After a patient has undergone total colectomy and ileostomy, the volume of ileal discharge, along with its water content gradually decreases over time. Post surgery, most patients can live a normal life. Iron and vitamin B12 absorption do not take place in the colon and hence are not affected significantly by a colectomy.

High-probability ECG features of MI are the following:
ST-segment elevation greater than 1 mm in two anatomically contiguous leads
The presence of new Q waves

Intermediate-probability ECG features of MI are the following:
ST-segment depression
T-wave inversion
Other nonspecific ST-T wave abnormalities
Low-probability ECG features of MI are normal ECG findings. However, normal or nonspecific findings on ECGs do not exclude the possibility of MI.

Special attention should be made if there is diffuse ST depression in the precordial and extremity leads associated with more than 1 mm ST elevation in lead aVR, as this may indicate stenosis of the left main coronary artery or the proximal section of the left anterior descending coronary artery.

Localization of the involved myocardium based on the distribution of ECG abnormalities in MI is as follows:
– Inferior wall – II, III, aVF
– Lateral wall – I, aVL, V4 through V6
– Anteroseptal – V1 through V3
– Anterolateral – V1 through V6
– Right ventricular – RV4, RV5
– Posterior wall – R/S ratio greater than 1 in V1 and V2, and – T-wave changes in V1, V8, and V9
– True posterior-wall MIs may cause precordial ST depressions, inverted and hyperacute T waves, or both. ST-segment elevation and upright hyperacute T waves may be evident with the use of right-sided chest leads.

Hyperacute (symmetrical and, often, but not necessarily pointed) T waves are frequently an early sign of MI at any locus.
The appearance of abnormalities in a large number of ECG leads often indicates extensive injury or concomitant pericarditis.
The characteristic ECG changes may be seen in conditions other than acute MI. For example, patients with previous MI and left ventricular aneurysm may have persistent ST elevations resulting from dyskinetic wall motion, rather than from acute myocardial injury. ST-segment changes may also be the result of misplaced precordial leads, early repolarization abnormalities, hypothermia (elevated J point or Osborne waves), or hypothyroidism.
False Q waves may be seen in septal leads in hypertrophic cardiomyopathy (HCM). They may also result from cardiac rotation.
Substantial T-wave inversion may be seen in left ventricular hypertrophy with secondary repolarization changes.
The QT segment may be prolonged because of ischemia or electrolyte disturbances.
Saddleback ST-segment elevation (Brugada epsilon waves) may be seen in leads V1-V3 in patients with a congenital predisposition to life-threatening arrhythmias. This elevation may be confused with that observed in acute anterior MI.
Diffuse brain injuries and haemorrhagic stroke may also trigger changes in T waves, which are usually widespread and global, involving all leads.
Convex ST-segment elevation with upright or inverted T waves is generally indicative of MI in the appropriate clinical setting. ST depression and T-wave changes may also indicate the evolution of NSTEMI.
Patients with a permanent pacemaker may confound recognition of STEMI by 12-lead ECG due to the presence of paced ventricular contractions.
To summarize, non-ischemic causes of ST-segment elevation include left ventricular hypertrophy, pericarditis, ventricular-paced rhythms, hypothermia, hyperkalaemia and other electrolyte imbalances, and left ventricular aneurysm.

Dukes staging and 5 year survival:
Dukes A – Tumour confined to the bowel but not extending beyond it, without nodal metastasis (95%)
Dukes B – Tumour invading bowel wall, but without nodal metastasis (75%)
Dukes C – Lymph node metastases (50%)
Dukes D – Distant metastases (6%)

The pancreas is divided into five parts; the head, body, neck, tail, and the uncinate process. Of the five parts, tumours located at the head of the pancreas in most instances cause obstruction of the common bile duct more often than tumours in the other parts of the pancreas. This is because the common bile duct passes through the head of the pancreas from the gallbladder and the liver (it is formed where the cystic and the hepatic bile duct join) to empty bile into the duodenum. This biliary obstruction leads to accumulation of bile in the liver and a consequent bilirubinaemia (raised levels of blood bilirubin). This results in jaundice. The pancreas is not divided into lobes.

