• Detailed history.
• Physical examination.

 

1. Name.
2. Age.
3. Sex.
4. Religion.
5. Occupation.
6. Address.
7. Date of admission.
8. Hospital number.

 

• Pain in the right knee joint—15 days.
• Swelling in the right knee joint—7 days.
• Fever since 2 days.

 

• GIT: history of haematemesis, melaena, heart burn, flatulence, weight loss, appetite, details of bowel habits, (frequency, nature, bleeding), jaundice.
• Respiratory system: H/O chest pain, cough, haemoptysis, breathlessness.
• Cardiovascular system: H/O chest pain, palpitation, breathlessness on exertion
• Urinary system: Details of urinary habits (frequency, dysuria, urgency, hesitancy), haematuria, burning micturition
• Neurological: H/O of head ache, vomiting, difficult speech, walk, weakness in limbs, etc.

 

• Do not simply mention ‘nothing significant’.
• History of any other major illness, pulmonary Koch's been treated, epilepsy (treated or on treatment), hypertension, jaundice, diabetes, psychiatric illness, autoimmune disorder.
• History of surgery in the past, nature of illness, type of surgery, emergency/elective, type of anaesthesia used, mode of recovery, any complication, any blood transfusion given.

 

• Dietary habits.
• Addiction (alcohol; drugs/cigarettes/tobacco, betel nut chewing).
• Sleep (disturbed or normal).
  3
• Bowel habits, micturition (if not mentioned in the h/o presenting complaints).
• Socioeconomic status, marital status.
• Menstrual history in females (nature of the cycle, duration of flow, obstetric h/o, LMP, postmenopausal bleeding in old women).

   

• History of treatment received for the present illness.
• History of receiving treatment for any other illness.

       

• Examination of inguinal region in hernia.
• Examination of breast in breast disease.

     

• Shape of abdomen (normal/obese scaphoid/distended).
• Position of umbilicus (central/deviated/pushed up or down).
• Movements of abdomen.
• Skin over the abdomen (scar/pigmentation/venous engorgement).
• Hernial sites (look for expansile impulse on cough).
• External genitalia.

 

• Swelling, if palpated, its relation to abdominal quadrants has to be mentioned, mobility, tenderness, consistency is noted.
• Tenderness both deep and superficial is elicited; any rebound tenderness with guarding and rigidity is noted.
• Liver, spleen, kidneys are palpated for enlargement, their consistency, tenderness, nodularity if any is noted.

 

• General note all over the abdomen.
• Shifting dullness.
• Free fluid thrill.
• Upper border of liver dullness.

 

• Bowel sounds, nature intensity, abnormality is noted.
• Any added sounds-bruit.

         

• Higher functions: Consciousness, speech, alertness, cooperation noted.
• Gait examined.
• Cranial nerves examined.
• Motor system: Tone, power of upper and lower limb muscles must be mentioned.
• Sensory system: Pain, touch, temperature over arms, chest, back and lower limbs; vibrations and reflexes are checked.
• Cerebellar sign ± noted.

     

1. HB%, TC, DC, ESR, blood for sugar, blood urea, creatinine.
2. Urine routine.
3. Stool for routine (ova/cyst/parasite).
4. Chest X-ray.
5. ECG.

           

• Peripheral: Periphery (tip of nose, tips of finger and toes, palms, soles, ear lobule) is blue due to sluggish circulation or vasoconstriction leading to more oxygen desaturation at capillary bed.
• Central: Excessive oxygen desaturation of central arterial blood (in severe VSD, tetrology of Fallot), looked for in the undersurface of tongue, and inner aspect of lips. Here periphery is also blue.

     

• Due to excessive of fluid collection in extra-vascular compartment.
• In ambulant patient, medial surface of tibia, 2.5 cm above the ankle is pressed for 5–10 seconds.
• Pitting on pressure becomes evident only when the circumference of limb increases by 10%.
• In non-ambulant patient, it is checked by pressing over the sacrum.

         

• It is lateral expansion of arterial wall by a column of blood forced by the contraction of heart into the peripheral circulation.
• Radial artery is ideally and conveniently used to palpate for pulse against the lower end of radius above the wrist joint.

           

• Swelling in the groin, right or left or both sided for….durations; or swelling in right/left/both inguinoscrotal region for….durations.
• Pain over the swelling for….durations.

     

• Duration of the swelling.
• Mode of onset of the swelling—spontaneous or on straining.
• Site of the first appearance of the swelling in the groin or in the scrotum.
• Progress and extent of the swelling, whether it limits only to the groin or extends to the scrotum.
• Any changes in the size and extent of the swelling on standing/walking/straining/lying down.
• Whether swelling is reducible on lying down/partially reducible or irreducible on lying down or needs any manoeuvre to reduce it. History of gurgling sound in the scrotum signifies enterocele.
• If swelling is irreducible, then whether it is painful or any abdominal distension vomiting should be asked.

 

• Site of pain—whether it is in the groin or in the scrotum.
• Duration of pain.
• Severity of the pain, type of pain—dull aching or severe pricking type.
• Aggravating or relieving factors. Aggravated by straining/walking/weight lifting; relieved by lying down.

 

• Chronic cough, tuberculosis, bronchial asthma or other respiratory diseases.
• Constipation, altered bowel habits, tenesmus, bloody stool—in relation to anorectal stricture/carcinoma.
• Dysuria/urgency/hesitancy/altered stream/night frequency/retention of urine/burning urine/haematuria—in relation to benign prostatic hyperplasia/urethral stricture.

 

• Past history of hernia surgery—same side/opposite side. Type of surgery whether mesh used or repair done.
• History of appendicectomy earlier and if so detail about the surgery (can cause right direct hernia).
• Past history suggestive of irreducibility/obstruction and treatment for that conservative/surgical.
  8

 

• Smoking- duration, number per day, whether beedi or cigarette. Pan chewing/alcohol intake.
• Appetite and altered weight.

       

• Mention the side of the swelling.
• Extent of the swelling is important. Incomplete indirect inguinal hernia and usually direct inguinal hernias are in inguinal region. Complete indirect inguinal hernia (rarely complete direct inguinal hernia) is inguinoscrotal extending down into the bottom of the scrotum. Swelling extends from the proximal part of the inguinal canal towards the scrotum below.
• Both transverse and vertical dimensions of the size should be mentioned.
• Shape of the swelling is pyriform in indirect inguinal hernia and globular in direct inguinal hernia.
• Expansile impulse on coughing over the swelling is diagnostic. It is better seen than felt.
• Surface smooth/uneven.
• Margin—well-defined/ill-defined.
• Visible peristalsis over the swelling should be noted if present. It means it could be enterocele.
• Scar/dilated veins/discolouration/redness over the swelling.
• On inspection, whether testis is seen sepa-rately from the swelling or covered by the swelling all over.

 

• Temperature and tenderness over the swelling
• Whether get above the swelling is possible or not- purely scrotal swelling one can get above the swelling but in inguinoscrotal swelling one can not get above the swelling.
• Position and extent of the swelling.
• Size in vertical and transverse directions.
• Margin well defined or ill-defined.
• Surface smooth/lobular/tense.
• Consistency is soft and elastic in enterocele; doughy in omentocele.
• Location of the swelling—swelling is above and medial to pubic tubercle in inguinal hernia and below and lateral to pubic tubercle in femoral hernia.
• Reducibility of the swelling is checked by different methods.
  Whether it is reducible spontaneously while lying down and gets reduced completely or partially.
  In enterocele, it is difficult to reduce the first part but last part gets reduced easily. In omentocele it is difficult to reduce the last part but first part gets reduced easily.
• Whether swelling needs any manipulation to get reduced like taxis. Taxis is gradual reduction of contents of the scrotum by gentle manipulation by flexion and rotation of hip join.
• Zieman's test is done to find out over which finger cough impulse is felt and so which type of hernia it could be whether femoral/direct inguinal or indirect inguinal.
• Deep ring occlusion test: When deep ring is occluded, if impulse on coughing is absent then it is indirect inguinal hernia; if impulse on coughing is still present then it is direct inguinal hernia.
• Finger invagination test: Size of the superficial ring is noted and site of the impulse felt is observed whether it is in the tip of the finger or on the pulp.
• Palpation of testis, epididymis and spermatic cord should be done without fail. Relation of swelling to testis also should be noted.
• Bulbar urethra is palpated by lifting the scrotum and feeling in the midline. (To look for thickening and button like depression-a feature of stricture urethra).
• Opposite inguinal region, opposite testis, epididymis and spermatic cord should be examined. Presence or absence of impulse on coughing on opposite side should be mentioned.

   

• Abdomen muscle tone should be checked by head raising test, leg raising test and Valsalva manoeuvre. It should be inspected for Malgaigne bulging and should be palpated to check whether the tone is adequate (firm) or inadequate (supple).
• Any scar over the abdomen (appendicectomy scar may cause right-sided direct inguinal hernia); ascites or mass per abdomen should be mentioned.

         

• All case sheets for long case should mention the investigations required for that particular case.
  11
• Relevant investigations required for inguinal hernia are chest X-ray, haematocrit, blood sugar, serum creatinine, ultrasound abdomen depending on the age/suspected cause of the hernia.

                     

• Index finger it is indirect inguinal hernia
• Middle finger it is direct inguinal hernia
• Ring finger it is femoral hernia.

       

• Obliquity of the inguinal canal.
• Arched conjoined tendon.
• Shutter mechanism of internal oblique.
• Ball valve mechanism of the cremaster.
• Slit valve mechanism of the intercrural fibres of the superficial inguinal ring.
  14

           

• Thumb for deep ring occlusion test.
• Index, middle and ring fingers for Zieman's test.
• Little finger for superficial ring invagination test.

 

• Never forget to check expansile impulse on coughing and reducibility.
• Never forget to examine opposite side.
  17
• Never forget to do perrectal examination.
• Never forget to examine bulbar urethra.
• Never forget to check abdominal muscle tone.

 

• Indirect/direct inguinal hernia.
• Hydrocele—vaginal/encysted.
• Femoral hernia.
• Lipoma of the cord.
• Inguinal lymphadenopathy.
• Groin abscess.

   

• medially by lateral border of rectus sheath.
• above by the arched fibres of internal oblique and transverse abdominis muscle.
• laterally by the iliopsoas muscle.
• below by the pectin pubis and fascia covering it.

       

1. Direct hernia, sliding hernia.
2. Pantaloon hernia.
3. Femoral hernia.

   

• Smoking.
• Obesity.
• Respiratory causes like bronchial asthma, tuberculosis, bronchitis.
• Ascites.
• Previous surgery like appendicectomy which causes direct inguinal hernia.
• Chronic constipation due to anorectal strictures. Rectal stricture may be due to chronic proctitis (amoebic), tuberculosis of anorectum, previous anorectal surgery, rectal carcinoma or stricture due lymphogranuloma venereum.
• Urinary problems like benign prostatic hyperplasia (BPH), urethral stricture.
• Straining.
• Multiple pregnancies.

 

• Routine investigations like haemoglobin, total count, blood urea, serum creatinine.
• Blood sugar
• Specific investigations like chest X-ray, U/S abdomen to confirm BPH.

 

• Initially precipitating causes should be treated. Asthma, tuberculosis and bronchiec-tasis are treated by proper drugs, broncho-dilators, respiratory physiotherapy.
• Later definitive surgical treatment is under-taken.
• Commonly used procedure at present is hernioplasty using prolene mesh. Modified Bassini's repair is done in young individual with indirect hernia. Shouldice repair is also used in some centers.

   

1. Nerve block method (point block)
   • 10 ml of xylocaine is infiltrated 2 cm above and medial to anterior superior iliac spine to block the iliohypogastric nerve.
   • Midinguinal point is infiltrated with 10 ml xylocaine.
   • Pubic tubercle place is infiltrated with 10 ml xylocaine.
   • 10 ml of xylocaine is infiltrated just below the inguinal ligament lateral to femoral artery to block the genital branch of genitofemoral artery.
   • Line of skin incision is infiltrated with 10 ml of xylocaine.
   • Later neck of the hernial sac is infiltrated with 10 ml of xylocaine.
2. Field block method (Shouldice method)
   • Skin of around 4 cm wide area is infiltrated into the subcutaneous plane as first layer from anterior superior iliac spine to pubic symphysis. Skin, subcutaneous and two layers of superficial fascia (Camper and Scarpa's) are incised.
   • Area deep to external oblique aponeurosis is infiltrated with 10 ml of xylocaine. External oblique aponeurosis is incised.
   • Exposed inguinal canal and hernial sac is infiltrated with 10 ml of xylocaine to continue with the dissection.

                                 

• Onlay mesh repair by placing mesh in front.
• Inlay mesh repair by placing mesh deep to conjoint tendon.
• Lichtenstein tension free mesh repair (1993) with encircling the cord with mesh which is often done under local anaesthesia.
• Nyhus pre-peritoneal mesh repair. It is done through suprainguinal horizontal incision. Mesh is placed in the preperitoneal space deep to the cord, conjoined tendon, and transversalis fascia. Below, it is folded deep to the iliopectineal ligament of Cooper and sutured to it using two or three interrupted non-absorbable sutures. It is sutured to transverse abdominis above and transversalis fascia from deep.
• Rives preperitoneal mesh repair is pre-peritoneal mesh repair through transinguinal approach. Here mesh is folded and sutured below to iliopectineal ligament, above to the transverse abdominis in deeper plane. Often transversalis fascia opened earlier is sutured back using nonabsorbable suture material in front of the placed mesh.
  

  Figs 1.38A to F: Hernial sac should be dissected up to the neck of the sac. It is then twisted and transfixed using catgut or vicryl and redundant sac is excised.
  26
  

  Figs 1.39A to G: Placement of prolene mesh in inguinal hernia repair. i.e Inlay-Lichtenstein mesh repair.
• Stoppa's giant prosthesis reinforcement of visceral sac (GPRVS). It is done in large hernias, hernias in elderly, bilateral hernias, recurrent and re-recurrent hernias, hernia with very lax abdomen. Horizontal length (size) of the mesh is 2 cm less than distance between two anterior superior iliac spines and vertical length (size) is distance between the umbilicus and pubic symphysis. Large mesh is placed between peritoneum and lateral, inferior, anterior abdominal wall which stretches in the lower abdomen and pelvis. It is done through lower midline or Pfannensteil incision.
  

  Fig. 1.40: Mesh after hernioplasty got infected with wound Dehiscence. It needs removal of mesh.
  27
  Usually such large mesh is placed without any anchorage.
• Gilbert mesh repair: after herniotomy, internal ring is plugged by cone-shaped piece of prolene mesh. Later onlay/inlay mesh repair of posterior wall of the inguinal canal is done.
• Transabdominal preperitoneal laparoscopic mesh repair (TAPP repair): becoming popular.
• Totally extraperitoneal laparoscopic mesh repair (TEP): becoming popular.

           

• Infection—most common—50%.
• Haematoma in the wound.
• Early straining.
• Retained indirect sac, after repair of a direct sac (Pantaloon hernia).
• Smoking, constipation, obstructive uropathy, old age, nutritional deficiencies.
• Altered tension in repair site. Altered collagen synthesis.

           

• Incisional hernia is a hernia occurring through a weak scar.
• Writing case sheets, taking detailed history is similar to inguinal hernia.

     

• Details of surgery patient has undergone earlier. After how long incisional hernia has occurred?
• History of wound infection, wound dehiscence, whether surgery done was an emergency or elective, and tension sutures placed or not.
• History of pain, irreducibility and details of precipitating factors to be asked.
• Other precipitating factors similar to inguinal hernia like smoking, urinary/respiratory/abdominal symptoms.

       

• Vertical incision has got higher chances of incisional hernia than horizontal incision.
• Layered closure of the abdomen has got higher chance than single layer.
• Continuous closure has got higher chances than interrupted closure.
• Use of absorbable suture material has got higher chances of hernia than nonabsorbable sutures.
• Emergency surgical wound has higher chances than elective surgical wound.
• Laparotomy for peritonitis, acute abdomen, and trauma can commonly cause incisional hernia.
• Drainage through the main laparotomy wound may precipitate formation of incisional hernia.
• Chronic cough, smoking, obstructive uro-pathy, constipation can precipitate incisional hernia.
• Diabetes, old age, malnutrition, malignancy, anaemia, hypoproteinaemia, jaundice, ascites, liver disease, uraemia, steroid therapy, immunosuppressive diseases are other precipitating factors.

 

• When the defect is less than 3 cm, and if the patient is having adequate abdominal muscle tone then layer by layer anatomical repair is done using monofilament non-absorbable suture material like polypropylene/polyethylene with ideally interrupted sutures. Sac should be dissected, ligated and excised prior to repair. Peritoneum and posterior rectus sheath is apposed as first layer and anterior rectus sheath as second layer.
• Double breasting of the rectus sheath using interrupted nonabsorbable sutures using monofilament suture material. It is over-lapping the rectus sheath in two layers with two rows of sutures.
• Mesh repair of the incisional hernia defect is always better and ideal with less chances of recurrence. Adequate sized mesh is placed either outer to peritoneum (inlay), or outer to musculoaponeurotic abdominal layer (onlay/overlay), or occasionally combined inlay and onlay mesh placement, both deep to peritoneum and outer to musculoaponeurotic layer. Rive's Stoppa's mesh placement for incisional hernia is placing mesh between posterior rectus sheath and rectus muscle. Commonly polypropylene mesh is used. Other materials used are Dacron, polytetrafluroethylene (PTFE) mesh, polyglycolic mesh (vicryl mesh) or combined polypropylene and polyglycolic acid mesh (vipro mesh). Drain (suction drain) must be placed after surgery.
• Laparoscopic mesh repair is done for incisional hernia by placing a mesh under the defect laparoscopically in intraperitoneal plane. The only problem of this underlay placement is chances of adhesion and GI fistula formation but it is found to be safer. Laparoscopic preperitoneal mesh placement also done for smaller defects. Now dual mesh (PTFE) or four layered mesh are available. In this mesh is placed under the peritoneum deep to the defect after reducing the contents. Mesh is fixed with sutures and tacks. In four layer mesh, deepest 1st layer is absorbable cellulose which allows new peritoneum to creep underneath. Second layer is PDS mesh 3rd layer is polypropylene mesh last 4th layer is again PDS mesh. It is ideal but costly.
• Keel's operation is done in large defect. Scar is excised and sac is dissected beyond the margin of the defect. Sac is never opened unless there is obstruction of the content. Sac in inverted using continuous/interrupted inverting nonabsorbable sutures, layer-by-layer until the defect margins are apposed together which is then again sutured with interrupted sutures. Keel is inverted beam of the ship.
• Nuttall's operation is done for lower midline incisional hernia. Recti attachments are detached from the pubic bones and are crossed over to fix to opposite pubic bones so as to create a firm abdominal wall support by crossed recti muscles.

 

• Reduction in weight and control of obesity.
• Nutrition, control of anaemia.
• Treatment for diabetes, hypertension, cardiac diseases, respiratory problems.
• Treating the precipitating causes.
• Chest X-ray, U/S abdomen to be done.
• Massive incisional hernia after reduction might cause IVC compression, paralytic ileus and diaphragmatic elevation with respiratory embarrassment (abdominal compartment syndrome). It is prevented by prior increasing the capacity of peritoneal cavity by creating the pneumoperitoneum using CO₂ so as to increase the peritoneal pressure by 12–15 cm of H₂O, daily for 3–6 weeks. Later definitive surgery is done.

 

• Outer to peritoneum is ideal method. Large-sized mesh is placed in preperitoneum. It need not be fixed as abdominal pressure keeps it in position.
• Under the peritoneum, directly over the content. Now it is accepted but there are chances of adhesions/fistula formation. It is used in laparoscopic repair.
• Overlay mesh placed outer to musculoaponeurotic layer.
• Combined inlay and overlay with two layers of mesh.
• Rive's Stoppa's method of placing mesh between posterior rectus sheath and rectus muscle.

 

• While reducing the bulky contents like bowel and omentum, inadequate intra-abdominal capacity leads to increased intra-abdominal pressure causing IVC compression, mesenteric oedema following stasis of splanchnic bed, paralytic ileus, diaphragmatic elevation and respiratory distress (abdominal compartment syndrome), urinary and bowel disturbances. Abdominal capacity can be raised by regular pneumoperitoneum over the period of 3–6 weeks.
• Lordosis and back pain may be presenting feature.
• Sac and contents may get adherent to the thin skin over the summit of the hernia leading to skin ulceration and occasionally fistula formation.
• Often might need resection of the adherent bowel segment.
• Large mesh placement is required.

                           

• Pain in the limb right/left/both—its duration.
• Intermittent claudication—its duration.
• Blackish discoloration/ulceration.

     

• Site of pain, type of pain—severe burning/aching/deep persisting.
  Whether pain radiates or not.
• Intermittent claudication—duration, grade/distance how much patient can walk/whether pain subsides after stopping walk or after continuous walk/whether patient is able to walk in spite of pain/change in the claudication distance eventually/site of claudication—foot/leg/thigh/buttock.
• Presence of rest pain—its location/severity/whether patient has to hold the limb/foot/leg/toes to relieve pain little bit (probably by transmission of temperature from holding hand into the part) or to hang the leg down to relieve the pain or by applying the warmth.
  

  Fig. 1.66: Rest pain in a TAO patient. Observe the way patient holding the foot to relieve the pain.
• Pain, discomfort, colour changes when exposed to cold.

 

• Whether precipitated by trauma/spontaneously.
• Pain in the ulcer/type/duration/aggravating or relieving factors.
• Discharge-type—serous-purulent-bloody.
• Progression.

 

• Site of gangrene/its onset/progression/pain.
• History of difficulty in walking/altered gait.
• Mode of onset—in atherosclerosis/Buerger's disease process is spontaneous and gradual. Gangrene due to embolism is sudden in onset, rapidly progressive.
• History of fever.
  41
• History of impotence—its duration.
• History of tingling/numbness/weakness in the limbs.
• History of syncope/blackouts/loss of consciousness/blurred vision.
• History of chest pain/cough or cardiac related symptoms.
• History of abdominal pain/bloody diarr-hoea/abdominal angina.
• History of paraesthesia over the skin.
• History suggestive of superficial thrombophlebitis like swelling/redness/pain along the line of superficial vein.

