Malignant bowel obstruction is caused by luminal narrowing of the small or large bowel due to metastatic intra-abdominal cancer. The most common primary cancers are colorectal, ovarian, breast, and melanoma. Treatment aims to palliatively relieve symptoms like pain, nausea, and vomiting to improve quality of life, as cure is not possible. Both non-operative treatments like octreotide, opioids, antiemetics, and stenting as well as surgical options may be considered depending on the extent of malignancy and patient's condition. The goal is symptom control and allowing oral intake and return home if possible.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Metro Curing Story-Hernia Treatment by Laparoscopic Surgery Vansh Pundit
High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of the intestine.
Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery
tutorials in surgery, surgery training curriculum, residency in surgery, surgical education, principles of surgery, operative surgery, surgical anatomy, pathology and radiology, research methodology, surgery mcqs, surgery essay writing, part 1 exams, part 2 fellowship exams.
resident doctors. medical officers and house officers
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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 Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. DEFINITION
• Malignant bowel obstruction is defined as luminal narrowing of
small or large bowel with clinical evidence of bowel obstruction in
the setting of metastatic intra-abdominal cancer.
3. MOST COMMON CANCERS
• INTRA-ABDOMINAL
• Colorectal cancer
• Ovarian
• EXTRA-ABDOMINAL
• Breast cancer
• Melanoma
6. PRESENTATION
• Gradual worsening of abdominal pain /distension
• Progressive worsening of nausea/vomiting
• Overflow diarrhea (bacteria overgrowth)
7. INVESTIGATIONS
1. PLAIN ABDOMINAL X-RAY;
• Multiple fluid level may be unremarkable because tumour
encasement of the bowel wall may prevent the classical sign of
bowel dilatation seen in non-maligant bowel obstruction.
2. Small bowel contrast
Using either barium or gastrograffin Opinions are divided on this. But
a failure of contrast to reach the caecum in 24 hours suggests high
grade or complete obstruction.
3. Ba Enema.
If this shows obstruction in addition with small bowel blockage this
suggests multiple levels of obstruction consistent with carcinomatosis
8. 4.Enteroclysis Studies.
• Duodenum is intubated directly under fluoroscopy and contrast
injected directly under pressure. Very reliable in showing sites and
degree of obstruction.
• This however needs an expert in this procedure
5.CT-Scan:
This is essential in all cases of MBO if surgical treatment is being
considered.
It is now the gold standard in diagnosing malignant bowel
obstruction
9. • Sensitivity of CT-Scan in the diagnosis of malignant bowel obstruction
= (78 –100%)
• Specificity = (> 90%)
• These will show the sites of obstruction, possible bowel strangulation
or ischaemia.
10. TREATMENT
• Realise this is end of life management, hence treatment is palliative to
improve the quality of life. No cure is expected, proper counseling of
patients and relatives. Increase in length of survival is bonus.
• About 15% of patients are terminally ill
11. PRIMARY GOAL OF TREATMENT
• Alleviate nausea, vomiting and pain
• Make patient to eat
• Return patient home or a nursing facility
12. NON-OPERATIVE TREATMENT
1. NASO-GASTRIC TUBE DRAINAGE ; Nasogastric tube This is very
uncomfortable. Used only on a time-limited basis for decompression.
2. IV FLUID; REHYDRATE.
3. NUTRITION; PARENTERAL
4. PHARMACOLOGICAL ; The goals are:
• Alleviate pain;
• Check nausea,
• Check vomoting,
• Intestinal inflammation and oedema
13. PHARMACOLOGICAL
1. OCTREOTIDE
• One of the most effective drugs for the relief of symptoms of MBO. It is a
synthetic analog of somatostantin. It reduces G. I. Secretions, increases small
bowel transit time, delays onset of oedema and ischaemia in anti-mesenteric
border of intestines. Effect can be dramatic. Within a few hours ! Response is
75 – 100%
• Dose: 0.3 – 0.6 mg/day sucut.
• Response is control of nausea and vomiting. Duration of treatment (Median
9.4 – 17.5 days).Relief period is for life of the patient
14. • 2. OPIODS
• A. Morphine and Hydromorphine
• Alleviate pain, produces adynamic ileus
• B. Methadone Very effective when used with metoclopramide
• C. Metoclopramide Some feel it is contraindicated in bowel
obstruction because it promotes gastric motility, but it is efficacious in
partial bowel obstruction.
15. • 3. ANTIEMETICS Oral medications should be avoided because of vomiting.
