Cholelithiasis are hard, stone like deposits inside the gallbladder. Cholelithiasis is the most common gastrointestinal disorder leading to surgical management. The size of the stone range from as small as a grain of sand to as large as a golf  ball.

What are the types of Cholelithiasis?

Gallstone is divided into following types:

1. Cholesterol Gallstone(80% of total gallstone) : It is radiolucent . Mainly contain cholesterol.
2. Pigment Gallstone(20% of total gallstone): It is radiopaque. Mainly contain calcium bilirubinate.

What is the pathogenesis of Cholelithiasis?

1. Cholesterol stones is formed when the ratio of cholesterol to phospholipids or bile salts is increased , bile salts is supersaturated with cholesterol results in crystallizes and forms a focus for stone formation .
2. Pigments stones is formed due to the crystallization of calcium bilirubinate.

What are the risks factor for cholelithiasis?

1. Female
2. More than 40 years
3. Obese individual
4. Pregnant women
5. Hemolytic anemia
6. Sickle cell anemia
7. Liver cirrhosis
8. Biliary tract infection
9. Diabetes
10. Eating high fat, high cholesterol , low fiber diet
11. Taking birth control pills
12. Taking drugs which contain estrogen.
13. Rapid weight loss
14. Fasting for long time
15. Long time intravenous feeding

What are the signs and symptoms cholelithiasis?

Many people (60%-80% )who have gallstones are asymptomatic( have never had signs and symptoms) . Symptoms commonly occur when stone blocks cystic or common bile duct , which includes:

1. Biliary colic ( Acute paroxysmal pain in upper right quadrant of the abdomen )
2. Pain spread to the back and right shoulder
3. Pain occur after fatty meal
4. Fever
5. Jaundice
6. Dyspepsia
7. Flatulence
8. Food intolerance
9. Nausea and vomiting
10. Abdominal fullness
11. Clay colored stools

What are the complications of cholelithiasis?

1. Acute Cholecystitis
2. Chronic Cholecystitis
3. Empyema of the gall bladder
4. Mucocele( dilation of the ball bladder with accumulated mucous secretion)
5. Mirizzi,s syndrome ( Mirizzi syndrome is a condition when common hepatic duct obstruction caused by compression from an impacted stone in the hartmann’s pouch or in cystic duct. )
6. Biliary obstruction
7. Acute Cholangitis
8. Acute Pancreatitis
9. Gallstone ileus ( Intestinal obstruction due to gall stone)
10. Gallbladder cancer

How is a cholelithiasis diagnosed ?

Diagnosis relies on history and physical examination and laboratory test with confirmatory radiological studies which includes:

1. Abdominal ultrasound ( 90% of gallstone are visible in USG)
2. Abdominal X-ray ( 10-15% of gallstone are diagnosed by x-ray
3. Abdominal CT and MRI scan
4. ERCP( endoscopic retrograde cholangiopancreatography)
5. HIDA scan(Hepatoiminodiacetic acid)
6. PTCA( Percutaneous transhepatic cholangiogram)
7. Laboratory tests includes Liver function tests, Serum lipase , Bilirubin and complete blood test.

How is a cholelithiasis managed ?

1. Asymptomatic Gallstones don’t required treatment. Cholecystectomy(open cholecystectomy and laparoscopic cholecystectomy) is being performed for those patients who developed symptoms or complications .Prophylactic cholecystectomy is considered in diabetes patients, congenital Hemolytic anemia , those due to undergo bariatric surgery. Other treatment for cholelithiasis includes:
2. ERCP( treat gallstones in the common bile duct)
3. Lithotripsy ( Lithotripsy is done for those who cant have surgery)
4. Medication which includes chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UCDA) are prescribed to dissolve cholesterol gallstones.

What is the prognosis of cholelithiasis?

Prognosis is excellent with early treatment.

References:

1. Sabiston textbook of surgery 18th edition
2. The Washington manual of surgery, 5th edition.
3. emedicine.medscape.com
4. http://www.medicinenet.com
5. http://en.wikipedia.org
6. http://www.uptodate.com
7. http://www.ncbi.nlm.nih.gov

No related posts.

Insulinoma is the beta cells tumor of the pancreas characterized by the signs and symptoms of hypoglycemia due to increased secretion of insulin.

What is the pathophysiology of Insulinoma?

