Small bowel obstruction is a common surgical condition where the small intestine becomes blocked. The most frequent cause is adhesions from prior abdominal surgery, accounting for up to 75% of cases. Symptoms include abdominal pain, nausea, vomiting and constipation. Diagnosis involves imaging like abdominal x-rays showing dilated bowel loops or CT scans identifying transition points. Treatment depends on the severity and cause but generally involves surgery to remove blockages or adhesions and repair hernias or tumors. Outcomes are good if caught early but mortality rises with delay in surgery or if the obstruction becomes strangulated.
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
acute abdomen conditions in radiology and their evaluation
acute pancreatitis, cholicystitis, pelvic pathology, mri evaluation , intra abdominal abcess, plain radiography evaluation of acute abdomen, vascular causes of acute abdomen, causes of acute abdomen.
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
acute abdomen conditions in radiology and their evaluation
acute pancreatitis, cholicystitis, pelvic pathology, mri evaluation , intra abdominal abcess, plain radiography evaluation of acute abdomen, vascular causes of acute abdomen, causes of acute abdomen.
the presention about abdominal pain and it s different cause we talking briefly about medical and surgical causes
and the presention mainly about the vascular causes for abdominal pain
i hope its helpful for you
ACUTE APPENDICITIS- RLQ ABDOMINAL PAIN
#surgicaleducator #rlqabdominalpain #acuteappendicitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Appendicitis
• It is the commonest surgical problem you see in surgical wards.
• I have discussed the various causes for RLQ pain, etiology, pathology, symptoms, signs, investigations , treatment and postop complications of Acute Appendicitis.
• I have also included a mind map, algorithm for RLQ pain and treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
the presention about abdominal pain and it s different cause we talking briefly about medical and surgical causes
and the presention mainly about the vascular causes for abdominal pain
i hope its helpful for you
ACUTE APPENDICITIS- RLQ ABDOMINAL PAIN
#surgicaleducator #rlqabdominalpain #acuteappendicitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Appendicitis
• It is the commonest surgical problem you see in surgical wards.
• I have discussed the various causes for RLQ pain, etiology, pathology, symptoms, signs, investigations , treatment and postop complications of Acute Appendicitis.
• I have also included a mind map, algorithm for RLQ pain and treatment algorithm for Acute Appendicitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
Shudh (natural internal cleanse): Shudh is a modern version of Shankhaprakshalana, an indian purification technique that has been used for over a 2,500 years. This technique cleanses the bowel naturally, using only salted water and a series of five yoga exercises.
Instead of chemical action, the body's own reflexes do the work. The Shudh process is ideal for healthy men and women who are fit enough to do little exercise.
Information about Obstructed Recto Sigmoid Malignancy by Dr Dhaval Mangukiya.
Details of introduction of obstructed recto sigmoid malignancy, Epidemiology, Pathophysiology, Complications, Early Presentation, Stools, History, Late Presentation, Diagnosis, Imaging, Contrast enema, Screenig, Treatment, Management, Surgical management, Surgical options etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Initially in my lectures you can see that I have talked about Approach to Pain in abdomen, now we will learn what imaging should be done and why as per case to case basis. CT or USG or X-ray !!
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Gall stone ileus is complication of cholithiasis. It is rare and seen in aged patients diagnosed as
cholelithiasis with co morbidities. High index of suspicion is necessary for arriving at a clinical diagnosis.
Contrast enhanced computed tomography is diagnostic. Enterolithotomy followed by closure of the fistula
with cholecystectomy as a two staged procedure is the safest approach for managing gall stone ileus.
2019 update of the EULAR recommendations for the management of systemic lupus...Jose Cortes
Actualización EULAR en el manejo del Lupus (LES) 2019.
Guías europeas sobre el manejo actual con revisión de la literatura.
Medicina Interna Reumatología
Artículo del BMJ
http://dx.doi.org/10.1136/annrheumdis-2019-215089
Transtorno de ansiedad social fobia socialJose Cortes
Psiquiatria, Transtorno de Ansiedad Social, Fobia Social.
