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THE ACUTE ABDOMEN (DOC)

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					THE ACUTE ABDOMEN
Recognition of symptoms in an acute abdomen:
History of a patient with acute abdomen (i.e. general gastrointestinal history):
(From OSCE: a teaching manual for medical undergraduates by H Twohig and A Majeed)
     Introduce yourself
      Ask patient’s name, DOB and occupation.
       Age is significant for certain conditions. Cancer of the colon is rare in the young.
      Ask about history of abdominal pain
       If there is abdominal pain then a specific history should be done for the pain which is written
       much further down the page.
      Ask if there is nausea, vomiting or haematemesis
       A specific history should be done for vomiting if present. Important things such as nature
       (projectile), colour (bilious, bloody or faeculent) and any other associated symptoms. Specific
       history for vomiting is in the medical objectives.
      Ask if there is dysphagia
       A specific history should be done if this symptom is present. Important questions are pain,
       course of dysphagia (acute or chronic), does food stick? History of heartburn? Solids and/or
       liquids etc. a full history is present in the medical objectives.
      Ask if there is heartburn or dyspepsia
       A specific history should be done if this symptom is present. Important questions are reflux
       symptoms, aggravation with postural change? Aggravating foods? Haematemesis or malaena?
       A full history is in the medical objectives.
      Ask if there is diarrhoea, constipation or recent change in bowel habit
       A specific history should be done if this symptom is present. Important questions are the nature
       of the bowel habit, how long it has been happening, if there is any blood, how long since they
       have been to pass a stool, if they are on any drugs, associated pain etc. a full history for
       diarrhoea and constipation is in the medical objectives.
      Ask about rectal bleeding
       A specific history should be done if this symptom is present. How long has it bleeding,
       amounts, fresh blood or digested? Pain? signs of anaemia etc. a full history is in the medical
       objectives.
      Ask if there is weight loss or loss of appetite
       This could indicate malignancy, malabsorption or hypermetabolic state.
      Ask if there is history of jaundice
       A specific history should be done if this symptom is present. Important as it could indicate a
       liver disease. Important to ask about colour of urine, stools, steatorrhoea, pruritis, how long they
       have been jaundiced, associated pain etc. a full history is in the medical objectives.
      Ask if there any medical conditions (past or present) and any previous abdominal surgery.
       Medical conditions and previous surgery may help influence the diagnosis. Important to know
       about conditions such as IBD which have a chronic course and exacerbations. History of
       epigastric pain may indicate a peptic ulcer that has just perforated etc.
       previous abdominal surgery can cause adhesions which can lead to intestinal obstruction.
      Ask if there is a family history of bowel cancer or other bowel disorders.
       Colorectal cancer can run in the family especially if the patient has familial adenamatous
       polyposis.
      Ask about smoking and alcohol
       Alcohol is a risk factor for liver disease, vomiting, pancreatitis, ulcers and upper GI bleeds.
       Smoking linked to increased risk of gastric and oesophageal cancer, it worsens reflux disease
       and can make Crohn’s worse.
      Ask about past or current medications and any drug allergies.
       NSAIDs can induce GI bleeding
       codeine and other antidepressants can cause constipation.
       The liver is damaged by many drugs and cholestasis can occur as a result of many drugs.
       anticholinergics, calcium channel blockers. Nitrates and theophylline can make reflux disease
       worse.
       Many drugs can induce vomiting.

The above history is a general history for the GI tract. Most people with an acute abdomen are in severe
pain so there is an important emphasis on the abdominal pain portion of the history.

A history of abdominal pain is as follows:
(From OSCE: a teaching manual for medical undergraduates by H Twohig and A Majeed)
     Point to where the pain is worse
       The site of the pain will give a clue to which organ may be affected.
      Does the pain radiate anywhere?
       Pain radiating to the back occurs with retrosternal organs. This is can occur in pancreatic
       disease, perforated duodenal ulcer or a ruptured abdominal aneurysm.
       Pain radiating to the neck, retrosternally indicates oesophageal reflux.
       Pain radiating from the loin to the groin is indicative of renal colic.
       Pain radiating to the shoulder tip can occur if the diaphragm is irritated. This can occur in liver
       disease, gallbladder and biliary disease etc.
      Describe the character of the pain
       Colicky pain can occur in any tube structures such as bowel, ureter or bile ducts. Colicky means
       that the pain comes and goes. True colic is bowel obstruction which produces pain that comes
       and completely goes in waves. Biliary colic and renal colic are not true colics as there is usually
       some residual pain.
       A dull or burning pain, especially in the epigastrium indicates peptic ulceration.
      Ask about the onset and duration
       It is important to understand if this is acute, acute on chronic or chronic. Chronic illnesses will
       not usually present in an acute setting and if it does it is important to know why the patient has
       presented now.
       Acute on a background of chronic dull pain can occur with recurrent pancreatitis or a perforated
       peptic ulcer.
      Rate the severity
      Ask if the pain is intermittent or constant
       Peptic ulcer disease is usually episodic
    Pancreatic pain is usually steady or constant
    Biliary pain can last for hours.
   Does anything make it better or worse (e.g. movement or coughing)?
    Patients try to relieve colicky pain by rolling around.
    Peritonitis is usually aggravated by moving or coughing.
    Antacids or vomiting can relieve pain due to peptic ulcers or reflux.
    Defaecation or passage of flatus may relieve pain due to irritable bowel syndrome.
    Pancreatic pain can be relieved by leaning forward or sitting.
   Is there a relationship to any food (particularly fatty food)?
    Eating may exacerbate pain due to gastric ulcer but will relieve pain due to a duodenal ulcer.
    Fatty foods will exacerbate pain due to gallbladder disease.
   Is there any associated nausea, vomiting or distension?
    Vomiting can occur as part of an actual obstructive pathology such as bowel obstruction or can
    be part of another abdominal pain such as biliary or renal colic.
   Has there been a change in bowel habit? When did they last open it and if it was a normal
    motion?
    A chronic disturbance of defaecation associated with abdominal pain and bloating is
    characteristic of irritable bowel syndrome.
    Recent constipation or diarrhoea associated with colicky pain may indicate a bowel malignancy
    or stricture formation. Blood and mucous is usually present in these circumstances but not
    always.
    Rectal malignancies can cause increased frequency of defaecation and can give a feeling of
    incomplete bowel emptying (tenesmus).
    Inflammatory bowel disease can cause diarrhoea in association with abdominal pain.
   Does the patient feel systemically unwell and if the patient suffers from night sweats?
    Pyrexia and night sweats can indicate an infective cause.
   Have they eaten anything unusual or undercooked in the past few days and if anyone else in the
    family is having similar symptoms?
    If they have travelled somewhere exotic recently or family members have similar symptoms
    then it can be an infective cause.
   Have they noticed any weight loss?
    Weight loss can point to malignancy but also malabsorption.
   Is there any associated jaundice with the pain?
    Jaundice with biliary pain indicates gallstones.
   Are there any urinary symptoms (haematuria, loin pain, renal colic etc.)
    These symptoms would be typical of renal stones.
   Ask a female patient when their last menstrual period was and whether there is a chance that
    they are pregnant?
    Abdominal pain in early pregnancy includes threatened abortion and ruptured ectopic
    pregnancy (which can occur before patient realises they are pregnant.
   What is there current drug treatment and if they are drugs such as NSAIDS regularly?
    NSAIDs exacerbate peptic ulcers.
      Have they have previous abdo surgery and any history of groin lumps.
       Previous surgery can lead to the formation of adhesions which can lead to intestinal obstruction
       and therefore pain.
       Irreducible hernias are a common cause of bowel obstruction.

Difference in symptoms of peritonitis and obstruction:
Peritonitis:
Peritonitis will present with either localised or generalised abdominal pain.
Movement or coughing will exacerbate pain
There will be guarding by the abdominal muscles because touching the abdomen will cause pain.
This guarding makes the abdomen very rigid.
An important sign is rebound tenderness which can be very painful for the patient.
Your hand is pushed into the abdomen and then suddenly released with the patient knowing.
If this sudden release aggravates the pain then the patient has peritonitis.
The sudden release allows the peritoneum to snap back into place causing pain.
Peritonitis can either be infective or non-infective (other body fluids in the region).
It can also be localised or generalised.
Localised peritonitis is exemplified by appendicitis or divertucilitis before perforating.
Generalised peritonitis can occur after perforations of the above plus many other causes.
The pain in generalised peritonitis may be the strongest over the underlying area.
Other symptoms are to do with the cause of the peritonitis.

Obstruction:
Obstruction (intestines) is either due to a physical block or a reduction of gut function (i.e. motility).
The important thing to realise is that bowel contents are not moving.
This will cause the gut to go into a hypermotilic mode (increased frequency and magnitude)
This will lead to the formation of pain, which as a result of the increased contractions will be colicky in
nature.
The pain will be relieved every time the obstructed is temporarily relieved or when the intestinal
contractions are taking a temporary break, hence the colicky nature.
The abdominal pain is usually central in nature and not well localised.
The obstruction will also produce symptoms depending on its location in the GI tract.
Upper GI obstruction can lead to vomiting, which usually contains food particles or bile (green colour).
It may also be faeculent in nature if a fistula forms between large bowel and the stomach.
A lower GI obstruction is more likely to cause constipation.
The constipation can be just passing of faeces but can also include the inability to pass wind.
Sometimes obstruction lower down the GI tract can lead to progressive decrease in bowel motions.
Blocking the passing of wind can lead to abdominal distension. The further down the GI tract the more
marked it is.
Other symptoms associated with obstruction depends on the cause.

Difference in symptoms of upper and lower intestinal obstruction.
The main difference is the vomiting and constipation.
Vomiting is associated with upper GI obstruction whereas constipation is a feature of lower GI
obstruction.
The spasms that occur in a lower GI obstruction (especially large bowel) is more prolonged and
painful.
The location of the pain may also be evident. Upper GI obstruction may present with pain in the chest
or epigastrium whereas lower GI obstruction will have pain much lower down (in the iliac fossae)
Recognition of signs in an acute abdomen:
Examination of an acute abdomen (from OSCE: a teaching manual for medical undergraduates):
    Introduce, explain and adequately expose the abdomen.
      Feel the radial pulse (rate and regularity)
       tachycardia can occur with infection or hypovolaemia.
      Look at eyes for jaundice or pallor
       Jaundice with abdominal pain indicates gallstones.
      Look with a torch inside the mouth for furring of the tongue, ulcers and smell the breath.
       Furring of the tongue and malodorous breath can occur in appendicitis or peritonitis or any
       other intra-abdominal sepsis.
       Apthoid ulcers can occur in Crohn’s disease.
       Ketotic breath can occur in DKA and the patient with a DKA can sometimes present with
       generalised abdominal pain.
       Alcoholic breath may indicate a cause of upper GI bleeds such as a Mallor-Weiss tear or
       Oesophageal varices.
      Inspect the abdomen. Comment on shape, movement with breathing, scars and any visible
       masses or pulsations.
       Absence of the movement of the abdominal wall with respiration indicates peritonitis.
       A Pulsatile ruptured abdominal aortic aneurysm may be visible but is usually only palpable.
       Areas of bowel may be visibly moving in skinny people.
       There may be obvious visible masses (e.g. hernia)
      Gently palpate the abdomen superficially for masses and tenderness examining the sore area
       last. If sore all over then do superficial palpation to check for peritonitis.
       Localised abdominal pain is usually caused by inflammation of the underlying organ.
       Rigidity occurs as a protective function by muscles as a result of peritoneal irritation.
      If soreness localised then determine if there is guarding in that region.
       Guarding refers to resistance to palpation by contracting the abdominal muscles. It is caused by
       tenderness and anxiety.
      Check for rebound tenderness.
       Rebound tenderness occurs when there is sudden pain in the patient’s abdomen after releasing
       your hands from palpation. This sign suggests peritonitis. It is not always performed because
       the patient may be in significant pain.
      Check for percussion tenderness.
       Tenderness to percussion indicates peritonitis.
      Ask the patient to cough and check if this elicits any pain.
       Coughing and movement can be painful in peritonitis.
      If pain in right upper quadrant then check for Murphy’s sign.
       Ask the patient to breathe out. Palpate the right hypochondriac region just under the costal
       margin. Ask the patient to breathe in. If the patient catches there breath whilst breathing then it
       is Murphy’s sign positive. Repeat the test on the left side and it should be negative. The theory
       is that an inflamed gallbladder will hit your hand while breathing in and this will cause pain
       stopping the patient from breathing. Murphy’s sign positive indicates and inflamed gallbladder.
        Check for ascites:
         Sometimes abdominal distension may be as a result of fluid. It is important to check for shifting
         dullness. Ascites may occur as a result of liver disease which may help indicate other
         pathologies in an acute abdomen (e.g. oesophageal varices). It is also to remember the 6 F’s of
         abdominal distension: faeces, flatus, fluid, foetus, fat and food
        Auscultate for bowel sounds
         Intestinal obstruction will produce tinkling bowel sounds.
         Peritonitis will have absent bowel sounds as the patient will be in a state of ileus.
        Check the hernial orifices.
         Small bowel can become strangulated in an inguinal or femoral hernia. It is important to check
         if it is reducible.
        PR examination and urinanalyis
         Important to check for masses in the rectum and any bleeding.
         Haematuria may indicate renal colic.
         Glycosuria and Ketonuria indicates DKA.