 

• Similar history earlier.
• History of drug intake earlier for similar conditions like vasodilators/drugs to increase the perfusion.
• History of earlier surgery like/sympathectomy/omentoplasty/their results or effects.

     

• Pulse-rate/rhythm/character/condition of vessel wall.
• Blood pressure of both arms and if possible of both lower limbs.
• Attitude of limbs.

   

• Inspect both lower limbs keeping side-by-side as comparison is needed during clinical examination.
• Change in colour is very important sign of ischaemia.
• Colour proximal to gangrene area/ischaemic area (usually ischaemic area is pallor).
• Limb deformity.
• Gangrene of toe/toes/foot/leg: Its extent, discharge from area, type of gangrene—dry or wet, line of demarcation—type/level/depth, colour of gangrenous area—black/purple/greenish black (in gas gangrene).
• Ulceration if any—its extent/discharge/size/shape/floor/surrounding area.
• Patchy ulcers proximal to gangrenous areaskip lesions which are usually black patchy lesions.
• Muscle wasting in the foot/leg/thigh should be observed. It should be compared and also should be measured using a tape from a fixed bony point keeping equal distance in both limbs.
• Features of ischaemia—shiny thin skin/loss of subcutaneous fat/hair loss- its extent/nail changes—brittle nail/transverse ridges in the nail.
• Plantar aspect of the foot for infective focus/abscess/callosities/skin changes/superficial ulcers in heel/malleoli/toes.
• Buerger's postural test: Patient in supine position is asked to raise his legs one after other with knee keeping straight. In normal limb even after 90° elevation limb remains pink without any palor. Diseased limb after elevation shows marked palor (overfoot) with empty-guttered veins. The angle with which palor develops (between limb and ground) is called as Buerger's vascular angle of insufficiency. In severe ischaemia, this angle will be less than 30°. If foot does not become palor or doubtful, then repeated ankle flexion and extension is done until it becomes palor empty-guttered veins on the dorsum of foot and after lowering the foot cyanotic congestion appears in the foot.
• Oedema in the foot/feet/legs.
• Status of the superficial veins—normally filled veins or pale/discoloured/guttered veins as seen in ischaemic limb.
  42
• Capillary filling time: Initially elevated limbs are made to hang down the bed. Limb will remain normal pink in elevated as well as down position because of rapid capillary filling time. In ischaemia, limb becomes palor in elevation and only gradually becomes purple-red and then pink in more than 20 seconds. Purple pink colour is due to deoxygenated blood. Prolonged capillary time signifies severe ischaemia.
• Venous refilling time: Elevated limb when laid horizontal in the bed normal venous refilling occurs within 5 seconds. It is delayed in ischaemic limb.

 

• Temperature of the skin is important factor in ischaemic limb. Extent of cold and proxi-mally where exactly limb/part become warmer also should be assessed.
• Tenderness: Site/extent/severity should be assessed.
• Gangrenous area to be palpated for extent/whether it is dry and shriveled or whether it is wet and oedematous. Crepitus in gangrenous present or not should be checked.
• Limb above the gangrenous area should be palpated.
• Capillary filling: Tip of the nail or pulp of the finger or toe is pressed to blanch it and pressure is released (in 2 seconds) to make it to become pink. Time taken from blanched area to turn into pink is capillary filling time. It is prolonged in ischaemic limb.
• Harvey's venous refilling test: Two fingers are placed over the vein. Pressure is elicited over the vein. Proximal finger is moved proximally for about 5 cm without releasing the pressure. Vein between the fingers gets emptied completely and becomes flat. Distal finger is released now to see the flow of the blood and its refilling is observed whether it is good or poor. It is poor in ischaemic limb.
• Elevated arm stress test (EAST): Both shoulders are abducted 90° with arms fully externally rotated. Patient will open and close the hands rapidly for 5 minutes. Normal individual can do this without any discomfort and pain. Patient with thoracic outlet syndrome develops pain, fatigue, paraesthesia of forearm with tingling and numbness of fingers. Patient will not be able to complete the test for 5 minutes. This test can also differentiate thoracic outlet syndrome from cervical disc prolapse disease.
• Roos test: Patient is asked elevate and abduct the shoulders 90° with external rotation of arms to keep it for 5 minutes. Patient feels fatigue in the diseased side.
• Costoclavicular compression manoeuvre: While feeling radial pulse of the patient, he is asked to place his shoulder backwards and downwards (exaggerated military position) causing absence/feeble radial pulse and while auscultating the supraclavicular region a bruit may be heard. This is due to com-pression of subclavian artery between clavicle and first rib.
• Hyperabduction manoeuvre (Halsted test): While palpating the radial pulse, arm on the diseased side is passively hyperabducted causing feeble or absence of radial pulse. This is due to compression of artery by pectoralis minor tendon (pectoralis minor syndrome). An axillary bruit may be heard on auscul-tation.
• Adson's test: While feeling the radial pulse of the affected side of the patient, patient is asked to take deep breath and to turn his neck/head towards the same side so as to compress the thoracoaxillary channel. Pulse becomes feeble or absent in positive Adson's test in thoracic outlet syndrome/scalenus anticus syndrome. While taking deep breath thoracic cage moves upwards and narrows the space causing aggravation of compression of subclavian artery by scalenus anterior muscle. Contraction of scalenus anterior further aggravates the feature (by turning neck towards same side).43
  

  Figs 1.67A and B: Adson's test
• Branham's/Nicoladoni's sign: In arteriovenous fistula, pressure over the artery proximal to fistula will cause reduction in pulse-rate and size of the swelling with pulse pressure becoming normal and disappearance of bruit.
• Allen's test: It is used in hand to find out the patency of radial and ulnar arteries. Both radial and ulnar arteries of the patient is felt and pressed firmly at the wrist. Patient clinches his hand firmly (often repeated clinching) and holds it tightly. After 1 minute, clinch is released to open the palm of the hand which looks pale. Pressure on the radial artery in wrist is released to see area of distribution of the radial artery. Normally, it becomes flushed with pink colour. If there is radial artery block area will remain white. Test is repeated again. This time pressure on the ulnar artery is released to check the patency of ulnar artery. Area will be pale and blanched after releasing in case of ulnar artery block. Otherwise in normal individual it becomes pink after release.
• Cold and warm water test: It is commonly done to confirm Raynaud's phenomena. Patient is asked to dip hands in cold water to precipitate the vasospasm and Raynaud's syndrome.
• Crossed-leg test (Fuchsig's test): Patient is asked to sit with the legs-crossed one above the other so that the popliteal fossa of one leg will lie against the knee of other leg. Oscillatory movements of foot can be observed synchronous with the popliteal artery pulsation. If the popliteal artery is blocked oscillatory movements will be absent.
• Disappearing pulse syndrome: Exercise the limb after feeling the pulse. Pulse will disappear once patient develops claudication. It is because of vasodilatation and increased vascular space occurring due to exercise wherein arterial tension can not be kept adequately and so pulse will disappear (unmasking the arterial obstruction).
• Buerger's postural test: Patient lying down on his back is asked to raise the leg forward for two minutes.
  

  Figs 1.68A to D: Allen's test
  44
  

  Figs 1.69A and B: Crossed-leg test—checking oscillatory movements.
  In normal individuals, limb (plantar aspect of foot) will remain pink even after raising to 90°. Ischaemic limb, when elevated shows marked pallor and empty veins. The angle in which pallor develops is called as Buerger's angle of vascular insuffi-ciency. Less than 30° angle indicates severe ischaemia. Ischaemic height of the heel in relation to the sternal angle where palor develops in heel signifies the severity of the disease. This height in centimeter is equal to the arterial pressure in the foot in mmHg. After that patient is asked to keep the legs below the bed to fill the vessels. Time taken to become leg pink colour is capillary filling time. Filling time more than 30 seconds suggests severe limb ischaemia.
• Guttering of vein while raising the leg for 15° is observed in ischaemic limb due to complete collapse of the veins whereas in normal individual veins are only partially collapsed while raising the leg.
• Reactive hyperaemia time test: Inflate the sphygmomanometer cuff around the limb up to 250 mmHg for 5 minutes to appear palor significantly. Release and assess the time of appearing of red flush in skin which signifies the reactive hyperaemia time. Normal time is 2 seconds. It is delayed in ischaemia.

         

• Commonest site is calf muscles.
• Pain in foot is due to block in lower tibial and plantar vessels.
• Pain in the calf is due to block in femoropopliteal site.
• Pain in the thigh is due to block in the superficial femoral artery.
• Pain in the buttock is due to block in the common iliac or aortoiliac segment, often associated with impotence and is called as Leriche's syndrome.

                     

• Separation by aseptic ulceration-seen in dry gangrene.
• Separation by septic ulceration-seen in infected cases and wet gangrene.

 

• Blood tests: Hb%, blood sugar, lipid profile, peripheral smear, platelet count.
• Doppler to find out the site of block.
• Duplex scan: It is combination of B mode ultrasound and Doppler study. Difference in transmitted beam of the ultrasound and reflected beam is called as Doppler shift which is assessed and converted into audible signals. To study the site, extent, severity of block, and also about collaterals. Audible sound—with normal flow and sound is important. Turbulence is heard with stenosed partially blocked artery. Audible sound will be absent, if there is complete block. Using Doppler probe blood pressure at various levels can be assessed. Pulse wave tracing along the artery is also important.
• Plethysmography.
• Ankle-brachial pressure index (ABPI):

 

• Direct aortic angiogram, practiced earlier, is discouraged at present because of the risk of aortic dissection and paraplegia due to blockage of anterior spinal artery.

 

• Here vessel (artery) is delineated in a better way by eliminating other tissues through computer system. A-V fistulas, haemangio-mas, lesion in circle of Willis, vascular tumours, other vascular anomalies are well-made out.
• Dye is injected either to an artery or vein. Injecting into a vein is technically easier but larger dose of dye is required. Injecting into an artery is technically difficult but small dose of dye is sufficient.
• Advantages: Only vascular system is visualised; other systems are eliminated by computer subtraction. Small lesion, its location and details are better observed with greater clarity.
• Disadvantages: Cost factor and availability.
• Complications: Anaphylaxis, bleeding, thrombosis.

   

1. Atherosclerosis:

2. Thromboangiitis obliterans. TAO: (Buerger's disease.)
3. Raynaud's disease.
4. Conditions causing Raynaud's phenomenon: Like Scleroderma, Rheumatoid arthritis, SLE, Granulomatosis, vasculitis of other causes.
5. Embolus.
6. Aneurysms.

     

• Hb%. Blood sugar.
• Arterial Doppler and Duplex scan (Doppler + B mode U/S).
• Transfemoral retrograde angiogram through Seldinger technique—
  • Shows blockage—sites, extent, severity.
  • Cork screw appearance of the vessel due to dilatation of vasa vasorum.
  • Inverted tree/spider leg collaterals.
  • Severe vasospasm causing corrugated/rippled artery.54
    

    Figs 1.94A to H: Different types of ischaemic ulcers. Also note wasting, loss of hair, shininess and other features of ischaemia.

    55
    • Distal run off is amount of dye filling in the main vessel distal to the obstruction through collaterals. If distal run off is good then ischaemia is compensated. If distal run off is poor then ischaemia is decompensated.
• Transbrachial angiogram: If femorals are not felt, then transbrachial angiogram (Through left side brachial artery—left subclavian artery – and so to descending aorta) should be done.
• Ultrasound abdomen
• Vein, artery, nerve biopsies.

   

• Vasodilators, e.g. nifedepine.
• Pentoxiphylline increases the flexibility of RBC'S and helps them reach the microcirculation in a better way so as to increase the oxygenation.
• Low dose of aspirin—antithrombin activity
• Prostacyclins, Ticlopidine, Praxilene.
• Clopidogrel 75 mg, atorvastatin 10 mg, parvostatin 40 mg
• Cilostazole 100 mg bid—is a phosphodiesterase inhibitor which improves circulation.

 

1. Lumbar sympathectomy to increase the cutaneous perfusion so as to make the ulcer to heal.
2. Omentoplasty to revascularise the affected limb.
3. Profundaplasty is done for blockage in profunda femoris so as to open more collaterals across the knee joint. (It often makes better perfusion to the knee joint and flap of below knee amputation).
4. Amputations are done at different levels depending on site, severity and extent of vessel occlusion. Usually either below- knee or above—knee amputations are done.
5. Ilzarov method of bone lengthening helps in improving the rest pain and claudication by creating neoosteogenesis and improving the overall blood supply to the limb.
6. Gene therapy: Intramuscular injection of vascular endothelial growth factor (VEGF) which is an endothelial cell mitogen which promotes angiogenesis.

   

• Raynaud's disease:
  • It is seen in females, usually bilateral.
  • It occurs in upper limb with normal peripheral pulses.
  • It is due to upper limb (hand) arteriolar spasm due to abnormal sensitivity to cold. Patient develops blanching, cyanosis and later flushing as Raynaud's syndrome. Occasionally, if spasm persists it result in gangrene. Symptoms can be precipitated and observed by placing hands in cold water.
• Working with vibrating tools: Like pneumatic road drills, chain saws, wood cutting, and fishermen traveling in machine boats.
• Collagen vascular diseases: Like scleroderma, Rheumatoid diseases causing vasculitis (All autoimmune diseases).
• Other causes: Cervical rib, Buerger's disease, Scalene syndrome.

   

• Treat the cause.
• Avoid the precipitating cause.
• Vasodilators, Pentoxiphylline.
• Small dose of aspirin (100 mg daily).
• Cervical sympathectomy.

     

• Stop smoking.
• Reduction of weight.
• Change in life style.
• Exercise.
• Care of feet.
• Control of diabetes and hypertension.
• Buerger's position and exercise—regular graded exercises upto the point of claudication improves the collateral circulation.

 

1. Transluminal balloon angioplasty/percutaneous transluminal balloon angioplasty/PTA): Through transfemoral Seldinger approach, initially angiogram is done. Then under guidance (fluoro-scopic) stenosed area is approached. Balloon of the angioplasty catheter is inflated at stenosed area for one minute and repeated if required. Catheter is withdrawn. It is useful in cases of localised stenosed areas.
   Complications: Thrombosis, bleeding, sepsis.
   57
2. Atherectomy: It is removal of atheroma from the wall of the artery either through open surgery or by percutaneous route of medium sized vessels.
3. Thrombectomy: It is removal of thrombus through an arteriotomy of larger vessels. It is done in aortoiliac, femoropopliteal region.
4. Endarterectomy: It is removal of thrombus along with diseased intima through an arteriotomy.
   

   Fig. 1.97: Endarterectomy technique. Both thrombus and diseased intima are removed through an arteriotomy. Often ring stripper is used to remove the atheromatous plaque.

   

   Fig. 1.98: Exposing femoral artery for endarterectomy technique.
5. Intraluminal stent placement.
6. Profundaplasty: It is done when there is localised block in opening of profunda femoris (deep femoral). Profunda femoris is opened, thrombus if present, is removed. Opening is widened using either venous or synthetic (Dacron or PTFE) grafts. This procedure allows collaterals across the knee joint through profunda femoris and so gives good blood supply below-knee level and may prevent patient going in for above-knee amputation.
   (May be able to save knee joint with below- knee amputation with better prosthesis).
   

   Fig. 1.99: Profundaplasty for deep femoral block.
7. Reverse saphenous vein graft: In case of femoropopliteal block, saphenous vein is dissected out, reversed and sutured above to the femoral artery and below to popliteal segment so as to bypass the blood through reverse saphenous vein graft. Saphenous vein is reversed to nullify the action of valves so as to allow easy flow of blood.
8. In-situ saphenous vein graft: It is arterialisation of saphenous vein. Saphenous vein intact in same position is sutured above and below the blocked femoropopliteal region to bypass the blood across. Venous valves are removed through valvulotomy instrument so as to allow the blood to pass.
   58
9. Arterial/venous grafts:

• Dacron woven graft.
• Dacron knitted graft.
• PTFE—Poly tetra fluoroethylene graft.

• Internal mammary artery.
• Long saphenous vein either reverse or in situ.

• Aorto-femoral bypass graft.
• Ileo-femoral bypass graft.
• Femoro-femoral bypass graft.
• Femoro-popliteal graft.
• Femoro-distal graft.

10. Cervical sympathectomy:

 

1. Supraclavicular approach: Through an incision in supraclavicular region, sternomastoid, omohyoid, scalenus anterior muscles are divided. Phrenic nerve is displaced medially; subclavian artery is pushed downwards; suprapleural membrane is depressed, stellate ganglion is identified in the neck of the first rib. All rami communicanting from second and third ganglia are divided and Kuntz nerve is also divided.
   Complications: Bleeding, injury to subclavian artery and nerves, pneumothorax and haemopneumothorax, Horner's syndrome with ptosis, miosis, anhydrosis, enophthalmos.
   

   Figs 1.104A and B: Patient underwent cervical sym-pathectomy left-side for ischaemic gangrene index finger tip which has healed now. Note the sympathectomy scar. In another patient typical ptosis after sympathectomy is seen.
2. Transthoracic approach (Hedley Atkins): This gives better visibility and easier removal of rami, lower down compared to supraclavicular approach.
3. Endoscopic sympathectomy is the choice and popular approach at present.

11. Lumbar sympathectomy

• Peripheral vascular disease like TAO.
• To promote healing of cutaneous ulcers.
• To change level of amputation and to make flaps to heal better after amputation.
• Causalgia of lower limb (it is common in upper limb).
• Hyperrhidrosis.

1. Injury to IVC or aorta.
2. Bleeding lumbar veins.
3. Spinal vessel spasm and so ischaemia of spinal cord and paraplegia.
4. Injury to bowel and ureter.
5. Wound infection and abscess formation.

12. Chemical sympathectomy
    It is done in lateral position using a long spinal needle under local anaesthesia. Position is confirmed by injecting dye under fluoroscopy. Later 5 ml of phenol in water or absolute alcohol (1: 16) is injected lateral to the vertebral bodies of second and fourth lumbar vertebrae. Care should be taken to see that the needle does not enter IVC or Aorta. Procedure is contraindicated in patients with bleeding disorders and in patients who are on anticoagulants.
13. Omentoplasty.
    Indications:
    1. Peripheral vascular disease—To improve circulation.
    2. For lymphoedema it helps by providing lymphatics and so to drain lymph from the limb.
    3. It is also tried for revascularisation of pharynx, cranial cavity.
       Omentum is supplied by omental vessels.

• Abdominal sepsis.
• Incisional hernia, where omental pedicle is tunneled into the limb from the abdomen.
• Adhesions and intestinal obstruction.

   

1. Trauma.
2. Embolism.

 

1. Thrombus due to trauma.
2. Subintimal haematoma.
3. Acute compartment syndrome.
4. During femoral or brachial arterial catheterisation, either diagnostic or therapeutic procedures.

 

• Myocardial infarction.
• Mitral stenosis.
• Atrial fibrillation.
• Aortic aneurysms.
  63
• Cervical rib causing poststenotic dilatation of subclavian artery.

• Fat embolism.
• Air embolism.

 

• Brain: Blockage at middle cerebral artery causes hemiplegia, transient ischaemic attacks (TIA), visual disturbances.
• Blockage at central retinal artery causes amaurosis fugax, or permanent blindness.
• Blockage at mesenteric vessels causes intestinal gangrene.
• Blockage at renal artery lead to haematuria, loin pain.
• Blockage at limb vessels causes pain, pallor, pulseless, paraesthesia, paresis, ulceration, gangrene.

 

• Emergency Doppler, ECG and echocardiography, angiogram.
• Relevant tests for origin of emboli.

 

1. Embolectomy: It is done as early as possible as an emergency operation. Under fluoroscopic guidance, Fogarty catheter (interventional radiology) is passed beyond the embolus and balloon is opened. Catheter is pulled out gently with embolus. Procedure has to be repeated until embolectomy is completed and bleeding occurs. Angiogram is repeated to confirm the free flow. Postoperatively initially heparin and later oral anticoagulant are used. Procedure is done under general anaesthesia.
   Open arteriotomy and embolectomy can be done by direct approach and later the arteriotomy has to be sutured. Postoperatively, anticoagulants, antibiotics should be given.
2. Intraarterial thrombolysis using fibrinolysins: After passing arterial catheter, angiogram is done and agents are injected intraarterially through the arterial catheter.

• Streptokinase (here lysis occurs in 48 hours).
• Urokinase.
• Tissue plasminogen activator. (TPA)— Here lysis occurs in 24 hours.
• TPA pulse- spray method – here lysis occurs in 6 hours.

 

• Mural thrombus after myocardial infarction.
• Mitral stenosis with atrial fibrillation.
• Aortic aneurysm.

• Features of ischaemia in both lower limbs.
• Gangrene of both lower limbs.
• Associated infection and its features.

• Arterial Doppler.
• Aortic angiogram.
• U/S abdomen.

• Initially, heparin is given intravenously - 10,000/ units and later 5,000 units/- subcutaneously 8th hourly.
• Embolectomy can be done using Fogarty catheter.
• Open arteriotomy and embolectomy can also be tried.
• Antibiotic prophylaxis has to be given to prevent infection.

 

• Cerebral: Drowsy, restless, disoriented, constricted pupils, pyrexia, coma.
• Pulmonary: Cyanosis, tachypnoea, right heart failure, froth in mouth and nostrils, fat droplets in sputum, eventually respiratory failure.
• Cutaneous: Petechial haemorrhages in the skin.
• Retinal artery emboli is the earliest sign to appear, causing striae haemorrhages, fluffy exudates confirmed on fundoscopic examination.
• Kidney: Blockage in renal arterioles results in fat droplets in urine.

 

• Through venous access like IV cannula.
• During artificial pneumothorax.
• During surgeries of neck and axilla.
• Traumatic opening of major veins sucking air inside, causing embolism.
• During fallopian tube insufflation.
• During illegal abortion.
  65

 

• Haemangiomas,
• AV fistulas,
• Malignancies like renal cell carcinoma, hepatoma,
• Craniovascular problems.
• To arrest haemorrhage from GIT, urinary and respiratory tract.

