✨Haemorrhoids✨
✅Haemorrhoids can be described as excessive amounts of normal endoanal cushions. They are associated with constipation and chronic straining.
☁️Haemorrhoids can be divided into:
👉Internal → Originating from the vascular anal cushions
✅Painless, fresh rectal bleeding
👉External → Originating from perianal vessels (originate below the dentate line)
✅Pain, itching, and swelling
✨Internal haemorrhoids can be classified into 4 grades✨
Grade I: No prolapse out of anal canal, just prominent blood vessels
Grade II: Prolapse seen when strains but spontaneously reduces and returns
Grade III: Prolapse is seen when strains requiring manual reduction
Grade IV: Prolapse is seen and cannot be manually reduced
☁️Management☁️
✨Conservative and medical management
👉Digital replacement of prolapse haemorrhoid, Often relieves the pain
👉Avoid straining and constipation by using laxatives or bulking agent
👉Local anaesthetic creams and ointments
✨Surgical
👉Sclerotherapy :Injection of a small volume of irritant solution reducing the blood supply to the haemorrhoid eventually decreasing the size of the haemorrhoid over weeks
👉Banding
👉Haemorrhoidectomy
Excision of haemorrhoids under general anaesthesia
✨Thrombosed prolapsed internal or external haemorrhoids may be treated conservatively with analgesia and ice packs applied to the area to reduce oedema and inflammation. However, these may require surgery especially if patients present within 72 hours✨
Tuberculosis -"যক্ষ্মা" শব্দটা এসেছে "রাজক্ষয়" থেকে। ক্ষয় বলার কারণ এতে রোগীরা খুব শীর্ণ (রোগা) হয়ে পড়েন ।
আমরা যারা ওয়ার্ডে গিয়ে রোগী দেখি, খুব অহরহ এই যক্ষ্মা রোগী পেয়ে যাবো, কেননা, বাংলাদেশের মতো জনবহুল দেশে এই রোগ খুবই common,
তো আমরা যখন পেশেন্ট কে গিয়ে জিজ্ঞেস করবো, বাবা, কি সমস্যা নিয়ে এসেছেন??
রোগী কি বলে সাধারণত??
খুশখুশে কাশি অনেকদিন ধরে, তাই না??
তাহলে চলো sign-symptoms জেনে নেই........
🔺General signs and symptoms : fever(evening rise of temparature)
- chills
- night sweats
- loss of appetite
- weight loss
- fatigue
- Significant nail clubbing may also occur
Ok, এবার এই যে, Tuberculosis, এর causative organism তো সবারই জানা, তাই না??
হ্যা, Mycobacterium Tuberculosis
তাহলে, এটাও জানা দরকার যে, এই organism কোথায় কোথায় affect করে, isn’t it??
🔷Those sites are :
- lungs mainly
🔷extrapulmonary infection sites ও কি থাকতে পারে??
হ্যা, সেগুলো হলো,
- the pleura (in tuberculous pleurisy)
- the central nervous system (in tuberculous meningitis)
- the lymphatic system (in scrofula of the neck)
- the genitourinary system (in urogenital tuberculosis)
- the bones and joints (in Pott disease of the spine)
- lymph nodes
- tonsils
তাহলে,🔆Tb হয় না কোথায় ?
Ans : Thyroid , Heart
▶তাহলে বলো, modes of infection কি হতে পারে??
-inhalation
- ingestion
- inoculation
- transplacental, তাই না??
হ্যা😉
এখন, আমরা আসি আসল কথায়,
🔴TB র pathogenesis কি হবে??
About 90% of those infected with M. tuberculosis have asymptomatic, latent TB infections (sometimes called LTBI),with only a 10% lifetime chance that the latent infection will progress to overt, active tuberculous disease.
🔷Primarily, TB infection শুরু হবে তখনই, যখন mycobacteria reach the alveolar air sacs of the lungs
↓
They are taken up by alveolar macrophage
↓
Macrophages identify the bacterium as foreign
↓
তারা চাবে phagocytosis এর মাধ্যমে সেটিকে বের করে দিতে,
And during this process, the bacterium is enveloped by the macrophage and stored temporarily in a membrane-bound vesicle called a phagosome.
↓
The phagosome then lysosome এর সাথে combine হয়ে form করবে phagolysosome. In the phagolysosome, the cell attempts to use reactive oxygen species and acid to kill the bacterium.
However,আমরা সবাই জানি, M. tuberculosis has a thick, waxy mycolic acid capsule that protects it from these toxic substances
পাশাপাশি আরেকটি কাজ হয়, সেটি কি??
