Urology / Clinical

TAKING HISTORY FROM A PATIENT WITH urological CONDITION

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Pain
  • Renal pain
  • Ureteric colic
  • Vesical pain
  • Prostatic pain
  • Urethral pain
  • Testicular and epididymal pain
Lower urinary tract symptoms “LUTS”
  • Irritative
    • Frequency
    • Noctorna
    • Urgency
    • Urge incontinence
    • Nocturnal enuresis
  • Obstructive (bladder outlet obstruction) “BOO”
    • Difficulty to initiate
      • Hesitancy
    • Difficulty to maintain
      • Weak stream
      • Interrupted stream
      • Forked stream
    • Difficulty to terminate
      • Dribbling
Symptoms related to change in urine
  • In Volume
    • Polyuria
    • Oliguria
    • Anuria
  • In Content
    • Heamaturia
    • Pyuria
    • Chyluria
    • Cloudy urine
    • Necroturia
    • Pneumaturia
Others
  • Incontinence
  • Discharge
  • Swelling
  • Sexual difficulties in men
  • Infertility
Occupations associated with exposure to bladder carcinogens
  • Dry cleaners
  • Leather workers
  • Painters and decorators
  • Paper and rubber manufacturers
  • Dental technicians

Bladder carcinogens

  • Aniline dyes
  • Alpha and beta naphthylamine
  • Xylenamine
  • Benzidine
Symptoms suggesting malignancy

Examination

Differential diagnosis of different urology presentation

Causes of haematuria
  • Kidney
    • Congenital
      • Polycystic kidney
    • Traumatic
      • Rupture kidney
      • Stone
    • Inflammatory
      • TB
    • Neoplastic
      • Carcinoma of the kidney
      • Carcinoma of the renal pelvis
    • Blood disorder
      • Anti-coagulant drugs
      • Purpura
      • Sickle-cell disease
      • Haemophilia
      • Scurvy
      • Malaria
    • Congestion
      • Right heart failure
      • Renal vein thrombosis
    • Infarction, Arterial emboli from:
      • Myocardial infarction
      • Sub acute bacterial endocarditis
  • Ureter
    • Stone
    • Neoplasm
  • Bladder
    • Traumatic
      • Stone
    • Inflammatory
      • Non-specific cystitis or ulceration
      • TB
      • Bilharzia
    • Neoplastic
      • Carcinoma
  • Prostate
    • Benign and malignant enlargement
  • Urethra
    • Traumatic
    • Rupture
    • Stone
    • Inflammatory
    • Acute urethritis
    • Neoplastic
    • Transitional cell carcinoma
Types of haematuria
Frank
Microscopic > 3-4/HPF
Painful Usually benign condition
Painless Must regarded as a symptom of tumor until proved otherwise
Total Origin from kidney Cylindrical clots
Origin from massive vesical bleeding Discoid clots
Senile prostatic enlargement
Tumors
Terminal Origin from bladder Trigone

Bladder neck

Origin  from posterior urethra
Senile prostatic enlargement
Initial Origin from urethra
Differential diagnosis of a renal mass
  • Hydronephrosis
  • Pyonephrosis
  • Polycystic kidney
  • Renal tumors
    • Hypernephroma
    • Wilm’s tumor
  • Big renal cyst
Causes of hydronephrosis
  • Unilateral hydronephrosis
    • Pelvi-ureteric obstruction
      • Congenital pelvi-ureteric junction stenosis
      • Pressure from aberrant arteries
      • Stones and tumors in renal pelvis occluding the opening of the ureter
    • Ureteric obstruction
      • Stones
      • Tumor infiltrating the ureter from: Cervix, Rectum, Colon or Prostate
      • Uretrocele
      • Schistosomiasis
      • Bladder tumor
  • Bilateral hydronephrosis
    • Retroperitoneal fibrosis
    • Prostatic enlargement
      • Benign
      • Malignant
    • Carcinoma of the bladder
    • Schistosomiasis
    • Urethral strictures and valves
    • Phimosis
Differential diagnosis of a suprabupic swelling
  • Full bladder
  • Pregnancy
  • Bladder tumour
  • Uterine or ovarian mass
The causes of retention of urine
  • Mechanical
    • In the lumen of urethra, or overlying the internal urethral orifice
      • Congenital valves
      • Foreign bodies
      • Tumors
      • Blood clots
      • Stones
    • In the wall of the bladder or the urethra
      • Phimosis
      • Trauma (rupture of urethra)
      • Urethral stricture
      • Urithritis
      • Meatal ulcer
      • Tumor
      • Prostatic enlargement; Benign or Malignant
    • Outside the wall
      • Pregnancy (retroverted gravid uterus)
      • Fibroids
      • Ovarian cyst
      • Faecal impaction
      • Paraphimosis
  • Neurogenic
    • Post-operative retention
    • Spinal cord injuries
    • Spinal cord disease
      • Disseminated sclerosis
      • Tabes dorsalis
    • Hysteria
    • Drugs
      • Anti-cholinergic
      • Anti-histaminic
      • Smooth muscle relaxants
      • Some tranquilizers

