Liver

∙ kasabach-merrit syndrome- cosumptive coagulopathy caused by sequestration of

platelets and clotting factors in a giant hemangioma.
∙ Contrast CT- Hemangioma > vascular lesion that fills from periphery to centre + delayed
contrast enhancement
hepatic adenoma > early contrast enhancement + well developed peripheral
arterialization of tumor
Focal nodular hyperplasia > bright homogenous enhancement with hypodense central
stellate scar
HCC > early uptake of contrast with mosaic pattern to tumor + enhances in arterial
phase and not in portal venous phase + washout (hypodense nodule as compared w
surrounding parenchyma) of contrast in delayed (portal venous) phase.

Thyroid
∙ Pandred's syndrome: dyshormonogenesis due to TPO deficiency, characterized by goiter
+ sensorineural hearing losss
∙ Deep cervical lymphadenopathy along internal jugular vein is diagnostic of papillary
carcinoma.
∙ B-blockers inhibit peripheral conversion of T4 to T3, drug is given 7 days post operatively
∙ Potassium iodide reduces vascularity of the gland, given 10 days before operation
∙ Complications of thyroidectomy: bleeding/neck hematoma, laryngeal edema,
tracheomalacia, external/recurrent laryngeal nerve damage, thyroid storm,
hypothyroidism, hypocalcemia
∙ Papillary CA is spread via lymphatics, follicular via hematogenous to lungs and bone.
∙ Measurement of serum thyroglobulin is of value in followup and detection of metastatic
disease in pts w/thyroid surgery for cancer.
∙ Medullary CA tumors are not TSH dependant. Tumor markers are calcitonin and CEA.
∙ Chr lymphocytic thyroiditis presents as goitre mostly in women at menopause,
eventually causes hypothyroidism
∙ Sestamibi (radio-isotope) scanninng is used to localize abnormal parathyroid glands and
allows minimally invasive parathyroidectomy
∙ calciphylaxis: metastatic calcification of blood vessels, end stage of secondary
hyperparathyroidism
∙ Insulinoma is screened w/ hypoglycemia and inc plasma insulin after 72 h fast.
Suppresed w/ IV insulin and measure C-peptide. Tumor localized by endoscopic
ultrasound.
∙ MC site for sporadic gastrinoma is the head of the pancreas and for tumors ass w/ MEN
1 is 1st and 2nd part of duodenum.
 ∙ Non functional endocrine pancreatic tumors stain positively for chromogranin A and
synaptophysin. tx w/ chemo w/ streptozotocin, octreotide and interferon. Surgery toc.
partial pancreaticoduodenectomy.
∙ alpha blockade first then beta blockade should be done before surgery for
pheochromocytoma.

Breast
∙ Ligaments of cooper extend from dermis of skin to the pectoral fascia and provide
support for the breast. Its invasion by cancer causes dimpling of skin or inversion of
nipple.
∙ Slit like retraction of nipple may be caused by duct ectasia/ chronic periductal mastitis. A
circumferential retraction may be carcinoma.
∙ Poland's syndrome: amazia + absence of sternal portion of pectoralis major.
∙ Mondor's disease: Thrombophlebitis of superficial veins of the breast and anterior chest
wall.
∙ Fibroadenoma/ breast mouse: mc discrete mass in women <30 yrs
∙ Infiltrating ductal carcinoma is the mc variant of breast cancer.
∙ DCIS is treated as malignancy whereas LCIS is not (loss of E-cedherin)
∙ Peau d'orange suggests local lymph node invovement
∙ Cancer en cuirasse is carcinomatous infiltration of skin of chest, local recurrence after
mastectomy
∙ Modified radical mastectomy aka patey mastectomy: pectoralis major is left intact.
Breast, axillary LN, nipple areola complex and pectoralis minor is removed.
∙ Axillary LN levels are based on relationship to pectoralis minor muscle. level 1: lateral, 2:
posterior, 3:medial
∙ Silicon gel implant or latissimus dorsi muscle flap or transversus abdominis flap can be
used for breast reconstruction surgery
∙ Chemotherapy regimens-> traditional: 6 monthly cycle of cyclophosphamide,
methotrexate and 5-flurouracil
current: an anthracycline + taxane based regimen given in 5-6 cycles
∙ Trastuzumab is used in pts with her2/neu +ve tumors combined w/chemo.
∙ Tamoxifen is used for receptor +ve beast cancer in premenopausal women.
∙ Anastrozole is used for receptor +ve breast cancer in post menopausal women. Licensed
for tx of recurrent disease.
∙ LNRH agonists like goserelin causes reversible ovarian suppression decreasing estrogen
levels causing a reversible chemical menopause.
∙ If tumor size is >2 cm prognosis is poor
∙ Nottingham prognostic index is based on tumor size, grade + nodal score. <3.4 good
prognosis, >5.4 poor prognosis
∙ BRCA 1 mut is also ass w/ risk of ovarian and colorectal cancers, BRCA2: inc risk of male
breast cancer
 ∙ Pregnancy can mask breast cancer symptoms

