Monday, February 20, 2012

Adenoid

Definition : Hypertrophy of the nasopharyngeal tonsil sufficient enough to obstruct the airway.

Age incidence : Usually 3-7 years
Regress : From 10 years
Complete regress : Within 20 years


Clinical features are due to –
Hypertrophy of the adenoid causing mechanical obstruction
Fig:Enlarge adenoid
Inflammation
Generalized symptoms

Symptoms due to nasal obstruction --    Mouth breathing
     Dryness of throat
     Dribbling of saliva
     Sore throat due to associated pharyngitis
     Deafness, earache( Due to blockage of Eustachian tube)
      
 Due to inflammation :
     I.  Nasal discharge
     II. Post-nasal drip
     III. Recurrent acute suppurative otitis 
          media
      IV. Persistence of chronic suppurative
          otitis media
       V. Rhinitis/Sinusitis
 
Generalized disturbances :
Mental apathy
Mental dullness
Nocturnal enuresis
Night terror

In long standing cases patient may develop adenoid facies.

Adenoid facies :
Open mouth
Pinched nose
Retraction of upper lip
Prominent upper incisor
High arched palate
Flat chest and rounded shoulder

Sign :
Mouth breath
Digital examination
Posterior rhinoscopy

Diagnosis :
By symptoms and Xray nasopharynx lateral view


Differential diagnosis :
Deviated nasal septum
Hypertrophied posterior end of inferior turbinate
Antrochoanal polyp
Congenital chonal atresia

Complications :
Pharyngitis
Tonsillitis
Secretory otitis media
Recurrent acute suppurative otitis media
Persistance of chronic suppurative otitis media
Sleep apnoea
Mental dullness

Treatment :
When symptoms are mild-
Nasal decongestants
Antihistamine

When there is recurrent symptoms and/or complications- Adenoidectomy
In secretory otitis media, myringotomy and possibly insertion of ventilation tube(Grommet) are done together with adenoidectomy.

DIPHTHERIA


It is an acute infection caused by Gram positive bacillus, Corynebacterium Diphtheriae.
It spreads by droplet infection.
Incubation period : 2-6 days

Incidence :
The incidence has fallen markedly in the last quarter of a century.
Children are particularly affected , especially those between 2-5 years of age. But any age group can be affected.

Because of widespread and routine childhood DPT immunizations, diphtheria is now rare in many parts of the world.
Risk factors include crowded environments, poor hygiene, and lack of immunization.

Symptoms :
Sore throat
Painful swallowing
Neck swelling
Low grade fever, headache, malaise
Vomiting
Sign :
Enlarged and tender cervical lymph nodes.
Sometimes presenting a “bull-neck” appearance.
Patches of false membrane are present on the tonsils, faucial pillars, soft palate and occasionally on the posterior pharyngeal pharyngeal wall. It is usually grey in colour. It is firmly attached and when detached, leaves a bleeding surface on which it tends to re-form. It often has a strong foetor. In atypical cases no false membrane is present and picture resembles a simple streptococcal infection.
Pyrexia : The temperature is rarely above 38.30C(1010F), but the pulse rate is usually raised out of proportion.
Toxaemia is marked.( Patient is ill and toxic but fever seldom rises above 380C)

Complications :
Myocarditis
Cardiac arrythmia
Acute circulatory failure
Paralysis of soft palate, diaphragm and ocular muscles.
Laryngeal diphtheria may cause airway obstruction.

Treatment :
Antitoxin must be given  immediately, without waiting for the bacteriological results of a swab, when the disease is suspected. 20,000 – 100,000 units are injected.
Systemic penicillin : helps to control the primary and any secondary infection.

Other treatments may include:

Fluids by IV
Oxygen
Bed rest
Heart monitoring
Insertion of a breathing tube
Correction of airway blockages

STOMAS(Colostomy)


                  A colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external appliance. Depending on the purpose for which the diversion has been necessary, a colostomy may be temporary or permanent.
Figure:Colostomy bag

     SUMMRY
     Stomas
·         May be colostomy or ileostomy
·         May be temporary or permanent
·         Temporary or defunctioning stomas are usually fashioned as loop stomas
·         An ileostomy is spouted; a colostomy is flush
·         Ileostomy effluent is usually liquid whereas colostomy effluent is usually solid
·         Ileostomy patients are more likely to develop fluid and electrolyte problems
·         An ileostomy is usually sited in the right iliac fossa
·          A temporary colostomy may be transverse and sited in the right upper quadrant
·         End colostomy is usually sited in the left iliac fossa
·         All patients should be counselled by a stoma care nurse before operation
·         Complications include skin irritation, prolapse, retraction, necrosis, stenosis, parastromal hernia, bleeding and fistulation.

