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E. Julio. Charter Oak State College.

The lack of vascular invasion plus patient with chronic pancreatitis showing massive dilatation of the history of associated autoimmune disease helps the pancreatic duct (arrowhead ) in establishing the diagnosis biaxin 500 mg fast delivery. Groove pancreatitis: because of the chronic inflammation and the formation of scar tissue within the pancreaticoduodenal groove ( buy biaxin uk. The enhancing fibrous mass order biaxin 500mg overnight delivery, duodenal inflammation and cystic changes, and vascular sparing are features that may be useful in differentiating groove pancreatitis from pancreatic carcinoma. Chronic pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. A pleuropancreatic fistula is seen as a fluid signal discoloration of the skin and the conjunctival membrane fistula that arises from the pancreatic duct and over the sclera due to high serum bilirubin level (hyperbiliru- ascends superiorly to the mediastinum on coronal binemia). Idiopathic fbrosing pancreatitis: a cause rophages in the reticuloendothelial system (liver, spleen, and of obstructive jaundice in childhood. Updates on acute pancreatitis: ultrasound, into biliverdin, a green color pigment, by oxidation, and then computed tomography, and magnetic resonance imaging into bilirubin, which is a yellow color pigment, by reduction. Acute pancreatitis: radiologic scores in pre- jugated/indirect) and requires a special transport mechanism senting severity and outcome. Idiopathic fbrosing pancreatitis in a 3-year-old liver by binding to unconjugated bilirubin creating a biliru- girl: a case report and review of the literature. Crigler–Najjar syndrome is a very rare disease capacity is reduced when the serum albumin is reduced (e. Neonates with Crigler– salicylate), and when albumin afnity is diminished by acido- Najjar syndrome present with severe serum sis. Type I Crigler–Najjar syndrome is the most severe bind to special proteins within the hepatocytes called Y type and it is due to the complete absence of the enzyme (ligandin) and Z proteins. A part of the conjugated mother’s milk but recover on withdrawal from bilirubin is stored in the gallbladder and a part enters the breastfeeding. Dubin–Johnson syndrome is a rare, autosomal recessive converted to urobilinogen by the intestinal bacterial fora. A disease characterized by serum conjugated part of urobilinogen is reabsorbed by the intestine and enters hyperbilirubinemia due to congenital abnormality in the the portal system back to the liver to complete the bilirubin active conjugated bilirubin excretion from the intestinal–hepatic cycle, and the rest is excreted in the stool hepatocytes to the biliary canaliculi. When the urobilinogen characterized by deposition of a melaninlike pigment reaches the liver, it is further excreted from the body later via within the liver causing the liver to be dark in gross the kidneys into the urine. A group of disorders and rare hereditary syndromes Tere are no purities or steatorrhea. Rotor syndrome is a rare variant of Dubin–Johnson metabolism mechanism described above. Some of these con- syndrome characterized by serum conjugated ditions are benign and some are fatal as the following: hyperbilirubinemia with the absence of purities or 1. Unlike Dubin–Johnson syndrome, there is neonates afer birth that arises when the binding capacity no melaninlike pigment deposition within the liver. Also, the amount of Z protein in the liver afer birth is comparable to that in the adult, Approximately 4 mg/kg of bilirubin is produced every but adult levels of ligandin are not attained until several day. Jaundice itself is not a Te condition is self-limited and