Showing posts with label Spotters. Show all posts
Showing posts with label Spotters. Show all posts

Case History

A 2 year old male child presented with this moist and pink tissue popping out of the umbilicus.  Patient complained of  minimal amounts of drainage and irritation of the surrounding skin. This swelling started appearing from 3rd month. It was initially small but started growing in size gradually. Patient was initially advised topical application of silver nitrate but it did not resolve with conservative management. It was surgically excised.

Case of Umbilical Pyogenic Granuloma

Umbilical Granuloma

The umbilical cord normally separates within 3 days to 2 months postpartum; after separation, an excess of granulation tissue may persist at the base of the umbilical stump, which may aggregate and persist, for sometimes, to form an umbilical granuloma (UG). Umbilical granuloma is the most common umbilical problem in neonates and young infants.

Differential Diagnosis of Umbilical Granuloma

  • Patent urachus
  • Omphalomesenteric duct
  • Umbilical polyps 
  • Neoplastic swellings 

Management Options

  • Chemical cauterization with silver nitrate or copper sulphate.
  • Topical application of common salt / 82% ethanol or Clobetasolpropionte.
  • Electric cauterization.
  • Cryocauterization.
  • Surgical excision.

PseudoainhumPseudoainhum is a rare and poorly characterised phenomenon involving autoamputation of a digit associated with an identifiable or related disease process.

Ainhum does not have any predisposing condition associated while pseudoainhum is associated with predisposing conditions like trauma, leprosy, scleroderma, and diabetes. Other diseases which can cause pseudoainhum include psoriasis, scleroderma, and Raynaud disease. The constricting bands of pseudoainhum can also occur secondary to scar formation from trauma, burns, and other injuries.

It is thought that histological changes in pseudoainhum resemble those in ainhum, which initially presents with gross thickening of the stratum coreneum, and calcification of the ducts and the sweat glands. At a more advanced stage, there is chronic inflammation below the hyperkeratotic epithelium. As the fissure deepens due to this fibrotic reaction of collagen with a hyperkeratotic epidermis, tendons, vessels and nerves are compressed with eventual absorption of the bone by pressure. The latter stages are generally thought to be sterile and avascular


These photos are of a female patient aged 36 years. She was a known case of traumatic paraplegia and congestive cardiac failure. The disease process was bilateral involving multiple toes.



- Amongst neural tube defects, the disorders involving spine, vertebral column and nerve roots are included in spinal dysraphisms. They can be classified as

  • Spina bifida aperta (open defects) 
  • Spina bifida occulta (closed defects)

- There is no specific treatment required for occult spina bifida if the abnormality is limited to the bone.

- Usually these deformities are found at the last lumbar vertebrae (L5) or at the first sacral vertebrae (S1)

- Faun's Tail is an abnormal lumbosacral hypertrischosis associated with spinal dysrasphisms

- A posterior lumbar bony defect is often present in 5% to 10% of the normal population, without any symptoms or deficits

- If other markers such as a tuft of hair, cutaneous hemangioma, or sinus tract are present, further investigations should be done.

- The term spina bifida occulta includes following:

  • Simple Spina Bifida Occulta: Mildest form of spina bifida. Usually asymptomatic.
  • Dermal Sinus: Dermal sinus tract from the cutaneous to spinal subarachnoid space. It can cause ascending infection
  • Diastematomyelia: Spinal cord is split into two hemicords, often by a bony or fibrous band that tethers the cord. Needs to be repaired surgically
  • Lipomyelomeningocele: There is fatty tissue in the spinal cord and in the spinal canal tethering the cord. Associated neurologic deficits, although uncommon at birth, usually develop later because of the tethering

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 20e


  • Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary renal disorders characterized by varied manifestations including renal cysts, extrarenal cysts, intracranial aneurysms and dolichoectasias, aortic root dilatation and aneurysms, mitral valve prolapse, and abdominal wall hernias
  • Approximately one per 800-1000 population carries a mutation for this condition.
  • There is established association between ADPKD patients with ESRD and Renal cell carcinoma
  • The association of liver, colon and renal cancer with polycystic kidney disease without end-stage renal disease has also been reported
  • But only a few cases of gastric carcinoma happening in ADPKD patients have been reported.

