In these slides we will go through the surgical anatomy of the gut,pathophysiology of intestinal obstruction, clinical presentation and management. Also we will discuss specific types of intestinal obstruction.
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
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
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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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
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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3. SMALL BOWEL
6ms length
Duodenum 25 cm
Jejunum :proximal 40%
Ileum:distal 60%
Blood supply: superior mesentric artery
Venous drainage: superior mesenteric vein
Nerve:sympT9-T11 parasymp:vagus
4.
5. LARGE BOWEL
1.5 meter
Blood Supply
♦ Iliocolic, right colic, and middle colic
arteries branches of superior mesenteric
artery supply the colon from caecum to
splenic flexure.
♦ Left colic, sigmoid, superior rectal arteries
branches of inferior mesenteric artery supply
the descending and sigmoid colon
6. CLACCIFICATIONS
Class 1:
Dynamic adynamic
Class 2:
Small bowel large bowel
Class 3:
Acute Chronic acute on chronic
Class 4:
Aquired congenital
11. PATHOPHYIOLOGY
Changes proximal to the bowel obstruction:
Intestinal obstruction
↓
Increased peristalsis
↓
Becomes vigorous
↓
Obstruction not relieved
↓
Peristalsis ceases.
↓
Flaccid, paralysed, dilated bowel
12. Fluid collects just proximal to the obstruction
which is derived from saliva, stomach, pancreas
and intestine
Defective absorption, decreased fluid intake,
loss of fluid by vomiting, sequestration of fluid
into the bowel lumen dehydration and
electrolyte disturbance
13. Increased bacterial colony in the bowel due
to altered luminal content and environment
→ multiplication →toxins → further mucosa
damage → translocation of bacteria across
mucosa into submucosa and also absorption
of bacterial into the circulation→bacteraemia
14. Changes at the site of the obstruction:
Initially venous return is impaired.
↓
Congestion, oedema of bowel wall occurs which turns
purple.
↓
Later this jeopardizes the arterial supply.
↓
Loss of shineness, blackish discolouration, loss of peristalsis.
↓
Gangrene.
↓
Perforation occurs.
↓
Bacteria and toxins migrate into the peritoneum.
↓
Peritonitis
15. Bowel distal to the obstruction is inactive
and collapsed
18. Proximal s.bowel Distal s.bowel Large bowel
Severe vomiting,
dehydration, no or
less distension,
colicky pain
Central distension,
vomiting,
dehydration
central abdominal pain
Constipation,
distension—
early;
Late vomiting less
pain
22. INVESTIGATIONS FOR DIAGNOSIS:
Erect +supine abdominal x ray:
Multiple air fluid level
Dilated loop:-
Small bowel > 3 cm diameter
proximal large bowel> 9 cm
transverse colon > 5.5 cm
sigmoid colon> 5 cm
Specific features
pneumobilia
CT scan
29. DUODENAL ATRESIA
- It is the commonest site of intestinal atresia
- It is usually a complete stenosis of the second
part
- Defective fusion of foregut and midgut with
failure of recanalization
-Duodenal atresia may be preampullary
(nonbilious vomiting) or postampullary (bilious
vomiting)
30.
31. Associated with:
Down syndrome 30%
CHD 30%
ARM 10%
Polyhydramnios and prematurity 50%
32. C/F
♦ Jaundice.
♦ Bilious/nonbilious vomiting immediately after
birth
♦ Dehydration. Electrolyte changes are
common.
♦ Growth retardation of newborn due to
deprived nutrition
33. INVESTIGATIONS
Plain X-ray shows classic double-bubble sign
with absence of air in the distal part
U/S will show distended stomach and
proximal duodenum( rail road track)
39. MALROTATION
Stages of normal rotation:
Stage 1: coelomic cavity cannot
accommodate midgut during this period
protrude into umblical cord as physiological
hernia
Stage 2: midgut migrate into coelomic
cavity;small bowel in left side;it rotate 270
anticlockwise into rt iliac
fossa;duodenojejunal segment rotate 270
anticlock to reach left of SMA and behind the
colon
40. Stage 3: fusion of different parts of mesentry
and posterior peritoneum
42. Dark blood per rectum
Erythrema of anterior abdominal wall
Teatment: ladd operation
43. MECONIUM ILEUS
Commonly associated with cystic disease of
pancreas but not necessarily always
Respiratory dysfunction
Exocrine pancreatic insufficiency
High salt in the sweat > 90 mmol/L
44. Complications of meconium ileus:
Intestinal bolus obstruction
Perforation and peritonitis
Gangrene, volvulus formation
45. INVESTIGATIONS
♦ Plain X-ray shows calcified meconium pellets with
multiple air fluid levels which appear as ‘soap-
bubbles’
♦ Vomitus of the patient which does not contain trypsin,
when poured on the exposed X-ray film will not digest
the gelatin of the film
♦ Pilocarpine is injected into skin to stimulate the
sweating and collected sweat (100 µg sweat)is
analysed for sodium and chloride.
