S6

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\par
\par
\par
\par \lang1033 \fs20 \f0 \fs50 \f1 \b \pard \qc \sl-0 The Abdomen
\par \pard \sl-0
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 Technique for ex
amination of the abdomen
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-0 \tx204
\par
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 The abdomen contains the stoma
ch, duode\-num, small and large bowel, liver, pancreas, kidneys, bladder, aorta,
vena cava, \fs8 \f5 \b ... \fs20 \f0 \plain \fs20 \lang1033 a large number of d
ifferent structures within a relative\-ly small cavity, all susceptible to disea
se or malfunction and capable of producing symp\-toms. It is not surprising, the
refore, that the diagnosis of abdominal complaints is extremely difficult.
\par \pard \qj \fi232 \sl-221 \tx232 Because the abdominal organs are so close t
o each other the brain cannot distinguish with any accuracy which of them is the
source of a pain. This means that the patient\'92s description of a pain may no
t be specific, although other symptoms may clearly indicate the organ in\-volved
, and the diagnosis of the source of the pain will depend on physical examinatio
n.
\par \pard \qj \fi232 \sl-221 \tx232 But here the examiner meets with another pr
oblem. Many of the contents of the abdominal cavity are inaccessible to palpatio
n. The abdo\-men stretches from the dome of the diaphragm, just below the level
of the nipples, to the bottom of the pelvis, a few inches above the anal canal.
The top part is covered by the lower ribs, the lower part is in the pelvis and t
he posterior aspect is hidden and protected by the spinal column.
\par \pard \qj \fi232 \sl-221 \tx232 Figure 16.1 shows the extent of the abdomin
al cavity and the area available for direct palpa\-lion. Fortunately, it is poss
ible to feel beneath the costal margin, and to reach into the pelvis per rectum
or vaginam; nevertheless, many of the abdominal contents are difficult to palpat
e, especially if the patient is protecting himself by tensing his muscles. Becau
se of these anatomic\-al restrictions the position of the patient and the techni
que of examination are of paramount im\-portance if you wish to obtain the maxim
um information.
\par \lang1033 \fs130 \f1 \pard \sl-0 \tx3395 (\tab \fs62 \f1 (
\par \pard \li2800 \fi-2285 \sl-0 \tx515 \tx2800 \fs10 \f1 \'95::~\tab \fs20 \f
1 \b A
\par \pard \sl-0 \tx515 \tx2800
\par
\par \fs8 \f1 \plain \fs8 \f1 \lang1033 \pard \li3639 \fi-2404 \sl-0 \tx1235 \tx
3639 \'97\tab \fs12 \f1 \i \b I..
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \plain \fs20 \f1 \lang1033 \b \pard \l
i1230 \sl-0 \tx1230 :2:2?
\par \fs10 \f1 \plain \fs10 \f1 \lang1033 \pard \sl-0 \tx204 I:
\par \pard \sl-0 \tqdec \tx1383 \tx1967 \tx2284 \tab 0\tab I\tab \fs8 \f5 \b \'9
7 \fs20 \f1 \plain \fs20 \f1 \lang1033 \b B
\par
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\par \fs10 \f1 \plain \fs10 \f1 \lang1033 \pard \li1814 \sl-0 \tx1814 I_I
\par \pard \sl-0 \tx192 \tx4291 \tab \fs10 \f0 \b -\tab \fs10 \f1 \plain \fs10 \
f1 \lang1033 i
\par \fs12 \f1 \i \b \pard \sl-215 \tx2375 \tx4098 I\tab \fs24 \f1 \plain \f1 \l
ang1033 \plain \f1 \lang1033 \b \'97c\line \pard \sl-215 \tx2375 \tx4098 \tab \
fs10 \f1 \plain \fs10 \f1 \lang1033 \i \b ~\tab I
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \plain \fs20 \f1 \lang1033 \b \pard \s
l-0 \tx2919 \tx4183 A\tab B\tab C
\par
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\par
\par
\par
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\par \fs8 \f1 \plain \fs8 \f1 \lang1033 \pard \li1632 \fi-1632 \sl-0 \tx1632 ~\t
ab \fs14 \f1 ~i~t.~4; I ~ L \fs16 \f0 \b Jr425,#~.4.~!
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f1 \b \pard \sl-221 \tx20
4 Figure 16.1 \fs20 \f0 \plain \fs20 \lang1033 These figures show the extent \fs
20 \f1 of \fs20 \f0 the \fs20 \f1 abdominal cavity. The dotted areas indicate th
e parts of the abdomen protected by the ribs and the pelvis. The levels of the t
hree cross-sections are indicated on the central diagram.
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 364 \i The Abdom
en
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 Preparation
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The environment
\par
\par \pard \qj \fi243 \sl-221 \tx243 The examination room must be warm and priva
te if you want your patient to lie undressed and relaxed. A cold couch, in a dra
ught, in view of other patients makes a proper examination impossible.
\par \pard \qj \fi243 \sl-221 \tx243 You must also have a good light. Daylight,
coming obliquely from one side of the patient so that the shadows are emphasized
, is the best light.
\par \pard \qj \fi243 \sl-221 \tx243 Beware of artificial light. If it comes fro
m a source directly above the patient you will lose the soft shadows that so oft
en give you the first indication of the presence of asymmetry; and many neon lig
hts falsify colours, particularly yellows and blues.
\par \pard \qj \sl-221 \tx243
\par \pard \qj \sl-221 \tx204 The examination couch or bed
\par
\par \pard \qj \fi243 \sl-221 \tx243 You must strike a compromise between the ve
ry hard, flat couch which, by making the patient lie absolutely flat, opens the
gap be\-tween the pubis and xiphisternum but stretches and tightens the abdomina
l muscles, and the soft bed which lets the lumbar spine sink into a deep curve a
nd closes the gap between pubis and ribs
\par \pard \qj \fi243 \sl-221 \tx243 The best compromise in an outpatient situa\
-tion is a hard couch with a backrest that can be
\par \lang1033 \pard \qj \li4614 \sl-221 \tx4614 raised by 15~2Oo. The hard couc
h makes the patient maintain most of his lumbar lordosis, so opening the access
to the abdomen and pushing the central contents anteriorly, but the elevation of
the thoracic cage relaxes the anterior abdo\-minal muscles.
\par \pard \qj \li4614 \fi204 \sl-221 \tx4614 \tx4818 This type of couch is, in
fact, essential because
\par \pard \qj \li4614 \sl-221 \tx4614 some patients with orthopnoea or musculo\
-skeletal deformities cannot lie flat.
\par \pard \qj \li4614 \sl-221 \tx4614 Exposure
\par \pard \qj \li4614 \fi204 \sl-221 \tx4614 \tx4818 You must see the full exte
nt of the abdomen.
\par \pard \qj \li4614 \sl-221 \tx4614 Therefore you must uncover the patient fr
om
\par \pard \qj \li4614 \sl-221 \tx4614 nipples to knees.
\par \pard \qj \li4614 \fi204 \sl-221 \tx4614 \tx4818 Many patients find this em
barrassing, but if you do not do it then you will easily forget to examine the a
reas that are not uncovered, such as the genitalia and hernial orifices. It will
relieve the patient\'92s embarrassment if you begin by examining the genitalia
and then cover them with a sheet or blanket before examining the rest of the abd
omen.
\par \pard \qj \sl-221 \tx4614 \tx4818
\par \pard \qj \li4637 \sl-0 \tx4637 Get the patient to relax
\par \pard \qj \li4637 \fi204 \sl-221 \tx4637 \tx4841 If the patient is tense yo
u will not be able to feel anything within the abdomen. There are a number of wa
ys by which you can encourage relaxation:
\par \pard \qj \li5261 \fi-414 \sl-0 \tx4847 \tx5261 (a)\tab First ask the patie
nt to rest his head on
\par \lang1033 \fs24 \f1 \b \pard \li5419 \sl-0 \tx5419 C
4 /7
\par
\par \fs24 \f1 \plain \f1 \lang1033 \b \pard \sl-0 \tx204 B
4 Figure 16.2 \plain \fs20 \f1 \lang1033 (A) Examine the abdomen with the patien
t on a firm couch or bed with just sufficient \fs18 \f1 support \fs20 \f1 beneat
h the shoulders and head to stop the anterior abdominal wall being stretched tig
ht. \b (B) \plain \fs20 \f1 \lang1033 If the abdominal wall is tight, raise the
head and flex the hips. (0 & \b D) \plain \fs20 \f1 \lang1033 These figures show
the reduction in the area of abdomen available for palpation if the patient lie
s on a soft bed that allows the lumbar lordosis to straighten.
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \li640 \sl-0 \tx640 D
\par \pard \sl-0 \tx640
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 ~1
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5714 \sl-0 \tx5714 Technique for
examination of the abdomen \plain \fs20 \lang1033 365
\par \fs20 \f0 \pard \sl-0 \tx5714
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 the couch or pillow. If he kee
ps lifting it up he will tense his rectus abdominis muscles.
\par \pard \qj \fi232 \sl-221 \tx232 \tx578 (b)\tab Ask him to rest his arms by
his side, not to hold them up behind his head.
\par \pard \qj \fi243 \sl-221 \tx243 (c) Suggest that he lets his back sink into
the couch.
\par \pard \qj \fi243 \sl-221 \tx243 (d) Ask him to breathe regularly and slowly
, and only press your hand into the abdomen during expiration when the abdominal
muscles relax.
\par \pard \qj \fi232 \sl-221 \tx232 If these manoeuvres do not succeed then fle
x the hips to \fs8 \f6 \b 450 \fs20 \f0 \plain \fs20 \lang1033 and the knees to
9O~ and put an extra pillow behind the head. Although this tips up the pelvis an
d reduces your area of access to the abdomen, it usually relaxes the abdominal m
uscles.
\par \pard \qj \sl-221 \tx204 The position of the examiner
\par
\par \pard \qj \fi243 \sl-221 \tx243 Your hands must be clean and warm and your
nails short. You cannot palpate deeply with long nails, and it is an insult to t
he patient to have dirty hands.
\par \pard \qj \fi232 \sl-221 \tx232 Your whole hand must rest on the abdomen. T
he only comfortable way to achieve this is by keeping your hand and forearm hori
zontal in the same plane as the front of the abdomen. This means that you must s
it or kneel beside the patient. If you stand up your forearm will not be horizon
tal, your wrist will be extended and gentle palpation much more difficult.
\par \pard \qj \fi243 \sl-221 \tx243 Sitting beside the patient with your forear
m
\par \lang1033 \pard \qj \sl-221 \tx204 level with the front of the abdomen puts
your eyes about 50 cm above your hand. This is the ideal level for seeing the s
oft shadows caused by lumps and bumps.
\par \pard \qj \fi232 \sl-221 \tx232 Palpate gently but deliberately; that is to
say, firmly and with purpose. Rapid, jerky or circular movements that look as t
hough you are knead\-ing dough are distressing for the patient, make him lose co
nfidence in your ability and yield no information. You will learn much more by k
eep\-ing your hand still and feeling the structures moving beneath it.
\par \pard \qj \sl-221 \tx204 The routine of examination
\par
\par \pard \qj \fi243 \sl-221 \tx243 Follow the standard routine \fs8 \f1 \'97 \
fs20 \f0 inspection, palpation, percussion and auscultation.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Inspection
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Look at the whole
patient. You will have done this already when examining the head, neck and ches
t, but look again for general abnormali\-ties particularly relevant to intra-abd
ominal dis\-ease such as cachexia, pallor and jaundice.
\par \pard \qj \fi243 \sl-221 \tx243 Look at the abdomen. Asymmetry is often eas
ier to detect if you stand at the foot of the couch, or bed, and look along the
length of the patient.
\par \pard \qj \fi243 \sl-221 \tx243 Note the shape of the abdomen. Is it symmet
\-rical \fs8 \f1 \'97 \fs20 \f0 flat, distended, or hollow (scaphoid) \fs8 \f1 \
'97 \fs20 \f0 or asymmetrical? If asymmetrical, note the posi\\par \fs20 \f0 \pard \qj \sl-0 \tx243
\par
\par
\par
\par
\par
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\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \li6502 \sl-198 \tx6502 Figure 16.3
\plain \fs20 \f1 \lang1033 When you palpate the abdomen, sit or kneel so that yo
ur forearm is horizontal and level with the anterior abdominal wall, and your ey
es 50cm above this level. If you are higher, your wrist will be extended and you
will not be able to palpate comfortably and firmly.
\par \lang1033 \fs20 \f0 \fs30 \f3 \pard \li408 \sl-0 \tx408 4,
\par
\par
\par
\par
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\par \fs104 \f3 \i \pard \sl-0 \tx204 Li.
\par \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0
\tx204 366 \i The Abdomen
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 tion, shape and size of any bu
lge, whether the shape of the bulge changes, moves with respira\-tion or changes
with coughing.
\par \pard \qj \fi243 \sl-221 \tx243 Look for scars, sinuses and fistulae.
\par \pard \qj \fi243 \sl-221 \tx243 Look for distended veins.
\par \pard \qj \fi243 \sl-221 \tx243 Watch for the reaction of the patient to co
ughing or moving. Patients with peritonitis find movement extremely painful and
conse\-quently tend to lie very still.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Palpation
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Begin by feeling
the areas that you might other\-wise forget:
\par
\par \pard \qj \li243 \fi-243 \sl-221 \tx243 1.\tab Feel the supraclavicular fos
sae, for lymph nodes.
\par \pard \qj \li243 \fi-243 \sl-221 \tx243 2.\tab Feel the hernial orifices, a
t rest and when the patient coughs (external inguinal ring, femor\-al canal and
umbilicus).
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 3.\tab Feel the femoral pulses.
\par \pard \qj \li243 \fi-243 \sl-221 \tx243 4.\tab Examine the external genital
ia (described in detail in Chapter 14).
\par \pard \qj \sl-221 \tx204 Two other vital procedures are easily forgot\-ten
\fs8 \f1 \'97 \fs20 \f0 auscultation for bowel sounds and bruits, and the rectal
examination\'97but it is more con\-venient to do these later.
\par
\par \pard \qj \sl-221 \tx204 General light palpation for tenderness
\par
\par \pard \qj \fi243 \sl-221 \tx243 This should be done by gently resting the h
and on the abdomen and pressing lightly. Move your hand systematically over all
areas of the abdomen.
\par \pard \qj \fi243 \sl-221 \tx243 If the patient has a pain, ask him to point
to its site so that you can begin palpation in a non-tender area and move towar
ds the tender spot.
\par \pard \qj \fi243 \sl-221 \tx243 Determine the \i area \plain \fs20 \lang103
3 of tenderness so that you can depict it on a drawing of the abdomen in your no
tes as a hatched area (see Figure 16.4).
\par \pard \qj \fi255 \sl-221 \tx255 Try to assess the degree of tenderness. Pal
pa\-tion over an area of mild tenderness just causes pain. If the area is modera
tely tender the pa\-tient\'92s abdominal muscles tighten as you press \fs8 \f1 \
'97 \fs20 \f0 this is guarding. Severe tenderness is also associated with guardi
ng but, in addition, the sudden withdrawal of the manual pressure causes a sharp
exacerbation of the pain\'97this is known as rebound or release tenderness. The
elicitation of release tenderness is usually dis\-tressing to the patient, so t
he technique should not be used routinely. Light percussion is just as accurate
a method of detecting tenderness.
\par \lang1033 \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 16.4 \plain \fs20 \f
1 \lang1033 Indicate areas of tenderness by oblique lines on a sketch like the a
bove. Masses are depicted by outlining their shape.
\par
\par
\par \fs20 \f0 \pard \qj \fi243 \sl-221 \tx243 Sometimes release of pressure on
a distant non-tender part of the abdomen may cause pain in the tender area.
\par \pard \qj \fi243 \sl-221 \tx243 Although these signs indicate increasingly
severe tenderness, it is usual to describe their presence or absence rather than
grade the tenderness because pain sensitivity varies so much from patient to pa
tient.
\par \pard \qj \sl-221 \tx204 General deep palpation for tenderness
\par
\par \pard \qj \fi243 \sl-221 \tx243 If systematic light palpation over the whol
e abdomen elicits no pain, repeat the process, pressing firmly and deeply to see
if there is deep tenderness.
\par \pard \qj \sl-221 \tx204 Palpate for masses
\par
\par \pard \qj \fi255 \sl-221 \tx255 Although your initial palpation for tendern
ess
\par \pard \qj \sl-221 \tx204 might have detected some other abnormalities, you
must feel firmly over the whole abdomen specifically searching for masses. If yo
u find a mass you must elicit all its physical signs\'97 position, shape, size,
surface, edge, composition (consistence, fluctuation, fluid thrill, resonance, p
ulsatility).
\par \i \pard \qj \fi243 \sl-221 \tx243 Tender masses \plain \fs20 \lang1033 in
the abdomen are very dif\-ficult to assess because of the protective guard\-ing
of the abdominal wall muscles. If you let your hand rest gently on the tender ar
ea and gradually press it a little deeper during each expiration you will find t
hat you will be able to overcome guarding and feel tender masses well
examination of the abdomen \plain \fs20 \lang1033 367
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 enough to get some idea of the
ir surface and size. If you just push hard you will feel nothing because the abd
ominal muscles will become iron hard.
\par
\par \pard \qj \sl-221 \tx204 Palpate the normal solid viscera
\par
\par \pard \qj \sl-221 \tx204 Liver With your hand resting transversely and flat
, on the right side of the abdomen, at the level of the umbilicus, ask the patie
nt to take a deep breath. If the liver is grossly enlarged its lower edge may mo
ve downards and bump against the radial side of your index finger.
\par \pard \qj \fi243 \sl-221 \tx243 If you feel nothing abnormal, repeat the pr
o\-cess with your hand a little higher, inch by inch, until you reach the costal
margin.
\par \pard \qj \fi243 \sl-221 \tx243 The liver edge may be straight or irregular
, thin and sharp, or thick and rounded.
\par \pard \qj \fi243 \sl-221 \tx243 If you begin palpation just below the costa
l
\par \lang1033 \pard \qj \sl-221 \tx204 margin you will miss a big liver. Gross
hepa\-tomegaly may fill the whole abdomen, so if in doubt begin your palpation i
n the left iliac fossa.
\par
\par \pard \qj \sl-221 \tx204 Spleen An enlarged spleen appears below the tip of
the 10th rib along a line heading for the umbilicus. A normal spleen is not pal
pable.
\par \pard \qj \fi243 \sl-221 \tx243 Begin palpating for the spleen with your fi
nger tips to the \i right \plain \fs20 \lang1033 of \i and below \plain \fs20 \l
ang1033 the umbilicus, because a very large spleen may extend across the abdomen
into the right iliac fossa. Then ask the patient to take a deep breath. If you
feel nothing, move your hand, in stages, towards the tip of the left 10th rib. W
hen you reach the costal margin put your left hand around the lower left rib cag
e and lift it forwards as the patient inspires. This manoeuvre occasionally lift
s a slightly enlarged spleen far enough for\-wards to make it palpable.
\par \fs20 \f0 \pard \qj \sl-0 \tx243
\par
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \li4405 \sl-198 \tx4405 Figure 16.5
\plain \fs20 \f1 \lang1033 (A) Palpate the liver by resting your fingers on the
abdomen almost parallel to the right coastal
\par \pard \li4405 \fi-216 \sl-198 \tx4189 \tx4405 +\tab margin and asking the p
atient to breath in. The liver edge can be made more prominent by putting your l
eft hand under the lower ribs and lifting them forwards. (B) Palpate the spleen
with your fingers lying transversely across the abdomen so that its tip will hit
the tips of your index and middle fingers when the patient breathes in. Make th
e spleen more prominent by lifting the lower ribs forwards with your left hand.
(0) Palpate the kidneys by pressing firmly into the lumbar region during inspira
tion while lifting the kidney forwards with your other hand in the loin.
en
\par \lang1033 \fs20 \f0 \pard \qj \fi243 \sl-221 \tx243 The spleen is recogniza
ble from its shape and site and, when present, the notch on its supero\-medial e
dge.
\par \pard \qj \sl-221 \tx204 Kidneys The kidneys are often impalpable, but both
lumbar regions should always be care\-fully examined.
\par \pard \qj \fi255 \sl-221 \tx255 To feel the right kidney, put your left han
d
\par \pard \qj \sl-221 \tx204 behind the patient\'92s right loin, between the 12
th rib and the iliac crest, and lift the loin and kidney forwards. Put your righ
t hand on the right side of the abdomen just above the level of the anterior sup
erior iliac spine and, as the patient breathes in and out, palpate deeply into t
he loin.
\par \pard \qj \fi255 \sl-221 \tx255 You will often feel the lower pole of a nor
mal
\par \pard \qj \sl-221 \tx204 kidney at the height of inspiration. If the kidney
is very easy to feel, it is either enlarged or abnormally low.
\par \pard \qj \fi243 \sl-221 \tx243 To feel the left kidney, lean across the pa
tient, put your left hand round the flank into the left loin to lift it forwards
, and your right hand on the abdomen.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Percussion
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Percuss over the
whole abdomen and particu\-larly over any masses.
\par \pard \qj \fi243 \sl-221 \tx243 Sometimes you will find a dull area and wit
h further palpation feel a mass that you had missed, so percussion is important.
\par \pard \qj \fi243 \sl-221 \tx243 If there is a circumscribed mass, tap it on
one side while feeling the other side with the other hand to see if it conducts
a fluid thrill.
\par \pard \qj \fi243 \sl-221 \tx243 Any area of dullness should be outlined by
percussion with the abdomen in two positions
\par \lang1033 \pard \qj \sl-221 \tx204 to see if it moves or changes shape. Fre
e fluid (ascites) changes shape and moves (shifting dullness) if the patient is
turned on his side.
\par \pard \qj \fi243 \sl-221 \tx243 Percussion will cause pain if there is unde
r\-lying peritonitis and is therefore a useful method for determining the extent
of a tender area.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Auscultation
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 First listen for
bowel sounds. Bowel can only produce gurgling noises if it contains a mixture of
fluid and gas. The pitch of the noise depends upon the distension of the bowel
and the prop\-ortions of gas and fluid. Normal bowel sounds are low-pitched gurg
les occurring every few seconds. If there are no bowel sounds then there is prob
ably no peristalsis, which may be a primary or secondary phenomenon. If you can
hear the heart and breath sounds but no bowel sounds over a 15\'9730 second peri
od, the patient probably has a paralytic ileus. Increased pens\-talsis increases
the volume and frequency of the sounds. Distension of the bowel caused by mecha
nical intestinal obstruction makes the sounds high-pitched, best described as \'
91tinkling sounds\'92.
\par \pard \qj \fi243 \sl-221 \tx243 Secondly, listen along the course of the ao
rta and the iliac arteries for systolic bruits.
\par \pard \qj \fi243 \sl-221 \tx243 When part, or the whole, of the abdomen is
distended, or if you suspect pyloric obstruction, hold the patient at the hips a
nd shake the abdomen from side to side. Splashing sounds (a succussion splash) i
ndicate that there is an intra-abdominal viscus, usually the stomach, distended
with fluid and gas.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Abdominal pain
\par
\par
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 The features of pain have been dis
cussed fully in Chapter 1. Being so important they deserve repeating \fs8 \f1 \'
97 \fs20 \f0 see Revision Panel 16.2.
\par \pard \fi209 \sl-221 \tx209 So many intra-abdominal diseases present with p
ain alone that time spent taking a careful history of all its features is never
wasted.
\par \pard \fi243 \sl-221 \tx243 The two most significant properties of an abdom
inal pain are its site and its nature. If you know about these features you have
a good chance of making the correct diagnosis.
\par \lang1033 \fs24 \f1 \b \pard \qj \sl-215 \tx204 The significance of the sit
e of abdominal pain
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The abdomen can b
e divided into three horizon\-tal zones\'97upper, central and lower; and each of
these can be divided into three regions\'97 central \fs8 \f1 \'97 \fs20 \f0 rig
ht and left lateral. The anatomical names of these nine regions are:
\par
\par \pard \qj \li578 \fi-346 \sl-221 \tx232 \tx578 (a)\tab Epigastrium and righ
t and left hypochondrium.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li7885 \sl-0 \tx7885 Abdominal pain
\plain \fs20 \lang1033 369
\par \lang1033 \fs20 \f0 \pard \li612 \fi-369 \sl-221 \tx243 \tx612 (b)\tab Umbi
lical and right and left lumbar.
\par \pard \li612 \fi-369 \sl-221 \tx243 \tx612 (c)\tab Hypogastnium and right a
nd left iliac fossa.
\par \pard \sl-221 \tx204 The localization of pain to the upper, middle and lowe
r zones is often more significant than localization to right or left, except for
the right hypochondrium and right and left iliac fossae.
\par \pard \fi209 \sl-221 \tx209 In general, colicky pain is referred to the cen
tre of the abdomen, whatever its source, as it is a visceral sensation; whereas
the pain from parietal peritonitis is felt over the inflamed area (somatic sensa
tion).
\par \pard \sl-0 \tx2965 \tab \fs18 \f1 Epigastrium
\par \pard \sl-0 \tx2965 \tab Hypochond ri urn
\par \pard \sl-0 \tx827 \tx1712 \tx2970 \tab \tab \tab Umbilical region
\par \pard \sl-0 \tx827 \tx1712 \tx2970 \tab \fs24 \f1 \b I\tab I\tab \fs18 \f1
\plain \fs18 \f1 \lang1033 Lumbar region
\par \pard \sl-0 \tx2965 \tab Hypogastrium
\par
\par
\par
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.6 \plain \fs20 \f1 \lang1033 Th
e names of the regions of the abdomen.
\par
\par
\par \fs20 \f0 \pard \sl-221 \tx204 Upper abdominal pain
\par
\par \pard \fi243 \sl-221 \tx243 Pain is most likely to come from the biliary tr
ee, stomach and duodenum, or pancreas. In general terms, and with a great deal o
f overlap, these structures produce right-sided, central and left-sided pain, re
spectively. The pain from these three sites also radiates in different direction
s.
\par
\par
\par
\par
\par \fs18 \f1 \pard \qc \sl-0 \tx243 Stomach &
\par \pard \sl-0 \tx827 \tx2965 \tab Gall bladder Duodenum\tab Pancreas
\par \lang1033 \fs20 \f0 \pard \fi209 \sl-221 \tx209 (a) Gall bladder pain may r
adiate through to the back and to the right, to reach the tip of the shoulder bl
ade; but more often it is referred to

\par
\par
\par
\par
\par \fs18 \f1 \pard \qc \sl-0 \tx209 Stomach &
\par \pard \sl-0 \tx617 \tx2823 \tab Gall bladder Duodenum\tab Pancreas
\par
\par \fs40 \f1 \pard \qc \sl-0 \tx617 \tx2823 4,
\par \pard \sl-192 \tx187 \tx1712 \tx3135 \tab \fs18 \f1 Through to the\tab Stra
ight\tab Through to\line \pard \sl-192 \tx187 \tx1712 \tx3135 \tab back \fs20 \f
1 and\tab \fs18 \f1 through\tab the back\line \pard \sl-192 \tx187 \tx1712 \tx31
35 \tab the right\tab to the back\tab and the left
\par
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.8 \plain \fs20 \f1 \lang1033 Th
e radiation of pain in the upper zones.
\par \pard \sl-0 \tx2194 \tx2823 \tab \fs8 \f5 \b -\tab \fs18 \f1 \plain \fs18 \
f1 \lang1033 -;r~-r~><~:
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.7 \plain \f
s20 \f1 \lang1033 The structures that cause pain in the upper three zones.
en
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 this area and consequently see
ms, to the pa\-tient, to be a separate and independent pain at this site.
\par \pard \qj \fi243 \sl-221 \tx243 (b) Stomach and duodenal pain goes straight
through to the back.
\par \pard \qj \fi243 \sl-221 \tx243 (c) Pancreatic pain tends to go through to
the back but to the left.
\par \pard \qj \sl-221 \tx204 Central abdominal pain
\par
\par \pard \qj \fi255 \sl-221 \tx255 This is likely to come from the small bowel
\par \pard \qj \sl-221 \tx204 and caecum, or from mid-line retroperitoneal struc
tures such as the aorta.
\par \fs20 \f1 \pard \qc \sl-0 \tx204 Small bowel
\par \pard \sl-198 \tx544 \tqdec \tx2177 \tab \tab Caeeu m\line \pard \sl-198 \t
x544 \tqdec \tx2177 \tab Kidney\tab \b 0
\par \plain \fs20 \f1 \lang1033 \pard \qc \sl-0 \tx544 \tqdec \tx2177 Retroperit
on
\par \fs18 \f1 \pard \qc \sl-0 \tx544 \tqdec \tx2177 structures
\par \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 16.9 \plain \fs20 \f1 \lang103
3 The structures that cause pain in the central three zones.
\par
\par
\par \fs20 \f0 \pard \qj \fi243 \sl-221 \tx243 Pain in the lateral zones of the
central region is most likely to come from the kidneys.
\par \pard \qj \fi243 \sl-221 \tx243 Pain from the kidney is also felt in the lo
in and may radiate down into the groin.
\par \pard \qj \fi243 \sl-221 \tx243 Small bowel pain does not usually radiate b
ut may move when somatic as well as visceral nerves become irritated.
\par \pard \qj \sl-221 \tx204 Lower abdominal pain
\par
\par \pard \qj \fi243 \sl-221 \tx243 This comes from the appendix and caecum, co
lon, bladder, uterus, ovaries and fallopian tubes.
\par \pard \qj \fi243 \sl-221 \tx243 Pain felt in the hypogastrium usually arise
s in the transverse or descending colon, bladder, uterus and adnexae. Right ilia
c fossa pain cOmes from the caecum and appendix, and left iliac fossa pain from
the sigmoid colon.