Medicina, Psiquiatría.
Presentación para la materia de Psiquiatría de 4to año medicina Torreón.
joseluistcm@gmail.com
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.
Antimicrobial stewardship to prevent antimicrobial resistanceGovindRankawat1
India is among the nations with the highest burden of bacterial infections.
India is one of the largest consumers of antibiotics worldwide.
India carries one of the largest burdens of drug‑resistant pathogens worldwide.
Highest burden of multidrug‑resistant tuberculosis,
Alarmingly high resistance among Gram‑negative and Gram‑positive bacteria even to newer antimicrobials such as carbapenems.
NDM‑1 ( New Delhi Metallo Beta lactamase 1, an enzyme which inactivates majority of Beta lactam antibiotics including carbapenems) was reported in 2008
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
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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
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Small bowel obstruction and Intestinal Fistulas
1. Small Bowel Obstruction
José Luis Cortés Sánchez
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
2. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Epidemiology
Most frequently encountered surgical disorder of the
small intestine
Anatomic relationship to intestinal wall:
1.- Intraluminal:
2.- Intramural
3.- Extrinsic
3. Intraabdominal adhesions related to
prior abdominal surgery account for
up to 75% of cases
300,000 patients are estimated to
undergo surgery to treat them
annually
From 1988 to 2007 there was no
decrease in this rate
Ongoing problems with this “old”
disease
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
4. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Other causes:
Hernias,
malignant, Chron’s
Few are due to
primary bowel
tumors
5. Congenital usually become evident during childhood,
but sometimes are not
i.e. Intestinal malrotation, mid-gut volvolus (without
history)
Superior mesentric artery Sx. (rare etiology)
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
6. Pathophysiology
Gas and fluid acumulate
Intestinal activity increases Pain and
diarrhea
Swallowed air
and produced
Swallowed liquids
and GI secretions
Bowel distends IM/ IL pressure rises
Motility is eventually reduced
Luminal flora changes
If IM pressure high enough perfusion is impaired ischemia - necrosis
Strangulated bowel obstruction
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
7. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Partial
Allows passage of some fluid
and gas
Event progression occur more
slowly
Less likely to become
strangulated
Closed-loop
Particularly dangerous
E.g. volvolus
Rapid rise in luminal pressure
Rapid progression to
strangulation
8. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Clinical presentation
Colicky abdominal pain, nausea, vomiting, obstipation
More vomiting w/proximal than distal
Feculent? bacterial overgrowth (more established)
Continuos passage of flattus/stool >6-12 hours=
Partial
9. Signs
Abdominal distention (more if distal)
Initially hyperactive bowel sounds then minimal
Lab:
Intravascular volume depletion
Hemoconcentration
Electrolyte abnormalities
Mild leukocytosis
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
10. Strangulated
Abd. pain disproportionate to degree of abd findings
-suggestive of intestinal ischemia
Tachycardia,
Localized abd tenderness
Fever
Marked leukocytosis
Acidosis
Alert!
Prompt early surgical
intervention!
