UDARA MODERN

SPLEENOMEGALY

Definition
Splenomegaly is defined as enlargement of spleen (size >12 cm, as measured by ultrasound along its longer dimension) Poulain et al. classify splenomegaly as:

Moderate splenomegaly, if the largest dimension is between 1120 cm Severe splenomegaly, if the largest dimension is greater than 20 cm

Splenomegaly should not be confused with hypersplenism. The former is a statement about the size of the spleen, and the latter about the spleen's function: these may coexist, or they may not.

Symptoms and signs

Symptoms may include; Abdominal pain Chest pain similar to pleuritic pain when stomach, bladder or bowels are full Back pain Early satiety due to splenic encroachment The symptoms of anemia due to accompanying cytopenia.

Signs of splenomegaly may include ; A palpable left upper quadrant abdominal mass or splenic rub.

It can be detected on physical examination by usingCastell's sign or Traube's spac, but an ultrasound can be used to confirm diagnosis.

Causes
The most common causes of splenomegaly in developed countries are; Infectious mononucleosis Splenic infiltration with cancer cells from a hematological malignancy

Portal hypertension (most commonly secondary to liver disease) Bacterial infections, such as syphilis An infection of the heart's inner lining (endocarditis)

The causes of massive splenomegaly (>1000 g) are much fewer and include:

thalassemia visceral leishmaniasis (kala-azar) schistosomiasis chronic myelogenous leukemia chronic lymphocytic leukemia lymphomas hairy cell leukemia myelofibrosis polycythemia vera Gauchers disease NiemannPick disease sarcoidosis autoimmune hemolytic anemia malaria

ACUTE PERITONITIS

Peritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.

CAUSES
Perforation of part of the gastrointestinal tract Spontaneous bacterial peritonitis (SBP) Disruption of the peritoneum,

Intra-peritoneal dialysis Systemic infections (such as tuberculosis) Leakage of sterile body fluids into the peritoneum, such as blood (e.g., endometriosis, blunt abdominal trauma), gastric juice (e.g., peptic ulcer, gastric carcinoma), bile (e.g., liver biopsy)

Pathology
In normal conditions, the peritoneum appears greyish and glistening; it becomes dull 24 hours after the onset of peritonitis, initially with scarce serous or slightly turbid fluid. Later on, the exudatebecomes creamy and evidently suppurative; in dehydrated patients, it also becomes very inspissated. The quantity of accumulated exudate varies widely. It may be spread to the whole peritoneum, or be walled off by the omentum and viscera. Inflammation features infiltration by neutrophils with fibrino-purulent exudation.

SIGNS AND SYMPTOMS Abdominal pain and tenderness

The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism. The localization of these manifestations depends on whether peritonitis is localized (e.g., appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen.

Collateral manifestations

Diffuse abdominal rigidity ("washboard abdomen") is often present, especially in generalized peritonitis Fever Sinus tachycardia Development of ileus paralyticus (i.e., intestinal paralysis), which also causes nausea vomiting and bloating.

Complications

Sequestration of fluid and electrolytes, as revealed by decreased central venous pressure, may cause electrolyte disturbances, as well as significant hypovolemia, possibly leading to shock andacute renal failure.

A peritoneal abscess may form (e.g., above or below the liver, or in the lesser omentum Sepsis may develop, so blood cultures should be obtained.

The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties.

Gastrointestinal perforation
Gastrointestinal perforation is a complete penetration of the wall of the stomach, small intestine or large bowel, resulting in intestinal contents flowing into the abdominal cavity. Perforation of the intestines results in the potential for bacterial contamination of the abdominal cavity (a condition known asperitonitis). Perforation of the stomach can lead to a chemical peritonitis due to leaked gastric acid. Perforation anywhere along the gastrointestinal tract is a surgical emergency.

