This document discusses non-alcoholic fatty liver disease (NAFLD), which has become very common in urban populations. NAFLD ranges from simple fatty liver to non-alcoholic steatohepatitis (NASH), which is characterized by fatty changes, inflammation, and fibrosis that can progress to cirrhosis. The main causes are obesity, insulin resistance, and dyslipidemia. Weight loss and improving insulin sensitivity through diet and exercise are the primary treatment approaches. Medications like vitamin E, pioglitazone, and metformin may also provide benefits, but more research is still needed on medical therapies for NAFLD.
NAFLD is a vast topic and recently gaining a lot of importance. Fatty liver, NASH, are other topics discussed here. sleissenger, sheila sherlock and Harrisons are used for reference
NAFLD is a vast topic and recently gaining a lot of importance. Fatty liver, NASH, are other topics discussed here. sleissenger, sheila sherlock and Harrisons are used for reference
An updated review on nonalcoholic steatohepatitis, epidemiology, pathology, diagnosis, treatment modalities and current clinical trials are reviewed.
New England Journal of Medicine review article from November 2017 entitled "Cause, Pathogenesis, and Treatment of Nonalcoholic Steatohepatitis" was extensively cited, please see references on the last slide (DOI: 10.1056/NEJMra1503519).
This is purely for educational purposes; I do not diagnose, treat, or offer patient-specific advice by sharing these slides.
An updated review on nonalcoholic steatohepatitis, epidemiology, pathology, diagnosis, treatment modalities and current clinical trials are reviewed.
New England Journal of Medicine review article from November 2017 entitled "Cause, Pathogenesis, and Treatment of Nonalcoholic Steatohepatitis" was extensively cited, please see references on the last slide (DOI: 10.1056/NEJMra1503519).
This is purely for educational purposes; I do not diagnose, treat, or offer patient-specific advice by sharing these slides.
Nonalcoholic steatohepatitis (NASH) is liver inflammation and damage caused by a buildup of fat in the liver. The report includes detailed competitive landscape of the global nonalcoholic steatohepatitis market and an analysis of Porter’s five forces model for the NASH market has also been included.
Nonalcoholic Steatohepatitis (NASH) also known as “silent disease” is a type of fatty liver disease, which mainly affects people with diabetes and obesity. Symptoms of NASH are found among all demographics (from children to adults); however, they are more prevalent in younger people. Corner stage of cirrhosis is a form of NASH that can be reversed with proper medication. Moreover, most of the NASH specific pharmaceutical solution are in clinical trial phase
The European Healthy Lifestyle Alliance (EHLA) is pleased to present - in close cooperation with ICCR - the first-ever 'Global Sugar-Sweetened Beverage Sale Barometer'.
diabetes was associated with insulin resistant state which affects liver cells.Also fatty liver may be called NAFLA OR NASH may lead to liver cirrhosis and sometimes to hepatocelular carcinoma
Future Considerations of Biological Disparities in Drug Development for NAFLD...semualkaira
Non-Alcoholic Fatty Liver Disease (NAFLD) has become a significant health concern not only in the US but also worldwide due to the
global obesity epidemic. Although the natural course in the majority
of NAFLD patients is relatively benign, those with non-alcoholic
steatohepatitis (NASH) are at an increased risk of disease progression, leading to hepatic fibrosis, cirrhosis, end-stage liver disease
(ESLD), and hepatocellular carcinoma (HCC).
