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After history and physical examination, the clinician is often left with a short differential diagnosis that must be further narrowed before appropriate treatment can begin. This almost always means that additional radiographic and or laboratory tests must be performed in order to confirm or discard a suspected diagnosis. In fact, even the questions asked of patients during the history and physical exam are all informal diagnostic tests in themselves. How likely is the patient to have a mass if you don't feel one How likely is the patient with recurrent biliary colic and normal transaminases to have a common bile duct stone, and should they have an ERCP before their cholecystectomy How confident can you be that your patient with a normal barium enema does not have polyps or cancer What if they had had a negative sigmoidoscopy as well The interpretation of the literature studying these tests and the translation of that information into a form that is easily applicable to a clinical...
Common constitutional symptoms referable to the GI tract include dysphagia, odynophagia, vomiting, abdominal pain (which may be focal or generalized), colic, constipation obstipation, diarrhea and GI bleeding, with or without anemia. Non-specific symptoms of anorexia, fatigue and wasting may also be observed. Individuals with chronic hyper-chloremic metabolic acidosis resulting from excess GI bicarbonate loss may present with obtundation
The mechanism by which the abnormalities of the fetal alcohol syndrome are produced is unknown, but it is thought to be due to a direct teratogenic effect. There is no general agreement regarding the limits of vulnerability of the fetus in terms of gestational age. To date, this syndrome has been described only in children of mothers who drank alcohol frequently during their pregnancy. Fetal alcohol syndrome results in low birth weight and small head circumference. Cranial and joint deformities are common, and the children feed poorly and are colicky and tremulous. The infant mortality rate associated with this
N. risticii circulates in monocytes and has a predilection for the mucosa of the cecum and large colon. Most infections are subclinical and when signs appear they are very inconsistent, including combinations of fever, depression, anorexia, colic, and ileus. Diarrhea occurs in under 60 of horses and laminitis in up to 40 of cases (54). The mortality rate can reach 30 signs in horses that survive without treatment usually resolve over 5 to 10 days. Organisms are seldom seen in blood smears, serology is unreliable, and diagnosis is best based on PCR detection of organisms (54).
The feeding arteries are ligated as close as possible to their sites of origin. For a cancer of the right colon, the right colic, ileocolic and right branch of the middle colic vessels are ligated and divided close to their origins and the proximal colon is then resected. For cancers of the left colon, the inferior mesenteric and ascending left colic vessels are ligated and a left hemicolectomy is performed. Intestinal continuity is restored by anastomosis using sutures or staples.
Care to avoid injury to middle colic vessels. Detachment of the omentum from the transverse colon will provide sufficient length to reach nipple level in 75 of patients. The precise plane of dissection between the omentum and epiploic appendices of the colon is often unclear. The epiploic appendices should be left attached to the colon to minimize bleeding. The omental pedicle thus established often reaches the desired point in the thorax.
Figure 12-8 Cholecystostomy tube placement and percutaneous gallstone removal. A, Scout view of the abdomen demonstrates a cholecystostomy tube with a retention pigtail in the gallbladder fundus. The tube was placed in preparation for gallstone removal in a patient with severe chronic obstructive pulmonary disease and a long-standing history of colicky upper abdominal pain and fatty food intolerance. B, Contrast injection through the tube demonstrates a large, solitary gallstone (S) in the gallbladder lumen. The cystic duct (C) and common bile duct (CBD) are patent. C, A spot film performed during the stone removal procedure demonstrates a flexible choledochoscope (large arrow) with its tip in the gallbladder lumen. The percutaneous tract was dilated to 18 French to permit introduction of the scope, which was advanced through a sheath. A safety guidewire (smallarrow) is adjacent to the scope. D, This cholangiogram performed 1 week after the stone removal procedure demonstrates that...
