In this condition if the patient is made to abduct his shoulder for the initial 30° cytoxan 50mg with mastercard symptoms of appendicitis, he will be able to complete the whole range of abduction with the help of the deltoid muscle discount cytoxan 50 mg fast delivery medications for bipolar disorder. The joints are palpated for local tenderness discount cytoxan 50 mg visa treatment questionnaire, temperature and to assess the swelling. The patient is asked if the joints become painful in different movements of the shoulder joint. X-ray examination — provides most of the required informations regarding diseases of the shoulder joint. It not only shows whether the joint is involved by acute or tuberculous arthritis, rheumatoid or osteoarthritis, but also shows calcification above the greater tuberosity in acute supraspinatus tendinitis. Sometimes the patients complain of referred pain in the shoulder joint due to cervical spondylosis or cervical rib or irritation of the diaphragm following gallstone or splenic rupture. Rheumatoid arthritis is also occasionally seen in shoulder joint and ususally the young adult females are the victims. Tuberculous affection of the joint is occasionally seen and the disease starts as a synovitis or osteomyelitis. In this condition cold abscess and sinus formations (florid type) are not uncommon, but "Caries Sicca" i. Degeneration leads to rapid swelling and tension with often calcium deposition which leads to tremendous pain. The first complaint is obviously a dull ache which quickly gets worse leading to agonizing pain and practically all movements — especially abduction are limited. After a few days pain subsides once the calcified substance has erupted into the subdeltoid bursa. On examination there is tenderness at the point of insertion of the supraspinatus on greater tuberosity just beneath the acromion process. Skiagram will reveal calcification of supraspinatus tendon which later on bursts into the subdeltoid bursa relieving pain. This is a case of pathology and is so situated that on abduction (during the middle acute supraspinatus tendinitis. This is the range of abduction in which there is very little space between the greater tuberosity and the acromion and the thickened supraspinatus tendon becomes nipped between these two bones. The painful arc syndrome is definitely the pathognomonic feature of chronic supraspinatus tendinitis but is sometimes come across in conditions like (a) subdeltoid bursitis, (b) incomplete rupture of the supraspinatus tendon and (c) crack fracture of the greater tuberosity of the humerus. The patient first experiences a pain which becomes worse at night and prevents the patient from sleeping on the affected side. In a matter of months all movements especially abduction and external rotation are restricted. Thus there are three phases of this disease: (i) increasing pain and increasing stiffness, (ii) decreasing pain with persistent stiffness and (iii) disappearance of stiffness with return of all the movements. X-ray appearance is widely accepted as normal, which differentiates this condition from others. The patient usually gives a history of trauma in the way of lifting weight or protecting himself from falling. The pain is felt immediately radiating from the shoulder to the middle of the outer side of the arm. But if he bends to the affected side a little to make an angle of 20° to 30° when the deltoid muscle takes over the process of abduction and completes the full range of abduction. The supraspinatus muscle is concerned to begin the process of abduction which is later carried on by the deltoid muscle. Straight X-ray will not give much information, but arthrography will reveal the tear. In this condition the humeral head can be distinctly palpated below the acromion process which differentiates this condition from the effusion of the shoulder joint. There are numerous causes of this condition and careful examination will reveal the exact cause in a particular case. Patient will complain of pain radiating from the neck towards the shoulder and down the arm with painful and restricted neck movements. X-ray will show diminished disc space, (ii) Tuberculosis of the cervical vertebrae, (iii) Vertebral body tumour, (iv) Cord or root tumour. In the shoulder— (i) Musculo-tendinous cuff lesions, (ii) Arthritis — any arthritis of the joint, be it rheumatoid, osteoarthritis, tuberculosis etc. A history of trauma is almost inevitable in the form of lifting weight or saving himself from a fall. One thing must be noted that pain in the elbow may be referred from the neck or shoulder disorders. Observe the carrying angle (normally it is 10° in case of males and 20° in case of females) and compare it with that of the sound limb. This angle is the outward deviation of the extended and supinated forearm from the axis of the arm. It must be noted that varus or valgus deformity of the elbow is only obvious when this joint remains straight. In case of effusion of the elbow joint, this joint is held in semiflexion position — the position of ease or greatest capacity. Normal hollows on either side of the olecranon and obliterated in effusion of the joint. Great effusion of the elbow joint will also show fullness in the antecubital fossa. Sometimes a bursa beneath the tendon of the biceps near its insertion may become inflamed giving rise to a condition known as bicipitoradial bursitis. This condition also gives rise to a slight swelling in front of the elbow joint which may be missed. In tennis elbow a localized tenderness will be elicited in the region of origin of the common extensor muscles at the lateral epicondyle. The three bony points — the tip of the olecranon, the medial epicondyle and the lateral epicondyle — form a triangle when the elbow is flexed. But these three bony points come to a straight horizontal line when the elbow is extended. In case of effusion of the elbow joint first there is filling up of the concavity on each side of the olecranon, as the synovial cavity is nearest to the surface at this region and the posterior ligament is thin and lax. When more fluid accumulates, a swelling is noticed on the posterolateral aspect of the elbow joint over the radiohumeral joint. Crossed fluctuation can be elicited between this area and swelling over the medial aspect of the olecranon. This sign distinguishes an effusion of the elbow joint from enlargement of bursa beneath the triceps tendon. The node will be palpated on the anterior surface of the medial intermuscular septum one cm above the base of the medial epicondyle. While unilateral enlargement of this lymph node indicates some infective lesions of the hand, wrist and forearm, but bilateral enlargement suggests a generalized disease e. The full range of flexion is 180° from this position that means when the soft tissues of the anterior aspect of the joint come to approximation.