Insulinoma is derived mainly from pancreatic islet cells , that secrets insulin. In insulinoma excessive amount of insulin is produced in short burst ,causing low blood glucose level.

What causes the Insulinoma?

The exact cause of this disease is still unknown but believed that MEN1 gene located at 11q13 is involved in the pathogenesis of this tumor.

What is the signs and symptoms of Insulinoma?

The signs and symptoms are similar to other hypoglycemia is general which includes:

1. Hypoglycemia occurs several hour after food.
2. Diplopia, blurred vision
3. Confusion ,abnormal behavior
4. Amnesia
5. Seizure
6. Weakness, sweating, tachycardia, hunger, tachycardia (these symptoms are results due to hypoglycemia cause adrenalin release).
7. Symptoms can be aggravated by alcohol, exercise and used of sulfonylureas.
8. Weight gain
9. Symptoms is reversal after glucose administration.

How is Insulinoma diagnosed?

Diagnosis relies on clinical finding, laboratory examination and radiological examination.

Laboratory examination includes:

A) Fasting (up to 72h) blood levels show:

1. Insulin level 10U/mL or more
2. Blood glucose less than 40mg/dL
3. C-peptide more than 205ng/mL
4. Proinsulin greater than 25%
5. Ratios of insulin to plasma glucose is increase

B) Whipple triad is positive ,which consists of :

1. Symptoms of hypoglycemia
2. Low blood glucose( 40-50mg/dL)
3. Relief of symptoms after intravenous administration of glucose.

C)Radiographic imaging including:

1. Computed tomography(CT) scan : Only 20% patients shows mass in CT scan because 80% have mass size less then 2cm. CT scan have the sensitivity of 82-94%.
2. Endoscopic ultrasound detects 77% of insulinoma .

Low blood sugar with a high insulin and c-peptide level confirm the diagnosis.

How is Insulinoma Managed ?

1. Surgery is the gold standard treatment for insulinoma . 90% of insulinoma is cured by surgery. Only tumor is removed if there is a single tumor. However ,if there is multiple tumor partial pancreatectomy(part of the pancreas removed) is needed.
2. Medical management with Diazoxide and somatostatin(octreotide) is reserved for patients who are unable or unwilling to undergo surgical treatment or unresectable metastatic disease .
3. CT-guided radiofrequency ablation has been used in an elderly patients.

What is the prognosis of Insulinoma?

After surgery prognosis is excellent.

References:

1. Sabiston textbook of surgery 18th edition
2. The Washington manual of surgery, 5th edition.
3. emedicine.medscape.com
4. http://www.medicinenet.com
5. http://www.sciencedirect.com
6. http://en.wikipedia.org

Related posts:

1. Meigs Syndrome

Varicose veins is defined as tortuous dilated veins with dysfunction or nonfunctional valve. Varicose veins most commonly occurs in legs and feet because long term standing increase the pressure in saphenous veins.

What is the pathogenesis of varicose veins?

Varicose veins may occur due to the increase in the collagen content and a significant reduction in elastic contain result in defect in the strength of the venous wall and secondary incompetence of the valves .

What are the risk factors for varicose veins?

1. Age>50 years
2. Female sex hormone
3. Heredity
4. Erect stance
5. Occupation
6. Constipation
7. Pregnancy
8. Smoking

What is the symptoms and signs of varicose veins?

1. Dilated tortuous veins seen in thing and back of leg.
2. Aching in the vein at the end of the day, after long standing.
3. Heaviness, discomfort and fatigue of leg which may relived after leg elevation or elastic support.
4. Ankle swelling
5. Itching
6. Bleeding
7. Eczema
8. Ulceration.
9. Visual examination shows downward going impulse on coughing or tapping on veins.
10. Perthes and Brodie-trendelenbury test is positive.

How is varicose veins diagnosed?

Diagnosis relies on clinical finding and investigations.

Investigations includes:

1. Standard Doppler
2. Duplex ultrasound imaging : Shows the direction of blood flow.
3. Varicography
4. Venography: It is not standard investigation but is very useful if duplex scan indicated , but cant confirm the presence of the post thrombotic change.

How is varicose veins managed ?

A) Life style changes

B) Nonsurgical treatment ;which includes,

1. External compression using elastic hose(bandage),20-30 mmHg , wore during day time.
2. Elevation of the leg above the level of heart for brief period during the day time.

