AMI

N’STI
P@ GENERALSURGERY

TOPI
CONE

MASTOLOGY

(
PATI
ENTWI
THBREASTLUMP)

I
mpor
tantNot
es

- Bef
orey
ou cl
erk a pat
ientwi
th br
eastl
ump,y
ou shoul
d know di
ff
erent
ial
di
agnosi
s(causes)ofbr
eastl
ump.

- NOTal
way
sthecaseofbr
eastl
umpst
hedi
agnosi
sisBr
eastcar
cinoma.

- I
fyouf
indapat
ientwi
thbr
eastl
umpt
hef
oll
owi
ngar
ethepossi
bledi
ff
erent
ial
s.

A.Tr
aumat
icbr
eastswel
l
ing

Tr
aumacancausebr
eastl
umpbyei
therf
atnecr
osi
sorhemat
omaf
ormat
ion.

B.I
nfl
ammat
orycondi
ti
ons.

i
. Acut
einf
lammat
orycondi
ti
on

- Mast
it
is

- Br
eastAbscess.

i
i
. Chr
oni
cinf
lammat
orycondi
ti
on

- TBMast
it
is

C.Neopl
asm

i
. Beni
gn

- Br
eastcy
st
 AMI
N’STI
P@ GENERALSURGERY

- Fi
broadenoma

- Fi
broadenosi
s

Abov
ear
eHor
monal
DependentBeni
gnTumor
s

-
Breastl
i
poma(
anonhor
monal
dependent
)

i
i
. Phy
ll
odesTumour

- Beni
gn

- Bor
der
li
ne

- Mal
i
gnant

i
i
i. Mal
i
gnant

- MostCommonBr
eastCar
cinoma

BREASTCARCI
NOMA

Ri
skf
act
ors;

Not
ethat

1.I
ncr
ease/pr
olongedexposur
etoEst
rogeni
ncr
easest
her
iskandv
icev
ersa.

Fact
orst
hati
ncr
easesmenst
rual
cycl
es,
Incr
easest
her
iskandv
icev
ersa.

Fact
orst
hati
ncr
easenumber(
frequency
)ofmenst
rualcy
cles,i
ncr
easet
her
isk
f
orbr
eastcar
cinomaexampl
e,

- Ear
lymenar
che

- Lat
emenopause
 AMI
N’STI
P@ GENERALSURGERY

- Nul
lpar
it
y

Fact
orst
hatdecr
easenumber(
frequency
)ofmenst
rualcy
cle,
reducest
her
iskof
br
eastcar
cinomaexampl
e,

-
longerl
act
ati
onper
iods

-
incr
easenumberofdel
i
ver
ies

-
exer
cise

2.Humanbr
eastdev
elopmenti
sapr
ogr
essi
vepr
ocesst
hati
sini
ti
ated dur
ing
embr
yoni
cli
fe,gl
andul
armat
urat
ionst
ati
ngatpuber
tyandat
tai
nmentoff
ull
br
eastdi
ff
erent
iat
ionandmat
urat
ionwi
thsubsequentpr
egnanci
esandl
act
ati
on.

Ter
minaldi
ff
erent
iat
ionofBr
eastepi
thel
i
um associ
atedwi
thf
ullt
erm pr
egnancy
,
i
ncr
easenumberoft
erm del
i
ver
iesandl
ongerl
act
ati
onper
iods–ar
epr
otect
ive
f
act
ors,t
her
efor
eincr
easenumberofabor
ti
ons/
Miscar
ri
agesi
ncr
easest
her
isk
f
orbr
eastcar
cinoma.Themor
ethenumberoft
erm del
i
ver
iesandl
ongert
he
l
act
ati
ondur
ati
onar
epr
otect
ive

3.Lat
eat
tai
nmentoff
ullbr
eastdi
ff
erent
iat
ionandmat
urat
ioni
ncr
easest
her
iskof
br
eastcancerwhi
l
eear
lyat
tai
nmentoff
ullbr
eastdi
ff
erent
iat
ionandmat
urat
ion
i
ncr
easest
her
iskofbr
eastcancer
.

e 1st chi
Lat l
d bi
rt
h,af
ter35y
ear
sincr
eases t
he r
isk.Ear
lychi
l
d bi
rt
h and
br
east
feedi
ng r
educes t
he r
isk.(
Ear
lybr
eastmat
urat
ion and di
ff
erent
iat
ion
makest
hebeastmor
est
abl
e)

4.Hor
monalr
epl
acementt
her
apy(
HRT)i
ncr
easesr
isk(
apr
ovedr
iskf
orbr
east
car
cinoma)

Or
alcont
racept
iveuse(
notpr
oven,butl
i
nkedt
oincr
easet
her
iskf
orbr
east
 AMI
N’STI
P@ GENERALSURGERY

car
cinoma)

5.Di
et

- Longt
erm consumpt
ionoff
oodswi
thhi
ghf
ats,i
ncr
easesl
evel
sofest
rogen
(
est
rogenexposur
e)i
ncr
easesr
iskofbr
eastcar
cinoma.

- Di
etl
ow i
n phy
toest
rogensi
ncr
easest
her
iskbr
eastcancer
,di
etwi
th hi
gh
phy
toest
rogenr
educest
her
isk.

- Phy
toest
rogens–ar
enat
ural
l
yoccur
ri
ngpl
antcompoundst
hatar
est
ruct
ural
l
y
si
mil
art
omammal
i
anest
rogenandt
hei
rmet
abol
i
tes.

- Ther
efor
e,t
hey compet
e wi
th est
rogen atest
rogen r
ecept
ors(
compet
it
ive
i
nhi
bit
ion)hencel
ower
sest
rogenef
fect
,andhencel
ower
sther
iskofbr
east
car
cinoma.

- Exampl
e–Phy
toest
rogenr
ichf
oodsber
ri
es,f
iberr
ichf
oods,gr
ainsandnut
s,
soy
abeansandot
herl
egumi
nousf
oods

6.Obesi
ty–i
ncr
easer
iskofbr
eastcancer

- Obesepeopl
ehav
eexcessf
att
y(adi
pose)t
issue,
theyhav
elongt
ermi
ncr
easei
n
exposur
etoest
rogen(
Aromat
izat
ion)

- Maj
orsour
ce ofest
rogen i
n postmemo pause women i
s conv
ersi
on of
andr
ost
enedi
one t
o est
erone i
n adi
pose t
issue (
Aromat
izat
ion cat
aly
zed by
ar
omat
aseenzy
me)

7.Al
coholconsumpt
ioni
sknownt
oincr
easeser
um l
evelofest
radi
ol(
der
ivat
iveof
est
rogen)
,ther
eforl
ongt
erm consumpt
ionofal
coholi
ncr
easet
heexposur
eof
 AMI
N’STI
P@ GENERALSURGERY

est
rogen

8.Radi
ati
onexposur
e(t
othechest
)

9.Smoki
ng

10.
Beni
gnbr
eastl
esi
on

11.
Maj
ori
tyofbr
eastcar
cinoma ar
e spor
adi
c cases,butcan al
so be f
ami
l
iar
.
Mut
ati
onoft
umorsuppr
essorgenes,
BRACA–IandBRACA–2.Fami
l
ialhi
stor
y
wi
thar
elat
ivedi
agnosedt
ohav
ebr
eastcanceri
ncr
easest
her
isk.Ther
isk
i
ncr
easesmor
efi
rstdegr
eer
elat
ivei
shav
ingbi
l
ater
albr
eastcancerory
oungage
orper
imenopausewomen

12.
Hist
oryofbr
eastcancer
,3–4t
imesi
ncr
easer
iskoft
heapposi
tebr
east

13.
Hist
oryofov
ari
an/
uter
ine/
col
on

Readont
hef
oll
owi
ng

- Li
–Fr
aumen’
ssundume

- Cowden’
ssundome

- Bannay
an–Ri
l
exRuv
alcabasy
drome
 AMI
N’STI
P@ GENERALSURGERY

Pr
esent
ati
onofBr
eastcar
cinoma

i
. Br
eastLump

Mostatt
heupperout
erquadr
ant
,duet
oabundantbr
eastt
issueher
e

i
i
. Ni
ppl
edi
schar
ge(
most
lyuni
l
ater
al;
andi
tsbl
oody
)

i
i
i. PaurdeOr
ange(
duet
otumori
nfi
l
trat
ionandbl
ocki
ngt
heder
mall
ymphat
ics
oft
hebr
eastt
hisl
eadst
oedemaoft
heski
nov
erl
yi
ngt
hebr
east
,hence
pr
esent
swi
thPaurdeor
ange)(
asi
gnofski
ninv
olv
ement
)

i
v. Ski
ndi
mpl
i
ng

Duet
umori
nfi
l
trat
ingt
hecooper
’ssuspensor
yli
gament
,henceshor
teni
ngof
t
hel
i
gamentwi
l
lbemani
fest
edont
heski
nasski
ndi
mpl
e(buti
t’
snotasi
gn
ofski
ninv
olv
ement
)

v
. Ni
ppl
eret
ract
ion,due t
otumori
nfi
l
trat
ing t
he l
act
if
erous ducthence
shor
teni
ngoft
heductwhi
chwi
l
lbemani
fest
edast
heni
ppl
eret
ract
ion(
it
’s
notasi
gnofski
ninv
olv
ement
)

v
i. Ul
cer
ati
on– Duet
otumori
nfi
l
itr
ati
ngt
heov
erl
yi
ngski
n.(
asi
gnofski
n
i
nvol
vement
)

v
ii
. Sat
ell
i
tenodul
es–duet
otumori
nfi
l
trat
ingt
heov
erl
yi
ngski
n.(
asi
gnofski
n
i
nvol
vement
)

Feat
uresofdi
stantmet
ast
asi
s

Tol
ungsandpl
eur
al

- (
Cannonbal
l
sifmet
ast
asi
sist
othel
ungpar
enchy
maandpl
uralef
fusi
oni
f
met
ast
asi
sis t
othepl
eur
al)
 AMI
N’STI
P@ GENERALSURGERY

- Di
ff
icul
tyi
nBr
eat
hing

- Hemopt
ysi
s

- Chestpai
n

- Chestheav
iness/t
ight
ness

Tot
heabdomen

- Li
ver–j
aundi
ce,
coagul
opat
hy

- Asci
tes

- Kr
uker
nber
g’st
umor

ToBone(
lumber
,femurandt
hel
ongbones)

- Bonepai
n,l
ocal
tender
ness,
swel
l
ingandpat
hol
ogi
cal
fract
ures.

Lumbosacr
alar
ea – Low back pai
n,numbness,par
apar
esi
s and ev
ent
ual
l
y
par
apl
egi
a

- Tot
heBr
ain

Feat
uresi
fincr
easedi
ntr
acr
ani
alpr
essur
e(Headache,Vomi
ti
ng,Bl
urr
edv
isi
on,
Conv
ulsi
ons,
Conf
usi
ons,
Lossi
fconsci
ous)

HI
STORYTAKI
NGI
NPATI
ENTOFBREASTLUMP

N:BDONOTCLERKAPATI
ENTWI
THBREASTCARCI
NOMABUTCLERKAPATI
ENT
WI
THBREASTLUMP)

Chi
efcompl
aint
s:Ri
ght
/lef
t/bot
hBr
eastswel
l
ing–(
foracer
tai
nper
iodoft
ime)

Hi
stor
yofpr
essi
ngi
l
lness(
HPI
)
 AMI
N’STI
P@ GENERALSURGERY

PART:
ADONPARA

Howdi
dshenot
icet
heswel
l
ing?

Onset–mostar
eofgr
adual
onset

Nat
ure– Mostar
epr
ogr
essi
vel
yIncr
easi
ng i
nsi
zeasday
sgoeson.How i
sthe
pr
ogr
ess?I
sitf
astgr
owi
ngorsl
owgr
owi
ng?

NB:
Youshoul
dknowt
hedoubl
i
ngt
imef
orbr
eastcar
cinoma

Quest
ion;
Whati
sdoubl
i
ngt
imef
orbr
eastcar
cinoma?

Answer
;

(
Onedoubl
i
ngt
imet
akes2–9mont
hs.Forr
eachi
ng1cm si
zeoft
het
umor30doubl
i
ng
t
imesar
erequi
red.Themi
nimum si
zer
equi
redf
orcl
i
nicalpal
pat
ionofat
umori
s1cm.
Onanav
erage,
itt
akesf
ivey
ear
sforat
umort
obecomecl
i
nical
l
ypal
pabl
eint
hebr
east
.)

Per
iodi
cit
y–Usual
l
yhav
enospeci
fi
cper
iodi
cit
y

Aggr
avat
ingandRel
i
evi
ngf
act
ors-
usual
l
yther
eisnospeci
fi
caggr
avat
ingar
eli
evi
ng
f
act
orwi
thexceptofBr
eastcy
stswel
l
ingswhi
char
eaggr
avat
edbymenses)

Associ
ati
ngsy
mpt
oms-aski
fther
eispr
esenceofanyoft
hef
oll
owi
ngassoci
ated
sy
mpt
oms

-
Breastpai
n

-
Nippl
edi
schar
ge

-
Anyski
nchangesi
ntheski
nov
erl
yi
ngt
hebr
east(
ski
ncol
or)

-
Ulcer

PARTB:
RULEOUTPOSSI
BLEDI
FERENTI
ALS
 AMI
N’STI
P@ GENERALSURGERY

STARTTORULEOUBREASTNEOPLASM

Askf
ort
hecompl
i
cat
ions

Hi
stor
yofuni
ntent
ional
wei
ghtl
oss

Rul
eoutmet
ast
asi
stot
hel
ungs

-Di
ff
icul
tyi
nbr
eat
hing

-Coughi
ngbl
ood

-Chestpai
n

-Chestt
ight
ness

Rul
eoutmet
ast
asi
stot
hel
i
ver

-Yel
l
owi
shdi
sl
ocat
ionofey
esandski
n

-Easybl
eedi
ngonbr
uises,
bleedi
ngf
rom t
hegumsdur
ingt
eet
hbr
ush

Rul
eoutmet
ast
asi
stot
hel
umbosacr
al

-Comesbackpai
nNumbnessi
nthel
owerl
i
mbs,
inabi
l
ityt
owal
k

Rul
eoutmet
ast
asi
stot
heBr
ain

-Headache

-Vomi
ti
ng

-Bl
urr
edv
isi
on

-Conv
ulsi
on.

Askf
ort
her
iskf
act
ors

Atwhatagedi
dsheat
tai
nmenar
che

Atwhatagedi
dsheat
tai
nmenopause(
ifpostmenopausepat
ient
)

Howmanynumber
sofchi
l
drenhasshedel
i
ver
ed?
 AMI
N’STI
P@ GENERALSURGERY

Atwhatagedi
dshedel
i
verherf
ir
stchi
l
d

Howl
ongdi
dshebr
east
feedherchi
l
dren?

Howmanynumber
sofabor
ti
onsormi
scar
ri
agesdi
dshehav
e?

Aski
fther
eishi
stor
yofhor
monalr
epl
acementt
her
apy
.(i
fpost–menopause)
,ify
es
f
orhowl
ong.

Hi
stor
yofcont
racept
iveuse? (
ifpr
e-menopauseandpost–menopause)
,Ify
es;what
t
ypeandf
orhowl
ong.

Askr
egul
ardi
etar
yconsumpt
ionofr
iskf
oodsandpr
otect
ivef
oods.(
askbynames)

Hi
stor
yofr
adi
ati
onexposur
e

Hi
stor
yofal
cohol
int
ake(
ify
esf
orhowl
ong)

Hi
stor
yofci
gar
ett
essmoki
ng(
ify
es,
howmanyst
icksperday
,forl
ong(
year
sspentf
or
smoki
ng)andexpr
essi
ntopacky
ear
s.

Hi
stor
yofpr
evi
ousbr
eastswel
l
ingsoranyt
heydi
seasei
ntheaf
fect
edoropposi
te
br
east
.

Enqui
ref
ami
l
yhi
stor
yofbr
eastcancer
,ov
ari
ancancer
s.(
Ify
eswhatwast
heageof
onsetandwasi
tuni
l
ater
alorbi
l
ater
al)

THENRULEOURCHRONI
CINFORMATI
ONCONDI
TIONS

TBMASTI
TIS

Aski
fshei
sknownt
ohav
eTB,
ify
es.I
t’
senough.

I
fNo:

Askf
orB-Sy
mpt
omswhi
char
eni
ghtsweet
s,ni
ghtf
ever
sanduni
ntent
ional
wei
ghtl
oss,
butwei
ghtl
osthav
ebeenment
ionedear
li
er,
noneedofr
epet
it
ion.

(
NB:TBmast
it
isi
sanext
ra–pul
monar
yTBandonl
y30-40% ofpat
ient
swi
thext
ra
pul
monar
yTBpr
esent
swi
thB-Sy
mpt
oms,sot
her
emaybenoanyBsy
mpt
omsi
nTB
 AMI
N’STI
P@ GENERALSURGERY

mast
it
is)

Thenaskf
ort
her
iskf
act
orsf
orTB.

OpenTBcont
ract(
exposur
etoapat
ientknownt
ohav
eTBanyper
sonwi
thchr
oni
c
cough.
)

NB:Maj
ori
tyoft
hepat
ient
shav
echr
oni
cdi
sease,t
heswel
l
ingi
smor
ethan1mont
h,
t
hat
’swhyacut
einf
lammat
orycondi
ti
onshav
enotbeenr
uledouti
nthei
nfl
ammat
ory
condi
ti
ons.

FI
NALLYRULEOUTTRAUMA:

-
Aski
fther
eishi
stor
yoft
raumat
othebr
eastbef
oret
heonsetoft
heswel
l
ing

PARTC:

- Askwhathappenedi
nthecour
seoft
hei
l
lnessbef
orebei
ngr
efer
redher
eand
whathasbeendoneher
eint
hewar
d.

(
Use pat
ient
s own wor
ds notmedi
calt
erms.Do notgi
ver
epor
ts oft
he
i
nvest
igat
ionsdoneandt
reat
mentgi
ven,j
ustment
iont
hem i
nor
dinar
yEngl
i
sh
l
anguage)

EXAMI
NATI
ONPATI
ENTWI
THBREASTLUMP

Gener
alexami
nat
ion

- Ausual

Local
Exami
nat
ionofbr
east
 AMI
N’STI
P@ GENERALSURGERY

Pat
ient
sposi
ti
oni
ngcanei
therbe

- Si
tt
ingup

- Semi
–recumbent(
45º
)

- Recumbent

Adv
ant
agesofsemi
–Recumbentposi
ti
on

- I
fly
ingf
lat–makest
heBr
eastf
lat
tenoutandf
all
sideway
s.

- I
fsi
tt
ingupr
ight–makest
hebr
eastpendul
ousandbul
ky

- f
orRecumbent–i
sgoodi
npal
pat
ingt
he(
breastl
umpagai
nstt
hechest
)

I
NSPECTI
ON

Posi
ti
ons

- Ar
msbyt
hesi
des

- Ar
msr
aisedst
rai
ghtabov
eherhead.

- Ar
msi
nherhi
ps

Fi
rst
,Compar
eBot
hBr
eastandr
epor
tont
hef
oll
owi
ng

- Si
ze

- Posi
ti
on(
Lev
eloft
heNi
ppl
e)

Thenexami
neeachBr
eastsepar
atel
y

i
. Ni
ppl
e–Ar
eol
acompl
ex

Repor
tthepr
esenceof

- ul
cer
ati
on

- r
etr
act
ion

- Vi
si
bleni
ppl
edi
schar
ge(
ify
es,
ofwhi
chnat
ure,
ser
ous?Bl
oody
?Pur
ulent
?)
 AMI
N’STI
P@ GENERALSURGERY

- Cr
acks

- Fi
ssur
e

i
i
. Ski
nov
ert
hebr
east

- Col
or

- Vi
si
blev
eins

- Di
mpl
i
ng

- Paude–deor
ange

- Cancer–en–cur
aise

i
i
i. Ar
m(I
psi
l
ater
alupperl
i
mb)

- I
sitedemat
ous?

- AnyChangei
ncol
or

i
v. I
nspectt
hesubmammar
yfol
d,t
ellt
hepat
ientt
ori
skupt
hear
msov
ert
he
head,
ifnotv
isi
ble,
usehandst
oli
ftupt
hebr
eastandi
nspect
.

v
. Axi
l
laandsupr
acl
avi
cul
arf
ossa.

PALPATI
ON

I
nit
ial
l
ysi
tt
ingorSemi
–recumbent
 AMI
N’STI
P@ GENERALSURGERY

Lat
er–Recumbent

Usepal
mersur
faceoft
hef
inger
swi
thhandf
lat

Pal
pat
eal
lfl
ourquadr
ant
s,cent
ral
quadr
antandaxi
l
lar
ytai
l

i
. Ni
ppl
e–ar
eol
arcompl
ex

- Feel
fort
heconsi
stency

i
i
. I
flumppal
pat
ed

Repor
t

-Numberoft
hel
umps

-Locat
ion(
usequadr
ant
stor
epor
tthel
ocat
ion)

-
Size(
incent
imet
er)

-
Sur
face(
smoot
horRough)

-
Consi
stency

-
Ifcy
sti
cassesf
orf
luct
uat
iont
est

-
War
mth

-
Tender
ness

-
Fixat
ion

 Tot
heski
n(Doski
npi
nchmet
hod)

 Tot
hechestwal
l(puthandsonherhi
psi
nrel
axedst
ateandmov
ethel
umpi
n
bot
hhor
izont
alandv
ert
ical
planes)

 I
FNOTf
ixedt
ochestwal
lthenassesf
orf
ixat
ionpect
oral
i
smaj
orandser
rat
us
ant
eri
ormuscl
es.

a.Forpect
oral
i
smaj
ormuscl
efi
xat
ion,i
nst
ructhert
oputherhandsi
nher
 AMI
N’STI
P@ GENERALSURGERY

hi
prel
axedst
ateandt
hent
ight
enst
atecont
ract
ingt
hepect
oral
i
smaj
or
muscl
e,mov
ethel
umpi
neachst
ate)

b.Forser
rat
usant
eri
ormuscl
e,i
nst
ructhert
o pushagai
nstt
hewal
lin
r
elaxedst
atet
henst
rongl
ycont
ract
ingt
heser
rat
usant
eri
ormuscl
e,mov
e
t
hel
umpi
neachst
ate)

NB:
Thef
oll
owi
ngpat
ter
nshav
ebeendescr
ibeddur
ingbr
eastexami
nat
ion

-
Ver
ti
cal
str
ippat
ter
n

Apr
efer
redmet
hodbecausei
tincor
por
atesNi
ppl
ear
eol
acompl
ex

-
Radi
alspokemet
hodandConcent
ri
cci
rcl
esmet
hod

Poort
hor
oughexam att
heNi
ppl
eisl
ess,t
her
efor
eneedsasepar
ateNi
ppl
ear
eol
ar
compl
exonpal
pat
ion

Thenpal
pat
efort
hei
psi
l
ater
alaxi
l
laf
oranypal
pabl
ely
mphNode

Thenr
epor
t

-
Numberofpal
pabl
eaxi
l
lar
yly
mphnode

-
Aret
heyf
ixedormobi
l
e

-
Ifmor
ethanone,
aret
heyDi
scr
eteormat
ted?

Thenpal
pat
efort
hesupr
acl
avi
cul
arf
ossaf
oranypal
pabl
ely
mphNode(
Bet
ween
 AMI
N’STI
P@ GENERALSURGERY

st
ernal
headsandcl
avi
cul
arheadoft
hest
ernocl
eidomast
oidmuscl
e)

NB:

i
) Af
tercompar
isonoft
hebot
hbr
east
sforsi
zeandl
eveloft
heNi
ppl
esst
art
exami
ning unaf
fect
ed br
eastf
oll
owed by t
he af
fect
ed one,al
so dur
ing
r
epor
ti
ngst
artr
epor
ti
ngunaf
fect
edbr
eastf
oll
owedbyt
heaf
fect
edone.

i
i
) Localexami
nat
ionoft
hebr
eastwi
l
lgi
vey
out
he(
TandNst
atusi
ncaseof
Br
eastcar
cinoma)

i
i
i) Rev
ise on TNM cl
assi
fi
cat
ion of Br
eastcancer
s(NB:v
eryi
mpor
tant
,
di
agnosi
sofbr
eastcar
cinomai
snotcompl
etei
fnoTNM st
agi
ngal
ongwi
thi
t)

I
NVESTI
GATI
ONS

1.Bi
opsy

Thef
oll
owi
ngar
eopt
ionsf
orbi
opsyi
npat
ientwi
thbr
eastl
ump.Bef
ore
choosi
ngoneopt
ionf
orbi
opsy
,youshoul
dknowi
ndi
cat
ions,adv
ant
ages
anddi
sadv
ant
agesofeach.

i
. FNAC

i
i
. Cor
eNeedl
e

i
i
i. I
nci
sional
biopsy

i
v. WedgeBi
opsy

Not
e:TheBestchoi
ceofbi
opsyi
nanon-
ulcer
ati
ng&anon-
fungat
ingt
umoratour
Cent
re-MNHi
sCor
e–Needl
ebi
opsyt
her
easonsar
est
atedabov
ewhi
char
e:

i
. Gi
ves y
ou hi
stol
ogi
caldi
agnosi
sforconf
ir
ming ei
theri
t’
s a beni
gn or
mal
i
gnantl
ump.
 AMI
N’STI
P@ GENERALSURGERY

i
i
. Al
so,i
tcangi
vey
oui
mmunohi
stochemi
str
y(Recept
or,ER,PR andHER-
2
r
ecept
ors)st
atus

i
i
i. Lessl
i
kel
ytoupst
aget
hepr
imar
ytumor

2.Met
ast
asi
sWor
k–Out

i
. CXR

i
i
. Abdomi
nal
Pel
vi
cUSS

i
i
i. I
ncaseofsuspect
edspi
remet
ast
asi
sdoSpi
nex–r
ay,
(Lumbo–sacr
alX
–r
ayi
fpr
esentwi
thl
owerbackpai
nandpar
apl
egi
a)

i
v. I
ncaseofsuspect
edbr
ainmet
ast
asi
s–CTBr
ain

v
. PET–Scan

NB:

Forpat
ient
swi
thunpal
pabl
ebr
eastmass,butpr
esent
swi
thf
eat
uressuchasbr
east
pai
nand Ni
ppl
edi
schar
get
hef
oll
owi
ngi
nvest
igat
ionsar
eusef
ul

-
Mammogr
aphy

(
iti
sindi
cat
edi
nol
derpat
ient
s,40y
ear
sandabov
e,somel
i
ter
atur
essay35y
ear
sand
abov
e,becauset
oav
oidf
alseposi
ti
ver
esul
tsi
nyoungwomen,becauset
heyhav
e
densebr
eastt
issuecompar
edt
ool
derones,hencet
hesedenset
issuescanmi
mict
he
car
cinomahencegi
vi
ngf
alseposi
ti
veofbr
eastcar
cinoma)

I
tisal
sousef
ulasy
oucandost
ereot
act
icbi
opsyi
fal
esi
oni
sseenorsuspect
ed

-
BreastMRI

I
tisanal
ter
nat
ivet
oMammogr
aphy
,canbedonet
oei
thery
oungorol
derpat
ient
s,
al
thoughi
thasadi
sadv
ant
agecompar
ingt
omammogr
aphy
,inbr
eastMRIi
fal
esi
oni
s
f
oundorsuspect
ed,
biopsycannotbedone
 AMI
N’STI
P@ GENERALSURGERY

-
Readi
ndi
cat
ionsandcont
rai
ndi
cat
ionsf
oreachandadv
ant
agesofeachov
ert
heot
her
t
wo

BASELI
NEI
NVESTI
GATI
ONS

Ful
lBl
oodcount

Renal
funct
ionst
est

Li
verf
unct
iont
est

Ser
um el
ect
rol
ytes

TREATMENT

ManagementofBr
eastCar
cinomai
sdi
vi
dedi
nto

Fi
rst
ly,
Ear
lybr
eastcar
cinoma.St
ageI(
T1N0)andSt
ageI
I(T1N1,
T1N1,
T2N1)

Secondl
y,Local
l
yadv
ancedBr
eastcar
cinoma.St
ageI
IB(
T3N0)andSt
ageI
IIDi
sease
(
T4a,
T4b,
T4candT4d,
wit
hanyN)and(
TI–T3,
N2)

Thi
rdl
y,Met
ast
ati
cBr
eastCar
cinoma(
anyTanyNandM1)

EARLYBREASTCARCI
NOMA

Pr
otocol
forEar
lybr
eastcar
cinomai
sSur
ger
yfol
l
owedbyAdj
uvantt
her
apy

Sur
ger
yis ei
ther Br
east conser
ving sur
ger
y(BCS) or MRM (
Modi
fi
ed Radi
cal
Mast
ect
omy
)

-
Def
ineeachBr
eastconser
vingsur
ger
y(BCS)orMRM (
Modi
fi
edRadi
calMast
ect
omy
(
sel
f-
read)
 AMI
N’STI
P@ GENERALSURGERY

-
Readi
ndi
cat
ionf
oreach(
sel
f-
read)

-
Read ev
olut
ion ofMRM (
From Hal
sted Radi
calMast
ect
omyt
o Pat
ey’
s MRM t
o
Scanl
on’
sMRM t
oAuchi
ncl
o’sMRM)
.(sel
f-
read)

-
Compl
i
cat
ionofbot
hMRM andBCSi
mmedi
ate,
ear
lyandl
ate(
sel
f-
read)

ADJUVANTTHERAPY

Ther
ear
eFOURadj
uvantt
her
api
espostMRM orBCS

FI
RST;
HORMONALTHERAPY(
thi
sther
apyi
sgi
veni
ncaseofERandPRar
eposi
ti
ve)

Quest
ion;Namet
he4opt
ionsofhor
monalt
her
apywhenER i
sposi
ti
veandt
hei
r
i
ndi
cat
ion(
premenopausal
andpostmenopause)

Answer
;

Fi
rst
,Est
rogen r
ecept
orbl
ocker
s(ant
agoni
st)e.
g.t
amoxi
fen and i
sindi
cat
ed i
n
pr
emenopausall
adi
es,si
nceal
lsour
cesofest
rogenpr
oduct
ionsar
est
il
lfunct
ioni
ng
t
heni
tsbet
tert
obl
ockatt
her
ecept
orsi
te

Second,Ar
omat
ase i
nhi
bit
ors,t
hese bl
ock est
rogen pr
oduct
ion f
rom andr
ogens
(
aromat
izat
ion)e.
g.anast
rozol
e,l
etr
ozol
eandi
sindi
cat
edi
npostmenopausel
adi
es
becauset
hei
rsour
ceofest
rogeni
sonl
yar
omat
izat
ion,
ovar
ieshav
eshutdown

Thi
rd,LHRHagoni
st(
medi
caloophor
ect
omy
)thesel
eadt
opi
tui
tar
ydesensi
ti
zat
ion(
in
mal
esi
tsef
fecti
stodecr
ease/
inhi
bitpr
oduct
ionoft
est
ost
eronei
nfemal
esi
tsef
fecti
s
t
odecr
ease/
inhi
bitpr
oduct
ionofest
rogen)

For
th,Hor
monalabl
ati
on can ei
ther be ov
ari
an abl
ati
on by sur
ger
y bi
l
ater
al
oophor
ect
omyorbyI
rr
adi
ati
on,pi
tui
tar
yabl
ati
onandadr
enal
ect
omy
,isi
ndi
cat
edi
n
postmenopausel
adi
es,becauset
hepr
emenopausall
adi
est
heyneedr
epr
oduct
ion
pr
ogr
essdespi
tet
hedi
seaseandt
reat
ment

When PR i
s posi
ti
ve what i
s t
he Dr
ug of choi
ce? -
Progest
ogens e.
g.
 AMI
N’STI
P@ GENERALSURGERY

Medr
oxy
progest
erone,
thesebi
ndst
opr
ogest
eroner
ecept
ors,
glucocor
ti
coi
dsr
ecept
ors
andandr
ogenr
ecept
ors

SECOND;
IMMUNOTHERAPY(
TARGETEDTHERAPY)

Thi
siswhenHER-
2ov
erexpr
essi
oni
sposi
ti
ve

Whati
sdr
ugofchoi
ce?-
Trust
uzumab

Quest
ion;
Ift
her
eisBr
ainmet
ast
asi
s,whati
sthedr
ugofchoi
ceandwhy
?

Answer
;Tr
ust
uzumabdoesnotcr
osst
hebl
oodbr
ainbar
ri
er(
BBB)f
ort
arget
ingt
he
met
ast
asi
stot
hebr
ain,henceLapat
ini
bwi
l
lbeusedi
nst
eadbecausei
tcr
ossest
he
BBB

THI
RD;
CHEMOTHERAPY

Whati
sther
oleofadj
uvantchemot
her
apyi
nbr
eastcar
cinoma?

Toel
i
minat
ecl
i
nical
l
yundet
ect
abl
edi
stantspr
ead

Whatchemot
her
apyRegi
mensand dosagei
sgi
ven f
oradj
uvantchemot
her
apyi
n
Br
eastcancerpat
ient
?

CAFat3weekl
yfor6cy
cles

ACwi
thTaxanesorACr
egi
men4cy
clesf
oll
owedbyTaxanes4cy
cles

CMF

Andot
her
s(sel
f-
read)

I
ndi
cat
ionsofchemot
her
apyar
easf
oll
ows;
 AMI
N’STI
P@ GENERALSURGERY

Al
lnodesposi
ti
vepat
ient
,pr
imar
ytumor>1cm,i
nfl
ammat
orybr
eastCA,pr
esenceof
poorpr
ognost
icsi
gns,
inf
lammat
orybr
eastcar
cinoma,
stageI
Vwi
thsecondar
y.

How chemot
her
apyandhor
monalt
her
apygi
veni
nadj
uvantt
her
api
es?Whi
chst
art
bef
oret
heot
herandwhy
?

Chemot
her
apygi
vesqui
ckerandbet
terr
esponsei
nit
ial
l
ysot
hati
tisusedear
lyf
or
neoadj
uvantandl
ateri
nadj
uvantt
her
apyhor
monet
her
apyi
scont
inued

Howchemot
her
apyandRadi
other
apygi
veni
nadj
uvantt
her
api
es?

Chemot
her
apyandRadi
other
apycanbegi
venconcur
rent
lyorassandwi
cht
her
apy

Whi
chchemot
her
apyi
sgi
veni
ncombi
nat
iononwi
thTr
ust
uzumabi
nHER–2ov
er
expr
essi
on(
posi
ti
ve)pat
ient
s?

Adr
iamy
cinandpacl
i
taxel

Whatar
ethecompl
i
cat
ionsofchemot
her
apy
?

Bonemar
rowsuppr
essi
on;
alopeci
a;car
diact
oxi
cit
y;GIsi
deef
fect
s

FOURTH;
RADI
OTHERAPY

Whati
stheRol
eofadj
uvantRadi
other
apy
??

I
stoer
adi
cat
ethel
ocalbr
eastcancercel
l
sandaxi
l
lar
yly
mphnodes(
localr
egi
onal
cont
rol
)

Af
terbr
eastconser
ving sur
ger
y,Br
eastand axi
l
la ar
eir
radi
ated whi
l
e postMRM
ext
ernal
irr
adi
ati
oni
sgi
vent
otheaxi
l
la

Whatar
ethecr
it
eri
asf
oradj
utantr
adi
other
apyi
npost–MRM Pat
ient
?

Pat
ient
swi
thhi
ghr
iskofl
ocal
rel
apsewhi
char
e;

i
nvasi
vecar
cinoma,
ext
ensi
vecar
cinomai
nsi
tu,
pat
ientl
esst
han35y
ear
sol
d
 AMI
N’STI
P@ GENERALSURGERY

nodal
posi
ti
vedi
seaseandmul
ti
focal
disease

Whati
stheDose(
Regi
mens)ofadj
uvantRadi
other
apyf
oll
owi
ngBCSandMRM?

Tot
aldosagei
s5000cGY,
200cGYuni
tsdai
l
y5day
saweekf
or6mont
hs

FORLOCALLYADVANCEDBREASTCARCI
NOMA

St
ageI
IB(
T3N0)andSt
ageI
IIDi
sease(
T4a,
T4b,
T4candT4d,
wit
hanyN)and(
TI–T3,
N2)

Thesehav
ehi
ghr
iskf
orRecur
renceanddi
stantmet
ast
asi
s

Pr
otocol
oft
reat
menti
sNeo–adj
utantf
oll
owedbysur
ger
ythenAdj
utantt
her
apy

-
Whatar
ethebenef
it
sofNeo–adj
uvantt
her
apyi
nlocal
l
yadv
ancedbr
eastcar
cinoma

Benef
it1;Toshr
inkt
hepr
imar
ytumorf
orr
esect
abi
l
itybecausei
nlocal
l
yadv
anced
t
umor
sther
eisski
ninv
olv
ementandmuscl
efi
xat
ionmaki
ngi
tdi
ff
icul
ti
esi
nresect
ion
t
oachi
evecur
ati
vegoal
,andt
oreducer
iskf
orr
ecur
renceanddi
stantmet
ast
asi
s

NB;
toshr
ink(
debul
k)t
hepr
imar
ytumornott
odownst
aget
het
umor

Benef
it2;
incr
easeschancesf
orBr
eastConser
vingSur
ger
y(BCS)

Benef
it3;
unr
esect
abl
etumor
sbecomer
esect
ed

Benef
it4;
syst
emi
ctr
eat
ment(
chemot
her
apy
)st
art
sear
ly

Quest
ion;How i
sNeo–Adj
uvantt
her
apygi
veni
nERposi
ti
veandHER–2posi
ti
ve
pat
ient
s

Answer
;
 AMI
N’STI
P@ GENERALSURGERY

Hor
monet
her
apyi
nERposi
ti
ve,i
sgi
veaf
tercompl
eti
onofchemot
her
apy
.Concur
rent
t
oget
heri
snotusedatpr
esent
.Iti
ssequent
ial
chemot
her
apyt
henhor
monal
ther
apy
.

ForHER-
2posi
ti
vepat
ient
sTr
ast
uzumabmaybegi
vent
oget
herwi
thchemot
her
apyi
n
Neo-
adj
uvantt
her
apy
,Pacl
i
taxelmaybecombi
nedwi
tht
rast
uzumabi
nHER-
2posi
ti
ve
pat
ient
s,Adr
iamy
cinal
soshowsbet
terr
esponset
oHER-
2posi
ti
vepat
ient
s

Quest
ion;
Doal
lpat
ient
swhogof
orneoadj
uvantt
her
apyr
espondst
hesame?

Answer
;No,
ther
esponddi
ff
erent
ly

Thef
oll
owi
ngar
ethe4TYPESofcl
i
nicalResponder
sfol
l
owi
ngNeo–adj
uvantt
her
apy
i
npat
ientwi
thBr
eastcancer

Compl
etecl
i
nical
responder
s(cCR)
,wi
thoutpal
pabl
etumor

Par
ti
alcl
i
nical
responder
s(pCR)
,int
hese>50%Decr
easei
ntumorsi
ze
Non-
cli
nical
responder
s,i
nthese,
<50%Decr
easei
ntumorsi
ze
Pr
ogr
essi
vedi
seasecl
i
nical
l
y,i
nthese,
>orequal
to25%i
ncr
easei
nsi
ze

Quest
ion;
whatar
etheact
ionsi
neachoft
heabov
egr
oupofr
esponder
s

Answer
;

Compl
ete and par
ti
alr
esponder
slat
erar
etr
eat
ed by MRM,occasi
onal
l
y Br
east
conser
vingsur
ger
y(BCS)
,thenwi
thi
n6weeksaf
tersur
ger
ytheygo t
ofi
nisht
he
r
emai
ning3or4cy
clesl
eftofchemot
her
apy
,lat
erhor
monalt
her
apyshoul
dbegi
venf
or
5y
ear
s.(
adj
uvantt
her
apy
)

I
fBCSt
henr
adi
other
apyf
ir
stt
henchemot
her
apyt
henhor
monal
ther
apy

Forcompl
ete cl
i
nicalr
esponder
sifr
esect
ed speci
men af
terMRM shows v
iabl
e
mi
croscopi
cdi
seaset
heni
twi
l
lbet
ermedaspar
ti
alpat
hol
ogi
calr
esponse(
pPR)andi
f
 AMI
N’STI
P@ GENERALSURGERY

NOmi
croscopi
cgr
owt
hisseeni
nar
esect
edspeci
menaf
terMRM f
orcompl
etecl
i
nical
r
esponder
stheni
twi
l
lbet
ermedascompl
etepat
hol
ogi
cal
response(
cPR)

Non-
responder
sandPr
ogr
essi
veDi
seasear
etr
eat
edbyr
adi
other
apyt
obr
east
,chest
wal
l
,axi
l
la and supr
acl
avi
cul
arr
egi
on.Taxanes,hor
monalt
her
apyand sur
ger
yif
r
esect
abl
e. For ent
ir
elyf
ixed f
ungat
ing t
umor
,chemot
her
apy
,pal
l
iat
ivet
oil
et
mast
ect
omy(
oft
en wi
th ski
n gr
aftt
o cov
ert
hedef
ect
).Axi
l
lar
ydi
ssect
ion i
snot
necessar
yint
hist
ype.Thenchemot
her
apyandr
adi
other
apyt
othebr
eastandaxi
l
la.
Lat
erhor
monal
ther
apy

METASTATI
C(SYSTEMI
C)DI
SEASE

AnyT,
anyNwi
thM1.

Whatar
etheai
msoft
reat
menti
napat
ientwi
thmet
ast
ati
cbr
eastcancer
?

Pal
l
iat
ion;t
oimpr
ovequal
i
tyofl
i
febyof
fer
ingsy
mpt
omat
icr
eli
efe.
g.t
orel
i
evef
rom
pai
nfr
om secondar
iesl
i
kebonepai
norneur
ologi
cal
probl
emsl
i
keconv
ulsi
on

Ment
ionpal
l
iat
ivet
her
api
esi
nmet
ast
ati
cBr
eastcancer

Pal
l
iat
ive chemot
her
apy
,Pal
l
iat
iver
adi
other
apy
,Hor
monalt
her
apy
,and Pal
l
iat
ive
sur
ger
ies/
procedur
es

Ment
ionpal
l
iat
ivesur
ger
iesi
nthef
oll
owi
ng

-
foul
smel
l
ing,
ulcer
atedbr
eastcar
cinoma-si
mpl
e/t
oil
etmast
ect
omy

-
ERposi
ti
vepat
ientwi
thBr
eastcancer
?-bi
l
ater
aloophor
ect
omy

-
Local
i
zedl
ungmet
ast
asi
s?Lungr
esect
ionormet
ast
asect
omy

Par
apl
egi
a?-
spi
nal
cor
ddecompr
essi
on

Pat
hol
ogi
cal
fract
ure?-
openr
educt
ionandi
nter
nal
fixat
ion(
ORI
F)
 AMI
N’STI
P@ GENERALSURGERY

Whati
str
eat
mentoft
hef
oll
owi
ngmet
ast
ati
ccompl
i
cat
ions.

-
Local
i
zedl
ungmet
ast
asi
s-Lungr
esect
ionormet
ast
asect
omy

-
Pleur
alef
fusi
on-
tubet
hor
acost
omyf
oll
owedbypl
eur
odesi
s

-
Met
ast
asi
stol
ungpar
enchy
mawi
thoutpl
eur
alef
fusi
on-
inj
ect
iondexamet
hasonewi
th
oxy
gent
her
apy

-
Bonemet
ast
asi
s-boner
adi
other
apypl
usbi
sphosphonat
ese.
g.or
alcl
odr
onat
es

ADDI
TIONS

NB:READONTHEFOLLOWI
NG

A.Readaboutmol
ecul
arsubt
ypesofbr
eastcar
cinoma.

Lumi
nalA(
ER+v
e,HER-
2-v
e,l
owl
evel
sofpr
otei
nKi
-67,
slowgr
owi
ng,
lowgr
ade
t
umor
,respondswel
ltohor
mone)

Lumi
nalB(
ERandPR+v
e,HER-
2+v
e/-
ve,hi
ghl
evel
sofpr
otei
nKi
-67,of
tenhi
gh
gr
ade,
respondswel
ltochemot
her
apy
,lumi
nalBt
ri
ple+v
eout
comei
spoort
han
l
umi
nal
Bwi
thHER-
2-v
e)

Basall
i
ke(
tri
ple-
ve,ER,PRandHER-
2al
lar
e-v
e,mostBRCA-
1mut
ati
ons,hi
gh
gr
adet
umor
s,poorpr
ognosi
s,hi
ghi
nci
denceofl
ungsandbonemet
ast
asi
s)

HER-
2ri
ch(
HER-
2+v
e,ERandPRar
e-v
e)t
hisi
saggr
essi
ve,
poor
lydi
ff
erent
iat
ed
t
umor
swi
thhi
gheri
nci
denceofbr
ainmet
ast
asi
s

Nor
malbr
eastl
i
ke(
ER+v
e,HER-
2-v
e,l
owl
evel
sofpr
otei
nKi
-67,l
i
kel
umi
nalA
butpr
ognosi
sissl
i
ght
lywor
set
hanl
umi
nal
A)

Cl
audi
n-l
ow(
tri
plenegat
ive,
ther
eisl
owexpr
essi
onofE-
cadher
in)
 AMI
N’STI
P@ GENERALSURGERY

B.i
) whati
sSIuni
tsofER/
PR?

Answer
;femt
omol
es/
mgpr
otei
n(NB:
femt
omol
eis10powernegat
ive15)

i
i
) Whenar
etheyconsi
der
edposi
ti
ve?

Answer
;nor
malERandPRi
s<10f
emt
omol
es/
mgpr
otei
n,i
fiti
smor
e
t
han10f
emt
omol
es/
mgpr
otei
niti
sconsi
der
edPOSI
TIVE.

C.i
.Whati
sHER–Rr
ecept
or?

