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K. Navaras. Indiana University - Purdue University, Fort Wayne.

Retention enemas with water soluble corticosteroids are often beneficial in patients with disease limited to rectum and sigmoid colon generic 80 mg tadapox with visa erectile dysfunction doctors in sri lanka. The main function of these agents is to maintain remission rather than treating an acute attack tadapox 80 mg amex erectile dysfunction doctor in pakistan. A balanced milk-free diet should be given and too hot or too cold food should be rejected. In nutshell medical management for mild and moderate attack should be as follows : Prednisolone 5 mg four times a day, sulphasalazine 0. If sudden relapse breaks out during this therapy medical management for severe attack should be adopted. Hydrocortisone sodium succinate 100 mg in approximately 120 ml saline administered by rectal drip twice a day. Parenteral feeding by aminosol with fructose or ethanol or some equivalent preparation and parentrovite are prescribed. Patient is discharged with the treatment of prednisolone 5 mg 4 times a day, sulphasalazine 0. Immunosuppressive drug like azathioprine should do good in this disease as it has got some autoimmune background. After the abdomen has been opened, a full exploration is made with particular attention to the state of the liver and of the biliary tract, as gallstones are not uncommon. The colon is examined carefully with particular reference to any adhesion to any neighbouring structures which might have sealed-off perforation. If so, care must be taken to mobilise the colon lest spillage of faeces should contaminate the peritoneal cavity. The ureters are identified at the pelvic brim and a nylon tape is passed round each one, so that the subsequent dissection of the rectum can be carried out without risk of damaging them. The blood vessels to the ascending, transverse and descending colons are ligated with catgut and divided. The tissue, surrounding the rectum, is distended by injection of a solution of 1 : 200,000 noradrenalin in normal saline. The perineal surgeon, after a concentric dissection of anal sphincters, concentrates on dissecting anteriorly until the pouch of peritoneum in front of the rectum is opened. He follows the plane of cleavage just behind the rectum without entering the presacral space, where he can injure the autonomic nerves. He follows this plane of cleavage right upto the tip of the coccyx, where he meets the surgeon from the perineum. The proximal end is closed with a purse-string suture, the ends of which are held with a pair of artery forceps. The perineal skin is also sutured with nylon with a pelvic drain in the middle of the perineal wound. A disc of skin and subcutaneous tissue, 3 cm in diameter is cut from the anterior abdominal wall from the site previously marked. The ends of the purse-string suture of the ileum are used to pull the ileum out through this hole in the abdominal wall until it protrudes about 3 inches, thus ensuring that the finished ileostomy will be a spout of at least Vi inches in length. The ileum is anchored to the posterior rectal sheath by a number of interrupted sutures to prevent prolapse. At this stage of operation, a drain from the pelvic floor is brought out through a stab wound in the left iliac fossa. The ileum is turned inside out and the edge of the mucosa is anchored to the edge of the skin with interrupted catgut sutures. A suitable ileostomy appliance is immediately fixed and the operation is completed. As soon as ileostomy has started working, the patient can take ordinary light diet which can be increased gradually. Sometimes ileostomy alone may be performed in gravely ill patients, who are not suitable for total colectomy. Attempt should always be made not to do this operation as the diseased colon, which is often toxic and may easily perforate is left in the abdomen. Total colectomy is not a very difficult operation and if required an experienced surgeon should be called for to do this operation. Moreover, in subsequent stage when the patient has recovered to certain extent and a total colectomy is being planned, the surgeon may face adhesions due to previous ileostomy operation. Such bag is supported by a waist strap and also is adhered to the skin by special adhesive plaster. Care must be taken that the lower rim of the bag does not press on the lower margin of the ileostomy spout. During the first few postoperative days, liquid stool comes out and fluid and electrolyte balance should be well maintained. If soreness or excoriation of the skin occurs, a paste of aluminium 10 parts and zinc oxide 90 parts should be applied on the skin. A paste of Karaya gum may also be used as both protective and adhesive before applying the ileostomy bag. After a few weeks the stool gradually becomes