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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
262
Hepatomegaly—smooth but not
tender
Some differential diagnoses and typical outline evidence
Cirrhosis of the
liver (early + fatty
change)
Suggested by: firm, round edge, ± splenomegaly,
other stigmata of chronic liver disease (e.g.,
spider nevi)
Confirmed by: small liver with abnormal parenchyma
on liver ultrasound and biopsy appearance
Lymphoma Suggested by: generalized lymphadenopathy,
splenomegaly
Confirmed by: lymph node biopsy, bone marrow
biopsy, CT thorax/abdomen
Leukemia Suggested by: anemia, lymphadenopathy,
splenomegaly
Confirmed by: abnormal WBC on blood film,
bone marrow examination
Hemochromatosis Suggested by: bronze skin pigmentation, evidence of
diabetes mellitus, cardiac failure, arthropathy
Confirmed by: elevated serum ferritin (>500 μg/L),
liver biopsy with hepatic iron measurement
Primary biliary
cirrhosis
Suggested by: xanthelasmata and xanthomas, scratch
marks, arthralgia, ± splenomegaly
Confirmed by: positive antimitochondrial antibody,
iserum IgM, liver biopsy
Amyloidosis
primary or
secondary to
chronic
inflammation
Suggested by: evidence of underlying chronic infective
disease if secondary
Confirmed by: biopsy of rectal mucosa, stained with
Congo red dye
HEPATOMEGALY—IRREGULAR, NOT TENDER1
263
Hepatomegaly—irregular, not tender
Some differential diagnoses and typical outline evidence
Metastatic
carcinoma
Suggested by: hard, ±
nodular, cachexia.
Confirmed by: liver ultrasound ± biopsy
Hepatoma Suggested by: firm, nodular edge, ± arterial bruit
iserum AFP
Confirmed by: α-fetoprotein i, liver ultrasound and
biopsy
Hydatid cyst Suggested by: sometimes hard, nodular
Confirmed by: liver ultrasound showing cyst and
daughter cysts inside, eosinophilia, serology
(Echinococcus granulosus), Casoni intradermal test.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
264
Splenomegaly—slight (< 3 fingers)
The spleen enlarges diagonally downward toward the RLQ. Begin there
so as not to miss the edge of massive enlargement.
Some differential diagnoses and typical outline evidence
Glandular fever Suggested by: cervical lymphadenopathy, hepatomegaly
with sharp edge
Confirmed by: Paul–Bunnell, positive heterophil
antibody test (monospot)
Brucella
Suggested by: occupation, e.g., farmer, hepatomegaly
Confirmed by: Brucella serology
Hepatitis A, B,
C, or D
Suggested by: jaundice, tender hepatomegaly,
lymphadenopathy
Confirmed by: abnormal liver function tests, hepatitis A,
B, C, and D serology
Bacterial
endocarditis
Suggested by: splinter hemorrhages, heart murmur,
anemia, microscopic hematuria
Confirmed by: blood cultures, transesophageal
echocardiography
Amyloidosis
primary or
secondary to
chronic
inflammation
Suggested by: evidence of underlying chronic infective
disease if secondary
Confirmed by: biopsy of rectal mucosa, stained with
Congo red dye
Hemolytic
anemia
Suggested by: anemia, jaundice
Confirmed by: CBC showing reticulocytosis, anemia,
liver function tests showing i unconjugated bilirubin,
haptoglobin
SPLENOMEGALY—MODERATE (3–5 FINGERS)1
265
Splenomegaly—moderate (3–5 fingers)
Some differential diagnoses and typical outline evidence
Lymphoma Suggested by: generalized lymphadenopathy,
non-tender hepatomegaly
Confirmed by: lymph node biopsy, bone marrow
biopsy, CT thorax/abdomen
Chronic
leukemia
Suggested by: lymphadenopathy, non-tender
hepatomegaly
Confirmed by: abnormal CBC and blood film, bone
marrow examination
Cirrhosis ±
portal
hypertension
Suggested by: hard, round edge, ± hepatomegaly, other
stigmata of chronic liver disease
Confirmed by: small nodular liver on ultrasound
± biopsy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
266
Splenomegaly—massive (> 5 fingers)
The spleen enlarges diagonally downward toward the RLQ. Begin there
so as not to miss the edge of massive enlargement.
