By L. Tarok. University of Puerto Rico, Rio Piedras.
Then the cuff is deflated and the time of appearance of red flush in the skin Fig cheap 150 mg epivir-hbv overnight delivery. It is 1 to 2 seconds in case of normal limb and it will be delayed in case of arterial occlusive disease and it may never appear in case of severely ischaemic limb buy epivir-hbv cheap online. Atherosclerosis is a generalized disease and the patient must be examined thoroughly to exclude ischaemic heart disease buy epivir-hbv 150 mg without prescription, cerebro-vascular disease, hypertension, renal artery stenosis etc. In embolic manifestation, the heart is examined for presence of cardiac murmur, which may indicate certain lesion to cause embolus formation. Estimation of serum P-lipoprotein, triglyceride and cholesterol should be performed when atherosclerosis is suspected. The common femoral artery is used for aortoiliac, renal, mesenteric and femoropopliteal arteriography, whereas the brachial artery is used for subclavian, vertebral, carotid and thoracic angiography. The needle is now withdrawn and a flexible guide wire is threaded through the cannula. The cannula is withdrawn and a polythene catheter is passed over the guide wire into the artery for a distance. Series of X-ray exposures are made to see particularly the whole length of the arterial tree, the origins and the adjacent part of its branches. In selective angiogram the tip of the catheter is introduced into the corresponding artery to delineate the artery and its branches precisely. Abdominal aorta (translumbar route) may be chosen for aortoiliac and femoropopliteal arteriography when the femoral arteries are occluded or the retrograde method has failed to produce necessary information. In patients with occlusive lesion, abnormal signals can be obtained distal to the block and will be lost entirely over the site of the block. The second and third sounds are absent when the flow signals are detected just below the stenotic lesion where high velocity flow is present, a single high-pitched continuous sound is present indicating turbulent flow. This simple apparatus can be used to measure blood pressure at the ankle and at the arm. Normally the ankle systolic blood pressure is greater than the brachial (arm) systolic blood pressure by 5 to 15 mm Hg. If this pressure index becomes less than one it indicates some degree of arterial occlusion. Recently Technetium 99 has become the isotope of choice though the technique remains essentially the same. More recently intravenous injection of isotope has been used to get a direct arterial visualization. Two electrodes are placed diametrically opposite to each other in contact with the arterial wall. The electrodes on the surface of the artery pick up an electromotive force induced in the blood by its motion through the magnetic field and feed it back to suitable electronic amplification. But the greatest disadvantage of this technique is that the artery has to be exposed. Many of these patients are diabetic, though they may not show increased level of sugar in the blood. Later on organic changes develop and sympathectomy does not do much good to the patient. So, importance of finding out the degree of vasospasm cannot be overemphasized to assess the value of sympathectomy. Any rise of skin temperature is recorded and is compared with the rise of mouth temperature. Venous outflow from a limb is briefly arrested while allowing arterial inflow to measure the volume change in the limb which is proportional to the arterial inflow. But it has rarely been found suitable for screening method for surgery, as the surgeon is more interested to know the site of the arterial block rather than to measure the blood flow as such. Recently segmental plethysmography has been introduced by placing venous occlusion cuffs around the thigh, calf and ankle. The cuffs are inflated to 65 mm Hg and the pulsation is the quantitative measure of the arterial diseases. In embolism, a sudden decrease in the movement of its needle is obtained at the level of arterial occlusion. In thromboangiitis obliterans, if no pulsation is obtained in the leg, amputation should be performed in the thigh. The affected part becomes dry, shrivelled, hard, mummified and discoloured from disintegration of haemoglobin. Due to infection and putrefaction the affected part becomes oedematous with blebs. The term ‘Pregangrene’ is used to describe the changes in the tissue to indicate that its blood supply is so precarious that it will soon be inadequate to keep the tissue alive. Syringomyelia, tabes dorsalis, peripheral neuritis, leprosy, caries spine, fracture-dislocation of spine etc. Various special investigations as stated above will help the clinician to diagnose the condition and the level of the block. It is the inflammatory reaction in the arterial wall with involvement of the neighbouring vein and nerve, terminating in thrombosis of the artery. In lower extremity the disease generally occurs beyond popliteal artery, starting in tibial arteries extending to the vessels of the foot. So far as aetiology is concerned this disease has a