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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
file:///C|/...illManual%20ColorectalSurgery%201stEdition/Chapter%201_%20Symptoms%20and%20Differential%20Diagnosis.htm[9/5/2009 19:15:13]
– ileus (postoperative)
– internal wrapping of small bowel around ileostomy-bearing small bowel segment
– volvulus
– intussusception
– fecoliths/fecal impaction in small bowel of patients with cystic fibrosis
– gallstone ileus
6. Traumatic/posttraumatic
– blunt abdominal trauma
– abdominal compartment syndrome (post-trauma, post–burn injury, etc)
– retroperitoneal/spinal pathology (hematoma, fracture, etc)
Top of the List
SMALL BOWEL
1. Crohn disease.
2. Adhesions.
3. Small bowel cancer (primary, carcinomatosis).
LARGE BOWEL
1. Cancer.
2. Diverticulitis.
3. Crohn disease.
4. Ischemia.
Keys to Diagnosis
Patient's surgical/medical history: previous abdominal surgeries, tumor, etc.
Clinical examination: patient's general condition, abdominal distention (may be absent if very proximal obstruction),
presence/absence of (tympanitic) bowel sounds, focal/diffuse tenderness to palpation, peritoneal signs, stool in rectal
vault.
Imaging:
– Abdominal x-ray series, chest x-ray: SBO vs LBO, free air, air/fluid levels, gastric dilation, small bowel dilation
(> 2.5 cm) with plicae circulares, transition point, presence of air in the distal colon, distended loops of bowel,
calcifications, pneumobilia.
– CT scan (if possible with oral and IV contrast): small bowel dilation, transition point, extensive mucosal
thickening, intestinal pneumatosis, pneumobilia, portal vein gas, suspicion of closed loop, tumor burden, etc.
– Contrast studies: small bowel follow-through: (a) with barium if chronic partial SBO, (b) diatrizoate
meglumine (Gastrografin) or 50%/50% Gastrografin/barium if more acute partial SBO.
Cross-Reference
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
file:///C|/...illManual%20ColorectalSurgery%201stEdition/Chapter%201_%20Symptoms%20and%20Differential%20Diagnosis.htm[9/5/2009 19:15:13]
Contrast enemas (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
LARGE BOWEL OBSTRUCTION (LBO)
Highlights of the Symptom
Grading: partial LBO, complete LBO.
Localization: anal canal, rectum, left-sided, right-sided.
Associated symptoms: time of last bowel activity, abdominal distention, abdominal pain and cramping, nausea,
vomiting (miserere: feculent vomiting), bleeding, altered bowel habits, urinary tract infections? Dehydration,
hemodynamic instability, sepsis?
Evolution: acute, intermittent, recurrent, chronic.
Underlying systemic disease: Crohn disease, malignancy, cardiovascular disease, history of previous surgeries.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– anorectal malformation: imperforate anus/atresia
– Hirschsprung disease
2. Vascular
– ischemic colonic stricture (peripheral vascular disease, embolic disease, vasculitis)
– radiation injury with stricture formation
– ischemic anastomotic stricture
3. Inflammatory
– Crohn disease
– chronic diverticulitis with stricture formation
– inflammatory anastomotic stricture (eg, leak)
– anal stenosis (postsurgical, chronic diarrhea, Crohn disease, etc)
4. Tumor
– colorectal cancer, anal cancer
– peritoneal carcinomatosis (various primary tumors)
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– desmoid
– lymphoma, mesenchymal tumors
– endometriosis
5. Degenerative/functional
– ileus (postoperative)
– internal wrapping of small bowel around ostomy-bearing large bowel segment.
– intussusception
– hernia (inguinal/ventral/internal)
– colonic pseudoobstruction (Ogilvie syndrome)
6. Traumatic/posttraumatic
– blunt abdominal trauma
– abdominal compartment syndrome (post-trauma, post–burn injury, etc)
– retroperitoneal/pelvic/spinal pathology (hematoma, fracture, etc)
Top of the List
1. Neoplasm.
2. Chronic diverticulitis.
3. Pelvic radiation injury with stricture formation.
4. Anastomotic stricture.
5. Herniation (external, internal).
6. Crohn disease.
Keys to Diagnosis
Patient's surgical/medical history: symptom characterization, previous abdominal/pelvic/anorectal surgeries, tumor,
radiation treatment, etc.
