Abdomen

Question 1

Mesenteric Cysts - Types

Answer 1

1. Chylolymphatic Cyst
   (clear fluid)
2. Enterogenous Cyst
   (wall of small bowel - contains mucus)
3. Urogenital Remnant
   (Arises from wolfian duct)
4. Teratomatous dermoid Cyst

Question 2

Differential Diagnosis of Cystic lesions in abdomen

Answer 2

Pseudo pancreatic Cyst
Hydatid Cyst of liver
Cystic lesion of spleen
Ovarian Cyst
Encysted TB Ascites of peritoneum
Omentum cyst
PCKD - polycystic Disease of Kidney

Question 3

Peritoneal lavage

Answer 3

• Used in Diffuse peritonitis
• 3-5L of isotonic crystalloid solution is used

❌Avoid antiseptics (betadine solution) or povidine iodine solutions ——> they may induce adhesions

AMINOGLYCOSIDE lavage may cause Resp. Depression due to neuromuscular blocking action of these drugs.
Mops must be used to dry the peritoneal cavity.
If fluid is left over it may dilute the opsonins and decreases phagocytes
__________________________________________________

🌟🌟Diagnostic Peritoneal lavage (DPL)🌟🌟

Test used to assess the presence of blood or contaminants in the abdomen

Gastric tube, urinary catheter,
Cannula inserted below the umblicus
•Aspirated for blood
(>10ml )➕

•Then 1000ml of warmed RL is injected and drained out
(>1,00,000 RBCs/ul or > 500 WBCs/ul )➕
= 20ml of free blood in abdomen cavity

👉DPL is especially useful in the hypotensive, unstable patient with multiple injuries as a means of excluding intra-abdominal bleeding.

Question 4

Peritonitis
(Inflammation of peritoneum)

Causes:

Answer 4

1️⃣. Localised , Generalised

2️⃣. BCATI
Bacterial
Chemical (Biliary P. , Barium swallow)
Allergic (Starch P.)
Traumatic
Ischemic

3️⃣. Primary , Secondary, Tertiary

🔹PRIMARY: 
• Spontaneous Peritonitis of Childhood
• S.P. of Adult
• Peritoneal dialysis
• TB peritonitis 

🔹SECONDARY
🌟Perforation of hollow viscus (GIT)
•Stomach - gastric ulcer, duodenal ulcer, Ca.
•Small Intestine- Enteric Ulcer (Typhoid), TB, Trauma, Meckel’s diverticulum, Crohn’s disease,

🌟Direct Spread: Post inflammatory
•Acute Appendicitis
•Acute Cholecystitis - Gangrenous
•Meckel’s diverticulitis 
• Gangrene of the intestine
•Acute necrotising pancreatitis 

🌟Penetrating/ Blunt injuries to the abdomen:

🌟Post-operative Peritonitis
•Improper sterilisation or inappropriate handling
•Foreign body (MOP) left behind

🌟Parturition Peritonitis

🔹TERTIARY:
🌟Multiple Surgeries

Question 5

Surgical segments of Liver:

Liver is divided into functional R and L lobes by Cantlie’s line
(Line passing from the left of GB fossa to the left of IVC) => COUNIAUD’s segments

8 Segments:

Answer 5

Segments 1, 2, 3, 4 (Left lobe)

Segments 5, 6, 7, 8 (Right lobe)

SEGMENT 1 is the caudate lobe of the liver
•has independent supply of portal and hepatic veins

Question 6

Signs of Liver Cell Failure:

Answer 6

• Gynaecomastia
• Palmar erythema
• Leuconychia
• Testicular atrophy
• Spider angioma
• Parotid Enlargement
• Cyanosis
• Tachypnea

Question 7

Sites of Portosystemic collateralisation

Answer 7

1. Lower end of esophagus
2. Umblicus
3. Lower end of rectum
4. Retroperitoneum ( vein of Retzius )
5. Barr area of the liver

Question 8

Causes of Upper GI bleeding:

HAEMATEMESIS

Answer 8

👉Chronic Peptic ulcer (duodenal and gastric) 65%

🔹ESOPHAGEAL causes:
•Reflux esophagitis
•Mallory-Weiss syndrome
•👉Esophageal varices 
•ca. Esophagus

