DYSPHAGIA

Defi difficulty in swallowing

History:
1. Regarding dysphagia
Duration
Stable/ intermittent/ progressive
Speed of progression
Unable to take solid/ liquid/ solid then liquid
A/w cough/ choking/ aspiration/ regurgitation/
pseudovomiting
2. Odynophagia painful swallowing
3. Globus sensation
4. LOW, LOA
5. Neurological deficits (stroke)
6. Neck swelling

heartburn/

oesophageal

Surgical causes of dysphagia:

1. Oesophageal Ca
2. Reflux oesophagitis
3. Hiatus hernia
4. Achalasia
5. Pharyngeal pouch
6. Pharyngeal web
7. etc.

OESOPHAGEAL CARCINOMA
>60 years old
M:F = 3:1
Risk factor
o Genetic (Tylosis A)
100% risk
a/w hyperkeratosis of palms and soles
o Diet
Alcohol
Chewing tobacco
Chewing betel nut
Smoking
o Oesophageal d/o
Plummer-vinson synd
Achalasia
Barretts oesophagus
Chronic oesophagitis
Caustic oesophageal injury
History
Dysphagia
o Progressive ~ 3 months
o From solid to fluid
o +/- regurgitation
+/- odynophagia
Anorexia (lower oesophagus)
LOW
Cx
o Haemorrhage (ulcerated/aorta invasion)
o IDA
o Respi Sx (aspiration/ fistula)
o Hoarseness (involve RLN)
o LN enlargement
o Metastatic dz (liver/ bone)
Risk
o Reflux sx
o Hx of heartburn
o Alcohol/ smoking/ chewing tobacco

Functional grades of dysphagia in oeso

cancer (takita H,et al)
Grade I
eating normally
Grade II
requires liquids with meal
Grade III
able to take semisolids only
Grade IV
able to take liquids only
Grade V
able to swallow saliva only
Grade VI
unable to swallow saliva

PE
Non-specific
o Cachexia, deH2O
o Respi Sx
2

o Anaemia
o Jaundice
o LN
Ix
Assess pt condition and fitness for op
o Hb, LFT, RFT, lung function test, ECG
Endoscopy + biopsy (Dx method)
Barium swallow
o Rule out functional d/o
o See longitudinal extension
CT scan ~ for staging
Others
o Endoluminal U/S (tumour, mediastinal spread, LN)
o Bronchoscopy (to see airway involvement)
Mx
Surgery
o Aim

Remove tumour with safety margin

Two-field lymphadenectomy (mediastinal & abd LN)
Leak free anastomosis

o Above carina
Mckeown operation
Rt thoracotomy mobilize tumour & oesophagus
Laparotomy mobilize stomach & make into a conduit
Neck incision oesophagectomy with tumour & anastomosis stomach
& prox oesophagus
o Below carina
Ivor Lewis operation
Laparotomy mobilize stomach & make into conduit
Rt thoracotomy mobilize oesophagus & excise tumour + LN &
anastomosis
Transhiatal oesophagectomy
Laparotomy mobilize oesophagus & tumour resection (via
diaphragmatic hiatus)
Neck incision anastomosis
o Cx of surgery - anastomosis breakdown causing
Mediastinitis
Lung abscess
Oesophago-pleural fistula

Chemo + radiotherapy

o As neo-adjuvant therapy

Palliative
o To relieve obstruction
Ablation with alcohol injection
Laser therapy to cut a pathway
Intubated by (good for middle 1/3)
Stent
Plastic tube
Reinforced rubber
Radiotherapy + chemotherapy

Staging (TNM)
Stage
tumour
0
is
1
1
2a
2/3
2b
1/2
3
3/4
4a
any
4b
any
Tis
T1
T2
T3
T4
M1a
M1b

nodes
0
0
0
1
1
any
any

metastasis
0
0
0
0
0
1a
1b

insitu
invading mucosa/ submucosa
invading muscularis propia
invading adventitia
invading adjacent structure
coeliac LN met from lower 1/3 tumour
non-regional LN/ other distant met

Cx
Dysphagia - progressive cachexia & deH2O
Perforation into bronchial tree pneumonia
Perforation into post mediastinum mediastinitis
Direct spread (mostly)
o Any structure in neck & mediastinum
o Lt main bronchus & trachea
o Aorta
o Lt recurrent laryngeal
Metastasis
4

o LN
Supraclavicular
Paraoesophageal + tracheobronchial subdiaphragmatic
Along lesser curvature coeliac axis
o Blood
Liver
Bone
REFLUX OESOPHAGITIS
F>M , increase with age
Causes
Primary
o Low LOS presure
o Reduce total LOS length (<2-3cm)
o Reduce intra-abd LOS length (<1-2cm)
o Loss of angle of His
o Sliding hiatus hernia
Secondary
o Poor oesophagus motility
o Excessive gastric acid production
o Impaired gastric emptying
o Excess duodeno-gastric reflux
o Reduce saliva production
Risk factor
o Obesity
o Smoking, alcohol
o Coffee, chocolate, excessive dietary fat
Clinical presentation
o Heart burn (ac inflammation)
o Regurgitation (bitter taste)
o Indigestion
o Severe chest pain mimic AMI, relieved by GTN (oesophageal spasm)
o Dysphagia, odynophagia
Ix
o OGDS - more easy to perform then barium swallow
o Barium swallow
o Intra-oesophageal pH measure duration, freq, severity of reflux
o Oesophageal mamometry determine length & position of LOS and measure
LOS pressure
Mx
o General
Weight loss
Avoid smoking, alcohol, coffee, chocolate & fatty food
Avoid tight cloths
5

 Propped up when sleep

o Drug
Antacids
PPI, anti-H2
Prokinetics metoclopramide
Alginates coating
o Anti-reflux surgery
Niesen fundoplication
Partial fundoplication
o Endoscopy dilatation of stricture
HIATUS HERNIA
Defi : prox stomach passes through the diaphragmatic hiatus into the chest
Causes:
o Adult obesity, smoking
o Early infancy congenital
Types
o Sliding type (90%)
Gastro-oesophageal junction is drawn up into the chest & segment of
stomach contricted at the hiatus
Slide up with each peristalsis
May reach huge size
Defective LOS mechanism
o Rolling type (10%)
Bulge of stomach herniates through the hiatus besides the oesophagus
Usually small
LOS mechanism intact
PHARYNGEAL POUCH
Causes
o Lack of coordination btw inf constrictor & cricopharyngeus during
swallowing (junction btw pharynx & oesophagus) causing progressive
mucosal outpouching btw 2 muscles
Clinical features
o Aspiration/ regurgitation
Occur min/ hrs after swallowing
Foul taste in mouth/ taste yesterday food
o Neck swalling
o Dysphagia
Dx
o Barium swallow
o No endoscopy will cause perforation
Mx
o Surgical excision

ACHALASIA
Epidemiology
o Young adult
o Elderly central defect
Causes
Defect involving Auerbachs myenteric plexus ( muscularis layer, whole oesophagus)

Abnormal peristalsis

Uncoordinated & inadequate relaxation of LOS

Ccardiac sphincter contricted

Prox oesophagus dilated with fluids & solids
Clinical features
o Dysphagia
Easy to take solid > fluid ( solid food tend to sink)
o Spluttering dysphagia, coughing (fluid spill over into trachea
o Vomiting, retrosternal pain
Ix
o CXR
Widening mediastinal shadow
+/- fluid level
o Barium swallow
Dilated prox
Constricted lower end
Contrast cant passes into stomach
o Fluoroscopic screening
Uncoordinated purposeless peristalsis wave
o Oesophageal manometry
Increase LOS pressure
Mx

o Hellers cardiomyotomy
Longitudinal incision of lower oesophagus & upper gastric till mucosa
bulge through
Nissen fundoplication to combat reflux
o Ballon dilatation
o Endoscopy
As f/u to exclude CA
PHARYNGEAL WEB
Circumferential mucosal folds (webs) causing annular narrowing
A/w IDA
In Plummer-Vinson syndrome

GASTRITIS
Acute gastritis
Acute mucosal inflammation, transient in nature +/- haemorrhage
Aetiology
o Drugs (NSAIDs) inhibit prostaglandin synthesis
o Smoking inhibit PG synthesis
o Alcohol chemical toxic
o Reflux biliary material after distal gastrectomy
o Stress severe burn, AMI, intracranial lesion (cushings ulcer)
o Trauma (eg by ryles tube)
o Chemotherapy
o Ischemic a/w shock, portal HPT
o Systemic infection
S&S
o Mild dyspepsia impairment of the power/ fx of digestion, epigastric
discomfort after meal
o Epigastric pain
o Nausea & vomiting
o Haematemesis/ malaena (d/t haemorrhage)
Chronic gastritis
Presence of chronic mucosal inflammation lead to gland atrophy & intestinal
metaplasia
Increase risk of gastric CA
Types
o Type A (autoimmune)
In pernicious anaemia
Pathology

Autoimmune mechanism

Progressive destruction of parietal cells

Chronic atrophic gastritis

Functional changes
Failure acid secretion (achlorhydria)

gastrin secretion

Hyperplasia of neuroendocrine cells

Failure vit B12 absorption

Megaloblastic anaemia

Mmultiple small carcinoid

o Type B
A/w H.pyloric, common at antrum

PEPTIC ULCER DISEASE

Ulcer breech in mucosa extends through muscularis mucosa into submucosa

Erosion loss of superficial epithelium of mucosa

Mechanism of protection of gastric mucosa

Anatomic intergrity of mucosa to prevent injured by acid
Mucous & HCO3- secretion
Rapid epithelium regeneration
Mucosal blood flow sweep away H+
Prostaglandin - HCO3- & mucous, blood flow, rate regeneration
Acid & pepsin secretion as jet without contact with surface epithelium
Aetiology
Helicobacter pylori - Gram Ve, rod, flagellated, grow in surface mucosa
NSAIDs/ aspirin suppress PG
Smoking impair mucosal blood flow & healing
Psychological/ stress
Zollinger-Ellison syndrome excess gastrin secretion by tumour in pancreas
Epidemiology
Age 55-65 YO, M:F 4:1
Duodenal : gastric 4:1
Sites of freq
1st duodenum (ant & post wall)

Stomach (lesser curvature & antrum)

Wwithin Barrets oesophagus

Margin of gastroenterostomy (stomal ulcer)

Dduodenum + stomach + jejunum (pt with Zollinger-Ellison syndrome)

Meckels diverticulum (that contains ectopic mucosa)

Pathology
Gross
o
o
o
Histo
o
o
o
o

Solitary, round to oval

Punched out edge, +/- raised margin, smooth floor, thick base
Mucosa fold radiate outward
Base & margin thin layer of necrotic fibrinoid debris
Active nonspecific inflammation
Granulation ts
Ficrous, collagenous scar
Predisposing factors

Acid-pepsin attack +/- breach of mucosal protection

Acute inflammation protective resolution

(gastritis) balance restore (without scarring)

Destruction of mucosa

Mucosa ulceration protective mucosal

balance restore (with min scar)

Extension through submucosal &
muscular layer (deep ulcer)

Perforation

Bleeding from

Eerosion of major

Granulation ts formed
10


mucosal surface
Peritonitis

IDA

blood vessel

Massive
haemorrhage

& attempts to repair

Chronic relapsing
Repair
ulcerartion

Considerable scarring
& distortion
+/- pyloric stenosis

Hx
Epigastric pain/ discomfort/ indigestion
o Agg
Meal (gastric)
Hrs after meal (duodenal)
o Relieve
By meal (duodenal)
By vomiting (gastric)
o Precipitated
Missing meal
Stress, anxiety
o Episodic
2-3 months cycle (gastric)
4-6 months (duodenul)
o A/w LOA, LOW, vomiting (> on gastric)
H/O
o Water/ acid brash
o Heart burn
Haematemesis/ melaena
Drug hx
o NSAIDs/ aspirin
o Steroid
Social hx

11

o Smoking
o Alcohol
o Stress
PE
Anaemia
Epigastric tenderness +/Ix
OGDS + urease test +/- biopsy of distal gastric mucosa
o Urease test
For detection of H. pyloric
Organism secrete ez to split urea into ammonia, increase the pH that
detected by the specific kits
Barium meal

Pentagastrin test gastric fx test for Zollinger-Ellison syndrome

o How?
Stomach empty by NG tube after over night fasting & measure (basal
volume)
Collection of gastric juice every 15 min for 1 hr & measure (BAO)
Gv sc pentagastrin ( synthetic, like gastrin, stimulate parietal cell to
secrete acid)
Stomach aspirate every 15 min for 1 hr (MAO)
o Interpretation
Condition
BAO (mmol/h) Basal volume MAO (mmol/h) Post stimulation
(ml/h)
volume (ml/h)
Normal
0-5
<12
1-20
250
Duodenal ulcer
5-15
60
20-60
330
(3x)
Gastric ulcer
0-5
<12
1-20
240
Zollinger>20
200
>60
360
Ellinger synd
DU VS GU
Causes

DU
Aggressive action of acid + pepsin

GU
Reduce mucosal defensive factor

12

Pain

2-3 hrs after eating

relieved by eating
agg by miss meal/ anxiety & stress
4-6 months cycle

Soon after eating

Relieved by vomiting
Agg by eating
2-3 months cycle

Mx
Conservative tx
o Life style (control predisposing fac/ agg fac)
Small, freq meal
Avoid ulcer-provoking drug
Atop alcohol
Stop smoking
Avoid irritant (coffee, acidic food, spicy)
o Drugs
Reduce acid secretion
PPI 9omeprazole, lansoprazole, pantoprazole)
Anti-histamin 2 (ranitidine)
Anti-muscarinic (pirerzipine)
Reduce effect of acid-pepsin
Antacids
PG analogs (misoprostol)
Alginate preparation (foamy layer on surface of gastric)
Mucosal protective agent sucralfate
Eradicate H. pyloric Abiotic (metronidazole + clarithromycin/
amoxicillin)
Surgical tx
o Vagotomy (laparoscopic) for chronic symptomatic duodenal ulcer
Truncal +/- pyloroplasty/ gastro-jejunostomy (ant & post vagal trunk)
Highly selective (preserve nerves of Catarjet- preserve nerve to
antrum)
Selective vagotomy +/- pyloplasty/ gastro-jejunostomy (prederve
hepatic & caeliac branch)
o Partial gastrectomy
GU
Billroth type I (remove distal or 2/3 of stomach, remnant
anastomosesd with 1st part of duodenum)
DU
Billroth type II/ polya-type gastrectomy (remove distal 2/3 of
stomach, anastomosis made to side of loop of prox jejunum,
duodenal stump is closed and ulcer left to heal)
*Cx of gastectomy
Early
o Paralytic ileus
13

o
o
o
o
Late
o
o
o
o
o

Duodenal; stump leakage & anastomotic breakdown

Stomal obst
Ac postop pancreatitis
Duodenal fistula
Malabsorption
Anaemia vit B deficiency
Regurgitation
Recurrent ulcer
Dumping syndrome
Early dumping (10-30 min postprandial)
Rapid gastric emptying
Hyperosmolar carbohydrates osmotic gradient fluid shift fr
vessel to bowel transient hypovolumic/ excessive diarrhea
Late dumping (2-4 hrs postprandial)
Large bolus of carbohydrate-rich food into small bowel
Rapid glucose absorption high glu concentration excessive
insulin rebound hypoglycaemia
Overcome by
Small, freq meal
Dry food & avoid fluid with meal
Small carbohydrates snacks 1-2 hrs after meal

Mx of cx
Bleeding UGIB sx
o Resuscitation, tx hypovolumic shock
o IV PPI
o Emergency OGDS if perfuse bleeding injection of adrenalin at bleeding site
o Partial gastrectomy if failed OGDS
Perforation of GU/DU
o Hx
Pain severe, constant, epigastric then generalized, agg by movement
H/o PUD/ drug hx NSAIDs, aspirin, steroid
o PE
Ill looking, in pain, lying still, sign of sepsis
Tender abd, broad-like rigidity
+/- liver dullness, painful percussion, +/- BS
PR pain on finger movement
o Ix