The diagnosis of pheochromocytoma depends on careful analysis of the levels of urinary catecholamines and catecholamine metabolites cheap cytoxan 50mg line treatment hypercalcemia. Any history of recurrent renal stones should of course make the search for hyperparathyroidism even more vigorous buy cheap cytoxan treatment 5th metacarpal fracture. The reason is that it frequently exists in various parts of the gland with multicentricity purchase cytoxan 50 mg otc medicine 101. If the lymph nodes are palpable one sided or bilateral neck dissection should be performed according to the case. To resect lymph nodes in the superior mediastinum, sternal splitting incision may be required. Medullary carcinoma does not respond to thyroxin therapy or radioiodine or to external irradiation. Chemotherapy with Adriamycin has led to some remissions of medullary carcinoma and should be tried if the metastatic disease is progressive. If the patients are found to be hypercalcaemic prior to thyroidectomy, one can expect to find enlargement of parathyroid glands at surgery. This should be done by bilateral subcostal incisions and exploration of both adrenal glands and the sympathetic chain. Adrenal medullary hyperplasia in normal sized adrenal glands is the common finding in these cases. In case of unilateral pheochromocytomas, it is advisable to remove only the tumourous gland. Postoperatively these patients will require long term glucocorticoid and mineralocorticoid as replacement therapy. Ultimately diagnosis is settled by receiving sufficient material by large-needle (Trucut) or open biopsy. When the diagnosis is established by biopsy, radiatidn is the main treatment and it offers a very good response. Occasionally this tumour may be a part of wide spread malignant lymphoma disease, whpn the prognosis is miserable. Chronic thyroiditis is more common which includes Hashimoto’s disease, de Quervain’s thyroiditis and RiedeFs thyroiditis. This disease is characterised by severe pain in the thyroid and in the adjacent neck, fever, chill and rigor. In case of abscess formation pus may extend into the deep spaces of tbe neck and into the superior mediastinum. Treatment consists of extensive antibiotic and drainage of abscess if it has formed. The thyroid gland seems to become sensitive to its own cell constituents and thyroglobulin. Four autoantigens have been detected — (i) Thyroid cell microsomes, (ii) Thyroid cell nuclear component, (iii) Thyroglobulin, and (iv) Nonthyroglobulin colloid. Members of the family with this disease hav« an increased incidence of spontaneous hypothyroidism, goitre, Hashimoto’s disease and less often thyrotoxicosis. Pernicious anaemia and autoimmune gastritis may be seen in the same family which confirms its autoimmune nature. Microscopically there is disruption of epithelial cells and remaining epithelial cells become larger and show oxyphilic changes (Askanazy cells). The main complaint is enlargement of the neck with slight pain and tenderness in the region of the thyroid. The patient may become mild hyperthyroid initially, but hypothyroidism is inevitable. Patient may complain of shortness of breath, fatigue and increase in weight — all related to hypothyroid state. The consistency is firm or rubbery depending upon the degree of fibrous tissue present. Less is the fibrosis the gland will feel soft and rubbery, whereas in case of more fibrosis the gland will be firm. Increased incidence of rheumatoid arthritis, haemolytic anaemia, myasthenia gravis and pernicious anaemia may be seen alongwith this disease. Addison’s disease, diabetes mellitus and ovarian insufficiency may also be seen as part of autoimmune disease. Diagnosis is confirmed by demonstration of high litres of antibodies in the serum. Where facilities for needle biopsy are not available, excisional biopsy is indicated. If the goitre is quite small and the patient is euthyroid no treatment is required. When the patient is hypothyroid and there is a goitre, full replacement doses of thyroxin is required. Surgical treatment is only required (i) when there are pressure symptoms, (ii) in case of an extremely enlarged goitre, (iii) for cosmetic reason when the patient wants it and (iv) when it is difficult to exclude malignant neoplasm. The surgical procedure is usually subtotal thyroidectomy with clearing of the trachea. But majority surgeons like surgical excision in the form of lobectomy and excision of the isthmus as excisional biopsy to exclude malignancy. It must be remembered that majority carcinomas associated with Hashimoto’s disease are of papillary variety. After surgery suppressive therapy with thyroid hormone should always be given postoperatively. Foreign body type of Giant cells containing many nuclei are quite common in this lesion. Prednisolone in the dose of 40 mg daily for 7 days and then the dose is gradually reduced over 1 to 2 months is the effective form of treatment. Salicylates and thyroid hormone may be added to this therapy to make it quite successful. Surgical treatment is contraindicated as possiblity of recovery less to normal thyroid function is there. This inflammatory process extends beyond the limit of the thyroid and involves surrounding fasciae, muscles, nerves, blood vessels, trachea and oesophagus. Symptoms are mosdy due to compression of the trachea, oesophagus and recurrent laryngeal nerve. Extent of removal depends on the amount of involvement of the gland in this disease. When there is bilateral involvement, the isthmus and as much of each lobe as possible should be resected.
