SURGERY

Ñame:BH_AR
 GENERAL
-
SURGERY

Epidermis :
keratinized cells

•
no arteries 1 veins / capillaries 1 lymphatics
•
Some veins here & there .

→
epidermis
mm
papillary dermis

Reticular Dennis

Saf

dermis
papillary
→
 Some skin cells lie in a
/w hair
follicles & sweat

glands
.

Bung :

Heat injury to
body
the .

Therefore Non thermal Burns

-

d. f-
Direct heat Indirect heat
injury injury
• Flash burns occur
°
Acid Burns

c- •
Electric burn
gas
I. °
Radiation Burns
Superficial but widespread
• Contact Burns

thot
obj)
silencer burns .

Scalds
dlt hot liquids
•

Eg :
water → 65°C severe
burn
1

even if skin is
exposed
for 1- 3sec .

Ideal Temp of to have bath

.
water : one
degree
centigrade above normal
body temp .
Dwayne ¥ Burnam :

partial
thickness
burns
-
{
poe
←

thickness
Burnt

Fisstdegeeeburns :

Involve
only epidermis
•
.

painful
• no blisters form .

1 collagen
}
elastin
Ipo of
-

✗ in
↳ epidermis
Fluid -

At VIC

heal within without

5- 7
days scarring
-

2°bymficialBurns_:
-

Epidermis +
papillary Dermis

painful
-

thin walled & have clear

Brister
form
-

fluid →

mostly
derived
from lymphatics)
heal
scarring
cells which lie
without :
epithelial
•

along.F.mu not burnt .

These cells
proliferate
wound & cover ( < 2 wks ) .
rileelpburns Epidermis papillary dermis some of
: +
+

the reticular
dermis
-

painful
walled
Blisters
form Thick
-

&
Turbid fluid [ dlt RIC / WBI

healing occurs c- scar

formation as most of
hair Burnt
the cells
along follicles are
.

✓ 4- 6 weeks .

mottled
appearance log Burn]
-

sensation be absent in some

pin pick may
-

areas .

30¥ :

A NICK
- Involve entire dermis → ×

nerves ×

flair follicle / Sweat off ✗

painless
-

blisters
form
no
-

sensation
pinprick
-
no

Burnt tissue is called

÷!%APgm_
-

My appearance
-

Burnt veins be visible

may
-

.
4th burn
degree
:
-

muscle / Bone Brent .

Assessmentoflburnloagetrea -

TBS_A Total Burn

surface area is
single
most
imp factor predicting turn
mortality
. .

1%
Palm method :
surface area
of palm
is
of body
to
crude
method .

surface area .

Wallace Rule
mm
mm -
of 9
~
:

↳ Children

Head &
9% 18%
neck

Thorax & 36%

36%
Abd
'

torso)

36%
lower limb 27%
( Both)

limb 18% 18%

tllfpu(Both)
Rule
of 9 .

& 1%
perineum 1%

genitalia
 to
Browder chart are used
for assessing damage
individual body part
.

ls
for all ages .

LowsOfBurns•_ 3
zones
.

3.) zone of -
hypegimia Tinner
damage
most
outermost
- man
zone
:
.

zone
heat
thermal coagulation of protein dlt
-

occur
• no

damageBut
zone
in this
this
\ : .

zone
of coagulation
.

space
.

has VD dlt •mYsto

cytokines : -

Sluggish Blood
flow
released
by dead tissue .
# Trauma vessel
air -

Reversible
thermal
damage
i
damage .

If further heat is
prevented from
reaching this we
area can
,

this
timely
save c-
zone
.

hydrotherapy
water
cooling I at 15-17°C

• Ice / Ice cold water can cause

severe vaso -
constriction

thence not used .

Hydrotherapy should begin c- in 1 hour

minimum
should continue
for 10min
PalHfy-ofB.my :

Activ#ent :

of Hageman factor
• Activation in Burnt tissue .

release
of cytokines
•

causes the .

1)
Cytokines : will cause severe vasodilatation .

} TNF capillaries dilated are

- - - - -

It , ←
dlt cytokines
capillaries
.

- -
-
- -

plasmajt.io
✓
(&
Hypnoses Blood volume
)
Mole of early
death in Burns .

death site accident

mfcfc of of Asphyxia
→ : -
•

shock
Neurogenic
•

dlt
injuries
to .

late
mfcfc of death
1 overall
shock
septicemic
a
.

mklc of death 1nF acid

poisoning 1 Electric Burn

a
shock
cardiogenic .
 2) lungs
⑤
¥€ u
→

-
-

-
-

oik
-
-
-
-

-
-

burn
If area > 33%
cytokines spread throughout the
-

body
.

Vasodilation in
lungs also .

ARDS -

Acute Respiratory distress

syndrome .

3) Kidneys normal times →

tidings get
20%
of cardiac

output
in Burns
hlypouolemia → .

blood
kidneys less
:
will
get
-

Acute Tubular necrosis occurs

causing renal
failure
-

d) Stomachs → mucous

has thick wall

•

stomach
Blood
good supply
o
.

Burns :
tlypovolemia
A
-

i. Stomach wall
develops ischemia i. ulcers
develop
in stomach .

4
(Acid prod "
is normal) CURLING
ULCERS .
 Cushingucus neuro trauma
-

hour in head
injury
nerves are irritated ( cranial nerve )
-

Vagus nerve ( Secreto motor-

nerve )
& ↳ T
A acid
"
peristalsis
prod
i. in head "
9T
injury → acid
prod
= .
Ulcers
developed in stomach .

- Skull

in:)
Brain head
1 swells up dft
-

yy
THE CAR C control
sangriatinglnuysuuo
c- ex -

external
hemorrhagic .

[ if present it
A-
Airway B-
Breathing

circulationtlypovobmiae.TV fluids [
c-

Adults
children
: >

:
15% Burns
> 10%
]
burns .
 →
comes crystalloid
normal saline
HES ( Hera ethyl
starch )
-

Penta starch Ringer lactate

Ringer Acetate

Dextrose .

very high molecular °

very
low molecular
net
weight
.

colloid
crystalloid

Expensive Inexpensive
-

payout
'

Buds
warrant
-
f- f- - - -

colloid
crystalloid
-
- - - - - -

1) Colloid :

Colloids .

-
=

4
- . .
-

:
. .
-

y
-
- -
- .
. .

Bacteria heavy evaporation

:

grow not
possible
.

i.
They settle on
-

- -

- -
-

surface .

2) Crystalloid
- -
- -
-
-
-

evaporate c-

sweat
-

-
- - - -

i
-

preferred fluid crystalloid

-

is .
 has
pt hyrpovobmia
.

↳
less Blood volemia
b
less Blood 402 )
4
Anaerobic respiration ( lactic Acidosis)
d.
metabolic acidosis

Riz : -

lactate is metabolized by body to release

Hcoj ( neutralize acidity)

How much
fluid ?
Parkland formula : 4mL ✗
kg body net ✗ TBSA

f.
4
¥
mlx 60
by 20%
: ✗

4800 ml
of RL / 24 hrs
=
.

Half of the
fluid should be
given
in initial this .

( 24 or ml
/ 8hm)
 AILS 10th

IAdr-traumaqeditionchanges.li
te support)
-
Too much cytokine release in 3° burns

not that much damage in 2° Burns

-
.

1) for partial thickness burns in adults

2mL
/ kg ITBSA .

But min urine

output 0.5mL
1kg1 hour
- .
.

2) for
partial thickness burns in children :

-
3mL
1kg1 TBSA .

have
: children immature
kidneys
•
.

To remove same amount

of
toxin from
body -
require larger amount
of
urine .

3) Infant / children c- wt .

<
30kg
: -

we need to add dextrose

Brain & muscles derive

energy from
i
: can

dextrose
only .

In children min urine

output: a.
mlfkg 1hr
.
.

children have
very low-Tech in liver ( small
size)
i. dextrose
4.) for 5 / electric Burns : 4mL
1kg1 TBSA .

(
Deep ) 13°)
1kg1
urine
min .

output : 1mL hi

15mL / (electric burn]

kg 1hr
After 12hr we can use colloid
fluid .

human albumin
preferred colloid → .

Barclay & Muir

/
-

to
- Brook :Ñ:rq%ImmY÷
evan
formula
-

Galveston formulas children

-

→ .

localdressing
→
Silversulphadiazine
Drawbacks_:
1) repeated application makes skin hard & black .

↳
known as
pseudo eschar .

2) can cause
marginalia of WBC into
spleen .
 sonic bond
(
→
silver nitrate
Ag NO
,)
-

&

after application on

skin : Bond breaks

É i.
hyponatremia
not
✓
Intense
blackening of tissue
•
.

Na No Ht
+
NHI (Ammonium)
-

→
,

Why + Hb

meth
heaemoglobinemia
-

painful to
apply
-

repeated application
-

Turns
dressings black
- .

Sie si d b to work on
surface only
iiiisñiañi i
-

sie nitrate
.

I Methim chocolates
→
color blood .

chocolate

Munroe Acetates : cerium nitrate

£ -

can
Both can
penetrate eschar .

cause met .

acidosis
langulines :

to
cosmetic incision is
given parallel

ÉÉarotomy
lines
longer .

tear to
incision is
always given
lines
longer

Uectmµw Tension → 1000 Volt

eg
: House
electricity
-

High Tension : > tooo ✓ ( overhead nioe)

lightening : > 1. 00,000 V

Heart in
can come
pathway of current :

cardiac
asrythmiafnycommon-V.fi b)
-

.
 has
Also ,
skin
high resistance to current .

i. current does not enter

large part skin

spared
-

of
- .

( muscle 1
Damage lies
deep under skin )
nerve

→
THEY : -

D myocardial rupture
2) clothes catches fire .

electricity body FLASH

:
-

arches over :

BURNS

¥Ñ☒µñanmnam
Filigree burns →

superficial burns dlt

reflected lightening .

7 Electric burn → mascle

*
Be myoglobin is released .

-0g &
myoglobin .ve
Acute Renal Failure .

Forced Alk . Diuresis

I
Injury : comes to
or
emergency
wheeled in

Trapped in
building
suspected
-

D If Ho being trapped in a
burning building
2) Facial Burns

palatial Burns

singed nasal hair

3) change in voice

4) carbonaceous
sputum .

laryngeal edema
develop even 12 his
after injury .

Best Ttt If inhalation

suspected
injury
: is :

Do endotracheal intubation
(
Before edema
develops )
(After edema
may
not be
possible] .

9¥
tracheostomy
: .
 -
CHEMICAL BURNS :

MID Alkali
•

coagulative
o

liquefactive
necrosis
of skin necrosis
of
skin

Alkali
Id ☐

↳ ↳
-

liquefaction
+
coagulum
( skin + Acid) ↳
-

Impervious
More
damage
Alkali
Acid cannot can cause
deeper
-

enter
deep damage
widespread burns
-

9¥ Tangential excision

III. : wash _c
copious amount of skin till normal
water
of skin is
Bleeding)
(
.

seen

( Brush solid chemicals

wet
first ) £
caOtHzO Calm
I
time
heat
tdaohime
antidote
never use
specific :
-

heat

NaOH + HCl Is NaCl + Hao

→
heat
-
i too much heat is released .
 HF Acid
poisoning
:

used
-

mile acid in industries .

¥É F-+ ca
"
→
hypocalcemia .

'
TT
Hyperkalemia
→
i. K .

6
Dangerous : cause cardiac arrest

burn
burn
/ acid
skin minimal skin
e
: is
no

absorbed
immediately .

T# Ing: calcium Gluconate

ca Gluconate gel .

Admission
-
:

•
Inhalation

face / hand /
genitalia
-

non accidental
inj
-
-

extremes
of age
-

psychiatric or social
background that necessitates
-

admission
-

Destitute 1 elderly
:

eg
 Shingling :

1) Graft_: Transfer of tissue

from one
place to other

i. out its blood

supply innervation
own or .

AUT0GRA -

Transfer of Tissue

↳ in same individual
leg Thigh
: to chest )

Jsogsaft :
Btw genetically identical individual
last skin
grafting)
Allograft :
Btw 2 members
of same
species ( HOMOGRAFT)

Xenogiaft Transfer of : tissue btw dff species .

Eg : Fish skin on human } FALLS .

Typhon
1) Split Thickness skin
graft : Theissen
graft
2) Full thickness :
Woolfe .

0
-
epi
stuck (meshing)
Dermis

oonorscrtndeimgmz.fr :

1) Ulcer c-
granulation tissue (
Healing ulcer
)
 2) Burns

3) wide excision
leg after malignancy )
4) Deafening injury ( Trauma
)
5) purpura fulminans ( multiple Blood clots develop in

the circulation
of
skin necrosis
] -

Contraindications :

Exposed bone tout

periosteum
-

tendon
Exposed out
paratenon
-

c- .

cartilage c- out
perichondrium
-

Infection ( 105 bacteria tissue)

Igm of
Absolute contra -
indication :
-

p hemolytic streptococci
"
Inf E -

blade
Down
Tools :
s
•

Razor blade

Humbug knife f
•
Down blade
1
Mumby knife
-

punctate bleeding b

good graft harvest

be stored wks at cic

graft can 2
-
 2°
DOnorAll Epi + some dermis → similar to

burn
superficial
.

-
heal within 2 wks .

Reharvested after 6 wks .

Take
up of graft
: -

t
surface area
of graft .

I. I
removed multiple
- -

graft cuts
• -

donor
fromarea stitching
meshing)
(

M÷ a

1
2 1 : 2

Ideal 1 : 1.5 to I :b
meshing ratio .

meshing ratio > I :b

( cobblestone appearance)

Rake¥komimud)
nutrients
" free flow of

Ñ÷fost host

10
to

-
graft
48 hrs
)
 2) Invocation :

Realignment of
¥ihost graft
& host
capillaries
continues
for 4- 7-
days
.

①
¥€host÷ymp
neovascularization

habits
develop
7th day
→
Afv develop
sinks
collagen I maturation
replacement continues
upto
.

of wound )

steps
harvest ↳
Graft
placement Jmbibatim / Inoculation
over →

Yonts actwre wound

neovascularization
?
2° contracture
Causesojicontracturei ( dy scarring )
deft Elastic properties of skin in
t,

if meshing is

done

Elastin / Collagen / myofibso blast .

Thicker will be
collagen 1 elastin
graft
the more

more will be contracture .

Donny
 thickness skin
Drawbacks of split grafting :

Hair don't
grow
-

does
-
sweat
1 sebum not
flow
color changes
-

nerves don't recover (

scarring
-

contracture (2)
full thickness skin
grafting : -

for
cosmetically appealing
:
-

areas

Joint & hands

donor
mfe area →
post
-
auricular
region
→ other common donor areas :

• scrotum

labia
Majora
o

Infra mammary area

•
sub
gluteal region
Supra Iaviculan
o

groin crease
Benif€* -

Better color match

-

Hair I sweat 1 sebum -

normally flow
 Deawbacks_ :

4
D greater i contracture .
1: more
collagen more

elastin
) .

2) only small area can be harvested .

¥1
1) FTSG
applied over chest donor .

Rt
thigh
area → .
.

§
2) STSG needs to taken
from
left thigh to cover the

donor area in st .

thigh

minimal
no
meshing for FTSG i.

2° contracture
?⃝
?⃝
 BUlrgoishislhslaka-wombangitisobliterans.IM
yrs )
•
males to -

to

small & med

sized affected commonly
•
.
arteries are

•
smokers .

Mfc : Tibial
artery (plantar artery)
lower limb is
always involved
first
•
.

in
Jews 19ndians
more
°
common
.

• lower socio-economic strata ( poor)

Pathogenesis :

D. Immune reaction
against collagen type
I & ☒

in vessel wall .

2) releases
smoking nicotine &
carbonytlb which

can cause vasoconstriction .

#
Ingrum
normal
← Inflammed BV .

Buerger
's

Immune
Blood
flow → Turbulent

¥unica media exposed

formed Alvin inflammed
'

are
i.
quorums

but
lymphatics spared
are
4€
1) Intermittent claudication

-
normal blood vessel
good Blood
flow
-

-
can walk
for long
distance .

BV
thy Inflamed / narrow
i a thrombus .

will
-

after some distance

pain
re-appear f of inadequate
:
Blood
supply) .

Intermittent claudication :
pain developing in

muscle
dlt accumulation
exercising of
substance P -

& lactic acid .

pain develops after walking

-

a certain distance
claudication
( distance
) .

my site →

calf muscle .

claudication
common →
iliac
erectile
.

dysfunction
t
Int lesiche Syndrome
.
.

a iliac
I
penis
Eat .

iliac .

Is
lower limb .
Rest [ horizontal ]
pain ←
appears
at
night

I
Blood is assisted
f. flow by
] problem space gravity
during day
.

heart
Of
at
calf &

same level

gravity
cannot
help to

blood
increase
flow .

rest
pain can be relieved
by keeping the
affected
dependant position
in
part
.

Claudication relieved
pain is not this
pain develops
•
:

dlt accumulation
of metabolites .

DIE : Varenicilline →
Bupropion [ to Quit
smoking]
' -

\
hair loose hair
Begins to
-

over
\

skin
Bone
affected part
-

-
\
fat -

skin becomes thin

1 muscle
,

Ulceration / gangrene develops

-

Bone .

Claudication → rest
pain →
IG
 BOYD 's
→
classification
Rutherford staging
→ Fontaine &

Investigation clinical
investigation
:

Elbow Brachial
f- Ankle artery
-

Bp
-

post tibial artery

-
-

② : Ankle
-
• ①
Elbow

low
Buerger ds
Ankle ( Narrow artery]
-

=
-

Brachial ( normal )

①
=¥w I
BD =
= Oo 66

120
→
Apps < 1

ABPI = 9- ( in normal )

⑥ ABPI = I -1.2

clinical
features
0 .
g -
g →
no

0.7-0.9 →
Intermittent claudication

0.5-0.7 → Rest
pairs
0.1 -
0.5 →
critical limb ischemia .

( ulceration &
gangrene can

)
occur

IOC :
femoral Angiography
i-Era are seen
lnotpathognomée
-
connective tissue dlo ,
collagen vascular ds -

forBD )
 1¥ Absolute cessation of smoking
.

•
:

•
Vasodilators
xanthine nicotinate (niacin)
eg
:

Aspirin / Clopidogrel
•

red blood cells)

pantoseyphylline IT flexibility of
•

•
calcium channel blockers

cilostazok.fm#EalTseatment-n
•

Lumbar
Sympathectomy .

SNS →
vasoconstriction ✗ ✗

[ Lg -

Lt ]

Y÷
It A- has me

be
4 should
spared on

one side .

Lay
_#
cut both sides
If we L , on

Ejaculation failure
-

LPNs) P erection
pointy
→
→
,

(SNS ) S shoot
→ →
ejaculation .
?⃝
 Acrocyanosis Causalgia
Raymond Hypertydrosis
most
effective ✓

Atherosclerosis
Erythrocynosis
Frostbite
Buerger 's

least effective
.

→
Omlntoplastyfomental Transposition] has variable results -

Bypass grafting
-
:

not lend
possible :
of multiple of obstruction .

wherever
possible me do it
by using saphenous
-

vein .

odympalhectomy cannot cure intermittent claudication

-

dft
t¥Ék
•

: it is caused .

not under the control

phenomenon of SNS
- Raynaud 1) 's
syndrome
disease .

Rayu{pheno_µnon
:
sequential ,
well -

defined .

self-limiting
color cold
changes on
exposure
to .

which last
are
BY &
for more than
eyes
.

£
syndrome
Raynaud
's
.

pathology
→
Idiopathic .

rsvc
A to Adrenaline & adrenaline
sensitivity
nor -

↳ sensitivity to NO [ VD ]
 limb
primarily affects
Disease arterioles
of upper .

Three
- stages

BCR / SAR

1)
BIanchinglbyncopen.io
Vaso at arteriole
spasm
• white color .

2)¥ña :

Spasm continues
•

dilate
capillaries
•

0
Bdlue color -

dff -

oxygenation
de

RWsorlrecorery.io
spasm relieved
ant of blood rushes
large
• .

•
leaks out through dilated
capillaries .

l Tes
smelling pain
•
.
 cold)
Raynaud phenomenon
's
( w/ BIR - color
changes -

↳ continues

yrs
for
.

