Transcript Conditions presenting with abdominal pain

 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
 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
 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
 NSAID
 Steroids-
Prednison
 Aspirin
may irritate gastro-duodenal mucosa
 Smoking
 Alcohol
 Coffee
 Mild-moderate
tenderness
 Complications:
• Bledding- anemia
• Stenosis- dehydration, succusion splash
• Gastric cancer- wasting, anemia
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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.
 Escape
of gastric acid or alkaline bile
into the peritoneal cavity- chemical
peritonitis- bacterial peritonitis
 Chief symptom- severe and constant
pain
 Sudden onset- epigastric area
 Respiratory movements make the pain
worse
 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
 Premalignant
conditions:
• Pernicious anemia
• Gastric polyps
• Atrophic gastritis
 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
 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
 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
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.
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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
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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.
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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..
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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.
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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.
 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 9th
rib, Murphy’s sign
Diagnosis is based on history and USS
Clinical signs are minimal
 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
 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
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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.
•
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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
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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
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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.
 Stones
in the CBD , usually migrated from
the GB.
 Symptoms: RH pain, jaundice, acholic
stools and dark urine
 Infection
of the bile duct
 Potentially
 Charcot’s
life-threatening condition
triad: fever, jaundice, RH pain
 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
 1/5th. of pts.- jaundice
 Abdomen: to tender to allow a deep
palpation/guarding
 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
 Female-
biliary obstruction
 Male- alcohol
 Symptoms:
• Upper abdo. pain
• Patient lies still
• Breathes shallowly
• Nausea, bouts of vomiting, retching
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
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Acute pancreatitis varies from a
mild uneventful disease to a
severe life-threatening 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.
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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
 Obstruction
of the lumen- fecolith
 Symptoms:
• RIF pain
• Loss of appetite
• Nausea
• vomiting
 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
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• 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
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Gastrointestinal
Abdominal pain, cause unknown
Crohn's disease
Diverticulitis
Meckel's diverticulitis
Mesenteric lymphadenitis
Necrotizing enterocolitis
Neoplasm (carcinoid,
carcinoma, lymphoma)
Perforated viscus
Volvulus
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Gynecologic
Ectopic pregnancy
Endometriosis
Ovarian torsion
Pelvic inflammatory
disease
Ruptured ovarian cyst
(follicular, corpus
luteum)
Tubo-ovarian abscess
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Systemic
Diabetic ketoacidosis
Porphyria
Sickle cell disease
Henoch-Schönlein purpura
Pulmonary
Pleuritis
Pneumonia (basilar)
Pulmonary infarction
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Genitourinary
Kidney stone
Prostatitis
Pyelonephritis
Testicular torsion
Urinary tract infection
Wilms' tumor
Other
Parasitic infection
Psoas abscess
Rectus sheath hematoma