Transcript Conditions presenting with abdominal pain (2)

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.



1.
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.




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
The only known genetic predisposition occurs in
hereditary tylosis, an autosomal dominant symmetrical
keratosis of the palms and soles.


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 patients
usually have excellent prognoses.

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 bile-stained
containing undigested food
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
Pain
Absolute
constipation
Bowel
obstruction
distention
vomiting




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 ileo-cecal
valve is incompetent
If the valve remains closed, the caecum
becomes grossly distended-visible assymetry

Complete obstruction with bowel below it
empty- absolute constipation
High small bowel obstruction
• Starts with pain and vomiting
• The distention is slight
• Absolute contipation is the last symptom to appear
Left-sided large bowel obstruction
• Starts with pain and absolute constipation
• Distention
• Vomiting is the last symptom to appear