Surgery MCQs (Grafts)
Posted by Dr KAMAL DEEP on May 27, 2011
Grafts:Skin grafting dates back >3000 years to India, where forms of
the technique were used to resurface nasal defects in thieves
who were punished for their crimes with nose amputation.
Full thickness skin graft can be taken from the following sites
except – (AIIMS 87) ?
a) Elbow b) Back to neck
c) Supraclavicular area d) Upper eyelids
Free skin graft is rejected on – (AIMS 89) ?
a) Muscle b) Fat
c) Deep fascia d) Dermis
Skin graft for facial wounds is taken from – (AIIMS 92)
a) Medial aspect of thigh b) Cubital fossia
c) Groin d) Post auricular region
The best skin graft for open wounds is – (A193)
a) Isograft b) Homograft
c) Allograft d) Autograft
The organism causing destruction of skin grafts is – (PGI 95)
a) Streptococcus b) Staphylococcus
c) Pseudomonas d) Clostridium
:
For on open wound of leg with exposure of bone, treatmen of choice
– (AIIMS 96)
a) Partial skin graft b) Complete skin graft
c) Pedicle graft d) Reverdin graft
(Reverdin is credited with performing the first "fresh skin" allograft,
and in 1869 while working in Paris, introduced the "pinch graft",
which is a procedure for removing tiny pieces of skin from a healthy
area of the body and seeding them in a location that needs to be
covered. This procedure is sometimes referred to as a "Reverdin
graft". His name is also associated with the "Reverdin suture needle",
which is a specialized surgical needle.)
Graft is not taken up on the following-(AIIMS 96)
a) Fat b) Muscle
c) Deep fascia d) Skull bone
Man sustained an injury with loss of skin cover exposing bone of
10×10 cms. The best treatment is –
a)Full thickness graft (AIIMS 99)
b)Pedicle graft
c)Amnion
d)Split thickness skin graft
Skin graft survival in the first 48 hrs is dependent on – (AIIMS 99)
a)Random connection between
host & donor capillaries
b)Plasmatic imbibition
c)Saline in dressing
d)Development of new blood vessels
:
Skin grafting is not done in infection with-(MP 2K)
a)Pseudonmonas aeroginosa
b)Staph. Aureus
c)Beta hemolytic streptococci
d)E. coli
Split skin graft can be applied over – (PGI 99)
a) Muscle b) Bone
c) Cartilage d) Eyelid
Best procedure to be done after an injury to leg associated with
exposure of underlying bone and skin loss – (MAHA 05)
a) Pedicle flap b) Split skin grafting
c) Full thickness grafting d) Skin flap
Dacron vascular graft is – (Al 06)
a) Nontextile synthetic b) Textile synthetic
c) Nontextile biologic d) Textile biologic
Which one of the following statements about Mesh Skin Grafts is
not correct? – (UPSC 06)
a)They permit coverage of large areas -True
b)They allow egrees of fluid collections under the graft) -True
c)They contract to the same degree as a grafted sheet of skin
d)They "take" satisfactorily on a granulating bed
Split skin grafts in young children should be harvested from – (UPSC
07)
a) Buttocks b) Thigh
c) Trunk d) Upper limb
Wolfe grafts is – (UP 07)
a)Full thickness -skin grafts
b)Partial thickness skin grafts
c)Split-skin grafts
d)Pedicled flap
:
Deep skin burns is treated with – (AIIMS 91)
a)Split thickness graft
b)Full thickness graft
c)Amniotic membrane
d)Synthetic skin derivatives
For aortic graft the best material available is – (JIPMER 81, Delhi 79,
92)
a) Dacron b) Artery
c) Vein d) None
A knitted Dacron artery graft (PGI 99, AIIMS 84)
a)Is not porous
b)Is eventually dissolived by tissue reaction
c)Never gets infected
d)Can be easily incised and the opening resutured
Not used as graft material in peripheral vascular disease – (PGI 97)
a) Dacron graft b) Vein
c) PTFE d) PVC
Graft used in infra inguinal by pass is 4Jipmer 2K)
a) PTFE b) Dacron
c) Autologous vein d) Autologous artery
Most common artery used for coronary artery bypass graft is –
(Rohtak 97)
a) Int. Mammary artery b) Intercostal artery
c) Radial artery d) Dorsalis pedisartery
e)Brachial artery
Skin Grafts and Skin Substitutes
:
Discussion of skin grafting requires a basic review of skin anatomy.
Skin is comprised of 5% epidermis and 95% dermis. The dermis
contains sebaceous glands, whereas sweat glands and hair follicles
are located in the subcutaneous tissue. The dermal thickness and
concentration of skin appendages vary widely from one location to
another on the body. The skin vasculature is superficial to the
superficial fascial system and parallels the skin surface. The
cutaneous vessels branch at right angles to penetrate subcutaneous
tissue and arborize in the dermis, finally forming capillary tufts
between dermal papillae.4
Each technique has advantages and disadvantages. Selection of a
particular technique depends on the requirements of the defect to
be reconstructed, the quality of the recipient bed, and the availability
of donor site tissue.
Type
Description
Thickness
(in)
Split
thickness
Thin (Thiersch-Ollier)
0.006–
0.012
Intermediate (Blair-Brown)
0.012–
0.018
Thick (Padgett)
0.018–
0.024
Full
thickness
Entire dermis (Wolfe-Krause)
Variable
Composite
tissue
Full-thickness skin with additional tissue
(subcutaneous fat, cartilage, muscle)
Variable
Split-Thickness Grafts
:
Split-thickness skin grafting represents the simplest method of
superficial reconstruction in plastic surgery. Many of the
characteristics of a split-thickness graft are determined by the
amount of dermis present. Less dermis translates into less
primary contraction (the degree to which a graft shrinks in
dimensions after harvesting and before grafting), more
secondary contraction (the degree to which a graft contracts
during healing), and better chance of graft survival. Thin-split
grafts have low primary contraction, high secondary contraction, and
high reliability of graft take, often even in imperfect recipient beds.
Thin grafts, however, tend to heal with abnormal pigmentation
and poor durability compared with thick-split grafts and fullthickness grafts. Thick-split grafts have more primary contraction,
show less secondary contraction, and may take less hardily. Split
grafts may be meshed to expand the surface area that can be
covered. This technique is particularly useful when a large area must
be resurfaced, as in major burns. Meshed grafts usually also have
enhanced reliability of engraftment, because the fenestrations allow
for egress of wound fluid and excellent contour matching of the
wound bed by the graft. The fenestrations in meshed grafts reepithelialize by secondary intention from the surrounding graft skin.