Clinical Presentation

  • The patient was a 55-year- old male whose chief complaints were abdominal pain, vomiting, jaundice and weight loss. 
  • He was a known case of Autosomal dominant polycystic kidney disease. 
  • His father also had Kidney problems  and elder brother also is a k/c/o ADPKD. 


  • Abdominal imaging studies showed bilateral polycystic kidneys, an irregular asymmetrical circumferential wall thickening of pylorus for a length of 5.6 cm with obstruction of the proximal bile duct and dilated intrahepatic biliary radicles.

Intraoperative Findings

  • A mass arising from pylorus was seen infiltrating into the lesser omentum along with involvement of porta hepatis lymph node with fibrosis and stricture at the confluence of hepatic ducts. 
  • However no compression or involvement of distal CBD was observed. 
  • Hence, the malignant stricture and fibrosis at the hepatic duct confluence was inferred as the cause for obstructive jaundice

Surgical Management

  • Roux en y hepaticojejunostomy, Subtotal gastrectomy, gastrojejunostomy, cholecystectomy and jejunojunostomy were done.

Histopathological Report

  • HPE revealed a well differentiated adenocarcinoma of the stomach. The duodenal stump and resected margins were free of tumour. Samples of fibrotic tissue from the site of obstruction at the confluence of hepatic ducts were negative for tumour infiltration as well.

Postoperative Period

  • Patient recovered uneventfully from surgery and the serum bilirubin reduced after which he was referred to medical oncology for chemotherapy.

ADPKD and Adenocarcinoma of Stomach

  • 4 cases of Carcinoma stomach were found in literature review which were reported in association with ADPKD. 
  • One of the case reports reported siblings with ADPKD, both developing adenocarcinoma of stomach.

Torres VE, Harris PC, Pirson Y (2007). "Autosomal dominant polycystic kidney disease.". Lancet. 369 (9569): 1287–1301. doi:10.1016/S0140-6736(07)60601-1. PMID 17434405
Dalgaard OZ (1957). "Bilateral polycystic disease of the kidneys; a follow-up of two hundred and eighty-four patients and their families". Acta Med. Scand. Suppl. 328: 1–255. PMID 13469269
Torres, Vicente; Harris, Peter C (2009). "Autosomal dominant polycystic kidney disease: the last 3 years“
Risk of cancer in patients with polycystic kidney disease: a propensity-score matched analysis of a nationwide, population-based cohort study: Yu, Tung-Min et al. The Lancet Oncology , Volume 17 , Issue 10 , 1419 – 1425
Halvorson CR, Bremmer MS, Jacobs SC. Polycystic kidney disease: inheritance, pathophysiology, prognosis, and treatment. International Journal of Nephrology and Renovascular Disease. 2010;3:69-83.
Two Cases of Gastric Carcinoma with Autosomal Dominant Polycystic Kidney Disease in the Same Family: KAYA, AKDAĞ, COŞKUNOĞLU, TÜRKELİ, YILMAZ. Turkiye Klinikleri J Med Sci 2012;32(6):1796-800
Carcinoma of the gastroesophageal junction associated with adult polycystic kidney disease: Aziz SA, Ahmad M, Shah A. Nephron. 1998;79(3):362-3.  PMID: 9678447

Adhesive Band causing Intestinal Obstrucction
Adhesive Band causing Intestinal Obstrucction

Which protein is responsible for formation of adhesions?
Adhesions are formed by fibrin deposits onto the damaged tissues. The fibrin acts like a glue to seal the injury and builds the fledgling adhesion. In body cavities such as the peritoneal, pericardial and synovial cavities, a family of fibrinolytic enzymes may act to limit the extent of the initial fibrinous adhesion, and may even dissolve it. In many cases however the production or activity of these enzymes are compromised because of injury, and the fibrinous adhesion persists. If this is allowed to happen, tissue repair cells such as macrophages, fibroblasts and blood vessel cells, penetrate into the fibrinous adhesion, and lay down collagen and other matrix substances to form a permanent fibrous adhesion.

