1. Investigation of the Surgical patient M K ALAM MS;FRCS

2. Objectives At the end of this presentation students will be able to:  Identify the need for establishing diagnosis.  Describe the whole spectrum of available investigations.  Choose relevant investigations and justify their use.  Understand the side effects and complications of some investigation.  Identify need for assessing physiological status.  Understand the need for screening common asymptomatic disorders.

3. Diagnosis History Clinical examination Investigations: -Support clinical suspicion -Refute clinical suspicion -Risk to patient -Cost

4. Other aims of investigation Assess physiological impairment for risk to surgical treatment. Example: Cardiac, renal respiratory diseases Screen for common asymptomatic disorders. Example : Diabetes, coronary artery disorders, hypertension

5. Hematological investigations FBC or CBC: Anemia (low Hb.), MCV, MCHC (normocytic, microcytic), leukocytosis (infection) Platelet count: Thrombocytopenia ( drug- heparin, ITP, autoimmune), Thrombocytosis ( post-splenectomy) Coagulation profile: PT, INR, APTT (disordered in patients of jaundice, bleeding, anticoagulant, antiplatelet medications)

6. Biochemical tests Na: 135-146 mmol/L ( water overload, NG asp., sepsis, vomiting) K: 3.5- 5.5 mmol/L (changes- vulnerable to arrhythmias) Urea: 2.6- 6.7 mmol/L ( dehydration, renal insufficiency) Creatinine: 60-120 mmol/L (marker of renal disease) Glucose: 3.9-5.6 mmol/L ( diabetes) Total protein: 62-80 G/L Albumin: 35-50G/L (nutritional assessment) Bilirubin <17 mmol/L (jaundice) ALP: 25-120 U/L AST: 10-40 U/L ALT: 5-30U/L LDH: 49-195U/L Creatinine phosphokinase: 24-195 U/L Amylase <100 u/L

7. Microbiological investigations Urine (UTI), sputum, stool Hepatitis screening (B, C) Antibiotic sensitivity

8. Tumour markers PSA- Prostate CEA- Colorectal α- fetoprotein (AFP)- Hepatocellular β-hCG- Testicular, gestational CA 19-9- Colorectal, pancreas CA 125 - Ovarian

9. Imaging studies Plain x-ray- CXR, AXR, tomograms Side effects: Induction of malignancy, genetic mutation.

11. AXR (gallstone)

12. Imaging studies Contrast studies- gastrografin swallow, barium meal, barium enema. Visualize GI tract Single contrast, double contrast Inferior to endoscopy Contraindicated if bowel perforation suspected

13. Gastrografin & Barium enema

15. Imaging studies CT scan (oral, iv contrast): Widely used for abdomen, chest, brain, vascular and urinary tract. (anaphylactic reaction, renal injury, radiation) Ultrasound: Safe, low cost. Operator dependent. Investigation of first choice for biliary disease and gynaecology. MRI: Good images of soft tissue (better than CT), blood vessel (MRI angiogram). No radiation, no known deleterious effect. Slow and expensive. Isotope scan: More information about function than structure. I131,Tc99, I123, Ga67, Th201- incorporated into other molecule to localize target organ. Detected by gamma camera. Bone metastasis, renal function, foci of infection, GI bleeding, infarction of myocardium, sentinel node detection PET scan: Expensive. Brain physiology, tumour detection, cardiac physiology.

16. Intestinal ischemia

17. Intussusception

18. Lower GI bleeding Scan

19. Meckel's scan

21. Endoscopy Precise diagnosis of GI, pancreatico-biliary, bronchus, urinary tract pathology. Perform cytology/ biopsy. Minimally invasive therapy- laparoscopy, arthroscopy, ERCP. Disadvantages: Unpleasant, uncomfortable (sedation/ anesthesia) Complications: Infection, perforation, aspiration, bleeding, cardiac arrhythmias, respiratory arrest

22. Upper GI endoscopy & Colonoscopy

23. CBD stone extraction

24. ERCP (Stone CBD, Periampullary carcinoma)

25. Tissue sampling Body fluids- pleura, peritoneum, sputum, urine. Smears, brush cytology FNAC ( insitu vs invasive, follicular adenoma vs carcinoma) Core biopsy Open biopsy Frozen section biopsy: (biopsy frozen in liquid nitrogen, sliced, stained and reported in minutes)

26. Function tests Cardiac evaluation: ECG, Thallium scan, echocardiography Respiratory function: ABG ( risk pCO2 > 45 mmHg) FVC & FEV1 ( risk- < 70% of predicted) Renal function Endocrine function

27. Screening Screening for malignant disease.(FOB, mammography, PSA) Screening for surgical disease ( abdominal aortic aneurysm)

28. Thank you!