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The bleeding is usually slight in amount and occurs with the stool or at the end of defaecation discount 40/60mg levitra with dapoxetine otc. If a careful history is taken one may differentiate between bleeding from internal pile and bleeding due to cancer levitra with dapoxetine 40/60 mg discount. It must be noted that it is a painless bleeding like an uncomplicated internal pile cheap 40/60 mg levitra with dapoxetine amex. Either it may be an increasing constipation or it is in the form of early morning diarrhoea. In case of annular carcinoma at the pelvirectal junction the patient suffers from increasing constipation. Instead of taking advice from his doctor the patient prefers to take increasing dose of laxatives. Ultimately, with the use of laxatives he shows a tendency towards diarrhoea for a limited period, which is again followed by constipation once the patient stops taking laxative. Sense of incomplete defaecation is quite common when a papilliferous or proliferative growth is situated at the lower half of the rectum. Every time the patient opens his bowel, he feels that more faeces are to be passed. But he fails to pass formed stool, instead he passes flatus and a little blood stained mucus (bloody slime). The intestinal obstruction may be the presenting symptom in case of stenosing growth. Only with intestinal obstruction due to stenosing growth of the rectosigmoid junction one may suffer from colicky pain from intestinal obstruction. When the growth has come out of the rectum and fascia propria the surrounding structures are involved and the patient complains of pain. A few patients may present with bizarre symptoms like loss of weight, slight pain and symptoms associated with distant metastases. These are palpable lump of liver metastasis, yellowness of jaundice and abdominal distension from ascites. Only in case of intestinal obstruction due to stenosing lesion at [he rectosigmoid junction one may palpate distended large bowel filled with stools. In late cases one may get enlarged liver from liver metastasis, ascites and secondary deposits in the peritoneum. So all cases of slight rectal problem should be examined by digital examination to exclude carcinoma. Even in case of higher growths, bimanual palpation may feel the carcinoma even at the rectosigmoid junction. One finger in the rectum and another on the lower part of the abdomen can feel such carcinoma. In case of females one finger in the rectum another in the vagina will give a good idea about the degree of infiltration. After rectal examination one must look at the gloved finger whether it is smeared with mucus and blood. Histological diagnosis is more important and it will also detect the histological grading which is essential to know the prognosis. When sigmoidoscope fails to visualise the growth because of the spasm of the bowel below it, barium enema X-ray is the only easily available diagnostic tool in the hand of surgeon. When carcinoma has been diagnosed by digital examination or by sigmoidoscopy, even then barium examination should be performed to exclude multiple adenomatous polyposis and other synchronous carcinomas higher up in the colon. The accuracy of digital examination is highly subjective and varies from 60% to 80%. Endorectal ultrasonography is also useful to identify patients with locally advanced disease, who may be considered for primary radiotherapy to down-stage the disease. Whereas left lateral position is commonly used for unsedated patients, but lithotomy position is more often used for patients under anaesthesia or when ultrasound guided biopsy is required. The assembled endoprobe is then passed through the sigmoidoscope to a position above the lesion. Following the insertion of the probe, the latex balloon is filled with degassed water. The sigmoidoscope is then withdrawn slowly and the transducer is activated so that a 360° scan of the rectal wall and the surrounding tissues are displayed on the screen. The probe can be moved gently and the volume of water in the balloon can be adjusted to bring a particular feature into the optimal focal range of the transducer. Endorectal ultrasonography is the best method for preoperative assessment of the depth of infiltration of rectal cancer. Other parameters concerning the internal structure of the node have been described as lobulation, inhomogeneity, presence of echo-poor rim, presence of hilar reflection etc. The detection of lateral lymphatic involvement is equally important as these nodes may be involved in the absence of mesorectal involvement. Colonoscopy, which is only available in a few specialised units, is definitely the best method to exclude any lesion higher up in the colon. Such radical excision means excision of the rectum with its sheath alongwith all nodes lying on the wall with 5 cm normal tissue above and below the growth and all involved regional lymph nodes. Obviously if the main nodes are involved the only way to do radical surgery is to ligate inferior mesenteric artery at its origin from the aorta (flush ligation). So the surgeon usually prefers to ligate inferior mesenteric artery below the origin of 1 or 2 branches. The type of resection which should be employed in a particular case depends on the situation of the carcinoma. For this, rectum has been divided into three parts, (a) The proximal third extends from the junction with the sigmoid colon which is 15 or 16 cm above the anus down to about 11 cm. Temporary proximal defunctioning colostomy may be advisable to secure anastomosis. In young subjects in whom cancers grow rapidly, probably it will be better to do abdomino-perineal resection instead of anterior resection to avoid recurrence. In these cases (i) abdomino­ perineal resection will be the safest, (ii) If the permanent colostomy has to be avoided one may perform abdomino-perineal pull through operation and making the anastomosis outside the anus to avoid the problem of doing an anastomosis deep in the pelvis. The principal drawback is that some patients do not regain faecal continence, (iii) There is now available a stapling instrument, die E. This has made it technically possible to resect midrectal carcinomas down to the distal limit and to restore continuity by a safe end-to-end anastomosis. This is usually achieved by a combination of mechanical cleansing and anti­ biotic treatment.

