By T. Sobota. Carrol University.
This line actually demarcates between the areas supplied by the anterior and posterior branches of the renal artery — so this is a relatively avascular line 400 mg levitra plus amex. Even if the stone is not palpable discount levitra plus 400mg with visa, the incision is placed according to the position determined by radiography order levitra plus 400mg fast delivery. Again care must be taken not to incise at the neck of the calyx to prevent excessive haemorrhage buy generic levitra plus 400mg. The length of the incision should be such that it should not be too long or should not be too small to bruise the surrounding tissue during the removal of the stone. When all stones have been removed, the cavity of the kidney is washed with normal saline in order to remove any debris which may be left behind. The renal cortical inci sion is closed by interrupted catgut sutures which are tied not too tightly to cut out the cortex. If the surgeon anticipates chance of bleeding even after suturing the cortex, the sutures should be tied over a piece of muscle graft or oxycel. If there is gross infection present within the kidney, a nephrostomy should be carried out by pushing a self-retaining catheter through this incision into the renal pelvis. This is particularly the case in case of stone in the lower most calyx (lower pole). But these calculi are notorious for recurring, so nephrectomy is often the best treatment. It must be remembered that ihe contralateral kidney must be proved healthy before considering this operation. These cases are — (a) During pyelolithotomy if the renal artery is injured and the torrential bleeding cannot be controlled, nephrectomy may be considered. Similarly after nephrolithotomy if haemorrhage cannot be controlled or if secondary haemorrhage starts after a few days of operation, nephrectomy may be considered. The indications of such operation are — (i) Stone with pyonephrosis when the patient is too ill to stand any other operation. This operation has been described in detail in ‘A Practical Guide to Operative Surgery’. Usually the kidney with the better function is operated on first and the operation on the contralateral side is postponed for no less than 2 months to allow adequate time for the first kidney to recover. If the kidneys are without infection or without any symp tom and particularly, if the patient is elderly it is probably better to avoid any operation. The main disadvantage is that the access is limited being bounded above by the last rib and below by the iliac crest. Position of the patient — The patient lies on his sound side with its back brought well over towards the edge of the table. The loin overlies the bridge of the table, which can be screwed up to increase the space between the costal margin and the iliac crest. To maintain the stability of this position, the lower hip and the knee are kept flexed and the upper leg is extended over them. Sand-bags are kept in position with a wide strapping to prevent the patient from rolling over. The upper arm is supported on an arm rest to prevent the shoulder from sagging forwards and to relieve the chest of compression by the weight of the arm. In case of obese patients or when a large kidney has to be operated on, the incision can be extended forwards as far as the lateral border of the rectus muscle. The lower fibres of the latissimus dorsi are cut along the line of the incision and while this incision is extended forwards, it cuts the most superficial i. The incision is now deepened at its highest part cutting another muscle — serratus posterior- inferior, to expose the lateral border of the quadratus lumborum with the lumbar fascia starting from its lateral margin. The anterior part of the incision is now deepened and one of the two muscles internal oblique cut along the line of the incision to protect the peritoneum from being incised. The neurovascular bundle comprising the 12th thoracic nerve and accompanying subcostal vessels are found passing downwards and forwards within the deeper layers of the internal oblique at right angle to its fibres. The lumbar fascia is now incised just in front of the lateral border of the quadratus muscle to expose the retro-peritoneal fat. Two fingers are inserted through this opening and used to separate the peritoneum from the under-surface of the transversus muscle. As this separation continues with one hand, the transversus muscle is divided with a pair of scissors throughout the extent of the incision. So five muscles are incised for this exposure :— Latissimus dorsi and serratus posterior-inferior posteriorly and the three lateral muscles of the abdominal wall anteriorly. To do this, the quadratus lumborum and associated fascia are detached form its lower border. By a little gauze dissection, the renal fascia is identified in the posterior part of the wound. This incision on the fascia is extended anteriorly as fas as required but care should be taken to safeguard the peritoneum in the anterior part of the wound. In the upper pole, the kidney may be anchored by fibrous bands which traverse from the capsule of the kidney to the diaphragm. The adrenal gland is carefully separated by the dissecting finger from the kidney. On the anterior surface of the kidney the peritoneum is adherent and must be detached with care. Other adhesions, if there be any, should be looked for and divided to mobilise the kidney properly. Care should be taken to include all the muscles which have been divided Drainage of the retro-peritoneal space should be provided either by a corrugated rubber sheet or by a suction drainage (Redi-vac). In case it happens, a water-seal drainage should be introduced through the 10th inter space and the pleura is closed. The incision starts a little medial to the lateral border of the erector spinae muscle at the level of the 12th rib. The incision is carried forwards along the line of the 12th rib and is continued beyond its tip as far as required. The Latissimus dorsi and serratus posterior-inferior are come across in the medial part of the wound and these are divided. The bed of the rib comprising of the periosteum and the fibres of the diaphragm are cautiously incised to get into the retro-peritoneal space. The lower reflection of the pleura is identified at the medial part of this incision and is carefully pushed upwards. The incision along the 12th rib is carried forward into the loin, while the medial end of this incision is extended upwards vertically upto just above the neck of the 10th rib. The upper vertical portion is deepened and 2 to 3 cm segments ofthe 11th and 10th rib are excised. This approach will give a very wide exposure, highly suitable for upper pole tumours. In case of hypernephroma, intra-peritoneal approach is preferred as the extent of the growth along the renal vein to the inferior vena cava is assessed and the renal vein is first ligated before the hypernephroma is mobilised. A long upper paramedian incision with a transverse extension at the level ofthe umbilicus, dividing the rectus and the lateral abdominal muscles is mostly employed. The peritoneum on the posterior wall is incised along the lateral side of the flexure of the colon. The colon is then mobilised and displaced medially to expose the anterior surface of the kidney and its vessels. At the end of the operation the peritoneum which was incised is sutured back and the retro-peritoneal space is drained through the loin. Gravity and peristalsis both contribute to spontaneous passage into and down the ureter. Stones with other composition have smooth surfaces and are often passed through the ureter without being impacted. A ureteral stone is only detected when it causes some symptoms due to its presence in the ureter or any pathological changes to the kidney or ureter. If the stone remains for weeks or months irrepa rable damage to the renal parenchyma may occur. There are 3 sites of anatomical narrowing of the ureter where a stone may be arrested. These are — (i) pelviureteral junction, (ii) when the ureter crosses the iliac artery and (iii) where it enters through the bladder wall.
