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(BQ) Part 2 book “Surgical diseases” has contents: Liver and gallbladder, pancreas and spleen, abdominal wall and hernia, oesophagus and stomach, intestine, rectum and anal canal, thoracic and neurosurgery and urology.
166 / Surgical Diseases FIGURE 8.1: Amebic liver abscess FIGURE 8.2: Amebic liver abscess-Anchovy sauce pus Amebic liver abscess is common in India and other tropical countries and is caused by Entamoeba histolytica Commonly it is single large abscess in right lobe but often can be multiple Pus is chocolate colored, anchovy-sauce type Often abscess can be secondarily infected by bacteria Right sided pleural effusion is known to occur It can be acute or chronic or can be calcified Amebic liver abscess can rupture into peritoneum, lung, pericardium or into intestine which often can be fatal Treatment is antiamebic drugs like metronidazole, chloroquine, U/S guided aspiration or open drainage Liver and Gallbladder / 167 FIGURE 8.3: Massive ascites FIGURE 8.4: Caput medusae Portal hypertension due to cirrhosis can cause massive ascites It is due to increased portal pressure, altered aldosterone mechanism, lymphatic blockage or hypoproteinemia Caput medusae is dilatation of veins around the umbilicus due to communication between paraumbilical and anterior abdominal veins 168 / Surgical Diseases FIGURE 8.5: Hydatid cyst of the liver Hydatid cyst of the liver is caused by Echinococcus granulosus It attains a large size slowly over few years Three finger hydatid thrill may be positive Pain and jaundice can occur If cyst ruptures anaphylaxis can develop U/S is diagnostic Praziquantel and albendazole are useful Cetrimide and hypertonic saline are the scolicidal agents used for hydatid cyst During surgery spillage of scolices should be avoided as it may lead into development of secondary hydatids elsewhere Colored mops are placed in the peritoneal cavity to identify the spilled scolices Liver and Gallbladder / 169 FIGURE 8.6: Endoscopic view of varices FIGURE 8.7: SengstakenBlakemore tube in situ Oesophageal varices due to portal hypertension are graded based on size and luminal prolapse Acute bleeding is controlled by Sengstaken Blakemore tube in place It can be kept in place for 72 hours Recurrent bleeding is controlled by sclerotherapy, endoscopic variceal banding and endoscopic intravariceal injection of Butyl-cyanacrylate (glueing) (most often for gastric varices) Shunt surgeries are not commonly used for acute variceal bleed 170 / Surgical Diseases FIGURE 8.8: CT picture of hepatoma CT scan picture of hepatocellular carcinoma (hepatoma) Hepatoma is common in patients with cirrhosis and hepatitis B and hepatitis C infection It is unicentric and right lobe is commonly involved Painless large palpable liver which is smooth, hard, nontender are the features Hepatic bruit, ascites and jaundice may develop later CT scan is a must Early case is treated by hemihepatectomy Chemotherapy with adriamicin is useful Hepatic artery ligation, intra arterial chemotherapy are other modalities available Liver and Gallbladder / 171 FIGURE 8.9: CT picture of secondaries in liver CT picture of the abdomen showing multiple liver secondaries in both lobes Common sites of primary to cause liver secondaries are stomach, colon, pancreas, small bowel Extraabdominal conditions like carcinoma breast, melanoma or carcinoma kidney can also cause liver secondaries Liver secondaries are multiple, hard, nodular and umbilicated due to central necrosis 172 / Surgical Diseases FIGURE 8.10: CT picture of hydrohepatosis In severe obstructive jaundice there will be dilatation of intrabiliary radicles along with the dilatation of extra biliary radicles Liver will be soft, smooth called as hydrohepatosis Common causes are growth in the pancreas, in the CBD and Klatskin tumor Liver and Gallbladder / 173 FIGURE 8.11: U S showing roundworm in the gallbladder Roundworm from the intestine occasionally can creep into the CBD and gallbladder across sphincter of Oddi to cause acute cholangitis and acute cholecystitis Figure shows roundworm in gallbladder Patient presented with features of acute cholecystitis and needed cholecystectomy 174 / Surgical Diseases FIGURE 8.12: U S showing stones in the gallbladder Figure shows ultra-sound picture of stones in the gallbladder Gallbladder with stones and post-acoustic shadow is obvious Patient requires cholecystectomy (laparoscopic or open) Thoracic and Neurosurgery and Urology / 279 FIGURE 14.24: Plain X-ray showing staghorn calculi both sides Staghorn calculus is the stone occupying renal pelvis and calyces It is usually triple phosphate stone It can be unilateral or bilateral In bilateral cases, renal failure can develop Pain, pyonephrosis, urinary infection and hematuria are the presentations Treatment is nephro-pyelolithotomy Often nephrostomy is required 280 / Surgical Diseases FIGURE 14.25: Plain X-ray showing vesical calculus Large urinary bladder stone which is smooth and radiopaque It is probably phosphate stone It often attains large size Oxalate stone has got spikes Patient presents with hematuria, suprapubic pain and urinary infection Treatment is cystscopic litholapaxy Occasionally suprapubic open cystolithotomy is needed Thoracic and Neurosurgery and Urology / 281 FIGURE 14.26: Fournier’s gangrene Fournier’s gangrene is an infective, vascular gangrene caused by hemolytic streptococci, microaerophilic streptococci and anaerobic bacteria involving scrotal skin It is common in diabetics and old age Acute in onset, causing extensive sloughing of scrotal skin, with toxicity It may extend above, to the lower abdomen Testes are normal 282 / Surgical Diseases FIGURE 14.27: Hydrocele—get above the swelling FIGURE 14.28: Hydrocele which is transilluminating Thoracic and Neurosurgery and Urology / 283 FIGURE 14.29: Hernia of the hydrocele Hydrocele is collection of fluid between two layers of tunica vaginalis of testis Getting above the swelling as shown in Figure 14.27 is the clinical method to confirm hydrocele It is fluctuant and transilluminant It can be primary and secondary It can cause hematocele, pyocele, testicular atrophy or hernia of hydrocele Hernia of hydrocele through dartos muscle is a rare complication of hydrocele 284 / Surgical Diseases FIGURE 14.30: Phimosis Phimosis is inability to retract the prepuce over the glans It may be present at childbirth or occur due to balanoposthitis Treatment is circumcision Circumcision is done under local anesthesia in adult and under general anesthesia in children Thoracic and Neurosurgery and Urology / 285 FIGURE 14.31A: Paraphimosis FIGURE 14.31B: Paraphimosis Paraphimosis is inability to place back the retracted prepuce over the glans Condition is very painful with a constriction ring around penis adjacent to corona Initially a dorsal slit is done and once edema subsides, circumcision is done 286 / Surgical Diseases FIGURE 14.32A: Verrucous carcinoma of penis FIGURE 14.32B: Verrucous carcinoma of penis Thoracic and Neurosurgery and Urology / 287 FIGURE 14.33: Carcinoma penis Verrucous carcinoma is well differentiated, exophytic, locally malignant squamous cell carcinoma It does not spread through lymphatics nor blood Treatment is partial amputation of penis Figure 14.33 shows carcinoma penis which can spread through lymphatics to bilateral inguinal and external iliac nodes Biopsy, FNAC of the node confirms the diagnosis and spread Treatment is amputation of penis with perineal urethrostomy If nodes are positive, ilio-inguinal block dissection is done 288 / Surgical Diseases FIGURE 14.34: Perineal urethrostomy Perineal urethrostomy is done by opening the bulbar urethra and placing a catheter into the bladder It is done as a permanent procedure after total amputation of penis for carcinoma penis It is done as a temporary procedure whenever diversion is needed for penile urethral surgeries like urethroplasties INDEX A Abdominal fecal fistula 22 Abdominal wall abscess Accessory nipple 130 Amebic liver abscess 166 Aortic aneurysm 26 Appendicectomy 240 Arch of aorta 26 Arterial graft 25 B Barium meal 227 Barons band instrument 251 Basal cell carcinoma 74 Bedsore sacrum 12 Bilateral cleft lip 88 Branchial cyst 107 Breast papilloma 131 Bursa 43 C Calcinosis cutis 44 Callosity foot 45 Callous ulcer Carcinoma breast 136 Carcinoma cheek 96 Carcinoma lip 95 Carcinoma pylorus 222 Carcinoma stomach 221 Carcinoma thyroid 121 Cellulitis Charle’s excision, Swiss-roll (Thompson’s) operation, sistrunk operation 38 Choledochoduodenostomy 176 Choledochojejunostomy 176 Cholesterol stone 176 Chronic osteomyelitis 18 Cimino fistula 29 Cleft lip 88 Cock’s peculiar tumor 55 Codman’s triangle 81 Cold abscess loin Colonic carcinoma 237 Colonic polyp 236 Colostomy prolapse 238 Complete rectal prolapse 246 Congenital AV malformation 32 Corn foot 45 Cutaneous