09/24/2017

SURGERY mci screening test and indian medical examz high yield important topics study tips

By Live Dr - Wed Feb 11, 3:15 am

SURGERY

Classification of wounds

Clean Viscus not opened
Clean contaminated Viscus opened without spillage
Contaminated Viscus opened with spillage
Dirty Infected wounds, like abscesses
Primary haemorrhage Immediately post-operative
Secondary haemorrhage Within 7-14 days post-operative, due to infection.
Reactionary haemorrhage Within 24 hours of surgery, due to slippage of ligature or hypertension.
Healing by primary intention Clean, surgically closed wounds
Healing by secondary intention Unsutured, infected wounds healing by granulation tissue formation.
Healing by tertiary intention Delayed closure for infected surgical wounds, in which skin was kept open in initial operation.

Skin grafts

Partial thickness graft Thin graft / Thiersch graft – through the tips of papillae

Thick graft/ split skin grafts- all of epidermis and variable part of dermis.

Whole thickness skin graft / Wolfe’s graft Includes entire epidermis and dermis.
partial thickness graft full thickness graft
Includes whole of dermis and part of epidermis. Includes whole of epidermis and dermis.
Wound contraction is more Wound contraction is minimal
Skin on the donor site can regenerate on its own. Skin on the donor site cannot regenerate and hence needs to be closed.
Used for resurfacing large areas Used for resurfacing small areas, as they match colour and texture.
Donor sites include upper thighs, buttocks, and abdominal walls. Donor site includes post-auricular area and upper eyelids.

*Skin graft can be stored in refrigerator for 2 weeks at 4 degrees centigrade

QUOTE CORNER

Happiness is having dreams, success is making those dreams come true.- C. A.Castro

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Skin grafts survive in recipient bed by

Imbibtion Absorption of nutrients into the graft which serves to feed the graft for the first 24 hours to 48 hours
Inosculation Process whereby donor and recipient capillaries become aligned
Revascularization Differentiation of connecting vessels into the arterioles and venules
Absorbable sutures nonabsorbable
Catgut

Vicryl

Homopolymer of glycolide

Homopolymer of polydioxanone

Polyster

Polyamide

Polypropylene

Polyethylene

Silk

Cotton

Port-wine stain Vascular malformation

Present at birth

Doesn’t regress

Strawberry angioma Capillary haemangioma

Not present at birth

Appear at 1-3 weeks

Slowly regresses

Salmon patch Present at birth
Sinus Blind track lined by granulomatous tissue, leading from the surface down to the tissues, which may contain cavity.
Fistula Communicating track between two epithelial surfaces.

One connecting hollow viscus with surface is called external fistula.

One connecting two hollow viscera.

TYPE OF edge ULCER
Undermined edge Tuberculous ulcer
Punched out edge Gummatous ulcer

deep trophic ulcer

Sloping edge Healing traumatic ulcer
Raised beaded edge Rodent ulcer
Rolled out edge Squamous cell carcinoma

TRIVIAL TRUTH

Symbol of surgery is striped barber pole, derived from bloodletting practiced by barbers.

Pole was used for grasping to make veins prominent, red represents blood, and blue represents veins while white represents bandages. Ball on top is the basin to hold leeches and blood.

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ULCERS WITH EPONYMS

Bazin’s ulcer Small multiple ulcers in ankle region.

Associated with erythrocyanosis frigida; seen exclusively in young women.

Low grade ischemia of ankle, due to abnormally small or absent perforating arteries, arising from the posterior tibial or peroneal arteries.

Footballer’s ulcer Non healing ulcer over shin due to direct trauma by football.
Phagedenic ulcer Tropical ulcers seen in malnourished, poorly immunized with history of trauma or insect bite. Infection is caused by Vincent’s organisms
Hunner’s ulcer Interstitial cystitis

Bladder capacity is educed to 30-50 ml

CRANIAL HAEMATOMAS WITH THEIR CAUSES

TYPE CAUSES
Epidural haematoma Rupture of middle meningial artery
Subdural haematoma Torn bridging veins (superior cerebral vein)
Subarachnoid haematoma Aneurysm rupture
Intracerebral haemorrhage Rupture of lenticulostriate arteries.

