Spontaneous fistula closure

Q) Adverse factor for spontaneous fistula closure:

a) Tract <1cm

b)Transferrin > 200

c) Location in esophagus

d) First surgery done in the same institution

Answer free

a) Tract less than 1 cm

Spontaneous fistula closure

Short-turnover  protein (prealbumin,  retinol-binding  protein,  transferrin)  levels should  be  measured  at  least  weekly  to  assess  the  adequacy of  protein  delivery. An  ongoing  catabolic  state  will adversely  affect  short-turnover  protein  levels,  even  with maximal  protein  delivery.

Failure  of  an  enterocutaneous  fistula  to  close  spontaneously  is associated with acronym FRIENDS): 

the  presence  of  a foreign  body  within  the  tract  or  adjacent  to  it,  previous radiation  exposure  of  the  site,  ongoing  inflammation (most  commonly  from  Crohn  disease)  or  infection  that contributes  to  a  catabolic  state,  epithelialization  of  the fistula  tract  (particularly  if  the  fistula  tract  is  less  than 2  cm  long),  neoplasm,  distal  intestinal  obstruction,  and  pharmacologic  doses  of  steroids. 

Fistulas  associated  with  a concurrent  pancreatic  fistula  also  have  a  low  rate  of  spontaneous  closure,  as  do  those  occurring  in  the  presence  of  malnutrition  or  adjacent  infection.

In general,  anatomic  locations  that  are  favorable  for  closure  are  the  oropharynx,  esophagus,  duodenal  stump,  pancreas,  biliary  tree,  and  jejunum.

Ventricular Septal defect

Q. Which of the following statements about VSDs is wrong ?

A. Spontaneous closure occurs in 25-50%  of patients during  childhood.
B. Tachypnea and failure to thrive are symptoms frequently associated with  large VSDs.
C. Patients with normal pulmonary vascular resistance and left-to-right  shunting across the VSD have Eisenmenger’s complex.
D. Patients with a large VSD and low pulmonary vascular resistance can  present with a mid diastolic murmur at the apex.

Answer for premium 

Investigations in lower GI Bleed

Q Least useful investigation in a pt with recurrent LGI bleed, multiple upper and lower GI endoscopies negative

a) BMFT

b) Double balloon enteroscopy

c) Capsule endoscopy

d) Push endoscopy

Answer

Free for all

A

Investigations in lower GI bleed should be specific and less time consuming

Small bowel enteroclysis, which uses a tube to infuse barium, methylcellulose, and air directly into the small bowel, yields better images than simple small bowel follow-through. Because the yield has been reported to be very low and the test is poorly tolerated, it is now rarely used.

Capsule endoscopy uses a small capsule with a video camera. capsule endoscopy is an excellent tool for the patient who is hemodynamically stable but continues to bleed, with reported  success  rates  as  high  as  90%  in  identifying  a  small bowel  pathology.

The hemodynamically stable patient should undergo small bowel enteroscopy. Usually performed with a pediatric colonoscope, it is referred to as push endoscopy. It can reach about 50 to 70 cm past the ligament of Treitz  in most cases and permits endoscopic management of some lesions. Overall, push enteroscopy is successful in 40% of patients .

Double-balloon endoscopy is another technique gaining in popularity. Although technically difficult, this approach is capable of providing a complete examination of the small bowel. In expert hands, double-balloon enteroscopy can identify a bleeding source in 77% of cases with occult bleeding, with the yield increasing to over 85% if the endoscopy is per-formed within 1 month of an overt bleeding episode.The advantage of this technique is that as well as visualization,  biopsies can be performed and therapeutic interventions undertaken.

To conclude investigations in lower GI bleed have to be specific and have high sensitivity also.

Sabiston

Chyle leak after esophagectomy

Q After  esophagectomy ICD draining 800 – 1000ml chyle 5-7 days post operatively. Next management

a) NPO, TPN

b) Enteral feeding with medium chain

c) Re explore and suture the defect

Answer free 

c

Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.

Feedings are stopped and total parenteral nutrition (TPN) is started. The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.

If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful. Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation. In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.

Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.

Burns management

Q) A 45 year old male sustains 30% burns on both legs and anterior abdominal wall.  There was  mild inhalation  injury associated with it. He initially responded well to treatment with IV fluids, Inj Tramadol and enteral feeding.

Three days after the treatment he is having slight tachypnea (30/min) pulse 110/min and BP 98/60. His temp is 97degree F and some areas of partial thickness have converted into full thickness. He is currently on Inj Magnamycin. His platelets are 70ooo, TLC is 17000 and sugar is 200 mg%. What is the next step in management?

a) Continue same management

b) Upgrade the antibiotic and send a fresh culture from skin

c) Treat it as carbon monoxide poisoning

d) Manage in lines of Acute Tubular Necrosis

Answer for premium members

Burns management involves critical care, intensive phase and rehabilitation. Loss of skin and eschar formation predispose individuals to gram positive, gram negative and fungal infections.

 

Esophagus Perforation

Q) Elderly healthy male with impacted denture. Removed endoscopically. Pt developed fever, dyspnoea and respiratory distress over 24 hrs. X-ray revealed Lt hydrothorax and mediastinal emphysema.

a) ICD and NG feeds

b) ICD and TPN

c) Cervical esophagectomy, FJ, debridement, ICD

d) Debridement, primary repair with buttress and ICD

Premium answer