Conditions presenting with abdominal pain Lidia Ionescu III

Conditions presenting with abdominal pain Lidia Ionescu III rd. Surgical Unit

Gastro-duodenal ulcer Benign GU and DU= peptic ulcer What digests mucosa-ulcer-acid pepsin Ulcer = mucosal defect that extends through the wall layers: • perforation, • penetration Erosion = superficial mucosal defect

Perforated peptic ulcer

PEPTIC ULCER DU>GU; DU/GU ratio=2: 1 UK, 20: 1 India More common in men High incidence in professional men Symptoms: • • • epig. discomfort- severe pain DU pts. eating relieves pain GU pts. eating causes pain DU pts. - vomitting- pyloric stenosis GU- vomiting relieves pain Hematemesis and melena

Pain in peptic ulcer DU –site- right paraombilical area GU- epigastric region Onset of pain: • DU-late after eating, • GU-soon after eating Relieving factors: • DU-eating, • GU-vomiting

Drug history NSAID Steroids- Prednison Aspirin may irritate gastro-duodenal mucosa

Habits Smoking Alcohol Coffee

Physical examination Mild-moderate tenderness Complications: • Bledding- anemia • Stenosis- dehydration, succusion splash • Gastric cancer- wasting, anemia

Chronic Gastric ulcer- Barium study There is pooling of barium in a defect in the posterior surface and lesser curve that extends beyond the lesser curve margin. There is a distortion of the uninterrupted mucosal folds of the stomach, which are drawn-in towards the centre of the lesion.

Perforated peptic ulcer Escape of gastric acid or alkaline bile into the peritoneal cavity- chemical peritonitisbacterial peritonitis Chief symptom- severe and constant pain Sudden onset- epigastric area Respiratory movements make the pain worse

Perforated Peptic Ulcer Previous history • History of indigestion • No history Drug history: STEROIDS, ASPIRIN General appearance: ill, in pain Abdo. inspection: imobile Ascultation: silent abdomen Palpation: board-like rigidity Percussion: not necessary DRE- painful

Intra-operative view of perforated duodenal ulcer. It was found to be a tipically punched out , peptic ulcer, 6 mm. in diameter

Carcinoma of the stomach Premalignant conditions: • Pernicious anemia • Gastric polyps • Atrophic gastritis

Symptoms and signs Peak incidence- 50 -70 years old More common in men Symptoms: • • • Indigestion or epigastric pain Eating or vomiting does not relieve the pain Loss of appetite-loss of weight Dysphagia- carcinoma of the cardia Vomiting- carcinoma of the pylorus

Physical examination GA- wasting, palor Jaundice: liver MTS or CBD obstruction by porta hepatis lymphadenopathy Left supraclavicular node- Virchow’s Abdomen- excavated, inelastic skin Abdominal distension-ascitis Sister Mary Joseph’s nodule

Physical examination Mild epigastric tenderness Palpable epigastric mass- unresectability Hepatomegaly- liver MTS Pyloric obstruction- succusion splash Ascitis-shifting dullness NBS DRE-pelvic mass- Blummer’s tumor or Krukenberg’s tumor

Advanced gastric carcinoma of the intestinal type. Resection specimen shows a protruding mass in the antrum

Gastric cancer- case report A 13 -year-old boy presented with complaints of vomiting, weight loss and generalized weakness. Cytological examination of blood showed iron deficiency anemia with a hemoglobin of 6. 5 g/dl. Stools were positive for occult blood. Barium studies showed a large irregular lobulated mass in the body of stomach and there was no gastric outlet obstruction.

Barium studies large irregular lobulated mass in the body of stomach.

Gastric cancer An ultrasound showed a large mass with bowel signature in the epigastric area; there were multiple hepatic metastases, lymphadenopathy and ascites. Osophagogastroduodenoscopy showed a large ulcerated mass in the anterior and posterior walls of the body and along the greater curvature of stomach; the surface of the mass was friable; there was significant bleeding noted at the base of ulcer. A biopsy showed moderate to poorly differentiated adenocarcinoma of stomach

USG showing hepatic metastases.

Gastric cancer, case report A computer tomography study revealed a large mass in the body of stomach along the anterior and posterior walls and along the greater curvature with local extension into the perigastric area, the gastro-splenic ligament, the transverse mesocolon, the transverse colon, the pancreatic body and the deep layer of the adjacent anterior parietal wall; Multiple hepatic metastases, lymphadenopathies, and ascites. The anemia was corrected by blood transfusion. He was offered palliative chemotherapy but he couldn't afford it due to financial constraints. He received best supportive care for 2 months until he died.

