Moodle task answers Facultative surgery 4/2

Task 1.1 Thyroid 1. Euthyroid simple nodular goitre stage 5 Nodular goitre with tracheal compression - operation thyroidectomy of right lobe 2. * Fine bore needle biopsy  * serum TSH measurement * Ultrasound * Fine needle aspiration cytology 3. Operation and removal of nodular tissue anti thyroid drugs: carbimazole, propylthiouracil Task 1.2 1. Euthyroid simple nodular goitre stage 5 Nodular goitre with tracheal compression - operation thyroidectomy of right lobe 2. * Fine bore needle biopsy  * serum TSH measurement * Ultrasound * Fine needle aspiration cytology 3. Operation and removal of nodular tissue anti thyroid drugs: carbimazole, propylthiouracil Task 1.3 1. Benign neoplastic goitre - thyroid cyst grade 2 Differential diagnosis: hashimoto's thyroiditis, toxic nodular goitre, malignant neoplastic goitre 2. * Measurement of serum TSH       * TRH test         * Thyroid autoantibodies          * Thyroid scanning. * Ultrasound         *  Fine-needle aspiration cytology (FNAC) * Large-bore needle biopsy  3. * Needle aspiration of fluid from cyst * thyroidectomy * bed rest  * radioiodide Topic 2 Task 2.1 Acute peritonitis 1. Perforated gastric ulcer with stomach contents in peritoneum; relative acute peritonitis 2. Laboratory tests: * Total blood analysis       * Leukocyte count             * Bacteriological test for H pylori Instrumental tests: * Fibrogastroduodenoscopy          * ultrasound             * x ray examination 3.Laparocentesis and evacuation of fluid from abdomen Perforated ulcer repair drugs to decrease acid secretion - Cimetidine, lansoprazole diet modification Task 2.2 1. Differential diagnosis: Carcinoma of caecum (differentiated from the above by a longer history, often presence of diarrhea, positive occult blood with anemia and finally the barium enema examination). Crohn's disease  Ileo-caecal tuberculosis Psoas abscess; but rare. Pelvic kidney. A distended gall bladder (which may quite often extend down as far as the right iliac fossa). Ovarian carcinoma or tubal mass. Aneurysm of the common or external iliac artery. Retroperitoneal tumor arising in the soft tissues of lymph nodes of posterior abdominal wall or from the pelvis. 2. Laboratory:  Complete blood count: Leukocytosis, Neutrophilia, shift to the left, Increase ESR Urine analysis: leukocytes and erythrocytes Instrumental:  Ultra sound examination of abdomen - Presence of high echogenicity area x ray - round shadow laparoscopy - bulging mass 3. Surgical tactics stages:  One stage (Res + ana +/- ostomy) Two stages (Hartmann's procedure)  Three stages (Drainage + ostomy) Abscess size  <3-5cm: Antibiotics and bedrest > 5cm: Antibiotics, drainage, bedrest Task 2.3 1. Perforated duodenal ulcer 2. Laboratory: CBC (complete blood count): leukocytosis, neutrophilia, shift to the left. Urine analysis: normal Instrumental: Plain abdominal X-Ray: shadow of gas below the diaphragm. US (ultra sound): fluid in the abdominal cavity. Pneumogastrography: gas in the abdominal cavity. FGDS (fibrogastroduodenoscopy): perforated ulcer. 3. Procedures: Emergency laparatomy through midline incision All infected liquid is sucked out. Perforation closed with interrupted suture (Rosue Graham operation) Drainage and gastroscopy Task 3.1 1.  Primary malignant tumor of the liver 2. Laboratory:  CBC (complete blood count): erythrocytes decrease, hemoglobin decrease, ESR increase leukocytosis, shift to left Bilirubin increase. Instrumental: liver tissue biopsy- hepatocarcinoma and cholanginocarcinoma US (ultra sound): nodules in parenchymal tissues of the liver. CT scan: cancer of gall bladder or ducts. Laparoscopy with biopsy: hepatomegaly, nodules in the liver  3. main method: Operation treatment: Liver resection, Right hemihepatectomy, left hemihepatectomy, Liver transplantation. Other methods can include: Radiofrequency ablation cryotherapy anti cancer drugs chemotherapy Task 3.2 1. Portal hypertension - intrahepatic variant post shistosomiasis 2. Instrumental methods: Fibrooptic or rigid oesophagoscopy + gastroscopy - presence of varicose veins Radiology after a barium swallow -  show filling defects angiography - portal thrombosis 3.  