I
samembr
anet
yrosi
neki
naser
ecept
orandamar
kerofcel
l
ularpr
oli
fer
ati
on

i
i
. Whati
sthei
nter
pret
ati
onofHER–2Resul
tsandsi
gni
fi
cance

I
nter
pret
ati
onofHER-
2resul
tswi
tht
hei
rmeani
ng(
signi
fi
cance)

1+v
emeansnegat
ive

2+v
emeansequi
vocal
resul
ts,
tobeconf
ir
medbyFI
SHt
est

3+v
emeansposi
ti
veorov
erexpr
essed/
ampl
i
fied

i
i
i. Whati
stheFI
SHTest
?

Fl
uor
escenceI
nSi
tuHy
bri
dizat
ion(
FISH)t
est
,ist
het
estdoneonbr
east
cancert
issuer
emov
eddur
ingbi
opsyt
oseei
fthecel
l
shav
eext
racopi
es
oft
heHER-
2genes,t
hemor
ecopi
esoft
heHER-
2genesar
epr
esentt
he
mor
eHER-
2recept
orst
hecel
l
shav
e

Bestper
for
medi
nti
ssuepr
eser
vedi
nwaxr
athert
hanonf
reshorf
rozen
t
issue

i
v. Whati
sthei
ndi
cat
ionofFI
SHt
est
?
 AMI
N’STI
P@ GENERALSURGERY

I
fresul
tsofHER-
2ar
e2+v
emeansequi
vocalr
esul
ts,t
obeconf
ir
medby
FI
SHt
est

D.Whati
ski
–67andWhati
sthef
unct
ionofki
–67?
?

Ki
-67pr
otei
nisapr
otei
nthati
nhumani
sencodedbyt
heMK167gene(
ant
igen
i
dent
if
iedbymonocl
onal
ant
ibodyki
-67)

Funct
ional
l
yiti
sacel
l
ularmar
kerofpr
oli
fer
ati
on.I
tisst
ri
ctl
yassoci
atedwi
th
cel
lpr
oli
fer
ati
on

Whati
sthesi
gni
fi
canceofki
–67i
nBr
eastcancer
?

I
nbr
eastcancerKi
-67i
dent
if
ieshi
ghpr
oli
fer
ati
vesubsetofpat
ientwi
thER+v
e,
hi
gherv
aluesofki
-67suggest
iveaggr
essi
vet
umor

Whatv
aluei
ski
–67consi
der
edhi
gh(
cut
-of
fval
ue)

Acut
-of
fval
ueof<14%i
sgener
all
yusedt
odenot
elowandhi
ghv
alues

E.SENTI
NILELYMPHNODEBI
OPSY(
SELFSTUDY)

i
. –Def
ini
ti
on

i
i
. -I
ndi
cat
ion

i
i
i. –Cont
rai
ndi
cat
ion

i
v. –Howi
sitdone

F.Whatar
ethecausesofDeat
hforBr
eastcancerpat
ient
s?

-
Secondar
ies i
nlungs/
pleur
al,Spi
ne i
nvol
vement
,Secondar
ies i
n br
ain and
Cancercachexi
a
 AMI
N’STI
P@ GENERALSURGERY

G.Whatar
epr
ognost
icf
act
orsf
orBr
eastcancer
?(Hostf
act
orsandTumorf
act
ors)

Hostf
act
ors;age,sex
,menopausest
atus,f
ami
l
yhi
stor
y,pr
evi
oushi
stor
yof
br
eastcancer
,immunosuppr
essi
onandnut
ri
ti
onst
atus

Tumorf
act
ors;t
umorsi
ze,nucl
eargr
ade,st
ageoft
hedi
sease,r
ecept
orst
atus,
spr
eadandDNAnat
ure

H.Ment
ioncr
it
eri
asf
orgenet
ict
est
ingf
orBr
eastcancer
.

-
thosewi
thknownBRCA1or
2genemut
ati
oni
nthef
ami
l
y

-
aper
sonal
hist
oryofbr
eastcanceratt
heageof45ory
ounger

-
aper
sonalhi
stor
yofbr
eastcanceratageof0ory
oungerandf ymember1st
ami
l
or2nddegr
eer
elat
ivedi
agnosedwi
thbr
eastcanceratanyage

-
aper
sonalhi
stor
yoft
ri
plenegat
ivebr
eastcancerdi
agnosedatt
heageof60or
y
ounger

-
aper
sonal
hist
oryofov
ari
ancancer

-
aper
sonal
hist
oryorf
ami
l
yhi
stor
yofmal
ebr
eastcancer

-
AshkenaziJewi
shher
it
ageandper
sonalorf
ami
l
yhi
stor
yofbr
eastorov
ari
an
cancer

N;B;Onceani
ndi
vi
dualt
est
sposi
ti
veshoul
dinf
orm her1st and2nd degr
ee
r
elat
ives

I
. Whatar
ethecancerpr
event
ionst
rat
egi
esi
nBRCAmut
ati
oncar
ri
ers?

Answer
;

-
Risk r
educi
ng sur
ger
ies (
e.g.bi
l
ater
almast
ect
omy and bi
l
ater
alsal
pingo-
oophor
ect
omy
)
 AMI
N’STI
P@ GENERALSURGERY

-
Chemopr
event
ion,byTamoxi
fen(
forBRCA-
2whoar
ehor
monalr
ecept
or+v
e,
notf
orBRCA-
1whoar
ehor
monal
recept
ornegat
ive)

-
Int
ensi
ve sur
vei
l
lance ofbr
eastand ov
ari
an cancer(
cli
nicalexami
nat
ion 6
mont
hly
,Mammogr
aphy orMRIatage 25 annual
l
y,CA 125 l
evel
sto be
moni
tor
edannual
l
y)

READON;

Br
eastcar
cinomai
npr
egnancy

Mal
ebr
eastcar
cinoma

Br
eastcar
cinomael
der
ly

I
nfl
ammat
oryBr
eastcar
cinoma

Phy
ll
odest
umor

Gy
necomast
ia

Anat
omyoft
heBr
east

-
Boundar
ies

-
Bloodsuppl
y

-
Venousdr
ainage

-
Lev
elsofaxi
l
lar
yly
mphnodes

-
Groupsofaxi
l
lar
yly
mphnodes

-
Lymphat
icdr
ainageoft
heBr
east
 AMI
N’STI
P@ GENERALSURGERY

-
Congeni
tal
anomal
i
est
hebr
east

TOPI
CTWO

THYROI
DSWELLI
NG
READON:

Theembr
yol
ogyofThy
roi
dgl
and

Congeni
tal
anomal
i
esoft
heThy
roi
dgl
and

Anat
omyoft
heThy
roi
dgl
and

Wei
ght
;

Lengt
hs(
crani
ocaudal
,ant
eropost
eri
orandmedi
olat
eral
)

Component
s

Hi
stol
ogy

Bl
oodsuppl
y

Venousdr
ainage

Rel
ati
onoft
hev
essel
swi
thagl
and
 AMI
N’STI
P@ GENERALSURGERY

Rel
ati
onoft
her
ecur
rentl
ary
ngeal
ner
vewi
tht
hegl
and

Rel
ati
onshi
poft
hesuper
iort
hyr
oidv
essel
swi
thsuper
iorl
ary
ngealner
ve(
Cer
neaand
col
l
eagues’
classi
fi
cat
ion)

Cer
neaandcol
l
eagues’
classi
fi
cat
iondescr
iber
elat
ionshi
poft
heext
ernalbr
anchoft
he
super
iorl
ary
ngeal
ner
vewi
thsuper
iort
hyr
oidar
ter
y

Ty
pe1anat
omy

Thener
vecr
ossest
hear
ter
ymor
ethanorequalt
oonecent
imet
erabov
ethesuper
ior
aspectoft
het
hyr
oidl
obe

Ty
pe2anat
omy

2a;
Thener
vecr
ossest
hear
ter
ylesst
hanonecent
imet
erabov
ethet
hyr
oidpol
e

2b;
Thener
vecr
ossest
hear
ter
ylesst
hanonecent
imet
erbel
owt
het
hyr
oidpol
e

Ty
pe2v
ari
ant
sar
ethemostv
ulner
abl
etoi
atr
ogeni
cinj
ury

Tr
iangl
esoft
heneck

Lev
elsofl
ymphNodesoft
heNeck

Phy
siol
ogy

Whati
sthedai
l
yrequi
rementofI
odi
neperday
?Iti
s100mcgt
o300mcg(
0.1mgt
o0.
3
mg)perday

St
epsofThy
roi
dHor
monessy
nthesi
s(sel
f-
study
)

TSH(
Thy
roi
dSt
imul
ati
ngHor
mone)

Whatar
ethemaj
orf
unct
ionsofTSHi
nthebody
?

-
sti
mul
atesv
ari
ousst
epsi
nthy
roi
dhor
monesy
nthesi
s(i
odi
det
rappi
ng,coupl
i
ngand
 AMI
N’STI
P@ GENERALSURGERY

r
eleaseoft
hyr
oidhor
mones)

-
cel
l
ularpr
oli
fer
ati
onoft
het
hyr
oidgl
and

-
incr
easei
nvascul
ari
tyoft
hegl
and

Thy
roi
dhor
mones(
T3andT4)

-
Whatar
ethei
rsour
ces?

T4i
sexcl
usi
vel
ysy
nthesi
zedbyt
het
hyr
oidgl
and

T3i
ssy
nthesi
zedbyt
het
hyr
oidgl
andf
orappr
oxi
mat
ely20%andt
her
emai
ning80%ar
e
sy
nthesi
zedf
rom per
ipher
alconv
ersi
onofT4t
oT3.

Whati
stheHal
f-
li
feofeach?

Hal
f-
li
feofT4i
s7t
o14day
swhi
l
ethatofhal
fli
fef
orT3i
s24hour
s

Whatar
ethei
rFunct
ionsandef
fect
sinv
ari
oussy
stems?(
sel
f-
read)

I
fyouf
indapat
ientwi
tht
hyr
oidswel
l
ingt
hef
oll
owi
ngar
epossi
bledi
ff
erent
ial
s(causes)

A.Si
mpl
eGoi
ter

B.Mal
i
gnantGoi
ter

C.Toxi
cGoi
ter

D.I
nfl
ammat
oryGoi
ter

A.SI
MPLEGOI
TRE

(
abeni
gnenl
argementoft
het
hyr
oidgl
andwi
thnot
oxi
csy
mpt
omsandsi
gns)

Causes;
 AMI
N’STI
P@ GENERALSURGERY

Pr
imar
yIodi
nedef
ici
ency(
endemi
cGoi
ter
)

Thi
siswhent
her
eisnoi
odi
nei
ntakeort
her
eisi
nadequat
eiodi
nei
ntakei
ndi
et.

I
odi
nei
sar
aw mat
eri
alf
ort
hyr
oidhor
monesy
nthesi
s,i
fther
eisnoi
odi
nei
ntakeor
t
her
eisi
nadequat
eiodi
nei
ntake,
thent
her
ewi
l
lbel
owpr
oduct
ionoft
hyr
oidhor
mones
T3andT4,hencehy
pot
hyr
oidi
sm t
hiswi
l
lleadt
oexcesspr
oduct
ionofTSHi
nor
dert
o
cor
rectt
hehy
pot
hyr
oidi
sm,soexcessTSH wi
l
lleadt
ohy
per
plasi
aoft
hegl
andand
i
ncr
easei
nsi
ze,
henceGOI
TRE

Secondar
yIodi
nedef
ici
ency–(
Goi
tr
ogeni
cFoods&Dr
ugs)

Thi
siswhent
her
eisadequat
eiodi
nei
ntakei
ndi
et.Butt
her
ear
edr
ugsorf
oodswhi
ch
i
nhi
bit
s orcompet
es wi
thi
odi
ne,t
her
efor
e makes i
odi
ne def
ici
ency secondar
il
y.
Exampl
efoodsl
i
ke;
cabbage,
foodscont
aini
ngf
luor
ide,
Drugsl
i
keami
odar
one,
li
thi
um.

Secondar
yIodi
nedef
ici
encywi
l
lleadt
olowpr
oduct
ionoft
hyr
oidhor
monesT3andT4,
hencehy
pot
hyr
oidi
sm t
hiswi
l
lleadt
oexcesspr
oduct
ionofTSHi
nor
dert
ocor
rectt
he
hy
pot
hyr
oidi
sm,
soexcessTSHwi
l
lleadt
ohy
per
plasi
aoft
hegl
andandi
ncr
easei
nsi
ze,
henceGOI
TRE

Phy
siol
ogi
cal
(Puber
ty,
PregnancyandLact
ati
on)

I
npuber
ty,pr
egnancyandl
act
ati
ont
her
ear
eincr
easeddemand,cat
abol
i
sm.
..t
hechi
ef
hor
monei
ncat
abol
i
sm i
sThy
roi
dhor
mones,t
her
efor
eev
eni
fthel
evel
sofT3andT4
ar
einnor
malr
angebutduet
oincr
easei
ndemandi
ntheset
hreegr
oupsofpeopl
e,TSH
wi
l
lber
eleasedi
nexcesssot
hatt
oful
fi
llt
her
equi
reddemandshenceov
eract
ivi
tyof
t
hegl
andwi
l
lleadt
ohy
per
plasi
aoft
hegl
andhencegl
andenl
argement
,al
soef
fectof
TSHi
nincr
easi
ngt
hecel
l
ular
it
y(hy
per
plasi
a)oft
hegl
and.

Bet
aHCGwhi
chi
sahor
monepr
oducedi
npr
egnancy
,hast
wosubuni
tswhi
char
eal
fa
andbet
asubuni
ts.Theal
fasubuni
tisst
ruct
ural
l
ysi
mil
art
oTSH;t
her
efor
e,t
heycan
bi
ndt
oTSHr
ecept
orandpr
oduceuncont
rol
l
edef
fect
s(f
unct
ions)ofTSHev
eni
fthe
 AMI
N’STI
P@ GENERALSURGERY

l
evel
sofTSH i
sver
ylow,andoneoft
hef
unct
ionsofTSH i
stoi
ncr
easecel
l
ular
it
y
(
hyper
plasi
a)oft
hegl
andhencegl
andenl
argement
,Goi
ter
.

Fami
l
ial
Goi
ter(
Dyshor
monal
genet
icdi
sor
der
s)

I
nthy
roi
dhor
monessy
nthesi
sther
esomest
epsr
equi
resenzy
meact
ivat
ion,exampl
e
oxi
dat
ionofi
odi
det
oiodi
ner
equi
resenzy
me Thy
roi
dper
oxi
dase,soi
fthi
senzy
mei
s
nott
her
e(absent
)thent
hisst
epwontbecompl
eted,andi
fthi
sst
epi
snotcompl
eted
t
hent
hesubsequentst
epscantpr
oceedwhi
chwi
l
lleadt
onopr
oduct
ionoft
hyr
oid
hor
monesT3andT4,hencehy
pot
hyr
oidi
sm t
hiswi
l
lleadt
oexcesspr
oduct
ionofTSH
i
nor
dert
ocor
rectt
hehy
pot
hyr
oidi
sm,soexcessTSH wi
l
lleadt
ohy
per
plasi
aoft
he
gl
andandi
ncr
easei
nsi
ze

B.MALI
GNANTGOI
TRES

(
amal
i
gnantenl
argementoft
het
hyr
oidgl
andwi
thpl
usormi
nust
oxi
csy
mpt
omsand
si
gns

Papi
l
lar
yThy
roi
dCar
cinoma

Mostcommonappr
oxi
mat
ely80–85%ofal
lthy
roi
dmal
i
gnancy

Most
lyi
niodi
nesuf
fi
cientar
eas

F>M,
Meanage30–40y
ear
s

Mostpat
ient
sar
eeut
hyr
oidwi
thasl
owgr
owi
ngpai
nlessmass

Pr
essur
esy
mpt
omsusual
l
yar
eassoci
atedwi
thl
ocal
l
yadv
anceddi
sease

Ly
mphat
icspr
eadi
scommon,
bloodspr
eadi
srar
e

(
??Lat
eral
aber
rantt
hyr
oid)

Di
agnosi
sisest
abl
i
shedbyFNACoft
het
hyr
oidmass

(
PresenceofOr
phanAnni
eNucl
ei)

Mul
ti
focal
i
tyi
scommonupt
oappr
oxi
mat
ely85%
 AMI
N’STI
P@ GENERALSURGERY

Mul
ti
focal
i
tyi
sassoci
atedwi
thani
ncr
easedr
iskofcer
vical
lymphnodemet
ast
asi
s

Mosti
mpor
tantr
iskf
act
ori
sRadi
ati
onexposur
e

Fol
l
icul
arThy
roi
dcar
cinoma

2ndmostcommont
hyr
oidmal
i
gnancy
,account
supt
o10–15%

Commonl
yini
odi
nedef
ici
entar
eas

F>M,
3:1andMeanagei
s50y
ear
s

Usual
l
ypr
esent
sasasol
i
tar
ythy
roi
dnodul
e

Pai
nisuncommonunl
esshemor
rhagei
ntot
heNodul
ehasoccur
red

Hemat
ogenousspeedi
scommon,
lymphat
icspr
eadi
srar
e

Char
act
eri
sti
cfeat
ureofamet
ast
ati
clesi
onf
rom f
oll
i
cul
arcar
cinomai
spul
sat
il
elesi
on,
mor
ecommonskul
l

(
Nameanyot
herpul
sat
il
eswel
l
ingsy
ouknow)

I
n<1%f
oll
i
cul
arcar
cinomamaybehy
perf
unct
ioni
ng,
leadi
ngt
osi
gnsandsy
mpt
omsof
t
hyr
otoxi
cosi
s

FNAC i
sinconcl
usi
vei
nfol
l
icul
arcar
cinoma,capsul
arand Angi
oinv
asi
on ar
enot
demonst
rat
edbyFNAC

(
Diagnosi
sisconf
ir
medaf
terhemi
thy
roi
dect
omyi
nor
dert
oappr
eci
atecapsul
arand
Angi
oinv
asi
on)

Hur
thl
ecel
lcar
cinoma

Appr
oxi
mat
ely3%

WHO consi
der
ed,i
tasasubt
ypeoff
oll
i
cul
arcar
cinoma.I
tisal
sochar
act
eri
zedby
capsul
arandAngi
oinv
asi
onandt
her
efor
ecan’
tbedi
agnosedbyFNAC
 AMI
N’STI
P@ GENERALSURGERY

Hur
thl
ecel
lcar
cinomadi
ff
ersf
rom f
oll
i
cul
arcar
cinoma

-
theyar
emor
emul
ti
focal
andbi
l
ater
al

-
theyusual
l
ydonott
akeupRAI(
Radi
oact
ivei
odi
ne)

-
unl
i
kel
yfol
l
icul
art
hyr
oidcar
cinoma,met
ast
asi
stocer
vicall
ymphnodei
scommoni
n
hur
thl
ecel
lcar
cinoma

Theyar
eassoci
atedwi
thhi
ghermor
tal
i
tyr
ate

Medul
l
aryt
hyr
oidcar
cinoma

Account
sforabout5%oft
hyr
oidmal
i
gnancy

Ar
isef
rom t
hepar
afol
l
icul
arcel
l(C–Cel
l
s).

Ther
ecel
l
sar
econcent
rat
edsuper
olat
eral
int
hyr
oidl
obes

Secr
etescal
cit
oni
nwhi
chl
ower
sCal
cium Lev
els

Mostoccur
sspor
adi
cal
l
y,25%ar
efami
l
ial
.

Bot
hly
mphat
icsandhemat
ogenousspr
eadi
scommon.

F>M,
1.5.
1

Peakagei
s50-
60y
ear
sinspor
adi
cdi
sease,
forf
ami
l
iaroccur
satear
lyage

Medul
l
aryt
hyr
oidcar
cinomapr
oduces–cal
cit
oni
n,CEA,
Ser
otoni
nandPGE2

Medul
l
aryt
hyr
oidcar
cinomasar
ety
pical
l
yuni
l
ater
ali
npat
ientwi
thspor
adi
cdi
sease
andmul
ti
cent
ri
candbi
l
ater
alupsoappr
oxi
mat
ely90%off
ami
l
ial
cases

FNAC–Thepr
esenceofamy
loi
disdi
agnost
ic
 AMI
N’STI
P@ GENERALSURGERY

Tumormakes–ar
ecal
cit
oni
nandCEA

Cal
ci
toni
nlev
el(
amor
esensi
ti
vet
umormaker
)

CEAl
evel
(abet
terpr
edi
cat
orf
orpr
ogr
ess)

Anapl
ast
ict
hyr
oidcar
cinoma

Account
sforappr
oxi
mat
ely10%

F>M

Peakof7th–8thdi
sease

Thet
ypi
calpat
ienthasal
ongst
andi
ngsi
mpl
ethy
roi
dgoi
ter
,whi
chr
api
denl
argesand
maybepai
nful
.

Pr
essur
esy
mpt
omsar
ecommon

Tumori
slar
geandmaybef
ixedt
osur
roundi
ngst
ruct
ures

Ly
mphat
icandhemat
ogenousspr
eadar
ecommon

FNACr
eveal
i
ngchar
act
eri
sti
csgi
antandmul
ti
nucl
eat
edcel
l
s

Pr
imar
ythy
roi
dly
mphoma

Mostar
eoft
hem Non–Hodgki
n’
sdi
seaseB-cel
lty
pe

Mostdev
elopi
npat
ientwi
thchr
oni
cly
mphocy
tict
hyr
oidi
ti
s(Hashi
mot
o’st
hyr
oidi
ti
s)

Pat
ient
,usual
l
ypr
esent
ssi
mil
arsy
mpt
omsasanapl
ast
iccar
cinomaal
thoughr
api
d
dev
elopmentoft
heneckmassi
sof
tenpai
nless

C.TOXI
CGRI
TURE

(
abeni
gnenl
argementoft
het
hyr
oidgl
andwi
tht
oxi
csy
mpt
omsandsi
gns)
 AMI
N’STI
P@ GENERALSURGERY

Di
ff
erent
iat
ebet
weent
hyr
otoxi
cosi
sandhy
per
thy
roi
dism

Ment
ionanddef
inet
hecausesoft
hyr
otoxi
cosi
s

Di
ff
erent
iat
ebet
weenpr
imar
ythy
rot
oxi
cosi
sandsecondar
ythy
rot
oxi
cosi
s

Gr
aves’
Diseasepr
esent
swi
th

-
Thy
rot
oxi
cosi
s

-
Dif
fuseGoi
ter

-
Ext
rat
hyr
oidal
mani
fest
ati
on

-
Opht
hal
mopat
hy(
???
cause)

-
Der
mopat
hy(
pre–t
ibi
almy
xedema)
,(?
??Causes)

-
Ony
chol
ysi
s

-
Gynecomast
ia

Quest
ion;
Expl
aint
hepat
hophy
siol
ogyl
eadi
ngt
oGr
aves’
disease

Answer
;Isanaut
oimmunecondi
ti
onwhi
chsecr
etsaut
o-ant
ibodi
es(
Thy
roi
dSt
imul
ati
ng
I
mmunogl
obul
i
n) t
oTSH r
ecept
ors,t
heseaut
oant
ibodi
eshav
esi
mil
arst
ruct
uret
o
TSH,t
heybi
ndTSH r
ecept
orsandbi
ndt
oTSH r
ecept
orandpr
oduceuncont
rol
l
ed
ef
fect
s(f
unct
ions)ofTSHev
eni
fthel
evel
sofTSHi
sver
ylow,
andoneoft
hef
unct
ions
ofTSH i
stoi
ncr
easecel
l
ular
it
y(hy
per
plasi
a)oft
hegl
andhencegl
andenl
argement
,
Goi
ter
.

Cl
i
nical
feat
ures

o Toxi
cfeat
ures(
Syst
emi
c)

o Ey
esi
gns

o (
Theyar
eabout20ey
esi
gns,
butt
hef
oll
owi
ngar
emor
eimpor
tant
)

o Exopht
hal
mos(
causes)
 AMI
N’STI
P@ GENERALSURGERY

o Li
dRet
ract
ion(
causes)

o St
ell
wag’
ssi
gns

o Von–Gr
aef
ey’
ssi
gn

o Dal
rympl
e’
ssi
gn

o Moebi
ussi
gn.

o Jof
frey
’ssi
gn

o Naf
ziger
’ssi
gn

o Gi
ff
ord’
ssi
gn

D.I
NFLAMMATORYGOI
TER

Commonl
ychr
oni
cly
mphocy
tict
hyr
oidi
ti
s(Hashi
mot
o’st
hyr
oidi
ti
s)

- Pr
esent
swi
tht
ohy
pot
hyr
oid

- Quest
ion;
Expl
aint
hepat
hophy
siol
ogyl
eadi
ngt
oHashi
mot
o’st
hyr
oidi
ti
s

Answer
;Isanaut
oimmunecondi
ti
onwhi
cht
her
eispr
oduct
ionofaut
o-ant
ibodi
es
agai
nstt
hyr
ocy
tes (
cel
l
sin whi
ch t
hyr
oid hor
mone sy
nthesi
stakes pl
ace)
,
l
eadi
ngt
odest
ruct
ionoft
het
hyr
ocy
tesandev
ent
ual
l
yly
mphocy
tesi
nfi
l
trat
ion
i
ntot
hegl
andhencet
henamechr
oni
cly
mphocy
tict
hyr
oidi
ti
s,t
heendr
esul
twi
l
l
behy
pot
hyr
oidi
sm.Hencehy
pot
hyr
oidi
sm t
hiswi
l
lleadt
oexcesspr
oduct
ionof
TSH i
n or
dert
o cor
rectt
he hy
pot
hyr
oidi
sm,so excess TSH wi
l
llead t
o
hy
per
plasi
aoft
hegl
andandi
ncr
easei
nsi
ze,
henceGOI
TRE

- Feat
uresofhy
pot
hyr
oidi
sm (
rev
erset
hoseofToxi
cGoi
ter
)
 AMI
N’STI
P@ GENERALSURGERY

HI
STORYTAKI
NGI
NAPATI
ENTWI
THTHYROI
DSWELLI
NG

Chi
efcompl
aint
s

- Ant
eri
orNeckSwel
l
ing(
foracer
tai
nper
iodoft
ime)

Hi
stor
yofPr
esent
ingI
ll
ness(
HPI
)

PARTA:
(DONPARA)

Askhowdi
dhe/
shenot
icet
heswel
l
ing.

Onset–Mostar
eofgr
adual
onset

Nat
ure– Mostar
epr
ogr
essi
vel
yIncr
easi
ng i
nsi
zeasday
sgoeson.How i
sthe
pr
ogr
ess?I
sitf
astgr
owi
ngorsl
owgr
owi
ng?

Per
iodi
cit
y–Usual
l
yhav
enospeci
fi
cper
iodi
cit
y

Aggr
avat
ingandRel
i
evi
ngf
act
ors-
usual
l
yther
eisnospeci
fi
caggr
avat
ingar
eli
evi
ng
f
act
or

Associ
ati
ngsy
mpt
oms

-
Neckpai
n

-
Changei
nvoce

-
Dif
fi
cul
tyi
nswel
l
ing

-
Dif
fi
cul
tyi
nbr
eat
hing

PARTB:

RUEOUTPOSSI
BLEDI
FFERENCI
ALSTARTRUEOUTSI
MPLEGREOTRE

-
Aski
fther
eisanyonewi
thasi
mil
arcondi
ti
onwher
ehe/
shel
i
ves(
tor
uleoutendemi
c
 AMI
N’STI
P@ GENERALSURGERY

goi
ter
)

-
Ask i
fther
eis any
one wi
th a si
mil
arcondi
ti
on i
n hi
s/herf
ami
l
y(f
orr
ule out
dy
shor
monal
genet
icdi
sor
der
)

-
Askaboutr
egul
arconsumi
ngofr
iskdi
ets(
bynames)

-
Aski
fhe/
shei
sonanychr
oni
cmedi
cat
ion.

RULEOUTTOXI
CGOI
TERANDI
NFLAMMATORYGOI
TER

Askpr
esenceof

o Easi
l
yIr
ri
tabl
e

o Di
stur
bancei
nsl
eepi
ng

o Anxi
ety

o Wei
ghtl
oss/wentgai
n

o Appet
it
e(i
ncr
eased/decr
ease)

o I
ncr
easesweat
ing

o I
ncr
easet
hir
st

o Unabl
etot
oler
atehot
/col
denv
ironment

o Awar
enessofhear
tbeat
s

o Easyf
ati
guabi
l
ity

o I
she/
sheabl
etocl
i
mbst
air
sorcanhest
andeasi
l
yandcomf
ort
abl
efr
om
si
tt
ingposi
ti
on?

o Di
arr
hea/const
ipat
ion

o I
ffemal
e

 Enqui
rehi
stor
yofmenses.

 I
nci
dencesofmi
scar
ri
ages.
 AMI
N’STI
P@ GENERALSURGERY

RULEOUTMALI
GNANTGOI
TER

-
Hist
oryofr
adi
ati
on,
exposur
epr
ioronsetoft
heswel
l
ing

-
Hist
oryofni
ghtf
ever
,ni
ghtsweat
s(t
oRul
eoutpr
imar
ythy
roi
dly
mphoma)

PART.C

Askwhathappenedi
nthecour
seoft
hei
l
lnessbef
orebei
ngr
efer
redher
eandwhathas
beendoneher
eint
hewar
d.

(
Usepat
ient
sownwor
dsnotmedi
calt
erms.Donotgi
ver
epor
tsoft
hei
nvest
igat
ions
done,
justment
iont
hem)

EXAMI
NATI
ONOFTHEPATI
ENTWI
THTHYROI
DSWELI
NG

Gener
alExami
nat
ionoft
hepat
ientwi
tht
hyr
oidswel
l
ing

Asusual
(li
kei
nanyot
herGener
alexami
nat
ion)

Buti
napat
ientwi
thanant
eri
orneckswel
l
ing,t
hef
oll
owi
ngmustbehear
diny
our
r
epor
tfi
ndi
ngs

Thef
oll
owi
ng shoul
d bei
ncl
uded i
ngener
alexami
nat
ioni
napat
ientwi
tht
hyr
oid
swel
l
ing(
whet
herpr
esentorNot
…hav
etobement
ioned)

Scal
p…exami
net
hescal
pandr
epor
tift
her
ear
eanyscal
pswel
l
ing.i
fyes,ar
ethey
pul
sat
il
eorNonpul
sat
il
e

Tonguef
or–i
fther
eisanyf
asci
cul
ati
ons

Fi
nger
s,check f
ort
he f
oll
owi
ng……….Forcl
ubbi
ng (
thy
roi
d acr
opachy
),I
fthe i
s
separ
ati
onoff
ingernai
l
sfr
om t
hei
rbeds(
Ony
chol
ysi
s)

Upperl
i
mbs–f
orf
inet
remor
s(Useapi
eceofpaper
)
 AMI
N’STI
P@ GENERALSURGERY

I
nassessi
ngf
ort
hef
inet
remor
s,ext
ensor
soft
heupperl
i
mbar
eof
tenusedi
fnot
al
way
s…(
Quest
ion;
whypr
efer
ri
ngext
ensor
sthanf
lexor
s)

Answer
;Fl
exor
soft
heupperl
i
mbar
est
rongercompar
ingt
otheext
ensor
s,soi
t’
seasi
er
t
ovi
sual
i
zef
inet
remori
next
ensor
sthanf
lexor
s(i
tseasyf
ort
het
remor
stobeev
ident
i
next
ensor
scompar
edt
ofl
exor
s)

Br
east
sforGy
necomast
ia–i
fmal
e

Lowerl
i
mbs–f
orpr
e–t
ibi
aMy
xedema

Ocul
arsi
gns(
Especi
all
ythepr
evi
ousl
i
stedi
mpor
tantey
esi
gnst
ober
epor
ted)

MOSTFREQUENTLYASKEDQUESTI
ONI
NSURGERYCLI
NICALEXAM

QN:DOGENEARALEXAMI
NATI
ONFORPATI
ENTWI
THTHYOI
D

ANS;
Asabov
e

Local
Exami
nat
ionofThy
roi
dswel
l
ing

 I
nspect
ion

o Si
te

o Vi
si
blev
essel
s

o Changei
ncol
oroft
heski
n(ski
nov
erl
yi
ngt
heswel
l
ing)

o Doest
heswel
l
ingmov
eswi
thswal
l
owi
ng?(
Youshoul
dknow t
her
eason
f
ort
his)

o Thy
roi
dswel
l
ingsmov
ewi
thswal
l
owi
ngbecausesuper
ior
-post
eri
orl
ythe
l
i
gamentofber
ryat
tachest
othecr
icoi
d car
ti
lage,and t
hiscar
ti
lage
mov
esuponswal
l
owi
ngsoi
tmov
esal
ongwi
tht
het
hyr
oidgl
and
 AMI
N’STI
P@ GENERALSURGERY

o Doest
heswel
l
ingmov
eswi
tht
onguepr
otr
usi
on?(
youshoul
dknow t
he
r
easonf
ort
his)

o Thy
rogl
ossalductcy
stsswel
l
ingsmov
ewi
tht
onguepr
otr
usi
onbecause
t
hef
ibr
oust
hyr
ogl
ossalduct
sisat
tachedt
othebaseoft
het
ongueatt
he
f
oramencaecum,
hencei
twi
l
lmov
ewhent
het
onguei
spr
otr
udedf
orwar
d.

o Per
for
m andRepor
tPember
ton’
stest
s

 Pal
pat
ion

o Si
zei
ncent
imet
er

o Sur
face(
smoot
horbossel
ated)

o Tender
ness

o War
mth

o Consi
stency

o Conf
ir
m mov
ementwi
thdegl
uti
ti
onbyhol
dingt
hegl
and

o Per
for
m speci
fi
cTest
s

 Kocher
’sTest

 Ber
ry’
s si
gns (
you shoul
d know t
he anat
omi
call
ocat
ion wher
e
Ber
ry’
ssi
gncaneasi
l
ybef
elt
)

 Ber
ry’
ssi
gncaneasi
l
ybef
eltatt
hepoi
ntofi
nter
sect
ionbet
ween
t
woi
magi
nar
yli
neswhendr
awn.Thef
ir
stl
i
nei
sani
magi
nar
yli
ne
dr
awnconnect
ingt
hest
ernalheadandt
hemast
oidheadoft
he
St
ernal
clei
domast
oideus(
SCM)muscl
e

 Chi
ntest

 St
ernomast
oidt
est

 Pal
pat
eforcer
vical
lymphnodes
 AMI
N’STI
P@ GENERALSURGERY

 Pal
pat
efort
heposi
ti
onoft
raches

Per
cussi
on–I
nanor
malper
son,
overt
hest
ernum gi
vesar
esonantnot
e,i
nret
rost
ernal
goi
ter
,itgi
vesadul
lnot
e

Auscul
tat
ion

I
tshoul
dbedonei
ntheupperpol
esoft
hegl
and

Quest
ion;
Whyi
sauscul
tat
iondoneatt
heupperpol
esandnotl
owerpol
es?

Answer
;Upperpol
esi
sbecausesuper
iort
hyr
oidar
ter
iesent
ert
hegl
andatsuper
ior
pol
eant
eri
orl
yandsuper
fi
cial
l
y,hencemakei
teasi
ert
oauscul
tat
eforbr
uit
s.Notl
ower
pol
esbecausei
nfer
iort
hyr
oidar
ter
iesent
ert
hegl
andati
nfer
iorpol
epost
eri
orl
yand
deep,
hencemakei
tdi
ff
icul
ttoauscul
tat
eforbr
uit
s

Pr
esenceoft
hil
landbr
uit
sar
efeat
uresoft
oxi
cgr
oti
e

I
nvest
igat
ion

FNAC

Thy
roi
dfunct
iont
est(
T3,
T4andTSH)

Thy
roi
dul
tr
asound

I
fToxi
cGoi
teri
sint
hedi
agnosi
s,doThy
roi
dScan

Thy
roi
dst
imul
ati
ngi
mmunogl
obul
i
n(TSI
)(I
fgr
aves’
diseasei
siny
ourdi
ff
erent
ial
s).

I
ncaseofmal
i
gnancyi
npr
ovi
sional
diagnosi
s,Tumormaker
s

o Thy
rogl
obul
i
n–f
orf
oll
i
cul
art
hyr
oidcar
cinoma

o Cal
ci
toni
nandCEAf
ormedul
l
arycar
cinoma

Tr
eat
ment

A.TOXI
CGoi
ter
 AMI
N’STI
P@ GENERALSURGERY

Opt
ionsoft
reat
mentofat
oxi
cgoi
ter
,canei
therbe

-
Medi
cal
or

-
Radi
oact
iveI
odi
ne(
RAI
)Abl
ati
onor

-
Sur
gical
treat
ment

-
Acombi
nat
ionofmedi
cal
+(ei
therRAIorSur
gical
)

Medi
cal
treat
ment

Quest
ion;
Whatar
eai
msofmedi
cal
treat
ment
?

Answer
;Ai
mscanei
therbet
hesol
etr
eat
mentopt
ion(
for18t
o24mont
hs)ORi
nor
der
t
oat
tai
neut
hyr
oidst
atef
orsur
gicalt
reat
mentORi
nor
dert
oat
tai
nthehy
pot
hyr
oid
st
atef
orr
adi
oact
ivei
odi
net
her
apy

Quest
ion;
Namet
hedr
ugsused(
Ant
i-
thy
roi
ds)

Answer
;Car
bimazol
e,pr
opy
lthi
our
aci
landpr
opr
anol
ol

NB;Car
bimazol
eisapr
o-dr
ug,af
terabsor
pti
oni
tisconv
ert
edt
otheact
ivef
orm,
Met
himazol
e

Quest
ion;
Wher
edoeachacti
nthest
epsoft
hyr
oidhor
monesy
nthesi
s?

Answer
;

Car
bimazol
eandpr
opy
lthi
our
aci
lact
s

Bydecr
easi
ngt
heupt
akeandconcent
rat
ionofi
nor
gani
ciodi
nebyt
hyr
oidgl
andand
al
sobypr
event
ingt
hyr
oidper
oxi
daseenzy
mef
rom i
odi
nat
ingandcoupl
i
ngt
het
yrosi
ne
r
esi
duesont
hyr
ogl
obul
i
n,hencer
educepr
oduct
ionoft
het
hyr
oidhor
monesT3andT4.
Pr
opy
lthi
our
aci
lhasanaddedadv
ant
ageofi
nhi
bit
ionofper
ipher
alconv
ersi
onofT4t
o
T3
 AMI
N’STI
P@ GENERALSURGERY

Pr
opr
anol
olAsanant
i-
thy
roi
dinhi
bit
sper
ipher
alconv
ersi
onofT4t
oT3

Quest
ion;
Whatar
etheadv
ant
agesofeachov
erot
her
?

Answer
;

Car
bimazol
e

I
tsadv
ant
agesar
eeasi
l
yaf
for
dabl
e(l
essexpensi
ve)

I
tsdi
sadv
ant
ageshav
esi
desef
fect
soft
erat
ogeni
cit
yandagr
anul
ocy
tosi
s

Pr
opy
lthi
our
aci
l

I
tsadv
ant
ageshav
enosi
deef
fect
sasofcar
bimazol
e,canbeusedi
npr
egnancy

I
tsdi
sadv
ant
agesar
etooexpensi
ve

Pr
opr
anol
ol

I
tsadv
ant
ageal
somanagest
hepal
pit
ati
onbecausei
tisaBet
abl
ocker

I
tsdi
sadv
ant
agei
tcannotbeuseal
oneasant
i-
thy
roi
ddr
ugs,i
tshoul
dgoal
ongwi
th
car
bimazol
eorpr
opy
lthi
our
aci
l

Af
terhowl
ongdoesbi
ochemi
cal
responseandcl
i
nical
responseexpect
edt
ooccur
?

Bi
ochemi
calr
esponsei
sexpect
edt
ooccuraf
ter4t
o6weeksandcl
i
nicalr
esponse
expect
edt
ooccur2t
o3weeks

NB;bi
ochemi
calr
esponsemeansi
mpr
ovementoft
het
hyr
oidhor
monespr
ofi
l
e(T3,T4
andTSH)whi
l
eCl
i
nical
responsemeansi
mpr
ovementofsy
mpt
omsandsi
gns
 AMI
N’STI
P@ GENERALSURGERY

Quest
ion;
Whyi
sther
edi
ff
erencei
nti
meofr
esponseofbi
ochemi
cal
andcl
i
nical
?

Answer
;Thi
sisbecauset
heonsetofant
it
hyr
oidef
fecti
srapi
dbutt
heonsetofcl
i
nical
ef
fect
sont
hyr
oidhor
monesl
eveli
nthebl
oodi
smuchsl
ower
.Thi
sisbecauset
hel
arge
st
oreoft
hepr
efor
medT3andT4i
nthet
hyr
oidgl
andandboundt
othy
roi
dbi
ndi
ng
gl
obul
i
n(99%)hast
obedepl
etedbef
oreanybenef
ici
alcl
i
nical
eff
ectoccur
s.

Radi
oact
iveI
odi
ne(
RAI
)Abl
ati
on

Quest
ion;
Whatar
ethei
ndi
cat
ionsofRAIt
her
apy
?

Answer
;RAIt
her
apyi
sindi
cat
edi
ntr
eat
mentoft
oxi
cgoi
terandmal
i
gnantgoi
ter

Quest
ion;
Whatar
etheabsol
utecont
rai
ndi
cat
ionsf
orRAI
?

Answer
;Pr
egnancyandbr
east
feedi
ngpat
ient
s

Whatar
ether
elat
ivecont
rai
ndi
cat
ionsf
orRAI
?

Answer
;

y
oungagel
esst
han45y
ear
s,

peopl
ewhosmoke(
incaseofgr
avesdi
seasebecausewi
l
lexagger
atest
heGr
ave’
s
ocul
opat
hy)
,

I
nmal
i
gnancyi
tisnotr
ecommended

-
fort
umor
slesst
han1cm whi
chi
sconf
ir
medt
othet
hyr
oid,

-
incaseofundi
ff
erent
iat
edt
hyr
oidcar
cinoma

-
andr
ecur
rentdi
ff
erent
iat
edt
hyr
oidt
umor
sthathav
elostabi
l
ityt
oconcent
rat
eiodi
ne
(
appr
ox.30% of adv
anced and r
ecur
rentdi
ff
erent
iat
ed t
hyr
oid car
cinomas wi
l
l
ev
ent
ual
l
yde-
dif
fer
ent
iat
e and a por
ti
on oft
hese cancer
s wi
l
llose t
he abi
l
ityt
o
concent
rat
eiodi
neduet
olossoft
heNa+/
Isy
mpor
terf
unct
ion

Quest
ion;
Whatar
ethepr
e–r
equi
sit
esf
oref
fect
iveRAI–t
reat
ment
?
 AMI
N’STI
P@ GENERALSURGERY

Answer
;

ForRAIt
obeef
fect
ivet
hepat
ientneedst
obei
nthehy
pot
hyr
oidst
atet
her
apy
,thi
scan
beachi
evedbymedi
cal
ther
apy
.Inhy
pot
hyr
oidst
atet
her
ewi
l
lbei
ncr
easei
npr
oduct
ion
ofTSH,andTSHwi
l
lincr
easei
odi
deupt
akehencer
adi
oact
ivei
odi
net
reat
mentwi
l
lbe
ef
fect
ive

Quest
ion;
Whati
srecommendeddosagef
orRAI
?

Answer
;

Recommended dose r
ange f
orRAIi
s 30mCit
o 150mCi(
mil
l
icur
ies)f
oradj
uvant
t
reat
ment

Quest
ion;
Whati
snextaf
terRAI
?

Sur
gical
treat
ment

I
ndi
cat
ionsofsur
ger
yinToxi
cgoi
ter

Quest
ion;
Whatar
ethet
ypesoft
hyr
oidect
omyi
ndi
cat
edi
nthef
oll
owi
ngt
oxi
cgoi
ter
s?

Answer
;

-
Grav
es’ Di
sease (
tot
al t
hyr
oidect
omy
, near t
otal t
hyr
oidect
omy and Dunhi
l
l
t
hyr
oidect
omy
)

-
Toxi
cMNG(
Mul
ti
nodul
arGoi
ter
)-(
tot
alt
hyr
oidect
omy
,neart
otal
thy
roi
dect
omy
)

-
Toxi
cnodul
eGoi
ter(
hemi
thy
roi
dect
omy
,thy
roi
dlobect
omy
)

Whatar
ethePr
e-r
equi
sit
esf
oref
fect
ivet
hyr
oidect
omyi
nToxi
cGoi
ter
?

Pr
e-r
equi
sit
esf
oref
fect
ivet
hyr
oidect
omyi
nTox
icGoi
terar
etomai
ntai
ntheeut
hyr
oid
st
ate,
andt
hishast
obeaccompl
i
shedbymedi
calt
reat
mentwi
thant
it
hyr
oid,
inor
dert
o
 AMI
N’STI
P@ GENERALSURGERY

pr
eventt
hyr
oidst
ormi
ntr
aoper
ati
vel
y

Whati
snextaf
terThy
roi
dect
omy(
Eacht
ypeoft
hyr
oidect
omy
)

Thy
roi
dlobect
omy
,ther
emai
ningt
hyr
oidt
issuei
senought
opr
oducet
hyr
oidhor
mones
neededi
nthebody
,sononeedofsuppl
ement
ati
onofor
alt
hyr
oxi
ne.

Hemit
hyr
oidect
omy
,the r
emai
ning t
hyr
oidt
issue i
s enough t
o pr
oduce t
hyr
oid
hor
monesneededi
nthebody
,sononeedofsuppl
ement
ati
onofor
alt
hyr
oxi
ne.

Subt
otalt
hyr
oidect
omy
,ther
emai
ning t
hyr
oidt
issuei
senought
o pr
oducet
hyr
oid
hor
monesneededi
nthebody
,sononeedofsuppl
ement
ati
onofor
alt
hyr
oxi
ne.

Neart
otalt
hyr
oidect
omy
,ther
emai
ningt
hyr
oidt
issuei
senought
opr
oducet
hyr
oid
hor
monesneededi
nthebody
,sononeedofsuppl
ement
ati
onofor
alt
hyr
oxi
ne.

Tot
alt
hyr
oidect
omy
,wi
l
lneedsuppl
ement
ati
onofor
alt
hyr
oxi
nebecauset
hewhol
e
gl
andi
sremov
ed

B.MALI
GNANTGOI
TER

Quest
ion;
Whati
sthet
reat
mentpl
anf
orwel
ldi
ff
erent
iat
edt
hyr
oidcar
cinoma?

