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By U. Trompok. Fitchburg State College.

Hypotension or shock buy pristiq 50 mg online, hematemesis buy 50 mg pristiq visa, endoscopic stigmata of recent hemorrhage buy pristiq from india, and ongoing There are two alternatives to Roux reconstruction which also transfusion requirement identify this high-risk group in decrease the risk of bile gastritis and bile esophagitis. Operation between the afferent and efferent limbs, theoretically allow- should be strongly considered in patients requiring transfu- ing bilious duodenal contents to go from the former to the sion of 4 or more units of blood, especially in patients who latter without having to enter the stomach (Vogel et al. The use of advanced endoscopic techniques to prior to the development of gastric outlet obstruction, though control bleeding ulcer has increased dramatically over the the operative mortality risk is probably two or three times last two decades and has decreased both the need for opera- higher than vagotomy and drainage. However, bleeding is by far the most common peptic ulcer complication requiring hospitalization, and it remains Operation for Nonhealing Gastric Ulcer a not infrequent indication for urgent or emergent surgical intervention. Type I gastric ulcers are located in the body of the stomach During operation for bleeding peptic ulcer, the first con- and are not associated with high acid output. For bleeding duodenal lesions, this is most often and thus are surgically treated more like duodenal ulcers. The bleeding duodenal high on the lesser curvature close to the gastroesophageal ulcer is controlled with nonabsorbable sutures. Historically, the elective operation of choice has duodenotomy and pylorotomy may be closed either longitu- been distal gastrectomy to include the ulcer with reconstruc- dinally or as a pyloroplasty. This compared favorably to a 20 % recurrence create a problematic duodenal stump, and it carries a much rate following vagotomy and drainage. Proximal gastric higher perioperative risk in this patient population than in the vagotomy with excision of the ulcer yielded lower morbidity elective setting. Obviously excision of a lesser curve are best treated with biopsy and oversewing or wedge resec- ulcer can be challenging and may denervate the antrum and tion. Stable low-risk patients can be treated with distal gas- pylorus, thwarting the “highly selective” vagotomy. The role of vagotomy gastric ulceration poses a challenge because of its relation to in gastric ulcer is controversial. Ideally, the ulcer is resected in continuity with a distal gastrectomy and reconstruction with gastroduo- denostomy (Pauchet operation). Total gastrectomy for benign gastric ulcer should be tion, nasogastric decompression, acid suppression, and H. An gastric resection can be nutritionally problematic in chroni- attempt at endoscopic balloon dilation may yield initial suc- cally thin patient. These operations were comparable in a small randomized clinical trial (Csendes Elective surgery for intractable or nonhealing duodenal ulcer et al. This operation is usually well tol- an acceptably low recurrence rate when performed electively erated in the patient who was well nourished or overnourished for intractable duodenal (Harbison and Dempsey 2005; 28 Concepts in Surgery of the Stomach and Duodenum 273 Millat et al. These operations should be needed pleteness of vagotomy (serum pancreatic polypeptide most infrequently nowadays as an elective treatment for response or gastric acid secretory response is assessed). Options include thoracoscopic vagotomy, the surgeon should consider the irreversibility of both pylo- takedown of loop gastrojejunostomy if gastric outlet is intact, roplasty and antrectomy. Ulcer or Marginal Ulcer Reoperation for recurrent ulcer after hemigastrectomy or marginal ulcer after Roux Y gastric bypass can be challeng- In the modern era, most postoperative recurrent peptic ulcers ing because of involvement of adjacent structures such as are marginal ulcers (e. When evaluating patients with recurrent revision of gastric bypass for marginal ulceration, if part of peptic ulcer following an ulcer operation or with a marginal the bypassed stomach is resected, it is important that some ulcer following some other gastric operation, the differential parietal cell mass be left in continuity with the antrum. For example, the patient has a there is no luminal acid (the shut off signal for gastrin secre- hemigastrectomy and Roux reconstruction without vagot- tion) in the antrum. Or the patient has a truncal vagot- stomach to include the antrum is preferable to this situation. Or the patient has a Roux Y gastric bypass for severe obesity and the proximal pouch is large, and/or the Gastrostomy and Duodenostomy patient develops a gastrogastric fistula. Causes include retained antrum which Gastrostomy is out of continuity with the proximal stomach or gastrinoma. Stump cancer may present as recurrent ulcer disease years room and does not require general anesthesia. Many patients