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Congenital Pyloric Stenois - Important Signs

1.  String sign: thin column of barium leaking through the tightened muscle
2. Shoulder sign: filling defect in the antrum due to prolapse of muscle inward
3.  Mushroom sign: hypertrophic pylorus against the duodenum
4. Railroad track sign: excess mucosa in the pyloric lumen resulting in 2 columns of barium.

Abnormal Pulses and Possible Etiologies

Abnormal Pulses 

Pulsus alternans: sign of left ventricular systolic dysfunction

Pulsus bigeminus: sign of hypertrophic obstructive cardiomyopathy

Pulsus bisferiens: in aortic regurgitation

Pulsus tardus et parvus: aortic stenosis

Pulsus paradoxus: cardiac tamponade and tension pneumothorax

Irregularly irregular: atrial fibrillation

Hypercalcemia of malignancy

Hypercalcemia of malignancy

Paraneoplastic Syndromes


Metastasis :  PTH low , High Ca , High Phosphate

(Squamous cell )PTH-rp in Lung : PTH low , High PTH r-p , High Ca , low Phosphate



  • Extracellular deposit of insoluble polymeric protein fibrils in tissue & organs
  • Can be primary (AL type) or secondary (AA) to chronic inflammatory conditions such as:
  • Inflammatory arthritis (e.g RA)
  • Chronic infections (e.g bronchiectasis, tuberculosis, osteomyelitis)
  • Inflammatory bowel disease (e.g Crohn's disease)
  • Malignancy (e.g. lymphoma)
  • Vasculitis

Clinical presentation

  • Asymptomatic proteinuria or nephrotic syndrome 
  • Restrictive cardiomyopathy
  • Hepatomegaly
  • Peripheral neuropathy &/or autonomic neuropathy
  • Visible organ enlargement (e.g. macroglossia)
  • Bleeding diathesis
  • Waxy thickening, easy bruising of skin


  • Tissue biopsy (e.g. abdominal fat pad)

Congo red stain shows amyloid deposits within vessel walls. 

Congo red stain shows apple green birefringence under polarized light.

List of Granulomatous diseases

  • Bartonella henselae(cat scratch disease)
  • Berylliosis
  • Churg-Strauss syndrome
  • Crohn disease
  • Francisella tularensis
  • Fungal infections (e.g., histoplasmosis, 
  • blastomycosis)
  • Granulomatosis with polyangiitis (Wegener)
  • Listeria monocytogenes(granulomatosis 
  • infantiseptica)
  • M. leprae(leprosy; Hansen disease)
  • M. tuberculosis
  • Treponema pallidum(tertiary syphilis)
  • Sarcoidosis 
  • Schistosomiasis

Th1cells secrete ╬│-interferon, activating macrophages. TNF-╬▒from macrophages 
induce and maintain granuloma formation. Anti-TNF drugs can, as a side effect, cause 
sequestering granulomas to breakdown, leading to disseminated disease. Always test for 
latent TB before starting anti-TNF therapy.

Features of constrictive pericarditis

Features of constrictive pericarditis

  • Idiopathic or viral pericarditis
  • Cardiac surgery or radiation therapy
  • Tuberculous pericarditis (in endemic areas)

Clinical presentation

  • Fatigue and dyspnea on exertion
  • Peripheral edema and ascites
  • Increased JVP
  • Pericardial knock may be heard
  • Pulsus paradoxus
  • Kussmaul's sign

Diagnostic findings
  • ECG may be nonspecific or show atrial fibrillation or low voltage QRS complex
  • Imaging shows pericardial thickening and calcification
  • Jugular venous pulse tracing shows prominent x and y decents.