Thursday, January 24, 2013

Liver trauma




Portal triad
Blood supply


Liver trauma is divided into:
  • Blunt and
  • Penetrating injuries
  • Blunt injury produces contusion, laceration and avulsion injury.
  • Penetrating injuries (like stab and gunshot wounds are often associated with chest or pericardial involvement.

Blunt force-liver injury
Penetrating injuries

Clinical features
  • Features of shock due to severe bleeding.(pallor, hypotension, tachycardia, sweating)
  • Distension of abdomen with dull flank, guarding, tenderness and rigidity.
  • Oliguria
  • Tachypnoea, respiratory distress and often cyanosis.
  • Rupture of right lobe is more common than the left lobe leading to haemoperitoneum.
  • Occasionally can cause localised hematoma which may form an abscess.
  • Bile leak from the injured site can lead to biliary peritonitis.

Investigations
  • Chest X-ray to look for the rib fracture.
  • USG abdomen
  • CT scan of chest and abdomen
  • Diagnostic peritoneal lavage
  • Hb%, PCV, blood groouping and cross matching.
  • Arterial blood gas analysis (ABG)
  • Coagulation profile.

Treatment :

General measures

Maintain airway
Breathing
Circulation-
  • I.V fluids, blood transfusion (massive), FFP
  • Have both central and peripheral venous access.
  • Bladder catheterization to measure the urine output

Specific treatment
  • Laparotomy is done through a large abdominal incision or thoracoabdominal incision, and extent of liver injury and also other associated injuries are looked for.
  • Small liver tear is sutured with absorbable sutures with placing of gel foam to control bleeding.
  • To control intraoperative bleeding, from hepatic artery and portal vein, both are temporarily occluded using fingers, compressing at foramen of Winslow. Often bull-dog clamp or vascular clamps can be used.
  • In deep severe injuries, following methods are used:
  1. Hepatic artery ligation
  2. Segmental resection
  3. Hemihepatectomy
  4. Packing the liver temporarily with mops.
  • Cholecystectomy and placement of “T” tube in CBD
  • In associated IVC injuries , it is very difficult to manage. A veno-venous bypass between femoral vein  and SVC is done and then repair of IVC is carried out.
  • ICT placement to thorax and repair of diaphragmatic injury.

Post operatively patients require:
  • Ventilator support
  • Blood transfusion
  • Electrolyte management
  • Antibiotics
  • FFP, cryoprecipitate

Complications and Sequelae of liver injury
  • Shock and haemorrhage
  • Intrahepatic haematoma
  • Liver abscess and septicaemia
  • Bile leak, biliary peritonitis, biliary fistulas
  • Disseminated intravascular coagulation
  • Hepatic artery aneurysm
  • Arterio-venous fistula
  • Arterio-biliary fistula
  • Electrolyte imbalance
  • Liver failure
  • Late sequelae
  • CBD stricture

Amoebic Liver Abscess

  • It is common in tropical countries.
  • It is caused by Entamoeba histolytica.
  • It exist in vegetative form outside the body and is spread by the faeco-oral route.

Pathology
  • Initially from infected recto-sigmoid or ileocaecal region, amoebic trophozoites reaches the liver through portal veins causing amoebic hepatitis, may be in the form of micro-abscesses all over the liver. This might resolve on its own or with antiamoebic drugs, but often leads to a localized amoebic liver abscess.
  • It may be single large abscess or multiple, and may involve both lobes.
  • Amoebic liver abscess is more common in right posterior-superior region because the portal vein is in direct continuation with the right tributary. It can be multiloculated.
  • Pus is chocolate coloured, classically called as anchovy-sauce, contains dead liver cells, RBCs, WBCs, necrotic material. Pus may be green due to bile admixture.
  • Often secondary infection by E. coli, staph, strepto may occur and thus may present with features of pyogenic liver abscess. Because of perihepatitis, liver is fixed to diaphragm or abdominal wall. There may also be pleural effusion on right side.
  • Amoebic abscess commonly presents as an acute entity, but it can also present as chronic type where it is covered by a capsule, that remains dormant for a long peroid.
  • Sometimes it can get calcified as well.
'Anchovy sauce' pus drained from and amoebic liver abscess.


