Surgery CP-Final (PRINT)

Surgery- CP
Abdominal Distension/Swelling
Diffuse Abdominal
distension
Other e.g. Foetus,

Fat Fluid Faeces and flatus large ovarian cyst,
fibroid uterus
<500 > 500 > 500

leukocytes/mcL leukocytes/mcL leukocytes/mcL
< 250 PMN > 250 PMN Mainly lymphocytes
SAAG * >1.1 mg/dl

SAAG < 1.1mg/dl Bacterial peritonitis TB peritonitis
Portal hypertension
Peritoneal
Hepatic congestion Malignancy
carcinomatosis
Nephrotic
Liver disease
syndrome
Portal vein Connective tissue

occlusion disease
Other e.g.
Hypothyroidism pancreatic, ovarian
disease
* SAAG serum ascites albumin gradient
Abdominal swelling is a common presenting complaint. There is a wide differential diagnosis and a
systematic approach is important.
Ask for:
How rapidly did the swelling occur or progress (sudden or gradual onset)?
Look for:
Shape of abdomen
Abdominal tenderness, presence of guarding or rebound
Abdominal masses on palpation or percussion
Presence of ascites (shifting dullness, fluid thrill, full flanks, dull on percussion, slit-like
umbilicus)
Bowel sounds hyperactive and tinkling suggests acute bowel obstruction, absence suggests
ileus
Hernial orifices for obstructed hernia
Scrotal examination if no testes in scrotum consider intra-abdominal testicular malignancy.
Investigations will be guided by further history and examination (see later in schema).
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Surgery- CP
Diffuse abdominal
distension
Faeces and flatus e.g. Other e.g. foetus,

Fat Fluid bowel obstruction, large ovarian cyst,
constipation, fibroid uterus
Ask for:
Was distension sudden or gradual in onset?
o over many years in an obese person suggests fat
o over a period of weeks or months suggests fluid
o distension that comes and goes suggest flatus or constipation
Associated pain rapid onset of pain with a history of not passing faeces or flatus for many
hours or days, suggests acute abdominal obstruction.
Bowel function
o Absolute constipation (not passing faeces or flatus) acute obstruction
o Hard infrequent stools suggests distension may be due to retained faeces
o Diarrhoea and bloating (gasesous distension) may be due to infection such as giardia
o Altered bowel habit, often diarrhoea and dull abdominal pain s/o malignancy
o Alternating diarrhoea and constipation s/o TB or constipation and overflow
Blood in stool s/o Bowel malignancy
Red-currant jelly stool in the younger child this suggests obstruction due to intussusception
Associated nausea and vomiting suggests bowel obstruction, or sometimes constipation
Urine output (decreased in acute renal failure and nephritic syndromes)
Blood in urine (nephritic syndrome)
History of chronic alcohol consumption suggests ascites due to liver cirrhosis and portal
hypertension, or acute pancreatitis
Known Hep B or Hep C infection leading to liver dysfunction and ascites
History of previous surgery possible adhesions leading to bowel obstruction, or recent
surgery leading to ileus (absence of peristalsis so flatus and faeces accumulate)
Shortness of breath and generalized oedema generalized fluid retention e.g. due to heart
failure or nephrotic syndrome with associated ascites.
History of trauma haemoperitoneum (blood in abdomen)
Fever, weight loss TB of abdomen or malignancy with ascites
Contact with patients with active TB
Age of patient (e.g. malignancy common in older people)
Previous history of abdominal problems
Last menstrual period in women of child bearing age possible unrecognised pregnancy
Heavy menstrual bleeding s/o uterine fibroids
Passage of ascaris worms in stool cause of intestinal obstruction in children
Look for:
Pulse, blood pressure, temperature, respiratory rate
General appearance of patient
o Anaemia
o BMI severe obesity
o Jaundice, clubbing, spider naevi, palmar erythema s/o liver failure which may lead to
portal hypertension as a cause of ascites
o Pallor, cachexia, lymphadenopathy s/o malignancy
o Obesity s/o abdominal swelling due to fat only
o Cushingoid appearance (get central obesity, striae on abdomen, moon face)
Firm lymph nodes in left supraclavicular or inguinal region, or metastatic deposits around
umbilicus suggest intra-abdominal malignancy
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Surgery- CP
Abdominal appearance
o Tense distended abdomen suggests massive ascites or acute obstruction
o Generalized fatty abdomen suggests fat
o Dilated abdominal veins suggests portal hypertension
o Scars from previous surgery (possible adhesions, recurrence of a malignancy)
Abdominal tenderness especially any generalized guarding or rebound which suggests acute
perforation requiring urgent surgery
Localized masses on palpation (suggestive of tumour or organomegaly)
Fluid thrill, Shifting dullness, slit-like umbilicus (ascites or free fluid in abdomen)
Bowel sounds hyperactive, tinkling sounds (acute obstruction).
Rectal examination for any masses or to see if loaded with faeces.
Scrotal examination (look for empty scrotum s/o testicular intra-abdominal malignancy).
Examination of groins to look for incarcerated hernia leading to obstruction
Raised JVP (congestive heart failure or constrictive pericarditis)
Basal crepitations, heart murmurs (cardiac cause)
PV examination if suspicion of large ovarian mass, fibroid uterus or ruptured ectopic
Foetal parts, foetal heart beat, foetal movements
Investigations:
CBC for anaemia, infection
ESR for evidence of malignancy, chronic infection
LFTs and INR if suspect liver disease
Renal function if suspect renal disease
Amylase if suspect pancreatitis
Urinalysis for microscopy, proteinuria or haematuria
Stool microscopy (e.g. ascaris leading to obstruction) and occult blood
Diagnostic paracentesis of ascitic fluid see later in CP
Ultrasound of abdomen and pelvis
CXR for air under diaphragm and evidence of heart failure
AXR for air fluid levels
CT of abdomen
Comments
There are multiple causes of acute abdominal obstruction (e.g. intra luminal tumour of bowel,
volvulus, intussusception, adhesions post surgery, compression or infiltration from tumour
outside bowel) but the distension itself is caused by faeces and flatus building up behind the
obstruction
Obstruction of the bowel may be acute or subacute. If the obstruction is not relieved (either by
conservative methods or surgically) then the affected bowel segment will die due to ischaemia
and there is risk of perforation and death.
Some middle aged women may not realize they are pregnant, thinking that they are just
menopausal. Young unmarried girls who are sexually active may also not recognise that they
are pregnant. A pregnancy test should always be considered. Foetal parts may be palpable on
examination and a foetal heart heard.
The fibroid uterus may be huge, extending up from the pelvis, above the umbilicus.
Diagnoses to consider:
Acute obstruction in children intussusception, worms
Acute or subacute obstruction in adults volvulus, bowel malignancy, adhesions etc
Ascites for causes see next section
Obesity
Constipation
Unrecognized late pregnancy
Massive fibroid uterus
Large ovarian cyst
Hirschprungs in children
Wilms tumour in children
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Surgery- CP
Diffuse abd distension
Other e.g. Foetus,

fibroid uterus
<500 leukocytes/mcL
> 500 leukocytes/mcL > 500 leukocytes/mcL
< 250 PMN
> 250 PMN Mainly lymphocytes
NORMAL
Bacterial peritonitis TB peritonitis
Peritoneal
carcinomatosis
Ascites is a common cause of diffuse abdominal distension. In rural setting there may be only a limited
number of investigations possible. Most places should be able to aspirate fluid from the abdomen and
perform a cell count. The next branch in the schema, uses the cell count to move forward with a
differential.
Raised cell count (> 500 leukocytes/mcL, >250 polymophonuclear neutrophils/mcL)
This is bacterial peritonitis until proved otherwise.
Ask for:
Fever
Abdominal pain
Known chronic liver disease with history of ascites with recent rapid increase in swelling
(spontaneous bacterial peritonitis, tuberculosis, malignancy)
Look for:
Pulse, temperature, BP, respiratory rate
Abdominal tenderness
Presence of rebound or guarding (suggests secondary bacterial peritonitis as usually minimal
signs in spontaneous bacterial peritonitis)
Investigations:
CBC (for systemic infection)
Blood culture
Serum glucose and LDH
Diagnostic paracentesis of ascitic fluid
o for general appearance (cloudy in infection)
o microscopy (cell count as above)
o protein content usually > 2.5g/dL in infection
o Culture of fluid
o Glucose and lactate dehydrogenase (LDH) usually low glucose and high LDH in
secondary bacterial peritonitis
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Surgery- CP
Comments:
In a patient with known ascites or known liver disease, dont assume that a rapid increase in
swelling is due to worsening of the previous underlying disease. There may be new
superimposed pathology, e.g. development of hepatocellular carcinoma, or spontaneous
bacterial peritonitis, or tuberculosis. Ascitic fluid tap should always be done.
Spontaneous bacterial peritonitis is seen in patients with a history of chronic liver disease and
ascites. There is usually fever and abdominal pain with often minimal peritoneal signs on
examination. Ascitic fluid neutrophil count is > 250 cells/mcL. Early recognition and treatment
is important, as there is a 30% mortality rate.
Spontaneous bacterial peritonitis must be distinguished form secondary bacterial peritonitis
(3% of cases of infected ascitic fluid) e.g due to appendicitis, diverticulitis, perforated gall
bladder. These patients will usually have at least two of low glucose (<50mg/dL), elevated LDH
level (greater than serum) and total protein >1g/dL
Raised cell count (>500 leukocytes/mcl, predominantly lymphocytes)

The most likely diagnosis here is either TB peritonitis or peritoneal carcinomatosis
Ask for:
Fever, weight loss, cachexia
Contact with TB patient or previous history of TB
HIV status (as HIV patients more likely to present with extrapulmonary TB)
Risk factors for HIV (sexual contact, IV drug abuse, blood transfusion)
Altered bowel habit
Known history of malignancy
Look for:
Pulse, temperature, BP, respiratory rate
Pallor (anaemia of chronic disease)
Lymphadenopathy
o Matted, rubbery LN in TB
Chest signs of TB crepitations especially in upper lobes
Abdominal tenderness or masses
PR for rectal mass
Investigations:
CBC (anaemia of chronic disease)
ESR (raised in both)
o for general appearance (cloudy in infection, 20% of malignant ascites are bloody, blood
in fluid is usually due to traumatic paracentesis)
o protein content usually > 2.5g/dL in both TB and carcinomatosis
o cytology may show malignant cells in peritoneal carcinomatosis
o AFB stain
CXR for primary TB

HIV test if risk factors
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Surgery- CP
Diffuse Abd distension
Other e.g. Foetus,

fibroid uterus
<500 leukocytes/mcL
> 500 leukocytes/mcL > 500 leukocytes/mcL
< 250 PMN
> 250 PMN Mainly lymphocytes
NORMAL
SAAG >1.1 mg/dl

SAAG < 1.1mg/dl Bacterial peritonitis TB peritonitis
Portal hypertension
Peritoneal
Hepatic congestion Malignancy
carcinomatosis
Liver disease Nephrotic syndrome
Connective tissue
Portal vein occlusion
disease
Other e.g. pancreatic,

Hypothyroidism
ovarian disease
Normal cell count (< 500 leukocytes/mcL)

Where the white cell count is normal a large differential remains. Where there are suitable facilities
then calculating the SAAG (Serum Ascites Albumin Gradient) is helpful to distinguish between portal
hypertension and other causes of ascites (see comments). At the same time as sending ascitic fluid for
albumin levels, blood should be taken for serum albumin.
Where there are no facilities for calculating SAAG then we need to rely upon history and examination.
Ask for:
Features of heart failure dyspnoea, orthopnoea, swelling of ankles, chest pain
History of jaundice
Features of hypothyroidism cold intolerance, slowing of mentation, constipation,
menorrhagia, dryness of skin
Weight loss, anorexia s/o malignancy
Whole body swelling s/o nephrotic syndrome or cardiac failure
Joint pain and swelling, skin rashes s/o connective tissue disease
Known malignancy
Known liver disease with cirrhosis cause of portal hypertension
Chronic alcohol abuse
Known Hep B or C infection
Known heart failure leads to hepatic congestion and portal hypertension
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Surgery- CP
Look for:
Pulse rate, BP
Anaemia (chronic disease, renal disease, malignancy)
Cachexia, LN (malignancy)
Jaundice, flapping tremor, reduced level of consciousness (fulminant hepatic failure)
Stigmata of chronic liver disease (spider naevi, palmar erythema etc)
Abdominal mass (malignancy)
Evidence of portal hypertension (hepatosplenomegaly, caput medusa, distended veins on
abdomen)
Raised JVP, basal crepitations, pitting oedema (cardiac failure)
Joint swelling, synovitis, skin rashes (connective tissue disease)
Investigations:
This will be directed towards the most likely underlying cause based on history and examination.
CBC and ESR
LFTs and INR for chronic liver disease
Serum albumin (to help calculate SAAG)
Serum LDH
Amylase if suspect pancreatitis
o for general appearance
o protein content see comments
o SAAG see comments
Urinalysis for proteinuria in nephrotic syndrome
CXR (if suspect cardiac disease)
USG of abdomen and pelvis
ECG for heart disease
TSH for possible hypothyroidism
Comments:
Serum ascites-albumin gradient (SAAG) is the single best test for classification of ascites into portal
hypertensive and non-portal hypertensive causes. It is calculated by: Serum albumin minus ascitic
fluid albumin
An SAAG > 1.1 g/dL suggests underlying portal hypertension, while gradients < 1.1 g/dL suggest
nonportal hypertensive causes. It is >95% accurate in classifying ascites, although 4% patients may
have mixed ascites with two different pathologies (e.g. Malignancy + portal hypertension).
Cytology is only helpful in the diagnosis of peritoneal carcinomatosis. It usually does not detect
other intra-abdominal malignancies, unless there is peritoneal involvement
Protein level can also be measured. Traditionally defined as: Transudate (<2.5g/dL of protein) or
exudate (>2.5g/dL of protein). On its own protein level is only 56% accurate for detecting exudate,
so it is no longer considered useful in the primary diagnostic process. It may be helpful as an
adjunct to the use of SAAG
o SAAG > 1.1 mg/dL and high protein most causes of hepatic congestion
o SAAG < 1.1 mg/dL and high protein s/o malignancy
Pathophysiology of ascites secondary to portal hypertension. There are a number of theories. The
most recent theory is called the peripheral arterial vasodilatation hypothesis. Portal hypertension
leads to an increase in nitric oxide levels, which causes splanchnic and peripheral vasodilatation.
This leads to reduction in effective arterial blood volume (EABV), which in turn leads to
neurohumoral excitation with activation of the renin/angiotensin mechanism and renal sodium and
water retention.
In addition, ascites is uncommon unless there is both portal hypertension and hypoalbuminaemia
(chronic liver dysfunction). Hypoalbuminaemia leads to reduced plasma oncotic pressure and
favours extravasation of fluid.
In chylous ascites, fluid is milky due to high triglyceride levels. It is due to the presence of thoracic
or intestinal lymph in the abdominal cavity due to disruption of the lymph system by trauma or
obstruction. In the West the commonest cause is malignancy or cirrhosis. In developing countries
the commonest cause is TB or filiariasis.
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Surgery- CP
Ascites due to Portal hypertension (SAAG>1.1g/dL)
o Liver disease (cirrhosis, alcoholic hepatitis, fulminant hepatic failure)
o Hepatic congestion (congestive heart failure, constrictive heart failure, Budd-chiari
syndrome, veno-occlusive disease) - usually also have total protein > 2.5g/dL
o Portal vein occlusion
Ascites due to hypoproteinaemia (SAAG <1.1g/dL)
o nephrotic syndrome
o protein-losing enteropathy
o severe malnutrition
Ascites due to infection (> 500 leukocytes/mcL)
o Bacterial peritonitis
o Tuberculosis
Ascites due to malignancy (SAAG < 1.1g/dL and high protein)
Hypothyroidism
Chylous ascites
Pancreatic ascites (rare)
References: Medscape website, Uptodate website, Harrisons textbook of Medicine
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Surgery- CP
Abdominal Lump
Abdominal
lump
Superficial / Deep/ Intra-

Parietal abdominal
Intra- Retro-
Epidermal
peritoneal peritoneal
Upper Lower
Subcutaneous Central Central
abdomen abdomen
Lt hypo- Vascular
Muscle Abscess Hypogastrium
chondrium (aneurysm)
Lymph node Small bowel Pancreatic

Epigastric RIF
(groin) tumours pseudocyst
Rt hypo-
Hernia Lymph nodes LIF Lymph nodes
chondrium
Colorectal Ca
Lumbar
(transverse)
Other e.g. soft

tissue tumour
Abdominal lump
(exclude pregnancy)
Superficial / Parietal Deep

(abd wall) (intra-abdominal)
It is important to exclude pregnancy as a cause of abdominal lump. This will be covered in obs/gynae.
The main way to decide if an abdominal lump is superficial or deep is by palpation.
Look for:
Does the lump appear to be superficial or deep on palpation?
If lump becomes more prominent on making abdominal muscles tight, this is s/o a parietal (in
the abdominal wall) lump
Comments:
Some middle aged women may not realize they are pregnant, thinking that they are just
menopausal. Young unmarried girls who are sexually active may also not recognise that they
are pregnant. A pregnancy test should always be considered. Foetal parts may be palpable on
examination and a foetal heart heard.
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Surgery- CP
Superficial
abdominal lump
Lymph node in
Epidermal or
Subcutaneous Hernia groin Muscle
dermal
(see separate CP)
Inguinal
Incisional (see scrotal Femoral
swelling CP)
Ask for:
Onset of lump and duration
Position of lump (groins s/o hernia or lymph node)
Change in size of lump over time, or with certain positions
Associated pain
Change in nature of the pain or severity of the pain
Change in bowel habit (s/o obstructed hernia)
History of surgery in area where lump is present (risk for incisional hernia)
Recent history of persistent cough or prolonged straining (risk factor for hernia)
Skin lumps elsewhere in body e.g. lipoma
Look for:
Appearance of overlying skin (redness s/o infection or inflammation e.g. skin abscess,
obstructed hernia, pigmentation s/o melanoma)
Surgical scars
Tenderness
Does the lump move with the skin (present within the epidermis or dermis), or can skin can be
moved over the lump? (subcutaneous or lymph node)
Is there induration of a skin lump (s/o infection or malignancy)
Nature of the lump (cystic or solid, soft or firm)
Position of lump in relation to pubic tubercle if suspected hernia
o Superolateral inguinal
o Inferomedial - femoral
Extension of mass from groin into scrotum (s/o inguinal hernia)
Change with standing (s/o hernia)
If lump becomes more prominent on making abdominal muscles tight, this is s/o a parietal (in
the abdominal wall) lump
Reducibility
Presence of lumps elsewhere in the body (skin lumps such as lipoma, cysticercosis)
Investigations:
Blood tests are rarely indicated and the diagnosis is often clinical
Skin biopsy may be indicated
Comments:
There are further details on hernia in the scrotal swelling CP
Tumours of the abdominal wall are quite common, but most are benign e.g. lipomas, fibromas,
haemangiomas. Endometriomas may occur in the scars from gynaecological procedures and
caesarean sections.
Most malignant tumours of the abdominal wall are metastatic either from direct invasion or
vascular dissemination. Common sources of metastasis are the lung and pancreas.
Abdominal wall nodules located around the umbilicus are known as St Mary Josephs nodules
and are a sign of distant metastasis from Ca stomach
Sudden appearance of a sensitive nodule anywhere in the abdominal wall that is clearly not a
hernia should arouse suspicion of an occult cancer.
10
Surgery- CP
Epidermal or dermal
o Simple skin polyps
o Melanoma
o Seborrhoeic wart
o Sebaceous cyst
o Skin abscess
Subcutaneous
o Lipoma
o Neurofibroma
Muscle
o Cysticercosis
Hernia
o Incisional
o Femoral
o Inguinal
Lymph node
Abdominal
lump
Superficial / Deep / intra-

parietal abdominal
Intra-peritoneal Retroperitoneal
Intra-abdominal lumps may be intraperitoneal or retroperitoneal. The main way distinguish between
the two is via radiological investigation (ultrasound or CT scan). A clinical method is to ask the patient
to get into the elbow-knee position (on all fours). In this position intra-peritoneal lumps generally
bulge out whereas retro-peritoneal lumps do not. However, this test is usually not done because the
patient is unwell.
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Surgery- CP
Abdominal lump
Superficial / Deep/ Intra-

Parietal abdominal
Intra-peritoneal Retro-peritoneal
Central /
Upper abdomen Lower abdomen Central
umbilical
Lt hypo- Vascular
Abscess Hypogastrium
chondrium (aneurysm)
Small bowel Lymph nodes

Epigastric RIF
tumours (TB, lymphoma)
Rt hypo- Colorectal Ca Pancreatic

LIF
chondrium (transverse) pseudocyst
Lymph nodes Lumbar
Other e.g. soft

tissue tumours,
psoas abscess
The next key step in assessing a deep abdominal mass is to look at its position within the abdomen.
This gives a clue to the underlying structures most likely to be involved. Other questions follow on
from this.
Ask for:
Age of patient (malignancy commoner in older patients, pregnancy in women of child bearing
age)
What was the rate of onset of swelling?
Position of mass (gives a clue to underlying organ e.g. flank likely kidney, suprapubic
bladder or pelvic organs)
Localizing features
o urinary symptoms such as dysuria, frequency, haematuria s/o kidney or bladder
disease
o Abnormal vaginal bleeding s/o gynae origin
o PV discharge s/o gynae origin
Systemic features e.g. fever, anorexia, weight loss s/o infection or malignancy
Associated features e.g. pain, vomiting, bowel habit, urine habit, menstrual cycle
Red flags for malignancy haematuria, weight loss, change in bowel habit, rectal bleeding,
abnormal vaginal bleeding
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Surgery- CP
Abdominal pain nature of pain, location of pain

Passing urine normally? (urine retention may present with lower abdominal swelling and pain)
Previous history of abdominal problems (e.g. pancreatitis leading to pancreatic pseudocyst)
Previous history of abdominal surgery (risk for incisional hernia or recurrence of previous
disease)
Recent surgery (increased risk urine retention)
Known prostatic hypertrophy or history of poor urine stream, dribbling or incontinence
(increased risk urine retention)
History of alcohol abuse (liver disease and hepatomegaly)
Fever and night sweats (? Lymphoma)
Family history of renal disease (polycystic kidneys), Crohns or ulcerative colitis.
Look for:
Pulse, blood pressure, temperature
General systemic signs e.g. jaundice, pallor, clubbing, spider naevi, palmar erythema, cachexia,
obesity
Lymphadenopathy in axilla, groin and supraclavicular area (in lymphoma)
Single node in supraclavicular area on left Virchows node (gastric cancer)
Shape of abdomen area which is distended, gives clue to underlying structures
Position of mass on palpation (e.g. epigastric mass s/o stomach malignancy, suprapubic mass
s/o uterus or ovarian mass, distended bladder or foetus)
Nature of mass solid or cystic
Tenderness (many tumours are not tender, tenderness may suggest abscess, urine retention,
congestion of the liver etc)
Organomegaly examine for liver, spleen, kidneys
Does the mass change with position (e.g. hernias are more apparent on standing if inguinal, or
raising upper body if epigastric)
Pelvic examination for pelvic masses
Percussion to help outline extent of the mass or organomegaly
Foetal parts, foetal heart beat, foetal movements
Investigations
CBC, ESR
Urea, creatinine
LFTs
Urinalysis for haematuria and proteinuria
Ultrasound
CT of abdomen
Upper
abdominal mass
Rt Lt
Epigastrium
hypochondrium hypochondrium
13
Surgery- CP
Right
hypochondrium
Hepatomegaly Hepatic flexure

Gallbladder mass Intussusception
(see separate CP) colorectal Ca
Acute
Hydrops of
cholecystitis / Malignancy
gallbladder
empyema
Carcinoma of
gallbladder (rare)
Periampullary Ca
head of pancreas
(common)
Ask for:
Age of patient intussusception commoner in children (6 months to 2yrs of age)
Nature of abdominal pain associated with mass
o sudden onset of colicky pain in a child associated with mass s/o intussusception
o constant dull ache s/o malignancy
o severe RUQ pain s/o acute cholecystitis
Fever (if very high suggests complication of acute cholecystitis e.g. empyema)
Nausea and vomiting
Anorexia, malaise, weight loss (s/o malignancy)
Previous history of gall stones
Progressive jaundice (getting deeper) with itch s/o periampullary Ca head of pancreas and
progressive obstructive jaundice.
Look for:
Temperature
Pulse and blood pressure
Jaundice
Tenderness in RUQ
Investigations
WCC (12,000 15,000 s/o acute cholecystitis, > 15,000 s/o empyema)
Serum bilirubin (slightly raised in acute cholecystitis)
USG of abdomen
Comments:
The gall bladder is palpable in 1/3 of cases of acute cholecystitis.
An impacted stone without cholecystitis will result in hydrops of the gallbladder. Here bile is
absorbed but the gallbladder epithelium continues to secrete mucous and the gall bladder
becomes distended with mucinous material. The gallbladder is distended but not usually
tender.
Courvoisiers Law in the presence of an enlarged gallbladder which is nontender and
accompanied with mild jaundice, the cause is unlikely to be gallstones.
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Surgery- CP
Intussusception the mass is usually palpable alone the distribution of the colon, most
commonly in the right upper quadrant of the abdomen. Red current jelly stool is a late sign.
Typically the child is well between bouts of severe pain.
Intussusception may also be palpable in other quadrants of the abdomen depending on which
part of the bowel is involved.
For details on hepatosplenomegaly see separate CP. Worth remembering that percussion over
the liver should be done to find upper and lower borders, as hyperinflation of the lung may
push the liver down, causing it to appear to be enlarged, when in fact it is normal.
Acute cholecystitis
Empyema (suppurative cholecystitis)
Hydrops of gallbladder
Periampullary Carcinoma of head of pancreas
Carcinoma of gallbladder
Intussusception
Congenital choledochal cysts (rare) may first present in adult hood
Epigastric mass
This is most likely to be a carcinoma of the stomach. Other features s/o of Ca stomach include:
Ask for:
History of weight loss, anorexia, early satiety, fatigue
Epigastric pain especially if of new onset, disturbing sleep, persisting > 4 weeks and not
responding to antacids
Malaena
Look for:
Pallor, cachexia, Virchows node
Epigastric mass
Associated hepatomegaly (due to metastases)
Investigations
CBC, ESR
Endoscopy
Ultrasound of upper abdomen
Comments:
An enlarged liver may also be palpable in the epigastric region, as may a pancreatic pseudocyst.
Left hypochondrium mass

