(BQ) Part 2 book Nutshell series for general surgery presents the following contents: Intestinal system, hepatobiliary and pancreatic system, urological surgery, liver, liver differentiating feature between, burns and cosmetic surgery, cardiothoracic surgery,...
i Intest nal S 12 ystem HIRSCHSPRUNG’S DISEASE ○ Male : female = : ○ Absence of ganglion cells in both myenteric and submucous plexus ○ Accompanying hypertrophy of nerve trunks ○ Rectal full thickness biopsy—diagnostic ○ May present as acute intestinal obstruction to chronic constipation in later life ○ Absence of fecal soiling differentiates it from other types of constipation ○ Surgeries done: Duhamel, Swenson, Soave MECKEL DIVERTICULUM ○ Meckels is true diverticulum, located in antimesentric border ○ M/c congenital anomaly of gastrointestinal tract (GIT) ○ M/c ectopic mucosa: m/c is gastric (60%), pancreatic, colonic, Brunner's glands, endometriosis ○ Rule of 2: Prevalence 2%, inch length, located feet proximal to ileocecal (IC) valve, presents m/c in < year age ○ M/c complication in adults: Obstruction, children—bleeding, overall— bleeding ○ Littre's hernia: Meckel's as content in the sac (Amyand’s hernia—appendix) ○ Tc-99 m pertechnate scan: Diagnosis ectopic gastric mucosa, angiography can diagnose active bleed ○ Surgery: Simple excision, wide mouth during other surgeries leave it ○ Resection of ileum with anastomosis is done if—peptic ulcer in ileum, gangrene affecting base, rarely if malignancy associated Contd tahir99 - UnitedVRG 119 Intestinal System Contd DIVERTICULAR DISEASE ○ Diverticulosis: Multiple diverticula ○ Diverticulitis: Perforated diverticulum due to inflammation ○ Diverticulosis: Best diagnosed by barium enema (Sawtooth appearance) Should not be done in acute settings ○ Diverticulitis: Best diagnosed by computed tomography (CT) scan ○ False divericula: Are m/c ○ Left side (sigmoid) colon: M/c site ○ Bleeding m/c from right side: Supplied by superior mesentric artery ○ In small bowel—Duodenum is m/c site, m/c on mesentric side, false diverticula ○ Most sensitive test—Enteroclysis ○ Small bowel diverticula are associated with blind loop syndrome: Bacterial overgrowth, B12 deficiency—megaloblastic anemia POLYPS �� F F ����������������� V F �������������������������������������� ○ Gardner's syndrome: PC + osteomas, epidermoid cysts, congenital hypertrophy of retinal pigment epithelium, desmoid tumor, retroperitoneal fibrosis, polyps of stomach, small intestine, adenomas in pancreas, thyroid, adrenal, parathyroid ○ Peutz-Jeghers syndrome: Hamartomatous polyps in jejunum* and other part, pigmentation of lips, tumors of ovary, breast, endometrium, pancreas ○ Cronkhite canada syndrome: Juvenile polyps are noted along with alopecia, cutaneous pigmentation, atrophy of nails and toe nail F ○ Pseudopolyps are not premalignant ○ Non-neoplastic polyps: Hyperplastic, juvenile, Peutz-Jeghers polyps ○ Neoplastic polyps: Tubular adenomas, �illous adenomas, �amilial polyposis coli, Gardner's syndrome, Turcot syndrome ○ Familial adenomatous polyposis (FAP): Autosomal dominant (AD) disorder, 5q*—colorectal cancer develops in all patients at age before 40 years if untreated Prophylactic colectomy needed ○ Turcot syndrome: amilial pancreatic cancer ( PC) + brain tumors like glioma, medulloblastoma—AR COLONIC CANCER Risk factors F ○ Geographic variation: Highest risk in Western countries and lowest risk in developing countries ○ Age: Risk increase sharply after the 5th decade ○ Diet: Increased with total and animal fat diets ○ Physical inactivity: Increased with obesity