Fistula

Definition of Fistula:

Fistula is defined as an abnormal tract lined by epithelium,endothelium,granulation tissue or fibrous tissue connecting two epithelial surfaces either in between the exterior and an internal viscus(External fistula) or in between two internal viscera(Internal fistula).

Classification:

A.Congenital:

• Bronchial fistula(neck,lower 1/3rd)
• Tracheo-oesophageal fistula

B.Acquired:

1. Fistula-in-ano
2. Arteriovenous fistula-Hemodialysis,Trauma
3. Neoplastic

• Rectovaginal fistula
• Gastrocolic fistula

Anorectal fistulas

Clinical features of Sinus/Fistula: 

1.Persistent or intermittent discharge from an abnormal opening.
2.intermittent swelling and pain of the local site followed by discharge and relief of pain.
3.Symptoms of underlying pathology,e.g.,
     a)TB

• Low grade fever
• Cough
• Haemoptysis
• Chest pain
• Dyspnoea

     b)Congenital sinus/fistula:
From birth,e.g.,Preauricular sinus
     c)Osteomyelitis(OM)

• High fever
• Pain
• Swelling of the bone concerned

     d)Perianal sinus/fistula:
History of ischiorectal abscess

Causes of persistence of a sinus:

1.Presence of FB or necrotic tissue

• Suture material
• Sequestrum(Necrotic tissue and foreign body)
• Bullet
• Pellet
• Worms

2.Non-dependent drainage or inadequate drainage
3.Abscess of rest for

• Fistula in ano(Proximal colostomy is done)

4.Distal obstruction
5.When the tract is lined by epithelium or endothelium
6.When the tract contains excessive fibrous tissue(prevents collapsing) around the tract(e.g.,Chronic empyema chest)
7.Naturre of infection

• TB
• Actinomycosis

8.Underlying malignancy
9.Persistent discharge(VVF-urine)
10.Chronic illness or systemic illness

• DM

11.Immunosuppression
12.Nutritional deficiency
13.Drugs

• Steroid

14.Irradication:

• RVF in treating carcinoma of cervix

15.Ischaemia

Principle of Treatment of Sinus/Fistula:

1.Excision followed by biopsy
2.Treatment of the underlying cause(e.g., TB,DM,Carcinoma,Malnutrition)

Peptic Ulcer

Definition of Peptic Ulcer: Peptic ulcers are chronic, most often solitary lesion occuring in any part of the GIT exposed to the aggressive action of acid peptic juices.

Or

It is a chronic ulcerative lesion of the GIT at sites exposed to aggressive action of acid peptic juices.

Peptic ulcer

Types of Peptic Ulcer:

• Duodenal Ulcer
• Gastric Ulcer

Sites of ulcer in GI tract:

1. Commonest site:First part of the duodenum on the anterior wall(about 70%)
2. Within the antral part of stomach towards the lesser curvatures close to the junction of acid secreting and non-acid secreting part.(About 28%)
3. Lower end of the esophagus (Barrett's esophagus,a site of columnar metaplasia)
4. Stomach ulcer,within the margins of a gastrojejunostomy.
5. In the duodenum,stomach or jejunum of patients with Zollinger Ellison Syndrome:Non -B cell of pancrease producing gastrin.This gastrin causes hyper secretion of gastric acid.This tumor may found in any part of GIT.
6. Mickle's diverticulum that contains ectopic gastric mucosa.

Risk factors/Causes of peptic ulcer:

Imbalance between gastric mucosal barrier (defense mechanism) and acid pepsin mixture(damaging forces):

1. Hyper acidity
2. Mucosal barrier defect(in gastric ulcer)
3. Predisposing condition:-

          a)Genetic influence(duodenal ulcer)

• Family
• 'O' negative blood group.

          b)Environmental
     4.H.pylori infection (Chronic gastritis)-About 85-100% of patients with duodenal ulcer & 65% with gastric ulcer.

Treatment of peptic ulcer:

A.Relieve pain by raising gastric pH(alkalization)

• Neutralization of gastric acid by antacids.
• Inhibition of gastric secretion by-H2 blocker,Anticholinergic drugs,PGE2
• Surgical removal -Gastrectomy

B.To prevent complication
C.To promote healing

• Bed rest & sedation-Diazepam]
• Use of ulcer healer drugs-sucralfate

D.To prevent recurrence-

• Regular diet
• Avoid ulcerogenic drugs-Aspirin,Steroids
• Avoid smoking,alcohol,tea,coffee.

Hernia

Definition:

It is an abnormal protrusion of a part or whole of a viscus through an opening in the wall of the cavity in which it is contained.

Types of hernia:

A.External:

1. Inginal
2. Umbilical
3. Femoral(female)
4. Incisional

B.Internal:

1. Hiatus hernia
2. Herniation of brain through the foramen of morgagni
3. Herniation of abdominal organ through the diaphram.