\par \fs100 \f3 \pard \qj \li3696 \sl-0 \tx3696 j
33 The structures that cause pain in the lower three zones.
\par \lang1033 \fs20 \f0 \pard \qj \li612 \fi221 \sl-221 \tx612 \tx833 Lower abd
ominal pains rarely radiate. The pain from structures deep in the pelvis may be
referred to the lower back or perineum.
\par
\par \fs24 \f1 \b \pard \qj \li640 \sl-215 \tx640 The significance of the nature
of abdominal pain
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li612 \sl-221 \tx612 It is poss
ible to subdivide almost all the painful conditions that occur within the abdome
n into two large categories: conditions associated with inflammation, and condit
ions associated with obstruction of a muscular conducting tube such as the bowel
or the ureter. Included in the latter are pains from muscular dysfunction (i.e.
dis\-orders of gastrointestinal motility such as the irritable bowel syndrome),
as opposed to true
\par \pard \qj \li612 \sl-221 \tx612 colic secondary to obstruction.
\par \fs164 \f1 \pard \qj \sl-0 \tx204 I
\par \fs20 \f0 \pard \qj \li612 \fi221 \sl-5 \tx612 \tx833 These two conditions
cause different types of pain. Inflammation, whether it be the mild
\par \pard \qj \li612 \sl-96 \tx612 inflammatory response around a chronic pepti
c ulcer or the acute response to a perforated
\par \pard \qj \li612 \sl-221 \tx612 appendix, causes a constant pain made worse
by any local or general disturbance, which per\-sists until the inflammation su
bsides. The pa\-tient describes it as \'91a pain\'92, of varying severity. Infla
mmation within the abdomen does not throb or burn in the same way that inflamma\
-tory pains often do elsewhere.
\par \pard \qj \li612 \fi221 \sl-221 \tx612 \tx833 Obstruction to a muscular con
ducting tube produces a colic. A colic is a pain which fluctu\-ates in severity
at frequent intervals and feels \'91griping\'92 in nature. Although the peaks of
pain are short and intermittent the pain seldom goes away completely between ex
acerbations.
\par \pard \qj \li612 \fi221 \sl-221 \tx612 \tx833 Prolonged obstruction to the
outflow of any hollow viscus ultimately causes distension of the viscus. This pr
oduces a constant stretching pain, different from the ache of inflammation, but
not colicky.
\par \pard \qj \li612 \fi221 \sl-221 \tx612 \tx833 A similar pain can come from
retroperitoneal conditions stretching the tissues.
\par
\par \fs24 \f1 \b \pard \qj \li640 \sl-215 \tx640 The significance of radiation
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li612 \sl-221 \tx612 When a pai
n radiates this signifies that other structures are becoming involved. For examp
le, when the pain from a duodenal ulcer radiates through to the back it indicate
s that the in\-flammation has spread beyond the duodenum into the structures of
the posterior abdominal wall, such as the pancreas. Thus radiation not only indi
cates the source of the pain but also the extent of the disease.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li4886 \sl-0 \tx4886 Conditions pre
senting with abdominal pain \plain \fs20 \lang1033 371
\par
\par \fs36 \f1 \b \pard \sl-0 \tx204 Conditions presenting with abdominal pain
\par
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 PEPTIC ULCERATION
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Benign gastric an
d duodenal ulcers are best classified together as peptic ulcers even though thei
r aetiology is different, because the subst\-ance that ultimately digests the mu
cosa and causes the ulcer is acid pepsin. Duodenal ulcer is more common than gas
tric ulcer
\par
\par
\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 History
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \sl-221 \tx204 Age. \plain \f
s20 \lang1033 The majority of patients with duodenal ulcers are between 20 and 6
0 years old.
\par \pard \qj \sl-221 \tx204 The majority of patients with gastric ulcers are b
etween 40 and 80 years old, a slightly older age group. Thus duodenal ulcers are
more com\-mon than gastric ulcers in patients under the age of 40 years.
\par \i \pard \qj \sl-221 \tx204 Sex. \plain \fs20 \lang1033 Both types of ulcer
are more common in men than women. In women the incidence of both types of ulce
r is approximately the same.
\par \i \pard \qj \sl-221 \tx204 Ethnic groups. \plain \fs20 \lang1033 The relat
ive incidence of duodenal to gastric ulcer varies throughout the world. In Great
Britain the ratio of DU to GU is approximately 2:1, whereas in the Indian sub\continent it is more than 20:1.
\par \i \pard \qj \sl-221 \tx204 Occupation. \plain \fs20 \lang1033 There is a h
igher incidence of
\par \lang1033 \pard \qj \sl-221 \tx204 peptic ulcer amongst professional men an
d ex\-ecutives, perhaps caused by the greater stresses, strains and responsibili
ties they carry.
\par \i \pard \qj \sl-221 \tx204 Symptoms. \plain \fs20 \lang1033 The main sympt
om is epigastric discomfort or pain, commonly recognized by the patient as indig
estion. It can vary from a vague and mild discomfort, which the patient ignores,
to a very severe pain that makes him lie down. The history of the pain helps to
disting\-uish the duodenal from the gastric ulcer in about half the cases. In t
he others it is not possible to make a clinical diagnosis more spe\-cific than p
eptic ulcer. (See Revision Panel 16.3.)
\par \pard \qj \sl-221 \tx204 Patients with gastric ulcers are afraid to eat bec
ause it causes pain. Patients with duodenal ulcers usually have a good appetite
and rarely lose weight because they eat frequently to re\-lieve their pain.
\par \pard \qj \sl-221 \tx204 The patient with a gastric ulcer may lose a little
weight because eating seems to cause the pain.
\par \pard \qj \fi255 \sl-221 \tx255 Acid brash, water brash and heartburn are
\par \pard \qj \sl-221 \tx204 symptoms common to both types of ulcer, but occur
slightly more often in patients with duodenal ulcers.
\par \pard \qj \fi255 \sl-221 \tx255 Vomiting relieves the pain of a gastric ulc
er
\par \pard \qj \sl-221 \tx204 and some patients force themselves to vomit after
eating to relieve symptoms. Vomiting is an
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs10 \f1 \pard \sl-0 \tx2874 \tx4586 \tx5340 \tx7409 \
tab -; Li I. \fs8 \f1 - \'97\tab -\tab \'97. - \fs10 \f1 -~ 4~\'97~\tab ~
en
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 uncommon symptom of duodenal u
lceration, unless complications supervene.
\par \pard \qj \fi255 \sl-221 \tx255 Haematemesis and melaena may complicate
\par \pard \qj \sl-221 \tx204 all forms of peptic ulcer.
\par \i \pard \qj \fi249 \sl-221 \tx249 Drugs. \plain \fs20 \lang1033 Take a car
eful drug history because many drugs irritate the gastric mucosa and exacerbate
the ulcer.
\par \i \pard \qj \fi249 \sl-221 \tx249 Social history. \plain \fs20 \lang1033 I
n past years patients with duodenal ulcers were more likely to belong to social
classes I and II, and have business and domestic worries, but these factors are
always changing.
\par \pard \qj \fi249 \sl-221 \tx249 A large proportion smoke.
\par
\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 Examination
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 General examinati
on is likely to be normal. There is usually no more than mild to moderate epigas
tric tenderness.
\par \pard \qj \fi249 \sl-221 \tx249 If there are complications such as bleeding
, pyloric stenosis, or malignant change there may be anaemia, visible peristalsi
s and a succussion splash, or wasting, respectively.
\par \pard \qj \fi249 \sl-221 \tx249 The clinical diagnosis is made from the his
\-tory and confirmed by special investigations.
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 PERFORATED PEPTIC ULCER
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 If a peptic ulcer
erodes the wall of the stomach or duodenum at a point where it is covered by vi
sceral peritoneum, the lumen of the gut be\-comes connected to the peritoneal ca
vity. The subsequent escape of gastric acid or alkaline bile into the peritoneal
cavity causes a chemical, later followed by a bacterial peritonitis, both of wh
ich are acutely painful.
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi249 \sl-221 \tx249 Age. \p
lain \fs20 \lang1033 Perforated peptic ulcers are most com\-mon between the ages
of 40 and 60 years, but can occur in the very young and the very old.
\par \pard \qj \fi249 \sl-221 \tx249 All the factors relevant to the incidence o
f peptic ulcer are obviously also applicable to the incidence of perforated ulce
rs.
\par \i \pard \qj \fi249 \sl-221 \tx249 Symptoms. \plain \fs20 \lang1033 The onl
y symptom that concerns the patient is pain. This is severe and constant. It usu
ally begins very suddenly, in the epigas\\par \lang1033 \pard \qj \sl-221 \tx204 trium, reaches its maximum intensity qui
ckly and remains severe for many hours. All move\-ments, including respiration,
make the pain worse, so the patient lies immobile on his bed.
\par \pard \qj \fi249 \sl-221 \tx249 Other gastric symptoms such as nausea and v
omiting are uncommon.
\par \i \pard \qj \fi249 \sl-221 \tx249 Previous history. \plain \fs20 \lang1033
The majority of patients give a history of indigestion or epigastric pain typic
al of a duodenal or gastric ulcer. Some patients have no history of dyspepsia. T
hey may have a perforation of an acute ulcer, a mild ulcer exacerbated by drug t
herapy, or simply just an ordinary peptic ulcer that has given no symptoms.
\par \i \pard \qj \fi249 \sl-221 \tx249 Drug history. \plain \fs20 \lang1033 It
is important to enquire whether the patient has taken any steroids or aspirin be
cause both these drugs can cause ulcers and exacerbate old ulcers to the point o
f perforation.
\par
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi249 \sl-221 \tx249 General
appearance. \plain \fs20 \lang1033 The patient looks ill, and is obviously in p
ain, lying unusually still. There is a tachycardia, and respiration is shallow,
but the temperature is normal.
\par \i \pard \qj \fi249 \sl-221 \tx249 Abdomen Inspection. \plain \fs20 \lang10
33 The abdomen is flat, and does not ri\'80e and fall with respiration. In thin
people the muscles can be seen to be contracted.
\par \i \pard \qj \fi249 \sl-221 \tx249 Palpation. \plain \fs20 \lang1033 The ab
domen is very tender and there is intense guarding, often described as board-lik
e rigidity. No intra-abdominal viscus or masses can be felt because of the guard
ing. In the early stages the tenderness and guarding may be confined to the epig
astrium and right side, but once the whole peritoneal cavity is contaminated the
full-blown clinical picture quickly appears.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 If ai
r has escaped into the pen\-toneal cavity, the area of liver dullness may be abs
ent or diminished.
\par \pard \qj \fi249 \sl-221 \tx249 Percussion is usually painful.
\par \i \pard \qj \fi249 \sl-221 \tx249 Auscultation. \plain \fs20 \lang1033 The
bowel sounds do not dis\-appear until the peritonitis is well established, 6\'9
712 hours after the onset of pain.
\par \i \pard \qj \fi249 \sl-221 \tx249 Rectal examination. \plain \fs20 \lang10
33 Movement of the finger in the pelvis causes pain.
\par \i \pard \qj \fi249 \sl-221 \tx249 BEWARE. \plain \fs20 \lang1033 The above
description applies to a perforation seen in the first 6\'9712 hours. After 4\'
976 hours the acid in the peritoneal cavity becomes diluted and the pain and gua
rding
senting with abdominal pain \plain \fs20 \lang1033 373
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 decrease. The patient thinks h
e is getting better. He is not; he is getting worse. His peritonitis is progress
ing and he is becoming hypovolaemic. The most valuable signs indicating these ci
r\-cumstances are an increasing tachycardia and absent bowel sounds.
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 CARCINOMA OF THE STOMACH
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Carcinoma of the
stomach is a common cause of death in men. Pernicious anaemia, gastric polyps an
d chronic gastric ulcers are known to be premalignant conditions, but the majori
ty of gastric cancers arise spontaneously. There is much speculation but no proo
f about the role of diet and foodstuffs in the aetiology of this condition.
\par
\par

s20 \lang1033 The incidence of gastric carcinoma reaches its peak between the ag
es of 50 and 70 years, but young adults and old men are often afflicted.
\par \i \pard \qj \sl-221 \tx204 Sex. \plain \fs20 \lang1033 Gastric cancer is t
wo to three times more common in men.
\par \i \pard \qj \sl-221 \tx204 Geography. \plain \fs20 \lang1033 There are une
xplained variations in the incidence of this disease between coun\-tries and wit
hin countries.
\par \i \pard \qj \sl-221 \tx204 Symptoms. \plain \fs20 \lang1033 The onset of i
ndigestion or epi\-gastric pain in a patient over 40 years old, however vague, s
hould always be treated very seriously. The pain may be so mild that the patient
ignores it or goes and buys himself some indigestion tablets, but antacids do n
ot relieve the pain.
\par \pard \qj \sl-221 \tx204 Many people think it is usual to have indiges\-tio
n; it is not.
\par \pard \qj \sl-221 \tx204 Unlike the indigestion and pain of a peptic ulcer,
the pain of a gastric cancer is not periodic and not solely started by eating.
It is often exacerbated by eating but can begin at any time. It is not usually r
elieved by eating or vomiting.
\par \pard \qj \fi249 \sl-221 \tx249 If the patient has had the symptoms of a be
nign gastric ulcer for many years he is usually aware that the nature of the pai
n has changed. Loss of appetite is a cardinal symptom of gastric cancer. Patient
s with benign ulcers may be frightened to eat because eating causes pain
\par \lang1033 \pard \qj \sl-221 \tx204 but they still want to eat. Patients wit
h stomach cancer do not want to eat.
\par \pard \qj \sl-221 \tx204 The inevitable consequence of the loss of appetite
is loss of weight. The patient may lose 10\'9720 kg in 1\'972 months. The loss
of appetite and weight may occur long before any other symp\-toms appear to indi
cate the site of the tumour.
\par \pard \qj \sl-221 \tx204 Carcinomata near the cardia may cause oesophagogas
tric obstruction. The patient may complain of difficulty in swallowing because h
e feels the food sticking behind the lower ster\-num. As the dysphagia increases
, food may be regurgitated from the oesophagus.
\par \pard \qj \sl-221 \tx204 Cancer of the pylorus often obstructs the outflow
tract of the stomach. The patient then has the symptoms of pyloric stenosis \fs8
\f1 \'97 \fs20 \f0 the vomiting of large quantities of undigested food, epigast
ric discomfort and distension. Eructa\-tions of gas may be frequent and foul sme
lling.
\par \pard \qj \sl-221 \tx204 Some cancers grow to a considerable size without p
roducing symptoms except mild weight loss. An unsuspecting patient may accidenta
lly feel his epigastric mass or enlarged liver and present with this finding as
his main complaint.
\par \i \pard \qj \sl-221 \tx204 Systematic questions. \plain \fs20 \lang1033 Th
e systematic review of the other systems may reveal evidence of distant metastas
es, such as weakness and tired\-ness; dyspnoea and chest pains from pulmon\-ary
and pleural deposits; and neurological dis\-turbances from cerebral secondaries
and peripheral neuritis.
33 Some cancers of the stomach may
\par \pard \qj \sl-198 \tx204 present as a palpable mass in the epigastrium but
the majority are impalpable.
en
\par \lang1033 \fs20 \f0 \pard \qj \fi209 \sl-221 \tx209 Cancer of the stomach i
s one of the tumours that sometimes presents with recurrent super\-ficial thromb
ophlebitis.
\par \i \pard \qj \sl-221 \tx204 Previous history. \plain \fs20 \lang1033 The pa
tient may have a long history of benign gastric ulceration, or have had an ulcer
some years ago which was \'91cured\'92 with medicine.

