Nursing(Degree) · First Year · NUR101
Anatomy and Physiology
Anatomy and Physiology is one of the most important foundation courses for nursing students in Zambia. This course helps you understand how the human body is structured and how it functions, from major organs to body systems such as the nervous, cardiovascular, respiratory, and digestive …
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Anatomy and Physiology is one of the most important foundation courses for nursing students in Zambia. This course helps you understand how the human body is structured and how it functions, from major organs to body systems such as the nervous, cardiovascular, respiratory, and digestive systems. A strong grasp of this subject is essential for exams set by nursing schools and regulatory bodies in Zambia. At 25schools, we simplify complex anatomy concepts using exam-focused questions, diagrams, and clear explanations designed for nursing exams. Whether you are preparing for tests, assignments, or final examinations, this course builds the clinical understanding every successful nurse needs. Start studying with 25schools today and gain the confidence to excel in anatomy and physiology exams.
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Diverticular Hemorrhage
Diverticular hemorrhage is the MOST COMMON cause of LOWER GI BLEEDING (30-50%). PATHOPHYSIOLOGY: Rupture of vasa recta at diverticulum neck/dome, right colon > left. CLINICAL: PAINLESS, LARGE VOLUME, MAROON OR BRIGHT RED BLOOD PER RECTUM. Hemodynamic instability in 30%. Usually SELF-LIMITED (80%). Risk factors: NSAIDs, anticoagulants, antiplatelets, hypertension. DIAGNOSIS: COLONOSCOPY (after rapid purge, if stable, diagnostic and therapeutic). CT ANGIOGRAPHY (active bleeding >0.5mL/min, localizes). RADIONUCLIDE SCAN (tagged RBC, slow bleeding). MANAGEMENT: RESUSCITATION: IV fluids, transfusion (restrictive, Hb <7-8g/dL), correct coagulopathy. IDENTIFY HIGH-RISK: hemodynamic instability, ongoing bleeding, comorbidities. ENDOSCOPIC THERAPY: epinephrine injection, HEMOCLIPS (preferred), bipolar coagulation. Effective, prevents rebleeding. ANGIOGRAPHY with EMBOLIZATION: if bleeding persists, colonoscopy negative/inaccessible. Nephrotoxicity, bowel ischemia risk. SURGERY: SEGMENTAL COLECTOMY (if refractory, after localization). Blind subtotal colectomy: HIGH MORBIDITY, MORTALITY, last resort. Prognosis: EXCELLENT. Rebleeding 15-20%. Zambian context: COMMON. COLONOSCOPY available tertiary. HEMOCLIPS available. CT ANGIOGRAPHY limited. Angiography/embolization limited. Surgery available. Focus: RESUSCITATE, COLONOSCOPY (after purge) for diagnosis and hemostasis (clips), CONSERVE BLOOD, SURGERY last resort.
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Colorectal Cancer: Epidemiology and Prevention