🔹GASTRIC causes:
•Gastric ulcer 
•Gastric Varices
•👉Acute erosive gastritis (Steroids, NSAIDs)
•Ca. Stomach
•Stromal tumors- GIST
•Gastric Polyp, Lymphoma, leiomyomas
•Portal Gastropathy
•Arteriovenous Malformations
•Dieulafoy’s vascular malformation
•Gastric Antral vascular entasis (GAVE)

🔹DUODENAL causes:
• Duodenal ulcers
• Ca. Duodenum
•AVM
•Polyp

🔹Other causes:
•Bleeding disorders- Haemophilia
•Pseudoaneurysms due to acute pancreatitis
•Pernicious Anemia
•Thrombocytopenia

Question 9

Liver Function Tests:

Answer 9

1. Serum bilirubin
   (Direct and indirect) - van den Bergh’s Test
2. Serum albumin, globulin and A:G ratio
3. Prothrombin time:
   Normal- 12-16s
4. Alkaline Phosphatase (ALP)
   * Secretary function
5. Aspartate Amino transferase
   AST/SGOT =5-40 IU/L
   *Signifies inflammation
6. Alanine Transaminase
   ALT/SGPT = 5-40 IU/L
   *Liver specific
7. 5 nucleotidase
8. GGT = 10-48 IU/L
9. Immunological tests: antimitochondrial or antinuclear antibodies
10. AFP
11. Specific Tests
    •for Haemochromatosis: serum Iron, serum ferritin, TIBC
    •Wilson’s Disease: serum Copper, urinary Copper, serum ceruloplasmin
12. FDG-PET
    Fluoro-deoxyglucose Positron emission tomography
13. Technetium 99m (uptake and excretion of bile)
14. Sulphur Colloid Liver scan - Kupffer Cell activity
15. Urine-
    Bile salts (Hay’s Test)
    Bile pigments (Fouchet’s Test)
    Urobilinogen (Ehrlich’s aldehyde Test)

Question 10

Liver Secondaries

Answer 10

Secondaries are common malignant tumors:
>in Bone
>in Liver
>in Brain

Causes:
ABDOMINAL- Ca. Stomach, Colon, Pancreas, Small bowel, Kidney, abdominal esophagus, Rectum and carcinoids

EXTRA-ABDOMINAL
Melanoma,
Ca. Breast, lung, thoracic esophagus, Bladder, prostate
Testicular and Adrenal Tumors
Follicular Carcinoma Thyroid (FCT)

CLASSIFICATION
🔹Colorectal
🔹Neuroendocrine
🔹Non-Colorectal and Non-Neuroendocrine

ROUTE OF SPREAD
a) Direct:
Stomach, Colon, Gall Bladder, Bile ducts

b) Hepatic Artery:
Melanoma

c) Portal Vein:
Carcinoid tumors, other GIT malignancies

d) Lymphatic
Breast, Lung

DDs
•Multicentric Hepatoma
•Macronodular Cirrhosis
•Polycystic liver disease, Hydatid Cyst of Liver

Question 11

Hydatid Cyst - Ix

Answer 11

•USG is diagnostic
•X-ray - calcification
•CT scan- cyst characteristics
(Cart wheel like, multivesicular rosette like)

•Primary Serological
ELISA
Indirect Haemagglutination Test
Latest agglutination 
IFA, Immunoelectrophoresis

• Secondary Serological
• LFT
• Casoni’s Test (intradermal Test), CFT
• MRI : to visualise biliary tree, it’s relation to Hydatid Cyst, to find out cystobiliary communication
• ERCP : to find out biliary communications

Question 12

Splenectomy - Indications

Answer 12

Benefit- Maximum
•Splenic tumors
•Hereditary Spherocytosis
•ITP
•Hypersplenism
•Splenic injury/Trauma
•Splenic cysts

Benefit-Equivocal
• AIHA
•Tropical Splenomegaly
•Felty’s Syndrome

Benefit- Low
• Thalassemia
• CML
• HL For staging laparotomy
• SCD
• Gaucher’s Disease

Question 13

Acute Pancreatitis

Answer 13

I Idiopathic

G Gall Stones
E. Ethanol
T. Trauma

S.     Steroid
M.    Mumps
A.     Auto-immune
S.     Scorpion Bite
H.     Hyperlipidemia
E.     ERCP
D.     Drugs- Azathioprine, 6-mercaptopurine, estrogen