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Rectal examination reveals that the rectum is empty and contracted and the anus is normal order levitra with dapoxetine 40/60mg online. As the time passes by the abdomen becomes increasingly distended with borborygmi and visible peristalsis cheap levitra with dapoxetine 40/60 mg with mastercard. There is no aganglionic segment and hence colonic distension extends upto the anal canal generic levitra with dapoxetine 40/60mg fast delivery. Rectal examination will reveal scyballous mass in the rectum and there may be anal fissure which indicates the cause of this condition. In chronic and recurrent type the patients gradually become wasted and anaemic from diarrhoea. The severity of the condition depends mainly on the extent of involvement of the disease, the depth of the mucosal ulceration and the age of the patient. When this condition is confined to the rectum and sigmoid colon it rarely causes severe illness. When the whole or a substantial portion of the colon is involved the attack is likely to be more severe with some systemic upset. Even though much of the colon is involved the illness can be mild if ulceration remains superficial. To the contrary, deep ulceration especially if the deep muscle is exposed over a moderately large area, severe illness will be the result. Systemic manifestations of this disease are erythema nodosum, pyoderma, arthritis etc. Depletion of the protein is always expected resulting in loss of muscle bulk and loss of body weight. Diagnosis is mainly confirmed by two investigations — (i) Barium enema and (ii) Sigmoidoscopy, colonoscopy & biopsy. In the early stage barium enema will fail to show any ulceration in chronic disease. As the rectum is almost invariably involved in ulcerative colitis, the disease can be diagnosed with confidence by sigmoidoscopy and biopsy. Biopsy specimen may be taken either with bronchoscopy forceps or with a suction type of instrument. The reason is that the vascular occlusion is always incomplete as the collateral supply comes from the marginal artery of Drummond to allow the ischaemic bowel to recover. There is often left-sided abdominal pain and tenderness along the course of the descending colon, which is more often located in the region of the splenic flexure, as that is the watershed junction between the superior and inferior mesenteric arteries supply. Later on there may be stricture formation at the site of ischaemic colitis leading to intestinal obstruction. Multiple polyps are found mostly in rectum and sigmoid colon, but ultimately the whole colon will be involved. Clinical features depend on whether the growth is in the right or left half of the colon. In the right half of the colon, the intestinal contents being of the fluid nature, obstruction is not an early feature although the growth is of the hypertrophic type. The most important diagnostic ,;J|§ finding is the presence of a lump at the site of Js|f the caecum or ascending colon. In the left half of the colon, the contents J; M being solid and the growth being ot the annular jfr jiggf type, the patient complains of increasing constipation requiring increasing dose of JjP^ wz j purgatives to nun c the bowel. Any intra-abdominal abscess may leak through the umbilicus and form a sinus or fistula. Black concretions develop inside the umbilicus which is formed by desquamated epithelium and dirt. It remains symptomless for years, but inflammation may supervene to cause abscess formation with discharge. It is not synonymous with omphalitis which is a condition of new born baby where adequate aseptic precaution is not taken while severing the umbilical cord. Umbilical abscess however may or may not be associated with umbilical calculus and purulent discharge. Condition of the skin over the swelling — whether it is tense, red, shining or pigmented? Swelling in connection with the transpyloric line midway between the kidney or suprarenal moves very little with respiration. Similarly either side through the midpoint between carcinoma of the transverse colon may produce visible the anterior superior iliac spine and peristalsis. The regions are : (1) Right left to right, whereas in the latter it will be from right to hypochondrium, (2) Epigastrium, (3) Left left. Rare cases of obstruction in intestine from malignant hypochondrium, (4) Right lumbar, (5) growth or enlarged lymph nodes may demonstrate Umbilical region, (6) Left lumbar, (7) Right similar visible peristalsis. It must be