Esophagus

Achalasia

Cause…… no relaxation of lower esophageal sphincter

Dysphagia… to both solid and fluids (more to fluids)

Regurgitation… risk of aspiration pneumonia

Inv:

Manometric studies… most accurate test “Weak or absent peristaltic waves & marked increase LES tone”

Barium mea l … Marked dilatation of upper 2/3 of the esophagus and tapering of lower end

Endoscopy

TTT:

HELLER'S OPERATION (myotomy)……of choice

Dilators OR botulinum toxin injection…elderly not able to tolerate operations.

Diffuse esophageal spasm (DES)

Retrosternal pain precipitated by hot and cold drinks

Dysphagia

N.B. Pt usually describe classical presentation of food stuck in food pipe associated e’ chest pain which is relieved by drinking water after which pt can continue meal

Barium study… Cork screw appearance (Nutcracker esophagus)

Most accurate inv… manometry studies

TTT… nitroglycerine, Ca channel blockers

SCLERODERMA/ CREST$

-Fibrosis and complete atrophy of the esophageal smooth muscle

-Dysphagia, heartburn, and sticking sensation in the throat

N.B. characteristic findings in manometric study… significant decrease in the lower esophageal sphincter tone “i.e. incompetent LES”

N.B. Possible complication of CREST $... Reflux esophagitis and a stricture

-TTT… PPIs

GERDTypical presentation… heartburn, regurgitation, gas/ excessive eructation

- Pt presents e’ typical symptoms of GERD… PPI +life style modifications

Alarm signals/ indications of upper GI endoscopy for GERD pts: 1) Nausea/vomiting 2) Weight loss, anemia or melena/blood in the stool 3) Long duration of symptoms (>1-2 years)4) Failure to respond to proton pump inhibitors

- Failure to respond to PPI or complication… upper GI endoscopy . - If upper GI endoscopy is negative… 24 hours Esophageal pH monitoring N.B. Most accurate test for GERD… Esophageal pH monitoring

‒ Complications… erosive esophagitis, & peptic stricture formation. Barrett's esophagus, adenocarcinoma of the esophagus,

Lines of TTT of GERD:

- Life style modifications (wt loss, light frequent meals… etc)- Medical… PPI is the best

- Surgical… Nissen’s fundoplicationN.B. long standing antacids use as OTC medication for heartburn/ hypracidity… risk of Milk Alkali $

Esophageal stricture

History of prolonged GERD

Now…dysphagia but no longer GERD …imp

Inv…….endoscopy

Small……PPI

Severe symptoms… dilation

N.B. other causes of esophageal stricture:

-Corrosive

-Medications (Bisphosphonate, NSAIDs… etc)

BARRET'S ESOPHAGUS :

Cause …….long standing GERD

Pathology… change of the squamous epithelium to Columnar

epithelium (VVV imp)

RISK………adenocarcinoma of the esophagus

Inv……….endoscopy

IF metaplasia……..biopsy

If NO dysplasia…….repeat the endoscopy every 3 ys

If low grade dysplasia…..repeat the endoscopy every 6 months

If high grade dysplasia… Laser ablation or surgery

Best medical ttt…….PPI……vvvv imp

HIATUS HERNIA:

Sliding type:

-Most common type (95%)

- Same as GERD

Rolling type:- Rare (only 5% of cases)- Severe type and herniation of gut organs may occur- TTT… surgery

Cancer esophagus:

Adenocarcinoma… GERD, Barret’s esophagus

SCC… smoking and alcohol

Location:

Adenocarcinoma… lower 1/3 (most common pathology nowadays)

SCC… mostly upper 2/3

Cp…..OLD pt e’ Dysphagia, WT LOSS +/- regurgitation

N.B. recent onset of dysphagia in pt >50 ys is highly suggestive of esophageal cancer especially if the pt had recent wt loss

TTT:

-Surgery, chemotherapy, radiotherapy according to stage

- STENT for dysphagia … VVV imp

ZENKER'S DIVERTICULUM

‒ Posterior herniation of mucosa of the proximal oesophagus above the upper oesophageal sphincter, through the fibres of the cricopharyngeal muscle. ‒ Motor dysfunction & incoordination… retention of food material, regurgitation… risk of aspiration pneumonia‒ Dysphagia, regurgitation, and halitosis

‒ Inv. Of choice… Barium esophagography ‒ TTT… surgical OR endoscopic [cricopharyngeal myotomy].