14

Erect CXR air under diaphragm

Plain AXR dilated bowel, air under diaphragm

o Mx
Laparotomy
DU simple closure
GU simple closure + omental patch/ Billroth I
Peritoneal toilet
Pyloric stenosis
o Hx
Hx of DU
Short hx of - Projectile vomiting- foul smelling, unrelated to meal,
semi-digested food, no bile contain
o PE
deH2O
Succussion splash produced by shaking pts abd side to side
Visible peristalsis
Palpable dilated stomach
o Ix
AXR dilated stomach
OGDS dx, TRO malignancy +/- dilatation
Barium meal
o Mx
Acid suppression + AB
OGDS dilatation
Open surgery
Oesophageal stricture
o Periodic dilatation
o Continuous reflux need anti-reflux surgery
Penetration ulceration through full thicknes into adjacent organ
Malignant transformation

GASTRIC CARCINOMA
Epidemiology
2nd most common CA
Age 40-60 YO
M:F 3:1
Predisposing condition
Pernicious anaemia
Atrophic gastritis polyps
Gastric adenomatous polyps
Post-gastrectomy & post-truncal vagotomy
Old age - acid production
15

Pathology
Sites
o
o
o
Gross
o

o
o

Antrum
Body
Fundus & cardia

60%
30%
10%

Ulcerative
Rolled edge
Necrotic base
Fungating
Infiltrating
Submucosal spread
Wall thickened, stomach contracted
Leather-bottle stomach
Colloid CA
A/w Krukenbergs tumour
CA 2 chronic GU

o
Histo
o AdenoCA 95%
o Carcinoid
o Sarcoma
Different
Intestinal type
Fr metaplasia
Polypoid, fungating
Well-differentiated, papillary or solid
mucin production
Expansile growth
Better prognosis

Diffuse type
De novo
Ulcerating, infiltrating
Poor differentiated, signet ring cells
mucin
Noncohesive
Worse

Hx
Epigastric pain/ discomfort/ indigestion
o Onset progressive/ change nature of pain in pt with PUD
o Not usually relieve by antacid/ eating/ vomiting
o Exacerbation by eating
o Not episodic
N&V
Early satiety
LOA, LOW
Epigastric mass
Sx of cx

16

o Haematemesis/ malaena +/- anaemia

o Obst sx
Dysphagia
Projectile vomiting, semi-digested, foul smelling
o Metastasis
Virchows node
Obst jaundice
Ascites
Thrombosis of superficial vein
Chest pain, SOB
Pelvic mass
Risk factors
o Smoking
o Chronic ulcer
o H. pylori
o Underlying gastric d/o
PA
Atrophic gastritis
Achlorhydria
Post-gastrectomy/ vagotomy
Diet (salt, nitroso compunds, vit C)

PE
General
o Cachexic
o Anaemia
o +/- jaundice
o Virchows node (Trosiers sign)
o Superficial thrombophlebitis (Trousseaus sign)
o A/w
Dermatomyositis
Acanthosis nigricans

Per-abd
o Epigastric distention/ mass
o Tenderness
o +/- liver
o Ascites (peritoneal spread)
o Sign of pyloric stenosis
Epigastric distention
Visible peristalsis

17

Succession splash

Nodules in pelvic
2 in ovaries (Krukenbergs tumour)

o PR

IX
General
o FBC Hb
o Buse deH2O
o LFT met to liver
For dx
o OGDS + biopsy
o Barium meal
o LN biopsy
Staging (TNM)
o CT abd
o U/S
o CXR
o Laparoscopic to look for met
Mx - depends on stage
Curative radical excision with 5cm macroscopically normal ts + lymphatic gland
o Pylorus & antrum
Billroth II partial gastrectomy + regional LN
o Upper/ middle 2/3
Total gastrectomy + omenta + LN + spleen +/- tail of pancreas
Roux-en-y anastomosis
o Cardia oesophagogastrectomy
Palliative
o Palliative gastrectomy pt with sx d/t blood loss
o Palliative gastrojejunostomy sx d/t obst of distal stomach
o Celestin tube sx of dysphagia
*signs of inoperability
Fixation to pancreas/ post wall/ mesentery (esp origin of sup mesenteric vessels)
LN fixity + retrograde spread to preaortic LN
Liver secondary
Peritoneal seedings
Cx
Ulceration + haemorrhage
Pyloric stenosis/ cardiac obst
Direct spread
Metastasis

18

Spread early & widespread

Direct
o Oesophagus
o Pancreas
o Transverse colon
o Mesocolon
o Liver
Lymphatic
o Local LN (celiac axis, periduodenal area) para-aortic, splenic hilum, portal
hepatic
o Virchows nodes (Lt supraclavicular)
Transcoelomic
o Ovaries
o Pelvic
Haematogenous
o Liver
o Lung
o Brain
o Bone
Prognosis
Early gastric CA confined to mucosa + submucosal irrespective of LN met > 90%
5yrs survival
Advanced gastric CA 10% 5 yrs survival

ACUTE APPENDICITIS
Anatomy

19

Pathogenesis
Obstruction of lumen (eg faecolith)

Mucosal inflame

Extend externally
Exudate extend to adjacent
peritoneal surface

localized peritonitis

Necrotic material sloughs

into lumen

Distended by pus

Appendicular artery thrombosed

Appendix infarted + gangrenous

Perforated
Generalized peritonitis

Spilled contents enveloped by omentum/ small bowel

Appendicular abscess/ mass

Hx
Classic
o Pain

o
o
o
o

Poorly localized, central, colicky (1/2 1 day)

Pain localized at Rt iliac fossa (sharp) for - 1 day
Pain extended to whole abd (peritonitis features) or become
appendicular mass
Anorexia
Toxic looking
Fever
Abd distension (ileus)

Other presentation
o Near rectum diarrhea
o Bladder/ ureter freq, dysuria, pyuria

20

o Retrocaecal psoas sign

o High retrocaecal - pain at Rt costal
o Near tube fallopian pelvic pain
PE
General
o Ill-looking, in pain
o Lying still
o Facial flush
o PR, Temperature
o faetor oris
Abd examination
o Guarding + tender
o Rebound tenderness
o Appendicular mass
o Pain on percussion
o +/- BS
o pain on PR (pelvic appendix)
o signs
Rovsing sign deep pressure LIF cause pain at RIF
Blumberg sign deep pressure at LIF + sudden release cause pain at
RIF
Psoas sign extension of hip cause pain
Copes sign flexion + internal rotation of Rt hip cause pain
Ix

FBC leucocytosis
BUSE DeH2O
Serum amylase if indicated
Urinalysis if suspect UTI
UPT
Abd X-ray
o Intestinal obst
o Air-fluid level
o Air under diaphragm
U/S if suspect gynae cause

Dx
21

Appendicitis is clinical dx
Alvarado scoring system
o Migration of pain to Rt lower quadrant
o Anorexia
o N&V
o Tender in Rt lower quadrant
o Rebound tenderness
o Temperature
o WBC > 10
*<4 exclusion
5-6 monitoring
>7 operation

(1m)
(1m)
(1m)
(2m)
(1m)
(1m)
(1m)

Diff dx
UTI
Ureteric colic
Gynaecology cause
Rupture ectopic preg
Twisted ovarian cyst
Mesenteric adenitis
o Enlargement of abd LN d/t viral infec
o High fever, +LN, no PR tenderness
Acute pancreatitis
Mx
Appendicectomy
o If clear dx and no localized mass
Ochsner-sherren regime (conservative tx)
Appendicectomy
Pre-op, gv a/biotic (metronidazole +/- cephalosporin/ gentamycin)
Technique
o Lanz incision (lower skin crease)
o Superficial fascia
o Aponeurosis + muscle opened along line of fibres (gridiron incision)
o Peritoneum opened
o Swab pus for C&S if perforated
o Locate the appendix, delivered into wound
o Blood supply ligated
o Base crush with haemostat
o Absorbable ligature is tied
o Peritoneal toilet if perforated/ gangrene/ pus found
o Abd wall closed

22

o Put drain if contaminated

Ochsner sherren regime
Analgesic
A/biotic (metronidazole, gentamycin, 3rd generation cephalosporin)
Bed rest
Charts V/S, I/O, mass progression
Diet bowel rest
Cx of appendicitis
Gangrenous + perforated
o Not walled off
Generalized peritonitis
Septicaemia, shock
Subphrenic + pelvic abscess
o Walled off
Appendix abscess intestinal obst
No perforation but obs persisted
o Mucocele cystic dilatation, may rupture myxoma peritonei mucoussecreting epi is splited loculation of mucin & adhesion
o Empyema if infected
Cx of appendicectomy
Early
o Wound sepsis
o Ileus
o Residual abscess
o DVT, pulm embolism
o Faecal fistula
Late
o Adhesion
o Incisional hernia
o Rt inguinal hernia

23

INTESTINAL OBSTRUCTION
Causes
Mechanical
o External compression (extramural)
Hernia
Adhesion
Fibrous band btw loops of bowel/ abd wall
Intestinal slide & become trapped (internal hernia)
Volvulus
Twisting of loop of bowel at the base of attachment
(mesentery)/ around an abN fibrous band
Commonly small bowel, sigmoid colon (elderly), caecum
(younger in malrotation of bowel)
Intussusception
Telescoping of one segment of bowel (proximal) into another
(distal)
Risk in
Infants during weaning expose to new Ag
hypertrophy of lymphoid follicles pushed into lumen
adults polypoid tumour
Large intraabdominal tumours
o Intrinsic lesions (intramural)
Malignant tumour
IBD
Diverticular dz
Outpouching of mucosa of intestine
Type
True hv all layers of intestinal wall
False mucosal herniation through weakened wall, no
muscularis externa, only mucosa & fibrous
TB granuloma thickening of wall healed by fibrosis
Congenital strictures & atresia
Acquired stricture eg. Radiation damage
o Luminal occlusion (intramural)
Foreign material
Polypoid tumour
Gallstone ileus
Ascaris worms

24

Meconium in cystic fibrosis

Functional
o Paralytic ileus post-op/ peritonitis/ low K+
o Bowel infarction embolus in mesenteric vessels
o Hirschsprungs dz infants, congenital megacolon d/t abN mesenteric plexus
o Metabolic disturbances/ drugs
o Smooth muscle dz
Pathology
Bowel obst

Accumulation of gas, fluid, faeces

Bowel distension
Initial phase of
enhanced peristalsis

Immobility/ atony

Increase pressure in
colonic lumen

Ischemic of bowel
(mucosa to wall)

Ulceration

Perforation

Peritonitis

Dilated bowel

Anti/ retroperistalsis

Vomiting

Loss of fluid & electrolyte

deH2O, electrolyte imbalance

Bacterial growth

Breakdown products

Proteolysis of wall

Diffusion of toxic material

into peritoneal cavity

Toxaemia
(endotoxic shock d/t
gram ve bacteria)

Intestinal strangulation:
Intestinal & vascular pedicle constricted

Immediate venous occlusion (continued arterial supply)

Progressive venous engorgement of bowel

Congestion, oedema of bowel

(mucosal infarction, interstitial haemorrhage, oedema)

Increasing bulk of intestine

Complete venous & arterial occlusion

Strangulation of bowel

25

Gangrene of bowel
(haemorrhagic infarct)
Bacterial proliferation

Wet gangrene, toxic transudate

across bowel wall into peritoneum

Perforation

Peritonitis
toxaemia, shock

Hx
Abdominal pain
o Colicky
o Site
Upper abd foregut
Middle abd midgut
Lower abd hindgut
o Onset
Sudden small bowel
Gradually large bowel
Vomiting
Upper small bowel
Lower small bowel
Large bowel
Onset
Start early & freq
Delayed & less freq
Delayed 2-3 days
A/w colicky pain Coincides
Several hrs after pain
Content
Semi-digested food
Semi-digested food
Faeculant
Opalascent
mucoid Opalascent
mucoid
gastric juice to water gastric juice to foul
green bile
smelling & dark brown
Degree
of Early & severe
Variable
Uncommon
deH2O
Abd distention
o High obst not much distention
o Lt side colon caecum grossly distended (if ileocaecal valve competent)
Absolute constipation
o No faeces, no flatus
o High obst occur late
o Distal obst occur early
PE
General
o Pt in pain?
Rolling colicky
Lying still peritonitis
o deH2O
Sunken eyeball
skin turgor
Dry mouth & tongue

26

 PR, BP, weak pulse

o Fever, tachycardia suggest strangulation
o +/- anaemia
o LN

Per abd
o Inspection
Abd distention
Visible peristalsis
o Palpation
+/- tenderness
+/- rigidity & guarding
+/- rebound tenderness
o Percussion
+/- pain
Resonant/ dull
o Auscultation (BS)
Loud, freq, high-pitched, tinkling - peristalsis
Absent ileus
o Signs of strangulation
Sign of obst
Abd tenderness, rigid, guarding, rebound tenderness (local)
o Signs of perforation (peritonitis)
Local to generalized
Severe deH2O (exudates to peritoneal cavity)
Toxaemia/ sepsis
Absent BS
PR anterior tenderness

Ix
General
o FBC TW, anaemia
o BUSE deH2O
o ABG to detect metabolic acidosis
o GSH
AXR
o Supine detect dilated bowel, detect gas-filled loops (proximal to obst)
o Erect detect air-fluid level
o Caecum > 12cm risk of perforation

27

Urgent barium enema

o Large bowel obst, less acute
o To detect site of obst, nature of obst, diff btw mechanical or pseudo-obst
Colonoscopy in large bowel obst that less acute
*most acute I/O dx after exploratory laparotomy

Mx
Initial resuscitation
o NBM
o NG tube
o Fluid resuscitation (transfuse if needed)
o Correction of electrolytes
o Correction of metabolic acidosis/ alkalosis
Operative tx
o Depend on the cause of I/O
o May delay 1-2 days
o Emergency laparotomy if strangulated + peritonitis
o Type
Adhesion adhesiolysis
Remove intraluminal obst open intestine (foreign body, gallstone
ileus)
Resection of obst/ strangulated intestine with anastomosis
Bypassing obst by proximal anastomosis
Formation of external stoma in large bowel perforation

28

PER RECTAL BLEEDING

Defi bleeding beyond ligament of treitz (DJ flexure)

Hx to ask
o Colour
Fresh (red) from anal/ rectum
Altered blood (black)
Black, tarry (stool become fluidy) malaena, d/t rapid bleeding from
UGIT
o Relation to stool
Mix with stool prox fr sigmoid
On the surface of stool
Separate fr the stool follow defaecation/ passess itself
Blood on toilet paper
Causes of PR bleeding
o Colorectal CA
o Haemorrhoid small volume, a/w defaecation, fresh
o Polyps
o Diverticular dz
o Angiodysplasia
o Inflammatory bowel dz bloody diarrhea
o Ischaemic colitis bleed + abd pain

29

COLORECTAL CA
Epidemiology
o 3rd causes of death fr CA
o 60-70 YO
o M=F
o 1/3 fr rectum
o fr rectum

Risk factor
o Family Hx (1st degree relatives)
< 50 YO dx colorectal CA
> 1 1st degree relative with colorectal CA
o Underlying bowel d/o
Polyps
Familial adenomatous polyposis (FAP)
Ulcerative colitis
o Diet
Low fibre, high fat increase transit time causing more contact with
carcinogen/ reduce in antioxidants

Pathology
o HPE

o Macro

AdenoCA 95%
Adenosquamous CA ( lesion close to anus)
Small cell CA
Cauliflower
Ulcerative
Tubular
Annular

30

o Spread
Local exophytic then ulcerative & invade muscular layer then serosa
& extracolic TS
Lymphatic mesenteric then para-aortic, LN at portal hepatis may
cause obst jaundice
Haematogenous later then lymphatic, via portal vein to liver, enter
syst vein to bone & lung very late
o Diff btw Rt & Lt side
Rt
Lt
Bowel diameter
Larger
Smaller
Stool consistency
> fluidy faecal stream
Harder
Lesion
> polypoid
> annular
Mass
Narrow obstruction
Bleeding