referred to the surgeon and the lack of suture fixation of the stomach to the inner with recurrent or marginal ulcer do not regularly take the abdominal wall. Open gastrostomy is the most invasive but continued noncompliance predicts another recurrent may be the only option in certain patients with prior abdomi- ulcer after revisional operation. The Stamm gastrostomy is the most commonly compliance usually predicts success with revisional used open method. This can be done under local anesthesia operation and may even obviate the need for revisional and sedation in many patients. Dempsey Janeway gastrostomy creates a permanent mucosa-lined Subtotal Versus Total Gastrectomy gastrocutaneous fistula, obviating the need for a continuous indwelling tube. Routine total gastrectomy for gastric adenocarcinoma is unnecessary and should be avoided. When compared to sub- total resection, the operative mortality is higher, the nutri- Duodenostomy tional side effects more devastating, and the cure rate no better after total gastrectomy than it is after subtotal gastrec- A tube is positioned in the duodenum for decompression, tomy (Bozzetti et al. Most tumors of the distal stom- usually to protect a tenuous duodenal suture line. The safest ach are adequately resected with distal subtotal gastrectomy way to accomplish this is via a 14 F or 16 F jejunal tube described above. A Billroth I reconstruction should be avoided placed in a Stamm fashion into the lateral duodenum or into in cases of gastric malignancy because of the risk of recur- the end of the duodenal stump. A closed suction drain is rence at the duodenal margin (usually the margin with the placed nearby. If 20 % or less of the proximal stom- between the duodenal tube site and the abdominal wall, the ach remains, reconstruction should be with a Roux limb or a site should be covered with omentum. We favor total gastrectomy for proximal gastric cancer though occasionally we have used a Adenocarcinoma of the stomach often extends submuco- proximal gastrectomy with esophagogastrostomy without sally much farther than is appreciated on gross examination. In this Early metastasis is usually to regional lymph nodes, but the instance, we always add a feeding jejunostomy. A better lymphatic drainage of the stomach is extensive and often option for reconstruction following proximal gastric resec- unpredictable. These facts support a generous gastric resec- tion may be isoperistaltic jejunal interposition (Henley loop). We margin may be acceptable for the intestinal subtype of gas- favor the construction of some sort of jejunal reservoir, tric cancer. The goal of operation for gastric cancer is an R-0 though there are studies that show this makes little differ- resection with negative margins and an adequate lymph ence. Frozen section analysis is important for the and nutritional status with jejunal pouch after total gastrec- intraoperative confirmation of negative margins. Roux-en-Y esophagojejunostomy past two decades, the standard operation performed for gas- with a J-pouch is easy to construct and functions well. Cancers of the cardia or fundus a minimum of 15 lymph nodes must be removed and assessed are treated with total gastrectomy or proximal subtotal gas- pathologically.

As many patients are nutritionally depleted and septic 50mg pristiq sale, urgent preparation with attention to fluid resuscitation buy generic pristiq 50 mg, parenteral nutrition pristiq 100 mg, administration of antibiotics and appropriate monitoring measures should be instituted preoperatively. Usually computerised tomography is used to localise the abscess and to find the ‘window’ for needle and catheter insertion. The ‘window’ is that portion of the abscess which is in contact with the abdominal wall without any intervening viscera. Ultrasound is then used to guide the percutaneous needle, guide wire and ultimately the catheter. The incision is made from the tip of the 11th rib and carried obliquely and anteriorly parallel to the costal margin. The dissection is largely extraperitoneal until the abscess cavity either anteriorly or posteriorly located is approached. If the abscess is situated anteriorly on the left side, a similar subcostal incision may be employed as performed for the right subphrenic abscess. It is important in approaching the left subphrenic abscess to avoid injury to the spleen. If a swelling is detected in the subcostal region or in the loin indicating subphrenic abscess, an incision should be made over the site of maximum tenderness or over the area where oedema is maximum. Through this region it is possible to reach the abscess cavity without opening or contaminating the general peritoneal cavity. Pelvic abscess often follows a ruptured appendix (pelvic position), infected fallopian tube, ruptured colonic diverticulum and other pelvic inflammatory diseases. Irritation of the urinary bladder and/or the rectum producing urgency and frequency or diarrhoea and tenesmus may be only symptoms received in a few cases. However the abscess usually can be palpated directly by rectal