According the sex

Females

Males

Retro-gravid uterus Infants Posterior urethral valve
Pelvic tumor Meatal ulcer crust
Multiple sclerosis Child Congenital bladder neck obstruction
Hysterical Teens Urithritis
Adult Stricture
Bilharzial
Old age BPH
Carcinoma of prostate
Causes of a urethral discharge
  • Infection (urithritis) by
    • Gonococcus
    • Chlamydia
    • Coliforms
    • Trichomonas
    • Candida
  • Lesions in the urethra
    • Warts
    • Herpes
  • Foreign bodies
The causes of urethral strictures
  • Congenital
    • Pinhole meatus
    • Urethral valve (not a true stricture)
  • Traumatic
    • Instrumentation (catheterization)
    • Foreign bodies
    • Prostatectomy
    • Amputation of the penis
    • Direct injuries
  • Inflammatory
    • Gonorrhea
    • Meatal ulceration
  • Neoplastic
    • Primary and secondary neoplasms
Differences between different types of trauma to the urinary bladder and the urethra

Extraperitoneal urinary blabber rupture

Intraperitoneal urinary bladder rupture

Injury of posterior urethra (intrapelvic)

Injury of  anterior urethra (extrapelvic)

History of trauma

  • Sever trauma
  • Shock
  • Pelvic fracture
  • A blow or kick to lower abdomen in presence of a full bladder
  • Sever trauma
  • Shock
  • Pelvic fracture
  • Falling Astride hard object
  • Kick to perineum
  • Perineal haematoma

Urine retention

  • Desire
  • Full bladder
  • No desire
  • No full bladder
  • Desire
  • Full bladder
  • Desire
  • Full bladder

Urine extravasation

Boggy swelling in suprapubic area Free fluid in peritoneal cavity with peritonism deep in extra-peritoneal space like extraperitoneal rupture of bladder If patient tries to void To superficial peritoneal poch

Bleeding per-urethra

No

Drops of blood at external meatus

DRE

Prostate in normal position

Prostate in higher position

Passage of catheter

Urine or not

blood

Contraindicated

Ascending Urethrography

Normal

Show the site of extravasation

Ascending cystography

Leakage of contrast outside the bladder

Differences between congenital and acquired bladder diverticulae

Congenital bladder diverticula

Acquired bladder diverticula

Rare Common
No obstruction Distal obstruction
Usually solitary Usually multiple
No bladder saccules Associated with bladder saccules
Medial to and above uriteric orifice Posterior wall
  • Full thickness pouch
  • Contains muscles
  • Mucosal pouch
  • No muscle
Wide neck Narrow neck
No stasis
  • Stasis
  • Infection
  • Stone formation can happen
Usually requires no treatment Treatment of obstruction and need excision

Anal canal / Clinical

TAKING HISTORY FROM A PATIENT WITH Anal condition

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Swelling
  • Pain
  • Discharge
  • Bleeding
  • Pruritus
  • Change bowel habits
  • Incontinence

Examination

Position
  • Left lateral position
  • Chin rest on the chest
  • Hip flexed 90o or more 
  • Knee flexed less than 90o
Inspection
  • Skin rash and excoriation
  • Faecal soiling, blood or mucus
  • Scaring, or opening of a fistula
  • Lumps and bumps
  • Ulcers, especially fissures
Palpation (digital rectal examination “DRE”)
  • Inspect your finger, when you remove it
  • The Anal canal
    • Tone of the sphincter
    • Pain or tenderness
    • Thickening or masses
  • The rectum
    • Texture of the wall of the rectum
    • Masses
      • Mobility of the mucosa over the mass to decide if it is within or outside the wall
    • Ulcers
    • Content of the rectum
      • Hard or soft
      • Faeces may feel like a tumor but are indentable
  • The recto-vesical/recto-uterine pouch
  • Bimanual examination
  • The cervix and uterus
  • The prostate and seminal vesicles
Proctoscopy
Sigmoidoscopy

