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What is the most likely diagnosis ?

A. Pneumonia.

B. Lung Abscess.

C. Empyema.

D. Pleural Effusion.

Correct Answer » A Explanation

Ans:A. Pneumonia.

Image shows:Frontal CXR showing ill-defined air space opacification in the right lower lobe (arrows) due to consolidation from pneumonia.

Pneumonia

• The inflammatory exudate within air-spaces and interstitium of the affected lung causes the opacification and air-filled bronchioles outlined by adjacent fluid-filled alveoli in affected lung produce the air bronchogram.

A. Antibiotics should be given.

B. May present with Pneumatosis Intestinalis.

C. Principal indication of surgery is Necrotic Intestine.

D. All of the above.

Correct Answer » D Explanation

Ans:D. All of the above.

Necrotizing enterocolitis

• Typically occurs in the second to third week of life in premature, formula-fed infants, is characterized by variable damage to the intestinal tract, ranging from mucosal injury to full-thickness necrosis and perforation.

• NEC affects close to 10% of infants who weigh less than 1500 g, with mortality rates of 50% or more depending on severity, but may also occur in term and near-term babies.

Presentation may be subtle and can include 1 or more of the following:

1. Vomiting
2. Diarrhea
3. Delayed gastric emptying
4. Abdominal distention, abdominal tenderness, or both
5. Ileus/decreased bowel sounds
6. Abdominal wall erythema (advanced stages)
7. Hematochezia

Systemic signs can include any of the following:

1. Respiratory failure
2. Decreased peripheral perfusion
3. Circulatory collapse.
4. Radiographic features
5. Plain radiograph

• Supine abdominal x-rays are the mainstay of diagnosis. If NEC is suspected clinically, or there is concern on supine films, then an additional cross-table lateral or left-lateral decubitus film should be obtained :

• dilated bowel loops (often asymmetrical in distribution)

• loss of the normal polygonal gas shape

• bowel wall oedema with thumb printing

• pneumatosis intestinalis (intramural gas)

• portal venous gas

• pneumoperitoneum secondary to perforation

• air on both sides of the bowel (Rigler sign)

• air outlining the falciform ligament (football sign)

Ultrasound

1. bowel wall thickening
2. alteration of vascular state
3. hypervascular (viable but engorged in early stage)
4. hypovascular (infarcted in later stage)
   intramural gas manifesting as hyperechoic foci within the bowel wall
   free fluid, especially with echogenic debris, is suspicious for perforation

MORPHOLOGIC FEATURES.

• Grossly, the affected segment of the bowel is dilated, necrotic, haemorrhagic and friable. Bowel wall may contain bubbles of air (pneumatosis intestinalis).

• Microscopically: initial changes are confined to mucosa and show oedema, haemorrhage and coagulative necrosis.

• A pseudomembrane composed of necrotic epithelium, fibrin and inflammatory cells may develop.

• As the ischaemic process extends to the subjacent layers, muscle layer is also involved and may lead to perforation and peritonitis.

MANAGEMENT:

• The initial course of treatment consists of the following:

• Stop enteral feedings

• Perform nasogastric decompression

• Initiate broad-spectrum antibiotics (eg, ampicillin, gentamicin, and clindamycin or metronidazole).

• The principal indication for operative intervention in NEC is perforated or necrotic intestine, which is most compellingly predicted by pneumoperitoneum. Other indications include the following:

1. Erythema in the abdominal wall
2. Gas in the portal vein
3. Positive paracentesis
4. Clinical deterioration

A. Crohn’s disease

B. Ulcerative colitis

C. Tuberculosis of colon

D. Carcinoma colon

Correct Answer » B Explanation

Ans:B.  Ulcerative colitis

Image shows:Single-contrast enema study with total colitis showing mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally orientated.

Imaging Manifestations in Ulcerative Colitis

Acute inflammatory stage

• Spasm and irritability

• Fine mucosal granularity=earliest finding on air-contrast BE

• Spiculated, serrated bowel margins from tiny, multiple ulcerations

• Collar button ulcers-from undermining (not specific for UC)

• Double-tracking=long, longitudinal ulcers in submucosa

• Thumbprinting=from edema of wall

• Pseudopolyps=scattered islands of edematous mucosa in a sea of ulcerated mucosa

• Widening of the presacral space

Subacute stage

• Coarser, more granular mucosa

• Inflammatory polyps= frondlike lesions of inflamed mucosa

Chronic stage

• Shortening of the colon=may be from spasm of longitudinal muscles or from irreversible fibrosis (lead-pipe colon)

• Loss of haustrations on left side of colon

• Postinflammatory polyps=filiform polyps=long worm-like lesions

• Backwash ileitis (5-10%)=wide open ileocecal valve and dilated terminal ileum

A. Ulcerative Colitis.

B. Intestinal Perforation.

C. Intestinal Obstruction.

D. Paralytic Ileus.

Correct Answer » A Explanation

Ans:A. Ulcerative Colitis.

