By L. Ningal. William Carey International University.

As the patient is in shock januvia 100 mg line, the veins are usually collapsed and venesection is often required generic januvia 100 mg on-line. A large-calibre cannula is pushed into a vein (which lies beneath unbumed skin) of sufficient size to permit fluid flow unimpeded generic 100mg januvia otc. Blood transfusion is required when bums involve more than 20% of full thickness or 40% of partial thickness of total body surface purchase 100mg januvia with mastercard. But subsequent studies have shown that the colloid solutions not only restore cardiac output more rapidly but also is more efficient in adequate organ perfusion. However on the 2nd day both crystalloid and colloid solutions are equally effective in restoring cardiac output and intravascular volume. The goal of bum patient resuscitation is the maintenance of vital organ function as soon as possible. The rate and amount of transfusion as well as efficacy of intravenous resuscitation are assessed by repeated red cell volume and haematocrit estimations and at the same time by hourly monitoring of vital signs, general condition and urinary output. These patients usually do not require any diuretic except in 4 categories — (i) those with high voltage electrical bum, (ii) those with associated mechanical soft tissue injury, (iii) those with particularly deep bums involving muscles and (iv) those with extensive bums and who remain oliguric inspite of giving excess fluid volumes than estimated needs. In first 3 categories there is chance of heavy loads of haemochromogens in their urine and are prone to develop acute renal failure unless the urine output is maintained with diuretic. Fluid should be infused at the rate needed to achieve an hourly urinary output of 75 ml to 100 ml. However chest X-rays should be obtained at least daily during resuscitation to exclude pneumonia or other pulmonary complications. Serum electrolytes, blood gases and other base line blood studies should be performed at frequent intervals. For bums involving more than 20% of full thickness or 40% of partial thickness of total body area, whole blood transfusion should be given and this whole blood is considered as part of colloid-containing fluid and may be given upto 50% of total. The diagnosis is confirmed by analyzing the concentration of carbondioxide in the blood. Upper airway obstruction may occur in patients with bums of head and neck during first 48 hours. Such obstruction is due to soft tissue oedema of oral pharynx and vocal cords due to exposure to hot fumes. Direct thermal injury to the lower respiratory tract is very uncommon, as nose and oral pharynx are quite efficient heat exchangers allowing cooling of inhaled hot gas prior to its entrance into the trachea. Though lower respiratory tract injury does occur when the patients are injured by superheated steam as it is difficult to extract heat from liquid. Impending upper airway obstruction is treated by immediate insertion of endotracheal tube. Once introduced endotracheal tube is not removed until 3rd postbum day, since reintubation becomes technically difficult. The clinical signs of such diminished distal flow include cyanosis, impaired capillary refilling and progressive neurologic signs particularly paresthesia. Restriction of chest wall motion to the point at which ventilatory exchange is impaired is an indication of the need for a chest wall escharotomy. Escharotomy is performed as a ward procedure and neither general nor local anaesthesia is required. The eschar, which is insensitive, is incised on either midlateral or midmedial line. The incision should extend along the entire length of the burned area and carried down deep through the eschar and the superficial fascia to a depth sufficient to allow the cut edges of the eschar to separate. Chest wall escharotomies are made on the anterior axillary line bilaterally extending from the clavicle to the costal margin. The need for limb escharotomies may be reduced by continuous elevation of the burned extremity and active motion of it for 5 minutes every hour. If escharotomy has been performed, constant coverage of the escharotomy wound with a topical antimicrobial agent is essential. Sometimes escharotomy may not result in improvement of blood flow to the peripheral part. Fasciotomy should be performed under general anaesthesia and the fascia of all involved compartments should be adequately released. Such fasciotomy is usually required in severe bums with extensive damage to the underlying fat and muscles. Fasciotomy is also required in the treatment of electrical bums where there is extensive muscle injury. Fasciotomy incisions, like escharotomy incisions, should be protected with bandage soaked in topical antimicrobial agent. But this is effective only if the patient receives a booster dose within the preceding 10 years. In case of absence of active immunisation within 10 years prior to bum injury 250 to 500 units of tetanus immunoglobulin (human) should be simultaneously administered at another site using different syringe and needle. These organisms will proliferate if topical chemotherapeutic agents are not applied. That is why there is a place of prophylactic administration of penicillin to patients with bums. But such systemic administration of antibiotics should be given on 1st or 2nd day, as the full thickness bum becomes relatively avascular after 48 hours. Once necrosis occurs, the wound is essentially avascular, which prevents effective delivery of systemic antibiotics if infection occurs. By the late 1960s, gram-negative bacteria, primarily