Differential diagnosis of different anal disorders and approach for diagnosis

Diagnosis of conditions which present with rectal bleeding
Bleeding but no pain
Blood mixed with stool Carcinoma of colon Also proctitis caused by specific infection (e.g. schistosomiasis)
Blood streaks on stool Carcinoma of the rectum
Blood after defecation Heamorrhoids
Blood and mucus Colitis
Blood alone Diverticular disease
Melena Peptic ulceration
Bleeding + pain
  • Fissure
  • Carcinoma of anal canal
Diagnosis of conditions which present with pain
Pain
  • Fissure (pain after defecation)
  • Proctalgia fugax (pain spontaneously at night)
  • Anorectal abscess
Pain and bleeding
  • Fissure
Pain and lump
  • Perianal haematoma
  • Anorectal abscess
Pain, lump and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Diagnosis of conditions which present with lump
Lump and no other symptoms
  • Anal warts
  • Skin tags
Lump and pain
  • Peri-anal haematoma
Lump, pain and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Common causes of acute anal pain
  • Fissure in ano
  • Anal abscess
  • Strangulated pile
  • Perianal heamatoma
  • Proptalgia fugax
The causes of Pruritus ani
Mucus discharge from the anus
  • Haemorrhoids
  • Polyps
  • Skin tages
  • Condylomata
  • Fissure
  • Fistula
  • Carcinoma of the anus
Vaginal discharge
  • Tricomonas vaginitis
  • Monilia vaginitis
  • Cervicitis
  • Gonorrhea
Skin disease
  • Tinea cruris
  • Fugal infections, especially monilial
  • Infection in diabetics
Parasites
  • Threadworm
Faecal soiling
  • Poor hygiene
  • Incontinence
  • Diarrhea
Psychoneurosis
Differences between acute anal fissure and chronic anal fissure

Acute anal fissure

Chronic anal fissure

Soft Indurated
Spastic muscle Fibrotic muscle
Conservative treatment Operative treatment

Cardinal symptoms of common anal disorders

Anal disorders usually share the same symptoms but every disorder has its own cardinal symptom

Disease

Cardinal symptom

Other symptoms

Fissure Pain Sentinel pile (swelling)
Abscess Swelling Continuous throbbing painful swelling
Fistula Discharge Pruritus
Haemorrhoids Bleeding Pruritus

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

Some of GI / Abdominal Symptomatology of Surgical Importance

TAKING HISTORY FROM A PATIENT WITH ABDOMINAL/GIT PROBLEM

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Abdominal pain
  • Abdominal swelling
  • Related to esophagus and mouth
    • Halitosis
    • Salivation
    • Dysphagia
    • Heart burn
    • Reflux
    • Painful swallowing or odynophagia
  • Related to upper GIT
    • Dyspepsia or indigestion
    • Eructation
    • Flatulence
    • Hiccups
    • Vomiting
    • Retching
  • Related to lower GIT
    • Bowel habits
    • Constipation
    • Diarrhea
    • Dysentery
    • Worms in stool
  • Related to bleeding
    • Haematemesis
    • Rectal bleeding
    • Melena
  • Hepatobiliary
    • Jaundice
    • Itching
    • Encephalopathy
    • Bleeding tendency
    • Weight loss
  • Constitutional manifestations
    • Fever
    • Headache
    • Malaise
    • Sweating
    • Fatigue

Differential diagnosis of different abdominal presentations

Abdominal Pain

Principle causes of abdominal pain
  • Inflammation/infection
  • Perforation of a viscus
  • Obstruction of a viscus
  • Infarction/strangulation
  • Intraperitoneal/retroperitoneal haemorrhage
  • Injury
  • Extra-abdominal and medical causes
  • Then think anatomical
The common conditions that present with acute upper abdominal pain
  • Oesophagitis
  • Boerhaave’s syndrome
  • Acute gastritis
  • Perforated peptic ulcer
  • Acute cholecystitis
  • Gallstone and biliary colic
  • Acute pancreatitis
The common conditions that present with chronic upper abdominal pain
  • Chronic peptic ulceration
  • Carcinoma of the stomach
  • Chronic cholecystitis
  • Chronic pancreatitis
  • Liver metastases
  • Splenomegaly
The common conditions that present with acute central abdominal pain
  • Meckel’s diverticulitis
  • Acute gastroenteritis
  • Inflammatory bowel disease
  • Acute Crohn’s disease
  • Acute ulcerative colitis
  • Yersinis ileitis
  • Typhoid
  • Tuberculosis
  • Urinary tract infection
The common conditions that present with chronic central abdominal pain
  • Crohn’s disease
  • Tuberculosis
  • Radiation bowel damage
  • Tumors of the small bowel
  • Recurrent adhesive obstruction/malrotation
  • Ischemia of small bowel
  • Endometriosis
The common conditions that present with acute and chronic lower abdominal pain
  • Appendicitis
  • Crohn’s disease
  • Carcinoma of caecum and right colon
  • Diverticular disease
  • Carcinoma of left colon/rectum
  • Bladder outflow obstruction
  • Interstitial/irradiation cystitis
  • Pelvic inflammatory disease
The causes of generalised abdominal pain
  • Irritable bowel syndrome
  • Recurrent adhesive obstruction
  • Mesenteric ischemia
  • Carcinomatosis
  • Chronic constipation
  • Radiation damage
  • Retroperitoneal tumors
  • Endometriosis
  • Pelvi-ureteric junction obstruction
  • Lumbar spine pain
  • Retroperitoneal fibrosis
  • Psychosomatic
Infarction of viscus causing abdominal pain
Organ  Mechanism
Small and large bowel
  • Strangulation
  • Volvulus
  • Arterial thrombosis
  • Arterial embolism
  • Dissecting aneurysm
  • Venous thrombosis
Ovary Torsion pedicle
Omentum/appendix epiploica Strangulation
Stomach Volvulus
Spleen/kidney/liver Arterial occlusion
Extra-abdominal and medical conditions causing acute abdominal pain