The major drawbacks of meshed grafts are poor cosmetic
appearance and high secondary contraction. Meshing ratios used
usually range from 1:1.5 to 1:6, with higher ratios associated with
magnified drawbacks.
Full-Thickness Grafts
By definition full-thickness skin grafts include the epidermis and the
complete layer of dermis from the donor skin. The subcutaneous
tissue is carefully removed from the deep surface of the dermis to
maximize the potential for engraftment. Full-thickness grafts are
associated with the least secondary contraction upon healing, the
best cosmetic appearance, and the highest durability. Because
of this, they are frequently used in reconstructing superficial wounds
of the face and the hands. These grafts require pristine, wellvascularized recipient beds without bacterial colonization, previous
irradiation, or atrophic wound tissue.
:
Graft Take:- Differences in Schwartz and Sabiston
Graft Take
Schwartz:- Skin graft take occurs in three phases, imbibition,
inosculation, and revascularization. Plasmatic imbibition refers to
the first 24 to 48 hours after skin grafting, during which time a thin
film of fibrin and plasma separates the graft from the underlying
wound bed. It remains controversial whether this film provides
nutrients and oxygen to the graft or merely a moist environment to
maintain the ischemic cells temporarily until a vascular supply is reestablished. After 48 hours a fine vascular network begins to
form within the fibrin layer. These new capillary buds interface
with the deep surface of the dermis and allow for transfer of some
nutrients and oxygen. This phase, called inosculation, transitions
into revascularization, the process by which new blood vessels either
directly invade the graft or anastomose to open dermal vascular
channels and restore the pink hue of skin. These phases are
generally complete by 4 to 5 days after graft placement. During
these initial few days the graft is most susceptible to deleterious
factors such as infection, mechanical shear forces, and hematoma or
seroma
:
Special considerations in choosing a skin graft donor site include
skin quality and color from the donor region that will best match the
recipient site. For example, skin harvested from the blush zone
above the clavicles is best suited for facial grafting. Skin grafts
harvested from areas caudal to the waist will result in tallow
discoloration and possible unwanted hair growth. Because splitthickness donor sites will permanently scar, it is wise to choose a
donor site that can be concealed. When a large amount of graft is
needed, the thighs and buttocks are areas that can be hidden with
everyday clothes. The inner arm and groin crease are each fine
sources for full-thickness grafts because both areas offer
relatively glabrous skin sources, the donor sites of which can be
easily hidden with clothes. One often overlooked split-thickness
donor site is the scalp, taking extreme care to avoid taking the graft
below the level of the hair follicle; this donor site heals quickly,
painlessly, and with imperceptible scar consequences.
Sabiston :- The skin graft must be applied to a well-vascularized
recipient wound bed. It will not adhere to exposed bone, cartilage, or
tendon devoid of periosteum, perichondrium, or peritenon,
respectively, or devoid of its vascularized perimembranous
envelope.There are three steps in the “take” of a skin graft:
imbibition, inosculation, and revascularization. Imbibition occurs up
to 48 hours after graft placement and involves the free absorption
of nutrients into the graft. Inosculation designates the time period
when donor and recipient capillaries become aligned. There
remains a debate as to whether new channels are formed or if
preexisting channels reconnect. Finally, after about 5 days,
revascularization occurs, and the graft demonstrates both arterial
inflow and venous outflow.
Time period and Graft take not well explained in bailey .
:
Sabiston:- By examining the skin graft before the fourth
postoperative day, a hematoma or seroma can be evacuated, and the
mechanical obstruction to revascularization of the graft is thus
removed. Some surgeons make stab incisions in the graft
preemptively to create small outlets for fluid to drain from beneath
the graft, a technique know as pie crusting. Others might use a
mesh expander device, which creates a chain-link fence pattern
in the graft. Although these methods may provide egress portals for
serous fluid or blood, an unsightly meshed pattern results, making
this technique unsuitable for aesthetic reconstruction.
Because split-thickness donor sites can be reharvested after reepithelialization, this method of wound closure is the workhorse for
burn injuries
Split grafts may be meshed to expand the surface area that can be
covered. This technique is particularly useful when a large area must
be resurfaced, as in major burns. Meshed grafts usually also have
enhanced reliability of engraftment, because the fenestrations allow
for egress of wound fluid and excellent contour matching of the
wound bed by the graft. The fenestrations in meshed grafts reepithelialize by secondary intention from the surrounding graft skin.
The major drawbacks of meshed grafts are poor cosmetic
appearance and high secondary contraction. Meshing ratios used
usually range from 1:1.5 to 1:6, with higher ratios associated with
magnified drawbacks.
:
Technical aspects
Graft take is only possible at well-vascularised recipient sites. Grafts
will not take on bare bone, bare tendon or cartilage, but can
survive on periosteum, paratenon and perichondrium. The graft must
remain adherent to the bed until it revascularises; shearing forces
must be eliminated. Meticulous care with suturing and dressings is
essential. Where grafts are applied over mobile areas appropriate
splintage must be used. Limbs that have been grafted should be
elevated to reduce venous pressure during the process of
revascularisation. Haemostasis at the recipient site must be good to
prevent bleeding beneath the graft resulting in its elevation by clot
and failure of take. Skin grafts can be stored in a refrigerator at 40C
for 2 weeks for delayed application. Grafts take well on granulation
tissue, but excessive contamination with bacteria will prevent take.
Streptococci at levels above 105 microorganisms per gram of
tissue will result in graft loss. Preparation of the bed with
dressings may help; it may be necessary to excise the
granulation tissue.
