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Saturday, 8 November 2014

Hernia Pic 1

What is a hernia ? A common question asked by people.

Hernia is defined as abnormal protrusion of a viscus or a part of viscus through an opening in the wall of it's containing cavity.

Hernia Pic 2

Hernia may be external or internal. External hernias are the most common type, includes inguinal, femoral, umbilical, para umbilical, epigastric and incisional hernia. Hiatus hernia is the type of internal hernia.

Inguinal Hernia


Umbilical Hernia




Para Umbilical Hernia



Incisional Hernia

Causes of hernia
A. Congenital
B. Acquired, may be due to
  1. Increased intra-abdominal pressure: Any condition which increases intra-abdominal pressure such as weight lifting, chronic cough and straining on micturition or defecation. Increases intra-abdominal pressure is the main cause of hernia. 
  2. Obesity: Stretching of the abdominal musculature due to an increase in contents.
  3. Intra-abdominal malignancy.
  4. Smoking:  Due to an acquired collagen deficiency which increases an individual's susceptibility to the development of hernias.
Types of hernia 
May be
  1. Reducible: Contents can be returned to back.
  2. Irreducible: Contents can not be returned back. Risk of srangulation is present at any time.
  3. Obstructed: Bowel is obstructed with good blood supply. Usually goes to the strangulation.
  4. Stangulated: Obstructed blood supply of the bowel. Gangrene may occur within 6 hours. Require urgent surgery.
  5. Inflammed: Contents have become inflamed.
Types of hernia according to its contents
  1. Omentocele: Contains the omentum.
  2. Enteroccele: Contains the intestine.
  3. Richter's hernia: Contains a portion of the circumference of the intestine. 
  4. Littre's hernia: Contains the Meckel's diverticulum.
Omentocele



Enterocele

Treatment of hernia
Surgery is the treatment of choice for hernia. Open or laparoscopic, depends on availability of facilities and experties.

Hernia and its Types

Hernia Pic 1

What is a hernia ? A common question asked by people.

Hernia is defined as abnormal protrusion of a viscus or a part of viscus through an opening in the wall of it's containing cavity.

Hernia Pic 2

Hernia may be external or internal. External hernias are the most common type, includes inguinal, femoral, umbilical, para umbilical, epigastric and incisional hernia. Hiatus hernia is the type of internal hernia.

Inguinal Hernia


Umbilical Hernia




Para Umbilical Hernia



Incisional Hernia

Causes of hernia
A. Congenital
B. Acquired, may be due to
  1. Increased intra-abdominal pressure: Any condition which increases intra-abdominal pressure such as weight lifting, chronic cough and straining on micturition or defecation. Increases intra-abdominal pressure is the main cause of hernia. 
  2. Obesity: Stretching of the abdominal musculature due to an increase in contents.
  3. Intra-abdominal malignancy.
  4. Smoking:  Due to an acquired collagen deficiency which increases an individual's susceptibility to the development of hernias.
Types of hernia 
May be
  1. Reducible: Contents can be returned to back.
  2. Irreducible: Contents can not be returned back. Risk of srangulation is present at any time.
  3. Obstructed: Bowel is obstructed with good blood supply. Usually goes to the strangulation.
  4. Stangulated: Obstructed blood supply of the bowel. Gangrene may occur within 6 hours. Require urgent surgery.
  5. Inflammed: Contents have become inflamed.
Types of hernia according to its contents
  1. Omentocele: Contains the omentum.
  2. Enteroccele: Contains the intestine.
  3. Richter's hernia: Contains a portion of the circumference of the intestine. 
  4. Littre's hernia: Contains the Meckel's diverticulum.
Omentocele



Enterocele

Treatment of hernia
Surgery is the treatment of choice for hernia. Open or laparoscopic, depends on availability of facilities and experties.

Posted at 23:59 |  by iqbal khatri

Monday, 27 October 2014


Anal fissure is a very disturbing and painful condition most commonly occurs in young patients, however it may present at any age. It is a longitudinal tear in the anal canal below the level of the dentate line. Cause, more commonly is the constipation and less commonly repeated passage of diarrhoea.
Patient complains of severe pain during defecation (Painful stool) and after defecation which may remains for many hours due to spasm of anal sphincters which causes ischemia.
Other symptom is bleeding per rectum. Blood bright red in colour, comes in a streak along the stool.


