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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 11 GI signs
252
Distended abdominal veins
Some differential diagnoses and typical outline evidence
Portal
hypertension
Suggested by: veins radiating out from umbilicus (caput
medusa), ± ascites, ± splenomegaly, other stigmata of
chronic liver disease, venous hum over collaterals
Confirmed by: ultrasound scan appearance of liver,
which is small cirrhotic with dilated portal veins
Inferior
vena cava
obstruction
Suggested by: distended veins with blood flow up from
groin toward chest when compressed and one end
released
Confirmed by: CT abdomen
Superior
vena cava
obstruction
Suggested by: distended veins with blood flow from
chest toward groin when compressed and one end
released
Confirmed by: CT thorax
ABDOMINAL BRUISING1
253
Abdominal bruising
Also consider the general causes of bruising as indicated in the general
examination findings.
Some differential diagnoses and typical outline evidence
Retroperitoneal
hemorrhage
e.g., in acute
pancreatitis
Suggested by: abdominal tenderness and rigidity and
bruises in and around the umbilicus (Cullen’s sign) or
on one or both flanks (Grey Turner’s sign)
Confirmed by: iserum amylase, CT abdomen
Ruptured or
dissecting
abdominal
aortic aneurysm
Suggested by: hypotension and abdominal pain,
tenderness, and rigidity, and bruises in and around the
umbilicus (Cullen’s sign) or on one or both flanks
(Grey Turner’s sign). Expansive pulsatile mass >3 cm
diameter and can hear bruit over the mass
Confirmed by: abdominal ultrasound or CT abdomen
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
254
Poor abdominal movement
From the sitting position, watch and ask about any areas of tenderness
and begin furthest away, palpating gently while looking at the patient’s
face to see if there is any reaction. “Rigidity” is when there is no initial
lack of resistance but reflex rigidity from the outset.
Some differential diagnoses and typical outline evidence
Small bowel
obstruction
(“flatus” again)
Suggested by: mild distension, early vomiting, central
and high abdominal pain, resonant percussion, and
increased bowel sounds. Supine
AXR shows central
gas but no peripheral abdominal large bowel shadow
(i.e., without haustra partly crossing) but valvulae
conniventes of small intestine crossing the entire
lumen. Fluid levels on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Large bowel
obstruction
(“flatus” again)
Suggested by: severe distension, late vomiting, visible
peristalsis, resonant percussion, and increased bowel
sounds. Supine AXR shows peripheral abdominal
large-bowel shadow (with haustra partly crossing the
lumen). Fluid levels on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Peritonitis
from perforated
stomach,
duodenum,
diverticulum;
intraperitoneal
hemorrhage, or
bowel infarction
Suggested by: decreased or absent abdominal
movement, generalized tenderness and rigidity,
absent bowel sounds, and board-like rigidity
Confirmed by: erect AXR or CXR showing free gas
under diaphragm and laparotomy
1
255
Localized tenderness in the
hypogastrium (suprapubic area)
Some differential diagnoses and typical outline evidence
Acute bladder
distension
(due to prostatic
hypertrophy in
males)
Suggested by: suprapubic mass (cannot get below),
dull to percussion
Confirmed by: bladder ultrasound scan, urethral
catheterization and drainage of high volume of urine
(e.g., >1 liter)
Cystitis Suggested by: frequency of urine, dysuria, turbid urine,
hematuria on dipstick
Confirmed by: excess WBC and organisms on micro-
scopy and growth of significant bacterial colonies on
urine culture
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CHAPTER 11 GI signs
256
Localized tenderness in the right
upper quadrant (RUQ)
Guarding is when there is reflex rigidity on palpation.
Some differential diagnoses and typical outline evidence
Acute
cholecystitis
Suggested by: fever, guarding and positive Murphy’s sign
(abrupt stopping of inspiration when the palpating
hand meets the inflamed gallbladder descending with
the liver from behind the subcostal margin on the right
side—but not on the left side)
Confirmed by: ultrasound gallbladder and biliary ducts
Acute alcoholic
hepatitis
Suggested by: history of recent drinking binge, tender
hepatomegaly, jaundice
Confirmed by: rise and fall in liver function tests to
coincide with binge, negative hepatitis serology
Acute viral
hepatitis A
Suggested by: negative history of recent binge drinking,
fever, tender hepatomegaly, jaundice
Confirmed by: positive hepatitis serology A, B C,
D, or E
Acute liver
congestion
Suggested by: tender hepatomegaly, iJVP, leg edema
Confirmed by: CXR showing large heart, liver
ultrasound showing distension
LOCALIZED TENDERNESS IN THE LEFT UPPER QUADRANT (LUQ)1
257
Localized tenderness in the left
upper quadrant (LUQ)
Some differential diagnoses and typical outline evidence
Pyelonephritis Suggested by: fever, rigor, vomiting, groin pain,
tenderness at costovertebral angle (CVA), iWBC
proteinuria, hematuria, leukocytes on urine testing
Confirmed by: above clinical picture and significant
growth of organisms on urine culture. Ultrasound scan
for possible anatomical abnormality
Splenic
rupture Suggested by: history of trauma, plain AXR showing loss
of left psoas shadow, peritoneal tap demonstrates free
blood
Confirmed by: CT scan and laparotomy
Splenic infarct Suggested by: presence of predisposing cause,
especially sickle cell disease and crisis
Confirmed by: CT abdomen
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
258
Localized tenderness in the epigastrium
or central abdomen
Some differential diagnoses and typical outline evidence
Gastritis Suggested by: epigastric pain, dull or burning discomfort,
nocturnal pain
Confirmed by: esophagogastroscopy, barium meal
and pH study
Duodenal ulcer Suggested by: epigastric pain, dull or burning
discomfort, typically relieved by food, nocturnal pain
Confirmed by: esophagogastroscopy, barium meal
and pH study. Helicobacter pylori present in mucosa
or serology
Gastric ulcer Suggested by: epigastric pain, dull or burning discomfort,
typically exacerbated by food
Confirmed by: esophagogastroscopy, barium meal and
pH study
Pancreatitis Suggested by: rigidity or guarding ± bruises, e.g., Cullen
or Grey Turner’s signs
Confirmed by: iserum amylase, CT pancreas
showing enlargement by cyst or pseudocyst
Small bowel
infarction
Suggested by: abdominal distension, absent bowel
sounds. Predisposing cause, e.g., atrial fibrillation,
extensive atheroma in diabetes
Confirmed by: AXR showing dilated loop of small bowel
with valvulae conniventes but no large bowel (with
haustra, etc.)
