What is Surgery – Nutritional Support In Malnourished
DEFINITION Oral nutritional support: Provision of fortified foods and/or supplements. Enteral nutrition is a type of nourishment that is delivered through the GI system and comprises oral nutritional supplements as well as tube feeding via the oral, nasal, or percutaneous routes. Parenteral nutrition is the administration of nutrients, electrolytes, and fluids through the veins. EPIDEMIOLOGY On admission, around 40% of patients are malnourished. HISTORY Weight loss, a loss of appetite, and indications of an underlying illness or problems are all possible outcomes. EXAMINATION Cachexia symptoms and physical appearance. Weight, BMI, mid-arm circumference, and triceps skin-fold thickness are all anthropometric metrics. PATHOLOGY/PATHOGENESIS Glycogen breakdown in the liver is the first source of glucose. Hepatic gluconeogenesis (using glycerol from fatty acids and amino acids from protein breakdown) occurs after 24 hours. Glycerol and free fatty acids are released during lipolysis, and the liver converts them to ketone bodies. INVESTIGATIONS SGA (subjective global assessment), albumin, Ca, Mg, P04, Zn, nutritional screening/evaluation on admission MANAGEMENT Should be coordinated/monitored by a multi-disciplinary team consisting of a dietitian, SALT and medical staff. INDICATIONS Oral nutritional support.:Those at risk of malnutrition (defined as a BMI of 18.5 kg/m2 and unintentional weight loss of more than 10% in the preceding 3–6 months, or a BMI of 20 and accidental weight loss of more than 5% in the previous 3–6 months). Enteral: malnutrition, dysphagia, blockage of the upper gastrointestinal tract (stricture, tumour), sedation (in ICU). Pancreatitis (reduces infective consequences and improves mortality in severe pancreatitis), poor stomach motility, gastric outflow obstruction, and patients at risk of aspiration are all treated with the Nasojejunal. When the gastrointestinal system is not functioning or available, such as in small bowel syndrome, high fistula, or persistent ileus/obstruction, parenteral nutrition is used. CONTRAINDICATIONS Enteral: Bowel obstruction, no peristalsis, and terminal sickness (unless the patient requests otherwise). Parenteral: Use with caution if you have kidney or liver disease, or if you have an egg or soy allergy. TYPES AND METHOD OF NUTRITIONAL SUPPORTS Feeds: Nutritionally, enteric formulas might be comprehensive or incomplete (supplement only). Standard formulas include macro- and micronutrients, complete protein, lipid (long-chain triglycerides) with or without fibre, and lipid (long-chain triglycerides) with or without fibre. Disease-specific formulae, immune-modulating formulae, low- or high-energy formulae, high-protein, whole-protein, peptide-based, free amino acid (elemental), high-lipid, and highly mono-unsaturated fatty acid formulations are among the others. Tube feeding by nasogastric, orogastric, nasojejunal, percutaneous endoscopic gastrostomy (PEG), PEG with jejunal extension, radiologically inserted gastrostomy (RIG), or surgical jejunostomy are some of the options for enteral feeding. TPN (parenteral nutrition): It's usually given by central venous access, but it can also be made for peripheral channels. While on TPN, keep an eye on the following: U&E, LFT, P04, Ca2 +, Mg2 +, glucose, Alb, CRP, Hb, WCC (do above 3 a week after initial 5 days unless issues). Triglycerides and iron studies are discussed every week. Selenium, copper, zinc, manganese, vitamin A, and vitamin E are all needed on a monthly basis. COMPLICATIONS Impaired wound healing, immunological dysfunction, muscle weakness, susceptibility to infection, pressure sores, hospital stay, readmission rates, and mortality are all symptoms of malnutrition. Enteral nutrition: Refeeding syndrome (possibly deadly metabolic shift characterised by hypophosphataemia, hypokalaemia, and hypomagnesaemia when individuals with depleted body stores of minerals such as K, Mg, and P04 have a carbohydrate source provided), fatty liver, and reduced renal function. Diarrhoea, vomiting, nausea, and abdominal discomfort are all mechanical symptoms. Sepsis and thrombosis are linked to parenteral feeding. Metabolic acidosis, abnormal LFTs, and fatty liver, hyperglycemia, bacterial translocation, renal failure, acute cholecystitis (bile stasis), and refeeding syndrome are all feed-related conditions. PROGNOSIS Malnourished patients have 2–3 times the number of problems as nourished people.