Hernia
∙ Hernia is caused due to anatomical weakness or high intrabdominal pressure
∙ Irreducibility without othet symptoms is diagnostic of an omentocele
∙ Strangulated hernia is more common in femoral hernia
∙ Indirect inguinal hernia arises lateral to inferior epigastric artery or hesselbach triangle,
common on right side in childhood. Strangulation common
∙ Direct Inguinal hernia arises medial to inf epigastric artery and protudes thru posterior
wall of inguinal canal (transversalis fascia)
∙ Dual hernia: indirect and direct sacs stradle the epigastric artery
∙ Lichtenstein repair is superior method to repair hernia.
∙ Sliding hernia is a type of hernia in which posterior wall of sac is partially formed by wall
of viscera
∙ Strangulation is the initial presentation of 40% of femoral hernias. It is irreducible and no
cough impulse
∙ Inguinal hernia is above and medial to pubic tubercle, femoral hernia is below and
lateral to pubic tubercle
∙ Umbilical hernia surgery after 2 yrs of age
∙ Crescent shaped appearance of umbilicus in para-umbilical hernia
∙ Epigastric hernia commences as protusion of extra-peritoneal fat aka fatty hernia of linea
alba. Mimics pain of peptic ulcer disease..
∙ Spigelian hernia is almost always above arcuate line, below level of umbilicus near edge
of rectus sheath
∙ Howship-Romberg sign: Pain referred along the geniculate branch of obturator nerve to
the inner aspect of knee should raise suspicion of an obturator hernia.

The peritoneum
∙ Adhesional small bowel obstruction: Bowel sounds increased
∙ paralytic ileus: bowel sounds reduced
∙ Pelvic abscess: pelvis ismc site for intraperitoneal abscess. Rectal examination reveals
bulging of anterior rectal wall. Pelvic pain + diarrhea + passage of mucus in stool
∙ Pneumococcal peritonitis spread via resp tract infection, middle ear or vagina or
fallopian tube, nephrotic synd or cirrhosis
∙ Tuberculous peritonitis: abdominal pain, fever, night sweats, ascites, abdominal mass
∙ Pseudomyxoma peritonei is caused by mucinous cystic tumors of appendix(mc) and
ovary
∙ Mesenteric cyst: Chylolymphatic (most common type)lined by flat endothelium, n
mesentery of ileum
Enterogenous cyst: lined by ciliated mucus membrane, arises from diverticulum of
mesenteric border of intestine
 ∙ Tillaux's sign: swelling moves freely in a plane at right angles to attachement of
mesentery

Esophagus
∙ Dysphagia is the predominant symptom in advanced esophageal cancer
∙ malignant tracheoesophaegal fistula is a sign of incurable disease
∙ Resp complications of esophagectomy are most common
∙ Benign anastomotic stricture is mc late complication of esophagectomy

