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52
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Urine: 1200 1500 ml/day; 50% .1
Lungs: 500 - 700 ml/day; 30% .2
Skin: 200 400 ml/day; 15% .3
Feces: 100 200 ml/day; 5% .4
21-" ,2-6 ml/kg/hour
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ECF
ICF
Na
136 -146 mEq/L
7 -10 mEq/L
3 mEq/L

98-106 mEq/L

Cl

10 mEq/L

22-26 mEq/L

HCO3

Very low

8.4 10.2 mg%

Ca

150 mEq/L

3.5 5.1 mEq/L

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Chlor: 154 mEq/L o
pH: 5.0 o
Osmolarity: 308 mosm/L o
:
Natrium: 130 mEq/L o
Kalium: 4 mEq/L o
Calcium: 3 mEq/L o
Chlor: 109 mEq/L o
Lactate: 28 mEq/L o
pH: 6.0 o
Osmolarity: 278 mosm/L o
,
.
7

 :
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6 10 % : Orthostatic hypotension; apathy, tachycardia, poor turgor. o
11 15 % : supine hypotension; cool skin. o
20% < : coma; anuria; hypothermia; circulatory collapse o
o ) ( , ) = Osmolality
) ,(( Na X 2) + (Glucose/ 18) + (BUN/2.8 280-290
,mosm/l , .

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8 . .
.

:
o Renin; Angiotensine; Aldosterone; Atrial Natriuretic Peptide; altered by -
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o Aldosterone; Epinephrine; Insulin; Intrinsic Renal mechanism -
o PTH; Calcitonine; Vitamin D -
> 150 mEq/L :
) , , (,
. , , ,
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, .
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ECW- "
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,CHF ,
ESRD ,SIADH ,

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, .130-
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.1mEq/L/hour .

CO2 RBC- .
, .
.

, Hepokalemic
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( Body weight X 0.2 X (Cl desired-Cl measured). :
> 5.5 mEq/L :
, .
/ .
, , - ,
, , . ,
.:
Calcium gluconate I/V . o
Glucose + insulin: 500 ml, 5% glucose + 15 units insulin I/V . o
Bicarbonate. o
Hyperventilation. o
Resins. o
Steroids. o
Beta agonists: Ventolin. o
Dialysis. o
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 :
pH = 7.35 7.45
pCO2 = 35 44 mmHg
HCO3 = 22 25 mEq/L
: ) (7.35- ) ? (7.45 )
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? ) anion gap- ?(12
pH- PCO2- ,
. ,
.

10

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11

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13

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14

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15

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16

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17

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18

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19

 - -'
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PTH .50-60
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50- PTH- PTH .
- , 4
) 4
( . ,bilateral exploration , 95%-
,. 1%- 0% , "
.gold standard-
,sestamibi scan
US MRI , sestamibi gamma detection
.probe (MIP) minimally invasive parathyroidectamy
.
. PTH ) .(iPTH PTH
10 20- . PTH
2-3 , PTH .50%- ,
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bilateral exploration- 3.5
.
:
o . hungry bone syndrome
.
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o thoracic duct-
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4- 1/2
.SCM-
o sestamibi
20

:
o
o
o
o morbidity-
:
o
o
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o -
minimally invasive parathyroidectamy- 120 97.6%,
43 . recurrent laryngeal-70%-
6 . .
, , ,
.
. PTH-
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PTH 6- .PTH-
PTH 6- , .
selective venous sampling
PTH ) 2 (,
. sestamibi scan- ,
PTH.
) (,
Cinacalcet PTH-
) (

21

 -"
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22

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, .
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14-15" .
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:
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)
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23


.
,
.
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24

 -'
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, .
.
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45 , .
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.
. . 4-5 ,
36-48 , , 12- .
, heart beating
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3-4 ,
.
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.
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,
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.
HLA . ,
) ( , .

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.
, " 24-48 , .
Acute o " " ,Tc
. ,
. :
o - .
, .

25

 - Calcineurin inhibitors o )(
, .
o , MMF
o )/(
.
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.

. .
Chronic o .
. ,
. .
.
90%- . 12 , 8-
.