 

• True aneurysm contains all three layers of artery.
• False aneurysm contains single layer of fibrous tissue as wall of the sac and it usually occurs after trauma.

 

• Fusiform
• Saccular
• Dissecting

 

• Atherosclerosis.
• Syphilis.
• Traumatic.
• Collagen diseases like Marfan's syndrome.

   

• Aorta.
• Femoral.
• Popliteal.
• Subclavian.
• Cerebral, mesenteric, renal, splenic arteries
• Commonest is true, fusiform, atherosclerotic, aortic aneurysms.

 

• Swelling at the site which is pulsatile, (expansile), smooth, soft, warm, compressible, with thrill on palpation and bruit on auscul-tation. Swelling reduces in size when pressed proximally.
• Distal oedema due to venous compression.
• Altered sensation due to compression of nerves.
• Erosion into bones, joints, trachea or oesophagus.
• Aneurysm with thrombosis can throw an embolus causing gangrene of toes, digits, extending often proximally also.

 

1. Pyogenic abscess: Abscess has to be always confirmed by aspiration; especially in axilla, popliteal region, groin.
2. Vascular tumours.
3. Pulsating tumours: Sarcomas, pulsating secondaries.
4. Pseudocyst of pancreas mimics aortic aneurysm.
5. A-V fistula.

   

• Reconstruction of artery using arterial grafts.
• Arterial endoaneurysmorrhaphy—MATA'S.
• Therapeutic embolisation,
• Clipping the vessel under guidance (e.g. cranial aneurysms).

     

• Infrarenal—Commonest. 95%.
• Suprarenal 5%.

 

1. Asymptomatic: Found incidentally either on clinical examination or on angiography or on ultrasound. Repair is required if diameter is over 5.5 cm on ultrasound.
2. Symptomatic without rupture: Present as back pain, abdominal pain, mass abdomen which is smooth, soft, nonmobile, not moving with respiration, vertically placed above the umbilical level, pulsatile both in supine as well as knee-elbow position with same intensity, resonant on percussion. GIT, 67urinary, venous symptoms can also occur. Hypertension, diabetes, cardiac problems should be looked for and dealt with.

 

• Blood urea, serum creatinine.
• U/S, aortogram.
• DSA, CT scan, MRI.

 

• Open surgical aneurysm repair using PTFE or dacron graft.
• Endoluminal stent graft procedure using interventional radiology with Seldinger's technique. Adequate amount of blood is required for surgery.

   

• Immediate diagnosis by ultrasound.
• Resuscitation.
• Massive blood transfusions (10–15 bottles).
• Emergency surgery is the only life saving procedure in these cases.

   

• Is commonest (70%).
• 65% are bilateral.
• 25% cases are associated with abdominal aortic aneurysm.
• 75% causes complications in 5 years.

• Swelling in popliteal region which is smooth, soft, pulsatile, well localised, warm, and compressible, often with thrill and bruit. It may mimic a pyogenic abscess.
• Thrombosis and emboli from popliteal aneurysm can cause distal gangrene which may be spreading proximally and may lead to amputation.
• Rupture may cause torrential haemorrhage.

• Duplex scan, angiogram.
• CT scan/CT angiogram.
• MRI/MR angiogram.

• Repair with arterial graft using PTFE, dacron.
• Endoluminal stenting.
• Aneurysmorrhaphy.

 

• Hypertension (It is associated in 80% of dissecting aneurysms).
• Cystic medial necrosis.
• Marfan's syndrome and collagen diseases.
• Trauma.
• Weakening of the elastic layers of the media due to shear forces.

• It is always seen in thoracic aorta, common in ascending aorta. (70%).
• It is uncommon in other part of aorta or other vessels.
• It can occur in aortic arch or thoracic descending aorta.
• This dissected aortic channel gets lined by endothelium, often re-opens distally into the aorta causing double-barreled aorta which in fact prevents complications.
• It is commonly associated with aortic insufficiency.

 

• Acute.
• Chronic.
• Healed dissecting aneurysm which communi-cates distally again to aorta as double barreled aorta.

• Pain in the chest, back which is excruciating.
• Features of ischaemia due to blockage of different vessels.

• Chest X-ray shows mediastinal widening.
• Arterial Doppler.
• Angiogram.

• Progressive disease
• Significant ischaemia
• Impending rupture.

       

1. Colour changes: Pallor, greyish, purple, brownish black due to disintegration of haemoglobin to sulphide.
2. Absence of pulse, loss of sensation, loss of function,
3. Line of demarcation between viable and dead tissue by a band of hyperaemia and hyperaesthesia with development of a layer of granulation tissue.
   In dry gangrene separation occurs by aseptic ulceration with minimum infection and gangrene is dry, and mummified.
   In moist gangrene separation takes place by septic ulceration. Often demarcation is vague with skip lesions more proximally and so landing with higher level of amputations. Even after amputation skin flap may show die back process, leading to failure of taking up of flap of amputation and so require still higher level of amputation.
4. Proximal ischaemic features may be present with rest pain, colour changes, hyperaesthesia— pregangrene.

   

• Hb%, blood sugar.
• Arterial Doppler, angiogram (Seldinger's technique).
• U/S abdomen to find out the status of aorta.

   

• Drugs: Antibiotics, vasodilators, pentoxiphylline, praxilene, dypyridamole, small dose of aspirin, ticlopidine.
• Care of feet and toes:
  • The part has to be kept dry.
  • Any injury has to be avoided.
  • Proper footwear is advised (Microcellular rubber footwear, MCR).
  • Measures for pain relief is taken.
  • Nutrition supplementation is done.
  • The limb should not be heated.
  • Pressure areas has to be protected.
  • Localised pus has to be removed.
• Cause has to be treated.
• Diabetes has to be controlled.
  71
• Surgeries to improve the limb perfusion: Lumbar sympathectomy, omentoplasty, profundaplasty, femoropopliteal thrombectomy or endarterectomy, arterial graft bypass are done according to the need.

 

• Below-knee amputation is a better option as BK prosthesis can be fitted better and also the movements of knee joint are retained. There is no need of external support and limp is absent.
• In above-knee amputation range of movements is less, limp is present and often requires third (stick) support to walk.
• Different amputations done are Ray ampu-tation, below-knee amputation (Buerges's amputation), Gritti-Stokes transgenial ampu-tation, above-knee amputation.

   

• Callosities, ulceration.
• Abscess and cellulitis of foot.

• Osteomyelitis of different bones of foot like metatarsals, cuneiforms, calcaneum.
• Diabetic gangrene.
• Arthritis of the joints.

 

• High glucose level in tissues is a good culture media for bacteria. So infection is common.
• Diabetic microangiopathy causes blockade of microcirculation leading to hypoxia.
• Diabetic neuropathy: Due to sensory neuropathy, minor injuries are not noticed and so infection occurs. Due to motor neuropathy, dysfunction of muscles, arches of foot and joints, and loss of reflexes of foot occurs causing more prone for trauma, abscess, etc. Due to autonomic neuropathy, skin will be dry, causing defective skin barrier and so more prone for infection.
• Diabetic atherosclerosis itself reduces the blood supply and causes gangrene. Thrombosis can be precipitated by infection causing infective gangrene. Blockage occurs at plantar, tibial, and dorsalis pedis vessels.
• Increased glycosylated haemoglobin in blood causes defective oxygen dissociation leading to more hypoxia. At tissue level there will be increased glycosylated tissue proteins, which prevents proper oxygen utilisation and so aggravates hypoxia.

 

• Pain in the foot.
• Ulceration.
• Absence of sensation.
• Absence of pulsations in the foot (Posterior tibial and dorsalis pedis arteries).
• Loss of joint movements.
• Abscess formation.
• Change in temperature and colour when gangrene sets in.

 

• Blood sugar, urine ketone bodies.
• Blood urea and serum creatinine.
• X-ray of part to see osteomyelitis.
• Pus for culture and sensitivity.
  72
• Doppler study of lower limb to assess arterial patency
• Angiogram to see proximal blockage
• U/S abdomen to see status of abdominal aorta.

 

• Antibiotics—decided by pus C/S.
• Regular dressing.
• Drugs: Vasodilators, pentoxiphylline, dipyridamole, small dose of aspirin.
• Diabetes has to be controlled by insulin only.
• Diet control, control of obesity.
• Surgical debridement of wound.
• Amputations of the gangrenous area. If blood supply is not present, then below knee or above knee amputation may be required. Level of amputation has to be decided by skin and temperature changes or Doppler study.
• Care of feet in diabetic:
  • Any injury has to be avoided.
  • MCR foot wears must be used.
  • Feet has to be kept clean and dry, especially the toes and clefts.
  • Hyperkeratosis has to be avoided.

 

• It is due to exposure to cold wind or high altitude.
• It is common in old age during cold spells.
• Damage to vessel wall causes oedema, blistering, gangrene formation.
• Part is painless and waxy.
• Treatment: Gradual warming is done. Part should be wrapped with cottonwool and rested. Warm drinks, analgesics, paravertebral injections to sympathetic chain, hyperbaric oxygen are effective.

 

• Commonly affects males (can also occur in females)
• Common in blacks, in Negroes.
• History of running barefoot in childhood is common.
• Fifth toe is commonly affected. A fissure develops in interphalangeal joint which becomes a fibrous band that encircles the digit causing necrosis. (Gangrene of little toe).
• Often it is bilateral.
• Treatment: is early ‘Z’ plasty. Amputation is often required later. Commonly autoamputation occurs.

 

Name:

Address:

Age:

 

• Pain in the leg/thigh/foot with the duration of pain and side.
• Swelling/dilated veins in the leg and its duration.
• Pigmentation/ulceration in the leg with duration.

     

• Pain in the leg/foot/or thigh with duration. Origin of pain, its severity, nature of onset whether acute or insidious has to be asked.
• Character of pain: Dull aching or cramping should be asked. Whether pain gets aggravated by walking/standing should be noted. Dull aching pain along the line of the vein is typical and usually aggravates in the evening and gets relieved by lying down. Pain in calf of short duration, may be due to co-existing deep vein thrombosis (DVT).
• Pain also can be due to ulcer/periostitis/infection.

 

• It is due to stasis and release of chemicals and usually occurs around ankle region.
• It is associated with itching and often ulceration.

 

• History: Mode of onset, duration, site of onset. Ulcer on the medial aspect of the ankle is due to long saphenous vein varicosity; on the lateral aspect is due to short saphenous vein varicosity.
• Discharge from ulcer: Its type, smell, quantity signifies the severity of the infection.
• Itching and bleeding in the ulcer bed are also important.

 

• History suggestive of earlier deep vein thrombosis like pain, calf swelling and fever.
• History of immobilisation, hospitalisation.
• History of any previous surgery.

 

• History of previous surgery for varicose vein, drug intake like warfarin for DVT, injection therapy—sclerotherapy, wearing stockings/crepe bandages.

 

• In females, history of pregnancy, delivery and postdelivery period, oral contraceptive intake.
• Smoking/alcohol/working pattern.

 

• Often varicose veins are familial, which are bilateral and severe, observed in young individuals. There are absent/defective valves in these patients.
  74

   

• Limb is looked for dilated long saphenous vein on the medial side and for short saphenous vein on posterior and lateral side. Other communicating veins are also looked for.
• Beginning of the varicosity in the foot, later its extent above also should be examined. Great saphenous vein tortuosity often extends into the thigh whereas short saphenous vein varicosity ends at popliteal region.
• Always limb is looked for skin changes, pigmentation, oedema, ankle flare, and ulcer. Cough impulse at saphenous opening (Morrisey's) may be significant.
• Extent, size, shape, margin, edge and discharge in an ulcer should be noted.

 

• Ulcer, if present should be described with tenderness, induration, warmness, mobility, fixity to the underlying bone, etc.
  

  Figs 1.125A and B: Bilateral varicose.
• Brodie-Trendelenburg test
  Vein is emptied by elevating the limb and milking the vein in lying down position; a tourniquet is tied just below the saphenofemoral junction (or saphenofemoral junction can be occluded using a thumb). Saphenous opening is located 3.5 cm below and lateral to the pubic tubercle. Pubic tubercle is palpated along the adductor longus tendon which is identified by adducting the thigh against resistance. Patient is asked to stand quickly. When tourniquet or thumb is released, rapid filling from above signifies sapheno femoral incompetence. This is Trendelenburg test I.
  In Trendelenburg test II, vein is emptied again in lying down position and tourniquet is applied at sapheno-femoral junction. After standing without releasing the tourniquet, the limb is observed. Filling of blood from below upwards rapidly can be observed within 30–60 seconds. It signifies perforator incompetence.75
  

  Figs 1.126A and B: Long saphenous vein varicosity. Note the prominent of veins and blow outs. Note the diagrammatic representation of varicose veins.

  

  Figs 1.127A to C: Emptying of the superficial varicose vein is important in all tourniquet tests for varicose veins. It is done in lying down position with elevating and milking the vein. Emptying is not done in modified Perthes' test. Note the marking of the saphenofemoral junction before applying the tourniquet.

  76
  

  Figs 1.128A and B: Note the site of applying the tourniquet at sapheno-femoral junction. It is 3.5 cm below and lateral to pubic tubercle.

  

  Fig. 1.129: Tourniquet test. After emptying the vein by elevating the leg and milking, tourniquet is applied. Patient is asked to stand, tourniquet is released immediately and saphenous vein is observed. Rapid filling of vein from above signifies LSV varicosity with sapheno-femoral incompetence.
• Three/multiple (Oschner's Mahoner's test) tourniquet test: To find out the site of incompetent perforator, three tourniquets are tied after emptying the vein—
  1. At sapheno-femoral junction.
  2. Above knee level.
  3. Another below knee level.
  4. Additional tourniquets often may be applied at below-knee and above ankle level.

• Schwartz test: In standing position, when lower part of the vein in leg is tapped, impulse is felt at the saphenous junction or at the upper end of the visible part of the vein. It signifies continuous column of blood and valves between two fingers are incompetent due to valvular incompetence. It signifies continuous column of blood and also signifies. Positive test is usually found in gross venous varicosity.
• Pratt's test: Esmarch bandage is applied to the leg from below upwards with a tourniquet tied at saphenofemoral junction. The bandage is released after that to see the ‘blow outs’ as perforators.
• Fegan's test: Line of varicose vein is marked. On standing, the site where the perforators enter the deep fascia bulges and these points are also marked. In lying down, button like depressions (crescentric gaps) in the deep fascia are felt at the marked out points which confirms the perforator site.
• Ian-Aird test: On standing, proximal segment of long saphenous vein is emptied with two fingers. Pressure from proximal finger is released to see the rapid filling from above which confirms saphenofemoral incompetence.
• Perthes' test: The affected lower limb is wrap-ped with elastic bandage and the patient is asked to walk around and exercise. Development of severe crampy pain in the calf signifies DVT.
• Modified Perthes' test: Tourniquet is tied just below the sapheno femoral junction without emptying the vein. Patient is asked to do a brisk walk which precipitates bursting pain in the calf and also makes superficial veins more prominent. It signifies DVT.
  DVT is contraindicated for any surgical intervention of superficial varicose veins. It is also contraindicated for sclerosant therapy.
• Homan's test is dorsiflexion of the foot to elicit pain in the calf and Mose's sign is squeezing the relaxed calf muscles sidewards to elicit pain. Both tests signify deep vein thrombosis (DVT).78
  Point to be remembered is that in case of acute DVT, Homan's/Mose's tests should not be done as it will precipitate the dislodgement of the clot and embolism.
• Bone thickening in the shin (tibia and ankle) is important which signifies periostitis.
• Measurement limb length and girth is needed especially in arterio-venous malformation with varicose veins and also to find out deformities.

       

1. Venous Doppler: With the patient standing; the Doppler probe is placed at saphenofemoral junction and later wherever required. Basically by hearing the changes in sound, venous flow, venous patency, and venous reflux can be very well-identified.

2. Duplex scan is a highly reliable U/S Doppler imaging technique (Here high resolution B mode ultrasound imaging and Doppler ultrasound is used) which along with direct visualisation of veins, gives the functional and anatomical information, and also colour map. Examination is done in standing and lying down position and also with valsalva maneuver. Hand held Doppler probe is placed over the site and visualised for any block and reversal of flow. DVT is very well- identified by this method.
   

   Fig. 1.131: Doppler machine used for varicose veins and DVT.
3. Venography
   • Ascending venography was a very common investigation done earlier to Doppler period.
     A tourniquet is tied above the malleoli and the vein of dorsal venous arch of foot is cannulated.79
     

     Fig. 1.132: Doppler showing DVT in leg. Deep vein thrombosis is contraindicated for varicose vein surgery.

     

     Fig. 1.133: U/S showing IVC thrombosis.
     Water soluble dye injected, flows into the deep veins (because of the applied tourniquet). X-rays are taken below and above knee level.
     Any block in deep veins, its extent, perforator status can be made out by this.
     Note: In the presence of Duplex scan ascending venography is not necessary investigation.
     If DVT is present, surgery or sclerotherapy are contraindicated.
   • Descending venogram is done when ascending venogram is not possible and also to visulalise incompetent veins. Here contrast material is injected into the femoral vein through a cannula in standing position. X-ray pictures are taken to visulalise deep veins and incompetent veins.
4. Plethysmography.
5. Ambulatory venous pressure.
6. Arm-foot venous pressure (Foot pressure is not more than 4 mmHg above the arm pressure).
7. U/S abdomen, peripheral smear, platelet count, and other relevant investigations are done depending on the cause of the varicose veins. If venous ulcer is present, then the discharge is collected for culture and sensitivity, biopsy from ulcer edge is taken to rule out Marjolin's ulcer, plain X-ray of the part is taken to find out periostitis.

 

• Haematocrit, blood urea, serum creatinine, blood sugar.
• Chest X-ray, ECG.

   

1. Elastic crepe bandage application from below upwards or use of pressure stockings to the limb.
2. Diosmin therapy which increases the venous tone.
3. Elevation of the limb.

 

1. Sapheno-femoral incompetence.
2. Varicose veins with venous ulcer.
3. DVT.

1. It can be done as an out patient procedure.
2. It does not require anaesthesia.

 

1. Trendelenburg operation: It is juxta-femoral flush ligation of long saphenous vein (i.e. flush with femoral vein), after ligating named (superficial circumflex, superficial external pudendal, superficial epigastric vein) and unnamed tributaries. All tributaries should be ligated otherwise recurrence occurs and retained stump of the vein becomes tortuous and dilated (saphena varix).
   

   Fig. 1.135: Incision for Trendelenburg operation is on below and medial aspect of the inguinal ligament at the level of the sapheno-femoral junction. Long saphenous vein is identified and ligated flush with femoral vein.
   81
2. Stripping of vein: Using Myer's stripper vein is stripped off. Stripping from below upwards is technically easier. Immediate application of crepe bandage reduces the chance of bleeding and haematoma formation.
   

   Figs 1.136A and B: Myer's stripper. Note the stripper and olive tip.
   Complication: Injury to saphenous nerve causing saphenous neuralgia.
   Stripping is not usually done for the veins in the lower part of the leg.
   

   Figs 1.137A to C: Note the stripper in place inside the vein and stripped vein entangled to stripper.

   

   Fig. 1.138: Diagrammatic representation of stripping vein.
   82
3. Subfascial ligation of Cockett and Dodd
   Perforators are marked out by Fegan's method. Perforators are ligated deep to the deep fascia through incisions in antero-medial side of the leg.
4. Ligation of short saphenous vein at saphenopopliteal junction. Stripping of the short saphenous vein is better. It is done using a rigid stripper.
5. Removal of superficial varicose veins by hook phlebectomy.
6. Linton's approach is vertical skin incision approach in the calf to do perforator ligation subfascially.
7. Contraindication for surgery: Deep vein thrombosis (DVT).

 

• Radiofrequency ablation (RFA) method (VNUS closure method) (VNUS medical technologies Inc; Sunnyvale, CA, USA) (by Goldman 2000): This procedure is done under general or regional anaesthesia. A RFA catheter is passed into long/short saphenous vein near sapheno-femoral or sapheno-popliteal junction under guidance. 85°C temperature is used for longer period of time to cause endothelial damage, collagen denaturation and venous constriction. Phlebectomy is done while withdrawing the catheter.
• TRIVEX method—By subcutaneous illumination, a large quantity of fluid is injected percutaneously to identify the superficial veins. Superficial veins are removed using suction.
• Subfascial endoscopic perforator ligation surgery (SEPS)—is becoming popular.
• Endo-venous laser ablation (EVLA): It is done as an OP procedure or as day- care surgery. Patient lies supine with diseased leg flexed, hip externally rotated and knee flexed. With aseptic precaution, under U/S guidance LSV is cannulated above the knee and a guide wire is passed beyond SFJ and 5-French catheter is passed over guide wire and tip is placed 1 cm distal to the junction. 200 ml of 0.1 % lignocaine is infiltrated along the length of the LSV. Laser fibre is inserted up to the tip of the catheter and catheter is withdrawn for 2 cm and laser fibre protrudes for 2 cm. Laser fibre is fired step by step using diode laser one second withdrawal in 2 seconds. Once procedure is over catheter is removed and pressure bandage is applied for 2 weeks. Heat produced (729°C at tip) by the laser produces steam bubbles with thermal damage of endothelium leading into occlusion of the vein.

   

• It is more common in females (10:1). It is much more common in females with a family history.
• Often it is familial.
• Familial varicose veins begin in younger age group and are seen bilaterally, involve all veins including deep veins.
• Visible dilated veins in the leg with pain, distress, nocturnal cramps, feeling of heaviness, pruritus.
• Pedal oedema, pigmentation, dermatitis, ulceration, tenderness, restricted ankle joint movement.
• Bleeding, thickening of tibia occurs due to periostitis.
• Positive cough impulse at the sapheno-femoral junction.

 

1. Primary varicosities are due to—
   • Congenital incompetence or absence of valves.
   • Weakness or wasting of muscles.
   • Stretching of deep fascia.
2. Secondary varicosities are due to—
   • Recurrent thrombophlebitis.
   • Occupational—standing for long hours.
   • Obstruction to venous return like abdo-minal tumour, retroperitoneal fibrosis, lymphadenopathy.
   • Pregnancy (due to progesterone hormone).
   • A-V malformations—congenital or acquired.
   • IVC/Iliac vein thrombosis.

