Pyogenic granuloma (lobular capillary haemangioma) is a relatively common benign vascular lesion of the skin and mucosa whose exact cause is unknown
The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically. Pyogenic granuloma of the oral cavity is known to involve the gingiva commonly. Extragingivally, it can occur on the lips, tongue, buccal mucosa, palate, and the like. A history of trauma is common in such sites. The aetiology of the lesion is not known, though it was originally believed to be a botryomycotic infection. It is theorized that pyogenic granuloma possibly originates as a response of tissues to minor trauma and/or chronic irritation, thus opening a pathway for the invasion of nonspecific microorganisms, although microorganisms are seldom demonstrated within the lesion. Pathogenesis of pyogenic granuloma is still debatable.
Patients with pyogenic granuloma may report a painless glistening red lesion that bleeds spontaneously or after irritation.

Ameloblastoma is a rare, benign or cancerous tumour of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw.
Ameloblastomas can be found both in the maxilla and mandible. Although, 80% are situated in the mandible with the posterior ramus area being the most frequent site. The neoplasms are often associated with the presence of unerupted teeth, displacement of adjacent teeth and resorption of roots.

Symptoms include a slow-growing, painless swelling leading to facial deformity. As the swelling gets progressively larger it can impinge on other structures resulting in loose teeth and malocclusion. Bone can also be perforated leading to soft tissue involvement.

The lesion has a tendency to expand the bony cortices because of the slow growth rate of the lesion allows time for the periosteum to develop a thin shell of bone ahead of the expanding lesion. This shell of bone cracks when palpated. This phenomenon is referred to as Egg Shell Cracking or crepitus, an important diagnostic feature.

Maxillary ameloblastomas can be dangerous and even lethal. Due to thin bone and weak barriers, the neoplasm can extend into the sinonasal passages, pterygomaxillary fossa and eventually into the cranium and brain. Rare orbital invasion of the neoplasm has also been reported.

In this patient, a blocked catheter is the case because the urine is flowing into the urostomy bag but it is not able to pass through the catheter.
It is recommended that in cases without hypotension, a bladder washout should be done if there is clot retention. The catheter may also be changed.

Acute subdural hematoma is usually caused by external trauma that creates tension in the wall of a bridging vein as it passes between the arachnoid and dural layers of the brain’s lining—i.e., the subdural space. The circumferential arrangement of collagen surrounding the vein makes it susceptible to such tearing.

Acute bleeds often develop after high-speed acceleration or deceleration injuries. They are most severe if associated with cerebral contusions. Though much faster than chronic subdural bleeds, acute subdural bleeding is usually venous and therefore slower than the arterial bleeding of an epidural haemorrhage. Acute subdural hematomas due to trauma are the most lethal of all head injuries and have a high mortality rate if they are not rapidly treated with surgical decompression. The mortality rate is higher than that of epidural hematomas and diffuse brain injuries because the force required to cause subdural hematomas tends to cause other severe injuries as well.

Generally, acute subdural hematomas are less than 72 hours old and are hyperdense compared with the brain on computed tomography scans. The subacute phase begins 3-7 days after acute injury. Chronic subdural hematomas develop over the course of weeks and are hypodense compared with the brain. However, subdural hematomas may be mixed in nature, such as when acute bleeding has occurred into a chronic subdural hematoma.
Lateralizing findings include ipsilateral pupillary dilatation with impaired reaction and motor deficit. Usually the pupillary dilatation will be ipsilateral and motor deficit (hemiparesis or hemiplegia) will be contralateral to the site of subdural hematoma.

Solitary rectal ulcer syndrome is a rare disorder that involves straining during defecation, a sense of incomplete evacuation, and sometimes passage of blood and mucus by rectum.
The syndrome is poorly named because associated lesions may be solitary or multiple and ulcerated or nonulcerated; they range from mucosal erythema to ulcers to small mass lesions.
Lesions are typically located in the anterior rectal wall within 10 cm of the anal verge.
It is probably caused by localized ischemic injury or prolapse of the distal rectal mucosa. Diagnosis is clinical with confirmation by flexible sigmoidoscopy and biopsy. Treatment is a bowel regimen for mild cases, but surgery is sometimes needed if rectal prolapse is the cause.

