Thyroiditis

Thyroiditis represents a diverse group of autoimmune and inflammatory disorders characterized by infiltration of the thyroid with inflammatory cells and subsequent fibrosis of the gland. Hashimoto's thyroiditis is a chronic autoimmune disorder characterized by destructive lymphocytic infiltration of the thyroid. The disease is 15 times more common in women, and more than 90 percent of patients have circulating antibodies directed against thyroid microsomes and thyroglobulin. Patients are...

Hypothyroidism

Hypothyroidism is almost always caused by primary hypofunction of the thyroid gland. Clinically, hypothyroid patients should be separated into those without goiter (primary atrophy), those with goitrous hypothyroidism (i.e., Hashimoto's thyroiditis, drug-induced hypothyroidism, iodine deficiency, and congenital causes of dyshormonogenesis), and those with postablative hypothyroidism (after thyroidectomy or treatment with RAI). Postablative hypothyroidism and Hashimoto's thyroiditis are the most...

References

An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 6(4) 428-442, 1993. 2. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 20(4) 247-278, 1999. 3. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 326 281-286, 1992. 4. Bratzler DW, Houck PM,...

Lichtenstein Repair

The most commonly performed method of inguinal hernia repair in the United States is the tension-free mesh repair introduced in the 1980s by Irving Lichtenstein.24'29'30 It involves placing a piece of mesh, typically polypropylene, to fill the space between the conjoint tendon transversalis fascia superiorly, and the inguinal ligament inferiorly. The mesh scars in place, and the scar acts to prevent recurrence. The conjoint tendon transversalis fascia are sutured to the mesh patch superiorly,...

Urethral Catheterization

Urethral catheterization is a useful procedure for the surgical patient. One of the more important indications for this procedure is to accurately measure urine output. Urine output is a critical parameter for the patient's hemody-namic status. Another indication is the relief of urinary retention, which could be due to medications, neurologic injury, or loss of bladder tone. Temporary treatment of urinary incontinence, collecting urine for bacterial culture, and treatment of perineal wounds...

Info

The most common organisms include Escherichia coli, E. faecalis, and E. faecium, but a wide variety of organisms are seen. Unlike more benign outpatient UTIs, catheter-related infections require a longer course of treatment of 10-14 days. Administration of preoperative antibiotics immediately prior to skin incision has recently been shown to decrease the rate of wound infection, although there is no evidence that there is a benefit from continuing them into the postoperative period. The...

Initial Evaluation

The initial evaluation of a patient with abdominal pain is extremely important. The physician's ability to collect a comprehensive medical history and perform a complete physical examination in a timely fashion is now often eclipsed and compromised by the facility of ordering a radiologic or serologic test and expecting that a single test will give the diagnosis. Although the sensitivity and specificity with which many tests can now aid in diagnosis often range in the upper 90th percentile, it...

Special Section on Drugs Anxiolytic of choice

A common anxiolytic that is used is lorazepam (Ativan), a benzodiazepine with rapid onset and moderate duration 0.5-2 mg IV is the recommended dose, but start with 0.5 mg at first and then give additional 0.5 mg doses every 5-10 min until the total dose is reached. Midazolam (versed), which is commonly used for procedures such as colonoscopy, is not ideal because it is too short acting and requires frequent dosing. The maximum dose of 1 percent lidocaine that one can use is 500 mg (based on 70...

Gastric cancer

Gastric cancer, or cancer of the stomach, is the second leading cause of cancer deaths worldwide. However, there are considerable differences in the geographic distributions of gastric cancer.11,12 In fact, in Japan where gastric cancer is a relatively common malignancy, screening for gastric cancer rivals the western practice of screening for colon cancer. The overwhelming majority (90-95 percent) of gastric cancers are adenocarcinomas arising from mucous producing cells of the gastric mucosa...

Midepigastric Pain

Midepigastric pain is associated with early stages of acute appendicitis, acute small bowel obstruction, peptic ulcer disease, and acute pancreatitis. Pancreatitis, depending on the etiology of the inflammation, including gallstones, alcohol or idiopathic causes, requires different types of intervention. Gallstone pancreatitis is one of the few types of pancreatitis that require early surgical intervention. It occurs when gallstones become lodged in the pancreatic duct causing obstruction and...

