Tongue cancer causes diagnosis and treatment

 Tongue cancer causes diagnosis and treatment

Introduction

The tongue is a muscular structure its surface covered by nonkeratinizing squamous epithelium the tongue has two parts anterior part which include anterior two third of the tongue such as both sides of the tongue and its tip its called oral part or oral tongue which appear when you protruded your tongue outside, cancers occur in this part are called mouth or oral cancers and the second part is the posterior part or base of the tongue which is related to the pharynx and cancers occur in this part are called oropharyngeal cancers

The tongue is composed of eight muscles four intrinsic and four extrinsic muscles and is separated at the midline by the median fibrous lingual septum

What are the causes of cancer tongue

There are many risk factors which may predisposing for tongue cancer these factors such as

smoking sepsis spirits spices syphilis alcohol recurrent trauma from sharp tooth chronic superficial inflammation of the tongue (glossitis) and leukoplakia white patches of the tongue these factors causing chronic irritation of the tongue which lead to change in its epithelium covering and by time causing tongue cancer also human papilloma virus has a role in cancer tongue formation also benign tongue tumor such as papilloma may undergo malignant changes to carcinoma

Tongue cancer pathology

Tongue cancer common sites are presents at the side of the anterior two third of the tongue this is the commonest site

Age and sex

Tongue cancer are common in old aged male than female

Types of tongue cancer

Tongue cancer may appear on naked eyes such as malignant ulcer with indurated base and everted raised edge and necrotic floor or appear as malignant nodule or fissure or papillary type or woody tongue when cancer causing diffuse infiltration of the tongue and the tongue become so hard like wood

Commonest microscopic picture of tongue cancer is squamous cell carcinoma

  

What are symptoms and signs of tongue cancer

• In the early stage the patient may be asymptomatic the patient usually presents when he discovers there is ulcer or white or red patches on his tongue
  •  The patient may complaining from sore throat which not relieved by usual treatment
  • The patient may feel by pain during swallowing called adenophagia
  • The patient may complaining from inability to swallowing which called dysphagia
  • The patient may complaining from difficulty in speech
  • The patient may complaining from bad odour from his mouth called foeter oris
  • The patient may complaining from inability to protruded his tongue completely outside and his tongue become deviated to the affected side this is called ankyloglossia  this due to infiltration of the muscles of the tongue and floor of the mouth by cancers cells
  • The patient may complaining from profuse or excessive salivation which be blood stained
  • The patient may feel pain in his tongue or referred to his ear called earache due to involved the lingual nerve by cancer cells
  • The patient may complaining from bleeding from the mouth this is either mild bleeding from irritation of the tongue ulcer or may be profuse bleeding due to erosion of the lingual artery  in case of cancer anterior two third or internal carotid artery in case of cancer posterior third of the tongue but this very rare to occurs
  • The patient may feel by tingling and numbness of the mouth
  • The patient may complaining from mass or swelling in his neck due to cancer spread to cervical lymph node but this considered as late stage of cancer
  • The patient may complaining from loss of taste sensation

Investigations of  tongue cancer

Biopsy

Either excisional biopsy means complete excision of the tumor for small tumor or incisional biopsy means excision of small part of the tumor for large tumor

Fine needle aspiration cytology may bee used for lymph node biopsy

  

Computerized tomography CT scanning

For the head and neck  to showing tumor extension and its spreading to other structures

MRI scanning

For the head and neck to show also tumor extension and its spreading to other structures

Other investigations according to the patient cancer

How tongue cancer spread or invasion to other structures

Tongue cancer like any cancer can be spread to other organs by process called metastasis which may spread direct to the remaining part of the tongue or to the floor of the mouth or gums in case of cancer of anterior two third or to soft palate and tonsil in case of cancer of posterior third

Lymphatic spread of the tongue is common and occur early to the surrounding lymph node such as mental sub mandibular lymph nodes and to cervical lymph nodes

 Blood spread of tongue cancer very rare

Treatment of tongue cancer

Treatment of tongue cancer can be divided into treatment of the primary tumor of the tongue and treatment of the neck lymph nodes

Treatment of the primary tongue cancer

Surgical treatment

Surgical excision of the tumor by V- shaped excision for tumor on the tip of the tongue

For tumor on the side or lateral margin of the tongue can be treated by partial excision of the tongue by operation called partial glossectomy

Tumor on the anterior two third of the tongue can be treated by excision of the half of the tongue by operation called hemiglossectomy

If the tumor infiltrating to the mandible can be treated by excision of the tongue (glossectomy) and removal of the half affected part of the mandible ( hemimandibulectomy) and total block neck dissection for lymph nodes these operation is called commando operation

This is followed by plastic reconstruction using either free rib graft or composite pectoralis myocutaneous flap MCF

Radiotherapy of tongue cancer

Radiation therapy may used before surgery either as primary treatment or to decreased cancer size or can be used after surgery to avoid cancer recurrence

Chemotherapy for tongue cancer

Can be used in combination of radiotherapy as chemotherapy alone has no effect on primary cancer and can be given after surgery to avoid risk of cancer recurrence

Treatment of the neck lymph nodes

This is done by operation called total block dissection of the neck which means complete removal of the lymph node on the affected neck side but if both sides of the neck lymph nodes are affected then do selective block dissection on one side with preserve of the internal jugular vein for brain drainage and do total block dissection on the opposite side