thickened and semisolid, so ileostomy care becomes easier. Occasionally there may be bolus obstruction or stenosis of the stoma, which requires digital dilatation. This type of ileostomy requires no bag or appliance and can be emptied by the patient at a time he desires to do it. It is made in such a fashion that ileal content cannot escape through the ileostomy until the patient passes a catheter for emptying of the ileal pouch. A disposable appliance can be placed over the ileostomy so that the surrounding skin remains healthy. Modern appliances are also available to get a better stoma care with almost no skin problem. Complications of ileostomy are prolapse, retraction, stenosis, bleeding and paraileostomy hernia. Other possible alternative operation is subtotal colectomy with ileorectal anastomosis. This procedure may be tried in patients who have refused ileostomy or if the rectal segment is not severely diseased or strictured or there is Fig. Some patients suffer from continuing severe ulcerative proctitis who will require total colectomy with ileostomy later on. The third alternative is colectomy, mucosal proctectomy and endorectal ileoanal anastomosis. As the disease is mostly confined to the mucosa and submucosa, mucosal proctectomy will get rid of the disease so chance of developing ulcerative colitis in the remnant rectum is minimal. About 30% to 60% (according to various reports) of cases of Crohn’s colitis are associated with disease of the ileum also. The small bowel is involved in approximately 50% of cases of Crohn’s colitis (considering various series), whereas in ulcerative colitis small bowel is involved in only 10% of cases as ‘back-wash ileitis’.

A certain length of thigh or leg or forearm should be kept for proper fitting of the stump buy tadapox with a visa erectile dysfunction pump. In forearm order discount tadapox erectile dysfunction unable to ejaculate, optimum length is 20 cm (8 inches), measured from the tip of the olecranon. But under no circumstances, the stump should be less than 8 cm for proper fitting of the artificial limb. In arm, the optimum length is again 20 cm (8 inches), as measured from inferior angle of acromion. In thigh, the optimum length is 25 to 30 cm (10-12 inches) as measured from the tip of the greater trochanter. The muscles are sutured in such a way that they will be converted into fibrous tissue and will serve as an effective cushion, which protects the skin; (v) The vascularity of the flaps should be normal; (vi) There should be no projecting spur of bone; (vii) The stump should neither be redundant nor be under tension; (viii) The position of the scar should be such, as to avoid pressure; (ix) The resulting scar should be fully mobile and should neither be adherent nor be infolded. In case of upper limb, the scar may be terminal, but in case of lower limb, a posterior scar is desirable to avoid pressure of weight on the artificial limb. In case of forearm, the scar should be transverse, as antero-posterior scar may be pulled up between the two bones. Otherwise this type of amputation has become obsolete as there is a good chance of secondary infection, which not only involves the soft tissues but also the bone. Whenever it is used nowadays, it is always followed by re-amputation at a higher level, in a flap method to cover the bone end with soft tissues. There are different types of flap method — circular, elliptical, racquet, semicircular or rectangular etc. In circular method the skin and muscles are divided circularly at a lower level than the bone, so that they provide a covering for the bony stump. This method has got special advantage in case of doubtful vascularity as the flaps are not long enough to become devitalised. In elliptical or oval method the upper end of the ellipse is placed on the level of the bone section while the lower end should lie at a distance below this, equal to M times the diameter of the limb. Racquet method is often used in case of disarticulation at the metacarpal or metatarsophalangeal joints and is also applied for disarticulation of the shoulder or the hip joint. The incision for this type of amputation looks like a racquet, with a straight incision resembling the handle of the racquet and a circular or elliptical incision, resembling the blade of the racquet, continuous with the straight incision. Semicircular or rectangular method is by far the most widely practised amputation. When a single flap is used, the length should be 1V£ times the diameter of the limb at the level of the bone section. The muscles are divided transversely at a level below the bone section just to allow them to be sutured together over the bone end. A rubber bandage may be wound to get rid of the venous blood and then the tourniquet is applied. After making the incision, it is the usual practice to get hold of the