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Calcium is also goitrogenic and areas producing chalk or lime stone are also goitrogenic areas e buy 100 mg extra super cialis with amex. In secondary thyrotoxicosis the brunt of the attack falls more on the cardiovascular system discount extra super cialis generic, whereas in primary thyrotoxicosis the brunt of attack falls more on the nervous system order extra super cialis in united states online. While simple goitre grows very slowly or may remain of same size for quite sometime cheap extra super cialis 100mg on-line, multinodular goitre or solitary nodular goitre or colloid goitre increases in size though extremely slowly for year. A special feature of papillary and follicular carcinoma of the thyroid is their slow growth. Malignant diseases of the thyroid gland are painless to start with, but become painful in late stages. Anaplastic carcinoma is more known to infiltrate the surrounding structures and the nerves to cause pain. It must be remembered that thyroid swellings can rarely obstruct the oesophagus as it is a muscular tube and can be easily stretched or pushed aside. As in the first stage of deglutition the thyroid gland moves up, so an enlarged thyroid gland makes swallowing uncomfortable but usually this is not true dysphagia. An enlarged thyroid may compress on the trachea or deviate it to one side or the other to cause difficulty in breathing. When air rushes through a narrowed trachea, a whistling sound is produced which is called stridor. Hoarseness is usually due to paralysis of one recurrent laryngeal nerve and anaplastic carcinoma infiltrating the nerve is often the cause. Preference for cold and intolerance to heat and excessive sweating are the next symptoms. Nervous excitability, irritability, insomnia, tremor of hands and weakness of muscles are the symptoms of involvement of nervous system which are the main features of primary thyrotoxicosis. Cardiovascular symptoms are not so pronounce as seen in secondary thyrotoxicosis, but even then palpitation, tachycardia (rise in sleeping pulse) and dyspnoea on exertion are symptoms of this disease. The patient may complain of staring or protruding eyes and difficulty in closing her eye lids. Oedema or swelling of the conjunctiva (chemosis) is seen in very late cases of exophthalmos alongwith persistent primary thyrotoxicosis. As mentioned above the brunt of the attack falls more on the cardiovascular system than on the nervous system. Palpitations, ectopic beats, cardiac arrhythmias, dyspnoea on exertion and chest pain are the usual symptoms. Muscle fatigue and lethergy are important symptoms with failing memory and mild hoarseness due to oedema of vocal cords. In case of thyroglossal fistula there may be a previous history of an abscess (an inflamed thyroglossal cyst) which was incised or burst spontaneously. Persons who are in the habit of taking a kind of sea fish which has particularly low iodine content, may present with goitre. Similarly enzyme deficiency within the thyroid gland which are concerned in the synthesis of thyroid hormones are also seen to run in families. The patient sweats a lot with wasting of muscles and in hypothyroidism the patient is obese and overweight. Not only the pulse rate becomes rapid, but it becomes irregular in thyrotoxicosis. Particularly sleeping pulse rate is a very useful index to determine the degree of thyrotoxicosis. In case of mild thyrotoxicosis, it should be below 90, whereas in case of moderate or severe thyrotoxicosis it should be between 90 to 110 and above 110 respectively. The clinician while feeling for the pulse should take the opportunity to touch the hand as well. In case of obese and short-necked individual inspection of the thyroid gland becomes more difficult. Rarely a swelling on the lateral side of the neck is not due to enlargement of an aberrant thyroid gland but is caused by metastasis in lymph nodes from hidden carcinoma of the thyroid gland. Ask the patient to sivalloiv and watch for the most important physical sign — a thyroid swelling moves upwards on deglutition. Other swellings which may move on deglutition are thyroglossal cysts, subhyoid bursitis and prelaryngeal or pretracheal lymph nodes fixed to the larynx or trachea. Such movement of the thyroid _ becomes greatly limited when it is fixed by inflammation or malignant infiltration. In retrosternal goitre, pressure on the great veins » r at the thoracic inlet gives rise to dilatation of the subcutaneous veins over the upper anterior part of the thorax. When these are present, ask the patient to swallow and determine, on inspection, the lower border of the swelling as it moves up on deglutition. Congestion of face and distress become evident in case of retrosternal goitre due to obstruction of the great veins at the thoracic inlet. But the pathognomonic feature is that it moves upwards with protrusion ol the tongue since the thyroglossal duct extends downwards from the foramen caecum of the tongue to the isthmus of thyroid gland. The opening of the fistula is indrawn and overlaid by a crescentic fold of skin (See Fig. The patient should be sitted on a stool and the clinician stands behind the patient. The thumbs of both the hands are placed behind the neck and the other four fingers of each hand are placed on each lobe and the isthmus (See Figs. The first figure shows inspection in normal position and the 2nd figure thyroid gland is shows Pizzillo’s technique, important, particularly the lower margin. Additional information about one lobe may be jp obtained bv relaxing the sternomastoid muscle of that side by flexing and rotating the face to the *B1| same side. To palpate the left lobe properly, the thyroid gland is pushed to the left from the right side by the left