Cushing Vs Curling Ulcer

Hello!

Its time to differentiate between two confusing ulcers - Cushing and Curling.

What is Cushing Reflex?
It is a triad of Bradycardia, Hypertension and altered respiration following Head injury.

What is Cushing Ulcer?
Stress Ulcer following Head injury.
Most common site - Acid producing area of Stomach.

What is Curling Ulcer?
Stress Ulcer following Burn.
Thomas Blizzard Curling.
Reduced plasma volume leads to ischemia and cell necrosis of the mucosa.
Most common site - 1st part of Duodenum.
cURling = bURn

This may help you to remember the difference between these two.

Thanks

MD Mobarak Hussain (Maahii)

Post operative ileus ( mechanical obstruction vs paralytic )

Hey Awesomites

Under normal circumstances, bowel movements usually do not appear till 72 hours after a certain abdominal or non - abdominal surgery, with a characteristic pattern of initiation of small bowel movements within 24 hours, stomach within 48 and colonic ( proximal to distal ) within 72 hours after surgery.

The assessment of gastrointestinal recovery is done with consideration to certain factors like the time taken to ingestion of first solid food, and time to either bowel movements or the first flatus passed, whichever occurs later.

Prolonged post operative paralytic ileus means:
- No return of bowel movements ( on auscultation ) after 72 hours
- Absence of flatus or stool on day 6 after surgery
- Feeling of discomfort, nausea or vomiting on oral intake, thus requiring i.v. support, NG tube placement by PO day 5.
- Partial return of bowel movements after PO day 5.

On the other hand, post operative ileus due to mechanical obstruction, inspite of sharing many signs and symptoms, is an important differential to exclude. Most of the patients with PO mechanical obstruction in the bowel ( due to herniation, adhesions, stomas, masses, etc. ) have an initial return of bowel function that may be partial/ complete, and oral intake, after a physiological period of 72 hours post operatively. 

It is then followed by intermittent episodes of nausea, feculent vomiting abdominal intense cramping pain and distension, that is often paroxysmal and rapidly progressing..

Also, patient with mechanical bowel obstruction after surgery may have other signs suggestive of ischemia of bowel loop distal to the obstruction, such as localised tenderness, fever, tachycardia, and peritoneal signs, which would mean immediate surgical intervention so as to prevent further complications !!
( Refer to UpToDate)

Thats all
Hope this helps :)

- Jaskunwar Singh

Cushing Ulcers : An overview

Hi Everyone ! Here's a short post on Cushing and Curling ulcers.

For Cushing Ulcers you need to remember these key points :

C
U - Ulcerating - can even perforate.
S - Stomach
H - Head injury induced Stress Ulcer
I   - lNcreased
N - INcreased
G - Gastric Acid secretion.

Stress ulcers are typically non ulcerative superficial erosions  of the gastric mucosa.
They occur when a person is subjected to physical stress in the form of Trauma, Sepsis, Burns, Hemorrhage among many others.
Psychological stress doesn't cause 'Stress ulcers' , although it does pre dispose to getting Peptic Ulcer Disease on its own accord. All the same, it doesn't cause 'Stress ulcer'.

Cushing ulcers are type of stress ulcers occuring secondary to Head injury. They occur in the stomach  commonly , and  are associated with increased Gastric acid secretion. They are typically erosive and ulcerative , more likely to perforate than other stress ulcers.

Another named stress ulcer is Curling Ulcer occuring secondary to Burns. They occur in the 1st part of duodenum  commonly , and  are NOT associated with increased Gastric acid secretion.

Presentation :
Painless upper GI bleeding within 1-2 days of traumatic event.
Usually slow and intermittent bleeding.

Diagnosis :
Endoscopy.
(More to rule out other causes of GI bleed rather than ruling this in).

Treatment :

- Treat underlying causes.
- Fluids
-  Gastric pH to be maintained > 5  (using PPI like Pantoprazole)
- If lot of bleeding - Ligation of vessel at base of ulcer.

That's all!
Happy studying !
Stay awesome !

