Colostomy is an artificial opening to divert faeces and flatus.

Bowel diversion surgery for artificial opening in large bowel in order to divert faces to exterior

COLOSTOMY

In simple terms, a colostomy is when the colon is cut in half and the end directive to the stomach is brought finished the surround of the abdomen and attached to the skin. The end of the colon that leads to the rectum is closed soured and becomes dormant. In other words we can say that its a artificial opening made into large bowel in order to divert feces ( & flatus ) to exterior  ,where they may be collected in an adhesive bag.

Usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. This is not an activeness to be taken lightly. It is truly quite serious and demands the close attention of both patient and doctor. A colostomy is ofttimes performed so that an incident crapper be stopped and/or the affected colon tissues crapper heal. The alternative to the colostomy is ofttimes pretty grim, death. Just be glad you are here. It is essential actualise that, with a few exceptions, you crapper look forward to having the colostomy reversed.

A colostomy is sometimes necessary for destined upbeat conditions or diseases. Some of these include cancer, diverticular disease, Crohn's disease and trauma or injury. A temporary colostomy may be necessary to allow the colon to rest and ameliorate for a period of time. A temporary colostomy may be in locate for weeks, months, or years. The temporary colostomy module eventually be closed and bowel movements module return to normal. A imperishable colostomy is usually necessary when a part of the colon staleness be distant or cannot be utilised again.

  

This is famous as a "Hartmann's Colostomy". There are other types of colostomy procedures, but this one is the most common.

It may be TEMPORARY or PERMANENT

TEMPORARY COLOSTOMY

A temporary colostomy haw be used when the conception of the colon (typically the lower section) needs to heal, such as after trauma or surgery. After the colon is healed, the colostomy can be reversed, backward the bowel function to normal. In a colostomy reversal, the digit ends of the colon are reconnected and the area where the stoma was created in the cavum is closed. The large gut is made, erst again, into a continuous tube between the small gut and the rectum. Bowel movements are eliminated through the rectum.

  

INDICATIONS to relieve a distal obstruction of sigmoid colon either by a carcinoma or diverticulitis ,vesicocolic fistula ,protection of a low colorectal anastomosis after anterior resection .To prevent fecal peritoniyis developing after traumatic injury to rectum or colon .To facilitate operative treatment of a high fistula-in-ano.

PROCEDURE

The operation usually takes between digit and four hours depending on difficulty, infection, and the severity of trauma if that is the case. Most of the reasons for a colostomy are: diverticulitis, other inflammatory bowel conditions, or cancer.

Since you are having the operation, you should discuss with your student whether or not you should hit the appendix distant at the same time, since they are going to be in there anyway. It is not a necessary organ and, if removed, it crapper never cause you problems in the future.

 It is normal practice to unstoppered the cavum with an incision from meet below track distinction to meet below the sternum. This gives unstoppered admittance to the internal organs. If you have infection, the student module suction and flush out the contaminates until you are clean.

A loop of bowel ( loop colostomy ) is brought to the surface , where it is held in place by a plastic or glass rod passed through mesentry .Bowel is opened & edges of colonic incision stitched to surrounding skin margins.When firm adhesion of colostomy to abdominal wal has taken place after 7 days , then rod can be removed.

Closure of colostomy performed ,following surgical cure of distal lesion .Done when the stoma is matured ,ie after 2 months .Usually performed by an intraperitoneal technique

PERMANENT COLOSTOMY

A imperishable colostomy (sometimes also called an end colostomy) is necessary for some conditions, including most 15% of colon cancer cases. This type of surgery is commonly utilised when the rectum needs to be removed because of disease or cancer. Most of the colon may also be removed, and the remaining assets utilised to create a stoma.

INDICATIONS after excision of rectum for a carcinoma by abdominoperineal technique ,through the lateral edge of rectus sheath 6cm above & medial to bony prominence.

PROCEDURE distal end ( end colostomy ) of divided colon is brought to surface in left iliac fossa ,where it is stitched in place immediately by sutures placed between colonic margin 7 surrounding skin .A colostomy bag is applied without impinging on bony prominence of anterior superior iliac spine.
  