Raynaud 's
syndrome
-
1° RS 2° RS .

i -

collagen vascular disease

( scleroderma )

↳ cold i -

Raynaud syndrome 's .

Blood vessels are narrow

g-
•
& informed .

expected Happened
-

told .

be
lumen will extremely
Raymond phenomenon
-

's
.

narrowed / closed

I
Reaynoud Syndrome 's

( aka Raynaud 's disease

)

-
MRS motoneuron
90%
IRS
-

Cause :
Idiopathic collagen vascular disease
scleroderma
Mfc : .

young middle
aged
•
• .

Good
prognosis poor prognosis
• •
Both i & 2. Rs : -

D common in
females
labile
a) common in
emotionally individuals .

3) people using vibrational hand tools .

Drill machine
piano / Typewritten /
-

Investigations SR will be raised in IRS

¥ :
90%
respond gust by avoidance
of
cold -

DOC
-
:* Calcium Channel Blockers .

Aspirin 1
clopidogrel
• .

•
ACE Inhibitors 1 AT
antagonist
-
.

mitogenic get [ Topically nitrates]

•

Sildenafil / Tadalafil ( DDE -5 inhibitors ] .

•
Botulinum Toxin

90% : I Rs →
young females 15-30
yrs
.

cyclical mastalgia
-

oil
evening pain
rise .

In severe cases :
endoscopic thoracic Sympathin -

syndrome tomy
-

R E S T
afw C .

Calcinosis Raymond Esophageal

Sd
"°da9Y ↳
cutis
defects Telangiectasia .
(
DVT-m.no#qj.p. fY?
vein

saphenous
vein

Superficial veins below

Deep

skin
veins

:
( femoral

Great saphenous vein

vein )

Deep vein : femoral vein

Saphenous vein → drains into

femoral vein near
groin
.

veins
perforating
connect veins
sup
. c-
deep
All veins have unidirectional valve
of
:

1) Blood can't
flow down but

can
flow up only .

2) Blood can
flow from sup . veins to
deep veins

But
can't flow from Deep veins to
superficial
.
Deepveinthsombosis-iR.IE?I-actors-:
Virchow 's Triad
-

1)
messily :

smoking ,
Atherosclerosis ,
CRF ,
diabetes

2)
Hypucoagulabilityi
-
mfcfc of genetic thrombophillia
leiden
Factor I
deficiency
-

protein C & S
deficiency
Antithrombin
plasminogen deficiency
-
.

Estrogen only oral

contraceptives
-

-
Sickle cell anemia .

DH Syndrome
lupus .

malignancy ,
Behchet .

3.) Stasis :

←
plasma
overcrowding of cells
←

(
Damage
to cells ) .

Egf Trauma
,
immobility (after Surgery ) pregnancy ,

varicose veins

HomocysteineItusia
→ causes
protein degeneration
→
also causes DVT
,
but mechanism is
unclear .
 2°DV Due to insertion
of venous catheter .

CIF
-
: -

in 60% →

Asymptomatic
Earliest
symptoms calf pain
tenderness
sign →
calf .

low
grade pyrexia
is
commonly seen
-
.

edema is most consistent

sign
-
.

Mose
sign
→
Bancroft sign
#-)
4
pain on
squeezing
the
calf muscle .

temps : is
pressure building up
in calf muscle

on
passive dorsi
flexion of feet .

the Doctor
+ve
if pt resist
.
.

Neuhoffsigni Subcutaneous edema .

skin
Thickening of

_µµµ
.

② Sif aey⇐
20% 80%
• "
↳ 40% 10% 150%7
] Balance
.

arteries → too % → t → 501

Phlegmasiattlbaolens
white
Painful leg
d \
i
ofdecreased
pale dft decreased
Blood
supply Blood supply .

I.
ischemia
of
muscle

obstructed but
-

deep veins
patent Superficial vein or

collateral veins

C
perforating)
-

plegmasiaceruleadel.us
•

Painfultbeueleg
both blocked
when
deep
•

& veins
sup are
- .
.

( blood blocked)
outgoing is
totally
blood also
This
may block arterial
causing
-

gangrene
venous .

Surgical emergency
-

DID : DVT

ruptured Baker ( knee)

cyst
hematoma
calf muscle

Ruptured plantains muscle

Arterial ischemia .
Investigations Ioc Duplex -

B scan
←
Enfwnsive
sound
Doppler
Duplex
-

sound translated into

graph :

←
dimer
Yim
: D -

¥ ¥=o← breaks
down
.
-8¥:
'

I
:{
'
i
fibrin
degradation products
LD )
-

dimer
.

D- dinner →
not detectable in normal individuals

In DVT D dimer level is raised

pt → - .
.

RAF⇐ Radioactive Fibrinogen Test

h
radioactive Iodine labelled
fibrinogen .

Thrombus
keeps dissolving daily
-

on

keeps on
forming daily →
need
fibrinogen .

Radioactive
fibrinogen
I

hours
After a
few : T
Radioactivity over
-

calf muscle .
1¥ :

low molecular
•

weight heparin
heparin starts acting immediately
-

warfarin starts
acting after 5
days .

i #-dhys
Relief Warfarin
Heparin is used
for
min J
days
-

started
warfarin is as
early as
possible
(
effect takes 5
days)
control over
coagulation is increased
by measuring
time lie INR ) ( Int Normalized Ratio ]
prothrombin
. .

prothrombin
time
TNR e

of fit
-

¥imntrol )
normal

2.0 -

3.0

Sensitive to
heparin →
heparinoids
-
sensitive to Both
b

Fondaparinuse ( indirect factor Ia

inhibitor
]
Direct factor Ia inhibitor : Rivoroxaban .

Thrombin inhibitor
Debigatran
:

avoid
Pregnant oral
anticoagulants
→ we

i. vena cava filters →

Green field filter .
pulmoembolisin :

Breathlessness
mlc
symptom :

TARR
sign
:

Mlc ECG : sinus

tachycardia
Fired 2nd Heart found
split
-

pleural rub
-

Duration
warfarin / Anticoagulant
: months →
3

If life long
recurrence → .

fresh
→
frozen plasma →

rapid reversal
of warfarin
.

we need to
bring ZNR < 1.4 to
perform Surgery
.

Prophylaxis pneumatic compression

.

devices

preferred method .

pharmacological prophylaxis → LMINH .

Varicose
-
veins

Dilated tortious
elongated superficial veins

" "
"
% th ^^ "

¥-7 # * 1-
developing dlt
varicose veins

competent sapheno femoral

an i -

→
function .

DVT →
heparin 1 warfarin
Thrombus →
WBC →
lysozymes →
Destroy value .

Once valve in
perforating
is
vein
damaged
Blood
flow from deep vein
to reins
i. can
sup
.

also
Varicose veins
-
can
develop due to : -

DSFI incompetence
2) perforated value
incompetence

1) 4mm Diameter → Flare 1 Thread veins

spider veins ,
Telangiectasia .

2) 1- 3mm : Reticular vein

b) > 3mm : nericose vein

Saphena varix
swelling soft compressible
-

near SFJ

Curvveiler
sign
-

Risk
- factor :

1) habit
of standing for long
Traffic policeman / Barber / Teacher

neurosurgeons
.

2) Age incidence T c-
age
-

3) Height -

longer the ft .

,
more are chances
of developing
varicose veins .

4.) Sese : more in

females
pregnancy svc stasis
compression
→

DVT
{ varicose veins
 ovaries
/ fallopian tubes / cervix
pelvis
→

tumors .

4€
• Dull ache → worse by day
(
calf)
swelling
•
ankle

nip

Ahklef ①
it
☐
-
① -

-
point of

collagen
maximum

pressure
→

b
scar

contracts
tissue .

tipo derma sclerosis

•

ñ
F-
-

collagen scar
-
.

Y )
"

calf - no
lipo derma sclerosis i. no contr

Ankle → contraction .

Inverted Beer Bottle

appearance .
 Hemosiderin leaks out
pumilio
i.pt
-
-

itching starts .

ulcer develops ulcer

→
o
venous

Bisgardreg.me#
To
1) Compression stockings give support to
→

veins

2) blood
massage To
improve flows
→

3) limb elevation → To reduce

pressure in

veins .

Duplex [ USG]
B
Investigation
: -
Toc → scan

Brodie
Clinicalosnrm
Trendelberg Test
:

Tests
incompetent
→

SFJ

Test -2 :
incompetent
veins
perforator
Incompetentralvei -

varicose veins
appear
immediately .

Competent
:

appear after
v. veins

become
they full from
below .
 lower end of varicose veins
Shwartztest Tapping
:

thrill end
will near
upper
give
.

Perthesrtest :

g
blood veins anomalous
sup . veins
carry all :
deep
or are absent .

We ask
pt to wear
compression stockings
.

They can
compress
-

superficial veins

can't
They compress deep
veins

we ask the to walk :

pt
.

normal
-
individual Anomalous deep veins
-

Blood will channel outlet

flow through . no
for Blood
of
deep veins f. )
-

severe pain
they open
are

PCD
[ Phlegmesia cerulean

Downs]

Pain is
subjective
.

Modifiedperthestesti -

use
of Twaiqueit
instead
of
compression stockings
Perthes Test used to Dvt
existing
is check co -
-
 DIT Variaseveins

Deep veins
hip veins
-
.
-

"
Dilation
clot
form of veins
- -

medicine / clot removal vein removal .

-
-

II. 9) for Arnall veins :

sclerosis
lipoderma reassurance
no → .

for small veins which are

causing cosmetic
disfigurement
.

Day sclerotrerapy
: .

&
converted
• Sodium Tetradecyl Sulphate
into
foam [ Tessari technique]

polidocanol
•

•
ethanolamine oleate .

2) Foxlargerveins
is
→ Treatment
of choice EVLT
( laser Ttt
sndogenous venous
)

Radiofrequency
→
Ablation I burn )

3) SwYicdTn
yundeeberg operation

¥m /
-

femoral
ligating sapheno femoral function
-
-

followed
by stripping of saphenous
A
vein
-

Mayo stripper -4dB .

{ Mayo stripper .

we
apply compression dressing immediately Iso that perforator
won't bleed) .

Complications :

wound > Recurrence

mfc →
infection >
Bruising
and
lmimpiongterwmmpin)
Me →

Bruising dlt Bleeding from perforator

veins .

Sub
fascial Endoscopic
perforator surgery .
 trauma
Trauma
MY / of death 40
in
1st < →
e
yrs .

3rd mfclc death overall Trauma

of
:

other two
"
: CVD 12nF →

Developing
CVD / Cancer →
Developed
.

deaths
50%
of trauma on the
spot :

head
inj
7g Blood
.

minutes
vessel AORTA
injury eg
:

304 .
c- in
few hours : ons / the

20%
infection :
multiple organ failure .

1st hour -
Trauma →
Golden hour .

1st so min →
platinum 10min .

.
 to
Metabolic 1 hormonal
Response Trauma : -

→
EBBphase_
catecholamines
y Bp ( Help to increase)
-

Aldosterone

lasts for hours

trying to survive
→

Body is .

Its
→
level of insulin

level testosterone late

of
→

Flowphase_ Catabolism
→

fever : BMRT

Temp T

cytokines
-

Insulin → levels increases ,

but insulin resistance

develops in the
body .

It dextrose levels)
-

Glucagon T

(Body
-

phase of net -
ve
nitrogen balance is
destroying
more
psolA is
making )

Recovering mile to -
so
days f- mo .

• more
proteins are made

phase of Nz Balance
•
+ ve

Growth hormone
° AT
IE-tauma.io
Baby Syndrome
Battered

Shattered
°

infant syndrome .

multiple#e : BBS

Redflagsi multiple # c- out

healing →

Resistant Rickets
-

posterolateral rib # Healed 1

Healing
ME →

metaphysical
-
# -

osteo -
Im

multiple injuries I # of varying age ( Healing )

-

occipital impression *

Domestic violence /
previous emergency dept visit
.

delay in
seeking
care -

child
any
bruise in non
ambulatory
- - .

(
If you
don't cruise ,
you
don't bruise %)
Illasscasualties :

Bus accident / Bomb Blast .

TRlAGE__: SORT -
in situation
of mass
casualty pt
. who

have higher chances

of survival are

attended
first .

START →

Simple triage & rapid ta

individuals
→
can be performed
by lightly trained

4
paramedics .

coded
pts are
given
color
tags : -

Red : -
immediate attention

If not attended within a

few minutes
they
will

die .

Tension
eg
:
pneumothorax
have
being shifted
These to
pt priority in the
→

hospital from scene

of accident .

HR >
iwfmin :
pt.is loosing Blood
supply .

RR< 10 head
→
injury
RR > 30 chest
injury
→ .

pt.is
unable to
follow your commands (heading:) .

Absent Radial pulse ( Shock) .

Yelling →
urgent
attention

• stable at the moment

• But require surgical intervention

would have been attended all

They 1st
of
•

if red
category pt
no .

☒
( slt Blood bn )
Open pneumothorax
2- 2.
,
pelvic

Grey :
delayed attention

closed #
egi simple
Blacky :
Dead 1 moribund
1 which are about to die & can't be saved
)

Bluey : moribund

Expectant Ma
-

supportive care .

aid
only first
White
require
-

CAB →
CPR
c. ABC
cardiopulmonary
(
-
massive
,
control external the resuscitation)
esesan
grating
c. →

ifpusent
Circuit -

Airway Breathing
 Airways should be
'

while due
checking airway
: care

cervical
given
to
spine
.

→
Time is limited .

we not waste it cervical

can on
getting a

spine X-ray
.

Fascial
L look
externally Trauma
→
→

→
large Teeth 1 Tongue .

E- Evaluate 3 distances .

M →
Mallampati score

0 obstrm
Eg Foreign body teeth
→
:

N neck
mobility
→ .

Airway can be blocked by food / vomiting Blood or

tongue falling Back

even .
 pod
the

mental distance distance

hyoid
yuyunmental
-

Guededttirway
:

oropharyngeal airway
 Sellicbismaneuveri
cricoid closes
pressure
→
•
over

esophagus
Tube will
only
• enter trachea .

Contraindications Endotracheal Tube

-
of :

1) Nasotracheal intubation is contra indicated

-
-

skull base #

Orotracheal
2) route is contraindicated :

mid -

face II .

7t__→ Surgical Airway

term control
Tracheostomy Done
if long airway
-
→

is
required
.

cricotnywitomy cutting open crieo

thyroid membrane
-

→ .
 → not be done in children
to
-

: cricoid →

only cartilage
that
supports
trachea in children .

Extreme
emergency
: -

needle
aicothyaoitomy .

inserts wide Bore needle

14-169 needle .

be used for
→ can
only is so min
- .

Breathing some conditions can be

diagnosed instantly .

Flail chest
-

Tension
pneumothorax
-

open pneumothorax
-

High flow Oz is
offered to all trauma
pts
-

Circulation : can be assessed

by :

→Consciousness level Blood to brain

supply
:

Skin color too blood

%) pale is much
: :
If there

loss .

b) Rapid Thready pulse loss

in acute → blood
Heart rate much than
raises earlier
fall
in BP

30°/ o → Blood is lost

HR → to -

15%
 → 1- It
of
-

warm Iv fluid (
Ringer lactate)

to
given pt
.

Antecubetal
→ 2 ✗ 18 G Cannula : Cubital
/ rein

(short in
length )
→
pennine hyphen :

systolic BP : 70 -

go
mmHg
If there is head
injury
→ BP (
systolic ) should be

blood
kept above go
mmHg
to maintain

to Brain
supply .

blood
If not available
→
cross matches is

units blood
falloossmatdnihsmim
: -
2
of one can

be used .

In
pregnantft/females
in
reproductive age
blood is to be used
group only
0 -
ve
.

To control
blooding ( covert)
•

&
after
Tranexamine acid this
sgm
→ .

repeat
.

Whole
Body
•
CT scan

9 cancer
→ 1.5% risk
of
.

only
i. Should be done in severe cases .

If pelvic # is
suspected pelvic Binder is
•
→

applied .
TAI score : -

Trauma Associated severe

hemorrhage Score .

SBP Hb level FAST

long / pelvic
→
+ + + Bone
LUSG )
#

→ Heart Rate Gender

Baseesecess_
+ t

metabolic problem

Mclaughlinscose :

[ McLaughlin lesion shoulder

post
→ in .

dislocation ] .

Disabilityassessnvte
-

Gcs

Digitalretctaleseaminah.cn#
Done check
sphincter function
→
.

spine injury -
lost

Exposure
•

Hypothermia should be
prevented
london
sign [ Patterned Bruising ]
•

thoracic
chest chances
eg
: →
It increases
of intra

/ intraab
dominating by
.

3- 4 times .
 logthollmethodi no
longer recommended
by Atvs .

min A
people
.

limb *
min 5
people →
if there is

• done to avoid
injury
to
spine
around
pt is
lifted to
• .

fingers 1 Tubes
eg Folley
: 's Cathet .

Traumabcoringbystems.PH a Score : measure

change
in
body
physiology after trauma .

RTs ( Revised trauma Score)

kg : Gcs , ,

APACHE → Acute
physiology & chronic

health evaluation .

SOFA →
Sequential organ failure
Assessment .

Score
EMTRAS →

Emergency Trauma

⇐d Score :
changes
in
body anatomy after
-

trauma .

Eg Injury severity
: • score

Abbreviated
injury
• score .

•
AP → Anatomical profile
Abdominal Trauma Index
PATI
penetrating
•
→
.
 combinedscore.TK
-

mechanism
ISS =
RTS +
Joy severity
: score +
Age +

cess ) of injury .

-
Revised Trauma Score :

Based rate (4)

on :
resp
.
•

(4)
Systolic Bp
•

•
Gcs score (4)
Score
range 0-12
=

12 labelled yellow
11
urgent
→

green
-
-

3- to -

immediate -
Red
<3 →
Black .

fÉycos :

6-
ME
glom
Body is divided into 6
regions A B C D E F

severely injured
3 which most
regions
are are

further studied -

In each
of these 3
regions ,
only most serious injury
is documented
for inj
.

severity score calculation .

 I f

Abbreviated Trying
score : -

for each
injury
↳ can
vary from 1-6
for each injury .

minor
injury
a. →

6 massive but survivable

injury
→
.

D all the 3 Als the

Square scores
of
3

most severe
injuries
-

2) Add up all the numbers .

Score range : 1- 75
min .

man -

trauma .

Trauma

Score > 15 →
major
Trauma → indication
of whole Body
CT scan .
 has Als
If even one
region of
the
body
6
grade
is set to maximum i. e. 75
injury the score .

most
of injury
: 4-8
-

É¥¥iyon
:

Nature
of force that caused
injury
•
.

energy 1 High energy

low
stab crush

Bad
good prog .

prog

shock
•

presence or absence
of
.

absence ischemia
presence of
•
or

Age ( younger Better outcome )

•
→

be saved
If total score = £6 → limb can

sit →
Amputation is
likely
 Gcs
-

Quick tool
for neurological assessment

EA Vs Mb
C 0 S R .

✓ Check :
-

with
factors that
interfere c- assessment
of pt
-

can

✓
Observe :
signs
in
pt
.

✓ Stimulate the
ft
.

✓ Rate

Abnormal
flexion was not a
part of
classical Gcs
•
.

It was added later .

Eyesigns
spontaneously → A

speech 3
→

Finger 2
→

pressure
/ no speech
→ a-

response
no

• not testable -

NT
 Verbalbigm
oriented
} phrases
→ 5
1 sentences

confused → 4

words
Single 3
→

Moans / groans → 2

I
response
→
no

local
• no
response dlt factor → NT

cg :
Bandage .

Motorresponse:_
command
Obeys → 6
•

above clavicle
.stg#n
move arm
•

on → 5 .

Trapezius finch f supraorbital

notch .

Rapid flexion farm away from body

I ,

normal
flexion on stimulus → 4 .

Abnormal
flexion
•

I → 3

Decorticate
rigidity
farm by the side
of the

body)
-

Thumb clinched .

•
Abnormal extension →
a.
Decerebrate
rigidity)
 no movement in
legs /
•
arms
→ q

interfering factor
no

paralyzed limiting
° or other → NT

factor
Gsi .

