This document provides information on infantile hypertrophic pyloric stenosis (IHPS). It summarizes that IHPS is a condition characterized by hypertrophy of the pyloric muscle which causes gastric outlet obstruction. It most commonly affects young infants, especially males. Surgical pyloromyotomy is the treatment of choice and has excellent outcomes when performed after resuscitation from dehydration caused by projectile vomiting from gastric outlet obstruction.
ANESTHETIC MANAGEMENT OF TRACHEOESOPHAGEAL FISTULA by Dr.Sravani VishnubhatlaDrSravaniVishnubhatl
Learning Objectives:
Review the clinical presentation of a patient with tracheoesophageal fistula (TEF)
Understand the prevalence of TEF, types, and associated syndrome
Discuss the diagnosis of TEF
Describe the medical and surgical management of TEF
Understand the anesthetic-related implications and develop an anesthetic plan
ANESTHETIC MANAGEMENT OF TRACHEOESOPHAGEAL FISTULA by Dr.Sravani VishnubhatlaDrSravaniVishnubhatl
Learning Objectives:
Review the clinical presentation of a patient with tracheoesophageal fistula (TEF)
Understand the prevalence of TEF, types, and associated syndrome
Discuss the diagnosis of TEF
Describe the medical and surgical management of TEF
Understand the anesthetic-related implications and develop an anesthetic plan
---------- Forwarded message ----------
From: UCD Graduate '09 None <ucdgrad09@gmail.com>
Date: 2009/2/12
Subject: Bambury tutorial Upper GI Surgery
To: ucdgrad09@gmail.com
She does not know that we have this so please don't print it and bring it to
the lecture
IHPS is a common problem in infancy presenting with vomiting after feeds. Undiagnosed cases present with profound dehydration.Initial intravenous fluids to correct fluid electrolyte imbalance,is followed by investigations and surgical correction of gastric outlet operation by a simple pyloromyotomy.
Seminar presentation by 5th year Medical Student under the supervision of a pediatric surgery specialist from HRPZ II. Reference as mentioned in the slide.
Different esophageal disorders are discussed in this lecture. The learning objectives are to understand:
The anatomy and physiology of the oesophagus and their relationship to disease.
The clinical features, investigations, and treatment of benign and malignant disease with particular reference to the common adult disorders.
Topics include: Surgical anatomy, Physiology, Symptoms, Investigations, Congenital lesions: TOF and Atresia, Benign tumours, Cancer of oesophagus, Foreign bodies,Oesophageal perforation, Gastro-oesophageal reflux diease, Hiatal hernia,
Oesophageal motility disorders: achalasia and diffuse spasm, Oesophgeal diverticula.
and Others.
The neonatal bowel obstruction is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.The presentations of NBO may vary. It may be subtle and easily overlooked on physical examination or can involve massive abdominal distension, respiratory distress and cardiovascular collapse.Unlike older children, neonates with unrecognized intestinal obstruction deteriorate rapidly.
Neonatal bowel obstruction is grouped into two general categories: high, or proximal, obstruction and low, or distal obstruction, both of which are suspected by failure to pass meconium at birth. High obstruction can be suspected based on the double bubble sign. Cases without distal gas are usually related to duodenal atresia, while high obstruction with distal gas need an upper gastrointestinal series because of the need to distinguish duodenal web, duodenal stenosis and annular pancreas from midgut volvulus, the latter being a surgical emergency. Confirmation is ultimately by surgical intervention.
Jejunal and ileal atresia are caused by in utero vascular insults, leading to poor recanalization of distal small bowel segments, a condition in which surgical resection and reanastamosis are mandatory. Hirschsprung disease is due to an arrest in neural cell ganglia, leading to absent innervation of a segment distal bowel, and appears as a massively dilated segment of distal bowel on contrast enema. Surgical resection is necessary for this condition as well. Imperforate anus also requires surgical management, with the diagnosis made by inability to pass the rectal tube through the anal sphincter.[6] Supportive intravenous hydration, gastric decompression, and ventilatory support may be needed due to poor neonatal nutrition resulting from dysfunctional bowel absorption.
