Early complications: sodes occur in the form of hemateme- • Hemorrhage sis or melena and remains uncontrolled • Paralytic ileus with medical measures buy discount beconase aq online allergy forecast in austin. It can be prevented by In frail and poor risk patient this is done It is therefore discount beconase aq 200MDI free shipping allergy shots and high blood pressure, mandatory to do a drain- i discount beconase aq generic allergy medicine for children under 5. A gastrojejunocolic fstula is an internal of 1 to 2 cm segment of each vagal trunk 48. What is the diference between antrec- communication between stomach, jeju- as it enters the abdomen, on the distal tomy and hemigastrectomy? The terms antrectomy and hemigastrec- a recurrent ulcer afer gastrojejunostomy, 41. What is the most efective surgery for should arouse the suspicion of Zollinger- • Postvagotomy diarrhea occurs in 10 reducing gastric acid output? Why a drainage operation is required with Vagotomy removes the vagal cholinergic to enteritis, caused by colonic content truncal vagotomy? The nature of upper abdominal pain is principal stimuli of gastric secretion are controlling the ulcer. What are the presentations in chronic It removes the major source of gastrin and Regarding pain patient gives the following cholecystitis? Suction of duodenal discharge if the signs and symptoms of any systemic complications like empyema, perfora- drain is in situ, if the drain is not present disease present. Barrier cream like zinc oxide is applied patient is of average build, pulse – 80/ Biliary colic is a sharp, intermittent pain to protect the skin. Abdomen moves normally by contraction of the gallbladder against a gastrojejunostomy. Tis sign is positive in acute this syndrome consisting of- • On palpation, mild tenderness is cholecystitis. The patient is asked to take a deep (stomach, esophagus, jejunum and no lump palpable. Marked increase in gastric acid and there is no free fuid in the abdo- point (a point beneath the right costal secretion. Tere is a catch in breath at the height of Tere will be diarrhea and hypokalemia rectal and per vaginal examination not inspiration and the patient complains of with hypergastrinemia and massive acid done. The patient is female, fertile and 40 and 11th ribs posteriorly on the right Omeprazole in the doses of 20-40 mg years old. Gallbladder is removed leaving a por- Tis is a triangular space bounded by the cholangitis or pancreatitis. What are the steps of operation of open Investigation for ftness of the patient for rienced surgeon. If ultrasonography shows dilatation of anatomy in the Calot’s triangle is not late complication. The advantages of this proce- lation of bile following cholecystectomy Advantages dure include little postoperative pain and in the right sided subdiaphragmatic or a. Metabolic – Altered concentration of wall is healthy and the virulence of the scopic cholecystectomy? The stone consists of concentric layers In case of mucocele of gallbladder, the history extending upto the right iliac fossa. Biliary dyspepsia suggestive of chronic (predominant component) around the cholecystitis. Pain in the right upper abdomen in a gallbladder in the absence of gallstones is a. Patient is having pyriform swelling in Acute acalculous cholecystitis occurs in b. It is lighter than bile, hence called foat- the right hypochondrium which moves the patients in intensive therapy unit, and ing stone. It occurs due to error in cholesterol dullness is continuous with that of the Cholecystoses is defned as chronic acal- metabolism. Which factors are responsible for forma- impacted either in the cystic duct or in dularis proliferans. A male patient aged 60 years presents with with no fuctuating character and there 2. Tere is no past history suggestive of due to back pressure the hepatocytes stool 3 months back which lasted for 10 days. White bile – It is a misnomer as Patient complains of a mass in the right in the gallbladder which is still sof and it is neither bile (actually mucin upper abdomen for last 6 months but no distensible. It is tory of acute or chronic cholecystitis, is The law states that in a patient with obstruc- opalescent. Efects on the intestine – Acute intes- On examination, on general survey, pal- the cause of obstruction is not choledocho- tinal obstruction known as gallstone lor is present, nutrition is poor and deep lithiasis as the gallbladder would have been ileus. The distended gallbladder producing a position and inverted, liver and spleen → not a. The stone impacted in the neck may A lump is palpable in the right hypochon- tion viz. The stone impacted is the neck should fnding (A hard fxed lump in the rectovesi- carcinoma? What are the diferences in clinical presen- rected by administration of injection of cogen stores. The following structures are removed in (ii) Absent Patients with obstructive jaundice are at whipple’s operation (Fig. How does jaundice of a periampullary increased risk for the development of renal a. In periampullary carcinoma, jaundice is tendency due to defciency of vitamin K, b. In carci- infections as a result of depressed immune whole of duodenum upto 10 cm of noma head of pancreas jaundice is persist- system, malnutrition and hypoproteine- proximal jejunum. What investigations will you suggest for Terefore, adequate preoperative prepara- d. Investigations for confrmation of diag- avoid the development of postoperative choledochal lymph nodes. The line of resection is 2 cm distal to widened C-loop in carcinoma head results in an osmotic diuresis and the pylorus. During each attack pain persists for half an hour or so and during 24 hours there are three to four attacks. Following acute pain, patient notched yellowish discolora- tion of the eyes, dark urine and clay-colored stool. Tis yellowish discoloration gradually increased day by day and thereafer started fading ofen disappearing completely by few days. On examination, on general survey patient is of average built, mild pallor and fig. Roux-en-Y cholecystojejunos- titis with jaundice and pancreatic ductal Hernial sites and external genitalia are tomy or obstruction?
