MSC - F. Surgery Answers 2025

II.Physical Examination MethodsInspection:

oPosture, cyanosis, chest shape (e.g., barrel chest in emphysema), use of accessory muscles.

oNail/clubbing changes in chronic hypoxia.

Palpation:

oVocal fremitus, tenderness, chest expansion.

Percussion:

oDullness (fluid or consolidation), tympany (air).

oUsed to map lung borders and assess diaphragmatic movement.

Auscultation:

oNormal (vesicular) vs. abnormal breath sounds (bronchial, amphoric).

oAdventitious sounds: wheezes, crackles, pleural friction rub.

III.Functional Tests

Spirometry / Spirography:

oMeasures vital capacity (VC), forced expiratory volume (FEV), etc.

o Evaluates airway obstruction or restriction.

IV. Laboratory & Instrumental Tests

Blood and Urine Tests:

oAssess inflammation, infection, or systemic effects.

Sputum & Pleural Fluid Analysis:

oCytology, microbiology (TB, malignancy).

Imaging:

o X-ray, CT, Tomography, Bronchography for structural details.

oFluorography for screening.

Endoscopy:

oBronchoscopy – direct airway visualization.

oThoracoscopy – direct pleural examination.

V. Key Clinical Syndromes

Consolidation Syndrome:

oE.g., pneumonia – dull percussion, bronchial breath sounds, increased fremitus.

Cavity Syndrome:

oE.g., lung abscess – amphoric breath sounds, tympanic percussion.

Pleural Effusion:

oDullness, decreased breath sounds, asymmetry, Damoiseau line on X-ray.

Pneumothorax:

oTympany, absent breath sounds, collapsed lung on X-ray.

8. Acute empyema of the pleura. Etiology, clinic, diagnosis, treatment

Acute Empyema of the Pleura (Acute Purulent Pleurisy):

Etiology:

Usually secondary to other purulent diseases (e.g., lung abscess, pneumonia, tuberculosis, gangrene of lung).

Can arise from hematogenous or lymphatic spread of infection from intraabdominal or systemic sources (e.g., appendicitis, peritonitis, osteomyelitis).

Common pathogens:

o Adults: Streptococcus (up to 90%)

o Children: Pneumococcus (up to 70%)

o Also: Staphylococcus, mixed flora.

Clinical Features:

Sudden pleuritic chest pain, worsens on breathing/coughing.

High fever (39–40 °C), tachycardia, dyspnea, dry cough.

On exam:

oAffected side: chest lag, dullness to percussion, reduced breath sounds.

oLarge effusions: mediastinal shift, flattened diaphragm, De

Mussy’s triangle (triangle of hyperresonance above dullness).

Diagnosis:

Chest X-ray: homogeneous opacity, fluid level, mediastinal shift.

Ultrasound/CT scan: loculated effusions.

Pleural aspiration: diagnostic and therapeutic—confirms purulent fluid, sent for culture and sensitivity.

Labs: Leukocytosis, neutrophilia, ↑ ESR, ↓ hemoglobin.

Differential Diagnosis:

Lung abscess (offensive sputum, cavity with air-fluid level).

Suppurative cyst, subphrenic abscess.

Malignancy, echinococcus, complicated pneumonia.

Treatment:

1.Conservative:

Broad-spectrum IV antibiotics, adjusted per culture.

Repeated thoracentesis (needle aspiration of pus).

Supportive care: oxygen, fluids, high-calorie diet, vitamins.

2.Surgical:

Closed drainage: Intercostal tube + active suction (preferred).

Open drainage: Rib resection + open cavity (for thick pus, loculations).

Thoracotomy if no response or complications like bronchopleural fistula.

3.Postoperative Care:

Continued drainage monitoring.

Chest physiotherapy (to re-expand lung).

Further antibiotics, nutrition, respiratory support.

Complications:

Bronchopleural fistula

Fibrosis, lung collapse, chronic empyema

Sepsis, spread to subcutaneous tissue (empyema necessitans)

9.Chronic empyema of the pleura. The reasons for the transition of acute empyema to chronic. Clinic, diagnostics, types of operations

A chronic empyema is a persistent accumulation of pus in the pleural space lasting beyond 4–8 weeks, often following inadequate resolution of acute empyema.