The cardinal symptom of Fissure in ano is pain.

The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for paediatric hydroceles (typically, communicating). If a testicular tumour is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumours may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumours.

This patient has an axillary vein thrombosis. It classically presents with pain and swelling of the affected limb. Venous duplex scan is needed to exclude a thrombus.

Primary proximal upper-extremity deep vein thrombosis (UEDVT) is less common than its secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in, otherwise, healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton/tennis, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Venous duplex scan: investigation of choice, provides information relating to flow and characteristics of the vessels.
5. D-dimer testing
6. CT scan: for VTOS

Treatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

2. Early thrombus removal and restoration of venous patency aim should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

Fractures of the distal radius account for up to 20% of all fractures treated in the emergency department. Initial assessment includes a history of the mechanism of injury, associated injury and appropriate radiological evaluation
Most of the fractures are caused by a fall on the outstretched hand with the wrist in dorsiflexion. The form and severity of fracture of distal radius as well as the concomitant injury of disco-ligamentary structures of the wrist also depend on the position of the wrist at the moment of hitting the ground. The width of this angle influences the localization of the fracture. Pronation, supination and abduction determine the direction of the force and the compression of the carpus and different appearances of ligament injuries.
The basic principle of fracture treatment is to obtain accurate fracture reduction and then to use a method of immobilization that will maintain and hold that reduction. While the goal of treatment in fracture distal end of the radius is the restoration of normal function, the precise methods to achieve that desired outcome are controversial. Intra-articular fractures of the distal end of the radius can be difficult to treat, at times, with a traditional conservative method. A number of options for treatment are available to prevent the loss of reduction in an unstable fracture of the distal end of the radius.
One of the recent advances in the treatment of distal radius fractures is the more frequent application of open reduction and internal fixation, especially for intra-articular fractures. There are two groups of fractures for which open reduction and internal fixation is advisable.
The first group includes the two-part shear fracture (Barton fracture), which actually is a radio-carpal fracture-dislocation. Although the anatomical reduction is possible by closed means in some cases, these fractures are very unstable and difficult to control in plaster. The second group includes complex intra-articular fractures in which the articular fragments are displaced, rotated or impacted and are not amenable to reduction through limited operative exposure.

Inflammatory breast cancer is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumour cells. Most commonly a ductal carcinoma.
Clinical features include erythematous and oedematous (peau d’orange) skin plaques over a rapidly growing breast mass. Tenderness, burning sensation, blood-tinged nipple discharge. Axillary lymphadenopathy is usually present. 25% of patients have metastatic disease at the time of presentation.
Differential diagnosis includes mastitis, breast abscess, Paget disease of the breast
Treatment is usually done with chemotherapy + radiotherapy + radical mastectomy. This type of cancer is usually associated with a poor prognosis. 5-year survival with treatment: ∼ 50% (without treatment: < 5%)

Unilateral vocal fold paralysis (UVFP) occurs from a dysfunction of the recurrent laryngeal (inferior laryngeal nerve) or vagus nerve innervating the larynx. It causes a characteristic breathy voice often accompanied by swallowing disability, a weak cough, and the sensation of shortness of breath. This is a common cause of neurogenic hoarseness. When this paralysis is properly evaluated and treated, normal speaking voice is typically restored. Specifically, thyroidectomy, carotid endarterectomy, anterior cervical spine surgery, thoracic, or mediastinal surgery most often result in a presentation of UVFP.

A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. Breast infections, including mastitis and breast abscesses, are most often seen in women aged 15 to 45 years. Mastitis can occur as a result of breastfeeding and if left untreated it can progress to an abscess. The bacteria most commonly associated with this is staphylococcus aureus.

As the stone is smaller in size, there is a strong likelihood (75%) of it to be passed spontaneously. Furthermore, distally sited stones are more likely to pass spontaneously than proximally sited ones. Hence, it should be arranged to review the patient in two weeks with a KUB X-ray.

Urolithiasis affects up to 15% of the population worldwide. The development of sudden-onset, colicky loin to groin pain is a classical feature in the history. It is nearly always associated with haematuria that is either micro- or macroscopic. The most sensitive and specific diagnostic test is helical, non-contrast CT scanning.