Treatment of massive hemorrhage from oesophageal varice - a) Resuscitation of the patients. - clear airway and rapid replacement of blood volume. b) Arrest of haemorrhage -   1) Tamponade     2) Vasopressin  c) Endoscopic ligation of esophageal varices d)  Endoscopic sclerotherapy     General management of patients: The bowel should be cleared of blood by enemas or purgatives (eg magnesium sulphate). Corrections of clotting problems Transjugular intrahepatic portasystemic shunt Liver transplantation Task 3.3 1. Portal hypertension - intrahepatic variant  2.  Instrumental methods: Fibrooptic oesophagoscopy + gastroscopy - varicose veins Radiology + barium swallow -   filling defects angiography - portal thrombosis 3.  Treatment of massive hemorrhage from oesophageal varice  - a) Resuscitation of the patients. - clear airway and rapid replacement of blood volume. b) Arrest of haemorrhage - 1) Tamponade 2) Vasopressin  c) Endoscopic ligation of esophageal varices General management of patients: The bowel should be cleared of blood by enemas or purgatives (eg magnesium sulphate). Corrections of clotting problems Transjugular intrahepatic portasystemic shunt (TIPS) Task 4.1 1. Lactational mastitis - intramammary abscess 2.  -Complete blood count - Leukocytosis, shift to the left, neutrophilia -Ultrasound of mammary glands - changes in echogenicity in ducts -Mammogram - Increase intensity of shadow in affected side 3. -Support breast with bandages -Continue lactation, mechanical removal of extra milk -Antibiotic treatment (clofazone; sulfanilamide) -repeated ultrasound guided with aspiration needle. -Drainage of abscess under general anesthesia if needed. Task 4.2 1.  Mammary dysplasia (fibrocystic mastopathy) 2. blood –normal  urine-normal ultrasound - increase in density mammography fnac-for breast biopsy 3.  conservative treatment treatment of adexitis testosterone propionate 1% 1 ml (in 3 days once) KI sol o. 25%, 15ml 2 tablets orally in premenstrual period topical and systemic NSAID's and analgesics Task 4.3 1.benign tumor of mammary gland - fibroadenoma 2.  Mammography- f mass with smooth, round edges, distinct from surrounding tissue ultrasound - solid lump, absence of cyst fine needle aspiration - cyst absent if no fluid. tissue biopsy - to check tumor markers 3.non surgical management - analgesics and regular assessment until it disappears. surgical mangaement - excisional biopsy / lumpectomy, cryoablation Task 5.1 1. Diverticular disease, irritable bowel syndrome 2. Blood analysis - Leukocytosis shift to left, neutrophilia ESR increased X ray with barium swallow - bright contours of colon Colonoscopy CT scan 3.  Increased frequency and intensity of pain Risk of development of complications if surgery isn't performed on time. Quick recovery of patient Task 5.6 1.perianal abscess 2.  Inspection  Digital examination Proctoscopy Blood analysis 3.  Thorough drainage by a making a cruciate incision over the abscess and excising the skin edges -  this completely removes the “roof” of the abscesses, self healing in few days Task 5.7 1.low level anal fistula 2.   Digital examination -   internal opening can be felt as a nodule on the anal canal. Proctoscopy  - to reveal the internal opening of the fistula. Probing - patient under an anesthetic in the operating theater. Radiography of the thorax (tbc). Fistulography 3.  * Preoperative cleansing enemas * insertion of a probe retrogradely * injection of diluted ethylene blue * A probe - pointed director is inserted into the distal orifice * The director is reinserted and again followed with the knife for a short distant * The edges of the tract are trimmed 1 to 3 mm