Evacuation of intraperitoneal then bring it through a puncture wound in the proximal collections or abscesses accelerates the return to normal jejunum 50 mg cytoxan mastercard treatment zone guiseley. Most of these abscesses can be evacu- catheter with a 4-0 silk purse-string suture buy cytoxan 50mg low price symptoms gluten intolerance. Peptic suture the jejunum to the parietal peritoneum around ulcer of the duodenum or jejunum may occur if the gastric the puncture wound through which the catheter exits order cytoxan toronto medicine mound texas. With bile diverted into the T-tube and all the pan- Postoperative Care creatic juice draining to the outside via the pancreatic duct catheter, one of our patients developed gastric pH 1 Perioperative antibiotics, which were initiated prior to the postoperatively while receiving cimetidine 100 mg/h operation, are repeated by the intravenous route every 4 h intravenously. The patient bled from a superﬁcial pyloro- during the procedure and then every 6 h for four doses post- duodenal ulcer that healed when the pancreatic secretions operatively. If the bile was infected prior to surgery, admin- were injected into the nasogastric tube together with ant- ister antibiotics until the infection is suppressed. During the early postoperative period, it is impor- Maintain the gastric pH at or above 5. Because it is an 89 Partial Pancreatoduodenectomy 821 Complications Leakage from pancreatic anastomosis. In our experience sepsis and hemorrhage are most often the result of leakage from the pancreaticojejunal anastomosis. In some cases this is due to the development of acute pancreatitis in the pancreatic tail. As discussed above, the only solution to this vicious cycle is sometimes surgical removal of the residual pancreas. If the gastric pH is kept elevated by antacid therapy, bleeding due to gastric ulcer- ation is rare. It can be prevented by dissecting these two vital structures with care and precision. We have had two patients who developed gastric phytobezoars following pancreatoduodenectomy with vagotomy. Initiate enteral feedings by way of the jejunostomy cath- Further Reading eter after the operation is completed and continue these feed- ings until the patient is able to take a full diet by mouth. Preoperative biliary stents in pancreatic cancer Leave the T-tube and the pancreatic catheter in place for – proceed with caution. If there has been no drainage of pancreatic juice or and some new insights into pancreaticoduodenectomy. Techniques of pancreaticojejunostomy in pan- this leak of pancreatic juice becomes complicated by an creatoduodenectomy. Long-term survival after vated and start digesting tissues in the vicinity of the anasto- pancreatoduodenectomy for pancreatic adenocarcinoma: is cure mosis. Do preoperative Initially, attempt conservative therapy by continuous irriga- biliary stents increase postpancreaticoduodenectomy complica- tion of the anastomotic site through the catheter using sterile tions? En bloc vascular the patient’s condition continues to deteriorate, relaparotomy resection for locally advanced pancreatic malignancies inﬁltrating to remove the remaining tail of the pancreas together with major blood vessels: perioperative outcome and long-term survival the spleen may prove lifesaving. Pancreaticoduodenectomy with or pancreaticoduodenectomies in the 1990’s: pathology, complications, without extended retroperitoneal lymphadenectomy for periampul- and outcomes. Chassin† Indications centrates on the additional features necessary to complete the pancreatic resection and should be read in conjunction with Carcinoma of the pancreas (see Chap. Contraindications Documentation Basics Distant metastases Findings Absence of an experienced surgical team Patient who lacks alertness and intelligence to manage diabetes Operative Technique Invasion of portal or superior mesenteric vein Incision Preoperative Preparation Except for extremely stocky patients, we use a long midline incision from the xiphoid to a point 10 cm below the See Chap. Operative Strategy Evaluation of Pathology, Determination of Resectability, Initial Mobilization Complete omentectomy is generally performed as part of a total pancreatectomy. Division of the splenic, short gastric, The technique followed here is identical to that described in right gastric, and gastroduodenal arteries leaves the gastric Figs. For this reason, do not divide the left gastric artery at its removed with the specimen (Figs. Rather, divide it along the lesser curvature distal to the point where the branches to the proximal stomach and esophagus arise. This chapter con- Splenectomy and Truncal Vagotomy With the stomach and omentum retracted in a cephalad direction, identify the splenic artery along the superior sur- C. Make an incision in the Ligate the gastric side of the vessel with 2-0 or 3-0 silk and avascular lienophrenic fold of the peritoneum (Fig. Elevate the tail of the until all of the short gastric vessels have been divided pancreas together with the spleen. Expose Now redirect attention to the tail and body of the pan- the posterior surface of the spleen and identify the splenic creas, which is covered by a layer of posterior parietal peri- artery and veins at this point. Insert moist gauze pads into the bed of the border of the pancreas and then again along the inferior elevated spleen. As the pancreas is elevated from costal margin and place it in the region of the sternum. Apply the posterior abdominal wall, follow the posterior surface traction in a cephalad and anterior direction, exposing the of the splenic vein to the point where the inferior mesen- abdominal esophagus. Incise the peritoneum over the teric vein enters; then divide this vessel between 2-0 silk abdominal esophagus. Follow the splenic artery to its point rate the crus of the diaphragm from the esophagus (Fig. Carefully dissect the junction Mobilizing the Distal Pancreas of the splenic and portal veins away from the posterior wall of the pancreas. After 2 cm of the terminal portion of Identify the proximal short gastric vessel, and insert the the splenic vein has been cleared (Fig. Apply a ligature to the distal end and an atrau- matic bulldog clamp to the proximal end and divide the duct. Freeing the Uncinate Process Cholecystectomy and Division of the