or vaginal examination. If left untreated pelvic abscess may finally rupture into the rectum and the patient recovers spontaneously. In women, the swelling, which is soft and cystic, is palpated in the posterior fornix. Treatment— As abscess anywhere in the body the pus should be drained by incision either through the rectum (in case of males) or through the vagina (in case of females). Incision for drainage should be delayed until formation of the pyogenic membrane or a definite abscess to exclude injury to the small bowel or other intraabdominal viscera. In fact when the most prominent part of the abscess presenting rectally or vaginally begins to soften, the condition is now ready for drainage. The needle is placed in situ as a guide and a sharp incision with a fine bladed knife is made into the abscess cavity. To ensure proper drainage, daily dilatation of the tract is made digitally or with an instrument till the abscess cavity becomes obliterated in a few days. In majority of cases it is the secondary involvement and there is some primary focus elsewhere in the body. Though sometimes the primary focus remains obscure, almost always it is later demonstrated to be in the lung. The various possible sites of primary are — (i) pulmonary tuberculosis, (ii) tuberculous mesenteric lymph nodes, (iii) tuberculous ileocaecal region, (iv) tuberculous kidney and (v) tuberculous pyosalpinx. Majority of cases are due to reactivation of latent peritoneal tuberculosis which had developed by haematogenous spread from a pulmonary focus. Straw-coloured fluid with tubercles scattered althroughout the peritoneum and greater omentum is found inside the abdomen. Immediately the fluid is evacuated and a portion is sent for bacteriological study. The onset is insidious, presenting with fever, anorexia, weakness and weight loss. The abdomen is very slightly tender and the feel is typically described as ‘doughy abdomen’. Clinical manifestations of generalised tuberculosis are seen in Yard of patients which includes anorexia, weight loss and night sweats. The ascitic fluid has increased protein content, there is lymphocytosis and a glucose concentration below 30 mg per dl. If these measures do not establish the diagnosis, peritoneoscopy and guided direct biopsy of the peritoneum are recommended. As a last resort exploratory laparotomy with peritoneal biopsy may be undertaken to establish the diagnosis. Fibrinous form is characterised by fibrinous deposits in the abdomen which cause adhesions of the coils of intestine. The coils become dilated and act as blind loop giving rise to wasting, abdominal pain and steatorrhoea. These cases may require operation in the form of plication or excision of strictured portion of the ileum, as sometimes the adhesions are accompanied by fibrous stricture of the ileum as well. Usually conservative treatment with antitubercular drugs after adequate surgery rapidly cures this condition. Usually general treatment of tuberculosis is enough to cure this condition, though occasionally surgery may be required to evacuate cold abscess or to relieve intestinal obstruction. On the whole tuberculous peritonitis is no more a dangerous condition due to advent of proper antitubercular drugs. But tuberculous peritonitis often heals with formation of dense fibrous adhesions which often liable to the future development of intestinal obstruction. Treatment with prednisone during the initial months of antituberculous drug therapy reduces the incidence of adhesion formation and subsequent development of obstruction. In these cases pneumococci have got access through the vagina and fallopian tubes into the peritoneal cavity. It must be remembered that after 10 years pneumococcal peritonitis is most unusual. Secondary pneumococcal peritonitis is usually secondary to the pneumococcal infection of the upper respiratory tract or the middle ear. Associated rise of temperature and frequent vomiting and diarrhoea are almost characteristic. Only when diagnosis is not very certain, laparotomy becomes necessary to exclude other conditions and to take a little peritoneal fluid for culture and sensitivity test. Odourless and sticky exudate is almost diagnostic of pneumococcal peritonitis found on exploration of the abdomen. Early surgical intervention is very much essential as soon as the patient is resuscitated to a respectable level. The most important feature of this type of peritonitis is the problem to diagnose. As there is no abdominal pain associated with this condition and tenderness being masked by presence of a recent wound, diagnosis becomes difficult. Failure of expected betterment of the patient’s condition following operation is probably the most important guide to diagnose. The patient becomes ill with rise in pulse rate and peripheral circulatory failure. The structure hangs in a double fold from the greater curvature of the stomach down to almost pelvis and then folds on itself and moves up in front of the transverse colon and mingles with the transverse mesocolon to end at the anterior border of the pancreas.

