---

LONG CASE - 2: COMPLETE CASE SHEET

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

1. Vomiting for the last 6 months
2. Loss of appetite for the last 6 months

---

HISTORY OF PRESENTING COMPLAINTS

• Patient felt full with half the quantity of food compared to before - suggests early satiety
• Vomiting is:
  • Non-bilious (stomach-level obstruction, no bile regurgitation)
  • Non-projectile
  • Not blood-stained
  • Contains undigested food particles - characteristic of retained gastric contents
  • Previous day's food particles in vomitus - pathognomonic of delayed gastric emptying / outlet obstruction
• Weight loss of ~7 kg over 1 month - significant
• No history of pain abdomen, fever, jaundice
• No history of hematemesis or melena

---

PAST HISTORY

• Known case of Type 2 Diabetes Mellitus, on treatment
• No past surgical history

---

FAMILY HISTORY

• Not significant

---

PERSONAL HISTORY

• Smoking: 80 pack-year history (significant risk factor)
• Alcohol: 25-year history of alcohol ingestion

---

TREATMENT HISTORY

• On oral hypoglycaemic agents / insulin for T2DM

---

GENERAL PHYSICAL EXAMINATION

---

ABDOMINAL EXAMINATION

• Abdomen slightly distended (dilated stomach)
• No visible peristalsis noted

• Soft, non-tender
• No palpable mass
• Succussion splash may be elicited (not documented but expected)

• Bowel sounds present

---

DIAGNOSIS

Gastric Outlet Obstruction (GOO) secondary to Carcinoma of the Stomach (Antro-pyloric region)

• GOO secondary to chronic peptic ulcer disease with pyloric stenosis
• GOO secondary to pancreatic head carcinoma

---

INVESTIGATIONS

A. ABG and Electrolytes - INTERPRETATION

B. Complete Blood Count & Biochemistry

C. Barium Meal X-ray Findings

• Grossly dilated, distended stomach - the stomach has an enormous rounded opacity occupying much of the upper abdomen (the "barium lake" or retained barium sign)
• Failure of gastric emptying - barium is retained in the stomach
• Irregular narrowing at the antro-pyloric region
• No passage of barium into the duodenum during the study

D. UGI Endoscopy Findings

• Dark retained old food material in the stomach (top left) - classic sign of GOO
• Whitish exudate coating gastric mucosa (top right)
• Narrowed, deformed pyloric channel with convergent mucosal folds (middle and lower panels)
• Clipping visible around a pyloric/antral lesion - suggests biopsy clips / haemostatic clips placed at the time of scope
• Irregular pyloric mucosa with ulceration

---

MANAGEMENT

Step 1 - Resuscitation and Pre-operative Stabilisation

1. IV Access - two wide-bore cannulae
2. Nasogastric tube insertion (wide-bore) - gastric decompression; lavage the stomach until clear (Bailey & Love, p.1190)
3. IV Fluids - Isotonic Normal Saline (0.9% NaCl) with KCl supplementation - corrects dehydration, hyponatraemia and hypochloraemia
   • Note: Do NOT use Ringer's lactate (avoid lactate in metabolic alkalosis)
4. Potassium replacement - IV KCl 20 mEq in each litre of saline; monitor K+ twice daily
5. Urine output monitoring - catheterize, target UO >0.5 ml/kg/hr
6. Blood glucose monitoring - patient is diabetic; manage with insulin sliding scale
7. Serial ABG - to monitor correction of metabolic alkalosis
8. Nutritional support - total parenteral nutrition (TPN) if surgery delayed; correct malnutrition
9. PPI infusion - IV Pantoprazole / Omeprazole 40 mg BD (reduces acid secretion, decreases gastric secretions)

Step 2 - Definitive Investigation

• Endoscopic biopsy with HPE - to confirm malignancy vs. benign peptic ulcer (Bailey & Love, p.1190)
• CT scan abdomen and pelvis with contrast - staging, assess resectability, lymph node status, liver metastasis
• H. pylori testing - Rapid urease test (CLO test) / serology / histology

Step 3 - Definitive Surgical Management

If Carcinoma Stomach (Antro-pyloric):

• Staging laparoscopy first to exclude peritoneal metastasis
• Curative intent:
  • Subtotal/distal gastrectomy (D2 lymph node dissection) - if resectable
  • Reconstruction by Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy) or Roux-en-Y
  • Perioperative chemotherapy (FLOT / ECF regimen)
• Palliative intent (unresectable):
  • Gastrojejunostomy - surgical bypass for GOO relief
  • Endoscopic duodenal/antral stenting (self-expanding metal stent - SEMS)

If Benign Pyloric Stenosis (PUD):

• H. pylori eradication - Triple therapy (PPI + Amoxicillin + Clarithromycin) / Quadruple therapy
• Endoscopic balloon dilatation - 85% amenable; 40% sustained response at 3 months (Mulholland & Greenfield, p.2269)
• Surgery if dilatation fails:
  • Vagotomy + Gastrojejunostomy (most common drainage procedure)
  • Vagotomy + Antrectomy - low ulcer recurrence, good gastric emptying (Mulholland & Greenfield, p.2269)
  • Jaboulay gastroduodenostomy - when duodenal scarring is extensive (Sabiston, p.1785)

---

VIVA QUESTIONS AND ANSWERS

---

Q1. What is the classical triad of features on examination in GOO?

---

Q2. What is the ABG pattern in GOO due to peptic ulcer disease?

---

Q3. Why is the urine paradoxically acidic in GOO?

---

Q4. What fluid and electrolyte regimen is used to correct GOO metabolic disturbance?

---

Q5. What is the most important investigation in GOO and why?

---

Q6. What are the causes of GOO?

• Benign: Chronic PUD with pyloric stenosis, post-surgical stricture, Crohn's disease, polyps, TB
• Malignant: Carcinoma stomach (antro-pyloric), carcinoma head of pancreas, carcinoma duodenum, lymphoma
• Other: External compression, bezoar, gallstone in duodenum (Bouveret syndrome)

---

Q7. What does the barium meal show in GOO?

---

Q8. What surgical operations are done for benign GOO?

• Vagotomy + Drainage (pyloroplasty or gastrojejunostomy) - most common
• Vagotomy + Antrectomy - gold standard, lowest recurrence
• Jaboulay gastroduodenostomy - side-to-side anastomosis when duodenum is scarred
• Endoscopic balloon dilatation - first-line in early cases

---

Q9. What is the significance of "previous day's undigested food" in vomitus?

---

Q10. What are the metabolic abnormalities in malignant GOO vs. benign GOO?

---

Q11. What is the role of H. pylori in GOO?

---

Q12. What are the risk factors for carcinoma stomach seen in this patient?

• Age - 58 years (peak incidence 6th-7th decade)
• Male gender
• Heavy smoking - 80 pack-years (strong association)
• Alcohol use - 25 years
• Type 2 Diabetes - associated increased risk
• (H. pylori infection would need to be tested - major risk factor)

---

Q13. What is the staging investigation for carcinoma stomach?

1. CT chest/abdomen/pelvis with contrast - assess T, N, M staging
2. Staging laparoscopy - detect peritoneal seeding (CT misses ~30%)
3. PET-CT - for distant metastasis
4. Endoscopic Ultrasound (EUS) - T staging accuracy, locoregional nodes
5. Tumor markers: CEA, CA 19-9, CA 72-4

---

Q14. What is the significance of D2 lymphadenectomy in gastric cancer?