This is most likely to be splenomegaly see separate CP. Also consider stomach, Splenic flexure
colorectal carcinoma and pancreas.
Central
abdominal mass
Lumbar
Umbilical
(Rt and Lt)
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Surgery- CP
Umbilical
Intra Retro-
peritoneal peritoneal
Small bowel Pancreatic

tumours pseudocyst
Abdominal
Lymph nodes Aortic
aneurysm
Colorectal
Lymph nodes
cancer
(TB lymphoma)
(transverse)
Abscess Abscess
In this section retroperitoneal and intraperitoneal conditions have been combined, as it is difficult
clinically to distinguish between the two. Only after radiological investigation can you be certain of
what the condition is.
Ask for:
Age aneurysm much more common in men > 60yrs
Associated pain
o intermittent and cramping typical of small bowel tumours
o acute severe pain may occur due to perforation of tumour or aneurysm.
o Pain not changed by position or movement and radiating to back or loins is s/o
aneurysm (although very non-specific)
Associated nausea and vomiting s/o tumour
Anorexia, weight loss, altered bowel habit (s/o tumour)
Malaena (s/o bleeding from tumour)
Previous history of pancreatitis (associated with pancreatic pseudocyst
History of abdominal trauma (s/o pancreatic pseudocyst)
Hypertension, coronary artery disease, cerebrovascular disease or hyperlipidaemia (strongly
associated with increased risk for aortic aneurysm)
Smoking history (increased risk aortic aneurysm)
Look for:
Anaemia, jaundice, LN (s/o malignancy)
Tenderness
Nature of the lump if it is expansile this suggests aortic aneurysm
Size of lump
Prominent distal pulses (femoral and popliteal) if suspect AAA as may be associated with other
aneurysms
Ascites or pleural effusion (In pancreatic pseudocyst due to fistulisation of pancreatic duct with
abdomen or chest respectively)
Investigations:
USG abdomen
CT scan
16
Surgery- CP
Comments:
Small bowel tumours are relatively rare. Symptoms are often vague and patients present late.
Most abdominal aortic aneurysms are asymptomatic. Symptoms suggest that rupture is
imminent. Clinically significant aneurysms are >4cm in diameter. Abdominal palpation is more
accurate for diagnosis in thinner patients.
Pancreatic pseudocyst
Pancreatic neoplasm
Aortic aneurysm
Adenocarcinoma of small bowel
Carcinoid tumour
Sarcoma (GIST gastrointestinal stromal tumour)
Lymphoma
Lumbar Mass
(Kidney)
Hydronephrosis Pyonephrosis or
Polycystic
Malignancy due to perinephric
kidney disease
obstruction abscess
Masses in the lumbar region, usually arise from the kidney. This is a retroperitoneal organ. Sometimes
hepatic or splenic flexure colorectal tumours can be in lumbar regions
Ask for:
Age and sex of patient renal cell carcinoma commoner in older men, polycystic kidney disease
usually diagnosed in patients in 30s or 40s, nephroblastoma occurs in children
Painless haematuria occurring throughout the urinary stream (s/o malignancy)
Intermittent haematuria (s/o polycystic kidney disease)
Flank pain
Malaise, weakness, anorexia and weight loss (s/o malignancy)
Fever (s/o secondary infection in urine)
Bone pain (s/o secondary spread of a primary renal malignancy)
Shortness of breath (s/o secondary spread of a primary renal malignancy)
Family history of polycystic kidney disease
Known history of stones (obstructive hydronephrosis)
Look for:
Anaemia, lymphnodes, cachexia (s/o malignancy)
Flank tenderness (late sign in malignancy)
Flank mass
Hypertension
Fever
Investigations:
Urinalysis (for haematuria, pyuria, protein) pyonephrosis or perinephric abscess
CBC may be anaemia or erythrocytosis
ESR raised in malignancy
Urea and creatinine
Calcium level may be raised in renal cell carcinoma
USG
IV urography
CT scan
17
Surgery- CP
Comments:
Malignant tumours of the kidney account for approx 3% of all tumours in adults. The cause is
unknown although risk factors include smoking, obesity and hypertension. It is 3 X more
common in men than in women. It commonly metastasizes to lungs, renal hilar LN, ipsilateral
adrenal, opposite kidney and lytic lesions in mainly long bones.
Paraneoplastic syndromes are common in renal cell carcinoma e.g. hypercalcaemia,
erythrocytosis, hypertension, fever of unknown origin, anaemia and hepatopathy. It may also
be associated with tumour thrombi in the renal vein and Inferior vena cava presenting with
lower limb oedema and acute scrotal varicocele.
Renal cell carcinoma may also present with pyrexia of unknown origin (PUO). Other tumours
that may present with PUO are Ca colon, lymphomas, atrial myxomas, hepatocellular
carcinoma
Wilms tumour is commonest in children under 5 yrs of age (peak 2-3yrs). The mass is usually
very large, firm and smooth.
Polycystic kidney disease is inherited and bilateral. The adult type is autosomal dominant and
the type presenting in infants is autosomal recessive.
Renal cell carcinoma (adenocarcinoma)
Sarcoma (e.g. leiomyosarcoma)
Wilms tumour (nephroblastoma)
Hydronephrosis due to obstruction by stone, tumour etc
Pyonephrosis
Perinephric abscess
Polycystic kidneys
Lower abdominal
lump
Hypogastrium
Right iliac fossa (bladder or pelvic Left iliac fossa
organ)
Urine retention
Tumour
(separate CP)
Pelvic masses are covered in a separate CP.
Ask for:
Gross haematuria
Urinary frequency and urgency
Pain (due to clot retention, tumour extension into bony pelvis or ureteral obstruction)
Look for:
General appearance anaemia, weight loss
Blood pressure
Suprapubic mass
Rectal exam may reveal large tumours invading the pelvic side walls.
18
Surgery- CP
Investigations:
Urinalysis for haematuria
Urine for cytology
CBC for anaemia or secondary infection
Urea and creatinine (may get secondary renal failure if both ureters blocked or urethra
blocked)
Liver function tests (for liver metastases)
IV urography
USG
Cystoscopy
CT scan
Comments:
Cystoscopy is mandatory in any adult patient with unexplained haematuria and a normal CT or
IV urogram.
When there is a suprapubic swelling with history of not passing urine for several hours, plus
lower abdominal pain, urinary catheterization may provide instant relief and a diagnosis of the
problem.
Lower
abdominal
lump
Right iliac Suprapubic

Left iliac fossa
fossa (bladder or
pelvic organ)
Right colon Left colon

malignancy malignancy
Infection /
Constipation
inflammation
TB Ovarian mass
Appendicular
lump
Other
e.g. Crohns
Ovarian mass
Ovarian mass will be covered in the CP on pelvic mass.
Clinical clues
Ask for:
Age of patient malignancy in older patients and inflammatory bowel disease in young adults
Fever (s/o TB, low grade fever in appendiceal abscess)
Weight loss, anorexia, fatigue (s/o malignancy or TB)
Nature of abdominal pain associated with mass
o acute RIF pain associated with nausea and vomiting s/o appendiceal abscess
Vomiting
19
Surgery- CP
Change in bowel habit alternating constipation and increased frequency of defecation s/o
malignancy, chronic diarrhoea s/o inflammation due to TB or inflammatory bowel disease)
see CP on diarrhoea
Blood in stool (s/o inflammatory bowel disease or malignancy) see CP on PR bleed
Chronic constipation common cause of lump in left iliac fossa
Associated cough + haemoptysis (s/o TB)
Known history of Crohns or ulcerative colitis ( also risk factor for malignancy)
Look for:
Anaemia, jaundice, cachexia, lymph nodes in supraclavicular area for metastasis or matted LN
of TB.
Location of abdominal mass (right or left colon, right iliac fossa)
Tubular mass in LIF s/o constipation
Extent of fixation of the mass (s/o malignancy)
Rectal examination
Vaginal examination to look for tumour extension in retrovaginal area
Evidence of metastases (liver enlargement)
Evidence of primary TB examine chest and cervical LN
Investigations:
CBC for anaemia, raised WCC in intussusceptions and appendix abscess
ESR raised in all
Serum protein, calcium, bilirubin, liver function if suspect metastases
Stool for occult blood
Colonoscopy
Ultrasound of abdomen
CT scan of abdomen
Comments:
Tuberculous infection of the intestine may be primary due to ingestion of the bovine strain of
M. Tuberculosis, or secondary due to swallowing of the human tubercle bacillus.
The distal ileum is the most common site of TB disease and may present with a mass here
Carcinoembryonic antigen (CEA) is a tumour marker for cancer of the large bowel, although it is
not specific for this. It is useful to help detect recurrence of disease after curative surgical
resection, but not for screening purposes
Diagnoses to consider
Cancer of large bowel e.g. adenocarcinoma
Lymphoma
TB
Crohns abscess
Appendiceal lump
Appendiceal abscess
Intussusception
Reference:
Current diagnosis and Treatment Surgery 13th edition - Lange
20
Surgery- CP
Abdominal Pain
Pain is a symptom i.e. complaint of a patient. Tenderness is a sign elicited by the doctor. Pain is one of
the most important symptoms causing patients to seek health care. Abdominal pain may be due to
intra abdominal or extra abdominal causes.
Abdominal pain
Acute Chronic
Traumatic Non-traumatic
Penetrating Localized (by

Blunt trauma Diffuse
trauma region)
Not Peritonitis Peritonitis Rt hypochondrium
Abdominal Extra-abdominal Epigastrium
Gastroenteritis Endocrine Lt hypochondrium
Peptic ulcer Right and left

Inflammatory
disease lumbar
Mesenteric
Haematological Umbilical
ischaemia
Intestinal
obstruction
Referred pain RIF
without
ischaemia
Muscular pain Toxins and drugs Hypogastrium
LIF
21
Surgery- CP
Ask for:
1. Original site / location of pain
2. Duration of pain
3. Onset sudden or insidious
4. Severity
5. Nature of pain
6. Progression of pain
7. Movements Referred, radiation or shifting
8. Aggravating factors
9. Relieving factors
10. Associated symptoms
Onset onset may be explosive (within seconds), rapidly progressive (within 1-2 hours), or gradual
(over several hours).
Nature of Abdominal pain
1. Colic
-obstructed hollow organ
-gripping in nature, fluctuates
-usually severe and makes patients restless
- eg. Intestine colic, ureteric colic, biliary colic.
Note- In the strict sense, the term biliary colic is a misnomer because biliary pain does
not remit. The reason is that the gall bladder and bile duct, in contrast to the ureters and
intestine , do not have peristaltic movements.
2. Burning pain eg. peptic ulcer
3. Throbbing pain eg. Abscess
4. Pins or needles sensation or pricking eg. Peripheral nerve injury
5. Stabbing pain sudden, severe, sharp and short lived-eg. Acute perforation peptic ulcer
6. Constricting pain eg in angina pectoris
7. Scalding pain- eg . cystitis or urethritis
Movements
1. Radiation pain at other site as original pain persist in initial site .eg. in duodenal ulcer
and pancreatitis original pain at epigastric region which may radiate to back.
2. Shifting pain pain originates at one site and later shifts and fixed to other site. Eg in
acute appendicitis original pain at periumbilical or epigastric but later shifts to right
iliac fossa.
3. Referred pain- pain is felt at distant from its source. Eg. Right shoulder pain in acute
cholesystitis.
Abdominal
Pain
Chronic
Acute
Non-
Traumatic
traumatic
Acute versus chronic pain
While an arbitrary interval, such as 2-4 weeks , can be used to separate acute from chronic abdominal
pain , there is no strict time period that will classify the differential diagnoses unfailingly. A clinical
judgement must be made that considers whether this is an accelerating process, one that has reached
a plateau , or one that is longstanding but intermittent:
22
Surgery- CP
Pain of less than a few days duration that has worsened progressively until the time of
presentation is clearly acute.
Pain that has remained unchanged for months or years can be safely classified as chronic.
Pain that does not clearly fit either category might be called subacute or requires consideration
of the differential diagnosis for both acute and chronic pain.
Pain in a sick or unstable patient should generally be managed as acute , since patients with
chronic abdominal pain may present with an acute exacerbation of a chronic problem or a new
unrelated problem
Acute abdominal pain
(non-traumatic)
Diffuse Localized
Peritonitis No peritonitis
Bowel
Visceral Ruptured abd
Pancreatitis obstruction with
perforation aortic aneurysm
ischaemia
Acute Abdominal pain ( non-traumatic):-

Abdominal pain may be generalised or localised.
If the pain is generalised :
Ask for:
Site of origin , onset and duration of pain ( where, when and how?)
History of periodicity, fever
History of Peptic ulcer disease, enteric fever (risk factor for bowel perforation)
Alcohol intake chronic alcohol use risk for pancreatitis
Ask for bowel habit absolute constipation s/o obstruction, prior history of malaena s/o
ruptured peptic ulcer
Vomiting
Look for:
General condition of patient. Is the patient looking sick? If so consider, some sinister
pathology. Look for dehydration.
Record vitals (Pulse, BP, temperature, respiratory rate). There may be tachycardia,
hypotension, fever in bowel perforation or sepsis.
Features of peritonitis tenderness with guarding and rebound. Absent bowel sounds (s/o
bowel perforation or small bowel obstruction with ischaemia).
Hernial orifices looking for evidence of obstructed hernia
Grey-Turners sign (bruising in flanks) or Cullens sign (bruising around umbilicus) present in
1% of cases of acute pancreatitis and associated with poor prognosis
Investigations:
Blood for haematocrit, T.C.,D.C.,(White count raised in infective conditions)
Serum amylase (for pancreatitis) see later for other investigations in pancreatitis
CXR-PA view- look for pneumoperitoneum present in bowel perforation.
Serum creatinine, electrolytes.( important in overall management of patients)
Comments:
Features of peritonitis are absent in early stages of bowel obstruction, gastroenteritis and constipation
Diagnosis to consider
If there are features of peritonitis, consider
Hollow viscus perforation
Small bowel obstruction with ischemic bowel
Abdominal AA rupture,
23
Surgery- CP
Acute, diffuse
abdominal
pain
Peritonitis No peritonitis
Extra
Abdominal
abdominal
Small bowel
Mesenteric Peptic ulcer
Gastroenteritis obst with no Muscular pain
ischaemia disease
ischaemia
In diffuse abdominal pain with no features of peritonitis, the cause may be Abdominal or extra-
abdominal. Common abdominal causes are listed in the schema above. In mesenteric ischaemia there
is pain out of proportion to the clinical findings.
Extra -
abdominal
Endocrine and Infection and Hematologic Toxin and

Referred pain
metabolic inflammatory disorders drugs
Endocrine and Infection and Toxic and

Hematologic Referred pain
metabolic inflammatory drugs
Lead or other
Acute Myocardial
Uremia SLE heavy metal
leukemia infarction
poisoning
Henoch- Basal
Diabetic
Schonlein pneumonia
ketoacidosis
purpura /pleurisy
Addisonian Acute
crisis pericarditis
Ask for:
Timing and onset of pain
Associated nausea and vomiting
Bowel habit diarrhoea s/o acute gastroenteritis, malaena s/o peptic ulcer disease
Known renal disease or diabetes (s/o uraemia or diabetic ketoacidosis DKA)
Skin rashes (SLE, Henoch schonlein)
Cough and sputum (s/o pneumonia)
Known ischaemic heart disease or hypertension
24
Surgery- CP
Look for:
Pulse, blood pressure, temperature, respiratory rate
Level of hydration (can get extreme dehydration in gastroenteritis and DKA)
Lymphadenopathy (leukaemia)
Notice unusual smell on breath (ketones in DKA)
Notice abnormal respiratory pattern (Kussmauls respiration deep laboured breathing
associated with metabolic acidosis)
Abdominal examination for tenderness, masses, bowel sounds
Hernial orifices for obstructed hernia
Joint swelling (SLE)
Skin rashes (SLE and HSP)
Cardiovascular and respiratory examination for source of referred pain
Investigations:
CBC, ESR
Creatinine and electrolytes
Blood glucose
Arterial blood gases (if suspect DKA)
Stool R/M/E , helpful in gastroenteritis.
Urine for protein or blood (HSP, renal disease)
ECG to exclude MI and for acute pericarditis
Cardiac troponin
Comments:
SLE leads to abdominal pain through vasculitis and mesenteric ischaemia
Acute abdominal pain - Localized
Localized pain
Rt Lt Rt and Lt Hypo-
Epigastrium Umbilical RIF LIF
hypochondrium hypochondrium Lumbar gastrium
The abdominal cavity is divided into nine regions for the purpose of describing the location of viscera ,
by four imaginary planes , two horizontal and two vertical. The abdominal region involved gives a clue
to the likely organs involved when there is abdominal pain.
According to developmental origin of abdominal organs abdomen can be divided into 1.upper , 2.
Middle and 3. Lower abdomen.
a. Upper abdominal pain- diseases of stomach, duodenum, hepatobiliary system, pancreas
b. Mid abdominal pain- diseases of small bowel eg.jejunum and ileum
c. Lower abdominal pain diseases of colon, reproductive organ, urinary bladder
Patients may also present with localized peritonitis in any of these nine regions. This occurs when an
inflamed organ is in contact with the peritoneum, leading to localized inflammation. If not treated this
will progress to generalized, diffuse peritonitis. The sign of localized peritonitis is guarding or rebound in
one particular area of the abdomen.
Right Hypochondrium
Ask for:
1. History of onset, duration, severity and nature of pain.
2. What is the relation with food habits like with fatty food.
3. Association with fever, anorexia, nausea and vomiting, jaundice.
4. Previous history of loose motion with stool floating on water (s/o steatorrhoea).
25
Surgery- CP
Look for:
1. Is there any swelling and scar marks?
2. Palpate to notice any lump ,tenderness and rigidity. Look for Murphys sign.
3. Percuss for liver dullness . Is there any intercostal space tenderness?
Investigations:
1. Blood for haematocrit ,T.C. D.C. Total count and neutrophil are increased in acute cholecystitis.
2. Serum amylase is helpful to exclude pancreatitis.
3. Liver function tests. Serum bilirubin, AST & ALT are raised in acute hepatitis. LFT is helpful to
differentiate medical from surgical hepatobiliary diseases.
4. CXR-PA view. It is essential to exclude pneumoperitoneum , pleural effusion and lower lobe
pneumonia. In liver abscess right hemidiaphragm may be elevated.
5. Ultrasonography : It is useful in evaluating liver , gall bladder and pancreatic diseases.
Comment;-
1. In biliary colic duration of pain will be shorter while longer in acute cholecystitis . Pain is
aggravated with fatty food in both of the conditions.
2. Pain may associated with fever in acute cholecystitis, liver abscess & hepatitis.
3. Intercostal space tenderness is seen in liver abscess; there may also be history of loose motion.
4. Murphys sign is positive (patient catches breath when pressure is applied at tip of ninth costal
and asked to take a deep breath) in acute cholecystitis; a tender lump may be palpable .
5. Serum amylase may be raised in acute cholecystitis (but less than 3 times upper limit of normal)
Acute cholecystitis
Acute hepatitis (A, B and E)
Liver abscess
Biliary colic
Right lower lobe pneumonia
Epigastric Pain
Ask for:
1. Onset, duration, severity and nature of pain.
2. Is there periodicity, water brash and drinking habit present?
3. Any history of vomiting of blood and passage of black stool.
Look for:-
1. Pallor and dehydration; record vitals.
2. Any swelling and scar marks.
3. Any lump, tenderness, rigidity and guarding.
4. Obliteration of liver dullness
5. Grey-Turners or Cullens sign (pancreatitis)
Investigations:
1. Blood for HCT, T.C., D.C. Haematocrit may decrease in PUD,
2. Serum creatinine & electrolytes.
3. S. amylase. > 3 to 4 fold diagnostic of acute pancreatitis.
4. CRP marker of severity of acute pancreatitis (especially if > 150mg/L after 48hrs)
5. Stool for occult blood.
6. CXR-PA view : look for pleural effusion , pneumoperitoneun .
7. Plain abdominal x-rays- supine and erect
8. USG: to know detail of pancreas. Whether pancreas is enlarged , oedematous, any fluid collection
inside or outside .
9. Upper G.I. endoscopy
26
Surgery- CP
Comments:
1. Presence of burning pain, periodicity, waterbrash and stool occult blood may be positive in peptic
ulcer disease (PUD).
2. Sudden sharp excruciating pain starting at epigastrium and later becoming generalised, presence of
pneumoperitoneum, guarding, dehydration and obliteration of liver dullness are features of
duodenal ulcer perforation.
3. Acute pancreatitis may appear just after heavy drinking. Pleural effusion may be seen Chest x- rays.
4. Commonest causes of acute pancreatitis are either alcohol or gallstones. Serum amylase rises in
the first 6 to 12 hours. The Apache II scoring system is used to calculate severity of disease and
prognosis in acute pancreatitis
5. Features of shock , severe sharp interscapular pain with radio femoral delay present in dissecting
aortic aneurysm.
Peptic ulcer disease
Gastritis
Acute pancreatitis
Left hypochondrium Pain

Ask for:
1. Site and radiation of pain.
2. History of other diseases that could cause portal hypertension.
Look for:
1. Organomegaly and tenderness.
Investigations:-
1. Blood for Hct ,T.C.,D.C.
2. USG
3. CT-SCAN
Comments:
1. Pain at LUQ, radiated to left shoulder with huge spleen and features of portal hypertension favours
for splenic infarction.
2. For more details see CP on splenomegaly
Lumbar Pain (right or left flank)

Ask for
1. History of onset, severity, duration and nature of pain.
2. Radiation or shifting of pain.
3. Is there fever, burning micturition and infrequency of urination?
4. What is the colour of urine? Clear? High colour? Reddish ?
Look for:
1. Temperature, pulse, blood pressure
2. Any swelling , scar marks ?
3. Any lump and tenderness. Is the renal angle tender?
4. Hernial orifices and testes if patient is male.
Investigations:
1. Haematocrit ,T.C.,D.C.
2. Urine R/M/E & C/S
3. Serum creatinine
4. X-Ray KUB
5. IVU
6. USG.
27
Surgery- CP
Comments:
1. In perinephric abscess there may be fullness in loin. Loin is the area in between below 12th rib and
above iliac crest.
2. Female patients suffer from acute pyelonephritis more than males.
3. KUB means kidney, ureter and bladder. It includes lower two ribs above and symphysis pubis below.
4. IVU is intra venous urogram . To do IVU bowel should be prepared and serum creatinine should be
normal. For IVU serial films are taken at i. control-before giving i.v. dye .ii.nephrogram just after
giving dye. iii. Pyelogram-5minutes, iv. Ureterogram-10 minutes, v.cystogram-15 minutes.
5. Most common organism of UTI are E.coli, Proteus, Klebsiela, and Pseudomonas.
Acute pyelonephritis
Perinephric abscess
Ureteric stone
RIF Pain
Ask for:
1. Site of origin of pain, its severity, onset, duration and nature. In appendicitis pain may shift from
periumbilical to RIF.
2. Urinary symptoms. Is there burning and frequency of micturition. What is the colour of urine?
These are helpful to rule out UTI, ureteric colic.
3. Any swelling present, if present when does it appear and is it reducible? It is necessary to rule out
inguinoscrotal hernia.
4. Is there pain in the scrotum? Note testicular torsion may give abdominal pain.
5. If patient is female of reproductive age, ask her LMP, any PV discharge
6. History of loose motion?
7. Presence of fever?
Look for:
1. Is there mass or lump? If present give its size , number ,mobility, surface and whether tender or
not. In appendicular mass lump is smooth surface, tender and non mobile.
2. Is McBurneys point tender? Look for Rovsings sign, rebound (percussion) tenderness, Copes psoas
and obturator signs. These all are signs of acute appendicitis.
3. Rigidity or guarding. It is present in appendicitis. If guarding and rigidity is generalised, consider
perforated appendix.
Investigations:-
1. Blood for HCT, Total Count, D.C.
2. Urine R/M/E. It is helpful to exclude UTI and urolithiasis.
3. Urine for pregnancy test.
4. Stool R/M/E helpful in enteritis.
5. USG. It is useful to diagnose appendicular lump and abscess. If patient female it is helpful to rule
out adnexal pathology like ovarian cyst, twisted cyst, ectopic pregnancy.
Comments:
1. Classical shifting of pain from periumbilical or epigastric to RIF in appendicitis is due to same nerve
innervations to appendix and umbilical area. Later once parietal peritoneum is inflamed then pain is
fixed to RIF.
2 McBurneys point .It is a point which lies at medial 2/3rd and lateral 1/3rd of spino umbilical line.
Appendicitis
Appendicular abscess
Ileocaecal TB
Ovarian cyst or torsion
Ectopic pregnancy
Tubosalpingitis
28
Surgery- CP
LIF pain
Ask for
Onset of pain, duration
History of constipation
Urinary symptoms. Is there burning and frequency of micturition. What is the colour of
urine? These are helpful to rule out UTI, ureteric colic.
Any swelling present, if present when does it appear and is it reducible? It is necessary to
rule out inguinoscrotal hernia.
Is there pain in the scrotum? Note testicular torsion may give abdominal pain.
If patient is female of reproductive age , ask her LMP, any PV discharge
Sexual activity
History of loose motion?
Drug history (including contraception)
Look for:
Abdominal tenderness, guarding, rebound
Pelvic or abdominal lump
PV exam to look for ovarian or adnexal pathology
Investigation: similar to pain in RIF
Comments:
Pain and tenderness similar to acute appendicitis but in older age group may occur in
diverticulitis but is rare in our part of the world.
Constipation
Ovarian cyst or torsion
Ectopic pregnancy
Tubosalpingitis
Diverticulitis
Hypogastric
Ask for:
Onset of pain, duration
Dysuria, frequency
Urinary retention
Menstrual cycle, abnormal PV bleeding, abnormal PV discharge
Look for:
Fever, pulse, BP
Abdominal tenderness and any masses or swelling
Pelvic examination in women to assess uterine size and tenderness
Rectal examination in men to assess prostate size and consistency
Comments
For further details see CPs on urinary retention, abnormal PV bleeding and PV discharge
29
Surgery- CP
Acute abdominal pain with history of trauma
Acute abd pain

with trauma
Blunt Penetrating
trauma trauma
Whether trauma is blunt or penetrating is usually obvious from the patients presentation. Penetrating
trauma may be due to knife wounds, bullet wounds or falling from a height onto a sharp object. Blunt
abdominal trauma is common, but often occurs in the presence of other distracting injuries or altered
mental status, so may be difficult to diagnose.
Ask for:
Details of the accident - Fatality at the scene, speed of vehicle, whether the vehicle rolled over,
extent of damage to vehicle, whether seat belts were used
Injuries elsewhere that might distract from the abdominal injury (e.g. fractures of pelvis, lower
limbs, head injury, chest injury)
Time since injury (delayed splenic rupture may occur)
Use of drugs such as warfarin which increase risk of bleeding
Pre-existing medical problems
Look for:
ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
Repeated assessment of ABCDE is important as patients may rapidly deteriorate
Inspection of abdomen for bruising or lacerations
Abdominal palpation for tenderness or mass
Investigations
Haematocrit
Blood group and cross match
Urinalysis to look for haematuria s/o renal injury
FAST ultrasound to assess for intra abdominal bleed, damage to liver and spleen
Diagnostic peritoneal lavage if ultrasound not available or equivocal.
Comments
Blunt abdominal trauma (BAT) most often results from a motor vehicle crash, but may also occur due to
blows to the abdomen and falls. Occult BAT may occur with child abuse and domestic violence.
Blunt abdominal trauma most often results in injury to the spleen. The liver and kidney can also be
injured. Less commonly, hollow viscus injury may occur. Elderly and alcoholic patients are more likely
to sustain laceration of the spleen as they have lax abdominal walls. Delayed splenic rupture may
occur.
Patients with significant intraabdominal injury may have minimal or no symptoms initially. A high level
of suspicion is needed in patients with extra abdominal injuries following a road traffic accident.
30
Surgery- CP
Chronic Abdominal Pain