\par \pard \qj \sl-221 \tx204 He may know that he has pernicious anaemia and be
taking vitamin B\sub 12\plain \fs20 \lang1033 .
\par
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \sl-221 \tx204 General appear
ance. \plain \fs20 \lang1033 The most noticeable fea\-tures are wasting and pall
or. The wasting is obvious in the face and hands. The anaemia may be caused by c
hronic bleeding from the carcinoma or lack of protein and iron in the diet.
\par \pard \qj \fi232 \sl-221 \tx232 Many patients present at an advanced stage
when multiple hepatic metastases have affected liver function, or metastases in
the lymph nodes around the porta hepatis have caused biliary obstruction. The re
sulting jaundice is at first mild and may be difficult to detect.
\par \i \pard \qj \fi232 \sl-221 \tx232 The neck. \plain \fs20 \lang1033 Feel th
e supraclavicular fossae with great care. Secondary deposits in the sup\-raclavi
cular nodes are common. A palpable left supraclavicular node is often called Vir
chow\'92s node, or its presence referred to as Troisier\'92s sign.
\par \i \pard \qj \fi209 \sl-221 \tx209 The lungs. \plain \fs20 \lang1033 If the
tumour has spread to the lungs there may be pleural effusions. Direct spread of
the tumour through the left side of the diaphragm will cause a left-sided effus
ion and basal consolidation.
\par \lang1033 \i \pard \qj \sl-221 \tx1326 Abdomen:\tab Inspection. \plain \fs2
0 \lang1033 The abdomen is scaphoid and the skin wrinkled and inelastic.
\par \pard \qj \fi249 \sl-221 \tx249 Paradoxically, there may be generalized abd
o\-minal distension if there is ascites.
\par \pard \qj \fi249 \sl-221 \tx249 There may be epigastric distension and visi
\-ble peristalsis if there is pyloric obstruction, or an irregular fullness in t
he epigastrium which moves with respiration.
\par \pard \qj \fi209 \sl-221 \tx209 These physical signs can only be seen in ve
ry thin patients; in the majority the mass is too high and too deep to be seen.
\par \i \pard \qj \fi232 \sl-221 \tx232 Palpation. \plain \fs20 \lang1033 In the
majority of patients the only physical sign will be epigastric tenderness. Deep
palpation at full inspiration may reveal an epigastric mass.
\par \pard \qj \fi232 \sl-221 \tx232 In a thin patient with advanced disease the
re may be a hard, irregular, dull epigastric mass which moves with respiration.
The liver may be palpable, and its edge and surface knobbly and irregular.
\par \pard \qj \sl-221 \tx204 If there is pyloric obstruction the epigastrium ma
y be distended but soft and there may be a succussion splash.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 Percu
ss the whole abdomen with care, not only to delineate any palpable masses, but a
lso to see if there is shifting dullness in the flanks, caused by ascites.
bowel sounds should be normal.
33 Metastatic nodules may be felt in the pelvis. The ovaries may be en\-larged b
y secondary deposits (Krukenberg\'92s tumours).
\par \i \pard \qj \sl-221 \tx204 The Limbs. \plain \fs20 \lang1033 Look for evid
ence of superficial thrombophlebitis and peripheral neuropathy.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 The biliary tree
\par
\par \fs24 \f1 \plain \f1 \lang1033 \b \pard \sl-0 \tx204 CHRONIC CHOLECYSTITIS
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Chronic or recurrent infection in
the gall blad\-der is commonly associated with gallstones. Indeed in some instan
ces the gallstone may \i precede \plain \fs20 \lang1033 the infection.
\par \pard \sl-221 \tx204 The combination of infection and stones may present a
variety of clinical pictures: indigestion
\par \lang1033 \pard \qj \sl-221 \tx204 (flatulent dyspepsia, chronic cholecysti
tis), acute pain (acute cholecystitis), gallstone colic, obstructive jaundice an
d less common presenta\-tions such as ascending cholangitis, pancreatitis and in
testinal obstruction. All these presenta\-tions may be associated with abdominal
pain.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li7885 \sl-0 \tx7885 The biliary tr
ee \plain \fs20 \lang1033 375
\par \lang1033 \fs20 \f0 \fs22 \f1 \i \pard \qj \sl-0 \tx204 History
\par
s20 \lang1033 Gallstones can form at all ages. The majority of patients with sym
ptoms are be\-tween 30 and 60 years old, but you will see a number of young wome
n between the ages of 15 and 25 years with gallstone symptoms.
\par \i \pard \qj \sl-221 \tx204 Sex. \plain \fs20 \lang1033 Gallstones and thei
r complications are far more common in women.
\par \i \pard \qj \sl-221 \tx204 Ethnic group. \plain \fs20 \lang1033 Some races
, such as the North American Indian, are particularly liable to de\-velop gallst
ones.
\par \i \pard \qj \fi255 \sl-221 \tx255 Symptoms. \plain \fs20 \lang1033 The com
mon complaint is in\-digestion or pain after eating, but not so closely related
to eating as the symptoms of peptic ulcer. The pain begins gradually 15\'9730 mi
nutes after the meal and lasts for 30\'9790 minutes. It is not relieved by anyth
ing except analgesic drugs.
\par \pard \qj \sl-221 \tx204 The patient often notices that the pain is worse a
fter eating fatty foods.
\par \pard \qj \sl-221 \tx204 The attacks of pain are irregular, lasting for wee
ks or months, with pain-free intervals of varying length.
\par \pard \qj \sl-221 \tx204 There is often postprandial belching, hence the de
scription \'91flatulent dyspepsia\'92.
\par \pard \qj \sl-221 \tx204 The patient\'92s appetite remains good and her wei
ght is steady, or increases.
\par \pard \qj \sl-221 \tx204 Nausea and vomiting are uncommon but the patient m
ay develop an intense distaste for fatty foods, akin to nausea.
\par \i \pard \qj \sl-221 \tx204 Previous history. \plain \fs20 \lang1033 Apart
from previous epi\-sodes of dyspepsia the patient may have been jaundiced or not
iced that her stool was pale, offensive and floated on the water in the lava\-to
ry pan.
\par
\par
\par
\par
appearance. \plain \fs20 \lang1033 It is the firm belief of all medical student
s that almost every patient with gallstones is female, fair, fat, fertile and fo
rty.
\par \pard \qj \sl-221 \tx204 Many are, but enough are male, thin, dark and of a
ny age to make one pay scant attention to the five \'91Fs\'92 as an aid to diagn
osis.
\par \pard \qj \fi249 \sl-221 \tx249 The skin should be normal colour, but might
be yellow if the patient has obstructive jaundice as well as chronic cholecysti
tis.
\par \i \pard \qj \sl-221 \tx1122 Abdomen:\tab Inspection. \plain \fs20 \lang103
3 The abdomen usually looks normal.
\par \i \pard \qj \fi249 \sl-221 \tx249 Palpation. \plain \fs20 \lang1033 The pa
tient is tender in the right hypochondrium, just below the tip of the 9th rib wh
ere the edge of the rectus abdominis muscle
\par \lang1033 \pard \qj \sl-221 \tx204 crosses the costal margin. It maybe nece
ssary to palpate deeply beneath the costal margin, as the patient takes a deep b
reath, to detect mild tenderness. If the tenderness is acute the right rectus mu
scle will be tense.
\par \pard \qj \fi249 \sl-221 \tx249 There should be no masses in the abdomen ex
cept when the chronic infection is associated with a stone obstructing the cysti
c duct and has consequently caused the development of a mucocele, empyema or chr
onic inflammatory mass.
\par \i \pard \qj \fi209 \sl-221 \tx209 Percussion, auscultation and rectal exam
ina\-tion. \plain \fs20 \lang1033 These should all be normal.
\par \pard \qj \sl-221 \tx204 The diagnosis of chronic cholecystitis is usually
based on the history and special investigations. The clinical signs are minimal
and usually not much help.
\par
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE CHOLECYSTITIS
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Acute inflammatio
n of the gall bladder is com\-monly caused by obstruction of the cystic duct by
a small stone, with proximal distension, stasis and secondary infection.
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi209 \sl-221 \tx209 Age, se
x and ethnic group. \plain \fs20 \lang1033 These factors are similar to those de
scribed for chronic cholecys\-titis.
\par \i \pard \qj \fi249 \sl-221 \tx249 Symptoms. \plain \fs20 \lang1033 The mai
n symptom is pain. It may be of sudden onset or superimposed on the pain of chro
nic cholecystitis. It is felt in the right hypochondrium and often radiates thro
ugh the trunk to the tip of the right shoulder blade.
\par \pard \qj \fi249 \sl-221 \tx249 The pain is continuous and is exacerbated b
y movement and breathing. Nothing except analgesic drugs relieves it. The patien
t often recognizes it as a severe version of her chronic indigestion pain.
\par \pard \qj \fi249 \sl-221 \tx249 The patient always feels nauseated and ofte
n vomits. The abdomen often feels distended.
\par \pard \qj \fi249 \sl-221 \tx249 The appetite is completely lost, but the bo
wel habit is unchanged.
There may be a history of flatulent dyspepsia, other acute attacks, or jaun\-di
ce.
\par \lang1033 \fs20 \f0 \pard \sl-0 \tqr \tx493 I\tab \i i
\par \plain \fs20 \lang1033 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 376
\i The Abdomen
\par \lang1033 \fs20 \f0 \fs22 \f1 \i \pard \qj \sl-0 \tx204 Examination
\par
appearance. \plain \fs20 \lang1033 The patient is distressed by the pain and li
es quietly, breathing shallow\-ly. She may be sweating. There is a tachycardia (
90-100 beats/mn) and a pyrexia 38\'9739\super 0\plain \fs20 \lang1033 C (100\'97
102\super 0\plain \fs20 \lang1033 F). There may be rigors.
\par \i \pard \qj \sl-221 \tx204 Abdomen: Inspection. \plain \fs20 \lang1033 The
movement of the abdomen with respiration is diminished.
\par \i \pard \qj \fi255 \sl-221 \tx255 Palpation. \plain \fs20 \lang1033 There
is tenderness and guarding in the right hypochondrium. If the patient is asked t
o take a deep breath while you are palpating the tender area, the downward move\
-ment of the gall bladder striking the palpating hand may cause a sharp pain tha
t prevents further inspiration. This is called Murphy\'92s sign. In severe cases
there may be an inflamma\-tory mass around the gall bladder which can be felt,
through the guarding, as a soft indistinct mass bulging down below the edge of t
he liver. It is exquisitely tender and moves a little with respiration. It can b
e so large that it reaches down to the level of the umbilicus.
\par \pard \qj \fi249 \sl-221 \tx249 When the pain radiates through to the tip o
f the scapula there may be an area of skin below the scapula which is hyperaesth
etic. This is called Boas\'92 sign.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 An in
flammatory mass may be detectable by percussion when guarding pre\-vents its pal
pation.
bowel sounds should be present unless the infection has spread beyond the gall
bladder to cause a general peritonitis.
33 The rectum and contents of the pelvis are normal.
\par \lang1033 \pard \sl-221 \tx204 The diagnosis of acute cholecystitis is
\par \pard \sl-221 \tx204 upon the site and nature of the pain, tachycardia and
tenderness in the hypochondrium.
\par \lang1033 \pard \sl-221 \tx204 based
\par \pard \sl-221 \tx204 fever, right
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx204 GALLSTONE COLIC (BILIARY PAIN
)
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 scribes
it as a griping pain. The common bile duct has very little smooth muscle in its
wall and probably cannot be the source of a severe colicky pain.
\par \pard \qj \fi249 \sl-221 \tx249 About one-fifth of the patients who present
with biliary colic become jaundiced.
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi249 \sl-221 \tx249 Symptom
s. \plain \fs20 \lang1033 Gallstone colic begins suddenly across the upper abdom
en. The patient is often unable to indicate which side of the abdomen is most af
fected. It is a very severe, constant pain, with excruciating exacerbations. Gal
lstone colic is not a true colic. The patient describes it as a severe pain, not
griping in nature, which does not remit between exacerbations. In spite of thes
e facts, the pain is by common usage called gallstone, or biliary colic because
its different features help differentiate it from the pains of acute and chronic
cholecystitis.
\par \pard \qj \fi249 \sl-221 \tx249 The severe pain seldom lasts longer than 2
hours. Nothing, except strong analgesia, re\-lieves it.
\par \pard \qj \fi249 \sl-221 \tx249 There is often nausea and occasional vomiti
ng.
Many patients give a history of flatulent dyspepsia, previous less severe epi\sodes of biliary colic, and jaundice.
\par
\par
appearance. \plain \fs20 \lang1033 The patient is frightened and made restless
by the intensity of the pain and so has a mild tachycardia, but in the early sta
ges the temperature is normal. There may be the beginning of a tinge of jaundice
.
\par \i \pard \qj \fi249 \sl-221 \tx249 Abdomen. \plain \fs20 \lang1033 The abdo
men is often too tender to allow deep palpation. Even when the patient lies quie
tly enough to be examined there is intense guarding in the upper abdomen.
\par \pard \qj \fi249 \sl-221 \tx249 The rectum and pelvis are normal.
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 OBSTRUCTIVE JAUNDICE
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-0 \tx204
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Gallstone colic is a severe pain c
aused by spasm of the gall bladder as it tries to force a stone down the cystic
duct. It is called a colic because it is intermittent but the patient seldom de\
\par \lang1033 \pard \sl-221 \tx204 The differential diagnosis of jaundice is di
scus\-sed in Chapter 8, page 195, but is mentioned here because it is such an im
portant symptom of biliary tract disease.
\par \lang1033 \fs20 \f0 \pard \fi232 \sl-221 \tx232 The principal features of j
aundice caused by gallstones are:
\par \pard \fi249 \sl-221 \tx249 A history of dyspepsia, pain or biliary colic.
No premonitory period of malaise and loss of
\par \pard \fi243 \sl-221 \tx243 appetite.
\par \pard \li232 \fi-232 \sl-221 \tx232 3.\tab A sudden onset.
\par \pard \li232 \fi-232 \sl-221 \tx232 4.\tab A simultaneous appearance of pal
e faeces and dark urine.
\par \pard \li232 \fi-232 \sl-221 \tx232 5.\tab Itching of the skin.
\par \pard \sl-221 \tx204 These are the features that help to differentiate obst
ructive from hepatic. and prehepatic jaun\-dice.
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 ACUTE PANCREATITIS
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \li776 \sl-0 \tx776 1.
\par \pard \li657 \sl-0 \tx657 2.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs22 \f1 \i \pard \li839 \sl-0 \tx839 History
\par
\par
\par
\par
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 f
\par \lang1033 \pard \qj \sl-221 \tx204 Acute pancreatitis is a condition in whi
ch acti\-vated pancreatic enzymes leak into the subst\-ance of the pancreas and
initiate the autodiges\-hon of the gland. One obvious cause of such an event is
obstruction of the pancreatic duct, but pancreatitis is also commonly associated
with the ingestion of alcohol, virus infections and trauma. The mechanism by wh
ich alcohol causes pancreatitis is not known, but it is a serious problem in cou
ntries with a high inci\-dence of alcoholism.
\par \pard \qj \sl-221 \tx204 One-third of the cases of pancreatitis have no ass
ociation with alcohol, no biliary tract disease and no pancreatic duct obstructi
on. These cases are labelled idiopathic pancreatitis; one day we may understand
their aetiology.
\par \pard \qj \sl-221 \tx204 Pancreatitis can vary from a very mild in\-flammat
ion to an acute haemorrhagic destruc\-hon of the whole gland which is fatal in 5
0 per cent of cases.
\par \lang1033 \i \pard \qj \sl-221 \tx204 Sex. \plain \fs20 \lang1033 Pancreati
tis occurs ~qually in men and women, in spite of the comni~rn association with g
allstones which are more common in females. \i Age. \plain \fs20 \lang1033 The p
eak incidence is in the fourth and fifth decades of life but pancreatitis can oc
cur at any age.
\par \i \pard \qj \sl-221 \tx204 Symptoms. \plain \fs20 \lang1033 The common pre
senting symp\-tom is pain. It begins suddenly, high in the epigastrium, and stea
dily increases in severity until it is very severe and makes the patient lie sti
ll and breathe shallowly.
\par \lang1033 \pard \qj \fi249 \sl-221 \tx249 Nothing relieves it. Movements ex
acerbate it. It may radiate through to the back, a little to the left of the mid
-line.
\par \pard \qj \fi249 \sl-221 \tx249 Frequent vomiting and retching are common s
ymptoms. Most acute abdominal conditions cause nausea and an occasional vomit. P
an\-creatitis is usually associated with frequent vomiting and retching. This is
a very important and valuable clue when considering the di\-agnosis.
\par \pard \qj \fi249 \sl-221 \tx249 There is persistent nausea between the bout
s of vomiting but the patient is not nauseated before the attack begins.
\par \pard \qj \fi249 \sl-221 \tx249 Many patients have eaten an unusually large
meal or drunk some alcohol an hour or so before the pain began.
\par \pard \qj \fi249 \sl-221 \tx249 When the pain is severe, any movement of th
e lower chest wall and abdomen causes more pain. This makes the patient breathe
rapidly and shallowly and he may complain of difficulty with breathing (dyspnoea
).
\par \pard \qj \fi249 \sl-221 \tx249 In severe and advanced pancreatitis the pa\
-tient may notice muscle twitches, cramps and spasms. This is tetany and is caus
ed by the hypocalcaemia which develops if there is exten\-sive intra-abdominal f
at necrosis.
In Great Britain nearly half of the patients who present with pancreatitis have
biliary tract disease. Thus there is a high possibility that the patient will h
ave a history of flatulent dyspepsia or other gall bladder symp\-toms.
\par \i \pard \qj \fi249 \sl-221 \tx249 Social history. \plain \fs20 \lang1033 T
ake a careful history of the patient\'92s alcohol intake. If in doubt ask a rela
\-tive. Some alcoholics will not reveal the true extent of their drinking habits
.
\par \pard \qj \fi249 \sl-221 \tx249 Also ask about any contact, within and with
\-out the family, with mumps.
\par
\par
\par
\par
appearance. \plain \fs20 \lang1033 The severity of the pain makes the patient l
ie still and causes fear and worry.
\par \pard \qj \fi232 \sl-221 \tx232 As the condition progresses the patient be\
-comes hypovolaemic. This makes him pale and sweaty. If the pain is interfering
with respiration he may be dyspnoeic and cyanosed, or grey and very apprehensive
.
\par \pard \qj \fi232 \sl-221 \tx232 The sclera may reveal a slight tinge of jau
n\-dice if the pancreatitis is secondary to a stone in
\par \lang1033 \fs8 \f5 \b \pard \sl-0 \tx3016 \tqr \tx5935 - - \fs8 \f1 \plain
\fs8 \f1 \lang1033 S 2~ \fs10 \f0 \b ~ \fs8 \f5 \plain \fs8 \f5 \lang1033 \b -;
\fs10 \f1 \plain \fs10 \f1 \lang1033 .. \fs8 \f5 \b fl \'97 -\tab -t \fs8 \f1 \p
lain \fs8 \f1 \lang1033 ~ \fs8 \f5 \b .\tab \fs8 \f1 \plain \fs8 \f1 \lang1033 ~ \fs14 \f1 ~V~1T~~Uu
en
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 the lower end of the bile duct
. This is rare. Mild jaundice may appear on the second or third day of the illne
ss if the oedema in the head of the pancreas compresses the bile duct.
\par \i \pard \qj \sl-221 \tx204 Abdomen: Inspection. \plain \fs20 \lang1033 If
the pain is severe the tone of the abdominal muscles will be increased and preve
nt the abdomen moving with respira\-tion.
\par \pard \qj \fi249 \sl-221 \tx249 A paralytic ileus may develop, causing mild
abdominal distension.
\par \pard \qj \fi249 \sl-221 \tx249 Severe, advanced cases may develop bruising
and discoloration in the left flank (Grey Turner\'92s sign) and around the umbi
licus (Cullen\'92s sign). These are rare and late signs of extensive des\-tructi
on of the pancreas.
\par \i \pard \qj \fi249 \sl-221 \tx249 Palpation. \plain \fs20 \lang1033 After
listening to the patient\'92s de\-scription of his symptoms you will expect to f
ind a very tender, rigid abdomen, but in fact excessive guarding is unusual beca
use the peri\-tonitis is caused by a chemical irritation and is not severe.
\par \pard \qj \fi249 \sl-221 \tx249 There is always tenderness and guarding in
the upper abdomen, but the guarding is never as intense as you expect. Thus in a
ny patient with severe pain but surprisingly weak abdo\-minal signs, think of pa
ncreatitis.
\par \pard \qj \fi249 \sl-221 \tx249 If there is a collection of inflammatory ex