Quick
neurological tool
-

-
assessed the
artificial airway requirement
Gcs indication endotracheal intubation
eg < →
of

scoring systems
other
part of :
-

lg RTS
:
, SOFA -

Final score :

3 - 15

min Mase .

Endotracheal tube CÉ +9+1 e)

Igwe
→ man -
"
.

brain
15 → minor
injury .& no Loc .

mild brain
13 it - →
injury
moderate brain
g- 12
injury
→

£8 brain
injury
→
severe .
 GCS -
P -

prs Gcs -

PA
-

pupiljheactivinjury
→
ityscosebas.us
Head can alter normal
pupil response
" 7am
pm
ALEC
-

Gcs 12
15

Head_Ifury
-
12
8/9/10 / 11/12/13/14
← →

abnormal
i.
PRI :
if both
pupil are

PRS
2-
→

:
if one
pupil is abnormal

PRS → a

If normal
i
both
pupil →

PRS →
zero

Gcs-Pscox_:
( Gcs score ] -

[PRS]

Head
injury is more
likely to be
fatal in the
elderly
-

than
young
.

Gcs-PAscore_
GCS P score
adjustment against age to
-

likely mortality from head injury

calculate .
 -7lb : IGOS )

Good 5
recovery
→

moderate [ needs assistance]

disability
→ 4

severe
disability → 3
Ipt cannot manage
-

individual (
personal) )

amorously persistent vegetative state → 2

no

of Hoffer rounding Death → 1

Traumatizes :

5- 6 lt blood
of
.

Trauma act blood is lost

of
→ .

low Blood volume low Oz

→
carrying capacity
Dmetabolicacidosis
lactic acid
-

Anaerobic
respiration → Accumulate

crystalloid fluids
2) tlyfpovolemia f- colloid
Fresh
fluids
blood
} don't have

clotting factors
.

blood
Suppose : Alt .

+
Ztt .
in
fluid → • it .

is
left but c- dilution
of
coagulation factors .

✓
i.
coagulopathy
 3) pt .
has lost blood

Blood carries Oz & also carries heat to other

-

parts of body .

Hypothermia →
-

causes severe
Arrhythmia .

i.
Tmtiad :

metabolic Acidosis

Trauma
triad
of
Death .

Coagulopathy Hypothermia .

Damagecontrolburgery.io has
pt If massive trauma
.
.

should
pt
not be
operated immediately
• .

(: surgery
is an additional trauma ) .

pt comes to the
emergency
.

Itef⇐
DE
:
Early management ABC

control
bleeding
-

-
Control contamination ( wash wounds)

↳ ICU

steps :
stabilization in Icu

I.

Steps :
Definitive surgery .
•

D.CI?amage surgery
control .

Hypothermia 34°C → <

acidosis
met
ft < 7-2
. →

smmoellmostimp predictor for

-
@ cs
Serum lactate >

Coagulopathy :

SBP
Fommtlg
• <

> 15 units blood have been

•

of given

Injury severity score 336

•
C-HESTTRAUMARIBtf-mpei.znd.fm rib 190% )

Ist rib & some

part of 2nd rib → covered
by
clavicle -
escape injury
-

gin 9th 410th rib : -

false ribs .
:

escape injury
.

11th & 12th :

floating ribs i.

they also
escape iy
:

4th 5th 4 6th rib

maximum
fractures involve : -

brittle bone
Elderly have which
easily #
•
are .

Mt : •

Analgesia only (Diclofenac slimes a

day)
•

Intercostal nerve block .

v
¥
✗

volume less
more
pressure
→

less volume → more

pressure .

Inspiration : not . →
High
low
pressure
→

Expiration : v01 .
→
low

pressure →

high .
Éclat :

chest wall dlt trauma

Depression of part of
( no # ) .

t-lailchestr.lt of 33 consecutive ribs at 2 or > 2

fits .

c.
£,
5
flail

Single
chest

bib A-
.

at coatocondral
function
can also cause
flail chest -

thermal respired of flail

: -

i -
e
-

outward movement

segment
at the time
of expiration .

& inward movement

of flail segment at the
-

time
of inspiration .

Pendultufft movement of Air : -

? V01 L > R
Insp
af1ail move
inwards
ribs

.
.

.
pressure
air moves
R > L

from R→l

esyn
torpid
÷+:
µ?↳°
"

v01 .
R > L
al
L > R
press
.

µ outside
go Air R
moves
from ↳
 pendullufftu
death
•
is the
mfefe of
.

• now
mfclc of death in
flial chest is a
/ w

Trachea bronchial
injury
.

-1¥ :
1) Intermittent the
pressure ventilation

2)
oxygen
3) Double lumen Endotracheal tube to deliver

more air to site which has

flail chest .

4) Fixation to successive normal ribs

brokered
↳
fin rib to normal rib .
 Pneumothorax
+ nice
of free
air in
pleural cavity
.

}
ctosedpt-i.no external wound Tension
pneumothorax
.

to

Air
Openpt : external wound
pressure
inside

becomes
pleura very
high .

Air black
X-ray
: on

solid
lung : →

grey
Bone : white x
ray
→ -

4£ :
to Air the side
entry
•
on

lung)
( in
of injury
.

:
lung is
compressed
by
-

high pressure in chest .

•
Mediastinum & Trachea

side
shift to
opp
.
.

ttypersesonance affected
•
on

side
0
to BP

•
T RR .
 I.mg is clinical
Diagnosis
to be wasted
ray confirmation
•
no time on X -
.

AILS If required ( Usa ) Can be done

→
E- FAST .

( 2- 4min) .

41£ Immediate needle

decompression .

In children needle in 2nd ZCS

put
:
we

mid Iavicular line

HG
✓
-

g-
Adult needle
: we
put in b-MICS in

mid line
axillary
-
.

Followed
by placement of Intercostal tube with water

seal .

3- side
tlemothorasei

presence of free
blood
pleural cavity
•
in

Tumors
]
( pressure ventilation
causing rupture of lungs
-
IPPV - .

-
central venous cannulaltom .

Where an
advancing cannula
may penetrate
the
lungs .

Trauma

blood
Upto 350 ml
of can hide behind liver

Hence this much hemothorase detection

escape
-

may
on

x-ray
.

• .

USG is considered a better tool to examine

less amount ( it can detect as little as 2- Uml

of Blood in
pleural cavity
.

insertion
1T€ .
ICT .

Affected lung will not be able to

expand .

Bleeding pt starts
touching chest wall
after lungs
°
.

expand
.

Bleeding
-

stops

blob
lÉÉtomy :

D massive Memo thorax :

⑨ drainage of 31500mL when

you
place an ICT ( large Blood vessel is

ing:)
@ continued
drainage of
> aooml 1hr -

( ICT is not
working
2) Damage to other
organs Eg diaphragm
. :
.

bronchial
Trachea
injury massive esophagus
- → .

3) clotted hemothorase

ICT -

should not be placed through an

already
wound
existing
.

Always through fresh wound .

CÉAE :

Trauma

-
Uraemia ( CRI)

4€ :
muffled heart sound

Distended neck veins } Beck 's triad .

Hypotension
¥ : needle
pericardiocentesis ( stop gap arrangement)
Thoracotomy

ABDOMINAL TRAUMA
- -

PeneÉÉ C
:

ABC DE

explorattmofwound
@ If peritoneum is intact .

1-
It it as lacerated wound

keep pt .
under observation .

wash the wound Debride dead tissue

any
-

⑧ Indications suturing .

of laparotomy :

1) Shock 2) peritonitis Cdlt rupture of intestine

3) Evisceration (Intra abdominal contents out )
coming
4) weapon still in situ 5) Blood
coming out
through or
a
nasogastric tube
rectum .
 6) Gross hematuria

mk injured organs liver

:
surface
•

largest anterior area .

and
Diaphragm
→

Blasting : : -

heterogenous tissue
suffer
livers solid
homogenous
-
.

Tympanic
} Interphase
numb
•

Intestine
solid /
of gas
lungs

BluntTraumaAbd
eg : road side accident I fall from height /
fist fight .

wound
usually
no
-

open

1) Stable : normal BP.HR ,

RR

FAST ( US G) → asst
investigation
focused-EEa.to Blood / free
4 Areas fluid collects in the
;
/ Mossi souls
pouch ( btw liver

Ñ Peri
splenic &
kidney) .

Pericardiac Pelvis
 done E in 2- 4min
Should be
.

radiation
Benefits Bed site
quickly exposure
no .

: -
, ,

Drawbacks :
lower
sensitivity : -

@
retroperitoneal injury
⑧ If Blood collection < too me

④ Hollow
organ injury
.

E- FAST
-
/ Extended -

)
FAST
 DI Loi
agnostic peritoneal lavage)
umbilical
Infra is
incision
given
- -

wmblicais
fused

A peritoneum
considered
DPL is + ve
if : -

out
of fresh blood
10mL rushes
1) min .

2) if food 1 Bile
/ fecal matter
/ vegetative matter
d t I
1

pfomach
liner colon
Small int
iij ing ing
-

ing
.
-

is
.

returning fluid
under
3.) µ scope
-
: -

> 1. 00,000 RBCs hidden

ing
→
.

4) Amylase content >

175101µL
injured)
( intra abdominal is
organ
-

contraindications

Absolute : clear cut indication

for laparotomy
Relatively : •
previous abd .
sx
"
: -

Dense adhesions inside abdomen .

pregnancy
•
morbid
obesity .
 DPL not available
→ done
if FAST

Stable Ioc → CECT scan

IV contrast : Blood : Radio

opaque
-
.

* .

Adelaide Corina Scale

Eye / motor → same as adult

verbal
sign -
dff .

Retroperitonealrawma : -

µ Retro peritoneal

Supra
-

kidney
-
renal
,
ureter
:

gland
duodenal

,
pancreas
,
colon

SAD -

PUCKER

Magus ,
Rectum =
Outside
peritoneum
2one- Central zone :

pancreas
duodenum

life
Ivc 1 Aorta
threatening
→ .

2one Lateral zone :

trauma ( stab)
penetrating
to
prone
should be
exposed Cod ,
kidneys
Blut trauma : examined I kept
under observation -
 Tonton
pelvic / Sacrum

pllivic #

Exposure if there is
expanding hematoma
→
.

Neckiwjuries-
injuries →

superficial to
platysma
considered
post triangle safe
-
in .
are .

they not
immediately life threatening
as are
.

to
Lionel : extends
from suprasternal notch cricoid .

Trachea be
injured immediately life threatening
•
can -

2om_ to
Extends
from cricoid
cartilage angle of mandible
•

branches
from eat carotid
Bleeding of a.
•
.

controlled
Easily
-
•

mandible to skull
Tonelli: Angle of base
of internal
•

be
damaged
vein
jugular can
.

be
carotid
artery
can
damaged
•
.

Ines to locate
zone
III angiography required source
of
: →

Bleeding
.
ÉÉEn :

Expanding tlaematoma
•

• Diminished carotid
pulse
-
Stridor 1 Hoarseness

Voice
change
-

-
Subcutaneous
emphysema
(trachea cut
)
-

lateralized neurological deficit [ Unilateral)

Altered consiousness (carotid injuries)

-

Dentro
alveolar
Pyramidal
&
complete
dysfunction dysfunction
skull / Face

← will have
Rhinosrhea .
 BRAIN INJURY_

A -

stationary head is set into motion .

head
DY moving suddenly stops
-

road
eg
: Biker
falling on the .

coup&Countucoup_

brain
•

After impact is set into motion .

opposite part also strikes the skull is

damaged
.

GradesYBraininjmy:_
1) concussion: min .

Temporary physiological disruption

anatomical
change
-
no

Recovery
b
is sudden (
lightening)
100%
 2) Contusion :
Bruising 1 edema

recovery is
delayed
•
.

5) laceration brain
tearing
substance
of
•
Avulsion membranes
of
.

Brain →
Oz : 3. 5mL
/ loogm / min

55mL
fwogml min
→ .

ibraininjwy-EDH-i.ccsetra -
dural Maematoma .

Skull
"

:
Arachnoid

where bones
pt
two
goin
.

→
suture

&-→
A
false
cerebei
Dura mater

It I

Ssetraduraltlamatoma

Bleeding between skull & dura mater

young
significant trauma
80%
of EDH are a) wtf skull .
 vessel Bleed middle
mfc to is
meningeal artery
.

it lies
immediately below the
pterivn
-

b-
Thinnest part of
skull .

CT
scan shows → Biconvex
/ tentiform hematoma -

41€
Hit
by heavy object / RSA → rupture of middle meningeal
artery (Haemmg
expanding)
concussion Brain
of I.
b
Apparent looses consciousness
Recovery
→

loss of
consciousness again
Lucid interval . to
dies
MonroekdlyDoctwne_
skull is closed
space
a

⑥ : Brain -1 Blood inside brain

Blood inside brain hematoma

EDH Brain Big
: + + .

→
pressure
inside skull will become so
high ,

that carotid a. can't

bring
in
fresh
blood .

/ 3-dog pt
' .

-
Brain dies .
 Inv .

-
• CT scan done

( non
-

contrast)

Quick : 5- 10min .

. no contrast used :c : no risk .

1- It
-
:
craniotomy .

*
Ofen I closed
pneumothorax Tension
pneumothorax
-

- -

pneumothorax afw central vein commutation

to

Resolve
spontaneously
.

(does not lead to tension

pneumothorax .

Sub-duralHematoma_:
•

Bleeding below duhamater

elderly
•

•
Trivial trauma

Cerebral
emissary veins
•

which have blood

• Hematoma
formed is dlt veins under

low
pressure
.

is not to brain
It able
displace the
•

← convex

plano
-
convex

plane concave
-

convex
CI : loss
of
consciousness 1 Focal neurological deficit from
the
beginning only
In that CIF
cognitive decline
- →

X-ray
CT-
scan : -
Blood 55-75 housefiebd
Brain 40 HU

water 0 HU

chronic SDH old

→ →
common in
pts who are
taking
anticoagulants
.

- - → ✗

Blood plasma
sub -
dural

hyguma
¥0 -%d Acute hematoma →
blood
i. e-
HyperBrain
dense wrt

55 -

75th -
( UOHU )

Subacute hematoma
3- 21
days
→

Iso dense I Brain

↳

Density nearly equals

is

Brain .

hematoma
> 21
days → chronic .

Water dense wot

Hypo
↳

1
plasma, Brain

✗ O - lo → Acute 10-14 Subacute 514 chronic

-1¥ : Burr hole evacuation

under local anesthesia .

]
Suction
drain
É Haemorrhage
mfcfc → Trauma

mklc
of spontaneous
SAH
Rupture of
: -

Berry circle Willis

at
aneurysm of
-

4¥ : -

Severe headaches headache

Thunderclap .

Often described worst headache

of life
-

as .

photophobia
}
-

Mt imitation
of meninges .

rigidity
-

neck

Ing : Dura mater is attached to sutures

of skull -

Arachnoid
totally inverted Brain spinal
-

is c- .

CT scan show
bleeding in relation to
false
Cerebro also .

-1¥ conservative Tlt fluids / 021

: -

IV
130° up )
prop up position
.

Aneurysm clipping of Aneurysm

→

coiling .
Intracerlbralttemouhage :

cerebrum
Bleeding
•
inside

mfc in males
hypertensive
•

85% → MTN

dilatation
A V
malformation Aneurysm ( localized of
•
-

Blood vessel )
2° Tumor
from leg Breast Ca
secondary
•
a -

which has reached Brain)

wife it lentriculosteeiate arteries

occurs
from near

Basal
ganglia & internal
capsule .

4€ .

Rapidly developing neurological deficit

IOC : NCCT scan

-

Ttt : Immediate evacuation → since it is a

surgical
emergency
.

Diffusettxonaling.my#
shear
injury
-

Anons break

severe c-
poor prognosis
-

if it is wide
spread .
 IOC : -
MRI since it can't be demonstrated on
,

CT scan .

TII : conservative tx

prognosis poor
: .

Racooneyelpandaeyei
Base
of skull #
involving the ant . cranial

fossa .
 Racoon eye
-
Blacky
•

Delay
-

6- to his .
•

Immediately after trauma .

•
more
commonly •

UIL or
BK
BK
Tarsal
plate sparing Blackening
involves
•
• area

around
is seen .

eyelashes too .

ICSF
• CSF → oltovhea .

leakage through ear )

Battle
sign
→
Bruising mastoid 124-28 hrs)
°

over

Fascial
injury
•
no .

•
Paradoxical shinosrheea : -
collection of CSF in ear which
later comes out
through nose .

P.osteriorskullbase.to Visual disturbances

•

Jugular foramen Syndrome (aka Vernet

syndrome)
loss
of Taste sensation →

post 43rd of Tongue

.
-
.

lbiwssopharyngeal n°7

vocal cords anesthesia

paralysis of of larynx
→
-

dlt
paralysis of vagus
→
no
 Sterno cleido mastoid muscle spinal accessory
Trapezius 1 1-
-

nerve .

1°
SDH / SDH
/ SAHI DAI
primary injury .

2°BrainIn_jwy : -

Hypoxia poz 8hPa

•
→ < .

Hypotension
< 90
mmHg
-

TICP > 20
mmHg
•
-

fever Brain
•

0 demand
pyrexia of
→ → increase ,

tissue .

Seizures 902 It Blood

supply
•
→ .

metabolic acidosis

NI-ct-gui-edinesfor-C-s-andme-i-DG.e s
any pt
score < 13 at .

of time .

2) Gcs 13-14 @ hrs

of injury
→
2 .

3) Focal
neurological deficit
4) Suspected open , depressed ,
skull Base # .

5) vomiting > a
episode .

6) Seizures 7)
Retrograde amnesia .
 should be done
Urgent if
CT > 65
yrs age
: .

of
mechanism
Dangerous
•

injury cgi high speed

.
crash .

pt is
warfarin or
•

any
.

on

other
type of coagulopathy
.

Anterograde amnesia
•
.

7¥
:
primary
aim
of head
injury tx is to avoid

2° Brain
injury
.

nursed
i.pt is in
propped up position
.

to
120° 30° -

)
Trendelenberg position is
= .

favorable .

If spine is also
injured → reverse
trendelbey
-

position
In ICP :
pupillary dilation .

mannitol reduces osmotic

temporarily
→ edema :

diuretic .

Sedation
1
→
with without muscle relaxants
-

Barbiturates
for seizures
→
→ not used
for prophylaxis
•
steroids 9
mortality hence →
not used .
v. nerve ←

stimulated
-
is
t,

Bradycardia -

lpesp centre
.

tmedulla
being compressed)
 711412011€
superficial of body
most
•

Largest & endocrine

gland
in wt
Zogm
•
.

•
wont
/ min (
very
vascular )

only
endocrine
gland which is
dependent upon

functioning
external environment
for its .

Iodine → in diet 45 hormones

T¢
.

I
100
150µg / day ( in salt Nats )
-

as

90^1
of body Iodine lies in
Thyroid gland
-

→
-

rest is excreted
by kidneys .

only endocrine
gland which can store its
products
Iz Hypothyroidism develops after Gmo
-
.

earliest endocrine
gland to
derelegp -
3 wks
of intrauterine

life to
earliest endocrine
gland start
functioning @
-

7- wks
of IU
life
.

extent → lobes G- →
Tis
Isthmus 4th Tracheal
i
2,3 rings
.

,
 Isthmus needs to enacted
during Tracheostomy
→ or
•
:

cut .

th
cecuni
growth appears
down

Tongue from foramen

cecum

I
,

Thyhoglossal
:&
tore tour
:&
Tongue Tongue
it
w
t

t%ñtF÷§,
Tongue
←

thyroid
""

tEam¥I?y
M
$kyyqf .

burned

thyroid _µgqus
tissue

Accessory up ( from left

>

tissue
lobe)
(
Pyramidal
lobe)
a -
remain
out
of
tract
thyeogbssal

Extension
of left
lobe .
 lobe
4-
Pyramidal lobe is an extension
of left
.

It contains tissue
accessory thyroid .

of general populm
tnt in to -30% .

lobe
All pt
-

of
Hashimoto
thyroiditis have
pyramidal .

