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By J. Inog. Louisiana Tech University.

It has all the characteristic features of carcinoma with a great tendency to fungate quite early (Fig cheap 10mg doxepin free shipping. A history of swelling purchase 10 mg doxepin overnight delivery, which is present for months or years and has recently enlarged rapidly purchase doxepin 25mg with amex, is frequently obtained. On examination, a large prominent swelling with dilated subcutaneous veins and without retraction of the nipple is observed. It is of inequal consistency, parts of it being hard, parts soft and parts fluctuating, due to cystic degeneration or haemorrhage. Only in the late stages does the skin become adherent (without being infiltrated) or fungation occurs. Though this condition may occur commonly at puberty idiopathically, yet one or other cause may be found out. To the contrary in infancy the common causes of dysphagia are oesophageal atresia, dysphagia lusoria and congenital cardiospasm. In children dysphagia may be caused by impaction of a foreign body, paralysis of soft palate (due to diphtheria) and acute retropharyngeal abscess. In middle age the common causes of dysphagia are benign stricture (may occur at any age of adult life), achalasia (30 to 40 years) and Paterson-Kelly (Plummer-Vinson) syndrome. A comparatively short history of difficulty in swallowing (a few months duration) in the elderly suggests carcinoma of oesophagus. A slow onset with a long history obtained in benign stricture, achalasia, pharyngeal pouch etc. Difficulty in swallowing first with solids and subsequently with liquids points to mechanical obstruction. Difficulty in swallowing first with liquids and subsequently with solids is typical of achalasia (cardiospasm). In this case a lump in the neck may be visible which may be emptied with pressure. But majority of patients with dysphagia will complain of some sort of discomfort at the site of obstruction. According to the site of obstruction this is felt either behind the upper part of the sternum or behind its lower part. When the oesophagus has been marked by dilatation the patient may complain of vomiting of foul-smelling stagnated intraoesophageal contents of 2 to 3 days old. Coughing, which occurs sometime after ingestion of meals may be due to regurgitation of food in case of cardiospasm or pharyngeal pouch. Similarly previous history of hiatus hernia repair indicates excessive tightness of the repair to be the cause of dysphagia. Anaemia is very much evident in Paterson-Kelly syndrome and carcinoma of oesophagus and in reflux oesophagitis. The tongue is also smooth, pale and devoid of papillae in Paterson- Kelly syndrome. A soft swelling which appear during meals just above the left clavicle is the third stage of pharyngeal pouch. The clinician stands behind the patient and holds the cricoid cartilage with a little upward traction. It must be remembered that if no relevant sign can be elicited on examination of the neck one must palpate the left supraclavicular fossa to exclude presence of enlarged lymph nodes which may be the only sign in case of carcinoma of the oesophagus. Aspiration pneumonitis, which may cause lung abscess, bronchiectasis, haemoptysis may be seen in achalasia. In this condition when the oesophagus is hugely dilated dyspnoea may be complained of with displacement of adjacent structures. On careful examination one may detect intra-thoracic hernial sac in case of paraoesophageal hernia. When the fluid is aspirated the cardiac orifice can only be located with difficulty due to its contracted condition. In case of benign stricture this investigation not only helps in the diagnosis but also can be used to dilate the stricture with an oesophageal bougie. In carcinoma of oesophagus it is not only diagnostic but also gives an indication about the histology of the cancer by taking biopsy specimen through oesophagoscopy. In reflux oesophagitis this investigation shows inflammation of the mucosa of the lower end of the oesophagus. In achalasia with a moderately dilated oesophagus if a lateral chest X- ray is taken a typical air-fluid level may be seen in the posterior mediastinum which along with the typical symptoms is diagnostic of achalasia. More or less all the conditions which may give rise to dysphagia will be diagnosed by this investigation. If a pharyngeal pouch is suspected a thin emulsion of barium should be used for barium swallow. This will show that the barium first feels the pharyngeal pouch, and then overflows from the top. In stricture the meal is first arrested in the dilated oesophagus immediately above the constriction and gradually trickles down through the stricture. The stenosed portion is usually smooth and does not produce any soft tissue shadow as may be obtained in carcinoma. In case of carcinoma the dilatation of the oesophagus above the tumour is less marked. In achalasia the radiographic appearance varies according to the extent of the disease. In early stage there is only mild dilatation of the oesophagus, whereas in late stage there is massive dilatation and tortuosity of the oesophagus. No benign oesophageal tumours produce characteristic features in barium swallow examination. In case of polyps there is also characteristic filling defect detected in this examination. In gastro-oesophageal reflux during the course of barium swallow examination reflux can be demonstrated. This study shows multiphasic, repeatitive and high-amplitude contractions that occur after swallowing in the smooth muscles of the oesophagus.