When carcinoma of lip is an ulcer hold the base of the ulcer with index finger an I thumb which is always hard order levitra plus 400mg visa. With one hand the lip is now fixed and with the other hand the lesion of the lip is held by two fingers and is attempted to move against the lip purchase levitra plus 400mg online. Mucous retention cyst is often seen on the inner surface of the lip (mostly in the lower lip) 400 mg levitra plus otc. For fluctuation test one should follow the technique for small swelling as mentioned in chapter 3 (page generic 400 mg levitra plus overnight delivery. The tongue must protruded, the contracted muscles may give an impression of lie at rest within the mouth. Palpate carefully for a sharp tooth or tooth plate against an ulcer in the tongue. The gums may bleed on palpation, which become swollen, spongy and tender in scurvy. The margin, consistency, surface, mobility should be noted to come to a definite diagnosis of the type of epulis. To know its extent, bimanual palpation of the floor of the mouth on one side and submandibular triangle on the other hand is necessary. Sublingual dermoid is not a translucent swelling but it is a tense fluctuant swelling on the midline. From Carcinoma of the floor of the mouth may be the tip — to the submental (S) and jugulo-omohyoid revealed by its indurated base and probable (J. The other figure shows decussation of lymph Fluctuation can be elicited by pressing on the top vessels. Papilloma is a solid tumour with irregular surface and mobile on the deeper structures. The lymph nodes of both sides must be examined even if the lesion is unilateral as the lymph vessels decussate. So this cyst may occur anywhere on the inner surface of the lips, cheek and the mouth where these mucous secreting glands are present. It is most common on the lower lip and in the buccal mucous membrane of the cheek at the level of the bite of the teeth. The main complaint is a lump on the inner side of the lip or cheek, which is not painful, but grows slowly and interferes with eating and may get bitten. The colour of such cyst varies according to the state of the overlying epithelium. If the epithelium is healthy the cyst is pale-pink with grey glairy appearance of the mucus inside the cyst. If the epithelium is damaged it looks white, scarred and obscure the colour of the mucus inside the cyst. This cyst is usually spherical with smooth surface and consistency varies from soft to hard according to the tension of fluid inside the cyst. Fluctuation and transillumination tests are positive when the cysts are large enough. This cyst is neither fixed to the overlying mucous membrane, nor fixed to the deeper structures e. There are various causes of stomatitis which can be broadly classified into two groups — General causes and Local causes. Poorly fitting denture, sharp tooth and nutrition, tuberculosis or disseminated excessive smoking. Infections with Vincents angina, folic acid and iron deficiency which Candida albicans, monilia or Herpes make the mucous membrane thin, Virus. Trauma — mechanical, chemical, varieties of Vitamin B may lead to red thermal or X-rays. Vitamin B and C deficiency are also come across in Sprue, Coeliac disease, Pellagra and Kwashiorkor. Foot and mouth disease, agranulocytosis, aplastic anaemia and hypogammaglobulinaemia and severe anaemia are the conditions which reduce ability of the oral mucosa to deal with various infections and thus lead to stomatitis. Excessive ingestion of iodides may also lead to stomatitis or sore mouth and excessive salivation. An autoimmune mechanism is often believed to be at the root of forming stomatitis. Infecting organisms of this disease can be classified into two groups — (i) Facultative pathogens, that means the pathogens which are normal oral commensals, but take advantage of any weakness in the defence mechanism of the oral mucosa to produce localized or generalized infection of the mouth. This usually occurs in association with acute upper respiratory tract infection and acute specific fever. The vesicles break and ulcers form which are round or oval in shape, with yellow base and red erythematous margin. These ulcers are exquisitely painful and are usually associated with generalized debilitating diseases. These ulcers are seen on the inside of the cheek, lips, soft palate and floor of the mouth. This is more commonly seen in children and in people with debilitating disease and also as a complication of a long continued antibiotic therapy. Small red patches appear on the buccal mucosa and tongue, which gradually turn white. This white colour is due to a layer of oedematous desquamating epithelium which is heavily contaminated with the fungus. Borrelia Vincenti is a mobile spirochaete whereas fusiformis fusiformis is a rod shaped organisfn with pointed ends. These ulcers bleed easily and patients often complain of spontaneous gingivial haemorrhage with fetor oris. Patients are often unwell in particularly acute cases with fever and loss of appetite. Malnutrition is the main predisposing cause and sometimes a complication of measles and leukaemia. The area of necrosis spreads on to the inside of the cheek, the lips and then through to the skin surface, producing a large area of full-thickness tissue loss. This is an extremely painful condition and the patient is very ill with anorexia, malaise and pyrexia. The saliva usually leaks at the corners of the mouth and the moist skin becomes infected by Candida and staphylococci. Gradually the mucosal covering breaks down and a superficial ulcer forms which is often covered with a thick crust. These are greyish white in colour due to oedema and desquamation of the epithelium. When this grey patch of dead epithelium separates, the underlying mucosa is seen raw and bleeding. So these ulcers are also seen on the inside of the lips, cheeks and mainly on the pillers of the fauces. Only when benign neoplasms develop in minor salivary glands such tumours are seen. Firm, slow growing, lobulated and mobile tumours are seen which are nothing but pleomorphic adenomas of the ectopic salivary glands. Exposure to sunlight, especially the ultraviolet part, seems to be an important aetiological factor. Leukoplakia of the lip, recurrent trauma from pipes and cigarettes are other aetiological factors. Gradually a nodule appears, the centre of which becomes ulcerated and the margin becomes everted. As the ulcer grows it gradually invades into deeper structures, it often bleeds and may produce offensive discharge. The regional lymph nodes are almost always enlarged and the patients often show lumps under their chins. Such attempt will cause eversion of the lateral margin of the tongue and heaping up of the midportion of the dorsum. The lesion starts as thin and wrinkled white patches which gradually coalesce to form creamy-white thick surface. In early cases if one is suspicious about this condition one may press a glass slide on the surface of the tongue which makes the thickened epithelium more obvious. While palpating, one must be careful to palpate the whole of the tongue to exclude any induration anywhere to suggest the malignant change which might occur.