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What is Surgery – Meckel Diverticulum
DEFINITION On the antimesenteric boundary of the ileum, there is a true congenital small-bowel diverticulum. The rule of twos is followed: 'It occurs in 2% of the population, is 2 feet from the ileocaecal valve, and is 2 inches long.' AETIOLOGY The omphalomesenteric/vitelline duct joins the developing midgut to the yolk sac in an embryo. A persistent diverticulum or, more rarely, an omphalomesenteric fistula, sinus, fibrous band, or vitelline duct cyst might arise if the duct does not entirely retract during the 5th–7th week. EPIDEMIOLOGY The most frequent congenital defect of the small intestine, affecting 2% of the population, males are 2–4 times more symptomatic than females, and 60% of them become so before the age of ten. HISTORY The majority of the time, this is an asymptomatic or coincidental discovery. PR bleeding (often seen in youngsters) is characterised by painless dark or red blood (brick red) combined with excrement that can be severe and cause shock. Diverticulitis/ulceration causes abdominal pain. Symptoms of volvulus or intussusception, which cause intestinal obstruction. Mucoid or purulent discharge from the umbilicus on rare occasions. EXAMINATION Signs may be minimal. There may be indicators of shock if there is bleeding. Inflammation-induced guarding/rebound tenderness might be mistaken for indications of acute appendicitis. A real diverticulum (0.5 to 50cm) has all layers of the bowel wall and is lined with small intestinal mucosa, however it frequently contains heterotopic tissue (5 percent of asymptomatic cases and 60% of symptomatic patients), often stomach or pancreatic mucosa (but rarely duodenal, jejunal or colonic). Acid is secreted by ectopic gastric mucosa, which can induce erosion or bleeding. INVESTIGATIONS FBC, U&E, clotting, and crossmatch if bleeding. Isotope scan: If ectopic gastric mucosa is present, 99mTc-pertechnetate is taken up by a Meckel's diverticulum (but a negative scan does not rule it out). It's tough to make a pre-operative diagnosis. During barium contrast investigations, it's possible to notice it. If there are symptoms of blockage or perforation, get an AXR and an upright CXR. Mesenteric angiography: May be effective in cases of aggressive bleeding; but, if bleeding is sluggish, it may not be sensitive. MANAGEMENT In case of an emergency (bleeding or obstruction), dial 911. Fluid and electrolyte imbalances are corrected during resuscitation. Surgical: Resection of the diverticulum (diverticulectomy) with or without small-bowel resection and band division. Resection of an accidental Meckel's diverticulum is not recommended, but it can be done laparoscopically with endostaplers. COMPLICATIONS Bleeding, blockage due to an internal hernia around an omphalomesenteric band, inflammation (diverticulitis), intussusception, or enterolith have a lifetime risk of 6%. A Littre's hernia is characterised by the confinement of a Meckel's diverticulum. There have been reports of carcinoid tumours in Meckel's diverticulum. PROGNOSIS With proper care, the prognosis is usually good. What is Surgery –Lipoma Causes
DEFINITION Lipomas are benign adipose tissue tumours that grow slowly. Multiple contiguous lipomas produce tissue distortion (e.g. on the buttocks or, rarely, the neck) in lipomatosis. Can be categorized by location such as subcutaneous, subfascial, and subsynovial. AETIOLOGY They can appear in any connective tissue, however they are most commonly found in subcutaneous fat. Lipomas are aggregates of adipocytes that are indistinguishable from regular adipocytes and are split into enormous lobules by thin fibrous septa. Unknown cause, but chromosomal abnormalities (e.g., translocation of a gene on chromosome 12) have been suggested. Multiple sensitive lipomas (Dercum's disease/adiposis dolorosa) are an unusual symptom. EPIDEMIOLOGY Adults and children of all ages, particularly in the 40s and 60s. There is no preference for one gender over another. HISTORY A lump is noticed by the patient, which is normally painless and slowly enlarging unless it has been subjected to trauma, in which case fat necrosis may cause it to swell and become sensitive. EXAMINATION It can happen any place there's adipose tissue, but it's more frequent in the upper arms' subcutaneous