Liver Cirrhosis and Neurological Disorder Associated with Liver Diseaseijtsrd
Normal brain function is closely and comprehensively related to normal liver function. Not only the liver plays an important role it supplies essential nutrients to the brain, but also to detoxify splanchnic blood. Impaired liver function thus leads to insufficient detoxification allowing neurotoxins such as ammonia, manganese and other chemicals to enter the brain. In addition, postosystem short circuits, ie common complications in advanced liver disease, facilitate the free transfer of neurotoxins into the brain. The problem has increased furthermore, due to other variables such as gastrointestinal bleeding, malnutrition and related kidney failure, which are often associated with the liver cirrhosis. Neurological damage in chronic liver disease and cirrhosis of the liver appear to be several major causes like the brain accumulation of ammonia, manganese and lactate, altered permeability of the blood brain barrier, monocyte recruitment after microglial activation and neuroinflammation i.e. the direct effects of circulating systemic proinflammatory cytokines such as tumor necrosis factor, IL 1ß, and IL 6. hepatocerebral degeneration, hepatic myelopathy, cirrhosis related parkinsonism, cerebral infections, bleeding and osmotic demyelination. In addition, neurological complications can occur exclusively in some diseases, such as Wilsons disease, alcoholism Wernickes encephalopathy, alcoholism .cerebellar degeneration, Marchiafava Bignami disease, etc. . The radiologist should be aware of their various clinical manifestations and radiological manifestations because the diagnosis is not always immediate. Medicaments should be aware of the problems of neurological complications that can occur in liver disease, including hepatic encephalopathy. Panshul Sharma | Dr. Kapil Kumar Verma | Mr. Hans Raj "Liver Cirrhosis and Neurological Disorder Associated with Liver Disease" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-6 | Issue-4 , June 2022, URL: https://www.ijtsrd.com/papers/ijtsrd50196.pdf Paper URL: https://www.ijtsrd.com/pharmacy/pharmacognosy-/50196/liver-cirrhosis-and-neurological-disorder-associated-with-liver-disease/panshul-sharma
AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE AND NEW TREATMENT APPROACHESPARUL UNIVERSITY
Autosomal dominant polycystic kidney disease is the most common inherited kidney disease, results in progressive loss of renal function due to the development and growth of cysts. Advances in understanding the nature of the disease have led to increased awareness of ADPKD, improvements in imaging modalities for diagnosis and assessment and the availability of effective therapies because patients with ADPKD often experience a range of renal and extrarenal complications. Approximately 78% of cases of ADPKD arise from PKD1 mutations. PKD2 mutations account for another 15%. These mutation-driven changes produce the hallmark disease process of ADPKD: development of large, fluid-filled cysts in the kidney, which over time increase kidney size and volume and compromise kidney function, leading to decreased life expectancy, need for dialysis and/or transplantation, cardiovascular/cerebro-vascular disease, and intracranial aneurysms. The involvement of the vasopressin system makes it a target for therapy designed to slow progression of ADPKD. Steps are to taken to slow down the progression of disease by early diagnosis and symptomatic treatment approaches are needed to be followed to prevent the complications. As RAAS mechanisms are prime factors for progression and worsening of the condition, steps should be taken to prevent the over activity of RAAS by using many of the newer therapeutic agents show promise in preventing or stabilizing cyst growth, providing much needed hope in this currently relentless condition. Hypertension should be kept in check to prevent any chances of strokes. Making lifestyle changes such as dash diet and maintaining adequate hydration to maintain the normal renal sufficiency are some of the key approaches to control or to prevent the progression of this condition and help the patient to lead normal life and life expectancy
Endpoint Selection of Non-alcoholic Steatohepatitis Clinical Trialssemualkaira
With the increasingly global epidemic of obese and metabolic syndrome, non-alcoholic steatohepatitis (NASH) has become a growing
common cause of cirrhosis, hepatocellular carcinoma, and end-stage
liver disease
Background: Nonalcoholic Fatty Liver Disease (NAFLD) is the most common liver disease in the developed countries. Patients with Nonalcoholic Steatohepatitis (NASH), a subset of NAFLD, are at risk for progressive liver disease and in need of effective treatment options. There is a lack of data assessing sleeve gastrectomy and their effect on NAFLD.
Objective: To assess the effects of Sleeve Gastrectomy (SG) on NAFLD.
Methods: An online search of PubMed, Medline, and Google Scholar was independently carried out by two researchers using key words like Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steato-Hepatitis, Bariatric Surgery, Obesity Surgery, Sleeve Gastrectomy and Liver Biopsy, percutaneous liver biopsy, to identify all articles. Articles were also identified from references of relevant articles. All sleeve gastrectomies that had ntraoperative and postoperative liver biopsies were included.