Hepatic Duct Retract the spleen, pancreas, and duodenum to the patient’s right. Gentle dissection discloses three or four venous The hepatic duct, portal vein, and hepatic artery have already branches between the posterior surface of the pancreatic been stripped of overlying peritoneum and lymph nodes. It bladder by dissecting it out of the liver bed from above down is now possible gently to retract the portal vein to the right. Obtain complete hemostasis in the liver bed At this point the superior mesenteric artery can generally be with electrocautery. Be certain that Expose the ligament of Treitz by elevating the transverse hemostasis is complete. Divide the jejunum as previously described and suction-drainage catheter in the right upper quadrant of the remove the specimen (Fig. The hepaticojejunostomy is performed ﬁrst, as Postoperative Care described in Chap. At a point about 50 cm downstream from the hepatico- The principles of postoperative care described in Chap.
The maxilla is rarely affected due to the fact that series of vertical arteries anastomose and maintain the blood supply to the bone purchase 50mg cytoxan symptoms zoloft overdose. Pain cytoxan 50 mg amex symptoms tracker, swelling buy generic cytoxan on-line medications related to the lymphatic system, tenderness and irregularity of the bone are usual features of this condition. Increased tension in the dental canal compresses the inferior dental nerve causing numbness of the chin in the distribution of the mental nerve. This condition usually follows apical dental infection or alveolar abscess or fractures. Chronic osteomyelitis may also follow radiation or chemical necrosis due to phosphorus poisoning. The cortical plate is penetrated and the abscess accumulates deep to the mentalis muscles. The pus ultimately escapes to the surface only in the midline through a sinus in a centre of the chin. The overlying skin becomes indurated and bluish in colour which gradually softens in patches. Swelling, brawny induration, irregularity of the bone with multiple sinuses are the features of this condition. There may be respiratory obstruction in case of neonates with micrognathism, as this deformity results in backward displacement of the tongue. Special airway plates should be used to prevent airway obstruction, which is much better than sewing of the tip of the tongue to the lower lip. Nowadays monoblock orthodontic appliance has been devised to correct this small mandible. Occasionally the maxilla may be hypoplastic producing a relative mandibular prognathism. Carcinoma of lip and Carcinoma of tongue occur more often in males above 50 years of age. While a mucous retention cyst usually occurs on the inner side of the lip or cheek and grows very slowly and presents for quite a long time; a cancer of the lip may present as a swelling or ulcer, gives a relatively short history though it is a slow-growing cancer and a cancer of the tongne gives an even shorter history. Pain is conspicuous by its absence in leukoplakia, mucous retention cyst and early stage of carcinoma of lip or tongue. If an old patient presents with ulcer of his tongue, but without pain, is an ominous sign. But it must be remembered that in late cases pain appears even in carcinoma of tongue. In certain late cases of carcinoma of tongue pain is referred to the ear of the affected side as lingual nerve and auriculotemporal nerve supplying the anterior surface of the external ear are both the branches of the mandibular nerve. If an old patient is seen in surgical outdoor holding handkerchief in his mouth, he is most probably suffering from carcinoma of tongue. Inability to protrude the tongue is a symptom of tongue-tie and late cases of carcinoma of tongue with invasion to the floor of the mouth. Difficulty in speech is the main complaint of cleft lip and cleft palate and carcinoma of tongue. Deviation of tip of the tongue when protruded towards the side of the lesion is a sign of carcinoma of tongue. Alteration of voice may be the first symptom in carcinoma of posterior 1/3 of the tongue which may remain unnoticed for quite sometime. To inspect the lips properly not only the outer surfaces of the lips are examined, but also the lips are retracted to see the mucosal surface of the lips. Similarly the cheeks are retracted outwards to see the buccal mucosal surface of the cheek as also the buccal side of the gum. To see the inside of the gum and floor of the mouth, the tongue is pushed away to one side or the other. For inspection of the tongue, the mouth is fully opened and the tongue is protruded to see the anterior 2/3rd of the tongue. To see th’e lateral aspect of its posterior third the tongue is pushed to one side or the other with a spatula. To see the fauces, tonsils and the beginning of the pharynx, one should depress the tongue with a spatula. Cleft lip may be complete when there is total failure of fusion and then the cleft extends upto the corresponding nostril. There may be bilateral complete cleft lip in which there is also a cleft palate and a protruberant pre-maxilla. This syndrome is a familial disease which is inherited by autosomal dominant gene and the main pathology lies in the small bowel in the form of adenomatous polyp which may cause intussusception or intestinal colic, but rarely undergo malignant change. Cracked lips are indolent cracks in the midline of the lower lip as a result of exposure to cold weather. Ectopic salivary neoplasms are usually seen in the upper lip as slow growing lobulated tumours. Carcinoma of the lip is seen in old individual which presents as erosion in the early stage — as red granular appearance with whitish flecks followed by yellowish crusting in the middle of the erosion. Congenital fissures are mainly transverse whereas syphilitic fissures are usually longitudinal, (d) Swelling and (e) An ulcer if any. If there is a swelling or an ulcer, note its site, size, shape, colour, surface, margin etc. Note also whether it has extended to the floor of the mouth, to the jaw or tonsil. Very rarely one can discover an angioma-like swelling in the region of the foramen caecum — this is lingual thyroid. This may be the only thyroid gland the patient possesses and therefore should not be removed. If the tongue