Symptom
o PR bleeding degree of blood mix with stool determine the site of lesion
o Altered bowel habit
Constipation, diarrhea
Early morning bloody diarrhea get up to defaecate, pass blood +
mucous
Narrow stool caliber
o Tenesmus
Persistent defaecation response with painful straining but without
resultant evacuation
D/t lesion at lower 2/3 of rectum (perceive as mass of faecal)
Spurious diarrhea pt try defaecate several times/ day with passing
flatus & little blood stained mucous
o Pain
Colicky- obstructive
Constant pain local advanced
o Abdominal mass
o Perforation causing peritonitis
o Fistula
Into stomach/ bladder/ uterus/ vagina/ skin
o Constitutional
LOW/ LOA/ fever/ malaise/ anaemic sx

Sign
o
o
o
o

Abd mass
Hepatomegaly
LN
Ascites
31

o PR
Mass palpable if 12cm fr anal verge
Mass at ant rectal wall spread to pouch of douglas)
Fixation of mass to surrounding
Blood + mucous + stool color + consistency
o General
Anaemia/ wasting/ supraclavicular LN

Ix
o General condition
FBC anaemia
Buse obst, poor oral intake
o Protoscopy
TRO local cause of bleeding ( eg. Haemorrhoid)

o Sigmodoscopy/ colonoscopy + biopsy

Rigid sigmoidoscopy scope up to 25cm (50% detect rate)
Flexible sigmoidoscopy scope up to splenic flexure (75% detect rate)
Colonoscopy scope up to caecum ( for primary lesion + synchronous
polyps/CA)
o Double contrast barium enema
Choice to examine prox segment if scope cant pass through the lesion
o Carcino-embryonic antigen (CEA)
CEA only present in embryonic & fetal ts
Not dx but for progression, effective of tx and recurrence
o For met
U/S abd liver met
CT abd
IVU ir ureteric involvement
o Others
Plain AXR in acute obst ( dilated bowel in supine film, air-fluid level
in erect film)
Instant barium enema (without bowel prep) to exclude pseudoobstruction

Mx
o Resection
Principles
Laparotomy
Remove affected segment with at least 5cm normal margin

32

 Rectal CA, only 2cm distal margin (to preserve anal sphincter,
lymphatic drainage is prox direction)
Resect lesion + mesentery + LN
Anastomosis end to end/ colostomy
Op depend on site of lesion
Rt hemicolectomy (CA caecum/ ascending colon)
Transverse colectomy (CA transverse colon)
Lt hemicolectomy (CA descending colon)
Sigmoidcolectomy (CA sigmoid colon)
CA rectum
Anterior resection tumour > 7cm fr anal verge
Abdominal perineal resection (APR) + permanent
colostomy tumour < 7cm fr anal verge
Hartmanns operation excise rectum prox end for
end colostomy oversewn rectal stump further op
for anastomosis (good for patient present emergency)
o Adjuvant radiotx
Give pre-op to shrink large/ tethered tumour
To enable anal sphincter preserved
Reduce local recurrence
o Chemotx
De grammont regime/ mayos regime ( centain 5-FU and folinic acid)
o Palliative
Resect lesion to relieve local effect, to reduce blood loss
Liver met if confirm to resectable anatomical lobe, partial
hepatectomy
Painful met radiotx
Painful liver met direct infusion 5-FU into lever
Staging (Dukes criteria)
Stage
Defi
A
Confined to bowel wall, no extracolic ts, no LN
B
Extend to extracolic ts, no LN
C1
Local LN
C2
Involve LN up to prox limit of resection
D
Distant met
LN which surgical incurable

5 years survival
75%
55%
40%
20%

Cx of large bowel operation

o Early
Wound infec
Intra-abd abscess
Anastomosis leak/ breakdown
33

o Late

Sepsis
Damage to other organ
Stoma problems
Persistant diarrhea (short bowel)
Impotence (Division of pelvic parasympathetic nerve)
Adhesion (small bowel obst)

ADENOMAS/ POLYPS
Site same as colorectal CA
Gross patho
o Pedunculated ( with stalks)
o Sessile (broad base)
HPE
o Tubular adenoma (75%) almost as normal mucosa
o Tubulovillous (15%) btw tubular & villous
o Villous adenomas secrete K+ rich mucous cause hypoK+
o Risk of malignancy increase fr tubular to villous
o Malignant also change proportional to size
Clinical features
o PR bleeding
o Excessive nucous discharge
o Tenesmus if distal lesion
o IDA
o Prolapsed polyps through anus
o Intussusception
Ix
o Sigmoidoscopy rigid/ flexible diathermy + biopsy

34

o Barium enema / colonoscopy for 1 lesion & to detect synchronous polyps/

CA

Mx
o Diathermy + biopsy
o Follow up with regular colonoscopy

Familial adenomatous polypoisis

Autosamal dominant
Polyps at childhood
100% malignant changes early adult

HAEMORRHOID
Epidemiology
o of population
o M>F
Causes
o Hereditary
Congenital weakness of vein walls
abN large arterial supply to rectal plexus
o Straining (defecation/ micturation)
o CA rectum
Compress/ thrombosis of superior rectal vein
o Pregnancy
Compression of venous return by gravid uterus
Progesterone with relaxing effect
Pathogenesis
Straining
intra-abd pressure

Pelvic floor sag downwards

35

Obstructed venous return

Venous plexus engorged

Minor mucosa prolapsed

Bulging mucosa dragged distally by stool

Trauma by stool bleeding

Obst by anal sphincter obst VR thrombosed
Venous strangulation & ulceration
Thrombosed fibrosis atrophy skin tag

Classification
o Internal above dentate line (covered with mucosa) , contain internal
haemorrhoidal plexus, will bleed but no pain
1st degree bulge but not prolapse
2nd degree prolapse during defaecation but reduce spontaneously
3rd degree - prolapse during defecation & reduce only by manually
4th degree - prolapse & cannot reduced
o External - below dentate line ( covered by squamuos epithelium), contain
external haemorrhoidal plexus, not bleed but thrombose and 2 scarring and
cause skin tag

Hx
o PR bleeding
Painless, fresh, on paper/ separated from stool
o Prolapse
+/- reduce +/- manually
o Pruritus + discharge
Mucous discharge
o Pain/ aching discomfort
D/t thrombosis/ strangulated (a/w late pregnancy/ after delivery)
o Anaemia (rare)

PE
o Inspection
Visible ext. Haemorrhoid/ skin tag
Oedematous, congested purplish mass (thrombose)
Necrosis, ulcerated
36

o PR

Not palpable unlaess thrombosed

Increase anal tone (thrombosed/ strangulated)
Exclude rectal mass (CA)
o Proctoscopy
Visible int. Haemorrhoid (normally 3, 7, 11 oclock in lithotomy)
For banding
o Sigmoidoscopy / colonoscopy
In older patient presented with PR bleeding, even with visible
haemorrhoid should at least proceed to sigmoidoscopy to exclude CA
Colonoscopy if highly suspicious
For banding
Acute presentation
o Thrombosis/ strangulation
Mx
o Treat acute presentation
Bed rest
Ice finger
Lignocaine gel LA for pain relief
Laxative
Sitz bath
Tab Daflon high dose
Avoid acute haemorrhoidectomy more complication, conservative
mx 1st then proceed to haemorrhoidectomy/ banding later
o Conservative
Avoid constipation give laxative (eg.syr lactulose)
Avoid straining no reading/ minimal time spend for defecation
Keep perianal area clean sitz bath, clean after defecation
Manual reduction for 3rd degree haemorrhoid
o Medical
Daflon reduce venous engorgement ( ? action)
o Surgical
Injection of sclerosants
Indication 1st degree & 2nd degree not regress with
conservative tx
How?
As outpt

Use proctoscope

3-5 ml 5% phenol in oil injected submucosally (not in the

vessels)

Cause fibrotic reaction

37


Atrophy

Repeat 2-3 occasions at interval of 4-6w

Banding/ ligation
Use Barrons bands to obliterate the vessels
How?
Suck a cone of mucosa above the haemorrhoid with banding
instrument

Shoot the band

Vvessels constricted
Haemorrhoidectomy
Indication - 3rd degree/ failed conservative tx
Milligan & Morgan
How?
Prophylaxis antibiotic, anaesthesia

Mass excised with overlying mucosa & some skin

nd
The defect heal by 2 intension & wound contracted
Cryosurgery
Apply liquid nitrogen
Extreme cold (-196C) cause coagulation necresis
Cx excessive mucous discharge
Photocoagulation
Apply infra-red coagulation
Advocated for tx of not prolapsed haemorrhoid

DIVERTICULAR DISEASE
Acquired condition d/t bowel motility & stool consistency (esp at sigmoid colon)
Clinical presentation
o PR bleeding acute, massive, fresh.
o Abd pain infected (diverticulitis)

Tx
o Infected antibiotic (metronidazole)
o Acute bleeding colectomy
ANGIODYSPLASIA
Vascular malformation a/w aging (>60YO)

38

Dilated, tortous submucosal veins

Commonly caecum/ Rt colon
Dx
o Angiography
o Colonoscopy
o Radioisotope
Tx
o Colonoscopic diathermy
o Colectomy

ISCHAEMIC COLITIS
Fresh blood (fairly)
A/w abd pain
INFLAMMATORY BOWEL DIASEASE
Hx
o Chronic recurrent diarrhea
Frequency, amount, content
? blood stained
? with mucous
o Cramping abd pain
Site
Severity
o Systemic sx
Fever, LOW, malaise
o Cx
Anaemia
deH2O
Symptoms of perforation & peritonitis
o Ass disease
Athropathy (joint pain)
Uveitis & iritis (painful, red eyes)
Skin lesion (tender, red nodules/ purulent skin lesion)
Liver failure, jaundice (sclerosing cholangitis)
o Family Hx
PE
o General
deH2o
Wasting
Anaemia
Joint pain
o Abd
Tenderness

39

Inflame mass (in CD)

PR
Perianal fissures/ fistular/ crohns piles
Nodular surface or rectal mucosa
Sigmoidoscopy
Cobblestone appearance (fissured ulceratin)
Biopsy

Ix
o General
FBC Hb
BUSE deH2O, electrolyte
ESR
o Barium enema
To see the extent of involvement (UC)
o Barium follow through
Used in CD
Findings
Narrowing lumen
Nodularity & cobblestoning
Deep fissured ulceration
Fistula
o Colonoscopy
Multiple biopsies (to differentiate btw UC & CD)
Excision/ biopsy of polyps
TRO malignancy
o Stool FEME
Exclude bacterial & paracitic causes

Differences btw UC & CD

Ulcerative colitis
Sex
F>M
Family Hx 6-8%
Pathology
Mucosa inflammation (mucosa &
submucosa only)

Crohns disease
F=M
20%
Transluminal inflame, discrete
segment
40


Neutrophil infiltration

Crypt abscess

Small superficial ulcers

Coalesce & extensive

Irregular ulceration & pseudopolyps

Days to months to years

quiescent periods
Acute inflammation resolves
Mucosa regeneraye
Lamina propria cont chronic
inflammation

Site
Macro

Micro

Major sx
Major sign
Ix

gland
Fibrosis
goblets cells

Dysplastic Less haustration

shorten colon
AdenoCA (lead pipe colon)
Large bowel

Deep fissured ulcers

cobblestone appearance

Non-specific granulomatous
inflame

Cchronic inflame

Ffibrosis

Tthickened wall & narrowing

Colon mucous + bloody
diarrhea
Small bowel impaired
digestive
&
absorptive
function
Ileum - bile salt
reabsorption gallstone
Transmural

serosal
inflame
causing
local
peritonitis

Mouth to anus
Commonest terminal ileum
Mucosal inflame & bleed
Wall thickened
Pseudopolyposis + ulceration
Lumen narrow
Cobblestone appearance
Fistulas & abscess
Skip lesion
Mucosal + submucosal inflame
Transmural inflame
Continuous, ill-demarcation btw Well demarcation btw normal &
inflame & normal mucosal
abN area
Granulomas
No granulomas
Goblet cells depleted
Normal goblet cells
Crpyt abscesses
+/- crypt abscess
Diarrhea blood + mucous
Cramping abd pain
More systemic illness
Non-specific
Fissures, fistula, abscess, RIF pain,
mass
Barium enema show extent/ lead Small bowel follow through string
pipe colon
sign (deep ulceration & narrowing)
41

Mx

Mild to moderate attacks rectal

steroid
(prednisolone
enemas/
hydrocortisone foam)
Severe exacerbation short course
high-dose steroid
Serious ill IV steroid
Immunosuppressive
drugs
(azathioprine) if steroid failed
Aminosalicylate

oral,
maintaine=ance to prevent relapse
Supportive anti-diarrhea/ high
protein & calories diet/ iron
Surgery
Indication
o Fulminant cases
o Toxic
megacolon/
perforation/ haemorrhage
o Chronic disabling
o Children
with
retardation/ FTT
o Malignant changes
types
o Proctocolectomy

permanent
ileostomy
with removal of anal
sphincter
o Sphincter-preserving op
rectal stump remain
after total colectomy
use terminal ileum to
fashion
ileo-anal
colectomy

anastomosed

Barium enema in large bowel dz

Exacerbation high-dose oral
steroid/ immunosuppressive drug
(as steroid sparing agent)
Maintenance aminosalicylate
Perianal dz oral metronidazole
(d/t 2 infection)
Supportive anti-diarrhea/ diet/
iron, folate, B12
Surgery
indication
o Unresponsice to steroid
o Acute Cx
o Persistent local ileal dz
o Intolerable long term sx
(obst/ pain/ perianal dz)
o Entero-cutaneous
fistulae
types
o Stricturoplasties

enlarging lumen
o Simple resection &
ETEA in limited dz
o Pan-proctocolectomy
with ileostomy in large
bowel dz
o Abscess drainage
o Fistula must do
surgery

PERIANAL ABSCESS
Aetiology
+/- ducts obstruction

Infection of anal glands

42


Intersphincteric abscess

Upwards
Downwards
Laterally

Supralevator
Perianal
Ischiorectal
abscess
abscess
abscess

Hx
o Perianal pain
Severe, throbbing
Agg by sitting, moving, defecation
o Lump
Tender
+/- dischanrge
o Systemic
Fever
Malaise
LOA
Sweating, rigors

PE

o General
Fever
Tachycardia
deH2O
o Perianal examination
+ tenderness, + increase temperature, + redness
+ mass palpable
+/- fistulae, scars, sinuses
Differential dx
o Crohn dz
o Pilonidal abscess
o Tuberculous abscess & fistula
Tx
o Early abscess antibiotic
o Antibiotic (cloxa + metronidazole)
o Surgical drainage (I&D + EUA)
Intersphincteric abscess internal sphincterotomy
Ischiorectal abscess drained via perianal skin
Supralevator abscess drainage by incision via rectal wall
EUA (examination under anesthesia) to exclude anal fistulae)
o Sitz bath, daily dressing
FISTULA IN ANO

43

Type

Hx
o
o
o
o
o
o

Intermittent watery/ mucous/ purulent discharge

Recurrent pain
Pruritus ani d/t discharge makes the skin wet & macerated
H/o of perianal abscess
H/o IBD diarrhea, abd pain, LOW, PR bleeding
H/o CA rectum tenesmus, PR bleeding

PE
o Small opening (papilla) on the skin 2-3cm of anal margin
o Discharge
o +/- tenderness
Tx
o Low type fistulotomy
o High type
Seton insertion
Colonostomy fistulotomy + sphincter repair colonostomy
reversal