Scars:
                                                  1  Subcostal/Kocher’s  cholecystectomy
                                                  2  Right Paramedian  laparotomy
                                                  3  Midline  laparotomy
                                                  4  Nephrectomy/Loin  renal surgery
                                                  5  Gridiron  appendicectomy (gridiron is named
                                                  because it cuts the obliques)
                                                  6  laparoscopic  cholecystectomy, appendicectomy,
                                                  colectomies.
                                                  7  left paramedian  anterior rectal resection.
                                                  8  transverse suprapubic  hysterectomy, pelvic
                                                  surgery
                                                  9  inguinal  hernia repair.


Signs of peritonitis (from cheese and onion):
Lying still
Shock
Positive cough test
Tenderness  both rebound and percussion
Rigidity  washboard rigidity
Guarding
Absent bowel sounds.
Gas under the diaphragm in an erect chest X-ray (due to a gas forming infection, bowel perforation and
others.)

Difference between localised and generalised peritonitis:
Localised is to do with a localised abscess that leads to the inflammation of the local area. This would
occur in cholecystitis, appendicitis, salpingitis and diveritculitis.
Generalised peritonitis is due to inflammation of the whole peritoneum and can occur due to rupture of
the above organism, introduction of infection to the peritoneal cavity (bowel rupture, surgery, catheter
for peritoneal dialysis etc.)

Signs of intestinal obstruction (from cheese and onion):
The symptoms have already been discussed and the importance in obstruction is to find whether it is
small or large bowel.
Shock  may be a part of the pathology causing the obstruction
Distension  usually around the level of obstruction. Distension is usually due to flatus.
Visible peristalsis  especially in thin patients. This shows the overactivity of the intestines.
Palpable mass  which may be the cause of the obstruction or a hernia.
Percussion  this produces a tympanic note due to excess air.
Bowel sounds are usually tinkling to indicate the overactivity of the bowels to overcome the
obsctruction.
Sometimes the bowel sounds are not heard if the intestines become paralysed by fatigue or due to
ischaemia caused by a thrombus or strangulation.
The pain is usually colicky but may be absent if there is ileus or may be sharp and constant if there is
strangulation.
Examination should be finished with the rectal examination for masses.

Difference in signs and symptoms or upper and lower intestinal obstruction.
Abdominal X-ray is the most important way of identifying obstruction.
Gas centrally in the abdomen will indicate the small bowel whereas gas in the caecum indicates large
bowel.
Large bowel gas trapping is held in the caecum because of the ileocaecal valve which prevents air from
going back into the small bowels. The problem occurs if the ileocaecal valve is incompetent which will
produce air in the small and large bowels.

Rectal examination:
An empty rectum means that there is a complete obstruction somewhere in the GI tract.
Rectal tenderness can be an important sign if there is a condition affecting the rectum but can also
occur in appendicitis whereby an inflamed retrocaecal appendix is palpated through the rectum.
Rectal examination may help identify if a bleed is close to the rectum or higher up the GI tract
(malaena)

Investigations of an acute abdomen:
Simple blood tests:
Haemoglobin  this may be low due to a chronic condition such as malignancy or IBD, it may also be
low due to acute bleeds such upper or lower GI bleed or a ruptured aortic aneurysm.
White cell count  if this is raised then it indicates an inflammatory condition. In the acute setting the
neutrophils will be raised.
Urea and electrolytes  usually not helpful but may be deranged if the patient is in diabetic
ketoacidosis or has been vomiting a lot. Urea and creatinine may be elevated with renal colic (and if the
other kidney is not functioning as well). The other electrolytes can be deranged in all the different
conditions.
Serum bilirubin  this will be raised in any form of jaundice. In the acute abdomen it is usually an
obstructive cause such as gallstones. Different types of bilirubin can be distinguished but not routinely
done.
Serum amylase  highly elevated amylase will occur in acute pancreatitis
Simple urine dipstick tests:
Haematuria  blood in the urine in an acute abdomen may occur as a result of a UTI or renal colic.
Glycosuria and ketonuria  glucose and ketones can be found in the urine in DKA. DKA can present
with non-specific abdominal pains.
Proteins and white cells  this is to exclude an acute pyelonephritis.
Nitrites  this indicates a UTI.
Bilirubin and Urobilinogen  if there is bilirubin (conjugated) and urobilinogen then this indicates
jaundice due to a hepatic cause. In an acute abdomen the cause of jaundice is more likely to be an
obstructive cause such as gallstones. This will present with a high urinary bilirubin (conjugated) but a
very low or no urobilinogen in the urine. This is because the bilirubin can not get into the intestinal
tract and get converted to urobilinogen.

Interpret plain abdominal X-ray:
From abdo X-ray made easy when looking at an abdominal X-ray always look at:
Bones  spine, pelvis, sacroiliac and hip joints and the lower ribs
Psoas muscles  these are muscles in the posterior abdominal wall connecting from the lumbar spine
to the lesser trochanters of the femurs. They must be present in all abdo films and its absence could
mean a severe condition but can also benign. An example of a loss of the psoas shadows are gas in the
peritoneum.
Kidneys  very hard to find but always look for them and the shape.
Liver  this will always show up as it is a very solid organ.
Spleen  usually very hard to find but look to see if there is spleomegaly.
Bladder  may be enlarged if bladder is full.
Uterus  may be present lying on top of the bladder. Intrauterine devices may pop up.
Stomach  gas and fluid is present in the stomach so a line of the level of the fluid may show up.
Important not to interpret this as a mass.
Small bowel  look for gas trapping the small bowel.
Appendix  hardly ever seen but sometimes it shows up if there is calcification of faeces (faecocolith)
here which may show up on X-ray.
Large bowel  start from the caecum, go up to the hepatic flexure and then across to the splenic
flexure and down the descending colon. It is easily identified usually due to solid faeces in the large
colon. Gas trapping in this area should be looked for in an acute abdomen.

Important X-ray signs in an acute abdomen:
Calcification  of various organs. The abdominal aorta may be calcified and this may show a size of
an aneurysm. Plus all the other various organs which may get calcified such as the pancreas, liver,
spleen, bladder, ureter etc. focal calcifications such as renal calculi or gallstones or faecocoliths may be
seen. 90% of renal stones show up on X-ray whereas 10% of gallstones show up on X-ray.
Bowel gas pattern air over the central region in the small bowel indicates small bowel obstruction
whereas air in the colon and caecum indicates large bowel obstruction. There may also be air trapped
under the diaphragm outside the bowels if the bowel perforates or if there is a gas-forming infection of
the peritoneum.
Loss of psoas shadow  important sign because it could mean a lot of fluid overlying the psoas
muscles or a lot of air.
Ascites  this would make it difficult to differentiate between all the different organs.
Organomegaly  look at the different organs and respect their sizes in the film presented.
Common causes of intestinal obstruction:
(From Clinical Surgery by M Henry & J Thompson)
Luminal causes:
      Gallstone (gallstone ileus)  gallstones are usually found in the biliary tree (especially the
       gallbladder. If they are large enough they may erode through the wall of the gallbladder into
       the adjacent small bowel or duodenum. The gallstone is then passed through the bowel until it
       gets trapped in the narrow ileum or at the ileocaecal junction which leads to a low small bowel
       obstruction. It is now a rare condition because gallstones are treated early. The history suggests
       bouts of intermittent obstruction because the gallstone acts like a valve, getting released from
       time to time. It is diagnosed radiologically due to air in the biliary tree that comes from the
       small bowel through the cholecystenteric fistula. The ileus portion comes once the bowel is
       fatigued from the obstruction and becomes paralysed. The gallstone is removed by enterotomy.
      Food bolus  undigested food, excess fibre, pyloric resection etc. can all lead to a food bolus
       causing obstruction. Its features are similar to a gallstone ileus.
      Meconium Ileus  meconium is the first few stools passed by the baby and it is a greeny tarry
       colour. It is very sticky and contains bile, amniotic fluid, epithelial cells and mucus. It is
       usually cleared out by the baby in the first few days and is sterile. Someone with cystic fibrosis
       will produce a lot of mucus which will make the meconium very thick. The large colon in
       newborns is very small and can not adapt to the extra thick consistency. The baby does not pass
       any meconium. The meconium gets stuck in the distal small bowel and as a result there is small
       bowel obstruction. Meconium ileus is present in 15% of CF cases at birth. The obstruction can
       perforate causing a peritonitis.
Mural causes:
     Stricture
           o Congenital:
               Dudoenal atresia  second most common neonatal obstruction and one-third of patients
               have down’s syndrome. Atresia means the passage is absent. It may sometimes be
               closed by a stenosis or an incomplete web. The infant presents with bilious vomiting and
               the abdo X-ray shows a double bubble appearance (gas in the first part of the duodenum
               and gas in the stomach).
               Small bowel atresia  though to be a vascular accident during fetal development.
               Hirschprung’s disease  loss of parasympathetic activity to the large colon due to
               failure of development of the myenteric plexus of ganglion cells. Features are a delay in
               the passage of meconium, bilious vomiting and abdominal distension. Rectal
               examination may lead to large passage of meconium and flatus. Barium follow through
               may help identify dilated ganglionic segments with narrowed aganglionic segments but
               this is hard to interpret. Biopsy of the rectum which is stained will show a lack of
               ganglion cells.
               Anorectal abnormalities  skin covering the anus may lead to obstruction. There may
               also be an absence of the anal canal without a fistula formed.
               Neonatal necrotising enterocolitis  necrosis of the small bowel which usually occurs
               in premature babies. It is due to vascular changes or due to respiratory distress. The
               bowel is infracted and then infected by bacteria.
           o Inflammatory  inflammatory conditions such as Crohn’s, ulcerative colitis, TB and
               diveritculitis may lead to an obstruction by protruding in the lumen or by causing a
               stricture by fibrosis. Potassium chloride tablets and NSAIDs can also cause formation of
               strictures in the small bowel.
          o Ischaemic  any reduction in vascular supply such as hypovolaemia, blood clots or a
              bleed can lead to ischaemia of any part of the bowel. Ischaemia will lead to lactic
              acidosis and eventually infarction. This infarcted material will mean the muscle will not
              contract at the area affected and so it is a functional obstruction (rather than
              mechanical). The infarction is also Godsend for bacteria and so it invades the bowel and
              causes sepsis. This may perforate and then cause peritonitis.
          o Neoplastic  carcinomas will grow and invade any space it can get and so this may
              obstruct the lumen. Colorectal carcinomas are the most common bowel malignancies but
              there are also small bowel malignancies.
    Intussusception
Extramural causes:
    Adhesions
          o Congenital
          o Inflammatory  the inflammatory conditions mentioned in the mural causes can all
              cause adhesions of the bowel to the abdominal wall or other parts of the bowel. The
              peritoneum has a fibrinolytic mechanism which can easily be activated if needed. So if
              any fibrin is formed in the peritoneum it is quickly broken down by the plasmin in the
              peritoneum. When this mechanism fails then the fibrin deposited becomes organised and
              as a result an adhesion forms. Any inflammation can make the fibrinolytic mechanism
              fail because inflammation is usually treated by deposition of fibrin (wound repair). The
              fibrous adhesion fixes the small bowel to another part in the abdominal cavity and as a
              result can not move freely. This will ‘pull’ the bowel from the outside and may cause a
              narrowing in the bowel which may become obstructed. Peritonitis can lead to
              widespread fibrosis in the peritoneum and stop the bowel from making its peristaltic
              contractions.
          o Malignant
          o Ischaemic  this also leads to inhibition of the fibrinolysis mechanism. Disrupting the
              vascular supply due to an internal cause or due to surgery will lead to ‘wound repair’
              and the formation of adhesions. Patients who have abdominal surgery may present a few
              days after the operation with obstruction which is due to adhesions. Sometimes these
              adehesions may be there for years and then present.
    Hernia
          o External  herniation of the gut out of the abdominal cavity. Various types such as
              Inguinal hernias (direct and indirect), femoral hernias, umbilical hernias, incisional
              hernias and many more. The importance is that if the bowel content is irreducible the
              bowel may be strangulated and so this is a surgical emergency. If the bowel is
              strangulated there is obstruction as well as a reduction in blood supply.
          o Internal  uncommon. This is a herniation through a peritoneal fold. An example is a
              herniation around the ligament of Treitz (the suspensory ligament of the duodenum). It
              may lead to strangulation of the bowel which will lead to ischaemia etc.
    Volvulus (twisting)
          o Congenital – this involves malrotation of the gut and as a result small bowel mesentery
              is narrow and unstable. This can lead to a strangulation of the blood vessels (which run
              in the mesentery) causing intestinal ischaemia. The infant presents with bilious vomiting
              and abdominal distension. The duodenal-jejunal junction is on the right or midline
              instead of on the left and so a barium meal will help show the location of the duodenum
              on an X-ray.
          o Acquired
As well as all the causes mentioned above the obstruction can be described as:
‘Open loop’  bowel content can escape proximally
‘Closed loop’  a segment of bowel is obstructed at two ends so bowel content can not escape – e.g. a
hernia. Large bowel obstructions are also closed loop if the ileocaecal valve is intact.

