Table of Contents

GIT ....................................................................................................................................................4
Tongue ..............................................................................................................................................5
Esophagus .........................................................................................................................................5
Stomach ............................................................................................................................................5
Peptic ulcer disease .................................................................................................................................. 5
Perforated PUD ..................................................................................................................................... 9
Gastric outlet obstruction ................................................................................................................... 10
Ca Stomach ............................................................................................................................................. 13
Small Intestine ............................................................................................................................................ 19
Typhoid ulcer perforation ....................................................................................................................... 19
Intestinal obstruction .............................................................................................................................. 20
Vermiform Appendix........................................................................................................................ 28
Acute appendicitis................................................................................................................................... 28
Appendicular lump + Abscess ................................................................................................................. 31
Colon ............................................................................................................................................... 35
Polyp ....................................................................................................................................................... 35
Carcinoma of colon ................................................................................................................................. 35
Carcinoma cecum.................................................................................................................................... 38
Rectum ............................................................................................................................................ 39
Per Rectal Examination ........................................................................................................................... 39
P/R bleeding ............................................................................................................................................ 40
Rectal prolapse ....................................................................................................................................... 42
Rectal polyp............................................................................................................................................. 43
Carcinoma rectum................................................................................................................................... 44
Anus and Anal canal ......................................................................................................................... 48
Anal fissure.............................................................................................................................................. 48
Hemorrhoids ........................................................................................................................................... 49
Anal pain ................................................................................................................................................. 50
Anorectal abscess ................................................................................................................................... 51
Fistula in Ano........................................................................................................................................... 51
Liver ................................................................................................................................................ 53

1
Gallbladder ...................................................................................................................................... 54
Gall stone ................................................................................................................................................ 54
Acute cholecystitis .................................................................................................................................. 56
Chronic cholecystitis ............................................................................................................................... 59
Mucocele of Gallbladder ......................................................................................................................... 60
Biliary tree ....................................................................................................................................... 61
Jaundice .................................................................................................................................................. 61
Obstructive jaundice ............................................................................................................................... 61
Choledocholithiasis ................................................................................................................................. 64
T-tube management ............................................................................................................................... 65
Choledochal cyst ..................................................................................................................................... 65
Laparoscopic cholecystectomy ............................................................................................................... 66
Pancreas .......................................................................................................................................... 68
Acute pancreatitis ................................................................................................................................... 68
Pancreatic pseudocyst ............................................................................................................................ 72
Spleen ............................................................................................................................................. 74
Splenic rupture........................................................................................................................................ 74
Splenectomy ........................................................................................................................................... 76
Urology............................................................................................................................................ 78
Hematuria ............................................................................................................................................... 78
Anuria, oliguria ........................................................................................................................................ 80
Retention of urine ................................................................................................................................... 81
Investigation in Urology .......................................................................................................................... 85
Hydronephrosis ....................................................................................................................................... 87
Renal Stone ............................................................................................................................................. 88
Ureteric stone ......................................................................................................................................... 93
Renal Neoplasm ...................................................................................................................................... 95
Palpable loin mass................................................................................................................................... 97
Bladder stone .......................................................................................................................................... 99
Prostate ................................................................................................................................................. 101
LUTS .................................................................................................................................................. 101
BOO (Bladder outflow obstruction) .................................................................................................. 102
Benign enlargement of prostate (BEP) ............................................................................................. 103

2
 Prostatectomy ................................................................................................................................... 106
Carcinoma Prostate........................................................................................................................... 107
Suprapubic cystostomy ......................................................................................................................... 108
Urethral stricture .................................................................................................................................. 109
Urethral rupture.................................................................................................................................... 111
Hypospadias .......................................................................................................................................... 113
Phimosis and paraphimosis .................................................................................................................. 115
Testis and scrotum ................................................................................................................................ 116
Testis not in scrotum......................................................................................................................... 116
Acute Scrotum + Scrotal/testicular swelling ..................................................................................... 117
Acute epididymo-orchitis .................................................................................................................. 118
Torsion testis ..................................................................................................................................... 119
Testicular tumor ................................................................................................................................ 121
Varicocele.......................................................................................................................................... 123
Fournier’s Gangrene ......................................................................................................................... 123
Hernia and Hydrocele..................................................................................................................... 125
Hernia introduction............................................................................................................................... 125
Inguinal hernia ...................................................................................................................................... 127
Ventral hernia ....................................................................................................................................... 132
Incisional hernia ................................................................................................................................ 133
Richter’s hernia ..................................................................................................................................... 134
Hernia repair ......................................................................................................................................... 135
Hydrocele .............................................................................................................................................. 138

3
GIT
Q. Management plan of hematemesis/upper GIT hemorrhage

Ans:

• History
o PUD
o NSAID
o Alcoholism
o Gallstone
o Pre-existing liver disease
• Clinical features
o Features of shock
o Anemia
o Dehydration
o In case of CLD: stigmata of CLD
o Epigastric tenderness
• Management
o Immediate: hospitalization
o Treatment of shock
o Correction of anemia
o Correction of fluid + electrolyte problem
o Analgesic
o Anti-emetic
o Anti-ulcerant
o Tranexamic acid
o Do necessary inv
• Investigations
o Upper GIT endoscopy: ulcer, varices
o Barium swallow x ray: ulcer, carcinoma
o Angiography
o Other:
▪ Hb
▪ Blood grouping
▪ Cross matching
▪ Serum electrolytes

Q. Enumerate the causes of acute abdomen (9 areas….)

Q. How site of abdominal pain help in diagnosis?

Q. How imaging helps in diagnosis of abdominal pain? (see the imaging part in general principles)

4
Tongue
(see paper 2 throat)

Esophagus
(see paper 2 throat)

Stomach
Peptic ulcer disease
Q. After ingestion of NSAID, a pt presented with upper abdominal pain and vomiting. What are the
probable causes?

Ans:

● Peptic ulcer disease

● Gastric erosion
● Perforated PUD

Q. Define PUD + common sites

Ans:

⮚ Ulcerative lesion in GIT

⮚ Involving both mucosa and submucosa and upto the muscularis layer
⮚ Due to action of acid peptic juices

Common sites:

⮚ Duodenum: 1st part

⮚ Stomach: lesser curvature
⮚ Lower esophagus
⮚ Meckel’s diverticulum
⮚ Gastro-jejunostomy soma

Q. Short note: H. Pylori

Ans:

● It is a gram -ve bacteria

● Mode of transmission: fecoral route
● Site of infection: in the antrum of stomach
● Lethal factors of this bacteria
○ Enzyme (urease)
○ Inflammation
○ Cytotoxin

5
 ● Mechanism of urease: breaks down urea ➞ NH3 + CO2 releases ➞ NH3 is alkaline ➞ redcues
local pH ➞ stimulates gastric acid production. Gastric acid then damages the denuded mucosa
caused by invasion of H pylori
● Pathogenesis (of chronic duodenal ulceration): Bacteria in antrum ➞ excess acid secretion ➞
these excess acids come to duodenum ➞ hyperacidity in the duodenum ➞ gastric metaplasia
➞ h pylori can infect here ➞ duodenitis ➞ duodenal ulceration
● diseases caused by H. Pylori:
○ Chronic duodenal ulcer
○ Gastritis
○ Gastric carcinoma
● Diagnosis of H. Pylori infection
○ Clinical features
■ It will depend upon the disease caused
○ Investigation
■ Non invasive
● Urea breath test
● Fecal antigen testing
■ Invasive
● Histopathology
● Swab taken via endoscopy, followed by microscopy and c/s
● Treatment of H. Pylori infection
○ Triple drug therapy
■ PPI such as Omeprazole
■ Antibiotic: any 2 among: metronidazol, amoxicillin, clarithromycin
○ If it fails, Quadruple drug therapy:
■ Omeprazole
■ Bismuth
■ Metronidazol
■ Tetracycline

Q. Management of a case of PUD

Ans:

⮚ Features:
o Pain:
▪ Epigastric
▪ Gnawing
▪ May radiate to back
▪ intermittent
o Nausea and Vomiting
o Weight change: may occur
o Bleeding
▪ hematemesis/melena

6
 o Periodicity: the clinical features may disappear for weeks/months, then reappear
(spontaneous healing of ulcer)
o Clinical examination
▪ Duodenal point tenderness

Investigation:

⮚ Gastroduodenoscopy (upper GIT endoscopy)

o Clear ulcer base with regular margin
o Base formed by muscularis
o Take biopsy to exclude cancer
o Biopsy of antrum taken: to exclude malignant ulcer
⮚ Barium meal x ray:
o will show niche and notching (gastric ulcer)
o deformed/absent duodenal cap (duodenal ulcer)

⮚ Investigation to identify H. Pylori

o Urea breath test

o Fecal antigen testing

Treatment of peptic ulceration

⮚ general mx
o avoid spicy food
o avoid cigarette smoking
o maintain hydration
⮚ Majority treated medically
o Drugs to reduce HCl secretion
▪ H2 blocker
▪ PPI
o Eradication therapy for h pylori: triple drug therapy
⮚ Surgical treatment
o Indication (Q. What are the indication of surgery in case of PUD)
▪ Complication (perforation, bleeding, gastric outlet obstruction)
▪ Not responding to medical therapy
▪ Recurrence
▪ Gastric ulcer: may turn into malignancy
o Surgical methods
▪ For gastric ulcer
● Bill Roth 1 gastrectomy
● Bill Roth 2 gastrectomy
● Gastrojejunostomy
▪ For duodenal ulcer
● Truncal vagotoy
● Highly selective vagotomy

7
Q. What are the D/D of PUD?

Ans:

⮚ Chronic cholecystitis
⮚ Chronic pancreatitis
⮚ Gastro-esophageal reflux
⮚ Carcinoma stomach

Q. What are the complications of PUD

Ans:

⮚ Gastric ulcer
o Perforation
o Bleeding
o Stenosis
▪ Hour glass contracture
▪ Tea-pot deformity
o Fistula formation with other organs
o Malignant transformation
⮚ Duodenal ulcer
o Perforation (anterior wall)
o Bleeding (posterior wall)
o Stenosis
▪ Pyloric stenosis
o Fistulation with pancreas
o Residual abscess

Q. What are the types of vagotomy?

Ans:

⮚ Highly selective vagotomy: only nerves supplying the parietal cells are ligated (nerve of Latarjet)
⮚ Selective vagotomy + pyloroplasty
⮚ Truncal vagotomy (anterior + posterior vagal trunks resected)
o Truncal vagotomy with gastrojejunostomy

Q. What are the complications of vagotomy?

Ans:

8
 ⮚ During operation
o Injury to surrounding structures
o Bleeding
⮚ Early dumping
⮚ Reflux Esophagitis
⮚ Esophageal stricture
⮚ Post vagotomy diarrhoea

Perforated PUD
Q. Clinical features of perforated PUD

Ans:

Symptoms:

➢ Sudden severe abdominal pain

o Initially in epigastrium
o Then in right side of abdomen (fluid in rt para colic gutter)
o Then generalized
➢ Fever, vomiting
➢ Past history suggestive of PUD

Sign:

➢ Pt is toxic
➢ Dehydration
➢ Tachycardia
➢ Decreased urine output
➢ There may be signs of shock
➢ Abdominal distention
➢ Epigastric tenderness
➢ Guarding and rigidity
➢ Absence of bowel sound

Q. Mention the radiological features of perforated PUD

Ans:

➢ Chest X ray with both domes of diaphragm, in erect posture: crescentic gas shadow under the
diaphragm
➢ USG: collection of fluid and gas in abdominal cavity
➢ CT scan: to exclude other d/d such as acute pancreatitis

9
Q. Mention the d/d of perforated PUD (never came in written)

Ans:

➢ Acute pancreatitis
➢ Acute appendicitis
➢ Acute cholecystitis
➢ Inferior MI
➢ Ruptured aortic aneurysm

Q. How will you manage a patient with perforated PUD?

Ans:

**clinical feature and investigation: from above

Add the following investigation: CBC, Serum creatinine, Serum electrolytes

Treatment:

➢ Patient is admitted
➢ Emergency management
o IV fluid
o Nothing per oral
o Nasogastric suction
o Catheterization
o Analgesic
o Parenteral antibiotic
o PPI, H2 blocker
o Do the necessary clinical and lab assessment
o Definitive surgery after stabilization
➢ Definitive management: surgery
o Emergency laparotomy (upper midline incision)
o Washout fluid
o Identification and repair of perforation
o Placement of omental patch
o Peritoneal toileting
o Placement of drain tube and closure of abdomen
➢ PPI, H2 blocker is continued
➢ Follow up Upper GIT endoscopy done

Gastric outlet obstruction

Q. What are the causes of Gastric outlet obstruction?

Ans:

➢ Congenital

10
 o Congenital hypertrophic pyloric stenosis
➢ Acquired
o Gastric cancer
o Pyloric stenosis (due to chronic duodenal ulceration)
o Adult pyloric stenosis

Q. Clinical features of GOO

Ans:

➢ Symptom
o Epigastric pain
o Vomiting
▪ not bile stained
▪ contains Undigested food particles
o Wt loss
➢ signs
o Dehydration
o Distended stomach (via ausculto-percussion test)
o Visible peristalsis
o Succussion splash +ve, even 4 hours after meal
o In advanced cases: features of electrolyte imbalance and acid base imbalance maybe
seen

Q. Write down the electrolyte imbalances that occur in Gastric outlet obstruction?

Ans:

➢ dehydration
➢ Hyponatremia
➢ Hypokalemia
➢ Hypochloremia
➢ Hypocalcemia (may lead to tetani, also exacerbated by metabolic alkalosis)
➢ Metabolic alkalosis
➢ Paradoxical aciduria

Q. What are the investigations in management of a case of gastric outlet obstruction?

Ans:

➢ For diagnosis
o Barium meal X ray
▪ Dilated stomach
▪ Absence of duodenal cap
▪ Failure of passage of barium into duodenum
▪ (In case of malignancy: there will be irregular filling defect)
o Upper GIT endoscopy

11
 ➢ For management purpose
o CBC
o Serum electrolyte
o Serum creatinine
o ABG
o ECG

Q. How will you prepare a patient with GOO for surgery?

Ans:

➢ Correction of dehydration
o Oral fluid
o IV fluid
o Monitor urine output
➢ Correction of electrolyte imbalance
o IV Normal saline
o K supplementation if needed
➢ Correction of anemia
o Blood transfusion
➢ Correction of hypoproteinemia
o High protein diet
o Albumin infusion
➢ Broad spectrum antibiotics
➢ Gastric lavage
o Purpose
▪ To remove residual food particle
▪ To reduce mucosal edema
▪ To bring back gastric tonicity
o Procedure: 3 days preparation
▪ 200 mL normal saline inserted into stomach by NG tube, then aspirated by 50cc
syringe. Aspiration done until returned fluid is clear.
▪ Connect NG tube to a bag: for drainage of gastric secretion
▪ Repeat lavage every 4 hourly
o Feeding:
▪ 1st 24 hour: low residual diet
▪ 2nd 24 hour: non residual diet
▪ 6 hours before surgery: NPO

Q. Treatment of a patient with GOO/pyloric stenosis

Ans:

➢ Write the preparation (…)

12
 ➢ Endoscopic balloon dilatation (temporary relief….high rate of recurrence)
➢ Surgery
o Truncal vagotomy (with gastro-jejunostomy)
o Highly selective vagotomy (with gastro-jejunostomy)
o Selective vagotomy (antrectomy)

Ca Stomach
Q. Classify Carcinoma Stomach

Ans:

Gross type:

⮚ Cauliflower type
⮚ Ulcerative type
⮚ Leather bottle/linitis plastica

Pathological classification/Lauren’s classification

⮚ Diffuse type – signet ring cell

o More stromal component
o Invades into the deeper
⮚ Intestinal type
o Polypoid lesion/ulcerative lesion present
o intestinal metaplasia
⮚ Some are mixed

Clinical classification

⮚ Early gastric cancer

o Invades into mucosa and submucosa
o w/wo LN involvement
o Subtype
▪ 1: protruded
▪ 2: superficial (2a: flat, 2b: depressed)
▪ 3: excavated
⮚ Late/advanced gastric cancer
o Involves muscularis and serosa
o w/wo LN involvement

13
 o Subtype
▪ I: single polypod
▪ II: ulcerative + clear margin
▪ III: ulcerated, no clear margin
▪ IV: diffuse/linitis plastica
▪ V: unclassified

Histological classification (WHO)

⮚ Adenocarcinoma
⮚ Adeno-squamous carcinoma
⮚ Squamous cell carcinoma
⮚ Undifferentiated carcinoma

Q. What are the routes of spread of CA stomach?

Ans:

Spread:

⮚ Direct
o To adjacent organs
o pancreas, colon, liver
⮚ Lymphatic
o in supra clav nodes (virchow’s nodes)– troisier sign
* (Nodal involvement doesn’t mean systemic spread )
⮚ Blood borne
o liver 1st,
o then other organs – lungs bones
⮚ Transperitoneal spread
o DRE: blumer shelf (egg shell cracking feeling)
o Krukenberg’s tumor – ovary
o to umbilicus – sister Mary joseph nodule

Q. What are the clinical features of CA stomach?

Ans:

Symptoms:

⮚ related to food habit

o loss of appetite
o early satiety
o dysphagia
o bloating sensation

14
 ⮚ abdominal symptoms
o mass in the epigastric region
o vomiting (non bile stained)
o abdominal discomfort (relived by vomiting)
o abdominal pain
o hematemesis, melaena
⮚ features of metastasis
o jaundice
o abdominal distension (ascites)

Sign

⮚ general
o anemia
o jaundice (liver mets)
o weight loss
o cachexia
o dehydration
o palpable left supra clavicular lymph nodes: enlarged, non tender
⮚ abdominal
o mass in the epigastric region: nodular, hard, non tender
o multiple hard, palpable nodularities in liver
o ascites
o in case of GOO: succusion splash
o in casr of perforation: features of peritonitis (rigidity)
o sister mary joseph nodule in umbilicus
o right iliac/left iliac fossa lump: ovarian tumor
o DRE: blummer shelf

Q. Investigation of Ca stomach

Ans:

⮚ For diagnosis
o Barium meal X ray
▪ Irregular filling defect in pyloric spinchter
▪ Loss of rugosity
▪ Dilatation of stomach
o Upper GIT endoscopy
▪ See the lesion
▪ Take at least 10 biopsies from 4 quadrants (punch biopsy)
o USG abdomen
▪ To see liver metastasis
▪ To see lymph node

15
 ▪ To see ascites
o CT scan of abdomen
▪ For staging, metastasis
o Palpable lymph node biopsy
⮚ To prepare pt for surgery
o CBC: low Hb
o Liver function test
▪ Prothrombin time
o RBS
o Serum electrolytes
o Serum creatinine
o Serum albumin

Q. How can you detect early gastric cancer?

Ans:

⮚ It is usually asymptomatic
⮚ In countries with high prevalence, screening is done
⮚ Any patient presenting with dyspepsia 🡪 undergoes a screening upper GIT endoscopy
⮚ Thus the lesion if present maybe identified

Q. Name a modality of treatment of early gastric carcinoma

Ans: Endoscopic mucosal resection + Lymph node clearance, if involved

Q. what are the treatment options for CA stomach?

Ans:

⮚ Surgery
o Total/radical gastrectomy
o Subtotal gastrectomy
o Palliative surgery
⮚ Chemotherapy
⮚ Radiotherapy

Q. Treatment of gastric carcinoma

Ans:

⮚ Surgery

16
 o Early carcinoma: endoscopic mucosal resection
o Early growth in pylorus: lower radical gastrectomy )(subtotal gastrectomy)
o Nodal involvement: clearance of lymph nodes
o Proximal carcinoma, Growth in body of stomach, Diffuse type carcinoma: Radical
gastrectomy
o Advanced carcinoma/Late carcinoma
▪ Neoadjuvant chemotherapy, followed by gastrectomy
⮚ Chemotherapy
o Mitomycin
o 5 fluoro-uracil
o Cisplatin
⮚ Radiotherapy
⮚ Chemoradiotherapy
⮚ Immune-therapy