Course and sequelae of Amoebic Liver Abscess
  • It can rupture into lungs leading to expectoration of chocolate-coloured sputum resulting in natural regression of abscess.
  • It can rupture into the peritoneum causing peritonitis which requires emergency laparotomy.
  • It can rupture into pleural cavity leading to empyema.
  • Rupture into bare area of liver causing retro-peritoneal abscess.
  • Rupture into the intestines, or to the skin (Amoebiasis cutis)
  • Rupture into pericardial cavity (cardiac temponade)-most dangerous complication.
  • Septicaemia and liver failure

Clinical Features
  • It is common in males, may be after an attack of amoebic dysentery or many months after the attack or h/o dysentery may not be there at all.
  • Pts. Present with fever, weight loss, chills and rigors.
  • Pain in the right hypochondrium.
  • Soft, tender, smooth liver with increased liver span.
  • Intercostal tenderness
  • Right sided pleural effusion may be present.
  • Mild jaundice may be present esp. in cirrhotic and multiple abscesses.
  • Tenderness, rigidity and skin oedema in right hypochondrium may be present acute cases.
  • In chronic amoebic liver abscess, smooth, firm/hard, nontender liver may be palpated.

Investigations
  • Isolation of the parasite from the liver lesion or the stool and confirming its nature by microscopy.
  • Total count may be increased.
  • LFT may show altered bilirubin and albumin level.
  • PT may be increased
  • Altered serum alk. Phosphatase, SGPT, SGOT levels.
  • USG abdomen:
  •  shows altered echogenicity, size, location, number of abscess, nature of the liver.
  • Chest X-ray findings:
  • Raised fixed diaphragm
  • Pleural effusion
  • Soft tissue shadow
  • Positive indirect haemagglutination test
  • CT scan

Treatment
  • Tab. Metronidazole 800mg X TID or inj. Metronidazole 500mg i.v X TID for 10 days.
  • I.V or oral antibiotics are essential to control secondary infection.
  • Small abscess <3cm drugs.="" li="" respond="" to="">
  • In case of large abscess and infected abscess aspiration with a wide bore needle is done under USG guidance after correcting the PT and sent for c/s, cytology and for study of trophozoites.
  • Surgery is done if above measure fail:
  • Through transperitoneal approach, abscess area is opened, pus is evacuated and malecot’s catheter is kept in situ until draining stops completely, which is confirmed by repeat USG



Malecot’s catheter 

Tuesday, January 15, 2013

INFLAMMATORY BOWEL DISEASES


Inflammatory bowel disease (IBD) is a term used to denote two diseases of unknown etiology with similar general characteristics: ulcerative colitis and Crohn's disease.

Crohn's Disease
  • Crohn's disease is a chronic, transmural inflammatory disease of the gastrointestinal tract of unknown cause. 
  • Crohn's disease can involve any part of the alimentary tract from the mouth to the anus but most commonly affects the small intestine and colon.
  • Crohn's disease can be complicated by intestinal obstruction or localized perforation with fistula formation.
  • bimodal distribution 
  • The risk for developing Crohn's disease is about two times higher in smokers than in nonsmokers.
  • strong familial association
  •  genetic role for Crohn's disease show a concordance rate of 67% in monozygotic twins.

Pathology
  • The most common sites of occurrence of Crohn's disease are the small intestine and colon.
  • The disease process is discontinuous and segmental.
  • In patients with colonic disease, rectal sparing is characteristic of Crohn's disease and helps to distinguish it from ulcerative colitis
  • Crohn's disease can also involve the mouth, esophagus, stomach, duodenum, and appendix.

Gross Pathologic Features
  • Grossly, thickened grayish-pink or dull purple-red loops of bowel are noted, with areas of thick gray-white exudate or fibrosis of the serosa.
  • Areas of diseased bowel are separated by areas of grossly appearing normal bowel called skip areas.
  • In Crohn's disease there is extensive fat wrapping caused by the circumferential growth of the mesenteric fat around the bowel wall.
  • On opening the bowel, the earliest gross pathologic lesion is a superficial aphthous ulcer noted in the mucosa. As the disease progresses, the ulceration becomes pronounced, and complete transmural inflammation results. The ulcers are characteristically linear and may coalesce to produce transverse sinuses with islands of normal mucosa in between, thus giving the characteristic cobblestone appearance.

Microscopic Features
  • A chronic inflammatory infiltrate appears in the mucosa and submucosa and extends transmurally.
  • Characteristic histologic lesions of Crohn's disease are noncaseating granulomas with Langerhans' giant cells.