Abdominal
pain
Acute Chronic
Diffuse Localized
Rt
Constipation
Hypochondrium
Irritable bowel Epigastrium
Lt
Muscular pain
Hypochondrium
Chronic
R and L lumbar
Infection
Chronic
Umbilical
inflammation
Malignancy RIF
LIF
Hypogastrium
Many of the causes of acute abdominal pain, may also cause chronic abdominal pain. Features to look
for in the history and examination are similar.
31
Surgery- CP
Diffuse Chronic
abdominal pain
Constipation (see
separate CP)
Irritable bowel
(Rome criteria)
Chronic infection
Helminths Tuberculosis
Chronic
inflammation
Inflammatory Other e.g. chronic

bowel disease e.g. pancreatitis, celiac
Crohns, Ulcerative disease
colitis
Malignancy
Muscular pain
Ask for:
Red flags of serious underlying disease
o Persistent Fever s/o TB
o Anorexia, weight loss s/o malignancy
o Malaena, or frank blood in stool s/o inflammatory bowel disease (IBD) or malignancy
o Persistent diarrhoea s/o malignancy or IBD
Timing of pain
Exacerbating and relieving factors
o Pain relieved by defaecation s/o irritable bowel
o Association with eating wheat products s/o celiac disease
Age of patient (malignancy more likely in elderly, inflammatory bowel disease commoner in
young adults)
Bowel habit constipation is a common cause of chronic abdominal pain, alternating diarrhoea
and constipation s/o irritable bowel
Menstrual history or history of PV discharge (for gynae causes of lower abdominal pain)
Social history helminths more common in patients from remote rural areas
Drug history have they taken antihelminths?
Alcohol intake chronic pancreatitis more common in alcoholics
32
Surgery- CP
Look for:
General appearance (sick or well, cachexia, anaemia, jaundice, lymph nodes)
Abdominal palpation looking for masses, tenderness
PR examination for rectal mass or malaena
Investigations
CBC (for anaemia or raised WCC)
ESR (raised in malignancy, TB, IBD)
Stool microscopy for helminths and RBC
Stool occult blood for malignancy
IgA endomysial antibodies for celiac disease
USG
CT abdomen
Chronic Localized abdominal pain
Upper abdominal pain (RUQ, epigastric and LUQ)

See CP on dyspepsia. Also consider: abscess liver, disease of spleen, gallbladder pathology.
Right and left flank pain

Source of pain is likely from the kidneys. Most common cause is ureteric stone. See CP on abdominal
masses
Ask for:
Associated haematuria (s/o polycystic kidneys)
Dysuria, frequency
Fever
Family history of polycystic disease
Look for:
Fever, anaemia
Masses in flank
Vesicular rash in a single dermatome (s/o herpes zoster)
RIF and groin pain

See CP on abdominal masses
Ask for:
Red flags of serious underlying illness (in malignancy or TB of ileocaecal junction)
Menstrual history, Last menstrual period (for ectopic pregnancy, or other gynae pathology)
Look for:
Anaemia, lymph nodes
Abdominal mass
PV for ovarian or uterine pathology
Hernia, Tuberculoma (ileocaecal region), ovarian cyst, ectopic pregnancy.
Hypogastrium
See CP on pelvic masses
Ask for:
Menstrual history, LMP, menorrhagia, dysmenorrhoea, abnormal PV bleeding or discharge
Urine hesitancy, dysuria, haematuria (bladder stone or bladder tumour)
33
Surgery- CP
Look for:
Abdominal mass
PV for uterine or ovarian pathology
Bladder cancer, uterine cancer, normal pregnancy, urinary retention
LIF and groin

See CP on abdominal masses
Ask for:
Red flags of serious underlying illness (in malignancy or TB of ileocaecal junction)
Look for:
Abdominal mass
PV for ovarian or uterine pathology
Ovarian cyst/cancer, sigmoid cancer/inflammation/TB, hernia, ectopic pregnancy
34
Surgery- CP
Blood in Stool
Blood in stool
Dark/ maroon
Bright red Black tarry
colour
Upper GI bleed
Anorectal Large bowel Small bowel (haematemesis
CP)
No abdominal No abdominal
Painless Anal pain Abdominal pain Abdominal pain
pain pain
Colitis
Infection e.g.
Haemo-rrhoid Fissure in ano (infectious, IBD, Colorectal Ca Tumours
Enteric fever, TB
ischaemic)
Anorectal Diverticula
Intus-suception Angio-dysplasia Ischaemia
Neoplasm (Meckels)
Diverticular NSAID
Crohns disease
disease enteropathy
Post
Vascular ectasia
intervention
Lower GI bleeding is less common than upper GI bleeding and accounts for about 25% of all GI bleeding
events. Lower gastrointestinal (GI) bleeding is defined as bleeding of recent onset that originates from
a site distal to the ligament of Treitz.
Bright red blood passed rectally is normally a symptom of anorectal disease. Occasionally it may be
Hematochezia due to heavy left sided colonic bleeding or due to massive upper GI bleeding. Massive
hematochezia/severe acute bleeding leads to hemodynamic instability and the need for transfusion.
Small intestinal sources of bleeding can present as overt obscure bleeding with melena or
hematochezia. It is estimated that about 5% of GI bleeding occurs between the ligament of Treitz and
the ileo-cecal valve.
35
Surgery- CP
Blood in stool
Dark/maroon
Bright red Black tarry
colour
Upper GI bleed
Anorectal Large bowel Small bowel (see
Haematemesis CP)
Clinical Clues
Ask about
Colour of stool
Black tarry s/o upper GI bleeding (malaena) usually also foul smelling
Dark red could be small bowel or colorectal bleed
Bright red anorectal or massive upper GI bleed
Is blood mixed with stool (colorectal origin) or separate (anorectal origin)
NSAID use (peptic ulcer or small bowel enteropathy)
Significant upper GI symptoms (dyspepsia, acid reflux, nausea and vomiting)
Age
o elderly patients - diverticulosis or vascular lesions
o younger patients - infectious or inflammatory conditions.
Abdominal pain and its location
Change in bowel habits (neoplasm, inflammatory bowel disease, colitis)
Previous history of peptic ulcer disease
History of radiation therapy, previous surgery (especially vascular surgery), and ano-rectal
disease or trauma.
Alcohol intake (risk varices and massive upper GI bleed)
Fever s/o bacterial dysentery
Recent party/festival and others with similar symptoms (possible dysentery)
Look for
Pulse, blood pressure (including orthostatic drop in systolic BP of > 20mmHg) - If
hemodynamically compromised, suspect significant GI bleed.
Pallor (s/o chronic blood loss)
Jaundice (s/o liver disease, impaired clotting and portal hypertension leading to varices)
Stigmata of chronic liver disease (e.g. spider naevi, clubbing, palmar erythema)
Lymph nodes esp in L suprclavicular fossa (s/o GI malignancy)
Colour of the stool.
Enlarged liver (portal hypertension)
Abdominal mass (malignancy)
PR mass in rectum or presence of malaena
36
Surgery- CP
Investigations
CBC for anaemia or infection, or low platelets
ESR for inflammatory bowel disease or malignancy
Stool examination microscopy for infection + occult blood if history of malaena
PT/INR, PTT for coagulopathy
Liver function tests
BUN and creatinine (impaired renal function due to prolonged hypotension, or increased
bleeding tendency due to renal failure).
Nasogastric tube aspiration to identify a possible upper GI source (in the patient with
hematochezia and hemodynamic compromise).
Upper endoscopy if the nasogastric lavage yields coffee-ground material or bright red blood
Colonoscopy for the evaluation of hematochezia.
Proctosigmoidoscopy if bright red bleeding per rectum
CT/MRI imaging
CT angiography has an ancillary role for colonic vascular ectasia.
Comments
Bright red blood most often indicates a distal colonic source or a rapidly bleeding proximal
(gastric or small bowel) source. Blood originating from the left colon is typically bright red,
while bleeding from the right colon usually is dark or maroon. Note that melena usually
suggests an upper GI bleed, but bleeding from the small bowel or cecum may present this way.
Distinctions based on stool color are therefore helpful, but not absolute.
Signs of hemodynamic instability include postural changes, pallor, palpitations, chest pain,
dyspnea, tachycardia. An orthostatic drop in systolic blood pressure of > 20mm Hg or an
increase in heart rate of > 30 beats/minute indicates at least a 15% acute loss of blood volume.
Resuscitation efforts are an important part of the initial management.
Hematochezia should be investigated in all cases. Patients should be categorized into low or
high risk for complications based on their clinical presentation and hemodynamic status.
o Low risk patients (e.g. a young otherwise healthy patient with self-limited bleeding)
may be evaluated in the outpatient setting.
o High risk patients (e.g. those with hemodynamic instability, serious comorbid disease,
the need for blood transfusions) should be resuscitated and hospitalized. A
gastroenterologist and surgeon should be involved early in the hospital course.
Haematochezia , massive upper GI bleed
Upper GI bleeding oesophageal varices, peptic ulcer
Small bowel bleeding vascular ectasias, NSAID enteropathy, tumors, Crohns disease,
infection, ischemia, small bowel varices, diverticula, and Meckels diverticulum. Crohns,
angiodysplasias, malignancy
Colorectal bleeding - diverticulosis, angiodysplasia, neoplasms, post-polypectomy bleeding,
colitis, colon ulcerations, haemorrhoids, fissure, bacterial or amoebic dysentery.
37
Surgery- CP
Dark/ Maroon
blood
Colorectal Small bowel
No pain in
Painful abdomen
abdomen
Tumours e.g. Infection (enteric

adenocarcinoma, fever, ulceration
GIST due to TB)
Diverticula Ischaemia
NSAID
Crohns disease
enteropathy
Vascular ectasia
.
Clinical clues
Ask for:
Colour of stool small bowel bleeding may be black and tarry or dark/maroon colour
Painful or painless
Associated diarrhoea (suggests infection, Crohns or tumour)
Weight loss (malignancy, Crohns)
Age of patient
o Younger Crohns
o Older - malignancy
History of multiple perianal fistulae (Crohns)
Use of NSAIDs
Family history
Look for:
Pulse, blood pressure
Anaemia, jaundice, cachexia, lymph nodes
Abdominal mass
Hepatomegaly (malignancy or portal hypertension)
Investigations
CBC/ESR
PTT/INR
Stool examination microscopy and occult blood
Liver function test
Upper GI endoscopy
38
Surgery- CP
Capsule endoscopy and push-enteroscopy have roles in evaluating the small bowel in cases of
obscure GI bleeding.
Radionuclide imaging with tagged red blood cell scintigraphy plays an ancillary role as a
screening test for mesenteric angiography.
Angiography has an ancillary role in localizing rapidly bleeding lesions and has potential for
therapeutic intervention.
Repeat upper endoscopy and colonoscopy with intubation of the terminal ileum may find a
bleeding source that was missed or intermittently bleeding from the small bowel.
Enteroscopy may be used to evaluate the small bowel.
Comments:
Capsule endoscopy is a new technology that enables endoscopic evaluation of the entire small
bowel. Images are transmitted from an ingested capsule endoscope to a recording device and
then downloaded to a computer workstation.
Radionuclide scanning may detect bleeding at a rate of 0.1 to 0.5 mL/ minute, but can only
localize bleeding to an area of the abdomen.
Angiography may be helpful in the evaluation of an overt GI bleed if the bleeding rate is greater
than 0.5 mL/minute and has the potential for localizing the bleeding site.
CT and MRI enterography are new techniques for small bowel exam.
Intraoperative enteroscopy during laparatomy may be used as a last resort to visualize most or
all of the small intestine.
Maroon/dark
blood
Large bowel Small bowel
Painful
No abd pain
abdomen
Post-
Diverticular
Neoplasm Angiodysplasia intervention
disease
(polypectomy)
Dark red bleeding with or without clots, mixed in with stool is most often due to colorectal sources. The
two most common causes of significant bleeding are colonic diverticulosis and angiodysplasia. Other
etiologies include colitis, neoplasms, and following biopsy or polypectomy.
Clinical Clues
Ask about
Associated pain
o Acute, painless hematochezia, s/o diverticular disease or angiodysplasia.
Recurrence of bleeding
o Episodic and self-limited - common in both diverticulosis and angiodysplasia.
39
Surgery- CP
o Low-grade, recurrent bleeding suggestive of colon cancer or polyps

Amount of bleeding
Colour of blood .
o Bright red blood suggests left-sided lesions
o Bright red on toilet paper or coating stool s/o haemorrhoids
o Maroon or melenic stools suggest right-sided lesions.
Associated diarrhoea or constipation
History of endoscopic biopsy or polypectomy (bleeding may be acute or delayed up to 2
weeks).
Drug history
History of bleeding disorder
Family history of bowel disease (familial polyposis coli, bowel malignancies)
Look for
Pulse, BP
Pallor, cachexia, lymph nodes
Palpable lump in the abdominal examination (malignancy)
Rectal exam for polyps or masses
Investigations
CBC/ESR
PTT/INR
Colonoscopy
Tagged red blood cell scintigraphy - a screening test prior to proceeding to mesenteric
angiography in a difficult case.
Mesenteric angiography
Comments
Bleeding from colonic diverticula is the most common cause of lower GI bleeding (30-50%). A
diverticulum is a sac-like protrusion of the colonic wall located in the colonic wall at the site of
penetrating nutrient vessels. The prevalence of diverticular disease increases with age.
Bleeding is arterial and can occur either at the dome or at the neck of the diverticulum.
Diverticular bleeding usually stops spontaneously, but the recurrent bleeding rate is 14% to
38%. Bleeding may be massive with diverticular disease.
The pathogenesis of bleeding in diverticular disease is related to penetration of an artery into
the dome of a diverticulum and rupture as a result of erosion from pressure rather than
infection. Patients with recurrent diverticular bleeding may require combinations of
colonoscopic, angiographic, and surgical treatment.
Angiodysplasia or vascular ectasias are common causes of lower GI bleeding (20%-30%)
associated with tortuous submucosal vessels. The prevalence of angiodysplasia and the risk of
bleeding increases with age. Bleeding is venous in origin, as opposed to arterial bleeding in
diverticula. The pathogenesis of angiodysplasia is unknown.
Bleeding angiodysplasia is an indication for endoscopic therapy (endoscopic coagulation,
injection, or metallic clip placement). Pre-operative localization of bleeding should be
attempted in all patients prior to surgical intervention. Vascular ectasias can occur anywhere
along the GI tract, but are predominantly located in the cecum and ascending colon.
Intermittent low-volume bleeding, bright red blood on toilet paper or coating the stool, usually
painless, suggestive of hemorrhoids. Severe hematochezia is rare with hemorrhoids, but can
occur, especially with coagulopathies or cirrhosis. Suspect hemorrhoids in a young patient with
hematochezia.
Hematochezia due to hemorrhoids results from rupture of internal hemorrhoids which are
supplied by the superior and middle hemorrhoidal arteries. Hematochezia due to neoplasm is
the result of overlying erosion or ulceration.
40
Surgery- CP
Colonoscopy plays both a diagnostic and therapeutic role in the management of acute
hematochezia. The diagnosis of diverticular disease is usually made by exclusion, most often by
the identification of diverticula by colonoscopy, in whom other causes of lower GI bleeding
have been excluded. Colonoscopy often identifies angiodysplasia that are not actively bleeding,
so the role of the lesion is uncertain.
There is a low rate of complications from colonoscopy, usually cardiorespiratory or perforation.
Angiography has a higher complication rate including arterial thrombosis, contrast reactions,
and acute renal failure.
Mesentric angiography may be useful to visualize active bleeding at a rate of at least 0.5 to 1.0
ml/minute. Indications include massive bleeding that precludes colonoscopy, or after a
colonoscopy fails to identify a bleeding site.
CT angiography is a recently introduced procedure that may have a place in the diagnostic
algorighm for detecting vascular extasias. Barium enema does not have a role in the initial
evaluation of patients with hematochezia.
Acute post-polypectomy bleeding involves an underlying artery or inadequate coagulation of
the polyp stalk. Delayed post-polypectomy bleeding is due to sloughing of the coagulated
eschar. Post-polypectomy bleeding may be managed endoscopically.
Simple polyp
Diverticular disease
Angiodysplasia
Neoplasm
Post intervention (biopsy, colonoscopy)
Maroon/
dark red
Colorectal Small bowel
Painless Painful
Colitis
(infectious, IBD*, Intussusception
ischaemic)
*IBD Inflammatory bowel disease (Ulcerative colitis or Crohns)
Clinical Clues
Ask about
Associated with abdominal pain
o with or without diarrhea suggests infectious colitis or inflammatory bowel disease
(ulcerative colitis, Crohns colitis).
o In elderly suggests ischemic colitis
o In young children with blood mixed in stool s/o intussusception
Bowel habit
o Constipation
o Diarrhoea colitis (infection, inflammatory, ischaemic, radiation)
History of radiation therapy for abdominal and pelvic cancers (radiation colitis - either as an early or
late complication)
41
Surgery- CP
Look for:
Pulse, BP
Fever (infection)
Anaemia, jaundice, LN
Abdominal pain
Abdominal mass (tubular mass in intussusception)
PR for any mass
Investigations
CBC/ESR
Anoscopy
Colonoscopy
Biopsies may evaluate suspected neoplasms and colitis.
Stool for culture, ova and parasites may detect causes of infectious colitis (i.e. Salmonella,
Shigella, Campylobacter, E. histolytica).
Ultrasound of the abdomen is helpful in intussusceptions.
Comments
Ischemic colitis therapy is directed at correcting the underlying cause and volume repletion.
Bleeding is usually self-limited.
Bleeding due to both ulcerative colitis and Crohns colitis may be managed medically, but at
times may require surgical intervention.
In pediatric age group, other than polyp, intussusceptions is one of the commonest causes of
lower GI bleeding due to ischaemic segment of the bowel usually idiopathic
In adult intussusceptions however there is usually a lead point Radiological reduction is
curative if bowel is healthy (no sign of peritonitis) otherwise surgical intervention is required.
Colitis (inflammatory bowel disease, infectious colitis, ischemic colitis, radiation colitis).
Intussusception
Bright red blood

(anorectal cause)
Painful Painless
Anorectal
Fissure in ano Haemorrhoid
neoplasm
Ask for:
Bowel habit
o Constipation risk factor for haemorrhoids
if also painful defecation with bright red blood s/o fissure in ano
Bright red on toilet paper or coating stool s/o haemorrhoids
Sensation of a lump coming down
Rectal itching common sign of haemorrhoids
Previous history of haemorrhoids, including previous surgery
Look for:
Presence of skin tags, external prolapsed pile, or excoriations
PR if painful s/o fissure in ano or prolapsed, thrombosed haemorrhoid
Investigations:
Proctoscopy to visualize the region.
42
Surgery- CP
Breast Disorders
Breast
Disorders
Breast Breast Nipple

lump pain discharge
Breast
Disorders
Nipple
Breast lump Breast pain
discharge
Non-discrete
discrete (nodularity)
Mobile with
Irregular
regular
mass
margin
Clinical clues
Ask for
Age : mobile lump in young age group is likely to be fibroadenoma; discrete lump in older age
group ( i. e>35 ) needs to be considered as malignant until proven otherwise
Duration of the lump
Rate of growth of the lump
Size of the lump when first noticed
Associated pain,(cyclical or non-cyclical) nipple retraction, nipple discharge
Any nodule in axilla
Family history of breast malignancy
Look for
Asymmetry Look for the breast outline and contour for any bulging areas.
Skin changes - Check for dimpling or retraction, edema, ulceration, erythema, or eczematous
appearance such as scaly, thickened, raw skin.
Nipples - Assess for symmetry, inversion or retraction, nipple discharge or crusting.
Axillary lymphadenopathy If palpable consistency, tenderness, matting and mobility should
be noted.
If any lump noted following things should be noted
o Location of the lump
o Size of the lump
o Mobility (Adherance with surrounding breast tissue, underlying pectoralis muscle,
chest wall or with overlying skin)
o Surface of the lump
o Consistency
o Tenderness
o Associated nipple discharge
43
Surgery- CP
Comments
In patiens presenting with breast lump, distinguish between non-discrete nodularity and
discrete mass. Non-discrete nodularity associated with pain in the breast (cyclical or non-
cyclical ) is most likely to be due to ANDI
Highly mobile lump in young age group is likely to be fibroadenoma.
All discrete mass needs a diagnosis
Hard lump with nipple retraction suggests malignancy.
In advanced disease, there may be peau de orange or ulceration.
Tumour may be fixed with surrounding breast tissue or with pectoralis or chest wall or with
overlying skin in advanced disease
Triple assessment should be done [ clinical , radiology eg. Mammogram, histological i.e FNAC or
biopsy ( core or open)] to ascertain the diagnosis.
Breast
Disorders
Nipple
Breast lump Breast pain
discharge
Without signs
With signs of
of
inflammation
inflammation
Breast pain is a common complaint that makes women seek medical help. It could be because of
normal physiological changes related to hormonal fluctuation or to a pathological process such as
breast cancer or any other inflammatory process such as breast abscess / mastitis.
Clinical clues
Ask for
Whether the pain is bilateral or localized to the single breast.
Severity of the pain.
Whether the pain peaks during midcycle or premenstrually.
Any associated fever.
History of recent trauma to the chest.
History of recent birth or pregnancy loss or termination.
Look for
Any signs of inflammation such as localized area of tenderness or erythema or increased
temperature.
Associated lumps in the breast or discharge from the nipple.
Enlarged axillary or supraclavicular lymph nodes.
Investigations
Diagnostic aspiration if indurated area with sign of inflammation is present. Presence of pus
confirms breast abscess. If there is no signs of inflammation and if aspiration shows milk,
diagnosis of Galactocele can be made.
Pus for culture and sensitivity not required routinely (as causative organism is frequently
Staphylococcus aureus) but sent if the abscess has occurred in non-lactating women.
Comments
Breast abscess is common in lactational period and is caused by obstructive lactopathy.
Occasionally non-lactational breast abscess can occur.
Cyclical pain arises from hormonal effects on the breast and is associated with ovulation. It
occurs during the luteal phase, occurs usually before menstruation and is diffuse.
44
Surgery- CP
Breast
Disorders
Breast Breast Nipple

lump pain discharge
Single
Multi-duct
duct
Nipple discharge could be the presenting complaint of the women .If associated with lump, investigate
as per lump.
Clinical clues
Ask for
Occurs spontaneously or during manipulation of the breast.
Whether it is from a single mammary duct or from multiple ducts.
Character of the discharge.
Whether it is foul smelling or not.
Whether the discharge is blood mixed or not.
History of drug intake (drugs like metoclopramide, chloropromazine, haloperidol and verapamil
can cause galactorrhoea)
Look for
Whether the discharge is from a single mammary duct or from multiple ducts.
Character of the discharge.
Presence of the underlying lump.
Nipple areola complex should also be examined to rule out conditions like Pagets disease or
Eczema that mimic nipple discharge.
Condition of the axilla.
Investigations
Mammography especially in women above 30 years of age.
Nipple discharge for cytology ( negative result does not rule out pathology).
Comments
Benign nipple discharge is usually bilateral, multiductal, and occurs with breast manipulation (
usually due to duct ectasia),.
Single duct discharge should be considered to be due to papilloma, sometimes due to
carcinoma and needs a definite diagnosis ( requires microdochectomy i.e single duct excision)
The most common cause of pathologic nipple discharge is a papilloma (52 to 57 percent).
45
Surgery- CP
Burn
Burn
Scald/Flame Electrical Chemical Radiation
Burn is the injury to tissues caused by contact with dry heat (fire), moist heat (steam or hot liquid)
chemicals (eg. alkali, acid), electricity (current & lightening) or radiant energy.
The incidence of burn injury varies greatly between cultures. Most common cause of burn is thermal
burn and other causes include electric/lightning, chemicals and radiations. About half of the victims are
of pediatric age group. The majority of burns in children are scald caused by accidents and few are the
result of physical assault. Among adolescent patients, flame burns are more common than scald. Most
of the adult burn victims requiring hospital admission come with associated conditions like mental
disease, suicidal attempts, assault, epilepsy and alcohol or drug abuse.
Burn wound is classified by the depth of injury and treated mainly with references to % body surface
area (BSA) involved.
Major determinants of the outcome of burn victims are %BSA burn, depth of burns and presence of an
inhalational injury
Clinical clues
Ask for:
Mode of injury including the information about the scene at the particular period of injury
Did the burn occur in an enclosed space (risk of inhalation injury)
Exact time of the burn, preferably in hours
Any associated trauma
Names of any chemicals involved
Initial first aid treatment or primary survey given prior coming to hospital
If any other victims are coming from the same accident
Look for
Airway, breathing, circulation, disability including neurological status
Exposure with environmental control and fluid resuscitation to complete primary survey as per
ATLS protocol.
Evidence of smoke inhalation and airway burn (soot in nostrils, singes or burns around nose or
mouth)
Thorough head to toe examination to complete secondary survey as per ATLS protocol.
Assess the body surface area burn quickly/roughly e.g. rule of nine for large burns and, palm
and fingers surface area of the patient himself for small burns (see later in CP)
Vital signs including body weight and adequate hourly urine output.
46
Surgery- CP
Investigations
Key initial investigations for the major burn patient:
o CBC
o Blood group and cross match
o Arterial blood gases (ABG)
o Carboxyhemoglobin level, especially important in patient with flame burn in closed
environment
o Electrolytes and Creatinine
o Serum glucose
Other investigations include:
o Pregnancy test in all females of childbearing age
o CXR
o Other X-rays may be indicated for associated injuries.
o Cardiac monitoring: dysrhythmias may be the first sign of hypoxia and electrolyte or
acid-base abnormalities.
Albumin and protein (in later phase as indicated)
HCT (in later phase as indicated) most of the patients show polycythemia due to
hemoconcentration at initial period
Comments
o Once patient is stable, calculate the BSA burn using most appropriate method e.g. Lund
and Browder chart
o Determine if the patient needs admission or can be discharged with wound care.
o Tetanus booster dose is mandatory in all burn victims
o Stress ulcer prophylaxis with histamine blockers as first line agents for preventing
stress ulcers is useful.
Type of burn and the mode of injury
Other associated injuries or disorders
Presence of Inhalation injury
47
Surgery- CP
Scald/Flame
?Airway Injury No Airway Injury