Clinical examination: patient's general condition, abdominal distention, presence of incarcerated hernia,
presence/absence of (tympanitic) bowel sounds, focal/diffuse tenderness to palpation, peritoneal signs, stool in rectal
vault.
Imaging:
– Abdominal x-ray series, chest x-ray: SBO vs LBO, free air, small bowel dilation and air/fluid levels (sign of
incompetent ileocecal valve), large bowel dilatation (> 6 cm in transverse, >12 cm in cecum), transition point,
air in the distal colon, calcifications, pneumobilia.
– CT scan (if possible with oral and IV contrast): large bowel dilation, tumor burden, transition point, extensive
mucosal thickening, intestinal pneumatosis, portal vein gas, nondistended small bowel (
suspicion of closed
loop), etc.
– Contrast studies: water-soluble contrast enema: point of obstruction vs pseudoobstruction?
Cross-Reference
Contrast enemas (Ch. 2)
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Colonoscopic stent placement (Ch. 5)
On-table lavage for primary anastomosis in LBO (Ch. 5)
LUMP OR MASS
Highlights of the Symptom
Localization/point of origin: perianal, rectal, presacral, rectovaginal, abdominal, lymph nodes.
Associated symptoms: obstruction, presence/absence of pain, discharge, incontinence, fever, weight loss, night
sweats, etc.
Time factor: rapid onset, slow progression, on-off, related to menstrual cycle.
Symptom evolution: unchanged, worsening, sporadic, constant, improving.
Appearance: visible lump, preserved epithelial cover, ulceration, erythema, discharge, tenderness.
Severity: benign, malignant.
Underlying systemic disease: known malignancy, IBD, endometriosis, etc.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– cyst
– skin tag
2. Vascular
– cavernous hemangioma
– external hemorrhoid
– thrombosed hemorrhoid
3. Inflammatory
– sentinel skin tag (from chronic anal fissure)
– abscess/fistula opening
– actinomycosis
– gumma
– inflammatory mass (diverticulitis, Crohn disease, appendicitis, etc)
– reactive lymphadenopathy
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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4. Tumor
– hypertrophied anal papilla
– cancer (including regional/distant metastases)
– desmoid
– lymphoma, sarcoma, GIST, other malignant mesenchymal tumors
– benign mesenchymal tumors
– endometriosis
– condyloma, giant condylomata (Buschke-Lowenstein)
5. Degenerative/functional
– hernia
– rectocele/cystocele/vaginal prolapse
6. Traumatic/posttraumatic
– hematoma
Top of the List
ANORECTAL
1. Thrombosed hemorrhoid.
2. Sentinel skin tag.
3. Abscess.
4. Condylomata.
5. Neoplasm.
ABDOMINAL
1. Neoplasm.
2. Hernia.
3. Inflammatory mass (diverticulitis, Crohn disease, appendicitis, etc).
Keys to Diagnosis
ANORECTAL MASS/LUMP
Patient's surgical/medical history: location of the mass, previous surgeries, symptom descriptors, risk factors, risk
behavior.
Clinical examination: exact location, palpation (including inguinal lymph nodes), visualization (including anoscopy,
sigmoidoscopy).
Surgical intervention or biopsy.
Rarely imaging needed: endorectal ultrasound, CT abdomen/pelvis, MRI, etc.
ABDOMINAL MASS/LUMP
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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Patient's surgical/medical history: location of the mass, previous surgeries, previous colonic evaluations, symptom
descriptors, risk factors.
Clinical examination: patient's general condition, abdominal scars, ostomy, hernia, tenderness to palpation, peritoneal
signs, stool in rectal vault, palpable mass, organomegaly.