named vessels and ligate them properly as the first step of operation. With a scalpel incision is made along the skin mark through the skin, subcutaneous tissue and deep fascia. Moreover, it will act as a barrier between the scar and the bone, so that the scar will not get a chance to be adhered to the bone. Whenever opposing groups of muscles will not be available as in case of amputations through the leg, one group of muscles should be taken over the end of the bone and sutured to the periosteum of the other side of the bone. If they are involved in the scar tissue, continuous pain or pain during movement of the limb will be intolerable to the patient. The periosteum is generally cut through the same level but it may be stripped only sufficiently to expose the bare bone and to prevent development of ring sequestrum. In only below-knee amputation, the periosteum is first cut at the level of the skin incision, and reflected off the tibia in continuity with deep fascia. Before a saw is used to divide the bone, the muscles should be well retracted either with a shield or with a towel. When the bone is subcutaneous, it should be bevelled, so that the sharp edge of the divided bone will not project through the skin. Opposing groups of muscles are sutured across the bone ends with interrupted stitches. It is a good practice to provide a drain, which should preferably be a suction drainage (Redivac). The wound is covered with gauze and cotton wool and bandaged tightly from below upwards. This can be best done by enclosing the stump in a plaster of Paris cast which should extend above the joint proximal to the stump. The stitches are removed from 7 to 10 days when the wound is healthy by taking off the plaster cast. Amputation may be followed by deep vein thrombosis and pulmonary embolism in the early postoperative days. So subcutaneous heparin 5,000 units twice daily is strongly advised for several weeks after operation. Stump neuroma, which is proliferation of nerve fibrils at the point of nerve division. In all amputations there will be some amount of neuroma formation, but painful neuroma is the result of a faulty technique. Painful phantom is a distressing condition, in which the patient complains of pain in the amputated part of the limb, which he actually does not possess. Necrosis of the skin flap may occur if the vascular supply of the flaps are not sufficient enough. Some patients may be troubled by cold and discoloured stump particularly during winter due to ischaemia. That means the palmar flap should be longer to retain the tactile sensation, which is the most important function of a finger. By this, one can preserve the attachment of the flexor and extensor tendons of the phalanges. But for better cosmetic purpose, the marginal metacarpal bones should be obliquely divided, so that it will be very difficult to realise that a finger is missing. A transverse incision is made on the dorsal surface th inch (7 mm) distal to the prominence of the knuckle. Two lateral incisions are extended distally from the two ends of this dorsal incision, so that they meet at the tip of the finger. The flaps are raised along with the subcutaneous tissue and the knife is played keeping close to the bone. The phalanx is divided with bone shears just distal to the attachment of the tendons. Special care should be taken in case of the index and the little fingers, where short stump i.

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Passage of a ureteral catheter beyond an area of obstruction may perforate ureter buy tadapox now erectile dysfunction after stopping zoloft. The patient may also complain of nausea buy cheap tadapox 80 mg erectile dysfunction due to diabetes icd 9, vomiting and distension of abdomen due to paralytic ileus. Sometimes ureterovaginal or cutaneous urinary fistula develops, which usually appears within first 10 days after operation. It must be remembered that bilateral ureteral injury or ligation is manifested by postoperative anuria. If there is stab or gun-shot wound in the loin, penetrating injury to the ureter should be suspected This usually takes place in the midportion of the ureter. Straight X-ray is not of much help except it may demonstrate a large area of increased density in the pelvis or in the retroperitoneal tissue which may arouse suspicion. Excretory urography is more valuable as it may show a diffuse shadow below the kidney on the injured side. If one ureter has been tied inadvertently non­ visualisation of kidney of that side may occur due to transient failure of function. It is a fairly useful means to detect ureteral injury in the post-operative cases. If the ureter has been partially clamped or included in a ligature, the clamp is immediately removed or the ligature is quickly cut. This is followed by cystoscopic catheterisation of the ureter and the