\-udate in the lesser sac, there may be epigastric fullness which may over the f
ollowing 5 to 10 days become more prominent if it turns into a pseudocyst or les
ser sac abscess.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 The a
bdomen is slightly dis\-tended and resonant with gas collecting in the bowel as
the paralytic ileus develops. A pseudo-cyst in the epigastrium will be dull to p
ercus\-sion.
bowel sounds will be pre\-sent in the first 12\'9724 hours of the disease but d
isappear when the bowel movement becomes paralysed.
\par \pard \qj \sl-221 \tx204 Pancreatitis is diagnosed on the history and exami
nation. Measurements of the serum amy\-lase can be misleading and should only be
used to confirm your clinical suspicions.
\par \pard \qj \fi249 \sl-221 \tx249 Pancreatitis can be extremely difficult to
di\-agnose and, as it has no distinctive clinical features, is often forgotten a
nd missed. Whenever you see an acute abdomen remember to ask yourself, \'91Could
it be pancreatitis, a mesenteric vascular accident, or a leaking aneurysm?\'92.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx249 ABDOMINAL AORTIC ANEURYSM
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Remember that the
aorta lies on the posterior abdominal wall, in the upper half of the abdo\-men,
and can cause abdominal pain.
\par \pard \qj \fi249 \sl-221 \tx249 The pain may come from the wall of a stretc
h\-ing or rupturing fusiform aneurysm, or from a circumferential split in the wa
ll of the aorta, an aortic dissection. Fusiform aneurysms common\-ly begin just
below the renal arteries. Aortic dissections begin in the arch of the aorta but
can extend down as far as the femoral arteries. Aneurysms caused by atherosclero
sis rarely dis\-sect; they just leak or rupture. \{
\par \pard \qj \fi249 \sl-221 \tx249 When an aneurysm has leaked or ri~ptured th
e patient has the general signs of n~assive blood loss \fs8 \f1 \'97 \fs20 \f0 p
allor, sweating, stertorous breath\-ing, tachycardia and hypotension, together w
ith abdominal tenderness and guarding. The aneurysm is palpable but the reduced
blood pressure and the haematoma make it less clearly defined. Some of the mass
may be haematoma and not pulsate.
\par \pard \qj \fi249 \sl-221 \tx249 The femoral pulses are usually present but
weak.
\par
\par
lain \fs20 \lang1033 Abdominal aneurysms become more frequent with increasing ag
e. The majority of patients are more than 60 years old.
\par \i \pard \qj \fi249 \sl-221 \tx249 Sex. \plain \fs20 \lang1033 Aneurysms ar
e less common in women. \i Symptoms. \plain \fs20 \lang1033 The common symptom i
s an aching pain in the epigastrium and central abdomen. It is a persistent pain
, present throughout the day and less noticeable when resting at night but not r
elieved or exacerbated by anything. The patient often thinks that he has indiges
tion even though his pain has no relation to eating.
\par \pard \qj \fi249 \sl-221 \tx249 The abdominal pain is often associated with
backache. Sometimes backache is the only symptom and it may radiate down to the
but\-tock or leg and be mista en for sciatica.
\par \pard \qj \fi249 \sl-221 \tx249 If the aneurysm~pThrges, leaks or ruptures
the patient experiences a severe abdominal pain. This pain is constant, in the c
entre of the abdomen, and radiates through to the back.
\par \pard \qj \fi249 \sl-221 \tx249 The patient may feel a pulsatile mass in hi
s abdomen or just be aware of a throbbing or pulsating sensation in his abdomen.
\par \pard \qj \fi249 \sl-221 \tx249 Other symptoms, caused by complications
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 such as arterial emboli and th
rombosis, present as vascular problems and are described in Chap\-ter 7.
\par \i \pard \qj \fi209 \sl-221 \tx209 Systematic questions. \plain \fs20 \lang
1033 The direct questions often reveal the presence of other cardiovascu\-lar sy
mptoms such as angina pectoris, intermit\-tent claudication and the aftermath of
previous strokes.
\par \i \pard \qj \sl-221 \tx204 Previous history. \plain \fs20 \lang1033 The pa
tient may have had other aneurysms treated, and may have had previous myocardial
and cerebral infarctions.
\par \i \pard \qj \sl-221 \tx204 Family history. \plain \fs20 \lang1033 Arterial
disease is often fami\-lial.
\par
\par
\par
appearance. \plain \fs20 \lang1033 There is no special facies associated with a
therosclerotic vascular disease. Many patients are fat but a significant number
are thin and have xanthomata and arcus senilis.
\par \i \pard \qj \sl-221 \tx204 Neck. \plain \fs20 \lang1033 There may be bruit
s over the carotid arteries.
\par \i \pard \qj \sl-221 \tx204 Heart. \plain \fs20 \lang1033 The blood pressur
e is often elevated and the heart slightly enlarged.
\par \i \pard \qj \fi209 \sl-221 \tx209 Abdomen: Inspection. \plain \fs20 \lang1
033 A pulsation may be visi\-ble in the epigastrium or umbilical region. If the
aneurysm is large it will be visible as a pulsating mass.
\par \i \pard \qj \fi255 \sl-221 \tx255 Palpation. \plain \fs20 \lang1033 If the
aneurysm is causing pain it will be tender to firm pressure but there will
\par \fs20 \f1 \b \pard \qj \sl-198 \tx204 FIgure 16.12 \plain \fs20 \f1 \lang10
33 An abdominal aortic aneurysm. The femoral pulses are usually palpable.
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 only be guarding and generaliz
ed tenderness if the aneurysm has leaked.
\par \pard \qj \fi255 \sl-221 \tx255 The mass is usually fusiform. If the iliac
arteries are involved it may feel bibbed.
\par \pard \qj \fi249 \sl-221 \tx249 The mass has an expansile pulsation. Put yo
ur hands on either side of the mass and make quite sure that they are being push
ed apart, not up and down. Many carcinomata present with vague abdominal pain an
d an epigastric mass which transmits aortic pulsations. You may diagnose an aneu
rysm only if you can feel an expansile pulse.
\par \pard \qj \fi249 \sl-221 \tx249 Abdominal aortic aneurysms are tethered abo
ve and below by the renal and iliac arter~es. As the artery distends and elongat
es it arch~s forwards. This means that aneurysms can ofte~i be moved from side t
o side but not up and down.
\par \pard \qj \fi249 \sl-221 \tx249 If you can feel the upper limit of the aneu
rysm it must begin below the origin of the renal arteries.
\par \pard \qj \fi249 \sl-221 \tx249 The femoral pulses and the limb pulses are
usually present. Indeed these vessels often feel dilated and may be aneurysmal.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 The a
neurysm will be dull to percussion if it is large enough to displace the bowel l
aterally and reach the anterior abdomin\-al wall.
re are often bruits over aneurysms caused by stenoses at their ends.
33 This may reveal pulsatile aneurysmal internal iliac arteries.
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 RENAL PAIN
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The symptoms and
signs of urinary tract disease are discussed in Chapter 17.
\par \pard \qj \fi249 \sl-221 \tx249 Pain from the kidneys is felt mainly in the
loins, but it may radiate anteriorly to the lumbar regions and cause the patien
t to complain of abdominal pain.
\par \pard \qj \fi249 \sl-221 \tx249 When a patient complains of a kidney pain h
e usually puts his hands on his waist, thumb forwards and fingers spreading back
wards be\-tween the 12th rib and the iliac crest. Such a demonstration by the pa
tient of the site of his pain is almost diagnostic of renal pain.
\par \pard \qj \fi249 \sl-221 \tx249 Renal pain is constant, aching or severe, r
e\-lieved only by analgesic drugs, and exacerbated by movement.
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 380 \i The Abdomen
\par \lang1033 \fs20 \f0 \pard \qj \fi249 \sl-221 \tx249 It does not usually rad
iate unless it is ureteric colic (see page 404).
\par \pard \qj \fi249 \sl-221 \tx249 It is important to ascertain the exact site
of the pain by asking the patient to point to it, and then palpate the area for
tenderness.
\par \pard \qj \fi249 \sl-221 \tx249 It is easier to feel the renal angle with t
he patient sitting up and leaning slightly forwards. If the pain is severe he ma
y be unwilling to do this and you will have to get him to roll over on his side.
\par \pard \qj \sl-221 \tx204 Palpation of the abdomen, especially the kid\-ney
area, is essential. The kidneys may be tender or enlarged.
\par \fs100 \f3 \pard \qj \li2959 \fi-692 \sl-0 \tx2267 \tx2959 /\tab /
33 The renal angle is between the 12th rib and the edges of the erector spinae m
uscle.
\par
\par
\par
\par
\par \fs20 \f0 \pard \qj \fi249 \sl-221 \tx249 Make sure that the bladder is not
enlarged.
\par \pard \qj \fi249 \sl-221 \tx249 Examination of the external genitalia and a
rectal examination are mandatory as these organs may be affected by the same di
sease process that is causing the renal pain.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE APPENDICITIS
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Acute appendiciti
s is one of the commonest causes of an acute abdomen in the Western world. In 9
cases out of 10 the infection develops in the appendix because its lumen is obst
ructed by a faecolith or a lesion in the caecum such as a carcinoma.
\par \lang1033 \fs22 \f1 \i \pard \qj \sl-0 \tx204 History
\par
lain \fs20 \lang1033 Appendicitis can, and does, occur at all ages.
\par \i \pard \qj \sl-221 \tx204 Sex. \plain \fs20 \lang1033 There is no differe
nce in incidence be\-tween the two sexes.
\par \i \pard \qj \fi209 \sl-221 \tx209 Race, diet and social status. \plain \fs
20 \lang1033 These factors may be associated with the incidence of appendicitis,
but their role is not yet clearly defined.
\par \i \pard \qj \sl-221 \tx204 Symptoms. \plain \fs20 \lang1033 The principal
symptom is pain. It commonly begins as a vague, central abdominal pain often tho
ught to be indigestion, and ignored. After a varying period, usually a few hours
but sometimes 2 or 3 days, the pain shifts to the right iliac fossa and becomes
intense.
\par \pard \qj \fi249 \sl-221 \tx249 Such a history is almost diagnostic of appe
n\-dicitis but it only occurs in about half of tl~ patients. The other half pres
ent a variety of patterns of pain. It may begin and remain in th~ right iliac fo
ssa, or may be felt only in the centre of the abdomen. There may be pain in both
places simultaneously and a few unfortunate patients have no pain at all.
\par \pard \qj \fi249 \sl-221 \tx249 The central pain is a referred pain. The vi
scer\-al innervation of the appendix comes from the 10th thoracic spinal segment
; the corresponding dermatome encircles the abdomen at the umbili\-cus. If the v
isceral innervation is higher the mid-line pain will be higher. Some patients ha
ve retrosternal pain that shifts to the iliac fossa. Therefore the important fea
ture of the initial pain is its central location, not its precise level.
\par \pard \qj \fi232 \sl-221 \tx232 Acute appendicitis may also present with co
lic and abdominal distention if part of the small bowel becomes involved in the
inflamma\-tory process.
\par \pard \qj \fi232 \sl-221 \tx232 If the inflammation has spread to the bladd
er or large bowel the patient may present with misleading bladder or large bowel
symptoms.
\par \pard \qj \fi249 \sl-221 \tx249 There is a loss of appetite which precedes
the pain by a few hours.
\par \pard \qj \fi249 \sl-221 \tx249 Most patients feel slightly nauseated. Fre\
-quent vomiting is uncommon but many patients vomit once or twice.
\par \pard \qj \fi249 \sl-221 \tx249 The majority of patients with appendicitis
state that they have been constipate for a few days before the attack of pain, f
ew have diarrhoea, and this may lead to a mistaken diagnosis of gastro-enteritis
, ecially in chil\-dren.
\par \pard \qj \fi232 \sl-221 \tx232 If the initial stages of the disease are si
lent the patient may present with the symptoms of general peritonitis: generaliz
ed abdominal pain,
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 nausea and vomiting, sweating
and sometimes rigors.
\par
\par
\par
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \sl-221 \tx204 General appear
ance. \plain \fs20 \lang1033 Children with appendici\-tis often look pale and ha
ve flushed cheeks. Their skin feels hot but pyrexia is not a feature of appendic
itis; the oral temperature is seldom above 38\super 0\plain \fs20 \lang1033 C (l
OOT).
\par \pard \qj \sl-221 \tx204 The tongue is white and furred and there is a dist
inctive foetor otis.
\par \pard \qj \fi232 \sl-221 \tx232 The pulse rate is elevated by 10 or 20 beat
s! minute, a change which increases as the infec\-tion spreads.
\par \i \pard \qj \sl-221 \tx204 Neck. \plain \fs20 \lang1033 Palpate the neck g
lands and look at the tonsils. If they are enlarged the diagnosis may be mesente
ric adenitis, not appendicitis.
\par \i \pard \qj \sl-221 \tx204 Chest. \plain \fs20 \lang1033 Examine the lungs
carefully. A right-sided basal pneumonia can cause right-sided abdominal pain a
nd mimic appendicitis, espe\-cially in children.
abdomen looks normal, and moves gently with respiration. If the appendix is lyi
ng upon and irritating the psoas major muscle the right hip may be kept slightly
flexed. Coughing and sudden move\-ments cause pain.
\par \i \pard \qj \sl-221 \tx204 Palpation. \plain \fs20 \lang1033 The right ili
ac fossa is tender and the overlying muscles guard.
\par \pard \qj \sl-221 \tx204 Palpate the tender area very carefully because the
re may be an underlying inflammatory mass. Three other physical signs will indic
ate the degree of tenderness and thus the severity of the peritonitis:
\par
\par \pard \qj \sl-221 \tx555 1.\tab There may be release (rebound) tenderness i
n the right iliac fossa.
\par \pard \qj \sl-221 \tx555 2.\tab Pressure on the left ilia~ fossa may cause
pain on the right.
\par \pard \qj \li232 \fi-232 \sl-221 \tx232 \tx578 3.\tab Release of pressure o
n the left may cause pain on the right.
\par \pard \qj \sl-221 \tx204 All these manoeuvres cause pain because they move
the appendix, as it lies in the right iliac fossa, by varying degrees and so ind
icate the extent of its inflammation.
\par \pard \qj \sl-221 \tx204 When the appendix is retrocaecal the tender\-ness
may be well out in the lateral part of the
\par \pard \qj \fi283 \sl-221 \tx283 lumbar region.
\par
\par
\par
\par
\par \fs30 \f3 \pard \qj \sl-0 \tx204 4
\par \lang1033 \fs20 \f0 \pard \qj \fi249 \sl-221 \tx249 A subhepatic appendix p
roduces pain and tenderness below the right costal margin.
\par \pard \qj \fi249 \sl-221 \tx249 The features and differential diagnosis of
an appendix mass and appendix abscess are de\-scribed on page 396.
\par \i \pard \qj \fi249 \sl-221 \tx249 Percussion. \plain \fs20 \lang1033 This
will cause pain if the patient is very tender but it can also help you to detect
the presence and limits of any mass that is being obscured by the tenderness an
d guarding.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
33 An appendix mass or abscess. The continuous line indicates the edge of the ma
ss, the hatching the area of tenderness.
\par
\par
\par
\par
\par
\par \fs20 \f0 \pard \qj \fi232 \sl-221 \tx232 Check that the liver dullness is
present.
\par \i \pard \qj \fi249 \sl-221 \tx249 Auscultation. \plain \fs20 \lang1033 Bow
el sounds will be present provided the infection is localized to the right iliac
fossa.
33 This usually causes pain, rather than the expected discomfort, deep in the pe
lvis if the finger is pushed high up to the right. If the appendix is in the pel
vis, rectal examination will be very painful. If \fs16 \f0 \b ~t \fs20 \f0 \plai
n \fs20 \lang1033 is, you should consider the possible alternativ diagno\-sis of
salpingitis.
\par \i \pard \qj \sl-221 \tx204 Hip movements. \plain \fs20 \lang1033 Extension
of right hip joint may cause abdominal pain. This sign is often noticed in chil
dren because the abdominal pain caused by walking makes them limp.
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \qc \sl-0 \tx204 382 \i The Abdomen
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 DIVERTICULAR DISE
ASE
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Acquired divertic
ula appear in the colon, espe\-cially the sigmoid colon, probably as a result of
changes in bowel motility and the consistence of the faeces. Many believe that
the condition is caused solely by the Western diet with its low roughage content
.
\par \pard \qj \fi249 \sl-221 \tx249 Diverticula are often present without symp\
-toms.
\par \pard \qj \fi249 \sl-221 \tx249 When they cause vague abdominal symptoms th
e syndrome is called painful diverticular dis\-ease. When the diverticula become
acutely in\-flamed the condition is called diverticulitis.
\par
\par
\par
\par
lain \fs20 \lang1033 The symptoms from diverticula com\-monly appear between the
ages of 50 and 70 years.
\par \i \pard \qj \fi283 \sl-221 \tx283 Sex. \plain \fs20 \lang1033 This conditi
on is more common in women.
\par \i \pard \qj \fi255 \sl-221 \tx255 Ethnic group. \plain \fs20 \lang1033 It
is rare in native Africans and Asians.
monest symptom is pain/indigestion. It may be very mild, or severe enough to mak
e the patient lie down. It is a persistent ache with colicky exacerbations.
\par \pard \qj \fi249 \sl-221 \tx249 The pain is usually felt in the left-hand s
ide of the lower abdomen but may spread across the whole of the lower abdomen. O
n rare occasions the pain is felt in the central region of the lower zone of the
abdomen. The pain of diverticular disease does not radiate and is not precipita
ted by eating.
\par \pard \qj \fi249 \sl-221 \tx249 Although the patients do not notice any dir
ect relationship between the time of eating and the appearance of the pain, they
often observe that certain foods make their attacks of pain worse. The type of
food which does this varies enor\-mously from patient to patient.
\par \pard \qj \fi255 \sl-221 \tx255 When the pain begins there is often gaseous
distension, flatulence and belching. This is probably due to mild colonic obstr
uction caused by the smooth muscle hypertrophy of the bowel wall.
\par \pard \qj \fi232 \sl-221 \tx232 Most patients with diverticular disease are
constipated; that is to say, they have infrequent bowel actions and hard stool.
Their appetite and weight remain normal.
\par \lang1033 \fs22 \f1 \i \pard \sl-0 \tx204 Examination
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li759 \fi-759 \sl-221
\tx759 There may be nothing abnormal to find on examination and the diagnosis i
s made by the
\par \pard \qj \sl-221 \tx204 appearance of the bowel on a barium enema. However
, in most patients the sigmoid colon is easily palpable and slightly tender. Dur
ing an attack of pain the whole of the left iliac fossa is tender.
\par
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE DIVERTICULITIS
\par
\par
\par \fs22 \f1 \plain \fs22 \f1 \lang1033 \i \pard \qj \sl-0 \tx204 History
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi209 \sl-221 \tx209 Age, se
x and ethnic group. \plain \fs20 \lang1033 These features are similar to those d
escribed above for pain~ess diverticular disease.
\par \i \pard \qj \fi255 \sl-221 \tx255 Symptoms. \plain \fs20 \lang1033 The pat
ient develops a severe pain in the left iliac fossa or the whole of the lower ab
domen. The pain begins suddenly, is constant and is exacerbated by movement. Occ
asionally the pain begins in the centre of the lower abdomen and then moves to t
he left side, in a manner (and for the same reasons) similar to appendicitis.
\par \pard \qj \fi255 \sl-221 \tx255 The abdomen usually feels a little distende
d. If the inflammation spreads, peritonitis and (sometimes) intestinal obstructi
on may develop and the distension increase.
\par \pard \qj \fi255 \sl-221 \tx255 The patient is nauseated, loses her appetit
e, but does not usually vomit.
\par \pard \qj \fi249 \sl-221 \tx249 Most patients are constipated; a few have d
iarrhoea.
\par \pard \qj \fi249 \sl-221 \tx249 The inflammation may cause the patient to f
eel hot, feverish and sweaty.
\par \pard \qj \fi232 \sl-221 \tx232 If the inflamed colon is lying on the vault
of the bladder it may cause an increased frequency of micturition and painful m
icturition.
The patient often has a long history of painful diverticular disease; flatu\-le
nce, distension and left iliac fossa pain.
\par \fs22 \f1 \i \pard \sl-0 \tx3928 Examination\tab \fs10 \f1 \plain \fs10 \f1
\lang1033 /
\par
\par \fs20 \f0 \i \pard \qj \fi249 \sl-221 \tx249 General appearance. \plain \fs
20 \lang1033 The patient lies still be\-cause of the pain. She looks flushed and
fever\-ish. The temperature is often 38\'9739\super 0\plain \fs20 \lang1033 C (
100-102\super 0\plain \fs20 \lang1033 F) and the pulse rate over 100/minute.
\par \lang1033 \fs20 \f0 \i \pard \qj \sl-221 \tx204 Abdomen: Inspection. \plain
\fs20 \lang1033 The abdomen moves with respiration because the inflamed bowel i
s confined to its lower half. It is slightly dis\-tended.
\par \i \pard \qj \fi255 \sl-221 \tx255 Palpation. \plain \fs20 \lang1033 The le
ft iliac fossa is tender and protected by spasm of the overlying muscles. Carefu
l palpation may detect a palpable tender sausage-shaped mass in the left iliac f
ossa. There may be rebound tenderness and left-sided pain during pressure on the
right side of the abdomen.
33 The mass and tenderness of acute diverticulitis.
\par
\par
\par
\par
\par \fs20 \f0 \i \pard \qj \fi255 \sl-221 \tx255 Percussion. \plain \fs20 \lang
1033 If there is a palpable mass in the left iliac fossa it should be dull to pe
rcussion.
\par \i \pard \qj \sl-221 \tx204 Auscultation. \plain \fs20 \lang1033 The bowel
sounds are normal or hyperactive until a general peritonitis de\-velops and caus
es a paralytic ileus.
33 The patient feels pain when the finger is pushed high into the left side of t
he pelvis. If the inflamed colon is lying in the pelvis, rectal examination is v
ery painful.
\par \pard \qj \sl-221 \tx204 The clinical diagnosis of diverticulitis rests sol
e\-ly on the site of the pain, the tenderness and, when present, the mass.
\par \fs20 \f1 \pard \qj \sl-221 \tx204 The \fs20 \f0 symptoms and signs of some
of the complications of diverticulitis \fs8 \f1 \'97 \fs20 \f0 diverticular abs
\-cess, intestinal obstruction and general peritoni\-tis \fs8 \f1 \'97 \fs20 \f0
are described later in this chapter.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx204 CANCER OF THE \fs20 \f0 \plai
n \fs20 \lang1033 LEFT \fs24 \f1 \b SIDE OF THE
\par \pard \qj \sl-215 \tx204 COLON
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The colon is a lo
ng organ. The symptoms of cancer of the colon differ according to the part affec
ted and the type of tumour, but pain is a common symptom of all types.
\par \pard \qj \fi255 \sl-221 \tx255 The majority of colon cancers are found in
the sigmoid colon and at the rectosigmoid junction. These cancers are usually sm
all, annular and ulcerated.
\par \pard \qj \fi255 \sl-221 \tx255 The next common site is the caecum, where t
he tumours tend to be bulky and papilliferous.
\par \pard \qj \fi232 \sl-221 \tx232 Three-quarters of all colon cancers are dis
tal to the splenic flexure.
\par
\par
lain \fs20 \lang1033 The majority of patients are over 50 years old, but colon c
ancer can occur in young adults and children, because it can complicate ulcerati
ve colitis and familial polyposis coli.
\par \i \pard \qj \fi255 \sl-221 \tx255 Sex. \plain \fs20 \lang1033 It has no pr
eference for either sex.
\par \i \pard \qj \fi238 \sl-221 \tx238 Symptoms. \plain \fs20 \lang1033 Pain is
not the commonest symp\-tom. When present it is usually a mild lower abdominal
colic or ache which, after some weeks or months, becomes a persistent pain in th
e left lower abdomen, with severe colicky exacerbations.
\par \pard \qj \fi255 \sl-221 \tx255 The commonest symptom is a change of bowel
habit. The initial change is constipation, meaning the infrequent passage of har
d faeces. Suddenly, often following an episode of colic, the patient passes a nu
mber of loose stools \fs8 \f1 \'97\fs20 \f0 diarrhoea. The constipation then ret
urns. Alter\-nating constipation and diarrhoea is typical of annular carcinomata
of the left colon. The con\-stipation is caused by the intestinal obstruction,
the diarrhoea by the liquefaction of faeces above the obstruction, helped by inf
lammation of the colonic mucosa and excess secretion of mucus.
\par \pard \qj \fi255 \sl-221 \tx255 The episodes of colicky pain are accompanie
d by distension.
\par \pard \qj \fi249 \sl-221 \tx249 Loss of weight and appetite are not very co
mmon symptoms. When they do occur the weight loss often precedes the anorexia.
\par \pard \qj \fi255 \sl-221 \tx255 The patient may feel a lump in his abdomen.
\par \pard \qj \fi255 \sl-221 \tx255 Rectal bleeding is not a common symptom of
sigmoid or descending colon tumours because these tumours only bleed a little an
d the blood becomes intimately mixed with the faeces.
\par \pard \li1933 \fi-1678 \sl-1474 \tx255 \tx1933 When the tumour\tab is at th
e rectosigmoid junc\-\fs12 \f0 \b L\'92 r \fs8 \f1 \plain \fs8 \f1 \lang1033 ~ \
fs12 \f0 \b ~ \fs10 \f1 \plain \fs10 \f1 \lang1033 \i \b i- \fs12 \f0 \plain \fs
12 \lang1033 \plain \fs12 \lang1033 \b \'97~ ~ \fs10 \f1 \plain \fs10 \f1 \lang1
033 \i \b &Th
\par \fs20 \f0 \plain \fs20 \lang1033 \plain \fs20 \lang1033 \fs20 \f0 \lang1033
\fs20 \f0 \pard \sl-0 \tx204 384 \i The Abdomen
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 tion it may prolapse into the
rectum and cause tenesmus, but this symptom is much more frequently associated w
ith rectal carcinoma.
\par \pard \qj \fi249 \sl-221 \tx249 Painful micturition and frequency indicate
involvement of the bladder.
\par
\par
appearance. \plain \fs20 \lang1033 The weight loss may be apparent. The patient
may be pale if chronic blood loss has caused anaemia.
\par \i \pard \qj \fi255 \sl-221 \tx255 Neck. \plain \fs20 \lang1033 The left su
praclavicular lymph nodes may be enlarged.
\par \i \pard \qj \sl-221 \tx204 Abdomen: Inspection. \plain \fs20 \lang1033 In
a thin patient there may be a swelling in the left iliac fossa. The colon, espec
ially the caecum, may be visibly distended with faeces.
\par \i \pard \qj \fi255 \sl-221 \tx255 Palpation. \plain \fs20 \lang1033 If the
tumour is small and lying in the paravertebral gutter the abdomen will feel nor
mal, but it may form a palpable mass on the left-hand side, usually in the left
iliac fossa. Part of this mass may be hard faeces above the tumour, not the tumo
ur itself. If this is the case the mass should be indentable.
\par \pard \qj \fi255 \sl-221 \tx255 The mass will be tender if there is any sur
\-rounding inflammation.
\par \pard \qj \fi255 \sl-221 \tx255 The liver may be palpable, with an irregula
r surface and edge.
\par \i \pard \qj \fi255 \sl-221 \tx255 Percussion. \plain \fs20 \lang1033 The m
ass in the left iliac fossa will be dull to percussion.
33 The mass of a carcinoma of the sigmoid colon, with metastases in the liver.
\par \lang1033 \fs20 \f0 \i \pard \qj \fi255 \sl-221 \tx255 Auscultation. \plain
\fs20 \lang1033 If there is any chronic intestinal obstruction the bowel sounds
will be hyperac\-tive. During an attack of colic, loud high-pitched continuous
gurglings can be heard.
33 A tumour in the apex of the loop of the sigmoid colon, hanging down into the
pelvis, may be felt on bimanual ex\-amination of the pelvis.
\par \pard \qj \fi255 \sl-221 \tx255 There may be secondary nodules on the pel\vic peritoneum.
\par \pard \qj \fi249 \sl-221 \tx249 Test the faeces for blood. The stool is oft
en dark brown and the test positive.
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 CANCER OF THE CAECUM
\par
\par
caecum has a deserved repu\-tation for being \'91silent\'92 until it has grown t
o a considerable size. The majority of patients with this disease ultimately pre
sent with abdominal pain, but many have had other symptoms for much longer which
they have ignored or which have been misdiagnosed.
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi249 \sl-221 \tx249 Symptom
s. \plain \fs20 \lang1033 The commonest type of pain is a dull ache in the right
iliac fossa, but this is a late symptom. If the growth occludes the ileocaecal
valve the patient will have intestinal colic and intestinal obstruction.
\par \pard \qj \fi238 \sl-221 \tx238 Loss of weight followed by anorexia is comm
on.
\par \pard \qj \fi255 \sl-221 \tx255 Large tumours in the caecum bleed continual
\-ly and the patient gets anaemic. This causes pallor, debility and breathlessne
ss but the blood loss is not sufficient to colour the faeces.
\par \pard \qj \fi255 \sl-221 \tx255 A change in bowel habit is not such a prom\
-inent symptom as with left-sided tumours, but it does occur. Sometimes there is
constipation, sometimes diarrhoea, but these symptoms do not alternate.
\par \pard \qj \fi255 \sl-221 \tx255 The patient may feel a lump in the righ ili
ac fossa.
\par \pard \qj \fi249 \sl-221 \tx249 If the tumour blocks the mouth of the appen
\-dix, the appendix will distend and become acutely inflamed. The possibility th
at the in\-flammation is caused by a carcinoma of the caecum should always be re
membered in any\-one over 40 years old who gets acute appendi\-citis.
\par \lang1033 \fs20 \f0 \fs22 \f1 \i \pard \qj \sl-0 \tx204 Examination
\par
appearance. \plain \fs20 \lang1033 The patient may be pale and thin.
\par \i \pard \qj \fi255 \sl-221 \tx255 Neck. \plain \fs20 \lang1033 The supracl
avicular lymph nodes may be palpable.
abdomen may be generally distended or \'91full\'92 in the right iliac fossa.
\par \i \pard \qj \sl-221 \tx204 Palpation. \plain \fs20 \lang1033 The right ili
ac fossa is often tender with some guarding of the covering muscles.
\par \pard \qj \sl-221 \tx204 There may be a firm irregular mass in the right il
iac fossa, which may be fixed or freely mobile. When it is mobile it tends to sl
ip up into the paravertebral gutter or medially and down\-wards into the pelvis.
\par \pard \qj \sl-221 \tx204 The liver may be palpable and irregular.
\par \i \pard \qj \fi255 \sl-221 \tx255 Percussion. \plain \fs20 \lang1033 The m
ass will be dull to percus\-sion.
\par \i \pard \qj \sl-221 \tx204 Auscultation. \plain \fs20 \lang1033 The bowel
sounds should be normal but if there is any obstruction of the ileocaecal valve
they will be hyperactive.
\par \i \pard \qj \sl-221 \tx204 Rectal examination. \plain \fs20 \lang1033 The
rectum is normal, but the faeces may contain blood.
\par
\par \pard \qj \sl-221 \tx204 When the tumour causes appendicitis the physical s
igns are indistinguishable from those of simple acute appendicitis. Even when a
mass is palpable it is rarely possible to be certain that it is not an inflammat
ory mass. If the mass is very hard, discrete, knobbly and not very tender you sh
ould suspect that it is not just caused by inflammation.
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE SALPINGITIS
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This is an infect
ion of the fallopian tubes. It is usually bilateral and the common infecting org
anisms are the gonococcus and Streptococ\-cus. These organisms reach the fallopi
an tubes by direct spread through the vagina and uterus, or by the blood stream.
Bacteria can also spread into the fallopian tubes across the peritoneal cavity
from an inflamed appendix or sigmoid diverticulum.
\par
\par
\par
\par \i \pard \qj \sl-221 \tx204 Age. \plain \fs20 \lang1033 Salpingitis occurs
most often between the ages of 15 and 40 years, but ca~ occur in children.
\par \lang1033 \i \pard \qj \fi249 \sl-221 \tx249 Symptoms. \plain \fs20 \lang10
33 The patient complains of the gra\-dual onset (a few hours) of lower abdominal
pain. It is constant and can become severe. It is not affected by movement or r
elieved by any\-thing but analgesic drugs. It may radiate to the lower part of t
he back. The abdominal pain is sometimes preceded by low backache.
\par \pard \qj \fi255 \sl-221 \tx255 The woman has often noticed a purulent, yel
low\'97white vaginal discharge a few days be\-fore the pain begins.
\par \pard \qj \fi255 \sl-221 \tx255 Menstruation may have been irregular over t
he previous months. These patients often have a history of dysmenorrhoea.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
33 The areas of tenderness associated with salpingitis.
\par
\par
\par
\par
\par
\par \fs20 \f0 \pard \qj \fi232 \sl-221 \tx232 Salpingitis is a recognized compl
ication of the puerperium and abortion.

\par \pard \qj \fi249 \sl-221 \tx249 Although the patient complains of abdominal
pain there is usually no nausea, vomiting or change in bowel habit.
\par \pard \qj \fi238 \sl-221 \tx238 By contrast, urinary tract symptoms such as
painful, frequent micturition are common be\-cause the urinary tract is often i
nfected.
\par \pard \qj \fi249 \sl-221 \tx249 Sweating and rigors occur if the temperatur
e is elevated.
The patient may have had previous attacks of salpingitis or know that she has h
ad gonorrhoea, or been exposed to it.
\par \lang1033 \fs20 \f0 \fs130 \f1 \pard \sl-0 \tx204 I
\par
\par
\par \fs22 \f1 \i \pard \li839 \sl-0 \tx839 History
\par
\par
\par
\par
\par
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 I
\par \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f0 \lang1033 \fs20 \f0 \pard \qc \s
l-0 \tx204 386 \i The Abdomen
\par \lang1033 \fs20 \f0 \fs22 \f1 \i \pard \sl-0 \tx204 Examination
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \fi249 \sl-221 \tx249 General app
earance. \plain \fs20 \lang1033 The patient looks flushed and feverish. There is
no distinctive foetor otis. The oral temperature may be 38\'9739~5\super 0\plai
n \fs20 \lang1033 C (101\'97 103\super 0\plain \fs20 \lang1033 F).
\par \i \pard \fi209 \sl-221 \tx209 \tx1122 Abdomen:\tab Inspection. \plain \fs2
0 \lang1033 The abdomen moves with respiration, and looks normal.
\par \i \pard \sl-221 \tx204 Palpation. \plain \fs20 \lang1033 There is tenderne
ss, with some guarding, across the lower abdomen. The tenderness will be asymmet
rical if one fallopian tube is more inflamed than the other.
\par \pard \fi249 \sl-221 \tx249 The tenderness is lower and nearer the mid\-lin
e than the tenderness of appendicitis.
\par \pard \fi232 \sl-221 \tx232 No masses can be felt.
\par \i \pard \fi243 \sl-221 \tx243 Percussion. \plain \fs20 \lang1033 This is n
ormal.
\par \i \pard \fi249 \sl-221 \tx249 Auscultation. \plain \fs20 \lang1033 The bow
el sounds are normal. The peritonitis is usually confined to the pelvis and rare
ly causes a paralytic ileus.
\par \i \pard \fi209 \sl-221 \tx209 Rectal and vaginal examination. \plain \fs20
\lang1033 There is a yel\-low\'97white vaginal discharge, a specimen of which s
hould be sent for culture.
\par \pard \fi249 \sl-221 \tx249 The cervix and uterus are of normal size, but
\par \lang1033 \pard \qj \sl-221 \tx204 bimanual palpation of the adnexae is ver
y pain\-ful, and movement of the cervix also causes pain.
\par \pard \qj \fi238 \sl-221 \tx238 If there is a pyosalpinx or tubo-ovanan abs
\-cess there will be a palpable mass at the side of the uterus.
\par \pard \qj \fi255 \sl-221 \tx255 Rectal examination will confirm the tender\
-ness on either side of the uterus. The inside of the rectum often feels hot.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE RETENTION OF URINE
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Acute retention o
f urine is very painful. The patient therefore presents with abdominal pain but
the diagnosis is made easy by his know\-ledge that he has not and cannot pass ur
ine in spite of a desperate desire to do so.
\par \pard \qj \fi238 \sl-221 \tx238 The varieties of retention are discussed in
Chapter 17. The significant physical sign is a palpable bladder, pressure on wh
ich increases the desire to micturate.
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \li1366 \sl-0 \tx1366 Alimentary con
ditions presenting with dysphagia or vomiting
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 Some serious alimentary diseas
es do not cause abdominal pain but do affect swallowing and may cause retrostern
al pain.
\par \pard \qj \fi249 \sl-221 \tx249 Carcinoma of the oesophagus rarely pro\-duc
es any physical signs apart from wasting and perhaps a palpable supraclavicular
lymph node. The diagnosis is suspected when the patient complains of dysphagia.
At first he cannot swallow large pieces of food, but ulti\-mately he cannot swal
low fluids. Patients are often able to locate the level of the obstruction in th
eir oesophagus quite accurately. For example, a carcinoma in the lower third of
the oesopha\-gus causes a block which the patient\'92feels to be behind the lowe
r part of the sternum.
\par \pard \qj \fi238 \sl-221 \tx238 Reflux oesophagitis causes a retrosternal b
urning sensation, described by the patient as heartburn. If the oesophagus becom
es very in\-flamed the patient will also have dysphagia.
\par \lang1033 \pard \qj \sl-221 \tx204 Apart from the nature of the pain, the c
lue to the diagnosis of reflux oesophagitis is its rela\-tionship to posture. Be
nding, stooping, heavy lifting and tight clothes all force acid up into the oeso
phagus and cause heartburn.
\par \pard \qj \fi238 \sl-221 \tx238 Reflux oesophagitis is sometimes the only s
ymptom of hiatus hernia.
\par \pard \qj \fi238 \sl-221 \tx238 Pyloric stenosis occurs in neon es with con
\-genital hypertrophic pyloric ste sis and adults with cicatrizing benign ulcera
ion of their pylor\-us or duodenum, or carcinoma of the antrum of the stomach.
The last two conditions may be associated with the symptoms of benign pepfic ulc
er or carcinoma of the stomach, previously described in this chapter.
\par \pard \qj \fi255 \sl-221 \tx255 An adult with pyloric stenosis presents wit
h vomiting. The vomit is usually large in volume, not bile-stained and, if the c
ondition is long\-standing, not acidic because gastric acid secre\\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5317 \sl-0 \tx5317 Conditions pre
senting with diarrhoea \plain \fs20 \lang1033 387
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 tion is reduced. The stomach c
ontents are there\-fore not digested and the patient may recognize food that he
ate 24 or 48 hours previously. Apart from epigastric distension, visible gastric
pens\-talsis and a succussion splash, there may be no other abnormal physical s
igns.
\par \pard \qj \sl-221 \tx204 The neonate with congenital hypertrophic
\par \lang1033 \pard \qj \sl-221 \tx204 pylonc stenosis vomits large quantities
of cur\-dled and unpleasant-smelling milk. The vomit is forcefully ejected, just
ifying the adjective pro\-jectile. The baby becomes thin and dehydrated but has
a good appetite.
\par \pard \qj \fi238 \sl-221 \tx238 Careful examination may reveal the dis\-ten
ded stomach and a smooth ovoid mass just below the right costal margin. This is
the hyper\-trophic pylorus. You can only be certain of the diagnosis if you can
feel the pylonic mass.
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 Some diseases of the large bow
el cause di\-arrhoea and no other symptoms. The nature of the diarrhoea sometime
s suggests the diagno\-sis, but its proof usually rests on the results of endosc
opy, biopsy, barium enema and stool cultures.
\par \pard \qj \sl-221 \tx204 The common causes of severe diarrhoea are as follo
ws (see also Revision Panel 18.5).
\par \pard \qj \fi238 \sl-221 \tx238 Infections in food such as typhoid and
\par \pard \qj \sl-221 \tx204 staphylococcal toxins, are often lumped together a
s \'91food poisoning\'92.
\par \pard \qj \sl-221 \tx204 The stool is watery, brown and passed with great f
requency. There is abdominal colic, nausea, vomiting and thirst.
\par \pard \qj \fi232 \sl-221 \tx232 Typhoid may present as a surgical problem w
ith abdominal pain from the perforation of the ulcers in the small bowel.
\par
\par
\par
\par
\par \fs30 \f3 \pard \qj \sl-0 \tx204 L
\par \lang1033 \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 In tropical countries t
he most likely causes of
\par \pard \qj \sl-221 \tx204 diarrhoea are bacillary dysentery, amoebic dysente
ry, malignant tertian malaria, kala-azar and schistosomiasis.
\par \pard \qj \fi238 \sl-221 \tx238 Ulcerative (and Crohn\'92s) colitis. The pa
tient
\par \pard \qj \sl-221 \tx204 complains of the sudden onset of frequent di\-arrh
oea. Some of the motions are watery brown fluid, others are just mucus. Both con
tain dark altered blood and flecks of fresh red blood. The patient may have to e
vacuate the rectum 20 or 30 times a day. Abdominal pain is uncommon unless compl
ications such as colonic distension and perforation occur. The patient is dehy\drated, thin, ill and feverish.
\par \pard \qj \fi238 \sl-221 \tx238 Cholera presents with vomiting, cramps and
severe diarrhoea. The diarrhoea lasts up to 3\'974 days. The patient passes colo
urless opaque
\par \pard \sl-0 \tx1303 \tx2619 \tx3174 \tqdec \tx4818 \tab \fs10 \f0 \b n \fs8
\f1 \plain \fs8 \f1 \lang1033 .\'97\'91 \'97. \fs10 \f1 \i \b t. I\tab \fs8 \f6
\plain \fs8 \f6 \lang1033 \plain \fs8 \f6 \lang1033 \b LA)-\tab \fs8 \f1 \plain
\fs8 \f1 \lang1033 -~ \fs8 \f6 \b Se ~\tab \fs8 \f5 \plain \fs8 \f5 \lang1033 \
b 31&
Conditions presenting with diarrhoea
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 stools, known as rice-water stools
, which con\-sist of an inflammatory exudate, mucus, flakes of epithelium, the c
asts of villi and the infecting organism.
\par \pard \fi238 \sl-221 \tx238 Rectal villous tumours. Most carcinomata on the
left-hand side of the colon cause a change in bowel habit, pain and bleeding. P
ersistent co\\par \lang1033 \pard \qj \sl-221 \tx204 pious diarrhoea is \i not \plain \fs20 \
lang1033 a prominent feature, but may Occur.

