By L. Phil. Louisiana State University at Shreveport.

The incision starts a little medial to the lateral border of the erector spinae muscle at the level of the 12th rib purchase generic atorlip-10 on line high cholesterol medication erectile dysfunction. The incision is carried forwards along the line of the 12th rib and is continued beyond its tip as far as required order atorlip-10 online from canada the cholesterol in shrimp. The Latissimus dorsi and serratus posterior-inferior are come across in the medial part of the wound and these are divided buy atorlip-10 10 mg without a prescription examples of cholesterol lowering foods. The bed of the rib comprising of the periosteum and the fibres of the diaphragm are cautiously incised to get into the retro-peritoneal space. The lower reflection of the pleura is identified at the medial part of this incision and is carefully pushed upwards. The incision along the 12th rib is carried forward into the loin, while the medial end of this incision is extended upwards vertically upto just above the neck of the 10th rib. The upper vertical portion is deepened and 2 to 3 cm segments ofthe 11th and 10th rib are excised. This approach will give a very wide exposure, highly suitable for upper pole tumours. In case of hypernephroma, intra-peritoneal approach is preferred as the extent of the growth along the renal vein to the inferior vena cava is assessed and the renal vein is first ligated before the hypernephroma is mobilised. A long upper paramedian incision with a transverse extension at the level ofthe umbilicus, dividing the rectus and the lateral abdominal muscles is mostly employed. The peritoneum on the posterior wall is incised along the lateral side of the flexure of the colon. The colon is then mobilised and displaced medially to expose the anterior surface of the kidney and its vessels. At the end of the operation the peritoneum which was incised is sutured back and the retro-peritoneal space is drained through the loin. Gravity and peristalsis both contribute to spontaneous passage into and down the ureter. Stones with other composition have smooth surfaces and are often passed through the ureter without being impacted. A ureteral stone is only detected when it causes some symptoms due to its presence in the ureter or any pathological changes to the kidney or ureter. If the stone remains for weeks or months irrepa­ rable damage to the renal parenchyma may occur. There are 3 sites of anatomical narrowing of the ureter where a stone may be arrested. These are — (i) pelviureteral junction, (ii) when the ureter crosses the iliac artery and (iii) where it enters through the bladder wall. Occasionally a stone may remain lodged in a ureter for many months without harming the kidney. When the stone has impacted patient may complain of dull ache which gets worse during walking and exercise. Pyelitis, pyelonephritis and pyonephrosis (from hydronephrosis) may occur due to infection. Diverticulum in the wall of the ureter may occur when the stone gets impacted and ulcerates the epithelium of the ureter. With the formation of diverticulum pain totally goes off with false belief of the patient that the stone has passed away. It is repeated at longer or shorter intervals till the stone is ejected into the bladder or becomes impacted in the ureter. This colic becomes severe when the stone becomes arrested at the anatomical narrowings of the ureter. In case of ureteric colic there is radiation of pain the position of which suggests the position of arrest of stone in the ureter. When the stone is arrested high in the ureter the pain passes from the loin to the groin along the distribution of the iliohypogastric and ilioinguinal nerves. When the calculus is in the lower-third of the ureter, colic starts at a lower level and radiates to the testicle in the male or labium majus in the female and to the medial aspect of the thigh as the pain is referred along the two branches of the genitofemoral nerve. This is due to common segment of innervation of the lower ureter and the genitofemoral nerve. When the stone enters the intramural part of the ureter, the pain is referred to the tip of the penis in the male and strangury’ in both sexes. The position of this dull ache depends on the position of impaction of the ureteric calculus Such pain is due to capsular tension and distension of the renal pelvis. This pain is aggravated by exercise, movement and jolting and is relieved by rest. The ureteric stone often gets impacted in the pelvic part of the ureter and at that time dull ache is complained of at the iliac fossa. When this pain passes off, it is due to the stone has formed a false diverticulum due to pressure necrosis at the point of impaction. When the pain becomes gradually severe for 1 or 2 days and then gradually subsides, it suggests complete obstruction of the ureter by the stone. Even in the absence of infection symptoms of urgency and frequency of urination may be complained of when the stone is very near the bladder. This may mimic intraperitoneal pathologies like peptic ulcer, cholelithiasis or acute appendicitis. This often gives difficulty in differentiating this condition from acute appendicitis when the right ureter is involved. On many cases no radio­ opaque stone may be seen due to its small size or presence of intestinal gas shadows in front of the stone. Sometimes the shadow may be of phlebolith or some other intra-abdominal calcification and not of ureteric calculus. It must be remembered that ureter starts at the level between the first and second lumbar vertebrae, somewhat higher on the left side and traverses in front of the tips of the transverse processes of the lumbar vertebrae. It then runs in front of the sacro­ iliac joint and then in front of the tip of the ischial spine after which it turns medially and forwards to enter into the bladder. But even in these cases a nephrogram may be seen without a good visualisation of renal pelvis or ureter. This also indicates ureteric obstruction with good reasonable renal function In excretory urography the following findings help in the diagnosis :— (a) The stone lies in the ureter with some dilatation of the ureter above the stone. This arises difficulty to differentiate it from ureteral tumour or blood clot within the ureter. In fact this should be avoided unless the diagnosis cannot be established by the above means, as instrumentation always carries bacteria from the urethra into the upper urinary tract. Cystoscopy does not reveal any abnormality when the calculus is in the upper part or middle part of the ureter. When the stone has reached the lower third of the ureter, the ureteric orifice looks patulous with minute petechial haemorrhages around the affected ureteric orifice. As the calculus descends and comes near the intramural portion, this petechial haemorrhages coalesce to form larger haemorrhagic spot. When the stone has entered the intramural portion, the ureteric orifice becomes grossly oedematous. When the calculus has reached the ureteric orifice it will be seen peeping through the orifice.