striking association with cigarette smoking. An autoimmune aetiology has been postulated and familial predisposition has been reported. The pedal arteries are involved first and the patients complain of pain while walking at the arch of the foot (foot claudication), somewhat less often at the calf of the leg, but never at the thigh or buttock (which is common in atherosclerosis). Gradually postural colour changes appear followed by trophic changes and eventually ulceration and gangrene of one or more digits and finally of the entire foot or hand may ensue. It is differentiated from senile gangrene by the age, by its association with superficial phlebitis and pitting oedema. Characteristic arteriographic appearance of this disease is the smooth and normal appearance of larger arteries combined with extensive occlusion of the smaller arteries alongwith extensive collateral circulation. Presence of localized tenderness at the site of embolus and complete disappearance of pulse below this level are the pathognomonic features of this disease. The heart when examined carefully often gives an indication of the source of the embolus. It may be caused by (i) cervical rib, (ii) scalenus anticus muscle, (iii) costoclavicular syndrome, (iv) pectoralis minor syndrome, (v) wide first thoracic rib, and (vi) fracture of the first rib or clavicle. Neurologic symptoms are pain, paraesthesia and numbness in the fingers and hand in the ulnar nerve distribution. The symptoms gradually appear due to sagging down of the shoulder girdle with the advent of puberty. Sometimes symptoms appear later in life due to weakness of the muscles of the shoulder girdle. Presence of cervical rib does not always reveal symptoms or brings the patient to the surgeon.
That means a gastric ulcer patient order epivir-hbv 100 mg overnight delivery, if loses his periodicity of pain one may suspect superimposition of carcinoma or penetration into the pancreas buy discount epivir-hbv online. In cholecystitis and appendicular dyspepsia pain has no relation with food epivir-hbv 150 mg for sale, but it may so happen that a few cholecystitis patients may complain of pain after having fatty meals. A griping pain is often experienced in biliary colic which may be associated with cholecystitis. In appendicitis pain may be severe and even griping in nature (appendicular colic) with quite a few months of intervals between the attacks. In majority of cases of chronic appendicitis pain is mild aching in nature which gets worse on jolting and running. As has been mentioned earlier, in duodenal ulcer food relieves pain (hunger pain). Sometimes patients with oesophageal hiatus hernia and chronic pancreatitis, may complain of flatulent dyspepsia. Projectile copious vomiting is often seen in pyloric stenosis complicating duodenal ulcer and in pancreatitis. In pyloric stenosis the vomitus often contains undigested food particles ingested even a day earlier. In pyloric stenosis it may occur at any time but usually takes place several hours after meal (more often in the evening). Vomiting from gallbladder diseases and pancreatitis (in which vomiting is a marked feature) has got no relation with food. Once the patient has learnt this fact he often resorts to it at the height of pain (induced vomiting) but vomiting affords little relief in pancreatitis, cholecystitis, carcinoma of the stomach and appendicitis. Peptic ulcer haemorrhage is a likely complication of a posteriorly situated ulcer whereas perforation is more common in an ulcer lying anteriorly. Though the commonest cause of haematemesis is a chronic peptic ulcer, yet acute peptic ulcer, multiple erosions, oesophageal varices, carcinoma of the stomach, Mallory-Weiss syndrome, purpura, haemophilia etc. In a gastric ulcer the amount of vomited blood varies — it may be small or profuse depending on the size of the blood vessel involved. It occurs commonly in peptic ulcer, but may be seen in all cases which may have induced haematemesis. To ascertain yellow discolouration of sclera, skin, nail bed, under surface of the tongue, soft palate etc. Itching often accompanies jaundice, so presence of scratch marks on the chest or abdomen sometimes gives a clue to the diagnosis even if yellow discolouration is not that prominent. An enquiry must be made about the mode of onset, duration and its progressiveness (that means whether the jaundice is gradually deepening or intermittent). Painful, intermittent jaundice is very much characteristic of stone in the common bile duct, whereas painless and progressively deepening jaundice is a feature of carcinoma of the head of the pancreas. In carcinoma of ampulla of Vater jaundice may be intermittent due to sloughing of tumour mass. Constipation is usually present in obstructive lesion of the stomach, gallbladder diseases, chronic appendicitis etc. The patient should be asked about the colour and quantity of the stool whether black tarry (melaena — which indicates haemorrhage in the upper G. Only in case of gastric ulcer the patient becomes reluctant to take food more often due to immediate resumption of pain rather than anything else. In case of