pseudomonas species emerge as the dominant organism. Microbial species colonise the surface of the wound and may penetrate the avascular eschar. Bacterial proliferation may occur beneath the eschar at the viable-non- viable interface, leading to subeschar suppuration and seperation of the eschar. In a few patients micro-organisms invade the underlying viable tissue producing systemic sepsis. Topical antibiotic has a significant role to play in bum infection, though systemic infections are not uncommon and such infections have actually increased as principal causes of death. Bronchopneumonia in burn patients is commonly caused by opportunistic organisms especially gram-negative bacteria. Haematogenous pneumonia may also begin relatively late in burn patients due to haematogenous spread of microorganisms from a remote septic focus. Bronchial secretions should be cultured and antibiotic treatment is begun on the basis of the sensitivity test. Usually an aminoglycoside and a semisynthetic penicillin are administered as the common causative organism is often a strain of Pseudomonas. It must be remembered that prophylactic antibiotics are to be avoided and antibiotics should be administered only on the basis of a clinical or laboratory diagnosis of infection. Indiscriminate use of antibiotics will develop antibiotic resistance in the bacteria present in the burn wound and elsewhere. To minimise such dissemination of organisms and development of bacteremias, antibiotics active against both gram-positive and gram-negative organisms should be administered to patients undergoing surgical debridement of the bum wound or bum wound excision. In bum patients with sepsis, blood cultures should be obtained and proper antibiotic should be administered. Resting metabolic rate approaches approximately twice normal in patients with burns of more than 50% of total body surface. Such hypermetabolism is also manifested by increased oxygen consumption, elevated cardiac output, increased core temperature, wasting of body mass and increased urinary nitrogen excretion. Adult patients with bums of over 40% of the total body surface such measurement estimates about 2000 calories per square meter of body surface per day. So one must be careful in providing adequate exogenous calorie and nitrogen to prevent excessive catabolism in bum patients. Wherever possible tube feeding should be utilised to provide nutritional needs of the patients. Feedings may be accomplished by insertion of a small silastic nasogastric feeding tube through which nutrients are delivered 24 hours a day with a constant delivery pump. If diarrhoea or ileus precludes gastrointestinal feeding, parenteral nutrition should be initiated using an intravenous cannula placed in a large-calibre high-flow central vein. Solutions of synthetic aminoacids mixed with hypertonic solutions of glucose are primarily used with blood sugar levels frequently monitored and kept below 200 mg/100 ml. Sudden intolerance of a previously well-tolerated glucose load is an early sign of sepsis and a careful search should be made for source of infection and its adequate cine. There always remains a high risk intravenous sepsis at the site of intravenous cannula, the site of which should be changed every 48 to 72 hours. That is why patients with major bums require introduction of a nasogastric suction to effectively decompress the stomach and upper small intestine until intestinal motility can be demonstrated. Moreover patients with major burns are at risk of haemorrhagic gastritis due to increased stress. So gastric aspirates should be monitored frequently for the presence of frank blood. Antacid may also be instilled through the nasogastric tube to prevent superficial erosions of the gastric mucosa. Cimetidine, a H2 receptor antagonist which suppresses gastric acid secretion may be used in this connection to prevent or to treat stress gastritis. When gastrointestinal motility returns, the antacid may be given orally till the extent of bum is reduced by healing or by grafting to less than 35% of body surface. If major upper gastrointestinal haemorrhage occurs, the patient should be promptly treated with iced saline solution lavage. When haemorrhage cannot be controlled by conservative means, surgical operation is indicated. After opening the abdomen gastrotomy or duodenotomy is performed to see the bleeding ulcer and to achieve haemostasis by oversewing the base of the ulcer. During closure, the subcutaneous tissue and the skin are left open to prevent soft tissue infection. Acute ulceration of colon usually heal by itself when bum wound has been adequately taken care of. Cold clean water should be applied to the burned area immediately and is continued every 5 minutes. It should be cleansed with a surgical detergent and all loose nonviable skin should be trimmed away. The second-degree bums or partial thickness bums usually present as vesicular lesions. The overlying blister should be punctured and the upper nonviable skin is removed. Such debridement should usually be performed without anaesthesia, but with tremendous aseptic care. Silver nitrate must be used soon after injury, before bacteria have proliferated on the wound. Although gram-positive organisms are slightly less susceptible to silver nitrate, true resistance does not occur. Cerium nitrate has been shown to be an effective topical antimicrobial drug and currently is undergoing clinical evaluation. Majority of the topical antimicrobial agents appear to be equally effective in controlling burn wound infection when applied early before heavy colonization has occurred.

