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

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

3 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

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

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

6 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.

7 Which of the following is the likely diagnosis?

8 Distractors 1.CA gall bladder 2.CBD stone 3.Hilar cholangiocarcinoma 4.CA head of pancreas 5.Biliary agenesis

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

10 J+ GB  Hard

11 J+ GB  Hard = CA GB

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

13 J+ GB Not palpable Pain present = ?

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

15 J+ GB Not palpable No pain

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

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

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

19 Congenital Syndromes Dubin Johnson Gilbert Rotor Criggler Najjar

20 J+ Hard liver- smooth

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

22 J+ Liver Hard- nodular

23 J+ Liver Hard- nodular = Secondaries in Liver Inv = search for primary= P 0 FNAC Liver (if PT is N)

24 J+ Pain + Fever +

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

26 Triad Hiatus hernia Cholelithiais Diverticulosis = Saint’s triad

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

28 RIF mass : DD 1.Appendicular 2.CA Caecum 3.Ileo-caecal TB 4.Crohn’s 5.Actinomycosis 6.Carcinoid 7.Amoeboma 8.LN mass

29 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

30 GB Stone : Types ? Examine Spleen in GB

31 Appendix No mass= Appendicectomy

32 Appendix Mass but normal temp= Conservative

33 Appendix Mass but  temp= Abscess= Image guided aspiration

34 Colorectal Cancer Anal Rectal Rectosigmoid Premalignant Inv & Rx

35 Colorectal Cancer Commonest symptom Inv

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

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