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The presence of arrow) represents air in the stomach; the right bubble (solid arrow) small amounts of gas distal to the obstruction indi- reflects duodenal gas purchase asendin overnight. There is no gas in the small or large bowel cates that the stenosis is incomplete buy asendin 50mg otc. The presence of gas in the bowel dis- tal to the diaphragm indicates that the high-grade obstruction is not complete cheap asendin 50mg without prescription. Often appears similar to annular pancreas, though granular mucosa in the narrowed segment suggests healed ulceration. Crohn’s disease Fusiform and concentric narrowing of the duo- Usually evidence of Crohn’s disease elsewhere. Crohn’s disease of the duodenal bulb and antrum produces tubular narrowing (pseudo–Billroth-I ap- pearance). Obstruction of the third portion of the duodenum (arrow) in a newborn infant, due to dense fibrous bands. Strongyloidiasis/sprue Single or multiple areas of stenosis of the duo- Strongyloidiasis is indistinguishable from Crohn’s denum. Duodenal carcinoma Annular constricting lesion with overhanging Approximately 90% are adenocarcinomas, which edges, nodular mucosal destruction, and ulcer- usually arise at or distal to the ampulla of ation. May be impossible to differentiate from sec- ondary neoplastic invasion of the duodenum due to extension of tumors of the pancreas, gallbladder, or colon. Although there Carcinoma of the pancreas pro- second portion of the duodenum and is narrowing of the second portion of the ducing an annular constricting causes marked mucosal edema and spicu- duodenum with widening of the duode- lesion (arrow). Intramural duodenal Tumor-like intramural mass causing narrowing Secondary to anticoagulant therapy, abnormal hematoma of the duodenal lumen. Aorticoduodenal fistula Extrinsic mass compressing and displacing the Often fatal complication of an abdominal aortic third portion of the duodenum. Radiation injury Smooth stricture, primarily involving the sec- Infrequent complication after radiation therapy to ond portion of the duodenum. Superior mesenteric artery Narrowing or obstruction of the third portion of Controversial entity referring to compression of the syndrome the duodenum with proximal dilatation. Thickening of Duodenal Folds Condition Imaging Findings Comments Peptic ulcer disease Diffuse fold thickening, primarily involving the Most common cause. Uremia (chronic dialysis) Nodular fold thickening, primarily involving the Simulates the appearance of pancreatitis, which bulb and second portion. Crohn’s disease/ Diffuse fold thickening, often with ulceration In Crohn’s disease, usually involvement of the tuberculosis and luminal narrowing. Diffuse thickening of denal sweep, double-contour effect, and sharp spic- folds in the proximal duodenal sweep is associated ulations. Infiltrative disorders Diffuse fold thickening (usually generalized in- Whipple’s disease; amyloidosis; mastocytosis; volvement of the small bowel). Especially in an obese patient with a high trans- verse stomach and a long vertical course of the descending duodenum. Chronic pancreatitis Generalized widening with fold effacement and History of alcoholism in more than half the pa- spiculation. Pancreatic pseudocyst Generalized widening and compression of the Common complication of pancreatitis. Lymphadenopathy due to lymphoma, metastases to lymph nodes, or inflammatory disease. Severe inflammation causes widening of the sweep and a high-grade duodenal obstruction. Peritonitis Generalized ileus, often with blurring of the mu- Suggestive findings include free peritoneal fluid, re- cosal pattern and intestinal edema. Gastroenteritis or enterocolitis without peritonitis can also present as generalized ady- namic ileus. Drugs with atropine-like effects (morphine, Lo- motil, L-dopa, barbiturates, and other sympath- omimetic agents). Most commonly hypokalemia, but also occurs with metabolic disorder hypochloremia, calcium or magnesium abnormal- ities, and hormonal deficits (hypothyroidism, hy- poparathyroidism). Abdominal trauma; retroperitoneal hemorrhage; chest conditions spinal or pelvic fractures; generalized gram-nega- tive sepsis; shock; acute pulmonary disease; mesen- teric vascular occlusion. The clinical presentation simulates tention of the cecum (often horizontally ori- mechanical obstruction. Chronic idiopathic intestinal Distention of the small bowel mimicking intes- Episodic symptoms of intestinal obstruction. Develops between the second and fifth postopera- tive days, especially if there was manipulation of the small bowel. The Colonic ileus in a patient with severe diabetes and diffuse small bowel