Answer
;forwel
ldi
ff
erent
iat
edt
hyr
oidcar
cinomat
otalt
hyr
oidect
omyst
art
sfol
l
owedby
r
adi
oact
ivei
odi
net
her
apy

Quest
ion;
Whati
sthet
reat
mentpl
anf
ormedul
l
aryt
hyr
oidcar
cinoma?

Answer
;formedul
l
aryt
hyr
oidcar
cinomat
otalt
hyr
oidect
omy
,nor
oom f
orr
adi
oact
ive
i
odi
net
her
apy

Quest
ion;
Whati
sthet
reat
mentpl
anf
orpr
imar
ythy
roi
dly
mphoma?

Answer
;forpr
imar
ythy
roi
dly
mphomachemot
her
apy
,theR-
CHOP r
egi
meni
sused,
sur
ger
yonl
ywheni
mmedi
ater
eli
efi
sneededf
rom pr
essur
esy
mpt
oms

Quest
ion;
Whati
sthet
reat
mentpl
anf
oranapl
ast
ict
hyr
oidcar
cinoma?

Answer
;foranapl
ast
ict
hyr
oid car
cinoma neo-
adj
uvantchemot
her
apyf
oll
owed by
 AMI
N’STI
P@ GENERALSURGERY

t
hyr
oidect
omy
,isusual
l
yadv
ancedt
henpal
l
iat
ivechemor
adi
other
apy

Quest
ion;Whatar
ethe adv
ant
ages oft
otalt
hyr
oidect
omy ov
erl
obect
omy (
or
hemi
thy
roi
dect
omy
)forwel
ldi
ff
erent
iat
edt
hyr
oidcar
cinoma?

Answer
;

1.Remov
alofmul
ti
focal
int
ra-
thy
roi
dtumor

2.I
nlobect
omyorhemi
thy
roi
dect
omyt
her
ear
enor
malt
hyr
oidt
issuer
emai
ned
t
hese wi
l
lef
fect
ivel
y compet
efor r
adi
oact
ivei
odi
de upt
ake wi
th mi
cro
met
ast
asi
s

3.Useofser
um t
hyr
ogl
obul
i
n,asasensi
ti
vemar
kerofper
sist
entorr
ecur
rent
di
sease

Quest
ion;
Wheni
stheappr
opr
iat
eti
mingf
orRAIpostt
otal
thy
roi
dect
omyandwhy
??

Answer
;foract
iver
adi
oact
ivei
odi
deupt
akepat
ientneedst
obei
nhy
pot
hyr
oidst
ate,
becausei
nhy
pot
hyr
oidst
atet
her
ewi
l
lbei
ncr
easepr
oduct
ionofTSH,andTSH wi
l
l
i
ncr
easei
odi
deupt
akehencer
adi
oact
ivei
odi
ne.

Al
thought
her
eisnopr
eci
set
hreshol
dhasbeenest
abl
i
shed,agener
alconsensusi
s
hel
dthat
;atTSHatt
hatt
imeofRAIshoul
dbegr
eat
erorequal
30mI
U/ml

Af
tert
otalt
hyr
oidect
omy
,thy
roxi
nei
snotgi
venf
oraper
iodof4weekssot
hatt
hyr
oid
r
emnant
scanbeabl
atedwi
thr
adi
oiodi
ne-
ti
ll
TSHar
elev
elsar
eabov
e30MI
UIL

Quest
ion; Papi
l
lar
ythy
roi
d car
cinoma and medul
l
aryt
hyr
oid car
cinoma bot
h
met
ast
asi
zet
ocer
vicall
ymphnodes,whi
chonet
het
wor
equi
resext
ensi
vecer
vical
l
ymphnodedi
ssect
ion?Andwhy
?

Answer
;

Nor
mal
l
y;af
tert
otalt
hyr
oidect
omyf
orpapi
l
lar
ythy
roi
dcar
cinoma,f
oll
owsr
adi
oact
ive
i
odi
neabl
ati
onf
oral
ldi
stantmet
ast
asi
sbecausepapi
l
lar
ythy
roi
dcar
cinomaor
igi
nat
es
f
rom t
hef
oll
i
cul
arcel
l
sther
eisupt
akeofr
adi
oact
ivei
odi
ne,butf
orMedul
l
aryt
hyr
oid
 AMI
N’STI
P@ GENERALSURGERY

car
cinomabecausear
efr
om par
afol
l
icul
arcel
l
sandnotf
rom t
het
hyr
oidf
oll
i
clest
her
e
i
snoupt
akeofr
adi
oact
ivei
odi
nef
ordi
stantmet
ast
asi
s,t
her
efor
efort
hisr
eason
Medul
l
aryt
hyr
oidcar
cinomar
equi
resext
ensi
vel
ymphnodedi
ssect
ionbecauset
her
eis
hasnoadj
uvantt
her
apyt
ogetr
idofmet
ast
asi
stot
hecer
vical
lymphnodes

Quest
ion; What i
s t
he t
reat
ment pl
an f
or a pat
ient wi
th MEN 2 Di
sease
(
pheochr
omocy
tomawi
thmedul
l
aryt
hyr
oidcar
cinoma)andGi
ver
eason?

Answer
;

Pheochr
omocy
tomast
art
stobet
reat
edf
ir
stbyadr
enal
ect
omyt
henmedul
l
aryt
hyr
oid
car
cinomabyt
otalt
hyr
oidect
omy
.Thi
sisbecausei
fthy
roi
dect
omyst
art
sfi
rst
,then
pheochr
omocy
tomaef
fect
scani
nter
fer
ewi
thanest
hesi
aandl
eadst
oint
raoper
ati
ve
compl
i
cat
ion,t
hese ef
fect
s ar
eless l
i
kel
yto occur when adr
enal
ect
omy f
or
pheochr
omocy
tomast
art
sfi
rsti
naeut
hyr
oidmedul
l
arycar
cinoma

Quest
ion;Whatcondi
ti
ons may t
otalt
hyr
oidect
omy be r
ecommended i
nst
ead of
hemi
thy
roi
dect
omyi
nfol
l
icul
arl
esi
onswhi
char
enotconf
ir
medt
obecar
cinoma?

Answer
;

Usual
l
y f
oll
i
cul
ar t
hyr
oid car
cinoma i
s conf
ir
med by t
issue bi
opsy af
ter
hemi
thy
roi
dect
omy
,thent
otalt
hyr
oidect
omywi
l
lfol
l
ow f
ordef
ini
ti
vet
reat
ment
,but
t
her
ear
eci
rcumst
ancesorcondi
ti
onswhi
cht
otalt
hyr
oidect
omymayber
ecommended
di
rect
lyi
nst
eadofhemi
thy
roi
dect
omyi
nfol
l
icul
arl
esi
onswhi
char
enotconf
ir
medt
obe
car
cinomabyhi
stol
ogy(
ti
ssue)whi
char
e,i
nwhi
chonl
yFNAChasbeendone

-
olderpat
ient
swi
thf
oll
i
cul
arl
esi
on>4cm becauseoft
hei
rhi
gherr
iskofcancer(
appr
ox.
50%)

-
pat
ient
swi
that
ypi
aonFNAC
 AMI
N’STI
P@ GENERALSURGERY

-
fami
l
yhi
stor
yoft
hyr
oidcancer

-
hist
oryofr
adi
ati
onexposur
e

C.SI
MPLEGOI
TRE

Quest
ion;

Howar
esi
mpl
egoi
ter
str
eat
ed(
ref
ert
hecausesofsi
mpl
egoi
ter
s)

Answer
;

I
fthecausei
spr
imar
yiodi
nedef
ici
ency
,theni
odi
nesuppl
ement
ati
oni
ncommont
hing
whi
chmaj
ori
tyoft
hepeopl
eoft
hatar
eaar
eusi
ngexampl
einsal
ts,
wat
er

I
fsecondar
yiodi
ne def
ici
ency
,due t
o goi
tr
ogens t
hen st
op consumpt
ion oft
he
goi
tr
ogeni
cfoodsanddr
ugs

I
fcausei
sphy
siol
ogi
calchanges,t
hencounsel
l
ingt
owai
ttheper
iodofphy
siol
ogi
cal
changest
opass,
e.g.pr
egnancy
,lact
ati
onandpuber
ty

I
fit
sfami
l
ialdef
ici
ency
/absenceoft
hyr
oidper
oxi
daseenzy
mesf
orsy
nthesi
soft
hyr
oid
hor
mones,
thensuppl
ement
ati
onofor
alt
hyr
oxi
nehor
mone

Quest
ion;
Wheni
ssur
ger
y(t
hyr
oidect
omy
)indi
cat
edi
nsi
mpl
egoi
ter
s?

Answer
;

Si
mpl
egoi
terdoesn’
tneedsur
ger
y(t
hyr
oidect
omy
)unl
esswhent
her
ear
epr
essur
e
sy
mpt
oms,mal
i
gnancycannotber
uledoutexampl
einf
oll
i
cul
arneopl
asm/
hyper
plasi
a
andpat
ient
’sdesi
re(
Cosmesi
s)

ADDI
TIONALREADI
NGS

Ment
ioncompl
i
cat
ionsoft
hyr
oidect
omy(
Immedi
ate,
Eal
yandLat
e)

Par
athy
roi
dtet
any
 AMI
N’STI
P@ GENERALSURGERY

-
Whatar
eear
lycompl
aint
soft
hepat
ient
?

-
Whatar
elat
ecompl
aint
soft
hepat
ient
?

-
Whatar
ethet
wobedsi
deexami
nat
iont
est
stoconf
ir
m?

Howi
sitt
reat
ed?

Whati
stheTuber
cleofZuker
kandl
andwhati
sit
ssi
gni
fi
cance?

Thy
roi
dst
orm

-
Def
ini
ti
on

-
Preci
pit
ati
ngf
act
ors

-
Treat
ment

Lar
yngeal
ner
vesi
njur
iesi
nthy
roi
dect
omy

Quest
ion;Whatmakes bot
h cor
ds t
o be par
aly
zed i
n(i
)abduct
ed posi
ti
on (
ii
)
Par
amedi
anposi
ti
onandwhatwi
l
lbet
hepr
esent
ati
onofapat
ienti
neach?

Answer
;

Bot
hcor
dst
obepar
aly
zedi
n

(
i) abduct
edpositi
on-thi
siswhent her
eisbilateralrecur
rentl
aryngealner
ve
i
njur
y.hereairmovementcanoccurbutt hepat ienthasanineffect
ivecough
andisi
ncreasedri
skofrepeatedrespi
rat
or yinfecti
onsfrom aspir
ati
on.And
thepat
ientwil
lhaveacri
ti
call
yli
mi t
edabili
tyt ophonate
(
ii
) Par
amedi
anposi
ti
on-t
hisi
swhent
her
eisbi
l
ater
alr
ecur
rentl
ary
ngealner
ve
i
njur
y,Pat
ient wi
l
lpr
esent wi
th ai
rway obst
ruct
ion (
str
idor i
s usual
l
y
 AMI
N’STI
P@ GENERALSURGERY

appar
ent
ly v
ery soon af
ter ex
tubat
ing) necessi
tat
ing emer
gency
t
racheost
omy
.

Quest
ion;Whatmakesonecor
dtobepar
aly
zedi
nanabduct
edposi
ti
onandwhatwi
l
l
bet
hepr
esent
ati
onoft
hepat
ient
?

Answer
;

Onecor
dtobepar
aly
zedi
nanabduct
edposi
ti
oni
sduet
oinj
uryt
ooner
ecur
rent
l
ary
ngealner
ve,t
hepat
ientwi
l
lpr
esentwi
thhor
sev
oicewi
thi
nef
fect
ivecough(
a
bov
inequal
i
tycoughwher
ether
eisl
ackofshar
p,per
cussi
vei
nit
iat
ion.

Quest
ion;Whatmakesonecor
dtobepar
aly
zedi
nanadduct
edposi
ti
ont
othemi
dli
ne
orbey
ondandwhatwi
l
lbet
hepr
esent
ati
onoft
hepat
ient
?

Answer
;

Onecor
dtobepar
aly
zedi
nanadduct
edposi
ti
ont
othemi
dli
net
hisi
sduei
njur
ytoone
r
ecur
rentl
ary
ngealner
ve,t
hepat
ientwi
l
lpr
esentwi
thnor
malbutweakv
oice(
not
hoar
se)

Whatwi
l
lbet
hepr
esent
ati
oni
napat
ientwi
thsuper
iorLar
yngealner
vei
njur
iesdur
ing
t
hyr
oidect
omy
?

Super
iorLar
yngealner
vei
njur
iesl
eadst
oinabi
l
ityt
otenset
hei
psi
l
ater
alv
ocalcor
dand
hencedi
ff
icul
ty‘
hi
tt
inghi
ghnot
es’
,di
ff
icul
typr
oject
ingt
hev
oice,
weakandhuskyv
oice
andv
oicef
ati
guedur
ingpr
olongedspeech

Quest
ion;How t
oav
oidl
ary
ngealner
vesI
njur
y(r
ecur
rentl
ary
ngealner
veandsuper
ior
l
ary
ngeal
ner
ve)dur
ingt
hyr
oidect
omy
?

Answer
;
 AMI
N’STI
P@ GENERALSURGERY

I
tisbet
tert
oident
if
yRecur
rentLar
yngealNer
vei
nal
lcasesoft
hyr
oidect
omyespeci
all
y
t
otalt
hyr
oidect
omyandl
obect
omy
.Super
iorLar
yngealner
vei
sawayf
rom t
hev
essel
s
neart
heupperpol
e.Hence,
dur
ingt
hyr
oidect
omy
,theupperpedi
cleshoul
dbel
i
gat
edas
cl
oset
othet
hyr
oidaspossi
ble.

-
Cli
nical
Sub-
typesofRet
rost
ernal
Goi
ter

Subst
ernal
Goi
termostcommon)

I
ntr
athor
aci
cGoi
ter

Pl
ungi
ngGoi
ter

-I
mpor
tantcausesofexopht
hal
mos

1.Thy
rot
oxi
cosi
s

2.Pr
imar
yCNSt
umor
s:Meni
ngi
oma,
opt
icner
vegl
i
oma,

hemangi
oma,
lymphoma,
etc.

3.Met
ast
ati
ctumor
s:Neur
obl
ast
oma,
cent
ral
car
cinoma.

4.Vascul
ar:
Cav
ernoussi
nust
hrombosi
s-aneur
ysm of

opht
hal
micar
ter
y

Causesofpul
sat
ingexopht
hal
mos

1.Cav
ernoussi
nust
hrombosi
s

2.Car
oti
d-cav
ernoussi
nus,
A-Vf
ist
ula

3.Or
bit
alv
ascul
art
umor

4.Opht
hal
micar
ter
yaneur
ysm Ment
ionot
hercausesofexopht
hal
mosapar
tfr
om
Gr
ave’
sdi
sease
 AMI
N’STI
P@ GENERALSURGERY

TOPI
CTHREE
CHEST(
THORACI
C)
Commoncompl
aint
sincl
udeHemopt
ysi
s(coughi
ngbl
ood)andDi
ff
icul
tyi
nbr
eat
hing

HI
STORYTAKI
NGI
NPATI
ENTWI
THHEMOPTYSI
S

Chi
efcompl
aint
s:Coughi
ngbl
ood–(
foracer
tai
nper
iodoft
ime)
 AMI
N’STI
P@ GENERALSURGERY

Hi
stor
yofpr
essi
ngi
l
lness(
HPI
)

PART:
ADONPARA

Onset–mostar
eofgr
adual
onset

Nat
ure–Col
our
?Amount
?Sput
um wi
thbl
oodst
ain

Per
iodi
cit
y–Usual
l
yhav
enospeci
fi
cper
iodi
cit
y

Aggr
avat
ingandRel
i
evi
ngf
act
ors-
usual
l
yther
eisnospeci
fi
caggr
avat
ingorr
eli
evi
ng
f
act
ors

Associ
ati
ngsy
mpt
oms-aski
fther
eispr
esenceofanyoft
hef
oll
owi
ngassoci
ated
sy
mpt
oms

-
dif
fi
cul
tyi
nbr
eat
hing

-
chestpai
n

-
chestt
ight
ness

NB;I
fdi
ff
icul
tyi
nbr
eat
hingi
spr
esenti
tshoul
dbet
akenupasasepar
atechi
ef
compl
aintandbeampl
i
fiedsepar
atel
yint
heHPI

PARTB:
RULEOUTPOSSI
BLEDI
FERENTI
ALS

Thef
oll
owi
ngdi
ff
erent
ial
sdi
agnosi
shav
etober
uledouti
ntheHPIt
ofi
ndt
hepossi
ble
causeofhemopt
ysi
s
 AMI
N’STI
P@ GENERALSURGERY

NB;

Youshoul
dknow al
lthecausesofhemopt
ysi
sfort
hesakeofknowl
edgeanddur
ing
di
scussi
onoft
het
opi
c,t
houghonl
yfewcanbeaskedandr
uledouti
ntheHPI

Thosewhi
chcanber
uledouti
ntheHPI

PULMONARYCAUSES

-
Tuber
cul
osi
s

I
she/
sheknownt
ohav
eTB?I
fyesi
t’
senough
 AMI
N’STI
P@ GENERALSURGERY

I
fNo,
thenaskf
or

Askf
ort
heBsy
mpt
oms(
wei
ghtl
oss,
nightf
ever
s,ni
ghtsweat
s)

Askf
ort
her
iskf
act
ors(
opencont
actwi
thpat
ientwi
thTB/
chr
oni
ccough)

-
Lungabscess&Pneumoni
a

Aski
fther
eishi
stor
yoff
ever

-
Pul
monar
ypar
enchy
mal
disease(
Sar
coi
dosi
s/Lungf
ibr
osi
s)

Askf
orhi
stor
yofoccupat
ionoft
hepat
ient(
rul
eoutr
iskyoccupat
ions)

Askf
orhi
stor
yofl
i
vingneari
ndust
ri
es

-
Asper
gil
l
oma(
postTBsequal
ae)

Askf
orhi
stor
yofpr
evi
ousTBcont
act

-
Par
asi
ti
cLungi
nfect
ion

Askf
ordewor
minghabi
t,whendi
dhe/
shel
astdewor
m?

-
Pul
monar
yneopl
asm

Pr
imar
yLungTumour

Askf
orr
iskf
act
ors(
cigar
ett
esmoki
ngexpr
essi
npacky
ear
s,occupat
ionoft
hepat
ient
,
hi
stor
yofTBi
npr
evi
ousy
ear
s,hi
stor
yofl
i
vingneari
ndust
ri
es)

Askf
orl
ocal
compl
i
cat
ionsf
rom l
ungt
umor
s

Pancoast
’ssy
ndr
ome,askpr
esenceofupperchestwal
lorshoul
derpai
n,i
fyeswhi
ch
si
del
eftorr
ight
?

Phr
eni
cner
vepal
sy,
askpr
esenceofhi
ccupsandshoul
derpai
n,i
fyeswhi
chsi
del
eftor
r
ight
?

Recur
rentl
ary
ngealner
vepal
syaskf
orpr
esenceofv
oicechange,of
tenr
efer
redt
oas
hoar
seness,
coughi
ng,
par
ti
cul
arl
ywhendr
inki
ngl
i
qui
ds

Super
iorv
enacav
asy
ndr
omeaskf
ort
hepr
esenceofswel
l
ingoft
hehead,neck,and
 AMI
N’STI
P@ GENERALSURGERY

ar
ms;
headache;
andswel
l
ingoft
heey
es

Backpai
n

Di
ff
icul
tinswal
l
owi
ng

Secondar
yLungTumour

Askf
orhi
stor
yof

Headaches,
blur
redv
isi
on,
conv
ulsi
on(
pri
mar
yfr
om br
ain)

Br
eastswel
l
ing(
pri
mar
yfr
om br
east
)

Di
ff
icul
tyi
nswal
l
owi
ngandr
egur
git
ati
on(
pri
mar
yfr
om oesophagus)

Abdomi
nal
pai
n,ear
lysat
iet
yorabdomi
nal
ful
l
ness(
pri
mar
yfr
om st
omach)

Yel
l
owi
shdi
scol
orat
ion(
pri
mar
yfr
om t
hel
i
ver
,ext
rahepat
icbi
l
iar
yandpancr
eas)

Bl
oodi
nst
ool
,al
ter
edbowelhabi
ts,mucoi
dst
oolandsensat
ionofi
ncompl
etebowel
empt
ying(
pri
mar
yfr
om col
orect
al)

Bl
oodi
nur
ine(
pri
mar
yfr
om ki
dney
,bl
adder
)

Scr
otal
swel
l
ing(
pri
mar
yfr
om t
het
est
es)

Lowerl
i
mbswel
l
ingsandul
cer
s(pr
imar
yfr
om t
hel
owerl
i
mbs)

-
Pul
monar
yembol
i
sm

Askhi
stor
yofmaj
orsur
ger
yorpr
olongedbedr
estpr
iort
otheonsetoft
hei
l
lness

-
Trauma

askf
orhi
stor
yoft
raumapr
iort
heonsetofi
l
lness

EXTRAPULMONARYCAUSES

-
Congest
iveHear
tFai
l
ure

Aski
fthepat
ientexpr
essesshor
tnessofbr
eat
honl
yi
ngf
lat
,awaki
ngdur
ingt
heni
ght
 AMI
N’STI
P@ GENERALSURGERY

duet
oai
rhungerandl
owerl
i
mbswel
l
ing

-
Coagul
opat
hy

Askf
orhi
stor
yofbl
eedi
ngf
rom anyot
herpar
toft
hebodyorv
omi
ti
ngbl
ood

-
Medi
cat
ions

Askf
orhi
stor
yofanychr
oni
cmedi
cat
ions/
inj
ect
ionsi
sthepat
ienton(
war
far
in,
hepar
in)

I
ATROGENI
CCAUSES

-
Int
rapul
monar
ycat
het
er

Askf
orhi
stor
yofi
nst
rument
ati
oni
nthel
ungsorhear
tpr
iort
otheonsetofi
l
lness

PARTC:

-
Askwhathappenedi
nthecour
seoft
hei
l
lnessbef
orebei
ngr
efer
redher
eandwhathas
beendoneher
eint
hewar
d.

(
Usepat
ient
sownwor
dsnotmedi
calt
erms.Donotgi
ver
epor
tsoft
hei
nvest
igat
ions
done,
justment
iont
hem)

HI
STORYTAKI
NGI
NPATI
ENTWI
THDI
FFI
CULTYI
NBREATHI
NG

Chi
efcompl
aint
s:Di
ff
icul
tyi
nbr
eat
hing–(
foracer
tai
nper
iodoft
ime)

Hi
stor
yofpr
essi
ngi
l
lness(
HPI
)
 AMI
N’STI
P@ GENERALSURGERY

PART:
ADONPARA

Onset–mostar
eofgr
adual
onset

Nat
ure–pr
ogr
essi
vewor
seni
ngwi
tht
ime?i
nter
mit
tent
?

Per
iodi
cit
y– Dependswi
tht
hecause(
askwhatper
iodoft
hedaydoesdi
ff
icul
tyi
n
br
eat
hingwor
sen)

Aggr
avat
ing-I
sitaggr
avat
edbyexer
ti
on,
lyi
ngf
lat
,

Rel
i
evi
ngf
act
ors–doesl
yi
ngwi
thpi
l
lows,exposur
einf
reshai
rrel
i
evet
hedi
ff
icul
tyi
n
br
eat
hing

Associ
ati
ngsy
mpt
oms-aski
fther
eispr
esenceofanyoft
hef
oll
owi
ngassoci
ated
sy
mpt
oms

-
coughi
ng

-
coughi
ngbl
ood

-
chestpai
n

-
chestt
ight
ness

-
soundsonr
espi
rat
ion

NB;
Ifei
thercoughorcoughi
ngbl
oodi
spr
esenti
tshoul
dbet
akenupassepar
atechi
ef
compl
aintandbeampl
i
fiedsepar
atel
yinHPI

PARTB:
RULEOUTPOSSI
BLEDI
FERENTI
ALS

Thef
oll
owi
ngdi
ff
erent
ial
sdi
agnosi
shav
etober
uledouti
ntheHPIt
ofi
ndt
hepossi
ble
 AMI
N’STI
P@ GENERALSURGERY

causeofdi
ff
icul
tyi
nbr
eat
hing

PULMONARYCAUSES

-
pul
monar
ypar
enchy
mal
disease

-
Bronchi
ti
s

-
Bronchi
ect
asi
s

-
Tuber
cul
osi
s

-
Lungabscess

-
Pneumoni
a

-
Pul
monar
yneopl
asm

-
Pul
monar
yinf
arct
ionorembol
i
sm

Howt
orul
eoutpul
monar
ycause:
ref
erabov
einhemopt
ysi
s

MEDI
ASTI
NALCAUSES
 AMI
N’STI
P@ GENERALSURGERY

NB;

Youshoul
dknow al
lthemedi
ast
inalcausesofdi
ff
icul
tyi
nbr
eat
hingf
ort
hesakeof
knowl
edgeanddur
ingdi
scussi
onoft
het
opi
c,t
houghonl
yfewcanbeaskedandr
uled
outi
ntheHPI
…..
REFERTOTHENOTESOFTHEMEDI
ASTI
NUM BELOW

CARDI
OVASCULARCAUSES

-
Congest
iveCar
diacFai
l
ure

Howt
orul
eoutcongest
ivecar
diacf
ail
ure:
Ref
erabov
einhemopt
ysi
s

PARTC:

-
Askwhathappenedi
nthecour
seoft
hei
l
lnessbef
orebei
ngr
efer
redher
eandwhathas
beendoneher
eint
hewar
d.

(
Usepat
ient
sownwor
dsnotmedi
calt
erms.Donotgi
ver
epor
tsoft
hei
nvest
igat
ions
done,
justment
iont
hem)
 AMI
N’STI
P@ GENERALSURGERY

EXAMI
NATI
ONAPATI
ENTWI
THHEMOPTYSI
SANDDI
FFI
CULTYI
NBREATHI
NG

Gener
alexami
nat
ionasusual
.

Don’
tfor
gett
o exami
neor
ganswhi
chwer
easked i
ntheHPIt
orul
eoutpr
imar
y
mal
i
gnancy(
breast
,test
esandl
owerl
i
mbs)

RESPI
RATORYEXAMI
NATI
ONSHOULDBEWELLEXHAUSTED

THEMEDI
ASTI
NUM

Descr
ibet
heboundar
iesoft
hemedi
ast
inum
 AMI
N’STI
P@ GENERALSURGERY

Descr
ibeal
ltheMedi
ast
inal
Lymphnodest
ati
ons

Expl
aint
hecompar
tment
soft
hemedi
ast
inum

a.Fourcompar
tment
smodel

b.Thr
eecompar
tment
smodel

-
Classi
cThr
eecompar
tment
smodel

-
TheShi
eld’
sThr
eecompar
tment
smodel
AMI
N’STI
P@ GENERALSURGERY
 AMI
N’STI
P@ GENERALSURGERY

LOCATI
ONSOFMEDI
ASTI
NALTUMOURS
 AMI
N’STI
P@ GENERALSURGERY

CLI
NICALFEATURES

Upt
o2/
3asy
mpt
omat
ic,
inci
dent
alf
indi
ng.

Whensy
mpt
omat
ic,
theset
umor
sar
esi
gni
fi
cant
lymor
eli
kel
ytobemal
i
gnant
.

Char
act
eri
sti
cssuchas

si
ze,

l
ocat
ion,

r
ateofgr
owt
h,

andassoci
atedi
nfl
ammat
ionar
eimpor
tantf
act
orst
hatcor
rel
atewi
thsy
mpt
oms.

Large,bulkytumors,expanding cy
sts,and terat
omas can cause compr
essi
on of
mediasti
nalst
ruct
ures,
inpart
icul
arthetrachea,
andleadt
ocough, dy
spneaonexert
ion,
orstri
dor
.

Chestpai
nordyspneamayber
eportedsecondaryt
oassoci
ated
pl
euralef
fusi
ons,
cardi
act
amponade,orphreni
cnervei
nvol
vement
.

Occasi
onal
ly,amediast
inalmassneartheaort
opul
monarywindowmaybeident
if
iedi
n
aworkupforhoar
senessbecauseoflef
trecur
rentl
ary
ngeal
nervei
nvol
vement
 AMI
N’STI
P@ GENERALSURGERY

Thehistor
yandphysicalexami
nat
ioni
nconj
unct
ionwi
tht
hei
magi
ngf
indi
ngsmay
suggestaspeci
fi
cdi
agnosi
s

I
NVESTI
GATI
ONS

I
maging
ChestCTorMRI

-
assessAnat
omypr
oper
ly

Ifther
eisconcer
nfori
nvasi
onofv
ascul
arst
ruct
uresorspi
nali
nvol
vement
,MRIi
s
superi
ort
oCTscan

-
assessr
espect
abi
l
ity
.

I
fat hyr
oidori
ginissuspect
ed,athyr
oidscanusing131Ior123Icani
dent
if
ymost
i
ntr
athor
acicgoi
ter
sandident
ifyt
heext
entoffunct
ioni
ngt
hyr
oidt
issue

PETi susefulfordi
sti
ngui
shi
ngmal i
gnantf
rom beni
gnt
umor
sandmayhel
pdet
ect
di
stantmetastasesi
nsomepatient
s
 AMI
N’STI
P@ GENERALSURGERY

• Ser
um mar
ker
s.

Nonsemi
nomat
ousv
ssemi
nomat
ousger
m cel
ltumor
s

Diagnosedandoft
endi
sti
ngui
shedfr
om oneanot
herbyt
hel
evel
sofα-
fet
opr
otei
n(AFP)
andhumanchor i
oni
cgonadot
ropi
n(hCG)
.

I
nover90%ofnonseminomatousger
m cel
ltumors,eit
hert
heAFPorthehCGl
evelwi
ll
beel
evated.Resul
tsar
ecloseto100% speci
fi
ci fthelev
elofei
therAFPorhCG i
s
gr
eat
erthan500ng/mL.

Some center
sinst
it
ute chemot
her
apybased on t
hisr
esul
tal
one,wi
thoutbi
opsy
conf
ir
mationoft
hediagnosi
s.

I
ncont
rast,t
heAFPlev
elinpat
ient
swithmediast
inalsemi
nomai
sal
way
snor
mal
;onl
y
10%wi
llhaveel
evat
edhCG,whi
chisusual
l
ylessthan100ng/mL.

Ot
herser
um mar
ker
s,

Suchasi nt
actpar athyr
oidhor
monel evelforect
opicpar
athy
roi
dadenomas,maybe
usefulf
ordiagnosingandalsofori
ntr
aoperati
vel
yconfi
rmi
ngcompl et
eresect
ion.Af
ter
successf
ulr esect
ion ofaparathyr
oid adenoma,thi
shormonel evelshoul
dr api
dly
normali
ze.

Di
agnost
icNonsur
gical
Biopsi
esoft
heMedi
ast
inum

CT-
guidedneedlebiopsy,andEUS-gui
dedFNA,andevencor
e-needl
ebiopsy(ei
therCT-
gui
dedEBUS-guided,orEUS-gui
ded)havepr
oven
most useful f
or cy t
ologic and ti
ssue di
agnosi
s of mediasti
nal masses and
l
ymphadenopathy.

Sur
gical
Biopsi
esandResect
ionofMedi
ast
inal
Masses

Fort
umor
soft
hemedi
ast
inum t
hatar
e

notamenabl
etoanendoscopi
corCT-
gui
dedneedl
ebi
opsy

ort
hatdonoty
iel
dsuf
fi
cientt
issuef
ordi
agnosi
s,asur
gical
biopsyi
sindi
cat
ed

Thedef
ini
ti
veappr
oacht
oasur
gicalbi
opsyoft
heant
eri
ormedi
ast
inum i
sthr
ougha
medi
anster
not
omy

Massesi
nthepar
atr
acheal
regi
onar
eeasi
l
ybi
opsi
edbymedi
ast
inoscopy
.
 AMI
N’STI
P@ GENERALSURGERY

Fortumor
soft
heanteri
ororposteri
ormedi
ast
inum,
alef
torr
ightVATSappr
oachof
ten
al
lowssaf
eandadequat
esurgicalbi
opsi
es

READONCOMMONMEDI
ASTI
NALTUMOURS

(
def
ini
ti
on,
causes,
present
ati
on,
inv
est
igat
ionsandt
reat
ment
)

• Thy
moma

• Neur
ogeni
ctumour
s

• Medi
ast
inal
ger
m cel
ltumour
s

• Medi
ast
inal
lymphoma

• Medi
ast
inal
cyst
s
 AMI
N’STI
P@ GENERALSURGERY

LUNGTUMOURS

Cl
assi
fi
cat
ionsofLungt
umor
s

 Pr
imar
ytumor
s20%)

-
Epi
thel
i
alt
umor
s(90%)

-
Sof
tti
ssueanduncl
assi
fi
edt
umor
s(10%)

 Secondar
ytumor
s(80%)

I
. PRI
MARYTUMOURS

• (
A)epi
thel
i
alt
umor
s

 beni
gn

-
Papi
l
loma

-
Adenoma

 car
cinomai
nsi
tu/
dyspl
asi
a

 Mal
i
gnantt
umor
sandt
hei
rsubt
ypes

• (
B)sof
tti
ssuet
umor
s

 l
ymphomaandsar
coma

• (
C)mesot
hel
i
alt
umor
s

 Mal
i
gnantandbeni
gn

• (
D)mi
scel
l
aneoust
umor
s

I
I. SECONDARYTUMOURS

Met
ast
asi
sfr
om di
stantor
ganst
othel
ungs
 AMI
N’STI
P@ GENERALSURGERY

PRI
MARYMALI
GNANTTUMOURSOFTHELUNGS

• non–smal
lcel
ll
ungcar
cinoma

• andneur
oendocr
inet
umor
s

Non–Smal
lCel
lLungCar
cinoma.

i
ncl
udi
ngl
argecel
l
,squamouscel
l
,andadenocar
cinoma

Adenocar
cinomaThei nci
denceincreasedoverthelastsev
eraldecades,andi
tisnow
themostcommonl ungcancer,accounti
ngf or30% ofl
ungcancersinmal esmoker
s
and40%ofl ungcancer
sinfemalesmoker s.

Adenocar
cinoma i
st he hi
stol
ogic subtype f
or80% and 60% ofl
ung cancer
sin
nonsmoki
ngf emal
esandmales,respecti
vely
.

F>M

I
tist
hemostf
requenthi
stol
ogi
csubt
ypei
n

women,

pat
ient
swhoar
eunder45y
ear
sofage,

andAsi
anpopul
ati
ons.

SquamousCel
lCar
cinomaRepresent
ing30% t
o40% ofl
ungcancer
s,squamouscell
car
cinomaist
hemostf r
equentcancerinmenandhighl
ycorr
elat
edwithcigar
ett
e
smoking.

Theyari
sepr
imari
lyinthemain,l
obar
,orf
ir
stsegment
albr
onchi
,whi
char
ecol
l
ect
ivel
y
ref
err
edtoasthecentr
alai
rways.

Occasi
onal
l
yamor eperi
pher
all
ybasedsquamouscellcar
cinomawi
l
ldev
elopi
na
t
ubercul
osi
sscarori
nthewall
ofabronchi
ect
ati
ccav
ity

Centralnecr
osi
sisfr
equentandmayleadt ot
heradi
ogr
aphi
cf i
ndingsofacav i
ty
(possibl
ywithanai
r-
fl
uidlev
el)
.Suchcav
iti
esmaybecomeinf
ected,wit
hresul
tant
 AMI
N’STI
P@ GENERALSURGERY

abscessf
ormat
ion

Lar
geCel
lCarci
nomaLar gecel
lcarci
nomaaccount
sfor10% t
o20% ofl
ungcancer
s
andmaybel
ocatedcent
rall
yorper
ipher
all
y.

Thesetumorshavecelldi
amet
ersof30t
o50µm,
whi
char
eof
tenadmi
xedwi
thv
ari
ous
othermal
ignantcel
lty
pes.

Neuroendocri
neNeoplasms.Neur oendocr
inel
ungt
umors
areclassi
fi
edintoneuroendocr
inehyperpl
asi
aandt
hreegr
ades
ofneuroendocri
necarcinoma(NEC) .

Immunohist
ochemicalst
aini
ngf orneuroendocri
nemarkers(i
ncl
udi
ngchromograni
ns,
synapt
ophysi
n,CD57,andneuron-speci
fi
cenolase)i
sessent
ial
toaccur
atedi
agnosi
s.

Gr
adeINEC(
classi
cort
ypi
cal
car
cinoi
d)

i
salow-gradeNEC;80% ar
isei
nthecent
ralai
rwayepi
thel
i
um andoccurpr
imar
il
yin
y
oungerpati
ent
s.

Hi
stol
ogical
ly,
tumorcell
sarear
rangedi
ncordsandcl
uster
swit
hari
chvascul
arst
roma,
whi
chcanl eadtoli
fe-
threat
eni
nghemorrhagewit
hevensimpl
ebr
onchoscopi
cbiopsy
maneuvers.

Regi
onall
ymphnodemetast
asesar
eseeni
n15%ofpat
ient
s,butsy
stemi
cspr
eadand
deat
hfrom Gr
adeINECi
srare

Gr
adeI
INECs(
aty
pical
car
cinoi
d)

haveamuchhi
ghermal
ignantpotent
ialand,unl
i
kegr adeINEC,ar
eet
iol
ogi
cal
l
yli
nked
toci
gar
ett
esmoki
ngandmor el
ikelyt
obeper i
pheral
l
yl ocat
ed.

Hi
stol
ogicfindi
ngsmayi
ncl
udear
eas ofnecr
osi
s,nucl
earpl
eomor
phi
sm,andhi
gher
mi
toti
crates.

Lymphnodemet ast
asesaref
oundin30% t
o50% ofpat
ient
s.Atdi
agnosi
s,25% of
pat
ient
sal
readyhaveremot
emetast
ases

Gr
adeI
IINECl
argecel
l
–ty
pet
umor
s

occurpr
imar
il
yinheav
ysmoker
sandi
nthemi
dtoper
ipher
all
ungf
iel
ds.

Of
tenl
argewi
thcent
ral
necr
osi
sandahi
ghmi
tot
icr
ate,
 AMI
N’STI
P@ GENERALSURGERY

Thei
rneuroendocr
inenaturei
sreveal
edbyposi
ti
vei
mmunohi
stochemi
calst
aini
ngf
or
atl
eastoneneuroendocr
inemarker

Gr
adeI
VNEC(
smal
lcel
ll
ungcar
cinoma[
SCLC]
)

i
sthemostmal
i
gnantNECandaccount
sfor25%ofal
ll
ungcancer
s;

TheseNECsof
tenhav
eear
ly,
widespr
eadmet
ast
ases.

Thesecancer
sal
soar
isepr
imar
il
yint
hecent
ral
air
way
s.

Thr
eegr
oupsofgr
adeI
VNECar
erecogni
zed:

 pur
esmal
lcel
lcar
cinoma(
prev
iousl
yref
err
edt
oasoatcel
lcar
cinoma)
,

 smal
lcel
lcar
cinomawi
thal
argecel
lcomponent
,

 andcombi
ned(
mixed)t
umor
s.

GradeIVNECsconsi
stofsmal
l
ercel
l
s(di
amet
er10t
o20µm)wi
thl
i
ttl
ecy
topl
asm and
verydar
knucl
ei

Theset
umor
sar
ethel
eadi
ngpr
oducerofpar
aneopl
ast
icsy
ndr
omes.

Ri
skFact
orsf
orLungCancer

Cigar
ett
esmoki
ng,causalf
act
ori
nappr
oxi
mat
ely90% ofl
ungcancer
sinmenand
nearl
y80%i
nwomen.

Othercausesoflungcancerincl
udeexposur
etoanumberofi ndust
ri
alcompounds,
i
ncludi
ngradon,
asbest
os,arseni
c,andchr
omium compounds.

Infact
,thecombi
nat
ionofasbest
osandci
gar
ett
esmokeexposur
ehasamul
ti
pli
cat
ive
eff
ectonrisk.

Preexisti
nglungdiseaseconf
ersanincr
easedr i
skofl ungcancer— upto13%—f or
i
ndividuals who hav
e neversmoked.Pati
ents wi
th chroni
c obst
ructi
ve pul
monary
di
seasear eathi
gherriskf
orl
ungcancerthanwouldbepr edi
ctedbasedonsmoking
ri
skal one.

Pati
entswit
hsecondar
yscarfor
mationrel
atedtoahistor
yoft
uber
cul
osi
sorot
herl
ung
i
nfecti
onsal
sohaveahigherr
iskofpri
marylungcar
cinoma.

Thi
sincr
easeisthoughttoberel
atedt
opoorcl
ear
anceofi
nhal
edcar
cinogensand/
or
tot
heeff
ectsofchroni
cinfl
ammati
on.
 AMI
N’STI
P@ GENERALSURGERY

Pr
imar
yLungCancer
-Associ
atedSi
gnsandSy
mpt
oms

Uptoone-f
our
thofal
lpeopl
ewi
thl
ungcancermayhav
enosy
mpt
omsatt
imeof
di
agnosi
s

Themaj
ori
tyofpeopl
e,howev
er,
dev
elopsy
mpt
oms

Sy
mpt
omsandsi
gnsi
srel
atedt
o

(
a)hi
stol
ogi
cfeat
ures,
whi
chof
tenhel
pdet
ermi
net
heanat
omi
csi
teofor
igi
nint
hel
ung;

(
b)t
hespeci
fi
ctumorl
ocat
ioni
nthel
ungandi
tsr
elat
ionshi
ptosur
roundi
ngst
ruct
ures;

(
c)bi
ologi
cfeat
uresandt
hepr
oduct
ionofav
ari
etyofpar
aneopl
ast
icsy
ndr
omes;
and

(
d)t
hepr
esenceorabsenceofmet
ast
ati
cdi
sease.

Symptoms rel
ated t
ot he l
ocalint
rat
hor
aci
c ef
fectoft
he pr
imar
ytumorcan be
conv
enient
lydi
videdi
ntotwogroups:

 pul
monar
yandnon-
pul
monar
ythor
aci
c

Pul
monar
ySy
mpt
oms.

Pulmonar
ysy
mpt
omsr
esul
tfr
om t
hedi
rectef
fectoft
het
umoront
hebr
onchusorl
ung
ti
ssue

Cough(
secondar
ytoi
rr
it
ati
onorcompr
essi
onofabr
onchus)
,

dy
spnea(usual
l
yduet
ocent
ralai
rwayobst
ruct
ionorcompr
essi
on,wi
thorwi
thout
at
elect
asi
s),

hemoptysi
s(ty
pical
ly,bl
oodst
reaki
ngofmucust
hati
srar
elymassi
ve;i
ndi
cat
esa
cent
ral
airwayl
ocati
on),

pneumoni
a(usual
lyduetoair
wayobst r
ucti
onbyt het
umor
),andl
ungabscess(
duet
o
necr
osi
sandcavi
tati
on,
withsubsequenti
nfect
ion)

Peripheral
l
ylocatedt umors(oft
enadenocar ci
nomas)extendi
ngthr
ought hevisceral
pleuraleadtoirr
itat
ionorgrowthi ntothepari
etalpl
eur
aandpotenti
all
ytocont i
nued
growthi nt
ot hechestwal lstr
uctures.Thr
eet ypesofsymptoms,dependingont he
extentofchestwalli
nv ol
vement,ar
epossibl
e:

(
a)pleur
it
icpain,f
rom noninv
asi
vecontactoft
hepar
iet
alpl
eur
awi
thi
nfl
ammat
ory
i
rr
it
ati
onordi
rectpari
etal
pleur
ali
nvasi
on;
 AMI
N’STI
P@ GENERALSURGERY

(
b)local
i
zedchestwal
lpai
n,f
rom deeperi
nvasi
onandi
nvol
vementoft
her
iband/
or
i
nter
cost
almuscl
es;
and

(
c)radicul
arpai
n,f
rom i
nvol
vementofthei
nter
costalner
ve(s)
.Radicularpainmaybe
mistakenforr
enal
col
ici
nthecaseoft
umorsinvadi
ngtheinf
eropost
eriorchestwal
l
.

Ot
herspeci
fi
cnonpul
monar
ythor
aci
csy
mpt
omsi
ncl
ude:

Pancoast
’ssy
ndr
ome.

Tumorsori
ginati
nginthesuper
iorsul
cus(post
eri
orapex)el
i
cit
:api
calchestwal
land/
orshoul
derpain(f
rom i
nvol
vementofthef
ir
stri
bandchestwall
);

Horner’
ssyndrome(uni
l
ater
alenophthal
mos,pt osis,miosis,andfaci
alanhi
drosi
sfrom
i
nvasionofthestel
l
atesympat
heti
cgangl i
on);andr adi
culararm pain(f
rom i
nvasi
onof
T1,andoccasi
onall
yC8,br
achi
alplexusnerveroots).

Mostar
enonsmal
lcel
lcancer
s

Phr
enicnerv
epalsy
.Thephr
enicnerv
etraver
sesthehemithor
axalongthemedi
ast
inum,
par
all
elandpost
eri
ort
othesuperi
orvenacavaandanter
iortothepul
monaryhi
l
um.

Tumor
satt
hemedi
all
ungsur
faceorant
eri
orhi
l
um candi
rect
lyi
nvadet
hener
ve;

symptomsincludeshoul
derpai
n(r
efer
red)
,hi
ccups,
anddy
spneawi
thexer
ti
onbecause
ofdi
aphragm paral
ysi
s.

Radi
ographical
ly,unil
ater
aldiaphragm elevat
iononchestr
adi
ographi
spresent;t
he
di
agnosisisconf i
rmedbyf l
uoroscopicexaminati
onoft
hedi
aphr
agm wi
thparadoxi
cal
moti
onwi t
hbr eathi
ngandsniffi
ng( t
he“snif
f”test
).

Recurr
entlaryngealnervepalsy.Recur
rentl
aryngealnerv
e(RLN)inv
olv
ementmost
commonl yoccursont helef
tside,gi
venthehi
larlocat
ionoft
helef
tRLNasitpasses
undertheaort
icarch.