If gallstones are present order 100mg januvia with mastercard, cholecystectomy should be performed alongwith splenectomy buy cheap januvia 100mg line. Due to absence of adhesions generic januvia 100 mg without prescription, the operation is comparatively easy generic 100mg januvia mastercard, which accounts for low operative mortality. Ultimately the reticuloendothelial system traps and destroys the immunologically altered red cells. The anti-red cell antibodies are classified as ‘warm’ and ‘cold’ antibodies dependig on whether they bind to red cells at 37°C or less than that. Cold antibodies cause immediate intravascular haemolysis and destruction of sensitised red cells by the liver. These patients usually suffer from chronic haemolysis that is worsened by exposure to ‘cold’ and show acrocyanosis (Raynaud’s phenomenon) due to intracapillary red cell agglutination. Usually the disease is chronic with varying degrees of severity of months or years. Splenectomy is usually performed (i) when steroids are ineffective, (ii) when complications preclude the use of steroids, (iii) if toxic manifestations of steroid become apparent, (iv) if steroids are contraindicated for some reason or the other or (v) in case of ‘warm’ antibody haemolytic anaemias. About 80% of patients selected for splenectomy show favourable responses after splenectomy. Many cases may represent the results of autoimmunity which damage the patient’s own platelets. The spleen is often implicated either as the major sequestrating site for sensitised platelets or as a source of antibody production. The most common presenting signs are the petechiae and/or purpuric patches or ecchymoses in the skin and mucous membranes. There is also a tendency to spontaneous bleeding revealed by bleeding gum, epistaxis, gastrointestinal haemorrhage, haematuria, haemarthrosis and menorrhagia in women. Incidence of central nervous system bleeding is only 2 to 4% and may be the cause of death. Bone marrow examination reveals megakaryocytes either normal or increased in number. Qualitatively there is degranulation of the cytoplasm, rounding of cytoplasmic edges, appearance of vacuoles in cytoplasm and disappearance of usual pseudopodia of platelets are seen. In children under 16 years of age about 80% of patients make complete and permanent recovery without specific therapy. In adult cases there are still debates about relative advantages and disadvantages of steroid therapy and splenectomy. However in majority of series the results achieved by splenectomy are clearly more impressive than those of the steroids. Steroid is given in the form of prednisone 1 mg/kg/day, An increase in platelet count occurs within 3 to 7 days in most patients. Splenectomy is obviously a definite indication for severe cases which do not response to steroid therapy and for the girls approaching menarche. About 75% of total number of patients subjected to splenectomy respond permanently and require no further steroid therapy. In most cases the platelet count rises to over 1 lac within 7 days after operation, though sometimes return to normal level may take months. If the patient does not respond with elevation of platelet count, splenectomy is performed. For patients with almost nil platelet count platelet packs should be administered following removal of spleen who continue to bleed. Specific pairs of genes are responsible for synthesis of Alpha, Beta, Gamma and Delta chains of the haemoglobin molecules and deficiency of synthesis of one of these chains will lead to thalassaemia. Beta-thalassaemia is most common type in which there is quantitative reduction in the rate of Beta chain synthesis. When abnormal genes are inherited from both parents (homozygous), thalassaemia major results. In thalassaemia major, reduction in the rate of Beta chain synthesis produces marked decrease in the amount of normal adult haemoglobin (HbA) and compensatory increase in foetal haemoglobin (HbF). Homozygous Alpha thalassaemia is incompatible with life and these infants are either stillborn or die shortly after birth. In thalassaemia major, deficiency of beta-chain synthesis results in relative over-production of Alpha chains, which form insoluble inclusions in bone marrow erythroid precursors. These inclusion-bearing red cells are detained in the spleen and are ultimately destroyed. There is pallor, retarded body growth and enlargement of the head with typical ‘thalassaemic fades’. Intractable leg ulcers, intercurrent infections and gallstones may be seen in certain cases. Intense erythroid hyperplasia in the bone marrow results in expansion of the medullary cavities and attenuation of the cortex producing bony abnormalities, which may predispose fractures. Thalassaemia minor patients lead normal lives, though a few show severe expression of the disease (these cases are known as thalassaemia intermedia). These cases may present with mild anaemia, mild jaundice and moderate splenomegaly. Repeated transfusions are usually required at regular intervals, which should be directed to maintain haemoglobin at the level of 10 g. Though splenectomy does not influence the basic haematologic