Right hemicolectomy involves removal of terminal 8 inches of the ileum order pristiq with amex, the caecum buy cheap pristiq 50 mg on line, the ascending colon and proximal ‘/ rd of the transverse colon effective pristiq 100mg, that means the3 portion of the bowel supplied by the ilieocolic a nd right colic branches of the superior mesenteric artery. Unless the obstruction is advanced, resection with primary anastomosis on the right side is quite a safe procedure. This is due to the fact that the anastomosis is performed between well vascularised small intestine and transverse colon. In very advanced cases of obstruction, one may have to perform ileo-transverse colostomy first, to be followed by hemicolectomy in the second stage. In case of inoperable growth of the right half of the colon, a palliative ileo-transverse colostomy should be performed to obviate the possibility of intestinal obstruction. Mostly the growths in the transverse colon occur in its middle V rd and the affected lymph nodes lie by the side ofthe middle colic artery, so this simple resection3 with primary anastomosis is the operation of choice. When the growth is inoperable, proximal transverse colostomy should be done to obviate the obstruction. A left hemicolectomy is advised which means resection of the distal third of the transverse colon, the whole of the descending colon, the pelvic colon and upper part of the rectum. But if at all it is found that the glands related to the inferior mesenteric artery are involved, this artery is ligated and divided at its origin from the aorta. The blood supply of the colon is maintained through ‘marginal anastomosis’, which is supplied by the middle colic artery from above and may well feed the colon right upto the middle ofthe pelvic colon. So after division of the inferior mesenteric artery, one should look for viability of the colon and the viable colon either upper part of the pelvic colon or the distal part of the transverse colon is anastomosed to the lower half of the rectum. In case of sigmoid colon cancer, it may not be possible to bring the distal cut end out and in this case the distal cut end is closed by suturing, so a Hartmann procedure is used. Proximal diverting colostomy alone is the procedure of choice for obstruction in poor risk patients. Liver involvement is found in 10 to 15% of patients at the time of initial operation. If the primary lesion is locally unresectable, a short-circuiting anastomosis around the tumouroffers worthwhile palliation. The type of palliative operation to be performed incase of growth indifferent regions of colon has been described in separate paragraphs under the heading of ‘Extent of resection and choice of operation. Though chemotherapy has been used in conjunction with surgical therapy, yet no current evidence suggests that any benefit may result from this type of therapy. The rectosigmoid junction lies at the level of 3rd sacral vertebra, hence it passes downwards and backwards, then downwards and finally downwards and forward. Below, the rectum is continuous with the anal canal by passing through the pelvic diaphragm, from where the anal canal passes downwards and backwards — this is known as ‘perineal flexure’. The upper one is convex to the right, the middle one (which is the most prominent) bulges to the left and the lower one is convex to the right. The peritoneum is related to the rectum in its upper l/3rd in front and on two sides, in its middle l/3rd in front only. The peritoneum is reflected from the anterior wall of the rectum to the bladder in the male forming the rectovesical pouch of peritoneum and on to the posterior wall of the vagina in female forming the recto-uterine pouch. The rectovesical pouch, in case of male, lies 3 inches above the anus, while in case of females, the recto-uterine pouch lies 2 inches above the anus. The peritoneum is loosely attached to the muscles of the rectum being intervened by fatty tissue, thus allows considerable expansion of this part of the gut. The three taeniae coli of the sigmoid colon fuse together about 5 cm above the rectosigmoid junction to form two thick bands of longitudinal muscles which descend in front and behind the rectum. There are three transverse folds of semilunar shape, mostly marked when the rectum is distended. The middle one is the largest and contains a few longitudinal muscle fibres as well. It lies at the level where the peritoneum is reflected from the anterior surface of the rectum. The rectum is related anteriorly in the females to the uterus, the upper part of the vagina, the recto-uterine pouch of peritoneum with its contents e. The lower part of the rectum is related to the pelvic sympathetic plexuses, the levator ani and a few branches of the superior rectal vessels. These branches pierce the muscular wall of the rectum and run down through each column of Morgagni. The middle recal artery arises from the internal iliac artery and runs through the lateral ligament of rectum. The inferior rectal artery, a branch of the internal pudendal artery, crosses the ischiorectal fossa and supplies the lower part of the rectum. The middle sacral artery, morphologically a continuation of the aorta, arises from the back of the aorta just above its bifurcation and supplies the posterior parts of the rectum and anal canal. Several collecting veins pass upwards in the submucosa and pierce the rectal musculature about 7. These veins unite to form the superior rectal vein, which is continued upwards as inferior mesenteric vein. Dilatation and tortuosity of these veins are called the internal haemorrhoids (Piles). This possibly occurs due to (a) absence of valves in these veins, (b) internal pressure from faecal impaction, (c) external pressure from a loaded pelvic colon, gravid uterus, fibroid etc. The middle rectal veins chiefly drain the rectal muscles and end in the internal iliac veins. The lymphatics of the rectum — follow the veins draining the rectum and are also divided into 3 groups. The middle group follows the middle rectal vein and drains into the internal iliac nodes. Lymphatics of the lower part of the rectum follow the inferior rectal vein and drain into the internal iliac nodes following the internal pudendal vein. Nerve supply of the rectum — is derived from both the sympathetic and parasympathetic systems. So long as the carcinoma remains confined within this fascia, excision is easy and little possibility remains for local recurrence to occur after excision. It starts from the anorectal junction and passes upwards to be attached to the periosteum of sacrum. During perineal excision of the rectum, after disarticulation of the coccyx and division of the levator ani, this fascia is come across. It must be divided transversely and completely before exerting a downward pull upon the rectum. These extend from the posterolateral walls of the rectum to the third piece of the sacrum. In front, it is in relation with the perineal body, which separates it from the membranous part of the urethra and the bulb of the penis in the male and from the lower part of the vagina in the female. Behind, it is inrelation with the anococcygeal ligament, which separates it from the tip of the coccyx. For the whole length, it is surrounded by sphincter muscles, which in tone keeps it closed. The upper half of the anal canal is lined by mucous membrane and is plum-coloured owing to the blood in the subjacent internal venous plexus.