\par \pard \qj \sl-221 \tx204 One rectal tumour, the villous papilloma, causes e
xcessive mucus secretion and the pa\-tient frequently passes stools of pure mucu
s. He may become dehydrated and sodium-depleted. This is a rare tumour.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Acute peritonitis
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 Many of the conditions mention
ed in this chap\-ter cause localized or general acute peritonitis. When you can
determine the cause of peritoni\-tis it is easy to formulate a plan of treatment
, but if you cannot make a specific diagnosis you must decide whether the patien
t needs a lapar\-otomy. There are two circumstances in which a laparotomy is ess
ential:
\par
\par \pard \qj \li232 \fi-232 \sl-221 \tx232 1.\tab If there is evidence of isch
aemia of the bowel (caused by strangulation or a vascular occlu\-sion).
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 2.\tab If there is an unexplained g
eneral peritonitis where laparotomy is needed to make the diagnosis.
\par \pard \qj \sl-221 \tx204 Both conditions produce similar physical signs. Th
e severity of the pain is not an indication of the degree of inflammation; the d
iagnosis of peritonitis must be based on the physical signs. The clinical featur
es of peritonitis are:
\par
\par \pard \qj \sl-221 \tx204 An increasing tachycardia If the pulse rate
\par \pard \qj \sl-221 \tx204 increases gradually during 1\'972 hours of observa
tion there is likely to be serious disease within the abdomen.
\par \pard \qj \sl-221 \tx204 Pyrexia The temperature rises only when the
\par \lang1033 \pard \qj \sl-221 \tx204 peritoneal cavity becomes heavily infect
ed. Remember that steroids damp down the in\-flammatory response. Patients on co
rticoster\-oids with a severe peritonitis may have a normal temperature.
\par \pard \qj \sl-221 \tx204 Tenderness and guarding Guarding is an ex\-cellent
indication of the severity of the tender\-ness. If the whole abdomen is tense t
here is likely to be general peritonitis.
\par \pard \qj \sl-221 \tx204 Rebound tenderness This is just another way
\par \pard \qj \sl-221 \tx204 of showing that the abdomen is very tender. It can
be a valuable sign because the patient is not expecting pain as you suddenly re
move your hand, so the apprehension which can cause guarding during direct palpa
tion is absent. However, it causes considerable discomfort and should be used sp
aringly.
\par \pard \qj \sl-221 \tx204 Localized pain during distant palpation If a
\par \pard \qj \sl-221 \tx204 tender spot hurts when you press a distant non-ten
der part of the abdomen, the structures in the painful area are likely to be ver
y inflamed.
\par \pard \qj \sl-221 \tx204 Absence of bowel sounds The absence of
\par \pard \qj \sl-221 \tx204 bowel sounds \i per se \plain \fs20 \lang1033 does
not indicate peritoni\-tis, but their absence in a tender rigid abdomen makes i
t highly likely that there is generalized peritonitis.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Intestinal obstruction
\par
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 The causes of intestinal obstructi
on are legion. Some are listed in Revision Panel 16.7.
\par \pard \fi249 \sl-221 \tx249 The clinician must be able to answer two questi
ons:
\par \pard \li238 \fi-238 \sl-221 \tx238 1.\tab Is there intestinal obstruction?
\par \pard \li238 \fi-238 \sl-221 \tx238 2.\tab Is the bowel strangulated?
\par \lang1033 \pard \fi232 \sl-221 \tx232 The signs of strangulation are the sa
me as the signs of local peritoneal inflammation \fs8 \f1 \'97 \fs20 \f0 pain, t
enderness, guarding and rebound tender\-ness \fs8 \f1 \'97 \fs20 \f0 discussed a
bove.
\par \pard \fi249 \sl-221 \tx249 The cardinal symptoms of intestinal obstruc\-ti
on are pain, vomiting, distension and absolute constipation, but the severity an
d time of onset
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6655 \sl-0 \tx6655 Intestinal obs
truction \plain \fs20 \lang1033 389
\par \lang1033 \fs20 \f0 \pard \qj \sl-391 \tx204 of each of these symptoms will
depend upon the level of the obstruction.
\par \pard \qj \sl-221 \tx204 Pain
\par
\par \pard \qj \fi226 \sl-221 \tx226 The pain of intestinal obstruction is a tru
e colic. There are severe gripping exacerbations, interspersed with periods of l
ittle or no pain.
\par \pard \qj \fi232 \sl-221 \tx232 Colic is uncommon with obstructions above t
he pylorus. Small-bowel colic is felt in the central part of the abdomen, largebowel colic in the lower third of the abdomen.
\par \pard \qj \sl-221 \tx204 Vomiting
\par
\par \pard \qj \fi232 \sl-221 \tx232 Intestinal obstruction causes frequent vomi
t\-ing. The nature of the vomitus depends upon the level of the obstruction. Wit
h pyloric ob\-struction the vomitus is watery and acid. High small-bowel obstruc
tion gives a greenish\'97blue bile-stained vomit. Obstruction below the mid\-dle
of the small bowel is associated with a brown vomit which becomes increasingly
foul-smelling as the obstruction persists. It becomes so thick, brown and foul t
hat it is often called \'91faeculent\'92 vomit, but this is a misnomer; it is no
t faeces, just stagnant lower small-bowel and caecal contents.
\par \pard \qj \sl-221 \tx204 Distension
\par
\par \pard \qj \fi226 \sl-221 \tx226 The lower down the gut the obstruction, the
more bowel there is available to distend and so ultimately the greater the dist
ension. High ob\-struction is not associated with much disten\-sion, particularl
y if the patient is vomiting fre\-quently.
\par \pard \qj \fi226 \sl-221 \tx226 An obstruction in the left side of the colo
n first causes the colon to distend. The distension extends into the small bowel
only if the ileocaec\-al valve is incompetent. If this valve remains closed the
right side of the colon, especially the caecum, can become grossly distended, c
ausing a visible asymmetry. The right iliac fossa bulges outwards and is hyper-r
esonant.
\par \pard \qj \sl-221 \tx204 Absolute constipation
\par
\par \pard \qj \sl-221 \tx204 I Once an obstruction is complete and the ~ below
it is empty there is absolute con\-stipation; that is to say, \i no \plain \fs20
\lang1033 defaecation. This \i takes \plain \fs20 \lang1033 a varying time i~o
de\'92~etop, depending upon the level of the obstruction.
\par
\par \pard \qj \sl-221 \tx204 The foregoing cardinal symptoms present in a diffe
rent sequence according to the level of the
\par \lang1033 \pard \qj \sl-221 \tx204 obstruction. A high small-bowel obstruct
ion starts with pain and vomiting, the distension is slight and the absolute con
stipation is the last symptom to appear. A left-sided large-bowel obstruction st
arts with pain and absolute con\-stipation, followed quite quickly by distension
, and vomiting is the last symptom to appear.
\par \pard \qj \fi255 \sl-221 \tx255 The bowel sounds of a mechanical intestinal
obstruction are at first hyperactive, loud and frequent. As the bowel distends
the sounds become resonant and high-pitched and even\-tually tinkling.

\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \pard \sl-0 \tx204 L
\par \pard \sl-0 \tx6752 \tqr \tx9569 \tab \fs10 \f1 C;- \fs16 \f0 \b r c \fs8 \
f5 \plain \fs8 \f5 \lang1033 \b ,\'97\tab \fs8 \f1 \plain \fs8 \f1 \lang1033 ~ \
fs10 \f1 IL \fs10 \f0 \b ~
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 The abdominal ma
ss: signs and causes
\par
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 The techniques for palpating the l
iver, spleen and kidneys are described on page 367.
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 Hepatomegaly
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 The causes of enlarge
ment of the liver, classified according to their clinical presentation, are list
ed below.
\par
\par
\par \pard \sl-221 \tx204 Smooth generalized enlargement, without jaundice
\par
\par \pard \sl-221 \tx204 Congestion from heart failure
\par \pard \sl-221 \tx204 Cirrhosis
\par \pard \sl-221 \tx204 Reticuloses
\par \pard \li255 \fi-255 \sl-221 \tx255 Hepatic vein obstruction (Budd\'97Chiar
i syn\-drome)
\par \pard \sl-221 \tx204 Amyloid disease
\par
\par
\par \pard \sl-221 \tx204 Smooth generalized enlargement, with jaundice
\par
\par \pard \sl-221 \tx204 Infective hepatitis
\par \pard \li255 \fi-255 \sl-221 \tx255 Biliary tract obstruction (gallstones,
carcinoma of pancreas)
\par \pard \li255 \fi-255 \sl-221 \tx255 Cholangitis
\par \pard \li255 \fi-255 \sl-221 \tx255 Portal pyaemia
\par
\par \pard \sl-221 \tx204 Knobbly generalized enlargement, without jaundice
\par
\par \pard \li255 \fi-255 \sl-221 \tx255 Secondary carcinoma
\par \pard \li238 \fi-238 \sl-221 \tx238 Macronodular cirrhosis
\par \pard \sl-221 \tx204 Polycystic disease
\par \pard \sl-221 \tx204 Primary liver carcinoma
\par
\par \pard \sl-311 \tx204 Knobbly generalized enlargement, with jaundice
\par \pard \li255 \fi-255 \sl-221 \tx255 Extensive secondary carcinoma
\par \pard \li255 \fi-255 \sl-221 \tx255 Cirrhosis
\par
\par \pard \sl-311 \tx204 Localized swellings

\par \pard \sl-221 \tx204 Riedel\'92s lobe
\par \pard \li255 \fi-255 \sl-221 \tx255 Secondary carcinoma
\par \pard \sl-221 \tx204 Hydatid cyst
\par \pard \li238 \fi-238 \sl-221 \tx238 Liver abscess
\par \pard \li255 \fi-255 \sl-221 \tx255 Primary liver carcinoma.
\par \lang1033 \pard \sl-221 \tx204 The Physical signs of an enlarged liver area
are:
\par
\par \pard \li249 \fi-249 \sl-221 \tx249 1.\tab It descends from below the right
costal mar\-gin and costal angle.
\par \pard \li249 \fi-249 \sl-221 \tx249 2.\tab You cannot get above it.
\par \pard \sl-221 \tx204 3. It moves with respiration.
\par \pard \li249 \fi-249 \sl-221 \tx249 4.\tab It is dull to percussion up to t
he level of the
\par \pard \fi255 \sl-221 \tx255 8th rib in the nud-axillary line.
\par \pard \li249 \fi-249 \sl-221 \tx249 5.\tab Its edge can be sharp or rounded
and its surface smooth or irregular.
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 18.18 \plain \fs20 \f1 \lang1033 H
epatomegaly. The \fs20 \f0 dotted \fs20 \f1 line indicates the site of Riedel\'9
2s lobe \fs8 \f1 \'97 \fs20 \f1 a normal anatomical variation.
\par
\par
\par
\par
\par \fs20 \f0 \pard \fi238 \sl-221 \tx238 Remember Riedel\'92s lobe. This is an
exten\-sion of the right lobe of the liver down below
\par \pard \sl-221 \tx204 the costal margin, along the anterior axillary line. I
t is often mistaken for a pathological enlargement of the liver or gall bladder.
It is a normal anatomical variation.
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 Splenomegaly
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 The spleen is almost
always uniformly enlarged, so concealing the cause of its enlargement. The cause
s of splenomegaly are best classified according to the underlying disease.
\par \lang1033 \fs20 \f0 \fs10 \f1 \pard \sl-0 \tx204 A
\par \lang1033 \fs20 \f0 \fs10 \f1 \i \b \pard \sl-0 \tx204 N.
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \plain \fs20 \lang1033 \fs24 \f1
\b \pard \sl-0 \tx204 z
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \li311 \sl-0 \tx311 0
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5317 \sl-0 \tx5317 The abdominal
mass: signs and causes \plain \fs20 \lang1033 391
\par \pard \li4558 \sl-0 \tx4558 Space-occupying lesions
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \sl-0 \tx204 Bacterial:
\par \plain \fs20 \lang1033 \pard \sl-221 \tx204 Typhoid
\par \pard \li238 \fi-238 \sl-221 \tx238 Typhus
\par \pard \sl-221 \tx204 Tuberculosis
\par \pard \li221 \fi-221 \sl-221 \tx221 General septicaemia
\par \i \pard \sl-0 \tx204 Spirochaetal:
\par \plain \fs20 \lang1033 \pard \sl-221 \tx204 Syphilis
\par \pard \sl-221 \tx204 Leptospirosis (Weil\'92s disease)
\par \i \pard \sl-0 \tx204 Viral:
\par \plain \fs20 \lang1033 \pard \li221 \fi-221 \sl-221 \tx221 Glandular fever
\par \i \pard \sl-0 \tx204 Protozoal:
\par \plain \fs20 \lang1033 \pard \sl-221 \tx204 Malaria
\par \pard \li221 \fi-221 \sl-221 \tx221 Kala-azar

\par
\par \pard \li238 \fi-238 \sl-221 \tx238 Cellular proliferation
\par \pard \sl-221 \tx204 Myeloid and lymphatic leukaemia
\par \pard \li221 \fi-221 \sl-221 \tx221 Pernicious anaemia
\par \pard \sl-0 \tx204 Polycythaemia rubra vera
\par \pard \sl-221 \tx204 Spherocytosis
\par \pard \li221 \fi-221 \sl-221 \tx221 Thrombocytopenic purpura
\par \pard \li238 \fi-238 \sl-221 \tx238 Myelosclerosis
\par \pard \li221 \fi-221 \sl-221 \tx221 Mediterranean anaemia
\par
\par \pard \sl-311 \tx204 Congestion
\par \pard \li249 \fi-249 \sl-221 \tx249 Portal hypertension (cirrhosis, portal
vein thrombosis)
\par \pard \li221 \fi-221 \sl-221 \tx221 Hepatic vein obstruction
\par \pard \li238 \fi-238 \sl-221 \tx238 Congestive heart failure (cor pulmonale
, con\-strictive pericarditis)
\par
\par \pard \sl-221 \tx204 Infarction
\par
\par \pard \li221 \fi-221 \sl-221 \tx221 Emboli from bacterial endocarditis, emb
oli from the left atrium during atrial fibrillation associ\-ated with mitral ste
nosis, emboli from the left ventricle after myocardial infarction Splenic artery
or vein thrombosis in polycy\-thaemia and retroperitoneal malignancy
\par
\par \pard \sl-221 \tx204 Cellular infiltration
\par
\par \pard \sl-221 \tx204 Amyloidosis
\par \pard \li249 \fi-249 \sl-221 \tx249 Gaucher\'92s disease
\par
\par \pard \sl-311 \tx204 Collagen diseases
\par \pard \li238 \fi-238 \sl-221 \tx238 Felty\'92s syndrome
\par \pard \li238 \fi-238 \sl-221 \tx238 Still\'92s disease
\par \lang1033 \pard \sl-0 \tx204 True solitary cysts
\par \pard \li238 \fi-238 \sl-221 \tx238 Polycystic disease
\par \pard \li238 \fi-238 \sl-221 \tx238 Hydatid cysts
\par \pard \sl-221 \tx204 Angioma
\par \pard \li221 \fi-221 \sl-221 \tx221 Lymphosarcoma
\par \pard \li221 \fi-221 \sl-221 \tx221 Lymphoma.
\par \lang1033 \fs20 \f1 \b \pard \sl-198 \tx204 Figure \fs20 \f0 \plain \fs20 \
lang1033 16.19 \fs20 \f1 Splenomegaly. The notch is not always palpable.
\par
\par
\par \fs20 \f0 \pard \li238 \fi-238 \sl-221 \tx238 The physical signs of an enla
rged spleen are:
\par \pard \li221 \fi-221 \sl-221 \tx221 1. It appears from below the tip of the
left 10th rib and enlarges along the line of the rib towards the umbilicus.
\par \pard \li221 \fi-221 \sl-221 \tx221 2. It is firm, smooth, and usually sple
en-shaped. It often has a definite notch on its upper edge.
\par \pard \li232 \fi-232 \sl-221 \tx232 3.\tab You cannot get above it.
\par \pard \li238 \fi-238 \sl-0 \tx238 4.\tab It moves with respiration.
\par \pard \li238 \fi-238 \sl-0 \tx238 5.\tab It is dull to percussion.

\par \pard \li249 \fi-249 \sl-221 \tx249 6.\tab Although it may be possible to b
ring it for\-wards by lifting the left lower ribs forwards, it cannot be felt bi
manually or be ballotted.
\par \lang1033 \pard \li640 \sl-0 \tx640 0
\par \fs14 \f1 \pard \sl-0 \tx822 \tqr \tx3860 C. b \fs8 \f1 ~..\tab \fs12 \f1 \
i \b LW \fs10 \f1 \plain \fs10 \f1 \lang1033 \plain \fs10 \f1 \lang1033 ~\tab L
~ ~7U~ ~ ...\'91iZ. ~
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \sl-0 \tx204 Enlargement of the kidn
ey
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 One or both
kidneys may be enlarged. The common causes of enlargement of the kidney are:
\par
\par \pard \li221 \fi-221 \sl-221 \tx221 Hydronephrosis
\par \pard \li221 \fi-221 \sl-221 \tx221 Pyonephrosis
\par \pard \sl-221 \tx204 Perinephric abscess
\par \lang1033 \fs20 \f0 \pard \sl-311 \tx204 Infection
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Malignant disease: carcinoma of th
e kidney and nephroblastoma
\par \pard \sl-221 \tx204 Solitary cysts
\par \pard \sl-221 \tx204 Polycystic disease
\par \pard \li221 \fi-221 \sl-221 \tx221 Hypertrophy
\par \pard \fi249 \sl-221 \tx249 A mobile or low-lying kidney may be easily palp
able and so seem to be enlarged.
\par \pard \fi238 \sl-221 \tx238 Polycystic disease is very likely to affect bot
h kidneys.
\par \pard \fi249 \sl-221 \tx249 Hydronephrosis may be bilateral if the ob\-stru
cting lesion is in or distal to the neck of the bladder.
\par \pard \fi255 \sl-221 \tx255 Nephroblastoma is occasionally bilateral.
\par \lang1033 \pard \li221 \fi-221 \sl-221 \tx221 0
\par \lang1033 \pard \sl-221 \tx204 es
\par \lang1033 \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 16.20 \plain \fs20 \
f1 \lang1033 Bilateral enlargement of the kidneys.
\par
\par
\par \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 The physical signs of an enlarged
kidney are:
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 1.\tab It lies in the paracolic gut
ter or can be pushed back into this gutter; that is to say, it can be reduced in
to the loin.
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 2.\tab It is usually only possible
to feel the lower pole, which is smooth and hemi-ovoid.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 3.\tab It moves with respiration.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 4.\tab It is not dull to percussion
because it is covered by the colon. Even when a large kidney reaches the anteri
or abdominal wall it has a band of resonance across it.
\par \pard \qj \li232 \fi-232 \sl-221 \tx232 5.\tab It can be felt bimanualiy.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 6.\tab It can be baliotted. This me
ans that it can be bounced between your two hands, one on the anterior abdominal
wall and the other behind the renal angle, rather like a ball being patted betw
een the hands. This sign is diagnostic of a renal mass and depends upon the mass
reducing into the loin.
\par \lang1033 \fs24 \f1 \b \pard \sl-0 \tx204 Pancreatic pseudocyst
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 This is a collection
of pancreatic secretion, caused by pancreatitis, on the surface of the pancreas
or in part or the whole of the lesser sac.
\par \pard \fi238 \sl-221 \tx238 The patient may give a history of acute pan\-cr
eatitis (see page 377) or present with epigastric fullness, pain, nausea and, so
metimes, vomiting.
\par \pard \fi249 \sl-221 \tx249 If the cyst becomes infected the patient will d
evelop severe pain, sweating and rigors.
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.21 A \plain \fs20 \f1 \lang1033
pancreatic, lesser sac, pseudocyst.
\par
\par
\par \fs20 \f0 \pard \fi255 \sl-221 \tx255 The physical characteristics of a pan
creatic pseudocyst are:
\par \pard \li255 \fi-255 \sl-221 \tx255 1. The epigastrium contains a firm, som
etimes tender, mass with an indistinct lower edge. The upper limit is not palpab
le.
\par \pard \li249 \fi-249 \sl-221 \tx249 2.\tab It is usually resonant to percus
sion because it is covered by the stomach.
\par \pard \li255 \fi-255 \sl-221 \tx255 3. It moves very slightly with respirat
ion.
\par \pard \li249 \fi-249 \sl-221 \tx249 4.\tab It is not possible to elicit flu
ctuation or a fluid thrill.
\par \pard \sl-221 \tx204 These swellings can be very difficult to feel as most
of their bulk is beneath the costal margin.
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 Mesenteric cysts
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 These are cysts of cl
ear fluid found in the mesentery. They arise from the vestigial rem\-nants of re
duplicated bowel.
\par \pard \fi249 \sl-221 \tx249 They may be found by chance, being symp\\par \lang1033 \fs20 \f0 \fs20 \f1 \pard \sl-198 \tx204 Resonant
\par
\par
\par
\par
\par \pard \sl-198 \tx204 dull
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6088 \sl-0 \tx6088 The
abdominal mass: signs and causes \plain \fs20 \lang1033 393
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 tomless, or cause abdominal di
stension or recur\-rent colicky pain.
\par \pard \qj \fi238 \sl-221 \tx238 Like all cysts they can rupture, twist and
have intraluminal bleeding. Twisting is rare because they are fixed within the s
mall bowel mesen\-tery.
\par \fs20 \f1 \pard \qj \li2834 \sl-0 \tx2834 Cyst moves freely \fs20 \f0 at \f
s20 \f1 right angles to the root of the
\par \fs18 \f1 \pard \qj \li2834 \sl-0 \tx2834 mesentery
\par \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 16.22 A \plain \fs20 \f1 \lang
1033 mesenteric cyst.
\par
\par
\par
\par \fs20 \f0 \pard \qj \fi221 \sl-221 \tx221 The physical characteristics of a
mesenteric cyst are:
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 1.\tab The cyst forms a smooth, mob
ile, spherical swelling in the centre of the abdomen.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 2.\tab It moves freely at right-ang
les to the line of the root of the mesentery, but only slightly along a line par
allel to the root of the mesen\-tery.