Imaging: CT scan, abdominal ultrasound.
Cross-Reference
Hemorrhoids (455.X) (Ch. 4)
Perianal/-rectal abscess (566) (Ch. 4)
Anal condylomata (078.10) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
MEGACOLON
Highlights of the Symptom
Setting: patient's age at presentation, inpatient vs outpatient.
Symptom evolution: acute, chronic progressive, intermittent, recurrent.
Signs of toxicity: fever/sepsis, tachycardia, elevated WBC.
Associated symptoms: abdominal pain and cramping, GI dysfunction (diarrhea, ileus, constipation), mental status
change.
Underlying colonic disease: IBD, C difficile colitis, intestinal ischemia, amebic or other infectious colitis, Ogilvie
syndrome (colonic pseudoobstruction), Hirschsprung disease, Chagas disease.
Comorbidities: immunosuppression, cardiovascular disease, embolic disease, retroperitoneal/mediastinal pathology,
spinal disease.
Probability of being sign of serious disease (liability issue): high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– Hirschsprung disease
2. Vascular
– ischemic colitis
3. Inflammatory
– IBD (ulcerative colitis, Crohn colitis)
– C difficile colitis
– other infectious colitis
4. Tumor
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
file:///C|/...illManual%20ColorectalSurgery%201stEdition/Chapter%201_%20Symptoms%20and%20Differential%20Diagnosis.htm[9/5/2009 19:15:13]
– tumor-related LBO
5. Degenerative/functional
– Ogilvie syndrome
– Chagas disease
– volvulus
6. Traumatic/posttraumatic
– blunt colon trauma
– new spinal cord injury with acute colonic distention
– retroperitoneal/spinal pathology (hematoma, fracture, etc)
Top of the List
ACUTE/TOXIC MEGACOLON
1. Ulcerative colitis.
2. C difficile colitis.
3. Any other acute colitis (infectious, ischemic).
4. Volvulus.
CHRONIC/NONTOXIC MEGACOLON
1. Ogilvie syndrome.
2. Chagas disease (endemic countries).
3. Hirschsprung disease.
Keys to Diagnosis
Patient's surgical/medical history: age at presentation, endemic country, current/recent bowel function, known history
of IBD, recent antibiotic use, previous surgeries (abdominal, cardiovascular, spinal), tumor, etc.
Clinical examination: patient's general condition, hemodynamic stability, extent of abdominal distention, peritoneal
signs.
Imaging:
– Abdominal x-ray series: colonic diameter > 6 cm (1½ vertebral heights) in transverse colon, > 12 cm in
cecum.
– CT scan: colonic diameter, colonic wall thickening, mucosal enhancement, pneumatosis, portal vein gas?
– Contrast studies: contraindicated under acute circumstances.
Cross-Reference
Pseudomembranous/Clostridium difficile colitis (008.45) (Ch. 4)
IBD—ulcerative colitis (556.9) (Ch. 4)
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Pediatrics—congenital aganglionic megacolon (Hirschsprung disease, 751.3) (Ch. 4)
Total abdominal colectomy with end-ileostomy (open) (Ch. 5)
PAIN, ABDOMINAL
Highlights of the Symptom
Localization/point of origin: upper abdomen, periumbilical, lower abdomen, migrating pain, referred pain location.
Associated symptoms: nausea, vomiting, diffuse distention, local bulging, hypotension, respiratory distress, bleeding
(coffee ground, melena), mass/lump, altered bowel habits, constipation, diarrhea, drainage, fevers/chills.
Timing: onset, constant, certain times, certain activity, waking up at night.
Evolution: increasing, decreasing, intermittent, certain time/activity.
Duration of episode: minutes, hours, days, weeks, or more.
Appearance: dull, sharp, on-off.
Maximum: acute, relief through bowel activity, paroxysmal, sporadic.
Underlying systemic disease: tumor, chemotherapy/immunosuppression, radiation, atrial fibrillation, peptic ulcer
disease, kidney stones, etc.