It is an oblique fracture at the base of the first metacarpal bone extending distally and medially from its articular surface buy 100mg pristiq free shipping. So a triangular piece of bone remains in its position whereas the main shaft dislocates proximally and laterally on the trapezium cheap pristiq 50 mg with mastercard. On examination there is abnormal swelling at the base of the first metacarpal bone and if the clinician pushes the projection distally and medially with his thumb the dislocated shaft moves causing a great pain to the patient purchase cheapest pristiq and pristiq. Dislocation of the metacarpo-phalangeal joint is diagnosed by careful palpation at the metacarpo­ phalangeal joint where the head of the metacarpal bone is dislocated anteriorly most of the time. The cause is usually a forced flexion of the terminal phalanx when the extensor is contracting. On examination, the typical flexion deformity of the terminal phalanx to a position of 30° flexion is obvious. The patient is unable to extend the distal interphalangeal joint to the full extent. Radiological investigation is of value in case of chip fracture of the terminal phalanx. Patient complains of severe pain in the region of the pelvis, which gets worse on moving the legs or the body. On examination, bruising and swelling over the injured site can be easily revealed. A careful palpation of the whole pelvis is required to know the exact type of fracture. In multiple injuries one can exclude the possibility of any bony injury to the pelvis by pressing two iliac bones and the greater trochanters medially by the two hands of the clinician (See Fig. In this group are the fracture of the blade of the ilium, fracture of the floor of acetabulum with central dislocation of the hip and fracture of ischiopubic ramus. One must be very methodical in palpating the parts of the pelvis one by one to elicit the fracture which might have occurred. X-ray examination is confirmatory and besides antero-posterior and lateral views, stereoscopic views are also required to diagnose fracture which may not be evident in these views. Injury to the urethra is diagnosed by the three classical signs — blood per urethrum, perineal haematoma and distended bladder. Injury to the bladder are of two varieties — extraperitoneal (commoner) and intraperitoneal. Extraperitoneal rupture is sometimes difficult to differentiate from the rupture of the posterior urethra. Of course the diagnosis of these conditions are discussed more elaborately in the chapter of "Examination of a urinary case", yet it is sufficient to narrate at this stage that a straight X- ray with ground glass appearance of fluid in the lower abdomen and intravenous pyelography with descending cystography may confirm a leak in the bladder. In ^e latter condition young patient lies with flexed, adducted and internally rotated lower limb. Abnormal swelling and bruising will be evident in the injured hip either due to haematoma in case of fracture neck of femur or due to abnormal position of the head of the femur. A note should be made whether the injured limb appears * ‘ ‘ •“9 T to be shortened or lengthened (see under "Measurement"), cation of right hip. In anterior dislocation or fracture of the neck of the femur the greater trochanter recedes from the anterior superior iliac spine due to external rotation of the femur. If the greater trochanter lies in its normal position but the lower limb is externally rotated, the possibility of fracture below- the greater trochanter (subtrochanteric fracture) should be kept in mind. In different types of dislocation the position of the head of the femur will vary. It may be on the dorsum ilii (posterior type), in the groin (pubic type) or rarely in the perineum (obturator type). Confirm the identity of the head by noting that it moves with rotation of the shaft. In this context one must remember that medial surface of the,medial condyle looks to the same direction as the head of the femur. Another important point in this regard is the palpation of the femoral artery at the base of the femoral triangle. Normally it is well palpated as the artery is being supported from behind by the head of the femur. In posterior dislocation due to the absence of the head of the femur in its normal position the artery cannot be palpated so easily. In transcervical and subcapital fractures, tenderness can only be elicited when an attempt is made to rotate the shaft of the femur. Another from ft the tip of the same spine to the tip of the greater trochanter and lastly a horizontal line is drawn from the tip of the greater trochanter to the first line. Diminution in the length of the last line or the horizontal line in comparison to the other side denotes an upward elevation of the greater trochanter, the commonest cause of which being the Fig. Elevation of the transcervical or subcapital fracture of the neck of the greater trochanter is determined by comparing femur or separation of the upper femoral epiphysis. See