In normal subject there is a twofold or greater increase in total urinary 17-hydroxycorticosteroids on the day or on the subsequent day of the test order atorlip-10 10mg with visa cholesterol serum. This method of investigation is now very popular and has almost replaced other techniques for detection of pituitary microadenoma in Cushing’s disease 10mg atorlip-10 mastercard cholesterol levels hdl vs ldl. Enlarged sella turcica may be noted in patients with pituitary tumours as in case of Cushing’s syndrome order atorlip-10 overnight delivery percent of cholesterol in shrimp. X-ray of bones in general may frequently demonstrate osteoporosis and even pathological fractures. Angiography may be performed to localise adrenal tumours or to demonstrate adrenal hyperplasia. More recently 131Iodocholesterol emission photoscanning has been effective in demonstrating adrenal lesion in Cushing’s syndrome. Three drugs have been tried in this syndrome — (a) Metyrapone may be used in the dose of 2 to 6 g. This drug acts by blocking steroid synthesis as some point between cholesterol and pregnenolone. This drug is also effective in Cushing’s syndrome due to adenoma and carcinoma, though it is not effective in A. This drug however has been banned due to its effect of hirsutism and goitre producing. The usual radiation dose is 4000 to 5000 rads to the pituitary fossa using a60 cobalt or high energy source. Recently 90Yttrium implantation in the pituitary fossa has been used for Cushing’s disease. With transphenoidal surgical technique the neurosurgeon can remove pituitary tumour and achieve remission of Cushing’s syndrome. In a large percentage of patients with Cushing’s disease the pituitary glands were found to have microadenomas. It should also be noted that the secretion of other anterior pituitary hormones can be preserved in the majority of patients following transsphenoidal surgery. The benefits from transsphenoidal hypophysectomy appear to present striking improvements over those achieved by transfrontal hypophysectomy or total adrenalectomy. Obviously in subjects with small pituitary adenomas, a transsphe­ noidal approach is the procedure of choice. Although bilateral adrenalectomy is usually curative in patients with Cushing’s disease, but there have been reported cases of recurrent hypercortisolism presumably due to ectopic adrenal tissue. Incomplete resection of adrenocortical tissue or rupture of cortical adenoma during surgery may cause recurrence. If there is bilateral adrenal hyperplasia, the left side is operated on first as exposure is easier in this side. If the gland appears atrophied, it is biopsied, left undisturbed and the wound is closed considering that the diagnosis was wrong and the patient has adrenocortical tumour on the opposite side. Bilateral adrenal glomerulosa cells hyperplasia also causes primary aldosteronism. The cells do not look like those of zona glomerulosa, but these are often hybrid cells with features of both zona glomerulosa and zona fasciculata. The patients often complain of frontal headache, muscle weakness, fatigue, polyuria, nocturia and thurst. In secondary aldoster­ onism there is also low plasma potassium level, though plasma sodium concentration is normal or low. The greater the degree of secondary aldosteronism and renin secretion, the lower the sodium level. Chlorothiazide may be used as a diagnostic aid to produce profound depression of plasma potassium level in patients with primary aldosteronism. In primary aldosteronism patients excrete aldosterone between 15 and 50 ng per day. The serum potassium level should rise by a minimum of 1 mEq/Litre if there is hyperaldosteronism. In small number of patients the increased aldosterone level can be suppressed by administration of drugs. The increased aldosterone levels can be suppressed by the administration of dexamethasone. Patient’s blood pressure becomes normal with a decrease in serum aldosterone level. Spironolactone may be used in this respect, though in majority of cases this is not required. If no adrenal tumour is palpable during surgery, the adrenal which yields higher aldosterone content in its venous blood should be removed. In patients with adrenocortical hyperplasia total or subtotal adrenalectomy should be carried out. Adrenal venous blood should always be sampled for localisation for aldosterone producing tumours. In female child congenital adrenal hyperplasia produces pseudohermaphrodite, while in male child it produces macrogenitosomia praecox. The treatment is usually not operative, though in occasional cases plastic operations may be required on the genitalia of female pseudohermaphrodites. In the female it produces masculinisation and in the male it produces sexual precocity. It is seen more commonly in women, in whom it produces virilism with or without signs of Cushing’s syndrome. Adrenogenital syndrome refers to any situation in which there is over-production of androgens. That is why this syndrome is more marked and distressing in the females than in the males. In a