Though distension is not a marked feature yet fullness of the epigastrium is often noticed purchase 400mg levitra plus mastercard. In this category acute dilatation of the stomach and pyloric stenosis may be included generic levitra plus 400 mg mastercard. In early stage the vomitus consists of gastric content later on bile and becomes faeculent in the last stage order levitra plus 400mg free shipping. Distension is marked and is central levitra plus 400mg low cost, visible peristalsis in the form of "ladder pattern", is often noticed. In large gut obstruction the patient is usually elderly the onset is gradual (so it is often said to be chronic). Careful palpation of the right iliac fossa may reveal the caecum to be distended and may harden under the examining finger. On palpation, muscle rigidity and rebound tenderness are conspicuous by their absence. Pulse becomes rapid, temperature may be elevated, there may be tachypnoea and blood pressure falls from the beginning. Presence of muscle rigidity and rebound tenderness immediately make the diagnosis. Two hours gastric suction if fail to relieve pain indicates internal strangulation. Though external strangulation is easier to diagnose by tense, tender and irreducible swelling without any impulse on coughing, yet internal strangulation is not so easy to diagnose and must be looked for. Paralytic ileus — may occur in the early post-operative period after an abdominal operation or as a complication of diffuse peritonitis. In adults, obstruction by a band, volvulus or growth should be considered whereas in the old, carcinoma of the colon is the usual cause. A fatty woman of 40, with previous history of cholelithiasis, if presents with intestinal obstruction possibility of gallstone ileus should be considered. Absence of distension with severe colic in the abdomen and pallor should give the suggestion towards the diagnosis. In the early stage normal stools are passed frequently, later on blood and mucus are evacuated which is popularly known as "Red-currant Jelly". The main diagnostic feature is palpation of a lump which is curved, sausage shaped and in the line of the colon with its concavity towards the umbilicus. Should the lump harden under the examining fingers synchronously with the attacks of screaming, the diagnosis is established. The lump may not be felt when it is lying just under the right or the left costal margin. The examination must be gently conducted as contraction of the abdominal muscles may stand in the way of good palpation of the lump. When everything has been made ready for operation it is a good practice to search for the lump under general anaesthesia. If intussusception has travelled far enough, its apex may be felt per rectum and will be felt like cervix uteri. Barium enema X-ray, in presence of ileocolic intussusception, shows the typical pincer-like ending of the barium enema. Of course in ileoilial intussusception barium enema X-ray will not be helpful if the ileo- caecal valve is competent. Abdominal distension soon follows and in no other condition abdominal distension becomes so severe. Constipation is usually absolute but occasionally large quantities of flatus and faeces may be voided due to untwist of the bowel. A straight X-ray is confirmatory and it shows enormous distension of the sigmoid colon with gas. Distension mainly prevails right lower abdomen which gradually involves the whole of the abdomen and picture becomes very much similar to low small bowel obstruction. Straight X-ray will show a large gas-filled caecum and later on loops of gas-filled ileum. Floating caecum together with whole of the small intestine rotates on a narrow stalk of mesentery. The child presents the symptoms of intestinal obstruction immediately after birth. The classical features and radiological findings are similar to any small bowel obstruction. Appearance of dehydration is very fast and treatment should be commenced as quickly as possible. In majority of cases the obstruction is incomplete so there should be some result from enema. Straight X-ray may reveal the stone to confirm the diagnosis, but even if it be not present, gas-distended loops of ileum should not be missed. Pronounced shock, colicky pain (which is quite severe), distension and frequent vomiting are the usual symptoms which may mimic acute appendicitis. On examination, localized rigidity and tenderness over the infarcted area can be elicited. An intra-abdominal obstruction or portal hypertension may predispose this condition. Aggregation of Ascaris Lumbricoides obstructs the lumen of the distal small bowel. If this condition is suspected the stool is examined, blood is examined for eosinophilia. The only complication of significance is perforation peritonitis in which the worms penetrate the intestinal wall. This only occurs after partial gastrectomy as normally these foods are retained in the stomach till they are partially digested. Dried fruit, coconut, unmasticated orange pulp usually cause this type of intestinal obstruction by forming bolus. Pain is often severe and mainly located in the hypogastrium with radiation backwards and downwards. Gradually the pain may involve whole of the abdomen and even to the tip of the shoulder due to irritation of the under surface of the diaphragm by sanguineous fluid (when haemorrhage is considerable and the foot of the bed is raised to combat shock). Blue discolouration of the umbilical region, though very rare, is a distinguished sign of this condition. Shifting dullness will be positive when there is sufficient fluid blood in the peritoneal cavity. Vaginal examination is important and may be diagnostic, (i) That the cervix feels softer than normal; (ii) that all the fornices are tender (in acute appendicitis only the right fornix and in case of pelvic abscess the posterior fornix will be tender) and (iii) that gentle movement of the cervix will cause tremendous pain — give enough indications of the diagnosis of this condition. Later on, restlessness, air-hunger, increasing pallor and running thready pulse will leave no doubt about diagnosis. So the history of the last menstrual period is very important and must always be asked. That the pain commences in the right iliac fossa and not that it started in the umbilical or epigastric region and then shifted to the right iliac fossa is very much suggestive of this condition. In exceptional cases intraperitoneal haemorrhage is considerable to make the shifting dullness test positive. If it be small enough to be situated entirely within the pelvis the lump will not be palpable abdominally. These are perforated peptic ulcer, coronary thrombosis, acute pancreatitis and ruptured or leaking aortic aneurysm. The patient with this condition is often a known hypertensive patient, but when leakage starts the blood pressure falls catastrophically. He usually complains of severe upper or central abdominal pain radiating through to the back (cf. If leakage has started there will be rigidity of the central abdomen more so a little to the left. A mass (blood clot) may be felt in the left iliac fossa resembling pericolic abscess in diverticulitis of sigmoid colon. Pain is excruciating, starts in the retrosternal region, radiates between the shoulders to the back and also spreads to the upper abdomen as dissection proceeds downwards.