dilatation simulates mechanical hypokalemia. Diffuse accumulation of a brown lipofuscin pig- ment in the muscularis due to long-standing mal- absorption and prolonged depletion of vitamin E. Causes include septicemia, hormonal or chemical deficits, hypoxia-induced vasculitis, respiratory dis- tress syndrome, intestinal infection, peritonitis, and mesenteric thrombosis. Adynamic ileus simulating mechanical obstruction on (A) supine and (B) upright views. External hernias May have gas or excessive soft-tissue density on External hernias (inguinal, femoral, umbilical, and the affected side. There is pronounced dilatation demonstrates the obstructing stone (white ar- of the duodenum and proximal jejunum to the rows) and barium in the biliary tree (black level of the annular constricting tumor (arrow). Congenital intestinal Double bubble (duodenal atresia) or triple bub- Barium enema may be required to distinguish atresia or stenosis ble (proximal jejunal atresia) signs, or a typical small from large bowel in a low ileal obstruction. Causes include neoplasm, inflammation (Crohn’s disease, tuberculosis, and parasitic infections), chemical irritation (medicines such as enteric- coated potassium chloride tablets), radiation ther- apy, massive deposition of amyloid, and intestinal ischemia (arterial or venous occlusion). Massive small bowel distention with a profound soap-bubble effect of gas mixed with meconium. Generalized dilatation of the small (and large) No point at which the caliber of the bowel dramat- Adynamic ileus bowel. Vagotomy clips or a history of previous ulcer sur- Vagotomy (surgical or gery; atropine-like medications (morphine, L-dopa, chemical) Lomotil, barbiturates). Moulage junal biopsy (flattening or atrophy of intestinal sign and frequent transient intussusception. Nontropical sprue is treated with a gluten-free diet, tropical sprue with antibiotics or folic acid. Occasionally has an appearance indistinguish- Rare manifestation of intestinal lymphoma. The entire small bowel can be diffusely the small bowel with extremely prolonged transit involved. Patients experience abdominal discomfort, cramps, and watery diar- rhea 30 minutes to several hours after ingesting milk or milk products. For the degree of dilatation, the small bowel folds are packed remarkably close together (hidebound pattern). Small bowel is usually normal in patients with dia- betes mellitus unless complicated by hypokalemia (probably represents a visceral neuropathy).

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Stasis in the incarcerated gastric pouch may lead to erosion of the gastric mucosa order asendin 50mg with mastercard. When the size of hernia is quite big there is an every possibility for gastric volvulus to develop cheap 50 mg asendin visa. After meals gurgling or splashing noises in the chest may be heard on auscultation buy 50mg asendin amex. Flexible fibre-optic gastro-oesophago- scopy should always be performed before operation to detect any abnormality in the oesophagus or stomach. But majority of the surgeons prefer thoracic approach as this type of hernia may be adhered to the surrounding structures. The principles of operation are (a) reduction of hernia, (b) elimination of the sac, (c) repair of the large opening in the hiatus and (d) an anti-reflux operation to eliminate the risk of post-operative gastro-oesophageal reflux. There is a chance of recurrence due to attenuation of surrounding tissues and the muscles of the diaphragm due to presence of a large hernia. He first described that this disease is due to failure of relaxation of the lower oesophageal sphincter. The term ‘achalasia’ has been derived from a Greek word which means ‘failure of relaxation’. In fact in this condition peristalsis is absent or feeble in the body of the oesophagus and the lower oesophageal sphincter fails to relax during swallowing. It must be remembered that there is no gas bubble in the stomach as no bolus with accompanying normal gas bubble can pass through the lower oesophageal sphincter. The most important fact is that there is increased incidence of the carcinoma of the oesophagus in patients with achalasia. Histology of muscle specimen shows reduction of ganglion cells with variable degree of chronic inflammation. The basic difference between achalasia and Hirschsprung’s disease of the colon is that the dilated oesophagus usually contains few ganglion cells, whereas the dilated colon contains normal ganglion cells proximal to the constricted, aganglionic segment. Pseudoachalasia is usually due to adenocarcinoma of the cardia or by cancers outside the oesophagus constricting the cardia and lower oesophagus leading to achalasia-like