A below-knee amputation (“BKA”) is a transtibial amputation that involves removing the foot, ankle joint, and distal tibia and fibula with related soft tissue structures. In general, a BKA is preferred over an above-knee amputation (AKA), as the former has better rehabilitation and functional outcomes. There are three major categories of indications for proceeding with a BKA. These include:
– Urgent cases where source control of necrotizing infections or haemorrhagic injuries outweighs limb preservation.
– Less acutely, urgent BKAs may be performed for chronic nonhealing ulcers or significant infections with the risk of impending systemic infection or sepsis.
– Urgent BKAs may be performed where limb salvage has failed to preserve a mangled lower extremity. Adequate resuscitation and stabilization must always have occurred before such a decision, as judged by vital signs, lactate, base deficit, and the management of concomitant injuries.
This man is hemodynamically unstable and the limb is likely to be non-viable after so many hours of entrapment. Hence, the safest option would be primary amputation of the injured limb.

A sperm granuloma is a lump of extravasated sperm that appears along the vasa deferentia or epididymides in vasectomized men.
Sperm granulomas are rounded or irregular in shape, one millimetre to one centimetre or more, with a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas can be either asymptomatic or symptomatic (i.e., either not painful or painful, respectively). If it is painful, it can be treated using over-the-counter anti-inflammatory /pain medication. If it causes unbearable discomfort, it may need to be surgically removed. However, they generally heal by themselves. Statistics suggest that between 15-40% of men may develop a granuloma post-vasectomy.

An increase in the frequency of sound waves results in a change in the position of maximal displacement of the basilar membrane in the cochlea. Low pitch sound produces maximal displacement towards the cochlear apex and greatest activation of hair cells there. With an increasing pitch, the site of greatest displacement moves towards the cochlear base. However, increased amplitude of displacement, increase in the number of activated hair cells, increased frequency of discharge of units in the auditory nerve and increase in the range of frequencies to which such units respond, are all seen in increases in the intensity or a sound stimulus.

Bile leak may be classified into a minor leak with low output drainage (<300 ml of bile/24 hours) or leaks due to major bile duct injury with high output drainage (>300 ml/24 hours).

The majority of minor bile leak results from Strasberg type A injuries with intact biliary-enteric continuity and includes leaks from cystic duct (CD) stump (55%-71%) or small (less than 3 mm) subsegmental duct in gall bladder (GB) bed (16%) and minor ducts like cholecystohepatic duct or supravesicular duct of Luschka (6%). An injury to the supravesicular duct occurs if the surgeon dissects into the liver bed while separating the gall bladder. This duct does not drain the liver parenchyma.
A leak from the cystic duct stump may occur from clip failure due to necrosis of the stump secondary to thermal injury/pressure necrosis or when clips are used in situations where ties are appropriate (acute cholecystitis) and in a significant majority from distal bile duct obstruction caused by a retained stone and resultant blow out of the cystic stump.
Strasberg type C and type D injuries usually present with a minor leak as well. The former results when an aberrant right hepatic duct (RHD) or right posterior sectoral duct (RPSD) is misidentified as the CD and divided because of the anomalous insertion of CD into either of these ducts.
Type D injuries are lateral injuries to the extrahepatic ducts (EHD) caused by cautery, scissors or clips.

High output biliary fistulas are the result of major transactional injury of EHD (Strasberg type E). Here the common bile duct (CBD) is misidentified as the CD and is clipped, divided and excised. This not only results in a segmental loss of the EHD but often associated with injury or ligation of right hepatic artery as well. Such devastating injuries are peculiar to LC and have been described by Davidoff as “classic laparoscopic biliary injury”.