deviates to one side during the protrusion, it indi cates impairment of nerve supply to that half of the tongue. This may be noticed in advanced carci noma of the tongue which has damaged the nerve supply of the consequent side. In case of a congenital cleft, note the extent of the cleft (involving only the uvula, only the soft palate or part or whole of the hard palate) and also whether the nasal septum is hanging free or is attached to one side of the cleft. Perforation of the hard palate is usually caused by gumma (syphilitic affection) (Fig. The student must be careful to note if there is any scar of operation around or such history, as sometimes a hole may persist after an operation for closure of a congenital cleft. A spatula and a torch will be essential to visualize more posterior portions of the gums. The earliest sign of pyorrhoea alveolaris is a deep red line along the free edge of the gum. Cancrum oris starts with a painful purple-red indurated papule found on the alveolar margin in the region of the molar or premolar teeth.
Extensive extramedullary hematopoiesis (hepato- splenomegaly and lymphadenopathy) purchase generic cytoxan on-line treatment 2nd 3rd degree burns. Picture-frame vertebral body with pelvis purchase cytoxan 50mg treatment qt prolongation, and hips in a 74-year-old woman with the tarda form of condensation of bone along its peripheral margins (ar- this condition cheap 50 mg cytoxan overnight delivery medicine in the 1800s. There is straightening of the anterior surface of the bone (arrowhead) and involvement of the pedicles. Patients have short there is mandibular hypoplasia with loss of the stature, but hepatosplenomegaly is infrequent. Unlike osteopetrosis, in the long bones the medullary cavities are preserved, and there is no metaphyseal widening. Obliteration of individual with a high concentration of fluorides, industrial trabeculae may cause affected bones to appear exposure (mining, smelting), or excessive thera- chalky white. There is often calcification of inter- peutic intake of fluoride (treatment of myeloma or osseous membranes and ligaments (paraspinal, Paget’s disease). Areas of increased scle- rosis subjacent to the cartilaginous plates produce the characteristic “rugger jersey” spine in this pa- tient with chronic renal failure. Hyper- trophy of cartilage widens the intervertebral disk spaces, whereas hypertrophy of soft tissue may lead to an increased concavity (scalloping) of the pos- terior aspects of the vertebral bodies. Increased trabeculation, which is most prominent at the periphery of the bone, produces a rim of thickened cortex and a picture-frame appearance. Dense sclerosis of one or more ver- tebral bodies (ivory vertebrae) may present a pattern simulating osteoblastic metastases or Hodgkin’s disease, though in Paget’s disease the vertebrae are also enlarged. Congeni- tal fusion can usually be differentiated from that resulting from disease because the total height of the combined fused bodies is equal to the normal height of two vertebrae less the intervertebral disk space. Enlargement of all vertebral bod- 4 of a vertebral body, producing an ivory vertebra. Benign bone tumor Expansion of a vertebral body may result from hemangioma, aneurysmal bone cyst, osteoblas- toma, or giant cell tumor. Fibrous dysplasia Proliferation of fibrous tissue in the medullary cavity may infrequently involve the spine and cause one or more vertebral bodies to expand. Essentially complete fusion of the cervical spine into a solid mass in a patient with Klippel-Feil deformity. Primarily the bone density of the vertebral body decreases the involves the lumbar and lower thoracic spine cortex appears as a thin line that is relatively dense (where weight-bearing stress is directed toward and prominent, producing a picture-frame pattern. In addition to the typical “fish vertebrae” appear- ance, osteoporotic vertebral bodies may demon- strate anterior wedging and compression fractures. The characteristic concave contours of the superior and inferior disk surfaces result from expansion of the nucleus pulposus into the weakened vertebral bodies. Hyperparathyroidism Generalized demineralization of the vertebral Subchondral resorption at the diskovertebral bodies produces arch-like contour defects of junctions produces areas of structural weakening the superior and inferior vertebral surfaces, that allow herniation of disk material into the simulating osteoporosis. In patients with hyperparathyroidism secondary to renal failure, thick bands of increased density adjacent to the superior and inferior margins of vertebral bodies produce the characteristic “rugger jersey” spine. This results in a striking thickening of the cortices and increased trabeculation of spongy bone. Nevertheless, the bony architecture is abnormal and is prone to fracture with relatively minimal trauma. Severe loss of bone substance in the the pedicles (lacking red marrow) that are fre- spine often results in multiple vertebral com- quently destroyed by metastatic disease. Metastases Destructive process involving not only the Destruction of one or more pedicles may be the vertebral bodies but also the pedicles and neural earliest sign of metastatic disease and aids in arches. Pathologic collapse of vertebral bodies differentiating this process from multiple myeloma frequently occurs in advanced disease. Because cartilage is resistant to invasion by metastases, preservation of the intervertebral disk space may help to distinguish metastases from an inflamma- tory process. Osteomyelitis Pyogenic Various radiographic patterns, including disk Rapid involvement of the intervertebral disks space narrowing, loss of the normally sharp (loss of disk spaces and destruction of adjacent adjacent subchondral plates, areas of cortical end plates), in contrast to the vertebral body demineralization, vertebral body destruction involvement and preservation of disk spaces in and even collapse, and sclerotic new bone metastatic disease. The diffuse myelomatous infiltration causes generalized demineralization of the vertebral bodies and a compression fracture of L2. Unlike pyo- genic infection, tuberculous osteomyelitis is rarely associated with periosteal reaction or bone sclero- sis. In