Temporary colostomy
                                        A transverse loop colostomy has in the past been most commonly used to de function an anaestomosis after an anterior resection. It is now less commonly employed as it is fraught with complications and is difficult to manage; a loop ileostomy is preferred.
    A loop left iliac fossa colostomy is still sometimes used to prevent faecal peritonitis developing following traumatic injury to rectum, to facilitate the operative treatment of a high fistula in ano and incontinence.
    A temporary loop colostomy is made bringing a loop of colon to the surface, where it is held in place by a plastic bridge passed through the mesentery. Once the abdomen has been closed, the colostomy is opened, and the edges of the colonic incision are sutured to the adjacent skin margin. When firm adhesion of the colostomy to the abdominal wall has taken place, the bridge can be removed after 7 days.
    Following the surgical cure or healing of the distal lesion for which the temporary stoma was constructed, the colostomy can be closed. It is usual to perform a contrast examination (distal lopogram) to check that there is no distal obstruction or continuing problem at the site of previous surgery. Colostomy closure is most easily and safely accomplished if the stoma is mature i.e. after the colostomy has been established for 2 months. Closure is usually performed by an intra peritoneal technique, which is associated fewer  closure breakdowns with faecal fistulae.
Double barrelled colostomy
                                                This colostomy was designed so that it could be closed by crushing the intervening spur by using an enterotome or a stapling device. It is rarely used now, but occasionally the colon is divided so that both ends can be brought to the surface separately, ensuring that the distal segment is completely defunctioned.

Permanent colostomy
                                      This is usually formed after excision of the rectum for a carcinoma by the abdomino-perineal technique. It is formed by bringing the distal end(end colostomy) of the divided colon to the surface in the left iliac fossa, where it is sutured in place, joining the margin to the surrounding skin. The point at which the colon is brought to the surface must be carefully selected to allow a colostomy bag to be applied without impinging on the bony prominence of the antero superior iliac spine. The best site is usually through the lateral edge of the rectus sheath, 6 cm above and medial to the bony prominence.

Complications of colostomies
                                                  The following complications can occur to any colostomy but are more common after poor technique or siting of the stoma:
  • Prolapse
  • Retraction;
  • Necrosis of the distal end;
  • Fistulae formation;
  • Stenosis of the orifice
  • Colostomy hernia
  • Bleeding
  • Colostomy diarrhoea; this is usually an infective enteritis and will respond to oral metronidazole 200 mg three times daily.
Many of these complications require revision of the colostomy.

Loop ileostomy
                           An ileostomy is now often used as an alternative to colostomy, particularly for defunctioning a low rectal anaestomosis. The advantages of a loop ileostomy over a loop colostomy are the ease with which the bowel can be brought to the surface and the absence of odour. Care is needed, when the ileostomy is closed, that the suture line obstruction does not occur.

        