Management options for urolithiasis are:
1. Most renal stones measuring <5mm in maximum diameter typically pass within four weeks of onset of symptoms. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney, and previous renal transplant.
2. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters, and ureteric stent placement.
3. In the non-emergency setting, the preferred options for treatment include extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, and open surgery (selected cases). Minimally invasive options are the most popular first-line treatment.

Carbimazole was not found to cause gynaecomastia.

Drugs frequently causing gynecomastia:
Antiandrogens – Bicalutamide, flutamide, finasteride, dutasteride
Antihypertensive – Spironolactone
Antiretroviral – Protease inhibitors (saquinavir, indinavir, nelfinavir, ritonavir, lopinavir), reverse transcriptase inhibitors (stavudine, zidovudine, lamivudine)
Environmental exposure – Phenothrin (antiparasitic)
Exogenous hormones – Oestrogens, prednisone (male teenagers)
Gastrointestinal drugs – H2 histamine receptor blockers (cimetidine)

Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE

M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide

In most cases, the treatment of choice for acute cholecystitis is cholecystectomy performed early in the illness. The procedure can be carried out laparoscopically even when acute inflammation is present. Delayed surgery particularly around five to seven days after presentation is much more technically challenging and is often best deferred.

Up to 24% of women and 12% of men may have gallstones. Of these, up to 30% may develop local infection and cholecystitis. The classical symptom of cholecystitis is colicky right upper quadrant pain that occurs postprandially. Others include swinging pyrexia, and general feeling of being unwell. They are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.

Murphy’s sign is positive on examination. The standard diagnostic work-up consists of abdominal ultrasound and liver function tests. For management, cholecystectomy should ideally be done within 48 hours of presentation. In patients unfit for surgery, percutaneous drainage may be considered.

Follicular thyroid cancer accounts for 15% of thyroid cancer and occurs more commonly in women over 50 years of age. Thyroglobulin (Tg) can be used as a tumour marker for well-differentiated follicular thyroid cancer. Follicular cells are the thyroid cells responsible for the production and secretion of thyroid hormones.

It is impossible to distinguish between follicular adenoma and carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis. Features for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumour cells. Capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid).

– Follicular carcinoma tends to metastasize to lung and bone via the bloodstream.
– Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes.
– HMGA2 has been proposed as a marker to identify malignant tumours.

In a radical nephrectomy, the surgeon removes the whole kidney, the fatty tissues surrounding the kidney and a portion of the tube connecting the kidney to the bladder (ureter). The surgeon may remove the adrenal gland that sits atop the kidney if a tumour is close to or involves the adrenal gland. Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.

Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than females and sporadic tumours typically affect patients in their sixth decade.

Antibody-mediated rejection (AMR) is defined as allograft rejection caused by antibodies of the recipient directed against donor-specific HLA molecules and blood group antigens. Although the mechanism by which HLA I antibodies promote inflammation and proliferation has been revealed by experimental models, the pathogenesis of HLA II antibodies is less defined. Antibodies to HLA II frequently accompany chronic rejection in renal transplants. AMR has been recognized as the leading cause of graft loss after kidney transplant if there is a donor-host antigenic disparity. Antibodies can be produced against epitopes of the antigen that differ from self by as little as one amino acid. Pre-existing antibodies or the development of de novo antibodies after transplantation has become a biomarker for AMR graft loss. HLA antibodies are risk factors for hyperacute, acute, and chronic allograft rejections.

The specificity of HLA antibodies can be determined using single-antigen luminex beads that consist of fluorescent microbeads conjugated to single recombinant HLA class I and class II molecules. Complement-fixing ability would be assessed by the binding of C1q to HLA antibodies present in the serum. In several studies, C1q-positive DSA had associated with antibody-mediated rejection in renal transplantation compared with antibodies identified only by IgG. Complement-fixing ability is relevant to hyperacute and acute rejections. Hyperacute rejection is predominantly complement-mediated severe allograft injury occurring within hours of transplantation. It is caused by high titre of pre-existing HLA or non-HLA antibodies in presensitized patients. But the incidence of hyperacute rejection is reduced due to improved DSA detection methods and desensitization protocols.

ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations: pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. It is important that her coagulation status is normalized prior to performing this procedure.