Acute airway injury in burn patient can occur either at supra glottis airway, from nose to larynx, by hot
gases inhalation or at infra glottis airway on inhalation of gases or stem with high latent heat of
evaporation. Airway and pulmonary gaseous exchange can be compromised in:
Direct inhalation injury (commonest)
Chemical pneumonitis
Mechanical block on rib movement impairing ventilation.
Clinical clues
Ask About
A history of being trapped in a burning room. Any one trapped in a fire for more than a couple
of minutes must be observed for signs of smoke inhalation.
Change in voice
Difficulty in breathing
Look for
Deep burns around the mouth and neck
Burns on the palate or nasal mucosa, or loss of all the nostril hairs
Carbonaceous sputum and wheezing
Altered consciousness level
Progressive hoarseness and stridor are ominous signs of impending airway obstruction, which
may develop over 1218 hours and they are very late symptoms of airway
obstruction/swelling.
Deep circumferential burn around neck and chest wall.
Investigations
Chest X-ray : patchy consolidation
ABG : initially may be normal or reveal only mild hypoxemia and metabolic acidosis due to
carbon monoxide.
Comments
Burn patient with inhalation injury has significantly high mortality
Hot gases can physically burn the upper airway resulting to laryngeal edema in few hours. If
proper action is not taken to secure air way complete air way obstruction can occur causing
acute respiratory failure and difficulty in securing air way. Therefore, elective ETT intubation is
mandatory in suspected victims.
Delay in securing airway can make intubation very difficult because of swelling. Therefore be
ready to perform an emergency cricothyroidotomy if intubation is delayed
Carbon monoxide is a product of incomplete combustion, which has 240 times greater affinity
to hemoglobin than oxygen. Blood level of >10% is alarming and need prompt treatment with
pure high flow of O2 for more than 24 hours.
Flexible bronchoscopy of the upper airway and the tracheobronchial tree reveals erythema,
edema, mucosal ulcerations and carbonaceous deposits
Suspicion of upper and lower airway injury
Circumferential full thickness burn requiring fasciotomy
48
Surgery- CP
Scald / Flame Burn

% BSA Burn Depth of Burn
Meeting
Admitting
Criteria
Not meeting
Admitting
criteria
Burn size needs to be formally assessed in a controlled environment, with a care not to cause
hypothermia.
Clinical clues
Ask for
Areas of the body which have been burnt (hands, face or genitalia should be admitted)
Mode of burn (e.g. electrical burns usually require admission)
Time since burn occurred
Age of patient very young and very old should be admitted
Pre-existing illnesses, drug therapy, allergies and drug sensitivities
History of psychiatric problems (is this a suicide attempt?)
Social problems (attempted homicide, or poor support at home for burn care?)
Tetanus immunisation status.
Look for
% TBSA involved
Examine entire body surfaces including perineum and genitalia
Evidence of inhalation injury
Signs of dehydration and shock (tachycardia, hypotension, reduced capillary filling)
Adequate urine output every hour
Comments
It is important to expose entire burn area in a warm and closed room. The extent of the burn can be
calculated using the rule of nines, which states that each upper limb is 9% TBSA (total body surface
area), each lower limb 18%, the torso 18% each side and the head and neck 9.
In the case of smaller burns or patches of burn, the best measurement is to cut a piece of clean paper
the size of the patients whole hand (digits and palm), which represents 1% TBSA, and match this to the
area.
Another accurate way of measuring the size of burns is to draw the burn on a Lund and Browder chart,
which maps out the percentage TBSA of sections of our anatomy. It also takes into account different
proportional body surface area in children according to age.
If not available:
o For children <1 year: head = 18%, leg = 14%.
o For children >1 year: add 0.5% to leg, subtract 1% from head, for each additional year
until adult values are attained.
49
Surgery- CP
Not all burned patients will need to be admitted to a burns unit. There are certain criteria for acute
admission to a burns units, which are :
o Suspected airway or inhalational injury
o Any burn likely to require fluid resuscitation
In children with burns over 10% TBSA and adults with burns over 15% TBSA,
consider the need for intravenous fluid resuscitation
Oral fluids / ORS may be used in first aid setting or mass casualty incident
o Any burn likely to require surgery
o Patients with burns of the hands, face, feet or perineum
o Patients whose psychiatric or social background makes it inadvisable to send them
home
o Any suspicion of non-accidental injury
o Patient at the extremes of age
o Any burn with associated potentially serious sequelae including electrical burns and
chemical burn
Common types of fluid used for resuscitation :
o ringers lactate or Normal saline
o human albumin solution or fresh frozen plasma when indicated
Simplest and most widely used formula for fluid resuscitation is Parkland formula
o Parkland formula : %TBSA x weight (kg) x 4 = volume in ml. Half of the volume is given
in the first 8 hours and the second half is given in the subsequent 16 hours.
Timing is from time of the burn, so if a patient presents to ER only after 4
hours, then the first half of the volume of fluid needed must be given in the
next 4 hours (so within 8hrs of burn occurring).
The key is to monitor urine output.
In children, maintenance fluid, usually dextrose saline, must also be given as
o 100 ml/kg over 24 hours for the first 10 kg
o 50 ml/kg for the next 10 kg
o 20 ml/kg for each kilogram over 20 kg body weight
Scald/Flame
burn
% BSA Depth of burn
1st Degree 2nd Degree 3rd Degree
Non
Circumferential
circumferential
The burning of human skin is temperature and time dependent, which ultimately determine the depth
of burn. Depth of burn is classified in 1st, 2nd and 3rd degrees, which corresponds to superficial partial
thickness, deep partial thickness and full thickness burns.
50
Surgery- CP
Clinical clues
Ask for
Temperature
Time in contact with burning material
Pain (full thickness burns are not painful, while partial thickness are extremely painful)
Look for
Blistering (present in 1st and 2nd degree, absent in 3rd degree)
Leathery feel with thrombosed vessels (3rd degree)
Color of underlying dermis : 10 pink and moist, 20 not much moist, with fixed capillary
staining, 30 - dry, white or black, no blisters
Capillary return : 10- clearly visible when blanched, 20- color doesnt blanch with pressure, 30 -
none
Pin prick sensation : 10 normal, 20 - reduced and not able to distinguish sharp from blunt
pressure, 30 completely anesthetized
Circumferential full thickness burn
o Distal pulses
o Cyanosis, impaired capillary refill, progressive neurological impairment
Investigations
Tissue or pus culture if get secondary infection
Doppler ultrasound of distal pulses in circumferential burn
Comments
Superficial partial thickness burns damages no deeper than the papillary dermis. It heals without
residual scarring in 2 weeks and the treatment is non surgical.
Deep partial thickness burn damages to the deeper parts of the reticular dermis and epidermis is
usually lost. It heals in 3-4 weeks without surgery, usually leading to hypertrophic scarring.
Full thickness burn usually destroys whole of the dermis and requires surgery. If it is circumferential in
areas like neck, arms and chest wall, requires fasciotomy
Burn wounds are dynamic and need reassessment in the first 24-72 hours because depth can increase
as a result of inadequate treatment or superadded infection. Burns can be superficial in some areas but
deeper in other areas
Electrical
Low Voltage High Voltage

.... ,,,,
Electrical injury may be either due to AC or DC current. The threshold for low and high voltage being
1000 volts
Clinical clues
Ask for
Type of electrical sources,
o Low-tension, or domestic appliance, injuries do not have enough energy to cause
destruction to significant amounts of subcutaneous tissues when the current passes
through the body.
51
Surgery- CP
o In high voltage current (power lines, lightning) can cause significant injury, often not
immediately obvious from external appearances
Did the patient find themselves held to the power source (due to tetany)? AC prolonged
contact with electricity source, so more damage
Were they thrown away from the electricity? DC
Trauma associated with the electrical shock
Look for
Airway, Breathing and Circulation as in other trauma cases.
Entry and exit wounds
Pulse rate and rhythm
Skin for burns and blisters
Compartment syndrome
Urine output and color of urine (aim for relatively higher urine output of about 2 ml /kg/h)
Neurologic function: assess mental status, pupillary function, strength and motor function, and
sensation
Ophthalmologic: assess visual acuity; inspect the eyes, including a funduscopic examination
Ear, nose, and throat: inspect the tympanic membranes; assess hearing
Musculoskeletal: inspect and palpate for signs of injury (eg, fracture, acute compartment
syndrome), and be certain to examine the spine
Investigations
12 lead ECG
Basic serum electrolytes (including potassium and calcium)
Creatine phosphokinase (to detect muscle injury)
Serum troponin
Basic blood counts
Renal function studies (creatinine and BUN)
Urine for myoglobin
ABG : Severe acidosis is common in large electrical burns and may require boluses of
bicarbonate
Radiographic studies if suspect injury (especially cervical spine)
Comments
MECHANISM OF INJURY Injuries due to electricity occur by three mechanisms:
o Direct effect of electrical current on body tissues
o Conversion of electrical energy to thermal energy, resulting in deep and superficial burns
o Blunt mechanical injury from lightning strike, muscle contraction, or as a complication of
a fall after electrocution
Factors influencing severity of injury include: amount of current flowing through the body
(most important), the voltage, resistance, type of current (AC or DC), the current pathway, and
duration of contact.
Tissues with higher resistance have a tendency to heat up and coagulate, rather than transmit
current. Skin, bone, and fat have high resistances, while nerves and blood vessels have lower
resistances. Wet skin has a much lower resistance than dry skin, allowing more current to be
transmitted and therefore more damage.
Entrance and exit wounds generally do not help predict the path of the current, and the skin
findings can significantly underestimate the degree of internal thermal injury.
The main danger with low voltage electric injuries is from the alternating current interfering
with normal cardiac pacing. This can cause cardiac arrhythmia or arrest. The electricity itself
does not usually cause significant underlying myocardial damage.
High-voltage electrical injuries can lead to three sources of damage: the flash, the flame and
the current itself. The damage to the underlying muscles in the affected limb can cause the
rapid onset of compartment syndrome requiring fasciotomy. The release of the myoglobins will
cause myoglobinuria and subsequent renal dysfunction. Sometimes severe injury through the
limb may require primary amputation to save the life.
52
Surgery- CP
Chemical
Alkali Acid Others
Ultimately, there are two aspects to a chemical injury. The first is the physical destruction of the skin,
and the second is any poisoning caused by systemic absorption
Clinical clues
Ask for
Type of chemical
Occupation of patient
Time of burn
Any first aid administered
Decreased vision
Eye pain and photophobia
Look for
Airway, Breathing and Circulation as in other trauma cases.
Degree of burn
Blepharospasm (inability to open the eyelids)
Conjunctival redness
Investigations
Not usually needed
pH of the eye using litmus paper as a guide to when irrigation may be stopped (normal 6.5-7.5) (urine
dipstick may be used as this contains litmus paper)
Comments
Management of chemical burns focuses on copious water irrigation, except in a few cases where the
chemical will react with water to produce heat e.g. dry lime, phosphorus, elemental potassium and
sodium, phenol, concentrated sulphuric acid.
Alkalis are usually the more destructive and are especially dangerous if they have come into contact
with the eyes
53
Surgery- CP
Radiation
Focal Whole Body
The commonest type of radiation burn is sunburn. Other types are rare.
Clinical clues
Ask for
Type of radiation exposure
Duration of exposure
Occupation e.g. works with X-Ray equipment, nuclear industry
History of radiotherapy treatment for cancer
Look for
Redness of skin
Ulcerations at exposed area
Pulse, blood pressure
Investigations
CBC
Electrolytes
Comments
Radiation burns are often associated with cancer due to the ability of ionizing radiation to interact with
and damage DNA. The clinical results of ionizing radiation depend on the dose, time of exposure, and
type of particle that determines the depth of exposure.
Certain parts of the body are more sensitive to radiation exposure than others e.g. gonads
(radiotherapy may lead to infertility), eyes (later develop cataracts).
Whole-body exposure to large doses of penetrating ionizing radiation (e.g. in a nuclear accident) can
cause acute radiation syndrome. There are three phases:
Prodromal phase 0 to 2 days after exposure

o nausea, vomiting, and diarrhea
Latent phase (asymptomatic) 2 to 20 days after exposure
Manifest illness 21 to 60 days after exposure
o Infection, anaemia and bleedeing
o Uncontrollable diarrhoea, hypovolaemia, electrolyte disturbances
o Deteriorating mental status, cerebral oedema, cardiovascular collapse
Children are at greater risk than adults for sequelae (eg, increased risk of leukemia, thyroid cancer,
ocular cataracts, growth retardation, and infertility) even at doses that do not cause immediate injury.
Local burns from radiation causing ulceration need excision and vascularised flap cover usually with
free flaps
54
Surgery- CP
Constipation
CONSTIPATION
Drugs
PRIMARY SECONDARY
Slow Normal transit & Pelvic floor Metabolic/

Obstruction Neurologic
transit pelvic floor dysfunction Endocrine
Idiopathic IBS-C Central Peripheral
Constipation usually refers to disordered bowel function associated with infrequent bowel movements,
staining, or hard stools. An international committee has proposed the following criteria for functional
constipation based on the presence of 2 of the following for at least 3 months with symptoms onset at
least 6 months prior to diagnosis:
1) Straining during at least 25% of defecations
2) Lumpy or hard stools in at least 25% of defecations
3) Sensation of incomplete evacuation for at least 25% of defecations
4) Sensation of anorectal obstruction/blockage for at least 25% of defecations
5) Manual maneuvers to facilitate at least 25% of defecations (e.g. digital evacuation, support of
the pelvic floor)
6) Fewer than 3 defecations per week
7) Loose stools are rarely present without the use of laxatives.
Clinical Clues
Ask about
o What the patient means by constipation; what features does the patient rate as most
distressing?
Infrequency
Straining
Hard stools
Unsatisfied defecation
Symptoms that occur in between infrequent bowel movements (bloating, pain,
malaise), suggestive of IBS
o The duration of symptoms, frequency of bowel movements, and associated symptoms
such as abdominal discomfort and bloating, and assessment of stool consistency, stool
size, and degree of straining during defecation.
55
Surgery- CP
Look for
o Any outstanding physical abnormalities.
o Fecal impaction, anal fissure, hemorrhoids, usually a consequence of the constipation
o Rectal mass present or stricture, on digital examination of the rectum; evaluate the
integrity of the rectum.
Investigations
Three major investigations are useful in the evaluation of constipation
Colonoscopy (useful to identify lesions which narrow or occlude the bowel).
Radiography (plain films of the abdomen or barium enema) useful to detect structural causes
of constipation and for the diagnosis of megacolon and megarectum.
Marker studies (colonic transit studies are useful in the evaluation if patients major complaint
is infrequent defecation).
Specialized testing also includes anorectal manometry, balloon expulsion and barium
defecography.
Drugs
Primary
Secondary
Evidence
1. Longstreth GF, Thompson G, Chey WD, et al. Functional bowel disorders. Gastroenterology
2006; 130: 1480 1491.
2. Patel SM, Lembo AJ. Constipation In: Feldman M, Friedman LS, Brandt LJ. Sleisenger and
Fordtrans Gastrointestinal and Liver Disease; Pathophysiology, Diagnosis, Management.
Saunders Elsevier: Philadelphia; 2006: pg 221 253.
3. Qureshi W, Adler DG, Davila RE, et al. ASGE guideline: Guideline on the use of endoscopy in the
management of constipation. Gastrointest Endosc 2005; 62: 199 201.
4. Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a
systematic review. Am J Gastroenterol 2005; 100: 1605.
CONSTIPATION
Drugs
PRIMARY SECONDARY
The first step in diagnosing chronic constipation is to determine whether the symptoms of constipation
are secondary to medications.
Clinical Clues
Ask about
o Review the past medical history and take a careful drug history, including the use of
OTC medications and herbal medications.
o The temporal relationship between starting a drug and the onset of constipation.
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Surgery- CP
Comments
Constipation may occur as a side-effect of commonly used drugs.
Medications most significantly associated with constipation are opiods used for chronic pain,
diuretics, antidepressants, antihistamines, antispasmodics, anticonvulsants, and aluminum-
containing antacids.
Analgesics
o Opiod agonists/opiates (e.g. loperamide, morphine, fentanyl),
Anticholinergic agents (antihistamines, antispasmodics, antidepressants, antipsychotics)
Cation containing drugs
o Iron supplements
o Aluminum (antacids, sucralfate)
Neurally active agents
o Antiparkinsonian drugs
o Anticonvulsants (e.g. phenobarbital, carbamazepine, phenytoin)
Antihypertensive drugs
o Calcium channel blockers (e.g. verapamil)
o Diuretics (e.g. furosemide)
o Ganglion blockers
Antineoplastic agents (e.g. vinca alkaloids).
5HT3 antagonists (e.g. alosetron)
CONSTIPATION
PRIMARY SECONDARY
An important step in the clinical approach to constipation is to distinguish primary from secondary
constipation.
Clinical Clues
Ask about
o Duration of symptoms, since long duration suggests a functional disorder, while the
new onset of constipation suggests structural disease.
o Abdominal pain: it is uncommon in 1o constipation.
o Absence of any other symptoms safe constipation is suggestive of primary conditions.
o Abdominal pain or rectal bleeding, suggestive of secondary constipation
o Recent and persistent change in bowel habits is suggestive of secondary disease (unless
there is a readily definable cause such as medications) should prompt further
evaluation to exclude structural bowel changes or organic disease.
o Excessive straining, incomplete evacuation, occult bleeding (especially in older
individuals), suggestive of secondary causes.
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Surgery- CP
CONSTIPATION
PRIMARY SECONDARY
Metabolic/
Endocrine
Secondary constipation on the basis of mechanical small or large bowel obstruction, and systemic
illnesses must be excluded.
Clinical Clues
Ask about
o A recent and persistent change in bowel habits that is not associated with a readily
definable cause of constipation suggests structural bowel changes or organic diseases,
especially in older patients.
o Presence of warning symptoms such as unintentional weight loss, abdominal pain,
rectal discomfort, blood in stool, family history of colon cancer.
o Other systemic symptoms.
o Other neurologic symptoms.
Ask about
o The possibility of pregnancy if applicable.
o The history of diabetes mellitus
o Changes in voice register, cold intolerance, suggestive of hypothyroidism
Look for
o Rectal mass, fissures, hemorrhoids, anal stricture, on rectal exam
o Hypothyroid facies, slow return of deep tendon reflexes.
Investigations
Tests to exclude systemic disease
Tests to exclude structural disease of the GI tract
Patients who are older than 50 and who have not previously had colon cancer screening should
have a colonoscopy. Colonoscopy with complete examination of the colon is necessary to
exclude a structural disease (colon cancer, colonic stricture) when there is a recent change in
bowel habits, the presence of blood in stools, or other alarming symptoms (e.g. weight loss).
Flexible sigmoidoscopy and colonoscopy are superior techniques to identify lesions which
narrow or occlude the bowel; they also permit biopsy and polypectomy to be accomplished.
If alarm symptoms are present, a complete blood count and metabolic profile should be
ordered.
Serum electrolytes, glucose, and calcium
Thyroid function tests.
Comments
A recent change in bowel habits suggests structural bowel changes of organic diseases,
particularly in older patients.
Patients with constipation should undergo colonoscopy if they have blood per rectum, heme-
positive stool, iron deficiency anemia, weight loss, obstructive symptoms, and recent onset of
constipation, rectal prolapse, or change in stool caliber.
Adults older than age 50 who present with constipation should undergo a colonoscopy.
58
Surgery- CP
Mechanical obstruction
o Colon cancer
o Extrinsic compression from malignant lesion
o Strictures: diverticular or post-ischemic
o Anal fissure/stenosis
o Post-surgical abnormalities
o Megacolon
o Rectocele (if large)
Neurogenic and myopathic disorders
o Amyloidosis
o Scleroderma
o Parkinsons
o Spinal cord injury or tumor
o CVA
o MS
o Autonomic neuropathy
Metabolic and endocrinologic disorders.
o Diabetes mellitus
o Hypothyroidism
o Panhypopituitarism
o Hypokalemia/hypomagnesemia
o Hypercalcemia
o Uremia
o Pregnancy.
Other
o Depression
o Immobility/degenerative joint disease
o Cognitive impairment
59
Surgery- CP
SECONDARY
Metabolic/
Endocrine
Central Peripheral
Clinical Clues
Ask about
o Neurologic disorders
Look for
o Neurologic signs
o A gaping or asymmetrical anal opening may suggest a neurologic disorder impairing
sphincter function.
Investigations
Anorectal manometry can be used to assess the resting and maximum squeeze pressure of the
anal sphincters, presence or absence of relaxation of the anal sphincter.
Comments
In Hirschsprungs disease, there is the absence of the rectanal inhibitory reflex.
Colonic and anorectal motor functions are coordinated by enteric, sympathetic, and
parasympathetic nerves. Therefore, diseases of the central and peripheral nervous systems are
often associated with constipation.
The high prevalence of constipation in multiple sclerosis and Parkinsons disease may be
worsened by physical inactivity or the use of medications with constipating side effects.
Central
o Multiple sclerosis
o Parkinsons disease
o Spinal cord injury
Peripheral
o Hirschsprung disease
o Autonomic neuropathy
o Intestinal pseudoobstruction
o Chagas disease
60
Surgery- CP
CONSTIPATION
PRIMARY SECONDARY
Slow Pelvic floor Normal transit &

transit dysfunction pelvic floor
Constipation is most often caused by disordered function of the colon or rectum (primary
constipation). Physiologically, it may be characterized as either normal transit constipation, slow
transit constipation and rectal evacuation disorders/outlet delay (pelvic floor dysfunction).
Clinical Clues
Ask about
o Prolonged and excessive straining before elimination are suggestive of pelvic floor
dysfunction
o If bowel movements are extremely infrequent, (less than 1 bowel movement per
week), it is suggestive of the least common type of primary constipation (functional
constipation): Slow transit constipation
Lack of urge to defecate.
Associated symptoms may include malaise and fatigue.
Poor response to fiber and laxatives.
More prevalent in young women.
o Infrequent bowel movements, ineffective and excessive straining, and the need for
manual disimpaction in elderly patients with chronic constipation and excessive
straining.
o Dietary history, level of activity.
Look for
o Contraction of the puborectalis and external anal sphincter muscles may be evaluated
by asking the patient to strain during rectal examination; it is useful in identifying
patients with possible dys-synergic defecation.
Investigations
An investigation may not be necessary for many patients since constipation is so common,
especially young adults.
Investigations may be indicated to determine the underlying pathophysiologic process when
the symptoms are unresponsive to simple treatment.
In younger patients, a flexible sigmoidoscopy may be sufficient to exclude distal colonic
disease.
Physiologic testing is not necessary for most patients with constipation and is reserved for
patients with reszfactory symptoms.
Colonic transit study can be done to confirm the patients complaint of constipation and assess
colonic motility for slow transit.
Colonic transit time is measured by performing an abdominal x-ray 120 hours after the patient
has ingested radiopague markers in a gelatin capsule.
The characteristic finding is retention in the colon of radiopaque markers 5 days after ingestion.
In the absence of alarm symptoms or a family history of colon cancer, anorectal testing is not
necessary until patients have failed conservative treatment (e.g. increased dietary fiber and
liquids, elimination of medications with constipating side effects).
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Surgery- CP
Colonic transit can be assessed by radiopaque markers.

The rectal balloon expulsion test, performed by measuring the time required to expel a rectal
balloon filled with water or air, is a useful test for evacuation disorders. Normally, a 50mL
water filled balloon can be expelled in less than one minute. An abnormal balloon expulsion
test indicates impaired evacuation.
Anorectal manometry can be used to measure intrarectal and anal pressures at rest and during
attempted defecation. Abnormal anorectal manometry is demonstrated by inappropriate
contraction of the pelvic floor muscles or impaired relaxation of basal resting sphincter
pressure.
Defecography can detect structural abnomalities (rectocele, rectal prolapse) and assess
functional parameters (e.g. the anorectal angle, perineal descent), but its value is controversial
due to poor standardization. Thickened barium is instilled into the rectum while the patient is
on a radiolucent commode.
Comments
The prevalence of self-reported constipation is more common in women than men.
The prevalence of constipation increases with age in most studies.
The yield of colonoscopy in isolated constipation is low, but findings may include colon cancer,
solitary rectal ulcer syndrome (indicating prolapic), and anal.
Colonic inertia is a term used to describe patients with symptoms at the severe end of the
spectrum.
Pelvic floor dysfunction refers to defecatory disorders arising from failure to empty the rectum
effectively because of an inability to coordinate the abdominal, rectoanal, and pelvic floor
muscles. Constipation is functional and caused by dysfunction of the pelvic floor muscles as
determined by physiologic tests.
Normal defecation involves the coordinated relaxation of the puborectalis and external anal
sphincter muscles, together with increased intraabdominal pressure and inhibition of colonic
segmenting activity.
The pathogenesis of defecatory disorders is probably multifactorial.
Normal colonic transit
Slow transit/colonic inertia
Outlet delay/pelvic floor dyssynergia
Structural abnormalities
o Rectocele
o Weakness of the pelvic floor
o Diminished rectal sensation
o Rectal prolapse
o Solitary rectal ulcer syndrome.
Evidence
1. Bharucha AE, Wald A, Enck P, et al Functional anorectal disorders.
Gastroenterology 2006; 130: 1510 1518.
62
Surgery- CP
PRIMARY
Slow Normal transit & Pelvic floor

transit pelvic floor dysfunction
Idiopathic IBS-C
The most common type of primary constipation is normal transit constipation (stool travels along the
colon at a normal rate). Irritable bowel syndrome (IBS) is associated with a change in bowel habit.
Functional constipation is a bowel disorder presenting as persistently difficult, infrequent, seemingly
incomplete defecation, without under-lying structural or biochemical disorder, and not meeting IBS
criteria.
Clinical Clues
Ask about
o Exactly what the patient means by constipation; what features are most distressing?
Symptoms that occur between infrequent bowel movements such as bloating,
pain, malaise, suggestive of IBS
o The patients GI symptoms quality, general health, psychological status, use of
constipating medications, dietary fiber intake, level of physical activity, and signs of
other medical illness.
Investigations
Testing is based on the patients age, duration and severity of symptoms, psychosocial factors,
and alarm symptoms.
Laboratory tests may include glucose, electrolytes including calcium, thyroid function tests.
Investigations may include a sigmoidoscopy or colonoscopy to look for inflammation, tumors or
melanosis coli due to regular laxative use.
Endoscopic evaluation of the colon may be justified for patients >50 years old with new
symptoms or patients with alarm features or a family history of colon cancer.
If fiber supplementation fails to help or worsens the constipation, measurements to whole gut
transit time may identify cases of anorectal dysfunction or colonic inertia.
Comments
Diagnostic criteria for IBS are recurrent abdominal discomfort at least 3 days per month in the
last 3 months associated with 2 or more of the following:
o Improvement with defecation
o Onset associated with a change in frequency of stool
o Onset associated with a change in form (appearance) of stool
These criteria are to be fulfilled for the last 3 months with onset of symptoms onset at least 6
months prior to diagnosis. IBS is sub-typed by predominant stool pattern: IBS-C (IBS with
constipation) hard or lumpy stools > 25% and loose (mushy) or watery stools < 25% of bowel
movements. Other subtypes of IBS, are IBS-D (IBS with diarrhea), mixed IBS, and
undifferentiated IBS.
Since symptoms do not discriminate between physiologic subgroups of patients with primary
constipation, the work up is similar regardless of presenting symptoms.
The finding of diverticulosis on colonoscopy does not change the diagnosis.
63
Surgery- CP
The first line of treatment for constipation is to alter lifestyle, particularly to increase fluid and
exercise, as well as increasing fiber intake either through changes in diet or commercial fiber
supplements.
Specific agents used in the treatment of chronic constipation include commercial fiber products
(bulking agents), osmotic laxatives, stimulant laxatives, stool softeners, enemas and
suppositories, pro-kinetic agents (not currently available in the U.S.), and secretory agents
(lubiprostone). One behavioral method is defecation training.
IBS-C
Idiopathic (predominantly in women)
o Normal colonic transit
o Colonic inertia
o Outlet delay
Evidence:
1. Kamm MA. Clinical case: chronic constipation. Gastroenerology 2006; 131: 233239.
2. Wald A. Chronic constipation: advances in management. Neurogastroenterol Motil 2007; 19:
4-10.
3. Zuckerman MJ, Guerra LG, Drossman DA, et al. Comparison of bowel patterns in Hispanics and
non-Hispanic Whites. Dig Dis Sci 1995; 40: 1763-1769.
64
Surgery- CP
Dying Patient
Dying patient
Patient dying with Patient dying with

acute illnesses chronic illnesses
Patients dying with acute illnesses present with conditions like sudden cardiac arrest, trauma patients
such as severe head injury or pnemothorax and such patients need resuscitation as most of the cause
are reversible. The American Heart Association (AHA) developed the most recent ACLS guidelines in
2010, which is followed widely all over the world (as will be discussed elsewhere).
Where as patients dying with chronic illnesses do not present with acute symptoms. They can be
recognized by following symptoms, which and mostly subtle and occurs for a course of days or weeks:
Profound weakness
Diminished intake of food and fluids
Drowsy or reduced cognition
Gaunt appearance
Difficulty swallowing medicine
Patient dying with

chronic illnesses
Not for Resuscitation

resuscitation needed
Based upon the diagnosis of the patient, patients are classified as patients not for resuscitation or
patients who needs resuscitation. Do Not Resuscitate (DNR) status of the patient should be discussed
with the patients kin beforehand and should be documented. A DNR order should be considered when
the frailty, comorbiity, maximal medical treatment or advanced age of a patient means that any
attempt at CPR in the event of a cardiac or respiratory arrest will be futile.
Clinical clues
Ask about the primary disease of the patient and the current concern of the patient.
Ask about whether the patient is experiencing profound weakness or ask the relatives or carers
whether patient is bedbound or needs assistance with all care.
Look for
o Whether the patient is in pain or distress
o Difficulty in intake of food and fluids
o Whether the patient is drowsy or disoriented or difficulty concentrating
o Look whether the patient is cooperating with the carers or not
65
Surgery- CP
Investigations
Investigations in the patients with terminal illnesses should be limited and if done, should be
justified.
Comments
A doctors duty in palliative care of the patient is to
o Ensure the patients comfort physically, emotionally and spiritually
o Make the end of the life peaceful and dignified
o Make the memory of the dying process as positive as positive to patients and their carers.
The terminal phase of the patient is defined as the period when day to day deterioration
particularly of strength, appetite and awareness are occurring.
It is notoriously difficult to predict when death will occur. Professionals should avoid the trap of
predicting or making a guess since they are like to be incorrect which may well leave patients
and families confused and angry.
Patient dying with

chronic illnesses

Symptom control Psycological Bereavement
Palliative care is surgical, medical and nursing care aimed specifically at relieving the problems
associated with terminal conditions, when the possibility of cure has been abandoned.
The following principles are followed at the time of palliative care
Focus on quality of life which includes good symptom control
Whole person approach along with psychosocial care
Support to the caregivers after the death of the patient during bereavement
Clinical clues
Ask for
Reason that is causing distress to the patient
o It can be a particular symptom that is troubling the patient
o Or it may be some social issue that is causing anxiety to the patient
Patients choice regarding place of care or treatment options
Look for
Physical examination to identify likely cause of pain or distress
o Patient in pain usually exhibit unhappy facial expression such as grimace or they might be
anxious and irritable.
o Limb pain or back pain or abdominal pain can be assessed by palpating the particular part.
o Headache due to raised intracranial pressure can be assessed with the help of
ophthalmoscope.
Investigations
Should be limited and if done, should be justified eg: in limb pain or in sever backache x-ray of
that particular area is done to rule out pathological fracture.
66
Surgery- CP
Dying patient