Endocrine and metabolic disorders
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Acute hyperlipoproteinemia
Hereditary Mediterranean fever
Hematologic disorders
Sickle cell crisis
Acute leukemia
Other dyscrasias
Toxins and drugs
Lead and other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Infections and inflammatory disorders
Tabes dorsalis
Herpes zoster
Acute rheumatic fever
Henoch-Schonlein purpura
Systemic lupus erythematosus
Polyarteritis nodosa
Referred pain
Thoracic region
Myocardial infarction
Acute pericarditis
Pneumonia
Pleurisy
Pulmonary embolus
Pneumothorax
Empyema
Hip and back

Abdominal pain caused by intra-abdominal or retroperitoneal haemorrhage
  • Ruptured abdominal aortic aneurysm
  • Ruptured spleen
  • Ruptured ectopic pregnancy
  • Ruptured ovarian cyst
  • Haemorrhage from a liver adenoma
  • Ruptured visceral aneurysms
    • Splenic
    • Hepatic
    • Mesenteric
  • Torn mesentery
  • Retroperitoneal haemorrhage
Causes of abdominal pain that are usually forgotten
  • Pancreatitis
  • Aneurysms (leaking or dissecting)
  • Mesenteric ischemia
  • Herpes zoster ‘shingles’
  • Prophyria
  • Diabetes
  • Tabes Dorsalis
  • Sickle-cell anaemia
  • Pneumonia

Abdominal Masses

CHIASMA

Hepatomegaly

Splenimegaly

Congestive
  • Right heart failure
  • Tricuspid regurgitation
  • Budd-Chiari syndrome
  • Portal hypertension
  • Hepatic vein obstruction
Heamatological
  • Lymphoma
  • Leukemia
  • Heamolytic anaemia
  • Sickle cell disease/thalasseamia
  • Lymphoma
  • leukemia
Infection
  • Viral (hepatitis – EBV – Cytomegalovirus)
  • Bacterial (TB – liver abscess)
  • Protozoal (malaria – amoebiasis – hydatid – schistosomiasis)
  • Acute (HIV – EBV – Cytomegalovirus – infective endocarditis)
  • Chronic (malaria – schistosomiasis – brucella – toxoplasmosis – leishmaniasis)
Amyloid
  • Sarcoidodsis
Storage disorder
  • Wilson’s disease
  • Haemochromatosis
  • Gaucher’s disease
Masses
  • Primary
  • Secondary
Autoimmune
  • Alcoholic (Fatty liver – cirrhosis)
  • Rheumatoid arthritis
  • Felty’s syndrome

Massive splenomegaly

  • Myelofibrosis
  • Chronic myeloid leukaemia
  • Malaria
  • Tropical splenomegaly
  • Kala-azar (visceral leishmaniasis)
Differential diagnosis of a renal mass
  • Hydronephrosis
  • Pyonephrosis
  • Polycystic kidney
  • Renal tumors (Hypernephroma – Wilm’s tumor – Big renal cyst)
The causes of abdominal distension
  • Fetus
  • Flatus
  • Faeces
  • Fat
  • Fluid
    • Free (ascites)
    • Encysted
      • Ovarian cysts
      • Hydronephrosis
      • Urinary bladder
      • Pancreatic pseudocysts
      • Mesenteric cysts
      • Hydatid cysts
  • Large solid tumor
    • Fibroid
    • Enlarged liver
    • Enlarged spleen
    • Polycystic kidneys
    • Retroperitoneal sarcomata
Causes of right iliac fossa mass

Think anatomical

  • Appendix mass
  • Appendix abscess
  • Tuberculosis
  • Carcinoma of caecum
  • Crohn’s disease ‘terminal ileitis’
  • Iliac lymphadenopathy
  • Iliac artery aneurysm
  • Psoas abscess
  • Chondrosarcoma or osteosarcoma of ilium
  • Tumor in an undescended testis
  • Actinomycosis
  • Ruptured Epigastric artery
  • Spigelian hernia
  • Kidney transplant
  • Ovarian cyst/tumor
  • Fibroid
  • Malignant change in an undescended testis
Causes of left iliac fossa mass