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
11. Diagnosis
1.-Distinguishing mechanical obstruction from ileus
2.-Determine the etiology
3.-Discriminate partial from complete
4.-Discriminate simple from strangulated
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
12. History
Prior abd operations
Abd disorders (cancer, IBD)
Meticulous search for hernias(inguinal, femoral)
Dx.- confirmed by radiographic exams
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
13. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Abdominal series
Rx of the abdomen patient in supine
Abdomen w/patient upright
Rx of the chest w/patient in upright
Most specific triad:
-Dilated small bowel loops (>3 cm in diameter)
-Air-fluid levels on upright
-Paucity of air in colon
S= 70-80%
E= lowDDX.-
Ileus, colonic obstruction
FN= proximal; fluid but no gas Closed-loop
Despite these limitations, abdominal radiographs
remain an important study in patients with
suspected small bowel obstruction because of
their wide- spread availability and low cost
14. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
CT scan
Discrete transition zonew/dilation of proximal
Decompression of distally
Contrast that doesn’t pass beyond transition
Colon with little gas or fluid
S= 80-90%
E= 70-90%
-CT may also provide
evidence of closed-
loop/strangulation
-
-Closed-loop U-/C-
shaped bowel+ radial
messenteric vessels in torsion
point
-Strangulation
Thickening of bowel wall,
pneumatosis intestinalis,
portal venous gas, mesenteric
haziness
Poor uptake of IV contrast
CT also reveals the etiology
15. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Appearance of contrast
in colon w(24hrs) is
predictive of non-
surgical resolution
Reduce overall length
of hospitalization
S= 50% , for low-grade
or partial
Small bowel series/
Enteroclysis can be
helpful
16. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Therapy
Marked depletion of IV volume –> fluid resuscitation is integral to
treatment
Central venous o pulmonary artery catheter assist fluid
management (CVS or severe)
Antibiotics? No data to support it
Isotonic fluid IV + Bladder catheter
NG tube to evacuate
stomach. Not jejunum nor
ileum
Decreases nausea, vomiting,
distention, aspiration
17. “the sun should never rise
and set on a complete bowel
obstruction.”
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
18. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
nonoperative
aproaches
R/O closed-loop ;
neither intestinal
ischemia
Observe closely and
undergo serial exams
Early surgical
intervention
Minimize the risk for
strangulation
Morbimortality
Signs and lab tests and imaging don’t distinct between
them
Goal? operate before onset of ischemia
A period of observation and NG decompression, provided no
tachycardia, tenderness or WBC increases
19. Conservative therapy
1. Partial small bowel obstruction
2. Obstruction occurring in the early postoperative
3. Intestinal obstruction due to Crohn’s disease
4. Carcinomatosis
Strangulation is unlikely to occur.
Succesful in 65-81%
Of these 5-15% don’t improve at 48 hrs
Patients with partial obstruction thath do not improve at
48h should undergo surgery!0
-Occur in 0.7% patients undergoing laparotomy.
-Pelvic surgery, especially colorectal procedures, have the greatest
risk.
-Should be considered if
-symptoms of intestinal obstruction occur after the initial
return -Function fails to return within the expected 3 to 5 days after
-25-33% of patients with
-Even in cases in which the obstruction is related to recurrent malignancy,
palliative resection or bypass can be performed.
-Patients with obvious carcinomatosis pose a difficult challenge, given their
limited prognosis.
May be best achieved by a bypass procedure
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
20. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Adhesions lysed
Tumors resected
Hernias reduced and repaired.
The affected intestine should be examined, and nonviable bowel
resected.
If the patient is hemodynamically stable, short lengths of bowel of
questionable viability should be resected
Bowel of uncertain viability should be left intact and the patient
re-explored in 24 to 48 hours in a “second- look” operation.
Criteria suggesting viability:
-normal color,
-peristalsis,
-marginal arterial pulsation
Operative procedure varies according to the
etiology
Laparascopic procedure have a
quicker recovery, less
complications, and lower costs.
Distended loops of bowel can
interfere with adequate
visualization, early cases likely
due to a single adhesion
Conversion rate to open surgery
is between 17% and 33%
21. Outcomes
Prognosis is related to the etiology
Less than 20% of conservative patients will have a
readmission over the subsequent 5 years
The perioperative mortality rate associated with
surgery for nonstrangulating small bowel obstruction is
less than 5%,
Mortality rates associated with surgery for
strangulating obstruction range from 8% to 25%.
Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
22. Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed
Prevention
Good surgical technique, careful handling
of tissue, and minimal use and exposure
of peritoneum to foreign bodies form the
cornerstone of adhesion prevention.
Colorectal or pelvic surgery, hospital
readmission rates of greater than 30%
over the subsequent 10 years
.
Seprafilm
23.
24.
25. fistula
abnormal communication between two
epithelialized surfaces.
internal fistula .- between two parts of the GI
tract or adjacent organs
external fistula involves the skin or another
external surface epithelium.
