Clinical signs in appendicitis

● Pyrexia
● Localised tenderness in the RIF
● Muscle guarding
● Rebound tenderness.

#Surgery

-The patient is then asked to point to where the pain began and where it moved (the pointing sign).


#Surgery

Effects and complications of gallstones:

● Biliary colic
● Acute cholecystitis
● Chronic cholecystitis
● Empyema of the gallbladder
● Mucocoele
● Perforation
● Biliary obstruction
● Acute cholangitis
● Acute pancreatitis
● Intestinal obstruction (gallstone ileus).

#Surgery

Differential diagnosis of acute cholecystitis:

Common:
● Appendicitis
● Perforated peptic ulcer
● Acute pancreatitis
Rare:
● Acute pyelonephritis
● Myocardial infarction
● Pneumonia – right lower lob.

#Surgery

Features of obstruction:

● In high small bowel obstruction, vomiting occurs early, is
profuse and causes rapid dehydration. Distension is minimal
with little evidence of dilated small bowel loops on abdominal
radiography
● In low small bowel obstruction, pain is predominant with
central distension. Vomiting is delayed. Multiple dilated small
bowel loops are seen on radiography
● In large bowel obstruction, distension is early and
pronounced. Pain is less severe and vomiting and dehydration
are later features. The colon proximal to the obstruction is
distended on abdominal radiography. The small bowel will be
dilated if the ileocaecal valve is incompetent.

Serum trypsin is the most accurate indicator but it is not commonly used in acute pancreatitis.

Serum lactescence (related to triglyceride metabolism)—Most specific in hereditary hyperlipidaemia or alcohol pancreatitis.

Serum lipase is more specific than amylase.

ERCP is usually not done in acute phase of pancreatitis.

Spiral CT (CECT–contrast enhanced CT) is better—gold standard in acute pancreatitis, it is done after 72 hours.

Instrumentation is by far the most common cause of perforation.

Saint's triad:
1-Cholecystolithiasis
2-Hiatus hernia
3-Diverticulosis of left colon.

Triad of choledochal cyst "in 10٪ of patients":

1-Right upper quadrant pain
2-Jaundice
3-Palpable abdominal mass.

Charcot's triad of ascending cholangitis:
1-Intermittent pain(may be colicky)
2-Intermittent fever
3-Intermittent jaundice

Reynold's pentad:خماسي
Charcot's triad +shock"toxicity"+ altered mental status.

Mirizzi syndrome:
gallstones impacted in the GB wall and compresses it causing pressure necrosis which further gets adherent to CBD. It leads to fistula.
Four types.

The Chvostek signis a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia.It refers to an abnormal reaction to the stimulation of the facial nerve.

Trausseu's sign:
placing the tourniquet around the hand and inflating up to 200mmHg for seconds induces spasm of the hand in hypoparathyroidism.

Whipple's triad:
1-Hypoglycemic episodes by fasting
2-Relief of illness by oral or intravenous glucose
3-Hypoglycemia lower than 3.3mmol/L.

Wermer's syndrome: "MEN" type1
1-Parathyroid adenoma 90٪
2-Pancreatic islets tumor in 80٪
3-Pituitary gland adenoma in 65٪.

Sipple's syndrome: MEN II
1-Parathyroid hyperplasia in 60٪
2-Medullary carcinoma of thyroid gland
3-Pheochromocytoma in 40٪.

Mucosal neuroma syndrome:
1-Medullary carcinoma of thyroid
2-Pheochromocytoma.

Thoracic outlet syndrome(TOS):
-It is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit.There are three main types: neurogenic, venous, and arterial.

1-The neurogenic type: is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb.

2- The venous type results in swelling, pain, and possibly a bluish coloration of the arm. 

3-The arterial type results in pain, coldness, and paleness of the arm.

Mediastinal syndrome:
SOB, congested neck veins and brassy cough.

Normal blood calcium level is between 8.5 to 10.5 mg/dL (2.12 to 2.62 mmol/L) and that of ionized calcium is 4.65 to 5.25 mg/dL (1.16 to 1.31 mmol/L).

Raise in amylase level is common in:

Acute pancreatitis, pseudocyst of pancreas, pancreatic trauma, after ERCP.

Amylase is also often increased in other conditions like:
1™ Salivary gland diseases like parotitis
2™ Mesenteric ischaemia
3™ Ruptured aortic aneurysm
4™ Intestinal obstruction
5™ Ectopic gestation, salpingitis
6™ Duodenal ulcer perforation
7™ Ectopic amylase production in cancers of breast, lungs, ovary,
multiple myeloma
8™ Renal failure

Causes of raised serum amylase level other than acute pancreatitis:

● Upper gastrointestinal tract perforation
● Mesenteric infarction
● Torsion of an intra-abdominal viscus
● Retroperitoneal haematoma
● Ectopic pregnancy
● Macroamylasaemia
● Renal failure
● Salivary gland inflammation.

#Surgery