Signs and symptoms

Sudden attack of pain in epigastrium to the right of midline in case of perforation of duodenal ulcer. In case of gastric ulcer the pain is in epigastrium. There is history of burning pain in epigastrium,flatulence and dyspepsia. History of drug intake without sufficient food intake may be present. In case of intestinal perforation pain starts from the site of perforation, visceral,and then spreads all over the abdomen. In any case there is board like rigidity of abdomen, tenderness, and rebound tenderness.after sometimes the abdomen becomes silent, heart sounds can be heard all over. Patient stops passing flatus and motion, abdomen is distended. Gastrointestinal perforation results in severe abdominal pain intensified by movement, nausea and vomiting. Later symptoms include fever and or chills.

Causes
Causes include Gastric ulcer , appendicitis, gastrointestinal cancer, diverticulitis, superior mesenteric artery syndrome, trauma, and ascariasis It can be caused by large objects inserted via the anus such as a colonoscope or sexual exploitation. It may also be due to foreign body such as ingested bone (e.g. a fish bone). typhoid fever, NSAID drugs,ingestion of corrosives may also be responsible.In case of small gut especially jejunum ingestion mangoes, mango juice, mango shake etc has been found to result in necrosis of bowel wall followed by perforation

Intestinal obstruction
Intestinal obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency

Signs and Symptoms Depending on the level of obstruction, intestinall obstruction can present with abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation. Intestinall obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischaemia or perforation from prolonged distension or pressure from a foreign body. In small intestinal obstruction the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting occurs before constipation. In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. Causes of small intestine obstruction include:

Adhesions from previous abdominal surgery Hernias containing bowel Crohn's disease causing adhesions or inflammatory strictures Neoplasms, benign or malignant Intussusception in children Volvulus Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and the abdominal aorta

Ischaemic strictures Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects) Intestinal atresia Carcinoid rare, preferred location: ileum

Causes of large intestine obstruction include:

Neoplasms Hernias Inflammatory bowel disease Colonic volvulus (sigmoid, caecal, transverse colon) Adhesion (medicine) Constipation Fecal impaction Fecaloma Colon atresia Intestinal pseudoobstruction Benign strictures (diverticular disease) Endometriosis

Differential diagnoses of bowel obstruction include:

Ileus Pseudo-obstruction or Ogilvie's syndrome Intra-abdominal sepsis Pneumonia or other systemic illness.

Ascites
Ascites term for an accumulation of fluid in the peritoneal cavity. Th emedical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy Signs and Symptoms Mild ascites is hard to notice, but severe ascites leads to abdominal distension.

Patients with ascites generally will complain of progressive abdominal heaviness and pressure as well as shortness of breath due to mechanical impingement on the diaphragm.

Ascites is detected on physical examination of the abdomen by visible bulging of the flanks in the reclining patient ("flank bulging"), "shifting dullness" (difference in percussion note in the flanks that shifts when the patient is turned on the side) or in massive ascites with a "fluid thrill" or "fluid wave" (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).

in portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes due to encephalopathy.

Those with ascites due tocancer (peritoneal carcinomatosis) may complain of chronic fatigue or weight loss Those with ascites due to heart failure may also complain of shortness of breath as well as wheezing and exercise intolerance.\

Causes
The Serum-ascites albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites Causes of high SAAG ("transudate") are:[3]

Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%) Heart failure - 3% Hepatic Venous occlusion: Budd-Chiari syndrome or veno-occlusive disease Constrictive pericarditis Kwashiorkor

Causes of low SAAG ("exudate") are:

Cancer (primary peritoneal carcinomatosis and metastasis) - 10% Infection: Tuberculosis - 2% or Spontaneous bacterial peritonitis Pancreatitis - 1% Serositis Nephrotic syndrome or Protein losing enteropathy Hereditary angioedema[5]

Other Rare causes:

Meigs syndrome Vasculitis

Hypothyroidism Renal Dialysis Peritoneum Mesothelioma

NON ULCER DYSPEPSIA WITH MAL NUTRITION

MODERATE ASCITIS WITH HYPOPROTENEMIA

ACUTE/CHRONIC PERITONITIS