteric ischemia :-
History and physical:-
“Severe abdominal pain out of proportion to physical exam,” nausea, most often cardiac embolus to superior mesenteric artery from atrial fibrillation, bloody diarrhea in severe cases
10-Ruptured AAA :-
History and physical:-
Severe abdominal/back/left flank pain, pulsatile abdominal mass, hypotension, elderly male smoker
11-Referred pain from myocardial infarction:-
History and physical:-
Atypical presentation more common in women and diabetics, cardiovascular disease, obesity, hypercholesterolemia.
#Surgery
1- Gastroenteritis:-
History and physical:-
Nausea, extensive vomiting, diarrhea, myalgia, fever, mild abdominal tenderness
2-Acute gastritis:-
History and physical:-
Burning/gnawing epigastric pain, NSAID use, mild abdominal tenderness
3-Acute cholecystitis:-
History and physical:-
Right upper quadrant/epigastric pain radiating to around the right back, nausea, vomiting, fever, Murphy’s sign
4-Peptic ulcer disease (PUD)
History and physical:-
Intermittent burning epigastric pain that is better (duodenal ulcer) or worse (gastric ulcer) with food intake, nausea, Helicobacter pylori infection, NSAID use, steroids
5-Perforated ulcer :-
History and physical:-
Initial epigastric pain, followed by diffuse tenderness, abdominal rigidity, rebound tenderness
6-Pancreatitis:-
History and physical:-
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, alcohol abuse
7-Appendicitis:-
History and physical:-
Periumbilical pain migrating toward the right lower quadrant (McBurney’s point), associated with nausea, vomiting, anorexia, fever, Rovsing’s sign, psoas sign
8-Small bowel obstruction :-
History and physical:-
Adhesions, hernia, neoplasms, dilated loops of bowel with air fluid levels, absence of distal colonic gas on plain radiograph
9-Mesenteric ischemia :-
History and physical:-
“Severe abdominal pain out of proportion to physical exam,” nausea, most often cardiac embolus to superior mesenteric artery from atrial fibrillation, bloody diarrhea in severe cases
10-Ruptured AAA :-
History and physical:-
Severe abdominal/back/left flank pain, pulsatile abdominal mass, hypotension, elderly male smoker
11-Referred pain from myocardial infarction:-
History and physical:-
Atypical presentation more common in women and diabetics, cardiovascular disease, obesity, hypercholesterolemia.
#Surgery