♦ Elevated albumin level in meconium
47. INTUSSUSCEPTION (ISS)
It is invagination of one portion (segment) of
bowel into the adjacent segment.
Types
1. Antegrade: Most common.
2. Retrograde
48. ♦ It can be ileo-colic (most common type,
75%), colocolic, ileoiliocolic
♦ It is common in weaning period of a child
(common in male),between the period of 6-9
months
49. AETIOLOGY
Change in diet during weaning
Upper respiratory tract viral infection
Intestinal polyps
Submucous lipoma
Leiomyoma of intestine
Meckel’s diverticulum
Carcinoma
50. ♦ Apex is the one which advances;
♦ Intussuscipiens is the one which receives
♦ Intussusceptum
51.
52. FEATURES
on/off
screaming
Red currant jelly stool
Palpable mass (85%)
– Sausage shaped smooth, firm mass
– Mass does not move with respiration
– Mobile in all directions
– Resonant
– Mass contracts under the palpating fingers
– Mass appears and disappears
Empty right iliac fossa
56. Recurrence rate:
♦ In hydrostatic reduction—10%.
♦ In open manual reduction—2%.
♦ In resection—very less < 1%
57. VOLVULUS
Definition
It is the twist (rotation) in the axis of the loop
of the bowel either clockwise or anticlockwise
58. ♦ Sigmoid colon is the commonest site (anticlock wise)—
65%.
♦ Caecal volvulus
Caecum is the second common site(clockwise) 30%
Caecum will be markedly distended and found in the
centre of the abdomen
X-ray shows round gas shadow in right iliac region.
CT scan is very useful. Barium enema is also helpful.
Resection and anastomosis (surgery) is the only treatmen
59. SEGMOID VOLVULUS
It is common in patients with chronic
constipation with laxative abuse
Predisosing factors:
Adhesions
Peridiverticulitis
Overloaded redundant pelvic colon
Long pelvic mesocolon
Narrow attachment of sigmoid mesocolon
60. More than 180 : luminal obsrtuction
It requires one and half turn of rotation to
cause vascular obstruction
64. PARALYTIC ILEUS
It is a state in which intestines fail to transmit
peristalsis due to failure of neuromuscular
mechanism
65. C/F
♦ No passage of flatus.
♦ No bowel sounds.
♦ Marked abdominal distension.
♦ Vomiting of large volume of fluid.
♦ Tachycardia.
♦ Respiratory distress due to pressure over the
diaphragm.
♦ Dull abdominal pain (not colicky).
♦ Features of fluid/protein/electrolyte imbalance
66. TREATMENT
♦ Nasogastric aspiration.
♦ The primary cause is treated.
♦ IV fluids.
♦ Electrolyte management.
♦ Catheterisation and urine output
measurement
67. Measurement of abdominal girth
Decompression of the large bowel can be
tried by inserting a flatus tube per anally
68. ADHESIONS AND BANDS
Causes may be classified as:—
Congenital adhesions
Ischaemic
Traumatic
Irritants
Inflammatory
69. TYPES
Type I—Fibrinous adhesions occur during 5-
10th post-surgical period. It usually gets
resolved completely. It is avascular .
Type II—Fibrous adhesions. Due to lack/poor
blood supply It will persist and precipitate
intestinal obstruction
70. 1) Pain may get aggravated or relieved on
change ofposture.
2) Pain in the region of old abdominal scar.
3) Tenderness is elicited by pressure over the
scar
72. INTERNAL HERNIA
Portion of bowel entrapped in one of the
retroperotineal fossae or congenital
mesenteric defect including:
Foramen of winslow
Defect in mesentry;transverse
mesocolon;broad ligament
Diaphragmatic hernia
Duodenal;ceacal or intersegmoid fossae