Pitfalls and Danger Points Extent of Lymphadenectomy Impairing the viability of the skin flaps Injuring the iliofemoral artery or vein Two lymph node groups are accessible and may be removed Injuring the femoral nerve and its branches during a groin dissection: inguinal and pelvic lymph nodes discount doxepin 75 mg free shipping. The inguinal (or superficial) nodes are located in the femoral triangle based on the inguinal ligament doxepin 25 mg online, with its apex formed by the crossing of the adductor longus and the sartorius muscles buy doxepin 25mg with mastercard. The pelvic (or deep) component of the dissection includes the lymph nodes in a triangular area whose apex is formed by the bifurcation of the common iliac artery and whose base is essentially the fascia over the obturator foramen. Chassin generally begins with the superficial component and then progresses more deeply. Exposing the Iliac Region When exposing the region of the iliac vessels for a pelvic lymphadenectomy, two approaches have commonly been employed. One involves vertical division of the inguinal ligament along the line of the iliofemoral vein with later resuturing of this ligament and the floor of the inguinal canal. Moreover, patients in whom this approach is employed appear to have an increased number of skin com- plications. An alternative approach to the pelvis for iliac lymphadenectomy is to place a second incision in the lower abdomen parallel to and about 3–4 cm cephalad to the ingui- nal ligament. After this incision has been carried through the transversalis fascia, the peritoneal sac is retracted upward to expose the iliac vessels and their adjacent fat and lymph nodes. Remember that it is not necessary to elevate • Transposition of sartorius muscle or not? The lateral boundary consists of the medial border of the sartorius muscle, and the lateral aspect of the adductor Operative Technique longus muscle is the medial boundary. The apex of the femo- ral triangle constitutes the point where the sartorius muscle Incision and Exposure meets the adductor longus. Dissecting the skin beyond the femoral triangle has no therapeutic value and may impair Position the lower extremity so the thigh is mildly abducted blood supply to the skin. Start the incision 2–3 cm cephalad and medial to the Exposing the Femoral Triangle anterosuperior spine of the ilium. Continue along the Initiate the dissection along a line parallel and 5–6 cm cepha- inguinal crease in a medial direction until the femoral vein lad to the inguinal ligament. At this point curve the incision gently in a rosis of the external oblique muscle. In men, identify and preserve the spermatic trocautery with a low cutting current or a scalpel to dissect cord as it emerges from the external inguinal ring (Fig. In obese patients we overlying the adductor longus muscle just below the inguinal make the plane of dissection somewhat deeper than 4–5 mm. Expose As the skin flap is dissected toward the outer margin of the the muscle fibers of the adductor muscle and use a scalpel to operative field, increase the thickness of the flap in a tapered dissect the fat and fascia down along the lateral boarder of fashion so the base of the flap is thicker than its apex. Continue the dissection along this muscle in a cephalad margin of the dissection should be 5–6 cm above caudal direction to a point where the sartorius muscle crosses the inguinal ligament. Now dissect the inferior skin flap in a the lateral margin of the adductor longus muscle. At the apex of the femoral triangle, identify, lymph node situated in this triangle, and label it for the pathol- ligate, and divide the internal saphenous vein. Continue to dissect the specimen laterally, exposing the the fascia overlying the sartorius muscle beginning at the length of the femoral artery. Several