appendicitis the patient often rejects food because it initiates nausea and vomiting. Dislike for fatty foods characterizes gallbladder diseases (qualitative dyspepsia). Appendicitis and acute ulcerative colitis are always associated with varying degrees of temperature. In case of gastric ulcer there may be slight loss of weight but in duodenal ulcer patient never loses weight on the contrary he may gain some weight. Whether the patient suffered from typhoid fever (in gallbladder disease), tuberculosis, syphilis, septic foci in the tonsil, throat or nose, jaundice etc. Majority of patients with peptic ulcer observe irregular dietary habit whereas patients with appendicitis or gallbladder diseases may maintain a regular dietary habit. Majority of the patients suffering from duodenal ulcer are accustomed to take spicy foods. Meat forms the major dish of patients with appendicitis as this is a disease of civilization. Excessive smoking and worry have some bearing on the pathogenesis of peptic ulcer. Cirrhosis of liver and portal hypertension are often accompaniments of excessive drinking of alcohol. The whole of the abdomen from the level of the nipples above to the saphenous openings below should be completely exposed. Examination should be carried out in good light (preferably day light) looking first from the side then tangentially and finally from either end of the bed. Then look for any erythema — this is due to hot-water bottle application and indicates the site of pain. If superficial veins are engorged, note (i) their positions — whether situated around the umbilicus (portal obstruction) or on the sides of the abdomen (obstruction of the inferior vena cava) and (ii) the direction of blood flow — whether away from the umbilicus (portal obstruction) or from below upwards (inferior vena caval obstruction). To determine the direction of blood flow two index fingers are placed close together on the vein. The process of emptying the vein is repeated and this time the other finger is taken off. The vein fills rapidly when the finger obstructing the flow of the blood is released. Whether it is linear scar (healing by first intention) or broad and irregular scar (indicating wound infection). Any hard subcutaneous nodules near the umbilicus, if present, are significant of an intra abdominal carcinoma, especially that of the stomach. Any swelling on one side of the abdomen will push the umbilicus to the opposite side. Generalized retraction is found in thin individual whilst symmetrical distension may be due to fat, fluid, flatus, faeces or foetus. Distension due to obesity should be differentiated from distension due to intra-abdominal causes. In the former the umbilicus is deeply inverted whereas in the latter the umbilicus shows varying degree of eversion. In case of chronic intestinal obstruction there will be fullness of the right iliac fossa. The patient lies in the examination couch straight in such a way that an imaginary line through both the anterior superior iliac spines will be precisely at right angle to the long axis of the examining couch. In case of enlargement or distension of viscus of the upper abdomen there will be distension of the upper abdomen. Similarly distension or tumour of the viscus of the lower abdomen will lead to distension of that region.
Cerebral irritation is said to be due to localised oedema which occurs around the area of contusion or laceration in the brain discount epivir-hbv 100mg otc. If it is less than an hour discount epivir-hbv amex, the injury can be regarded as slight order 100mg epivir-hbv with visa, if it is between 1 to 24 hours head injury is moderate, if it persists between 1 to 7 days, it is severe. Such scar tissue undergoes contraction over a period of months and years exerting a constant pull on the brain not only locally, but also on the whole frame work of the brain. This may cause traumatic epilepsy of the Jacksonian type after a few years of head injury. Initially oedema is localised to the demaged part of the brain, but it gradually extends rapidly throughout one or both the cerebral hemispheres. So there is considerable rise in intracranial pressure which may lead to cerebral compression. When contents of supratentorial compartment herniate through the tentorial hiatus due to compression in the supratentorial compartment it is called coning. Similarly when the contents of the infratentorial compartment herniate through the foramen magnum due to increased pressure within that region it is also called coning. When there is compression of the supratentorial compartment, usually the medial part of the temporal lobe (the uncus) herniates through the tentorial hiatus. The result is early constriction and later dilatation of the pupil of the same side (Hutchinson’s pupil). The midbrain is distorted and gradually displaced away to be impacted against the free edge of the tentorium on the other side. This may interfere with the descending motor pathways coming from the opposite hemisphere. This ultimately leads to deterioration in the level of consciousness due to pressure on the reticular formation of the brain stem(See