Psycological
Symptom control Aspects of terminal Bereavement
illnessl
Skin, neurological
And Respiratory Psyciatric
Pain GI Symptoms
Orthopaedic problems Problems
problems
Supportive symptom control helps the patient and their family to cope with cancer and treatment of it.
Clinical clues
Ask for
Detail clinical history to determine the cause of pain.
o Site, severity, timing, duration and quality of pain
o Impact of psychological factors
o Whether there are any associated GI symptoms like constipation or vomiting.
o Analgesic drug history along with route of administration
Look for
Detail physical examination to determine the cause of pain
o Abdominal distention and tenderness
o Limb or spine tenderness
o Ophthalmoscopic examination to rule out raised intracranial pressure
o Pressure sores
o Per Rectal Examination
o Psychiatric assessment.
Review medication to assess if medication is the cause for the distress.
Comments
Having identified the cause of the pain, it is useful to classify the pain into predominantly
nociceptive or neuropathic in order to determine the correct management. Nociceptive pain is
again divided into Somatic or Visceral pain.
A patients treatment should start at the level of the WHO analgesic ladder appropriate for the
severity of the pain.
Choice of pain management according to the cause of pain should be as follows
o Bone pain NSAIDs, palliative radiotherapy, IV bisphosphonates, Immobilization if
pathological fracture
o Abdominal pain if colicy pain Hyoscine Butylbromide (upto 20-60 mg/24 hrs), enema
or stool softener if constipation, prokinetics with antacids if gastric distention, Coeliac
plexus block if upper GI tumour, NSAIDs,
o Neuropathic pain amitriptyline, carbamazepine, gabapentin, phenytoin or sodium
valproate,
o Anal spasms GTN ointment 0.1-0.2%,
o Muscle pain Paracetamol, NSAIDs, muscle relaxants like diazepam, baclofen or
dantrolene.
o Pain of short duration eg dressing changes- fentanyl or oral morphine.
67
Surgery- CP
Patient dying
with chronic
illnesses

Psycological
illnessl
Skin, neurological
And Respiratory Psyciatric
Pain GI Symptoms
Orthopaedic problems Problems
problems
Nausea and vomiting are two symptoms that can cause patients and their caretakers in distress. Apart
from that GI problems like constipation, Intenstinal Obstruction and diarrhea can add problem to the
patients.
Clinical clues
Ask for
Patients appetite.
If the patient is not taking food normally, ask for the reason that is causing decreased intake, either
nausea or dysphagia.
Whether the patient is experiencing nausea, vomiting, constipation, obstipation or diarrhea.
o If patient is vomiting, nature, colour and timing of the vomiting.
o Ask if patients vomitus contained blood or is of coffee coloured.
o If having diarrhea, ask for frequency, consistency, colour and if the stool contains mucus or
blood.
o Ask if the patient is passing flatus or not
Look for
Pallor, nutritional and hydration status.
Whether the patient is having oral ulcers.
Check for the tenderness, distention or lump in the abdomen.
If distention present, check for fluid thrill or shifting dullness.
Per Rectal Examination: look for anal tone, whether rectum contains impacted stool, blood in
the examining finger or extraluminal mass.
Review patients drugs to see whether there are any drugs causing nausea or constipation. For
example: Metronidazole causing nausea and Opoids causing constipation.
Investigations
Like in other cases with palliative care, investigations should be limited. But few indicated tests
are well justified such as stool routine examination to rule out infective cause of diarrhea and
x-ray abdomen supine to diagnose intestinal obstruction.
Comments
Causes of vomiting and choice of antiemetic
o Drug induced or metabolic eg hypercalcaemia Haloperidol or Levopromazine
o Chemotherapy / radiotherapy Granisetron or ondansetron, Haloperidol or
Dexamethasone, Metoclopramide
o Increased intracranial pressure Dexamethasone
o Anxiety, fear or pain Diazepam or Midazolam or Levpromazine
o Gastric stasis Domperidone or Metoclopramide
o Constipation Laxatives / Suppositories / Enemas
68
Surgery- CP
o Intestinal Obstruction surgery if appropriate, Dexamethasone and antiemetic or

venting gastrostomy or antisecretary agenets eg Octreotide
Causes of Constipation
o Disease related (Immobility, paraplegia, poor intake, low residue diet)
o Fluid depletion (Poor intake, loss due to diarrhea or vomiting)
o Drugs (Opoids, Diuretics, TCA, Ferrous sulphate)
o Intestinal obstruction (Disease related eg Bowel mass or metabolic eg hypokalaemia)
Causes of diarrhea-
o Imbalance in laxatives
o Drugs such as antibiotics or Antacids
o Radiotherapy
o Malabsorption (due to gastrectomy, ileal resection or colon resection)
o Rectal tumors (causing mucus mixed diarhoea)
Patient dying
with chronic
illnesses

Psycological
Symptom control Aspects of Bereavement
terminal
illnessl
Skin, neurological Respiratory Psyciatric

Pain GI Symptoms And problems Problems
Orthopaedic
problems
A wide variety of dermatological, neurological and orthopaedic problem may happen in patients with
chronically debilitating illnesses.
Clinical clues
Ask for
o Patients conscious level
o Whether the patient is bed ridden or need assistance for mobilization.
o Whether the patient wets his or her bed.
o Whether the patient had wound on the pressure points such as sacral area, occipur or heel
area of the feet.
Look for
o Fungating wound (eg breast fungation)or metastatic skin nodules.
o Look for redness or wound at the pressure points such as occiput, scapular region, sacral
region, heels.
o Stiffness of the joints.
o Sensation and motor functions of the limbs along with tone and power.
Investigations
o Pus culture from the wound.
o Otherwise other investigations should be limited.
Comments
o While choosing a wound care regimen, we should consider pain, odour, infection, exudate,
necrotic tissue, bleeding, cosmesis and psychological effects.
69
Surgery- CP
Patient dying
with chronic
illnesses

Psycological
Symptom control Bereavement
Aspects of terminal
illnessl

Orthopaedic
problems
Cough and breathlessness are the two common respiratory problems that trouble the patients with
terminal illnesses. These symptoms are prominent in the case of lung cancer but can happen in other
malignancies with lung metastasis.
Clinical clues
Ask for
o Whether cough is associated with breathlessness or not.
o Any prolong bouts of cough.
o Associated haemoptysis, vomiting.
Look for
o Anaemia, cyanosis, oxygen saturation.
o Always look for stridor.
o Tracheal displacement.
o Breath sound: determine whether it is diminished on one side of chest.
o Percussion note: determine whether it is dull on percussion of hyperresonant.
o Associated facial puffiness and hoarseness suggest superior venacava syndrome.
Investigations
o Chest X-ray to rule out pnemothorax or hydro/haemothorax.
o Bronchosopy might be indicated in few to assess mechanical obstruction to the trachea or
bronchus by tumor or foreign body or secretions.
Comments
General respiratory care can relieve the patient from distressing cough
o Patients may benefit from vibration, percussion and postural drainage of the chest along
with nebulised normal saline to clear the sputum.
o Simple linctus and nebulized bupivacaine might be helpful as the peripheral cough
suppressant.
o Opoids such as codeine or morphine can be used as central cough suppressant.
o Increased respiratory secretion can respond to glucocorticoids and ipratropium inhalation
.Causes of breathlessness are
o Disease related (Lung cancer, lung metastasis, pleural effusion, SVC obstruction,
pericardial effustion or phrenic nerve palsy)
o Treatment related (Surgery like lobectomy, radiotherapy, chemotherapy causing
pneumonitis, fibrosis)
o Pre-existing conditions (like infection chronic respiratory or cardiac disease, pulmonary
edema, pneumothorax or pulmonary embolus)
o Co-existing debilitating factors (infection, anemia, muscle weakness, fatigue)
o Co-existing psychological factors (fear, anxiety)
70
Surgery- CP
o Treatment of the reversible causes must always be tried

o Bronchospasm nebulized broncholdilators and steroids.
o Pleural effusion pleural aspiration or pleurodesis.
o Infection antibiotics with physiotherapy
o Lung related pain adequate analgesia
o Symptomatic anaemia consider blood transfusion
o Large airway obstruction steroids, stenting.
o SVC Obstruction consider steroids, chemotherapy or radiotherapy.
Patient dying
with chronic
illnesses

Psycological
illnessl
Skin, neurological
Respiratory Psyciatric
Pain GI Symptoms And
problems Problems
Orthopaedic
problems
Anxiety is common in the terminally ill patient for a variety of reasons. Te spectrum of anxiety ranges
from normal through the persistent and severe anxiety. Similarly, depressed mood, irritability, loss of
interest in anything, feelings of worthlessness and lack of hope for the future are important causes of
suffering.
Clinical clues
Ask for
o A detail psychiatric assessment should be done
o If the anxiety and depression severe
o Is it long standing?
o Is it related to a specific fear?
o Are the family anxious?
Look for
o Look for any reversible factor such as pain or unfounded worries.
Investigations
o No investigations are helpful hence are better avoided.
Comments
o It is necessary to provide time and opportunity for patients to express their worries and
concerns and for these concerns to be addressed honestly and clearly.
o Relaxation or complementary therapies may help.
o Benzodiazepines are useful to break the anxiety cycle, to restore sleep and to reduce the
suffering of the situation.
o TCAs and SSRIs are commonly used for patients with terminal illness with moderate success.
71
Surgery- CP
Patient dying
with chronic illnesses

Psycological
illnessl

Orthopaedic
problems
Grief is normal reaction to a bereavement or other major loss. Its manifestations will vary from person
to person but will often include physical, cognitive, behavioural and emotional elements.
Normal manifestations of grief
o Physical manifestation tightness in chest and throat.
o Emotional manifestation feelings of anger or guilt, anxiety, sadness, helplessness.
o Cognitive manifestation disbelief, denial and a sense of unreality.
o Behavioural manifestation disturbed appetite and sleep.
Psychological stages of phases of grief
o Kubler-Ross (1970)- shock/denial, anger, bargaining, depression and finally acceptance.
Ways of helping a bereaved person
o Being there for them
o Non-judgemental listening
o Encouraging them to talk about the deseased
o Giving permission for the expression of feelings
o Offering reassurance about the normality of feelings
o Providing information when requested about the illness and death of their loved ones
o Educating others about how best to help the bereaved person
o Becoming familiar with ones own feelings about loss and grief.
Breaking bad news
Patients and relatives need time to absorb information and to adapt to bad news. Health professionals
need good communication skills, including sensitivity and empathic active listening.
o Preparation
o What does the patient know?
o Give a warning shot
o Allow denial
o Explain (if requested) and check understanding
o Is more information wanted/
o Listen to concerns
o Encourage ventilation of feelings
o Summary and plan
o Offer availability
72
Surgery- CP
Haematuria
Haematuria
(distinguish from
pigmenturia)
No history of
History of trauma
trauma
Blood at urethral
Glomerular
meatus
Blood thoroughly
Extraglomerular
mixed with urine
Blood at end of
Non-significant
micturition
Haematuria is the presence of RBCs in urine. Haematuria can be frank or microscopic. Frank or Gross
haematuria is red coloured urine. Microscopic haematuria is significant when there is more than 5 RBCs
per High Power Field (HPF) from centrifused freshly voided urine.
True haematuria must be distinguished from red pigmentation of the urine. If the urine is allowed to
sit in a container for some time or centrifused, there may be sedimentation. If the sediment is red
this is red blood cells. If the supernatant fluid is red then this is pigmenturia. Red supernatant fluid
should be dipsticked for haem.
Haem negative fluid:
Ingestion of beetroot
Intake of drugs like Phenazopyridine, Nitrofurantoin. (Rifampicin may give orange coloured
urine).
Porphyria
Haem positive fluid:
Myoglobinuria (ask about crush injury)
Haemoglobinuria (intravascular haemolysis e.g. G6PD deficiency)
73
Surgery- CP
Haematuria
History of trauma + No history of trauma
Clinical clues
Ask for:
Pain at the flank.
History of trauma? Direct trauma to the abdomen or to the lower chest can cause injury to
kidneys. Presence of frank peritonitis raises suspicion of injury to other intra-abdominal organs
like liver, spleen or intestines.
Whether there is any history of instrumentation in the urinary tract such as cystourethroscopy,
ureterorenoscopy, TURP or Foleys catheterization.
Look for
Airway, breathing and circulation as in other trauma cases.
In secondary survey, look for flank bruising or haematoma, tenderness in chest compression,
loin tenderness, fullness of the loin and abdominal distention.
Investigations
Dipstick test: Dipsticks impregnated with chemicals that change colour in presence of blood is a
rapid method to detect haematuria.
Urine routine examination: Urine microscopy is essential to detect presence of RBCs or WBCs in
urine. Presence of bacteria indicates infection. Similarly, presence of RBC casts suggest disease
affecting renal parenchyma.
Ultrasonography can shows perirenal haematoma or urinoma, free fluid in abdomen and
presence of absence of urine in bladder as well as other associated injury.
Contrast CT Scan is indicated to assess the degree of renal injury. It is also useful to diagnose
associated other intra-abdominal organ injury.
For assessment of bladder injury, cystogram should be performed.
Comments
Haematuria can also be classified as glomerular or extra-glomerular, based on its urine
examination finding.
o Glomerular: presence of dysmorphic RBCs, presence of RBC casts. clots absent,
proteinuria >500gms/day,
o Extra-glomerular: isomorphic RBCs and absence of RBC casts. Clots present sometimes,
proteinuria <500 gms/day
Presence of myoglobin in urine is associated with crush syndrome after major trauma.
Diagnoses to be considered
Traumatic causes
Blunt and penetrating renal injury
Ureteric injury
Bladder injury
Urethral injury
Iatrogenic injury to renal tract
74
Surgery- CP
Non-traumatic
Glomerular
Glomerulonephritis
IgA nephropathy
Thin basement membrane disease
Alports syndrome
Extraglomerular
1. Painless
Bladder Carcinoma
Benign enlargement of prostate
Prostate carcinoma
Renal Cell Carcinoma
Bleeding disorders
Polycystic disease
SLE
Interstitial nephritis
Wilms Tumor
2. Painful
UTI/cystitis
Renal / Ureteric / Bladder / Urethral Stones
Pyelonephritis
Renal Cell Carcinoma
Haematuria
No history of
History of trauma
trauma
Blood at urethral Blood

Blood at the end of
meatus mixed with urine
micturition
i.e. urethral injury i.e. renal injury
Haematuria following trauma can be both microscopic haematuria or gross haematuria.
Clinical clues
Ask about
Difficulty passing urine or urinary retention after trauma.
o Unable to pass urine signifies complete urethral disruption or bladder injury
Is urine more red at the beginning or the end of micturition or if blood is thoroughly mixed
with urine.
Look for
Pelvic compression test
Palpable Bladder
Blood in the meatus or not.
Perineal haematoma or not.
75
Surgery- CP
Per rectal examination, high riding prostate (suggests disruption of urethra)
Investigations
Ultrasonogram or abdomen and pelvis
Contrast CT scan of the abdomen
Ascending urethrogram
Cystogram
Comments
Ureteric injury is rare and is usually due to penetrating injury. It is usually associated with other
intraabdominal organ injury.
Blood appearing at the beginning of the urinary stream indicates a lower urinary tract cause,
whereas urinary staining throughout the stream points to a cause higher up. Terminal
haematuria is typical of bladder origin. Similarly, blood at the meatus is typical of urethral
injury.
Renal trauma : Closed or blunt kidney injury is usually due to blow or fall on the loin, crush
injury to the loin typically after road traffic accident. Open kidney injury may be because of stab
injury in the loin or gunshot injury. Conservative watchful management of closed renal trauma
is usually successful. If there are signs of progressive blood loss or expanding mass in the loin or
if patient condition is deteriorating or if there are associated other injuries, surgical exploration
is needed.
Male urethra because of its length is more prone to injury. Site of urethral injury depends upon
the mode of injury. Blow to the perineum for example during cycle accident, man-hole injury or
gymnasium injury might injure the bulbar part of the urethra. Injury to the pelvis causing pelvic
fracture might cause membranous urethra injury. Vigorous sexual intercourse causing penile
fracture may be associated with penile urethral injury. If patient is able to pass urine,
observation should be done. If patient not able to pass urine, suprapubic catheterization should
be the immediate management modality. Per urethral catheterization or instrumentation can
further exacerbate the damage.
Bladder injury may occur either extraperitoneally or intraperitoneally. Extraperitoneal bladder

rupture is more common (80%) than intraperitoneal. Fall on a full bladder may cause
intraperitoneal bladder rupture, whereas blunt abdominal trauma and associated pelvic
fracture are usually the cause of extraperitoneal bladder rupture. It may be very difficult to
differentiate extraperitoneal bladder rupture from membranous urethral injury. Surgical repair
is needed for intraperitoneal bladder rupture. When there is extraperitoneal bladder rupture
Foleys catheterization for about 2 weeks may be adequate.
76
Surgery- CP
Haematuria
History of No history of
trauma trauma
Extraglomerular Glomerular Non-significant
With proteinuria
Pyuria present (See Proteinuria
CP)
Without
Pyuria absent proteinuria
(isolated)
In the absence of a history of trauma, causes of haematuria can be divided into glomerular,
extraglomerular and non-significant.
A single urinalysis with microscopic haematuria is common and may result from menstruation, viral
illness, allergy, exercise or mild trauma. However persistent or significant haematuria (> 5 RBCs/HPF on
centrifused urine sample on three occasions or a single urinalysis with >100 RBCs, or gross haematuria
visible to the naked eye) require further investigation as there is a high incidence of significant
pathology.
Clinical clues
Ask for:
History of abdominal pain, its position and nature (for stones).
History of urinary tract symptoms such as dysuria, frequency, difficulty passing urine, urinary
retention (suggest an extraglomerular cause).
Systemic features suggestive of renal failure (fatigue, easily tired, nausea, vomiting)
Systemic features suggestive of underlying systemic disease which is affecting the kidney (e.g.
joint pains in SLE, lung haemorrhage in Goodpastures)
History of current menstruation or recent vigorous exercise
Look for:
Pallor, facial puffiness, edema
Hypertension
Raised JVP, hepatomegaly, lung crackles suggestive of heart failure
Renal angle tenderness (tenderness at the junction of 12th rib and sacrospinalis muscle)
Tenderness at iliac fossae and hypogastric region
Per rectal examination to assess prostate consistency (usually in male patients >50yrs old)
Investigations
77
Surgery- CP
The key investigations to distinguish between glomerular and extraglomerular causes of haematuria
are:
Urine microscopy looking for dysmorphic RBCs or RBC casts these suggest there is
glomerular disease
Frank haematuria with or without clots is usually suggestive of an extraglomerular cause,

although it may also occur in IgA nephropathy and hereditary nephritis.
24 hour urinary protein - >500mg/24hr suggests glomerular disease
Other investigations will be discussed under the relevant headings.
Comments
IgA nephropathy is the commonest cause of haematuria in children. The majority present with gross
haematuria. Some may present with microscopic haematuria (with or without proteinuria)
Hypercalciuria and hyperuricosuria are risk factors for unexplained isolated haematuria in both children
and adults. In some of these patients, reducing calcium and uric acid excretion through dietary
interventions can eliminate the microscopic haematuria.
Glomerular causes of haematuria are usually painless. The commonest cause of extraglomerular
haematuria are stones which are usually painful
Glomerular causes
Extra glomerular causes
Non-significant
o Asymptomatic isolated microscopic haematuria
o Viral illness
o Vigorous
o Exercise
Glomerular
Isolated
haematuria Presence of
proteinuria
(no proteinuria)
See CP on
proteinuria
Many causes of haematuria due to glomerular disease are also associated with proteinuria. These
causes will be covered in a separate CP on proteinuria.
Investigations
A simple dipstick of urine will reveal whether proteinuria is present or not.
Diagnoses to consider in isolated haematuria
Thin basement membrane disease (defined by persistent microscopic haematuria and isolated
thinning of the glomerulobasement membrane on electron-microscopy)
IgA nephropathy
Alports syndrome
Diagnoses to consider in haematuria with proteinuria
Glomerulonephritis e.g. post streptococcal GN, SLE
Vascular causes e.g. Henoch schonlein purpura
IgA nephropathy
78
Surgery- CP
Haematuria
History of No history of
trauma trauma
Extraglomerular Glomerular Non-significant
Pyuria present Pyuria absent
UTI/cystitis Painful
Pyelonephritis Painless
In extraglomerular causes of haematuria, the next step in the diagnostic process is to look for presence
or absence of pyuria during routine urinalysis. Presence of pyuria suggests infection. When there is
pyuria plus haematuria there is usually pain.
Extraglomerular causes of haematuria pyuria present

Clinical clues
Ask for:
History of urinary tract symptoms such as dysuria, frequency, difficulty passing urine, urinary
retention.
Presence or absence of abdominal pain.
Associated fever, nausea or vomiting
Previous history of urinary tract infection
History of current pregnancy
Look for:
Temperature, pulse rate
Blood pressure
Renal angle tenderness, suprapubic tenderness
Palpable bladder (for retention)
Loin mass sign of formation of hydronephrosis or pyonephrosis
Investigations:
Urine microscopy (including dipstick for protein and glucose)
Urine culture
Blood culture (if systemically unwell with high grade fever)
CBC looking for raised count suggestive of infection (usually only done if suspecting
pyelonephritis. It is not necessary if the features are just of a simple UTI).
USG after an episode of pyelonephritis, recurrent UTIs or when presence of a stone
suspected
79
Surgery- CP
Comments:
Urinary symptoms like dysuria and retention suggest infection but may be present in renal stones
or other causes of inflammation in the urinary tract system.
A simple UTI or cystitis usually does not present with abdominal pain, except for occasional mild
suprapubic pain. In pyelonephritis there is usually pain in the loin. Pain radiating from the loin to
groin suggests an associated renal stone (can get infections secondary to the presence of a renal
stone).
UTI and pyelonephritis are common in pregnancy and may be relatively asymptomatic. Rapid
diagnosis and management is important because of potential harm to the foetus.
UTI
Pyelonephritis
Haemorrhagic cystitis
Extraglomerular causes of haematuria pyuria absent
Extra glomerular
Pyuria absent
Painful Painless
Other e.g. polycystic

Fixed renal Hypogastric Bleeding Malignancy or
Loin to groin kidney, interstitial
angle pain pain disorder tumour
nephritis
In the absence of pyuria infection is uncommon. Where pyuria is absent the next question to ask is the
presence or absence of pain.
Painful haematuria with no pyuria (extraglomerular)