tissue. Variable size, ovoid or spherical in shape, and frequently lobulated (a useful diagnosic feature). Non-tender, soft, and compressible; nonetheless, they rarely vary or transilluminate. The skin on top is generally normal. There should be no palpable lymph nodes in the area. INVESTIGATIONS MRI can be used to visualise lipomas that are deeply located; no other tests are usually required. MANAGEMENT Conservative: If it isn't causing any discomfort or distorting the appearance, it can be left alone. Surgical: If the condition is bothersome or unattractive. Under local anaesthetic, it is possible to remove it: To expose the lipoma, surgical incision is made over it; a common feature is that the lipoma can be milked out via the incision using mild pressure on the surrounding tissue, with little dissection. To avoid the formation of a haematoma, haemostasis in the resultant cavity should be maintained. Excision of larger lipomas or those in more difficult locations will require general anaesthesia. COMPLICATIONS Rather than the lipoma itself, it's usually associated with surgery to remove it. Fat necrosis may occur if traumatised. PROGNOSIS Lipomas rarely progress to malignancy (liposarcomas, for example, develop spontaneously in the retroperitoneum). What is Surgery – Venous Ulcer Treatment
DEFINITION of venous leg ulcers Leg ulcers are caused by venous insufficiency and account for 80–85 percent of all leg ulcers. AETIOLOGY Increased hydrostatic pressure, tissue oedema, decreased microcirculation, and eventually tissue necrosis and ulceration ensue from venous hypertension produced by superficial or profound venous incompetence. The 'fibrin cuff' in the tissue, white cell entrapment, and/or persistent inflammation after ischaemia reperfusion damage have all been proposed as mechanisms. EPIDEMIOLOGY In affluent countries, about 1% of the population may develop a leg ulcer, a substantial burden on healthcare services that increases with age, female>male. HISTORY Heaviness, leg pain, ankle swelling, skin changes, itching, and ulceration are all symptoms of chronic venous insufficiency. Determine whether there are any risk factors for DVT or peripheral vascular disease. EXAMINATION A venous ulcer is most commonly found in the 'gaiter area' above the medial malleolus. Lipodermatosclerosis, varicose eczema, pigmentation, and atrophie blanche are common causes of superficial ulceration with sloping borders. While the patient is standing, check for varicose veins. To check for concomitant peripheral arterial disease, calculate the ankle–brachial pressure index (ABPI). Atherosclerotic, diabetic, neuropathic, vasculitic, infective, and neoplastic ulcers are among the differential diagnoses. INVESTIGATIONS ABPI (ankle–brachial pressure index): ABPIs should be used to screen all patients for vascular disease. Modified compression may be possible for people with an ABPI of 0.5–0.8, and those with an ABPI of 0.5 should be referred/assessed for arterial insufficiency therapy in the first instance. If there are symptoms of infection, such as discharge, erythema, cellulitis, or pyrexia, a microbiology swab should be taken. If there is any suspicion of cancer, a biopsy or cytology should be performed. MANAGEMENT Compression bandaging with multiple components: Multi-layer compression, such as the Charing Cross four-layer bandage of wool, crepe, elastic, and cohesive bandages, is used to treat venous hypertension. Leg elevation and mobility tips. Compression stockings prevent recurrence once the wound has healed. Antibiotics should only be used in the case of infected ulcers with cellulitis. Pentoxifylline could be a useful supplement. Topical treatments, routine systemic antibiotics, and dressing style have all been demonstrated to have little effect on healing. Varicose veins can be treated with endovascular or open surgery. The ESCHAR (Effect of Surgery and Compression on Healing and Recurrence) study found that superficial venous surgery did not hasten healing but does assist prevent recurrence once it is healed. In some cases, skin grafting may be necessary. COMPLICATIONS Chronic wounds, infection, recurrence, and cancer development in long-term ulcers (Marjolin's ulcer). PROGNOSIS It's usually a long-term issue with varying recovery times. Recurrence rates are roughly 25% after one year and 33% after 18 months after healing. What is Surgery - intussusception treatment