disorder, yet there is considerable decrease of blood transfusion requirements after splenectomy and it also relieves discomfort from splenomegaly. Though there is a trend to offer therapeutic iron to these cases, it should be avoided as there is risk of iron overload. This disease is characterised by presence of sickle and crescent shaped erythrocytes. HbS defers from normal adult haemoglobin (HbA) in the substitution of valine for glutamic acid in the 6th position of the beta chain. Presence of HbS imparts the sickle shape to deoxygenated red cells which is responsible for this disease. In the homozygous state HbA is totally lacking and the red cells contain mainly HbS. Under reduced oxygen tension, HbS molecules undergo crystalisation within the red cell, which elongates and distorts the cells. The sickle cells themselves contribute to increased blood viscosity and circulatory stasis. Manifestations of this disease may be both acute or episodic (crisis) and chronic or progressive. Patients with sickle cell crisis complain of severe abdominal pain and cramps due to visceral arterial stasis simulating an acute abdomen. Depending on the vessels involved the patient may have bone and joint pain, haematuria, priapism, neurological manifestations or ulcers over the malleoli. The incidence of pigment gallstones increases with age and are present in approximately 70% of adult patients. Thrombosis of splenic vessels may result in an unusual complication of splenic abscess manifested by splenomegaly, pain and fever. Chronic features of sickle cell anaemia include retarded growth and development of bone and joint disease, pulmonary, hepatobiliary, genitourinary and neurologic manifestations and ulcerations over the malleoli after the first decade. But later on this spleen undergoes infarction and marked contraction with eventual autosplenectomy. Majority of patients with this disease die in the first decade of life, though a few may survive upto 5th decade. Continued fibroblastic proliferation impairs normal haematopoiesis and ultimately produces sclerosis of the bone marrow and myelofibrosis. This condition is closely related to polycythemia vera, myelotic leukaemia and idiopathic thrombocytosis, all these conditions together constitute a disease spectrum known as myeloproliferative disorders. The characteristic features of this condition are (i) progressive fibrosis of the bone marrow, (ii) extramedullary haematopoiesis, (iii) presence of immature erythroid and granulocytes precursors in the peripheral blood and (iv) massive splenomegaly. Generalised abdominal discomfort, feeling of fullness after meals and intermittent pain of splenic infarction are often seen. Other symptoms include malaise, dyspnoea, weight-loss, spontaneous bleeding, bone pain, pruritis etc. Hyperuricemia is present frequently and should be anticipated to avoid episode of gout and renal calculi. Bone marrow biopsy shows varying degrees of fibrosis with scattered foci of haemopoietic elements. Blood transfusions, corticosteroids and androgen therapy may be of value in this condition. Alkylating agents may be effective in reducing splenic size and transfusion requirements. Busulfan is the most commonly used alkylating agent, but cyclophosphamide may also be used in thrombocytopenic patients as it is less likely to suppress platelet production. Some patients do respond to chemotherapy, but this drug should be used with caution. Splenectomy has been effective in controlling anaemia and relieving symptoms due to splenomegaly. In patients with oesophagogastric varices portal pressures should be determined before and after splenectomy. It may occur in patients with long history of rheumatoid arthritis as these patients cannot show granulocytosis in response to infection. This is particularly performed in those patients with recurrent infections and chronic leg ulcers. The granulocyte response is immediate and majority of patients will have resolution of granulocytopenia within 48 to 72 hours after splenectomy. Sometimes corticosteroids have been used to reverse neutropenia to reduce susceptibility to infection. Proliferation and enlargement of these cells produce enlargement of the spleen, the liver and lymph nodes. Progressive enlargement of the abdomen occurs primarily due to splenomegaly and to lesser extent by hepatomegaly. Bone pain is common due to bone destruction and pathological fractures or collapse of vertebral bodies may develop in long standing cases. Moderate thrombocytopenia and normocytic anaemia with mild leukopenia are not uncommon. There is no evidence to show that splenectomy influences the basic course of the disease. Cough, shortness of breath and night sweats are often seen mostly due to mediastinal or pulmonary involvement. Generalised lymphadenopathy is quite frequent and skin lesions are seen in 50% of patients. In /sth of cases hypersplenism is seen with haemolytic anaemia, neutropenia, pancytopenial and thrombocytopenic purpura. If there be splenomegaly with hypersplenism, splenectomy should be considered as correction of haematologic abnormalities is always seen following splenectomy.

