Causes
Primary Lymphatic disease-Lymphoma
Secondary Lymphadenopathy
Malignant disease
Benign
Physiological reaction to inflammatory state
Management
Exclude Inflammatory causes
Examine, Observe, Antibiotics etc.
Exclude obvious malignancy
Biopsy-FNA/Open
Saphenous Varix
Prominent Varicosity of Upper Long Saphenous Vein.
Typical Patient
Middle aged and older
F>M
Usual Risk Factors
Pregnancy, Pelvic Mass
Clinically
Dragging lump over upper thigh, disappears when lying
Cough impulse +
Thrill down vein when percussing.
Management-surgical ligation.
Femoral Artery Aneurysm.
True aneurysms
Pulsatile lump in groin
Associated with other aneurysmal disease
Mx-Vascular surgical repair if >2-3cm
False aneurysm
Secondary to puncture
Dx on duplex
Mx-Call a vascular surgeon-thrombose or repair.
Undescended Testes
Rare in adults
Usually Dx and treated as children
In adults usually present as infertility
Alt painless lump in Inguinal canal
Prone to infertility and testicular cancer.
Managemant
Refer to Urologist.
Graves’disease
Toxic adenoma (solitary)
Toxic multinodular goiter
Subacute thyroiditis
Hashimoto’s thyroiditis (transient hyperthyroid phase)
Thyrotoxicosis factitia
Postpartum
Struma ovarii
Metastatic thyroid carcinoma
Hydatidaform mole
TSH-secreting pituitary tumor
Pituitary resistance to triiodothryonine and thyroxine
Thyroiditis – Classification
Hashimoto’s thyroiditis - Chronic lymphocytic thyroiditis, Chronic autoimmune thyroiditis, Lymphadenoid goiter
Painless postpartum thyroiditis - Postpartum thyroiditis, Subacute lymphocytic thyroiditis
Painless sporadic thyroiditis - Silent sporadic thyroiditis, subacute lymphocytic thyroiditis
Painful subacute thyroiditis - Subacute thyroiditis, de Quervain’s thyroiditis, Giant-cell thyroiditis, Subacute granulomatous thyroiditis, pseudogranulomatous thyroiditis
Suppurative thyroiditis - Infectious thyroiditis, Acute suppurative thyroiditis, pyrogenic thyroiditis, bacterial thyroiditis
Drug-induced thyroiditis (amiodarone, lithium, interferon alfa, interleukin-2)
Riedel’s thyroiditis
Subacute thyroiditis - features
5:1 female predominance
Age of onset 20-60y
Prodrome (myalgias, fever, pharyngitis)
Seasonal variation (?correlation with enterovirus?)
Fever/severe neck pain
50-60% develop thyrotoxicosis
2-9% with recurrent disease
Normal thyroid function returns in 95%
5% residual hypothyroidism
Usually low to absent titer of anti-TPO immunoglobulins
Both physicians and women faced off-label manipulation of this regimen for years, for example, to minimize days of bleeding or to treat other medical conditions.
Extended use of COCPs has been used for many years to treat:
1- Endometriosis
2- Dysmenorrhea
3- Menstruation-associated symptoms
4-Menorrhagia
5-Simple Ovarian cysts
6-Androgen excess conditions: reduction in acne lesions and hirsutism
7-Prevent Non Chlamydial pelvic inflammatory disease
8-Reduced risk or slower progression of rheumatoid arthritis
9-Reduced conditions appearing during menses,
seizures, and asthma
10-Personal preference (most common )
Side effects
Extended use of COCPs or non oral combined hormonal contraceptives carries the same risk of side effects and medical risks as traditional COCP use.
loss of sex drive (libido), headaches, acne, weight gain, vaginal (fungal)infections, and depression.
Serious risks of COCPs that can be life threatening include blood clots, stroke, and heart attack. These risks are increased in women who smoke cigarettes.