Q. Surgical treatment of Ca Stomach with one indication of each

Ans:

⮚ Radical/total gastrectomy
o Removal of:
▪ Stomach+greater omentum + lesser omentum
▪ Dissection of LN along hepatic artery, splenic artery, gastroepiploic artery,
o Indication:
▪ Growth in body of stomach
▪ Growth in proximal stomach
▪ Diffuse type/linitis plastic
⮚ Subtotal gastrectomy
o Removal of distal stomach + gastro-jejunal anastomosis
o Indication
▪ Early carcinoma of the distal stomach
⮚ Palliative gastrectomy
o In advanced cases: symptoms of obstruction + bleeding
o Palliative anterior gastro-jejunostomy

Q. How will you prepare a patient of Ca stomach for surgery?

Ans:

⮚ Correction of anemia
⮚ Correction of fluid + electrolyte imbalance

17
 ⮚ Correction of hypoproteinemia
⮚ Gastric lavage
⮚ Prophylactic antibiotics
⮚ Necessary investigation
o Chest x ray
o ECG
o RBS
o Prothrombin time
o Coagulation profile, CBC
o Liver function test
o Serum electrolyte
o Serum creatinine

Q. What are the signs of inoperability of Ca stomach?

Ans:

⮚ Fixation to
o Pancreas
o Colon
o Mesocolon
⮚ Hematogenous metastasis
o Liver: ascites, secondaries in liver
⮚ Sister Mary Joseph nodules
⮚ Blumer shelf
⮚ Left supraclavicular lymph nodes
⮚ Involvement of distant peritoneum
⮚ N4 nodal disease and beyond

18
Small Intestine
Q. Short note: Meckel’s diverticulum

Ans:

● Defn: congenital diverticulum

○ Arising from terminal ileum
● Features
○ Occurs in 2% patients
○ 2 feet proximal to the ileocecal valve
○ Length: 2 inches
● Location:
○ Anti-mesenteric border of ileum
● True diverticulum: contains all three layers of intestine
● Clinical feature
○ Asymptomatic mostly
○ If symptomatic
■ If ectopic gastric mucosa present: peptic ulcer disease
■ Severe hemorrhage
■ Intestinal obstruction
■ Perforation
■ Intussusception
● Investigation
○ Small bowel enema
○ Radioisotope scan
○ In case of features of perforation: X ray abdomen erect posture with both domes of
diaphragm
● Treatment
○ Asymptomatic: left alone
○ Resection and anastomosis

Typhoid ulcer perforation

Q. Surgical complications of typhoid fever

● Paralytic ileus
○ Abdominal distention
● Hemorrhage
○ Hematemesis
○ Melaena
● Perforation of typhoid ulcer
● Chronic cholecystitis
● Osteomyelitis
● Perichondritis
● Metastatic abscess

19
Intestinal obstruction
Q. Classify intestinal obstruction:

Ans:

● Site
○ Small bowel
○ Large bowel
● Duration
○ Acute
○ Subacute
○ Chronic
○ Acute on chronic
○ Closed loop obstruction
● According to presence/absence of peristalsis
○ Dynamic
○ Adynamic
● According to status of blood supply
○ Non-strangulated
○ Strangulated
● According to etiology
○ Mechanical
○ Functional

Q. Mention the causes of intestinal obstruciotn

Ans:

● Dynamic
○ Intraluminal
■ Fecal impaction
■ Foreign body
■ Gallstone
■ Bezoar: tricho/phyto
○ Intramural
■ Stricture
■ Malignancy
■ Volvulus
■ Intussusception
○ Extramural
■ Bands
■ Adhesion

20
 ■ Obstructed hernia
● Adynamic
○ Paralytic ileus
■ Metabolic
● Hypokalemic
● Uremic
■ Infective
● Septicemic
■ Post operative
○ Pseudo-obstruction

Q. Radiological Hallmark of small bowel obstruction and large bowel obstruction:

Ans:

Small bowel obstruciton:

● Multiple air fluid level in the center of the abdomen

● Valvulae conniventis (seen in jejunum)
○ Multiple ring like radiopaque shadow that crosses whole thickness of the bowel
● Ileal obstruction: usually featureness

Large bowel obstruction

● Multiple air fluid level in the periphery

● Haustral fold
○ Multiple ring like opacity that doesn’t cross thickness of the bowel

Q. Clinical features of acute small bowel obstruction

21
Ans:

Clinical features

● Cardinal features
○ Abdominal pain
○ Vomiting
○ Distension
○ Constipation
● Dehydration
● Toxic features (due to ischemia/septicemia)
○ Tachycardia
○ Tachypnea
○ Fever
○ Sunken eyes
○ Cold periphery
● Due to strangulation
○ Continuous pain
○ Severe pain
○ Shock
○ Tenderness
○ Rebound tenderness
● Abdominal sign
○ Visible peristalsis
○ Guarding/rigidity
○ Loud bowel sound (dynamic); absent bowel sound (adynamic)
● DRE
○ Empty, dilated rectum

**large bowel: distension 1st, then constipation, then pain, then vomiting

**small bowel: high up: 1st is vomiting, then pain, no distension, then constipation

Low small bowel: 1st is pain

Q. Investigations in case of intestinal obstruction

Ans:

To diagnose:

⮚ Plain X ray erect posture with both domes of diaphragm (also to exclude perforation)
o Multiple air fluid levels
o Valvulae connivestes: jejunum obstruction
o Haustral folds: large gut obstruction

22
 o Omega sign/coffee bean sign/pneumatic tire sign: sigmoid volvulum
⮚ Contrast radiograph
o Such as barium enema: birds beak appearance (sigmoid volvulus)
⮚ CT scan of abdomen
o Dilated loops
o Mass lesion
o Target sign (Intussusception)

To assess the status of the patient

⮚ CBC
⮚ ESR
⮚ Chest x ray
⮚ RBS
⮚ Serum electrolytes
⮚ Serum albumin
⮚ Urine R/M/E

Q. Treatment principles of a patient with intestinal obstruction

Ans:

⮚ Nothing per oral

⮚ Nasogastric suction
⮚ IV fluid: to correct fluid and electrolyte status
⮚ Antibiotics
⮚ Prepare the patient for surgery
⮚ During preparation, enema should be given
⮚ Surgery
o Laparotomy
o Find the obstructed segment
o Relieve the cause of obstruction
o Management of the underlying cause + specific technique for specific causes
o Check for viability of the segment (color, appearance, pulsation, prick)
o If not viable, resection and anastomosis

Q. How will you prepare a patient with intestinal obstruction for surgery?

Ans: 3 day’s preparation

⮚ Day 1 and Day2: Low residual diet

23
 ⮚ Day 3: Non residual diet (clear fluid)
⮚ 6 hours before: NPO
⮚ Laxative: Poly ethylene glycol
⮚ Purging of the abdomen: Sodium Picosulphate
⮚ Enema simplex repeated times
⮚ Broad spectrum antibiotics (IV ceftriaxone + IV metronidazole)

Q. Difference between viable vs non-viable gut.

Ans:

Viable Non viable

Color Pink Dark
Appearance Smooth moist shiny Dull and lusterless
Capillary pulsation Present Absent
Peristalsis Present Absent
Pricking Bleeding will occur No bleeding

Q. How will you treat a case of sigmoid volvulus in a patient?

Ans: (feature same) + tire like feel of the abdomen

Investigation:

⮚ Plain x ray
o Omega sign (𝛺) sign
o Coffee bean sign
o Pneumatic tire like shadow
o (two dilated loops of bowel, running parallel, with two separate fluid level)

24
 o
⮚ Contrast enema: bird’s beak sign
⮚ CT scan: whirl pattern
⮚ Other investigation: to assess the status of the patient….write form above

Treatment:

⮚ Nothing per oral

⮚ Nasogastric suction
⮚ IV fluid: to correct fluid and electrolyte status
⮚ Antibiotics
⮚ Prepare the patient for surgery
⮚ During preparation, enema should be given
⮚ Definitive treatment
o Pass a flatus tube/sigmoidoscope gently
▪ The volvulus may de-rotate
▪ Pt will pass flatus and feces
▪ The obstruction will subside
o if not, surgery
▪ laparotomy 🡪 manual de-rotation 🡪 if gut viable 🡪 fixation (sigmoidopexy)
▪ if not viable, resection of the non viable part followed by,
● the proximal loop and distal loop both brough out, 4-6 weeks later,
anastomosis is done (Paul Mikuliz); or
● the proximal loop brough out, the distal loop is closed, 4-6 weeks later,
anastomosis (Hartman’s operation)

25
 ▪
▪ P=proximal loop; D=distal loop

Q. Pseudo-obstruction: define + causes

Ans:

⮚ Intestinal obstruction
⮚ Usually of colon
⮚ That is not due to mechanical cause
⮚ Or abdominal cause

Causes/associated factors:

⮚ Idiopathic
⮚ Metabolic
o DM
o Uremia
o Hypokalemia
o Hypothyroidism: myxedema/myxedema coma
⮚ Traumatic

26
 ⮚ Shock
o Burn
o MI
o Stroke
o Sepsis
⮚ Drugs
o Anti-cholinergic drugs
o TCA

Q. Paralytic ileus: define + causes

Ans:

⮚ Failure of peristalsis
⮚ Due to neuromuscular cause
⮚ Leading to stasis
⮚ And accumulation of fluid, gas within bowel
⮚ Distension + absence of bowel sound
⮚ And absolute constipation

Causes/varieties:

⮚ Post operative
⮚ Metabolic
o DM
o Uremic
o Hypokalemic
⮚ Infection
o Sepsis
⮚ Reflux ileus

27
Vermiform Appendix
Acute appendicitis
Q. What are the positions of appendix?

Ans:

➢ Retro colic (12)

➢ Paracolic (11)
➢ Pelvic (4)
➢ Pre-ileal (2)
➢ Post-ileal (2)
➢ Mid-inguinal (6)
➢ Promonteric (3)

Q. Clinical feature of acute appendicitis?

Ans:

Symptoms:

➢ Fever
➢ Anorexia
➢ Nausea
➢ Vomiting
➢ Abdominal pain
o Peri-umbilical at 1st
o Pain shifts to right iliac fossa

28
Signs:

➢ General examination
o Fever
➢ Abdominal examination
o Localized tenderness in right iliac fossa
o Muscle guarding
o Rebound tenderness
➢ Other special signs
o Pointing sign
o Rovsing sign
o Psoas sign (retrocecal appendix)
o Obturator sign (pelvic appendix)

Q. What are the D/D of acute appendicitis? (Not Du, but important for mcq and to know the
investigations)

Ans:

➢ Children
o Gastro-enteritis
o Intussusception
o Meckel’s diverticulitis
o Pneumonia
➢ Adult
o Perforated PUD
o Acute pancreatitis
o Ureteric colic
o Torsion of testis
➢ Adult female
o Mittelschmerz (ovulatory pain)
o PID
o Ectopic pregnancy
o Torsion ovary
o Endometriosis
➢ Elderly
o Diverticulitis
o Intestinal obstruction
o Colon cancer

Q. Write down the investigations of suspected appendicitis./mention the investigation for acute app in a
woman with rationale (always keep in mind the d/d and justify them)

Ans:

➢ Routine
o CBC: neutrophilic leukocytosis, raised ESR

29
 o Urine RME
➢ Selective (not needed in all patients, to exclude d/d)
o Pregnancy test (to exclude ruptured ectopic pregnancy)
o Urea and electrolytes
o Chest X ray with both domes of diaphragm in erect posture (to exclude perforated PUD)
o USG of abdomen and pelvis (pregnancy, pancreatitis, cholecystitis)
o CT scan abdomen (CECT) (exclude pancreatitis)

Q. What are the points of Alvarado score + interpretation? (MANTRELS score)

Ans: It is a scoring system to establish the dx of acute appendicitis

Alvarado score:

Score
Symptoms
Migratory RIF pain 1

Anorexia 1
Nausea and vomiting 1

Signs
Tenderness in RIF 2

Rebound tenderness 1

Elevated temperature 1

Laboratory
Leukocytosis 2
Left shift (more immature 1
neutrophils in blood)

Total 10

Interpretation:

30
 ➢ Score of 7 or more: strongly predictive of acute appendicitis
➢ Score of 5-6: should be confirmed by USG/CECT

Q. What are the possible outcomes of acute appendicitis?

Ans:

➢ Spontaneous resolution
➢ Relapse and recurrent appendicitis
➢ Appendicular lump
➢ Appendicular abscess
➢ Gangrene of appendix
➢ Perforation
➢ Peritonitis
➢ Portal pyemia
➢ Septicemia
➢ Intestinal obstruction

**management of acute appendicitis:

Conservative/non operative management:

➢ NPO
➢ Parenteral nutrition
➢ IV fluid
➢ IV antibiotics
o Metronidazol
o 3rd general cephalosporin
➢ Analgesic
➢ Monitor the patient
o Temperature
o Urine output
o Pulse and BP

Surgical treatment: Appendicectomy

➢ Open: the approaches are via

o Gridiron incision
o Rutherford morrison incision
o Lanz incision
o Right lower paramedian incision
➢ Laparoscopic

Appendicular lump + Abscess

Q. How is appendicular lump formed?

Ans:

➢ Formed by localization of infection 3-5 days after attack of acute appendicitis

31
 ➢ Greater omentum, in an attempt to limit the spread of infection and inflammation, wraps
around
o Inflamed appendix + mesentery
o Cecum (swollen)
o Terminal ileum (swollen)
o Parietal peritoneum
➢ This mass is localized in the right iliac fossa
➢ During this time, the classical symptoms have resolved, but a right iliac fossa lump is felt

Q. Mention the management of appendicular lump.

Ans:

Clinical features:

➢ History (suggestive) of acute appendicitis 3-5 days back

➢ Now patient presents with right iliac fossa lump
o Tender
o Ill defined margins
o Smooth
o Firm
o Doesn’t move with respiration
o Not mobile (free from overlying skin, fixed to underlying structure)
➢ May have
o Fever
o Malaise

Investigation:

➢ CBC: Raised WBC

➢ USG: mass is found in RIF (+other dd excluded)
➢ MT test and genexpert test (to exclude abdominal TB)

Management: “Ochsner-Sherren Regimen”

➢ Conservative treatment (observation mainly)

o Careful monitoring of patient
o Follow up
▪ Pulse
▪ BP
▪ Temperature
▪ State and progression of mass
o Treat with
▪ IV fluid
▪ Antibiotic
▪ Analgesic
▪ NG suction
➢ Usually within 2-3 days the mass reduces, other symptoms disappear

32
 ➢ Then patient is discharged
➢ Advised for interval appendicectomy 6 weeks later
➢ When to stop conservative treatment
o Increasing size of mass
o Increasing abdominal pain
o Tachycardia

Q. What are the d/d of RIF lump?/A 30 year old lady presented with RIF mass. What may be the
probable causes?

Ans:

➢ Appendicular lump
➢ Appendicular abscess
➢ Ileocecal tuberculosis
➢ Carcinoma cecum
➢ Ovarian cyst (neoplastic)
➢ Mesenteric lymphadenitis

Q. A 30 year old female presented with RIF lump with fever. How will you evaluate her?

Ans:

Probable Diagnosis Clinical features Investigations

Appendicular lump History of acute appendicitis Raised WBC
Tender, ill defined, fixed lump in RIF USG confirms mass
Fever
Ileocecal TB Low grade fever (evening rise of temperature) MT test
Night sweats Genexpert test
History of contact with TB patient These may be +ve
Non tender RIF mass
Ovarian cyst Heaviness in abdomen USG: to confirm the mass
Dull aching pain Tumor marker: CA-125, CEA, Beta HCG
Rarely some menstrual symptoms
Wt loss cachexia
Cystic swelling, mobile in all direction, non
tender
Mass felt in per vaginal examination
Ectopic pregnancy History of amenorrhea Ultrasonography: to confirm tubal
Per vaginal bleeding pregnancy
Sudden severe abdominal pain Beta HCG: to confirm pregnancy
Features of shock

(Didn’t include malignancy due to her age)

Q. Management of appendicular abscess.

33
Ans:

Clinical features:

➢ High grade fever

➢ Patient is toxic
➢ History of appendicitis/appendicular lump
➢ Examination
o Tender mass in RIF
o Margin ill defined
➢ Investigation
o CBC: raised WBC
o USG: confirm the presence and origin of the mass
➢ Treatment
o Antibiotic
o Aspiration (CT guided)
o Incision and drainage by lapartomoy (extra-peritoneal drainage)
o After 3 months, interval appendicectomy

34
Colon
Polyp
Q. Classify intestinal polyp

Ans:

⮚ Non neoplastic
o Inflammatory: ulcerative colitis (psuedopolyp)
o Hyperplastic polyp
o Hamartomatous polyp
▪ Peutz-Jeghers polyp
▪ Juvenile polyp
⮚ Neoplastic
o Adenoma
▪ Tubular
▪ Villous
▪ Tubule-villous
o Adenocarcinoma
o Carcinoid tumor

Carcinoma of colon
(60 year old man – alternate constipation and diarrhoea + occasional passage of fresh blood with stool
for 5 months)

Q. Classify Ca colon

Ans:

➢ Microscopic: adenocarcinoma
➢ Macroscopic
o Annular
o Tubular
o Ulcerative
o Cauliflower
➢ Sites
o Rectum (most common)
o Sigmoid colon
o Ascending colon
o Desc. colon

Q. Management of Ca colon ( I wrote very short)

Ans:

35
Clinical:

Right:

➢ Anemia
➢ RIF mass
➢ Wt loss

Left

➢ Alteration of bowel habit

➢ Per rectal bleeding
➢ Dull aching pain
➢ LIF lump
➢ Features of obstruction
➢ Wt loss
➢ Anemia

Features of complication/metastasis

Examination:

➢ Anemia
➢ Cachexia
➢ Wt loss
➢ Abdominal lump
➢ DRE
o Pelvic deposit in pouch of Douglus
o If no growth in rectum, nothing specific cannot be found
o Growth maybe found in rectum which is
▪ Hard
▪ Fixed
▪ Non tender
▪ After taking out finger, there is blood stained

Investigations:

➢ Screening test
o Fecal occult blood test
o Colonoscopy
o Sigmoidoscopy
➢ Diagnostic test
o Double contrast barium enema
▪ Stricture
▪ Constant irregular filling defect
▪ Apple core deformity
o Sigmoidoscopy
▪ To see tumor in recto-sigmoid junction

36
 o Colonoscopy
o Biopsy from the lesion
o USG: secondary in liver, peritoneum etc.
o CT scan
o Tumor marker: CEA (prognostic)

Treatment:

Surgery: wide resection of growth + lymphatics

Ca-cecum/ca asc col: right hemicolectomy

Ca-hepatic felxure: right hemicolectomy extended upto transverse colon

Ca-transverse colon: extended right hemicolectomy (upto splenic flexure)

Splenic flxre/desc colon: left hemicolectomy

Emergency surgery: if there is obstruction

Left side: hartman’s procedure

Right side: right hemicolectomy

If there is perforation: ileo-colostomy (double loop)

Resection followed by anastomosis

If inoperable: but more than 95% is resectable

Left: transverse colostomy

Right: ileo-colic bypass anastomosis

Liver metastasis: segmental hepatic resection: for solitary liver secondarry; multiple: hemihepatectomy

Radiotherapy (only if locally advanced)

Chemotherapy

Q. What are the DRE findings of CA colon?

Ans:

Q. How will you stage colorectal malignancy?

Ans:

Duke’s staging

➢ A: mucosa, submucosa

37
 ➢ B: muscularis layer + wall
➢ C: lymph node involved

Modified

➢ A: rectum
➢ B: local spread to extra rectal tissue
➢ C: no LN
➢ D: distal

TNM staging

T1: sm

T2: mp

T3: sub serosa

T4: serosa breach

Carcinoma cecum
Q. A 50-year-old man presented with right lower abdominal mass. How will you assess the patient
clinically and how will you confirm your diagnosis? Same as right sided…

38
Rectum
Per Rectal Examination
Q. Mention the procedure of DRE. (Mention the different positions of per rectal examination)

Ans:

Different Positions of DRE:

➢ Common position
o Left lateral position
o Dorsal position
o Lithotomy position
➢ Other positions
o Knee elbow
o Right lateral
o Picker position (patient leaning forward onto a stool)

Procedure:

➢ Pre-requisites: Explanation, consent, privacy, proper positioning, good light source

➢ Inspection
o Gently apart the buttocks
o Inspect the peri-anal region
o Note any ulceration, abscess, fistula opening, discharge, fecal material, other lesion
➢ Digital examination
o Right hand is gloved and index finger is adequately lubricated
o Gently insert pulp of the index finger
o At 1st insert the distal phalanx and check the anal tone
o Wait for the sphincter to relax, then insert further
o After insertion, check all the walls, rectal mucosa, and prostate
o After examination, withdraw the finger and check for mucus, pus, blood

Q. Short note/procedure: Proctoscopy

Ans:

Indication of proctoscopy:

➢ Diagnostic
o Hemorrhoids
o Anal fissure (under anesthesia)
o Polyp
o Malignant lesion
➢ Therapeutic
o Injection sclerotherapy for hemorrhoids
o Cryotherapy for hemorrhoids

39
 o Polypectomy
o Take biopsy from lesion

Parts of a non illuminating proctoscope:

➢ Proctoscope
➢ Obturator (to allow easy, non traumatic insertion)

Procedure:

➢ Proper counselling and consent, privacy, proper positioning

➢ It is done as a part of per rectal examination: after inspection and DRE
➢ Instrument is lubricated
➢ Inserted with obturator
➢ Obturator is removed
➢ Visualization is done while the proctoscope is slowly withdrawn outside
➢ Other necessary procedure done
➢ Withdrawal of the instrument

P/R bleeding
Q. Name the causes of per rectal bleeding

Ans:

➢ Painful
o Anal fissure
o Rectal polyp (prolapsed)
o External hemorrhoids
o Prolapsed internal hemorrhoids
o Carcinoma in anal canal
➢ Painless
o Internal hemorrhoids
o CA-Rectum
o CA-colon
o Colonic polyps
o Inflammatory bowel disease
o Dysentery
o PUD
o Diverticulitis

40
Q. Name the causes of fresh bleeding per rectum (almost same as above, just don’t write PUD – that
causes melaena)

Q. Causes of per rectal bleeding in a 5 year old boy vs an adult

Ans:

➢ Causes of PRB in children

o Rectal polyp
o Intussusception
o Meckel’s diverticulum
o Arteriovenous malformation
o Bleeding disorder
➢ Causes of PRB in an adult
o (Write the causes of PRB except the ones in child)

Q. History + examination + investigation / clinical evaluation of a patient with per rectal bleeding

Ans:

Some common D/D for per rectal bleeding: (only a few but the most common ones will be evaluated)

➢ Haemorrhoids
➢ Anal fissure
➢ Rectal polyp
➢ Diverticulosis
➢ Carcinoma rectum (don’t talk about this point if the patient is younger)

Clinical + lab evaluation to reach a definite diagnosis:

Some History (along with P/R Examination finding Lab investigation

common D/D bleeding)
Haemorrhoids ➢ Painless ➢ Seen and felt in Endoscopy:
➢ PR bleeding after DRE only if
defecation prolapsed Proctoscopy
➢ Feeling of lump while ➢ Blue-red mucosa Sigmoidoscopy
cleaning anus ➢ Usual position: 3, Colonoscopy
(prolapse) 7, 11 o clock Upper GIT endoscopy
➢ Peri anal discomfort ➢ There may be (PUD)
➢ Itching bleeding or (Take punch biopsy from
ulceration lesion seen via these
Anal fissure ➢ Severe pain (Usually DRE procedures
➢ Blood streaked with contraindicated without
stool anaesthesia) Radiology:
➢ Staining of toilet paper ➢ Inspection: Endo-anal usg
➢ Feeling of mass (skin sentinel skin tag Pelvic MRI
tag) while cleaning ➢ Spastic internal Pelvic CT scan
➢ Itching sphincter X ray abdomen

41
 ➢ Constipation Barium meal, follow
Rectal polyp ➢ Mucus discharge ➢ Polyp can be felt through, enema
➢ Diarrhoea as firm, mobile
➢ Peri anal discomfort mass on DRE
➢ Itching
➢ If prolapsed, feeling of
lump
Diverticulosis ➢ Elderly patient ➢ Patient is
➢ Left sided lower anaemic
abdominal pain ➢ There will be
➢ Alteration of bowel tenderness in LIF
habit (left iliac fossa)
➢ Passage of fresh blood
and clot while
defecation
Carcinoma ➢ Tenesmus ➢ Ulcer felt in DRE:
rectum ➢ Early morning spurious hard, bulges into
diarrhoea lumen, everted
➢ Alternating diarrhoea edge, irregular
and constipation margin,
➢ Per rectal bleeding indurated and
➢ Weight loss hard base, fixed
➢ +ve family history ➢ Upon withdrawal
of finger: blood,
mucus maybe
seen
➢ Para aortic LN,
inguinal LN may
be palpable
➢ Liver palpation
may reveal
metastasis

Rectal prolapse
Q. Short note: Rectal prolapse

Ans:

➢ Defn: circumferential descent of rectum through the anal canal

➢ Types
o Partial: only mucosa and submucosa is prolapsed
o Complete: descent of muscle layer as well (also called procidentia)
➢ Cause
o Chronic straining
o Diarrhoea, constipation, cough

42
 o Malnutrition, decreased ischiorectal fat
o Multipara woman (multiple vaginal delivery)
o Weakness of muscle
o Nerve damage

Partial prolapse Complete prolapse

Clinical Feeling of mass per anus when straining Complete descent of rectum per anus
feature for defecation Mass is red
Mass is pink in color + circumferential Circumferential
Reducible
Painless
Fecal incontinence
P/R bleeding
DRE: loss of sphincter tone
Investigation Sigmoidoscopy
Treatment Correct nutrition Young patient: rectopexy
Correct constipation Elderly patient: recto-sigmoidectomy
Injection of sclerosant agent
Excision of prolapsed mucosa (Goodsall’s Repair, stregthening of pelvic floor muscles
operation)

Complications that may develop in rectal prolapse

➢ Ulceration
➢ Bleeding
➢ Anemia
➢ Sepsis e

Rectal polyp
Q. Short note: rectal polyp

Ans: Rectum and anal canal are the most common site for development of polyp in the body.

Classification of intestinal polyp (same applicable for rectal polyp):

➢ Inflammatory polyp: Pseudo-polyp (In ulcerative colitis)

➢ Metaplastic polyp/hyperplastic polyp
➢ Hamartomatous polyp: Juvenile polyp
➢ Neoplastic polyp
o Gross classification
▪ Tubular
▪ Tubulo-villous
▪ Villous
o Microscopic classification
▪ Adenoma
▪ Adenocarcinoma
▪ Carcinoid tumor

43
Clinical feature:

➢ Mucus discharge
➢ Diarrhoea
➢ Per rectal bleeding
➢ If prolapsed, maybe painful
➢ Sudden change in symptoms may indicate malignant transformation
➢ DRE: firm, mobile mass may be felt (benign); staining of finger with blood + mucus
➢ Proctoscopy: red glistening pedunculated mass seen (cherry tumor)

Investigation

➢ Sigmoidoscopy
➢ Colonoscopy
➢ Take biopsy from the polyp to exclude malignancy

Treatment:

➢ Polypectomy
o Polyp <1 cm: endoscopic polypectomy
o > 1cm: Endoscopic mucosal resection
o Larger: Trans-anal endoscopic micro-surgery (TEMS)
➢ After excision, send the polyp for histopathology to exclude malignancy
➢ In case of FAP (Familial adenomatous polyposis), total procto-colectomy with end-ileostomy
maybe done

Carcinoma rectum
**scenario: elderly patient presents with early morning spurious diarrhea, weight loss and anemia. On
per rectal examination, an ulcero-proliferative growth was found in the rectum.

Q. Clinical features of CA rectum.

Ans:

➢ Most common, early symptoms

o Per rectal bleeding
▪ Painless
▪ Bright red
o Tenesmus (sense of incomplete + painful defecation)
o Early morning spurious diarrhoea (overnight accumulation of mucus and blood)
o Passage of bloody slime (blood + mucus)
➢ Other features
o Alteration of bowel habit (alternating episodes of constipation, followed by diarrhoea)
o Pain (due to obstruction and involvement of nerve plexus)
o Weight loss

44
Examination finding:

➢ General examination
o Anemia
o Weight loss
o Malnutrition
o Jaundice (if liver metastasis)
➢ Abdominal examination
o Maybe normal
o Signs of obstruction: distension
o Signs of liver metastasis: liver palpable, ascites
➢ Digital rectal examination
o Mass (felt, if situated close to anal verge)
o Ulceration: everted edge
o Fixed mass
o Finger stained with blood upon withdrawing
o In case of female: do P/V examination to see the involvement of vagina
➢ Proctoscopy, sigmoidoscopy: visualization of mass + take biopsy material

Q. What are the d/d of CA rectum? (scenario diye bolbe…what are the possible causes)

Ans: D/D of CA rectum:

➢ Stricture: due to IBD

➢ Amoebic granuloma
➢ Abdominal TB
➢ Carcinoid
➢ Solitary ulcer syndrome

Q. Investigation of CA rectum

Ans:

➢ Detection of primary lesion

o Proctoscopy, sigmoidoscopy, colonoscopy: to see the lesion + take biopsy from it
o Barium Enema study
➢ Staging of the disease
o Local spread
▪ Endo-luminal ultrasound (endo-anal: probe inside anal canal)
▪ Pelvic MRI
o Distal metastasis
▪ USG of WA (liver involvement, ascites)
▪ Abdominal CT scan (operability, local extension, LN involvement)
▪ PET-CT scan
o Tumor marker: CEA (raised in case of metastasis)
➢ Pre-operative assessment
o CBC

45
 o Urine RME
o Liver function test
o Serum creatinine
o Coagulation profile
o Serum albumin
o HBSAg

Q. How will you stage CA rectum?

Ans: There are 2 methods of staging:

➢ Duke’s staging
o Stage A: growth limited to rectal wall (excellent prognosis)
o Stage B: Growth spread to extra rectal tissue. No LN involvement (Reasonable
prognosis)
o Stage C: Regional lymph nodes are involved
▪ C1: Para-rectal lymph nodes
▪ C2: LN accompanying the blood vessel, arising from aorta
o Stage D (not in original duke’s staging): distant metastasis
➢ TNM staging: radiological staging (if less time, no need to write in detail)
o T (extent of local spread)
▪ TX: primary tumor cannot be assessed
▪ T0: no primary tumor
▪ T1: tumor in submucosa
▪ T2: tumor in muscularis layer
▪ T3: tumor in peri-colorectal tissues
▪ T4a: tumor in visceral peritoneum
▪ T4b: tumor in adjacent organs
o N (Nodal involvement)
▪ Nx: nodal involvement cannot be assessed
▪ N0: no nodal involvement
▪ N1: 1-3 LN involved
▪ N2: 4 or more LN involved
o M (presence of distant metastasis)
▪ M0: no distal metastasis
▪ M1: presence of distal metastasis

Q. Management of a patient with ca rectum

Ans: Clinical features + investigations: from above

Treatment: treatment will depend upon the stage of the disease

Treatment modalities:

➢ Surgery

46
 o principle: there should be 2 cm tumor free margin ideally
o pre-operative preparation undertaken (to optimize the patient)
o options for surgery
▪ Anterior resection
• Sphincter is spared
• Anastomosis is done with distal segment
• Done in case of growth in upper + middle third of rectum
• Alternatively, tumor situated >7cm above anal verge
▪ Abdomino-perineal excision of rectum (APER)
• Sphincter is not spared
• Permanent end colostomy is done
• Done if tumor is in lower third of rectum
▪ Palliative surgery: in advanced cancer: Hartmann’s operation
o In case of liver mets: segmental resectopn/hemihepatectomy (downstaging of tumor)
➢ Radiotherapy
o Adjuvant (Post-operative)
o Neo-adjuvant (pre-operative)
o Palliative (in advanced, inoperable cases)
➢ Chemotherapy
o Adjuvant
o Neoadjuvant
o Combined with RT (chemo-radiation)

Q. Pre-operative preparation for a patient with CA rectum.

Ans:

➢ Optimization of patient
o Correction of anemia: blood transfusion + Fe supplementation
o Correction of nutritional status: Nutritional support
o Correction of electrolyte imbalance and dehydration: IV fluid
o Correction of hypoalbuminemia
o Correction of coagulopathy
o Prophylactic broad spectrum antibiotics
o DVT prophylaxis
➢ Bowel preparation (three days preparation)
o 48-72 hours prior: low residual diet
o 24 hour prior: non residual diet (clear fluid)
o NPO, 6 hours before surgery
o Laxative: Polyethylene glycol
o Enema simplex before surgery
o Antibiotic: neomycin

47
Anus and Anal canal
Anal fissure
(pain on defecation, red blood on stool, mucus discharge and constipation)

Q. Management of anal fissure

Ans:

Clinical feature

➢ Blood streaked stool: bright red bleeding

➢ Severe pain during defectation
➢ Mucus discharge
➢ Itching
➢ Constipation

Sign

➢ Sentinel skin tag

➢ Gently apart: DRE contraindicated
➢ Examination under anesthesia

Investigation

➢ Examination under anesthesia

o Proctoscopy
o Sigmoidoscopy
o Colonoscopy
➢ Needed only in case of elderly patients or patients with risk of malignancy
➢ Biopsy and histopathology from lesion

Treatment:

➢ Non surgical
o Dietary modification (fiber, adequate water, stool softener)
o Local anesthetics
o Sitz bath
o Medical management to relax internal sphincter (and reflex spasm + pain)
▪ GTN/NO → if not healed → CCB (diltiazem) → if not healed → Botulinum toxin
➢ Surgical
o Older methods: forceful manual dilatation of anal sphincter (risk of incontinence)
o Modern method
▪ Lateral internal sphincterotomy
▪ Anal advancement flap

Q. Non-surgical management of anal fissure

48
Hemorrhoids
Q. Define + classify hemorrhoids

Ans:

➢ Dilatation
➢ Elongation
➢ tortuisisty
➢ of ano-rectal venous plexus,
➢ formed by radicals of superior, middle, inferior rectal veins

Classification:

➢ according to location
o internal hemorrhoid: above the dentate line
o external hemorrhoid: below the dentate line
➢ according to position
o primary hemorrhoid: found at 3,7,11 o clock positions (branch of superior hemorrhoidal
vessels)
o secondary hemorrhoids: occurring in between the primary sites
➢ clinical classification
o 1st degree: bleed only
o 2nd degree: bleed + prolapse + spont. reduce
o 3rd degree: bleed + prolapse + manually reduce
o 4th degree: bleed + prolapse + cannot be reduced even manually (permanently
prolapsed)

Q. clinical features of hemorrhoids

Ans:

➢ Painless bright per rectal bleeding

➢ Prolapsed
➢ If prolapsed + thrombosed: painful
➢ Anal irritation + itching
➢ Mucus discharge
➢ Usually not seen on inspection

Q. Treatment options of hemorrhoids

Ans:

➢ Exclude other causes (such as malignancy)

➢ Conservative
o Diet modification
o Stool softener
➢ Minimal invasive techniques (1st and 2nd degree)

49
 o Injection sclerotherapy
o Rubber band ligation
o Cryotherapy
➢ Surgery (3rd and 4th, and 2nd degree not responding to above methods)
o Open hemorrhoidectomy (Milligan-Morgan’s Operation)
o Closed hemorrhoidectomy
o Stapled hemorrhoidopexy (Longo operation)
o Hemorrhoidal artery ligation operation (HALO)

Q. complications of hemorrhoids

Ans:

➢ Profuse bleeding
➢ Strangulation
➢ Thrombosis
➢ Gangrene
➢ Ulceration
➢ Fibrosis
➢ Portal pyemia

Q. Principles of treatment of prolapsed hemorrhoids

Ans:

➢ Pre-op preparation: gut preparation

➢ Treatment methods….
➢ Post op management
o Two hot baths each day
o Laxative + soft food /stool softener
o Oral antibiotic therapy
o Regular dressing

Anal pain
Q. Causes of painful anal conditions

Ans:

➢ Anal fissure
➢ Anorectal abscess
➢ Proctalgia fugax
➢ External hemorrhoids
➢ Prolapsed and thrombosed internal hemorrhoids

50
 ➢ Prolapsed malignant lesion
➢ Prolapsed polyp

Anorectal abscess
Q. types of anorectal abscess

Ans:

➢ Peri-anal abscess
➢ Ischio-rectal abcess
➢ Submucous abscess
➢ Pelvi-rectal abscess

Fistula in Ano
Q. Classify fistula in ano

Ans:

➢ Park’s classification
o Intersphincteric
o Trans-sphincteric
o Supra-sphincteric
o Extra-sphincteric
➢ According to location
o Low level fistula (below the internal anal sphincter)
o High level fistula (above the internal anal sphincter)

Q. what are the treatment options for fistula in ano

Ans:

➢ Non operative: diet modification + stool softener

➢ Operative
o Fistulectomy
o Fistulotomy
o Ligation of inter-sphincteric fistula tract (LIFT)
o Anal advancement flap
o Seton
▪ Loose seton
▪ Cutting seton

Q. Outline the principles of management of high variety of fistula in ano

51
Ans:

Clinical features

➢ Symptom
o Discharge from external opening of fistula
o Pain
o Features of the underlying cause
➢ Sign
o External opening of fistula: may appear as a puckered scar
o Discharge seen
o DRE: to see associated lesion

Investigation

➢ Proctoscopy, sigmoidoscopy, colonoscopy

➢ Probing: to delineate the track
➢ Fistulogram: to delineate the track

➢ Low level: fistulotomy

➢ High level
o Supra-levator fistula: treatment of cause, colostomy
o Supra-sphincteric: seton
o Trans-sphincteric: seton
o Inter-sphincteric: whole tract is laid open (fistulotomy)

52
Liver
Q. Metastatic liver disease/secondary tumor in liver: Short note

Ans:

➢ Inv
o Imaging: USG, CT scan, MRI,PET CT
o FNAC, Core biopsy
o LFT
o Tumor marker
➢ Treatment
o Chemotherapy
o Surgery
▪ 2 stage liver resection: in patients with colorectal carcinoma
o Portal vein embolization
o Radiofrequency ablation
o Microwave therapy
o Focused USG therapy

53
Gallbladder
Gall stone
Q. What are the types of gallstone?

Ans:

➢ Cholesterol stone (due to relative increase in cholesterol in relation to bile acid and
phospholipid)
➢ Pigment stone
o Black pigment stone (Associated with hemolytic disease)
o Brown pigment stone (forms in bile duct, due to infection and de-conjugation of
bilirubin by organism)
➢ Mixed stone (associated with bile stasis)

Q. Mention the factors of gall stone formation.

Ans:

➢ Cholesterol stone
o Impairment of gall bladder function
o Supersaturation of bile due to increased cholesterol concentration (obesity, diet,
genetics)
o Presence of cholesterol nucleating factors (infection, mucus, glycoprotein)
o Impaired enterohepatic circulation of bile acid
▪ Deoxycholate
▪ Decreased bowel transit time
▪ Gut resection
▪ Fecal/enteric flora
▪ Cholestyramine
➢ Pigment stone
o Black pigment stone
▪ Increased bilirubin production due to hemolysis
• Sickle cell disease
• Hereditary spherocytosis
o Brown pigment stone
▪ Infection of bile: organism causes de-conjugation of bilirubin
• Ascaris lumbricoides
• Clonorchis sinensis
➢ Mixed stone: associated with bile stasis

Q. Mention the effects and complications of gallstone

Ans: Effects of gallstone:

➢ Effect in gallbladder
o Asymptomatic
o Biliary colic

54
 o Acute cholecystitis
o Chronic cholecystitis
o Mucocele of GB
o Empyema GB
o Gangrenous GB
o Perforation of GB
o Porcelain GB
o Carcinoma GB
➢ Effect in CBD
o Secondary CBD stone
o Cholangitis
o Pancreatitis
o Mirizzi syndrome (fistula formation between GB and CBD)
➢ Effect in the intestine
o Gallstone ileus (fistula between GB and gut and stone in gut causes intestinal
obstruction)
➢ Effect in liver
o Liver abscess
o Liver cirrhosis (secondary biliary cirrhosis)

Q. A patient presented with palpable GB. What are the d/d and how will you differentiate them
clinically?

Ans:

➢ Malignant cause (associated with obstructive jaundice)

o Carcinoma head of the pancreas
o Cholangiocarcinoma
o Peri-ampullary carcinoma
o Carcinoma gallbladder
➢ Benign cause
o Mucocele of gallbladder
o Empyema of gallbladder

D/D Presence of obstructive Gallbladder Other features

jaundice, pale stool,
dark urine, itching
Carcinoma Head of Present (progressive) Palpable Wt loss
pancreas Soft Cachexia
Non ender Ascites
Left supraclavicular LN
palpable
Blumer’s shelf on DRE
Cholangiocarcinoma Present (progressive) Palpable Wt loss
Soft Anorexia
Non tender Liver palpable and hard

55
 Peri-ampullary Present (fluctuating) Palpable Wt loss
carcinoma Soft Anorexia
Non tender Left supraclavicular LN
Blumer’s shelf on DRE
Carcinoma Gallbladder Present Palpable RUQ pain
Hard Wt loss
Non tender Anorexia
Palpable liver
Mucocele of GB Absent Palpable Dyspepsia
Soft RUQ pain (uncommon)
Non tender
May be huge, down
to the pelvis
Empyema GB Absent Palpable Swinging pyrexia
Soft High grade fever
Tender Pt is toxic
Pain in RUQ

Acute cholecystitis
*(scenario: 40 year fair fertile fatty female with RUQ pain, tenderness, fever, USG reveal multiple
gallstone)

Q. Mention the clinical features of biliary colic. (SOCRATES)

Ans: (non-inflammatory pain: due to presence of stone in GB)

➢ Severe Pain in RUQ + tenderness and muscle guarding

➢ Spasmodic pain
➢ Radiates to chest, upper back, shoulder
➢ Associated with:
o nausea, vomiting
o fever: absent
o tachycardia: present
➢ Timing
o Constant pain
o Lasts a few minute to several hours
➢ Exacerbated by: fatty meal
➢ Relived by: strong analgesic
➢ No periodicity

Q. Mention the clinical features of acute cholecystitis

Ans:

➢ History: severe Pain (SOCRATES)

o In RUQ

56
 o Onset: sudden
o Radiates to back and to tip of right scapula
o Associated with:
▪ nausea, vomiting
▪ fever
▪ tachycardia
o timing
▪ continuous pain
▪ lasts >6 hours
o exacerbated by
▪ fatty meal
▪ movement
▪ respiration
o relived by
▪ strong analgesic
➢ examination
o pt lies quietly + shallow respiration
o fever
o tachycardia
o +ve murphy’s sign
o Tenderness and muscle guarding in RUQ
o Area of hyperesthesia between 9th-11th ribs right side posteriorly (Boas’ sign)

Q. Mention the investigation and treatment of acute cholecystitis

Ans:

Investigation:

➢ USG of whole abdomen, with special attention to hepato-biliary pancrearuc system

o Thickening of gallbladder wall
o May show presence of gallstones
➢ Palin X ray abdomen:
o May show radio-opaque stone
o To exclude other d/d (such as perforation)
➢ Blood test
o CBC: neutrophilic leukocytosis
o Liver function test: (obstructive jaundice pattern: raised bilirubin and ALP may indicate
CBD stone)
▪ Serum bilirubin
▪ ALT
▪ ALP
▪ AST
o Amylase, lipase: to exclude pancreatitis
➢ HIDA scan (Hepatic immino diacetic acid scan) (radio-isotope study)

57
Treatment:

➢ Hospitalization of the patient

➢ Initially: conservative management (until acute inflammation subsides)
o NPO and IV fluid until pain resolves
o Analgesic (Tramadol)
o Antispasmodic (hyoscine butyl bromide)
o Broad spectrum antibiotics
o Resume normal diet when pain resolved, pulse and temperature normal
o Do USG to confirm resolution of inflammation
➢ 3-6 weeks later, elective interval cholecystectomy
o Open cholecystectomy
o Laparoscopic cholecystectomy
➢ If there is the following:
o Empyema GB
o Persistent and progressive symptoms
o Then emergency cholecystostomy, 3 weeks later elective cholecystectomy

Q. What are the d/d of acute cholecystitis

Ans:

➢ Common
o Perforated PUD
o Acute appendicitis
o Acute pancreatitis
➢ Rare
o Acute inferior MI
o Acute pyelonephritis
o Right lower lobe pneumonia
o Ruptured ectopic pregnancy

Q. What are the complications of acute cholecystitis? (in absence of treatment)

Ans:

➢ Empyema GB
➢ Gangrenous GB
➢ Perforation
➢ Peritonitis
➢ Cholangitis
➢ Septicemia
➢ Shock

58
Q. Short note: Murphy’s sign

Ans:

➢ Sign of cholecystitis
o Acute cholecystitis
o Acute on chronic
➢ John Benjamin Murphy
➢ Procedure
o Patient lies down supine
o Finger placed on the tip of the 9th costal cartilage
o Patient asked for a deep inspiration
o At the height of inspiration there is sudden wincing with pain and cessation of
inspiration
o This is referred as murphy’s sign

Chronic cholecystitis
Q. Mention the causes of chronic cholecystitis

Ans:

➢ Gallstone
➢ Cholecystoses (defective transport of absorbed cholesterol that accumulates in mucosa)
➢ Chronic acalculous cholecystitis

Q. Clinical features of chronic cholecystitis

Ans:

Symptom:

➢ Right hypochondriac pain

➢ Flatulent dyspepsia
➢ fatty food intolerance

Sign:

➢ fever
➢ deep tenderness in RUQ
➢ murphy’s sign negative

Q. Investigation and treatment

Ans:

59
 ➢ USG:
o bright echogenic structure with posterior acoustic shadowing
o thickened gallbladder
➢ LFT
➢ Isotope scan: HIDA scan
➢ MRCP, ERCP

Treatment

➢ General
o Analgesic
o Antispasmodic
o Antibiotic
➢ Specific
o Cholecystectomy (open/laparoscopic)

Q. What are the complication/sequelae of chronic cholecystitis (not DU)

Ans:

➢ CBD stone
➢ Cholangitis
➢ Mirizzi syndrome
➢ Pancreatitis

Mucocele of Gallbladder
Q. Write down the pathogenesis of mucocele of the gallbladder

Ans: stone/neoplasm → obstruction of cystic duct → failure of bile drainage out of the GB → absorption
of water soluble contents of bile → hypersecretion of mucus → distension of gallbladder with
accumulated mucus → mucocele

60
Biliary tree
Jaundice
Q. A patient presented with jaundice 2 days after operation. What are the causes?

Ans: Causes of post-operative jaundice:

➢ Prehepatic
o Hemolysis (due to mismatched transfusion)
o Resolution of hematoma
➢ Hepatic causes
o Toxicity of drugs e.g anesthetic, sedatives
o Septicemia
o Viral hepatitis due to infected material/blood
o Exacerbation of pre-existing liver disease
o Hypoxia/ischemia of liver
➢ Post hepatic cause (write down 4 surgical causes of jaundice in patient presented 2 days after
lap chol)
o Retained stone/residual stone
o Clot in CBD
o Injury to the CBD
o Stricture

Obstructive jaundice
**malignant: non tender/painless progressive jaundice for /…. Months….on examination, painless cystic
swelling in RUQ

Q. What are the causes of surgical/obstructive jaundice?

Ans:

➢ Intraluminal cause
o Choledocholithiasis
o Parasitic infection
o Blood clot
➢ Intramural cause
o Congenital/in children
▪ Biliary atresia
▪ Choledochal cyst
o Benign: stricture, cholangitis
o Malignant: cholangiocarcinoma
➢ Extraluminal cause
o Malignant
▪ Carcinoma head of pancreas
▪ Peri-ampullary carcinoma

61
 ▪ Carcinoma GB
▪ Metastatic enlarged LN
o Benign
▪ Acute and chronic pancreatitis

Q. What is Charcot’s triad?

Ans:

Triad of

➢ RUQ pain
➢ Fever (high grade with child and rigor)
➢ Obstructive jaundice

This indicates presence of cholangitis

Q. How will you investigate a case of obstructive jaundice?

Ans:

➢ To confirm the diagnosis

o Serum bilirubin: conjugated hyperbilirubinemia
o Serum ALP: raised markedly
o Serum ALT: slightly raised
o Imaging
▪ USG of the hepatobiliary system:
• Gallbladder: distended/thick wall + stone maybe present
• Biliary tree: dilated
• Liver: intrahepatic biliary dilation, liver mass/metastasis
• Pancreas: see any mass
▪ MRCP: stone/stricture/malignant obstruction
▪ CECT: better delineation of mass + invasion of mass
▪ ERCP: diagnostic + therapeutic
o Tumor marker: CA 19-9 (prognosis)
➢ To see the effect of the disease on the patient
o Liver function test
▪ ALT: raised
▪ Serum albumin: maybe decreased
▪ A/G ratio: altered
▪ PT and coagulation profile: PT increased
▪ Serum electrolytes
➢ For pre-operative optimization of the patient + GA fitness
o CBC
o ESR

62
 o ECG
o RBS
o CXR
o Urine RME
o Serum creatinine
o HBsAg

**USG report of choledocholithiasis: dilated CBD, bright echogenic structure casting posterior acoustic
shadow. GB thickened, fibrosed, shrunken/contracted.

Q. Give a flowchart of investigations to reach a definitive diagnosis

Q. How will you prepare a case of obstructive jaundice for operation?

Ans:

➢ Appropriate investigations to reach a definitive diagnosis

➢ Correction of fluid and electrolyte imbalance
o Correction of dehydration: adequate hydration/transfusion
o Correction of dyselectrolytemia
➢ Nutritional status improvement
o Replenishment of glycogen store: 5% DA/ 5% DNS
o Regular high protein diet
o Albumin containing solution
➢ Correction of coagulopathy
o Injection Vitamin K IV
o Follow up by PT
o If not improved: FFP
➢ Control of infection
o Cefuroxime
o Lactulose
o Neomycin
➢ Correction of anemia: blood transfusion
➢ Prevention of hepato-renal syndrome
o Adequate hydration
o DA/DNS
o Monitor urine output at least 40 mL/hour
o If not maintained: use diuretics
▪ Mannitol
▪ Furosemide
o If stil not treated
▪ Dopamine
▪ Dialysis

Q. Risks of operation of a patient with obstructive jaundice?

63
Ans:

➢ Fluid and electrolyte

o Dehydration
o Hypovolemia
o Hypokalemia
➢ Coagulation function
o Hemorrhage
o DIC
➢ Renal function
o Hepato-renal syndrome
o AKI
➢ Wound healing
o Impaired wound healing
o Wound infection
o Anastomotic leakage
o Sepitcemia
➢ Drug metabolism hampered: chance of overdose and toxicity
o Antibiotic
o Sedative

Q. What do you mean by Courvoisier’s law?

Ans:

➢ Palpable gall bladder in obstructive jaundice → most likely to be due to malignant biliary
obstruction
➢ If there is stone, it is due to chronic cholecystitis → in that case GB is shrunken and will most
likely be non palpable
➢ Exception
o Palpable GB with benign cause
▪ Mucocele
▪ Stone in hartman’s pouch
▪ Double impaction
o Non palpable GB with malignant cause
▪ Previous cholecystectomy
▪ Intra-hepatic gallbladder
▪ Congenital absence of GB

Choledocholithiasis
Q. Treatment options of choledocholithiasis

Ans:

64
 ➢ Pre-operative preparation accordingly
➢ If stone size/CBD diameter is less (less than 15 mm): ERCP: endoscopic sphincterotomy and
stone extraction by dormia basket
➢ If stone size/CBD diameter is more (>15 mm):
o Cholecystectomy with choledocholithotomy followed by T tube drainage

Q. Indications of CBD exploration

Ans:

➢ obstructive jaundice
➢ stone in CBD
➢ dilated CBD
➢ abnormal LFT
➢ failure of stone extraction by ERCP

T-tube management
Q. discuss post operative t-tube management after choledocholithotomy

Ans:

➢ Placement of tube:
o A saline bag is attached
o Bile is drained in the bag
o Observe bile for: quantity, color of bile
➢ Drainage of bile up to 7th POD
➢ Progressive clamping on 7th, 8th, 9th POD
o 4 hours on 7th POD
o 12hours on 8th POD
o 24 hours on 9th POD
➢ Check for the following during clamping (charcot’s)
o Jaundice
o Fever
o RUQ pain
➢ T tube cholangiogram on 11th POD: to see retained/residual stone
➢ Removal of the T-tube cholangiogram on 12/13th POD
o By slow and gentle traction
o Prerequisite for removal
▪ Jaundice subsided
▪ Color of stool, urine normal
▪ Bile drained thru T tube is gradually decreasing

Choledochal cyst
(5 year old boy, upper abdominal pain, jaundice, generalized itching, palpable non tender lump in right
upper abdomen for 3 months. )

65
**choledochal cyst: congenital condition of the extra and intrahepatic biliary tree\

**infant, children usually; RUQ pain, Jaundice, fever, palpable abdominal mass (mass appears and
disappears), failure to thrive

Q. investigation of choledochal cyst

Ans:

➢ LFT: raised biliruibin, ALP, ALT slightly

➢ Imaging
o USG: unilocular cyst seen + dilatation of the biliary channels both intra and extraheptic
o CT scan
o MRCP
o ERCP
o PTC

Q. Preparation of this patient for surgery: same as for OJ

Laparoscopic cholecystectomy
Q. What do you mean by Lap. Chole

Ans: removal of GB….by means of laparoscope….w/o opening the abdominal cavity

Q. Describe the steps of lap. Chole

Ans:

➢ Position: reverse trendelenberg: supine, head end up, slightly rotated to the left
➢ Anesthesia: General anesthesia
➢ Abdomen prepared (paintaing and draping)
➢ Establish pneumoperitoneum: infuse CO2 after creation of sub-umbilical port
➢ Enter camera through sub umbilical port : 30 degree angled telescope is preferred
➢ Other ports created
o Subxiphoid/epigastric
o Right subcostal
➢ In RT position: Fundus of GB exposed: it is retracted towards the diaphragm
➢ Neck of GB: retracted towards RIF: callot’s triangle exposed
➢ After clearly defining the anatomy and identifying cystic duct and cystic artery
➢ Clipping and division of cystic duct and cystic artery
➢ GB is removed from the whole GB bed
➢ GB Removed via umbilicus
➢ Then normal saline washout is done, any bleeding points are cauterized

66
Q. What are the ports in lap chole.

Ans:

➢ Sub-umbilical port: 10 mm: for creation of pneumoperitoneum and camera

➢ Sub-xiphoid/epigastric port: 10 mm: working hand of surgeon
➢ 5 mm ports
o Right subcostal: one in anterior axillary, another in mid axillary line

Q. Mention the port related complications of lap. Chole

Ans:

➢ Injury to
o Gut
o Blood vessel
➢ Hemorrhage
➢ Infection
o Wound infection
o Peritonitis
o Septicemia
➢ Herniation of viscera
➢ Seeding of cancer cells
➢ Peritoneal adhesion

Q. Short note: Lap. Chole

Ans:….

Complication of lap chole:

➢ Injury
➢ Hemorrhage
➢ Accidental ligation of CBD
➢ Retained stone
➢ Abscess
➢ Other complication
o Respiratory
o Cardiac
o Renal
o CNS
o Wound infection

67
Pancreas
Acute pancreatitis
Scenario: sudden severe upper abdominal pain radiating to the back + vomiting

Q. Etiology of acute pancreatitis (not DU)

Ans:

➢ Gallsone
➢ Alcoholism
➢ Post ERCP
➢ Abdominal trauma
➢ After surgery in GIT, biliary tract, cardiothoracic surgery
➢ Ampullary tumor
➢ Drugs
➢ Hypercalcemia
➢ Hyperparathyroidism
➢ Autoimmune pancreatitis
➢ Hereditary pancreatitis
➢ Viral infection

Q. Clinical feature of acute pancreatitis

Ans:

Symptoms:

➢ Pain
o Sudden
o Severe
o Epigastric pain
o Radiated to the back
o Duration: hours/days
o Relieved on bending forward
o Doesn’t respond to usual dose of analgesics
➢ Nausea, vomiting, retching
➢ Fever
➢ Hiccough

Signs:

➢ General
o Pt toxic
o Signs of shock (tachycardia, tachypnea, hypotension)
o Fever
o SIRS

68
 o Mild jaundice
➢ Abdomen
o Grey turner sign and Cullen sign
o Distended abdomen: ascites/int obstruction
o Epigastric mass
o Muscle guarding
o Shifting dullness
o Silent abdomen (paralytic ileus)

Q. D/D of acute pancreatitis

Ans:

➢ Perforated PUD
➢ Acute cholecystitis
➢ Ruptured ectopic pregnancy
➢ Ruptured aortic aneurysm
➢ DKA
➢ Inferior MI

Q. Investigations of acute pancreatitis

Ans:

➢ Blood
o CBC, ESR: leukocytosis, raised ESR, HCT high due to dehydration, low due to blood loss
o Serum amylase: raised 3x
o Serum Lipase: more specific + persists longer
o LFT: s. bilirubin raised, ALP/ALT maybe raised
o Coagulation profile
o ABG/SPO2
o Blood urea: maybe raised if shock
o S. creatinine: raised if shock and oliguria
o S. electrolytes: there maybe hypocalcemia
o RBS: hyperglycemia
➢ Urine
o Urine RME
o Urinary amylase: increased
➢ Imaging
o Abdominal X ray
▪ Intestinal obstruction
• Sentinel loop
• Colon cut off sign
• Air fluid level
▪ Calcified/stone in pancreatic duct and CBD/gallbladder
▪ Peri-renal halo
▪ Obliteration of psoas shadow

69
 ▪ Exclude other d/d e/g perforation
o Chest X ray
▪ Left sided pleural effusion
o USG
▪ Ascites
▪ Peri-pancreatic collection/swelling (hard to see)
▪ Gall stone
▪ Biliary tree dilatation
o CECT: peri-pancreatic collection, necrosis, pancreatic pseudocyst
o MRCP: see pancreatic duct, CBD stone
o ERCP
➢ Diagnostic/exploratory laparotomy

Q. Early management/immediate/initial management of acute severe pancreatitis

Ans:

➢ Admission to HDU/ICU
➢ Oxygenation
➢ Fluid resuscitation
➢ Strong analgesics
➢ Catheterize and monitor urine output
➢ Prophylactic antibiotics
➢ Anti-emetic
➢ Anti-ulcerant
➢ Nutritional support: NG feeding
➢ Monitoring of: vital sign, urine output, ABG, Spo2
➢ Supportive therapy for organ failure
o Ventilator (resp failure)
o Dialysis (renal failure)
o Inotropes (cardiac failure)
➢ Stabilize the patient and then consider next plan of treatment

Q. Surgical management of acute pancreatitis

Ans: initial treatment: same as above

If there is stone: Stone removal

In case of necrotizing pancreatits: surgery/necrosectomy + peritoneal lavage + insertion of drain tube

Q. complications of acute pancreatitis

Ans:

➢ Systemic (during 1st week)

o CVS

70
 ▪ Shock: septic, hypovolemic
▪ Arrhythmia
o Resp
▪ ARDS (due to sepsis)
o Renal
▪ Renal failure
▪ AKI
o GIT
▪ Ileus
o Neurological
▪ Confusion
▪ Irritability
▪ Encephalopathy
o Hematological
▪ DIC
o Metabolic
▪ Hyperglycemia
▪ Hyperlipidemia
▪ Hypocalcemia
o Miscellaneous
▪ Subcutaneous fat necrosis
▪ Arthralgia
➢ Local (after 1st week)
o Acute peri-pancreatic fluid collection
o Sterile pancreatic necrosis
o Infected pancreatic necrosis
o Pancreatic abscess
o Pancreatic pseudocyst
o Pleural effusion
o Ascites
o Portal/splenic vein thrombosis
o Progression to chronic pancreatitis

Q. Mention the ranson criteria of acute pancreatitis

Ans: It is a diagnostic tool that is used to determine whether a patient has severe pancreatitis.