N.B. triad of dysphagia + Glossitis + IDA… plummer- vinson $

N.B. Dysphagia in Plummer- Vinson $ is DT… post-cricoid esophageal we b

N.B. TTT of Plummer- Vinson $… dilation of esophageal web + iron supplementation for IDA

Schatzki ring:

RING Narrowing of the lower esophagus

CP: dysphagia

INV: esophagogastroduodenoscopy or barium swallow

TTT… endoscopic dilatation

Mallory Weiss VS Boerhaave$

Mallory Weiss syndrome

Gastro-esophageal laceration ……partial tears

Severe alcoholism, retching, coughing, or vomiting

Cp…..vomiting up blood after violent retching or recurrent attacks of vomiting

Definitive diagnosis ………. endoscopy.

Treatment: supportive

Boerhaave syndrome:Full-thickness tear… rupture of the esophageal wall

History…….. Severe alcoholism, retching, recurrent vomiting.

Presentation… severe chest pain, upper abdominal pain

O/E… supra-sternal crepitus (DT pneumomediastinum)

Inv… gastrograffin study (esophagography)

TTT… urgent surgical repair

Stomach

Hematemesis:

Causes:

Peptic Ulcer……most common cause

Reflux Esophagitis

Esophageal Varices

Mallory Weis$

Esophageal and gastric cancer

Acute erosive gastritis (e.g. long standing NSAIDs)

Investigation ……… Upper Endoscopy (diagnostic & therapeutic)

First step……….fluid resuscitation

If you need to give blood…………….PACKED RBCS IS THE BEST

Medical TTT:

-IV PPI… for acute erosive gastritis, bleeding peptic ulcer

-IV terlipressin (or IV octreotide)… for rupture esophageal varices

Congenital hypertrophic pyloric stenosis (CHPS)

Pathology…..hypertrophy of pyloric muscles

Age… symptoms start at 2-6 weeks…..vvv imp

Clinical picture;

NON- BILIOUS vomiting

Dehydration and loss of weight

Exam…………..olive like mass

Inv…………..ULTRASONOGRAPHY

RISK………..HYPOKALEMIA AND DEHYDRATION

TTT..…

First step…….correct dehydration and electrolyte disturbances

Then…………..surgery (Ramsted pyloromyotomy)

Peptic ulcer

Site……Duodenum more than gastric…..imp

Risk factors:

Helicobacter

pylori…………main cause (80%)

Others……….smoking, alcohol, stress, NSAIDS

CLINICAL PICTUR:

Abdominal pain, dyspepsia, N&V

N.B. Abdominal pain is a key point in DD of gastric and duodenal ulcers is timing of pain;

-Gastric… during eating> pt avoid food> wt loss

-Duodenal… 2-3 hs after food (eating improves pain)> Pt eat more> wt gain

Investigations of H. pylori…

- Serum antibody, stool antigen, or urea breath test (C13 breath test)

- Best inv for F/U after eradication… Urea breath test

Most accurate investigation… endoscopy and biopsy (only gastric ulcer)

TTT……….ERADICATION OF H.PYLORI

Triple therapy… amoxicillin, clarithromycin, and PPI

If penicillin allergy… metronidazole, clarithromycin and PPI

Follow up after eradication… urea breath test

Complications:

-MC complication of PUD… hemorrhage

-perforation… sudden onset abdominal pain+ peritonitis in pt e’ long standing H/O dyspepsia

-1st inv… x-ray

N.B. Site of collection after peptic ulcer perforation….lesser sac

N.B. Artery injured after perforation of duodenal ulcer……gastro-duodenal A

-2ry pyloric stenosis… pt e’ long H/O dyspepsia presented e’ early satiety, frequent N&V, abdominal distension

N.B. 3 important scenarios of pyloric stenosis; - CHPS, Post- corrosive injury, and complication of PUD (duodenal ulcer)

Gastric cancer

Symptoms Early: Heartburn, upper abdominal pain, nausea, loss of appetite. Later: Weight loss, vomiting, difficulty swallowing, blood in the stool

Risk factors

H. pylori, blood group A, smoking

inv : Biopsy done during endoscopy

Virchow's node (Troisier’s sing)

Enlarged lymph node in the left supraclavicular fossa

It takes its supply from lymph vessels in the abdomen

Clinical significance: cancer stomach/ cancer pancreas

Dyspepsia:Functional painNo organic lesionAny abdominal discomfort with no organic lesionEpigastric pain , fullness, bloating,heart burn, nauseaN.B. Recent onset dyspepsia, H. Pylori serology is negative and the pt didn’t respond to PPI therapy… next step: upper GI endoscopy