LIVER FUNCTION TEST

44

1. Serum enzyme
Aspartate aminotransferace (AST)
o Mitochondrial ez
o in infiltrating dz (both membrane & mitochondrial damaged)
Alanine aminotransferace (ALT)
o Cytosol ez
o in inflame dz (> membrane damaged)
Alkaline phasphatase (ALP)
o In canalicular & sinusoidal membranes
o in biliary obst/ space-occupying lesion/ infiltrative dz
5-nucleotidase
o ALP
Gamma glutamyl transpeptidase (-GT)
o ALP
o in pt ingest drug (alcohol, phenytoin, barbiturate)
2. Excretory products
Bilirubin
Bile acid
Serum ammonia
3. Syn products
Serum albumin
o Long T1/2, level N in acute liver dz
o Indicate severity of chronic liver dz
o level is bad prognostic sign
Coagulation fac
o All syn by liver except VIII
o II, VII, IX, X vit-K dependent (use PT as indicator)
Cholesterol/ cholesterol-derived hormones
o cholesterol
o hormone, eg testosterone
Globulin
o in chronic dz
o d/t phagocytosis by Kuppers cells of Ag for gut

antibody production in spleen & LN

45

INTRODUCTION TO LIVER DISEASE

Hepatic injury
Removal of 75% liver produce minimal functional effect
If connective tissue framework intact restitution can occur
Types of liver injury
o Inflammation (hepatitis)
Injury to hepatocytes & influx of acute/ chronic inflammatory cells
o Degeneration
o Necrosis
o Fibrosis
o Cirrhosis
Hepatic failure
Aetiology
o Massive hepatic necrosis
Fulminant viral hepatitis
Drugs/ chemical-direct toxic
o Chronic liver dz
o Hepatic disfx
Hepatocytes viable but unable to perform normal fx
Reyes syndrome
Acute fatty liver preg
Tetracycline toxicity
Diff btw acute & chronic liver failure
Acute
Chronic
Causes
Massive necrosis/ reyes/ fatty Progressive necrosis & fibrosis
liver preg/ tetracycline toxicity (cirrhosis)
Jaundice
Yes
Yes
Hypoglycaemia
Yes
?
Bleeding tendency
Yes
Yes
Hepatic
Yes
Yes
encephalopathy
Hepatorenal synd
Yes
Yes
Portal HPT
No
Yes
Low albumin
No
Yes
Fetor hepaticus
No
Yes
Endocrine changes
No
Yes

46

HEPATITIS
Viral hepatitis
Aetiology
o Hep A, B, C, D, E
o Yellow fever
o Cytomegalo virus
o Herpes simplex
Clinical pathologic syndrome
o Carrier stage
HAV & HEV no carrier stage
Without sx, transmission
o Asymptomatic infection
No sx , serology evidence only
o Acute viral hepatitis
Incubation period
Infectivity occur
Symptomatic pre-icteric phase
Malaise, fatigue
LOA, LOW
Low grade fever
Skin rash
Symptomatic icteric phase
When jaundice appear (conjugated hyperbilirubinaemia)
Dark color urine, light color stool
Pruritus
Convalescence
Sx clear
o Chronic viral hepatitis
Defi symptomatic, biochem, serologic abN of continuing/ relapsing
hepatic dz for > 6 months
Not by HAV, HEV
Clinically
Asymptomatic
Viral serology +ve
Minimal chronic hepatitis
Minimal sx
Mild biochem abN
Inflammation restricted to portal triad
Little/ no active hepatocytes necrosis
Minimal fibrosis

47

 Chronic active hepatitis

Necrosis
Portal triad severe inflame, extend to lobule
Portal fibrosis
Cirrhosis
*death d/t cirrhosis or hepatocellular CA
o Fulminant hepatitis
Acute liver failure a/w submassive/ massive necrosis
1% in HBV, HCV, greater in co-infec (HDV & HBV, HEV in preg)
High mortality rate
Autoimmune hepatitis
70% female
Absence viral aetiology
IgG, titres of autoantibody
5% progress to cirrhosis

ALCOHOLIC LIVER DISEASE

Types
o Hepatic steatosis/ fatty liver
o Acute alcoholic hepatitis
o Alcohol cirrhosis
Hepatic steatosis/ fatty liver
D/t
o Shunting normal substrate catabolism towards lipid biosynthesis
o Impaired secretion of lipoprotein
o Increase peripheral catabolism of fat
Fat accumulate as droplets, large liver, soft, yellow & greasy
Reversible
Acyte alcoholic hepatitis
Cause swelling & necrosis increase ez level
S&S
o Acute fever
o Jaundice
o Tender hepatomegaly
o Non-specific LOA, LOW, abd discomfort, malaise
Alcoholic cirrhosis
Progressive fibrosis & loss architecture
S&S

48

o Non-specific malaise, weakness, LOW, LOA

o Cirrhosis sx
Ascites, oedema
Jaundice
Portal HPT
Hepatic encephalopathy
Bleeding
Hepatorenal syndrome
Endocrine changes

LIVER CIRRHOSIS

Characteristic
o Hepatocytes necrosis
o Fibrosis
o Nodular regeneration
o Disruption of architecture
o Diffuse involvement
Pathogenesis
Stimulation of fibrosis

Type I & II collagen deposited

In all portion of lobule

Alteration in sinusoidal endothelial cells

Disruption of blood flow

Portal HPT

impaired diffusion of solutes

Btw hepatocytes & plasma

albumin, clotting factors, lipoprotein

Clinical features
o Non-specific
o Chronic liver failure
o Portal HPT
Haematemesis/ maelena d/t gastrooesophageal varices rupture
Ascites
Splenomegaly
Caput medusae
*premalignant lesion hepatocellular CA
Aetiology
o Cryptogenic (10-15%)
No cause identified

49

 May follow immune-mediated/ drugs/ chemicals

o Alcoholic (60-70%)
Progress slowly
Evidence of fatty changes/ acute alcoholic hepatitis
o Viral-induced (10%)
In chronic active hepatitis
Serology evidence of Hep B & C
o Biliary (5-10%)

o Haemochromatosis
Iron overload
Familial
Secondary causes
o Wilsons dz
excretion of copper in bile, total body copper & accumulate in
kupffer & hepatocytes
extrapyramidal dysfx
deposit in sclerocorneal jx
o 1-antitrypsin (ATT) deficiency
abN synthesis of ATT in liver & accumulated
o Galactosemia
Galactose metabolites accumulate in Hc
a/w cataracts & mental retardation
Portal hypertension
Elevation of portal venous pressure > 12mmHg
Types
o Presinusoidal/ prehepatic
Obst by thrombosis/ neoplasm/ inflame of extrahepatic portal vein
Transmission of arterial pressure through arteriovenous fistula
Massive splenomagaly shunt excessive blood into splenic vein
o Sinusoidal/ intrahepatic
90% caused by cirrhosis
o Postsinusoidal/ posthepatic
Hepatic vein outflow obst
Rt heart failure
Constrictive pericarditis
Effect
o Ascites
o Porto-systemic anastomosis
o Splenomegaly d/t long-standing congestion causes enlargement

50

o Hepatic encephalopathy
Ascites
Defi collection of fluid in peritoneal cavity
Content
o Protein rich from lymph
o Neutrophil influx infection
o Red cell disseminated intra-abd cancer

Pathogenesis:
Impaired liver fx

albumin

hypoalbuminaemia

sinusoidal HPT
aldosterone metabolism

fluid into space of Disse

hyperaldosteronism

removed by hepatic lymphatic water & Na+ retention

exceeding thoracic duct capacity

percolation of protein rich fluid of hepatic lymph

ascites

long standing

transdiaphragmatic lymphatic

hydrothorax (rt site)

Portosystemic anastomoses
Principal sites
o Rectum (haemorrhoid)
o Cardio-oesophageal jx (oesophageal varices)
o Retroperitoneum
o Falciform ligament, periumbilical & abd wall collaterals(caput medusae)
Pathogenesis
Portal vein & systemic vein anastomoses

blood bypass

dilated & toutous

excludes detoxification

51


ruptured

hematemesis, melena
anaemia, death

hepatic encephalopathy

Hepatic encephalopathy
Cerebral dysfx
o Hypersommia
o Altered consciousness
o Behaviol abN (confusion, stupor)
o Coma
o Rigidity, hyperreflexia, asterixic (flapping tremors)
Pathogenesis
Loss Hc fx in detoxification
shunting blood
nitrogenous products of GI bacteria accumulate in systemic blood
eg, ammonia, amides

Cross brain barrier

Act as false neurotransmitter

Oedema & neuronal degeneration

Hepatorenal syndrome
Occurance of renal failure in pt with liver dz
Hypothesis
False neurotransmitter

Sympathetic nervous system

Vasoconstriction

renal blood flow

CHILDS CRITERIA
52

For assessing operative risk in portal HPT

1
Encephalopathy
X
Ascites
X
Bilirubin
<35
Albumin
>35
PT ratio
<1.4
A
Good
5-6
B
Moderate
7-9
C
Bad
10-15

2
Minimal
Slight
35-50
28-35
1.4-2.0

3
Marked
Moderate
>50
<28
>2.0

LIVER ABSCESS
Defi wall-off collection of pus within liver parenchymal
Type
Pyogenic
Amoebic
Fungal
Route of entry
Portal triad
o Ascending biliary tract infec
o Portal vein (fr GIT)
o Hepatic artery (haematogenous)
Adjacent structure lung abscess, empyema
Trauma
Pyogenic liver abscess
Agents
o E.coli
o S.aureas (haematogenous route)
*multiple abscesses
Amoebic liver abscess
Agent E. histolytica
Patho
o Large abscess, solitary, thin wall
o Rt > Lt
o Pus anchory sauce

53

Clinical features
Swinging high fever, +/- night sweat, LOA, LOW
Rt hypochondriac pain
Jaundice
Hx of sepsis else where
Ix

FBC leucocytosis
LFT
U/S liver
CXR exclude basal lobe pneumonia/ collapsed

Mx
General tx IV fluid, pain analgesic
AB Metronidazole, cephalosporin
Surgical drainage large abscess > 7cm/ clinically not respond a/biotic/ sepsis

HEPATOCELLULAR CARCINOMA (HEPATOMA)

Epidemiology
80% of 1 liver malignancy
Age 40-60 YO (developed countries), 20-40 YO (developing countries)
M>F 3:1
Rt > Lt lobe
Pathology
Slow-growing
Gross
o Massive single large
o Nodular cluters of nodules
o Diffuse widespread
Causes
Cirrhosis alcohol, Hep B,C, metabolic d/o
Aflatoxins
Presitic infestation schitosomiasis, echinopcoccus, clonorchis sinensis
Hx
General Low fever, no LOW & LOC
Rt hypochondrium pain, dull, persistent
Stigmata of chronic liver dz
Hx of alcohol, Hep B, billirady dz
PE
General
54

o Cachexic
o Stigmata of liver failure
Hepato +/- spleenomegaly
Ascites

Ix

LFT - transaminase
Tumour marker AFP
U/S liver for dx
CT scan to localize site
FNAC HPE

Tx
Localized dz hepatectomy
Advanced dz
o Hepatic arterial ligation + local chemo
o Chemoembolization
o Liver transplant ( high recurrence rate)
2 tumour
20x > 1
50% fr GIT
o Stomach
o Large bowel
o Pancreas
o Breast
o Lung
o Kidney
o Ovaries
Growth of liver met rapid than 1 site
CF
o Asymptomatic
o LOA, LOW, fever
o Dull pain
o Fullness of epigastrium
o Jaundice (rare)
Ix
o LFT
o AFP negative
o U/S

55

GALLSTONE DISEASE

Epidemiology
o Increase risk in (5F) fat, fertile, fair, female, forty
Types of stone
o Cholesterol (6%)
Large, smooth, egg-shaped, solitary
Yellowish
Radiolucent
o Pigment (Ca bilirubinate) in haemolytic dz with excess bilirubin
0.5-1.0cm, uniform, multiple
Jet-black
Radiolucent
o Ca carbonate (rare) d/t excess Ca excretion
Feceted, grayish
Radiopaque
o Mixed (90%) cholesterol + pigment + Ca
Multiple, diff size, irregular, hard faceted
Near white yellow green black
10% radiopaque
Aetiology
o Metabolic
bile cholesterol

56

bile salt (oestrogen effect, enterohepatic circulation)

o Infection
Act as nidus
o Bile stasis
gallbladder contractility (oestrogen, preg, truncal vagotomy)
o Haemolytyic dz
Cinical presentation
o Cholelithiasis
Biliary colic
Acute cholecystitis
Chronic cholecystitis
Cholecysto-duodenal fistula +/- gallstone ileus
Ca of gallbladder
o Choledocholithiasis
Obstructed jaundice
Acute pancreatitis
Ascending cholangitis

BILIARY COLIC
d/t intermittent cystic duct obstruction and contraction of gallbladder
Hx
o Sudden severe, upper abd pain (RHC)
o Increase to plateau (minutes) constant resolved spont (hrs)/ analgesic
o N&V
o Previous episode
PE
o No fever
o Mild tender RHC
o If pain > 24 hrs suggest acute cholecystitis
Mx
o Analgesic
o U/S for dx
o Cholecystectomy
ACUTE CHOLECYSTITIS
d/t physical/ chemical irritation + bac infec (E.coli, Klebsella, strep. Faecalis)
Hx
o RHC pain, sudden, constant, severe

57

o
o
o
o
o

Severe N&V
Fever high grade
LOA
Previous attack/ jaundice
Hx of flatulent dyspepsia (indigestion) felt full after meal with belching &
heartburn

PE

o General
Fever, tachycardic, sweating, lie still
o Abd
movement
Tender, guarding RHC
+ Murphys sign press 9th ribs tip, ask pt to breath in, pt catch breath
Mass
Boass sign hyperesthesia of skin below scapula
Patho
Transient obst
biliary colic
Persist obst
ac cholecystitis
Inflame
mucocele (distended with mucous)
Infec
empyema of gallbladder
Gangrene + perforated local abscess/ generalized peritonitis (usually perforation at
fundus which is far fr blood supply )

Ix
o FBC leucocytosis
o Blood C&S
o U/S HBS
Confirm dx
Distended bladder with thick wall
Stone
o HIDA assess fx of gallbladder

Tx
o Conservative
NBM + IVD + NG aspiration
Analgesic
A/biotic
o Surgical
Do when acute inflame subside fat-free diet then cholecystectomy
Open/ laparoscopic (preferred) +/- CBD exploration or ERCP

58

CHRONIC CHOLECYSTITIS
Defi chronic & recurrent infec of gallbladder
Sx
o Flatulent dyspepsia
o Pain
RHC
Radiate to Rt shoulder
+/- N&V
Agg by large meal/ fatty food
Not > 24 hrs (> 24 hrs consider acute cholecystitis)
Only relieved by analgesic
o Episodes of attack, previous h/o jaundice, pale stool, dark urine, stetorrhoea
PE (in acute attack)
o Tenderness
o +ve Murphys sign
Ix
o U/S stones, thick wall, CBD size
Tx
o Analgesic
o Low-fat diet
o Cholecystectomy
CA OF GALLBLADDER
d/t chronic irritation
adenaCA
clinical features
o as chronic cholecystitis
o jaundice if tumour obst bile duct
CHOLECYSTO-DUODENAL FISTULA
Gallbladder inflame

Adherent duodenum

Stone ulcerating

Fistula formed

Large cholesterol stone pass out

Impacts at distal ileum (narrowest)

Gallstone ileus

59

CHOLEDOCHOLITHIASIS
Small stone passed out fr gallbladder

Stay in CBD + enlarge in situ

Lodge at lower end (narrowest of CBD)

Progressive/ intermittent jaundice (stone as ball-valve)

Dilatation of CBD
* gallbladder not distended (Courvoisiers law) d/t fibrosis/ mural hypertrophy
Clinical presentation
Asymptomatic
Obst jaundice
Ac pamcreatitis
Ascending cholangitis
Bile stasis + duct dilatation