 Palliative treatment of tongue cancer

these are indicated in case of patient inoperable these palliative measures depend on patient complaining such as give analgesic for pain ryle,s feeding in advanced cases when patient unable to swallow or eating palliative radiotherapy to relieve of pain obstruction in severe cases with air way obstruction patient may need for tracheostomy this an operation in trachea done by making artificial opening in the trachea and special device inserted through which the patient can be take its breathing

What are the complications of tongue cancer

these complications can be divided into complications related to tongue cancer itself and complications related to surgical operations or radiotherapy and chemotherapy these complications such as infection and air way obstruction or asphyxia and edema of the glottis

inflammation of the lung and bronchus called broncho-pneumonia

  bleeding starvation anemia and cancer cachexia

inability to speech or to eating

tags:tongue,treatment,glossectomy,commando,ankyloglossia,cancer

Cancer esophagus upper lower middle thirds

Cancer esophagus upper lower middle thirds

 Introduction

Cancer esophagus is cancer or malignant tumor which arise in the esophagus which its muscular tubular structure extended from the throat or pharynx above to the stomach or cardia of the stomach below and responsible for carrying the food and drinking through its length to reach the stomach

The esophagus can be divided into three parts upper third ,middle third and lower third each about 9 cm

also esophagus can be divided according to its location into three parts cervical part which present in the neck and it is about 5 cm and thoracic part which lies within the chest cavity and it is about 20 cm and abdominal part which lies within the abdominal cavity and it is about 2 cm

Incidence of esophageal carcinoma

Common in male more than female

Common in old age more than 60 years rare below age 40 years

Common in China Russia and South Africa

What are the site of cancer esophagus

Common site at the points of normal narrowing and at lower esophagus and gastroesophageal junction GOJ

What are the types of cancer esophagus

• Squmamous cell carcinoma is the most common types which can be arise at any level within the esophagus
• Adenocarcinoma which mainly arise in the lower third of the esophagus and at the gastroesophageal junction the major predisposing factor is Barrett,s esophagus which originated from the metaplastic Barrett,s mucosa and resembles gastric cancer
•   Oat cell carcinoma is rare type and associated with poor prognosis
• Other rare tumors are adenoid cystic carcinoma , melanoma and carcinoid tumors

What are the causes of cancer esophagus

  There are many risk factors which associated with development of cancer esophagus

 Which can be divided such as

Risk factors associated with squamous cell carcinoma

• Smoking and tobacco used
• High alcohol intake
• Nitorso compounds in pickled vegetables and smoked meats or nitrosamines in diet
• Minerals deficiencies such as zinc and molybdenum
• Vitamins deficiencies such as vitamins A and C
• Achalalesia and leukoplakia
• Congenital esophageal web or plummer -vinson syndrome which it is rare disease of females from iron deficiency characterized by dysphagia due to development of post-cricoid web with glossitis spoon shaped nails splenomegaly and anemia 
• Corrosive ingestion or swallowing strong alkaline such as lye or acids
• Coeliac disease
• Esophageal strictures and diverticula
• Peptic ulcer
• Tylosis and Howel-Evans syndrome which is hereditary or autosomal dominant disorders characterized by hyperkertosis or thickness of the skin of the palms of the hands and soles of the foots
•  Human papilloma virus and fugal infections of the esophagus
• Prolonged exposure to radiation therapy
• Partial complete removal of the stomach

Risk factors associated adenocarcinoma

•  Barrett,s esophagus
• Gastroesophageal reflux
• High fat intake
• Cigarette smoking
• High alcohol intake
• Zollinger - Ellison syndrome
• Hiatus hernia

What are symptoms and signs of cancer esophagus

• The patient may complaining from difficult in swallowing called dysphagia which may represented late in the disease because for dysphagia to occur it need at least 60% of esophageal circumference to involved or infiltrated by the cancer this type of malignant dysphagia has the following characters malignant dysphagia of short duration few months dysphagia to solid but not to the fluid in the start but later for both solids and fluid  the dysphagia is progressive in nature due to increased the tumor size it is accompanied by bad general condition of the patient due to it is associated with old age malnutrition toxeamia due to absorption of necrotic malignant tissue
• The patient may complaining from pain during swallowing called adenophagia
• The patient may complaining from loss of appetite poor nutrition and loss of weight
• The patient may complaining from  pain in the form of heart burn behind the sternum or at epigastric region the pain may severe and increased by eating may continuous most of the day
• The patient may complaining from cough and choking and aspiration pneumonia if the tumor extended to trachea and causes tracheoesophageal fistula 
• The patient may complaining from stridor if the tumor extended to the tracheobroncheal tree
• The patient may complaining from hoarseness of voice if the tumor extended to the recurrent laryngeal nerve causing its paralysis which lead to vocal cord paralysis
• The patient may complaining from systemic manifestations when the tumor spread or metastasis to other organs such as jaundice and ascites in case of liver metastasis and bone pain or pathological bone fractures in case of bone metastasis or shortness of breathing or dyspnea and pleural effusion in case of lung metastasis
•      The patient may complaining from non specific gasrtointestinal symptoms  so most of the esophageal cancers are discovered late  because the patient symptoms may unclear untill more than half of the esophageal lumen become obstructed by the cancer
• The cancer may discovered incidentally during endoscopic esophageal survey
• The patient may complaining from regurgitation and vomiting
• The patient may complaining from vomiting of blood  which may be massive called haematemesis
• The patient may complaining from hiccough due to extended of the cancer to phrenic nerve  may causes diaphragmatic paralysis
• The patient may complaining from swelling such as lymph nodes enlarged or lymphadenopathay 