Coeliac Disease ( Gluten -Sensitive Enteropathy ):

Any age (children 9-18 months)Cause… auto-immune disease C/P:-Previously healthy infant FTT (wasting buttocks is very characteristic) + fatigue -Malabsorption… Steatorrhea + abdominal distension - IDA, Folate Deficiency Anemia, vitamin B12 deficiency anemia Investigations:For screening :

IG Antiendomysial AB IGA Transglutamines IGA Antigliadin

For confirmation : Duodenoscopy & Biopsy … golden standard… atrophic villi

Complications:- Intestinal Lymphoma…….MOST FEARED COMPLICATION- Skin… dermatitis herpitiformis - OsteoporosisN.B. Celiac sprue can be associated e’ other A-I conditions (e.g. T1DM, hypothyroidism… etc)TTT:1-Gluten free diet 2-vitamin replacement3-Dapsone ……..for dematitis herpitiformis

N.B. Pt with long term celiac sprue, recently developed diarrhea and wt loss… DX: small intestinal lymphoma

N.B.Any pt with confirmed celiac disease who experience recurrence of the symptoms despite gluten-free diet +/- wt loss… intestinal lymphoma until proven otherwise N.B. dimorphic RBCs in celiac diseases strongly suggest overlap between vitamin B12 deficiency and IDA (even if MCV is high)

N.B. when you decide to test pt for celiac sprue… Gluten must be included in pt diet

Whipple's disease

Rare, systemic disease caused by the bacterium Tropheryma whipplei

Signs and symptoms

Diarrhea, steatorrhea, abdominal pain, weight loss

Fever and Migratory arthropathy

Neurological symptoms

Diagnosis: Duodenal endoscopy … (PAS -positive macrophages )

TTT… penicillin, ampicillin, tetracycline, or co-trimoxazole for one to two years

Tropical sprue

Signs and symptoms

Diarrhoea Steatorrhoea or fatty stool Weight loss and malnutrition

Diagnosis

Abnormal flattening of villi and inflammation of the lining of the small intestine

Low levels of vitamins A, B12, E, D, and K, as well as serum albumin, calcium, and folate,

Excess fat in the feces (steatorrhoea).

TTT… tetracycline or Co-trimox for 3 to 6 months.

N.B. specific point for DX of Whipple’s disease… positive PAS macrophage on lamina propria of jujenal biopsyN.B. specific point for DX of tropical sprue… onset of symptoms after recent travel

Diarrhea tips and tricks:Most common adenoma causing electrolytes disturbances…..villousMost common electrolyte imbalance in diarrhea….. HypokalemiaAcid-base imbalance in diarrhea… Non- anion gap metabolic acidosisMost common cause of bloody diarrhea….campylobacterSecond most common cause of bloody diarrhea…shigellaMost common cause of traveler diarrhea….E-coliDiarrhea after camping…..GiardiaTraveler diarrhea lasting >2 weeks and associated e’ steatorrhea… GiardiaMost common cause of diarrhea in pediatrics…viralMost common virus causing diarrhea in kids……rotavirusDiarrhea followed by weakness and areflexia (Ascending paralysis)…GBSDiarrhea followed by renal impairment….HUSBloody diarrhea followed by RUQ pain….ameba> amoebic liver abscessChronic bloody diarrhea in young male…..IBDDiarrhea after long term antibiotics....clostridium difficileMC Antibiotic causing clostridium difficile….clindamycinTTT of clostridium difficile ….metronidazole (vancomycin for severe cases/ failure to respond to metronidazole)Diarrhea after eggs or chicken…..salmonellaDiarrhea/ vomiting just hours after meal… staph toxinDiarrhea in bed ridden with constipation...fecal impaction Main TTT of diarrhea…..fluid TTT of traveler diarrhea…..fluid onlyTTT of staph toxin…..fluid onlyTTT of shigella or campylobacter….antibioticsTTT of ameba or giardia….metronidazole1st Inv of choice for acute diarrhea (<14 days)… stool C&MHIV+ watery diarrhea… cryptosporidium parvum HIV+ bloody diarrhea… CMVLong standing diarrhea after recent travel:1. Non- bloody/ watery/ steatorrhea… Giardiasis2. Bloody… campylobacter jejuni