Fig. In the last stage both the pupils become dilated and fixed without reaction to light. This may occur above or below the tentorium cerebelli and becomes responsible for causing brain compression. This period varies according to the type of the vessel (whether artery or vein) and the calibre of the vessel injured. Intracerebral haemorrhage hardly causes cerebral compression of considerable magnitude. When a central artery ruptures, the bleeding may become fatal, as it may rupture into the ventricle causing intraveniricular haemorrhage, the main symptom of which is hyperthermia. Of course this period depends on the type of vessel ruptured or any pathology associated with it. Intracercbral haemorrhage may be small enough and blood clots or haematomas in the brain may produce signs and symptoms which mimic those of cerebral tumours. Removal of such masses may be effective particularly when these are situated in the anterior part of the frontal or temporal lobe. It is caused by — (i) Laceration of the cortex associated with venous or arterial haemorrhage, the haematoma of which collects under the dura mater. These veins run upwards along the surface of the cerebral hemispheres and then pierce the arachnoid mater and enter into the subdural space before it reaches the superior sagittal sinus. So these veins are fixed on one side to the arachnoid mater and surface of the brain and on the other side to the dura mater lining the sagittal sinus. Between these two fixed points, these veins lie free and remain mobile in the subdural space. Impact to the front or back of the head may lead to rupture of these veins causing subdural haemorrhage. The cerebral hemisphere moves alongwith the lower parts of the superior cerebral veins, whereas the upper parts of these veins are fixed to the superior sagittal sinus into which they drain. Subdural haemorrhage is much commoner in the elderly as the brain atrophies in these individuals giving rise to more space for the brain to move within the skull. In these individuals subdural haemorrhage may occur following a trivial injury or shaking of head. The primary brain damage, which usu- causes early unconsciousness, is rap idly followed by unconsciousness due to cerebral compression from acute subdural haemorrhage. In bilateral cases such symptoms tearing of superior cerebral veins at the level of the arachnoid. Extensive craniot omy should be performed todetect the haem orrhage and the haemorrhagic vessel. Burr-holes are of no value, as it is extremely impossible to localise the site of haemorrhage precisely inspite of all in vestigations. The patient may succumb to the exten sive brain damage which may associate acute Fig. The importance of extradu ral haemorrhage lies in the fact that it is amenable to surgery and if the case is not diagnosed in right time the patient may die. Probably in no other lesion in head injury surgery has got such a definite role to play to save the patient. The classical syndrome of ex tradural haemorrhage results mostly from injury to the main trunk of the middle meningeal artery or more commonly one of its branches — anterior or posterior. The anterior branch is more commonly injured than the posterior in the ratio of 5:1. Sometimes bleeding may occur in the posterior cranial fossa and the source is a torn posterior meningeal Fig. In this case a similar deterioration in level of consciousness will be noticed when the haematoma enlarges to a big size. Very occasionally the bleeding may occur from one of the venous sinuses — either superior sagittal sinus (in the anterior or middle cranial fossa) or from the transverse sinus (in the posterior cranial fossa). A blow on the thin bone of the temporal plate may be caused with a golf ball or cricket ball or football. This causes a fracture in the squamous part of the temporal bone which drives the dura inwards. The middle meningeal artery leaves the bony canal in the pterion, crosses the extradural space and gains attachment to the outer surface of the dura mater. Of course sometimes the anterior branch or posterior branch of the middle meningeal artery is injured due to direct trauma of the fractured bone fragments against these arteries. The blood which escapes from the tom vessel passes in three directions : (i) Some of it passes outwards through the fracture to form a boggy swelling due to haematoma under the temporal muscle. This finding not only is an indication for admission of a conscious patient to the hospital, but also indicates occurrence of extradural haemorrhage. This haematoma is the most important in causing lethal problems of extradural haemorrhage. The amount of this haematoma depends on the ease with which the dura mater is stripped off from the inner surface of the skull. In children and young adults extradural haematoma very easily takes a big size and a big extradural haematoma is often possible without fracture in children due to excessive elasticity of the skull. When the haematoma has reached a considerable size, it causes sufficient rise in intracranial pressure to cause cerebral compression. Uncus herniates through the tentorial hiatus with such rise of intracranial pressure and the midbrain gets distorted at the tentorial hiatus This causes unconsciousness clue to pressure on the reticular system of the midbrain.