2caps-ules-i.gs False
True
capsule
capsule

÷÷÷÷÷÷÷÷÷÷÷÷
M

remove

ofneins .
.me .me
.

Thsoid ima
artery →

only unpaired a.
of thyroid
-

&
Be .

of or
Rt -
Beaches
cephalic
Aorta 13% )
or

common carotid
or
SCA .
 trachea
.

of
frontinjunedmiug
in
)
Runs
e. icon get Tracheostomy
retracts into

injury g-
* chest .

mediastinal clots

* .

Access
any
a.
from trachea &
esophagus
.

Veins :

Rt .
STU Lt -

MTV it
# Int -

Jugular vein

Rt
'

Rt ITV lt Bracken
cephalic vein
-
.
-

Kochh_I vermin → Int

jugular vein
.

Drain
inf surface
.
.
 Kocher collar incision

Kocher's

forceps
.

torgau
Bladder 1
bfmthwdn
.

'
'

Kocher incision
for
lymph nodes .

Kocherisation duodenum
of Is

duodenum
exposure of
( Retro
peritoneum)

M : Sst vascular str.to be

managed (
ligated )
-

Bm attest vein

Drains into internal

jugular
-

vein
Recurrentlaryngean : -

Buoy lig
's .

false
capsule
→ .

I Berry
's
lig [
formed when
.

HI
false capsule
up )
thickens .

"

7 →
Moves
up
when we

deglutition)
Remnant
Trachea swallow (
laryngeal m .

Swelling related to
Thyroid gland moves
up
e-
deglutition
Skin
•

swellings don't move

up
on
deglutition .

sup laryngeal n

Vagus
. .

no
y
Recurrent laryngeal m .

4¥ :
.
-

@ Internal
laryngeal no :
sensory above the
vocal cords .

@ lantern at
laryngeal motor
only
no : → one

muscle
orimE¥Ld
→ -
 2) Recusunt#m : -

@ lateral Bs : -

sensory supply to
buy me

below level vocal cords

of
@ motor be .

: medial
6
branch RLN
nyc
injured of

Mfc injured
at →
Berry
's
ligament .

Hence
consistently identified at the level
i. is
RLN
is
of cricoid
cartilage & kept away from
surgical field
.

simontriangleiqhyhor.cl a.

Riddle
B
/
I. Écarao.tw
Tracheal esophagus

•
Into thyroid a.

•
RIN
•
Common carotid a .

"Ñmost of thyroid
post region directly
.

overlies RLN .
 Rt -

RLN →
shorter

hence more
commonly injured
.

Non -

recurrent RLN is common on the rt .

side 12%)

It is
commonly injured .

Dojconcerni Area where Mase .

Vascular accidents

have occurred in the fast .

( middle thyroid vein

)

MpaceofRI
avascular Trachea &
space bfw
thyroid .

lymphatic supply to
thyroid gland goes
to level VI

lymph nodes .

Then to level level LN

3,4
of
2
goes , , 5,7 .
 Pizillo's method
be
used
for inspection of
thyroid gland
.

visible
Normal
thyroid gland
→ not .

visible →
physiological goitre
t

pregnancy
}
•

•
Adolescence
thseguiremenls

Crile's method .

method (
Lahey 's
of palpation )
.
 kocheistesl-Tracheo.vn
alacia →
Trachea becomes

soft
-

Feedbag
mechanism : -

-131T¢ levels are low → TSH TT

34, texts are

high → TSH Its
 •
Iodide → Taken into cell
Cthyeocyte)
b

oxidation to Iodine (Active form)

•
Thysoglobulin formed
in RER / Golgi app
.

•
Both TG + I move to colloid

•
mono iodo • Di -

iodo

Di +
D; →
7¢ Di + mono →
73 ( 7- %)
1. to
93% active
of
more

Total ant .

Breast
.
enlargement

iodine
90%
of Bodey →
Thyroid gland
Iodine
Thyroid gland Thymocytes
→
→
 I
'"
( Radioactive iodine)

typo
functioning
a

-
→ typnpmctioning

Plummer 's disease :

Hyperactive
Autonomous ( not under control of TSH
)
Motwane

Thysotoxic
→
off dlt Hyperthyroid
Hyperthyroid → in levels of Esta .

"
Cold module
'
: oh I scan

D cyst
A
B
Thyroid cyst

µnodg fluid filled swelling

-

wife colloids degeneration

B→ colloid
Thymocytes +

A
only colloid
lnothywoytes)
→

' "
cold
area → A
off cyst) → will
appear
as a nodule on
scan
I
-
 Normal
some
some
2.) cell do →
+

reproduction
function
cancer will do → min .

/ no Too much
+

function reproduction
"

- A →
cancer : no
731T¢ prod
1123
' '

A
→
will not be taken
by area

cddnodY
"
will be taken
'
or little I
very

*
"
20%
'
cold nodules
of
I
they malignant
the on -

scan are .

3%
only of hot have
1-
nodules can cancer .

females
.

in
common
more

CIF :
tot .

pt
-

have
hypothyroidism
Dyssnea Dysphagia
speech difficulties .

"
on exam
post pharyngeal swelling which
: c-
moves

protrusion of tongue
-
Investigation :
→ RAI scan →
confirms
Thyroid etiology .

USG thyroid
→
neck Absence neck
of
: .

-1¥ :
Surgical excision
fib oral
thyroxine

of of develop follicular Ca
i
chances
of
.
.

If :

Thyroid swelling )
1
midline
always
→ near

It
develops from degeneration of thywglossal tract .

midline
swelling t:
thysoglossal tract is midline )

But tilted
slightly towards
left ( :
thysoglossal tract

is attached to
left lobe
of Thyroid) .

mfc → Sub
hyoid location

2nd Me
thyroid cartilage itself
→
on -
①
1) protrusion of tongue

✗
Tongue
to
TGC
TGC moves c-
protrusion of
tongue

(
②→
Trachea 2) moves e-
deglutition :

it is attached to
thyroid

☒
Tour
TG
!

d. Fixed
moved
be side by
{
TGC can

Trachea
little bit
side
.

But it can't be moved

up
& down
by the examiner
if the

tongue 1 thyroid gland are

not moved
along
.

Degeneration

pseudo stratified ciliated column

any epithelium
(
secretory)
for thymocytes
-

1¥ Sistrunk
operation Bone
middle
143rd )
cyst +
remaining
TG Tract +
Hyoid
-
Ta tract
passes
- '

thvogh hyoid bone .

 Thysoglossalfistulaie • never
congenital
£ o
midline

papillary /
? "¥←
→
Ca can
wet

dwwpaady
.

macerated contracted

idnfeanmed fibrosed
'
Hood
•

Sigurd
→

contracted

TGfistulaf-os.ms :

D infm of TG cyst
2) dlt inadequate excision
of %st .

considered
flood
Sign :
pathognomic of TG
fistula
-

Semilunar sign →

Tft : Sistrunk
operation
.

congenital
away from
GOlTRE_ i
midline
term
generic
enlargement of thyroid gland by any pathology .

Iodinedefgoitre
i iodine
deficiency :

don't have Iodine

Hilly soils areas →
enough
like kosher salt
Food FADS
pt might
.

→
-
 dlt Iz
def .
→ 731T$ will not
form
i. Tsn it

gland will be stimulated .

i. T size (
early )
:
min .
731T¢ production .

but
.pt develops goitre not
hypothyroid for long
be
•

may
.
.

li-e.pt
.

remains
euthysoid )
iodine still be available from
:

of
•

some
may
food .

¥ :
improve diet
Thyroxine ( oral)

If give too iodine

-

we much

unit
of 73
- l
zogm

zooogm & too unit -13

iodine of

Tod Basedow
effect
i.

&
induced
Is
Hyperthyroidism
.

Hire Too much

:

iodine

Temporary phase of hypothyroidism appears called as

wolf chaikoff effect - .

 Gravelsdisease :

Stimulatory Antibodies
develop against
the
thyroid
-
-

① TSH stimulates qraveisdisease

thyroid gland to
produce Abs stimulates
Thyroid gland
.

I / Ta -

-131T¢ hormone produced .

When
gland produces Ag stimulation
continues
-

enough Tzltt
-
stimulation ceases

( i. e. TSH level
fills)

Auto Antibody :

- DM / pernicious anemia
/ Addison disease .

¥ mfc"

female : so -40
yrs
.

Thyroid gland enlarges & vascular .

Bruit be heard
- may
on the
surface .

males
gynecomastia
→

Diarrhea
Mfc GIT
symptom
→

sjs → Extra ocular

-

muscles
will be
dlt inflammation → there
deposition of
& Glucosamine
muco
polysaccharides glycans .
 no wrinkles

f.

Is

lag of convergence
LPs muse
.

Doctor
lid
lag sign
-

_ -

÷
Investigations •
Anti Ta ,
Anti TPO ( Thyro peroxidase)
•
RAI scan →

diffusely warm scan

"E &
i
Alopecia
}
:

-1¥ TH → Anti
thyroid drugs
↳ liver
failure
pt gutayun ,
To make .
,

710.1-0.515
Definitive Tx :

<45yrsofage_
Sub -
total
Thysoidectomy
s45ynsofage_
)
' "
radioactive Iodine ( I

Anti thyroid drugs are used for quick relief .

RAI is

slow to act 16 wks )

methimazole 1 PTU
b b

force a
day ) ( 3- u times a
day )

solitary-hysoidvodule-i.com# Thysoidhormonestatus
e) Thyroid cyst
liquid suthysoid
( colloid
degeneration)
2) Plummer '
disease solid
hyperthyroid
[ Toxic Adenoma)

3) Benign Tumor Solid buthysoid

4) Malignant Tumor Solid eaethyooid
 STN

fast investigation Thyroid function

→ test

= .

Hd Eulhyroid_
f. RAI scan Lusa
→ T .

solid
Hot nodule

¥Y
Hotnodule
liquid -

@ < 3am I ↳ FNAC

defied
y
RAI -131
cyst = .

(aspirate)
,

Wait
for ⑨ > 3cm
Benign malignant
6 wks & Hemi Hoovers Tumor Tumor
thysoidectomy
-

RAI t t
repeat Aspirate Henri
scan
again Total
-

thysoidectomy
thyroidal
,
tomy
a- -

3rd reoccurrence Histopathological

is examination
indication
of
.

an

surgery lthmirfhyroidectony)
.

( MPE)

If hÉÉ shows
malignancy → do total

thysoidectomy .

f :
follicular carcinoma can't be dye on FNAC
,
it can

be die
by HPE
)
70% total cancers Ca
( FNAC
•

of papillary da )
→ can

1-3^1 . →

Anaplastic Ca ( FNAC ✓ )
5% →

medullary
Ca ( FNAC ✓ )
10% Follicular ( FNAXC)
→
Ca
RI-sosternalbyoitse.ve
pressure inside chest 1 pulls the
thyroid gland ]
•
Gravity pulls the
thyroid gland
Minimum 50% of the
thyroid
gland lies in chest

iRTSG_:
arises
from an
ectopic
khest)
thyroid →
Goitre

Blood
supply from chest
-

2°RTSG_:
Extension
of neck
goitre dlt pull of gravity & - ne

in chest
pressure the

vent.

Ribs the trachea

oeso compress
""
b
aupoid
Dyspnea
.

ster .
clavicle
•
Stridor

Dyspnea marked at
night time
-
more .

neck
\
chest / I s b narrowing
oftrachea
supine
vertical
gravity .

standing up
.
 shoulders
pemberton sign :
upon raising above
arm .

-
veins / Trachea are
compressed
- : stridor /
Dyspnea → will worsen

facial congestion appears / veins

scabbard
Tracheal
trachea
deviation

scabbard
x-ray
→

Trachea .

Goitre %
enlargement Izdef
→ •

9
°Gra
Enlarges
[
°
Cancer
t
STN
•

RTSG
Tse :

Dongs
2) Sx ( < 45yd
3) Radio - iodine 5431 ) I > Usyr )

In RTSG is
:
only Tn option surgery
-

Radio iodine -

can't be used .

B- says -
lethal to
thymocytes ( Range )
0.5mm

Im →
Thyroid Gamma rays
-

gland , ,, ✗ -

says
 neck RTSG_
It 31

µ
:#
Tuy
. →

far .
Rupture of carotid a. wall

by 1131113 rays )
-

I
-
:
131 cannot be used :
of proximity of imp .
str .

near
by .

8k€ 50% neck → cervical incision

chest
Thoracotomy
501 .
→
.

be
99%
of RTSG can
operated by neck incision .

Thoracotomy is done : -

1) if MO neck
surgery
-

fibrosis
a) of ectopic goitre Blood
supply from
→

chest vessels .

3) If there is
suspension of cancer .

Came

Papillary : -

mile
thyroid cancer 170-80%1

Mlc thyroid cancer children

-

mk
thyroid cancer -

Radiation exposure
1 nuclear accident)

Mfc multi centric .

;
least malignant : slow
growing .
?⃝?⃝
 have micro metastasis
Mfc thyroid cancer which may
-

node)
in LN [
lymph
no
capsule
-

0 if capsules
→ known as LINDSAY
TUMOR
-

psamomoma Bodies →
can be tht in other disease

Orphan Annie nucleus is the more

specific finding
-

c- -
-
-
-
-
.
.
.

LN
d.

replaced
by malignant
Thyroid
to

cells slow
growing
-
FNAC
Lateral Aberrant
thyroid
 Thyroid function
Test most
of pts suthywid
.

central LN
HI : Total
thipoidectomy +
dissection ( v1 )

total
near
thyeoidectomyx
-

If other LNS are not involved

clinically no
prophylactic
dissection is done .

0.1102 Thyroid left

After Thysoidectomy
-
Ts / 7+1 ^ : can lead to
malignancy
✗ again
after thyhoidectomy Thyroxine should
given
i. -
be

so that TSH levels don't rise

pwgnosticcriteuia-r.AGEScuitoeiamac.is
criteria
Bad
T.metastas.es + at A Age
→

- nt → Good

Good G Grade
A- Age < 40
> 40 Bad
E Extra
thyroid
C-
Completeness of excision spread
involved Bad
8
-

1- Invasion
of capsule not "
-

Good size .

S > 4cm Bad

size
-

AMEsñ :

A
Age
-

M -
metastasis -
distant (nye organ →
lungs)
E Extra
thyroid spread ( local )
-

S
size
-
.
 Follicular carcinoma Hwrthle cell Ca .

__
-
Twin
1 Rare)

aggressive
-

total ca
only lot
of
the
-
.
.

PTEN mutation
-

,
p53 gene
blood vertebrae & Ribs
spread by
Bones (
commonly)
.

-
→ →

spread by LN →

extremely rare .

FNAC → can't
differentiate b/w follicular adenoma
/ Carcinoma

239 → insert it into tumor → take out some cells .

% ④mine cells under

microscope
.

Papi orphan Annie

medullary : c- cell
Hyperplasia
Anaplastic :
multiple mitosis

biopsy biopsy
FA FC

Benign Tx malignant Tx

capsule not
capsule involved .

involved
FNAC : some cells some cells .

Biopsy :
I • tm_B@
Capsule is
free capsule is invoked .
 useful
in
FNAC is not : -

hard needle break

Riedel thyroiditis :
may
° - .

°
Multi centric disease some area be missed
may
-
-

HI :
Total
Thyroidectomy
Block dissection UV
-

of u
necessary
as LN are

rarely involved .

Bony secondaries need external Beam

Radiotherapy
-

tbuthlecellcai -

Aggressive .

IN
-

spread is common & occurs

early

}
← small
part of thyroid left after sx .

t.

Radio Iodine 123 Scan

to
Radio Iodine 131 ablation .

cell
thuthk cell don't take
avidly
carcinoma I -123
up .

i. RAI scan not used .

Technetium 99 is used [sestamibi Scan] .

T.lt Retinoic acid

:
if reoccurrence :
chemotherapy + + PPAR

agonist
lfnaplasliccarcinoma
yrs)
170
of elderly
- Disease -
so

involves
nearby areas
quickly
-

LN
spread occurs

Distant to
spread commonly occurs
lungs
Mt modified
thysoidectomy
:
Total + central LN dissection +

Radical LN
( Level VI)
Dissection
( level 2-
E)

M¥ma_ :

C- cells cancer - neural crest .

•
Thyroid module
+

Prostaglandins
Diarrhea
Lsu AA

G- Hydroxy Indole Acetic Acid )

•
secretes Vasoactive
peptide
secretes Vaso active intestinal
peptide
-
.

:( weak hormone
-
Calcitonin excess is not afw Hypocalcemia
.

- sot
.

of total case are

sporadic
familial
20-1 total
of cases are
.
-

to
Afw MEN 2A
,
MEN 2B
If medullary carcinoma is alw pheochromocytoma :

Aggressive
- Tumor

should be operated first

pheochromocytoma
-

Ivan :

FNAC cell
hyperplasia
• -

c-

www.CEA ( Cancino embryonic

Antigen)
• 9 Calcitonin

role Iodine
no
of scan
-

: these cells don't take Radio iodine

up

d0%familial_:
to
gene screening -

offered family members .

RET
-

mutation
gene →

prophylactic Thysoidectonug
After Cancer → Total
thysoidectomy + CLNI -
VI + MRLND

→ I ,z , ✗✗

Vandetanib
chemotherapy
: .
→

→
cabozanitinib

¥8 :
of thyroid

non-Hodgkin lymphoma B-
type .

pre existing pathology ( usually

Hashimoto
Thyroiditis)
- -
 Inv : FNAC
Better inv
Biopsy
→ .

Tx :
Radiotherapy +
chemotherapy .

Surgeries .

Rose position : -
neck
expressed head
supported by
pillow .

Incision : - Kocher 's cervical incision

sternal notch
-
2
fingers above .

tlemithysoidectomy
:
Benign tumor
•

Affected lobe Isthmus

•

I of lobes isthmus is
function of one c-
°

nye site for a

solitary thyroid module

.tl#-Up.:
half Affected lobe -1 isthmus +

lobe
of normal

I - not done these

days .

Subtotaltnyroidectomy trachea :

only 6-
Sgm of
the tissue

g) fgm
.

→
is
left .

Rest is excised .

disease
[ Trachea § multi
Graves:

esophageal nodular

groove goitse
.

( RLN )
used
for Benign disease
affecting all
gland
'
 meartotaltryeoidectomy Rarely for papillary Thyroid
: used

Trachea
tissue
left
carcinoma 1- is in -

zgm og
.

esophageal groove I
Raaully used )

only for papillary Ca .

Totallhyeoidectomy
the
gland
remove all .

Cancers .

Parathyroids if removed
along
&

/
Mince cut them into 1mm
pieces /
to slices

We
put them into sternocleido mastoid
or Bsachio radiate 's muscle .

compl
)
icatiomog-nyroi
Respiratory
dectomy.it
obstruction →
dlt hematoma .

while GA
doing to

endotracheal intubation -
cause trauma .

vocal
nose →
pharynx → cord → Trachea .
 edema
Trauma cause
of larynx .

obstruction
laryngeal edema nyala
of resp
.
.
→

BP low
During surgery
→

After a → BPP →
Anxiety /Pain

Er
2) Hyperparathyroidism :

¢④
small
f¥rtny goes
into
spasm
PTH 4 →
t.cat

"
• t.ca levels
>
8mg / dl no Tx
required
-
.

all
6mg / Iv calcium Gluconate
< -

G- 1dL oral cart

8mg
-

karliestclf poi oral

tingling
: -

Chizuru :
Tapping over
fascial nerve

Twitching of fascial muscles .

 Caysof xsm
Torossian
sign
:

obstetrician hands .

3)
RLNinjwylsuviflatnjmy-i.MN .
→
sensory
below vocal cords .

med -

→
motor .

1) Abduct vocal cords : A - X -

strong
2) Adduct vocal cords : A → A -

weak .

motion vocal cords vibrations

of
→
-

swum : -

int
sensory
-

eat .
-
motor -
Arico
thyroid →
Adductor → vocal cords .

working]
RLN IELN
injured is

Media ligation
M Ttt
:

✗ $ vibrating up injury .
Tor
pt . to
speak
R properly
-

L Adducted

inj .

by CT

µ →

↳
µ/ Adducted pt
. can't breathe

both are
inf by arico
thyroid
.