On examination a longitudinal ulcer is seen at anal canal more commonly at 6 O' clock and less commonly at 12 O' clock. Anal fissure at 12 O' clock is usually seen in females after vaginal delivery.
Multiple fissures away from these sites suggest other pathology, like inflammatory bowel disease (Crohn's disease), tuberculosis, sexually transmitted related ulcers or squamous cell carcinoma. Digital rectal examination (DRE) and proctoscopy are containdicated.

Anal fissure may be acute or chronic. Chronic anal fissure is characterised by a hypertrophied anal papilla internally and a sentinel tag externally.


Anal Fissure: A very painful condition


Anal fissure is a very disturbing and painful condition most commonly occurs in young patients, however it may present at any age. It is a longitudinal tear in the anal canal below the level of the dentate line. Cause, more commonly is the constipation and less commonly repeated passage of diarrhoea.
Patient complains of severe pain during defecation (Painful stool) and after defecation which may remains for many hours due to spasm of anal sphincters which causes ischemia.
Other symptom is bleeding per rectum. Blood bright red in colour, comes in a streak along the stool.


On examination a longitudinal ulcer is seen at anal canal more commonly at 6 O' clock and less commonly at 12 O' clock. Anal fissure at 12 O' clock is usually seen in females after vaginal delivery.
Multiple fissures away from these sites suggest other pathology, like inflammatory bowel disease (Crohn's disease), tuberculosis, sexually transmitted related ulcers or squamous cell carcinoma. Digital rectal examination (DRE) and proctoscopy are containdicated.

Anal fissure may be acute or chronic. Chronic anal fissure is characterised by a hypertrophied anal papilla internally and a sentinel tag externally.


Posted at 23:59 |  by iqbal khatri
Gall Bladder Full of Stones

History of the patient is very important to recognize the gallstones (cholelithiasis). It plays 80% role to diagnose any condition. The gallstones may be asymptomatic.

Inflammed Gall Bladder & Pigmented Stones


Gallstones symptoms are pain in right hypochondrium which radiates to back of chest. Pain is colicky in nature and usually associated with nausea and vomiting and aggravated by fatty food and relieved by taking medicines. But pain ismore often dull and constant. Dyspepsia and flatulence

Gall Bladder Stones

Clinical examination plays 10% role. Deep tenderness is present at right hypochondrium. Increased temperature of the body is also a sign. Gallbladder may be palpable if distended  by an  impacted stone in its neck.

Multiple Gall Bladder Stones

Investigations play 10% role. Ultrasound of upper abdomen is a diagnostic tool of gallbladder stones. It shows presence of stones in the gall bladder with posterior shadowing. It also shows the anatomy of the gall bladder and the biliary tree and condition of the liver.

Ultra Sound of Gall Bladder Showing Single Stone


Ultra Sound of Gall Bladder Showing Multiple Stones

So the gallstones diagnosis is not difficult. Gallstone is common in females. The treatment of gallstones is the cholecystectomy.

How will you recognize the Gallstones (Cholelithiasis)

Gall Bladder Full of Stones

History of the patient is very important to recognize the gallstones (cholelithiasis). It plays 80% role to diagnose any condition. The gallstones may be asymptomatic.

Inflammed Gall Bladder & Pigmented Stones


Gallstones symptoms are pain in right hypochondrium which radiates to back of chest. Pain is colicky in nature and usually associated with nausea and vomiting and aggravated by fatty food and relieved by taking medicines. But pain ismore often dull and constant. Dyspepsia and flatulence

Gall Bladder Stones

Clinical examination plays 10% role. Deep tenderness is present at right hypochondrium. Increased temperature of the body is also a sign. Gallbladder may be palpable if distended  by an  impacted stone in its neck.

Multiple Gall Bladder Stones

Investigations play 10% role. Ultrasound of upper abdomen is a diagnostic tool of gallbladder stones. It shows presence of stones in the gall bladder with posterior shadowing. It also shows the anatomy of the gall bladder and the biliary tree and condition of the liver.

Ultra Sound of Gall Bladder Showing Single Stone


Ultra Sound of Gall Bladder Showing Multiple Stones

So the gallstones diagnosis is not difficult. Gallstone is common in females. The treatment of gallstones is the cholecystectomy.

Posted at 23:59 |  by iqbal khatri

Wednesday, 22 October 2014

Multiple sebaceous cysts are not commonly seen. More commonly seen on scrotum.

Multiple Sebaceous Cysts on Scrotum Posterior Aspect

A 25 years old patient came at my clinic with complains of multiple swellings on his scrotum since six months. He was afraid of about his disease and understanding that he was suffering in a dangerous condition like carcinoma.