Enterocutaneous Fistula


Figure:Enterocutaneous fistula

An external fistula communicating with the gut mucosa to the skin surface. It may occur following an operation for gangrenous appendicitis or the draining of the appendix abscess. A faecal fistula can occur from necrosis of a gangrenous patch of intestine after the relief of a strangulated hernia, or from a leak from an intestinal anaestomosis. The opening of an abscess connected with chronic diverticulitis or carcinoma of the colon frequently results in faecal fistila. Radiation damage is also another cause of faecal fistula. The most common cause of cutaneous fistula is however previous surgery. This happens most often in patients with adhesions following previous operations. Enterocutaneous fistula can be divided into:-
1)       Those with a high output, more than 1 L/day
2)        Those with a low output, less than 1 L/ day.
They can also be describe anatomically as simple, with a direct communication between the gut and the skin, or complex, i.e. those with one or more tracts they are tortuous and sometimes associated with an intervening abscess cavity half way along the tract.
The discharge from a fistula connected with the duodenum or jejunum is bile stained and causes severe excoriation of the skin. When the ileum or caecum is involved is involved, the discharge is fluid faecal matter; when the distal colon is the affected site, it is solid or semisolid faecal matter. The site of the leakage and the length of the fistula can be determined by small bowel enema and Ba-enema, by fistulogram and more importantly, by CT scan of the abdomen will show up any associated abscesses.
Treatment
                     This can be very challenging in patients with a high output fistula. Low output fistula can be expected to heal spontaneously, provided that there is no distal obstruction. Reasons for failure of spontaneous healing also include:
1)        epithelial continuity between the gut and the skin;
2)        the presence of active disease where, for example there is crohn’s disease or carcinoma at the site of anaestomosis or in the tract;
3)        an associated complex abscess.
The abdominal wall must be protected from erosion by the use of appliances. The patients must remain nil by mouth; intravenous nutrition is started and signs of a decrease in fistula output are sought. The higher the fistula in the intestinal tract, the more skin excoriation must be expected, and this is worst in the case of a duodenal fistula. High output fistula cause rapid dehydration and hypo-proteinaemia. Vigorous fluid replacement  and nutritional support is essential. The drainage of an intra-abdominal abscess can be life saving. This can be achieved by either CT guided drainage or occasionally laparotomy. In patients with a complex  fistula, it may be necessary to bring out a de-functioning stoma upstream of the fistula site, even if this result in a high output stoma.    
 Operative treatment  
                                        Operative repair should be attempted only after a trial of conservative management. The surgery can on occasion be extremely technically demanding and an anaestomosis should not be fashioned in the presence of continuing intra-abdominal sepsis or when the patient is hypo proteinaemic.

ABDOMINAL TUBERCULOSIS


Abdominal tuberculosis can be divided into
·         Tuberculous peritonitis and
·         Tuberculosis of the intestine.

TUBERCULOUS PERITONITIS

Acute tuberculous peritonitis
                                                  Tuberculous peritonitis sometimes has an onset that so closely resembles acute peritonitis that the abdomen is opened. Straw coloured fluid escapes and tubercles are seen scattered over the peritoneum and greater omentum. Early tubercles are greyish and translucent. They soon undergo caseation and appear white or yellow and are then less difficult to distinguish from carcinoma. On opening the abdomen and finding tuberculous peritonitis, the fluid is evacuated, some being retained for histological studies. A portion of diseased omentum is removed for histological confirmation of the diagnosis and the wound closed without drainage.




Chronic tuberculous peritonitis
                                                        The condition presents with abdominal pain (90% of cases), fever (60%),          weight loss (60%), ascites(60%), night sweats (37%) and abdominal mass (26%).

Origin of the infection
                                       Infection originate from:
·         tuberculous mesenteric lymph  nodes
·         tuberculosis of the ileocaecal region
·         a tuberculous pyosalphinx
·         blood borne infection from pulmonary tuberculosis usually the miliary.

Varieties of tuberculous peritonitis

 There are four varieties of tuberculous peritonitis:
ascitic, encysted, fibrous and purulent.

Ascitic form
                     The peritoneum is studded with tubercles and the peritoneal cavity becomes filled with pale, straw-coloured fluid. The onset is insidious. There is loss of  energy, facial pallor and some loss of weight. The patient is usually brought for advice because of the distension of the abdomen. Pain is often absent; in other cases there is considerable abdominal discomfort, which may be associated with constipation or diarrhoea. On inspection, dilated veins may be seen coursing beneath the skin of the abdominal wall. Signs of ascites can be elicited readily. Because of raised intra-abdominal pressure, an umbilical hernia commonly occurs. On abdominal palpation, a transverse solid mass can often be detected. This is rolled- up greater omentum infiltrated with tubercles.
  Diagnosis is seldom difficult except when it occurs in an acute form or when it first appears in an adult, in which case it has to be differentiated from other forms of ascites, especially malignancy. Laparoscopy is useful by allowing inspection of the peritoneal cavity, where the appearance is often diagnostic. Areas of caseation an be biopsied for histopathology. The ascitic fluid is pale yellow, usually clear and rich in lymphocytes.
  Once the diagnosis of tuberculous peritonitis has been made, it is always important to look for tuberculous disease elsewhere. A chest radiograph should always be taken before laparoscopy or laparotomy is performed.