Clinical Manifestations
  • Crohn's disease can occur at any age, but the typical patient is a young adult in the second or third decade of life. 
  • two genders are affected equally
  • The onset of disease is often insidious, with a slow and protracted course.
  • The most common clinical manifestations are abdominal pain, diarrhea, and weight loss. 
  • There is intermittent and colicky abdominal pain, most commonly noted in the lower abdomen. The pain, however, may be more severe and localized and may mimic the signs and symptoms of acute appendicitis.
  • Diarrhea is the next most frequent symptom and is present patients with Crohn's disease typically have fewer bowel movements, and the stools rarely contain mucus, pus, or blood
  •  Characteristically, there are symptomatic periods of abdominal pain and diarrhea interspersed with asymptomatic periods of varying lengths. 
  • Systemic nonspecific symptoms include a low-grade fever (present in about one third of the patients), weight loss, loss of strength, and malaise.
Diagnosis

Barium contrast studies and endoscopy:

Barium contrast studies
  • Barium radiographic studies of the small bowel reveal a number of characteristic findings, including a cobblestone appearance of the mucosa composed of linear ulcers, transverse sinuses, and clefts
  • Segmental and irregular patterns of bowel involvement may be noted.
  • Fistulas between adjacent bowel loops and organs may be apparent .


Endoscopy
  • When the colon is involved, sigmoidoscopy or colonoscopy may reveal characteristic aphthous ulcers with granularity and a normal-appearing surrounding mucosa.
  • CT may be useful in demonstrating the marked transmural thickening, fistulae, intra abdominal abscess, etc.

Treatment

Medical therapy:

Steroids

Prednisolone 40mgXdaily
Supplement with 5-ASA compounds incase of colonic involvement.

Antibiotics- for pt. having s/s of mass or an abscess.
Infliximab

Nutritional support-iv or NG feedings

Anemia, hyponatremia, electrolyte, vitamins and metabolic problems should all be corrected.


Surgical therapy
Surgery in mainly for the complications. They are:

  • Recurrent intestinal obstruction
  • Bleeding
  • Perforation
  • Failure of medical therapy
  • Intestinal fistula
  • Fulminant colitis
  • Malignant change
  • Perianal disease


Ileocaecal resection- For ileocaecal disease,
Anastomosis between the ileum and the transverse colon.
Segmental resection- T/T of short segments of small and large bowel.
Colectomy and ileorectal anastomosis- For widespread colonic disease with rectal sparing with normal anus.
Temporary loop ileostomy- Used in pt. with distal Crohn’s disease or in pt. with severe perianal or rectal disease.
Proctocolectomy- Colonic and anal disease not responding to the medical t/t.
Strictureplasty- For t/t of stricture area of Crohn’s disease.
Simple drianage of abscess- For anal diseases.

Ulcerative Colitis

Cause- unknown

All ages are susceptible, but it more commonly affects patients younger than 30 years.

Both sexes are equally affected

More prevalent in 1st degree relative of the pt.

Smoking have protective effect.

Pathologic Features

Gross Appearance
  • Ulcerative colitis is a disease in which the major pathologic process involves the mucosa and submucosa of the colon, with sparing of the muscularis.
  • The rectum is invariably involved with the inflammatory process.
  • The mucosal inflammation starts in the rectum and extends in a continuous fashion for a variable distance into the more proximal colon.
  • A diagnostic characteristic of ulcerative colitis is continuous, uninterrupted inflammation of the colonic mucosa beginning in the distal rectum and extending proximally to a variable distance.

Histologic Appearance
  • The typical microscopic finding in ulcerative colitis is inflammation of the mucosa and submucosa
  • The most characteristic lesion is the crypt abscess, in which collections of neutrophils fill and expand the lumina of individual crypts of Lieberk├╝hn.
  • The number of goblet cells in the crypts is diminished, as is mucus production.
  • Ulcerative colitis spares the muscular coats of the colon, but in rare cases of severe inflammation characteristic of toxic megacolon in patients with ulcerative colitis, all layers of the colon may be involved, and perforation may occur if treatment is delayed (may be related to factors such as prolonged colonic distention with vascular compromise).