Colorectal cancer (CRC) is the THIRD MOST COMMON CANCER and SECOND LEADING CAUSE OF CANCER DEATH worldwide. For Zambian students, CRC incidence is LOW but RISING with urbanization, Western diet, obesity, and aging population. It is no longer a 'Western' disease. ADENOCARCINOMA (95%). LOCATION: Left-sided (descending, sigmoid, rectum) > right-sided (cecum, ascending). EPIDEMIOLOGY: Age >50 (90%). Risk factors: MODIFIABLE: obesity, physical inactivity, red/processed meat, smoking, alcohol. NON-MODIFIABLE: age, male, family history, IBD (UC, Crohn's colitis), hereditary syndromes. HEREDITARY SYNDROMES (5-10%): LYNCH SYNDROME (hereditary nonpolyposis colorectal cancer, HNPCC): MLH1, MSH2, MSH6, PMS2, EPCAM. Autosomal dominant, 70-80% lifetime CRC risk, early onset (45y), right-sided, MSI-H. Associated with endometrial, ovarian, gastric, small bowel, hepatobiliary, urinary tract cancers. FAMILIAL ADENOMATOUS POLYPOSIS (FAP): APC mutation, hundreds of adenomas, 100% lifetime CRC risk by age 40-50. Colectomy indicated. Attenuated FAP. MUTYH-associated polyposis (MAP): autosomal recessive, multiple adenomas. PREVENTION: PRIMARY: healthy diet (high fibre, fruits/vegetables, low red/processed meat), physical activity, weight management, smoking cessation, alcohol moderation. SECONDARY: CRC SCREENING. Detects PRECANCEROUS POLYPS (adenomas) and EARLY-STAGE CANCER (curable). REDUCES INCIDENCE and MORTALITY. METHODS: FAECAL IMMUNOCHEMICAL TEST (FIT): annual, non-invasive, detects blood. COLONOSCOPY: every 10 years, GOLD STANDARD (diagnosis + polypectomy). FLEXIBLE SIGMOIDOSCOPY: every 5-10 years (left colon only). CT COLONOGRAPHY (virtual colonoscopy): every 5 years. FIT-DNA (Cologuard): every 3 years. SCREENING RECOMMENDATIONS: Average risk: age 45-50 to 75 years. Individualize >75. HIGH RISK (family history, IBD, hereditary syndromes): earlier, more frequent, colonoscopy. Zambian context: CRC INCIDENCE LOW but RISING. SCREENING: not population-based. FIT: not widely available. COLONOSCOPY: available tertiary, limited capacity, long waits, cost prohibitive for screening. FOCUS: SYMPTOMATIC DIAGNOSIS (alarm features: rectal bleeding, change in bowel habit, weight loss, anaemia), COLONOSCOPY for investigation, SURGICAL RESECTION (curative intent for localized disease). PREVENTION: lifestyle modification, awareness of alarm symptoms, high index of suspicion in at-risk patients (family history, IBD).
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Colorectal Cancer: Diagnosis, Staging, and Management
Colorectal cancer (CRC) management is MULTIDISCIPLINARY, stage-dependent, and increasingly individualized. For Zambian students, while advanced therapies (laparoscopic surgery, modern chemotherapies, targeted agents) may be limited, SURGICAL RESECTION remains the CORNERSTONE of curative treatment, and PALLIATIVE CARE is essential for advanced disease. DIAGNOSIS: COLONOSCOPY + BIOPSY is GOLD STANDARD. Location, size, morphology (polypoid, ulcerated, stricturing). HISTOLOGY: adenocarcinoma (95%), mucinous, signet-ring, neuroendocrine, squamous. MOLECULAR TESTING: MSI (mismatch repair deficiency, Lynch screening, prognostic, predictive of immunotherapy response), RAS/BRAF (metastatic disease, anti-EGFR therapy), HER2. STAGING: TNM (8th edition). T: depth of invasion (T1: submucosa, T2: muscularis propria, T3: subserosa, T4a: perforates visceral peritoneum, T4b: invades adjacent structures). N: regional lymph nodes (N1: 1-3, N2: ≥4). M: distant metastases (M1a: single organ, M1b: multiple organs, M1c: peritoneum). STAGE GROUPING: STAGE 0 (Tis), STAGE I (T1-2N0M0), STAGE II (T3-4N0M0), STAGE III (any T N1-2 M0), STAGE IV (M1). STAGING WORKUP: COLONOSCOPY (complete to cecum, synchronous lesions 3-5%). CHEST/ABDOMEN/PELVIS CT (CECT) with IV/PO contrast: liver, lung, nodal, peritoneal metastases. MRI RECTUM: essential for rectal cancer (assess circumferential resection margin, CRM, extramural vascular invasion, EMVI). PET-CT: equivocal metastases, recurrent disease. CEA: baseline, monitor treatment response, surveillance. MANAGEMENT: STAGE 0-I: ENDOSCOPIC RESECTION (Tis, T1 low-risk: EMR, ESD) or SURGICAL RESECTION (T1 high-risk, T2). COLECTOMY with LYMPHADENECTOMY. STAGE II: SURGICAL RESECTION alone. ADJUVANT CHEMOTHERAPY (FOLFOX, CAPOX) indicated for HIGH-RISK FEATURES: T4, perforation, obstruction, poor differentiation, lymphovascular invasion, perineural invasion, <12 nodes examined, positive margins. MSI-H stage II: excellent prognosis, NO benefit from 5-FU adjuvant therapy. STAGE III: SURGICAL RESECTION + ADJUVANT CHEMOTHERAPY (FOLFOX, CAPOX x 3-6 months). STAGE IV (METASTATIC): GOAL: CURATIVE-INTENT if limited, resectable metastases (liver, lung). Perioperative chemotherapy + METASTASECTOMY. PALLIATIVE INTENT if unresectable. CHEMOTHERAPY: FOLFOX, FOLFIRI, CAPOX, FOLFOXIRI. BIOLOGICS: BEVACIZUMAB (anti-VEGF), CETUXIMAB/PANITUMUMAB (anti-EGFR, RAS wild-type), REGORAFENIB, TAS-102. IMMUNOTHERAPY: PEMBROLIZUMAB, NIVOLUMAB (MSI-H metastatic CRC, first-line). RECTAL CANCER: MULTIMODALITY MANAGEMENT. TOTAL NEOADJUVANT THERAPY (TNT) is NEW STANDARD: chemotherapy (FOLFOX/CAPOX) + chemoradiation (long-course 50.4Gy + 5-FU/capecitabine) → RESTAGING → TOTAL MESORECTAL EXCISION (TME) surgery. SHORT-COURSE RADIOTHERAPY (5x5Gy) → surgery (alternative). SELECTIVE NON-OPERATIVE MANAGEMENT (WATCH-AND-WAIT): clinical complete response after TNT, rigorous surveillance. SURGERY: LOW ANTERIOR RESECTION (LAR, sphincter-preserving), ABDOMINOPERINEAL RESECTION (APR, permanent colostomy). SURVEILLANCE: HISTORY, CEA, COLONOSCOPY (1 year, then 3-5 yearly), CT chest/abdomen (3-5 years) for stage II-III. Prognosis: STAGE I: 5y survival 90%. STAGE II: 70-80%. STAGE III: 50-60%. STAGE IV: 10-15%, median survival 2-3 years (modern therapy). Zambian context: CRC PRESENTS LATE (Stage III/IV). COLONOSCOPY available tertiary. STAGING CT available. MRI rectum limited. CEA available. SURGERY: COLECTOMY, LAR, APR available (tertiary surgical centres). ADJUVANT CHEMOTHERAPY: 5-FU/leucovorin, capecitabine, oxaliplatin available (Cancer Hospital). FOLFOX, CAPOX accessible? Cost. BIOLOGICS (bevacizumab, cetuximab) NOT AVAILABLE. IMMUNOTHERAPY NOT AVAILABLE. MSI testing NOT AVAILABLE. RECTAL CANCER: NEOADJUVANT RADIOTHERAPY available (Lusaka). TOTAL MESORECTAL EXCISION (TME) surgery available (specialized colorectal surgeons, limited). PERMANENT COLOSTOMY: common (late presentation, APR). PALLIATIVE CARE: essential, often sole option. FOCUS: EARLY DIAGNOSIS (symptomatic patients, alarm features), SURGICAL RESECTION (curative intent), ADJUVANT CHEMOTHERAPY (if accessible and indicated), PALLIATION (symptom control, stenting, colostomy, pain management).