Think anatomical 

  • Diverticulitis
  • Carcinoma of colon
  • Carcinoma of caecum !
  • Crohn’s disease ‘terminal ileitis’
  • Iliac lymphadenopathy
  • Iliac artery aneurysm
  • Psoas abscess
  • Chondrosarcoma or osteosarcoma of ilium
  • Tumor in an undescended testis
  • Actinomycosis
  • Ruptured Epigastric artery
  • Spigelian hernia
  • Kidney transplant
  • Ovarian cyst/tumor
  • Fibroid
  • Malignant change in an undescended testis

Clinical sequelae of portal hypertension

  • Porto-systemic collaterals
Site Presentation
Lower part of oesophagus and fundus of stomach Oesophageal or gastric varices
  • Haematemesis
  • Melena
  • Fresh bleeding per rectum
Anterior abdominal wall Caput medusa Venous hum
Lower rectum and anal canal Anorectal varices
Retroperitoneum
  • Splenomegaly
  • Congestion of whole GIT (Anorexia – Dyspepsia – Indigestion – Malabsorption – Abdominal discomfort)
  • Ascites

Gastrointestinal bleeding

Causes of haematemesis and melena
  • Common causes
    • Oesophgeal varices
    • Acute gastric erosion
      • Aspirin
      • Steroids
      • Trauma
      • Burn
      • Phenyl-butazone
    • Chronic peptic ulcer (spontaneous, steroid)
    • Carcinoma of stomach
    • Purpura
    • Heamophelia
  • Anatomical approach
    • Oesophgeal causes
      • Oesophageal varices
      • Reflex oesophagitis
      • Mallory Weiss syndrome
      • Booerheaves syndrome
    • Gastric causes
      • Multiple gastric erosions
      • Acute haemorrhagic gastritis
      • Chronic gastric ulcer
      • Benign or malignant neoplasm of the stomach
    • Duodenal causes
      • Acute duodenal ulcer
      • Chronic duodenal ulcer
  • General causes
    • Blood diseases
    • Purpura
    • Haemophilia
    • Thrombocytopenia
    • Leukaemia
  • Rare causes
    • Fundal varices
    • Hiatus hernia
    • Dieulafoy’s lesion
    • Aortic aneurysm
    • Aorto-enteric fistula
    • Haemobilia
    • Watermelon stomach
Causes of bleeding per rectum
  • General causes
    • Purpura
    • Haemophilia
    • Thrombocytopenia
    • Leukaemia
  • Lesions of anal canal
    • Haemorrhoids
    • Anal fissure
  • Colorectal causes
    • Congenital
      • Familial poliposis coli
    • Inflammatory
      • Acute bacillary dysentery
      • Amoebic dysentery
      • Bilharzial colitis
      • Ulcerative colitis
    • Vascular
      • Ischemic colitis
    • Neoplastic
      • Malignant and benign neoplasms of colon and rectum
    • Diverticular disease of the colon
    • Angiomatous malformation of colon
  • Hemorrhoids is the commonest cause of bleeding per rectum
  • Causes of massive bleeding per rectum
    • Diverticula
    • UC
    • Ischemic colitis
    • Angiodysplasia
    • Massive upper GIT bleeding
    • In children 
      • Meckel’s diverticulum
Forms of bleeding per rectum
Blood mixed with stool
  • Proximal colonic
Blood on surface of stool
  • Distal colonic
Blood without stool
  • Bleeding in rectum
  • Sever bleeding from a proximal site
Blood on toilet paper
  • Anal fissure or ulcer
General rules for GIT bleeding
2-5 ml normal blood loss
10-50 ml FOB ‘foecal occult blood’ in screening of colorectal cancer
50-100 ml  Enough to produce melena
1000 ml From upper GIT produce haematochesia
1000 ml In a day produce melena for 3-5 days, melena poor indicator of recent bleeding
The character (color) of blood passed from GIT depend upon:

  • Time expense in GIT
  • Site
Lower GIT bleeding by definition originate below Treitz ligament at D-J junction
Upper GIT bleeding by definition originate above Treitz ligament at D-J junction
Melena is bleeding above ilio-ceacal valve (digested blood)
So presence of melena indicate