and sedentary lifestyle ○ Adenoma: Risk dependent on type and size AP penetrance in gene carriers 100% ○ Hereditary non-polyposis colorectal cancer (HNPCC) penetrance in gene carriers 80% ○ Hamartomatous syndromes: Risk increased with PeutzJeghers syndrome and juvenile polyposis, but not isolated juvenile polyps ○ Previous history of colon cancer: Increased risk for recurrent cancer ○ Ulcerative colitis: 10%–20% after 20 year ○ Radiation: Associated with a mucinous histology and poor prognosis ○ Ureterosigmoidostomy: 100–200 times increased risk at or adjacent to the ureterocolonic anastomosis tahir99 - UnitedVRG 120 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery PERCENTAGES ○ M/c—rectosigmoid ○ Rectum—38% ○ Sigmoid—21% ○ Caecum—12% ○ Ascending—5% ○ Descending—4% ○ Transverse—5.5% V Peak age: 60-80 years 98% cases are adenocarcinoma Symptoms: ague and nonspecific MANAGEMENT ○ Malignant obstruction is the M/c cause of large bowel obstruction ○ The primary goal of treatment is decompression of obstructed segment to prevent perforation ○ Removal of diseased segment is second goal Right colon Left colon ○ Both should be done whenever possible ○ If lesion is unresectable a diversion colostomy is done Stable case—resection and ileocolic anasto- Traditionally and most commonly performed surgery is resection of lesion mosis in a single stage and proximal diversion (Hartmanns) Unstable/perforated colon—two stage, Stable patient with no peritonitis, resectable tumors—primary resection resection with ileostomy, later anastomosis and anastomosis or subtotal colectomy and ileo rectal anastomosis Staging Dukes classification ○ T1—Limited to mucosa and submucosa ○ T2—Extends to muscularis o T3—Extends into or through serosa Depth of penetrance is an important predictor for distant mets Carcinoembryonic antigen (CEA)—marker for recurrence ○ Stage A: Limited to mucosa ○ Stage B1: Extending into muscularis propria, but not penetrating through it; nodes not involved ○ Stage B2: Penetrating through muscularis propria; nodes not involved ○ Stage C1: Extending into muscularis propria, but not penetrating through it Nodes involved ○ Stage C2: Penetrating through muscularis propria Nodes involved ○ Stage D: Distant metastatic spread tahir99 - UnitedVRG 121 Intestinal System SMALL BOWEL TUMORS ○ Duodenum is m/c site of small bowel tumors ○ Leiomyoma is m/c tumor, m/c malignant tumor is adenocarcinoma ○ Adenocarcinoma does not have good prognosis ○ In small and large bowel tumors, the liver mets per se is not a contraindication for primary curative resection ○ Chemotherapy is not a proven treatment for small bowel cancers SMALL BOWEL CARCINOIDS ○ Primary: Usually small ○ Secondary: Those metastasized produces many symptoms together known as carcinoid syndrome Most common site is ileum*, 2nd common is rectum, 3rd common site is lungs Being the most common site previously appendix is now pushed to 4th place Features APUDomas Arise from enterochromaffin like cells (ECL) also known as kulchis- ○ Amine precursor uptake is derived from neural crest tissue as they migrate to different parts of ky/argentaffian cells the body Produces—5HT (serotonin), ACTH, somatostatin and peptide YY GIT—carcinoids 80% are asymptomatic Pancreas—insulinomas Only when serosa is invaded they produce intense desmoplastic Central nervous system (CNS)—neuroblastomas reaction presenting with abdominal pain, intusussception and diar4 Adrenal—pheochromocytoma rhea (mainly due to partial obstruction and not due to serotonin.) Lungs—small cell carcinoma Carcinoid syndrome ○ Metastasis depends on: Size: < cm (< 2%); >2 cm (90%) Site: Appendix (3%); ileal (35%) least with appendix Depth of invasion Malignant carcinoid syndrome develops only liver mets develop; because all the above listed hormones are detoxified in liver ○ asomotor symptoms (80%): Cutaneous flushing ○ GIT: Explosive diarrhea Due to serotonin ○ Cardiovascular: Pulmonary stenosis (90%), tricuspid stenosis and insufficiency ○ Asthmatic attacks: bronchospasm ○ Malabsorption and pellagra (dementia, diarrhea, dermatitis) due to excessive diversion of tryptophan V Metastatic carcinoids (secondary) Treatment 24 hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** are highly specific Neuroendocrine tumor marker—chromogranin A Pentagastrin provocative tests Small bowel carcinoids: Difficult to diagnose preoperatively Recently: Somatostatin receptor scintigraphy with indium-111 labelled pentreotide has shown higher sensitivity than CT scan • If size < cm—segmental intestinal resection • If size > cm, nodes+ or if there are multiple metastasis—wide excision along with mesentry • Terminal ileum: Right hemicolectomy • Liver mets: Resection, hepatic artery ligation or embolization or radiofrequency ablation (R A) F Investigations INFLAMMATORY BOWEL DISEASE (IBD) Crohn disease (CD) Ulcerative colitis (UC) ○ Histopathologic examination of Crohn’s disease typically demonstrates transmural inflammation characterized by multiple lymphoid aggregates in a thickened submucosa ○ Non-caseating granulomas are a valuable diagnostic feature of Crohn’s disease, but they are seen in only 50% of resected specimens and are rarely seen ○ The earliest gross manifestations of Crohn’s disease are the development of small mucosal ulcerations called aphthous ulcers ○ As the disease progresses, the mucosa begin to erode leaving only small islands of mucosa that resemble polyps, but are actually pseudopolyps ○ Histologically, the typical early lesion consists of an infiltration of inflammatory cells, primarily polymorphonuclear leukocytes, into the crypts at the base of the mucosa, forming crypt abscesses Contd tahir99 - UnitedVRG 122 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Contd INFLAMMATORY BOWEL DISEASE (IBD) Crohn disease Ulcerative colitis ○ Serpiginous network of linear ulcerations that surround islands of edematous mucosa producing the classic ‘cobblestone’ appearance Mucosal ulcerations may penetrate through the submucosa to form intramural channels that can bore deeply into the bowel wall and create sinuses, abscesses or fistulas ○ Although ulcerative colitis is generally confined to the mucosa and submucosa, in the most severe forms of the disease, such as fulminant colitis or toxic megacolon, the disease process may extend to the deeper muscular layers of the colon and even to the serosa Clinical features Ulcerative colitis Crohn disease Location ○ Colon only • Anywhere in the alimentary tract Anatomic distribution ○ Continuous, beginning distally • Asymmetrical skip lesions Rectal involvement ○ > 90% • Occasionally Diarrhea/gross bleeding ○ Severe, often bloody with mucus • Less severe, infrequent bleeding Abdominal pain ○ Yes • Occasionally Perianal fistulas ○ Rare • Common Abdominal mass (palpable) ○ Rare • Common Strictures and obstructions ○ Uncommon • Common Fistulas and perforations ○ Rare • Common Extraintestinal manifestations ○ Common • Common Recurrence after surgery ○ If retained rectal mucosa • Yes Endoscopic features Ulcerative colitis Crohn disease Mucosal involvement ○ Contiguous • Discontinuous Discrete ulcers (aphthous) ○ Rare • Common Surrounding mucosa ○ Abnormal • Relatively normal Longitudinal ulcers (serpiginous) ○ Rare • Common Cobblestoning ○ No • In severe cases Rectal involvement ○ > 90% • Sparing common Mucosal friability ○ Common • Uncommon Vascular pattern ○ Distorted • Normal Radiographic features ○ No • Yes Terminal ileum abnormalities ○ Rare • Yes Segmental colitis ○ No • Yes Asymmetric colitis ○ No • Yes Stricturing ○ Occasionally • requently F Small bowel abnormalities tahir99 - UnitedVRG 123 Intestinal System LOCAL COMPLICATIONS OF IBD is TREATMENT FOR IBD r e p Ulcerative colitis / r i s s n a Crohn disease ○ Conservative ○ Surgical—Elective and emergency ○ Indications for surgery ○ Remember UC can be cured by resection of affected segment, but CD needs only palliative care p Emergency Elective Proven or suspected perforation of colon Intractable disease Massive hemorrhage Dysplastic changes/cancer Toxic megacolon not responding to medical treatment Chronic colitis > 10 years tt p /: / Emergency iv • Fulminant colitis: Total colectomy with end ileostomy rather than a total proctocolectomy (rectum also removed) This is because rectum symptoms improve invariably and also first procedure avoids unnecessary time waste in pelvis dissection in critically ill patient • If too unstable: Loop ileostomy and decompressing colostomy h Elective Indications of surgery istulas Intra-abdominal abscess Perianal abscess Strictures F • Restorative proctocolectomy with ileal pouch anal anastomosis (procedure of choice) • Total proctocolectomy with end ileostomy • Total proctocolectomy with continent ileostomy (Kock’s pouch) ○ Toxic megacolon ○ Massive bleed ○ Dysplasia/cancer ○ Intractability EXTRAINTESTINAL MANIFESTS Dermatologic • Erythema nodosum • Pyoderma gangrenosum (m/c in UC) Contd tahir99 - UnitedVRG 124 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Contd EXTRAINTESTINAL MANIFESTS Dermatologic • Sweet syndrome • Psoriasis • Neutrophilic dermatosis • Perianal skin tags (70%–80% cases of CD) • Oral lesions (aphthous stomatitis, cobblestone appearance—m/c in CD) Rheumatologic • Peripheral arthritis (m/c in CD)* • Ankylosing spondylitis (m/c in CD) • Sacroilitis • Hypertrophic osteoarthropathy • Osteomyelitis • Relapsing polychondritis Ocular is • Conjunctivitis, uveitis, episcleristis Hepatobiliary r e p • Hepatic steatosis • Cholelithiasis (m/c in CD) • Primary sclerosing cholangitis p Others • Calculi—m/c in CD • Ureteral obstruction • istulas • Thromboembolic manifests • Osteoporosis • Amyloidosis • Endo, myo, pericarditis F Urologic tt p Types of tuberculosis (TB) Ulcerative Hyperplastic /: / h iv / r i s s n a Primary sclerosing cholangitis (PSC) is most serious and also does not resolve after colectomy Colitis associated colon cancer m/c occur in left side, but in patients with PSC+UC—cancer m/c on right side TUBERCULOSIS OF ABDOMEN Acquired as Primary infection: Mycobacterium bovis, infected milk—hyperplastic (TB) Secondary infection: Swallowing tubercle bacilli—ulcerative type TB—M/c form of intestinal (TB) Points Hyperplastic Ulcerative Cause ○ M bovine primary ingestion Secondary to swallowing infected sputum M/c site ○ Ileocecal valve Longer parts of terminal ileum Presentation ○ As obstruction As transverse ulcers Typhoid presents with transverse ulcers Clinical features ○ Acute abdominal pain with intermittent diarrhea ○ Mass in right iliac fossa ○ Blind loop syndrome may develop Diarrhea and weight loss Barium meal ○ Pulled up cecum, ileocecal angle becomes obtuse Absence of filling of lower ileum Treatment ○ Augmentation