How to listen your body in crisis with Volvulus ?

VOLVULUS  ( Twisting of intestine )

VOLVULUS  refers to the winding of a assets of the intestine around itself or a stalk of mesentery tissue to cause an obstruction. Volvulus occurs most ofttimes in the colon, although the breadbasket and small bowel crapper also twist. The conception of the digestive grouping above the volvulus continues to function and haw swell as it fills with digested food, fluid, and gas. A condition called strangulation develops if the mesentry of the bowel is twisted so tightly that murder line is cut off and the tissue dies. This condition is called gangrene.

VOLVULUS IS A SURGICAL EMERGENCY because gangrene crapper amend quickly, cause a mess in the wall of the bowel (perforation), and become life-threatening.

ITS AXIAL ROTATION HAS DIFFERENT TYPES

Volvulus Neonatorum

Volvulus of Small Intestine

Volvulus of Cecum

Volvulus of Sigmoid Colon

VOLVULUS NEONATORUM an intestinal obstruction in a new born resulting from a twisting of the bowl caused by malrotation or nonfixation of the colon .Floating of cecum , together with whole of small intestine which has a narrow attachment ,revolves.

Arrested rotation  , in which cecum remains in left hypochondrium ,and a peritoneal band is found running from cecum to right side of abdomen and then across the 2nd part of duodenum ( transduodenal band of Ladd )

In the clinical fearures ,there is some symptoms of Repeated vomiting , which will be bile stained .can also cause abdominal distension .

It can cause some signs of Dehydration and abdominal distension.
Few diagnostic test ,that shows or revealed a diseased portion.For this reason we can do PLAIN ABDOMINAL X-RAY it reveal stomach and upper part of duodenum are greatly distended ith air ,so called 'double stomach.

This condition needs immediate surgery included :

Early Laprotomy
Whole of the midgut is delivered on to the surface .
Untwisting is done in opposite direction .
Transduodenal band of Ladd is divided .
Abdomen is closed in layers .

VOLVULUS OF CECUM  nearly always occur in a clockwise direction. First twist obstructs the ascending colon  ,if a 2nd twist occurs ,it obstructs the ileum also .Axial torsion, the most common form of volvulus, occurs with the development of a twist of 180-360^o; along the longitudinal axis of the ascending colon. This form has a high mortality rate because the obstructive process is associated with vascular compromise, which can lead to gangrene and perforation, often on the antimesenteric border, where the ischemic changes may be most pronounced.

Nonspecific abdominal symptoms occasionally occur with abnormalities of fixation. Traction on the superior mesenteric artery with partial compression of the duodenum, gallbladder, pylorus, or kidneys has been implicated. The most important complication of the abnormalities of fixation is a volvulus of the right side of the colon and/or cecum.

The common presentation of a cecal volvulus is an acute abdomen, with colicky abdominal pain of sudden onset. Most cases of cecal volvulus reportedly occur in patients with a mobile, defectively fixed right colon while they are asleep. Normal movement of the patient from side to side during sleep may result in displacement of the right colon to an ectopic or abnormal location. When gaseous distention occurs, the displaced right colon is trapped, resulting in symptomatic acute volvulus.

The diagnosis is mostly based on plain abdominal radiographic findings aided by those of single-contrast barium enema examination. CT is useful in identifying signs of ischemia, which include mural thickening, infiltration of the mesenteric fat, and pneumatosis intestinalis. Treatment is surgical, but reduction of the volvulus has been reported after barium enema examination.colonoscopy may be considered for the purpose of decompression. Simple abdominal radiographs had a low diagnostic accuracy but revealed bowel obstruction. 

TREATMENT 

Laprotomy should be done ,Deflate the ballooned cecum by insertion of a needle .Untwisting is accomplished in opposite direction ,ie anticlockwise . Cecostomy is performed  , which relieves the distension  , and fixes the organ to abdominal wall ( preventing recurrence ) ,If cecum is gangrenous ,right hemicolectomy is performed .Abdominal wound is closed .

