1

Abdomen

Professor Ravi KantMS FRCS (Edin) FRCS (Glasg) FAMS FACS

DNB FICS FAIS

2

MCQ

• Short story = clinical vignette

• One line question

• 5 options= distractors

• One will be correct

• Blue print

3

Blue print

• 10 basics = trauma• 10 H&N• 10 Breast• 10 hernia, etc• 10 jaundice, abdomen• 10 abdomen• 10 colo-rectal• 10 Ped surgery• 5 vascular• 5 Thoracic• 10 Plastic surgery

4

Jaundice (J+)

• Surgical √

–Itching

–Clay colored stool

–Se Alkaline Phosphatase –Direct bilirubin –Total Bilirubin

5

J+

• If GB = NOT a case of CBD STONE

• Courvoisier’s law

= palpable

6

J+

• GB Soft

• A 45 y old male presents to OPD with jaundice, clay colored stools, itching. On examination, soft gall bladder is palpable. Total and direct bilirubin is raised.

7

A 45 y old male presents to OPD with jaundice, clay colored stools, itching. On examination, soft gall bladder is palpable. Total and direct bilirubin is raised.• Which of the following is the likely

diagnosis?

8

Distractors

1. CA gall bladder

2. CBD stone

3. Hilar cholangiocarcinoma

4. CA head of pancreas

5. Biliary agenesis

9

J+

• GB Soft= CA head of Pancreas of CA Periampullary (D or B or P)

10

J+

• GB Hard

11

J+

• GB Hard = CA GB

12

J+

• GB Soft

= CA Head of Pancreas

or

• CA Periampullary

• GB Hard

= CA GB

13

J+

• GB Not palpable

• Pain present

• = ?

14

J+

• GB Not palpable

• Pain present

• Young

• = CBD Stone

• Courvoisier’s law

15

J+

• GB Not palpable

• No pain

16

J+

• GB Not palpable

• No pain

=

• Hilar Cholangiocarcinoma (Klatskin’s tumor)

• Intra-hepatic

• Congenital

17

J+

• 2 months age

• GB Not palpable

• No pain =

• Intra-hepatic

• = Biliary agenesis= Kasai operation

18

J+

• GB not palpable

• Pain +

• CBD stone

• Inv MRCP

• Rx ERCP

• GB not palpable

• Pain –

• Hilar Cholangiocarcinoma

• Inv MRCP

• Rx Excision + H-J• (Hepatico-jejunostomy)

19

Congenital Syndromes

• Dubin Johnson

• Gilbert

• Rotor

• Criggler Najjar

20

J+

• Hard liver- smooth

21

J+

• Hard liver- smooth

• = Primary Carcinoma of Liver

• Inv =AFP, CT scan, MRA

• FNAC is CONTRAINDICATED

• Rx = Surgery= Resection

22

J+

• Liver Hard- nodular

23

J+

• Liver Hard- nodular

• = Secondaries in Liver

• Inv = search for primary= P0

• FNAC Liver (if PT is N)

24

J+

• Pain +

• Fever +

25

J+

• Pain +• Fever += Charcot’s triad=Surgical emergency= IV fluids, antibiotics►Later, when stabilized, Inv MRCP ; Rx ERCP

26

Triad

• Hiatus hernia

• Cholelithiais

• Diverticulosis

• = Saint’s triad

27

Liver ▲

• Hydatid

• Amoebic- pain & thump sign present

• Tumors- primary & Secondary

28

RIF mass : DD

1. Appendicular2. CA Caecum3. Ileo-caecal TB4. Crohn’s5. Actinomycosis6. Carcinoid7. Amoeboma8. LN mass

29

RIF mass : DD

• Appendicular• CA Caecum• Ileo-caecal TB• Crohn’s• Actnomycosis• Carcinoid• Amoeboma• LN mass•

• Undescended testis• Ectopic kidney• In F= TO Mass• Aneurysm of Iliac Art• Bone tumour

30

GB Stone : Types

• ? Examine Spleen in GB

31

Appendix

• No mass= Appendicectomy

32

Appendix

• Mass but normal temp= Conservative

33

Appendix

• Mass but temp= Abscess= Image guided aspiration

34

Colorectal Cancer

• Anal

• Rectal

• Rectosigmoid

• Premalignant

• Inv & Rx

35

Colorectal Cancer

• Commonest symptom

• Inv

36

LIF Mass DD

• Diverticulosis

• Rectosigmoid CA

• LN

• TO- mass--- CA 125

37

Types, Inv & Rx of

• Hemorrhoids

• Fistula in Ano

• Fissure in Ano