ULCERATIVE COLITIS
DEFINITION
It is an inflammatory condition of rectum & colon of unknown aetiology perhaps related to stress, westernized diet, autoimmune factor, familial tendency, allergic factor.
commonly starts in the rectum, spreads proximally to the colon & often into the ileum as back wash ileitis (5%).
INTUSSUSCEPTION (ISS)
DEFINITION
It is telescoping or invagination of one portion (segment) of bowel into the adjacent segment.
TYPES
1. Antegrade: Most common.
2. Retrograde: Rare (jejunogastric in gastrojejunostomy stoma).
CARCINOMA RECTUM
It is common in females.
In 3% of cases, it occurs in multiple sites (syn chronous).
Usually originates from a pre-existing adenoma or papilloma (tubular polyp).
Any tumour within 15 cm proximal to the anal margin is called as rectal tumour/cancer.
More than 95% are adenocarcinoma.
REFLUX OESOPHGITIS
TYPES
Acute: Following burns, trauma, infection, peptic ulcer.
Chronic: Reflux of acid in sliding hernia, after gastric surgery. Reflux is quite common in pregnancy. Site is always in lower oesophagus
REGIONAL ENTERITIS (Crohn’s Disease)
DEFINITION
It is a granulomatous, non-caseating (transmural) inflammatory condition of the ileum commonly and of the colon often.
It is independent of age, sex, socioeconomic status and geographic areas.
DIVERTICULAR DISEASE OF THE COLON
DEFINITION
They are acquired herniations of colonic mucosa through circular muscles at the points where blood vessels penetrate (points of least resistance).
INTUSSUSCEPTION (ISS)
DEFINITION
It is telescoping or invagination of one portion (segment) of bowel into the adjacent segment.
TYPES
1. Antegrade: Most common.
2. Retrograde: Rare (jejunogastric in gastrojejunostomy stoma).
CARCINOMA RECTUM
It is common in females.
In 3% of cases, it occurs in multiple sites (syn chronous).
Usually originates from a pre-existing adenoma or papilloma (tubular polyp).
Any tumour within 15 cm proximal to the anal margin is called as rectal tumour/cancer.
More than 95% are adenocarcinoma.
REFLUX OESOPHGITIS
TYPES
Acute: Following burns, trauma, infection, peptic ulcer.
Chronic: Reflux of acid in sliding hernia, after gastric surgery. Reflux is quite common in pregnancy. Site is always in lower oesophagus
REGIONAL ENTERITIS (Crohn’s Disease)
DEFINITION
It is a granulomatous, non-caseating (transmural) inflammatory condition of the ileum commonly and of the colon often.
It is independent of age, sex, socioeconomic status and geographic areas.
DIVERTICULAR DISEASE OF THE COLON
DEFINITION
They are acquired herniations of colonic mucosa through circular muscles at the points where blood vessels penetrate (points of least resistance).
CURLING ULCER
DEFINITION
They are acute ulcers which develop after major burns, presenting as pain in epigastric region, vomiting or haematemesis.
Curling’s ulcer occurs when burn injury is more than 35%.
It is observed in the body and fundus not in antrum and duodenum
TESTICULAR TUMOURS
PREVALANCE
99% of testicular tumours are malignant.
Life time prevalence of getting testicular tumour is 0.2%.
Very common in Scandinavia; least common inAfrica andAsia.
4 times common in whites than blacks.
ANORECTAL ABSCESS
AETIOLOGY
Most common causative organism is E. coli
Others are
Staphylococcus
Bacteroides
Streptococcus
B. proteus.
Commonly occurs due to infection of anal gland in perianal region.
MECKEL’S DIVERTICULUM
DEFINITION
It is congenital, results from incomplete closure of vitellointestinal duct..
It is the most common congenital anomaly of small intestine.
FISTULA IN ANO
TYPES
It is a track lined by granulation tissue which connects perianal skin superficially to anal canal; anorectum or rectum deeply.
It usually occurs in a pre-existing anorectal abscess which burst spontaneously.
STRICTURE URETHRA
CLASSIICATION -I
I: Aetiologically.
2. Congenital.
3. Inflammatory:
Post-gonococcal
is most common
Gonococcal stricture occurs one year after infection.
Retention develops only 10–15 years later.
HYDRONEPHROSIS (HN)
DEFINITION
It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine.
AETIOLOGY
unilateral
bilateral.
HYDATID CYST
DEFINITION
Word meaning is ‘dew drop’ (Latin).
In Greek it means ‘watery vesicle’.
Echinococcus means ‘hedge hog berry’ in Greek.
Caused by Echinococcus granulosus (EG), dog tape worm .
