❇️ Guidelines for management of Graves disease
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#تفاعل_ومشاركة_للمنشور ❤️🫶
#clinical
@Surgery_Practice

#Remember..

♦️ Virchow's node ♦️
Metastatic tumor to left supraclavicular node (usually due to gastric cancer)

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#تفاعل_ومشاركة_للمنشور ❤️🫶
#clinical
@Surgery_Practice

✅ Practical Guidelines for diagnosis and management of cholecystitis and cholangitis

Tokyo Guidelines

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#clinical
@Surgery_Practice

🔴Peritonitis

▪︎Inflammation Of The Peritoneal Coverings Of The Abdomen

▪︎Most Cases Of Peritonitis Due To Bacterial invasion Of The Peritoneal Cavity

🔷Causes Of Peritonitis
🔶A. Secondary Causes (Most Common)
▪︎Due To Intra-Abdominal Pathology & Results in Peritonitis Due To Mixture Of Bacterial Invasion

📍1. GIT Viscous Perforation
▪︎Appendix Perforation (More in Young & Middle Ages)

▪︎Diverticular Perforation (More in Elderly)

▪︎Ulcer Perforation (Duodenal & Gastric)

▪︎Tumours Perforation (Colonic & Gastric)


📍2. TransMural Translocation Of Bacteria (No Perforation) Due To
▪︎Acute Pancreatitis
▪︎Bowel Ischaemia


📍3. Postoperative Peritonitis Due To
▪︎Anastomotic Leakage
▪︎Bowel Injury


📍4. Chemical Peritonitis
▪︎Biliary Peritonitis ➡️ After Cholecystectomy Or Hepatectomy Or Duodenal Surgery

▪︎Barium Contrast Peritonitis


🔶B. Primary Causes
▪︎No Intra-Abdominal Pathology & Results in Peritonitis Due To Single Organisms (Streptococcus/Pneumococcus/Staphylococcus/Haemophilus)

📍1. Exogenous (External) Contamination Of The Abdomen Due To
▪︎Surgical Drains
▪︎Open Surgery
▪︎Abdominal Trauma
▪︎Peritoneal Dialysis


📍2. Female Genital Tract Infection (Ascending Infection By Chlamydia & Gonorrhea) & PID (Pelvic Inflammatory Disease)


📍3. Primary (Spontaneous) Bacterial Peritonitis (SBP)
▪︎Acute Bacterial Infection Of The Ascitic Fluid Of The Abdomen

▪︎Hx Of Liver Cirrhosis Or Abdominal Ascites Due To Other Causes

▪︎Dx By ➡️ Paracentesis Of Ascitic Fluid (Neutrophilia 250/mm³)

▪︎Most Common Organisms ➡️ E.Coli/Streptococcus/EnteroCoccus

▪︎Mx Of SBP ➡️ 3rd Generation CephaloSporins (Cefotaxime) Or AmoxiClav Or Ciprofloxacin


📍4. Primary Pneumococcal Peritonitis
▪︎Causes Of Primary Pneumococcal Peritonitis
I.Nephrotic Syndrome Or Liver Cirrhosis in Children

II.Middle Ear Or Respiratory Tract infection

III.Female Genital Tract Infection

▪︎Clinical Features Of Primary Pneumococcal Peritonitis
I.Sudden Pain in Lower Half Of Abdomen

II.Frequent Vomiting With Profuse Diarrhoea & Increase Micturition (Severe Pelvic Peritonitis)

III.High Fever (39°C)

IV.Leckocytosis >30k (Neutrophils)

V.Sticky Odourless Exudate


📍5. TB Peritonitis
▪︎TB Spread To The Peritoneum From
I.GIT Tract Via Mesenteric LN
II.Blood Spread (Miliary TB)
III.Cavitation Of Pulmonary TB
IV.Fallopian Tubes


▪︎Types Of Tb Peritonitis
I.Wet (Most Common 90%) ➡️ Cause Abdominal Ascites

II.Dry ➡️ Cause Fibrosis & SubAcute Bowel Obstruction


▪︎Dx Of Tb Peritonitis
I.Gradual Chronic Abdominal Pain & Distention

II.Weight Loss & Night Sweats

III.Abdominal US Or CT ➡️ Ascites/LN Enlargement/Thickening Of Peritoneum & Mesenery & Omentum

IV.Paracentesis ➡️
•Straw-Coloured Exudate (Proteins >25-30g/L & WBCs >500 & Lymphocytes >40%)

•Elevated Adenosine Deaminase (Highly Sensitive & Specific)

V.Laparoscopy & Biopsy

VI.MTB/RIF & Interferon-Gamma Tb Test


📍6. Familial Mediterranean Fever (Periodic Peritonitis)
▪︎Autosomal Recessive (AR) Inherited Auto-inflammatory Disorder Due To Mutation in MEFV Gene

▪︎Results in Episodes Of Diffuse Abdominal Pain With Tenderness & Mild Pyrexia & Joint Pain

▪︎Symptoms Resolve in 24-48h

▪︎Mostly Present in Children (DDX Appendicitis)

▪︎Colchicine Used To Reduce Severity & Frequency Of Attacks


📍7. Allergic Peritonitis (Starch Allergy)

📍8. Systemic Sepsis

Peritonitis Part 1
#Surgery_rotation
https://t.me/Surgery_Practice

🔷Types Of Peritonitis
📍A. Localized Peritonitis
▪︎Inflammation Of Localized Area Of The Peritoneum