Intussusception DEFINITION The process of an intestine segment, the intussusceptum, invaginating into the adjacent intestinal lumen, the intussuscipiens, resulting in bowel vascular compromise or obstruction. AETIOLOGY three years: Many cases are idiopathic (up to 90%), with lymphoid hyperplasia in Peyer's patches, Meckel's diverticulum, polyp, and haematoma. Henoch–Schonlein purpura, blood dyscrasias (owing to submucosal haematomas), and recent upper respiratory tract infections in children. Juvenile/Adult: A mass in the gut wall or lumen, such as a polyp, tumour, or Meckel's diverticulum, accounts for roughly one-third of small-bowel cases and two-thirds of large-bowel cases. EPIDEMIOLOGY The prevalence is 1–3/1000. Usually affects children under the age of three (majority in 3- to 9-montholds). In adults, it is quite rare. HISTORY Intermittent episodes of acute stomach discomfort in children, often accompanied by leg drawing up. Bloody mucus that resembles'red currant jelly' can be passed PR. It can resemble intestinal blockage in later stages, with vomiting and distension. Adults may have a wide range of symptoms. EXAMINATION In the right hypochondrium, there is a'sausage-shaped' lump. Shock symptoms include paleness, hypotension, and tachycardia. Abdominal distension and tinkling bowel noises are signs of blockage. Abdominal guarding, rebound, and the absence of bowel sounds are all symptoms of peritonism. PATHOLOGY/PATHOGENESIS A diseased 'lead point' causes bowel telescoping and aberrant peristalsis. The ileocolic junction is the most common location, however ileo-ileal and colocolic junctions can also occur. If not treated, venous congestion and oedema develop on the bowel wall, with the risk of infarction and perforation. INVESTIGATIONS AXR: May reveal a lack of air on the right side of the bowel or blockage features. The intusscepted segment shows as a target-shaped lump on ultrasound. Contrast/Air enema: This is the traditional method of demonstrating intussusception, with contrast at the location giving the impression of a coiled spring. This has the potential to be therapeutic . FBC, U&Es, ABG (for lactic acidosis), and G&S are all blood tests. MANAGEMENT Supportive measures include IV fluid resuscitation, analgesics, antibiotic cover, and NG tube insertion if vomiting occurs. Therapeutic enema: Can be administered with barium, air, or saline to reduce the invaginating segment back. Perforation, peritonitis, or a suspected tumour are all contraindications. Surgical: If enema fails to treat the problem or if there are symptoms of peritonitis, surgery is required. To minimise intussusception, the afflicted bowel is gently massaged. Resection of the implicated segment is required if the involved bowel is non-viable, cannot be decreased, or if Meckel's diverticulum is discovered. It's possible to do it laparoscopically. COMPLICATIONS Ischemia, haemorrhage, blockage, and perforation are all possible outcomes. PROGNOSIS Up to 10% of paediatric cases can have spontaneous decrease. The recurrence rate is 5–10%. If treated promptly, it can be beneficial; but, if not treated promptly, it can be fatal. What is Surgery – Bowel Obstruction Treatment
Obstruction of the bowel / intesinte DEFINITION The usual movement of bowel contents is obstructed. Site-specific classification: SBO (small bowel obstruction) or LBO (large bowel obstruction), partial or complete, simple or strangulated AETIOLOGY Obstruction of the intestine without vascular compromise (simple obstruction): The intestine distal to the occlusion quickly empties and compresses, while the gut above it dilates with gas and fluid. Distension reduces the blood supply to the intestinal wall, which can lead to mucosal ulcers and bowel perforation. Strangulated obstruction: The blood supply to the affected segment is disrupted, causing impairment of the normal mucosal barrier, bacterial transudation into the peritoneal cavity, and peritonitis, as well as gangrene and perforation of the unrelieved bowel. The following are the different types of obstructions: Hernias, adhesions, bands, volvulus, and external compression by a space-occupying lesion are examples of extramural lesions. Tumors, inflammatory strictures, such as in Crohn's disease or diverticulitis, and