Pathophysiology behind obstruction:
Bowel is obstructed. The bowel proximal to the obstruction will increase its contractions in frequency
and force. The bowel wall becomes dilated (due to build up of gas) which may make the contractions
weak. The activity here makes the wall oedematous which will lead to a reduced reabsorption of
secretion so there may be a volume deficiency in the blood (the bowels are long!). Strangulation of the
bowel will shut off venous and then arterial blood supply which will cause bowel infarction. Initially
there is a lactic acidosis due to lack of oxygen and then the bowel will die and finally it will rupture
releasing bacteria into the peritoneum which may cause peritonitis.

Common causes of peritonitis and their presentations:
Peritonitis is either local or generalized depending on whether organ involved has ruptured.
Generalized peritonitis can occur due to:
Perforation of a peptic ulcer  presents with pain that was initially epigastric but then becomes
generalized due to peritonitis. All the features of peritonitis are present and the patient may have
haematemesis or malaena. Patients may also experience breathing difficulties due to the peritonitis
pushing up at the diaphragm.
Perforation of a diverticulum  there is ileus and peritonitis. Air may also escape from the bowels
which will trap under the diaphragm and above the liver (this can be seen on an erect chest X-ray or
Abdo X-ray.
Perforated appendix (in appendicitis)  the omentum initially tries to engulf the appendix to prevent
the perforation from spreading. This will lead to an abscess formation and eventually generalised
peritonitis.
Perforated bowel (usually due to obstruction)  present with peritonitic features plus air trapped under
the diaphragm as well as features of obstruction.
Perforated gall bladder (in cholecystitis)  peritonitic features with an empyema formed in the gall
bladder.
Post-abdominal surgery.
Infected catheter in peritoneal dialysis.

Common conditions associated with acute right iliac fossa pain:
Appendicitis  a faecocolith (faecal stone) or oedema blocks the appendicular lumen. This allows
bacteria to grow in the occluded portion. This leads to inflammation which will cause pain. The
omentum will grow and cover the appendix to form and appendicular mass (which can be palpated).
Pus will develop in the appendix forming an appendicular abscess. The pain associated with
appendicitis usually starts around the central part of the abdomen around the umbilicus as it is ill
localised. The patient has associated anorexia, nausea and vomiting. As the appendix becomes more
inflamed local peritoneal irritation will localise the pain to the right iliac fossa. The patient will have
maximal tenderness and guarding over McBurney’s point. McBurney’s point is a region one-third the
way up an imaginary line from the ASIS to the umbilicus. The position of the appendix may also
influence the position of the pain. The patient may also have pyrexia, foul breath and a furry tongue
(but these features are not always present). A Vaginal exam should be done in females to exclude other
causes and find which side is most tender and in all patient a rectal examination should be done. If the
appendix perforates then there may be peritonitis.
Acute Salpingitis  acute infection of the fallopian tubes. The term is sometimes referred to pelvic
inflammatory disease, however, this term refers to any pelvic organ and should not be used. Infection is
usually preceded by cervical or vaginal infection which then rises up to the fallopian tubes. Gonorrhaea
and Chlamydia are the two organisms that are fairly common in acute salpingitis. Infection can rise due
to a number of reasons such as retrograde menstrual flow, intercourse, sperm, local investigations such
as biopsy, IUCD and so on. A varying spectrum of features can present. There is usually pain along the
lower abdomen which is bilateral in 90% of cases. Patients are sometimes asymptomatic but can
sometimes present with peritonitis. The pain is constant and dull but occasionally cramp-like. There is
associated pain with menstruation and sexual intercourse. 75% of patients will havea purulent vaginal
discharge. Diagnosis is usually on clinical findings. This will not present to the A+E unless the pain is
severe or there is peritonitis.

Tubo-ovarian abscess An advanced form of pelvic inflammatory disease. It is usually the progression
from acute salpingitis.

Ruptured ectopic pregnancy  an ectopic pregnancy is when the zygote implants anywhere but the
uteral lining. Nearly all cases are in the various locations of the fallopian tube but it can also implant
anywhere in the abdominal cavity and on the ovary or cervix. The cause is usually due to fallopian tube
damage, either because of infection or previous surgery or abnormal anatomy from birth. The invading
embryo grows onto the structure disrupting the vascular supply which can cause bleeding.
Prostaglandin release and local bleeding causes peritoneal irritation which will cause the lower
abdominal pain usually found in an ectopic pregnancy. Ruptured ectopics can also present with vaginal
bleeding and with excessive loss of fluid there may be shock. It is important to know when the patient
had their last period as this may indicate a pregnancy. There are sometimes vague signs such as back
pain or shoulder pain which is to do with blood irritating there areas.

Renal/ureteric stones  presents with renal colic if in the ureters. This pain is the loin to groin pain
which comes and goes. When the pain is there it is very intense and can make the patient faint. Other
features are haematuria, dysuria, oligouria (or renal failure if one functional kidney). An inflamed
appendix may rub against the right ureter causing dysuria as well.

Strangulated hernia  a strangulated hernia will present as a mass in the inguinal or femoral region (in
this case the right side). If strangulated the bowel will become ischaemic which will infarct and be the
breeding ground for bacteria. There will be features of obstruction as well as a palpable mass which is
usually irreducible.

Mesenteric adenitis  this is inflammation of the mesenteric lymph nodes. Its presentation mimics that
of acute appendicitis. The condition is self limiting. The pain mimics that of appendicitis but is usually
diffuse over the right lower quadrant rather than focused on McBurney’s point. The cause is usually
viral in origin but can be caused by bacteria as well. It can be diagnosed by laporoscopy but usually it
is just diagnosed after surgery has found the appendix is not inflamed.

Meckel’s diveritculitis  The Meckel’s diverticulum is common congenital abnormality in the small
intestine. It is a little diverticulum that is a remnant of the vitelline duct in early stages of the foetus.
The way too remember the Meckel’s diverticulum is the rule of 2’s:
2% of population have it.
2% of those that have it are symptomatic.
It is 2 feet up from the ileocaecal valve in the ileum.
It is 2 inches long
Commonly presents at 2 years.
Males are 2 times more likely to have it.
It has two types of ectopic tissue – gastric and pancreatic.

This pouch is a nice place for bacteria to grow and as it is not following the continual flow of the bowel
contents. Infection here can mimic that of acute appendicitis. The diverticulum can also act as point
around which volvuls can occur. The diverticulum may also act as a lead point for intusussception.
Intussusception is a process by which a part of the bowel prolapses down into the bowel.

Crohn’s disease  cramp-like pain anywhere in the gut but usually in the lower right quadrant. The
pain is relived by diarrhoea. The mass that forms may be palpable and can lead to obstruction in the
gut. Other features can be found such as ulcers in the mouth, perianal skin tags and anal fissures as well
as extra GI features.

Perforated Caecum

Psoas Abscess  usually caused by TB infection of the lumbar vertebra that tracks itself down the
psoas muscle but can also occur in renal sepsis or posterior bowel perforation. The psoas major
attaches from the lumbar vertebra to the lesser trochanter of the femur. It present with a mass just under
the inguinal ligament which is close to the lesser trochanter. It is easily confused with femoral hernia or
lymph nodes. Psoas sign is a good clinical feature. Lie patient on their side. Keep their knee straight
and then extend their hip back. This will cause abdominal pain if the psoas major in inflamed. This sign
may be positive in acute appendicitis because the appendix can lie on top of the psoas muscle and will
get irritated when the muscle contracts.

Treatment:
Appendicitis:
This depends on whether there is an appendix mass. If the acute appendicitis is progressing then it is
important to go in and remove the appendix to prevent progression to a perforation. If a mass has
formed then this means omentum and bowel are trying to contain the appendix. The patient is given IV
fluids, antibiotics and no food to help clear up the infection. The mass would then hopefully resolve. If
the patient deteriotes then it is important to take out the appendix. The appendix can be removed
laposcopically or open. If an abscess has formed then it must be drained and then the appendix
removed. The abscess is easily identified on ultrasound. By the appendix can be removed electively as
a prophylactic measure against future appendicitis.