catheter is passed beyond the point of injury. The distal end of the ureteric catheter is brought out per urethra and secured to a small indewelling Foley catheter. If the viability of the ureter is in question, the damaged segment is excised and the ends are mobilised for end-to-end anastomosis with interrupted 4/0 Dexon. A splinting catheter is always used in these cases which is removed endoscopically after 1 week. Firstly the superior pedicles of the bladder and if needed the inferior pedicles are divided to mobilise the bladder up. This allows the fundus of the bladder to be brought up about 2 inch above the pelvis, where it is anchored to the psoas sheath. This tubularisation of the bladder will allow 3 inches of extra length for a tension free implantation of the ureter. If this also fails ileal interposition may be used In all cases a reflux preventing reimplantation of the ureter into the bladder should be performed. A submucous tunnel is created into which the ureter is implanted obliquely through the muscles of the bladder. In case of upper ureteral injuries, if ureteral anastomosis is not possible, ureteroureterostomy is performed by swinging the proximal ureter across to the ureter of the other side for anastomosis. Often however the surgeons may face stiff resistance from the patients as they have already undergone extensive surgery very recently. At this stage if the ends are clean cut and no length is lost, end-to-end anastomosis should be performed. In upper ureteral injuries either end-to-end anastomosis or uretero­ ureterostomy should be performed. If for whatever reason the patient cannot be reoperated within 3 days, it is wise to wait for as many months as possible. It is unwise to re-explore on the 10th day or within 1 month, as the reparative processes are in full swing with hyperaemia, tissue oedema and new capillary loops formation It will be unwise to enter this field, as nothing can be seen or done due to excessive haemorrhage from the new capillary loops. If at all one has to re-explore at this time, then ureteroureterostomy should be carried out leaving the initial operation field undisturbed. If surgery is undertaken after an interval of 3 months, then any of the techniques described in Group I may be adopted. For the result of complete block the students are referred to the section of ‘Acute renal Failure’, later in this chapter. Congential hydronephrosis means it is caused by obstruction which developed congenitally e. Unilateral hydronephrosis occurs when the obstruction is somewhere in the ureter, above the level of the urinary bladder. Bilateral hydronephrosis occurs when the obstruction is below the level of the urinary bladder e. When there is a definite detectable cause of hydronephrosis, it is called secondary hydronephrosis. Pressure on the ureter by loaded sigmoid colon, gravid uterus, uterine tumours and ovarian tumours. It is often a lower polar artery which supplies the inferior segment of the kidney. Such artery may not arise from the renal artery but instead from aorta, common iliac artery or spermatic or ovarian artery. Such aberrant vessel may cause hydronephrosis in children and may be considered as congenital hydronephrosis. Often this displaced vessel may cause rapid increase in the size of hydronephrosis, but may not be a cause of it. The hydronephrosis might have been an idiopathic’ variety or due to neuromuscular imbalance at the pelviureteric junction and this so called aberrant vessel’ may have just increased the size of the hydronephrosis or is a simple coincident. Ureterocele and congenital atretic ureteric orifice also cause congenital hydronephrosis 3. There are certain acquired intramural causes which may lead to unilateral hydronephrosis. These are inflammatory stricture of the ureter mostly due to tuberculosis or following removal of an impacted stone. Stricture of ureter may follow trauma to the ureter during other operations in the pelvis or may follow ureteroureterostomy. Neoplasm of the ureter (mostly papilloma of the ureter) is rare and may cause unilateral hydronephrosis. What is more common is a malignant neoplasm of the bladder involving one ureteric orifice C. Calculus in the ureter is not only the most common in this group, but also the most common cause of unilateral hydronephrosis. Congenital folds at the upper end of the ureter may cause congenital unilateral hydronephrosis. Congenital valves are more commonly seen in the posterior urethra and these cause bilateral congenital hydronephrosis, although one side hydronephrosis may be bigger than the other side. Benign prostatic enlargement and pros­ tatic carcinoma are very common causes ofbilat- eral hydronephrosis with hydroureter. Inflammatory stricture of the urethra is the commonest cause of acquired bilateral hydronephrosis in the young and young adults.

