Abdomen

1. 1
Abdomen
Professor Ravi Kant
MS FRCS (Edin) FRCS (Glasg) FAMS FACS
DNB FICS FAIS

2. 2
MCQ
• Short story = clinical vignette
• One line question
• 5 options= distractors
• One will be correct
• Blue print

3. 3
Blue print
• 10 basics = trauma
• 10 H&N
• 10 Breast
• 10 hernia, etc
• 10 jaundice, abdomen
• 10 abdomen
• 10 colo-rectal
• 10 Ped surgery
• 5 vascular
• 5 Thoracic
• 10 Plastic surgery

4. 4
Jaundice (J+)
• Surgical √
–Itching
–Clay colored stool
–Se Alkaline Phosphatase 
–Direct bilirubin 
–Total Bilirubin 

5. 5
J+
• If GB  = NOT a case of CBD STONE
•Courvoisier’s law
• = palpable

6. 6
J+
• GB  Soft
• A 45 y old male presents to OPD
with jaundice, clay colored stools,
itching. On examination, soft gall
bladder is palpable. Total and
direct bilirubin is raised.

7. 7
A 45 y old male presents to
OPD with jaundice, clay
colored stools, itching. On
examination, soft gall bladder
is palpable. Total and direct
bilirubin is raised.
• Which of the following is the likely
diagnosis?

8. 8
Distractors
1. CA gall bladder
2. CBD stone
3. Hilar cholangiocarcinoma
4. CA head of pancreas
5. Biliary agenesis

9. 9
J+
• GB  Soft= CA head of Pancreas
of CA Periampullary (D or B or P)

10. 10
J+
• GB  Hard

11. 11
J+
• GB  Hard = CA GB

12. 12
J+
• GB  Soft
= CA Head of
Pancreas
or
• CA
Periampullary
• GB  Hard
= CA GB

13. 13
J+
• GB Not palpable
• Pain present
• = ?

14. 14
J+
• GB Not palpable
• Pain present
• Young
• = CBD Stone
• Courvoisier’s law

15. 15
J+
• GB Not palpable
• No pain

16. 16
J+
• GB Not palpable
• No pain
=
• Hilar Cholangiocarcinoma (Klatskin’s
tumor)
• Intra-hepatic
• Congenital

17. 17
J+
• 2 months age
• GB Not palpable
• No pain
=
• Intra-hepatic
• = Biliary agenesis= Kasai operation

18. 18
J+
• GB not palpable
• Pain +
• CBD stone
• Inv MRCP
• Rx ERCP
• GB not palpable
• Pain –
• Hilar
Cholangiocarcinoma
• Inv MRCP
• Rx Excision + H-J
• (Hepatico-jejunostomy)

19. 19
Congenital Syndromes
• Dubin Johnson
• Gilbert
• Rotor
• Criggler Najjar

20. 20
J+
• Hard liver- smooth

21. 21
J+
• Hard liver- smooth
• = Primary Carcinoma of Liver
• Inv =AFP, CT scan, MRA
• FNAC is CONTRAINDICATED
• Rx = Surgery= Resection

22. 22
J+
• Liver Hard- nodular

23. 23
J+
• Liver Hard- nodular
• = Secondaries in Liver
• Inv = search for primary= P0
• FNAC Liver (if PT is N)

24. 24
J+
• Pain +
• Fever +

25. 25
J+
• Pain +
• Fever +
= Charcot’s triad
=Surgical emergency
= IV fluids, antibiotics
►Later, when stabilized,
Inv MRCP ; Rx ERCP

26. 26
Triad
• Hiatus hernia
• Cholelithiais
• Diverticulosis
• = Saint’s triad

27. 27
Liver ▲
• Hydatid
• Amoebic- pain & thump sign present
• Tumors- primary & Secondary

28. 28
RIF mass : DD
1. Appendicular
2. CA Caecum
3. Ileo-caecal TB
4. Crohn’s
5. Actinomycosis
6. Carcinoid
7. Amoeboma
8. LN mass

29. 29
RIF mass : DD
• Appendicular
• CA Caecum
• Ileo-caecal TB
• Crohn’s
• Actnomycosis
• Carcinoid
• Amoeboma
• LN mass
•
• Undescended testis
• Ectopic kidney
• In F= TO Mass
• Aneurysm of Iliac Art
• Bone tumour

30. 30
GB Stone : Types
• ? Examine Spleen in GB

31. 31
Appendix
• No mass= Appendicectomy

32. 32
Appendix
• Mass but normal temp= Conservative

33. 33
Appendix
• Mass but  temp= Abscess= Image
guided aspiration

34. 34
Colorectal Cancer
• Anal
• Rectal
• Rectosigmoid
• Premalignant
• Inv & Rx

35. 35
Colorectal Cancer
• Commonest symptom
• Inv

36. 36
LIF Mass DD
• Diverticulosis
• Rectosigmoid CA
• LN
• TO- mass--- CA 125

37. 37
Types, Inv & Rx of
• Hemorrhoids
• Fistula in Ano
• Fissure in Ano