Apply stretches the bowel wall discount tadalafil 20mg visa erectile dysfunction unable to ejaculate, so it becomes relatively thin discount 2.5mg tadalafil overnight delivery erectile dysfunction urologist new york, medium-size hemostats in pairs to the intervening tissue generic tadalafil 2.5mg otc fast facts erectile dysfunction. After the wedge of mesentery has been completely freed, distal , should be loosely placed in the operative ﬁeld. After the ﬁrst seromuscular bite has been taken, the nee- Apply noncrushing intestinal clamps proximally and distally dle is ready to be reinserted into the wall of the opposite to prevent spillage of intestinal contents. At this time it is often helpful to use eased segment of intestine by scalpel division. Elevation relaxes this segment of the Open Two-Layer Anastomosis bowel and permits the suture to catch a substantial bite of Considerable manipulative trauma to the bowel wall can be tissue, including the submucosa. Each bite should encom- avoided if the anterior seromuscular layer of sutures is the pass about 4–5 mm of tissue. First, use 4-0 silk on an atraumatic 43 Small Bowel Resection and Anastomosis 397 needle, and insert a seromuscular suture on the antimesen- and 43. Turning in the corners with this technique is sim- teric border followed by a second suture on the mesenteric ple. Then, complete the ﬁnal mucosal between these two sutures, and insert and tie the third layer using the Connell technique or a continuous Cushing Lembert suture at this point. After this mucosal layer has been com- anterior seromuscular layer has been completed (Fig. Rotate the bowel by passing guy suture A sive bisection is not necessary in the ﬁnal layer because the behind the anastomosis (Fig. Tie the suture and close the posterior layer, one wall of the intestine through the anastomosis with the tip which should include the mucosa and a bit of seromuscu- of the index ﬁnger. Cut the tails of all the sutures except the two at the end and rotate the bowel to expose the opposite, unsutured bowel (Fig. Approximate this too with interrupted 4-0 silk seromuscular Lembert sutures, paying special attention to the mesenteric border, where fat and blood vessels may hide the seromuscular tissue from view if the dissection has not been thorough. Alternatively, instead of Lembert sutures, “seromuco- sal” stitches may be inserted (Fig. This suture enters the seromuscular layer and, like the Lembert sutures, penetrates the submucosa; but instead of emerging from Fig. Small Bowel Anastomosis Using Stapling Technique In our experience, the most efﬁcient method for stapling the small bowel is a two-step functional end-to-end technique. Insert a cutting linear stapling device, one fork in the proximal and the other fork in the distal segment of the intes- tine (Fig. Fire the stapling instrument, which forms one layer of the anastomosis in an inverting fashion (Fig. Close the remaining defect in the anastomosis in an everting fashion after applying four or ﬁve Allis clamps to maintain apposition of the walls of the proximal and distal segments of bowel (Fig. After all the Allis clamps have been aligned, staple the bowel in eversion by applying a 90/3. It is essential that the line of staples cross the cut edge of the serosa and underlying mucosa. This both the anterior and posterior terminations of the anastomotic stitch has the advantage of inverting a smaller cuff of tis- staple line to avoid gaps in the staple line. Fire the stapler, and sue than does the Lembert or Cushing technique and may excise the redundant bowel ﬂush with the stapling device using therefore be useful when the small bowel lumen is exceed- Mayo scissors. When inserted properly the seromucosal Carefully inspect the staple line to be sure each staple has suture inverts the mucosa but not to the extent seen with formed a proper B. If feasible, cover the everted mucosa by the mesenteric suture line to minimize the possibility of it becoming a nidus of adhesion formation. Chassin† Indications Enter the abdomen through a scar-free area and carefully dissect the bowel from the underside of the abdominal Enterolysis is indicated for acute cases of complete small wall. The additional exposure gained by doing the easy dissection ﬁrst facilitates work in the more difﬁcult parts. Work on the collapsed region Preoperative Preparation (distal to the obstruction) ﬁrst, if possible, and keep the dilated proximal bowel in the abdomen as long as possible. After all adhesions have been freed, repair any injured seg- Initiate ﬂuid and electrolyte resuscitation. Pitfalls and Danger Points Documentation Basics Inadvertent laceration and spillage of the contents of the • Note ﬁndings intestine is a hazard of this procedure. Failure to identify and • Presence or absence