Conditions Presenting With Abdominal Pain (2)
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Anatomy of the colon: - caecum –RIF, 6 cm. long- intraperit. - ascending colon-13 cm.cecum-right flexure, retroperitoneally - transverse colon-38 cm. right to left colic flexure, transverse mesocolon, intraperit. - descending colon-25 cm.long,left flexurepelvic brim, retroperit. - sigmoid colon- 35 cm.pelvic brim- S3, mesocolon, intraperit.
Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine. 2. Risk factors for colorectal cancer include heredity, colon polyps, and long standing ulcerative colitis. 3. Most colorectal cancers develop from polyps. Removal of colon polyps can prevent colorectal cancer.
1.
4. Colon polyps and early cancer can have no symptoms. Therefore regular screening is important. 5. Diagnosis of colorectal cancer can be made by barium enema or by colonoscopy with biopsy confirmation of cancer tissue. 6. Treatment of colorectal cancer depends on the location, size, and extent of cancer spread, as well as the age and health of the patient. 7. Surgery is the most common treatment for colorectal cancer
Early
stage- asymptomatic-silent cancer
Late
stage- RIF pain, bowel obstruction, weight loss, anorexia, asthenia- chronic blood loss-anemia, change in bowel habit, palpable lump if large tumor.
GA- thin and pale patient
Abdomen: ◦ ◦ ◦ ◦ ◦ ◦
Distended or “full” in the RIF Palpable mass RIF; fixed or mobile Palpable liver-MTS Dullness over the mass NBS or hyperactive in bowel obstruction DRE-normal
Frequent location: sigmoid colon, rectosigmoid junction
Usually, small, annular, obstructive, ulcerated
Age>50 years old, Young adults- cancer on UC or familial polyposis coli Symptoms: pain LIF, change in bowel habit
GA- pale patient due to chronic blood loss
Abdomen: ◦ Swelling LIF, ceacal distension if left colon obstruction ◦ LIF palpable mass, mobile on sigmoid location ◦ Tender mass if pericolic inflamation - pericolic abscess ◦ Hepatomegaly- liver MTS ◦ BS hyperactive- bowel obstruction ◦ DRE- color of feces, pelvic palpable mass.
Sudden inability to micturate in the presence of a painful bladder Hypogastric region severe pain The patient cannot pass urine inspite of a desperate desire to do so Causes: Mechanichal: urethral stones, rupture of the urethra, urethral stricture, prostatic enlargement, paraphimosis Neurogenic: postop. retention, spinal cord injury, anticholinergic drugs
Symptoms: severe pain, feels like grossly exaggerated desire to micturate The patient knows that his bladder is overdistended Physical examination:
◦ distended bladder is palpable as a tense, dull, rounded mass, arising out of the pelvis ◦ Pressure on the swelling exagerbates the p’s desire to micturate DRE- prostate or uterus is pushed backwards and downwards -you can not assess the size of the prostate gland when the bladder is full
Often the patient - always an elderly gentleman with gray hair and cataract arrives in severe agony with a huge, distended bladder due to acute retention of urine.
Carcinoma
of the esophagus
Reflux
esophagitis
Pyloric
stenosis
Rarely produces any physical signs apart from: ◦ - wasting and ◦ - perhaps a palpable supraclavicular lymph node
The main symptom is DYSPHAGIA
Progressive dysphagia from solids to fluids
Dysphagia= late symptom in the natural history of the disease – 60% of circumference is infiltrated with cancer
Squamous
cell carcinoma of the esophagus is largely associated with a poor prognosis.
Direct invasion of adjacent organs such as the aorta, respiratory tract and lungs,
and distant metastasis to other organs such as the liver, lungs and bone are commonly found in advanced esophageal cancer cases. I
Examination of geographic areas of high incidence have identified a number of environmental factors strongly linked to the development of esophageal dysplasia and squamous carcinoma In the United States and Europe alcohol and smoking
In China nitrosamine containing foods, fungal contamination of foods and vitamin and essential metal deficiency
This 73 year old, male presented progressive dysphagia for solid and liquid and lost of weight of 20 pounds.
Endoscopy revealed a large tumor.
Esophageal cancer is a treatable disease, but it is rarely curable.
The overall 5-year survival rate in patients amenable to definitive treatment ranges from 5% to 30%. The occasional patient with very early disease has a better chance of survival. Patients with severe dysplasia in distal esophageal Barrett’s mucosa often have in situ or even invasive cancer within the dysplastic area.
Following resection, these
This 72 year-old man with progressive dysphagia (difficulty swallowing) to solids, who was found to have this malign neoplasia. Cancer of the esophagus remains a devastating disease because it is usually not detected until it has progressed to an advanced incurable stage.
