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1.Crohns dis
Ulcerative colitis
Skip lesions
Continuous
Cobbled appearance
Lead pipe appearance
Deep ulcers
Small supf ulcers
Longitudinal, tortuous ulcers
Pseudopolyps and rough mucosa
Haustra preserved
Haustra destroyed
Shortening less noticible
Bowel shortened
Local stenosis
Large bowel and rectum involved
Small bowel involved with colon in 50%
Sometimes mild distal ileitis
Rectum spared in 50%
N, small bowel not involved
Microscopic characteristics
Infl penetrates through bowel wall
Infl confined to mucosa and submucosa
Crypt abscess rare
Crypt abscess is common
Granuloma is common
Granulomas is rare
Complications
Crohns
UC
Abscesses
Ca of colon
Fistulae
Toxic megacolon
Bowel obstruction
Perforation of colon
Ca of colon
Haemorrhage
Ca of small bowel
stenosis
Toxic megacolon
stenosis
Systemic Cx of both:
Skin and mucosal lesions pyoderma gangrenosum + aphthous stomatitis
Uveitis
Arthritis and ankylosing spondylitis
Pericholangitis, sclerosing cholangitis, gallstones
Indications for surgery
Crohns
UC
Perforation = abscess/ fistula
Perforation
Obstruction that does not respond to Rx
Obstruction
Uncontrollable bleeding
Uncontrollable bleeding
=acute lesion resection of macroscopic
involved part
= chronic lesion fibrotic stricturoplasty
No response to conservative Rx
Toxic megacolon
Ca severe dysplasia
Children with FtT
Total colectomy remove colon and rectal mucosectomy
Alcoholic pancreatitis
younger men, OH abuse, previous attacks
Increased protein content in pancreatic juice
Chronic pancreatitis
OH ->acute panc -> tissue destruction&
calcification
Obstruction of exocrine ducts:
1. Stenosis of sphincter of Oddi
2. Stenosis of pancreatic duct
3. Pancreas divisum
CF
Coelic fibrosis
Bile duct tumours
Nutritional AN
Hyperlipidaemia
Drugs: steroids, cyclosporine A, tetracyclines
Viral infections = mumps,Coxsackie B ascaris
Trauma
idiopathic
Oedematous interstitial pancreatitis
Chronic inflammation
Obstructions of ducts
Permanent destruction of tissue
Congestion
=>exocrine tissue destroyed first
Oedema
=> then endocrine
obstruction = complete recovery
Necrotising pancreatitis
>85% destroyed= insufficiency
Obstruction& Inflammation
Cx:
Enzyme release
Pseudocyst
Collagenase: c.t.
Stones and strictures
Lipase: neutral fat
Biliary strictures
Elastase: blood vessels =
duodenal stenosis
haemorrhage
pHT
Cx: secondary infection; recurrent:
Ca
calcification
Functions of Saliva
Digestion amylase, lingual lipase
Lubrication
Solvent
Oral hygiene
Excretion
Regulation of water balance
Tonus of LOS
tonus
tonus
Gastrin
Secretin fat digestion
glc
Progesterone pregnancy
Motilin
OH
H1 receptor
H2- receptor
PgF
Ach: muscarinic Rec
- Receptor
Substance P
Serotonin
Histology of salivary glands
Parotid
Largest
Surrounded by dense ct
capsule
Lymph & fat in septa
Tubule-alveolar gland
Uniform SEROUS
PgE
Ach: nicotine rec
- Receptor
VIP
GIP
Submandibular
Sublingual
Dense ct capsule
NO ct capsule
Compound tubule-alveolar
Compound tubule-alveolar
MIXED:
MIXED:
20% - mucinous = serous
80% - mucinous = serous
demilumes
demilumes
80% - serous
20% - serous
Difference btw squamous cell ca and adenoma
Squamous cell Ca
Adenocarcinoma
Most common
Common in Western society
Middle or thoracic oes
Distal end of oes gastric Ca which affects
oes
Painless, progressive
Complication of GORD
dysphagia, LOW
Different growth patterns
Intestinal Metaplasia
Detected late
Detected early on followup of Barrets/PU
Spread:
Transmural
Contiguity
Lymphatics
haematogenous
DD