Fasting and Caloric Restriction Show Promise for Reducing Type 2 Diabetes Bio...Premier Publishers
The global epidemic of type 2 diabetes (T2D) and its co-morbidities threatens to overwhelm public health services and urgent patient intervention is necessary. A review of mainly randomised controlled trials investigating the reduction of biochemical T2D risk markers through fasting or caloric restriction (CR) found that in T2D or where baseline fasting glucose or HbA1c were elevated, there were significant improvements in fasting glucose and HbA1c, while fasting insulin and insulin resistance may show improvement regardless of condition or baseline levels. There may, however, be ethnic differences, with a clear positive correlation found only in Caucasians. Intermittent CR (i.e. non-continuous periods of fasting) is at least as effective as isocaloric continuous CR, while CR of 400-800 kcal/day is possibly more effective than higher levels for reducing fasting glucose and HbA1c. Time restricted feeding also shows promise but there are few human studies. The findings suggest that the optimum regimen to reduce biochemical risk markers for T2D is an intermittent fasting programme employing a very low-calorie diet with the longest possible number of consecutive days of fasting. The addition of liquid meal replacements, low carbohydrate CR and supplementation of vitamin D, ω-3 PUFAs and L-carnitine may also be of benefit.
Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis
is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is
a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the
diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along
with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma
of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is
invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum
prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for
other age groups is advisable.
Hyperbaric oxygen therapy a boon for complex post traumatic woundsKETAN VAGHOLKAR
Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.
Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral
veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein
thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the
cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management
thereby reducing the morbidity and mortality associated with the disease.
Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...KETAN VAGHOLKAR
Background: Fluid collection in a femoral hernia sac designated as a femorocele is an
extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and
one case of bilateral femorocele have been reported in English literature. Objective: Thus
making the case presented the second case of bilateral femorocele in English literature.
Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease
who had undergone dual valvular replacement with ascites due to cardiac cirrhosis
is presented to highlight the surgical challenges in management of such a rare case. Discussion:
Pathophysiology, clinical features, investigations and managemeny of femorocele
are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is
diagnostic. Open surgery in the form of dissection of sac with high ligation followed by
obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.
Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a
dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential
for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal
hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding
hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia.
Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.
Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.
Fournier’s gangrene of the scrotum after inguinal hernia repair: case reportKETAN VAGHOLKAR
Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.
Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a
great challenge to the attending surgeon. There are various variants of embryological abnormality of the
processes vaginalis manifesting in different forms. Understanding the embryological development of the
processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical
option for treating these rare cases.
Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple
sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to
hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities
such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical
intervention in the form of debridement and desloughing followed by wound care is the next line of
management. Patient education at the time of discharge is necessary for prevention of recurrence.
Foreign body in the male urethra: case reportKETAN VAGHOLKAR
Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.
Morel-Lavallée Lesion: Uncommon Injury often MissedKETAN VAGHOLKAR
Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have
been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to
the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is
to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma
patients.
Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over
accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid
in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to
induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage.
Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early
diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along
with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.
Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such
an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case
report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced
CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete
excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair.
Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the
mainstay of surgical treatment.
Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...KETAN VAGHOLKAR
Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle
in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes
fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case
report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar
hernia. He had a severe two wheeler accident. Following the accident he had undergone
various surgical interventions for a fractured pelvis with a deglowing injury involving the
right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia
for which he had undergone open mesh repair. Subsequently he developed recurrence of
the post traumatic right-sided lumbar hernia. After complete investigation he underwent
open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and
was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with
bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes
drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles.
They were double-breasted to cover the mesh. Postoperative outcome was excellent
with no recurrence for the last six months. Discussion: The various anatomical and technical
considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion:
Bone fixation of the mesh with bone anchors is a viable option especially in cases where
there is severe attenuation of adjacent muscles for mesh fixation.
LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...KETAN VAGHOLKAR
Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of
laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention.
As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to
evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and
safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients
who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied
prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right
hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes.
In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure.
10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic
cholecystectomy is a safe and viable option for treating acute calculous cholecystitis
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)KETAN VAGHOLKAR
Background: Appendicectomy is one of the common procedures performed by a general surgeon. However,
the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore
there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The
study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and
postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised
into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised
25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative
findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced
need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed
in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure
for appendicectomy.
Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to
be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation
and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ
involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal
tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various
surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was
commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia
were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early
histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant
adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis
Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or
contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly
suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical
intervention for complications is the mainstay of treatment.
PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...KETAN VAGHOLKAR
Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending
surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both
morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify
these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to
identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials
and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed
by clinical and radiological investigations were included in the study and studied prospectively. On admission to the
hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients
subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated
and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented
in an advanced stage developed complications. The majority of patients were males. The interval between the onset
of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was
the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most
common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process,
were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by
perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication.
Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination
found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the
complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria
and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the
diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher
complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early
meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.
COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...KETAN VAGHOLKAR
Background: Skin approximation is a very important step in a surgical operation. The quality of skin
approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications.
Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare
traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound
complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients
are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation).
The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation)
had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction.
Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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.
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
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Non Alcoholic Fatty Liver Disease: A New Urban Epidemic.
1. NON ALCOHOLIC FATTY LIVER
DISEASE (NAFLD)
Dr. Ketan Vagholkar
MS, DNB, MRCS (Eng), MRCS (Glasgow), FACS
Consultant General Surgeon
2. Dr. Ketan Vagholkar ,Dr. Abhijit Budhkar JMSCR Volume 2 Issue 7 July 2014 Page 1773
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Non-Alcoholic Fatty Liver Disease: A New Urban Epidemic
Authors
Dr. Ketan Vagholkar1
, Dr. Abhijit Budhkar2
1
Professor, Department of Surgery: MS, DNB, MRCS (Eng), MRCS (Glasg), FACS
Dr.D.Y.Patil Medical College, Navi Mumbai-400706, MS, India
2
Senior Resident Department of Surgery: MBBS Rajawadi Municipal General Hospital, Mumbai-400077
MS, India.
Correspondence Author
Dr. Ketan Vagholkar
Annapurna Niwas, 229 Ghantali Road, Thane 400602, MS, India
E mail: kvagholkar@yahoo.com
ABSTRACT
Non-alcoholic fatty liver disease (NAFLD) comprises of a spectrum of pathological changes in the liver. It
has become a very common disease in the urban population. Understanding the pathophysiological
mechanisms underlying this disease is pivotal in planning a management strategy. The etiopathogenesis,
clinical features, diagnosis and management is discussed in this paper.
Keywords: non-alcoholic, fatty, liver, disease, steatohepatitis,
INTRODUCTION
The traditionally used term fatty liver was
synonymous with early alcoholic liver disease.
However extensive research over period of time
has revealed that a variety of other causes can lead
to liver changes exactly simulating alcoholic liver
disease. This has led to a confusion in the
nomenclature. The non-alcoholic variant is now
classically described as non-alcoholic fatty liver
disease. Non-alcoholic fatty liver disease
(NAFLD) is typically described as a condition
characterized by lipid deposition in hepatocytes of
liver parenchyma. The condition has assumed
epidemic proportions in urban population.
www.jmscr.igmpublication.org Impact Factor 1.1147
ISSN (e)-2347-176x
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DEFINITION
The condition was initially described as NASH
i.e. Non Alcoholic Steatohepatitis. [1] The
histologic features closely simulate alcoholic liver
disease. However when it was understood that
there is a wide spectrum of conditions having
similar histological findings but with varying
severity, the condition was named as NAFLD.
[2]The spectrum of histological finding ranges
from simple fatty liver typically described as
hepatic steatosis to non-alcoholic steatohepatitis
(NASH) which is characterized by significant
fatty changes, lobular inflammation,and presence
of Mallory hyaline with progressive fibrosis
eventually leading to cirrhosis.[2,3]
ETIOPATHOGENESIS
Though the worldwide prevalence is yet to be
determined it is approximately present in 10-24 %
urbanpopulation. [4] With improved nutrition
obesity has become rampant across all age groups.
Obesity is associated with insulin resistance and
dyslipidaemia. This triad constitutes a very
important precursor to the development of
NAFLD. [4]
Though the exact pathogenesis of NAFLD
is still a challenging topic for research,various
hypothesis have been put forward. The hit theory
is the most commonly accepted one. [5] Hit refers
to the insult inflicted onto the hepatocytes.