Pancreatitis:
Epigastric and left hypochondriac pain that radiates to the back and is relieved by leaning forward.
Treatment is usually supportive because pancreatic surgery is messy. The cause should be removed
(usually gallstones or alcohol). Therapy is supportive and the basis of it is fluid management as patients
may be in shock due to massive retroperitoneal bleeds and fluid loss. IV fluids (0.9% saline or plasma
expanders) are given and the fluid status in the body is measured by urine output (more than
30ml/hour). A catheter may need to be placed in elderly patients and this will help assess urine output.
The patient’s central venous pressure can also be assessed (central venous line) to look at the fluid
status. The bowels are rested to help prevent the pancreas from contracting to release enzymes for
digestion. The patient will have nil by mouth until they are clinically better. Opiate analgesics are given
to help reduce the pain. Morphine, however, can cause the sphincter of Oddi to contract more and
therefore make it more painful. The patient should be assessed in ITU if the have three or more of the
following on the Glasgow criteria:
P  Pa02 < 8kPa
A  age >55 yrs
N  neutrophils (WBC > 15x10^9/L
C  calcium, <2mmol/L
R  renal function, urea > 16mmol/L
E  enzymes, LDH > 600iu/L, AST >200 iu/L. amylase not important because it varies in patients
A  albumin <32g/L
S  sugar, blood glucose > 10mmol/L

Cholecystitis:
Cholecystitis is usually caused by a gallstone blocking the cystic duct. The patient is given fluid
replacement as well as pain killers intravenously to help stop the pain. They are also given antibiotics if
infection is suspected. The patient is not allowed to eat anything as this will rest the gallbladder. This
initial medical management will help reduce the pain and hopefully allow the gallstone to fall back into
the gallbladder. It is also hoped that the inflammation is reduced in the process. After several weeks the
gall bladder is removed by a laparoscopic cholecystectomy or open laporotomy. This is a prophylactic
against future formation of gallstones and cholecystitis. If the stone is blocked further down the biliary
treat it is removed by ERCP.

Diveritculitis:
This occurs when any diverticula become inflamed and infected.
Diverticula are areas where faeces may be able to get trapped and then allow the growth of bacteria. It
is initially treated with IV fluid management with bowel rest. The patient is also given IV antibiotics to
treat infection. Surgery is only indicated if there is a perforation and as a result a generalised peritonitis.
The perforation is repaired and the abdomen is given a nice washout to clear infection.

Principles of treatment of intestinal obstruction:
IV fluid management prior to surgery:
Pre-operative fluid management is very important. The patient is usually dehydrated in intestinal
obstruction and should be adequately hydrated. Anaesthetic drugs cause vasodilation and slow the heart
rate so the patient may go into shock if operated on when dehydrated. Obstructed patients also have an
electrolyte imbalance and this should be corrected.

Pass a NG tube and verify its position (Whipps Cross guidelines):
Wash hands prior to procedure (social hand wash this is not an aseptic procedure)
Apply gloves
Get patient to sit up and support their head upright if needed.
Take the nasogastric tube out and measure the distance needed to be roughly inserted by checking the
length from the xiphisternum to the bridge of the nose and then along to the patient’s ear lobe.
The tip of the tube is lubricated with local anaesthetic and nostrils assessed.
The tube slowly inserted as patient swallows water.
Once the correct distance has been placed in stomach contents are aspirated to check the pH.
The pH is checked on the pH indicator strips and should be below pH 5, looking towards a much lower
pH. This is the procedure to check position. If pH was higher then it may have gone in to the lungs or
the tube may curl up at the back of the mouth.
The patient can be questioned to check for any complications.
It is important to know if the patient has just recently had a proton pump inhibitor or previous gastric
surgery as this may affect the pH. If this is the case then leave the guidewire to check position on X-ray
or re-assess pH a few hours later. The tube is then flushed with water.
Remove gloves and then wash hands.

Surgery in the obstructed patient:
Emergency surgery is required in peritonitis and when there has been a perforation of bowel or other
organs. This can be closed or large excision may be needed. Excision can not always result in end-end
anstomosis but sometimes in a stoma. Less urgent surgery will require excision or repair. This is
usually repair of a hernia (that is not strangulated) to prevent strangulation from occurring or excision
of carcinomas or bowel affected by IBD. Excision may also result in a stoma. ‘closed bowel’
obstruction is an emergency as is a perforation.

Recognise and classify abdominal stomas.
End stomas  this is where the bowel is cut proximal to the damage. The bowel is then brought up
through the abdominal wall as a stoma. The distal portion can have several options:
 it is left in the abdomen and closed (Hartmann’s procedure)
 mucus fistula  this is when the distal portion is brought out as a stoma as well on the abdominal
wall. This is known as a non-functioning stoma and removes mucous and fluid from the bowel. The
functioning stoma is the one that allows faeces to pass out.
 double barrel stoma  this is where the distal part is brought out in a stoma with the functioning
stoma. It is similar to a mucous fistula except a mucous fistula is formed elsewhere on the abdomen.

Loop stomas  this is usually to create a temporary stoma before forming an ilio-anal pouch. A loop
stoma is done by pulling a loop of bowel out of the abdominal wall. A bridge is palce under the loop to
prevent it falling back in to the abdomen. An incision is made in the looped bowel to allow faeces out.
The bridge is removed after a week or so and in this time fibrosis under the loop will prevent it from
falling back in. It can be reversed quite easily without another laparotomy.

Colostomy refers to a stoma formation involving the colon and is usually located in the lower left
quadrant.
Ileostomy refers to a stoma formation involving the ileum and is located usually in the lower right
quadrant.

Talk to a patient undergoing a laparotomy for acute abdominal conditions.
I am going to cut down the middle of your tummy. I am then going to cut some of your bowel, or
remove your gallbladder or remove your uterus etc. I am then going to close your tummy. Something
along those lines.
SWELLING IN THE GROIN

History of any lump:
Where is it?
How and when was it noticed?
Is it enlarging, staying the same or getting smaller?
Any changes in size, shape and colour?
Is their any pain, itching, bleeding, discomfort, discharge, redness and heat?
How long has it been there?
Any predisposing factors such as sun, insect bite, trauma and infection?
Are there lumps anywhere else similar to this one?
Are there any systemic symptoms? Fever, weight loss, rigors and malaise?
Followed by the rest of the history: PMH, TH, SH and FH etc.

What’s in a hernia  a sac, its covering and its contents
The sac is what is holding the hernia and has a mouth at its opening, a neck where it leads to its body
and a fundus at its tip. The coverings are the layers that emerge with the hernia as it protrudes through
(e.g. abdominal wall coverings). Its contents are what are inside, usually bowel.

Terms used when describing hernias:
Reducible  the hernial contents can be returned into the abdominal cavity but the sac remains outside.
The contents may bulge out again on any pressure such as coughing or gravity.
Irreducible  the contents can not be returned into the abdominal cavity. The reasons for this is a
narrow neck, i.e. the hernia is going through a narrow orifice such as the femoral canal or it may occur
as a result of an adhesion between the bowel contents and the sac. Irreducible hernias are at a higher
risk of strangulation and obstruction.
Obstructed  the intestine inside has become obstructed. This may because of the narrow neck or
adhesions. If the obstruction is at both ends of the bowel then it is a closed loop obstruction.
Obstructions can be strangulated but not always.
Strangulated  the blood supply to the herniated bowel contents and the sac is cut off. Initially it is
venous and lymphatic supply cut off. This pools blood in the veins which can lead to haemorrhage
locally. The soft tissue swells leading to arterial supply being shut off and then the sac and contents
become necrotic. The sac and its coverings can be individually affected in which case it is a sterile
necrosis (no bowel contents) but usually the bowel is affected. The bacteria can invade the necrotic
tissue and cause a local infection. As the infection gets worse the herniated bowel can perforate leading
to a peritonitis.
Inflamed the contents are inflamed due to an organ that is not usually there e.g. acute appendicitis,
Meckel’s diveritculitis, acute salpingitis etc. it is difficult to distinguish from a strangulated hernia.
Incarcerated  a hernia that is irreducible but not strangulated. It may also be obstructed.

Examination of the groin:
Expose the abdomen adequately all the way down to the knees with patient lying flat.
Are there any obvious swellings?
If so where is it  above the inguinal ligament or below, or in the scrotum. What colour is it?
Previous surgery scars.
If you can’t see anything then ask the patient to stand to see if you can see anything.
Examine the swelling and measure it dimensions – length, width and depth.
Define the shape of it.
What does it feel like?
Can it be transilluminated (torch behind it)?
Does it extend beyond any obvious skin markings?
Test the lump for cough impulse (place hands on it and ask patient to cough) does it get worse?
Ask the patient to reduce the swelling. Put pressure over the deep inguinal ring and ask patient to
cough. If the swelling appears medial to the pressure then it is a direct inguinal hernia.
Release the pressure and the patient to cough now and if it now appears then it is an indirect inguinal
hernia.
check for lymphadenopathy in the local area.

Inguino-Scrotal lumps  a lump that goes down the inguinal canal and into the scrotum.
Scrotal lumps  this will be present in the scrotum but not up in the inguinal canal. The importance to
see if you can get above the lump. If you can get above then the lump is purely scrotal. If you can not
get above the lump then it is an inguino-scrotal lump and is likely to be a direct or indirect hernia.

Surface anatomy:




                                               The pictures show the inguinal ligament, pubic
                                               symphysis, pubic tubercle and the canals relative to it.
                                               The inguinal canal sits above the inguinal ligament (the
                                               inguinal ligament forms the base of it). The inguinal
                                               ligament is above the femoral canal. The boundaries of
                                               the femoral triangle is formed by the medial edge of the
                                               sartorius muscle, inguinal ligament and the lateral edge
                                               of the adductor longus muscle. The femoral canal is just
                                               medial to the femoral vein and latertal to the lacunar
                                               ligament. It contains the lymphatics.

                                               The superficial inguinal ring is weakness in the
                                               aponeurosis of the external oblique. The deep inguinal
                                               ring is at the mid-inguinal point where the spermatic
                                               cord or the round ligament enters. It is formed by a gap
                                               through the layers of the abdominal wall.
Risk factors for inguinal hernias:
Family history
Chronic cough, either due to smoking or due to another lung condition
Chronic constipation  straining increases pressure on abdomen.
Excess weight  pressure on abdomen
Pregnancy  weakens abdominal wall and increased pressure on abdomen
Occupation  heavy lifting or periods of long standing increases risk
Premature birth
History of hernias.

These risk factors should be found in the history.

Differentials of groin swellings:
Inguinal region:
Direct/indirect inguinal hernia
Femoral hernia
Lymphadenopathy
Femoral aneurysm
Undescended testis
Saphena varix  swelling at the top of the long saphenous vein due to valve incompetence.

Scrotal regions (discussed in separate topic):
Indirect inguinal hernia protruding into the scrotum
Hydrocele (will transilluminate)
Epidydmal cyst
Testicular tumour
Haematocele
Orchitis (mumps)
TB epididymitis.

Management:
A truss is a support belt that can be worn to help keep a hernia reduced and is usually only offered to
those who can not undergo an operation.
An elective surgical repair is the main way forward. There are two main methods:
Shouldice  layered suture technique into the transversalis fascia which will hopefully cause fibrosis
in the area.
Lichenstein  put a nylon or polypropylene mesh to cover the hernial orifice. This will stimulate
fibrosis and strengthen the posterior wall through the hernia is protruding. This method can be done
laporoscopically.

The repair can be done under general, regional or local anaesthetic and in many cases is only a day
case.

Complications (especially in males as it is more common):
Urinary retention due to urinary organ proximity to the inguinal region.
Scrotal haematoma due to massive resection
Damage to the ilio-inguinal nerve which reduces sensation over the pubic tubercle, scrotom or labia.
EXAMINATION OF A LUMP
History of any lump:
Where is it?
How and when was it noticed?
Is it enlarging, staying the same or getting smaller?
Any changes in size, shape and colour?
Is their any pain, itching, bleeding, discomfort, discharge, redness and heat?
How long has it been there?
Any predisposing factors such as sun, insect bite, trauma and infection?
Are there lumps anywhere else similar to this one?
Are there any systemic symptoms? Fever, weight loss, rigors and malaise?
Followed by the rest of the history: PMH, TH, SH and FH etc.

Malignant masses may not be painful unless they have a direct effect on a local structure.