The stomach
∙ Post gastrectomy, it is a common practice to perform a water soluble contrast swallow at
5-7 days after the operation to determine whether anastomosis is intact
∙ The recurrence rates after truncal vagotomy and antrectomy are exceedingly low
∙ Criminal nerve of grassi is usually the first branch from posterior vagal trunk, it can lead
to recurrent ulcers if not ligated during vagotomy.
∙ Duodenojejunal flexure can be identified by the presence of suspensory ligament of
treitz

The pancreas
∙ In acute pancreatitis, on abdominal x-ray, sentinal loop sign, colon cut off sign and renal
halo sign are seen
∙ Antibiotics are given in severe pancreatitis, cefuroxime, imipenim, ciprofloxacin and
metronidazole
∙ Pseudocyst develops 4 weeks after acute pancreatitis, encapsulated collection of
amylase rich fluid
∙ Tropical pancreatitis is associated w cassava ingestion and SPINK-1 mutation
∙ Autoimmune pacreatitis ass w elevated IgG4
∙ Chr pancreatitis shows dilated chains of lakes on ERCP
∙ Dictal adenocarcinoma is mc, involves head of pancreas. Mets to liver and peritoneum
∙ Mucinous tumor -> peri menopausal women
∙ Elevated tumor marker CA 19.9 is seen in CA pancreas
∙ EUS more accurate than CT if tumor less than 3 cm, vascular invasion

The small and large intestine

∙ Littre's hernia refers to inguinal or femoral hernia in which the content of sac is
Meckel's diverticulum
∙ vesico-colic fistula is a complication of diverticular disease
∙ Hinchey classification details the degree of contamination in acute diverticulitis. Stage 4
w feculent peritonitis from colonic perforation
∙ CT scan is IOC in acute attacks and complications of diverticulitis. Barium enema and
colonoscopy are contraindicated
∙ Smoking and appendectomy have a protective effect on ulcerative colitis
∙ Toxic megacolon is diagnosed by plain abdominal x-ray w colonic diameter of > 6cm
∙ DNA of mycobacterium paratuberculosis is found in the intestine of 60 % of pts w
crohn's disease.
∙ Small bowel enema is the best Ix of small intestine, shows string sign of kantor in CD
∙ Metronidazole is useful in perianal disease. Infliximab is effective in the tx of fistula.
∙ Perianal abscess=drainage, fistula in ano= seton placement
∙ Metronidazole is first line drug to tx intestinal amoebiasis and diloxanide furoate is best
for chronic infection ass with passage of cysts in stool
∙ Salmonella typhosa causes typhoid ulcer parallel to the long axis of gut, most common
site is terminal ileum. Paralytic ileus is most common complication.
∙ Tuberculous ulcers are multiple and transverse to the long axis of the gut.
∙ Ulcerative TB: terminal ileum, Hyperplastic TB: ileocecal region
∙ mc site of gastrointestinal carcinoid= appendix, followed by ileum
∙ carcinoid synd occurs only with liver metastasis: flushing, diarrhea, hepatomegaly,
reddish blue cyanosis, right sided valvular heart disease (tricuspid stenosis), asthma,
borborygmi. (octreotide given preoperatively)
∙ Villous adenomas can cause hypokalemia, hypoalbuminemia and high risk of malignancy
∙ Colonic cancer has macroscopic forms: annular (obstructive), tubular (bleeding),
ullcerative (bleeding + local invasion), cauliflower (bleeding, least malignant)
rectum mc site
∙ Right sided tumors: bleed, blood mixed in stool, anemia.
Left sided tumors: Obstruct, bright red blood coats stool
∙ right sided tumor double contrast barium enema: apple-core, left: napkin ring
appearance
∙ hepatic resection criterion is <3 lesions in one lobe of liver
∙ Heyde's syndrome: aortic stenosis + gastrointestinal bleeding from colonic
angiodysplasia
∙ Barium enema should be avoided in angiodysplasia, pill endoscopy for small bowel,
colonoscopy for large bowel + sup inf mesenteric angiography or technetium 99m
labelled red cells may confirm and localize source of bleeding
∙ Blind loop synd/bacterial overgrowth synd in upper intestine causes fat malabsorption/
steatorrhea and in lower intestine causes defect in B12 absorption/anemia
∙ Previous surgery is the mcc of enterocutaneous fistula
∙ High output fistula >500 ml per day: SNAP; Sepsis control and skin protection, nutrition,
anatomical assessment and planned surgery
∙ Megarectum causes fecal incontinence and mega colon causes abdominal distention and
pain
 ∙ Investigations of megacolon constipation: AXR, Double contrast enema, rectal biopsy,
anorectal physiologic tests
∙ Ix for non-megacolon constipation: defecating proctography, whole gut transit time
measurement