Infection

Ascend to intrahepatic duct

If serious acute suppurative cholangitis

*Charcots intermittent hepatic fever
fever swinging
pain
jaundice
MX OF GALLSTONE DISEASE
Asymptomatic (accidental finding fr U/S) - no tx
Symptomatic cholelithiasis
Dx from U/S
No S&S suggest of CBD stone
Pt not jaundice

treat acute attack with a/biotic and analgesic

acute phase subside

lap cholecystectomy (preferred)

open cholecystectomy

+/- operative cholangiography

60


if stone present

exploratory of CBD

ERCP

Percutaneous transhepatic cholangiography

(PTC)
noted filling defect

endoscopic sphincterotomy
+
stone extraction
bile duct stenting
Cholecystectomy

Jaundiced pt

U/S
Stone
Dilatation of duct system
Tumour

open cholecystectomy
+ CBD exploration

open chole + CBD exploration

if failed

Open chole + CBD exploration

Laparoscopic cholecystectomy
Cystic duct ligate with metal clips
C/I
o Abd infec
o Late preg
o Major bleeding disorder
Open cholecystectomy
1. Ligate cystic artery & divided
2. Ligate cystic duct near gall bladder
3. +/- on table cholangiography
4. Divide cystic duct
5. Stump ligated with absorbable tie
6. Gallbladder disserted out of liver bed

61

Operative cholangiography
1. Small incision of cystic duct
2. Cannula inserted + ligation secured
3. Contrast injected
4. X-ray/ fluoroscopy
CBD exploration
1. Duct cut longitudinally
2. Retrieve stone
3. Operative choledochoscopy with fibreoptic
4. T-tube inserted to drain bile externally
5. Closed
6. 1-2 weeks later, T-tube cholangiography to ensue no stones remain
7. Off T-tube if no stone remain
*if CBD grossly dilated / if multiple stone proceed to choledocho-duodenostomy
(anastomosis btw CBD & duodenum)
- d/t stone adhere and dilated CBD remain boggy post-op, this cause bile stasis and stone
reform
Indication of endoscopic sphincterotomy
1. Urgent drainage in cholangitis (high risk of infec if open surgery)
2. Retrieval of stone missed at operation
3. Pt unfit for surgery
4. Acute pancreatitis d/t gallstone
5. Pre-op stone retrieval for jaundice pt for elective cholecystectomy

Cx of billiary surgery
Retained stone
Biliary peritonitis
o d/t leaking chemical peritonitis
o if infec generalized peritonitis + sepsis
o Tx with a/biotic
Bile duct damage
o d/t unrecognized ligation of CBD/ fibrotic stricture
o tx urgent re-exploration/ recontraction
Haemorrhage
o Trauma to cystic/ hepatic arteries
Ascending cholangitis/ other infec d/t
o CBD exploration in jaundice pt (gv prophylaxis a/biotic)

62

o Reflux of intestinal content via anastomosis

ACUTE PANCREATITIS
Defi sudden onset of diffuse inflammation of pancreas reversible anatomy &
physiology fx.
Causes
G
gallstone & obst
E
ethanol (alcohol)
T
trauma
S
M
A
S

steroid
mumps
autoimmune (PAN, DM)
scorpion venom

63

H
E
D

hyperlipidaemia, hyperCa, hypotemia

post-ERCP
drugs (azathioprine, asparaginase, diuretic)

Pathophysiology
Activation of pancreatic ez in gland
mild
local
interstitial oedema
peritoneal exudates
+/- fat necrosis
(Ca sequeatered in area of necrosis)

severe
activation of complements
& kinin system
SIRS
shock
ARDS
ARF
DIC

pancreatic necrosis
infected
necrotizing
pancrestitis
(gram ve)

pancreatic abscess

Hx
Epigastric pain
o Sudden, constant, severe, agg by movement, radiate to back
o Pt lie still & breath slowly (peritonitis)
o Pancreatic position (leaning forward)
N&V + retching (very freq)
Fever
Causes
o Eaten unusual large meal, large alcohol consumption
o Drug hx
o h/o ERCP done, mumps, trauma
Cx
o Muscle cramps
o SOB, shock, ARF
PE
General
o Lie still
o Respi distress
o Hypovolumic pale, sweety, weak pulse, increase PR, low BP
o Jaundice
o Oedema
Abd
o Inspection
Abd distended
Grey Turners sign (bruises/ discoloration over left flank)
Cullens sign (bruises/ discoloration aroung umbilicus)

64

o Palpation
Tender, rigid, guarding
Epigastric fullness (lesser sac exudates pseudocyst/ abscess)
o Percussion
Resonant
Dull if pseudocyst
o Auscultation - +/- BS (might have paralytic ileus)
Others
o Lt pleural effusion

Ix
Serum amylase (>1000) on adm for dx and daily to chart progression
Ix for scoring
o FBC WBC + haematocrit
o LFT AST, LDH
o RBS
o ABG PO2, base excess
o RFT urea + Ca2+
Abd x-ray
o Reverse 3 sign dilated duodenal c-loop + duodenal oedema
o Sentinel loop localize segment of dilated gas-containing in duodenum/
terminal ileum/ ceacum
o Colon cut-off sign dilated transverse colon with abrupt change to gasless
descending colon
o Moderate distended duodenum with air-fluid level
U/S abd
o Pancrease swollen, hypoechoic
o Peripancreatic fluid collection
o Stone
ERCP Diagnostic & therapeutic
Abd paracentesis/ laparoscopic if dx uncertain
o Clear fluid (mild)
o Dark (severe)
o Foul smelling + bac
Mx
Mild
o Analgesic
o Bowel rest NBM, IVD, NG tube aspiration
o Tx cx
o Tx the cause if any
Severe
o Adm ICU
o Analgesic + a/biotic

65

o Bowel rest
o Resuscitation IVD, monitor I/O, CVP
o Tx cx
hypoCa
ARDS (ventilator support)
o Peritoneal lavage - reduce systemic absorption of ez
o Surgery/ endoscopy
Debridement
Infected necrotizing pancreatitis
Infected peripancreatic fluid
Stone removal
Elective cholecyctectomy + operative cholangiography
Cx
Early
o
o
o
o
Late
o

Shock d/t 3rd space loss, GI loss, interstitial space loss

ARF
ARDS
HypoCa - d/t fat necrosis, hypoalbuminaemia

Pancreatic pseudocyst
Fluid exudates collection in lesser sac
Clinically, se amylase remain high, ileus and mass palpable
Ix by U/s & CT scan
Tx
>10cm CT guided percutaneous drainage
observe 6w
o Pancreatic abscess
2 infec of necrotic ts
High swinging fever
Ix U/S
Tx operation
o Colonic stricture
Long term (rare)
o DM
o Malabsorption

Scoring & prognosis

Ranson criteria (one score each)
On admission
o Age >55YO (no stone, > 70YO (gallstone)
o WBC >16
o Glucose >10

66

o AST >100
o LDH >350
Next 48 hrs
o Haematocrit >10%
o Serum urea >10
o hypoCa <2.0
o PO2 <60mmHg
o Base excess > -4
o Estimated fluid sequestration > 6L
Severe 3
Mortality rates
o 0-2
2%
o 3-4
15%
o 5-6
40%
o 7
80%

Modified Glasgow criteria

P
PaO2
< 60mmHg
A
Age
>55/ >70
N
Neutrophil
>16
C
Ca2+
<2
R
Renal (urea) >10
E
Ez (LDH)
>350
A
Albumin
<32
S
Sugar
>10

PANCREATIC CARCINOMA
Epidemiology
60-70 YO
M>F
67

Exocrine > endocrine

Exocrine
o Benign cystadenoma
o Malignant
Ductal adenoCA (90%)
Acinar cell CA (2%)
cystadenoCA (1%)
Endocrine
o Insulinoma
o Gastrinomas
Head (70%), body & tail (30%)

Risk factor
Smoking
Previous resectional gastric surgery
Nitrosamines & N-nitroso compounds ingestion
Patho
Poor differentiated
Spread early
o Local CBD, portal vein, sup mesenteric vessels, duodenum, stomach, SI
o Lymph celiac, para-aortic, supraclavicular LN, portal hepatic LN
o Blood liver (via portal vein)
o Peritoneum/ omentum
Hx
Upper abd pain indicate local invasion
o Severe, constant, radiate to back
o Nocturnal
o Not relieved by analgesic
o Pancreatic position
LOA & LOW d/t malabsorption/ reduce intake/ liver disfx
Obst
o Obst jaundice
Block CBD/ LN at portal hepatic
Insidious onset
Dark urine, pale stool
+/- pruritus
o Acute pancreatitis block pancreatic duct
o Gastric outlet obst
Disturbances of fx
o Exocrine
Steatorrhoea/ malabsorption
68

o Endocrine - DM
Thrombophlebitis migrans recurrent thrombosis of superficial vein

PE

Cachexia & wasting

Hepatomegaly
Palpable gallbladder (Courvoisiers law)
LN

Ix
U/S abd
o Mass
o Dilated pancreatic duct/ CBD
o Hepatic met
ERCP
o Peripapillary lesion
o Duct dilatation
o Duodenal aspiration for HPE
CT abd
o Enlarged pancreas
o LN, liver met
o Invasion locally
Percutaneous biopsy use U/S or CT controlled
Laparoscopy
o Small lesion
o Peritoneal fluid cytology
Mx
Head + < 3cm resectable
> 5cm unresectable
Surgical whipples operation
o Pancreatoduodenectomy
Palliative
o Pain relieve
o Tx jaundice
Bypass
Stenting
Peripapillary CA
Defi juxtapancreatic CA (CA ampulla/ duodenal CA/ CA of lower CBD
Less aggressive, slow grow & met
Present early with obst jaundice & occult GI bleed

URINARY STONE (UROLITHIASIS)

69

Defi calculus at any level of urinary collecting system

Epidemiology
Often arised st kidney/ bladder
M:F 2:1
Familial tendency
80% unilateral
Types of stone
1. Calcium oxalate calculi (70%)
Excessive excretion of uric acid provide a nidus for Ca deposition
Hypercalciuria cause deposition
Small, hard, jagged, cause mucosa damage
2. Phosphate calculi (15%)
UTI by proteus (urea splitting bacteria) produce ammonia urine alkaline
Bacteria serve as nidus
Solitary, large, soft
Enlarging form staghorn calculus
3. Uric acid stones (10%)
A/w gout/ hyperuricaemia/ in dz involving rapid cell turnover
Radiolucent
4. Cystine stones
Genetically defect in renal transport of certain amino-acid (eg cystine)
When urine acidic
Semi-opaque
5. Xanthine stones
Rare
Radiolucent
Hx
Pain
o Loin pain (renal colic)/ loin to groin pain (ureteric colic)
o Chronic/ recurrent/ intermittent
o a/w N&V
Urinary sx
o Haematuria
o Sandy urine
o Acute urinary retention (AUR)
Sign of infection
o Dysuria
o Pyuria
o Fever
Sign of renal failure
70


PE

Dietary hx for hyperuricaemia, hypercalciumia, less water intake

In pain
Abdomen soft, non-tender
Ballottable kidney hydronephrosis
Palpable bladder in AUR

Ix
Urine
o Urine dipstick test
o Urine FEME - +ve erythrocyte +/- leucocyte
o Urine C&S
FBC sign of infection
BUSE/ creat to assess renal fx
Test for metabolic d/o
o Ca2+, phosphate, oxalate, uric acid
o 24 hrs urinary Ca2+, uric acid, cysteine
KUB X-ray 90% radio-opaque
U/S KUB
o Can detect most of the stone
o Hydronephrosis
o Degree of parenchymal impairment
Intravenous urography (IVU)
o Take pre-injection/ 20 min/ after micturartion X-ray
o Can detect size, site of stone accurately (filling defect)
o Can detect present of obstruction
Contrast studies
o Percutaneous (anterograde) pyelography
o Ascending (retrograde) ureterography
Mx
1. For acute renal/ ureteric colic
o Analgesic
o Encourage water intake
2. Stone removal
o Indication to remove stone
Obstruction
Infection
Persistent, recurrent, severe pain
Stone likely to cause future obst/ infec
Metabolic stone which will grow rapidly
in pt where colic pain could be disastrous, eg pilots
o Factor affect technique of stone removal
71

Size & site

Nature of stone
Availability of expertise & equipment
Need to correct congenital/ acquired structural abN

Cystoscopy
For bladder & lower 1/3 ureter stone
Stone broken by lithopaxy (lithotrite)/ stone crushing jaws/ U/S/ laser
How?
o Fragment washed out by irrigation
o Dormia basket (<0.5cm0
o Ureteroscope
o Ureteric stenting (after repeated instrumentation)
Open surgery
Rarely done now
Indication
o Other techniques not available/ not indicated/ failed
o To correct abN
How?
o Pyelolithotomy
o Ureterolithotomy
o Cystolithotomy
Percutaneous techniques
Perc nephrostomy
o + stone removal by dormia basket/ steerable grasping tool
o +/- fragmentation 1st
o Indication (to preserve renal fx
If complete obst
If infec
Extracorporeal shock wave lithotripsy (ESWL)
Apply external shock wave (U/S) to fragment the stone
Stone pass out in urine (may cuase ureteric colic/ obst) ureteric stent before ESWL
3. Long term mx
Tx metabolic d/o
Good fluid intake
f/u for
o stone not remove
o recurrent stone

72

ACUTE PYELONEPHRITIS
Defi suppurative inflammation of kidney & renal pelvis by bacteria infec
Aetiology
E.coli, proteus, klebsiella, enterobacter, pseudomonas
2 routes
o Haematogenous
o Ascending infec
Pathogenesis

Colonization of distal urethra

Move against urine outflow ascend to bladder

Ascend to ureter, pelvis & parenchymal

Suppurative necrosis & abscess

Predisposing factors
o Obstruction (stasis)
o Vesicourethral reflux
o Urethral instrumentation
o Short urethra (female)
o Trauma
o Diabetes
o Structural abN

Pathology
Uni/ bilateral
+/- enlarged kidney
Discrete, raised abscesses on cortex, pelvis covered with exudates
Extension to perinephric (perinephric abscesses)
Hx
Pain
o Loin/ lumbar pain
o Sudden onset, constant
Fever

73

PE

Ix

o High grade, A/w chills & rigors

Urinary sx
o Dysuria
o Pyuria
o Freq
Fever, sepsis looking
Renal punch +ve, ballotable kidney
FBC leucocytosis
BUSE/creat renal fx
RBS TRO DM
Urine
o FEME leu +++, +/- erythrocyte
o Urine C&S for sensitivity
U/S
o For dx
o For underlying cause stone, structural abN
After acute event
o IVU
o Micturating cystourography (MCU) in children

Mx
Hydration
Analgesic
A/biotic ciprofloxacin, unasyn (depend on sensitivity)
Surgical drainage if pyonephrosis
Cx
Gram ve sepsis with shock
Pyonephrosis
o When infec with obstruction
o In hydronephrotic kidney
o Dilated pelvicaliceal filled with pus
o Tx surgical/ percutanous drainage
Perinephric abscess
o At perinephric fat
o A/w staghorn calculi
o Tx drainage
Renal papillary necrosis
o A/w DM pt/ analgesic abuse
o Coagulative necrosis at papillae & slough into calicea
74

Emphysematous pyelonephritis
o A/w DM
o Anaerobic bacteria fementation of glucose with gas formation

CHRONIC PYELONEPHRITIS
Defi chronic interstitial inflammation with scarring of renal parenchymal
Aetiology
Chronic obstructive pyelonephritis
o Mechanical calculi, BPH, tomour, structural abN
o Paralytic neurogenic bladder
o Recurrent infec
o 50% h/o acute pyelonephritis
Reflux nephropathy
o Congenital vesicourethral reflux/ intrarenal reflux
o Superimposed with UTI
o Uni/ bilateral
Pathology
Diffuse/ pathy
Irregular scarring & contraction
Deformity of pelvicaliceal syst
Hydronephrosis
S&S
Graduallt onset may progress to CRF
HPT
Pyuria, mild proteinuria, bacteuria
Bilateral involvement tubular dysfx with loss concentrating ability polyuria,
nocturia

75

RENAL CELL CARCINOMA

Epidemiology
o Arise from renal tubules
o 3% of adult malignancy
o M:F 2:1
o 50-70 YO
Clinical features
o Triad
Haematuria
Mass
Loin pain
o Para-neoplastic syndrome
Erythropoietin polycythemia
Rennin HPT
PTH-like protein hyperCa2+
o Fever
o Cx
Anaemia
Secondary to lung/ bone
Ix
o FBC TW/ Hb
o Renal fx
o ESR
o U/S KUB solid mass
o CT + IV contrast
Defined renal vein & IVC spread
Detect invasion of paranephric ts, LN, liver met
o Arteriography
For segmental resection
Therapeutic embolisation to vascularity before surgery
76

o CXR
Staging
Stage I
Confined to renal capsule
Stage II
Confines by Gerotas perinephric fascia
Stage III
Renal vein & LN involvement
Stage IV
Distant met
Mx
o Radical nephrectomy
Kidney + perinephric fat + LN