Patients are able to locate the level of obstruction Extension of the tumor into the tracheobronchial tree- fistula formation:
◦ ◦ ◦ ◦
-
Stridor Coughing Choking Aspiration pneumonia
Distant metastasis- liver, lung, peritoneum
Regurgitation of gastric contents into the lower esophagus: ◦ Incompetent lower esophageal sphincter ◦ Slinding hiatus hernia
Factors that decrease the LOS pressure: Alcohol Cigarette smoking Morphine Estrogen therapy Fatty foods Presence of a NG tube
Main symptom-heartburn-retrosternal burning sensation Associated symptom- dysphagiainflammation- fibrous stenosis Relationship of pain to posture of the patient: Bending Stooping Heavy lifting Tight clothes All forces acid up into the esophagus
Gastric outlet obstruction:
Chronic complication- 5% of GDU
Neo-nates-congenital HT pyloric stenosis
Adults- carcinoma of the gastric antrum
Main symptom- vomiting The vomit is large in volume, not bilestained containing undigested foof
Associated symptom- epigastric discomfort Signs:
◦ epigastric distension, ◦ visible peristalsis, ◦ succusion splash
Infections in food
Ulcerative colitis
Crohn’s disease
Cholera
Rectal villous tumor
Inflammatory bowel disease Main symptom: diarrhea Ulcerative colitis - loose bloodstained stools - frequency-up to 20 stools/day - preceded by cramping abdo. pain - urgency to defecate- the worst symptom Crohn’s disease: Diarrhea is watery with mucus Abdo. pain is colicky in nature
Progressive inflammation- muscle paralysisdilatation- toxic megacolon
Diarrhea - dehydration - electrolyte disturbance - anemia due to bloody diarhhea Toxic megacolon- colonic perforation- fatal peritonitis
is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses.
Inflammatory bowel disease (IBD) is a general term that covers two disorders: Ulcerative colitis Crohn's Some evidence suggests that they are part of a biologic continuum, but at this time they are considered distinct disorders with somewhat different treatment options. The basic distinctions are location and severity. As many as 10% of patients with IBD have features and symptoms that match the criteria for both disorders, at least in the early stages. (This is called indeterminate colitis.)
Plain radiograph of the abdomen show moderate dilation of the colon with loss of haustration in the descending colon.
Thickening of the wall of the colon indicating edema is also visible .
Affects any part of the digestive system Inflammation involves the whole thickness
Complications: ◦ Stenosis ◦ Fistula formation ◦ Abscess formation
Crohn’s disease is a chronic inflammatory disease of the intestines that can affect the digestive system from the mouth to the anus. The most commonly affected areas tend to be in the small and the large intestines. Terminal ileitis (inflammation that affects the end of the small intestine (terminal ileum), the part of the small intestine closest to the colon
Acute inflammation of the peritoneal serosa
Acute peritonitis - localized - generalized
If you can not determine the cause of peritonitis you must decide whether the patient needs a laparotomy
Two circumstances in which a laparotomy is essential 1. If there is evidence of ischemic bowel caused by strangulation or vascular occlusion
2. If there is an unexplained general peritonitis where lapatomy is needed to make the diagnosis
Increasing tachycardia Pyrexia Tenderness and guarding Rebound tenderness Localized pain during distant palpation Absence of the bowel sounds
Causes in relation with the age: Neo-nates: congenital pyloric stenosis 6-9 months: intussusception Teenagers: intussusception of Meckel’s diverticulum Young adult: hernia, adhesions, Crohn’s stenosis, bowel tumors Elderly: bowel tumors, diverticulitis,sigmoid volvulus
A segment of bowel which becomes invaginated into the bowel immediately distal to it
The invaginated segment progressively elongates as it is propelled distally by peristalsis
Ileo-cecal invagination is the most common variety
A huge sigmoid loop, heavy with faeces that becomes twisted on its mesenteric pedicle to produce a close loop obstruction
Venous infarction with perforation and faecal peritonitis might appear unless emergent surgical intervention is decided
Is there intestinal obstruction ?? ◦ Obstruction: colicky pain, vomiting, abdominal distention and absolute constipation
Is the bowel strangulated?? ◦ Strangulation: pain, tenderness, guarding and rebound tenderness
It is a true colic
There are severe gripping exacerbations mixed with periods of little or no pain
Small bowel colic is felt in the central abdomen
Large bowel colic in the lower third of the abdomen
The nature of the vomitus depends upon the level of the obstruction: ◦ Pyloric stenosis- vomitus is watery and acid ◦ High small-bowel obstruction- greenish bilestained vomit ◦ Middle small bowel obstruction- brown vomit, thick and foul smelling as the obstruction persists
The lower down the gut the obstruction, the more bowels is available to distend and the greater the distention High obstruction is not associated with much distention, particularly if the patient vomits frequently Obstruction in the left colon- distention extends into the small bowel if the ileocecal valve is incompetent If the valve remains closed, the caecum becomes grossly distended-visible assymetry
Complete obstruction with bowel below it empty- absolute constipation
Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine. 2. Risk factors for colorectal cancer include heredity, colon polyps, and long standing ulcerative colitis. 3. Most colorectal cancers develop from polyps. Removal of colon polyps can prevent colorectal cancer.