of obstruction relieve all points of obstruction can occur unless the entire small bowel is dissected free. Operative Technique Operative Strategy Incision and Bowel Mobilization Dissect carefully and patiently to avoid spillage of intesti- A long midline incision is preferable. Bacterial overgrowth occurs rapidly when the ous midline incision, start the new incision 3–5 cm cephalad contents stagnate. Massive distension with thinning of the to the upper margin of the scar so the abdomen can be entered bowel makes it much more likely to occur and more serious through virgin territory. To avoid this mishap, dissection soon as the peritoneum is entered, air ﬂows into the perito- should be done carefully and patiently. The basic dissection strategy consists in entering the At the same time, dissect away any adherent segments of abdominal cavity through a scar-free area. Access to the peritoneal cavity through an unscarred area often gives the surgeon an opportunity to Whereas the content of the normal small intestine is sterile, assess the location of adhesions in the vicinity of the antici- with intestinal obstruction, the stagnation of bowel content pated incision. After the free abdominal cavity is entered and results in overgrowth of virulent bacteria with production of any adherent segments of intestine are freed, the remainder toxins. When these substances spill into the peritoneal cavity, of the incision is carefully done. Metzenbaum scissors can generally then be insinu- ated behind the various layers of avascular adhesions to incise them (Fig. If the left index ﬁnger can be passed underneath a loop of bowel adherent to the abdominal wall, it helps guide the dissection. The aim is to free all the intes- tine from the anterior and lateral abdominal wall, ﬁrst on one side of the incision and then on the other, so the anterior and lateral layers of parietal peritoneum are completely free of intestinal attachments (Fig. Once the intestine has been freed, trace a normal-look- ing segment to the nearest adhesion. If possible, insert an index ﬁnger into the leaves of the mesentery, separating the two adherent limbs of the intestine. By gently bringing the index ﬁnger up between the leaves of the mesentery, the adherent layer can often be stretched into a ﬁne, ﬁlmy membrane, which is then easily divided with scissors Fig. Chassin the left index ﬁnger or closed blunt-tipped curved between the thumb and index ﬁnger without damaging the Metzenbaum scissors underneath an adhesion to delineate serosa of the bowel. If this principle is always followed, the dif- Operative Intestinal Decompression ﬁcult portion of a dissection becomes easy. Avoid tackling a dense adherent mass directly; if the loops of intestine If the diameter of the small bowel appears to be so distended going to and coming from the adherent mass are dissected that closing the incision would be difﬁcult, operative decom- on their way in and on their way out of the mass of adhe- pression of the bowel makes the abdominal closure simpler sions, a sometimes confusing collection of intestine can be and may improve the patient’s postoperative course. Decompression may also lessen the risk of inadvertent lac- In the case of an acute small bowel obstruction, frequently eration of the tensely distended intestine.
A picture from 3 years ago shows a person of very different buy tadalafil 5mg short term erectile dysfunction causes, more normal appearance order tadalafil 2.5mg line do erectile dysfunction pumps work. The appearance is so typical that you will probably be given before and after photographs on the exam tadalafil 2.5 mg cheap erectile dysfunction doctor atlanta, with a brief vignette. If she suppresses at a low dose, she is an obese, hairy woman, but she does not have the disease. If she does not suppress at the low dose, verify that 24-hour urine- free cortisol is elevated, and then go to high-dose suppression tests. Extensive medical management including eradication of Helicobacter pylori fails to heal her ulcers. If the value is not clearly normal or abnormal, a secretin stimulation test is added. A second-year medical student is hospitalized for a neurologic workup for a seizure disorder of recent onset. During one of the convulsions, it is determined that his blood sugar is extremely low. Further workup shows that he has high level of insulin in the blood with low levels of C- peptide. If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma. Had it been a baby with high insulin levels and low blood sugar, it would have been nesidioblastosis. A 48-year-old woman has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “herbs and unguents. If inoperable, somatostatin can help symptomatically, and streptozocin is the indicated chemotherapeutic agent. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2. If confirmatory (aldosterone high, renin low), proceed with determinations lying down and sitting up to differentiate hyperplasia (appropriate response to postural changes—not surgical) from adenoma (no response or wrong response to postural changes—surgical). A thin, hyperactive 38-year-old woman is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration, and pallor, but by the time she gets to her doctor’s office she checks out normal in every respect. Surgery will eventually be done, with careful pharmacologic preparation with alpha-blockers. This is checked repeatedly in both arms, and it is always found to be elevated, but when checked in the legs it is found to be normal. A 23-year-old woman has had severe hypertension for 2 years, and she does not respond well to the usual medical treatment for that condition. A 72-year-old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset and refractory to the usual medical therapy. Two examples of renovascular hypertension; the first one caused by fibromuscular dysplasia, the second one secondary to arteriosclerosis. Once the diagnosis has been made, the decision for therapy is easy in the young woman: she has many years of potential life, and her hypertension must be cured. Angiographic balloon dilation with stenting is the first choice, surgery the other alternative. Treatment of the renovascular hypertension makes sense only if other manifestations of the arteriosclerosis are not going to kill him first. The vertebral and radial will be seen in the same x-ray you already took, you need echocardiogram for the heart, sonogram for the kidneys, and physical examination for the anus. This is done with an x- ray while holding the baby upside down, with a metal marker taped to the anal dimple. It is better to wait 36 to 48 hours to do surgery to allow transition from fetal circulation to newborn circulation. At the time of birth, it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect is a matted mass of angry-looking edematous bowel loops. A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord (the cord goes to the sac, not to the baby). Medical school professors love to emphasize differential diagnoses of somewhat similar problems. You’ve got to get those intestines back into the belly, and the technical details are best left to the pediatric surgeons. They will be on the lookout for atresias (which babies with gastroschisis can have) or multiple defects (which are seen with omphalocele), and they will close small defects directly. Very often, however, the defects are large, most of the bowel is outside the abdomen, and there is no room to “push it in. A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. These are very rare anomalies that only very highly specialized centers can repair. The problem is that unless the repair is done within the first 48 hours, it will not have a good chance to succeed. X-ray shows a “double bubble sign”: a large air-fluid level in the stomach, and a smaller one in the first portion of the duodenum. Kids vomit, burp, and regurgitate all the time (ask any parent), but the innocent vomit is clear- whitish. Malrotation is also possible, but I expect that one to be presented to you as in the next vignette. With complete obstruction, surgery will be needed, but these kids have lots of other congenital anomalies, look for them first. X-ray shows a “double-bubble sign”: a large air-fluid level in the stomach and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended. Now you have 3 choices: it could be an incomplete obstruction from duodenal stenosis or annular pancreas, or it could be malrotation. If you are dealing with incomplete obstruction, you have time to do what’s needed, i. But if it is malrotation the bowel could twist and die, so that would be a super-emergency. A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. This one is caused by a vascular accident in utero; thus, there are no other congenital anomalies to look for, but there may be multiple points of atresia. The baby is 4 days old, and was treated with indomethacin for a patent ductus arteriosus. Surgical intervention may be needed if the baby develops abdominal wall erythema, air in the portal vein, or pneumoperitoneum. A 3-day-old, full-term baby is brought in because of feeding intolerance and bilious vomiting.