Tx :
lateralization of
cords .

(so that pt .
can breathe)
 ELIN cricothysoid paralysed
:
.

can't
pt
.

adjust pitch of his voice

coupleѵ§
divorced STV are
ligated as close to
gland as

possible .

Thyroid

fRLN ligated
ITV too should be
married
as

couple in
close to
gland possible
as .

☒
Artery to Parathyroid
To avoid
damage to
-

parathyroid artery .

4) Cervical
syrup
.
trunk →

injured → Horner Sx .

5) Thyroid storm →

Before every Sx pt should be

euthysoid
Deluge of -13174 hormone in blood .
-

rate
rapidly increasing Basal metabolic
- .

THR → heart
Tired →
circulatory collapse
lmlcfc of death is
avythmia )
It : ( water
Cooling )
to
of pt Temp bath
.
.

Ice
pack
IN steroids

Anti
thyroid drugs →
PI :
apart from 6
proof
Tz / Ty It also to conversion
of
.

73
of Ta →
.
pre-0¥ bigots
iodine → makes
gland firm &
easy
to

handle
during surgery .

drug propranolol
most valuable Blocker
p
-
→ → -

I / Tie stimulate
Adrenergic Receptors only
^

: → .

wound "

inf I for mm
→

scar → leads to
keloid mm
for
Hypothyroidism
.
 Breast

to 6th rib
Vertical extent → 2nd rib

side
Horizontal →

of
sternum to
line
axillary
.

mid

→
Modified gland
sweat

Superficial fascia
→
.

Ancillary
-
Tail
of
spence
.
Breast & lobules
is
composed of duct
- .

Terminal lobuleeaer unit

functional
duct is unit
of
breast .

stimulates
Estrogen growth of Breast .

g-
Too much
/ Too
long
d.
Cancer .

progesterone stimulates tubular

proliferation
.

prolactin →

production of milk .
 polythelia
}
→ additional
nipples Always
in milk dine .

polymastia → additional Breast

Polland
Syndrome : -

Absent Breast
along
c-
p major
.

muscle .

( UIL)
absence Breast
Amazia :
of
v11 or
BIL

Benigndisordus
-
Fibro adenoma

Fibsoadenosis

Sclerosing adenosis (cyst)

fibroadenomai.benign
mx tumor
of breasts

Mfc age 15-24

yr
.

lobule
pathology Hyperplasia of single
-
.

freely
Breast mouse -
moves in Breast

Encapsulated ( has a
capsule)
most common in Blacks .
 mammography involving fibro adenoma : .

Popcorn calcification .

FNAC Antler horn

configuration
: -
.

7¥ : Reassurance / waterfowl observation .

Sx : > 5cm ( Giant)

-

Recurrent Tumor

rapid increase in size

-

family history
-

cosmesis
poor
-

psychological disturbances

incision :
-

areolar incision small

peri
→
8 -
.

Big tumor -
€ Gillard Thomas incision .

Infra mammary
-
Fibsoadenosis
:_
Breast hormones
Exaggerated response of to .

t -

normal
€
:

t -

Exaggerated
to
response
hormones .

•¥!-• →
cyclical nostalgia
c-
modularity .

& #
ducts
→

hyperplasia of multiple
miaocyst formation
→

one

of cyst
→

may develop
into
large cyst : -

Blue dome
cyst of
blood
good .

FNAC
powdery calcification
→ .

7¥ : •
Reassurance
•
Avoidance of extra salt /
caffeine .

DOc .

oil
Evening primrose .

mÉÉ Danazol .

function of
LH
interfere FSH
-
It c-
,

Cause Hirsutism .

other
dungs : -

Bromoaipttne
Tamoxifen
 Tietzebyndromeinon cyclical .

mastaigia
.

dlt Costco conduits

lesion al asteroid Kenacort

¥ : Tantra →

Triamici lone

sckrosmgfdenos.es#:*- Mw:I.- Tg
premenopausal postmenopausal
-

f.
co-ordinated involution .

Non -
coordinated involution : -

Ftz
Duct
→
involutes lobule
remains

Big
coordinated involution
dft non macro
cyst form in
-

Breast .

Ttt : Aspiration
.

8¥
IID reoccurrence
for
.

proliferating terminal duchies .

epithelial hyperplasia -
 a -

adenocarcinoma
cyst .

ANDI
:

Aberration &
normal
development involution
in .
Phyllodestwmor
Cyst sarcoma
phyllodes .

misnomer : -

not
cystic charges
-
are seen .

-
sarcomatous
change
→
happens early .

leaf like
appearances are seen on
microscopy
-

phyllodes tumor .

disease Brodie
Aka Seno
cystic of
.
-

Tumor
of perimenopausal age group
-

not
just giantfibro adenoma
a .

.
-

some tumors can become metastatic .

mfE→ lungs .

Cystic →
infarction
4€ : Tumor is not
fixed to skin
/ onset

Doesn't metastasize to
lymph mode .

IOC
Biopy
i .

Tft : wide local excision → Small Tumor

simple mastectomy
→
large
[ entire breast )
✓
Modified Radical Mastectomy - Breast +
Axillary 1N

is not necessary : tumor doesn't involve lymph nodes .

 Galactica :

Blockage of lactiferous
ducts
by milk &
epithelial
debris

Hours → cessation
of lactation

calcification may
mimic carcinoma
→ → .

1- It
Aspiration
:

I. fails
Incision &
drainage
mastitis
Deuctectasia : aka
plasma
cell

•
smokers
women
young
• .

Dlt unknown mechanism ,

ducts dilate &
periductal
mastitis
develops .

= -

•E
fibrosis

also Ducts blocked

by desquamated cells .

greenish discharge
→
is common

contraction
fibrosis of the duct
may cause .

E- →
¥ duct
contracture of
.

Slit like retraction .

 involved
It Come excision duct
.

: →
one

had
field operation
ekisim
of all
major
ducts .

Ductpapilwmainyop og papilloma
-

ulcerates

Bleed

Me 4F Bloody nipple
:

discharge
Mek of Bloody nipple discharge
.

°
Small Tumor .

not risk Ca
→ even
malignant
i. no
of
.

pre
-

→
usually found near areola .

Inv 1- It
ductogs.am micro

dochectomy
.

&
con
tennis
← By
racket
T incision
filling defect

Redflagsofnippledisharge :

g. spontaneous discharge
Age 340
Mondoisdisease :

string phlebitis
spontaneous thrombophlebitis
hat thoracic vein
involved
{
-

veins vein
sup .

epigastric
→
Tenderness .

-1¥ NSAIDs + warm

compresses
.

BwastCan%€ ca in women worldwide .

India
nyc Ca in urban women
of
.

2nd belated death India

mfelc of cancer women
of .

Risktactors :

Early menarche
/ late menopause
•
high alcohol consumption
Early child birth & lactation to risk
0
.

• multi
parity CT risk)
•

history of ovary 1 colon/ endometrial

malignancy
.

→ OCP → don't 9 risk .

Hormone
Replacement Therapy High estrogen :P risk
° →

if used for 10
yrs
.
 Gene mutation :
mya gene mutation →

p53
Mfc mutation in
familial case BRCA
→

gene
70%
of case →
sporadic [ no
family history
.

hi Fraumeni
Syndrome
-

MW Cowden syndrome .

Sarcoma Brain
/ Leukemia Tumor .

BRCAttm.comlong arm
of
chr 17 .

Tumors
• are
Estrogen receptor -
ne .

High grade ,

poorly differentiated
•
Invasive ductal carcinomas .

Early age
•

tumor
BIL
° .

Basal
o

type 1 medullary histology

→

Tipple
ne
-

(no
receptors for estrogen ,

progesterone .

Her -
2- men
)
BRCA-2_ :

→
long→

Invasive ductal
arm
of Chr -

13 .

→
early age . less
aggressive
Estrogen receptor
→ + we
 "# BHAI
Ovary Ovary
Colon
Colon

Prostate
Prostate
Pancreas / GB
stomach
Ca melanoma
types of
: .

i lets

hJ
invasive

Duct / lobule
IDC
Invasive
lobularca .

Mfc type : Invasive ductal carcinoma - NOS

(not otherwise
specified)
Dam :

Ductal carcinoma in situ is

dysplasia ,
which has

not breached basement membrane .

c- est
High expression of gene
• .

High grade
or
lomgrade
°

t to
,

solid / Comedo
papillary type /cribriform
cinecrosis

ductal carcinoma
°
Anatomical precursor of
invasive .

DCIS - IDC

LEIS ILC
 not be
9¥: lump may I may palpable .

is also low
→ Risk
of LN
spread
.

Axillary lump Luvs)

may
also not be
palpable .

LI
mammography
:
micro
calcification
→ .

FNAC : can't
differentiate btw DCIS
/ IDC
Breast conservation
E-
surgery [ preserve form function
&

of Breast ] .

wide local excision → 1cm

marginatus
t
changed .

1mm

trow

specimen [ Tumorshould
no ink on the not

be visible ]
it should be surrounded all sides
by
i.

I normal tissue .

RT
}
→

controversial
→
CT

Van indicators
Nuys prognostic
can be used to access
=
the
requirement of adjuvant
therapy .

chemotherapy
is
often unnecessary
as
usually there

not distant metastasis

are
.
 Therapy for Estrogen Receptor
- Hormone the Tumors .

Mastectomy
Tumor
If the
margins
→
: →

pregnancy ( : no
radiotherapy can be
-

given )
→
No collagen vascular disease .

intraduclal
→ Intensive
Component
cancer is seen in ducts )

1
many
Invasive carcinoma )

" " " + math

"

Basement numb .

disease
Paget 's
→

cancer
Superficial manifestation of
.

o 90% → Dc is ,

malignancy spreads right upto nipple through duct

a
.

Destroyed nipple
mimics
eczema
• .

Paget Ds
mm
Eogeinam
lactational
peri menopausal
women
age young
- - -

UIL ( only on the side

of Ca) BIL
-

vesicles
-

no vesicle .

nipple dies
toyed by ca nipple is not
destroyed
-

.
-

not
☐BCsX Mastectomy ,
Bcs
possible .
Lynn :

committee
Acc .
to 8th ATCC ( American joint of
d.
Cancer
)
disease
benign
I
It considered
just
is a

go malignancy
.

LC Is - I LC
XX

ductal also
may develop
• Same Breast Invasive ca .

provoke calcification
° Does not .

hence
may
not be detected
by mammography
-

i. MRI
may
be
required
multi centric
Frequently
• it is
.

tumor)
Ttt :
Tamoxifen ( till regression cause
of

BIInvasineductalcarcinoma.is
or
prophylactic mastectomy

ome times

lump hard
c¥ : Me GF → .
I
irregular margins , ,
fixed to

nearby stir .

)
Before being
Ian
palpable
→ : -

→
2nd rule UF :
nipple discharge
Axillary lymphadenopathy
-

metastatic ds
 LAI :
75^1 Breast is to
Axillary lymph
of drainage of
.

nodes .

Arillarygsoupoflymphnodes
"
÷ -1¥ .
.

Levett : -

Below & lateral to

muscle
p minor
. .

Anterior lateral thoracic

:
along vessels

nodes
:
pectoral
External nodes
mammary
:

involved in Ca
imfc LN .

Posterior : sub -

scapular
lateral
along axillary vein
:

levelli Central
lymph nodes
:

lie behind pectoralis minor .

benefit :
Apical lymph nodes .

Infra Navicular LN ( Halsted Nymph nodes)

RoHeisNodes_ →
btw
p
.

major &
p
.
minor muscle .

drain
Later all
of them into
supraclaricular LNS .
SILK Changin :

D Paeu -
de -

orange
: obstrn of dermal
lymphatics .

2) Cancer cuts
asset
-
en -

skin
stuffed c-

cancer modules .

Mc
pathologically Breast cancer is Schirrous ( scar forming)
t
contraction .

GF related to skin : -

Dimpling of skin
occurs
dlt rice of tumor +

along suspensory ligament of

Cooper .

fat at

Retrn of nipple
 -

Ulcer

has reached
already
Skin involvement : cancer the skin

P : de
paeuu orange
-
-

U : ulceration

S : satellite Tumor modules .

ChesFi×iy :

wall
Tumor is
fired to the chest .

muscle
-
Pectoralis
major 1 minor ✗ ✗

}
→ serratus ant -
muscle
I should be
→ Intercostal muscle involved .

ÉpgBS
MIELE Inn :

It
> 1cm :
gets its own blood
supply
:
can to
go any organ
.
 ftagingmi.TN M

1° Tumor
To : no evidence
of
Tis : Carcinoma in situ

Tisp :
Paget disease

micro invasion
→ Os Icm
Timic :

Tia 0^1-0 's

g-
Tg : < 2cm in
size
-

Tib 0 . 5 - 1^0

( T 1^0 2.0
c
-

2- 5am in size
Tz :
.

Tz : > 5am .

Ty : a- chest wall

b → skin

any c → Both

sized →
Inflammatory Breast Ca .

IN I Good sx removed

Axillary LN
→
mobile discrete
: :

N ,
a →
ipsilateral , ,

" Bad
Good
"

b → internal
mammary IN detected only ,
SLN
biopsy on .

HI : Worse

& internal but detected

Both
axillary only supradaniadar
c. →

mammary on SLNB .
LN involved → worst

Nz a. → Fired to each other /surrounding str .

(
Axillary)
Bad
to →
clinically apparent internal
mammary live
Nz a →
infraclavicullar IN (Apical , level II)

worse to → Internal
mammary +
Axillary
clinically]
c. →
Supsaclavicular .
Mo → no distant metastasis

Distant metastasis tnt

M ,
→

staging
:

Breast
only
I →

Breast -1 other
→
any organ
II. is B & C
Inflammatory
→

Ie →
Svpraclaricular

I : T, No Mo - Mo LN

nodes
I :a To T, N,
lymph appear .

Tz ( 2- 5cm)
b Tz + N,

]
HI / N2
:q Tg +
HE To -

q -
2-3
+
Worst

b :
Inflammatory Breast ca .

T* + No , , -2 lymph
nodes .

1- +
c :
any Nz

II :
Any T +

any
N +
Ms .
 Mesina
of
contralateral
lymph node in absence
of
breast Tumor other Breast disease
in
stage #
a → is .

Beeastca.io
more common in
left Breast 1-: Bigger)
Outer Quad .fm/ c) density Breast
upper of
•
→ max .

tissue .

04C →
inner lower Quad .

stage I. I
Early Breast
→
Ca → Bcs

advanced
Stage II →
locally Breast ca → MRM .

stage I →
metastatic ds . →
palliative
c- ✗
only
.

BI→ near
nipple aerola

wide local excision →

Radiotherapy .

Absolutely:(for )
RelativeclI-i.pk targeted #
RT

Ps :
Pregnancy 0h10 Collagen vascular Disease harmful
polycentric o

multifocal Tumor .

RT
prior Centrally located Tumor
- '

positive margins

Axillary LN → not a contraindication for

Bcs
Relative
+ +
.
Absolute

multi centric
multifocal
II
Lapse Stage
-

modified Radical mastectomy .

1) Auchincloss wife
→ Breast
nipple Areola + level I + II
✓
+
-

True MRMT minor

retracted
LNS

p
. →
.

( To remove level I

LN )

2) Scanlon → B + NA -1 It # + II LNS

minor incised to remove II LN

p
- . →

b) Patey's → B +
NIA + I +I + II LNS

Pminor → excised .

Complications .

Mfc complications seriema

&
formation
collection
of serum -

prevented by placement
drain
of
-

injury to
axillary vein
-
 major Ip
minor
lateral & medial
pictorial nerve
p
- . .
-

Thoraco dorsal nerve : latissimus dorsi muscle

internal rotation
weakening of
-

ABDUCTION

Interest brachial numbness

injury
over
-

nerve

medial
upper part of arm .

Breast
Phantom
phenomenon
→

lymphedema : common uns

for arm / Breast
- -

After logos →
lymphangio sarcoma .

de
Treatment →
Amputation

(
older Halsted Radical
Mastectomy : Bt N/A t I I II +
p major pminor
+
- -
-

tended Radical → + Internal

mammary .

Super extended RM → a
supra clavicular .

Radiotherapy :

for local control

of the disease

1) Bcs

2)Axilla
after axillary clearance .

3)
Multifocal disease

4) In Bone → t
pain
5) Tumor > 5cm / skin
,
involved .
 Radiation
clay of
5000 the .

week weeks
days
b-
day
✗

hooky
✗ 5 a
.

every
-

Radiation can cause severe

damage to normal tissue .

Accelerated Breast
partial Irradiation
-

Radiation source lie within the

Brachytherapy :

Body .

Benefits lower radiation dose required

3000 -3500
OGY .

Chemotherapy :

CT Sx
Adjuvant After
→

> 1cm in size

Neo
adjuvant CT
Before
→
sx
inflammatory
to reduce size
secondary
.

CMF / CAF : -

I Doseorubin 5- Fu
Cyclophosphamide Addriamycin ,

Episnbiais
Docitasul 1 Paclitaxel .
 tlosmonmi .
Hormone
dependent Tumor .

Tamoxifen :
-

keeps the real

hormone out

by blocking receptor .

10mgHuiice
BD - 5
years
.

a
day)

for frost menopausal

-

women : -

Adrenal androgen is
only
I. source of estrogen .

Doc Letrozole I Anastrozok

s@tler-2-neu_tneTranstuzumab.I
: .

nftammatorybseastcarcinoma.is 33% skin → involved

by inflammatory
changes .

lump may not be

palpable
-

75^1
.
→ LN + ve

25^1
.
→ metastasis .

IOC skin
Biopsy malignant cells
→
: .

Tlt : MRM .
 carcinomapsreastinpugnancy-i.gr/PR-nem
Cancer →
vomiting/ Anorexia } cachexia .

pregnant
→ " " ✓

d. can't be
Breast size T - : tumor can't be
identified
.

(palpated)
i. Dx is delayed in
pregnancy
:
pregnancy masks

cancer
changes of
.

1st Trimester only ↳ c- risk to

fetus
Biopsy
→

Ioc :
.

2nd Trimester → Get

chemotherapy
3rd Trimester but
chemotherapy
→
.

CT is not done in 1st Trimester it is period of

-

: a

organogenesis
Hormone Tf Radio T →
GI in all Trimesters .

Male Female

µ µ
Male
mm
Breast cancer
mm men
:

mfc age 50-60 yrs .

ER / PR ne +
chest skin /
.

time to
take
long
¥ : involved reach chest / skin

cirrhosis
fun descended testes early -

X
-

BRCA -2
Joe
Biopsy
→

Gynecomastia → is not a
Rpf .

Tlt → same as
female .
* Tumor have million walllined
will
of small
single cell
.

BV → micro
calcification
.

Mammography :

started @ 40
yr
.

done
annually .

Radiation dose → 0.1C

Gy
14 chest
X-ray)
Abdominal ✓
-

dome
pregnancy
→ .

Cranio caudal view To

compression of tumor
→
see .

Medio lateral view

larger volume Breast
→

of
- .

Cancer looks like :

1) calcification
micro

2) Rough lspiculatcd margins }

a) stellate
calcification ¥1
4) Ill defined margins
Benigni
- Tram Track

popcorn
-

curvilinear
fact necrosis
-

BIRADS Breast & Data

:
imaging reporting system .

" "

O Could be assessed Additional

not
imaging
→ →

USG / MRI

Annual
mammography
-1 : -

ne : .

I
Benign
: : n
"

II :
probably benign i short term
follow up
-
-

< 2% risk C- Gmo)

og ca .

I :
Suspicious :
Biopsy .

(2-951)

I Intervention
Highly suspicious
:
:

7951 risk
.

VI Mammo Ca
proven
:
Tram
track
app
.
 Mammography screening : inv .

of choice > 40
yr of age
.

> less
of glands of fat mammography
no →
→ more →
.

( low density)

of gland /
< 40 less USG MRI
→ more
of fat →
-

1
high density)
MRT-w.ir
Screening IOC in
high bisk individuals .

Ca Breast
Eg : Relatives
of pt
c-
-
-

lifraumeni Sr .

staging
-

Occult
primary Tumor
-

eg Las
:

To
distinguish scar
from recurrence
-

To check extent Dc is
of high grade
-

✗
Intra
capsular implant
rupture
 Usda :

-
Dense Breast .

