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In spondylolisthesis pain is usually intermittent and of dull ache nature which gets worse after exercise nexium 20mg on line. In a number of cases of spinal pathologies patients present with deformity of the spine discount nexium 40 mg on-line. In spina bifida occulta there may be a dimple or a tuft of hair or dilated vessels or fibrofatty tumour or a naevolipoma over the bony deficiency in the lumbosacral region buy discount nexium line. A typical deformity is also seen in case of spondylolisthesis in which the sacrum becomes unduly prominent with deep transverse furrows seen on both sides of the trunk between the ribs and iliac crests (See Figs generic nexium 40 mg free shipping. This is occasionally complained of alongwith pain and definitely the latter symptom predominates. Only in ankylosing spondylitis stiffness of back is a prominent symptom, though this is sometimes complained of in cases of tuberculosis of the spine. Enquiry must be made if there is any complaint of the abdomen or gynaecological problem or genitourinary problem or vascular disorders. Even prolapsed intervertebral disc has been seen to involve more than one member in a family. In case of secondary carcinoma of the spine, patients often give history of quick loss of weight in near past. In ankylosing spondylitis malaise, fatigue and loss of weight are often complained of. Fever or rise of temperature is mainly come across in inflammatory conditions of the spine. Starting from above note :— (i) Position of the head, whether bent or twisted to one side; (ii) the level of the shoulders; (iii) the position of the scapulae, whether one is elevated or displaced forward, backward, laterally or medially; (iv) the lateral margins of the body from axilla to the crest of the ilium — whether the affected side is flatter or more curved than the other; (v) the relative prominence of the iliac crest, e. It should be remembered that the bodies of the vertebrae are rotated towards the convexity of the curve and the spinous processes are rotated towards the concavity. Differentiation should immediately be made between mobile scoliosis (transient) and fixed scoliosis (structural). In case of scoliosis if the patient is asked to lean forward, postural scoliosis will Fig. In I 1 scoliosis, the chest diagonally opposite to posterior convexity I " is more prominent. In advanced kyphosis, the sternum also A becomes convex anteriorly to compensate for the diminished ^ ^ v „ vertebral measurement of the thorax. In caries of the spine the patient walks with short step and often on the toes to avoid jerking on the spine. In case of to rotate the vertebra by pressing on the sacro-iliac arthritis the Fig. This will elicit patient may limp and either side of the spine to elicit tender­ tenderness in pathologies of the spinal if this condition is ness. In spina bifida occulta, there may be a swelling, a tuft of hair, dilated vessels, a fibrofatty tumour or even a dimple to show the point of attach­ ment of membrana reuniens to the skin. Congenital sacrococcygeal teratoma is occasionally seen in the sacrococcygeal region. Tenderness may be elici­ ted by press­ ing upon the side of the spinous pro­ cess in an attempt to rotate the vertebra (Fig. Tenderness can also be elicited by percussing on the spinous processes with a finger (See Fig. In such cases pinch up the skin to differentiate whether the pain is in the skin or in the spine. This is to perform the anvil test always to elicit tenderness being determined by eliciting cross fluctuation. In this test sudden jerk is applied over the head or the patient is asked to jump down from a chair. In case children the meningocele may be pressed with one hand keeP* 8n other hand on the anterior fontanelle to feel for the 3. Extension is free in the lumbar and lumbo- while the meningocele is being dorsal regions. Nodding movement of the head takes place at the atlanto-occipital joint whereas rotation of the head occurs mainly at the atlanto-axial joint. Movements of the cervical spine should be examined with great caution as sudden death may occur from dislocation of the atlanto-axial joint. Mobility of the costovertebral joints is judged from the range of chest expansion. The normal difference of the chest girth between full expiration and full inspiration is about 2Vi inches. In the early stage it is due to reflex muscular spasm — a natural