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Colostomy
Stoma- an artificial opening of an internal organ on the surface of the body. Eg: Colostomy,
ileostomy, tracheostomy, cecostomy, thoracostomy, gastrostomy, cystostomy

Colostomy:

Def: an artificial opening made in the large bowel to divert faces and flatus to the
exterior where it can be collected in an external appliance.

Types: Permanent: if the distal rectum and anorectal sphincter are removed the
colostomy is permanent eg: rectal ca distal third, incontinence 2ry to sphincter removal.
Inflammatory process UC, congenital (imperforated anus, Hirschsprung)

Temporary: colostomy done either for decompressing an obstructed of

perforated distal colon or diverting colostomy to permit healing of fistula tract or ac
inflammation

Decompressing: transverse loop colostomy, cecostomy

Diverting: loop colostomy, double barrel, spectacles, Hartman

Site of colostomy- depend on the indication but the commonest site, specially for
permanent colostomy, lateral edge of rectus sheath, 6 cm above and medial to ASIS

Indications:

 Distal obstruction 2ry to ca, diverticulum and sigmoid volvulus( major

reason in Eth)
 Trauma: left sided penetrating injury, stab; to prevent fecal peritonitis
 Perianal, vesicocolic, rectovesical, rectovaginal, colovaginal fistulas
 Congenital: inperforated anus, Hirschsprung’s disease
 Inflammatory Bowel disease: UC n CD
 Gangrenous sigmoid volvulus

Complications:

 Prolapse
 Retraction
 Necrosis of distal end
 Stenosis of the orifice ( stomal)
  Parastomal fistula formation
 Colostomy hernia ( parastomal hernia)
 Colostomy diarrhea
 Peristomal skin infection

Differences from ileostomy: yellowish discharge in ileo, but solid n offensive smell in colostomy

NG Tube
Indications:

 Feeding ( comatose)
 Decompression in case of ER surgery. Ac pancreatitis and SBO. Poisoning (pre-op Achalasia)
 To adminster drugs, fluid and electrolyte
 For determination of gastric content by taking specimen
 To diagnosis GOO
 To know the extent of diaphragmatic hernia
 After esophagectomy to prevent anastomosis leakage
 Pot-op (after peritonitis b/c it can coz ileus and fecal obs)
 Pt with gastric stenosis

Contraindications:

 Severe facial trauma (basal skull fracture)

 Obstruction of airway
 Obstructed esophagus
 Esophageal varices
 Gastric bypass surgery or recent surgery to that area
 Zenker’s diverticulum
 Patients with penetrating neck wound

Complications:

 Nose bleeding
 Esophageal perforation
 Pulmonary aspiration
 Pneumothorax 2ry to placing the tube in the trachea/ bronchus
 Hydrothorax, empyema
  Sinusitis, sore throat

How to make sure that the NG tube is in the stomach:

1. Using a syringe and a stethoscope over the lung field push air in n try to listen
2. Submerge the end of the tube in water, if in the airway bubbles will be formed
3. Aspirate the tube n u should c gastric content coming out of the tube?

Chest tube

Indications:

 Air: pneumothorax, bronchopulmonary fistula

 Fluid:
o Hemothorax
o Hemopneumothorax
o Empyema
o Malignant pleural effusion
o Chylothorax

Site of placement:

 Air: 2nd ICS in Mid-clavicular line

 Fluid: in the safe triangle: ( medial- lateral border of the pec major, lateral- midaxillary line,
lower-6th ICS)

When to remove:

 symptomatic improvement of patient

 general appearance and vital signs
 P/E of the chest
 Amount of output <50mL/24 hr of serous fluid (no pus no blood)
 CXR for confirmation
Catheter
3 way Foley catheter

2 way Foley catheter

Type of catheter, size and inflation amount should be described if s1 wants to prescribe catheter

Urinary bladder catheter:

Indications:

 Acute urinary retention

 Urinary output measurement
 During surgery to asses fluid status
 Immobilized pt and unconscious pt
 Neurogenic bladder
 Intravesical pharmacologic therapy
 Pt with urinary incontinence
 Hematuria associated with clots

Contraindications:

 Absolute: urethral trauma during pelvis trauma

 Relative:
o Urethral stricture
o Recent urinary tract surgery
o Presence of an artificial phincter

Complications:

 Infections
 Bladder fistula
 Bladder perforation
 Stricture ( urethral)
 Reduced functional capacity of the bladder
 Squamous cell carcinoma
Tracheostomy
2 types:

 Metallic: no cuff and has inner tube the pt can change it

 Plastic: cuffed( avoid air leak and aspiration) and can be with or w/o inner tube

Indications:

 Obstruction of upper airway

o Foreign body
o Burn
o Laryngeal diphtheria, tetanus
o Severe maxillofacial injury
 To improve respiratory function:
o Fulminant bronchopneumonia to reduce dead space ( by 50%)
o Chronic bronchitis with subcutaneous emphysema
o Chest injury
 Respiratory paralysis
o Unconsciousness
o Coma
o Tetanus

Complications:

 Immediate: hemorrhage, hypoxia, RL nerve injury, infection, esophageal damage,

pneumothorax(though uncommon), subcutaneous emphysema
 Early:
o Tube obstruction or displacement
o Aspiration
o Bleeding
 Late:
o Aspiration pneumonia
o Laryngeal/ tracheal stenosis
o Tracheomalacia
o TEF&TEAF

Tracheostomy care:

 Wet gauze to humidify the air

 Frequent suctioning
 Mucolytic agent- use saline
 Change the tube every month ( mainly for the plastic)
Varicose vein
Def: dilated tortuous veins

Site: - veins of the lower limbs

-portosystemic anastomosis

~esophageal

~hemorrhoidal

~periumbilical

~retroperitoneal

-testicle

Classification:

 Primary:
o Defect in the wall of the vein
o Defect in the valve
 Secondary:
o Intrabdominal masses
o Pelvic masses
o Pregnancies
o Obesity
o Long time standing
o DVT
o AV fistula
Examination:
 Trendelenburg’s test
 Multiple tourniquet test
 Modified perthes test
 Homan’s sign
 Schwartz test
 Fregam test

Investigations:

 Doppler U/S
 Duplex U/S
 Venography
 Arteriography
Management:
 Conservative
o Bed rest and elevate
o Elastic band
 Surgery
o Multiple ligation

Complication:

 Skin change
 Thrombophlebitis
 Hemorrhage
 Lipodermatosclerosis
 Calcification of the vein
 Periostitis
 Major ulcer( due to long standing ulcer)

Hernia
Def: abnormal protrusion of intra abdominal tissue through a fascial defect in the abdominal wall

Contents of hernia:

 Small intestine
 Omentum
 Appendix
 Diverticula
 Bladder
 Ovary
 Rectum
Examination:
 Finger invagination test
 3 fingers test
 Deep ring occlusion test
 Reducibility
Investigation:
 Doppler U/S
Predisposing factors:
 Chronic cough
 Constipation
 BOO
 Pregnancy
 Ascites
 Pelvic tumor
 Obesity
 Heavy exercise

Complications:

 Irreducibility
 Obstructed hernia
 Strangulation
 Incarcerated hernia
 Inflamed hernia

Nephrostomy
Placed in the renal pelvis or lower calus

Indication:

 Obstruction
 PNL
 Open nephrolithotomy
 Uretrolithotomy
 Pylolithotomy

Complications:

 Infection
 Leakage of urine> localized collection (urinoma)
 Slippage
 Haemorrhage
 Peritonitis –rare- coz kidneys are retroperitoneal

Suprapubic cystostomy
Indication:

 Boo 2ry to urethral stricture (after failed catheterization)

 BPH (after failed catheterization)
 Other causes (after failed catheterization)
 Urethral trauma

Contraindications:

 Absolute- Bladder tumor

 Relative- sever e bleeding tendency

Complications:

 Infections
 Perforation to bowel
 Leakage – high risk of foreigners gangrene
 Slippage & catheter not inflated
 Fistula( after removing a catheter specially in long standing one
 Care change the catheter bag every month

Cholelithiasis
Fat/ fertile/ female/ forty/ flatus

Dyspepsia

Pain ( Dur, type and radiating)

Bloating

Bowel habit change

Yellowish discoloration

Signs of anemia

Alcohol

DM

Vomit

Long parentral feeding

Breast

 Familial
 Early menarche and late menopause
 Previous Hx lump surgery
 Swelling how noticed, rate of growth
 Hx of HRT/ OCP
 Age, sex and race
 Smokin, diet
 DM, HTN, Tb
 Pregnancy ( lactation)
 Radiation
 Hx of trauma
 Nulliparity

Gastrostomy tube

Indication: obstruction of esophagus

Complication: -infection

-intraperitoneal leak

T-tube

Indication:

 After CBD exploration

 Injury to CBD
 CBD stone

Complication:

 Infection
 Biloma ( localized collection of bile)
 Leakage skin irritation

Removal after 10 days

  When drained bile looks normal
 When amount drained become small enough
 After clamping for 24 hr if no pair or jaundice or fever development
 When T-tube cholangiogram is clear

PUD Gastric Ca.

