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Then sew over the remnant an omental Then feel for the splenic artery along the upper border of patch purchase amlodipine 10 mg without a prescription, bringing the edges of the V together proven 5 mg amlodipine. The mass may be tympanic because it usually is filled with If you have damaged the pancreas generic amlodipine 5mg amex, suture a piece of gas, arising from oxygen liberated by red cells in the omentum over the damaged segment of pancreas and leave spleen, and carbon dioxide from tissue metabolism rather a drain. An erect film will show a gas leave packs tightly in situ, close the abdomen, and return bubble and fluid level below the left hemidiaphragm, after 48hrs to remove them by which time the bleeding pushing it upwards. Look for a fluid-filled cavity in the area If shock suddenly develops postoperatively, a ligature of the spleen (38. Aspiration will confirm the diagnosis, but with good suction available to try to find the bleeding beware of causing severe haemorrhage or rupturing the vessel, and tie it off. Treat with antibiotics 48hrs If the wound sloughs and there is a fluid discharge, beforehand and then follow a procedure as for a liver the tail of the pancreas or stomach may have been injured. If there is fever with no obvious cause, and you have given penicillin, check for a subphrenic abscess (10. Make a left subcostal incision or usually affecting domestic or wild animals, and get both Chevron (inverted-V double subcostal) for very big thick and thin blood films. Drain the abscess and leave a large tube or catheter in the space, passed through a separate stab incision in the lateral If there is respiratory distress postoperatively, think of abdominal wall. Place a further pack (or two) above and behind the spleen to lift it forward, and perform a splenectomy (15. If you find a gastric perforation, the tissues will be very It occurs in sickle cell disease, acute myeloid leukaemia, friable. Make sure you drain the occasionally as a result of acute pancreatitis or perforation stomach with a nasogastric tube. The danger is rupture into the able to save the spleen because unravelling the inflamed peritoneal or pleural cavity and may be accompanied by tissues will damage it and result in considerable bleeding. Grasp the hilum of the spleen, place a pack or two behind it, and perform a splenectomy (15. But operate if the bowel obstructs completely (the plastic or stricturing type) or, rarely, if bleeding from tuberculous ulcers persists. You may not be able to diagnose some of the other forms of tuberculous peritonitis until you do a laparotomy. The plastic type, which causes intestinal obstruction, and may affect the gynaecological organs (23-3D). Strictures anywhere in the bowel, but usually in the caecum and distal small bowel, where they are caused by contracture of a tuberculous ileocaecal mass to form a fibrous constriction. A tuberculous ulcer may perforate the bowel, or bleed; because this occurs distally, bleeding is usually from the rectum. Do an abdominal ultrasound scan to look for Tuberculosis may be responsible for 80% of all your cases of lymphadenopathy, and the condition of the liver and kidneys. Presentation is with a swollen abdomen containing many litres of straw-coloured fluid. The fluid accumulates as a result of large If the fluid has fewer lymphocytes than this, the ascites is numbers of exudative miliary tubercles on the peritoneum. In tuberculous but you can be wrong, so take a biopsy of the parietal peritonitis it is usually 4-10g/l, but it may be up to 20g/l, peritoneum and/or the liver. Occasionally the ascites If it contains >4g/l of protein, it is likely to be an exudate. If it contains <4g/l, it is likely to be a transudate as found in cirrhosis or periportal fibrosis. You may be able to get special dipsticks for ascites which, though expensive, are very useful. Suggesting ascites secondary to liver disease: the liver may be enlarged, hard, and irregular, or small and hard to feel; the spleen is usually large; there are usually <4g/l of protein in the peritoneal fluid. Suggesting the nephrotic syndrome: the ascites is less marked than the generalized oedema. B, draw off the fluid Suggesting heart failure leading to cirrhosis and ascites: slowly before you start. C, miliary tubercles of the parietal peritoneum a raised jugular venous pressure, and other signs