Multiple hits lead to progressive liver injury. The
initial hit is by virtue of insulin resistance which
most likely plays a central role in net retention of
lipids within the hepatocytes. This is most
probably the result of decreased disposal of fatty
acids due to impaired mitochondrial beta
oxidation. The second hit or insult is generally
attributed to oxidative stress which causes lipid
peroxidation in the hepatocyte membrane in
addition to cytokine production and Fas ligand
induction. This is supposed to be responsible for
progression of mild disease or steatosis to NASH
eventually leading to cirrhosis. Obesity is
associated with alteration of leptins. Increase
serum leptins promotes the development of
NAFLD. [6, 7] The role of iron by virtue of
stellate cell activation and collagen deposition is
still undergoing investigation. [8.9]
The molecular basis of obesity related
NAFLD has been studied on the rat model which
has phenotype features similar to human
obesity.[9] These rats exhibit insulin resistance
and dyslipidaemia as well. The rats exhibited
oxidative stress,endoplasmic reticulum
stress,mitochondrial dysfunction and decreased
expression of survival genes. [7] Extra hepatic
signals may add to the complexity of injury. These
are by virtue of peripheral insulin resistance
associated with an increase in adipose mass and
systemic free fatty acids. NAFLD is seen in
patients suffering from hepatitis C and
inflammatory bowel disease. [10,11] NAFLD
happens to be a result of inflammatory bowel
disease, seen in 10-20% of IBD patients.[11]
NAFLD has also been sighted as a predisposing
factor for colorectal neoplasms.[12] The higher
prevalence of colorectal neoplasms especially
right sided colon have been noted.[12] Therefore
4. Dr. Ketan Vagholkar ,Dr. Abhijit Budhkar JMSCR Volume 2 Issue 7 July 2014 Page 1775
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colorectal cancer screening is strongly advisable
in this high risk group. The natural history of
NAFLD is variable depending upon the severity
of liver injury. [13] 25% of patients may progress
to cirrhosis and portal hypertension. The
relationship between comorbidities of coronary
disease and malignancy add to complexity of the
natural history. NAFLD has been found to be a
risk factor for a variety of extra hepatic diseases
such as chronic vascular disease,chronic kidney
disease,colorectal cancer as described, thyroid
disorders and osteoporosis. [14]
DIAGNOSIS
Majority of patients of NAFLD are asymptomatic
in whom the condition may be diagnosed during a
routine annual health check. The symptomatic
group in the early stages may present with mild
fatigue,increase flatulence and mild upper
abdomen discomfort. [2] Nausea, anorexia and
malaise may be present. Asymptomatic disease if
left undiagnosed and untreated may present with
lethal complication of cirrhosis at a later date. [3,
4]
Physical examination of patient with
NAFLD usually exhibit high or low BMI and
hepatomegaly.[3,4] High BMI is seen in obese
diabetic patients with altered lipid profile where as
low BMI may be associated with surgical
procedures on the gut,rapid weight
loss,starvation,protein energy malnutrition as seen
in vegans. History of inborn errors of metabolism
and drug therapy may also be associated with
NAFLD.[2,3,4] Anticancer drugs such as
methotrexate, nucleoside analogues and tamoxifen
are associated with NAFLD.[2,3,15, 16] In a few
cases patients present with signs of hepatocellular
failure due to cirrhosis.[8]
INVESTIGATIONS
Mild to moderate elevation of serum
aminotransferases is the commonest abnormality.
In NAFLD the AST: ALT ratio is usually <1 ratio
but tends to increase with development of
cirrhosis thereby losing its accuracy. Alkaline
phosphatase may be elevated in few patients.
Elevated lipid profiles and blood glucose
concentrations are seen in 25-75% of patients. A
minority of patients with NAFLD may have low
titre of positive antinuclear antibodies (ANA).
Few patients may also exhibit elevated serum iron
suggestive of overload. Hepatitis C (HCV) may be
a concomitant finding in a select few cases of
NAFLD.