Goes
Ast inv →

pregnant females Biopsy)

.
-

→
equivocal mammography findings
-

malignant-h.co#-GfforTeucut
tall wide
more than
Biopsy
g.
Not
compressible be
• Ncis can
dff
irregular wall .

from IDC

ER PR status be
/
•
can

seen .

sLNPgn ( Sentinel lymph Node

Biopsy) :

&

firstly used to do
for melanoma .

later :
Penix →
known as CABANA -
OP

Oral / vulval Breast .

fair people → Blue

dye → Tso
suephan blue
Blue
methylene
Dark →
Tca
"
labelled
sulphur colloid

we don't need to do
axillary dissection .

main Beni
fit
to
chances
of
t
lymphedema .
 oxide
Santi -

may Technique
: -
use
ferric .

Reenters ague :

we can use
implants →
Allopathic (outside the
body
material
)
for small Breast → Silicon
jelly pouch
large
saline
for Breast →
silicon jetty +
pouch

muscle
kept behind p major
.
.

implant →
Autologous tissue : -

nyc used flap : TRAM

Transverse Rectus Abdominis

flap .

4- Risk Hernial wall weakness)

of
-

Deep inferior epigastric perforator flap

.

-
: use Diep →

→ no muscle is removed .
 small Breast size
→
Lattismus Dorsi Flap →

male Breast
kgi
.
 Kidney
paired Retroperitoneal organs
.

size →
9- loan
long
5- 7cm wide

A- P diameter : 3- 5am

in males
females
not 150 135 in
gun gm
: .

"
rib
Renal angle [ outer border
of
saaospinalis
Kidney pains are
referred here .

Renal
artery
-

¥¥← 954
abdominal

aneurysm
Aortic
-
arise

artery
below renal
origin of
hence
left kidney has longer renal
vein .
it is

puffuud for organ transplantation .

 Brodel Avascular
plane plane
:
-

posterolateral
on

surface of
kidney
.

C0NGE-Ac Discs OI KiD_E :

-

A
smooth .

Adult
multiple
lobulatim

D•µumY_
→ lobnlaeion on the outer

surface of kidney
.

-
 Hereinto kidney : -

A \
rare common
→ when assent
08
stays]
(
upper
is halted pole : ,

kidney fused) UTI

by inf . mesenteric

artery
.

→ occurs because
polls of kidney are
fused c- each other

lower
( nyc
pole)
-

→
more common in males .

GI Asymptomatic Cmyc)
-

wife presentation
UTI :

abdomen
mfc off →
pain .

Rousing Sign pain abdomen

hevomitingon
→
, nausea

hyperextension .

⑨
formation
to stone
prone
→ .

IN
orography → D Hand
shaking sign
2) ureters → Flower vase
appearance
.

Ttt :
pyetoplasty
→
if meters are
deformed .

done to access
separation of kidney is
only
→

Abdominal Aortic Aneurysm .

 Disease
1¥ Kidney
•
Autosomal Dominant
•
Defect chr .

4116
•
PKD -
9-
,
PKD -

2 .

BIL Mfc age : 30-40

yrs
.

Blood
less
4€ "
☐ It to renal ischemia
My puiphny

§ @ Renin

is
Angiotensin system
activated

Aldosterone TT

754 MTN ( malignant HTN)

fit →

@ Angiogenesis → small
capillaries
form .

c-
may rupture along
wall
cyst :
-

wall Blood vessels also

cyst rupture
.

tlaematuria .

② loose couch
Kidneys to
ability

pogonia
Nocturna .

nyclc of death →
untreated : cardiovascular
morbidity y MI :

Treated :
CRF .
-

Bury aneurysm may develop SAM .

be liver
cyst found in other
organs wife
- → :

may

IOC → CECT

MRI →
if suspicion of Rcc (Renal cell carcinoma)

1-It : Treat HTM

(ACE inhibitors)

devoting of cyst pursing operation

→
-

to
will
just give pain relief
.

Definitive Tx :
Renal Transplant .

Ureter
E¥e
:

Females → Ant .
urethra .

Continuous
dribbling of urine

males urethra
→
post
.
.

continuous
dribbling of
no urine .

Vern montanum
seminal in
Epi dydimo
-
orchitis
resides unter
opens
was prepubutal boy the ,

deepen dx of ectopic ureter

down to testis
is certain
 NÉE :

Sup pole Inferno medially

.
-

Inf pole supero

-

laterally
Drooping lily sign In
-

ltreterocoetei
dilation lower part
cystic of of meta .

mlc
type →
Ectopic meter .

safe presentation v72 →

Abdominal
sign
mass
mile →

of hydroI. nephrosis
i

stricture
formation [narrowing )
•

of
:

IVU →
Cobra head
appearance
( Adder head
app )
aka .

Ttt → Tncision wall

over
cyst
Retuocavalureter :

water behind the IVC

passes
has is
congenital anomaly but
• Ureter no
Ivc

defective .

has sub cardinal

i. e- it
persistent vein
-

Ivc → Reverse J
appearance [ Fish hook ]

Ttt → Relocation urltero -

ureterostomy
Nephrolithiasesmnn
'

Calcium oxalate
Mfc Renal stones are

salts in
Randall Plague Theory →
deposition of
acts nidus stone forms
urine as a
for
.

Carr postulates → stones

form dlt blockage of lymphatics .

N¥ "

• Hot & humid climate → saturation

of urine

Malls
/
females work
•
> :

outdoors

infections by urea
splitting organisms
.
-

2
• Wease → urea

Nui (change pH of urine )

-

proteus
mirabilis / vulgaris
4.
-

Klebsiella
coli - X
no urease )
Nocavdia

It
pylori
Hypercalcemia dft PT adenoma
-

→ .

prolonged immobilization
bones blood
from
"
-
→ ca → .

-
Diet excess → oxalate lesecessvitc →
oxahuia)

salts Natriwusis
-
+
Na Cat →
 Calciwmosealate :

stones
•

Mulberry
Brown colored have
sharp projections
•
,

room
any pH
•
in

ethylene glycol poisoning

flscopically
→ Dumbell
shaped crystals
move
glass
enveloped pyramidal shaped
bi .

Calcium oxalate
dihydrate SOFT →

Calcium oxalate
monohydrate HARD_
→
run

single f. Sakha launda >

Phosphate :
Triple phosphate 1 Stannite

Call Cal -

magnesium
-

Ammonium
phosphate
to
°
Women ,
due
infections .

•
mfc →
protean
Xanthe
granulomatous pyelonephritis
•

cysteineHard :

Radio
opaque Cyteinuria AR disorder
•
° • →

occur in Acidic urine

•

Ion exposure to air)

multiple yellow
→

green
•

.
 Xanthine
in Xanthinuria
•

Radiolucent ° occur

•
Brick red in color

Tui÷ons :

diuretics
K+
sparing .

2ndinavirf silicate
f
•

amino tones .

↳ Antacids

°
lÉÉrs :
•
mfc Radiolucent stones

form in Acidic urine

•
.

•
Gout Ttt ottuopurinol
:

Leisch hair Sx
my
°

•
Alkalinisation wine
of
Mydoproliferative
° disorders .

•
Rasburicasem
Tumor
lysis Sx
•
low animal
protein
.

critical C →
Calcium oxalate T A ✗ I

d. L t \
C Cysteine
.

can →
Uric
Xanthine Indinavir
Triamterene
Acid
unit u uric acid
cnn.it
→

Radiolucent stone
in Acidic urine
form HC Bc
→ Hard stones .

Bruski -61cal / Cysteine

Hydroxyapatite /
-
ox .

mono .
 4€ :

meteoric obstruction
•
Wyck of
.

sarcospinahis
pain renatangllpm
°

over
rib .

upper 43rd of
• ureter

pain may
radiate to
thigh fdltobturakn ]
-
.

°
middle 43rd of
ureter

fdltiltiohypogasntr.iq
radiateto iliac
fossa → mimic
appendicitis
• lower 43rd of ureter →
perineum
→ illio
inguinal n .

Intra mural part

Strangury
•
→
-

( wall of bladder)

1¥ Ioc →
NCCT

→ contrast enhancement → Radiolucent .

✗ 901
ray opaque
-
→ . .

KUB
rule locations to La vertebra
Opp
.
.

Calcification of tip of 12m rib

calcified IN

Ant Post
Gau Stone ( in
front of vertebral colouring
.

Gall B. R .
Renal stones →
Behind

for checking functional

IVU → status ,

obstruction .
 USG > Shows
hydronephrosis
DTPA scan is now Ioc
for obstruction .

( Acid Scan)
Diethyl Tri amine acetic
penta
- -
-

It :
< 5mm in
size :
-

•
conservative

pain
killer
Diclofenac
° -

•
Salt Restricted diet

Entree
corporeal shock wave
lithotripsy Toc
• -
→ .

£
shock
°
Piezo electro
/ electromagnetic waves are
generated
outside the
body & are
focused on the stone .

I )
pass through a water bath

multiple fragments of the stone formed which

°
are ,
can

pass through water easily .

Absolute CI: 1.)

pregnancy
2.) Uncontrolled
Bleeding disorders

3.) Distal obstruction .

4¥11 : -
D UTI / Sepsis
2) Cardiac
pacemaker .

3) lie down
Kypho -
scoliosis →

Inability to on table
.

d) Morbid
obesity
.

g) stones > 2.5cm in size

a) Horseshoe b) Renal failure

kidney
6) Hard Stones Cncrsc) 9) Calcified Aortic
aneurysm
 hematuria
nyc complication
→

pain flb .

PCNL ( Percutaneous Nephewlithotomy

to

enter via : posterior Calyceal approach .

to
prevent damage to renal

artery)
.
Stone > 2. 5cm

Hard stone

lower
for calyx stone

mfa complications Bleeding

.

my injured organs
→
pleural colon .

OpenSx€
renal
pyetolithotomy open pelvis
-

nepheo lithotomy

Anatrophicnephrolithotomy
vascular to
clamp
kidney before opening it
up
-
.

www.btonewceteroscopy → small stone

ESKIL
wutesoscopy Big stones
+ -
.
 tumors

Angiomyolipoma :

Benign Renal Tumor → Blood vessels + muscle fibres

+ fat .

Mle
age : 50-60 Yr

Mfc unilateral

if Tumor is
afw Tuberous sclerosis →
BPL
b
tumors &
multiple pt
will be
young
.

to check conversion
HMB 45 Tumor marker
malignant
→ -
: .

IOC : CECT
Biopsy ✗ ( vascular Tumor)
run

"

compel → Wander lick Syndrome → Tumor bleed

profusely
causing retroperitoneal haemoitoma .

1¥ nephron
sparing surgery
:
.

Hema :

tlypnmephroma commonly
arises
from
•

aka :
upper
→

pole .

Gravity Tumor ( on name

of scientist)

clear cell :
nyc pathological variant .

Internist 1. has Sx
many paraneoplastic
'
: -
? it .
 Renal Tubular
Adenocarcinoma :
arising from proximal cells .

more common →
males 50 Go
yrs
-
.

Heavy
metal Arsenic I lead
poisoning
•

poisoning
-

cigarette smoking
•

•
HTN

•
Obesity
Thorotrast : contrast media used in
exposure
•
→

te past
had Thorium oxide .

i. A incidence RCC &

of HCC

renal
spread by Blood -

may
enter the ✗
veins &
lymph nodes
to
Parer aortic IN
t
to other
go organs
: -

Cannon Ball Secondaries

lungs
→ .

2° Tumor
Osteolyñc
Bones → .

"

my →

painless Hematuria -

pain
rent late in disease
-
very
in lot
Renal
mass
Hematuria only .pt
.

Sx Raised ESR
Mfc paraneoplastic
: -

.
 → PVO [ Pyrexia of unknown
origin ) .

secretion PTH like substance

Hypercalcemia aft of
→

MTN dlt secretion Ronin like substance

of
→ .

1¥ Er non -

neoplastic liver
failure .

↳ mediated
by Il -6 (secreted
by Tumor )

neurological Symptoms LEMs Kamber Eaten

•
:

Myasthenic syndrome)
Twi '
-

• zoe → Contrast CT

Renal
Angiography → Contrast Blush
☐
.

☒ d.
contrast
,
After
Adrenaline
☒
contrast media -

opaque
all
Adrenaline -
VC
of BV
✓
BV
of Tumor have no muscles : .

super
Bright .

called as contrast blush .

MR
Angiography of
•
vascular invasion
soc
for
-

tumor .

IOC
for most accurate
staging PET
°
→ -
CT
 It
1- → chemo -
radio Resistant .

Ix : Radical supra renal gland

nephrectomy :
kidney + +
upper
- -

43rd of
ureter
( pelvic Brim)
upto
.

lymph
nodes
from Hilum → to
para
aortic
-
-

region
.

Renal vein
clamped early to
dislodgement
is
prevent
-
-

Tumor)
of
-
Vinblastine
-

Sunitinib

sorafinib
-

If other side
kidney has stones →
partialnephrectomy
(
only pole of kidney
having tumor is cut
)
&
it is also done has
if pt -

BIL Tumor

•
< 4cm tumor

°
disease is restricted to

pole of kidney
one .
 Other chemo resistant Tumors : - •

Gastric
•
Bladder
tissue
•
Soft
•
liver
not oat cell
•

lung
→
type .

cell Ca Head &Ñeck

•

Squamous of
.

chemo-sensitietumor-n.toibms Tx Teratoma

ALL in children
lymphoma
choriocarcinoma Rkabdomyo
enema
sarcoma
chemo :)
Ewing sarcoma

WibmTwmo
2nd
my, intra-abdominal
malignancy in
children .

Me intra-abdominal → neuroblastoma )

mfc →
ALL

aka
nephroblastoma :
primitive cells

V11 ,
seen @ poles .

afw •
Beckwith Wiedman Sx

WAGR Sn : With Tumor Aniridia

Genitourinary
•

, . ,

Retardation .

Dohhsh Sse
Denys
•
.
 does not midline
CIE mass abdomen which cross .

: ,

( Adrenal neuroblastoma → can cross midline )

Fever ( Dlt fever )

rapid growth necrosis
- -

Hematuria
gave sign
-

indicates Tumor
rupture
-

prognostic
Factor :
Grade of Tumor

IOC : CECT

Ttt
Nephrectomy RIGO days surgery)
→
+
after
•

Chemotherapy : VCD
•

vincristine

cyclophosphamide
Doxorubicin .
 Prostate
&

accessory gland of male

reproductive
system
.

Anatomy : 5 lobes → 3
zones
2
capsule ( 1 True + 1 False
capsule)

Post perineal zone ( Ant

-

deficient )
Ca
site
for prostate
.

nye
-

Lat . MJ Lat .
Centralism • chronic

periostitis
Ant

Transiting
-

→ wife -
BPH
zone

True
capsule should not be
damaged during surgery
it
may expose pui prostatic venous
plexus
-

: .
-
.

severe the
during In
→ -

BPIn :

I.Benign Prostatic
Hyperplasia]
aka
Fibromyoadtnoma
.

Prostate
gland enlarges
central starts to the urethra which
zone compress
causes static clinical
→stream
features : static qf
mine
.

of
 Hesitancy of urine
-

urine
Dribbling of
-

Urethra above rerumontanunr

enlarges
-
.

dlt median lobe

enlargement of
.

lobe closes the urethra when

median the
ft
-

at the time micturition

strains of
.

Frequency micturition

DynamicCIF :

Urgency of
of
micturition

Nocturia

There is no co -
relation btw prostate size &
syrup
.

Tw °
Clinical →
DRE ( Digital Rectal bream )
d.
A
prostate size ( should be done
empty
Bladder )
•

tboflowmeteuy
a-
meter
ODD → urine
flow Rate < lomllsec
→ &

Drain Diagnostic
for BPH

⇐ ①-
•

urethra narrow

urethra .

normal

voiding pressure
t
voiding I > soon tho )
pressure
•

prostate specific Antigen : @ 0.4

nglml
ml
BPH : 4-
long /
.

7¥ :
Drugs :

✗
,
-

Blocker →
Terazosin
d. a
blocker → Tamsulosin / Alfazosin

b- ✗ -
reductase -0 : Duta stride ,
Finasteride .

↳
SIE : loss
of
libido
/ Breast Tenderness

TURD [Trans urethral Resection of prostate] .

indication
Mfc of prostatectomy : no
improvement in

prostrations
.

most
impi
indication
for psotatectomy :

complications eg
:
formation
stone

Diverticula form ?

→ TORP

→
NESBIT method

Mower Technique
Meyer
→ .

Distal limit
of resection
of prostate tissue
→
is

Vern montanum .

if cut
beyond veuumontenum we
might
-

: we .

damage
the external urethral
sphincter
.
 solution used is ist
glycine
-

.
.

the current
act → will
dissipate
Distilled water be absorbed
can

6
very quickly
causing severe water intoxication .

Complications :

- Immediate complications -
Bleeding : Flasch ar .

linf
.

vesical a.)

→
water intoxication

>
Fñgm
> 90min Surgery time

&
will also be absorbed
glycine
.

i. metabolites of glycine toxic to

eyes
are .

Along i
glycine water is also absorbed
causing
-

severe
hyponatremia
&
Bolus BY saline is to treat
of given
.

latecomers :

stricture Bladder neck

formation
- -
.

-
meatal stenosis
"

Mfc compel Retrograde ejaculation

→
.
 TUIP ( urethral Prostrate ) to avoid
Trans Iweision
Of :

<
200pm retrograde
-
ejaculation
prostrate 7
' '
5
→
☐ using
collin's
knife
.

@ ño clock
& to clock
position
TULIP ( Trans urethral laser induced
prostatectomy)
-

c- USG
guidance
.

Laser emulation Prostate]

-

Hobp ( tlolomiwm of .

c_¥a :

•
Mfc malignant tumor in men > 65
yr of age
.

Americans
o
Afro .

o
Mfc gene mutation → GSTP -1

( Glutathione -5
Transferase
-
s )
-

BRCA -2 mutation also .

in lmfe in lobe)
Occurs
peripheral posterior
°
zone

Adenocarcinoma less
of glands of surrounding tissue
•
: more
,

CII : • most
of
the pt .
are
asymptomatic for long -

pt have bladder outlet obstruction

some
may
° . .

•
some have low backache
may
.
 On DRE module be noticed in the
may prostate
°
→ a .

all should
@ of age
Beginning
Ind : 50 men
yrs
,

iQDRE-QPSAlenels.BA
undergo screening
levels
after activity 9. sexual
DRE
•

after
•
dlt infection .

III : TRUS ( Trans rectal ultrasound Based

Biopsy
PSA levels > to are
suspicious
> 35
nglml →
diagnostic .

PSA levels
•

¥4 : rate
of change of every
year
.

if >
0.75mg /ml →

further diagnostic
work

up
is
required .

PSAdens-ityipwf-w.br#
•

=
0.15 indicates + rice

cancer
of .

prostate
TNM
-
Staging : IOC
for staging MRI →

Ioc
for overall staging : PET -
CT

Ty a →
Cancer
incidentally discovered → TURD /
Biopsy
cancer found < 5%
specimen .

b →
> 5%
of specimen
.

c but PSA high

impalpapk
→ .

,
 Tz :
palpable on DRE →
but limited to
prostate
side / lobe
limited to one
Tza :

Tab ⑨ lobes
i
→ Both .

-13 a
☐• Extra -

capsular extension

Tzb capsular to
•]seminal
Extra extension
⇐
vesicle
seminal vesicle .

Ty : Fired pelvic / rectum

to
adjacent str .
wall .

involved obturator LNS

N: Sst LN to be are .

Mo → no metastasis

Mia LNS
→ non
regional .

Bones
Mlb →

Other
M
,e→ organs

É :
prostate cancer →

glands ☒
.

I
☒
most WE Too least

diff .→%Y
all
types of glands → → →

less
→

diff
differentiated
.

pt 1) login :
Lgm 3gm ( Iott)
+ 5+2=70
-

I cells
Type Gleason
score
pt 2) Ggm +48m ⑤ Gleason
.

login :( Type
=
.