of heart and bowel. Ascites predominating over other symptoms are subacute or chronic, and may have lasted signs usually requires a mini-laparotomy. The adhesions which stick the loops of the indicated when the ascites is not predominant, as in the bowel together are extensive and difficult to separate, generalized oedema of heart failure, or renal disease. If there is more than mild because there is always a danger that a fistula may follow. Re-examine the abdomen once the ascites is drained obstruction; use these only when extensive matting of bowel away; you may be able to feel a liver, spleen or other prevents you from reaching the site of obstruction, abdominal masses previously obscured. To avoid possible injury to a large spleen, which may be difficult to feel because of the ascites, Avoid these common mistakes: drain the fluid from the right lower abdomen. Tubercles are remarkably uniform in size, (5) If the patient is desperately ill, do not make meddlesome and fairly uniform in appearance (like salt grains). Biopsy the and dangerous attempts to resect grossly scarred bowel, peritoneum by removing an elliptical piece of the parietal nor to free difficult adhesions. Abdominal pain (90%) is usually constant, central, Tenderness is not constant, and palpable masses of worms are and not severe. Suggesting an appendix mass: a short history, and an acute Alternating constipation and diarrhoea, cramps, and onset. Suggesting amoebiasis: a history of passing blood and Rectal bleeding (5%) may be severe.

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Accepting the null hypothesis when it is false Question 4 Type 1 error reflects: A 5 mg amlodipine with amex. Accepting the null hypothesis when it is false Answers 2-5 2- a; 3-b; 4-c; 5-d Sensitivity reflects ability to detect disease purchase amlodipine 10mg. Fistulae involving the stomach are the least likely to close Question 7 Biliary-enteric fistula most commonly connect the: A order 10mg amlodipine with amex. This is usually caused by severe cholecystitis with abscess and/or perforation and subsequent erosion into the duodenal wall A large stone may erode into the duodenum and subsequently cause gallstone ileus Question 8 Meckels diverticulum: A. The stomach is the most common site of gastrointestinal lymphomas Question 10 Rightward shift of oxyhemoglobin dissociation curve occurs with: A. A patient that is suffering from hypophosphatemia may demonstrate insulin resistance. Leiomyomas are usually located in the distal 1/3 of the esophagus They are the most common benign tumor of the esophagus Dx- endoscopy, esophogram to r/o cancer Symptoms- dysphagia, pain Do not biopsy- scarring can make subsequent resection more difficult Operate when they are >5cm or symptomatic. Enucleation via thoracotomy is appropriate Question 14 The best operative approach to a choledochal cyst is: A. Cyst excision with reconstruction via a hepaticojejunostomy is the preferred treatment. Of the choices, weight loss is the most common presenting symptom of small bowel malignancies. Radiation proctitis leading to severe bleeding is best treated by formalin fixation of the rectum Question 20 You perform laparoscopy for presumed appendicitis on a 25 yo man. Pts with presumed appendicitis but instead are found to have terminal ileitis should undergo appendectomy so that confusion of ileitis and appendicitis will not occur in the future. Resection may be indicated in pts with chronic intractable abdominal pain due to pancreatitis Question 3 Treatment for intractable abdominal pain in a patient with chronic pancreatitis and a dilated pancreatic duct is usually: A. Patients with intractable pain due to chronic pancreatitis and a dilated duct may benefit from lateral pancreaticojejunostomy (Puestow procedure ) if the duct is greater than 8 mm Question 4 You operate on a 25 yo man with presumed appendicitis, send a frozen section because there is a mass at the tip of the appendix, & path comes back as a 2. Appendectomy is appropriate management for carcinoid localized to the appendix, as long as they are less than 2 cm, not at the base, and there is no evidence for metastatic disease. You perform mediastinoscopy and a right paratracheal lymph node is positive for cancer. Positive paratracheal nodes identified on mediastinoscopy are considered N2 disease and the pt is unresectable. Question 7 A 50 yo woman comes in with a chief complaint