Shape of hAematomaS on CT – scan.

Acute Subdural haematoma Concavo-convex
Extradural haematoma Biconvex
Subacute Subdural Biconvex
amputation level stump length
Arm

Forearm

8 inches
Leg 5.5 inches
Thigh 10-12 inches
amputation eponyms description
Lisfranc’s Disarticulation through tarso-metatarsal joint
Chopart’s Disarticulation through midtarsal joint
Syme’s Removal of foot anterior to medial malleolus
Burger’s Below knee
Gittistoke’s Supracondylar

QUOTE CORNER

What this power is I cannot say; all I know is that it exists and it becomes available only when a man is in that state of mind in which he knows exactly what he wants and is fully determined not to quit until he finds it.” Alexander Graham Bell

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indication for operative treatment of penetrating thoracic injuries
Caked haemothorax

Large air leaks with inadequate ventilation or persistent collapse of lung

Drainage of more than 1500 ml of blood when chest tube is first inserted

Continuous hemorrhage of more than 200 ml per hour for > 3 consecutive hours

Esophageal perforation

Pericardial tamponade

Extrinsic system of coagulation Factor 7
Common system of coagulation Factors 1, 2, 5, 10
Intrinsic system of coagulation Factors 8, 9, 11, 12.
PT Detects deficiency of common and extrinsic system of coagulation.

Elevated in deficiency of factors 1, 2, 5, 7, 10.

Also elevated in liver disease and early vitamin K deficiency.

PTT (aPTT / PPTk) Detects deficiency of intrinsic and common system of coagulation.

Elevated in deficiency of factors 1, 2, 5, 8, 9, 10, 11, 12.

Also elevated in liver disease and late vitamin K deficiency, Von Willebrand’s disease, lupus anticoagulants.

Clot solubility in urea Detects factor 13.

*Vitamin K dependant factors are 2, 7, 9, 10, proteins C and S.

Wallace’s rule of nine

To estimate the total body surface area in burns patient

IN ADULTS IN CHILDREN
Head-9

Chest  front-9

Abdomen front-9

Chest back-9

Lower back-9

Each upper limb-9

Each thigh-9

Each leg-9

Perineum-1

Head-18

Chest  front-9

Abdomen front-9

Chest back-9

Lower back-9

Each upper limb-9

Each lower limb-13.5

Perineum-1

*Hand -1 %

Most common nonbacterial opportunistic organism from burn wounds is candidiasis

Most common bacterial infection in burn wounds is pseudomonas

trivial truth

During the fifteenth century, sick people were often dressed in red and surrounded by red objects because it was though to help them get better.

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Cleft lip operation Done at 3 – 6 months.
Cleft palate operation Done between 6 months to 1.5 years.

*Suture removal after cleft lip operation is done on fifth day.

Lymphoedema grading

grade characteristic
0 Subclinical
1 Pits on pressure, disappears on elevation / rest.
2 Non-pitting ; doesn’t disappear on elevation and rest
3 Irreversible skin changes like fibrosis and papillae.
Superior thyroid artery Ligated close to superior pole to avoid external laryngeal nerve.
Inferior thyroid artery Ligated away from pole to avoid recurrent laryngeal nerve.
graft type characteristic
Autograft Received from self
Allograft Received from same species
Isograft Received from different individual who is genetically identical
Xenograft Received from different species.
Signs / symptoms of ischemia
Pain

Pulse-absent

Pallor

Paraesthesia

Paralysis

STORAGE OF BLOOD
CPD 3 weeks
CPDA-I 5 weeks
Conditions indicating significant ischemia
Ischemic ulceration

Neuropathy

Rest pain

Gangrene

*Caludication is due to mild ischemia

Signs OF DVT

Homan’s sign Pain in the calf on dorsiflexion of the foot
Moses’ sign Pain is caused by squeezing  of the calf muscle form side to side

QUOTE CORNER

Anyone can give up; it’s the easiest thing in the world to do. But to hold it together when everyone else would understand if you fell apart, that’s true strength.- Anonymous

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*Leriche’s Syndrome-

Occlusion in the region of bifurcation of aorta and internal iliac arteries, leading to

intermittent claudication involving both the buttocks, thighs and calves, with impotence in males.