Any rise in portal venous branches of lef gastric vein (portal) and with the following problems to the surgeon: pressure above this level is said to be portal lower esophageal veins (systemic) buy beconase aq 200MDI amex allergy symptoms lymph nodes. Gastrointestinal hemorrhage due to vein (portal) and inferior and middle rec- esophageal varices or hemorrhoids order discount beconase aq on line allergy medicine green cap. In the majority (80%) panying the round ligament of the liver investigations of the cases buy beconase aq 200MDI on-line allergy symptoms nyc, the cause of obstruction is within (portal) and superfcial veins of the ante- a. Retroperitoneal and diaphragmatic anas- bleeding from this source and that from vein atresia. Portal vein thrombosis due to: colic veins and the portal radicals with the both of which are common in patients • Spreading portal vein thrombosis in lef renal vein, other tributaries of inferior with cirrhosis. The efect of this anastomosis anatomy of the splenic vein, portal vein, appendicitis. Portal hypertension increases transuda- demonstrate the patency and size of portal b. Ascites Nil Easily controlled Not controlled therapy is the standard treatment for portal 4. Prothrombin time (Prolongation) 1 - 4 4 - 6 Above 6 Treatment should be done only when Grade A = 5 – 6 points, suitable for shunt, prognosis good. Jaundice, Ascites and low albumin are of varices does not mean that they will bleed contraindications for shunt surgery. Tus treatment of portal hypertension • In case of failure of the above measures, 2. Sigura procedure-Sigura extended the may be discussed under the following three balloon tamponade is done. Treatment of acute variceal bleed Balloon Tamponade more extensive periesophageal clearance ii. Defnitive procedures for acute or recur- It exerts direct pressure over the varices and through a thoracotomy. The advantage of rent bleeds is efected by using the Sengstaken tube or its these procedures is that hepatic encepha- iii. The best results • Pulse rate, blood pressure, central venous are seen in patients with compensated liver pressure and urine output should be mon- Definitive Procedures disease. Nonshunt Procedures for deciding the suitability of a patient • Rapid clearing of the blood from the 1. Porta azygos disconnection – In this oper- for shunt surgery and for prognostication bowel should be done with mild purga- ation the varices around the lower end of (Table 36. Tis will reduce ammo- esophagus and upper stomach are divided Indications nia and uric acid levels so as to prevent at the cardio esophageal junction with 1. Intravenous pitressin (vasopressin)-20 cations between the two systems within tioned above. Tis produces a marked fall is portal venous pressure and temporary cessa- tion of bleeding by mesenteric arteri- olar constriction. The complications include postshunt encephalopathy in about 30 to 40 percent cases and intraperitoneal bleeding due to perforation of the liver capsule. Selective shunts – In selective shunts some Child’s ‘C’ class cirrhotics with variceal bleed- had bleeding in the past. The absolute 1 year sur- Types Distal splenorenal shunt (Warren’s shunt) vival is 90 percent. Control of Ascites the liver and the end is anastomosed to It controls variceal hemorrhage • Dietary salt restriction. Partially selective shunts-It employs an • Correction of hypoalbuminemia with encephalopathy is 30 percent because of anastomosis less than 8 mm size to pro- albumin infusion. Tese can • Paracentesis gives immediate relief if dis- comfort is intense but the disadvantage is that the patient loses protein. The shunt has a unidirectional pressure activated valve which shunts ascitic fuid from the peritoneal cavity back into the venous system via the inter- nal jugular vein. Control of Porta-Systemic Encephalopathy Porta systemic encephalopathy may be pre- cipitated by acute hemorrhage, electrolyte imbalance or sepsis in cirrhotic patients. Antibiotics administration – oral neo- mycin to reduce bacterial load inside the bowel lumen, 1 gm 4-6 hourly. Acute form-It is the dangerous type and results in severe abdominal pain, vomit- ing, hypotension and ofen death. Body-The body is in contact with the hormone cholecystokinin secreted by duode- frst part of duodenum. It passes back- It is a pear-shaped organ developed from num in presence of fatty food. Fundus-It is the portion which projects rows into the neck which lies at a higher It is 8 to 12 cm long and has a capacity of just below the sharp lower border of liver level than the fundus and against the free 50 ml. It acts as a reservoir of bile, afer con- at the tip of 9th costal cartilage intersect- edge of the lesser omentum. The wall of centrating it 10 times and expels the same by ing the transpyloric plane. Cystic duct-The neck continues into the cystic duct which is 2 to 3 cm long and 2 to 3 mm in diameter. A