clinical- abdomen & inguinoscrotal discussion

ABDOMEN

Abdominal Examination & signs CLD

What are signs of CLD?

Clubbing: Obliteration of angle between nail & nail bed – chr. disease

Palmar erythema: (sign of decompensated CLD) in hypothenar, thenar, head of metacarpals & tip fingers

Flapping tremors: sign decompansated CLD

Dupuytren’s contracture: nodular or cord like fibrosis of palmar fascia of ring +/- little finger in (alcohol, CLD, DM, drug, manual workers) – D.D. ulnar claw hand

Jaundice: sign decompensated CLD - seen in sclera

Hepatic fetor: sign decompansated CLD

Spider naevi: is sign CLD- central arteriole with radiating branches – in H & N (distribution of SVC)- > 6 in distribution SVC is pathological

Gyaencomastia: is sign CLD- other causes: physiological- drugs (cimitidine-spironolactone)- hormonal ttt – tumors secr hs (testicular or adrenal)

Encephalopathy

What are signs of decompansated CLD?

Edema

Ascites

Jaundice

Flapping tremors

Encephalopathy

Bleeding

Fetor hepaticus

What are signs P.H.? Splenomegaly, ascites & caput medusa (rare)

What are the porto-systemic shunts?   ………………………..

In abdominal palpation keep hand & forearm at same level

Where is traub’s area? Lower rib cage ant. to MAL

                                  ( Above: 6^th rib, below: costal margin, lat.: MAL )

Difference between splenic & renal swelling? Splenic swelling has following ccc

cannot insinuate hand between it & C.M.

not felt in renal angle

continous with dullness over Traub’s area

cannot get above it

no area of resonance above it

    renal swelling is the reverse

What is diagnosis of this case (CLD)? Example,

Tinge of jaundice, pallor, clubbing, Liver enlarged- Rt lobe 5 cm below C.M., well defined edge, smooth surface, firm consistency, Lt lobe 5 Cm below C.M. ,………., liver span is 18 cm, spleen enlarged 7 cm below C.M., no masses felt

→ Case of HSM propably CLD

Evaluation of CLD?

Lab: FBC (anemia from bleeding or chr.ds, thrombocytopenia, leucopenia from splenomegaly)

T.Bilirubin ↑ (mixed but mainly indirect)

AST, ALT ↑

Alb. ↓

Bleeding profile

Abdominal U/S: Liver size (enlarged/shrunken), spleen (N/enlarged), P.V. (P.H.), HCC

UGI Endoscopy

What are the Lethal complications CLD?

hematemesis

encephalopathy

HCC (malignant change)

SBP (spontaneous bac. Peritonitis) C/O: F & abdominal pain

What is ttt CLD?

If compensated → liver supportive ttt

If uncompensated → liver transplantation (according to Child score: 5items: Bil, Alb, INR, encephalopathy & ascites)

What is Koilonychia? Spoon shaped nails in iron deficiency anaemia

What is Leuconychia? White nails (due to hypoalbuminemia)

How to suspect Ascites? LL edema (Gen.exam.) & full flanks by inspection

How to examine for ascites?

Mild → U/S,     Moderate → shifting dullness,      Severe→ fluid thrill

Causes of clubbing?

1-    GIT: liver cirrhosis, Inflamm.B.D., malabs.

2-    Resp.: Bronchial carcinoma, mesothelioma, suppurative lung ds

3-    Cardiac: cong. Cyanotic ht. ds, IEC

4-    Familial & occupational

What does oral pigmentation indicate? Peutz Jhegar syndrome = oral pigmentation + intestinal polyps

What does supraclavicular L.N. indicate? Abdominal malignancy (e.g, stomach & pancreas)

What are diseases of umbilicus?

PUH

Metastatic nodules

Discharge (urine or pus)

Dilated veins (caput medusa) = P.H.

What are causes of Hepatomegaly?

1-    Inf.: viral→hepatitis B & C, CMV, IMN (EBV), Bac→T.B., abscess, Protozoa→ Bilharz., amoeba, malaria

2-    Neopl.: 1ry (HCC), 2ries, lymphoma, leukemia

3-    Metab. & storage ds: Alcohol, Glycogen storage d, Wilson, Hemochromatosis

4-    CHF

 

What are causes of Splenomegaly?

1-    Inf.: viral→ CMV, IMN (EBV), Bac→  abscess, Protozoa→ Bilharz., malaria, Leishmaniasis (Kala azar)

2-    Neopl.: lymphoma, leukemia

3-    Metab. & storage ds: amyloidosis & sarcoidosis

4-    Blood ds: Hemolytic anemia

What are causes of massive Splenomegaly?