These cells are derived from the perivascular lymphatic sheath or lymphoid tissue and are one of the principal sources of gamma globulins buy levitra plus 400mg without prescription. This lack of vascularity influences in the production of caseation which begins to appear in the centre of the tubercle follicle by the end of the second week levitra plus 400 mg with visa. The cells in the centre undergo necrosis and fuse together to form granular structureless cheesy material discount levitra plus 400mg online. This coagulation necrosis is partly due to action of the bacterial toxins which are produced by disintegration of tubercle bacilli buy levitra plus 400mg without a prescription. The fibroblasts proliferate forming a fibrous zone around the tuberculous area walling it, so that the caseous area becomes enclosed in a fibrous capsule. Tubercle bacilli may remain viable for long periods within this tubercle follicle. Due to influence of antitubercular drugs the tubercle bacilli die and the fibrous tissue gradually invades the tubercle follicle in which the epitheloid and giant cells are also destroyed, converting it into a fibrous mass which is known as healed tubercle. So this liquified material, which is known as cold abscess, has a high infectivity when discharged. The cold abscess is so named, because it produces a soft swelling without the signs of acute inflammation. The wall of the abscess is lined by granular, caseous material which contains tubercle bacilli. The fluid inside the cold abscess is not true pus, but consists of fatty debris, floating in a serous fluid, intermingled with a few necrotic cells. The course of the disease is profoundly influenced by the use of the antitubercular agents. Due to advent of various antibiotics which are effective against this organism, there has been a dramatic decline in incidence of this disease. The disease is transmitted by direct contact from a surface lesion containing the organisms. So the disease remains infective in the primary and secondary stages for first 2 years. The organism dies rapidly on drying, so early lesions are mostly seen in moist areas e. It first develops as an indurated papule, which gradually becomes eroded and forms into a hard chancre (Hunterian chancre). It is characteristically hard, shallow and non-bleeding ulcer, which is oval or round in shape. Its edge is raised and hyperaemic extending into dusky red oedematous surrounding skin. This primary chancre is often seen on the inner surface of the prepuce or glans of the penis and even in the coronal sulcus, where it may be missed if the prepuce is not fully retracted. In case of females the chancre is hardly seen from outside as it often involves the innerside of labia minora or even the cervix, which the patient may not be aware of. While genital chancres are always painless, extragenital chancres may be painful and may occur in the anal or perianal region, lip, tongue, nipple etc. It must be remembered that serum tests do not become positive for 2 to 3 months after the appearance of chancre. The commonest manifestation of secondary syphilis is a generalized rash dull red or coppery in colour. This rash is characteristically pleomorphic showing macular, roseolar, papulo-squamous and even other varieties. The next important manifestation is the appearance of snail-track ulcers, which are formed by coalescence of small, round and superficial erosions in the mouth. These are wart-like growths which are teemed with treponemes and are seen in the mucocutaneous junctions e. The most characteristic finding is enlargement of epitrochlear and suboccipital groups of lymph nodes which are almost always present. Occasionally acute meningitis, cranial nerve or spinal nerve palsies may occur due to irregular pachymeningitis. Plasma cells are the characteristic element in the reaction to the treponema pallidum. The inner coat of the small arteries is concentrically thickened, which is known as syphilitic endarteritis obliterans which results in ischaemia of the tissue. This is an accumulation of granulation tissue with central necrosis due to syphilitic hypersensitivity reaction. Microscopically surrounding the necrotic or the caseous centre there are lymphocytes and plasma cells which are further surrounded by proliferating fibroblasts and definite fibrous tissue. To the naked eye gumma appears as a yellow homogeneous mass surrounded by fibrous tissue. Diffuse manifestations of this stage of syphilis may involve almost any structure. Congenital syphilis can be divided into 2 groups — (i) early congenital syphilis and (ii) late congenital syphilis. Loss of weight, periostitis, osteochondritis, hepatosplenomegaly and basal meningitis are the various manifestations. Affection may be so severe as to cause death in early infancy due to syphilitic pneumonia. Procaine Penicillin G 6 lacs units daily for 15 days is highly effective in early syphilis. Serological tests should be performed at regular intervals for 20 years after treatment to be confirmed about the cure of the disease. Those patients who are allergic to penicillin, tetracycline, erythromycin and cephaloridine are the useful antibiotics for this condition. Doxycycline is a very useful drug and should be used in the dose of 100 mg thrice daily for 15 days. Prednisone 10 mg 4 times daily for 3 days may be given before penicillin injection to prevent this reaction. To prevent congenital syphilis the same dose of procaine penicillin G should be given to the mother for 15 days as early as possible in pregnancy. Israelii may be recovered from the oral mucosa, tonsillar crypts, dental cavities and pharynx of many normal persons. Entry into the tissue is resumed to result from trauma or ulceration or by tooth extraction. It is not known whether additional factors like hypersensitivity is necessary for subsequent evolution. When these granules are crushed under a cover glass and examined unstained, two elements may be distinguished — branching mycelial elements and club forms. The filaments are gram-positive and constitute greater part of the body, whereas the clubs are gram-negative pear-shaped bodies which form a fringe around the periphery of the colony of the body. The filaments are arranged in radiate fashion from the centre part of the granule. The basic pathology is a subacute pyogenic inflammation with considerable induration and multiple sinus formation. The connective tissue, the muscle and the bone are successively destroyed and replaced by granulation tissue. An abundant fibrous tissue reaction may lead to brawny induration in the affected area. Gradually softening occurs at few places with appearance of abscesses, which ultimately burst to form multiple sinuses. So the overlying skin becomes indurated and bluish in colour with openings of numerous sinuses. In the submucosa flat grey nodules appear, which turn into a large firm mass, readily mistaken for malignancy. Ultimately the abdominal wall is involved with multiple sinuses discharging thin pus with sulphur granules. It is involved either by direct extension or by blood borne infection through portal vein. The lesion is a honey-comb mass within the liver which resembles a sponge saturated with pus.