▪︎Due To Local Organ Inflammation (Appendicitis/Salpingitis)


📍B. Diffuse (Generalised) Peritonitis
▪︎Life Threatening Diffuse Inflammation Of The Entire Peritoneum

▪︎Due To
I.Perforation Of Viscous

II.Ruptured Aortic Aneurysm (Large Amount Of Blood Enter The Peritoneum)

III.Anastomotic Leakage

▪Factors Increase Risk Of Diffuse Peritonitis
I.Young Children (Small Omentum Less Effective in Localising The Infection)

II.Stimulation Of Bowel Peristalsis By Food Intake

III.Highly Virulent Organisms

IV.Disruption Of Localized Collection (Abscess) During Surgical Manipulation

V.immune Deficiency

VI.Rapid Peritoneal Contamination (Mostly After Viscous Perforation)


🔷Clinical Features Of Peritonitis
📍1. Abdominal Pain
▪︎Start As Localized Then Becomes Diffuse

▪︎Acute Or Gradual Onset

▪︎Sharp & Constant

▪︎Aggravated By Movement/Coughing/Deep Respiration

▪︎Pain Radiating To Shoulder Or Back (Referred Pain)

▪︎+Ve Rebound Tenderness (Worsening Pain On Sudden Hand Lifting From The Abdomen)

▪︎Pain & Tenderness On Rectal Or Vaginal Examination (Pelvic Peritonitis)


📍2. Contraction Of Abdominal Muscles
▪︎Guarding (Voluntary Contraction)

▪︎Rigidity (involuntary Contraction)

▪︎Board-Like Rigidity (Diffuse Involuntary Contraction) ➡️ More With Diffuse Peritonitis


📍3. Generalised Ileus
▪︎Absent Or Decrease Bowel Sounds
▪︎Then Abdominal Distention


📍4. Fever & Anorexia & Malaise With Hypotension & Tachycardia


📍5. Cold Extremities With Sunken Eyes & Dry Tongue & Thready Irregular Pulse & Anxious Face (Hippocratic Face)


📍6. Disorientation Then Loss Of Consciousness


📍7. Septic Shock Then Multiple Organs Failure & Death (If Not Treated)


🔷Dx Of Acute Peritonitis
📍1. Hx & Examination


📍2. Blood Ix
▪︎Leckocytosis (Neutrophilia)
▪︎Elevated ESR & CRP


📍3. Erect Or Lateral Decubitus Xray
▪︎Gas Under Diaphragm (Perforated Viscous)

▪︎Multiple Air-Fluid Levels & Dilated Bowel Loops (Ileus)


📍4. Abdominal CT Scan (Best) ➡️ Ix Of Choice To Detect Cause Of Peritonitis


📍5. US ➡️ For Tubo-Ovarian Diseases


📍6. Amylase & Lipase ➡️ To Exclude Acute Pancreatitis


📍7. Laparoscopy ➡️ If Other Ix Failed To Reach The Cause Of Peritonitis


🔷Complications Of Peritonitis
1. Septic Shock
2. Multiple Organs Dysfunction
3. Systemic Inflammatory Response
4. Paralytic Ileus
5. Abscess Or Inflammatory Mass Formation
6. Portal Pyaemia & Liver Abscess
7. Adhesion & Small Bowel Obstruction
8. Death


🔷Mx Of Acute Peritonitis
1. Fluids & Electrolytes Correction

2. NG Tube Decompression & Urinary Catheter

3. Broad Spectrum IV Antibiotics ➡️ Metronidazole 500mg + Cefuroxime 750mg

4. Analgesics

5. Determine The Cause & Treat It

6. Surgical Peritoneal Lavage Or Drainage

Peritonitis Part 2
#Surgery_rotation
https://t.me/Surgery_Practice

فيديوهات لtechniques في الDRcABCDE Approach 👇 :

📌 Cervical stability:

     📍Neck collar:
https://youtu.be/hHHy1mc7sqY
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📌 Airway:

     📍Head tilt- Chin lift, Jaw
       thrust maneuvers:
https://youtu.be/5iwogajl-n8

     📍Oropharyngeal airway:
https://youtu.be/Hzc_T4QBp4E

     📍Nasopharyngeal airway:
https://youtu.be/gVgAlWRCZBs
https://youtu.be/f_kUeNjRw28

     📍Endotracheal intubation:
https://youtu.be/pXjyeHMYqUI
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📌 Breathing:

     📍Respiratory distress:
https://youtu.be/5OR-0zuw9v0

     📍Needle decompression of
         Tension Pneumothorax:
https://youtu.be/2eZnT3V6cT8
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📌 Circulation:

     📍Capillary Refill Time:
https://youtu.be/EwaDSZRH1LE

     📍IV Cannula insertion:
https://youtu.be/xnzUdr3c6wE

     📍 Urinary Catheterization:
https://youtu.be/XcU6g_ppWRI
https://youtu.be/Stc5mzIFJBY

     📍Applying Torniquet:
https://youtu.be/BVij7f6Brgo
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📌 Disability:
    
    📍How to measure GCS:
https://youtu.be/vxOpsig-ft0

    📍Pupil examination:
https://youtu.be/ROEiGc_j2u4

    📍Neurological examination:
https://youtu.be/vZBpNsFPJVQ