In renal hypertension the rise is too little (segment A) and prolongation of third phase order tadapox cheap online impotence pills. This when injected intravenously and scanned by gamma camera will provide more information regarding renal plasma flow purchase tadapox with paypal erectile dysfunction doctors in nc. By this technique one can also perform an antegrade pressure perfusion test devised by Whitaker, in which method a fine needle puncture of the collecting system is performed and thus inflow and continuous monitoring of intrapelvic pressure are assessed. This test is not so efficient to determine the function of kidney as the previous test, but in injury, it shows the portion of kidney affected and supersedes the previous test to determine the type of operation to be required. So the patient has to halt respiration which may not be possible for all and there may be some blurring of images especially in the upper abdomen, (iii) The apparatus is large and expensive. One must be veiy careful to select the type of investigation he would require in a particular case. Angiography can delineate the source and extent of vessels supplying renal tumours, but the examination is relatively expensive, commonly requiring a hospital stay. Now particularly the external genitalia with retracted prepuce is cleansed with a soapy antisep­ tic solution. This instrument is introduced through the urethra in the similar fashion as a bougie. Cystoscope is mainly used to visualise inside ofthe bladder, though ureteric catheters may be intro­ duced through the ureteric orifices retrogradely to perform retrograde urography. Systemic inspections of the inside of the bladder is extremely important to exclude any pathology there. After the cystoscope has been introduced into the bladder, sterile water is instilled into the bladder to distend it. The ureteric openings are usually situated at 4 O’clock and 8 O’clock positions indicated by a knob on the handle. Ureteric catheterisation is performed for — (i) To collect specimen of urine from individual kid- (ii) To perform retrograde pyelography. Nowadays more sophisticated endoscopes have been introduced to inspect the inside of the ureter (ureteroscope) and inside of the kidney (nephroscope). In case of chronic prostatitis one may notice pus exuding through the numerous prostatic ducts. The kidney is well protected by ribs, vertebral bodies, lumbar muscles and the viscera. Blows, or falls on the loin and crushing road traffic accidents are the usual causes of injury to the kidney. Fractured ribs and transverse vertebral processes may penetrate the renal parenchyma. Any such injury in the back or in the flank should be well examined to exclude renal injury. Associated abdominal visceral injuries are present in majority (80%) of such penetrating wounds. Pathology and classification — Blunt trauma usually causes laceration of the kidney in the transverse plane. This minor renal trauma in fact constitutes majority (85%of cases) of renal injuries. Under this heading three types arc commonly seen — (i) Subcapsular haematoma in association with contusion. The various types in this category are :— (i) Complete fissure or tear of the renal parenchyma and pelvis to cause gross haematuria. The vascular injury is rare and constitutes only 1% or less of all renal injuries. Various types of injury in this category are :— (i) Stretch on the main renal artery without avulsion may cause renal artery thrombosis. The most important feature of vascular injuries is that it is difficult to diagnose and if this is not made quickly, it results in total destruction of the kidney. This can be easily diagnosed by excretory urography after all major renal injuries. Blood flow in non-viable tissue due to injury is compromised, which also results in renal hypertension. In case of penetrating injuries, the type of weapon should be interrogated and assessed. In case of gun-shot wounds, the type of gun should be questioned as high velocity bullets cause much more extensive damage than low velocity ones. Microscopic or gross haematuria following trauma to the abdomen or loin indicates injury to the kidney. Gross haematuria may occur in minor renal injury, whereas mild haematuria can occur in major trauma. Presence of haematuria should not be taken lightly and it demands full evaluation of injury to the kidney. Pain may be due to fractured ribs or pelvic fractures and due to injury to other abdominal viscera. The patient often complains of haematuria following accident Haematuria may occur just after the accident, or may appear some hours after the accident, or it may be as delayed as between 3rd day to 3rd week after the accident. So when kidney injury has been suspected, the patient must be followed up carefully. When haematuria is profuse, the patient may complain of clot colic, which is almost similar to ureteric colic due to calculus. General abdominal distension may be complained of after one or two days of injury This generalised abdominal distension is called ‘metcrorism’. In local examinations there may be ecchymosis or bruise in the loin or upper part of the abdomen or in the back. A large palpable mass represent large retroperitoneal haematoma or extravasation of urine. Occasionally if the peritoneum is ruptured blood or urine may enter the peritoneal cavity causing distension of the abdomen. Straight X-ray ofthe abdomen will disclose fracture of lower ribs or vertebral body or transverse process fracture. An increased soft tissue opacity in the renal area and obscuring the psoas shadow are the features of extravasation of blood and urine. Extent of haematoma may be judged by displacement of colon and stomach and there may be small bowel dilatation due to ileus if there be extensive retroperitoneal haemorrhage. Excretory urography is performed as soon as the intravenous lines are established and resuscitation has begun. It is mandatory to demonstrate first and foremost an intact functional kidney on the other side.

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