26

 -"
.1:8-9 2-
, 4- , 9- . 4000-
. '90-
. ,
: , , , , , ,
.
- .
, internal mammary-.axila-
. :
o 100 . ,
.
o .25 .
.40
o , .
.
.
BRCA o ) (40-80% .
BRCA- .
o .
o , .
o , .
o .
o )(HRT
o ,
Lobar carcinoma in-situ o ,
.LCIS-
, , .
o
o ,.
o ,
.inflammatory breast cancer-
o ) .(kupper ligament
o .
: , ,BRCA-
" .
:
o , .:
) 50%
( , ) ,(20-35% . : ,
,50 ,75 " false
."positive ,50-69 1-2
. 70 10 , 40-49
.
5 .
US o , .
,
. ) (.

27

 MRI o )
( . MRI . MRI-"
, ) false positive 3
(.
) excisional .(core
FNA . " .
.in-situ
.
excisional biopsy .gold standard-
. incisional , .
Core biopsy .
. ) .(HER2/neu ,
.
:
) , ( , ' sclerosing adenoma , . (DCIS) Ductal ca. in-situ (10%) lobular ca ,(80%) invasive duct ca.:
, ) (. . :TNM
T tumor size o
Tis DCIS o
T1 up to 2 cm o
T2 2- 5 cm o
T3 above 5 cm o
T4 pentrating skin or chest wall o
N lymph node status o
N0 negative o
N1 solitary nodes (1-3) o
N2 mass of matted nodes (4 -10) o
M metastases ( lung, bone, liver) o
) early breast cancer- (locally ,
) advanced breast cancer / ( Metastatic breast cancer-
) , ( .
. " .
.
) (maximal tolerable , ,
. 70- )(minimally effective
. 30 ,
. -
,radical mastectomy
) 40%(.

28

 .
, ) (
. . 75%-
. ,
) , / ( .
) ( .
) ,(sentinel lymph node biopsy .
, ,false negative . "
" .
,axilla-
3 .axilla-

.

) (lumpectomy
) ,(mastectomy + .
5 , 5-7 .

. ) (
. , .
,- ,
) ( ,
.
) "( . "
latissimus dorsi- .
.
neoadjuvant
. 65%- 50% .

,
. )
( , .
15%- , , .
, ) , (
. ,
.

29

- -"
- ' 4.5" .
. ' . ) (
, ) ( .
:
o ' .
.
o , ( . " S2-4
pudendal n-
. .
. ) dentate
.(line
- , .
) (
. .
' .
90" . , 1-
1.5 .' .
- ) pubo-rectalis ( -
) levator ani (.
, "
, .
. .

.
:
, , , , , :
, , , ,skin tags ,. rectal prolapse PR , ,/ , .
)/( , ,:
) , ( defecography
US MRI/CT -

30

Pudendal nerve terminal motor latency

.

- :
? ,
? ) , (? fecal
) impaction ( ,- .
. - IBD
. .
.
) -(.

, .
- ) 1- .(20
, ) ( ,,US ,
.pudental nerve-
" , , ,,
.
90 " ,
. .60-70% ,
) .(gracilis muscle
) colostomy -( Thiersch procedure . .
- - . ,
. .
:Rectal prolapse
: ) .internal mucosal prolapse
, ( , ) (
) , ( . , ,
. ,,
, . -
. 6-8"
, .
- )
( ) ( . -
. ,
.

31

:Peri-anal abcess
)" (
. .
, , -
) ,(40-50% ) ,(5-20% ischio-rectal .supralevator
,/ , .
, , , .
coccyx- , ,
. " US .CT " .
. ,,
, .
) (25-50% .
Fournier gangrene
labia/ . , .
Fistula-in-ano .
, .
. .
" . -
seton procedure
.
CD , , .
, .
, .
:Hemorrhoids
50%- . 10%- .
'
) .(right posterior, right anterior, left lateral:
BPH ) ( )( .
.
:
I . :.
II .
III .
IV - .
: .
, ,-.
:
o , , ,
o .
o .
o ,
) .(sclerosants )
( . .
PPH hemorrhoidopexy
.
32

 6 .
.
.
o ,
. , . 2-
3 , . .
:
/ . ) .(20-40
. )
(.
;
. ) ( .
. .
, .
) , , '( .
.IBD- : ,AIDS , ,TB , ,.
.
) ( .
, , . , .
) sentinel pile
( .
. , .
- " 40% .
, , )
( .Botox , ,
- 5-7%- . )
( ) sphincterotomy (lat. Int. sphincterotomy-
.
) 5%(
) ,IBD .(CD .IBD-
:Pilonidal disease
. , , ) '(.