• A. Prochloperazine given rectally
• B. Promethazine given rectally
• C. Hydroxyzine given rectally
• D. Ondansetron given subcutaneously
• E,. Methotrimprazine given intramuscularly
• Haloperidol given subcutaneously.
• Haloperidol is believed to be the drug of choice, for it controls nausea, vomiting and
agitated delirium. With anti-emetics, complete relief of emesis is achieved in only
30% of patients.
16. • 4. ANTICHOLINERGICS
• They decrease peristalsis, secretions, vomiting and intestinal colic
• Scopolamine might be more cost effective than Octreotide. It is given subcut
or as a transdermal patch
• 5. CORTICOSTEROIDS
• This reduces peritumoral oedema,
• Activate central and peripheral anti-emetic effect
• It is co-analgesic in intestinal obstruction related pain.
Dexamethasone dose is 2 – 60mg per day. Usually prescribed for
terminal patients.
18. SURGICAL TREATMENT
• Operative Mortality = ( 5 – 32%)
• Operative Morbidity = (42%)
• Re-obstruction = (10 – 50%)
• Therefore proper consideration must be given before performing
surgery. NO RUSH TO SURGERY.
• Obstruction usually partial
• Gangrenous bowel is rare
19. LESS LIKELY TO BENEFIT FROM SURGERY.
• Those with
• Ascites,
• Carcinomatosis,
• Abdominal mass that is palpable,
• Multiple obstruction,
• Very advanced carcinoma, and
• Those with very poor clinical status.
20. THE KREBS AND GOPLERUD PROGNOSTIC INDEX
• Palliation is regarded as successful if survival is at least 2 MONTHS
• This depends also on age, nutritional status, tumour status, ascites,
previous chemotherapy, and radiation treatment..
21. SURGICAL OPTIONS
The quickest and the safest is preferred
• RESECTION with or without anastomosis
• INTESTINAL BY-PASS especially for radiation-induced obstruction
• INTESTINAL STOMA, enterostomy, entero-colostomy,entero-
gastrostomy
• GASTROSTOMY is essentially for drainage to relieve nausea and
vomiting which are really very troublesome symptoms.
22. ENDOSCOPIC TREATMENT
• Usually for a single site obstruction
• Patients NOT fit for operation
• Extensive disease
• Patients refusing operation
23. • ENDOLUMINAL WALL STENTS
• Successful in 64 –100% in rectal carcinoma either complete or partial.
• In 70% of cases of upper intestinal obstruction, gastric outlet obstruction,duodenal
and jejunal obstructions.
• Expertise and necessary equipment are needed for this procedure
• The Procedure
• Canalise bowel using laser or ballon dilatation, insert a guide wire under fluoroscopy
(Seldinger’s technique to canalise the bowel. The neodymium-doped yttrium aluminium
garnet (Nd:YAG) laser can be used at the time of stenting for initial canalisation of bowel for
low rectal carcinoma, but not ideal for long term palliation
• Laser therapy requires repeated treatments to maintain luminal patency.
But balloon dilatation can be a short term measure at the time of stenting
or use of Nd:YAG laser. If stenting is possible it is probably the optimal
endoscopic technique.
24. • SEMS show success of about 90%. Show to maintain patency longer.
• Complications;
• Perforation
• Stent migration
• Stent obstruction
25. • PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
• Usually well tolerated
• Alleviate nausea and vomiting
• Allows intermittent oral intake.
• Patients with ascites are poor candidates for Percutaneous Endos
Gastrost. (PEG)
26. RADIOTHERAPY
• This is to produce local palliation to pelvis, duodenal area, and to
intestinal stoma blockages by tumor.
• Combination with 5-FU is beneficial
• Generally, complication of radiation will not occur before patient dies. This is
END OF LIFE (EOL) management/palliation.
27. CONCLUSION
• MBO is a common and difficult problem.
• Objectives are to relief pain, nausea,vomiting, early removal of N/G tube,
keep patient out of the hospital as much as possible and to restore ability to
eat.
• Non-surgical interventions should be considered in all patients.
• The decision to pursue surgical vs non-surgical treatment hinge on variety of
factors ; general patient condition and the extent of the malignancy.
28. REFERENCES
• 1. Prof. O. G. Ajao, Dept of Surgery, U. C. H. Ibadan, Nigeria. UPDATE
MATERIAL. WACS.
• 2. Sarah FH et ael. Malignant bowel obstruction. Expert analysis. 2015
• 3. Eric R, Charles F V. Current concept in malignant bowel obstruction
management. Curr Oncol. 2009; 11(4):293-303.