The history of bloodstained vaginal discharge and lower abdominal tenderness makes ectopic pregnancy a strong possibility. Therefore, a pregnancy test (for beta hCG) and abdominal and pelvic USS should be performed. If the beta HCG is high, that is an indication for intrauterine pregnancy. If it is not, then an ectopic pregnancy is likely, and surgery should be considered.

Generally, the differential diagnosis of right iliac fossa (RIF) pain includes:
1. Appendicitis
2. Crohn’s disease
3. Mesenteric adenitis
4. Diverticulitis
5. Meckel’s diverticulitis
6. Perforated peptic ulcer
7. Incarcerated right inguinal or femoral hernia
8. Bowel perforation secondary to caecal or colon carcinoma
9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion
10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
11. Other causes—tuberculosis/typhoid/ infection with herpes zoster

Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm.

The classification of priapism is conventionally divided into three main groups. The commonest classification is into non‐ischaemic (high flow), ischaemic (low flow), and stuttering (recurrent) subtypes.

The EAU guidelines refer to the subtypes as ischaemic (low flow, veno‐occlusive) and arterial (high flow, non‐ischaemic). Of these, ischaemic priapism is the commonest, with refractory cases at risk of smooth muscle necrosis in the corpus cavernosum leading to sequelae of corporal fibrosis and erectile dysfunction (ED).

One of the key considerations in the management of priapism is the duration of the erection at presentation.
The EAU guidelines do differentiate the periods such that the intervention varies accordingly, which is particularly important for prolonged episodes that are refractory to pharmacological interventions and allow a step‐wise intervention.

Ischaemic priapism is a medical emergency as the progressive ischaemia within the cavernosal tissue is associated with time‐dependent changes in the corporal metabolic environment, which eventually leads to smooth muscle necrosis. As the duration of the penile erection becomes pathologically prolonged, as in the case of low‐flow priapism, the partial pressure of oxygen (pO2) progressively falls as the closed compartment prevents replenishment of stagnant blood with freshly oxygenated arterial blood.
Investigations using corporal blood aspiration, that in itself can be a therapeutic intervention leading to partial or complete penile detumescence, helps to differentiate ischaemic from non‐ischaemic priapism subtypes based on the pO2, pCO2 and pH levels. The AUA guidelines state that typically the blood gas analysis would give a pO2 of <30 mmHg and pCO2 of >60 mmHg and a pH of <7.25 in ischaemic priapism, whereas non‐ischaemic blood gas analysis would show values similar to venous blood. Once the diagnosis of priapism has been made, the initial management involves corporal blood aspiration followed by instillation of α‐agonists directly into the corpus cavernosum.
The EAU guidelines recommend several possible agents for intracavernosal injection, as well as oral terbutaline after intracavernosal injection.
Phenylephrine – 200 μg every 3–5 min to a maximum of 1 mg within 1 h.
Etilephrine – 2.5 mg diluted in 1–2 mL saline.
Adrenaline – 2 mL of 1/100 000 solution given up to 5 times in a 20‐min period.
Methylene blue – 50–100 mg intracavernosal injection followed by aspiration and compression.

Shunt surgery allows diversion of blood from the corpus cavernosum into another area such as the corpus spongiosum (glans or urethra) or the venous system (saphenous vein). Both the EAU and AUA guidelines recommend surgical intervention using firstly distal shunts and then proximal shunts in cases where aspiration and instillation of pharmacological agents fails to achieve penile detumescence. The EAU guidelines recommend that distal shunts should be attempted before proximal shunts, although the specific technique is left to the individual surgeon’s preference. The EAU guidelines also define a time point (36 h) when shunt surgery is likely to be ineffective in maintaining long‐term erectile function and may serve to reduce pain only. This is an important consideration when contemplating early penile prosthesis placement.

Pilar or Trichilemmal cysts are common dermal cysts. They occur in less than 10% of the population. Of all skin cysts, Pilar cysts are the most common cysts. Pilar cysts usually occur in areas with dense hair follicle so that they are most commonly seen on the head especially the scalp, but they can also be found on the face, head, and neck.
Trichilemmal cysts never give rise to malignant lesions. They are usually sporadic. The cysts contain keratin and are outlined by stratified squamous epithelium similar to what we see in the outer(external) root sheath of the hair follicle. Proliferating trichilemmal cysts are the tumour form of pilar cysts, and it would appear in less than 3% of all cases of pilar cysts, and it might ulcerate and may be locally aggressive.