What are the investigations of cancer esophagus

Barium swallow

Which may showing short esophageal segment narrowing, irregular filling defect, rat tail appearance in case of cancer lower third and mild proximal dilatation may appear

Upper endoscopy or esophagoscopy

Which showing the growth lesion and a biopsy has been taken for histological examination

Other investigations for cancer staging to detect cancer spread or metastasis to other organs such as

Plain X rays and  computerized  tomography CT scanning of the chest

Abdominal ultrasound and CT scanning

Thorascopy and laporascopy

 Magnetic resonance imaging MRI  scanning

Endoscopic ultrasound

Positron emission tomography

tags:esophagus,cancer,upper,middle,lower,squamous,tylosis

DISEASES OF BILIARY SYSTEMS

DISEASES OF BILIARY SYSTEMS

This section will be included most important  diseases or disorders of the biliary systems such as gall bladder anatomy function stones diseases and cancer and bile ducts such as the common bile duct common hepatic duct right and left hepatic duct and the cystic duct including the anatomy function diseases and cancer and methods or diagnostic studies of this system as follow

• Gallbladder anatomy
• Biliary duct anatomy including the common bile duct common hepatic duct and its branches and cystic duct anatomy
• Diagnosis or investigations of biliary channels
• Gallbladder function
• Gallbladder stones causes types diagnosis and treatment
• Acute cholecystitis causes types diagnosis and treatment
• Chronic cholecystitis causes types diagnosis and treatment
• Acaclular or non calcular cholecystitis causes diagnosis and treatment
• Ascending cholangitis causes diagnosis and treatment
• Sclerosing cholangitis  types causes diagnosis and treatment
•    Gallbladder cancer causes diagnosis and treatment
• Bile duct cancer or cholangiocarcinoma causes diagnosis and treatment
• Bile duct cysts or choledochal cysts causes types diagnosis and treatment
• Bile ducts injury or strictures causes types diagnosis and treatment
• Problems after gall bladder removal or postcholecystectomy complications

tags:biliary,diseases,systems

EXPLAINING THE ANATOMY OF THE BILE DUCTS

EXPLAINING THE ANATOMY OF THE BILE DUCTS

The extrahepatic bile ducts consists of the right and left hepatic ducts the common hepatic duct the cystic duct and the common bile duct these structures are the system of the biliary channels

BILE DUCTS ANATOMY

  Common bile duct anatomy

The common bile duct is about 7-11 cm in length and 5-10 mm in diameter the common bile duct enters the second part of the duodenum through a muscular structure called the sphincter of Oddi which consists of a thick coat of circular smooth muscle surrounds the common bile duct at the ampulla of vatar it is regulate flow of the bile and pancreatic juice into the duodenum and prevent the regurigitation of duodenal contents into the biliary channels and diverts bile into the gallbladder

The common bile duct divided into three thirds

  

 The upper third is the part above the duodenum

supraduodenal portion) which passes downward in the free edge of the hepatoduodenal ligament to the right of the hepatic artery and anterior to the portal vein

 

The middle third of the common bile duct  is the part present behind the duodenum (retroduodenal portion) which curves behind the first part of the duodenum and diverges laterally from the portal vein and the hepatic arteries

The lower third of the common bile duct is the part which present behind the pancreatic head( pancreatic portion ) which curves behind the head of pancreas in a groove or traverses through it and enters the second part of the duodenum where the pancreatic duct frequently joint it

  

The common bile duct  runs obliquely downward within the wall of the duodenum for 1 to 2 cm before opening on a papilla of the mucous membrane called ampulla of vater which lies about 10 cm distal to the pylorus of the stomach

 The union of the common bile duct and the main pancreatic duct may take one of these features most of the people these ducts unite outside the duodenal wall as a single duct in some people they join within the duodenal wall and have or no common duct in rare people they may exit by separate opening into the duodenum

  Common hepatic duct anatomy

 The common hepatic duct is 1 to 4 cm in length and it is diameter about 4 mm  it is lies in the front of the portal vein and to the right of the hepatic artery

 The common hepatic formed by union of right and left hepatic duct close to their emergence from the liver the left hepatic duct is longer than the right

The common hepatic duct is joined at an acute angle by the cystic duct to form the common bile duct

  Cystic duct anatomy

The length of cystic duct variable it may be to short or absent and may join the hepatic duct in high position or long and runs parallel  behind or spiral to the main hepatic duct before joining it

These variation of cystic duct very important to be in mind during removal of gallbladder by cholecystecomy operation

 These variation such as the cystic duct may joined the common hepatic duct at low level  or it may become adherent to the common hepatic duct

Or may joined common hepatic duct at high level or the cystic duct may open into the right hepatic duct instead of common hepatic duct the cystic duct may be long that joined the common hepatic duct behind the duodenum

Or it may cross behind the common hepatic duct and joined it anteriorly the cystic duct may be absent  or it may courses anterior to the common hepatic duct and joint it posteriorly

the segment of the cystic duct adjacent to the gallbladder neck have mucosal folds called the spiral valves of Heister