       

• Area where venous ulcer commonly develops is around and above the medial malleoli because of presence of large number of perforators which transmit pressure changes directly into superficial system. This area is called as Gaiter's zone. It can be seen on both malleoli.
• Ulcer is often large, nonhealing, tender, recurrent with secondary infection. Vertical group of inguinal lymph nodes are usually enlarged and tender.
• Often it leads to scarring, ankylosis, Marjolin's ulcer formation. Slough from the ulcer bed may give way causing venous haemorrhage.
• Periostitis is common which also prevents ulcer from healing.
• Due to regular walking on toes so as to get relief from pain causes contraction and extra-articular fibrosis of Achilles tendon. Proper exercise is the remedy – talipes equino varus.

 

• Discharge from the ulcer for C/S.
• X-ray of the area to look for periostitis.
• Biopsy from the ulcer edge to rule out Marjolin's ulcer.

 

• Pressure bandage (crepe bandage). Multilayered (four) pressure bandage with pressure of 45 mmHg is also very useful. This optimum pressure promotes the ulcer healing without injuring the leg.
• Care of ulcer by regular cleaning with povidone iodine, H₂O₂.
• Dressing with EUSOL. (EUSOL is Edinburgh university solution of lime containing boric acid, hypochlorite, and calcium hydroxide).
• Antibiotics depending on C/S of the dis-charge.
• Once ulcer bed granulates well, split skin graft (SSG, Thiersch graft) is placed.
• Specific treatment for varicose veins should be undertaken—Trendelenburg's operation, stripping of veins, perforator ligation.

 

1. Long saphenous vein varicosity.
2. Short saphenous vein varicosity.
3. Varicose veins due to perforator incompetence.
   

   Figs 1.145A and B: Tortuous, elongated dilated long saphenous vein.

   

   Figs 1.146A and B: Photo of short saphenous vein varicosity and its diagrammatic location.
   86
4. Thread veins (dermal flares): Are small varices in the skin usually around ankle which look like dilated, red or purple network of veins. <3 mm in size.
5. Reticular varices: Are slightly larger than thread veins located in subcutaneous region. >3 mm in size.
6. Combinations of any of above.

   

• Ankle perforators (May or kuster).
• Lower leg perforators I, II, III (of Cockett).
• Gastrocnemius perforators (of Boyd).
• Mid thigh perforators (Dodd).
• Hunter's perforator in the thigh.

     

1. Arterial pressure across the capillary increases the pumping action of vein.
2. Calf musculovenous pump: During contraction phase of walking, pressure in the calf muscles increases to 200–300 mmHg. This pumps the blood towards the heart. During relaxation phase of walking, pressure in the calf falls and so it allows blood to flow from superficial to deep veins through perforators. Normally while walking, pressure in the superficial system at the level of ankle is 20 mmHg.
3. During walking, foot pump mechanism propels blood from plantar veins into the leg.
4. Gravity.

   

• Stasis.
• Hypercoagulability.
• Vein wall injury.

 

1. Following childbirth.
2. Trauma.
3. Muscular violence.
4. Immobility.
5. Debilitating illness, obesity, bed rest, pregnancy, puerperium, oral contraceptives, and estrogens.
6. Postoperative thrombosis: Common after the age of 40 years. Incidence following surgeries is 30%. In 30% of cases both legs are affected. Usually seen after prostate surgery, hip surgery, major abdominal sur-geries, gynaec surgeries, cancer surgeries. Bedridden for more than 3 days in the postoperative period increases the risk of DVT.
7. Spontaneous thrombosis is common in visceral neoplasm like carcinoma pancreas or carcinoma stomach. It is often migrating type.
8. Thrombus may start in a venous tributary which eventually may extend into the main vein causing DVT.
9. Axillary vein thrombosis can occur spontaneously, following compression by cervical rib, by various causes of thoracic inlet syndrome, or arm being in the hyper abduction state for prolonged period (e.g painting the ceiling), after axillary lymph node block dissection, after radiotherapy to axilla, occasionally as a complication of venous cannulation.
10. Polycythaemia vera, thrombocytosis.
11. Deficiencies of antithrombin III, protein C, protein S.

 

1. Pelvic veins: Common.
2. Leg veins: Common in femoral and popliteal veins—(Common on left side).
3. Upper limb veins: Not uncommon (Axillary vein thrombosis).

     

• Fever—earliest and common symptom.
• Pain and swelling in the calf and thigh (often). Commonly associated with fever. Pain is often so severe that the patient finds difficult to flex (or move) the leg.
• Leg is tense, tender, warm, pale or bluish with stretched and shiny skin.
• Positive Homan's sign: Passive forceful dorsiflexion of the foot with extended knee will cause tenderness in the calf.
• Mose's sign: Gentle squeezing of lower part of the calf from side to side is painful. Gentleness is very important otherwise it may dislodge a thrombus to form an embolus.
• Neuhof's sign: Thickening and deep tenderness is elicited while palpating deep in calf muscles.
• Most often, DVT is asymptomatic and presents suddenly with features of pulmonary embolism like chest pain, breathlessness and haemoptysis.

 

1. Venous Doppler.
2. Duplex scanning.
3. Venogram.
4. Radioactive I¹²⁵ fibrinogen study.
5. Haemogram with platelet count.

 

1. Rest, elevation of limb, bandaging the whole limb with crepe bandage.
2. Anticoagulants: Heparin, warfarin, phenindione.
3. For fixed thrombus: Initially high dose of heparin of 25,000 units/day for 7 days has to be given. Later patient is advised to continue with warfarin for 6 months. Low molecular heparin can also be used. Dose is controlled by assessing Activated Partial Thromboplastin Time (APTT). Duration of heparin treatment is usually for 5 days.
4. For free thrombus: Fibrinolysins-Strepto- kinase or urokinase or tissue plasminogen activator are used to dissolve thrombus (It should not be given when patient is on heparin).
5. Venous thrombectomy is done using Fogarty venous balloon catheter.
6. Thrombotic emboli is prevented from reaching the heart by filtering it at IVC level using Kim ray Greenfield filter, suture sieve plication, stapler plication, vena caval ligation, Mobin Uddin umbrella filter.
7. Palma operation: In iliofemoral thrombosis, common femoral vein below the block is communicated to opposite femoral vein through opposite long saphenous vein.
8. May-Husni operation: When blockage is in popliteal vein, popliteal vein below the block is anastomosed to long saphenous vein (end to end) so as to by pass the blood across popliteal block.

 

1. Care has to be taken to see for proper positioning of legs with no pressure on the calf muscles.
   89
2. Pressure bandage to the legs has to be applied during major surgeries, laparoscopic surgeries. During postoperative period, elevation, massaging, pressure bandage, early ambulation, maintaining hydration are essential measures.
3. Low dose heparin is given in suspected cases, in major surgeries and continued during post operative period till the patient is ambulated. 5000 units is given subcutaneously 2 hours before surgery.
4. Various measures like graduated static compression, elastic stockings, electrical stimulation of calf muscles, pneumatic compression are used to prevent sluggish flow of blood.
5. Intravenous dextran 70, 500 ml during surgery and another 500 ml postoperative period in 24 hours can also be used to prevent DVT.

   

• It is a natural anticoagulant, a mucopolysaccharide.
• It prevents clotting of blood both in vivo and in vitro by acting on all three stages of coagulation. It prolongs clotting time and activated thromboplastin time in specific (by 1.5–2.0 times the control).
• Heparin also causes hyperkalaemia.
• Commercial heparin is derived from lung and intestinal mucosa of pigs and cattle.
• The onset of action is immediate after administration and lasts for 4 hours.
• It is metabolised in the liver by heparinase.
• It does not cross placental barrier and not secreted in breast milk.

 

• As prophylaxis in major surgeries, post- operative period, puerperium.
• As therapy in DVT.

 

• For prophylaxis: 5,000 units/SC ly. 8th hourly.
• For therapy: 10,000 units/IV ly. 6th or 8th hourly. Later change to subcutaneous dose.
• In severe cases, 5000 units to 20,000 units is given daily through IV infusion at a rate of 1000 units per hour. Daily dose should not exceed 25,000 units.

     

• They are absorbed more completely.
• Have a longer duration of action.
• Have a better anticoagulant effect.
• Less interaction with platelets.
• Less antigenic.
• Usage is easier and acceptable.

     

1. Coumarin derivatives: Bishydroxycoumarin (Dicoumarol)— First coumarin drug derived from sweet clover.
   Warfarin sodium: Commonest oral anticoagulant used.
2. Indandione derivative:
   • Phenindione.
   • Anisindione.

 

• By suppressing synthesis of prothrombin, factors VII, IX, and X.
• By inhibiting carboxylation of glutamic acid through vitamin K.

 

• Oral anticoagulant does not have in vitro action.
• They are slow acting, and long acting.
• Control of oral anticoagulant therapy is by monitoring prothrombin time.
• PT comes to normal only 7 days after cessation of the drug.
• They cross placental barrier and known to cause teratogenicity when given in 1st trimester.
• They are secreted in breast milk.

 

• In DVT, for maintenance therapy after cessation of heparin.
• After valve replacement surgery.

 

1. Bleeding: It may require blood transfusion to control.
2. Cutaneous gangrene.
3. Fetal haemorrhage and teratogenicity.
4. Alopecia, urticaria, dermatitis.
5. Drug interactions: With NSAIDs, cimetidine, omeprazole, metronidazole, cotrimoxazole, erythromycins, barbiturates, rifampicin, griseofulvin.

       

• Swelling in the right/left breast/both breasts; its time duration.
• Pain in the breast with duration.
• Ulceration in the breast with duration.
• Discharge from nipple.
• Ulceration over the breast/swelling.
• Swelling in the axilla/neck.

                   

• Examine both breasts.
• American cancer society recommends monthly BSE after 20 years of age.
• Remind the patient that 90% of breast lumps are not cancer.
• Better way is in lying down position with arm raised with a mattress support behind.
• Palpation is done over all quadrants of the breast using the fingers.
• If any doubtful swelling is palpable, consult the surgeon.
• Nursing mother should perform BSE just after feeding the baby.

 

Stage A —	No skin oedema, ulceration, or fixation to chest wall. Axillary nodes are not clinically involved.
Stage B —	Clinically involved axillary nodes less than 2.5 cm in diameter. Not fixed.
Stage C —	Grave signs of comparatively advanced carcinoma. Oedema of skin, skin ulceration, fixation to chest wall Massive axillary involvement with nodes > 2.5 cm in diameter Axillary fixation.
Stage D —	Advanced carcinoma including two or more signs in stage C. In addition satellite nodules, supraclavicular nodes. Inflammatory cancer, arm oedema or distant metastasis.

     

• For screening purpose it is done after 40 years. Early screening is indicated when there is family H/o carcinoma breast or histological risk factor. Mammography before 25 yr of age is usually not done unless there is a lump or a strong family history.
• In obese patients.
• To find out spread or de novo tumour in the opposite breast.
• Mastalgias.
• Mammography guided biopsy can be done.
• Evaluation and follow up in benign breast disease with malignant potential.
• Follow up mammography after conservative breast surgery.

 

• To look for whether the lesion is solid or cystic, margin of the lesion, internal echoes, retro-tumour acoustic shadowing, compressibility, dimensions.
• Irregular margin, irregular internal echoes, irregular posterior shadowing, non-compressibility, ratio between antero-posterior to width (lateral/horizontal) dimensions more than 1 are the features of carcinoma. Doppler will show high frequency signals with continuous flow.
• Benign lesions are smooth, rounded with well-defined margins with weak internal echoes and compressibility.
• Disadvantage is lesions less than 1 cm may not be identified.
• FNAC can be done under U/S guidance.
• It is cheaper, easily available and there is no risk of radiation.
• It is preferred method of screening in pregnancy and early lactation.

             

• They are estrogen sensitive receptors, which are cytosolic glycoprotein present in the breast and tumour tissue. It is an important indicator of prognosis of carcinoma breast.
• Tissue for receptor study is sent in low temperature in ice flasks. It is assessed by quantitative analysis. (Frozen −70°).
• If value is more than 10 units (Femto mols) per ng gram tissue it is called as ER +ve status. If value is 5–9 it is borderline and if it is less than 5 femtomoles per nanogram tissue it is called as ER –ve status.

• Prognosis is good.
• Hormone therapy including Tamoxifen is very beneficial.
• Response to treatment is better.

• Prognosis is poor.
• Hormone therapy is not very beneficial (but used) as compared to ER +ve patients.
• Response to treatment is not good.

   

• To differentiate scar from recurrence.
• To image breasts of women with implants.
• To evaluate the axilla and recurrent disease.
• Both pre contrast and post contrast MRI are done. T1 and T2 weighed images are taken
• Irregular mass with spiculations, changes in skin and nipple, lymphoedema are the findings in carcinoma breast.

     

• Carcinoma breast.
• Carcinoma penis.
• Malignant melanoma.

   

1. Clinical assessment.
2. Radiological imaging.
3. Cytological or histological analysis.
   109

       

• Curvilinear nonradial incisions (Do not place radial incisions, as if there is a need to convert into total mastectomy, then incision plan may be difficult).
• Separate incision for axillary dissection.

• Try to avoid undermining of the skin flap
• Confirm tumour clearance by frozen section. It may be often difficult and so tumour is cut and only margin which is close and doubtful is advocated for frozen section.
• Radiotherapy is a must to breast and chest wall region (locally)

   

• It is like a key-hole surgery of breast
• Skin sparing/limited skin excision (5–10%) will not alter/affect the recurrence rate.
• Indications are— central tumour/multicentral/extensive intraductal/T1/not feasible for conservation.
• Excision of nipple—areola complex with very limited skin removal.

• Marginal skin excision over the tumour/biopsy site.
• Total glandular mastectomy.
• Axillary dissection using either same (extension of SSM incision) or separate incision in the axilla.

 

• When tumour is more than 4 cm.
• Multicentric tumour.
• Poorly differentiated tumour.
• Tumour margin is not clear of tumour after breast conservative surgery.

     

• Injury/thrombosis of axillary vein
• Seroma—50%.
• Shoulder dysfunction 10%.
• Pain (30%) and numbness (70%).
• Flap necrosis/infection.
• Lymphoedema(15%) and its problems
• Axillary hyperesthesia (0.5–1%).
• Winged scapula.

     

1. Simple (total) mastectomy: Along with the tumour, entire breast, areola, nipple, skin over the breast, including axillary tail are removed. There is no axillary dissection. Often the patient is later subjected to radiotherapy (external) to axilla.

   CMF regime	CAF regime	MMM regime
   Cyclophosphamide 600 mg/sq m.	Cyclophosphamide	Methotrexate.
   Methotrexate 40 mg/sq m	Adriamycin 50 mg/sq m	Mitomycin C.
   5-Fluorouracil 500 mg/sq m	5-Fluorouracil	Mitozantrone.

   CMF is commonly used.
   All regimes are given in monthly cycles/3 weekly for 6 months.
   Toxic effects are: Alopecia, bone marrow suppression, cystitis, megaloblastic anaemia, GIT disturbances, and nephritis.
   113
2. Simple mastectomy with axillary clearance: Commonly used procedure. Total mastectomy is done along with removal of axillary fat, fascia and lymph nodes.
3. Modified radical mastectomy (MRM)
   1. Patey's operation: Commonly done. Here along with tumour, entire breast, overlying skin, nipple, areola, fat, fascia and level I, II and III lymph nodes of axilla are removed. Pectoralis minor is divided from its origin or removed completely, (so as to have good assess to the upper part of axilla and also to clear the interpectoral nodes of Rotter, which are commonly involved) but pectoralis major is retained so as to have better cosmetic result.
   2. Scanlon's operation: Is a modified Patey's operation wherein instead of removing pectoralis minor, it is incised to approach the affected Level III lymph nodes.
   3. Auchincloss operation: Here pectoralis minor muscle is left intact and level III lymph nodes are not removed.
      

      Fig. 1.190: Stewart incision for mastectomy.

      

      Fig. 1.191: Gray incision for mastectomy in carcinoma breast which extends to opposite side.

      

      Fig. 1.192: Greenough's incision for mastectomy.

      

      Fig. 1.193: Other incision often used for total mastectomy—horizontal incision.
      114
      

      Fig. 1.194: Kocher's incision for mastectomy.

      

      Fig. 1.195: Orr incision for mastectomy.

      

      Fig. 1.196: Rodman's incision for mastectomy.
4. Halsted Radical Mastectomy.^*[Complete Halsted)[R M):

   In radical mastectomy (Halsted)-

   Structures removed are:

   • Tumour
   • Entire breast, nipple, areola, skin over the tumour with margin
   • Pectoralis major and minor muscles
   • Fat, fascia, lymph nodes of axilla
   • Few digitations of serratus anterior.

   Structures retained are

   • Axillary vein,
   • Bells nerve (nerve to serratus anterior)
   • Cephalic vein.
   ^*Not commonly done at present.
   Complications are lymphoedema and eventual lymphangiosarcoma (after 3 to many years later) of the limb.
   

   Fig. 1.197: Note the original Halsted and modified Halsted incision.

   

   Fig. 1.198: Other incision used for radical and often modified radical mastectomy. Note the extension of the incision into the anterior axillary fold.
   115
   

   Fig. 1.199: Complete Halsted operation—radical mastectomy with removal of fat, lymph nodes, pectoralis major, pectoralis minor, entire breast with tumour and skin over the breast, nipple and areola.
5. Conservative breast surgeries: Tumour is removed with a rim of 1 cm of normal tissue. It may be
   1. Wide excision.
   2. Lumpectomy.
   3. Quadrantectomy as part of Quart Therapy- Entire segment of the involved breast is removed along with axillary dissection (done through a separate incision in the axilla, level I and either level II or level III removal) and radiotherapy.
6. Toilet mastectomy: In locally advanced tumour, tumour with breast tissue and whatever possible is removed to prevent further fungation. But its use and significance is under question.
7. Extended Radical Mastectomies: It includes Radical mastectomy + removal of internal mammary lymph nodes of same side with or without opposite side. It is not done at present.

   

• Specimen is sent in formalin for histology.
• It is sent in saline in low temperature for ER/PR/Her 2 neu status study (histochemistry).116
  

  Figs 1.200A to E: Different steps of Patey's mastectomy with incision, flap raise, dissection in breast and axilla and specimen after surgery.
• Tumour grading, tumour clearance, nodal involvement—its number and capsular breach are assessed histopathologically.

 

• It is an antiestrogen. It blocks cytosolic estrogen receptors.
• Dose is 20 mg daily for 5 years.

• Tamoxifen flare—flushing, tachycardia, sweating.
• Occasionally it causes bone pain associated with hypercalcaemia, particularly in patients with bone metastasis.
• It increases the incidence of endometrial cancer.

• It reduces the recurrence rate by 25%.
• It improves the prognosis.
• It is used presently in all age group, ER +ve and ER –ve patients; even though it is more 117effective in ER + ve patients and perimenopausal age group.
• Cheap, easily available, less toxic effects, very effective.
• It is equally effective in carcinoma male breast.

 

• Do not cause endometrial hyperplasia or endometrial carcinoma.
• Drugs include Raloxifen, Tormefin.

 

• It means locally advanced tumour with muscle/chest wall involvement, extensive skin involvement or fixed axillary nodes. It will be T3, T4a, T4b, T4c or T4d or N2 or N3.
• It is investigated by FNAC of tumour, mammography of opposite breast, chest CT, CT abdomen or whole body bone scan.
• Treatment of LACB is always palliative by simple mastectomy, chemotherapy and hormone therapy using tamoxifen.
• Palliation is to control pain, to prevent fungation or bleeding.
• In inoperable fixed tumour initial chemotherapy is given. Later, after 3–4 cycles of chemotherapy, when tumour size reduces and becomes operable, total mastectomy is done.
• Postoperative radiotherapy is given to breast field and axilla.
• Usually axillary dissection is not necessary in LACB.
• Only chemotherapy and radiotherapy to breast and axilla (without palliative mastectomy) also can be used in LACB.
• There is no role of breast conservative surgery for LACB.
• 5 year survival is 40% and 10 year survival is less than 25%.
• Inflammatory carcinoma is T4d LACB. It is also called as mastitis carcinomatosis or lactating carcinoma of breast. It is 2% common. It is observed in younger age group usually pregnancy or lactating period. There will be extensive skin involvement with pain. It often mimics mastitis of lactation. FNAC or incision biopsy concludes diagnosis. It is treated by initial chemotherapy or radiotherapy; later if tumour reduces in size then total mastectomy with axillary clearance can be done. But most often it is inoperable. After surgery, chemotherapy and tamoxifen is given. 5 year survival for inflammatory carcinoma of breast is 25–30%.

 

• It is a non-steroidal competitive inhibitor of the enzyme ‘aromatase’. This enzyme converts adrenal androgens to estrogen (aromatization). So it is an aromatase inhibitor.
• Other aromatase inhibitors are anastrozole and exemestane.
• Letrozole is used as an adjuvant endocrine therapy in post-menopausal women with hormone sensitive breast cancer. (In pre-menopausal women this will cause rise in gonadotrophins and ovarian aromatase is not well suppressed). It can also be used in metastatic and recurrent cases. It slows down and stops the growth of estrogen sensitive breast tumours. It reduces estrogen level by 98%. Its half-life is 45 hours. It decreases the bone density.
• Dosage of letrozole is 2.5 mg once daily.
• It is given for 5 years or for 2 years following 3 years of tamoxifen.
• Side effects of letrozole are vaginal dryness, night sweats, hot flushes, vaginal bleeding, cardiovascular problems and osteoporosis.

 

• It is a monoclonal antibody that blocks HER-2/neu receptors thereby preventing growth of cancer cells. It is a new drug. It is presently marketed as herceptin. It is ErbB2 inhibitor.
• It has very little effect on HER-2/neu negative cancers.
• It is useful only in HER-2/neu positive cancers. It is currently approved by FDA for use only in metastatic disease. It is given as intravenous infusion.
• Studies have shown that substantiate improvement in disease free and overall survival can occur.
• It has got cardiac side effects.