Myocardial Infarction

The incidence of postoperative MI varies from 0.4 to 12 percent depending on the patient population and the manner studied. Patients at highest risk include those with preoperative congestive heart failure, ischemia, who are over 70 years of age, those with other comorbidities such as diabetes mellitus, renal insufficiency, or other atherosclerotic disease (e.g., carotid artery stenosis and peripheral vascular disease). The most recent data on perioperative MI show that those at the highest...

Treatment

Because there is no cure for chronic pancreatitis, therapeutic options are based on controlling the symptoms. These should include abstinence from alcohol, which has been shown to decrease the degree of pain. Patients require narcotics for relief of abdominal pain, and drug dependence is common in this population. Pancreatic enzyme replacements and dietary fat restriction are used to treat steatorrhea, and diabetes is managed with standard, intermittent insulin injections. The management of...

Hematologic Disorders Affecting the Spleen Hereditary Spherocytosis

Hereditary spherocytosis is an autosomal dominant genetic defect resulting in the absence of spectrin, an RBC membrane protein, which results in the loss of RBC membrane plasticity. The rigid RBCs are unable to pass through the splenic vasculature, resulting in RBC trapping and increased rate of RBC destruction within the spleen. The RBC trapping in the spleen results in massive splenomegaly, as well as anemia and jaundice from increased bilirubin production from hemoglobin breakdown. The...

P

Figure 14-3 TRAM flap breast reconstruction.The dotted line is the tissue carried with the flap which can be used to replace missing breast skin and fat tissues. (1) Internal mammary vessels exposed after rib removal for recipient site for free flap reconstruction. (2) Thoracodorsal vessels also used for recipient vessels. (3) Mastectomy defect awaiting reconstruction. (4) Muscle pedicle used for pedi-cled TRAM flaps based on the superior epigastric system. (5) Deep inferior epigastric vessels...

Des

Simultaneous (nonperistaltic) contractions Repetitive (at least three peaks) Increased duration (> 6 s) Spontaneous contractions Intermittent normal peristalsis Contractions may be of increased amplitude Nutcracker esophagus Mean peristaltic amplitude (10 wet swallows) in distal esophagus > 180 mmHg Increased duration of contractions (> 6 s) frequent Normal peristaltic sequences Hypertensive LES LES pressure > 45 mmHg but with normal relaxation Nonspecific esophageal motility disorders...

Insulinoma Clinical Features

Patients with insulinoma develop profound hypoglycemia during fasting or after exercise. The clinical picture includes the signs and symptoms of neu-roglycopenia (anxiety, tremor, confusion, and obtundation) and the sympathetic response to hypoglycemia (hunger, sweating, and tachycardia). These bizarre complaints initially may be attributed to malingering or a psychosomatic etiology unless the association with fasting is recognized. Many patients eat excessively to avoid symptoms, causing...

Unusual Islet Cell Tumors

VIPomas secrete vasoactive intestinal peptide and cause profuse secretory diarrhea (fasting stool output greater than 1 L day), hypokalemia, and either achlorhydria or hypochlorhydria (watery diarrhea, hypokalemia, and achlorhydria or Verner-Morrison syndrome). Hyperglycemia, hypercalcemia, and cutaneous flushing may be seen. Other, more common causes of diarrhea and malabsorption must be excluded. A diagnosis of VIPoma is established by the finding of elevated fasting serum vasoactive...

Direct Inguinal Hernia

Direct inguinal hernias are generally acquired in origin, arising as a result of an imbalance between intra-abdominal stresses and the strength of the abdominal wall. The stresses alone cause weakening of the wall, and when the strength of the abdominal wall is exceeded, herniation occurs. The etiologic factors in direct hernia thus relate to conditions with high intra-abdominal pressure and thus, wall stresses , and loss of structural integrity of the abdominal wall. High intra-abdominal...

Cellular system

Various cells have a specific role during wound healing and are briefly described in the following section. Contraction is an active and essential part of the repair process to close the gap in soft tissues. A contracture, on the other hand, is an undesirable result of healing due to contraction, fibrosis, or other type of tissue damage.3 Myofibroblasts are responsible for wound contraction. These cells differ from regular fibroblasts due to their cytoplasmic microfilaments similar to those of...

Hypertension

Hypertension is a minor clinical predictor of increased preoperative cardiovascular risk. Hypertension is classified as primary essential or idiopathic in 95 percent of cases. Secondary hypertension is found in 5 percent of patients. The five most common causes of secondary hypertension include renal artery stenosis, primary hyperaldosteronism, Cushing syndrome, pheochromocytoma, and aortic stenosis. Several studies have suggested that intraoperative blood pressure changes may be greater in...