International surgical boards

2021-12-22 10:35:56 Massive splenomegaly

Usually defined by most authorities as a spleen long axis of more than 20 cm, or a spleen that weigh more than 1 kg.

Causes of a massive splenomegaly can be remembered as CML

C stands for chronic myeloid leukemia.

M stands for malaria and also myelofibrosis.

L stands for Leishmania, specifically visceral leishmaniasis. Open / Comment

2021-12-20 18:15:26 Ascending cholangitis caused by Clostridium perfringens

Ascending cholangitis is caused by infected static bile within the biliary passages.

It is famously recognized by the Charcot's triad (Fever, Pain and Jaundice).

C.perfringens (previously known as C.Welchii) are gram positive anaerobic spore forming bacilli (see fig above), Septicemia caused by this bacteria most commonly arise in the context of ascending cholangitis.

The special feature about this, is that this bacteria produces an enzyme known as Lecithinase, which when produced in this blood can cause a severe degree of hemolysis secondary to disruption of red cell membrane.

So in such event, the intravascular disruption of RBC, releases free hemoglobin that precipitate in the renal tubules causing acute renal failure. Open / Comment

2021-12-19 19:04:26 Precautions when splenectomy is considered

The spleen is an important organ, especially interms of immunity.

Spleen contain a properdin system which helps with opsonisation of encapsulated organisms, removal of the spleen will entail loss of this feature and risk of infection, which at times is very severe and known as overwhelming postsplenectomy infection (OPSI).

Infection in splenectomy patients is usually due to pneumococci, meningococci, and H.influenza.

To avoid this, give vaccinations 2-3 weeks before elective splenectomy, and in case of emergency splenectomy, vaccination is still given although less effective.

Give annual influenza vaccine and re-vaccinate with pneumococcal vaccine 5 years later.

Patients underwent splenectomy should wear a bracelet stating that they have no spleen (see fig above) to alert health care professionals about the risk of serious septicemia in this patient. Open / Comment

2021-12-19 10:49:22 Open / Comment

2021-12-18 18:45:58 Answer

Unfractionated high molecular weight heparin is the drug of choice, low molecular weight heparin is not favoured here.

Reason:

It is known that, heparin action is mediated by attachment of heparin to antithrombin III, a natural anticoagulant that act to inhibit mainly active factor X, heparin attaches to a specific pentasaccharide site, promoting the action and increasing the activity of AT III, protamine sulfate, is the antidote for heparin, it acts through physical antagonism, in which different charges repel the heparin from its attachment to AT III, with low molecular weight heparin, this repelling is weaker and occur slowly, whereas with unfractionated heparin it occurs rapidly and strongly, it means that the effects of unfractionated heparin can be more rapidly reversed, this can be very useful when rapid reversal is needed, like in this patient, he has a peptic ulcer prone to severe bleeding, but at the same time, has a DVT that could pose danger of an embolic event,, for this reason unfractionated heparin is a better option because if bleeding occured, it can be rapidly reversed. Open / Comment

2021-12-18 16:06:21 Open / Comment

2021-12-18 13:48:47 Answer

This patient developed Heparin induced thrombocytopenia, it develops when heparin binds to a platelet surface protein called platelet factor 4, forming a complex called (heparin-PF4 complex) which is antigenic, this stimulate production of antibodies against this complex, these antibodies bind via their Fc portion to other platelets, forming platelet clumps and clots which will clog blood vessels both arteries and veins throughout the body with reduction of platelet count due to platelet consumption in this process, additionally, the spleen recognizes platelet coated antibodies and cause platelet sequestration which adds to thrombocytopenia.

Early recognition is key to avoid a poor prognosis, before commencing heparin therapy you should measure a baseline platelet count, and monitor if there is any reduction, if platelet count drop more than 30% of baseline, STOP HEPARIN.

Notes :

1) This complication is more common with unfractionated heparin.
2) Confirmative diagnosis requires detection of those antibodies using ELISA.
3) it usually occur 5 days after commencing therapy. Open / Comment

2021-12-18 12:59:58 Question

50 year old female lady, presented with unilateral leg swelling, it was painful, red, and tender, a duplex scan revealed an occluding thrombus at the deep leg veins.

Treatment was started, the patient was put into leg elevation position, and heparin infusion started.

6 days later, the patient developed severe headache, chest pain, abdominal pain, and necrotic skin lesions started appearing (see above figure),Laboratory results showed :

Hb : 8 g/dL.
WBC : 5000 cell/microlitre.
Platelet : 10000 cell/microlitre.
Urine RBC : 400 cells/HPF, with RBC casts.

Patient expired next morning.

Q1: What is the most likely cause of death in this patient?.

Q2: How could this be diagnosed and treated early?. Open / Comment

2021-12-18 12:17:59 Question

45 year old patient, presented with right leg swelling, it was tender and swollen and red, duplex scan revealed a thrombus occluding the deep veins, at the same time, the patient complained of epigastric pain and started vomitting blood, he was positive for H. Pylori stool antigen, endoscopy showed one large peptic ulcer at the greater curve of the stomach.

Q: In this particular patient, what anticoagulant you would like to use to treat his deep vein thrombosis?, give reasons why you have chosen that drug?. Open / Comment

2021-12-18 09:21:30 Toes above nose

This describe the position that a patient should assume in case of established or a high risk of deep vein thrombosis.

Use one or two pillows to elevated the affected leg above the level of the heart, generally described as "toes above nose".

It helps reduce swelling, relief pain, and reduce stasis with subsequent reduction in risk of thrombus formation/propagation. Open / Comment