 After the colostomy, squander is composed on the outside of the body with an ostomy appliance. Today’s ostomy appliances become in a variety of shapes, sizes, colors, and materials to meet the wearer’s lifestyle. The aperture and the surrounding wound (peristomal skin) will order primary care that is taught to patients post-surgery by an enterostomal therapy (ET) nurse....... read more

Treatment for acute appendicitis

THE APPENDIX DOES NOT APPEAR TO HAVE ANY FUNCTION IN THE HUMAN BODY ...SO HOW CAN WE PANIC THROUGH NON FUNCTION ORGAN ???

TREATMENT

INDICATION FOR SURGICAL CONSULTATION AND SURGERY
A surgeon should evaluate any patient with classic migrating abdominal  tenderness. Because only a little more than half of patients with appendicitis present with a classic history and physical findings, acute appendicitis should be on the list of possible diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients with focal RLQ tenderness or progressively worsening abdominal pain.
To minimize the time between show and appendectomy, obtain surgical conference prior to performing additional diagnostic studies, such as CT scan, ultrasound, and technetium (Tc)-labeled WBC scan.3

Indications for operation
Any patient with suspected appendicitis who has
(1) persistent discompose and becomes febrile,
(2) an increasing WBC count, or
(3) worsening clinical examination findings should undergo extirpation or at least diagnostic laparoscopy. In patients with an atypical presentation, the most important determination for extirpation is serial physical examinations. The WBC count often does not process after the patient is admitted and hydrated; therefore, any patient sent home from the emergency department should undergo a follow-up evaluation the incoming day.3

APPENDICECTOMY
Open by giving INCISION

• Grid-iron incision.
• Paramedian incision.
• Rutherford Morison's incision.

REMOVAL OF APPENDIX
A retractor is placed under the medial side of peritoneum & abdominal wall is lifted up.Any pus or serous exudate is removed with a sucker & a pack is inserted into wound on medial side.Using a a swab,cecum is withdrawn.A finger may be inserted into wound to aid delivery of appendix.Cecum is grasped by an assistant. Atissue -holding forceps is applied around the appendix in such a way as to encircle the organ & yet not damage it .Base of mesoappendix is clamped in a hemostat,tied & severed.when mesoappendix is broad,procedure must be repeated with a 2nd or a 3rd hemostat.Appendix ,now completely freed,is crushed near its junction with cecum in a hemostat,which is removed & reapplied just distal to crushed portion.A catgut ligature is tied around crushed portion close to cecum,& an atraumatic catgut purse-string suture is inserted into cecum about 1.25 cm frombase  & is left  untied until appendix has been amputated with a scalpal below hemostat.Stump is invaginated while purse -string suture is tied,thus burying the appendix stump.

PERITONEAL LAVAGE
Peritoneum is washed out with antibiotic laden irrigating fluids.

ANTIBIOTICS
Prophylactic antibiotics active against aerobic & an aerobics organism are given in 2 doses ( one at the time of surgery & next 8-12 hours later )

DRAINAGE OF PERITONEAL CAVITY
Unnecessary, provided adequate peritoneal lavage has been done.However ,performed if there is considerable purulent fluid in retrocecal space or pelvis, or if there is persistent oozing.

DRAINAGE OF PARIETES
Indicated if there is any soiling of wound ,especially in obese & in children.


COMPLICATIONS OF APPENDICECTOMY

EARLY

• ILeus
• Wound sepsis
• Residual abscess
• Intestinal obstruction from adhesins
• Fecal fistula
• Pyelophlebitis
• Postoperative thrombosis & embolism
• Actinomycosis
• Pulmonary complications (pulmonary collapse or pneumonia )

LATE

• Intestinal obstruction from adhesions
• Incisional hernia
• Right inguinal hernia following grid iron incision
• Sterility in female from frozen pelvis.