Commonest:Indirect inguinal hernia(commonest of all)
Commoner hernias:

1. Inguinal
2. Femoral
3. Incisional
4. Umbilical

Clinically 4 types:

1. Reducible
2. Irreducible
3. Obstructed
4. Strangulated

Parts of hernia: Herniaa consists of three parts
1.Sac:

• Mouth
• Neck
• Body
• Fundus

2.Contents:

• Intestine-enterocele
• Omentum-Omentocele

Hernia pictures:

Hernia pictures of male genitalia:

Symptoms of hernia:

1.A lump
2.Discomfort of pain-due to stretching of neck.
severe pain-obstruction/strangulation
3.Vomiting

Treatment of hernia:

• Indirect inguinal hernia(Uncomplicated)

Adolescent,Young adult-Herniotomy
They have very good inguinal muscle.
Elderly-Herniotomy and herniorrhaphy.

• Complicated(strangulated)

Emergency operation done after resuscitation.

Buerger's Disease

Definition:

It is a progressive,peripheral,vascular occlusive disease due to involvement of all the three layers of small to medium sized arteries in an non specific inflammatory process.

Features:

1.Occlusive disease of medium and small sized arteries:

• Digital
• Planter
• Dorsalis pedis
• Anterior tibial
• Radial

2.Thrombophlebitis of superficial and deep veins.
3.Raynaud's phenomenon:In male patient in younger age group.

Symptoms:

1.Pain in the limb
a)Intermittent claudication
b)Rest pain
Tingling and numbness/Paresthesia

• Loss of sensation
• Coldness of the part
• Color changes
• Ulceration or combination of the affected part

 Buerger's Disease pictures:

Sign:

A.General signs:

1.patient is anxious
2.Patient prefers to sit by the side of the bed hanging the limb,unwilling to lie flat

B.Local signs:

• Inspection:

1. Color changes with line of demarcation
2. Loss of hair
3. Skin-dry,shrivelled,mummified,blackened,greasy to touch
4. Ulcer (if any) examine accordingly
5. Nails:falling or trophic changes.
6. Muscle wasting.

• Palpation:

1. Temp:cold
2. Pulse:lost
3. Sensation:decreased
4. Motor power:decreased
5. Reflex function:decreased
6. Buerger's test
7. Buerger's angle.

• Auscultation:

1. Bruit

C.Systemic examination: CVS

Treatment:

A.General:

1. Stop smoking:prevents progress of disease
2. Nutritious diet and vitamin supplements
3. Care of the foot/feet:wearing soft shoes and socks,keeping the feet dry,Careful paring of toe nails
4. Regular exercise within the limit of claudication pain(distance)
5. Vasodilator drugs:Nicotinic acid,Isosorbide dinitrate
6. Analgesics:Diclofenac

B.Specific Rx:Depends on the condition/situation

Sexually Transmitted Disease(STDs)

What is STD: Sexually transmitted disease (STDs) are agroup of communicable diseases that are transmitted predominantly by sexual contact and caused by a wide range of bacterial,viral,protozoal & fungal agents & ectoparasite.

Classification of STDs:

1.Disease manifested by discharge-

• Gonorrhea(N.gonorrhoae)
• Non gonococcal urethritis

2.Disease manifested by ulcer-

• Syphilis(T.pallidum)
• Herpes and cervical cancer(HHV-2 & HHV-1)
• Chancroid (H.ducreyi)
• Granuloma inguinale

3.Disease manifested by lumps-

• Lymphogranuloma venereum(Chlamydia trachomatis)
• Molluscum contagiosum(one of the pox virus)
• Genital warts(Papilloma virus)

4.Vaginitis-

• Trichomoniasis(T.vaginalis)
• Vaginal thrush(Candida albicans)
• Bacterial vaginitis(Gardnerella vaginalis)

5.Infestation with parasite-

• pediculosis pubis
• Genital scabies(Sarcoptes scabei hominis)

6.AIDS- HIV-I,HIV-II


7.Hepatitis virus- HBV,HCV,CMV

8.PID,Nonspecific urethritis,Proctitis,Cervicitis- Bacterial infection (Chlamydia,Mycoplasma, hominis,urea plasma)

9.Additional infection in homosexual man-

• Bacterial: Shigella,Salmonella,Campylobacter jejuni
• Viral: HIV-I,HIV-II,HBV,HDV,HCV,HAV,CMV
• Protozoal: Giardia,E.histolytica,Cryptosporidium and Microsporidium.
• Helminthic: Enterobius vermicularis,Trichuris trichuria,Strongyloides stercoralis.

Investigation of STD:

1.Material collection
a.urethral specimen or swab in urethritis
b.Vaginal swab in vaginitis
c.Cervical swab in women with or without puerperal sepsis
d.Fluid and pus from genital ulcer

2.Laboratory examinations:
Examinations are to be planned on clinical diagnosis-

A.First day-

• Microscopic examination of the specimen,Gram stain of the smear
• Culture of the specimen

B.Second day & onwards-

Serology:

1.Test for detection of HIV:

• ELISA-screening test
• Western blot-confirmatory test

2.Test for detection of HBsAg-(ELISA) ,Haemagglutination test.

3.Test for syphilis:

• VDRL test
• Complement fixation test
• Kahn test

4.Antitreponemal  antibody tests:

• TPHA
• FIA-ABS test

5.Other tests:

• Gonococcal CFT
• Herpes CFT
• Chlamydia CFT