Intestinal Obstruction
∙ Dynamic Obstruction: Peristalsis present and works against a mechanical obstruction.
Extramural adhesions mcc.
∙ Adynamic Obstruction: Peristalsis may be absent or present in a non propulsive form
without any mech obst.
∙ Absolute obstruction means neither feces nor flatus is passed. It is a cardinal feature of
complete intestinal obstruction
∙ Radiological dx of intestinal obstruction is based on supine abdominal x-ray
∙ Fluid levels appear later than gas shadows and are prominent on erect x-rays
∙ The development of severe colicky abdominal pain is indicative of strangulation
∙ Dehydration is seen most commonly in small bowel obstruction
∙ Coiled spring sign seen in jejunal obstruction
∙ If cecum is collapsed= small bowel obstruction
If cecum is dilated= large bowel obstruction
∙ Acute intestinal obstruction is managed firstly by nasogastric decompression and IV
rehydration w Hartmann's sol or normal saline and antibiotics
∙ MC type of intussusception in children is ileocolic (claw sign) and in adults is colocolic.
MC age group is 5-10 months.
∙ Sing of dance i.e feeling of emptiness in RIF, sausage shaped lump concavity towards
umbilicus, red currant jelly stool -> features of intussusception
∙ Cecal volvulus -twist is clockwise, common in females, bird beak deformity on barium
enema
∙ Sigmoid volvulus -twist is anticlockwise, most common type, coffee bean sign on AXR
∙ Conservative management for adhesions should not exceed 72 hours
∙ Ogilvie's syndrome: acute colonic pseudo-obstruction
∙ Embolisation of SMV(middle colic artery) is the mcc of acute mesenteric ischemia. c/f:
sudden onset of severe abdominal pain in pt w atrial fibrillation or atherosclerosis
∙ MC site of ischemic colitis is splenic flexure, may presnt in 3 forms: gangrenous, transient
and structuring (causes obstruction) forms.
∙ Intestinal pseudo-obstruction -> autoimmune destruction of myenteric plexus
∙ Distension in small bowel obst is greater, colonic obst is delayed and in mesenteric or
vascular occlusion is minimal or absent
∙ Billious vomiting is the dominant feature in jejunal atresia and distention in ileal atresia.

The vermiform appendix

∙ During childhood, appendix rotates into a retrocecal but intraperitoneal position
 ∙ The appendicular artery (branch of ileocolic) is an end artery; thrombosis of which
results in necrosis of the appendix. Ischemic necrosis of appendix wall produces
gangrenous appendicitis
∙ The appendix is the most common site for carcinoid tumors arising thru argentaffin cells
in the base of crypts aka kulchitsky cells.
∙ Signs of acute appendicitis: pointing sign, rovsing sign, psoas sign (retrocecal
appendicitis), obturator sign (pelvic appendicitis), hamburger sign
∙ Retrocecal appendix -> silent appendix because cecum filled w gas prevents pressure
exerted by hand from reaching the inflammed structure
∙ Pelvic appendix: diarrhea + frequency of micturition
∙ postileal appendix: least common position, lies behind terminal ileum
∙ Obesity can obsure and diminish all the local signs of acute appendicitis
∙ Appendicitis is the mc extra uterine abdominal condition in pregnancy
∙ Vomiting follows pain (in gastroenteritis pain follows vomiting)
∙ If alvardo score is <4 diagnosis is unlikely, 5-6= observe, >operation req
∙ Babcock forceps is used to hold appendix
∙ Post-op complications: wound infection (mc early comp), intra-abdominal abscess, Ileus,
Resp complications, portal pyaemia, fecal fistula, adhesive intestinal obstruction (mc late
comp)
∙ Management of appendix mass is by Ochsner-Sherren Regimen