---

Q15. Why does this patient have anaemia?

• Chronic disease/malnutrition - 7 kg weight loss in 1 month, poor nourishment
• Iron deficiency from bleeding ulcer/tumour (though no overt haematemesis/melaena)
• Poor oral intake from early satiety and vomiting

---

• Bailey & Love's Short Practice of Surgery 28th ed., Chapter 67 (Stomach & Duodenum)
• Sabiston Textbook of Surgery, Chapter on Complicated PUD
• Mulholland & Greenfield's Surgery 7th ed.
• Costanzo Physiology 7th ed., Box 7.2

---

LONG CASE - 3: COMPLETE CASE SHEET

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

1. Intermittent epigastric pain for 1 year
2. Aggravated epigastric pain for 1 week
3. Vomiting for 1 week

---

HISTORY OF PRESENTING COMPLAINTS

• Patient developed dull aching epigastric pain, occasionally radiating to the back - classic feature of pancreatic pathology
• Sought native treatment; symptoms partly relieved
• Did not pursue further investigation

• Epigastric pain worsened in duration and intensity, radiating to the back, relieved partially by pain medications
• Associated with 4-5 episodes/day of non-bilious, non-blood stained vomiting, occurring 15-30 minutes after food intake
• History of non-quantifiable weight loss and loss of appetite for 1 week

• No fever, no jaundice
• No abdominal distension
• No melena, no bleeding per rectum
• No altered bowel habits

---

PAST HISTORY

• Not significant

FAMILY HISTORY

• Not significant

PERSONAL HISTORY

• Alcoholic for 20 years - abstinent for the last 6 months (strong etiological factor)
• Smoker for 20 years - 10 beedis/day
• Sleep disturbed (due to pain)

PAST SURGICAL HISTORY

• Nil

---

GENERAL PHYSICAL EXAMINATION

---

ABDOMINAL EXAMINATION

• Abdomen shows a visible epigastric/upper abdominal swelling / fullness
• A palpable mass in the epigastric region is clearly demarcated with a marker pen on the photographs - oval/rounded outline drawn over the epigastrium and left hypochondrium
• The mass is non-pulsatile, appears to be in the epigastric region extending toward the left hypochondrium
• Previous laparotomy scar visible (midline incision in upper image - may represent prior surgical intervention or the mass has stretched skin)

• Epigastric mass - smooth, rounded, non-tender / mildly tender
• Fluctuant, cystic in nature
• Does not move with respiration (retroperitoneal/pancreatic origin)
• Cannot get above the mass

• Dull over the swelling (fluid-filled cyst)

• Bowel sounds present; bruit absent

---

DIAGNOSIS

Pancreatic Pseudocyst (secondary to chronic alcoholic pancreatitis)

• Cystic neoplasm of pancreas (IPMN, MCN, serous cystadenoma)
• Walled-off necrosis (WON)
• Pancreatic abscess
• Retroperitoneal cyst / mesenteric cyst

---

INVESTIGATIONS

A. Blood Investigations - With Interpretation

• Markedly elevated amylase (523) and lipase (459) confirm pancreatitis / pancreatic pathology
• Serum amylase is elevated in approximately 50% of patients with a pseudocyst - this does not indicate recurrent pancreatitis but reflects continued pancreatic enzyme leakage (Current Surgical Therapy 14e)
• Elevated GGT and ALP - consistent with chronic alcoholic liver disease / biliary obstruction by pseudocyst
• Elevated ESR, mildly prolonged INR - chronic inflammatory state, nutritional impact of alcoholism
• Mild hyponatraemia - vomiting + poor intake

B. Imaging Required

USG Abdomen (First-Line)

• Cystic lesion in the pancreatic region - thick-walled, no internal septations (pseudocyst vs. neoplasm)
• Assessment of biliary tree, liver
• Doppler for vascular involvement

CECT Abdomen (Investigation of Choice)

• Defines the size, location, wall thickness, content of the cyst
• Differentiates pseudocyst from WON (no solid debris in pseudocyst)
• Sensitivity 82-100%, specificity 98% for diagnosing pseudocysts (Current Surgical Therapy 14e)
• Assesses surrounding structures, ductal dilation, calcifications

MRCP / MRI Abdomen

• Delineates ductal communication with the pseudocyst
• Identifies main duct strictures, disconnected pancreatic duct
• Guides treatment planning; has largely replaced diagnostic ERCP (Current Surgical Therapy 14e)

EUS + FNA (if diagnosis uncertain)

• Fluid analysis: high amylase → pseudocyst; high CEA → mucinous neoplasm
• Cytology to exclude malignancy

---

MANAGEMENT

Step 1 - General Supportive Measures (Acute Phase)

1. NPO (nil per oral) - rest the pancreas
2. IV fluids - isotonic saline or Ringer's lactate, maintain hydration
3. Analgesia - IV Tramadol / Diclofenac; avoid morphine (causes sphincter of Oddi spasm)
4. Antiemetics - IV Ondansetron / Metoclopramide
5. NG tube - if persistent vomiting
6. Nutritional support - enteral nutrition (nasojejunal tube) preferred over TPN; low-fat diet
7. Absolute alcohol abstinence - counselling and de-addiction referral
8. Smoking cessation
9. Monitor - vitals, urine output, blood glucose (risk of endocrine insufficiency)
10. PPI - IV Pantoprazole (reduces stimulation of pancreatic secretion by acid)

Step 2 - Watchful Waiting (Conservative)

• Up to 90% of peripancreatic fluid collections resolve spontaneously within 6 weeks (Current Surgical Therapy 14e)
• Serial USG / CT at 4-6 week intervals to monitor resolution
• If asymptomatic and <6 cm - observe conservatively
• Features suggesting low chance of spontaneous resolution: increasing size >6 weeks, calcifications in pancreatic duct, ductal strictures, multiple cysts, tail location, complex cysts

Step 3 - Intervention (indicated when)

• Pseudocyst persisting >6 weeks and symptomatic
• Size >6 cm (controversial; size alone not an absolute indication)
• Complications: infection, rupture, haemorrhage, biliary obstruction, GOO
• Increasing size on surveillance

A. Percutaneous Drainage (least invasive)

• USG or CT-guided pigtail catheter
• Reserved for: critically ill patients, infected/complicated pseudocysts, not fit for endoscopy/surgery
• Disadvantage: high re-accumulation rate, risk of pancreaticocutaneous fistula if ductal communication exists (Current Surgical Therapy 14e)

B. Endoscopic Drainage (preferred first-line for eligible patients)

• Endoscopic cystgastrostomy - drain into stomach; gold standard endoscopic approach
• EUS-guided transmural drainage - passes through stomach/duodenal wall under USS guidance; lumen-apposing metal stent (LAMS) placed
• Transpapillary drainage (ERCP + stent) - when pseudocyst communicates with pancreatic duct
• Success rates comparable to surgery, less invasive (Current Surgical Therapy 14e)

C. Surgical Drainage (gold standard; lowest recurrence ~5%)

• Internal drainage preferred over external drainage (avoids pancreaticocutaneous fistula)
• Options:
  • Cystogastrostomy - posterior cystogastrostomy; direct anastomosis between posterior stomach wall and anterior cyst wall; simple, effective
  • Roux-en-Y Cystojejunostomy - ideal internal drainage; Roux limb of jejunum anastomosed to cyst; best for large/complex pseudocysts (Maingot's Abdominal Operations)
  • Cystoduodenostomy - when cyst adherent to duodenum
• Laparoscopic cystgastrostomy - feasible in experienced centres (Bailey & Love, p.1298)
• Distal pancreatectomy - for pseudocysts in the tail not amenable to drainage

---

COMPLICATIONS OF PANCREATIC PSEUDOCYST

---

VIVA QUESTIONS AND ANSWERS

---

Q1. Define pancreatic pseudocyst.

