MS FRCS (Edin) FRCS (Glasg) FAMS FACS DNB FICS FAIS Abdomen Professor Ravi Kant MS FRCS (Edin) FRCS (Glasg) FAMS FACS DNB FICS FAIS

MCQ Short story = clinical vignette One line question 5 options= distractors One will be correct Blue print

Blue print 10 basics = trauma 10 H&N 10 Breast 10 hernia, etc 10 jaundice, abdomen 10 abdomen 10 colo-rectal 10 Ped surgery 5 vascular 5 Thoracic 10 Plastic surgery

Jaundice (J+) Itching Clay colored stool Se Alkaline Phosphatase  Surgical √ Itching Clay colored stool Se Alkaline Phosphatase  Direct bilirubin  Total Bilirubin 

J+ If GB  = NOT a case of CBD STONE Courvoisier’s law = palpable

J+ GB  Soft A 45 y old male presents to OPD with jaundice, clay colored stools, itching. On examination, soft gall bladder is palpable. Total and direct bilirubin is raised.

A 45 y old male presents to OPD with jaundice, clay colored stools, itching. On examination, soft gall bladder is palpable. Total and direct bilirubin is raised. Which of the following is the likely diagnosis?

Distractors CA gall bladder CBD stone Hilar cholangiocarcinoma CA head of pancreas Biliary agenesis

J+ GB  Soft= CA head of Pancreas of CA Periampullary (D or B or P)

J+ GB  Hard

J+ GB  Hard = CA GB

J+ GB  Soft = CA Head of Pancreas or CA Periampullary GB  Hard = CA GB

J+ GB Not palpable Pain present = ?

J+ GB Not palpable Pain present Young = CBD Stone Courvoisier’s law

J+ GB Not palpable No pain

J+ GB Not palpable No pain = Hilar Cholangiocarcinoma (Klatskin’s tumor) Intra-hepatic Congenital

J+ 2 months age GB Not palpable No pain = Intra-hepatic = Biliary agenesis= Kasai operation

J+ GB not palpable GB not palpable Pain + Pain – CBD stone Inv MRCP Rx ERCP GB not palpable Pain – Hilar Cholangiocarcinoma Inv MRCP Rx Excision + H-J (Hepatico-jejunostomy)

Congenital Syndromes Dubin Johnson Gilbert Rotor Criggler Najjar

J+ Hard liver- smooth

J+ Hard liver- smooth = Primary Carcinoma of Liver Inv =AFP, CT scan, MRA FNAC is CONTRAINDICATED Rx = Surgery= Resection

J+ Liver Hard- nodular

J+ Liver Hard- nodular = Secondaries in Liver Inv = search for primary= P0 FNAC Liver (if PT is N)

J+ Pain + Fever +

J+ Pain + Fever + = Charcot’s triad =Surgical emergency = IV fluids, antibiotics ►Later, when stabilized, Inv MRCP ; Rx ERCP

Triad Hiatus hernia Cholelithiais Diverticulosis = Saint’s triad

Liver ▲ Hydatid Amoebic- pain & thump sign present Tumors- primary & Secondary

RIF mass : DD Appendicular CA Caecum Ileo-caecal TB Crohn’s Actinomycosis Carcinoid Amoeboma LN mass

RIF mass : DD Appendicular CA Caecum Ileo-caecal TB Crohn’s Actnomycosis Carcinoid Amoeboma LN mass Undescended testis Ectopic kidney In F= TO Mass Aneurysm of Iliac Art Bone tumour

GB Stone : Types ? Examine Spleen in GB

Appendix No mass= Appendicectomy

Appendix Mass but normal temp= Conservative

Appendix Mass but  temp= Abscess= Image guided aspiration

Colorectal Cancer Anal Rectal Rectosigmoid Premalignant Inv & Rx

Colorectal Cancer Commonest symptom Inv

LIF Mass DD Diverticulosis Rectosigmoid CA LN TO- mass--- CA 125

Types, Inv & Rx of Hemorrhoids Fistula in Ano Fissure in Ano