  • Bleeding >100 ml
  • presence of melena for 3-5 days indicate
  • bleeding of 1000 ml
The causes of a discharge from the umbilicus
  • Congenital
  • Intestinal fistula
  • Patent uracus
  • Umbilical adenoma
  • Acquired
  • Umbilical granuloma
  • Dermatitis (intertrigo)
  • Ompholith (umbilical concretion)
  • Fistula (intestinal)
  • Secondary carcinoma
  • Endometriosis
Causes of portal hypertension
  • Increased resistance to flow
  • Prehepatic (portal vein obstruction)
    • Congenital atresia or stenosis
    • Thrombosis of portal vein
    • Thrombosis of splenic vein
    • Extrinsic compression (for example, tumours)
  • Hepatic
    • Cirrhosis
    • Acute alcoholic liver disease
    • Congenital hepatic fibrosis
    • Idiopathic portal hypertension (hepatoportal sclerosis)
    • Schistosomiasis
  • Posthepatic
    • Budd­Chiari syndrome
    • Constrictive pericarditis
  • Increased portal blood flow
    • Arterial­portal venous fistula
    • Increased splenic flow

Jaundice

Jaundice

Hemolytic Hepatocellular Obstructive
Cause Destruction of RBCs Liver dysfunction Outflow obstruction
Color Lemon yellow Orange yellow Olive green
Bilirubin Indirect Direct& idirect Direct
Associations Evidence of hemolysis Picture of LCF PruritusOther evidence of obstruction
Urine Darken on standing Dark Frothy dark
Stools Dark Pale Clay colored
Differences between hepatocellular jaundice and uncomplicated obstructive jaundice in LFTs
Test Normal value

Hepatocellular jaundice

Uncomplicated obstructive jaundice

Bilirubin

Direct

0.1-0.3 mg/dl + +
indirect 0.2-0.7 mg/dl
Urine bilirubin None + +
Serum albumin 3.5-5.5 g/dl Unchanged
ALP 30-115 units/l + +++
PT 1.0-1.4
  • Prolonged if sever damage
  • No response to parentral vitamin k
  • Prolonged if sever obstruction
  • Responed to parentral vitamin k
ALT 5-35 unit/l
  • +++
  • Hepatocellular damage
  • Viral hepatitis
+
AST 5-40 unit/l
Differences between calcular and malignant obstructive jaundice

Calcular

Malignant

Peak age incidence Middle age Elderly
Gender More in females More in males
Duration of jaundice May be long Short
Course if jaundice Intermittent Progressive
Depth of jaundice Moderate May be very deep
Abdominal pain Colicky

More in right hypochonderium

May be absent

If present it is dull aching

And referred to back

Anorexia & loss of weight Absent Marked
Fever May be present Usually absent
Gall bladder palpation Usually impalpable Commonly palpable
Ultrasound Usually fibrosed gall bladder with stones Marked distended thin walled gall bladder
CT scan Gall stones Head neoplasm is usually seen
ERCP Stone in CBD Irregular filling or

Failure of cannulation of CBD

Causes of postoperative jaundice
  • Prehepatic jaundice (bilirubin overload)
    • Hemolysis (drugs, transfusions, sickle cell crisis)
    • Reabsorption of hematomas
  • Hepatocellular insufficiency
    • Viral hepatitis
    • Drug-induced (anesthesia, others)
    • Ischemia (shock, hypoxia, low-output states)
    • Sepsis
    • Liver resection (loss of parenchyma)
    • Others (total parenteral nutrition, malnutrition)
  • Posthepatic obstruction (to bile flow)
    • Retained stones
    • Injury to ducts
    • Tumor (unrecognized or untreated)
    • Cholecystitis
    • Pancreatitis
    • Occlusion of biliary stents

Dysphagia

  • Causes in the mouth
    • Stomatitis
    • Glossitis
    • Neoplasm of the tongue and cheek
  • Causes in the pharynx
    • Pharyngitis
    • Retropharyngeal abscess
    • Plummer Vinson syndrome
    • Pharyngeal diverticulum
    • Post-cricoid carcinoma
    • Lusoria (game of nature)
    • Globus hystericus
    • Neuromuscular
    • DM
    • Poliomyelitis
    • Myopathy
    • CVA
    • Pulpar palsy
  • Causes in the oesophagus
    • Mechanical
      • In the lumen
        • Foreign body
      • In the wall
        • Congenital
          • Atresia
        • Traumatic
          • Corrosive
          • Post-operative stricture
        • Inflammatory
          • Reflux oesophagitis
        • Neoplastic
          • Carcinoma
    • Compression from outside
      • Malignant thyroid
      • Malignant lymph nodes
      • Aortic aneurysm
      • Mediastinal tumors
  • Neuromuscular
    • Achalasia of the cardia
    • Paralysis of glossopharyngeal or vagus nerve
    • Tetanus
    • Myasthenia gravis
    • Hysteria