CURLING ULCER
DEFINITION
They are acute ulcers which develop after major burns, presenting as pain in epigastric region, vomiting or haematemesis.
Curling’s ulcer occurs when burn injury is more than 35%.
It is observed in the body and fundus not in antrum and duodenum
TESTICULAR TUMOURS
PREVALANCE
99% of testicular tumours are malignant.
Life time prevalence of getting testicular tumour is 0.2%.
Very common in Scandinavia; least common inAfrica andAsia.
4 times common in whites than blacks.
ANORECTAL ABSCESS
AETIOLOGY
Most common causative organism is E. coli
Others are
Staphylococcus
Bacteroides
Streptococcus
B. proteus.
Commonly occurs due to infection of anal gland in perianal region.
MECKEL’S DIVERTICULUM
DEFINITION
It is congenital, results from incomplete closure of vitellointestinal duct..
It is the most common congenital anomaly of small intestine.
FISTULA IN ANO
TYPES
It is a track lined by granulation tissue which connects perianal skin superficially to anal canal; anorectum or rectum deeply.
It usually occurs in a pre-existing anorectal abscess which burst spontaneously.
STRICTURE URETHRA
CLASSIICATION -I
I: Aetiologically.
2. Congenital.
3. Inflammatory:
Post-gonococcal
is most common
Gonococcal stricture occurs one year after infection.
Retention develops only 10–15 years later.
HYDRONEPHROSIS (HN)
DEFINITION
It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine.
AETIOLOGY
unilateral
bilateral.
HYDATID CYST
DEFINITION
Word meaning is ‘dew drop’ (Latin).
In Greek it means ‘watery vesicle’.
Echinococcus means ‘hedge hog berry’ in Greek.
Caused by Echinococcus granulosus (EG), dog tape worm .
GASTRIC ULCER
AETIOLOGY
It occurs due to imbalance between protective and damaging factors of gastric mucosa.
Atrophic gastritis
duodenogastric bile reflux
gastric stasis
abnormalities in acid and pepsin secretion.
Acid becomes ulcerogenic even to normal gastric mucosa.
CARCINOMA STOMACH
INCIDENCE
‘It is the captain of men of death’.
It is more common in Japan—70 per 1,00,000 population.
It is more common in males 2:1.
Decrease incidence in western world
Similar to Ulcerative colitis by Dr.AmrithaAnilkumar (20)
RUPTURE OF URETHRA (Anterior Urethra)
Usually, due to a fall astride a projecting object, like in sailing ships, cycling, over loose manhole cover, gymnasium.
RENAL CALCULUS AETIOLOGY
Males- radio-opaque gall stones
Females - Radiolucent gall stones
Diet:Vitamin A deficiency
it causes desquamation of epithelium
which acts as a nidus for stone formation.
Climate:
In hot climate urinary solutes will increase with decrease in colloids,
PARAPHIMOSIS
DEFINITION
Inability to place back (cover) the retracted prepucial skin over the glans is called as paraphimosis.
It causes ring like constriction proximal to the corona and prepuceal skin.
HYPOSPADIAS
DEFINITION
It is the most common congenital malformation of urethra wherein external meatus is situated proximal than normal, over the ventral (under) aspect of the penis.
EPISPADIAS
Here the urethra opens on the dorsum of the penis, proximal to the glans.
COMMON SITES
abdominopenile junction.
It is associated with a dorsal chordee, ectopia vesicae, urinary incontinence, separated pubic bones.
It is uncommon in females.
BENIGN PROSTATE HYPERPLASIA (BPH)
AETIOLOGY
It is benign enlargement of prostate which occurs after 50 years, usually between 60 and 70 years.
BPH affects both glandular epithelium and connective tissue stroma.
It is involuntary hyperplasia due to disturbance of the ratio and quantity of circulating androgens and estrogens.
VARICOCELE
It is dilatation and tortuosity of the pampiniform plexus of veins and so also the testicular veins.
Normally, there will be numerous plexus of veins (pampiniform) in the scrotum,
↓
which all join together to form about 4–8 veins in the inguinal canal.
ORCHITIS
AETIOLOGY
It is an inflammation of the testis.
It is commonly associated with inflammation ofthe epididymis. Hence, called as epididymo-orchitis.
Orchitis is due to infection through blood, lymphatics or epididymis.
EPIDIDYMITIS,
CAUSES
Inflammation of epididymis is commonly associated with orchitis— epididymo-orchitis.
Nonspecific
viral like mumps.
Bacterial.
Filarial.
Tuberculosis
PERFORATED PEPTIC ULCER
PERFORATION
DEFINITION
It is the terminology used for perforation of duodenal ulcer or gastric ulcer or stomal ulcer.