Par
alysi
sr esul
tsfrom:(a)inv
asi
onoft
hev
agusner
veabov
etheaor
ti
car
chbya
medial
lybasedlef
tupperlobet
umor;

or(b)di
rectinvasi
onoft
heRLNbyhi
l
art
umorand/
orhi
l
aroraor
topul
monar
yly
mph
nodemetastases.

Symptomsincl
udevoicechange,of
tenr
eferr
edt oashoarseness,butmor
etypi
call
ya
l
ossoftoneassoci
atedwithabreat
hyquali
ty,andcoughi
ng,parti
cul
arl
ywhendr
inki
ng
l
iqui
ds.

Super
iorv
enacav
a(SVC)sy
ndr
ome.Asar
esul
tofbul
kyenl
argementofi
nvol
ved
 AMI
N’STI
P@ GENERALSURGERY

mediasti
nall
ymphnodescompr
essi
ngoramedi
all
ybasedr
ightupperl
obet
umor
i
nvadingtheSVC,

SVCsyndromesymptomsincl
udevari
abl
edegr
eesofswel
l
ingoft
hehead,neck,and
ar
ms;headache;
andconj
uncti
val
edema.

I
tisseenmostcommonl
ywi
thNECgr
adeI
V(smal
lcel
l
)lungcancer
.

Peri
cardialtamponade.Per i
car
dialef
fusi
ons( beni
gnormal ignant
),associ
atedwi
th
i
ncreasinglev elsofdyspneaand/orar
rhyt
hmias,andper
icar
dialtamponadeoccurwi
th
di
rectpericardiali
nvasi
on.

Di
agnosi
srequi
resahighindexofsuspi
cioni
ntheset
ti
ngofamedi al
lybasedt
umor
wi
thsymptomsofdyspneaandisconf
ir
medbyCTscanorechocar
diogr
aphy

Backpai
n.Result
sfr
om di
recti
nvasi
onofavert
ebralbodyandisoft
enlocal
izedand
sever
e.I
ftheneur
alf
orami
naarei
nvol
ved,
radi
cul
arpainmayalsobepr
esent.

Otherlocalsympt oms.Dy sphagi

ai s usuall
y secondaryt o externalesophageal
compressi
onbyenl argedlymphnodesi nv
olvedwithmet astat
icdisease,usual
l
ywi th
l
owerlobetumors.Finall
y,dyspnea,
pleur
aleff
usion,orr
eferredshoulderpai
ncanr esul
t
fr
om i
nvasionofthediaphragm byat umoratthebaseofal owerlobe.

Associ
atedPar
aneopl
ast
icSy
ndr
omes

Al
llung cancerhi
stol
ogi
es ar
e capabl
e ofproduci
ng a var
iet
yofpar aneopl
ast
ic
sy
ndromes,mostof t
en f
rom syst
emicreleaseoftumor-
deri
ved bi
ologi
cal
lyacti
ve
mater
ial
s

Par
aneoplast
icsyndr
omesmaypr oducesymptomsevenbefor
eanylocalsy
mpt
oms
ar
eproducedbytheprimar
ytumor
,ther
ebyai
dingi
near
lydi
agnosis.

Theirpresencedoesnotinfl
uenceresect
abi
li
tyortr
eatmentopti
ons.Sy
mptomsoften
abatewithsuccessf
ult
reatment;par
aneopl
ast
icsymptom r
ecurr
encemayheral
dtumor
recurr
ence.

The major
it
y ofsuch sy
ndromes are associ
ated wi
th gr
ade I
V NEC (
smal
lcel
l
car
cinoma)
,incl
udi
ngmanyendocr
inopat
hies

Hy
per
trophi
cpul
monar
yost
eoar
thr
opat
hy(
HPO)
.

Hy
per
cal
cemi
a.

Hy
ponat
remi
a.
 AMI
N’STI
P@ GENERALSURGERY

Cushi
ng’
ssy
ndr
ome.

Per
ipher
alandcent
ral
neur
opat
hies.

Lamber
t-
Eat
onsy
ndr
ome

Sy
mpt
omsAssoci
atedwi
thMet
ast
ati
cLungCancer
.

Lungcancermet astasi
zesmostcommonl ytot
heCNS,v
ert
ebr
albodi
es,bone,l
i
ver
,
adrenal
glands,
lungs,ski
n,andsof
tti
ssues.

CNSmet ast
asesarepresentatdiagnosi
sin10%ofpat
ient
s;anot
her10%t
o15%wi
l
l
dev
elopCNSmet ast
asesfoll
owingdiagnosi
s.

Lungcanceri
sthemostcommoncauseofspinalcordcompressi
on,ei
therbypr
imary
tumori
nvasi
onofani
nter
ver
tebr
alf
oramenordir
ectextensi
onofver
tebr
almetast
ases.

Bonymetast
asesar
eidenti
fi
edin25%oflungcancerpat
ient
s.Theyarepri
mar
il
yly
tic
andproducepai
nlocal
ly;t
hus,anynew andlocal
izedskel
etalsymptomsmustbe
eval
uat
edradi
ogr
aphi
cal
ly

Li
vermetast
ases and adr
enalmetast
ases aretypi
call
yasymptomati
c and usual
l
y
di
scov
eredbyrout
ineCTscan.Adr
enalmetast
asismayleadt
oadrenal
hypofunct
ion

Nonspecifi
c Cancer
-Rel
ated Symptoms.Lung canceroft
en produces a v
ari
ety of
nonspecif
icsymptomssuchasanor exi
a,weightl
oss,f
ati
gue,andmalaiseandtheir
presencerai
seconcernf
ormet ast
ati
cdisease

I
nvest
igat
ions

• CXR

• CTscanorMRI

• Sput
um t
est
ingf
orcy
tol
ogy

• Thor
acocent
esi
s

• Br
onchoscopy

• Needl
ebi
opsy

• Thor
acot
omy
 AMI
N’STI
P@ GENERALSURGERY

?
??TREATMENTOFLUNGCANCER

READON

A.Mesot
hel
i
oma

Def
ini
ti
on

Ty
pes

Ri
skf
act
ors

Cl
i
nical
feat
ures

Management(
inv
est
igat
ionsandt
reat
ment
)

B.Empy
emaThor
aci
s

Def
ini
ti
on

Pat
hogenesi
s

Cl
i
nical
feat
ures

Management(
inv
est
igat
ionand

t
reat
ment
)

C.Pl
eur
alEf
fusi
on
 AMI
N’STI
P@ GENERALSURGERY

Def
ini
ti
on

Causes

Management(
inv
est
igat
ionand

t
reat
ment
)

D.Underwat
erseal
drai
nage

I
ndi
cat
ions

Cont
rai
ndi
cat
ions

Mechani
cs

Thi
ngst
omoni
tor
 AMI
N’STI
P@ GENERALSURGERY

Ref
erenceshav
ebeenmadef
rom t
hef
oll
owi
ngr
ecommendedt
extbooks
Schwar
tz’
sPr
inci
plesofSur y11thEdi
ger ti
on
Gr
eenf
iel
d’sSur
ger
ySci
ent
if
icpr
inci
plesandpr
act
ice6thEdi
ti
on
SRB’
sManual
ofSur y5thEdi
ger ti
on
Mani
pal
Manual
ofSur y4thEdi
ger ti
on
 AMI
N’STI
PS@GENERALSURGERY

TOPI
CFOUR

DYSPHAGI
A
I
mpor
tantt
ermi
nol
ogi
est
oknow

Dy
sphagi
a–di
ff
icul
tyi
nswal
l
owi
ng

Ody
nophagi
a–pai
nful
swal
l
owi
ng

Gl
obus–f
eel
i
ng(
sensat
ion)ofal
umporf
oodst
acki
ngi
ntheneck/chest

MUSTREADTOPI
CS

Anat
omyoft
heEsophagus

Gr
ossst
ruct
ure–l
engt
handdi
amet
er

Lay
ers.(
Cont
ent
sineachl
ayer
)

Li
ningepi
thel
i
um

Anat
omi
cal
andphy
siol
ogi
cal
Const
ri
cti
ons

Par
tsoft
heesophagus

Bl
oodsuppl
y

Venousdr
ainage

Ly
mphat
icdr
ainage

Ner
voussuppl
y

Phy
siol
ogy

Mechani
sm ofswal
l
owi
ng

Vol
unt
ary(
Orophar
yngeal
)phase

I
nvol
unt
ary(
Esophageal
)phase

Re-
feedi
ngsy
ndr
ome

1
 AMI
N’STI
PS@GENERALSURGERY

CausesofDy
sphagi
a

1.Or
ophar
yngeal
phase

i
. I
nfl
ammat
oryCondi
ti
ons

(
these condi
ti
ons l
ead t
o dy
sphagi
a whi
ch associ
ates wi
th pai
n=
Ody
nophagi
a)

a.Tonsi
l
iti
s

b.Phar
yngi
ti
s

c.Per
it
onsi
l
larabscess

i
i
. Neur
ologi
cal
/Neur
omuscul
arCauses

(
thechar
act
eri
sti
cfeat
ureofdy
sphagi
aduet
oneur
ologi
cal
/neur
omuscul
ar
causesi
sinabi
l
ityt
oini
ti
ateswal
l
owi
ng)

Af
fer
ent
s ofswal
l
owi
ng ar
ethe Gl
ossophar
yngealner
ve and Super
ior
Lar
yngeal
branchofVagusner
ve

The swal
l
owi
ng cent
eratt
he medul
l
a coor
dinat
es t
he compl
ete actof
swal
l
owi
ngbydi
schar
gingi
mpul
sest
hroughcr
ani
alner
vesTr
igemi
nal
,Faci
al,
VagusandHy
pogl
ossal
ner
vesandMot
orneur
onsofC1t
hroughC3

Ther
efor
e,Cr
ani
alner
vesi
nvol
vedi
nswal
l
owi
ngar
e(5,7,9,10,and12)any
damage/
lesi
ont
othesener
veswi
l
lleadt
oneur
ologi
cal
dysphagi
a,exampl
e

 St
roke

 HeadTr
auma(
most
lyt
raumat
othet
empor
alr
egi
on,i
thousesi
mpor
tant

2
 AMI
N’STI
PS@GENERALSURGERY

st
ruct
uresi
ncl
udi
ngmostoft
heabov
ener
vesi
nvol
vi
ngi
nswal
l
owi
ng)

 Di
abet
esmel
l
itus

 Neur
omuscul
arcondi
ti
onsl
i
keMy
ast
heni
agr
avi
s

i
i
i. Neopl
ast
iccondi
ti
on(
Tumor
s)

Mostcommon–Hy
pophar
yngealTumor(
usual
l
ypr
esent
swi
thchangesi
n
v
oice,r
oughorhoar
se,gl
obus,chr
oni
csor
ethr
oat
,earpai
n-(
earpai
nis
r
efer
redpai
ntot
heearv
iat
heAr
nol
dner
ve,
adi
vi
si he10thcr
onoft ani
alner
ve

2.Esophageal
phase

Causesofdy
sphagi
aint
heesophageal
phasecanei
therbe

i
. Mechani
cal
causes

I
nthi
spar
t,t
her
eissomet
hingphy
sical
l
y(mechani
cal
l
y)obst
ruct
ingt
he
l
umenoft
heesophagus

i
i
. Mot
il
it
ydi
sor
der
s

I
nthi
spar
tthel
umenofesophagusi
spat
ent
,notobst
ruct
edmechani
cal
l
y,
butt
her
e ar
e di
sor
der
s ofper
ist
alsi
s oft
he esophagealbody
,and
abnor
mal
rel
axat
ionandcont
ract
ionsoft
heesophageal
sphi
nct
ers

3
 AMI
N’STI
PS@GENERALSURGERY

MECHANI
CALCAUSES

Thesemechani
cal
causesar
edi
vi
dedi
nto:

a.I
ntr
insi
ccauses

Thecausesar
ewi
thwi
thi
ntheesophagus,ei
therf
rom t
hel
umenoft
heesophagus
(
int
ral
umi
nal
)orf
rom t
hewal
loft
heesophagus(
int
ramur
alcauses)

b.Ext
ri
nsi
ccauses

Thecausesar
efr
om out
sideesophagus,ext
ernalcompr
essi
on t
otheesophagus
l
eadi
ngt
onar
rowi
ngoft
hel
umen.

MOTI
LITYDI
SORDERS

 Achal
asi
a

(
it
s mot
il
it
y di
sor
deri
s char
act
eri
zed by f
ail
ure ofr
elaxat
ion oft
he l
ower
esophagealsphi
nct
er,aper
ist
alsi
soft
heesophagealbodyand hy
per
tensi
ve
l
oweresophagealsphi
nct
er)
.Pat
ientpr
esent
spr
edomi
nant
lywi
th dy
sphagi
a
(
canei
therbepr
ogr
essi
veordy
sphagi
atol
i
qui
ds)al
sowi
l
lpr
esentwi
thchest
pai
n.

 Di
ff
useEsophageal
Spasm (
DES)

(
it
smot
il
it
ydi
sor
deri
schar
act
eri
zedbypr
esenceofsi
mul
taneousst
rongand
peakcont
ract
ions;i
.e.pr
oxi
maland di
stalpar
tsoft
he esophagusst
rongl
y
cont
ractt
oget
heruncoor
dinat
ed)i
nher
esphi
nct
err
elaxat
ionsandcont
ract
ions
ar
enor
mal

4
 AMI
N’STI
PS@GENERALSURGERY

Pat
ientpr
esent
swi
thi
nter
mit
tentdy
sphagi
aandchestpai
n.

 Nut
crackeresophagus(
Esophageal
angi
na/
supersqueezeesophagus)

(
it
smot
il
it
ydi
sor
deri
schar
act
eri
zedbyt
hepr
esenceofpr
olongat
ionoft
het
ime
ofst
rongandpeakcont
ract
ions)

Nor
mal
l
ythewhol
ecour
seoft
her
iseandf
allofcont
ract
ionmayoccupyone
poi
nti
s3t
o5seconds,
thatmeanscont
ract
ionwav
eis,
from st
artt
opeakt
akes
about1.
5seconds,peakcont
ract
ionsl
ast
sforabout0.
5to1secondsandf
rom
peakt
oendofcont
ract
iont
akesal
soabout0.
5seconds

Fort
heNut
crackert
her
eisal
ongdur
ati
onofcont
ract
ionwav
esmor
ethan6
seconds.

I
nher
esphi
nct
err
elaxat
ionsandcont
ract
ionsar
enor
malandt
hesequenceof
per
ist
alsi
sisnor
mal

Pat
ientpr
esent
spr
edomi
nant
lywi
thchestpai
nandl
essl
i
kel
ytohav
edy
sphagi
a

I
NTRI
NSI
CCAUSES

-
Inf
ect
ious,
esophageal
candi
diasi
s,mai
nlyi
nHI
Vposi
ti
vepat
ient
s

-
For
eignbody(
mostcommoni
nki
ds)

-
Beni
gnst
ri
ctur
eswhi
char
ecausedby

 Cor
rosi
vei
ngest
ion(
alkal
iandaci
ds)

5
 AMI
N’STI
PS@GENERALSURGERY

 I
nst
rument
ati
ont
hrought
hemout
h,anOGDcanbet
hecauseofst
ri
ctur
e

 Radi
ati
onexposur
e

 GERD(
Gast
roEsophageal
Ref
luxDi
sease)t
hisi
sthemostcommoncause
ofst
ri
ctur
eappr
oxi
mat
ely75%ar
ethePept
icst
ri
ctur
e

-
Div
ert
icul
um (
Zenker
’sDi
ver
ti
cul
um att
heKi
l
ian’
str
iangl
eaweakpoi
ntatt
hepost
eri
or
aspectoft
hephar
yngeal
esophageal
junct
ion,
iswher
eanoutpouchoccur
s)

-
Esophageal
webs(
commonestwebcondi
ti
oni
sthePl
ummerVi
nsonSy
ndr
ome,
PVS)

Pl
ummerVi
nsonSy
ndr
ome,
PVSconsi
stsof
;

 Dy
sphagi
a(sy
mpt
omst
hepat
ientpr
esent
swi
th)

 Esophageal
webs(
foundonendoscopi
cev
aluat
ion)

 Feat
uresofi
rondef
ici
encyanemi
a(angul
archei
l
iti
s,gl
ossi
ti
s,l
eukony
chi
a,
l
eukopl
aki
a)

-
Esophageal
rings

-
Mal
i
gnantst
ri
ctur
es(
mostcommoni
scar
cinomaoft
heesophagusandt
umoratt
he
car
dia)

EXTRI
NSI
CCAUSES

(
Ext
ernalcompr
essi
ont
otheesophagusl
eadi
ngt
onar
rowi
ngandev
ent
ual
l
ybl
ockage
oft
heesophageal
lumen)

Cer
vical
esophaguscanbecompr
essedbyThy
roi
dswel
l
ings(
Goi
ter
)

Thor
aci
cesophaguscanbecompr
essedby

-
Medi
ast
inalt
umor
s(medi
ast
inall
ymphomamai
nlyi
nthepost
eri
ormedi
ast
inum and
Thy
moma,
50%ofpat
ient
swi
thThy
momapr
esent
sfeat
uresofMy
ast
heni
aGr
avi
s)

-
Compr
essi
onf
rom Car
diov
ascul
arcauses

6
 AMI
N’STI
PS@GENERALSURGERY

 Aor
ti
caneur
ysm i
nthedescendi
ngt
hor
aci
caor
ta

 Lef
tat
ri
alenl
argementand

 Dy
sphagi
aLusor
ia

Nor
mal
l
yar
chofaor
tabr
anchesi
ntot
hreebr
anches,
namel
y

-
thebr
achi
ocephal
i
ctr
unk(
whi
chl
aterdi
vi
desi
ntor
ightsubcl
avi
anar
ter
yand
r
ightcommoncar
oti
dar
ter
y)

-
lef
tcommoncar
oti
dar
ter
y

-
andl
eftsubcl
avi
anar
ter
y,

I
nDy
sphagi
alusor
iat
her
ightsubcl
avi
anar
ter
yor
igi
nat
esf
rom t
hear
chofaor
ta
di
stal(
mor
elef
t)t
othe l
eftsubcl
avi
an ar
ter
yand passespost
eri
ort
othe
esophagus t
o suppl
ythe r
ightsi
de…t
his can l
ead t
o compr
essi
on oft
he
esophagus.

Abdomi
nal
esophagus

Canbecompr
essedbyt
hehi
atusher
niaTy
peI
I,
II
I,
andt
ypeI
V

CARCI
NOMAESOPHAGUS

I
ncar
cinomaesophaguspat
ient
sst
art
stopr
esentwi
thdy
sphagi
awhenappr
oxi
mat
ely
60%(
2/3)ofi
tsl
umeni
soccl
udedbyt
het
umor

Et
iol
ogy
,ri
skf
act
orsf
orcar
cinomaesophagus

(
1)Di
etar
y

o Hotdr
inks(
ri
skydi
et)

o Spi
cyf
oods(
ri
skydi
et)

o Smokedf
oods(
ri
skydi
et)

7
 AMI
N’STI
PS@GENERALSURGERY

o Def
ici
encyi
nvi
tami
nA,
CandE(
prot
ect
ivedi
et)

(
2)Ci
gar
ett
esmoki
ng

(
3)Al
cohol
i
sm

(
4)Resi
dencewi
thi
ntheEsophageal
cancerbel
t

(
5)Humanpapi
l
lomav
irus(
18,
16)t
hosewhoengagewi
thor
alsex

(
6)Pr
emal
i
gnantcondi
ti
ons

 Bar
ret
te’
sEsophagus(
duet
opr
olongedexposur
eofGERD)

 Ty
losi
s(pal
mopl
ant
ar ker
ato – edema) char
act
eri
zed by t
hickeni
ng and
hy
per
pigment
ati
onofski
nofpal
m andsol
e.Waxyy
ell
ow l
esi
onswhi
chdonot
i
tch,appr
oxi
mat
ely 60% ofmember
s oft
he f
ami
l
ies dev
elops car
cinoma
esophagus,
most
lyatt
heageof60

 Pl
umerVi
nsonSy
ndr
ome(
Esophageal
webs)

 Achal
asi
a

 Cor
rosi
vest
ri
ctur
es

Fami
l
iacondi
ti
onl
eadi
ngt
ocar
cinomaesophagus

 Ty
losi
s

 Pl
umerv
isi
onsy
ndr
ome

Quest
ion;

H.py
lor
iisar
iskf
act
orf
orGast
ri
ccar
cinomabutatt
hesamet
imei
sapr
otect
ivef
act
or
f
oresophageal
car
cinoma,
why
?

H.py
lor
ileads t
o at
rophi
c gast
ri
ti
s;hence r
educt
ion i
s gast
ri
c aci
d pr
oduct
ion
(
achl
orhy
dri
cst
ate)i
nthest
omach,
theef
fectoft
hisi
sasf
oll
ows;

I
nthest
omach,
theachl
orhy
dri
cst
atei
sther
iskf
orgast
ri
cmal
i
gnancyt
ooccur

I
ntheesophagus;
duet
olowornoaci
dhenceef
fect
sofGERDwi
l
lnotbesi
gni
fi
cantt
o

8
 AMI
N’STI
PS@GENERALSURGERY

causebar
ret
tesesophagusandadenocar
cinomaoft
heesophagus,t
her
efl
uxwi
l
lbe
aci
dfr
eehencet
hepr
otect
ionagai
nstcar
cinomaesophagus.

Pr
esent
ati
onsofCar
cinomaEsophagus

(
1)Pr
ogr
essi
veDy
sphagi
a(ment
iont
hegr
adesofdy
sphagi
a,pr
ogr
essi
vel
yfr
om
gr
ade1t
ogr
ade6)

(
2)Regur
git
ati
on

(
3)Anor
exi
a

(
4)Cachexi
a

(
5)Subst
ernal
/abdomi
nal
pai
n

(
6)Chocki
ng-i
ncaseofesophageal
tracheal
fist
ula

(
7)Hi
ccups–Duet
odi
aphr
agmat
ici
nfi
l
trat
ion

(
8)Hoar
senessofv
oice(
duet
orecur
rentl
ary
ngeal
ner
vei
nfi
l
trat
ion)

(
9)Hemat
emesi
s/Mel
ena(
Rar
eifoccur
sisduet
oaor
ti
cinf
il
tr
ati
on(
it
sfat
al)

(
10) Feat
uresofdi
stantmet
ast
asi
s

Tol
ungsandpl
eur
al

- (
Cannonbal
l
sifmet
ast
asi
sist
othel
ungpar
enchy
maandpl
uralef
fusi
oni
f
met
ast
asi
sis t
othepl
eur
al)

- Di
ff
icul
tyi
nBr
eat
hing

- Hemopt
ysi
s

9
 AMI
N’STI
PS@GENERALSURGERY

- Chestpai
n

- Chestheav
iness/t
ight
ness

Tot
heabdomen

Li
ver–j
aundi
ce,
coagul
opat
hy

Asci
tes

Kr
uker
nber
g’st
umor

ToBone(
lumber
,femurandt
hel
ongbones)

Bonepai
n,l
ocal
tender
ness,
swel
l
ingandpat
hol
ogi
cal
fract
ures.

Lumbosacr
alar
ea–Lowbackpai
n,numbness,
par
apar
esi
sandev
ent
ual
l
ypar
apl
egi
a

Tot
heBr
ain

Feat
ures i
fincr
eased i
ntr
acr
ani
alpr
essur
e(Headache,Vomi
ti
ng,Bl
urr
ed v
isi
on,
Conv
ulsi
ons,
Conf
usi
ons,
Lossi
fconsci
ous)

HOW TOCLERKTHEPATI
ENTWI
THDYSPHAGI
A

 NB:Ther
ear
eot
hercausesofdy
sphagi
a(asshownpr
evi
ous)sodon’
tcl
erka
pat
ientwi
th car
cinoma oft
he esophagus al
one,r
athery
ou shoul
d cl
erka
Dy
sphagi
cpat
ient
,meani
ngal
soy
ouhav
etor
uleoutot
hercausesofDy
sphagi
a
i
nyourHPI

 Nat
ureofDy
sphagi
a

Ther
ear
ethr
eev
ari
ousnat
uresofdy
sphagi
a,t
hesecanei
therbe

i
. Pr
ogr
essi
ve.I
fgr
adei
ncr
easesf
rom gr
adeIt
ogr
adeVI(
incar
cinomaof
t
heesophagus,st
ri
ctur
e,al
so achal
asi
acan pr
esentwi
th pr
ogr
essi
ve

10
 AMI
N’STI
PS@GENERALSURGERY

dy
sphagi
a)

Schwar
tz11thedi
ti
onpage1074

(
Youshoul
dknowt
hedoubl
i
ngt
imef
orcar
cinomaoft
heesophagus)

St
udy by Ken Har
uma,TadashiTokut
omietal(
Nat
uralHi
stor
y ofEsophageal
SquamousCel
lCar
cinoma,
wit
hSpeci
alRef
erencet
oEv
aluat
ionofCl
i
nicalGr
owt
hRat
e
byTumorVol
umeDoubl
i
ngTi
me)

Thedoubl
i
ngt
imef
orcar
cinomaesophagusr
angesf
rom 0.
6to6.
9mont
hs(
mean3.
4
mont
hs)

Doubl
i
ngt
ime=t/10(
logD2-l
ogD1)

D1i
sthet
umordi
amet
eratf
ir
stmeasur
ement
,D2i
sthatatf
inalmeasur
ementandti
s
t
hei
nter
val
bet
weenmeasur
ement
s

i
i
. Dy
sphagi
atol
i
qui
dfoodswhi
chi
srel
i
evedbyt
aki
ngi
nsol
i
dfoods(
a
f
eat
urei
ncl
assi
cachal
asi
a)

11
 AMI
N’STI
PS@GENERALSURGERY

i
i
i. I
nter
mit
tent(
afeat
ureofDESwher
ether
ear
eper
iodsofdi
ff
icul
ti
esi
n
swal
l
owi
ng and per
iods ofnor
malswal
l
owi
ng,and t
hese di
ff
icul
ti
es
occur
smostaf
teraggr
avat
orsl
i
kecol
dfoodsanddr
inks,hotf
oodsand
dr
inks)

HI
STORYTAKI
NGFORAPATI
ENTWI
THDYSHAGI
A

Chi
efcompl
aint
s;Di
ff
icul
tyi
nswal
l
owi
ng(
foracer
tai
nper
iodoft
ime)

HI
STORYOFPRESENTI
NGI
LLNESS(
HPI
)

A:
DONPARA

Onset–usual
l
ygr
adual
inonset
,Nat
ure-el
abor
atewhi
chnat
ure(
asexpl
ainedabov
e)

I
fpr
ogr
essi
vedy
sphagi
arepor
tst
het
rendoft
hepr
ogr
essandcur
rent
ly,whati
sthe
pat
ientabl
etoswal
l
ow.Per
iodi
cit
y– Nospeci
fi
cper
iod.Aggr
avat
ingandRel
i
evi
ng
f
act
ors;wi
thexcept
ionofDESwhi
chi
saggr
avat
edbyhot
/Col
dfoodsanddr
inks)ot
her
causesofdy
sphagi
ausual
l
yhasnospeci
fi
caggr
avat
ingorr
eli
evi
ngf
act
ors.Associ
ated
sy
mpt
omsaskSensat
ion(
feel
i
ng)off
oodst
acki
ngi
ntheNeck/
chest
,Hi
stor
yofpai
n
dur
ingswal
l
owi
ngandRegur
git
ati
on
(
youshoul
dknowt
hedi
ff
erencebet
weenr
egur
git
ati
onandv
omi
ti
ng)

(
Answer
;vomi
ti
ng i
s a f
orcef
ul (
act
ive) backf
low of cont
ent
s f
rom t
he
st
omach/
int
est
ineswhi
l
eregur
git
ati
oni
sapassi
ve(
nonf
orcef
ul)backf
lowofcont
ent
s
f
rom t
heesophagus)

Keywor
dsi
nthedi
ff
erence,f
orcef
ulv
spassi
veandf
rom t
hest
omach/
int
est
inesv
s
f
rom t
heesophagus

NB:
THEPATI
ENTWI
THDYSPHAGI
AREGURGI
TATES,
DOESNOTVOMI
T)

PARTB:
RULI
NGOUTPOSSI
BLEDI
FFERENTI
ALS

MALI
GNACY

12
 AMI
N’STI
PS@GENERALSURGERY

(
Car
cinomaoft
heesophagus,
car
diaTumorandhy
pophar
yngeal
tumor
)

Ask

Hi
stor
y ofuni
ntent
ionalwei
ghtl
oss,Hi
stor
y ofl
oss ofappet
it
e,choki
ng dur
ing
swal
l
owi
ng(
Rul
eoutesophagealt
rachealf
ist
ula)
,Changei
nvoi
ce(
rul
eouti
nfi
l
trat
ion
t
other
ecur
rentl
ary
ngeal
ner
ve)andHi
ccups(
rul
eoutdi
aphr
agmat
ici
nfi
l
trat
ion)

Rul
eoutmet
ast
asi
stot
hel
ungs

Di
ff
icul
tyi
nbr
eat
hing,
Coughi
ngbl
ood,
Chestpai
nandChestt
ight
ness

Rul
eoutmet
ast
asi
stot
hel
i
ver

Yel
l
owi
shdi
scol
orat
ionofey
esandski
nandEasybl
eedi
ngonbr
uises,bl
eedi
ngf
rom
t
hegumsdur
ingt
eet
hbr
ush

Rul
eoutmet
ast
asi
stot
hel
umbosacr
al

Backpai
n,Numbnessi
nthel
owerl
i
mbs,
inabi
l
ityt
owal
k

Rul
eoutmet
ast
asi
stot
heBr
ain

Headache,
Vomi
ti
ng,
Blur
redv
isi
onandConv
ulsi
on

Askf
ort
her
iskf
act
ors

-
Hist
oryofci
gar
ett
essmoki
ng(
ify
es,how manyst
icksperday
,forhow l
ong(
year
s
spentsmoki
ng)andexpr
essi
ntopacky
ear
s

-
Hist
oryofal
cohol
i
sm (
howl
ongandwhatt
ype)

-
RiskyDi
ets,
Hotdr
inks,
Spi
cyf
oodsandSmokedf
oods

-
Hist
oryofpr
act
ici
ngor
alsex

-
Fami
l
yhi
stor
yofasi
mil
arcompl
aint

-
Hist
oryofr
ecur
renthear
tbur
nsbef
oret
heonsetofdi
ff
icul
tyi
nswal
l
owi
ng

13
 AMI
N’STI
PS@GENERALSURGERY

-
Hist
oryofr
adi
ati
onexposur
ebef
oret
heonsetofdi
ff
icul
tyi
nswal
l
owi
ng

RULEOFOUTBENI
GNSTRI
CTURE

Hi
stor
yofcor
rosi
vei
ngest
ionbef
oret
heonsetofdi
ff
icul
tyi
nswal
l
owi
ng

Hi
stor
yinst
rument
ati
ont
hrought
hemont
hbef
oret
heonsetofdi
ff
icul
tyi
nswal
l
owi
ng

Hi
stor
yofNeck/Chestsur
ger
iesbef
oret
heonsetofdi
ff
icul
tyi
nswal
l
owi
ng

RULEOUTEXTRI
NSI
CCAUSES

Rul
eoutmedi
ast
inal
lymphomabyaski
ngt
hef
oll
owi
ng

Hi
stor
yofni
ghtsweet
sandhi
stor
yofni
ghtf
ever
s

Rul
eoutThy
momaandMy
ast
heni
agr
avi
sbyaski
ngt
hef
oll
owi
ng -

Hi
stor
yofeasyf
ati
gabi
l
ity
,hi
stor
yofbl
urr
edv
isi
on,hi
stor
yofdoubl
evi
sion,hi
stor
yof
pr
olongedChewi
nganddi
ff
icul
tyt
oini
ti
ateswal
l
owi
ng,hi
stor
yofheadt
raumapr
iort
o
t
heonsetofdi
ff
icul
tinswal
l
owi
ng

I
sheknownpat
ientwi
thDM orHI
V(whyaski
ngt
hisquest
ion?
)

EXAMI
NATI
ONFORTHEPATI
ENTWI
THDYSPHAGI
A

Gener
alExami
nat
ionasusual

Thef
oll
owi
ngmustbei
ncl
uded

- Dehy
drat
ionst
atus

- Wast
ing

- Pal
msandsol
esi
far
ethi
ckened,
hyperpi
gment
edwi
thwaxyy
ell
owi
shl
esi
ons

(
exami
neandr
epor
tforhy
per
pigment
ati
onandhy
per
ker
atosi
s)

(
whyi
siti
mpor
tantt
oexami
net
hepal
msandsol
eint
hesepar
ti
cul
arpat
ient
s?)

14
 AMI
N’STI
PS@GENERALSURGERY

Ans;
Checki
ngf
orTy
losi
s

- Exami
net
heneckandr
epor
tift
her
eisanyswel
l
ing

(
whyi
siti
mpor
tantt
oexami
net
henecki
nthesepar
ti
cul
arpat
ient
s?)

Ans;
Checki
ngf
orGoi
ter

LOCALEXAMI
NATI
ONOFTHEMONTH

(
Becausemast
icat
ioni
sthef
ir
stst
epi
nswal
l
owi
ngexami
net
hemout
hfi
rst
)

Repor
tont
hef
oll
owi
ng

Sy
mmet
ryoft
hemont
h

Angul
archei
l
iti
s

Or
alt
hrush

Mont
hul
cer
s

I
nfl
amedt
ongue(
Glossi
ti
s),
Leukopl
aki
a

Exami
net
hest
ateoft
het
onsi
l
s,ar
etheyi
nfl
amedornot
?(makesur
eyouhav
ea
spat
ulaandapent
orch,
inst
rument
sthatai
dyout
ovi
sual
i
zet
het
onsi
l
s)

Af
teror
alexami
nat
ion,
thensy
stemi
cexami
nat
iont
ofol
l
owasusual
.

I
nfor
mul
ati
ngt
hedi
agnosi
sinapat
ientwi
thpr
ogr
essi
vedy
sphagi
aandcar
cinomaof
t
heesophagusi
ssuspect
ed,
thenwr
it
e

Exampl
e:Dx:
Esophageal
mal
i
gnancywi
thdy
sphagi
agr
ade(
?)

Andi
facompl
i
cat
ioni
snot
edi
nHPI
,thenwr
it
e,

Exampl
e:Dx:Esophagealmal
i
gnancywi
thdy
sphagi
agr
ade(
-)andEsophagealt
racheal
f
ist
ula

Key
;(-
)meansacer
tai
nnumber1t
o6

I
nvest
igat
ions

15
 AMI
N’STI
PS@GENERALSURGERY

Di
agnost
ic

1.Bar
ium swal
l
ow,

I
t’
saf
ir
stdi
agnost
ict
est
,thi
spr
ovi
desanat
omi
cinf
ormat
ione.
gobst
ruct
ing
l
esi
onsandst
ruct
ural
abnor
mal
i
ty

I
sbar
ium swal
l
owi
mpor
tantbef
oreupperGIendoscopy(
esophagoscopy
)??
?

Yes,i
tishel
pfult
otheendoscopi
stbydi
rect
ingat
tent
iont
olocat
ionsofsubt
le
change and al
ert
ing t
he exami
nert
o such pot
ent
ialdangerspot
s as an
esophageal
div
ert
icul
um,
adeepl
ypenet
rat
ingul
cerorcar
cinoma/
Tumor

(
Ifchoki
ng,
wat
ersol
ubl
econt
rast(
Lowosmol
arcont
rastmedi
um)i
spr
efer
red,

(
Stat
ether
easonoft
heabov
epr
efer
ence)

The r
eason i
s;i
t’
s because t
o av
oid chemi
calpneumoni
ti
sincase Bar
ium
cont
rasti
sused,andwat
er-
sol
ubl
econt
rastwi
thLow osmol
ari
tyi
spr
efer
red
becausewhenwat
ersol
ubl
econt
rastwi
thhy
perosmol
ari
tyi
susedwi
l
lleadt
o
l
i
fet
hreat
eni
ngpul
monar
yedema,i
ncaset
her
eiswat
ersol
ubl
econt
rastwi
th
hy
perosmol
ari
tyi
sonl
yav
ail
abl
eithast
obedi
l
uted.

(
NB:
NOTBar
ium MEAL)

Youshoul
dknowt
hedi
ff
erencebet
weenbar
ium swal
l
owandbar
ium meal

Bar
ium swal
l
ow i
sthef
luor
oscopi
cst
udyusedt
ost
udyt
heesophaguswhi
l
eBar
ium
meali
sthef
luor
oscopi
cst
udyusedt
ost
udyupt
othel
eveloft
heduodenum,Bar
ium
swal
l
owi
smor
evi
scoust
hanswal
l
ow.

Keyt
ermsi
nthedi
ff
erencear
e

Lev
elsofst
udy
;esophagusv
supt
otheduodenum andmor
evi
scoust
hant
heot
her

You shoul
d know f
eat
ures and i
nter
pret
ati
on ofBar
ium swal
l
ow oft
he f
oll
owi
ng
di
agnosi
s

16
 AMI
N’STI
PS@GENERALSURGERY

-
Car
cinomaesophagus

Cont
rasthol
dupwi
thi
nver
tedshoul
der
ingsi
gnandi
rr
egul
arf
il
li
ngdef
ect
sgi
vi
ngt
her
at
t
ail
appear
ance

-
Achal
asi
a

Penci
l
-li
kesmoot
hnar
rowi
ngoft
hel
oweresophagusgi
vi
ngabi
rdbeakappear
ance,
wi
thdi
l
atat
ionofpr
oxi
malesophagusandscant
y/absenceoff
undi
cgasbubbl
e.Lat
eral
v
iew doubl
e medi
ast
inalst
ri
p oft
he di
l
ated esophaguswi
th ai
rfl
uidl
eveli
nthe
post
eri
ormedi
ast
inum

17
 AMI
N’STI
PS@GENERALSURGERY

-
DES

Abar
ium swal
l
owwi
thacockscr
ewappear
ance

18
 AMI
N’STI
PS@GENERALSURGERY

2.Esophagoscopy+/
-Bi
opsy(
NB:
NOTOGD)

What
’st
he di
ff
erence bet
ween Esophagoscopyand OGD and Whati
sthei
r
si
gni
fi
cance?

Esophagoscopyi
sanupperendoscopi
cst
udywhi
chi
susedt
odi
rectv
isual
i
ze
t
he esophagus whi
l
e OGD (
esophago-
gast
ro-
duodenoscopy
)is an upper
endoscopi
cst
udywhi
chi
susedt
odi
rectv
isual
i
zet
othel
evel
oft
heduodenum

19
 AMI
N’STI
PS@GENERALSURGERY

Thesi
gni
fi
cancef
orbot
hisudi
rectv
isual
i
zet
hepat
hol
ogyandcanai
dtot
ake
t
issuebi
opsy

I
siti
mpor
tantt
odoanupperendoscopy(
esophagoscopy
)af
terdoi
ngaBar
ium
swal
l
ow?
??

Yes,r
egar
dlessoft
hebar
ium swal
l
owi
nter
pret
ati
onofabnor
malf
indi
ngs,each
st
ruct
uralabnor
mal
i
tyshoul
dbeexami
nedv
isual
l
ywi
thanendoscope,al
so
t
issuebi
opsyi
fneededmaybedonewi
thanendoscope

Quest
ion;Bet
weenbar
ium swal
l
ow andanupperendoscopy(
esophagoscopy
)
whi
chhel
psi
nest
imat
ingst
ri
ctur
elengt
hinesophageal
mal
i
gnancy
???

Answer
;It
sBar
ium swal
l
ows

3.EsophagealManomet
ry– I
ncaseofmot
il
it
ydi
sor
der
sispar
tofoneoft
he
di
ff
erent
ial
s

20
 AMI
N’STI
PS@GENERALSURGERY

Schwar
tz11t
hedi
ti
onpage1022

Youshoul
dknowt
hemanomet
ri
cfeat
uresofeachoft
hef
oll
owi
ng

-
Achal
asi
a

-
DES(
Dif
fuseEsophageal
Spasm)

-
Nut
crackerEsophagus

21
 AMI
N’STI
PS@GENERALSURGERY

Schwar
tz11thedi
ti
onpage1056

4.Endoscopi
cul
tr
asound(
forst
agi
ngTNM)

Thi
shel
pst
oassessTst
atusmeani
ngdept
hofi
nvasi
onoft
hepr
imar
ytumor
,
andNst
atusmeani
ngnumber
sofi
nvol
vedl
ymphnodes

5.CT–ScanThor
aco-
abdomi
nal
(forst
agi
ngTNM)

Thi
shel
pst
oassessTst
atusmeani
ngdept
hofi
nvasi
onoft
hepr
imar
ytumor
,
andNst
atusmeani
ngnumber
sofi
nvol
vedl
ymphnodesandal
soM st
atusf
or
chestandabdomi
nal
met
ast
asi
s

6.Br
onchoscopy(
ifchoki
ng,
fordi
agnosi
soft
heesophageal
tracheal
fist
ula)

22
 AMI
N’STI
PS@GENERALSURGERY

7.Met
ast
asi
sWor
k–Out

i
. CXR(
ift
hor
aco-
abdomi
nal
CTscanhasnotbeendone)

i
i
. Abdomi
nal
Pel
vi
cUSS(
ift
hor
aco-
abdomi
nal
CTscanhasnotbeendone)

i
i
i. I
ncaseofsuspect
edspi
nemet
ast
asi
sdoSpi
nex–r
ay,(
Lumbo–sacr
al
X–r
ayi
fpr
esentwi
thl
owerbackpai
nandpar
apl
egi
a)

i
v. I
ncaseofsuspect
edbr
ainmet
ast
asi
s–CTBr
ain

v
. PET–Scan

BASELI
NEI
NVESTI
GATI
ONS

Ful
lBl
oodcount

Renal
funct
ionst
est

Li
verf
unct
iont
est

Ser
um el
ect
rol
ytes

TREATMENT

-
Rev
iseTNM cl
assi
fi
cat
ionofcar
cinomaoft
heesophagus

23
 AMI
N’STI
PS@GENERALSURGERY

Schwar
tz11thedi
ti
onpage1071

-
Rev
iset
reat
mentofcar
cinomaEsophagusst
agewi
se

Ear
lygr
owt
h(nonodal
spr
ead,
noadj
acentst
ruct
uresi
nvol
vement
)

Cur
ati
vet
her
apybyesophagect
omyf
oll
owedbyadj
uvantchemor
adi
other
apy

Buti
fear
lygr
owt
hwi
thl
ymphnodesspr
eadwi
thnoadj
acentst
ruct
ures’i
nvol
vement
,
neo adj
uvantchemo r
adi
other
apy f
oll
owed by esophagect
omy (
ifl
ymph nodes
i
nvol
vementi
smor
ethan5i
ndi
cat
espoorpr
ognosi
swhi
l
eifl
esst
han5hasbet
ter
pr
ognosi
s)

Esophagect
omy(
proxi
malr
esect
ion10cm abov
ethemacr
oscopi
ctumoranddi
stal
r
esect
ion5cm f
rom t
hemacr
oscopi
ctumor
)

-
Typesofesophagect
omi
es

McKeownt
hreephasedesophagect
omy(
appr
oachesl
apar
otomy
,thor
acot
omyand
r
ight
-si
deneck)f 3rdgr
orupper1/ owt
h.

24
 AMI
N’STI
PS@GENERALSURGERY

I
vor
-Lewi
sesophagect
omy(
appr
oachesl
apar
otomyandt
hor
acot
omy
)formi
ddl 3rd
e1/
anddi
stal
growt
hs.

Tr
anshi
atalbl
i
ngt
otalesophagect
omy(
Orr
ingerappr
oach)l
apar
otomyt
omobi
l
izet
he
st
omachandl
owerpar
toft
heesophagusf
oll
owedl
eftsi
deneckappr
oacht
omobi
l
ize
t
heupperesophagusf
oll
owedbyanast
omosi
s

-
Modal
i
tiesofpal
l
iat
ivet
reat
mentf
orcar
cinomaEsophagus

Appr
oxi
mat
ely80% wi
l
lhav
epal
l
iat
ivet
reat
ment
,suchast
hosewi
thbl
oodspr
eador
adj
acentspr
eadt
othenear
byst
ruct
ures4B.

-
indi
cat
ionswher
ecur
ati
vet
her
apyi
snotpossi
blear
e;

Nodesmor
ethan5ar
einv
olv
ed

Lengt
hoft
het
umor>8cm

Met
ast
ati
cdi
sease

I
nvasi
ve,
poor
lydi
ff
erent
iat
edgr
ade

Lossofwei
ght>20%

Ther
efor
epal
l
iat
ivemodal
i
tiesar
easf
oll
ows;

Sel
f-
expandi
ngst
ent
s(met
all
i
corpl
ast
ic)

Pal
l
iat
iver
adi
other
apy(
ext
ernal
ori
ntr
alumi
nal
)

Pal
l
iat
iveChemot
her
apy

Endoscopi
clesser

25
 AMI
N’STI
PS@GENERALSURGERY

MUSTREADTOPI
CS

ACHALASI
A

Et
iol
ogy
-ideopat
hic

Pat
hol
ogy
-ther
eisabsenceorl
essnumber
edgangl
i
onsi
nthemy
ent
eri
cpl
exus

Ther
eisdegener
ati
onoft
heAuer
bach’
smy
ent
eri
cpl
exusal
ongt
heent
ir
elengt
hoft
he
esophagusmor
esoi
nloweresophageal
sphi
nct
er

Manomet
ri
cfeat
ure-asabov
e

Chi
cagocl
assi
fi
cat
ionofachal
asi
aunderhi
ghr
esol
uti
onmanomet
ry

Ty
pe1(
Classi
cachal
asi
a)-
nopr
essur
ewav
esar
erecor
dedi
nthedi
stalesophagus,
100%f
ail
edper
ist
alsi
s

Ty
pe2(
Achal
asi
awi
thesophagealcompr
essi
on)
-nonor
malper
ist
alsi
s,panesophageal
pr
essur
izat
ionwi
th>20%

Ty
pe3(
Vigor
ousAchal
asi
a,Achal
asi
awi
thDES)atl
east20% ofswal
l
owsr
eveal
ed
spast
icsi
mul
taneouscont
ract
ions.