Multiple Sebaceous Cysts on Scrotum Anterior Aspect

 I reassured him and told that these were benign as they occurred due to blockage of ducts of sebaceous glands of skin and the accumulation of sebum (secretions of sebaceous glands) in them. I explained him that these were easy to treat as day care surgery.

Multiple Sebaceous Cysts Scrotum Pic 1

After all basic investigations like Blood complete picture, Blood urea, Random blood sugar, Anti-Hcv, HBsAg. Urine detailed report and X-Ray chest P/A view, surgical excision of these sebaceous cysts were done under spinal anaesthesia.

Multiple Sebaceous Cysts Scrotum Pic 2

Patient discharged on the same day as a day care surgery. Stitches removed on 8th post operative day.

Multiple Sebaceous Cysts

Multiple sebaceous cysts are not commonly seen. More commonly seen on scrotum.

Multiple Sebaceous Cysts on Scrotum Posterior Aspect

A 25 years old patient came at my clinic with complains of multiple swellings on his scrotum since six months. He was afraid of about his disease and understanding that he was suffering in a dangerous condition like carcinoma.

Multiple Sebaceous Cysts on Scrotum Anterior Aspect

 I reassured him and told that these were benign as they occurred due to blockage of ducts of sebaceous glands of skin and the accumulation of sebum (secretions of sebaceous glands) in them. I explained him that these were easy to treat as day care surgery.

Multiple Sebaceous Cysts Scrotum Pic 1

After all basic investigations like Blood complete picture, Blood urea, Random blood sugar, Anti-Hcv, HBsAg. Urine detailed report and X-Ray chest P/A view, surgical excision of these sebaceous cysts were done under spinal anaesthesia.

Multiple Sebaceous Cysts Scrotum Pic 2

Patient discharged on the same day as a day care surgery. Stitches removed on 8th post operative day.

Posted at 23:59 |  by iqbal khatri

Saturday, 18 October 2014

Diabetic Foot Pic 1

Diabetic foot infections are major and dangerous complication of diabetes mellitus. The ulceration of foot with infection can lead to tissue necrosis and amputation. It is a leading non-traumatic cause of major amputation of the lower limbs.Foot in diabetic patient is prone to ulceration, trauma and infection due to peripheral neuropathy, peripheral vascular disease, glucose rich environment and impaired resistance. High glucose level in tissues is a good culture media for bacteria therefore infection is common.

Diabetic Foot Pic 2

It can be neuropathic, ischaemic or neuroischaemic. About 20 - 40% of patients have neuropathy while 50% will develop symptomatic pheripheral vascular disease within 20 years of diagnosis. About 15% in diabetic mellitus have the lifetime prevalence of foot ulceration.The Charcot foot can lead to significant bone destruction, deformity and ulceration.

Diabetic Foot Pic 3

Due to sensory neuropathy, the protective sensations of pain, heat and pressure are lost. Minor injuries are not noticed by diabetic patient and so the infection occurs. Due to motor neuropathy dysfunction of muscles, arches of foot, joints and loss of reflexes cause more prone to trauma and abscess. Due to autonomic neuropathy skin is dry causes defective skin barrier so more prone to infection.
Ischemia is due to accelerated atherosclerosis in large vessel (usually in the femoral, popliteal and tibial arteries) and structural and functional abnormalities of the micro-vascular endothelium. The skin of foot is red, dry and thin, and susceptible to breakdown on minor trauma.

Diabetic Foot Pic 4

Some contributing factors are also responsible to the onset of ulceration of foot in diabetic patients in addition to neurovascular disease like poor vision, cerebrovascular disease, limited mobility in the joints and peripheral oedema due to coronary heart disease.

Clinical assessment of the foot at-risk

Neuropathy is detected by
1. Testing vibration by using a biosthesiometer or tuning fork.
2. Discriminatory touch using a 10-g monofilament.
3. Assessing the ankle jerks.

Vascular examination
1. Palpation for dorsalis pedis, posterior tibial, popliteal and the
femoral  pulses.
2. Skin colour and temperature.
3. Strength of pulsation
4. Presence of abdominal and femoral bruits.

Risk factors
1. Glycaemic control
2. Duration of diabetes
3. Renal disease
4. Cigarette smoking
5. Poor social circumstances.