   

• To improve quality of life.
• To relieve pain of secondaries like bone, lungs.
• To relieve neurological problems like convulsions, space occupying cranial problems.
• Other symptomatic relief.

 

• Chemotherapy—CMF, CAF, Taxanes in combination.
• High dose of chemotherapy using cyclophosphamide, cisplatin, carmustine, melphalan is tried in view to get high response rate of 55–70% along with bone marrow transplant. But toxic effects are often life threatening.
• Haemopoietic growth factor also used along with chemotherapy to enhance the cell kill with less bone marrow toxicity. It also may allow multiple high dose chemotherapy to increase the response rate.
• Radiotherapy is used in bone metastasis, brain secondaries, to prevent paraplegia in spine involvement, and advanced axillary nodes.
• Hormone therapy has got important role.
• Blockage of over expression of epidermal growth factor (EGF)/transforming growth factor alpha (TGF-alpha) which are related to ErbB1/ErbB2 receptors in relation to aggressive carcinoma factor.
• Palliative surgeries done are total/toilet mastectomy, fixation of bones in case of pathological fractures, lung resection in case of localized secondaries, bilateral oophorectomy.
• Trastuzumab (herceptin) is monoclonal antibody used in cancers with good results. It blocks the Her-2/neu and erbB2 receptors.

• Bilateral oophorectomy (Beatson—1896).
• Bilateral adrenalectomy.
• Pituitary ablation.

 

• Estrogen receptor antagonists - Tamoxifen.
• Ovarian ablation by surgery (Bilateral oophorectomy) or by radiation.
• LHRH agonists. (Medical Oophorectomy). Goserelin causes reversible ovarian ablation by suppressing gonadotrophin release. It acts at hypothalamo-pituitary axis via tachyphylaxis causing reversible chemical castration (ovarian ablation). 3.6 mg/28 days cycle for 2 years.
• Oral aromatase inhibitors for post menopausal women. Letrozole and anatrozole are recent aromatase inhibitors available.
• Adrenalectomy or pituitary ablation.
• Progesterone receptor antagonist.
• Androgens. – Inj Testosterone propionate 100mg IM three times a week.
• Aminoglutethimide - blocks the synthesis of steroids by inhibiting conversion of cholesterol to pregnenolone - medical adrenalectomy.
• Progestogens, e.g. medroxyprogesterone acetate.
  119

 

• RT reduces the local recurrence of tumour and in the axillary region; and improves the quality of life.
• But survival benefit?—Not proved.

 

• Patient who undergoes conservative breast surgery—breast is irradiated after surgery using external radiotherapy.
• After simple mastectomy—external irradiation is given to axilla.
• Patients with higher risk of local relapse after surgery:—a) Invasive carcinoma. b) Extensive in situ carcinoma. c) Patients under 35 years. d) With multifocal disease.
• In bone secondaries—to palliate pain and swelling. If there is pathological fracture in the bone, internal fixation has to be done along with external irradiation.
• Inflammatory carcinoma of breast.
• In atrophic scirrhous carcinoma of breast, as a curative radiotherapy.
• As preoperative radiotherapy— to reduce the tumour size and to downstage the tumour, so that the operability is better.
• In conditions where there are more than 4 positive axillary nodes, pectoral fascia involvement, positive surgical margins, extranodal spread or axillary status not known/not assessed.
  120

   

• Carcinoma breast is more common in developed western countries. In African-American women, it is more aggressive. It is less common in Japan.
• It is second most common carcinoma in females. Incidence is 19–34%. Median age is 47 years.
• It is more common after middle age, but do can occur at any age group after 20.
• It is familial in 2–5% cases.
• Carcinoma in one breast increases the risk of developing carcinoma on opposite breast by 3–4 times. Incidence of bilateral carcinoma is 2%.
• Diet low with phytoestrogens and high alcohol intake.
• It is common in nulliparous woman. Early child bearing and breast feeding reduces the incidence of malignancy. Breast carcinoma is directly related to oestrogen level increase. Early menarche and late menopause has got higher risk probably due to increased oestrogen level.
• It is more common in obese patient.
• Breast cancer relative risk is qualified as Relative Risk (RR). RR 2.0 means risk is twice the normal population. If RR is 0.5 means risk is 50% less than normal population.
• In males, occasionally gynaecomastia turns into carcinoma.
• Benign breast diseases with atypia, hyperplasia and epitheliosis have got higher risk in a patient with family history of carcinoma breast.
• Mutation of tumour suppressor genes BRCA 1 and BRCA 2 has got high risk of carcinoma breast. BRCA 1 has got more risk (35–45%). It is located in long arm of chromosome 17. It is also associated with ovarian carcinoma. BRCA2 is located in long arm of chromosome 13. It is also associated carcinoma male breast. Occasionally mutation of BRCA3 and p53 suppressor gene is also involved.
• Cowden's syndrome and Li-Fraumen's syndromes are associated with carcinoma breast.
• Presently carcinoma breast is considered as systemic disease. Halsted concept of spread is sequential spread. Breast—axillary lymph node—systemic spread. Fischer concept is early 121to begin with itself, only then there is distant blood spread because of micrometastasis without nodal disease. Only tumour lesser than 1 cm size can be sequential.
• Prior diagnosis of uterine/ovarian/colonic cancers.

 

• Solid.
• Comedo with necrosis is high grade with increased chances of micro invasion.
• Cribriform.
• Papillary.
• Micropapillary.

         

1. Ductal carcinoma.
   Lobular carcinoma.
2. 1. In situ carcinoma
      • DCIS (Ductal carcinoma in situ).
      • LCIS (Lobular carcinoma in situ).
   2. Invasive.
      • Invasive ductal carcinoma.
      • Invasive lobular carcinoma. It is commonly multifocal and often bilateral.
3. Unilateral.
   Bilateral. 2–5% common.
4. Unifocal.
   Multifocal.

4. Multifocal—tumour tissues within the same quadrant.
   Multicentric—tumour tissues within the breast but in different quadrant.

 

• Spread to axillary nodes is the most important prognostic indicator. More than 2 in number of nodes and nodal size more than 2.5 cm carries poor prognosis. More than 4 nodes/level III (apical nodes) involvement has got worst prognosis (5 year survival is 30%) and also decides for radiotherapy to axilla.
• Age: Younger the age worse the prognosis.
• Sex: Carcinoma male breast has got worse prognosis compared to female breast, because of early spread in carcinoma male breast.
• Stage I and II has got better prognosis.
• Atrophic scirrhous has got best prognosis.
• Medullary carcinoma has got better prognosis than scirrhous carcinoma because of lymphocytic infiltration.
• Invasive carcinoma has got worse prognosis.
• Inflammatory carcinoma breast has worst prognosis.
• ER +ve tumours has got better prognosis.
• Differentiation also decides prognosis.
• Presence of elastic fibers in histology has got better prognosis.
• Tumour grade, growth factor and oncogene factors. ErbB2 –Her-2/neu positive has got poor prognosis. ErbB1 with over expression of epidermal growth factor (EGF) and TGF alpha has got poor prognosis.
• DNA flow aneuploid status has got poor prognosis. Low S phase fraction has got good prognosis.

   

• It signifies terminal event.
• It has got poor prognosis.
  123
• HRCT is ideal diagnostic tool.
• Respiratory distress and failure is the main feature.
• Treated by
  • Intercostal tube drainage.
  • Pleurodesis using talc/tetracycline.
  • Chemotherapy.

 

• Incidence is 3%.
• Treatment is modified radical mastectomy (MRM).
• Chemotherapy can be given in 2nd trimester with care.
• Radiotherapy has no role.
• As commonly ER negative, hormone therapy is not used.
• When distressing secondaries are present termination of pregnancy may be required.
• Women with breast cancer can become pregnant 2 years after the completion of therapy, as recurrence is more common in 2 years.

   

• Immediate reconstruction.
• Delayed reconstruction.

 

• Silicon gel implant under pectoralis major muscle.
• Expandable saline prosthesis with prior tissue expansion.
• If there is less skin or after radiotherapy- Latissimus dorsi musculocutaneous flap (LD flap) or contra lateral transversus abdominis muscle flap (Tram flap).

• Breast reconstruction is done in young patients with early stage disease.
• Skin sparing mastectomy with removal of nipple areola complex may be better for reconstruction.
  

  Fig. 1.202: LD flap (A) Donor area (B) Recipient area.

  

  Fig. 1.203: Latissimus dorsi flap (LD FLAP) placed after mastectomy. It is based on thoracodorsal artery.

  

  Fig. 1.204: Transverse rectus abdominis myocutaneous flap. Note the blood supply of the flap.

  124
  

  Figs 1.205A to D: Different operative steps in TRAM flap.
• Symmetry is the most important factor in breast reconstruction.
• External breast prosthesis which fits within the bra is a simpler cosmetic method.

• Local breast flaps 3 months after breast reconstruction.
• Nipple sharing from contralateral nipple using composite graft.
• Skate flap: Local flap with deepithelialised donor site around the periphery over which a full thickness graft is applied to reconstruct the areola.

• Full thickness skin graft from non hairy skin lateral to labia majora, as the pigmentation of this graft matches that of the areola.
• From contralateral areola if reduction mammoplasty is done on that side.
• Tattooing – Colour tends to fade with time and may need to be repeated.
• SSG from retroauricular area or from thigh.

 

• Superior gluteal flap based on superior gluteal vessels.
• Ruben's flap using soft tissue pad overlying the iliac crest based on deep circumflex iliac vessels.

 

• Technically simple.
• Achieves symmetry easily.
• Implant in submuscular plane is better whenever muscle has not been removed during surgery.
• If muscle is removed like during radical mastectomy, then subcutaneous implant is placed.
• Silicon gel implants are used.

   

• Soft.
• Hard.
• Giant (>5 cm in size).

• Intracanalicular—small and hard—mainly fibrous.
• Pericanalicular—large and soft—mainly cellular.

• It presents as a painless swelling in one of the quadrants, which is smooth, firm, non tender, well localized and moves freely within the breast tissue (‘mouse in the breast’).
• Axillary lymph nodes are not enlarged.

• Mammography (well localized smooth regular shadow).
• FNAC.
• Ultrasound (to confirm solid nature).

 

• It is an estrogen dependent condition. One of the cysts may get enlarged to become a clinically palpable well localized swelling - bluedome cyst of Bloodgood.
• Diffuse, small, multiple cysts in fibrocystadenosis is called as Schimmelbusch's disease.
• Disease is common in upper outer quadrant.
  127

 

• Presentation is during menstruating age group as a bilateral, painful, diffuse, granular, tender, swelling which is better felt with palpating fingers (poorly felt with palm).
• Not fixed to skin, muscle or chest wall.
• Pain and tenderness are more during menstruation (Cyclical mastalgia).
• It subsides during pregnancy, lactation and after menopause.
• Discharge from the nipple when present will be serous or greenish.

 

• FNAC (Epitheliosis, when florid is undoubtedly premalignant).
• Ultrasound, mammography.

 

1. Conservative line of management is preferred.
   • Reassurance.
   • Oil of evening primrose (capsules): Contains gamolenic acid which reverses the saturated fatty acids to unsaturated fatty acids.
   • Gamolenic acid — 120mg.
   • Bromocriptine.
   • Vitamin E and B₆.
   • LHRH agonist.
   • Danazol.
   • NSAID'S.
   • Tamoxifen—antiestrogen.
2. Surgery: Subcutaneous mastectomy with prosthesis placement.

 

• They are not simply giant fibroadenoma.
• They show a wide spectrum of activity, varying from almost a benign condition to a locally aggressive and sometimes metastatic tumour.
• Depending on mitotic index and degree of pleomorphism they are graded as low grade to high grade tumours.

   

• It contains cystic spaces with leaf like projections, hence the name.
• Cells show hypercellularity and pleomorphism.
• It may be a variant of intracanalicular fibroadenoma of breast.

 

• They occur in premenopausal women (30–50 years).
• It is usually unilateral, grows rapidly to attain a large size.
  128
• Swelling is smooth, non tender, soft, fluctuant with necrosis of skin over the summit due to pressure.
• Recurrence is common.

 

• Excision or subcutaneous mastectomy is done.
• If malignant (sarcoma), total mastectomy is indicated. Sarcoma may spread to lungs and so chest X-ray/chest CT has to be taken.

     

• Painless swelling in the breast which is smooth, hard, nontender and adherent to breast tissue. (D/D-Carcinoma). It is nonprogressive.
• FNAC shows chalky fluid with fat globules.
• Mammography is done to rule out malignancy.
• It often mimics carcinoma breast.
• Treatment is excision.

   

• Lump in the lower quadrant of the breast which is usually unilateral, large, soft, fluctuant, with smooth surface and nontender. It is a retention cyst — subareolar type.
• It may get precipitated, inspissated, or get calcified.
• When it is calcified it mimics carcinoma breast.
• If it gets infected it will form an abscess.
• U/S and FNAC are used to diagnose.
• Treatment is excision (by submammary incision). Abscess when formed should be drained under general anaesthesia under cover of antibiotics.

   

• Subareolar.
• Intramammary.
• Retro mammary (Submammary).

 

• It is the infection under the areola due to cracks in the nipple or areola.
• Red, inflamed, oedematous areola with tender swelling underneath.
  129
• Differential diagnosis is Paget's disease of the nipple.
• Treatment is under cover of antibiotics pus is drained of by making a sub areolar incision.

 

1. Lactational abscess of the breast

• Pain in the breast and fever.
• Diffuse redness, tenderness, and induration in the breast.
• Purulent discharge from the nipple.
• Full breast may get involved eventually.
• Differential diagnosis is inflammatory carcinoma of breast.

• Antibioma formation.
• Sinus formation.
• Recurrent infection.

2. Non-lactational abscess of the breast

• Antibiotics.
• Repeated aspirations.
• Drainage and later cone excision of the duct is done.

3. Retromammary mastitis

• Chest X-ray, FNAC, ESR.
• Peripheral smear.
• CT chest.

• Cause has to be treated. Antibiotics are used.
• Drainage under general anaesthesia with sub- mammary incision reaching submuscular plane.
• Often may need intercostal tube drainage in specific causes.

   

• Previous history of mastitis treated with antibiotics.
• Swelling which is painless, smooth, non tender, hard, fixed to breast tissue without involving the pectorals and chest wall.
• Differential diagnosis is carcinoma breast. (Scirrhous carcinoma breast).
• Investigations are FNAC, mammography and U/S breast.
• Treatment is excision (Submammary incision). Later antibiotics are given.

 

• It is dilatation of lactiferous ducts due to muscular relaxation of duct wall with periductal mastitis (Plasma cell mastitis). Many ducts are commonly involved.
• Greenish discharge from the nipple.
• Indurated mass under the areola which is often tender.
• Retraction of nipple which occurs at later stage of the disease.
• Eventually it forms an abscess, and fistula.
• Often they are bilateral and multifocal.
• Differential diagnosis is carcinoma breast.
• Investigations are — discharge study and mammography.
• Treatment is cone excision of involved major ducts (Hadfield operation) with antibiotics.

 

• Mondor's disease is thrombophlebitis of the superficial veins of the breast and anterior chest wall.
• Presents as a thrombosed subcutaneous cord which is attached to the skin.
• It is often a self limiting disease without any recurrence, complication or deformity.
• It mimics the lymphatic permeation of carcinoma breast.

 

• It is usually single, from a single lactiferous duct.
• It is the commonest cause of nipple discharge.
• By blocking the duct it causes ductal dilatation.

 

• Papilliferous swelling (projection), usually near the nipple orifice (4–5 cm from orifice).
• Blood stained discharge from the nipple is common.
  131
• But serous or serosanguinous discharge can also occur.
• Single papilloma is not premalignant.
• But multiple papillomas in many ducts can be premalignant
• Study of discharge and ductogram may be needed.
• Treatment—Microdochectomy: Probed lactiferous duct is opened with excision of the papilloma using tennis racquet incision.

 

• It is secretion of milk not related to pregnancy or lactation.
• Primary galactorrhoea is due to stress and other factors. Reassurance is the treatment.
• Secondary galactorrhoea is due to enhanced dopamine activity.
  • By drugs (haloperidol, methyldopa, chlorpromazine, metoclorpramide),
  • Hyperprolactinaemia due to tumours.
• Treatment—bromocriptine/cause has to be treated.

 

• It is hypertrophy of male breast more than usual, often attaining features of female breast.
• It can be unilateral or bilateral.

 

• Diffuse enlargement of breast occupying all quadrants or as a well localized, small, firm or hard nodule under the areola which is often painful and tender.

 

• Idiopathic.
• Teratoma testis.
• Ectopic hormonal production in bronchial carcinoma.
• Anorchism, after castration.
• Adrenal and pituitary disease.
• Leprosy, because of bilateral testicular atrophy.
• Drugs: Stilboestrol, Digitalis, Cimetidine, Spironolactone.
• Liver diseases and liver failure.
• Klinefelter's syndrome. (XXY Trisomy).

 

• When symptomatic or large or long standing, excision through circumareolar incision is done.
• Often subcutaneous mastectomy is needed.

   

• Cyclical

• Noncyclical

               

• Swelling in front of the neck and its duration
• Pain in the swelling and its duration
• Hoarseness of voice due to recurrent laryngeal nerve palsy.
• Difficulty in swallowing or breathing
• Tremor in the hands
• Generalized weakness
• Palpitation
• Loss of significant weight

                           

• Thyrotoxic patient is anxious/thin and undernourished. Obesity is seen in myxoedema. Patient may be cachexic in thyroid carcinoma which is advanced.
• Exophthalmos should be looked for in toxic patient. Irritable/agitated tensed face with eye signs is seen in toxic thyroid.
• Myxoedema face is typical. It is expression- less, mask-like puffy face. Patient will be dull with low intelligence.
• Hasty—rapid gait is seen in hyperthyroid and slow—lethargic gait in hypothyroidism.
• Pulse—its character, whether tachycardia, collapsing or pulsus paradoxus or ectopic or fibrillation has to be looked for.
• Blood pressure may be high in toxic thyroid.
• Sleeping pulse rate is checked at late night or early morning for three consecutive nights and average is taken. Sedation like diazepam or phenobarbitone to be given to check sleeping pulse rate prior to sleep is a controversial. Sleeping pulse rate is graded as Crile's grading.
  

  Fig. 1.217: Palpation of radial pulse for its count, volume, variations should be done in thyroid diseases.

  Crile's grading	Sleeping pulse rate/minute
  I	Up to 90
  II	90–110
  III	> 110

  134
• In toxic thyroid, patient will be thin and underweight. In hypothyroidism, patient will be obese and overweight. In metastatic thyroid cancer patient is cachexic.
• Agitated stressful facial expression is observed in toxic thyroid. Puffy, expressionless, dull and mask-like face is seen in myxoedema.
• Rapid aggressive gait is seen in toxicity but lethargic and slow gait is observed in hypothyroidism.
• Skin is wet and warm in hyperthyroidism (moist palm while shaking hands).
• Ankle (Achilles tendon) reflex is prolonged with delayed relaxation in hypothyroidism and it is shortened and brisk in hyperthyroidism.
• Both legs and ankle region in front should be inspected for pretibial myxoedema. It is a feature of primary thyrotoxicosis. It is due to deposition of myxomatous tissue.

                       

• Lower margin of the swelling/goitre is not visible-even on deglutition.
• Lower margin is not palpable on deglutition.
• Dilated veins over neck or chest wall may be visible.
• Normal resonant note becomes dull over the sternum on percussion.
• Pemberton's sign—patient is asked to raise the both arms above the shoulder so as to touch the ears and made to keep like that for 3 minutes. Patient will develop dilated veins and cyanosis in the neck and upper chest wall, puffiness in face and respiratory distress and rarely dysphagia. It means sign is positive signifying retrosternal extension of goitre.
  

  Figs 1.232A and B: Pembertones sign for retrosternal goitre.
• Dyspnoea at night during lying down or neck extended.
• Rarely recurrent nerve palsy can occur.
  

  Fig. 1.233: Retrosternal extension of thyroid—diagram.
  Retrosternal goitre is defined as having > 50% goitre below the suprasternal notch.
• Primary is rare—1%. Primary retrosternal goitre arises from ectopic thyroid tissue from mediastinum. It gets its blood supply from mediastinum itself, not from the neck. And also it is not related to the existing thyroid in the neck.
• Secondary is common. It is extension from the enlarged thyroid from the neck.

• Drooping of upper eyelid (ptosis).
• Anhidrosis.
• Miosis due to paralysis of dilator pupillae.
• Absence of ciliospinal reflex.
• Flushing of face and nasal congestion.

• Both the eyelids cover the bulbar sclera partially in normal individual.
• Upper sclera is visible in only lid retraction—due to spasm of involuntary levator palpebrae superioris muscle. Here lower eyelid is in normal position. It does not indicate exophthalmos.
• In exophthalmos lower bulbar sclera is clearly visible and lower eyelid is below and will not cover the bulbar sclera. In severe exophthalmos sclera all over both above and below will be visible.144
  

  Fig. 1.240: Cardiovascular system is examined and auscultated for cardiac problems in secondary thyrotoxicosis.

  

  Fig. 1.241: Hepatomegaly can occur in Graves' and Hashimoto's diseases as part of the autoimmune disease.

  

  Fig. 1.242: Abdomen is percussed for free fluid.
• Exophthalmos is measured using exophthalmometre.