Needlescopic instruments may be used to perform other operations such as appendicectomy trusted levitra plus 400 mg, fundoplication discount levitra plus 400mg line, adrena lectomy levitra plus 400 mg amex, inguinal herniorrhaphy etc cheap 400mg levitra plus with mastercard. The benefits to the patients have to be weighed against the additional expenses involved in the use of needlescopic instruments. Non thickened and relatively less inflammed gallbladders should be selected for needlescopic surgery, other wise conversion to laparoscopic cholecystectomy may be more. It must be remembered that dissection to identify the cystic structures are done safely using 10 mm laparoscope. The view is changed to 3 mm needlescope only for clipping and not for division of the cystic artery and duct. Renal calculi pass spontaneously after fragmentation, but the biliary tract does not provide such a simple passage for fragment stones. This technique however may be used as an adjunct to pharmacological dissolution therapy. These cholesterol stones form as the patients secrete bile which is saturated in cholesterol or due to reduced bile acids in bile. If bile acids are given therapeutically, this not only increases concentration of bile acids in the bile, but also decrease cholesterol saturation in bile. Chenodeoxycholic acid and ursodeoxycholic acid are two naturally occur ring bile acids that may be given orally for gallstone dissolution. Moreover bile acid synthesis from cholesterol in the liver may be increased by ursodeoxycholic acid. Both these drugs have been widely used in clinical practice and appear to be safe. Chenodeoxycholic acid may cause diarrhoea and it also causes minor lipid alterations and carries a small theoretical risk of promoting atherosclerosis. Ursodeoxycholic acid on the other hand does not have any adverse effect and is therefore more preferred in treating gallstones, though it is more expensive. Rowachol is a non-bile acid compound and when administered orally dissolve gallstones in human beings. It should be remembered that patients should have functioning gallbladders if these dissolving drugs are to be used. Small floating and radiolucent stones on oral cholecystog raphy are usually rich in cholesterol and are particularly suitable for dissolution therapy. Radio-opaque stones or pigment stones with non-functioning gallbladder are contraindications for this therapy. The symptoms may continue during therapy, though the risk of complications is not apprehending. Only less than 20% of patients with gallstones fulfill the requirements for dissolu tion therapy. Even when the cases are suitable, success rate is 60% in neutral studies and the duration of treatment is about 18 to 24 months. However it remains as a safe alternative to those who are unwilling or unfit for surgery. In direct contact method, a 5-french pigtail polyethylene catheter is introduced transcutaneously and through the liver into the gallbladder using local anaesthesia and under a combination of fluoroscopic and ultrasound control. The recurrence rate in 2 to 12 years after confirmed complete gallstone dissolution is between 30 and 60%. Only one word I would like to mention regarding prevention of recurrence is that non-steroidal antiinflammatory drugs (e. Probably this drug inhibits prostaglandin-mediated stimulation of mucin secretion by the gallbladder and in fact mucin acts as a nucleating agent. Unfortunately in 15% of cases the same symptoms persist following cholecystectomy. For these cases sometimes the term ‘postcholecystectomy syndrome’ is often used wrongly. Actually the patients suffer from the same symptoms as previously so the better nomenclature is ‘postcholecystectomy symptoms’. The causes may be (a) extrabiliary disorders or (b) disorders of the extrahepatic biliary tract. But the main disease remains causing the same symptoms as previous to cholecystectomy. Further, postoperative T-tube cholangiogram has also reduced incidence of this condition. Some times the long cystic duct stump may be dilated resembling a miniature gallbladder. Operative cholangiography has also helped to detect such condition and give warning to the surgeons so that he also removes the cystic duct stump during cholecystectomy. Sometimes the cystic duct joins with the common bile duct lower than usual and after dissecting that region the surgeons may miss this condition. The concept of biliary distension as a result of spasm of the sphincter of Oddi in the absence of such organic changes in the ampulla may be developed in many patients This stenosis of sphincter of Oddi is commoner in females than in males in the ratio of 3 : 1 The condition may be revealed at any age, but more frequently observ ed between 50 to 70 years of age. With extraction of water from the gallbladder, bile is reduced to a viscid material known as sludge’. Such viscid bile may cause functional obstruction of the gallbladder leading to oedema, venous and layniphaticobstruction, necrosisetc. Such stasis has been caused by lack of oral nutrient intake, trauma, major operative procedures, serious debilitating diseases and administration of narcotics. Decreased blood flow to the gallbladder epithelium may cause ulcers in the mucous membrane through which concentrated bile acid gets access to the gallbladder wall. But again acalculous cholecystitis is a rare consequence of hypotension, so question remains how far ischaemia or hypotension causes acalculous cholecystitis. Thrombosis of the arterioles of cystic artery may also cause ischaemia and acute acalculous cholecystitis, (iv) A few other causes have also been incriminated to cause such acalculous cholecystitis. These are (a) spasm