*Most common vessel to be involved in embolism is femoral

Stages seen in Raynaud’s phenomenon

Stage of local syncope / stage of blanching Pallor
Stage of local asphyxia / stage of dusky anoxia Cyanosis
Stage of recovery / stage of red engorgement Redness
Beurger’s disease
Thromboangitis obliterans

Inflammatory reaction in the arterial wall, and neighbouring veins and nerves

More common in middle aged men

Associated with smoking

Segmental, small and medium sized arteries are affected

Both distal extremities are affected

AneurysmS

True aneurysm Contains all the three layers of arterial wall
False aneurysm Single layer of fibrous tissue as the wall of sac
Mycotic aneurysm Produced by the growth of microorganisms in the wall of the vessel.
Cirsoid aneurysm Mass of dilated pulsating serpiginous vessels, found in congenital arteriovenous aneurysms
Aneurismal varix Artery and vein are communicating directly with a short wide channel
Varicose aneurysm Anastomosis between artery and vein is indirect through an intermediate sac.

*Atherosclerotic aneurysms are the commonest.

*Cimino fistula-for renal dialysis temporary iatrogenic av fistula is made in the wrist or ankle

*Branham’s sign

If a finger is pressed on the artery proximal to a-v fistula, there will be slowing of pulse rate and rise in the diastolic pressure.

*Marjolin’s ulcer-

Squamous cell carcinoma which arises in a chronic benign ulcer or scar.

Most commonly seen in long standing venous ulcer.

TRIVIAL TRUTH

If  a surgeon in Ancient Egypt lost a patient while operating, his hands were cut off.

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RODENT ULCER/ BASAL CELL CARCINOMA
90% of basal cell carcinomas are seen in the face.

Majority occur above the line connecting angle of mouth with lobule of the ear.

Commonest site is around the inner canthus of eye. (Tear cancer)

Typical rolled edge.

Spreads by local spread.

Geographical or ‘field fire’ basal cell carcinoma has irregular raised edge around the flat white scar.

Regional lymph node metastasis is characteristic

Superficial radiotherapy is the treatment of choice.

Melanomas
Lymphatic spread is the commonest route of spread.

Radioresistant

Best treated by surgery and local regional isolation and perfusion with high doses cytotoxic agents.

MELANOMA

Most common type Superficial spreading
Least common type Lentigo maligna melanoma
Least malignant Lentigo maligna / Hutchinson’s freckle
Most malignant Nodular variety
Most common site in males Lower back
Most common site in females Legs

CARCINOMA BREAST

Carcinoma breast is more common on Left side
Most common site Upper outer quadrant
Most common histological variant Ductal carcinoma
Histological variant with good prognosis even in presence of axillary lymph node metastasis Medullary carcinoma
Epulis A swelling situated on the gum arising from the alveolar margin.
Dental cyst Associated with chronically infected pulpless tooth.

Always associated with a normally erupted tooth.

Dentigerous cyst Associated with non erupted permanent tooth.

Cyst contains molar tooth

Adamntinoma True neoplasm of odontogenic epithelium.

Epithelia tumour arising from ameloblasts

QUOTE CORNER

Our greatest glory consists not, in never falling, but in rising every time we fall.
Oliver Goldsmith

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*Sentinel node-

First node in the ipsilateral axilla to drain the tumor in the breast.

Sentinel node biopsy is done in carcinoma breast and malignant melanoma

testicular torsion
Urine analysis is negative

Elevation will not decrease the pain (negative Phren’s sign)

Roche’s sign-

In torsion of testis, the epididymis cannot be distinguished from the body of the testis, whereas in epididymitis, the body of the testis can be felt in the enlarged crescent of the epididymis.