What are the types of adhesions?
There are three general types of adhesions: filmy, vascular, and cohesive

What percentage of individuals develop adhesions after surgery?
A study showed that more than 90% of patients develop adhesions following open abdominal surgery and 55–100% of women develop adhesions following pelvic surgery [1].

Does adhesive intestinal obstruction always require surgery?
Simple obstruction secondary to an adhesion is most likely to resolve nonoperatively.

What is the most common cause of small bowel obstruction?
Adhesive obstruction is the most common cause of small bowel obstruction. In the United States, peritoneal adhesions account for over half of the cases of small bowel obstruction.

View the link below for more important points:

[1] Liakakos, T; Thomakos, N; Fine, PM; Dervenis, C; Young, RL (2001). "Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management". Digestive surgery 18 (4): 260–73. doi:10.1159/000050149. PMID 11528133

Growth Involving Incisura and Lesser Curvature of Stomach
Growth Involving Incisura and Lesser Curvature of Stomach
Explain the T staging (Primary Tumour) for Gastric Ca. (Tis, T1, T2, T3, T4)

Layers of Stomach Wall
Layers of Stomach Wall(Source: Cancer.Org)

TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1Tumor invades lamina propria, muscularis mucosae, or submucosa
T1aTumor invades lamina propria or muscularis mucosae
T1bTumor invades submucosa
T2Tumor invades muscularis propria
T3Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures
T4Tumor invades serosa (visceral peritoneum) or adjacent structures
T4aTumor invades serosa (visceral peritoneum)
T4bTumor invades adjacent structures

Explain the N staging in Gastric Cancer

NXRegional lymph node(s) cannot be assessed
N0No regional lymph node metastasis
N1Metastasis in 1-2 regional lymph nodes
N2Metastasis in 3-6 regional lymph nodes
N3Metastasis in seven or more regional lymph nodes
N3aMetastasis in 7-15 regional lymph nodes
N3bMetastasis in 16 or more regional lymph nodes

Growth Involving Incisura and Lesser Curvature of Stomach
Growth Involving Incisura and Lesser Curvature of Stomach
What are various risk factors for Gastric Cancer?
    • Age
    • Ethnicity
    • Geography
    • Helicobacter pylori infection
    • Stomach lymphoma 
    • Diet
    • Tobacco use 
    • Being overweight or obese 
    • Previous stomach surgery 
    • Pernicious anemia 
    • Menetrier disease (hypertrophic gastropathy) 
    • Type A blood
    • A family history of stomach cancer 
    • Adenomatous polyps
    • Epstein-Barr virus (EBV) infection 
    • Workers in the coal, metal, and rubber industries
    • Common variable immune deficiency (CVID) 
    • Inherited Cancer Syndromes
    Name various Inherited cancer syndromes which increase the risk of getting a Gastric Ca.
    • Hereditary diffuse gastric cancer 
    • Hereditary non-polyposis colorectal cancer (HNPCC) 
    • Familial adenomatous polyposis (FAP) 
    • BRCA1 and BRCA2 
    • Li-Fraumeni syndrome 
    • Peutz-Jeghers syndrome (PJS)  

    Chocolate Cyst of Ovary

    Chocolate Cyst of Ovary

    What is the Chocolate Cyst of Ovary?
    Chocolate cyst of ovary is caused by endometriosis. It is formed when a tiny patch of endometrial tissue bleeds, sloughs off, becomes transplanted, and grows and enlarges inside the ovaries. As the blood builds up over months and years, it turns brown.

    What is the gold standard diagnostic technique for Endometrial cyst of ovary?
    The gold standard diagnostic technique of an ovarian endometrioma is laparoscopy.

