Abdominal Pain - hernia, colon cancer, peritonitis Flashcards
Anatomical factors, causes, risk of strangulation, common age and gender in Direct Inguinal Hernia:
A: protrudes through Hesselbach’s triangle
Passes medial to the inferior epigastric artery
C: Weakness in the posterior wall of inguinal canal
R: Low risk of stangulation
Age: adults
G: More common in males
What are the borders of the Hesselbach’s triangle?
Medially: Rectus abdominis
Laterally: Inferior epigastric artery
Inferiorly: Inguinal ligament
Anatomical factors, causes, risk of strangulation, common age and gender in indirect Inguinal Hernia:
A: Protrudes through inguinal ring. Passes lateral to inferior epigastric artery
C: No piercing through the wall instead contents pass from deep to superficial ring. Failure of processus vaginalis to close
R: Low risk
Age: May occur in infants
G: More common in males
Anatomical factors, risk of strangulation, common age and gender in femoral Hernia:
A: Protrudes below inguinal ligament, lateral to pubic tubercle
R: High risk of strangulation
Age: Seen in adults
G: More common in females
What passes through the inguinal canal?
in males:spermatic cord (to facilitate ejaculation)
in females: the round ligament.
In both sexes the canal also carries a sensory nerve known as the ilioinguinal nerve.
Where are the deep and superficial inguinal rings located anatomically?
The deep inguinal ring is located just above the mid-point of the inguinal ligament. The superficial ring lies just above and medial to the pubic tubercle
On clinical examination of a hernia how will direct and indirect inguinal hernias present differently?
you can place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), then you can control an indirect inguinal hernia which has been reduced. If when you press the deep ring, the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is therefore a direct hernia.
Causes for inguinal hernias:
Increased intra-abdominal pressure
Weakness of the abdominal muscles
Chronic cough Constipation Heavy lifting Advanced age Obesity
What is the cause for an indirect inguinal hernia?
normally due to failure of embryonic closure of the processus vaginalis, meaning they are
mainly of congenital type.
This type of hernia protrudes through the internal inguinal ring, following the course of the spermatic
cord. The protrusion is lateral to the inferior epigastric vessels and is covered in spermatic cord fascia.
What happens in a femoral hernia?
protrusion of a peritoneal sac through the femoral ring into the femoral canal, posterior and inferior to the inguinal ligament. The sac may contain preperitoneal fat, omentum, small bowel, or other structures
Relatively uncommon
Cough impulse is absent
What is an incisional hernia?
This is a type of hernia caused by an incompletely-healed surgical wound following abdominal
exploratory surgery. Symptoms include:
A palpable bulge at or near the area of surgical incision,
Past medical history of abdominal surgery,
Mainly occur down the linea alba,
High recurrence rate following hernia repair.
Risk factors include infection of the surgical site, chronic cough, constipation, urinary obstruction (BPH),
pregnancy or ascites.
What is an umbilical hernia?
This is where the abdominal wall posterior to the navel is damaged, causing weakening along the linea
alba and enabling peritoneal contents to protrude through. Signs and symptoms:
Bulge at the navel/umbilicus,
Incarceration and strangulation is rare,
Tend to be asymptomatic.
Causes of umbilical hernias?
1) Congenital:
This is a congenital malformation of the umbilicus, three times more common in
women than men. It is most common in African descent.
2) Acquired:
This herniation is a direct result from increased intra-abdominal pressure caused by obesity, heavy
lifting, chronic coughing or multiple pregnancies.
3) Paraumbilical:
Mesenteric fat or bowel passes through a weak point of the muscles or ligaments near the umbilicus.
Ways in which hernias present:
Palpable mass (location dependent on type),
Pain (if incarcerated or strangulated),
Cough impulse (inguinal and umbilical),
Abdominal discomfort,
Some hernias may be reducible.
Spigelian hernia:
Also known as a lateral ventral hernia, is a herniation of intestinal contents through the Spigelian fascia
located in the lower regions of the abdomen.
This is the aponeurotic layer between the rectus
abdominis muscle medially, and the semilunar line laterally.
These are small hernias, so the risk of
strangulation of the blood vessels is high.
Explain strangulation because of hernias:
a hernia becomes tightly constricted by the posterior containing wall. It forms a narrow
neck which may occlude the blood supply to the protruding peritoneal contents. If the blood supply is
not restored promptly, gangrene can occur and may cause death. Signs of hernia strangulation include:
Sudden growth and discoloration of the hernia,
Pain,
Irreducible,
Nausea and vomiting.
Explain incarceration in hernias:
The herniated content is a loop of the bowel, which becomes occluded so that solids cannot pass. Thus,
preventing normal digestion and forming a bowel obstruction. The section of intestine herniated cannot
return to its anatomical position without surgery. Signs include:
Palpable mass,
Pain,
Nausea and vomiting,
Constipation.
Features of right sided colon cancer
~ Cancer of caecum and A.colon upto hepatic flexure
~ Arisen from midgut embryology
~ Genetic predisposition - FAP (lynch syndrome) or HNPCC (microsatellite instability)
~Exhibits symptoms when more advanced (because contents still liquid and caecum is larger/wider)
~ pain, cramps, obstruction, anaemia?
Features of left sided colon cancer
~ Cancer of splenic flexure and distal regions +rectum
~ Arisen from hindgut embryology
~ Genetic predisposition - FAP (lynch syndrome) or HNPCC (microsatellite instability)
~Exhibits symptoms earlier as food is more solid and causes visceral pain
~ pain (in suprapubic region), rectal bleeding, mucus stools, cramps, obstruction
Acute appendicitis:
Appendix becomes obstructed with faecolith.
Initially there is inflammation of mucosa, then of submucosa involving peritoneal regions. Accumulation of mucus causes ischaemia of deeper mural layers allowing bacteria (gangrene).
If not treated, perforation can occur and faecal contents could empty into peritoneal cavity.
When do we get localised peritonitis?
Virtually with all acute inflammatory conditions of GI tract
Pain and tenderness treated by treating underlying disease
When can we get generalized peritonitis?
Irritation due to infection or chemicals leaking from intestinal content
What is the complication seen with generalized peritonitis?
Acute inflammation causes production of exudate that spreads throughout peritoneum -> intestinal dilation and paralytic ileus
Toxaemia, septicaemia
What are the clinical features for peritonitis?
In perforation:
Sudden onset, severe abdo pain, general collapse and shock
Secondary to disease:
Onset is less rapid and initial disease may present first
Ix for peritonitis?
Erect Chest X-ray
Can see free air under diaphragm
What is the most common cause of bowel obstruction in adults?
Adhesions
Some causes of small bowel obstruction
Adhesions Hernia (strangulation can impede blood supply leading to gangrene, perforation and peritonitis) Crohn's disease Intussception Cancer
Causes of colonic obstruction
Colon cancer
Sigmoid volvulus
Diverticular disease
How might a patient with renal colic present differently than patient with peritonitis?
Renal colic patients roll around to find a comfortable position
Peritonitis are lying still
Describe the stages of Duke’s staging:
A - Tumour confined to mucosa
B1- Tumour in muscularis propria
B2 - Tumour in musularis and serosa
C1 - Tumour spread to 1-4 regional lymph node
C2 - Tumour spread to more than 4 regional lymph nodes
D - Distant metastasis
Abdominal pain, flushing and diarrhoea are seen in which diagnosis?
Carcinoid syndrome