hand of the examiner. This makes the left lobe more prominent so that the examiner can palpate it thoroughly with his right hand. During palpation the patient should be asked to swallow in order to settle the diagnosis of the thyroid swelling. Slight enlargement of the thyroid gland or presence of nodules in its substance can be appreciated by simply placing the thumb on the thyroid gland while the patient swallows. During palpation the following points should be noted :— (i) Whether the whole thyroid gland is enlarged? If so, note its surface — whether it is smooth (primary thyrotoxicosis or colloid goitre) or bosselated (multinodular Fig. It must be remembered that a cystic swelling in the thyroid gland often feels firm due to great tension within the cyst which is surrounded by relatively soft surrounding tissue of the gland. Note how the thumbs are placed on the occiput to flex the neck in the lateral view (Fig. Pressure may be on the trachea or larynx, which may lead to stridor (inspiratory noise of inrushing air through narrowed trachea) and later on dyspnoea. Pressure may be on the recurrent laryngeal nerve, which may lead to hoarseness r ^ of voice. The patient is asked its position or any pressure effect being exerted on it due to to swallow. The thyroid gland will move thyroid enlargement, up and the lower border is palpated may produce stridor. This carefully to exclude any extension tes{ j particularly positive in multinodular goitres ands downwards. Simple palpation by an experienced hand will indicate the position of the trachea. The carotid sheath may be pushed backward by a benign swelling of the thyroid gland where the pulsation of the carotid artery may be felt (Fig. A malignant thyroid may engulf the carotid sheath completely and pulsation of the artery cannot be felt. Obstruction to the major veins in the thorax causes engorgement of neck veins are not uncommon. This sign becomes obvious when the patients are asked to raise the hands above the head and the arms touch the ears. Primary toxic thyroid is generally not enlarged whereas an enlarged thyroid or nodular thyroid with toxic manifestation is generally a case of secondary thyrotoxicosis.

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If open exploration is required buy discount extra super cialis 100 mg line, a T-tube chol- may be abdominal distension and vomiting unless shock and angiogram plus the hepatic arteriogram may help the surgeon hypoxia supervene buy extra super cialis mastercard. The mortality rate following postopera- identify the appropriate vessel to ligate generic 100mg extra super cialis with visa. When this study is read as competent surgeons purchase extra super cialis with a visa, so almost all residual stones can be positive for calculi by the radiologist, carefully review the removed by this technique. Request a repeat study to rule out the possibility that the right and the left hepatic ducts to remove stones. Also, some of the radiographic and extraction of retained stones with 1–2 % mortality. If shadows, interpreted as calculi, may indeed be artifacts that expertise with this technique is not available, a stone block- disappear without treatment. Some surgeons elect to remove the T-tube, con- indicated if tolerated by the patient. This should not be per- tinue to observe the patient, and reserve reoperation for formed before the 12th postoperative day. Alternatively, it normal saline with 5,000 units of heparin through the T-tube may well be argued that it is safer to perform an elective over a 24-h period, provided it does not produce excessive operation to remove the stone than an urgent procedure in the pain. If the radiographic appearance of the stone shows a reduction in size, repeat the series of saline flushes the following week. Otherwise, have the choledochostomy in the surgical treatment of patients with common patient inject 30–60 ml of sterile saline into the T-tube daily. Laparoscopic the T-tube cholangiography to confirm the persistence of T-tube cholechotomy for biliary lithiasis. Choledocholithiasis, endoscopic retrograde est method for extracting residual calculi is that described cholangiopancreatography, and laparoscopic common bile duct by Burhenne. Cholecystectomy deferral in arm of the T-tube be at least the size of a 14–16 F catheter. Cochrane Database Syst After cholangiography is completed and confirms the pres- Rev. With a continuous flow of contrast medium appropriateness method statistical analysis. Laparoscopic common bile duct exploration: trancystic the catheter toward the calculus, insert a Dormia stone bas- duct. The surgical management of impacted withdraw the basket, the stone, and the catheter through the common bile duct stones without sphincter ablation. Common bile duct exploration for choledo- have reported a success rate better than 90 % with this tech- cholithiasis. Operative Strategy This approach is also used when reconstructive biliary tract surgery is required. In such cases, it must be adapted to If the patient’s first operation was not followed by any signifi- the known anatomy and previous procedure performed cant collection of bile, blood, or pus in the right upper quad- (see Chap. On the other hand, occasionally the right upper quadrant is obliterated by dense adhesions requiring a care- Preoperative Preparation fully planned sequential dissection. First, dissect the perito- neum of the anterior abdominal wall completely free from Generally, ultrasonography has demonstrated ductal dilata- underlying adhesions. The dissec- Obtain a copy of the operative report and any cholangio- tion now goes from lateral to medial and from anterior to pos- grams, as for any reoperative surgery. If this dissection becomes difficult and there is a risk of Give vitamin