A patient is more likely to have severe pancreatitis if:

➢ On admission
o Age > 55y
o WBC count > 16k
o Blood glucose >11.1 mmol/L
o LDH elevated
o AST > 250
➢ Within 48 hours

71
 o HCT decreases more than 10%
o BUN increases more than 5 mg/dL than normal
o PaO2 <60 mmHg / 8 Kpa
o Serum calcium <2 mmol/L
o Base deficit: >4 mmol/L
o Fluid sequestration > 6 liter

**in Glasgow: there is extra: serum albumin

Pancreatic pseudocyst
Scenario: person presented with painless upper abdominal mass for 1 month. Hx of severe acute
abdominal pain 2 months back that was treated conservatively in a hospital

Q. Short note:

Ans:

➢ Defn: collection of amylase rich fluid in cavity lined by granulation tissue

➢ Represents acute peripancreatic fluid collection that has not resolved and has matured
➢ Takes 4 weeks to develop after attack of AP

Q. Management of pancreatic pseudocyst

Ans:

Site: in the lesser sac

Clinical features:

➢ History of attack of AP few weeks/months back (sudden severe epigastric pain radiating to the
back
➢ Palpable mass in the epigastric region
o Globular
o Soft
o Retroperitoneal mass
o Doesn’t move with respiration
➢ Weight loss
➢ Jaundice
➢ Mild fever

Investigations:

➢ Blood
o LFT: maybe elevated
o CBC: leukocystosis
o Serum amylase/lipase: maybe elevated
➢ Imaging
o USG: size + thickness
o CT scan/CECT: best inv: size, thickness, necrotic tissue, state of pancreas

72
 o MRCP: ductal communication
o ERCP
o Endoscopic aspiration of fluid and cytology + CEA level (to exclude cystic neoplasm of
pancreas)

Treatment:

➢ Conservative (spontaneous resolution)

➢ Drainage
o Percutaneous drainage
o Endoscopic drainage
o ERCP drainage
o Surgical
▪ Cyst-gastrostomy
▪ Cyst-jejunostomy

Q. complications if not treated properly

Ans:

➢ Infection
o Pancreatic abscess
o Sepsis
➢ Rupture
o Into gut: fistula
o Into peritoneum: peritonitis
➢ Enlargement + pressure effect
o Compression of CBD: OJ
o Bowel obstruction
o Pain
➢ Erosion into blood vessel
o Hemorrhage/hemorrhagic shock
o Hemoperitoneum

73
Spleen
Q. Function of spleen in our body

Ans:

➢ Immune function: contains lymphocyte

➢ Filter function: has macrophage, does opsonization
➢ Removal of inclusion from RBC: such as parasite
➢ Reservoir function: hypersplenism
➢ Hematopoiesis: in intra-uterine life

Q. What do you mean by hypersplenism? (not DU)

Splenic rupture
Scenario: left lower chest pain, abdominal distension, shock following RTA

Q. How many ways can a patient with splenic rupture present, write down the classical presentation.

Ans:

Splenic rupture can present in 3 ways

➢ Early presentation
o Rapid development of shock → fast deterioration → death
o Shock, LUQ pain, tenderness → later bleeding (hemoperitoneum, hemothorax)
➢ Delayed presentation
o Initial injury and pain → settles → 15 days asymptomatic period → shock and
progressive bleeding

Classic presentation of splenic rupture

➢ History of trauma
➢ LUQ pain, tenderness
➢ Sign
o General
▪ Pallor
▪ Tachycardia
▪ Tachypnea
▪ Low BP
▪ Restlessness
o Abdominal
▪ LUQ tenderness
▪ Muscle guarding
▪ Kehr’s sign: referred pain in tip of left shoulder
▪ Abdominal distension (hemoperitoneum)
▪ Dullness in left flank without shifting (Balance’s sign)

Q. Physical findings on abdominal examination of splenic rupture

74
(From above)

Q. Radiographic findings of this case on plain x ray of abdomen

Ans: Investigations in splenic rupture

➢ CBC, blood grouping, cross matching

➢ USG W/A: FAST (focused abdominal sonar for trauma)
➢ Abdominal X ray
o Obliteration of splenic outline
o Obliteration of left psoas shadow
o Indentation of fundic gas
o Fracture of adjacent ribs
o Elevation of left side of diaphragm
o Free fluid b/n coils of intestine
➢ CT scan
➢ Diagnostic peritoneal lavage

Q. D/d of splenic rupture

Ans:

➢ Left kidney injury

➢ Fracture of lower ribs

Q. Treatment plan

Ans:

➢ Initial
o Resuscitation
o ABC management
o Blood transfusion
o Antibiotic
o Proper assessment of injury + associated lesion
➢ Conservative management
o Indication
▪ Grade I, II, III
▪ Pt is hemodynamically stable
o Bed rest
o Followup of the invetigations
o Angiographic embolization (maybe tried)
➢ Surgical management: for grade IV, V, if patient’s hemodynamic status remains unstable
o Splenectomy
o Splenorrhaphy
o Mesh repair

75
Splenectomy
Q. Indications of splenectomy

Ans:

➢ Splenic rupture
o Traumatic
o Iatrogenic
➢ Oncological
o Part of radical gastrectomy
o Part of distal/total pancreatectomy
o Neoplasm of spleen
➢ Infective
o Splenic abscess
o Hydatid cyst
➢ Hematological
o Hereditary spherocytosis
o Thalassemia
o ITP
➢ Portal Hypertension

Q. common indications of splenectomy

Q. Absolute indications of splenectomy

Ans:

➢ All the indications except the hematological ones

➢ In splenic injury: say non salvageable splenic injury

Q. Preparation of a patient before splenectomy

Ans:

➢ Correct coagulopathy and other hematological status

o Blood transfusion
o FFP
o Platelets
➢ Antibiotic prophylaxis
➢ Prophylactic vaccination against capsulated organism
o Pneumococcus
o Meningococcus
o Hemophilus influenzae

Q. Post-operative complications of splenectomy

76
Ans:

➢ Immediate
o Hemorrhage
o Shock
o Injury to: stomach, pancreas
o Fistula b/n stomach and large gut
o Collapse of left lower lobe of lung (left basal atelectasis)
o Left sided pleural effusion
o Pancreatitis
o Pancreatic fistula
o Hematemesis/meleana: due to gastric mucosal injury
➢ Late
o Post splenectomy septicemia
o Opportunistic post splenectomy infection (OPSI)
o Sub-phrenic abscess
o Venous thromboembolism
o DIC

77
Urology
Hematuria
Q. Name the causes of hematuria

Ans:

➢ According to pain
o Painful
▪ UTI
▪ Stone
▪ Trauma
o Painless
▪ Renal TB
▪ Renal Tumor
▪ Tumor of urethra, bladder, prostate
▪ Glomerulonephritis
▪ Acute tubular necrosis
▪ Acute interstitial nephritis
▪ Bleeding disorder
▪ Anticoagulant therapy
➢ According to hematuria visibility
o Visible hematuria (frank/gross)
▪ Stone
▪ Trauma
▪ Tumor
o Non visible hematuria (microscopic/dipstick)
▪ Acute glomerulonephritis
▪ Interstitial nephritis
▪ Black water fever
➢ According to timing of bleeding in relation to urinary stream
o Initial: urethral pathology
o Throughout the stream: bladder pathology/upper
o Terminal: pathology of prostate, bladder neck

Q. A patient presents with hematuria. How will you approach to diagnose the patient?

Ans:

History:

➢ Age
➢ Color: gross red or smoky
➢ Timing of bleeding, in relation to urinary stream
o Initial
o Throughout the stream

78
 o Terminal
➢ Associated with pain
➢ Associated loin pain
➢ Any feeling of lump by the patient (loin pain + painless hematuria + lump in loin = renal tumor)
➢ Associated feature: urinary urgency, frequency, retention, weight loss, edema, recent skin
indection, fever

Examination:

➢ General examination for anemia, wt loss, lymph nodes

➢ Examination of abdomen: kidney, urinary bladder, lymph nodes
➢ DRE, for examination of prostate

Investigation

➢ Urine RME
➢ Urine for C/S
➢ Urine cytology for malignant cells
➢ Coagulation profile
➢ Renal function test
➢ USG: stone, tumor
➢ IVU: to see kidney function and anatomy
➢ CT scan of abdomen
➢ Cystourethroscopy

Q. Indication of cystoscopy

Ans:

➢ To examine:
o Urethra
o Bladder
o Ureter
o Kidney
➢ To visualize bladder fistula
➢ To treat
o Stricture urethra (urethrotomy)
o BPH and Ca Prostate (TURP = trans urethral resection of prostate)
o Bladder tumor = resection
o Bladder stone – removal
o Posterior urethral valve: to destroy/fulgurate
o Catheterization of ureter

79
Anuria, oliguria

Q. Define anuria:

Ans: Anuria is defined as the complete absence of urine production

Q. Define oliguria

Ans: oliguria is defined when less than 300 mL of urine is excreted in a day

Q. Mention the causes of anuria/oliguria

Ans:

⮚ Pre renal
o Hypovolemia
o Blood loss
o Sepsis
o Cardiogenic shock
o Anesthesia
⮚ Renal
o Drugs
o Poison
o Radiologic contrast media
o Mismatched blood transfusion
o Myoglobinuria
o Eclampsia
o DIC
⮚ Post renal/obstructive
o Stone/calculi
o Pelvic tumors
o Surgery
o Retroperitoneal fibrosis
o Schistosomiasis
o Crystalluria

Q. Management of pre renal anuria

Ans:
➢ Aim
o Restoration of circulatory volume deficit
o Correction of tissue hypoxia
➢ Monitor
o Pulse oximeter
o BP
o SVP
o Pulse

80
 o Serum urea, creatinine level
o Serum electrolyte level
o ECG
➢ IV fluid
➢ 100% O2
➢ Inotropic support (dopamine) → improve cardiac function → increase renal blood flow
➢ Diuretic
o Frusemide
o Mannitol (plasma expander + osmotic diuretic)
➢ Correction of hypokalemia (life threatening)
o Calcium gluconate
o Calcium resonium (enema)
➢ Correction of metabolic acidosis: NaHCO3 (should not be used at 1st detection of acidosis)
Other support: supportive
➢ Nutrition
➢ Control of infection
➢ Renal support
o Hemodialysis
o Peritoneal dialysis

Retention of urine
Q. Define retention of urine

Ans:

➢ Inability to pass urine

➢ Despite normal production of urine

Q. Causes of urinary retention:

Ans:

➢ Mechanical
o Intraluminal:
▪ Stone
▪ Clot
▪ foreign body
▪ valves (congenital anomaly)
o Intramural:
▪ trauma (rupture of urethra),
▪ stricture,
▪ urethritis,
▪ tumor,
▪ BPH

81
 o Outside the wall:
▪ Phimosis
▪ Paraphimosis
▪ pregnancy,
▪ fibroid,
▪ ovarian cyst
➢ Neurogenic
o Diabetes mellitus
o Denervation of bladder
o Spinal cord
▪ Injury
▪ Disease
▪ Spinal anesthesia
o CNS disease: MS
o Psychogenic
o Drugs
▪ Anticholinergic
▪ Antihistamine
▪ Smooth muscle relaxant
▪ Alcohol

Q. Causes of acute urinary retention (many causes from above)

Ans:

➢ Male
o Bladder outlet obstruction
o Stricture
o Acute urethritis
o Acute prostatitis
o Phimosis
➢ Female
o Retroverted gravid uterus
➢ Both
o Stone in urethra
o Clot
o Ruptured urethra
o Injury to spinal cord
o Anesthesia
o Post-op analgesia
o Drugs
o Anal pain (after hemorrhoid surgery)

Q. Causes of urinary retention in pediatric age group

82
Ans: (mainly congenital anomaly)

➢ Congenital urethral stenosis

➢ Congenital urethral valve
➢ Phimosis
➢ Paraphimosis
➢ Acute urethritis

Q. Management of a case of acute retention of urine (stone, clot, stricture, injury, BPH, pregnancy,
phimosis, paraphimosis….)

Ans:

➢ Clinical feature
o No urine passed for several hours
o Pain in lower abdomen
o Visible, palpable, tender abdomen
o There may be sign of neurological problem
▪ Assess by neurological examination
o Sign of associated causes
▪ Bladder: tender, tense, dull on percussion
▪ DRE: prostate
▪ Female: PVE
▪ Neurological examination
➢ Investigation
o Imaging (see stone, stricture, FB)
▪ X ray KUB
▪ Intra venous urography
▪ USG of KUB
o Cystoscopy
o NCS, EMG (for neurological causes)
o Urine RME (after catheterization/suprapubic puncture)
➢ Treatment
o Reassurance
o Warm bath in case of post-operative retention
o Urethral catheterization (gentle attempt)
o If failed to catheterize, the causes may be
▪ Urethral trauma
▪ Stricture
▪ Indwelling stone/clot
o If failed to catheterize, do
▪ Supra pubic puncture
▪ Urethral instrumentation
o After successful passage of urine, manage the underlying cause

83
Q. Chronic retention of urine (not in DU)

Ans:

➢ 2 types
o High pressure type: bladder outlet obstruction → pressure in upper parts of urinary
tract → dilatation of the proximal ducts → renal failure (post renal)
o Low pressure type: due to bladder muscle atony → no backpressure effect on kidney
o Low type
➢ History
o Age: male (BPH)
o Pt may be unaware
o Hx of hesitancy
o Poor flow
o Post micturition dribbling
o Painless
o Nocturia
o Overflow incontinence
➢ Examination
o Bladder palpable
o Not tense or tender
o Dull on percussion
o Fluid thrill present
o Fluctuation test +ve
o Signs of underlying cause may be present
➢ Investigation
o Urine RME
o X ray KUB
o IVU
o USG KUB
o Cystoscopy
o Serum urea
o Serum creatinine
➢ Treatment
o General supportive management
o Treatment of underlying cause

Q. Difference between acute and chronic retention of urine

Ans:

Acute retention Chronic retention

84
 Passage of urine Absent Decreased, relieved with
overflow incontinence
Pain Present Absent
Overflow incontinence Absent Present
Chornic change in urinary Absent Present
passage
Renal failure Less likely More likely with high pressure
type
Treatment Immediate relief by Mainly, treatment of the
catheterization/SPC; then treat underlying cause
underlying cause

Investigation in Urology

Q. Name the imaging investigations commonly done in neurological cases

Ans:

Investigations Extra info (not needed)

Plain X Ray of Kidney, ureter and bladder (X ray
KUB)
Intra venous urogram (IVU)
Cystoscopy
Retrograde pyelography (RGP)
Size of kidney
Stone
Calcification
Lesion in bladder, prostate, urethra
A KUB should be done first
IV contrast given (urograffin)
Serially, multiple x rays are taken
Early x rays show kidney pathology, the latest
ones shows bladder pathology
See details in above question
Cystoscope entered → catheter entered → dye
injected to ureter → reaches kidney → visualized

Used to see: renal TB, renal tumor

MCU (micturition cystourethrography) Catheter passed in bladder → dye injected in
bladder → xray taken during micturition →
reflux is tested

Used to see: vesico-ureteric reflux

CT scan
MRI
PET-CT

Other investigation in urology:

85
 ➢ Blood test:
o CBC
o Serum urea
o Serum creatinine
o Serum electrolytes
o eGFR
o tumor markers
o PSA
➢ Urine
o Urine RME

Q. Short note: Intravenous Urogram (IVU)

Ans:

➢ Bowel preparation (to clear bowel, otherwise ureter and kidney maynot be seen well)
➢ Drugs for preparation
o Gut preparation
▪ Low residual diet
▪ Activated charcoal
▪ Laxative
o Pre-requisite
▪ Inj Hypaque, urograffin/iodinated contrast (IV contrast)
▪ Inj. Chlorpheniramine (antihistamine)
▪ Inj. Dexamethasone/Hydrocortisone
▪ Syringe, butterfly needle etc.
➢ An Xray KUB should be done first
➢ Overnight fasting
➢ IV contrast given ()
➢ Serially, multiple x rays are taken
➢ Early x rays show kidney pathology, the latest ones show bladder pathology
➢ Indication
o Hydronephrosis
o Congenital anomaly
▪ Horseshoe kidney (flower vase appearance)
▪ PKD
▪ Double kidney
▪ Double ureter
▪ Ureterocele (cobra head appearance)
o Renal cell carcinoma
o Renal stone
o Renal injury
➢ Contraindication
o Hypersensitivity to IV contrast

86
 o Acute renal failure

Hydronephrosis
Q. Define hydronephrosis

Ans:

➢ It refers to
➢ Aseptic dilatation of urinary tract (mainly pelvis and renal calyces)
➢ due to urinary tract obstruction

Q. Causes of hydronephrosis (**PUJO = Pelvi-ureteric junction obstruction)

Ans:

➢ unilateral
o intraluminal: stone in renal pelvis, papilla; sloughed papilla in case of papillary necrosis
o intramural: congenital PUJO, Ureter cancer, stricture ureter
o extramural: ca cervix, ca rectum, retroperitoneal fibrosis
➢ bilateral (causes of chronic retention of urine)
o congenital
▪ meatal stenosis (pin hole meatus)
▪ posterior urethral valve (failure of canalization)
o acquired
▪ BPH
▪ Ca prostate
▪ Ca cervix
▪ Ca rectum
▪ Post operative fibrosis/stricture of bladder neck
▪ Phimosis

Congential PUJO: most common cause

Q. Cause of bilateral enlargement of kidney

Ans:

➢ Bilateral hydronephrosis and all its causes

➢ Polycystic kidney disease

Q. Management of a case of hydronephrosis (not in DU)

Ans: Clinical feature

➢ Unilateral

87
 o Unilateral loin pain (mild)
o Unilateral loin mass
o Acute renal pain + mass, that goes away with passage of large volume of urine (Dietl)
o Hematuria, dysuria, renal angle tenderness
➢ Bilateral
o Due to lower urinary tract obstruction (LUTO)
▪ Loin pain
▪ Frequency, hesitancy, poor stream
o Due to UUTO
▪ Loin pain
▪ Loin mass
▪ Renal colic
▪ Features of renal failure