---

Q2. What is the Atlanta Classification of pancreatic fluid collections?

• Interstitial edematous pancreatitis (<4 weeks) → Acute Pancreatic Fluid Collection (APFC)
• Interstitial edematous pancreatitis (>4 weeks) → Pancreatic Pseudocyst
• Necrotizing pancreatitis (<4 weeks) → Acute Necrotic Collection (ANC)
• Necrotizing pancreatitis (>4 weeks) → Walled-Off Necrosis (WON)

---

Q3. What is the most common cause of pancreatic pseudocyst?

---

Q4. Why are both amylase and lipase elevated in this patient despite the pseudocyst being the main finding?

---

Q5. What is the investigation of choice for diagnosing a pancreatic pseudocyst?

---

Q6. How do you differentiate pseudocyst from cystic neoplasm (e.g., MCN)?

---

Q7. When do you intervene in a pancreatic pseudocyst?

1. Persistence beyond 6 weeks with symptoms
2. Complications (infection, haemorrhage, rupture, biliary/bowel obstruction)
3. Increasing size on follow-up
4. Unable to exclude cystic neoplasm

---

Q8. What are the surgical drainage options for pseudocyst?

• Cystogastrostomy - posterior wall of stomach anastomosed to cyst; simplest
• Roux-en-Y Cystojejunostomy - most versatile; ideal for any location; lowest recurrence (~5%)
• Cystoduodenostomy - for cysts adherent to the duodenum
• Recurrence rate for surgical drainage is ~5%, the lowest of all modalities (Bailey & Love)

---

Q9. What is the significance of elevated GGT in this patient?

1. Chronic alcohol consumption - alcohol induces GGT microsomal enzyme induction; most sensitive marker of chronic alcohol use
2. Biliary compression - pseudocyst compressing the bile duct/intrahepatic radicles raising ALP and GGT

---

Q10. Why is INR elevated (1.47) in this patient?

---

Q11. What is a "disconnected pancreatic duct syndrome"?

---

Q12. What are the complications of cystgastrostomy?

• Bleeding from the anastomosis
• Gastric food debris entering the cyst (acting as a sump)
• Recurrence (higher than Roux-en-Y)
• Inadvertent anastomosis to a cystic neoplasm
• Pancreaticocutaneous fistula (in external drainage)

---

Q13. What is the role of alcohol abstinence in management?

1. Prevents further episodes of acute-on-chronic pancreatitis
2. Allows spontaneous resolution of acute fluid collections
3. Reduces progression to exocrine and endocrine insufficiency
4. Reduces risk of pseudocyst recurrence after drainage

---

Q14. What is the best analgesia for acute pancreatitis/pseudocyst pain?

---

Q15. What is the expected outcome of this case?

• Pseudocyst likely secondary to alcoholic pancreatitis (history consistent)
• Patient now abstinent for 6 months
• No overt complications (no fever, no jaundice, hemodynamically stable)

---

• Current Surgical Therapy 14e - Management of Pancreatic Pseudocyst
• Bailey & Love's Short Practice of Surgery 28e, Chapter 72 (Table 72.6)
• Maingot's Abdominal Operations, Chapter 55
• Costanzo Physiology 7e, Box 7.2

---

LONG CASE 1: COMPLETE CASE SHEET

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

• Yellowish discolouration of eyes and urine for the last 5 months

---

HISTORY OF PRESENTING COMPLAINTS

• Patient was apparently well until 5 months ago when he noticed progressive deepening yellowish discolouration of eyes and urine - insidious onset, gradually progressive
• Associated with:
  • Clay-coloured (pale/acholic) stools - hallmark of complete biliary obstruction
  • Generalised itching (pruritus) - due to bile salt deposition in skin
  • Significant weight loss of ~22 kg in 5 months - alarming, suggests malignancy
• No pain abdomen - painless progressive jaundice points to malignant obstruction
• No fever (no cholangitis)
• No vomiting
• No bowel disturbances
• No previous abdominal surgery

---

PAST HISTORY / FAMILY HISTORY / PERSONAL HISTORY

• Not documented / not significant

---

GENERAL PHYSICAL EXAMINATION

• Deep icteric sclera bilaterally - confirms significant hyperbilirubinemia
• Jaundice of skin visible

---

ABDOMINAL EXAMINATION

• Image (a): Visible bulging/distension in right hypochondrium / epigastrium - consistent with grossly enlarged gallbladder
• Image (b): Palpable rounded mass in right hypochondrium outlined by marker - confirms palpable distended gallbladder

• Courvoisier's sign POSITIVE - palpable, non-tender, distended gallbladder in a jaundiced patient without pain
  • Courvoisier's Law: In obstructive jaundice, if the gallbladder is palpably enlarged and non-tender, the obstruction is unlikely to be due to gallstones (chronic inflammation scars the gallbladder) and is most likely malignant (Sleisenger & Fordtran)
• Liver may be enlarged (hepatomegaly from biliary congestion)
• No ascites initially

---

DIAGNOSIS

Obstructive Jaundice due to Cholangiocarcinoma (Klatskin tumour) / Carcinoma Gallbladder

---

INVESTIGATIONS

A. Blood Investigations - With Interpretation

• Total bilirubin 14.8 mg/dl with predominantly direct (conjugated) fraction = obstructive / hepatic jaundice
• Markedly raised ALP (250) and GGT (294) = biliary obstruction/cholestasis pattern
• Normal amylase and lipase = pancreas not primarily involved (argues against pancreatic cancer)
• Prolonged PT/INR = failure of fat-soluble vitamin K absorption (cholestasis → fat malabsorption → coagulopathy)
• Leukocytosis with neutrophilia = mild inflammation / early cholangitis
• Low albumin + anaemia = chronic malnutrition/malignancy

B. Imaging Investigations Required

USG Abdomen (First-line)

• Dilated intrahepatic bile ducts (IHBRD) - shows level of obstruction
• Dilated CBD > 8 mm
• Distended gallbladder (Courvoisier's)
• USG sensitivity for biliary dilation ~85-90%; exact cause determined in only 2/3 (Current Surgical Therapy 14e)

CECT Abdomen (Triple Phase with CT Angiography) - Investigation of Choice

• Delineates level, cause, and extent of obstruction
• Assesses vascular involvement (portal vein, hepatic artery) for resectability
• Lymph node staging, liver metastases
• Identifies: hilar mass (Klatskin tumour), GB wall thickening/mass, periductal enhancement