FLAPS
Skin flap is used in all except – (AIIMS 89)
a) Bone b) Tendon
c) Burn wound d) Cartilage
The subdermal plexus forms the vascular basis for –
a)Randomised flaps (JIPMER 2002)
b)Axial flaps
c)Mucocutaneous flaps
d)Vasciocutaneous flaps
full thickness loss of middle one third of the upper lip is best
reconstruted by – (AIIMS 84)
a) Naso labial flap b) Cheek flap
c) Abbey flap d) Estlander’s flap
In the reconstruction following excision of previously irradiated cheek
cancer, the flap will be – (AIIMS 85)
a)Local tongue
b)Cervical
c)Forehead
d)Pectoralis major myocutaneous
Reconstruction of the breast following total mastectomy for cancer is
done ideally by using –
a)Distant tube pedicvle (AIIMS 84)
b)Opposite breast
c)Trapezius myocutaneous flap
d)Latissmus dorsi myocunaneous flap
:
Flap commonly used in breast reconstruction is -a) Serratus anterior
b) TRAM (TN 03)
c) Flap from arm d) Delto pectoral flap
:
Best flap for eosphagus repair – (CMC Vellore)
a) Colon b) Stomach
c) Jejunum d) Latismus dorsi
Vascular patterns of random pattern (A) and
axial pattern (B) skin flaps Graphic representation of the bilobed
flap commonly used for nasal reconstruction. P, primary flap; S,
secondary flap
:
A flap is defined as a partially or completely isolated segment of
tissue perfused with its own blood supply. Flaps are the
reconstructive option of choice when a padded and durable cover is
needed to reconstruct an integumentary defect over vital structures,
tissues devoid of perivascular membrane, or implants. Flaps vary
greatly in terms of complexity from simple skin flaps with a random
blood supply to microvascular free flaps containing composite
tissue. Numerous schemes exist to classify flaps. Flaps may be
classified based on the type of tissue contained in the flap:
fasciocutaneous, musculocutaneous, or osteocutaneous flaps. Flaps
are also described based on their design and method of transfer:
advancement, rotation, transposition, interpolation, or pedicled flaps.
Flaps may be further defined by the source of their blood supply:
random, axial, or free. Random flaps rely on the low perfusion
pressures found in the subdermal plexus to sustain the flap and
not a named blood vessel. Nevertheless, random flaps are used
widely in reconstruction of cutaneous defects, including those
resulting from Mohs excision of cutaneous malignancies. These local
flaps recruit adjacent tissue based on geometric design patterns.
Advancement and rotation flaps represent commonly used
random-pattern skin flaps. The Z-plasty, bilobed flap, rhomboid,
and V-Y (or Y-V) advancement flaps are commonly used random
flaps. Z-plasty involves transposing two adjacent triangular flaps to
redirect and lengthen an existing scar (the central limb).The angles
of the Z-plasty can be increased to provide greater length. Typically
a 60-degree angle is used that lengthens the central limb by
75%.The bilobed flap is commonly used for nasal reconstruction;
here, a larger primary and smaller secondary flap are transposed into
adjacent defects borrowing the loose adjacent tissue to close the
defect . The rhomboid flap described by Limberg uses a 60- and
120-degree parallelogram to transpose tissue into a diamondshaped defect. It is an extremely versatile flap option and the
workhorse for most plastic surgeons. Finally, the V-Y (or Y-V)
advancement flaps are commonly used to lengthen scars around the
nose and mouth. A backcut at the base of a flap may decrease
tension at a flap’s tip, creating a greater arc of rotation; overzealous
back cut or tension at flap inset can each cause ischemia to the flap
and threaten its survival.
:
An axial flap is based on a named blood vessel and can provide a
reproducible and stable skin or skin-muscle (myocutaneous) flap.
Flaps can also be raised with the underlying fascia
(fasciocutaneous), which recruits the fascial blood supply, thereby
increasing the predictable vascularity to the flap. Because of its
reliable blood supply, the axial flap can be used to provide much
needed length and bulk, which the random flap cannot. An axial flap
that remains attached to its proximal blood supply and is
transposed to a defect is known as a pedicled flap. Alternately,
the vascular pedicle can be completely transected and the paddle of
tissue transferred and reanastomosed to recipient vessels in a
remote location. This technique requires the use of an operating
microscope and is known as microsurgery
Keratoacanthoma is- (AIIMS 85)
a)A type of basal cell carcinoma
b)Infected sebaceous cyst
c)Self healing nodular lesion with central ulceration
d)Pre-malignant disease
True about keratoacanthoma – (PGI 2000)
a)Benign tumor
b)Malignant skin tumor like squamous cell carcinoma
c)Treatment same as for squamous cell carcinoma
d)Easy to differentiate from squamous cell Ca. histologically
e)Treatment is masterly inactivity (Watchful Waiting:-A hands-off
management philosophy in which certain conditions are closely
monitored, but treatment withheld until symptoms either appear or
some measurable parameter changes. Active management is begun
once the patients become symptomatic)
:
Keratoacanthoma
Keratoacanthoma (molluscum sebaceum) arises as a rapid
proliferation of squamous epidermal cells. The nodule grows rapidly
for 6—8 weeks at which time it usually begins to resolve
spontaneously. Keratoacanthoma must be distinguished from SCC.
Usually rapid evolution to relatively large size, irregular crater shape
and keratotic plug, and the undamaged surrounding skin make a
distinction possible. Spontaneous healing further confirms the
diagnosis. Histologically, it is difficult to differentiate between a
keratoacanthoma and SCC. There is also a possibility of a highly
anaplastic SCC behaving like a keratoacanthoma. Excision biopsy is
mandatory if the diagnosis is in doubt as curetted specimens yield
poor sections.
Which of the following is a regressing
tumour- (AI 91)
a) Portwine stain b) Strawberry angioma
c) Venous angioma d) Plexiform angioma
Spontaneous regression is seen in all except –
a)Salmon patch (Al 93)
b)Small Cavernous hemangioma
c)Portwine stain
d)Strawberry angioma
All are features of pesudopancreatic cyst, except
a)Follows acute pancreatitis (AI 97)
b)Lined by false epithelium
c)May regress spontaneously
d)Treatment of choice is percutaneous aspiration
Least likely to regress spontaneously is(AIIMS 96)
a) Osteosarcoma b) Retinoblasoma
c) Choriocarcinoma d) Malignant melanoma
:
Spontaneous Regresssion is seen in all except –
a) Retinoblasoma b) Malignant melanoma (AI 98)
c) Osteosarcoma d) Choriocarcinoma
Cystic hygroma – (SCTIMS 98)
a)Should be left alone
b)Excision of cyst at an early age
c)Spontaneous regression
d)Manifests in 2nd – 3rd decade
[Ref Bailey & Love 240/e p. 771 & 23"/e p. 701] Spontaneous
regression may occur in cystic hygroma
Spontaneous regression of malignant tumour is seen in – (JIPMER
80, AIIMS 81)
a) Burkits lymphoma b) Neuroblasoma
c) Wilm’s tumour d) Renal cell carcinoma
Salmon patch usually disappears by age- (PGI 80, 81, a) One mouth
b) One year UPSC 89)
c) Puberty d) None of the above
Regarding hemangiomas following are true –
a)Salmon patch disappears after the age of one
b)Port wine stain present throughout life
c)Salmon patch-on forehead midline and over occiput
d)all are correct
Eleven month old child presents with erythematous lesion with
central clearing which has been decreasing in size – (Al 97)
a)Strawberry angioma
b)Nevus
c)Portwine stain
d)Cavernous haemangioma
:
The best cosmetic results for large capillary (port wine)
hemangiomas are achieved by – (UPSC 05)
a)Excision and split-thickness skin
b)Laser ablation
c)Cryosurgery
d)Tattooing
True about Hemangioma of head & neck -(PGI 01)
a) Are very common b) Sturge Weber synd
c) High output failure d) Thrombocytopenia
Hemangioma of the rectum – (PGI June 07)
a)Common tumour
b)Fatal haemorrhage seen
c)Ulcerative colitis like symptoms seen
True about lymphangioma – (PGI 03)
a)It is a malignant tumour
b)It is a congenital sequestration of lymphatic
c)Cystic hygroma is a lymphangioma
d)Laser excision is done
e)Sclerotherapy is commonly done’
Which is the commonest incidentaloma detected in the liver – (Karn.