With all extended-cycle COCPs, breakthrough bleeding is the most common side effect, especially in the first 3-6 months of use although it tends to decrease over time. In a 12-month study of a continuous COCP regimen, 59% of women experienced no bleeding in months six through twelve and 79% of women experienced no bleeding in month twelve
Contraindications
Combined oral contraceptives are generally accepted to be contraindicated in women with pre-existing cardiovascular disease, in women who have a familial tendency to form blood clots (such as familial factor V Leiden), women with severe obesity and/or hypercholesterolemia (high cholesterol level), and in smokers over age 35.
COC are also contraindicated for women with liver tumors, hepatic adenoma or severe cirrhosis of the liver, and for those with known or suspected breast cancer.
DESIRE
- Subjective feeling .
- Motivation & inclination to be sexual.
- Mediated by neuroendocrine changes.
- Erotic feeling.
- Vaginal lubrication.
- Mediated by parasympathetic system.
- Myotonic response.
- Peak of sexual tension.
- Sudden release of tension.
- Mediated by sympathetic system.
- Complete relaxation.
- Reversal of all changes.
DSM IV: CLASSIFICATION OF FEMALE SEXUAL DISORDERS
Desire disorder
*hypoactive sexual desire disorder.
*sexual aversion disorder
Arousal disorder
Orgasmic disorder
Sexual pain disorder
* dysparenia
* vaginismus
* noncoital sexual pain disorder...
While there is a useful staging system for puberty (Tanner/Marshall system),
a similar staging system for late reproductive function has not been developed.
Confusion & duplication in the nomenclature of the reproductive aging e.g. climactric, perimenopause
Reproductive aging:
A natural process that begins at birth and proceeds as a continuum.
It is a process and not an event, and the end (menopause) is much easier to define than the beginning.
Chronological age is a very poor indicator of reproductive aging.
Etiology
Oocyte depletion in the ovary.
Reproductive aging consists of a steady loss of oocytes through atresia or ovulation, which does not necessarily occur at a constant rate.
The relatively wide age range (42–58 years) for menopause in normal women indicate that either
- Wide variation in number of follicles at birth or
-Wide variation in the rate of oocyte loss
Reproductive stages
After menarche (entry into stage -5) it usually takes several years for regular menstrual cycles to become established. Menstrual periods should then occur every 21 to 35 days for a number of years ( stages -4 & -3).
A woman’s peak fertility occurs in her mid- to late twenties, after which it progressively decreases until menopause (stage -4 to -1).
Loss of fertility is the first sign of reproductive aging that precedes the Monotropic increase in FSH and
Changes in menstrual cyclicity.
An elevated FSH level is the first measurable sign of reproductive aging. This initial elevation in FSH level is most prominent in the early follicular phase of the cycle; a single venous blood sample should be obtained between cycle days 2 and 5 and subsequently assayed for
FSH and estradiol. ..
Vulval vestibulitis, a cause of introital dysparunia among the women of reproductive age and
dysasthetic Vulvodynia; a condition where constant localized vulval pain is experienced,
together form the “vulval pain syndromes” as these relates to vulval pain when infection and organic causes have been excluded.
The diagnosis vulval dermatosis (lichen sclerosus), vestibular papillomatosis and cyclical vulvitis do not fit into a diagnosis of vulval pain syndrome.
Vestibular papillomatosis where filamentous projections of epithelium are found within the vestibule and inner labia minora is now considered a variant of normal.
Cyclical vulvitis causes intermittent swelling and pain of the labia usually prior to menstruation, which resolves soon after. The patients responded to maintenance treatment with antifungal.
Vulval vestibulitis
Severe pain on vestibular touch or attempted vaginal entry.
Tenderness to pressure localized within the vestibule.
The physical findings of erythema confined to the vestibule.
Test : A swab test is a useful way to demonstrate tenderness within the vestibule.
A cotton tipped swab is applied gently to normal skin as a control and than around different areas of the external genitalia.
Dysasthetic Vulvodynia
It is a cutaneous diathesis causing non localized vulval pain.
Constant neuralgic type of pain in the region of vulva or perineal region occasionally.