Conversely order 150mg epivir-hbv free shipping, patients with melanoma generic epivir-hbv 150 mg otc, sarcoma purchase epivir-hbv 100 mg on-line, or testicular carcinoma are more likely to have a solitary metastasis than a primary lung cancer. This left upper lobe nodule containing what appears to be dense calcification (arrow) proved to be a metastatic osteosarcoma. Non-Hodgkin’s lymphoma More commonly multiple and a manifestation of primary or secondary disease. Because the tumor rarely obstructs the bronchial tree (unlike carcinoma), air bronchograms can often be detected within the mass. Neuroendocrine tumor Up to 40% of carcinoids occur in the peripheral lung (Figs C 7-20 and C 7-21) and present as solitary pulmonary nodules. They appear as round or ovoid, well-defined masses that may have slightly lobulated borders and usually show intense contrast enhancement. Malignant neuroendocrine tumors usually show heterogeneous contrast enhancement due to intratumoral necrosis. Plasmacytoma Extrapleural mass that usually represents spread into the thorax of a primary rib lesion (therefore almost always a destructive process in one or more ribs). Poorly marginated nodule in the right mid lung containing small focal areas of low atten- uation, an appearance highly suggestive of bronchoalveolar cell carcinoma. Large mass containing punctuate calcifications (arrowhead) and low attenuation areas related to necrosis. Granulomatous infections Generally round or oval, well-circumscribed Histoplasmosis, tuberculosis, coccidioidomyco- (Figs C 8-2 and C 8-3) nodules. Several round lesions, many with cavitation, are seen throughout the lungs in this intravenous drug abuser with staphylococcal tricuspid endocarditis. Bilateral diffuse intermediate-sized nodules Fig C 8-2 24 along with patchy consolidation at the lung bases. Varicella (chickenpox) nodules often calcify 1 year or more after the initial infection (see Fig C 17-5). Paragonimus westermani Well-circumscribed cystic masses that have a Characteristic appearance of multiple ring opacities (Fig C 8-6) predilection for the periphery of the lower lobes. Multiple ill-defined and occasio- throughout the lungs that developed in a patient who nally confluent nodules throughout the lungs in a young child had undergone a renal transplant 3 months earlier and with severe combined immunodeficiency disease. The cysts are thin walled, and most have a prominent crescent-shaped opacity along one side of their borders, the characteristic ring shadow of paragonimiasis. Bronchioloalveolar Poorly defined nodules scattered throughout Other presentations include a single well- (alveolar cell) carcinoma both lungs. Lymphoma Multiple nodules that often have fuzzy outlines Manifestation of secondary disease. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. The lesions may change in third of the fistulas are multiple (arteriography of size between the Valsalva and the Mueller both lungs required if surgical resection is contem- maneuvers. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (see Fig C 11-14) may simulate metastases. Rheumatoid necrobiotic Smooth, well-circumscribed nodules that Rare manifestation of rheumatoid lung disease nodules predominantly occur in peripheral subpleural that tends to wax and wane in relation to the acti- (Fig C 8-10) locations. Cavitation is common (thick walled vity of the rheumatoid arthritis and the presence of with smooth inner margins). Amyloidosis Multiple nodules that may cavitate and show Discrete masses of amyloid may develop in the rare calcification or ossification. The nodular parenchymal form of the disease has a better prognosis than the tracheobronchial (obstructive) or diffuse interstitial types (see Fig C 4-27). Pulmonary hematomas Unilocular or multilocular, round or oval Result from hemorrhage into pulmonary paren- (see Fig C 6-14) nodules that are occasionally huge. May peripheral subpleural locations deep to areas of communicate with the bronchial tree (air-fluid maximum trauma. Multiple well-circumscribed, rounded nodules of varying size in a patient with subcutaneous rheumatoid nodules. Usually associated with a (Fig C 8-12) nodules that may simulate metastatic disease. Pulmonary ossification Small, densely calcified or ossified nodules Primarily a manifestation of mitral stenosis (or throughout the lungs. Pneumoconiosis (progressive Conglomerate masses that predominantly Masses represent confluence of individual silicotic massive fibrosis) involve the upper lobes and are usually irregular nodules, sometimes associated with superimposed (Figs C 8-13 and C 8-14) and ill defined with peripheral stranding. They typically develop in the mid-zone or periphery of the lung and tend to migrate toward the hilum. Polyarteritis Poorly defined nodules that are often associated The pulmonary manifestations typically show with patchy consolidations. The angiographic demonstration of multiple arterial aneurysms in one or