94)
a)Focal nodular hyperplasia
b)Haemangioma
c)Hepatocellular adenoma
d)Hydatid cyst
:
"Crumbled egg appearance" in liver seen in –
a) Hepatic adenoma (UP 07)
b) Chronic amoebic liver abscess c)Hydatid liver disease
d)Haemangioma
Earliest tumour to appear after bith is-(JIPMER 87)
a) Sternomastoid tumour b) Cystic hygroma
c) Branchial cyst d) Lymphoma
Ans. is ‘b’ i.e., Cystic hygroma [Ref Bailey & Love 24th/e p. 771 &
23’/e p. 700] 50% to 65% of Cystic hygroma prasent of birth
Cystic compressible, translucent swelling in the posterior triangle of
neck- (Al 89) a) Cystic hygroma
c) Thyroglossal cyst
b) Branchial cyst
d) Dermoid cyst
Treatment of cystic hygroma is – (JIPMER 88)
a)Surgical excision
b)Injection of sclerosants
c)Irradiation
d)Masterly inactivity
The brilliantly transilluminant tumour in the neck may be- (AI 91)
a) Branchial cyst b) Thyroglossal cyst
c) Sternomastoid tumour d) Cystic hygroma
All are true about cystic hygroma except –
a)Pulsatile (AMU 95)
b)May cause respiratory obstruction
c)Common in neck
d)Present at birth
:
All are true about cystic hygroma except -(PG1 99)
a)Aspiration is diagnostic
b)50% present at birth
c)Presents as posterior cervical swelling
d)Sequstration of lymphatic tissue
True about cystic hygroma – (PGI 2000)
a)Congenital sequestration of lymphatics
b)Resolves spontaneouly by 5 year of age
c)Common in upper 1/3rd of lateral neck
d)Surgery is the treatment of choice
Calcifying epithelioma is seen in – (JIPMER 95)
a) Dermato fibroma b) Adenoma sebaceum
c) Pyogenic granuloma d) Nevo cellular nevus
none?
Margins of squamous cells carcinoma is -(JIPMER a) Inverted b)
Everted 81,Delhi 86)
c) Rolled d) Undermined
Calcifying epithelioma is also known as —
a)Pilomatrixoma (AIMS 86)
b)Myoblastoma
c)Calcinosis cutis
d)Dermatofibroma lenticulare
VASCULAR MALFORMATION.
Vascular malformations are developmental errors in blood vessel
formation. Malformations do not regress and slowly enlarge. They
should be named after the predominant blood vessel forming the
lesion .Table helps differentiate vascular malformations from true
hemangiomas.
:
Vascular Malformations
TYPE
EXAMPLES
Capillary
Port-wine stain
Venous
Venous malformation
Angiokeratoma circumscriptum (hyperkeratotic venule)
Cutis marmorata telangiectasia congenital (congenital
phlebectasia)
Arterial
Arteriovenous malformation
Lymphatic
Small vessel lymphatic malformation (lymphangioma
circumscriptum)
Large vessel lymphatic malformation (cystic hygroma)
Major Differences Between Hemangiomas and Vascular
Malformations
HEMANGIOMAS
Clinical
VASCULAR
MALFORMATIONS
(CAPILLARY,
VENOUS,
LYMPHATIC,
ARTERIAL, AND
ARTERIOVENOUS,
PURE OR
COMPLEXCOMBINED)
Variably visible at birth
Usually visible at
birth (AVMs may be
quiescent)
Subsequent rapid
growth
Growth
proportionate to the
skin’s growth (or
slow progression);
present lifelong
:
Slow, spontaneous
involution
Sex ratio F: M
3 : 1 to 5 : 1 and 7 : 1 in
severe cases
1:1
Pathology
Proliferating stage:
hyperplasia of
Flat endothelium
endothelial cells and
SMC-actin+ cells
Radiology
Bone changes
Multilaminated
basement membrane
Thin basement
membrane
Higher mast cell
content in involution
Often irregularly
attenuated walls
(VM, LM)
Fast-flow lesion on
Doppler sonography
Slow flow (CM, LM,
VM) or fast flow
(AVM) on Doppler
ultrasonography
Tumoral mass with flow
voids on MRI
MRI: Hypersignal on
T2 when slow flow
(LM, VM); flow voids
on T1 and T2 when
fast flow (AVM)
Lobular tumor on
arteriogram
Arteriography of
AVM demonstrates
AV shunting
Rarely mass effect with
distortion but no
invasion
Slow-flow VM:
distortion of bones,
thinning,
underdevelopment
Slow-flow CM:
hypertrophy
Slow-flow LM:
distortion,
hypertrophy, and
invasion of bones
High-flow AVM:
destruction, rarely
extensive lytic
lesions
:
Combined
malformations (e.g.,
slow-flow [CVLM,
Klippel-Trenaunay
syndrome] or fastflow [CAVM, ParkesWeber syndrome]):
overgrowth of limb
bones, gigantism
Immunohistochemistry
on tissue samples
Proliferating
hemangioma: high
expression of PCNA,
type IV collagenase,
VEGF, urokinase, and
bFGF
Lack expression of
PCNA, type IV
collagenase,
urokinase, VEGF, and
bFGF
One familial (rare)
form of VM linked to
a mutated gene on
9p (VMCM1)
Involuting hemangioma:
high TIMP-1, high bFGF
Hematology
No coagulopathy
(Kasabach-Merritt
syndrome is a
complication of other
vascular tumors of
infancy, e.g.,
Kaposiform
hemangioendothelioma
and tufted angioma,
with a LM component)
Slow-flow VM or LM
or LVM may have an
associated LIC with
risk of bleeding (DIC)
From Eichenfield LF, Frieden IJ, Esterly NB: Textbook of Neonatal
Dermatology. Philadelphia, WB Saunders, 2001, p 337.