K if necessary to restore the prothrombin time perforating the duodenum or colon, enter the right paracolic to normal. The maneuver uncovers the descending portion of duodenum, also in virgin territory. Chassin Now, resume the lateral to medial and anterior to poste- ascending colon in the right gutter. Incise the parabolic peri- rior dissection until the undersurface of the liver has been toneum and slide the left hand behind the ascending colon. It is not Liberate the hepatic flexure up to the undersurface of the necessary to free the undersurface of the liver for a large area liver, and then free the colon from the liver. If similar difficulties are encountered when identifying or dissecting the duodenum, perform a Kocher maneuver and slide the left hand behind the duodenum, dissecting this Documentation Basics organ away from the renal fascia, vena cava, and aorta. Now start dissecting the omentum, colon, and duodenum from the • Findings undersurface of the liver, going from anterior to posterior • Cholangiogram until the hepatoduodenal ligament has been reached. Placing the incision at a site away from the previous exploration is no different from that described in Chap. The indications for sphincteroplasty or biliary- In the usual case, initiate the dissection on the right lateral intestinal bypass are discussed in Chap. When it is difficult to differen- Postoperative care and complications are similar to those tiate colon or duodenum from scar tissue, identify the discussed in Chap. After making the initial incision about Ampullary or pancreatic duct orifice stenosis with recurrent 5–6 mm in length, locate the orifice of the pancreatic duct. In pain or pancreatitis (rare) 80 % of cases, it can be identified at about 5 o’clock where it enters the ampulla just proximal to the ampulla’s termina- tion. Wearing telescopic lenses with a magnification of about Preoperative Preparation 2. If the orifice of the pancreatic duct cannot be identified, inject secretion to stim- Perioperative antibiotics ulate flow of the watery pancreatic secretion and facilitate Vitamin K in the jaundiced patient identification of the ductal orifice. Some surgeons prefer to insert a alize the pancreatic duct 6 F or 8 F pediatric feeding tube into the duct to protect it while suturing the sphincteroplasty. We agree with Jones that keeping a tube in the duct is not necessary if one keeps the Pitfalls and Danger Points ductal orifice in view during the suturing process. When the indication for sphincteroplasty is ampullary Trauma to the pancreatic duct or pancreas resulting in stenosis, abdominal pain, or recurrent pancreatitis, it is postoperative pancreatitis essential to add a “ductoplasty” of the pancreatic ductal ori- Postoperative duodenal fistula secondary to a leak from fice by incising the septum that forms the common wall sphincteroplasty or duodenotomy suture line between the distal pancreatic duct and the ampulla of Vater. Postoperative hemorrhage After the pancreatic duct’s orifice has been enlarged, it should freely admit a No. Preventing Hemorrhage The long sphincterotomy incision used for sphincteroplasty C. Chassin to palpate the area behind the ampulla to detect pulsation of sions in the second portion of the duodenum cause serious if an anomalous artery. If such a vessel is behind the ampulla, not lethal consequences; therefore, take special care when sphincteroplasty by the usual technique may be resuturing the duodenotomy incision. We are aware, by anecdote, of two patients who died subsequent to a classic sphincteroplasty by the Documentation Basics Jones technique owing to massive postoperative hemorrhage despite reexploration. In one case, autopsy demonstrated lac- • Findings eration of an anomalous right hepatic artery. The laceration • Identification of pancreatic duct had apparently been temporarily controlled by the 5-0 inter- • Procedure on pancreatic duct? Using Jones’s technique, initially small straight hemostats Operative Technique grasp 3–4 mm of tissue on either side of the contemplated ampullary incision. Next, a 5-0 silk suture is inserted behind each of the two hemostats, and two additional hemostats are inserted. Make a long right subcostal or midline incision, free any The sphincterotomy incision is lengthened, and silk sutures adhesions, and perform a routine abdominal exploration. During the postoperative period, the artery may escape from the 5-0 stitch, and serious hemorrhage may fol- Kocher Maneuver low. Although hemorrhage is a rare complication, it appears prudent to omit this prior application of hemostats. By first Perform a complete Kocher maneuver and gently elevate the making a 3- to 4-mm incision with Potts scissors, one should duodenum up almost to the level of the anterior abdominal become immediately aware of any laceration of a major ves- wall, facilitating exposure of the ampulla (see Figs. Otherwise, inflammation that occurs 5–6 and elevate it from the flimsy attachments to the vena cava days after the operation may make accurate identification of and posterior abdominal wall. Place a gauze pack behind the the anatomy difficult during any relaparotomy for hemor- pancreatic head. A longitudinal duodenotomy is tip of the dilator through the anterior duodenal wall facili- preferred because it may be extended in either direction if tates placement of the duodenal incision accurately with the situation requires more exposure. Otherwise, distortion of the duodenum takes place, and linear tension on the suture line may impair suc- Duodenotomy and Sphincterotomy cessful healing. Precise insertion of sutures, one layer in the mucosa and another in the seromuscular layer, can be accom- Make a 4-cm scalpel incision along the antimesenteric plished without narrowing the duodenum.