therapy (ATT) + surgery if obstructed ATT + surgery if perforated Complications ○ Obstruction Perforation, fistula tahir99 - UnitedVRG 125 Intestinal System SHORT BOWEL SYNDROME ○ Resection of terminal ileum—malabsorption of bile salts and vitamin B12 Results in: Megaloblastic anemia Watery diarrhea—unabsorbed bile salts into colon Malabsorption of fat soluble vitamins Steatorrhea—reduction in bile salt pool Oxalate kidney stones—unabsorbed fatty acids bind with calcium Cholesterol gallstones—decreased bile salt in bile Increased gastrin secretion: due to reduced hormonal inhibition Risk factors for short gut syndrome • Small bowel length < 200 cm • Absence of ileocecal valve • Absence of colon • Diseased bowel remaining (Crohn disease) • Ileal resection ○ Removal of significant portion of small bowel ○ M/c causes—mesentric infarction, Crohn disease, trauma / r i Treatment Medical treatment Non-transplant surgeries H2 antagonists/Proton pump inhibitors (PPI) to reduce gastric secretion Antimotility agents—Loperamide Octerotide Total parenteral nutrition (TPN) Bianchi intestinal lengthening operations Serial transverse enteroplasty is SUPERIOR MESENTERIC ARTERY (SMA) SYNDROME r e p ○ Wilkie’s syndrome ○ Rare condition in which the 3rd part of duodenum compressed between SMA and aorta Factors that precipitate the syndrome Sudden weight loss Rapid growth in height Body casts application Supine immobilization /: / Clinical features p iv n a ○ Conservative/postural therapy ○ If not responding—duodenojejunostomy ENTEROCUTANEOUS FISTULA ○ M/c cause of enterocutaneous (EC) fistula is iatrogenic ○ Other causes—Crohn’s disease, diverticulitis, carcinoma colon ○ High fistulas drain > 500 mL/day Complications of fistula luid and electrolyte disturbance Malnutrition Necrosis of skin Sepsis leading to multiple organ failure and death F h s s Treatment ○ M/c seen in thin young female ○ Presents with gastric outlet obstruction (GOO) symptoms tt p • Intestinal transplantation Treatment TPN Surgery indicated, if fistula fails to heal after 4-6 week istulous tract excision along with involved segment and reanastomosis Megacolon Toxic megacolon ○ Megacolon describes chronically dilated, elongated, hypertrophied large bowel ○ Defined as transverse colon diameter > 5–6 cm with loss of haustration F Correction of fluid and electrolyte imbalance Antibiotics Skin protection Contd tahir99 - UnitedVRG 126 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Contd ENTEROCUTANEOUS FISTULA Megacolon Toxic megacolon ○ Congenital: Hirschsprungs, ○ Acquired: Chagas disease: T cruzi infection Medications: Anticholinergics Neurological: Polio, paraplegia, multiple sclerosis, motor neuron disease Rectal cancer ○ Caused by: Ulcerative colitis Crohn disease Salmonellosis Amebic colitis Pseudomembranous colitis Ischemic colitis Treatment of toxic megacolon: Surgery is a must as it may go for perforation Points V • Unlike UC, which starts with rectum and almost always involves rectum, rectal sparing is seen in Crohn disease • Angiodysplasia is a vascular malformation associated with ageing It occurs m/c in ascending colon and cecum • A patient presents with lower GI bleeding, biopsy from sigmoid colon ulcers are flask-shaped-amoebic colitis ulcers— treatment: I Metrogyl APPENDIX ACUTE APPENDICITIS Normal position of appendix Etiology factors ○ Retrocecal: 70% ○ Pelvic: 20% ○ Preileal and postileal ○ Idiopathic ○ ecoliths and worms ○ alve of Gerlach: alve at base of appendix V V F ○ Subcecal ○ Paracecal ○ Subhepatic ○ First symptom: Anorexia followed by pain ○ Murphy’s triad: Pain, vomiting and fever ○ Blumberg sign—rebound tenderness ○ Rovsing’s sign (American): Palpation of left iliac fossa produces pain in right iliac fossa by shift of bowels ○ Rovsing’s sign (Europe): Retrograde strikeouts of leftsided colon leads to pain in the ascending colon and cecum ○ Douglas sign: Right-sided pain in rectal or vaginal examination ○ Sherren’s triangle hyperesthesia: Triangle formed by ASIS, umbilicus and pubic symphysis due to irritation of lower abdominal nerves ○ Bastede’s sign: Pain in right iliac fossa, if air is insufflated into rectum Investigations • Clinical examination is the diagnostic • Ultrasonography (USG) and CT scan are used to confirm the diagnosis • On the basis of clinical examination normal appendix is found in 15%–30% cases Tests Cope’s psoas test: Retrocecal appendicitis on extension of hip produces pain due to irritation over psoas major Cope’s obturator test: Pelvic appendicitis, flexion and fedial rotation produces pain Contd tahir99 - UnitedVRG 127 Intestinal System Contd ACUTE APPENDICITIS Alvarado scoring • M—Migratory pain • A—Anorexia • N—Nausea and vomiting • T—Tenderness • R—Rebound tenderness • E—Elevated temperature • L—Leukocytosis • S—Shift to left, segmented neutrophils Score of > is strongly suggestive of appendicitis Complications Appendicular mass ○ Early antibiotics not prevent rupture ○ Occurs most frequently distal to obstruction along the antimesenteric border ○ Suspect rupture if there is high grade fever > 39 degrees ○ Risk factors of perforation—extremes of age, immunosuppression, diabetes mellitus, fecolith obstruction, pelvic appendix, previous abdominal surgery ○ Infection sealed off by greater omentum, cecum, terminal ileum, which results in a tender soft to firm mass in RI ○ Ochsner-Sherrens conservative regimen followed ○ Interval appendicectomy done after weeks F Perforation Appendicular abscess ○ If infection is not properly controlled abscess results presenting with high grade fever and chills ○ Drain pelvic abscess via rectum, drain retrocecal abscess extraperitoneally, pre and postileal abscess by laparotomy In all cases, elective appendicectomy done in a later date ○ Diffuse peritonitis following appendicitis occur if perforation occurs in < 24 hours of onset In later stages the omentum and small bowels usually surround the inflammed appendix and prevent spread Incisions Special situations • McBurney’s grid iron incision • Lanz incision: Cosmetic horizontal skin incision • Rutherford-Morrison incision: Muscle cutting incision and not a skin incision extending upwards and laterally • Ilio hypogastric nerve is injured in grid iron incision • Results in direct hernia right side ○ Cecal wall edematous and inflamed: Stump must not be invaginated and purse string not used ○ Base of appendix inflamed: Base is not crushed, ligated close to cecum and stump invaginated ○ Base is gangrenous: Neither crushed nor ligated remove the appendix close to base and apply two layer stitches at the cecal wall ○ On opening appendix is normal patient is having Crohn disease: If Crohn disease is not involving base of appendix appendicectomy, if it involves leave it as such MUCOCELES Histological types Retention cysts Mucous hyperplasia Cystadenoma Cystadenocarcinoma ○ Intraluminal accumulation of mucoid substance ○ Benign tumor, low grade malignancy: Hence simple appendicectomy is enough CARCINOID APPENDIX ○ Argentaffinomas or carcinoid tumors are the m/c neoplasm of appendix ○ M/c in distal third ○ Rarely metastasis to liver Treatment Depends on size of