attempt to immobilize the painful part. Presence of rigidity is determined by testing the different movements of the spine as follows: (i) Flexion. The clinician the dorso-lumbar region is picking up places his hands over the spine to note the movements of a coin from the floor by bending the the spinous processes. It may be possible to touch the toes by excessive flexion of the hips while the spine remains stiff. When the spine is rigid the child will stoop bending his knees and hips keeping the spine straight. While raising the body he puts his hands successively on the legs, knees and thighs as if he is climbing up his own legs. This movement mainly occurs in the lumbar region and will not be affected until this region of the spine is involved (Fig. The clinician lifts up his legs in an attempt to bend the lumbar spine whilst the other hand fixes the dorsal spine. If the lumbar spine is affected it cannot be bent but will be lifted as one piece (Fig:19. The other hand of the clinician is placed on the thoracic spine to detect the movement of the spine (Fig. He should continue ^ to raise the leg till he experiences pain as r evidenced by watching his face. To be sure the test is repeated and as the angle j is approached additional cate is exercised to ^ note when the pain started. In a child this is possible to the extent of 30° to If the pain is evoked at an angle above 40° it 40° from the median line. At the angle when the patient experiences first twinge of pain, the ankle is passively dorsiflexed (Fig. It suggests irritation of one or more nerve roots either by disc protrusion or from some other space occupying lesion. Note that the pelvis is being steadied sciatica from diseases of the by the clinician. This indicate that probably the protruding disc is L2-3 which is irritating the femoral nerve. The patient is asked to lie on his abdo­ men and flex the knee of the affected side. This is important to differentiate the sacro-iliac lesion protrusion of cervical intervertebral disc or an from sciatica. Now the head of the patient is bent down passively (flexing the cervical spine) and simultaneously the lower limbs are lifted (flexing the hip joints) keeping the knees straight. Neck and hip are simultaneously position of the sacro-iliac joint is flexed keeping the knees in full extension. Sharp pain is experienced determined by presence of a dimple down the spine into the upper or lower extremity due to irritation situated just medial to the posterior of the spinal dura either by tumour or by protruded intervertebral superior iliac spine. In standing position the patient is asked to point out the site of pain and the direction in which it radiates. In recumbent position it should be noted whether the hip and knee joints are slightly flexed or not. A search \ --------- for presence of a cold abscess should be made over the (_------ ca ) buttock, iliac fossa and pelvis (by rectal examination). This will exert a rotational strain on the sacro-iliac joint and will cause sharp pain. A sharp pain is felt by the patient when the concerned sacro-iliac joint is diseased. The patient is steadied on the table by grasping the shoulder of the side to be tested. The knee and hip of that side are flexed and brought up towards the shoulder of the opposite side.

Hypothalamic disturbance with increased sition of copper within the liver due to defciency in its car- appetite order nexium 20mg amex, with development of diabetes mellitus and diabetes rier ceruloplasmin) buy cheapest nexium. Moreover order nexium online, two important ocular manifestations are observed in postencephalitis Parkinsonism that are not usu- ally seen in Parkinson’s disease: oculogyric crises and blepha- rospasm cheap 20mg nexium free shipping. Oculogyric crises are attacks of involuntary conjugate upward deviation of the eyeballs, whereas blepha- rospasm is a period in which the eyes go nearly or completely shut, causing the patient to be virtually blind during this episode. Te disease is rare with an incidence of <1 per million in the general popu- lation. Te stif-man syndrome can be seen in cases of syringomyelia, tetanus, dia- betes mellitus type 1, and Hashimoto’s thyroiditis. Biochemistry of Parkinson’s disease 28 years 5 T2W hypointense areas in the putamen and the later: a critical review. Te disease is caused by deposition of A amy- common cognitive brain function lost in dementia. Memory loss can interfere with