Operation should not be delayed for more than 4 hours from the time of onset of symptoms

*Duplication of renal pelvis is the commonest congenital abnormality of the upper tract

*Commonest cause of lower urinary tract infection in boys is posterior urethral valve

Meatal ulcer with scabbing is the most common cause of acute retention in boys

Cystic hygroma
Cystic swelling containing clear lymph.

Its caused due to sequestration of apportion of a jugular sac from the lymphatic system , which fails to join and regular lymphatic system.

Commonest site is posterior triangle of neck.

Manifests in early infancy.

Brilliantly translucent

Excision is the treatment of choice.

Thyroglossal cyst
Cystic swelling developing from the remnant of Thyroglossal tract

Subhyoid position is the commonest

Moves with deglutition.

Excision is treatment.

Thyroglossal fistula-

Never congenital

Caused by the external opening of an infected Thyroglossal cyst

*Sternomastoid tumour/ Congenital torticollis

Caused by the infarction of the central portion of one of the sternomastoid muscle at the time of birth.

TRIVIAL TRUTH
In the UK there was 100 times more research money spent on AIDS than on Prostate cancer, but 100 times more men died from Prostate cancer than from AIDS.

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The thyroid moves with deglutition due to its attachment with the larynx and trachea by
Ligament of Berry

Posterior lamina of the pretracheal fascia

Levator glandulae thyroidae

*Commonest post operative complication in thyroidectomy is hemorrhage

Vagotomy

Truncal Vagotomy / vagectomy Both the trunks of Vagus nerves are resected
Selective Vagotomy Removal of all gastric fibres of the Vagus nerves, leaving the hepatic and celiac branches.
Highly selective Vagotomy- Denervation of acid secreting part of stomach, keeping supply to the alkali secreting part of the stomach and other abdominal viscera intact.

*Sterile pyuria is seen in tuberculosis

Golf hole ureteric orifice is seen in late stages of tuberculosis of urinary system as the ureter is pulled upward.

Thimble bladder

Seen in late stages of tuberculosis.

Fibrosis leads to reduced capacity

Indications of percutaneous nephrolithotomy
Stones bigger than 3 cm

Staghorn calculus

Hard stones

Anatomic abnormality like scoliosis or obesity

Stones unresponsive to eswl

Coexisting obstructive uropathy

Contraindications TO Eswl
Pregnant women

Abdominal aortic aneurysm

Uncorrectable coagulation disorders

Hard stones.

Stones in poorly draining hydronephrotic kidney.

Management of Ureteric stones

Upper third eswl
Middle third eswl / Ureteroscopic removal
Lower third Ureteroscopic extraction

QUOTE CORNER

Accept nothing, challenge everything.- Anonymous

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*Triple phosphate stones-

Consists of calcium-ammonium-magnesium phosphate

Usually formed as a result of inflammation.

Form Staghorn calculus.

Locations of ectopic testis
Superficial inguinal pouch (commonest)

In front of the pubis

Superficial perineal pouch

Near the saphenous opening

Undescended testis Ectopic testis
The testis is arrested in its normal path of descent Testis deviates from its normal path of descent
Usually undeveloped Fully developed
Scrotum is not well developed Scrotum is well developed
Spermatogenesis is poor Spermatogenesis is perfect
May be associated with indirect inguinal hernia Never associated with indirect inguinal hernia
Frey’s syndrome Damage to the auriculotemporal nerve and greater auricular nerve.

On healing there is cross joining, so that when the patient eats, there is sweating in the parotid region.

Crocodile tears Following, facial nerve paralysis, due to inaccurate regrowth of regenerating fibers. S o on eating, there is lacrimation.
Beck’s triad of cardiac tamponade
muffled heart sounds
distended neck veins
hypotension

*Potts puffy tumour is seen in chronic frontal sinusitis, it is subperiosteal swelling with edema of scalp.