:
AVM, Arteriovenous malformation; bFGF, basic fibroblast growth factor;
CAVM, capillary arteriovenous malformation; CLVM, capillary lymphatic
venous malformation; CM, capillary malformation/port-wine stain;
DIC, disseminated intravascular coagulation; LIC, local-ized intravascular
coagulopathy; LM, lymphatic malformation; MRI, magnetic resonance
imaging; PCNA, proliferating cell nuclear antigen; SMC, smooth muscle
cell; TIMP, tissue inhibitor of metalloproteinase; VEGF, vascular
endothelial growth factor; VM, venous malformation
CAPILLARY MALFORMATION (PORT-WINE STAIN/CAPILLARY
NEVUS
Port-wine stains are present at birth. These vascular malformations
consist of mature dilated dermal capillaries. The lesions are
macular, sharply circumscribed, pink to purple, and tremendously
varied in size .The head and neck region is the most common site
of predilection; most lesions are unilateral. The mucous membranes
can be involved. As a child matures into adulthood, the port-wine
stain may become darker in color and pebbly in consistency; it may
occasionally develop elevated areas that bleed spontaneously.
True port-wine stains should be distinguished from the most
common vascular malformation, the salmon patch of neonates,
which, in contrast, is a relatively transient lesion .When a port-wine
stain is localized to the trigeminal area of the face, specifically
around the eyelids, the diagnosis of Sturge-Weber syndrome
(glaucoma, leptomeningeal venous angioma, seizures,
hemiparesis contralateral to the facial lesion, intracranial
calcification) must be considered .Early screening for glaucoma is
important to prevent additional damage to the eye. Port-wine stains
also occur as a component of Klippel-Trenaunay syndrome and with
moderate frequency in other syndromes, including the Cobb (spinal
arteriovenous malformation, port-wine stain), Proteus, BeckwithWiedemann, and Bonnet-Dechaume-Blanc syndromes. In the
absence of associated anomalies, morbidity from these lesions may
include a poor self-image, hypertrophy of underlying structures, and
traumatic bleeding.
:
The most effective treatment for port-wine stains is the pulsed dye
laser (PDL). This therapy is targeted to hemoglobin within the lesion
and avoids thermal injury to the surrounding normal tissue. After
such treatment, the texture and pigmentation of the skin are
generally normal without scarring. Therapy can begin in infancy
when the surface area of involvement is smaller; there may be
advantages to treating within the 1st year of life. Masking cosmetics
may also be used.
SALMON PATCH (NEVUS SIMPLEX:- Salmon patches are small, pale
pink, ill-defined, vascular macules that occur most commonly on
the glabella, eyelids, upper lip, and nuchal area of 30–40% of normal
newborn infants. These lesions, which represent localized vascular
ectasia, persist for several months and may become more visible
during crying or changes in environmental temperature. Most lesions
on the face eventually fade and disappear completely, although
lesions occupying the entire central forehead often do not. Those on
the posterior neck and occipital areas usually persist. The facial
lesions should not be confused with a port-wine stain, which is a
permanent lesion. The salmon patch is usually symmetric, with
lesions on both eyelids or on both sides of midline. Port-wine stains
are often larger and unilateral, and they usually end along the midline
Boil can occur at all sites except – (TN 95)
a) Pinna b) Skin
c) Scalp d) Palm
Excision of the hyoid bone is done in – (PGI 88)
a) Branchial cyst b) Branchial fistula
c) Thyroglossal cyst d) Sublingual dermoids
Cystic Hygroma
:
Nelson:- Lymphangioma (cystic hygroma) is a mass of dilated
lymphatics. Some of these lesions also have a hemangiomatous
component .Surgical treatment is complicated by a high incidence of
recurrence. Intralesional sclerosing with OK-432, a streptococcal
derivative, has been used successfully in selected patients.
Macrocystic lesions appear to respond better than microcystic
lymphangiomas to sclerotherapy. Lymphatic dysplasia may cause
multisystem problems. These include lymphedema, chylous ascites,
chylothorax, and lymphangiomas of the bone, lung, or other sites.
Bailey:- Cystic hygroma:-Cystic hygroma is an abnormal lymphfilled, often multilocular, space which usually presents in childhood
as a soft, brilliantly transluminable swelling in the base of the
neck. It is also found in the head and inguinal regions as they
develop from primitive lymph cisterns. It behaves like a benign
tumour and grows gradually in size, leading to cosmetic problems
and compression of surrounding structures. Recurrence is common
after simple aspiration and injection of sclerosant. Excision is
technically challenging due to the large number of vital structures in
the vicinity.
Sabiston:-A cystic hygroma is a lymphatic malformation that occurs
as a result of a maldeveloped localized lymphatic network, which
fails to connect or drain into the venous system. Most (75%)
involve the lymphatic jugular sacs and present in the posterior
neck region .Another 20% occur in the axilla, and the remainder are
found throughout the body, including the retroperitoneum,
mediastinum, pelvis, and inguinal area. Roughly 50% to 65% of
hygromas present at birth, and most become apparent by the
second year of life.
:
Because hygromas are multiloculated cystic spaces lined by
endothelial cells, they usually present as soft, cystic masses that
distort the surrounding anatomy. The indications for therapy are
obviously cosmetic. In addition, the hygroma may expand to
compress the airway, resulting in acute airway obstruction. Prenatal
recognition of a large cystic mass of the neck is associated with
significant risk to the airway, greater association with chromosomal
abnormalities, and higher mortality rates. Improved fetal imaging
modalities may allow for intervention at the time of delivery based on
principles of pharmacologic maintenance of placental circulation
until endotracheal intubation is achieved. This technique is referred
to as the ex utero intrapartum therapy (EXIT) procedure.and is
discussed later in this chapter. In addition to accumulating lymph
fluid, hygromas are prone to infection and hemorrhage within the
mass. Thus, rapid changes in the size of the hygroma may
necessitate more urgent intervention.
Complete surgical excision is the preferred treatment; however,
this may be impossible because of the hygroma infiltrating
within and around important neurovascular structures. Careful
preoperative magnetic resonance imaging (MRI) to define the extent
of the hygroma is crucial. Operations are routinely performed with
the aid of loupe magnification and a nerve stimulator. Because
hygromas are not neoplastic tumors, radical resection with
removal of major blood vessels and nerves is not indicated.