C) Surgical treatment;which includes,

1. Saphenofemoral junction ligation and great saphenous stripping
2. Saphenopoplitel ligation and lesser saphenous stripping
3. Radiofrequency ablation : This is the new technique in which a catheter is passed up to saphenous vein from the lower leg and with drawn under ultrasound control while radiofrequency wave is used to destroy the endothelial lining through series of metal prongs.

What is the prognosis of varicose veins ?

Prognosis is excellent after treatment.

References:

1. Sabiston textbook of surgery 18th edition
2. Bailey and love, surgery 25th edition
3. The Washington manual of surgery, 5th edition.
4. emedicine.medscape.com
5. http://www.mayoclinic.com

No related posts.

Acute Cholecystitis is a condition characterized by acute abdominal pain, fever and positive Murphy’s sign due to inflammation of the Gall bladder.

What causes the Acute Cholecystitis?

1. Gallstone, Ninety percent of cases involve stones in the cystic duct (i.e., calculous Cholecystitis)
2. Non Calculous includes:

• Severely ill patients with nothing by mouth since long time
• Burn Patients
• Trauma
• Post surgical patients
• Pregnancy
• Infection
• Drugs (especially hormonal therapy in women)
• Diabetes mellitus

What is the pathophysiolgy of acute Cholecystitis?

In calculous Cholecystitis there is obstruction of cystic ducts due to gall stone leading to biliary colic. If the cystic duct remains obstructed, the Gall stone wall distends and the gallbladder wall then becomes inflamed and edematous. In most common cases the gall stone dislodges and the inflammation gradually resolve but in some and severe cases there is ischemia and necrosis of the gall bladder wall.

What are the signs and symptoms of acute Cholecystitis?

• Biliary colic (right upper quadrant abdominal pain)
• Fever
• Nausea and vomiting
• Anorexia
• Tenderness or rebound tenderness
• Guarding and rigidity
• Jaundice
• Murphy’s sign positive, ie Inspiration arrest of during deep palpation of the right upper quadrant)

What are the complications of Acute Cholecystitis?

1. Emphysematous Cholecystitis
2. Empyema of gall bladder
3. Acute cholangitis
4. Acute pancreatitis

What is the differential diagnosis of acute Cholecystitis?

• Appendicitis
• Perforated peptic ulcer
• Acute pancreatitis
• Bowel obstruction
• Acute pyelonephritis
• Myocardial infraction
• Pneumonia right lower lobe

How to diagnosed acute Cholecystitis?

Diagnosis relies on patient’s history, physical examination, Radiological examination and Laboratory studies.

Laboratory studies shows leukocytosis (increased WBC count), Liver function tests; including serum bilirubin, alkaline phosphatase, alanine transaminase (ALT), asparate transaminase (AST) and serum amylase also may be abnormal.

Diagnostic Imaging includes:

• Ultrasound: it is the most commonly used test for diagnosis acute Cholecystitis with the sensitivity and specificity of 84% and 99% respectively.
• Radionuclide cholescintigraphy: Biliary radionuclide scanning is used less frequently but may be helpful in atypical cases. No filling of the gallbladder with the radiotracer (99m Tc-HIDA) after 4 hours indicates an obstructed cystic duct with a sensitivity and specificity of 95%.
• Computed tomography (CT): Nowadays CT   is performed frequently in patient with abdominal pain, but is less sensitivity than ultrasound for acute Cholecystitis.

How to managed acute Cholecystitis?

• After the diagnosis of acute Cholecystitis hospitalized the patients and managed with giving iv fluid, parenteral antibiotic (eg. Piperacillin/ tazobactam) and analgesic.
• Patients with acute Cholecystitis should have gone cholecystectomy as definitive treatment. Cholecystectomy may perform in either an early (2 to 3 days of symptoms) or a delayed (6 to 10 weeks after initial medical therapy).
• Tube cholecystectomy should be performed in patients who have acute Cholecystitis and who are failing systemic therapy but are not candidates for cholecystectomy because of severity of illness or concomitant medical problems.

What is the prognosis of acute Cholecystitis?

After the proper treatment of acute Cholecystitis prognosis is excellent.

References:

• Sabiston textbook of surgery 18th edition
• Bailey and love, surgery 25th edition
• www.sciencedirect.com
• The Washington manual of surgery, 5th edition.
• emedicine.medscape.com

No related posts.