Intestinal tuberculosis is significantly increasing in developed countries with HIV

INTESTINAL TUBERCULOSIS Is a Major Health Problem in Many Underdeveloped Countries

                                           

                                                       BUT

 

A Recent Significantly Increase In Developed Countries In Association With HIV Infection

 

 

TUBERCULOSIS OF INTESTINE

Some bacterial infections are surgically  important include INTESTINAL TUBERCULOSIS usually seen in the uk as ileocecal tuberculosis and present with thickening and narrowing of the terminal ileum.It may be indistinguishable from crohn's disease on naked eye examinaton.although pale tubercle may be seen on the serosa in tuberculosis.Complications include adhesive obstruction ,perforation and malabsorption due to widespread mucosal involvement or lymphatic blockage.

 

 INTESTINAL TUBERCULOSIS is a field health problem in some underdeveloped countries. A recent momentous increase has occurred in matured countries, especially in connexion with HIV infection. Autopsies of patients with pulmonary TB before the epoch of effective treatment demonstrated viscus involvement in 55-90% of mortal cases. The previously noted regular connexion between pulmonary TB and viscus TB no longer prevails, and only a minority of patients (<50%) with abdominal TB now hit deviant dresser radiographic findings. However, approximately 20-25% of patients with GI TB hit pulmonary TB. Any conception of the GI system haw be infected, although the ileum and colon are common sites.

Pathologically GI TB is characterized by inflammation and fibrosis of the bowel surround and the regional lymph nodes. Mucosal ulceration results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this initiate of the disease, the changes are reversible and healing without scarring is possible. As the disease progresses, the ulceration becomes confluent, and comprehensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral mass lesions. Strictures and fistulae formation may occur.

 

We can categarize Intesinal Tuberculosis into Three TYPES on gross pathologic examination

ULCERATIVE modify of TB is seen in approximately 60% of patients. Multiple ostensible ulcers are largely confined to the epithelial surface. This is considered a highly active modify of the disease, with the daylong axis of the ulcers rectangular to the daylong axis of the bowel.

HYPERTROPHIC modify is seen in approximately 10% of patients and consists of thickening of the bowel wall with scarring; fibrosis; and a rigid, masslike appearance that mimics that of a carcinoma.

ULCEROHYPERTROPHIC modify is a subtype seen in 30% of patients. These patients hit a compounding of features of the ulcerative and hypertrophic forms.

 Clinical features  of viscus TB include abdominal pain, weight loss, anemia, and feverishness with night sweats. Patients may present with symptoms of obstruction, correct iliac fossa pain, or a palpable mass in the correct iliac fossa. Hemorrhage and perforation are constituted complications
 of viscus TB, although free perforation is less frequent than in doc disease.  The diagnosis of purging tuberculosis requires a broad index of suspicion. In cases where the information available does not reveal a definite differentiation between colonic tuberculosis and Crohn's disease.

 Intestinal tuberculosis is a thin disease in western countries, affecting mainly immigrants and immunocompromised patients. Intestinal tuberculosis is a diagnostic challenge, especially when active pulmonary infection is absent. It may mimic many other abdominal diseases.

The most common place of GI TB is the ileocecal region, if the area can be reached with a flexible endoscope. A rapid diagnosis can be achieved if smudge or culture results are positive or if caseating granulomas are seen in biopsy samples. In countries where GI TB is endemic, a therapeutic trial of antituberculosis treatment haw be justified if the clinical picture is compatible with TB.

 TREARMENT OF INTESTINAL TUBERCULOSIS

 

A course of chemotherapy

Surgery is required in cases of complicated obstruction in HYPERPLASTIC TUBERCULOSIS - Right hemicolectomy with removal of diseased segment of ileum or defunctioning ileocolostomy .

Surgery is required  in cases of Stricture causing intestinal obstruction or in perforation in ULCERATIVE TUBERCULOSIS

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.

Intestinal pain - Acute intussusception if you avoid can lead to death

What Could Happen If You Avoid The TREATMENT ?

IT Will Get So Extreme.........Lead To DEATH

ACUTE INTUSSUSCEPTION :

INTUSSUSCEPTION is an invagination of size of intestine ( intussuscepiens ) into the immediate portion of bowl ( intussusceptum ) and  most of cases occur in children during the first 5 decades of life. This can often result in an obstructio .The part that prolapse into the other is called the INTUSSUSCEPTUM and the part that recieves it is called INTUSSUSCEPIENS.