Postoperative morbidity includes recurrence, lymphatic leak,
infection, and neurovascular injury.
Injection of sclerosing agents such as bleomycin or the derivative of
Streptococcus pyogenes OK-432 have also been reported to be
effective in the management of cystic hygromas. Intracystic
injection of sclerosants appears to be most effective for
macrocystic hygromas, as opposed to the microcystic variety.
Ex Utero Intrapartum Therapy Procedure (Schwartz)
:
The ex utero intrapartum therapy (EXIT) procedure is used in
circumstances in which airway obstruction is predicted at the time of
delivery due to the presence of a large neck mass, such as a cystic
hygroma or teratoma .or to congenital tracheal stenosis. The success
of the procedure depends on the maintenance of uteroplacental
perfusion for a sufficient duration to secure the airway. To achieve
this, deep uterine relaxation is obtained during a cesarian section
under general anesthesia. Uterine perfusion with warmed saline also
promotes relaxation and blood flow to the placenta. On average,
between 20 and 30 minutes of placental perfusion can be achieved.
The fetal airway is secured either by placement of an orotracheal
tube or performance of a tracheostomy. Once the airway is secured,
the cord is cut, and a definitive procedure may be performed to
relieve the obstruction in the postnatal period. In general, infants with
cystic neck masses such as lymphangiomas have a more favorable
response to an EXIT procedure than infants with solid tumors such
as teratomas; this is particularly true for premature infants
Marjolin ulcer – (PGI June 07)
a)Ca in marjolin’s is squamous cell ca
b)Chronic venous insufficiency
c)Basal cell carcinoma
d)arise from base of the ulcer
:
Wounds that are chronically inflamed and do not proceed to closure
are susceptible to the development of squamous cell carcinoma
.Originally reported in chronic burn scars by Marjolin,other conditions
have also been associated with this problem, including
osteomyelitis, pressure sores, venous stasis ulcers, and
hidradenitis. The wound appears irregular, raised above the surface,
and has a white, pearly discoloration. The premalignant state is
pseudoepitheliomatous hyperplasia. If this report is obtained on a
biopsy specimen, the biopsy is repeated because squamous cell
carcinoma may be present in other areas.
True about Marjolins ulcer – (PGI 03)
a)Develops in long standing scar
b)Sq cell Ca develops
c)Slow growing lesion
d)Also know as Baghdad sore
e)Common in Black races
True about marjolins ulcer is – (PGI 97)
a) Ulcer over scar b) Rapid growth
c) Rodent ulcer d) Painful
Chronically lymphoedematous limb is predisposed to all of the
following except – (Al 04)
a)Thickening of the skin
b)Recurrent soft tissue infections
c)Marjolin’s ulcer
d)Sarcoma
Chronic lymphedema predisposes to all except – (PGI 89)
a) Lymphangiosarcoma b) Marjolins ulcer
c) Recurrent infections d) Thickening of skin
Not a premalignant ulcer – (Kerala 94)
a)Bazin’s ulcer
b)Pagets disease of nipple
c)Marjolins ulcer
d)Lupur vulgaris
Commonest cancer in burn scar is – (PGI 97)
a) Sq. cell Ca b) Fibrosarcoma
c) Adenoa Ca d) Adeno-squamous Ca
:
Oriental sore (syn. Delhi boil, Baghdad sore, etc.):-This disease is
due to infection by a protozoal parasite, Leishmania tro pica, and is a
common condition in Eastern countries which is occasionally
imported to Western zones.
Malignancies of Skin
Margins of squamous cells carcinoma is -(JIPMER a) Inverted b)
Everted 81,Delhi 86)
c) Rolled d) Undermined
In pigmented basal cell carcinoma, treatment of choice is – (PGI 98)
a) Chemotherapy b) Radiotherapy
c) Cryosurgery d) Excision
Diagnostic procedure for basal cell Ca – (PGI 98)
a) Wedge biopsy b) Shave
c) Incisional biopsy d) Punch bio
Moh’s Micrographic excision for basal cell carcinoma is used for all of
the following except –
a)Recurrent Tumour (Karnataka 06)
b)Tumor less than 2 cm in diameter
c)Tumors with aggressive histology
d)Tumors with perineural invasion
Basal cell carcinoma spread by – (MAHE 07)
a) Lymphatics b) Haematogenous
c) Direct spread d) None of the above
The commonest clinical pattern of basal cell carcinoma is – (Corned
08)
a) Nodular b) Morpheaform
c) Superficial d) Keratotic
:
A 48-year-old sports photographer has noticed a small nodule over
the upper lip from four months. The nodule is pearly white with
central necrosis, telangiectasia. The most likely diagnosis would be –
a)Basal cell carcinoma (AIIMS 06)—Telangiectasia uncommon in
SCC
b)Squamous cell carcinoma
c)Atypical melanoma
d)Kaposis sarcoma
Match list I with list II and select the correct answer using the code
given below the lists – (UPSC 07)
List I List II
(Carcinoma) (Characteristic)
A.Seminoma testis 1. Hormone dependent
B.Carcinoma prostate 2. Does not spread by
C.Basal cell carcinoma lymphatics
D.Malignant melanoma 3. Prognosis depends on thickness
4. Highly radiosensitive
Code :
a)A B C D
4123
b)A B C D
4213
c)A B C D
3124
d)A B C D
3214
Ans. is ‘a’ i.e., Basal cell carcinoma [Ref: Sabiston 17"/e p. 796;
Harrison 166/e p. 497;
S.Das text book of Surgery Pile 101-103]
:
Basal Cell Carcinoma BCC is a malignancy arising from epidermal
basal cells. The least invasive of BCC subtypes, superficial BCC,
classically consists of truncal erythematous, scaling plaques that
slowly enlarge. This BCC subtype may be confused with benign
inflammatory dermatoses, especially nummular eczema and
psoriasis. BCC can also present as a small, slow-growing pearly
nodule, often with small telangiectatic vessels on its surface
(nodular BCC). The occasional presence of melanin in this
variant of nodular BCC (pigmented BCC) may lead to confusion
clinically with melanoma. Morpheaform (fibrosing) BCC and
micronodular BCC, the most invasive subtypes, manifest as solitary,
flat or slightly depressed, indurated, whitish or yellowish plaques.
Borders are typically indistinct, a feature associated with a greater
potential for extensive subclinical spread.