of the sphincter of Oddi, (b) specific infections such as typhoid fever and actinomycosis and (c) wide variety of febrile illnesses in young children. Acute acalculous cholecystitis is often caused by recent trauma, major surgery, bacterial sepsis, cardiovascular disease, diabetes, debilitating diseases, prolonged illness, multiple transfusions and administration of total parenteral nutrition. This itself in creases higher mortality rate and late diagnosis of acute cholecystitis. The most significant physical findings are fever and tenderness in the right upper quadrant of the abdomen. Cholescintigraphy, which is the best investigative procedure in case of acute calculous cholecystitis is also accurate in about 85% of these cases. Higher incidence of false positive scans have been reported, as radionuclide may not be able to enter the otherwise normal gallbladder if the bile is viscid. During operation, if possible operative cholangiography may be per formed to exclude possibility of passage of single gallstone into the common bile duct. In difficult cases one may perform cholecystostomy It must be remembered that mortality rate of acute acalculous cholecystitis is more than acute calculous cholecystitis because of the antecedent and concomitant conditions. Anyway symptoms of chronic cholecystitis when present with absence of stone in the gallbladder, found out by repeated ultrasonography, is a condition known as chronic acalculous cholecystitis. The treatment is again confusing, though cholecystectomy has been reported to relieve the symptoms. In this condition the red mucosa of the gallbladder is studded with tiny yellow flecks giving a typical picture of ripe strawberry. Sometimes the entire gallbladder may be involved and other times only one portion is involved. This condition represents a local disturbance in cholesterol metabolism and not associated with disturbance of the cholesterol level in the blood. A few views have been put forward to explain this condition -— (a) excessive abnormal absorption of cholesterol from the bile by the epithelial cells of the gallbladder causes this condition; (b) Lymphatic and venous stasis predispose to the accumulation of cholesterol absorbed from the bile contents; (c) Failure of the mucosa to secrete cholesterol results in an abnormal deposition of cholesterol within the mucosa and submucosa. Histologically there is distension of the mucosal folds with aggregation of round and polyhedral histiocytes within these mucosal folds. When the deposits become more massive these cells die with release of lipids giving rise to precipitation of cholesterol crystals in the subepithelial region. The yellow material is sometimes confined to the summit of the ridges and sometimes it can be traced down into the depth of the recesses. Cholesterol content of the mucosa of strawberry gallbladder is enormously in excess to that found in the normal organ. Occasionally focal collections of lipid-laden histiocytes may take the form of polyp formation, which are known as cholesterol polyps. Some inflammatory reaction with presence of white cells, giant cells and fibroblasts may be seen around Clinical features.
Conglomerate masses and Fig C 9-12 adjacent small nodules in coal workers’ pneumoconiosis generic levitra plus 400mg otc. Bilateral irregular nodular The arrowhead points to a thoracostomy tube that was 10 149 areas of high attenuation in the upper lobes order 400mg levitra plus fast delivery. There may be minimal symptoms in severely debilitated patients 400mg levitra plus, especially elderly persons and those receiving steroids levitra plus 400 mg cheap. Fungal diseases Hematogenous dissemination, most commonly (Figs C 10-2 and C 10-3) of histoplasmosis but also coccidioidomycosis, blastomycosis, and candidiasis. Disseminated hematogenous Most commonly thyroid carcinoma (“snowstorm”), metastases which may remain unchanged for a long time (Fig C 10-4) because of the very low grade of malignancy. Other causes include trophoblastic disease, bone sarcomas, renal cell carcinoma, and, infrequently, melanoma and carcinomas of the breast and gastrointestinal tract. Bronchioloalveolar Other presentations include a well-circumscribed, (alveolar cell) carcinoma peripheral solitary nodule (see Fig C 6-13), focal (Fig C 10-5) “pneumonia” (see Fig C 1-25), and multiple poorly defined nodules (see Fig C 7-6). Coned view of the left lung shows a diffuse pattern of fine nodules simulating miliary tuberculosis. The nodules represent localized areas of fibrosis (or the summation of linear shadows). Sarcoidosis Associated bilateral and symmetric hilar adeno- (see Fig C 14-8) pathy is virtually pathognomonic (though the ad- enopathy classically regresses as the parenchymal disease progresses). Allergic alveolitis Allergy involving the alveolar wall due to a variety (farmer’s lung) of noninvasive fungi. Viral pneumonia Primarily chickenpox pneumonia (adults more (Fig C 10-8) than children). May heal with the development of multiple calcified nodules (as in histoplasmosis). Alveolar microlithiasis Diffuse, very fine micronodules of calcific density (see Fig C 2-15) that are usually asymptomatic. Characteristic black pleura sign (due to contrast between the extreme density of the lung parenchyma on one side of the pleura and the ribs on the other side). Pulmonary hemosiderosis Develops in patients with long-standing severe (Fig C 10-9) mitral stenosis who have had multiple episodes of hemoptysis. Amyloidosis Rare manifestation in which amyloid infiltrates almost every alveolar septum and is deposited around capillaries and within interstitial tissue. Bronchiolitis obliterans End result of lower respiratory tract