Examination of a lump (from the CMCS booklet):
Observation:
Location/position
Contour  irregular or regular
Pulsation  aneurysm or high blood flow
Colour of skin  red, pigmented etc.
Abnormalities in skin  peau d’orange (skin looks like that of an orange (dimply)
Abnormal vessels

Palpation:
Cough impulse
Consistency  soft, firm, hard, rubbery, uniform, varied, lobulated
Emptying
Fluctuation
Position (from a landmark)
Surface  smooth, rough, irregular
Shape
Size
Tenderness
Temperature
Thrill or pulsation

Movement:
Skin tethering  attempt to pick up skin over the lump
Deeper structures  attempt to move swelling in different planes to the surrounding tissue.
Muscles and tendons  palpate the swelling while asking the person to move the muscle (contracting)

Specifics:
Transillumination  if you suspect it is fluid filled
Auscultation  for bruits or bowel sounds.

Lymph nodes:
Examine the lymph nodes draining that particular area.
PRE-OPERATIVE AND POST-OPERATIVE CARE
Ask any of the Royal London people for the handouts on pre and post-operative care.

SWELLING IN THE NECK
This does not follow the objectives. The objectives are crap so just done a few important things on neck
swellings.
Regions of the neck:




Other triangles/regions in the neck are shown in the picture below:




History of neck swelling:
This is similar to the history of any lump but there are some extra questions that might be relevant
                        Is it a hard lump?
                        Is it a relatively soft, pliable, bag-like (cystic) mass?
                        Is it a painless bag-like (cystic) mass?
                        Is the entire neck swollen?
                        Where is the lump located?
                        Has it been growing bigger? Over how many months?
                        What other symptoms are also present (weight loss, night sweats)?
                        Is there a rash?
                        Is there difficulty breathing, difficulty swallowing or hoarseness?

Differentials of neck swellings:
This is from Churchill’s pocketbook of differential diagnosis
Type                Cause                 Notes
                    Sebaceous cyst        Obvious on inspection.
                                                            Will have whitish sebum (a bit like feta cheese) inside and will have a
                                                            point where the sebum comes out.
                                                            It occurs because the sebaceous gland is blocked and can become very
                                                            painful (not always) and red.
                                                            Management is when it keeps on growing is to excise the cyst so that you
                                                            prevent infection or ulceration.
                                                            Occurs on scalp, face, neck, back (i.e. areas that produce sebum)
                                     Lipoma                 Can occur anywhere in the body.
                                                            They are soft and lobulated and not fixed to the skin.
                                                            They are very slow growing and painless.
                                                            Look for other clues such as multiple lipomas (familial condition known
                    Superficial                             as Dercum’s disease).
                                                            They are not attached to the skin.
                                     Dermoid cyst           This is a teratoma that has matured into skin tissue (skin, appendages and
                                                            hair follicles).
                                                            It looks like a sebaceous cyst without the punctum and sebum.
                                                            It is a benign mass because it is differentiated.
                                                            It is usually congenital but can be acquired (in relation to scars)
                                     Abscess and others     Tender, red, inflamed swelling will be obvious of an abscess.
                                                            Other lumps related to the skin would be malignancies such as:
                                                            Basal cell carcinoma
                                                            Squamous cell carcinoma
                                                            Melanoma
Lymph nodes                                                 Lymph nodes can be affected in many condition and it is important to
                                                            check for tenderness, enlargement, firmness, rubbery feeling, if it is small
                                                            and hard.
Deep lumps:
                                     Thyroid                Thyroid swellings will move on swallowing (give water when
                                                            swallowing).
                                                            Other symptoms must be looked for depending on hyper or hypo.
                                                            Compression symptoms (breathing difficulties, dysphagia, hoarseness)
Anterior triangle




                                                            may also occur if grossly enlarged.
                                                            It may be a diffuse goitre or may have nodules.
                         Move on                            If a nodule it is found it is important to rule out malignancy by feeling
                        swallowing                          the shape and checking local lymph nodes.
                                     Thyroglossal cyst      The thyroid gland develops in the pharynx embryologically and then
                                                            moves down through the tongue and hyoid bone to its normal location
                                                            down the thyroglossal duct.
                                                            If this duct is persistant (i.e. doesn’t atrophy) then it may fibrose and
                                                            become a thyroglossal cyst.
                                                            It is a painful lump in the midline of the neck (or just off midline) just
                                         above the hyoid bone.
                                         It moves on swallowing and moves on protrusion of the tongue (part of
                                         the thyroid examination!).
                                         It can become infected leading to more pain and swelling.
                                         It may also present with compressive symptoms.
                     Lymph node          Lymphadenopathy in the anterior triangle.
                     Salivary glands     There are three main salivary glands- submandibular, parotid and
                                         sublingual.
                                         The secretions released are transported to the mouth by ducts and if it is
                                         obstructed then it can lead to swelling of the gland.
                                         Salivary stones can form in any of the ducts but usually in the
                                         submandibular salivary gland.
                                         They are palpable in the floor of the mouth.
                                         Parotid gland can be obstructed but the swelling is usually due to a
                                         tumour (adenoma).
                                         It may also be infected (due to a blockage by a stone) and this will give a
                                         unilateral or bilateral parotitis.
                                         Mumps is the most common viral infection of the parotid gland and is
                                         associated with orchitis in males. It is usually a bilateral swelling.
                                         Salivary gland swellings usually become bigger or painful during
                                         mastication.
                     Branchial cyst      This is a cyst that forms in an unobliterated second branchial arch.
       Do not                            Branchial arches are swellings that occur embryologically in the foetus.
      move on                            The second arch is involved in the formation of the neck.
     swallowing                          If the arch does not obliterate then it can form a cyst.
                                         This cyst is soft and putty like and is found next to the upper portion of
                                         the sternocleidomastoid.
                                         It is usually asymptomatic but can become infected and painful
                     Carotid body        This is a firm tumour that occurs at the bifurcation of the carotid artery
                     tumour              into the internal and external carotids.
                                         The carotid body is located at this bifurcation.
                                         The tumour is usually benign but can be malignant.
                                         They are usually symptomless but can cause cranial nerve palsies such as
                                         the vagus and hypoglossal nerve and can cause blackouts if they are large
                                         enough to cause partial obstruction of the internal carotid artery.
                     Carotid aneurysm    A rare condition.
                     Sternomastoid       Occurs only in babies after birth trauma.
                     ‘tumour’            It is not a real tumour.
                                         It occurs as a result of a swelling in the middle of the sternomastoid.
                                         This makes the head turn to the opposite side with the chin tilted towards
                                         the shoulder on the side of the swelling.
                     Cervical rib        A bony hard swelling in the back of the neck.
                                         Occurs in 1 in 200 people and is an extra rib on the seventh cervical
                                         vertebra. It is usually unilateral but can rarely be bilateral.
                                         It could compress the brachial plexus or the subclavian artery
                     Subclavian artery   An obvious Pulsatile mass in the posterior triangle which is often
                     aneurysm            associated with a cervical rib.
                     Pharyngeal pouch    This is a lump that can form as a result of a protrusion in the wall of the
Posterior triangle                       pharynx (due to a weakness between two muscles)
                                         The pouch is located posterior to the lower border of the
                                         sternocleidomastoid.
                                         The swelling enlarges on swallowing and lying down.
                                         Patients have symptoms of dysphagia and gurgling can be heard over the
                                         swelling. Patients also have halitosis and night time coughs.
                                         The coughs occur as result of emptying of contents from the pouch which
                                         causes the patient to choke. Emptying usually occurs on lying down.
Other specifics
Salivary gland excision or salivary stone extraction of the submandibular can result in damage to the
lingual nerve which is a division of the submandibular division of the trigeminal nerve (cranial nerve
V). The lingual nerve also carries some of the nerve fibres for the facial nerve which is for the taste
sensation over the anterior two thirds of the tongue. Damage to the nerve therefore leads to loss of taste
over the anterior two thirds of the tongue.
Parotid gland excision can result in palsy to the facial nerve (cranial nerve VII). The facial nerve passes
through the parotid gland (but does not innervate it) and then branches into its 5 major divisions.

Thyroidectomy is indicated in thyroid disease when:
The patient can not comply with medication either because it is contraindicated or allergic or side
effects etc.
The patient has relapsing thyroid disease.
Radioiodine is contraindicated.
There are compressive symptoms from the thyroid.
If they have a carcinoma.

Complications of thyroidectomy:
Haemorrhage  the thyroid is highly vascular. The haemorrhage can be large leading to dyspnoea and
stridor. The wound will need reopening to stop the haemorrhage or drainage with intubation can be
done.
Thyroid storm  very rare because patients are given drugs to control thyroid before hand. Surgery
may lead to a quick release of hormones in to the blood. If the patient is not euthyroid before operation
then this phenomenon.
Recurrent laryngeal nerve damage  vocal cord paralysis leading to a hoarse voice. If both nerves are
affected then there can be breathing difficulties.
Superior laryngeal nerve damage  this will make it hard to hit pitch notes
Hypoparathyroidism  this may occur as a result of damage to the parathyroid gland. The patient is
hypocalcaemic. Features to look for are parathesia around the mouth and digits, then muscle spasm and
then tetany. Trousseau’s sign and Chovstek’s sign can also be elicited.
BREAST LUMP, BREAST PAIN AND NIPPLE DISCHARGE
The history of any breast problem is the same for any lump, pain or discharge. The differentials below
will give an indication what to ask in the history.
All the differentials listed are from Churchill’s pocketbook of differential diagnosis.

Differentials of a breast lump:
Type                      Cause                     Notes
                          Carcinoma                 Hard irregular swelling
                                                    Fixed to skin or fixed deeper
                                                    Skin dimpling (peau d’orange) and Nipple retraction
                                                    Paget’s disease of the nipple  an intraductal carcinoma that
                                                    gives the nipple an eczema appearance.
                                                    Look for signs of metastases
                    Malignant                       Liver  jaundice
                                                    Bone  pain and pathological fractures
                                                    Lung  breathlessness
                                                    Brain  personality change, fits, headaches
                                                    Family history is common with breast cancer
                                Phylloides tumour   A fibroadenocarcinoma of the breast which is a large mobile
                                                    mass.
                                Fibroadenoma        Smooth, rounded, mobile mass.
                                                    Also known as breast mouse because it moves around under
   Discrete lumps




