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Conditions presenting with abdominal pain

Conditions presenting with abdominal pain. Cancer of the colon. 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.

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Conditions presenting with abdominal pain

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  1. Conditions presenting with abdominal pain

  2. Cancer of the colon 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 flexure-pelvic brim, retroperit. - sigmoid colon- 35 cm.pelvic brim- S3, mesocolon, intraperit.

  3. Fast Facts About Colon Cancer • 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. Fast Facts About Colon 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

  5. Cancer of the caecum • 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.

  6. Cancer of the caecumPhysical examination • 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

  7. Caecal cancer

  8. Caecaltumor

  9. Cancer of the left side of the colon • Frequent location: sigmoid colon, recto-sigmoid 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

  10. Cancer of the left side of the colonPhysical examination • 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.

  11. The erect plain-film view shows gas distension of transverse colon. Obstructive left-side colon cancer.

  12. Single barium contrast - tracks as far as proximal descending colon, where a lobulated mass obstructs the flow. The angle between wall and soft-tissue masses is an acute angle, implying a sudden change in the lumen to significant mural thickening.

  13. Mature adult female with abdominal distension and loss of appetite. The erect view shows multiple fluid levels in the small-bowel and significant distension of caecum beyond 10 cm.

  14. Sigmoid colon cancer .There is an area of stenosis of the sigmoid colon, which has a typical "apple core" appearance of significant lobulated thickening of the walls at a site of stenosis.

  15. 68 year old woman with recent change in bowel habit. This single contrast barium enema shows an "apple-core" narrowing of the sigmoid colon. The appearance is due to significant thickening of the walls of the abnormal section which overlaps the normal luminal margin at the edges of the stricture. Within the soft tissue mass of the upper (mesenteric) and more proximal side of the stenosis, there is a faint irregular track of barium contrast.

  16. Rectosigmoid cancer

  17. ACUTE RETENTION OF URINE • 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

  18. ARU-Diagnosis • 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

  19. ACUTE RETENTION OF URINE • 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.

  20. Conditions presenting with dysphagia or vomiting • Carcinoma of the esophagus • Reflux esophagitis • Pyloric stenosis

  21. Carcinoma of the esophagus Rarely produces any physical signs apart from: • - wasting and • - perhaps a palpable supraclavicular lymph node

  22. This specimen is a segment of an esophagus and a portion of the stomach from a patient with high-grade dysplasia in Barrett's esophagus. The inside lining is whitish on the right but appears reddish and velvety closer to the stomach. The reddish area is Barrett's esophagus. There is no tumor (mass) in this specimen, which showed high-grade dysplasia (severe pre-cancerous change) on microscopic examination

  23. This specimen depicts a cancer at the area of the junction between the esophagus and stomach. It is a large irregular mass. The objective of endoscopic surveillance in Barrett's esophagus is to detect these processes early on when there is a high probability for cure

  24. EsophagealSquamous Cell Carcinoma.Ulcerating Squamous cell carcinoma of the lower end of the esophagus.This 72 year-old female, presented with progressive dysphagia

  25. Carcinoma of the esophagusDiagnosis • 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

  26. EsophagealSquamous Cell Carcinoma • 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

  27. Etiology •  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.

  28. EsophagealSquamous Cell Carcinoma. •  This 73 year old, male presented progressive dysphagia for solid and liquid and lost of weight of 20 pounds. • Endoscopy revealed a large tumor.

  29. EsophagealSquamous Cell Carcinoma of the middle third. • 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.

  30. Esophageal cancer • 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.

  31. Carcinoma of the esophagusDiagnosis • Patients are able to locate the level of obstruction • Extension of the tumor into the tracheo-bronchial tree- fistula formation: • - Stridor • - Coughing • - Choking • - Aspiration pneumonia Distant metastasis- liver, lung, peritoneum

  32. Reflux esophagitis • Regurgitation of gastric contents into the lower esophagus: • Incompetent lower esophageal sphincter • Slinding hiatus hernia

  33. Reflux esophagitis • Factors that decrease the LOS pressure: • Alcohol • Cigarette smoking • Morphine • Estrogen therapy • Fatty foods • Presence of a NG tube

  34. Reflux esophagitis • Main symptom-heartburn-retrosternal burning sensation • Associated symptom- dysphagia- inflammation- fibrous stenosis • Relationship of pain to posture of the patient: • Bending • Stooping • Heavy lifting • Tight clothes • All forces acid up into the esophagus

  35. Pyloric stenosis • Gastric outlet obstruction: • Chronic complication- 5% of GDU • Neo-nates-congenital HT pyloric stenosis • Adults- carcinoma of the gastric antrum

  36. Pyloric stenosis • 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

  37. Postcontrast examination: 24 hours after drinking contrast material most of it is still visible in the stomach with residual food above it. The stomach is dilated, its lower pole hangs below the iliac crest. Only minimal contrast material filling is observed in the small intestines.

  38. Patient with a large antraltumor, stenosing the pylorus, confirmed on biopsies as a medium-differentiated adenocarcinoma. Linear EUS allowed visualisation of the tumor (blue arrows) as a hypoechoic, inhomogenous mass that replaced the normal five-layered structure of the gastric wall. The tumor was invading the serosa and the left liver lobe

  39. Conditions presenting with diarrhea • Infections in food • Ulcerative colitis • Crohn’s disease • Cholera • Rectal villous tumor

  40. Ulcerative colitisCrohn’s disease • 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

  41. Ulcerative colitis • Progressive inflammation- muscle paralysis- dilatation- toxic megacolon • Diarrhea • - dehydration • - electrolyte disturbance • - anemia due to bloody diarhhea • Toxic megacolon- colonic perforation- fatal peritonitis

  42. ULCERATIVE COLITIS • 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.

  43. IBD • 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.)

  44. TOXIC MEGACOLON • 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 .

  45. Colonic pseudopolyps of a patient with intractable ulcerative colitis

  46. Crohn’s disease • Affects any part of the digestive system • Inflammation involves the whole thickness • Complications: • Stenosis • Fistula formation • Abscess formation

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