BLADDER CARCINOMA

Transitional cell Ca
>50 YO
M:F 3:1
4x > RCC
Aetiology (urinary excretion of carcinogen)
o Smoking
o Industrial exposure
o Hairdressers
Clinical features
o Haematuria
o Incontinence (near bladder neck)
o Hydronephrosis (near ureteric orifice)
o Uraemia (bilateral ureteric obst)
o Infec
Ix
o General FBC, renal fx
o U/S KUB
o Cystoscopy (dx) + transurethral resection of bladder tumour (TURBT)
Tx
o Tumour resection (T1, T2)
o Total cystectomy +/- neoadjuvant chemo + single dose intravesicle chemo
(prevent recurrant) + urostomy (use ileum) (T3)
o Radiotx unfit/ old/ relapse
o Palliative radiotx to reduce pain & haematuria

77

PROSTATE

Anatomical median + 2 lat lobes

Surgical median + 2 lat + post + ant lobes
Weight 20-25g

BENIGN PROSTATIC HYPERPLASIA

weight of prostate
Age > 50 YO
Pathogenesis
o Hormonal changes androgen/ oestrogen ration stimulate glandular &
stromal hyperplasia
Gross
o Enlarge
o Firm, rubbery consistency
o Diffuse small nodular +/- cystic changes
Micro
o Nodular hyperplasia of paraurethral transitional zone Glandular ts proper
compressed peripherally
o Infarction of nodules acute swelling + AUR
o Infarction in periurethral nodule haematuria
Pathophysiology
Prostatic obstruction
residual urine (chronic retension)
Detrusor ms
hypertrophy

Ttransmit pressure
to upper tract

Quick reach
threshold

intravesical pressure
Stagnant

Bladder distension
& atony
78

Ttrabeculated wall Hydronephrosis

incontinence

Renal parenchymal
Further pressure
damage

Sacculation diverticula
urine stasis
Stone

Frequency

Infection

Outflow

Hx
o Sx of prostatism
Obst features
Hesitancy
Poor stream
Dribbling
Sense of poor emptying
Episodes of near retention
Irritative features
Freq
Urgency
Nocturia
Incontinence
o Acute urinary retention
Precipitate by bladder overfilling (excessive fliud intake)
Precipitate by surgical procedure

PE
o Palpable bladder
o PR
Enlarge prostate diffusely
Smooth
Firm, rubbery
Median sulcus +
Rectal mucosa move freely over the gland
Pelvic floor normal

Ix

79

o U/S KUB
Estimate residual urine
Dilatation of upper tract
o RFT
o Midstream urine exclude infec
o Prostatic specific antigen (PSA) exclude prostate CA
o Transrectal U/S of prostate & needle bx
o Cystoscopy
Bladder outlet obst
Trabeculation, diverticula, tumour, stone
Uretral stenting (in elderly unfit pt)

Mx
o Pharmacology
Finasteride
Block ez 5-alpha reductase (testosterone cannot convert to
dihydro-testosteron)
6 month trail
60% respond
Selective -adrenagic blocking agent
Relax bladder neck & open prostatic urethal
o Relieve chronic retention
Indication
> 750ml retention
abN RFT/ dilated upper tract
Catheterization 3weeks
Why?
Allow detrusor ms recover
Allow correction of reversible RF
Cx massive diuresis causing electrolyte & fluid imbalance
o Urethral stenting
o Transurethral resection of prostate (TURP)
Remove bulk of prostate but leave the compressed normal peripheral ts
(protect subcapsular venous plexus which will bleed if traumatized)
Preserve sphincter mechanism
How ts cut off chip by chip with cutting diathermy wire loop, irrigate
with isotonic solution to wash away debris
Bladder neck incision (BNI) if neck hypertrophy present
Cx
Fail ejaculation
Erectile impotence
Urethral stricture
Haemorrhage
Damage sphincter mechanism

80

o Retropubic prostatectomy
When very large gland (cannot do TURP)/ a/w bladder diverticula/
huge stone
o Long term catheterization/ stenting
By suprapubic catheter/ CBD/ stenting
Indication
Unfit for surgery
Severely debilitated, demented/ immobile
Incontinence d/t ext sphincter damage (previous surgery)
Sacral neurogenic bladder

PROSTATE CARCINOMA
Epidemiology
o Familial, white skin, >65 YO
Etiology
o Environmental factors
o Androgen most CA arise at subcapsular region at post lobe (most sensitive
to androgen
o Increase risk in previous vasectomy
Pathology
o Gross
Hard, irregular, ill-defined
o Micro
AdenoCA from glandular epithelium (arise in peripheral glandular
proper ts)
Spread
o Locally, through capsule to
Pelvic fat
Seminal vesicle
Base of bladder
Ureter
Rectum

81

o Lymphatic
Iliac, para-aortic, inguinal LN
o Haematogenous
Lumbosacral spine (early) d/t subcapsular venous plexus drain
directly into spinal venous syst (Batsons plexus)
o Syst haematogenous late

Hx
o
o
o
o

Sx of prostatism (appear suddenly & progess more rapid) late sx

Back pain
Pelvic pain
RF

PE
o Palpable bladder
o PR
Asymmetrical enlarges, irregular
Hard knobbly
Obliterated median sulcus
Tethered rectal mucosa
Winging of prostate d/t infiltration of pelvis & rectum at lateral
gland
o Sn of met
LN
Bone

Ix

o Tumour marker
Acid phosphatase
PSA
For progression & severity
False positive in prostatitis & BPH (but rarely reading very
high)
o Transurethral U/S + bx
For dx, size & staging
o X-ray lumbosacral spine
Osteosclerotic lesion
Cotton-wool appearance
o Others
Bone scan
CXR
FBC
LFT
Staging

82

T1
no tumour palpable
T2
confined within prostate
T3
extend beyond capsule
T4
fixed to neighbouring structure
Mx
o Early stage (T1, T2, No, Mo)
Watch & wait
Total prostatectomy (remove prostate to distal sphincter + seminal
vesicle reconstruction. Anstomosis to urethral, LN resection)
Radical radiotx
o Locally advanced (T3, T4, N0, M0)
TURP for bladder outlet obst
Neo-adjuvant/ adjuvant radiotx
+/- hormonal tx
o Metastases dz (N+, M+)
TURP for bladder outlet obst
Local radiotx for painful met
Hormonal tx

TESTICULAR SWELLING
Testicular swelling
Painful

Painless

Testicular tortion
Epididymoorchitis (TB, Gonorrhea, Chlamydia)
Strangulated hernia
Acute haematoma

cystic

solid

Hydrocele
thick wall hydrocele
Spermatocele

haematoma
Neoplasm
Varicocele
Lipoma

83

HYDROCELE
Defi abN collection of fluid in tunica vaginalis
Types
o (1)
Unknown cause
> 40YO/ children with patent processus vaginalis
Asymptomatic till large & tense
Vaginal (most common) only tunica distended
Infantile (rare) patent processus till inguinal ring, cannot get
above
Congenital d/t PPV, connect with peritoneal cavity, in
children < 1YO and resolve spontaneously
Hydrocele of cord fr remnant of processus vaginalis along
spermatid cord, positive testis retraction test (swelling move
down & < mobile when testis pulled downward)
Causes
Excessive production (2 cause)
Defective absortion (1 cause)
Interference with lymphatic drainage
Connect btw peritoneal cavity
o (2)
Wwith underlying pathology
20-40 YO
Rapid appear, small, palpable testis
Contain altered blood
Causes
Trauma
Infection
Tumour
Hx
o Swelling
Pain? Discomfort?
size?
Rel/ agg fac (lying, heavy job)
o Ass Sx
Urinary freq, painful micturation (epididymoorchitis)
LOW, LOA
o Not affect fertility
PE
o Inspection
Scrotal swelling, normal skin, oval
o Palpation

84

o
o
o
o

Non-tender (tender in 2 cause)

Not increase in temperature
Smooth surface, well defined
Not reducible, no cough impulse, non-pulsatile
Soft, mobile, fluctuant (hard if calcified)
Unable to palpate testis
Dull percussion
No BS
+ve translumination test
others
LN
Para-aortic LN (fr testis)
Iliac LN (fr covering of testis & cord)
Inguinal LN (skin of scrotum)
Abd exam + PR

Ix

o U/S to exclude testis pathology

Tx depend on size
o Lords operation (mild) Plicate the redundant tunica
o Jaboulays operation (moderate) Partial excise tunica vaginalis & everted
behind epididymis
o Subtotal excision of hydrocele (large) Excision except a thin rim around
testis
o Herniotomy in cong hydrocele
o Others
Aspiration repeated (old pt, unfit for op)
Injection of sclerosant (tetracycline)
Cx
o Rupture (spontaneous/ trauma)
o Herniation of hydrocele sac through dartus muscle
o Haematocele (spontanoues/ trauma)
o Calcification of sac
o Trauma
VARICOCELE
Defi dilated and tortous of the veins of pampiniform plexus of the spermatid cord
Lt > Rt 9:1
In 10% of young males
Causes
o Unknown
o Lt testicular vein drained to Lt renal vein ( pressure)
o Rt testicular vein drained to IVC
o RCC invade renal vein obstruct blood flow cause varicocele
Clinical features
85

o Scrotal swelling
Dragging discomfort
Arching pain
o Infertility
Increase scrotal temperature which inhibit normal sperm function and
cause testicular atrophy
PE
o
o
o
o

Empty on supine (except d/t RCC)

A bag of worm
+/- cough impulse
Small/ soft testis (atrophy)

Ix
o U/S kidney if
Short Hx
Rt site
Elderly
Not collapsed on supine

Tx
o Surgery if
Pain
Oligospermia
To preserve spermatogenesis (in children/ adolescent)
o Types of surgery
Varicocectomy
Open surgical ligation of testiculat cein at deep inguinal ring
Embolisation of testicular vein percutaneously via femoral vein

EPIDYDIMAL CYSTS (SPEMATOCELE)

Defi fluid-filled cystic swelling which connected to epididymis
Epididymal cyst contain clear fluid
Spermatoceles contain fluid with spermatozoa (-ve translumination test)
Clinically hydrocele except
o Testis palpable
o +/- multilocular surface (multiple cysts)
o +/- translumination
86

Tx excision
o C/I in bilateral young patient
o Excison cause obst sperm passage infertility

HAEMATOCELE
Defi collection of blood within tunica vaginalis
Causes
o Trauma
o Malignancy
o Post-op
Acute haematocele
o Clinically hydrocele
o ve translumination
o Tender
Chronic haematocele
o Clot contract harden
o Clinically testicular tumour/ gumma (testis atrophy)
o Non-tender, not fluctuant
o Loss testicular sensation (clot cause ischemic necrosis)
Explore testis from firm Dx

TESTICULAR TUMOUR
Epidemiology
o 25-35 YO
o 1 of malignancy
o Undescended testis 30x more
Classification

87

o Geminal 96%
Seminoma (fr seminiferous tubules) 60%
Non-seminoma (NSGCTs) 40%
Teratoma (fr totipotent cell)
chorioCA (trophoblastic ts) hormonal effect + hCG
yolk sac tumour
embryonal CA (undifferentiated)
o Non-geminal 4%
Hormonal effect
Sertoli cell tumour feminization
Leydig cell tumour produce androgen (propuberty/
feminization)
No hormonal effect
Orchioblastoma
Supportive ts tumour eg. Lipoma, fibroma
Seminoma
30-40 YO
Histologically cannot diff fr RCC
Rapid grow but confined within tunica albuginea
Spread
o Llymph
Para-aortic
Inguinal LN (if scrotal skin involved)
o Blood lung & liver (late)
Radiosensitive
Teratoma
20-30 YO
Highly malignant in adult, benign in children
Rapid grow
Histo structure fr 3 geminal layer
o Ectoderm (squamous epithelium)
o Mesoderm (cartilage, smooth muscle)
o Eendoderm ( respi epithelium)
Gross variegated with area of cystic/ necrotic/ haemorrhage
Spread blood early
Less radiosensitive

Hx
o Painless scrotal swelling
o Might have acute pain & tender
88

o
o
o
o
o
o
o
o

Aching/ dragging pain if very large

Malaise, LOW, LOA suggest met
Abd pain/ distention if para-aortic LN very large
Leg swelling lymphatic & venous obst by LN
2 hydrocele
Iinfertility
Precocious puberty
Feminization gynaecomastia

PE
o Swelling
Scrotal
Non-tender
Irregular shape
Smooth surface, irregular if involve the tunica albuginea
Hard, dull, non-fluctuant, not transluminated
+/- attachment
o LN
para-aortic/ iliac/ inguinal
o Others
Liver
Supraclavicular LN
Auscultate lung (collapsed, pleural effusion)
Diff Dx
o Chronic epididymo-orchitis
o Haematocele
o Gumma
Ix
o U/S scrotal
Hypoechoic
Solid testicular mass
o Serum tumour marker
-fetoprotein (AFP)
pre-op for Dx
post-op to monitor progress/ residual/ recurrent
yolk sac/ teratoma
hCG
chorioCA
teratoma 50%
embryonal 90%
seminoma 10%
LDH
Metastatic seminoma (>50%)

89

o Staging
CXR
CT scan thorax
Abd U/S liver
o Direct surgical examination (orchidertomy)
Exploratory via inguinal incision (avoid scrotal skin)
Temporarily clamp spermatic cord (preclude venous spread)
Testis examined
If malignant orchidectomy (divide cord at internal ring)
If Dx doubt Bx & examined immediately under frozen section then
+/- orchidectomy
Staging
I
testis only
II
retroperotoneal LN
A
LN < 2cm
B
LN 2-5 cm
C
LN >5cm
III
LN above diaphragm
IV
extraLN spread (lung, liver)

Mx depend on histo type & staging

Type
Stage
Mx
Seminoma
I
Orchidectomy + radio to paraaortic LN
IIa + IIb
Orchidectomy + radical radio to
para-aortic & iliac LN
Advanced Above + chemo (cis-platinum,
etoposide, bleomycin)
Non-seminomatous
I
Orchidectomy +/- LN dissection
II
Orchidectomy + chemo
III
Orchidectomy + chemo + remove
large metastases

Prognosis 5 yrs
>90%
>95%
75%
80%
80%
60%

NOTES
Tumour that cannot take Bx/FNAC
Testis
Kidney
Hydatid cyst
Ovary
Hemangioma in liver
Pheochromocytoma

90

Paratid CA

EPIDIDYMITIS/ ACUTE EPIDIDYMO-ORCHITIS

Defi infection of epididymis with some inflame changes of testis
Causes bacterial infec
o E. coli
o Chlamydia trachomatis
o Neisseria gonorrhoeaes
Hx
o Painful swelling
Acute onset, unilateral
Relieved by supporting the scrotum
o Sx of infec
Fever, malaise
o Sx of UTI
Freq, dysuria
PE
o Unilateral swelling with inflame changes
o Testis palpable
o 2 hydrocele
o No LN palpable
o +/- skin attachment (if infection spread to skin)
Tx
o Bed rest
o AB doxycycline
o AB sensitivity fr blood/ urine/ urethral C&S
Others
o TB epiddymo-orchitis
Via blood/ urinary tract spread
Scrotal lump dull aching, Sx of 1 TB
PE no pain, hard, knobbly, irregular surface, no LN
o Chronic epididymitis
Chronic scrotal swelling and tender
d/t
Ppersistent infection
Inadequate Abiotic during acute infection
o Orchitis
Most d/t mumps virus
Bac infec very rare
4-6 days after parotitis
Painful 2 hydrocele
Bilateral will cause infertility