                                                    your fingers.
                                Cyst                Smooth mobile swelling. May be tender.
                                                    Associated with general lumpiness of the breast.
                                Galactocele         Smooth, mobile swelling occurring in the lactating breast
                                Fat necrosis        Hard irregular swelling.
                                                    There may be overlying bruise marks or teeth marks.
                                                    History of trauma there.
                                                    Lesion may be fixed to skin so hard to differentiate with
                                                    cancer.
                      Benign    Lipoma              Soft lobulated swelling that is rare in the breast.
                                                    Pseudolipoma is when there is bunching of fat between
                                                    suspensory ligaments and is due to carcinomas.
                                Duct ectasia        This is dilation of the ducts in the breast. The cause is due to
                                                    exaggeration in normal cyclical changes leading to wear and
                                                    tear of the ducts.
                                                    Tender retroareolar area.
                                                    Retroareolar erythema
                                                    Nipple retraction
                                                    Thick, creamy nipple discharge
                                Sebaceous cyst      Mobile swelling fixed to the skin with a punctum.
                                                    May be infected with discharge and redness.
                       Generalised swelling         The patient will have generalised swelling in pregnancy,
                                                    puberty and lactation due to hormones.
                                                    There may be generalised swelling in mastitis and it is also
                                                    enlarged, red, tender and hot.
                    Swellings behind the breast     These are rare.
                                                    Tietze’s disease most common (a type of Costochondritis.)
Differentials of breast pain:
Causes                   Notes
Carcinoma                15% of carcinomas are painful.
                          On examination there is a hard, irregular lump suggestive of carcinoma
                          ESR or C-RP will be raised in widespread carcinoma.
                          Features associated with mets to liver (jaundice, LFT’s deranged), bone (hypercalcaemia and
                          pain), lungs (breathlessness, CXR, pleural effusion) etc.
Cyclical mastalgia        Soreness, usually in the upper outer quadrant of the breast a week before the period. The pain
                          disappears after the period and comes again before the period. Common in women aged 20-45.
                          Tenderness and lumpiness occasionally with a smooth mobile swelling (cyst) in the upper outer
                          quadrants of the breast.
Duct ectasia              Pain usually behind the nipple associated with subareolar erythema and a thick creamy nipple
                          discharge.
                          There is tenderness and occasionally there is a lump behind the nipple.
                          There may also be nipple retraction (inverted nipple)in long standing cases.
                          It occurs due to dilatation of the ducts which can become blocked. This leads to a discharge
                          forming which can be bloody. Ulcers may also form due to irritation of the ducts.
                          It usually occurs in the fifth decade of life before menopause.
Fat necrosis              Usually due to trauma such as the partners teeth marks (love bites).
                          The adipocytes are damaged releasing fat, this invites an inflammatory reaction leading to
                          fibrosis and calcification of the area which leads to a hard irregular lump tethered to the skin
                          that may be mistaken for malignancy.
                          It is important to do a biopsy to exclude malignancy.
Breast abscess            Usually occurs during pregnancy or lactation but can be retroareolar in patients who have duct
                          ectasia. Usually due to staph aureus in lactation which gets in through the cracks of the nipple
                          while breast feeding.
                          There will be redness, swelling, heat and pain during lactation or pregnancy.
Pregnancy                 Breast fullness and soreness is a symptom of early pregnancy due to the excess oestrogen
                          stimulating breast production.
                          Check if the patient was planning a pregnancy or that the patient is having sex without
                          contraception etc. usually the patient will know they are pregnant by the time they develop the
                          pain.
Lactation                 Nipples can become sore and painful (may blister) due to breast feeding.
                          The breast may also become painful as a result of lactation
Mastitis                  Inflammation of the breast which may be due to blockage of the ducts leading to infection or
                          just a general infection in the breast.
                          It will be swollen, red, hot and painful.
                          It is important to rule out inflammatory breast cancer.
Tietze’s disease          Costochondritis of the costal cartilages which may lead to pain which the patient believes is in
                          the breast but actually behind it.
                          There may also be swelling of the 3,4,5 ribs.
Mondor’s disease          Superficial thrombophlebitis of the subcutaneous veins of the chest wall.
                          The veins become red and tender and extend into the axillary fold.
                          Other masses should be searched for because this condition is related to carcinoma in the breast.
Rib Secondaries           Bone metastases in the ribs can cause pain
Herpes Zoster             Pain radiating round into the breast depending on which dermatome affected.
                          2-3 days later it is followed by a vesicular eruption.

Nipple discharge:
Questions to ask yourself while examining:
Is discharge obvious? It may stain the clothes
Is it associated with a painful or lumpy breast? Suggestive of fibroadenoma
Is there an underlying discrete lump? Suggestive carcinoma
Is there retroareolar tenderness or nipple retraction? Suggestive of duct ectasia
Are there signs of infection of abscess?
Is the nipple destroyed? Suggestive of Paget’s disease of the nipple
Are there visual symptoms and headache? Associated with a prolactinoma (or a non-functioning
adenoma) in the anterior pituitary

Differentials of nipple discharge:
Discharge type       Cause                   Notes
                     Early pregnancy
     Serous                                  See below
                     Fibroadenosis
                     Late pregnancy          These will be apparent on presentation. Patient will be obviously
                     Lactation               pregnant or you will know they just had a baby
                     Lactorrhoea of the      Discharge in newborns is due to the effect of mother’s hormones
      Milky          newborn                 passing through the placenta.
                     Puberty                 Serous or milky discharge can occur at puberty
                     Prolactinoma            Associated with other symptoms such amenorrhoea or no sex drive
                                             plus visual symptoms etc.
                    Fibroadenosis            Yellow, brown, green discharge
                                             Maybe associated with cyclical mastalgia or non-cyclical
                                             It is due to development of cystic lesions in the breast due to an
                                             overgrowth of fibrous stroma, ducts and lobules leading to the
                                             abnormal development of breast tissue.
    Coloured                                 It is malignant and has a very small risk of cancer if the epithelia is
                                             hyperplasic.
                                             Occurs usually in women aged 30-50 (pre menopausal).
                    Duct ectasia             Thick and creamy
                                             Retroareolar pain, nipple retraction etc.
                    Breast abscess           Rare in producing a discharge
    Purulent        Retroareolar abscess
                    TB
                    Intraduct carcinoma      Blood may be red or dark brown (partially altered).
                                             There will be a hard irregular lump in the breast.
  Bloodstained      Intraduct papilloma      This refers to benign tumour of epithelia tissue.
                    Paget’s disease of the
                    nipple

Other objectives:
Investigations:
Mammogram  mammogram can help in a quick scan for tumours. Not useful in younger women
(under 35) because there breast tissue is dense and so may not reveal masses.
Ultrasound  discriminates solid from cystic masses. Doppler can be used to observe blood flow to
tumours (usually much higher). Can be used in guidance for procedures such as biopsy. More useful in
younger women where the mammogram may not be clear.
CT/MRI  staging disease confirming the mass.
Fine-needle aspiration cytology  cells are aspirated through a needle and then the cells are expressed
onto a slide to allow microscopic investigation.
Wide-bore core needle biopsy  takes out tissue for histology rather than cytology. Cellular
architecture can be assessed and so cancer is diagnosed more easily than in cytology.
Vacuum suction biopsy  removing a biopsy by suction means a needle does not need to be inserted
every time allowing a larger biopsy needle to be inserted.
Excision biopsy  removal of all evidence of the abnormality plus surrounding innocent breast tissue.
Incision biopsy  only a part of the lump is removed.
Mammographic-guided needle biopsy  a needle is placed into the mass under x-ray guidance.
Afterwards everything around the needle is excised.
Ultrasound-guided biopsy  allows needle guidance or aspiration to be done under the guidance of
ultrasound

Staging breast cancer:
Stage 1  smaller than 2cm, no spread
Stage 2a  cancer smaller than 2 cm but spread to local lymph nodes or axilla but not stuck together or
cancer is smaller than 5cm but lymph node spread. Lump may not be seen but the is axillary lymph
node spread but not stuck together
Stage 2b  cancer smaller than 5cm and spread to axilla lymph nodes but not stuck together or bigger
than 5cm but no lymph node spread.
Stage 3a  no mass seen but there is lymph node spread and they are stuck together. Tumour less than
5cm and there is spread to lymph nodes and stuck together or tumour bigger than 5cm and there may be
spread to axillary lymph nodes and may be stuck together.
Stage 3b  tumour fixed to skin or chest wall with or without lymph node involvement
Stage 3c  tumour is any size but there is lymph node spread to axilla, under breast bone or above the
clavicle
Stage 4  any size tumour with or without lymph node involvement but there is distant metastases in
the body.
Staging is required to make the best possible decision for treatment

Treatment options:
Local resection  this preserves as much of the breast as possible and is limited to early stages of
cancer. The problem is that it may lead to an occurrence if cancer is left behind. Complications of any
resection of breast tissue can be cosmetic problems, shoulder stiffness, brachial plexus damage and
lymphoedema in the upper arm.
Mastectomy  removal of the breast, can include all the way up to the lymph nodes in the axilla and
removal of underlying muscle (pec major).
Adjuvant cytotoxic therapy  chemotherapy can be give as an adjuvant therapy or for metastatic
disease. Effective agents are folic acid, 5-flurouracil, adriamycin and epirubicin.
Hormonal therapy  can be given as an adjuvant. Hormonally stimulated tumours are attacked. The
cells may have oestrogen or progesterone receptors. Example is tamoxifen which against oestrogen
recptors.
Oophrectomy  either surgically or medically by GnRH will reduce female hormones that affect the
cancers.
Breast reconstruction  reconstruction is not a purely cosmetic procedure but also a functional one.
Reconstruction looks for symmetry, adequate form, consistency and size, lasting effects and no
detrimental effects on treatment. reconstruction can be done by implantation of silicone into the breast
or can be done by autogenous tissue. Tissue flaps (skin and muscle) can be taken from the latissimus
dorsi or the rectus abdominis muscle.

Follow-up:
Follow-up is required because there is a risk of recurrence in patients locally which can be excised
again. The problem is that mammograms of breasts that have undergone surgery are difficult to
interpret due to scarring of tissue. This means that sometimes metastatic disease may by the first
presentation in the patient. Symptoms of possible metastases should be looked for. This means that the
patient might have jaundice in liver mets, breathing difficulties in lung or pleural disease, CNS
complications, bone pain and hypercalcaemia in bone mets and possible spinal compression.
ACUTE AND CHRONIC RETENTION OF URINE

Acute retention of urine will present with the inability to pass at all with suprapubic pain and a
suprapubic mass. The suprapubic mass is usually the bladder. An important differential for this is
abdominal aortic aneurysm which will present with a Pulsatile mass in the same area and the pain will
radiate to the back and the patient will be anuric due to shock. Acute retention will usually be a surgical
emergency.
Chronic retention of urine is a gradual process that will lead to gradual enlargement of the bladder,
dribbling incontinence and little or no pain. The bladder is more severely enlarged in chronic retention
but is usually painless. This is because the stretched nerve fibres slowly compensate for its growth
whereas in acute there is no gradual compensation so there is severe pain.
Treatment will be based on the diagnosis, severity of renal damage caused by retention and the general
condition of patient (if they are fit for surgery).

Differential causes of urinary retention:
This from Churchill’s pocketbook of differential diagnosis.
Types                   Causes                    Notes
Local
                        Urethral valves           This is a congenital defect in males that leads to the formation
                                                       of valve like structures in the urethra
                          Tumours                      Chronic retention
                          Stones                       Stones are the most common forms of presentation of the acute
                                                       retention. There will be symptoms of colic if stuck in the
 Urethral lumen or                                     ureters. Once in the bladder it may irritate the bladder or block
   bladder neck                                        the bladder neck. There may be other features such as symptoms
                                                       of a UTI and haematuria
                          Blood clots                  Blood clots may form in the bladder after surgery to the bladder
                                                       and this may be the cause of the obstruction.
                          Meatal ulcer                 Ulcer at the meatus will obstruct the lumen as well as give
                                                       haematuria.
                          Urethral trauma              Look for signs of any pelvic trauma as this may damage the
 Urethral or bladder                                   urethra.
        wall              Urethral stricture
                          Urethral tumour              Chronic retention
                          Prostatic enlargement        Prostatic enlargement will cause a chronic retention as it takes a
                                                       long time develop. A rectal examination should be performed to
                                                       check for prostatic enlargement. Symptoms of chronic retention
                                                       include difficulty in starting (hesitancy), poor stream, nocturia,
  Outside the wall                                     frequency, dysuria and incomplete emptying.
                          Faecal impaction             Is the patient constipated? How often do they pass stools?
                          Pregnant uterus              An obvious finding. Retention will resolve on birth.
                          Pelvic tumour                Chronic retention
General
                                                       Postoperative retention is common especially in elderly males.
                                                       This is usually due to anxiety, embarrassment, supine position,
                   Postoperative                       pain, drugs, fluid overload and previous unrecognised
                                                       prostatism.
                                                       Posteoperative retention is usually obvious.
                          Spinal cord injuries         Spinal trauma is obvious and a full neurological exam should be
                                                       performed. Common spinal cord diseases that cause urinary
     Neurogenic                                        retention are:
                          Spinal cord disease          Tabes dorsalis, spinal tumour, multiple sclerosis and diabetic
                                                       autonomic neuropathy.
                                                  A neuropathic bladder would result in a long term stasis of
                                                  urine. This makes the patient prone to urinary infections, renal
                                                  damage and prone to stone formation which may cause further
                                                  problems with urinary retention.
                        Anticholinergic drugs     These are drug causes of urinary retention. This has an effect by
                                                  stopping the parasympathetic stimulation to the bladder which
                        Antidepressants           results in relaxation of the bladder.
       Drugs                                      Certain antidepressants express anticholinergic effects.
                        Alcohol                   Alcohol can cause a diuresis but reduce sensation in the bladder
                                                  so the bladder becomes acutely full.

