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Delayed concentration of dye in one kidney may suggest decreased renal blood flow and function order cialis soft 20 mg on line impotence natural remedies. At 25 minutes a film is taken in erect posture to note the efficiency with which the renal pelvis and ureters drain generic 20mg cialis soft overnight delivery top 10 causes erectile dysfunction, ureterograms and also the mobility of the kidneys generic 20mg cialis soft free shipping erectile dysfunction diabetes type 2 treatment. All films should incl tide kidneys cheap 20 mg cialis soft fast delivery erectile dysfunction drugs in the philippines, ureters and bladder areas, as fine changes in the ureters which imply the presence of vesico-ureteral reflux may be detected. It is advisable to inject additional radio-opaque medium if there is impaired concentration in the initial films. In infants and children the films should be taken at 3,5,8 and 12 minutes as their kidneys excrete the fluid more rapidly than do those of the adult. X-ray of the bladder region after voiding should be routine in all urologic patients. At the conclusion ofthe urography study, the patient is instructed to pass urine and a film of the bladder area is taken immediately. Excretory urogram is contraindicated in (i) allergic patients, (ii) multiple myeloma (the dye makes insoluble complex with Bence-Jones protein and precipitate in the renal tubules), (iii) congenital adrenal hyperplasia, (iv) diabetes and (v) primaiy hyperparathyroidism. Excretory urogram is a physiological as well as an anatomical test since it not only determines the function of the kidney but also clearly demonstrates the contour of the renal pelvis and calyces. The overlying gas and faecal material in the bowel can be eliminated in this method. Slices of kidney are seen beginning from posteriorly and gradually advancing anteriorly. For hydronephrosis more amount of medium is required, (e) Supine urogram is taken, developed and viewed. If filling is not complete, more dye is instilled before further X-rays are taken, (f) Oblique, lateral and upright radiograms are taken as indicated, (g) Pneumopyelography. A stone may show some opacification, but a tumour will not, but both these will cause a filling defect in the pelvis or calyx in excretory urogram. Under fluoroscopic or ultrasonic control an 18-gauge needle, 15 cm long should be passed into a dilated calyx or pelvis. It is better to pass the needle into a dilated calyx rather than pelvis as there will be a better seal round the needle track and less danger of puncturing large hilar vessels. Temporary drainage can also be provided with by a small plastic catheter introduced through the needle, which will be subsequently removed. Calyces — A normal calyx looks like a cup due to projection of the apices of the papillae into the calyces. Inward directed calyces suggest congenital abnormality such as horse-shoe shaped kidney. The right pelviureteric junction is situated opposite the transverse process of the second lumbar vertebra whereas the left is slightly higher up. The most important is the shape of the pelvis and the students must leam the normal shape of the pelvis. Also look at the position of the ureter, whether it is kinking or not and whether there is any congenital deformity or not. If these are not satisfactory to delineate clearly the pathological conditions of the bladder, retrograde cystogram may be required. Besides these, this test has a diagnostic value in rupture of the bladder and recurrent infection (vesico-ureteral reflux is the commonest cause of perpetuation of infection). This will also reveal function of the bladder neck, presence of posterior urethral valves or urethral stricture. A catheter is passed to the level of the renal arteries under fluoroscopic control. It is also possible to do the catheterisation through the brachial or axillary artery. Selective renal angiography is accomplished by passing a femoral catheter into one of the renal arteries under fluoroscopic control. About 8 ml of the contrast medium is injected and 16 exposures are taken within a few seconds. This technique gives detail demonstration of the arterial pattern in the kidney and thus differentiates efficiently between renal cyst and tumour. If this technique fails to differentiate in case of small lesion or becomes obscured by overlying arteries, epinephrine can first be injected into the catheter followed by instillation of radio-opaque medium. This technique causes spasm of normal vessels but has no effect on arteries in tumours. Embolisation of renal tumour deprives a tumour of its major blood supply so as to cause infarct and shrinkage of the tumour. This can be used preoperatively to minimise blood loss during subsequent nephrectomy particularly with large vascular tumours. This will also reduce showering of tumour cells into systemic circulation at the time of surgical handling. Such preoperative embolisation is also of value to avert severe haematuria from adenocarcinoma of kidney when the patient is unfit for surgery. A midstream aortogram and selective renal arteriogram should always precede embolisation. The catheter should have a single end hole and should be positioned as selectively as possible to avoid the problem of overspill of emboli and distal complications. Embolisation with autologus blood clot is the simplest and safest, which becomes lysed within a few days. Blood clot treated with epsikapron