lasts 8 days in normal disease but rather a sign of an underlying condition. Gilbert syndrome is a rare disease characterized by into three main categories: isolated serum unconjugated hyperbilirubinemia (usually 1. Te other liver serum biochemical tests increase rate of hemolysis with increased production of are normal. Prehepatic jaundice is typically precipitated by fatigue, alcohol consumption, stress seen in hemolytic anemia, malaria, glucose-6-phosphate situations, and diseases like infuenza. Te disease afects dehydrogenase defciency, rat fever (leptospirosis), and 1 % of the population. Tere is increased serum caused at least by the defciency of ligandin and Z unconjugated bilirubin level with normal urinary color proteins in hepatocytes. Te serum unconjugated and bilirubin concentration, stool color, and serum liver hyperbilirubinemia is reduced by phenobarbital therapy. Hepatic jaundice: this type of jaundice arises due to 1 hepatocyte disease or liver enzyme failure. Hepatic jaundice is typically seen in hepatitis, hepatic failure, liver cirrhosis, Gilbert’s syndrome, Crigler–Najjar syndrome, and Niemann–Pick disease type C. Laboratory investigations show abnormal liver enzyme profle and increased urinary urobilinogen level. Posthepatic jaundice: this type of jaundice arises due to interruption to the drainage of the bile within the biliary tree. Posthepatic jaundice is typically seen in biliary gallstones (choledolithiasis), carcinoma of the pancreatic head, cholangiocarcinoma, biliary atresia, and Mirizzi syndrome. Laboratory investigations show hypercholesterolemia, abnormal liver enzyme profle, and increased urinary urobilinogen level. Patients may present with purities due to the neuronal irritation of the dermal nerve endings by the urobilinogen in the skin. Radiological modalities can be used as tools to defne the cause or asses complications of jaundice. Te following dis- cussed diseases show well-documented radiological signs that can be looked for in assessing a patient with jaundice. Up to 50% of patients with kernicterus die, while survi- vors develop bilirubin encephalopathy with the previous Obstructive Jaundice described manifestations. In the early form of the disease, symptoms may mimic sepsis, asphyxia, or hypoglycemia. Predisposing factors for choledocholithiasis include female sex, obesity, and older age. Signs of pancreatitis or carcinoma in the second part full of sludge observed in 20–30 % of ill newborns with of duodenum may be detected. Te disease is usually found in Asian countries and arises due to parasitic infection with Clonorchis sinensis (Clonorchiasis). Bile plug syndrome: successful manage- shows bulging into the second part of the ment with mucolytic agent. Computed tomographic diagnosis of Choledochal Web obstructive jaundice in the absence of intrahepatic ductal dilatation. Congenital extrahepatic portocaval shunt a rare cause of childhood intermittent jaundice. Obstructive associated with hepatic hyperplastic nodules in a patient jaundice may develop due to biliary sludge formation, mucus with Dubin-Johnson syndrome. Abnormal intestinal motility: the enteric nervous system 1 supplies the nervous supply to the smooth muscles in the Diarrhea is defned as passing loose stool >200 g/day. Infammation of the neurons diarrhea is defned as diarrhea that persists >4 weeks, while of the enteric system causes dysfunction of the intestinal severe diarrhea is defned as passing loose stool more than 6 wall’s muscle movement, causing diarrhea or constipa- times/day. In intestinal infammation, many infammatory nocturnal, is associated with weight loss, contains bloody mediators such as serotonin , acetylcholine, histamine, sub- content, and is accompanied by fever.