responsible for language and memory functions, whereas the the daily activities such as following job instructions or driv- frontal lobe is responsible for strategic planning, logic, plan- ing. In later stages, loss of judgment and reason ofen devel- ning, and social judgment. Delusions are common in the later stages of the disease, T e hippocampus is a critical structure for long-term with 10% of patients likely to develop Capgras syndrome. Emotions have a powerful infuence on Capgras syndrome is a form of delusion where the patient learning and memory, and they are controlled by the limbic believes that a person has been replaced by one or more system. Te delusion is specifc to one person, usually the Te limbic system is a complex brain network that con- patient’s closest relative. It was frst described by James Papez in 1937 (Papez circuit) and later was completed by Yakovlev in 1948 (Yakovlev circuit). Te limbic system is generally composed of fve main structures: 5 Limbic cortex includes the cingulated gyrus and the parahippocampal gyrus. Two types of strokes are ofen linked to VaD: watershed neurodegenerative diseases that include three syndromes: infarctions and strategic infarctions. Bilateral watershed visuospatial and visuoconstructive skills important for draw- infarctions are typically caused by severe brain hypovolemia. Tese new enhanced artistic skills Strategic infarctions occur in areas important for normal are believed to be attributed to loss of inhibitory activity over cognitive function of the brain. Examples of strategic infarc- the posterior parietotemporal regions involved in visuospa- tions include: tial and visuoconstructive processes. Pathologically, the disease is characterized by deposition of Lewy bodies in the hippocampus and subcortical nuclei. When 5 A characteristic pontine hyperintensity in a cross atrophy afects the autonomic nervous system mainly, the pattern referred to as hot cross bun sign may be disease is called Shy–Drager syndrome. Patient usually presents between 40 and 60 years of age with a history of chronic hypertension and multiple stroke episodes. Lack of interest and alteration in mood and personality with loss of appetite for social conducts are among the psychiatric symptoms of the disease. They Virchow–Robin space dilatation surrounding the are typically seen in the basal ganglia, parallel to the perforating arteries (état criblé). Prion diseases can be found in both animals and human Kuru is a disease confned to the Fore linguistic group, a beings. Kuru is a prion disease linked to wasting disease in deer and elks, scrapie in sheep and goats, ritual tribal cannibalism. Other neurological features include cerebellar ataxia, pyramidal and extrapyramidal signs, and cortical blindness. This sign can be observed in other diseases like carbon monoxide poisoning, hypoglycemia, hemolytic uremic syndrome, and Wilson’s disease. Te case of lost Wilma: a clinical report of dancing-like movement of the distal limbs (Huntington’s 2 Capgras delusion. Te value of T1-weighted images in the is high, especially in the early stage of the disease. Report on the frst Chinese family with Gerstmann-Sträussler-Scheinker disease manifesting the codon 102 mutation in the prion protein gene. Classically, the patient pres- is characterized clinically by involuntary and uncoordinated ents with cerebellar atrophy symptoms weeks to months afer movements, frequent falls, dysarthria, and multiple weak- the initial heat stroke attack. Tere is female gender predominance and mean age marked degeneration of Purkinje cells with pyknotic nuclei, of 11. Interestingly, patients with previous history of SyC develop psychiatric manifestations later in life, such as obses- sive–compulsive disorder, major depressive disorders, or attention defcits. Follow-up scans after weeks or months may show bilateral Further Reading cerebellar atrophy with dilatation of the Angelini L, et al. Tourettism as clinical presentation of cerebellopontine angle cisterns and the fourth Huntington’s disease with onset in childhood. Clinical, laboratory, psychiatric and mag- 5 There is an absence of increased intracranial netic resonance fndings in patients with Sydenham cho- pressure signs. Computed tomography in Huntington’s the cerebellum hemispheres may be seen disease. Heat stroke is a medical emergency characterized by a core body temperature >40 °C or more, hot dry skin, and neuro- logical