lasts longer and may be used as preoperative embolus. Sterisponge is a versatile agent, which is nothing but sterile absorbable gelatine sponge, which is easy to prepare and small pieces of these are injected through the catheter. It also does not cause permanent block and recanalisation occurs after a few weeks. If permanent occlusion is required, a small steel coil may be passed through the catheter. Small quantities of embolic material is injected, followed by check radiographs made with contrast to assess the flow and distribution. The major complication of therapeutic embolisation is inadvertent embolisation of normal tissue. Alternatively each hypogastric artery is selectively catheterized and 10 ml of radio-opaque fluid is injected. This technique is occasionally required to judge the size and depth of penetration of the vesical neoplasms. This leads to opacification of the inguinal, pelvic, aortic groups and supraclavicular lymph nodes. Metastatic infiltration can be demonstrated in regional lymph nodes by filling defect in malignant tumours of the testis, prostate, bladder and penis. Space occupied by a cyst or abscess fails to opacity, whereas a malignant tumour shows a normal or increased opacification.
Nowadays contact method has been used and a lower power of laser light can be used for treatment cialis soft 20 mg without a prescription erectile dysfunction protocol book pdf, thus reducing the risk of perforation cialis soft 20 mg with visa erectile dysfunction medicine in pakistan. Typical power setting ranges from 50 to 100 w and the energy is delivered in 1-2 second pulses from a distance of about 1 cm from the tumour surface in case of non-contact method cialis soft 20 mg for sale erectile dysfunction lotions. Lasering starts from the distal tumour margin and progresses circumferentially upto the proximal margin generic 20 mg cialis soft with mastercard erectile dysfunction doctors in richmond va. In this technique the oesophageal lumen is always in view and should reduce the incidence of perforation. As yet there is no clear advantage between the contact and non contact methods with respect to the number of treatment sessions, relief of dysphagia or complications. A delay of upto 1 week between initial treatment and relief of dysphagia is typical. Perforation and creation of tracheo-esophageal fistula may occur in 5% to 10% of cases (this is less than intubation technique). In both laser and intubation there is significant initial improvement in quality of life which gets deteriorated in the terminal phase of the disease. At endoscopy the tumour is exposed to 6-30 nm wave length (red light) from a tunable argon pumped dyelasar. Necrosis follows damage to the tumour vasculature by cytotoxic singlet oxygen liberated from the activated pho tosensitizer. These probes are inexpensive and a recent comparative trial has shown it to be as efficacious and safe as laser treatment. It neither improves patient’s general condition nor gives any relief to the patient from the distressing complaint, i. Traditionally radiation is given by external beam from a linear accelarator or cobalt source. The optimum dose for external beam radiotherapy is unknown, but the minimum accepted for radical treatment is 5000 cGy; and more than 6000 cGy often leads to unacceptable side affects. With a daily dose of 200 cGy and 5 treatments per week, a full course of treatment lasts for 5 weeks. But many patients cannot complete the full course of treatment due to poor tolerance. Postirradiation stricture and creation of oesophagorespiratory fistula are serious complications of this treatment. Debilitating effects of radiotherapy may also deteriorate the quality of life remaining to the patient. In fact this gives considerable palliation to squamous carcinoma, though dysphagia may recur which is commonly due to fibrous stricture rather than the primary tumour. Adenocarcinoma of the oesophagus has often been considered radioresistant, but there are data showing little difference in survival rates between patients with adenocarcinoma and squamous carcinoma affecting the cardia treated by radio therapy. The applica tor is fixed at the mouth and the patient is transferred to a protected treatment room and connected to the Selectron machine. In this treatment a single high dose fraction is given to obtain rapid palliation. The great advantage of brachytherapy is that the radiation dose is highest to the tumour while adjacent normal tissues are almost spared, though some patients develop troublesome oesophagitis. A combination of a low dose external beam radiotherapy alongwith intracavi tary treatment is an attractive new development. Response rate with single agent chemotherapy has been poor, but a measurable response rate (20% to 30%) has been obtained when cyclical combination chemotherapy has been used particularly with cisplatin and 5-fluorouracil. Combined chemotherapy (5-fluorouracil cisplatin x 4 cycles) and radiotherapy (5000 cGy) has been compared with radiotherapy (6400 cGy) alone in patients with either squamous or adenocarcinoma. It has been seen to produce considerable shrinkage of the disease in about 60% of the patients. A significant improvement in survival and quality of life have been noticed in combined chemotherapy and radiotherapy group. Surgical bypass is sometimes a major procedure for use in a patient with limited life expectancy. Randomised prospective studies of preoperative and postoperative radiotherapy have not