\par \pard \qj \li238 \fi-238 \sl-221 \tx238 3.\tab It is dull to percussion.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 4.\tab If it can be fixed it can be
felt to fluctuate and have a fluid thrill.
\par \pard \qj \sl-311 \tx204 It is difficult to discriminate between a very lar
ge cyst and a tight ascites.
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Retroperitoneal tumours
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Retroperitoneal t
umours, excepting primary and secondary tumours of the lymph nodes, are rare; th
e commonest variety is the liposarcoma. They grow slowly and silently and are us
ually quite large before they are noticed by the patient or become palpable. The
patient complains of distension, a vague abdominal pam, and some\-times anorexi
a and loss of weight.
\par \lang1033 \fs14 \f1 \pard \sl-0 \tx204 C
\par
\par
\par
\par
\par
\par
\par
\par \fs20 \f0 \pard \sl-221 \tx204 it
\par
\par
\par \pard \sl-221 \tx204 Id
\par
\par
\par \pard \sl-221 \tx204 as
\par \fs14 \f1 \pard \sl-0 \tx204 1.
\par
\par
\par
\par
\par
\par \fs20 \f0 \pard \sl-221 \tx204 he
\par \lang1033 \pard \qj \sl-221 \tx204 They produce the following physical sign
s:
\par
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 1.\tab Abdominal distension.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 2.\tab A smooth or bosselated mass
with an indis\-tinct edge and a soft-to-firm consistence.
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 3.\tab While they are covered with
bowel they are resonant, but when they reach the anterior abdominal wall and pus
h the bowel out to the flanks they become dull to percussion.
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 4.\tab They move very little with r
espiration.
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 5.\tab They may transmit aortic pul
sations or occlude the vena cava.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Carcinoma of the stomach
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The symptoms of c
arcinoma of the stomach are described on page 373.
\par \pard \qj \fi221 \sl-221 \tx221 Although stomach cancers are often large, h
ard masses, they are notoriously difficult to feel because they are high in the
abdomen, beneath the costal margin. If there is a palpable mass it will be hard
and irregular, disappear beneath the costal margin so you cannot get above it, a
nd move with respiration.
\par \pard \qj \fi238 \sl-221 \tx238 The symptoms \fs8 \f1 \'97 \fs20 \f0 abdomi
nal pain or indiges\-tion with loss of appetite and weight \fs8 \f5 \b \'97 \fs2
0 \f0 \plain \fs20 \lang1033 are far more significant than the physical signs. T
he common finding in a patient with carcinoma of the stomach is a normal or slig
htly tender epi\-gastrium. Thus although carcinoma of the sto\-mach can present
with an abdominal mass, the message of this section is do not expect to feel a m
ass in a patient with carcinoma of the sto\-mach.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 The gall bladder
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The gall bladder
is usually easy to recognize from its shape and position. The causes of enlargem
ent of the gall bladder are:
\par
\par \pard \qj \fi238 \sl-221 \tx238 (a) Obstruction of the cystic duct, usually
by a gallstone, rarely by an intrinsic or extrinsic carcinoma. The patient is n
ot jaundiced and the gall bladder will contain bile, mucus (a mucocele) or pus (
an empyema).
\par \pard \qj \fi238 \sl-221 \tx238 (b) Obstruction of the common bile duct, us
ually by a stone or a carcinoma of the head of the pancreas. The patient will be
jaundiced.
\par \pard \qj \fi232 \sl-221 \tx232 Courvoisier\'92s law states: \'91When the g
all blad\-der is palpable and the patient is jaundiced the obstruction of the bi
le duct causing the jaundice is unlikely to be a stone because previous
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 inflammation will have made th
e gall bladder thick and non-distensible.\'92 This is a very useful clinical rul
e but there are a number of excep\-tions to it:
\par
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 1.\tab Stones can form in the bile
duct and obstruct it, in the presence of a normal distensible gall bladder.
\par \pard \qj \li243 \fi-243 \sl-221 \tx243 2.\tab There may be a double pathol
ogy: a stone in the cystic duct causing gall bladder disten\-sion and a carcinom
a or a stone blocking the lower end of the bile duct.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 3.\tab The converse of the law, jau
ndice without a palpable gall bladder, does not mean that the jaundice is caused
by stones. In such cases the obstruction may be caused by a cancer of the head
of the pancreas and the gall bladder distension be insufficient to be palpable,
or the jaundice may be caused by a carcinoma of the biliary tree above the entry
of the cystic duct.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure \fs20 \f0 \plain \fs20 \lang10
33 18.23 \fs20 \f1 An enlarged gall bladder.
\par
\par
\par \fs20 \f0 \pard \qj \fi255 \sl-221 \tx255 The physical features of an enlar
ged gall bladder are:
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 1.\tab It appears from beneath the
tip of the right
\par \pard \qj \fi255 \sl-221 \tx255 9th rib.
\par \pard \qj \li243 \fi-243 \sl-221 \tx243 2.\tab It is smooth and hemi-ovoid.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 3.\tab It moves with respiration.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 4.\tab You cannot feel a space betw
een the lump and the edge of the liver.
\par \pard \qj \li249 \fi-249 \sl-221 \tx249 5.\tab It is dull to percussion.
\par \pard \qj \sl-221 \tx204 If the gall bladder is acutely inflamed it becomes
surrounded by adherent omentum and bowel
\par \lang1033 \pard \qj \sl-221 \tx204 and loses some of its characteristics. A
gall bladder mass is diffuse, and tender, lies in the right hypochondrium, and
does not move much with respiration.
\par \pard \qj \fi238 \sl-221 \tx238 As the infection subsides it becomes more d
iscrete and mobile, and less tender.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Faeces
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The colon can bec
ome grossly distended with faeces as a result of a mechanical obstruction or chr
onic constipation. The patient may complain of diarrhoea, but this is actually m
ucus and a little watery faeces leaking out around the main mass of faeces.
\par
\par \fs14 \f1 \pard \qj \li3299 \sl-0 \tx3299 /
33 A colon distended with faeces. The
\par \pard \qj \sl-198 \tx204 masses are indentable. Faecal impaction of this de
gree is likely to be caused by Hirschsprung\'92s disease or gross constipation.
\par
\par \fs20 \f0 \pard \qj \fi255 \sl-221 \tx255 The physical characteristics of f
aeces are:
\par \pard \qj \li351 \fi-351 \sl-221 \tx351 1.\tab The masses lie in that part
of the abdomen occupied by the colon\'97the flanks and across the lower part of
the epigastrium.
\par \pard \qj \li334 \fi-334 \sl-221 \tx334 2.\tab Faeces feel firm or hard but
are indentable. This means that they can be dented by firm pressure with the fi
ngers and this dent per\-sists after releasing the pressure.
\par \pard \qj \li334 \fi-334 \sl-221 \tx334 3.\tab There may be multiple separa
te masses in the line of the colon, but in gross cases the faeces coalesce to fo
rm one vast mass which is easy to mistake for a tumour.
\par \pard \qj \li340 \fi-340 \sl-221 \tx340 4.\tab When there is no mechanical
obstruction, rectal examination will reveal a rectum full of rock-hard faeces, b
ut if there is a blockage in the lower colon the rectum will be empty.
\par \lang1033 \fs20 \f0 \fs104 \f3 \i \pard \sl-0 \tx204 L
\par \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li
5317 \sl-0 \tx5317 The abdominal mass: signs and causes \plain \fs20 \lang1033 3
95
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \sl-0 \tx204 The urinary bladder
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 The causes of retenti
on of urine are listed on page 411. The bladder may be tense and pain\-ful \fs8
\f1 \'97 \fs20 \f0 acute retention; or enlarged and painless \fs8 \f1 \'97\fs20
\f0 chronic retention.
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.25 A \plain \fs20 \f1 \lang1033
distended urinary bladder.
\par
\par
\par
\par \fs20 \f0 \pard \fi221 \sl-221 \tx221 The physical features of an enlarged
bladder are:
\par \pard \li226 \fi-226 \sl-221 \tx226 1.\tab It arises out of the pelvis and
so it has no lower edge.
\par \pard \li255 \fi-255 \sl-221 \tx255 2. It is hemi-ovoid in shape, usually d
eviated a little to one side.
\par \pard \li232 \fi-232 \sl-221 \tx232 3.\tab It may vary in size; a very larg
e bladder can extend up above the umbilicus.
\par \i \pard \li226 \fi-226 \sl-221 \tx226 4.\tab \plain \fs20 \lang1033 It is
not mobile.
\par \pard \li249 \fi-249 \sl-221 \tx249 6.\tab If it is large enough to permit
the necessary simultaneous percussion and palpation it will have a fluid thrill.
\par \pard \li255 \fi-255 \sl-221 \tx255 7. Direct pressure on the swelling ofte
n pro\-duces \fs20 \f1 \b a \fs20 \f0 \plain \fs20 \lang1033 desire to micturate
.
\par \pard \li255 \fi-255 \sl-221 \tx255 8. It does not bulge into the pelvis an
d can only be felt indistinctly on bimanual (rectal and abdominal) examination.
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 Ovarian cyst
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Small ovarian cysts a
re common and are not palpable. When they enlarge they rise up out of the pelvis
into the lower abdomen and become palpable.
\par \lang1033 \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.26 \plain \fs20 \f1 \
lang1033 A large ovarian cyst.
\par
\par \fs20 \f0 \pard \fi238 \sl-221 \tx238 The physical features of a large ovar
ian cyst are:
\par \pard \li249 \fi-249 \sl-221 \tx249 1.\tab Like all cysts, it is smooth and
spherical, with distinct edges.
\par \pard \li243 \fi-243 \sl-221 \tx243 2.\tab It arises from the pelvis so its
lower limit is not palpable; i.e. you cannot \'91get below it\'92.
\par \pard \li243 \fi-243 \sl-221 \tx243 3.\tab It may be mobile from side to si
de but cannot be moved up and down.
\par \pard \li249 \fi-249 \sl-221 \tx249 5.\tab It has a fluid thrill.
\par \pard \li249 \fi-249 \sl-221 \tx249 6.\tab Its lower extremity may be palpa
ble in the pelvis during rectal or vaginal examination, and movement of the cyst
may produce some movement of the uterus.
\par \lang1033 \fs24 \f1 \b \pard \sl-0 \tx204 The pregnant uterus
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \li311 \sl-0 \tx311 0
\par \fs8 \f1 \pard \sl-0 \tqr \tx3361 \'97 - -\tab \fs10 \f1 \i \b S \fs8 \f6 \
plain \fs8 \f6 \lang1033 \plain \fs8 \f6 \lang1033 \b S \fs8 \f5 \plain \fs8 \f5
\lang1033 \b ;.~ \fs8 \f1 \plain \fs8 \f1 \lang1033 -~
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Never forget that pregnancy is the
commonest cause of enlargement of the uterus, and of abdominal distension.

\par \pard \fi221 \sl-221 \tx221 The uterus enlarges to the xiphisternum by the
36th week of pregnancy. At this stage the fetus is palpable and jumping about.
\par \pard \fi249 \sl-221 \tx249 The diagnosis of pregnancy is more difficult in
the first 20 weeks, when the uterus is smaller and there are no fetal movements
.
\par \pard \fi221 \sl-221 \tx221 A pregnant uterus is a smooth, firm, dull swell
ing, arising out of the pelvis.
\par \pard \fi221 \sl-221 \tx221 The diagnosis is made with a bimanual ex\-amina
tion which reveals that the mass cannot be moved independently of the cervix and
the cervix is soft and patulous.
\par \pard \fi221 \sl-221 \tx221 Never squeeze an enlarged uterus during a biman
ual examination\'97you might cause an abortion.
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \sl-0 \tx204 Fibroids
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Fibroids can grow to
an enormous size and fill the whole abdomen. They are usually multiple.
\par \pard \fi243 \sl-221 \tx243 They cause irregutar and heavy periods, dis\-tu
rbed micturition, lower abdominal pain and backache.
\par \pard \fi226 \sl-221 \tx226 The physical signs of a fibroid uterus:
\par \pard \li226 \fi-226 \sl-221 \tx226 1.\tab It arises out of the pelvis and
so its lower edge is not palpable.
\par \pard \li226 \fi-226 \sl-221 \tx226 2.\tab It is firm or hard, bosselated o
r distinctly knobbly\'97each knob corresponding to a fibroid.
\par \pard \li238 \fi-238 \sl-221 \tx238 3. The mass moves slightly in a transve
rse direction and any movement of the abdomin\-al mass moves the cervix.
\par \pard \li238 \fi-238 \sl-221 \tx238 4. It is dull to percussion.
\par \pard \li255 \fi-255 \sl-221 \tx255 5. It is palpable bimanually. A moderat
ely en\-larged uterus can be pushed down into the pelvis.
lang1033 A large tibroid uterus
\par
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \sl-0 \tx204 The causes of a mass in
the right iliac fossa
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 A mass in the right iliac foss
a is a common physical finding and there are many possible causes to remember wh
en you are considering the diagnosis. This section describes the impor\-tant fea
tures in the history and examination of each cause.
\par \lang1033 \fs24 \f1 \b \pard \qj \sl-215 \tx204 Appendix mass
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi255 \sl-221 \tx255 History
. \plain \fs20 \lang1033 The patient complains of a period of central abdominal
pain followed by a pain in the right iliac fossa, with malaise, loss of appetite
and a slight change of bowel habit.
\par \i \pard \qj \fi255 \sl-221 \tx255 Examination. \plain \fs20 \lang1033 Ther
e is a tender, indistinct mass, dull to percussion, fixed to the iliac fossa pos
teriorly. The patient will have a persistent fever and tachycardia.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Appendix abscess
\par
. \plain \fs20 \lang1033 This is the same as for appendicitis, with the addition
al symptoms of an abscess such as fever, rigors, sweating and increased local pa

in.
\par \i \pard \qj \fi255 \sl-221 \tx255 Examination. \plain \fs20 \lang1033 Ther
e is a tender mass, which in its late stages may fluctuate and be associated wit
h oedema and reddening of the overlying skin. The patient will have a swinging,
intermit\-tent fever and an increasing tachycardia.
lang1033 A common diagnostic problem: a mass in the right iliac fossa.
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li4886 \sl-0 \tx4886 The
causes of a \plain \fs20 \lang1033 mass \i in the right iliac fossa \plain \fs20
\lang1033 397
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 Tuberculosis
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 In many parts of
the world tuberculosis is more often the cause of an inflammatory mass in the ri
ght iliac fossa than appendicitis. The mass consists of the inflamed ileocaecal
lymph nodes and parts of the caecum and terminal ileum that are also inflamed.
\par \i \pard \qj \fi238 \sl-221 \tx238 History. \plain \fs20 \lang1033 The pati
ent often has a vague cen\-tral pain for months, with general ill-health and los
s of weight, and changes in bowel habit. The pain then becomes intense and settl
es in the iliac fossa. An acute episode of central abdomin\-al pain moving to th
e right iliac fossa similar to appendicitis is uncommon.
\par \i \pard \qj \fi209 \sl-221 \tx209 Examination. \plain \fs20 \lang1033 The
mass is firm, tender and very indistinct. The surface and the edge are difficult
to define. If there is a tuberculous peritonitis the abdomen will be swollen an
d less flexible \fs8 \f1 \'97 \fs20 \f0 often described as a \'91doughy\'92 abdo
men.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Carcinoma of the caecum
\par
. \plain \fs20 \lang1033 Often there is no acute pain, just a dull discomfort in
the right iliac fossa. Some patients present with anaemia, diarrhoea, or intest
inal obstruction.
mass is firm, distinct and hard. Sometimes it is fixed to the posterior abdomina
l wall but sometimes it is mobile. It is not tender and does not resolve with ob
serva\-tion. The patient\'92s temperature and pulse are normal.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Crohn\'92s disease (terminal ileitis)
\par
. \plain \fs20 \lang1033 The patient experiences recurrent episodes of pain in t
he right iliac fossa, general malaise, loss of weight and, sometimes, epi\-sodes
of diarrhoea and melaena.
swollen terminal ileum forms an elongated sausage-shaped mass which is rubbery a
nd tender. It lies in a transverse position and often slips up and down the abdo
\-men during examination.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Iliac lymph nodes
\par
. \plain \fs20 \lang1033 The symptoms depend on the cause of the lymphadenopathy
. There may be a gener\-alized disease, or local disease in the limb, perineum o
r genitalia.
\par \lang1033 \i \pard \qj \fi238 \sl-221 \tx238 Examination. \plain \fs20 \lan
g1033 Enlarged iliac lymph nodes form an indistinct mass, with no clear contours
, which follows the line of the iliac vessels. The mass can bulge forwards just
above the inguinal ligament and be easy to feel, or be no more than a fullness i
n the depths of the iliac fossa.
\par \pard \qj \fi221 \sl-221 \tx221 Examine all other lymph nodes, and the lowe
r limb for the cause of the lymphadenopathy.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Iliac artery aneurysm
\par
. \plain \fs20 \lang1033 The patient may have noticed a pul\-sating mass or felt
an aching pain in the right iliac fossa.
common iliac artery dilates more often than the external iliac artery, so the sm
ooth, distinct mass with an expansile pulsa\-tion is usually in the upper medial
corner of the iliac fossa.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Psoas abscess
\par
. \plain \fs20 \lang1033 The patient is likely to have felt ill for some months
and had night sweats and loss of weight. He may also complain of back pain and a
bdominal pain.
iliac fossa is filled with a soft, tender, dull, compressible mass. There may be
a fullness in the lumbar region which is accentuated by pressing on the mass in
the iliac
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 fossa. The swelling may extend
below the groin and it may be possible to empty the swelling below the groin in
to the swelling above, and vice versa.
\par \pard \qj \fi221 \sl-221 \tx221 Back movements may be painful and limited.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Chondroma of the ilium
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Chondromata and c
hondrosarcomata occur in the iliac bones. They grow slowly and may bulge into th
e iliac fossa. They are large, hard, not tender and clearly fixed to the skeleto
n. They often lie out in the lateral part of the iliac fossa, more so than the i
ntra-abdominal causes of a right iliac fossa mass.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Actinomycosis
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This invariably d
evelops as a complication of appendicitis, but may present \i de novo \plain \fs
20 \lang1033 as a mass in the iliac fossa with a number of discharging sinuses.
It is rare.
\par \lang1033 \fs24 \f1 \b \pard \qj \sl-215 \tx204 Ruptured epigastric artery
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This occurs as a
result of straining or coughing. The haematoma tracks beneath the abdominal wall
, extraperitoneally, to produce a mass in the iliac fossa. It is diffuse and the
re may be discol\-oration of the skin. This is the only right iliac fossa mass w
hich is always attached to the anterior abdominal wall, but as it is on its deep
surface it becomes impalpable when the mus\-cles contract, like all the other i
ntra-abdominal masses. Contraction of the abdominal muscles is usually painful.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Malignant change in an undescended te
stis
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This is a rarity
but is easily suspected provided you remember to examine the scrotum whenev\-er
you examine the abdomen.
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \sl-0 \tx204 The causes of a mass in
the left iliac fossa
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 The causes of a mass in the le
ft iliac fossa are identical to those of a mass in the right iliac fossa, with t
he exception of appendicitis, carci\-noma of the caecum and tuberculosis, which
are replaced by diverticulitis and carcinoma of the colon.
\par \pard \qj \fi221 \sl-221 \tx221 It must be remembered that the normal sig\moid colon is palpable in one out of three of all patients.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx221 Diverticulitis
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Diverticular dise
ase presents in many ways, but when the diverticula become inflamed it can prese
nt as an inflammatory mass.
\par \i \pard \qj \fi221 \sl-221 \tx221 History. \plain \fs20 \lang1033 The pati
ent may have suffered from recurrent lower abdominal pains and chronic constipat
ion for years. The acute episode starts suddenly with a severe left iliac fossa
pain, nausea, loss of appetite and constipation.
\par \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Examination. \plain \fs20 \lan
g1033 The left iliac fossa contains a very tender, indistinct mass whose long ax
is lies parallel to the inguinal ligament. There may be a general or a local per
itonitis, and intestinal obstruction. The diagnosis depends upon the site of the
tenderness. There are very few acute inflammatory conditions which present with
a mass in the left iliac fossa.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Carcinoma of the sigmoid colon
\par
. \plain \fs20 \lang1033 The patient may present with lower abdominal pain, abdo
minal colic, intestinal ob\-struction, a change in bowel habit, rectal bleed\-in
g and general cachexia.
mass is hard, easily palp\-able and not tender. It may be mobile or fixed. The c
olon above the mass may be distended with indentable faeces.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6088 \sl-0 \tx6088 The causes of
a lump in the groin \plain \fs20 \lang1033 399
\par
\par \fs36 \f1 \b \pard \li317 \sl-0 \tx317 The causes of a lump in the groin

\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \li351 \sl-221 \tx351 The inguinal region is
part of the iliac fossa, and swellings in it, and just below it in the groin, ca
n be confused with iliac fossa masses.
\par
\par \fs24 \f1 \b \pard \qj \li408 \sl-0 \tx408 Hernia (inguinal or femoral)
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li238 \sl-221 \tx238 The diagno
sis is made from its site and shape and, if present, reducibility and an expansi
le cough impulse.
\par
\par \fs24 \f1 \b \pard \qj \li408 \sl-0 \tx408 Lymph nodes
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li283 \sl-221 \tx283 Inguinal l
ymph nodes present as hard or firm discrete nodules, or an indistinct mass, spre
ad\-ing across the groin, down the thigh along the
\par \pard \qj \li334 \fi-334 \sl-221 \tx334 \'95\tab line of the long saphenous
vein, and up into the iliac fossa. Look for a local cause of lym\\par \pard \qj \li351 \fi-351 \sl-221 \tx351 \'95\tab phadenopathy and examine a
ll the other lymph glands.
\par
\par \fs24 \f1 \b \pard \qj \li408 \sl-0 \tx408 Saphena varix
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li283 \sl-221 \tx283 A saphena
varix is a soft, compressible dilata\-tion at the top of the saphenous vein. It
has an expansile cough impulse. A fluid thrill will be felt when the saphenous v
ein lower down the leg is percussed.
\par
\par \fs24 \f1 \b \pard \qj \li408 \sl-0 \tx408 Psoas abscess
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li334 \sl-221 \tx334 A psoas ab
scess may pass down beneath the inguinal ligament and present in the upper part
of the femoral triangle as a soft, fluctuant, compressible mass. It is possible
to elicit fluctua\\par \lang1033 \pard \qj \sl-221 \tx204 tion between the parts of the abscess ab
ove and below the inguinal ligament, and empty one part into the other.
\par
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Psoas bursa
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The psoas bursa l
ies between the psoas tendon and the lesser trochanter of the femur. If it becom
es distended or inflamed it bulges into the upper outer corner of the femoral tr
iangle, lateral to the femoral vessels, where it causes a diffuse swelling. It i
s too deep to have a distinct shape or to fluctuate. It is painful when the hip
joint is moved.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Femoral aneurysm
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This presents as
a mass with an expansile pulsation lying in the line of the femoral artery.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Hydrocele of a femoral hernial sac
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 See page 321.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Hydrocele of the cord, or canal of N\
'fcck
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qc \sl-0 \tx204 See page 329.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Ectopic testis
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 See page 343.
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 Abdominal disten
sion
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 The causes of abdominal disten
sion can be remembered by using the letter \'91f\'92 six times:
\par \pard \qj \sl-221 \tx204 fetus, flatus, faeces, fat, fluid (free and en\-cy
sted), fibroids and other solid tumours.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Fetus
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Pregnancy is the
most common cause of abdo\-minal distension. The features of a pregnant uterus a
re described on page 395.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Flatus (also known as tympanites)
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Gas in the intest
ine can cause considerable abdominal distension.
\par \pard \qj \fi221 \sl-221 \tx221 In the early stages the distension may be l
ocalized to that part of the abdomen containing the distended gut, such as the e
pigastrium when the stomach is distended or the right iliac fossa when the caecu
m is distended, but as the distension progresses through the gut the whole abdom
en swells.
\par \pard \qj \fi221 \sl-221 \tx221 The distension will remain localized if the
bowel twists into a volvulus. This is a common complication of a long sigmoid c
olon combined with a narrow base of the mesocolon.
\par \pard \qj \fi221 \sl-221 \tx221 Distended bowel has no palpable surface or
edge. The only diagnostic feature is hyper\-resonance and, when there is obstruc
tion, visi\-ble peristalsis. The bowel sounds may be hyper\-active. Shaking the
patient causes a splashing sound as the thin layer or fluid in the distended bow
el splashes about. This is known as a suc\-cussion splash and is particularly co
mmon in gastric distension secondary to pyloric stenosis.
\par \pard \qj \fi226 \sl-221 \tx226 The causes of tympanites are aerophagy, acu
te dilatation of the stomach, mechanical in\-tenstinal obstruction and paralytic
ileus.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Faeces
\par
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \pard \qj \sl-221 \tx204 Faecal \fs20
\f0 impaction may present as abdominal distension or an abdominal mass. The phys
ical features of faecal masses in the abdomen are described on page 394. The dia
gnosis can usual\-ly be suspected from the history of the patient\'92s bowel hab
its. The common causes are Hirsch\par \lang1033 \pard \qj \sl-578 \tx204 sprung\'92s disease, acquired megacolon,
chronic intestinal obstruction and chronic constipation.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Fat