 

1. Von Graefe's sign: Lid lag sign is inabitility of the upper eyelid to keep face with eyeball when looking downwards—lid lag. Place the examiner's left hand over the patient's head. Place examiner's right index finger near the level of eye and slowly bring it down and patient is asked to see the downward moving finger. If sclera upward is visible then it is positive lid lag sign.145
   

   Figs 1.245: Lid lag check in primary thyrotoxicosis.
   Test is repeated few more times for confirmation. Normally upper eyelid follows the finger downwards properly but in primary thyrotoxicosis lid lag is observed.
2. Naffziger's sign: While examiner standing behind the patient, patient's neck is extended and examiner looks from behind along the superior orbital margin of the patient. Eyeball is seen beyond the superior orbital margin in exophthalmos.
3. Dalrymple's sign: Upper eyelid retraction, so visibility of upper sclera.
4. Stellwag's sign: Absence of normal blinking - so starring look. First sign to appear.
5. Joffroy's sign: Absence of wrinkling on forehead when patient looks up (frowns) with the neck flexed.
6. Moebius sign: Lack of convergence of eye ball. Defective convergence is due to lymphocytic infiltration of inferior oblique and inferior rectus muscles in case of primary thyrotoxicosis. There will be diplopia. It may be an early sign of eventual ophthalmoplegia. Examiner's left hand is placed over the patient's head. Right index finger from distance is brought towards root of the nose between the eyes and patient is asked to follow the converging finger visually to look for convergence. If positive patient will be unable to converge and develops diplopia.
7. Jellinek's sign: Increased pigmentation of eyelid margins.
8. Enroth sign: Oedema of eyelids (lower eyelid specifically) and conjunctiva.
9. Rosenbach's sign: Tremor of closed eyelids.
10. Gifford's sign: Difficulty in everting upper eyelid. Differentiates from exophthalmos of other causes.
11. Loewi's sign: Dilatation of pupil with weak adrenaline solution.
12. Knie's sign: Unequal pupillary dilatation.
13. Cowen's sign: Jerky pupillary contraction to consensual light.
    146
14. Kocher's sign: When clinician places his hands on patient eyes and lifts it higher, patients upper lid springs up more quickly than eyebrows.
15. Naffziger's sign: With patient in sitting position and neck fully extended, protruded eye ball can be visualized when observed from behind.
16. Grove's sign. Upper lid resistance to downward traction.
17. Rochin's sign: Reduced amplitude of blinking.
18. Boston's sign: Uneven jerky movement of the upper eyelid in inferior movement.
19. Mean's sign: Eye globe lags behind upper eyelid on upward gaze.
20. Griffith's sign: Lower eyelid lags behind the eye globe on upward gaze.
21. Sainton's sign: Frontalis contraction after cessation of levator activity.
22. Vigourox's sign: Puffiness of lids.
23. Ballet's sign: Ophthalmoplegia- paralysis of more extraocular muscles.
24. Suker's sign: Difficulty in maintaining fixation in extreme lateral gaze.
25. Wilder sign: Jerking of eyes on movement from abduction to adduction.
26. Trousseau's/Payne's sign: Dislocation of the eye globe.
27. Reisman's sign: Bruit over eyelid.
28. Snellen/Donder's sign: Bruit over the eye.
29. Goldzieher's sign: Deep injection of conjuctiva.

 

• It is proptosis of the eye, caused by infiltration of the retro bulbar tissues with fluid and round cells, with visible lower bulbar sclera and with lid spasm of upper eyelid. (Lid spasm is spasm of levator palpebrae superioris muscle which is partly innervated by sympathetic fibres.)
• Sclera can be seen clearly below and often above the limbus of the eye.
• Proptosis can be measured by exophthalmometer.
• Exophthalmos is often self limiting, but not always. Sleeping in propped up position and lateral tarsorrhaphy will help to protect the eye.

   

• Eyelid oedema, chemosis, conjuctival injection.
• Diplopia, ophthalmoplegia (Complete weakness of all extraocular muscles and so no movements possible).
  148
• Corneal ulceraion.
• Papilloedema soon develops.
• Finally it may also cause loss of vision.

 

• T3, T4, TSH, Free T3, Free T4.
• U/S neck for thyroid and neck nodes.
• FNAC thyroid and lymph node.
• Radioisotope study.
• CT neck in malignancies or large goitre.
• Trucut biopsy if two trials of FNAC are inconclusive. It can injure deeper structures like recurrent laryngeal nerve and also can cause haemorrhage.
• Frozen section biopsy on table and proceed may be needed.
• Serum calcitonin, serum thyroglobulin estimation in neoplasms of thyroid.

• On table frozen section biopsy is useful in negative FNAC but doubtful cases. Definitive procedure is undertaken once frozen section report comes on table. But in frozen section biopsy itself, 15% of follicular carcinoma report may be inconclusive or negative which causes difficulty in taking decision. In such occasion hemithyroidectomy is done and once histology report of follicular carcinoma is obtained completion thyroidectomy is done usually immediately within a week. If biopsy report is delayed then completion thyroidectomy is done after 6 weeks.
• Trucut biopsy gives tissue diagnosis but danger of haemorrhage and injury to vital structures like trachea, recurrent laryngeal nerve, vessels are likely.

     

• Thyroid adenomas—
  Colloid—commonest.
  Hurthle cell.
  Follicular.
• Papillary carcinoma of thyroid.
• Only one nodule may be palpable in an underlying multinodular goitre.
• Thyroid cyst.

 

1. Toxic solitary nodule.
2. Nontoxic solitary nodule.

 

1. Hot—Means autonomous toxic nodule.
2. Warm—Normally functioning nodule.
3. Cold—Non-functioning nodule; may be malignant-20% (need not be always). Cold nodule may be due to malignancy, thyroiditis, thyroid cyst or haemorrhage.
4. Hot or warm in 99m technetium scan but cold in I¹²³ scan—commonly they are malignant.

• Thyroid nodule in children and elderly can be malignant.
• Rapid enlargement of thyroid nodule can be malignant.
• Medullary carcinoma of thyroid commonly and 6% of papillary carcinoma of thyroid can be familial.
• Recurrent laryngeal nerve palsy, fixity, stridor, presence of palpable neck nodes are usually features of carcinoma thyroid.
• Follicular carcinoma causes pulsatile, localized, warm, vascular secondaries in skull bone.
• 30% of solitary nodules are cystic.
  152

 

1. Single nodule palpable in one or other lobes of the thyroid which is usually smooth, globular, well-defined margin and firm. Skin overlying is normal.
2. Lahey's test does not show any other nodules in posterior part of the gland.
3. Tracheal deviation towards opposite side is common – confirmed by trail sign, three finger test and auscultation.
4. U/S neck is very useful. FNAC is essential. When FNAC is inconclusive Trucut needle biopsy may be done but it can cause pain/bleeding/recurrent laryngeal nerve injury.
   

   Figs 1.254A and B: Solitary nodule right lateral lobe. It is a clinical entity.
5. T3, T4, TSH are done to find out the function
6. Radioisotope study. (I^123/I¹³¹/^99mTc).
7. CT scan or MRI neck is done only in selected cases but not routinely. Large swelling/to see vascularity/retrosternal extension are the indications.

 

• If it is a nontoxic nodule due to any cause, hemithyroidectomy with complete removal of lateral lobe and whole of the isthmus is done.
• If it is papillary carcinoma thyroid, then near total thyroidectomy is done along with suppressive dose of L-Thyroxine given 0.3 mg OD daily.
• If it is a toxic nodule, radioiodine therapy, I ¹³¹ —5 milli curie is given orally, if the age of the patient is more than 45 years.
• If age is less than 45 years, then initially toxicity has to be controlled by antithyroid drugs, always followed by surgery - Hemithyroidectomy.
• If FNAC is follicular adenoma, then hemithyroidectomy is done. If histology becomes follicular carcinoma (capsular and vascular invasion) then completion total thyroidectomy is done. Completion thyroidectomy is done usually within 7 days or after 3 weeks. If frozen section biopsy proves carcinoma then total thyroidectomy is done.
  153
• If there is a nodule in the isthmus, isthmectomy with excision of part of adjacent lateral lobes is done.
• If FNAC is medullary carcinoma of thyroid, then total thyroidectomy with bilateral neck nodal dissection including central compartment is done.
• Colloid nodule may response for conservative drug treatment using thyroxine orally in 50% cases. If nodule reappears/enlarges progressively significantly/causing cosmetic problem then hemithyroidectomy is indicated in colloid nodule.

       

• It is a slowly progressive disease with many years of history.
• Multiple nodules of different sizes are formed in both lobes, also in isthmus, which is firm, nodular, non tender, moves with deglutition.
  

  Fig. 1.259: Nodular thyroid involving both lobes in a female.
• Recent increase in size signifies malignant transformation or haemorrhage.
• Investigations are T₃, T₄, TSH, U/S neck, FNAC, X-ray neck will show ring or rim calcification.

 

• Total thyroidectomy is universally accepted method presently. Only problems are chances of recurrent nerve palsy and postoperative risk of patient developing hypocalcaemia often severe.
• Subtotal thyroidectomy is done depending on the amount of gland involved, amount of normal gland existing and location of nodules.
• Hartley-Dunhill procedure is removal of one entire lobe which is more affected with subtotal removal of other gland.
• Partial thyroidectomy wherein gland behind the tracheo oesophageal groove is retained with removal of diseased glands in front. Earlier it used to be a popular method. Currently it is not well practiced.
• Postoperatively L-thyroxine is often given to prevent further fluctuation in TSH level.

   

1. Diffuse toxic goitre—(Grave's disease, Basedow's disease. Primary thyrotoxicosis).
2. Toxic multi-nodular goitre (Secondary thyrotoxicosis.). (Plummer disease).
3. Toxic nodule.
4. Hyperthyroidism of rarer causes:
   1. Thyrotoxicosis factitia- drug induced. Due to intake of L-thyroxine more than normal.
   2. Jod Basedow thyrotoxicosis - because of large doses of iodides given to a hyperplastic endemic goitre.
      156
   3. Autoimmune thyroiditis or de' Quervain's thyroiditis.
   4. Occasionally carcinoma thyroid.
   5. Neonatal thyrotoxicosis. It subsides in 3–4 weeks as TsAb titres fall in the baby's serum.

 

1. It is eight times more common in females.
2. Occurs in any age group.
3. Primary type is seen commonly in younger age group.
4. Secondary is common in older age group.

   

• Weight loss in spite of increased appetite
• Diarrhoea (due to increased activity at ganglionic level).

 

• Palpitations, chest pain.
• Shortness of breath at rest or on minimal exertion.
• Angina.
• Cardiac irregularity.
• Cardiac failure in the elderly (CCF).

 

• Undue fatigue and muscle weakness, exaggerated tendon reflexes, myasthenia like syndrome.
• Tremor, hyperkinesias, increased sweating.

   

• Oligo- or amenorrhoea.
• Occasional urinary frequency.

 

• Hair loss.
• Pruritus.
• Palmar erythema.

 

• Irritability.
• Nervousness.
• Insomnia.

 

1. Eye signs in toxic goitre (Refer above)
2. Cardiac Manifestations:
   1. Tachycardia is common.
      Sleeping pulse rate is usually checked for three consecutive nights and average is taken as the value.
   2. Ectopic.
   3. Pulsus paradoxus.
   4. Wide pulse pressure.
   5. Multiple extrasystoles.
   6. Paroxysmal atrial tachycardia.
   7. Paroxysmal atrial fibrillation.
   8. Persistent atrial fibrillation (not responsive to digoxin).
      158
3. Myopathy:
   1. Weakness of proximal muscles occurs, i.e. the front thigh muscles, or arm muscles.
   2. Weakness is more when muscle contracts isometrically either while getting down steps, or lifting a full bucket, etc.
   3. Often when it is severe it resembles myasthenia gravis. Once hyperthyroidism is controlled recovery occurs.
4. Pretibial myxoedema is often a feature of primary thyrotoxicosis (It is a misnomer)
   • It is usually symmetrical, shiny, red thickened skin, with coarse hair.
   • In severe cases skin of whole leg below the knee with foot and ankle is involved.
   • It is due to deposition of myxomatous tissues (mucin like deposits) in skin and subcutaneous plane.
   • It might or might not regress completely after treatment for toxicity
   • It is associated with exophthalmos with high levels of thyroid stimulating antibodies.
5. Thyroid acropachy is clubbing of fingers and toes in primary thyrotoxicosis. Hypertrophic pulmonary osteoarthropathy may develop.

 

• Is a solitary overactive nodule.
• There is an autonomous hypertrophy and hyperplasia of the part of the gland where there is a nodule. (It is not due to Thyroid stimulating antibody (Ts Ab)).
• Here high levels of circulating thyroid hormones suppress TSH secretion, and so normal thyroid tissue surrounding the nodule is itself suppressed and inactive.
• Once patient becomes euthyroid by drugs, surgery (hemithyroidectomy) is done or radioactive iodine therapy I¹³¹ in a therapeutic dose of 5mcurie is given orally.
• Because normal gland is inactive, radioactive iodine affects only the autonomous nodule, allowing the normal gland to remain intact which later gets activated and functions normally.

  Differentiating points between Primary and Secondary hyperthyroidism

  Primary thyrotoxicosis

  Secondary thyrotoxicosis

  Symptoms appear first, then swelling Goitre is diffuse, smooth, firm or soft, both lobes are involved There is thrill and bruit Features are much more severe compared to that of secondary toxicosis Eye signs and exophthalmos are common As it is an autoimmune disease, there may be hepatosplenomegaly Histologically, there is hyperplasia of acini, lined by columnar epithelium, often containing vacuolated colloid

  Swelling appears first Swelling is large nodular, obvious Symptoms appear after long time, which is less severe and slowly progressive compared to primary toxicosis Cardiac features are more common Eye signs are not common

  159
• Drugs are used initially, only for a temporary period to make the patient euthyroid.

   

• Serum T₃ and T₄ levels are very high. TSH is very low or undetectable. Some times, only T₃ level is increased and is called as T₃ toxicosis. Here in T₃ toxicosis, free T₃ estimation is important.
• Radioisotope study by I¹³¹ (Diagnostic dose 5 micro curie is used) will show more up take, i.e. hot nodules or hot areas. This is very useful in autonomous solitary toxic nodule.
• TRH estimation.
• ECG—To look for cardiac involvement and if required opinion from cardiologists' is taken and cardiac problems are managed.
• Total count and neutrophil count are very essential base line investigations before starting antithyroid drugs (as it may cause agranulocytosis).

 

1. Antithyroid drugs.
2. Surgery.
3. Radio-iodine therapy.

 

1. Carbimazole:
   • It is the commonest drug used.
   • Dose is 5–10 mg, exactly 8th hourly, (as T1/2 of carbimazole is 8 hours).
   • Usually given for 12–18 months.
   • Peak plasma level should be maintained in optimum concentration to have a proper benefit.
   • Often tri-iodo thyronine 20 micro gram 4 times daily or Thyroxine 0.1 mg daily is given in combination with antithyroid drugs, to prevent iatrogenic thyroid insufficiency or to prevent the increase in size of goitre.
   • It acts by blocking thyroid hormone synthesis.
   • Carbimazole also suppresses the autoimmune process in thyroid in Graves' disease. So thyroid stimulating antibody (TsAb) production diminishes.
2. Methimazole: Similar like carbimazole. Dose is 5–20 mg daily.
3. Propylthiouracil:
   1. It acts by blocking thyroid hormone synthesis as well as by blocking peripheral conversion of T₄ to T₃.
   2. It also decreases the thyroid autoantibody levels.
   3. It can be given in hyperthyroidism in children and pregnancy.
   4. Dose is 200 mg 8th hourly.

 

• It decreases the vascularity of the gland and makes it more firm and easier to handle during surgery. Dose is 10–30 drops/day (minims) for 10 days prior to surgery. Potassium iodide tablets 60 mg tid also can be given instead of Lugol's iodine. But its use at present is disqualified.
  (One minim = one drop. One ml = 16 drops).

 

1. Avoids surgery and its complications
2. Avoids radiotherapy.

 

1. Prolonged course of treatment for 18 months and inspite of this can not predict the remission or relapse. Relapse rate is 40%.
2. Size of swelling may not regress.
3. It may lead to agranulocytosis and thrombocytopenia, liver damage, hair loss.

 

1. Recurrent thyrotoxicosis (5%). It is treated by radioiodine therapy or antithyroid drugs. Resurgery is technically difficult.
2. Thyroid insufficiency (20–45%). It is revealed in 6 months to 2 years and confirmed by doing T₃ and T₄ and TSH estimation. Hypothyroidism is better than recurrent thyrotoxicosis. It is treated by tab. L-thyroxine 0.1 mg daily (OD) for life long.
3. Complications of thyroid surgery itself.

 

• Radioiodine destroys the cells and causes the complete ablation of thyroid gland. It is given only after the age of 45yrs, as the chances of genetic mutation (damage), leukaemia; carcinomas are high in younger individual.
• Usual dose is 50–60 milli curie, or 160 micro curie/gm of thyroid. (300–600 MBq).
• It takes 3 months, to get full response, and so until then, the patient has to take antithyroid drugs. Often additional one or two doses of radioiodine are required to have complete ablation. Eventually they go for hypothyroidism (80%) and so require maintenance dose of l-thyroxine 0.1mg daily.
• To give therapeutic dose, patient should be admitted and isolated for 7 days (Half life) to prevent irradiation. It is given orally soon after getting from the manufacturer without much delay to have optimal efficacy.
  161

 

1. No surgery.
2. No prolonged drug therapy.

1. Availability of facilities.
2. Proper follow-up is essential.

 

• Radioiodine therapy is an absolutely contraindicated in pregnancy (High risk to foetus).
• Antithyroid drugs can be administered carefully.
• But, the problem here is that both TSH and antithyroid drugs crosses the placental barrier and baby born may be hypothyroid and. goitrous.
• Propylthiouracil is preferred in pregnancy.
• Subtotal thyroidectomy can be done in second trimester.

     

• Any thyroid swelling can be malignant. It can be of short or long duration. It can be solitary/multinodular goitre. It can be solid/cystic/complex in nature.
• Preexisting thyroid swelling with recent history of rapid increase in size.
• Palpable neck lymph nodes.
• Recurrent laryngeal nerve palsy, dyspnoea, stridor are other presentations.
• Medullary carcinoma thyroid and papillary carcinoma thyroid (6%) can be familial.

 

1. Benign.
   1. Follicular adenoma.
   2. Hurthle cell adenoma.
   3. Colloid adenoma—commonest.
      

      Fig. 1.264: Carcinoma thyroid. Note the superficial tissue infiltration.
   4. Papillary adenoma—its existence is doubtful. It is invariably low grade papillary carcinoma.

1. Differentiated.
   1. Papillary carcinoma (60%).
   2. Follicular carcinoma (17%).
   3. Papillofollicular carcinoma behaves like papillary carcinoma of thyroid.
   4. Hurthle cell carcinoma behaves like follicular carcinoma.
2. Undifferentiated.
   Anaplastic carcinoma (13%).
3. Medullary carcinoma (6%).
4. Malignant lymphoma (4%).
5. Secondaries in thyroid (rare) - from colon, kidney, melanoma.

 

1. Radiation either external or radioiodine can cause papillary carcinoma thyroid. There is increased incidence of thyroid carcinoma among children following exposure to ionising radiation after the Chernobyl nuclear disaster in Ukraine in 1986. Irradiation to head and neck region used to be the therapy for benign conditions like adenoids, acne vulgaris, thymus enlargement, haemangiomas which predisposed papillary carcinoma of thyroid.
   

   Fig. 1.265: Carcinoma thyroid showing vascularity.

   163
   Radiotherapy for Hodgkin's lymphoma in younger age group may cause papillary carcinoma of thyroid.
2. Preexisting multinodular goitre. It turns into follicular carcinoma of thyroid.
3. Medullary carcinoma thyroid is often familial.
4. Hashimoto's thyroiditis may predispose to papillary carcinoma of thyroid and also NHL.

 

• It is 60% common.
• Common in females (3:1) and young age group.

 

• Radiation either external or radioactive iodine therapy.
  • TSH levels in the blood of these patients are high. and so it is called as hormone dependent tumour.
  • It is a slowly progressive and less aggressive tumour.
  • It is commonly multicentric.
  • It spreads within the gland throgh intra- thyroidal lymphatics to other lobe, comes out of the capsule and spreads to lymph nodes.
  • Usually there is no blood spread.

 

1. Occult (< 1.5 cm)
2. Intrathyroidal
3. Extrathyroidal
4. Micropapillary carcinoma is less than 1 cm in size or clinically not detectable.

     

1. Soft or hard or firm, solid or cystic, solitary or multinodular thyroid swelling.
2. Compression features are uncommon in papillary carcinoma thyroid.
3. Often discrete lymph nodes in the neck are palpable.

   

• Near total thyroidectomy or total thyroidectomy
• Suppressive dose of L-Thyroxine 0.3 mg O.D life long.
• Block dissection (modified radical neck dissection) is required if lymph nodes are involved.
• Occasionally if small lymph nodes are present, ‘Berry picking’ may be done. (Not accepted now).
• Extrathyroidal type needs radioactive iodine therapy also (I¹³¹).

 

• It is 17% common.
• It is common in females.
• It can occur either denovo or in a preexisting multinodular goitre.
• It is a more aggressive tumour.
• It spreads mainly through blood into the lung, bones, liver.
• Bone secondaries are typically vascular, warm, pulsatile, localized, commonly in skull, long bones, ribs.
• It can also spread to lymph nodes in the neck occasionally.

 

• Non-invasive-blood spread is not common.
• Invasive- blood spread is common.

   

1. Swelling in the neck, firm or hard and nodular.
2. Tracheal compression and stridor.
3. Dyspnoea, haemoptysis, chest pain when there are lung secondaries.
4. Recurrent laryngeal nerve involvement causing hoarseness of voice, positive ‘Berry's sign’ signifies advanced malignancy. (Infiltration into the carotid and so absence of carotid pulsation).
5. Pulsatile, warm, well localized, vascular secondaries in the skull (frontal/parietal bones), long bones.

 

• Most often FNAC is inconclusive, because capsular and angioinvasion which is the main feature in follicular carcinoma cannot be detected by FNAC.
  

  Figs 1.270A and B: X-ray skull showing secondaries from follicular carcinoma thyroid.
• Frozen section biopsy is very useful. But in 15% cases it shows negative results.
• U/S abdomen, Chest X-ray, X-ray bones are the other investigations required.