Early recognition is the most important part of the management of bile leak due to iatrogenic injuries.
Unfortunately, most of the bile duct injuries are not recognized preoperatively. Optimal management of BDI detected postoperatively requires good coordination between the radiologist, endoscopists and an experienced hepatobiliary surgeon.

There is a scope of re-laparoscopy, within 24 hours of surgery, in situations where a low output fistula (<300 ml/day) is confirmed (by reviewing the operative video), to be because of a slipped CD clip. Through lavage, clipping or tying the CD stump with an endoloop may be a simple solution. Such an approach is not useful after 24 hours as inflammatory adhesions and oedema will make the job difficult. If low output controlled biliary fistula is detected after 24 hours, a wait and watch policy should be followed as many of the minor leaks will close within 5 to 7 days. If the leak fails to resolve or if the drainage amount is >300 ml/day (high output), an ERCP should be performed both to delineate the biliary tree and some therapeutic interventions if indicated.

Sarcoidosis is an inflammatory disease of unknown aetiology that affects multiple organs but predominantly the lungs and intrathoracic lymph nodes. Systemic and pulmonary symptoms may both be present. Pulmonary involvement is confirmed by a chest X-ray and other imaging studies. The main histological finding is the presence of non-caseating granulomas.

Answer: MAG 3 renogram

This is the agent of choice due to a high extraction rate, which may be necessary for an obstructed system. Diuretic (furosemide) renogram is performed to evaluate between obstructive vs. nonobstructive hydronephrosis. The non-obstructive hydronephrosis will demonstrate excretion (downward slope on renogram) after administration of diuretic from the collecting system. Whereas mechanical obstructive hydronephrosis will show no downward slope on renogram, with retained tracer in the collecting system.

Pelviureteric junction (PUJ) obstruction/stenosis can be one of the causes of an obstructive uropathy. It can be congenital or acquired with a congenital PUJ obstruction being one of the most common causes of antenatal hydronephrosis. This is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter.
Many cases are asymptomatic and identified incidentally when the renal tract is imaged for other reasons. When symptomatic, symptoms include recurrent urinary tract infections, stone formation and even a palpable flank mass. They are also at high risk of renal injury even by minor trauma.

Symptom: Classically intermittent pain after drinking large volumes of fluid or fluids with a diuretic effect is described, due to the reduced outflow from the renal pelvis into the ureter.

Tc-99m DMSA (dimercaptosuccinic acid) is a technetium radiopharmaceutical used in renal imaging to evaluate renal structure and morphology, particularly in paediatric imaging for detection of scarring and pyelonephritis. DMSA is an ideal agent for the assessment of renal cortex as it binds to the sulfhydryl groups in proximal tubules at the renal cortex with longer retention than other agents. This results in higher concentration and hence much higher resolution with pinhole SPECT imaging. Also, it allows better assessment of differential renal function. It is a static scan as opposed to dynamic DTPA or MAG3 scans.

Jejunostomy feeding (enteral feeding) is now the standard of care in most feeding protocols after esophagectomy. The feeding regimen consists of a gradually increasing volume of feeds in the first five to seven days. Patients should resume oral intake as soon as possible after surgery. In hospital, all forms of enteral access appear to be safe. Out of hospital, the ability to provide home feeding by feeding jejunostomy is likely where meaningful nutritional improvements can be made. Improving nutrition and related quality of life in the early months might improve the long-term outcome

Lymphovenous anastomosis – Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Causes of lymphoedema:
Primary:
Sporadic, Milroy’s disease, Meige’s disease
Secondary:
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis

Other options given:
Homans operation – Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.

Charles operation – All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.

