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Abdominal Masses and Hernias. Objectives : the Lecture Had No Slides So, This Teamwork Is from the Raslan’S Notebook

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Abdominal Masses and Hernias. Objectives : the Lecture Had No Slides So, This Teamwork Is from the Raslan’S Notebook Abdominal masses and hernias. Objectives : The lecture had no slides So, this teamwork is from the Raslan’s Notebook Sources : Raslan’s Notebook Color Index : Slides & Raslan’s | Textbook | Doctor’s Notes | Extra Explanation 2 Mind Map Abdominal masses RIGHT UPPER LEFT UPPER EPIGASTRIC RIGHT ILIAC FOSSA LEFT ILIAC FOSSA HYPOGASTRIC QUADRANT MASS QUADRANT MASS MASSES MASSES MASSES MASSES Hernias INGUINAL FEMORAL UMBILICAL AND INCISIONAL EPIGASTRIC RARE EXTERNAL METHODS OF PARAUMBILICAL HERNIA HERNIA HERNIA HERNIA HERNIA HERNIAS HERNIA REP AIR 3 RIGHT UPPER QUADRANT MASS HEPATIC MASSES: GALLBLADDER MASSES • Congestive heart failure • Mucocele: Containing Mucus • Macronodular cirrhosis • Empyema: Containing pus • Hepatitis • Courvoisier law: • Hepatoma or secondary carcinoma If the gallbladder is palpable and the patient is Jaundiced, the • Hydatid cyst obstruction of the common bile duct causing the Jaundice is DDx • Liver abscess unlikely to be a stone because the previous inflammation will have • Riedel’s lobe: an extension of the right lobe down below made the gallbladder thick and non-distensible the costal margin along the anterior axillary line • Can’t go above it, and moves with respiration • Moves with respiration • Dull to percussion up to the level of the 8th rib in the • Not dull because it is covered by the colon midaxillary line • It can be balloted i.e. felt bimanually • Edge: Sharp or rounded Sings Physical • Surface: Smooth or irregular LEFT UPPER QUADRANT MASS SPLEEN ENLARGED LEFT KIDNEY • Typhoid • Myeloid and lymphatic leukemia • Tuberculosis • Spherocytosis • Syphilis • Thrombocytopenia purpura • Glandular fever • Portal hypertension DDx • Malaria • True solitary cyst • Ka lazar • Hydatid cyst • Lymphoma • Appears from below the costal margin and enlarges towards the umbilicus 4 • Firm, smooth and has a defined notch on its upper edge • Cannot get above it, and dull on percussion Sings Physical EPIGASTRIC MASSES Cause CARCINOMA OF THE STOMACH PANCREATIC PSEUDOCUST • Abdominal pain/mass • Collection of pancreatic secretion, caused by pancreatitis, • Indigestion on the surface of the pancreas or in part of the whole lesser • Loss of weight and appetite sac. DDx • There is history of acute pancreatitis followed by epigastric fullness, pain, nausea and sometimes vomiting. • When palpable it is hard and irregular and • Firm mass in the epigastric region with indistinct lower disappears below the costal margin i.e. cannot edge. get above it • The upper limit is not palpable. • Moves with respiration • Usually resonant because it is covered by the stomach • Moves very slightly with respiration Physical Sings RIGHT ILIAC FOSSAMASSES APPENDICULAR MASS APPENDICULAR ABSCESS TUBERCULOSIS • Central abdominal pain • As for appendicitis with additional • Inflamed ileocecal lymph nodes, parts of shifting to the right iliac fossa symptoms of an abscess such as and the terminal ileum and the cecum associated with nausea, fever, rigors, sweating and • Vague chronic central pain for months DDx vomiting and loss of appetite increased local pain • General ill health and weight loss • The pain eventually becomes intense and settles in the iliac fossa • Tender indistinct mass, dull to • A tender mass which in its late • The mass is firm, distinct and hard percussion and fixed to the stages may fluctuate and be • It is not tender and does not resolve with right iliac fossa posteriorly. associated with edema and observation reddening of the overlying skin Physical Sings 5 Continued: RIGHT ILIAC FOSSA MASSES CHRON’S DISEASE PSOAS ABSCESS OTHERS • Recurrent episodes of pain in the • General ill feeling for months, night • Cecal carcinoma right iliac fossa, malaise, loss of sweats and weight loss • Actinomycosis DDx weight and episodes of diarrhea • Ruptured epigastric artery and melena. • Iliac lymphadenopathy • Iliac artery aneurysm • The elongated terminal ileum • Soft, tender, dull and compressible forms an elongated sausage- • There may be fullness in the lumbar shaped mass which is rubbery and region tender. • The swelling extends below the groin and it may be possible to Physical Sings empty the swelling. LEFT ILIAC FOSSA MASSES DIVERTICULITIS CARCINOMA OF THE SIGMOID COLON OTHERS • Recurrent lower abdominal pain and • General cachexia • Chron’s disease chronic constipation for years • Lower abdominal pain associated with • Psoas abscess • The acute episodes starts suddenly with rectal bleeding DDx severe pain, nausea, loss of appetite and • Change in bowel habits and sometimes (Same masses of the right constipation intestinal obstruction iliac fossa ) • Tender indistinct mass, with