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At the same age the disc-like centre of ossification appears at the upper end of the radius generic 100mg januvia overnight delivery. The centre for the medial part of the trochlea appears in the ninth year in females and tenth year in males discount januvia 100 mg with mastercard. At about the same age or a year later a thin scale-like epiphysis appears on the top of the olecranon process buy januvia 100mg with mastercard. The centre of ossification in the lateral epicondyle appears at about the twelfth year in both sexes order januvia 100mg mastercard. The centres for the lateral epicondyle, capitulum and trochlea fuse around puberty and the large epiphysis thus formed unites with the shaft of the humerus in the fourteenth year in the females and the sixteenth year in the males. The upper epiphysis of the radius fuses with the shaft at the same age as the previous one (14th to 16th year). An additional centre sometimes appears in the tuberosity of the radius at about the fourteenth or fifteenth year. This fact can be verified by drawing a line which is drawn downwards along the anterior surface of the humerus which divides the circular trochlea into anterior l/3rd and posterior 2/3rd in the lateral X-ray film. The following conditions are to be considered in injury around the elbow :— 1) Supracondylar fracture. This is due to the fact that the lower epiphysis of the humerus after it has fused with the shaft is bent 8) Fracture of the olecranon process. Note also the position and shape of the epiphysis 9) Posterior dislocation of the elbow forming the olecranon. This must not be mistaken for a with or without fracture of the coronoid fracture which usually occurs at the base of the olecranon process. The mechanism of backward supracondylar fracture is a fall on the hand with bent elbow, when the distal fragment is pushed backwards and twisted inwards as the forearm is usually full pronated. The displacement of the distal fragment is backwards, upwards, backward angulation with a slight internal rotation. The victims are usually children and present with a gross swelling at the elbow which is supported by the patient with his other hand. On examination there may be bruising and the posterior prominence of the elbow which requires differentiation from the posterior dislocation of the elbow. The possibility of an injury to the brachial artery as well as three main nerves should be foreseen and properly examined to exclude such possibility. An immediate reduction of the displaced fracture is essential and the elbow joint is kept flexed in collar and cuff in such a position as the radial pulse is well palpated. The mechanism of forward supracondylar fracture which is very much rarer than its previous counterpart is caused by a fall on the stretched hand with fully extended elbow so that the lower fragment is tilted forward. The patient presents with a more extended elbow than its previous counterpart and swelling around the elbow. The lower fragment is displaced laterally for a considerable distance which is obvious in anteroposterior film. The centre of ossifcation for the capitulum is likely to be mistaken for that of the head of the radius in anteroposterior view but not in the lateral view. In fact the centre of ossification for the head of the radius has not yet appeared. The elbow remains slightly flexed supported by the other hand and movement is extremely painful and restricted. Swollen elbow and tenderness on the lateral condyle are the usual clinical features. The mechanism of injury is usually a severe abduction force and young children between ten and fifteen years of age are the usual victims (before the medial epicondylar epiphysis fuses with the shaft). The peculiar feature of this fracture is that besides slight rotational displacement the medial epicondyle may be included into the joint by the forced abduction which momentarily opens up the medial side of the joint and thus sucks in the fractured medial epicondyle. The anterior half of the capitulum and the trochlea are broken off and displaced proximally. It is actually an epiphyseal separation with a triangular metaphysis attached to it. There is tenderness at the upper end of the radius with a lateral projection of the head of the radius which can be palpated. X-ray shows fracture of the neck of the radius with the head tilted forwards, outwards and distally. On examination there will be localized tenderness on the head of the radius and rotation of the forearm i. X-ray will confirm the diagnosis by showing either a vertical split in the radial head or a lateral major fragment of the head broken off and displaced laterally or a comminuted fracture with multiple fragments. The fracture line is at the narrowest point of the olecranon almost where it joins with the shaft of the ulna and must not be confused with the epiphysial line which lies near the tip of the olecranon process. If the triceps muscle goes in action during the injury a gap is expected between the two fragments of the olecranon process. If there is just a crack fracture, slight swelling, bruising, localized bony tenderness and bony irregularity will be the clinical features. Whereas in more severe injury with separation of fragments there will be more swelling, oedema and bruising at the fracture site. X-ray examination is obligatory not only to know the details of the fracture and displacement but also to assess the type of treatment