remembered that a swelling over the hernial site may not necessarily be a hernia. Malignancy of the testis may lead to metastasis in the pre-and para-aortic lymph nodes. There may be difficulties when some part of the swelling disappears under the costal margin or the pelvis. Is it of same consistency throughout the swelling or there is variable consistency at different parts of the swelling. In case of a cystic swelling tests for fluctuation and fluid thrill should be performed. Of course if the cyst becomes tense, fluid thrill test may be negative and fluctuation will be difficult to elicit. This is an up and down movement and must not be confused with the anteroposterior movement of the abdominal wall during respiration. During inspiration the swelling will move downwards alongwith the downward excursion of the diaphragm. A mesenteric cyst moves freely at right angle to the line of attachment of the mesentery but not so along the line (the line of attachment of the mesentery is an oblique line starting 1 inch to the left of the midline and 1 inch below the transpyloric plane and extending downwards and to the right for about 6 inches).

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The patient has to say whether the joint is being moved or not and if so in which direction generic levitra with dapoxetine 40/60 mg mastercard. White portion vibration is lost in peripheral of the first figure is supplied by the musculocutaneous nerve levitra with dapoxetine 40/60 mg on line, whereas neuritis discount levitra with dapoxetine 40/60mg with visa, posterior column disorder white portion of the second figure (sole of the foot) is supplied by and tabes dorsalis. There may be evidence of injury such as displaced bone fragments or a scar to suggest an old injury. The nerve should be palpated, as in many cases of leprosy there may be thickening of the involved nerve. Moreover after injury to the nerve or suturing of the nerve, signs of regeneration can be assessed by the palpation. Regeneration starts after a couple of months and if gentle tapping over the course of the nerve from distal to the proximal side is made, a sensation of "pins and needles" or hyperaesthesia will be felt at the site of regeneration. Normally the range of active movement is similar to that of the passive movement of the same joint. But when the muscles, which are concerned in the movement, are paralysed or their tendons are torn, the passive movement will by far exceed the active movement of the same joint. So in case of peripheral nerve lesion one must note the extent of active as well as passive movements of the joint. In this context the students should remember that matting together of the muscles in the scar tissue, adhesion of the tendons with their sheaths or ankylosis of the joints will impair both the active and the passive movements of the joints. Deformity may also be from wasting of the muscles which are paralysed due to peripheral nerve lesion. In this respect the students should remember a fallacy that wasting of the muscles may be due to affections of the joints e. Besides these, alcoholism may be the cause of peripheral nerve lesion such as "Saturday night palsy". According to extent of damage, injury to the peripheral nerves can be divided into three categories — 1. It may occur due to minor stretching or torsion or vibratory effect of a high-velocity missile passing near the nerve. Clinically it is manifested by temporary loss of sensation, paraesthesia or weakness of the muscles supplied by the nerve. Recovery takes place slowly by down growth of the axons into the empty distal nerve sheath. There may be some loss of nerve fibres due to blockage of down growing axons by intraneural fibrosis. The relative positions of the axons are preserved and hence the quality of regeneration is quite good. Regeneration rate is 2 mm per day, which diminishes to 1 mm per day after a couple of months. Recovery is almost complete, though partial paralysis, slight sensory loss or causalgia may persist. Axonotmesis usually results from a stress, traction or compression of the nerve in closed fracture and dislocations or from excessive zealed manipulation to reduce such injuries. Clinically there is loss of sensation, tone and power of muscles with diminished reflex activity of the limb. Later on area of anaesthesia and paralysis of muscles will be restricted to those which are supplied by the damaged nerves only. Usually the total area affected is less than the known anatomical