, III ) score .
 i.
Gleason 's Score is based on
multiformity
&

heterogeneity of glands + nt in cancer

specimen
.

•
Cancer I
higher Gleason score are considered more

aggressive
.

Grading of
the
type of glands found in
specimen
•

is done
from 1-5

11 well
differentiated ) least
diff
5- .

Based on their occurrence in the Tumors

•

specimen .

are
graded .

has %
of
man

egad if
a cancer
specimen age
least cells -5
differentiated .

2) score
of 2nd nyc occurring type of glands
is also noticed .

2- 4 : well
differentiated slow
growth
-
.

5-7 : moderate

8- 10
poor prognosis &
explosive growth
.
:

-11T€ Early : T
-12 → limited to
prostate < to
,
yrs
, ,

tf
fit for anesthesia
Prostate +
÷
Do radical (
prostectomyObt seminal LN
vesicle ✓ .
+ Iliac
 > to : Observation
yr
. -

for advanced disease :

Tz 1-14 .

Radiotherapy -
( can include B
Peachy
By
=
)

Implant
seeds
radioactive .

II -125 / Pallidum 103 )

Metastatic :
Hormone
Therapy
Sx TH → sub
capsular orchidectomy .

¥ 6.*.

Dhwgf :

Goserebein
Analogue
[ µpµ →

leuposidetfutamide
Chemotherapy : Hormone Resistant Tx

Paclitaxel .

Carbazitasul

Degante 're

sipuleucel
-
T f vaccine for early stage
cancer
) -
 Urethra
POI Urethral Kes :

Anomaly exclusively male urethra

of
• .

problems appear before the child is born .

o
not able to mine
pass : -

oligo hydras amnio s

-

lung maturity is
deficient
-

when child stream micturition

weak
of
-

grows up
:

Lnr .

micturition
cysto wutherogeam
-
.

-1¥ :

endoscopic fulguration
Myc of death
lung hypoplasia
→ .

Hypospadias :

urethra
opens
on the under
surface of penis
( ventral )
alw undescended tests 1 inguinal hernia .

mfc type Glannlae

just proximal to the normal
→ -

opening
.

2nd Me → coronal (i -

e -

near corona sulcus)

 include
9£ also
flattening of glans penis
Hooded
prepuce
.

Chordee
[ Bowing
ventral dft fibrosis
of penis
TI :
min .

age
-
6 no
[ 6- 24m)

chordee is corrected set all

of
-

no circumcision : skin is to be used

for neo -
constr
(reconstrm)
magpi -

repair
Brown
Dennis
repair
Me complication of surgery
: -

#w
fistula
leaking
urine

hpispadt.hn meatus dorsal

surface
present on -

penis is curved
upwards
•

pubic
bone diathesis ( separated
from each other )

Females ( Bifid clitoris )

-

incontinent .

1- It → reconstruction
 Peysoniesdisease
:

usually
in
pt > 40yrs of age
seen .

ahh
penile fibromatosis
afw dupvtryn contracture
Fibrous
plaque appears on the dorsal
surface of
penis which causes
bending of penis
.

may be
uncertain but it
Etiology
- is

result trauma
the
past repetitive .

intralesional steroid
7¥ .
-

Excision
of plaque
-
.

Priapism :

penile
sustained erection > 4ms .
without sexual

stimulation .

Tumnescence
MY
→
✓
word
Tvotypesi
low C ischemic
1) flow priapism priapism)
2) high flow priapism ( non ischemic
priapism)
-

3) Stuttering priapism ( unknown etiology )

1.
(✗ med )
1- It
Etilefrine adrenergic
.

:
-
low Flow
Priapism Veinous
: -

obstruction ,
which later
arterial blood to
coming penis
&
may
cause -

Blood will lose

already
in the
-

penis oxygen
-

Acidic .

rule :

infection of papaverine into

corpora
: sickle cell Anemia .

i cocaine

:
Phenothiazines
i.
Tmombophillia
Ind : Blood Acidosis]
gas Analysis [
TI 1) Aspiration Blood will be relieved
of majority
→
: .

2) Infection ✗
agonist :
Phenylepherine
3) Surgical :

Shunting procedure : -
Winter 's shunt
El Ghaurub 's
-

shunt

1ÉÉm :

pelvic Trauma

Spine Trauma

blood
-

from a
damaged a. which
supplies
to
continuously the
penis .
 that dramatic
QF are not .

less
e) Erection is
rigid
.

Tension
2) Blood has
high oxygen
It :O
Application of Ice packs
.

Embolization of Artery which

is
responsible for
bringing in additional blood .

ca-penis-i.me -
60
yrs of age
.

But tot .
-

< uoyrs of age .

Circumcision
if
done <
lyr age provides immunity .

Hygiene
.

HPV 16,18
Smegma
-
• • -

P.ua#-s:DBusdvke lowenstein Tx

2) Leukoplakia .

3) Balanitis
nerotica.CI
Fungating
:

foul smelling
mass → .

Associated LAP 1 majority of LNS -

dltinfn
Antibiotics)
Regress
c-

Phimosis → is common

→
spreads to 1ns ( Buck 's Fascia is barrier
)
 metastatic →
rule 4r_ →
Priapism .

dentinal node
Biopsy [ RABANA procedure]
lymph
IOC MRI
for staging →

Tlt :

partial / Total Penectomy

Ca limited
if is to
prepuce
→ circumcision is
sufficient
if Flat lesion → stfu cream .

vessels
death
Bleeding
iliac
nyala of
→
from
which
may
be eroded dlt rapid
growth of malignant lymph node
.

or
sepsis & other complm .

Bulbar urethra
- Injury :

straddle
•

Commonly occurs out a

injury .

Kick / Blow to
perineum
•

crushed Bone
•
urethra is
against the
pubic
.

perineal hematoma
4¥ :
Triad .

Blood at urine

meatus Retention .
 @ catheter
fails
passing
a
•

If one
gentle attempt

supra pubic cysts stony

•
-

I.

heals
urethra
normally
But doesn't heal
if it →

tuetmoptasty
.

E- # Injury
*
alw pelvic
91€ : °
Retention of urine

Digital rectal examination should not be done

•
.

( Vermonters sign →

gone)
7¥ :
Supra pubic catheterization &
delayed
urethral
repair
.

8€

Retrograde Uuthwgram
thingy Blad_dn
Ectopia vesicae :
incomplete development of infra
-
umbilical
wall
abdominal
part of
.

be
pubic Rami may also
widely separated
1 musculoskeletal defect)
have
more common in males :
which
may
also
epispadias
Bladdne wall visible
post
-
is .
 may undergo metaplasia &
may develop even

adenocarcinoma .

Ttt Reconstruction
:
of Abdominal
wall .

Bladetu-iaumai.mperitoneal
: e rupture
Extra

dlt A-
of pelvis
GI :
Gurage of micturition
Boggy swelling in the Suprapubic region
's

30£
wogeaphy
: CT .

Cryptogram injecting : radio contrast media in the

-

f. Bladder -

can be done unstable

if the
pt is
.

d.
Flame
sign
.

injured
urethra also
Often membranous is .

71€ placement of Folley 's

: catheter → zwks
t ,

Bladder wall heals meanwhile

to
Surgical done D Tear extends neck
Tx is
if of
Bladder .

2) Bony fragment infringement

Jntsa.peaitonealiy.my/ruptme-:
occurs when full bladder is stuck
by some

objects .

wheel
log : car
steering
@ dome Bladder
Tear
commonly
occurs
of
-

TH immediate
flb catheterization
:

repair .

Tev : •

ground glass appearance

•
sunburst
appearance .

PsoasHiteh_

loss
large segment ureter : -

wvtew
ureterostomy
-

Boari
- flap →
for lower metric Trauma .

IEY.tn I,
: -

thinner ulcer .

musculature
Pancystitis
c-
fibrosis of
 linear ulcers Bladder mucosa

Bladder reduced
capacity of markedly
-

distention
paint
Hematuria .

It
1- →

Hydrostatic dilatation

Dimethyl sulfoxide injection ( intra

vesicallg)
→ -

Bladdutumou :

mlc Transitional cell carcinoma

Etiology cigarette smoking

:

Aniline
Dye exposure .

phenacithin

Chlornaphayine
-

Hfo pelvic radiation .

Schistosomiasis →
Tccf sq . cell Ca .

Adenocarcinoma →
Ectopia vesicae .

GI:
painless tlaematuria

MIC 5th decade -6

"
decade
age
→ .

101 :
MRI
 It lesion
Single
Transuhelhral resection
papillary
: →

of Bladder Tumor
/ Introversion
ITURBT) BCG .

Intiaueside
Chemotherapy using mitomycin
• - c -

Adranceddisease : Radical
cystectomy
&

Bladder + Iliac + Obturator nodes .

+
Hysterotomy ( in females)
f. ftb
Neo bladder construction
-

Based
cisplatin chemotherapy .

Testes

llndlscendedtestis :

Abdomen
form scrotal
in → descend to sac
f
dlt arrest
of descent
the
testes
of
reach DIR (
Deep inguinal ring by 9th month of pregnancy .

reach scrotum
just before delivery
I to -
.

Just above the DIR →

Abdomen

lie in canal location

may Inguinal → nyc
-

→
may
lie in
superficial Inguinal pouch .
 lesser to
function
Require temp properly
.
.

-
: in un descended testis : -

hypoplasia of Leydig cells

: -
: -

Resistant ,
but not
totally
destroyed .

- thence 2° sexual characters are normal .

Delayed appearance of spermatogenesis

complications
•
Torsion
•

epidydimitis 46
yr
sterility ( spermatogenesis may completely cease
•
:

if testes dont descend or

brought
down
by surgeon)
☒ trauma &
tumors
more
•

prone
Me
malignancy semi
→ noma

Inguinal hernia

IOC -

laproscopic examination
I Enploration

Additional benefit of laproscopy : hernia can also be

examined
along
.

Tlt : →
additional
malignant changes
adv .
→

Owchidoplkym( means
plication /fixation
can be

b
Gmo 1-
caught early -

yr of age
-

.
•
Bell
clappers
deformity

0
pediatric
point
me
intraveaginalis torsion

common in adolescent
boys .

Riskfactors :

High investment
of Tunica
vaginalis
Bell
dapper deformity
•

spiral attachment
of oumastsic fibres over
spermatic cord .

Brisk oemasteric
reflex
•
.

GI :
agonising pain
•
severe

vomiting out pylorospasm

•
.

Absent crennastric
reflex
-

.
 orchitis
Differential dx -

spidydmo
-

⑧ free
heavy
to
&
Torsion .

t,

Affected testes
lying high up
in scrotum in

Torsions
Deming Sign
.

In heavier
epidydmo orchitis
affected testes is than
-
-

usual → it lies lower than the normal Testis .

Prehnsign :
pain in dtestes
get relieved
when

testes is
supported I lifted up
.

in
epidydmo orchitis
- .

Angdsign:_ opposite testis is also

lying horizontally
( prone to torsion)

Ioc :
Doppler -

USG →
flow of Blood .

Differential dx :
strangulated hernia /
ftp.dydmo-orchitg
1-It : immediate mammal detorsion

→
left testes -
clockwise

→ Rt .

testes -
Anti-clockwise .

Oerchidopesey should be
-

done
b.
It should be done side also
Opp
on .
.
 Extra newborn
vaginal Torsions

prenatal Ttt
orchidectomy
→

post-natal -

orchidopesey .

swelling
Trans illuminant
-

Vericocele
.gg/-oTFidal/-
Testicular vein

§
pampiniform Rt .
it .

I b

plexus
1.
drains into drains into

Ivc Renal vein

veins
veins around testes begin to dilate →
varicocele
to
wyefc of sub
futility
-

dilated veins release heat hence t

they the
-

:
,

ternnp around testes which to rate

of
spermatogenesis
.

more common
left side -2 lt testicular
•
on .

drains
vein into renal vein at
right angle
i. has more
pressure
.

& loaded
sigmoid colon :
of
solid
faecal
-

matter

compression of renal vein btw sup . mesenteric

artery
& aorta .

IOC → Doppler USG

Tx Palomo
operation
:
drain darts
b , through muscle/
Retroperitoneal ligation of gonal vein .
vas

deference
.

scwl#ach is
often complicated byreairrana
(
Bag of worms )
Tesliculaetumors :

99%
malignant
→

Risk
um factor
um
:

• Undescend testes

hfo Testicular tumor in

sibling
•

in utero
•

exposure to
Diethylstilbestrol .

• Testicular
atsopy
Kleinfelter Syndrome
• .

Mtc →
seminoma__ thot pure semi noma ,
often it has

mixed elements)

0 non -
semi noma :
-

Teratoma .

Mfc 1° Testicular Tumor

( BK) → Seminoma .

Testicular
Mfc 2° Tumor
lymphoma ( mk tumor in
→

(BK)
elderly )

seminoma.me age
: 30 -

to
yr
.

lymphatic route
of spread .

Para -

aortic 1ns →
supra clavicular LNS .

Brain
Blood spread to
lungs Bones .

, ,
 hCG levels raised
P ILDH are
.
-

✗ -

filo protein → In
pure semi noma : a- FP levels
Are not raised .

Teratoma : arise from Toti

potent cells .

Me 20-30
yrs
age
→ .

Me hematogenous
route is

of spread
•

•
All tumor →
raised .

leydigcelltumors-i.co has
Excessive
output of Androgens which

masculine
sing effect
-

precocious puberty
-

herculieasm
•

Infantile .

It
1- →
Sn →
chemo & Radio resistant .

Seutohmor :

Femi
wising tumor
pt may develop gynecomastia
-

&

loss libido
of ,

aspermia .

no FNAR /Biopsy :
^
: this
may cause
seedling of
tumor cells into scrotal skin .
-

ca :

clamp
.

vascular
F-
✓
Frozen
section

Soft cord vascular clamp is applied to

spermatic
.

Biopsy is taken sent

for frozen
-

section
-

is it
High inguinal orchidectomy
done tumor
-

is
present
.

1-It
Radiotherapy for
:
semi noma

Tekatoma → CT +
Retroperitoneal LN Dissection .
 GIT
-

EsE

Anatomy :

hollow
long muscular tube → 25cm

• lie in posterior mediastinum

&
Flat in
upper 43rd
in
sound 43rd
☐

GIT oteum
of appendix
narrowest
part of
• →
.

3Narrowi-ngsoyesophagom-i
from
5cm .li upper
incisor tooth

(
upper esophageal sphincter)
my site
for foreign body impaction Hmm
→

2) 25cm
¥

esophagus crosses the aortic arch &

left
main Bronchus

used to be mlc site

of perforation
-

during rigid endoscopy

.

of iatrogenic perforation of esophagus

Now mk site

is cervical
esophagus ldlt
flexible endoscopy)
 •

perforation
is
usually small . it can be
managed
tube
by insertion of nasogastric
: 5- 7-
days
•
perforation heals
by itself .

3) @ town
from upper
incisors

-
lower esophageal sphincter
'

if f- myenteric plexus
i
→
Aurebach
I

✓ Sub mucosal
-

plexus
-
mlisseners

(
deficient in
esophagus)
esophagus
-
no serosa in .

TT
Benefit →
peristalsis of semi -
solid
food ✓

easy
extension
loss → serosa is a
strong barrier
against
Tumors
of
.

i.
oesophageal
Ca
ft presents at advanced
stages
.

Hand Egmont g- lymphatic

¥¥¥¥ longitudinal
axis stomach I
→ incision .
 In
esophageal cancer .
→
spread longitudinally i. e.

it will involve
large part of
esophagus
.

Hence &
10cm
proximal margin of clearance
distal clearance is
margin of
seen

entire tumor
required to remove .

is
→
for other GI
malignancies only ,
sun
margin
required .

CONGEN1TALD# :

1) Trachea -

esophageal fistula [ esophageal )

atresia

congenital esophageal atresia he often accompanied

is

between
by trachea a
esophageal fistula
trachea & lower end
of esophagus
.

c: .

Drooling of saliva
Regurgitate first & subsequent feeds
•
-

Episodes of coughing
•
.

Diagnosis Before birth is suspected

:

mother
polyhydraamnios
i. → .

o
USG

BE Bedside ( NG tube it 'll curl &

passage of up
→
→

will not enter stomach .

 → Barium / Dianosit swallow
→ CT scan can also be done .

be
-11€ :
Surgical correction should done c- in +8 hrs .

there
If is too much
gap
t.me allow child to
grow up
the

little
a so that
esophagus gains
some length
meanwhile child can be fed by a

feeding
jcjunostomy
Mfc complication →

pneumonia .

afw
VA÷R. group of anomalies

vertebral
Body defects
And atresia
✓SD
cardiovascular
defects (PDA
TE Fistula

Renal or
Radial agenesis
 False
(
diverticulum
only mucosa

pouches)
out

True

diverticulum

Abdul

Yunis
au

② → ←

→
2eemtÉÉum :
¥f
•

nyc diverticulum
of esophagus
pnlsion diverticulum
•

•
false diverticulum
[ True diverticulum - Michel's
Diner .
]
-60
•

wife age yrs

.

Trumpet players I 4
pressure
in
pharynx .
 a) Killian 's dehiscence/ D.

l
Tnyrophayngeus)
pharyngeal plexus
-
#

cricopharyngeus
IRLN )
herniates btw
mucosa out
through a
gap thysophasy
-

&
-

ngeus cricopharyngeus .

neck diverticulum is midline But

of
-
sac

protects laterally theft)

EE mfc asymptomatic
into presenting CIF →
Dysphagia .

diverticulum to mouth
regurgitation of food from
to
breath
Foul
smelling .

Cough Regurgitate into trachea

-

-
.

lung abscess wife

pneumonia
→
,

T Risk
of lung
→ carcinoma .

-100 → Barium Swallow

be avoided
Endoscopy should →
perforation .

diverticulum Fit
If
is
Ttt : small +

to

Chico pharyngeal myotomy

 If diverticulum < 4cm
Dinerliculopesey .

b
diverticulum to
suturing
of pharynx
wall .

If diverticulum > 4am

to

Diverticula
ctomy .

& Unfit for Anesthesia ( unfit for open surgery)

d.

Endoscopic surgery
.

&
Dohlman
Operation

§y^h"
.

^^" " "

" ""

parabronchial
-
True -
Traction

Epi phrenic False

pnlsion.AM#Cardia-omkhypomotil ty
-
-

disorder
of esophagus .

lower relax
esophageal sphincter to to
°

fails give

passage
to the
food
.

Aurebadr
Deficiency of in
myenteric plexus of
• neurons

Idiopathic
-

similar disease
findings are in
chagas
•

seen .
 o Male : Female incidence equal
is .

Dysphagia
both
for solid lrliquid
.

-
is

wt solids)
initially
because
( solids
may pass of more
of

Barium swallow :
Rat Tail
Appearance ( Bird beak

pencil Tip appearance app )

.

( Rat
filling defect
* Tail → ciarcinoma)

confirmatory investigation manometry

- .

TH →
medications → Ca
"
Channel Blockers .

=) Botulinum
&
Toxin
injection endoscopically
-

1) repeated injections effect

It is
requires →

short lived

2) It fibrosis which
causes .
makes
subsequent
less
surgeries effective

Pneumatic dilatation :
only non-surgical tlt
which has
long lasting results .

1-It Heller 's

→
lap .

myotomy
+
floppy Nissen
fundoplication
1360°
Mapp)
Partial
fundo plication Dor / Watson
/ Betsey mark
-

→
 pseudoachlasia
:

dlt tumor @ lower end

of esophagus .

In
achlasiashynpomotility of esophagus
hypertensive
& '
Les .

Here ,

vigrougc Achlasia >

hyper motility of esophagus
+

Hypertensive t.ES

newer Tlt method : POEM →

Peroral endoscopic
myotomy
GERI
"

squamoqY.FI
:

4AM
columnar
rssqiamo : lower end
-

has
junction
moved Y esophagus
upwards .

develops metaplasia .

Hq Columnar). →

Factors which te les

pressure : -

meal ]
cholecystokininfdlt fatty
•
.

•
secretin
• chocolate
•

coffee
•
Ethanol

9€ :
Retreat and pain ( Heartburn) ,
regurgitation
Epigastric pain
1st town →
Endoscopy .

b) Based
los
Staging system Angeles classification
→ .