trochanter is elevated the line will cross that this line normally touches the tip of the greater trochanter. It will reveal any medial (posterior and central dislocation) or lateral (anterior dislocation of hip) displacement of the trochanter. The length of the lower limb is measured from the anterior superior iliac spine to the medial malleolus. It was customary to make the upper border of the patella or more commonly the adductor tubercle as the lower landmark instead of the joint line. But the former is moveable and the latter is difficult to locate particularly in obese individuals. It is always advisable to mark the bony points first and then measured with the measuring tape. If the patient is able to lift his leg off the bed keeping the knee straight, it indicates no bony injury around the hip. It must be remembered that some use of limb is possible in an impacted fracture of the neck of femur. In posterior dislocation, there is complete limitation of abduction and lateral rotation whereas slight adduction and internal rotation may be possible. Blood transfusion is often required at the time of operation, (b) Sciatic nerve injury may occur in posterior dislocation of the hip and subtrochanteric fracture. Femoral nerve may be rarely injured in pubic type of dislocation and the obturator nerve in the obturator type of dislocation. Rectal examination is essential in central dislocation of the hip joint where the head of the femur lies within the pelvis. While doing rectal examination if the limb is rotated, the head of the femur can be felt rotating by the finger in the rectum.

The blood in the vomit may be altered to blackish or dark brown in colour in contact with gastric juice pristiq 50 mg with mastercard. It must be remembered that blood in the vomit may have come from the nose or lungs which have been swallowed cheap 50mg pristiq mastercard. Before any operation is performed such skin conditions must be cured first until and unless the surgical condition deserves immediate operative interference purchase pristiq 50 mg with mastercard. However in old people with dry skin pruritus is common and is of no systemic significance. Local irritation by dirty under-clothes may also cause pruritus from local irritation. Majority of these cases are due to allergic hypersensitivity and vary from person to person. Majority of these hiccups are of no significance and have been experienced by almost all of us without the presence of any organic disease. The first group occurs in early postoperative period and signifies upward pressure on the undersurface of the diaphragm due to increased abdominal pressure. Obviously such hiccup requires introduction of a nasogastric tube and aspiration through such tube will cause diminution of intra-abdominal pressure and hiccup is relieved. The second group is often due to peritonitis involving the diaphragmatic peritoneum. So in any case of hiccup the patient should be asked to protrude his tongue and brown dry tongue should indicate renal failure and immediate investigations should be performed in this line. Only when there is raised venous pressure, engorgement of the external jugular vein occurs. Bilateral engorgement of neck veins indicates too much intravenous fluid infusion or myocardial failure. Unilateral engorgement may be due to pressure on the vein by enlarged lymph nodes, a tumour or a subclavian aneurysm. Bilateral or unilateral engorgement may also be due to presence of retrosternal goitre or due to something obstructing the superior vena cava. Radiating veins from the umbilicus in the abdominal wall indicates obstruction to the portal venous system and this is known as the caput medusae. Sometimes engorged superficial veins may be seen in the flank extending from the axilla to the groin. These are called inguino-axillary veins and engorgement of such vein indicates obstruction of the inferior vena cava. When vein of one side is affected, it indicates blockage of the common iliac or external iliac vein of that side. Importance is probably much more in case of medical diseases, yet there is quite a big list of surgical cases in which examination of tongue is quite important. Inability to protrude the tongue is due to ankyloglossia, tongue-tie (in case of children) or advance carcinoma of the tongue involving the floor of the mouth (in old age). Such deviation is due to hemiplegia of the tongue due to involvement its motor nerve supply the hypoglossal nerve mostly by carcinomatous lesion. Such large tongue may be due to acromegaly, cretinism (in children), myxoedema, lymphangioma, cavernous haemangioma and amyloidosis. Tremor of the tongue after its protrusion is a very characteristic feature of primary thyrotoxicosis though delirium tremens and perkinsonism are other rare causes. Its particularly reach blood supply with a capillary network close to the surface has made the colour of the tongue dark red. Dry tongue means the water content of the body is below standard and the patient is dehydrated. A