distribution of the nerve due to the fact that a few fibres within the nerve usually escape. There may be impaired circulation due to disuse which makes the affected portion cold and blue. Wallerian degeneration is noticed both in the distal segment and in the proximal segment. In the proximal segment retrograde degeneration takes place upto the first node of Ranvier. After fortnight the distal ends of the axons in the proximal segment start grow downwards. But, as there is a gap between the divided ends which is replaced by organic clots and fibrous tissue further downgrowth of the axons is not possible, so suturing is the only treatment if restoration of function is to be achieved. In the distal end typical Wallerian degeneration takes place, in which axis cylinder becomes fibrillated, medullary sheath breaks up into droplets of myelin and the cells of the sheath of Schwann are converted into phagocytes which remove remnants of axis cylinder and medullary sheath. The cells of Schwann proliferate forming a slight bulb at the commencement of the distal end from which sprouts of Schwann cells grow proximally towards the downgrowing axons of the proximal segment by chemotaxis. There will be complete loss of motor, sensory and reflex functions of the limb supplied by the nerve. Secondary pathological changes may occur in the skin and joints of the affected part. A motor nerve may grow down a sheath previously occupied by a sensory nerve, so it cannot function. So recovery of the radial nerve injury at the elbow will be better than the ulnar nerve or median nerve injury at the wrist. The source of infection is mainly from nasal secretions of patients with lepromatous leprosy. According to resistant of the host two external varieties of leprosy are noticed — lepromatous leprosy and tuberculoid leprosy. In lepromatous leprosy there is least resistant from the host and the bacteria multiply with little cellular response. In tuberculoid leprosy there is resistance from the host and the tissue responses are strong. There are localized lesions where bacilli are present alongwith epitheloid cells, foreign body giant cells and many lymphocytes almost like a tubercle. Clinically it is a systemic infection and mainly involves the skin, upper respiratory tract and peripheral nerves. Common peroneal nerve at the neck of the fibula and median nerve at the wrist may also be affected.

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In patients with pre-existing cardiac or pulmonary disease or in patients with severe pancreatitis purchase levitra with dapoxetine 40/60mg free shipping, invasive monitoring including urethral catheterisation purchase levitra with dapoxetine 40/60 mg line, cen­ tral venous pressure measurement order 40/60mg levitra with dapoxetine mastercard, measurement of cardiac output and cardiac filling pressures via a Swan-Ganz catheter is necessary. Shock in acute pancreatitis is mainly due to massive fluid se­ questration and accumulation of fluid within bowel lumen secondary to paralytic ileus and due to marked oedema in the peripancreatic region. When there is hypocalcaemia calcium gluconate will need to be added to the parenteral fluid. Hypomagnesemia may also be observed and should be corrected as this may hasten the normalisation of serum ionised calcium. This now appears to be false, and indeed it seems that depriving the gut lumen of nutrients is likely to impair gut mucosal barrier function and exacerbate the problem of translocation. In clinical trials it is shown that patients with severe acute pancreatitis can tolerate enteral nutrition delivered either by oral intake or by nasoenteric tube feeding with no adverse effect. Pain is very severe and agonising in acute pancreatitis, so it should be relieved as soon as possible. Moreover pain is frequently accompanied by vasoconstriction which may be harmful to the myocardium and may reduce the blood supply to the pancreas to convert simple oedema to necrosis. Morphine, which is quite effective in relieving severe pain, cannot be given in acute pancreatitis as this causes spasm of sphincter of Oddi. Moreover, administration of morphine is frequently followed by nausea and vomiting. Demerol (Meperidine hydrochloride) in a dose of 50 to 100 mg every 4 hours is considered to be the analgesic of choice because of its anticholinergic action. It may be used in combination with Papaverine (100 mg intravenously) or Nitroglycerine. In only extreme cases bilateral paravertebral splanchnic block or epidural