Main sites of metastases for some common cancer types. Primary cancers are denoted by “…cancer” and their main metastasis sites are denoted by “…metastases”. List of included entries and references is found on main image page in Commons: (Photo credit: Wikipedia)

Sister Mary Joseph Dempsey (born Julia Dempsey; 1856-1939) was the surgical assistant of William J. Mayo at St. Mary’s Hospital in Rochester, Minnesota,USA from 1890 to 1915. She drew Mayo’s attention to the phenomenon, and he published an article about it in 1928. The eponymous term Sister Mary Joseph nodule was coined in 1949 by Hamilton Bailey.

What is Sister Mary Joseph Nodule?

Sister Mary Joseph nodule or node, also called Sister Mary Joseph sign, refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.

Etiology

1.Gastrointestinal malignancies account for about half of underlying sources (most commonly gastric cancer, colonic cancer or pancreatic cancer, mostly of the tail and body of the pancreas)

2.Gynecological cancers account for about 1 in 4 cases (primarily ovarian cancer and also uterine cancer).

3.Unknown primary tumors and rarely, urinary or respiratory tract malignancies cause umbilical metastases.

Mechanism of spread

Proposed mechanisms for the spread of cancer cells to the umbilicus include direct transperitoneal spread, via the lymphatics which run alongside the obliterated umbilical vein, hematogenous spread, or via remnant structures such as the falciform ligament, median umbilical ligament, or a remnant of the vitelline duct.

Importance of the finding

Sister Joseph nodule is associated with multiple peritoneal metastases and a poor prognosis.So once you find a Sister Mary Joseph nodule in a patient you can brace for a bad outcome.
Source:Medcosmos surgery

Seen in suppurative tenosynovitis,which involves infection of the flexor tendon sheath, which is usually caused by a puncture wound to the volar aspect of the digit or palm.

Diagnosed by:Cardinal Signs of Kanavel

• Finger held in flexion.
• Fusiform swelling of the finger.
• Tenderness along the tendon sheath.
• Pain on passive extension.

1.Healing by secondary intention is the simplest approach but is not always feasible. Absolute contraindications include exposed vessels, nerves, tendons, viscera, or bone. Relative contraindications include a large or poorly vascularized wound with a prolonged (>3 weeks) anticipated period of healing and undesirable aesthetic consequences.

3.Skin grafting is the most common method of large-wound closure. Skin grafts require a healthy, uninfected bed, protected from shear forces, to survive. Wound surfaces such as bare tendon, dessicated bone or cartilage, or infected tissue beds will not support skin graft survival. In addition, exposed vessels, nerves, or viscera are relative contraindications for skin grafting.

4.Local tissue transfers of skin, fascia, and muscle may be used in regions with healthy adjacent tissue. If the adjacent tissue cannot be adequately mobilized or the wound requires more bulk than is locally available, the sole use of local flaps may not be adequate.

5.Distant tissue transfers were the mainstay of difficult wound closure until the advent of free tissue transfer in the 1970s. This involves transferring healthy tissue into the wound bed while leaving it attached to its native blood supply. The pedicle is divided in a subsequent procedure. Inherent disadvantages of this technique include multiple operations, prolonged wound healing, immobilization for at least 3 weeks, and a limited choice of donor sites.

6.Free tissue transfer is the most technically demanding approach to wound closure but has several potential advantages, including single-stage wound closure, a relatively wide variety of flaps to ensure closure specifically tailored to coverage needs, and, in many cases, an aesthetically pleasing outcome.

7.Vacuum-assisted closure has altered wound management by decreasing bacterial load and accelerating granulation. Wounds may be treated adequately with vacuum-assisted closure that would not traditionally be candidates for healing by secondary intention. Furthermore, it may convert a wound that would otherwise need adjacent or free tissue transfer into a wound that needs only split-thickness skin grafting.

Source:Washington manual of Surgery

English: Diagram shows insulin release from the Pancreas and how this lowers blood sugar leves. (Photo credit: Wikipedia)

During our training period in surgical wards in the medical college, we encounter a lot of accident cases, non healing ulcers, necrotizing fascitis etc. Most of these people have one thing in common, increased blood sugar levels. One thing to note is that,these people were having completely normal or near normal values before they met with an accident or developed the disease.Naturally the question which springs up in our mind is:why does this happen?

Why do blood sugar values rise in injuries and infections?

In severe injury(including surgeries) and infections,plasma insulin concentrations initially fall as a result of sympathetic inhibition of pancreatic beta cells,but may rise to supra physiological levels after several days.A state of insulin resistance may persist for several weeks.There is increased breakdown of glycogen,lipid and muscle protein yielding amino acid precursors for glucose production.This increased hepatic glucose production cannot be inhibited by administering glucose or with physiological insulin concentrations.When combined with impaired insulin mediated glucose storage in skeletal muscle due to insulin resistance, this leads to a tendency to marked hyperglycemia and diabetes like state.

X-ray KUB showing Left vesico ureteric junction calculus.

Left VUJ calculus