damage in which the bronchioles become obstructed by organizing exudate and polypoid masses of granulation tissue. Oil embolism Complication of lymphography (lipid material in the extravascular interstitial tissue). Interstitial fibrosis Early stage before the development of the more classic reticulonodular and reticular patterns. The miliary nodule pattern (and early age of onset) is a differential point from Gaucher’s disease. Wegener’s granulomatosis Rare manifestation representing a diffuse gran- ulomatous reaction occurring around vessels. The small fine nodules usually develop in combination with larger, more ill-defined densities that often cavitate. Perivascular granulomas irregular granular densities is distributed produce small nodular and linear densities throughout both lungs. Develops in approximately 50% of children with (Fig C 11-2) staphylococcal pneumonia. Results from a check- valve obstruction of the communication between a peribronchial abscess and the bronchial lumen. Large, thick-walled left upper lobe abscess with an air-fluid level (arrow) and an associated infiltrate. Multiple lung abscesses with air-fluid levels (arrows) associated with diffuse air- space consolidation and a large pleural effusion. Residual thin-walled cystic spaces (arrows) in the pulmonary parenchyma many years after a childhood staphylococcal pneumonia. Tuberculous cavities predominantly involve the apical and posterior regions of the upper lobes and the posterior segments of the lower lobes. Thin-walled cavities may persist after chemotherapy in the absence of acute disease. Histoplasmosis typically involves the apical and posterior segments of the upper lobes (indistinguishable from tuberculosis), whereas coccidioidomycosis is characteristically located in the anterior segment. Candidiasis, aspergillosis, sporotrichosis, and mucormycosis are essentially limited to debilitated patients and those with underlying diseases (diabetes mellitus, lymphoma, leukemia). Frontal tomogram shows extensive bilateral smooth, elliptical, homogeneous mass (arrowheads) re- upper lobe cavities. Almost always in the right lower lobe and associated with a right pleural effusion (organisms from a liver abscess enter the thorax by direct extension via the right hemidiaphragm). Hydatid cyst (Echinococcus Thin-walled cavity, typically with a lower lobe Rupture of the cyst into a bronchus results in part granulosus) predominance. Paragonimus westermani Thin-walled cysts (ring shadows) that are Typically a crescent-shaped opacity along one (Fig C 11-9) generally multiple and have a predilection for aspect of the inner lining. The endocyst membranes (arrow) are floating on the surface of fluid in a ruptured hydatid cyst. 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. Hematogenous metastases Thin- or thick-walled cavities may develop in a Cavitation in approximately 4% of cases. Most commonly involves squamous cell neoplasms commonly involves upper lobe lesions. Hodgkin’s disease Single or multiple thick-walled cavities with Cavitation typically develops in peripheral paren- irregular inner linings. Septic embolism Generally thin-walled cavities (less commonly Almost always multiple with lower lobe pre- (Figs C 11-13 and C 11-14) thick walled with shaggy inner linings). Silicosis Thick-walled cavity with an irregular inner Generally a background of nodular or reticulono- lining. Often multiple with strong upper lobe dular disease and associated hilar lymph node predominance. Cavitation in conglomerate lesions is more often the result of superimposed tuberculosis than ischemic necrosis. Wegener’s granulomatosis Usually multiple thick-walled cavities with Cavitation eventually occurs in approximately half (Fig C 11-15) irregular inner linings (may eventually become of patients. Large cavity lesions (arrows) fluid levels (arrows) of squamous cell carcinoma on a film in the left lung of an intravenous drug abuser with septic obtained after two cycles of chemotherapy. Multiple cavitary nodules Fig C 11-15 throughout both lungs representing Nocardia septic emboli in Wegener’s granulomatosis. Traumatic lung cyst Single or several thin-walled cavities that may Typically occurs in a peripheral subpleural location contain air-fluid levels. Sarcoidosis Cystic lesions developing on a background of Very uncommon manifestation (should suggest diffuse reticulonodular pulmonary disease. Intralobar Thin- or thick-walled cystic mass that is often Almost invariably arises contiguous to the bronchopulmonary multilocular or multiple. Bronchogenic cyst Solitary thin-walled cystic mass that may Approximately 75% of bronchogenic cysts that are contain an air-fluid level. Congenital cystic Multiple air-containing cysts scattered ir- Expands the ipsilateral hemithorax (depresses the adenomatoid malformation regularly throughout a mass of soft-tissue hemidiaphragm and shifts the mediastinum to the (see Fig C 15-7) density. Large bullae in the right with air-fluid levels (arrows), predominantly involve the upper lung. Laryngeal papillomatosis is a common disease in (Fig C 11-19) children that infrequently seeds distally in the tracheobronchial tree to produce excavating lesions in the lung. Plombage Plastic (lucite) spheres appear radiographically Former therapy for pulmonary tuberculosis that (Fig C 11-20) as multiple perfectly round, cavity-like lucencies. The spheres are often not entirely watertight, so that a small amount of fluid may collect in each. On upright views, the resulting air- fluid levels can simulate cavitation and suggest the incorrect diagnosis of acute infection. Multiple small cysts super- Fig C 11-19 imposed on a diffuse, coarse, reticular pattern.