Figure 19-11c J, Superior mesenteric artery emboli usually lodge distal to the orifice of the superior mesenteric artery, often at the origin of the middle colic artery. The superior mesenteric artery is exposed immediately medial to the ligament of Treitz by retracting the small intestine to the right upper quadrant. A length of the superior mesenteric artery is exposed. Small jejunal branches may be controlled with fine vessel clamps. A transverse arterial incision is used. Fine Fogarty catheters are passed proximally and distally to retrieve embolic material. K, Vigorous forward and back bleeding from the superior mesenteric artery should be observed before arterial closure. L, When visceral revascularization requires graft placement, proximal and distal control of the supraceliac aorta and clamping of the celiac axis is required. A small elliptical aortotomy is made for the proximal anastomosis. M The left limb of the bifurcated vascular prosthesis is anastomosed to the...
A, The terminal ileum has been divided approximately 5 cm proximal to the ileocaecal valve, and the mesentery has also been divided, preserving the main arcade between the ileocolic artery and the right colic artery. B, The proximal end of the ileum is brought out as an end ileostomy. The distal end of the ileum is raised to the abdominal wall as a mucous fistula. (From Keighley, M.R.B., and Williams, N.S. Surgery of the Anus, Rectum, and Colon, ed 2. London, W.B. Saunders Ltd., 1997, p. 2112.)
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S. africana-caerulea Used by European settlers as a remedy for coughs, colds and chest troubles, a tincture also for whooping cough and uterine troubles. An old household remedy for colic, diarrhoea, heartburn and indigestion prepared as a tea to which Epsom salt and lemon juice was added.
The complexity of operation depends upon the pathology. Cervical exenteration for postcricoidal carcinoma of the esophagus requires laryngectomy, upper trachiectomy, pharyngectomy, and esophagectomy. Esophageal reconstruction is done by bringing up the stomach or the left colon, either in the bed of the resected esophagus or substernally, with anastomosis to the pharynx and establishment of a tracheostomy low in the neck rather than in the upper mediastinum. Cervicomediastinal removal of extensive adenoid cystic carcinoma may well not require esophagectomy. The pharyngeal defect is closed, as in total laryngectomy, and mediastinal tracheostomy established. However, if the mobilized stomach is to be used for gastrointestinal continuity rather than the colon, the residual esophagus is best removed by the transhiatal technique. The gastric tube is usually placed substernally. If only a portion of the anterior esophageal wall is involved, as occurs in some thyroid cancers, this is excised...
Internal iliac artery via the inferior and middle rectal arteries to an occluded IMA. SMA, superior mesenteric artery IMA, inferior mesenteric artery MC, middle colic artery AOR, arch of Riolan LC, left colic artery S, sigmoid arteries SR, superior rectal artery MR, middle rectal artery IR, inferior rectal artery IIA, internal Figure 10-17 Collateral blood flow from the IMA via the marginal arteiy and arch of Riolan to an occluded SMA. SMA, superior mesenteric artery IMA, inferior mesenteric arteiy MC, middle colic artery AOR, arch of Riolan LC, left colic artery S, sigmoid arteries SR, superior rectal arteiy MR, middle rectal artery IR, inferior rectal artery IIA, internal iliac artery. Figure 10-18 The entire rectal blood flow Is dependent on collateral flow after occlusion of both Internal Iliac arteries. In this figure, the IMA Is also occluded, leaving rectal blood flow dependent on collateral flow from the SMA via the arch of Riolan and the marginal artery and then via the...
Limited duration (12-18 hours) may occur several days prior to the onset of depression and anorexia. The clinical course of the disease then progresses to include the following signs subcutaneous edema of the lower limbs and ventral abdomen, colic, mild to profuse diarrhea, laminitis, and abortion (123).
There are many patients with radiologic or even endoscopic obstruction of an upper rectal or rectosigmoid cancer that clinically has little interference with bowel function. Such patients may undergo an elective resection. In the presence of a locally advanced rectal cancer with symptomatic obstruction, patients should undergo a preliminary diversion, receive chemoradiation therapy, and then undergo rectal resection. All such patients should be extensively evaluated preoperatively with chest radiography and computed tomography or ultrasonography, or both, of the liver. A stoma can be created laparoscopically or with a limited laparotomy. A low sigmoid loop colostomy is advantageous in that it will be outside the radiation field and can allow a two-stage operation with resection of the colostomy as part of low anterior resection after the completion of radiation therapy. A left-sided transverse colostomy is to be avoided, because of the potential for interference with colon...