In some of children with intussuscetion , an anatomic predisposing condition . Such as Meckle's diverticulum , Burkitt lymphoma, or hamartomatous polyps ,can be found .And in most of the cases are associated with hyperplastic lymphoid tissue.suggesting an infectious causes ,which is not confirmed in most of the cases.By using serology and virus isolation from fecal and pharyngeal swabs.Adeno virus , Rotavirus ,Enterovirus , Human herpes virus  ,Cytomegalovirus and Epstien-barr-virus.some bacterial agents can also involved in this condition include Yersinia ,enterocolitis and salmonella typhimurium and candida albican .

TYPES

Ileocolic  ( 77 % ) 

Ileoileocolic ( 12 % ) 

Ileoileal (5 % ) 

Colocolic ( 2 % ) 

Multiple (! % ) 

Retrograde ( 0.2 % )

Others  ( 2.8 % ) .

CLINICAL FEATURES :

SYMPTOMS

• Sudden paroxymsm of abdominal pain ,with drawing up of legs and screaming  :each attack lasts a few minutes and recur about every 15 minutes.
• Facial pallor 
• Vomiting
• Listleness and somewhat drawn between the attacks .
• Stool : intially normal later  blood and mucus are evacuated called  "red currant jelly stool " 
• when not relieved upto 24-36 hours

        a . Pain becomes contineous

          b. Abdomen distends

          c. Vomiting becomes copious

          d. Absolute intestinal obstruction follows

SIGNS

• A lump is felt ,which may harden on palpation .
• PR examination : if intussuscetion has travelled far enough ,its apex ( a conical ) mass will be felt .
• When not relieved ,upto 24 - 36 hours  

         a . Dehydration

         b . Abdominal distension

         c . Abdominal guarding , tenderness and rebound tenderness if gangrene has occured.

DIAGNOSTIC INVESTIGATIONS :

INTUSSUSCEPTION is often suspected based on history and physical examination , including observation of Dance's sign .Per rectal examination is particularly helpful in children as part of thintussusceptum may be felt by the finger .A definite  diagnosis often requires confirmation by diagnostis imaging modalities .

ULTRASOUND is today considered the imaging advanced technology of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation.A target like mass ,usually around 3 cm in diameter confirm the diagnosis.

PLAIN ABDOMINAL X-RAY
Revealed increased gas shadow in small intestine and at times absence of cecal gas shadow .

X-RAY WITH BARIUM ENEMA :
Reveal characteristic " claw sign " in ileocolic intussusception .

TREATMENT :

The condition is not usually immediately life threatning.The intussusception can be treated with either a barium or water soluble contrast enema or an air contrast enema .which both confirms the diagnosis of intussusception, and inmost cases successfully reduce it . The success rate is over 80% .Therefore approximately 5 - 10 % of these recur within 24 hours .If it cannot be reduced by an enema or if the intestine is damaged , then surgical reduction is necessary.

PRELIMINARY TREATMENT 


Gastric aspiration should be carried out and contiued during and after operation.
Give IV dextrose - saline solution.

REDUCTION OF INTUSSUSCEPTION
REDUCTION BY HYDROSTATIC PRESSURE


OPERATIVE REDUCTION :


Abdomen is opened through a right lower paramedian incision .First part of reduction is accomplished by squeezing lower part of sausag like mass ,and little intussusception is reduced.Last part is most difficult to reduce and should br withdrawn and gently compressed in a warm saline soaked pack,to

lessen the edema.
After reduction if a specific cause is revealed appropriate treatment is carried out ,eg Meckle's diverticulum.

PROGNOSIS :

The outlook for intussusception is excellent .when treated immediately .but when untreated it can lead to death within 2-5 days .Quick treatment can avoid this surgery .Prolonged intussusception can lead to ischemia and necrosis and it requires surgical resection.

AFTER TREATMENT


Gastric aspiration should be continued for 12-24 hours
Dextrose-saline is given IV or SC with hyaluronidase.
On 2nd day ,gastric tube is removed and sips of water are given.
Few hours later ,feeding is commenced with mother's milk ( if infant is still being breast-fed ).