small arterial branches apex of the femoral triangle and continuing in a cephalad going to the specimen must be divided and ligated before the direction up to the origin of the sartorius muscle at the iliac specimen can be separated from this vessel. Sweep the fat, lymphatic tissue, and fascia overlying oral nerve, situated just lateral to the femoral artery, is covered the sartorius muscle by dissecting in a medial direction. Carefully incise this layer at a point below the inguinal ligament and lateral to the femoral artery. Identify and preserve the branches of the Dissecting the Femoral Artery, Vein, and Nerve femoral nerve as the nerve passes deep to the sartorius muscle. Identify the femoral artery and vein near the apex of the femo- Irrigate the operative field and achieve complete hemosta- ral triangle. This step areolar tissue and fat from the anterior surfaces of the femoral concludes the inguinal (superficial) groin dissection. Identify the Transposing Sartorius Muscle entrance of the internal saphenous vein into the anterior sur- face of the femoral vein. Necrosis of the skin overlying the femoral vessels occurs in This dissection has exposed the pectineus muscle deep to the some patients and endangers the viability of these structures. The To protect the femoral artery and vein from the consequences femoral canal is located deep to the inguinal ligament just of a possible slough, we prefer to transpose the sartorius 1036 C. Identify muscle at its insertion with the electrocoagulating device and preserve the ureter, which generally remains adherent to (Fig. Free the proximal 6–7 cm of this muscle from the peritoneal layer and has been elevated together with the underlying attachments, and transpose it in a medial direc- abdominal structures behind the retractor. Suture the cut end of the sartorius muscle to the external iliac and the internal iliac vessels down to the obtu- inguinal ligament using interrupted 3-0 Tevdek sutures rator membrane overlying the obturator foramen (Fig. Initiate the mobilization by dissecting the lymph nodes and fat overlying the external iliac artery and vein beginning at the inguinal ligament and proceeding in a cephalad direction Pelvic Lymphadenectomy to the junction with the internal iliac vessels. Be careful when clearing fat and lymphatic tissue from the iliac vein, as Make an incision with the scalpel in the direction of the this structure is quite fragile. Lacerations of the vein produce fibers of the external oblique aponeurosis at a level about considerable hemorrhage that is difficult to control. After 3–4 cm above the inguinal ligament from the region above sweeping the fat and lymphatic tissues from the apex of the the external inguinal ring to the anterosuperior spine dissection in a downward direction, identify and preserve the (Fig. Terminate the dissection at this with the electrocoagulator, carrying the incision through the point and remove the specimen. Hemostasis is achieved dur- transversus muscle together with the underlying transversa- ing this dissection primarily by careful application of hemo- lis fascia but not through the peritoneum. Identify the deep inferior epigastric artery and vein inserting interrupted 2-0 silk sutures into the transversalis arising just above the inguinal ligament from the external fascia and the overlying aponeurosis of the transversus mus- iliac artery and vein. Ligate and divide the deep inferior epi- cle, then into the internal oblique muscle, and finally into the gastric vessels. Close the defect in the femoral neum together with the abdominal contents in a cephalad canal by suturing the inguinal ligament down to Cooper’s 118 Inguinal and Pelvic Lymphadenectomy 1037 Fig. No drains are In the operating room, apply the elastic stocking that was placed in the pelvis.