“”Efforts have been made to reduce the risk of secondary lymphoedema by preoperative and postoperative counselling and education and by early detection.”

The goal of this study was to assess the efficacy of early physiotherapy in reducing the risk for secondary lymphedema after surgery for breast cancer. At a university hospital in Madrid, Spain, 120 women who had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007 were randomly assigned to an early physiotherapy group or to a control group.

Patients in the early physiotherapy group were treated by a physiotherapist with a program involving manual lymph drainage, massage of scar tissue, and progressive active and action-assisted shoulder exercises, as well as an educational strategy, whereas the control group received only the educational strategy. The primary study endpoint was the incidence of clinically significant secondary lymphedema, defined as more than a 2-cm increase vs the nonaffected side in arm circumference measured at 2 adjacent points.

Of 116 women who completed 1-year follow-up, 18 (16%) developed secondary lymphedema, including 14 in the control group (25%) and 4 in the physiotherapy group (7%; P = .01; risk ratio, 0.28; 95% confidence interval [CI], 0.10 – 0.79). Survival analysis showed that secondary lymphedema was diagnosed 4 times earlier in the control group vs the physiotherapy group (intervention/control, hazard ratio, 0.26; 95% CI, 0.09 – 0.79).

“Early physiotherapy could be an effective intervention in the prevention of secondary lymphoedema in women for at least one year after surgery for breast cancer involving dissection of axillary lymph nodes,” the study authors write. “This result emphasises the role of physiotherapy in the awareness, prevention, early diagnosis, and treatment of secondary lymphoedema.”

Limitations of this study include physiotherapy provided by trained physiotherapists, limiting generalizability; use of a particular criterion for diagnosing lymphedema; and possible measurement errors.

In an accompanying editorial, Dr. Andrea Cheville, from Mayo Clinic in Rochester, Minnesota, suggests that physiotherapy shows promise in a selected group of women.

“Limited but compelling evidence supports the usefulness of physiotherapy after surgical clearance of the axillary lymph nodes to control pain, enhance shoulder functionality and range of motion, and reduce a woman’s risk of developing lymphoedema,” Dr. Cheville writes. “Clinicians should therefore consider referring patients to physiotherapists who are trained in treating lymphoedema. Future research is needed to assess the efficacy of specific treatment modalities such as education and manual lymphatic draining.”

Related posts:

1. Surgery Quiz 2

a b s t r a c t

Aim: To evaluate the impact of selective imaging on clinical management of patients who present with Symptoms suggesting acute appendicitis.

Materials and methods: During a two-and-half year period, 941 consecutive patients with right lower quadrant pain were analyzed. Patients who underwent selective imaging were compared to those treated without further imaging.

Results: In 650 (69%) patients with right lower quadrant pain, diagnosis was based on medical history, physical and laboratory examination only. The diagnostic accuracy was 84%. Another 291 patients (31%)

underwent selective imaging reaching a diagnostic accuracy of 71%. Ultrasound was conducted in 277 patients (sensitivity: 59%; specificity: 91%). CT scan was conducted in 43 patients (sensitivity: 100%; Specificity: 95%).

Conclusion: The present study shows that, in the majority of patients, appendicitis acuta can be diagnosed without the aid of imaging studies. In all these cases, high diagnostic accuracy rates and low morbidity rates were achieved. In all the other cases when clinical diagnosis is uncertain, further evaluation should include imaging. In our series ultrasound is of limited value; CT scan or diagnostic laparoscopy seems superior

Abstract taken form International Journal of Surgery 7 (2009) 451–455

No related posts.

Diagnosis appendicitis in pregnancy is challenging task for all surgeon.

Features such as nausea and vomiting may be thought to be those normally seen with pregnancy, and abdominal pain may be thought to be due to false labor or Braxton Hicks contractions.Even laboratory findings of elevated white blood cells in acute appendicitis occurs in normal pregnancy.The typical sign of appendicitis mc-Burney tenderness is not seen in pregnancy.As the uterus gets bigger, it pushes the appendix upwards towards the right kidney. This causes the pain expected down in the lower right abdomen to be in the flank or even on the back. Thus the patient may be suspected of having right kidney infection, instead of appendicitis. Any pregnant woman with pain on the right side of the abdomen should therefore be scanned for a possible appendicitis….otherwise it could be fatal for both mother and baby………………….

No related posts.