History:
This is like a normal history but you would like to know if they are on certain drugs, if they have had
spinal trauma, if they have had it before (such as stones) etc.

Symptoms of uraemia:
Fatigue
Decreased alertness and confusion which may lead to a coma
Pale skin with a yellow tinge, Itching and evidence of scratching (excoriations)
Pericarditis  which can lead to cardiac tamponade and then lung symptoms.
Oedema  generalised and pulmonary
Loss of appetite, nausea and vomiting
Platelet function is impaired.

Investigations:
Urea and electrolytes and serum creatinine are just markers of how much renal damage has occurred as
a result of the urinary retention. Urinary retention will lead to hydronephrosis which is a dilatation of
the renal pelvis and damage to the kidneys.
Flow rate  a person voids into a machine that measures the volume of urine and the maximal flow
rate. A normal flow rate is greater than 15ml/sec.
Ultrasound scan  this can look at the extent if the dilatation and how the bladder is voided.
Radio-isotope scan  this looks at how the well the kidney’s perform and how well the bladder expels
the urine.
Urodynamic studies  this is done by voiding the bladder and then filling the bladder with water or a
contrast. The pressures are then obtained as the bladder expels the urine. The detrusor muscle pressures
are obtained to see if the cause is neurological or obstructive.
Serum prostatic antigen  used to assess levels in benign prostatic hyperplasia and malignant disease.
Its amount is related to the volume of tissue.

Treatments:
Catheterization is required in patients who have urinary retention and pain almost immediately. This is
to prevent kidney damage. If catheterization can not occur due to stricture or a tumour etc. then the
patient should be given a suprapubic cystostomy (suprapubic catheter). A normal foley cathether
should be attempeted first because a suprapubic catheter is leaky and smelly.
Once the catheterization is done then the cause should be investigated. The cause may be obvious in
some cases but the catheterization is important in preventing damage.
In chronic retention the patients can be given a long term catheter until treatment kicks in.
Treatment of the neuropathic bladder can be done by intermittent catheterization 4/5 times a day. This
is done by the patient of a carer or nurse. This will help prevent distension and allow the patient to void
the bladder as you do normally through out the day.

Benign prostatic hyperplasia should be treated initially with the following methods:
Alpha blockers  this relaxes the smooth muscle of the internal urethral sphincter which is surrounded
by the prostate. Relaxing this sphincter gives eases some of the pressure of the bladder.
Finasteride  this is a 5-alpha reductase inhibitor which inhibits the formation of dihydrotestosterone.
It is used in low doses in BPH. The drug reduces the size of the prostate which usually feeds of the
hormone.
Thermotherapy  this locally destroys some of the prostate by a diathermy. Used in cancer treatment
as well.
Temporary prostatic stents  a stent is placed across the lumen of the urethra allowing urine flow. It is
a temporary measure until the prostate is removed.

Transurethral resection of the prostate (TURP):
This is the treatment of choice if the prostate is less than a 100g. can be used in benign or in
malignancy if the patient has an acute retention.
The prostate is viewed through the urethra and is cauterised.
Complications are bleeding, clotting that leads to retention and hyponatraemia due to bladder irrigation.

Radical prostectomy:
This is a procedure in removing a cancer that does not have a huge meteastatic potential and is a tricky
process. Its use is controversial but is becoming increasingly common. If correctly performed then it
will eradicate disease confined to the prostate.
Radiotherapy is used for bone mets and primary tumour if confined to the prostate.

Hormonal therapy:
This is used in advanced local cancer or metastatic disease.
LHRH analogues are given to the patient which initially stimulate the pituitary but then down
regulation occurs. Testosterone levels fall and this will lead to reduction in the size of the cancer. Prior
to given the LHRH analogue the patient is given a two week anti-androgen treatment such as
finasteride which will reduce levels of duhydrotestosterone in the mean time.The patient can also be
given a bilateral orchidectomy which would have the same results but the choice remains with the
patient.
LUMP IN SCROTUM/UNDESCENDED TESTIS

History of scrotal swellings:
When did it develop?
Was it a sudden development?
Is it getting worse?
How big is the swelling?
Does the swelling appear to be fluid?
Can you feel tissue in the swollen area?
Is the swelling in one part of the scrotum or the entire scrotum?
Is the swelling the same on both sides?
Have you had genital surgery?
Have you had injury or trauma to the genitals?
Have you had a recent genital infection?
Does the swelling go down after you rest in bed?
Do you have any other symptoms?
Is there any pain around the scrotum?

Examination:
There are three main questions you should be asking yourself while examining:
Can you get above the swelling? If you cant then it is most likely to be a inguinal hernia.
Does it transilluminate or fluctuate? This is a check for fluid  i.e. hydrocele, epididymal cyst
Can you feel the testis separately from the mass? This would indicate if it is attached to the testis or not
and may bare importance on the type of lump. Hydrocele may prevent you from feeling the lump.

Differentials for scrotal swellings: (from churchill’s pocketbook of differential diagnosis)
Causes                      Features
Sebaceous cyst              Several painful lumps on the scrotal skin.
                            They may be red, inflamed, tender with a discharge and a central punctum.
                            The discharge material is a cheesy yellow.
Indirect inguinal hernia    The lump may be reducible or may be painful and irreducible with signs of obstruction.
                            Hernias that descend into the scrotum are usually indirect.
                            You can not get above the swelling which is a sign of an inguino-scrotal swelling. Scrotal
                            swellings you can get above them.
                            There is an expansile cough impulse and bowel sounds may be heard over the hernia.
Hydrocele                   A painless unilateral scrotal swelling which can become quite large.
                            Usually occurs over the age of 50.
                            There may be pain and discomfort if there is underlying testicular disease.
                            A young patient with a hydrocele should be suspected for a malignancy.
                            It is fluctuant, transilluminates and is dull to percussion
                            There may be a fluid thrill
                            The testes can not be palpated separately from the hydrocele.
                            You can get above the swelling unless it is infantile which usually goes up to deep inguinal
                            ring.
Epididymal cyst             This is a slow painless scrotal swelling which grows over many years and is usually
(spermatocele)              bilateral.
                            It is usually above and behind the testes and the testes can be palpated separately from it.
                            It can feel lobulated because the fluid is in locules.
                            They are fluctuant.
                            If they contain fluid then they transilluminate.
                            If they contain a milky fluid then it is a spermatocoele.
Epididymo-orchitis          There is pain and swelling, usually unilaterally.
                            Symptoms of malaise and fever.
                             May be accompanied by a urinary tract infection.
                             The scrotal skin is hot, red and oedematous.
                             Tenderness usually confined to the epididymis but can spread into the testis.
Testicular torsion           Usually occurs around puberty and rare after 25.
                             Sudden onset of pain in the scrotum and groin which can radiate to the lower abdomen.
                             May be accompanied by nausea and vomiting.
                             History of violent exercise  straining in the gym and masturbation.
                             Always find the exact time of symptoms.
                             Surgery should be carried out within 6-8 hours to salvage the testicles.
                             The scrotal skin is usually hot, red and oedematous.
                             The testis is very tender and often drawn up to the groin.
Testicular tumour            Teratomas occur between 18 and 30 years
                             Seminomas occur between 30 and 45 years.
                             Heaviness in the scrotum accompanied by a painless swelling.
                             Symptoms may be due to secondary mets.
                             This is a firm irregular swelling in the scrotum.
                             Patient notices the lump when it is very small.
                             Lymph nodes especially around the para-aortic area are usually palpable is spread has
                             occurred. Inguinal nodes are not involved unless scrotal skin is involved which is rare.
                             Tumour markers are Alpha-fetoprotein, Beta-HCG and LDH. Alpha fetoprotein only
                             presents in the teratomas and not in the seminomas.
Varicocele                   Patient or partner notices varicose veins in the scrotum.
                             The symptom may be a dragging ache in the scrotum or groin.
                             Subfertility may be a presentation and occurs with bilateral varicoceles.
                             Varicoceles are more common on the left.
                             It is palpated when the patient is standing up which allows the dilated veins to become
                             palpable and visible.
                             They feel like a bag of worms or like boiled spaghetti.
Haematocele                  Clear history of trauma
                             Tense, tender, fluctuant swelling.
                             There may be an obvious scrotal bruise.
                             The testis cannot be felt separately.
Sperm granuloma              This develops 2-4 months after a vasectomy
                             Patient complains of a small tender nodule at the site of the vasectomy.
                             It is due to a build of sperm at the site of the cut which can no longer travel through
Tuberculosis                 Rare
                             Dull aching pain is usual presentation.
                             History of lung or renal TB.
                             Usually confined to epididymis. Spermatic cord and vas are thickenened.
Gumma                        Rare
                             Painless swelling of the testis as a result of syphilis.
                             Other features of syphilis may be present

Maldescended testes (cryptorchidism)  if the testis is undescended then it may be in any location
along its path of descent and will be a small swelling along the path from the kidney to the scrotum.
Sometimes it follows an abnormal path so the testis will be in an ectopic position. The maldescended
testis will lead to reduced fertility and increased risk of testicular cancer. If the patient has hypospadias
as well then it could mean the patient has female virilization. Maldescended testes is associated with
several syndromes such as Prader-Willi and Noonan syndrome.
Lymphatic drainage of the testis and scrotum:




lymphatics from the testes drain via channels that ascend in the spermatic cord through the inguinal
canal and than up the posterior abdominal wall to connect directly with the lateral aortic and preaortic
nodes. They completely bypass the superficial and deep inguinal nodes and the external iliac nodes.
The penis, scrotum and foreskin drain into these nodes whereas the testes bypass this through the
inguinal canal and directly into the nodes higher up.

Investigations:
Urinary microscopy and culture  this would check for UTI’s that may be involved with the pathology
of orchitis or epididymo-orchitis or epididymitis etc. you may also culture syphilis or TB as well as
common STI’s involved in the infection.
Ultrasound  this is to check for fluid and to check if the fluid is cystic or hydrocele. It will also show
if it is a solid mass compared to fluid and where it is attached. Ultrasound of the abdomen maybe
indicated in a left varicocele. Very rarely a carcinoma of the left kidney may invade the left renal vein
which will effect the left testicular vein (which drains into the left renal vein) and this may be the cause
of the left varicocele.
Alpha-fetoprotein  this is a tumour marker in the serum of teratomas. Teratomas also produce Beta-
HCG and LDH as does seminomas.
CXR  this is to check for intial TB or secondary mets of the cancer.
MRI/CT  to do the staging of the cancer, lymphadenopathy etc.
Conservative measures:
Orchitis and epididymo-orchitis  this is most commonly caused by Chlamydia. Bed rest is important
with scrotal elevation and antibiotics (tetracycline and erythromycin). Antibiotics may be changed on
bacterial analysis. Once the infection is treated the swelling should reduce.
Hydroceles  if they are congenital then they will spontaneously resolve by age of 3, but after this will
need operative treatment and ligation of the processus. If the hydrocele is acquired and symptomatic
then aspiration of the outer portion may be necessary to prevent symptoms.

Surgery :
Testicular torsion  twisting cuts of the blood supply so this condition is a surgical emergency. Prior
to surgery the testicles may be derotated and then afterwards may be fixed by surgery. If rotation does
not work then it is operated on to rotate and then fixed. If the testis is gangrenous then it is removed.
Testicular cancer  majority of testicular tumours are curable due to early diagnosis and specialist
treatment. Orchidectomy is the best way to remove the scrotum and is removed via the groin instead of
the scrotum. This way the cord is mobilised and occluded prior to removal to prevent tumour cell
implantation. A biopsy can be taken from the other testis. 5% of patients will have carcinoma in both
testes.

