Rüzgar Miroğlu

Surgery 2

Large Bowel Obstruction

Filed under: GASTROENTEROLOGY, SURGERY by medippt — Leave a comment
November 8, 2010

Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion.Depending on the level of obstruction, bowel obstruction can present with abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation.Bowel obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischaemia or perforation from prolonged distension.In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent.

Ogilvie syndrome is the acute pseudoobstruction and dilation of the colon in the absence of any mechanical obstruction in severely ill patients.Colonic pseudo-obstruction is characterized by massive dilatation of the cecum and right colon on abdominal X-ray.It is a type of megacolon, sometimes referred to as “acute megacolon,” to distinguish it from toxic megacolon.Usually the patient has abdominal distention, pain and altered bowel movements.The exact mechanism behind the acute colonic pseudo-obstruction is not known.
Ogilvie’s syndrome may occur after surgery, especially following coronary artery bypass surgery and total joint replacement.It is also seen with neurologic disorders, serious infections, cardiorespiratory insufficiency, and metabolic disturbances. Drugs that disturb colonic motility (opioid analgesics) contribute to the development of this condition.
 

 

 
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Breast Cancer Genetics

 

Filed under: GENETICS, ONCOLOGY, SURGERY by medippt — Leave a comment
October 29, 2010

BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors.

In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth. Mutation of these genes has been linked to the development of hereditary breast and ovarian cancer.
A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2. Such a woman has an increased risk of developing breast and/or ovarian cancer at an early age and often has multiple, close family members who have been diagnosed with these diseases. Harmful BRCA1 mutations may also increase a woman’s risk of developing cervical, uterine, pancreatic, and colon cancer.Harmful BRCA2 mutations may additionally increase the risk of pancreatic cancer, stomach cancer, gallbladder and bile duct cancer, and melanoma.
Men with harmful BRCA1 mutations also have an increased risk of breast cancer and, possibly, of pancreatic cancer, testicular cancer, and early-onset prostate cancer. However, male breast cancer, pancreatic cancer, and prostate cancer appear to be more strongly associated with BRCA2 gene mutations.
Genetic tests are available to check for BRCA1 and BRCA2 mutations. A blood sample is required for these tests, and genetic counseling is recommended before and after the tests.

 

 
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Compartment Syndrome

 

Filed under: SURGERY, TRAUMA by medippt — Leave a comment
October 20, 2010
Compartment syndrome is the compression of nerves, blood vessels, and muscle inside a closed space within the body. This leads to tissue death from lack of oxygenation; the blood vessels being compressed by the raised pressure within the compartment. Compartment syndrome most often involves the forearm and lower leg. It can be divided into acute, subacute, and chronic compartment syndrome.
There are classically 5 “Ps” associated with compartment syndrome — pain out of proportion to what is expected, paresthesia, pallor, paralysis and pulselessness.
Compartment syndrome is a clinical diagnosis. However, it can be tested for by gauging the pressure within the muscle compartments. If the pressure is sufficiently high, a fasciotomy will be required to relieve the pressure. Various recommendations of the intracompartmental pressure are used with some sources quoting more than 30 mmHg as an indication for fasciotomy while others suggest  less than 30 mmHg difference between intracompartmental pressure and diastolic blood pressure.
Failure to relieve the pressure can result in necrosis of tissue in that compartment, since capillary perfusion will fall leading to increasing hypoxia of those tissues. This can cause Volkmann’s contracture in affected limbs.If left untreated, acute compartment syndrome can lead to more severe conditions including rhabdomyolysis and kidney failure potentially leading to death.

 

 

 

 
 
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Gallstone Disease

 

Filed under: GASTROENTEROLOGY, SURGERY by medippt — 1 Comment
October 19, 2010
Gallstones (choleliths) are crystalline bodies formed in the biliary system of the body by accretion or concretion of normal or abnormal bile components.
Gallstones have different appearance, depending on their contents. On the basis of their contents, gallstones can be subdivided into the two following types:
* Cholesterol stones are usually green, but are sometimes white or yellow in color. They are made primarily of cholesterol.Increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.
* Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They contain less than 20% of cholesterol. Risk factors for pigment stones include hemolytic anemia (such as sickle cell anemia and hereditary spherocytosis), cirrhosis, and biliary tract infections.
Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid.Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy following endoscopic retrograde cholangiopancreatography.Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis.However, there is a significant portion of the population who develop a condition called postcholecystectomy syndrome.
 