sings of • Hard mass, non tender general or local peritonitis • May be mobile or fixed • The colon above the mass may be distended with indentable feces Physical Sings 6 HYPOGASTRIC MASSES URINARY BLADDER FIBROIDS PREGNANT UTERUS • Acute retention: the bladder is full and • They cause irregular and heavy • The uterus enlarges to the tender. periods, disturbed micturation, lower xiphisternum by the 36th DDx • Chronic retention: Painless abdominal pain and backache week of pregnancy, at this • History of prostatism stage the fetus is palpable • A pregnant uterus is smooth, • Arises out of the pelvis and so it has no • Arises out of the pelvis and so the firm and dull lower edge lower edge is not palpable • Not mobile and dull to percussion • Firm or hard, moves slightly in • Direct pressure often produces a desire transverse direction and dull on to micturate. percussion Physical Sings 7 ABDOMINAL HERNIA • DEFINITION: • COMPOSITION: • An abnormal protrusion of intra-abdominal contents through a defect in ü The sac: diverticulum of peritoneum consisting the abdominal wall. of a mouth, neck, body and fundus • Protrusion of a viscus or part of it through an opening in the wall of its ü The body: varies in size and is not necessarily containing cavity. occupied • Abdominal hernias have a peritoneal sac, the neck of which is often ü The coverings: derived from the layers of the unyielding and constitutes a potential source of compression of the abdominal wall hernial contents ü The contents: may be omentum, bowel, ovary, • ETIOLOGY bladder... Etc • CONGENITAL DEFECTS: • COMMON CLINICAL PRESENTATION • Indirect inguinal hernia, umbilical hernia OF ABDOMINAL WALL HERNIA: • Patent processes vaginalis: almost always causes indirect inguinal hernia ü Swelling • ACQUIRED ü Reduction ü Site • Loss of tissue strength and elasticity, due to aging or repetitive stress: ü hiatal hernia • ABDOMINAL WALL SITES: • Operative Trauma, in which normal tissue strength is altered surgically: ü Mid-line ü incisional hernia ü Umbilical area • Increased intra-abdominal pressure: ü Inguinal region ü Heavy lifting ü Femoral canal ü Coughing, asthma, and COPD ü Para-median lineObturator ü Straining at defecation or urination (e.g. Benign prostatic ü Lumber area hypertrophy, constipation, colon/rectal cancer) ü Obturator foramen ü Multiparity (Multiple pregnancies) ü Incisional or scar line ü Ascites and abdominal distension o Obesity 8 REDUCIBLE The contents of the sac are reduced spontaneously or manually • Trapped or imprisoned • Initially it is reducible, then it becomes irreducible => cannot be reduced (either INCARCERATED spontaneously or manually). IRREDUCIBLE • Does not denote obstruction • Blood supply remains intact The contents • Nausea, vomiting, and symptoms of bowel obstruction (possible). remain constantly • Contains obstructed intestine outside OBSTRUCTED • Small intestine obstruction presents with pallor and vomiting • Large intestine obstruction presents with distention and constipation • Blood supply remains intact IRREDUCIBLE • A surgical emergency • Likely in hernias with narrow necks The contents • Blood supply is seriously impaired rendering the contents ischemic i • Gangrene may occur within 5-6 hours after the inset of symptoms remain • Symptoms of an incarcerated hernia present combined with a toxic appearance. constantly • Strangulation is probable if pain and tenderness of an incarcerated hernia IRREDUCIBLEoutside • persist after reduction. STRANGULATED • The femoral hernia is the most liable to strangulation due to its narrow neck and its The contents rigid surroundings i remain constantly • The constricting agents that compress the blood supply are: (In order of frequency) outside ü The Neck CLASSIFICATION ü External ring in children ü Adhesions with the sac (rare) Symptoms ü Sudden pain over the hernia o Nausea and vomiting ü Signs ü Tense and tender ü Absent cough impulse (non expansile) INFLAMED Rare , due to inflammation on the sac contents, e.g. acute appendicitis or Salpingitis 9 SURGICAL ANATOMY (Just for your information) • Superficial ring: triangular aperture in the external •In males, it contains oblique aponeurosis 1.25 cm above the pubic tubercle üThe ilioingunal nerve • Deep ring: U-shaped condensation of the transversalis üThe spermatic cord and its contents, which are fascia 1.25 cm above the inguinal ligament oGenital branch of the genitofemoral nerve • The inguinal canal: oTesticular artery üIn infants the two triangular aperture are oPampiniform plexus of veins superimposed and the canal is slightly oblique oCremasteric muscle fibers üIn adults it is 3.75-4 cm long oCremasteric vessels üIn females, it contains the round ligament of the oVas deferens uterus Contains the spermatic cord and round •Boundaries of the inguinal canal ligament of the uterus üAnteriorly: external oblique aponeurosis üPosteriorly: facia transversalis and conJoined
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