series of crescentic mucosal folds, 5 to 12 in number exist in the upper part of the cystic duct due to prominent circular muscle fbers. Cystic vein drains directly into the portal vein which explains early spread of gallbladder malig- nancy to liver. Section 9 Hepatobiliary, Pancreas and Spleen cholecystohepatic triangle or triangle of calot Boundary Base-Common hepatic duct. Caterpillar turn or Moynihan’s hump-It is the very tortuous hepatic artery running in front of origin of the cystic duct. Hepatorenal pouch of Morison-It is a part of subphrenic space which opens into the general peritoneal cavity and lies between Fig. Tere Triad of Choledochal Cyst Ducts of Luschka-Tese are the ducts that is progressive jaundice in the newborn with It consists of jaundice, palpable abdominal drain bile directly from the liver into the steatorrhea. Several small ducts may drain directly common bile duct and more common in in symptomatic patients. The cystic artery may pass in front of the Type I-Cystic or fusiform dilatation of 5. When The most common biliary pathology is gall- It means fbrosis of extra and intra- this is associated with hepatic fbrosis, it is stone. Gallstone disease is common in the 240 hepatic biliary tree either due to viral known as Caroli’s disease. Types excessive hemolysis with increased pro- According to their chemical composition and duction of unconjugated bilirubin, e. Efect on the gallbladder- Cholesterol Stones (6%) leading to biliary sludge and stone for- i. Tey may form either in the is discovered accidentally during gallbladder or in the bile ducts (primary imaging studies such as plain X-ray • Mostly solitary (cholesterol solitaire) ductal stones).
Serum leptin increases as adipose tissue mass increases; thus discount 200MDI beconase aq overnight delivery allergy symptoms cats, leptin is significantly greater in obese subjects than in lean subjects 200MDI beconase aq overnight delivery new allergy treatment 2013. Activation of leptin receptors reduces the expression of neuropeptides that stimulate food intake (neuropeptide Y and agouti-related protein) and increases expression of neuropeptides that reduce feeding (α-melanocyte–stimulating hormone) purchase beconase aq with a visa allergy shots safety. Administration of exogenous leptin to increase serum levels has been tested as a therapy for weight loss in humans, but leptin treatment had only modest effects on appetite and body weight. In addition to regulating food intake, leptin signaling in the hypothalamus also alters anterior pituitary hormone secretion to influence energy expenditure. Reduced caloric intake and starvation initiate a complex series of biochemical and behavioral adaptations to promote survival, one of which is to reduce whole-body energy expenditure. Thyroid hormones stimulate metabolism and increase energy use (discussed in detail in Chapter 32); thus, it is adaptive to reduce thyroid hormone levels during periods of insufficient food intake. Growth and the ability to reproduce are both energy- intensive processes that are also curtailed during starvation. Although leptin circulates in the blood in proportion to the amount of body fat, serum leptin falls rapidly with restriction of food intake, providing a signal to the hypothalamus to conserve body energy stores. Evidence that leptin coordinates the hypothalamic–pituitary response to starvation was originally derived through replacement experiments in rodents. Preventing the starvation-induced fall in leptin by infusion of recombinant protein blunted the reduction in gonadal, adrenal, and thyroid hormones that would normally occur in starved mice. Similar types of replacement experiments have demonstrated that leptin can regulate anterior pituitary hormone secretion in humans. Thus, leptin may prove useful in treatment of disease resulting from reduced hypothalamic–pituitary function secondary to reductions in adipose tissue mass caused by lipodystrophy or excess energy expenditure such as that in highly trained, female athletes. Arginine vasopressin and oxytocin are synthesized in hypothalamic neurons whose axons terminate in the posterior pituitary. Arginine vasopressin increases water reabsorption by the kidneys in response to a rise in blood osmolality or a fall in blood volume. Oxytocin stimulates milk letdown in the breast in response to suckling and muscle contraction in the uterus in response to cervical dilation during labor. Adrenocorticotropic hormone, thyroid-stimulating hormone, growth hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin are synthesized in the anterior pituitary and secreted in response to hypothalamic-releasing hormones carried in the hypophyseal portal circulation. Hypothalamic corticotropin-releasing hormone stimulates adrenocorticotropic hormone release from corticotrophs, which, in turn, stimulates glucocorticoid release from the adrenal