disturbance. Heat stroke may be environmental due to prolonged Further Reading exposure to sun heat with hydration, endogenous as in run- Becker T, et al. Cerebellar gait ataxia following neuroleptic characterized clinically by hyperpyrexia, muscular rigidity, malignant syndrome. T e most dramatic efect of heat stroke is observed in the central nervous system, especially the cerebellum. Downbeat nystagmus, which is defned as a primary position nystagmus with rapid downward phase Aphasia is a term used to describe the inability to use lan- and slow upward drif, may be seen with heat stroke cerebel- guage. Broca’s area (area 45) 118 Chapter 2 · Neurology occupies the opercular and triangular parts of the inferior muscles, causing diferent voice resonance. In contrast, Wernicke’s area (areas 21 and 42) moves during mandibular depression. Vocal cords: the vocal cords vibrate rapidly moving 18, and 19) receives visual information during reading inward and outward during phonation, converting the (word shapes) and projects them to diferent brain steady fow of air fowing from the lungs through the regions specialized with language processing. When vocal cords close, their vibration results lef) receives inputs from the occipital, temporal, and in voiced sounds; when they open, this vibration stops, parietal lobes, and it associates words with the their and unvoiced sounds result. Wernicke’s area: Wernicke’s area (Brodmann’s areas 21 outward fow of air from the lungs usually provides the and 42) is the auditory association area responsible for power of speech production. Wernicke’s area is a region that involves part of the supramarginal gyrus, the angular gyrus, the bases of the middle gyrus, the Aphasia Pathophysiology and Subtypes posterior part of the superior temporal gyrus, and the planum temporale. Te planum temporale is the Language production is a very complex mechanism that can superior aspect of the temporal lobe, and it lies in the be oversimplifed by the following models: visual informa- depth of the Sylvian fssure. Arcuate fasciculus (Wernicke’s arc): arcuate fasciculus is 19) and processed in various ways, and then the information an axonal band that transfers information from are projected via the dominant angular gyrus, which associ- Wernicke’s area (temporal lobe) to Broca’s area (frontal ates words with the object and its attributes; the words are lobe). Te arcuate fasciculus lies within the superior then transferred to Wernicke’s area, which assemble them longitudinal fasciculus in the dominant hemisphere into sentences; Wernicke’s area then activates the appropriate (usually the lef). Activation of the word’s motor pro- the opercular and triangular parts of the lef inferior gram in Broca’s area activates the motor cortex (precentral frontal gyrus, and it is the “primary language area” gyrus, area 4). Aphasia can result in disturbance of this neu- responsible for words motor articulation planning. Broca’s aphasia results in defect in the motor activation of gyrus, Brodmann’s area 4) receives inputs from Broca’s words. Te patient tries to produce words, but he is unable area regarding spoken sentences to be produced, and it to or produces few written or spoken words. However, is responsible for motor articulation of spoken words/ they may speak or write in a telegraphic way (only the sentences. Lips: the lip is important for the fnal sound aphasia deprives the motor cortex from the instruction manipulation. Tongue: tongue movement against the hard palate detected when the clinical picture shows expressive apha- causes the production of the majority of phonemes in sia with a brain lesion that afects the opercular and trian- English. Wernicke’s aphasia results from the inability to assemble velum closes the gap between it and the nasopharynx sentences. Patients with Wernicke’s aphasia are able to (nasopharyngeal opening) during speech by the action produce spoken or written words, but the words or their of the levator veli palatini muscle. Mandible: the mandible movement assists in tongue content (sometimes called cocktail hour speech). Te mandibular elevators are temporalis, patient may substitute one letter or a word for another masseter, and medial pterygoid muscles, and the (paraphasia), insert new meaningless words (neologism ), mandibular depressors are digastric, mylohyoid, or string words together in order to convey little or no geniohyoid, and lateral pterygoid muscles.