Monitoring and self care are key parts of management. 3-6 monthly review should be done. Patient education includes
  • Washing
  • Inspection
  • Care of corns and calluses
  • Toenail cutting
  • Wearing suitable footwear
  • Keep your feet as clean as your face
  • Ablution (Wazoo) five times a day in Muslims
The ulcerated foot

May be intrinsic defects in the ulcer healing in diabetic patients
  • Impaired fibroblast function
  • Deficiency in growth factors
  • Abnormalities found in the extra cellular matrix
Therefore delayed foot wounds healing and prolonged hospital stay is common.

Neuropathic ulcers which are associated with the callus, which develops on the plantar aspects of the metatarsal heads.
Neuroischaemic ulcers which are common on the margins of the diabetic foot.

Diabetic Foot Pic 5

Infection is divided in to
  • Local and superficial
  • Spreading soft tissue infection and the cellulitis 
  • Osteomyelitis
The signs of inflammation and early infection in foot may be difficult to detect in the presence of peripheral vascular disease. 

Deep wound swabs often show the presence of several bacteria (Gram +ve, Gram -ve, aerobic and anaerobic organisms). Antibiotics should be used accordingly.

Osteomyelitis is a common sequela of diabetic foot ulceration, usually caused by staphylococcus aureus. Plain x-rays of all patients of diabetic foot ulcers should be done. MRI when osteomyelitis is suspected.
Duplex ultrasound of lower limb is done for diabetic ischaemic ulcer.
Surgery (Debridement or amputation) is needed when antibiotics failed.

Diabetic Foot After Debridement



Diabetic Foot Infection: A Major and Dangerous Complication of Diabetes Mellitus

Diabetic Foot Pic 1

Diabetic foot infections are major and dangerous complication of diabetes mellitus. The ulceration of foot with infection can lead to tissue necrosis and amputation. It is a leading non-traumatic cause of major amputation of the lower limbs.Foot in diabetic patient is prone to ulceration, trauma and infection due to peripheral neuropathy, peripheral vascular disease, glucose rich environment and impaired resistance. High glucose level in tissues is a good culture media for bacteria therefore infection is common.

Diabetic Foot Pic 2

It can be neuropathic, ischaemic or neuroischaemic. About 20 - 40% of patients have neuropathy while 50% will develop symptomatic pheripheral vascular disease within 20 years of diagnosis. About 15% in diabetic mellitus have the lifetime prevalence of foot ulceration.The Charcot foot can lead to significant bone destruction, deformity and ulceration.

Diabetic Foot Pic 3

Due to sensory neuropathy, the protective sensations of pain, heat and pressure are lost. Minor injuries are not noticed by diabetic patient and so the infection occurs. Due to motor neuropathy dysfunction of muscles, arches of foot, joints and loss of reflexes cause more prone to trauma and abscess. Due to autonomic neuropathy skin is dry causes defective skin barrier so more prone to infection.
Ischemia is due to accelerated atherosclerosis in large vessel (usually in the femoral, popliteal and tibial arteries) and structural and functional abnormalities of the micro-vascular endothelium. The skin of foot is red, dry and thin, and susceptible to breakdown on minor trauma.

Diabetic Foot Pic 4

Some contributing factors are also responsible to the onset of ulceration of foot in diabetic patients in addition to neurovascular disease like poor vision, cerebrovascular disease, limited mobility in the joints and peripheral oedema due to coronary heart disease.

Clinical assessment of the foot at-risk

Neuropathy is detected by
1. Testing vibration by using a biosthesiometer or tuning fork.
2. Discriminatory touch using a 10-g monofilament.
3. Assessing the ankle jerks.

Vascular examination
1. Palpation for dorsalis pedis, posterior tibial, popliteal and the
femoral  pulses.
2. Skin colour and temperature.
3. Strength of pulsation
4. Presence of abdominal and femoral bruits.

Risk factors
1. Glycaemic control
2. Duration of diabetes
3. Renal disease
4. Cigarette smoking
5. Poor social circumstances.

Monitoring and self care are key parts of management. 3-6 monthly review should be done. Patient education includes
  • Washing
  • Inspection
  • Care of corns and calluses
  • Toenail cutting
  • Wearing suitable footwear
  • Keep your feet as clean as your face
  • Ablution (Wazoo) five times a day in Muslims
The ulcerated foot

May be intrinsic defects in the ulcer healing in diabetic patients
  • Impaired fibroblast function
  • Deficiency in growth factors
  • Abnormalities found in the extra cellular matrix
Therefore delayed foot wounds healing and prolonged hospital stay is common.

Neuropathic ulcers which are associated with the callus, which develops on the plantar aspects of the metatarsal heads.
Neuroischaemic ulcers which are common on the margins of the diabetic foot.