Check it before applying the intestine or stomach purchase 2.5mg tadalafil impotence zoloft, as it would prevent formation of a stapler generic 2.5mg tadalafil otc erectile dysfunction treatment options exercise. The segments of the bowel should be in a relaxed position Human Error/Judgment when a stapling device is applied to them buy tadalafil mastercard erectile dysfunction protocol book. If excessive ten- sion is applied while the stapler is being ﬁred, the tissue may Do not place a staple line so it includes the mesentery of the be too thin for proper purchase by the staples. Similarly, do not include mesenteric fat between the seromuscular layers of an anastomosis. Whenever the Special Precautions linear cutting stapling device is used on the gastric wall, carefully inspect the staple line for gastric bleeding. Transﬁx After completing a stapled anastomosis, always inspect the bleeding points with absorbable sutures. Occasionally an entire circumference meticulously to ascertain that each sta- entire staple line in the stomach bleeds excessively. Test the lumen by oversew the entire line with absorbable sutures inserted in invaginating the bowel wall with the index ﬁnger. Although it is preferable to insert at which two or more staple lines cross should be carefully sutures superﬁcial to the staple line, there may not be sufﬁ- checked for possible leakage. Although the need to oversew the staple line occurs in These sutures must be tied with excessive tension. We have no more than 1–2 % of cases managed by a surgeon experi- not observed signiﬁcant bleeding following stapling in enced in performing stapled anastomoses, oversewing can be organs other than stomach. Minor bleeding may be con- an essential step in preventing leaks in some situations. During the last step of a functional end-to-end anastomo- When an excessive amount of tissue is bunched up in the sis, the defect is closed with a linear stapling device. If the crotch of the linear cutting stapler, ﬁring the knife assembly ﬁrst two stapling lines (Fig. As a result there is narrowing or absence of an believe that such a point is weak and permits development of anastomotic lumen. Every linear cutting staple line must be an anastomotic leak because the presence of many staples inspected for completeness and hemostasis upon removing and excess tissue in one spot results in failure to close prop- the instrument. Occasionally this situation is seen in the operating room been made by the stapler knife assembly, it should be accom- when carefully inspecting the completed anastomosis. Although this type of stapler prevent this weak point, we have modiﬁed our technique by failure is rare, its possibility should not be overlooked. A better way to Further Reading avoid this problem is to use our modiﬁcation of the func- tional end-to-end anastomosis, as illustrated in Figs. Handsewn versus stapled anastomoses in The many possible technical pitfalls of stapled low colon and rectal surgery: a meta-analysis. Chassin† Techniques for Achieving Hemostasis ligature, to feed the thread into the jaws of the open Mixter clamp. Hemostat and Ligature Pass the Mixter clamp behind the vessel again, feed a second ligature into its jaws, and ligate the distal portion of the ves- A hemostat of the proper length and design is a suitable sel. Divide the vessel, leaving a 1 cm stump distal to the instrument for occluding most bleeding vessels, followed by proximal tie and about 0. Leaving a ligature of a size compatible with the diameter of the ves- a long stump of vessel distal to a single tie of 2-0 silk pre- sel. As demanded by the situation, hemostats the size of a vents the ligature from slipping off, even when it is subjected Halsted, Crile, Adson, Kelly, or Mixter may be indicated (see to the continuous pounding of arterial pulse waves. Silk provides greater security when tying major ves- sels, such as the left gastric or inferior mesenteric artery. If the splenic artery is being divided and Two simple ligatures of 2-0 silk placed about 3 mm apart, ligated during resection of a pseudocyst of the pancreas, use with a free 1 cm stump distal to the ligatures, ensure a 2-0 ligature of Prolene. If there is not a sufﬁcient length of artery to meet these conditions, a 2-0 silk ligature supple- Tying “In Continuity” with a Ligature Passer mented by insertion of a transﬁxion suture ligature that pierces the wall of the artery 3 mm distal to the simple liga- When ligating large vessels such as the inferior mesenteric, ture is almost as good as a free 1 cm arterial stump. Pass the ileocolic, or left gastric artery, it is convenient to pass a blunt- suture part of the way through the vessel wall rather than tipped right-angle Mixter clamp behind the vessel. This maneuver avoids bleeding tip of the clamp separates the adventitia of the artery from through the needle hole. This problem may occur on the sur- passer, which consists of a long hemostat holding the 2-0 silk face of the pancreas, where attempts to grasp a retracted ves- sel with hemostats can be much more traumatic than a small ﬁgure-of-eight suture of atraumatic 4-0 silk. Chassin Hemostatic Clips a large grounding electrode placed on the patient’s thigh or back. Two