 

 Blood supply

The arterial supply of the bile duct is derived from the gastroduodenal and the right hepatic arteries with major trunks running along the medial and lateral walls of the common bile duct referred to as 3 o`clock and 9 o`clock these arteries anastomose within the duct walls venous drainage following their arterial supply

Nerve supply

Same as gall bladder see here but the density of the nerve fibers and ganglia increase near the sphincter of Oddi

You can see also

• Gallbladder anatomy
• Biliary duct anatomy including the common bile duct common hepatic duct and its branches and cystic duct anatomy
• Diagnosis or investigations of biliary channels
• Gallbladder function
• Gallbladder stones causes types diagnosis and treatment
• Acute cholecystitis causes types diagnosis and treatment
• Chronic cholecystitis causes types diagnosis and treatment
• Acaclular or non calcular cholecystitis causes diagnosis and treatment
• Ascending cholangitis causes diagnosis and treatment
• Sclerosing cholangitis  types causes diagnosis and treatment
•    Gallbladder cancer causes diagnosis and treatment
• Bile duct cancer or cholangiocarcinoma causes diagnosis and treatment
• Bile duct cysts or choledochal cysts causes types diagnosis and treatment
• Bile ducts injury or strictures causes types diagnosis and treatment
• Problems after gall bladder removal or postcholecystectomy complications

tags:anatomy,bile,ducts,explaining 

EXPLAINING OF TREATMENT OF ASCITES OR ASTSGA

EXPLAINING OF TREATMENT OF ASCITES OR ASTSGA

Introduction

Ascites treatment can be divided into many regimens which either can be used in usual or refractory ascites which most common causes is liver cirrhosis

This treatment can be divided into the following items

As in case of ascites there is salt like sodium and fluid or water retention so the patient need to restricted dietary salt as sodium intake in the diet and also restricted water intake especially in case associated with hyponatremia

Patients with  liver cirrhosis often can not excreted more than 50 mEq of sodium per day so dietary sodium is usually restricted to 50 mEq (1 gram sodium equal to 3 gram salt) so if serum sodium is low less than 130 mEq|l fluid restriction to 1000ml|day 

As in ascites there is more or excessive body fluid so patients need drugs to decrease this fluid and excreted it outside the body these drugs are called diuretics drugs which excreted fluid through the kidney into the urine and patient feel increased the number of micturation in each time micturated fluid excreted outside the body as urine

Diuretic therapy is better used in combination to avoid decreased serum potassium  (hypokalemia)  or  increased serum potassium( hyperkalemia ) if one drug alone also to give better results

These diuretic drugs combination such as spironolactone in initial dose 100 mg combined with furosemide in initial dose 40 mg or bumetanide in initial dose 1 mg which inhibit sodium absorption so increased its secretion in urine

The dose of these drugs spironolactone and furosemide can be increased gradually in multiples 50 and 40 mg four to five times untill a diuresis is obtained

It should be known that an increased urine output of 500 ml|day correspond to a weight loss of 1 pound per day

It is also should be considered that the large diuretic may result in decreased renal perfusion and high level of nitrogen contaninig compounds such as urea and creatinine (azotemia ) so

At least during the initial diuretic treatment it is important to determine serum electrolytes like sodium and potassium urea nitrogen and serum creatinine

The dose of diuretic should be adjusted to a lower maintenance dosage  known by the patient weight become dry  this to prevent decreased plasma volume and hyponatremia

In some patient during treatment of ascites there is may be no response to treatment can occurred and this is known as refractory ascites
  
 Definition of refractory ascitis  as it is intraaddominal fluid which not respond to sodium restriction and high dose of diuretic therapy or early recurrence of ascites after therapeutic aspiration of the ascitic fluid (paracentesis ) that cannot be prevented by sodium restriction and diuretic therapy which need special treatment such as

Treatment of refractory ascites

There are many options for treatment of refractory ascites such as

• Therapeutic aspiration or paracentesis of ascitic fluid
• Transjugular intrahepatic portasystemic stent-shunt TIPS
• Peritoneovenous shunt
• Liver transplantation

Theraputic paracentesis

This can be done by repeated aspiration of  large volume of the ascitic fluid by paracentesis up to 4-6 litre at a time this procedure can be done by using 18 gauge needle with plastic catheter is placed in the left lower abdomen and the fluid drained by plastic catheter into 1 litre vacutainer bottles 

It may give the patient salt poor or free albumin during paracentesis to decreased changes in electrolytes plasma renin and serum creatinine

Repeated paracentesis with maintenance diuretic helps control of ascites and the patient feel comfortable

 

 Transjugular intrahepatic portosystemic stent-shunt TIPS

It is has good result with high successful rate in reducing portal pressure and preventing recurrent bleeding from esophageal and gastric varices and reduced ascites

The procedure consists of the placement of a self expanding metallic stent (Wallstent)  between the hepatic vein and the portal vein under radiological screening with patient under mild sedation have good success rate in most of major  medical centres

Peritoneovenous shunt

Effective by increasing intravascular volume and decreasing ascites and allow to used lower dose of diuretic to control ascites but it is rare used nowadays because it has major and fatal complications

Liver transplantation

Chronic liver disease complicated by refractory ascites is a good indication for liver transplantation

 

    

tags:treatment,ascites,astsga,explaining

 