Abdominal X ray in the image shows:

• yellow arrow = lead pipe sign of the distal transverse colon

• red arrow = thumbprinting of the proximal transverse colon.

The thumbprinting represents wall oedema and likely represents more acute (active) disease, with lead pipe appearance more distally representing chronic disease.

Thumb print and lead pipe sign suggests inflammation of the bowel.

A. Colitis.

B. Paralytic Ileus.

C. Sigmoid Volvulus.

D. Cecal Volvulus.

Correct Answer » C Explanation

Ans:C. Sigmoid Volvulus.

Abdominal X ray in the image shows the features of Sigmoid Volvulus

• The sigmoid colon is very dilated because it is twisted at the root of its mesentery in the left iliac fossa (LIF). The proximal large bowel is also dilated .

• The twisted loop of sigmoid colon is said to resemble a coffee bean.(marked by red dots) .

Twisting of the bowel – or ‘volvulus’ – is a specific cause of bowel obstruction.

• The two commonest types of bowel twisting are sigmoid volvulus and caecal volvulus.

Sigmoid volvulus

• The sigmoid colon is more prone to twisting than other segments of the large bowel because it is ‘mobile’ on its own mesentery, which arises from a fixed point in the left iliac fossa (LIF).

• Twisting at the root of the mesentery results in the formation of an enclosed loop of sigmoid colon which becomes very dilated.

• If untreated this can lead either to perforation, due to excessive dilatation, or to ischaemia due to compromise of the blood supply.

A. Deaver retractor.

B. Langenbeck retractor.

C. Army-Navy retractor.

D. Richardson retractor.

Correct Answer » C Explanation

The surgical instrument shown in the picture above represents Army-Navy retractor.

Also known as Parker Langenbeck, or retractor double end. Used to expose surface layers of skin, commonly in plastic surgery procedures. It is a double-ended retractor with a fenestrated handle.

The blades at each end are angled at 90 degrees and also have a slightly curved, rounded lip. The blades also face in the same direction.

A. The retractor has a smaller blade.

B. The retractor has a larger blade.

C. The retractor has a smaller handle.

D. The retractor has a larger handle.

Correct Answer » A Explanation

The surgical instrument shown in the picture above represents Richardson retractor.

The Richardson retractor is often mistaken for a Kelly retractor; however, the Richardson retractor has a smaller blade.

A. Richardson retractor.

B. Army-Navy retractor.

C. Langenbeck retractor.

D. Weitlaner retractor.

Correct Answer » D Explanation

The surgical instrument shown in the picture above represents Weitlaner retractor.

Weitlaner retractor is a self-retaining, finger ring retractor with a cam ratchet lock used for holding back tissue and exposing a surgical site. The Weitlaner retractor is a popular instrument, most commonly used in basic plastic surgery, large bone and joint procedures, and mastoid surgeries. It is also useful with small, deep incisions and soft tissue dissection at a superficial level.

A. Ligasure.

B. Diathermy.

C. Laser.

D. None of the above.

Correct Answer » A Explanation

The electrosurgical instrument shown in the picture above represents Ligasure.

Vessel sealer and divider, designed to be used in confined surgical spaces where access and visibility are a necessity. The instrument has a low temperature profile and seals effectively at a cooler temperature.

Designed for use in open procedures. Procedural applications include: ENT, general, plastic/reconstructive, urologic, thoracic

A. Diathermy.

B. Ligasure.

C. Weitlaner retractor.

D. None of the above.

Correct Answer » A Explanation

The electro surgical instrument shown in the picture above represents Diathermy.

Diathermy can be monopolar or bipolar. High frequency A.C. electric current either as a cutting modality or else to cauterize small blood vessels to stop bleeding.

This technique induces localised tissue burning and damage, the zone of which is controlled by the frequency and power of the device.