🔴Gallstones (Cholelithiasis) & Cholysystitis

▪️Gallstones Are Most Common Biliary Pathology (Affect 10-15% Of Population)

▪️Cholecystitis is Acute Or Chronic
Inflammation Of Gallbladder (Mostly Due To Presence Of Gallstones)

▪︎Cholysystitis is The 2nd Most Common Non-Obstetric Indication For Surgery in Pregnant Women (After Appendicitis)

🔹Risk Factors For Gallstones Formation (Fat/Fertile/Female/Forty)
1. Obesity & High Calorie Intake (Increase Cholesterol & Concentrate The Bile)

2. Terminal Ileum Resection (Diminished EnteroHepatic Circulation)

3. Drugs (Oral Contraceptives/Estrogen/CloFibrate/Cholestyramine/DeoxyCholate)

4. Abnormal Emptying Of Gallbladder 

5. Female Gender & Pregnancy (MultiParity)

6. Liver Diseases & DM

7. Rapid Weight Loss

8. Risk Factors For Pigmented Stones ➡️ Blood Hemolysis/Biliary Stasis (Obstruction & Infection)/Liver Cirrhosis

9. Old Age

10. Long Term Parenteral Nutrition


🔹Clinical Features Of Gallstones
📍1. Most Gallstones Asymptomatic (>80%)

📍2. Acute Cholecystitis
▪︎Start As Mild To Moderate Episodes Of Right Upper Quadrant Or Epigastric Pain
▪️Dull Or Colicky in Nature

▪️Radiate To Back Or Right Shoulder

▪️Intermittent Episodes (Comes & Go During The Day) & Constant in Severity

▪️Associated With Dyspepsia & Flatulence & Food Intolerance & Alteration in Bowel Frequency

▪️Aggravated Or Induced By Eating Fatty Meals


📍3. Biliary Colic (10-25%)
▪️Severe RUQ Pain Last Minutes Or Hours Radiate To Chest & Associated With Nausea & Vomiting

▪︎Due To Temporary Stone Obstructing The Cystic Duct

▪️Change In Severity (Ebbs & Flows)

▪️Starts During Night & Wakes Patient From Sleep & Associated With Minor Intermittent Episodes During The Day

▪️When Pain Resolve The Patient is Able To Eat & Drinks Again


📍4. Obstructive Jaundice (Jaundice With Pale Stool & Dark Urine & Itching)
▪︎Due To CBD Stones ➡️ Stone Migration From Gallbladder To Common Bile Duct

▪︎Or Due To Mirizzi Syndrome ➡️ Stones Impacted in Hartmann Pouch Of The Gallbladder & Causing Pressure Over The CBD (Risk Of CBD Fistula)


🔹Types Of Cholysystitis
📍1. Calculus Cholecystitis (Acute/Chronic) ➡️ Due To Gallstones

📍2. Acalculous Cholecystitis ➡️
▪️Gallbladder Inflammation Without The Presence Of Gallstones

▪️Mostly Seen in ➡️ Critically ill Patients/Patients Recovering From Major Surgery Or Trauma Or Burns/Immunocompromised/Typhoid Fever

▪️High Mortality Rate

📍3. Emphysematous Cholecystitis
▪︎Acute Severe & Life-Threatening Cholecystitis Due To Gas-Forming Bacterial infection Of The Gallbladder (C.Perfingrens/C.Welchii/E.coli/Bacteroides Fragilis)

▪︎More in Men With DM (50-70 Years)

▪︎Risk Of Gallbladder Gangrene & Perforation


🔹Dx Of Acute Cholecystitis
📍1. Persistent Clinical Features With Fever

📍2. +Ve Murphy Sign ➡️ RUQ Tenderness Exacerbated By Right SubCostal Palpation During Patient Inspiration

📍3. Leukocytosis & Increase Liver Enzymes

📍4. Palpable Mass in RUQ (Omentum Walls Off The Inflamed Bladder)

📍5. US Or CT (Confirm Dx) ➡️ Stones Present With Gallbladder Wall Thickening & Fluid Collection


🔹DDX Of Acute Cholecystitis
1. Acute Appendicitis
2. Perforated Peptic Ulcer
3. Acute Pancreatitis
4. Acute Pyeleonephritis
5. Myocardial Infarction
6. Right Lower Lobe Pneumonia

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🔹Mx Of Cholecystitis
🔸A. Conservative
▪️Conservative Mx Will Resolve The Symptoms in 90% Of Cases

📍1. Nill By Mouth (NPO)
📍2. IV Fluids & Analgesic
📍3. Antibiotics (Cefazolin/Cefuroxime/Ciprofloxacin)


🔸B. Surgery (Cholecystectomy)
📍1. Do Early CholecysteCtomy Within 5-7 Days From Admission & After Symptoms Resolution