    What are the symptoms of Chocolate cyst?
    Women with endometriomas have many of the same symptoms as those with endometriosis, including abdominal pain, dyspareunia and/or subfertility.
    What is Skin Involvement or T4b ?
    Edema (including peau d’ orange) or ulceration of the skin of the breast or satellite skin nodules confined to the breast.

    What is not Skin Involvement or T4b ?
    Dimpling of the skin and nipple retraction is not considered skin involvement.

    Skin involvement in breast showing a skin nodule  surrounded by edema (peau d orange)
    Skin involvement in breast showing a skin nodule 
    surrounded by edema (peau d orange)
    How does peau d’ orange appearance develop?
    Localised edema (peau d’orange) develops when drainage of lymph fluid from the skin is disrupted by infiltration of lymphatics by metastatic cells.

    Read more about Ca Breast:





    A case of gynaecomastia with pectus excavatum
    A case of gynaecomastia with pectus excavatum

    What are the criteria for diagnosis of Gynaecomastia?

    In the nonobese male, breast tissue measuring at least 2 cm in diameter must be present before a diagnosis of gynecomastia may be made. Mammography and ultrasonography are used to differentiate breast tissues. 

    What is the differential diagnosis of Gynaecomastia?

    I. Estrogen excess states

    A. Gonadal origin

        1. True hermaphroditism

        2. Gonadal stromal (nongerminal) neoplasms of the testis

           a. Leydig cell (interstitial)

           b. Sertoli cell

           c. Granulosa-theca cell

        3. Germ cell tumors

           a. Choriocarcinoma

           b. Seminoma, teratoma

           c. Embryonal carcinoma

      B. Nontesticular tumors

        1. Adrenal cortical neoplasms

        2. Lung carcinoma

        3. Hepatocellular carcinoma

      C. Endocrine disorders

      D. Diseases of the liver—nonalcoholic and alcoholic cirrhosis

      E. Nutrition alteration states

    II. Androgen deficiency states

      A. Senescence

      B. Hypoandrogenic states (hypogonadism)

        1. Primary testicular failure

           a. Klinefelter's syndrome (XXY)

           b. Reifenstein's syndrome

           c. Rosewater-Gwinup-Hamwi familial gynecomastia

           d. Kallmann syndrome

           e. Kennedy's disease with associated gynecomastia

           f. Eunuchoidal state (congenital anorchia)

           g. Hereditary defects of androgen biosynthesis

           h. Adrenocorticotropic hormone deficiency

        2. Secondary testicular failure

           a. Trauma

           b. Orchitis

           c. Cryptorchidism

           d. Irradiation

      C. Renal failure

    III. Drug effects

    IV. Systemic diseases with idiopathic mechanisms

    What are various grades of Gynaecomastia?

    Grade I Mild breast enlargement without skin redundancy
    Grade IIa Moderate breast enlargement without skin redundancy
    Grade IIb Moderate breast enlargement with skin redundancy
    Grade III Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

    What is the surgical management of Gynaecomastia?

    The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion.

    Webster's Incision
    Webster's Incision

    Round punched out lesions in the heel of an 18 year old female patient

    Round punched out lesions in the heel of an 18 year old female patient, any idea what these can be due to? (Give your answer in the comments section below)

    1) Fibrokeratoma
    2) Corn foot
    3) Plantar Warts
    4) Neuropathic Ulcer
    Pyogenic granuloma of tongue
    Pyogenic Granuloma of Tongue
    Patient gave history of minor injury to tongue while eating. After a few days, he saw reddish nodule arising at the same site. The nodule was excised under LA. But after 15 days the patient came back with a recurrence. Re-excision was done with a wider margin. There was no recurrence after that.

    The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically. It is a reactive inflammatory process filled with proliferating vascular channels, immature fibroblastic connective tissue, and scattered inflammatory cells.