intussusception are all examples of intramural conditions. Intraluminal: Pedunculated tumours, foreign substances such as bezoars and gallstones; infection such as worms and constipation/faecal impaction. EPIDEMIOLOGY Common. Adhesions, hernias, and cancer are becoming more common among the elderly. HISTORY Colicky discomfort that is severe and gripping, with times of relief, in the middle (small intestine) or lower abdomen (large intestine). Distension in the abdomen. Early in SBO or late with faeculent vomiting in distal SBO or LBO, frequent vomiting of greenish bile-stained vomit. Absolute constipation is defined as the inability to pass stool or flatus. EXAMINATION Abdominal distension and discomfort all over. It's possible to see peristalsis. ↑ Bowel sounds (in character, 'tinkling'). Peritonitis has developed, as evidenced by guarding and rebound, and bowel sounds may be lacking. Examine for hernias. Any abdominal scarring increases the risk of adhesions. Examine your abdomen for any abdominal masses (such as intussusception, cancer, a tumour in the Douglas pouch, or faecal impaction). INVESTIGATIONS Lactic acidosis may indicate intestinal ischaemia and imminent perforation in the blood. Microcytic anaemia could be a sign of cancer in the large intestine. Dehydration and electrolyte imbalance caused by vomiting can be treated with urea and electrolytes. AXR: Assists with blockage diagnosis and localization. SBO is indicated by a central ladder pattern of dilated loops with valvulae conniventes spanning the full breadth of the bowel. This suggests LBO if the inflated gut is more peripheral, with haustrations that do not overlap the intestine breadth. It is possible to see the fluid levels. To exclude perforation, considered erect CXR. In LBO, a water-soluble contrast enema can be used to show the obstruction site. Follow-up with a water-soluble contrast: To determine the degree of impediment. CT scan: Enables pre-operative identification of the source and/or degree of obstruction, as well as management strategy. It could show signs of metastasis or perforation. MANAGEMENT General: Resuscitation involves intravenous fluids and electrolyte replacement, insertion of a nasogastric tube, and careful monitoring of vital signs, fluid balance, urine output, and clinical condition For adhesional blockage, gastrografin follow-through may be both therapeutic and diagnostic. The hyperosmotic contrast is hypothesised to ease the blockage by reducing oedema in the gut wall. If the results of the investigation point to a different diagnosis, an early procedure can be planned. Conservative therapy may resolve an acute obstruction; however, if the obstruction does not resolve or there are indicators of complications, operational intervention should be performed. Surgical: To treat the reason, a laparotomy or laparoscopy is performed. Adhesiolysis, band division, or bowel resection +/–stoma may be used. In small-bowel resection, primary anastomosis, Hartmann's surgery, or hemicolectomy with a defuncting stoma are used. In large-bowel resection, hemicolectomy with a defunctioning stoma is used. It's possible that post-operative treatment in an HDU or ITU is required. Endoscopic: Obstructing colonic tumours can be stented endoscopically either before surgery or as a palliative therapy to avoid emergency surgery. Endoscopically, obstruction caused by a sigmoid volvulus can be addressed with a flexible sigmoidoscope or the passage of a flatus tube. COMPLICATIONS Dehydration, intestinal perforation, peritonitis, toxaemia, and gangrene of the ischemic gut wall are all possible complications. PROGNOSIS Variable. Dependent on the patients' overall health and the frequency of problems. What is Surgery – Ischemic Bowel Treatment