shown much improvement in survival. At present preoperative chemotherapy may be used as oesophageal cancer is a systemic disease and this treatment may improve the results still further in coming days. Their uses in the management of benign oesophageal perfora tion and strictures, relief of pyloric and duodenal obstruction, benign bile duct strictures and obstructing rectal carcinoma are controversial. It is common practice to predilate the stricture using a balloon before employing the stent. When there is no plastic cover the stent adheres to the full length of the stricture as the surrounding tissues project through the mesh and minimises migration. Plastic covered prostheses are protected from ingrowth, but these are more liable to migration. In malignant oesophageal disease at least 50% of patients will be unfit for or have diseases too ad vanced for surgery. Whereas intubation is one-stage treatment, but producing tumour necrosis requires repeated treatment at regular intervals. Dysphagia may be functional mainly due to neurological causes or physical due to pressure on the lumen or foreign body in the lumen. A list of causes of dysphagia is given below to help the students in differential diagnosis : 1. In the mouth : Tonsillitis, quinsy, carcinoma of the tongue and paralysis of the soft palate (due to diphtheria in children and bulbar paralysis in adults) etc. Patients with reflux oesophagitis feel burning retrosternal discomfort as soon as they swallow hot beverages or alcohol. Just distal to this dilatation the gut is connected with the vitello-intestinal duct which opens into the yolk sac. At this stage the stomach is placed in the median plane and is connected posteriorly to the body wall by a short dorsal mesentery, termed the dorsal mesogastrium. Anteriorly the stomach is connected to the distal part of the septum transversum with ventral mesogastrium. Due to rapid growth of the dorsal border the pyloric end of the stomach is carried ventrally and a concavity appears in the lesser curvature. Now the stomach is displaced to the left of the median plane and is rotated on its vertical axis so that the right surface is directed dorsally and the left surface ventrally. Due to this rotation the right vagus becomes the posterior vagus and the left vagus becomes the anterior vagus. The dorsal mesogastrium increases in length and becomes folded on itself to form the greater omentum. The ventral mesogastrium becomes the lesser omentum which after the rotation almost lies in the coronal plane rather than the anteroposterior plane. Approximation of the duodenum to the dorsal abdominal wall leads first to adhesion of the right layer of its mesentery to the parietal peritoneum and later absorption of both the layers. It lies in the epigastric, left hypochondriac and umbilical regions of the abdomen.
Such haematoma usually occurs in either in the second connective tissue layer of the scalp or in the 4th layer which consists of loose areolar tissue of the scalp generic 20mg cialis soft erectile dysfunction age 25. Cephal haematoma (subpericranial haematoma) occurs due to accumulation of blood beneath the pericranium purchase cialis soft 20 mg free shipping erectile dysfunction san antonio. It forms a localized swelling being limited to the affected bone bounded by its suture lines order cialis soft 20mg without a prescription erectile dysfunction medication options. Acute localized pain cheap cialis soft 20mg online erectile dysfunction song, localized tenderness and swelling over the affected bone are the clinical features of this condition. Boils, carbuncles, cellulitis and erysipelas are quite common in the head and face. The infection spreads (i) along the angular vein to the ophthalmic vein — a tributary of the cavernous sinus or (ii) along the deep facial vein which communicates with the cavernous sinus through the pterygoid plexus of veins passing through the foramen ovale and foramen lacerum. Diagnosis of such complication is made by noting severe constitutional disturbances, proptosis, squint and paralysis of the ocular muscles, especially the rectus lateralis which is supplied by the abducent nerve. Rodent ulcer is commonly found in the face particularly above the line joining the angle of the mouth to the tragus of the ear. Actinomycosis rarely affects the lower jaw and may cause multiple sinuses of the face with surrounding induration discharging pus with sulphur granules. Extragenital chancre or mucous patches or condylomas (manifestations of syphilis) may be seen in the lip. Plexiform haemangioma or arterial haemangioma or cirsoid aneurysm is almost only seen in the face particularly in the forehead. It is nothing but a network of a dilated interwoven arteries commonly affecting the superficial temporal artery and its branches. Occasionally there may be ulceration of skin over this haemangioma which may lead to serious haemorrhage. X- ray of the skull almost always shows erosion and occasionally there may be perforations in the skull due to intracranial extension of such haemangioma being connected with dilated tortuous vessels in the extradural space. Osteoma particularly sessile type (compact osteoma or ivory exostosis) is a tumour commonly seen affecting the outer table of the skull. Very occasionally this tumour may originate from the inner surface of the skull when it may give rise to focal epilepsy. The adolescents or young adults are the common victims and the presenting symptom is the hard