Infectious mononucleasis
HIV acute sero conversion
CMV
HHV6
Toxoplasmosis
Enteroviruses Cox. A, EV71
VZV
-Hand, foot & mouth dis
Herpetic gingivostomatitis
- Herpangia
Aphthous stomatitis
Portal- systemic anastomosis
location
portal
systemic
Clin pic pHT
Gastro-oes
L gastric V
Azygous V
Oes varices
anorectal
Sup rectal V cnt as
Inf & middle rectal V
Haemorrhoides
Para-umbilical
Bare area of liver
IMV
Para-umbilical V of
ant abd wall
Hep V cnt as portal V
into IVC
Supf epigastric V
Diaphragmatic V &
azygous V cnt as IVC
Caput medusa
Subphrenic abscess
Indirect Hernia
Transverses through deep inguinal ring ->
spermatic cord -> scrotum
Lat to inf epigastric vessels
Descends the whole length of inguinal canal
Round
Oval
Older people
Younger ppl
Less Cx
More Cx
Splits transverse fascia
Patent processus vaginalis
Extends anteriorly
Extends medially
Cx of inguinal hernias
Incarceration: inducible, obstruction
Strangulation: blood supply of incarcerated hernia is compromised ->ischaemia ->
bowel necrosis
Sliding hernia: hernia contents forms part of the hernia sac
Acute scrotum: strangulated indirect inguinal hernia (in scrotum)
Syptoms of haemorrhoids
Painless rectal bleeding bright red
Piles = prolapse
Constipation
Pruritis ani
Mucous drainage
Abdominal wall defects
1. Omphacele
2. Gastroschisis
Circular abd wall defect with umbilicus as
Slit like abd wall defect to R of umbilicus
centre
Contents is covered by translucent avascular
Bowel not covered by membrane =
membr ( peritoneum+amnion)
completely unprotected
Sac contains small, large bowel, stomach,
Sac usually conatin only bowel
liver
Other assc malformations
No other malformations except for
- vertebra
Bowel atresia
- ano-rectal
-cardiac
- trachea-oesophageal
- renal/radius
- limb
VACTERL
3. Familial polyposis
Autosomal dominant congenital
1000s of tubular adenomas in colon and rectum
Rectum is always affected
Clinical = rectal bleeding
Pre-malignant
Histology of anus
1. Anal canal divided by pectinate line
Sup : columnar epithelium
Inf : squamous epithelium
2. Anal canal fold = anal columns
3. Epithelium changes to skin at orifice
4. Submucosa is rich in bloodvessel
5. No crypts of LieberKuehn
Dx of rectal Cancer
Same as colon Ca +
- digital rectal examination
- sigmoidoscopy, rectosigmoidoscopy
- US, XR, CT, metastases
NO BARIUM MEAL!!!
Types of anal Ca
Squamous Ca of mucosa in the anal canal above the pectinate line
Squamous Ca of cutaneous epithelium
Malignant melanoma of epi above pectinate line
2. Anterior resection
Abd approach
Excision of sigmoid colon and part of rectum
with tumour and free border of 5cm
Descending colon is sutured to rectum
Management of anal Ca
Chemotherapy Nigro chemoregulation regimen: 5FU+ mitomycin for 6weeks
Irradiation for 6 weeks
Resection:
0-4 cm from anus abd.perineal resection
4-8 cm from anus depending
8-12 cm from anus anterior resection
Complications
Diverticularis
Pericolic abscess
Fistulae
Perforation
Haemorrhage
L descending colon
Smaller lumen, semisolid faeces
Tumour infiltrates circumferentially ->
stenosis
Fatigue
Change of bowel habits
Constipation/ diarrhoea
Blood in stool
Vague/colicky pain due tu obstruction
Dx of colonic Ca:
Faecal occult blood
CEA carcino embryoinic Ag
Sigmoidscopy and colonoscopy
Barium enema: R
- filling defect = polypoid
- destroyed mucosal pattern
L
- apple core appearance
1.
2.
Adults
Haemorrhoids
Spastic colon
Diverticular disease
Colon Ca
Stop bleeding
- mostly spontaneous
- Vit K
- blood component therapy
- emergency endoscopic approach
3.