DEFINITION Ischemic bowel or is also known as intestinal ischaemia.Intestinal ischaemia is a condition in which a mesenteric vascular is blocked (for example, by an embolus or thrombosis), resulting in bowel ischaemia and necrosis. AETIOLOGY Embolus (60%) is the most common type of thrombosis, followed by arterial thrombosis (25%), and venous thrombosis (25%). (15 percent ). Volvulus, intussusception, bowel strangulation within a hernia, or surgical excision are all possible causes. RISK FACTORS/ASSOCIATIONS Emboli are caused by atrial fibrillation, cardiac mural thrombus, and endocarditis. Hypercholesterolemia, hypertension, diabetes mellitus, and smoking are all risk factors for arterial thrombosis. Portal hypertension, splenectomy, septic thrombophlebitis, and heart failure are all linked to venous thrombosis. EPIDEMIOLOGY It is dependent on the aetiology. Older people are more likely to have this condition. HISTORY Acute colicky stomach pain that is severe. It's possible that it'll cause you to vomit or have rectal bleeding. Chronic mesenteric artery insufficiency (e.g., gross weight loss and abdominal pain after eating) is a risk factor. History of heart or liver illness is significant. EXAMINATION Tenderness and distension across the abdomen. If a hernia is present, there will be a sensitive palpable mass. It's possible that bowel sounds aren't present. The degree of cardiovascular collapse is disproportionate. INVESTIGATIONS Diagnosis can be challenging, and it may be based on clinical suspicion or discovered via a laparotomy. ABG (lactic acidosis), FBC, U&Es, LFT, clotting, and crossmatch are all blood tests. AXR may reveal thickening of the intestinal wall or thumbprinting. Gas in the intestinal wall may be visible on a CT scan. Mesenteric arteriography allows for localization, a measurement of the extent, and a trial of intervention if it is stable. MANAGEMENT Nil by mouth, IV fluid resuscitation and electrolyte balance correction, IV antibiotics. Surgical: An emergency laparotomy was performed, and the infarcted bowel was resected. Embolectomy or a saphenous vein bypass from the iliac artery to the superior mesenteric artery below the obstruction can restore arterial supply to non-necrotic bowel. A temporary dead stoma is frequently employed. After surgery, you'll need to be monitored and cared for closely, usually on HDU or ITU. Extensive small-bowel resection has occasionally been aided by total parenteral feeding, followed by small-bowel transplantation at a later stage. Medical: Heparin for post-operative thrombosis prevention. Warfarinization for a long period of time may be necessary. COMPLICATIONS Lactic acidosis, intestinal perforation, peritonitis, and multi-organ failure are all possible complications. PROGNOSIS A dangerous condition with a high mortality rate (50–100%). What is Surgery –Ingrown Toenail Surgery
DEFINITION When a toenail's lateral edge develops into the soft tissue of the nail fold, it causes inflammation and infection. Onychocryptosis is the medical word for this condition. AETIOLOGY Along its edge, the toenail grows into and enters the skin. It can cause a foreign body reaction, with a bacterial or fungal infection on top of it. Exuberant granulation tissue production can occur as a result of tissue healing. RISK FACTORS/ASSOCIATIONS Footwear that isn't well-fitting (particularly those with a tapering front), toenails that aren't well-trimmed, toe damage, and poor cleanliness. EPIDEMIOLOGY Common. Young adults and teenagers are more susceptible. HISTORY Pain along the toenail's borders, as well as a painful swelling toe. Make a diabetes inquiry. EXAMINATION Erythema, oedema, warmth, and soreness on the big toe are the most typical symptoms. The lateral side of the toenail is more likely than the medial side to be affected. INVESTIGATIONS In most cases, none is required. Swab of the pus: Culture and sensitivity, if infected Radiograph (toe): For osteomyelitis in diabetics and those with a serious infection. MANAGEMENT Medical: Simple pain analgesia and podiatrist therapy. If the foot is presenting early, it should be cleansed on a regular basis and dried carefully. Wearing clean socks and wide-fitting shoes is recommended, as is cutting toenails transversely. If infected (after incision and drainage if pus is found), antibiotics may be required, especially in diabetics. SURGERY Surgery is reserved for instances that are severe or recurrent. Local anaesthetic with a ring block. If there is a localised pus collection, an incision and drainage procedure should be performed. Avulsion of the toenail: The toenail is removed without causing damage to the nail bed. There's a 50% possibility of it happening again. Wedge resection: Using phenol to damage the nail bed, the lateral part of the nail that is ingrowing together with the nail bed is excised. This relieves pressure on the toe's sides and prevents the nail from growing back into the skin. Zadik's technique is as follows: This procedure entails the removal of the entire nail as well as the destruction of the complete nail bed. COMPLICATIONS Secondary fungal infection of the nail and toe, malformation of the nail bed and surrounding toe, and permanent nail loss. PROGNOSIS If caught early, the prognosis is often favourable. Recurrence can occur in up to 30% of cases. Diabetics have a greater morbidity rate, which can lead to toe amputation (or even limb). What is Surgery – Causes of Excessive Sweating