MRCP / MRI Abdomen

• Best non-invasive imaging of biliary tree - sensitivity 95% (Current Surgical Therapy 14e)
• Delineates Bismuth-Corlette classification for hilar cholangiocarcinoma
• Differentiates benign from malignant strictures

ERCP / PTC

• Therapeutic and diagnostic - biliary decompression (stent placement)
• For tissue diagnosis via brushings / forceps biopsy
• PTC (Percutaneous Transhepatic Cholangiography) - for proximal hilar obstructions

Tumour Markers

• CA 19-9 - elevated in cholangiocarcinoma and pancreatic cancer
• CEA - elevated in GI malignancies
• CA 125 - if GB cancer suspected

---

MANAGEMENT

Step 1 - Pre-operative Preparation and Resuscitation

1. IV access - wide bore cannulae
2. IV fluids - Normal saline/dextrose saline; correct dehydration
3. Vitamin K injection - 10 mg IM/IV for 3 days to correct coagulopathy (fat malabsorption → Vit K deficiency → prolonged PT) - target INR <1.5 before any invasive procedure (Current Surgical Therapy 14e: INR must be <1.7 for PBD)
4. Treat pruritus - Cholestyramine 4g BD (binds bile salts in gut)
5. Nutritional support - enteral nutrition; high protein, fat-restricted diet
6. Correct anaemia - blood transfusion if Hb <8 pre-operatively
7. Broad-spectrum antibiotics - cover gram-negative organisms; mandatory before any biliary instrumentation (prevents cholangitis)
8. Monitor - urine output, LFTs, coagulation profile

Step 2 - Biliary Decompression (Pre-operative or Palliative)

• ERCP + stenting - endoscopic biliary stent for distal CBD obstruction (plastic or self-expanding metal stent - SEMS)
• PTC + external/internal biliary drainage (PBD) - for proximal hilar obstruction not accessible by ERCP
• Pre-operative biliary drainage is indicated if: cholangitis, very high bilirubin (>15 mg/dl), coagulopathy, renal impairment

Step 3 - Definitive Surgical Management

For Cholangiocarcinoma (Hilar / Klatskin):

• Bismuth-Corlette Classification guides resectability:
  • Type I/II: Hepaticojejunostomy (Roux-en-Y)
  • Type IIIa/b: Right/Left hepatectomy + biliary reconstruction
  • Type IV: Liver transplantation (in select centres) or palliative only
• Excision of bile duct + Roux-en-Y hepaticojejunostomy

For Carcinoma Gallbladder with CBD involvement:

• Extended cholecystectomy + en bloc resection of liver segments IVb+V + regional lymphadenectomy
• CBD excision if involved + Roux-en-Y hepaticojejunostomy

Palliative Options (unresectable):

• Biliary stenting (ERCP or PTC)
• Surgical bypass - Roux-en-Y hepaticojejunostomy if endoscopic stenting fails
• Chemotherapy: Gemcitabine + Cisplatin (standard for cholangiocarcinoma)
• Photodynamic therapy (PDT) for biliary palliation

---

VIVA QUESTIONS AND ANSWERS

---

Q1. What is Courvoisier's Law? Is it applicable in this case?

---

Q2. Why is PT/INR prolonged in obstructive jaundice?

---

Q3. What is the LFT pattern in obstructive vs. hepatocellular jaundice?

---

Q4. What does "paintless progressive jaundice" suggest?

---

Q5. What is the Bismuth-Corlette Classification of hilar cholangiocarcinoma?

---

Q6. What is the investigation of choice for obstructive jaundice?

---

Q7. What is the significance of clay-coloured stools and dark urine in this patient?

---

---

---

LONG CASE 5: COMPLETE CASE SHEET

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

1. Anxiety
2. Weight loss
3. Watering of eyes, burning sensation, photophobia

---

HISTORY OF PRESENTING COMPLAINTS

• Anxiety / nervousness - adrenergic excess from elevated T3/T4
• Weight loss - hypermetabolic state; weight loss despite normal/increased appetite
• Tremors (likely present but not documented)
• Palpitations / tachycardia (likely associated)
• Heat intolerance, excessive sweating (likely)
• Watering of eyes, burning, photophobia - symptoms of Graves' Ophthalmopathy (orbitopathy)
• Duration to be elicited

---

CLINICAL PHOTOGRAPHS - EXAMINATION FINDINGS

• Bilateral exophthalmos/proptosis - eyeballs prominently protruding
• Lid retraction visible
• Stare present
• Consistent with Graves' Ophthalmopathy

• Diffuse smooth goitre - bilateral symmetrical enlargement of thyroid gland
• Previous thyroidectomy scar visible at the base of neck (collar incision) - suggests this may be a post-operative case or a prior attempt at management

---

PAST HISTORY / FAMILY HISTORY / PERSONAL HISTORY

• Not documented

---

GENERAL PHYSICAL EXAMINATION

• Exophthalmos / Proptosis (leading cause in adults)
• Dalrymple's sign - upper lid retraction
• Von Graefe's sign - lid lag on downward gaze
• Stellwag's sign - infrequent blinking
• Joffroy's sign - absent forehead wrinkling on upward gaze
• Moebius sign - inability to converge

---

DIAGNOSIS

Primary Thyrotoxicosis - Graves' Disease (Autoimmune diffuse toxic goitre with Graves' Ophthalmopathy)

• Toxic multinodular goitre (Plummer's disease)
• Toxic adenoma
• Thyroiditis (subacute, Hashimoto's)
• Exogenous thyroid hormone intake

---

INVESTIGATIONS

A. Thyroid Function Tests - With Interpretation

B. Ultrasound Thyroid Findings

• Diffuse enlargement of both lobes - consistent with Graves' diffuse goitre
• Multiple nodules in both lobes - require evaluation (rule out concurrent malignancy in ~1-2%)
• Thyroid Trans image: Both lobes enlarged flanking trachea

C. Doppler Findings

• Markedly increased vascularity in both lobes - the classic "thyroid inferno" sign on colour Doppler
• Pathognomonic of Graves' disease - reflects massively increased blood flow from TSH receptor antibody stimulation

D. Additional Investigations Required

---

MANAGEMENT

Step 1 - Immediate Medical Control (Render Euthyroid Before Surgery)

• Carbimazole 30-40 mg/day (divided doses) OR Propylthiouracil (PTU) 300-400 mg/day
• Mechanism: Inhibit thyroid peroxidase → block iodine organification → inhibit T3/T4 synthesis
• PTU also blocks peripheral T4→T3 conversion (preferred in thyroid storm)
• Duration until euthyroid: 4-6 weeks (monitor TFTs monthly)

• Propranolol 40-80 mg TDS or Atenolol 50-100 mg OD
• Controls adrenergic symptoms: tachycardia, tremor, anxiety, palpitations
• Does NOT reduce thyroid hormone synthesis but blocks peripheral effects

• Lugol's solution (5% iodine + 10% KI, 5-7 drops TDS) OR Potassium Iodide drops
• Given for 7-10 days immediately before surgery
• Mechanism: Wolff-Chaikoff effect - high iodine suppresses iodine organification → reduces thyroid hormone synthesis + reduces thyroid vascularity and blood flow → less intraoperative bleeding (Current Surgical Therapy 14e)

Step 2 - Modality Selection (ATA Guidelines 2016)