*Teitze disease

Painful and non suppurative swelling of 2nd and 3rd costal cartilage

*Fournier’s gangrene

Idiopathic gangrene of scrotum, mostly by hemolytic streptococci

TRIVIAL TRUTH

Prussic acid, in a crystalline powder called Zyklon B, was used to kill in Germany’s gas chambers. The gas would paralyze the victim’s lungs, causing them to suffocate.

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*Proctalgia fugax

Intermittent

Levator muscle spasm

Painful spasm of anal sphincter which awakens the patient at night

*Felon

Infection of the distal pulp space, usually secondary to a puncture wound

Late osteomyelitis may develop

*Dercum’s disease / Adiposis dolorosa

Variant of lipoma in which there are tender lipomatosis on the trunk.

*Enlargement of Krause’s nodes (located at jugular foramen) leads to jugular foramen syndrome (compression of 9th, 10th, 11th cranial nerve)

*PSA over 4 ng /ml is abnormal

TURP syndrome is seen due to glycine absorption

*Thymoma is the most common mediastinal tumour

Most common malignant tumor of the mediastinum is Seminoma

*Superior vena cava syndrome is most commonly caused by lung cancer

Raspberry tumour-

A small part of vitello-intestinal duct remains patent near the umbilicus, giving to rise to a mucus discharging sinus, with its epithelium everted.

*Honeymoon pyelitis-

Acute pyelitis occurring in females soon after marriage.

*Seminoma is the most common testicular tumour

*Hypospadias commonest type Glandular

*Champagne urine

Fistula into urinary tract by diverticulosis gives rise to pneumaturia.

Intussusception is the most common cause of intestinal obstruction in children under 2 years of age

Salivary gland Histological type
Parotid Serous
Submandibular Mixed
Sublingual Mucous

QUOTE CORNER

The more you sweat in training, the less you bleed in battle. – Anonymous

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Pleomorphic adenoma
Commonest benign tumour of salivary glands

Radioresistant

Patey’s operation/ superficial parotidectomy is done

Warthin’s tumour
Benign tumour

Only involves parotid and usually lower portion.

Shows hot spot on Tc 99m pertechnate scan.

Superficial parotidectomy is done.

*Haemangioma is the most common benign tumours of parotid in children.

indication of radiotherapy in parotid tumors
Recurrent disease

Residual disease left at surgery

High grade lesion

Those who refuse surgery

Unfit for surgery

Unresectable local lesion

Triad of  Mikulicz’s disease
Enlargement of salivary glands

Narrow palpebral fissure

Parchment like dryness of mouth.

*Tongue carcinoma-Most common site

Anterior 2/3rd, near the lateral margin

Zenker’s diverticulum
Most common complication of esophageal atresia

Seen ion elderly

Characteristic site is within inferior pharyngeal constrictor, between the oblique fibres and horizontal fibres, at Killian’s triangle

Lung abscess due to aspiration is the most common complication

*Plummer-Vinson syndrome/ Brown- Kelly -Paterson syndrome/ Sideropenic dysphagia

Esophageal web with iron deficiency anemia

Premalignant- precricoid carcinoma

*Palmar and solar keratosis is seen in esophageal cancer

TRIVIAL TRUTH

In 1979 Dr. Christian Barnard was offered $250 000 by the American National Enquirer to perform a human head transplant.

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Sclerosing agents for endoscopic sclerotherapy
Polidocanal / polydochyl

N-butyl-cyanoacrylate (glue injection)

Absolute alcohol

Phenol

Ethanolamine maleate/ oleate

Sodium tetradecyl sulphate

*Stomach is the conduit of choice after Oesophagectomy

Opsi

Opportunistic Post Splenectomy  Infection

Streptococcus pneumoniae

N. meningitides

H. influenza

Babesia microti

Blood disorders treatable by splenectomy
Hereditary spherocytosis

Hereditary elliptocysis

Thalassemia major

Acquired hemolytic anemia

Itp

Idiopathic myelofibrosis

*Opitz’s disease-

Thrombosis of Splenic veins leading to thrombophlebitic splenomegaly

*Kehr’s sign

Splenic rupture

Peritoneal hemorrhage irritates diaphragm causes referred pain to the left shoulder.