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Understanding Risk factors for Breast Cancer

 

Filed under: ONCOLOGY, SURGERY by medippt — Leave a comment
October 17, 2010

Breast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas.Worldwide, breast cancer comprises 10.4% of all cancer incidence among women, making it the most common type of non-skin cancer in women and the fifth most common cause of cancer death.

The risk of getting breast cancer increases with age. In 5% of breast cancer cases, there is a strong inherited familial risk.Two autosomal dominant genes, BRCA1 and BRCA2, account for most of the cases of familial breast cancer. Family members who harbor mutations in these genes have a 60% to 80% risk of developing breast cancer in their lifetimes.Persistently increased blood levels of estrogen are associated with an increased risk of breast cancer. Increased blood levels of progesterone are associated with a decreased risk of breast cancer in premenopausal women.A number of circumstances which increase exposure to endogenous estrogens including not having children, delaying first childbirth, not breastfeeding, early menarche and late menopause are suspected of increasing lifetime risk for developing breast cancer.Prophylactic oophorectomy and mastectomy in individuals with high-risk mutations of BRCA1 or BRCA2 genes reduces the risk of developing breast cancer as well as reducing the risk of developing ovarian cancer.

 

 
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Total parenteral nutrition

 

Filed under: MEDICINE, SURGERY by medippt — Leave a comment
October 10, 2010

Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process of eating and digestion.It is called total parenteral nutrition (TPN) when no food is given by other routes.

Parenteral nutrition is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired.It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Indications: TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following: Some stages of Crohn’s disease or ulcerative colitis, bowel obstruction, certain pediatric GI disorders, e.g., congenital GI anomalies, prolonged diarrhea regardless of its cause, or short bowel syndrome due to surgery.
Complications are either related to catheter insertion, or metabolic, including refeeding syndrome. Catheter complications include pneumothorax, accidental arterial puncture, and catheter-related sepsis.Metabolic complications include the refeeding syndrome characterised by hypokalemia, hypophosphatemia and hypomagnesemia. Hyperglycemia is common at the start of therapy, but can be treated with insulin added to the TPN solution. Hypoglycaemia is likely to occur with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration.Also total parenteral nutrition increases the risk of acute cholecystitis due to complete unusage of gastrointestinal tract, which may result in bile stasis in the gallbladder.

 

 
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Case-Based Abdominal Trauma

 

Filed under: SURGERY, TRAUMA by medippt — 1 Comment
October 6, 2010

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The liver is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma.

The liver is the largest intra-abdominal solid organ and is enclosed anteriorly and laterally by the rib cage. The large size of the liver, its friable parenchyma, its thin capsule, and its relatively fixed position in relation to the spine make the liver particularly prone to blunt injury.
 
Liver trauma may result in the following:
    * Subcapsular hematoma or intrahepatic hematoma
    * Laceration
    * Contusion
    * Hepatic vascular disruption
    * Bile duct injury
 
A patient history of blunt or penetrating abdominal trauma may be forthcoming
    * Signs and symptoms of hepatic injury are related to loss of blood, peritoneal irritation, right upper quadrant tenderness, and guarding
    *Clinical signs and symptoms of biliary peritonitis include abdominal pain, nausea, and vomiting. These signs may evolve gradually, making diagnosis difficult and leading to increased morbidity and mortality rates.
Contrast-enhanced CT scanning remains the examination of choice in patients with blunt abdominal trauma.Diagnostic peritoneal lavage has been shown to be useful in evaluating patients with blunt abdominal trauma, with reported sensitivities of as high as 95%.

 

 
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Roux-en-y procedure and Postgastrectomy Syndrome

 

Filed under: GASTROENTEROLOGY, SURGERY by medippt — Leave a comment
October 1, 2010

Operations that make use of a Roux-en-Y procedure

* Some gastric bypasses for obesity.
* Roux-en-Y reconstruction following partial or complete gastrectomy for stomach cancer.
* Roux-en-Y hepaticojejunostomy used to treat bile duct obstruction which may arise due to:
  • common bile duct tumour or hepatic duct tumour (e.g. resection of cholangiocarcinoma)
  • bile duct injury (e.g. cholecystectomy, surgical misadventure, trauma)
  • an infection/inflammation (e.g. pancreatic pseudocyst)
* Roux-en-Y choledochojejunostomy – indications same as Roux-en-Y hepaticojejunostomy.
 