more abdominal organs is considered virtually diagnostic of this disease. Mucoid impactions Multiple (more commonly single), round, oval, Usually associated with hypersensitivity broncho- (see Fig C 6-18) or elliptical opacities caused by plugs in dilated pulmonary aspergillosis in patients with asthma or bronchi. Non- Fig C 8-14 segmental areas of homogeneous density in both upper Progressive massive fibrosis in silicosis. Granulomatous infections Generally round or oval, well-circumscribed Histoplasmosis, tuberculosis, coccidioidomycosis, (Fig C 9-2) nodules. Calcification is common in histoplasmosis, tuberculosis, and coccidioi- domycosis; cavitation is common in coccidioi- domycosis. Hematogenous metastases Various patterns (from diffuse micronodular Nodules typically vary in size in the same patient. Ground-glass opacification, with peripheral solitary nodule, Focal “pneumonia,” a (Fig C 9-5) areas of increased density representing ele- miliary pattern, or thin-walled cystic lesions. Multiple cavitating nodules Fig C 9-2 (Nocardia) in a young immunocompromised man. Multiple intermediate-sized nodules in a feeding vessel sign (vessel leading directly to the nodule) in patient with persistent and worsening symptoms of cough, several nodules (arrows). Several cavitating nodules Fig C 9-4 (arrows) in both lower lobes with irregular thickening of the Kaposi’s sarcoma. Innumerable, bilateral, poorly defined walls in a patient with metastatic squamous cell cancer of the peribronchovascular micronodules, some of which exhibit lungs. The mass in the left lower lobe also contains solid elements, consistent with the diagnosis of bronchoialveolar carcinoma with adenocarcinoma features. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (Fig C 9-8) may simulate metastases. Multiple pulmonary nodules on a study obtained some of which contain air-fluid levels. Cavitation is common (thick walled the rheumatoid arthritis and the presence of with smooth inner margins).
Sometimes the patients may wake up from sleep with a feeling of suffocation followed by a severe cough purchase epivir-hbv toronto. When the pouch enlarges it tends to compress the oesophagus which leads to dysphagia buy 100mg epivir-hbv with amex. When the patient drinks the pouch can be seen to be enlarging with gurgling noise in the neck purchase epivir-hbv 100 mg line. X-ray with a very thin barium emulsion should be performed as thick mixture refuses to be washed out from the pouch following examination. Traction diverticula may be occasionally seen in the middle portion of the oesophagus near tracheal bifurcation. These result from pull of scar tissue from an adjacent inflammatory process, usually tuberculous lymph nodes. X-ray with barium meal will show a long tortuous stricture with some dilatation of the proximal oesophagus and without any shouldering at the proximal end of the stricture. Some sort of emotional stress and anxiety are often associated with along chest pain and dysphagia. There is also regurgitation of food, though many patients experience regurgitation of intraoesophageal saliva during oesophageal colic. Irritable bowel syndrome, pylorospasm, peptic ulcer disease, gallstone and pancreatitis may stimulate diffuse oesophageal spasm. Oesophageal manometry has been considered the ultimate test in the diagnosis of this condition. This is due to fibrous replacement of oesophageal smooth muscle and then the distal oesophagus loses its tone and normal response to swallowing and gastro-oesophageal reflux occurs. In distal 2/3rds or 3/4ths of the oesophagus normal peristalsis gives way to weak nonpropulsive contractions. At its most upper part at the pharyngo- oesophageal junction and is known as pharyngo- oesophageal diverticulum or pharyngeal pouch which has been discussed above. This occurs in association with tuberculosis or histoplasmosis of the subcarina and parabronchial lymph nodes to which this diverticulum becomes adherent. This condition rarely causes symptom and is discovered accidentally on barium oesophagogram. This is due to oesophageal motor dysfunction of the distal oesophagus leading to mechanical distal obstruction. There is virtually no the mucosa and submucosa of the oesophagus dilatation of the oesophagus above the growth. Many patients may remain constricted part is very much irregular — ‘rat-tail’ deformity of the lower end of the oesophagus. This condition is diagnosed by barium oesophagogram, though oesophageal manometry should be performed to identify the exact motor disturbance. It is generally located at the oesophagogastric junction and has squamous epithelium on one side, gastric mucosa on the other side and fibrous tissues in the centre. Due to sloughing of a portion of the growth dysphagia may be eased out temporarily. Regurgitated material is usually alkaline mixed with saliva and streaked with blood from malignant growth. Anorexia is another symptom but more often seen in growths at the lower end of the oesophagus. Exfoliative cytology from oesophageal lavage may clinch the diagnosis very early even when radiology has not been positive. In late stages pressure on