*Balance sign

Rupture spleen shows non shifting dullness in the left flank

Hypersplenism
Splenomegaly

Anemia, leucopenia, and thrombocytopenia.

Compensatory bone marrow-hyperplasia

Improvement after splenectomy

*Banti syndrome

Congestive splenomegaly with hypersplenism associated with cirrhosis and portal hypertension.

QUOTE CORNER

Winners never quit, and quitters never win.- Anonymous

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Duct of Wirsung Major pancreatic duct
Duct of Santorini Minor pancreatic duct

Pancreatitis

Most commonly elevated and tested enzyme Serum amylase
Low serum amylase is seen in Serum protein loss in congestive heart failure
Single best enzyme for pancreatitis Serum lipase
Pancreas is the only source of Serum trypsinogen
Drugs inducing pancreatitis- L-asparginase, thiazides, steroids.
Organism causing pancreatitis Mumps.
Best prognosis Gall stone pancreatitis

*Serum amylase is not raised in acute appendicitis.

*Grey Turner’s sign

In hemorrhagic pancreatitis, bluish discoloration in the flank is seen.

Cullen’s sign- in hemorrhagic pancreatitis, bluish discoloration in the periumbilical area is seen.

*Most common site of pseudo pancreatic cyst is body and tail of pancreas

Pseudo cyst > 5 cm in diameter is an indication of drainage

Pseudocyst < 5 cm and < 6 weeks duration should be observed only

Pancreatic tumours

Gastrinoma Arises from G-cells

Secretes gastrin

Produces Zollinger-Ellison syndrome

Malignant tumour.

Insulinoma Most common

Arises from beta cells

Hypoglycemia

Glucagonoma Arises from alpha cells.

Causes diabetes, anemia, thrombosis, skin rashes

Somatostatinoma Arises from delta cells.

Causes diabetes, gallstone, steatorhhoea, hypochlorhydria

Malignant

VIPoma Verner-Morrison syndrome

D1 tumour

Diarrhea with hypokalemia, hypochlorhydria.(pancreatic cholera)

TRIVIAL TRUTH

Humans shed about 600,000 particles of skin every hour – about 1.5 pounds a year. By 70 years of age, an average person will have lost 105 pounds of skin.

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Normal Portal pressure 6-12 cm of Hg.

10-15 mm of water

Portal hypertension > 40 mm of Hg.
Whipple’s criteria for diagnosis of hypoglycemia
Symptoms of hypoglycemia

Serum glucose < 2.8 mmoles/ L

Prompt relief of symptoms after glucose administration.

Charcot’s triad is seen in cholangitis and bile duct stones
Pain

Jaundice

Fever

hemobilia- triad
Biliary colic

Jaundice

Malaena

Portosystemic venous shuts
Anastomoses between veins of falciform ligament and superior and inferior epigastric veins- caput medusae

Anastomoses between gastric veins and esophageal veins-esophageal varices

Anastomoses between superior hemorrhoidal vein and middle and inferior rectal  veins-hemorrhoids

Anastomoses between vein soft retroperitoneal structures and the body wall(veins of Retzius)

Emphysematous cholecystitis
Associated with presence of gas in the gallbladder

Seen in diabetics, due to infection with gas forming bacilli

Ultrasound shows gas in the gallbladder

Needs to be operated immediately.

Structures in free border of lesser peritoneum

From anterior to posterior

Common bile duct

Hepatic artery

Portal vein

QUOTE CORNER

The aim of education should be to teach us rather how to think, than what to think – rather to improve our minds, so as to enable us to think for ourselves, than to load the memory with thoughts of other men.-Bill Beattie

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Saint’s triad
Gallstones

Diverticulosis coli

Hiatus hernia

Calot’s triangle

Boundaries Cystic artery superiorly

Cystic duct inferiorly

Common hepatic duct medially

Contents Lymph node of Lund

*Blood supply to the liver is derived 80% from portal vein and 20 % from hepatic artery.

*CAROLI’s disease-congenital dilatation of intrahepatic biliary tree.