91

HERNIA
Type
o Inguinal hernia
Direct
Indirect (>)
o Incisional hernia
Occur if the recurs not properly closed
Normally within 1 yr of surgery
Normally bowel content
o Umbilical hernia
Congenital
Centrally
Everted umbilicus
Noticed after separation of umbilical cord
Use tip of finger to feel the defect
Reducible
Normally small defect, no need surgical intervention, some will
disappear itself
If large, need surgical intervention because risk high risk of
strangulation
Use mayos repair
Acquired
Peraumbilical
Hernia from periumbillical, push umbilical to one side
o Epigastric hernia
Sx like peptic ulcer dz
Pain after meal
Irreducible
mass
o Femoral hernia
From femoral canal
Below inguinal ligament/ medial end of groin crease
Point downward & laterally
No cough impulse, not reducible, dullness
Cause strangulation easily
Richters hernia content omentum & extreperitoneal fat

92

Inguinal hernia
Definition protrusion of abd content through its containing wall in inguinal region
Anatomy of inguinal canal
4cm. oblique, fr deep to superficial ring
Walls
o Ant ext oblique aponeurosis + int oblique ms
o Post fascia transversalis + conjoint tendon
o Roof arching fibres of int oblique ms
o Floor inguinal ligament + lacunal ligament
Cover of inguinal canal
o Ext epermatid fascia fr ext oblique aponeurosis
o Cremasteric (L1, L2) ms fr int oblique ms
o Int spematid fascia fr transversalis fascia
Content of inguinal canal
o 3 arteries
Testiculat a.
Cremasteric a.
Artery to vas deferens
o 3 nerves
Genitofemoral n.
Ilioinguinal n.
Sympathetic n.
o 3 structures
Pampiniform plexus
Vas deferens
Lymphatic
Differences btw direct & indirect
Direct
Indirect
Through hesselbach triangle
Through deep ring
Old pt posterior wall weakness
Young pt patent processus vaginalis
Hernia sac transversalis fascia
3 fascia like in spermatid cord
Usually not enter scrotum
Enter scrotum
Less cx
More cx
Can feel the defect
Not feel the defect
*only academic importance, mx same btw two

93

Hx
Age all age
o Peak
1st few months of life
late teens/ early 20s
40-60 YO
Sx
o Inguinal & inguino-scrotal swelling - size slowly, reducible ?, agg factor
o Pain/ discomfort
Sx of intestinal obst
o Abd pain colicky
o Vomiting
o Abd distension
o Constipation
o PR bleeding
Risk factor
o H/o heavy lifting job
o Chronic constipation
o Chronic difficulty in micturation
o Chronic cough
o H/o appendicectomy weakens the muscle, accasionally divides the
subcostal/ ilioinguinal nerve (L1)
PE
Inspection
o Pear/ oval shape
o Size
o At inguinal +/- extended to scrotum
o Skin normal color, no dilated vein, no ulceration, no discharge, scar (red if
strangulated)
o +/- cough impulse
Palpation
o non-tender unless strangulated
o not increase temperature unless strangulated
o Ill-defined margin, cannot get above the swelling
o Smooth surface
o Soft/ firm
o Mobile
o Not attach to overlying skin or underlying structure
o Translumination test negative
o Palpate the spermatid cord
o Reducible +/o Ring occlusion test

94

Press on deep ring and ask pt to cough

+ve (no cough impulse if press, hernia recur if release) indirect
-ve (cough impulse present +/- pressing the deep ring) direct

Percussion
o Dull omentum
o Resonant bowel
Auscultation
o BS + if contain bowel
Other
o Abd sign of intestinal obst, intraabd mass, palpable bladder
o PR BPH
o Respi COAD, PTB
Differential dx
Undescended testis
Cyst of canal of duct woman
Hydrocele/ lipoma of spermatid cord
Iliac nodes
Large femoral hernia (rare)
Ix

FBC, BUSE for pre-op assessment

CXR TRO cause of chronic cough if any
AXR if sign of intestinal obst
U/S of swelling if doubt of dx

Classification of hernia
Reducible
Irreducible - d/t adhesiuon btw sac & content or big size & over crowded of the
content
Obstructed
o Irreducible hernia containing intestine which is obstructed
o Not interfere the blood supply
Strangulated
Impair blood supply

Impair venous return

Wall of intestine congested & bright red

Impair arterial supply

Blood extravasaded under serosa into lumen

95

PR bleeding
Gangrene can occur as early as 5-6 hrs
Gangrene usually at site of ring constriction

Perforation Peritonitis & septic shock

Inflamed
o Inflammation of content of sac/ external cause (ulcer/ infected)

Mx
Herniotomy in children, hernia not d/t posterior wall weakness
Herniorrhaphy in adult, hernia d/t posterior wall weakness
o Herniotomy + mesh (mesh cause fibrosis around to straighten the post wall)
o Recurrence rate - < 1%
THYROID
Causes of thyroid swelling/ goiter
Goiter
Multinodular

MNG

Solitary nodule

Adenoma
CA
Dominant nodule in MNG
Degeneration/ haemorrhage
Into colloid cyst/ nodule

Diffuse swelling

Simple goiter
Graves dz
Thyroiditis
Hyperplastic (colloid) goiter

Hx
Thyroid swelling
o ? duration
o Rapid/ progressive increase size
o Pain
Obstructive sx
o Stidors
o Difficult breathing
o Dysphagia
o Change of voice/ hoarseness
o Horner syndrome
Hyper/ hypothyroidism sx
o Hyper
Metabolic
Increase appetite but LOW
Hot intolerance

96

Sympathetic
Palpitation
Excessive sweating
CCF
Neuro
Irritability
Nervousness
Insomnia
Change appearance
Exopthalmos
Diarrhea
Prox myopathy, atrophy, periodic paralysis
Oligomenorrhoea

o Hypo
Metabolic
Increase weight, LOA
Cold intolerance
Neuro
Depression
Dementia
Change appearance
Dry hair, alopecia
oedema
Constipation
Lethargic, tiredness, prox myopathy
Menorrhagia/ other mensus abN
FHx

PE
General
o Sign of hyper
General
Muscle wasting
Facies anxiety, thyroid stare
Hand
Warm, sweaty
Pallor
Palmar erythema
Acropathy
Onycholysis tremors

97

Pulse tachycardia, AF, collapsing pulse

BP increase pulse pressure
Arms
Prox myopathy
Vitiligo
Head fine & thinning hair
Eye
Oxopthalmos
Horners syndrome
Cornea
Conjunctiva
Lig lag & retraction
Ophthalmoplegia
Visual acuity
Tongue tremors
LL
Pretibial myxoedema
Ankle jerk hyper
Prox myopathy
o Sign of hypo
Hand
Cold & dry
Pallor
Yellowish discoloration of skin
Tinels sign
Pulse bradycardia
BP high
Arm prox myopathy
Head
Coarse & dry hair/ alopecia
Loss outer 2/3 of eyebrow
Oedema
Eye
Harners syndrome
Xanthelasma
Enlarged tongue
Course, hoarse voice
LL
Non-pitting oedema
Ankle jerk delayed relaxation
Prox myopathy
Specific examination of the swelling

98

Ix
TFT

o To see euthyroid/ hyper/ hypo

o Use serum T4, TSH
o Serum T3 if pt clinically hyperT but T4 normal
o Should be euthyroid before operation
Thyroid autoab
o If suspect autoimmune dz
Tissue biopsy
o FNAC in solitary/ recently change nodules
o Core bx under U/S guided give large specimen
o Incision bx if lymphoma
For morphology of gland
o U/S
Retrosternal extension
Cysts
o CT
Suspect tracheal displacement/ compression
CT neck & thorax if malignancy
o Plain x-ray
Retrosternal extension, tracheal displacement
Isotope scan
o Use radioactive iodine, now replace by 99m Techneium
o To differentiate cold & hot nodule
o 10% cold nodules are malignant
IDL indirect laryngoscopy before op
o To demonstrate vocal cord fx (medigo-legal)

Mx
HyperT
o Anti-T +/- -blocker
Thioamides (Carbimazole/ propylthiouracil)
Inhibit thyroid peroxidase & block organification
PTU also inhibit peripheral conversion of T4 to T3 & not cross
milk/ placenta (save in preg or BF)
o Radioactive iodine therapy
Oral radioactive iodine
Good in middle age/ elderly
Disadvantages
Slow effect & unpredictable effect
Late hypoT
Risk of malignancy
Contraindication in preg

99

Thyroidectomy
o Indication
Malignancy
Solitary nodule
Obstructive effect
Ectopic
Cosmetic
2 hyperT in MNG
1 thyrotoxicosis if
failed medical tx
recurrence after medical tx
allergy/ side effect of medication
o Type
Total
Near total (1-2g ts preserved contralateral side to protect blood supply
to parathyroid gland)
Subtotal (leave 3-4g on each side)
Hemithyroidectomy (include isthmus)
Lobectomy
Isthmusectomy

o How?

Collar incision (2cm above suprasternal notch)

Divide platysma
Vertical incision of strap muscle
Ligate & divide middle thyroid vein
Upper pole vessel ligated & divided close to the gland (preserved
parathyroid gland blood supply)
Lower pole vessel ligated & divided closed to the gland
Locate inferior thyroid artery & recurrent nerve
Ligate inf thyroid a.
Identify parathyroid gland

o Cx

Intra-op
Uncontrolled bleeding
Recurrent laryngeal n. damage
Damage to other structure tracheal, oesophagus, laryngeal
muscle & n.
Early

100

Major bleeding & tension haematoma

Rapid swelling of neck
Large blood loss via drain
Emergency exploration needed
Respiratory obst d/t
Tension haematome
Laryngeal oedema
Bilateral laryngeal n. palsy
Thyrotoxic crisis/ storm
Rapid onset of agitation, high fever, profuse sweating,
tachycardia, arrhythmias
Tx -blocker, IV hydrocortisone, K+I
Tracheamalasia
d/t removal of compressing lesion of trachea and
trachea collapsed
Intermediate
Hypoparathyroidism (after 2-5 days)
RLN paralysis
Late
HypoT
Recurrent thyrotoxicosis (d/t insufficient removal of gland)
Wound infection
Keloid scar

Thyroid neoplasm
Benign
o Adenoma
Almost follicular adenoma
o Cysts
o Lipoma
o Hemangioma
o Teratoma
Malignant
o Papillary CA (75-85%)
Commonest
Peak in 5th decade
Slight female preponderance
o Follicular CA (10-20%)
Common in female

101

 Peak 5-6th decade

Tend to spread via haematogenous lung, bone & liver
o Medullary CA (5%)
Neuroendocrine neoplasms of parafollicular cells
Secrete calcitonin
80% sporadic, 20% familial z9in MEN 2A or 2B)
50-60 YO
o Anaplastic CA (<5%)
Most aggressive
In elderly
In endemic goiter region

BREAST DISORDER
Differential dx
Breast d/o
With lump
Painless
CA
Cyst
Fibroadenoma
Fibroadenosis

No lump but pain

Painful
cyclical fibroadenosis
Cyst
Abscess
periductal mastitis
CA (rarely painful)

cyclical mastalgia
non-cyclical mastalgia
mastitis

102

Nipple discharge
Colour
Red (blood)
Pink (blood + serum)
Clear pale yellow (serum)
Brown/ green/ black (breast secretion + debris)
Creamy white/ yellow (pus)
Thin white (milk)

Causes
Duct papilloma
Duct CA
Duct ectasia
Duct ectasia/ cyst
Duct ectasia
Lavtation

Fibroadenoma
HPE with fibrous + epithelium component
o Fibrous = connective tissue capsule
o Epithelium = glandular structure with mammary ductal cells
Hx
o 15 30 YO
o lump
Painless
Discrete
Slow growing
o usually multiple & bilateral
PE
o Vary size (> 5cm = giant fibroadenoma)
o Spherical/ oval/ knobbly
o Smooth & bosselated surface
o Well-defined edge
o Firm rubbery
o Dull percussion
o Not fluctuant
o High mobile
o No LN
o No skin changes
Ix - for dx & exclude CA
o FNAC
Young pt, less scar
Small lump
o Core bx
Older pt, larger lump
o Excision bx
Suspect CA/ large lump
Mx
o Small (<1-2cm) reassurance + f/u the lump
o >2cmm excision

103

Fibroadenosis
Definition
o D/o physiological response to circulating hormones causing distorted &
overgrowth of breast component
o Can be ducts/ lobules/ fibrous ts
Hx
o Reproductive age 35-45 YO peak
o Lump
Painless/ painful
Premenstrual tension/ premenstrual change of size
o Premenstrual
Water retension
Irritability
PE
o Focal/ diffuse
o Usually outer upper quadrant & axillary tail
o +/- dilated vein
o Variable tenderness
o Solid
Rubbery hard, mobile
No attachment
No LN
o Cystic
Smooth spherical, variable consistency
+/- fluctuation/ fluid thrill
+/- translimination +ve
Mx
o Exclude CA
FNAC/ bx
Mammpgraphy
o Surgical excision if isolated lesion
o Drugs
If severe cyclical pain
Danazol/ bromocriptine
Mammary duct ectasia
Definition dilatation of large breast ducts
Pathology
Contain green/ sterile pus

Rupture/ leak

Chemical/ bacterial periductal mastitis

104

Recur/ chronic

Periductal fibrosis

Nipple retracted

Clinical features
o Tender mass with thick wall
o Skin fixation
o Nipple retraction
o +LN
Mx
o Exclude CA
o Excision
o *no drainage will cause fistula formation

Duct papiloma
Defi localized epithelial proliferation
Hx
o 30-40 YO
o Blood/ serous nipple discharge
o Swelling
Painful if large
Fluctuate size
PE
o Discharge
o Lump
Solid
Fusiform/ tense / fluctuate
o +/- LN
Mx
o Exclude CA
o Excision

Breast infection
D/t
o Cellulites
o Abscess
o Infected sebaceous (Montgomerys) gland rare
Risk factors secretion retention
o Pregnant
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o Lactation
o Inverted nipple
Route
o Cracked nipple skin
o Ascending through lactiferous duct
o Blood
Organism Staph aureus
Hx
o Preg/ lactation
o Pain
From dull-arching to severe throbbing (when tense abscess)
o Lump
Sign of acute inflammation
Pus discharge
o General
Fever, swinging, rigors
Malaise
PE
o Sign of acute inflammation
o Spherical
o Indefinable
o Mass
Firm to soft (if abscess liquefied)
+/- fluctuated
o Not transluminated
o +/- fix
o +/- LN tender
o general sign of infection
Mx
o Antibiotic cloxacillin
o I&D

Fat necrosis
d/t trauma causing necrosis of adipose ts saponification cyst with oil fluid/
small hard mass
Mx excision bx & exclude CA

Breast carcinoma
Epidemiology
Third most common cancer worldwide

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Most comman CA in women

40-50 YO
Breast CA in male 1%, worse prognosis
Predominant among the Chinese
Majority of cancer, 44%, are diagnosed at Stage 2
Most adenoCA
15% breast CA will have contralateral dz

Risk factors
Family hx
Previous breast CA
a/w ovarian & endometrial CA
Age >50 YO
HRT
Early menarche (aged 12 and younger)
Late menopause (aged 55 and older)
Nulliparous at age 40 YO
Late 1st pregnancy (>35 YO)
Alcohol/ smoking/ high fat diet
Geographic variation
Biopsy confirmed benign proliferative breast disease
Previous radiation to the breast
Obesity in postmenopausal women
Evidence of specific genetic susceptibility (such as carriage of BRCA1, BRCA2 or
BRCA3)
Classification
Ductal CA
75%
Lobular CA
5-10%
CA in situ not invade epithelial basement membrane
o Lobular (LCIS)
o Ductal (DCIS)
o Pagets
Other
o Medullary (numerous lymphocytes & cells)
o Colloid/ mucinous
o Tubular
o Scirrhous (numerous fibrous tissue)

Spread

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Local
o Skin
o Pectoral muscle
o Chest wall
Lymphatic
o Axillary LN ,a,,ary, supraclavicular/ infraclavicular
Haematogenous
o Osteolytic bone met
o Liver
o Lung
o Brain
o Adrenal
o Ovary