disorder. Degeneration or absence of the ganglion cells of Auerbach’s plexus throughout the body of the oesophagus is a definite histological feature. In 30% of cases this degeneration or absence of ganglion cells is not present, so some extraoesophageal cause has been found out. Various causes have been incriminated : (i) Emotional stress, (ii) External compression or trauma, (iii) Chagas’ disease, caused by Trypanosoma Cruzi and (iv) Infection. Men and women are affected with equal frequency though there may be a slight tilt towards women. Though this condition may occur at any age, yet it is more often seen between the ages of 30 and 50 years. In the beginning difficulty in swallowing is more obvious with cold than with warm foods. Patient feels obstruction particu­ larly in case of liquids, whereas solid seems to pass more easily. Gradually the patients feel difficulty in swallowing solid as well and show a tendency towards taking water with food so that food can be washed away into the stomach. In late cases patient may complain of regurgitation of foul-smelling intraoesophageal contents. Pain is not a usual symptom of this condition, though retrosternal pain may be complained of occasion­ ally in early cases. This pain may even radiate to the interscapular region or even to any of the arms simulating angina pectoris. It must be remembered that in 5 to 10% of cases carcinoma may be associated with this condition. This is mainly due to the result of mucosal irritation and subsequent metaplasia induced by the retention oesophagitis. It must be noted that oesophageal carcinoma in this condition tends to arise in the middle-third of the organ. As the disease progresses the oesophagus becomes dilated and the lower most portion of the oesophagus ends like a ‘bird-beak’ tapering. It will reveal that the pressure in the body of the oesophagus is higher than normal and may be equal to the atmospheric pressure. Being a thoracic organ its pressure should be much below the atmospheric pressure. This manometric study will also reveal that there is no typical co-ordinated peristaltic wave of the oesophagus in response to swallowing, instead feeble and repetitive contractions may occur throughout the oesophagus. The pecu­ liarity one may notice that the upper oesophageal sphincter relaxes normally in the majority of cases, but the lower oesophageal sphincter fails to relax after swallowing. This produces marked elevation of the intra-oesoph- ageal pressure and frequency of simultaneous oesophageal contractions corresponding with complaints of chest pain. In the former condition the lower oesophagus will look whit­ at the oesophago-gastric junction. So for symptomatic relief there are three devices which have been put forward by their proponents as the treatment of choice. Sublingual nifedipine may be used for transient relief of symp­ toms, but hence no place in definitive treatment. Its effect is also not permanent and the injection may be repeated after a few months. Previously such dilatation was also tried by Hurst-Maloney bougies in the range of 50 to 54 French type. Nowadays plastic balloons with precisely controlled external diameter are being used. Balloons of 30-40 mm in diameter are being used and are inserted over a guide wire. The most probable complication of this technique is oesophageal perforation, which is less than 0. The risk is more with bigger balloons, but these may be used by progressive dilatation over a period of weeks. But he performed the operation transabdominally and oesophagotomy was performed both on the anterior and posterior walls of the gastro-oesophageal junction. But the modern oesophagomyotomy is a modification of Heller’s operation in which thoracic approach is preferred and the myotomy is performed only on the anterior wall of the oesophagus. Preoperatively washing of the dilated oesophagus should be performed for the last 24 hours and the patient should be on liquid diet. A longi­ tudinal incision is made on the anterior wall of the oesophagus 7 to 10 cm in length through all the muscle layers of the distal oesophagus. The incision must reach well above the constricted portion of the oesophagus proximally and must reach the stomach within 1 cm distally. Damage to the vagus nerve and the supporting structures around the hiatus is avoided. So majority of surgeons believe that this should be the treatment of choice in achalasia of the oesophagus. But others are in the opinion that as non-operative treatment like hydrostatic dilatation can cure 65% of patients, it is worthwhile trying first and opera­ tion should be reserved for those who have failed to show good result by hydrostatic dilatation.