1.
4. Colon polyps and early cancer can have no symptoms. Therefore regular screening is important. 5. Diagnosis of colorectal cancer can be made by barium enema or by colonoscopy with biopsy confirmation of cancer tissue. 6. Treatment of colorectal cancer depends on the location, size, and extent of cancer spread, as well as the age and health of the patient. 7. Surgery is the most common treatment for colorectal cancer
Early
stage- asymptomatic-silent cancer
Late
stage- RIF pain, bowel obstruction, weight loss, anorexia, asthenia- chronic blood loss-anemia, change in bowel habit, palpable lump if large tumor.
GA- thin and pale patient
Abdomen: ◦ ◦ ◦ ◦ ◦ ◦
Distended or “full” in the RIF Palpable mass RIF; fixed or mobile Palpable liver-MTS Dullness over the mass NBS or hyperactive in bowel obstruction DRE-normal
Frequent location: sigmoid colon, rectosigmoid junction
Usually, small, annular, obstructive, ulcerated
Age>50 years old, Young adults- cancer on UC or familial polyposis coli Symptoms: pain LIF, change in bowel habit
GA- pale patient due to chronic blood loss
Abdomen: ◦ Swelling LIF, ceacal distension if left colon obstruction ◦ LIF palpable mass, mobile on sigmoid location ◦ Tender mass if pericolic inflamation - pericolic abscess ◦ Hepatomegaly- liver MTS ◦ BS hyperactive- bowel obstruction ◦ DRE- color of feces, pelvic palpable mass.
Sudden inability to micturate in the presence of a painful bladder Hypogastric region severe pain The patient cannot pass urine inspite of a desperate desire to do so Causes: Mechanichal: urethral stones, rupture of the urethra, urethral stricture, prostatic enlargement, paraphimosis Neurogenic: postop. retention, spinal cord injury, anticholinergic drugs
Symptoms: severe pain, feels like grossly exaggerated desire to micturate The patient knows that his bladder is overdistended Physical examination:
◦ distended bladder is palpable as a tense, dull, rounded mass, arising out of the pelvis ◦ Pressure on the swelling exagerbates the p’s desire to micturate DRE- prostate or uterus is pushed backwards and downwards -you can not assess the size of the prostate gland when the bladder is full
Often the patient - always an elderly gentleman with gray hair and cataract arrives in severe agony with a huge, distended bladder due to acute retention of urine.
Carcinoma
of the esophagus
Reflux
esophagitis
Pyloric
stenosis
Rarely produces any physical signs apart from: ◦ - wasting and ◦ - perhaps a palpable supraclavicular lymph node
The main symptom is DYSPHAGIA
Progressive dysphagia from solids to fluids
Dysphagia= late symptom in the natural history of the disease – 60% of circumference is infiltrated with cancer
Squamous
cell carcinoma of the esophagus is largely associated with a poor prognosis.
Direct invasion of adjacent organs such as the aorta, respiratory tract and lungs,
and distant metastasis to other organs such as the liver, lungs and bone are commonly found in advanced esophageal cancer cases. I
Examination of geographic areas of high incidence have identified a number of environmental factors strongly linked to the development of esophageal dysplasia and squamous carcinoma In the United States and Europe alcohol and smoking
In China nitrosamine containing foods, fungal contamination of foods and vitamin and essential metal deficiency
This 73 year old, male presented progressive dysphagia for solid and liquid and lost of weight of 20 pounds.
Endoscopy revealed a large tumor.
Esophageal cancer is a treatable disease, but it is rarely curable.
The overall 5-year survival rate in patients amenable to definitive treatment ranges from 5% to 30%. The occasional patient with very early disease has a better chance of survival. Patients with severe dysplasia in distal esophageal Barrett’s mucosa often have in situ or even invasive cancer within the dysplastic area.
Following resection, these
This 72 year-old man with progressive dysphagia (difficulty swallowing) to solids, who was found to have this malign neoplasia. Cancer of the esophagus remains a devastating disease because it is usually not detected until it has progressed to an advanced incurable stage.