Investigation

➢ Serum urea, serum creatinine

➢ Urine RME
➢ USG abdomen: see swollen kidneys
➢ IVU:
o Renal pelvis: dilated
o Calyces become club shaped
➢ Best test: isotope renography

Treatment

➢ In mild cases, follow up by repeated USG

➢ If indication present, surgery done
o Pyeloplasty (a new PUJ is formed)
o Endoscopic pyelolysis (balloon dilatation at PUJO)

Renal Stone
Q. Mention the causes of renal stone

Ans:

➢ Idiopathic calcium stone

➢ Hypercalcemia (metastatic calcification)
o Primary hyperparathyroidism
o Prolonged immobilization (due to bone resorption)
o Milk alkali syndrome (hypercalcemia and alkalosis, due to ingestion of large amount of
Ca, Vit D, alkali)
o Sarcoidosis (granuloma produces excess vitamin D → hypercalcemia)
o Disseminated cancer/hyperthyroidism

88
 ➢ Renal tubular syndrome (in these cases, urine becomes acidic and stone precipitates)
o Renal tubular acidosis type I
o Cystinuria (defect of some amino acid reabsorption in renal tubule) (cysteine stone)
➢ Uric acid stone
o Hyperuricemia/Gout
o Excessive acidic urine
o Excess cellular breakdown/turnover (tumor lysis syndrome)
➢ Enzyme disorder
o Primary hyperoxaluria (oxalate stone)
o Xanthinuria (xanthine stone)
➢ Secondary stones
o Secondary hyperoxaluria
o Diet: tea, oxalate, chocolate, cocoa may cause
o Infection/UTI by proteus: urease produced by Proteus → urea breaks down to ammonia
and co2 → urine alkaline → formation of struvite Mg(NH4)Po4 stone → formation of
staghorn calculi (also by Psuedomonas, staph; but never by E coli) (phosphate/struvite
stone)
o Obstruction in urinary tract
o Stasis of urine
o Urinary diversion
o Drugs (thiazide, acetazolaminde, allopurinol)
➢ Other factors
o Geography
o Climate (hot climate)
o Water intake
o Diet
o Occupation (sedentary job)

Q. Types of renal stone (COXUP)

Ans:

➢ Oxalate stone (in oxaluria; sharp pointed stone with irregular shape) (Calcium oxalate stone =
most common kidney stone) (hyperoxaluria – primary)
➢ Phosphate stone: includes,
o Struvite stone (Mg NH4 PO4): in proteus UTI → causes staghorn calculi (infection)
➢ Uric acid stone: Radiolucent stone (seen in CT, rather than X ray) (hyperuricemia)
➢ Urate stone
➢ Cysteine stone (cystinuria)
➢ Xanthine stone (rare)
➢ Calcium stone (hypercalcemia/idiotpathic)

Q. Management of renal stone

89
Ans: (scenario: fixed dull aching pain in loin….pain increases on movement, relieves on rest, hematuria)

Clinical feature

➢ Pain (dull aching 1st, then colicky)

o Renal pain (In renal angle – dull aching pain, dragging pain, that increases with
movement and relieves with rest) (when stone in calyces)
o Acute ureteric colic (loin to groin – severe pain) (when stone in pelvis)
➢ Hematuria
➢ Pyuria (fever maybe present)
➢ Renal angle tenderness

Investigation

➢ To detect stone
o Non contrast CT scan (earliest inv)
o Plain X ray KUB (to see whether stone is radio opaque, and whether x ray can be used
to follow up)
o USG abdomen
➢ Other inv (to identify the cause + extent of lesion)
o Blood tests: urate, phosphate, oxalate, PTH level, S. calcium
o Urine test: RME, CS, calcium, urate
o IVU

Treatment:

➢ General rx: NSAID for pain relief + monitor patient + antibiotic + plenty of fluid
➢ Expectant (stone <5 mm will pass away spontaneously -follow up later)
➢ Surgical (to relieve symptoms by removing/destroying stone)
o Minimal access methods
▪ Extra corporeal shockwave lithotripsy (ECSWL)
▪ Percutaneous Nephrolithotomy (PCNL)
▪ Ureteroscopy
• Followed by dormie basket stone retrieval
• Or followed by lithotripsy (litholaplaxy)
o Open surgical methods (pyelolithotomy, nephrolithotomy, partial/total nephrectomy)
➢ Medical (to prevent future stone)
o Hypercalcemia: increase fluid intake, calcium binding agent
o Renal tubular acidosis and cystinuria: NaHCO3/KHCO3 (make urine alkaline)
o Uric acid stone: allopurinol
o UTI: antimicrobials

Q. How will you prevent recurrence of renal stone? (DU)

Ans: I will investigate the underlying cause of stone and treat the cause.

Investigation:

90
 ➢ Blood tests: urate, phosphate, oxalate, PTH level, S. calcium
➢ Urine test: RME, CS, calcium, urate

Upon establishing a cause, following measures are to be taken

➢ Hypercalcemia: increase fluid intake, calcium binding agent
➢ Renal tubular acidosis and cystinuria: NaHCO3/KHCO3 (make urine alkaline)
➢ Uric acid stone: allopurinol
➢ UTI: antimicrobials
➢ General
o Good urinary hygiene
o Avoid excess chocolate, cocoa
o Always maintain good hydration

Q. Plain X ray KUB shows radio-opaque shadow in right/left lumbar region. What might be the causes?
(not only renal stone)

Ans:

➢ Kidney
o Renal stone
o Calcification due to renal TB
o Calcified adrenal gland
➢ Calcified lymph node
➢ Calcification of wall of veins
➢ GIT
o Gallstone
o Concretion/thick secretion in appendix
o Tablet in gut
o Foreign body in gut

Q. SN: ECSWL (Not DU)

Ans: Extra corporeal shock wave lithotripsy (shockwave created outside body → reaches stone →
crushes it)

➢ Non invasive method of rx of urinary tract stone

➢ Now, the most common method of treating stone
➢ Generation of shockwave and crushing of stone, then stone fragments pass thru urine (a
ureteric stent is placed to prevent impaction of fragments)
➢ May remove stone upto 1.5 cm
➢ Prophylactic antibiotics given beforehand
➢ Complication: hematuria, renal hemorrhage, peri renal hemorrhage, infection due to passage of
infected stone

91
 ➢ Cysteine stone cannot be removed by ECSWL (very hard)
➢ Contraindication: bleeding disorder, obese pt (shockwave cannot penetrate thick layers of fat)

Q. PCNL: SN (not du)

Ans:

➢ Communication created between skin and pelvis-calyces by puncture and incision in loin
➢ Tube inserted that collects stones form pelvis-calyces and drain outside skin
➢ Indication
o Stone larger than 2.5 cm
o Stone that cannot be removed by ECSWL + its contraindications
o Large stone (struvite) or hard stone (cysteine)
o Presence of renal stone with pyonephrosis (pus/abscess in kidney)
➢ Complication
o Injury to spleen, lung, colon
o Hemorrhage
o Sepsis
o Retained stone

Stone <0.5 cm: spontaneous, upto 1.5 cm: ECSL, larger than 2.5 cm: PCNL

92
Ureteric stone
Q. Mention the common sites of stone impaction in ureter/mention the normal anatomical narrowings
in ureter:

Ans:

93
Q. Management of ureteric stone (In DU, only treatment comes, but read the clinical feature for viva –
severe loin to groin pain and tip of penis)

Ans:

Clinical feature

➢ Pain (severe colic, then dull aching, then disappear)

o Ureteric colic (severe loin pain radiates to the groin and also to tip of penis) (due to
peristaltic effort to pass stone)
o Impaction of stone: consistent dull pain (impaction in the anatomical narrowing)
o Complete cessation of pain after 1-2 days: indicates complete obstruction of that
ureter (paralytic ileus of involved ureter)
➢ Hematuria
➢ Abdomen: tender along pathway of ureter
➢ Rule out appendicitis

Imaging:

➢ Non contrast CT scan

➢ X ray KUB
➢ IVU
➢ Cystoscopy
➢ Retrograde uretero/pyelography

Treatment:

➢ Pain: NSAID + diet + water intake

➢ Small stone: will go away spontaneously (<0.5 cm)
➢ Surgery for removing stone
o Endoscopic/ureteroscopic stone removal
▪ Dormia basket stone removal
▪ Laser destruction
▪ Stone pushed up to kidney → later destroyed by ECSWL (push bang)
▪ Widening of ureter narrowing with diathermy knife (urteric meatectomy)
o ECSWL (lithotripsy in situ) (not for stone with prolonged obstruction)
o Open surgery: ureterolithotomy

(stone in upper 1/3: ECSWL / Push bang;

stone in middle 1/3: Ureteroscopic laser destruction/open surgery ;

stone in lower 1/3: Ureterscopic laser destruction/endoscopic dormia basket)

94
**role of ECSWSL in ureter stone:

➢ Push bang: stone in ureter upper 1/3: passed upwards by ureteroscope → destroyed later by
ECSWL
➢ Lithotripsy in situ (stone in upper 1/3) (not done if complete obstruction/prolonged impaction)

Renal Neoplasm
Q. Classify the tumors of kidney

Ans:

➢ Benign
o Adenoma
o Angioma
o Angiolipoma
➢ Malignant
o Primary
▪ Renal cell carcinoma (adenocarcinoma)
▪ Wilm’s tumor/nephroblastoma
▪ Uroethelial carcinoma of kidney and pelvis
▪ Squamous cell carcinoma
o Secondary: metastasis from other organs

Q. Clinical features of renal cell carcinoma (In du, only clinical feature)

Ans: (arises from epithelium of PCT, types are: clear cell RCC, papillary RCC, chromophobe RCC)

➢ Gender: more in males

➢ Classical triad: (seen in <10% pt)
o Loin mass
o Hematuria
o Loin discomfort/pain
➢ Features of malignancy
o Anemia
o Cachexia
o Weight loss
➢ Atypical presentation:
o Fever (PUO)
o Polycythemia/erythrocytosis (excess EPO)
o Features of hypercalcemia
➢ Symptoms of metastasis (bone pain, lung problem etc)
➢ Examination
o Hypertension

95
 o There may be left sided varicocele (obstruction of renal vein by tumor)

Q. Investigation: (not DU)

Ans:

➢ Urine RME (hematuria)

➢ To investigate hematuria and confirm presence of RCC:
o USG (+doppler to see tumor thrombus in IVC)
o CT scan
o IVU
➢ Staging
o CECT
o MRI
o Chest x ray (lung metastasis)
o Bone scan (bone metastasis)

Q. Treatment options (not DU)

Ans:

➢ Organ confined disease: surgery

➢ Metastatic disease: Tyrosine kinase inhibitor

Surgery

➢ Partial nephrectomy: in tumor <7 cm

➢ Total nephrectomy
➢ If IVC invaded, tumor should be cleared form IVC as well

Medical management:

➢ Tyrosine kinase inhibitor (1st line)

➢ Anti VEGF antimoby (bevacizumab)
➢ mTOR inhibitor (temsirolimus)

Q. Clinical feature, management of Wilm’s tumor

Ans:

Clinical feature:

➢ age: w/n first 5 years of life

➢ painless hematuria
➢ abdominal mass: smooth, firm-hard, moves with resp, bimanually palpable, ballotable,
resonant on percussion, doesn’t cross midline

96
 ➢ there maybe hypertension
➢ fever

Investigation

➢ CT scan
➢ Color doppler study of IVC: tumor thrombus, may extend upto RA

Treatment:

➢ Unilateral
o Neo-adjuvant chemo, followed by nephrectomy
o Bilateral disease: partial nephrectomy on one/both side, with total nephrectomy on the
other side (nephron sparing surgery)

Palpable loin mass

Q. Cause of palpable loin mass

Ans:

➢ Enlarged kidney
➢ Enlarged spleen (only on left side)
➢ Enlarged liver (only on right side)
➢ Soft tissue tumor

Q. Causes of palpable kidney

Ans:

➢ Hydronephrosis
➢ Purulent
o Pyonephrosis
o Perinephric abscess
➢ Kidney cyst
o Solitary cyst
o Polycystic kidney disease
➢ Neoplasm of kidney (RCC, Wilm’s tumor)

Q. Causes of palpable kidney (non-tender ballotable mass) in case of pediatric age group

Ans:

➢ Tumor
o Wilm’s tumor
o Neuroblastoma
o Sarcoma
➢ Hydronephrosis

97
 ➢ Cystic kidney

Q. How will you differentiate between a palpable spleen and palpable kidney

Ans:

Spleen Kidney
Shape Mostly smooth and regular Maybe irregular in case of
polycystic kidney
Movement with inspiration Diagonally Vertically downwards
Position of the mass Superficial Deeper
Palpable notch (on medial Yes No
surface)
Bilaterally palpable No Maybe in polycystic kidney
Percussion over mass Dull Resonant
Mass extent beyond midline Maybe No excest

Q. Investigation of palpable kidney

Ans:

➢ X ray KUB
➢ USG of abdomen
➢ CT scan
➢ MRI
➢ IVU
➢ Cystoscopy
➢ Urine RME
➢ DTPA scan: to see renal function

98
Bladder stone
Q. Classify bladder stone/types of bladder stone

Ans:

➢ By origin
o Primary bladder stone: originates in kidney (develops in sterile urine)
o Secondary stone (due to infection, outflow obstruction, foreign body, impaired bladder
emptying
➢ By composition
o Mixed stone
o Oxalate stone
o Uric acid stone
o Cystine stone
o Struvite stone/triple phosphate stone (due to Proteus infection)

Q. Management of bladder stone (not in DU, but many times in other U, and imp for viva)

Ans:

Clinical feature

➢ Frequency
➢ Incomplete bladder emptying
➢ Pain
o At the end of micturition
o Tip of penis pain
➢ Hematuria
o Terminal hematuria (at the end of micturition)
➢ Interruption of urinary stream (due to interruption by stone)
➢ UTI/cystitis
➢ Stone may be palpable if large

Investigation

➢ Urine RME
o Hematuria
o Pus
o Crystal
➢ Imaging
o X ray KUB
o USG KUB
o IVU (to exclude upper tract stones)

Treatment:

99
 ➢ Supportive
➢ Specific (litholaplaxy = crushing of stones and then taking them out)
o Cystoscopic litholaplaxy (cystoscope introduced → an instrument called lithotrite
entered in bladder thru that → stone is crushed by mechanical
force/lase/electromagnetic waves → fragments evacuated per urethra)
o Suprapubic open cysto-lithotomy (pfannenstiel incision → bladder opened → stone
removed)
o Suprapubic percutaneous litholaplaxy (like PCNL, a tube inserted thru skin towards
bladder → stone crushed → stone is taken out)

**Name the tumors of urinary bladder:

➢ Urothelial carcinoma/transitional cell carcinoma

➢ Squamous cell carcinoma
➢ Adenocarcinoma

***clinical feature of Urothelial carcinoma/transitional cell carcinoma: painless hematuria, anemia,

features of cystitis (suprapubic pain, frequency, dysuria), hydronephrosis, pain in pelvic wall

100
Prostate
Q. Mention the functions of prostate (not du)

Ans:

➢ Nutrition to spermatozoa (fructose)

➢ Maintains pH of sperm: acidic pH: inhibits organism growth and prevents UTI
➢ Maintains bulk of sperm

LUTS
Q. Mention the lower urinary tract symptoms (LUTS)

Ans:

➢ Storage LUTS (irritative=causes problem with storage)

o Frequency
o Nocturia
o Urgency
o Urge incontinence
o Nocturnal incontinence (enuresis)
➢ Voiding LUTS (obstructive LUTS=causes problem with voiding)
o Hesitancy
o Straining on micturition
o Poor flow
o Reduced urinary stream
o Intermittent urinary stream
o Incomplete emptying
o Post micturition dribble (PMD)

Q. How will you assess a patient with LUTS? (not in DU, but same ans for mx of BPH almost) (DD of LUTS
also given in brackets)
Ans:
Examination
➢ General examination (signs of chronic renal failure)
o Anemia
o Dehydration
➢ Abdominal examination
o Bladder: distended (retention)
o Ext. urethral meatus: check for stenosis
➢ Rectal examination
o Firm prostate, with retained urine above, smooth surface,median sulcas prominent,
rectal mucosa free, finger not blood stained (BPH)
➢ Nervous system
o To eliminate neurological causes of LUTS

101
Investigation

➢ Blood
o CBC
o Serum creatinine
o Serum electrolyte
o Serum PSA (BPH, Prostate cancer)
➢ Urine
oUrine RME
▪ (Glucose (diabetes)
▪ Blood (stone/infection→ hematuria))
o Urine C/S
➢ Radiology:
o Intra venous urogram (IVU)
o USG KUB (Transabdominal)
o USG Transrectal (to see prostate)
o X ray KUB
➢ Study of urine flow
o Flow rate measurement
o Urodynamic study
➢ Cystourethroscopy (see lesion in bladder and urethra)
**LUTS:

➢ Essential inv
o Urine analysis (Urine RME) for protein, glucose, blood
o Urine C/S for infection
o Serum creatinine
o Urinary flow rate and residual volume measurement
➢ Additional investigation
o PSA
o Pressure flow studies

BOO (Bladder outflow obstruction)

What is BOO: low flow rate (<10 mL/s) + high residual urine (>100 mL) + high voiding pressure

(scenario: 60 year old man presented with LUTS. Write down the causes)

Q. Name the causes of bladder outflow obstruction. (Obstruction distal to bladder)

Ans:

➢ BPH
➢ Bladder neck stenosis
➢ Bladder neck hypertrophy
➢ Prostate cancer
➢ Urethral stricture

102
 ➢ Neurological condition (functional obstruction) (the rest are mechanical obstruction)

Q. Name the symptoms and long term effects of bladder outflow obstruction (Not DU)

Ans:

➢ Primary effect/symptom
o Urine flow rate decrease
o Voiding pressure increase
➢ Long term effect
o Bladder muscle gradually less efficient and weaker
o Residual urine develops
o Detrusor muscle overactivity (urge incontinence develops)
➢ Complication
o Acute retention of urine
o Chronic retention of urine
o Impaired bladder emptying: stone formation
o Hematuria
o Urge incontinence

Benign enlargement of prostate (BEP)

(in elderly male, testosterone decreases, but estrogen decreases less. These increased estrogenic effects
cause prostate enlargement. Another theory is, testosterone converts to Dihydrotestosterone (DHT) by
the enzyme 5 alpha reductase inhibitor. DHT causes BPH)

Q. Management of BEP/BPH. / A 60-year-old man presented with difficulty in passing urine. How will
you evaluate this patient?