. . ,
. , .
, .
:
Hidradentitis suppurativa .
subcutan- . Staph. aureus, -
.epidermidis, hominis ; Strep. Milleri , .
,anal stenosis , . :+
. .50%
Condyloma acuminatum HPV-6- .11 / -
. " . -
. . "
.
. / , .
, )
/(.

33

 Anal intraepithelial neoplasia HPV-16- .18- .

.
Bowenoid papulosis " .
- . .squamous cell carcinoma
Inflammatory cloacogenic polyp , ,
.
Keratoacanthoma ) ( . 4-6
. .
:
4% ' . ' , ,
. - ,
. 2-" .
:
Squamous cell o
Adenocarcinoma o
Small cell carcinoma o
Undifferentiated o
Paget's disease o
. ) 2/3 (.
67%- .HPV
Anal margin squamous cell carcinoma , .
Verrucous carcinoma , ,
.
! , -
. .TNM . +
) .(mitomycin + -FU5 -
.
Anal gland carcinoma .HPV )
( HPV .
) (mucinous .
Paget's disease DD . . .
Small cell carcinoma . .
.
1% Malignant melanoma . )(melanotic
) .(non-melanotic . 5-
,20%- . :
,
. -
. .sentinel-node biopsy
Basal-cell carcinoma . " , .
.

34

 -" '

:
o'
o'
o
o

:
Hematemesis vomiting of blood (or coffee ground material) (indicates
)bleeding proximal to the Treitz
Melena passage of black tarry stools > 50ml (indicates degradation of blood
)in the bowel
Hematochezia (rectal bleeding) passage of red blood
Occult bleeding bleeding that is not apparent to the patient and results from
small amounts of blood
Obscure bleeding occult or obvious but source not identified

o " " , , ,
o , , , ,,
" , , , ) 8 -
,(10 ) ,FFP ,(K
o
o ,
o '
o , ,) aortic graft ,
graft- ( , , ) (,
) NSAIDS- ( , ) ,(Mallory-weiss
, .
o , , ,
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o ' ,
' , colon- .
,colon- ' )
(.
o . , '
.
o/ . '
.esophagogastrodeudenoscopy 12
90%- , 70% .85%
o
.
80%- , 20% .
. .
' :
.1 : ' .
o
o .
GERD o
o/
o

35

.2
.3
.4
.5
.6
.7
.8
.9
.10

, ,
) ,(gastroduadenal artery-
) vagotomy ,partialqtotal gastrectomy ,PPI ,
( , ,H.pylori-
.
,NSAIDS , .
, , ,
.
.portal hypertension- )
( .
Mallory-weiss 90%- .
)" (.
,/ , )(
Dieulafoy ,

Osler-weber-rendu

' :
80% . .
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.
:
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( , ) ( ,NSAIDS , , ,
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. ,
.
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,
.
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o 25%. , ,
.
. .
o )(meckel
o
IBD o
o
o ' .
/ . ,
.
o - .AVM .
, , ,.
o - ,
Ischemic colitis o

36

 -"
.
" . 2.5-3-" %
4-5" % ) .(0.1-0.2 heme .
80% " 20% , hepatic heme protein-
98% . . . "
, )
( .
.
:
o , ,
o ,crigler najar- ,-' , ),
(
o ) ischemic hepatitis " ( , ) TPN-
(acute fatty liver of ,
.pregnancy
o ) (
) (:
o ,G6PD , ,
.
o .glucorinic transferase-
".
)(:
o ) , , , (
o , drug ,
,induced cholestasis .
-:
o .cholangio/choledochal ca.
) klatskin tumor '(.
o ) (.
o " .vater
o .
o .
o .
o
o
o
TB o
o
o
o )(cholangiocarcinoma
- ) (:
o
PBC o
o
o
GVH o
37

 o
o , ,chlorpromazine , .