📍2. Emergent Choleystectomy ➡️ Due To Severe Presentation Or Complications

📍3. Do Emergent ECRP ➡️ For CBD Stones Removal

📍4. If Empyema Present ➡️ Do Drainage (CholeCystoStomy) Then Later CholecysteCtomy

📍5. Cholecystitis in Pregnancy ➡️ Do Cholecystectomy During 2nd Trimester Only (Not In 1st Or 3rd Trimester)


🔹Indications for Cholecystectomy
1. Cholecystitis (Symptomatic Patients)

2. Complications Develop (Emergency)

3. Typhoid Carrier

4. Cholesterolosis (Cholesterol Polyps)

5. Risk Of Gallbladder Cancer (Porcelain Gallbladder/Adenomatous Gallbladder Polyps)

6. CBD Stones (Choledocholithiasis)

7. Prophylaxis in
▪︎DM/Congenital Hemolytic Anaemia/Bariatric Surgery

▪︎Large Palpable Stones (>2.5-3cm)/Multiple Small Stones


🔹Complications Of Cholecystitis
🔶A. Preoperative
1. Acute & Chronic Cholecystitis

2. Biliary Colic

3. Obstructive Jaundice (CBD Stones Or Mirizzi Syndrome)

4. Acute Pancreatitis

5. Gallbladder Perforation & Peritonitis

6. Acute Cholangitis

7. Empyema Of Gallbladder (Pus Accumulation)

8. MucoCele Of Gallbladder (Fluid Accumulation)

9. Bowel Obstruction (Gallstone Ileus)


🔶B. Postoperative (After CholecysteCtomy)
1. Bile Ducts Injury ➡️ Present As Postoperative Obstructive Jaundice

2. Post-CholecysteCtomy Syndrome ➡️ Postoperative Continuation Of The Symptoms Due To Residual Stones in The Biliary Tree

3. Post-CholecysteCtomy Choledocholithiasis ➡️ Development Of New Stones in Bile Ducts Many Years After Cholecystectomy Which Then Leads To Obstruction Or Cholangitis

4. Bile Leakage & Peritonitis (Clips Dislodgment)

5. Biliary Strictures

6. Visceral Or Vessels Injury & Haemorrhage

7. Abdominal Abscess

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📍CHEST TUBE INSERTION

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📍طريقة إدخال الأنبوب الأنفي المعدي Nasogastric tube insertion

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📍 Acute pancreatitis

❇️ common cause of acute pancreatitis :
Just remember GET and 3i
🔺️GET
1-Gallstone [ The commonest cause   ]
2-Ethanol    [ The 2nd common cause ]
3-Trauma    [ The 3rd common cause  ]

🔺️3i
1- Idiopathic [ 20 % ]
2- Infection
3- Infarction [ vascular insufficiency ]


♦️ CLINICAL FEATURES

🔷 Main symptom is Severe upper abdominal pain radiating to the back increase on supine position and relieve by laying forward
May be associated with
   🔷 Vomiting 
   🔷 Mild tenderness and rigidity

#Pancreas
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♦️Glasgow criteria for acute pancreatitis

REMEMBER  WORD "pancreas":-

🔸P= PO2<60mmhg
🔸A=Age>55
🔸N=neutrophil =WBCs>15,000
🔸C=Calcium <2mmol/L
🔸R=Renal=urea>16mmol/L
🔸E=Enzyme elevated LDH>600
🔸A=Albumin<32gm/L
🔸S=Suger >200mg/dl=10mmol/L

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ملخص ضخم لأغلب مواضيع الجراحة
يساعدك للمراجعه السريعة خلال فترة الراوند 😻

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🔴Compartment Syndrome

▪︎Increase In The Interstitial Pressure Within Closed OsteoFasical Compartment To The Level That Compromise Tissue Perfusion Which Leads Then To Ischaemia & Gangrene

▪︎More in Lower Limb Injuries (Calf Muscles)

🔷Causes Of Compartment Syndrome
1. Bone Fractures (Most Common 70%)

2. Soft Tissue Contusions Or Trauma (23%)

3. Bleeding Tendency & Anti-Coagulant Drugs

4. Burns (3rd Degree Circumferential)

5. Reperfusion Injury (Tissue Perfusion After Prolonged Shock & Ischaemia)

6. Tight Dressings Or Casts Or Tourniquets

7. ExtraVasation Of IV Infusion (Contrast Injection)

8. Arterial Injury (Iatrogenic Or Trauma)


🔷Clinical Features & Dx Of Compartment Syndrome
📍1. Pain On The Affected Limb
▪︎Out Of Proportion
▪︎Increasing Gradually
▪︎Aggravated By Limb Stretching