OGD - Ulcerated mass over stomach

Computer Tomography - large mass in the body of stomach with surrounding extension with multiple hepatic metastases, lymphadenopathy and ascites.

Gastric cancer The Internet Journal of Oncology™ ISSN: 1528 -8331 Gastric carcinoma is the most common gastrointestinal malignancies worldwide and is the world's second most common cause of death due to cancer Patients with pernicious anemia have a twenty times increased risk than that of the general population. Intestinal metaplasia (replacement of the gastric epithelium by intestinal epithelium containing Goblet cells) appears to be a precursor and this in turn may result from known carcinogens and after gastric resection for a benign gastric ulcer. Gastric cancer is thought to result from a combination of environmental factors and accumulation of specific genetic alterations, and consequently mainly affects older patients (>50 years of age). Some authors have postulated that gastric cancer can be related to chronic infection with Helicobacter pylori. .

Gastric cancer In our case the patient did not have any premalignant conditions of the stomach or a family history of carcinoma. There was no signs of protein energy malnutrition, Helicobacter Pylori and genetic assay were not done in this case. He presented with anemia, which was due to iron deficiency secondary to melena. At the time of diagnosis he had widespread metastases to the liver and the lymph nodes and the patient died within 2 months after diagnosis, again stressing the fact that the childhood gastric cancers are more aggressive with poor prognosis. Gastric carcinoma needs to be considered in any patient with persistent gastro-intestinal symptoms, iron deficiency anemia and melena, even in the young.

Empathy Physicians may miss opportunities to respond with empathy Empathy is an important element of effective communication between patients and physicians and is linked to improved patient satisfaction and compliance with recommended therapy. Patients who are more satisfied with the communication in their medical encounters have improved understanding of their condition, with less anxiety and improved mental functioning. However, responding to patients' emotional needs can be challenging for physicians; they may begin medical school with empathy for their patients but gradually learn detachment, perhaps in order to cope with time constraints or sadness.

Archives Of Cancer-blog From Medicineworld. Org

Advanced gastric carcinoma of the diffuse type. Resection specimen shows marked thickening of the wall, having the contour of a leather bottle (the so-called linitus plastica )

Gastric cancer

Chronic cholecystitis Symptoms: RH pain after eating fatty meals Physical examination • GA- female, fair, fat, fertile, forty • Abdomen looks normal • Palpation- RH tenderness, below the tip of the 9 th rib, Murphy’s sign Diagnosis is based on history and USS Clinical signs are minimal

Gross appearance of gallbladder after sectioning longitudinally. Notice thickness of galldladder wall, abundant polyhedric stones and small papillary tumor in the cystic duct.

Acute cholecystitis Symptoms: sudden onset of moderate/severe pain in the RH Radiation- to the tip of the right scapula Exacerbation by movements and breathing Nausea, biliary vomiting Appetite lost

Physical examination GA: the pt. looks ill, lies quietly, breathing shallowly, tachycardia, fever, chills Abdomen: • Movements diminished • Tenderness/guarding in the RH • Palpable mass below the edge of the liver Auscultation, RDE- WNL

Acute cholecystitis Laparoscopic view

Acute cholecystitis Laparoscopic view

Symptoms of Gallbladder Inflammation (Acute Cholecystitis) Between 1 - 3% of people with symptomatic gallstones develop inflammation in the gallbladder (acute cholecystitis), which occurs when stones or sludge obstruct the duct. The symptoms are similar to those of biliary colic but are more persistent and severe. They include the following: • Pain in the upper right abdomen is severe and constant and can last for days. Pain frequently increases when drawing a breath. • Pain also may radiate to the back or occur under the shoulder blades. About a third of patients have fever and chills. • Nausea and vomiting may occur. •

Acute cholecystitis Symptoms Infection develops in about 20% of these cases, which increases the danger. Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated. People with diabetes are at particular risk for serious complications

Symptoms of Chronic Cholecystitis or Dysfunctional Gallbladders Chronic gallbladder disease (chronic cholecystitis) is marked by gallstones and low-grade inflammation. In such cases the gallbladder may become scarred and stiff. Symptoms of chronic gallbladder disease include the following: • Complaints of gas, • nausea, and • abdominal discomfort after meals are the most common, Chronic diarrhea (4 - 10 bowel movements every day for at least 3 months) may be a common symptom of gallbladder dysfunction

Symptoms of Stones in the Common Bile Duct (Choledocholithiasis) Stones lodged in the common bile duct (choledocholithiasis) can cause symptoms that are similar to those produced by stones that lodge in the gallbladder, but they may also cause the following symptoms: • Jaundice (yellowish skin), dark urine, lighter stools, or both • Fever, chills, • Nausea and vomiting, and • Severe pain in the upper right abdomen. These symptoms suggest an infection in the bile duct (called cholangitis). As in acute cholecystitis, patients who have these symptoms should seek medical help immediately. They may require emergency treatment.

