Abdominal Lump

History

-          38 years, male

-          Low socio-economic status

-          Severe pain upper abdomen- since 3 days- sharp stabbing, radiating to back, associated with recurrent vomiting(gastric content), passage of black tarry stools(fowl smelling).

-          Similar episode 2 months back that subsided following medications for few days.

-          Known alcoholic- 15 years , >200ml/day

-          Patient gives history of malena- 3 days, bulky greasy stools- 1month.

-          No H/O jaundice, haemoptysis, haematochezia, IV drug abuse.

-          Past history- no history of T.B., DM, HTN, CHD, CVD, Asthma.

-          Personnel History: smoker, alcoholic

Examination findings:

-          General Physical Examination(GPE)- patient was conscious, co-operative, oriented to time place and person and lying in his bed. General condition was poor, hydration was poor and performance score was 70% by karnofsky scale. Pallor++, icterus-, cyanosis-, edema-, clubbing-, peripheral lymphadenopathy-.

-          PR=106/min, Rt arm, supine, normal volume, no Radio-Radial or Radio-Femoral delay.

-          BP=100/60 mm Hg,

-          RR= 20/min.

-          Hair, skin and oro dental hygiene poor.

-          Chest: reduced air entry at bases; Lt>Rt with crepitation.

-          CVS: S1 S2 normally heard

-          CNS: NAD

Abdominal Examination:

Inspection-

-          Skin normal

-          No dilated vein or scar

-          Umbilicus is displaced down(25cm vs 18cm), inverted

-          Decreased movement with respiration

-          Apparent fullness in upper part of abdomen more in central part

-          All hernia sites are free

Palpation-

-          Temperature normal

-          Tenderness over (epigastrium, Rt & Lt hyponchondrium & Umbilical region)

-          No guarding, no rigidity, no rebound tenderness

-          Vague lump 25*15cms extending from – Rt & LT hypochondrium, epigastrium & umbilicus

-          Smooth surface and soft firm in consistency, no organomegaly.

Percussion:

-          Dullness, moderate ascites.

Auscultation:

-          Bilateral sluggish

Case summary:

-          A 38 years chronic alcoholic male

-          Epigastric lump probably pseudocyst pancreas in acute over chronic pancreatitis

Pseudocyst

-          Retroperitoneal

-          It does not move on respiration

-          It is fixed in its position

-          It does not fall forward on tilting

Investigation:

X ray-  

-          Pleural effusion more on the left side

USG abdomen-

CECT Abdomen-

-          Sensitivity of CT is higher for retroperitoneal masses

-          Delineates lymph node status

-          Vessel status

-          Pancreas visualized better

Balthazar’s CT scoring:  

Fallacies of Balthazar’s CT scoring-

-          It’s only a imaging modality

-          Doesn’t include clinical scenario

-          Doesn’t consider multiple organ failure

APACHE II SCORE:

APACHE O: - 

Factors leading to poorer outcome in pancreatitis-

-          Age

-          Alcohol

-          Obesity

-           

 

Obstructive Jaundice

History

·         50 yrs old male

·         Low socio-economic

·         H/O fever – 1 month

·         H/O pain and lump Right upper abdomen – 15 days

·         H/O yellowish discoloration of eyes – 10 days

·         Fever  -  Off and on – 1month, sudden onset, high grade, intermittent and associated with chills and rigors, reduced on taking oral medicines.

·         Pain over right upper abdomen – 15 days, insidious onset, dull aching, non-shifting, non-radiating and decreased on medication.

·         Patient noticed lump in right upper abdomen since past 15 days of size 6*4cms and progressively increased in size to present size.

·          Yellowish discoloration of eyes -  insidious onset and deepened since then.

·         H/O of passing clay coloured stools since 10 days.

·         H/O loss of appetite and weight loss – 5 kgs – 2 months

·         No H/O itching, vomiting, abdominal distension, obstipation, haematemesis, malena, other constitutional symptoms and urinary complaints.

·         No H/O contact, IV drug abuse, blood transfusions.