VOLVULUS OF SIGMOID COLON  

This  is the terminal section of the colon. Two body differences can increase the risk of colon volvulus. One is an elongated or movable colon colon that is unengaged to the left sidewall of the abdomen. Another is a narrow mesentery that allows winding at its base. Sigmoid volvulus, however, can occur modify without an body abnormality.

This type of twisting in the sigmoid can occur due to Band or Adhesions ( peridiverticulitis ) ,Overloaded pelvic colon ,Long pelvic mesocolon .Narrow attachment of pelvic mesocolon.

Loop  may rotate  half a turn , in which event spontaneous rectification sometimes occur .After the loop has rotated 1 1/2 turns ,veins involved in torsion are compressed  ,and loop becomes greatly congested .if it rotates more than 1 1/2 turns ,blood supply is cut off entirely and loop becomes gangrenous .Rotation nearly always occur in anticlockwise direction .

In clinical fearures ,it can shows the sumptoms of  sudden severe abdominal pain ,often coming on while the patient is straining at stool .Abdominal distension  ,hiccough and retching occur early ,Vomiting occur late ,absolute constipation .

some sgns of abdominal distension ,abdominal guarding and tenderness

DIAGNOSTIC INVESTIGATION

PLAIN ABDOMINAL X-RAY 
A connatural stark abdominal x-ray will demonstrate a huge air filled distended bowel like the appearance of an inverted U, with the convexity of the U covering the right upper abdominal quadrant. This appearance has been described as the kidney noodle shape, coffee noodle shape, bent inner plaything shape, ace of spades or ‘Omega loop Sign’. You can wager an example down in the inventiveness section.
  

BARIUM ENEMA 

With a water solvable metal enema, the distention in the sigmoid colon can be demonstrated to be cod to a twist, as it will show an Atlantic of rank obstruction with some twisting in the so called shuttle beak or shuttle of beast sign. 

TREATMENT

DEFLATION AT SIGMOIDOSCOPY 

Sigmoidoscopy is carried out and when obstruction is reached an attempt  is made to coax a soft rectal tube into twisted gut .This will immediately deflate the gut and operation can be delayed for a few days until the patient is more fit.

OPERATION 

Laparotomy is performed ( immediately if dilation is not successful ) .Untwist the gas filled viscus in aclockwise direction .Simultaneously ,a rectal tube is passed to deflate the colon .Resection and end-to-end anastomosis is carried out .Abdominal wound is closed.

Colostomy products

DIFFERENT TYPES OF PRODUCTS FOR COLOSTOMY

Pouch
There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special concealment that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release pedal tardily and support to decrease pedal odor. The mass is general aggregation most types of colostomy pouches



Stoma covers and caps
Stoma caps or covers crapper be placed on the aperture when the aperture is not active (draining). People with descending or colon colostomies who wet may use aperture covers or caps. The cover or cap is attached to the wound in the same artefact as a pouch.



COLOSTOMY CARE



Psychic activity of the enduring for the necessity of colostomy is a daylong first step toward his adjustment to experience with an artificial anus. Proper surgical positioning of the activity module assist tending of the bowel. Control of fecal property and peristaltic rate should ideally display degradation susceptible exclusive to habit or enemata. 


The goal of the enema is to display an evacuation thorough enough to prevent soiling for a day or two. The goal of fare variations is to display a manageable volume and property of fecal stream. The framework of enemas and pick of diet can be personalised when the underlying principles are understood.