Pilar cysts are lined by thick capsules containing small layers of cuboidal, dark-staining basal epithelial cells in a palisade arrangement without an obvious intercellular gap. Those cells coalesce with multiple layers of keratinocytes forming squamous epithelium; these cells showed more maturation with dense eosinophilic-staining keratin in the absence of a granular cell layer. Sometimes we might see some areas of calcifications. Keratin in the pilar cysts stains with antikeratin antibodies similar to that seen in keratin derived from human hair. Trichilemmal cysts might rupture and of their components will leak into the dermis leading to the formation of foreign-body reaction.
Trichilemmal cysts are usually asymptomatic unless they calcify or rupture their contents leading to inflammatory process and pain in the affected site. Sometimes, the presence of pilar cyst overpressure or bony prominence might lead to pain. Trichilemmal cysts usually present as flesh-coloured, smooth, mobile, firm, and well-circumscribed nodules. Family history is very important since this condition can have an autosomal dominant pattern of inheritance. Usually, they are slow-growing nodules but sometimes they increase in size rapidly and it would indicate infection or malignant transformation. Young females are affected more than males.

Catheter-directed thrombolysis (CDT) is recommended as the next step of management for patients with proximal upper-extremity deep vein thrombosis (UEDVT) of recent onset or severe symptoms.

Primary UEDVT is less common than secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in otherwise healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Duplex scan: investigation of choice
5. D-dimer testing
6. CT scan: for VTOS

Treatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

2. Early thrombus removal and restoration of venous patency should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

Lymphocele has been defined as a lymph-filled collection in the retroperitoneum without an epithelial lining. In kidney transplanted patients, lymphocele is a pseudocystic entity with lymph content covered with a hard fibrous capsule frequently localized around the graft. Lymphocele is one of the most common complications after kidney transplantation. It is usually asymptomatic, but can cause pressure on the kidney transplant, ureter, bladder, and adjacent vessels with deterioration of graft function, ipsilateral leg oedema, and external iliac vein thrombosis. Peritoneal fenestration is a well-established method for treatment.

Holstein-Lewis fracture is a fracture of the distal third of the humerus resulting in entrapment of the radial nerve. The radial nerve is one of the major peripheral nerves of the upper limb. It innervates all the muscles in the extensor compartments of the arm.

Conservative treatment for this fracture includes reduction and use of a functional brace. However, vascular injury may require open surgery.

Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.

Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.
Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate.

Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered.

Intraductal papilloma is the most common cause of blood-stained nipple discharge in young females.

An intraductal papilloma is a benign breast condition that develops in one or more of the milk ducts in the
breast. It is usually close to the nipple, but can
sometimes be found elsewhere in the breast. It most commonly occurs in women between ages 35–55 and generally does not increase the risk of developing breast cancer. There are no known risk factors for intraductal papilloma.

Signs and symptoms include:
1. Small lump or a discharge of
clear or blood-stained fluid from the nipple
2. Discomfort or pain around the area (usually not painful)

Diagnosis can be made by:
1. Breast examination
2. Mammogram
3. Ultrasound scan
4. Core biopsy
5. Fine needle aspiration

Women under the age of 40 are more likely to have an
ultrasound scan than a mammogram. The breast tissue in such patients can be dense which can
make the X-ray image in a mammogram less clear.
However, some women under 40 may still have
a mammogram.

Intraductal papillomas are often removed using
surgery. The surgical options include:
1. Excision biopsy
2. Vacuum assisted excision biopsy

If nipple discharge continues, then further surgical options are explored:
1. Microdochectomy (removal of the affected duct or ducts)
2. Total duct excision (removal of all the major ducts)

Klippel-Trenaunay syndrome is a condition that affects the development of blood vessels, soft tissues (such as skin and muscles), and bones. The disorder has three characteristic features: a red birthmark called a port-wine stain, abnormal overgrowth of soft tissues and bones, and vein malformations.

Most people with Klippel-Trenaunay syndrome are born with a port-wine stain. This type of birthmark is caused by swelling of small blood vessels near the surface of the skin. Port-wine stains are typically flat and can vary from pale pink to deep maroon in colour.