Chemotherapy and DXT in tumours.
If chemotherapy is required in the treatment as an adjuvant or for metastatic disease then the patient is
asked to give a semen sample prior to chemotherapy as the drugs involved may cause irreversible
damage to germ cells. The semen can be stored for future children (remember testicular cancer occurs
in young males).
Deep radiotherapy (DXT) is also used as a treatment for testicular carcinoma.
TISSUE TYPING/GRAFT REJECTION/IMMUNO-SUPPRESSION
MHC: the major Histocompatability complex.
The body has the ability to recognise between self and non self antigens by the major
Histocompatability complex. This complex is a region of genes involved in the immune system and
autoimmunity. The main genes involved are the human leukocyte antigens (HLA).
The 6 HLA genes are:
HLA-A                 HLA-B                 HLA-C
HLA-DP                HLA-DQ                HLA-DR

HLA-A, -B and –C all belong to class I
The other three belong to class II.
People have a different combination of the HLA molecules and there are many alleles for each HLA-
type. The chance of getting a match for all of them between two people is rare unless they are identical
twins. Siblings may have some alleles that are the same as they are inherited from parents.
Different HLA alleles are associated with diseases such as HLA-DR4 in rheumatoid arthritis or B14 in
hereditary haemochromatosis etc.
The HLA genes are expressed in these cells in the body:
Class I in all cells except erythrocytes and trophoblasts. Class I HLA attaches with CD-8 to be killed.
Class II are expressed on professional antigen-presenting cells such as dendritic cells or macrophages.
Class II attaches to CD-4 to ask for help in immunity.

So what is the point of having the MHC?
There is huge polymorphism amongst the MHC genes. This allows organisms and individuals to be
unique. The MHC gives the person a code to which they can say I am probably the only person with
the code. If a cell enters the body without this code then it is attacked by the cells immune system. This
is something that could potentially happen in transplantation if the tissue is not a perfect match.

Tissue typing and genetic fingerprinting:
Tissue-typing is done by antibodies to specific HLA subtypes or by DNA analysis to find out which
combination of HLA the patient has. It can also be done through genetic fingerprinting that allows
electrophoresis to occur to identify the different HLA-types.
If there is a perfect match between the donor and recipient then the only thing that will result in
rejection is poor surgical technique.
Ideally you want a close as match as possible, so some HLA molecules may be matched and some may
not.

Practical difficulties of mismatch and immunosuppression
There are difficulties in finding a match especially for certain ethnic communities because different
HLA subtypes tend to run in different races. There are many people who need a transplanted organ but
not many people are dying to provide the organs. Even organs from live related or unrelated people are
short. You want to get a close a match as possible as this reduces the chances of rejection.
If there is a mismatch then you will require immunosuppression. This will suppress the immune system
so that the donor organ is not attacked by the immune system. The greater the mismatch the greater the
immunosuppression required. It is important not to give patients requiring a transplant too many blood
transfusions as this will lead to the development of antibodies to different HLA-subtypes which may
reduce their chances of accepting an organ.
Various immunosuppressants are:
Azathiprine, 6-mercaptopurine, Mycophenolate-mofetil, corticosteroids, Tacrolimus, Ciclosporin and
new monoclonal antibodies such as Daclizumab (against IL-2 receptor).
Principles behind graft rejection:
Graft rejection is essentially the body’s immune system attacking the donor organ as it recognises it as
foreign tissue.
The rejection process can be T-cell mediated or due to antibodies.
There are three categories of rejection:
Hyperacute rejection  this is a rejection that occurs within minutes of the organ being placed in to the
patient and requires removal to prevent a systemic inflammatory response. The rejection is complement
mediated and is due to the existence of pre-existing antibodies in the body such as antibodies to ABO
blood group (these antigens are on every cell not just blood cells) or the HLA-molecules. Complement
mediated events leads to an accelerating rejection. Checking for ABO blood group match prevents
hyperacute rejection because most people have develop antibodies to the blood group antigens they do
not have.

Acute rejection  this usually occurs several days after transplant and is due to the fact that the patient
may not be adequately immunosuppressed. There are strong immunosuppressants that prevent this. If
an cute rejection is recognised quickly then the organ can be preserved by quick action with
immunosuppressants. It is very common to get cases of acute rejection. The MHC genes are usually
involved in acute rejection.

Chronic rejection  this may be due to fibrosis of the organ and its blood vessels. The term implies
that a new organ is required in the next few years. Chronic rejection may be due to a mismatch in the
minor Histocompatability complex genes instead of the MHC. The minor genes are not looked at as
they do not bare as much importance as the major genes.

Graft-versus-host disease:
This is a condition that usually occurs in bone marrow transplant. The white blood cells produced by
the marrow are not from the patient’s body and this can lead to an attack on the patient’s own body
thinking it is a foreign organ.
SOURCE OF ORGANS
Types of organ donation:
Cadaveric donor  the person is brainstem dead and the organs needed are taken out and preserved
until placed into the recipient.
Live donor  an organ or tissue is donated from a live person to another person. The person may be
related or unrelated.

Brain death and its criteria:
Brain death is a term used for patients who have lost all their brainstem reflexes and can not sustain life
without invasive ventilation.
The brainstem reflexes that are tested for are:
Oculocephalic reflexes  absent. When head is rotated side to side eyes should move.
Papillary reflex  pupils fixed and unresponsive
Corneal reflex  absent
Vestibulo-ocular reflex  absent on caloric testing
No gag or cough reflex
Spontaneous respiration is absent

Brainstem death is confirmed by two senior doctors on separate days.
Other tests are not necessary.
The aim of brainstem death diagnosis is to demonstrate that to continue mechanical ventilation is futile.

To check for braindeath the patient must be in an unresponsive coma with a ventilator. There also has
to be a diagnosis to confirm irreversible damage to brainstem. Certain exclusion criteria are:
The unresponsive apnoea should not be caused any offending drugs such as neuromuscular blocks or
sedatives.
Hypothermia should not be the cause of the coma. The body should be above 35C.
There should be no metabolic or endocrine disturbance that could produce or contribute to the coma or
cause it to persist.
There should be no profound abnormality of the plasma electrolytes and glucose.

Ethical and moral problem of brain death:
Certain problems that arise from brainstem death is the question of whether the patient can actually be
considered dead if they are being kept alive by the ventilator and there heart is beating. Although there
is the futility argument the patient still has its vital body organs so is still alive. However, if the
patient’s higher level of conscience can not return then does that define that the patient is dead?
Another dilemma is that of the organ shortage in this country. Patients families have the grief of there
loved ones being in a coma and yet doctors are asking for organs off the patient. People may interpret
this as doctors not making any effort to save the persons life but to use them as a source for organs.
Although this is not true this is how it may be interpreted.

Informed consent for organ donation:
Nowadays, if patients have signed up to the organ donor register then there organs can be used even if
the family disagree. This is because the patients wishes are taken into account and in the past many
families were against it.
Families should be consented and informed of transplanting organs if there loved ones are brainstem
dead. They should be told of what would happen and how they could save someone’s life.
Donation from live donors should be full explained and it is important that no commercialism is
involved in the donation.
The human tissue act 2004 has the purpose of regulating the storage and use of the human tissue from
the living and the removal. Storage and use of tissue from the deceased

Practical difficulties of organ preservation
Organs when removed are first cold perfused. This is done by cannulating the aorta and pumping in
cold solution. The inferior vena cava and portal vein are also cannulated to allow fluid to come back
out. This initial perfusion allows the preservation of the organ to begin. After removal they are checked
to make sure they are satisfactory structurally for transplantation and then they are placed in double
plastic bags and placed on crushed ice for transfer. They are not placed directly on ice as this may
cause damage to the organ.
The cold ischaemia time is the time from pumping in the cold preservation solution prior to organ
procurement until the reperfusion of the organ in the recipient. Once preserved, the organ may only
have several hours before damage starts to occur.
The warm ischaemia time is the time of extubation of the brain dead patient until the time the
preservation fluid hits the organ. There is only a small amount of time before the organ begins to die.
This time may be about half an hour (not sure).
Reducing the warm ischaemia time can only occur if there is swift action after extubation of the patient.
There are difficulties in the sense that the relatives may want to see their dying loved ones.
Cold ischaemia time may increase due to travelling far distances to deliver the organ or the fact the
recipient is not ready to receive the organ or the practical difficulties of placing the organ into the
patient and establishing reperfusion.
Different organs have different ischaemia times.
IRREVERSIBLE ORGAN FAILURE
Causes of end-stage renal failure:
End-stage renal failure usually occurs as a result of chronic renal failure where the kidneys function is
reduced to less than 5% its normal function and where renal replacement therapy would be required to
prevent toxic effects and death to the body. It may also occur as a result of severe acute renal failure
that does not resolve. Causes are:
Diabetic nephropathy
Hypertensive nephropathy
Glomerulonephritis (all the various types)
Polycystic kidney disease
Reflux nephropathy
Obstructive uropathy
Kidney stones and infection
Analgesic nephropathy  NSAIDs are damaging to the kidney parenchyma.

End-stage renal failure will lead to a build up of urea in the blood which will have toxic effects if at
high amounts. There would also be fluid retention as well a distortion of the other effects the kidney
controls such as blood pressure, erythropoietin, calcium control etc.

Indications for a kidney transplant:
All patients are considered for a kidney transplant irrespective of age if they have end-stage renal
failure. However there are several contraindications:
Cancer
Active systemic infection
Uncontrolled ischaemic heart disease
AIDS and its opportunistic infections
Mental incapacity
Hep B/C
Extensive peripheral vascular disease

Causes of heart failure:
Coronary artery disease  leading to angina or MI
Hypertension
Diabetes
Cardiomyopathies
Valvular heart disease
Arrhythmias
Myocardial injury  radiation, chemotherapy, thyroid disorders, alcohol, cocaine (and other drugs) etc.

Indications for a heart transplant:
If the patient’s life expectancy is reduced to another 12-18 months
If it is unmanageable with any medical therapy
Usually under 60 years of age because complications of the aging process, however if they are fit old
people than it may be done.

Although there are indications for heart transplant there are many absolute and relative
contraindications which means that not many people are considered for a heart transplant.
Some of the absolute contraindications are:
Chronic current systemic infection
Active peptic ulcer
Continued abuse of alcohol and drugs
Irreversible secondary organ failure (unless considered for combined transplant)
Malignancy
Severe Cerebrovascular disease
Other life-threatening conditions that are likely to make the patient die in 5 years.

Some relative contraindications are:
HIV, Hep B/C
Acute Pulmonary embolus (in last 3 months)
Obesity
COPD
Diabetes with target organ damage
Continued smoking
Osteoporosis
Amyloidosis
Hypercholesterolaemia that is resistant to drugs
And many more.

As patients tend to have co-morbidities with heart failure the likeliness of receiving a heart is very low.
Heart transplants usually occur in young people who have no co-morbidities and have a congenital
heart problem.

Causes of end-stage liver cirrhosis:
Alcoholic liver disease
Chronic Hep B/C infections
Non-alcoholic steatohepatitis  fatty accumulation leading to cirrhosis
Primary biliary cirrhosis  autoimmune disease damaging the bile caniculi.
Primary sclerosing cholangitis  inflammatory disease of the bile ducts.
Autoimmune hepatitis
Hereditary haemochromatosis  iron accumulation
Wilson’s disease  copper accumulation
Alpha-1 antitrypsin deficiency
Cardiac cirrhosis  right heart failure causing liver congestion and cirrhosis
And many more such as drugs, infection etc.

Indications for a liver transplant:
Anyone who has irreversible liver dysfunction (complete) is indicated for a liver transplant. The
contraindications are similar to that of heart failure and kidney failure.

Supportive therapy in irreversible organ failure:
This is covered in the medical objectives on renal replacement therapy.

Transplantation programmes:
http://www.uktransplant.org.uk/ukt/statistics/statistics.jsp