Over 80% of enterocutaneous fistulas represent
iatrogenic complications that occur as the result
of enterotomies or intestinal anastomotic
dehiscences.
Spontaneously without antecedent iatrogenic
injury are Crohn’s disease or cancer.
low-output fistulas
Entero- cutaneous fistulas that drain
less than 200 mL of fluid per day
high-output fistulas.
those that drain more than 500 mL of
fluid per day
28. Clinical
Presentation
Fever
Leukocytosis
prolonged ileus
abdominal tenderness,
wound infection
evident between the 5th-10th
postoperative days.
initialsigns.
Iatrogenic enterocutaneous fistulas
The diagnosis is obvious
when drainage of enteric material
occurs.
These fistulas are often associated with
29. Diagnosis
CT scanning following the
administration of enteral
contrast
Most useful initial test?
Leakage of contrast material from the
intestinal lumen can be observed.
Intraabdominal abscesses should be
sought and drained percutaneously.
-Small bowel series or enteroclysis
examination can be obtained to
demonstrate the fistula’s site of origin
in the bowel.
-Useful to R/O the presence of intestinal obstruction distal to the site of origin.
If the anatomy of the fistula
is not clear on CT
scanning?
A fistulogram,
30. Therapy
1. Stabilization.
Fluid and electrolyte resuscitation is begun.
Nutrition is provided, usually through the parenteral route initially.
Sepsis is controlled with antibiotics and drainage of abscesses.
The skin is protected from the fistula effluent with ostomy appliances or
fistula drains.
2. Investigation. The anatomy of the fistula is defined
3. Decision. Tx options considered, and timeline for conservative
4. Definitive management. surgical procedure
5. Rehabilitation.
31. Objective is to increase the probability of
spotaneous closure.
Nutrition and time are the key components
of this approach.
Most patients will require TPN
however, a trial of oral
enteral nutrition should
attempted in patients w
low-output fistulas
originating from the dis
intestine.Octreotide is a useful adjunct, particularly
in patients with high-output fistulas;
-reduces the volume of fistula output
thereby
facilitating fluid and electrolyte management.
32. Timing of Surgical
Intervention.
2 to 3 months of conservative therapy before
considering surgical intervention.
surgical intervention after this time period is
associated with better outcomes and lower
morbidity
90% of fistulas that are
going to close do so
within 5 weeks
fails to resolve during this period ?
fistula tract, together with the segment of
intestine from which it originates, should be
resected.
Simple closure of the opening in the intestine from which the fistula
originates is associated with high recurrence rates.
33. Outcomes
“FRIEND”
Foreign body within the fistula tract
Radiation enteritis
Infection/Inflammation at the fistula origin
Epithelialization of the fistula tract
Neoplasm at the fistula origin
Distal obstruction of the intestine
Over 50% of intestinal fistulas close spontaneously.
34. 153 cases of
enterocutaneous fistulas
Majority were found to originate from the small bowel
Patients having undergone 5 or + previous surgeries.
30-day mortality of approximately 4%
1-year mortality of 15%.
Morbidity was over 80%.
First surgical repair attempt was successful 70% of
cases
Some patients
requiring up to
three attempts at
surgical repair.
Owen RM, Love TP, Perez SD, et al. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experi- ence.
Arch Surg. 2012;15:1.
35. A 43-year-old woman comes to the emergency department with a
3-day history of abdominal distention, nausea, and vomiting. She
also reports decreased urine output over the last 24 hours. She
has a history of total abdominal hysterectomy 5 years ago for
benign disease. She does not take any medications. Her pulse is
110 beats/minute. Her abdomen is distended and there is mild
diffuse tenderness. Bowel sounds are hyperactive. The rest of
her exam is normal. Serum electrolytes are sodium—140,
chloride—90, bicarbonate—32, and potassium—4.0. Which of
the following is the most appropriate initial intravenous fluid to
administer to this patient?
A.-D5 1⁄2 normal saline with 40 mEq KCl/L
B. Lactated Ringer’s solution
C. Normal saline
D. Colloidal starch solution
E. 5% albumin in normal saline