~ A.P.Burkholderia

Causes of hematuria mnemonic

Hey Awesomites

Some common Glomerular causes of Hematuria:
( mnemonic: GH )
- Glomerulonephritis ( post infectious, membranoproliferative, rapid progressive, IgA nephropathy )
- Henoch- Schonlein nephritis

Non - glomerular causes of hematuria :
( mnemonic : HEMATURIa )
- Hemorrhage ( cystitis, PCKD )
- Allergic reaction ( interstitial nephritis )
- Trauma or Tumors
- Urinary tract infections / increased Urinary calcium 

Thats all

- Jaskunwar Singh 

Renal colic : Important points

Hey Awesomites

Some important points to be noted regarding renal colic:

Image Based MCQ on ENT instruments

Hello guys!

Yesterday we posted an Image based MCQ on ENT instruments.
And here's the answer for it.

#ENT
#Instruments

Q. The instrument shown in the above image is used in?

A. Thyroidectomy
B. Adenoidectomy
C. Tonsillectomy
D. Parathyroidectomy

Ans: c) Tonsillectomy

The instrument shown in the above image is Eve’s Tonsillar Snare, used in tonsillectomy.

Identification of the Instrument:

It consists of a long, thin, hollow tube with a stainless steel wire loop at one end which has Ratchet action. The other end has three large rings. These three rings allow the instrument to be operated using three fingers.

Uses:

It is used to snare the lower pole of Tonsil at the end of dissection. Advantage of using the snare to resect the tonsil is to minimize the bleeding by crushing the vascular pedicle, not cutting unlike scissors.

Procedure:

The instrument is held by inserting the forefinger and the middle finger into two rings on either side of the snare.The thumb is placed in the single ring at the back. This ring is actually located at the end of the plunger. Pulling the plunger with the thumb draws out the wire loop while it can be pulled back in by pressing the plunger with the thumb. The wire loop is first threaded over the Denis Browne tonsil holding forceps. The dissected tonsil is then held with the forceps and the wire loop moved over it until it surrounds the pedicle of the tonsil. The thumb is then pressed down to draw back the loop. The pedicle of the tonsil is crushedby this movement.

That's all!
Thank you.

MD Mobarak Hussain (Maahii)

Masks and Respirators (Respiratory type of PPE)

Hello :)

Have you ever seen people wearing those mask like thing during certain infections?

I used to consider it some kind of fashion or trend. But now I got to know what those masks are for?

Those are the RESPIRATORY types of the PPE (Personal protective equipment).

RESPIRATORS:-

It protect against multiple airborne contaminants. 

These are different from surgical masks.

INDICATION:-

It is used in emergencies like influenza epidemic. Here you need protection from air-borne transmissible diseases.

AIR-BORNE TRANSMISSIBLE DISEASES:-

-TB

-Pandemic Flu outbreak

-Avian Flu

-SARS

-Small pox

TYPES OF RESPIRATORS SELECTED:-

-N95 (means the respirator blocks at least 95% of very small (0.3 micron) test particles.)

-High efficiency particulate air (HEPA)

-Powered air purifying respirators (PAPRs)

N95 limitation:-

-they leak 

-Risk reduced but not eliminated

-facial hair compromises seal

-Don't work for Oxygen deficient conditions

-Breathing resistance increases overtime.

SURGICAL MASKS:-

The surgical masks are the main barriers to protect the patient against possible infection or contamination of exhaled organism by medical personnel, and in turn are barrier to surgical personnel against possible splashing fluids.

For more details, Click the link below :

https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/ucm055977.htm

It is important for prevention of the community. 

Although the main reason for sudden spread and increased mortality are:-

-Delay in reporting to health care centre 

-Further delay in diagnosing the disease and referral services.

 Studies have been done to compare the effectiveness of surgical masks and respirators during Respiratory infection emergency.

1. AMONG HEALTH CARE WORKERS

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868605/
2. AMONG THE PATIENTS  
https://www.ncbi.nlm.nih.gov/pubmed/23505369/

That's all for today.

:D

-Upasana Y.  :)

Acute Pancreatitis - Mnemonic

Hello Awesomites!
Here's a Mnemonic on the causes of Acute Pancreatitis.
The mnemonic is- GET SMASHED

G- Gall Stones
E- Ethanol (Alcohol consumption)
T- Trauma
S- Steroids
M- Mumps
A- Autoimmune
S- Scorpion stings
H- Hyperlipidemia /Hypercalcemia
E- ERCP (Iatrogenic)
D- Drugs

I hope that this is useful for you guys.
Thank you.