Otherwise all clinical features and management are similar.
Perforation is common in duodenal ulcer
Mortality is more in gastric ulcer perforation and perforation in elderly
Congenital (infantile) hypertrophic pyloric stenosis by Dr.K.AmrithaAnilkumarDr. Amritha Anilkumar
CONGENITAL (INFANTILE) HYPERTROPHIC PYLORIC STENOSIS
DEFINITION
It is hypertrophy of musculature of pyloric antrum, especially the circular muscle fibres, causing primary failure of pylorus to relax.
Duodenum is normal.
PILONIDAL SINUS/DISEASE (Jeep Bottom; Driver’s Bottom)
Pilus—hair; Nidus—nest
It is epithelium lined tract, situated short distance behind the anus, containing hairs and unhealthy diseased granulation tissue.
It is due to penetration of hairs through the skin into subcutaneous tissue.
PILES/HAEMORRHOIDS
DEFINIION
Piles = a ball or mass, Haemorrhoids = blood to ooze, Figs = a fruit (Anjoora).
The word ‘Haemorrhoids’ is derived from Greek word Haima (bleed) + Rhoos (flowering), means bleeding.
The pile is derived from the Latin word ‘Pila’ means Ball
FISSURE IN ANO
It is an ulcer in the longitudinal axis of the lower anal canal.
It is superficial, small but distressing lesion.
Fissure ends above at the dentate line.
HIATUS HERNIA
DEFINITION
It is the most common type of diaphragmatic hernia
TYPES
Sliding hernia (85%).
Rolling hernia (10–12%).
Combined
SAINT’S TRIAD
Hiatus hernia
Diverticulosis
Gallstones .
ACHALASIA CARDIA (Cardiospasm)
DEFINITION
It is failure of relaxation of cardia (oesophago- gastric junction) due to disorganized oesophageal peristalsis, as a result of failure of integration of parasympathetic impulses causing functional obstruction
(Achalasia means failure to relax—Greek).
ACHALASIA CARDIA (Cardiospasm)
DEFINITION
It is failure of relaxation of cardia (oesophago- gastric junction) due to disorganized oesophageal peristalsis, as a result of failure of integration of parasympathetic impulses causing functional obstruction
(Achalasia means failure to relax—Greek).
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
3. ULCERATIVECOLITIS
DEFINITION
• It is an inflammatory
conditionof rectum& colon
of unknownaetiology
perhaps related to stress,
westernized diet,
autoimmune factor, familial
tendency, allergic factor.
• commonly starts in the
rectum, spreads proximally
to thecolon& oftenintothe
ileumas back wash ileitis
(5%).
4. AETIOLOGY
• Westernized diet
• red meat
• Defective mucinproduction
in the colonic mucosaand
mucosal immunological
reaction.
• Autoimmune factors—
cytotoxicT lymphocytes
against colonicepithelial
cells& presence of anti-
colon antibodies.
• Association with HLA DR2
is observedin ulcerative
colitis.
• DR 1501 is associated with
less severe type’
• DR 1502 is associated with
more severe form.
• Appendicectomy &
smoking protects ulcerative
colitis especially from
extraintestinal features
and frompostoperative
complications.
5. • Allergy to milk(cow milk)
and other dietaryfactors.
• Excessreactive oxidative
metabolismin ulcerative
colitis.
• Psychological aspects
• Stress
• Lifestyle
• Personality disorders
PATHOLOGY
To begin with, multiple minute
ulcers (pinpoint ulcers) occur
with proctitis and colitis
↓
Theseulcers extendintothe
deeper layer
↓
Spasmof the bowel
↓
Stricture of the colon↓
Permanently contractedcolon
(pipe stemcolon)
6. ↓
In between ulcers, epithelial
thickening occurs which
appears likepolyps –
Pseudo polyposis
↓
It is confined to mucosaand
submucosa.
↓
no bowel wall thickening
and no granuloma
formation& no skiplesions.
↓
Rectumis alwaysinvolved,
thenspreads proximally.
↓
Entire colonincluding
caecumand appendix may be
involved.
↓
Proctitis occurs in 25%cases.
↓
5%risk of developing rectal
cancer
↓
In 15% left sided ulcerative
colitis presenting withsevere
recurrent diarrhoea.
7. ↓
In 25%patients, total
proctocolitis is the presentation.
↓
Bloody diarrhoea,
Malnutrition.
↓
complications like toxic
megacolon, perforation (steroid
may maskthe features) and
carcinoma are common here.
↓
Pseudo polyps are of
inflammatoryin nature.
↓
Absence of normal mucosa
betweenthesepseudo
polyps is importantto
differentiate it from
neoplastic polyps.