which would be best suited for the particular case. The mechanism of posterior dislocation is a fall on the outstretched hand with the elbow in slightly flexed position. The coronoid process may pass posteriorly below the distal end of the humerus intact or may be fractured by the thrust against this part of the humerus. Very often the posterior dislocation is associated with lateral displacement of varying range. Clinically this condition may mimic the supracondylar fracture and the differentiating points between these two conditions should be borne in mind. Generally such a history can be elicited and the patient presents with a complaint of pain at the elbow. The elbow is more or less fixed in slight flexion and pronation; more flexion of the elbow and supination become painful and limited. On palpation one may find the head of the radius a little below and lateral to its normal position. When the displacement of the ulnar fracture is anteriorly and the head of the radius is dislocated anteriorly — this is known as Monteggia fracture-dislocation. When the displacement of the ulnar fracture is posteriorly and the head of the radius also dislocates backwards — this is known as reversed Monteggia. Mechanism is usually a fall on the hand and the body twists at the moment of impact thus forcibly pronating the forearm. A careful palpation will reveal radial dislocation besides rather easy detection of ulnar fracture-displacement. Movement of the elbow joint is completely restricted — both extension and flexion as well as supination and pronation. But two points deserve mentioning — (i) that the dorsal prominence is not at the level of the wrist but about one inch above it and (ii) that there is also a slight radial deviation which makes the head of the ulna more prominent. When the patient is asked to make a fist, the line of knuckles may not be on the normal line. In "mallet finger", which is caused by rupture of the extensor tendon at its insertion at the base of terminal phalanx, there is persistent flexion of the terminal phalanx. It must be remembered that normally the lower third of the radius is smoothly concave in front. In this case squeezing of the upper part of the radius and ulna together will elicit pain at the site of fracture. In order to demonstrate this, the clinician uses his two index fingers to locate the tips of the styloid processes in pronated forearm of the patient. The dotted line scaphoid bone is most important as very often fracture of the represents the horizontal level at the scaphoid is misdiagnosed as simple sprain and the patient tip of the ulnar styloid process. Moreover fracture of the scaphoid requires prolonged immobilization as this fracture is notorious for non-union and avascular necrosis of the proximal fragment. The scaphoid is palpated at the anatomical snuff-box with the wrist bent medially to expose the bone for palpation. If there is any fracture of the scaphoid bone, the patient will complain of pain as soon as a pressure is made over the anatomical snuff-box. This bone may be dislocated anteriorly and requires careful palpation for the diagnosis of this condition. For this, the examiner should run his finger along the length of the said bone to find out any gap, bony irregularity, bony tenderness or abnormal projection. A careful palpation of the metacarpo-phalangeal joints and inter phalangeal joints should be a must to exclude subluxation or dislocation of the said joints which are often missed. In case of metacarpal fractures movement of the metacarpo-phalangeal joints will be restricted. Similarly in fractures of the phalanges movement of the interphalangeal joints will be painful and restricted. In differential diagnosis complications of the important fractures around the wrist will be discussed in nut-shell. In all fractures, not only the fracture is diagnosed but also a careful study of the displacement of the fractured fragments will help the clinician in reduction of the fracture concerned. In this case, to reduce the fracture a pull is directed downwards, slightly medially and anteriorly holding the thumb and the heads of the metacarpals of the patient simultaneously, while with the two thumbs of the clinician the upper edge of the lower fragment is pushed anteriorly so that the normal alignment of the radius is restored. After discussing the general points, the peculiarity of the X-ray examination of the scaphoid requires special mention. Very often the orthodox antero-posterior and lateral views fail to detect a minor crack fracture of the scaphoid. For this an oblique view and views from different angles are very much essential to diagnose fracture of the scaphoid bone. If clinical findings go very much in favour of the diagnosis of fracture of the scaphoid, one should treat the case according to that and take another X-ray after ten days, as by that time the fracture line often delineates itself. The victims are usually elderly ladies, which is attributed to the osteoporosis in post-menopausal women. The fracture line lies about 2 cm proximal to the distal articular surface of the radius. The distal fragment is displaced dorsally, proximally, slightly laterally and angulated backwards. On examination, there is tenderness and bony irregularity of the lower end of the radius. The radial styloid process does not remain lower than the ulnar styloid process which is normal. On the contrary it remains at the same level or a little higher than the ulnar styloid process.