·          No H/O respiratory distress, bone pains, headache, or seizures.

·         No H/O diabetes mellitus, hypertension, Kochs

·         Alcoholic and smoker since 20 years

Prodromal symptoms	Constitutional symptoms
Eg. – infective hepatitis Short history Loss of appetite Smoker will lose taste of smoking Jaundice appearing and then receding

Is Clay coloured stool always means obstructive jaundice?

-          No

-          In some cases of infective type of hepatitis initially obstructive type of features are present due to oedema of liver cells- stools can be clay coloured, alkaline phosphatase may be raised.

-          But they (obstructive jaundice) do not progress.

Examination-

-          Elderly male, conscious, co-operative, well oriented to time, place and person

-          Performance status – 80 Kornoffosky

-          Nutritional status – poor

-          Hydration status – adequate

-          Pulse – 86/min, regular

-          BP – 124/78 mm Hg

-          RR – 18/min, abdominothoracic

-          Afebrile

-          Patient is albino with yellowish discoloration of skin

-          Icterus – present, pedal edema+

-          Pallor +, no generalised lymphadenopathy

-          Respiratory system – WNL

-          Cardiovascular – WNL

-          Central and peripheral Nervous system – WNL

-          Stigma of liver disease-

o   Hair texture – change or alopecia

o   Icterus

o   Spider naevi

o   Palmar erythema

o   Dupeytren’s contracure

o   Clubbing

o   Gynaecomastia

o   Caput medussae

o   Ascites

o   Testicular atrophy

o   Pedal  oedema

-          Liver failure (include more feature)-

o   Posterior column disorders eg. Flapping tremors

o   Fetor hepaticus

How do you look for hydration status?

-          Tongue

-          Skin turgor- over dorsum of hand.

Abdominal examination-

Inspection:

·         Visible fullness in Rt Hypochondrium

·         All the quadrants moving well with respiration

·         Umbilicus is central

·         Skin over abdomen is normal

·         No dilated veins, scars

·         No visible peristalsis or pulsations

·         Hernia orifices are normal

·         Flanks are not full

Palpation:

·         Tender hepatomegaly with span of around 17cms, palpable 7 cms below the costal margin in MCL, round borders, firm in consistency with small area of softening around 5*6cms present at the middle of swelling.

·         No other organomegaly, no free fluid+

·         Spine, Genitals and Hernial orifices are normal

·         Left supraclavicular lymph node not enlarged

·         P/R examination – WNL.

What gives the colour to stool?

·         Stercobilinogen (formed by bacteria acting upon bilirubin:  Bilirubin=Urobilinogen+Stercobilinogen

In a patient of jaundice what happens to cardiovascular system?

·         In jaundice there is rise in serum bilirubin.

·         Serum bilirubin directly acts on SA nodes.

·         It causes bradycardia or even blocks occur.

Effect of jaundice on CNS?

·         Kernicterus (in children)- kernicterus is deposition of unconjugated bilirubin on basal ganglia after crossing blood brain barrier.

·         Adult and elderly-  (posterior column affected)

o   Tremor

o   Gait of patient

Provisional diagnosis-

·         Obstructive  jaundice due to rapidly progressive malignancy with superimposed infection

Features of infective jaundice:-

·         Prodromal symptoms

·         Jaundice initially progresses and then start receding

·         Clay coloured stool intially which later on disappears

Itching in obstructive type of jaundice take more than one month time to manifest. Deposited in subcutaneous plane. Affinity for elastin.

Points in favour of malignant obstructive jaundice – painless progressive jaundice

Ca Stomach (features)-  LOADS

-          Lump

-          Obstructive features (vomiting, pain abdomen)

-          Anaemia, asthenia, anorexia

-          Dyspepsia (new onset)

-          Silent (jaundice, ascites, Krukenberg’s tumour, Sister Joseph nodules or Virchows nodules)

Investigation-(confirm the diagnosis, support the diagnosis, treat the patient)

-          USG abd-

-          LFT-