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Central cord syndrome occurs in the elderly with forced hyperextension of the neck discount nexium 40mg on line, such as a rear-end collision discount nexium 20 mg fast delivery. There is paralysis and burning pain in the upper extremities cheap nexium express, with preservation of most functions in the lower extremities discount nexium 20mg with visa. There is some evidence that high-dose corticosteroids immediately after the injury may help, but that concept is still controversial. X-ray of Multiple Rib Fractures due to Trauma Copyright 2007 Shout Pictures - Custom Medical Stock Photo. Mechanisms include penetrating injury, rib fracture with puncture of lung, and secondary iatrogenic causes (e. There is typically moderate shortness of breath with absence of unilateral breath sounds and hyperresonance to percussion. Diagnosis is confirmed with chest x-ray, and management consists of chest tube placement. Hemothorax occurs when blunt or penetrating injury results in bleeding into the chest cavity. The blood can originate directly from the lung parenchyma or from the chest wall, such as an intercostal artery. Physical examination reveals decreased breath sounds on the affected side, accompanied by dullness to percussion. Chest tube placement is necessary to enable evacuation of the accumulated blood to prevent late development of a fibrothorax or empyema, but surgery to stop the bleeding is sometimes required. If the lung is the source of bleeding, it usually stops spontaneously as it is a low pressure system. In some cases where a systemic vessel such as an intercostal artery is the source of bleeding, thoracotomy is needed to stop the hemorrhage. Indications for thoracotomy include: Evacuation of >1,500 mL when the chest tube is inserted Collecting drainage of >1 L of blood over 4 hours, i. If there is a flap that sucks air with inspiration and closes during expiration it could lead to a tension pneumothorax. A sucking chest wound can also arise from an open pneumothorax, where a larger open wound leads to the inability to exchange air on the side of the injury. Initial management is with a partially occlusive dressing secured on 3 sides, with one open side acting as a one-way valve. This allows air to escape but not to enter the pleural cavity (to prevent iatrogenic tension pneumothorax). This allows a segment of the chest wall to retract during inspiration and bulge out during expiration (so-called, “paradoxical breathing”). A contused lung is very sensitive to fluid overload, thus treatment includes fluid restriction and aggressive pain management. Pulmonary dysfunction may develop, thus serial chest x-rays and arterial blood gases have to be monitored. Pulmonary contusion may be detected immediately after chest trauma with “white-out” of the affected lung(s) or can be delayed up to 48 hours. Although serum troponin level was historically obtained, elevations do not generally change management and are therefore not indicated, and treatment is focused on the complications of the injury such as arrhythmias. Traumatic rupture of the diaphragm shows up with the bowel in the chest (by physical exam and x-rays), almost always on the left side (the liver protects the right hemidiaphragm). If diaphragmatic injury is suspected it should be evaluated with laparoscopy, although gas insufflation of the peritoneum may complicate anesthetic care. Such an injury can occur in the setting of a significant deceleration injury and may be totally asymptomatic until the hematoma contained by the adventitia ruptures resulting in rapid death. Surgical repair is indicated once the patient has been stabilized and more immediate live-threatening injuries have been managed. Traumatic rupture of the trachea or major bronchus is suggested by the presence of subcutaneous emphysema in the upper chest and lower neck, or by a large “air leak” from a chest tube. Differential diagnosis of subcutaneous emphysema also includes rupture of the esophagus and tension pneumothorax. It should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator. It also can occur in a spontaneously breathing patient if the subclavian vein is opened to the air (e. Immediate management includes cardiac massage, with the patient positioned in Trendelenburg with the left side down to “trap” air in the atria until it can be absorbed or aspirated. Prevention of air embolism includes use of the Trendelenburg position when the great veins at the base of the neck are to be accessed. Fat embolism may also produce respiratory distress in a trauma patient who is without direct chest trauma. The typical setting is the following: Patient with multiple traumatic injuries (including several long bone fractures) develops petechial rashes in the axillae and neck; fever, tachycardia, and low platelet count At some point patient develops a full-blown picture of respiratory distress, with hypoxemia and bilateral patchy infiltrates on chest x-ray The mainstay of therapy for fat embolism is respiratory support. Other therapies for this syndrome including