Anal fissure and haemorrhoids are common painful conditions caused by constipation or hard stools. Anal fissures are tears in the lining of the anal canal that cause sharp pain during bowel movements. Haemorrhoids are swollen veins in the anal canal that can cause bleeding. Treatment depends on severity but includes dietary changes, topical ointments, injection therapy, surgery. Sphincterotomy or fissurectomy may be needed for chronic anal fissures that do not heal with conservative treatment.
Gallstones:
Most common biliary pathology
Asymptomatic in majority of cases (>80%)
Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
ACUTE CHOLECYSTITIS- RUQ ABDOMINAL PAIN
#surgicaleducator #ruqabdominalpain #acutecholecystitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Cholecystitis
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for RUQ pain, etiology, pathology, clinical features, investigations, complications and treatment of Acute Cholecystitis.
• I have also included a mind map, a diagnostic and a treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Gallstones:
Most common biliary pathology
Asymptomatic in majority of cases (>80%)
Approx. 1–2% of asymptomatic patients develop symptoms requiring cholecystectomy per year.
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
ACUTE CHOLECYSTITIS- RUQ ABDOMINAL PAIN
#surgicaleducator #ruqabdominalpain #acutecholecystitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Cholecystitis
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for RUQ pain, etiology, pathology, clinical features, investigations, complications and treatment of Acute Cholecystitis.
• I have also included a mind map, a diagnostic and a treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
PROCTOLOGY AND USE OF LASER SURGERY.
CLINICAL EXAMINATION
RELEVANCE OF PR AND PROCTOSCOPY
HAEMORRHOIDS
FISTULA ANO
PILONIDAL SINUS
FISSURE
ROLE OF LASER SURGERY
PER RECTAL EXAMINATION
PROCTOSCOPY
A brief presentation on inguinal hernia covering the all aspects regarding anatomy, presentation, treatment and complications, esp for undergraduate and post graduate students.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
3. Definition
– Superficial linear tear in the anoderm (distal to the dentate line )
– Very common and painful condition
– Site
posterior midline ( 90% )
Anterior midline (10%)
4. Aetiology
– Constipation
– Spasm of internal sphincter
– Secondary causes
Ulcerative colitis
Crohn’s disease
Syphilis
Tuberculosis
• Previous anal surgery
• Anal cancer
Predisposing factors
Hard faeces
Ischemia
Haemorrhoidectomy
Sphincter hypertonia
Repeated child birth
Abuse of laxatives
5. Posterior midline is most
common site because….
– Posterior angulation of the anal canal
– Relative fixation of the anal canal
– Divergence of the fibres of external sphincter muscle posteriorly
– Elliptical shape of the anal canal
6. Pathology
– Strained evacuation of hard stool trauma ( most common )
– Repeated passage of stools – diarrhoea ( less common)
– Anterior anal fissure – most commonly in females occurs following vaginal
delivery .
Fissure starts proximally at the dentate line , lies in the sensitive skin of the anal
canal – produces pain
7. Two types
Acute
tear of skin of the lower half of the anal canal.
Hardly any inflammatory induration or oedema
Anal sphincter spasm is present
Chronic
Deep – shaped ulcer with thick oedematous margins .
Upper end – hypertrophied papilla
Lower end – skin tag called ‘sentinel pile’ is present
Characteristic inflammation and induration is present
Base – scar tissue and internal sphincter muscle .
They have specific cause
e.g. – crohn’s disease , ulcerative colitis , TB , syphilis
8. Clinical features
– More common in females
– Age – 30 – 50 years
– In Children sometimes cause acquired megacolon
• Symptoms
Pain starting with and following defection , characterised by sharp ,biting ,
burning
Bleeding – its variable , usually occurs as a streaks on the outside of the stool or
spots noted on toilet tissue.
Slight discharge may present
Pruritis ani
9. Physical examination
Patient in left lateral decubitus position with knees drawn up toward the chest
• Acute fissure – appear similar to laceration , erythematous and bleed easily
• Chronic fissure
Deep ulcer
Sentinel pile
Enlarged anal papillae at dentate line
Characteristic crater of the vertical fissure is felt
• A tightly closed puckered anus – pathognomonic .
11. Differential diagnosis
1. Carcinoma of the anus ( early stage)
2. Tuberculous ulcer
3. Proctalgia fugax – characterised by severe pain arising from the rectum and
occurs at irregular intervals .
13. Conservative management
Helpful in most of the cases
Main objective to treat constipation
High fibre diet
Laxatives to make the stool soft
Encourage water intake
Application of local anaesthetic – lignocaine jelly
Glyceryl trinitrate ointment
Local application
It’s a nitric oxide donor produces internal sphincter muscle relaxation
14. Antibiotics
Botulinum toxin injection
Site – internal sphincter
MOA : inhibits presynaptic release of Ach from cholinergic nerve endings – paresis of
striated muscle and release the spasm
Hot sitz bath
15. Surgical management
1. ANAL DILATATION - “LORD’S PROCEDURE”
Simplest method of anal dilatation
Under GA , patient in lithotomy position , the index and middle
fingers of each hand are inserted simultaneously into the anus
and pulled apart to give maximal dilatation .