    Multiple choice questions on Obstructive Jaundice

    Case Presentation

    A 27 year old male came with complaints of Jaundice for a duration of 2 months which was insidious in onset, gradually deepening in color, not intermittent and not associated with pain. He says his stool are lighter in colour than normal. He also had gradually distending abdomen from past 1 month and pedal edema -10 days. He now complaints of fever from past 2 days not associated with chills and rigors. He is a known chronic alcoholic but does not reports of any other medical illnesses.

    He is febrile on examination. Gall bladder or any lump is not palpable. Abdomen is moderately distended and mildly tender.

    His bilirubin total is 7.5 and direct is 3.8. Bile salts and pigments are postive in urine. SAP was found to elevated more than 3 times the normal value and mildly elevated ALT/AST . Usg Abdomen shows Ascites and chest X ray shows bilateral pleural effusion.

    Q.1: What is the lowest level of bilirubin to detect jaundice in the sclera?

    Q.2: What can be the cause of this presentation.
    1. Liver cirrhosis with spontaneous bacterial peritonitis
    2. Carcinoma of periampullary region with spontaneous bacterial peritonitis
    3. Acute Fulminant Viral Hepatitis
    4. Carcinoma Stomach with liver metastasis and peritoneal seeding
    Give your responses in the comments section below. Explanation to be posted tomorrow.
    Epididymal Cyst and Differential Diagnosis of Swellings of Scrotum
    This patient had Spermatocoele along with Indirect Inguinal hernia

    Case Presentation
    • A 45 year patient came with complaints of pain in scrotum. There was a swelling near the root of left scrotum which came to the attention of patient recently. He pointed that there was a difference in size and shape of left and right side of scrotum. The swelling was soft, cystic and transilluminant. Also, there was a swelling in left Inguinal region which increased in size on coughing. An Inguinal hernioplasty and excision of the cystic lesion was done.
    • Spermatocele is a retention cyst of tubule of rete testis or head of the epididymis 
    • It contains clear fluid, spermatozoa and lymphocytes 
    • Manifests as a palpable lump of the scrotum
    • Transilluminant, get above the swelling is positive

    Spermatocoele and Differential Diagnosis of Swellings of Scrotum

    Differential Diagnosis of Swellings in Scrotum
    • Hydrocoele - Collection of fluid secreted from tunica vaginalis
    • Inguinal Hernia - Get above the swelling is negative
    • Varicocoele - Dilated plexus of vein along the spermatic cord 
    • Simple Epididymal Cyst - Not possible to differentiate anatomically, however sperms are typically found in a spermatocele but are absent in epididymal cyst  
    • Neoplasm - Hard in consistency, irregular in shape

    Epididymal cyst
    Acquired retention cyst
    Behind the body of the testis
    Behind and above the testis
    Looks like bunch of grapes
    Looks like 3rd testis
    Clear fluid
    Barley water like fluid
    Brilliantly transilluminant

    Management of Spermatocele
    • Usually asymptomatic, hence small cysts do not need treatment. 
    • Larger cysts can be removed in case patient complaints of feeling of mass or pain 
    1. SRB's Manual of Surgery (Purchase Link)

      Ileal perforation due to Typhoid fever
      Ileal perforation due to Typhoid fever
        Clinical History
      • A 29-year-old male patient was admitted with complaints of fever for 2 weeks, abdominal pain and vomiting for 2 days, abdominal distension for 2 days, and not passing stools and flatus for 1 day. 
      • He did not receive any treatment during 2 weeks. There was no history of long term abdominal pain and analgesic abuse, but patient was a chronic smoker and alcoholic.
      • There was no history of previous similar complaints
      • On examination, there was a mild distinction. Guarding and board like rigidity was present.
      • Bowel sounds were not heard. PR revealed empty rectum.
      • ESR was elevated, WBC count was 15200
      • Xray showed air under diaphragm
      • Hence a diagnosis of hollow viscous perforation was made.
      • Later, widal test was also found to be positive 