The nature of pain is burning or aching & is after analogous with neuralgic pain syndromes such as post herpetic neuralgia.
Clinical examination of vulva - normal.
Erythema is anatomical variant.
Allodynia : not usually seen.
Peri or post menopausal women with h/o multiple inappropriate use of topical agents prior to the diagnosis.
Superficial dysparunia is not consistently reported...
When people think about cloning they usually think about copying complete human beings or animals like Dolly the sheep.
But cloning is also used for purposes other than making exact copies of animals or people.
Individual cells of plants, animals and human beings are copied every day in research and clinical laboratories.
What is a Clone?
An organism that has the same genetic information as another organism
Why Clone?
To mass produce organisms with desired qualities
Repopulate endangered or even extinct species
Organ transplants for humans
Recovery of lost loved ones
Infertility: cloning a fertile copy of themselves
Creation of spare body parts (Organs, blood, kidney’s, etc.)
Reproduction of their own body parts
Eugenics
Is the choosing of specific traits and the deleting of others.
Scientist could eliminate all the disease-causing genes and guarantee a healthy baby.
Human Cloning and Genetic Modification
Genes are strings of chemicals that help create the proteins that make up your body.
Genes are found in long coiled chains called chromosomes.
They are located in the nuclei of the cells in the body.
"THREE WAYS TO MAKE AN EMBRYO"
Sexual reproduction
Cloning or asexual reproduction
Parthenogenesis..
patterned on the sebum-rich areas of the scalp, face and trunk.
linked to Pityrosporum ovale
immunologic abnormalities and activation of complement.
aggravated by changes in humidity, by trauma (scratching), seasonal change and by emotional stress.
Severity varies from mild dandruff to exfoliative erythroderma.
Seborrheic dermatitis may worsen in Parkinson disease and in AIDS.
Seborrheic dermatitis is associated with normal levels of Pityrosporum ovale, but an abnormal immune response.
The contribution of P. ovale may come from its lipase activity—releasing inflammatory free fatty acids (FFA)—and from its ability to activate the alternative complement pathway.
Generalized seborrheic erythroderma is rare. It is more often seen in AIDS, CHF, Parkinson disease, and in immunocompromised premature infants.
Differential Diagnosis
Asteatotic Eczema
Atopic Dermatitis
Candidiasis, Cutaneous
Contact Dermatitis, Allergic
Contact Dermatitis, Irritant
Dermatomyositis
Drug Eruptions
Drug-Induced Photosensitivity
Physical Exam
Scalp appearance varies from mild, patchy scaling to widespread thick adherent crusts. Plaques are rare.
From the scalp, seborrheic dermatitis can spread onto the forehead, posterior neck and postauricular skin, like psoriasis.
Skin lesions present as branny or greasy scale over red, inflamed skin.
Hypopigmentation is seen in blacks.
Infectious eczematoid dermatitis, with its oozing and crusting, suggests secondary infection.
A seborrheic blepharitis may occur independently
Distribution follows the oily and hair-bearing areas of head and neck, such as the scalp, forehead, eyebrows, lash line, nasolabial folds, beard and postauricular skin.
Presternal or interscapular involvement is more common than the nonscaling intertrigo of the umbilicus, axillae, inframammilae inguinal fold, perineum or anogenital crease that may also be present...
Failure to properly occl. the cystic duct
Injury to the ducts in the liver bed caused by entering a plane too deep to the gallbladder
Cautery Misuse – thermal necrosisductal tissue loss
Pulling forcefully up on the gallbladder when clipping the cystic duct tenting injury to the junction of the CBD & common hepatic duct
Strasberg & Soper classificaiton of bile duct injuries
Type A – bile leak from minor duct still in continuity w/ the CBD…cystic duct or liver bed
Type B – occlusion of part of the biliary tree; ex. Result of an injury to an aberrant right hepatic duct.