. ) 6"(
.
:
o / .
. )
( .
)(.
o
o , ' . .
. .
o
. .
:
Direct hyper Bilirubinemia o
Obstruction o
Dilated bile ducts o
GGT ALP o
AST ALT o
:
Indirect hyper Bilirubinemia o
Hepatocellular damage o
Normal size of bile ducts o
AST ALT o
GGT ALP o
:
85-90%- " , )
(.
/ , ,/ , / ,
,RUQ- , ) , ( ,
, , , / ,, ,,
, ) ?( ,
, , .
) ( ) (.
) ,caput medusa , ,,
,(spider angiomata/ , " ) courvoiser
.
( , " virchow .
) ,(GGT, AST, ALT, ALP, LDH ,,
) CBC - " ,
( , , , , , )CEA, CA19-
,(9 .
:
US o , .
. ,
, ) ( , ",

38

o
o

o
o

CT US- ,
. , , .

. percutaneous transhepatic cholangiogram PTC
.CBD- . :
.
."
) ( . -
) , (.
ERCP .
, , .
/ . ) 10%,
1%( : , , )
.(precut .
EUS . . .95-100%
MRCP/MRI , .

o , , PTC- .ERCP
.
.
o ) (
o , , , .
-PTC / ERCP o - )
/ /-(.
o ) / ( )
(.
o ) (
o .
o " ) Whipple ( : ,
, .
o ) - (
o .
o PTCD ERCP .
o ERCP )(
o .
o ) } {(.
o .
ERCP o .
o .

39

 -"
.
, , , ) , ( .
) ( . ,
.
:
- ," '.
e. coli- .
, .
, )( , )
( , , ,.
/
. - .
:
" ) fecalit ( ,
) , ( . , ,
" .

. ,
. sup. Mesenteric artey-
. ) (
,' 2/3 ASIS- ) .(ASIS-
.periappendicular abcess

o , , )( , .
o " .
o ) (
o
o - ) .(37.8-38.3
."
.
o 24 RLQ-
:DD
:
PID o
o
o )(torsion
o -HCG .
:GI
IBD o
o
o ) ,
( . CT- .
o ) (
o ) (;
o ,
o , , ) (
o
o
o

40

:
Renal colic o , .
,
) (.
UTI o , ) ( ,
:
FMF o , , . .
o ) RLL- ( .
, , ,
.
:
o RLQ- ) rebound tenderness ( .
,
) (.
o rovsing .
o , .
o .
o psoas
.
o .PID-
. .
o ) (
o ) CBC 13-14( ,
, ) - ,( ,
) , ( ,-HCG , )
(,
) CT (.
o , ,
:
o : .RLL-
o : ,
) (sentinel loop fecalit- .
.
- , .
" .
US o ) 7"( , ,
.
. US- -
.CT
CT o gold standard- . CT
. ,
, CT )
(.
CT- .PO ,
. : , )
(target sign .fecalit-
:
.
, , ,
, , )'
(.
41


, , ,
) ,PID
( . - ,
) ( .
) ( ,
.

,- , , , ) ( ,
, , , )
( , . .
) ,)((-
. .
, ,
. , .

, , , ,
, . , ,
)' ( .
.
" , ) (periappendicular abcess
. CT-
) .(CT )" (
) , ,( . .
6-8- ) interval
,(appendectomy .
5 " " .
. " )50%
( , .
Mesenteric adenitis ) (.
,
.
) ,(
. .
) (20% )
.(5%-

42

 -"
- : . ),(ileus
, ) ( .
.
:
o : ,
)" ( phytobezoar
; ,
; , ) CD- ( ) .(CRC
2" .
o : ; ) (strangulation
;
.
o : ; )
, (; ;
) bezoar ( .
.
20% .
80% , ) ( .
, .
,50% .10%-
, ' ) (GI decompression
.
:
) (
) ( ) ( .'
, ) ,
800" , . ( .
, , , . .
) " (
.
.
. ." )
3-5 10-15 , / ( .
).(hyperdistention
) ( .
.
, .
.

. " .
.CRC )
.(volvulus ileo-cecal-
.
. .
) <- (
10-".