Whati
sthedi
ff
erencebet
weenAchal
asi
aandPseudoachal
asi
a?Whatt
esti
sdonet
o
di
ff
erentt
hem?

Pseudoachal
asi
ashowsf
eat
uresofachal
asi
acar
diaseeni
nel
der
lyduet
ocar
cinoma
att
hecar
dia,
Amy
lni
tr
atei
nhal
ati
oncausessphi
nct
err
elaxat
ioni
nachal
asi
acar
diabut
noti
npseudoachal
asi
a

Tr
eat
mentofachal
asi
a

-
Medi
cal

Ni
tr
ates,
cal
cium channel
blocker
sandbot
uli
num t
oxi
n
26
 AMI
N’STI
PS@GENERALSURGERY

-
Sur
gical

Modi
fi
edHel
l
er’
smy
otomy

Whati
sthedi
ff
erencebet
weenor
igi
nalHel
l
er’
smy
otomyandt
hemodi
fi
edHel
l
er’
s
my
otomy
?

Themy
otomyi
nor
igi
nalHel
l
er’
smy
otomywasdoneonbot
hant
eri
orandpost
eri
or
aspect
soft
heesophagus,whi
l
ethemy
otomyi
nthemodi
fi
edHel
l
er’
smy
otomyi
sonl
y
doneont
heant
eri
oraspect

(
IsHel
l
er’
sCar
diomy
otomyadef
ini
ti
veorpal
l
iat
ivet
reat
menti
nAchal
asi
a?Gi
vet
he
descr
ipt
ionofmodi
fi
edHel
l
er’
sCar
diomy
otomy
)

I
tisapal
l
iat
ivepr
ocedur
e,t
o pal
l
iat
edy
sphagi
acausedbyachal
asi
a,cannotbe
def
ini
ti
veandcur
ati
vebecauset
heexactcauseofachal
asi
aisunknownandhasnot
beenmanaged

I
sther
eanypr
ocedur
enecessar
ytobedonepostmy
otomyi
nmodi
fi
edHel
l
er’
sCar
dio
my
otomy
?Andwhy
?

Yes,t
henecessar
ypr
ocedur
etof
oll
ow af
termy
otomyi
sfundopl
i
cat
ion(
Dorant
eri
or
f
undopl
i
cat
ion)i
stor
einf
orcet
heant
eri
orwal
lwhi
chhasbecomeweakpostmy
otomy
andt
oactast
hel
oweresophagealsphi
nct
ert
opr
eventr
efl
ux(
GERD)becauseLEShas
beendi
srupt
eddur
ingt
hemy
otomy

-
Endoscopi
c

POEM (
PerOr
alEndoscopi
cMy
otomy
)incl
udi
ngt
hePl
ummer
’sPneumat
icdi
l
atat
ion
Bal
l
oon’
sandt
heNegushy
drost
ati
cdi
l
atat
ion

27
 AMI
N’STI
PS@GENERALSURGERY

BENI
GNESOPHAGEALSTRI
CTURE

Endoscopi
cgr
adi
ngofacut
ecaust
ici
njur
ytot
heesophagus

I
njur
y Endoscopi
c Dept
hofgr
ade

Appear
anceofi
njur
y

I Super
fi
cial
hyper
emi
a Mucosal

I
IA Sl
oughi
ng mucosa, super
fi
cial Pat
chypar
ti
alt
hickness
ul
cer
ati
on

I
IB Deepul
cer
ati
on(
int
omuscul
arl
ayer
? Ci
rcumf
erent
ial

28
 AMI
N’STI
PS@GENERALSURGERY

I
II Escher
,necr
osi
s Ful
lthi
ckness

ManagementofBeni
gnEsophageal
str
ict
ure

I
tisbet
tert
ounder
standt
hephasesoft
issuei
njur
yincor
rosi
vei
ngest
ionandt
he
degr
eesandgr
adi
ngaf
tercor
rosi
vei
ngest
ion

Acut
ephasemanagement
:

Neut
ral
i
zat
ionwi
thv
inegarorci
tr
usf
oodi
fiti
sal
kal
ii
ngest
ionandi
fiti
saci
dingest
ion
i
tiswi
thant
aci
ds,
mil
k,eggwhi
tes.

NB;
IfpHoft
hesol
uti
oni
slesst
han11.
5,t
hendamagei
sless

Ear
lyendoscopyi
sneededt
oassesst
hesev
eri
tyandext
ent
.

Emet
icsandNaHCO3ar
eav
oidedast
heymaypr
eci
pit
ateper
for
ati
on.

I
n1stdegr
eebur
ns:48hour
sobser
vat
ion;
oralf
eedsar
est
art
edoncepat
ientswal
l
ows’
sal
i
vapai
nlessl
y.Regul
arf
oll
ow-
upendoscopyat1st
,2ndand8t
hmont
hs,St
ri
ctur
e,i
f
f
ormed,
canbei
dent
if
iedbyt
hist
ime.

2ndand3r
ddegr
eebur
ns:Theyar
etr
eat
edwi
thf
lui
dther
apy
,ant
ibi
oti
cs,nut
ri
ti
on,
r
esusci
tat
ion, PPI
s, aer
osol
i
zed st
eroi
ds, f
iber
opt
ic-
gui
ded ai
rway i
ntubat
ion i
f
needed/
tracheost
omy
; endoscopi
c esophageal st
ent
ing, f
eedi
ng j
ejunost
omy
,
l
apar
oscopyf
orev
aluat
ion.Unst
abl
epat
ient
shav
ehi
ghmor
tal
i
ty.

Lapar
otomyi
sdonei
nsuchpat
ient
s.I
fesophagusandst
omachshow f
ullt
hickness
necr
osi
s,r
esect
ion oft
hese par
tsi
s done and end cer
vicalesophagost
omywi
th
j
ejunost
omyi
sdone.Wheni
ndoubt
,re-
expl
orat
ionf
orsecondl
ooki
sdoneaf
ter36–48
hour
stoassesst
hest
omach.

St
ri
ctur
e,i
ffor
med(
Phaset
hree)

Regul
aresophagealdi
l
atat
ioni
sdonef
orst
ri
ctur
e.St
ri
ctur
eisdi
l
atedendoscopi
cal
l
y
usi
ng gui
dewi
re.Di
l
ator
sar
esol
i
dty
pewi
th gr
aduali
ncr
easei
n di
amet
ers.Of
ten
r
adi
ologi
cC-
arm gui
dancei
sneededt
opasst
hegui
dewi
rei
ntot
hest
omach.Di
l
atat
ion

29
 AMI
N’STI
PS@GENERALSURGERY

shoul
dbedoneupt
omi
nimum 16mm di
amet
er.Pneumat
icorbal
l
oondi
l
atat
ioni
sal
so
pr
act
icedandbal
l
oondi
l
ator
sar
eot
herdi
l
ator
sused.

Ear
li
er,bl
i
nd di
l
atat
ion usi
ng esophagealbougi
esofi
ncr
eased di
amet
erswast
he
pr
act
ice,
whi
chi
sfol
l
owedev
ennowi
nmanypl
aces,
butchancesofper
for
ati
oni
smor
e.

Esophagealr
esect
ion i
n cor
rosi
ve st
ri
ctur
es i
stechni
cal
l
y di
ff
icul
tand may be
hazar
dous.

Esophagealby
passi
sbet
terandeasi
er,andf
oll
owi
ngl
aterbyr
egul
arendoscopi
c
sur
vei
l
lancef
ormal
i
gnantt
ransf
ormat
ion(
5%)
.Col
oni
susedasr
epl
aci
ngcondui
tas
st
omachi
tsel
fmaybedi
seasedi
ncor
rosi
vepat
hol
ogy
.

I
nmul
ti
plest
ri
ctur
esesophagealr
esect
ionandcol
oni
ctr
ansposi
ti
onmaybeadv
ocat
ed
i
fri
skofmal
i
gnancyi
sconsi
der
ed.

NB;

I
fyouar
easkedaboutt
hemanagementofbeni
gnesophagealst
ri
ctur
e,t
hismeanst
hat
phaset
hreet
reat
ment
,soy
ouranswer
sshoul
dnoti
ncl
udet
heacut
ephasebecausei
n
acut
ephasest
ri
ctur
eisnoty
etf
ormedunl
essy
ouar
easkedt
odoso.

GERD(
Gast
roEsophageal
Ref
luxDi
sease)

Ty
picalsy
mpt
oms(
Tri
ad)
-hear
tbur
n,epi
gast
ri
cpai
nwi
thorwi
thoutdy
sphagi
aand
r
egur
git
ati
on

At
ypi
calsy
mpt
oms-cough,hoar
seness,wheezi
ng,sor
ethr
oat
,non-
car
diacchestpai
n
andpal
atal
/dent
aler
osi
on

Whatar
ethe compl
i
cat
ions ofGERD?
??(
bot
h esophagealand ext
ra esophageal
compl
i
cat
ions)

Esophageal compl
i
cat
ions i
ncl
ude; esophagi
ti
s, esophageal st
ri
ctur
e, bar
ret
tes

30
 AMI
N’STI
PS@GENERALSURGERY

esophagus,
esophageal
shor
teni
ng,
adenocar
cinomaoft
heesophagus

Ext
ra esophagealcompl
i
cat
ions i
ncl
ude;ast
hma,l
ary
ngi
ti
s,r
ecur
rentpneumoni
a,
pr
ogr
essi
vel
ungf
ibr
osi
s,hy
per
sal
i
vat
ionandpal
atal
/dent
aler
osi
on

Anat
omi
cal
andphy
siol
ogi
cal
fact
orsl
eadi
ngt
oGERD

Anat
omi
cal
fact
ors;

Obesi
ty

Lengt
hofani
ntr
a-abdomi
nalesophagus,t
hemor
ethel
engt
h,mor
eint
raabdomi
nal
pr
essur
eisneededt
ocauser
efl
exandsol
esst
her
efl
uxwi
thmor
elengt
h

Al
ter
ati
onoft
hephr
eno-
esophageal
li
gament

Al
ter
edobl
i
qui
tyofesophageal
gast
ri
cjunct
ion(
alt
erat
ionoft
heangl
eofHi
s)

Al
ter
edi
nsl
i
ngmechani
sm ofgast
ri
cmuscul
atur
e

31
 AMI
N’STI
PS@GENERALSURGERY

Reduci
ngpi
nchi
ngact
ion(
pinch-
cockef
fect
)ofr
ightconsoft
hedi
aphr
agm

Phy
siol
ogi
cal
fact
ors

Reduced l
oweresophagealsphi
nct
erpr
essur
e(nor
malr
est
ing l
oweresophageal
sphi
nct
erpr
essur
eis10-
25mmHg,dur
ingswal
l
owi
ngpr
essur
edr
opst
o1-
3mmHgf
or
about10seconds,
thi
sloweresophageal
sphi
nct
erpr
essur
ecanber
educedbysecr
eti
n,
CCK,
glucagon,
Cal
ci
um channelbl
ocker
s,cof
feeandf
att
ymeal
,al
sol
oweresophageal
sphi
nct
erpr
essur
ecanbei
ncr
easedbygast
ri
n,chol
i
ner
gic,adr
ener
gicandpr
oki
net
ic
dr
ugs)

Al
ter
ed(
incr
eased)t
ransi
entr
elaxat
ionper
iodi
nloweresophageal
sphi
nct
erpr
essur
e

Del
ayedgast
ri
cempt
ying

I
ncr
easegast
ri
cdi
stensi
on

Decr
easeesophageal
clear
ancemechani
sms

Ot
herf
act
orspr
edi
sposi
ngt
oGERD(
miscel
l
aneous)

Al
cohol
,smoki
ng,
str
ess,
li
fest
yleandi
tismor
eini
nfant
sandpr
egnantwomen

LosAngel
escl
assi
fi
cat
ionofEr
osi
veesophagi
ti
s

Gr
adeA-oneormor
emucosalbr
eak<5mm t
hatdoesnotext
endbet
weent
het
opsof
mucosal
fol
ds

Gr
adeB-oneormor
emucosalbr
eak>5mm t
hatdoesnotext
endbet
weent
het
opsof
mucosal
fol
ds

Gr
adeC-
oneormor
emucosal
fol
dsbr
eakt
hati
scont
inuousbet
weent
het
opoft
he2or
mor
emucosal
fol
dsbuti
nvol
ves<75%oft
heci
rcumf
erence

32
 AMI
N’STI
PS@GENERALSURGERY

Gr
ade D-one ormor
e mucosalbr
eak t
hati
nvol
ves >orequalt
o 75% oft
he
ci
rcumf
erence

Hi
l
lGr
ade oft
he Gast
roesophagealv
alv
e(v
isual
i
zed byr
etr
ofl
exi
on oft
he upper
endoscope)

Gr
ade1,
apr
omi
nentf
oldoft
issueal
ongt
hel
essercur
vat
urenextt
otheendoscope

Gr
ade2,t
hef
oldi
slesspr
omi
nentandt
her
ear
eper
iodsofopeni
ngandr
api
dcl
osi
ng
ar
oundt
heendoscope

Gr
ade3,
thef
oldi
snotpr
omi
nentandt
heendoscopei
snott
ight
lygr
ippedbyt
het
issue

Gr
ade4,t
her
eisnof
oldandt
hel
umenoft
heesophagusi
sopenandof
tenal
l
owv
iew
t
othesquamousepi
thel
i
um f
rom bel
ow.Ahi
atal
her
niai
susual
l
ypr
esent

Ambul
ator
ypHmoni
tor
ing

-
Obj
ect
iveoft
het
est

Hi
ghl
ysensi
ti
veandspeci
fi
cit
yforGERD.Thi
stestal
l
owsobj
ect
iveassessmentof
esophagealexposur
eto gast
ri
cjui
cei
napat
ienti
nacont
inuousset
ti
ng,al
so i
s
i
ndi
cat
edi
npat
ient
swi
that
ypi
calpr
esent
ati
onofGERD exampl
e,non-
car
diacchest
pai
nandr
espi
rat
orysy
mpt
oms

NB;t
het
esti
snotat
estf
orr
efl
ux,r
atheri
tisameasur
ementoft
heesophageal
exposur
etogast
ri
cjui
ce.

-
Inst
ruct
ionsgi
vent
othepat
ientpr
iort
het
est

Car
rydai
l
yact
ivi
ti
esnor
mal
l
ybutt
oav
oidst
renuousexer
ti
ons

Remai
nupr
ightwhi
l
eawakei
ntheday
,ly
ingdownsupi
neonl
yatni
ghtwhi
l
esl
eepi
ng

Toi
ngestt
womeal
satt
heusualt
ime(
standar
dabsenceoff
oodandbev
erageswi
th

33
 AMI
N’STI
PS@GENERALSURGERY

pHv
aluel
esst
han5andgr
eat
ert
han6)

Thepat
ienti
stheni
nst
ruct
edt
onot
eint
hedi
aryt
hef
oll
owi
ng;t
imeofmeal
s,t
imeof
r
eti
ri
ngf
orsl
eep,t
imeofr
isi
ngt
hef
oll
owi
ngmor
ningandt
imeoft
hepr
esenceand
dur
ati
onofanysy
mpt
om

H2bl
ocker
sandpr
oki
net
icsdi
scont
inued48hour
sbef
oret
het
est

PPI
sdi
scont
inuedt
woweeksbef
oret
het
est(
duet
olongl
ast
ingact
ion)

-
Esophageal
exposur
etogast
ri
cjui
cei
sbestassi
stedbywhi
chmeasur
ement
?

Themeasur
ementi
sexpr
essedast
heper
cent
ageoft
imet
hatt
heesophaguspHwas
bel
ow4dur
ingt
he24hour
sper
iod

Theot
hert
woassessment
sar
enecessar
y

-
thef
requencyoft
her
efl
uxepi
sodes

-
andt
hei
rdur
ati
on

Esophageal
exposur
etogast
ri
cjui
cei
sbestassessedbyt
hef
oll
owi
ngmeasur
ement
s

-
Cumul
ati
vet
imet
hatt
heesophagealpHi
sbel
ow4expr
essedast
heper
cent
ageoft
he
t
otal
,upr
ightandsupi
nemoni
tor
edt
imes

-
Frequencyofr
efl
uxepi
sodeswhenpH dr
opsbel
ow 4,expr
essedast
henumberof
epi
sodesper24hour
s

-
Thenumberofepi
sodesdur
ingwhi
cht
hepHr
emai
ned4f
orl
ongert
han5mi
nut
es/
24
hour
s

And

-
the t
ime i
n mi
nut
es f
ort
he l
ongestr
ecor
ded epi
sode,t
he l
ongestt
ime t
he pH
consi
stencyr
emai
nedbel
ow4

34
 AMI
N’STI
PS@GENERALSURGERY

Expl
aint
he pat
hophy
siol
ogy of GERD i
ncl
uded Respi
rat
ory sy
mpt
om (
Aty
pical
sy
mpt
oms)basedon:

-
Ref
luxt
heor
y

Respi
rat
ory sy
mpt
oms ar
ethe r
esul
tofaspi
rat
ion ormi
cro-
aspi
rat
ion ofgast
ri
c
cont
ent
s.Fol
l
owi
ngaci
dinst
all
ati
oni
nthel
ungst
hisr
esul
tsi
ntopneumoni
ti
s,epi
thel
i
al
damageandi
ncr
easei
nai
rwayr
esi
stance.

-
Ref
lext
heor
y

Vagal
l
ymedi
atedbr
oncho-
const
ri
cti
onf
oll
owsaci
dif
icat
ionofl
oweresophagusv
iaa
r
efl
exneur
ologi
car
ch.Fol
l
owi
ngt
hei
nfusi
onofaci
dint
othel
oweresophaguscauses
br
oncho-
const
ri
cti
on expl
ained by common embr
yol
ogi
c or
igi
n of t
he t
rachea-
esophageal
tractandi
tsshar
edv
agal
inner
vat
ion

Tr
eat
mentofGERD

-
Lif
est
ylemodi
fi
cat
ions

Cont
rol
obesi
ty

St
opsmoki
ng/
alcohol
i
sm

Av
oidt
ea,
cof
feeandchocol
ates

Pr
oppedupposi
ti
on

Smal
l
,fr
equentmeal
s

-
Medi
cal
(Dr
ugs)

Ant
i-
aci
ds,
H2ant
agoni
sts

PPI
s

35
 AMI
N’STI
PS@GENERALSURGERY

Pr
oki
net
icdr
ugs

Ant
ichol
i
ner
gicdr
ugs

Mucosal
prot
ect
ionwi
thant
aci
ds

-
Sur
gical

I
ndi
cat
ions

Fai
l
ureofl
i
fest
yleandmedi
cal
treat
ment

Sl
i
dingher
nia

Bar
ret
tesesophagus

Sev
erepai
n

Compl
i
cat
ionsl
i
kebl
eedi
ng,
str
ict
uri
ng,
shor
teni
ng,
respi
rat
orycompl
i
cat
ions

Ant
i-
ref
luxsur
ger
iesar
easf
oll
ows

Ni
ssen’
s(360degr
eespost
eri
orf
undopl
i
cat
ion)

Commoncompl
i
cat
ionsassoci
atedwi
tht
hist
ypear
egasbl
oat
ingsy
ndr
ome(
inabi
l
ity
t
obel
ch)
,dy
sphagi
a,i
nabi
l
ityt
ovomi
t,par
aoesophagealher
nia,
proxi
malmi
grat
ionand
spl
eni
cinj
ury

Was t
hen modi
fi
ed t
o Fl
oppy Ni
ssen’
sfundopl
i
cat
ion t
hisr
educed Gas bl
oat
ing
sy
ndr
ome

Toupet
e’spar
ti
al180degr
eespost
eri
orf
undopl
i
cat
ion(
gasbl
oat
ingi
sver
yless)

Dorant
eri
orf
undopl
i
cat
ion

Fundopl
i
cat
ionshoul
d

36
 AMI
N’STI
PS@GENERALSURGERY

-
prev
entsphi
nct
ershor
teni
ng

-
unf
oldi
ngdur
inggast
ri
cdi
stensi
on

-
all
owspr
operbel
chi
ng

-
all
owsv
omi
ti
ngwhenneeded

-
preser
venor
mal
swal
l
owi
ngabi
l
ity

HI
ATUSHERNI
A

Ty
pesofHI
ATUSHERNI
A

Ty
pe1Sl
i
dingher
nia

Ty
pe2Rol
l
ingher
nia

Ty
pe3Mi
xed(
combi
ned)t
ype1andt
ype2

Ty
pe4Rol
l
ingher
niawi
thot
herv
iscer
al

Ty
pes2,
3and4ar
eref
err
edasPEH(
par
aesophageal
her
nia)

Cl
i
nical
feat
uresofHI
ATUSHERNI
A

Abdomi
nalpai
nandchestpai
n,Hi
-cough,Ear
lysat
iet
y,Regur
git
ati
on,postpr
andi
al
bl
oat
ing,
dysphagi
a,dy
spnea,
andcar
diacar
ryt
hmi
as

40%pr
esent
swi
thacut
efeat
uresofbl
eedi
ng,
per
for
ati
onandgangr
ene

Compl
i
cat
ionsofHI
ATUSHERNI
A

Gangr
enest
omach

Per
for
ati
oni
ntot
heper
it
oneum andmedi
ast
inum

Gast
ri
cvol
vul
us

37
 AMI
N’STI
PS@GENERALSURGERY

Camer
onul
cer(
ischemi
clongi
tudi
nal
ulceri
ntheher
niat
edst
omach)

I
nvest
igat
ions

Bar
ium meal

Thor
aco-
abdomi
nal
CTscanwi
thor
alcont
rast

OGD

Pl
ainabdomi
nal
X-r
ayswi
l
lshowr
etr
o-car
diacai
rfl
uidl
evel

ECGi
ncaseofar
rhy
thmi
as

Tr
eat
ment

Ant
aci
ds/
PPI
s,butal
way
sissur
gical

Exci
si
onoft
hesacandr
epai
roft
hedef
ect
,Ref
luxsur
ger
ies,meshr
einf
orcementmay
beneeded

I
fgangr
enous-Gast
rect
omy

38
 AMI
N’STI
PS@GENERALSURGERY

Si
ewer
tcl
assi
fi
cat
ionofGast
ro–Esophageal
junct
ionTumor
sandmanagement
)

39
 AMI
N’STI
PS@GENERALSURGERY

Bar
ret
t’
sEsophagus

Ty
pes

-
BasedonLengt
h(i
.e.l
engt
hofmet
apl
asi
a,i
nher
ewehav
elongsegmentbar
ret
tes
esophagus,i
fthel
engt
hofmet
apl
asi
ais>3cm andt
hisi
stheCl
assi
calt
ypeanot
her
onei
stheshor
tsegmentbar
ret
tesesophagus,
ift
hel
engt
hofmet
apl
asi
ais<3cm)

-
Basedi
nHi
stol
ogy(
i.
e.her
ewehav
ethr
ee,Gast
ri
cty
pe,t
hesecont
ainschi
efand
par
iet
alcel
l
s,i
ntest
inalt
ype,t
hesecont
ainsGobl
etscel
l
sandl
ast
lyJunct
ionalt
ype,
cont
ainsmucosal
glandsal
i
keofgast
ri
ccar
dia)

Bar
ret
t’
sEsophagusi
spr
onet
omal
i
gnancyt
ransf
ormat
ion,
Int
est
inalmet
apl
asi
ari
skof
mal
i
gnancyi
shi
gheraswel
lassev
eri
tyofdy
spl
asi
aincr
easet
her
iskofmal
i
gnancy
t
ransf
ormat
ion.

Dy
spl
asi
amaybei
ndef
ini
te,
lowgr
adeorhi
ghgr
ade

Compl
i
cat
ions

Ul
cer
ati
onandst
ri
ctur
e

Dy
sphagi
a

40
 AMI
N’STI
PS@GENERALSURGERY

Bl
eedi
ng

Per
for
ati
on

adenocar
cinoma

Management

I
flowgr
adet
henr
egul
arendoscopi
cbi
opsyandsur
vei
l
lance,
laserabl
ati
on,
argonbeam
coagul
ati
on,
PPIhi
ghdoses,
Sur
gical
treat
mentofGERD

Resect
ioni
sal
way
sbet
terchoi
cef
orhi
ghgr
adedy
spl
asi
a(Tr
anshi
atalesophagect
omy
i
spr
efer
red)
,al
soendoscopi
cmucosal
resect
ioncanbedone

TOPI
CFI
VE

HEPATOLOGY,
EXTRAHEPATI
CBI
LLI
ARYTREEANDTHE
PANCREATOLOGY

(
PATI
ENTWI
THJAUNDI
CE)
Def
ineJaundi
ce,
andst
atet
hel
evel
ofbi
l
irubi
nthatwi
l
lmakesomeonet
obej
aundi
ced?

Jaundi
cei
syel
l
owi
shdi
scol
orat
ionoft
hescl
eraoft
heey
es,mucousmembr
aneand
ski
n.

Nor
malser
um bi
l
irubi
nis0.
2to0.
8mg%,scl
erai
cter
usi
svi
sibl
ewhenser
um bi
l
irubi
n
l
evel
exceeds2.
5mg%

Descr
ibeHemedegr
adat
ionpat
hway(
from RBCbr
eakdownt
ost
ercobi
l
inf
ormat
ion)

RBCbr
eakdowni
nther
eti
cul
oendot
hel
i
alsy
stem hemeandgl
obul
i
nhemeoxi
dized
byhemeoxy
genasei
nto bi
l
iver
din(
greenpi
gment
)whi
chi
sther
educedbybi
l
iver
din
r
educt
asei
nto bi
l
irubi
n(y
ell
ow pi
gment
)whi
chi
sunconj
ugat
ed t
hisi
sinsol
ubl
e
compoundneedsacar
ri
erpr
otei
n,f
rom t
heci
rcul
ati
oni
tst
hencar
ri
edbyAl
bumi
ntot
he

41
 AMI
N’STI
PS@GENERALSURGERY

l
i
verf
orconj
ugat
ion.Thi
sunconj
ugat
edbi
l
irubi
nisi
nsol
ubl
ehencecannotbeexcr
eted
i
nur
inebyt
heki
dney
s,i
tsexcr
eti
onwi
l
lbev
iat
hel
i
veraf
terconj
ugat
ion.

Hepat
ic upt
ake t
hen bi
l
irubi
nis conj
ugat
ed under t
he i
nfl
uence of Gl
ucor
ony
l
t
ransf
eraseenzy
me.Thi
sconj
ugat
edbi
l
irubi
niswat
ersol
ubl
e,i
sthenexcr
etedt
hrough
bi
l
iar
y canal
i
cul
ireachi
ng t
he i
ntest
ine i
tis conv
ert
ed t
o st
ercobi
l
inogen and
ur
obi
l
inogenbyi
ntest
inalbact
eri
a.Ur
obi
l
inogeni
sasol
ubl
ecompoundwi
l
lbeabsor
bed
byt
heent
erocy
tesi
ntot
heci
rcul
ati
onandwi
l
lbeexcr
etedi
nur
inebyt
heki
dney
s,
st
ercobi
l
inogenwi
l
lbeconv
ert
edt
ost
ercobi
l
inbyGutf
lor
a,andt
hisst
ercobi
l
ini
sthe
oner
esponsi
blet
ogi
venor
mal
col
orofst
ool
.(whati
sthenor
mal
col
orofst
ool
)

Bi
l
e,

o Whati
stheamountofbi
l
epr
oduced i
n adul
tper
son perday
?(500ml
sto
1000ml
sperday
)

o Component
sofbi
l
eandpH

Component
sar
ewat
erwhi
chi
sthemaj
orcomponentappr
ox.>90%,
elect
rol
ytes,
bi
l
esal
ts,pr
otei
ns,l
i
pids(
phosphol
i
pidsandchol
est
erol
),Cal
cium,Magnesi
um
andbi
l
epi
gment
s

pHofbi
l
eisneut
ralorsl
i
ght
lyal
kal
i
ne,butv
ari
eswi
thdi
et,i
fincr
easei
npr
otei
n
i
ntakeshi
ft
stoaci
dicpH

Bi
l
eaci
ds

o Namepr
imar
yandsecondar
ybi
l
eaci
ds?

Pr
imar
ybi
l
eaci
dsar
eChol
i
caci
dandChenodeoxy
chol
i
caci
d,Secondar
ybi
l
e
aci
dsar
edeoxy
chol
i
caci
dandl
i
thochol
i
caci
d

o Whati
sthepr
ecur
sorf
orpr
imar
ybi
l
eaci
dsy
nthesi
s?Chol
est
erol
,ther
efor
e
excesschol
est
erol
leadst
oexcessbi
l
eaci
dsl
evel

o How ar
ethesecondar
ybi
l
eaci
dsf
ormed?Byt
hedehy
droxy
lat
edpr
imar
ybi
l
e

42
 AMI
N’STI
PS@GENERALSURGERY

aci
dsbyt
hegutf
lor
a

(
chol
i
caci
ddehy
droxy
lat
edi
ntodeoxy
chol
i
caci
dandchenodeoxy
chol
i
caci
dis
dehy
droxy
lat
edi
ntol
i
thochol
i
caci
d)

o Whatar
ethef
unct
ionsofbi
l
eaci
ds(
whatar
etheconsequencei
fbi
l
eaci
ds
concent
rat
ioni
nbi
l
eisr
educed)
?

Ther
ear
etwomaj
orf
unct
ionsofbi
l
eaci
ds,mai
ntai
ningchol
est
erolsol
ubi
l
ityi
n
t
hebi
l
eandemul
sif
icat
ionoff
atf
orabsor
pti
onf
atandf
at-
sol
ubl
evi
tami
n

Consequenceswhenbi
l
eaci
dconcent
rat
ioni
sreducedar
eincr
easi
ngr
iskf
or
chol
est
eroli
n bi
l
eto pr
eci
pit
atehencei
ncr
easesr
iskofchol
est
erolst
ones
f
ormat
ion,anot
herconsequencei
sfatmal
absor
pti
onwhi
char
est
eat
orr
heaand
f
at-
sol
ubl
evi
tami
n def
ici
ency l
eadi
ng t
o coagul
opat
hy i
ncase ofv
itami
nK
def
ici
ency

o Whati
stheef
fectofi
ncr
easedconcent
rat
ionofsecondar
ybi
l
eaci
dst
ocol
oni
c
mucosa?

I
ncr
easedconcent
rat
ionofsecondar
ybi
l
eaci
dsi
npar
ti
cul
arLi
thochol
i
caci
dis
car
cinogent
ocol
oni
cmucosa.

o Whyi
sapat
ientwi
thobst
ruct
ivej
aundi
cepr
otect
edf
rom col
orect
almal
i
gnancy
?

Duet
oobst
ruct
ionofbi
l
ereachi
ngi
ntest
inesr
educesconcent
rat
ionofbi
l
eaci
ds
i
n col
on,par
ti
cul
arl
y Li
thochol
i
c aci
d,hence r
educes t
he concent
rat
ion of
car
cinogenhencer
educesr
iskofcol
orect
almal
i
gnancy

Anat
omyoft
heLi
ver

Lobes(
funct
ional
lobesandanat
omi
cal
lobes)

Sect
ionsoft
heLi
ver

Segment
soft
heLi
ver -

Li
gament
s

43
 AMI
N’STI
PS@GENERALSURGERY

Bl
oodsuppl
y

Venousdr
ainage

Phy
siol
ogyandf
unct
ionsoft
heLi
ver

Anat
omyoft
heext
rahepat
icbi
l
iar
ytr
ee

Anat
omyoft
hepancr
eas

Par
ts

Anomal
i
es(
congeni
tal
)

Phy
siol
ogyandf
unct
ionsoft
hepancr
eas

Gal
lBl
adderandsphi
nct
erofodd–(
Phy
siol
ogyofcont
ract
ionandt
hei
rrel
axat
ion)

JAUNDI
CE

Canei
therbemedi
cal
(Pr
eandi
ntr
ahepat
ic)orsur
gical
(posthepat
ic)

Pr
ehepat
ic,
thi
sisduet
oIncr
easei
nhemol
ysi
s

Congeni
tal
causes

RBCMor
phol
ogyDi
sor
der
se.
g.-
Spher
ocy
tosi
sandEl
l
ipt
ocy
tosi
s

Hemogl
obi
nopat
hiese.
g.-
Sickl
ecel
lDi
seasesandβt
hal
assemi
a

Acqui
redcauses

I
nfect
ion(
sev
ereMal
ari
a)

Bl
oodt
ransf
usi
onr
eact
ions

44
 AMI
N’STI
PS@GENERALSURGERY

Hy
po–pr
otei
nemi
a(hy
poal
bumi
nemi
a,Quest
ion;
How?
??)

Answer
;Thi
swi
l
lleadaccumul
ati
onofunconj
ugat
edbi
l
irubi
ninser
um hencej
aundi
ce,
duet
olackofcar
ri
erpr
otei
nwhi
chi
sal
bumi
n

Exampl
e-Kwashi
orkorandMaj
orBur
ns

I
ntr
ahepat
ic,
thi
sisduet
opat
hol
ogywi
thi
ntheLi
ver

Congeni
talcauseswhi
char
e;Gi
l
ber
t’
sdi
sease,Cr
igl
er– Naj
j
arsy
ndr
ome,Dubbi
n–
Johnsonsy
ndr
omeandRot
orssy
ndr
ome

Acqui
redcauses

Mai
nlyar
eduet
o;

-
Liv
erci
rr
hosi
sandHepat
ocel
l
ularcar
cinoma

Ri
skf
act
orsf
or(
Liv
erci
rr
hosi
sandHepat
ocel
l
ularcar
cinoma)ar
e;

-
Alcohol
i
sm

-
Vir
alhepat
it
is(
BandC)
,canbeacqui
redt
hrough

 Bl
oodt
ransf
usedf
rom i
nfect
edBl
ood

 Mul
ti
plesexual
par
tner
s

 Unpr
otect
edsexual
int
ercour
se

 Tat
tooi
ng

 i
/vDr
ugabuse

-
Afl
atoxi
n–B1(
afungusf
oundcommoni
npoor
lyst
orednut
sandgr
ains)aswel
lasi
n
mushr
oom

Posthepat
ic(
obst
ruct
ive/
sur
gical
jaundi
ce)

1.I
ntr
a–l
umi
nal
causes

45
 AMI
N’STI
PS@GENERALSURGERY

These ar
ethe causes wi
thi
nthe l
umen ofext
rahepat
ic bi
l
iar
ytr
ee whi
ch
obst
ruct
sthel
umen

-
Hydat
idcy
st,
Clonor
chi
ssi
nensi
sandAscar
is

Youshoul
dknowt
hel
i
fecy
cleofeachoft
heabov
epar
asi
te

-
Chol
edochol
i
thi
asi
s(CBDSt
ones)
,thi
sist
hemostcommoni
ntr
alumi
nal
cause

NB:
Appr
oxi
mat
ely90% oft
heCBD st
onesar
eSecondar
ygal
lbl
adderst
ones,meani
ng,
pr
imar
il
ytheywer
efor
medi
nthegal
lbl
adder

Andonl
ylesst
han10%ar
epr
imar
il
yfor
medi
ntheCBD

Quest
ion;
Duet
oabov
eexpl
anat
ions,
doesev
erypat
ientwi
thchol
eli
thi
asi
s(gal
lbl
adder
st
ones)dev
elopschol
edochol
i
thi
asi
s(CBDst
ones)
???

Answer
;NO.notev
ery pat
ientwi
th chol
eli
thi
asi
s(gal
lbl
adderst
ones)dev
elops
chol
edochol
i
thi
asi
s(CBD st
ones)t
hisi
s because cont
ract
ion oft
he gal
lbl
adder
pr
oducesaf
unct
ionalv
alv
ecal
l
edVal
veofHei
sterwhi
chpr
event
sthemi
grat
ionof
st
onesf
rom t
hegal
lbl
adderi
ntot
heCBD,somaj
ori
tyoft
hem wi
l
lbepr
otect
edbyt
he
v
alv
eofHei
ster

Youshoul
dunder
standandbeabl
etoexpl
aint
het
heor
iesofgal
lst
onesf
ormat
ion

Met
abol
i
ctheor
y

Met
abol
i
ctheor
yisduet
oimbal
ancedr
ati
oofbi
l
eaci
dst
ochol
est
erol

Nor
mal
l
y,t
her
ati
obet
weenBi
l
eaci
dst
ochol
est
erol
is25:
1,

Rat
iobel
ow13:
1pr
eci
pit
ati
onoccur
s,howdoest
hisl
eadt
ost
onesf
ormat
ion?

(
rememberf
unct
ionofbi
l
eaci
dinbi
l
e)

46
 AMI
N’STI
PS@GENERALSURGERY

Fact
orsf
avor
sincr
easechol
est
erol
lev
el

Femal
e,For
ty,
Fer
ti
le,
Fet
us(
pregnancy
)andFat(
incl
udi
ngf
att
yfoodsconsumpt
ion)

Or
alcont
racept
ives(
whatar
etheef
fect
sofor
alcont
racept
ivesi
nst
onesf
ormat
ion)

Fact
orsf
avor
sreduct
ioni
nbi
l
eaci
dsl
evel
are

-
Ter
minal
il
eo-
resect
ion(
how?
?)

(
impai
redr
eabsor
pti
onofbi
l
eaci
dsatt
het
ermi
nali
l
eum backt
othel
i
veri
nthe
ent
erohepat
icci
rcul
ati
on,duet
oabsenceoft
het
ermi
nali
l
eum,hencedecr
easebi
l
e
aci
dsconcent
rat
ion)

-
Cal
ci
um r
ichf
oods(
youshoul
dknowhow)

(
cal
cium bi
ndswi
thbi
l
eaci
dshencepr
event
sreabsor
pti
onofbi
l
eaci
dsatt
het
ermi
nal
i
l
eum backt
othel
i
veri
ntheent
erohepat
icci
rcul
ati
on,hencedecr
easebi
l
eaci
ds
concent
rat
ion)

St
asi
stheor
y

Duet
oGal
lbl
adderr
elaxat
ion;
fai
l
ureofcont
ract
ionoft
hegal
lbl
addert
opumpbi
l
eout
f
rom i
ttocommonbi
l
eductv
iacy
sti
cducthencest
asi
sofbi
l
eint
hegal
lbl
adder
occur
s

Condi
ti
onsl
eadst
ost
asi
sofbi
l
eint
hegal
lbl
adderi
ncl
udes;

-
Vagot
omy(
how?
?)

Answer
;Vagusner
vei
nner
vat
est
hegal
lbl
adderhencei
tscont
ract
il
it
y,i
fvagot
omyi
s
donewi
l
lleadt
ofai
l
ureofcont
ract
il
it
yoft
hegal
lbl
adderl
eadi
ngt
ofai
l
ureofr
eleaseof
bi
l
efr
om t
hegal
lbl
adderhencest
asi
sofbi
l
eint
hegal
lbl
adder

-
ReducedorNopr
oduct
ionofCCK(
whati
sCCKandi
tsf
unct
ionandwhatcausesi
ts
pr
oduct
iont
ober
educed?

47
 AMI
N’STI
PS@GENERALSURGERY

CCKi
sapept
idet
hati
spr
oducedf
rom epi
thel
i
alcel
l
soft
heGIt
ractandmuchi
sfound
i
nthe duodenum,r
eleased i
nresponse t
o aci
d,f
atorami
no aci
ds r
eachi
ng t
he
duodenum.CCK act
sdi
rect
lyonsmoot
hmuscl
erecept
orsoft
hegal
lbl
adderand
st
imul
atesi
tscont
ract
ionandal
sor
elaxest
ermi
nal
bil
educt
s,sphi
nct
erofOddiandt
he
duodenum.

SoCCKpr
oduct
ioni
simpai
redorr
educedi
ncondi
ti
onssuchaspr
olongedf
ast
ing,
st
arv
ati
on and non-
ent
eralf
eedi
ng such as par
ent
eralf
eedi
ng (
because i
nthese
condi
ti
onsnof
oodsr
eachi
ngt
heduodenum)

Expl
ainhowdoesst
asi
sleadst
ost
onesf
ormat
ion

Pr
olongedst
asi
sofbi
l
eint
hegal
lbl
adderl
eadst
odeconj
ugat
ionoft
heconj
ugat
ed
bi
l
irubi
n…t
heunconj
ugat
edbi
l
irubi
nwhi
chhasbeenf
ormedwi
l
lcombi
newi
thcal
cium
i
nbi
l
etof
orm cal
ci
um bi
l
li
rubi
nat
e,hencebl
ackst
onesf
ormat
ion

Hemol
yti
ctheor
y

Condi
ti
onsl
i
keSi
ckl
ecel
ldi
sease,
spher
ocy
tosi
sandel
l
ipt
ocy
tosi
sincr
easeshemol
ysi
s

Howdoesi
ncr
easei
nhemol
ysi
sleadst
ost
onesf
ormat
ion?

Excessi
vehemol
ysi
swi
l
llead t
o ani
ncr
eased r
ateofpr
oduct
ionofunconj
ugat
ed
bi
l
irubi
nwhi
chsomewon’
tbeconj
ugat
edi
nthel
i
verandpassunconj
ugat
edi
ntot
he
gal
lbl
adder
,theunconj
ugat
edbi
l
irubi
nwi
l
lcombi
newi
thcal
cium i
nbi
l
etof
orm cal
cium
bi
l
li
rubi
nat
e,hencebl
ackst
onesf
ormat
ion

I
nfect
ioust
heor
y

Par
asi
ti
cinf
est
ati
on(
Clonor
chi
ssi
nensi
s)l
eadst
oobst
ruct
ionofbi
l
e,whi
chl
eadst
o
superi
mposedbact
eri
ali
nfect
ionbyE.Col
i(Mostcommon)

Thenhowdoest
hisl
eadt
ost
onesf
ormat
ion?
??

48
 AMI
N’STI
PS@GENERALSURGERY

Par
asi
ti
cinf
est
ati
on(
Clonor
chi
ssi
nensi
s)l
eadst
oobst
ruct
ionofbi
l
e,whi
chl
eadst
o
superi
mposed bact
eri
ali
nfect
ion byE.Col
i(Mostcommon)whi
ch secr
ete bet
a
gl
ucur
oni
dase t
hat enzy
mat
ical
l
y cl
eav
es bi
l
irubi
n t
o pr
oduce t
he i
nsol
ubl
e
unconj
ugat
edbi
l
irubi
n,t
heni
tpr
eci
pit
ateswi
thcal
cium andal
ongwi
thdeadbact
eri
al
cel
lbodi
es,t
hesebact
eri
alcel
lbodi
esgi
vesbr
owncol
orhencebr
ownpi
gment
ed
st
ones

2.Ext
ral
umi
nal
causes

Thesesar
ethecauseswhi
chor
igi
nat
esout
sidet
heext
rahepat
icbi
l
iar
ytr
eel
eadi
ngt
o
compr
essi
onoft
hebi
l
iar
yleadi
ngt
oobst
ruct
ion

-
Car
cinomaheadofpancr
eas(
Youshoul
dnow t
her
iskf
act
orsandpr
esent
ati
onof
Pancr
eat
icCar
cinoma)

-
Chr
oni
cpancr
eat
it
is

-
Mal
i
gnantl
ymphnodesatpor
tal
hepat
is

(
thi
s met
ast
asi
stot
hese l
ymph nodes atpor
talhepat
is can ei
therbe f
rom t
he
car
cinoma oft
he esophagus (
int
raabdomi
nalpar
toft
he esophagus)
,orgast
ri
c
car
cinomaorcol
orect
alcar
cinoma)

NB:
Por
tal
hepat
isa.
k.ahepat
oduodenal
li
gament

3.I
ntr
amur
alcauses

Thesear
ethecauseswhi
chor
igi
nat
esf
rom t
hewal
loft
hebi
l
iar
ytr
ee

49
 AMI
N’STI
PS@GENERALSURGERY

-
Car
cinomaoft
heAmpul
l
aofVar
ter(
Car
cinomaoft
hesphi
nct
erofOddi
)

You shoul
d beabl
eto di
ff
erent
iat
ebet
ween t
wo t
ermswhi
ch ar
emostoft
imes
conf
usi
ngst
udent
sandseni
ordoct
ors.

Thet
ermsar
eAmpul
l
aryt
umorandPer
iampul
l
aryt
umor

Answer
;Ampul
l
aryt
umora.
k.aCar
cinomaoft
heAmpul
l
aofVar
tera.
k.aCar
cinomaof
t
hesphi
nct
erofOddi
thi
stumoror
igi
nat
ing/
ari
singatt
heampul
l
aofVar
ter
.

Theampul
l
aofVar
teri
slocat
edatt
hesecondpar
toft
heduodenum appr
ox.10cm
f
rom t
hepy
lor
us.Att
heampul
l
aofVar
tert
her
eisat
hickcoatofci
rcul
arsmoot
h
muscl
essur
roundi
ngt
heCBD,t
heseci
rcul
arsmoot
hmuscl
eswhi
chsur
roundst
he
i
ntr
aduodenalCBDi
scal
l
edsphi
nct
erofOddi
,andi
stheonewhi
chcont
rol
sfl
owofbi
l
e
andpancr
eat
icj
uicei
ntot
heduodenum

Per
iampul
l
aryt
umor
,Per
imeans ar
ound can be pr
e,i
ntr
a and post
)ther
efor
e
per
iampul
l
aryt
umorar
ethet
umor
sar
oundt
heampul
l
aofVar
ter
.