Some differential diagnoses and typical outline evidence
Chronic
myeloid
leukemia
Suggested by: variable hepatomegaly, bruising, anemia
Confirmed by: presence of Philadelphia chromosome,
BCR-ABL fusion mRNA or BCR-ABL protein
Myelofibrosis Suggested by: anemia, ± hepatomegaly,
± lymphadenopathy
Confirmed by: bone marrow tap is usually dry, bone
marrow biopsy shows fibrosis
Malaria Suggested by: anemia, jaundice, hepatomegaly,
paroxysmal rigors
Confirmed by: thick and thin blood films showing
Plasmodium
Kala-azar
(visceral
leishmaniasis)
Suggested by: pancytopenia, hepatomegaly
Confirmed by: demonstration of Leishmania donovani in
Giemsa-stained smears, specific serological test
BILATERAL MASSES IN UPPER ABDOMEN1
267
Bilateral masses in upper abdomen
The lower half of a normal right kidney is often palpable. A renal mass is
bimanually ballotable and moves slightly downward on inspiration.
Some differential diagnoses and typical outline evidence
Polycystic renal
disease
Suggested by: masses are bimanually ballotable,
hypertension
Confirmed by: ultrasound/CT kidneys
Amyloidosis,
primary or
secondary to
chronic
inflammation
Suggested by: evidence of underlying chronic infective
disease
Confirmed by: biopsy of kidney or rectal mucosa,
stained with Congo red dye
Bilateral
hydronephroses
Suggested by: masses bimanually ballotable, renal
impairment
Confirmed by: dilated ureters ± renal calyces on
abdominal ultrasound
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
268
Unilateral mass in right or left upper
quadrant
Some differential diagnoses and typical outline evidence
Renal
carcinoma
Suggested by: hematuria, fever of unknown origin
(FUO), ± polycythemia
Confirmed by: renal ultrasound/CT with biopsy
Unilateral
hydronephrosis
Suggested by: no other symptoms and signs except
bimanually ballotable mass
Confirmed by: unilateral dilated ureter ± renal calyx on
abdominal ultrasound
Renal cyst Suggested by: tense, fluctuant feel
Confirmed by: cyst on abdominal ultrasound
Distended gall
bladder
(on right side)
Suggested by: right-sided pear-shaped, rounded mass
that continues with the liver above (Courvoisier’s
sign—implies extrahepatic biliary obstruction)
Confirmed by: ultrasound of gallbladder and biliary
ducts
MASS IN EPIGASTRIUM (± UMBILICAL AREA)1
269
Mass in epigastrium (± umbilical area)
Some differential diagnoses and typical outline evidence
Gastric
carcinoma
Suggested by: anorexia, weight loss over weeks to
months, hard, irregular mass, left supraclavicular node
(Virchow’s node giving Troisier’s sign)
Confirmed by: gastroscopy with biopsy
Carcinoma of
pancreas
Suggested by: progressive painless jaundice
± abdominal or back pain later
Confirmed by: ERCP or MRCP
Aortic
aneurysm
Suggested by: >3 cm in diameter, pulsatile swelling with
bruit
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
270
Mass in right lower quadrant (RLQ)
Some differential diagnoses and typical outline evidence
Appendix mass Suggested by: recent history of fever and right iliac
fossa (RIF) pain
Confirmed by: ultrasound or CT abdomen and
finding at laparotomy
Crohn’s
granuloma
Suggested by: aphthous ulcers, wasting, anemia, tender
mass, scars of previous surgery, anal fissures, fistulae
Confirmed by: barium follow-through and small bowel
enema, colonoscopy with biopsy
Carcinoma of
cecum
Suggested by: asymptomatic RIF mass, iron-deficiency
anemia
Confirmed by: colonoscopy with biopsy
Transplanted
kidney
Suggested by: obvious history of transplant and scar
over mass, usually in iliac fossa
Confirmed by: abdominal ultrasound
Other causes:
intussusception,
carcinoma of
ascending colon,
cecal volvulus
MASS IN HYPOGASTRIUM (SUPRAPUBIC REGION)1
271
Mass in hypogastrium (suprapubic
region)
Some differential diagnoses and typical outline evidence
Distended
bladder
Suggested by: suprapubic dullness, resonance in flank,
tender mass, and acute retention of urine
Confirmed by: mass disappears on bladder ultrasound
scan and catheterization, abdominal/pelvic ultrasound
Pregnant uterus Suggested by: suprapubic dullness, resonance in flank
Confirmed by: pregnancy test positive, bimanual
examination, abdominal/pelvic ultrasound scan
Uterine fibroid Suggested by: asymptomatic, hard, rounded,
non-tender mass on bimanual palpation
Confirmed by: pelvic examination and ultrasound
Uterine
neoplasm
Suggested by: postmenopausal bleeding, blood-stained
vaginal discharge, irregular bleeding
Confirmed by: pelvic examination and pelvic ultrasound
Ovarian cyst Suggested by: tense, fluctuant feel, fluid thrill if cyst is
large
Confirmed by: pelvic examination and ultrasound of
ovary
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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