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Dr David Swar Department of General Surgery (Resident) Stomach and colorectal diseases

Intra-Abdominal Masses. Dr David Swar Department of General Surgery (Resident) Stomach and colorectal diseases Qilu hospital, Shandong University. Appendix Caecum Right Ovary Small bowel. Urinary Bladder Uterus Small bowel Rectum . Sigmoid colon Left ovary Small bowel Rectum .

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Dr David Swar Department of General Surgery (Resident) Stomach and colorectal diseases

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  1. Intra-Abdominal Masses Dr David Swar Department of General Surgery (Resident) Stomach and colorectal diseases Qilu hospital, Shandong University

  2. Appendix Caecum Right Ovary Small bowel

  3. Urinary Bladder Uterus Small bowel Rectum

  4. Sigmoid colon Left ovary Small bowel Rectum

  5. Descending colon Small bowel Kidney Adrenal gland

  6. Spleen Colon Stomach Kidney Adrenal gland

  7. Stomach Duodenum Tr colon Aorta Pancreas

  8. Liver Gallbladder Colon Duodenum Kidney Pancrease Adrenal gland

  9. Ascending colon Kidney Adrenal gland

  10. Aorta Small bowel

  11. DDx of Intra-Abdominal Masses • Right iliac fossa : GIT causes: - Appendix - caecum - crohn’s disease (abscess) - TB - carcinoid tumor - amoebic mass (amoeboma) extra-GIT causes: - ovarian tumor or cyst - psoas abscess - hernia - transplanted kidney - tumors of un-descended testis

  12. DDx of Intra-Abdominal Masses • Hypogastrium : - urinary bladder: full bladder, tumors or urine retention. - ovarian tumor or cyst - pregnancy - uterine tumors - small bowl obstruction

  13. DDx of Intra-Abdominal Masses • Left iliac fossa : GIT causes: - Loaded sigmoid colon (in sever constipation) - carcinoma of sigmoid or descending colon - diverticular abscess - Bilharzial colonic mass - amoebic mass (amoeboma) extra-GIT: - ovarian tumor or cyst - psoas abscess - hernia - transplanted kidney - tumors of un-descended testis

  14. DDx of Intra-Abdominal Masses • Left hypochondrium : - splenomegally - tumor in splenic flexure - stomach - kidney - suprarenal gland - subphrenic abscess

  15. DDx of Intra-Abdominal Masses • Epigastrium : - retroperitoneal lymphadenopathy - left lobe of liver - aortic aneurysm - stomach - pancreatic pseudocyst or tumor - carcinoma of the transverse colon - small bowl obstruction

  16. DDx of Intra-Abdominal Masses • Right hypochondrium : - hepatomegaly - gallbladder - subphrenic abscess - kidney - suprarenal gland • Umbilical : - aortic aneurysm - small bowl obstruction - pancreatic pseudocyst or tumor

  17. How to Reach a Diagnosis ? 1- History . 2- Clinical Examination . 3- Investigations .

  18. 1- History • Abdominal mass is a common surgical presentation . • A full history should be obtained .

  19. 1- History 1- When & Where ? • Ask the Patient when he first noticed the mass and where . • Be precise about the time course and location .

  20. 1- History 2- What ? • What brought his attention to the mass . • he felt / saw it • felt a pain & saw a mass • someone else told him

  21. 1- History 3- Associated symptoms • Pain / tenderness . • Fever . • Nausea / vomiting . • Weight loss / anorexia . • Abdominal distension . • Dysphagia . • jaundice .

  22. 1- History 4- Changed or not ? • Ask whether the mass changed in size . • Ask if changed in consistency . • Ask if he noticed a change in the color of the overlying skin .

  23. 1- History 5- Disappear or not ?

  24. 2- Clinical Examination • Perform a full physical examination . • Examine the mass . 1- Inspection . a- site b- shape c- size d- color e- surface f- edge g- pulsation

  25. 2- Clinical Examination 2- Palpation . a- temperatureb- tenderness c- composition d- reducibility e- pulsation f- surface

  26. 2- Clinical Examination h- composition 1-consistancy 2- fluctuation 3-fluid thrill 4- translucency 5-percussion 6-pulsatility 7-compressibility 8-auscultation for bruit

  27. 2- Clinical Examination i- relation to surrounding structures j- state of regional LN k- state of local tissue

  28. 3- Investigations 1- routine investigations * CBC * RFT * LFT * UA * electrolyte 2- physical imaging A- Ultrasonography B- Radiology 1- plain radiology 2- contrast radiology 3- CT 4- MRI

