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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
272
Mass in left lower quadrant (LLQ)
Some differential diagnoses and typical outline evidence
Diverticular
abscess
Suggested by: fever, tender mass
Confirmed by: ultrasound or CT abdomen/pelvis
Carcinoma of
descending or
sigmoid colon
Suggested by: hard mass, not tender
Confirmed by: barium enema, colonoscopy with
biopsy
Fecal
impaction
Suggested by: paucity of bowel movement and
constipation. AXR shows stippled pattern of fecal
loading
Confirmed by: resolution of swelling with evacuation or
partly with flatus tube
CENTRAL DULLNESS, RESONANCE IN FLANK1
273
Central dullness, resonance in flank
Some differential diagnoses and typical outline evidence
Distended
bladder
Suggested by: suprapubic mass, tender in acute
retention of urine
Confirmed by: mass disappears on bladder ultrasound
scan and catheterization
Pregnant uterus Suggested by: suprapubic mass
Confirmed by: i serum or urine β-hCG, pelvic or
abdominal ultrasound
Massive ovarian
cyst
Suggested by: tense, fluctuant feel, fluid thrill
Confirmed by: pelvic or abdominal ultrasound
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
274
Shifting dullness
This implies ascites.
Some differential diagnoses and typical outline evidence
Carcinomatosis
with spread to
peritoneum
Suggested by: cachexia
Confirmed by: diagnostic paracentesis including
cytology, liver ultrasound with biopsy
Cirrhosis Suggested by: stigmata of chronic liver disease,
± splenomegaly
Confirmed by: paracentesis, liver ultrasound with
biopsy
Congestive
cardiac failure
Suggested by: iJVP, leg edema, ± tender hepatomegaly
Confirmed by: liver function tests, FBC, diagnostic
paracentesis, CXR
Nephrotic
syndrome
Suggested by: generalized edema including face on
rising from bed
Confirmed by: proteinuria, hypoalbuminemia
TB peritonitis Suggested by: fever, history of tuberculosis,
generalized tenderness
Confirmed by: diagnostic paracentesis including
microscopy, bacterial and AFB cultures
Peritoneal
dialysis
Suggested by: renal failure, continuous ambulatory
peritoneal dialysis (CAPD)
Confirmed by: elevated serum creatinine
SILENT ABDOMEN WITH NO BOWEL SOUNDS1
275
Silent abdomen with no bowel sounds
Some differential diagnoses and typical outline evidence
Peritonitis
e.g., due
to bowel
perforation
Suggested by: decreased or absent abdominal
movement, generalized tenderness with board-like
rigidity
Confirmed by: AXR, erect CXR show gas under
diaphragm
Bowel
infarction
Suggested by: decreased or absent abdominal
movement, generalized tenderness with board-like
rigidity
Confirmed by: AXR, erect CXR show no gas under
diaphragm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
276
High-pitched bowel sounds
Some differential diagnoses and typical outline evidence
Small bowel
obstruction
Suggested by: mild distension, early vomiting, central,
high abdominal pain, resonant percussion, increased
bowel sounds. Supine AXR showing central gas but no
peripheral abdominal large-bowel shadow (i.e., without
haustra partly crossing) but valvulae conniventes of
small intestine entirely crossing the lumen. Fluid levels
on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Large bowel
obstruction
Suggested by: severe distension, late vomiting, resonant
percussion, increased bowel sounds. Supine AXR
showing peripheral abdominal large-bowel shadow
(with haustra partly crossing the lumen). Fluid levels on
erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Adhesions of
bowel
Suggested by: scars, signs of bowel obstruction
Confirmed by: abdominal ultrasound and laparotomy
findings
Tumor in bowel Suggested by: palpable abdominal mass, signs of bowel
obstruction
Confirmed by: abdominal ultrasound and laparotomy
findings
Hernial orifice
strangulation
Suggested by: hernia visible, not reducible, very ill,
peritonism, signs of bowel obstruction
Confirmed by: laparotomy findings
Sigmoid
volvulus
Suggested by: signs of severe bowel obstruction. Supine
AXR showing U-shaped gas shadow
Confirmed by: sigmoidoscopy and reduction with flatus
tube and laparotomy findings
Irritable bowel
syndrome
Suggested by: slight distension, history of abdominal
pain, and small, hard motions
Confirmed by: abdominal ultrasound and spontaneous
resolution
Fecal
impaction
Suggested by: paucity of bowel movement and
constipation. Hard feces on rectal examination. AXR
shows stippled pattern of fecal loading
Confirmed by: resolution of swelling with evacuation or
partly with flatus tube
ABDOMINAL OR GROIN BRUIT1
277
Abdominal or groin bruit
Some differential diagnoses and typical outline evidence
Aortic
aneurysm
Suggested by: systolic bruit in the epigastrium (over
mass), expansive pulsatile swelling
Confirmed by: ultrasound/CT abdomen
Renal artery
stenosis
Suggested by: systolic bruit in the right upper quadrant,
hypertension
Confirmed by: renal arteriography—digital
subtraction angiography
Dissecting aorta Suggested by: tearing abdominal pain radiating to