Gold Std -
Test → dahs
manometry
.

- De muster 's score : -

> 14-7 -

GERD

PNH for > st.

of total time
suggests GERD .

Doc -

ppi

Sn
fun duplication
: Nissen 's

to

If Barret 's
esophagus showing dysplasia
is not

short Barret
Dysplasia < sun →
segment
> 3cm →
long segment Barret

1) metaplasia → Annual endoscopy &

biopsy according to

Seattle score .

2) low
grade →
Radiofrequency ablation or

dysplasia photodynamic therapy

.

6
monthly endoscopy -

3) high grade dysplasias "

bit smo
-

endoscopy .

4) Cancer ( Adenocarcinoma)
ocsophagectomy
→
.
 metallic beads
LINX →
placement of
distal
Diffuse es¥ spy :(aka esoph spasm )
.

d.
lssmooth
primarily
distal
a disease
of 213 of esophagus
)
muscle

-
chest
paint dysphagia .

Repetitive peristaltic contraction

-

: -

mmng

Barri um swallow → corkscrew

app
.

Rosary Bead
app
.

Pseudo diverticula
app
-
.

aka
Curling 's
esophagus
.

predisposition for Epi phrenic diverticulum

-

- .

Ttt :(CBs .

I nitrates

details
linear
long myotomy
NÉɵgus : (aka Jack Hammer
esophagus)
aka
teypercontractile esophagus

|.
180
mmHg
condm
painful
called as
super squeezer esophagus .

1- It
1¥ Sxlmyotomy
:C
Best nitrates
 2 SD above normal
Peak amplitudes
are
greater than .

Dysphq'a :

Disorder
of swelling
which is caused
by
abnormal vessels
compressing esophagus .

Abnormal it .
subclavian a .

- Double aortic Arch

-

Rt aortic arch .

Dysphagia when child shifted from

is
1st
appears
liquid to solid
foods
Angiography
Ioc G-
→
.

1- It anomalous
surgical fixation of artery
→

Bocvhaav 's Sx
Mallory Weiss Tear

full thickness tear Sub mucosa

mucosal
Stomach
only oesophagus oesophagus/ .
 ←

Mfc cause
of spontaneous
esophageal perforation .

(mHc of esophageal perform

iatrogenic i. endoscopy)
is e.

• Due to sudden increase in

the intra
esophageal pressure
( vomiting)
+ " 9 1^9 A
Full thickness tear occurs continuous
diaphragm sign
•

mic
posterolateral part of distal
esophagus (a)
contents stomach enter chest & cause
of severe
•

mediastinum
inflame :
pleura &
-
.

GI :O Hamman's crunch : Audible subcutaneous

emphysema
.

Subcutaneous
emphysema
.

Mackler 's
Triad

vomiting chest

pain
 X-ray : continuous
diaphragm sign .

Naclerio's V
sign
Tse : Immediate
surgical repair
-
within the .

minimal contamination .

this
After & maximum contamination : -

& mediastinal
Lavage of pleural
perform delayed
cavities &

¥
Malloryk1eissTea
•
mucosal submucosa tear

o lower
esophagus / fundus of
stomach .

•
linear ulcer

is arterial
Bleeding
0

Hence it
requires embolization / cautery
•

Baltimore Tube to control

sangs rariual
taken : -

which is used
bleed 1 cirrhosis) is not
helpful .
 Shatzkirings sub : Twin -

mucosal

rings 1 circumferential .

• tnt on lower
esophagus
Often afw
• Hiatus hernia .

IOC → Barium swallow

TOC → Dilatation

SIuo.duma_:
Systemic disorder →
causing esophageal anomalies

occurs so -40
yrs of age
o .

smooth muscle
atrophy
•

Manometry 1/3
Shows normal in
response upper
→

(striated muscles)

-
weakness in lower 43rd -

positional dysphagia
Collis
Ttt :

Gastsoplasty
.

vi_af Bronx Peterson

Kelty SI

→
sideropenic dysphagia
IDA
commonly occurs

middle
aged pwomen .
 cricoid web
mfc locations
post
.

pumalignant
•
.

Dilatation web Iron ( oral)

of +

Ioc Barium or
endoscopy
→
.

cauEOesophagus-i.ir
men -

✓ 50-60
yrs
✓ nyc →
Squamous cell ca overall -

world)→
location
Adenocarcinoma ( western Mfc

t.nl/zrdmfc
1/3 ( location → middle )

✓
predisposing factors : -

smoking
•

pickles vegetables/
• meals

stricture ( caustic soda NaOH )

Lye
• -

Zenker 's diverticulum

/ Achlasia Candia
0

0
Tylosis -
Autoimmune -

0
Plummer vinson sx

•
HPV

for Adenocarcinoma → GERD ,

Alcohol
Scleroderma
,
obesity
.
l
"
¥0
yspnagia
•

43rd of circumference involved

flirting feature )
fairly adv
- .

Dysphagia -

initially for solids But later

for liquids also .

• Cachexia → not .
loss

• Adv disease
.

RLN
paralysis Hoarseness
• →

•
Homes 's
Syndrome Sympathetic chain involvement
-

1^408*4 malignant Trachea -

esophageal fistula .

phrenic nerve -
involved -

paralysis of diaphragm .

malignant pleural effusion

•

Inv .
i. Barium swallow

lesion
•
Apple core

Rat Tail
filling defect
•

&
for Endoscopy
Toc dx
Biopsy
:

Joe
for staging Endo luminal Usa:

Joe
for overall staging PET : - CT
TI : porringer 's operation ( Trans -
hiatal -

esophagectomg
£
lower 43rd
for Tumors .

Anastomosis btw the

remaining esophagus lie .

Thoracic & Abdomen ) is done c-

cervical •
esophagus in neck .

chances Anastomotic leak ( Teston)

- more
of
leak
But is less
dangerous it in
-

as occurs

cervical
region
.

lewis lewis
2) Iron
/ Tanner
operation : -

&
2 incision : -

1)
Thoracotomy
2) Abdominal incision .

Anastomosis is created in chest .

so less chances leak but leak is

of
more
,

dangerous .

3) -

G-
Bdemsophagectomy_:
3 incisions : cervical Thoracic & Abdominal

colon )
colon ( left is used
for reconstruction .
 CT → cisplatin 15 FU
Gemcitabine

effective for
carcinoma
=) RT -
more squamous cell

-
Adenocarcinoma .

Pattie IE :

metallic stent
SEMS -

self Expanding .

- Saultar tube
-
Celestin
-

Atchison tube .

Stomacher coney
mucus
producing
cells)
t

←
①
Angle of His
→

④ fundus ( of acid
more + mucus
1 ←
cells)
Bleeding during producing
Bariatric greater
surgery
Angularity
.

curvature
y
pylorus Body - Acid +
pepsinogen producing
f.
cells .

D- somatostatin cells)
(parietal +
chief
G-
gastrin
EU -
Histamine .

nerve
supply vagus
→ .

Rt-spost.vn
RP
2 Branches → LA
Left → Ant .

as a branch called
CNG → criminal m .

og grassy)
 identified @
of ragotomy
CNG not be time
may
-

and
may cause recurrence
of symptoms
.

doing ragotomy supply pylorus

-
while -
nerve to is

preserved to preserve normal

opening of pylorus
-

9¥ thyme ¥ IIHPS)
d.

Idiopathic
Thickening ( hypertrophy) of pyloric muscles .

@
presents 2-3 wks
of age
.

afw -

tlirschpung 's disease

oesophageal atresia .

maternal intake
erythromycin
-

more common in 1st born male child -

4T€ : • child is born normal @ birth

btw
Symptoms appear anywhere
2- sinks
of age
• .

f.

(non Billions)
Forceful vomiting
-

feeds but
child well
immediately vomit i
-
-

e .

voracious
appetite
-

Failure to thrive .

Wasting will
appear
-
.
 gastric peristalsis left Right
visible
•
to

•
Akmal ode i hypertrophied pylorus
-
e .

I. palpable as a mass .

Diagnostic .

NE
tlypochlovmic
I
hypokalemia
} metabolic alkalosis

III.
- H+
Kidney compensates
: -

Ma
#
tlcoj → out →
Na_ Has
µE+

rtowestigation palpation of abnormal olive (clinical)

-

dx

USG stomach
-

Lia .
> 13mm .

Bariwmmeal → shows mushroom

sign
.
-1¥ :

•
not a
surgical emergency
"
But metabolised
compel are

emergency
-
°

saline
y Dehydrm
Alkalosis

Sxtlt → • Balloon dilatation

Ramsstedt (extra mucosal ]

pyloromyotomy
• -

If mucosa is incident
by
cut
,
withhold
feeding
36ms
for .
This area is covered with a

patch of omentum .

pytoromyotomy.PH#isease:
At another side we do

Ulcer related to Acid /

pepsinogen
.

Stomach
/ Duodenum

site Ist duodenum

mfe part of
→ .

In Stomach → less curvature

 " "

videogame : •
Blood
group
- O → move
prone for
Pu

prone for
"
"
-

A → more cancer

smoking
•

•
stress

0
Zollinger ellison
Syndrome Ccrastrinoma)

Trauma (Head
injury ing Cushing
•

vagus
→ n - - →

ulcers
)
Burns ulcers
curling
• -

•
Cocaine
Alcohol
spicy food
o .

•
NSAIDs (Cox -
9- -0)

¥ :

AGE Duodenatulcer
meals
pain after
•

⑨
settles
pain
" •
-

Reappear
after
meals

2-3 hrs

later .

Hunger Pangs)
Avoids like lot
eating eating
• •
a

• loose wet .
•
Gain weight
Acid ( variable) Acid
production High production
• •
.

of malignancy negligible / Rare

1- 3% chances
of
•
.
chances

ulcer
in cancer in ulcer .

Drugs :
Sucralafate Doug : PPI
 :

b-
types of gastric ulcer -

I :
wife type →
present near Sciarra angular's
Hessen curvature )
acid normal / low
production
• -

low
mucus
production
- -
.

I : Two ulcers
one in stomach
one in duodenum

Acid
"
it
prod is

I :
prepyloric region
"
normal 9T
Acid
prod either
or

Iet
mucus
production :

II : near Candia

Acid
production →
@ 11
t.to (
"

Mucus prod →
Defence mechanism is

defecting
I: ulcer
NSAIDs
causing
stomach
occur
anywhere in .

DX : for stomach also take

be obtained
by endoscopy
-

can
.

Biopsy.
lugical
"
Duodenal to acid
ulcer → Aim → seduce
prod
1) tlinmghy selective ragotomym :

only the nerves

going
to the
body stomach cut
are
of
i. to Acid production .

nerve to
pylorus are
spared
- -

-
more
physiological , less damaging surgery
.

2) Selective
ragotomy :

Hepatic & celiac nerve are

preserved but stomach is

completely denervated .

3) Turned
Vagotomy :

main trunk is cut

te
Secreto motor nerve

d.

peristalsis is
gone
.

→
pylorus opening
is
affected
.

i.
Drainage procedure is required .

§y
1) Gastrojejunostomy

pylorus
not 2) Anterectomy .

opening
 GEE Utcenmi
Aims at
excising
the ulcer (:
of
chances
of malignancy) .

1) Bilrotn I
gastrectomy
2) Psibueth # gastrectomy

Complicaltmofulcer
1) Bleeding :
mfclc of ulcer related death

post
.
duodenal ulcer →
gastro -
duodenal
artery
→ Cause Melena -

2)
1¥ :
2nd nyc complication
•

may
cause
peritonitis
5¥

µ
:

Acute →
out edema around ulcer

too! Chronic out around ulcer

scarring
→ .

4) Deformities
border
→ Tea
pot deformity if : ulcer is on
longitudinal
lesser curvature
of
Hourglass stomach
→
5) 0.5 it risk
malignancy
:
-

51 risk →

susceptible population
.
.

¥-1m -91¥ ↳
surgery :

e) Recurrent ulceration :
Magoto my failure can occur
dft
criminal
of grassi
nerve

Ellison
zollinger Syndrome
-

Turned :b acid
ragotomy
Anteuctomy : & hormone .

2) Early satiety small stomach

of
:
-

3) Billions
vomiting
:

4.) Dumping syndrome

②÷mYytd
.

te
cone
f food enters

early dumping Ppf

.

jejunum

tlypovolemia :
dlt sequester
thgpovolemia
of fluids from of walls within iñ wmin
-

)
into lumen
jejunum
lightheadedness epigastric
-

fullness
1- It small / meals
frequent
:

-
octseotide

conversion Billroth II to Bilsoth I

of
-

.
 Latetumping
conch
food enters

Rapid rise in
glucose
levels in Blood .

Rapid rise
of insulin

TH : Octuotide
Hypoglycemia
-

5. post ragotomy diarrhoea .

Acid t.to Bacterial TT

6.
post ragotomy malignancy
t
:

-
nutritional
deficiencies
Cat ,
Te , B12

7- Gastwjejunostomy
•
site
may
also
develop ulcer

MÉEas :

Hypertrophic gastroapathy .

&
Epithelial hyperplasia
giant gastric fold form
"

te
TGF -

afw a.
pylori Cetuseimad
protein loss
Ttt :
/ Gastric
pt develops enteropathy
-
.

resection .
Dieulafoijslesioni
Av
malformation
-

usually large & tortuous sub mucosal small

artery/
arteriole .

middle man
age
-

CIF → Haemat emesis

Iwvutigm Endoscopy :

1-
It :
Endoscopic cautery / Emboli Salim .

GAVt Gastric Antral vascular

ectasia

endoscopy
-

Water melon stomach -

on

-
middle
aged females .

-
Dilated vessels
-

Melena .

Ttt :
Endoscopic cauterization

Bezoars collection :

of indigestible matter in stomach .

1) Tricker bezoar -

( Hair) &
psychotic females
young
→

2) Phyto bezoar matter Gastro paresis

indigestible
→

wog
.
- → .
 37 Lacto
beggars formula fed children .
-
→

4¥ pain abdomen L
vomiting
:
.

( intractable
)
Inu .
: -

Endoscopy
be
CT scan can
equally informative
.

be
Tlti removal can done
endoscopically after
.

digestion c- chemo
pepainf papain
.

removal
•

Surgical

Ranpunzel Syndromes Bezoar entering into

duodenum &
causing
obstruction .

qastriccancer-r.
type
m e -

adenocarcinoma

Disease males
of
.

Riskfactossi
1) Diet
high in starch / pickled food .

smoked
food
-

-
nitrates .
 2.) pylori inf
"
H .

3) Pernicious Anemia

4) Gastric Adenoma

5) Familial
polyposis
6) peptic ulcer -1 Menterier 's disease

7) Tobacco
consumption
.

B) A blood
group
- .

Vitamin -

C ,
Aspirin →
protective role .

macroscopic appearance of the tumor .

criterion like
Lauren's classification - based on
µ scopic
mutation
gene
4 Recent onset
dyspepsia in a middle
aged male
•
.

•
wt loss dlt cachexia

• t
food intake .

syndrome Thrombophlebitis
:
• Trousseau's .

mentation
Acanthosis nigricans
:
ttyperpig of& axilla
.
•

.
 multiple peripheral neuropathy
•

Ca involvement
may spread by
: direct

lymphatic route
lleftsupraclaviaeul
: .

beeneargeoytakhf-roiese.ee
UU
may
's node
/ sign ]
or virchow 's node ( level II)

:
peritoneum
umbilicus → sister
Mary Joseph
-

Recto vesical
pouch : Blummu 's
shelf
-

Kannenberg Tumors
Ovary
-

- .

-1¥
only Tlt
curative
surgery
:
→

total
Radical sub -

gastrectomy c- a 5cm

margin
Cunningham Royal Regimen
CT : Manson

A- → epieoubicin
C-
cisplatin
F -

5 FU
 19¥ Intend steam Emory :

→ Arise
from mesenchyme .

(cells of Cajal)
→

express CD -117 ,
CD -34 [surface marker ]
Me →
stomach

2nd
wife →
Ileum .

Sub muco
salty growing small Tumors .

nyc presentation Bleeding

→

75cm in size
> 50 mitosis/
high power field
} cancer is
growing
extremely rapidly
-

IOC → CECI

Ioe
for confirm Endoscopic
"

Biopsy
: .

only -1ft is
Surgery 42cm incision
)
•
otherwise
b- on
margin
LN resection is not
required . is
required
.

•
Imatinib

•
Sunitinib .
 filmdom :

sudden loss
weight
•

females /Tight dress

•

Cosette -

compression of 3rd part of duodenum btw

& Aorta
sup mesenteric
.
a. .

"
fat pad byw Aorta & SMA lost
-

is .

meals
lying
1-It : down in
prone position after
.

Sy Dwodeno
duodenostomy
: -
.

Appendix
Appendix lacks 1) taenia coli

& sacculatton
2) Hamster

3) Appendices epiploicae
Base fixed @ the end
of appendix
is anterior
of
Taenia coli .

But
lip is
found in variable
position .

retro cereal
mfc position is :

2nd mfc :
pelvic
Rarest post ileal splenic position
: - → aka .
 Appendicitis
mfe age : 10-30
yr
.

males t: of habit
of eating from outside)

wife oyw faecolith .

In children faecolith
:

Appendicitis can occur c- out

£
catarrhal
type
.

4€ pain
.

,
which
initially begins around umbilicus &

later settles @
mc#oint
.

line umbilicus to ASIS

joining .

Triad
Murphy
's

pain y¥.s )
normal
Anorexia
fever :
rarely i above

fever
,

/ episodes
vomiting just two

vomiting
: one
 Rebound
Blumberg sign
-

tenderness .

Psoas
sign
→

pain on
hyperextension
of leg
Obturator medial
sign :
pain on

rotation

Dunphy sign :
pain on
coughing .

Ten horn sign

i
pain on traction
of testis

IOC :
CECT

in child IOC :
USG
S ✗ 70C
lap appendicectomy
: .

incision incision
Open appendicectomy
:
mile McBurney
-

aka : Mcarthur / Grid

iron

incision .

splitting
-

muscle .

muscle cutting
:
Rutherford -

AIÉose :

R
M -

migratory pain
E
A -

Anorexia
L
N -

nausea

T S
-

Tenderness
 5- 6 CECT
confirmatory
: not →

1- 4 :
Ruled out

likely
>7
Appendicitis is
:

⑨
Carcinoid

Right hemioolectomy
> 2cm →

1- 2cm
Base Henri
colectomy
: : .

Tip further Ttt

:
→ no
.

Meckel 's diverticulum : Teme diverticulum on anti - mesenteric

border
of Intestine .

Rule
-
of
2 :

• tnt 2
feet away from SC
function .

half I /2) of zyrs of

'
pt are less than
age
• .

2
types of ectopic mucosal stomach &
pancreatic]
•

tough
mm

02 inches
CIF
-

Melena
Bleeding from diverticulum → .

abdomen
pain
•

obstruction
Interruption causing int .

• .

Ttt :
Surg al
stalk
long narrow base
→
dinerticulectomy .

#
discovered
Incidentally : -

should be excised
excised
not
if :

Abdominal
sepsis
pt > says of age
.

generalized sepsis
✓dmb0M_
Twisting int
loop the
of along base
of
.

mesentery
Me in
sigmoid colon
base
-

long mesentery ,
narrow

-
solid contents
 direction rotation Anticlockwise
mfe of
→ .

sudden onset abdomen

pain
→

→
massive distention

X-ray :
coffee Bean
sign
Bent inner Tube
sign
Omega sign
-

← Barium enema

sign/
Bird Beak Bird
of prey
sign
.

Joe : CECT

Ttt :

sigmoidoscopy .

( Detection occur
immediately)
Resection when
pt stabilizes
. .

Caecalralvutous so -60
yr age
-

(
sigmoid to soya)
: -

clockwise rotation

✗
ray :
embryo sign
-

Mt :
Surgical fixation .
 Before
:

Acute colonic
pseudo
-

obstruction .

imbalance
It occurs dft
btw sympathetic &

parasympathetic nervous
system .

Common in narcotics addicts 1 Bed ridden I hospitalized .

intestine
Karge)
dilatation
-
Massive
of

Ht Tube)
:
decompression ( Matus
Then →

neostignine