the untreated patient, progressive vertebral collapse and anterior wedging lead to the develop- ment of a characteristic sharp kyphotic angulation and gibbous deformity. Healed lesions may demon- strate mottled calcific deposits in a paravertebral abscess and moderate recalcification and sclerosis of the affected bones. Fungal infections Generally produce spinal involvement mimick- Infrequent manifestation of actinomycosis, blasto- ing tuberculosis. Severe compressive patients, it may be difficult to distinguish an acute forces may drive the nucleus pulposus into the spinal fracture from the vertebral compression that vertebral body, resulting in a burst fracture with is frequently associated with osteoporosis. In the posterosuperior fragment often driven into acute trauma, there is often evidence of cortical the spinal canal. In patients who have jumped disruption, a paraspinal soft-tissue mass, or an ill- from great heights, compression fractures of defined increase in density beneath the end plate the thoracolumbar junction are frequently of an involved vertebra, indicating bone impaction. In osteoporosis, vertebral compression is often associated with osteophytic spurs arising from the apposing margins of the involved and adjacent vertebral bodies. An acute spinal fracture may be difficult to distinguish from a pathologic fracture caused by metastases or multiple myeloma. The affected vertebrae tend to become produces a dorsal kyphosis, which persists even wedge shaped (they decrease in height ante- after the disease has healed. The overall radiographic appearance is indistinguishable from that of tuberculous spondylitis. Paget’s disease Arch-like contour defects of the superior and Although there is typically enlargement of the inferior vertebral surfaces or a pathologic frac- vertebral body with increased trabeculation that is ture. There may also be which retard growth in the central portion of the biconcave indentations on the superior and vertebral cartilaginous growth plate while the inferior margins of the softened vertebral bodies periphery of the growth plate (with a different blood due to expansile pressure of the adjacent supply) continues to grow at a more normal rate. Gaucher’s disease Localized step-like central depression of mul- Probably caused by circulatory stasis and ischemia, tiple vertebral end plates. This inborn error of metabolism is characterized by the accumulation of abnormal quantities of complex lipids in the reticuloendothelial cells of the spleen, liver, and bone marrow. Severe kyphoscoliosis results from a combination of ligamentous laxity, osteoporosis, and post-traumatic deformities. Although the degree of compres- sion may be substantial, the fractures infrequently cause pain and usually do not lead to neurologic sequelae. Amyloidosis Loss of bone density and collapse of one or more Rare manifestation caused by diffuse infiltration of vertebral bodies. Gene- ralized demineralization with collapse of vertebral bodies is usually a manifestation of underlying multiple myeloma. Hydatid (echinococcal) cyst Expanding lytic lesion causing a pathologic Bone involvement occurs in approximately 1% of fracture. Thanatophoric dwarfism Extreme flattening of hypoplastic vertebral An H or U configuration of the vertebral bodies can bodies. Generalized flattening of verte- bral bodies associated with fractures of multiple ribs and long bones in an infant.
The obstruction can be demonstrated after the introduction of a small amount of oily contrast material into the nostrils purchase cytoxan us treatment 3rd nerve palsy. Enlarged tonsils and Soft-tissue mass narrowing the airway in the May be gross hypertrophy without upper airway adenoids (Fig C 44-5) nasopharynx and oropharynx cheap cytoxan 50mg mastercard medications you can take while pregnant. Lateral view of the neck shows a sharply defined homogeneous soft- tissue density (arrow) arising from the upper anterior Fig C 44-5 portion of the trachea discount cytoxan 50 mg with visa medications 563. Marked perienced dyspnea and inspiratory stridor for several impressions (arrows) on the upper airway. Pharyngeal airway Micrognathia associated with airway obstruc- Pierre Robin syndrome (cleft palate, micrognathia, obstruction by retroplaced tion that varies between inspiratory and ex- retrodisplaced tongue); Möbius’ syndrome (cranial tongue piratory films. Esophageal atresia and Blind air-filled upper esophageal pouch causing Diagnosis confirmed by the looping of a radiopaque tracheoesophageal fistula anterior displacement and compression of the catheter (may inject a small amount of contrast (Figs C 44-6 and C 44-7) tracheal air shadow. Laryngomalacia Downward displacement and buckling of the Aryepiglottic hypermobility (the larynx itself is aryepiglottic folds in inspiration. Tracheomalacia Collapse of the trachea on expiration (may be Entity that is distinct from laryngomalacia, much (Fig C 44-8) focal or generalized). Congenital vocal cord Unilateral or bilateral absence of normal Life-threatening if bilateral (vocal cords tend to paralysis movement of the vocal cords. Contrast material injected through a feeding tube demonstrates occlusion of the proxi- mal esophageal pouch (arrows) in (A) frontal and (B) lateral projections. Note the sharp downward course of the fis- tula from the trachea to the esophagus (arrow). Wiedemann syndrome (visceromegaly, omphalo- cele or umbilical hernia, pancreatic and adrenal hyperplasia, increased bone age, or neoplastic disease). Membranous stenosis in a glottic, supraglottic, or (Fig C 44-10) infraglottic position. Extension of the characteristic membrane from the pharynx into the larynx, trachea, and even the bronchial tree can lead to increasing airway obstruction, cyanosis, and even death. Life-threatening anaphylactic reactions occur seconds to minutes after the administration of a specific antigen (generally by injection, as with radiographic contrast material or less commonly by ingestion) and cause upper or lower airway obstruction, or both. Laryngeal edema may be experienced as a “lump” in the throat, hoarseness, or stridor, while bronchial obstruction is associated with a feeling of tightness in the chest or audible wheezing. Conditions include benign