They may only be diagnosed if endoscopy is performed within a day or two of the bleeding buy januvia 100mg overnight delivery. They may be seen as small buy cheap januvia 100 mg online, discrete lesions with hyperaemic margin and sometimes with a large vessel exposed at the base of the ulcer januvia 100 mg with mastercard. Gastric lesions are often associated with low rate of acid secretion januvia 100mg otc, whereas the duodenal ulcers develop when there is high rate of acid production. There appears to be an increased tendency to haemorrhage if the patient is of blood group ‘O’. In case of gastric ulcer bleeding usually occurs from chronic ulcer near lesser curvature. In case of duodenal ulcer the ulcer is often situated on the posterior wall and bleeding occurs from a branch of gastroduodenal artery. The initial haemorrhage is usually not fatal, except when the bleeding vessel is unusually big. It becomes fatal when — (a) recurrent haemorrhage occurs in a day or within 2 or 3 days, (b) initial repeated small haemorrhages followed by a sudden severe haemorrhage. The reasons are — (i) Extensive fibrosis at the base of the ulcer prevents retraction of the vessel, (ii) Sometimes the branch of the artery is eroded on its lateral wall and fails to contract as occurs in case of complete cut where the ends contract, (iii) When the vessel is atherosclerotic particularly in old people where surgery is indicated. The patient feels a sense of ill being with faintness, sweating and pallor when haemorrhage starts. Later on black tarry stool (melaena) or vomiting of blood (haematemesis) is complained of. Only when the bleeding is massive and the pylorus is open haematemesis may be complained of. No definite clue may be obtained on examining the abdomen, except that a definite tenderness may be felt on the gastric or the duodenal point. He must be explained that he is bleeding from ulcer and will be cured if blood is transfused. Sedation with phenobarbitone injection, which is preferred to morphine as this may cause nausea and vomiting and this may induce more bleeding. Frequent pulse rate, central venous pressure and blood pressure readings should be taken to know the amount of blood to be transfused. Even after bleeding has ceased and blood transfusion is discontinued, these readings will give an idea about any further haemorrhage. If it is decided that surgery is not required at present, soft diet with milk may be given to the patient. A few tests should be performed to know the cause of haemorrhage : (i) Hess test for capillary fragility; (ii) Testing for blood coagulation or bleeding defect; (iii) Liver function tests. The patient’s pharynx is spread with local anaesthetic and the patient is slightly sedated with slow intravenous injection of diazepam in the dose of 10 to 20 mg. As the instrument is introduced through the pharynx into the oesophagus, careful watch should be maintained to detect bleeding point. Acute linear mucosal tear at the end of the oesophagus indicates Mallory-Weiss syndrome. Presence of oesophageal varix can also be detected here with bulged dilated vessels at the lower end of the oesophagus. In case of bleeding ulcer attempt at laser coagulation or injection of a sclerosant (e. If blood is seen coming through the pylorus, there is every possibility that duodenal ulcer is bleeding. Bleeding from the stomach and duodenum can be treated with a number of haemostatic measures. Gastroduodenoscopy with fibreoptic instrument is essential to find out duodenal bleeding point. If endoscopy does not give any clue to the diagnosis, a barium meal examination should be performed on the following morning. A decision should be made within 48 hours of commencement of bleeding, whether surgery should be undertaken or not. Experience has shown that when operation is delayed beyond that time the mortality rises sharply. In a few cases operation should be undertaken quickly after preliminary resuscitation. Indications for immediate operations are :— (i) Those patients who rebleed after admission to hospitals. In case of chronic duodenal ulcer the treatment of choice is probably underrunning the bleeding point, pyloroplasty and vagotomy. In case of gastric ulcer, gastrotomy and underrunning of the bleeding vessels should be performed. At this time four-quadrant biopsy of the ulcer should be taken to prove it to be benign. If the bleeding vessel is near the pylorus, a wide pyloroplasty should be made alongwith direct suturing of the bleeding vessel at the ulcer base. If no ulcer is found, the gastrotomy is extended to detect erosions or vascular malformations. If erosions are found to cover a wide distal area of the stomach, a Billroth I partial gastrectomy should be performed. Diagnosis and finding out of the bleeding vessels are extremely important in case of upper G. Chronic Stenosis Mainly three types of stenosis are seen as complications of peptic ulcer. After months of intermittent obstruction it may suddenly cause complete obstruction of the pylorus. Though the patient can usually take breakfast and lunch, yet rejects