The commonest cause of this is stones in the renal tract. The level and nature of pain gives clues as to
the level of the stone. Occasionally a renal cell carcinoma (in adult) or Wilms tumor (in child) may
present with fixed renal angle pain, haematuria and an abdominal lump.
Clinical clues
Ask for:
Site of pain
o Loin to groin suggests ureteric stone
o Fixed renal angle pain suggests renal stone(or renal tumor)
o Hypogastric pain suggests bladder stone
Radiation of pain
Associated burning micturition, fever or vomiting
Difficulty passing urine (bladder stone)
History of passage of stones in urine in the past
Look for:
Temperature, pulse rate
Renal angle tenderness
Loin mass sign of formation of hydronphrosis or pyonephrosis or tumor
80
Surgery- CP
Investigations:
Urine routine examination and urine for culture
X-Ray KUB radio-opaque shadow in the area of kidney, ureter and bladder if branched
confirms the diagnosis.
Ultrasound scanning radiolucent stones if not seen in X-Ray can be detected by USG along
with presence or absence of hydronephrosis
CT scan can show stones not revealed by either of the above
Intravenous Urography
Renal isotope scan (useful to obtain information about function in individual renal units)
o 99m Technetium labeled DTPA (Diethyltraminepentaaceticacid) assesses renal
function
o DMSA (Dimercaptosuccinic acid) can also be used for the same purpose.
Comments
Pain is the leading symptoms in 75% of people with urinary stones. Sometimes, large staghorn
calculi may cause no symptoms but causes progressive destruction of the renal parenchyma.
Types of stones can be divided as follows
o Calcium containing stones (common, 90% - radio-opaque) Calcium oxalate, Calcium
phosphate, Triple phosphate (Struvite)
o Non-calcium containing stones (less common, 10% - radio-lucent) cystine, uric acid
The causes of renal stones can be divided as follows
o Solute problems
Hypercalciuria
Hyperuricosuria
Hyperoxaluria low calcium intake
o Solvent problems
Hypocitrauria
Low urine volume
pH changes
Most stones of size less than 0.5 cm pass spontaneously from the ureter but there are five sites
of narrowings in ureter where stones may be arrested.
o Pelvi-ureteric junction
o Crossing of iliac artery
o Juxtaposition of vas deferens or broad ligament
o Entering of bladder wall
o Ureteric orifice
Most urinary calculus can be treated by minimal access techniques
o Percutaneous Nephrolithotomy (PCNL)
o Extracorporeal Shock Wave Lithotripsy (ESWL)
o Ureterorenoscopic lithotripsy (URSL) for ureteric stones.
81
Surgery- CP
Painless haematuria with no pyuria (extraglomerular)

Extraglomerular
(pyuria absent)
Painless Painful
Other e.g.
Malignancy or
Bleeding disorder polycystic disease,
tumour
interstitial nephritis
Drug related Kidney
Urothelial (mainly
Other
bladder)
Prostate
Painless haematuria in the absence of pyuria can be broadly due to a bleeding disorder, malignancy (or
polyp) in the UT system, or polycystic kidney disease. Malignancy is commoner in older persons and
those with certain occupational exposures.
Although these conditions classically present with painless haematuria, they can all cause pain if a clot
forms and is passed.
Clinical clues:
Ask for:
History of gross haematuria this tends to suggest a malignancy
History of smoking smoking is thought to contribute to up to 50% of urothelial cancers in men
and up to 40% in women (Harrisons 17th edition)
Occupation risk of urothelial disease is increased with exposure to aniline dyes (textile,
chemical, rubber, dye factory workers), the drugs phenacetin and chlornaphazine and external
beam radiation.
Geographical exposure to Schistosoma haematobium (Middle East, Africa and Far East)-
increases risk of malignancy of the bladder
Intake of drugs which increase bleeding e.g. warfarin, heparin, aspirin
Drugs such as cyclophosphamide which can cause haemorrhagic cystitis
Drugs which can cause interstitial nephritis e.g. penicillin, cephalosporin, anticonvulsants,
lithium, NSAID
History of purpura, gum bleeding, haemarthrosis, malaena
History of bleeding disorders in family
Family history of polycystic kidney disease
History of jaundice suggesting chronic liver impairment with resultant reduction in
production of clotting factors (chronic alcohol disease, chronic Hepatitis B or C etc)
Urinary symptoms retention, difficulty passing urine
Systemic symptoms suggestive of malignancy (weight loss, flank pain, fever, mass in flank)
82
Surgery- CP
Look for:
Pallor, icterus, oedema
Hypertension
Ballotable mass in loin (renal cell carcinoma in adults, Wilms tumour in children, polycystic kidneys)
Purpura, echymoses (suggest bleeding disorder)
Suprapubic pain/fullness
Tenderness at the spine (metastases from kidney cancer)
Per-rectal examination to assess consistency of prostate (hard craggy prostate suggests malignancy)
Liver enlargement (metastasis)
Signs of liver dysfunction (clubbing, ascites, flapping tremor, spider naevi, caput medusa, etc)
Investigations:
Not all the following investigations are needed. Investigations should be directed towards the probable
cause after taking a full history and examination. All adult patients with gross haematuria should have
cystoscopy to exclude malignancy.
Urine routine examination and urine for culture
Full blood count including platelet count
PT / INR and APTT, and bleeding time
Urea, creatinine, sodium and potassium
Ultrasound of abdomen and pelvis (to assess prostatic size, Intravesical prostatic protusion, residual
urine and also to assess presence of bladder mass)
Cystoscopy papillary or solid growth may be seen into the bladder lumen. Prostatic median lobe
enlargement or bladder neck stenosis can also be differentiated by cystoscopy.
Urine for cytology (malignant cells)
Intravenous urography (to look for filling defects in renal pelvis, ureter and bladder)
Transrectal Ultrasound to view prostate
Prostate Specific antigen 3-4ng/ml in 50-69 years male
CT / MRI to see invasion of Bladder Carcinoma / Prostatic Carcinoma to surrounding organs
Bone Scan: for secondaries from prostate cancer. Is done only if PSA level is > 10 ng/ml or the biopsy
shows high grade prostatic carcinoma.
Urine microscopy for schistosomia ova / ELISA test for schistosomiasis (if appropriate travel history)
Liver Function test
Diagnosis to be considered
Bladder carcinoma
Renal cell Carcinoma
Drug induced bleeding disorder
Interstitial nephritis
Thrombocytopenia
Haemophilia A & B
Liver Failure
Disseminated Intravascular Coagulation
Benign enlargement of prostate
Prostatic Carcinoma
Wilms tumour in children
Polycystic kidney disease
Schistosomiasis
Comments
Gross haematuria occurs in 80-90% of patients with urothelial tumours, and the bladder is the most
common source. However, benign cystitis is a commoner cause of gross haematuria than bladder
cancer.
Microscopic haematuria more commonly arises from the prostate
If there is suspicion of prostatic carcinoma because of local per rectal findings, a raised PSA or
metastatic disease, then a transrectal prostatic core biopsy from 10 systematic sites and suspicious
nodule is needed.
Schistosomiasis is endemic in countries like Egypt, parts of Africa, Syria, Saudi Arabia, Iran, Iraq and is
not common in this part of the world.
Reference
Harrisons Principles of Internal medicine, Ed 17 Volume I p 589-594
83
Surgery- CP
Lumps and Bumps
Lumps and
Bumps
Superficial Deep
Epidermis Dermis and

Muscle and
(see dermatology subcutaneous Bony
connective tissue
CPs) tissue
Cystic Soft Firm
There are many causes of lumps and bumps found in the body. A careful history and examination will
help to narrow down the differential diagnosis
Ask for:
Size of lesion and changes in size since discovery (rapid change s/o sarcoma)
Change in appearance since discovery
Are lesions scattered or solitary? Tumors and noninflammatory nodules tend to be solitary,
while infectious and inflammatory lesions are often multiple.
Are there signs of systemic disease fever, weight loss, joint swelling and pain (s/o infection or
inflammatory disease)?
Has the patient had previous lesions that have disappeared (eg, erythema nodosum or acute
rheumatic fever nodules)?
Look for:
General appearance (sick or well, anaemia, jaundice, lymphadenopathy)
Fever
Is the lump superficial or deep?
Is the lump cystic, solid or bony?
Changes in over lying skin
Features of systemic disease especially joint swelling
84
Surgery- CP
Lumps and bumps
Superficial Deep
Epidermis
Dermis and
(see dermatology subcutaneous tissue
CPs)
Cystic Soft Firm
Benign Tumour e.g.

Ganglion lipoma, fibroma, Sebaceous cyst
neuroma
Inflammatory e.g.
tophi, rheumatoid
Bursae Dermoid cyst
nodule, erythema
nodosum
Non-inflammatory
Tenosynovitis e.g. Synovial cyst
Malignant e.g.
liposarcoma,
metastatic carcinoma
Lumps which arise in the epidermis move with the skin on examination and there are surface changes
in the skin. When lumps arise in the dermis or subcutaneous tissue the skin appears normal and
usually moves over the lump on examination.
Lumps arising from the epidermis will be covered in dermatology. Lumps arising from the dermis and
subcutaneous tissue will be covered here.
Ask for:
Size of lump and change in size over time
Multiple or single lump
Associated pain
Associated paraesthesia (s/o neuroma)
Systemic features such as fever, anorexia, weight loss, joint pains or swelling s/o systemic
disease
Known systemic illness such as gout, rheumatoid arthritis, tuberculosis, sarcoidosis which may
have skin manifestations
Known malignancy that may metastasize to skin
Drug history (associated with erythema nodosum)
85
Surgery- CP
Look for:
Location (over pressure points at knees and elbows s/o bursitis, extensor surfaces s/o
rheumatoid nodules, digits of hand or helix of ear s/o tophi)
Size of lump (measure it and record in notes)
Moves with skin (epidermal) or skin moves over it (dermal or subcutaneous)
Appearance of skin (if normal then lesion is dermal, if abnormal then from epidermis)
Nature of lump (soft, cystic or hard)
Colour of overlying skin (red with inflammation)
Tenderness and warmth s/o inflammation or infection (e.g. bursitis, abscess, erythema
nodosum)
Transillumination confirms a cystic swelling
Multiple or single
Investigations
These are usually not necessary and a clinical diagnosis can be made. Most of these lumps are benign.
Occasionally the following may be indicated:
CBC and ESR if suspect inflammatory lesion
Rheumatoid factor
Uric acid (if suspect tophaceous gout)
Biopsy if suspect malignancy
Comments:
It can sometimes be hard to distinguish soft lumps from cystic, and some of the causes of firm
lump, may also sometimes be soft.
Sebaceous cysts are very common. They contain cheesy white debris and sebum and arise
from the dermis. They form soft smooth swellings over which skin cannot be moved. Usually
they are painless unless there is a secondary infection when they become red and painful.
Dermoid cysts are nests of epithelial cells which have been trapped in the dermis during
development or implanted after trauma. They form a soft rubbery swelling deep to the skin
which may be fixed deeply and extend down into underlying tissues.
A ganglion is a cystic swelling overlying a joint or tendon sheath. Ganglia are thought to arise
due to herniation of synovial tissue from a joint capsule or tendon sheath.
Lipomas are very common slow-growing benign tumours of fatty tissue. They are soft and
painless. Rarely a large lipoma can undergo malignant (sarcomatous) change.
Two common types of neuroma are the neurilemmoma (which arises from the Schwann cells of
a nerve sheath and is laterally mobile but fixed in the direction of the nerve) and neurofibroma
(a hamartoma of nerve tissue commonly multiple as in neurofibromatosis). Neurilemmomas
may cause pain in the distribution of the involved nerve.
Rheumatoid nodules are usually found on bilateral, extensor joint surfaces of extremities. They
are <1 cm in size and non-tender. They are associated with rheumatoid arthritis.
Erythema nodosum lesions are symmetrical red or violet subcutaneous nodules, 1 to 5 cm in
diameter and may be more easy to palpate than to see. Commonly found in the pre-tibial
region they may be associated with fever, malaise, and an acute polyarthritis. Erythema
nodosum is often associated with infections, drugs, or systemic diseases.
86
Surgery- CP
Lumps and bumps
Superficial Deep
Muscle and Bony (see CP on limb Lymph nodes

connective tissue deformity) (separate CP)
Fibrosarcoma Infection
Tumour e.g. Ewings

Rhabdomyosarcoma
sarcoma
Lipoma Metabolic
Fracture
Deep lumps and bumps may arise from muscle, connective tissue or from bone. Bony lumps will be
very hard and fixed to underlying skeletal bone. The differential diagnosis of bony lumps is covered in
the CP on limb deformity.
Here we will focus on lumps arising from muscle and connective tissue
Ask for:
When was the lump first noticed
Speed of growth
Distal neurological symptoms e.g. tingling or weakness
Look for:
Size of lump
If it is mobile until the muscle is contracted and then it is fixed s/o lump arising from muscle
Is the lump fixed to adjacent structures?
Reduced sensation or power distal to lesion.
Tenderness (s/o infection, most soft tissue sarcomas are not painful, Ewings sarcoma is painful)
Lymphadenopathy
Investigations
Plain XRay of site (for evidence of calcification)
CXR for lung metastases or TB
CT scan
Biopsy to confirm diagnosis
87
Surgery- CP
Comments
Delay in diagnosis of soft tissue sarcomas is common. Patients frequently do not seek prompt
medical attention due to the painless nature of the tumor, doctors may also assume they are
benign.
Given that benign soft tissue masses are at least 100 times more common than malignant soft
tissue sarcomas it can be difficult to determine which soft tissue masses warrant further
evaluation. The United Kingdom Department of Health has published criteria for urgent referral of
a patient with a soft tissue lesion:
o Soft tissue mass >5 cm (golf ball size or larger)
o Painful lump
o Lump that is increasing in size
o A lump of any size that is deep to the muscle fascia
o Recurrence of a lump after previous excision
Tumor depth was found to be the most sensitive marker of malignancy, followed by size >5 cm, and
a history of rapid growth.
There are over 50 different histological types of sarcoma. Soft tissue sarcomas most commonly
present as an enlarging, painless mass in the extremities or trunk. The presence of distant
metastatic disease at the time of initial diagnosis is uncommon but more likely in large, deep, high
grade sarcomas. About 80 percent of metastases are located in the lungs.
88
Surgery- CP
Lymphadenopathy
Enlarged Lymph
nodes
Painful Painless
Reaction to local Reaction to

/regional infection or generalized infection Localized Generalized
inflammation or inflammation
Haematological
TB lympadenopathy
malignancy
Infection e.g. HIV,

Neoplasia secondary syphilis,
CMV, EBV
Primary syphilis Drugs e.g. phenytoin
Other e.g. connective

tissue disease
sarcoidosis
The size of normal lymph nodes depends on the site. In adults, lymph nodes are said to be enlarged:
In cervical region if > 0.5cm
In axilla if >1cm
In groin if > 2cm
Most lymph nodes are not palpable in the neonate. With recurrent antigen exposure, lymphoid tissue
increases in volume. In children the cervical, axillary and inguinal nodes are commonly palpable. They
are not considered to be significantly enlarged unless > 1cm in cervical and axillary region, and > 1.5cm
in groin.
Lymphadenopathy may be caused by benign or malignant disease.
The main groups of lymph nodes are found in:

neck (pre-auricular, parotid, submandibular, submental, anterior cervical, posterior cervical
and supraclavicular)
axillary area
Epitrochlear (around elbow)
Inguinal
Femoral
Popliteal fossa
89
Surgery- CP
Enlarged
lymph nodes
Painful Painless
One of the key distinguish features of enlarged lymph nodes is whether there is pain or not. Painful
enlarged lymph nodes are usually due to infection or inflammation (reactive lymph nodes)
Clinical clues
Ask for:
Painful or not
Duration short suggests acute infection, longer suggests TB or malignancy
Rate of enlargement (rapid expansion suggests a reactive lymph node)
Persistence or continued enlargement (malignant lymph nodes gradually continue to increase
in size)
Associated symptoms
o weight loss, night sweats (suggest TB or malignancy)
o local infection (s/o reactive lymphadenitis)
Look for:
Site of lymph nodes (local or generalized)
Size (measure in centimetres)
Character: hard, soft, rubbery
Fixed or mobile
Search area that node drains for abnormalities
Other general examination (e.g. joints, rashes, clubbing)
Comments:
Lymphadenopathy is said to be generalized if 2 or more non-contiguous regions are involved. i.e. R
axilla and R cervical region are contiguous, while R axilla and R groin nodes are non-contiguous.
90
Surgery- CP
Enlarged lymph nodes
Painful Painless
Localized Generalized
For painful lymphadenopathy, the next question is to decide if only one group of lymph nodes is
involved or multiple areas. The search is for underlying causes which drain to the affected lymph node
groups.
Clinical clues
Ask for:
Which lymph node regions are involved?
Fever
Pain, redness or swelling (or other signs of infection) in regions draining into that lymph node
region e.g.
o Scalp, ear, mouth, face or teeth for neck nodes
o Breast and upper extremities for axillary LN
o Perineum, external genitalia and lower extremities for inguinal nodes
Rate of onset of swelling and progression
Systemic illness e.g. malaise, anorexia, aches and pains (generalized viral illness with
generalized lymphadenopathy or septicaemia after cellulitis with regional lymphadenopathy )
Unsafe sexual contact (risk factor for sexually transmitted disease e.g. chancroid,
lymphogranuloma venereum)
Look for:
Region of lymph nodes involved
Skin lesions or obvious infection in areas draining to that lymph node region
Red streaks on skin extending in direction of regional lymph nodes (cellulitis and lymphagitis)
Fever
Tenderness
Consistency (rubbery suggests lymphoma, soft suggests reactive)
Are lymph nodes fixed to underlying structures (suggests malignancy) or mobile (reactive)
Is there matting of LN with discharge (s/o TB)
Investigations
In recent onset, tender lymphadenopathy with an obvious source of local infection or
inflammation it may not be necessary to do any investigations.
CBC for leukocytosis in the sick patient with cellulitis
Blood culture (if systemically unwell)
Swabs from wound exudate or pus for culture and sensitivity
Gram stain of pus from buboes (in lymphogranuloma venereum LGV)
Localized painful LN
ENT infections
Dental infection
Staphylococcal or streptococcal skin infection
STDs e.g. chancroid, LGV, herpes
Generalized painful LN
Epstein-Barr virus
Comment:
In children enlarged palpable cervical lymph nodes are very common due to recurrent URTI.
91
Surgery- CP
Enlarged lymph
nodes
Painful Painless
Localized Generalized
TB Haematological
lymphadenopathy malignancy
HIV/ secondary
Neoplasia
syphilis
Others
Primary syphilis e.g.Connective
tissue disease,
Sarcoid
Drugs e.g.
phenytoin
In painless lymphadenopathy, particularly lymph nodes that are persistent and gradually increasing in
size, the number one diagnosis to consider is a malignancy. Localized lymphadenopathy should lead to
a search for a tumour within the drainage area of that region (metastasis), while generalized painless
lymphadenopathy suggests a haematological malignancy.
Clinical clues
Ask for:
Which group of lymph nodes is involved?
Localized or generalized?
Age of patient Certain conditions are more common in particular age groups.
o Elderly patients most likely to be malignant.
o Acute lymphoblastic leukaemia in children
Rate of enlargement of LN and persistence
Chronic discharge from the LN (s/o TB)
Associated features which help to localize the underlying disease e.g.
o Cough and haemoptysis metastasis from bronchial carcinoma (cervical LN)
o Nasal obstruction nasopharyngeal malignancy
o Unilateral deafness
o Voice change, hoarseness (laryngeal Ca)
o Abdominal pain, dysphagia, nausea metastasis from GI tumour (supraclavicular LN)
o Breast lump (axillary LN)
Systemic features which suggest an underlying diagnosis
o Fever, weight loss, cough s/o tuberculosis
o Weight loss, anorexia s/o malignancy
o Night sweats, malaise s/o haematological malignancy
o Joint swelling, skin rash s/o connective tissue disease
92
Surgery- CP
History of previous malignancy

Smoker, occupational history (risk factors for malignancy)
History of unprotected intercourse, use of IV drugs, blood transfusion (risk factors for HIV)
Drug history e.g. phenytoin, phenobarbitone
Look for:
Temperature (infection or inflammation)
Which group of lymph nodes is involved important to check other regions as patient may not
have noticed LN that are painless.
Consistency and mobility of LN
o hard, craggy LN that are fixed to underlying tissues suggests malignancy usually
metastases
o rubbery LN with matting and sometimes suppuration suggests TB.
Signs of underlying disease
o Creps in the chest TB or lung cancer
o Inspection of nasopharynx, tonsils, tongue base, pyriform fossae, supraglottic larynx
if suspicious LN in cervical region
o Abdominal mass GI tumour
o Skin cancer
o Hepatosplenomegaly lymphoma or leukaemia
o Joint swelling (Stills disease, Adult onset Stills disease or SLE)
Pallor (anaemia)
Jaundice
Discharging pus with no other sign of inflammation (cold abscess of TB)
Investigations
Painless, enlarging lymph nodes require investigation.
CBC with differential for infection, malignancy
ESR for chronic infection, inflammation, TB, haematological malignancy
CXR
Sputum AFB for tuberculosis
FNAC (fine needle aspiration cytology) or biopsy
CT or USG may be useful to help guide FNAC (in non-palpable deep seated LN)
CT to search for site of primary if malignancy suspected
HIV serology (where indicated)
ANA
Bone marrow aspiration and cytology
Comments
Metastatic spread of squamous cell carcinoma (80% of head and neck cancer) most commonly
occurs with tumours of the nasopharynx, tongue base, tonsil, pyriform fossae and supraglottic
larynx.
Approximately 50% of patients with nasopharyngeal carcinoma will present with a mass of
malignant nodes in the neck, indicating an advanced tumour.
General examination of the patient is important in all cases of painless lymphadenopathy to
rule out the primary site of the problem.
Skin of head and neck should be palpated to rule out primary skin malignancies in those sites.
Assessment of cranial nerve function may suggest neural tumor or involvement of nerve by
adjacent lymph nodes or parotid glands.
Oral cavity, larynx and pharynx must be examined with the help of light source, spatulas,
indirect laryngoscopy or with direct flexible fiberoptic pharyngolaryngoscopy.
In approximately 80% of patients, the tuberculous process is limited to the clinically affected
group of lymph nodes, but a primary focus in the lungs must always be suspected.
Collar-stud abscess and discharging sinuses are the sequelae of the untreated tubercular
adenitis.
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Surgery- CP
Lymphomas of the head and neck may arise in nodal or extranodal sites and both Hodgkins
disease and non-Hodgkins lymphoma commonly present as lymph node enlargement in the
neck.
Sarcoidosis can present with localized (perihilar) or generalized LN.
A system of levels is used to describe the location of these neck nodes. Level 1, submental and
submandibular group; level II, upper jugular group; level III, middle jugular group; level IV,
lower jugular group; level V, posterior triangle group; level VI, anterior compartment group;
level VII, mediastinal.
The upper jugular nodes, level II, which contain the large jugulodigastric node, drain the naso-
and oropharynx, including the tonsils, posterolateral aspects of the oral cavity, and the
superior aspects of the larynx and pyriform fossae.
Any reactive lymphadenitis not subsiding after 2 weeks despite proper antibiotic therapy
should be investigated for tuberculosis.
94
Surgery- CP
Nausea and Vomiting CP

Nausea and
Vomiting
Vestibular
Central GI related Psychiatric Pregnancy
system
With abdominal
Drugs and toxins Motion sickness Simple nausea
pain
Radiotherapy, Middle ear Hyperemesis

With Jaundice
chemotherapy disease gravidarum
Inner ear or
Metabolic central With Diarrhoea
connections
Raised
With
intracranial
constipation
pressure
Other e.g.
Epigastric pain
migraine
Other e.g.
mesenteric
ischaemia
Without
abdominal pain
Gastric stasis
Gastric outlet
obstruction
Nausea is an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms.
Vomiting is the forceful expulsion of gastric contents through the mouth. It should be distinguished
from regurgitation, when there is reflux of undigested food back up the oesophagus into the mouth.
There are a huge number of possible causes of nausea and vomiting. It is helpful to remember the
pathophysiology of the mechanism of vomiting when trying to find a cause.
Pathophysiology:
There is close interaction between the upper gastrointestinal system and the central nervous system in
the control of nausea and vomiting. The major pathways involved are:
The chemoreceptor trigger zone (CTZ) on the floor of the fourth ventricle. This is sensitive to many
humoral factors, including neurotransmitters, drugs and toxins.
The CTZ provides information to the medulla at the nucleus tractus solitarius (NTS) or the vomiting
centre. This area also receives information from visceral afferents via the vagus nerve.
The NTS projects to various efferent pathways to control the vomiting reflex.
The motor function of the gut is controlled by parasympathetic and sympathetic nervous systems;
enteric brain neurons; and smooth muscle cells
Other neurons from the NTS ascend to the hypothalamus, limbic and cortical regions where they
are perceived as symptoms of nausea.
The vestibular system has neural connections to the vomiting centre in the medulla
95
Surgery- CP
Nausea and
vomiting
Vestibular
Central GI related Psychiatric Pregnancy
system
Clinical clues
Ask for:
Timing of nausea and vomiting
o Intermittent
o Constant
o Acute / sudden
o Chronic (> 1month)
Duration of symptoms
Exacerbating and relieving factors e.g.
o During travel only (motion sickness vestibular)
o Sudden head movements exacerbate (vestibular)
o Relieved by eating (s/o peptic ulcer disease)
o Exacerbated by fatty foods (s/o cholelithiasis)
Last menstrual period for pregnancy
Associated features
o Headaches and nausea worse in the morning s/o central cause (raised intracranial
pressure)
o Tinnitus and vertigo s/o disease in vestibular system
o Diarrhoea or constipation s/o GI related
o Jaundice s/o GI related
o Abdominal pain s/o GI related
Past psychiatric history
Known malignancy (brain metastases leading to central cause of vomiting)
Drug history (central cause)
Known chronic renal disease, diabetes
Look for:
Examination should focus on both finding the underlying cause, but also assessing for complications of
nausea and vomiting such as hypovolaemia and low potassium.
Pulse, BP, capillary refill time evidence of hypovolaemia
Dehydration status
Temperature (acute infection)
Anaemia (chronic disease), Lymph nodes (malignancy or infection), Jaundice (hepatitis)
Nystagmus (peripheral vestibular disease)
Full physical examination, with particular focus on area suggested in history as a possible cause
of nausea and vomiting.
Investigations:
This will be lead by the clinical suspicion from history and examination. Common baseline
investigations for severe nausea and vomiting would be:
Urea and creatinine for acute renal failure associated with hypovolaemia, or chronic renal
disease as a cause of vomiting
Electrolytes for low potassium and abnormalities in sodium (effect of vomiting + cause of
vomiting)
CBC for infection
Pregnancy test if delayed period
96
Surgery- CP
Central causes
Tumour or raised Other e.g.