Thef
oll
owi
ngt
umor
sar
efal
li
nthenameofper
iampul
l
aryt
umor

-
Thet
umoratt
heampul
l
aofVar
ta

-
Dist
alchol
angi
o-car
cinoma

-
Duodenal
tumor
s

-
Car
cinomaheadoft
hepancr
eas

-
Chol
angi
ocar
cinoma(
Classi
fi
cat
ionofchol
angi
ocar
cinoma)

Canbecl
assi
fi
edi
ntot
hreecl
assi
fi
cat
ions
50
 AMI
N’STI
PS@GENERALSURGERY

CLASSI
FICATI
ONIFORCHOLANGI
OCARCI
NOMA

Ther
ear
etwot
ypesofChol
angi
ocar
cinoma,namel
yInt
rahepat
icchol
angi
ocar
cinoma
(
ari
ses f
rom t
he bi
l
iar
ytr
ees wi
thi
nthe l
i
ver
) appr
ox.10% and Ext
rahepat
ic
chol
angi
ocar
cinoma(
ari
sesf
rom t
heext
rahepat
icbi
l
iar
ytr
ee)appr
ox.90%

Ext
rahepat
icchol
angi
ocar
cinomai
sfur
thersubdi
vi
dedi
ntopr
oxi
mal(
per
ihi
l
ar)appr
ox.
65%anddi
stal
chol
angi
ocar
cinomaappr
ox.25%

Pr
oxi
mal (
per
ihi
l
ar) chol
angi
ocar
cinoma i
s f
urt
her subdi
vi
ded i
nto (
Bismut
h
cl
assi
fi
cat
ion)

-
Type1,
inv
olv
ingCHDonl
y

-
Type2,i
nvol
vi
ngCHDandt
heconf
luence(
chol
angi
ocar
cinomaatt
heconf
luencei
s
cal
l
edKl
atski
ntumor
)

-Ty
pe3A,
inv
olv
ingCHDandt
heconf
luence+r
ighthepat
icduct

-Ty
pe3B,
inv
olv
ingCHDandt
heconf
luence+l
efthepat
icduct

-Ty
pe4,
inv
olv
ingCHDandt
heconf
luence+bot
hhepat
icduct
sori
tsmul
ti
focal

Quest
ion;Whatar
etheshor
tcomi
ngsoft
heBi
smut
hcl
assi
fi
cat
ionoft
hepr
oxi
mal
(
per
ihi
l
ar)chol
angi
ocar
cinomaandwhati
sthecl
assi
fi
cat
ionwhi
chov
ercomest
hese
shor
tcomi
ngs)
?

Answer
;

Bi
smut
hcl
assi
fi
cat
ionoft
hepr
oxi
mal(
per
ihi
l
ar)chol
angi
ocar
cinomaf
ocusedonl
yin
t
hel
ocat
ionandext
entofbi
l
educti
nvol
vement(
longi
tudi
nalgr
owt
h)not
ransv
erse
gr
owt
hinv
olv
ement

Memor
ialSl
oan-
Ket
ter
ing CancerCent
re Cl
assi
fi
cat
ion i
s st
agi
ng sy
stem f
orhi
l
ar
chol
angi
ocar
cinomaaccor
dingt
othr
eef
act
orsr
elat
edt
olocal
tumorext
ent
:

-
the l
ocat
ion and ext
entofbi
l
e ducti
nvol
vement(
in agr
eementt
othe Bi
smut
h
Cl
assi
fi
cat
ionsy
stem)
,

-
thepr
esenceorabsenceofpor
tal
venousi
nvasi
on,

51
 AMI
N’STI
PS@GENERALSURGERY

-
andt
hepr
esenceorabsenceofhepat
icl
obarat
rophy
.

Thei
nit
ialsy
stem compr
isesf
ourst
agi
nggr
oups,
butwassi
mpl
i
fiedt
hreey
ear
slat
ert
o
t
he def
ini
te modelwhi
ch compr
ises t
hree st
age gr
oupi
ngs r
athert
han f
ourand
r
epr
esent
sasi
mpl
ecombi
ningoft
wost
agesf
rom t
heear
li
erf
ormat
.

CLASSI
FICATI
ONI
IFORCHOLANGI
OCARCI
NOMA

Scl
erosi
ng(
80%)

Nodul
ar

Papi
l
lar
y

CLASSI
FICATI
ONI
II(
oft
heext
rahepat
icchol
angi
ocar
cinomaonl
y)

52
 AMI
N’STI
PS@GENERALSURGERY

Uppert
hir
dappr
ox.50%(
ext
rahepat
icbi
l
iar
ytr
eepr
oxi
malt
othecy
sti
cductconf
luence
wi
thCHD)

Mi
ddl
ethi
rdappr
ox.25%(
from cy
sti
cductconf
luencewi
thCHDt
otheuppermar
ginof
he1stpar
t toft
heduodenum

Lowert
hir
dappr
ox.20%(
from t
heuppermar
gi he1stpar
noft toft
heduodenum t
othe
ampul
l
a)

Di
ff
uset
ypeappr
ox.5%

-
Chol
edochal
cyst(
Classi
fi
cat
ionofchol
edochal
cyst
)

53
 AMI
N’STI
PS@GENERALSURGERY

Ty
pesofchol
edochal
cyst
s

Ty
pe1t
hemostcommont
ype(
80—90%)i
nvol
vi
ngsaccul
arorf
usi
for
m di
l
atat
ionofa
por
ti
onorent
ir
eCBDwi
thnor
mal
int
rahepat
icduct
s

Ty
pe2i
sol
ateddi
ver
ti
cul
um pr
otr
udi
ngf
rom t
heCBD

Ty
pe3chol
edochocel
e;ar
isef
rom di
l
atat
ionofduodenalpor
ti
onofCBD orwher
e
pancr
eat
icduct
smeet

Ty
pe4achar
act
eri
zedbymul
ti
pledi
l
atat
ionsoft
hei
ntr
ahepat
icandext
rahepat
icbi
l
e
duct
s

Ty
pe4bmul
ti
pledi
l
atat
ionsi
nvol
vi
ngonl
ytheext
rahepat
icbi
l
educt
s

Ty
pe5Car
oli
’
sdi
sease;
cyst
icdi
l
atat
ionofi
ntr
ahepat
icbi
l
iar
yduct
s

*
*Ty
pe6i
sol
atedcy
sti
nthecy
sti
cductonl
y

-
Bil
i
aryAt
resi
a(Cl
assi
fi
cat
ionofbi
l
iar
yat
resi
a)

Kasaicl
assi
fi
cat
ioni
susedt
odescr
ibet
het
hreemai
nanat
omi
calt
ypesofbi
l
iar
y
at
resi
a

NB:someaut
hor
shav
ement
ionedt
hisanat
omi
calcl
assi
fi
cat
ionasJapaneseand
Angl
o-Saxoncl
assi
fi
cat
ion

Ty
pe1:
obl
i
ter
ati
onofCBD(
pat
entcy
sti
candCHD)

Ty
pe2:

2a;obl
i
ter
ati
onofCHD(
pat
entcy
sti
candCBD)somet
imeswi
thacy
stathi
l
um hence
t
ermedcy
sti
cbi
l
iar
yat
resi
a

2b;
obl
i
ter
ati
onofCHD,
cyst
icductandCBD

Ty
pe3:(
mostcommont
ype,
appr
ox.90%)
:obl
i
ter
ati
onofr
ightandl
efthepat
icduct
sat
t
hel
evel
ofpor
tal
hepat
is

54
 AMI
N’STI
PS@GENERALSURGERY

-
Pri
mar
yscl
erosi
ngchol
angi
ti
s(PSC)

Def
ini
ti
on-i
sthef
ibr
oust
hickeni
ngofCBDandbi
l
iar
yduct
ularwal
l
sassoci
atedwi
th
mul
ti
plest
ri
ctur
eswi
thdi
l
atat
ionsbet
weenst
ri
ctur
es

Whati
sthemostsev
erel
yst
ri
ctur
edsegmenti
nthePSCi
satt
heConf
luenceofRHD
andLHD?

-
Bil
i
aryst
ri
ctur
e(CBDst
ri
ctur
e)

Causes

Postopappr
oxi
mat
ely80% (
exampl
echol
ecy
stect
omy
,gast
rect
omy
,duodenaland
pancr
eassur
ger
ies)

I
nfl
ammat
orycondi
ti
ons,st
ri
ctur
esduet
orecur
rentat
tackofchol
angi
ti
sduet
oCBD
st
ones,
par
asi
tes(
Clonor
chi
ssi
nensi
sandascar
is)
,andPSC

Mal
i
gnantdi
sease—Chol
angi
ocar
cinoma

Tr
auma

I
nst
rument
ati
onexampl
eERCP

I
ntr
aabdomi
nal
TB

Bi
smut
hcl
assi
fi
cat
ionofBi
l
iar
yst
ri
ctur
e

Ty
pe1;
lowCBDst
ri
ctur
ewi
thst
ump(
proxi
mal
tost
ri
ctur
e)>2cm

Ty
pe2;
middl
eCBDst
ri
ctur
ewi
thpr
oxi
mal
stump<2cm

Ty
pe3;
hil
ar,
att
heconf
luenceofr
ightandl
efthepat
icduct
s

Ty
pe4;
separ
atedr
ightandl
efthepat
icduct
s

Ty
pe5;
str
ict
urei
nvol
vi
ngi
ntr
ahepat
ic

55
 AMI
N’STI
PS@GENERALSURGERY

Whatar
ethet
hreecommonestcausesofObst
ruct
ivej
aundi
ceatourset
ti
ng?

Thet
hreecommonestcausesofObst
ruct
ivej
aundi
ceatourset
ti
ngar
e

1.Car
cinomaoft
heheadofpancr
eas

2.Chol
edochol
i
thi
asi
s

3.Mal
i
gnantl
ymphnodesatpor
tal
hepat
is

CARDI
NALSYMPTOMSANDSI
GNSOFOBSTRUCTI
VEJAUNDI
CE

(
i) Jaundi
ce

Whyj
aundi
ce?

Whi
chf
orm(
type)ofbi
l
irubi
nisel
evat
ed?Bywhatr
ati
o?

Conj
ugat
edbi
l
irubi
nisel
evat
edbymor
ethan50%oft
het
otal
bil
i
rubi
n

Nat
ureofj
aundi
ce–canei
therbe

-
Progr
essi
veor

-
Int
ermi
tt
entor

-
Fluct
uat
ing

(
NB:
Knowt
hedi
ff
erencebet
weeni
nter
mit
tentandf
luct
uat
ingj
aundi
ce)

I
nter
mit
tent
-onandof
fjaundi
ce(
epi
sodewi
thj
aundi
cet
hent
her
ecomesepi
sodeof
compl
eter
emi
ssi
onofj
aundi
ce)whi
l
efl
uct
uat
ingv
ari
ati
onofi
ntensi
tyofj
aundi
ce.
(
deepj
aundi
cewi
tht
inge(
sli
ght
)jaundi
cewi
thoutcompl
eter
emi
ssi
onofj
aundi
ce)

56
 AMI
N’STI
PS@GENERALSURGERY

Eachnat
urecanpr
edi
ct–cause(
diagnosi
s),
giv
eexampl
e

Car
cinoma head pancr
eas,Mal
i
gnantLy
mph nodes atpor
talhepat
is of
ten cause
pr
ogr
essi
vej
aundi
ce

Chol
angi
ocar
cinoma,chol
edochalcy
standpr
imar
yscl
erosi
ngchol
angi
ti
scanof
ten
causef
luct
uat
ingj
aundi
ce

CBDst
onesof
tencausei
nter
mit
tentj
aundi
ce

Quest
ion;
CanCBDst
ones(
chol
edochol
i
thi
asi
s)causepr
ogr
essi
vej
aundi
ce?

Answer
;Yes;whent
hest
onecompl
etel
yimpact
stheCBD,i
twi
l
lcausepr
ogr
essi
ve
j
aundi
ce,butwhent
hei
mpact
edst
onedi
slodgesonandof
ftheni
nter
mit
tentj
aundi
ce
occur
s

(
ii
) Bodyi
tchi
ng–whyi
tchi
ng?Becauset
her
eisdeposi
ti
onofbi
l
esal
tsi
nthe
t
inybl
oodv
essel
soft
heski
n(sogi
vi
ngant
i-
hist
ami
nest
orel
i
evei
tchi
ngi
n
obst
ruct
ivej
aundi
cei
sNOTi
ndi
cat
edbecausehi
stami
nei
snott
hecauseof
j
aundi
ce)

(
ii
i) Dar
kyel
l
owur
ine–why
?Becauset
her
eisexcessbi
l
irubi
ninbl
oodwhi
chi
sin
conj
ugat
edf
orm andt
hisonei
ssol
ubl
ether
efor
ecanbeexcr
etedi
nur
ineby
t
heki
dney
,ther
efor
eitwi
l
lal
sobeexcr
etedi
nexcessbecausei
tisi
nexcess
i
nbl
ood,r
ememberbi
l
irubi
nisay
ell
ow pi
gmenthencedeep(
dar
k)y
ell
ow
col
oredur
ine

(
iv) Pal
e st
ool– (
stool
s ar
efoulsmel
l
ing,bul
kyand di
ff
icul
ttof
lash,can
somet
imebegr
easy
)whypal
est
ool
s?Becausebi
l
edoesnotr
eacht
he
i
ntest
inesi
tisobst
ruct
edatacer
tai
npoi
ntbef
orer
eachi
ngt
hei
ntest
ines,
t
her
efor
ether
ewi
l
lbenost
ercobi
l
inf
ormat
ion,
andweknowst
ercobi
l
ini
sthe
onewhi
chgi
vesnor
malcol
ort
ost
ool
,(r
eferhemedegr
adat
ionpat
hway

57
 AMI
N’STI
PS@GENERALSURGERY

abov
e)t
henwhati
sther
eal
nor
mal
col
orofst
ool
??

Compl
i
cat
ionsofobst
ruct
ivej
aundi
ce

Regar
dlessoft
hecauseofobst
ruct
ivej
aundi
ce,
whet
herabeni
gnormal
i
gnantcause

Apat
ientwi
thobst
ruct
ivej
aundi
cewi
l
lfacet
hef
oll
owi
ngcompl
i
cat
ions

1.Fatmal
absor
pti
on

- Why f
atmal
absor
pti
on? Because bi
l
e does notr
each t
he i
ntest
ines i
tis
obst
ruct
edatacer
tai
npoi
ntbef
orer
eachi
ngt
hei
ntest
ines,t
her
efor
ether
ewi
l
l
benobi
l
eaci
ds/
sal
tsi
nthei
ntest
inewhi
chemul
sif
iesf
atsf
orabsor
pti
onoff
at
andf
at-
sol
ubl
evi
tami
nADEK,
hencewi
l
lleadt
ofatmal
absor
pti
on

Ef
fect
soff
atmal
absor
pti
onar
e;

Uni
ntent
ional
wei
ghtl
oss(
lackoff
ati
nthebody
,hencei
mbal
anceddi
et)

i
fthecausei
smal
i
gnantpr
ocesswei
ghtl
ossi
ssev
ereduet
ocanceref
fect
s,cachexi
a

Coagul
opat
hy(
def
ici
encyofv
itami
nK,whi
chi
sfatst
abl
evi
tami
n,Whycoagul
opat
hy
i
nvi
tami
nKdef
ici
ency
?)

Answer
;Ther
ear
ecl
ott
ingf
act
ors(
2,7,
9,and10)whi
char
eVi
tami
nKdependent
,soi
n
absenceofv
itami
nKt
hesecl
ott
ingf
act
orsar
einact
ive,
hencepr
olongedcl
ott
ingt
ime

St
eat
orr
hea(
fat
tydi
arr
hea)(
Bul
ky,
foul
smel
l
ingst
ool
swhi
char
edi
ff
icul
ttof
lash)

2.Ascendi
ngchol
angi
ti
s

58
 AMI
N’STI
PS@GENERALSURGERY

Howdoest
hishappen?

Duet
obi
l
est
asi
sther
eissuperi
mposedbact
eri
ali
nfect
ion,mostcommonE.
Col
i
,bi
l
eget
sinf
ect
edandt
hepat
ientwi
l
lpr
esentwi
thChar
cot
’st
ri
ad

Howi
sitpr
esent
ed(
Char
cot
’st
ri
ad)
?

I
tpr
esent
swi
thJaundi
ce,
fev
erandupperabdomi
nal
pai
n

3.Rey
nol
d’spent
ad

Howdoest
hishappen?

Undert
reat
edornegl
ect
edascendi
ngchol
angi
ti
smor
ecompl
i
cat
ionsoccur
,bi
l
e
get
ssuppur
atedandl
eadst
osev
eresy
stemi
ccompl
i
cat
ionsandsept
icshock
andt
hepat
ientwi
l
lpr
esent
swi
thRey
nol
d’
spent
ad

Howi
sitpr
esent
ed(
component
soft
hepent
ad)
?

I
tpr
esent
swi
thf
eat
uresofChar
cot
’st
ri
adpl
usal
ter
edl
evelofconsci
ousness
andsept
icshock.

4.Bi
l
iar
yci
rr
hosi
s,

How?Duet
oincr
easedbi
l
econgest
ioni
ntheCBD,
ther
eisbackf
lowofbi
l
eint
o
t
hel
i
ver
,thel
i
verbecomesenl
argedgr
eenbi
l
est
ained(
hydr
ohepat
osi
s).Once
i
ntr
aduct
alCBD pr
essur
eri
ses,i
ntr
ahepat
ic congest
ion i
ncr
eases and bi
l
e
secr
eti
onf
rom t
hel
i
veri
sreduced,
causi
ngf
ormat
ionofwhi
tebi
l
einCBD.Bi
l
iar
y
ci
rr
hosi
smaydev
elopl
ater

5.Hepat
orenal
syndr
ome,

How?I
saf
orm ofacut
erenalf
ail
uret
hatdev
elopsasLi
verDi
seasewor
sens?

59
 AMI
N’STI
PS@GENERALSURGERY

Theet
iol
ogyi
suncl
ear
,butspl
anchni
cvasodi
l
atat
ionandi
ncr
easepr
oduct
ionof
v
asodi
l
ator
sresul
tsi
nadecl
i
neofr
enal
per
fusi
on

NB:
PATI
ENTWI
THPAI
NINJAUNDI
CEFROM CARCI
NOMAHEADOFPANCREASVERSUS
CHOLEDOCHOLI
THIASI
S

Al
thoughitisoft
ent aughtthatcarci
nomaoft hepancreaspresent
swithpainl
ess
j
aundice(
tohel
pdist
ingui
shitfr
om choledochol
i
thiasi
s),
thi
saphori
sm i
snotaccur
ate

Mostpat
ient
sdoexper
iencepai
naspar
toft
hesy
mpt
om compl
exofpancr
eat
iccancer
,
andi
tisoft
enthef
ir
stsymptom

Theref
ore,awarenessofthewaypancr
eat
icpai
nisper
cei
ved mayhel
p cl
i
nici
ans
suspectpancr
eati
ccancer

Thepainassoci
atedwit
hpancreat
iccanceri
susual
lyper
cei
vedintheepigast
ri
um but
canoccuri
nanypartoftheabdomen,andoft
en,
butnotal
ways,
penetr
atestotheback

Whenquesti
onedinretr
ospect
,pat
ient
sof
tenr
ecal
lmi
l
dandv
aguepai
nformany
mont
hsbefor
ediagnosi
s

Reference:
Schwar t
z’sPri
nci
plesofSur y11thEdi
ger ti
onPage1486l
astpar
agr
aphr
ightcol
umnt
o
fi
rstparagraphl
eftcol
umnPage1487

HOW TOCLERKAJAUNDI
CEDPATI
ENT

NB;

1.Youhav
etocl
erkaj
aundi
cedpat
ientandnotapat
ientwi
thobst
ruct
ivej
aundi
ce

(
meani
ng;bei
ngj
aundi
cedcanei
therbemedi
cal(
preandi
ntr
ahepat
ic)orsur
gical
(
obst
ruct
ive/
ext
rahepat
ic)
,sobot
hoft
hem hav
etober
uledouti
ntheHPI

2.Forpedi
atr
icspat
ient
s,congeni
talcausesofj
aundi
ceshoul
d bet
aken i
nto
consi
der
ati
ons

60
 AMI
N’STI
PS@GENERALSURGERY

HI
STORYTAKI
NGFORAPATI
ENTWI
THJAUNDI
CE

Chi
efcompl
aint
s

Yel
l
owi
shdi
scol
orat
ionoft
heey
es/
ski
n(f
oracer
tai
nper
iodoft
ime)

HPI

PARTA

DONPARA

Howdi
dhe/
shenot
ice?

Onset
,usual
l
yonseti
sgr
adual
l
y,Nat
ure,canei
therbepr
ogr
essi
ve,i
nter
mit
tentor
f
luct
uat
ing,Per
iodi
cit
y,usual
l
ynotper
iodspeci
fi
c,Aggr
avat
ingorr
eli
evi
ngf
act
ors,
usual
l
yther
eisnospeci
fi
caggr
avat
ingorr
eli
evi
ngf
act
ors,
Associ
atedsy
mpt
oms;
Ask-
i
fther
eishi
stor
yofbodyi
tchi
ng,i
fhe/
shepassesdeepy
ell
ow col
oredur
ine,col
orof
st
ool
,isi
tcl
ayornor
mal
?bul
kyst
oolwi
thf
oulsmel
l
ing?How i
sit
stendencydur
ing
f
lashi
ng,
isi
teasyordi
ff
icul
ttof
lash?(
enqui
ret
ypeoft
oil
ets/
hei
susi
ngt
oknowt
his)
I
sther
eabdomi
nalpai
n?(
ifabdomi
nalpai
nispr
esentt
henr
emov
eitf
rom associ
ati
ng
sy
mpt
omsandmakei
tadi
ff
erentchi
efcompl
aint
,andampl
i
fyi
tsepar
atel
yint
heHPI
)

PARTB

RULLI
NGOUTPOSSI
BLEDI
FFERENTI
ALSOFJAUNDI
CE

Aski
fthef
oll
owi
ngcompl
i
cat
ionsar
epr
esent
;

uni
ntent
ionalwei
ghtl
oss,easybl
eedi
ngonbr
uises,bl
eedi
ngeasi
l
yfr
om gumsdur
ing
t
eet
hbr
ush,
hist
oryoff
ever

Askf
orpossi
blecausesofj
aundi
ce(
youshoul
dknowt
her
easonf
oreachquest
iony
ou
ask)

St
artt
oaskf
orcausesobst
ruct
ivej
aundi
ce

Enqui
rehi
stor
yof
;

-
how manychi
l
drendoesshehav
e?(
iff
emal
e),hi
stor
yofcont
racept
iveuse?I
fyes,

61
 AMI
N’STI
PS@GENERALSURGERY

whi
cht
ype&f
orhow l
ong?hi
stor
yofabdomi
nalsur
ger
ies,di
et(
askdi
rect
lyonr
isky
di
etsf
orst
ones f
ormat
ion,i
n met
abol
i
ctheor
y),i
sther
e hi
stor
y ofpr
olonged
st
arv
ati
on/
orf
eedi
ngt
hroughot
herr
out
esapar
tfr
om mout
h,suchasi
ntr
avenous
f
eedi
ngi
nanypoi
ntofhi
sli
fet
ime?

-
whati
shi
s/herdewor
minghabi
t?Whendi
dhe/
shel
astdewor
m?

-
ist
her
ehi
stor
yofl
i
vingi
nar
easwi
thl
i
vest
ockkeepi
ngar
easi
nhi
s/herl
i
fet
ime?

-
hist
oryofi
nst
rument
ati
onpermout
hpr
ioronsetofi
l
lness

-
hist
ory ofdi
ff
icul
tyi
n swal
l
owi
ng and r
egur
git
ati
on,hi
stor
y ofear
ly sat
iet
y and
abdomi
nal
ful
l
ness,
hist
oryofbl
oodi
nst
ool
,passi
ngmucoi
dst
ool
,al
ter
edbowel
habi
ts,
i
sther
eanyhi
stor
yofat
tacksofabdomi
nalpai
nspr
iort
othecur
renti
l
lness,andi
s
t
her
eany
onei
nthef
ami
l
ywi
thsi
mil
arcondi
ti
on

St
artt
oaskcausesf
ori
ntr
ahepat
icj
aundi
ce

Enqui
rehi
stor
yof
;

-
Hist
oryofal
cohol
i
sm,i
fyes,whatt
ypeandf
orhowl
ongandci
gar
ett
esmoki
ng(
tobe
expr
essedi
npacky
ear
s)

-
hist
oryofbl
oodt
ransf
usi
onbef
oret
heonsetofi
l
lness,hi
stor
yofmul
ti
plesexual
par
tner
sandpr
act
ici
ngunpr
otect
edsexuali
nter
cour
se,hi
stor
yoft
att
ooi
ng,hi
stor
yof
i
/vdr
ugabuseandi
ss/
hehabi
tual
consumerofgr
oundnut
sandmushr
ooms

St
artt
oaskcausesf
orpr
ehepat
icj
aundi
ce

Enqui
rehi
stor
yof
;

-
ishe/
sheaknownpat
ientwi
thsi
ckl
ecel
ldi
sease,
diabet
esmel
l
itusandHI
Vdi
sease?

ONEXAMI
NATI
ONOFAPATI
ENTWI
THJAUNDI
CE

NB:

Ther
ear
eabout20st
igmat
aofLi
verdi
sease.Youmustknow t
hem al
l
.(f
orr
esi
dent
s

62
 AMI
N’STI
PS@GENERALSURGERY

mustknowhowdot
heycomeabout
)

Repor
teachsi
gni
nit
scor
rectposi
ti
ondur
ingexami
nat
ion

Thati
s,t
her
ear
esomest
igmat
aofLi
verdi
seaset
hatwi
l
lber
epor
tedi
nthegener
al
exami
nat
ion,some i
nrespi
rat
ory exami
nat
ion and some dur
ing perabdomi
nal
exami
nat
ionet
c.

Perabdomi
nal
exami
nat
ionofaj
aundi
cedpat
ienti
sver
yimpor
tant

Pal
pabi
l
ityoft
hegal
lbl
adderi
sver
yimpor
tantf
eat
ure(
sign)t
onot
ice

Nameandst
atet
hel
awgov
erni
ngpal
pabi
l
ityoft
hegal
lbl
adderi
naj
aundi
cedpat
ient

Cour
voi
sier
’sl
aw st
atest
hat
,inaj
aundi
cedpat
ientwi
thapal
pabl
egal
lbl
adderi
tis
unl
i
kel
ythecauset
obest
ones

Whati
sther
easonbehi
ndt
hel
aw?

Appr
oxi
mat
ely90% oft
heCBD st
onesar
eSecondar
ygal
lbl
adderst
ones,meani
ng,
pr
imar
il
ytheywer
efor
medi
nthegal
lbl
adder
,whi
l
ethesest
oneswher
eint
hegal
l
bl
addert
her
ewer
erepeat
edat
tacksofi
nfl
ammat
ionwhi
chhasmadet
hegal
lbl
addert
o
heal
byf
ibr
osi
shencei
tbecomesshr
unk.

Whatar
etheexcept
ionsoft
hel
aw?

1.Doubl
eimpact
ionsofst
ones,onei
ntheCBDanot
heri
nthecy
sti
cduct
.Theone
i
ntheCBDwi
l
lcauseobst
ruct
ivej
aundi
cewhi
l
ethati
nthecy
sti
cductwi
l
lcause
gal
lbl
adderout
letobst
ruct
ionhenceaccumul
ati
onofmucuswhi
chi
sregul
arl
y
pr
oducedbyt
hegal
lbl
adderwi
thbi
l
e(mucocel
eoft
hegal
lbl
adder
)whi
chcan
l
edt
odi
stensi
onoft
hegal
lbl
adderhencei
twi
l
lbepal
pabl
e

2.Mi
ri
zzisy
ndr
ome st
one i
nthe cy
sti
c duct
/i
nfundi
bul
um oft
he gal
l
bladder
obst
ruct
ingCHD/
CBD,soasi
ngl
est
onei
nwi
tht
woobst
ruct
iveef
fect
s,f
ir
st
obst
ruct
ingt
heCHD/
CBDwi
l
lleadt
oobst
ruct
ivej
aundi
ce,secondgal
lbl
adder
out
letobst
ruct
ionbyi
mpact
ingt
hecy
sti
cduct
/i
nfundi
bul
um oft
hegal
lbl
adder
,
henceaccumul
ati
onofmucuswhi
chi
sregul
arl
ypr
oducedbyt
hegal
lbl
adder
wi
thbi
l
e(mucocel
eoft
hegal
lbl
adder
)whi
chcanl
edt
odi
stensi
onoft
hegal
l

63
 AMI
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bl
adderhencei
twi
l
lbepal
pabl
e

3.Pr
imar
yCBDst
ones,
thesest
onehav
enev
erbeeni
nthegal
lbl
adderatf
ir
stt
ime,
t
heyar
epr
imar
il
yint
heCBD and so no r
epeat
ed at
tacksofi
nfl
ammat
ion
expect
edt
ohav
eoccur
red,t
her
efor
ethegal
lbl
adderi
snotshr
unkenandcan
di
stendandbepal
pabl
e.

Common i n Asi
an popul
ati
on, i
n t
he di
sease cal
l
ed Pr
imar
y Or
ient
al
Chol
angi
ohepat
it
is
4.Pat
ient wi
th car
cinoma head of pancr
eas i
n whom hav
e under
went
chol
ecy
stect
omy(
sur
gicalr
emov
aloft
hegal
lbl
adder
).Asal
aw suggestwe
expecti
napat
ientwi
thcar
cinomaheadofpancr
easagal
l
bladdert
obepal
pabl
e,
buti
nthi
sitwon’
tbepal
pabl
ebecausei
thasbeenr
emov
edi
nthepast

-
onDRE,
don’
tfor
gett
oinspectt
hegl
ovedf
ingerandr
epor
tthecol
orofst
ool

DI
AGNOSI
SFORMULATI
ON

I
fthepat
ienti
shav
ingf
eat
uresofObst
ruct
ivej
aundi
ce(
from HPIandexami
nat
ion)

Thent
hedi
agnosi
swi
l
lbe

Dx:
Obst
ruct
ivej
aundi
ceSecondar
yto(
--
-)(
from HPIandexami
nat
ion)

Thenputy
ourdi
ff
erent
ial
s

I
NVESTI
GATI
ONS

1.Li
stt
hei
nvest
igat
ionst
hatconf
ir
m pr
esenceofobst
ruct
ivej
aundi
ce,
whi
char
e;

Ser
um bi
l
irubi
n(bot
hdi
rectandt
otal
)

Whati
stheexpect
edpi
ctur
eofser
um bi
l
irubi
ninapat
ientwi
thobst
ruct
ive
j
aundi
ce?

Conj
ugat
edbi
l
irubi
nisexpect
edt
obemor
ethan50%oft
het
otal
val
ue

64
 AMI
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Ser
um ALP(
howi
sitexpect
edt
obei
napat
ientwi
thobst
ruct
ivej
aundi
ce,
and
why
?)

Ser
um GGT(
howi
sitexpect
edt
obei
napat
ientwi
thobst
ruct
ivej
aundi
ce,
and
why
?)

Ser
um ALP andGGT ar
eel
evat
edi
nobst
ruct
ivej
aundi
ce,becauset
heyar
e
pr
oducedf
rom t
hechol
angi
ocy
tes,anyst
resst
othechol
angi
ocy
teswi
thr
aise
GGTandALP

NB;
GGTandALPar
enotpar
tofl
i
verf
unct
ion

Ur
inal
ysi
s(t
hisi
sthemosti
mpor
tanti
nvest
igat
iont
odi
agnoseobst
ruct
ive
j
aundi
ce atpr
imar
y heal
thf
aci
l
iti
es (
dispensar
ies)
.Indi
cat
es pr
esence of
obst
ruct
ivej
aundi
cebutNOTt
hecauseofobst
ruct
ivej
aundi
ce

Howcani
tdi
agnoseobst
ruct
ivepat
ient
?

Undernor
malci
rcumst
ancesbi
l
irubi
nisnotf
oundi
nur
ine,ur
obi
l
inogeni
sthe
onef
oundi
nur
inenor
mal
l
y

Ther
efor
e,i
fbi
l
irubi
nisf
ound i
n ur
ine i
tindi
cat
es t
her
eis an i
ncr
ease i
n
conj
ugat
edbi
l
irubi
nint
heci
rcul
ati
onbecausei
tist
heonewhi
chi
sexcr
etedi
n
ur
inebyt
heki
dney
srat
hert
hanunconj
ugat
edbi
l
irubi
n

NB:Maynotbeappl
i
edr
egul
arl
yatMNH(
becausei
t’
saNat
ionall
evel
,Ter
ti
ary
Hospi
tal
)buti
tisi
mpor
tantt
oknowasy
ouar
etr
ainedt
owor
kany
wher
enotonl
y
atMNH

65
 AMI
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2.I
nvest
igat
ionsf
orcompl
i
cat
ions

Bl
eedi
ngi
ndi
ces,
PT,
PTTandI
NR(
howar
etheyexpect
edt
obei
napat
ientwi
th
obst
ruct
ivej
aundi
ce)
?Theset
imesar
eexpect
edt
obepr
olonged(
reasonr
efer
backt
ocompl
i
cat
ionsofobst
ruct
ivej
aundi
ce)

3.I
nvest
igat
ionst
ofi
ndt
hecausesofobst
ruct
ivej
aundi
ce

Abdomi
nal
ult
rasound

Abdomi
nal
CTScan

MRCP

ERCP

Endoscopi
cul
tr
asound

PTC

Readont
hei
ndi
cat
ionsofeachoft
heabov
einv
est
igat
ions

4.Thendobasel
i
nei
nvest
igat
ions

NB:
TI
PSFORDIAGNOSTI
CIMAGI
NGI NAJAUNDICEDPATIENT
I
npat i
entspresent
ingwi
thj
aundi
ce,ar
easonabl
efi
rstdi
agnost
icimagi
ngst
udyi
s
abdominalul
tr
asound

1.I
fbi
l
eductdi
l
ati
oni
snotseen,
hepat
ocel
l
ulardi
seasei
sli
kel
y.

2.Ifcholel
it
hiasis(stonesinthegal lbladder)and bi
l
eductdilat
ionareseen,
suggestsadi agnosisofchol
edocholi
thiasi
s,andthenextl
ogi
calstepwoul
dbe
ERCPt oclearthebil
eductstones.

66
 AMI
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3.I
nt heabsenceofgall
stones,BUTpresenceofbi
l
eductdil
ati
ont
henmali
gnant
obstr
uct
ionofthebi
leductisli
kel
y,andaCTscanrat
hert
hanERCPwoul
dbet he
nextl
ogical
step.

4.Forpat i
ents suspect
ed ofhav i
ng pancr
eati
c cancerwho pr
esentwithout
jaundi
ce,aCTscanshoul dbet hefir
stt
est
Refer
ence:
Schwartz’
sPri
ncipl
esofSurgery11thEdit
ionPage1487secondpar
agr
aphri
ghtcol
umn

CTf
indi
ngsf
orcar
cinomaheadofpancr
eas

Fi
ndi
ngsthatindicat
eat umorisunr esect
ablei
nclude
1.inv
olv ementof≥180°oft hecel i
acaxi
s,hepati
corsuperiormesent
eri
car
ter
y
2.enlargedlymphnodesout sidetheboundari
esofresect
ion
3.ascit
es
4.anddi stantmetastases(
e. g.,
li
ver)

-
Inv
asionofthesuper
iormesent
eri
cvei
norpor
talv
eini
snoti
nit
sel
facont
rai
ndi
cat
ion
t
oresecti
onaslongasthevei
nsarepat
ent

Tumor
sareconsidered“borderlineresect
able”i f
1.thereisabutmentof≤180degr eesoft heci r
cumfer enceoft heSMA,celi
acaxis,
orhepaticart
eryorifther eisashortsegmentofv einoccl usion
2.Also,pati
entswit
hCTf indingssuspiciousf ormet astati
cdisease,l
i
ke1mm l iv
er
lesi
onstoosmal lt
ochar acter
izeorbiopsy ,areconsidered“ bor
der
li
neresect
able”
asar epati
entswit
hmul t ipl
ecomor bi
ditiesormar ginalperformancest
atus

Refer
ence:
Schwart
z’sPr
inci
plesofSur y11thEdi
ger ti
onPage1487t
hir
dpar
agr
aphr
ightcol
umn

TREATMENT

Chol
edochol
i
thi
asi
s

Readon;

Tr
eat
mentmodal
i
tiesofbot
hpr
imar
yandsecondar
yCBDst
ones

Whati
sthedi
ff
erencebet
weenr
etai
nedCBDst
onesandr
ecur
rentCBDst
ones?

Managementofr
etai
nedst
ones

67
 AMI
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Whati
sSUMPsy
ndr
omeandi
tsmanagement
?

Whati
sSai
ntst
ri
ad?

Mi
ri
zzi
’
sSy
ndr
ome

Csendescl
assi
fi
cat
ionofMi
ri
zzi
’
sSy
ndr
ome

Compl
i
cat
ionsofgal
lst
ones

Pancr
eat
icheadcar
cinoma

Cur
ati
vei
ntent

Ty
pesofWhi
ppl
e’
soper
ati
onandi
ndi
cat
ions

Pal
l
iat
ivei
ntent

Chol
angi
ocar
cinoma

Cur
ati
vei
ntent
ion

Pal
l
iat
ivei
ntent
ion

Beni
gnst
ri
ctur
emanagement

68
 AMI
N’STI
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MUSTTOREADTOPI
CS

I
nfect
ionsoft
heLi
verandt
hei
rmanagement

Beni
gnLi
verl
esi
ons

Mal
i
gnantLi
verl
esi
ons(
pri
mar
yandmet
ast
ati
c)

Por
tal
hyper
tensi
on

BuddChi
ari
syndr
ome

Hepat
icencephal
opat
hy

Acut
eli
verf
ail
ure

Chr
oni
cLi
verdi
sease

Pancr
eat
ict
umor
s

Bot
hendocr
ineandexocr
inepancr
eas

Acut
epancr
eat
it
is

Chr
oni
cpancr
eat
it
is

69
 AMI
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TOPI
CSI
X

LOWERGIBLEEDI
NG
UpperGIbl
eedi
ng i
s bl
eedi
ng pr
oxi
malt
oli
gamentofTr
eit
z(cov
ered i
nInt
ernal
medi
cine)

LowerGIbl
eedi
ngi
sbl
eedi
ngdi
stal
tol
i
gamentofTr
eit
z(Sur
gical
Topi
c)

Mor
ethan90%t
hecausesofl
owerGIbl
eedi
ngar
efr
om l
argebowel
s(col
on,r
ect
um)
andl
esst
han10%i
sfr
om smal
lbowel

LOWERGIBLEEDI
NG

Causesofl
owerGIbl
eedi
ng

1.I
nfl
ammat
orycondi
ti
ons(
Col
i
tis)

a.I
nfect
iousCol
i
tis

Can ei
therbe bact
eri
al,v
iraland par
asi
ti
c.Bact
eri
al(
E.col
i
,Sal
monel
l
a,Shi
gel
l
a,
Yesseni
a).Vi
ral(
CMV common i
nimmunodef
ici
entpeopl
e).Par
asi
ti
c(ent
amoeba,
schi
stosomi
asi
s)

b.I
schemi
cCol
i
tis

70
 AMI
N’STI
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Commonatt
heSpl
eni
cfl
exur
e(wat
ershedar
ea)

Gi
ver
easonwhy
?Becauseofr
educedbl
oodsuppl
ytot
hisar
ea,t
hisar
eahaspoor
col
l
ater
als,canei
therbet
hromboembol
i
cphenomenonoranyf
act
orwhi
chwi
l
lreduce
per
fusi
ont
othecol
on

c.Aut
oimmuneCol
i
tis

TheI
BDs(
Inf
lammat
oryBowel
Condi
ti
ons)

Ul
cer
ati
veCol
i
tis(
U.C)andCr
ohn’
sdi
sease(
C.D)

-
Dif
fer
encesbet
weenU.
CandC.
D

-
Compl
i
cat
ionsofI
BD+ext
racol
oni
cmani
fest
ati
onsofI
BD

-
Treat
mentoft
heI
BD

2.Di
ver
ti
cul
osi
s

Def
ini
ti
on:
out
pouchi
ngofcol
onmucosaandsubmucosat
hroughweakmuscl
elay
er

Commonestsi
te;
sigmoi
danddescendi
ngcol
on

Ri
sk f
act
ors;l
ong st
andi
ng hi
stor
yofconst
ipat
ion,l
ow f
iberdi
et,el
der
lyf
emal
e
(
commonestcauseofl
owerGIbl
eedi
ng i
n el
der
ly)
,mor
einv
eget
ari
an t
han non-
v
eget
ari
an,
useofNSAI
Dsandst
eroi
ds,
smoki
ngandal
cohol
i
sm

Pr
esent
ati
on;
pai
nlessperanal
bleedi
ng

Management
;conser
vat
ivewi
thdi
etmodi
fi
cat
ion,Si
gmoi
dcol
ect
omywi
thendt
oend
anast
omosi
scanbeper
for
med,i
ndi
cat
ionsf
orsur
ger
yar
erecur
rentdi
ver
ti
cul
i
tisand
di
ver
ti
cul
i
tiswi
thcompl
i
cat
ionsl
i
keper
for
ati
on,
fist
ula

3.Angi
oect
asi
a(Angi
ody
spl
asi
a)

Def
ini
ti
on:
dil
atedt
inybl
oodv
essel
sont
hesur
faceoft
hemucosa

Commonsi
te:
rightcol
on

71
 AMI
N’STI
PS@GENERALSURGERY

Ri
skf
act
ors;
elder
ly

Pr
esent
ati
on;
pai
nlessperanal
bleedi
ng

Management
;resect
ion,t
her
apeut
ic embol
i
zat
ion i
s usef
uli
n 85% ofcases and
col
onoscopi
cful
gar
ati
on,(
ful
gar
ati
on meansdest
ruct
ionofsmal
lgr
owt
hs/
areasof
t
issueusi
ngdi
ather
my

4.Beni
gncondi
ti
onsofCol
on-Rect
um –Anus

Hemor
rhoi
ds

o Ty
pes:
int
ernal
andext
ernal
hemor
rhoi
d’s

o Gr
adesofi
nter
nalhemor
rhoi
ds(
Grade1;
pai
nlessperr
ect
albl
eedi
ngwi
th
nomass,Gr
ade2;peranalpr
otr
usi
onwi
thspont
aneousr
educt
ion,Gr
ade
3;peranalpr
otr
usi
onwi
thmanualr
educt
ion,
Grade4;peranalper
manent
pr
otr
usi
onwi
thnor
educt
ionei
therspont
aneousormanual

o Ri
skf
act
ors;
longst
andi
nghi
stor
yofconst
ipat
ion,
lowf
iberdi
et,

o Pr
esent
ati
on:a pai
nless pe r
ect
albl
eedi
ng,pai
nis onl
y when t
he
hemor
rhoi
dsget
sinf
ect
edort
hrombosed

o Tr
eat
ment
;hemor
rhoi
dect
omy

Anal
fissur
e

 Ri
skf
act
ors;l
ongst
andi
nghi
stor
yofconst
ipat
ion,l
ow f
iberdi
et,
posthemor
rhoi
dect
omy
,tr
auma,
anal
sex

 Pr
esent
ati
on;pai
nfulperanalbl
eedi
ng,
char
act
eri
sti
cal
l
yst
reaksof
bl
oodonst
ool
,duet
opai
nmostof
tenDREi
sabandonedt
owai
t
EUA

 Management
;int
ernall
ater
alsphi
nct
erot
omy
,inpat
ient
swi
thanal

72
 AMI
N’STI
PS@GENERALSURGERY

f
issur
etheyi
nvol
unt
ari
l
ycont
ractt
hei
rint
ernalsphi
nct
er,def
ense
mechani
sm agai
nstpai
nfr
om t
hef
issur
e,t
her
efor
ebl
oodsuppl
y
doesnotr
each t
hef
issur
epr
oper
ly,henceno heal
i
ng.I
nter
nal
l
ater
alsphi
nct
erot
omyr
educesspasm ofi
nter
nalsphi
nct
erhence
bl
oodsuppl
yisenought
othef
issur
ehenceheal
i
ng

Pol
yps

 Pr
esent
ati
on;
apai
nlessper
ect
albl
eedi
ng,

 Ty
pes

Ty
pe1;
inf
lammat
ory(
pseudopol
yps)

Ty
pe2;
hyper
plast
ic/
met
apl
ast
ic

Ty
pe3;hamar
tomat
ous(
juv
eni
l
e,cr
onkchi
te-
canadasy
ndr
omeand
Peur
tz-
Jegher
ssy
ndr
ome(
readeachi
ndet
ail
s)

Ty
pe4;
neopl
ast
icpol
yps(
tubul
ar/
peduncul
ated,
vil
l
ous,
andt
ubul
o
-
vil
l
ous(
thesehav
ehi
ghmal
i
gnancyt
ransf
ormat
ionpot
ent
ial
)

 Management
;pol
ypect
omy

5.Mal
i
gnantcondi
ti
onsoft
heCol
on+Rect
um +Anus

6.Mi
scel
l
aneous

- Tr
auma

- Bl
eedi
ngdi
sor
der
s

COLORECTALMALI
GNANCY

73
 AMI
N’STI
PS@GENERALSURGERY

Ri
skf
act
orsofCol
orect
almal
i
gnancy

Pr
imar
yBi
l
e aci
dschol
i
cand chenodeoxy
chol
i
caci
d,appr
oxi
mat
ely95% t
heyar
e
r
eabsor
bedatt
het
ermi
nal
il
eum backt
otheLi
ver(
ent
erohepat
icci
rcul
ati
on)
.

Themi
nor
it
y(appr
oxi
mat
ely5%)ent
erst
hecol
on. Undert
hei
nfl
uenceofcol
oni
c
bact
eri
a,pr
imar
ybi
l
e aci
dsar
e conv
ert
ed t
o secondar
ybi
l
e aci
dsbyr
emov
ing a
hy
drox
ylgr
oupt
opr
oducedeoxychol
i
caci
dfr
om chol
i
caci
dandl
i
thochol
i
caci
dfor
m
chenodeoxy
chol
i
caci
d.