 

• Total thyroidectomy is done, along with block dissection whenever lymph nodes are enlarged.
• Maintenance dose of L-Thyroxine 0.1mg.O.D is given lifelong.
• FNAC in 50% of follicular carcinomas are inconclusive as it is difficult to differentiate between follicular adenoma and carcinoma. In such occasions frozen section biopsy on table may be useful. If on-table frozen section biopsy is positive for malignancy then total thyroidectomy is done.
• In 15% cases frozen section biopsy also may be inconclusive or frozen section biopsy facility may not be available in many places then initial hemithyroidectomy is done. If later report comes as follicular carcinoma of thyroid then completion thyroidectomy is done. It is done usually in 7 days of initial surgery otherwise 3 weeks after the first surgery.
• When neck nodes are present in 10 % cases, modified radical dissection is done one or both sides.
  167

   

• If secondaries are detected therapeutic dose Ra I¹³¹ is given. L-thyroxin has to be stopped for 6 weeks prior to RT, and then required dose of Ra I¹³¹ is given.
• Secondaries in bone are treated by external radiotherapy. Internal fixation should be done whenever there is pathological fracture.
• There is no role of chemotherapy for follicular carcinoma thyroid.

• High dose of retinoic acid will make I¹³¹ to concentrate in tumor cells (70mg/daily for 2 weeks).
• Fertility should be avoided for 1 year after I¹³¹ therapy.
• Avoid contrast CT in thyroid diseases as much as possible because I¹³¹ study in later period will be difficult.
• MRI is ideal when radioiodine therapy is needed.

• Toothpaste colloid- follicular carcinoma.
• Chewing gum colloid papillary carcinoma.
• Nuclear grooving papillary carcinoma.
• Psammoma bodies papillary carcinoma.
• Amyloid—medullary carcinoma.
• Follicular adenoma aneuploid and in fcdiploid—DNA ploid study.

 

• It is a very aggressive tumour of short duration, presents with a swelling in thyroid region which is rapidly progressive causing-
  1. Stridor and hoarseness of voice.
  2. Dysphagia.
  3. Fixity to the skin.
  4. Infiltration into the carotid sheath-Berry's sign.
• Swelling is hard, with involvement of isthmus and bilateral lateral lobes.
• FNAC is diagnostic.
• Tracheostomy and isthmectomy has got a role to relieve respiratory obstruction temporarily.
  

  Fig. 1.275: Anaplastic carcinoma of thyroid with infiltration through the capsule. It commonly encases the carotid artery causing Berry's sign positive.

  

  Fig. 1.276: Anaplastic carcinoma of thyroid.
  169
• Treatment is external radiotherapy as usually thyroidectomy is not possible.
• However prognosis is poor.

• Proper clinical examination in the neck for residual/nodal disease and for distant spread.
• Whole body radioisotope scan after one week of surgery to see residual tumour in the neck or metastases.
• Estimation of thyroglobulin at regular intervals is very important.
• Follow-up whole body radioisotope scan at 3–6 months intervals. Thyroxine should be stopped for 6 weeks. It is commonly done if thyroglobulin level in the blood is significantly high.

 

• It is uncommon (5%) type of thyroid malignancy.
• It is arises from the para follicular ‘C’ cells which is derived from the ultimo bronchial body (neural crest). They are part of APUD (Amine Precursor Uptake Decarboxylation) cells. C cells are more in upper pole of the thyroid.
• It contains characteristic ‘amyloid stroma’ wherein malignant cells are dispersed.
• In these patients blood levels of calcitonin both basal as well as that following calcium or pentagastrin stimulation is high, a very useful tumour marker.
• Tumour also secretes 5-H.T (serotonin), prostaglandin and vasoactive intestinal polypeptide (VIP).
• It spreads mainly to lymph nodes (60% common).
• It may be associated with MEN II syndrome and phaeochromocytoma with hypertension.
• There may be mucosal neuromas in lips, oral cavity.

 

1. Thyroid swelling often with enlargement of neck lymph node.
2. Diarrhoea, flushing.
3. Hypertension, phaeochromocytoma and mucosal neuromas when associated with MEN II syndrome.
4. Sporadic and familial types occur in adulthood whereas cases associated with MEN syndrome II occur in younger age groups.

 

1. Sporadic: Usually solitary—70%.
2. MCT with MEN II syndrome: MCT with MEN II B with phaeochromocytoma is most aggressive
3. Familial MCT: It is autosomal dominant with proto-oncogene in chromosome number 10. It is commonly multicentric.

 

• FNAC: Shows amyloid deposition with dispersed malignant cells and ‘C’ cell hyperplasia.
• Tumour marker: Calcitonin level will be higher. Normally, it is less than 0.08 ng/L.
• U/S neck-thyroid region.
• Urinary VMA, urinary catecholamines, urinary metanephrine, serum calcium, serum parathormone estimation.
• CT neck and chest to evaluate nodal status is a must.
• 111 Indium octreotide scanning is useful in detecting medullary carcinoma thyroid (70% sensitivity). It is also useful in postoperative follow-up to find out residual/metastatic disease.

 

• Total thyroidectomy with Central node dissection (level 6) in all patients even if there are no nodes in the neck. + Maintenance dose of L-thyroxin.
• Neck lymph nodes block dissection if lymph nodes are involved (bilateral modified radical dissection of neck nodes). Later regular U/S neck to detect early neck nodes.
• Adriamycin is the drug used as chemotherapy with limited results.
• No role of suppressive hormone therapy or radioactive iodine therapy.
• External beam radiotherapy for residual tumour disease.
• Somatostatin/octreotide for diarrhoea.
• If there is associated phaeochromocytoma it should be treated surgically by adrenalectomy first and later only total thyroidectomy is done.
• All family members of the patient should be evaluated for serum calcitonin and if it is high they should undergo prophylactic total thyroidectomy (Can also be assessed by genetic evaluation). If there is positive RET proto-oncogene in MCT with MEN II A and familial MCT types, prophylactic total thyroidectomy is done at the age of 5 years. In positive RET proto-oncogene in MCT with MEN II B prophylactic total thyroidectomy is done at the age of one year.
• MCT with associated parathyroid hyperplasia (30%) in MEN IIA, total thyroidectomy with central nodal dissection with total parathyroidectomy and autotransplantation of half of gland in sternomastoid or non-dominant forearm brachioradialis muscle.

 

• Sporadic MCT and MCT with MEN II are aggressive.
• Familial MCT not associated with MEN II has got better prognosis.

 

• It is NHL type. Occurs in a pre-existing Hashimoto's thyroiditis (Not proved well).
• FNAC is useful to diagnose the condition.
• Chemotherapy is the main treatment.
• Often total thyroidectomy is done to enhance the results.

 

• Also called as diffuse nongoitrous thyroiditis
• It is an autoimmune thyroiditis is common in women.

 

1. Painful, diffuse, enlargement of usually both lobes of thyroid which is firm, tender and smooth (occasionally one lobe is involved).
2. Initially, they present with toxic features but later, they manifest with features of hypothyroidism.

   Hyperplasia	→ Hyperthyroid.
   	→ Euthyroid.
   Fibrosis	→ Hypothyroid.

3. There may be hepatosplenomegaly.
4. It is often associated with other autoimmune diseases.
5. In 85% cases significant rise in the thyroid antibodies (microsomal, thyroglobulin, or colloid antibodies) is observed.
6. Papillary carcinoma may develop in Hashimoto's thyroiditis.
7. Often condition may be associated with or may predispose to malignant lymphoma. It is at present not well proved.

   

1. L-thyroxine therapy.
2. Steroid therapy often is helpful.
3. If goitre is large and causing discomfort, then subtotal thyroidectomy is done.

   

• Pain is diffuse, swelling in thyroid which is tender.
• Commonly seen in females.
• Initially, there will be transient hyperthyroidism with high T³ and T⁴ but poor radioiodine uptake.
• It is usually a self limiting disease.

 

• A very rare benign entity wherein thyroid tissue is replaced by fibrous tissue which interestingly infiltrates the capsule into muscles, paratracheal tissues, carotid sheath.
• It is often associated with retroperitoneal and mediastinal fibrosis (Woody Thyroiditis, Ligneous Thyroiditis).

     

• T³, T⁴ may be low due to hypothyroidism.
• Radioisotope scan will not show any uptake.
• FNAC to rule out carcinoma.

       

1. Hemithyroidectomy: Along with removal of one lobe, entire isthmus is removed. It is done in benign diseases of only one lobe.
2. Subtotal thyroidectomy commonly done in toxic thyroid either primary or secondary and also often for nontoxic multinodular goitre. Here about 8 grams, or a tissue, size of pulp of finger is retained on lower pole, on both sides and rest of the thyroid gland is removed.
3. Partial thyroidectomy is removal of the gland in front of trachea after mobilization. It is commonly done in nontoxic multinodular goitre.
4. Near total thyroidectomy: Here both lobes except the lower pole which is very close to recurrent laryngeal nerve and parathyroid is removed. It is done in case of papillary carcinoma of thyroid.
5. Total thyroidectomy: Entire gland is removed. It is done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid.

 

• Blood grouping and cross matching. Keep the required blood ready.
• Indirect laryngoscopy. Patient is asked to tell' E' to check the abduction of vocal cord.
• Serum calcium estimation—ionic calcium
• T3, T4, TSH.
• Thyroid antibodies.
• ECG and cardiac fitness especially in toxic goitre.

   

1. Haemorrhage: May be due to slipping of ligatures either superior thyroid artery or other pedicles. It will cause tachycardia, hypotension, breathlessness, and compression over the trachea may cause severe stridor, respiratory obstruction. As a first aid, immediate release of sutures including that of deep fascia has to be done and pressure over the trachea is released. Then patient is shifted to operation theatre, and under general anaesthesia exploration is done and bleeders are ligated. Blood transfusion may be required.
2. Respiratory obstruction. It may be due to haematoma (if it is so, the haematoma has to be evacuated), or due to laryngeal oedema. For laryngeal oedema, immediate emergency endotracheal intubation is done along with steroid injections. Often emergency tracheostomy may be required as a life saving procedure.
3. Recurrent laryngeal nerve palsy: It can be transient or permanent. Transient is 3% common. They usually recover in 3 weeks to 3 months. Often they require steroid supplement and speech therapy. Permanent paralysis is rare.
4. Hypoparathyroidism is rare 0.5% common. Mostly it is temporary due to vascular spasm of parathyroid glands, occurs in 2–5th postoperative day. Present with weakness, +ve Chvostek's sign, carpopedal spasm, convulsions. Serum calcium estimation has to done and then 10 ml of 10% calcium gluconate— is given IV eighth hourly, and later supplemented by oral calcium 500 mg 8th hourly.175
   

   Figs 1.289A and B: Anatomical location of recurrent laryngeal nerve. Note the different variations of recurrent laryngeal nerve.
   After 3–6 weeks, patient is admitted, drug is stopped and serum calcium level is repeated.
   

   Fig. 1.290: Note the location of parathyroid glands.
5. Thyrotoxic crisis (Thyroid storm): Occurs in a thyrotoxic patient inadequately prepared for thyroidectomy and rarely a thyrotoxic patient presents in a crisis following an unrelated operation or stress. They present in 12–24 hours with severe dehydration due to circulatory collapse, hypotension, hyperpyrexia, and often cardiac failure.
   Treatment is injection hydrocortisone, oral antithyroid drugs, tepid sponging of whole body, beta blocker injection, oral iodides, large amount of IV fluids for rehydration, digitoxin, cardiac monitor, often ventilator support, and observation. It has got high mortality rate with critical period of 72 hours. Fluid and electrolyte management, cardiac management are important aspects to be monitored and treated.
   176
6. Injury to external laryngeal nerve causes weakness of cricothyroid muscle leading to alteration in pitch of voice.
7. Hypothyroidism. Revealed clinically after 6 months.
8. Wound infection, stitch granuloma formation.
9. Keloid formation.

     

1. Swelling in the midline, towards the left.
2. Moves with deglutition as well as with the protrusion of tongue. Patient is asked to open the mouth and keep the lower jaw still. Examiner holds the cyst between the thumb and forefinger. When the patient is asked to protrude the tongue, a ‘tugging sensation’ can be felt.
3. Swelling is smooth, soft, fluctuant, (cystic), nontender, mobile, often transilluminant.
4. Thyroid fossa is empty, if there is no thyroid in normal location.
5. Thyroglossal cyst can get infected and may form an abscess.
6. Malignancy can develop in thyroglossal cyst (Papillary carcinoma).

 

1. Radioisotope study I¹³¹.
2. U/S neck.
3. FNAC from the cyst.
4. T3, T4 and TSH estimation.

 

1. Sistrunk operation: Excision of cyst along with full tract up to the foramen caecum is done along with removal of part of the body of the hyoid bone as the tract passes through it. Anaesthetist should wear a glove and support and guide over the posterior third of the tongue while reaching the tract to foramen caecum.
2. If there is no normal thyroid gland after the surgery, maintenance dose of l-thyroxine 0.1 mg od is given life long.

 

• It is not a congenital condition.
• It either follows infection of thyroglossal cyst which bursts open or after inadequate removal of the cyst.
• It is lined by columnar epithelium, discharges mucus, and is a seat of recurrent inflammation. ‘Hood sign’ is characteristic.

     

• It is an autosomal recessive condition wherein there is either deficiency of thyroid enzymes (either peroxidase or dehalogenase) or inability to concentrate or to bind or to retain iodine.
• It may be familial and patient presents with large diffuse vascular goitre involving both lobes.
• They respond very well to L-thyroxine and may not require surgery at any time.
• Condition may be associated with congenital deafness which is being called as Pendred's syndrome.

   

1. Dysphagia.
2. Speech impairment.
3. Respiratory obstruction.
4. Haemorrhage.

 

• Radioisotope study shows the uptake of iodine by the lingual thyroid and also says the status of the thyroid in normal fossa.
• U/S neck has to be done to see the absence of thyroid in normal location.
  180

   

1. I¹³¹—is used for radioactive iodine therapy (beta rays).
2. I¹²³—is used for diagnostic studies (gamma rays).

• Hot area suggests more uptake,
• Warm area suggests normal uptake,
• Cold area suggests no uptake.

1. Doubtful toxicity.
2. Ectopic thyroid.
3. Autonomous toxic nodule.
4. After total thyroidectomy, to look for secondaries in follicular carcinoma thyroid.
5. Retrostrernal thyroid.

 

1. In primary thyrotoxicosis after 45 years.
2. In autonomous toxic nodule after 45 years, it is useful as remaining gland still will function adequately after radiotherapy (As during radiotherapy radioisotope will not be taken up by this retained normal gland as it is suppressed in the presence of toxic nodule which will function later adequately).
3. In follicular carcinoma of thyroid, after total thyroidectomy, if there are secondaries elsewhere in the body, as in bone or lungs, then radioiodine therapy is given. I¹³¹ is given as its half-life is 8 days. Patient should be isolated for this period. It is given orally in a dose of 5 milli curies (160 micro curie/gm of thyroid).

 

• Pain: Site, nature, aggravating or relieving factors, duration of pain, referred pain.
• Vomiting: Type, content, haematemesis, relation to food, frequency.
• Jaundice: It is an important factor in relation to liver, gallbladder or pancreatic masses.
• Bowel habits: Constipation, diarrhoea, bloody diarrhoea, furious diarrhoea, tenesmus.
• Decreased appetite and weight.
• Inspection of the mass: Anatomical location, margin, surface, movement with respiration.
• Palpation of the mass: Site, extent, surface, tenderness, consistency, movement with respiration, mobility, borders, plane of the swelling (by leg rising test), presence of other masses.
• Percussion is an important aspect of examination in case of a abdominal mass. Percussion over the mass is important to predict the anatomical location of the mass. If mass is dull, then it is in the anterior abdominal wall or in front of the bowel intra- abdominally like liver, spleen, gallbladder, etc. If the mass is with a impaired resonant note, then the mass is arising from the bowel like stomach, colon, small bowel. If the mass is resonant on percussion, then the mass is probably in the retroperitoneal region. Other than this, liver dullness, free fluid in the abdomen should be elicited during percussion.
• Per/rectal examination: It is done to look for any secondaries in recto-vesical pouch, primary tumour or relation of lower abdomen masses (pelvic masses).
• Pervaginal examination is done to assess pelvic masses.

     

1. Upper horizontal or transpyloric line is mid-way between the suprasternal notch and symphysis pubis or line between tips of ninth costal cartilages on each side. It is often midway between xiphisternum and umbilicus.
2. Lower horizontal line is transtubercular line at the level of two tubercles (5 cm behind the anterior superior iliac spine along the iliac crest) on the iliac crest.
3. Right vertical line is the line through the midpoint of right anterior superior iliac spine and pubic symphysis. It is usually a line joining midclavicular and midinguinal points.
4. Left vertical line is the line thro' the midpoint of left anterior-superior iliac spine and pubic symphysis. It is usually a line joining midclavicular and midinguinal points.

 

• Mass per abdomen – duration, progress, site, mass appearing/disappearing (like intussusception, Dietl's crisis hydronephrosis kidney, and choledochal cyst).
• Pain in the abdomen – region of pain to be mentioned; duration of pain.
• Vomiting – duration.
• Haematemesis, malaena – duration.
• Satiety – sensation of fullness after taking food (early satiety signifies gastrointestinal pathology like carcinomas.
• Yellowish discoloration of sclera – duration.
• Loss of appetite and decreased weight – weight loss more than 10 kg in short period/6 months is significant.
• Altered bowel habits/constipation/diarrhoea.
• Fever – its character like in abdominal tuberculosis, amoebic liver abscess, cholangitis, malignancy with tumour necrosis, infected pseudocyst of pancreas.

     

• Site of origin of pain — onset (sudden/insidious); duration.
• Radiation of pain/referred pain.
• Type of pain — intermittent/persistent; dull, severe pricking, colicky.
• Periodicity with an interval of free period — ulcer pain has got often periodicity unless it is complicated.
• Relation to food intake — more/less/not related to meals.
• Relation to vomiting/induced vomiting.
• Aggravating/relieving factors.
• Pain in relation to bowel habits/urinary habits.

 

• Duration, frequency, relation to food, (type projectile/effortless).
• Vomitus – content (food/blood/bile), quantity, smell, colour – coffee ground/bloody/yellow, taste.
• Relation to pain, details of haematemesis if present.
• It is better to ask the patient to collect and keep the vomitus and clinician should personally observe it.

 

• Duration, color–greenish yellow suggests obstruction, severity, progress – progressive/intermittent/static/reducing.
• Presence of fever with jaundice – cholangitis.
• Association with pruritus, clay stool/silvery stool.

   

• Frequency/urgency/haematuria/pyuria/oliguria/painful urination/burning urine/difficulty in passing urine/hesitancy/hiccough/oedema feet or face.
  183
• Relation of urinary symptoms to pain, mass in abdomen.

               

• Inspection of the abdomen is done in supine position with exposure from midchest to midthigh region with arms extended. Inspection is done from side of the bed as well as from foot end with eye level at the level of the patient.
  

  Figs 1.303A and B: Proper exposure of the abdomen is important from midchest to midthigh and position of the patient for proper abdominal examination.

  

  Figs 1.304A and B: Inspection of the abdomen should be done at the level of the patient's abdomen both from right side as well as from foot end.
  184
• Shape–contour–normal/scaphoid/distended.
• Skin over the abdomen–stretched/pigmented/presence of scar–healed primarily or secondarily/site of scar/length and width of scar; whether there is incisional hernia or not.
• Dilated veins over the abdomen – caput medusae – is radiating dilated veins from the umbilicus – seen in portal hypertension. In inferior vena cava obstruction, (lateral abdominal wall) dilated veins are visible with their blood flow are from below upwards towards superior vena cava. In superior vena cava obstruction dilated veins with blood flow from above downwards. Dilated veins should be inspected in standing position and also direction of flow should be checked by placing two fingers apart over the vein and to release the finger one by one to see the direction of blood flow. Normally, above the umbilicus abdominal wall drains to superior vena cava and below the umbilicus towards inferior vena cava—water shed area.
  

  Fig. 1.305: Superior vena caval obstruction causing dilated veins in the neck chest wall and shoulder. Note the neck swelling extending into the mediastinum.
• Movements with respiration of regions.
• Pulsations over the mass or any region – patient should hold the breathing after full expiration to see pulsations.
• Inspection for visible peristalsis–Visible gastric peristalsis (VGP) is seen in upper middle region with waves beginning at left upper abdomen directing downwards and towards right to umbilical region. It is stimulated by drinking glass of water or by massaging the epigastrium. It signifies gastric outlet obstruction. It may be absent in gastric outlet obstruction if gastric paresis develops and stomach becomes dilated but silent without any motility. Visible intestinal peristalsis (VIP) is step ladder pattern in central abdomen from left to right or vice versa in umbilical region. Visible colonic peristalsis may be obvious from right to left along the line of colon.
  

  Figs 1.306A and B: Inferior vena caval obstruction causing dilated veins over the lateral aspect of the flank with flow of blood upwards.
• Inspection of the mass — its location (exact location should be mentioned as in which region and then its extension into the other region should be mentioned later); extent; approximate size; well defined or ill defined (often mass is not clearly seen but fullness is visible); margin whether clear or not or which part is clear and which part is not clear; mass movement with respiration present or not (upper abdomen mass like liver, stomach, spleen, gallbladder, omental mass, kidney mass moves with respiration). Mass which is initially mobile once gets fixed to retroperitoneum or deeper plane may not be mobile later. Mass initially not mobile once gets attached to structures like omentum may start moving with respiration occasionally. Lower abdominal mass, retroperitoneal mass 185will not usually move with respiration. Mass which comes in contact with diaphragm closely will move with respiration. Composite mass may move with respiration because of its component like omentum, lymph nodes, bowel, etc.
  

  Fig. 1.307: Visible large mass upper abdomen – could be liver/pseudocyst of pancreas/retroperitoneal mass
• Carnett's test – raising test (head or leg): It is done to confirm whether mass is in the abdominal wall or intra-abdominal. Mass is seen initially and palpated and patient is asked to raise his head and if mass disappears, it is intra-abdominal; if becomes more prominent it is in the abdominal wall.
  

  Fig. 1.308: Head raising test should be done to find out whether mass is intra-abdominal or in the abdominal wall.
• Umbilicus—position, everted/inverted. Tanyol sign: Umbilicus is shifted upwards in pelvic/ovarian mass and shifted downwards in ascites.
• Hernial orifices and genitalia inspection – is a must.