cortex, to comprise the hypothalamic–pituitary–adrenal axis. Glucocorticoids, physical and emotional stress, arginine vasopressin, and the sleep–wake cycle regulate adrenocorticotropic hormone secretion. Hypothalamic thyrotropin-releasing hormone stimulates thyroid-stimulating hormone release from thyrotrophs, which, in turn, stimulates triiodothyronine and thyroxine release from the thyroid follicles, to comprise the hypothalamic–pituitary–thyroid axis. The thyroid hormones, cold temperatures, and the sleep–wake cycle regulate thyroid-stimulating hormone secretion. Hypothalamic growth hormone–releasing hormone increases and hypothalamic somatostatin decreases growth hormone secretion from somatotrophs, which, in turn, stimulate the release of insulin-like growth factor I from liver and other target cells, to comprise the hypothalamic– pituitary–growth hormone axis. Luteinizing hormone–releasing hormone stimulates the secretion of follicle-stimulating hormone and luteinizing hormone from the anterior pituitary, which, in turn, affects functions of the ovaries and testes, to comprise the hypothalamic–pituitary–reproductive axis. Hypothalamic dopamine inhibits prolactin release from lactotrophs in the anterior pituitary. Which of the following statements most accurately describes the feedback effects of thyroid hormones? Thyroid hormones exert a negative feedback signal on the hypothalamic–pituitary–thyroid axis to inhibit their own synthesis and secretion. A 30-year-old woman completed a routine pregnancy with the uncomplicated delivery of a normal- sized baby girl 6 months ago. The woman is currently experiencing galactorrhea (persistent discharge of milklike secretions from the breast) and has not yet resumed regular menstrual periods. Galactorrhea is diagnosed if present longer than 6 months postpartum in a nonnursing mother. A 50-year-old man complains of decreased muscle strength, libido, and exercise intolerance. Examination reveals a 10% reduction in lean body mass and an increase in body fat, primarily localized to the abdominal region. Growth hormone deficiency in adults is characterized by decreased muscle strength and exercise intolerance, and a reduced sense of well-being (including effects on libido). Lean body mass (muscle) is lost, and excess body fat deposition occurs in the abdominal region. Glucocorticoid deficiency usually results from primary adrenal insufficiency, as in Addison disease. Clinical symptoms include a decreased sense of well-being, gastrointestinal disturbances, and abnormal glucose metabolism. Adrenal insufficiency is not usually associated with a redistribution of body fat to central stores. The boy’s height is between 2 and 3 standard deviations below the average height for his age. Initial physical examination rules out head trauma, chronic illness, and malnutrition. Insulin resistance is a condition in which tissues in the body do not respond very well to insulin. Explain the function of thyroid-stimulating hormone in regulating the synthesis and release of thyroid hormones. Predict the effect of changes in the concentration of thyroid hormones in the circulation on thyroid- stimulating hormone release from the anterior pituitary. Explain the function of the peripheral tissue deiodinases in synthesizing the physiologically active thyroid hormone triiodothyronine. Describe how triiodothyronine interacts with its receptor and activates transcription of target genes. Outline the effects of thyroid hormones on central nervous system development, growth hormone release, and target tissues such as bone. Explain how thyroid hormone regulates basal metabolic rate and intermediary metabolism. Predict the effects of excess thyroid hormone and thyroid hormone deficiency on metabolic rate, mental status, and body weight. The cell not only meets its basic metabolic “housekeeping” needs but also remains poised to do its own special work in the body, such as conducting nerve impulses and contracting, absorbing, and secreting. During its life span, the cell continues to make the enzymatic and structural proteins that ensure the maintenance of an appropriate rate of metabolism. The thyroid hormones, thyroxine (T )4 and triiodothyronine (T )3, play key roles in the regulation of body development and govern the rate at which metabolism occurs in individual cells. These hormones are not essential for life, but without them, cellular housekeeping moves at a slower pace, eventually influencing the ability of individual cells to carry out their physiologic functions. The thyroid hormones exert their regulatory functions by influencing gene expression and affecting the developmental program and amount of cellular constituents needed for the normal rate of metabolism. A band of thyroid tissue, the isthmus, lies just below the cricoid cartilage and connects the two lobes.
By W. Killian. Salem International University.