If haematuria gradually ceases biaxin 250 mg discount, it is a good sign but the patient should be kept at rest for a few days more as such cessation of haematuria may be due to occlusion of the ureter by blood clot generic biaxin 500mg mastercard. A critical injury is such when the kidney is shattered or there is a tear in the renal artery or one of its branches purchase cheapest biaxin and biaxin. A patient who after injury did not reveal any sign of kidney injury suddenly suffers from profuse haematuria usually between 3rd and 5th days of accidents. This usually occurs due to some movement which dislodges the clot into the renal pelvis. So rest in bed is extremely important even when minimum injury to kidney is suspected. Intraperitoneal rupture can only occur when someone is drunk so that his abdominal musculature remains relaxed during the blow and the bladder is full. Symptoms of ruptured bladder are usually masked due to multiple injuries and shock. After a few hours there will be increasing tenderness over the lower abdomen and the pulse rate will rise. These factors in association with failure to pass urine and no evidence of bladder distension will confirm the diagnosis. There will be varying degrees of abdominal rigidity and a few hours later abdomen becomes obviously distended. Though the patient has not passed urine he does not show any intention whatsoever to do so. To confirm the diagnosis, a straight X-ray in the erect position will show ground glass appearance in the lower abdomen due to presence of urine. In case of intraperitoneal rupture retrograde cystography is very helpful and may show the site of rupture. But retrograde cystography may be performed in extraperitoneal rupture when a diagnosis of rupture of urethra has definitely been ruled out. But the last-mentioned investigation does provide a serious risk of introducing infection, hence better be avoided. A careful history should be taken indicating the symptoms of the patient and a careful examination to find out the physical signs and their interpretations which are of high significance to come to a diagnosis in these cases. It goes without saying that how important it is to make the diagnosis as early as possible in these conditions. Delay will definitely worsen the condition of the patient and may lead to fatal outcome. But a few acute abdominal conditions are peculiarly more often seen in females than males. Pancreatitis is more common in Western countries due to their habit of consuming alcohol. Appendicitis is also more common in Western countries may be due to their habit of taking low residue diet. In acute intestinal obstruction the pain may not be severe at the onset but gradually increases in intensity. In acute appendicitis the pain becomes boring in the beginning and suddenly becomes acute in case of obstructive appendicitis which often wakes up the patient in the early morning. Similar type of pain with varying intensity appearing on and off for the last few years is the feature of appendicitis, cholecystitis, etc. The patient is asked to indicate the site of pain with tip of one finger (Pointing test). If the pain is diffuse the patient will obviously use his whole hand instead of one finger to locate its site. When it is below the right costal margin — liver or gallbladder disease is suspected. If it is in the epigastric region, peptic ulcer perforation, acute pancreatitis, etc. The pain is initially felt around the umbilicus, but later on shifts to the right iliac fossa with the onset of parietal peritonitis. When the patient complains of a radiating pain towards the left iliac fossa while he is suffering from acute appendicitis, the condition is one of spreading peritonitis. The cutaneous nerves from the same segments are concerned in supplying the skin over the shoulder as also the upper part of the front of the chest through the supraclavicular nerves (C. Any irritation on the undersurface of the diaphragm either by gastric contents or blood or bile (after operation on the biliary tract) or inflammatory exudate may give rise to referred pain to the corresponding shoulder. In suspected cases the foot-end of the bed may be raised by about 18 inches to allow the exudates to gravitate down towards the undersurface of the diaphragm which will obviously initiate pain on the corresponding shoulder. In renal colic, pain is referred from the loin to the groin, testis and inner side of the thigh, i. In biliary colic the pain radiates from the right hypochondrium to inferior angle of the right scapula since the gallbladder is supplied by the 7th to 9th thoracic segments. Of course pain is frequently referred to the right the same viscus also receives the parasympathetic shoulder and migrates along the right supply mostly from the vagus (the sole exception paracolic gutter towards the right iliac being the hindgut and the bladder which receive fossa. Ffein originating in the gallbladder may radiate to the back just below the the sacral sympathetic supply). Splenic (S) pain is may occur in pleurisy, haemothorax or referred to the left shoulder (Kehr’s sign). It indicates Bilateral pain and tenderness over the hypogastrium (shown by criss-cross) obstruction to a hollow organ — either bowel characterize acute salpingitis. Colicky pain of acute intestinal obstruction may change into constant burning type which indicates strangulation. In acute appendicitis it may indicate perforation of an obstructive gangrenous appendix. In 2nd stage (stage of irritation) of peptic perforation, pain diminishes in intensity although the disease is continuing. This is due to the fact that the peritoneal exudate dilutes the irritant gastric content. In diaphragmatic pleurisy pain is aggravated during deep inspiration and coughing. In case of pain due to diaphragmatic irritation either due to inflammatory exudate or due to blood from injury to the liver or spleen deep inspiration will aggravate the pain. In case of cholecystitis fatty foods will aggravate the pain whereas fat-free diet will give some relief. In case of peptic ulcer alkalis will make the pain better whereas alcohol, spicy food or drugs like aspirin will aggravate the pain. In case of hiatus hernia and reflux oesophagitis, stooping will make the pain worse. In acute pancreatitis the pain is relieved to a certain extent by sitting up from the recumbent position.