EXPLAINING OF ASCITES OR ASTSGA

EXPLAINING OF ASCITES OR ASTSGA

Definition

Ascites or astsga means the presence of abnormal fluid which accumulated inside the abdominal cavity or in the peritoneal cavity called ascitic fluid

Ascites is not a disease but it is a sign of many diseases which can causes it such as liver cirrhosis which most common causes of ascites

What are the causes of ascites

There are many causes of ascites such as

• Liver cirrhosis
• Nephrotic syndrome
• Congestive heart failure
• Malignancy or cancer
•  Tuberculosis peritonitis
• Acute pancreatitis
• Nutritional defieicncy
• Constrictive pericarditis
• Ovarian disease like Meig,s syndrome
• Protein loosing enteropathy such as ulcerative colitis grohn,s disease
• Lymphatic obstruction as in lymphoma causes chylous ascites
• Myxoedema
• Chronic peritoneal dialysis

Symptoms and signs of ascites

What patient complains or feels

• Small amount of ascites may be asymptomatic and patient not complaining
• Increased amount of ascites patient complaining from abdominal discomforts abdominal distension and sense of fullness
• Large amount of ascites the patient may complaining from respiratory distress as dyspnea because ascites compress the diaphragm
• Anorexia pain in abdominal flanks
• Symptoms and signs of the associated disease such as jaundice esophageal varices bleeding in case of liver cirrhosis

    The fluid of ascites may take the following nature in specific causes

• Transudate ascites which has the following criteria its specific gravity less than 1017 protein content less than 2.5 gm|dl protein ascites |serum ratio less than .5 lactic dehydrogenase less than 200 IU|L such as in liver cirrhosis congestive heart failure nephrotic syndrome
• Exudate ascites or turbid ascites which has the following criteria specific gravity more than 1017 protein content ,ore than 2.5 gm|dl protein ascites| serum ratio more than .5  lactic dehydrogenase more than 200 IU|L such as in bacterial peritonitis or infection tumors and myxoedema
• Chylous ascites which containing lymphatic fluid also called milky ascites due to lymphatic duct disruption as in lymphoma or trauma
• Bile ascites such as ruptured gall bladder
• urine ascites as in ruptured urinary bladder
• sero-sangianous or meat like or bloody ascites such as in malignancy
• Hemorrhagic ascites such as trauma to abdomen malignancy acute hemorrhagic panctreatitis disrupted ectopic pregnancy
• Pancreatic ascites such as acute or chronic pancreatitis which common causes of it alcohol or trauma to the pancreas

How ascites is formed or pathogenesis of ascites

There are several factors which contributed to form ascites such as

In case liver cirrhosis which account for most common causes of ascites about 85%  it is result from

• Portal hypertension which means increased pressure in the portal vein or liver blood flow which lead to increased hepatic or liver and splanchnic lymph production and transudated fluid which lead to increased hydrostatic pressure
• Liver cirrhosis causes hypoalbuminaemia and hypoproteinaemia normally the albumin formed by the liver in case of liver cirrhosis liver fail to form it  this lead to decreased colloid osmotic pressure
• Impaired renal sodium and water excretion secondary to hyperaldosteronsim and increased levels of antidiuretic hormone
• These factors also causes edema in the lower legs pleural effusion or fluid accumulation at any part of the body like stomach caused gastric congestion and anorexia

Others contributing factors in formation of ascites

• Increased hydrostatic pressure such as hepatic veins occlusion or thrombosis from portal hypertension (Budd- Chiari Syndrome) constrictive pericarditis tense pericardial effusion congestive heart failure
• Decreased colloid osmotic pressure such as nephrotic syndrome with protein loos malnutrition protein loosing entropathy
• Increased permeability of peritoneal capillaries such as tuberculosis (TB) peritonitis bacterial peritonitis malignant disease of the peritoneumn cancer colon cancer ovary cancer stomach etc
•    Fluid retention such as end stage of renal failure and heart failure due to accumulation of the fluid inside the body and inability to excreted it

What are differential diagnosis of ascitis

Ascites should be differentiated from other causes of abdominal distension such as

• Obese patient
• Intestinal or colonic distension by gases
• Large abdominal tumors
• Large abdominal cysts like huge ovarian cysts
• Large intraabdominal fat deposition in the mesentery of the intestine
• Pregnant women

 Investigations of ascites

Laboratory

Liver function test

The most common causes of ascites liver cirrhosis  this test showing serum bilirubin level which may increased SGOT and  SPGT liver enzymes are raised plasma protein such as albumin decreased

Prothrombin time become prolonged

Hepatitis markers

In case of acute or chronic hepatitis showing hepatitis B and C virus markers

Complete blood count

showing leucocytosis in case of infection increased white blood cells

Anemia decreased red blood cells

Thrombocytopenia decreased platelets count may lead to easy bleeding tendency

Complete urine analysis

Protein or albumin in urine as in case of nephrotic syndrome or renal failure

Amlyase enzyme concentration

Smear is prepared from the ascitic fluid and stained by special stain and examined for malignant cells it common positive in case of malignant ascites

Cytological examination of ascitic fluid

Aspiration of the ascitic fluid usually 100-200 cc  from the intraabdominal cavity and send for cytology may showing that

marked increased in the white blood cells suggestive infection if the most cells are polymorphonuclear

 