RADIOLOGICAL INVESTIGATION
Ultrasound (USG), CT scan and MRI have been
advocated as diagnostic tests for NAFLD. USG
however is the most important screening as well
as diagnostic test. The findings on USG include
diffuse hyper-echoic texture of the liver, vascular
blurring and deep attenuation. [15]The hepatic
echo texture is usually denser than that of the
kidney. CT scan may show typically a low density
liver parenchyma. Magnetic resonance
spectroscopy is a new method proposed to
diagnose NAFLD. However its diagnostic role
requires confirmation.
5. Dr. Ketan Vagholkar ,Dr. Abhijit Budhkar JMSCR Volume 2 Issue 7 July 2014 Page 1776
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Liver biopsy is the most accurate method for
diagnosing NAFLD. [3, 4, 15, 16] However the
investigation needs to be used judiciously in view
of a variety of morbid complications. Typically
histological features are predominantly
macro vascular steatosis alone
macro vascular steatosis and varying
amount of cytological ballooning, spotty
necrosis, scattered inflammatory foci,
glycogen nuclei, peri-sinusoidal fibrosis.
The severity of steatosis may be graded on the
basis of the extent of the involvement of the liver
parenchyma. [16]
TREATMENT
Weight management and medications are
mainstay of treatment.
An appropriate diet and exercise program
leading to 10 % gradual weight loss can lead to
improvement in liver biochemistry and histology.
[15] This can also provide benefits to patients with
cardiovascular disorders. However rapid weight
loss can have disastrous consequences as it can
cause worsening of steatohepatitis and can
precipitate liver cell failure. Bariatric surgery has
also been proposed. However the risk of
developing decompensated liver disease during
rapid weight loss post operatively remains high.
[15, 16]
Medical treatment aims at controlling
insulin resistance. [16] Thiazolidinediones are
drugs of choice as they improve insulin
sensitivity. This drug administered for 3-6 months
showed normalization of ALT. However the long
term safety of these drugs precludes their routine
use in NAFLD.
Metformin another OHA which
improves insulin sensitivity is also associated with
decreased aminotransferase activity. [16]
As these observation are based on studies
with very small sample size, more rigorous studies
with a large sample size are required to
substantiate and standardize the therapeutic
protocol of these drugs.
Lipid lowering agents have also been
tried. Clofibrate was the first medication to be
tried but unfortunately did not yield positive
results.
Gemfibrosil is another drug which
showed significant improvement in ALT levels.
However due to paucity of medical data these
drugs cannot be routinely advised as a standard of
practice.
The most commonly used pharmacological
therapy is that which offers hepatocyte protection.
These agents include Ursodeoxycholic acid
(UDCA) and antioxidants like betaine and
Vitamin E. [15, 16] The therapeutic role of
UDCAwas extensively studied. However the
results did not reveal any improvement in liver
biochemistry and histology.
Vitamin E (alpha tocoferol) in the dose of
400-1200 IU daily was associated with significant
improvement in liver enzymes. However
significant improvement was also seen in fibrosis
scores in NASH. [16]
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A combination of Pioglitazone and Vitamin
E was found to deliver more therapeutic benefits
as compared with Vitamin E alone.
Betaine, a normal component of
metabolism of methionine is a precursor of s-
adenosine methionine (SAM) which is supposed
to have hepatoprotective effect. However the
results need to be confirmed with long-term
prospective trials. Liver transplantation has been
offered to patients with NAFLD presenting as
endstage liver disease. However the results are
dismal with development of NAFLD in the
transplanted liver. [16]
Other agents such as tricholine citrate,
sorbitol and ornithine containing compounds also
exert a protective effect thereby leading to
resolution of biochemical and radiological
changes in NAFLD. However data on the effect of
these medications on histology is lacking.
CONCLUSION
NAFLD is a complex liver disease with a wide
spectrum of changes in the liver parenchyma.
No specific therapeutic medical regimen can
be advised authentically for cure of the disease.
Treating the underlying metabolic
derangements is therefore the mainstay of
treatment.
Gradual supervised weight reduction and
improvement in insulin sensitivity accompanied
with hepatoprotective agents remain the mainstay
of treatment.
ACKOWLEDGEMENT
We would like to thank Mr. Parth K. Vagholkarfor
his help in typesetting the manuscript.
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