\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Fat rarely causes
distension, but frequently makes the patient pot-bellied.
\par \pard \qj \fi221 \sl-221 \tx221 A large fat abdomen may be caused by a thic
k layer of subcutaneous fat, or by excess fat in the omentum and mesentery. Thes
e two sites of fat deposition do not necessarily enlarge together. The protubera
nt, round abdomen often has a thin layer of subcutaneous fat but contains, a hea
vy, thick omentum.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx221 Fluid: ascites
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Fluid that is fre
e in the peritoneal cavity is called ascites.
\par \pard \qj \fi221 \sl-221 \tx221 It is caused by a variety of conditions but
they all fall into four groups: those which raise the portal venous pressure, t
hose which lower the plasma proteins, those which cause a peritoni\-tis, and tho
se which allow a direct leak of lymph into the peritoneal cavity.
\par \pard \qj \sl-221 \tx204 The causes of an increased portal venous pressure
\par \i \pard \qc \sl-0 \tx204 Prehepatic:
\par \plain \fs20 \lang1033 \pard \qj \fi221 \sl-221 \tx221 Portal vein thrombos
is
\par \pard \qj \fi249 \sl-221 \tx249 Compression of the portal
\par \pard \qc \sl-0 \tx249 nodes
\par \i \pard \qj \sl-0 \tx204 Hepatic:
\par \plain \fs20 \lang1033 \pard \qc \sl-0 \tx204 Cirrhosis
\par \pard \qj \li453 \fi-227 \sl-221 \tx226 \tx453 Multiple hepatic metastases
\par \i \pard \qc \sl-0 \tx226 \tx453 Post -he patic:
\par \plain \fs20 \lang1033 \pard \qj \fi221 \sl-221 \tx221 Budd\'97Chiari syndr
ome
\par \i \pard \qj \sl-0 \tx204 Cardiac:
\par \plain \fs20 \lang1033 \pard \qj \fi221 \sl-221 \tx221 Constrictive pericar
ditis
\par \pard \qj \li351 \sl-221 \tx351 Right heart failure caused by mitral stenos
is or tricuspid incompetence
\par \i \pard \qc \sl-0 \tx351 Pulmonary:
\par \plain \fs20 \lang1033 \pard \qj \li453 \fi-227 \sl-221 \tx226 \tx453 Pulmo
nary hypertension and right heart failure
\par \lang1033 \pard \sl-221 \tx204 vein by lymph
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \qj \sl-311 \tx204 The causes of hypopr
oteinaemia
\par \pard \qj \fi226 \sl-221 \tx226 Kidney disease associated with albuminuria
\par \pard \qj \fi226 \sl-221 \tx226 Cirrhosis of the liver
\par \pard \qj \li453 \fi-227 \sl-221 \tx226 \tx453 The cachexia of wasting dise
ases, malignancy and starvation
\par \pard \qj \li238 \sl-221 \tx238 Protein-losing enteropathies
\par \pard \qj \sl-311 \tx204 The causes of chronic peritonitis
\par \i \pard \qj \sl-0 \tx204 Physical:
\par \plain \fs20 \lang1033 \pard \qj \li453 \fi-227 \sl-221 \tx226 \tx453 Post
irradiation
\par \pard \qj \li238 \sl-221 \tx238 Talc granuloma
\par \i \pard \qj \sl-0 \tx204 Infection:
\par \plain \fs20 \lang1033 \pard \qj \fi221 \sl-221 \tx221 Tuberculous peritoni
tis
\par \i \pard \qc \sl-0 \tx221 Neoplasms:
\par \plain \fs20 \lang1033 \pard \qj \li453 \fi-227 \sl-221 \tx226 \tx453 Secon
dary peritoneal deposits of carcinoma
\par \pard \qj \li283 \fi-74 \sl-221 \tx209 \tx283 \'91Mucus\'92-forming tumours
(pseudomyxoma peritonei)
\par \pard \qj \sl-311 \tx204 The causes of chylous ascites
\par \pard \qj \fi226 \sl-221 \tx226 Chylous ascites is caused by the leakage of
lymph from the lacteals or the cisterna chyli as a result of congenital abnorma
lities, trauma, and primary or secondary lymph gland disease.
\par \pard \qj \sl-221 \tx204 The physical signs of ascites are:
\par
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 1.\tab A fluid thrill.
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 2.\tab Shifting dullness.
\par \pard \qj \fi221 \sl-221 \tx221 A fluid thrill is elicited by flicking one
side of the abdomen with your index finger and feeling the vibrations, when they
reach the other side of the abdomen, with your other hand. Before doing this yo
u must place the edge of the patient\'92s (or an assistant\'92s) hand on the abd
o\-men at the umbilicus to prevent the percussion wave being transmitted in the
abdominal wall.
\par \pard \qj \fi221 \sl-221 \tx221 A fluid thrill is present in any fluid-fill
ed cavity so that the difference between free and encysted fluid depends upon th
e recognition of shifting dullness.
\par \pard \qj \fi238 \sl-221 \tx238 Shifting dullness is a dull area which move
s or changes shape when the patient changes position. The dullness of ascites is
found in the flanks and across the lower abdomen.
\par \pard \qj \fi238 \sl-221 \tx238 Percuss the medial limits of the flank dull
ness carefully. Then ask the patient to turn on his side to an angle of approxim
ately \fs8 \f5 \b 450\'95 \fs20 \f0 \plain \fs20 \lang1033 Wait a few seconds an
d percuss again. If there is free fluid moving under the influence of gravity, t
he me\-dial limit of dullness will have extended to\-wards the mid-line on the l
ower side of the abdomen and retracted on the upper side.
\par \lang1033 \i \pard \sl-0 \tx2063 \tab Abdominal distension \plain \fs20 \la
ng1033 401
\par \pard \sl-0 \tx1457 \tx2624 \tab \fs100 \f3 j\tab \fs130 \f1 I
\par \fs20 \f1 \pard \sl-192 \tx1457 \tx2624 Distribution \fs18 \f1 of\tab \tab
Redistribution of\line \fs20 \f1 \pard \sl-192 \tx1457 \tx2624 dullness caused\t
ab \tab dullness when patient\line \pard \sl-192 \tx1457 \tx2624 by ascites\tab
\tab is tilted \fs8 \f5 \b 450 \fs20 \f1 \plain \fs20 \f1 \lang1033 \b to\line \
fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \sl-192 \tx1457 \tx2624 when \fs20 \f1
\b supine\tab \tab the right
\par
\par \pard \sl-198 \tx204 Figure 16.29 \plain \fs20 \f1 \lang1033 Shifting dulln
ess is diagnostic of free intraperitoneal fluid (ascites).
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \qc \sl-0 \tx204
402 \fs20 \f0 \plain \fs20 \lang1033 \i The Abdomen
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \sl-0 \tx204 Fluid: encysted
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Fluid trapped in a cy
st, or in the renal pelvis, or between adhesions, will have a fluid thrill, be d
ull to percussion, but not shift.
\par \pard \fi238 \sl-221 \tx238 The position and features of a cyst depend upon
its anatomical origin. The following cysts or fluid-filled swellings may become
large enough to present as abdominal distension:
\par \pard \fi221 \sl-221 \tx221 Ovarian cysts
\par \pard \fi221 \sl-221 \tx221 Hydronephrosis
\par \pard \fi232 \sl-221 \tx232 Polycystic kidney
\par \pard \fi238 \sl-221 \tx238 Urinary bladder
\par \pard \fi221 \sl-221 \tx221 Pancreatic cysts
\par \pard \fi221 \sl-221 \tx221 Mesenteric cysts
\par \pard \fi232 \sl-221 \tx232 Hydatid cysts

\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs18 \f1 \pard \li566 \sl-0 \tx566 Tends to become
\par \fs20 \f1 \pard \qc \sl-0 \tx566 spherical
\par \lang1033 \fs20 \f0 \fs20 \f1 \pard \sl-198 \tx204 Fluctuates
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \pard \sl-198 \tx204 Hasa
\par \pard \sl-198 \tx204 fluid thrill
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \sl-0 \tx204 /
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs130 \f1 \pard \sl-0 \tx204 )
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \sl-198 \tx204 Figure 16.30 \plain \
fs20 \f1 \lang1033 The features of encysted fluid.
\par \lang1033 \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 A large aortic aneurysm
can also distend the abdomen, but although an aneurysm is full of fluid it does
not have a detectable fluid thrill because it is being subjected to repeated in
trin\-sic percussion \fs8 \f1 \'97 \fs20 \f0 the pulse. It is diagnosed by the p
resence of an expansile pulsation.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 Solid tumours
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The solid tumours
which can become so large that they may cause abdominal distension are, in appr
oximate order of occurrence:
\par
\par \pard \qj \fi221 \sl-221 \tx221 Hepatomegaly
\par \pard \qj \fi221 \sl-221 \tx221 Fibroids
\par \pard \qj \fi221 \sl-221 \tx221 Splenomegaly
\par \pard \qj \fi221 \sl-221 \tx221 Large cancers of the colon
\par \pard \qj \fi238 \sl-221 \tx238 Carcinoma of the pancreas
\par \pard \qj \fi226 \sl-221 \tx226 Polycystic kidneys
\par \pard \qj \fi221 \sl-221 \tx221 Retroperitoneal lymphadenopathy
\par \pard \qj \fi221 \sl-221 \tx221 Carcinoma of the kidney
\par \pard \qj \fi221 \sl-221 \tx221 Primary carcinoma of the liver
\par \pard \qj \fi226 \sl-221 \tx226 Perinephric abscess
\par \pard \qj \fi221 \sl-221 \tx221 Retroperitoneal sarcoma
\par \pard \qj \fi238 \sl-221 \tx238 Ganglioneuroma (in children)
\par \pard \qj \fi221 \sl-221 \tx221 Nephroblastoma (in children)
\par \pard \qj \sl-221 \tx204 The physical signs of most of these tumours are de
scribed in the preceding parts of this chapter.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6655 \sl-0 \tx6655 Abdominal dist
ension \plain \fs20 \lang1033 403

\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs20 \f1 \pard \li969 \sl-198 \tx969 Ascites secondary
to carcinoma of the stomach. Note the wasting and the right inguinal hernia ful
l of ascitic fluid.
\par \b \pard \sl-204 \tx204 Figure 16.31 Some examples of abdominal distension.
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f1 \pard \sl-198 \tx204 A
bdominal distension caused by a retroperitoneal liposarcoma in a young man.
\par \lang1033 \fs20 \f0 \fs50 \f1 \b \pard \sl-0 \tx204 1.2<
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f1 \pard \sl-198 \tx204 A
bdominal distension caused by intestinal obstruction. ne oostruction Uongenital
crlylous ascites. Note was caused by the large right inguinal hernia. The disten
ded loops of the lymphoedema of the genitalia bowel can be seen because the abdo
minal wall is very thin. Peristaltic and left leg. waves were clearly visible.
\par \fs20 \f0 \fs20 \f0 \pard \sl-0 \tx204
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs50 \f1 \b \pard \sl-0 \tx204 The Kidneys, Urinary Tr
act and Prostate
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \sl-0 \tx204 Symptoms of renal and u
rinary
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs36 \f1 \b \pard \qc \sl-0 \tx
204 tract disease
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 It is very important to obtain
an exact history of the symptoms of renal and urinary tract disease because the
kidney, ureter and bladder are not accessible for close physical examination.
\par
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Renal pain
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Site. \
plain \fs20 \lang1033 Pain from the kidney is felt in the loin \fs8 \f1 \'97 \fs
20 \f0 the space below the 12th rib and the iliac crest; and in the renal angle
\fs8 \f1 \'97 \fs20 \f0 the angle between the 12th rib and the edge of the erect
or spinae muscles.
\par
\par
\par \fs20 \f1 \b \pard \qj \li2466 \sl-0 \tx2466 )
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs104 \f3 \plain \fs104 \f3 \lang1033 \i \pard \qj \li2239 \sl-0 \tx2239 /
1
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \b \pard \qj \sl-198 \tx204 Figure 17.
1 \plain \fs20 \f1 \lang1033 The renal angle is the area in the loin
\par \pard \qj \sl-198 \tx204 between the 12th rib and the edge of the erector s
pinae muscle.
\par
\par
\par \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 When you ask a patient with renal
pain to show you the site of the pain, he usually spreads his hand around his w
aist with his fingers covering the renal angle and his thumb above the anterior
superior iliac spine.
\par \lang1033 \i \pard \qj \fi238 \sl-221 \tx238 Severity. \plain \fs20 \lang10
33 Renal pain can vary from a constant dull ache to a very severe pain.
\par \i \pard \qj \fi238 \sl-221 \tx238 Nature. \plain \fs20 \lang1033 Do not us
e the term \'91renal colic\'92. True colic can only come from an obstructed musc
ular conducting tube such as the ureter. Because the severity of renal pain ofte
n fluctu\-ates rapidly it gets called renal colic, but it rarely has a \'91gripp
ing\'92 nature, and never disappears completely between exacerbations.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 Ureteric colic
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Site. \
plain \fs20 \lang1033 Colic from the ureter is felt along the line of the ureter
. The point where it begins usually corresponds to the level of the obstruc\-tio
n.
\par \pard \qj \fi226 \sl-221 \tx226 In most cases the pain starts in the loin a
nd then radiates downwards, around the waist, obliquely across the abdomen just
above the inguinal ligament, to the base of the penis, the scrotum or the labia.
\par \i \pard \qj \fi221 \sl-221 \tx221 Severity. \plain \fs20 \lang1033 The exa
cerbations of ureteric colic are extremely severe. The patient tries to relieve
the pain by rolling around the bed or walking about.
\par \i \pard \qj \fi226 \sl-221 \tx226 Nature. \plain \fs20 \lang1033 Ureteric
colic is a true colic. It is gripping in nature and comes in waves, with pain-fr
ee periods between each attack.
\par \i \pard \qj \fi238 \sl-221 \tx238 Cause. \plain \fs20 \lang1033 The patien
t may notice that his attacks of colic follow episodes of jolting or unusual phy
sical activity. Such a history sug\-gests that he has a stone in the ureter, whi
ch is being moved by the jolting.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 Haematuria

\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The patient may n
otice blood in the urine dur\-ing or after micturition. A few red cells have no
visible effect on urine colour, but if there is
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li4756 \sl-0 \tx4756 Symptoms of re
nal and urinary tract disease \plain \fs20 \lang1033 405
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 17.2 \plain \fs20 \f1 \lang1033 Ur
eteric colic radiates down from the renal angle along a line parallel to the ing
uinal ligament into the base of the penis, the scrotum or the labium majus.
\par
\par
\par
\par \fs20 \f0 \pard \sl-221 \tx204 heavy bleeding the urine may look like pure
\par \pard \sl-221 \tx204 blood.
\par \pard \fi226 \sl-221 \tx226 If the blood is coming from the lower part of
\par \pard \sl-221 \tx204 the bladder it may appear only at the end of
\par \pard \qc \sl-0 \tx204 micturition.
\par \pard \fi226 \sl-221 \tx226 The causes of haematuria are listed in Revi\-si
on Panel 17.1.
\par \pard \fi226 \sl-221 \tx226 Make quite sure that female patients have not
\par \pard \sl-221 \tx204 mistaken menstrual bleeding for haematuria.
\par \pard \fi226 \sl-221 \tx226 Check that other causes of discoloration of
\par \pard \sl-221 \tx204 the urine are not present, such as:
\par
\par \pard \fi221 \sl-221 \tx221 Excess beetroot eating
\par \pard \fi243 \sl-221 \tx243 Paroxysmal haemoglobinuria
\par \pard \qc \sl-0 \tx243 Porphyria.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx243 Vesical pain
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Pain from the bladder
is usually a dull, suprapu\-bic ache, made worse by micturition.
\par \pard \qj \fi221 \sl-221 \tx221 A painful desire to micturate, which starts
in the bladder and radiates into the urethra, is called strangury. When the pat
ient tries to micturate he cannot produce any urine and fails to relieve the pai
n.
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 Frequency of micturition
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Retention of urine in
the bladder following inadequate emptying increases the frequency of micturitio
n. This is first noticed at night, so
\par \pard \sl-0 \tx1224 \tx2568 \tx3004 \tab \fs8 \f5 \b \'97 ~- \fs12 \f0 \pla
in \fs12 \lang1033 \b ~ \fs10 \f5 \plain \fs10 \f5 \lang1033 p \fs12 \f0 \b Er\t
ab \fs8 \f1 \plain \fs8 \f1 \lang1033 -\tab ~ \fs8 \f5 \b \'97
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs66 \f1 \i \pard \sl-0 \tx204
I
\tx204 406 \i The Kidneys, Urinary Tract and Prostate
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 remember to ask about the frequenc
y of noctur\-nal micturition and record the 24-hour frequen\-cy as a day/night r
atio.
\par \pard \fi221 \sl-221 \tx221 \'91Dysuria\'92 is a meaningless and misused wo
rd \fs8 \f1 \'97 \fs20 \f0 do not use it. Describe each facet of micturition, th
e pain, the nature of the stream and the frequency.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx221 Prostatic pain
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Pain from the pro
state gland is felt deep inside the pelvis and between the legs in the perineum.
It cannot be clearly defined and the patient often thinks the pain is coming fr
om tl~e rectum.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Diseases of the urinary tract
\par
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qc \sl-0 \tx204 HYDRONEPHROSIS
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 A hydroneph
rosis should:
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Hydronephrosis is the di
stension of the calyces and pelvis of the kidney, caused by an obstruc\-tion to
the flow of unne.
\par \pard \fi221 \sl-221 \tx221 The causes of hydronephrosis are listed in Revi
sion Panel 17.2.
\par \pard \fi221 \sl-221 \tx221 Hydronephrosis may be symptomless ~y de\-tected
only when the condition which is creat\-ing the obstruction to the flow of urin
e causes symptoms of its own.
\par
\par \fs22 \f1 \i \pard \sl-0 \tx204 History
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \fi238 \sl-221 \tx238 Age. \plain
\fs20 \lang1033 Hydronephrosis occurs at all ages. \i Symptoms. \plain \fs20 \l
ang1033 The commonest symptom is pain in the loin. This is a dull, persistent ac
he which can be so mild that it is accepted by the patient as mild backache and
ignored.
\par \pard \fi221 \sl-221 \tx221 If the hydronephrosis develops quickly the pain
can be severe. The pain is sometimes referred to the epigastrium and mistaken f
or the pain of duodenal ulceration.
\par \pard \fi221 \sl-221 \tx221 Sometimes the pain is severe and colicky. The p
ain may be exacerbated by drinking an excessive amount of water or alcohol, or b
y taking any drug which causes a diuresis.
\par \pard \fi221 \sl-221 \tx221 If the hydronephrosis becomes very large the ab
domen may be distended.
\par \pard \fi221 \sl-221 \tx221 There are usually no general symptoms un\-less
both kidneys are so badly damaged that uraemia is developing.
\par
\par \fs22 \f1 \i \pard \qc \sl-0 \tx221 Examination
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 The kidney will be en
larged and should be palpable. The features of an enlarged kidney are described
in detail in Chapter 16.
\par \lang1033 \pard \qj \li255 \fi-255 \sl-221 \tx255 1.\tab Arise from the loi
n.
\par \pard \qj \li283 \fi-283 \sl-0 \tx283 2.\tab Be reducible into the loin.
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 3.\tab Be palpable bimanually.
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 4.\tab Ballotte.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ACUTE PYELITIS
\par
\par
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \pard \qj \sl-198 \tx204 (pyelonephrit
is)
\par
\par \fs20 \f0 \pard \qj \sl-221 \tx204 Acute pyelonephritis, or pyelitis, is an
infection in the upper part of the urinary tract by bacteria which have come fr
om the blood stream or up the ureter from the urethra or bladder. Pyelitis is co
mmon in women because the shortness of their urethra makes it easy for bacteria
to get into the bladder.
\par
\par
\par \fs22 \f1 \i \pard \qc \sl-0 \tx204 History
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi226 \sl-221 \tx226 Sex. \p
lain \fs20 \lang1033 Pyelitis is much more common in females.
\par \i \pard \qj \fi221 \sl-221 \tx221 Age. \plain \fs20 \lang1033 It is common
in children, and in women soon after marriage as a complication of \'91honeymoo
n cystitis\'92, and during pregnancy.
ient complains of the sud\-den onset of a severe pain in one or both loins. The
pain may also be felt anteriorly and when it is on the right-hand side can be mi
staken for the pains of cholecystitis.
\par \pard \qj \fi209 \sl-221 \tx209 At approximately the same time as the onset
of loin pain, micturition becomes frequent and painful. Although there may be a
vague supra\-pubic ache, the main pain during micturition is a burning sensatio
n along the length of the urethra, which persists after micturition. The
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6525 \sl-0 \tx6525 Diseases of th
e urinary tract \plain \fs20 \lang1033 407
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 patient may also complain of s
trangury, a pain\-ful but fruitless desire to micturate.
\par \pard \qj \fi221 \sl-221 \tx221 Headache, nausea and vomiting often begin a
few hours before the pain.
\par \pard \qj \sl-221 \tx204 The urine may become cloudy and blood\-stained. Th
e patient feels ill, hot and sweaty and, in severe cases, may suffer rigors.
t may have had similar attacks and know of their relationship to sexual intercou
rse or pregnancy.
\par
features. \plain \fs20 \lang1033 The patient looks ill. She may be flushed and
sweating. The tongue is dry and furred. The temperature is usually between 39 an
d 40\super 0\plain \fs20 \lang1033 C (102 and 104\super 0\plain \fs20 \lang1033
F) and there is a marked tachycardia.
\par \i \pard \qj \fi221 \sl-221 \tx221 Abdomen. \plain \fs20 \lang1033 One or b
oth kidneys are tender when palpated through the abdomen, and the renal angle is
very tender. The degree of guard\-ing depends upon the tenderness.
\par \pard \qj \fi226 \sl-221 \tx226 The kidneys are not enlarged unless the inf
ec\-hon has arisen in a previously hydronephrotic kidney.

\par \pard \qj \fi226 \sl-221 \tx226 There may be mild suprapubic tenderness.
\par \i \pard \qj \fi226 \sl-221 \tx226 Urine. \plain \fs20 \lang1033 The urine
looks cloudy and blood\-stained. Red blood cells and pus cells will be seen if t
he sediment is inspected with a micro\-scope.
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 CARCINOMA OF THE KIDNEY
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This tumour is al
so called a hypernephroma, because of its macroscopic appearance and common site
of occurrence.
\par
\par
\par
lain \fs20 \lang1033 Carcinoma of the kidney is uncommon below the age of 50 yea
rs.
\par \i \pard \qj \fi221 \sl-221 \tx221 Sex. \plain \fs20 \lang1033 It is twice
as common in males than females.
\par \i \pard \qj \fi221 \sl-221 \tx221 Symptoms. \plain \fs20 \lang1033 It can
present in many ways, but there are four common forms of presentation.
\par \pard \qj \sl-221 \tx204 Haematuria This is the most common symp\-tom. It i
s usually sufficient to stain the unne a
\par \lang1033 \pard \qj \sl-221 \tx204 pale red colour and appears intermittent
ly. Occasionally, the haem~aturia is profuse and the patient gets ureteric colic
as blood clots pass down the ureter (clot colic).
\par \pard \qj \sl-221 \tx204 General debility More than one-quarter of the pati
ents with renal carcinomata have no symp\-toms until the secondary deposits, or
the size of the primary growth, cause general malaise, loss of energy and loss o
f weight. Some patients present with bone pain and pathological frac\-tures.
\par \pard \qj \sl-221 \tx204 Pain in the loin tom, especially through its false
structures.
\par \pard \qj \sl-221 \tx204 A mass A mass may frequently be chance at a routin
e examination, or patient, or cause abdominal distension.
\par \lang1033 \pard \sl-221 \tx204 This is also a common symp\-when the tumour
breaks capsule and invades nearby
\par \lang1033 \pard \sl-221 \tx204 Because of the seriousness of the underlying
disease it is also important to know the rarer symptoms.
\par \lang1033 \pard \sl-221 \tx204 felt by by the
\par \lang1033 \fs20 \f0 \fs130 \f1 \pard \sl-0 \tx204 I
\par
\par \fs62 \f1 \pard \sl-0 \tx204 I
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 408 \i The Kidne
ys, Urinary Tract and Prostate
\par \lang1033 \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 Pyrexia of unknown orig
in (PUO), often associated with night sweats, suggests a clinical diagnosis of a
n infection such as tuberculosis or a lymphoma, \fs28 \f1 ~ \fs20 \f0 every pati
ent who presents with a PUO should have an intraVenous pyelo\-gram.
\par \pard \qj \fi226 \sl-221 \tx226 Some kidney diseases are associated with an
increased production of erythropoetin and erythrcic~\'92thaemia. This causes~ed
ness of_the face (and-\'92 hands, dyspnoea,~heart failure, \fs24 \f1 \b (Tai4 \f
s20 \f0 \plain \fs20 \lang1033 spontaneous venous and arterial thromboses.
\par \pard \qj \sl-221 \tx204 ~ Occlusion of the left renal and testicular vein
by direct spread of the tumour along the renal vein can cause a varicocele (see
page 348).jf the tumour spreads into the vena cava the patient may present with
oedema of both legs and the abdominal wall.
\par \pard \qj \fi238 \sl-221 \tx238 A suddeiy severe abdominal pain may indi\-c
ate haemorrhage into the tumour, or, if there is acute abdominal tenderness, rup
ture of the tumour in the peritoneal cavity.
\par \pard \qj \fi238 \sl-221 \tx238 Hypertension, which is a common presenta\-t
ion of other forms of renal disease, is rarely a complication of renal carcinoma
.
\par
features. \plain \fs20 \lang1033 The patient usually shows signs of recent weig
ht loss.\'92 If the haematuria has cause anaemia he will be pale.
\par \i \pard \qj \fi221 \sl-221 \tx221 Abdomen. \plain \fs20 \lang1033 Large tu
mours are palpable and have all the signs of an enlarged kidney, de\-scribed on
page 391.
\par \pard \qj \fi226 \sl-221 \tx226 A small tumour in the upper pole of the kid
ney may push the whole kidney downwards and make the lower pole easier to feel.
\par \pard \qj \fi238 \sl-221 \tx238 There is not usually any tenderness or guar
ding.
\par \i \pard \qj \fi238 \sl-221 \tx238 Skeleton. \plain \fs20 \lang1033 There m
ay be areas of swelling and tenderness in the bones, caused by secondary deposit
s. Secondary deposits of renal carcinoma can be very vascular and may feel soft,
pulsatile and compressible and have an audible bruit.
\par \i \pard \qj \fi238 \sl-221 \tx238 Chest. \plain \fs20 \lang1033 There may
be a pleural effusion on the side of the tumour if it has spread up through the
diaphragm.
\par \pard \qj \fi238 \sl-221 \tx238 Carcinoma of the kidney is one of the tumou
rs which can cause a solitary pulmonary metastasis worthy of resection.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx238 TRANSITIONAL CELL CARCINOMA O
F
\par \pard \qc \sl-0 \tx238 THE RENAL PELVIS
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 These tumours pre
sent with haematuria. The urine is coloured pale pink or red. Occasionally the p
atient has clot colic and passes \'91stringy\'92 blood clots. If the lesions are
obstructing the pelviureteric junction and causing a hyd\-ronephrosis the patie
nt may have a vague loin pain or a loin mass.
\par \pard \qj \fi221 \sl-221 \tx221 The causes of transitional cell carcinoma o
f the uroepithelium are discussed on page 410.
\par \pard \qj \fi226 \sl-221 \tx226 The symptoms and signs of these tumours are
non-specific. Their presence must be proved by cystoscopy and intravenous pyelo
graphy.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 RENAL AND URETERIC CALCULI
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Stones in the ren
al pelvis may lie silent for years and not present until complications such as i
nfection or renal parenchymal damage occur. Stones in the ureter invariably caus
e pain.
\par
\par