This syndrome is manifested by chest pain or an upper abdominal pain buy 400mg levitra plus free shipping, tachycardia and a low blood pressure generic levitra plus 400mg without a prescription. This condition is fatal and no time should be wasted to re-explore the abdomen buy discount levitra plus 400 mg, once this diagnosis is made levitra plus 400 mg. Naso gastric aspiration and intravenous fluid administration are continued until the peristalsis of the intestine comes back and the patient passes flatus. At this time aspiration and fluid administration are stopped and liquid diet is gradually allowed by mouth. It should not be considered that exploration of the bile duct can be done as a routine practice along with cholecystectomy as this little operation is not without its cost. A small stone at the ampulla of Vater can be missed by all the indications given above but would not be missed by operative cholangiography. Small soft calculi may be missed by palpating fingers but not by operative cholangiography. In various studies it is proved that the therapy for 2 years resulted in complete dissolution in 14% and partial dissolution in 40% of cases. This drug therapy must be continued even after dissolution to prevent recurrence of stones. The side effects of this drug is mild diarrhoea and elevated serum transaminase level. Ursodeoxycholic acid has been used with similar success and with little side effects. At present this drug therapy should be reserved for elderly patients or young individuals who have other associated diseases that pose a high operative risk. Nasogastric tubes can often be omitted or removed soon after surgery and early postoperative feeding has been instituted to minimise hospital stay. The necessity of draining the subhepatic space following cholecystectomy is no longer accepted as routine and may indeed lead to more complications and prolonged hospital stay. The incision is slightly longer than appendicectomy incision and basically the same muscle splitting type. This can give an adequate exposure for safe biliary surgery particularly if the surgeon uses modern fixed retraction system. During cholecystectomy fundus to neck method has been adopted to shorter the period of operation. The rationale for laparoscopic cholecystectomy is based on good cosmetic result, rapid healing of the operative wound, reduction of hospital stay and ability to return to work soon after surgery. But the standard procedure is that the surgeon stands on the patient’s left side with the monitor level with the patient’s right shoulder. A second monitor may be placed on the left of the patient for the benefit of the assistants. A second 10 mm cannula is inserted just to the right of the midline below the xyphoid process and to the right of the falciform ligament to introduce operating instruments Two 5 mm cannulas are inserted under laparoscopic vision into the right upper quadrant of the abdomen — one in the midclavicular line close to the costal margin and a second low down on the anterior axillary line These will be used to carry ratracting forceps held by the assistant. After the fundus of the gallbladder has been grasped and retracted up and over the liver, any adhesions are taken down by blunt dissection, or divided with scissors as appropriate. The second grasping forceps is placed on the neck of the gaflbladder and the cystic duct and artery are displayed by blunt dissection with curved dissecting forceps or with a hooked diathermy dissector. After demonstration of the anatomy of the structures in Calot’s triangle, the cystic duct is nicked and may be cannulated for an operative cholangiogram The operation proceeds are exactly same as in traditional cholecystectomy with division of the cystic duct and artery and dissection of the gallbladder from its bed. Freeing of the gallbladder from the liver may be performed using an electrocautary probe of laser dissection for haemostasis. Irrigation and suction are used to wash away blood, and haemostasis is achieved as the dissection progresses. After the gallbladder is freed, it is grasped at the cystic duct remnant and withdrawn into one of the 10 mm cannulas. When part of the gallbladder appears on the surface of the abdomen, the gallbladder is opened and its contents evacuated prior to the delivery of the remainder of the gallbladder through the wound. If the gallbladder is performed during dissection leakage of the bile may be controlled either by repositioning the grasping forceps or by application of a ligature to the gallbladder. An acutely inflamed friable gallbladder may be removed piece-meal, in which case the fragments of the gallbladder and the gallstones are placed in an Espiner bag (Ethicon) introduced for this purpose. This frees the surgeon’s hand for manipulating the dissecting instruments while allowing the surgeon and all the assistants an excellent view of the operative field. Its advocates are excited by its early promise and suggests that over 90% of patients coming to cholecystec tomy are suitable for this operation. Intravenous cholangiography should be performed preoperatively in all the patients and if choledocholithiasis is confirmed then a formal open operation is performed. As open operation might be required at any time during the laparoscopic procedure, this should always be performed by the biliary surgeons. Major operative complications of this procedure are — (i) bile leakage in 4% of cases, (ii) bile duct injury in 1% of cases, (iii) perforation of viscus e. As experience grows and operative expertise improves, it is possible, that such complications may become less frequent. Indeed in some centres the procedure is performed on a day-case basis, though in majority of cases postoperative stay is usually 1 to 2 days. Patients with this surgery had less pain and obviously smaller scars than conventional laparoscopic cholecystectomy. So needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy. For needlescopic procedure, the ports are 10 mm, 2 mm, 3 mm and 2 mm in the umbilicus, right lateral abdomen, right hypochon- drium and epigastrium respectively. The gallbladder fundus is held with a 2 mm grasper, Hartmann’s pouch is held with 3 mm grasper and dissection is performed using a 1. The camera is charged to a 3 mm needlescope for clipping of the cystic artery and cystic duct and subsequently changed back to the 10 mm instrument for division of the cystic structures using a pair of 2 mm scissors. The combined lengths of the incisions are measured and dressings are the same in both categories of patients. All patients receive a standard analgesic protocol with oral naproxen 375 mg twice daily and intramuscular pethidine 1 mg/kg every 6 hours according to individual need. It must be remembered that the conversion rate is around 10% when the author is writing this article mostly to conventional laparoscopic cholecystectomy or rarely to an open operation. Patients after needlescopic cholecystectomy usually have less postoperative pain and intramuscular pethidine injec tion requirements is fewer than the laparoscopic group. The operating time may be slightly longer, but due to reduction in scar size the need for postoperative analgesia is less. Needlescopic instruments may be used to perform other operations such as appendicectomy, fundoplication, adrena lectomy, inguinal herniorrhaphy etc. The benefits to the patients have to be weighed against the additional expenses involved in the use of needlescopic instruments. Non thickened and relatively less inflammed gallbladders should be selected for needlescopic surgery, other wise conversion to laparoscopic cholecystectomy may be more. It must be remembered that dissection to identify the cystic structures are done safely using 10 mm laparoscope. The view is changed to 3 mm needlescope only for clipping and not for division of the cystic artery and duct. Renal calculi pass spontaneously after fragmentation, but the biliary tract does not provide such a simple passage for fragment stones. This technique however may be used as an adjunct to pharmacological dissolution therapy. These cholesterol stones form as the patients secrete bile which is saturated in cholesterol or due to reduced bile acids in bile. If bile acids are given therapeutically, this not only increases concentration of bile acids in the bile, but also decrease cholesterol saturation in bile. Chenodeoxycholic acid and ursodeoxycholic acid are two naturally occur ring bile acids that may be given orally for gallstone dissolution. Moreover bile acid synthesis from cholesterol in the liver may be increased by ursodeoxycholic acid. Both these drugs have been widely used in clinical practice and appear to be safe. Chenodeoxycholic acid may cause diarrhoea and it also causes minor lipid alterations and carries a small theoretical risk of promoting atherosclerosis. Ursodeoxycholic acid on the other hand does not have any adverse effect and is therefore more preferred in treating gallstones, though it is more expensive.