Choledocholithiasis Stones in the CBD , usually migrated from the GB. Symptoms: RH pain, jaundice, acholic stools and dark urine

Cholangitis Infection of the bile duct Potentially life-threatening condition Charcot’s triad: fever, jaundice, RH pain

Biliary colic Severe pain caused by a spasm of the GB as it tries to force a stone down the cystic duct Biliary colic- severe constant pain with excruciating exacerbations 1/5 th. of pts. - jaundice Abdomen: to tender to allow a deep palpation/guarding

Acute pancreatitis Activated pancreatic enzymes leak into the pancreatic parenchyma and initiate the auto digestion of the gland Cause: obstruction of the pancreatic duct Pathology: mild inflammation to acute hemorrhagic destruction

Acute pancreatitis Female- biliary obstruction Male- alcohol Symptoms: • • Upper abdo. pain Patient lies still Breathes shallowly Nausea, bouts of vomiting, retching

Physical examination GA: the pt. looks ill, in pain, hypovolemic, pale, dyspnea, cyanosis, jaundice Abdomen: - imobile abdomen - distension- paralytic ileus - discoloration left flank( Gray Turner’s) - discoloration around umbilicus (Cullen’s sign) -tenderness upper abdomen - hyperresonance

Etiology Acute pancreatitis varies from a mild uneventful disease to a severe lifethreatening illness with multisystemic organ failure (MOF) with shock, renal failure, respiratory failure and death. Gallstones and alcohol abuse are the most common causes of acute pancreatitis, accounting for 80% of cases. Clinical forms: mild acute pancreatitis and a severe acute pancreatitis.

Acute necrotizing pancreatitis 80 -85% of cases of acute pancreatitis run a mild course without the development of multiple organ failure. This group has a mortality of < 1%. 15 -20% of cases of acute pancreatitis run a serious clinical course with pancreatic necrosis and the development of multiple organ failure. Of these, pancreatic necrosis remains sterile in 60% of patients, whereas in 40% of these patients the necrosis becomes infected. This last category of patients has the highest mortality rate of 25 -70

Cullen’s signs and Gray-Turner sign Acute pancreatitis

Acute appendicitis Obstruction of the lumen- fecolith Symptoms: • • RIF pain Loss of appetite Nausea vomiting

Acute appendicytis left- congestive, right- perforated

Fecalith within appendiceal lumen

Lap. appendectomy

Lap. appendectomy

Lap. appendectomy

Physical examination GA: p. looks ill, flushed cheeks Fever>38 Neck-tonsils- mesenteric adenitis Chest-right sided basal pneumonia Abdomen: • • Coughing causes pain Tenderness RIF/guarding Rebound tenderness DRE- painful pelvis if pelvic position of appendix

Schema demonstrates possible appendix position variants

Diagram shows possible appendix positions in relation to caecum and ileum. Figures depicts frequency of each position in percents.

Common signs of acute appendicitis • Right lower quadrant pain on palpation (the single most important sign) • Low-grade fever (38°C [or 100. 4°F])--absence of fever or high fever can occur • Peritoneal signs : Localized tenderness to percussion , guarding • Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis) : • Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix) • Obturator sign--pain on internal rotation of right thigh (pelvic appendix) • Rovsing's sign--pain in right lower quadrant with palpation of left lower quadrant • Dunphy's sign--increased pain with coughing • Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix) • Patient maintains hip flexion with knees drawn up for comfort

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur

Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver

Computed tomographic scan showing enlarged and inflamed appendix (A) extending from the cecum (C).

Differential Diagnosis of Acute Appendicitis Gastrointestinal Abdominal pain, cause unknown Crohn's disease Diverticulitis Meckel's diverticulitis Mesenteric lymphadenitis Necrotizing enterocolitis Neoplasm (carcinoid, carcinoma, lymphoma) Perforated viscus Volvulus Gynecologic Ectopic pregnancy Endometriosis Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular, corpus luteum) Tubo-ovarian abscess

Differential Diagnosis of Acute Appendicitis Systemic Diabetic ketoacidosis Porphyria Sickle cell disease Henoch-Schönlein purpura Pulmonary Pleuritis Pneumonia (basilar) Pulmonary infarction Genitourinary Kidney stone Prostatitis Pyelonephritis Testicular torsion Urinary tract infection Wilms' tumor Other Parasitic infection Psoas abscess Rectus sheath hematoma