Mon nuclear cells predominate suspected tuberculosis or fungi infection

Marked increased in red blood cell count may indicated either malignancy or tuberculosis or trauma

 Appearance of the fluid or its colour

Clear straw coloured is common seen in liver cirrhosis and transudate ascites bloody fluid suggests malignancy or tuberculosis peritonitis  turbid fluid indicates infection milky fluid ( chylous ascites ) is common due to lymphatic causes also triglycerides elevated in chylous ascites

Gram staining and culture

For diagnosis of bacterial infection

Radiological

Abdominal ultrasound

Showing ascitic fluid liver pathology tumors

CT scanning of the abdomen

As abdominal ultrasound with specific indications according to disease causing ascites

MRI scanning of the abdomen

As CT scanning

Plain X rays

On the chest may show tubercles in case of tuberculosis or associated pleural effusion or cardiac enlargement

On the abdomen may showing calcification in the mesentric or para aortic lymph nodes

Echocardiography

For suspected  heart causes of ascites

Complications of ascites

Most important complications of ascites are

Infection which consider major problems these due to invasion of the peritoneal ascites by the normal intestinal flora or bacteria which occurs spontaneously and so called spontaneous bacterial peritonitis in the form of fever abdominal pain in this case examination of ascitic fluid revealed high specific gravity high protein concentration  and polymorphic leucocytosis

Hepatorenal syndrome which manifested by slow onset of oliguria decreased urine amount during micturation may decreased daily to 100-150 ml but not lead to anuria  what are the criteria for diagnosis of hepatorenal syndrome

  The criteria of hepatorenal syndrome are

• Liver disease with liver failure and portal hypertension
• Low glomerular filtration rate creatinine less than 1.5 mg|dl
• Urine volume less than 500 ml|day
• Urine sodium less than 10 mEq|l
• Urine osmolarity more than plasma osmolarity
• No significant abnormalities of urinary sediment
• No improvement in renal function following diuretic withdrawal and volume expansion

Treatment of ascites

This depend on the underlying causes see here for treatment of ascites

tags:ascites,explaining,astsga

PROBLEMS AFTER GALL BLADDER REMOVAL

PROBLEMS AFTER GALL BLADDER REMOVAL

Introduction

The gall bladder removal is done by operation called cholecystectomy which either done by open surgery (open choelcystecomy ) or by laparoscopy (laparoscopic cholecystectomy

 This operation is very common all over the world which done mainly for stones in the gall bladder and most of the patients are recovered postoperative without any complications

 There are many problems can be associated with removal of the gall bladder but these problems are very rare to occurs

These problems ( postcholecystecomy problems ) can be divided into either early problems which occurs sooner or days after the operation or late problems months or years or postcholecystectomy syndrome

Early postcholecysteomy problems

Normally the patient after cholecystectomy operation stay in hospital one or two days then go to home and recovered with full activities within 10 days any deviation from this course should be raise the concerns about the possibility of a complications and the causes are evaluated by the surgeon

these complications may be

• The patient may complaining from persistent abdominal pain bloating abdominal distension
• Anorexia,vomiting
• Pain and jaundice

These problems if happened should be investigated seriously because that mean there is a problem with this operation such as

• Bile leakage which appear in the intrabdominal catheter drain as yellowish or biliary fluid this catheter drainage is left in the patients abdomen to drainage any fluid residual after the operations that means either there is biliary tract injuries or slipped cystic duct stump
• This bile leakage also can come from the liver bed from intracanalcuilar biliary ducts which can not seen by the eyes that type of biliary leakage can be stopped alone without any interference if the catheter drain still present inside the abdomen
•  Intraperitoneal fluid collection in the form of bile ascites when bile leakage spread in the whole abdomen or become localized in the site of operation gall bladder or liver bed called( bilioma
• Hemoperitoneum due to bleeding from vascular injuries or slipped ligature of the cystic artery which is the only artery ligated during cholecystectomy operations or injury to other vessels like to hepatic artery rare to portal vein because this type of injury seen easy during the operation
• Common bile duct or hepatic duct obstructions which may occurs either due to wrong ligation by suture or clipped  instead of ligation of the cystic duct or due to missed stone in the common bile duct the patient come with picture of obstructive jaundice as yellowish discolouration of the skin and sclera of the eyes the colour of his urine become dark red like tea and the stool colour become pale or calley and fever due to inability of the bile salts to reach the intestine due to this obstruction
• Biliary-cutaneous fistula may occurs also
• Retained bile inside the abdomen without drainage can causes major problems because bile very irritant and causes peritonitis which lead to sepsis and infections and can causes multi-organs failure if not treated rapid
• Injury to the abdominal viscera like colon duodenum or stomach or others organs but these injuries can be seen during the operation and can be deal with it but if not discovered the patient come also with a picture of peritonitis with severe abdominal pain abdominal distension fever vomiting  injury to the colon causes feacal peritonitis due to the presence of the feaces inside the abdomen injury to the duodenum causes also biliary peritonitis
• Other complications like any operation like wound infection seroma or heamatoma of the wounds

Late postcholecystectomy problems

Late complications of cholecystectomy may range from mild gastrointestianl tract (GIT) complains to severe incapacitating pain such as