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It is also sensible to render the gastric contents alkaline with cimetidine before the examination generic extra super cialis 100 mg overnight delivery, although the value of this drug is still to be proved discount 100mg extra super cialis otc. Treatment with cimetidine may however help prevent bleeding from chronic peptic ulcers purchase 100mg extra super cialis fast delivery. Sedation is difficult since excessive drowsiness increases the risk of inhalation 100mg extra super cialis overnight delivery. Some endoscopists therefore never use any sedation, but this often leads to a difficult examination. But endoscopy should better be performed under sedation with intravenous diazepam, which should be administered slowly in anaemic and shocked patients and dose should better not to exceed 5 mg. If necessary, the gastroscope can be withdrawn into the oesophagus (to stop the tip becoming obscured by blood) and the patient is rolled on to his right side so that the blood clot moves to the antrum, the fundus can then be seen. If no bleeding point can be found out with a forward-viewing endoscope, the second and third parts of the duodenum and ampulla should be examined using a side-viewing instrument if necessary Contraindications to endoscopy. Endoscopy is a good vagal stimulus and can precipitate heart block in these patients. So ideally endoscopy should be performed on all patients between 12 to 48 hours after admission. It should always be performed by experienced endoscopist in the endoscopy room preferably in the operation theatre. Occasionally indirect pointers to the source of bleeding may be revealed, for example an enlarged spleen in portal hypertension, a soft tissue mass in an intussusception, a gastric carcinoma calcification or metastasis on the chest radiography. The source of active bleeding may remain undetected by barium studies in 50% of patients or even more. Nevertheless, if endoscopy has proved impossible barium studies are worth attempting. The accuracy of a barium meal in detecting lesions such as erosions, small ulcers or early tumour is greatly increased by the use of the double-contrast technique. This is performed in a fasting patient by the use of hypotonic agents such as buscopan or glucagon. The stomach is distended with gas and adequate quoting of the mucosa with barium can reveal such lesions. The site of bleeding is revealed by extravasated contrast medium remaining in the bowel in the late films of angiographic series. It must be remembered that selective study of coeliac axis and superior mesenteric artery should be performed rather than midstream aortography. When a bleeding point has been found haemorrhage can be controlled by the selective infusion of vasopressin or by deliberate injection of embolic material such as sterile absorbable gelatin sponge (Sterispon), lyophilized human duramater (Lyodura), steel coils, acrylic polymers or detachable balloons. In case of portal hypertension with bleeding varices, various radiological techniques may be used to assess the liver disease and to demonstrate the anatomy of the portal venous system prior to any surgery. But in most centres it has not proved to be particularly useful in clinical practice. The other isotope technique that may be useful in the demonstration ofheterotopic gastric mucosa in a Meckel ’ s diverticulum by the intravenous inj ection of "“T c pertechnetate, which is excreted by the cells of the gastric mucosa. The superior surface of the liver is in direct relation with the undersurface of the diaphragm. In the adult the normal liver extends in the midclavicular line from approximately the right 5th intercostal space down to slightly below the costal margin. The inferior surface of the liver is in contact with duodenum, the right kidney, the right adrenal gland, the right colic flexure, the oesophagus and the stomach. The gallbladder lies on the under surface of the liver and its fundus lies on the transpyloric plane. The entire liver is invested by peritoneum except (i) the ‘bare’ area on the posterior surface adjacent to the inferiorvenacavaand(ii) the gallbladder fossa where peritoneum reflects from the liver to cover the superficial surface of the gallbladder. Reflections of the peritoneum from the liver are important, (a) The falciform ligament which extends from the anterior surface of the liver to the anterior abdominal wall from the diaphragm to the umbilicus. At the inferior border of the falciform ligament lies the ligamentous teres hapatis, which is the obliterated umbilical vein and the small periumbilical veins, (b) The coronary ligament is formed by reflection of the peritoneum from the diaphragm to the superior and posterior surfaces of the right lobe. It consists of an upper and a lower layers which are continuous at the right extremity with the right triangular ligament and enclose a triangular area of the liver which is not covered