1-    CML

2-    Malaria

3-    Kala azar (Leishmaniasis)

4-    Myelofibrosis

What are causes of HSM?

1-    Portal hypertension

2-    Inf.: viral→ CMV, IMN (EBV), Bac→  abscess, Protozoa→ Bilharz., malaria

3-    Neopl.: lymphoma, leukemia

What are causes of ascites?

General causes: CLD, CHF (Rt VF), Nephrotic (rare), Hypoalbuminemia

Local causes: abdominal malign., T.B., chylous ascites (lymphatic obstr.) (rare)

OSCE advanced Qs

How to  interpret ascetic tap? Taken under complete Aseptic condition

Transudate: protein < 30gm/L, due to CHF or Trauma

Exudate: protein > 30gm/L, due to Cirrhosis or malign.

What is ttt ascites?

1-      diuretics

2-      salt restriction

3-      weight reduction

4-      Shunts (if above failed): Lee veen shunt to IJV or TIPSS (bet P.V. & Hep V.)

What is Portal Hypertension? ↑ P.V. pr. > 10mmHg (N=5-10mmHg)→ reverse or ↓ flow in liver

Causes P.H.?

Extrahepatic: P.V. or Splenic v. thrombosis

Intrahepatic: Cirrhosis, CHF, Bilharz.(ova obstr, portal venules), sarcoidosis

Indic. Splenectomy? Trauma, Hypersplenism (hemolytic anemia, ITP, CML)

Post-splenic blood film? ↑plat., ↑ WBCs. Howell jolly bodies

Functions of spleen? Immunity (IgM & opsonization, capsulated orgs as pneumococci, H.inf, Meningococci), Bl.storage, Fe storage

Post-splenectomy precautions? Vaccines (Pneumococci, H.inf, Meningococci), LAP, beware malaria

What is jaundice? Yellowish discoloration of sclera & mucus membrane (best seen in soft palate)

To see jaundice in sclera T.Bil > 50 μmol/L (N= 17 μmol/L)

Causes Jaundice?

	Pre-hepatic	Hepatic	Post-hepatic
Cause	Hemolytic anemia Heridetary (Gilbert ds)	Hepatitis Decompansated CLd	Stone in CBD Cancer head of pancreas cholestatic
Type Bilirubin	Unconjugated	Conjugated (+/- un)	Conjugated
Level Bilirubin	↑	↑↑↑	↑
ALT	↑	↑↑↑	↑
ALP	↑	↑↑	↑↑↑

Investigation of jaundice case?

Lab: FBC, LFT, KFT (hepato-renal), Bl.profile. , Radio: U/S (liver size, CBD dilatation), CT

Causes Post-operative jaundice? Prehepatic→bl.transfusion, Hep→anesthesia, sepsis, PostH→bilary injury

What is Malgaigne bulge? Bulge above lat. Part of ing.lig. with straining due to weak ms in old

D.D. Abdominal mass

D.D. mass RIF (Rt iliac fossa)?

1- GIT: Cecal carcinoma (presented by persistent anemia +/- mass +/- I.O.)

Crohn’s disease

2- Urinary: Ectopic kidney, transplanted kidney

3- Male: Undescended testis with malignancy

4- Female: Ovarian mass or fibroid uterus

5- Inflammation (appendicular mass, T.B., Psoas abscess, Crohn’s)

6- L.N.

D.D. mass LIF?

1- Sigmoid carcinoma (presentation acute I.O. +/- mass)

2- Diverticular disease (esp, Diverticular abscess)

D.D. mass in epigastrium?

1- epigastric hernia

2- GIT: Lt lobe of liver, cancer stomach, cancer pancreas & pseudo-pancreatic cyst

3- Vascular: AAA

4- paraaortic L.N. (esp, 2ry to testicular tumor)

D.D. mass in groin?

1- Skin & SCT: lipoma, seb.cyst, impl. Dermoid cyst

2- GIT: Hernia (inguinal or femoral)

3- GenitoUrinary T: ectopic testis +/- tumor, transplanted kid.

4- Vascular: a.→femoral a. aneurysm, v.→saphena varix, lymphatic→L.N.

5- ms: psoas abscess

What is tidal percussion?

Percussion of upper border of liver & differentiate from lung dullness

Percuss in intercostals spaces (4^th opposite nipple in males) or from 2^nd (sternal angle)

Dullness found usually in 5^th space

Ask pt. to take deep inspiration & hold breath

Percuss again if change note → liver, if still dull → lung consolidation

What is diagnosis of abdominal case? Example

Case 1: Mass in Rt iliac fossa, solid, welll defined edge, smooth surface, firm consistency, measure 5 X 5 cms, not reducible, not pulsatile.