Total Thyroidectomy is the preferred treatment

Step 3 - Surgical Management

• Total thyroidectomy is associated with the lowest recurrence rate: 0.3% vs. 10% for subtotal thyroidectomy vs. 21% for RAI single dose (Current Surgical Therapy 14e)

1. Patient must be euthyroid (TFTs normal)
2. Lugol's iodine for 7-10 days
3. Propranolol continued until surgery
4. INR, CBC, LFTs, serum calcium baseline
5. Laryngoscopy to document vocal cord function (rule out pre-existing RLN palsy)
6. DEXA scan - bone density assessment (thyrotoxicosis causes osteopenia)

1. Collar incision along Langer's lines
2. Subplatysmal flaps raised
3. Strap muscles separated
4. Thyroid mobilized - individual ligation of superior and inferior thyroid vessels
5. Identify and preserve: recurrent laryngeal nerve (RLN), parathyroid glands (x4)
6. Total thyroidectomy specimen
7. Drain placement

• Hypoparathyroidism (permanent) - due to vascularity and adherence of glands
• RLN injury - bilateral damage → respiratory distress
• Thyroid storm (if inadequately prepared)
• Neck haematoma (high vascularity - "thyroid inferno")
• Hypothyroidism - expected; requires lifelong L-thyroxine

Step 4 - Post-operative Management

1. Calcium and Vitamin D - monitor serum calcium every 6 hours post-op; supplement if low
2. L-Thyroxine replacement - start at 1.6 mcg/kg/day (target TSH 0.5-2.0)
3. Continue Propranolol - taper over 1-2 weeks post-op
4. Ophthalmopathy management - IV methylprednisolone, selenium, orbital radiotherapy, decompression surgery (in conjunction with ophthalmology)

Step 5 - Graves' Ophthalmopathy Treatment

• Selenium 200 mcg/day (mild active disease - EUGOGO guidelines)
• IV Glucocorticoids (methylprednisolone) for moderate-severe active GO
• Orbital decompression surgery for compressive optic neuropathy
• Avoid RAI - worsens ophthalmopathy

---

VIVA QUESTIONS AND ANSWERS

---

Q1. What is the mechanism of Graves' disease?

---

Q2. Why is TSH undetectable (<0.001) in primary hyperthyroidism?

---

Q3. What is the purpose of Lugol's iodine before thyroidectomy for Graves' disease?

1. Wolff-Chaikoff effect - high iodine load inhibits thyroid peroxidase → blocks thyroid hormone synthesis
2. Reduces thyroid vascularity and blood flow - makes gland firmer, less vascular, easier to dissect
3. Reduces intraoperative bleeding significantly
4. Reduces risk of thyroid storm perioperatively

---

Q4. What is thyroid storm and how is it managed?

1. PTU 600 mg loading then 200-250 mg 4-hourly (blocks synthesis AND peripheral conversion)
2. Iodine solution (at least 1 hour after PTU) - blocks hormone release
3. IV Propranolol/Esmolol
4. Hydrocortisone 100 mg 8-hourly (blocks T4→T3 conversion, treats relative adrenal insufficiency)
5. Cooling measures, IV fluids, glucose
6. ICU monitoring

---

Q5. What are the eye signs specific to Graves' disease vs. general thyrotoxicosis?

---

Q6. Why is total thyroidectomy preferred over subtotal for Graves' disease?

---

Q7. What are the complications of thyroidectomy for Graves' disease?

1. Hypoparathyroidism (transient ~10%; permanent ~2-3%) - hypocalcaemia, tetany, Chvostek's/Trousseau's sign
2. RLN injury - unilateral: hoarseness; bilateral: stridor, respiratory distress, re-intubation
3. Thyroid storm - if inadequately prepared pre-op
4. Neck haematoma - airway emergency; requires immediate wound opening
5. Hypothyroidism - expected; requires lifelong L-thyroxine
6. Wound infection, keloid scar (collar incision)
7. Chyle leak (rare - left neck dissection)

---

Q8. What is the "thyroid inferno" sign on Doppler?

---

• Current Surgical Therapy 14e - Graves' Disease (Tables 2 & 3, ATA 2016 Guidelines)
• Current Surgical Therapy 14e - Evaluation of Obstructive Jaundice (Table 2)
• Sleisenger & Fordtran's GI & Liver Disease
• Cummings Otolaryngology Head & Neck Surgery
• Harrison's Principles of Internal Medicine 22e

---

LONG CASE 4 - PERIPHERAL VASCULAR DISEASE (PVD)

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

1. Pain in both lower limbs (left > right) for 8 months
2. Blackish discolouration of left foot for 10 days

---

HISTORY OF PRESENTING COMPLAINTS

• 8 months: Cramping-type pain in calf region of both lower limbs (left > right), appearing after walking ~1 km, relieved by rest - intermittent claudication (Fontaine Stage IIb)
• 1 month: Rest pain in left leg - progression to Fontaine Stage III
• 10 days: Blackish discolouration of left foot; developed small wound on dorsum of left foot; visited local hospital 5 days ago for debridement - Fontaine Stage IV (gangrene)
• No h/o trauma, stroke/TIA, chest pain, postprandial abdominal pain (mesenteric ischaemia), upper limb pain

---

PAST HISTORY

• Not a k/c/o DM / HTN / IHD / TB
• No previous surgeries

PERSONAL HISTORY

• Smoking: 20 pack-years (stopped 1 month ago - major risk factor)
• No significant family history

---

GENERAL PHYSICAL EXAMINATION

---

LOCAL EXAMINATION (Lower Limbs)

Inspection:

• Blackish discolouration of left foot - dry gangrene (line of demarcation present)
• Wound on dorsum of foot (post-debridement)
• Skin dry, shiny, hair loss, trophic changes (thin skin, brittle nails)
• Muscle wasting of calf bilaterally

Palpation:

• Skin temperature: Cool - bilateral lower limbs
• Capillary refill time: Prolonged (>3 sec)
• Peripheral pulses:
  • Left: Absent - femoral, popliteal, dorsalis pedis, posterior tibial
  • Right: Feeble - femoral, popliteal, dorsalis pedis, posterior tibial
• Sensation: Reduced in affected areas (ischaemic neuropathy)

Auscultation:

• Bruits over femoral/iliac region (may indicate stenosis)
• Buerger's test: Positive (pallor on elevation, rubor on dependency - reactive hyperaemia)

---

DIAGNOSIS

Peripheral Vascular Disease (Atherosclerotic Peripheral Arterial Disease) - Fontaine Stage IV Left lower limb: Critical limb ischaemia with dry gangrene of left foot

---

INVESTIGATIONS

Bedside:

• Ankle-Brachial Index (ABI): <0.4 indicates severe disease (normal >0.9; critical ischaemia <0.4) (Tintinalli's EM)
• Buerger's test - angle at which pallor occurs; rubor on dependency
• Capillary refill time >6 seconds (as noted in Long Case 7 equivalent)

Blood:

Imaging:

---

MANAGEMENT

Step 1 - Medical / Conservative (all patients):

1. Absolute smoking cessation - single most important intervention
2. Antiplatelet therapy - Aspirin 75-150 mg/day OR Clopidogrel 75 mg/day
3. Statin therapy - Atorvastatin 40-80 mg/day (reduces cardiovascular events and may slow PAD progression)
4. Control DM, HTN if present
5. Cilostazol 100 mg BD (phosphodiesterase III inhibitor) - increases claudication distance
6. Supervised exercise programme - improves collateral circulation
7. Wound care - debridement, daily dressing