Li
thochol
i
cinpar
ti
cul
ari
sacar
cinogent
ocol
oni
cmucosa

Ther
efor
e,anycondi
ti
onswhi
chi
ncr
easesconcent
rat
ionofl
i
thochol
i
caci
dint
hecol
on,
wi
l
lincr
easet
her
iskofcol
orect
alcar
cinoma

Anycondi
ti
onwhi
chl
eadst
oconst
ipat
ion,wi
l
lincr
easer
iskofcol
orect
alcar
cinoma,
duet
opr
olongeddur
ati
onofcont
actofcar
cinogent
ocol
oni
cmucosa. About80%
col
orect
alcancer
sar
espor
adi
cwhi
l
e20%ar
efami
l
ial

Ri
skf
act
ors;

1.Di
et

I
ncr
easesr
isk(
Sat
urat
ed/
Ani
mal
fat
s,Foodsr
ichi
nchol
est
erol
sandLowf
iberdi
et)

Pr
otect
ivedi
et(
Unsat
urat
edf
at/pl
antf
ats,Hi
ghf
iberdi
et,FoodsRi
chi
ncal
cium and
Vi
tami
nsA,
C,andE+Zi
nc

2.Env
ironment
alf
act
ors

Al
cohol
i
sm,
Smoki
ng,
Obesi
tyandSedent
aryl
i
fe(
Phy
sical
inact
ivi
tydecr
easesi
ntest
inal
mot
il
it
yleadi
ngt
oconst
ipat
ion)

3.Post
-sur
gical
procedur
e

Ter
minali
l
ealr
esect
ionandchol
ecy
stect
omy-I
ncr
easesbi
l
eaci
dsconcent
rat
ioni
n
col
on

74
 AMI
N’STI
PS@GENERALSURGERY

How?I
nter
minali
l
eo-
resect
iont
her
eisbr
eakdownofent
erohepat
icci
rcul
ati
on,nobi
l
e
aci
dst
hatgoesbackt
othel
i
ver
,ther
efor
eal
lofi
tpassesi
ntot
hecol
on,
ther
efor
ether
e
wi
l
lal
sobeexcesssecondar
ybi
l
eaci
dsf
rom pr
imar
ybi
l
eaci
dswhi
chhasent
eredi
n
t
hecol
oni
nexcess.Ther
emor
ethei
ncr
easei
nLi
thochol
i
cconcent
rat
iont
hehi
ghert
he
r
iskofcol
oni
cmal
i
gnancy

Chol
ecy
stect
omy
,Incr
easesbi
l
eaci
dsconcent
rat
ioni
ncol
on,undernor
malcondi
ti
on
gal
lbl
adderst
oresbi
l
etempor
ari
l
yandr
eleasei
twhenneeded,t
akei
nmi
ndt
hel
i
ver
sy
nthesi
zes bi
l
e al
way
s, i
fgal
lbl
adderi
sremov
ed t
hen t
her
e wi
l
lbe excess
accumul
ati
onofbi
l
eaci
dsi
nint
est
ines,
par
twi
l
lber
eabsor
bedbackt
othel
i
vert
hrough
ent
erohepat
icci
rcul
ati
on,par
twi
l
lent
ert
hecol
on(butt
heamountwhi
chent
erst
he
col
oni
sinexcesscompar
ingt
otheamountt
hatent
ersi
ncol
onundernor
mal
stat
e)

Ur
eter
osi
gmoi
dost
omy

How?Epi
thel
i
um oft
hesi
gmoi
dcol
onandr
ect
um ar
eadapt
edt
ost
oolandnotur
ine,
in
ur
eter
osi
gmoi
dost
omy (
anast
omosi
s of ur
eter
s t
o t
he si
gmoi
d col
on)
,hence
met
apl
asi
athendy
spl
asi
aandev
ent
ual
l
ymal
i
gnancy

4.PostRadi
ati
onexposur
e(Pel
vi
s/abdomen)–r
adi
ati
oncar
cinogenesi
s

5.Dr
ugs

-
NSAI
Ds-Ef
fect
sofPr
ost
agl
andi
ns(
PG)i
ncol
oni
cmucosai
sincr
easei
ncel
l
ular
pr
oli
fer
ati
onandi
nhi
bit
sapopt
osi
s,t
heset
woef
fect
spr
edi
sposet
ocol
orect
al
mal
i
gnancy
,any
thi
ngt
hat
’si
nhi
bit
sPr
ost
agl
andi
nwi
l
lbeapr
otect
iveagai
nst
col
orect
almal
i
gnancy
,NSAI
Ds i
nhi
bit
s cy
clooxy
genase (
COX)and l
eads t
o
i
nhi
bit
ionofPr
ost
agl
andi
nrel
easet
her
efor
eNSAI
Dsi
sapr
otect
ivef
act
or,

Al
so,anot
herr
iskf
act
orf
orcol
orect
almal
i
gnancyi
sthepr
emal
i
gnantl
esi
ons
I
nfl
ammat
oryBowelDi
seases(
IBD)
,theul
cer
ati
vecol
i
tisandCr
ohn’
sdi
sease.
Any
thi
ngwhi
chsuppr
esses/
treat
sInf
lammat
oryBowelDi
seases(
IBD)wi
l
lbea
pr
otect
ivef
act
orf
orcol
orect
almal
i
gnancy
,becausei
tsuppr
essest
her
iskf
act
or.
NSAI
Dsar
eusedf
ort
reat
ing/
suppr
essi
ngI
nfl
ammat
oryBowelDi
seases(
IBD)
,

75
 AMI
N’STI
PS@GENERALSURGERY

t
hisi
sthesecond r
eason whyNSAI
Dsar
epr
otect
ivef
act
orsf
orcol
orect
al
mal
i
gnancy

-
Cal
cium cont
aini
ng Dr
ugs,cal
cium combi
nes wi
th pr
imar
y bi
l
e aci
ds,t
he
compl
exi
nhi
bit
sthet
ransf
ormat
ionofpr
imar
ybi
l
eaci
dst
osecondar
ybi
l
eaci
ds,
t
her
efor
e a secondar
y bi
l
e aci
d(l
i
thochol
i
c aci
d)whi
ch i
s car
cinogen f
or
col
orect
almal
i
gnancyi
sinhi
bit
ed,
Cal
cium cont
aini
ngDr
ugsar
epr
otect
ive

6.Pr
e–mal
i
gnmentcondi
ti
ons

I
nfl
ammat
oryBowel
Disease,
theul
cer
ati
vecol
i
tis(
UC)andCr
ohn’
sdi
sease(
CD)
,
UChasmor
emal
i
gnantt
ransf
ormat
ionpot
ent
ial
thanCD

Pol
yps(
Classi
fi
cat
ion/Ty
peofPol
yps)

Cl
assi
fi
cat
ionofPol
yps

Ty
pe1;
inf
lammat
ory(
pseudopol
yps)

Ty
pe2;
hyper
plast
ic/
met
apl
ast
ic

Ty
pe 3;hamar
tomat
ous (
juv
eni
l
e,cr
onkchi
te-
canada sy
ndr
ome and Peur
tz-
Jegher
ssy
ndr
ome(
readeachi
ndet
ail
s)

Ty
pe4;
neopl
ast
icpol
yps(
tubul
ar/
peduncul
ated,
vil
l
ous,
andt
ubul
o-v
il
lous(
these
hav
ehi
ghmal
i
gnancyt
ransf
ormat
ionpot
ent
ialmeani
ngt
heyar
epr
emal
i
gnant
condi
ti
on)

7.Fami
l
ial
condi
ti
ons

76
 AMI
N’STI
PS@GENERALSURGERY

- Fami
l
ial
Adenomat
ousPol
yposi
s(FAP)

- At
tenuat
edFami
l
ial
Adenomat
ousPol
yposi
s(AFAP)

- Knowdi
ff
erencesbet
ween(
FAPandAFAP)

FAP AFAP

Numberofpol
ypsr
anges100t
o1000 Numberofpol
ypsr
anges10t
o100

Al
l(100%)ofpat
ient
s wi
l
ldev
elop Notal
l
,(appr
ox.50%)ofpat
ient
swi
l
l
col
orect
almal
i
gnance dev
elopcol
orect
almal
i
gnance

Occur
slat
eri
nli
fe,f
rom 30y
ear
sand
Occur
sear
lyi
nli
fe,
aty
oungage,
at15
abov
e(pol
ypsaf
ter30y
ear
sFAP i
s
t
o 30 y
ear
s.(
pol
yps af
ter30 y
ear
s
unl
i
kel
y)
FAPi
sunl
i
kel
y)

Ly
nchsy
ndr
ome

Ty
pesofLy
nchsy
ndr
ome(
Her
edi
tar
yNon-
Pol
yposi
sCol
orect
alCancer
).Ly
nch1and2
(
Lynch 1 canceri
s conf
ined t
othe col
orect
alr
egi
on whi
l
e Ly
nch 2 ext
racol
oni
c
i
nvol
vementmost
lyendomet
ri
alcar
cinoma,ov
ari
ancar
cinoma,gast
ri
ccar
cinomaand
chol
angi
ocar
cinoma)

Amst
erdam cr
it
eri
aofdi
agnosi
ngLy
nchsy
ndr
ome

Thedi
agnosi
sismadebasedonf
ami
l
yhi
stor
y.

TheAmst
erdam Icr
it
eri
aforcl
i
nicaldi
agnosi
sofLy
nchsy
ndr
omear
ethr
eeaf
fect
ed
r
elat
iveswi
thhi
stol
ogi
cal
l
yver
if
iedadenocar
cinomaoft
hel
argebowel(
onemustbea
f
ir
st-
degr
eer
elat
iveofoneoft
heot
her
s)i
ntwosuccessi
vegener
ati
onsofaf
ami
l
ywi
th
onepat
ientdi
agnosed

bef
ore age 50 y
ear
s.The pr
esence ofot
herr
elat
ed car
cinomasshoul
drai
se t
he
suspi
cionoft
hissy
ndr
ome

Rev
isedcr
it
eri
aAmst
erdam I
Irequi
rest
hreeormor
erel
ati
veswi
thanHNPCCr
elat
ed

77
 AMI
N’STI
PS@GENERALSURGERY

mal
i
gnancyi
nwhi
chatl
eastonei
saf
ir
stdegr
eer
elat
iveoft
heot
her
s,t
wogener
ati
ons
ar
eaf
fect
ed,atl
eastonecanceroccur
redbef
oreage50,FAPhasbeenexcl
uded,and
pat
hol
ogyoft
het
umor
shasbeenr
evi
ewedandconf
ir
med

Ot
herf
ami
l
ial
condi
ti
onsar
e;

-
Gar
dner
’ssy
ndr
ome

-
Tur
cot
’ssy
ndr
ome

-
Non–sy
ndr
omi
cfami
l
ial
col
orect
alcar
cinoma

Ri
skFact
orsofanal
mal
i
gnancy

- HI
VDi
sease

- Recept
iveanal
sexual
int
ercour
se

- Al
cohol
i
sm

- Ci
gar
ett
esmoki
ng

- Radi
ati
onexposur
e

Cl
i
nical
dif
fer
encebet
weenanal
mar
ginTumor
sV/
Sanal
canal
Tumor
s

Anal
mar
gint
umor
s Anal
canal
tumor
s

Ar
e t
hose wher
e by on per r
ect
al Ar
e t
hose wher
e by on per r
ect
al
exami
nat
ionwhent
het
umori
svi
sibl
eon exami
nat
ionwhent
het
umori
snotv
isi
ble
gent
let
ract
ionoft
hebut
tocks ongent
let
ract
ionoft
hebut
tocks

78
 AMI
N’STI
PS@GENERALSURGERY

HOW TOCLERKPATI
ENTWI
THLOWERGIBLEEDI
NG

Chi
efcompl
aint
s;Passi
ngofBl
oodi
nst
ool
s(t
hrought
heanus)f
oracer
tai
nper
iodof
t
ime

HPI

PARTA

DNPARA

Nat
ure;

I
sitf
reshbr
ightr
edbl
ood?I
sitdar
kredbl
ood?I
sther
eanycl
ots? Doest
hebl
ood
comeoutbef
oreoraf
terst
ool
sori
sitmi
xedwi
thst
ool
s?

Per
iodi
cit
y–usual
l
yther
eisnospeci
fi
cper
iod

Aggr
avat
ingandr
eli
evi
ngf
act
ors–usual
l
yther
eisnospeci
fi
caggr
avat
ingandr
eli
evi
ng
f
act
ors

Associ
atedsy
mpt
oms

I
sitassoci
ated wi
th;Pai
n dur
ing def
ecat
ion,abdomi
nalpai
n,al
ter
ed bowelhabi
t,
passi
ngofmucusi
nst
ool
,reducedst
oolcal
i
ber(
goat
li
kepel
l
etsort
hint
hreadl
i
ke
st
ool
),I
sther
eanyswel
l
ingpr
otr
udi
ngt
hrought
heanus?I
sther
esenseofi
ncompl
ete

79
 AMI
N’STI
PS@GENERALSURGERY

def
ecat
ion?

NB:I
fabdomi
nalpai
n and swel
l
ing/
prot
rusi
on ar
e pr
esent
,remov
ethem f
rom
associ
atedsy
mpt
omsandputt
hem assepar
atel
ychi
efcompl
aint
sandampl
i
fyt
hem
separ
atel
y

PARTB(
RULEOFPOSSI
BLEDI
FFERENTI
ALS)

COLORECTAL+ANALMALI
GNANCY

Hxofuni
ntent
ional
wei
ghtl
oss

Hxofabdomi
nal
dist
ensi
on+v
omi
ti
ng

Hxofpassi
ngur
inemi
xedwi
thst
ool
s.

Hxofeasyf
ati
gabi
l
itydi
zzi
nessandawar
enessofhear
tbeat
s

HxofDi
ff
icul
tinbr
eat
hing,
coughi
ngbl
oodandchestpai
n

Hxofy
ell
owi
shdi
scol
orat
ionoft
heey
es,easybl
eedi
ngonbr
uisesandbl
eedi
ngf
rom
gumsdur
ingt
eet
hbr
ush

Hxofconv
ulsi
on,
headachesandconf
usi
ons

Askhabi
tual
int
akeofr
iskydi
etandpr
otect
ivedi
et

HxofAl
cohol
i
sm,
(ify
es,
whatki
ndandf
orhowl
ong)

Ci
gar
ett
esmoki
ng(
expr
essedi
npacky
ear
s)

Askabouthi
sjob,
andi
fhei
nvol
veshi
msel
finex
erci
ses

I
sther
eanyhxofabdomi
nal
sur
ger
ies.

I
sthehxofr
adi
ati
onexposur
e

I
sther
eany
onei
nthef
ami
l
ywi
thsi
mil
arcondi
ti
on?

I
sther
eanyhxofchr
oni
cmedi
cat
ion(
Rul
eoutUSAI
Ds,
cal
cium cont
aini
ngdr
ugs)

80
 AMI
N’STI
PS@GENERALSURGERY

I
sther
eHXofpr
act
ici
ngr
ecept
iveanal
sexual
int
ercour
se,
ify
esf
orhowl
ong

Repor
tHi
s/HerHI
Vst
atus

I
sther
ehxofbl
eedi
ngf
rom anyot
herar
eas

I
sthehi
stor
yofTr
aumapr
iort
otheonsetofi
l
lness

NB:-
COLI
TIS,
DIVERTI
CULOSI
S,ANGI
OECTASI
A,BENI
GNCONDI
TIONSOFTHECOLON
+RECTUM +ANUS

Theabov
e-ment
ionedcondi
ti
onshav
ebeenr
uledoutaut
omat
ical
l
yint
heHPI

EXAMI
NATI
ON

TheMosti
mpor
tantex
ami
nat
ioni
napat
ientwi
thl
owerGIbl
eedi
ng i
sperr
ect
al
exami
nat
ion(
Thi
sisapar
tinperabdomi
nal
exami
nat
ion)

PerRect
alexami
nat
ion

Oni
nspect
ion

I
nspectf
oranyv
isi
bleul
cerand mass(
ifseen r
epor
tit
slocat
ion)oranyv
isi
ble
abnor
mal
i
tyatt
heanal
ver
ge

Onpal
pat
ion/
DRE

Repor
tont
het
oneoft
hesphi
nct
eruponent
ry

I
fmassi
spal
pabl
e,Repor
tthef
oll
owi
ng;

Locat
ion(
inr
elat
iont
orect
alwal
l
)

Di
stancef
rom t
heanal
ver
ge

Cany
ougoabov
eit
?

Consi
stency

Mobi
l
ity

81
 AMI
N’STI
PS@GENERALSURGERY

Gl
ovedf
ingerst
ainedwi
thwhat
??(
nor
mal
stool
col
ororpal
eorbl
oody
??)

I
nvest
igat
ions

Doubl
econt
rastBar
ium enema

I
tist
hemet
hodofchoi
cet
hansi
ngl
econt
rast
,becausei
tdemonst
rat
esmucosal
pat
ter
n

Quest
ions;
(whatar
ethecont
rast
sused?Andwhi
chonest
art
sandwhi
chonef
oll
ows?
)

Answer
;cont
rastusedar
ebar
ium sul
phat
eandai
r,Bar
ium sul
phat
est
art
sfol
l
owedby
ai
r

Somecent
ersuseCO2i
nst
eadofai
rithasshownt
oreducet
hei
nci
denceofsev
ere,
post
-doubl
econt
rastenemapai
n

Col
onoscopy+Bi
opsy

CT–Col
onogr
aphy

Pel
vi
cMRI(
bestf
orr
ect
alt
umort
hanCTScan)

Abdomi
nal
CTscan(
Stagi
ngTNM)

Endoscopi
cUl
tr
asound(
forst
agi
ngTN)

EUA+Pr
oct
oscopy+Bi
opsy

CEA (
usual
l
yel
evat
esi
ncol
orect
almal
i
gnancy
,especi
all
yinwel
ldi
ff
erent
iat
edand
moder
atel
ydi
ff
erent
iat
edt
umor
swhi
l
enor
malr
angesorl
ow i
npoor
lydi
ff
erent
iat
ed
andundi
ff
erent
iat
edt
umor
s)

I
fthe t
umori
sfel
ton DRE dur
ing exami
nat
ion t
hen EUA+Pr
oct
oscopy
+Bi
opsyi
s
r
ecommendert
hancol
onoscopy+Bi
opsy

82
 AMI
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QUESTI
ONS

Quest
ion;Whypat
ientwi
th Obst
ruct
ive Jaundi
ce ar
e pr
otect
ed/hav
elow r
isk of
col
orect
alcar
cinoma?

Answer
;Pr
imar
yBi
l
eaci
dschol
i
candchenodeoxy
chol
i
caci
d,appr
oxi
mat
ely95%t
hey
ar
ereabsor
bedatt
het
ermi
nal
il
eum backt
otheLi
ver(
ent
erohepat
icci
rcul
ati
on)
.

Themi
nor
it
y(appr
oxi
mat
ely5%)ent
erst
hecol
on. Undert
hei
nfl
uenceofcol
oni
c
bact
eri
a,pr
imar
ybi
l
e aci
dsar
e conv
ert
ed t
o secondar
ybi
l
e aci
dsbyr
emov
ing a
hy
drox
ylgr
oupt
opr
oducedeoxychol
i
caci
dfr
om chol
i
caci
dandl
i
thochol
i
caci
dfor
m
chenodeoxy
chol
i
caci
d.

Li
thochol
i
cinpar
ti
cul
ari
sacar
cinogent
ocol
oni
cmucosa

Ther
efor
e,anycondi
ti
onswhi
chi
ncr
easesconcent
rat
ionofl
i
thochol
i
caci
dint
hecol
on,
wi
l
lincr
easet
her
iskofcol
orect
alcar
cinoma

Ther
efor
e,i
nobst
ruct
ivej
aundi
cebi
l
edoesn’
treacht
hei
ntest
inest
her
efor
etheabov
e
st
epsi
nthef
ormat
ionf
orLi
thochol
i
caci
dwon’
thappen,t
her
efor
enol
i
thochol
i
caci
d
pr
oduct
ionhencei
tpr
otect
iveagai
nstCol
orect
almal
i
gnancy

Rev
ise on TNM – Cl
assi
fi
cat
ion and st
agi
ng ofcol
orect
aland analt
umor
s and
STAGI
NG

Ty
pesofr
esect
ionsoft
umorateachoft
hef
oll
owi
ngsi
te

 Ascendi
ngcol
on r
ighthemi
col
ect
omywi
thI
leot
ransv
erseanast
omosi
s

 Tr
ansv
ersecol
on(
proxi
mal
/mi
d/di
stal
) ext
endedr
ighthemi
col
ect
omywi
th
I
leo descendi
ng anast
omosi
s ort
ransv
erse col
ect
omy wi
th Col
o col
oni
c
anast
omosi
s

 Descendi
ngcol
on l
efthemi
col
ect
omywi
thCol
ocol
oni
canast
omosi
s

83
 AMI
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 Si
gmoi
dcol
on si
gmoi
dcol
ect
omywi
thcol
orect
alanast
omosi
s

 Rect
um (
Rect
osi
gmoi
d,upper
,mi
ddl
eandl
owerr
ect
um)

Ref
erencef
rom Schwar
tz11thedi
ti
onpage1273t
o1274)

Ther
ear
etwoappr
oachesf
orr
ect
alsur
ger
y

1st i
s Tr
ans abdomi
nalappr he 2nd i
oach and t str
ansabdomi
nal& per
ineal
appr
oach

Ant
eri
orResect
ion.Ant
eri
orr
esect
ion i
sthegener
alt
erm used t
o descr
ibe
r
esect
ionoft
her
ect
um f
rom anabdomi
nalappr
oacht
othepel
vi
swi
thnoneed
f
oraper
ineal
,sacr
al,
or

ot
heri
nci
si
on

Thr
eet
ypesofant
eri
orr
esect
ionhav
ebeendescr
ibed

Fi
rsti
sHi
ghAnt
eri
orResect
ion.Ahi
ghant
eri
orr
esect
ioni
sthet
erm usedt
o
descr
ibe

r
esect
ionoft
hedi
stalsi
gmoi
dcol
onandupperr
ect
um andi
stheappr
opr
iat
e
oper
ati
onf
orbeni
gnl
esi
onsanddi
seaseatt
her
ect
osi
gmoi
djunct
ionsuchas
di
ver
ti
cul
i
tis

Secondi
sLow Ant
eri
orResect
ion.Al
ow ant
eri
orr
esect
ioni
susedt
oremov
e
l
esi
onsi
ntheupperandmi
drect
um.Ther
ect
osi
gmoi
dismobi
l
ized,t
hepel
vi
c
per
it
oneum i
sopened,andt
hei
nfer
iormesent
eri
car
ter
yisl
i
gat
edanddi
vi
ded
ei
therati
tsor
igi
nfr
om t
heaor
taorj
ustdi
stal
tot
het
akeof
foft
hel
eftcol
i
car
ter
y

Thi
rdi
sExt
endedLowAnt
eri
orResect
ion.Anext
endedl
owant
eri
orr
esect
ioni
s
necessar
ytor
emov
elesi
onsl
ocat
edi
nthedi
stalr
ect
um,
butsev
eralcent
imet
ers
abov
ethesphi
nct
er

84
 AMI
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Abdomi
noper
inealResect
ion.An abdomi
noper
inealr
esect
ion (
APR)i
nvol
ves
r
emov
aloft
he ent
ir
erect
um,analcanal
,and anus wi
th const
ruct
ion ofa
per
manentcol
ost
omyf
rom t
hedescendi
ngorsi
gmoi
dcol
on.Theabdomi
nal
-
pel
vi
cpor
ti
onoft
hisoper
ati
onpr
oceedsi
nthesamef
ashi
onasdescr
ibedf
oran
ext
endedl
owant
eri
orr
esect
ion.

Sel
f-
readonCol
ost
omi
esf
ocusi
ngon;

 Cl
assi
fi
cat
ion

 Compl
i
cat
ions

 DManagementofcompl
i
cat
ions

MUSTREADTOPI
CS

Pr
ognost
icf
act
orsf
orcol
orect
al+anal
mal
i
gnancy

Fol
l
owupi
napat
ientwi
thcol
orect
almal
i
gnancyaf
tersur
ger
y

Pat
ient
s who hav
e been t
reat
ed f
orone col
orect
alcancerar
e atr
isk f
ort
he
dev
elopmentofr
ecur
rentdi
sease(
eit
herl
ocal
l
yorsy
stemi
cal
l
y)ormet
achr
onous

85
 AMI
N’STI
PS@GENERALSURGERY

di
sease (
a second pr
imar
ytumor
).I
ntheor
y,met
achr
onous cancer
s shoul
d be
pr
event
abl
ebyusi
ngsur
vei
l
lanc0[
‘
ecol
onoscopyt
odet
ectandr
emov
epol
ypsbef
ore
t
heypr
ogr
esst
oinv
asi
vecancer
.

Formostpat
ient
s,acol
onoscopyshoul
dbeper
for
medwi
thi
n12mont
hsaf
tert
he
di
agnosi
soft
heor
igi
nalcancer(
orsooneri
fthecol
onwasnotexami
nedi
nit
sent
ir
ety
pr
iort
otheor
igi
nalr
esect
ion)
.Ift
hatst
udyi
snor
mal
,col
onoscopyshoul
dber
epeat
ed
ev
ery3t
o5y
ear
sther
eaf
ter
.

Pat
ient
swhohav
eunder
gonel
ocalr
esect
ionofr
ect
alt
umor
sal
soshoul
dbef
oll
owed
wi
thf
requentendoscopi
cexami
nat
ions(
ever
y3–6mont
hsf
or3y
ear
s,t
henev
ery6
mont
hsf
or2y
ear
s).CEA

i
sof
tenf
oll
owedev
ery3t
o6mont
hsf
or2y
ear
s.CT scansar
eof
tenper
for
med
annual
l
yfor5y
ear
s

Pr
event
ion(
Scr
eeni
ngandsur
vei
l
lance)ofcol
orect
almal
i
gnancy(
sel
f-
study
)

Sy
nchr
onoust
umorV/
Smet
achr
onoust
umor(
sel
f-
study
)

 Ri
ghtCol
oni
ctumor
smost
lypr
esentwi
thamassi
nther
ighti
l
iacf
ossa.Name
ot
herdi
ff
erent
ial
sofRI
Fmass(
ref
erSRB’
sManualofSur y5th edi
ger ti
onpage
731)

Ni
gro’
sPr
otocol
ofmanagementofanal
mal
i
gnancy

Maj
ori
tyofanalmal
i
gnancyar
e squamous cel
lcar
cinoma,and i
tis known t
hat
squamouscel
lisr
adi
osensi
ti
ve,
Nigr
o’spr
otocoli
stheappr
oachorpr
otocoloft
reat
ing
squamouscel
lcar
cinomaoft
heanus.

Thi
sregi
menconsi
stsofdel
i
ver
ing30Gyi
n15f
ract
ionst
othepr
imar
ytumorandpel
vi
c
l
ymph nodes wi
th concur
rentgi
vi
ng oft
he r
adi
osensi
ti
zer
s chemot
her
apy 5FU
(
1000mg/
m2asa4daycont
inuousi
nfusi
on)andmi
tomy
cinC(
MTC)(
15mg/
m2bol
us
i
nject
ion)

86
 AMI
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Anat
omy

Youshoul
dknow;

Par
tsoft
hecol
on,
thei
rlengt
handdi
amet
er

Lay
ersoft
hecol
on

Whatmakessaccul
ati
on(
Haust
rasegment
ed)i
nthecol
on?

Def
inedi
ver
sioncol
i
tis

Expl
aint
hephy
siol
ogyofDef
ecat
ion

Funct
ionsof

 Col
on

 Rect
um

 Anus

87
 AMI
N’STI
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COMMONQUESTI
ONI
NTHEORYEXAM
COLORECTALI
NJURI
ES/
TRAUMA
Di
vi
dedi
ntoTHREEcat
egor
ies
1.Penet
rat
ingCol
orect
alI
njur
y
2.Bl
untCol
orect
alI
njur
y
3.I
atr
ogeni
cInj
ury

Penet
rat
ingCol
orect
alI
njur
y
Col
orectalinj
uryi
scommonf ol
l
owi ngpenetr
ati
ngt
raumat
otheabdomenandhas
hi
stor
icall
ybeenassoci
atedwi
thhighmortal
i
ty.

Penet
rat
ingI
njur
ytot
heCOLON
Ther
ear
ethr
eemet
hodsf
ort
reat
ingcol
oni
cinj
uri
es:

1.Primar
yrepair
Primar
yr epair
si ncl
ude lat
eralsutur
er epai
rorr esect
ion oft he damaged
segmentwithreconst
ructi
onbyileo-
col
oanastomosisorColo-col
oanastomosis.
Allsutur
ing and anastomoses are per
formed using a runni
ng si
ngle-
lay
er
techni
queorinter
rupt
ed

2.Endcol
ost
omy
3.Andpri
maryr
epai
rwi
thdi
ver
ti
ngl
oopi
l
eost
omy

88
 AMI
N’STI
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Managementofcol
oni
cinj
urydependsont
hef
oll
owi
ngf
act
ors:
-
mechani
sm ofi
njur
y,
-
thedel
aybet
weent
hei
njur
yandsur
ger
y,
-
theov
eral
lcondi
ti
onandst
abi
l
ityoft
hepat
ient
,
-
thedegr
eeofper
it
oneal
cont
ami
nat
ion,
-
andt
hecondi
ti
onoft
hei
njur
edcol
on.

Apr
imar
yrepai
rmaybeconsi
der
edi
n
-
hemody
nami
cal
l
yst
abl
epat
ient
swi
thf
ewaddi
ti
onal
inj
uri
es
-
andmi
nimal
cont
ami
nat
ioni
fthecol
onappear
sot
her
wiseheal
thy
.

Cont
rai
ndi
cat
ionst
opr
imar
yrepai
rincl
ude
-
shock,
-
inj
uryt
omor
ethant
woot
heror
gans
-
mesent
eri
cvascul
ardamage
-
andext
ensi
vef
ecal
cont
ami
nat
ion
-I
njuri
escausedbyhi gh-v
eloci
tygunshotwoundsorbl asti
njur
iesareof
tenassoci
ated
wit
hmul ti
pleint
ra-
abdomi nali
njur
iesandtissuelossandtherefor
eareusual
lytr
eated
byfecaldi
versi
onafterdebri
dementofallnonviabl
eti
ssue.
-Adelayofgreat
ert
han6hoursbet
weenthei
njur
yandtheoper
ati
onal
soisassoci
ated
wit
hincreasedmorbidi
tyandmortal
i
tyandisar el
ati
vecont
rai
ndi
cat
iontoprimary
r
epair

Pati
entfactors,suchasmedicalcomorbi
dit
ies,adv
ancedage,andt
hepr
esenceof
tumororradiati
oninj
ury
,mustal
sobeconsi
dered

Penet
rat
ingI
njur
ytot
heRECTUM
Pr
imar
yrepai
roft
her
ect
um i
smor
edi
ff
icul
tthanpr
imar
yrepai
roft
hecol
onandmost

89
 AMI
N’STI
PS@GENERALSURGERY

r
ect
ali
njur
iesar
eassoci
atedwi
thsi
gni
fi
cantcont
ami
nat
ion.
Forthatreason,themaj or
it
yofpenet
rat
ing r
ect
ali
njur
iesshoul
d bet
reat
ed wi
th
proxi
malf
ecal di
ver
sion.
Thecurr
entopt
ionsoffecaldi
ver
sioninPenet
rat
ingI
njur
ytot
heCOLON ar
eloop
i
leost
omyandsi
gmoidl
oopcolost
omy .
Si
gmoi
dloopcol
ost
omyi
spr
efer
redbecause
-
iti
squi
ckandeasyt
oper
for
m,
-
andpr
ovi
desessent
ial
l
ytot
alf
ecal
div
ersi
on.
-
Forsi
gmoi
dcol
ost
omy
,techni
cal
element
sincl
ude:
(a)adequatemobil
izat
ion ofthesi
gmoi
d col
on so t
hatt
hel
oop wi
l
lreston t
he
abdominalwal
lwi
thouttensi
on
(b)mai
ntenanceofthespurofthecol
ostomy(thecommonwal
loftheproxi
maland
dist
all
i
mbsaf termatur
ati
on)abov
etheleveloftheski
nwi
thaone-
hal
f-
inchPenr
ose
drai
norsi
milardev
ice
(
c)l
ongi
tudi
nal
inci
si
oni
nthet
aeni
acol
i
,and
(
d)i
mmedi
atemat
urat
ioni
ntheOR

Smal
l,cl
ean r
ectalinj
uri
es maybe cl
osed pr
imar
il
ywi
thoutf
ecaldi
ver
sion i
n an
ot
her
wisest
ablepati
ent.
I
ftherectalinj
uryi
sext ensi
ve,anotheropti
onistodiv
idether
ectum att
hel
evelofthe
i
njur
y,overseworstaplethedistalr
ectalpouchi
fpossi
ble,
andcreat
eanendcolost
omy
(
Hartmann’sprocedure).
Ext
ensiveinj
uri
esmaywar r
antpresacraldrai
nagewithPenrosedr
ainsplacedalong
Waldeyer
’sfasci
av iaaper i
analinci
sion,butrout
inepresacr
aldr
ainageandr ectal
washoutisnolongerpr
act
iced.
Inr ar
ei nstances i
n which destr
ucti
vei nj
uri
es are present,an abdomi
noperineal
resecti
onmaybenecessar ytoav ertl
ethalpel
vicsepsis.(Ver
yr ar
ely
,hemorr
hageor
extensi
vetissueloss(especi
all
yiftheanalsphi
ncteri
ssev erel
ydamaged)mayr equir
e
anemer gentAPR)
Howev er,t
hisoper
ati
onshoul
dbeavoi
ded,i
fatal
lpossi
ble,becauseoft
hemor
bidi
ty
associ
atedwithanext
ensi
vepel
vi
cdi
ssect
ioni
naseverel
yinj
uredpati
ent
I
ntr
act
abl
erect
albl
eedi
ngmayr
equi
reangi
ogr
aphi
cembol
i
zat
ion.

90
 AMI
N’STI
PS@GENERALSURGERY

Bl
untCol
orect
alI
njur
y

Bl
untI
njur
ytot
heCOLON

Bluntinjurytot hecolonandr ectum isconsider

abl
ylesscommont hanpenetrat
ing
i
njury.Nev er
theless,bl
unttr
aumacancausecol onperf
orat
ion,andshearinj
uryt
ot he
mesent erycandev ascul
ari
zetheintest
ine.Managementoftheseinj
uri
esshouldf
oll
ow
thesamepr i
nciplesoutl
i
nedformanagementofpenet r
ati
nginjur
ies.

A serosalhematomaalonedoesnotmandat
eresecti
on,butthebowelshoul
dbe
car
efull
yinspect
edtoensur
ethatt
her
eisnotanassoci
atedper
for
ati
onorsi
gnif
icant
bowel i
schemia.

Bluntinjur
yt otheRECTUM
Bluntinjur
yt ot herect
um mayr esul
tf rom si
gni
fi
canttrauma,suchasapel vi
ccr ush
i
njury,ormayr esul
tfrom l
ocalt r
aumacausedbyanenemaorf oreignbody .Crush
i
njuri
es,especi al
ly wi
th an associated pelv
icfractur
e,are oft
en associated with
si
gnificantrectaldamageandcont ami nati
on.Thesepatient
srequi
redebridementofall
nonviabletissue,proxi
malfecaldiversion,andadistalr
ectalwashout,withorwithout
drai
npl acement

Smal lmucosalt ear

smaybecl osedpr imari
lyifthebowelisrel
ati
v el
ycl
eanandt hereis
l
ittl
econtami nati
on
Iatr
ogenicInjury
Intr
aoperati
v eInj
ury.
The colon and r ectum are atr isk forinadv er
tenti
njur
ydur ing ot
herpr ocedures,
especial
ly during pelvi
c operati
ons.The key t o managing these i
njuri
es is earl
y
recognit
ion.
Thev astmaj ori
tyofiatr
ogeniccolorectali
njur
iesmaybecl osedpr i
mari
lyift
hereisli
ttl
e
contaminationandi fthepati
entisot herwi
sest abl
e

Delayedrecogni
ti
onofcol orectali
njuri
esmayr esul
tinsi
gnif
icantper
it
oni
tisandli
fe-
thr
eateni
ngsepsis.Inthesecases,f aecaldi
versioni
salmostalwaysrequi
red,andt
he
pati
entmayneedr epeatedexplorat
ionfordrai
nageofabscesses

I
njur yfr om Barium Enema.
Col orect alinj
uryfrom abar ium enemai sanext remelyr arecompl i
cat
ionassoci
ated
withahi ghrateofmor bidit
yandmor tal
it
y.
Per forationwi t
hspill
ageofbar ium, especi
all
yabov et heper i
tonealr
efl
ecti
on,mayresul
t
i
npr ofoundper i
toni
ti
s, sepsis,andasy st
emi cinf
lammat oryr esponse.
I
ft heper forat
ionisr ecogni zedear l
y,i
tmaybecl osedpr i
maril
yandt heabdomen
i
rrigatedt oremov estool andbar i
um.
Howev er,ifthepat i
enthasdev elopedsepsi s,fecaldiversion( wi
thorwi t
houtbowel
resect i
on)i salmostal way srequired.
Rar ely,asmal lmucosali njuryt ot heextraperi
tonealr ectum maybemanagedwi th

91
 AMI
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bowel
rest
,br
oad-
spect
rum ant
ibi
oti
cs,
andcl
oseobser
vat
ion.

ColonoscopicPerf
orat
ion
Perforat
ion i
st he mostcommon maj
orcompl
i
cat
ion af
terei
therdi
agnost
ic or
therapeuti
ccol
onoscopy.

Fort
unatel
y,this compli
cat
ion i
srar
e and occursinl ess t
han 1% ofprocedures.
Perf
orati
onmayr esul
tfr
om tr
aumafrom theti
poft heinst
rument,f
rom shearfor
ces
rel
atedtot hef or
mationofa“ l
oop”inthecolonoscope,orf r
om barot
raumaf r
om
i
nsuffl
ati
on.Biopsyorful
gur
ati
oncanalsocauseper
forat
ion

Pol
ypect
omyusingelectr
ocauter
ymaypr oduceaf ul
lthi
cknessburn,r
esult
inginpost
pol
ypect
omy syndr
ome i n which a pati
entdev el
ops abdominalpain,fever
,and
l
eukocyt
osi
swit
houtevidenceofdif
fuseperi
toni
ti
s

Managementofcol onoscopi
cperfor
ati
ondependsont hesizeoft heperfor
ati
on,t
he
durati
onofti
mesi ncetheinj
ury
,theover
allcondi
ti
onofthepati
ent,andtheunderl
yi
ng
di
agnosis
Alargeperf
orat
ionrecogni
zedduri
ngtheprocedur
erequi
ressur
gicalexpl
orati
on.

Becausethebowelhasalmostal
waysbeenpr
eparedpri
ortothecol
onoscopy
,t her
eis
usual
lyli
tt
lecont
aminat
ionassoci
atedwit
htheseinj
uri
es,andmostcanber epair
ed
pri
maril
y

I
fthereissi
gnifi
cantcont
ami nat
ion,i
ftherehasbeenadelayi
ndi
agnosi
swithresul
ti
ng
per
itoni
ti
s,orifthepat i
entishemody namical
l
yunstabl
e,pr
oxi
maldiver
sionwithor
wit
houtresect
ionisthesafestapproach

I
tisal
soimportantt
oknowtheindi
cat
ionforandf
indingsatt
heti
meofcolonoscopy
.
I
fthepat
ienthasanunder
lyi
ngneopl
asm andisst
able,def
ini
ti
ver
esect
ioni
sbest

Occasionall
y,apat i
entwi l
ldevelopabdomi nalpainandlocal
i
zedsignsofper f
orat
ion
afterwhatwast houghtt obeanunev ent
fulcol
onoscopy.Manyofthesepatientswil
l
hav ea“microperfor
ation,
”whichwi l
lresol
ve
-withbowelrest
-broad-
spectrum ant
ibi
ot i
cs
-andcloseobservati
on.
Evidenceofperit
oniti
soranydet eri
orati
onincli
nicalcondi
ti
onmandatesexpl
orati
on

Simi l
arl
y,f r
eer et
roperi
tonealorintr
aperitonealairmaybedi scov er
edincidental
lyaf ter
colonoscopy .I
nacompl etel
yasympt omat i
cpat ient
,t hi
sfindingi sthoughtt or esult
fr
om bar otraumaanddi ssectionofairthroughtissuepl aneswit houtaf r
eeper foration.
Manyoft hesepatient
scanbesuccessf ull
ytreatedwi thbowelr estandbr oad-spect r
um
antibiot
ics.Surgicalexplorati
onisi
ndicatedifanycl i
nicaldeter
ior ati
onoccurs

92
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Refer
ence:
Schwart
z’sPr
inci
plesofSur y11thEdi
ger ti
onPage1321-
1322

TOPI
CSEVEN

GASTRI
CTUMOURS
Anat
omyoft
hest
omach

-
Grossanat
omy

-
Lay
ers

-
Epi
thel
i
all
i
ning

Bl
oodsuppl
y

VenousDr
ainage

I
nner
vat
ion

Ly
mphat
icsdr
ainage

Phy
siol
ogy

93
 AMI
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Commonl
yPr
imar
yGast
ri
cMal
i
gnancy

Adenocar
cinoma

Ly
mphoma

GI
ST

Rar
e–Car
cinoi
ds

-
Squamouscel
lcar
cinoma

-
Angi
osar
coma

Rar
ely
,thest
omachbei
ngsi
teofmet
ast
asi
sandsecondar
ies

I
fpr
esentcommonl
yfr
om

Br
east

Mel
anoma

Commonl
y,secondar
iest
othest
omachar
eduet
odi
rectext
ensi
on/i
nfi
l
trat
ionf
rom
adj
acentor
ganse.
g.Col
on(
transv
ersecol
on)
,pancr
eas

GASTRI
CCARCI
NOMA

Mor
ecommoni
nAsi
anandEast
ernEur
ope,mor
ecommoni
nLow soci
aleconomi
c
st
atus

Bl
ackRace2t
imesmor
ethanwhi
te

Ri
skf
act
orsofGASTRI
CCARCI
NOMA

1.Di
et

Ri
sky–sal
tedf
oods,
smokedf
oods,
diet
aryni
tr
ates,
foodsRi
chi
nNi
tr
osami
ne

94
 AMI
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Pr
otect
ive–Fr
uit
s,v
eget
abl
eandf
iber
s(Ri
chi
nVi
tami
nCandE)

2.Smoki
ng

3.Bl
oodGr
oupA

4.H.Py
lor
iinf
ect
ion(
leadst
oachl
orhy
dri
cst
ate)

5.Regul
aruseofNSAI
Ds

6.Per
nici
ousanemi
a(l
eadst
oachl
orhy
dri
cst
ate)

7.Genet
icf
act
ors

(
Spor
adi
cGast
ri
ccancerandFami
l
ial
Gast
ri
ccancer
)

Spor
adi
cGast
ri
ccar
cinoma

o Del
eti
onorsuppr
essi
onofp53gene

o Ov
erexpr
essi
onofCOXgenes(
Mor
eaggr
essi
vet
umor
s)

Fami
l
ial
Gast
ri
ccar
cinoma

 Her
edi
tar
ydi
ff
usegast
ri
ccar
cinoma

 Fami
l
ial
int
est
inal
gast
ri
ccar
cinoma

 Li
Fraumensy
ndr
ome

 Ly
nch–2sy
ndr
omes

8.Pr
e–Mal
i
gnantLesi
ons

o Pol
yps(
Classi
fi
cat
ionsofgast
ri
cPol
yps)

o At
rophi
cgast
ri
ti
s

o Beni
gnGast
ri
cul
cer

o Gast
ri
cRemnantf
oll
owi
ngsubt
otalgast
rect
omy(
Bil
l
rot
hIIMor
ecommon
t
hanBi
l
lrot
hI)

95
 AMI
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o Menet
ri
es’
sDi
sease

9.Radi
ati
onExposur
e

10.
EBV–I
nfect
ion

11.
Zinc,
Lead,
tal
c,asbest
osal
lcancausecar
cinomast
omach

12.
Occupat
ion–Rubber
swor
ker
s,coal
wor
ker
s

Quest
ion;

H.py
lor
iisar
iskf
act
orf
orGast
ri
ccar
cinomabutatt
hesamet
imei
sapr
otect
ivef
act
or
f
oresophageal
car
cinoma,
why
?

Answer
;

H.py
lor
ileads t
o at
rophi
c gast
ri
ti
s;hence r
educt
ion i
s gast
ri
c aci
d pr
oduct
ion
(
achl
orhy
dri
cst
ate)i
nthest
omach,
theef
fectoft
hisi
sasf
oll
ows;

I
nthest
omach,
theachl
orhy
dri
cst
atewhi
chi
sther
iskf
orgast
ri
cmal
i
gnancyt
ooccur

I
ntheesophagus;
duet
olowornoaci
dhenceef
fect
sofGERDwi
l
lnotbesi
gni
fi
cantt
o
causebar
ret
tesesophagusandadenocar
cinomaoft
heesophagus,t
her
efl
uxwi
l
lbe
aci
dfr
eehencet
hepr
otect
ionagai
nstcar
cinomaesophagus.

