Abdominal pain Flashcards
what increases intra-abdominal pressure?
-straining
-holding breath (using
loo/lifting heavy objects)
-coughing
what causes weakness of abdominal muscles?
age
obesity
iatrogenic (surgery)
describe how a hernia occurs?
Occurs when organ or fatty tissue squeezes through weak spot in surrounding muscle of connective tissue called fascia
The abdominal wall, a sheet of tough muscle and tendon that runs down from the ribs to the legs at the groins, acts asthe body’s corset. Its function, amongst other things, is to hold in the abdominal contents, principally the intestines.
If a weakness should open up in that wall, then the corseteffect is lost and what pushes against it from the inside (the intestines) simply pushes through the opening. The ensuing bulge, which is often quite visible against the skin, is the hernia.
what are the most common types of hernias?
Inguinal Femoral Umbilical Midline Recurrent Incisional Strangulated Hiatus
are hernias painful?
Most hernias do not hurt. Paradoxically, the larger ones often hurt less, the reason being that a large ‘window’ in the abdominal wall that allows the intestine to slide in and out easily is not usually the cause of pain. Pain tends to occur when something is getting ‘squeezed’. That is often (although not exclusively) associated with smaller hernias.
do most hernia’s occur in men or women?
95% men
if in women more likely femoral than inguinal
describe inguinal hernias?
inguinal-75% of abdominal wall hernias. Fatty tissue, bowel section pushes into groin. Most common type of hernia and most common in men. Superb-medial to pubic tubercle, 2 types-direct (superficial) and indirect (deep). Direct inguinal hernias are due to defect in posterior abdominal wall which is more common and pressure on the deep inguinal ring won’t affect it. Indirect hernias have no defect in the wall and the contents enter via the deep ring, less resistance for structures to pass through anatomical inguinal ring compared to muscle defects, so these are more likely to emerge within the tested. Not able to reappear if deep inguinal ring were occluded
describe femoral hernias?
fatty tissue/bowel section pushes into groin. This is uncommon but is more common in females. Inferno-lateral to the pubic tubercle (and medial to femoral pulse
what type of hernias are associated with ageing and repeated abdominal strain?
inguinal and femoral
how would a hiatus hernia present?
stomach pushing up into chest by getting through diaphragm which can cause dyspepsia, unknown aetiology
how would a diaphragmatic hernia present?
organs in abdomen move into chest through diaphragm being incomplete of weak
how would a surgical/incisional hernias present?
tissue pokes through surgical wound that hasn’t fully healed
what actions make hernias appear and what reduces it?
coughing and straining makes hernias appear
lying down reduces it
where does the spermatic cord and abdominal contents enter and exit the inguinal canal?
Entry of abdominal contents into inguinal canal = deep ring = superior to the midway point of the inguinal ligament
Exit of abdominal contents = superficial ring = superior to pubic tubercle
where is the inguinal ligament?
runs between the ASIS and the ‘midpoint between the ASIS-Pubic tubercle’
These two structures are effectively sitting next to each other, with the canal being most medial.
what are the 2 types of inguinal hernia?
direct
indirect
what is a direct inguinal hernia?
pierces through posterior wall of abdomen
what is an indirect inguinal hernia
Indirect doesn’t pierce through the posterior wall, it follows the path of least resistance (and is therefore more common)
which type of hernia are more common; inguinal or femoral?
inguinal
which type of hernia occurs more laterally; inguinal or femoral?
femoral
how can you clinically tell the difference between a direct and indirect hernia?
Clinically telling the difference… stick your finger over the deep inguinal ring which should be above the mid-point of the inguinal ligament. If you’re on the deep ring and there’s change, you’re controlling an indirect hernia. If there isn’t any change, it’s because the herniation originated via muscle weakness in the posterior abdominal wall. N.B. This test isn’t that reliable and doesn’t carry significance with respect to management.
what is the femoral canal?
: NAVY VAN – pneumonic used to remember how the femoral nerve, artery and vein run anatomically (the Y represents the creases in the groin)
Femoral artery & vein enclosed within a sheath which the femoral canal is medial to. It contains the lymph node of Cloquet & a little bit of fatty tissue.
why is there a high risk of strangulation with a femoral hernia?
If abdominal contents leak into the femoral canal, there is a high risk of strangulation & obstruction, purely because the canal sits on the lateral side of the lacunar ligament which has a sharp edge.
what is a strangulated hernia?
Strangulated: a hernia that has strangulated will present as an irreducible and tender tense lump with pain out of proportion to clinical signs which may be accompanied with features of obstruction
describe epigastric hernia?
Upper midline through fibres of linea allba
Usually secondary to raised chronic intra-abdominal pressure such as obesity, pregnancy or ascites
Prevalence - upto 10% in mainly middle aged men
Typically asymptomatic may present as midline mass that disappears when lying on back
Differential-divarication of recti
describe paraumbilical hernias?
Herniation through the linea alba around the umbilical region but not through umbilicus itself.
Secondary to raised chronic intra-abdominal pressure and present as lump around umbilical region.
Common.
Risk factors – obesity and pregnancy
Contain pre-peritoneal fat
Don’t commonly strangulate
describe spligelian hernia?
Rare and occurs at semilunar line around level of arcuate line
Small tender mass at lower lateral edge of rectus abdominus.
High risk of strangulation so should be repaired
describe obturator hernias?
Hernia of pelvic floor through obturator foramen into obturator canal. More common in women due to wider pelvis and typically older patients. Mass in upper medial thigh and features of small bowel obstruction. In Half of patients compression of obturator nerve will cause Howship-Romberg sign