A low obstruction is suspected on plain film, but needs follow up with a gastrografin enema, which itself can be therapeutic. The differential for low obstruction is ileal atresia, meconium ileus, meconium plug syndrome and Hirschsprung disease. In cases of meconium ileus or ileal atresia, the colon distal to the obstruction is hypoplastic, usually less than 1 cm in caliber, as development of normal colonic caliber in utero is due to the passage of meconium, which does not occur in either of these conditions. When diffusely small caliber is seen, it is referred to as microcolon. Radiographs in meconium ileus classically demonstrate a bubbly appearance in the right lower quadrant due to a combination of ingested air and meconium. If, on contrast enema, reflux into the dilated distal small bowel loops can be achieved, the study is both diagnostic and therapeutic, as the ionic contrast medium can dissolve the meconium to allow passage of enteric content into the unused colon.
If contrast cannot be refluxed into the distal small bowel, ileal atresia remains a diagnostic possibility.
With early intervention, morbidity and mortality.
---------- Forwarded message ----------
From: UCD Graduate '09 None <ucdgrad09@gmail.com>
Date: 2009/2/12
Subject: Bambury tutorial Upper GI Surgery
To: ucdgrad09@gmail.com
She does not know that we have this so please don't print it and bring it to
the lecture
IHPS is a common problem in infancy presenting with vomiting after feeds. Undiagnosed cases present with profound dehydration.Initial intravenous fluids to correct fluid electrolyte imbalance,is followed by investigations and surgical correction of gastric outlet operation by a simple pyloromyotomy.
Seminar presentation by 5th year Medical Student under the supervision of a pediatric surgery specialist from HRPZ II. Reference as mentioned in the slide.
Different esophageal disorders are discussed in this lecture. The learning objectives are to understand:
The anatomy and physiology of the oesophagus and their relationship to disease.
The clinical features, investigations, and treatment of benign and malignant disease with particular reference to the common adult disorders.
Topics include: Surgical anatomy, Physiology, Symptoms, Investigations, Congenital lesions: TOF and Atresia, Benign tumours, Cancer of oesophagus, Foreign bodies,Oesophageal perforation, Gastro-oesophageal reflux diease, Hiatal hernia,
Oesophageal motility disorders: achalasia and diffuse spasm, Oesophgeal diverticula.
and Others.
The neonatal bowel obstruction is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.The presentations of NBO may vary. It may be subtle and easily overlooked on physical examination or can involve massive abdominal distension, respiratory distress and cardiovascular collapse.Unlike older children, neonates with unrecognized intestinal obstruction deteriorate rapidly.
Neonatal bowel obstruction is grouped into two general categories: high, or proximal, obstruction and low, or distal obstruction, both of which are suspected by failure to pass meconium at birth. High obstruction can be suspected based on the double bubble sign. Cases without distal gas are usually related to duodenal atresia, while high obstruction with distal gas need an upper gastrointestinal series because of the need to distinguish duodenal web, duodenal stenosis and annular pancreas from midgut volvulus, the latter being a surgical emergency. Confirmation is ultimately by surgical intervention.
Jejunal and ileal atresia are caused by in utero vascular insults, leading to poor recanalization of distal small bowel segments, a condition in which surgical resection and reanastamosis are mandatory. Hirschsprung disease is due to an arrest in neural cell ganglia, leading to absent innervation of a segment distal bowel, and appears as a massively dilated segment of distal bowel on contrast enema. Surgical resection is necessary for this condition as well. Imperforate anus also requires surgical management, with the diagnosis made by inability to pass the rectal tube through the anal sphincter.[6] Supportive intravenous hydration, gastric decompression, and ventilatory support may be needed due to poor neonatal nutrition resulting from dysfunctional bowel absorption.
A low obstruction is suspected on plain film, but needs follow up with a gastrografin enema, which itself can be therapeutic. The differential for low obstruction is ileal atresia, meconium ileus, meconium plug syndrome and Hirschsprung disease. In cases of meconium ileus or ileal atresia, the colon distal to the obstruction is hypoplastic, usually less than 1 cm in caliber, as development of normal colonic caliber in utero is due to the passage of meconium, which does not occur in either of these conditions. When diffusely small caliber is seen, it is referred to as microcolon. Radiographs in meconium ileus classically demonstrate a bubbly appearance in the right lower quadrant due to a combination of ingested air and meconium. If, on contrast enema, reflux into the dilated distal small bowel loops can be achieved, the study is both diagnostic and therapeutic, as the ionic contrast medium can dissolve the meconium to allow passage of enteric content into the unused colon.