 NSAIDs  Smoking
 Smoking  Age
 H. pylori  Alcohol
 Vomit  Metastasis feature
 Pain  Short duration
 Duration : long  Diet
 Hx dyspepsia  Familial
 Urinary change  Hx of surgery
 Relieving factor
 Stool color change
 Early satiety
 Hx of dyspepsia

Esophageal Ca

 Hot spicy food ( genfo, hot coffee)

 Area
 Progressions ( solid > liquid)
 Regurgitation / vomit ( type)
 Associated Symptoms
 Metastatic
 Appetite wt loss anemia
 Mumps, H. zoster
 Trauma High alcohol, chemical
 Tb/ HIV/ Dna
 Choke hiccup
 Chest pain,
 Symptoms of anemia
 Hx of melena, bowel change
 Smoking
 Canned food, aflatoxin
Dysplasia, DDx:

 Achalasia
 Eso. Ca
 Esophageal stricture 2ry Tb

Investigations:

 CBC- Hb
 High ALP if 2ry occur
 Occult bloody stool
 U/S
 Barrium Swallow
 Endoscopic biopsy

Mass Examination
Inspection:

 Site, size, shape, surface ( smooth, irregular, nodular), border

 Skin color change, scar, dilated veins
 Mvt with swallowing or protrusion of tongue
 Mvt with cough
 Ulcer, discharge

Palpation:

 Tenderness
 Temperature over the mass
 Consistency ( hard, firm, soft and cystic)
 Pulsation
 Fixation to the skin/ mobility

Percussion

 Retrosternal extension
 Tympanic or dull ( abdo mass and hernia)

Auscultation:
  Bruit
 Bowel sound ( hernia)
 Friction rub

Long on Thyroid
C/C: -Swelling in front or side, pain over the swelling

-Difficulty in breathing or swallowing

-Hoarseness of voice, bulging of eyes

HPI:

Details about the swelling:

 Duration
 Onset
 Site where it was first noticed
 Progress :- gradually increasing in size ( b9)
 Rapidly increasing in size ( mal)
 Sudden enlargement of the swelling( may be hemorrhage)

Pain: dur , site, character( usu dull aching), radiation, RAF

Pressure symptoms:

-difficulty of swallow

wing and breathing

-hoarseness of voice

Symptoms of thyrotoxicosis:

 Appetite
 Wt loss
 Bowel habits ( diarrhea in hyper)
 Palpitation
  Nervousness
 Easy irritability
 Tremor of the hand, tongue
 Bulging of the eyes
 Increased sweating
 Intolerance to heat
 Any menstrual pb ( amenorrhea in toxic goiter)

Past Hx n at the end Rx Hx anti thyroid drugs

Personal Hx: menstrual and obstetrics

Family Hx: Hx of thyroid

Long for Breast Cancer

C/C swelling( lumps, pain ulceration, nipple discharge, change in size.

HPI:

If swelling: dur, rate of growth, any swelling in the opposite breast

If Pain: PQRST, relation with menstrual cycle

If Ulcer: any discharge, dur

If Nipple Discharge: type ( serous, bloody/ milky)

Any swelling in the axilla or neck or groin

Personal or fam Hx of breast diss

Hx of ovarian, endometrial or colonic ca

Radiation exposure to Chest wall

Cigarette smoking, alcohol, high fat diet

Hx of bone pain or back pain

Chest pain, cough, SOB, hemoptysis

Yellowish discoloration of the eye and skin Abd pain, wt loss, loss of appetite
Any Hx of headache, vomiting, weakness of any limb

Age of menarche and number of children

Hx of HTN, TB, DM, Asthma, bleeding tendencies

Family Hx: detailed fam Hx regarding similar illness or any Hx of GI or ovarian mal

Personal Hx: -menstrual Hx

-pregnancy: age at 1rst preg, total number of preg, no of abortion, modes of delivery, last child
birth

-Hx of OCP

-Hx of lactation