 Encysted form
                          The encysted form is similar to the ascitic form except that one part of the abdominal cavity alone is involved. Thus a localized intra-abdominal swelling is produced, which may give rise to difficulty in diagnosis. In the women above the age of puberty when the swelling is in the pelvis an ovarian cyst will probably be diagnosed. In the case of  a child it is sometimes difficult to distinguish the swelling from a mesenteric cyst. Late intestinal obstruction is a possible complication.

Fibrous form
                      The fibrous form is characterized by the production of widespread adhesions, which cause coils of intestine, specially the ileum, to become matted together and distended. This distended coils act as a ‘blind loop’ and give rise to steatorrhoea, wasting and attacks of abdominal pain. On examination the adherent intestine with omentum attached, together with the thickened mesentery, may give rise to palpable swelling. The first intimation of the disease may be sub-acute or acute intestinal obstruction. If the adhesions are accompanied by fibrous strictures of the ileum as well, it is best to excise the affected bowel, provided that not too much of the small intestine need to be sacrificed. Anti-tubercular therapy will often rapidly cure the condition without the need for surgery.

Purulent form
                        The purulent form is rare. When it occurs, usually it is secondary to tuberculous salphingitis. Amidst a mass of adherent intestine and omentum, tuberculous pus is present. Sizeable cold abscess often form and point on the surface, commonly near the umbilicus, or burst into the bowel. In addition to prolonged general treatment, operative treatment may be necessary for the evacuation of cold abscesses and possibly for intestinal obstruction. If a faecal fistula forms, it usually persists because of distal intestinal obstruction. Closure of the fistula must therefore be combined with some form of anaestomosis between the segment of intestine above the fistula and an unobstructed area below. The prognosis of this variety of tuberculous peritonitis is relatively poor.




Tuberculosis of the intestine
                                                        Tuberculosis can affect any part of the gastrointestinal tract from mouth to the anus. The sites affected most often are the ileum, proximal colon and peritoneum. There are two principal types.

 Ulcerative tuberculosis
                                          Ulcerative tuberculosis is secondary to pulmonary tuberculosis and arises as a result of swallowing tubercle bacilli. There are multiple ulcers in the terminal ileum, lying transversely and the overlying serosa is thickened, reddened and covered in tubercles

Clinical features
                             Diarrhoea and weight loss are the predominant symptoms, and the patient  will usually be receiving treatment for pulmonary tuberculosis.

Radiology
                 A barium meal and follow thorough or small bowel enema will show the absence of filling of the lower ileum, caecum and most of the ascending colon as a result of narrowing and hyper motility of the ulcerated segment.

Treatment
                  A course of chemotherapy is given. healing often occurs provided the pulmonary tuberculosis is adequately treated. An operation is only required in the rare event of a perforation or intestinal obstruction.


Hyperplastic tuberculosis
                                            This usually occurs in the ileo-caecal region, although solitary and multiple lesions in the lower ileum are sometimes seen. This is caused by ingestion of Mycobacterium tuberculosis by patients with a high resistance to the organism. The infection establishes itself in lymphoid follicles, and the resulting chronic inflamation causes thickening of the intestinal wall and narrowing of the lumen. There is early involvement of regional lymph nodes, which may caseate. Unlike CD with which it shares many similarities, abscess and fistula formation is rare.

Clinical features
                             Attacks of abdominal pain with intermittent diarrhoea are the usual symptoms. The ileum above the partial obstruction is distended, and the stasis and consequent infection lead to steatorrhoea, anaemia and loss of weight. Sometimes, the presenting picture is  of a mass in the right iliac fossa with vague ill health. The differential diagnosis is that of an appendix mass, carcinoma of the  caecum CD, tuberculosis or actinomycosis of the caecum.


Radiology
                 A barium follow thorough or small bowel enema will show a long narrow filling defect in the terminal ileum.

 
Treatment
                  When the diagnosis is certain and the patient has not yet developed obstructive symptoms, treatment with chemotherapy is advised and may cure the condition. When obstruction is present, operative treatment is required and ileocaecal resection is best.