If contrast cannot be refluxed into the distal small bowel, ileal atresia remains a diagnostic possibility.
With early intervention, morbidity and mortality.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
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Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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2. INTRODUCTION
⚫A condition characterised
by hypertrophy of the two
circular muscle layers of
the pylorus.
⚫Resulting in constriction
and obstruction of gastric
outlet.
⚫Described by
Hirschprung in 1888
3. EPIDEMIOLOGY AND ETIOLOGY
INCIDENCE - 1.5 to 4 per 1000 live births
EPIDEMIOLOGY - Male : female ratio = 4:1
Increased risk in first born boys
ETIOLOGY
IDIOPATHIC
GENETIC-11q14-22 and Xq23
Rarely autosomal dominant
FAMILIAL
ETHNIC ORIGIN (more in whites): more commonly seen in
Caucasians
ENVIRONMENTAL
Erythromycin or azithromycin exposure
Transpyloric feeding of premature babies
4. ETIOLOGY (contd.)
EMERGING NEW THEORIES
GI hormones like gastrin, substance P (could produce chronic
pylorospasm and stenosis) , Epidermal growth factor, deficiency
of NO (can induce muscle spasm preventing smooth muscle
relaxation in stomach).
Muscle layer deficient in
quantity of nerve terminals
markers for nerve supporting cells
peptide containing nerve fibres
This abnormal innervation of muscular layer
leads to failure of relaxation of pyloric muscle,
increased synthesis of growth factors
7. PATHOPHYSIOLOGY contd
Vomiting
•Loss of water -----> DEHYDRATION
• Loss of gastric acid from stomach
(HYPOCHLORAEMIA) -----> Impairment
of kidney’s ability to excrete bicarbonate
ion ----> prevents correction of alkalosis
HYPOVOLAEMIA Secondary
Hyperaldosteronism
Acts on kidneys
8. PATHOPHYSIOLOGY contd
• Retains Na+ to correct intravascular volume depletion
•Excretes increased amount of K+ in urine
---->HYPOKALAEMIA ----> hypomagnesemia and hypocalcemia
•Excretion of H+ leading to aciduria
Body’s compensatory response to metabolic alkalosis is
HYPOVENTILATION ---> increased arterial pCO2
(SECONDARY RESPIRATORY ACIDOSIS)
Initial alkalotic urine becomes acidic - PARADOXICAL
ACIDURIA
9. CLINICAL PRESENTATION
ONSET at 2 to 8 weeks of age
(commonly at around one
month of age)
SYMPTOMS
Projectile ,forcible,
frequent episodes of non-
bilious coffee ground
vomiting 30 to 60
minutes after feeding.
Weight loss
Persistent hunger
Lethargy
Constipation or
hunger diarrhoea
10. CLINICAL PRESENTATION(contd)
SIGNS
Palpable,olive shaped,
mobile, smooth, firm
mass (1.5 to 2 cm) with
all borders well made
out, moves with
respiration, with
impaired resonance on
percussion to right of
epigastric area.(95%
cases)
11. CLINICAL PRESENTATION(contd)
SIGNS (contd.)
Visible gastric peristalsis from left upper
quadrant to epigastrium (golf ball waves)
Signs of dehydration
Jaundice (2%) (due to decreased hepatic
glucuronosyl transferase associated with
starvation)
12. DIAGNOSIS
⚫ ABDOMEN X RAY (erect
posture)
upper abdominal gas bubble in
the stomach.