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Colonic Polyps and Polyposis Syndromes
Colonic polyps are protrusions into the colonic lumen, classified by HISTOLOGY (adenomatous, serrated, hamartomatous, inflammatory) and MORPHOLOGY (pedunculated, sessile, flat). ADENOMATOUS POLYPS (TUBULAR, VILLOUS, TUBULOVILLOUS) are PREMALIGNANT, progress to adenocarcinoma via ADENOMA-CARCINOMA SEQUENCE (APC, KRAS, TP53 mutations). Risk: size (>1cm), villous histology, high-grade dysplasia, multiplicity. SERRATED POLYPS: HYPERPLASTIC POLYPS (benign, left colon). SESSILE SERRATED LESIONS (SSL, right colon, dysplastic, BRAF mutation, CpG island methylator phenotype—CIMP, progress to MSI-H cancer). TRADITIONAL SERRATED ADENOMA (TSA, left colon). HAMARTOMATOUS POLYPS: Peutz-Jeghers, juvenile polyposis, PTEN hamartoma (Cowden). INFLAMMATORY POLYPS (pseudopolyps): IBD. POLYPECTOMY: ENDOSCOPIC RESECTION (snare polypectomy, EMR, ESD) is DIAGNOSTIC and CURATIVE for most polyps with benign histology or intramucosal carcinoma (Tis). SURVEILLANCE COLONOSCOPY: based on polyp characteristics (size, number, histology). USMSTF guidelines. POLYPOSIS SYNDROMES: FAMILIAL ADENOMATOUS POLYPOSIS (FAP): APC mutation, AD, 100+ adenomas, 100% CRC risk by 40-50y. Extracolonic: duodenal adenomas/cancer, gastric fundic gland polyps (benign), desmoid tumours, osteomas, CHRPE, thyroid cancer, hepatoblastoma. Attenuated FAP (AFAP): <100 adenomas, later onset. MANAGEMENT: COLECTOMY (total proctocolectomy with IPAA or total colectomy with ileorectal anastomosis). UPPER ENDOSCOPY SURVEILLANCE (duodenal adenomas, Spigelman stage). MUTYH-associated polyposis (MAP): AR, MUTYH mutation, 10-100 adenomas, CRC risk 80-100%. COLECTOMY. LYNCH SYNDROME (HNPCC): AD, MMR mutation, <10 adenomas, but RAPID PROGRESSION to cancer. Right-sided, MSI-H. MANAGEMENT: COLONOSCOPY q1-2y starting age 20-25y, prophylactic colectomy? Not routine. PEPTZ-JEGHERS SYNDROME: STK11 mutation, mucocutaneous pigmentation, hamartomatous polyps (small bowel, colon), cancer risk (GI, breast, pancreas, gynecologic). SURVEILLANCE. JUVENILE POLYPOSIS: SMAD4, BMPR1A, hamartomas, CRC risk. COLECTOMY if numerous. Zambian context: COLONIC POLYPS are DETECTED at colonoscopy. POLYPECTOMY is therapeutic and PREVENTS CRC. PATHOLOGY (histology) essential. POLYPOSIS SYNDROMES are RARE but important (family history, early onset, multiple polyps). GENETIC TESTING NOT AVAILABLE. Diagnosis is CLINICAL (colonoscopy findings, family history, extracolonic features). MANAGEMENT: COLECTOMY for FAP, MAP. COLONOSCOPY SURVEILLANCE for Lynch. FOCUS: COMPLETE POLYPECTOMY, ACCURATE PATHOLOGY, APPROPRIATE SURVEILLANCE INTERVAL, RECOGNIZE POLYPOSIS SYNDROMES (refer, colectomy).
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Appendicitis: Diagnosis and Management
Acute appendicitis is the MOST COMMON SURGICAL EMERGENCY worldwide. For Zambian students, it is a DAILY PRESENTATION. Delayed diagnosis increases morbidity (perforation, abscess, peritonitis). PATHOPHYSIOLOGY: Luminal obstruction (faecolith, lymphoid hyperplasia, parasites, tumour) → bacterial overgrowth, distension, venous congestion, ischemia, necrosis, PERFORATION (24-36h). CLINICAL: CLASSIC: PERIUMBILICAL PAIN (visceral) → MIGRATES to RLQ (parietal), ANOREXIA, NAUSEA, VOMITING, LOW-GRADE FEVER. ATYPICAL: retrocecal (flank pain), pelvic (suprapubic, urinary frequency), subhepatic, pregnancy (pain location higher). PHYSICAL EXAM: RLQ TENDERNESS (McBurney's point), REBOUND, GUARDING, ROVSING'S SIGN (palpation LLQ → RLQ pain), PSOAS SIGN (retrocecal), OBTURATOR SIGN (pelvic). DIAGNOSIS: CLINICAL (history, exam). LABS: LEUKOCYTOSIS (left shift). CRP elevated. ALVARADO SCORE (MANTRELS): Migratory pain, Anorexia, Nausea/vomiting, Tenderness RLQ, Rebound, Elevated temp, Leukocytosis, Shift (left shift). Score 1-4: low risk, observe. 5-6: equivocal, imaging. 