The rectum
∙ Puborectais muscle creates the anorectal angle
∙ Denonvillier's fascia: Separates the lower 3rd of rectum from prostate/vagina in front
∙ Waldeyer's fascia: Separates the lower 3rd of rectum from coccyx and lower two sacral
vertebra from behind
∙ Rectal mucosal prolapse is 1-4 cm, tx by submucosal inj of 5% phenol in almond oil,
rubber bands, excision or endoluminal stapling
∙ Full thickness prolapse aka procidentia, 10-15 cm, tx is suregry by perianal or abdominal
approach
∙ Strawberry lesion of rectosigmoid is caused by infection by Spirochaeta vincenti and
bacillus fusiformis.
∙ Rectal bilharziasis is caused by schistosoma mansoni, caused by stage 3 of the disease,
from deposition of ova in rectum
∙ Rectum is the most common site of colorectal carcinoma (adenocarcinoma)
∙ C/f of rectal CA include spurious diarrhea i.e the pt may endevour to empty rectum
several times a day often w passage of flatus and small amount of blood stained mucus.
∙ Pt w annular growth at rectosigmoid junction suffers w constipation
∙ Pt w growth in ampulla of rectum suffers from early morning bloody diarrhea
∙ Invasion of sacral plexus-> sciatica, liver met: weight loss
∙ Assesing local spread of rectal CA is by endoluminal US and MRI pelvis
 ∙ Anterior resection is an anal sphincter preserving resection of rectum, thru abdominal
approach. It is preferable for all the tumors whose lower margin is >2cm above the anal
canal. Upper 2/3rd of rectum
∙ Abdominoperineal resection: Does not preserve sphincter. When the lower margin of
tumor is <2cm below anal margin. Lower 1/3rd of rectum
∙ Hartmann's and brunschwig's procedure: In old frail pt. Removal of all pelvic organs +
end colostomy
∙ Mc drug used for chemo -> 6 fluorouracil + folinic acid
∙ Lower ant resection syndrome: frequency, urgency, altered bowel movements
∙ Complications of AR and APR-> impotence, anastomotic leak, pre-sacral venous bleed

Anus and Anal Canal

∙ Anal canal lies below the pelvic diaphragm and ends at anus
∙ Interphincteric place aka hilton's whit line separates the internal and external sphincters,
is a potential route for spread of pus
∙ Low imperforate anus (below puborectalis sling) is prone to constipation, high
imperforate anus is prone to fecal incontinence
∙ Pilonidal sinus (jeep disease) refers to sinus in the natal cleft overlyiing the coccyx which
communicate w fibrous track lined by granulation tissue and containing hair within the
lumen
∙ Most common site of anal fissure is posterior midline. (ant in females)
∙ Tx of fissure-> conservative management, manual dilatation, lateral anal sphincterotomy
and anal advancement flap
∙ Bright red painless bleeding is most common and earliest symptom of hemorrhoid
∙ Injection sclerotherapy(5% phenol in almond oil) is indicated for 1st and 2nd degree
hemorrhoids, useful when bleeding is the main complaint
∙ Banding also for 1st or 2nd degree, when prolapse in the main complaint
∙ Hemorrhoidectomy for 3rd and 4th degree hemorrhoids
∙ Thrombosed external hemorrhoids aka perianal hematoma present as sudden onset
olive shaped painful blue subcutaneous swelling at the anal margin, called 'a 5 day,
painful, self curing lesion'
∙ Perianal abscess presents w short hx of severe pain, palpable tender lump at anal
margin, indurated hot tender perianal swelling
∙ Ischiorectal abscess: longer hx, diffusely swollen buttocks w widespread induration and
deep tenderness
∙ Ix of anal fistula by perineal and rectal examination, EUA, inj of dilute hydrogen peroxide
in ext opening to look for bubbles in int opening, endoanal US, MRI (gold standard), CT
scan and fistulography (for extrasphincteric fistula)