Intestinal Obstruction

The Conditions likely to cause acute mechanical intestinal obstruction
  • In the lumen
    • Faecal impaction
    • Gall stone ileus
    • Parasitic infestation
    • Mecomium
  • In the wall
    • Congenital atresia
    • Tumors
    • Crohn’s disease
    • Chronic diverticulitis
    • Mesenteric vascular occlusion
  • Outside the wall
    • Adhesions commonly Postoperative
    • Strangulated hernia
    • Volvulus
    • Intussusceptions
    • Malignant tumors
Age and the common causes of alimentary tract obstruction
Neonates
  • Atresia (duodenal, ileum)
  • Meconium obstruction
  • Volvolus neonatorum
  • Anorectal malformations
  • Hirschsprung’s disease
3 weeks
  • Congenital hypertrophic pyloric stenosis
6-9 monthes
  • Intussusception
  • Hirschsprung’s disease
  • Strangulated hernia
Teenage
  • Inflammatory masses (appendicitis)
  • Intussusception of Meckel’s diverticulum or polyp
Young adult
  • Hernia
  • Adhesions
Adult
  • Hernia
  • Adhesions
  • Inflammation
  • Appendicitis
  • Crohn’s disease
  • Carcinoma
Elderly
  • Carcinoma
  • Inflammation
  • Diverticulitis
  • Sigmoid volvulus
  • Strangulated hernia

 

Scrotal examination

 

Scrotum

Plan for examination of the scrotum
Scrotal neck Junction between corrugated & smooth skin

At root of penis

At the pubic tubercle

Skin
Tunica Normally not felt except there is fluid If Minimal fluid it is felt by benching

If large amount of fluid it is felt as swelling

Testis Testicular sensation

Size

Epididymis
Cord Thickness

Vas felt like tough structure

Inguinal region Inguinal lymph nodes (that drain scrotal skin)
Penis Shaft for Hypospadias

Epispadias

Circumcision
DRE Prostate

Seminal vesicles

Perineum
Abdomen Para-aortic lymph nodes

Maldescended testis

Neck Left  supraclavicular LNs ( Verchow’s sign)

 

Aim of examination in case of scrotal swelling is to answer 4 questions

Can you get above the swelling?

Can you identify the testis and the epididymis?

Is the swelling is translucent?

Is the swelling is tender?

and these are examples for how you can comment on your examination of scrotum.

Hydrocele

  1. “Enlarged right side of the scrotum”
  2. Look to back of the scrotum and penis
  3. “No signs of inflammation (scars, sinuses or dilated veins)”
  4. “No cough impulse and not reducible (بيرجع؟)”
  5. “I can get above the swelling so it is pure scrotal swelling”
  6. Feel the swelling (relation to testis and epidydimis)
  7. Transillumination

Varicocele

  1. Examine in supine position after standing
  2. Inspection normal
  3. Feel bag of worms
  4. May feel cough impulse or thrill
  5. Separate from testis
  6. Can get above it
  7. No transillumination

Continue reading “Scrotal examination”

Clinical Examination of the Hernia

 

Inguinal hernia

Ask the patient to stand up (or can done in supine position first)

Always examine both inguinal regions

Look

at the lump from in front

Is this swelling a hernia?
  • Anatomical site of a hernia (groin)
  • Expansile impulse on cough (except if strangulated) (كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
  • Opaque by transillumination (except in infants)
Which type (femoral or inguinal)?
  • Exact site (palpate ASIS and pubic tubercle ‘inguinal ligament’)   above or below?
Is it recurrent? (Scars)
Scrotum and penis
Feel Feel from in front (same items as inspection +)

Examine the scrotum

If you can “get above it

Feel from the side Stand at the side of the patient on the same side as the hernia. Place one hand in the small of the patient’s back to support him And your examining hand on the lump with your fingers and arm roughly parallel to the inguinal ligament

Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)

Expansile cough impulse (كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Internal ring test (direct or indirect?)
Percuss and auscultate

the lump

Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) vs. Omentum (omentocele)

Consistency: Soft  vs. Doughy

Gurgling: Occurs during reduction vs.  None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

Ventral hernias

Ask the patient to stand up (or usually done in supine position first)
Look Is this swelling a hernia?
  • Anatomical site of a hernia
  • Expansile impulse on cough (except if strangulated (هم براسك او كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
Which type ? Umbilical, paraumbilical or epigastric.
Is it recurrent? (Scars)
Feel Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)
Expansile cough impulse (هم براسك او كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Percuss and auscultate the lump Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) Omentum (omentocele)

Consistency: Soft vs.  Doughy

Gurgling: Occurs during reduction  vs. None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