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Generally of the tumor are difficult to define on T1-weighted intense buy discount asendin online, homogeneous buy asendin 50mg low price, and sharply marginated images unless they are outlined by syrinx cavities focal contrast enhancement discount asendin uk. On T2-weighted images, it is difficult to distinguish the tumor from surrounding edema. Astrocytoma Widening of the spinal cord that is isointense on Second most common primary spinal cord tumor. Tendency to more patchy and Although different patterns of contrast enhance- irregular contrast enhancement consistent with ment have been reported in some ependymomas a more diffusely infiltrating tumor. Intense enhancement of the highly (simulating an arteriovenous malformation) on the vascular tumor nidus. The association of a strongly enhancing tumor nodule within a cystic intramedullary mass is very suggestive of heman- gioblastoma. After contrast injection, the en- T1-weighted images and hyperintense on T2- hancing tumor nodule (often smaller than the area weighted images. Generally marked contrast of cord enlargement) can be distinguished from enhancement. Immediate and uniform contrast en- in the head, spinal tumors tend to maintain signal hancement. The intramedullary expansion of the cord above and below this level was attributed to cord edema. They may have ment depending on internal architecture of the a characteristic extradural component that extends tumor. Other patterns include enhancement of a thin leptomeningeal veil that diffusely coats the spinal cord or nerve roots and a homogeneous increase in signal within the subarachnoid space. The high signal on T1-weighted images and decreas- characteristic bright signal on T1-weighted images ing intensity on progressively more T2-weighted can be confused with contrast enhancement if only images); parallels the signal intensity of subcu- post-contrast studies are obtained, thus leading to taneous fat. In the lumbar area, before making the diagnosis of intradural lipoma, it is important to note that fat may be present in the distal conus medullaris and filum terminale in approximately 5% of normal individuals. The linear area of signal loss at the periphery of the mass (arrows) represents calcifications. The high intensity could represent either contrast enhancement or the paramagnetic effect of melanin. Epidural metastases almost always occur in association with osseous metastases, in which the bright signal of marrow in the vertebral body is replaced by low-signal tumor on T1-weighted images. Contrast studies may mask metastases by increasing the signal of osseous metastases, so that they appear isointense to normal marrow on T1-weighted scans. Lymphoma Mass that is hypointense on T1-weighted Bulky soft-tissue mass insinuating itself into fora- images and of increased signal intensity on T2- mina, extending over multiple segments, and pro- weighted images. Vertebral neoplasm with Mass that is hypointense on T1-weighted Myeloma; chordoma; sarcoma. Note how the intensity of the lesions is similar to that of paraspinal and subcutaneous fat. Heman- giomas can be differentiated from relatively com- mon interosseous islands of fat because they maintain their high signal intensity on T2-weighted images. Note the widening of the spinal canal with posterior scalloping of adjacent vertebral bodies (small arrows). Large lesions must be differentiated from metas- tases or infection based on their sharp margins, low intensity of their rims, and association with nar- rowed disk spaces. Findings that suggest neoplasm include a large soft-tissue mass, destruction of bone cortex, and involvement of multiple levels. One clear indication of metastases is the presence of another lesion with similar signal characteristics at a nonfractured vertebral level. Pathologic fractures secondary to meta- static disease usually are hypointense to marrow on T1-weighted images and hyperintense on T2- weighted images. Sagittal (A) T1-weighted material through the superior end plates of T12 and (B) T2-weighted images show anterior compression deformities (wedging) and L3 (arrows). The signal intensity of the marrow is normal at T11, indicating a healed chronic compression fracture. At T7, the signal intensity of the marrow is decreased on the T1-weighted image and slightly increased on the T2-weighted image in a linear, heterogeneous fashion (small arrows, B), consistent with a subacute compression fracture. Multiple sites larged vessels (these changes disappear in the include primarily the spine (75%), skull (65%), and mixed phase). New onset of pain