Pseudomembranous colitis: Organism………………Clostridium difficile

Cause...............recent use of antibiotics..........key word

Most common causative antibiotic............clindamycin

Signs and symptoms:

Abdominal pain+

Watery diarrhea (mild to severe life-threatening)

Recent Abs use/ hospitalization followed by severe watery diarrhea… pseudomembranous colitis

Inv:Stool analysis… cytotoxic stool assay

Treatment:

Mild cases ...........no treatment…..majority heal spontaneously

Metronidazole ….. initial drug of choice for mild to moderate disease Oral vancomycin is preferred for more severe disease or diarrhea

persists after a course of metronidazole

Colon disorders:

•Colon Cancer :

Risk factors:

• Older age and family history • A personal history of colorectal cancer or polyps. ... • Inflammatory Bowel disease (esp: UC)... • Low-fiber, high-fat diet. ...

Rt ColonLt ColonSigmoidRectum

Iron deficiency Anemia

Altered bowel habit

Complete Bowl Obstruction

Bleeding

DyspepsiaPartial Obstruction

Altered bowl Habits

Abdominal Mass

Abdominal massPainRectal bleedingTenesmusMC symptom of cancer cecum……….anemia, pallor and fatigue

Caner cecum may cause……….mass in RT iliac fossa

MC symptom of cancer rectum…..bleeding per rectum

MC symptom of cancer left colon….alteration in bowel habits

Investigation

1-X-ray… apple core apperance

2-Colonoscopy & biopsy… investigation of choice

N.B. EVACULATE the colon one day before the endoscopy using Mg citrate enema

N.B. TTT of choice of fecal impaction… Mg citrate enema

N.B. TTT of choice of constipation that failed to respond to oral medications, suppositories... Mg citrate enema

Screening for recurrence after colon cancer operation :

•Colonoscopy…the most imp…..EVERY YEAR

CEA……in between

Inflammatory bowel disease (IBD)

Crohn's disease (CD)Ulcerative colitis (UC)

Features Diarrhoea usually non-bloody

Steatorrhea Weight loss more

prominent. Upper GI symptoms,

mouth ulcers. Perianal disease. Abdominal mass

palpable in the right iliac fossa.

Bloody diarrhoea more common.

Tenesmus. Abdominal pain in the left

lower quadrant.

Extra-Gallstones morePrimary sclerosing cholangitisintestinalcommon 2ry to(PSC) more common

reduced bile acidreabsorption.

Oxalate renal stones.

ComplicationsObstruction, fistula, anal tags, colorectal cancer.

Risk of colorectal cancer high in UC than CD.

PathologyLesions may be seen anywhere from the mouth to anus.

Skip lesions

Inflammation always starts at rectum and never spreads beyond ileocaecal valve.

Continuous disease.

HistologyInflammation in all layers from mucosa to serosa (transmural)

↑ Goblet cells. G ranulomas (non-caseating

granuloma)

No inflammation beyond submucosa

Depletion of goblet cells Crypt abscesses.

Endoscopy Deep ulcers, Skip lesions, 'Cobble-stone'

appearance.

Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps')

RadiologySmall bowel enema High sensitivity and

specificity for examination of the terminal ileum.

Cobblestone appearance String sign'. 'Rose thorn' ulcers. Fistulae (e.g.

colovesical)

Barium enema Loss of haustrations Superficial ulceration,

'pseudopolyps' Long standing disease: colon is

narrow and short-'drainpipe colon'

Management of Crohn's disease (CD):

- Inducing remission … 1st line… Glucocorticoids 2nd line… 5-ASA (mesalamine or sulphasalazine)

- Maintenance of remission… Azathioprine or mercaptopurine - Crohn’s e’ isolated peri-anal disease… Metronidazole - Crohn’s e’ multiple peri-anal fistula… Infliximab - Patients should be strongly advised to stop smoking.