Patients are able to locate the level of obstruction Extension of the tumor into the tracheobronchial tree- fistula formation:
◦ ◦ ◦ ◦
-
Stridor Coughing Choking Aspiration pneumonia
Distant metastasis- liver, lung, peritoneum
Regurgitation of gastric contents into the lower esophagus: ◦ Incompetent lower esophageal sphincter ◦ Slinding hiatus hernia
Factors that decrease the LOS pressure: Alcohol Cigarette smoking Morphine Estrogen therapy Fatty foods Presence of a NG tube
Main symptom-heartburn-retrosternal burning sensation Associated symptom- dysphagiainflammation- fibrous stenosis Relationship of pain to posture of the patient: Bending Stooping Heavy lifting Tight clothes All forces acid up into the esophagus
Gastric outlet obstruction:
Chronic complication- 5% of GDU
Neo-nates-congenital HT pyloric stenosis
Adults- carcinoma of the gastric antrum
Main symptom- vomiting The vomit is large in volume, not bilestained containing undigested foof
Associated symptom- epigastric discomfort Signs:
◦ epigastric distension, ◦ visible peristalsis, ◦ succusion splash
Infections in food
Ulcerative colitis
Crohn’s disease
Cholera
Rectal villous tumor
Inflammatory bowel disease Main symptom: diarrhea Ulcerative colitis - loose bloodstained stools - frequency-up to 20 stools/day - preceded by cramping abdo. pain - urgency to defecate- the worst symptom Crohn’s disease: Diarrhea is watery with mucus Abdo. pain is colicky in nature
Progressive inflammation- muscle paralysisdilatation- toxic megacolon
Diarrhea - dehydration - electrolyte disturbance - anemia due to bloody diarhhea Toxic megacolon- colonic perforation- fatal peritonitis
is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses.
Inflammatory bowel disease (IBD) is a general term that covers two disorders: Ulcerative colitis Crohn's Some evidence suggests that they are part of a biologic continuum, but at this time they are considered distinct disorders with somewhat different treatment options. The basic distinctions are location and severity. As many as 10% of patients with IBD have features and symptoms that match the criteria for both disorders, at least in the early stages. (This is called indeterminate colitis.)
Plain radiograph of the abdomen show moderate dilation of the colon with loss of haustration in the descending colon.
Thickening of the wall of the colon indicating edema is also visible .
Affects any part of the digestive system Inflammation involves the whole thickness
Complications: ◦ Stenosis ◦ Fistula formation ◦ Abscess formation
Crohn’s disease is a chronic inflammatory disease of the intestines that can affect the digestive system from the mouth to the anus. The most commonly affected areas tend to be in the small and the large intestines. Terminal ileitis (inflammation that affects the end of the small intestine (terminal ileum), the part of the small intestine closest to the colon
Acute inflammation of the peritoneal serosa
Acute peritonitis - localized - generalized
If you can not determine the cause of peritonitis you must decide whether the patient needs a laparotomy
Two circumstances in which a laparotomy is essential 1. If there is evidence of ischemic bowel caused by strangulation or vascular occlusion
2. If there is an unexplained general peritonitis where lapatomy is needed to make the diagnosis
Increasing tachycardia Pyrexia Tenderness and guarding Rebound tenderness Localized pain during distant palpation Absence of the bowel sounds
Causes in relation with the age: Neo-nates: congenital pyloric stenosis 6-9 months: intussusception Teenagers: intussusception of Meckel’s diverticulum Young adult: hernia, adhesions, Crohn’s stenosis, bowel tumors Elderly: bowel tumors, diverticulitis,sigmoid volvulus
A segment of bowel which becomes invaginated into the bowel immediately distal to it
The invaginated segment progressively elongates as it is propelled distally by peristalsis
Ileo-cecal invagination is the most common variety
A huge sigmoid loop, heavy with faeces that becomes twisted on its mesenteric pedicle to produce a close loop obstruction
Venous infarction with perforation and faecal peritonitis might appear unless emergent surgical intervention is decided
Is there intestinal obstruction ?? ◦ Obstruction: colicky pain, vomiting, abdominal distention and absolute constipation
Is the bowel strangulated?? ◦ Strangulation: pain, tenderness, guarding and rebound tenderness
It is a true colic
There are severe gripping exacerbations mixed with periods of little or no pain
Small bowel colic is felt in the central abdomen
Large bowel colic in the lower third of the abdomen
The nature of the vomitus depends upon the level of the obstruction: ◦ Pyloric stenosis- vomitus is watery and acid ◦ High small-bowel obstruction- greenish bilestained vomit ◦ Middle small bowel obstruction- brown vomit, thick and foul smelling as the obstruction persists
The lower down the gut the obstruction, the more bowels is available to distend and the greater the distention High obstruction is not associated with much distention, particularly if the patient vomits frequently Obstruction in the left colon- distention extends into the small bowel if the ileocecal valve is incompetent If the valve remains closed, the caecum becomes grossly distended-visible assymetry
Complete obstruction with bowel below it empty- absolute constipation
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