with peritoneum and is termed the ‘ bare area ’ of the liver, (c) The right triangular ligament is formed by approximation of the upper and lower layers of the coronary ligament. This connects the lateral part of the posterior aspect of the right lobe of the liver to the diaphragm, (d) The left triangular ligament passes from the upper surface of the left lobe to the undersurface of the diaphragm. It consists of two closely applied layers of peritoneum, whose anterior layer is continuous with the left layer of falciform ligament. On the left the ligament ends in the free margin, (e) The lesser omentum is the two folds of peritoneum extends from the lesser curvature of the stomach to the fissure for ligamentum venosum of the liver. Its anterior layer becomes continuous with the posterior layer of the left triangular ligament and its posterior layer is continuous with the line of reflection of peritoneum from the upper end of the right border of the caudate lobe (indirectly with the lower layer of the coronary ligament). This falciform ligament anatomically divides the liver into the right and left lobes. The lesser omentum comes down in front of the porta hepatis to be attached to the lesser curvature of the stomach. The right border of the lesser omentum forms the anterior boundary of the epiploic foramen of Winslow. The foramen is bounded above by caudate process, in front by the right free margin of the lesser omentum which contains bile duct on the right side, common hepatic artery on the leftside and portal vein posterior to these two structure. This foramen is bounded posteriorly by the inferior vena cava and inferiorly by the hepatic artery proper. By putting the index finger into the foramen of Winslow and thumb in front of the bile duct one can feel the supraduodenal part of the bile duct to know its thickness and presence of stone inside it. Through this foramen of Winslow the lesser sac com­ municates with the greater sac of the peritoneum. The line of demarcation between the right and left lobes Is represented as a bold line shown by arrow. This lineinto a medial segment which lies to the right of the stretches from Inferior vena cava to the gallbladder fossa. The caudate lobe is the posterior projection of the liver bounded on the left by the fissure of the posterior extension of the falciform ligament and the ligamentum venosum and on the right by the groove for the inferior vena cava. This lobe is also in the medial segment of the left lobe but is in the anatomical right lobe. So there are altogether eight segmental lobes of the liver, four in the right and four in the left lobe. Knowledge of the exact anatomy of the segments of the liver help in the segmental resection of the liver in case of neoplastic lesions. It is formed by the junction of the superior mesenteric and splenic veins behind the neck of the pancreas. Then it passes upwards posterior to the first part of the duodenum and passes through the right free margin of the lesser omentum slightly posterior to the common bile duct and the hepatic artery. In only 10% of cases it divides into two right branches going to the right lobe and one to the left lobe. There are certain areas where there is natural communication between the portal and systemic venous systems. These are : (1) The left gastric vein and short gastric veins, tributaries of portal vein send oesophageal tributaries and these communicate with the oesophageal venous plexus, tributaries of superior vena cava at the lower end of the oesophagus. This is the most important portal-systemic anastomosis and duri ng portal hypertension nature tries to divert blood through this anastomosis into the systemic circulation. The result is that the communicating veins become dilated and tortuous and is called oesophageal varix. This varix may rupture and bleed profusely to cause haematemesis in a patient with portal hypertension. These veins when dilated during portal hypertension will result in the formation of caput medusae. But it must be remembered that internal haemorrhoid which is dilatation of the superior haemorrhoidal veins is hardly caused by portal hypertension. This artery first forms the floor of epiploic foramen and then moves up through the right free border of the lesser omentum and ends into the right and left branches at the porta hepatis. The cystic artery usually arises (i) from the right hepatic artery, although there is some variability. The most common of which is origination of the cystic artery (ii) from the gastroduodenal artery, the next common is its origination (iii) from the left or common hepatic artery. Within the liver the right and left branches subsequently divide into smaller branches corresponding to the portal venous system and segmental anatomy. Due to abundant collaterals ligation of the hepatic artery proximal to the gastroduodenal artery can be performed without damage to the liver.

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