•  Patients common complains from indigestion bloating flatulence and diarrhea
• Patients whom complaining from abdominal pain fever and jaundice after long postoperative symptoms free period should be suspected recurrent common bile duct stones
• Other late complications may occur such as bile duct stricture  biliary fistula retained stones in common bile duct or in cystic duct pancreatitis and infection
• It should be consider that these symptoms may due to other causes such as pancreatic cancer peptic ulcer gastric cancer renal disease reflux esophagitis and coronary artery disease irritable bowel syndrome cholangiocarcinoma sclerosing cholangitis stenossing papillitis and wound neuroma these need careful examination and investigations

Postcholecystectomy syndrome

 These syndrome can appear after cholecytectomy operation in the form of the presence of symptoms of gall bladder stone where the exact causes unclear which

•  Some patients may continue to have symptoms like abdominal colic pain diarrhea vomiting nausea and bloating after cholecystectomy and after careful and repeated investigations of these patients there is no evidence of cancer stones strictures ulcers can be found
• There are two diseases may can explained this syndrome which are biliary dyskinesia and papillary stenosis

• Biliary dyskinesia  refers to motility disorders and papillary stenosis refers to  structural abnormailties
• Biliary dyskinesia it is motor abnormailities of the sphincter of Oddi and may produce disturbances of the biliary function and give symptoms such as unexplained biliary pain
• Papillary stenosis it may causes recurrent biliary pain after cholecystectomy may also causes recurrent pancreatitis that stenosis may due to papillary fibrosis from intermittent passage of stones other causes may include instrumentation intubation Ascariasis worms cholesterolsis peptic ulcer and pancreatitis the patient may complaining from that pain after 5 years from postcholecystectomy 
• The pain of papillary stenosis is episodic severe and located in the epigastric or right upper quadrant region of the abdomen  the pain can occur at any time  not related to meals typically the pain lasts for 12-36 hours and the relieved may need for narcotic to relief the pain during the attack
• Other causes of postcholecystectomy syndrome are may due to technical errors as leaving long or very short stump of cystic duct but nowadays these may be not important as in laparosopic cholecystectomy long cystic duct remnant are left without complaining

These patients need for careful examination and investigations as follow see here

You can see also 

• Gallbladder anatomy
• Biliary duct anatomy including the common bile duct common hepatic duct and its branches and cystic duct anatomy
• Diagnosis or investigations of biliary channels
• Gallbladder function
• Gallbladder stones causes types diagnosis and treatment
• Acute cholecystitis causes types diagnosis and treatment
• Chronic cholecystitis causes types diagnosis and treatment
• Acaclular or non calcular cholecystitis causes diagnosis and treatment
• Ascending cholangitis causes diagnosis and treatment
• Sclerosing cholangitis  types causes diagnosis and treatment
•    Gallbladder cancer causes diagnosis and treatment
• Bile duct cancer or cholangiocarcinoma causes diagnosis and treatment
• Bile duct cysts or choledochal cysts causes types diagnosis and treatment
• Bile ducts injury or strictures causes types diagnosis and treatment
• Problems after gall bladder removal or postcholecystectomy complications

tags:gallbladder,removal,after,problems,postcholecystectomy,syndrome

 

BILIARY OR (CHOLEDOCHAL )CYSTS

BILIARY OR (CHOLEDOCHAL )CYSTS

Definition

Choledochal cysts are congenital abnormalities of the biliary channels which characterized by cystic dilatation of the biliary tree which either affected the extrahepatic or intrahepatic biliary tree or both affection which can be present at any age from antenatal periods to late in adult life

BILIARY OR CHOLEDOCHAL CYST TYPE I

Causes

There is no definite causes but theories suggestive that its due to reflux of pancreatic juice into the biliary tree related to the long anomalous pancreaticobiliary channel also weakness of the bile duct wall and increased pressure secondary to biliary obstruction are required for biliary cyst formation

Types of choledochal cysts

It can be divided into five types according to Todani modification of the Alonso-Lej classification

Type I cysts

Fusiform saccular or cystic dilatation of the extrahepatic biliary tree

BILIARY OR CHOLEDOCHAL CYST TYPE II

It is the most common type up to 50% of all choledochal cysts

Type II cysts

Saccular or diverticulum of an extrahepatic bile duct or extrahepatic biliary diverticulum

 Rare comprising less than 5%  of choledochal cysts

Type III cysts choledochocele

 Bile duct dilatation within the duodenal wall (choledochocele) or dilatation of extrahepatic intradoudenal biliary tree

 less than 10 % or choledochal cysts
Types IV cysts A and B

 

 IV A cysts

Both extrahepatic and intrahepatic saccular or cystic dilatation

BILIARY OR CHOLEDOCHAL CYST TYPE III

Second most common type of cyst seen in adults 30-40%

IV B cysts

Multiple extrahepatic bilary cyst

  Less than 5%

Type V cysts  Caroli,s disease

  

Intrathepatic biliary cysts

    Less than 10% of choledochal cysts this disease can be associated with periportal fibrosis and liver cirrhosis

Incidence

 Affect female more than male

BILIARY OR CHOLEDOCHAL CYST TYPE IV A

affect any age from antenatal to late adults life

vary in size from 2 cm in diameter to giant cysts

Symptoms and signs

These depend on the age of the patient

The classic triad of choledochal cysts which are jaundice abdominal pain in the right upper quadrant and abdominal mass can be present up to 20 % of the patients

Antenatal periods

May discovered during routine abdominal ultrasound during pregnancy which appear as abdominal mass