dry, brown tongue may be found in later stages of severe illness, in acute intestinal obstruction and in advanced uraemia. Furring on the dorsum of the tongue is of little value as an indication of disease. Furring may also result from local infection of the mouth (stomatitis), local infection of nose or throat (tonsillitis) or from the infection of the lungs (bronchitis or pneumonia). Generalized atrophy of papillae which produces a smooth and bald tongue is characteristic of vitamin B12 deficiency, iron- deficiency anaemia or certain gastrointestinal disorders. In chronic superficial glossitis, whitish opaque areas of thickened epithelium (known as leukoplakia) are seen separated by intervening smooth and scarred areas, with no normal papillae seen on the dorsum of the tongue. In congenital fissuring the papillae are normal but the surface is interrupted by numerous irregular folds which run horizontally. In median rhomboid glossitis a lozenge-shaped area of loss of papillae and fissuring is seen in the midline anterior to the foramen caecum. The sides and undersurface of the tongue should always be examined with a spatula to retract the cheeks and lips. Injury is the most common cause of changes in the nails and may permanently impair their growths. A transverse groove at a similar level of each of the nails indicates a systemic disturbance and previous illness. Splinter haemorrhages under the nails are manifestations of systemic vasculitis caused by immune complexes which may cause haemorrhages in the skin and retina also. Long standing iron deficiency may make the nails brittle, then flat and ultimately spoon shaped (koilonychia), so this type of nail is seen in advanced cases of anaemia and in Plummer-Vinson syndrome. Nails may be pitted in psoriasis which may also discolour and deform the nails which is often confused with fungal infection. In clubbing of the fingers, the tissues at the base of the nail are thickened and the angle between the nail base and the adjacent skin of the finger is obliterated. The nail itself loses its longitudinal ridges and becomes convex from above downwards as well as from side-to-side. In advanced degree of clubbing there is swelling of the subcutaneous tissue over the base of the nail which causes the overlying skin to become tense, shiny and red. Lesser degree of clubbing may be found in carcinoma of the lung, pulmonary tuberculosis and in certain chronic abdominal conditions e. Nail bed infarcts may occur in vasculitis especially in systemic lupus erythematosus and in polyarteritis. The pitting may persist for several minutes until it is obliterated by slow reaccumulation of the displaced fluid. Generalized oedema is often due to disorder of the heart, kidneys, liver, gut or diet. Local oedema is more of surgical importance and may be due to venous or lymphatic obstruction, allergy or inflammation. Pretibial myxoedema may be occasionally seen in thyrotoxicosis patients who are overzealously treated so that the patient is now symptom-free but presents with pretibial myxoedema (myxoedema in the subcutaneous tissue in front of the tibia) and probably persistent exophthalmos. Inflammatory causes are of main concern in surgical practice and in fact any inflammation starting from the bone to the skin causes oedema of variable extent.

The Jarisch-Herxheimer reaction is associated with treatment and occurs in 50% of pregnant women pristiq 100mg. It is associated with acute fever purchase 50 mg pristiq amex, headache buy 50 mg pristiq with visa, myalgias, hypotension, and uterine contractions. She received 2 units of packed red blood cells two years ago after experiencing postpartum hemorrhage with her last pregnancy. Sharing contaminated needles, having sexual intercourse with an infected partner, and perinatal transmission are the most common ways of transmission. Fetal infection: Transplacental infection is rare, occurring mostly in the third trimester. The main route of fetal or neonatal infection arises from exposure to or ingestion of infected genital secretions at the time of vaginal delivery. Of those neonates who get infected, 80% will develop chronic hepatitis, compared with only 10% of infected adults. Chronic hepatitis: Cirrhosis and hepatocellular carcinoma are the most serious consequences of chronic hepatitis. Prevention includes: Vaginal delivery is indicated with cesarean section only for obstetric indications. On pelvic examination the fetal membranes are seen bulging into the vagina, and no cervix can be palpated. Two years ago she underwent a cervical conization for cervical intraepithelial neoplasia. In the past, a diagnosis was made on the basis of a history of painless cervical dilation after the first trimester with expulsion of a previable living fetus. Recent studies using U/S to examine cervical length suggest that cervical function is not an all-or-none phenomenon, but may be a continuous variable with a range of degrees of competency that may be expressed differently in subsequent