lymphatics 140 Cystadenocarcinoma 186 Cystic hygroma 106 Cystosarcoma phylloides 133 D Dermoid cyst ovary 48 Diabetic foot 24 Diplopia 120 Doppler study 10 Duct papilloma 131 290 / Surgical Diseases Duodenal ulcer perforation 149 Dupuytren’s contracture 65 E Ectopia vesicae 270 Edge biopsy 78 Electric burns 59 Embolism 156 Epigastric hernia 198 Epithelioma 78 Exomphalos major 195 Exophthalmos 120 Extradural hematoma 260 F Facial nerve 104 Fecal fistula 197 Fibro-adenoma 132 Filarial leg 38 Fissured tongue 93 Fistula 22 Fistula in ano 243 Foley’s catheter 204 Follicular carcinoma 121 Foramen bochdalek 258 Fournier’s gangrene 281 Fungating carcinoma of parotid 103 Graves’ disease 119 Gynaecomastia 141 H Haemangioma face 31 Hemothorax 259 Hernia of the hydrocele 283 Horner’s syndrome 34 Hydatid cyst of the liver 168 Hydrocele 282 Hydrocephalus 263 Hydrohepatosis 172 Hypospadias 277 I Idiopathic thrombocytopenic purpura 188 Ileocecal tuberculosis 164 Ileum 234 Ingrowing toe nail 16 Inguinal hernia 203 Intercostal tube 259 Intestinal atresia 146 Intestinal tuberculosis 163 Intrathecal methotrexate 267 Intussusception 147 Ischemic ulcer foot 10 J G Gall stones 176 Gastroschisis 194 Glioblastoma multiform 266 Jaw tumors 89 Jejunal diverticula 231 Jejunal hemangioma 232 Jejunal tumor 233 Index / 291 K Keratoacanthoma 66 Multinodular goiter 117 Multiple neurofibromas 52 N L Laryngeal carcinoma 98 Laryngocele 109 Latissimus dorsi 143 Leukoplakia 92 Level of amputation 10 Lipoma 63 Ludwig’s angina Lymph cyst 51 Lymph nodes 40 Lymphangiitis 11 Lymphangiosarcoma/StewartTreves syndrome 142 M Madura foot 17 Malignant cachexia 83 Malignant dermatofibrosarcoma protuberance 84 Marjolin’s ulcer 37 Mastectomy lymphoedema 142 Meckel’s diverticulum 192, 130 Melanoma 76 Melanoma sole 75 Meningiomas 265 Meningoencephalocele 264 Mesenteric cyst 160 Millard criteria 88 Molluscum sebaceum 66 Nasal cartilage 58 Necrotizing fasciitis Neurofibroma 53 Neurofibromatosis with cafe au lait spots 52 Non-Hodgkin’s lymphoma 40 O Obstructive jaundice 178 Oesophageal candidiasis 211 Oesophageal varices 169 Oesophagus 215 Omphalocele 195 Ophthalmoplegia 120 Orrhinger’s transhiatal blind oesophagectomy 216 Osteosarcoma 80 P Pancreaticoduodenectomy 185 Pancreatitis 180 Papilloma 49 Paraphimosis 285 Paronychia Partial rectal prolapse 245 Patent vitello intestinal duct 192 Perineal urethrostomy 288 Phimosis 284 Piles 248 292 / Surgical Diseases Pilonidal sinus 244 Polydactyly 64 Pott’s puffy tumor 19 Pseudocyst 182 Pseudomonas infection Psoas abscess 161 Ptosis 34 Pulmonary hypoplasia 258 Pyloric stenosis 228 Pyogenic granuloma 20 Spinal tumors 267 Spino-ciliary reflex 34 Split skin graft 62 Squamous cell carcinoma 49 Staghorn calculus 279 Strangulated inguinal hernia 205 Subdural hematoma 261 Submandibular salivary gland 100, 105 Submuscular lipoma 63 Syndactyly 64 R Radiopaque appendix 239 Ramstedt’s pyloromyotomy 228 Rectal polyp 252 Recurrent cystosarcoma phylloides 134 Recurrent hernia 207 Retroperitoneal tumors 162 Rhinophyma 67 Roundworms 155, 173 T Therapeutic embolization 33 Thoracic aorta 27 Thromboangiitis obliterans 23 Thyroglossal cyst 114 Thyroglossal fistula 115 Thyrotoxicosis 119 Torticollis 108 Transitional cell carcinoma 271 Tuberculous lymphadenitis 110 S Sacrococcygeal teratoma 242 Saphenous vein varicosity 36 Sebaceous cyst 54 Seborrhoeic keratosis 68 Sequestration dermoid 46 Sequestrum 18 Sigmoid volvulus 158 Soft tissue sarcomas 79 Solitary nodule thyroid 116 Spina bifida 269 Spina bifida occulta 268 U Umbilical hernia 193 Unilateral cleft lip 88 Urethral stricture 276 V Vascular carcinomas 121 Venous flare in ankle 35 Venous ulcer 37 Verrucous carcinoma 78 Index / 293 Verrucous carcinoma of penis 286 Vesical calculus 280 Volvulus 158 X Xeroderma pigmentosa 72 Z W Whipple’s operation 185 Z plasty 64 ... when diagnosis is in doubt Necrotizing pancreatitis has got high mortality rate 1 82 / Surgical Diseases FIGURE 9 .2: CT picture of pseudocyst of pancreas FIGURE 9.3: On table aspiration of pseudocyst,... secondaries Liver secondaries are multiple, hard, nodular and umbilicated due to central necrosis 1 72 / Surgical Diseases FIGURE 8.10: CT picture of hydrohepatosis In severe obstructive jaundice there... presented with features of acute cholecystitis and needed cholecystectomy 174 / Surgical Diseases FIGURE 8. 12: U S showing stones in the gallbladder Figure shows ultra-sound picture of stones