Hx
Lump in breast
o Pain/ painless
o Change of breast
Shape & size change?
Skin change? - tethering/ fixation
Nipple change? retracted/ destroyed
Ulcerated/ fungating
o Nipple discharge color, contain
Lump in axillary
2 metastases
o bone pain
o SOB/ cough, chest pain
o Jaundice/ abd distension
o Mental change/ fits
General
o Malaise
o LOW, LOA
Family hx breast/ ovarian/ endometrial CA
Risk factor
o HRT/ OCP
o Parity
o Menstrual hx
o Smoking/ alcohol
o Previous breast CA

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PE
Inspection
o Visible lump & describe
o Discoloration
o Skin changes tethering/ dimpling/ Peau dorange/ erythema
o Ulcer/ discharge
o Nipple discharge/ retracted/ eczema
o Dilated vein
Palpation
o Hard, irregular, ill-defined
o Non-tender
o Fixation
LN
Nearby structure
o Lymphoedema
o Venous thrombosis
Ix
General
o FBC/ BUSE/ LFT/ se Ca2+
Specific
o Biopsy
FNAC
For young pt, small lump
False negative rate of 1%-35%, sensitivity of 94%.
Core bx for large lump, older pt
Excision bx big lump, fail to get sample on FNAC/ core bx
o U/S breast
Distinguish btw solid & cystic
If cystic aspiration & send for cytology if reappear aspirate
again reappear excision bx
o Mammography
100% sensitivity
unreliable for pt <40 YO d/t dense breast ts
Indication
Screening (>50 YO in 1-2 tears interval)
F/u for high risk (hx of CA/ lobular CA)
Suspicious if FNAC negative
To detect multifocal lesion
Significant features
Opaque mass with speculations

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Microcalcification
Distorted architecture
Single dilated duct
Large lesion with nodular outline
Change on serial film
o Tumour marker
Carcinoma antigen 15-3 (CA 15-3)
Carcino-embryonic ag (CEA)
Mammary serum ag (MSA)
o Estrogen/ progesterone receptor (ER/ PR)
Staging (routine)
o U/S abdomen
o CXR
Ix for met done if clinically suggest of met
o Bone scan
o CT abdomen/ brain/ thorax

Staging
Primary Tumour (T)
o TX: Primary tumour cannot be assessed
o T0: No evidence of primary tumour
o Tis: Carcinoma in situ
Tis (DCIS) Ductal carcinoma in situ
Tis (LCIS) Lobular carcinoma in situ
Tis (Pagets) Pagets disease of the nipple with no tumour
Note: Pagets disease associated with a tumour is classified
according to the size of the tumour
o T1: Tumour < 2.0 cm
o T2: Tumour 2-5cm
o T3: Tumour > 5.0 cm
o T4: Tumour of any size with direct extension to chest wall, skin, edema,
peau doraqnge .
Regional lymph nodes
o NX: Regional lymph nodes cannot be assessed (e.g. previously removed)
o N0: No regional lymph node metastases
o N1: Metastases to movable ipsilateral lymph nodes
o N2: Metastasis in ipsilateral axillary lymph nodes fixed or matted, or in
clinically apparent ipsilateral internal mammary lymph nodes in the
absence of clinically evident axillary lymph node metastasis
o N3: Metastases to ipsilateral infraclavicular lymph node(s), with or
without axillary lymph node involvement, or in clinically apparent*
ipsilateral internal mammary lymph nodes in the presence of clinically
evident axillary lymph node metastasis; or metastasis in ipsilateral

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supraclavicular lymph node(s), with or without axillary or internal

mammary lymph node involvement.
Distant metastases (M)
o MX: Presence of distant metastasis cannot be assessed
o M0: No distant metastases
o M1: Distant metastasis
AJCC Stage groupings
o Stage 0
Tis, N0, M0
o Stage 1
T1, N0,M0
o Stage IIA
T0,N1,M0
T1, N1, M0
T2,N0,M0
o Stage IIB
T2, N1,M0
T3, N0,M0
o Stage IIIA
T0, N2, M0
T1, N2, M0
T2,N2,M0
T3, N1, M0
T3, N2, M0
o Stage IIIB
T4, N0, M0
T4, N1, Mo
T4, N2, M0
o Stage IIIC
Any T, N3, M0
Any T, N3, M0
o Stage IV
Any T, Any N, M1

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Mx
Pre-op consultation
Explain choise of tx
Aim
o Choose suitable op to increase survival rate
o Prevent recurrence
o Pt cosmetic effect
o Local/ regional control
o Social factors
Stage I And II
The Choice of Operation
o Breast conservation surgery (BCS) + radiotherapy
o Mastectomy +/- axillary clearance
Mastectomy is better choice if
o Age <29YO
o Size >4cm or large tumour in proportion to breast
o Inavailability of RT/ pt refuce RT/ contraindicated to RT
o Factors that increase the risk of local recurrence, such as extensive malignanttype calcifications visible on the mammogram, multiple primary tumours or
failure to obtain tumour-free margins.
o Patients clear preference for mastectomy
Stage III, IV
Stage IIIa, Stage IIIb
(operable)

FBC, LFT, CXR, mammography, U/S liver

CT liver/ lungs/ bone scan

Mastectomy and axillary dissection

Neoadjuvant chemotherapy followed by

mastectomy and axillary dissection

Chemotherapy followed by radiotherapy

to chest or wall Tamoxifen if ER positive

Additional chemotherapy and radiotherapy
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to chest wall.
Tamoxifen if ER positive

Stage IIIa, Stage IIIb

(inoperable)

FBC, LFT, CXR, mammography, U/S liver

CT liver/ lungs/ bone scan

Neoadjuvant chemotherapy

If there is response
If no response

mastectomy and axillary clearance

individualized therapy
Additional chemotherapy and radiotherapy to chest wall
Tamoxifen if ER positive
Stage IV

FBC, LFT, CXR, Mammogram

US liver/ CT liver/ lungs/ Bone scan

Treatment is indivualised depending on physical

condition, ER status, cerbB2 status, utilizing various
options of surgery, chemotherapy, hormonal therapy,
immunotherapy and radiotherapy to optimize quality of
life and to palliate symptoms
Adjuvant Chemotherapy
Moderately chemo-sensitive tumour.
Adjuvant chemotherapy should be offered to all patients in the high-risk category:
o All node positive patients
o Patients with tumours 2 cm or more
o Patients with ER negative tumours
Adjuvant chemotherapy is not required in patients in the low-risk category, that
include
o All patients with tumours less than 1 cm
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o Patients with tumours of special types of histology (tubular, mucinous and

cribriform) less than 2 cm.
Acceptable adjuvant chemotherapy regimes are:
o CMF for 6 cycles (Cyclophosphamide, Methotrexate and 5-Fluorouracil)
o AC for 4 cycles (Adriamycin and Cyclophosphamide)
o FAC or FEC for 4-6 cycles (5-Fluorouracil, Adriamycin or Epirubicin and
Cyclophosphamide)

Adjuvant Radiotherapy
Moderately radiosensitive tumour.
Indication for chest wall DXT
o After breast conserving surgery (BSC)
o Post mastectomy when the risk of local recurrence is high
Tumour is T3 and aboveL
Lymph node metastases is present especially with equal to or more
than 4 nodes positive
Margins are involved or less than 5 mm
o suggested in wide local excision for ductal carcinoma in situ
Should be given as soon as possible after surgery and not later than 12 weeks except
in whom radiotherapy is preceded by chemotherapy.
Axillary radiotherapy is indicated in
o Axillary dissection not done
o Obvious disease post-dissection
o For node positive patients where dissection is inadequate (less than 4 nodes
found)
Adjuvant Hormone Therapy
20 mg daily for 5 years
Should not be used concurrently with chemotherapy
Indication
o All patients with ER positive tumours
o Post-menopausal patients with ER negative tumours.
Follow up
The suggested follow-up schedule is as follows:
o 3 monthly for the first 2 years
o 6-monthly for the next 3 years
o Yearly thereafter
What to do?
o Monthly breast self-examination

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o History and physical examination

o Annual mammography

SEBACEOUS CYSTS

Should called epidermal cysts

Etiology
o Sabaceous glands secrete sebum
o Mouth open into hair follicles
o Mouth blocked, gland distended with own secretion & epithelial degraded
products
Hx
o Site
Face, neck, scalp
Never on palms & soles
o Duration rarely before adolescent
o Size changes slow
o Sx
Pain, enlarged (infected)
Discharge
PE
o Site, size
o Shape (round)
o +/- punctum
o Skin
Normal color, no discharge, no ulcer, no scar
o Temperature normal
o Tenderness no
o Well-defined edge
o Surface smooth
o Consistency hard
o Compressible no
o Pulsatile no
o Fluatuation - +/- apparent fluatuated
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o Dull to percussion
o Mobility
Attached to skin
Not attached to deep ts
o LN normal

Tx
o Excision under LA

Inflamed cyst
temperature, tender, discharge, redness
Tx excision & I&D under LA
Sebaceous horn content exudes slowly from punctum, cysts dry & harden into conical
spike
Cocks peculiar tumour infected, ulcerated, granulating, oedematous cysts

DERMOID CYSTS

Lined by squamous epithelium

Contain
d/t cystic changes in epithelial remnant lefted when skin dermatoses fused

Hx
Site
o Mid-line, trunk, neck
o Fusion of ophthalmic & maxillary facial processes
o Inner & outer ends of upper eyebrow
Duration
o At birth
o Years later when distended
Size changes
o +/- increase in size
Sx
o Rarely infected
o Rarely machanical effect
o Disfigurement
o Rarely multiple
PE

Site
Size 1-2cm
Shape ovoid/ rpund
Skin normal
Temperature normal

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Tenderness no
Well-defined edge
Surface smooth
Consistency soft
Not compressible
Not pulsatile
Mobility not attached to skin/ deep ts
Fluatuation - +
Translumination - +/Percussion dull
Fruid thrill - +ve if large
LN no

Tx
Excision

IMPLANTATION DERMOID CYSTS

Patho
Injury (usually small deep cut/ stab injury)

Piece of epidermal fragment implanted into subcutaneous ts

Cystic changes
+/- contain foreign body
Hx
Site palms & fingers
Duration variable
Size change - +/ Sx
o Pain/ tender (subjected to repeated trauma)
o Interfere with grip & touch
o Rarely infected
Hx of injury
PE

Site palms/ fingers

Size small 0.5-1cm
Shape round
Skin - + scar

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Temperature normal
Tenderness - +/Edge well-defined
Surface smooth
Consistency hard & tense (sometimes stony hard)
Compressible no
Pulsatile no
Mobility
o +/- tethered to the scar
o Not attached to deep ts (unless deeper ts also injured)
Fluatuation - -ve
Percussion dull
Fluid thrill - -ve
LN normal

Tx
Excision

LIPOMA

Cluster of fat cells become over-active & distended by fat

Never turn malignant

Hx
Sites any where
Duration often years
Size change slowly increase
Sx
o Disfigurement
o Hard & painful (fat necrosis follow repeated trauma)
o Ulcerated (repeated friction)
Multiple often
PE
Site, size
Shape
o Round (unrestricted)
o Flat (restricted btw 2 resistant ts)
o Lobulated
Skin normal
Temperature normal

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Tenderness no
Edge
o Well-defined
o Irregular curves (lobulated)
o Slip sign
Surface smooth
Consistency soft
Compressible - +ve
Pulsatile no
Mobility
o Subcutaneous (freely)
o +/- attached to deep ts
Fluatuation - +/Translumination - +/LN normal

Tx
Excision

PILONIDAL SINUS/ ABSCESS

Young adult
Hirsuate men
Nest of hairs (implanted into the dermis)
Risk
o Long period sitting
o Hairdressers
o Farmers
o Hirsuate
o Congenital dimple/ pit (natal cleft)
Abscess d/t 2 infected
Tx
o Excision remove the hair, skin excision
Prevent recurrent
o Hygiene
o Regular shaving
CYSTIC HYDROMA
Not true cyst (no epithelial lining)
Lymphatic hamartomas
119

Multilocular cyst-like space

Painless
Below angle of mandible
Soft
Fluctuant
Highly transluminable
Tx excision

BRACHIAL CYST
Remnant of 2nd pharyngeal pouch/ brachial cleft
Late adolescent/ early adulthood
Painless
Side of neck
Vary in size time to time
Deep to stenocleidomastoid (btw upper 1/3 & lower 2/3)
Protruding to anterior triangle
Soft
Fluctuant
Transluminates
Tx
o Percutaneous drainage
o Excision

VARICOSE VEIN
Definition dilated, tortous of superficial vein of lower limb
Anatomy

Physiology
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Muscle contract squeeze deep vein venous return

pump pressure

close perforated valve

prevent back flow

Aetiology
Primary
o Unknown cause
Familial
Probably weakness of vein wall that permits valve ring dilatation
o Congenital absence of valve (rare)
Secondary
o Obstruction to venous outflow
Pregnancy
Fibroid/ ovarian cyst
Abd lymphadenopathy
Pelvic CA
Ascites
Iliac venous thrombosis
Retroperitoneal fibrosis
o Valve destruction DVT
o High flow & pressure arteriovenous fistula
Hx
Varicosity duration, progression
Sx
o Dull aching pain
Increase through the day
Relieve by lying down
o Ankle swelling
o Night cramp
Cx
o Venous ulcer
o Haemorrhage
o Thrombophlebitis red, tender, painful lump
o Chronic venous insufficiency lipodermatosclerosis
o Equines deformity d/t fibrosis & contrction of joint
Causes
o Pregnancy
o Abd mass
121

o Hx of DVT
o Family hx
o Occupation (long standing period)
Ix
Doppler U/S for dx of DVT
Exclude others secondary cause
Mx
Conservative
o For asymptomatic
o Elevation of LL
o Compression stoking
o Medication Daflon
*contraindication in secondary varicose vein (need to tx the cause)
Surgical
o Indication
Pain esp at night/ agg by standing/ relieve by elevation
Haemorrhage
Thrombophlebitis
Lipodermatosclerosis
o Type
High saphaneous ligation
Long saphaneous strip
Avulsion of varicosity
*contraindication in DVT

Sclerotherapy
o For small, cosmetically unattractive, below knee
o Use 30% sodium tetradecylsulphate (STD)
o Procedure
Hang down
1-2 ml STD syringes is prepared & placed in each vein
Elevate the leg with needles syringes
Inject 0.5-1ml
Foam pad placed
Elastic bandage from toe upwards
Bandages reapplied after 1 week & left for 2-6 weeks then discarded
Pt should walk 1-2 miles/day & elevate leg when not walking

122

DEEP VEIN THROMBOSIS

Hx
Swelling of LL
o Sudden onset
o Unilateral, bilateral (rare)
o Level depends on where is the thrombosis occur
Pain bursting pain (calf/ thigh)
Causes
o Pregnancy/ OCP (increase coagulation)
o Prolonged bed rest major operation/ LL #/ stroke
o Cardiac failure (blood stasis)
o Trauma (injury to vessel wall)
Cx

123

o Pulmonary embolism
SOB
Pleuritic chest pain
Haemoptysis
Collapse
o Venous gangrene blackish
Differential dx
o Cellulites
o Arterial occlusion

PE
Swelling
o Pale (phlegmosia alba dolens) severe oedema
o Blue (phlegmasia cerulean dolens) congested arterial supply venous
gangrene
Hard, tender muscle
Warm leg
Homans sign forced dorsiflexion cause calf pain
Dilated superficial vein
Signs of pulmonary embolism
o Respiratory distress
o Cyanosis
o Pleural rub
Ix
Doppler U/S
o Detect flow changes in vein
o Unreliable in iliac/ calf vein
o Negative test not exclude DVT
Contrast venography inject contrast into foot vein
MRI
Mx
Bed rest with leg elevation 1-2 days
Analgesic (NSAIDs)
Anticoagulant heparin continued with warfarin
Thrombolytic in extensive, large vein thrombosis
IVC filter large, free-floating thrombus in ileo-femoral vein
Find the cause of DVT

124