Hyperhidrosis DEFINITION Excessive sweating by eccrine glands beyond physiological requirements is a disease. Primary focal, secondary generalised, and localised are the three types. AETIOLOGY The main focus is on eccrine sweat glands, due to neurogenic sympathetic overactivity on them. Secondary causes include Diabetes, thyrotoxicosis, hypoglycemia, gout, pheochromocytoma, menopause, infections, such as tuberculosis, medicine (propanolol, physostigmine, pilocarpine, tricyclic antidepressants, venlafaxine), alcoholism, and cancer are all examples of secondary generalised hyperhidrosis. Gustatory stimuli (Frey's syndrome), eccrine naevus, eccrine angiomatous hamartoma, Riley–Day syndrome are all localised conditions (familial dysautonomia). EPIDEMIOLOGY Palmoplantar hyperhidrosis is 20 times more common in Japanese ethnicity, with an estimated incidence of 0.6–2.8 percent. HISTORY Hands, feet, and/or axillae that are wet/sweaty may result in social shame and, in certain cases, professional issues. Patients may grumble about having to change clothes frequently. Puberty is the most common time for primary focal hyperhidrosis to appear. The onset of hyperhidrosis later in life should motivate a search for secondary reasons. EXAMINATION Sweating that is visible can be a sign of dermatitis or tinea. Minor’s Iodine–starch test: The light brown iodine colour turns dark purple as an iodine-starch complex formed in sweat when starch is rubbed upon skin previously painted with 2% iodine. INVESTIGATIONS Only if you have hyperhidrosis in general. TFTs, glucose, urate, LH/FSH, and urinary catecholamines are all measured in the blood. Imaging: As needed, such as a CXR, CT, or MRI scan. MANAGEMENT First-line topical therapies, such as aluminium chloride and glycopyrrolate. lonophoresis: uses a direct current to travel through the skin, and involves a 30-minute daily treatment of the palm or sole (mechanism of action unclear). Intradermal botulinum toxin injection Is effective and lasts 4–12 months if reconstituted in lignocaine may be less painful. Anticholinergics, such as oxybutynin, have unpleasant side effects such as dry mouth and eyes. Surgery: T2/3 palmar hyperhidrosis, T3/4/5 axillary hyperhidrosis, and T1 face hyperhidrosis are treated with thorascopic sympathectomy, which comprises segmental resection, transection, cauterization, or clipping of the sympathetic chain. Immediately effective (success rate of 9B–98%). Axillary skin disconnection/excision (risk of scarring, skin necrosis) or subcutaneous liposuction with dermal curettage to remove eccrine sweat glands are two other axillary methods. COMPLICATIONS Skin irritation, as well as physical, psychological, social, and occupational illness. The following are the effects of thorascopic sympathectomy: Horner's syndrome, recurrence, compensatory sweating (up to 50%–60%), pneumothorax, intercostal neuralgia PROGNOSIS There is no increased mortality, but it can have an impact on quality of life. Previously difficult to manage, current treatments have proven to be helpful. What is Surgery – Inguinal Hernia Pain
INGUINAL HERNIA DEFINITION A peritoneal sac protrudes abnormally due to a weakening in the inguinal area. Indirect (60%), direct (35%), and a combination 'pantaloon' (5 percent ). Hesselbach's triangle (medially the lateral boundary of the rectus, laterally the inferior epigastric vessels, and interiorly the inguinal ligament) is where direct hernias appear. Reducible, irreducible (incarcerated), and strangulated hernias are the three types of hernias. Direct: Hernial sac protrusion through the transversalis fascia and posterior wall of the inguinal canal, immediately medial to the inferior epigastric vessels. Indirect: Hernial sac protrusion through a deep inguinal ring with spermatic cord coverings, following