43

 :
o - " .
, , ,
- .
o ,"
. -
) (.
o .
o .
o .
o ) (.
o ) ( . .
6-8 .
o - ,
) (.
:
o , , , ) (
o WBC 15- , 15-25.
40,000 .
o .
:
o )
( . .
.
o -.
o / ) Pseudo-obstraction of colon .
(ogilivie syndrome , )
( . .
:
o
o
o ) (80% ,
.
24 : , ,CVP , ,
. )
(.
, :
, , , , '.
:
o
o
o
o .
.
o .
Ileus ) , ,( , -.
) 24 , 48 , 5(.
,renal colic : , " , ,,
, ,MI , . .
.
)(.

44

 -"
40% ) 50% ( . ' ,2 65
' .1 ) "
(.
DD :
o B
o ) , (CRC
o -feto-protein ,-HCG
o -
CEA .
CA19-9 , -feto-protein ,
.
, .
.
LDH ) ( , .
) incisional : ( ) excisional-
( .
.
, FNA FNA .Pap smear-
. ,
. ,
.
. ,
.
- Staging ) (stage . TNM-"
) sentinel node biopsy ,Laparoscopy ,mediastinoscopy ( .
CT ,
. TNM ) cTNM
,(clinical Tumor Node Metastase"
/ , '.
TNM- -
) ( . - .
) (
. , adjuvant -
- treatment , , .
) (
. , .US ,CT ,
Adjuvant therapy ,
, "" / .
.
Neoadjuvant therapy .
:
o in-vivo ) (
o
o
) (.
o

45

 o
, .
:
o ).(grading
o ".
o
.
o
o - .
-+ .
/ , neoadjuvant
,therapy .
. Clarke
." ) breslow ( ,
. ) 1"(
, ) 4"( ,
.
.
" .

. )
( ) (.
.

)( .
. ,
3 .
. ,
. ) (adjuvant
, .
:
. .
CRC 25%- 5- ,
. /
" .microwave/RF ablation/ cryoablation

, "
, ) , , , , ,,
( . , .CT ," ,cTNM
) , ,( .

46

 -'
:
o . .
o . 50%
' . . "
.

o 0.3 .
) ( . .
GIST o . pacemaker- .
.
.
o
:
o 5 , .5
o 25 3 .
, , .
- 70%- , 50%-
, , . ,
, , .
:
o
o , ,
CT o , -
staging .
US o , ,
.staging-
50% , .
. ,
) G ( . -
MALToma ) ,
( . .
.

. -
,R0 .
) ,( , .
adjuvant.neoadjuvant-

50%- ,
. ,
. ,
47


staging- 18 .
, .
5- .
, .

. 7-" .
)''( ''
) (
. ) Reux en Y .(Y
) .(Baret's esophagus-
, .bezoar
: , ,
.
, .
, - .

48

 -'
.
' ) ( '
.
:
)( .
) wirsung's duct ( .
" . .
) 1.2 .(10,000-
. , . .
.mkk4 ,brca2 ,dpc4 ,p53 ,p16 -
.
89% ) 70% ( 1% , ) acinar
( 9% . 1% . .
.
:
,acinar ,giant cell tumor ,adenosquamous primary solid nonendocrine o
.pancreatoblastoma .
) mucinous primary cyctic nonendocrine o ( 25%-
) serous , ,
( " solid and cystic papillary tumor ,
hamudi tumor , 20" .
intraductal papillary .

) ( .
, .
o )(
:
o courvasier
o
o .
) (.
o
o
o ) TG , ,(.
:
CT o ,gold standard- .
EUS o CT- .portal vein-
) ( .
ERCP o ,
. ,
Double duct sign .
) ( .
MRCP o , .
CA19-9 o " . )
( . 300 ) 300
, (.
o - .
.
49

:
TNM o 9.
o -.
o
o 30% -
, . .
1 -T -2 , , , - ) -
( -3 . , , .
:
.
) , '(.
30%- , 30% -
) (.
:
30-50% . .
.
. .
,
) ( .
.ACTH ,GH ,PTH
,
. 1-6 90% . .
, . 5-10%-
.MEN-1-
,(intra-operative US) IOUS ,MRI ,CT ,US )
( .
.
, ) (splenic v.
.
.
) ,(60% 0.2-1 .
" 25% . ) MEN-1 ( . ,MEN
, , -
30%.
, .
. .
, .
: , ) ,(cysticus 70% .
, .
. , 50%-
.
. , , ,.
Necrolytic migratory erythema ," .
.
) 4"( , ).(70-90%
.1000 pg/ml

50

 VIPoma , . ,
,hypochlorhydria , 50%-.
50% , .40%
1-2% . .
. " .
" .
" , ,.
Nonfunctioning endocrine tumors .
. , .
.
. ,HCG .
, 5-6.
:
. US-
, .