ID site of haemorrhage
Hx
Character of blood
- haematemesis = fresh/ coffee ground
- haematochezia = fresh with stool/ mucous/ jelly dark
- melaena = tarry black
- upper gut endoscopy
- lower gut contrast studies/ isotope scan/ endoscopy
4. ID and manage aetiology
5. follow up for recurrence
Diarrhoea
Osmotic
Disappears with fasting
Disappears with ingestion of offensive
substance
Electrolyte abs is not impaired low
[electrolyte] in stool and water
Cause:
Ingestion of poorly abs elements
= MgSO4, MgPO4, mannitol, sorbitol
= lactose intolerance
Excessive water is drawn into lumen
Secretory
Does not disappear with fasting
Not
Electrolyte abs impaired
Cause:
Infection - cholera
Enterotoxins
Peptides fromendocrine tumours VIP,
calcitonin
- Net secretion of Cl- or HCO3
- inhibition of net Na+ abs
-stimulated sectretion by epi cells
GOO
Penetration into surrounding organs with fistula formation
Malignant transformation rare
Pathogenesis and pathology of H.pylori (GN bacillus)
Pathogenesis:
Lives beneath mucous layer, where pH almost neutral
Buffers acidity by prod of urease -> produces NH4+ from urea
Raises pH around H.pylori
Release of cytotoxins -> local inflammation -> chronic gastritis
Pathology:
Stimulates acis production by parietal cells
Reduces mucosal resistence to acid and pepsin
In 1%; pangastritis -> gastric atrophy and hypochloridia -> proliferation of H.pylori
-> mutagenic nitritis -> predisposition to Ca
Diagnosis:
Endoscopy with biopsy
Barium meal
Urea breath test for H.pylori
Functional dyspepsia
No structural/ biochemical AN
Vague pain in central abd
No nocturnal pain
Not assc with meals
Recurrent episodes
Causes:
IBS
Motility disorders
Management of GU
1. H.pylori eradication
PPI + clarithromycin+ amoxicillin/metranidazole
PPI+ bismuth+ tetracycline+ metranidazole
2. Medical treatment
Antacids Al, Mg, Ca salts
H2 Receptor blockers Cimetidine, Ranitidine
PPI Omeprazole
Mucosal protective agents
Sucralfate
Misoprostol PG analogue
Colloidal bismuth compound
3. Lifestyle changes
stop smoking, avoid NSAIDS, no/moderate OH
4. Surgical Rx
Gastrectomy = Billroth 1 anastomoses
Vagotomy
= truncal + drainage
= truncal and antrectomy
= highly selective vagotomy
Approach on to obstructive jaundice
LFT:
conjugated BR
ALP
N serum alb
GGT
ALT, AST
Radiological investigations
ERCP
US
PTC
MRCP
CT
Impila poisoning
Callipses laureola in herbal medicine
Hypoglc
Renal damage
Centrilobular necrosis of liver
Sudden vomiting, diarrhoea, convulsions, coma
No jaundice, acidotic, floppy
Biochemical evidencve of liver failure
Reye sd
Preceding viral inf treated with salicylates
Progressive anicteric hepatic encelopathy
and microvascular fatty infiltration of
viscera
No jaundice, mtb acidosis, hypoglc
Biochemical:
AST, ALT
NH3
Prolonged PT
alb serum
acute phase reactants
Leucocytosis
High mortality and morbidity in
SURVIVORS
Biliary obstruction
White stools
AST/ALT/GGT
Serology might be Cultures Scan obstruction
Explanatory laparotomy/ intraop
cholangiogram
GGT/AST >2
Early surgery if possible
Liver tumours
Benign
Haemangioma cavernous/most common
Adenoma
Biliary Harmatoma
Focal nodular hyperplasia
- HBsAb IM
If markers are positive repeat serology after 6 months
HBsAg still + - chronic carrier
HBeAg still + - supercarrier highly infective
2. HBV DNA PCR
Qualitative
Quantative, viral load
Malignant
HCC = hepatoma 85%
Cholangiosarcoma
Angiosarcoma
Hepatoblastoma
Fibrolamellar hepatoma
Diagnosis of HCV
1. Serology of blood
Anti HCV = exposure
2. HCV RNA PCR
Qualitative
Quantative, viral load
3. RIBA radio immunoblot assay
Detects viruses itself
4. Genotyping
Prognostic and therapeutic value
Generall Lab request
HAV: anti-HAV IgM
HBV:
1. HBsAG
2. HBcAb/ anti-HBc
3. HBsAb/ antiHBs
- HCV: anti-HCV