Klippel-Trenaunay syndrome is also associated with overgrowth of bones and soft tissues beginning in infancy. Usually this abnormal growth is limited to one limb, most often one leg. However, overgrowth can also affect the arms or, rarely, the torso.

Malformations of veins are the third major feature of Klippel-Trenaunay syndrome. These abnormalities include varicose veins and deep veins in the limbs. Malformations of deep veins increase the risk of a deep vein thrombosis (DVT).

Other complications of Klippel-Trenaunay syndrome can include cellulitis, lymphedema, and internal bleeding from abnormal blood vessels. Less commonly, this condition is also associated with fusion of certain fingers or toes (syndactyly) or the presence of extra digits (polydactyly).

Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein of the legs, thigh, or pelvis. Thrombosis is most often seen in individuals with a history of immobilization, obesity, malignancy, or hereditary thrombophilia. Vascular endothelial damage, venous stasis, and hypercoagulability, collectively referred to as the Virchow triad, are the main factors contributing to the development of DVT.
Symptoms usually occur unilaterally and include swelling, tenderness, and redness or discoloration. Pulmonary embolism (PE), a severe complication of DVT, should be suspected in patients with dizziness, dyspnoea, and fever. The diagnostic test of choice for DVT is compression ultrasound. In most cases, a negative D-dimer test allows thrombosis or PE to be ruled out, but a positive test is nonspecific.
Initial acute treatment of DVT consists of anticoagulation with heparin and, if the thrombus is large or unresponsive to anticoagulation, may also include thrombolysis or thrombectomy. Secondary prophylaxis is achieved with oral warfarin or direct factor Xa inhibitors and supportive measures such as regular exercise and compression stockings.

Dumping syndrome is the effect of altered gastric reservoir function, abnormal postoperative gastric motor function, and/or pyloric emptying mechanism. Clinically significant dumping syndrome occurs in approximately 10% of patients after any type of gastric surgery and in up to 50% of patients after laparoscopic Roux-en-Y gastric bypass. Dumping syndrome has characteristic alimentary and systemic manifestations. It is a frequent complication observed after a variety of gastric surgical procedures, such as vagotomy, pyloroplasty, gastrojejunostomy, and laparoscopic Nissan fundoplication. Dumping syndrome can be separated into early and late forms, depending on the occurrence of symptoms in relation to the time elapsed after a meal.
Postprandially, the function of the body of the stomach is to store food and to allow the initial chemical digestion by acid and proteases before transferring food to the gastric antrum. In the antrum, high-amplitude contractions triturate the solids, reducing the particle size to 1-2 mm. Once solids have been reduced to this desired size, they are able to pass through the pylorus. An intact pylorus prevents the passage of larger particles into the duodenum. Gastric emptying is controlled by the fundic tone, antropyloric mechanisms, and duodenal feedback. Gastric surgery alters each of these mechanisms in several ways.

The late dumping syndrome is suspected in the person who has symptoms of hypoglycaemia in the setting of previous gastric surgery, and this late dumping can be proven with an oral glucose tolerance test (hyperinsulinemic hypoglycaemia), as well as gastric emptying scintigraphy, which shows the abnormal pattern of initially delayed and then accelerated gastric emptying.

The clinical presentation of dumping syndrome can be divided into GI symptoms and vasomotor symptoms. GI symptoms include early satiety, crampy abdominal pain, nausea, vomiting, and explosive diarrhoea. Vasomotor symptoms include diaphoresis, flushing, dizziness, palpitations, and an intense desire to lie down.

The expression of these symptoms varies in different individuals. Most patients with early dumping have both GI and vasomotor symptoms, while patients with late dumping have mostly vasomotor symptoms. Patients with severe dumping often limit their food intake to avoid symptoms. This leads to weight loss and, over time, malnutrition.

Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine, whereas late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness.

Early dumping systemic symptoms are as follows:
Desire to lie down
Palpitations
Fatigue
Faintness
Syncope
Diaphoresis
Headache
Flushing

Early dumping abdominal symptoms are as follows:
Epigastric fullness
Diarrhoea
Nausea
Abdominal cramps
Borborygmi

Late dumping symptoms are as follows:
Perspiration
Shakiness
Difficulty to concentrate
Decreased consciousness
Hunger