Neontal and infants

BILIARY OR CHOLEDOCHAL CYST TYPE IVB

• Neonatal jaundice yellowish discoloration of the skin and sclera of the eye
• Palpable abdominal mass in the right upper quadrant  and  may be enlarged liver

Children,s

• Abdominal pain colicky pain
• Palpable abdominal mass in the right upper quadrant
• Jaundice
• Fever nausea and vomiting may present

Adults

• Abdominal mass may difficult to become palpable due to increased abdominal wall muscle development may felt in thin patient
• Abdominal pain is common colicky pain in the epigastric or right upper quadrant of the abdomen
• Jaundice
• Fever nausea and vomiting
• picture of pancreatitis



BILIARY OR CHOLEDOCHAL CYST TYPE V

• picture of cholangitis

Complications of choledochal cysts

Most dangerous one it is changes to malignancy or carcinoma of both gall bladder called gall bladder carcinoma see here and bile ducts called cholangiocarcinoma see here

Other complications such as liver cirrhosis cholangitis acute pancreatits and cholecystitis
 

 Postoperative complications also cholangitis pancreatitis and sepsis anastomosis leakage biliary strictures intrahepatic stones formation

Investigations

Laboratory

Liver function test

serum biliurbin are elevated to some extend

Alkaline phosphatase and gamma glutamy transferase are common elevated due to obstructive effect of these cysts the transaminases alanine ALT and asparate aminotransferase AST are also elevated but to some extend

Serum amalyse and lipase

 may be elevated in patients with acute abdominal pain and signs and symptoms of clinical pancreatitis

Complete blood count

may showing raised white blood cells count leukocytosis in case of cholangitis

Urine analysis

Showing the colour of urine may be dark colour like tea due to associated obstructive jaundice  also urobilinogin and uribiurbin may be present

Radiological studies

    

Abdominal ultrasound and CT scanning of the abdomen

Showing the cystic as mass and CT showing and define the anatomy of the hepatobiliary and pancreatic regions

 Magnetic resonance cholangiopancreatography MRCP also MRI

very excellent for diagnosis and define the anatomy of the biliary channels

Percutaneous transhepatic cholangiograpgy PTC

Very important especially in case of type IV cyst also used to placement of transhepatic stents

Endoscopic retragrade cholangiopancreatograpgy  ERCP

Which delinated the distal part well but  may  not define  the most proximal biliary anatomy

 For more details see here

Treatment of choledochal cysts

Because the choledochal cysts are associated with malignant transformation to cholaniocarcinoma which can present in young age in contrast to typical presentation of cholangiocarcinmoa which present in old age and gall bladder cancer so all patients with type I, II or type IV should have the cysts excised and the mucosa of the cysts should also be removed

In the past enteric drainage of the cyst was performed but this drainage do not decrease the possibility of malignancy and also was associated with biliary stasis and recurrent infection and biliary strictures

 Operations of choledochal cysts

Type I cysts
   

Either surgical or laparocopically

Removal of gall bladder by cholecystectomy operation
The most distal cystic dilatation is identified
and then the common bile duct (CBD ) is then transected at the intrapancreatic portion with extreme care not to injury the pancreatic duct
A standard 60-cm-Roux-en-Y loop is used for an end to side hepaticojejunostomy

Type II cysts

Can easy to treated by simple excision of the cyst and the closure the defect in the wall of the common bile duct in transverse fashion not in longitudinal fashion to avoid narrowing of the CBD

Type III cyst choledochoceles

The risk of malignancy in this type rare
Treated by approached from a lateral duodenostomy in the second part of the duodenum with intubation of the pancreatic and bile duct with small silastic tube to avoid their injuries
then the cyst is excised and the mucosa of the CBD and pancreatic duct are sutured to the duodenal mucosa using interrupted sutures

Sphincteroplasty may performed and the duodenostomy is closed transversely

Type IV cysts

The entire portion of the extrahepatic biliary tree involved should be resected if possible   individual reconstruction of the left right and any accessory ducts is necessary if possible

then hepaticojejunostomy is constructed as type I


Type V cysts

Also called Caroli,s disease

Common confined to single liver or hepatic lobe usually the left one
 Treated by hepatic resection

large cyst treated by unroofed to Roux-en-Y limb

In some cases the intrahepatic disease result in extensive fibrosis  and need for liver transplantation

These patient need for life long follow up for fear of malignancy

You can see also

• Gallbladder anatomy
• Biliary duct anatomy including the common bile duct common hepatic duct and its branches and cystic duct anatomy
• Diagnosis or investigations of biliary channels
• Gallbladder function
• Gallbladder stones causes types diagnosis and treatment
• Acute cholecystitis causes types diagnosis and treatment
• Chronic cholecystitis causes types diagnosis and treatment
• Acaclular or non calcular cholecystitis causes diagnosis and treatment
• Ascending cholangitis causes diagnosis and treatment
• Sclerosing cholangitis  types causes diagnosis and treatment
•    Gallbladder cancer causes diagnosis and treatment
• Bile duct cancer or cholangiocarcinoma causes diagnosis and treatment
• Bile duct cysts or choledochal cysts causes types diagnosis and treatment
• Bile ducts injury or strictures causes types diagnosis and treatment
• Problems after gall bladder removal or postcholecystectomy complications

tags:cysts,biliary,choledochal