7-10: high risk, surgery. IMAGING: ULTRASOUND (first-line, non-ionizing, operator-dependent): non-compressible, dilated appendix (>6mm), appendicolith, periappendiceal fluid, increased Doppler flow. CT ABDOMEN (with IV contrast): GOLD STANDARD, highest accuracy (95-98%). Findings: dilated appendix (>6mm), wall thickening, fat stranding, appendicolith, abscess. MRI: pregnancy, children. MANAGEMENT: UNCOMPLICATED (early, non-perforated): APPENDECTOMY (LAPAROSCOPIC or OPEN). Laparoscopic: faster recovery, less pain, lower wound infection. NON-OPERATIVE MANAGEMENT (antibiotics only) in SELECTED PATIENTS: uncomplicated, no faecolith, mild symptoms. IV antibiotics (piperacillin-tazobactam, ceftriaxone+metronidazole) → oral antibiotics (7-10d). Failure rate 20-30%, recurrence 10-20%. COMPLICATED (perforated, abscess, phlegmon): PERCUTANEOUS DRAINAGE of abscess (if accessible) + IV antibiotics → INTERVAL APPENDECTOMY (6-12 weeks). EMERGENCY SURGERY if diffuse peritonitis, uncontrolled sepsis. Prognosis: EXCELLENT. Mortality <0.5% (uncomplicated). Perforation increases morbidity. Zambian context: APPENDICITIS IS COMMON. DIAGNOSIS: CLINICAL (Alvarado score). ULTRASOUND available, operator skill variable. CT limited. SURGERY: OPEN APPENDECTOMY (standard, widely available). LAPAROSCOPIC APPENDECTOMY (tertiary centres). ANTIBIOTICS: ceftriaxone, metronidazole, piperacillin-tazobactam available. PERCUTANEOUS DRAINAGE: limited. INTERVAL APPENDECTOMY: performed. FOCUS: CLINICAL DIAGNOSIS, TIMELY SURGERY (uncomplicated), PERCUTANEOUS DRAINAGE + INTERVAL APPENDECTOMY (complicated), AVOID DELAY (perforation).
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Mesenteric Ischemia
Mesenteric ischemia is a VASCULAR EMERGENCY with HIGH MORTALITY (50-80%). For Zambian students, it is a DIAGNOSTIC CHALLENGE, often missed. CLASSIFICATION: ACUTE MESENTERIC ISCHEMIA (AMI): superior mesenteric artery (SMA) embolism (50%), SMA thrombosis (20-30%), mesenteric venous thrombosis (MVT, 10-15%), non-occlusive mesenteric ischemia (NOMI, 20%). CHRONIC MESENTERIC ISCHEMIA (CMI): 'intestinal angina'. CLINICAL: AMI: SUDDEN, SEVERE ABDOMINAL PAIN 'OUT OF PROPORTION TO EXAMINATION'. Early: pain, minimal tenderness. Late: peritonitis (bowel infarction), bloody diarrhoea, vomiting, shock. Atrial fibrillation (embolism), atherosclerosis (thrombosis), hypercoagulable state (MVT). NOMI: ICU, vasopressors, dialysis. CMI: POSTPRANDIAL ABDOMINAL PAIN (15-30 minutes after meals), FEAR OF EATING (sitophobia), WEIGHT LOSS, abdominal bruit. DIAGNOSIS: HIGH INDEX OF SUSPICION. LABS: LACTATE (elevated, LATE marker), leukocytosis, metabolic acidosis. CT ANGIOGRAPHY (CECT, arterial and venous phases): GOLD STANDARD. Findings: SMA occlusion/filling defect, pneumatosis intestinalis, portal venous gas, bowel wall thinning/thickening, pneumoperitoneum. MVT: thrombus in SMV/portal vein, bowel wall thickening. CMI: stenosis/occlusion of mesenteric vessels, collaterals. PLAIN X-RAY: non-specific, ileus, thumbprinting (late). MANAGEMENT: AMI: RESUSCITATION (IV fluids, correct electrolytes). BROAD-SPECTRUM ANTIBIOTICS (cover gut flora). SYSTEMIC ANTICOAGULATION (heparin). REVASCULARIZATION: EMBOLECTOMY, THROMBECTOMY, BYPASS, ANGIOPLASTY/STENTING. URGENT LAPAROTOMY: resection of non-viable bowel, second-look laparotomy (24-48h). MVT: ANTICOAGULATION (heparin → warfarin) x 3-6 months (indefinite if thrombophilia). NOMI: treat underlying cause, intra-arterial vasodilators (papaverine). CMI: REVASCULARIZATION (angioplasty/stenting, bypass). Prognosis: AMI: MORTALITY 50-80%. Delayed diagnosis = death. CMI: good with revascularization. Zambian context: AMI IS UNDERDIAGNOSED. Suspect in: elderly, AF, severe abdominal pain, lactate elevated. CT ANGIOGRAPHY: available tertiary, limited. SURGERY: laparotomy, bowel resection available. ANTICOAGULATION: heparin, warfarin available. VASCULAR SURGERY/INTERVENTIONAL RADIOLOGY (embolectomy, stenting): LIMITED. HIGH MORTALITY. FOCUS: HIGH INDEX OF SUSPICION, EARLY CT ANGIOGRAPHY, AGGRESSIVE RESUSCITATION, ANTIBIOTICS, ANTICOAGULATION (MVT, embolism), URGENT SURGICAL CONSULTATION (laparotomy, resection).