and malignant tracheal tumors and diffuse tracheal narrowing (postintubation edema, tracheobronchitis, posttraumatic stenosis, re- lapsing polychondritis). Causes of mediastinal Lymph node enlargement (sarcoidosis, metastases, widening lymphoma, tuberculosis, histoplasmosis); hemor- (Fig C 45-1; see Figs C 14-4, rhage from blunt chest trauma; mediastinitis; C 14-5, and C 14-8) intrathoracic goiter; and postsurgical changes from mediastinoscopy, cardiac surgery, and right radical neck dissection. Neurofibromatosis involving the right vagus nerve can also cause widening of the right paratracheal stripe. Pleural disorders Diseases that cause thickening of the parietal or visceral pleura or an increase in pleural fluid can widen the right paratracheal stripe. These include free or encapsulated pleural effusion, mesothe- lioma, and pleural thickening or fibrosis from any cause. Miscellaneous disorders Right upper lobe atelectasis, radiation fibrosis, polyarteritis nodosa, Wegener’s granulomatosis, and desquamative interstitial pneumonia. In approximately 10% of individuals, the hemidiaphragms are at the same height or the left is higher than the right. Eventration Unilateral hypoplasia of a hemidiaphragm (very (Figs C 46-1 and C 46-2) rarely both) with the thinned, weakened muscu- lature inadequate to restrain the abdominal viscera. Localized eventration primarily involves the anteromedial portion of the right hemidia- phragm, through which a portion of the right lobe of the liver bulges. In a posterior eventration, upward displacement of the kidney can produce a rounded mass. Eventrations may have paradoxical diaphragmatic motion (though more commonly seen in diaphragmatic paralysis). Phrenic nerve paralysis Unilateral or bilateral diaphragmatic elevation (Fig C 46-3) with characteristic paradoxical motion of the diaphragm (tends to ascend rather than descend with inspiration). Results from any process interfering with the normal function of the phrenic nerve (inadvertent surgical transection, primary bronchogenic carcinoma, or mediastinal metas- tases); intrinsic neurologic disease (poliomyelitis, Erb’s palsy, peripheral neuritis, hemiplegia); injury to the phrenic nerve, thoracic cage, cervical spine, or brachial plexus; pressure from a substernal thyroid or aneurysm; or lung or mediastinal infection (paralysis may be temporary). Also perinephric, hepatic, or splenic abscess; pancre- atitis; cholecystitis; and perforated ulcer. Intra-abdominal mass Unilateral or bilateral diaphragmatic elevation (Fig C 46-4) caused by enlargement of the liver or spleen; abdominal tumor or cyst of the liver, spleen, kidneys, adrenals, or pancreas; or distended stomach or splenic flexure (left hemidiaphragm). Primary bronchogenic carcinoma (arrow) involving the phrenic nerve causes paralysis of the right hemidiaphragm. Tumor or cyst of diaphragm Very rare lesion that simulates unilateral dia- phragmatic elevation. On (Fig C 46-6) frontal views, the peak of the pseudodiaphragmatic contour is lateral to that of a normal hemi- diaphragm (situated near the junction of the middle and lateral thirds rather than near the center). Altered pulmonary volume Unilateral or bilateral diaphragmatic elevation due to atelectasis (associated pulmonary opacity); postoperative lobectomy or pneumonectomy (rib defects, sutures, shift of the heart and mediastinum); hypoplastic lung (crowded ribs, mediastinal shift, absent or small pulmonary artery, sometimes the scimitar syndrome). Diaphragmatic hernia Mimics unilateral diaphragmatic elevation on (Figs C 46-7 and C 46-8) frontal views. Lateral views show the characteristic anterior location of Morgagni’s hernia or the posterior position of Bochdalek’s hernia. Injury diaphragm to the right side causes herniation of the soft-tissue (Figs C 46-9 and C 46-10) density of the liver into the right hemithorax. On the left, air-containing stomach and bowel herniate into the chest (may mimic diaphragmatic elevation if the bowel loops are filled with fluid). The peak of the pseudodiaphrag- due to splinting secondary to a right lower lung infiltrate. Herniation of a portion of the splenic flexure (arrow), with obstruction to Fig C 46-8 the retrograde flow of barium. Also (Fig C 47-1) pleural, vascular, and bronchial interfaces with occurs in patients with asbestosis and colla- normal parenchyma. The predominant pattern of ground-glass (rather than reticular) opacities is seen in nearly all patients, reflecting the presence of intra-alveolar macrophages and interstitial inflammation. Typical litis, chronic eosinophilic pneumonia, and collagen peribronchial thickening. In most patients, however, no cause is found and the condition is referred to as idiopathic or cryptogenic. Scan at the level of the right upper lobe bronchus in a woman with id- iopathic pulmonary fibrosis shows a reticular pattern and irregular in- terfaces predominantly in the sub- pleural lung regions. Scan at the carinal level shows patchy areas of air- space opacification (“ground-glass” density). Air-space consolidation in the subpleural regions associated with peribronchial thickening (arrows). Usually most evident in the lung periphery, where (Fig C 47-5) the septa appear as lines running perpendicular to the pleura. Sarcoidosis Irregular nodules or interstitial thickening along In late stages, fibrosis typically radiates from the (Fig C 47-6) the bronchovascular bundles. Scan through the septa (small arrows) and ill-defined centrilobular opac- right lower lung shows extensive abnormalities with ities (large arrows).