variety of situation in young women, including the Stein Leventhal syndrome, there is mild oveiproduction of androgens leading to hirsutism, acne and amenorrhoea. If this tumour occurs in young girls, it results in striking premature sexual development. In males the presenting sign is usually gynaecomastia, feminising hair change and atrophy of testis and penis. In females the diagnosis is often not made unless it presents as Cushing’s syndrome. There is marked increase in urinary oestrogen, 17-hydroxycorticosteroids and 17-ketosteroids. Oestrogen secreting tumours in men are often malignant and radical resection with lymphadenectomy should be the treatment of choice as this tumour is relatively insensitive to irradiation and chemotherapy. This condition is due to progressive destruction of the three zones of the adrenal cortex and medulla with lymphocytic infiltration. Though the cause is still not very clear, yet autoimmune disease is held responsible for 60% of cases. Other autoimmune diseases such as thyroiditis (Hashimoto’s disease), pernicious anaemia, hypoparathyroidism and gonadal failure are seen associated with this condition.

Fever order atorlip-10 10 mg mastercard cholesterol medication herbal, frequent and recurring infections and oral ulcerations are noted with neutropenia cheap 10mg atorlip-10 cholesterol ratio nhs direct. In the peripheral blood smear there should not be any evidence of leukaemia or myeloproliferative disorders buy 10 mg atorlip-10 free shipping cholesterol ratio us. Primary hypersplenism is a diagnosis of exclusion and an exhaustive search should be made for a specific aetiology of hypersplenism. Only after such search has been unrewarding that a diagnosis of primary hypersplenism can be made. Splenectomy is the only answer and should be carried out once this diagnosis is made. Occasionally patients followed for long periods have subsequently developed leukaemia, histiocytic lymphoma or reticulum sarcoma. The mechanisms producing splenic enlargement are work hypertrophy from immune response e. In both primary and secondary hypersplenism, the degree of splenomegaly does not correlate closely with the severity of clinical symptoms or the degree of depression of formed elements of the blood. The mode of spread is unpredictable and many patients have disseminated disease at the time of presentation. Usually at the time of diagnosis the patients are about 50 years of age without any sex preference. If the disease is diagnosed before the age of 35 or after the age of 65 it is mostly a diffuse variety. The type of treatment is based on the histopathologic type of lymphoma and the stage of the disease. However it is indicated in patients with limited disease in whom laparotomy findings may influence selection of therapy. Splenectomy in this condition is considered for 3 reasons — to improve haematologic depression, to relieve symptomatic splenomegaly and to prevent from recurrent splenic infarctions. Almost all patients undergoing splenectomy for hypersplenism will require red cell and platelet transfusions preoperatively. In about 80% to 90% of patients significant therapeutic benefit may be achieved by splenectomy. Majority of the patients are in the 6th decade of life and males predominate in the ratio of 2 : 1. Proliferation and accumulation of abnormal lymphocytes in the lymphatic tissues result in lymphadenopathy, splenomegaly and lymphocytosis in the peripheral blood. Bone marrow examination reveals variable degree of infiltration of abnormal lymphocytes. As with non-Hodgkin’s lymphoma, splenectomy in this condition is performed for haematologic depression seccondary to hypersplenism and for palliation of symptomatic splenomegaly. Significant haematologic improvement follows splenectomy in 80 to 90% of patients, though natural course of the disease remains unchanged. Splenomegaly is the most common finding alongwith lymphadenopathy, hepatomegaly and sternal tenderness. A peculiar chromosomal abnormality called as the Philadelphia chromosome (Ph) occurs in 90% of cases. Busulfan is the mostly used chemotherapeutic agent Splenectomy has less effective result than the previous condition. It may be of benefit in selected patients during chronic stage to palliate massive splenomegaly, to relieve pain from splenic infarctions and to palliate severe thrombocytopenia and/or anaemia. Enlargement of spleen occurs due to hyperplasia which is induced by phagocytosis of disintegrated worms and toxins. This infestation also produces hepatic fibrosis which in turn causes portal hypertension and splenic enlargement. Splenomegaly from this condition may occur at any age and males are more often affected. One type of splenomegaly is often seen in Africa and New Guinea and it is difficult to find out any cause as mentioned above. Probably an abnormal immune response to malaria or some unknown species of plasmodia is the cause of this type of splenomegaly. Portal hypertension may be due to intrahepatic or extrahepatic portal obstruction. Splenomegaly with engorgement