The external carotid artery is a major artery of the head and neck. It arises from the common carotid artery when it splits into the external and internal carotid artery. It supplies blood to the face and neck. The external carotid artery begins opposite the upper border of the thyroid cartilage and, taking a slightly curved course, passes upward and forward and then inclines backward to the space behind the neck of the mandible, where it divides into the superficial temporal and internal maxillary arteries. It rapidly diminishes in size in its course up the neck, owing to the number and large size of the branches given off from it. At its origin, this artery is more superficial and placed nearer the midline than the internal carotid and is contained within the carotid triangle. The external carotid artery is covered by the skin, superficial fascia, platysma, deep fascia and anterior margin of the sternocleidomastoid. It is crossed by the hypoglossal nerve, by the lingual, ranine, common facial and superior thyroid veins; and by the digastric and stylohyoid; higher up it passes deeply into the substance of the parotid gland, where it lies deep to the facial nerve and the junction of the temporal and internal maxillary veins. It is here that it is in danger during surgery of the parotid gland.

Post-operative fever is very common.
It is known to occur after all types of surgical procedures, irrespective of the type of anaesthesia.
Postoperative fever can occur after minor surgical procedures but is rare and depends on the type of procedure. Overall, both abdominal and chest procedures result in the highest incidence of postoperative fever.

In this case:
Acute Fever
Fever occurs in the first week (1 to 7 POD)
POD 7 (5 to 10): Wound infection: Risk increases if the patient is immunocompromised (e.g., diabetic), abdominal wound, duration of surgery greater than 2 hours or contamination during surgery. Signs include erythema, warmth, tenderness, discharge.
Rule out abscess or collections by physical exam plus ultrasound if needed. If an abscess is present, drainage and antibiotics are needed. Prevention is by careful surgical technique and prophylactic antibiotics (e.g., intravenous cefazolin at the time of induction of anaesthesia as well as postoperatively if needed)

Other causes of Postoperative fever:
An Immediate Fever
Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.
– Malignant hyperthermia: high-grade fever (greater than 40 C), occurs shortly after inhalational anaesthetics or muscle relaxant (e.g., halothane or succinylcholine), may have a family history of death after anaesthesia. Laboratory studies will reveal with metabolic acidosis and hypercalcemia. If not readily recognized, it can cause cardiac arrest. The treatment is intravenous dantrolene, 100% oxygen, correction of acidosis, cooling blankets, and watching for myoglobinuria.
– Bacteraemia: High-grade fever (greater than 40 C) occurring 30 to 40 minutes after the beginning of the procedure (e.g., Urinary tract instrumentation in the presence of infected urine). Management includes blood cultures three times and starting empiric antibiotics.
– Gas gangrene of the wound: High-grade fever (greater than 40 C) occurring after gastrointestinal (GI) surgery due to contamination with Clostridium perfringens; severe wound pain; treat with surgical debridement and antibiotics.
– Febrile non-haemolytic transfusion reaction: Fevers, chills, and malaise 1 to 6 hours after surgery (without haemolysis). Management: Stop transfusion (rule out haemolytic transfusion reaction) and give antipyretics (avoid aspirin in the thrombocytopenic patient).

B. Acute Fever
– Fever occurs in the first week (1 to 7 POD).
POD 1 to 3: atelectasis: After prolonged intubation, the presence of upper abdominal incision, inadequate postoperative pain control, lying supine. Should be prevented by incentive spirometry, semi-recumbent position, adequate pain control, early ambulation. Clinically may be asymptomatic or with increased work of breathing, respiratory alkalosis, chest x-ray with volume loss. Treatment includes spirometry, chest physiotherapy, semi-recumbent position (improves expansion of alveoli by preventing pressure from intra-abdominal organs on the diaphragm and hence improving functional residual capacity)
– POD 3: Unresolved atelectasis resulting in pneumonia (respiratory symptoms, Chest x-ray with infiltrate or consolidation, sputum culture, empiric antibiotics and modify according to culture result and sensitivity), or development of urinary tract infection (urine analysis and culture, treat with empiric antibiotics and modify according to culture result and sensitivity)
– POD 5: Thrombophlebitis (may be asymptomatic or symptomatic, diagnose with Doppler ultrasound of deep leg and pelvic veins and treat with heparin)
– POD 7: Pulmonary embolism (tachycardia, tachypnoea, pleuritic chest pain, ECG with right heart strain pattern (a low central venous pressure goes against diagnosis), arterial blood gas with hypoxemia and hypocapnia, confirm diagnosis with CT angiogram, and treat with heparin, if recurrent pulmonary embolism while anticoagulated with therapeutic INR, Inferior vena cava filter placement is the next step