. 15 staging- .
90-95% .
Whipple procedure .
, , , .
, .
.
,
.

51

 -"
) (CRC .
. 10%- CRC
. , ,CRC
3-9 .
.
:CRC
) .(20% <- <- <- <- <-
< CRC IBD :CRC-.
,
. 80%- tubular
adenoma ) sessile , ,
( ) pedunculated ( .
. 20% - villous adenoma
. 2-" , 60%
.
30%- CRC , ,
.
:
20% CRC- .PR- 20-25%
. 1-" , -
.0.2% CRC , ) synchronus
.6-8% (carcinoma .
CT ) ,
( CT . . MRI- CT.CRC-
PET-CT
,CT- PET-
.
tranrectal US TRUS . )(
, )( - ,
- , ) ,(muscularis propria
.
T1 -- 2 , 3 , 4 ,
.
:
. ,
:
50 - UC 10 CD , familial ) FAP ,.(hereditary non-polyposis colorectal cancer) HNPCC ,(poliposis
CRC . 40 3
.50 :
52

 , 3 " 5 .
CRC CRC ).(metachronus carcinoma
) (:
,GI- ) ( , )
( 6-8%. .40
:
o ,
" + .
o ,
. " ,
, , .
o 10%- " .
o " . )(
)(.periappendicular abcess :DD .
o
, , CEA , CEA .CT- ,
.
.
)-( .
) ( .
, . '
.
, ) (right hemicolectomy
) right ,ileo-colic
midcolic ,rolic marginal artery- ( midcolic artery -.
.
.extended right hemicolectomy

) ( .
,
) <-(.
.left hemicolectomy
.sigmoidestomy
:
- Two stage operation ) ( , - )(,
, )
( .
Sub-total colectomy . :( .( -
) ( .( ,
.( .metachronus carcinoma-
.
, )
.(5-FU .CRC-

53

 :
, ,
- . .
,
.
2" ) ( ,
, . ,
- .
" pudendal- hypogastric-
- .
.
" .PR .
- ) (anal verge- "
rigid rectoscopy
) ( .
.
CT .TRUS .
:
T1- .5%
- Anterior resection Low anterior resection .tumor mesorectal excision TME .
Abdominal perineal resection . T3 - 30% .
40% .
) neoadjuvant 5-6( ) (
.
TME ) (
. 50%- .75%- 30%--
.8% 20%-- 50%-.15%-
T1 ,
AR T2 + APR
+ neoadjuvant T3

54

 -"
:ZD Zenker's diverticulum
73 )( , , .
. .
.ZD
ZD inf. constrictor- .cricopharyngeus-

. , . ,
. .
) 50 (70 , .30 50%-
,GERD .
, , )
( . , )
" "( . , .
, ) ,(esophageal lung
) ( ,
.
" .
,
.
: . )
( )
( . ) ,(diverticulectomy
.
) (cricopharyngeus .
85% - 10% , . 2.5% ) recurrent laryngeal-
( 2.5% , ) ( 1% , ) "
, (.
:DES Diffuse esophageal spasm

. ,30-50 .
, .
. vaben-.
:
) ,(corkscrew . .
. - -
. 10 , -pH .
) ( , 20%- GER "
.
: ) , ,( .
, "
. 50% .
-
.
:Achalasia

) .(LES ,
. ,30-50 .
, , .-
LES , .
. vigorous

55

 .bird beak
LES .
) (pseudoachalasia !
) (
) 15% 25(.
:
o :DES- , , .
o
) ( . 70-80%- , 15% ,20%
. .1.5%
,
.
o ,Heller's myotomy .
8" " ) .(LES-
-
,GERD .
,
) , , ( . ,90-95% ,
.2%-
GERD
- ,
. , , ,
. ,60-30 , ,,
.
: , , ,,
.
:




,



- , .
70-80% < .30% 80-90%
3% -.
:
) -
.(GEJ .adenocarcinoma ,60
) (6 ) ,squamous cell- (.
:
GERD o
Barrett's esophagus o
o
o
o

56

:
o ,"
o )
.(TNF
o 75%-

! .
):(cTNM
o .
,
.
EUS o ,T- .N-
CT o ,T- N-.M-
PET-CT o
1 T ; 2 ) (muscularis propria
; 3 ; 4 .
1 - N 5-"; 2 5" . N-
.
:
o " .
o . .squamous cell-
o .
, -
.
5-:
5%-
,10-80% ) Ia (95%
,
.
(SCC ) Squamous cell ca. , . :
o
o
o
o
, .
.