COMPLICATIONS OF COLOSTOMIES



Prolapse , Retraction ,Necrosis of distal ends , Stenosis of orifice , Colostomy of hernia , Bleeding ( usually from granulomas around the margin of colostomy ) Colostomy diarrhea ( usually an infective enteritis responds to metronidazole )



Recovery at home is mostly most six weeks, although it haw be longer for patients who are very ill before surgery or who hit complications. Activity module be limited at first, and lifting, housework, and driving are not recommended. The infirmary staff module advise you most your diet when you prototypal get home, which haw be limited to low fiber. Regular appointments with your surgeon module help ensure that your cavum and the surface  around the aperture are sanative well........read more

Gall stones(cholelithiasis)-Gall bladder problems common in women eat high fibre diet for prevention

PATHOLOGICAL CONDITIONS OF THE GALL BLADDER ARE COMMON SURGICAL PROBLEMS....

GALL STONES ( CHOLELITHIASIS )

In medicine, gallstones (choleliths) are crystalline bodies formed within the embody by increment or concretion of normal or deviant bile components.In 80% of patients gall stones are composed predominantly of cholesterol with smaller amounts of calcium salts and bile pigments . They are referred to as mixed stones , are usually multiple with a faceted surface , and have a characteristic laminated surface on cross section. Only about 10 % of them contain sufficient calcium to be visible on a plain X-ray .Pure cholestrol stones form less than 10% of stones .They are usually solitary ( the cholestrol " solitaire " ) up to 5 cm in diameter ,and have a characteristic radial arrangement of crystals on cross section . Cholestrol stones usually form in bile which is supersaturated with cholestrol. When bile contains more cholestrol than can be solublised in the bile- acid -lecithin micelles ,crystals of cholestrol form in the bile .

The greater the concentration of bile acids and lecithin in bile ,the greater is the amount of cholestrol that can be contained in the mixed micelles .Lecithin is important because lecithin - cholestrol mixed micelles can solubilise more cholestrol than can micelles of bile acids alone .Following Crohn's disease of the terminal ileum or ileal resection thebile salt pool is reduced because of lack of absorption of bile salts ,and the liver can not make good the losses .

Such patients are prone to cholestrol stones. Oestrogen increases the hepatic synthesis of cholestrol ,and this may explain why females of child - bearing age have a higher incidence of cholestrol stones . A high animal fat ,low fibre diet is also associated with cholestrol stones because of excretion in bile of the excess cholestrol absobed from the gut.Clofibrate , a cholestrol-lowering agent ,has been implicated in cholestrol stone formation ,because it increases excretion of cholestrol in the bile . Decreased gall bladder motility probably plays a rle in aetiology of gall stones .

Cholestrol and other substances which form the nuclei for gall stone formation must remain in the gall bladder long enough for crystal growth to occur .Stasis occurs during pregnancy due to the smooth muscle relaxing effect of progesterone.Motility of the gall bladder is also decreased during starvation and total parenteral nutrition , due to decreased stimulation of the gall bladder by CCK.Stones may also form after vagotomy ,because of lack of vagal potentiation of CCK.Bile pigment stones account for about 10 % of stones in the UK.The major constituent is the calcium salt of unconjugated bilirubin.

They are associated with chronic haemolytic disease where there is breakdown of red cells with release of excessive bilirubin.Pure pigment stones occur in sickle cell disease , thalassaemia and hereditary spherocytosis .Pigment stones are found in the Far East ,where they are associated with biliary tract infection with E.coli and Bacteroides fragilis ,These organism produce beta-glucuronidase which splits bilirubin diglucuronide and releses free bilirubin.The latter combines with calcium to form the relatively insoluble calcium bilirubinate.

PATHOLOGICAL CONSEQUENCES OF GALL STONES ARE :

• Inflammation of the gall bladder ,acute cholecystitis ,chronic cholecystitis ,acute on chronic cholecystitis
• obstructive jaundice due to impaction of a stone at the lower end of the common bile duct : secondary biliary cirrhosis may result .
• ascending cholengitis
• empyema of the gall bladder.
• mucocele
• gall stone ileus __ a fistula occurs between the gall bladder and duodenum ,and a large stone enters the small bowel ,causing obstruction .usually at the terminal ileum .
• pancreatitis ,usually associated with multiple small stones .
• carcinoma of gall bladder .
• perforation of the gall bladder .
  

