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

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

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

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  1. Conditions presenting with abdominal painLidia IonescuIII rd. Surgical Unit

  2. 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

  3. Perforated peptic ulcer

  4. 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

  5. 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

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

  7. Habits Smoking Alcohol Coffee

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

  9. 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.

  10. Perforated peptic ulcer 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

  11. 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

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

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

  14. 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

  15. 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

  16. 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

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

  18. 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.

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

  20. 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

  21. USG showing hepatic metastases.

  22. 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.

  23. OGD - Ulcerated mass over stomach

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

  25. Gastric cancerThe 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..

  26. 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.

  27. 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.

  28. Archives Of Cancer-blog From Medicineworld.Org

  29. 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 linitusplastica )

  30. Gastric cancer

  31. 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 9th rib, Murphy’s sign Diagnosis is based on history and USS Clinical signs are minimal

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

  33. 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

  34. 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

  35. Acute cholecystitisLaparoscopic view

  36. Acute cholecystitisLaparoscopic view

  37. 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.

  38. Acute cholecystitisSymptoms • 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

  39. Symptoms of Chronic Cholecystitisor 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

  40. 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.

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

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