Management of UC:

- TTT of acute exacerbation… IV steroids -Maintenance TTT …

1st line… oral 5-ASA (e.g. mesalamine)

Ulcerative colitis& colorectal cancer

- Risk of colorectal cancer is 10-20 times that of general population- Related to the duration, frequency of relapse and severity of the

disease- Surveillance by… colonoscopy

Toxic megacolon

Megacolon= marked enlarged colonToxic= full of toxin

Simply, it’s marked enlargement of the colon (or segment of it) which became full of toxins

Etiology… - Infectious (e.g. severe cases of pseudomembranous

colitis)- Inflammatory (e.g. ulcerative colitis)

Presentation…- Severe abdominal pain, bloody stool- Marked toxicity (weakness, lethargy, confusion)

- Examination… marked abdominal distension and picture of peritoneal irritation

Investigation… - Abdominal X-ray

TTT…- Medical/ surgical emergency- Admission to ITU, IV fluids- IV steroid in case of IBD/ IV antibiotics in case of

infectious cases- Possible surgical resection (high risk of perforation

and death)- If rupture colon is suspected… urgent laparotomy

Irritable bowel syndrome:age… more in young peoplepersonality… more in pt under stressChronic abdominal painAlternating constipation with diarrheaStool…..ribbon shapedDiagnosis…..clinicallyAll investigations are… normalTTT:High fiber diet……main line of tttLaxatives… for constipationLoperamide… for diarrhea Spasmolytics… for the pain/ colic

TTT of choice… SSRIOther lines of TTT… psychotherapy/ CBT

Anus

1-Piles

PF………. Constipation and pregnancy

Cp…………bleeding but NO PAIN

Piles not painful unless complicated (2ry infected or thrombosed)

Inv… colonoscopy with old age… to exclude cancer

TTT…

Mild…..diet and band ligation

Severe …..Surgery

If thrombosed piles ….give analgesia 1st step ….imp

Anal fissure

Etiology:

Constipation

Chron's causes multiple fissures

.PAIN with slight bleeding

How to examine… just inspection… DRE contraindicates

TTT:

Diet….increase fluid and vegetables

Local Anesthesia +GTN cream…….1st line

Peri-anal hematoma

-Sudden pain around anus developed over few hours (Acute presentation)

-No fever or discharge

-O/E… purplish (Red- Purple) lesion in or on the border of the anus

-No H/O piles or anal fissure (it is neither External hemorrhoid nor sentinel pile)

-TTT… syringe aspiration in the 1st few hours

-TTT… I&D if blood clot is formed (later presentation)

Anal abscess

Painful Swelling in the anal area Throbbing pain is characteristic Pus drainage near the anus Fever

TTT: incision and drainage + Abs

Anal fistula

Most common cause of:

Perianal fistula……..abscess

Recurrent or multiple fistulae……crohn's

Cp… Persistent purulent discharge

TTT… surgery

N.B. TTT of choice of Crone’s disease e’ fistula… Infliximab

Anal cancer :

Draining LN……….inguinal LN

TTT…………chemo and radio

Gall bladder disorders

GB stone/ biliary colic:

Obese, fecund woman in her 40s.

.Recurrent episodes of RT UPPER QUADRANT pain

Radiating to the right shoulder & back .

Often triggered by fatty food.

.Inv of choice… abdominal USG

TTT of biliary colic… Laparoscopic Cholecystectomy

N.B. TTT of asymptomatic GB stone/ accidently discovered … Reassure.

ACUTE CHOLECYSTITIS

By a stone cause………… occlusion of the CYSTIC DUCT.

. CP:

Constant pain in the RUQ

. Fever

leukocytosis & peritoneal irritation.

MOST IMP INV……………US (Thick walled gall bladder - Pericholecystic fluid)

IF US IS EQUIVOCAL………..HIDA scan

TTT: resuscitation (IV fluids and abs) and laparoscopic cholecystectomy within 72 hours

: ACUTE ASCENDING CHOLANGITIS

.medical emergency

Obstruction of the CBD… ASCENDING INFECTION

Most common organism……….E-coli

. High fever & very high WBC count

. High levels of alkaline phosphatase

. High levels of total & DIRECT bilirubin

Clinical picture :

Charcot’s triad… abdominal pain, Fever, and jaundice

If not treated urgently… hypotension & confusion DT septic shock (Charcot’s triad+ hypotension & confusion= Reynold’s pentad)

TTT…

1st… resuscitation (IV fluids, IV antibiotics)

2nd… emergency decompression (ERCP)

Then… Cholecystectomy

US AND GALL BLADDER STONES :

Most imp inv for gall bladder stones……US

If the CBD is markedly dilated next step……ERCP

Pain only……………biliary cholic

Pain and fever……….cholecystitis

Pain and jaundice………….choledicolithiasis

Pain, jaundice, fever, (+/- hypotension, and confusion)… cholangitis

Gallstone ileus

Small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine.