C. Subacute Fever
Fever occurs between postoperative weeks 1 and 4.
– POD 10: Deep infection (pelvic or abdominal abscess and if abdominal abscess could be sub-hepatic or sub-phrenic). A digital rectal exam to rule out the pelvic abscess and CT scan to localize intra-abdominal abscess. Treatment includes re-exploration vs. radiological guided percutaneous drainage
Drugs: Diagnosis of exclusion includes rash and peripheral eosinophilia

D. Delayed Fever
Fever after more than 4 weeks.
Skin and soft tissue infections (SSTI)
Viral infections

The treatment approach primarily depends on the histopathologic classification and the disease stage and involves a combination of surgical management, radiation therapy, and systemic therapy. Surgical management is either breast-conserving therapy (BCT) or mastectomy. Systemic therapy has significantly improved in recent years with the development of hormone therapy (tamoxifen) and targeted therapy (trastuzumab). The most important prognostic factors are lymph node status, tumour size, patient’s age, and tumour receptor status (hormone receptors and HER2).

Clinical characteristics associated with increased venous thromboembolism (VTE) risk in children (listed alphabetically, owing to the current lack of expert consensus or robust data regarding relative risk contributions)
-Anticipated hospitalization > 72 h
-Cancer (active, not in remission)
-Central venous catheter presence
-Oestrogen therapy started within the last 1 month
-Inflammatory disease (newly diagnosed, poorly controlled, or flaring)
-Intensive care unit admission
-Mechanical ventilation
-Mobility decreased from baseline (Braden Q‐score < 2)
-Obesity (BMI > 99th percentile for age)
-Post pubertal age
-Severe dehydration, requiring intervention
-Surgery > 90 min within last 14 days
-Systemic or severe local infection (positive sputum/blood culture or viral test result, or empirical antibiotics)
-Trauma as admitting diagnosis

Pharmacological prophylaxis may be instituted in the following risk groups:
Children in an ICU with a CVC and one other risk factor fit a high‐risk profile and may benefit from pharmacological thromboprophylaxis in the absence of strong contraindications.
For children with either a CVC or admission to an ICU (but not both), two risk factors are recommended before the initiation of pharmacological thromboprophylaxis.
For children with neither a CVC nor ICU admission, at least three risk factors should be present before the initiation of pharmacological thromboprophylaxis.

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally include pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.

Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.
Scaphoid fractures are often diagnosed by PA and lateral X-rays. However, not all fractures are apparent initially. Therefore, people with tenderness over the scaphoid (those who exhibit pain to pressure in the anatomic snuff box) are often splinted in a thumb spica for 7–10 days at which point a second set of X-rays is taken. If there was a hairline fracture, healing may now be apparent. Even then a fracture may not be apparent. A CT Scan can then be used to evaluate the scaphoid with greater resolution. The use of MRI, if available, is preferred over CT and can give one an immediate diagnosis. Bone scintigraphy is also an effective method for diagnosing a fracture which does not appear on x-ray.

The oesophagus receives its blood supply from the following arteries: the inferior thyroid branch of the thyrocervical trunk, the descending thoracic aorta, the left gastric branch of the coeliac artery and the from the left inferior phrenic artery of the abdominal aorta. Hence ligation of the left inferior phrenic will lead to ischemia to some portions of the oesophagus.

Monocytes are white cells that protect the body against harmful pathogens. They are mobile and are produced in the bone marrow, mature there and circulate in the blood for about 1-3 days, where they enter the tissues and transform into macrophages. They are characteristically identified by their large bi-lobed nuclei.

Structures passing through the foramen magnum include the medulla, meninges, tectorial membrane, anterior spinal artery, vertebral artery and spinal branches of the accessory nerve.