↓
Multiple crypt abscesses
↓
Sparing of the deeper
layersof the colonicwall
↓
Inflammatory
pseudopolyps
↓
8. Multiple pinpointulcers
Increase in substance p
containing nerve fibres
↓
Lymphoidhyperplasia in
mucosaand submucosa
↓
Presence of anti neutrophil
cytoplasmic antibodies with
a perinuclear staining
pattern
↓
Decreasedgoblet cell
mucin
↓
Only in toxic megacolon-
there is acuteinflammation
extending to entire thickness
of the colonicwall including
the serosa.
↓
It is precipitatedby non
specificcauses, during
bariumenema study, due to
drugs like opiates,
antidiarrhoeal drugs and
anticholinergics.
↓
9. Toxic megacolon commonly
affects the transversecolonwhich
will be more than6 cm in
diameter.
↓
Left colon or entire colon also may
be involved.
↓
Caecumwhenrarely involved;
becomes more than10 cm in
diameter.
↓
Colonwill be likewet
blotting paper
↓
Carcinoma in ulcerative
colitis is more prevalent than
in Crohn‘s disease.
10. FACTORS INVOLVEDARE
• Extent of involvement (more
in total colonic)
• Durationof the disease;
continuous active disease
thanintermittent disease.
• Dysplasia developing into
cancer is common.
• Ulcerative colitis with
primary sclerosing
cholangitis has still
increasedriskof
developing cancer.
• In ulcerative colitis,
dysplasia is very
importantfactor to
transforminto
carcinoma.
11. INCIDENCE
• Incidence of carcinoma is
equal in both sexes.
• Carcinoma in ulcerative
colitis is commonly
aggressive
• poorlydifferentiated
• Multicentric
• Synchronous
• infiltrative & scirrhous
• half the patients will
havecolloid carcinoma
(signet ring)
CLINICALFEATURES
• Disease usuallybegins in
rectumas proctitis later
becomes left sidedcolitis
and eventually causes
severetotal proctocolitis.
• Waterydiarrhoea, mucus
or blood staineddis
charge per rectum.
• Colickypain, spasms.
• Decreasedappetite and
loss of weight.
• Relapses and remissions
at regular intervals
12. TYPES
a. Fulminanttype
• 5%common
• It is a severe form, with
continuous diarrhoea
withpassage of blood,
mucus and pus.
• Mimics fulminant
amoebic colitis
• severe typhoid
• Dysentery
• Fever
• Hypokalaemia
• Acidosis
• Dehydration
• Shock
• Abdominal distension
occurs
• Acute toxic dilatation of
transversecolon may
occur wherethe diameter
of transversecolon >6 cm.
• requires surgery
• i.e. either colostomyor
resection withileostomy
and later illeo-anal
anastomosis.
• Here colon is likewet
blotting paper.
13. b. Chronictype
• 95%common
• Lasts for months to
years
• withdiarrhoea
• blood loss
• Anaemia
• Invalidism
• abdominal discomfort
• pain.
• Severe malnutrition
• hypoproteinaemia
INVESTIGATION
• Bariumenema shows loss of
haustrations
• Narrowcontracted
colon (hose pipe colon)
• Mucosal changes
• Pseudo-polyps.
• Sigmoidoscopy &
biopsy.
• Colonoscopy is also required.
• High incidence of malignant
transformation - multiple
biopsies should be taken
16. TREATMENT
• Correctionof anaemia ™
• Fluid and electrolyte
supplimentation™
• Nutrition
• highprotein
• Carbohydrate
• Vitamin
• but low fat diet
• TPN™
Sedatives and
tranquillisers ™
• Psychological counselling
INDICATIONS OF SURGERY
• Intractability—
commonest indication™
• Toxic dilatation ™
• Perforation™
• Haemorrhage ™
• Risk of malignant
transformation
• Dysplasia (DALM) ™
• Onset at earlyage ™
• Chronicinvalidism™
17. • Progressive disease with
• Stricture
• Abscess
• Fistulae ™
• Steroiddependency,
• Persistent active disease™
• Malignancy ™
• Severe extraintestinal
manifestations ™
• Growth retardationin
children
SURGERY
• Total proctocolectomy with
ileo-anal anastomosis with
pouches as reservoir (“J’, ’S’,
or “W’ pouches). I
• It is called as restorative
proctocolectomy withileal
pouchanal anastomosis
(IPAA).
• It is ideal curative
procedurefor ulcerative
colitis.
18. • Total proctocolectomy
with ileostomy
(permanent, continent
Kock’s ileostomy, with one
way valve is done)
• Total proctocolectomy
with end non continent
ileostomy was the earliest
operation done for
ulcerative colitis.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhatM
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das