 

• While palpating the abdomen patient should take deep breath with open mouth to relax the abdomen otherwise it is difficult to get proper finding. Hands should be warm and forearm should be horizontal at the same level as patient's abdomen.
  

  Fig. 1.311: Checking the temperature of the abdomen using dorsum of the hand.
  186
  

  Fig. 1.312: Palpation of abdominal mass using fingers.

  

  Fig. 1.313: Lower abdominal mass–retroperitoneal tumour/ovarian tumour/uterine mass.
  Palpation is done with ventral aspect of the fingers. Legs should be partially flexed at hips and knees.
• Liver is palpated by placing flat of the hand parallel to the right costal margin – initially near right iliac fossa with fingers towards upwards up to the margin of the right rectus. Slowly with each phase of respiration fingers should be moved upwards towards right hypochondrium to feel the lower margin of the liver. Then feel the surface of the liver for tenderness, nodularity, round/sharp margin.
  

  Figs 1.314A to C: Method of palpating the liver right lobe and left lobe.
  187
  Level of lower margin at should be measured in centimeters from right costal margin. In children below 3 years, liver is 3 cm below the right costal margin. Liver is not palpable or just palpable in normal adult. Whenever there is ascites liver is palpated by ‘dip method’ (dipping fingers quickly so as to displace the fluid).
• Gallbladder palpation—normally it is not palpable. When enlarged its lower margin may be in right side of umbilical region/right lumbar region/right iliac fossa. It moves with respiration, globular in shape, smooth and soft, may be horizontally mobile but not vertically, upper margin merges under the liver when liver is enlarged or under the right costal margin. It is usually in right hypochondrium, just right of the right rectus muscle.
• Murphy's sign is elicited in sitting position. While palpating in gallbladder area during summit of inspiration, patient winces with pain. During deep inspiration, inflamed gallbladder comes down and touches the gallbladder to cause tenderness. It is observed in chronic cholecystitis. If it is elicited in lying down position it is called as Moynihan's sign.
• Stomach is palpated in the epigastrium. Entire stomach may be dilated and palpable due to gastric outlet obstruction. Succussion flash and auscultopercussion tests should be elicited in such occasion.

     

• Small bowel mass is felt as mobile, localized mass with resonant or impaired resonant note. It does not move with respiration. Intussusception is sausage shaped mass with concavity towards umbilicus. It appears and disappears; contracts under the palpating finger.192
  

  Fig. 1.322: Renal bruit should be auscultated.

  

  Fig. 1.323: Often abdominal mass also should be examined in side position to get better feeling and findings.
• All masses in the lower quadrants should be palpated after emptying urine or passing a urinary catheter. Upper border is clearly felt but not lower border which merges into the pelvis. Mass also should be bimanually palpated by placing fingers in rectum or per vagina.
• External genitalia should be palpated for any swelling/loss of testicular sensation, secondary hydrocele.
• Often there will be many masses in the abdomen. So once one mass is felt always look for other relevant mass also.
• Retroperitoneal masses and pulsatile mass like aneurysms should be examined in knee- elbow/knee – chest position.
  

  Fig. 1.324: Lower border of the mass is very important in lower abdominal masses. Bladder should be emptied or catheterised before palpation.

  

  Figs 1.325A and B: Intrinsic mobility of the mass should be checked in all abdominal masses.
  193
  

  Fig. 1.326: external genitalia should be palpated for mass/hydrocele, etc.
  Retroperitoneal mass will not fall forward whereas intra-abdominal mass will fall forward. Aortic aneurysm with expansile pulsation will retain its pulsation whereas mass with transmitted pulsation will show reduced/absent pulsation in knee- elbow position.

 

• Liver dullness should be assessed by percussion. It is done by percussion from above downwards over right intercostal spaces in midclavicular line. Liver span also can be assessed by this.
• Percussion over the mass is very important. Mass in front of the bowel is dull on percussion like parietal/abdominal wall mass, liver, spleen, gallbladder, etc. Mass from the stomach/small bowel/colon shows impaired resonance on percussion. Mass from retroperitoneum shows resonance on percussion.
• Percussion for free fluid is important. Patient in supine position, initially percussion is done over the epigastrium to confirm resonance note. Then percussion is continued over one side flank until one gets dullness. Patient is tilted towards opposite side to make area of percussion outwards so as to displace the fluid from that side.
  

  Figs 1.327A to C: Knee elbow position–palpation of retroperitoneal mass. Mass can be held to check mobility, relations, etc.
  194
  

  Fig. 1.328: Liver dullness should be assessed (upper border of liver) by percussing from above in intercostal spaces midclavicular line downwards until dullness is elicited and space is marked.

  

  Fig. 1.329: Percussion over the mass is essential to say whether mass is anterior to bowel (dull); from the bowel (impaired resonant) or behind the bowel (resonant).

  

  Fig. 1.330: Looking for minimal ascites in knee-elbow position – Puddle sign.

  

  Figs 1.331A to C: Massive ascites. Eliciting fluid thrill in massive ascites.
  195
  After 1–2 minutes (time to allow fluid to shift towards opposite side) without removing the fingers same area is percussed to get resonance note which confirms the presence of fluid. For massive ascites, fluid is confirmed by eliciting fluid thrill. Patient's side of the hand is placed over the midline epigastrium firmly. Examiner should keep his one hand over one lumbar region and with fingers of other hand on the opposite lumbar region tapping is done to elicit fluid movement as fluid thrill. Small quantity of fluid can be elicited in knee elbow position. In this position over the umbilical site percussion is done to elicit dullness which signifies positive puddle sign—signifying minimal ascites.
• Percussion over renal angle for resonance (normal) or dullness (abnormal).
• Auscultation for bowel sounds, bruit over the renal artery just side of the umbilicus, over the mass like liver which signifies vascularity, over aneurysm for bruit.
• Left supraclavicular fossa between two heads of sternomastoid muscle should be palpated for Virchow's node enlargement – Troisier's sign—as secondary deposits.
• Examination of respiratory system for effusion, altered breath sounds suggestive of metastases.
• Examination of skeletal systems—sternum, spine, skull and other bones for tenderness, swelling, pathological fracture, neurological deficits.
• Digital examination of rectum (Per Rectal examination/P/R): P/R must be done in all abdominal mass cases. It is done in lateral position towards left side of the patient with right leg is flexed completely and left is straight. After informing patient above the technique and consent, procedure is done. Xylocaine jelly is applied over the anus. It is inspected for discharge, opening, skin changes and swelling. Pulp of the gloved right index finger is gently pushed into the anorectum in the direction of the umbilicus.
  

  Figs 1.332A to D: Confirming ascites/free fluid in the peritoneal cavity by percussion—classical method.
  196
  

  Figs 1.333A and B: Spine and other skeletal system should be examined in mass abdomen patient.
  Sphincter tone is assessed. Posteriorly sacral curvature, rectal mucosa are assessed. Finger is turned towards front. Prostate, its texture, size, median groove are felt. Rectum is palpated for any growth, stricture or secondary nodule in front above (as a hard nodule with free rectal mucosa – Blumer shelf). Gently finger is removed and finger tip should be inspected for content staining – blood/mucus/pus, etc. P/R is contraindicated in acute fissure in ano.

   

• It is horizontally placed.
• It usually moves with respiration.
• Upper border is not felt.
• It is dull on percussion. (This dullness continuous over liver dullness above).
• Fingers cannot be insinuated under right costal margin.

 

1. Soft, smooth, nontender liver—
   • Hydrohepatosis. It is due to obstruction of CBD causing dilatation of intrahepatic biliary radicles.
   • Congestive cardiac failure.
     

     Figs 1.334A to C: Digital examination of the rectum is important (P/R; Per Rectal examination).
     197
   • Hydatid cyst of the liver — Here mass is well localized in the liver with typical hydatid thrill (Three fingers are placed over the mass widely. When central finger is tapped fluid movement is elicited in lateral two fingers).
2. Soft, smooth, tender liver:
   • Amoebic liver abscess. Here liver often gets adherent to the anterior abdominal wall and will not move with respiration. Intercostal tenderness, right sided pleural effusion are common.
3. Hard, smooth liver:
   • Hepatoma: (HCC): Here a large single hard nodule is palpable in the liver. But occasionally there can be multiple nodules when it is multicentric. Rapidly growing tumour can be soft also. Hepatoma often can also be tender due to tumour necrosis or stretching of the liver capsule. Vascular bruit may be heard over the liver during auscultation. It mimics amoebic liver abscess in every respect.
   • Solitary secondary in liver.
4. Hard, multiple nodular liver:
   • Multiple secondaries in liver: Hard nodules here are having umbilication which is due to central necrosis.
   • Macronodular cirrhotic liver.

 

• It is smooth and soft (Except in carcinoma gallbladder).
• It is mobile horizontally (side-to-side).
• It moves with respiration.
• It is located right of the right rectus muscle, below the right costal margin or below the lower margin of the palpable liver.
• It is dull on percussion.

1. Soft, nontender gallbladder:
   • Mucocele of the gallbladder.
   • Enlarged gallbladder in obstructive jaundice due to carcinoma head of the pancreas or periampullary carcinoma or growth in the CBD.
   

   Figs 1.335A and B: Multiple secondaries in liver with umbilication. It is due to central necrosis. Secondaries are the commonest malignant tumour of the liver. It could be from GIT or extragastrointestinal like from breast, lungs, melanoma, thyroid, prostate, kidneys, etc. Patient with liver secondaries has got poor general condition. It should be differentiated from multicentric hepatoma. It is usually treated by palliative chemotherapy. Solitary secondary from carcinoma colon can be removed by segmentectomy. It has got poor prognosis.
2. Hard gallbladder:

     

• Absence of gallbladder
• Intrahepatic gallbladder
• Previous cholecystectomy
• Double impacted stone
• Large stone in Hartman's pouch.

   

1. Biliary atresia.
2. Choledochal cyst.
3. CBD stones.
4. Ascending cholangitis.
5. Biliary strictures.
6. Sclerosing cholangitis.
7. Carcinoma of head and periampullary region of the pancreas.
8. Cholangiocarcinoma.
9. Klat skin tumour (Carcinoma at the confluence of hepatic ducts above the level of the cystic duct and so will cause hydrohepatosis without GB enlargement).
10. Extrinsic compression of CBD by lymph nodes or tumours.
11. Parasitic infestations.

 

1. Congenital: Biliary atresia, choledochal cyst.
2. Inflammatory: Ascending cholangitis, sclerosing cholangitis.
3. Obstructive: CBD stones.
4. Neoplastic: Carcinoma of head or periampullary region of pancreas, cholangiocarcinomas, Klatskin tumour.
5. Extrinsic compression of CBD by lymph nodes or tumours.

 

1. Serum bilirubin. Normal value is less than 1.0 mg%. Both direct and indirect are assessed. Direct is increased in obstructive jaundice, 200i.e. conjugated hyperbilirubinaemia. Vandenberg test is done.
2. Serum albumin, globulin and A: G ratio. Normal S. albumin is more than 3.5 gm%.
3. Prothrombin time. Normal value is 12–16 seconds. If more than 4 from the control or more than one and half times the control is significant. It is corrected by injection vitamin K 10 mg IM od for 5 days or by fresh blood transfusion.
4. Serum alkaline phosphatase, SGPT, SGOT, 5'nucleotidase.
5. U/S abdomen.
6. ERCP to visualize site of obstruction, brush biopsy, bile sample for analysis.
7. MRCP—Noninvasive diagnostic tool.
8. CT scan in case of tumours to assess operability.
9. Urine tests: Fouchet's test for bile pigments, Hay's test for bile salts and test for urobilinogen in urine.

 

• Proper diagnosis and assessment.
• Injection Vitamin K IM 10 mg for 5 days.
• Fresh Frozen plasma—often requires 6 bottles or more.
• Blood transfusion in case of anaemia.
• Oral neomycin, lactulose.
• Mannitol 100–200 ml BD IV to prevent hepato- renal syndrome.
• Repeated monitoring by doing prothrombin time, electrolytes.
• Antibiotics like third generation cephalosporins.
• Calcium supplements as calcium chloride IV.

 

• CBD stones—ERCP stone removal, choledocholithotomy, transduodenal sphincteroplasty, choledochojejunostomy or Choledochoduodenostomy.
• Carcinoma periampullary or head of pancreas—Whipples operation or Triple bypass or ERCP stenting.
• Biliary stricture—Stenting, choledocho- jejunostomy, Roux en Y hepaticojejunostomy.
• Klatskin tumour—Radical resection or palliative stenting.
• Biliary atresia—Kasai's operation or liver transplantation.
• Choledochal cyst—Excision, hepatico- jejunostomy, mucosal resection.

 

• Monitoring with prothrombin time, bilirubin, albumin, creatinine, electrolyte estimation.
• FFP or blood transfusion.
• Antibiotics.
• Observation for septicaemia, haemorrhage, pneumonia, pleural effusion, bile leak.
• Care of T tube and drains.
• T tube cholangiogram in 10–14 days.
• TPN, CVP line, nasogastric tube, urinary catheter.

 

• Prehepatic – portal/splenic vein thrombosis, trauma, periportal inflammation, hypercoagulable status, neonatal umbilical sepsis.
  201
• Hepatic (80%) – cirrhosis, idiopathic, primary biliary cirrhosis, hepatitis, schistosomiasis, Wilson's disease, haemochromatosis, congenital hepatic fibrosis.
• Posthepatic—Budd-Chiari syndrome, constrictive pericarditis, veno occlusive disease, congestive cardiac failure.

     

• It is in the epigastric region.
• Its upper border cannot be felt.
• It moves with respiration.
• It extends towards left hypochondriac region.
• It is dull on percussion.

• Hepatoma.
• Amoebic liver abscess in left lobe.
• Left lobe secondaries.
• Hydatid cyst of the left lobe.

 

• It is in the epigastric region.
• It moves with respiration. It is intra-abdominal.
• It is resonant or impaired resonant on percussion.

  	Child A	B	C
  Bilirubin	< 2.0 mg	2.0–3.0 mg	> 3.0 mg
  Albumin	> 3.5	3.0–3.5	< 3.0
  Ascites	None	Controlled	Uncontrollable
  Mental status	Normal	Disoriented	Coma
  Nutrition	Very good	Good	Poor
  Score	5–6	7–9	10–15
  P.T.	Increase up to 3	Increase between 3 and 6	Increase > 6
  (Pugh's modification)

  202
  

  Figs 1.339A and B: Different masses at different regions in the abdomen.
  

  Figs 1.340: Hepatosplenomegaly is the common condition (clinical entity). It is due to macronodular cirrhosis with portal hypertension, lymphoma, autoimmune diseases, congestive cardiac failure, hepatoma with portal hypertension, haemolytic diseases, etc. There may be ascites, supraclavicular palpable lymph node, pleural effusion (right sided).
• Mass may be better felt on standing or on walking.
• Mass is often mobile, unless it gets adherent posteriorly.
• In pylorus mass, all margins are well felt which is mobile with features of gastric outlet obstruction.
• Mass from the body of the stomach is horizontally placed without any features of obstruction.
• Mass from the upper part of the stomach near the OG junction causes dysphagia.
• Mass from the fundus of the stomach is in the upper part of the epigastric region towards left side.
• Carcinoma stomach is nodular and hard. It is commonest cause for stomach mass.
• Leiomyoma of stomach is smooth and firm.

 

• Mass in the epigastric region. It is smooth, soft. It can be tender if it gets infected.
• It does not move with respiration.
• It is not mobile.
• It has got transmitted pulsation. It is confirmed by placing the patient in knee-elbow position.
• Lower border is well felt. Upper border is not clear.
• It is resonant on percussion.
• Baid test: Because stomach is pushed in front, Ryle's tube when passed, can be felt per abdomen on palpation.

   

• It is carcinoma of transverse colon.
• It is mobile, horizontally placed, nodular, hard mass which does not move with respiration. Caecum will be dilated and palpable.
• It is resonant or impaired resonant on percussion.
• Patient will be having bowel symptoms, loss of appetite and decreased weight.

 

• Mass in the epigastric region which is deeply placed, not mobile, not moving with respiration.
• It is vertically placed, above the level of the umbilicus and resonant on percussion.
• Causes for enlargement are: Secondaries, Lymphomas or Tuberculosis.

     

• Spleen has to enlarge three times to be palpated clinically.
• It enlarges towards the right iliac fossa from left costal margin.
• It moves with respiration, mobile, obliquely placed, smooth, soft or firm, with a notch on the lower margin.
• Fingers cannot be insinuated over the upper border.
• ‘Hook sign’ is positive, i.e. one cannot insinuate the fingers under the left costal margin.
• It is dull on percussion.

 

• It is mobile, nodular, and resonant.
• It does not move with respiration.
• It is commonly due to carcinoma colon.

   

• It does not move with respiration. It is not mobile.
• It is deeply placed mass. Often it crosses the midline.
• It is resonant on percussion. It mimics kidney mass.

     

• There will be fullness in the loin which is better observed in sitting position.
• Mass moves with respiration. It is vertically placed.
• It is bimanually palpable. It is ballotable.
• Renal angle is dull on percussion (Normally it is resonant due to colon).
• There is a band of resonance in front due to reflected colon.
• It does not cross the midline.

   

• It is smooth, soft, lobulated, nontender mass.

 

• History of throbbing pain in the loin, pyuria and fever with chills.
• It is smooth, soft and tender kidney mass.

 

• History of loin pain and haematuria.
• Hypertension, anaemia and features of renal failure.
• Usually bilateral. But one side can present early than on the other side.
• Lobulated smooth surface.

 

• History of mass in the loin, haematuria, fever and dull pain.
• Mass is nodular and hard.
• It does not crosses the midline.
  206

 

• History of altered bowel habits with decreased appetite and weight.
• Mass is nodular, hard which does not move with respiration and is not ballottable.
• It is resonant or impaired resonant on percussion.
• Renal angle is resonant.
• Proximal dilated bowel may be palpable.

 

• It is nodular and hard.
• It does not move with respiration.
• It is not mobile and often crosses the midline.
• It is felt on deep palpation.
• It is resonant in front.
• It is not ballottable.

 

• They are not mobile, resonant and do not fall forward in knee-elbow position.
• They are deeply placed mass which are usually smooth and hard.
• They may be retroperitoneal sarcomas or teratomas, etc.

   

• Mesenteric cyst.
• Omental cyst.
• Ovarian cyst (Pedunculated).
• Small bowel tumours.
• Extension of masses from other region.

 

• Tillaux triad:
  • - Soft intra-abdominal umbilical region mass.
  • - Mobile in the direction perpendicular to the attachment of the mesentery.
  • - Resonant mass.
• May precipitate intestinal obstruction, volvulus.

 

• It is smooth, soft and nontender.
• It moves with respiration. It is mobile in all directions.
• It is dull on percussion.

 

• Small bowel lymphomas.
• Small bowel carcinomas.
• Intussusception.

 

• Mass in umbilical region usually towards left and above the umbilicus.
• Occasionally towards right side.
• Mass is intra-abdominal which is sausage shaped, well-defined, smooth, firm and mobile.
• Mass does not move with respiration.
• Mass contracts under palpating fingers.
• Often mass disappears and mass reappears.
• Mass is resonant or impaired resonant on percussion.
• ‘Red currant jelly’ stool with features of intestinal obstruction may be present.
  207

 

• Appendicular mass or abscess.
• Carcinoma caecum.
• Ileo-caecal tuberculosis.
• Amoeboma.
• Psoas abscess.
• Lymph node mass either mesenteric or external iliac lymph nodes.
• Bony swellings.
• Ectopic kidney.
• Undescended testis (Abdominal).
• Actinomycosis.
• Crohn's disease.
• Iliac artery aneurysm.
• Ovarian swelling-ovarian cyst, tubo-ovarian mass.
• Tubo-ovarian mass.
• Uterine mass: like pedunculated fibroid.

 

• It is smooth, firm, tender mass in the right iliac fossa.
• It is not mobile. It does not move with respiration.
• It is resonant on percussion. It is well localized mass with distinct borders.

   

• It is nodular, hard mass in the right iliac fossa.
• It does not move with respiration.
• It is mobile but mobility may be restricted once it gets adherent to psoas muscle.
• Mass is resonant or impaired resonant on percussion.
• Often features of intestinal obstruction may be there.

 

• Mass in the right iliac fossa which is smooth, hard, resonant and nontender.
• It does not move with respiration and has restricted mobility.
• Caecum may be pulled up to lumbar region due to fibrosis.
  208

 

• H/O dysentery with pain in the right iliac fossa.
• Smooth, hard, well-defined mass in the right iliac fossa which is not mobile.
• It may or may not be tender.

 

• It is localized; smooth, soft, nonmobile mass in the right iliac fossa.
• Psoas spasm (flexion of the hip joint) is typical.
• Spine may show gibbus, tenderness, paraspinal spasm. Spinal movements will be restricted.

 

• Carcinoma sigmoid or descending colon.
• Bony masses.
• Ovarian/uterine masses.
• Psoas abscess.
• Ectopic kidney.
• Lymph node mass.
• Undescended testis.

   

• It is in the midline. It is dull on percussion. Lower border is not felt.
• It can be mobile in horizontal direction. Mass reduces in size after emptying the bladder. It can be felt on per-rectal examination.
• It is either carcinoma bladder (common) or leiomyoma or sarcoma bladder.

 

• It is midline mass which is smooth, hard.
• Lower border is not felt which extends in to the pelvis.
• It is felt on pervaginal examination.

 

• Pelvic soft tissue mass.
• In all lower abdomen masses P/R and or P/V is must.

 

• Haematocrit, liver function tests, renal function tests, stool/urine examination.
• Ultrasound abdomen.
• Endoscopies-Gastroscopy-Colonoscopy-ERCP.
• Barium studies-Barium meal-Barium enema- Barium meal follow through.
• CT scan – contrast CT is ideal for mass abdomen. It clearly gives idea about the origin of mass, its extent and operability, vascularity, relation to major vessels. Intravenous as well as oral water soluble iodine contrast agent should be given.
• MRI, MRCP.
• Endosonography.
• Ascitic tap.
• Diagnostic laparoscopy.
• U/S guided/CT guided biopsy.
• IVU/RGP/Cystoscopy/Isotope renogram.
• Exploratory laparotomy.