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The calyces are blunted and gradually they distend to destroy the substance of the kidney purchase biaxin with mastercard. On section a typical hydronephrosis kidney looks like a huge lobulated bag of fluid in which there are vestiges of the interlobular septa generic 500 mg biaxin free shipping. The fluid which occupies the hydronephrotic sac is clear and watery and contains urea cheap biaxin 250 mg free shipping, uric acid and low quantity of salts. If infection occurs in hydronephrosis, the clear fluid gradually changes into pus and then the kidney becomes a bag of pus. In early stages the tubules are dilated, which gradually become atrophied in later stages. The glomeruli remain comparatively intact and they appear more in number than normal due to parenchymal atrophy of kidney. Secretion of fluid is mainly through the glomerulus, whereas absorption of fluid occurs through various paths These paths are as follows :— (i) Pyelovenous back-flow, in which absorption occurs through veins which lie in the wall of the pelvis (ii) Pyelotubular back-flow, in which absorption occurs by way of the renal tubules into which the fluid flows back from the hydronephrotic sac. After 3 weeks of complete obstruction, the affected kidney’s function becomes tremendously deteriorated, so much so that even if the obstruction is removed it cannot get its function to normal level. A few hours later or even on the next day there is suddenly excess voiding of urine (polyuria), the pain is relieved and the swelling also disappears. The findings in the early stages of hydronephrosis differ according to the type of hydronephrosis. A portion of the pelvis becomes more dependent part below the level of the pelviureteric junction. This is also due to dilution of the excreted dye by the huge quantity of fluid in the sac. A fine needle puncture of the kidney through the loin is made and the kidney is perfused with radio-opaque medium at a constant rate of 10 ml per minute. With this tech­ nique one can assess the changes of the pelvis and calyces in a better way. The causes have been de­ Recently, the operation used for hydronephrosis, is mostly conservative e. But it must be remembered that this type of surgery is only suitable when hydronephrosis is Aberrant renal vessel. When there is extensive damage to the renal parenchyma, nephrectomy is dence of hydronephrosis. Again one point should be very much considered renal arterv should not be divided that hydronephrosis, whose aetiology is still obscure, is often a bilateral condition and affects the other kidney casually, as it may be the sole artery sometimes later in the process. The renal pelvis and the upper end of the ureter is again exposed and dissected clearly. A vertical incision is made from just above the pelvi-ureteric junction along the ureter for 2 cm. From the upper end of this incision, two incisions are made to diverge from each other so the whole incision has now become a Y-shaped one The apex of the Y is gradually pulled down and sutured to the lower end of the ureteric incision to give it a V-shape. The sides of the opening are closed with interrupted sutures This is again drained with a nephrostomy tube for 10 days. There always remains a problem of prolonged leakage of urine, but they generally stop by themselves. Only a handful of surgeons may still advocate this operation on the belief that this may cure the spasm at the pelviureteric junction due to sympathetic overactivity In this operation the renal pedicle is exposed through the typical renal exposure. The renal artery, vein and the pelvis are preserved but the other soft tissues lying outside these structures in the renal pedicle are stripped off. The sympathetic nerve fibres which form a plexus around the renal vessels to supply the kidney is thus sacrificed. This operation probably plays a significant role in relieving pain associated with hydronephrosis. This has a bad effect that the patient, thus relieved of pain, ignores hydronephrosis which is steadily dilating. The high incidence in females appears to be related to their short urethra which often harbours urinary pathogens which migrate from neighbouring perineum to the vaginal vestibule. This mode of infection also increases in males above 60 years of age in which benign enlargement of prostate is common. Theoretically ascending infection may occur by three routes : (i) Through the lumen of the ureter; (ii) By passing up the lymphatics in the wall of the ureter; (iii) By blood stream. The mucosa and