recurrent laryngeal nerve may cause hoarseness of voice or erosion of bronchus may lead to broncho-oesophageal fistula. If symptoms occur these are usually fullness after meals, early satiety and post prandial vomiting. Gastro-oesophageal reflux, which is a very common occurrence in sliding or axial or type I hiatus hernia, does not take place in this condition. The filling defect is then it courses behind the oesophagus (or in rare instances usually more irregular than is shown in front of the oesophagus between the oesophagus and the in this case. It is only when reflux occurs with increased frequency and at times when the stomach is not distended that pathologic gastro-oesophageal reflux is considered. The symptoms of this reflux are heart-burn and regurgitation aggravated by postural change. These are associated with dysphagia, substernal chest pain, sensation of something sticking in the throat and bleeding. Reflux of gastric contents irritates the oesophagus causing secondary muscle spasm alongwith inflammation of the mucosa leading to fibrosis and stricture. Closed injuries are due to waves of shock or direct compression of a viscus against a bony prominence. If a large segment of the abdomen or abdominothoracic wall is compressed it may burst or split organs like liver and spleen. It should be remembered that a similar force, particularly if the breath is held and the diaphragm is tense, may split the diaphragm. In case of penetrating wounds, the length of the weapon and the velocity with which it was struck are important. High velocity injuries produced by gunshot or fragments from exploding mines and shells penetrate deeply and may damage extensively anything in or around their paths. Seat-belt injuries, though not common in India, yet often seen in other countries where wearing a seat-belt is a must at the time of driving a car. The harness may impinge heavily on the points of contact with the trunk and the viscera may continue to move when the abdominal wall has suddenly been decelerated. The combination of these two factors may result in contusion of the abdominal contents, detachment of the gut from its mesentery and less commonly rupture of solid viscera. In suspected injury to the kidney and pelvic bones enquire whether the patient has passed urine or not. If the patient has passed blood mixed with urine, chance of injury to the kidney should be kept in mind. If the patient shows intense desire to pass water but no urine comes out, instead a few drops of blood comes out, extraperitoneal rupture of the bladder or rupture of the membraneous urethra is the most probable diagnosis. If the patient has not passed water and has no intention to do so, possibility of intra-peritoneal rupture of bladder should be kept in mind. Signs of hypovolaemia out of proportion of external injury, if blood in the chest can be excluded, is an almost cardinal indication for opening the abdomen. Bruise, laceration or perforating wound is the external sign of injury which one may locate on careful inspection and injury to internal organ may be at the depth of this external wound. There will be absence of abdominal movements in respiration due to peritonitis from perforation or due to internal haemorrhage. Generalized distension of the abdomen occurs in internal haemorrhage or in late case of peritonitis.
Chassin Jaundiced Patient Although jaundice in the presence of a pseudocyst may well be the result of extrinsic pressure by the cyst against the dis- tal common bile duct order cheap epivir-hbv online, it is also important to rule out the pres- ence of calculi or periductal pancreatic fibrosis as the cause of bile duct obstruction purchase epivir-hbv 100mg mastercard. If the jaundice is due to chronic fibrosis in the head of the pancreas buy epivir-hbv with paypal, endoscopic stenting or a bypass operation is required. It may be necessary to perform a side- to-side choledochojejunostomy to the defunctionalized limb of the Roux-en-Y distal to the cystojejunostomy. If the retrogastric mass is pulsatile, con- • Cystogastrostomy or cystoduodenostomy or sider seriously whether the mass represents an aortic aneu- cystojejunostomy? Expose the aorta at the hiatus of the dia- phragm, and prepare a suitable large vascular clamp for emergency occlusion of this vessel should it be necessary. If Operative Technique the surgeon has had no previous experience with this maneu- ver, he or she should request the presence of a vascular sur- External Drainage geon. Explore the abdomen and Make a 6- to 8-cm incision in the anterior wall of the identify the pseudocyst. Obtain hemostasis with electrocautery insert a needle into the cyst to rule out the presence of fresh or ligatures. Then insert an 18-gauge needle through the back blood, then incise the cyst wall, and evacuate all of the cyst wall of the stomach into the cyst and aspirate. If the cyst obtained, make an incision about 3–6 cm in length through wall is too thin for anastomosis, insert a soft Silastic catheter the posterior wall of the stomach and carry it through the and bring it out through an adequate stab wound in the left anterior wall