Mycobacterium Tuberculosis also produce tuberculosis necrotizing toxin (TNT)
↓
This TNT cleaves NAD within macrophage
↓
death of infected macrophage
and will eventually kill the immune cell.
↓
Spread to regional lymph node
↓
Lymphangitis হবে
↓
Enlargement of hilar lymph node
↓
Gohn's complex→healed up and calcified→Gohn's body
➡Gohn's complex may spread and giving rise to milliary tuberculosis
🔷এবার আসি secondary TB র pathogenesis এ,
Endogenous(Gohn's complex) and exogenous source
↓
Sensitized T-cell lymphokines secrete করবে
↓
Macrophage activated হবে
↓
Macrophage secrete cytokines
↓
Necrosis(caseation types of necrosis) and vigorous pus formation
↓
Macrophage transformed into epitheloid cells
↓
Aggregate
Form giant cells and fibrosis
↓
Tubercle formation
and ultimately clinical S/S reveal হবে🤢🤢
🆚তাহলে বলো
primary & secondary TB র difference কি হবে?? Ok, let's discuss,
◾primary mainly children দের হয় আর secondary TB adult দের
◾primary TB র source exogenous and on the other hand secondary TB র source exogenous ও হতে পারে, আবার, endogenous ও
◾primary TB তে parenchymal lesion এর৷ site subpleural and
Secondary TB তে site subepical
◾Fate of
primary TB: 95% heal by calcified scar
Secondary TB : Fibrocalcific scar/may progress
◾ characterstic lesion:
Gohn's focus and gohn's complex in primary TB;
Tubercle formation in secondary TB(no regional lymph node involvement)
🤔🤔Gohn's focus🤨🤨
🚩Inhale করার পরে tubercle bacilli alveoli এ যাওয়ার পরে, macrophage এটাকে engulf করার try করবে,
এরপরেও কিছু সংখ্যক bacilli, intercellularly multiply করবে and they reach the Hilar lymph node through lymphatics,
Lung এ এই local lession ই Gohn's focus নামে পরিচিত
🚩 এই Gohn's focus, strands of affected lymphatics and enlarged Hilar lymph nodes, একসাথে মিলে form করে Gohn's complex
🚩 আর যদি infection এই stage এ seized হয়ে যায়, তাহলে Gohn's focus gradually healed and calcified হয়ে form করবে Gohn's body
🔆What is the name of pathological giant cell in TB ?
Ans : Langhan's type of Giant Cell
🔆 What type of Hypersensitivity Reaction occurs here ?
Ans : Type - IV hypersensitivity reaction
এই যে, TB হলো, এটি persist করলে, outcome কি হতে পারে??
Primary TB may undergo -
- complete resolution
- dissemination - isolated organ TB, milliary TB
- calcification হতে পারে
- fibrosis হতে পারে
- reactivation ও হতে পারে
🔴 Milliary Tuberculosis কি??
এটি এমন একটি আলাদা রূপ tuberculosis এর যেখানে,
- wide dissemination পাবো, আর
- অনেকগুলো tiny size এর lesions (1–5 mm) ও পাবো।
এর নাম এসেছে মূলত chest radiograph এ অনেকগুলো tiny spots এর কারণে, এই tiny spots গুলো পুরো lung fields এ থাকবে, যেটার appearance হবে millet seeds এর মতো—এর জন্যই এর নাম দেয়া হয়েছে "miliary" tuberculosis.🙂🙂
Miliary TB may infect any number of organs, including the lungs, liver, and spleen.
⛔ microscopic findings in TB
- Coalescent Granulomas in lung
- Granuloma with caseous necrosis, high power microscopic.
- Granuloma with epithelioid macrophages and a Langhans giant cell, high power microscopic.
- Granulomatous endometritis, high power microscopic.
- Ziehl-Neelsen acid fast stain, microscopic, AFB stain.
- Auramine stain, M. tuberculosis, fluorescence microscopy.
💁💁How'll i diagnose that this is a case of TB??
Ok, definitely by sign/symptoms 🤦♀🤦♀
Besides this, you can do
→ sputum for Mycobacterium Tuberculosis
→ Lymph node excision and biopsy
→ Mantoux test/ Tuberculin test
though It's not confirmatory
→chest X-ray
What do u see in X-ray ?
Ans : fibrocalcific nodule
Last but not the least
🚩Differential diagnosis কি হতে পারে??
❎Occasionally fungal infections
❎ sarcoidosis can cause noncaseating epithelioid cell granulomas
❎ Xanthogranulomatous pyelonephritis
Hope this will help you a lot
Thank you
@minhaz_chaion
Armed Forces Medical College,Dhaka cantonment
session:2016-2017