MD Mobarak Hussain (Maahii)

Spine abnormalities in neurofibromatosis

Neurofibromatosis is an autosomal dominant disease.There are 3 types of neurofibromatosis. Type 1 is more common among all and is characterized by tumors that develop along nervous system.

This post deals with spinal abnormalities that occur in type 1 neurofibromatosis.

Due to presence of multiple neurofibromas of spinal nerves, there is increased CSF pressure, this causes protrusion of duramater, this ballooned sac containing cerebrospinal fluid is known as dural ectasia.

This condition may result in pain in the back and limbs, bladder control problems, and numbness in severe cases.
Neurofibromatosis may cause tumors around the spinal cord. Scoliosis, an irregular side curvature of the spine from left to right, and kyphosis, or a rounded or forward angulated back, occur together or separately in about one in five people with neurofibromatosis type 1.

Children with neurofibromatosis type I develop one of two forms of scoliosis, dystrophic or non- dystrophic scoliosis. Non-dystrophic type is similar to ' typical ' scoliosis called as adult idiopathic scoliosis.

Dystrophic scoliosis, on the other hand, is a form of scoliosis that occurs due to bony changes related to neurofibromas affecting the spine. Dystrophic scoliosis is identified by looking for specific features on X-rays of the spine. For patients and their families, dystrophic scoliosis is known as a more severe form of scoliosis. It may also occur with abnormally thin ribs, weakened vertebral bones, and severe spinal curvatures including kyphosis and rotational deformities and is often associated with dural ectasia.

Treatment for scoliosis due to neurofibromatosis is challenging, particularly when dystrophic scoliosis is present. Effective treatment requires the knowledge and skill of an experienced orthopedic surgeon who specializes in scoliosis treatment.

Thanks for reading.

Madhuri Reddy

Image based question on gallstone

Hello awesomites!

Yesterday, we posted an Image based MCQ on Facebook, Instagram, Tumblr and Twitter - And as promised, here is the answer!

Q. What type of stone is this?
Hint - This is the most common stone worldwide.

Options:
A. Cholesterol
B. Mixed
C. Black
D. Brown 

The correct answer is B. Mixed gallstone.

The given pathological specimen shows a Gall Bladder removed after cholecystectomy and multiple faceted stones found inside it.

Stones are multiple in number, the cut section shows the central brown core which is pigmented surrounded by whitish/pale layer of cholesterol making it a mixed stone.

Hope you enjoyed this question and we will be back with another one soon!

-MD Mobarak Hussain (Maahii)

Emphysematous Cholecystitis

Hello guys! Here's a brief description about Emphysematous Cholecystitis.

What are the risk factors for Emphysematous Cholecystitis?

1. Diabetes Mellitus (Most Important)
2. Immunosuppresion
3. Vascular compromise (Obstruction & stenosis of Cystic artery).

Emphysematous Cholecystitis is a life-threatening form of Acute cholecystitis & caused due to infection of the gall bladder wall with Gas forming bacteria like: Clostridium welchi.
Gas forms in gall bladder wall with occasional detection of crepitation (that's why called Emphysematous).

Development of gangrene & perforation is common.

It is managed by Emergency cholecystectomy with broad spectrum antibiotics.

Thank you

MD Mobarak Hussain (Maahii)

Fact of the day: Liquid biopsy for cancer detection

Hey Awesomites

We have known since long that surgical biopsies done routinely in cancer patients to diagnose and detect progression of the disease may increase the risk of carcinogenic changes in the cells in future, due to the changes that had prompted the biopsies.

A non - invasive and painless diagnostic tool that replaces the cutting is "liquid biopsy" that finds the hidden cancer cells anywhere in the body. The liquid biopsy is taken from a simple blood test to look for microscopic pieces of DNA circulating in the blood that contains genetic mutations causing tumors to spread, among billions of other DNA that were in the blood.
A year ago, a circulating tumor DNA test was approved by FDA that spots these mutations.


Thats all
- Jaskunwar Singh

Ultrasonography in Acute Appendicitis

Hey Awesomites

Ultrasonography ( graded compression technique ) is the investigation of choice in cases of acute appendicitis.

Fact of the Day : Pantaloon Hernia

So this is just a very interesting fun fact.

When a person has a Direct Inguinal Hernia along with an Indirect Inguinal hernia , the person is said to have a Dual / Pantaloon/ Romberg / Saddle bag hernia.