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The child has a decreased appetite but is able to take fluids and has good urine output discount doxepin 75 mg line. Treatment Based on presumptive cause and clinical appearance Hospitalized—parenteral ampicillin (if S purchase doxepin 25 mg with amex. Up to 30% may have coexisting bacterial pathogens; deterioration should signal possible secondary bacterial infection and should start empiric treatment discount 75mg doxepin with mastercard. Chlamydophila or Mycoplasma—erythromycin or other macrolide Feature Bacterial Viral C. Pneumonia Clinical Recall A 15-month-old girl presents to the outpatient clinic on a winter afternoon with fever, shortness of breath, and wheezing. If a chest x-ray revealed hyperinflated lungs with peribronchial cuffing without consolidation, what would be the likely diagnosis? The parents also note that she has a foul-smelling bulky stool each day that “floats. According to the mother, the patient was in his usual state of good health until 4 A. At midnight the infant was fed 4 ounces of formula without any difficulty and then placed to sleep in a crib. Males > females Modifiable: Shorter interpregnancy interval Less prenatal care Low birth weight, preterm, intrauterine growth retardation Maternal smoking Postnatal smoking Sleep environment Higher incidence related to prone sleeping Supine position now better than side-lying No increased problems in supine, i. Reducing risk Supine while asleep Use crib that meets federal safety standards No soft surfaces (sofas, waterbeds, etc. Clinical Recall You are offering advice to a new mother as she and her newborn are about to be discharged home after an uneventful delivery. Epinephrine—alpha and beta adrenergic effects; drug of choice for anaphylaxis Immunotherapy: Administer gradual increase in dose of allergen mixture → decreases or eliminates person’s adverse response on subsequent natural exposure Major indication—duration and severity of symptoms are disabling in spite of routine treatment (for at least two consecutive seasons). Food allergic reactions are most common cause of anaphylaxis seen in emergency rooms With food allergies, there is an IgE and/or a cell-mediated response. Manifestations: Skin—urticaria/angioedema and flushing, atopic dermatitis; 1/3 of children with atopic dermatitis have food allergies, but most common is acute urticaria/angioedema Gastrointestinal—oral pruritus, nausea, vomiting, diarrhea, abdominal pain, eosinophilic gastroenteritis (often first symptoms to affect infants): predominantly a cell-mediated response, so standard allergy tests are of little value; food protein–induced enterocolitis/proctocolitis presents with bloody stool/diarrhea (most cow milk or soy protein allergies) Respiratory—nasal congestion, rhinorrhea, sneezing, laryngeal edema, dyspnea, wheezing, asthma Cardiovascular—dysrhythmias, hypotension Diagnosis Must establish the food and amount eaten, timing, and nature of reaction Skin tests, IgE-specific allergens are useful for IgE sensitization. A negative skin test excludes an IgE-mediated form, but because of cell-mediated responses, may need a food elimination and challenge test in a controlled environment (best test) Treatment Only validated treatment is elimination Epinephrine pens for possible anaphylaxis Clinical Recall A 14-year-old-boy has persistent rhinorrhea, itchy eyes and nose, and post-nasal drip. Subacute and Chronic Atopic Dermatitis Most Commonly Affects the Flexural Surfaces of Joints Courtesy of Tom D. Selective IgA deficiency Selective IgA deficiency is the most common immunodeficiency. Other structures are also involved: great vessel anomalies (right-sided aortic arch, interrupted aortic arch), esophageal atresia, bifid uvula, congenital heart disease (conotruncal malformations, septal defects), facial dysmorphism (short philtrum, thin upper lip, hypertelorism, mandibular hypoplasia, low-set, often notched ears), and cleft palate. Must confirm diagnosis for complete form by molecular genetics (fatal without definitive treatment). Clinical findings: from almost no infections with normal growth to severe opportunistic infections and graft-versus-host disease. Genetics: mutations of any one of 13 genes encoding the components of immune system critical for lymphoid cell development; result in very small thymuses which fail to descend from the neck and a lack of normal components + splenic depletion of lymphocytes and absent (or very undeveloped) remaining lymphatic tissue. Genetics: autosomal recessive with 3 types; affects neutrophil adhesion; mutation of 21q22. Genetics/pathogenesis: one X-linked and 3 autosomal recessive genes; most are males with X-linked inheritance; neutrophils do not produce hydrogen peroxide, which usually acts as a substrate for myeloperoxidase needed to oxidize halide to hypochlorous acid and chloramines that kill microbes; if organism is catalase positive, the organism’s hydrogen peroxide is metabolized and the organism survives, while catalase-negative organisms are killed Clinical findings: variable age on onset and severity; recurrent abscesses (skin, lymph nodes, liver), pneumonia, osteomyelitis; most common pathogens are S. Ophthalmia neonatorum Redness, chemosis, edema of eyelids, purulent discharge Causes: Chemical conjunctivitis most common in first 24 hours of life (from silver nitrate and erythromycin) N. Purulent, Bacterial Conjunctivitis Secondary to Gonococcal Infection of the Eye phil. Allergic Chemical Household cleaning substances, sprays, smoke, smog Extensive tissue damage, loss of sight Keratitis—corneal involvement H. Infection of orbital tissue including subperiosteal and retrobulbar abscesses Physical examination Ophthalmoplegia (eyeball does not move) Chemosis Inflammation Proptosis Toxicity, fever, leukocytosis, acute onset Causes: paranasal sinusitis, direct infection from wound, bacteremia Organisms nontypable H. Physical examination is remarkable for a bulging tympanic membrane with loss of light reflex and landmarks. Physical examination reveals enlarged, erythematous tonsils with exudate and enlarged, slightly tender cervical lymph nodes. Infants: Feeding difficulties Easily fatigued Sweating while feeding Rapid respirations Older children: Shortness of breath Dyspnea on exertion Physical examination Need to refer to normal heart and respiratory rates for ages to determine tachycardia and tachypnea. Grade Quality 1 Soft, difficult to hear 2 Easily heard 3 Louder but no thrill 4 Associated with thrill 5 Thrill; audible with edge of stethoscope 6 Thrill; audible with stethoscope just off chest Table 13-1. Therefore, if the first heart sound is not heard at the lower left sternal border, there is most likely a congenital heart defect, and there will be other clinical and auscultatory findings. Murmurs may not be heard in early life because of increased pulmonary vascular resistance (from fetal to neonatal transition physiology). Physical examination reveals a harsh, pansystolic 3/6 murmur at the left lower sternal border, and hepatomegaly. Pulmonic stenosis (either valve or branched artery) is common in Alagille syndrome (arteriohepatic dysplasia). Physical examination reveals an underweight infant, with a harsh long systolic ejection murmur and a single second heart sound. Ebstein anomaly Development associated with periconceptional maternal lithium use in some cases Downward displacement of abnormal tricuspid valve into right ventricle; the right ventricle gets divided into two parts: an atrialized portion, which is thin-walled, and smaller normal ventricular myocardium Right atrium is huge; tricuspid valve regurgitant Right ventricular output is decreased because Poorly functioning, small right ventricle Tricuspid regurgitation Variable right ventricular outflow obstruction—abnormal anterior tricuspid valve leaflet. Truncus overlies a ventral septal defect (always present) and receives blood from both ventricles (total mixing). Clinical presentation With dropping pulmonary vascular resistance in first week of life, pulmonary blood flow is greatly increased and results in heart failure. Ductus arteriosus supplies the descending aorta, ascending aorta and coronary arteries from retrograde flow. Strep viridians is more common in patients with underlying heart disease or after dental procedures. Etiology/epidemiology Most are Streptococcus viridans (alpha hemolytic) and Staphylococcus aureus Organism associations S. Actinobacillus actinomycetemcomitans Cardiobacterium hominus Eikenella corrodens Kingella kingae These are slow-growing gram-negative organisms that are part of normal flora. Physical examination is remarkable for swollen, painful joints and a heart murmur. Etiology/epidemiology Related to group A Streptococcus infection within several weeks Antibiotics that eliminate Streptococcus from pharynx prevent initial episode of acute rheumatic fever Remains most common form of acquired heart disease worldwide (but Kawasaki in United States and Japan) Initial attacks and recurrences with peak incidence Streptococcus pharyngitis: age 5–15 Immune-mediated—antigens shared between certain strep components and mammalian tissues (heart, brain, joint) Clinical presentation and diagnosis—Jones criteria.