These tumours may occur in the epithelial tissue purchase cytoxan with visa treatment quotes images, connective tissue and in the perinephric tissue purchase 50 mg cytoxan amex symptoms zinc toxicity. Benign tumours are (i) adenoma discount cytoxan online master card medications prescribed for pain are termed, (ii) haemangioma, (iii) carcinoid tumours, (iv) fibromas, (v) lipoma, (vi) myomas, (vii) neurofibromas, (viii) angiomyolipoma (hamartoma) and (ix) endometriosis. Such adenomas may occur in any part of the cortex, although they are commonly seen close to the surface. The tumour has got all the elements like excessive blood vessels, muscle elements and excessive fat. It is interesting to note that ‘A th of this tumour may turn malignant and may lead to metastasis. Adenocarcinoma, which occurs in adults usually above the age of 40 years and constitutes 4/5ths of all renal neoplasms. Nephroblastoma, which is exclusively a tumour of children, mostly occurs under 4 years of age, average 1 to 7 years. Between the ages of 7 years and 40 years malignant neoplasms of kidney are unusual. Von Grawitz considered this tumour to arise from ‘adrenal cortical rest’, which may sometimes be present in the cortex of the kidney. He came to this view as the microscopic appearance of the tumour closely resembles that of the zona glomerulosa of the adrenal cortex. Subsequently this view has been cancelled from the facts :— (i) That hypernephroma is never seen in other sites e. The aetiology of renal cell carcinoma is still uncertain, although a number of factors have been recognised which increase the risk of developing this carcinoma. These are — Shoe workers; Workers exposed to cadmium, particularly if they smoke; Leather tanners; Those who are exposed to contrast medium thorotrast; those exposed to petroleum products. Chronic administration of oestrogen to males in animal models have induced renal cell carcinoma. Renal cell carcinoma is not a typical familial disease, though it has been found to affect more than 1 member in the family. Autosomal dominant von Hippel-Lindau syndrome (cerebelloretinal haemangioblastomatosis) is considered to possess a high risk in developing this disease, which occurs at an earlier age than usual and is often bilateral. Most of the chromosomal abnormalities which have been described in spontaneous renal cell carcinoma involve deletions in the short arm of chromosome 3. As the tumour gradually grows in size, it compresses adjacent renal tissues and displaces calyces and the pelvis. This tumour is more common in the upper pole than lower pole, but are rarely found in other parts of the kidney. On cut surface the two chief characteristic features are its yellow colour and remarkable variegated appearance. The tumour cells may be (i) large with clear abundant cytoplasm with small eccentric nuclei, which are known as clear cells, (ii) small and compacl with cytoplasm containing basophilic granules, which are known as granu lar cells (dark cells), (iii) large and eosinophilic cells known as oncocytic cells and (iv) anaplastic cells. The clear cells are large and peculiarly clear owing to the presence of abundant lipids and glycogen. The majority are clear cell type, whereas the dark cell type is usually less common. The microscopic appear ance is very much similar to renal adenoma, from which many of these tumours arise. A particular type which is known as papillary cystadenocarcinoma is mainly composed of large eosinophilic cells (oncocytes), which are cystic with papillary arrangements. The anaplastic cells extremely vary in size and shape which may be polygonal or fusiform. This probably accounts for haemorrhages inside the tumour and great tendency of the tumour for blood spread. After the renal capsule has been penetrated, the surrounding perinephric fat is gradually invaded. When the tumour penetrates through the renal capsule and invades the perirenal fat, it then metastasises to the lymph nodes in relation to the hiluni of the kidney and from there to the paraaortic group of lymph nodes. Involvement of regional lymph nodes is reported in only 20% of cases undergoing radical surgery. Blood spread occurs in two ways — (i) by embolism, in which pieces of growth become detached and are swept into the venous circulation to become first arrested in the lungs. In the lungs the metastasis produces ‘cannon-ball’ deposits which are revealed in X-ray as round opaque metastases in the lungs and later on further small pieces may enter into arterial circulation and may be deposited in the bones. Thus the tumour may extend through the inferior vena cava into the right atrium keeping continuity with the parent tumour. Sometimes the solid columns of tumour tissue inside the renal vein may cause obstruc tion to the testicular vein particularly on the left side, in which side the testicular vein drains into the renal vein. Obstruction of drainage of the testicular vein may cause varicocele on the left side. So sudden left sided varicocele in an old man should arouse suspicion of adenocarcinoma affecting the left kidney. Through blood spread multiple metastases are common, though occasionally one may find solitary me tastasis only in the lung. In X-ray film the secondary deposits in the lung often present round appearance with a clean-cut circumscribed outline, to which the name cannon-ball appearance has been applied. In the bone the tumour is remarkably destructive or osteolytic so that it may cause pathological fracture later on. A solitary metastasis in the bone occurs more frequently in this than in any other tumour. It is the third tumour surpassed only by lung and breast to involve brain by metastasis. Its maxi mum incidence, which constitutes about l/3rd of cases, is in the 6th decade. As mentioned, bleeding is painless unless accompanied by renal colic due to passage of blood clots. Such low grade pyrexia is often due to absorption of blood and necrotic material from the tumour itself. This type of pyrexia usually disappears after nephrectomy, but if it persists, it indicates presence of metastasis. Such symptoms are :— (a) In case of lung metastasis — persistent cough, haemoptysis, chest pain and dyspnoea. Oedema of the legs may be occasionally seen which is secondary to neoplastic involvement of the inferior vena cava. Physical examina tion of the chest may not reveal any definite sign, though metastasis is present. Liver is a common site of metastasis, in which case it becomes enlarged and nodular. Haematuria is the earliest symptom and all cases of haematuria should be investigated with utmost care to exclude malignant tumour in the urinary tract. If blood is seen coming through one ure teric orifice and clear urine through the other orifice, probably he is having an adenocarcinoma or a papil loma in that kidney. Excretory urography and other investigations as mentioned below should be per formed quickly to exclude adenocarcinoma of the kidney.