Pr
esent
ati
onofGast
ri
cCar
cinoma

Anor
exi
a

Wei
ghtl
oss

Ear
lysat
iet
y

Upperabdomi
nal
(epi
gast
ri
c)pai
n

96
 AMI
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Vomi
ti
ngwi
thf
eat
uresofgast
ri
cout
letobst
ruct
ion(
Tumoratt
heant
rum)

Massi
ntheabdomen(
Epi
gast
ri
cMass)

Dy
sphagi
a(Tumor
satt
heCar
dia)

Asci
tes

Posi
ti
veTr
oiser
’ssi
gn(
presenceoft
heVi
rchow’
snode)

Posi
ti
veBl
umer
’sshel
f

Sr
.Mar
yJosephnodul
esandI
ri
shnodes

Kr
uker
nber
g’st
umor

UpperGIbl
eedi
ng(
Rar
ely
)

Par
a–Neopl
ast
icsy
ndr
omest
hatmaybeassoci
atedwi
thgast
ri
ccar
cinoma

 Tr
ousseaussy
ndr
ome

Venoust
hrombophl
ebi
ti
s,char
act
eri
zedbyr
ecur
rentmi
grat
oryt
hrombosi
sin
super
fi
ci
alv
einsandi
nuncommonsi
tessuchast
hechestwal
landar
ms

 Acant
hosi
sni
gri
cans

I
schar
act
eri
zedbyhy
per
pigment
ati
onandhy
perker
atosi
soft
heski
noft
heneck,
axi
l
laandgr
oin)

 Per
ipher
alNeur
opat
hy

READON;

1.Ty
pes of dy
spl
asi
a as pr
e-mal
i
gnance of Gast
ri
c car
cinoma and t
hei
r
management

Dy
spl
asi
aisgener
all
yaccept
eduni
ver
salpr
ecur
sort
ogast
ri
ccar
cinoma,can
ei
therbemi
l
ddy
spl
asi
apat
ientwi
l
lrequi
rest
rongl
yfol
l
owsupbyendoscopi
c
97
 AMI
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bi
opsyandH.py
lor
ier
adi
cat
ion,

Sev
eredy
sphagi
acanei
therbel
ocal
i
zedormul
ti
focal(
widespr
ead)
,forpat
ient
wi
thsev
eredy
spl
asi
awhi
chi
slocal
i
zedshoul
dbeconsi
der
edf
orEndoscopi
c
mucosalr
esect
ion (
EMR)f
ort
hose wi
th wi
despr
ead ormul
ti
focalsev
ere
dy
spl
asi
atheyshoul
dbeconsi
der
edgast
ri
cresect
ion(
prophy
lact
icgast
rect
omy
)

2.Ear
lyGast
ri
ccar
cinoma

a.Def
ini
ti
on

Adenocar
cinomal
i
mit
edt
omucosaandsubmucosa,r
egar
dlessoft
he
l
ymphnodest
atus

b.Cl
assi
fi
cat
ion

Japanesecl
assi
fi
cat
ionofEar
lyGast
ri
cCar
cinoma

Ty
pe1Pr
otr
udi
ngt
umor
s(pol
ypoi
d)

Ty
pe2super
fi
cial
tumor
s

2Asuper
fi
cial
elev
ated

2Bsuper
fi
cial
flat

2Csuper
fi
cial
depr
essed

Ty
pe3Deepdepr
essedt
umor
s(excav
ated)

3.Adv
ancedGast
ri
cCar
cinoma

a.Def
ini
ti
on

Adenocar
cinoma wi
th muscul
ari
sinv
olv
ementand/
orser
osa wi
th or
wi
thoutl
ymphnodesi
nvol
vement

b.Cl
assi
fi
cat
ion(
Bor
man’
s)

98
 AMI
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Ty
pe1pol
ypoi
dtumor

Ty
pe2f
ungat
ingt
umor

Ty
pe3ul
cer
ati
vet
umor

Ty
pe4i
nfi
l
trat
ivet
umor(
Dif
fuset
umor
/Li
nit
isPl
ast
ica)

NB:Ty
pe1&2f
ormsbul
ktumormassi
ntr
alumi
nalwhi
l
ety
pe3&4bul
k
t
umormasswi
thi
nthewal
l

c.Pol
ypoi
dvsFungat
ingmass,
whati
sthei
rdi
ff
erence?

Fungat
ingt
umor
sar
etheul
cer
atedpol
ypoi
dtumor
s

4.Hi
stol
ogi
ccl
assi
fi
cat
ionofGast
ri
ccar
cinoma

a.Laur
eancl
assi
fi
cat
ion

I
ntest
inal
type(
goodpr
ognosi
s)

Di
ff
uset
ype(
poorpr
ognosi
s)

Uncl
assi
fi
ed

b.Mi
ng’
sCl
assi
fi
cat
ion

Expandi
ng(
goodpr
ognosi
s)

I
nfi
l
trat
ive(
poorpr
ognosi
s)

c.WHOcl
assi
fi
cat
ion

Adenocar
cinoma(
papi
l
lar
y,t
ubul
ar,
muci
nous,
signet
-r
ing)

99
 AMI
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Adenosquamouscar
cinoma

Squamouscel
lcar
cinoma

Smal
lcel
lcar
cinoma

Undi
ff
erent
iat
edcar
cinoma

Ot
her
s-uncl
assi
fi
ed

d.Japanese cl
assi
fi
cat
ion (
simi
l
art
o WHO cl
assi
fi
cat
ion,buti
ts mor
e
det
ail
ed)

5.Di
ff
erencesbet
weenPr
oxi
mal
andDi
stal
Gast
ri
ccar
cinoma

Pr
oxi
mal
gast
ri
cCar
cinoma Di
stal
gast
ri
ccar
cinoma

Notdi
etr
elat
ed Di
etr
elat
ed

Notenv
ironment
alr
elat
ed Env
ironment
alr
elat
ed

Endemi
c Epi
der
mic

Di
ff
uset
ype I
ntest
inal
type

Poorpr
ognosi
s wi
thl
ess t
han 20% Bet
ter pr
ognosi
s wi
th 30%
r
esect
abi
l
ity r
esect
abi
l
ity

Tr
eat
menti
sbyt
otal
gast
rect
omy Tr
eat
menti
sbysubt
otal
gast
rect
omy

100
 AMI
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6.Mol
ecul
arsub-
typesofGast
ri
ccar
cinoma

Thet
radi
ti
onalmor
phol
ogy
-basedcl
assi
fi
cat
ion(
e.g.Laur
ean,Mi
ng’
sandWHO
cl
assi
fi
cat
ionsabov
e)cannotconv
eyt
hemol
ecul
arhet
erogenei
tyofgast
ri
c
adenocar
cinoma and cannot gui
de cl
i
nicalpr
act
ice i
n adv
anced gast
ri
c
adenocar
cinoma f
or det
ermi
ning pr
ognosi
s or pr
edi
cti
ng t
reat
ment
r
esponsi
veness

Thef
ir
stcl
assi
fi
cat
ioni
sTheCancerGenomeAt
las(
TCGA)Subt
ypes

101
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102
 AMI
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Thesecondcl
assi
fi
cat
ioni
sTheLei
subt
ypes

103
 AMI
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Thet
hir
dcl
assi
fi
cat
ioni
sTheI
ntr
insi
csubt
ypes

7.Spr
eadofGast
ri
ccar
cinoma(
Lymphnodesst
ati
ons1–24)(
sel
f-
read)

Forunder
graduat
es(
MD3andMD5)st
ati
ons1-
12i
senought
ounder
stand

8.TNM cl
assi
fi
cat
ion(
sel
f-
read)

9.Leat
her
ed–Bot
tl
edst
omach(
sel
f-
read)

10.
Vir
chow’
sNode(
Signal
nodea.
k.aseatofdev
ilnodesa.
k.aTr
oiser
’ssi
gn)

11.
GASTRI
CLYMPHOMAS(
sel
f-
read)

104
 AMI
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12.
GIST&GASTRI
CCARCI
NOI
DS(
sel
f-
read)

HOW TOCLERKAPATI
ENTWI
THGASTRI
CCARCI
NOMA

Apat
ientwi
thgast
ri
ccar
cinomacanei
therpr
esent
swi
tht
hef
oll
owi
ng

A:
Abdomi
nal
pai
n

B:
Gast
ri
coutl
etobst
ruct
ion

C:
Epi
gast
ri
cmass

D:
Dysphagi
a

A:
Abdomi
nal
pai
n

Most
lyepi
gast
ri
cpai
n,dul
lachi
ngwi
thnon-
speci
fi
csy
mpt
omsofanor
exi
a,ear
lysat
iet
y
andabdomi
nal
ful
l
ness

Usual
l
y–Chr
oni
c(Longdur
ati
on)

I
nthese pat
ient
syourHPIshoul
drul
e outal
lthe causes ofChr
oni
c abdomi
nal
(
epi
gast
ri
c)pai
n

Beni
gncondi
ti
ons

o PUD(
Gast
ri
candduodenal
ulcer
s)

105
 AMI
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o Gast
ri
ti
s

o Chr
omi
cpancr
eat
it
is

o Chr
oni
cchol
ecy
sti
ti
s

o GERD

Mal
i
gnantcondi
ti
ons

o Gast
ri
ccar
cinoma

o Hepat
ocel
l
ularcar
cinoma

o Pancr
eat
iccar
cinoma

NB;
Int
heHPIy
oushoul
drul
eoutCompl
i
cat
ionsandRi
skf
act
orsf
oreachoft
heabov
e
di
ff
erent
ial
s,av
oidr
epet
it
ionsbecausemor
ethanonedi
ff
erent
ialcanshar
eri
skf
act
ors
andcompl
i
cat
ions

B.Gast
ri
cout
letobst
ruct
ion(
G.O.
O)

I
ftheTumori
satt
heAnt
rum,i
twi
l
lobst
ructt
heGast
ri
coutl
et,hencepr
esent
swi
th
G.
O.O

Vomi
ti
ngi
nG.
O.O usual
l
yisdescr
ibedasnon-
bil
i
ousandchar
act
eri
sti
cal
l
ycont
ains
undi
gest
edf
oodpar
ti
cles,Vomi
ti
ngmaybei
nter
mit
tentandusual
l
yoccur
swi
thi
n1
houraf
terameal
.

I
nthesepat
ient
s,y
ourHPIshoul
drul
eoutal
lthecausesofGast
ri
cout
letobst
ruct
ion

Thef
oll
owi
ngar
ecausesofGast
ri
cOut
letObst
ruct
ion(
G.O.
O)

St
omach

Beni
gncauses

- Gast
ri
cVol
vul
us

106
 AMI
N’STI
PS@GENERALSURGERY

- Gast
ri
cPol
yp

- Gast
ri
cBezoar
s

- Pr
e-Py
lor
icgast
ri
cul
cer

- Gast
ri
cTB

- Caust
icI
ngest
ion

- Cr
ohn’
sDi
sease

- Gast
rost
omyt
ubemi
grat
ion

Mal
i
gnantcauses

-
Gast
ri
cadenocar
cinoma

-
Gast
ri
cly
mphoma

-
GIST

-
Gast
ri
ccar
cinoi
d

-
Gast
ri
cLei
omy
osar
coma

Duodenum

Beni
gn

-
Traumat
ichemat
oma,

-
Dupl
i
cat
ioncy
st

-
Crohn’
sdi
sease

-
Bouv
eret
’ssy
ndr
ome

-
Duodenal
ulcer

Mal
i
gnant

-
Duodenal
adenocar
cinoma

107
 AMI
N’STI
PS@GENERALSURGERY

Pancr
eas

Beni
gn

Annul
arPancr
eas

Pancr
eat
it
is

Pancr
eat
icpseudocy
st

Mal
i
gnant

Pancr
eat
icadenocar
cinomaatt
hehead

NB:

1.I
tisbet
tert
ounder
standal
lthecausesofGOO,
alt
houghNOTal
lcanber
uledandi
n
y
ourHPI(
theycanhel
pyoui
ndi
scussi
onsessi
onsandev
eni
nyourt
heor
yexams)

2.
TheHPIshoul
drul
eoutcompl
i
cat
ionsand Ri
skf
act
orsf
oreach oft
heabov
e
di
ff
erent
ial
s,t
hosewhi
chcanber
uledouti
ntheHPI
,av
oidr
epet
it
ionsbecausemor
e
t
hanonedi
ff
erent
ial
canshar
eri
skf
act
orsandCompl
i
cat
ions.

NB:

Don’
tfor
gett
oRepor
tonsuccessi
onspl
ashi
nper–abdomi
nal
exami
nat
ion.

(
Shoul
dber
epor
tedi
napat
ientsuspect
edwi
thG.
O.Owhet
her+v
eor-
ve

108
 AMI
N’STI
PS@GENERALSURGERY

Remembersuccussi
onspl
asht
ohav
etr
ue+v
efi
ndi
ngst
hepat
ientshoul
dhav
enot
eat
enf
or2-
3hour
s,r
emembert
oaskwhendi
ds/
hel
asteatsoast
oav
oidf
alse+v
e
f
indi
ngs)

C.Epi
gast
ri
clump(
swel
l
ing)

Thel
umpcanei
therbef
rom Ant
eri
orAbdomi
nal
wal
lorani
ntr
a-abdomi
nal
mass

Quest
ion;CLI
NICALLY(
onexami
nat
ion)how t
odi
ff
erent
iat
eant
eri
orabdomi
nalwal
l
massf
rom ani
ntr
a-abdomi
nal
mass

Answer
;Inst
ructt
hepat
ientt
oli
eonsupi
neposi
ti
on,t
het
ori
seupbyusi
nghi
s/her
abdomi
nal
muscl
es(
asi
ndoi
ngsi
tupexer
cise)

Foranant
eri
orabdomi
nalwal
lmass,t
hemasswi
l
lincr
easeorr
emai
nconst
anti
nsi
ze
dur
ingsi
tt
ingup

Forani
ntr
a-abdomi
nalmass,i
twi
l
ldi
sappearorr
educei
nsi
zet
hisi
sduet
otheef
fect
ofcont
ract
ingt
heant
eri
orabdomi
nal
wal
lmuscl
es

Swel
l
ingatt
heepi
gast
ri
um f
rom t
heant
eri
orabdomi
nal
wal
lcanbe;

-
Epi
gast
ri
cHer
nia

-
Sof
tti
ssueTumorf
rom ant
eri
orabdomen

o Li
pomaofant
eri
orabdomi
nal
wal
l

o Rhabdomy
oma

o Rhabdomy
osar
coma

Swel
l
ingatt
heepi
gast
ri
um f
rom I
ntr
a-abdomencanbef
rom;

109
 AMI
N’STI
PS@GENERALSURGERY

Li
ver

Beni
gn

Hepat
iccy
sts,
Hepat
icHemangi
omaHepat
icAdenoma

Mal
i
gnant

Hepat
ocel
l
ularCar
cinomal
eftl
obeoft
hel
i
ver(
Pri
mar
yMal
i
gnancyoft
heLi
ver
)

Secondar
iest
othel
eftl
obeoft
heLi
ver

St
omach

Gast
ri
cAdenocar
cinoma

Gast
ri
cly
mphoma

GI
ST

Pancr
eas

Pancr
eat
icpseudocy
st

Cy
stadenocar
cinomaoft
hepancr
eas

Tr
ansv
ersecol
oni
cmass

Par
aaor
ti
cly
mphadenopat
hyduet
o;

-
ly
mphoma,

-
TB–adeni
ti
s

-
Orsecondar
iest
othepar
aaor
ti
cly
mphNodes)e.
g.i
ntest
icul
arcar
cinoma

Aor
ti
cAneur
ysm

NB;
Int
heHPIy
oushoul
drul
eoutcompl
i
cat
ionsandRi
skf
act
orsf
oreachoft
heabov
e
di
ff
erent
ial
swhi
chcanber
uledouti
ntheHPI
,av
oidr
epet
it
ionsbecausemor
ethanone
di
ff
erent
ial
canshar
eri
skf
act
orsandCompl
i
cat
ions

I
tisbet
tert
ounder
standal
lthecausesofepi
gast
ri
cmass,al
thoughNOTal
lcanbe

110
 AMI
N’STI
PS@GENERALSURGERY

r
uledandi
nyourHPI(
theycanhel
pyoui
ndi
scussi
onsessi
onsandev
eni
nyourt
heor
y
exams)

1.Don’
tfor
gett
o di
ff
erent
iat
ewhet
hert
heepi
gast
ri
cswel
l
ing or
igi
nat
esf
rom
ant
eri
orabdomi
nalwal
lori
ntr
a-abdomi
nali
n or
igi
n dur
ing perabdomi
nal
Exami
nat
ion,
DURI
NGI
NSPECTI
ONI
NPERABDOMI
NALEXAM

2. Repor
ti
ngaMassonperabdomi
nal
exam

St
atet
hef
oll
owi
ng

 Si
te(
Locat
ion,
basedont
heni
ner
egi
onsoft
heabdomen)

 Sur
face

 Si
ze

 Consi
stency

 Cany
ougoabov
e/bel
owi
t?

 Reduci
bil
i
ty(
Ist
hemassr
educi
ble)i
ftheswel
l
ingi
sreduci
bleepi
gast
ri
cHer
nia
shoul
dbesuspect
ed

 Compr
essi
bil
i
ty(
ist
hemasscompr
essi
ble)

 I
sthemasspul
sat
ing?I
fyes,i
sitexpansi
l
epul
sat
ion(
ori
gini
sAneur
ysm)or
t
ransmi
tt
edpul
sat
ions(
amassr
est
ingonanar
ter
y)

Youshoul
dknowhowt
odemonst
rat
eexpansi
l
eandt
ransmi
tt
edpul
sat
ions

 Repor
tift
hemassi
sanant
eri
orabdomi
nal
wal
lor
igi
nori
ntr
a-abdomen

3.
Inapat
ientwi
thsuspect
edGast
ri
ccar
cinoma,
don’
tfor
gett
ocheck

-Kr
uker
nbur
g’st
umor(
bybi
-manual
pal
pat
ionoft
headnexa)

-
Blummer
’sshel
f(bybi
-manual
pal
pat
iondur
ingDRE)
111
 AMI
N’STI
PS@GENERALSURGERY

D.DYSPHAGI
A

I
ftumori
satt
heCar
dia,
thepat
ientwi
l
lpr
esentwi
thdy
sphagi
a

(
ref
ercl
erkshi
pint
opi
cofDy
sphagi
a)

I
nvest
igat
ions

-
Doubl
econt
rastBar
ium meal

I
tist
hemet
hodofchoi
cet
hansi
ngl
econt
rast
,becausei
tdemonst
rat
esmucosal
pat
ter
n

(
Quest
ion;whatcont
rast
sused,whi
ch onebegi
nfi
rst
?Cont
rastused ar
eBar
ium
sul
phat
eandai
r/
gas)

Answer
;A gaspr
oduci
ng agenti
sswal
l
owed f
astt
hen t
hepat
ientdr
inksbar
ium
sul
phat
e

-
OGD+BX

-
EUS(
endoscopi
cul
tr
asound)(
forTNst
agi
ng)

-
Abdomi
nal
ult
rasound

-
Abdomi
nal
CTScan(
forTNM st
agi
ng)

-
Expl
orat
oryLapar
oscopy(
forst
agi
ng)

-
CEA

-
MRI

Knowi
ndi
cat
ions,
adv
ant
agesandl
i
mit
ati
onsofeachoft
heabov
einv
est
igat
ions

Tr
eat
ment

112
 AMI
N’STI
PS@GENERALSURGERY

Quest
ion;
Whatar
ethet
ypesofGast
rect
omyandt
hei
rindi
cat
ions?

Answer
;Ther
ear
ethr
ee;

Subt
otal
(di
stal
)gast
rect
omyi
sindi
cat
edi
ndi
stal
tumor
s,ant
ral
tumor
s

Tot
algast
rect
omyi
sindi
cat
edi
npr
oxi
mal
tumor
s,i
nthef
undus,
andbody

Ext
endedt
otal
gast
rect
omyi
sindi
cat
edi
ntumor
soft
hecar
dia,
Siewer
tcl
ass2and3

Quest
ion;
Whatar
etheReconst
ruct
ionspostgast
rect
omyandt
hei
rindi
cat
ions?

Answer
;

Postsubt
otal
(di
stal
)gast
rect
omyt
her
ear
ethr
eev
ari
ousr
econst
ruct
ionsnamel
y;

Bi
l
lrot
hI;
gast
roduodenost
omy

Bi
l
lrot
hII
;gast
roj
ejunost
omywi
thBr
aunanast
omosi
s(j
ejunal
jej
unost
omy
)

Roux-
en-
Yreconst
ruct
ion;(
gast
roj
ejunost
omyatt
hedi
stalj
ejunall
i
mb wi
thj
ejunal
j
ejunost
omyoft
hepr
oxi
mal
anddi
stal
li
mbs)

Postt
otal
gast
rect
omyt
her
econst
ruct
ionsi
sone,
namel
y;

Roux-
en-
Yreconst
ruct
ion;(
esophagoj
ejunost
omyatt
hedi
stalj
ejunall
i
mb,andj
ejunal
j
ejunost
omyoft
hepr
oxi
mal
anddi
stal
li
mbs)

I
ngast
rect
omy
,whatdoesR0,
R1,
andR2Resect
ionsmeans?

Ror
esect
ionmeansgast
ri
cresect
ion(
eit
hersubt
otalort
otal
)wi
tht
heai
m ofachi
evi
ng
bot
hmacr
oscopi
cal
l
yandmi
croscopi
cal
l
yfr
eemar
gins

R1r
esect
ionmeansgast
ri
cresect
ion(
eit
hersubt
otalort
otal
)wi
tht
heai
m ofachi
evi
ng
macr
oscopi
cal
l
yfr
eemar
gins,
wit
hposi
ti
vemar
ginsmi
croscopi
cal
l
y

R2r
esect
ionmeansgast
ri
cresect
ion(
eit
hersubt
otalort
otal
)wi
tht
heai
m ofachi
evi
ng
bot
h macr
oscopi
cal
l
y and mi
croscopi
cal
l
y posi
ti
ve mar
gins,t
his si
mpl
y means
debul
ki
ngsur
ger
y

113
 AMI
N’STI
PS@GENERALSURGERY

Quest
ion;Regar
dingt
otheext
entofl
ymphadenect
omy
,whatdoesf
oll
owi
ngt
erms
means?

Answer
;

D1Di
ssect
ional
socal
l
edD1Ly
mphadenect
omyt
hismeanscl
ear
anceofper
igast
ri
c
l
ymphnodes(
stat
ion1t
o6)

D2Di
ssect
ional
socal
l
edD2Ly
mphadenect
omyt
hismeanscl
ear
anceofl
ymphnodes
al
ongmaj
orv
essel
s(al
ongt
hecel
i
acandspl
eni
car
ter
iesst
ati
on1t
o12)
,forbet
ter
pr
ognosi
sD2i
sbet
tert
hanD1

Ext
ended D2 Resect
ion means t
otalgast
rect
omywi
th di
stalpancr
eat
ect
omywi
th
spl
enect
omy

NB:Pr
ophy
lact
ic spl
enect
omy and di
stalpancr
eat
ect
omy whi
ch was pr
evi
ousl
y
pr
act
icedi
sNOl
ongerusef
ul,i
tisonl
ydonewhent
het
umori
sadher
edt
othespl
een
andpancr
eas,
thent
hiswi
l
lbet
ermedasExt
endedD2Resect
ion

D3React
ion;D3Ly
mphadenect
omyt
hismeanscl
ear
anceofl
ymphnodes(
stat
ion1t
o
16)anav
erageof43l
ymphnodesr
emov
ed

D4React
ion;D4Ly
mphadenect
omyt
hismeanscl
ear
anceofl
ymphnodes(
stat
ion1t
o
18)
,thi
sisnotcommonl
yused

Quest
ion;
Dif
fer
ent
iat
ebet
weenr
esect
abl
etumor
sandoper
abl
etumor
s?

Answer
;Bot
hoft
heset
umor
scanber
essect
ed,
butt
hei
ntent
ionofr
essect
ingt
hem i
s
t
heonewhi
chmakest
hedi
ff
erence;
ify
our
esectat
umorwi
thani
ntent
ionofcur
ethen
t
hist
umorwi
l
lbecal
l
edoper
abl
etumor(
exampl
ebr
eastt
umorT1N0M)
;buti
fyou
r
esectat
umorwi
thanNOi
ntent
ionofcur
e(pal
l
iat
iver
essect
ion)t
hent
hist
umorwi
l
lbe
cal
l
edr
esect
abl
etumor(
exampl
ebr
eastt
umorT1N0M1)

114
 AMI
N’STI
PS@GENERALSURGERY

Quest
ion;Why does a pat
ient post gast
rect
omy pr
esent wi
th t
he f
oll
owi
ng
compl
i
cat
ions?

Answer
s;

1.Dumpi
ng(
Ear
lyandl
ate)

Dumpi
ngi
saphenomenoncausedbyt
hedest
ruct
ionorby
passoft
hepy
lor
icsphi
nct
er,
t
hesy
mpt
omsar
ethoughtt
obet
her
esul
toft
heabr
uptdel
i
ver
yofahy
per
osmol
arl
oad
i
ntot
hesmal
lbowelduet
oabl
ati
onoft
hepy
lor
usordecr
easedgast
ri
ccompl
i
ance.
Ty
pical
l
y,15t
o30mi
nut
esaf
terameal
,thepat
ientbecomesdi
aphor
eti
c,weak,l
i
ght
-
headed,
andt
achy
car
dic.

Cr
ampyabdomi
nal
pai
nisnotuncommon,
anddi
arr
heaof
tenf
oll
ows.Thi
sisr
efer
redt
o
as ear
ly dumpi
ng and shoul
d be di
sti
ngui
shed f
rom post
prandi
al (
react
ive)
hy
pogl
ycemi
a,al
socal
l
edl
atedumpi
ng,
whi
chusual
l
yoccur
slat
er(
2–3hour
sfol
l
owi
ng
ameal
)andi
srel
i
evedbyt
headmi
nist
rat
ionofsugar

Thecauseofpostv
agot
omydi
arr
heai
suncl
ear
.

Possi
blemechani
smsi
ncl
udei
ntest
inaldy
smot
il
it
yandaccel
erat
edt
ransi
t,bi
l
eaci
d
mal
absor
pti
on,
rapi
dgast
ri
cempt
ying,
andbact
eri
alov
ergr
owt
h

2.Di
arr
hea

Di
arr
heaf
oll
owi
nggast
ri
csur
ger
ymaybet
her
esul
toft
runcalv
agot
omy
,dumpi
ng,or
mal
absor
pti
on.Ther
esul
toft
heabr
uptdel
i
ver
yofahy
per
osmol
arl
oadi
ntot
hesmal
l
bowelduet
oabl
ati
onoft
hepy
lor
usordecr
easedgast
ri
ccompl
i
ancel
eadst
oshi
ftof
t
hef
lui
dsf
rom t
hei
nter
sti
ti
ali
ntot
hel
umenf
orneut
ral
i
zingt
hehy
per
osmol
arl
oad,
hencet
hiswi
l
lleadt
heso-
cal
l
edOsmot
icdi
arr
hea

3.Gast
ri
cst
asi
s

I
tmaybe secondar
yto del
i
ber
ate oruni
ntent
ionalv
agot
omy
,orr
esect
ion oft
he

115
 AMI
N’STI
PS@GENERALSURGERY

domi
nantgast
ri
cpacemakerasi
tisknownt
hatGast
ri
cmot
il
it
yismedi
atedbyv
agus
i
nner
vat
ionandgast
ri
cpacemaker
.

Anobst
ruct
ionmaybemechani
cal(
e.g.
,anast
omot
icst
ri
ctur
e,ef
fer
entl
i
mbki
nkf
rom
adhesi
ons orconst
ri
cti
ng mesocol
on,ora pr
oxi
malsmal
l
-bowelobst
ruct
ion)or
f
unct
ional
(e.
g.,
ret
rogr
adeper
ist
alsi
sinaRouxl
i
mb)
.

Gast
ri
cst
asi
spr
esent
swi
thv
omi
ti
ng(
oft
enofundi
gest
edf
ood)
,bl
oat
ing,epi
gast
ri
c
pai
n,andwei
ghtl
oss

4.Bi
l
eref
luxGast
ri
ti
sSy
ndr
ome

Mostpat
ient
swhohav
eunder
goner
esect
ionoft
hepy
lor
ushav
ebi
l
eint
hest
omach,
Howev
er,i
tisgener
all
yaccept
ed t
hatasmal
lsubsetofpat
ient
shav
ebi
l
eref
lux
gast
ri
ti
ssy
ndr
ome.Thesepat
ient
spr
esentwi
thnausea,
bil
i
ousv
omi
ti
ng,
andepi
gast
ri
c
pai
n,andquant
it
ati
veev
idenceofexcessent
erogast
ri
cref
lux,
sympt
omsof
tendev
elop
mont
hsory
ear
saf
tert
hei
ndexoper
ati
on

5.Remnantgast
ri
ccar
cinoma,

Theef
fectofpr
olongedexposur
eofbi
l
etogast
ri
cmucosawi
l
lleadt
omet
apl
asi
athen
dy
spl
asi
aandev
ent
ual
l
ycar
cinomai
nther
emai
ningst
omach,
asgast
ri
cmucosai
snot
adapt
edt
obi
l
e.

6.Gal
lst
ones(
chol
eli
thi
asi
s)

Gal
lbl
addercont
ract
il
it
yismedi
ated byv
agusi
nner
vat
ion,so gal
l
stonef
ormat
ion
f
oll
owi
nggast
ri
csur
ger
ygener
all
yist
houghtt
obesecondar
ytov
agaldener
vat
ionof
t
hegal
l
bladder(
ant
eri
orv
agot
omy
),l
eadi
ngt
ogal
l
bladderdy
smot
il
it
yandst
asi
sofbi
l
e
i
nthegal
l
bladder
,readonhowst
asi
stheor
yint
hef
ormat
ionofgal
lst
ones

7.Anemi
a(bot
hir
ondef
ici
encyandv
itami
nB12def
ici
ency
)

I
ronabsor
pti
ont
akespl
acepr
imar
il
yint
hepr
oxi
malGIt
ract
,andi
tisf
aci
l
itat
edbyan

116
 AMI
N’STI
PS@GENERALSURGERY

aci
dicenv
ironment
,postgast
rect
omyt
her
eisr
educedornopar
iet
alcel
l
swhi
chi
s
r
esponsi
blef
oraci
dpr
oduct
ion,t
her
eforpoorornoi
ronabsor
pti
on.I
ntr
insi
cfact
or,
essent
ialf
ort
heent
eri
cabsor
pti
onofv
itami
nB12att
het
ermi
nali
l
eum,
int
ri
nsi
cfact
or
i
sal
somadebyt
hepar
iet
alcel
l
soft
hest
omachwhi
chi
ngast
rect
omyt
her
ear
e
r
educed orabsent
.Vi
tami
n B12 bi
oav
ail
abi
l
ity al
so i
sfaci
l
itat
ed by an aci
dic
env
ironment
.Fol
ate-
ri
chv
eget
abl
esmaybepoor
lyt
oler
ated i
fgast
ri
cempt
ying i
s
del
ayedori
fgast
ri
ccapaci
tyi
sli
mit
ed.Si
ncei
ron,B12,andf
olat
epl
ayv
italr
olesi
n
hemat
opoi
esi
s,i
tiseasyt
ounder
standwhypat
ient
swhohav
ehadagast
ri
coper
ati
on
ar
eatr
iskf
oranemi
a.

8.Bonedi
seasesl
i
ke(
Ost
eopor
osi
sandPat
hol
ogi
cal
fract
ure)

Gast
ri
c sur
ger
y somet
imes di
stur
bs cal
cium and v
itami
n D met
abol
i
sm.Cal
cium
absor
pti
on occur
s pr
imar
il
y i
n t
he duodenum, whi
ch i
s by
passed wi
th
gast
roj
ejunost
omy(
Bil
l
rot
h2r
econst
ruct
ion)
.

Fatmal
absor
pti
onmayoccurbecauseofbl
i
ndl
oopsy
ndr
omeandbact
eri
alov
ergr
owt
h
orbecauseofi
nef
fi
ci
entmi
xi
ngoff
oodanddi
gest
iveenzy
mes.Thi
scansi
gni
fi
cant
ly
af
fectt
heabsor
pti
onofv
itami
nD,af
at-
sol
ubl
evi
tami
n.Bot
habnor
mal
i
tiesofcal
cium
and v
itami
n D met
abol
i
sm can cont
ri
but
eto met
abol
i
c bone di
sease i
n pat
ient
s
f
oll
owi
nggast
ri
csur
ger
y.Thepr
obl
emsusual
l
ymani
festaspai
nand/
orf
ract
uresmany
y
ear
saf
tert
hei
ndexoper
ati
on.

9.Wei
ghtl
oss+Anor
exi
a

Thecausesofwei
ghtl
ossaf
tergast
ri
csur
ger
ygener
all
yfal
li
ntooneoft
wocat
egor
ies:
al
ter
eddi
etar
yint
akeormal
absor
pti
on.I
fast
ool
stai
nforf
ecal
fati
snegat
ive,
iti
sli
kel
y
t
hatdecr
easedcal
ori
cint
akei
sthecause.Thi
sist
hemostcommoncauseofwei
ght
l
ossaf
tergast
ri
csur
ger
y,andi
tmaybeduet
osmal
lst
omachsy
ndr
ome,
post
oper
ati
ve
gast
ropar
esi
s,anor
exi
aduet
olossofghr
eli
n,orsel
f-
imposeddi
etar
ymodi
fi
cat
ion
becauseofdumpi
ngand/
ordi
arr
hea.

Thedegr
eeofwei
ghtl
osst
endst
opar
all
elt
hemagni
tudeoft
heoper
ati
on.I
tmaybe

117
 AMI
N’STI
PS@GENERALSURGERY

i
nsi
gni
fi
canti
ntheobesebutdev
ast
ati
ngi
ntheast
heni
cpat
ient
.Thesur
geonshoul
d
al
way
sconsi
dert
hepossi
blenut
ri
ti
onalconsequencesbef
oreper
for
mingagast
ri
c
r
esect
ionf
orbeni
gndi
seasei
nat
hinpat
ient

10.
Roux-
enYSy
ndr
ome

A subset of pat
ient
s who hav
e had di
stal gast
rect
omy and Roux-
en-
Y
gast
roj
ejunost
omywi
l
lhav
egr
eatdi
ff
icul
tywi
thgast
ri
cempt
yingi
ntheabsenceof
mechani
cal
obst
ruct
ion.

Thesepat
ient
spr
esentwi
thv
omi
ti
ng,epi
gast
ri
cpai
n,andwei
ghtl
oss.Thi
scl
i
nical
scenar
iohasbeenl
abel
edt
heRouxsy
ndr
ome.Endoscopymayshowr
etai
nedf
oodor
bezoar
s,di
l
ati
onoft
hegast
ri
cremnant
,and/
ordi
l
ati
onoft
heRouxl
i
mb.

TOPI
CEI
GHT

ULCERS
Def
ineanul
cer

Di
ff
erent
iat
eanul
cerandawound

St
agesofwoundheal
i
ng

Ty
pesofwoundheal
i
ng

Anat
omyoft
heski
n–(
byl
ayer
s)

PARTSofanul
cer

i
) Mar
gin-
aboundar
yofanul
cer

i
i
) Edge-
par
tofanul
cert
hatconnect
sthemar
gint
othef
loor

i
i
i) Fl
oor
-i
stheexposedsur
faceofanul
cer

118
 AMI
N’STI
PS@GENERALSURGERY

i
v) Base-
iswher
etheul
cerr
est
,canei
therbemuscl
e,t
endon,
Ligament
se.
tc

v
) Sur
roundi
ngepi
thel
i
um

Ty
pesofEdges

- Sl
opi
ngedgei
ndi
cat
esheal
i
ngul
cer

- Under
minededgei
ndi
cat
est
uber
cul
ousul
cer

- Rai
sededgei
ndi
cat
esmal
i
gnantul
cer

- Rai
sedandev
ert
ededge(
rol
l
edout
)indi
cat
essquamouscel
lcar
cinoma

- Punchedoutedgei
ndi
cat
est
rophi
cul
cer

Youshoul
dunder
standhoweachedgel
ooksl
i
keonexami
nat
ion,andwhatdoeseach
edgei
ndi
cat
es(
possi
bledi
agnosi
s)

Ul
cer
sar
ecl
assi
fi
edei
therby

i
. Cl
i
nical
Classi
fi
cat
ion

i
i
. Pat
hol
ogi
cal
classi
fi
cat
ion

Cl
i
nical
Classi
fi
cat
ionsofUl
cer(
Howanul
cerl
ooksoncl
i
nical
exami
nat
ion)

I
nthi
scr
it
eri
ont
her
ear
ethr
eet
ypes

Spr
eadi
ngul
cer

Fl
owi
scov
eredwi
thsl
oughs

Nat
ureoft
hedi
schar
gei
spur
ulent

Thesur
roundi
ngepi
thel
i
um hasf
eat
uresofi
nfl
ammat
ionwhi
char
etender
,hy
per
emi
a,
war
mthandswol
l
en

119
 AMI
N’STI
PS@GENERALSURGERY

Heal
i
ngul
cer

Edge-i
ssl
opi
ngedgewi
thbl
uish/
pur
pli
shcol
or

Fl
owcov
eredwi
thgr
anul
ati
ont
issue(
redcol
ored)

Nodi
schar
ge,
ifpr
esenti
tisscant
yandser
ous

Thesur
roundi
ngepi
thel
i
um i
snoti
nfl
amed

Non-
heal
i
ngul
cer

Fl
owi
scov
eredwi
thpal
egr
anul
ati
ont
issue(
pinkcol
ored)

Nat
ureofdi
schar
gei
sser
osangui
nous

Sur
roundi
ngski
nisnoti
nfl
amed

1.Pat
hol
ogi
cal
classi
fi
cat
ion

Thi
sisduet
otheet
iol
ogyoft
heul
cer

-
Traumat
icul
cer

-
Inf
ect
iousul
cer(
syphi
l
isandTuber
cul
ous)

-
Vascul
arul
cer(
Art
eri
alandVenousul
cer
)

-
Mal
i
gnantul
cer(
SquamousCel
lCar
cinoma,
Basal
Cel
lCar
cinoma,
Mel
anoma)

-
Diabet
icf
oot
.(Youshoul
dknow t
hepat
hophy
siol
ogyofdi
abet
esl
eadi
ngf
oranul
cer
Hi
nts;
neur
opat
hyandv
ascul
opat
hy)

-
HIV–Rel
ated

-
Mal
nut
ri
ti
on-Rel
ated

-
Hyper
tensi
veul
cer

-
Trophi
cul
cer

-
Neur
ogeni
cul
cer

120
 AMI
N’STI
PS@GENERALSURGERY

HOW TOCLERKAPATI
ENTWI
THANULCER

Chi
efcompl
aint
s

- Anul
cer–(
sit
eanddur
ati
on)

HPI

PARTA

I
sitspont
aneousorf
oll
owi
ngt
rauma?

Associ
ati
ngsy
mpt
oms

-
Pai
n

-
Inabi
l
ityt
ouset
hel
i
mb

-
Swel
l
ingoft
hel
i
mb

NB:
Ifspont
aneoust
henaskhowdi
ditst
art
edandpr
ogr
essedt
ofor
m anul
cer
?

PARTB

RULEOUTTHEPOSSI
BLECAUSE

Aski
fthepat
ienti
shav
ingTB.

I
fNO–Askt
hepr
esenceofB-
sympt
omswhi
char
e;

Ni
ghtf
ever
s,Ni
ghtsweat
sanduni
ntent
ional
wei
ghtl
oos

-
andaskf
orr
iskf
act
orwhi
chi
sHi
stor
yofopenTBcont
ract

Enqui
rehi
stor
yoft
hef
oll
owi
ng,

-
Diabet
esMel
l
itus

-
HIV

-
Hyper
tensi
on
121
 AMI
N’STI
PS@GENERALSURGERY

I
fyes,t
heabov
e,f
orhow l
ong? i
she/
sheon r
egul
armedi
cat
ions,i
fyeswhi
ch
medi
cat
ions?Anddosage(
amount
)ifpossi
ble.

Hi
stor
yofci
gar
ett
esmoki
ng(
inpacky
ear
s)

Hi
stor
yofAl
cohol
i
sm,
ify
esf
orhowl
ong

LOCALEXAMI
NATI
ONOFULCER

I
NSPECTI
ON

Repor
tnumberoful
cer
s(howmanyul
cer
s)i
sitasi
ngl
eul
cer
?Or

Locat
ion/Si
te

Locat
ion/
sit
ecanhel
pyoui
ndi
agnosi
s

eg-
Neck–t
uber
cul
ousul
cer

-
Medi
alMal
l
eol
us–v
enousul
cer

-
Dor
sum oft
hef
oot–ar
ter
ial
ulcer

-
Peni
l
eHead–sy
phi
l
iti
cul
cer

Mar
gin-
isi
tregul
ar/
ir
regul
ar

Edges-
whi
cht
ype?Ref
erabov
e

Fl
oor
-Whatcov
erst
hef
looroft
heul
cer(
slough?Gr
anul
ati
ont
issues?Pal
egr
anul
ati
on
t
issues?
)

Anydi
schar
ge?i
fyes–whatnat
ure(
nat
uresofdi
schar
gear
eser
ous,pur
ulent
,bl
oody
,
ser
osangui
nous)

Soundi
ngEpi
thel
i
um,
her
einspecti
fiti
shy
per
emi
candswol
l
en

PALPATI
ON

Si
ze–Measur
elengt
handwi
dthi
ncent
imet
ers

122
 AMI
N’STI
PS@GENERALSURGERY

NB:

I
fitcan’
tbemeasur
edduet
ohow t
heshapeofanul
ceri
s,t
hent
hesi
zecanbe
est
imat
edi
nper
cent
ageofapar
ti
cul
arr
egi
on

Forexampl
e:-Theul
ceroccupi
esappr
oxi
mat
ely75%r
ightf
orear
m

ThenPal
pat
e–Mar
ginandedge-
fort
heconsi
stency

Beni
gnul
cer
sar
eSof
t

Mal
i
gnantul
cer
sar
eFi
rmt
ohar
d

Thenpal
pat
ethef
loor

-
Forconsi
stency

-
Anydi
schar
geonpal
pat
ions

NB:
Mal
i
gnantul
cer
sbl
eedsi
ntouch

Thenpal
pat
efort
hesur
roundi
ngepi
thel
i
um (
Pal
pat
efort
ender
nessandwar
mth)

Thenpal
pat
eforf
ixat
ion

Exami
nef
ort
hef
ixat
iont
othebase

Beni
gnul
ceri
snotf
ixed

Mal
i
gnantul
cer
,canbef
ixedt
otheunder
lyi
ngst
ruct
uresduet
olocali
nfi
l
trat
ionof
mal
i
gnantcel
l
s.

Pal
pat
eforRegi
onal
lymphNodes

-
UpperLi
mbs–axi
l
la

-
LowerLi
mbs–i
ngui
nal

Repor
t-
Number
sofl
ymphNodespal
pabl
e,

-
tenderornot

123
 AMI
N’STI
PS@GENERALSURGERY

-
Ifmor
ethan1ar
etheymat
tedordi
scr
ete

-
Consi
stency

-
Mobi
l
eorf
ixed

Per
ipher
alPul
sat
ion

Forl
owerl
i
mbsul
cer
s,pal
pat
efort
hef
oll
owi
ngpul
ses,Dor
sal
i
sPedi
s,Post
eri
orTi
bial
,
Popl
i
teal
andFemor
al

Forupperl
i
mbul
cer
s,pal
pat
efort
hef
oll
owi
ngpul
ses,
radi
alandBr
achi
al

(
repor
tchar
act
erofpul
seasdonecar
diov
ascul
arexam)

Exami
nef
orSensat
ion

-
Touch

-
Pai
n

-
Vibr
ati
on

-
Posi
ti
on

I
NVESTI
GATI
ONS

Random Bl
oodGl
ucose(
RBG)–I
fDi
abet
icf
ooti
ssuspect
edorwant
edt
ober
uledout

X–Rayoft
hel
i
mb/f
oott
olookf
orBonei
nvol
vement
/Ost
eomy
eli
ti
s

Doppl
erul
tr
asoundorCT–Angi
ogr
am t
olookf
orVascul
ar(
Per
fusi
on)st
atus

I
fDi
schar
gei
sPr
esent
,dowoundswabf
orcul
tur
eandsensi
ti
vi
ty

I
fchr
oni
cul
cerORi
fther
ear
efeat
uresofmal
i
gnancyexampl
ebl
eedi
ngont
ouch&
r
aisededgest
hendowedgeBi
opsy

124
 AMI
N’STI
PS@GENERALSURGERY

DI
AGNOSI
SISACOMBI
NATI
ONOFPATHOLOGI
CALANDCLI
NICALCLSSI
FICATI
ON.

FORDI
ABETI
CFOOTGRADETHEULCERBYEI
THERWAGNER’
SCLASSI
FICATI
ONOR
UNI
VERSI
TYOFTEXASCLASSI
FICATI
ON

TREATMENT

1.ManagementofDi
abet
icf
oot

Goal
1:Cont
rol
sugar

Swi
tchf
rom or
alhy
pogl
ycemi
ctoi
nsul
i
ninj
ect
ioni
fsugarl
eveli
snotwel
lcont
rol
l
ed,
if
cont
rol
l
edwi
thor
alhy
pogl
ycemi
cthencont
inuewi
thor
alhy
pogl
ycemi
cs

Sel
f-
readon,
dosageandr
out
eofi
nsul
i
nandhowt
obudgetbet
weensol
ubl
eandLent
e

Moni
torRBG,
fol
l
owi
nsul
i
nregi
men

Goal
2:Cont
rol
inf
ect
ion

Gi
veBr
oadspect
rum ant
ibi
oti
csi
fNOCul
tur
eresul
ts

Whencul
tur
eresul
tsar
eout
,gi
veant
ibi
oti
csaccor
dingt
ocul
tur
eresul
ts(
sensi
ti
vi
ty
pat
ter
n)

Wounddr
essi
ng

I
fsl
oughspr
esent
,thendosl
oughect
omy

Whatar
eTy
pesofsl
oughect
omy
?Sur
gicalsl
oughect
omyi
sbyusi
ngsur
gicalkni
fe,
medi
calsl
oughect
omyi
sbyusi
ngt
opi
calmedi
cat
ionsexampl
eSi
l
ver
exoi
ntmentand
bi
ologi
cal
sloughect
omybyi
sbyor
gani
sm suchasmaggot
s

Goal
3:Def
ini
ti
veTr
eat
ment

Thi
swi
l
lbegui
dedbyWagner
’scl
assi
fi
cat
iononUni
ver
sit
yofTexascl
assi
fi
cat
ionsof
Di
abet
icf
oot(
Read)

2.Readont
hemanagementofeacht
ypeoful
cer
.(pat
hol
ogi
cal
classi
fi
cat
ion)

125
 AMI
N’STI
PS@GENERALSURGERY

126
 AMI
N’STI
PS@GENERALSURGERY

Ref
erenceshav
ebeenmadef
rom t
hef
oll
owi
ngr
ecommendedt
extbooks
1.Schwar
tz’
sPr
inci
plesofSur y11thEdi
ger ti
on

2.Gr
eenf
iel
d’sSur
ger
ySci
ent
if
icpr
inci
plesandpr
act
ice6thEdi
ti
on

3.SRB’
sManual
ofSur y5thEdi
ger ti
on

4.Mani
pal
Manual
ofSur y4thEdi
ger ti
on

127