block may be necessary. This can be performed (i) by stopping everything by mouth, (ii) by nasogastric aspiration and (iii) by non-absorbable liquid antacid (preferably a combination of mag­ nesium trisilicate and aluminium hydroxide as a liquid gel). Cimetidine may be effective as an antacid, (iv) An adequate dose of anticholinergic drug such as probanthine 30 mg every 8 hours or atropine sulphate 0. But its general acceptances is still awaited, (vii) Calcitonin also suppresses pancre­ atic exocrine and gastric acid secretion, so this drug can also be used. Aprotinin is a specific drug which is being used in this condition with improved prognosis, (viii) Somatostatin is a potent in­ hibitor of pancreatic exocrine secretion and gastric acid output. This can only be used by continu­ ous intravenous infusion as its circulating half-life in the blood is less than 3 minutes. Though this drug has been effective in reducing mortality from bile-induced pancreatitis in animal models, however multicentre clinical trials have failed to produce reduction in mortality rate in patients with acute pancreatitis, (ix) Chole- cystokinin-receptor antagonist proglumide has also been proved efficacious in animal models and its use is being investigated in human beings. However recent trials have failed to show any detectable improvement in this condition by using this group of drugs. Some of the deleterious effects of acute pancreatitis are caused by activation of pancreatic proteolytic enzymes and to liberation of biologically active polypeptides similar to bradykinin. The release of trypsin from the affected gland is capable of activating pancre­ atic Kallikrein another proteolytic enzyme which splits to vasoactive decapeptide Kallidin from a globulin. An antienzyme preparation shown to be effective toward trypsin and Kallikrein in both experimental and human acute pancre­ atitis is Trasylol (Aprotinin). But it should be remembered that once the ne­ crotic process is well established Trasylol becomes ineffective. So Trasylol has to be used at the earliest possible opportunity in a massive dose (1,00,000 units or more daily intravenously). Recent studies however have failed to show any significant improvement in the condition of patients with acute pancreatitis by using this group of drugs. Although the initial study of aprotonin showed evidence of benefit, several subsequent randomised studies have failed to con­ firm this. Studies of therapy aimed at inhibiting pancreatic secretion with anticholinergic agents or inhibitory hormones such as glucagon, somatostatin or somatostatin analogues, have all yielded negative findings. There is in fact nothing to demonstrate any effect of octreotide in over 400 patients. The incidence of infec­ tion is 20% in first week, 40% in second week and 60% in the 3rd week. The or­ ganisms responsible for infection traverse by translocation from intact gut and are the enteric flora mostly coliform, with 20 to 30% anaerobes. Imipenem is the antibiotic of choice, as (i) it has the maximum blood-pancreas diffusion and (ii) it has widest spectrum against organisms of enteric flora and anaerobes. The next best choice is quinolone (especially ofloxacilin) as the previous drug is quite expensive. Use of these prophylactic antibiotics have significantly reduced the incidence of pancreatic sepsis. It will counteract superimposed infection, prevent widespread peritonitis and suppurative complications. Third generation Cepha­ losporin has also been claimed to be highly successful in fulmination pancreatitis. It is definite that antibiotic is quite effective against the infective complications of acute pancreatitis. What is not known is the most appropriate antibiotic to be used, and the appropriate duration of therapy. The organisms which infect pancreatic necrosis are usually enteric bacteria and in this respect cefuroxime is a relatively inexpensive, widely available and safe antibiotic which can destroy this bacteria. Attempts to improve pancreatic perfusion with dextran have proved certain beneficial effect in experi­ mental animals, though not in human beings. Its use is limited to those who continue to deteriorate inspite of the best conservative treatment and when the diagnosis is absolutely confirmed. A lower midline or left lower quadrant incision is used and the peritoneal lavage catheter is introduced by making a nick through the abdominal muscles. This fluid is then drained out by lowering the bottle to the floor in the next 90 minutes.