HBV infection
Past HBV infection
HAV anti-HAV IgM HAV anti-HAV IgM HBV 1. HBsAg +
HBV 1. HBsAg 2. anti-HBc +
2. anti-HBc +
3. antiHBs 3. antiHBs +
HCV anti-HCV HCV anti-HCV
- HBcAb IgM
- HBcAb
- HBeAb
Complication of gallstones
Cholecystitis
Gallstones ileus
Stones of bile duct -> obstructive jaundice
Cholangitis
Benign bile duct stenosis
HBV vaccinated
HAV anti-HAV IgM HBV 1. HBsAg 2. anti-HBc 3. antiHBs +
HCV anti-HCV
Gallstone pancreatitis
Ca of gallbladder
5 most NB causes of jaundice
1. OH
2. Drugs
3. Gallstones
4. Viral infection
5. Cancer
Imaging of bile duct
1. Ultrasound
Shows dilated bileducts obstructive jaundice
Gallstones in ducts or gallbladder
Mass in head of pancreas
2. ERCP
Dye injected in bile and pancreatic duct
Shows filling defects in dilated ducts gallstones in ducts
Narrowing of bile/pancreatic duct proximal dilatation Ca of head of pancreas
1. US
2. ERCP
3. CT
4. MRCP
5. PTC
6. Operative cholangiography
7. Post-op cholangiography
8. AXR
9. Radio-nuclide imaging
Risk of cholesterol stones
Forty +
Female
Fertile
Fat
Fair
Family history
Functions of liver
1. Nutrient and Vit mtb
synthesis of:
Secretin
Stimulates ducts and
epithelium in pancreas
NaHCO3- in duodenum
- neutralizes chime
- optimal pH for enzymes
Emptying of
stomach
insulin secretion
Hypertrophy of gastric mucosa
perfusion of gastric walls
Contraction of GOS, small intestine
Relaxation of sphincter of Oddi
Bilesecretion
1. Hepatocytes flows peripherally
[bile acids], [cholesterol] + organic substances
2. Ducts adds watery solution of Na+ and HCO3- = bilecanaiculi -> terminal bileduct->
hepatic duct-> common bile duct
nd
2 secretion stimulated by secretin, bile as much as 100%
DD on acute cholecystitis
3. Pancreatitis
4. Perforated PU
5. Renal calculus
6. Acute appendicitis
7. Liver infections
8. Coronary thrombosis
Complications of a sliding hh
1. Stenosis
2. Inflammatory reflux
3. Chronic bleeding ->Fe deficiency anaemia
4. Barretts oes
5. Schatzki ring
Clinical picture of lesion of the facial nerve
Paralysis of facial muscle =
1. Cant show teeth
2. Drooling
3. Cant blow out cheeks
4. Blinking, eye closure
5. Cant raise eyebrows
6. Pucking of lips
Management of Ca of tongue
anterior 2/3
9. T +T : & irradiatio if ell differe tiated
free order
10. T3: irradiation + N1, N2; elective resection of LN, block dissection, N3 irradiation
Posterior 1/3
11. Late, anaplastic
12. Irradiation
13. LN block dissection
14. Poor Px
Oral lesions in AIDS pt:
15. Oral hairy leukoplakia EBV
16. HHV8
17. Severe herpes labialis
5 reflux oes.itis
6 Ca
Factors that increase bile production:
1. Parasympathetic
2. Secretin
3. CCK
4. Gastrin
5. Bile
Factors that decrease gastric emptying
Chyme in duodenum
volume
unprocessed food
Not isotonic
pH
Hormones
CCk
Secretin
GIP
Somatostatin
Position
Not standing
Factors that increase gastric emptying
Motilin
Insulin
Thyroxin
Gastrin
Defaecation reflex
Faeces move down the rectum via mass movement propulsions
Intrinsic reflex:
1. Distension of rectum, stimulation of myenteric plexus
2. Peristalsis in descending colon, sigmoid& rectum
3. Wave reaches anus
Relaxation of internal anal sphincter
Voluntary relaxation of external sphincter
4. Defaecation
Extrinsic reflex
1. Parasympathetic reflex intensify intrinsic reflex
2. Stimulus distension of rectum and internal sphincter
Lactation reflex
1. Suckling ->
2. Mechanoreceptors in nipple->
3. Hypothalamus ->
4.
5.
6.
7.
8.
Nervous pathway
Posterior pituitary
Oxytocin
Contraction of myoepithelial
Cells surrounding alveoli
Milk ejection
Somatic pain
Well localised
Sharp and severe
Can be referred
Somatic afferent fibres
Layers of stomach
MUCOSA
Exacerbated by movement
Colon
4. No villi
5. Plicae semicircularis
Epithelium
1.