of a nodule in her neck. Type 1 branchial cleft cysts extend from the angle of the mandible to the external auditory canal. Question 11 A 10 yo boy presents with a cyst in his lateral neck medial to the anterior border of the sternocleidomastiod. This inhibits formation of the T- cell receptor complex and causes opsonization of the T cell. It is often used with induction therapy immediately after transplantation Question 14 All of the following are true of Pagets disease of the breast except: A. It describes scaly lesions on the nipple that when biopsied demonstrate Pagets cells B. Patients usually have a calcium in the 9-11 range and decreased levels of urine calcium B. Parathyroid hormone levels in these patients is normal Answer 15 B is incorrect. The calcium levels in these patients is usually not that high; they do not require parathyroidectomy Question 16 A 4 yo female is brought to see you because of a painful limp. She has no other diagnosed past medical history though there is a strong family history for forming blood clots. You attempt to pass your finger behind the pancreas from below and get a large amount of blood return when you remove it. You place pressure on the neck of pancreas to tamponade the bleeding which seems to control it. Mucinous cystic neoplasms do not communicate with the pancreatic duct Question 1 A 15 yo boy is struck in the abdomen when he goes over the handlebars on his bike. If a trauma patient has a chance in clinical status or fails to progress, you should consider repeating imaging studies. Ovarian cancer with peritoneal mets is usually treated primarily with total abdominal hysterectomy, bilateral oophorectomy, resection of peritoneal mets, and omentectomy B. Ovarian cancers is one malignancy where debulking can be effective Question 10 Which of the following statements about von Willebrand factor is correct? When you enter the abdomen you notice that the tumor is directly invading into the liver about 0. Direct invasion of another structure by colon cancer requires en bloc resection if possible. A tumor at the cerebello-pontine angle almost ensures the diagnosis Question 15 The most important step in the treatment of a pt with Zenkers diverticulum is: A. The most important step in treating a Zenkers diverticulum is performing a cricopharyngomyotomy. Resection of the subclavian vein and reconstruction with a 10 mm Gore graft Answer 16 A. Classically, it presents in pitchers or patients who have a lot of strenuous repetitive motion in that arm. Usually the st 1 rib is resected during the same hospital stay in order to not have a repeat episode Question 17 A 75 yo woman falls while getting up from her wheelchair and experiences numbness in her index finger and thumb as well as difficulty moving her thumb..

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Gently draw the greater curve of the stomach whereas further haemorrhage is an uncontrolled risk order amlodipine 2.5 mg with visa. If you have seen an adherent blood clot amlodipine 5mg low cost, or a vessel standing up in an ulcer base on endoscopy cheap amlodipine 10 mg, re-bleeding is Suggesting peptic ulceration: a scarred, deformed first very likely. There may be nothing to feel if a posterior ulcer is eroding into the pancreas, or the liver. If this has not happened after 4hrs, Suggesting bleeding gastro-oesophageal varices: a firm abandon this method. If you find this, and there are no signs of an ulcer have to rely on the pulse and peripheral circulation to also, think about an oesophageal transection, and treat the know when bleeding has stopped. If there is no obvious bleeding site, feel every part of the If you decide to operate, open the stomach and stomach between your thumb and forefinger, and go right duodenum. Open the lesser sac ulcer, the simplest way to stop it bleeding is to undersew by dividing the greater omentum between the lower edge it. Perform a pyloroplasty: just remember not to close a pylorotomy longitudinally otherwise gastric outlet If you still cannot find the source of the bleeding, obstruction will result. Blood might be coming from anywhere from the duodeno- The 2 common mistakes are: jejunal flexure to the caecum. Then check the colon for ileocaecal tuberculosis, carcinoma, amoebic colitis, and intussusception. If you have not been able to perform an that there is no bleeding from a post-bulbar ulcer. You may not be able to If