Radiotherapy, Metabolic
Drugs and toxins intracranial migraine,
chemotherapy abnormalities
pressure meningitis, severe
pain, ischaemia
Diabetic
Uraemia Hypercalcaemia
ketoacidosis
Numerous factors can act directly on the chemoreceptor trigger zone on the floor of the 4th ventricle.
Clinical clues
Ask for:
Duration of symptoms (Acute or chronic)
Timing of nausea or vomiting if early morning suspect raised intracranial pressure (ICP) or
pregnancy
Drug intake - e.g. metronidazole, morphine, codeine
Alcohol intake excess of alcohol or alcohol withdrawal
History of chemotherapy or radiotherapy as part of treatment for cancer
Toxins or poisons (accidental or deliberate)
Fever any viral illness can cause nausea and vomiting especially in children, serious CNS
infection may also present with fever and vomiting.
Associated headache
o Chronic, progressive and worse in early morning s/o raised ICP
o Episodic, associated with flashing lights, long history s/o migraine
o With fever and neck stiffness s/o meningitis or encephalitis
Known diabetes (ketoacidosis) or chronic renal disease (uraemia)
Severe pain of any cause may be associated with nausea and vomiting via neurohormonal
stimulation of the CTZ or the NTS e.g. renal colic
Known malignancy
o Breast, lung and GI tumours commonly metastasize to the brain.
o Risk factor for hypercalcaemia which stimulates the CTZ
History of stroke or risk factors for stroke (hypertension, high cholesterol, diabetes, smoker)
Associated chest pain, sweating Myocardial infarction can cause nausea through stimulation
of the sympathetic nervous system.
Look for:
Pulse, BP, hydration status
Fever
LN, jaundice, anaemia, cachexia (signs of malignancy)
Neck stiffness (meningitis)
Fundoscopy (raised ICP)
Respiratory rate may be raised in uraemia and diabetic ketoacidosis
Full neurological examination (for signs of space occupying lesion)
Full physical examination
Nystagmus/ cerebellovestibular function tests
97
Surgery- CP
Investigations:
CBC for infection
Urea and creatinine acute or chronic renal failure
Electrolytes
Blood glucose
Calcium
Lumbar puncture if suspect meningitis
CT or MRI for assessment of space occupying lesion in brain
ECG if suspect Myocardial infarction
Brainstem Evoked Response Audiometry (BERA)
Diagnoses to consider (central)
Drug induced
Chemotherapy or radiotherapy induced
Hypercalcaemia
Uraemia
Diabetic ketoacidosis
Brain tumour (primary or metastatic disease)
Brain abscess
Meningitis/encephalitis
Migraine
Cerebrovascular ischaemic event
Myocardial infarction
Comments
Some drugs produce nausea by their effect on the GI system rather than the CTZ.
Anxiety may lead to nausea through its central effects.
Viral infections, UTIs and renal colic are very common causes of nausea and vomiting mediated
through central pathways.
Vestibular system
Middle ear disease Inner ear disease e.g.

e.g. complication of Vestibular neuritis,
Motion sickness
CSOM acute labrynthitis,
Menieres
The vestibular system causes nausea and vomiting by its neural connections to the vomiting centre.
Clinical clues
Ask for:
Timing of nausea/vomiting
o Only during travel, s/o motion sickness
o On sudden movements of head s/o Benign Paroxysmal Positional Vertigo (BPPV)
o Intermittent, associated with tinnitus and decreased hearing s/o Menieres
Intermittent, acute or chronic
Vertigo this strongly suggests a vestibular cause of nausea
Tinnitus s/o inner ear disease
Reduced hearing
Pain in ear s/o acute otitis media (AOM)
Discharge from ear s/o acute or chronic suppurative otitis media (CSOM)
History of trauma especially head injury
Odd neurological symptoms elsewhere e.g. paraesthesia, weakness in different parts of the
body possible multiple sclerosis with vestibular neuritis
98
Surgery- CP
Look for:
Anaemia, Lymph nodes
Nystagmus horizontal (suggests peripheral vestibular disease), vertical or rotatory (suggests
disease of central connections between vestibular apparatus and brain stem e.g.
cerebellopontine angle tumour)
Gait instability s/o vestibular neuritis
Cranial nerve examination (particularly if suspect cerebellopontine angle tumour)
Visualize tympanic membrane for bulging (AOM), perforation and any discharge (CSOM), fluid
behind TM.
Hearing loss sensorineural or conductive (Weber and Rinne test)
Dix-Hallpike (Epleys) manoeuvre for BPPV
Investigations
Audiometry to assess level of hearing loss
CT/MRI is suspect cerebellopontine angle tumour or Multiple sclerosis
Diagnoses to consider (vestibular system):

Motion sickness
Acute otitis media
Chronic suppurative otitis media
Vestibular neuritis
Acute labrynthitis
Menieres disease
Multiple sclerosis
Cerebellopontine angle tumour
GI related
With abdominal Without

pain abdominal pain
Gastric outlet
With jaundice
obstruction /
pyloric stenosis
With diarrhoea
Gastric stasis
With
constipation
Constipation
Epigastric pain
Other e.g.
Mesenteric
ischaemia
Gastrointestinal disease causes nausea and vomiting either by:

Mucosal irritation, mechanical obstruction, motility problems all of which lead to stimulation
vagal afferent nerves, which transmit to the vomiting centre in the medulla
Metabolic disturbance e.g. of sodium and potassium which acts on the CTZ (and is therefore
a central mechanism)
99
Surgery- CP
Nausea and vomiting associated with abdominal pain

Clinical clues
Ask for:
Acute or chronic
Nature of the vomit
o Food particles s/o acute gastroenteritis
o Feculent s/o distal bowel obstruction
o Bile stained s/o proximal bowel obstruction
o Blood stained s/o peptic ulcer
Position of the pain
o Epigastric pain may be due to peptic ulcer, acute gastritis, acute pancreatitis
o RUQ pain s/o acute cholelithiasis or acute hepatitis
o Generalized pain s/o peritonitis or gastroenteritis or bowel obstruction
o RIF pain s/o acute appendicitis
o Loin pain s/o renal stones
Nature of the pain
o Very severe pain s/o perforation, pancreatitis or mesenteric ischaemia
o Burning epigastric pain s/o peptic ulcer or non-ulcer dyspepsia
o Colicky pain s/o cholelithiasis, acute gastroenteritis
Associated reflux or heart burn s/o gastro-oesophageal reflux disease
Diarrhoea
o Acute gastroenteritis due to virus, bacterial or protozoal infection
Constipation
o General constipation is a common cause of chronic nausea
o Absolute constipation of stool and flatus s/o bowel obstruction
Abdominal distension s/o bowel obstruction
Blood in stool e.g. bacterial dysentery
Jaundice s/o acute hepatitis, chronic liver disease, obstructed biliary stones
Acute fever, malaise, anorexia s/o acute hepatitis or acute gastroenteritis
Chronic fever, malaise, anorexia s/o abdominal TB
Drug history e.g. NSAID causing gastric irritation
History of abdominal surgery s/o adhesions leading to bowel obstruction
Known GI malignancy
Alcohol intake (for pancreatitis and acute hepatitis)
Others with similar symptoms in house or community (food poisoning)
Look for:
Pulse, BP, dehydration status, fever
Anaemia, jaundice, LN, stigmata of chronic liver disease
Abdominal distension
Abdominal masses
Tenderness of abdomen
Guarding and rebound s/o peritonitis
Hepatomegaly
Increased bowel sounds s/o obstruction
Absent bowel sounds with pain more severe than clinical findings suggest, s/o mesenteric
ischaemia
PR for loaded rectum of constipation
Investigations:
CBC for infection or anaemia
Urea and creatinine and Electrolytes (for effect of vomiting)
Serum amylase (if suspect pancreatitis)
Liver function test (if suspect hepatitis)
Stool test (for gastroenteritis but actually not always needed)
AXR for fluid and air levels in intestine with obstruction, or air under diaphragm if suspect
perforation, will also show if loaded with faeces in chronic constipation
USG for gallstones or renal stones
CT scan if suspect malignancy
Endoscopy if persistent epigastric pain
100
Surgery- CP
Nausea and vomiting without abdominal pain

Ask for:
Acute or chronic
Timing of vomiting if food eaten several hours earlier s/o gastric outlet obstruction
Projectile vomiting immediately after feeding in a baby starting around 4-6 weeks of age s/o
hypertrophic pyloric stenosis
Constipation common cause of nausea, not always associated with abdominal pain
Diet history low fibre diet, with few fruit and vegetable, risk factors for constipation
History of diabetes risk factor for gastroparesis due to autonomic neuropathy
Drug history constipating agents e.g. codeine, morphine, amitryptiline, hyoscine
History of chronic dyspepsia may be a stricture leading to gastric outlet obstruction
Known malignancy paraneoplastic autonomic neuropathy
Look for:
Succussion splash s/o gastric outlet obstruction
Palpable lump in epigastrium in baby during breast feeding s/o pyloric stenosis
Palpable stool in descending colon (LIF) constipation
PR for loaded rectum
Investigations
Blood glucose and HbAIC for diabetic control
USG to assess for hypertrophic pyloric stenosis
Endoscopy
Psychiatric
causes
Anorexia
Cyclic vomiting
nervosa or Anxiety
syndrome
bulimia
Clinical clues
Ask for:
Age and sex anorexia nervosa and bulimia commonest in teenage girls
Perceived body image a thin girl who perceives herself as being fat
Food intake may need to take history from the family as patient may not accurately report in
anorexia nervosa or bulimia
Induced vomiting binges of eating (bulimia)
Low mood, generalized anxiety
Social circumstances
Repeated episodes of nausea and vomiting that last for hours to days and are separated by
symptom-free periods of variable length (cyclical vomiting syndrome)
Use of medication
Look for:
Weight and body appearance extreme thinness in anorexia nervosa, may be normal in
bulimia
Bulimia is associated with dental enamel erosion, parotid gland enlargement, lanugo-like hair,
and calluses on the dorsal surface of the hand
Investigations
Urea and electrolytes may be severe disturbances in anorexia nervosa
Comments:
Anorexia nervosa is a life threatening condition. There can be extreme electrolyte disturbances.
Cyclic vomiting syndrome has been most often described in children in whom symptoms often begin in
the early school years and stop spontaneously at puberty. It may also occur in adults.
101
Surgery- CP
Pregnancy
related vomiting
Simple Hyperemesis
emesis gravidarum
Early pregnancy is one of the commonest causes of nausea and vomiting in women of child bearing
age. About 70 to 85 percent of pregnant women suffer nausea and/or vomiting. Approximately 0.5
2% of pregnant women will suffer hyperemesis gravidarum.
Clinical clues
Ask for:
Last menstrual period
Duration of nausea
Frequency and severity of vomiting
Ability to take oral fluids
Other features of early pregnancy e.g. breast tenderness
Family history of hyperemesis
Look for:
Pulse, BP, dehydration status in hyperemesis can become very dehydrated
Fundal height uterine size larger than dates suggest molar pregnancy or multiple gestation
both of which are associated with hyperemesis
Investigations:
Pregnancy test to confirm early pregnancy
Electrolytes if severe vomiting
Urine for ketones if severe vomiting and suspect hyperemesis
102
Surgery- CP
Inguino-Scrotal Pain / Swelling
Inguino-Scrotal
pain / swelling
Inguino-scrotal
Scrotal
(hernia)
Painful Painless Painful Painless
Solid e.g. tumor

Acute Obstructed Inguinal hernia
testis
Cystic e.g.
Inflammatory Irreducible Direct
Hydrocele
Testicular Bag of worms

Strangulation Indirect
torsion (varicocele)
Acute
epididymo Femoral hernia
orchitis
Trauma/post-
Anascara
surgical
Chronic
Haematocele,
pyocele, urinary
extravasation
103
Surgery- CP
Inguino-Scrotal
swelling
Inguino-
Scrotal
scrotal
Ask for:
Does the swelling change with position? (inguino-scrotal swellings due to hernia will often be more
prominent on standing, and may disappear on lying flat)
Does the swelling increase on coughing or straining?(s/o inguino-scrotal swelling)
Look for:
Can you get above the swelling? (If you can, then this is a scrotal swelling, if not it is an inguino-
scrotal swelling).
Comments:
Inguino-scrotal swellings are usually some kind of hernia.
Scrotal swelling
Painful Painless
Acute Chronic
Traumatic / post-
Inflammatory
surgical
Haematocele,
Testicular torsion pyocele, urinary
extravasation
Acute epididymo
orchitis, Acute
orchitis, Cellulitis
Painful causes of scrotal swelling

Ask For:
Age :
o Funiculitis is a disease of young age
o Torsion of testes is most common in 12 20 years, where as epididymitis, having same
clinical picture, more often occurs in sexually active males, after 20
Occupation :
o Prolonged standing may be cause of varicocele
Residence:
o Filariasis is commonly found in Tarai area
Duration of pain
Fever, dysuria s/o epididymo orchitis
Nausea and vomiting is almost always present in testicular torsion (less so in orchitis etc)
History of surgery or trauma to that area
o s/o bleeding in scrotum
104
Surgery- CP
Look for:
Position and extent of swelling : mostly acute scrotum presents with generalized swelling of the
scrotum
Skin over the swelling : red and edematous, with signs of inflammation eg. cellulitis
Pulse, blood pressure, Fever, tachycardia
Tenderness
Transillumination test s/o fluid in scrotum (hydrocele)
Effect of elevation of testis on pain worse in torsion, relief in orchitis.
Investigations:
TC, DC to see acute inflammatory conditions eg in torsion, orchitis, epididymo-orchitis
Urinalysis: UTI might be preceding cause for epididymo orchitis
USG : to look for scrotal collection eg following trauma or post operatively
Doppler USG to differentiate torsion from epididymo orchitis
Retrograde cystourethrogram : if urinary extravasation is suspected following trauma
Comments:
Acute Scrotum : A sudden onset of painful scrotum is called acute scrotum. A child or adolescent with
acute scrotal pain, tenderness, or swelling should be looked on as an emergency situation requiring
prompt evaluation, differential diagnosis, and potentially immediate surgical exploration.
Chronic Orchalgia
Chronic orchalgia is defined as intermittent or constant scrotal pain, which may be unilateral, bilateral,
or bilaterally alternating, lasting longer than 3 months.
Testicular torsion Vs Epididymo Orchitis :

o The twisting of the testes on the spermatic cord, results in strangulation of the blood
supply and infarction of the testis. The patient usually presents with sudden onset of
pain and swelling of the involved testis. The pain may radiate into the groin and lower
abdomen; thus, it may be confused with appendicitis unless the physician examines the
genitalia carefully.
o Redness of the skin and a mild pyrexia may result in both conditions; however, in
epididymo-orchitis there will usually be dysuria associated with the accompanying
urinary infection.
o Doppler ultrasound scan will confirm the absence of the blood supply to the affected
testis, but performing this test may squander vital minutes. If there is any doubt about
the diagnosis, the scrotum should be explored without delay.
o Testicular torsion demands prompt exploration within hours or so.
Particular issues in examination of the scrotum

- Consent for physical examination
- Privacy of patient
- Accompanying persons at examining room
- It is always convenient in these cases to examine the patient in the standing position first and
later on in the recumbent position (to help identify hernias which are reducible)
- Remember to examine the contra lateral side also
105
Surgery- CP
Scrotal Swelling
Painful Painless
Acute Chronic
Funiculitis, TB, Chronic Epididymo Orchitis,

Varicocele, Sperm granuloma
Ask for :
Character of pain : dragging pain is common in varicocele,
Temperature pattern: moderate to high grade temp in UTI/ epididymo orchitis, evening rise of
temp in TB
Hematuria and burning micturition:
Hx of same kind of problems in past : previous hx of periodic attacks of fever accompanied by
pain and swelling of a scrotum is suggestive of filarial infection.
Hx of trauma / surgery : eg sperm granuloma develops following vasectomy
Look for :
Skin over the swelling: red and edematous skin in funiculitis
Loss of rugosity of scrotum
"Bag of worms" feeling, specially at left side : a characteristic features of varicocele
Thickened and firm consistency of spermatic cord :
Investigations :
CBC, ESR for infection/inflammation
Urinalysis
USG scrotum
Eosinophilia and living microfilariae in blood drawn at night for filariasis
24 hours urine collection of AFB
Comments:
Varicocele : condition in which the veins of the pampiniform plexus become dilated and tortuous.
Varicocele may be painful or painless
Usually left side probably due to longer left spermatic vein, it connects right renal vein at right
angle, left renal vein compresses by testicular artery and left colon is usually loaded to
compress the left testicular vein.
106
Surgery- CP
Scrotal swelling
Painful Painless
Cystic e.g. Bag of worms

Solid
Hydrocele (varicocele)
Tumour of
Lipoma
testis
Ask for:
Age in infants get congenital hernia and hydrocele
Duration of swelling
Is the swelling gradually progressive? possible testicular malignancy
General health may be systemically unwell if malignancy
Place of residence filiariasis common on the terai
Look for:
Consistency of the swelling
o Soft and fluctuant likely hydrocele
o Smooth and firm lipoma of cord or sebaceous cyst
o Hard, craggy testes or lump within testes possible testicular cancer
Presence of transillumination - hydrocele
bag of worms feeling - varicocele
Investigations:
USG of scrotum is one of the most useful tests
Comments:
In infants hydrocele is usually congenital and resolves on its own, usually within 1 yr.
In adults, simple hydrocele will also often spontaneously resolve after a few months. If it
persists, or if there is associated hernia then surgery is required.
Diagnoses to consider (Scrotal painless):

Hydrocele
Lipoma of cord
Lymph varix
Varicocele
Testicular tumour
Chylocele
Filiariasis
Sebaceous cyst
107
Surgery- CP
Inguino-scrotal
swelling
Painful Painless
Obstructed
Inguinal hernia
hernia
Irreducible
Direct
hernia
Strangulated
Indirect
hernia
Femoral hernia
Anascara
(generalized
oedema)
Inguino-scrotal swellings are almost always a hernia, although occasionally they may be due to
anascara (generalized oedema).
Painful inguino-
scrotal swelling
Obstructed Irreducible Strangulated

hernia hernia hernia
Ask for :
Hx of using truss, previous surgery for previous presence of hernia
Duration of onset of pain
Character of Pain
o An irreducible hernia is not usually very painful, unless some further complication has
occurred
o Pain from a strangulated hernia is very severe
Aggravating factor if any eg. BEP, chronic cough, constipation
Status of bowel movement and flatus passed obstructed, incarcerated and strangulated
hernia all lead to acute obstruction (no stool, no flatus)
Nausea and/or Vomiting, if yes - color of vomitus (faeculent vomit occurs in acute bowel
obstruction)
Passage of blood in stool s/o strangulated hernia with ischaemic bowel
Urine out put
108
Surgery- CP
Looks for:
Absence of impulse on coughing classical sign of complicated hernia
Non-reducibility - classical sign of complicated hernias.
Distribution of tenderness
o If localized to the hernia then likely incarcerated or early obstructed hernia
o Abdominal tenderness severe suggests late obstructed hernia, if very severe suggests
strangulated hernia
Abdominal distension due to bowel obstruction
Visible peristalsis, bowel sounds
o increased and tinkling in acute obstruction due to obstructed or incarcerated hernia
o absent bowel sounds in strangulated hernia due to ischaemia
Rebound, guarding of abdomen sign of peritonitis (late obstruction or strangulated hernia)
Overlying skin changes, reddened skin suggests strangulated hernia
Position of swelling with respect to inguinal ligament and pubic tubercle (inguinal hernia is
superolateral to pubic tubercle and femoral hernia is inferomedial)
Consistency : strangulated hernia feels doughy (omentum) or elastic (bowel) and tense and
tender
Bowel sounds : in complicated obstructed hernia, bowel sound is audible and usually increased
Pulse, BP, temperature (patients with acute peritonitis may go into shock)
Investigations:
TC,DC, Hct
AXR (Erect / Supine): to see dilated bowels and air fluid levels (supine is better than erect to
show bowel dilatation)
Serum electrolytes
Comments:
Only inguinal herniae are found in the scrotum
Manual reduction of obstructed hernia should be discouraged.
Irreducible hernia:
o In this case the contents cannot be returned to the abdomen but there is no evidence
of other complications.
o It is usually due to adhesions between the sac and its contents or overcrowding within
the sac.
o Any degree of irreducibility predisposes to strangulation.
Obstructed hernia
o Irreducible hernia containing intestine that is obstructed but without interference to
the blood supply to the bowel.
Incarcerated hernia
o Only when the lumen of the portion of the colon occupying a hernial sac is blocked with
faeces is called incarcerated hernia.
Strangulated hernia
o A hernia becomes strangulated when the blood supply of its contents is seriously
impaired, rendering the contents ischaemic.
109
Surgery- CP
Painless inguino-
scrotal swelling
Anascara
Inguinal hernia Femoral hernia (generalized
oedema)
Direct Indirect
Ask for:
Duration of swelling
Previous surgery for hernia
Symptoms of shortness of breath on exertion, orthopnoea or PND s/o heart failure causeing
anascara.
Look for:
Can the swelling be reduced by gentle manipulation (suggests uncomplicated hernia)
Does the swelling become more evident on standing (hernia)
Cough impulse : helps to differentiate hernia from other condition in this region
Position of swelling with respect to inguinal ligament and pubic tubercle (inguinal hernia is
superolateral to pubic tubercle and femoral hernia is inferomedial)
Direct vs indirect hernia
Evidence of generalized oedema e.g. pitting oedema of legs or on abdomen (anasarca)
Raised JVP, basal crepitations, (heart failure as a cause of anasarca)
110
Surgery- CP
Urinary Retention
Urinary
retention
Male or
Female?
Child Adult
Acute Chronic Acute Chronic
Post. urethral
Trauma Trauma Obstruction
valve
Urethral
Non-trauma Phimosis Neurogenic
injury
Spinal cord
UTI Uterocele Other
injury
Stones Non-trauma
Obstruction
Inflammation
Neurogenic
When a patient fails to pass urine (despite the presence of urine in the bladder) the condition is called
retention of urine. In anuria patient does not pass urine due to the kidneys failing to excrete urine and
there is no urine in the bladder. Anuria will be covered in a separate CP.
Ask for:-
Sex of the patient. Some conditions are seen only in women, and others only in men.
Age of the patient?
Comments:-
Urinary retention in female is less common than in male.
Conditions seen only in women include pregnancy related obstruction to the urethra, and
uterine prolapse.
Conditions seen only in men include prostate disease and phimosis.
111
Surgery- CP
Child
Acute Chronic
As a general rule acute causes of urinary retention are painful, while chronic causes are painless.
Ask for:
Pain in the abdomen especially suprapubic pain
Onset and duration of pain
Urine flow prior to retention
previously normal flow suggests acute cause
previously poor flow with hesitancy suggests chronic cause
Dribbling, overflow and incontinence suggests chronic cause
Previous history of urinary symptoms or urine flow problems (may be an acute-on-chronic problem)
Look for:
Abdominal distension
Palpable bladder
Comments:
In infants and children the urinary bladder is more of an abdominal organ and can be palpated
without retention of urine.
Child
Acute Chronic
Non-
Trauma
trauma
Urethral
UTI
injury
Spinal cord
Stones
injury
In acute urinary retention in a child

Ask for:
1. Whether there is pain or not (almost always painful)
2. Onset, duration of pain.
3. History of trauma and nature of the trauma
4. If there is history of trauma has there been any blood at the tip of the urethra (strongly
suggests urethral damage)
5. Fever, dysuria (prior to retention) s/o urinary infection
6. Haematuria
7. Previous history of urine infection or renal stones
112
Surgery- CP
Look for:-
1. General condition of patient. Usually patient is restless.
2. Temperature, pulse, blood pressure
3. Distension of abdomen , especially lower abdomen.
4. Whether urinary bladder is palpable? If yes, is it tender or not ? Evaluate the percussion note. A
full bladder will be dull on percussion.
5. Foreskin , urethral meatus , phimosis and meatal stenosis (in male child)
6. Palpate urethra , there may be presence of stones. (in male child)
7. Perianal sensation (in trauma for spinal cord lesion)
8. Power, sensation and reflexes in lower limbs (in trauma for spinal cord lesion)
Investigations:-
1. Urinalysis: WBC raised in UTI, RBC may be seen in stone cases or UTI, haemorrhagic cystitis
2. USG of abdomen and pelvis
Stones may be seen - location , site , size
Distended bladder,
Thickened bladder wall (cystitis)
3. KUB if stones suspected
Diagnosis to consider:-
1. Stones
2. UTI
3. Post traumatic damage to urethra
4. Acute spinal cord damage (after trauma)
Child
Acute Chronic
Posterior
Phimosis Ureterocele
urethral valve
Chronic urinary retention in a child
Ask for
1. Presence of pain (usually chronic urinary retention is pain free, or have a dull ache)
2. Urinary flow prior to retention
3. History of dysuria or haematuria prior to retention
4. Previous surgery e.g. circumcision
5. Chronic neurological problem e.g. cerebral palsy
Look for
1. General condition of the patient
2. Distension of the abdomen
3. Palpable bladder
4. State of the foreskin, urethral meatus. Look for presence of meatal stenosis and phimosis
113
Surgery- CP
Investigations
1. Urinalysis: WBC and RBC may be seen if concurrent infection
2. USG of abdomen and pelvis
i. Dilatation of prostatic urethra , saccules and diverticula may be present (in long
standing urinary retention)
ii. Associated hydronephrosis, hydroureter (e.g. Posterior urethral valves)
iii. Trabeculated bladder
3. Voiding cystourethrogram may reveal dilatation of urethra above valve (posterior urethral
valve).
Comments ;-
1. Phimosis and stones are common causes of urinary retention in children.
2. In young boys urethral valves are usually found just distal to the verumontanum. They usually
behave as flap, or one way valve.
3. Suprapubic catheter is inserted to relieve the back pressure and allow the kidneys to recover
(may get post-renal failure in obstruction) before definitive treatment by transurethral
resection of the valves using a paediatric resectoscope.
Posterior urethral valve
Ureterocele (especially in girls)
Bladder diverticulum
Neurogenic bladder (in chronically disabled child)
Adult
Acute Chronic
Trauma Non-trauma Obstruction Neurogenic Other
Urethral
Obstruction
injury
Spinal cord Inflammation
Neurological
In adults as well as children, acute urinary retention is almost always painful.
Where there is a history of trauma:

Ask for:
Nature of trauma, type and how it occurred.
o If fall from height or road traffic accident suspect spinal cord injury
o If injury to perineum, suspect urethral injury
Was the trauma related to insertion or removal of a catheter? (urethral injury)
Determine whether patient himself or herself pulled catheter. Sometime older, senile
semiconscious & agitated , violent patients may pulled catheter themselves.
Ask and determine is retention due to iatrogenic trauma.
114
Surgery- CP
Look for:-
Blood present in urethral meatus (urethral injury)
Ecchymosis or haematoma in perineal area (may be urethral injury).
Determine position of prostate by digital rectal examination. If it is high rising it may be due to
urethral injury which might cause retention of urine.
Examine the patient for any bony lesion
o fracture of pelvis may be associated with urethral injury.
o Localized tenderness or deformity over spinal vertebra suggests spinal cord injury
Neurological examination of limbs abnormalities suggest spinal cord trauma as a cause of
urinary retention
INVESTIGATION:-
X-Ray of pelvis & spine
MRI spine (if spinal injury suspected)
COMMENTS:-
Any trauma or injury leading to fracture pelvis , spine injury & iatrogenic urethral injury might
cause retention of urine.
Urethral injury
Iatrogenic urethral injury
Fracture pelvis
Neurogenic bladder secondary to spinal cord injury
115
Surgery- CP
Adult
Acute retention
Trauma Non-traumatic
Inflammation
Obstruction Neurological
e.g. UTI
Male e.g.
prostatic
disease
Female e.g.
uterine
enlargement
Ask for:
Age and sex of patient
o older men e.g. prostatic hypertrophy leads to obstruction
o middle aged women e.g. fibroid uterus leads to obstruction
o young girls of pubertal age e.g. impeforate hymen leads to obstruction
Presence of pain (acute is usually painful)
Is the woman pregnant? (retroverted gravid uterus obstructs the urethra) If so, gestational age.
Menstrual cycle
o time of menarche (imperforate hymen teenage girl not yet started)
o irregular or heavy bleeding (suspect uterine fibroid or malignancy)
o Post coital bleeding (suspect malignancy)
History of vaginal prolapse (obstructive)
Ask for h/o increased frequency of micturation , difficulty in micturation and overflow
incontinence. Usually present in chronic or acute on chronic .
Dysuria with or without fever s/o urine tract infection which may present with acute retention
especially in the elderly.
Haematuria s/o bladder stone or tumour
Drug history certain drugs may precipitate acute urinary retention e.g. tricyclic
antidepressants, antiparkinsonian drugs, atropine.
Back pain and paraesthesia in both lower limbs s/o neurological cause e.g. spinal cord
compression from collapsed vertebrae or prolapsed disc.
Look for:
See whether patient is restless or quiet?
Distension of lower abdomen or distended bladder may be visible and/or palpable.
If urinary bladder is distended look for tenderness. .
Keep record of percussion note whether dull or tympanic!
Abdominal masses (e.g. huge fibroid uterus)
Pelvic masses on PV examination (e.g. ovarian mass)
In pregnancy assess fundal height, presenting part of foetus and whether part is engaged in the
pelvis or not.
Rectal examination for prostate size, consistency and presence of central sulcus
Obvious uterovaginal prolapse
Health of the vaginal mucosa and any oedema of the vulva
Perianal sensation if suspect neurological cause
Neurological examination of the lower limb
116
Surgery- CP
Investigations:-
Send blood for T.C.DC, serum urea and creatinine.
USG is helpful and it will show distended bladder, detail of prostate (in men), presence of
uterine fibroid (in women) and status of upper urinary tract.
Cystoscopy
Prostate specific antigen
MRI if suspect neuropathic bladder, brain or spinal cord lesion
Comments:
1. Chronic retention usually occurs in elderly people.
2. In urine retention prompt decompression of bladder is needed. It can be performed by
urethral catheterisation or suprapubic cystostomy. Sometimes needle decompression can be
performed but usually not done It is followed by definitive procedure.
3. Urethral catheterisation should not be done if there is h/o recent urologic surgery like radical
prostatectomy and urethral reconstruction.
4. Rate of bladder decompression:- It is now recognized that partial drainage and clamping is
not necessary with acute urinary retention and may increase risk for urinary tract infection.
Rapid complete bladder decompression can be conducted safely, provided prudent supportive
care is available with special attention given to elderly patients. Hematuria occurs in 2 to 16
percent of patients but is rarely clinically significant.
5. Relief of urinary tract obstruction can lead to a postobstructive diuresis, which is defined as a
diuresis that persists after decompression of the bladder. A postobstructive diuresis is
primarily a problem with chronic, not acute, urinary retention and usually represents an
appropriate attempt to excrete excess fluid retained during the period of obstruction.
In women:
retroverted gravid uterus
benign tumours like fibroids
malignant tumours of pelvis, urethra & vagina
post partum vulvar oedema
labial fusion or imperforate hymen
In older female patient senile urethritis & uterovaginal prolapse
In men:
Benign prostatic hypertrophy (BPH)
Prostatic malignancy
Phimosis (acquired secondary to STD)
In both sexes:
Bladder Stones
Bladder tumours
Urinary tract infection
Drug side effect
Spinal cord compression e.g. due to vertebral collapse (osteoporosis or malignancy)
Psychiatric illness (foreign body)
117
Surgery- CP
Chronic
retention
Obstruction Neurogenic Others
Post-
Male e.g. Spinal cord
gonococcal
BPH compression
stenosis
Female e.g. Post trauma

Central brain
prolapse stenosis
Autonomic
neuropathy
Many causes of acute urinary retention may also present more chronically.
Ask for:
Age and sex of patient
Presence of pain (Chronic is usually non-painful)
Menstrual cycle
History of vaginal prolapse (obstructive)
h/o increased frequency of micturition , difficulty in micturition and overflow incontinence. Usually
present in chronic or acute on chronic .
Drug history
Back pain and paraesthesia in both lower limbs s/o neurological cause e.g. spinal cord compression
from collapsed vertebrae or prolapsed disc.
Known neurological disease e.g. paraplegia, stroke, multiple sclerosis
History of diabetes (autonomic neuropathy)
History of sexually transmitted disease or penile discharge
History of previous catheterization, especially frequent catheterization (post trauma stenosis)
Family history of BPH or prostate cancer
Look for:
See whether patient is restless or quiet?
Look for distension of lower abdomen or distended bladder
Abdominal masses e.g. huge fibroid uterus
Pelvic masses e.g. ovarian mass
In pregnancy assess fundal height, presenting part of foetus and whether part is engaged in the
pelvis or not.
Rectal examination for prostate size, consistency. Nodules, induration, asymmetry and absence of
central sulcus all raise suspicion for malignancy
Rectal sphincter tone should be determined (for spinal cord injury)
Obvious uterovaginal prolapse
Health of the vaginal mucosa and any oedema of the vulva
Perianal sensation if suspect neurological cause
Neurological examination of the lower limb
Investigations:-
Serum urea and creatinine - may be raised due to bladder outlet obstruction or to underlying renal
or prerenal disease
CBC
Urinalysis for blood (s/o stones or malignancy)
Urinalysis for WBC - evidence of infection
USG is helpful and it will show distended bladder, detail of prostate (in men), presence of uterine
fibroid (in women) and status of upper urinary tract.
Cystoscopy
Prostate specific antigen to look for evidence of prostate malignancy
MRI if suspect neuropathic bladder, brain or spinal cord lesion
118
Surgery- CP
Comments:
One of the commonest causes of chronic and acute urinary retention in men is benign prostatic
hypertrophy (BPH)
Benign prostatic hyperplasia (BPH) is a common disorder that increases in frequency progressively with
age in men older than 50 years
The clinical manifestations of BPH are lower urinary tract symptoms including increased
frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. Symptoms
typically appear slowly and progress gradually over a period of years. These symptoms are not
specific for BPH.
In a small percentage of men, untreated BPH can cause acute urinary retention, recurrent
urinary tract infections, hydronephrosis, and even renal failure.
Measurements of serum PSA, maximal urinary flow rate, and post-void residual urine are
optional, but are useful in most men. The performance of other tests (pressure-flow studies,
urethrocystoscopy, intravenous urography, ultrasonography and abdominal x-rays) should be
reserved for unusual patients and for those being considered for surgical intervention.
The correlation between symptoms and the presence of prostatic enlargement on rectal examination
or by transrectal ultrasonographic assessment of prostate size is poor. This is probably due to
enlargement of the transitional zone of the prostate that is not always evident on rectal examination.
Prostate cancer BPH is not believed to be a risk factor for prostate cancer. Both diseases are
common in older men. BPH occurs primarily in the central or transitional zone of the prostate, while
prostate cancer originates primarily in the peripheral part of the prostate.
Serum prostate specific antigen Prostate cancer can cause obstructive symptoms, although the
presence of symptoms is not predictive of prostate cancer. Measurements of serum PSA may be used
as a screening test for prostate cancer in these men with BPH, preferably in men between the ages of
50 to 69 years and before therapy for BPH is discussed.
The following points should be kept in mind when serum PSA determinations are ordered and the
results interpreted
High values occur in men with prostatic diseases other than cancer e.g. prostatitis, BPH.
Some men with prostatic cancer have low levels of serum PSA
A combination of digital rectal examination and serum PSA determination provides the most
acceptable means for excluding prostate cancer.
Post-void residual urine volume Residual urine volume can be determined by in-out catheterization,
radiographic methods, or ultrasonography. Normal men have less than 12 mL of residual urine. A large
residual volume is probably associated with increased risk of infection.
119
Surgery- CP
Upper GI Bleeding
GI BLEEDING
BLEEDING PER
BLOOD IN VOMITUS
BLACK TARRY RECTUM
(Fresh/coffee STOOL (Bright red/Maroon
ground)
colored)
UPPER GI BLEED UPPER GI BLEED LOWER GI BLEED
Gastrointestinal bleeding (GI) has several possible origins and manifestations:

1. Upper GI bleeding (from the upper GI tract esophagus, stomach, duodenum; i.e. blood origin
proximal to the ligament of Treitz).
2. Lower GI bleeding (from the lower GI tract distal small bowel, colon; i.e. blood origin is distal to
the ligament of Treitz).
3. Occult blood loss (hemorrhage of such small proportions that the blood can be detected only by
chemical test, microscope, or spectroscope
4. Obscure blood loss (from an unknown site in the GI tract).
The clinical signs of GI bleeding reflect the site, etiology and rate of bleeding.
Blood loss from the GI tract may present in five ways:
Hematemesis is defined as the vomiting of blood. This includes fresh bright red blood or blood
with coffee-grounds appearance.
Melena is defined as passage of black, tarry, foul-smelling stools. Melena results from the
degradation of blood by bacteria.
Hematochezia is defined as passage of bright red blood or maroon stool from the rectum. The
blood may or may not be mixed with stool.
Occult bleeding is defined as bleeding unapparent to the patient that causes small amounts of
bleeding. It may be identified by stool examination for occult blood. Patients may present only
with the symptoms of blood loss or anemia (e.g. lightheadedness, syncope, angina, or
dyspnea).
120
Surgery- CP
Clinical Clues
Ask about possible site of bleeding
o Hematemesis indicates an upper GI source of bleeding.
o Melena indicated that the blood has been in the GI tract for at least 14 hours. This is
usually the result of upper GI bleeding, but the source may be distal small bowel or right
colon.
o Hematochezia usually indicates a lower GI source of bleeding, but may be due to rapid
bleeding from an upper GI source.
o Blood originating from the left colon typically is bright red. Blood originating from the right
colon usually appears dark or maroon and may be mixed with stool.
Look for ways to assess the severity of the bleeding:
o Heart rate and BP
Clinically significant bleeding causes decreased pulse pressure postural changes in
heart rate or blood pressure, i.e. tachycardia, or hypotension. Resuscitation may
be necessary, depending upon the severity of bleeding.
Look for site of bleeding
o Nasogastric lavage may differentiate upper from lower GI sources. A bloody nasogastric
aspirate confirms that bleeding originated in the upper GI tract. However, a non-bloody
bile-stained aspirate does not exclude an upper GI source.
Investigations
The major diagnostic tests for GI bleeding are endoscopy, radio-nuclide imaging, angiography, and
miscellaneous tests {e.g. abdominal computed tomographic scanning (CT scan)}.
Some tests are purely diagnostic and some have therapeutic potential (e.g. endoscopy).
Proctosigmoidoscopic examination is mandatory in case of suspected LGI bleeding
Comments
Distinctions based on stool color are helpful, but not absolute, since melena can be seen with
proximal lower GI bleeding, and hematochezia can be seen with massive upper GI bleeding.
Examination of the stool provides information about the acuity of bleeding, as well as about the site
of bleeding.
Management of GIT bleeding involves immediate assessment and stabilization of the patients
hemodynamic status, determination of the site of bleeding, stopping active bleeding, treating the
underlying abnormality, and preventing recurrent bleeding.
Upper GI bleeding
Lower GI bleeding
Evidence
1. Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. Gastroenterology
1988; 95: 1569.
2. Laine L. Gastrointestinal bleeding. In: Kasper, Braunwald, Fauci et al. Harrisons Prin Int Med.
McGraw Hill: New York; 2005: pg. 235-8.
3. Rockey DC. GI bleeding. In: Feldman, Friedman, et al GI and Liver Disease: Pathophysiology,
Diagnosis, Management. Saunders Elsevier: Philadelphia; 2006: pg. 255-299.
121
Surgery- CP
UGI
BLEEDING
PAINLESS PAINFUL
Alcohol Abuse H/O

Retching With Anorexia/weight
H/O Liver disease or loss
vomiting
Portal
Mallory- Malignant pathology
Hypertension
Weiss tear
With Without
dysphagia dysphagia
Ca
Ca esophagus
stomach
Portal hypertension may lead to bleeding from esophageal varices, gastric varices, and portal
hypertensive gastropathy. Upper GI bleeding is due to varices in about 10% of patients in some series.
Portal hypertension is usually secondary to cirrhosis.
Mallory-Weiss tears account for 5% to 15% of patients with upper GI bleed. These are longitudinal
mucosal lacerations in the region of the gastroesophageal junction, primarily on the gastric side.
Vascular lesions include Dieulafoy lesion (found to have in any part of GI tract mainly affecting stomach
which is large tortuous arteriole in the submucosa and bleeds from a pinpoint mucosal defect), vascular
abnormalities, and gastric antral vascular ectasias (or watermelon stomach).
Neoplasms of the esophagus, stomach and duodenum may cause bleeding, but the tumor most likely
to cause an acute upper GI bleed is gastric adeno-carcinoma.
Clinical Clues
Ask about
o History of prior GI bleeding, previous GI disease, previous GI surgery, underlying medical
disorders (especially liver disease), use of alcohol, anticoagulation or antiplatelet therapy.
o A history of liver disease may suggest bleeding associated with portal hypertension.
o Vomiting, retching, or coughing prior to hematemesis, with bleeding usually stopping
spontaneously, suggestive of Mallory-Weiss Tear(especially in an alcoholic patient).
o Bleeding from Mallory-Weiss tears is usually self-limited, patients with ongoing or severe
bleeding may be treated endoscopically (multipolar electrocoagulation, or else epinephrine
injection, clips or band ligation).
o Massive, recurrent bleeding, suggestive of a Dieulafoy lesion.
o History of renal failure, cirrhosis, scleroderma, collagen disease, or hereditary telangiectasia,
suggestive of vascular ectasias (usually occult blood loss, occasionally acute GI bleeding).
Gastric vascular ectasia may be seen alone or in association with portal hypertension/cirrhosis.
o A history of previous surgery (e.g. previous aortic surgery) may suggest an aortoenteric fistula.
o Associated anorexia, and weight loss suggest carcinoma stomach and in case of dysphagia
carcinoma esophagus need to be ruled out.
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Surgery- CP
Look for
o Assess hemodynamic status
o Cutaneous sign of portal hypertension (e.g. spider angiomata, palmer erythema, caput medusa)
or other evidence of liver disease (e.g. hepatomegaly, splenomegaly, ascites, jaundice).
o Cutaneous telangicetasias may suggest hereditary hemorrhagic telangiectasia.
o Upper abdominal mass, ascites, hepatomegaly with hard and irregular surface, Virchows node
(left supraclavicular lymph node), and Blumers shelf tumor (palpable nodule in pelvis by DRE)
which suggest advanced stage of malignancy.
Investigations
A nasogastric (NG) tube or orogastric tube lavage that yields blood or coffee-ground material
confirms the diagnosis and may predict whether bleeding is due to a high risk lesion.
Laboratory evaluation should include a complete blood count, platelets, coagulation profile
(PT/INR, PTT), and liver chemistries, BUN, creatinine.
The primary diagnostic modality for evaluation of upper GI bleeding is upper GI endoscopy i.e.
esophagogastroduodenoscopy (EGD). Endoscopy is sensitive and specific for locating and
identifying bleeding lesions in the upper GI tract and also provides possible treatment. The
approach to therapy depends on the specific cause of bleeding.
Other diagnostic tests for acute active upper GI bleeding are less often used, but include
angiography and a tagged red blood cell scan.
Barium studies can diagnose many upper GI lesions, but do not offer the opportunity to
provide therapy. They are not used in the setting of acute GI bleeding and will interfere with
subsequent endoscopy.
Comments
Upper GI bleeding is a common condition with an overall mortality rate of approximately 10%.
In patients with upper GI bleed, the most common etiologies are: peptic ulcer disease (35%-
55%), portal hypertension (esophagogastric varices) (15%), as well as esophagitis, Mallory-
Weiss tear of the esophagus, vascular malformations, tumors, and other rare causes.
In patients taking anticoagulant therapy, who have an elevated INR (international normalized
ratio), GI bleeding is nevertheless most often caused by underlying GI tract pathology.
Lavage may not show blood if the bleeding has stopped or if it is due to a source beyond a
closed pylorus. The presence of bilious fluid suggests that the pylorus is open. A negative
lavage with bilious fluid indicates that there is no active upper GI bleeding.
The hematocrit value may not accurately reflect blood loss when determined soon after the
onset of bleeding. Equilibration between the intravascular and extravascular spaces and
subsequent hemodilution may take several hours. The hematocrit will fall as extravascular
fluid enters the vascular space to restore volume, which may take 24 to 72 hours.
The BUN (blood urea nitrogen) level may be elevated, typically disproportionate to creatinine
level, due to the breakdown of blood proteins to urea by intestinal bacteria and the
subsequent intestinal absorption of these proteins, as well as a mild reduction in glomerular
filtration rate.
Patients with upper GI bleeding should undergo stabilization and resuscitation before
endoscopy.
Endoscopy should be performed only when it can be done safely and effectively. The patient
must be adequately resuscitated and the airway must be protected during the procedure.
Appropriate endoscopic equipment is required.
123
Surgery- CP
Risks of upper endoscopy include aspiration, adverse reactions to the medications used for
sedation, perforation, and increasing bleeding while attempting therapeutic intervention.
The approach to therapy depends on the specific cause of bleeding.
The spectrum of severity in patients with upper GI bleeding varies from minor bleeding to that
with a high mortality risk. Studies have addressed the factors that predict outcome in patients
with upper GI hemorrhage. These include both clinical and endoscopic features.
Adverse prognostic variables in patients with upper GI bleeding include increasing age,
presence of co-morbid conditions (e.g. liver failure, heart failure), severity of bleeding, and
diagnosis (e.g. variceal bleeding).
Bleeding from esophageal varices or gastric varices is often severe. However, bleeding from
portal hypertensive gastropathy typically causes low-volume bleeding that may be occult.
Patients with variceal hemorrhage have higher rates of recurrent bleeding and death than
patients with other common causes of upper GI bleeding. Patients are often started on
pharmacologic therapy (e.g. intravenous octreotide) to lower portal venous pressure.
Endoscopic therapy is used to stop active bleeding or to reduce the risk of re-bleeding. The two
types of endoscopic therapy are esophageal variceal banding and endoscopic variceal
sclerotherapy.
Patients with persistent or recurrent bleeding despite medical and endoscopic therapy may
require esophageal balloon tamponade (Sengstaken-Blakemore tube) or transjugular
intrahepatic portosystemic shunt (TIPS) and sometime surgical management is required like
portosystemic shunts, esophageal transaction, splenectomy and gastric devascularisation.
Most of patients with Mallory-Weiss tear can be managed conservatively with acid
suppression(e.g. omeprazole) and antiemetic drug therapy. Only some patients need
interventional therapy (endoscopic therapy e.g. contact thermal therapy with or without
epinephrine injection, band ligation, haemo-clipping, sclerosant injection or argan plasma
coagulation; angiotherapy with either selective vasopressin infusion or embolization of the left
gastric artery; and surgical oversewing of the tear which is reserved for the occasional bleeding
case that is refractory to endoscopic therapy or angiotherapy.
Endoscopic techniques also can be used in the treatment of Dieulafoy lesion.
Portal hypertension
Mallory-Weiss tear
Ca esophagus and stomach
Evidence
5. Adler DA, Leighton JA, Davila RE, et al. ASGE guideline: the role of endoscopy in acute non-
variceal upper - GI hemorrhage. Gastrointest Endosc 2004; 60: 497-504.
6. Boonpongmanee S, Fleischer DE, Pezzullo JC, et al. The frequency of peptic ulcer as a cause of
upper GI bleeding is exaggerated. Gastrointest Endosc 2004; 59: 788.
7. Eisen GM, Dominitz JA, Faigel DO, et al. An annotated algorithmic approach to upper GI
bleeding. Gastrointest Endosc 2001; 53: 853-858.
8. Jutabha R, Jensen DM. Management of severe upper gastrointestinal bleeding in the patient
with liver disease. Med Clin North Am 1996; 80: 1035.
9. Rockall TA, Logan RF, Devlin HB, et al. Incidence of and mortality from acute upper
gastrointestinal hemorrhage in the United Kingdom. BMJ 1995; 311: 222-226.
10. Rockey DC. Gastrointestinal bleeding. In: Feldman M, Friedman LS, Brandt LJ. Sleisenger and
Fordtrans Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management.
Saunders Elsevier: Philadelphia; 2006: pg. 255-299.
124
Surgery- CP
UGI
BLEEDING
PAINLESS PAINFUL
Without Anorexia/weight loss
Benign Pathology
H/O periodic Pain Abdomen Water brash

NSAIDS, Aspirin Abuse Heart burn
Esophagitis
Peptic Ulcer Disease
Gastritis
Ulcer disease of the stomach or duodenum is the most common cause of upper GI bleeding, accounting
for about 55% of cases. There are 4 major risk factors for bleeding peptic ulcers Helicobacter pylori,
nonsteroidal anti-inflammatory drugs (NSAIDs), stress, and hypersecretion of gastric acid. Other causes
of upper GI bleeding include esophagitis, and gastritis. Esophagitis accounts for about 5% to 15% of
upper GI bleeds. Gastritis and erosive gastropathy refer to findings seen at endoscopy and may be
associated with ingestion of NSAIDs, alcohol, or physiologic stress. Ulcers are mucosal defects that
extend through the muscularis mucosa. An ulcer bleeds when it erodes into the wall of the blood
vessel.
Clinical Clues
Ask about
o History of use of aspirin/steroid/NSAIDs, heartburn, dysphagia, abdominal pain and weight
loss.
o Epigastric pain, suggestive of peptic ulcers. However, peptic ulcerations may be
asymptomatic. Also, chronic pain syndromes similar to those of classic peptic ulcer disease
may occur in patients who have no demonstrable ulcer.
o Ingestion of aspirin or other NSAIDs suggests bleeding from gastroduodenal ulceration.
o In younger patients, bleeding is more likely to be from ulcer disease, varices, or esophagitis.
o Gastro-esophageal reflux disease, suggestive of esophagitis. Bleeding from esophagitis is
usually occult rather than acute.
o Other medical problems: stress related ulcer occurs in extremely ill patients, usually in the
intensive care unit.
o Associated diarrhea, extremely severe ulcer disease with complications, suggestive of
Zollinger-Ellison
Look for
o Assess hemodynamic status
o Abdominal tenderness, suggestive of peptic ulcer or pancreatitis, or other causes.
o Pigmented lip lesions are seen with Peutz-Jeghers syndrome
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Surgery- CP
Investigations
Upper endoscopy is the diagnostic modality of choice for acute upper GI bleeding. Once a
bleeding lesion is identified, endoscopic therapy may be used to stop bleeding or reduce the
risk of recurrent bleeding.
In addition to clinical predictors of outcome, the appearance of an ulcer at endoscopy provides
prognostic information and is useful in guiding subsequent management. Endoscopic therapy
benefits patients who have actively bleeding ulcers or ulcers with non-bleeding visible vessels
(lesions with a high risk of continued bleeding or re-bleeding).
Comments
Many patients who present to the hospital with complications of peptic ulceration, such as
hemorrhage or perforation, have no previous symptoms of ulcer disease.
Patients taking aspirin and other NSAIDs are at increased risk for developing ulcers and
complications of ulcers, such as hemorrhage and perforation. Other cofactors increase the risk
of developing NSAIDS related ulcers and bleeding older age, history of peptic ulcer, history of
previous GI bleeding, steroid and anticoagulant use. Cyclooxygenase 2 (COX-2) inhibitors are
also associated with an increased risk of bleeding, but less than nonspecific NSAIDs.
Stress related ulcers (stress related mucosal disease) occur in extremely ill patients, usually in
intensive care units. The risk of stress ulcer related bleeding is increased in patients with
respiratory failure or coagulopathies. Other risk factors are extensive trauma, severe burns,
major surgery, serious medical illness (e.g. sepsis, renal failure, and neurologic trauma or
intracranial disease).
Consider hypersecretory conditions (Zollinger Ellison syndrome) in any patient who has peptic
ulcer disease in the absence of H. pylori infection or NSAID use, especially if associated with
diarrhea and severe, complicated ulcer disease involving the distal duodenum.
The goals of therapy are to treat the ulcer, stop the active bleeding, and prevent re-bleeding.
An intravenous proton pump inhibitor should be administered to patients with high risk ulcer
bleeding.
Endoscopic therapy is effective for controlling acute ulcer bleeding and for decreasing the risk
of re-bleeding. Endoscopic treatment include injection methods (e.g. epinephrine), thermal
methods (e.g. bipolar electro-coagulation or heater probe), and mechanical therapy (e.g.
endoscopic clips).
All patients with peptic ulcer disease should be tested for H. pylori. H. pylori eradication with
an antibiotic regimen should be attempted for all patients who are diagnosed.
Patients with bleeding ulcers who have been taking an NSAID, should discontinue the NSAID
and be treated with a proton pump inhibitor. For prevention of recurrent ulcer in a patient
who must restart aspirin or an NSAID, options include co-therapy with a proton pump inhibitor
or misoprostol, or to use a COX-2 specific inhibitor.
Esophagitis may be caused by GERD, infection, medications, caustic ingestion, or radiation.
Usually no endoscopic therapy is required.
Recurrent bleeding is common with GI tumors. Surgery or angio-graphy may be better therapy
than endoscopy, but all suspicious lesions seen at the time of endoscopy should be biopsied.
Esophagitis and gastritis
Peptic ulcer disease
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Surgery- CP

Other e.g. Foetus,

<500 > 500 > 500

SAAG * >1.1 mg/dl

Portal vein Connective tissue

Faeces and flatus e.g. Other e.g. foetus,

Diffuse abd distension

Other e.g. Foetus,

Bacterial peritonitis TB peritonitis

Raised cell count (> 500 leukocytes/mcL, >250 polymophonuclear neutrophils/mcL)

This is bacterial peritonitis until proved otherwise.

Raised cell count (>500 leukocytes/mcl, predominantly lymphocytes)

CXR for primary TB

Diffuse Abd distension

Other e.g. Foetus,

SAAG >1.1 mg/dl

Liver disease Nephrotic syndrome

Other e.g. pancreatic,

Normal cell count (< 500 leukocytes/mcL)

Superficial / Deep/ Intra-

Lymph node Small bowel Pancreatic

Other e.g. soft

Superficial / Parietal Deep

Superficial / Deep / intra-

Superficial / Deep/ Intra-

Small bowel Lymph nodes

Rt hypo- Colorectal Ca Pancreatic

Lymph nodes Lumbar

Other e.g. soft

Abdominal pain nature of pain, location of pain

Hepatomegaly Hepatic flexure

Left hypochondrium mass

Small bowel Pancreatic

Pelvic masses are covered in a separate CP.

Right iliac Suprapubic

Right colon Left colon

Ovarian mass will be covered in the CP on pelvic mass.

Penetrating Localized (by

Not Peritonitis Peritonitis Rt hypochondrium

Abdominal Extra-abdominal Epigastrium

Gastroenteritis Endocrine Lt hypochondrium

Peptic ulcer Right and left

Muscular pain Toxins and drugs Hypogastrium

Acute Abdominal pain ( non-traumatic):-

Endocrine and Infection and Hematologic Toxin and

Endocrine and Infection and Toxic and

Acute abdominal pain - Localized

Left hypochondrium Pain

Lumbar Pain (right or left flank)

Investigation: similar to pain in RIF

Acute abdominal pain with history of trauma

Acute abd pain

Chronic Abdominal Pain

Irritable bowel Epigastrium

Inflammatory Other e.g. chronic

Chronic Localized abdominal pain

Upper abdominal pain (RUQ, epigastric and LUQ)

Right and left flank pain

RIF and groin pain

LIF and groin

Colorectal Small bowel

Tumours e.g. Infection (enteric

Large bowel Small bowel

o Low-grade, recurrent bleeding suggestive of colon cancer or polyps