Patient might have faecal incontinence for 10 days
In case of chronic fissure – anal dilatation could be a failure
because of excessive fibrosis and skin tag.
16. POSTERIOR SPHINCTEROTOMY AND FISSURECTOMY
Anaesthesia – general anaesthesia
Position – lithotomy
Sim’s speculum introduced internal sphincter ( transverse direction ) are divided and floor is
made smooth deep ulcer with fibrotic edges and sentinel pile is
post operatively – liquid diet for 3 days , passage of anal dilator daily till wound is healed .
Disadvantage - prolonged convalescent period for 7- 10 days.
17. LATERAL ANAL SPHINCTEROTOMY
Anaesthesia –regional or General
Position – lithotomy
Steps
i. Palpate the distal internal sphincter with the help of bivalve
speculum at the inter sphincteric groove
ii. A small longitudinal incision in right or left lateral position
iii. Mucosa is cut
iv. Palpating the submucosa and inter sphincteric planes
v. Internal sphincter is exposed
vi. Internal sphincter is cut up to he apex of the fissure
vii. Wound is left open or closed with absorbable sutures.
19. ANAL ADVANCEMENT FLAP
Useful in females and those with normal or low resting anal pressure
Edge of the fissure are excised and mobilized as full thickness anal skin flap .
These flaps are slid over the fissure and sutured in place
Minimal chance of incontinence
21. Definition
– Dilated veins within the anal canal in the subepithelial region formed by radicles
of the superior middle and inferior rectal veins.
– Classified according to their anatomic growth within the anal canal
Internal haemorrhoid
External haemorrhoid
22. Act of straining during defecation
Impedes rapid emptying of cushions
Congestion
Oedema
Swelling and stretching of tissues
Hypertrophy
23. Aetiology
Hereditary
Anatomical
Absence of valves in superior haemorrhoidal veins
Veins pass through the rectal musculature 10 cm above the anus will cause
occlusion of veins and congestion during defecation
Radicles of superior rectal lie unsupported in loose submucous connective
tissue of rectum
24. Physiological cause
Hyperplasia of corpus cavernosum rectum result from failure of mechanism
controlling the arteriovenous shunt producing superior haemorrhoidal veins
varicosity and haemorrhoids.
Diet
Secondary haemorrhoids
Carcinoma of rectum
Pregnancy
Chronic constipation
Difficulty in micturition
Portal hypertension
25. Internal haemorrhoid
• Haemorrhoid is within the anal canal and
internal to the anal orifice
• Covered with mucous membrane
• Bright red or purple in colour
• Usually commences at the anorectal ring and
end at the dentate line
26. External haemorrhoid
• Haemorrhoid situated outside the anal orifice and is covered by skin
• Internal and external haemorrhoid coexist – “interno-external haemorrhoid”
• Two peculiar condition associated with external haemorrhoid
Dilatation of veins at the anal verge seen in persons of sedentary life particularly
during straining
Perianal haematoma or thrombosed external haemorrhoids
27. Thrombosed external haemorrhoid
• Small clot in the perianal subcutaneous tissue seen
superficial to the corrugator cutis ani muscle.
• It is due to back pressure on the anal venule consequent
upon straining at stool , coughing or lifting heavy
weight .
• Appears suddenly and its painful
28. • Present lateral to the anal margin
• Tense and tender swelling
• If untreated – suppurate or may fibroses giving rise to cutaneous tag or may
burst giving rise to bleeding .
TREATMENT
Incise the haemorrhoid under LA
Opening in the skin is packed with gauze in light antiseptic solution to
allow the wound to heal by granulation tissue
29. Clinical features
Bleeding - bright red , painless and occurs along with defection .
Vascular haemorrhoid – veins become larger and heavier , partial prolapse
occur with each bowel movement gradually stretching the mucosal
suspensory ligament at the dentate line until the 3rd degree haemorrhoid
results .
Mucosal haemorrhoid – thickened mucous membrane slides downwards .
30. Prolapse
First degree – haemorrhoid does not come out of the anus
Second degree – haemorrhoid come out only during defaecation , reduced spontaneously after defaecation
Third degree – haemorrhoid come out only during defaecation and do not return by themselves . Need to be
replaced manually and then they stay reduced
Fourth degree – haemorrhoids that are permanently prolapse . Patient will have great discomfort with a
feeling of heaviness .
31. Pain
Mucous discharge
particular symptom of haemorrhoid
It softens and excoriates the skin of the anus
mucous discharge is due to engorged mucous membrane
Pruritis ani will be caused
Anaemia – due to long standing haemorrhoids due to persistent
and profuse bleeding
32. On inspection
Internal haemorrhoid with out prolapse does not show any
abnormal feature
Second degree and third degree internal haemorrhoid – seen only
when patient strains , prolapse disappears after the straining is
over .
Fourth degree – prolapse piles seen in 3 , 7 , and 11’0 clock
position
33. On examination
DIGITAL EXAMINATION
• Cannot feel an uncomplicated internal piles unless it is thrombosed
PROCTOSCOPY
• Proctoscope introduced as far as it does .