It is normal for infants to wake at night, but by around 6 months many children can sleep through the night. Sleepiness and crying in infants may also be due to 'colic', food or cow's milk allergy, gastro-oesophageal reflux, or chronic middle ear infections, which may not be readily apparent. Most children are able to sleep through the night after the age of 6 months without requiring feeding. Frequent waking at night requiring feeding to fall asleep again is usually due to a conditioned reflex rather than a physiological need. The frequency of night-time feeds should be gradually reduced.
Exposure of the superior mesenteric vein at the base of the transverse mesocolon. The transverse incision in the mesentery may be extended cephalad as an inverted T to carry the exposure of the vein further over the uncinate process of the pancreas and expose the middle colic vein. Insert, preferred midline abdominal incision. (From Zuidema, G.D., Cameron, J.L., andZeppa, R. Portal hypertension. II Operative procedures. In Nora, P.F. ed. Operative Surgery Principles and Techniques. Philadelphia, Lea & Febiger, 1980, p. 652, with permission.)
Most hemangiomas are asymptomatic and are discovered incidentally. The prevalence of symptoms is usually associated with larger tumor size. In a review of the Mayo Clinic experience, investigators reported that 90 of patients with hemangiomas larger than 10 cm were symptomatic, compared with only 15 of patients with lesions smaller than 10 cm. The most common symptoms are nonspecific and include abdominal pain or fullness, early satiety, nausea, vomiting, or fever. Many of these symptoms may ultimately be attributed to other disease processes, such as biliary colic or peptic ulcer disease, and these findings confirm that the hemangioma was an incidental finding. Less commonly, patients may present with obstructive jaundice, gastric outlet obstruction, or intra-abdominal hemorrhage from spontaneous rupture.
A carcinoma of the ascending colon would be predicted to have lymphatic drainage extending towards the origin of the ileocolic vessels and the right colic vessels (if present). As such, surgery would include ligation of the ileocolic lymphovascular pedicle close to its' origin as well as the right colic pedicle. The terminal ileum and right colon are thereby rendered ischemic and are resected. The apron of lymph nodes along the vascular pedicles are included with the specimen. The ileum is then anastomosed to the proximal transverse colon completing the right hemicolectomy. Gastrointestinal function is usually well preserved despite even extensive colectomy. Therefore, generous resections of the colon are well tolerated with relatively minor effects on subsequent bowel function.
Figure 22-4 Anatomy of the extrahepatic portal venous system. A.P. accessory pancreatic vein, C. coronary vein, cystic cystic vein, I. intestinal veins, I.C. ileocolic vein, I.M. inferior mesenteric vein, I.P.D. inferior pancreaticoduodenal vein, L.B.P. left branch of portal vein, L.C. left colic vein, L.G.E. left gastroepiploic vein, M.C. middle colic vein, O. omental vein, P. pancreatic veins, Pyloric pyloric vein, R.C. right colic vein, R.G.E. right gastroepiploic vein, R.B.P. right branch of portal vein, S. splenic vein, S.G. short gastric veins, S.H. superior hemorrhoidal vein, S.M. superior mesenteric vein, S.P.D. superior pancreaticoduodenal vein, S.T. splenic trunks. (From Douglass, B.E., Baggenstoss, A.H., and Hollinshead, W.G. The anatomy of the portal vein and its tributaries. Surg. Gynecol. Obstet., 91 562, 1950. By permission of Surgery, Gynecology and Obstetrics.) Figure 22-6 A, Typical textbook pattern of the hepatic artery with its three hepatic branches right, left,...
The position of the colon as shown is based on radiographic study in living humans. The anterior wall of the cecum is removed to show the ileocolic valve, characteristic folds, and opening of the appendix. Note that the blood supply is from two sources (1) the superior mesenteric artery through the middle, right, and ileocolic branches and (2) the inferior mesenteric artery through the left colic, sigmoid, and superior hemorrhoidal branches. An enlarged segment of transverse colon is shown above with details of the wall and plicae. A magnified portion of cecum wall is seen at the lower left. (From Bockus, H.L. Gastroenterology, Vol. 2, ed. 3. Phildelphia, W.B. Saunders, 1976.)
Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.