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In more benign form all elements are differentiated and present no elements of potentially malignant embryonic cells cheap 10 mg doxepin amex. Sometimes these malignant foci reproduce the pattern of embryonal carcinoma or choriocarcinoma buy cheap doxepin 25 mg line. Thus embryonal carcinoma may present a bewildering array of histologic patterns recapitulating all of the embryonic or differentiated cell types derived from ectoderm generic 25mg doxepin fast delivery, mesoderm and entoderm. In the adult form there is a small tumour that does not replace the entire testis, but bulky tumours may be found. On cut surface the tumour is basically grey-white, poorly demarcated with foci of haemorrhages and necroses. Histologically the cells grow in alveolar, glandular, tubular or papillary patterns. The neoplastic cells have epithelial appearance and are anaplastic with hyperchromatic nuclei having prominent nucleoli. Microscopically there are varying spaces lined by flattened embryonal epithelial cells. The individual tumour cells are quite anaplastic and contain vacuoles and granules of alpha-fetoprotein. Due to relatively rapid growth of the tumour, haemorrhage and necrosis are common. The lesion is usually very small and often they cause no testicular enlargement, only small palpable nodule may be detected. The primary lesion may be a haemorrhagic or a clotted mass in which bits of grey tumour can tr seen. Microscopically the syncytiotrophoblastic cell is large with many irregular hyperchromatic nuclei and an abundant eosinophilic vacuolated cytoplasm. The cytotrophoblastic cells are more regular, polygonal with distinct cell border with a single fairly uniform nucleus. These grow in cords or masses usually the syncytial cells form a cap around a cluster of cytotrophoblastic cells. Majority of these cancers metastasise widely by haematogenous route virtually to any organ in the body. The primary testicular focus may be difficult to detect and disseminated metastases steal the show. Despite all combinations of surgery, radiation and chemotherapeutic efforts, 5-year survival rate is less than 5%. The lymphatics from the testis run upwards in the spermatic cord and pass through the deep inguinal ring. They then divide into a few branches and course upwards alongwith the testicular vessels in the posterior abdominal wall, being adherent to the posterior peritoneum. These lymphatics drain into the para-aortic group of lymph nodes in the region of the origin of the testicular arteries from the aorta. The efferent lymphatics from these lymph nodes drain into the thoracic duct to the left supraclavicular fossa which drains into the left brachiocephalic vein. So in advanced cases of testicular tumours the left supraclavicular lymph nodes (Virchow’s nodes) may be involved. Some lymphatics from the medial side of the testis run along the artery to the vas and drain into a lymph node lying at the bifurcation of the common iliac artery. It must be remembered that contralateral lymph nodes may be affected by lymphatic spread. Teratomas also spread by this route but it has got a predilection towards blood borne metastasis. Choriocarcinoma is particularly notorious to spread very early through this route and patients often present with metastatic features when the growth is insignificantly small. The presenting features vary in each case and can be broadly classified into 3 groups — 1. Though the testis is easily palpable, yet the patient usually does not report to the clinician before 4 months of onset of symptoms. It usually takes about 20 days to double the size of the testis in a malignant teratoma. Though some surgeons tried a lot to find out trauma as an aetiological factor yet it seems trauma merely calls attention to the testicular enlargement and it does not initiate the neoplasm. Sometimes patients ignore the testicular swelling considering it to be hydrocele and gives more importance to the other symptoms which are due to metastasis. These symptoms are : (i) Patient may present with abdominal or lumbar pain and/or an abdominal swelling. The swelling is usually smooth (as in seminoma) or may be lobulated (as in teratoma). Consistency is usually equal all over in seminoma, but consistency may vary in teratoma with one or more softer bosses. As the testicular tumour gradually enlarges, the spermatic cord may be thickened due to cremasteric hypertrophy to pull up the heavy testis and engorgement of testicular vessels. In a typical case of testicular tumour no abnormality of the prostate or seminal vesicle may be detected through this examination. This is done to detect pulmonary metastasis or detection of enlargement of pulmonary and mediastinal lymph nodes. Para-vertebral nodal masses and enlargement of paratracheal nodes may also be detected by this investigation. Being in the abdomen it is difficult to palpate slight enlargement of these lymph nodes. Nodal metastasis is indicated by filling defect or nodal enlargement with pseudolymphomatous lacy appearance. In case of massively enlarged nodes there may be virtually no entry of contrast medium into the lymph node mass. However infiltration of the testis by leukaemia or lymphoma is difficult to diagnose by this technique. However, ultrasound remains the investigation of choice as it is less expensive and time-consuming. This is in contrast to teratoma where isotopic tumour localisation has proved disappointing.