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Intestinal Obstruction
Intestinal obstruction is a COMMON SURGICAL EMERGENCY, a mechanical blockage of bowel lumen. For Zambian students, ETIOLOGIES reflect local epidemiology: ADHESIONS (most common, 60%, post-surgical), HERNIA (external: inguinal, femoral; internal), TUMOUR (colorectal, metastatic), VOLVULUS (sigmoid > cecal, high incidence in Africa), INTUSSUSCEPTION (children), CROHN'S DISEASE (stricture), GALLSTONE ILEUS (elderly, female). CLASSIFICATION: SMALL BOWEL OBSTRUCTION (SBO) vs LARGE BOWEL OBSTRUCTION (LBO). PARTIAL vs COMPLETE. SIMPLE vs STRANGULATED (ischemia, necrosis, perforation). CLINICAL: SBO: ABDOMINAL PAIN (colicky, periumbilical), VOMITING (early, bilious), ABSOLUTE CONSTIPATION (late, complete obstruction), ABDOMINAL DISTENSION (mild). LBO: CONSTIPATION (early), ABDOMINAL DISTENSION (marked), PAIN (crampy, lower), VOMITING (late, feculent). PHYSICAL EXAM: tachycardia, fever (strangulation), abdominal tenderness, distension, high-pitched tinkling bowel sounds (early), silent abdomen (late, peritonitis), HERNIA ORIFICES (always check!), SCARS (adhesions). SIGMOID VOLVULUS: massive distension, tympanic. INTUSSUSCEPTION: 'red-currant jelly' stool, palpable sausage-shaped mass (children). DIAGNOSIS: PLAIN ABDOMINAL X-RAY (SUPINE + ERECT): dilated bowel loops (>3cm small bowel, >6cm colon), air-fluid levels, 'step-ladder' pattern (SBO), 'coffee-bean' sign (sigmoid volvulus), 'bird-beak' (barium enema). CT ABDOMEN (with IV/PO contrast): GOLD STANDARD, identifies level, cause (mass, adhesion, hernia, volvulus), strangulation (pneumatosis, portal venous gas, bowel wall thinning, poor enhancement). LABS: leukocytosis, elevated lactate (strangulation), electrolytes, creatinine (dehydration). MANAGEMENT: RESUSCITATION: IV FLUIDS (crystalloids), CORRECT ELECTROLYTES, NGT (decompression, vomiting). URINARY CATHETER (monitor output). BROAD-SPECTRUM ANTIBIOTICS (if strangulation/peritonitis suspected). SURGICAL CONSULTATION. NON-OPERATIVE MANAGEMENT (SBO, partial, simple, no strangulation): NGT, NPO, IV fluids, serial abdominal exams. 60-80% resolve. OPERATIVE MANAGEMENT: INDICATIONS: COMPLETE OBSTRUCTION, STRANGULATION (peritonitis, fever, tachycardia, leukocytosis, lactate), FAILED NON-OPERATIVE (48-72h), specific etiologies (malignancy, hernia, volvulus, gallstone ileus). PROCEDURE: LAPAROTOMY/LAPAROSCOPY, ADHESIOLYSIS, HERNIA REPAIR, BOWEL RESECTION (tumour, strangulated bowel, gallstone ileus). SIGMOID VOLVULUS: ENDOSCOPIC DETORSION (rigid/flexible sigmoidoscopy, rectal tube placement) → SUCCESSFUL (80%), then ELECTIVE SIGMOID COLECTOMY (high recurrence). EMERGENCY SURGERY if ischemia, perforation, peritonitis. INTUSSUSCEPTION (paediatric): AIR/ CONTRAST ENEMA (diagnostic, therapeutic). SURGERY if fails, peritonitis. Prognosis: SBO: mortality 3-5% (simple), 30% (strangulated). LBO: higher (malignancy, elderly). Zambian context: INTESTINAL OBSTRUCTION IS COMMON. ETIOLOGIES: ADHESIONS (increasing surgery), HERNIA (inguinal, femoral, neglected), VOLVULUS (sigmoid, endemic), TUMOUR (colorectal, advanced), INTUSSUSCEPTION (children). DIAGNOSIS: PLAIN X-RAY (available). CT (limited). SIGMOID VOLVULUS: plain film (coffee-bean), SIGMOIDOSCOPY (rigid/flexible) for detorsion + rectal tube. SURGERY: LAPAROTOMY, ADHESIOLYSIS, HERNIA REPAIR, BOWEL RESECTION, COLECTOMY available. FOCUS: RESUSCITATION, NGT, IDENTIFY STRANGULATION (urgent surgery), NON-OPERATIVE TRIAL (adhesions, partial), ENDOSCOPIC DETORSION (sigmoid volvulus), TIMELY SURGERY (complete obstruction, strangulation, failed non-operative).