" . gastric pull
.up , ,
' . ) (
) ( )
(.

57

 -"
.
) -
( . , , '
.
, , , , .
, , .

. ) Harrison-
:(Benedict
Male _ Basel _ energy = 660 + 13.7 Xweight + 5 Xheight 6.8 Xage

Female _ Basel _ energy = 655 + 9.6 Xweight + 1.7 Xheight 4.7 Xage
35" 45" .
) ( )
( 10% . .10-20%-
.10-20%
.30-60%- ) 20% ( 2 .

1 -' ) 6.25' ( 125-150" . 0.8'
" . ) 2.2' , 6 1.1'
.(0.8- turnover- 250-300 . 50'
, 250' .
, . ,
, , , .
: 3' , 6'
, 12' , 15' , 18' .
- . . .-
, . . ) (branched chains
.

7' " . RBC- ,
, .
) CO2
(.

' ) 9" '( ." 2' " .
, 4-' " ." ,3-
.6- ) ,(MCT
. . ,
" ' ' ) .
(.
:
.(TPN) IV ,
) ,(nasogastric tube .
) .(jejunostomy ,
) , ,
( ,
.TPN-

58

 , ,
.
) ( .-
, ) (
.
" ) ( .
) ( "
) ( ) jejunostomy- ( .
,
. , ) (50% ) 30-"
90 ,60- 100" ( " )" 75% .(100%
.
" , :

. ,
.CO2-
):(PO
:
o
o
o
o
o
Otitis media o
:GI
o ,
o
:
oosmotic diuresis ,
o
prerenal azotemia o
:
:
o
o (failure to thrive) FTT
o ) (SBS
o ) ,(
o Ileus
o ,IBD ,
o ,CVA ,
,.
o "
) (.
:
o
o ) '
(.
o - , -
TPN .

59

 o
TPN .PO
TPN . 35
" " 30-50% . )
( . ) 10% ( ) 20%
( . 50-150' " )
"( . 1 :' ) 6.25' ( 125-150-" . ,TPN-
) 60-120"; 60-100";
8-10"; 200-400"; 300-400"( ,- ) ,K
( ,trace elements , ) TPN- (.
TPN
) 900-(.

TPN
o
o
o
o
o
Subclavian artery injury o
o/
o CO2
o
o
o , ,/
o
:
o , , ,
.
o , , ) triceps- - (-
) ( , , )( ,
.
o ) 21( , ) 7(,
- ,RBP - retinol binding protein , , ,
) ,(Delayed cutanenous hypersensitivity
.
, ,
.
:
1- Normal status
2- Mild to moderate malnutrition:
6-12% of body weight loss
serum albumin > 3.5 g/dl
serum transferrin >200mg/dl
3-Severe malnutrition
>12% of body weight loss
serum albumin < 3.5 g/dl
serum transferrin <200mg/dl

60

 :

.
. ,
) , 10-(.
" . - ,
. ,
. ) lean body mass
(.
. ,
. .
.

) (10-20
) (10-30


100-' .
, . .
. .
. " ,
. ,
. ,
..

"

"

,
.
. .
) 12-24 .(0-
TG " .
.

61

 . 7 , ,TPN -
IV 5% 2 , 100'
.

- ) IL-1,
.(IL6, TNF . ,
,GH .
:
.1 ? ) (
, .
)
( . TPN ,
. 50%
TPN ;7 , TPN- .
.2 ? 24
72 . 3 ,
. 18
.gastroparesis-
) ( , '' 48
.
, .
)
(.
.3 ?
.
) (GER
''.
.4 25-30" " .
30" " , " 20-22 Quadriplegics" "
) (22-24 Paraplegics ,
" " . 25" " 40 +" .
TPN 50% ,
.
1.25' " . 2'
" ; 5" " ; 30%-
) ( . .
)( CO2 ,
, , . 20% -
. 2.2'
" .
.5 ? - RBP-
, .
) (multiple trauma - .
" .
.6 ) immunonutrition
, ' (
.
.