Type C – leak from duct NOT in communication w/ CBD
Type D – lateral injury to extra-hepatic bile duct
Type E – circumferential injury
Diagnosis of Bile Leaks
Persistent fullness, anorexia, abdominal pain, fever & tenderness,jaundice, elev WBC
High level of suspicion following surgery
Bile draining from a drain left in the operative field
Radiographic Diagnosis of Biliary Injury
US/CT – detect bilomas (poss. perc drainage)
HIDA – presence of active bile leak (physiologic)
MRCP – demonstrate dilated/stenotic biliary tract; retained stones…..not physiologic nor therapeutic
ERCP
Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree.
Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site; may entail removal of retained stone or internal stenting +/- sphincterotomy
Percutaneous Transhepatic Cholangiography
Another method of non-surgical Mx of bile leak
Usually reserved for when ERCP unsuccessful; since bile ducts of normal caliber increasing the difficulty of the procedure
53M with jaundice x 3 weeks
Mild abdominal pain 9/04
PMH: negative
No abd masses, nontender
Bilirubin 22
CT: pancreatic mass @ head
Resectable?
At presentation:
50% with metastatic disease
40% locally advanced
10% confined disease
Only 20% deemed resectable
80% unresectable:
Local invasion ----> 6 month median survival
Stage IV ----->3 months
Palliation
Primary goal for majority of patients
Obstructive jaundice
Gastric outlet syndrome
Pain
Surgical:
Hepaticojejunostomy
Choledochojejunostomy
Choledochoduodenostomy
Cholecystojejunostomy
Non-surgical:
ERCP (plastic or metal)
Transhepatic
Idiopathic Thrombocytopenic Purpura (ITP)
Hereditary Spherocytosis
Chronic Autoimmune Hemolytic Anemia
Non Hodgkins Lymphoma
Hairy Cell Leukemia
Chronic Lymphocytic Lymphoma / Chronic Myelogenous Lymphoma
Chronic ITP
Autoimmune disorder of Adults
Autoantibodies to platelet glycoproteins
Antibodies act as opsonins and accelerate platelet clearance by phagocytic cells
Also can bind to critical regions of the glycoproteins and impair function
F > M 3:1, ages 20-40
Purpura, epistaxis, gingival bleeding
Rarely GI, GU, intracranial hemorrhage
Diagnosis – low platelet count, normal bone marrow, exclusion of other causes of thrombocytopenia
Drugs
Viral infections
Autoimmune diseases
Lymphoproliferative diseases
Refractory ITP
Most respond to steroids, but >75% pts recurr after steroids tapered
Splenectomy – removes source of antiplatelet Ig, removes source of phagocytic cells
Indications –
Plts < 10K after 6 wks med tx
Plts < 30K, had insuffic response to med tx after 3mos
Emergent splenectomy in cases of intracranial bleeding
Platelet transfusions should only be given after splenic artery ligated to prevent destruction
Splenectomy for ITP
65-80% successful
Usually platelet counts respond by 10 days
Age < 60, good inititial response to steroids are favorable factors
Laparoscopic splenectomy popular as spleen is usually small to normal sized
Hereditary Spherocytosis
Autosomal dominant deficiency of spectrin, red cell cytoskeletal protein - maintains osmotic stability
Membrane abnormality results in red cells which are small, spherical, and rigid
Spherocytes more susceptible to becoming trapped in spleen and destroyed..
Preparation of The Cervix
Vaginal misoprostol prior to diagnostic hysteroscopy reduced cervical resistance in non-pregnant women
Normal saline should be used as it offers: advantages (shorter and less discomfort) over co2 instillation.
Routine Infertility Investigation
Tests which have an established
correlation with pregnancy are:
1- Semen analysis
2-Tubal patency by HSG or laparoscopy
3-Mid luteal progesterone for the diagnosis of ovulation
They are the basic essential tests for diagnosis of infertility
Hysteroscopy should not be considered as a routine investigation in the infertile couple.
Indications of Diagnostic Hysteroscopy for Reproductive Failure
Abnormal hysterosalpingogram.