:
Rx:- The most frequently employed treatment modalities for BCC
include electrodesiccation and curettage (ED&C), excision,
cryosurgery, radiation therapy, laser therapy, Mohs micrographic
surgery (MMS), topical 5-fluorouracil, and topical
immunomodulators. The mode of therapy chosen depends on tumor
characteristics, patient age, medical status, preferences of the
patient, and other factors. ED&C remains the method most
commonly employed by dermatologists. This method is selected for
low-risk tumors (e.g., a small primary tumor of a less aggressive
subtype in a favorable location). Excision, which offers the advantage
of histologic control, is usually selected for more aggressive tumors
or those in high-risk locations or, in many instances, for aesthetic
reasons. Cryosurgery employing liquid nitrogen may be used for
certain low-risk tumors but requires specialized equipment
(cryoprobes) to be effective for advanced neoplasms. Radiation
therapy, while not used as often, offers an excellent chance for cure
in many cases of BCC. It is useful in patients not considered surgical
candidates and as a surgical adjunct in high-risk tumors. Younger
patients may not be good candidates for radiation therapy because
of the risks of long-term carcinogenesis and radioderma
Squamous Cell Carcinoma Primary cutaneous SCC is a malignant
neoplasm of keratinizing epidermal cells. SCC can grow rapidly
and metastasize. The clinical features of SCC vary widely.
Commonly, SCC appears as an ulcerated erythematous nodule or
superficial erosion on the skin or lower lip, but it may present as a
verrucous papule or plaque. Overlying telangiectasias are
uncommon. The margins of this tumor may be ill-defined, and
fixation to underlying structures may occur. Cutaneous SCC may
develop anywhere on the body but usually arises on sun-damaged
skin. A related neoplasm, keratoacanthoma, typically appears as
a dome-shaped papule with a central keratotic cra-ter, expands
rapidly, and commonly regresses without therapy. This lesion
can be difficult to differentiate from SCC. Actinic keratoses and
cheilitis, both premalignant forms of SCC, present as hyperkeratotic
papules on sun-exposed areas. The potential for malignant
degeneration in untreated lesions ranges from 0.25 to 20%. Bowen’s
disease, an in situ form of SCC, presents as a scaling, erythematous
plaque. Treatment of premalignant and in situ lesions reduces the
subsequent risk of invasive disease.
:
Rx:- SQUAMOUS CELL CARCINOMA The therapy of cutaneous SCC
should be based on an analysis of risk factors influencing the
biologic behavior of the tumor. These include the size, location, and
degree of histologic differentiation of the tumor as well as the age
and physical condition of the patient. Surgical excision, MMS, and
radiation therapy are standard methods of treatment. Cryosurgery
and ED&C have been used successfully for premalignant lesions and
small primary tumors. Metastases are treated with lymph node
dissection, irradiation, or both. 13-cis-retinoic acid (1 mg orally every
day) plus INF-α (3 million units subcutaneously or intramuscularly
every day) may produce a partial response in most patients.
Systemic chemotherapy combinations that include cisplatin may also
be palliative in some patients.
This basal cell
carcinoma shows central ulceration and a pearly, rolled,
telangiectatic
tumor border.
:
Squamous cell carcinoma is seen here as a hyperkeratotic crusted
and somewhat eroded plaque on the lower lip. Sun-exposed skin
such
as the head, neck, hands, and arms are other typical sites of
involvement.
Keratoacanthoma
is a low-grade squamous cell carcinoma that presents as
an exophytic nodule with central keratinous debris
:
Keratoacanthoma
Keratoacanthoma (molluscum sebaceum) arises as a rapid
proliferation of squamous epidermal cells. The nodule grows
rapidly for 6—8 weeks at which time it usually begins to resolve
spontaneously. Keratoacanthoma must be distinguished from SCC.
Usually rapid evolution to relatively large size, irregular crater shape
and keratotic plug, and the undamaged surrounding skin make a
distinction possible. Spontaneous healing further confirms the
diagnosis. Histologically, it is difficult to differentiate between a
keratoacanthoma and SCC. There is also a possibility of a highly
anaplastic SCC behaving like a keratoacanthoma. Excision biopsy is
mandatory if the diagnosis is in doubt as curetted specimens yield
poor sections.
Malignant pustule occurs in – (PGI 88) a) Melanoma b) Gas
gangrene ) Ovarian tumour d) Anthrax
All are true statement about malignant melanoma except- (A197)
a)Clark’s classification used for prognosis
b)Women have better prognosis
c)Acral lentigenous have better prognosis
d)Limb perfusion is used for local treatment
Prognosis of malignant melanoma depends on – (JIPMER 98)
a) Grade of tumor b) Spread of tumor
c) Depth of invasion d) Metastasis
Worst prognosis in Melanoma is seen in the subtypea)Superficial spreading (Kerala 2001)
b)Nodular Melanoma
c)Lentigo Maligna Melanoma
d)Amelanotic Melanoma
:
Least malignant melanoma is- (Kerala 2001)
a) Lentigo maligna b) Superifcial spreading
c) Nodular d) Amelanotic
Prognosis of melanoma depends on – (PGI 98)
a)Stage
b)Depth of melanoma on biopsy
c)Duration of growth
d)Site
Which one of the following is not included in the treatment of
malignant melanoma – (UPSC 05)
a) Radiation b) Surgical excision
c) Chemotherapy d) Immunotherapy
In the Clatke’s level of tumor invasion for malignant melanoma level 3
refers to – (COMED 06)
a)All tumar cells above basement membrane
b)Invasion into reticular dermis
c)Invasion into loose connective tissue of papillary dermis
d)Tumor cells at junction of papillary and reticular dermis
True about melanoma of the anal canal is -(PGI 99)
a)Present usually as anal bleeding
b)AP resection gives better result than local excision
c)Local recurrence at the same site after resection
d)Radiosensitive
Most common site of Ientigo maligna melanoma is –a) Face b) Legs
(PGI 01)
c) Trunks d) Soles
:
Most common origin of melanoma is from –
a)Junctional melanocytes (AMU 01)
b)Epidermal cells
c)Basal cells
d)Follicular cells
Melanomas originate from neural crest-derived melanocytes;
pigment
cells present normally in the epidermis and sometimes in the
dermis.
The back is the
most common site for melanoma in men. In women, the back and the
lower leg (from knee to ankle) are common sites.