Complications of Postgastrectomy Syndrome
  • Afferent and efferent loop syndrome
  • Dumping syndrome
  • Alkaline reflux gastritis
  • Nutritional disturbance
  • Retained antrum syndrome
  • Marginal ulcer
  • Postvagotomy diarrhea
  • Postvagotomy atony
  • Incomplete vagal transection
Gastric dumping syndrome is a condition where ingested foods bypass the stomach too rapidly and enter the small intestine largely undigested. Early dumping begins concurrently or immediately succeeding a meal. Symptoms of early dumping include nausea, vomiting, bloating, cramping, diarrhea, dizziness and fatigue. “Late” dumping happens 1 to 3 hours after eating. Symptoms of late dumping include weakness, sweating, and dizziness. Many people have both types. The syndrome is most often associated with gastric surgery.
People with this syndrome often suffer from hypoglycemia and it is referred to as “alimentary hypoglycemia”.

 

 
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Gastric Cancer

 

Filed under: GASTROENTEROLOGY, SURGERY by medippt — Leave a comment
September 26, 2010
Gastric cancer can develop in any part of the stomach and may spread throughout the stomach and to other organs.Infection by Helicobacter pylori is believed to be the cause of most stomach cancer while autoimmune atrophic gastritis, intestinal metaplasia and various genetic factors are associated with increased risk levels. American Cancer Society lists the following dietary risks, and protective factors, for stomach cancer: “smoked foods, salted fish and meat, and pickled vegetables.Nitrates and nitrites are substances commonly found in cured meats.
Gastric adenocarcinoma is a malignant epithelial tumor, originating from glandular epithelium of the gastric mucosa. Stomach cancers are overwhelmingly adenocarcinomas (90%).Histologically, there are two major types of gastric adenocarcinoma:intestinal type or diffuse type.Intestinal type adenocarcinoma tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma.Diffuse type adenocarcinoma (mucinous, colloid, linitis plastica) Tumor cells are discohesive and secrete mucus which is delivered in the interstitium producing large pools of mucus/colloid.
Surgery is the most common treatment. The surgeon removes part or all of the stomach, as well as the surrounding lymph nodes, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the intestine or pancreas. Tumors in the lower part of the stomach may call for a Billroth I or Billroth II procedure.Endoscopic mucosal resection is a treatment for early gastric cancer.
 
 
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Esophageal cancer

 

Filed under: GASTROENTEROLOGY, SURGERY by medippt — Leave a comment
September 18, 2010
Esophageal cancer is malignancy of the esophagus.The subtypes are adenocarcinoma and squamous cell carcinoma. Squamous cell carcinoma arises from the cells that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells that are present at the junction of the esophagus and stomach.Esophageal tumors usually lead to dysphagia , odynophagia (painful swallowing) and other symptoms, and are diagnosed with biopsy. Small and localized tumors are treated surgically with curative intent. Larger tumors tend not to be operable and hence are treated with palliative care; their growth can still be delayed with chemotherapy, radiotherapy or a combination of the two.
Squamous cell carcinomas, which are similar to head and neck cancer in their appearance and association with tobacco and alcohol consumption, and adenocarcinomas, which are often associated with a history of gastroesophageal reflux disease(GORD) and Barrett’s esophagus. A general rule of thumb is that a cancer in the upper two-thirds is a squamous cell carcinoma and one in the lower one-third is a adenocarcinoma.
Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) are the most common symptoms of esophageal cancer. Dysphagia is the first symptom in most patients. Odynophagia may also be present.Substantial weight loss is characteristic as a result of reduced appetite and poor nutrition and the active cancer.Most of the people diagnosed with esophageal cancer have late-stage disease. This is because people usually don’t have significant symptoms until half of the inside of the esophagus, called the lumen, is obstructed.If the disease has spread elsewhere, this may lead to symptoms related to this: liver metastasis could cause jaundice and ascites, lung metastasis could cause shortness of breath, pleural effusions,etc.

 

 
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