📍2. Paraesthesia & Numbness
📍3. Paralysis Of Affected Limb
📍4. Pallor Of The Affected Limb's Skin
📍5. Pulselessness (Loss Of Pulse)
📍6. Swelling Of The Affected Limb

📍7. Intra-Compartmental Pressure ≥30 mmHg اكثر من

📍8. Pressure Difference (Diastolic P - Compartment P) ≤30 mmHg اقل من


🔷Complications Of Compartment Syndrome
1. Limb Amputation

2. Limb Infection

3. Rhabdomyolysis & Renal Failure & Death

4. Volkmann's Ischemic Contracture (Muscle Fibrosis & Shortening)



🔷Mx Of Compartment Syndrome
🔸A. Removal Of All Limb Compressions (Casts Or Dressings)


🔸B. Limb Elevation


🔸C. Emergent FascioTomy Of The Skin & Deep Fascia
📍1. One Long Axial Incision ➡️ For Upper Limbs

📍2. Two Incisions ➡️ For Lower Limb
▪︎Media Longitudinal Incision (Decompress Superficial & Deep Posterior Compartment) ➡️ Done 1-2cm Posterior To Medial Border Of Tibia

▪︎Lateral Longitudinal Incision (Decompress Peroneal & Anterior Compartments) ➡️ Done 2cm Lateral To Anterior Tibial Border


🔰Abdominal Compartment Syndrome
▪︎Increase in The Intra-Abdominal Pressure To The Level That Reduces Perfusion (Blood Supply) To Abdominal Organs Then Results in Multiple Organs Failure

▪︎Seen More in Critically-ill Patients

▪︎Intra-Abdominal Pressure >20 mmHg ➡️ Confirm Dx

🔷Causes Of Abdominal Compartment Syndrome
1. Severe Intra-Abdominal Sepsis
2. Severe Ascites (Liver Cirrhosis)
3. Pancreatitis
4. Ruptured Aortic Aneurysm
5. Tight Wound Closure After Abdominal Surgery


🔷Mx Of Abdominal Compartment Syndrome
1. Stomach & Bladder Decompression
2. Peritoneal Fluid Aspiration
3. Open Laparotomy

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⚠️ Analgesics is contraindicated  if appendicitis is suspected  to avoid mask of diagnosis.

🔵 The main symptom of appendicitis is "abdominal pain" but the first symptom to appear is  "  Anorexia ".

⚠️ How We can differentiate between acute appendicitis and gastroenteritis clinically ❗️

Simply If abdominal  pain precedes  vomiting it indicates acute appendicitis, but if vomiting precedes abdominal  pain  it indicates AGE.


⚠️ يمنع استخدام المسكنات في حالة الاشتباه بالتهاب الزائدة الدودية لتجنب إخفاء التشخيص.

🔵 العرض الرئيسي لالتهاب الزائدة الدودية هو "آلم في البطن" لكن أول الأعراض ظهوراً هو "فقدان الشهية ".

⚠️ كيف يمكننا  التفريق بين التهاب الزائدة الدودية الحاد والتهاب المعدة والأمعاء سريريا❗️

ببساطة إذا سبق ألم البطن القيء فهذا يدل على التهاب الزائدة الدودية الحاد، أما إذا سبق القيء ألم البطن فهو يشير إلى التهاب المعدة والأمعاء.


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✅Abnormal findings in Diabetic Patients

▪︎Dehydration and Kussmaul respiration (hyperventilation) are common in ketoacidosis.

▪︎Bacterial skin infections, e.g. cellulitis, boils, abscesses and fungal infections

▪︎Acanthosis nigricans in patients with insulin-resistant type 2 diabetes.

▪︎Necrobiosis lipoidica (a yellow indurated or ulcerated area surrounded by a red margin) due to collagen degeneration

▪︎Xanthelasmata and xanthomata indicate significant hyperlipidaemia

▪︎Glycosuria suggests hyperglycaemia and, if accompanied by ketonuria and Kussmaul respiration indicates ketoacidosis.

▪︎Proteinuria occurs in diabetic
nephropathy.

▪︎Detection of nitrite ± haematuria suggests urinary infection

#Diabetic
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❇️Abnormal Findings in Diabetic Foot

▪︎Hair loss and nail dystrophy occur with ischaemia,

▪︎skin fissures or tinea infection (‘athlete’s foot’).

▪︎The foot arch may be excessive in neuropathy or collapsed (rocker-bottom sole) cause abnormal pressures and increase risk of plantar ulceration.

▪︎Warm feet occur in neuropathy

▪︎cold feet in ischaemia.

▪︎Sensory neuropathy is present if the patient cannot feel the monofilament in any site

▪︎Charcot’s arthropathy is disorganised foot architecture,

#Diabetic_Foot
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