Pneumobilia … (air within the biliary tree)

Evidence of small bowel obstruction radiopaque gallstone on abdominal radiograph

Treatment:

Initial TTT… Fluid resuscitation and NGT decompression

Definitive TTT… surgery

Post-cholecystectomy syndrome:

Presence of abdominal symptoms after (cholecystectomy).

Dyspepsia, nausea, and vomiting. Persistent pain in the upper right abdomen.]

CAUSES:

Persistence of Stone in CBD

Biliary microlithiasis

Sphincter of Oddi dysfunction

Functional pain

Inv:

1st inv... US

Inv of choice... ERCP

Post- cholecystectomy$

Pt who experience biliary colic after cholecystectomy

- 1st… USG- ERCP>>> if stone found… residual stone in CBD… removal- If no stone>>> do tonometry… sphincter of oddi dysfunction…

ERCP sphinctrotomy- If tonometry is normal… functional pain… reassure

Pancreatic disorders

Acute pancreatitis:

Causes :

Gall stones….commonest for acute pancreatitis

Alcoholism….commonest for chronic pancreatitis

Hyperlipidemia

Post ERCP

CP:

SEVERE EPIGASTRIC ABDOMINAL PAIN RADIATING TO THE BACK (relieved by setting and leaning forward)

Nausea, vomiting

O/E… Tenderness and guarding

Investigations:

1st inv to be done… Amylase and lipase

Then… CT abdomen

TTT… mainly conservative (NPO, BOWEL RSET, ANALGESIC, and HYDRATION)

Complications:

1-Pseudocyst…..most common complications

Timing …………..within 4-6 weeks

Cp…………………..epigastric MASS

Fate………………..usually resolve spontaneously

When to drain… If it persists more than 6 wks, size more than 6 cm

How to drain it… Endoscopic internal drainage to stomach

2 -Acute renal failure

3--ARDS…….BILATERAL INTERSTITIAL INFILTRATE

4-Hypotension, hypoxemia, and hypocalcemia

N.B. Small beads on pancreas after ERCP… pancreatitis (fat necrosis)

CHRONIC PANCRATITIS

MC Cause… alcoholism

Cause in young age… Cystic fibrosis (true story of “fault in our stars” movie)

Chronic epigastric pain

Malabsorption… diarrhea and steatorrhea

Weight loss and DM

Amylase and lipase …….normal/ mildly increase

CT… THE BEST … calcification

TTT… PANCREATIC ENZYMES REPLACEMENT

PANCREATIC CANCER

Sex……….usually old age male

Most cancer causes death within 5 years

Risk factors… SMOKING, DM, ALCOHOL

Dull abdominal pain radiating to back

Weight loss

If at head…………deep jaundice

Recurrent thrombophlebitis (Trousseau sing)

Enlarged Lt supraclavicular LN (Troisier’s sing) (Virchow’s node)

Investigations:

Serum bilirubin…….increased (direct)

US……..DILATATION OF GALL BLADDER

MASS AT HEAD OF PANCREAS

CT………….BEST (inv of choice)

TTT… Whipple’s operation

Symptomatic TTT… stent

N.B. Cause of jaundice in cancer pancreas… Obstruction of CB

Salivary gland disorders

ACUTE PAROTITIS:

Cause…..bad oral hygiene and dehydration

Organism……staph

Cp……. Painful swelling and pus from the duct

Preverntion………..hydration and oral hygiene

TTT……antibiotic

Salivary gland stones:

Site:

Submandibular……..most common

Parotid…….. rare

Cp:

Swelling and pain increased by eating

Pain referred to the ear

Exam…..enlarged and tender gland

INV:

Intraoral X-ray

Sialogram…..if x-ray doesnot reveal stones

TTT… incision over the duct and stone removal OR total removal of the gland

Mikulicz's disease

In 80% of cases, the parotid gland is affected. Lacrimal glands are also affected.

Most cases appear in conjunction with Sjögren's syndrome.

Lacrimal gland enlargement, parotid gland enlargement

dry mouth and dry eyes

Salivary gland tumors

Most common bengin………pleomorphic adenoma

Most common malignant……….mucoepidermoid carcinoma

Cp:

If benign… painless, slowly growing, well- defined

If malignant…… painful, rapid growing, affecting facial nerve

So if a patient with swelling in front of the ear with facial nerve paralysis… parotid malignancy until proven otherwise

Inv:

BIOPSY… the main INV … vvvv imp

Pleomorphic adenoma…….recurrence after removal

Main nerve affected during surgery…….facial nerve