painless lump. Among malignant tumours squamous cell carcinoma, malignant melanoma, osteosarcoma and secondary carcinoma in the skull may occur. Ectopic salivary tumour may be rarely seen particularly in the lip of a young adult male. A tumour arising from the skin or subcutaneous tissue can be moved freely over the bone. Skin can be moved freely over the tumour which is arising from subcutaneous tissue or bone. It is considered to be a type of basal cell carcinoma, though a few pathologists are of the opinion that it is an endothelioma. In the first figure note the ‘kiss lesion’ affecting the upper tumour of the skull. Soft and very vascular metastases often show pulsation presenting as pulsatile swelling. This condition almost always affects the skull and the skull enlarges so that the patient often requires a bigger hat after certain time interval. This disease usually affects old individuals above 40 years and males are more often affected. The thickened cranial bones are sometimes quite vascular so as to produce systolic bruit on auscultation. Mucous cysts are often found on the mucous surface of the lip and cheek (these are recognized by their blue colour and translucency). It is in fact due to dehydration rather than peritonitis that the appearance of sharp nose, hollow eyes and collapsed temples are produced. But when this facial appearance is combined with thready pulse and a grossly distended abdomen, the condition is nothing but an advanced case of diffuse peritonitis. There is also presence of spider naevi and all these indicate a moderately advanced case of hepatic cirrhosis. However this concept has been challenged nowadays and these features are not considered to be pathognomonic of enlarged adenoids. This condition produces characteristic facial flushing, which is known as carcinoid facies. In the last figure the patient has been asked to breathe through the naris of the affected side while his other naris and mouth are kept closed. The inferior orbital margins of both sides are palpated and note any difference in sharpness and level. One may have a glance at each profile of the patient in order to consider relative protuberance of the eyeball. If the nostril on the affected side is not blocked, it is obvious that the medial wall of the maxilla is not bulging to any great extent. The patient should be asked if any discharge is coming out through the nostril of the affected side. Constant overflow of tears from the eye (epiphora) indicates obstruction of the nasolacrimal duct. Only extension of the growth from this surface may firstly be felt in the infratemporal region. So this region must be palpated before completion of the palpation of the surfaces of the maxilla. While examining these surfaces, if any swelling or ulcer is discovered, examine it in the usual way. If there is any tenderness in the maxillary antrum without any distension of its wall, it may suggest empyema of the antrum. This is confirmed by anterior rhinoscopy, posture test, transillumination, X-ray and aspiration of the antrum through the inferior meatus. The cervical lymph nodes must always be examined, particularly the submandibular group. Any inflammatory lesion or carcinoma will lead to enlargement of the regional lymph nodes. But sarcoma of the upper jaw does not lead to enlargement of the regional lymph node. The 2nd division (maxillary division) of the 5th cranial nerve (trigeminal nerve) is always tested for its integrity. This nerve and its branches are likely to be involved when the growth extends backwards and upwards. When the patient tries to support the fragments with his hands, speech is impossible and when the saliva is blood-stained (as the fracture of the mandible is nearly always compound into the mouth), one may suspect the case is one of fracture of the mandible. The intimately adherent mucoperiosteum always gives way in case of fracture of the mandible to make the fracture compound. Majority of the fractures of the mandible occur in the horizontal portion (at the region of the canine tooth as the bone is weak due to deep canine socket).
The ligature pyloroplasty is made to avoid bleeding from the ascending oesophageal ves sels buy cialis soft 20 mg cheap erectile dysfunction pills images, which run up along with the nerves 20mg cialis soft with visa impotence meds. The most important operative complication is gastric retention for which drainage operation is performed along with this operation purchase cialis soft 20 mg on-line erectile dysfunction diabetes. This operation is probably contraindicated to patients already suffering from severe diarrhoea 20mg cialis soft with amex erectile dysfunction by country. The reason may be a few intact vagal fi bres, which may be detected by Holland er’s insulin test and in this case reoperation should be performed to com plete vagotomy. One must keep in mind the possibility of Zollinger-Ellison syndrome in these cases. The hepatic branches of the anterior vagus are identified in the upper part of the lesser omentum. The dissection is started along with the anterior vagus nerve in the lesser omentum downwards to find out all the gastric branches which are ligated and divided one by one. Now for posterior selective vagotomy, an incision is made through the peritoneum at the angle of His. Right index finger is passed through the hole to reach behind the gullet and the right thumb is passed through the hole made in the lesser omentum. These two fingers will meet behind the