Clinical presentation of some abdominal/GIT disorders of surgical importance

Inflammatory Bowel Disease

IBD
IBD “Other Options of Surgical Treatment not mentioned here”

Clinical presentation of a patient with chronic duodenal ulcer

  • Type of patient
    • Young & Active
    • Well fed & Plump
    • No apparent signs of ill health
  • Symptoms
    • Pain
Site Deep seated in the epigastrium
Onset
Course
  • Periodicity
  • Pain occur during periods of activity
  • Usually lasts for few weeks followed by a period of quiescence which lasts for few months
Duration
Severity All grades of sevirity
Character Boring
Radiation
Referral Back if there is penetration of the pancreas
Relieving factors
  • Food
  • antacids
Exacerbating factors
  • Few hours after meals
  • Spicy food
  • Use of condiments
  • At night
Relation to other symptoms Vomiting does not bring relief
Cause Acid chyme passing on ulcer following gastric evacuation
  • Nausea and vomiting
  • Complication
    • Bleeding
      • Melena
      • Haematemesis
      • Hypovolaemia
    • Pyloric stenosis
      • Vomiting
      • Dehydration
      • Electrolyte imbalance
      • Hyponatraemia
      • Hypokalaemia
      • Alkalosis
      • Hypocalcaemia
    • Perforation
      • Sudden sever pain
      • Peritoneal irritation
Differences between the common 3 complications of peptic ulcer

Haemorrhage

Perforation

Obstruction

Incidence 10-20% 5-10% <5%
Sex Male Male Female
Cardinal symptom Haematemesis Sudden sever upper abdominal pain Vomiting
Cardinal signs Pallor Peritoneal irritation Seen, felt and heard

Electrolyte disturbance

Investigation of choice Upper GI endoscopy Chest X ray erect Barium meal
Main line of Treatment Non surgical

Endoscopy

Surgical

After preoperative preparation

Surgical

After preoperative preparation

Clinical differences between chronic duodenal ulcer and chronic gastric ulcer

DU

GU

Causes Common causes

  • H pylori infection
  • Non-steroidal anti-inflammatory drugs

Rare causes

  • Zollinger-Ellison syndrome
  • Hypercalcaemia
  • Granulomatous diseases (Crohn’s disease, sarcoidosis)
  • Neoplasia (carcinoma, lymphoma, leiomyoma, leiomyosarcoma)
  • Infections (tuberculosis, syphilis, herpes simplex, cytomegalovirus)
  • Ectopic pancreatic tissue
  • H pylori infection
  • Non-steroidal anti-inflammatory drugs
  • Neoplasia (carcinoma, lymphoma, leiomyosarcoma)
  • Stress
  • Crohn’s disease
  • Infections (herpes simplex, cytomegalovirus)
Age 3rd &4th decades Past middle age
M:F 5:1 2:1
Pain 2-3 hours after meals

Nocturnal pain

Hunger pain

Shortly after meals
Nausea and vomiting May occur Present

Brings bile

Periodicity Marked Less marked
Appetite Good Afraid to eat
Weight May be over-weight Weight loss

Clinical sequelae of gall stones

Migrate

Colic

Irritate

Metaplasia

Impact

Infection Cattaral Mucocele
Suppurative Empyema
Gangrenous Perforation
  • Fistula
  • Localized peritonitis
  • Generalized peritonitis
Mirrizi syndrome Jaundice
CBD Cholangitis Charcot triad
  • Pain
  • Jaundice
  • Fever and rigors
Reynold’s pentad
  • Charcot triad +
  • Confusion
  • hypotension
Pancreatitis
Intestinal obstruction

Clinical assessment of intestinal obstruction

  • Is there intestinal obstruction?
    • Pain
    • Vomiting
    • Distension
    • Absolute constipation
  • Is the bowel strangulated?
    • Pain is
      • Sever
      • Not relieved by decompression
    • Toxaemia
    • Abdominal tenderness and rigidity
  • Is the site of obstruction in the small bowel or large bowel?

High small bowel

Low small bowel

Colonic

Pain
Vomiting Early And early dehyderation Delayed about 12 hours May be absent or Occur after few days
Distension slight Central abdominal Marked,Especially in the flanks
Constipation Early
  • What is the possible cause?

Clinical features of carcinoma of the colon and rectum

Right colon cancer

3 A

Anemia, asthenia and anorexia

Pain

Recurrent attacks of pain in right iliac fossa

Mass

Hard mass may present in right iliac fossa

No obstruction

Rarely if the lesion obstruct ileocaecal valve
 Left colon cancer

Constipation

Progressive constipation and change of bowel habits

Spurious diarrhea

Obstruction

Acute, sub acute or chronic large bowel obstruction

Bleeding

Bleeding per rectum

Mass

rare
Rectal cancer

Bleeding

Tenesmus

Sense of painful incomplete evacuation

Painless

Mass

By DRE