      Pathogenesis of typhoid intestinal perforations
      Pathogenesis of typhoid intestinal perforations
      • Peyer patches become hyperplastic and subsequently ulcerate, with complications of hemorrhage or perforation
      Differential Diagnosis 
      • Includes appendicitis, appendicular perforation, perforated peptic ulcer, strangulated gut with volvulus, and necrotizing amoebic colitis 
      • Simple closure of the perforation is the treatment of choice and was done in this case.
      • With multiple perforations, which occur in about 25% of patients, resection with primary anastomosis or exteriorization of the intestinal loops may be required 

      (Wait until the video loads)

      Visible Intestinal Peristalsis

      Points to remember:

      In a healthy person, peristalsis is not visible
      In patients with...
      Posted by World Surgery Forum on Saturday, April 9, 2016

      Two large ulcers, one each, on opposite walls of the duodenal bulb
      Kissing duodenal ulcer
      • Two large ulcers, one each, on opposite walls of the duodenal bulb . Hence called Kissing duodenal ulcers.
      • 40 year male patient presented with complaints of epigastric pain from past 6 months which increased in severity over past week. Pain was relieved after eating food and was aggravated after taking spicy diet, tea or coffee. Patient is a known alcoholic and a smoker.

      • Familial multiple lipomatosis
        Familial multiple lipomatosis
        Familial multiple lipomatosis
        Familial multiple lipomatosis
      • 58-year-old male presented with a history of multiple subcutaneous nodules that began to appear when he was 10 years of age
      • Physical examination revealed multiple subcutaneous nodules mainly concentrated all over the abdomen and both upper limbs which were painless.
      • Histopathological examination revealed adipose tissue
      • His father also had similar disease
      • The differential diagnosis includes Dercum's disease (a painful syndrome of the adipose tissue associated with obesity) and Madelung's disease (characterised by symmetric fat deposits in the head, neck, and upper trunk and is associated with chronic alcoholism).

      A 35 year old male presented with abdominal pain, cramping, abdominal distension and multiple episodes of vomiting. X ray revealed dilated small bowel loops with multiple air fluid levels. The vitals of patient were stable and showed no signs of strangulation. The patient was initially managed conservatively with analgesia, intravenous fluids, nasogastric suction and an indwelling urinary catheter. But even after a day of conservative therapy the symptoms were not relieved and an exploratory laprotomy was done to reveal a dense adhesion kinking the small bowel around its axis.

      Abdominal Adhesions: Important Points
      1. Opening the peritoneal cavity, in whatever type of surgery, leads to the formation of potentially obstructive structures (adhesions or bands) in almost 95% of patients.[1]
      2. Today, with the increased incidence of abdominal surgery, these structures are the most frequent cause of small bowel obstruction (SBO)- almost over two third cases of SBO caused by adhesions.[2]
      3. Although most adhesions cause no symptoms or problems, others cause chronic abdominal or pelvic pain. Adhesions are also a major cause of intestinal obstruction and female infertility.
      4. Abdominal Adhesions and Female Infertility: Abdominal adhesions can lead to female infertility by preventing fertilized ova from reaching the uterus. Women with abdominal adhesions in or around their fallopian tubes have an increased chance of ectopic pregnancy.

      1] Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.
      Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, McGuire A, Lower AM, Hawthorn RJ, O'Brien F, Buchan S, Crowe AM
      Lancet. 1999 May 1; 353(9163):1476-80.
      2]Miller G, Boman J, Shrier I, et al. Etiology of small bowel obstruction. Am J Surg. 2000;180:33–36

      • A patient who came with history of fall while boarding a running local train under effect of alcohol
      • He was brought to the hospital after 2 hours of injury by the local police 
      • When he came he was very restless and agitated
      • There were no signs suggestive of any head injury
      • Only sign we were able to elicit was marked tenderness over Right side of chest
      • There were no obvious dilated veins over the neck, though a slight tracheal deviation was present
      • A chest xray showed
        • -Over expanded Right hemithorax
        • -Shift of the mediastinum to the left side
        • -Depression of the Right hemidiaphragm
      • SPO2 was 78%. Immediately a needle thoracostomy was done. The SPO2 increased to 94%.
      • An intercostal drain with under water seal was inserted.

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