*Caterpillar turn or Moynihan’s hump- tortuous right hepatic artery.

*Most common route of infection of liver is along the bile ducts followed by via the hepatic artery.

*Commonest cause of liver abscess is pyogenic 80 %

*Honey comb liver is found in actinomycosis

*In Budd Chiari syndrome, obstruction occurs at hepatic vein

*Haemangioma is the commonest benign tumour of the liver

*Commonest primary lesion causing metastasis to liver is colon carcinoma, pancreas, and breast

*Gold standard for liver imaging is triple phase spiral CT scan

*Upto 80 %of liver resection may be tolerated

*Acute cholecystitis- most commonly caused by E coli

Child-Pugh grading

features 1 point 2 points 3 points
Encephalopathy Grade 1/2 Grade 3, 4
Ascites Absent Slight Moderate
Serum bilirubin 1-2 mg 2-3 mg > 3mg
Serum albumin > 3.5 mg 2.8 -3.5 mg < 2.8 mg
Prothrombin time (seconds prolonged) 1-4 4-6 >6
Most common indication for hepatic transplantation Chronic liver failure
In children Biliary atresia is the most common indication

TRIVIAL TRUTH

Honey is believed to be the only food that does not spoil.  Honey found in the tombs of Egyptian pharaohs has been tasted by archaeologists and found to still be edible.

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METABOLIC DISEASES WHICH CAN BE CURED BY LIVER TRANSPLANTATION
Wilson’s disease

Alpha 1 antitrypsin deficiency

Oxalosis

*Hogarth Pringle maneuver

Hepatic artery is compressed between fingers and thumb in lesser omentum through foramen, to stop bleeding from injured cystic artery, when it cannot be controlled by packing, suction and ligation f bleeding artery

EPONYMS description
Hernia through foramen of Morgagni Herniation through the retrosternal defect between sternal and costal attachment of diaphragm
Hernia through foramen of Bochdalek Herniation posterolaterally through pleuro-parietal opening.
Spigelian Interparietal and subumbilical herniation, lateral to rectus muscle at the level of arcuate line.
Richter’s hernia Herniation of circumference of intestine
Littre’s hernia Herniation of Meckel’s diverticulum
Maydl’s hernia Hernia en W

*Landmark for differentiating femoral hernia from inguinal hernia is the pubic tubercle

Neck of the sac of inguinal hernia is above and medial to it, while that of femoral hernia is below and lateral to it.

Landmark for differentiating direct from indirect inguinal hernia is inferior epigastric vessels.

Neck of direct is medial to it, while that of indirect is lateral to it.

Herniotomy Neck of the sac is transfixed and ligated and then the hernial sac is excised, no repair is done
Herniorrhapy Herniotomy with repair of posterior all of the inguinal canal
Hernioplasty Herniorrhapy with reinforced repair of the posterior wall of the inguinal canal by filing the gap between the conjoined tendon and inguinal ligament.

*Congenital hypertrophic pyloric stenosis shows- hypochloremic alkalosis

Congenital pyloric stenosis is best diagnosed by usg-

Hypertrophied pyloric muscle mass > 4 mm or pyloric length > 14 mm

*Most common benign neoplasm of stomach is leiomyomas.

QUOTE CORNER

Those who don’t make decisions never make mistakes.

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Posterior duodenal ulcer perforation Intense hemorrhage due to rupture of gastroduodenal artery
Anterior duodenal artery perforation Pneumoperitoneum and peritonitis

TYPHOID

Typhoid ulcers are placed longitudinally along the ileum
Perforation of typhoid ulcer usually occurs in the 3rd week
Most common complication of typhoid paralytic
Most common presentation intestinal bleeding
Most common site involved ileum

*Tubercular ulcers are placed transversely along the ileum

*Acute mesenteric lymphadenitis is the disease with symptoms and signs most similar to those of acute appendicitis

*Carcinoid tumor is most frequently found in distal third of appendix

*Most common position of appendix-retrocecal

*Nurse’s syndrome-

Acute nonspecific mesenteric adenitis of teenage girls.