tumor < cm—plain appendicectomy > cm—right hemicolectomy If cecal wall or mesoappendix or lymph nodes involved right hemicolectomy tahir99 - UnitedVRG 273 Walls of canal 213 femoral canal 215 Wardill operation 239 Warthin tumor 51 Water intoxication 194 Watery diarrhea 125 Weight loss 107 Wharton submandibular duct 49 Whipple procedure 156 Whitaker test 188 Whole blood 13 Wilkie’s disease 112 syndrome 125 Wilm’s tumor 185, 188 Wolman’s classification 64 Wunderlich’s syndrome 186 Ulcer of oral cavity 37 Ulcerative colitis 121-123 Ultimately inoperable tumors 111 Umbilical calculus 218 granuloma 218 Umbilicus 213 Undescended testis 207 Upper gastrointestinal bleeding 106, 112 limb 237 part of rectus abdominis 86 Urea breath test 105 Ureterocele 190 Ureteroscopy 181 Ureterosigmoidostomy 119 Urethra 200 Urethral injuries 193 Uric acid stones 192 Urinary bladder 190 Urological injuries 27 surgery 180 X Xanthogranulomatous pyelonephritis 189 Y W Y U Variety of intraparietal hernia 215 Vascular masses 227 surgery 244 Vein of Mayo 103 Venous drainage 57 grafts 232 plane 48 system 244 Vigorous achalasia 97 Virchow’s triad 246 von Graefe’s sign 61 von Hippel-Lindau syndrome 183 von Recklinghausen’s disease 256 flaps 238 graft 172 head injury 22 hernia 214 hydrocephalus 223 hypospadias 198 neck dissection 35 nutrition of tuberculosis 124 primary lymph edema 251 renal calculus 180 skin graft 238 stockings 251 toxicosis 60 ulcer urethral injuries 201 wound suturing gastrectomy 110 parenteral nutrition Toupet posterior fundoplication 93 Toxic megacolon 125 multinodular goiter 61 nodular goiter 61 Tracheobronchial injury 24 Tracheoesophageal fistula 2, 95 Traditional classification of hemorrhagic shock 13 Transabdominal preperitoneal mesh 217 Transanal excision of cancer rectum 132 Transjugular intrahepatic portal shunt 166 Traumatic fat necrosis 81 Treatment of complete prolapse 136 established lymph edema 251 fistula-in-ano 134 hydrocephalus 223 hypospadias 199 intraductal papilloma 80 partial prolapse 136 skin cancers 258 vesical calculus 192 Triangles of neck 46 Triangular cord sign 150 Triple assessment of breast 79 Troisier sign 156 Trophic ulcer Trousseau sign 156 True shortening of esophagus 96 Trypanosoma cruzi 98 Tuberculosis 1, 46 of bladder 193 of testis 209 Tuberculuos sinus Tuberous sclerosis 183, 255 Tubular carcinoma 83 Tubulodermoid Tumor like malformations 224 localization 74 of ovary 119 of vagal body 40 thickness 259 Turcot syndrome 119 Types of allograft rejection 16 anal carcinoma 133 aneurysms 252 bariatric surgery 114 biliary atresia 149 casts 189 donor 188 emergency thoracotomy 26 enteral nutrition Index Z Zenkers diverticulum 99 Zollinger-Ellison syndrome 104 Zona fasciculata 73 glomerulosa 73 reticularis 73 Z-plasty 135, 239 Vaginal hydrocele 209 Vagotomy 107 Vagus nerve 92, 103 Vanillymandelic acid 74 Vanishing bile duct syndrome 151 Varicella zoster 98 Varicocele testis 207 Varicose veins 244, 246 V loop 110 tahir99 - UnitedVRG ... anastomosis tahir99 - UnitedVRG 120 Nutshell Series for FMGE/DNB/NEET-PG General Surgery PERCENTAGES ○ M/c—rectosigmoid ○ Rectum—38% ○ Sigmoid 21 % ○ Caecum— 12% ○ Ascending—5% ○ Descending—4%... leukocytes, into the crypts at the base of the mucosa, forming crypt abscesses Contd tahir99 - UnitedVRG 122 Nutshell Series for FMGE/DNB/NEET-PG General Surgery Contd INFLAMMATORY BOWEL DISEASE... mm Hg 16 25 mm Hg 26 –35 mm Hg > 35 mm Hg V ○ The following grading system has become accepted if IAH is present ○ (Normal IAP: 0–7 cm H2O) • Grade I, 13 20 cm H2O • Grade II, 21 –35 cm H2O • Grade