Tried a lot to find out why the name is 'Pantaloon'. Pantaloon = Saggy pants or a Foolish old man. So take your pick !

That's all!
Happy studying!
Stay Awesome.
~ A.P.Burkholderia

Response of Vagus to Systemic Injury.

Hello!

Let's learn/revise.

The vagus nerve exerts several homeostatic influences, including enhancing gut motility, reducing heart rate, and regulating inflammation.

Central to this pathway is the understanding of neurally controlled anti-inflammatory pathways of the vagus nerve.

This neurally mediated anti-inflammatory pathway allows for a rapid response to inflammatory stimuli and also for the potential regulation of early proinflammatory mediator release, specifically tumor necrosis factor (TNF).

Vagus nerve activity in the presence of systemic inflammation may inhibit cytokine activity and reduce injury from disease processes such as pancreatitis, ischemia and reperfusion, and hemorrhagic shock.
This activity is primarily mediated through nicotinic acetylcholine receptors on immune mediator cells such as tissue macrophages.

Furthermore, enhanced inflammatory profiles are observed after vagotomy, during stress conditions. 

Let's learn Together!
-Medha.

Lymphedema - High yeild Information.

Hello there!
So today in the surgery OPD I happened to see a case of Lymphedema feet ,and hence thought of reviewing some important points on same.

So, Congenital lymphedema may involve a single lower extremity, multiple limbs, the genitalia, or the face. 

The edema typically develops before 2 years of age and may be associated with specific hereditary syndromes -Turner syndrome,Milroy syndrome, Klippel-Trenaunay-Weber syndrome.

 Lymphedema praecox is the most common form of primary lymphedema, accounting for 94% of cases. 

Lymphedema praecox is far more common in women, with the gender ratio favoring women 10:1. 

The onset is during childhood or the teenage years, and the swelling involves the foot and calf. 

Lymphedema tarda is uncommon, accounting for <10% of cases of primary lymphedema. The onset of edema is after 35 years of age. 

Secondary lymphedema is far more common than primary lymphedema. Secondary lymphedema develops as a result of lymphatic obstruction or disruption.

 Other causes of secondary lymphedema include radiation therapy, trauma, infection, and malignancy. 

Globally, filariasis (caused by Wuchereria bancrofti, Brugia malayi, and Brugia timori) is the most common cause of secondary lymphedema.

Hope It helps.
Let's Learn Together!
-Medha.

Hematuria: A clinical pearl

Hey Awesomites

Hematuria (blood in urine) may be microscopic or macroscopic/ gross.

The American Urological Association (AUA) defines microscopic hematuria as 3 red blood cells/ high - power field on microscopic examination of the centrifuged urine specimen in two of the three freshly voided, clean- catch, midstream urine samples.

Gross/ visible hematuria can result from as little as 1mL of blood in 1L of urine, and therefore, the color of urine does not necessarily reflect the degree of blood loss.

Now lets have a brief review of the clinical presentation of hematuria on the basis of its source -

- A glomerular source of bleeding (nephronal/ glomerular hematuria) usually results in persistent microscopic hematuria that may be with/ without intermittent periods of gross hematuria.

- Total hematuria (present throughout the void) indicates bleeding of bladder/ upper tract origin.

- If renal sources of hematuria are present, the blood is equally dispersed throughout the urine stream  and does not clot.

In cases of clotting, its localisation is a must to evaluate the underlying cause:

- Hematuria/ clots at the beginning of the urine stream ( initial hematuria ) is a symptom of a urethral cause.

Terminal hematuria occurring at the end of stream may be caused due to either prostatic, bladder, or trigonal source of bleeding.


Thats all
- Jaskunwar Singh

Differentials of lower limb ulceration: Venous, arterial or neuropathic?

Hello!

Q. Today, in our OPD, a 45 year old diabetic Male, farmer by profession presented with an ulcer on left lateral malleolus.

He had a history of edema in lower limb associated with an itching 2 years ago. Since 6 months he got a non-healing ulcer on left lateral malleolus.

On examination:-

Pigmentation of skin, eczema lipodermatosclerosis, atrophied Blanche are present and dilated veins on the medial aspect of left lower limb.

My question is how to differentiate whether the ulcer is due to neuropathy, venous stasis or obliteration of artery.

Why do the above doubt arise?