• Obturator is then removed and with an illuminator the inside of the canal is
visualized .
• Proctoscope is now withdrawn slowly
• Internal haemorrhoid seen bulging into the proctoscope
38. Medical management
1. Bowel regulation
High residue diet
Mild laxatives
2. Topical ointments
Reduces oedema and pruritis
Treatment of haemorrhoid depends in its degree .
Manual dilatation of the anus frequently successful in relieving
symptoms by preventing congestion of haemorrhoidal veins .
39. Injection therapy
Sclerotherapy
• Principle – it scars submucosa and fixation of haemeorrhhoidal
complex in normal location
• Sclerosant
Albright solution – 5 % phenol in almond or archis oil with 140
mg of menthol to make 30 ml solution .
Sodium morrhuate
Sodium tetradryl sulphate
40. ADVANTAGE
Method is quick
Relatively painless
Comparatively free from complications
First degree haemorrhoidal results
DISADVANTAGE
• Asscoiated thrombosis or sepsis
• Active inflammatory bowel disease
• Acute leukaemia
COMPLICATION
• Chemical prostatitis and impotence rare
• Anovaginal fistula
41. Rubber band ligation
Done for 2nd degree haemorrhoids .
“BARRON’S “ bander is commonly available
Causes ischemic necrosis and piles fall off , which slough off with
in 10 days Asscoiated with bleeding
Bands should be placed for pile mass to take care of breakage
Three haemorrhoidal mass can be taken care in one session
Repeat banding can be done only after 3 weeks
42. Equipment is inexpensive , simple to perfom
Can be done without anesthesia
Contraindicated – fissure / fistula
Complications :
If applied low into skin – severe pain
Discomfort
Secondary haemorrhage
Ulceration
43. Cryosurgery
Extreme cold temperature used to coagulate and cause necrosis of piles which
gets separated and falls of subsequently
Used agent – nitrous oxide (-98 degree) or liquid nitrogen ( -196 degree)
Procedure
Pt in lithotomy position
Cryoprobe applied in longitudinal axis of internal pile above the dentate line
Pressure maintained above 700 lb continuously
44. Traction and slight rotation in both directions to draw entire
pile mass
Entire tissur is frozen for 20 -30 secs .
Probe detached from mass
Procedure repeated on other pile mass
Advantage
Painless
Simple
Safe
Less bleeding
Disadvantage
Profuse watery discharge
Itching .
Incontinence occasionally
45. Infrared coagulation
Includes by tungsten halogen lamp which is focused on the tissue from a gold plated
reflector through a polymer tubing
Discrete area of necrosis which heals to form a scar , reduces or eliminate blood flow
through haemorrhoid
3 or 4 sittings are needed at 1 month intervals .
46. Laser therapy
– For 3 degree piles
– Agent used – Nd – YAG laser , diode and carbon
dioxide laser
– Advantage
Less operative time
Less intraoperative and post op bleed
Rapid healing
Quick recovery
•Disadvantage
Need skill , sphincter to be
taken care of
Secondary haemorrhage
47. Doppler guided haemorrhoidal
artery ligation ( DGHL)
– Advanced instrument that works under doppler
guided ultrasound .
– Cures all degree of haemorrhoid
– Causes choking and blocking of blood supply of
piles
– Painless
– 20 –minute procedure that cures all degree of
haemorrhoids .
48. Haemorrhoidectomy
INDICATIONS
2nd degree haemorrhoids not cured by non-surgical management
Fibrosed haemorrhoids
Interno – external haemorrhoids
TECHNIQUE
– Open technique – Milligan-Morgan operation
– Closed technique
49. 1. Ligation and excision of piles ( Milligan –Morgan )
Procedure
Under anaesthesia , in lithotomy position
Sphincter dilated
Skin held with forceps
Internal sphincter separated and pushed up
Pedicle is transfixed with vicryl or catgut and distal
part is excised
Post operatively
Sitz bath
Antibiotics
Laxatives ‘analgesics
Local applications
50. 2. Submucous haemorrhoidectomy of ‘Parks’ (
submucous haemorrhoidectomy )
3 . Hill – Ferguson closed method
Procedure
Patient in prone position
Under GA/ caudal anaesthesia
Retraction is done using Hill – Ferguson
retractor
Incision made around pile mass , pedicle is
dissected to its proximal base
Ligated with trans-fixation using 2-0 vicryl or
silk
Mucosa and skin sutured
51. Management of strangulated or thrombosed or gangrenous pile
• Initially conservative management
• Warm water saline sitz bath
• Antibiotics
• Elevation
• Bed rest
• Saline compression dressing and analgesics
• Haemorrhoidectomy after 4 -5 days , once oedema reduces
52. Endo –Stapling haemorrhoidectomy
• Recently introduced
• Stapling gun is used
Procedure
• Stapling gun introduced through anus
• Strip of mucosa and submucosa just above the
dentate line is excised circumferentially
• Gun is activated which repairs the cut mucosa and
submucosa by stapling the edges together