heparin, steroids, alcohol, or low-molecular-weight dextran have been discredited. Penetrating trauma is further differentiated into gunshot wounds and stab wounds as the pattern of injury based on mechanism is quite different. Gunshot wounds to the abdomen require exploratory laparotomy for evaluation and possible repair of intra-abdominal injuries, not to “remove the bullet. However, the presence of protruding viscera or the development of peritoneal signs/evidence of ongoing bleeding requires exploratory laparotomy. If the fascia is not violated, the intra-abdominal cavity likely has not been penetrated and no further intervention is necessary. If the fascia has been violated, surgical exploration is indicated to evaluate for bowel or vascular injury, even in the setting of hemodynamic stability and lack of peritoneal findings on physical examination. Blunt trauma to the abdomen with obvious signs of peritonitis or suspected intra-abdominal hemorrhage requires emergent surgical evaluation via exploratory laparotomy. Signs of internal injury include abdominal distention and significant abdominal pain with guarding or rigidity on physical examination consistent with peritonitis. The occurrence of blunt trauma even without obvious signs of internal injury requires further evaluation because internal hemorrhage or bowel injury can be slow and therefore present in a delayed fashion. Patients tend to be cold, pale, anxious, shivering, thirsty, and perspiring profusely. These signs of shock occur when 25–30% of blood volume is acutely lost, ~1,500 ml in the average-size adult. There are few places in the body that this volume of blood can be lost without being obvious on physical or radiographic exam. The pleural cavities could easily accommodate several liters of blood, with relatively few local symptoms, but such a large hemothorax would be obvious on chest x-ray, which is routinely obtained as part of the primary survey in a trauma patient. This volume of bleeding could also occur with a pelvic fracture and > 1 liter of blood can be lost with a mid-shaft femur fracture. That leaves the abdomen, retroperitoneum, thighs (secondary to a femur fracture), and pelvis as the only places where a volume of blood significant enough to cause shock could “hide” in a blunt trauma patient that has become unstable. The femurs and pelvis are always checked for fractures in the initial survey of the trauma patient by physical exam and pelvic x-ray. So any patient who is hemodynamically unstable with normal chest and pelvic x-rays likely has intra-abdominal bleeding. Ultrasound is an important, readily available, adjunct to identify intra-abdominal and pericardial fluid. Fluid is not typically present in these locations, so if there is a clinical suspicion such as hypotension following blunt trauma, consider an internal injury. A stable patient in whom the diagnosis is less definite should undergo a more definitive study, i. Additionally, grading scores exist for the extent of solid organ injury, with specific guidelines as to when a surgical intervention is indicated versus observation. Generally speaking, a patient with intra-abdominal bleeding injury from the liver or spleen can be observed as long as they are hemodynamically stable or respond to fluid and blood product administration; the moment instability is mentioned in a vignette, surgical exploration is indicated. If surgical exploration is indicated for penetrating or blunt trauma, certain principles must be employed. Prolonged surgical time and ongoing bleeding can lead to the “triad of death”: hypothermia, coagulopathy, and acidosis. The longer a patient is open, the worse these components get, and they can interact in a vicious cycle ultimately leading to death. Accordingly, the “damage control” approach has been adopted: that is, immediate life-threatening injuries are addressed, less urgent injuries are temporized or left to be addressed at a later time point.

This is a completely passive drain buy cheap nexium on line, and fluid exits around the drain by capillary Drains permit purulent material purchase nexium 40mg, blood 20 mg nexium otc, serum order nexium 40mg fast delivery, lymph, bile, action and gravity. Ideally, the drain is placed to create a pancreatic juice, and intestinal contents to escape from the dependent tract through which fluid escape may be aided by body. If the surgeon does not take pains to bring the drain source of infection or fluid buildup to the outside. This pas- out in a straight line, without wrinkles, stagnant pools of sageway, or tract, must persist for a period long enough to serum accumulate around the wrinkled areas of the drain. More fundamen- In the presence of a discrete abscess, the need for and tally, the passive latex drain does not empty a cavity; it sim- purpose of a drain is obvious and not controversial, as its ply permits secretions to overflow from the abdomen to the therapeutic benefits are clear. It is not particularly effective in evacuating oozing drain acts as a prophylactic instrument to prevent accumula- blood before a clot forms. Because it is a foreign