of vascular spaces leads to accelerated destruction of the circulating cells within the spleen. This hypersplenism associated with portal hypertension secondary to cirrhosis seldom requires splenectomy. Cytopenias are usually improved after shunt operation between the portal and systemic circulations presumably due to relief of congestive splenomegaly. The effectivity of splenectomy is not equal for all diseases and this is also described alongwith each disease. In nutshell the conditions in which splenectomy is beneficial is mentioned below: 1. Blood should be administered at room temperature in cases of leukaemia and malignant lymphoma. In cases of acquired haemolytic anaemia and thalassaemia grouping and cross matching may be difficult and sufficient time is required to accumulate the blood which may be required during the operation. Nasogastric tube is inserted after endotracheal intubation of decompression of the stomach to facil ita te handl ing of the short gastric veins within the gastrosplenic ligament. Left upper paramedian incision may be used with division of the outer fibres of the left rectal muscle. It is rarely necessary to use a thoracoabdominal incision even to remove a massively enlarged spleen. The surgeon puts his hand on the lateral side of the spleen and brings it medially, so that the lateral layer of the lieno-renal ligament will be made taut. This is incised and the fascia beneath it is carefully dissected, so that the splenic vessels will be under view. After this, a pack is inserted on the posterior surface of the spleen and attention is directed to the anterior surface where lies the gastro-splenic ligament. If compromise of blood supply to the fundic portion of the greater curvature of the stomach is a concern, enfolding of this area should be performed to prevent development of a gastric fistula. Usually the technique of dividing splenic ligaments and mobilisation of the spleen toward the midline prior to securing the hilar vessels is adopted in case of normal sized of slightly enlarged spleens and for ruptured spleens. But in case of massive splenomegaly initial ligation of the splenic artery and vein along the upper edge of the pancreas before splenic mobilisation is a very useful technique as it controls major portion of vascular supply to the spleen and allows safer mobilisation of the spleen and dissection of its hilar branches. The pancreatic tail is dissected off the splenic vessels, which are now seen distinctly. The artery and the vein are ligated separately, the artery being ligated first so that blood in the spleen will get a chance to be drained through the vein before ligation thus restoring the normal blood volume. Gentle handling is of utmost importance, otherwise the vessels of the spleen may be tom. Firstly the tail of the pancreas is dissected off and then the vascular pedicle is clamped and divided from below in small segments.

Therefore any haemorrhoid treatment must be preceded by sigmoidoscopy and barium enema cheap atorlip-10 10mg on line ldl cholesterol lowering foods. Associated fissure-in-ano should also be excluded and if present should be treated first generic atorlip-10 10mg fast delivery cholesterol juice recipes. Treatment of haemorrhoid should start with bowel regulation which has a prophylactive effect generic 10 mg atorlip-10 cholesterol definition chemistry, but once the haemorrhoid is established there is no evidence that the process is readily irreversible. Topical ointments for local applications may do good by reducing oedema and pruritus. During an attack of piles some relief of discomfort may be obtained by use of suppositories. Manual dilatation of the anus is frequently successful in relieving symptoms probably by preventing congestion of haemorrhoidal veins. The most commonly used sclerosant is 5% phenol in almond or arachis oil with 140 mg of menthol to make 30 ml solution (Albright solution). This solution is injected into the submucosa around the pedicle of the haemorrhoid with two objects in view. Firstly to produce a chemical thrombosis in the internal haemorrhoidal plexus and secondly to produce a fibrous reaction in the submucous layer which will fix the loose redundant mucous membrane to the inner muscle layer and draw up the pile so that it no longer prolapses or is grasped by the sphincters. Good sclerosis can often be obtained by a single injection of 5 ml into each primary haemorrhoid. If the injection is given slowly around the base of the pile above the anorectal ring very little discomfort is experienced. If subsequent injections are required the sclerosed mucosa will not usually take such a volume and 2 or 3 ml are then injected 1 cm below the initial injection site. In case of large second degree haemorrhoids 2 or 3 injections may be required at intervals of 6 weeks in order to obtain maximum fibrosis. Advantages are that (i) this method is quick, (ii) relatively painless, (iii) comparatively free from compli­ cations and (iv) in first degree haemorrhoid results in a high percentage of