types of current are supplied by most electrocau- Metallic hemostatic clips offer a secure, expedient method tery generators: cutting and coagulating. Cutting current is for obtaining hemostasis, provided the technique is properly continuous-wave, high-frequency, relatively low-voltage applied. It produces rapid tissue heating, which allows the ference of a vessel is visible, preferably before the vessel has blade of the cautery to cut through tissue like a scalpel. Coagulating current is pulsed- incomplete occlusion of the vessel and continued bleeding, waveform, low-frequency, high-voltage current that heats following which the presence of the metal clip obstructs any tissues slowly. The resulting protein coagulation seals small hemostat or suture ligature in the same area. The resulting coaptive coagula- tion, such as when performing a Kocher maneuver, the sub- tion seals the front and back wall of the collapsed vessel sequent surgical maneuvers often dislodge the clips and together. Small punctate bleeders may be secured by touch- lacerate the vessels, producing annoying hemorrhage. Hemostatic clips may similarly interfere with application of Bipolar cautery units generally have a forcepslike con- a stapling device. It is It is futile to apply multiple clips in the general area from less useful, however, for cutting. Again it must be emphasized that applying a clip is stasis, provided certain contraindications are observed. As with hemostatic clips, In the absence of these contraindications, hemostatic clips any tissue that will subsequently be subjected to blunt dissec- speed dissection and allow secure control of bleeding ves- tion or retraction may not be suitable for electrocautery, as the sels. An example is in the mediastinum during esophageal friction often wipes away the coagulum, causing bleeding to dissection or in the retroperitoneal area during colon resume. Similarly, when many subcutaneous bleeding points are subjected to electrocoagulation, the extensive tis- Staplers sue insult may contribute to wound infection. Laparoscopic surgeons are familiar with use of staplers, loaded with “vascular cartridges,” for control of vessels too Ultrasonic Shears large to securely clip or ligate. These staplers are gradually making their way into common use during open surgery as Ultrasonic shears were initially introduced for minimal well. These devices use ultrasound to They appear particularly useful for large diameter veins such heat and coagulate tissue in a coapted position.
Large mass containing punctuate calcifications (arrowhead) and low attenuation areas related to necrosis generic tadalafil 5mg on line erectile dysfunction causes in young men. Granulomatous infections Generally round or oval buy genuine tadalafil online erectile dysfunction medication contraindications, well-circumscribed Histoplasmosis order tadalafil 2.5mg online erectile dysfunction massage, tuberculosis, coccidioidomyco- (Figs C 8-2 and C 8-3) nodules. Several round lesions, many with cavitation, are seen throughout the lungs in this intravenous drug abuser with staphylococcal tricuspid endocarditis. Bilateral diffuse intermediate-sized nodules Fig C 8-2 24 along with patchy consolidation at the lung bases. Varicella (chickenpox) nodules often calcify 1 year or more after the initial infection (see Fig C 17-5). Paragonimus westermani Well-circumscribed cystic masses that have a Characteristic appearance of multiple ring opacities (Fig C 8-6) predilection for the periphery of the lower lobes. Multiple ill-defined and occasio- throughout the lungs that developed in a patient who nally confluent nodules throughout the lungs in a young child had undergone a renal transplant 3 months earlier and with severe combined immunodeficiency disease. The cysts are thin walled, and most have a prominent crescent-shaped opacity along one side of their borders, the characteristic ring shadow of paragonimiasis. Bronchioloalveolar Poorly defined nodules scattered throughout Other presentations include a single well- (alveolar cell) carcinoma both lungs. Lymphoma Multiple nodules that often have fuzzy outlines Manifestation of secondary disease. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. The lesions may change in third of the fistulas are multiple (arteriography of size between the Valsalva and the Mueller both lungs required if surgical resection is contem- maneuvers. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (see Fig C 11-14) may simulate metastases. Rheumatoid necrobiotic Smooth, well-circumscribed nodules that Rare manifestation of rheumatoid lung disease nodules predominantly occur in peripheral subpleural that tends to wax and wane in relation to the acti- (Fig C 8-10) locations. Cavitation is common (thick walled vity of the rheumatoid arthritis and the presence of with smooth inner margins). Amyloidosis Multiple nodules that may cavitate and show Discrete masses of amyloid may develop in the rare calcification or ossification. The nodular parenchymal form of the disease has a better prognosis than the tracheobronchial (obstructive) or diffuse interstitial types (see Fig C 4-27). Pulmonary hematomas Unilocular or multilocular, round or oval Result from hemorrhage into pulmonary paren- (see Fig C 6-14) nodules that are occasionally huge. May peripheral subpleural locations deep to areas of communicate with the bronchial tree (air-fluid maximum trauma. Multiple well-circumscribed, rounded nodules of varying size in a patient with subcutaneous rheumatoid nodules. Usually associated with a (Fig C 8-12) nodules that may simulate metastatic disease. Pulmonary ossification Small, densely calcified or ossified nodules Primarily a manifestation of mitral stenosis (or throughout the lungs. Pneumoconiosis (progressive Conglomerate masses that predominantly Masses represent confluence of individual silicotic massive fibrosis) involve the upper lobes and are usually irregular nodules, sometimes associated with superimposed (Figs C 8-13 and C 8-14) and ill defined with peripheral stranding. They typically develop in the mid-zone or periphery of the lung and tend to migrate toward the hilum. Polyarteritis Poorly defined nodules that are often associated The pulmonary manifestations typically show with patchy consolidations. The angiographic demonstration of multiple arterial aneurysms in one or more abdominal organs is considered virtually diagnostic of this disease. Mucoid impactions Multiple (more commonly single), round, oval, Usually associated with hypersensitivity broncho- (see Fig C 6-18) or elliptical opacities caused by plugs in dilated pulmonary aspergillosis in patients with asthma or bronchi. Non- Fig C 8-14 segmental areas of homogeneous density in both upper Progressive massive fibrosis in silicosis. Granulomatous infections Generally round or oval, well-circumscribed Histoplasmosis, tuberculosis, coccidioidomycosis, (Fig C 9-2) nodules. Calcification is common in histoplasmosis, tuberculosis, and coccidioi- domycosis; cavitation is common in coccidioi- domycosis. Hematogenous metastases Various patterns (from diffuse micronodular Nodules typically vary in size in the same patient. Ground-glass opacification, with peripheral solitary nodule, Focal “pneumonia,” a (Fig C 9-5) areas of increased density representing ele- miliary pattern, or thin-walled cystic lesions. Multiple cavitating nodules Fig C 9-2 (Nocardia) in a young immunocompromised man. Multiple intermediate-sized nodules in a feeding vessel sign (vessel leading directly to the nodule) in patient with persistent and worsening symptoms of cough, several nodules (arrows). Several cavitating nodules Fig C 9-4 (arrows) in both lower lobes with irregular thickening of the Kaposi’s sarcoma. Innumerable, bilateral, poorly defined walls in a patient with metastatic squamous cell cancer of the peribronchovascular micronodules, some of which exhibit lungs. The mass in the left lower lobe also contains solid elements, consistent with the diagnosis of bronchoialveolar carcinoma with adenocarcinoma features. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (Fig C 9-8) may simulate metastases. Multiple pulmonary nodules on a study obtained some of which contain air-fluid levels. Cavitation is common (thick walled the rheumatoid arthritis and the presence of with smooth inner margins). Amyloidosis Multiple nodules that may cavitate and show Discrete masses of amyloid may develop in the rare calcification or ossification. Pulmonary hematomas Unilocular or multilocular, round or oval Result from hemorrhage into pulmonary paren- nodules that are occasionally huge. May peripheral subpleural locations deep to areas of communicate with the bronchial tree (air- maximum trauma fluid level). Usually associated with a (Fig C 9-10) nodules that may simulate metastatic disease. Pneumoconiosis (progressive Conglomerate masses that predominantly Masses represent confluence of individual silicotic massive fibrosis) involve the upper lobes and are usually irregular nodules, sometimes associated with superimposed (Fig C 9-11) and ill defined with peripheral stranding. They typically develop in the mid-zone or periphery of the lung and tend to migrate toward the hilum. Two large, pleural-based nodules (large arrows) are seen at the level of the left upper lobe. The nodules are associated with marked posterior left-sided pleural thickening (small arrows). Diffuse small nodules may be When oral medications are crushed, dissolved, and the first manifestation of talc-induced lung injected intravenously, talc particles embolize small disease.