COMPLICATIONS:

Intestinal obstruction
Gangrene

Biliary stricture

IT CAN OCCUR AS A RESULT OF A TECHNICAL MISHAP......

DURING CHOLECYSTECTOMY IF IGNORED CAN DRIVE  LIFE- THREATENING COMPLICATIONS

STRICTURE OF BILE DUCT 
  

A bile duct stricture is caused by narrowing of the bile duct. The narrowing bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood feat obstructive jaundice  ,it crapper cause through Surgical trauma ( postoperative ) ,Stones ,Primary sclerosing cholangitis ,Carcinoma of bile funiculus Carcinoma of head of pancreas.

Bile duct pathology (biliary stricture) is an uncommon but hard clinical condition that requires a integrated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma , Bile duct strictures (biliary strictures) may be well but, if ignored, can drive life-threatening complications, such as ascending cholangitis,  liver abscess, and secondary biliary cirrhosis

POSTOPERATIVE STRICTURE it is the result of a preventable non achievement in technique , during the performance of cholecystectomy ;Blind plunge application of a hemostat to a bleeding cystic or accessory cystic artery ,or to right hepatic artery.Should cholecystectomy be performed by dissecting from fundus ,too such traction applied to freed gall sac may so tent the bile funiculus that some forceps witting for cystic funiculus apprehension angulated main channel .Failure to identify anatomy in Calot's polygon when there is such inflammation .Common hepatic funiculus is tied instead of cystic duct.Ignorance of anatomical anomalies o bile ducts.Laceration of bile patch explration for stones.Injury to bile funiculus during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE

Bile funiculus injuries may be rcognized at the instance of surgery .

Postoperatively by profuse and persistent discharge of bile if evacuation has been provided.Bile peritonitis if evacuation

has not been provided.Deepening obstructive jaundice.

In the absence of symptoms of the primary disease, most patients with bile funiculus strictures (biliary strictures) rest asymptomatic until the lumen of the bile funiculus is sufficiently narrowed to drive position to the flow of bile. Occasionally, patients may hit intermittent episodes of right upper line pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often inform with features of obstructive jaundice. On occasion, a patient may inform dramatically with sepsis and hypotension due to ascending cholangitis.

Cholangitis occurs in the proximity of partial or complete obstruction of the common bile funiculus , with accumulated intraluminal pressures, bacterial infection of the bile with procreation of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can apace embellish a life-threatening condition. Clinical show varies, with the Charcot set of fever and chills, jaundice, and right upper line abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also hit altered mental position and hypotension (ie, Reynold pentad). In the epilepsy of previous instrumentation, cholangitis is uncommon with malignant strictures.

Tests that shows stricture in the bile duct: ERCP (endoscopic retrograde cholangiopancreatography) , PTC (percutaneous transhepatic cholangiogram)  ,MRCP (magnetic kinship cholangiopancreatography)

Blood tests that indicate deviant function of biliary system:

Bilirubin level is higher than normal
ALP (alkaline phosphatase) is higher than normal

TREATMENT 

PREOPERATIVE TREATMENT temporary external biliary drainage ,by passing a cather percutaneously into an intrahepatic duct ,or by passing a cather through stricture at ERCP and left to drain through mouth.

OPERATIONS

Roux-en-Y choledochojejunostomy

Cholecystojejunostomy

Choledochoduodenostomy

Insertion of a stent  

COMPLICATIONS 

Recurrent inflammation of the biliary duct and stricture can occur in whatever patients. Patients are at risk for infection developing above the stricture. Long-standing strictures can advance to cirrhosis.

Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.

Diverticulum common birth defect in about 2% of all infants

MECKLE'S DIVERTICULUM  The vitello-intestinal funiculus is the remnant of the yolk cover which is attached to the primitive midgut in the first some weeks of embryonic development .

It was first described by FABRICIUS HILDANUS in the sixteenth century and later named after Jhann friedrich meckle , who described the embryological origin of this type of diverticulum in 1809.

It should completely obliterate during the six week ,but haw persist completely or in conception .if it persist completely , there is a diverticulum ,the Meckle's diverticulum ,which arises from the terminal ileum .The classical description in adults is that it is present in 2% of he population , is 2 inches ( 5 cm ) daylong and 2 feet (60 cm )from the ileocaecal valve .