pregnancies. Studies show the benefit of elective cervical cerclage with a history of ≥1 unexplained second-trimester pregnancy losses. Serial transvaginal ultrasound evaluations of the cervix after 16–20 weeks may be helpful. With sonographic demonstration for fetal normality, elective cerclage placement at 13–14 weeks’ gestation. With sonographic evidence of cervical insufficiency after ruling out labor and chorioamnionitis, possible emergency or urgent cerclage. Consider cerclage if cervical length <25 mm by vaginal sonography prior to 24 weeks and prior preterm birth at <34 weeks gestation. The benefit is that vaginal delivery can be allowed to take place, avoiding a cesarean. Shirodkar cerclage utilizes a submucosal placement of the suture that is buried beneath the mucosa and left in place. Cerclage removal should take place at 36–37 weeks, after fetal lung maturity has taken place but before the usual onset of spontaneous labor that could result in avulsion of the suture. The fetuses may arise from one or more zygotes and are usually separate, but may rarely be conjoined. Mono–Mono–Di Twins Twin pregnancy Gender always same One placenta but two sacs Dizygotic twins are most common. Identifiable risk factors include race, geography, family history, or ovulation induction. Risk of twinning is up to 10% with clomiphene citrate and up to 30% with human menopausal gonadotropin. Mono–Mono–Mono Twins Twin pregnancy Gender always same One placenta and one sac Complications for all twin pregnancies include nutritional anemias (iron and folate), preeclampsia, preterm labor (50%), malpresentation (50%), cesarean delivery (50%), and postpartum hemorrhage. Multiple Gestation Dizygotic twins arise from multiple ovulation with two zygotes. Chorionicity and amnionicity vary according to the duration of time from fertilization to cleavage. Up to 72 hours (separation up to the morula stage), the twins are dichorionic, diamnionic. Between 4–8 days (separation at the blastocyst stage), the twins are monochorionic, diamnionic. A specific additional complication is twin–twin transfusion, which develops in 15% of mono-di twins. The donor twin gets less blood supply, resulting in growth restriction, oligohydramnios, and anemia. The recipient twin gets more blood supply, resulting in excessive growth, polyhydramnios, and polycythemia. Intrauterine fetal surgery is indicated to laser the vascular connections on the placental surface between the two fetuses. Monochorionic, Diamniotic Twin Gestation Between 9–12 days (splitting of the embryonic disk), the twins are monochorionic, monoamnionic. Specific additional risks are twin–twin transfusion but particularly umbilical cord entanglement which can result in fetal death. Dichorionic–diamnionic 0–3 days Morula Monochorionic–diamnionic 4–8 days Blastocyst Monochorionic–monoamnionic 9–12 days Embryonic disk Conjoined >12 days Embryo Table I-8-2. Intrapartum: Route of delivery is based on presentation in labor—vaginal delivery if both are cephalic presentation (50%); cesarean delivery if first twin in noncephalic presentation; route of delivery is controversial if first twin is cephalic and second twin is noncephalic. Postpartum: Watch for postpartum hemorrhage from uterine atony owing to an overdistended uterus. She has been married to the same husband for 10 years and states he is the father of both her pregnancies. The concentration of antibodies is reported in dilutional titers with the lowest level being 1:1, and titers increasing by doubling (e. Other pregnancy-related risk factors are amniocentesis, ectopic pregnancy, D&C, abruptio placentae, and placenta previa. Fetus must be antigen-positive, which means the father of the pregnancy must also be antigen-positive. Rosette test is a qualitative screening test for detecting significant feto- maternal hemorrhage (≥10 mL). Her previous pregnancy ended with spontaneous vaginal delivery at 30 weeks’ gestation. Preterm delivery categories include: Extreme preterm: <28 weeks Very preterm: <32 weeks Moderate preterm: 32–33 6/7 weeks Late preterm: 34–36 6/7 weeks Risk Factors. Particularly in primigravidas, symptoms may be present for a number of hours to days but are not recognized as contractions by the patient. Antenatal corticosteroid therapy for stimulation of pulmonary surfactant: A single course of corticosteroids is recommended for pregnant women with gestational age 23–34 weeks of gestation who are at risk of preterm delivery within 7 days. Neonates whose mothers receive antenatal corticosteroids have significantly lower severity, frequency, or both of respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis and death. Clinical monitoring is based on decreasing but maintaining detectable deep tendon reflexes. Side effects include muscle weakness, respiratory depression, and pulmonary edema. Side effects include hypertension, tachycardia, and possible hyperglycemia, hypokalemia, and pulmonary edema.

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