back and hypotension. Brachial–ankle gradient and
pulse delay
Confirmed by: urgent ultrasound/CT abdomen
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
278
Lump in the groin
Some differential diagnoses and typical outline evidence
Inguinal hernia
Suggested by: origin horizontally just above and medial
to pubic tubercle, impulse on coughing or bearing
down, reducible
Confirmed by: above clinical examination and surgery
Femoral hernia
Suggested by: origin horizontally just below and
lateral to pubic tubercle, cough impulse rarely
detectable, usually irreducible (because of narrow
femoral canal)
Confirmed by: above clinical examination and surgery
Strangulated
hernia
Suggested by: irreducible, tense and tender, red,
followed by symptoms and signs of bowel obstruction
Confirmed by: above clinical examination and surgery
Lymph node
inflammation
Suggested by: enlarged, tender, mobile, nodes, usually
multiple
Confirmed by: above clinical examination
Lymphoma or
secondary
tumor
Suggested by: fixed nodes when infiltrated by tumor
Confirmed by: ultrasound, exploration of groin
Femoral artery
aneurysm
Suggested by: lump lies below the midpoint of the
inguinal ligament, expansive pulsation
Confirmed by: above clinical examination. Duplex
ultrasound scan
Saphena varix
(dilatation of
long saphenous
vein in the
groin)
Suggested by: soft and diffuse swelling that lies below
inguinal ligament, empties with minimal pressure and
refills on release, disappears on lying down, cough
impulse
Confirmed by: above clinical examination
Cold abscess
of psoas sheath
Suggested by: fluctuant tender swelling arising below
the inguinal ligament
Confirmed by: ultrasound, exploration of groin
ANAL APPEARANCE1
279
Anal appearance
The rectal examination (with a chaperone) begins with an examination of
the anus by parting the buttocks with the patient lying in the left lateral
position with knees flexed.
Some differential diagnoses and typical outline evidence
Prolapsed
internal
hemorrhoids
Suggested by: segmental, plum-colored rectal
protrusion
Confirmed by: proctoscopy
Acute anal
fissure
Suggested by: acute pain during defecation, exquisite
anal tenderness. Mucosal fissure with skin tag if chronic
(sentinel pile)
Confirmed by: above history and clinical examination
under anesthesia
Spontaneous
perianal
hematoma
Suggested by: blue-black lump in the skin near the anal
margin
Confirmed by: above history and examination
Perianal
abscess
Suggested by: tender, fluctuant, perianal mass
Confirmed by: above clinical examination
Rectal
prolapse
Suggested by: smooth, elongated rectal protrusion
continuous with anal skin
Confirmed by: above clinical examination
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 11 GI signs
280
Melena on finger
The rectal examination ends by inspecting the fecal smear on the examining
gloved finger for color, especially bright red blood or tarry melena.
Some differential diagnoses and typical outline evidence
Bleeding
duodenal ulcer
Suggested by: epigastric pain and tenderness, nausea
Confirmed by: esophagogastroscopy
Gastric erosion Suggested by: history of NSAIDs or alcohol ingestion,
epigastric pain, dull or burning discomfort, and
nocturnal pain
Confirmed by: esophagogastroscopy, barium meal and
pH study
Gastric ulcer Suggested by: epigastric pain, dull or burning
discomfort, and nocturnal pain
Confirmed by: esophagogastroscopy, barium meal and
pH study
Mallory–Weiss
tear
Suggested by: preceding marked vomiting and later
bright red blood
Confirmed by: esophagogastroscopy
Gastroesoph-
ageal reflux
Suggested by: heartburn, anorexia, nausea, and
± regurgitation of gastric content
Confirmed by: esophagogastroscopy, barium meal and
esophageal pH study
Hiatus hernia Suggested by: heartburn, worsens with stooping or
lying, and relieved by antacids
Confirmed by: esophagogastroscopy, barium meal
False (pseudo)
hematemesis
Suggested by: epistaxis or hemoptysis
Confirmed by: normal esophagogastroscopy and ENT
endoscopy
Esophageal
carcinoma
Suggested by: progressive dysphagia with solids, which
sticks, and weight loss
Confirmed by: barium swallow, fiber-optic gastroscopy
with mucosal biopsy
Gastric
carcinoma
Suggested by: marked anorexia, fullness, pain,
Troisier’s sign (enlarged left supraclavicular lymph
node [Virchow’s node])
Confirmed by: esophagogastroscopy with biopsy
Ingestion of
corrosives
Suggested by: history of ingestion, etc.
Confirmed by: esophagogastroscopy later
MELENA ON FINGER1
281
Esophageal
varices
Suggested by: liver cirrhosis, splenomegaly, prominent
upper abdominal veins
Confirmed by: esophagogastroscopy
Bleeding
diathesis
Suggested by: symptoms or signs of bleeding elsewhere
(or bruising), history of warfarin use, etc.
Confirmed by: abnormal clotting screen and/or low
platelets and/or improvement on withdrawal of a
potentially causal drug (but consider possibility of
another cause)
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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