Step 2 - Revascularisation (Critical Limb Ischaemia):

Endovascular (preferred first-line for suitable anatomy):

• Percutaneous Transluminal Angioplasty (PTA) ± stenting - for iliac, femoral stenosis
• Balloon angioplasty with drug-eluting stent

Surgical Revascularisation:

• Aorto-bifemoral bypass - for aortoiliac occlusion (Leriche syndrome)
• Femoro-popliteal bypass - for SFA occlusion; autologous great saphenous vein preferred over synthetic graft
• Femoro-distal bypass - using reversed saphenous vein graft to tibial/peroneal vessels
• Endarterectomy - for localised disease

Step 3 - For Gangrene:

• Dry gangrene of toes/foot - allow to auto-amputate OR
• Amputation if wet/infected gangrene develops or revascularisation fails:
  • Toe amputation / Ray amputation - for limited digital gangrene
  • Transmetatarsal amputation
  • Below-knee amputation (BKA) - preferred over AKA; better rehabilitation
  • Above-knee amputation (AKA) - if BKA not feasible

---

VIVA QUESTIONS

Q1. What is intermittent claudication? What is its mechanism?

Q2. What is Fontaine Classification? Where does this patient fit?

Q3. What is the ABI and its significance?

Q4. What are the differences between arterial and venous ulcers?

Q5. What is dry vs. wet gangrene?

Q6. What is Leriche's syndrome?

---

---

LONG CASE 7 - PVD (BUERGER'S DISEASE / ATHEROSCLEROTIC PAD WITH GANGRENE)

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

1. Discolouration of 2nd and 3rd toes of left foot - 1 year
2. Wound over dorsum of left foot - 6 months

---

HISTORY OF PRESENTING COMPLAINTS

• 1 year: Insidious blackish discolouration of tips of left 2nd and 3rd toes, progressively extending proximally to the base; associated loss of sensation over each toe
• 6 months: Small wound on dorsum of left foot, insidious, gradually increasing; extremely painful; non-foul smelling, no discharge
• Bilateral calf pain after walking ~200m, relieved by rest - intermittent claudication (Fontaine IIb/III)
• No trauma, no DM/HTN history

PERSONAL HISTORY

• Beedi smoker 20 years (1 pack/day) - stopped 6 months ago (strongly suggests Buerger's disease / TAO - Thromboangiitis Obliterans in a young smoker)
• Alcohol: 15 years

---

LOCAL EXAMINATION

Inspection:

• Blackish discolouration of left 2nd and 3rd toes extending to base - digital gangrene
• Clear line of demarcation (dry gangrene)
• 6×4 cm oval ulcer on dorsum of left foot - erythematous margins, sloping edge, slough + necrotic tissue on floor - ischaemic ulcer
• Skin: dry, hair loss, brittle nails - trophic changes
• Fuchsig's test negative (left leg) - indicates non-filling of superficial veins, confirming arterial insufficiency

Palpation:

• 2nd and 3rd toes: insensitive, no temperature sensation
• Ulcer: painful, tender; base = subcutaneous tissue
• Both lower limbs: cool on touch
• CRT: 6 sec right, 8 sec left (severely impaired)
• Peripheral pulses - Left: NO pulses below femoral artery; Right: Dorsalis pedis, anterior tibial, posterior tibial - feebly palpable

Auscultation: No bruit over either leg

---

DIAGNOSIS

Buerger's Disease (Thromboangiitis Obliterans - TAO) with Critical Limb Ischaemia Left foot: Dry gangrene of 2nd and 3rd toes + ischaemic ulcer, Fontaine Stage IV

• Young age (40 years)
• Heavy beedi smoker (beedis have higher nicotine content)
• Distal small vessel involvement (digits first)
• Progressive distal gangrene
• No DM, HTN, dyslipidaemia

---

INVESTIGATIONS

• Allen's test - assess upper limb involvement (TAO often affects upper limbs too)
• Segmental limb pressures - confirms distal occlusion pattern
• DSA / CTA - classic "corkscrew collaterals" around occlusion pathognomonic of Buerger's disease
• Biopsy of affected vessel (rarely done) - shows acute segmental thrombosing vasculitis with preservation of internal elastic lamina
• Hypercoagulability screen - ANA, ANCA (to exclude vasculitis mimics)

---

MANAGEMENT

1. Absolute and permanent smoking cessation - MANDATORY; only intervention that halts progression
2. Antiplatelet therapy - Aspirin/Clopidogrel
3. Iloprost (prostacyclin analogue) IV infusion - improves tissue perfusion, reduces ulcer pain
4. Calcium channel blockers (Nifedipine) - vasodilation
5. Wound care - antiseptic dressings
6. Sympathectomy (lumbar) - for rest pain palliation; increases skin blood flow; does NOT improve claudication
7. Revascularisation - limited options due to distal small vessel involvement; bypass rarely feasible; omental transfer (rarely)
8. Amputation - if gangrene extends, infection supervenes, or conservative management fails; aim for most distal level that heals

---

VIVA QUESTIONS

Q1. What is Buerger's disease?

Q2. How do you distinguish TAO from atherosclerotic PAD?

Q3. What is Fuchsig's test?

Q4. What is the role of sympathectomy in PVD?

---

---

LONG CASE 6 - BREAST CARCINOMA

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

• Lump in the left breast for 6 months

---

HISTORY OF PRESENTING COMPLAINTS

• Insidious onset, gradually progressive
• Initially 2×2 cm → now 8×8 cm - rapid enlargement over 6 months
• Distortion of shape of left nipple - nipple retraction/deviation
• No pain over the lump, no ulceration
• No nipple discharge or bleeding
• No trauma to breast
• No swelling in same breast, opposite breast, or axillae (at presentation)

---

PAST / FAMILY / PERSONAL HISTORY

• Not a k/c/o DM/HTN/IHD/TB
• No previous surgeries
• No significant family history

---

GENERAL PHYSICAL EXAMINATION

• Moderately built and nourished; conscious, oriented
• Pulse: 88/min; BP: 110/70 mmHg
• PICCLE: Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema - to be checked

---

LOCAL EXAMINATION - LEFT BREAST

Inspection:

• Asymmetry of breasts; left breast larger
• Nipple retraction / deviation - left nipple
• Skin changes: to note peau d'orange (dimpling), erythema, satellite nodules
• Dilated veins over left breast

Palpation:

• Single, ovoid, 8×7 cm, hard, non-tender lump
• Moves with breast tissue (not fixed to chest wall)
• Surface smooth with well-defined margins
• Occupies upper outer + inner quadrants + central quadrant (extending across)
• Clinical photographs show: lump being measured (~8 cm), hard mass, nipple distortion

• Single, 2×2 cm, firm, non-tender, mobile lymph node in left central group (level I)

---

DIAGNOSIS

Carcinoma of Left Breast - T3 N1 M0 (Stage IIIA)

• T3: Tumour >5 cm (this is 8 cm)
• N1: Mobile ipsilateral axillary lymph node involved
• M0: No distant metastasis (to be confirmed with staging)