Histo: UC
Clinical Presentation
  • The first symptom is watery and bloody diarrhoea.
  • Ulcerative colitis and colonic Crohn's disease often have similar clinical presentations. Both may present with diarrhea and the passage of mucus. Patients with ulcerative colitis tend to have more urgency than those with Crohn's disease, likely because ulcerative colitis is invariable associated with distal proctitis. Rectal bleeding is also common in ulcerative colitis; although it may be present in patients with Crohn's disease, it is typically not as severe
  • Rectal involvement is present in virtually 100% of patients with ulcerative colitis.
  • Extraintestinal Manifestations
Arthritis
Ankylosing spondylitis
Skin lesions: erythema nodosum, pyoderma gangrenosum, aphthous ulceration.
Eye: iritis and 
Liver disease: Primary sclerosing cholangitis
  • It is HLA-B27 positive .

Diagnosis
  • Barium enema
Signs seen are:
Loss of haustration (esp. in distal colon)
Mucosal changes
Pseudopolyps
Narrow contracted colon ( in chronic cases)
  • Sigmoidoscopy
Used for Dx of early and mild disease not seen in barium enema.

  • Initial findings are those of proctitis, like:
Hyperaemic mucosa
Bleeds on touch
There maybe pus like exudate seen
  • Later- tiny ulcers may be and appear to coalesce
  • Colonoscopy and biopsy
To know the extent of inflammation
Helps distinguishing UC from CD
Monitor response to t/t
To access malignant changes


Edoscopy: UC
Treatment

Medical Therapy
  • Acute attack

Corticosteroids: inflammation of the rectum (locally) or extensive disease (systemically)
Sulfasalazine and 5-ASA (maintain remission): can be given topically and systemically
  • Mild attacks

Mild attack and limited disease- Steroids (rectal)
More extensive disease- Oral prednisolone 20-40 mg/day X 3-4 wks plus sulfasalazine 1g X tid or 5-ASA compounds.
  • Moderate attacks

Oral prednisolone 40mg/day, Steroid enema X BD and 5-ASA 
  • Severe attacks

NPO
Fluid and electrolyte balance
Correction of anemia
Adequate nutrition
I.V hydrocortisone 100-200mg X qid
  • If no imrovement within 5-7 days, surgery is done.

Surgery


Indications for the surgical management:
-Severe or fulminant disease not responding to medical therapy.

-Chronic disease with anemia, frequent stools, urgency and tenesmus.

-Steroid dependent disease.

-Risk of malignant transformation.

-Extraintestinal manifestations.

-Severe hemorrhage/stenosis causing obstruction.


Total abdominal colectomy and ileostomy:
In the emergency situations
Proctocolectomy and ileostomy:
In this there will be a permanent ileostomy.
Restorative Proctocolectomy with an ileo-anal anastomosis with pouch as reservoir (‘J’, ‘S’, or ‘W’ pouches)
Colectomy and ileorectal anastomosis:
This can occasionally be used in case of minimal rectal inflammation.
Ileostomy with a continent intra-abdominal pouch:
Rarely used. 



Tuesday, January 8, 2013

Pilonidal sinus




  • It is of infective origin and occurs  in sacral region between the buttocks, umbilicus, axilla.
  • It is also common in hair dressers (seen in interdigital clefts), jeep drivers.
  • Common in third decade of life. It is common in males and mostly hairy males.
  • Most common site: Interbuttock sacral region



Pathology

  • The sinus extends into the subcutaneous planes as an infected track. There may be branching side channels.
  • Stratified Squamous epithelial lining of varying degree of integrity can be found in many cases.
  • Hair shafts are found lying loose in the sinus, embedded in granulation tissue or deep in mature scar tissue.
  • Foreign body giant cell maybe present.





Clinical features
  • Discharge- either sero sanguinous or purulent.
  • Pain- throbbing and persistent type.
  • A tender swelling seen just above the coccyx in the midline (primary sinus); and on either sides of the midline (secondary sinus)
  • Tuft of hairs may be seen in the opening of the sinus.
  • Presentation may be as an acute exacerbation, or as a chronic one.

Treatment
  • Initially drainage of an abscess (acute phase), and later t/t for the sinus.
  • Definitive t/t is excision of all sinus tracks with removal of hairs and unhealthy granulation tissues under G/A (In Jack knife posotion)
  • Methylene blue is injected to demonstrate the branches of the sinus.
  • Secondary closure or delayed skin grafting is done or left to heal by granulation.
  • Recurrence rate is very high.
  • Bascom technique: Through lateral approach, sinus is reached and excised.

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