  29. 3- Investigations 3- Endoscopy A- Upper GI endoscopy B- Lower GI endoscopy 4- Biopsy & Histopathology

  30. Always Remember ! • Suspect Clinically . • Confirm by Imaging . • Prove by Histology .

  31. Common Abdominal Masses Crohn's disease Intestinal TB Colon Cancer Abdominal Aortic Aneurism

  32. Crohn's Disease ETIOLOGY The etiology of Crohn's disease is unknown, and possible causes have been the subject of many theories. Crohn's disease is more likely the result of a combination of multiple predisposing factors and environmental or infectious triggers that set an immunologic derangement into motion

  33. Crohn's Disease cobblestone appearance

  34. Crohn's Disease It is categorized based on the gross pattern. The three categories of Crohn's disease are: 1. inflammatory, Uncomplicated inflammation is manifested by mucosal ulceration and thickening of the bowel wall. it can often be relieved with medical treatment. 2. perforating, characterized by the development of fistulae and abscesses. It dictates the surgical strategy. • stricturing, is referred to as “fibrostenotic” lesions. Fibrotic strictures are not reversible with medical treatment, so that symptomatic stricturing disease often requires surgical management

  35. Crohn's Disease Clinicalmanfistation a) Crohn's Disease of the Small Bowel The symptoms of small bowel Crohn's disease include • chronic abdominal pain(in up to 90% of cases), • weight loss, • fever, • anorexia . • a tender palpable mass associated with an abscess or phlegmon. • Fistulization to the skin, urinary bladder, or vagina may also occur. • An enlarged inflammatory mass that adheres to the retroperitoneum can compress the right ureter and cause symptomatic ureteral obstruction and hydronephrosis. b) Patients with Crohn's disease of the colon typically have 1. diarrhea along with abdominal pain 2. and hematochezia.

  36. Crohn's Disease 1. laboratory tests • No specific laboratory test allows the diagnosis of Crohn's disease to be made. • Occasionally, tissue obtained during endoscopic biopsy can be diagnostic. Diagnosis

  37. Crohn's Disease • Typical radiographic appearance of extensive jejunoileal Crohn's disease. 2. Radiography of the Small Bowel

  38. Crohn's Disease • Crohn's disease of the terminal ileum. Resultant mass effect has displaced several loops of small bowel from the right lower quadrant.

  39. Crohn's Disease 3. Colonoscopy • The best for colon and rectum. • Characteristic features of Crohn's disease seen on colonoscopy include: • aphthoid ulcers, • discrete ulcerations that usually track along the long axis of the bowel, • diseased mucosa separated by areas of normal mucosa, • rectal sparing, • and strictures

  40. Crohn's Disease 4.Computed Tomography • The most typical finding of uncomplicated Crohn's disease is thickening of the bowel wall. • CT can be useful in identifying the complications associated with Crohn's disease, and when an abscess or inflammatory mass is suspected, CT of the abdomen and pelvis should be performed.

  41. Crohn's Disease • Computed tomogram showing an abscess of the right lower quadrant resulting from Crohn's disease of the terminal ileum.

  42. Crohn's Disease Indications for Operation • Failure of Medical Management • Intestinal Obstruction • Enteric Fistulae • Abscess and Inflammatory Mass • Hemorrhage is an uncommon complication • Perforation is a rare complication • Cancer and Suspected Cancer Surgical Treatment

  43. Intestinal TB • Etiology: • Caused by M.tuberculosis which come from : • 1-Ingestion of contaminated food • 2-From other TB focus in the body • Pathophysiology • Ulceration • Lymph node enlargement • Caseation and calcification • Healing with formation of strictures

  44. Intestinal TB • Low grade fever • Weight loss • Anemia • Diarrhea • Vague lower abdominal pain • Frank rectal hemorrhage • Ascites • Intestinal obstruction Clinical Features

  45. Intestinal TB Investigation • Plain x-ray of chest and abdomin • Contrast enema show distortion of caecum • US ,CT,MRI show: • thickened bowel loops • Intestinal obstruction • Lymph node enlargement and calcification • Abscess or ascites

  46. Intestinal TB • Primary treatment is chemotherapy like Isoniazid,rifampicin,streptomycin, Ethanbutol • Surgeon task: • Establish diagnosis by laparoscopy if necessary • Manage complications such as bleeding ,obstruction. Management

  47. Colon Cancer Epidemiology and Risk factors • Accounts for 14% of all cancer death (second to lung cancer) • Risk factors include: • Adenomatous polyps • Genetic Factor • Dietary Factors • Inflammatory Bowel Disease

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