Thick walled gall bladder is very common investigation findings. Approaching this problem in algorithmic manner is necessary for improving patient outcome.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
Self-Assessment Module concerning Diagnostic Imaging Modalities' role in Gastric cancer detection,evaluation and staging. Gastric cancer radiographic features. The Quiz includes MCQs, Pictorial questions and clinical case.
Bladder cancer is a disease of urinary bladder in which cells grow abnormally and have the potential to spread to other parts of the body. This is one of four parts of presentations on Bladder cancer. Please do go through the rest of the presentations too.
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
All you need to know about peri-ampullary cancer
Periampullary cancer is a common diagnosis with patient with progressive jaundice in northern part of India
Timely diagnosis and proper treatment in a way towards cure
Self-Assessment Module concerning Diagnostic Imaging Modalities' role in Gastric cancer detection,evaluation and staging. Gastric cancer radiographic features. The Quiz includes MCQs, Pictorial questions and clinical case.
Bladder cancer is a disease of urinary bladder in which cells grow abnormally and have the potential to spread to other parts of the body. This is one of four parts of presentations on Bladder cancer. Please do go through the rest of the presentations too.
Benign Biliary Stricture is a common condition which we encounter during gastro practice. Here we discuss in detail about its diagnosis and management.
All you need to know about peri-ampullary cancer
Periampullary cancer is a common diagnosis with patient with progressive jaundice in northern part of India
Timely diagnosis and proper treatment in a way towards cure
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
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. • Gallbladder wall thickening is a commonly encountered imaging
finding and can be seen in a broad spectrum of pathological
conditions.
• The differentiation of benign and malignant gallbladder wall
thickening is critical as well as challenging.
• Appropriate utilization and interpretation of imaging may allow
discrimination between benign and malignant GB wall thickening
4. Why it is important to differentiate
• Thick walled gall bladder can be caused by- Gall stone disease leading
to acute cholecystitis (reversible), Chronic cholecystitis (irreversible),
Gall bladder cancer or gall bladder polyps
• Management of each modality is different- As benign lesions with
need some form of simple cholecystectomy but malignancy require
algorithmic management
5. Back ground
• Risk factors for GB neoplasm include gallstones and a history of
chronic cholecystitis.
• Others risk factors include choledochal cysts, anomalous
pancreaticobiliary duct junctions, and gallbladder polyps > 1 cm in
size.
• Gallbladder carcinoma has a peak incidence in the sixth and seventh
decades of life and is three to five times more predominant in females
7. Ultrasound
Radiology 1987
The type 1, or “striated,” pattern consisted of
irregular, discontinuous, alternating lucent and
echogenic bands,
while the type 2, on “three-layer,” pattern was
characterized by one smooth circumferential lucent
zone interposed between two relatively uniform
echogenic layers.
Intrinsic
GB
disease
No
intrinsic
GB
disease
Thickness >6mm-
severe inflammation
8.
9. • Adenomyomatosis- Symmetrical
wall thickening, intramural cystic
spaces, intramural echogenic
foci
• CAGB- Irregular thickening of the
outer wall, focal IHL
discontinuity, IHL irregularity, IHL
thickening greater than 1 mm,
loss of the multilayer pattern in
the GB wall and intralesional
vascularity on colour Doppler
10.
11. Gall bladder polyps
• The prevalence of gallbladder polyps varies from 0.3% to 12% in
healthy adults who undergo abdominal ultrasonography (US).
• GB polyps are classifed into 2 groups-- neoplastic (adenomas,
adenocarcinomas) and nonneoplastic (cholesterol polyps,
infammatory polyps, adenomyomatosis)
12. • Ultrasound features to be considered
in diagnosis of polyps are
• number (solitary or multiple),
• size (<6 mm, 6– 10 mm,>1 cm),
• shape (pedunculated or sessile),
• echogenicity (hypo, iso, and hyper),
• surface (smooth or nodular),
• internal echogenicity (homogenous or
inho-mogeneous), and
• hyperechoic spots (single 1–5mm,
highly echogenic dot, or partial
aggregates of1–3mmsized,multiple,
highly echogenic spots)
• EUS is considered superior to
transabdominal US for imaging the
biliary system, with higher ultrasound
frequencies (5–12MHz versus 2–
5MHz).
• Sadamoto et al. proposed EUS
formula:
• Maximum diameter (in millimeters) +
internal echo pattern score
(heterogenous = 4, homogenous = 0) +
hyperechoic spot.