→Mass in the RIF & Considering age (old) have to exclude cancer by:

1- Colonoscopy & Biopsy

2- CT scan

3- exploration

How to manage abdominal mass suspected to be cancer?

1- Colonoscopy & Biopsy

2- CT scan

3- exploration

How to diagnose mass RIF?

U/S (to exclude ectopic kidney, aneurysm, L.N., female causes)

Scrotal examination to exclude undescended testis

Colonoscopy & biopsy for suspected cancer cecum

Abd. Exam. L.N. are multiple, irregular, rubbery (not in exam)

Abd. Exam. Inflamm. (appendicular mass) Tender, signs inflamm., irregular, fixed (not in exam)

How to manage ectopic kid. (mass RIF)?

Reassurance (not appendicitis)

Abdominal U/S: for diagnosis

IVU or Renal scan: for function

If non-functioning → nephrectomy ????????

How to manage tumor in undescended testis?

U/S

CT abdomen, pelvis, chest (for metastasis)

Tumor markers (α-FP, β-HCG, LDH)

Prepare for exploration & orchiectomy

How to manage in normally descended testis?

U/S

CT abdomen, pelvis, chest (for metastasis)

Tumor markers (α-FP, β-HCG, LDH)

Prepare for radical orchiectomy (inguinal)

How to treat tumor in normally descended testis? Radical orchiectomy via inguinal incision

How to treat cecal mass? Exploration & asses resectability

if resectable → Rt hemicolectomy

if irresectable → palliative Ileotransverse anastomosis

what does groin L.N. mean with cancer cecum? Infiltration of AAW

What is cryptorchidism? Absent both testes

What is difference between Undescended testis & Ectopic testis?

	Undescended testis	Ectopic testis
Scrotum	Undeveloped (not pass ext. ring)	developed
Sites	1-    abdominal 2-    Int. ring 3-    Ing. Canal 4-    Ext. ring	1-    Superficial ing. Pouch 2-    Femoral triangle 3-    Base of penis 4-    Perineum

OSCE advanced Qs

How to investigate case of unilat. undescended testis with prev. exploration?

Trans-aortic testic. angiography 

Groin Hernia (Inguinal/ Femoral)

How to diagnose inguinal hernia?

Mass in (Rt/Lt/bilat.) groin

Exp.imp. on cough

Reducible (Reducible/ not /Partially)

Example: Rt side oblique inguinal hernia non-complicated

Is ext. ring or 3 finger test used now? NO, obsolete due to pain

How to clinically differentiate inguinal from femoral hernia? Relation to P.T.

Above & med. → inguinal. Below & lat. → femoral

How to define P.T.?  1^st bony prominence med. To inguinal lig. (rolled)

 OR        attachment of tendon adductor longus (flex, abd & ext.rot. thigh) رجل على رجل

How to clinically differentiate oblique from direct hernia? Internal ring test

How to do int. ring test? Better supine, standing if examiner asked

locate ASIS

locate P.T. (1^st bony prominence med. to ASIS)

locate mid-point ing.canal (int.ring) is half way between ASIS & P.T.

control by 2 fingers

stand & cough: if contolled → indirect (oblique) / if not controlled → direct

How to differentiate inguinal from femoral hernia?

Inguinal H.	Femoral H.
Usually male	Usually female
Above & med. To P.T.	Below & lat. To P.T.
Usually reducible & give expansile imp.	Usually irreducible & no expansile imp.
globular	rounded

How to clinically differentiate Oblique (indirect) from Direct inguinal hernia?

Oblique (indirect) Inguinal H.	Direct Inguinal H.
Remnant patent processus vaginalis	Weak post. Wall of ing. canal
Pass through int. ring	Pass through post. Wall of ing. canal
Pass through inguinal canal with cord	Not in canal & not related to cord
Can descend to scrotum	never

What is ttt inguinal hernia? Surgery (for fear complications- as all hernias)

1-    Lechnestein Open repair with mesh via inguinal incision (standard)

2-    Laparoscopic H repair: if bilateral or recurrent

Why surgery for hernia? Because it is liable for complications

What is complications of hernia?

1-    Irreduciblity & inflammation

2-    strangulation

3-    obstruction of contents (I.O.)

What is complication of hernial operations? General & Specific→

1-    inf. (suspect mesh=F.B.)