cure. If injection therapy is done for treatment of first and small second degree haemorrhoids, the cure rate is in the order of 95% and recurrence may take place in about 15% of cases within 3 years. The disadvantages are : (i) It is contraindicated in prolapsed piles, in arterial piles and in presence of infection, (ii) Faulty technique may lead to sloughing, which is dangerous. Rubber banding is the ideal method of treatment of treating large first degree and second degree internal haemorrhoid in absence of associated tags or external haemorrhoidal component. The upper part of the mucocutaneous line is grasped by an instrument and a small elastic band slipped over it. A recent modification uses a modified proctoscope with bands stretched over the inner drum and pushed off by advancing the outer drum of the proctoscope over it. The tissue distal to the elastic band undergoes necrosis and excess mucosa in the anal canal is removed. The lower anal mucosa is drawn up by the ensuing fibrosis, which also causes adherence of the mucosa to the underlying muscle. The advantages are that (i) the whole operation can be done without assistance and (ii) the band can be placed over larger piles. Care must be taken to insert the band so that it occludes the base of the haemorrhoid at least 1 cm above the dentate line. Should the dentate line be included in the ligating band considerable pain will result. The ligated haemorrhoid will necrose in 24 to 48 hours and slough off in about 7 days. The main disadvantage is that (i) it is associated with pain, which is more or less always experienced for the first 24 to 48 hours and sometimes pain is very severe, (ii) Secondary haemorrhage is another problem. One or two haemorrhoids may be banded at a time and three large haemorrhoids should not be banded at a time lest subsequent ulceration covers a large area resulting in stenosis. In absence of complications the patient should be reviewed 1 month later and any further haemorrhoid is banded or injected as seems most appropriate. The new form of cryotherapy involves freezing the tissues of the haemorrhoid for a sufficient time to cause necrosis. If carefully used and applied only to the upper part of the haemorrhoidal area at the anorectal junction, it achieves a similar result to elastic band but there is no pain. Cryosurgical probe using liquid nitrogen at a temperature of-160°C is used at the pedicle of the haemorrhoid for 3 minutes each. When the cryo-probe is placed on the tissue, an ice ball forms as a visible white area which will eventually slough. The procedure usually takes 10 to 15 minutes and the patient is obseved for 30 minutes before he leaves. The main disadvantage is the profuse watery discharge which starts within 3 hours of the procedure and lasts for 2 to 4 weeks. This requires wearing of surgical pads for 2 to 3 weeks and healing is complete in 4 to 6 weeks. In the advanced case when there is prolapse of haemorrhoid this technique has little efficacy. So cryosurgery and elastic band ligation are unlikely to replace surgfery, but nevertheless be valuable additions to conservative therapy. The whole of the anal canal and lower rectum are slowly and uniformly dilated with the fingers until 3 fingers of both hands are inserted. It is important to realise that the pecten bands cannot normally be felt by the fingers of one hand. To feel the pecten band the index finger of the left hand is placed well inside the anal canal and lifted upwards, while the right index finger is inserted into the rectum pressing downwards. It is important to avoid tearing so that the dilatation must be gentle and combined with a rotating movement. Although Lord suggested that this method is best reserved for patients with third degree or large second degree haemorrhoids, yet many surgeons who have adopted this procedure regard it as an ideal method for treating many anal conditions particularly fissure-in-ano. However it does not eliminate redundant tissue and there is significant incidence of incontinence particularly in the elderly with pelvic floor problems. This treatment is now a more recognised treatment of fissure-in-ano and in selected cases of early stage of haemorrhoids. Many patients are reluctant to submit to haemor­ rhoidectomy because the operation has become notorious of being associated with a great deal of postoperative pain and it also has the considerable economic disadvantage that the patient has to live in hospital for several days postoperatively and a further period away from work. A V-shaped cut is made on the skin adjacent to the primary pile, so that the base of this V is directed towards the primary pile and the apex away from the centre of the anus. A little dis­ section will now expose the subcutaneous part of the external sphincter. The haemorrhoids are now further dissected upwards so that they are now fixed by the mucosal suspensory ligament. This newly formed pedicle is now transfixed with a stout ligature (silk or catgut).

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