The most important prognostic factor is the stage at the time of
presentation. Fortunately, most melanomas are diagnosed in clinical
stages I and II. The revised American Joint Committee on Cancer
(AJCC) staging system for melanoma is based on microscopic
primary tumor depth (Breslow’s thickness), presence of
ulceration, evidence of nodal involvement, and presence of
metastatic disease to internal sites
An alternative prognostic scheme for clinical stages I and II
melanoma, proposed by Clark, is based on the anatomic level of
invasion in the skin. Level I is intraepidermal (in situ); level II
penetrates the papillary dermis; level III spans the papillary
dermis; level IV penetrates the reticular dermis; and level V
penetrates into the subcutaneous fat. The 5-year survival for these
stages averages 100, 95, 82, 71, and 49%, respectively.
:
Any pigmented cutaneous lesion that has changed in size or shape
or has other features suggestive of malignant melanoma is a
candidate for biopsy. The recommended technique is an excisional
biopsy, as that facilitates pathologic assessment of the lesion,
permits accurate measurement of thickness if the lesion is
melanoma, and constitutes treatment if the lesion is benign. For large
lesions or lesions on anatomic sites where excisional biopsy may not
be feasible (such as the face, hands, or feet), an incisional biopsy
through the most nodular or darkest area of the lesion is acceptable;
this should include the vertical growth phase of the primary tumor, if
present. Incisional biopsy does not appear to facilitate the spread of
melanoma.
The following margins can be recommended for primary melanoma:
in situ: 0.5 cm; invasive up to 1 mm thick: 1.0 cm; >1 mm: 2.0 cm.
For lesions on the face, hands, and feet, strict adherence to these
margins must give way to individual considerations about the
constraints of surgery and minimization of morbidity. In all instances,
however, inclusion of subcutaneous fat in the surgical specimen
facilitates adequate thickness measurement and assessment of
surgical margins by the pathologist.
Patients who have advanced regional disease limited to a limb may
benefit from hyperthermic limb perfusion with melphalan. High
complete response rates have been reported, and responses are
associated with significant palliation of symptoms
wedge biopsy:- An excisional biopsy in which a lesion identified at
the time of a surgical procedure is removed, with a wedge of normal
surrounding tissue
Trophic ulcers are caused by – (PGI 02)
a) Leprosy b) Buerger’s disease
c) Syringomyelia d) DVT
e) Varicose veins
:
Trophic ulcers [trophe (Greek) = nutrition] are due to an impairment
of the nutrition of the tissues, which depends upon an adequate
blood supply and a properly functioning nerve supply. Ischaemia and
anaesthesia therefore will cause these ulcers. Thus, in the arm,
chronic vasospasm and syringomyelia will cause ulceration of the
tips of the fingers (respectively painful and painless). In the leg,
painful ischaemic ulcers occur around the ankle or on the dorsum of
the foot. Neuropathic ulcers due to anaesthesia (diabetic neuritis,
spina bifida, tabes dorsalis, leprosy or a peripheral nerve injury) are
often called perforating ulcers .Starting in a corn or bunion, they
penetrate the foot, and the suppuration may involve the bones and
joints and spread along fascial planes upwards, even involving the
calf.
Nonspecific ulcers are due to infection of wounds, or physical or
chemical agents. Local irritation, as in the case of a dental ulcer, or
interference with the circulation, e.g. varicose veins, are predisposing
causes.
A healing, nonspecific ulcer has a shelving edge. It is pearly, rolled
or rampant if a rodent ulcer, and raised and everted if an
epithelioma, undermined and often bluish if tuberculous,
vertically punched out if syphilitic.
Treatment for pyoderma gangrenosum is –
a)Steroids (Jharkand 03)
b)I.V. antibiotics
c)Surgery + antibiotics
d)Surgery alone
Which of the following materials for implants will
evoke least inflammatory tissue response –
a)Polypropylene (SGPGI 04)
b)Bovine collagen
c)Polygiactin
d)Cotton
:
Chronic Burrowing ulcer is caused by – (.AI07)
a)Microaerophilic streptococci
b)Peptostreptococcus
c)Streptococcus viridans
d)Streptococcus pyogenes
Schwartz:- Pyoderma gangrenosum is a relatively uncommon
destructive cutaneous lesion. Clinically, a rapidly enlarging, necrotic
lesion with undermined border and surrounding erythema
characterize this disease. Linked to underlying systemic disease in
50% of cases, these lesions are commonly associated with
inflammatory bowel disease, rheumatoid arthritis, hematologic
malignancy, and monoclonal immunoglobulin A
gammapathy.Recognition of the underlying disease is of paramount
importance. Management of pyoderma gangrenosum ulcerations
without correction of underlying systemic disorders is fraught
with complication. A majority of patients receive systemic steroids
or cyclosporine.Although medical management alone may slowly
result in wound healing, many physicians advocate chemotherapy
with aggressive wound care and skin graft coverage.
:
Sabiston:- Extraintestinal manifestations of ulcerative colitis include
arthritis, ankylosing spondylitis, erythema nodosum, pyoderma
gangrenosum, and primary sclerosing cholangitis. Arthritis,
particularly of the knees, ankles, hips, and shoulders, occurs in about
20% of patients, typically in association with increased activity of the
intestinal disease. Ankylosing spondylitis occurs in 3% to 5% of
patients and is most prevalent in patients who are HLA-B27 positive
or have a family history of ankylosing spondylitis. Erythema nodosum
arises in 10% to 15% of patients with ulcerative colitis and often
occurs in conjunction with peripheral arthropathy. Pyoderma
gangrenosum typically presents on the pretibial region as an
erythematous plaque that progresses into an ulcerated, painful
wound. Most patients who develop this condition have underlying
active inflammatory bowel disease. Arthritis, ankylosing
spondylitis, erythema nodosum, and pyoderma gangrenosum
typically improve or completely resolve after colectomy.
Colectomy has no effect on the course of PSC.
:
According to Harrison:- Pyoderma gangrenosum (PG) is seen in 1–
12% of UC patients and less commonly in Crohn’s colitis. Although it
usually presents after the diagnosis of IBD, PG may occur years
before the onset of bowel symptoms, run a course independent of
the bowel disease, respond poorly to colectomy, and even
develop years after proctocolectomy. It is usually associated with
severe disease. Lesions are commonly found on the dorsal surface
of the feet and legs but may occur on the arms, chest, stoma, and
even the face. PG usually begins as a pustule and then spreads
concentrically to rapidly undermine healthy skin. Lesions then
ulcerate, with violaceous edges surrounded by a margin of erythema.
Centrally, they contain necrotic tissue with blood and exudates.
Lesions may be single or multiple and grow as large as 30 cm. They
are sometimes very difficult to treat and often require intravenous
antibiotics, intravenous glucocorticoids, dapsone, azathioprine,
thalidomide, intravenous cyclosporine, or infliximab.