SWORD as usual

A case of blocked PEG - to look for distal obstruction and then consider replacing it

PGU:
Q - How much air is needed to see air under diaphragm
A - "More than 250cc" - Mr. Azim

Q - How many percent pt with PGU presented without air under diaphragm
A - "20 to 22%"

Q - What abdominal xray sign suggest PGU
A - "Rigler's sign" - Mr. Hanafiah * double wall sign

SWORD Again

Shanker presented a case of Forest IIb ulcer at cardia of stomach. Patient presented with heamatemesis and currently having dengue fever. One of his differential was varieces.

"haematemesis is not equal to varieces" - Prof. Ismail
"ulcer at cardia is not common" - Mr Hanafiah

Q - risk of developing ulcer in a dengue fever case?
Q - what is Deiu La Foy?
Q - pathogenesis of PUD, how does aspirin induce PUD?

Fuad

Q - "Does a midline scar withold you from laparascope surgery?" - Prof. Ismail
A - nope, can go through Palmars point


Fresh PR bleed

"massive PR bleed secondary to UGIT is about 20%" - Prof. Rohaizak
"do colonoscope first then +/- OGDS"
"I will kill you if you say do OGDS first in a patient with massive fresh PR bleed" - Prof. Rohaizak....

SWORD

A case of advance CA rectum complicated with colocutaneus fistula.
- defination of high output fistula
- management:
fluid loss replace with hartmans, Hartmans is not use for fluid maintainance because of its HCO3 content. Prolong use of Hartmans pt will become metabolic alkalosis.
local control - stoma bag around fistula, to avoid skin excoriation

A case POD 12 for lap cholecystectomy, discharge post op day 1 - op uneventful until 5 days ago pt developed epigastric pain which radiate to back.
Q: what could be the diagnosis or worries?
A: bile leak, maybe due to dislodge clips

Pt amylase was 651, with LFT showed hepatocellular injuries i.e. raised in ALT, AST
A diagnosis of acute pancreatitis was made

2nd case was a referral from orthopaedic wanting as to do scope to look for primary. She presented with right shoulder pain and swelling x 6/12 and now paraplegic x 1/12. Noted a scapulla mass. HPE preliminary came back as metastasis tumour. Thoracolumbar ? mets to T12. CA 125 raised 241. No GI symptoms. No obstructive sx. No neck or breast mass.
Prof Ismail bought up the issue was for advance cases like this is scope indicated or just academic. If a tumour was to be found in GI, prognosis is poor. The best management for her is to palliate the pain with radiotherapy and palliative chemo.

* to do a mammogram one need to be standing so paraplegic pt is out of the question

TQ

Previous SWORD

Previous SWORD

ERCP (Prof. Razman)
- precut?
- different type of biliary stent
- can be divided into internal and external stent
- internal consists of plastic and metallic stent. Plastic to change every 3/12. Metalic for advance cases
- external consists of PTBD, T-Tube

Management of acalculous cholecystitis (Prof Ismail)
Pathology of acalculous cholecystitis
- usually happens in ill pt bed bound
- due to biliary stasis, ischemic gallbladder i.e. poor blood supply - not contracting

Colovesico Fistula
- how does it present (Mr. Hanafiah)
- pneumothuria
- why does pt pass air thru the meatus not the other way round i.e. pass urine thru anus

* Faizi was highlighted as always gets away with question thrown to him

Sword 2/11/2007

"Bilateral adrenal mass are commonly from metastasis, common primary are thyroid, breast and kidney
Adrenocortical adenoma of usually does not cause pain, unless inflammation of adrenal glands"

Sword 16/11/2007

"Pt with hepatitis B with no chirrosis can get HCC" - Azim
"TB does not enhance on arterial phase"

Sword 27/1//2007

Pathology of liver abscess
What does skeletal survey comprises of - Prof. Rohaizak