in a bone involved the marrow returns to normal, and the bony in Paget’s disease should raise the possibility of cortices are thickened. The boundaries between the image in a patient after radiation therapy disks and the end plates are obliterated (arrows). Osteochondroma Heterogeneous appearance with the cartilag- Primarily involves the posterior elements, espe- inous components of increased signal intensity cially the spinous processes. Osteoid osteoma Heterogeneous appearance with the calcifica- Intense enhancement of the highly vascular nidus, tion within the nidus and the surrounding bony which not only helps to localize the nidus but also sclerosis having low signal intensity on all aids in differentiating the lesion from a nonenhanc- sequences, whereas the noncalcified portion of ing process such as a Brodie’s abscess. Sagittal proton-density image shows a high-signal lesion (H) within a lower thoracic vertebral body. The lesion is well defined, and a discrete cortical margin is evident posteriorly (arrow). Cystic components generally have low material, solid portions of the tumor enhance. The anterior extent of the tumor and its relationship with the cord cannot be established. Note the partial obliteration of the posterior subarachnoid space (curved arrow in C) on the sagittal image. Note the bubbly appearance of the tumor, with small cysts of different signal intensity. Note the band of decreased signal intensity (curved arrow in B) between the tumor and vertebral body, representing the rim of sclerosis. Primary malignant tumors Destructive lesions that have decreased signal Osteosarcoma, chondrosarcoma, Ewing’s sarcoma. Tumor surrounds the neural canal containing the first left ventral sacral nerve root (arrow). Note the posterior calcification (arrowhead) and fat-fluid level (arrow) in the lesion. The high- intensity fat (solid arrow) is layering on the lower intensity fluid in the lesion. Sagittal T1-weighted scan demonstrate compression deformity (vertebra plana) of the T11 vertebral body (short shows an extensive neoplasm (arrow- arrows). Soft tissue (long arrow) also projects posteriorly into the ventral epidural space. Note preservation of the S1-S2 disk (arrow), which indicates potential for radi- cal resection.

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Clinical features are more or less same as those of the infection of the middle volar space purchase asendin 50 mg with visa. Once the pus has been localized in either of the above spaces purchase asendin 50 mg with mastercard, the treatment is to drain the pus order asendin 50 mg on line. If abscess has spread sidewise, it is better to make a longitudinal incision just in front of the digital vessels. If the pus is mostly localized at the palmar aspect, a transverse incision should be made on the site of greatest bulge and tenderness. Great care should be taken not to injure the tendon sheath or joint at the time of drainage, lest infection should spread into these structures to cause stiff fingers. The anterior part of each web space contains a lumbrical muscle, the digital vessels and nerve. Distally the web space is continuous with the loose connective tissue on the side of the finger. Proximally the web space communicates with the deep fascial spaces of the palm through the lumbrical canals — the fascial canals containing lumbrical muscles. Later on there is localization of infection within the space, which is indicated by oedema on the back of the web space. The bases of the fingers are swollen and the adjacent fingers are widely separated. The infection usually remains confined to the web space and spreads more towards the dorsal surface, as the skin here is thinner than the anterior surface. In later stage pus may track across the base of the finger into the adjacent web space and may also spread proximally along the sides of the proximal segments of the adjacent fingers. Maximum tenderness is found in the web and on the anterior surface of the base of one of the fingers. It must be remembered that spread of infection from web space to the deep palmar spaces through lumbrical canals is almost impossible. The best approach is a short transverse incision on the palmar surface about 1 cm proximal to the web margin. The incision must be short (less than 7 mm) to avoid injury to the digital vessels and nerves. If after evacuating pus through the palmar incision, there is still bulging of the dorsal skin, a counter-incision on the dorsum should be made to evacuate pus from the dorsal pocket. Proximally, the sheaths of the index, middle and ring fingers end in a cul-de-sac at the distal palmar crease. The