oesophagus and will only be intervened by the so-called ‘mesentery’ in which will be lying the posterior vagal trunk. The tissues behind the posterior vagus nerve are burst through and a tube is inserted to include the gullet and the vagi. With the right index finger, the posterior trunk is pushed posteriorly and tissues in front of the finger are very minutely dissected to secure the gastric branches of the posterior vagus nerve. The last part of the oesophagus is now thoroughly exposed to clear any additional fibres, which may be left behind. The whole circumference of the cardia is examined and all residual vagal branches are divided, leaving behind a ring of bare muscles. These nerves are preserved and separated from the proximal gastric branches by passing forceps through the lesser omentum to the left of the nerve of Latarjet close to the gastric wall about 3 inches (7. It is very convenient to save the posterior nerve of Latarjet through the lesser sac, which is entered through the greater omentum at the middle part of the greater curvature. The proximal gastric branches are dissected, ligated and divided and the main nerve, which supplies the antrum and pylorus, is preserved. In this operation posterior truncal vagotomy is being performed alongwith anterior lesser curve seromyotomy. A few surgeons are performing seromyotomy in both anterior and posterior aspects of the lesser curve. The advantage of this operation is that the disturbance to the neighbouring structures is least and it can be performed by minimal access procedure also. In uncomplicated duodenal ulcer, this operation is often used along with the vagotomy. In gastric ulcer, some surgeons are liking this operation along with vagotomy and the ulcer is biopsied. As Palliative measure this operation can be performed in gastric carcinoma for the relief of pyloric obstruction. When the general condition of the patient is not good enough to carry out the operation, a long-continued milk-drip therapy is advisable for fortnight. For this, a Ryle’s tube is passed through the nostril of the patient into the stomach. The tube is connected with a milk reservoir, hung about 3 feet above the patient’s head. The milk is allowed to drop into the stomach at such a rate that five pints can be given in 24 hours. In patients with cachexia or upper gastro-intestinal bleeding, blood transfusion will be required. The patient’s blood is sent for grouping and crossmatching with a requisition of such amount of blood which will be required for the particular patient. By the time the blood is received, intravenous infusion of glucose-saline should be administered. Gastric lavage with normal saline or plain sterile water should be carried out by means of a Ryle’s tube 3 or 4 days before operation. Of course, the Ryle’s tube is kept in situ as it will be required to deflate the stomach during and after the operation. One should not forget to institute proper doses of vitamins, particularly vitamin C, which is connected for proper healing of the anastomosis several days before the operation is performed. The opening in the stomach is made vertical (Moynihan) for easy evacuation, though oblique (Mayo) or horizontal (Kocher) opening does not make much difference in emptying. The steps of operation are : Upper right paramedian incision is used to explore the abdomen. The greater omentum, transverse colon and the lower part of the stomach are brought out of the wound and are turned upward The transverse mesocolon is split vertically through an avascular area to enter the lesser sac. With the right hand a vertical fold of the posterior wall of the stomach, close to the greater curvature is drawn out through the split in the mesocolon. Two pairs of Allis’ tissue forceps are applied 3 inches apart to the fold of the wall of the stomach. A pair of occlusion clamp may be used to hold this fold of stomach so that gastric secretion and bleeding from the stomach wall will not disturb the anastomosis. The transverse colon is lifted upwards and allowed to fall on the upper part of the wound so that the posterior surface of the transverse mesocolon is exposed. A hand is passed along the under-surface of the transverse mesocolon to near the hilum of the left kidney just below the tail of the pancreas, where the duodeno-jejunal flexure will be grasped. The ligament of Treitz, which leads to the duodeno-jejunal junction, also serves as a guide. There should not be any redundant loop of jejunum between the duodeno-jejunal flexure and the anastomosis. In fact the portion of thejejunum between the duodeno-jejunal flexure and the anastomosis should not be more than 6-9 inches. The loop of the jejunum, which is kept very close to the posterior wall of the stomach, should be such that the proximal portion of the jejunum will be lying against the portion of the fold near lesser curvature of the stomach, while the distal portion of thejejunum will be lying against the portion of the stomach close to the greater curvature. Two Allis forceps are applied to the jejunum about 3 inches apart and an occlusion clamp may or may not be applied to hold the anastomotic site of the jejunum by the side of that of the stomach. A piece of swab soaked in warm sterile water is placed between the two guts just beneath the anastomosing site. All other viscera are returned to the abdomen and covered with two hot moist mops from both the sides, so that only the two portions of the gut held by occlusion clamps will be exposed.