you still cannot find any cause for the bleeding, see your way clearly because of a lot of blood clots in the try to pass the flexible endoscope through the duodenal stomach: in this case, unless there is continued massive opening distally. If this is unhelpful, or you are faced with catastrophic haemorrhage, open the stomach and duodenum. You have a choice of 2 incisions, depending on the degree of fibrosis of the duodenum: If the scarring and fibrosis of the duodenum is mild or absent, make a linear incision (13-12A) with of it in the stomach, and in the duodenum. If the scarring and fibrosis of the duodenum is severe, make a Y-shaped incision (13-12E). Make your linear or Y-shaped incision through the serous and muscular coats of the anterior wall of the stomach, starting 4cm proximal to the pylorus, and extending over the front of the 1st and 2nd parts of the duodenum for 3cm beyond the pylorus. If there is an ulcer, centre the linear incision on this, and make it about 1cm above the lower border of the stomach and duodenum, (13-12A). Use tissue forceps and a scalpel to make a cut through the mucosa of the gastric end of the incision, so as to open the Fig. Enlarge the opening a little with scissors or stomach is slightly longer than that into the duodenum. Slowly cut through the remaining mucosa with incision open with stay sutures, held in haemostats, while you scissors. C, pull on stay sutures, so as to elongate or bleeding from the incision will obscure everything. Evert the mucosal layer with If you find a bleeding ulcer, control bleeding by Babcock forceps. Retract the edges of the V-shaped Place a deep retractor in the upper end of the opening in pyloroplasty incision. Using non-absorbable suture on a the stomach and ask your assistant to expose as much of its curved needle, pass 2-3 sutures deep to the ulcer, interior as he can. Ask your assistant to keep the area dry, and be sure to go Feel the inside of the stomach. You may see or feel: deep enough to include the walls and base of the ulcer, (1);An artery spurting from an ulcer on the posterior wall st but not so deep that you catch important structures, such as of the 1 part of the duodenum (the common site), nd the common bile duct. If the ulcer is in the distal duodenum, mobilize it, and make a small duodenotomy, and undersew the If you tear the oesophagus (which should never happen! If the bleeding point in the duodenum is obscured by First make sure bleeding is controlled as described above. The kind of pyloroplasty you should make will depend on the kind of incision you made, which in turn depended on If bleeding re-starts after the operation, manage this the severity of the fibrosis you found. If you made a linear incision, because there was only mild fibrosis, hold it open with stay sutures. Pull on these so as If you find what looks like a malignant gastric ulcer, to elongate it, and close it transversely with 2/0 absorbable adapt what you do to the size of the lesion (13. If the lesion is still and fix this across the suture line with a few sutures which bleeding, try a figure-of-8 suture with haemostatic gauze, pick up only the seromuscular layer. Leave an adjacent drain Consider first if, in your circumstances, a partial and a wide-bore nasogastric tube in situ. If you can operate gastrectomy might not be a better option, even if you have quickly, fashion a gastrojejunostomy (13-16); otherwise to refer the patient for this. If the spleen starts to bleed during the operation, They are usually multiple, shallow, and irregular. They usually give little pain, and severe bleeding is likely Pack around the spleen and wait to see if bleeding stops. Minor harmless gastric Then finish the rest of the procedure, and if there is no bleeding is common after an alcoholic binge. If further this kind may ooze severely, so that there are melaena bleeding ensues, depending on your experience, stools for several days. Treat with antacids hrly, and try a either replace the pack and perform a 2nd look laparotomy, noradrenaline in saline lavage (13. Exclude hypercalcaemia and the you need to devascularize the stomach by ligating both Zollinger-Ellison syndrome (gastrinoma, usually of the gastro-epiploic arteries as well as the left and right gastric pancreas). It presents as forceful bile-free vomiting, with constipation rather than diarrhoea, in a baby of about 3-6wks; the range can be 5days to 5months.