2-    recurrence (recurrence in repair with mesh is < 2%  = 0.5-2%)

3-    hematoma

4-    testicular atrophy

5-    injury of vas

6-    Urinary retention, pain

what is rate of recurrence in repair with mesh? < 2%

D.D. mass in groin?

1- Skin & SCT: lipoma, seb.cyst, impl. Dermoid cyst

2- GIT: Hernia (inguinal or femoral)

3- GenitoUrinary T: ectopic testis +/- tumor, transplanted kid.

4- Vascular: a.→femoral a. aneurysm, v.→saphena varix, lymphatic→L.N.

5- ms: psoas abscess

What Qs can you ask for pt. with inguinal H.? ask about ppf

bowel problems (ascites & chr.constipation → straining)

urinary problems (BPH → straining)

chest problem (chr. Cough)

occupation

OSCE advanced Qs

What is position of hernia examination? It can be examined in 2 positions

Standing: should start standing to see & feel hernia easily

Supine: easier to define anatomical landmarks (But NO time in exam)

Causes of lost exp.imp. on cough? Omentum (omentocele), obstruction, strangulation

What is ttt femoral hernia?  Surgery (fo fear complications)

Low approach: (commonest) easy- for elective cases – risk of narrowing femoral v.

McEvedy (abdominal): for emergency (strangulated H.)- pfannsteil or midline

Inguinal (rare): if suspect inguinal vs femoral

What is consent for Inguinal H. repair?

1-      LA or GA

2-      Daucase surg.

3-      Risk of testicular damage, recurrence, hematoma, retention, pain, inf.

What are instructions to pt.?

1-      Early mobilization

2-      Keep area clean

3-      Avoid ppf (cough→antitussive, strain→laxative, no wt. lifting)

Epigastric Hernia

What is Epigastric hernia? Protrusion fat +/- peritoneal contents (rare) through linea alba (midway between umbilicus & xiphisternum)

The usual content is fat (so called, Fatty hernia of linea alba)

How to diagnose any hernia?

Mass at anatomical site

Expansile impulse on cough (=more prominent with cough or straining)

Reducible or partially reducible or history irreducibility

How to diagnose epigastric hernia?

Mass or fullness above umbilicus

Exp.imp. on cough

Partially reducible (because it contains omentum)

Defect can be felt /not

What is presentation of  pt. with epigastric hernia? Usually dyspepsia +/- mass

What is the ttt of epigastric hernia?

Repair: longitudinal incision to repair weak linea alba & repair fatty h. of linea alba

What Qs can you ask for pt. with epig.H.? ask about ppf as above

D.D. mass in epigastrium? See above

PUH

What is difference between Umbilical & Para-Umbilical H.?

PUH: beside umbilicus pushing ubmbilical scar (crescent) to side [BUT umb. scar is preserved] – usually > 40ys, ppf are ↑ intra-abd. Pr. (ascites, preg., COPD, obesity)

Umbilical H.: Hernia through umbilicus itself (umbilical scar is lost) – in neonate resolve by time (usually regress before puberty) – ttt: if not corrected → Mayo oper.

How to diagnose PUH (para-umbilical hernia)?

Mass above umbilicus + umb. scar preserved + scaly skin + dilated vs?????

Exp.imp. on cough

Reducible ( reducible/ not)

How to identify contents of hernia?

Palpation →gurgling = intest. / doughy → omentum

Auscultation → bowel sounds

X-ray lat. → intest. Gases

What are complications of PUH? (if huge)

1-    Irreduciblity (if huge) & inflammation & ulceration (in huge PUH)

2-    Strangulation (rare due to wide defect) (if huge)

3-    obstruction of contents (I.O.) (if huge)

What is ttt PUH? Surgery

Mayo oper.= dissection sac, reduction &overalp lower edge over upper edge + mesh

- If uncomplicated → Elective surgery (for fear complications)   

- If huge & irreducible → semi-urgent surgery

Incisional Hernia

What is incisional H.? Protrusion peritoeal content through weak abd. Scar (partial wound dehiscence= skin intact)

What are ppf. Of Incisional H.?

Pre-oper: old, immunocompromised, cancer, abd. Distension (ascites, HSM)

Oper.: poor technique, drain through same stab (should be through separate stab)

Post-oper: inf., hematoma, chest inf & atelectasis

What is ttt Incisional H.?

Surg: if fit, after control of ppf. → repair with mesh (good dissection sac, reduction contents, cut sac, closure in layers +/- drain)

Conservative: if unfit with persistent ppf.