afternoon tea and never takes dinner. If this symptom is not present, the diagnosis of pyloric stenosis should be reconsidered. This usually takes place in the evening and the vomitus contains undigested particulate matter taken on that day or one or more days earlier. Visible peristaltic waves passing from left to right is quite characteristically noticed after giving anything to drink. A succussion splash is often heard on shaking the patient and keeping the clinician’s ear very near to the patient’s abdomen. On ausculto-percussion the greater curvature can be delineated and the stomach is found grossly distended. Gastric function tests will show huge quantity of fasting content due to stagnation of old food. There is low acid content due to chronic gastritis from fermentation of stagnant food in the stomach. Absence of bile in all the samples and copious amount of mucus due to chronic gastritis are detected in aspirated samples. Barium meal examination will show a large and low stomach and presence of barium even after 6 hours. Emptying of stomach is much below normal and in the first plate while the stomach is full of barium yet the duodenal bulb is not full with barium. Gastric juice contains 10 mEq/ litre of potassium so potassium deficiency is also obvious. To replenish this loss, administration of sodium chloride and potassium chloride solution usually suffice. When a patient with gastric outlet obstruction is admitted to the hospital, any significant acid base and electrolyte abnormality must be corrected. Polythene Ryle’s tube or large bore Ewald tube should be introduced into the stomach. Due to technical reasons gastrojejunostomy or gastroenterostomy is more preferred to pyloroplasty. Since duodenal ulcer is almost always associated with high acid secretion and this condition is a complication of chronic duodenal ulcer the treatment should always be vagotomy alongwith antrectomy or more often gastrojejunostomy. Periodicity is lost k H a n d the symptoms practically fplrcontinue without any remission. It may be confused with pyloric stenosis when the second pouch fails to fill with barium. Gastroscopy will reveal the upper chamber and the scarred channel leading to the lower compartment. This will produce stagnation and may mimic in many ways the symptoms of pyloric stenosis. Note the ulcer crater with malignant guide lines Penetration to pancreas from a posteriorly placed gastric or that no longer run straight and are be­ duodenal ulcer may take place. Ulcers near the greater curvature and near the lesser curvature below the angulus are more prone to malignant change. Ulcers in the characteristic situation near the lesser curvature are very rare to undergo carcinomatous change. It is due to this prone to malignancy that treatment of gastric ulcer is different from that of duodenal ulcer. Endoscopy and even four quadrant biopsy will definitely give a clue whether malignant change has involved in an ulcer or not. When periodicity is lost and vomiting does not relieve pain in gastric ulcer, malignancy may be suspected. Residual Abscess Subacute perforation or leaking perforation or chronic perforation may cause residual abscess formation. Benign tumours are mostly (i) Polyps, (ii) Leiomyoma, (iii) Lipoma; (iv) Neurofibroma and (v) Ectopic pancreas. While the former is an inflammatory lesion and much more common (20% of benign tumour and 90% of benign polyps), the latter is the true tumour. Besides the two varieties mentioned above, adenomatous polyps may arise in the stomach in conjunction with multiple small bowel polyposis (Peutz-Jeghers syndrome) or the familial polyposis of Gardner’s syn­ drome. These are usually asymptomatic, except when they are adjacent to the pylorus and prolapse through it causing symptoms of pyloric obstruction to appear. These polyps are usually associated with atrophic gastritis, megaloblastic anaemia, achlorhy- dria and intestinalisation of gastric mucosa. Intense interest has existed and conflicting opinions have been expressed regarding the malignant potentiality of hyperplastic polyp of the stomach. Approximately 30% of these polyps may coexist in stomachs with invasive carcinoma. The possibility may be that achlorhydric patient with intestinalisation of gastric mucosa are responsible for development of both cancer and hyperplastic polyp. This adenoma also develops in achlorhydric patients with atrophic gastritis and intestinalisation of gastric mucosa. Fibreoptic endoscopy has facilitated the diagnosis and treatment of gastric polyps. Pedunculated lesions can be totally excised by use of the snare and cautery and the histology of the lesion is established. Further surgical treatment is indicated (a) when the polyp is more than 2 cm in diameter and one is not sure from the histological report that the tumour is benign and (b) when the sessile lesion is more than 2 cm in diameter. A solitary sessile lesion is best removed by wedge excision with a margin of surrounding gastric wall and submitted for frozen section examination.

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