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Hernia: Inguinal and Femoral
Groin hernias are EXTREMELY COMMON worldwide. For Zambian students, INGUINAL HERNIA is a DAILY SURGICAL PROBLEM. NEGLECTED HERNIA leads to INCARCERATION and STRANGULATION (high morbidity, mortality). ANATOMY: INGUINAL CANAL: deep ring (lateral to inferior epigastric vessels), superficial ring (external oblique). INDIRECT INGUINAL HERNIA: enters deep ring, lateral to epigastric vessels, congenital (patent processus vaginalis), can extend into scrotum. DIRECT INGUINAL HERNIA: through Hesselbach's triangle (medial to epigastric vessels), acquired (weakness of transversalis fascia), rarely enters scrotum. FEMORAL HERNIA: through femoral canal (medial to femoral vein), below inguinal ligament. MORE COMMON IN WOMEN, HIGH RISK OF STRANGULATION (40%). CLINICAL: GROIN MASS, increases with Valsalva/cough, reducible, palpable cough impulse. INDIRECT: oblique, into scrotum. DIRECT: medial, broad-based, rarely scrotal. FEMORAL: small, below inguinal ligament, more common in women, often presents with incarceration/strangulation. INCARCERATION: irreducible, non-tender. STRANGULATION: irreducible, TENDER, overlying erythema, fever, obstruction, PERITONITIS. DIAGNOSIS: CLINICAL. Ultrasound if equivocal. MANAGEMENT: ELECTIVE HERNIA REPAIR: indicated for ALL symptomatic hernias, and for asymptomatic hernias (risk of incarceration). MESH REPAIR: LICHTENSTEIN TENSION-FREE REPAIR (open, anterior approach, polypropylene mesh) is GOLD STANDARD. LOW RECURRENCE (<5%). LAPAROSCOPIC REPAIR (TAPP, TEP): less postoperative pain, faster recovery, higher cost, steep learning curve. FEMORAL HERNIA: requires repair (high strangulation risk). McVay (Cooper's ligament) repair, mesh repair. INCARCERATED/STRANGULATED HERNIA: EMERGENCY SURGERY. RESUSCITATION (IV fluids, NGT, antibiotics). REDUCTION (gentle taxis) under sedation/analgesia. SURGERY: HERNIOTOMY, HERNIORRHAPHY, ± BOWEL RESECTION (if non-viable). Use of mesh in contaminated field is CONTROVERSIAL (higher infection). COMPLICATIONS: RECURRENCE, CHRONIC PAIN (mesh, nerve entrapment), SEROMA, HEMATOMA, WOUND INFECTION, ISCHEMIC ORCHITIS, TESTICULAR ATROPHY. Prognosis: EXCELLENT. Elective repair: recurrence <5%. Emergency repair: higher morbidity, mortality (5-10%). Zambian context: INGUINAL HERNIA IS EXTREMELY COMMON, often PRESENTS LATE (large, neglected, incarcerated). OPEN LICHTENSTEIN MESH REPAIR is the STANDARD, affordable, low recurrence. MESH available (donated, purchased). EMERGENCY SURGERY for strangulation: bowel resection often required. LAPAROSCOPIC REPAIR: limited availability (tertiary, cost). FOCUS: ELECTIVE REPAIR (prevent complications), PROMPT RECOGNITION OF STRANGULATION (tender, irreducible, obstructed), EMERGENCY RESUSCITATION + SURGERY, BOWEL RESECTION IF NON-VIABLE. Hernia is a CURABLE condition. DO NOT NEGLECT.