Kidneys and ureters

∙ Horseshoe kidney is ass w turner's syndrome
 ∙ Urography confirms dx of APKD
∙ In women ectopic ureter opens into urethra below the sphincter therefore incontinence
can occur. (not in men)
∙ Meteorism: abdominal distention 24-48 hrs after renal injury, due to retroperitoneal
hematoma implicating splanchnic nerves
∙ Complications of renal trauma: clot retention, pararenal pseudohydronephrosis,
hypertension, post traumatic aneurysm of renal artery
∙ Surgical trauma during hysterectomy is the mcc of ureteric injury
∙ Baori operation is when a strip of bladder wall is fashioned into a tube to bridge the gap
b/w the cut ureter and the bladder
∙ Contrast enhanced CT scan is mainstay of investigation for acute ureteric colic
∙ Uric acid calculi are radiolucent(not visible on xray) and mag ammonium phosphate
calculi precipitate at acidic pH
∙ ESWL is preferred tx option for stones<2 cm
∙ Percutaneous nephrolithotomy for >2cm, >1 cm in renal pelvis, when ESWL contraindi
∙ Thyroidization of tubules occurs in chronic pyelonephritis
∙ Renal cell carcinoma aka as hypernephroma or grawitz's tumor. Adenocarcinoma mc site
is upper pole. Triad of costovertebral pain + palpable mass and hematuria
∙ RCC mets to lungs giving cannonball appearance
∙ Wilms tumor is a mixed tumor containng blastemal, stromal and epithelial elements

The Urinary Bladder

∙ Frequency is the earliest symptom of bladder stones
∙ Laser lithotripsy with holmium laser can deal with most large stones
∙ Bilharzial pseudotubercles are the earliest appearance of schistosomiasis of bladder
∙ Schistosomiasis can causes squamous cell carcinoma of bladder
∙ Cigarette smoking is the most imp risk factor for transitional cell carcinoma of bladder
∙ Painless gross hematuria is indicative of bladder CA until proven otherwise
∙ Cysto-urethroscopy is the mainstay of daignosis
∙ Mitomycin C is the mc agent used for intravesical chemotherapy

The Prostate
∙ Skene's tubules on female urethra are homologous of the prostate
∙ BPH is mcc of bladder outflow obstruction in men >70 yrs of age
∙ Prostate enlarges because of increased estrogenic effects
∙ Persistence of median sulcus is a definite sign of BPH, it is obliterated in cancer
∙ TURP is gold standard for tx of BPH. Ass w water intoxication ->hyponatremia
∙ Ca of prostate spreads most commonly to pelvic bones and lumbar vertebra and
obturator nodes
∙ On DRE, median sulcus is obliterated and rectal mucosa tethered to gland in ca prostate.
Tissues lateral to gland may be infiltrated giving rise to winging of gland
 ∙ PSA levels more than 3 nmol/ml is dx of prostatic cancer
∙ Curative therapy is for stage 1 and 2 (radical prostatatectomy in young and TURP in
elderly) and palliative therapy for stage 3 and 4
∙ Medical castration for T3 and T4 can be achieved by 2 methods: LHRH agonists
(Goserelin) and Anti-androgen (flutamide)
∙ Acute prostatitis: fever + rigors, lower back + perineal pain, threads in initial voided
sample, tender prostate
∙ Chronic prostatitis: Persistent threads in voided urine, pus cells w or without bacteria in
absence of urinary infection. Dx by 3 glass test, DRE (soft boggy tender prostate),
prostatic fluid, urethroscopy
∙ Prostatic abscess should be suspected when there is no response after using antibiotics
for prostatitis