Ans:

Symptoms:

➢ Write down the LUTS symptoms

➢ Write down the BOO symptoms (not effects)
➢ Then write the “complications” of BOO

Examination:

➢ General examination: anemia, dehydration

➢ Abdominal examination
o Inspection:
▪ bulging in the suprapubic region
▪ loss of suprapubic skin crease

103
 o Palpation:
▪ Distended bladder, which is non tender (chronic retention)
▪ Distended, tender bladder (acute retention)
▪ Examination of external urethral meatus (to exclude meatal stenosis)
▪ Palpation of posterior urethra, epididymis (to exclude inflammation)
o Percussion
▪ Dull percussion note over the distended bladder
▪ Percussion exacerbates desire to micturate
o Auscultation: normal
➢ Rectal examination
o Prostate enlarged
o Smooth, convex
o Firm consistency
o Non tender
o Rectal mucosa free from prostate
o Residual urine felt above prostate level
o After taking out, finger is not blood stained
➢ Nervous system examination
o To exclude neurological causes

Investigation: LUTS investigation (from above)

Treatment:

➢ General measures / early/ immediate measures

o in case of acute retention: relieve retention by catheter
o in case of chronic retention with uremia (due to chronic renal impairment)
▪ catheterization
▪ correct dehydration
▪ correct electrolyte imbalance
▪ correct anemia
o if catheterization fails: supra pubic cystostomy
➢ specific treatment
o conservative:
▪ watchful waiting
▪ fluid restriction
▪ restrict caffeine intake
o drug therapy
▪ Tamsulosin (alpha 1D blocker – specific for prostate)
▪ Finsteride (5 alpha reductase inhibitor)
▪ Mirabegron (Beta 3 agonist: to prevent detrusor instability)
o Surgical therapy: prostatectomy
▪ Trans-Urethral resection of Prostate (TURP)
▪ Retropubic prostatectomy (RPP)
▪ Transvesical Prostatectomy (TVP – thru the bladder)

104
Q. Mention the effects of BPH/BEP on the urinary tract

Ans:

➢ Urethra
o Prostatic urethra lengthened
o Posterior curve of urethra exaggerated
o Distortion may occur, if only one lateral lobe involved

o
➢ Bladder (due to bladder outlet obstruction)
o Hypertrophy of bladder muscle (due to effort to overcome the BOO)
o Detrusor muscle instability → urge incontinence
o Development of residual urine
▪ Increased chance of infection (cystitis)
▪ Stone formation
o Increased blood flow to base of bladder → hematuria
o (Trabeculation, Sacculation, diverticulum formation)
➢ Ureter: hydroureter (distension of bladder, due to chronic retention)
➢ Kidney:
o hydronephrosis (distension of pelvis-calyces, due to chronic retention)
o inability to concentrate urine (loss of fluid and electrolyte)

Q. Indication for conservative/watchful waiting in BPH: (not for written)

Ans:
➢ mild symptoms
➢ reasonable urinary flow rate (>10 mL/S)
➢ good bladder emptying (residual urine <100 mL)

Q. Indication for drug therapy in BPH (not for written)

Ans:
➢ symptoms not improved by conservative therapy
➢ men concerned about sexual dysfunction after surgery

105
(p.s considering cost and efficacy and long term improvement, prostatectomy (TURP, RPP, TVP) is always
superior to drug therapy.

Question regarding surgery for prostate, indication, complication: see the next section

Prostatectomy
Q. Mention the methods of prostatectomy
Ans:
➢ trans Urethral resection of prostate (TURP)
➢ retropubic prostatectomy (RPP)
➢ trans vesical prostatectomy (TVP)
➢ perineal prostatectomy (PP)

Q. Mention the indications of prostatectomy / Mention the indication of prostatectomy in BPH patients
Ans:
➢ BEP/BPH with
o Worsening symptom
▪ Increasing difficulty in micturition
▪ Increased frequency
▪ Delay in starting (hesitancy)
▪ Poor stream
o Severe symptoms (BOO)
▪ Low flow rate (<10 mL/s)
▪ High residual volume of urine in bladder (>100 mL)
o Failure of other methods: no response to conservative/drug therapy
o Development of complications of BEP (stone, infection, hematuria)
o Fit for anesthesia and operation
➢ Early stage of prostatic cancer

Q. What are the complications during prostatectomy/TURP?

Ans:
➢ Local
o Hemorrhage: primary, reactionary, secondary
o Perforation of bladder
o Perforation of prostatic capsule
➢ Urological problems
o Retrograde ejaculation (sperm inside bladder → comes with urine)
o Impotence
o Incontinence
o Urethral stricture
o Bladder neck contracture
➢ Need of reoperation
➢ General complications
o Sepsis
o CVS: MI, CCF, DVT

106
 o Water intoxication

Q. How will you manage hemorrhage (secondary/reactionary) after prostatectomy? (not DU)
Ans:
➢ Patient readmitted
➢ Catheter introduced
➢ Bladder washed out
➢ Bed rest
➢ High fluid intake
➢ Blood transufusion if needed

Q. Management of retained clot in bladder, after prostatectomy (not DU)

Ans:
➢ Pt readmitted
➢ Catheter introduced
➢ Bladder washed out with normal saline
➢ If failed, aspiration by tommy syringe
➢ If failed, cystoscopic removal
➢ If failed, open suprapubic cystectomy

Carcinoma Prostate
Q. difference between DRE finding of BEP and carcinoma prostate

Ans:

BEP Carcinoma prostate

Surface Regular Irregular/nodular
Consistency Firm Stony hard
Median sulcus Prominent Obliterated
Rectal mucosa Free Maybe fixed
Residual urine Felt Not always
Extension to base of bladder Absent Present
Examining finger Not blood stained Maybe blood stained, if
extension up to rectum

**Most common site for metastasis of prostate cancer: vertebral column

**BPH occurs in central zone, and periurethral zone: so it causes urinary obstruction and LUTS/BOO
commonly; but Prostate cancer usually occurs in peripheral zone, so it may not cause LUTS/BOO in early
stage, only in advanced case. Actually, in early case, pr cancer is asymptomatic, pt presents only at
advanced stage

107
Suprapubic cystostomy
Q: Short note: Suprapubic Cystostomy

Ans: temporary opening thru the abdominal wall into the bladder

Indication

➢ In case of acute urinary retention, catheter cannot be passed despite adequate lubrication due
to
o Stricture of urethra
o Rupture of urethra
o Malignancy/malignant stricture
o Stone
o Clot
➢ Congenital anomalies of urethra

Prerequisite:

➢ Bladder must be full

Procedure

➢ Position of pt: supine

➢ Local anesthesia
➢ Vertical midline incision of 3cm, 3-4cm above symphysis pubis
➢ Incision thru linea alba and fat
➢ Bladder is identified
➢ Confirmation (that it is blaader) by aspiration of urine via syringe
➢ Insertion of trochar and cannula
➢ Suture around the opening
➢ Close the wound

Complication: injury to bowel, perineum, infection

Contraindication: CA Urinary Bladder (will cause seedling of malignant cells)

108
Urethral stricture
Q. Mention the causes of stricture of urethra

Ans:

➢ Congenital
➢ Acquired
o Inflammatory
▪ Urethritis (gonococcal, non gonococcal)
▪ Tuberculosis
o Traumatic
▪ Urethral injury
▪ Pelvic fracture
o Iatrogenic
▪ Due to catheterization, cystoscopy, urethroscopy (instrumentation)
▪ Due to TURP operation (surgery)
▪ Due to radiotherapy for Prostate cancer
o Idiopathic

(**scenario: hx of dysuria/urethral discharge (urethritis)/trauma to urethra/fall on buttock + followed by

difficulty in passing urine with reduced flow and straining to void.)

Q. Management of urethral stricture (never in DU, but many times in other U)

Ans:

➢ Clinical features
o Hesitancy
o Straining to void
o Poor stream
o Prlonged micturition
o Post micturition dribbling
o If co-existing detrusor instabiluity/overactivity: frequency
o If associated retention: stone/hematuria
o If stricture too narrow: retention of urine
➢ Investigation
o Urine RME
o Urine C/S
o Serum creatinine
o Radiology
▪ X ray KUB
▪ IVU (to se problem in kidney, ureter)
▪ Ascending urethrogram (to see stricture)
o Uroflowmetry
o Urethroscopy (endoscopic visualization of urethra)
➢ Treatment
o Immediate relief of retention by Supra pubic cystostomy

109
 o Specific: stricturotomy, urethroplasty, urethral dilator
▪ Internal Endoscopic urethrotomy/stricturotomy (cutting of the stricture by an
endoscopic knife)
▪ Urethroplasty (excision of the stenosed part, then re-anastomosis) (possible
only in case of short stricture, not involving the penile urethra)
▪ Urethral dilatation (by urethral dilator – not performed much now) (done by
Lister’s dilator)

110
Urethral rupture
**scenario: fall astride a cycle bar/gymnastic bar, followed by inability to pass urine and unable to void
urina, blood at meatus

Q. Short note: Rupture of urethra (if not otherwise mentioned, only write about rupture of bulbar
urethra)

Ans:

Cause:

➢ Instrumentation (catheterization, cystoscopy, urethroscopy)

➢ Trauma (blow to perineum, falling astride (দুই পা চ্াাংদদালা হদে buttock er upor পড়া)
o Blow to perineum
o RTA
o Cycling/gymnasium accidents
➢ Prolonged labor

Clinical feature:

➢ History
o History of blunt trauma
o Inability to void
➢ Examination
o Blood at external urethral meatus
o Bruising in perineum
o Distended, tender bladder (acute retention)
o Dull percussion note over bladder
o Swelling of lower abdomen, scrotum, penile skin (extra vasation of urine)

Investigation

➢ Retrograde/ascending urethrogram (dye injected in urethra, and visualized by X ray whether

rupture has occurred)
➢ X ray of the Pelvis and KUB (for fracture management)

Treatment:

➢ Analgesia
➢ Antibiotic
➢ Definitive
o Suprapubic cystostomy, followed by delayed urethroplasty
▪ A suprapubic catheter is inserted
▪ It is kept in situ
▪ The bruising and injury heals
▪ Stricture develops
▪ Later stricture is managed by urethroplasty (the strictured portion resected,
followed by anastomosis of the remining ends)

111
 ➢ Orthopedic management needed if there is associated fracture

** cardinal sign of ruptured urethra: acute retention of urine, blood at meatus, bruising in perineum

Complication:

➢ Hemorrhage
➢ Infection
➢ Extravasation of urine
➢ Stricture
➢ Erectile dysfunction

112
Hypospadias

113
 fig: chordee (abnormal curvature of the penis)

Q. Short note: Hypospadias (scenario: child presented with soiling of undergarments during micturition,
narrow stream, downward bending of distal penis)

Ans:

➢ Commonest urethral congenital anomaly

➢ Occurs in 1/300 male live birth
➢ 3 cardinal features:
o Opening of EUM on underside (ventral aspect) of penis (child cannot micturate
standing)
o Poor development of prepuce (hooded foreskin)
o Abnormal bending/curvature of the erect penis (chordee)
➢ Other features
o Penile and scrotal dermatitis (Urine soaks the scrotum and undersurface of penis)
o There may be other congenital anomalies

114
 ➢ Classification (see fig above)
o Glanular
o Coronal
o Penile
o Perineal
➢ Management
o Goal: repair the defect so that
▪ The child can urinate in standing position
▪ Soaking of perineum doesn’t occur with micturition
▪ Upon erection, the penis has a normal appearance
▪ To improve sexual function in future
▪ For cosmetic reasons
o Correction
▪ Correction of chordee (orthoplasty)
▪ Urethroplasty, (utilizing the prepucial skin→ so circumcision is contraindicated
in a child with untreated hypospadias)
▪ Done before 18 months of age

**Epispadias: rare; urethra opens of the dorsal aspect (superior surface), upward curvature of erect
penis (co-exist with bladder exstrophy

Phimosis and paraphimosis

Phimosis: inability to retract the prepuce over the glans (বের করা যাদেনা glans)

(cause: infection of glans – balanitis, inflammation of glans and prepuce – balanoposthitis, congenital)

Paraphimosis: inability to place back (cover) the retracted prepucial skin over the glans (বের কদর আর
ঢুকাদনা যাদেনা); treatment: circumcision

treatment:

➢ manual reduction attempted,

➢ then incision in the skin to relief edema and necrosis,
➢ antibiotic, analgesic,
➢ then 3 weeks later, circumcision

Which is more dangerous: paraphimosis: the retracted prepuce causes cord like constriction → risk of
ischemic necrosis of the glans;

Priaprism: persistent erection of penis, lasting longer than 4 hours + surgical emergency

115
Testis and scrotum

Testis not in scrotum

Q. What do you mean by incompletely descended testis, ectopic testes, retractile testis

Ans:

Incompletely descended testis: it means testis is arrested in some part of its normal path to the scrotum.
It is 3 types

➢ intra-abdominal: deep to the deep inguinal ring (may be intra peritoneal, extra peritoneal)
➢ intra canalicular: inside the spermatic cord
➢ extra canalicular: outside the superficial ring, but not inside testis
➢ clinical feature
o empty scrotum/hemiscrotum
o poor development of scrotum

Ectopic testes:

➢ testes not in its normal path of descent to the scrotum

➢ ended up in an unusualy location
➢ example:
o superficial inguinal pouch
o femoral triangle
o perineum
o opposite hemiscrotum

Retractile testis (RT):

➢ a testis of a child
➢ which is very mobile
➢ and in them the cremasteric reflex is very active
➢ so, even a minor stimulation on the skin of the scrotum/thigh (e.g during examination by doctor)
➢ causes sudden contraction of cremasteric muscle
➢ and their testes temporarily disappear in inguinal canal
➢ later reappears again
➢ in these children
o scrotum is normal
o reappeaes when not touched
o testis can be brought down by milking action
o Orr-chair test: testis will come down on squatting position

**cryptorchidism: bilaterally undescended testis

116
P.S: undescended testis (UDT) = incompletely descended testis (IDT) + ectopic testis (ET) (not retractile
testis)

What are the D/D of empty scrotum: UDT + RT

Q. Complication/hazard of UDT

Ans:

➢ infertility
➢ malignancy: seminoma most commonly
➢ torsion
➢ hernia (patent processus vaginalis)

**to detect the testis: USG, diagnostic and therapeutic laparoscopy

**Treatment: orchidopexy (done before 12 months of age) (testis brought down and fixed to the
scrotum)

**vanishing testis: testis develops, but disappears before birth (cause: pre natal torsion)

Acute Scrotum + Scrotal/testicular swelling

Q. Name the causes of scortal swelling

Ans:

➢ acute
o torsion of testis
o torsion of appendix of testis
o trauma
o acute epididymo-orchitis
o scrotal cellulitis
➢ chronic
o tumor inside scrotum
o hydrocele
o varicocele
o hernia
o lymphatic filariasis

117
Q. Causes of painful/painless scrotal swelling

Ans:

➢ painful
o testicular torsion
o tortiosn of appendix of testis
o acute epididymo-orchitis
o trauma to the testis
o strangulated hernia
➢ painless
o tumor inside scrotum
o hydrocele
o varicocele
o uncomplicated hernia

Q. What are the causes of acute scrotum? (sudden painful swelling of the testis)

Ans:

➢ testicular torsion
➢ torsion of appendix of testis
➢ acute epididymo-orchitis
➢ trauma
➢ strangulated hernia

Q. Name some causes of cystic swelling above the testis

Ans:

➢ hydrocele (encysted)
➢ varicocele
➢ epididymal cyst
➢ incomplete inguinal hernia

Acute epididymo-orchitis
(infection in urethra/prostate/seminal vesicle→ vas deferens → reaches epididymis → reaches testis )

In sexually active man: most common cause STI (chlamydia, gonorrea), in older men: due to
UTI/catheter

Q. Management of acute epididymo-orchitis (in du, only clinical features)

Ans:

History:

118
 ➢ pain in groin
➢ fever
➢ previous hx of UTI/catheterization/unprotected sexual exposure
➢ painful micturition, frequency

Examination:

➢ swollen testis, thickened epididymis

➢ tender testis
➢ scrotal wall: red, edematous, shiny
➢ upon elevation of testis, pain will be relieved (PHREN’S SIGN) (TO EXCLUDE TORSION)

Inv

➢ doppler USG (to exclude torsion)

➢ urethral swab
➢ Urine RME/CS
➢ Microbiological test to detect organism (NAAT to detect gonorrhea)

Treatment:

➢ (Exclude torsion in adolescents, if not excluded, exploration of testis)

➢ Antibiotic (for 2 weeks at least/until inflammation subsides)
➢ analgesic
➢ Adequate hydration
➢ Scrotal support
➢ If pus formation, drainage needed

Name one cause of chronic epididymo-orchitis: tuberculosis (from tubercular cystitis)

Torsion testis
Q. predisposing factors of torsion testis / pathophysiology

Ans:

➢ Clapper-in a bell abnormality (high investment of tunica vaginalis)

➢ Inversion of testis
➢ Separation of testis from epididymis
➢ Sudden contraction of cremasteric muscle
o Due to mechanical, thermal, chemical stimuli (straining, coitus, spontaneous during
sleep)

119
Q. Management of torsion testis

Ans:

Symptoms

➢ Common age: 10-25 years

➢ Sudden severe agonizing pain in scrotum/groin/lower abdomen
➢ Pt feels nauseated/toxic

Examination

➢ Testis swollen
➢ Tender
➢ Skin not erythematous in early cases
➢ There is no fever
➢ Testes is highly placed in the scrotum
➢ Elevation of testis – worsening of pain

Invesigation

➢ Doppler USG (reduced blood flow)

Treatment

➢ Emergency exploration of scrotum

➢ Derotation of the testis
➢ Check for viability of the testis
➢ If viable, testis is fixed to scrotum using non absorbable suture – to prevent future torsion (three
point fixation)
➢ Fixation of the opposite testis as well
➢ If not viable, orchidectomy (three point fixation) + prosthetic testis placement

**if pt comes within 6 hours, testis can be saved. If later than 12 hours, gangrenous mostly

DD of torsion: acute epididymo-orchitis (elevation reduced pain), torsion of appendage of testis – pain is
less than torsion )

Q. Complication of testicular torsion

Ans:

➢ Gangrene
➢ Infarction
➢ Abscess formation
➢ Infertility (due to exposure of sequestered antigen)

120
Q. Difference between testicular torsion and acute epididymo-orchitis

Ans:

Acute epididymoorchitis Testicular torsion

Age Any age group 10-25/adolescent
History UTI/dysuria/sexual No significant history
exposure/catheterization
Onset Sudden Gradual
Sign
Inflammation sign Present Absent
Fever Present Absent
Scrotal skin redness Early redness May be red in later stages
Position of testis Normal High up
Epididymis Thickened Normal
Elevation of testis Pain decreases Pain increases
Investigation
Doppler Increased flow Reduced flow
CBC Leukocytosis Normal (present if gangrene)
Treatment Antibiotics Surgical (three point fixation)

Testicular tumor
Q. classify testicular tumors

Ans:

➢ Germ cell tumor

o Seminoma
o Non seminomatous germ cell tumor:
▪ Embryonal carcinoma
▪ Yolk sac tumor
▪ Endodermal sinus tumor
▪ Choriocarcinoma
▪ Teratoma
➢ Interstitial tumor
o Leydig cell tumor
o Sertoli cell tumor
➢ Others
o Gonadoblastoma
o Lymphoma
o Secondary tumors

121
Q. Management of seminoma

Ans:

Clinical feature

➢ Age: 4th decade of life

➢ Painless testicular swelling (some pt may present with pain → due to intra tumor hemorrhage)
➢ Sensation of heaviness in scrotum
➢ Loss of sensation in testis
➢ Features of metastasis
o Abdominal lump
o Hemoptysis/dyspnea
➢ Examination
o Firm-hard, nontender, solid mass in scrotum
o Para aortic lymph nodes may be palpated
o Liver maybe enlarged
o Inguinal lymph nodes maybe enlarged (if skin involved)

Investigation

➢ USG of the testis to see both scrotum (diagnostic)

➢ Staging
o CT scan of chestmbdomen, pelvis
o Tumor marker: AFP, Beta HCG, LDH (for prognosis)

Stage:

Stage I: tumor confined to tested

Stage II: tumor to LN below diaphragm

Stage III: tumor to LN above diaphragm

Stage IV: non lymphatic distal metastasis

Treatment:

➢ Scrotal exploration and orchidectomy

➢ Followed by,
o Stage I:
▪ adjuvant radiotherapy to para-aortic nodes
▪ adjuvant platinum based chemotherapy (excellent response)
o stage II-IV
▪ BEP based chemotherapy (Bleomycin, etoposide, cisplatin)

122
**spread of testicular tumor: local invasion, lymphatic spread, distal metastasis

Varicocele
Q. Short note (varicocele)

Ans:

➢ It is the dilatation and tortuousity of veins draining the testis (pampiniform plexus + testicular
vein)
➢ Cause (left testicular vein drains perpendicularly into IVC via left renal vein)
o Obstruction of left testicular vein by tumor
o Absence of valves
o Prolonged standing
➢ Clinical features
o Asymptomatic in many case
o Dragging sensation/discomfort
o Scrotum of one side hangs lower than normal
o Palpation: bag or worms feeling
o Cough impulse
o When pt lies down, the varicocele disappears
➢ Inv
o USG
o Doppler study (to see blood flow)
o Semen study
➢ Treatment
o Not needed if there is no symptom
o Symptoms present
▪ Embolization of gonadal veins
▪ Surgical ligation of testicular vein

Fournier’s Gangrene
Q. Short note: Fournier’s gangrene

Ans:

➢ Seen in/after
o Minor injury to perineum
o In immunocopm patients
o In patients with very poor self hygiene
➢ Cause
o Mixed aerobic – anaerobic infection (polymicrobial infection)

123
 o Infection → arteritis → obliteration of vessel lumen → ischemia → sloughing of scrotl
skin
➢ Clinical feature
o Sudden pain in scrotum
o Fever
o Pt toxic
o Examination
▪ Early: scrotal skin necrosed
▪ Late: sloughing of scrotal skin (shameless exposure of testis)
▪ Foul smellin exudte
▪ Dehydration/shock
➢ Treatment:
o It is surgical emergency
o General
▪ IV fluid to treat shock/dehydration
▪ Nutritional support
▪ Broad spectrum antibiotics
o Specific
▪ Wide surgical excision of the dead tissue
▪ Regular dressing
▪ After the acute episode, skin grafting

124
Hernia and Hydrocele
Hernia introduction
Q. Define hernia

Ans:

➢ A hernia is a protrusion of an organ

➢ Or a part of an organ
➢ Through a defect/weakness
➢ Of its containing wall

Q. Classify hernia according to site

Ans:

➢ External hernia
o Ventral hernia
▪ Epigastric hernia
▪ Umbilical hernia
▪ Paraumbilical hernia
▪ Incisional hernia
▪ Spigelian hernia
▪ Parastomal hernia
o Inguinal hernia
o Femoral hernia
o Obturator hernia
o Gluteal hernia
o Sciatic hernia
➢ Internal hernia
o Diaphragmatic hernia
▪ Hiatus hernia
• Sliding hernia
• Rolling hernia
▪ Morgagnian hernia
▪ Bochdalek’s hernia
o Intracranial herniation
▪ Tentorial herniation
▪ Brainstem herniation

Q. Classify hernia clinically/irrespective of site

Ans: Classification

➢ Occult hernia: not detectable clinically, but may cause severe pain
➢ Reducible hernia

125
 ➢ Irreducible hernia
➢ Obstructed hernia: hernia with intestinal obstruction
➢ Inflamed hernia
➢ Strangulated hernia: hernia with vascular compromise (urgent surgery required)
➢ Infarcted hernia: herniated loops have become gangrenous

**other classification

➢ Congenital
➢ Aquired

Acc to content

➢ Omentocele
➢ Enterocele
➢ Cystocele
➢ Richter’s hernia

Q. Causes/predisposing factors of hernia (not DU)

Ans:

➢ Basic design weakness

➢ Developmental failure
➢ Weakness due to structures entering and exiting the abdomen
➢ Generic weakness of collagen
➢ Weakness due to ageing and pregnancy
➢ Weakness due to neurological and muscle disease
➢ Sharp and blunt trauma
o Injury
o Surgical
➢ Excessive intra abdominal pressure
o Straining
o Heavy weight lifting
o Chronic cough
o Chronic constipating
o Straining for micturition

Q. Mention the composition of external hernia

Ans: three parts (from outside to inside)

➢ Covering: derived from layers of abdominal wall

➢ Sac:

126
 o It is the peritoneum covering the content
o Consists of mouth, neck, body, fundus
➢ Content: maybe variable
o ((Omentum: omentocele
o Loops of gut: enterocele
o Urinary bladder: cystocele
o One wall of gut: richter’s hernia
o Meckel’s diverticulul: littre’s hernia

Q. What are the groin hernias?

Ans:

➢ Inguinal hernia
➢ Femoral hernia

Inguinal hernia
(types: direct/indirect; incomplete/complete)

Q. How will you examine a patient who presented with an inguinoscrotal swelling?

127
Ans:

➢ Patient in standing position

o Inspection
▪ Site
▪ Size
▪ Extension
▪ Overlying skin
▪ Visible cough impulse
o Palpation of scrotum
▪ Palpation of the contents
▪ If I can get above the swelling (I won’t get in case of hernia)
o Palpation of the swelling/lump
▪ Temperature
▪ Tenderness
▪ Composition (solid/fluid/gaseous)
▪ Palpable Cough impulse
o Examine the other side
o Examination of urethral orifice (to see stricture/stenosis)
➢ Patient lying down
o Reducibility
o Deep ring occlusion test (+ve in indirect)
➢ DRE (to see BPH/anorectal lesions)
➢ Examination of other systems to see predisposing factors

Q. Mention the operations for inguinal hernia

Ans:

➢ Herniotomy
➢ Open repair
o Open suture repair (Bassini, shouldice, desarda)
o Open flat mesh repair (Lichtenstein)
o Open complex mesh repair (plugs, hernia systems)
o Open preperitoneal repair (Stoppa)
➢ Laparoscopic repair
o Total extraperitoneal pre peritoneal (TEPP)
o Trans abdominal pre peritoneal (TAPP)

Q. Mention the differential diagnosis of inguinal hernia

Ans:

➢ Hydrocele
➢ Undescended testis
➢ Femoral hernia

128
 ➢ Groin abscess
➢ Lipoma of cord
➢ Inguinal LN enlargement

Q. Mention the complications of inguinal hernia

Ans:

➢ Obstruction
➢ Inflammation
➢ Strangulation
➢ Infarction
➢ Hydrocele through the hernial sac

Q. Management of a case of strangulated inguinal hernia

Ans:

Clinical feature (surgical emergency)

➢ Sudden severe pain

➢ History of pre-existing hernia
➢ Persistent vomiting/distention/constipation (if obstructed as well)
➢ Examination
o Patient toxic
o Dehydrated
o Abdominal distension
o Features of shock
o Hernia examination
▪ Tense
▪ Tender
▪ Irreducible
▪ Usually no cough impulse
▪ Overlying skin color is altered
➢ Investigation
o CBC: raised WBX
o Plain x ray: air fluid level (if obstruction)
o Serum electrolyte
➢ Management
o Admission
o Rylles tube aspiration
o IV fluid: correct dehydration
o Antibiotics
o Prepare patient for emergency surgery

129
 ▪ Exposure of the hernial sac
▪ Constriction ring is cut
▪ Sac is opened
▪ Check for viability of the gut
▪ If gangrenous, resection and anastomosis
▪ Repair of the defect is done
▪ Mesh placement usually not done in case of strangulated hernia; biological
mesh maybe used

Q. complications of strangulated hernia

Ans:

➢ Gangrene
➢ Perforation
➢ Peritonitis
➢ Septicemia
➢ Septic shock
➢ DIC
➢ Multi-organ failure
➢ Death

Q. Management of obstructed hernia:

Ans:

Clinical features:

➢ Features of intestinal obstruction

o Constipation
o Vomiting
o Abdominal pain
o Distension
➢ History of hernia
➢ Examination
o Dehydration
o Abdominal distension
o Examination of hernia
▪ Tenderness
▪ Irreducible
▪ Usually no cough impulse
➢ Management: same as strangulated hernia

130
Q. Mention the pathological changes in strangulated hernia

Ans:

Obstruction > wall compressed > Impairment of venous and lymphatic drainage > congestion > also,
secretion from intestinal glands accumulate > bowel swells more > ultimately artery is compressed >
ischemia > wall becomes very fragile > it may perforate > alternately, bacterial translocation occurs from
gut to peritoneum > peritonitis and septicemia may occur

**also, blood is extravasated, and goes into the lumen.

Q. How will you assess the viability of the gut?

Ans:

➢ Check for peristalsis

➢ Check whether the overlying peritoneum is shiny or note
➢ Check the color of the gut
o Dark/black color is warning sign
o Pink indicates viability
➢ Prick the mesentery: bleeding of fresh blood indicates viability
➢ Check pulsation in mesentery vessels
➢ If there is doubt
o High flow o2
o Wrap the bowel segment in hot mop and check for viability after 10 minutes

Q. What feature will help differentiate inguinal from inguinoscrotal swelling?

Ans:

➢ Extension of hernia: check the lower limit of the swelling

o Inguinal swelling usually doesn’t reach the scrotum
o Inguinoscrotal swelling reaches the scrotum
➢ Palpation of scrotum
o Inguinoscrotal swelling will occupy the scrotum

Q. How will you differinate inguinoscrotal from scrotal swelling?

Ans:

➢ If I can get above the swelling: scrotal swelling

➢ If I cannot get above the swelling: inguinoscrotal swelling

131
Ventral hernia
(**scenario: a 50 year old male pt presents with an epigastric swelling, that imparts impulse on cough.

Q. What is ventral hernia?

Ans:

➢ Hernias through the anterior abdominal wall

➢ Including lumbar hernia
➢ Except inguinal and femoral hernia

Q. What are the ventral hernias?

Ans:

➢ Epigastric hernia
➢ Umbilical hernia
➢ Paraumbilical hernia
➢ Incisional hernia
➢ Spigelian hernia
➢ Parastomal hernia

Q. Factors that influence development of ventral hernia?

Ans: same as causes/predisposing factors of hernia

Q. Umbilical hernia vs paraumbilical hernia (viva)

Ans:

Umbilical hernia: through the umbilicus, peri-umbilical border is intact

Para-umbilical hernia: beside the umbilius, peri-umbilical border is not intact

Q. Surgery/treatment of umbilical hernia (not DU)

Ans:

➢ <2 cm:
o anatomical repair

132
 o mayo’s procedure: double breasted repair
➢ >2 cm: hernioplasty (mesh repair)

**if a hernia is strangulated, at 1st operation we will only manage the strangulation and do herniotomy
and repair. At a later operation, we will do hernioplasty (because if we put mesh during 1st time, there is
high chance of mesh becoming infected and rejected)

Q. Peculiarity of epigastric hernia (viva)

Ans:

➢ Content is only extraperitoneal fat

➢ May resemble lipoma
➢ Slipping sign should be done
➢ Cough impulse maybe negative
➢ Very small size hernia can be extremely painful (early strangulation)

Incisional hernia
Q. Factors producing incisional hernia

Ans:

➢ Patient factor
o DM
o Immune suppression
o Chronic cough/constipation
o Malnutrition
o Obesity
➢ Wound factor
o Wound infection
o Weak tissue
o Wound dehiscence
➢ Surgical factor
o Poor technique
o Incorrect suture placement
o Poor quality of suture material

Q. How will you manage a patient with incisional hernia?

Ans:

Preoperative preparations:

➢ Reduction in weight
➢ Control of obesity

133
 ➢ Treatment of diabetes
➢ Nutritional support
➢ In case of massive incisional hernia repair: pre-operative abdominal expansion by creating
progressive pneumoperitoneum

Treatment options:

➢ Open mesh repair

➢ Laparoscopic mesh repair

Postoperative care

➢ Antibiotic
➢ Analgesic
➢ Abdominal binder
➢ Drain tube kept in place
➢ Advice: control of obesity, stop smoking and alcoholism
➢ Treatment of any aggravating factors (chronic cough, constipation)

**spigelian hernia: they arise through a defect in spigelian fascia, which is the aponeurosis of
transversus abdominis. They appear below the level of umbilicus at the lateral edge of rectus sheath

Richter’s hernia
Q. Short note: Richter’s hernia

Ans:

➢ It is a hernia
➢ In which, the sac contains
➢ Only a portion of the circumference of the intestine
➢ The remaining circumference is not inside the hernial sac

134
 ➢ Feature
o No feature of obstruction
o Constipation doesn’t occur
o But strangulation can occur
o Mimics gastroenteritis: pain, diarrhoea, vomiting, toxicity
➢ Treatment
o Resection and anastomosis
o Treatment of the hernia

Hernia repair

135
Q. Hernitomy, herniorrhaphy, hernioplasty

Ans:

➢ Herniotomy
o Identification of the sac
o Dissection of the sac
o Reduction of content
o Trans fixation of neck (by non absorbable suture material)
o Excision of redundant part of the sac
➢ Herniorrhaphy
o Herniotomy followed by
o Repair of the defect of the wall (in case of inguinal hernia, repair of the posterior wall of
hernia weakness)
o And reinforcement/strengthening of the weakness (posterior wall)
➢ Hernioplasty
o If reinforcement is done by prolene meshwork placement (tension free hernioplasty)

** Treatment option of indirect inguinal hernia: if the age of the patient is below 14-16, treatment is
herniotomy only

If age is more than 14-16, treatment will be hernioplasty (herniotomy + implantation of the prolene
mesh to strengthen the posterior wall of the inguinal canal)

**Treatment of direct inguinal hernia: hernioplasty (but not preceded by herniotomy)

Q. Mention the steps of operation of inguinal hernia for a 5-year-old boy

Ans: in this case, I will do only herniotomy, since the inguinal canal formation has not yet completed. (in
case of adult, we need hernioplasty)

Steps:

➢ Dissection of the covering of the hernia (skin, anteiror abdominal wall)

➢ (Rest are like herniotomy)
➢ Identification of the sac
➢ Dissection of the sac
➢ Reduction of content
➢ Trans fixation of neck (by non absorbable suture material)
➢ Excision of redundant part of the sac

Q. Where will you find the mesh in Lichtenstein’s repair? (Open flat mesh repair)

Ans:

• Mesh measuring 8x15 cm

136
 • Placed over posterior abdominal wall
• Behind spermatic cord
• Split to wrap around the spermatic cord around the deep inguinal ring

Q. Complications of inguinal hernia repair

Ans:

➢ Early
o Pain
o Hemorrhage
o Nerve injury (ilioinguinal, ilio hypogastric)
o Urinary retention
o Anesthesia related complication
➢ Intermediate
o Seroma formation (due to excessive inflammatory response to suture/mesh)
o Wound infection (should give prophylactic antibiotics)
➢ Delayed
o Chronic pain (less in laparoscopic hernia surgery)
o Hernia recurrence
o Testicular atrophy (in case of damage of testicular artery)

Q. Post-operative advice following hernia surgery

Ans:

➢ Control of obesity
➢ Weight reduction
➢ Stop smoking and alcoholism
➢ Referral to specialist for treatment of predisposing factors
➢ Avoid heavy work for 3 months post-operative

137
Hydrocele
Q. Define hydrocele

Ans:

➢ Hydrocele maybe defined as

➢ Abnormal collection of fluid
➢ In a part of processus vaginalis
➢ Especially the tunica vaginalis

Q. Classification of hydrocele (in bracket, pathogenesis)

Ans:

➢ Congenital hydrocele (due to patency of lumen of processus vaginalis +- persistence of

communication with peritoneal cavity)
o Vaginal hydrocele
o Infantile hydrocele
o Congenital hydrocele
o Encysted hydrocele of the cord
➢ Acquired hydrocele
o Primary (defective absorption of fluid)
o Secondary (excessive production of fluid within sac)
▪ Infection (filariasis)
▪ Inflammation (epididymo-orchitis)
▪ Trauma
▪ Tumor (hydrocele in 30 yo young man: be alert about testicular tumor)

138
Q. D.D of cystic swelling in scrotum

Ans:

➢ Vaginal hydrocele
➢ Encysted hydrocele of the cord (d in the pic)
➢ Epididymal cyst
➢ Spermatocele

Q. Clinical features of hydrocele/examination of hydrocele

Ans:

➢ Scrotal swelling
➢ Can palpate the spermatic cord above the hydrocele (can get above the swelling)
➢ Fluctuant swelling
➢ Brilliantly transilluminating
➢ Hydrocele completely surrounds the testis and epididymis, so those cannot be palpated

139
 ➢ It cannot be reduced

Inv: USG of the scrotum

Q. Mention the treatment options for hydrocele

Ans:

➢ Congenital hydrocele
o May resolve spontaneously
o If not, herniotomy
➢ Others (if large size, and bothering the patient)
o Lord’s plication: if the sac is thin walled, small, contains clear fluid
o If sac is thick, large, doesn’t contain clear fluid
▪ Eversion (eversion of the sac behind the testis, testis placed in a pouch in
scrotum) (Jaboulay’s procedure)
▪ Excision (may cause large scrotal hematoma – no more recommended)
o repeated aspiration of fluid, if patient not fit for surgery

**lord’s and jaboulay’s for vaginal hydrocele, excision for infantile and encysted hydrocele

Q. Describe the procedure of Lord’s operation

Ans:

➢ shaving of the pubic and scrotal region

➢ appropriate antiseptic measures
➢ anesthesia: GA/LA (spinal)
➢ cleaning, draping
➢ incision 6-8 cm made over scrotum, parallel and laterally to median raphe
➢ dissection of
o skin
o dartos
o external spermatic fascia
o cremasteric muscle and fascia
o internal spermatic fascia
➢ exposure of parietal layer of tunica vaginalis (bluish sac of hydrocele)
➢ evacuation of hydrocele fluid using trocar and cannula
➢ opening of the sac (upto this same for eversion and excision procedure)
➢ if the sac is small, thin, contains clear fluid, we will proceed with lord’s procedure
➢ after evacuation of fluid, redundant portion of tunica vaginalis/sac is “plicated” or “bunched”
➢ using a series of interrupted, absorbable suture

140
 ➢ this will cause the sac to undergo fibrosis
➢ closure of the wound
➢ adequate post operative care

Q. Complications of hydrocele/primary vaginal hydrocele (Not DU)

Ans:

➢ infection
➢ hematocele
➢ pyocele
➢ testis atrophy
➢ infertility
➢ hernia may occur through hydrocele sac

Q. Short note: encysted hydrocele of the cord

Ans:

➢ in this form of hydrocele

➢ there is fluid collection in a patent portion of tunica vaginalis
➢ the sac is closed above and below
➢ it may be located in
o inguinal
o inguinoscrotal
o scrotal cell
➢ the swelling is fluctuant, transilluminating
➢ treatment: excision under local anesthesia

Q. Congenital hydrocele

Ans:

➢ processus vaginalis communicates with the peritoneal cavity

➢ the communication is small, so herniation doesn’t occur
➢ when lying down, fluid disappears gradually
➢ reappears while patient is standing
➢ it cannot be emptied by digital pressure

Q. How can you differentiate between different types of hydrocele clinically?

Ans:

141
 Vaginal COngential Infantile hydrocele Encysted
hydrocele hydrocele hydrocele
Palpation of testis Not palpable Not palpable Not palpable May be
palpable
Location of Scrotal Inguinoscrotal Inguinosrotal/scrotal Inguinal/
swelling inguinoscrocal/
scrotal
Disappearance of Doesn’t occur Occurs Doesn’t occur Doesn’t occur
fluid upon lying
down

Q. How would you differentiate inguinal hernia from vaginal hydrocele clinically

Ans:

Inguinal hernia Vaginal hydrocele

Location Inguinal/inguino scrotal Scrotal
Palpation of testis Palpable Not palpable
Get above the swelling Couldn’t get Could get (spermatic cord
palpable)
Cough impulse +ve -ve
Fluctuation -ve +ve
Transillumination Not done/absent Brilliantly transilluminating
Reducible Yes No
Consistency Doughy (omentocele) Cystic
Crepitation/bubbly (enterocele)

Q. How will you differentiate hydrocele from testicular tumor?

142
Ans:

Hydrocele Testicular tumor

Consistency Cystic Hard
Fluctuation +VE -VE
Transillumination +ve -ve
Para aortic LN Not palpable palpable

Q. An 8 year old boy presented with inguinoscrotal swelling present from birth. What might be the d/d

Ans:

➢ congenital inguinal hernia

➢ congenital hydrocele
➢ infantile hydrocele
➢ encysted hydrocele

143