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Topic 252Coming soon
Anorectal Diseases: Hemorrhoids
Hemorrhoids are vascular cushions in the anal canal. For Zambian students, they are EXTREMELY COMMON. INTERNAL HEMORRHOIDS: above dentate line, columnar epithelium, visceral innervation (painless). EXTERNAL HEMORRHOIDS: below dentate line, squamous epithelium, somatic innervation (painful). ETIOLOGY: Straining (constipation), prolonged sitting, pregnancy, obesity, low-fibre diet. INTERNAL HEMORRHOIDS: CLASSIFICATION (Goligher). GRADE I: bleed, no prolapse. GRADE II: prolapse with straining, reduce spontaneously. GRADE III: prolapse, require manual reduction. GRADE IV: prolapsed, irreducible. CLINICAL: PAINLESS RECTAL BLEEDING (bright red blood, on toilet paper, coating stool). PROLAPSE. MUCOUS DISCHARGE, PRURITUS. EXTERNAL HEMORRHOID THROMBOSIS: ACUTE, SEVERE PAIN, palpable perianal lump (bluish). DIAGNOSIS: CLINICAL. ANOSCOPY/PROC TOSCOPY. COLONOSCOPY: indicated if RED FLAGS (age >50, change in bowel habit, weight loss, iron deficiency anaemia, family history CRC). MANAGEMENT: CONSERVATIVE (Grade I-II): HIGH-FIBRE DIET (20-30g/day), FIBRE SUPPLEMENTS (psyllium), increased fluids, STOOL SOFTENERS, SITZ BATHS, TOPICAL (corticosteroids, anaesthetics). OFFICE PROCEDURES (Grade II-III): RUBBER BAND LIGATION (RBL)—gold standard, effective, outpatient. SCLEROTHERAPY, INFRARED COAGULATION (IRC). SURGICAL (Grade III-IV, failed office procedures): HEMORRHOIDECTOMY (Milligan-Morgan, open; Ferguson, closed). Excisional, effective, HIGH POST-OPERATIVE PAIN. STAPLED HEMORRHOIDOPEXY (PPH): for circumferential prolapse, LESS PAIN, HIGHER RECURRENCE, higher cost. DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION (HAL): ligate feeding arteries, minimal pain. EXTERNAL HEMORRHOID THROMBOSIS: EXCISION (within 72h) provides immediate relief. Conservative: analgesia, sitz baths, resolution over 1-2 weeks. Prognosis: EXCELLENT. Recurrence common. Zambian context: HEMORRHOIDS ARE COMMON. DIAGNOSIS: clinical. COLONOSCOPY: limited availability, reserved for RED FLAGS. CONSERVATIVE: dietary advice (increase fibre), psyllium (ispaghula) available. RUBBER BAND LIGATION: simple, effective, outpatient, requires anoscopy and suction ligator (available). HEMORRHOIDECTOMY: widely performed (surgical registrars). EXTERNAL THROMBOSIS: excision in clinic/OR. FOCUS: CONSERVATIVE first (fibre, fluids). RUBBER BAND LIGATION for grade II-III. HEMORRHOIDECTOMY for grade IV, failed RBL. DO NOT MISS COLORECTAL CANCER (red flags = colonoscopy).