2.
3.
4.
5.
6.
Simple columnar
Abs cells 90%
Goblet cells
Enteroendocrine cells
Paneth cells
Crypts of Lieberkuehn
1.
2.
3.
4.
5.
6.
Lamina propria
1.
2.
3.
Lacteals
Plasma cells, EP, lymphocytes
Peyers pat hes
1.
2.
Simple columnar
Abs cells
Goblet cells
Enteroendocrine cells
No Paneth cells
Colonic glands stem cells at
base
NO lacteals
GALT/MALT
Muscularis
mucosa
SUBMUCOSA
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
MUSCULARIS
EXTERNA
coli-> Haustra
Duodenum = partly serosa/adventitia
Serosa
Rest = serosa
Omental appendices
Histology of the breast
Nipples:
i)
15-25 lactiferous ducts open
ii)
Open in lactiferous sinus
iii)
C.t. and s.m. around ducts
iv)
Glands of Montgomery in areola
Glandular tissue:
i)
Coopers liga e ts = .t septa hi h di ide i to lo es
ii)
20 glands = lobe-> subdivided lobules => compound tubule-alveolar glands
iii)
Alveoli lined by single layer of cuboidal epithelium - > RER -> protein production
iv)
Myoepithelial cells
SEROSA
Cx of a retropharyngeal abscess
1. Haemorrhage
2. Rupture into AW with aspiration
3. Laryngeal spasm
4. Bronchial erosion
5. Jugular vein thrombosis
Palliative managemnent of oes Ca dysphagia
REPEATED DILATATION!!!
1. Stenting
2. Radiotherapy
3. Laser therapy
4. Photodynamic therapy
5. OH injection
6. Chemotherapy
Pathophysiology in oes Ca
1. Strictures
Dysphagia
Regurgitation - > aspiration
2. Malignant involvement of adjacent structures
Oes-tracheal fistula
Oes-bronchial fistula
Vocal chord paralysis
Pharyngeal swallowing
1. Soft palate contracts -> lifts and closes post nares
2. Elevation of hyoid, larynx -> close vocal chords
3. Tongue presses on soft palate -> close oral cavity
4. Longi muscle contraction of pharynx -> open pharynx
5. Relaxation of inf pharyngeal sphincter -> opens oes
6. Constriction of sup sphincter -> peristalsis -> forces food into oesophagus
7. Swallow
Vomiting mechanism
1. Deep inspiration
2. Closure of glottis
3. Elevation of soft palate
4.
5.
6.
7.
Sliding hh
Stomach slides through hiatus
Gastro-oes jnc lies in chest cavity
Reflux
Covered by peritoneum
Causes of aphthous ulcers
HHV8
CMV
EBV
HPV
HSV1
Rolling hh
Stomach rolls up anteriorly through hiatus
Cardia remains in N position
No reflux
3.
4.
5.
6.
RBC destruction
Spherocytosis
Thallasaemia major
Neoplastic
Meatastatic Ca
Hairy cell leukaemia
Myeloproliferative
Myelofibrosis
Essential thrombocytopaenia, purpura
Miscellenous
Splenic cysts
Haemangioma
Abscess
Splenic infarct
Splenic A aneurysm
Management of breast Ca
OPERABLE
STAGE 1
Mass confined to breast
No nodes
No metastases
1. Modified radical mastectomy ( breast
tissue& axillary block dissection)
OR
Removal of mass with 2cm border,
complete dissection of axillary LN& irradiation
2. Adjuvant chemo
Staging via needle Bx, CXR, ALP
INOPERABLE
STAGE 3
Mass infiltrates skin/chest wall
LN >5cm &/ fixed
Advanced local disease
1. Neo-adjuvant chemo (irradiaton)
2.
3. Irradiation
Staging via Histology of lesion, oestrogen
receptors
STAGE 2
Mass confined to breast
Mobile nodes in axilla
No skin or chest wall infiltration
1. Modified radical mastectomy with
detachment of pec major for more
thorough axillary block dissection
2. Adjuvant chemo
Staging via CXR, ALP, radio-isotope liver scan,
bone scan
STAGE 4
Any local lesion
Any node involvement
Distal metastases
1. Palliative chemo
2. Hormonal treatment
3. Lo al lesio : / irradiatio