the course of the inguinal canal. AETIOLOGY Congenital: A persistent processus vaginalis allows abdominal contents to enter the inguinal canal. Intra-abdominal pressure, as well as muscle and transversalis fascia weakening, were acquired. RISK FACTORS/ASSOCIATIONS Prematurity, age, and elevated intra-abdominal pressure, e.g. persistent cough, constipation, and bladder outflow blockage EPIDEMIOLOGY Common. In 4% of male births, there are congenital indirect inguinal hernias. Adults reach their peak between the ages of 55 and 85. The ratio of men to women is 9 to 1. Every year, ten elective repairs per 10,000 people are carried done in the United Kingdom. HISTORY The patient may be asymptomatic, or he or she may notice a lump or swelling in the groin. Discomfort or pain may be present, as well as irreducibility, a change in size, or indications of consequences. EXAMINATION A mass in the groin that may expand to the scrotum. Emerges above and medial to the pubic tubercle, distinguishing it from femoral hernias. Examine the patient while he or she is standing; the hernia is linked to a cough reflex. Pressure applied to the deep inguinal ring can help reduce indirect hernias. Auscultation of the hernia might reveal bowel noises. If incarcerated, the hernia may be irreducible, and if strangulated, it may be exceedingly tender. It may also be associated with indications of problems, such as bowel obstruction and systemic distress, pyrexia, and tachycardia. INVESTIGATIONS If you have a acute painful irreducible hernia, you should: If operational intervention is likely, blood tests include FBC, U&Es, CRP clotting, and G&S. ABGs can be used to detect the existence of intestinal ischaemia (metabolic acidosis, lactate) within the hernia. In emergency situations, erect CXR and AXR. Hernias can be diagnosed by an ultrasound or a herniogram, and other explanations of groin lumps can be ruled out. MANAGEMENT An inguinal truss, a type of belt that restricts the decreased hernia from protruding, can be used to treat patients who are deemed unfit or reluctant to undergo surgery. Surgical: Surgical repair of simple hernias is an option. Local, epidural, spinal, or general anaesthesia can all be used. Surgical repair comes in a variety of forms. Mesh repair (Lichtenstein): Above the inguinal ligament, an oblique incision is made, with the external oblique aponeurosis opened and the spermatic cord gently loosened. The contents of an indirect sac are reduced after it is separated from the cord and opened (herniotomy). The sac is removed, and the defect in the transversalis fascia is fixed with a mesh to reinforce the defect. This is the most usual method of treatment. The Shouldice repair, which employs non-absorbable sutures to strengthen the defect, and the Stoppa repair are two more open procedures. The use of completely extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) methods for laparoscopic mesh repair is now popular. In general, laparoscopic surgery allows patients to heal faster and resume normal activities sooner. For bilateral and recurring hernias, this is the method of choice. In an obstructed or strangulated hernia, emergency surgery is required. If gangrenous bowel is present within the hernia, a laparotomy with intestinal resection may be recommended. In this scenario, mesh insertion may not be appropriate. Herniotomy is used to repair indirect hernias caused by a patent processus vaginalis (PPV). The PPV is ligated and the contents are decreased, thus this isn't a mesh repair. COMPLICATIONS Maydl's hernia (strangulated Wshaped small-bowel loop), Richter's hernia (strangulation of only part of the bowel wall circumference), Amyand's hernia (acute appendicitis in a right inguinal hernia), Richter's hernia (strangulation of only part of the bowel wall circumference), Richter's hernia (strangulation of only part of the From the operating room: Pain, wound infection, haematoma, penile or scrotal oedema, nerve injury or neuroma formation, osteitis pubis, mesh infection, testicular ischaemia, and recurrence are all possible complications. PROGNOSIS If left alone, they have a tendency to grow slowly. Strangulation risk is 0.3–3% each year. Surgical mesh repair has a good success rate, with recurrence occurring in only 1% of patients. |
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