*Treatment of duodenal atresia is duodenostomy

*Bishop Koop’s operation is done in meconium ileus

Short bowel syndrome
Massive bowel resection

Minimum amount of small bowel required to prevent short bowel syndrome is 100 cm.

Absorption of fat, water, electrolytes, and vitamin b12 is affected.

Associated with hypergastrinemia

Causes
Massive intestinal resection

Regional enteritis with multiple bowel reactions

A jejuno- ileal bypass for morbid obesity

Meckel’s diverticulum Result of partial obliteration of vitelline duct
Persistent vitelline fistula Result of failure of closure of vitelline duct.

*Meckel’s diverticulum is a true diverticulum, situated on antimesentric border

Present in 2 % population

2 inches long

2 feet proximal to ileo-colic valve.

Most common complication of Meckel’s diverticulum is intestinal obstruction followed by bleeding, and diverticulitis.

TRIVIAL TRUTH

Kotex was first manufactured as bandages, during WWI.

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Classic quartet of intestinal obstruction
Pain

Abdominal distention

Vomiting

Obstipation

early dumping syndrome late dumping syndrome
Immediately after meals Second hour after meals
Relief by lying down Relief by eating
Aggravated by more food Aggravated by exercise
Symptoms of epigastric fullness, sweating, light headedness, tachycardia, colic, Symptoms of tremor , fainting, prostration
Blind loop syndrome
Stagnation of small intestinal contents by strictures, stenosis, blind-pouch syndrome, or diverticula, the bacterial flora in the stagnant area is increased in number

Leading to anemia, hypoproteinemia, steatorhhoea,

In distal small intestine, the abnormal bacterial flora compete for vitamin B12, leading to deficiency

In proximal small intestine, they deconjugate bile salts, leading to steatorhhoea.

Also leads to hypoproteinemia and avitaminosis.

*Red currant jelly stool is seen in intussusception

Polyposis coli

Not Premalignant Premalignant
Juvenile polyposis

Peutz- Jegher’s syndrome

Tubular adenoma

Villous adenoma

Familial adenomatous polyposis coli- 100% malignancy risk, autosomal dominant.

Gardner’s syndrome, Turcot’s syndrome.- 100% progression to malignancy

*Strawberry lesion of recto-sigmoid is due to infection by spirochete vincenti and bacillus fusiformis.

Grading of piles

First degree Contained within the anal canal
Second degree Extruded on defecation, but return at the end of act
Third degree Prolapse on defecation and then need to be manually reduced
Fourth degree Prolapse on defecation and then cant be reduced

QUOTE CORNER

I thought it was impossible too before I did it.- Lance Armstrong

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Treatment OF PILES

1st degree Sclerosants
2nd degree Sclerosants , rubber banding
3rd degree Sclerosants, rubber banding
4th degree Rubber banding, haemorrhoidectomy.

*Goodsall’s rule-

Anal fistulae with an external opening in relation to anterior half of anus tends to have a straight path, whereas those related to posterior half , usually have curving tracks and may be of the horseshoe variety.

*Most serious complication of end colostomies is parastomal hernia

carcinoma colon left carcinoma colon right
Obstructive syndromes predominate Anemia is more common

Duke’s classification of colon carcinoma

Stage A Growth is limited to the bowel
Stage B Spread into adjoining structures, without lymphatic metastasis
Stage C Lymphatic metastases

Duke’s classification of rectal carcinoma

Stage A Growth limited to rectal wall
Stage B Beyond rectal wall, but no involvement of lymph nodes
Stage C Growth beyond rectal wall, with involvement of regional lymph nodes.

*Bleeding is the earliest complication of rectal carcinoma followed by alteration of bowel movements

TRIVIAL TRUTH

Viagra (sildenafil citrate) was initially studied for use in hypertension and angina pectoris. Phase I clinical trials suggested that the drug had little effect on angina, but that it could induce marked penile erections, thus leading to its use in impotence.

Eleventh hour surgery                                                                                                                  217

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