Because venous ulcer are commonly found at the lower third of the leg usually on the medial side and even on the foot.

Ans.

(I) to rule out neuropathy,

1. Ask whether he feel the ground and pebble while walking barefoot

2. Test for the pain sensation, whether it is intact or not.

(II) Venous ulcer have characteristic findings. History is utmost important. They are shallow and flat. The edge is sloping and purple blue color.

The floor: - appears pink due to presence of granulation tissue. If it is a chronic ulcer there is more white fibrous tissue. Most important is A FAINT BLUE RIM of advancing epithelium may be seen at the margin.

(III) To check for arterial obliteration

1. Feel the dorsal pedis pulsation.

2. Ask for claudication also.

Conclusion: - It was venous ulcer.

Then why did it appear on the lateral side? Remember! On inspection dilated veins were found on the medial side.

Before answering the above question. Let us ask why is it most common on medial side?

There are more perforating veins on the medial side means more pressure in that area. But that doesn't mean lateral side is spared .There is some rise in pressure on lateral side also. The only thing that precipitated this was “Trauma”. Due to more itching on lateral side, he traumatised that area .It was initially small in size, non-healing ulcer which is gradually increasing in the size.

Found this great article on the lower limb ulcers.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127371/

Take care:)

-Upasana Y.

Diaphragmatic hernia : Mnemonic and Review

Here's a short post on the key points about Congenital Diaphragmatic Hernia.

So there's deficiency in the diaphragm during development causing abdominal contents to budge into the Thorax.

There are 2 main types -->

1. Bochdalek.

2. Morgagni.

Now out of these 2, Bochdalek is commoner.
(It's hard to remember the word Bochdalek. I struggle with it every day. )

You can memorize it by realising that it rhymes with ' Scotch da Lake '
(Which means a lake of scotch in Punjabi)

Key points about Bochdalek -
BBBB

- Back  - Located posteriorly
- Big - Bigger than the Morgagni form
- Bad - Poor prognosis
- Bag and Mask Contra indicated. 

Also realise - Bochdalek
So it's got an L in it. L = Left. So it's more common on the left side. These hernia classically cause a scaphoid abdomen and Mediastinal shift to the opposite side.

Morgagni can be remembered by the opposite of the BBB
So it's
- Not on the back - Anteriorly
- Not Big - Small sized.
- Not as Bad - Prognosis is alright.

Also realise - Morgagni
It's got an R in it = Right. So it's more common on the right side. And it contains the Transverse colon generally.

So that's all !
Happy studying! 
Stay awesome !

~ A.P.Burkholderia 

Alvarado Score Parameters Mnemonic ; For Appendicitis

Alvarado score is one of the most famous scores to clinically diagnose Appendicitis. Without further adieu let us delve into it.

            Anorexia or ketones in urine           - 1 
            Leukocytosis >10,000                      -2  
            Vomiting/Nausea                             -1
     migrAtory pain to right iliac fossa            -1
           Rebound tenderness                         -1
 temperAture above 37.3 celsius                 -1
      tenDerness in right iliac fossa              -2
   neutrOphilia >70%                                 -1

Of these the second parameter from above and second parameter from below have 2 points credited for each. Every other parameter is credited with 1 point each.

The overall aggregate comes out of 10, which the highest possible score for Alvarado score.

If, the aggregate is,

<3 - Low risk for appendicitis
4-6 - Mid risk for appedicitis
>=7 - High risk for appendicitis

In some hospitals where a differential count is difficult to find, use a modified score with 9.

That's all guys, if you find any mistake let me know.

With love,
Jay~

P.S. - yayyy.....missed me much awesomites? I was away from the blog for the last 6 months from posting, because I had very disastrous scores for surgery in my university and I didn't feel worthy enough to write for you guys. (So my activity was largely concentrated in the Whatsapp Medicowesome groups, and the Author's page.) Anyways, I had to take a remedial exam for Surgery 2 weeks ago. And BAAM!!!!.....the results were released today, and yayyyyy.....I passed surgery! :)

I must thank all my Medicowesome admin/author collegues for tolerating my rants and, help me to push through the hellish scary time together. Thanks everyone. Finally I'm through it, and I'm back to writing for you all guys. So thought to start the first post after returning, with a General Surgery Diagnosing score with the help of Schwartz Textbook of Surgery.

See ya soon peepz! :)