---

INVESTIGATIONS

Diagnostic Triple Assessment:

1. Clinical Examination (done)
2. Imaging - Mammography ± USG breast
3. Histopathology - Core biopsy (preferred over FNAC)

Imaging:

Histopathology:

• Core needle biopsy (Trucut biopsy) - provides tissue diagnosis + receptor status
• Receptor status (IHC):
  • ER (Oestrogen Receptor)
  • PR (Progesterone Receptor)
  • HER2/neu
  • Ki-67 (proliferation index)
• Triple-negative (ER-/PR-/HER2-) = poorest prognosis

Staging Investigations:

---

MANAGEMENT

Step 1 - Multidisciplinary Team (MDT) approach

Step 2 - Neoadjuvant Chemotherapy (NAC)

• For T3/T4 or N+ disease - recommended before surgery
• Aims: downstage tumour → potentially allow breast conservation; assess chemosensitivity
• Regimen: Anthracycline-based (AC) followed by Taxane (T): AC×4 → Paclitaxel×4
• Response assessed by clinical exam + imaging after 3 cycles

Step 3 - Surgery

Option A: Modified Radical Mastectomy (MRM) - standard for this case

• En bloc removal of: all breast tissue + nipple-areola complex + level I + II axillary lymph nodes + pectoralis minor fascia (Patey's operation)
• Pectoralis major preserved (unlike Halsted radical)
• Indication here: Large tumour (8 cm), central location, nipple involvement

Option B: Breast-Conserving Surgery (BCS/Lumpectomy)

• Wide local excision + sentinel lymph node biopsy (SLNB) / axillary clearance
• Requires: tumour <4-5 cm, adequate margins, patient preference, facility for radiotherapy
• Not ideal here given 8 cm tumour and nipple distortion

Axillary Management:

• SLNB - if axillary node clinically suspicious but small and mobile
• Axillary lymph node dissection (ALND) Level I-III - for confirmed N1 disease

Step 4 - Adjuvant Therapy

---

VIVA QUESTIONS

Q1. What is the triple assessment for a breast lump?

Q2. What are the clinical signs suggesting malignancy in a breast lump?

Q3. What is peau d'orange? What causes it?

Q4. What are the levels of axillary lymph nodes?

• Level I: Lateral to pectoralis minor (anterior, posterior, lateral groups)
• Level II: Deep to pectoralis minor (central group, interpectoral/Rotter's nodes)
• Level III: Medial to pectoralis minor (apical/infraclavicular) This patient has central group (Level I) involvement.

Q5. What is the difference between MRM and Halsted radical mastectomy?

Q6. What is the significance of ER/PR/HER2 status?

• ER/PR+: Endocrine therapy (Tamoxifen/AI) - 50% relative risk reduction in recurrence
• HER2+: Trastuzumab (monoclonal antibody against HER2) + Pertuzumab
• Triple negative (ER-/PR-/HER2-): Chemotherapy only; BRCA mutation testing; poorest prognosis

---

---

LONG CASE - INDIRECT INGUINAL HERNIA

---

PATIENT DETAILS

---

CHIEF COMPLAINTS

• Swelling in right groin since 1 year

---

HISTORY OF PRESENTING COMPLAINTS

• Single swelling, appeared above groin crease, then extended into scrotum
• Initially small, gradually increasing in size
• Increases in size with cough, straining, lifting weight
• Disappears on lying down - reducible
• No pain, no vomiting, no bowel changes

---

LOCAL EXAMINATION

• Pyriform shaped swelling, 8×4 cm (or 5×6 cm in repeat exam)
• Extending from above and medial to inguinal ligament down into scrotum
• Cough impulse: PRESENT - expansile impulse on coughing
• Penis in midline
• Spontaneously reduces in supine position - reducible hernia
• Cannot get above the swelling - confirms inguino-scrotal nature
• Consistency: doughy, granular (omentum/bowel)
• Testis palpable SEPARATELY from swelling - distinguishes from hydrocele

• Ring Occlusion Test: On occluding deep ring with thumb → swelling DID NOT appear on coughing = Indirect hernia (deep ring occlusion controls indirect hernia)
• Zieman's test: Cough impulse at index finger (pointing at deep ring) - confirms indirect
• Finger Invagination test: Cough impulse felt at TIP of finger - confirms indirect (direct = side of finger)

---

DIAGNOSIS

Right-sided Reducible Indirect Inguinoscrotal Hernia

---

INVESTIGATIONS

Pre-operative:

• FBC, RFT, LFT, blood sugar, urine routine
• ECG, CXR (anaesthetic fitness)
• Coagulation profile
• USG Groin - if diagnosis in doubt; differentiates hernia from hydrocele, lymph nodes
• Spirometry if chronic cough (identify cause)

---

MANAGEMENT

Surgical - Standard Treatment: Inguinal Hernia Repair

Open Tension-Free Mesh Repair:

• Lichtenstein's Repair - most common operation worldwide; polypropylene mesh placed in the inguinal canal over the posterior wall; tension-free (Bailey & Love; Current Surgical Therapy 14e)
• Recurrence rate: ~1% (vs. 10-20% for tissue repairs)

Laparoscopic:

• TAPP (Transabdominal Preperitoneal) - mesh placed laparoscopically
• TEP (Totally Extraperitoneal) - avoids peritoneal cavity; preferred
• Advantage: faster recovery, bilateral repair simultaneously

For Inguinoscrotal hernia:

• Herniotomy (ligation of sac at deep ring) + herniorrhaphy/hernioplasty
• Sac dissected from cord structures; high ligation at deep ring; mesh reinforcement

---

VIVA QUESTIONS

Q1. What is the difference between indirect and direct inguinal hernia?

Q2. What is Hesselbach's triangle?

Q3. What is the significance of "cannot get above the swelling"?

Q4. What is Lichtenstein's repair?

Q5. What are complications of inguinal hernia repair?

---

---

SHORT CASE 2 - VARICOSE VEINS WITH VENOUS ULCER

---

PATIENT DETAILS

• 37-year-old male, painter by profession
• Non-healing, painful ulcer of right lower limb for 6 months
• History of "swollen nerves" (tortuous dilated veins) and blackish discolouration of skin of lower 1/3rd of same limb

---

CLINICAL PHOTOGRAPH

• Medial aspect of right ankle/gaiter area - classic location for venous ulcer
• Lipodermatosclerosis - thickened, indurated, pigmented (haemosiderin deposition) skin in lower 1/3rd
• Hyperpigmentation of gaiter area (inverted champagne bottle leg)
• Tortuous dilated veins (varicosities) visible on leg

---

DIAGNOSIS

Primary Varicose Veins with Venous (Stasis) Ulcer - CEAP Class C6

• C0: No visible venous disease
• C1: Telangiectasia/reticular veins
• C2: Varicose veins
• C3: Oedema
• C4: Skin changes (pigmentation, lipodermatosclerosis)
• C5: Healed ulcer
• C6: Active venous ulcer ← this patient

---

INVESTIGATIONS

• Duplex Doppler USG - confirms venous reflux; identifies incompetent perforators; assesses deep vein patency (rule out DVT)
• Trendelenburg test - locates sapheno-femoral junction (SFJ) incompetence
• Perthe's test - excludes deep vein thrombosis/obstruction
• ABI - rule out arterial component before compression therapy (ABI must be >0.8)
• Wound swab C&S

---

MANAGEMENT

Ulcer Care:

1. Four-layer compression bandaging - mainstay of treatment; reduces venous hypertension; heals 70-80% ulcers
2. Elevation of limb at rest
3. Wound debridement + antiseptic dressings (silver-impregnated, alginate)
4. Skin grafting for large chronic ulcers

Varicose Vein Treatment:

1. High saphenous ligation + stripping (Trendelenburg operation) - ligation of SFJ + stripping of long saphenous vein
2. Endovenous laser ablation (EVLA) / Radiofrequency ablation (RFA) - preferred in modern practice
3. Foam sclerotherapy - injection of sclerosant (sodium tetradecyl sulphate) for smaller veins
4. Subfascial endoscopic perforator surgery (SEPS) - for incompetent perforators near ulcer

---

VIVA QUESTIONS

Q1. What is the pathophysiology of venous ulcer?