) - (20-30% ) 18( .
) ( ,
, . 2' "
.

62

 /
72- .
: 300" 12- )
,(gastroparesis .
, .
, . -
1.25-2' " , 30-35 -" " .

) 300-" 12-
( . .
. .TPN 1.25-2 -' " ,
30-35 -" " . ) quadriplegia
22-24 paraplegia,20-22" " (. 48.

63

 - -"
-
) .(eating disorder - , .
BMI ) 25 ( 15.5% . ) BMI 3- ,(30
5% - .
BMI . 18.5- - , 25
, -30- ,I - 35 ,II - 40 .III
88" , 102".
- BMI 40 BMI 35 .
: , ,
. , ghrelin
,PY 3-36 , .
:
CVA o
o
o '
o
o
o
o
o
o
Sleep apnea o
GERD o
o- )(PCOD
o
35-40 BMI- . ) BMI -(
. , .
/ .
5% .DM-II
:
BMI- 35 : , ,
. 35 " .
.
?
. 0.68% -
.6.17%
) baros( ,
+ .
- 5- , 18-
.60 ,
. .
, . 5 57%
.
:
o
US o
o ,

64

 :
restrictive procedure o adjustable
- sleeve gastrectomy ,VBG - vertical banding gastroplasty ,AGB - gastric banding
.SG .
o Gastric bypass
o Bilio-pancreatic malabsorptive
.diversion
VBG " .
) '(.
AGB . .
' 15-20" .
, .
SG , ,
.
Gastric bypass
. ) 75"
'( . ,AGB-
. .PYY 3-36-
.
Bilio-pancreatic diversion ,
) '( . ,
.
* .

65

 -" '
, ,
.

0.837 . )
.(33%
.
:
o
Cholecystitis o
o
o
UTI o
o
:
o
Adrenal insufficiency o
Atelectasis o
o
o
drug fever o
o
MI o
o
o
PE o
o
o
o
:
o , )( , )
, , ,( , ) malignant hyperthermia , -
succinyl choline MH .(halothane
.dantrolane
o 24 ) (
Necrotizing strep. and clostridial wound infection .
.
24-48 o - ) ,( )
(; aspiration pneumonia ,'.
o 72 3-5) UTI( ,
) ,(BHP , ) 7-10(; intra-
abdominal abcess 4-7 anastomotic leak; 5-7 DVT.
:
Hematoma .
) .(soft-tissue flap necrosis
.

66

 :
o -.
o )( ,
.
o .
o .
o , .
o" .
.
Seroma ) ( .
) , ,( . "
. ) .(drain
.
, , . :
clean I o ' ///.
.
clean contaminated II o ' "
) , (.
contaminated III o . .
infected IV o . .
I- ,2% ,6-8% II- ,18% III-.50% - IV -
" , '.
7-10 . - , , ,
. " . ' ,
" ) (- ,
.
) (wound dehiscence ) (fascia
. 0.5-3%-.
Evisceration .
Evintration .
:
o .
o , , , ,-.
o ,- , .
o ,- ,.
o , , .
evisceration . Evintration .
, .
.
' :
Illeus . , 2-
3 , 3-5 .
. .
5- ) , '(
.

67

 :
o 60%
o 20%
o 10%
5% IBD o
) Volvulus o ( 3%
:
o
o ) (
o ) (
o
o
o
o ) (
o
Abdominal compartment syndrome - ACS 15" )4-15%
( . ; ; ;
; ; ;
. ACS- :
o
o
o .
" .
25".
Stress ulcers , , , ,CNS ,
.MI , .
. .
. ) PPI( 70-80% .
.
Anastomotic leak .
. ,3- . CT : .
, ,
.
. - ,- ,-
' . .3-
Antibiotic associated colitis . 50%-
- . -.
1%- , .
clostridium defficile )
( . , .
.toxic megacolon . '
. 20%- .

68

 ' :
25-50%- , ) , ,(COPD ,
) ( .
, .
5% , . - ,
, . .
.
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69

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70

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72

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74

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75

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76

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77