Ruptured or
dissecting
abdominal
aortic
aneurysm
Suggested by: hypotension and abdominal pain,
tenderness and rigidity, bruises in and around the
umbilicus (Cullen’s sign) and on one or both flanks
(Grey Turner’s sign). Expansive pulsatile mass >3 cm
in diameter and can hear bruit over the mass
Confirmed by: abdominal ultrasound or CT abdomen
LOCALIZED TENDERNESS IN THE LEFT OR RIGHT LOIN1
259
Localized tenderness in the left
or right loin
Some differential diagnoses and typical outline evidence
Pyelonephritis Suggested by: fever, rigor, vomiting, groin pain,
tenderness at renal angle, iWBC proteinuria,
hematuria, leukocytes on urine testing
Confirmed by: clinical picture and significant growth of
organisms on urine culture. Ultrasound scan for
possible anatomical abnormality
Renal calcul
ll
lus Suggested by: colicky pain beginning in loin and
radiating down to lower abdomen. Tenderness at renal
angle
Confirmed by: hematuria, dilated ureter on renal
ultrasound, filling defect on IVU
Ruptured or
dissecting
abdominal
aortic
aneurysm
Suggested by: hypotension and abdominal pain,
tenderness and rigidity, bruises in and around the
umbilicus (Cullen’s sign) and on one or both flanks
(Grey Turner’s sign). Expansive pulsatile mass >3 cm
in diameter, bruit over the mass
Confirmed by: abdominal ultrasound or CT abdomen
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
260
Localized tenderness in left or right
lower quadrant
Some differential diagnoses and typical outline evidence
Appendicitis Suggested by: abdominal pain, then localized to right
(rarely left in situs inversus) lower quadrant, fever,
guarding, positive Rovsing’s sign (tenderness on contra-
lateral side), psoas sign (pain from passive extension of
right hip), adductor pain (pain on passive internal
rotation of flexed thigh); anterior tenderness on rectal
examination
Confirmed by: macroscopic and microscopic
appearances at laparotomy
Diverticulitis Suggested by: left iliac fossa tenderness ± tender mass
Confirmed by: flexible sigmoidoscopy, barium enema
Ureteric
calculus
Suggested by: colicky pain with radiation to lower
abdomen, microscopic or frank hematuria
Confirmed by: ureteric dilation on renal ultrasound,
filling defect on IVU
Mesenteric
adenitis
Suggested by: symptoms and signs similar to those for
early appendicitis but without guarding or rectal
tenderness
Confirmed by: clinical findings or made at laparotomy or
laparoscopy
Salpingitis Suggested by: severe adnexal tenderness, cervical
motion tenderness, cervical discharge
Confirmed by: cervical swab culture, laparoscopy
Ectopic
pregnancy
Suggested by: enlarged uterus (but often small for
dates), vaginal bleeding, faintness or shock in acute
rupture
Confirmed by: pregnancy test positive, mass on biman-
ual examination. Pelvic ultrasound shows empty uterus
with thickened decidua
HEPATOMEGALY—SMOOTH AND TENDER1
261
Hepatomegaly—smooth and tender
Some differential diagnoses and typical outline evidence
Right heart
failure
from
pulmonary
hypertension
acutely due to
pulmonary
embolus
Suggested by: iJVP, leg edema
Confirmed by: large heart on CXR and associated large
pulmonary arteries or pulmonary edema if congestive
heart failure (CHF)
Alcoholic
hepatitis
Suggested by: history of drinking binge, iMCV,
jaundice
Confirmed by: abnormal liver function tests: iAST:
iALP, liver biopsy later
Infectious
hepatitis
Suggested by: sharp edge, no or slight splenomegaly,
jaundice
Confirmed by: abnormal liver function tests,
hepatitis A serology positive
Glandular fever
(infectious
mononucleosis)
Suggested by: cervical lymphadenopathy, sharp edge, ±
splenomegaly, ± jaundice
Confirmed by: Paul–Bunnell, positive heterophil
antibody test
Right heart
failure
due to tricuspid
regurgitation
Suggested by: pulsatile liver, ± jaundice, iJVP with
prominent v waves, systolic murmur louder
on inspiration
Confirmed by: echocardiography
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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