Diabetic Foot Pic 5

Infection is divided in to
  • Local and superficial
  • Spreading soft tissue infection and the cellulitis 
  • Osteomyelitis
The signs of inflammation and early infection in foot may be difficult to detect in the presence of peripheral vascular disease. 

Deep wound swabs often show the presence of several bacteria (Gram +ve, Gram -ve, aerobic and anaerobic organisms). Antibiotics should be used accordingly.

Osteomyelitis is a common sequela of diabetic foot ulceration, usually caused by staphylococcus aureus. Plain x-rays of all patients of diabetic foot ulcers should be done. MRI when osteomyelitis is suspected.
Duplex ultrasound of lower limb is done for diabetic ischaemic ulcer.
Surgery (Debridement or amputation) is needed when antibiotics failed.

Diabetic Foot After Debridement



Posted at 23:59 |  by iqbal khatri

Monday, 6 October 2014

Gall Bladder Stones

Medically Gallbladder stones are called cholelithiasis. Chole means gall bladder, Lithia means stone, Sis means formation.( Stone formation in gall bladder).

Gall Bladder, Stones & Bile
  • Common and present in 10% of population over 50 years of age.
  • More common in females mostly in multiparous women.
  • 80% of Gallbladder stones are asymptomatic.
  • Symptoms are related to their complications which they cause.
  • Aetiological factors of Gallstone are
  1. Obesity
  2. Drugs
  3. Contraceptive pills
  4. Clofibrate
  5. Haemolytic disorders
  6. Ileal diseases ( Resection, Crohn's disease)
Gall Bladder during open cholecystectomy
Gall Bladder during open cholecystectomy

Types of Gallstones
  1. Pure Cholesterol Stones
  • 10%
  • Often solitary, round & large (>2.5 cm)
  • Radiolucent

Pure Cholesterol Stone
Pure Cholesterol Stone



Solitary Gall Stone in Ultrasound
Solitary Gall Stone in Ultrasound



 2.  Pure Pigment Stones
  • 10%
  • Occur with haemolysis
  • Small, black, irregular & friable
  • Radiolucent

Pure Pigment Stones
Pure Pigment Stones

  3.  Mixed Stones
  • 80%
  • Most common
  • Usually multiple
  • Often faceted
  • Contain calcium, pigment & cholesterole
  • 10% are radiolucent.


Mixed Gall Stones Pic 1
Mixed Gall Stones Pic 1




Mixed Gall Stones Pic 2
Mixed Gall Stones Pic 2




Mixed Gall Stones Pic 3
Mixed Gall Stones Pic 3



Mixed Gall Stones Pic 4
Mixed Gall Stones Pic 4





Introduction of Gallbladder Stones (Cholelithiasis)

Gall Bladder Stones

Medically Gallbladder stones are called cholelithiasis. Chole means gall bladder, Lithia means stone, Sis means formation.( Stone formation in gall bladder).

Gall Bladder, Stones & Bile
  • Common and present in 10% of population over 50 years of age.
  • More common in females mostly in multiparous women.
  • 80% of Gallbladder stones are asymptomatic.
  • Symptoms are related to their complications which they cause.
  • Aetiological factors of Gallstone are
  1. Obesity
  2. Drugs
  3. Contraceptive pills
  4. Clofibrate
  5. Haemolytic disorders
  6. Ileal diseases ( Resection, Crohn's disease)
Gall Bladder during open cholecystectomy
Gall Bladder during open cholecystectomy

Types of Gallstones
  1. Pure Cholesterol Stones
  • 10%
  • Often solitary, round & large (>2.5 cm)
  • Radiolucent

Pure Cholesterol Stone
Pure Cholesterol Stone



Solitary Gall Stone in Ultrasound
Solitary Gall Stone in Ultrasound



 2.  Pure Pigment Stones
  • 10%
  • Occur with haemolysis
  • Small, black, irregular & friable
  • Radiolucent

Pure Pigment Stones
Pure Pigment Stones

  3.  Mixed Stones
  • 80%
  • Most common
  • Usually multiple
  • Often faceted
  • Contain calcium, pigment & cholesterole
  • 10% are radiolucent.


Mixed Gall Stones Pic 1
Mixed Gall Stones Pic 1




Mixed Gall Stones Pic 2
Mixed Gall Stones Pic 2




Mixed Gall Stones Pic 3
Mixed Gall Stones Pic 3



Mixed Gall Stones Pic 4
Mixed Gall Stones Pic 4





Posted at 18:52 |  by iqbal khatri

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