The endocardial cushions in the heart are the mesenchymal tissue that make up the part of the atrioventricular valves, atrial septum and ventricular septum. An incomplete fusion of these mesenchymal cells can cause an atrioventricular septal defect. The terms endocardial cushion defect, atrioventricular septal defect and common atrioventricular canal defect can be used interchangeably with one another.

Duodenal ulcers are more common than gastric ulcers and unlike gastric ulcers, are caused by increased gastric acid secretion. Duodenal ulcers are commonly located anteriorly, and rarely posteriorly. Anterior ulcers can be complicated by perforation, while the posterior ones bleed. The reason for that is explained by their location. The peritoneal or abdominal cavity is located anterior to the duodenum. Therefore, if the ulcer grows deep enough, it will perforate, whereas if a posterior ulcer grows deep enough, it will perforate the gastroduodenal artery and bleed.
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food.

Maternal serum screening during the second trimester is a non-invasive way of identifying women at increased risk of having children with a neural tube defect and should be offered to all pregnant women. The results are most accurate when the sample is taken between 15 and 20 weeks of gestation. Elevated levels of alpha-fetoprotein suggest open spina bifida, anencephaly, risk of pregnancy complications, or multiple pregnancy.

Transverse sinus: part of pericardial cavity that is behind the aorta and pulmonary trunk and in front of the superior vena cava separating the outflow vessels from the inflow vessels.
Oblique pericardial sinus: is behind the left atrium where the visceral pericardium reflects onto the pulmonary veins and the inferior vena cava. Sliding a finger under the heart will take you to this space.
Cardiac notch: indentation of the ‘of the heart’ on the superior lobe of the left lung.
Hilar reflection: the reflection of the pleura onto the root of the lung to continue as mediastinal pleura.
Costomediastinal recess: part of the pleural sac where the costal pleura transitions to become the mediastinal pleura.
Sulcus terminalis: a groove between the right atrium and the vena cava

Ankylosing spondylitis usually appears between the ages of 20-40 years old and is more frequent in men. It is strongly associated with HLA-B27, along with other spondyloarthropathies, which can be remembered through the mnemonic PAIR (Psoriasis, Ankylosing spondylitis, Inflammatory bowel disease, and Reactive arthritis).

Rh disease is also known as erythroblastosis fetalis and is a disease of the new-born. In mild states it can cause anaemia with reticulocytosis and in severe forms causes severe anaemia, morbus hemolytcus new-born and hydrops fetalis. RBCs of the Rh+ baby can cross the placenta and enter into the maternal blood. As she is Rh- her body will form antibodies against the D antigen which will pass through the placenta in subsequent pregnancies.

On transmission of a loud sound into the central nervous system, an attenuation reflex occurs after a latent period of 40-80 ms. This reflex contracts the two muscles that pull malleus and stapes closer, developing a high degree of rigidity in the entire ossicular chain. This reduces the ossicular conduction of low frequency sounds to the cochlea by 30-40 decibels. In this way, the cochlea is protected from damage due to loud sounds (these are low frequency sounds) when they develop slowly.

Free radicals are a by-product of chemical reactions with an unpaired electron in their outer most shell. They are capable of causing wide spread damage to cells. They can cause autolytic reactions thereby converting the reactants into free radicals. By absorbing sun light, the energy is used to hydrolyse water into hydroxyl (OH) and hydrogen (H) free radicals which can cause injury by lipid peroxidation of membranes, oxidative modification of proteins and damage to the DNA structure.

The splenic vein runs behind the pancreas, receives the inferior mesenteric vein and joins the superior mesenteric vein to form the portal vein behind the pancreatic neck.

There are two lateral rotators of the arm, the infraspinatus and the teres minor muscles. The infraspinatus muscle receives nerve supply from C5 and C6 via the suprascapular nerve, whilst the teres minor is supplied by C5 via the axillary nerve.