body, the depth of the wound can be irrigated with this type of drain as drain also has the paradoxical effect of potentiating infec- there is when a tube or sump type is used. When and how a drain should be used for prophylactic Finally, the most important objection to the latex drain purposes has long been a source of controversy. Controlled arises from the fact that it requires a 1- to 2-cm stab wound trials have significantly decreased the indications for “pro- in the abdominal wall, which permits retrograde passage of phylactic” drainage; some are cited in the references at the pathogenic bacteria down into the drain tract. Penrose drains are also used for retraction, for example, Various Drains and Their Pros and Cons when the esophagus is retracted during hiatal hernia repair. Latex (Penrose) Drain Polyethylene or Rubber Tube Drain The Penrose drain is a soft latex drain of various dimensions. It has the shape of a flattened cylinder and is made of a thin, These are also passive drains, but are tubular and more rigid radiopaque sheet of rubber. It is also successful in encouraging fibrosis, so drains establish tracts to the outside, as they are mildly irri- it forms a well-established tract within 8–10 days. Patient mobility is unimpaired, as the able for placement deep in the abdominal cavity for a period plastic container is easily attached to the patient’s attire. The of more than a few days, as there is considerable danger of depths of the wound can be irrigated with an antibiotic solu- erosion through an adjacent segment of intestine, resulting in tion by disconnecting the catheter from the suction device an intestinal fistula. These drains are, therefore, primarily and instilling the medication with a sterile syringe. In time, tissues are sucked into the fenestrations, and tissue Silicone or Silastic tubes are less reactive than are other ingrowth may even occur. They are less prone to become plugged as a (occasionally to the point of requiring relaparotomy), and result of clotting serum. Because of the soft texture of sili- most surgeons are reluctant to leave a fenestrated closed suc- cone, erosion into the intestine is uncommon. Fluted A disadvantage of silicone drains is their lack of reactiv- (channel-type) suction drains are also available and avoid ity; hence, there is minimal fibrous tract formation. When a gauze pack is inserted into an abscess cavity and is brought to the outside, the gauze, in effect, serves as a drain. Sump Suction Drains Unless the packing is changed frequently, this system has the disadvantage of potentiating sepsis by providing a foreign body Generally constructed of silicone or polyethylene tubing, that protects bacteria from phagocytosis. Management of pan- sump drains must be attached to a source of continuous suc- creatic abscesses by marsupialization and packing is an example tion. The sump allows (generally filtered) room air to enter as suction is applied, much as a sump naso- Prevention of Drainage Tract Infection gastric tube continuously aspirates air. This air intake channel can also be used for instillation of an antibiotic solution when Retrograde transit of bacteria from the patient’s skin down into indicated. If used regularly, fluid instillation prevents obstruc- the drainage tract is a source of postoperative sepsis and may tion of the drain due to coagulation of serum or secretions. When a polyethylene sump or a Drainage tract infections with sumps are uncommon even silicone closed suction catheter is brought through a puncture though unsterile, bacteria-laden air is drawn into the depths of wound of the skin, it is easy to suture it in place and minimize the patient’s wound by the continuous suction. A major disad- or eliminate the to-and-fro motion that encourages bacteria to vantage of sump drains is the requirement that the patient be migrate down the drain tract. On the other hand, when a latex attached permanently to a suction device, thereby impairing drain is brought out through a 1- to 2-cm stab wound in the mobility. These drains are predominately used for very diffi- abdominal wall, there is no possibility of eliminating the to- cult abscesses, such as those associated with peripancreatic and-fro motion of the drain or retrograde passage of bacteria sepsis, where other drains tend to stop working. Consequently, when latex or gauze drains are required for an established abscess, the surgeon must accept the added risk of retrograde contamination with Closed Suction Drain bacteria despite sterile technique when dressings are changed. The closed suction drain consists of one or two multiperfo- Management of Intraperitoneal Sepsis rated silicone or polyethylene catheters attached to a sterile plastic container, the source of continuous suction. It is a When managing intraperitoneal sepsis, a distinction must be closed system; and the catheters are brought out through made between an isolated abscess (e. These drains have replaced other drains dix) and multiple abscesses involving the intestines 10 Rational Use of Drains 71 accompanied by generalized peritonitis. With the latter