OSCE advanced Qs

What are other types of H. you know & their anatomy?

Spigelian, Lumbar (greater or lesser triangle), Gluteal, Obturator, Sciatic

Stoma

What type of stoma is this (Spot diagnosis)?

Rt side: ileostomy, urostomy (bag contains urine) or colostomy

Lt side: descending colostomy (after Hartman’s or abdomino-perineal resection)

How to examine stoma? Comment on

Site,

abdominal scar,

stoma itself (mucosa, spout or flush with skin, type (end, loop, 2 separate openings))

content (urine, stool, intest.contents)

Bag

Varicocele

What is varicocele? Dilated tortous pampiniform plexus of vs of testis [Rt → Rt testicular (gonadal) v. → drain to IVC] & [Lt → Lt testicul. v. → drain to Lt renal v.]

How to diagnose varicocele?

Inguinoscrotal swelling or fullness (Rt/ Lt/ Bilat.)

Sensation bag worms

Thrill on cough

Evacuated on elevation of scrotum (1ry)

Example: Rt side 1ry varicocele

What is thrill? Transmitted pulsation

What are types of varicocele?

1ry varicocele: 15% of male at puberty (98% Lt side)

2ry varicocele: renal tumor, pelvic tumor or retroperitoneal tumor or fibrosis

Why 1ry varicocele more common on Lt side (98%)?

1-    Lt testicular v. more vertical

2-    Lt testicular v. liable to compression by colon

3-    Lt testicular v. longer

4-    Lt testicular v. has no valves at its termination

What is presentation of varicocele (what bring pt. to clinic)?

1-    pain

2-    infertility

How to investigate  pt.? varicocele is clinical diagnosis but

Scrotal Duplex

Semen analysis

What is ttt varicocele?

Surgery: because it worsen with age (till surgery use Conservative: scrotal support & avoid long standing)

1-    Open Surgery

2-    Laparoscopic ligation

3-    Transfemoral embolization

What are approaches for Open varicocelectomy?

1-    high approach (Balomo): (complics: hematoma, recurrence, 2ry hydrocele)

2-    Inguinal approach: not done now

3-    Subinguinal:

Hydrocele

What is Hydrocele? Accumulation of excess fluid in part or whole of processus vaginalis

How to diagnose hydrocele?

Non-tender purely scrotal swelling

Fluctuant (cystic)

Translucent (Transimmunable) (clear) or not (due to complication)

No testicular masses

Example: Rt side 1ry vaginal Hydrocele not complicated

What are types hydrocele?

1ry:     due to patent processus vaginalis (4 types)

1-    Vaginal: fluid in tunica vaginalis

2-    Encysted Hyd. Of cord: fluid in unobliterated part of proc.vag. around cord

3-    Cong Hyd.: fluid in all proc. vag. & communicating with abdomen

4-    Infantile Hyd.: fluid in all proc. vag. & NOT communicating with abdomen

2ry:    Post-oper. (varicocele, hernia), inf. or testicular tumor

Why some hydroceles are not translucelt (transimmunable)? Complications

What are complications of hydrocele?

Inf. , hge, rupture (rare)

Why this hydrocele 1ry (no tumors)? Age (old) & no testicular masses

What if bilat. Hydrocele? Do abdominal examination

Why not aspirate hydrocele anymore? NO, due to high incidence inf. & recurrence

How to differentiate hydrocele, encysted hydrocele of cord & spermatocele (sperm cyst)?

hydrocele: purely scrotal, not separable from testis, fluctuant, translucent / not

Encysted H cord: scrotal, separable with space bet. It & testis,……..

Spermatocele: scrotal, separable from testis by small gap,……….

What is ttt Hydrocele? Ask pt. How it affect his life

1-    Conservative

2-    Surgery: Lord (placation) or Jaboulay (excision excess sac)

3-    Aspiration: → recurrence & inf.

Epididymal Cyst (Spermatic cyst) (Spermatocele)

What is epididymal cyst?

Cyst in head of epididymis (retention cyst)

If full with sperms called Spermatocele (opaque) may be complication of vasectomy

What is ttt Epididymal cyst?

1-    Conservative: for fear fibrosis → infertility

2-    Surgery: if pain or cosmetic by Excision (rarely may need epididymectomy)

Pilonidal sinus

What is pilonidal sinus? Sinus +/- inf. At site of a hair in natal cleft

What is ttt pilonidal sinus?

Conservative: good hygiene, shave, keep dry

Surgery: drainage if abscess

What is complication of drainage pilonidal sinus & how to treat?

Recurrence & ttt by open technique