of the cyst. Sometimes what Approximate the cut edges of the stomach and cyst by appears to be pus is only grumous detritus. Close the abdomi- ing four or five Allis clamps and then perform a stapled clo- nal incision in the usual fashion after lavaging the abdominal sure using the 90 mm stapler. If the gallbladder contains stones, per- form cholecystectomy and cholangiography. Prepare a seg- the posterior wall of the stomach, cystogastrostomy is the ment of jejunum at a point about 15 cm beyond the ligament 93 Operations for Pancreatic Pseudocyst 851 Fig. Liberate enough of the mesentery of the distal jejunal segment to permit the jejunum to reach the cyst with- out tension. Make a small window in an avascular portion of the trans- verse mesocolon, and delivery the distal jejunal segment into the supramesocolic space. Perform a one-layer anastomosis between the open end of jejunum and the window in the anterior wall. Anastomose the divided proximal end of the jejunum to the antimesenteric border of the descending limb of the jeju- num at a point 60 cm beyond the cystojejunal anastomosis. Align the open proximal end of jejunum so its opening points in a cephalad direction. Pancreatic Resection The techniques of pancreatic resection are described in Chaps. If the culture report of the cyst contents comes back positive, administer the appropriate antibiotics for 7 days. In cases of external drainage, administer antibiotics depending on the culture reports. Leave the drain in place until the amount of fluid obtained is mini- mal and a radiographic study with aqueous contrast material shows that the cyst has contracted to the size of the drain. It may be helpful to instill a dilute antibi- otic solution into the drain at intervals if the cyst is infected. The completed cystojejunostomy is illustrated in Postoperative bleeding into gastrointestinal tract (rare if Fig. Operative and nonoperative management of with pancreatic pseudocyst causing persistent cholestasis. Percutaneous drainage of pancreatic pseudocysts is associated with a higher failure rate Pancreaticojejunostomy (Puestow) for 9 4 Chronic Pancreatitis Carol E. Several variations in this procedure have been described and Chronic pancreatitis producing intractable pain not are referenced at the end of the chapter. Separate the greater omentum from the Pitfalls and Danger Points middle of the transverse colon for a distance sufficient to expose the pancreas. Aspiration cytology in the operating room may be helpful in this Incising the Pancreatic Duct situation. The main pancreatic duct is generally located about one- third the distance of the cephalad to the caudal margin of the Operative Strategy pancreas. If the duct cannot be palpated, inserting a 22-gauge needle and attempting to aspirate pancreatic juice may serve Because the dilated pancreatic ducts are thick walled and to locate the pancreatic duct. If the duct has not been suc- fibrotic, pancreaticojejunal anastomosis is a safe procedure. A sufficient length of gram in the operating room by aspirating 2 ml of pancreatic juice with a 22-gauge needle; then inject an equal amount of C. Apply an Allen clamp incision farther into the head of the pancreas than is shown just proximal to the stapling device. Remove any calculi or sion, and position it side-to-side to the open pancreatic duct. The stapled cut end of the jejunum should be approximated to the tail of the pancreas and the distal jejunum to the head. Now incise the antimesenteric border of jejunum over a Constructing the Roux-en-Y Jejunostomy length approximately equal to the incision in the pancreatic duct using a scalpel or electrocautery. Because the fibrotic Prepare the proximal jejunum for a Roux-en-Y operation as pancreas accepts sutures easily, one layer of sutures is suf- illustrated in Fig. For the posterior layer of the anastomosis, approxi- beyond the ligament of Treitz. After a sufficient amount of mate the full thickness of the jejunum to the incision in the 94 Pancreaticojejunostomy (Puestow) for Chronic Pancreatitis 857 Fig. Insert the If desired, make a puncture wound in the left upper needle through both the mucosal and seromuscular portions quadrant, and insert a Jackson-Pratt closed-suction silicone of the jejunal wall. Then pass the needle through the fibrotic drainage catheter down to the region of the pancreaticojejunal parenchyma of pancreas and through the pancreatic duct. For the anterior layer of the anastomosis, use a seromucosal or Lembert stitch on the jejunum. Then Postoperative Care pass the needle through the full thickness of the duct includ- ing some of the pancreatic parenchyma (Figs. Close the defect in the mesocolon by inserting fine Administer perioperative antibiotics no longer than 24 h. At a point at least 60 cm distal to the pancreaticojejunos- Complications tomy, construct an end-to-side jejunojejunostomy to com- plete the Roux-en-Y anastomosis. We generally accomplish Pancreatic fistula this anastomosis by stapling as described in Figs. Endoscopic management after pancreaticojejunal decompression for chronic pancreatitis: of acute and chronic pancreatitis.