type Blood and Serum of sepsis, the presence of fibrin and necrotic tissue prevents adequate phagocytosis and perpetuates sepsis. The presence of blood, serum, or fibrin in a perfectly sterile When an abscess has developed rigid walls that do not area is not dangerous to the patient, although the operative collapse after evacuation of pus , large drains must be field is never completely sterile following any major opera- inserted to establish a reliable tract to the outside. For this reason, postoperative puddles of blood or serum Sometimes a rigid abscess cavity requires 2–5 weeks to in combination with even a small number of bacteria can fill with granulation tissue. It is not safe to remove the result in abscess formation because the red blood cell impairs drains until injecting the abscess with an aqueous iodin- antibacterial defenses. With the low colorectal anastomosis, ated contrast medium has produced a radiograph demon- accumulated serum or blood in the presacral space, together strating that the cavity is no longer significantly larger in with secondary infection and abscess formation, may result diameter than the drainage tract. For rigid-walled abscesses of efforts should be exerted to eliminate bleeding during any this type, several large latex drains should be inserted abdominal operation. Some surgeons by some type of drainage, the ideal method is to insert one or place an additional straight 10F catheter for intermittent two multiperforated Silastic drains, which are brought out instillation of dilute antibiotic solution. At least one drain through puncture wounds in the abdominal wall and attached is left in place until the sinogram shows that the abscess to a closed suction system. Care should be taken Closed suction drainage is extremely effective following that none of the rigid drains comes into contact with the radical mastectomy or regional lymph node dissections of intestine or stomach, as intestinal fistulas can be a serious the neck, axilla, or groin. This technique has also been employed successfully following abdominoperineal proctectomy with primary clo- sure of the perineal floor and skin. Percutaneous Drainage of Abdominal Abscesses with Computed Tomography or Ultrasound Guidance Bile Treatment of abdominal abscesses underwent a revolution- Because bile has an extremely low surface tension, it tends to ary change during the 1990s owing to the demonstrated effi- leak through tiny defects in anastomoses or through needle cacy of percutaneous drainage by the interventional holes. A sump drain or closed suction system skilled radiologist can find a safe route along which to insert works well for this purpose. Silastic tubes are contraindi- a drainage catheter that evacuates the pus without a need to cated whenever formation of a fibrous tract to the outside for perform laparotomy for drainage. This technology is espe- the bile is desirable, especially with use of a T-tube in the cially welcome in the critically ill patient who may not toler- common bile duct, as previously noted. Pancreatic Secretions Other Indications and Methods of Drainage It is not dangerous for pure pancreatic juice to drain into the Abscess abdominal cavity, as is evident in patients who have pancre- atic ascites or a fistula. If the pancreatic secretion is activated For abscesses of the extremities, trunk, or perirectal area, by the presence of bile, duodenal contents, or pus, however, the important step is to unroof the abscess by making a cru- trypsinogen is converted to trypsin and the adjacent tissues ciate incision so the tract does not close before all the pus are subjected to a raging inflammatory reaction. An unroofing procedure is adequate constructed adjacent anastomoses may be digested and for superficial abscesses, and any type of temporary drain destroyed. The packing atic secretions completely, especially after pancreaticoduo- is then changed often enough to keep it from blocking the denectomy. Chassin catheter is brought through the segment of jejunum to which from drainage. Unless the tube If complete hemostasis cannot be achieved in the vicinity is accidentally displaced, it conveys all pancreatic secretions of an anastomosis, there may be some merit to inserting a from the abdominal cavity. In addition, a suction catheter is silicone closed suction drain for a few days to prevent pool- inserted in the vicinity of the anastomosis, between the tail of ing of blood next to the anastomosis, provided the drain does the pancreas and the jejunum. Adverse reac- nal anastomosis simply because the surgeon has some doubt tions following T-tube removal. Risk-benefit assessment of closed intra-abdominal presence of a drain may not prevent generalized peritonitis. Langenbecks failure, the anastomosis should be taken apart and done over, Arch Surg. A prospective, con- trap of fuzzy thinking, which would permit acceptance of an trolled study of prophylactic drainage after colonic anastomoses. Practical experience of a no abdominal drainage policy in patients undergoing liver resection.

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