TAKING HISTORY FROM A PATIENT WITH A Hernia

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Lump
    • Anatomical site of hernia
    • Expansile impulse on cough (except if strangulated)
    • Reducible (except if irreducible, obstructed or strangulated)
  • Symptoms suggesting complication
    • Symptoms of intestinal obstruction (Pain – Vomiting – Distension – Absolute constipation)
    • Symptoms suggesting sliding hernia
      • Urinary symptoms (urinary bladder in inguinal hernia)
      • Dyspepsia (stomach in epigastric hernia)
  • History of suggesting cause
    • Congenital (sense birth)
    • Acquired
      • Raised intra-abdominal pressure (Chronic cough – Straining at micturation or stools – Heavy work – Obesity – Huge abdominal swelling)
      • Weak abdominal wall (Obesity – Senility – Debility – Pregnancy – Weak scar – Damage nerve supply of the muscles)

Differential diagnosis of hernias

Abdominal herniae
  • Common
    • Inguinal
    • Umbilical
    • Incisional
    • Femoral
    • Epigastric
  • Rare
    • Spigelian
    • Obturator
    • Lumbar
    • Gluteal
The differential diagnosis of a lump in the groin
  • Inguinal hernia
  • Femoral hernia
  • Enlarged lymph glands
  • Sapheno-varix
  • Ectopic testis
  • Femoral aneurysm
  • Hydrocele of the cord or hydrocele of the canal of Nuck
  • Lipoma of the cord
  • Psoas bursa
  • Psoas abscess
The differential diagnosis of inguinal hernia
  • Femoral hernia
  • Vaginal hydrocele
  • Hydrocele of the cord or the canal of Nuck
  • Undescended testis
  • Lipoma of the cord
Differences between indirect (oblique) inguinal hernia and direct inguinal hernia

Indirect inguinal hernia

Direct inguinal hernia

Age Any age Elderly
Side Uni or bilateral Commonly bilateral
Shape Oblong hemispherical
descent into the scrotum Can (and often does) Does not (hardly ever)
Direction of reduction upwards, then laterally and backwards upwards, then straight backwards
Internal ring test Controlled, after reduction ,by pressure over internal inguinal ring Not Controlled, after reduction ,by pressure over internal inguinal ring
The defect not palpable, as it is behind the fibres of the external oblique muscle may be felt in the abdominal wall above the pubic tubercle
Direction of descent After reduction, the bulge reappears in the middle of inguinal region and then flows medially before turning down to the neck of the scrotum After reduction, the bulge reappears exactly where it was before
at operation Neck of the sac is Lateral to the inferior epigastric artery Neck of the sac is Medial to the inferior epigastric artery
Anatomical types of oblique inguinal hernia
  • Congenital type
    • Reaches down to the bottom of the scrotum
    • Testis lies among the content of the sac
  • Infantile type
    • Operative finding
  • Adult type
    • Bubonocele
      • Limited to inguinal canal
    • Funicular hernia
      • Reaches down to the neck of the scrotum
    • Complete (scrotal) hernia
      • Descends to the bottom of the scrotum
      • Testis is behind the hernia and difficult to locate
The differential diagnosis of femoral hernia
  • Inguinal hernia
  • Enlarged lymph gland
  • Sapheno-varix
  • Ectopic testis
  • Psoas abscess
  • Lipoma
Complication of hernia
  • Irreducibility
  • Obstruction
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Distended – Irreducible – Soft)
  • Strangulation
    • Acute pain
    • Sudden enlargement of the hernia
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Tense – Tender – Irreducible – No impulse on cough)
  • Inflammation
    • Locally hernia becomes (Tender – Not tense – Overlying skin is red and oedematous)
  • Hydrocele of a hernia sac
  • Torsion of omentum
Causes for raised intra-abdominal pressure or weak abdominal wall?
  • Occupation
  • Multiplicity of hernias
  • Divercation of recti
  • Bulge of lower abdomen on straining
Operative differences between viable and non viable intestine

Viable

Non viable

Luster Normal luster Lusterless
Color Pink Grey or black
Mesenteric arteries pulsation Pulsating Not pulsating
Bleeding Bleeds if injured Does not bleed
Consistency Firm Flabby and thin
Effect of pinching Contract if pinched No response
Contents of spermatic cord

3 arteries

  1. Testicular artery (abdominal aorta)
  2. Artery of vas (inferior vesical)
  3. Cremasteric (inferior epigastric)

3 nerves

  1. Ilioinguinal
  2. Cremasteric
  3. Sympathetic

3 tubes

  1. Vas deferens
  2. Pampiniform plexus of veins
  3. Lymphatic vessels

Jaundice

 

Jaundice

Hemolytic Hepatocellular Obstructive
Cause Destruction of RBCs Liver dysfunction Outflow obstruction
Color Lemon yellow Orange yellow Olive green
Bilirubin Indirect Direct& idirect Direct
Associations Evidence of hemolysis Picture of LCF Pruritus

Other evidence of obstruction

Urine Darken on standing Dark Frothy dark
Stools Dark Pale Clay colored