Abnormal uterine bleeding
Suspected intrauterine pathology
Uterine anomalies
Pregnancy wastage
Unexplained infertility
Hysteroscopy done at laparoscopy time, has low complication rate,high degree of safety, minimal time requirement and adds little equipment & cost.
Unexplained infertility
Small endometrial polyp
Small cervical polyp
Adhesion at cornual cones
Cornual polyp
Endometrial dystrophies(atrophy or hyperplasia) that may affect receptivity or implantation especially in ART.
Indications of Operative Hysteroscopy for Reproductive Failure
Polyp.
Submucous leiomyoma.
Uterine septa.
Intrauterine Adhesions.
Misplaced or embedded IUD
Tubal cannulation and Falloposcopy...
Mesenteric ischemia - reduction in intestinal blood supply
Acute Mesenteric Ischemia
Most often involves SMA
from emboli, arterial and venous thrombi, or vasoconstriction secondary to low flow
Chronic Mesenteric Ischemia
postprandial abdominal pain, marked weight loss
caused by repeated transient episodes of inadequate intestinal blood flow
Colonic ischemia
After aortic or cardiac bypass surgery
Certain systemic conditions
vasculitides (eg, systemic lupus erythematosis, periarteritis nodosum)
infections (eg, cytomegalovirus, E. coli O157:H7)
coagulopathies (eg, protein C and S deficiencies, anti-thrombin III deficiency, APC resistance)
Medications (eg, oral contraceptives) or illicit drugs (eg, cocaine)
After strenuous and prolonged physical exertion (eg, long-distance running)
After any major cardiovascular episode accompanied by hypotension
With).
COLONIC ISCHEMIA
Most frequent form of mesenteric ischemia
Commonly left colon
Mostly elderly population
Etiology
Low-flow state (hypotension)
Embolus (A-fib)
Post MI (hypotension, mural thrombus)
Post AAA reconstruction
Closed loop construction - left side with intact ileocecal valve
Volvulus
Mesenteric Vein Thrombosis
Catastrophic if not recognized
Ischemic Colitis:
Vascular Supply
Superior mesenteric artery (SMA)
Ileocolic artery – terminal ileum, cecum, appendix, prox ascending colon
Right colic artery – ascending colon, hepatic flexure
Middle colic artery – transverse colon
Inferior mesenteric artery (IMA)
Left colic artery – descending, transverse colon, splenic flexure
Sigmoid arteries – sigmoid and descending colon
Superior rectal artery – proximal rectum
Collateral flow
Marginal artery of Drummond – collateral connection between SMA and IMA along the mesenteric border
IMA and internal iliac – supply good collaterals to the rectum
Cupping is an ancient method of causing local congestion.
A partial vacuum is created in cups placed on the skin either by means of heat (old) or suction(recent).
This draws up the underlying tissues.
When the cup is left in place on the skin for a few minutes, blood stasis is formed and localized healing takes place.
Cupping therapy was originally used in Egypt and China dating back some 3,500 years
Cupping is applied by acupuncturists to certain Acupuncture points,
as well as to region of the organ or the area of dysfunction
as well as to regions of the body that are affected by pain (where the pain is deeper than the tissues to be pulled)
Cupping has also been found to affect the body up to four inches into the tissues,
causing tissues to release toxins,
activate the lymphatic system,
clear colon blockages,
help activate and clear the veins, arteries and capillaries,
activate the skin,
clear stretch marks
and improve varicose veins.
Cupping is the best deep tissue massage available
Infertility
the inability of a couple to conceive after one year of unprotected intercourse (6 months for women over 35)
infecundity (the inability of a couple to produce a live birth)
How can Cupping help improve my success rate with in-vitro fertilization?
1. Regulate the hormones to produce a larger number of follicles 2. Improve the function of the ovaries to produce better quality eggs 3. Relax the patient and decrease stress 4. Increase blood flow to the uterus and increase the thickness of the uterine lining 5. Strengthen the immune system 6. Lessen the side effects of drugs used in IVF 7. Prevent the uterus from contracting 8. Improve semen to create better quality and quantity of embryos 9. Decrease chances of miscarriage