submucosa of the urinary bladder are supplied with an extensive network of lymphatics which pass up along the wall of the ureter to the kidney. Bacteria placed in the urethral mucosa pass into the lymphatics and up the walls of the bladder and ureter. Bacteria from infected tonsils, carious teeth, cutaneous infections particularly boils and curbuncles may affect the kidney. The kidney is one of the main filters of the body and any bacteria gaining access to the blood stream are obviously eliminated by this route and thus coming in contact with the kidneys. The bacteria first lodge in the glomeruli where they may form large masses readily seen under microscope. Escherichia coli lodge in the pelvic portion of the kidney, although later infection may spread into the cortex. The urine gradually becomes loaded with pus and becomes strongly acid in reaction. Coli is lower than that of pathogenic cocci and a chronic infection may linger for years in Ihe renal pelvis. In experimental animals, intravenous injections of urinary pathogens lead to pyelonephritis only if the ureter is temporarily obstructed or the kidney is trauma! So it seems that urinary obstruction or vesicoureteral reflux or injury to the kidney may prepare the ground for haematogenous infection. The most obvious examples of renal infection via haematogenous route are tuberculosis and renal curbuncle (due to metastasis from skin infections). It has been discussed above in ‘ascending infection’ how lymphatics play a prominent role in ascending infection. In Proteus and Staphylococcal infections the urine becomes alkaline in reaction, as these organisms split urea into ammonia. The term ‘pyelitis’ means inflammation of the renal pelvis only, but it is doubtful whether such condition can exist alone or not. It has been shown that vesicoureteral reflux may occur during acute cystitis, but ceases when the infection has been cured. Acute pyelonephritis is quite common after marriage (‘Honey-moon pyelitis’) and during pregnancy. In case of haematogenous infection element of obstruction is of greatest importance. If colon bacilli are injected intravenously into rabits in which one ureter had been partially ligated, acute pyelonephritis develops in the obstructed kidney in 75% of cases, but never in the unobstructed kidney. Under the capsule there are numerous yellow spots representing areas of suppuration.

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In a typical case of testicular tumour no abnormality of the prostate or seminal vesicle may be detected through this examination discount 500mg biaxin otc. This is done to detect pulmonary metastasis or detection of enlargement of pulmonary and mediastinal lymph nodes buy biaxin 500mg line. Para-vertebral nodal masses and enlargement of paratracheal nodes may also be detected by this investigation purchase discount biaxin on line. Being in the abdomen it is difficult to palpate slight enlargement of these lymph nodes. Nodal metastasis is indicated by filling defect or nodal enlargement with pseudolymphomatous lacy appearance. In case of massively enlarged nodes there may be virtually no entry of contrast medium into the lymph node mass. However infiltration of the testis by leukaemia or lymphoma is difficult to diagnose by this technique. However, ultrasound remains the investigation of choice as it is less expensive and time-consuming. This is in contrast to teratoma where isotopic tumour localisation has proved disappointing. Inferior venacavogram — may be performed to detect pressure on inferior vena cava by the involved lymph nodes particularly in case of right sided tumours. As soon as the diagnosis is confirmed inguinal orchidectomy with high cord ligation at the deep inguinal ring is mandatory. Then the treatment defers according to the histopathological report of the testis whether it is seminoma or teratoma. This is the best form of getting the biopsy specimen without disturbing the tunica albuginea, which acts as a barrier for direct spread of the tumour mass. It is ligated at the level of the deep inguinal ring and then divided just distal to the ligature. The spermatic cord is gradually dissected from the surrounding tissues downwards and ultimately the spermatic cord alongwith the testis is removed. If the histopathological report goes in favour of malignancy, orchidectomy is performed through inguinal incision with division of the cord at the deep inguinal ring. The contralateral testis is protected from scattered radiation by means of thick lead cup. It is preferable to use high energy X-rays — either 6 MeV or 8 MeV linear accelator is employed. The penetrating beam of this apparatus facilitates irradiation of deeply seated structures such as the retroperitoneal lymph nodes with high doses resulting in short treatment exposures, and the sharply defined beam edges which minimize irradiation to critical adjacent structures such as kidney and testis. In case scrotal sac is involved — the scrotal sac is irradiated and the inguinal nodes are included in the fields. Following completion of the abdominal radiation and after a period of 4 weeks the mediastinal and supraclavicular nodes are irradiated. Thus for example, pulmonary and hepatic irradiation may be carried out with some prospect of success. In presence of widespread disease the best plan is to attempt to irradiate all identifiable disease and then to follow this with chemotherapy. A combination chemotherapy containing cis-platinum has been very effective in treating testicular tumour. The cure rate in these two groups is strikingly different with 80% cure rate in stage Ha, whereas 35% in stage lib. Early detection of lung metastasis should be followed by chemotherapy and lung irradiation. Retroperitoneal lymph node dissection or radical excision of the retroperitoneal lymph nodes. Irradiation also minimises unnecessary radical retroperitoneal node dissection for histologically-negative lymph nodes. There is no evidence at present to suggest superiority of either irradiation or lymphadenectomy in the management of retroperitoneal node metastasis from testicular teratoma. A long midline incision provides excellent access for the mass situated below the renal vessels. If the mass extends above the renal vessels, a thoracoabdominal incision is required. One can make a separate staged approach that means separate incisions for dissection of wide-spread retroperitoneal lymph node metastasis. It must be remembered that more than 20% of cases who underwent para-aortic lymphadenectomy reported permanent impotence or retrograde ejaculation following this procedure. However it must be concluded that ideally all residual masses should be removed after completion of chemotherapy, first to define whether or not there is active malignancy in the lump and secondly because complete surgical removal and follow-up chemotherapy appear to offer best chance of cure. Patients with liver metastasis carry a particularly bad prognosis and the median survival for this group has been less than 4 months. Chemotherapy is used to secure maximal tumour regression and radiation is then directed to the sites of initially detected disease. After chemotherapy the lymph nodes (iliac, para-aortic, mediastinal and cervical) and both lungs are irradiated. The use of chemotherapy increases the sensitivity of the lung to irradiation and profound changes in pulmonary function can occur. Alterations of gonadotrophin levels and Leydig cell insufficiency are particularly common, which cause fertility adversely, but it usually returns to normal in those who had normal spermatogenesis prior to diagnosis. Other long term sequelae include renal impairment, arterial hypertension and elevation of serum cholesterol. There is an increased incidence of Raynaud’s phenomenon in 30% of cases, thought to be related to bleomycin exposure. Cumulative dose of platinum may cause ototoxicity in 20% of cases and peripheral neuropathy in 15% of cases. Concern has also been raised about the possible carinogenic effects of chemotherapy in the long term. Etoposide is known to be leukaemogenic and secondaiy tumours have been reported following etoposide containing therapy. In pure seminoma, residual masses can be safely observed on serial scans and most will shrink and calcify over time. A growing mass however would indicate recurrent disease requiring further treatment. These must be surgically removed before it enlarges locally and becomes inoperable. Current policies should include resection of all masses greater than 1 cm in diameter. The long-term risk and toxicities of such treatment will require careful prospective evaluation. First, the benefits and risks of contralateral testicular biopsy and second the correct identification of residual masses containing undifferentiated or mature teratoma which require surgical removal. With the advent of radiation and chemotherapeutic regimens the outlook for patients with testicular carcinoma is becoming increasingly better. If there are metastasis the survival rate drops considerably according to the stage of metastasis.

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