Q2. Why is the gaiter area (medial malleolus) the classic site for venous ulcers?

Q3. What differentiates venous from arterial ulcer? (See Long Case 4 comparison table above.)

Q4. What is lipodermatosclerosis?

---

---

SHORT CASE 5 - THYROGLOSSAL CYST

---

PATIENT DETAILS

• 15-year-old female
• Spherical cystic swelling in front of neck of size 1.5×1.5 cm
• Moves with protrusion of tongue AND moves with deglutition

---

CLINICAL PHOTOGRAPHS

• Two images showing a midline anterior neck swelling in a young female
• Smooth, well-defined, cystic swelling in the midline at the level of hyoid bone/just below
• No skin changes; skin freely mobile over swelling

---

DIAGNOSIS

Thyroglossal Duct Cyst

---

INVESTIGATIONS

• USG Neck - confirms cystic nature; confirms presence of normal thyroid inferiorly (mandatory before surgery - 1-2% of cases, the cyst IS the only functioning thyroid)
• Thyroid function tests - rule out hypothyroidism
• FNAC - if any doubt about diagnosis or firm component (rule out ectopic thyroid carcinoma - ~1% risk, papillary carcinoma most common)
• CT scan - for large cysts or retrosternal extension

---

MANAGEMENT

1. Transverse incision over the cyst
2. Complete excision of cyst
3. Excision of central portion of hyoid bone (body)
4. Excision of entire tract from hyoid to foramen caecum (base of tongue)

• Rationale: Removing the hyoid body and complete tract prevents recurrence (recurrence if only cyst excised = 30-40%; with Sistrunk = <5%)

---

VIVA QUESTIONS

Q1. What is the embryological basis of thyroglossal cyst?

Q2. Why does a thyroglossal cyst move with tongue protrusion?

Q3. What are the common sites of thyroglossal cyst?

Q4. Why must you confirm the presence of a normal thyroid before surgery?

Q5. What is the most common malignancy arising in a thyroglossal cyst?

---

---

SHORT CASE 10 - SOLITARY THYROID NODULE (GOITRE)

---

PATIENT DETAILS

• 32-year-old male, Tumkur
• Swelling in front of neck for 6 years, gradually increasing
• No pressure symptoms (no dysphagia, dyspnoea, stridor)
• No hypo/hyperthyroidism symptoms

---

EXAMINATION

• Single smooth-surfaced swelling; lower border visible
• Left carotid pulse felt (pushing the carotid laterally)
• Trachea shifted to the RIGHT - mass effect from left-sided/large right nodule
• Moves with deglutition (attached to thyroid gland)
• No other neck swellings
• No lymphadenopathy documented

---

DIAGNOSIS

Solitary Nodule Thyroid (Solitary Thyroid Nodule - STN) Most likely: Benign colloid/adenomatous nodule OR follicular adenoma Must exclude: Carcinoma thyroid (40% risk of malignancy if radiation history (Schwartz's Surgery))

---

INVESTIGATIONS

TIRADS (Thyroid Imaging Reporting and Data System):

• TIRADS 1-2: Benign
• TIRADS 3: Probably benign; follow-up
• TIRADS 4-5: Suspicious/malignant; FNAC mandatory

Bethesda Classification (FNAC):

• I: Non-diagnostic (repeat)
• II: Benign (follow-up)
• III: Atypia of undetermined significance (repeat/molecular testing)
• IV: Follicular neoplasm (surgery)
• V: Suspicious for malignancy (surgery)
• VI: Malignant (surgery)

---

MANAGEMENT

Conservative (Bethesda II, TIRADS 1-2):

• Regular USG follow-up every 6-12 months
• Levothyroxine suppression (controversial; not routinely recommended)

Surgical (Indications):

• FNAC Bethesda IV-VI (suspicious/malignant)
• Tracheal deviation / compressive symptoms (as in this patient)
• Size >4 cm
• Rapid growth
• Cosmetically unacceptable

• Hemithyroidectomy (Lobectomy + isthmusectomy) - for indeterminate FNAC (Bethesda III/IV) or benign-appearing large nodule; allows definitive histology
• Total thyroidectomy - if FNAC malignant, bilateral nodules, family history, or frozen section confirms malignancy intraoperatively
• Frozen section - if FNAC inconclusive; extends to total thyroidectomy if malignancy confirmed

---

VIVA QUESTIONS

Q1. What features of a thyroid nodule raise suspicion for malignancy?

• Hard consistency, fixed, irregular
• Rapid growth
• Hoarseness (RLN invasion)
• Dysphagia
• Palpable cervical lymphadenopathy
• History of neck irradiation
• Family history of thyroid cancer or MEN
• Male sex (higher risk in males)
• Cold nodule on scan
• TIRADS 4-5 on USG

Q2. What is Pemberton's sign?

Q3. What are the types of thyroid carcinoma in order of frequency?

1. Papillary (~80%) - best prognosis; psammoma bodies; RET/PTC mutation; lymph node spread
2. Follicular (~10%) - haematogenous spread (bone, lung); worse prognosis than papillary
3. Medullary (~5%) - from parafollicular C-cells; elevated calcitonin; associated with MEN2
4. Anaplastic (~1-2%) - worst prognosis; elderly; rapidly fatal

Q4. What is the management of a "cold nodule" on thyroid scan?

Q5. What structures are at risk in thyroid surgery?

1. Recurrent laryngeal nerve (RLN) - runs in tracheoesophageal groove; unilateral injury = hoarseness; bilateral = stridor/respiratory distress
2. Parathyroid glands (4 in number) - devascularisation → hypocalcaemia; tetany (Chvostek's/Trousseau's signs)
3. External branch of superior laryngeal nerve - injury → loss of high-pitched phonation (singer's nerve)
4. Superior/inferior thyroid vessels
5. Thoracic duct (left side)

---

• Bailey & Love's Short Practice of Surgery 28e (Varicose veins CEAP, Inguinal hernia, Hernia repairs)
• Sabiston Textbook of Surgery (Thyroglossal duct cyst, Breast cancer)
• Schwartz's Principles of Surgery 11e (Solitary thyroid nodule, Breast cancer)
• Current Surgical Therapy 14e (Inguinal hernia repair, PVD)
• Tintinalli's Emergency Medicine (ABI, peripheral arterial disease)
• Fitzpatrick's Dermatology (ABI approach diagram)