• With this system, the sensitivity and
specificity for the risk of neoplastic
polyps with scores of >12 were 77.8%
and 82.7%, respectively
13. Vijayakumar A, Vijayakumar A, Patil V, Mallikarjuna MN, Shivaswamy BS. Early diagnosis of gallbladder carcinoma: an algorithm
approach. ISRN radiology. 2012 Oct 18;2013.
14. Computed tomography
• Goshima et al. described that the presence of three out of five
findings: Diffuse wall thickening, continuous mucosal layer, intramural
hypoattenuating nodules in the thickened wall, absent liver invasion
and lack of biliary dilatation favors XGC
• The findings of two-layered enhancing pattern of GB wall with
hyperenhancement of thick inner wall ≥ 2.6 mm, non or faint
enhancement of thin outer wall ≤ 3.4mm and focal irregular wall
thickening were seen in GBC
• Presence of enlarged lymph nodes and infiltration of liver favor GBC
• Local staging
15. Positron Emission Tomography
• Increased FDG uptake is seen in malignancy.
• False-positive FDG uptake can be seen in adenomyomatosis or XGC,
resulting in a misdiagnosis of GBC.
• Delayed PET uptake is a feature of malignancy.
• Gupta et al. showed that focal thickening with FDG avidity is a feature
of malignancy.
• For diffuse thickening, SUV value may be helpful. With a cut off value
of 5.95, sensitivity and specificity of PET-CT are 92% and 79%
respectively for diagnosing malignancy
• Systemic staging
16. TWGB with Pancreaticobiliary Mal-junction
• Pancreatic and biliary confluence is outside duodenum and either
sphincters are absent or there is common channel is >6-8mm– High
confluence of pancreaticobiliary ducts (HCPBD)
• There is substantial increase in chance of biliary CA
17. IDUS/PG/ERCP
Vijayakumar A, Vijayakumar A, Patil V, Mallikarjuna MN, Shivaswamy BS. Early diagnosis of gallbladder carcinoma: an algorithm
approach. ISRN radiology. 2012 Oct 18;2013.
18. High suspicion of GBC
• Diffusion weighted MR imaging (DWI) may help to differentiate
between benign and malignant TWGB but is not accurate
• Tumor markers e.g., CEA, CA 19-9 and CA 125 have not been found
to be useful to differentiate between XGC and GBC
• Preoperative FNAC may identify most GBC and some XGC but a
negative FNAC does not exclude GBC.
• Moreover, FNAC is not recommended in resectable GBC because of
fear of tumor spread along the needle tract.
• EUS guided FNAC from TWGB has been reported but requires
equipment and expertise which is not available easily and everywhere.
19. Problem with Simple Cholecystectomy
• If SC is performed for TWGB harboring GBC, it will result in breach
of tumor planes between GB and liver and compromise oncological
principles; this will deny the possible chance of cure in an
early GBC
• Moreover, if SC is done laparoscopically, GB perforation and bile spill
are more likely to happen and may result in peritoneal dissemination
and port site recurrence in malignant TWGB (GBC)
20. What should be done !!
• Refer the patient to higher centres
• Concept of anticipatory Extended cholecystectomy can be exploited
• Extended Cholecystectomy with wedge resection– frozen proceed
• In case of GBC- Radical Cholecystectomy with lymphadenectomy
21. Summary of investigations
Features Benign GB wall thickening Malignant GB wall thickening
Degree of mural thickening Less More *
Symmetry of mural thickening Symmetrical Asymmetrical, irregular, focal thickening
Mural stratification Preserved Lost
Enhancement pattern homogenous or stratified enhancement
Presence of dotted –linear vessels (on CEUS)
Delayed washout (>40 s)
Inhomogeneous enhancement Branched or
linear intralesional vessels (on CEUS) Early
washout (<40 s)
Intramural characteristics Continuous inner wall Intramural cystic
spaces, echogenic foci, hypoechoic nodules,
twinkling artifacts
Focal discontinuity of inner and outer layer
Irregularity and thickening > 1 mm of
innermost layer Irregular thickening of outer
layer
Ancillary findings Pericholecystic fluid in absence of ascites,
intraluminal membranes, sandwich sign, halo
sign, visualization of Rokitansky Aschoff
sinuses
Diffusion restriction, direct invasion of
adjacent organ, biliary obstruction,
lymphadenopathy