⚫ ABDOMINAL
ULTRASONOGRAPHY
(Gold standard at present)
Doughnut sign or cervical
pyloric sign
pyloric muscle thickeness >4
mm
pyloric length >16mm
in presence of functional
gastric outlet obstruction
13. DIAGNOSIS (contd.)
⚫ BARIUM MEAL/ Fluoroscopy
Peristaltic waves (caterpillar sign)
Delayed gastric emptying
Elongated and narrow pyloric canal-
String sign / Railroad track sign
The pylorus indents the contrast-filled antrum
(shoulder sign) or base of the duodenal bulb
(mushroom sign)
14. The barium may
outline crowded
mucosal folds as
parallel lines - DOUBLE
TRACT SIGN
Bulge in the distal
antrum with streak of
barium pointing towards
pyloric canal- BEAK SIGN
Double tract sign Beak sign
15.
16. DIAGNOSIS ( contd.)
BIOCHEMICAL CHANGES
Dehydration
Malnutrition
Hypochloraemic hypokalaemic metabolic alkalosis
Paradoxical aciduria
Hyperbilirubinemia
ARTERIAL BLOOD GAS ANALYSIS
Low serum levels of potassium and chloride
Increased blood pH and high blood bicarbonate level
17. MANAGEMENT
⚫Medical but not a surgical emergency
⚫RESUSCITATION
⚫MEDICAL TREATMENT –
Atropine methyl nitrate orally is tried to relax the
pylorus muscle.
18. PRE OPERATIVE PREPARATION
⚫Resuscitation with IV rehydration.
⚫Correct hypovolaemia with 10 ml/kg 0.9 % saline.
⚫Correct hypochloraemic alkalosis and
hypokalaemia (over 24-48 hrs): 0.45% NaCl in 5%
dextrose with added KCl at a rate of 120-150
mL/kg/24hr.
⚫Nasogastric tube drainage to prevent aspiration of
vomited secretions.
19. Surgery should take place
when:
⚫Dehydration corrected
⚫Normal serum Na and K
⚫Chloride ion >90mmol/l
⚫Bicarbonate ion < 28
mmol/l
21. PYLOROMYOTOMY
FREDET-RAMSTEDT’s
PYLOROMYOTOMY
Division of pyloric muscle fibres
without opening of bowel lumen.
Done via right upper quadrant
incision or laparoscopically.
Caution not to open mucosa and
avoid the prepyloric vein of Mayo.
22. LAPARASCOPIC
PYLOROMYOTOMY
⚫ Effective alternative
⚫ Time to achieve full enteral feeding is significantly
shorter ( 18.5hrs) in those treated laparoscopically
vs those having open pyloromyotomy(23.9 hrs)
⚫ Better cosmesis
23. A, Laparoscopic
pyloromyotomy is
started using a
retractable blade.
B, A spreader with
grooves on the outer
surface is used to
complete the
pyloromyotomy. Intact
mucosal bulging along
with independent
muscular wall motion is
confirmed.
25. ⚫The double-Y pyloromyotomy (Alayet's pyloromyotomy)
seems to be a good technique for the surgical
management of IHPS.
⚫It offered a better functional outcome in terms of
postoperative vomiting during the first postoperative
week and weight gain during the first 10 days in our
initial series while having a safety profile similar to
Ramstedt's pyloromyotomy.
26. POST OPERATIVE CARE
⚫Patient started on feedings of glucose and water or an
electrolyte infant formula ( eg - pedialyte) 4-6 hrs after
surgery.
Gradual increase in oral fluids till feeds are accepted
without emesis. Full feedings reached after 24 hrs from
surgery.
⚫Antibiotic prophylaxis not required.
⚫Postoperative monitoring for 12 hrs required in patients
with
Hypoglycemia
Hypothermia
Respiratory depression and apnoea(due to CSF alkalosis and
intraoperative hyperventilation)
27. COMPLICATIONS
Duodenal perforation – may go undetected especially in
laparoscopic RAMSTEDT’s.
Continued postoperative bleeding
Persistent vomiting (due to incomplete pyloromyotomy )
dehydration, weight loss and severe electrolyte imbalance .
If persists >1 week, redo surgery.
Foveolarcell hyperplasia (FCH), a rare cause of persistent
gastric outlet obstruction.(This requires an extended
pyloromyotomy) .
28. PROGNOSIS
⚫Excellent unless diagnosis is delayed and
prolonged severe dehydration occurs.
⚫Once adequately treated, pyloric stenosis does
not recur.
⚫Mortality is rare after pyloromyotomy.