Etiology

Occurs in 5–20% of acute empyema cases due to:

1.Bronchopleural fistula

2.Multiple-cavity empyemas

3.Fibrosing/sclerotic changes in lung tissue

4.Lung destruction with formation of sequestra

5.Residual lung volume mismatch post-resection (i.e., "trapped lung")

6.Ongoing chronic pulmonary infection

7.Inadequate or delayed treatment

Clinical Features

Exacerbation Phase (like acute empyema):

Fever, chills, night sweats

Chest pain, dyspnea

Cough with purulent or foul-smelling sputum

Remission Phase:

Low-grade or absent fever

Reduced sputum output

Mild dyspnea

Chronic Physical Signs:

General intoxication: pallor, fatigue, cyanosis of mucosa

Clubbing (drumstick fingers)

Chest wall deformity

Percussion: dullness over lower chest

Auscultation: decreased or absent breath sounds; possible moist crackles

Diagnostics

1.Clinical history: recurrent infections, non-resolving empyema

2.Chest X-ray (2 projections): air-fluid levels, loculations, fibrous thickening

3.Pleurography (contrast pleural imaging):

o Gold standard for chronic empyema

oAssesses size, shape, and bronchopleural fistula presence

4.CT chest (alternative): defines pleural thickening, trapped lung, fistulas

Treatment

Conservative (Preoperative Phase):

Antibiotics (targeted)

Chest drainage (if possible)

Nutritional and supportive care

Breathing exercises

Note: Conservative measures alone are rarely curative in chronic cases.

Surgical (Definitive Treatment):

Decortication:

o Stripping of fibrous pleural layers to allow lung re-expansion

oIndicated when lung is "trapped" by fibrous peel

Thoracoplasty:

oRemoval or collapse of ribs to obliterate empyema cavity

oMay include muscle flap filling (muscle tamponade)

Open window thoracostomy (Eloesser flap) in select refractory cases

Bifurcation Diverticulum (70–80%):

Traction/mixed type

Symptoms: retrosternal pain, dysphagia, regurgitation, mild fever

Supradiaphragmatic Diverticulum (10–15%):

Pulsion origin

Often asymptomatic (small)

Large ones: dysphagia, vomiting, discomfort, vagus irritation

Pharyngoesophageal Diverticulum (Zenker):

Rare

Often presents with:

o Dysphagia, halitosis

o Regurgitation of undigested food

o Aspiration, cough, gurgling sound in neck

Diagnosis:

Barium swallow (contrast X-ray): shows outpouching

Esophagogastroscopy (EGD): visualization of lumen and diverticulum

Treatment:

Conservative:

Sparing diet: 4–5 meals/day, soft foods

Posture: upright while eating and sleeping

Surgical (if symptomatic or complicated):

Diverticulectomy: removal of diverticulum

Sometimes combined with myotomy (e.g., in Zenker)

11. Chemical burns of the esophagus. Causes, classification, clinic, diagnosis. First aid for chemical burns of the esophagus.

Chemical Burns of the Esophagus

Etiology:

Common: Ingestion of concentrated acids or alkalis (accidental or suicidal).

Rare: Thermal burns.

Pathogenesis:

Acids → Coagulation necrosis (forms a protective eschar; limits penetration).

Alkalis → Colliquative (liquefactive) necrosis (deep tissue penetration, more severe).

Classification by Depth:

1.1st Degree (Mild) – Mucosal injury only.

2.2nd Degree (Moderate) – Involves muscularis, leads to scarring.

3.3rd Degree (Severe) – Full-thickness injury with possible mediastinal involvement.

Clinical Stages:

1. Acute (0–10 days):

oSymptoms: Anxiety, hypersalivation, vomiting, hoarseness, burn toxemia.

2.Stage of Imaginary Well-Being (up to 1 month):

oSymptoms subside, but risk of hemorrhage, perforation, mediastinitis, pleural empyema.

oWeight loss, retrosternal pain.

3.Scarring Stage:

oFormation of esophageal strictures, dysphagia.

Diagnosis:

Contrast radiography (barium swallow) – for stricture and perforation assessment.

Esophagoscopy (cautiously) – after 24–48 hours if no signs of perforation.

First Aid (within 6 hours):

1. Neutralize:

o Acid → 3% sodium bicarbonate, chalk, vegetable oil.

oUnknown agent → Water or milk irrigation (never induce vomiting).

2.Symptomatic Management:

oAnalgesics, antihistamines, cardiac glycosides (for toxemia).

3.Hospitalization:

oAnti-shock, detox therapy, IV fluids, parenteral nutrition.

o Start oral intake on day 3: milk, eggs, butter, juice.

Treatment of Complications:

Stricture → Bougienage (dilatation), plastic surgery.

Severe cases → Esophagectomy + Esophagoplasty (e.g., stomach or colon interposition).

Indications for surgery:

o Complete stricture

o Fistula