Probability of being sign of serious disease (liability issue): moderate to high.
Pathogenesis-Oriented Differential Diagnosis
1. Malformation
– paraesophageal hernia, upside-down stomach
– ectopic pregnancy
– SBO
– Meckel diverticulum
– pancreas divisum
2. Vascular
– mesenteric ischemia
– myocardial infarction, pulmonary embolism
– ruptured aortic aneurysm
– incarcerated hernia
– splenic infarction
3. Inflammatory
– appendicitis, diverticulitis, pancreatitis, cholecystitis, pyelonephritis
– perforated viscus (peptic ulcer, diverticulitis, etc)
– GYN pathology (adnexal, pelvic inflammatory disease, Fitz-Hugh-Curtis, etc)
– primary bacterial peritonitis
4. Neoplastic
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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– advanced tumor bowel perforation, strangulation, necrosis, obstruction, etc
5. Degenerative/functional
– urinary retention
– volvulus
– intermittent hernia
– IBS
– urolithiasis
– spinal origin
– diabetic pseudoperitonitis, Mediterranean fever, porphyries
– Munchausen syndrome
6. Traumatic/posttraumatic
– blunt/penetrating trauma
– autoeroticism, foreign body
– splenic rupture
– anastomotic leak
Top of the List
ACUTE DIFFUSE PAIN
1. Perforated viscus.
2. Pancreatitis.
3. Urinary retention.
4. Primary bacterial peritonitis.
5. Mediterranean fever, porphyries, hemascos, etc.
ACUTE LOCALIZED PAIN
1. RLQ: appendicitis, Crohn disease, lymphadenitis mesenterica, urolithiasis, Meckel diverticulum, GYN pathology,
hernia.
2. LLQ: diverticulitis, GYN pathology, LBO, urolithiasis, neoplasm, hernia.
3. RUQ: cholecystitis, urolithiasis, peptic ulcer, pyelonephritis, pancreatitis.
4. LUQ: pancreatitis, peptic ulcer disease, paraesophageal hernia, Boerhaave syndrome, splenic rupture, incarcerated
diaphragmatic hernia.
5. Central: incisional pain, hernia, early appendicitis, SBO.
6. Flanks: urolithiasis, pyelonephritis, hydronephrosis, ruptured aortic aneurysm, aortitis, spinal.
CHRONIC PAIN
1. IBS/constipation.
2. Adhesions.
AccessSurgery | Print: Chapter 1. Symptoms and Differential Diagnosis
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3. Chronic diverticulitis.
4. Recurrent (sub-)volvulus or intussusception.
Keys to Diagnosis
Patient history: circumstances of the pain, evolution, associated symptoms? Precursor symptoms? Underlying
diseases? Bowel function? Previous interventions/tests?
Clinical examination: hemodynamic and cardiopulmonary stability, femoral pulses, presence of incarcerated hernia,
diffuse/localized tenderness to palpation, peritoneal signs, involuntary guarding, bowel sounds, etc.
Monitoring: ECG, urine output, etc.
Imaging:
– Upright chest x-ray or left lateral decubitus: evidence of free air?
– Cross-sectional imaging (eg, abdominal ultrasound, CT): evidence of organ pathology?
– Contrast imaging: road map of the pathology.
GI evaluation: EGD, colonoscopy, SBFT, etc.
Surgical exploration?
Cross-Reference
Conventional x-rays (plain films) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
PAIN, PERIRECTAL
Highlights of the Symptom
Localization/point of origin: outside, inside, tailbone, perineum, lateral, radiating.
Associated symptoms: swelling, lump, bleeding, prolapse, altered bowel habits, constipation, diarrhea, drainage,
fevers/chills.
Timing: onset, constant, certain time, certain activity, waking up at night.
Evolution: increasing, decreasing, intermittent, certain time/activity.
Duration of episode: minutes, hours, days, weeks, or more.
Appearance: dull, sharp, on-off.
Maximum: acute, related to bowel activity (during/after), paroxysmal, sporadic.