Urethra and Penis

∙ Posterior urethral valves are most commo cause of bladder outflow obstruction in young
boys
∙ voiding cystogram is inv of choice
∙ Avoid cicumcision in pts with hypospadias as the prepuce may be used in procedures to
correct hypospadias
∙ Rupture of bulbar urethra is caused by a blow to perineum due to a fall sastride a
projecting object, on DRE: high riding prostate. Bladder should be drained by
percutaneous subprapubic catheterization
∙ Rupture of membranous urethra occurs as a result of pelvic fracture
∙ Intraperitoneal bladder rupture ->peritonitis
∙ Extraperitoneal bladder rupture -> pain, bruising and dullness to percussion above the
umbilicus
∙ Urethral stricture is main complication of above. Tx by endoscopic urethrotomy or
urethroplasty
∙ Post-gonorrheal infection can cause urethral stricture of bulbar urethra
∙ True phimosis is most commonly due to balanitis xerotica obliterans. Indication for
cicumcision.
∙ Paraphimosis is a urological emergency caused by retraction of a tight foreskin
∙ Peyronie's disease is a fibromatosis that affects focl areas of tunica albuginea of the
corpus cavernosum. Ass w dupuytren's contracture
∙ Causes of priapism include -> sickle cell disease, leukemia, injection of papaverine,
malignancy or spinal cord disease
∙ Penile CA spreads to inguinal then to iliac nodes
∙ Genital warts in men occur under the prepuce and in women, occur on vulva

Testis and Scrotum

∙ hCG stimulates growth and migration of testis
 ∙ Undescended testis have malignant potential of transformation into seminoma
∙ Orchidopexy is performed before 1 year
∙ Superficial inguinal ring is most common site for ectopic testis
∙ Absent ipsilateral cremastric reflex is most reliable sign of testicular torsion
∙ Prehn's sign: Elevation of testis reduces the pain in the epididymo-orchitis
Elevation of testis aggravates the pain in testicular torsion
∙ The most common torsion of testicular appendage is the appendix testis, acute onset of
hemiscrotal pain, pain superior pole of testis, <11 yrs, absent nausea vomiting, nodule at
superior pole with blue dot appearance, cremasteric reflex is present
∙ Chronic tuberculous epididymo orchitis most commonly involves the lower pole of
epididymis
∙ Varicocele is more common on left side. Embolisation of testicular vein is TOC
∙ Classically hydrocele transilluminates
∙ Pure embryonal CA= raised hCG, normal APF
mixed embryonal CA= raised hCG. raised AFP
∙ AFP= teratoma + yolk sac tumors
HCG= choriocarcinoma + embryonal cell carcinoma
Lactate dehydrogenase= seminomas + nonseminomas
ALP= seminomas
∙ Idiopathic scrotal gangrene is aka fournier's gangrene

Hernia
∙ Reducible hernia has positive cough impulse
∙ Irreducibility without other symptoms is almost diagnostic of an omentocele
∙ Obstructed hernia is on which intestine is obstructed but has good blood supply
∙ strangulated hernia: blood supply of bowel is obstructed(more common in femoral
hernia)
∙ Superficial inguinal ring: Triagular aperture in the aponeurosis of external oblique
muscle, lies 1.25 cm above pubic tubercle
∙ Deep inguinal ring: U shaped condensation of transversalis fascia, 1.25 cm above
inguinal ligament
∙ Inferior epigastric vessels lie posteriorly and medially to deep inguinal ring
∙ Direct inguinal hernia: within hesselbach triangle
∙ Indirect Inguinal hernia: lateral to ", strangulation common
∙ Indirect inguinal hernia arises lateral to inferior epigastric artery and often protudes thru
deep inguinal ring, mc hernia of all, esp in children, more common on right side
∙ Direct inguinal hernia: Medial to inf epigastric artery + protudes thru psterior wall of
inguinal canal,mc in older men
∙ Dual hernia aka saddle bag or pantaloon hernia
∙ Sliding hernia: posterior wall of sac is partially formed by wall of viscera
∙ Femoral hernia: protusion of extra-peritoneal tissue, peritoneum/ abdominal contents
thru femoral canal