sheath of the thumb is continuous with the radial bursa, which surrounds the tendon of the flexor pollicis longus and extends proximally to a point about 1 inch above the crease at the wrist. The synovial sheath, covering the flexor tendon of the little finger, sometimes has direct communication with the ulnar bursa or common palmar sheath, which surrounds all the flexor tendons to the four fingers. The ulnar bursa also extends proximally upto 1 inch proximal to the crease at the wrist. At times, the radial and ulnar bursae intercommunicate each other, while they lie in the carpal tunnel. Tenderness will be present althroughout the extent of the sheath, but will be maximum over the flexor creases and over the proximal cul-de-sac of the sheath. When the synovial sheaths of the flexor tendons become infected with pyogenic organism and ultimately pus forms within these sheaths, the condition is called suppurative tenosynovitis. As soon as the infection enters the sheath, a reactive effusion occurs which spread for the whole extent of the sheath. Pressure within the sheath alongwith virulent infection will cause damage to the flexor tendon inside the sheath. The infection is mainly a direct one from a prick of a needle, a thorn or a dorsal fin of a fish. The prick is obviously through the skin overlying the tendon sheath, mostly through a digital flexion crease as at this part the skin surface is remarkably nearer to the sheath. Sometimes this condition may develop from injudicious incision for drainage of the distal pulp space or from spread of infection from the middle and proximal volar spaces. Infection of the thumb or little finger spreads upto the palm to involve the radial or ulnar bursa respectively. This is an early sign, (iii) Tenderness over the anatomical disposition of the sheath. To determine the area of tenderness the end of a match stick serves the purpose admirably. Usually the tenderness is most marked at the proximal ends of the sheaths in case of the index, middle and ring fingers. Slight movement of the metacarpophalangeal joint by contraction of the lumbrical and interosseous muscles may be possible but movement of the interphalangeal joints is completely restricted, (v) Any attempt to straighten the finger actively or passively causes exquisite pain. The infection may result from a direct spread from tenosynovitis of the 5th finger. This is evident by the fact that swelling of the thumb is seen to extend into the thenar eminence. If after 24 hours of conservative treatment, there is not much improvement of pain, swelling, tenderness and if the temperature continues to be high, operation should be performed without delay. After the pus has been evacuated, plastic cannula or a ureteric catheter of suitable calibre is introduced into the sheath. Dry dressing is applied and the hand is immobilized and elevated in a plaster splint. If pain, tenderness and fever continue to be present, it seems that the drainage site has become blocked. As soon as the infection has been controlled, active exercises should be commenced, but antibiotic therapy should be continued for a few days more, as there is a chance of relapse as soon as the movement of the finger is started. If the tendon is seen to have sloughed and non-viable, amputation of the finger through its base should be considered. Sometimes there is a constriction in the sheath at the level of the metacarpophalangeal joint which may prevent spread of infection to the ulnar bursa in early stage. One at the midlateral line of the proximal segment of the thumb which lies just in front of the digital vessels and nerve. Lastly a transverse incision may be made just proximal to the flexor retinaculum on the radial bursa. In ulnar bursa, incision may be made just in front of the metacarpophalangeal joint of the little finger. A ureteric catheter may be passed both proximally and distally for proper irrigation. But a transverse incision 1 cm proximal to the distal crease of the wrist joint is more often required for proper drainage. In these cases, the flexor retinaculum has to be divided through an incision from the proximal incision carried distally for a short distance which skirts the thenar eminence. Pus in this space will not show much swelling, but there will be brawny induration above the wrist in the flexor surface of the forearm. The pus here is drained by making incision on the lateral or medial border of the forearm and by pushing a haemostat through this incision. Continuation of suppuration — is possible when there is sloughing of tendon or bone necrosis.

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