The diverticulum is usually supplied by the omphalomesenteric artery (a remnant of the vitelline artery), which arises from the ileal branch of the superior mesenteric artery. Usually, the artery terminates in the diverticulum; however, it has been reported to continue up to the abdominal wall in some cases. Rarely, these blood vessels persist in the form of fibrous remnants that run between the Meckel diverticulum and the abdominal wall or small bowel mesentery.

Meckel's diverticulum occurs on the antimesenteric abut of the ileum, commonly 40-60 cm proximal to the ileocecal valve. On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half include ectopic mucosa. Meckel diverticulum is typically lined by ileal mucosa, but another paper types are also institute with varied frequency.

The heterotopic membrane is most commonly gastric. This is important because peptic ulceration of this or conterminous membrane can lead to painless bleeding, perforation, or both. In one study, heterotropic viscus membrane was institute in 62% of cases, pancreatic paper was institute in 6%, both pancreatic paper and viscus membrane were institute in 5%, jejunal membrane was institute in 2%, Brunner paper was institute in 2% and both viscus and duodenal membrane were institute in 2%.2 Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.

A persistent vitello-intestinal funiculus can present at birth , as a swelling at the base of the umbilical cord ,or as a fistulous connection to the umblicus ,or as an umblical polyp, which does not move like simple granulation tissue to cautery , because it has a mucosal surface , Surgical excision is required .It haw be lined by ileal membrane ,or contain ectopic gastric membrane ,which haw unergo peptic lesion with ensuant bleeding .

Most people who have a Meckel's diverticulum have no symptoms or problems. Only about 1 in 25 persons who are born with it will have problems. These problems vary by age. In infants and children, the problem is commonly injury from the rectum. Sometimes blood stained stool can be seen .

In adults, the gut may become blocked. If this happens, the mortal may have breadbasket pain and vomiting. Other symptoms allow fever, degradation and swelling of the stomach.

It haw present with

SEVERE HAEMORRHAGE blood is passed per rectum , and is blakish red in colouration.


INTUSSUSCEPTION ,MECKALIAN DIVERTICULITIS ( Without Perforation ) clinical features simulate those of acute appendicitis ,(With Perforation ) clical features simulate those of cut ulcer  .

CHRONIC PEPTIC ULCERATION symptomatic peptic ulcer pain , related to meals , but is felt around the umblicus ( because diverticulum is conception of midgut ).


INTESTINAL OBSTRUCTION a adornment present between apex of diverticulum and umblicus , haw cause obstruction either by adornment itself or by a volvulus around it .


LITTER's HERNIA meckle's diverticulum is found in an inguinal or femoral hernial cover .


SILENT MECKLE's DIVERTICULUM encouraged in barium meal follow-through or during an abdominal operation . 

DIAGNOSTIC INVESTIGATIONS 1 . X-RAY with BARIUM MEAL  may demonstrate Meckle's diverticlum  ,and failure to visualize is of no significance ,because so often the entrance of diverticulum is blocked by edema .

TECHNETIUM (Tc ) SCANNING may localize heterotopic gastric mucosa in a diverticulum .There is no definitive scan or investigation to confirm the existence of a Meckle's diverticulum .A radiolabelled technetium  scan looking for ectopic gastric mucosa ( that is outside the stomach ) is only positive in about 70 % of patients with a Meckle's diverticulum who present with rectal bleeding .

TREATMENT : management is by excision after the diagnosis has been made - which is often only at laparotomy , although it may be suspected beforehand.

MECKELIAN DIVERTICULECTOMY a broad base Meckle's diverticulum is resected with invagination technique in the same way as a vermiform appendix ,If the base of Meckle's diverticulum is indurated  and especially .when such induration  extends into neighboring ileum ,resect a short segment  of ileum containing the Meckle's diverticulum ,and restore the continuity of bowel by end-to-end anastomosis .

FREQUENCY

The figure of Meckel diverticulum is usually noted to be approximately 2% of the population,3 but publicised program arrange from 0.2-4%.4 Complications are only seen in about 5% of those with the anomaly.