Medicines titled chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given in preventive form to dissolve cholesterin gallstones. However, they may take 2 eld or longer to work, and the stones may return after communication ends.

Rarely, chemicals are passed into the gallbladder finished a catheter. The chemical apace dissolves cholesterin stones. This communication is not used rattling often, because it is difficult to perform, the chemicals can be toxic, and the gallstones may return.

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients staleness be indicated to surgery. The lack of a gall bladder does not seem to have any perverse consequences in some people. However, there is a momentous assets of the population — between 5 and 40% — who amend a information called postcholecystectomy syndrome which haw drive gastrointestinal painfulness and persistent discompose in the upper right abdomen. In addition, as some as 20% of patients amend chronic diarrhea.

Electrohydraulic damper wave lithotripsy (ESWL) of the gallbladder has also been utilised for selected patients who cannot have surgery. Because gallstones often become backwards in many patients, this treatment is not utilised very often any more.

Test for appendicitis -Pinch-an-inch test

PINCH-AN-INCH TEST FOR APPENDICITIS

Its a prospective comparative assesment of two physical exam technique for evaluating patients with doubtable appendicitis.Rebound tenderness is a widely acclimated assay address for patients with doubtable appendicitis.but it can be absolutely uncomfortable.an another analysis for peritonitis is termed THE PINCH-AN-INCH TEST.

This address call two patients who presented with balmy belly affliction who subsequently were begin to accept appendicitis.In both patients classic peritoneal signs were absent but the compression an inch analysis was positive.the accomplished physicians bedside analytic assay remains the most critical component for rapidly anecdotic peritonitis.Although rebound tenderness is a broadly acclimated examination.It is afflictive and may be inaccurate.

To perform the pinch-an-inch test,a bend of belly derma over McBurney's point is grasped and animated abroad from the peritoneum.The derma is recoil back briskly against the peritoneum.If the patient has added affliction if the derma bend strikes the peritoneum, the analysis is absolute and peritonitis apparently is present.

As an added feature,if the affliction seems boundless just during the antecedent compression phase,the patient may accept a actual low affliction threshold,a factor that can be taken into account when deciding if the patient has a surgical abdomen.We anecdotally accept begin the analysis to be appreciably accessible for the appraisal of appendicitis.

Delayed analysis of acute appendicitis can advance to cogent morbidity.However recent technological advances in radiological imaging, the alert analysis of acute appendicitis can be difficult.Indeed,some experts accept that overreliance on imaging at the amount of the bedside assay may in fact access appendicitis accompanying morbitity.Arguably,both of these patients ability accept been bigger served by undergoing surgery directly without the delay of of CT imaging.Therefore analysis efforts should be directed against developing and acceptance bigger bedside assesment of peritonitis.

One important admonition to clinicians is the actuality that patients with appendicitis may in fact accept hyperesthesia over McBurney's point,and an boundless affliction acknowledgment to he compression appearance should not be absolved out of the hand.

The technique potencially allows for a added objective and reproducible physical assay than rebound tenderness which requires the examiners abjure his easily rapidly abundant to break advanced of the accustomed natural recoil of the belly wall.Rebound tenderness as well requires that the physicians does not added abase his easily in a form of backswing.Pinch an inch in contrasr allows for a added accelerated and reproducible absolution of tension.

In an accomplishment to advance patient's abundance during the belly assay we developed an alternating address for detecting peritonitis.we appellation this pinch-an-inch,we accept that compression an inch after-effects in less affliction than rebound tenderness.while not compromising effectiveness.

We achievement that our pinch-an-inch assay address may eventually action a added adequate and authentic another to classic rebound tenderness.Toward this effort,we will conduct a -to-be abstraction to appraise its accurateness and about abundance in diagnosing appendicitis.
several studies have shown it to be quite accurate in the evaluation of the appendicitis so its use should not be stoped.