Learn medicine the easy way. - Part 2

Sister Mary Joseph Nodule

Main sites of metastases for some common cance...

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

Cardinal Signs of Kanavel

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.

Classification of nerve injuries

Sunderlanda Seddonb Structure injured Prognosis
First degree Neurapraxia Schwann cell (demyelination) Complete recovery within 12 wk
Second degree Axonotmesis Axon (wallerian degeneration) Complete recovery regeneration 1 mm/day
Third degree Endoneurium Incomplete recovery
Fourth degree Perineurium No recovery
Fifth degree Neurotmesis Epineurium No recovery
Sixth degree Mixed injury, neuroma, incontinuity Unpredictable recovery

Compartment Syndrome

English: This is a picture of compartment synd...

English: This is a picture of compartment syndrome of the lower leg (Photo credit: Wikipedia)

Compartment syndrome results from increased pressure within an osseofascial space, leading to decreased perfusion pressure. If it is left untreated, muscle and nerve ischemia may progress to necrosis and fibrosis, causing Volkmann ischemiccontracture.Compartment syndrome is usually seen in hand and forearm

  • Etiology. Fractures that cause bleeding, crush and vascular injuries, circumferential burns, bleeding dyscrasias, reperfusion after ischemia, or tight dressings can lead to the syndrome.
  • Diagnosis is based on a high index of suspicion, clinical examination, and symptoms of pain that are exacerbated with passive stretch of the compartment musculature, paresthesias, paralysis, or paresis of ischemic muscles. Pulselessness may occur and indicates a late finding (and is usually also a sign of irreversible damage) or the presence of major arterial occlusion rather than compartment syndrome. Measurement with a pressure monitor of a compartment pressure of greater than 30 mm Hg confirms diagnosis.
  • Treatment for incipient compartment syndrome involves close observation and frequent examinations and should include removal of tight casts and dressings. Elevation of the extremity to, or slightly above, the level of the heart is recommended. Acute or suspected compartment syndrome requires urgent fasciotomies of the involved areas. Decompression within 6 hours of established compartment pressures is necessary to prevent irreversible muscle ischemia. Forearm fasciotomies involve volar, carpal tunnel, and dorsal compartments. Hand fasciotomies include dorsal incisions for interossei and adductor pollicis, thenar, and hypothenar compartments, as well as midaxial incisions of the digits (ulnar for the index, long, and ring fingers and radial for the thumb and small finger).
Source:Washington Manual of surgery

The Reconstructive ladder of soft tissues

The reconstructive ladder of soft-tissue coverage begins with consideration of the simplest approach (healing by secondary intention) and culminates with the most complex (free tissue transfer)

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.

2.Primary Closure may provide the most aesthetically pleasing result, but excessive tension on the skin may cause displacement of neighboring structures (e.g., lower eyelid) or necrosis of the skin flaps.

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

Why do people undergoing surgery develop transient diabetes

English: Diagram shows insulin release from th...

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 VUJ calculus

X-ray KUB showing Left vesico ureteric junction calculus.

Left VUJ calculus

Left VUJ calculus

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