lain \fs20 \lang1033 Renal \fs30 \f3 ~i\'e3 \fs20 \f0 ureteric calculi are most
often found between the ages of 30 and 50 years.
\par \i \pard \qj \fi226 \sl-221 \tx226 Sex. \plain \fs20 \lang1033 They are sli
ghtly more common in men than women.
\par \i \pard \qj \fi221 \sl-221 \tx221 Symptoms. \plain \fs20 \lang1033 The pr~
Uominant symptoms caused by the stone are pain ~~haematuria. The pain is either
a constant pain in the loin, or a ureteric colic. The patient notices a dull ach
e in the loin which becomes a severe colic, radiat\-ing down along the line of t
he ureter. The pain is so severe that he has to walk or roll about. Although thi
s movement helps ease the acute colic, it often makes the constant loin pain wor
se. The loin pain is caused by the acute hydronephrosis which follows obstructio
n of the ureter.
\par \pard \qj \fi221 \sl-221 \tx221 If the stone impacts in the lower ureter th
e ureteric colic precedes the loin pain.
\par \pard \qj \fi221 \sl-221 \tx221 A patient with ureteric colic invariably ha
s microscopic haematuria, but rarely visible haematuria. Sometimes stones can ul
cerate through the uroepithelium without causing pain yet cause heavy haematuria
.
\par \pard \qj \fi221 \sl-221 \tx221 The first indication of the presence of a s
tone
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6088 \sl-0 \tx6088 Diseases of th
e urinary tract \plain \fs20 \lang1033 409
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 may be the symptoms of acute p
yelitis \fs8 \f5 \b \'97 \fs20 \f0 \plain \fs20 \lang1033 fever, loin pain and s
calding micturition.
\par \pard \qj \fi238 \sl-221 \tx238 Large bilateral staghorn calculi and small
bi\-lateral stones blocking both ureters may cause uraemia. The symptoms of urae
mia are headache, restlessness, twitching, fits, convul\-sions, drowsiness and c
oma.
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi238 \sl-221 \tx238 Abdomen
. \plain \fs20 \lang1033 It is not possible to examine the abdomen properly when
a patient is having an attack of ureteric colic because he is rolling around an
d holding his muscles tense. Between these attacks the abdomen feels normal unle
ss there is a secondary pyelitis or hydronephrosis causing tenderness and/or enl
argement of the kidney.
\par \pard \qj \fi221 \sl-221 \tx221 The confirmation of the diagnosis rests on
special investigations which reveal the presence of the stone.
\par
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 BLADDER CALCULI
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Stones may form i
n the bladder in association with stasis, infection or tumours, or come into the
bladder from the ureter.
\par
\par

\par
lain \fs20 \lang1033 Bladder stones are most common in middle-aged adults, but t
hey are also quite common in malnourished children in countries that are hot and
dry.
\par \i \pard \qj \fi238 \sl-221 \tx238 Sex. \plain \fs20 \lang1033 Males are af
fected more than females.
\par \i \pard \qj \fi238 \sl-221 \tx238 Symptoms. \plain \fs20 \lang1033 The mos
t common symptom is an increased frequency of micturition, usually related to po
sture. When the patient stands up the stone falls on to the trigone and initiate
s a desire to micturate. During the night the stone rolls off the trigone and th
e frequent desires to micturate abate.
\par \pard \qj \fi238 \sl-221 \tx238 As the stone moves around the bladder it ca
uses a suprapubic, stabbing pain which is exacerbated by standing and any sudden
, jolt\-ing movement.
\par \pard \qj \fi238 \sl-221 \tx238 Haematuria at the end of micturition is als
o a
\par \lang1033 \pard \qj \sl-221 \tx204 common symptom which is made worse by ex
ercise.
\par \pard \qj \fi221 \sl-221 \tx221 The presence of the stone increases the cha
nces of developing cystitis, which causes burning micturition, frequency and sup
rapubic pain.
\par \pard \qj \fi238 \sl-221 \tx238 The symptoms caused by the stone are often
preceded by the symptoms of its cause \fs8 \f1 \'97\fs20 \f0 prostatism, infecti
on and bladder tumours.
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 There may be slig
ht suprapubic tenderness but there are rarely any other physical signs.
\par \pard \qj \fi238 \sl-221 \tx238 Very large stones can sometimes be felt on
bimanual examination of the pelvis.
\par
\par
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 CYSTITIS
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Cystitis is an in
fection of the urine within the bladder, with a concomitant inflammatory reac\-t
ion in the bladder wall. The common predis\-posing factors of cystitis are incom
plete emptying of the bladder, abnormalities within the bladder and, in women, a
scending infection.
\par
\par
\par
lain \fs20 \lang1033 Cystitis occurs often in young and mid\-dle-aged women, in
young men with urethritis and in elderly men with prostatism and bladder tumours
.
\par \i \pard \qj \fi238 \sl-221 \tx238 Symptoms. \plain \fs20 \lang1033 The mos
t common symptom is an increased frequency of micturition. It begins suddenly an
d persists through the night as well as the day. The patient often wants to mict
urate every few minutes.
\par \pard \qj \fi221 \sl-221 \tx221 Passing urine causes a burning or scalding
pain along the length of the urethra. It is often so bad that the patient does h
er utmost to avoid passing water. There is also a mild suprapubic ache.
\par \pard \qj \fi238 \sl-221 \tx238 Haematuria is common. It is usually a few d
rops at the end of micturition but it may turn the urine mahogany brown.
\par \pard \qj \fi238 \sl-221 \tx238 The urine is usually cloudy and often foul\
-smelling.
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 410 \i The Kidneys, Urinar
y Tract and Prostate
\par \lang1033 \fs20 \f0 \fs22 \f1 \i \pard \qc \sl-0 \tx204 Examination
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Apart from mild supra
pubic tenderness there are rarely any other abnormal physical signs.
\par \pard \fi221 \sl-221 \tx221 Remember to look at the urine and examine the s
ediment for pus cells.
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 CARCINOMA OF THE BLADDER
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 Bladder cancer can be
formed~ of transitional cells or squamous cells. It rarely produces any physica
l signs so the diagnosis must be sus\-pected from the history.
\par
\par
\fs20 \lang1033 Bladder cancer occurs throughout adult life but the peak incide
nce is between the ages of 60 and 70 years.
\par \i \pard \fi209 \sl-221 \tx209 Sex. \plain \fs20 \lang1033 Males are afflic
ted more than females. \i Occupation. \plain \fs20 \lang1033 Some chemicals are
excreted in the urine and can stimulate malignant change in the uroepithelium. T
he better known ones are alpha- and beta-naphthylamine, benzidine and xylenamine
, and artificial sweeteners such as cyclamates. The industries which use these c
he\-micals are the rubber and cable industries, prin\-ters and dyers.
\par \lang1033 \i \pard \qj \fi209 \sl-221 \tx209 Predis posing conditions. \pla
in \fs20 \lang1033 Bilharzia and squa\-mous cell carcinoma are so often found to
gether that it is believed that the chronic irritation caused by this infection
stimulates neoplastic change.
\par \i \pard \qj \fi232 \sl-221 \tx232 Symptoms. \plain \fs20 \lang1033 In 95 p
er cent of cases carcinoma of the bladder presents with haematuria, which turns
the urine bright red and may be passed intermittently or every time the bladder
is emptied. The passage of blood clots may cause pain and difficulty during mict
urition.
\par \pard \qj \fi226 \sl-221 \tx226 If the urine becomes infected the patient w
ill experience a suprapubic ache, burning micturi\-tion and strangury.
\par \pard \qj \fi226 \sl-221 \tx226 Pain in the loin is a common presenting sym
ptom because bladder tumours often begin near the ureteric orifice and obstruct
the lower end of the ureter.
\par \pard \qj \fi226 \sl-221 \tx226 Pain in the pelvis and lower abdomen, and n
erve root pain down the legs, can occur if the tumour spreads through the wall o
f the bladder into the pelvis.
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 It is unusual to
find any abnormality. If the tumour is large it may be felt bimanually and if it
has spread beyond the bladder the floor of the pelvis may be indurated.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Retention of urine
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 There are two forms of retenti
on of urine \fs8 \f1 \'97 \fs20 \f0 acute and chronic \fs8 \f1 \'97 \fs20 \f0 an
d they are usually easy to dis\-tinguish. Acute retention is painful. Chronic re
tention is painless. This simple differentiation fails when infection supervenes
on chronic re\-tention because this makes the bladder painful. In some textbook
s this is called acute-on-chronic retention. This is not a good expression. The
term \'91infection-on-chronic retention\'92 is better.
\par \pard \qj \fi226 \sl-221 \tx226 Acute retention in the presence of a normal
bladder is rare and occurs only after a surgical operation, anaesthesia or an i
njury to the urethra. In all other circumstances there has usually been some mil
d, symptomless, chronic retention before the acute attack. These cases
\par \lang1033 \pard \qj \sl-221 \tx204 could also be called acute-on-chronic an
d soit is better not to use the expression. I suggest that you use the following
definitions.
\par \pard \qj \fi249 \sl-221 \tx249 Acute retention is the sudden inability to
micturate in the presence of a painful bladder (whatever its size).
\par \pard \qj \fi226 \sl-221 \tx226 Chronic retention is an enlarged painless b
ladder, whether or not the patient is having difficulty with mitcturition.
\par \pard \qj \fi238 \sl-221 \tx238 The causes of retention are presented in Re
vi\-sion Panel 17.3. It is a long list. The common causes are pregnancy, pelvic
and lower abdo\-minal operations and prostatic enlargement. A]though the other c
auses are important they are far less common.
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li7268 \sl-0 \tx7268 The prostate g
land \plain \fs20 \lang1033 411
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \li408 \sl-0 \tx408 ACUTE RETENT
ION
\par \fs22 \f1 \plain \fs22 \f1 \lang1033 \i \pard \qc \sl-0 \tx408 History
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \li357 \fi272 \sl-221 \tx357
\tx629 Symptoms. \plain \fs20 \lang1033 The patient is likely to have some sympt
oms related to one of the causes listed in Revision Panel 17.3, as well as an in
ability to pass urine and pain. The pain is severe and feels like a grossly exag
gerated desire to micturate. The patient knows that his bladder is overdis\-tend
ed.
\par
\par \fs22 \f1 \i \pard \qc \sl-0 \tx357 \tx629 Examination
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \li351 \sl-221 \tx351 Even if th
e bladder was completely normal before the onset of the retention it will have e
nlarged sufficiently to become a palpable, tense, dull, rounded mass arising out
of the pelvis. Pressure on the swelling exacerbates the patient\'92s desire to
micturate.
\par \pard \qj \li351 \fi193 \sl-221 \tx351 \tx544 A rectal examination will rev
eal that the pros\-tate or uterus is pushed backwards and down\-wards, and the c
ystic mass of the bladder will be felt filling the front half of the pelvis. You
cannot assess the size of the prostate gland when the bladder is full.
\par \pard \qj \sl-221 \tx204 \'95 If the patient has had chronic retention befo
re
\par \pard \qj \li351 \fi-351 \sl-221 \tx351 \'95\tab the acute episode, the bla
dder may reach up to,
\par \pard \qj \li351 \fi-351 \sl-221 \tx351 \'95\tab or above, the umbilicus. T
he physical signs of the underlying chronic retention may be pre\-sent.
\par \pard \qj \li351 \fi261 \sl-221 \tx351 \tx612 Remember to examine the prost
ate, the urethra and the contents of the pelvis as well as the sensory, motor an
d reflex functions of the nerves of the perineum and lower limbs.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx351 \tx612 CHRONIC RETENTION
\par \fs22 \f1 \plain \fs22 \f1 \lang1033 \i \pard \qc \sl-0 \tx351 \tx612 Histo
ry
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi238 \sl-221 \tx238 Age and
sex. \plain \fs20 \lang1033 Chronic retention is most com\-mon in elderly men.
ient may be unaware of his chronic retention but complains of symp\-toms related
to the cause of the retention, such as an increased frequency of micturition, a
nd difficulty with micturition (i.e. delays on start\-ing, a poor stream and a d
ribbling finish).
\par \pard \qj \fi238 \sl-221 \tx238 If the urethral sphincters fail the patient
will become incontinent. Overflow incontinence is an uncontrollable leakage and
dribbling of urine from the urethra. The patient may still be able to void a no
rmal volume of urine but after having done so feels that his bladder is not empt
y, and the leak continues.
\par \pard \qj \fi238 \sl-221 \tx238 Chronic retention is painless.
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The bladder will
be palpable. It is likely to reach at least halfway up to the umbilicus. It is n
ot tense or tender, and suprapubic pressure may not induce a desire to micturate
.
\par \pard \qj \fi221 \sl-221 \tx221 The palpable bladder of chronic retention i
s dull to percussion, and will fluctuate and have a fluid thrill if the patient
is thin enough to enable you to perform the manoeuvres necessary to elicit these
signs.
\par \pard \qj \fi238 \sl-221 \tx238 Look for the signs of the cause of the rete
n\-tion in the pelvis, prostate, urethra and nervous system.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 The prostate gland
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 BENIGN HYPERTROPH
V OF THE PROSTATE GLAND
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The inner portion
of the prostate gland hyper\-trophies during late adult life. As it grows it co
mpresses the outer layers into a false capsule, and bulges centrally into the ur
ethra and the base of the bladder. The cause of this hypertro\-phy is not known.
The popular theory is that it is an involutional hypertrophy in response to a c
hanging hormone environment.
\par \lang1033 \pard \fi221 \sl-221 \tx221 The majority of the symptoms result f
rom a mechanical interference with the act of micturi\-tion.
\fs20 \lang1033 The prostate starts enlarging at the age of 40 years but the sy
mptoms commonly appear between 50 and 70 years.
\par \i \pard \fi238 \sl-221 \tx238 Ethnic group. \plain \fs20 \lang1033 There a
re variations in the pre\-valence of prostatic hypertrophy. It is rare in Far Ea
stern races.
\par \lang1033 \fs20 \f0 \fs14 \f1 \pard \qc \sl-0 \tx238 I \fs12 \f0 \b i~~)1
\tx204 412 \i The Kidneys. Urinary Tract and Prostate

\par
\par \lang1033 \fs20 \f0 \i \pard \qj \fi221 \sl-221 \tx221 Symptoms. \plain \fs
20 \lang1033 The commonest, and usually the first symptom is an increased freque
ncy of micturition. This is first noticed by the patient when he finds that he h
as to pass urine in the middle of the night. It is caused by inadequate emptying
of the bladder. In addition to the increased frequency of micturition, the pati
ent finds that he must pass water as soon as the desire arises. This is urgency
and is caused by urine leaking into the prostatic urethra.
\par \pard \qj \fi238 \sl-221 \tx238 Difficulty with micturition is very common.
The patient has to wait before the stream starts, the stream is weak and dribbl
es down to no\-thing as it finishes. Straining does not help; it prolongs the wa
iting time before the stream starts.
\par \pard \qj \fi238 \sl-221 \tx238 Haematuria, in the form of a little dark bl
ood at the end of micturition, is not an uncommon symptom.
\par \pard \qj \fi221 \sl-221 \tx221 Some patients present with acute retention
(i.e. severe suprapubic pain and an inability to pass water).
\par \pard \qj \fi238 \sl-221 \tx238 Conversely, others present with overflow in
\-continence.
\par \pard \qj \fi238 \sl-221 \tx238 The symptoms of uraemia may be present\'97
headaches, fits and drowsiness.
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi238 \sl-221 \tx238 Abdomen
. \plain \fs20 \lang1033 The bladder will be palpable if there is acute or chron
ic retention.
\par \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Rectal examination. \plain \fs
20 \lang1033 The normal features of the prostate gland are described on page 417
. Benign hypertrophy causes a diffuse enlarge\-ment. The gland bulges into the r
ectum, its surface is smooth but the enlargement is often slightly asymmetrical
and the surface bosse\-lated. The consistence of the gland is firm, rubbery and
homogeneous.
\par \pard \qj \fi221 \sl-221 \tx221 The median sulcus usually remains palpable
even when the gland is grossly enlarged, and the rectal mucosa moves freely over
the gland. The gland is not tender.
\par \pard \qj \fi238 \sl-221 \tx238 The floor of the pelvis is normal.
\par \pard \qj \fi238 \sl-221 \tx238 Remember that a full bladder pushes the pro
state downwards and makes it feel bigger.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 CARCINOMA OF THE PROSTATE
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Cancer of the pro
state begins in the outer part of the prostate gland, so it does not develop a f
alse capsule and can easily spread into the floor of the pelvis. It is usually q
uite advanced before it causes symptoms.
\par
\par
lain \fs20 \lang1033 Carcinoma of the prostate is common in old men, 65\'9775 ye
ars old.
monest symptoms are
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li6927 \sl-0 \tx6927 The prostate g
land \plain \fs20 \lang1033 413
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 similar to those caused by ben
ign prostatic hypertrophy\'97frequency, urgency and difflcul\-ty of nucturition,
which are collectively called prostatism. The only difference is that these sym
ptoms often appear suddenly and get worse rapidly.
\par \pard \qj \fi221 \sl-221 \tx221 Nearly half the patients with carcinoma of
the prostate present with some form of retention of urine \fs8 \f1 \'97 \fs20 \f
0 acute or chronic \fs8 \f1 \'97 \fs20 \f0 the symptoms of which are described o
n page 412.
\par \pard \qj \fi238 \sl-221 \tx238 If the tumour spreads into the floor of the
pelvis it may cause pain in the lower abdomen and perineum.
\par \pard \qj \fi238 \sl-221 \tx238 General debility and loss of weight are com
\-mon presenting symptoms, because this tumour often spreads throughout the body
be\-fore causing local symptoms. Metastases in the bones of the pelvis and the
lumbosacral spine often cause bone pains and pathological frac\-hires. When scia
tica develops in an elderly man it may well be caused by bony metastases from a
malignant prostate gland.
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The bladder will
be palpable if there is retention of urine.
33 The prostate gland is asymmetrically enlarged or distorted. It is irregular i
n contour and heterogeneous in tex\-ture. Some areas are hard and knobbly, other
s are soft. The median sulcus may be absent and the rectal mucosa may be tethere
d to the gland.
\par \pard \qj \fi238 \sl-221 \tx238 The tissues of the pelvis, lateral to the g
land and around the rectum may be infiltrated by tumour. This is known as \'91wi
nging\'92 of the prostate. Nine out of ten prostatic carcinomata are diagnosed b
y rectal examination.
\par \pard \qj \fi238 \sl-221 \tx238 The only other physical signs will be those
caused by any metastases. Carcinoma of the prostate gland sometimes gives rise
to metas\-tases in the skin. If the spread around the rectum is extensive the tu
mour may spread along the lymphatics of the anal canal to the inguinal lymph nod
es.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 URETHRAL STRICTURE
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs22 \f1 \i \pard \qc \sl-0 \tx
204 History
lain \fs20 \lang1033 Urethral strictures occur at all ages. The most common caus
e is gonorrhoea, which is a disease of the sexually active, so the strictures th
at follow it appear in young and middle-aged men.
monest symptom is dif\-ficulty with micturition but, in contrast to the difficul
ty which occurs with benign prostatic hypertrophy, the difficulty of passing uri
ne caused by a stricture can be partly overcome by straining. The stream is thin
and dribbles at its end. Attacks of cystitis and acute retention are common.
\par \pard \qj \fi221 \sl-221 \tx221 There may be a slight glairy urethral dis\charge which is particularly noticeable in the morning.
\par \pard \qj \fi221 \sl-221 \tx221 An increasing frequency of micturition indi
\-cates the development of retention of urine.
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The bladder may b
e palpable. In long-standing cases both kidneys may be hydronephrotic and palpab
le.
\par \pard \qj \fi238 \sl-221 \tx238 The penis and urethra usually feel normal b
ecause the commonest site for stricture is where the urethra passes through the
perineal membrane, but a stricture caused by scarring of the penile urethra can
sometimes be felt as an area of induration. Meatal strictures can be seen.
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Urethral strictures follow damage
or destruction of the urethral mucosa. The common causes of urethral stricture a
re given in Revision Panel
\par \pard \qc \sl-0 \tx204 17.4.
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs50 \f1 \b \pard \qc \sl-0 \tx204 The Rectum and Anal
Canal
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 The principal symptoms of rectal a
nd anal con\-ditions are bleeding, pain, tenesmus, change of bowel habit, change
s in the stool, discharge and
\par \lang1033 \pard \sl-221 \tx204 pruritis. These have been mentioned in Chapt
er 1, but deserve more detailed consideration.
\par \lang1033 \fs36 \f1 \b \pard \sl-0 \tx204 Symptoms of anorectal disease
\par
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qc \sl-0 \tx204 Bleeding
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Blood passed per
rectum may be fresh or altered. When blood is degraded by intestinal enzymes and
bacteria it becomes black. A black tarry stool is called melaena. The blood mus
t come from high in the intestinal tract to have time to turn black before it re
aches the rectum.
\par \pard \qj \sl-221 \tx204 Recognizable blood may appear in four ways:
\par
\par \pard \qj \li351 \fi-351 \sl-221 \tx351 1.\tab Mixed with the faeces.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 2.\tab On the surface of the faeces
.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 3.\tab Separate from the faeces, ei
ther after or unre\-lated to defaecation.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 4.\tab On the toilet paper after cl
eaning.
\par \pard \qj \sl-221 \tx204 Blood mixed with the faeces must have come from bo
wel higher than the sigmoid colon, where the softness of the stool and the time
left for transit is still sufficient for mixing.
\par \pard \qj \sl-221 \tx204 Blood on the surface of the faeces has usually com
e from the lower sigmoid colon, rectum or anal canal.
\par \pard \qj \sl-221 \tx204 Blood separate from the faeces If the bleeding fol
lows defaecation then it is probably from an anal condition such as haemorrhoids
. If the blood is passed by itself then either it has accumulated in the rectum
so as to give a desire to defaecate and is from a rapidly bleeding carcinoma, in
flammatory bowel disease or di\-verticulitis, or it has passed down rapidly from

high up in the gut from a bleeding Meckel\'92s diverticulum or a peptic ulcer.
\par \pard \qj \sl-221 \tx204 Blood on the toilet paper is usually caused by min
or bleeding left on the anal skin from anal conditions such as fissures or haemo
rrhoids.
\par \lang1033 \pard \qj \sl-221 \tx204 Colour of recognizable blood Bright red
blood is likely to have come from an anal or low rectal condition. Dark blood (l
ike red wine) has usual\-ly come from a more proximal lesion in the large bowel.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Pain
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Pain from the ana
l canal is protracted, cramp-like and distressing. Its presence is extremely sig
nificant because haemorrhoids and rectal cancer are \i not \plain \fs20 \lang103
3 usually painful.
\par \pard \qj \fi221 \sl-221 \tx221 An annular lesion high in the rectum may ob
struct the lumen of the bowel and cause lower abdominal colic. Excessive stretch
ing of the anal canal during defaecation may cause a sharp, splitting pain.
\par \fs24 \f1 \b \pard \qc \sl-0 \tx221 Pruritis
\par \pard \qj \sl-215 \tx204 Incontinence and soiling
\par
\par
\par \pard \qc \sl-0 \tx204 Tenesmus
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This is an intens
e, painful but fruitless desire to defaecate. The rectum feels full, but when th
e patient tries to empty it, nothing appears. Tenesmus is caused by a space-occu
pying le\-sion in the lumen or wall of the rectum which mimics the presence of f
aeces.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Bowel habit
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Beware of the ter
ms \'91diarrhoea\'92 and \'91constipa\-tion\'92. Make sure that you find out wha
t the
anorectal examination \plain \fs20 \lang1033 415
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 patient means when he uses them. I
t is better to record the frequency of bowel action and the consistence of the s
tool than to use these lay
\par
\par
\par
\par \fs36 \f1 \b \pard \sl-0 \tx204 Technique for anorectal examination
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-221 \tx204 terms. What
is \'91constipation\'92 to one patient may be \'91diarrhoea\'92 to another.
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 This is commonly called a rect
al examination, but I have added the prefix \'91ano\'92 to remind you to look at
and feel the anal canal as well as the rectum.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Preparation
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Position of the p
atient
\par
\par \pard \qj \fi221 \sl-221 \tx221 Ensure adequate privacy and uncover the pat
ient from the waist to the knees.
\par \pard \qj \fi221 \sl-221 \tx221 The patient should lie in the left lateral
posi\-tion with his neck and shoulders rounded so that his chin rests on his che
st, hips flexed to 900 or more, but knees flexed to slightly less than \fs16 \f0
\b 900. \fs20 \f0 \plain \fs20 \lang1033 If the knees are flexed more than 90~
the patient\'92s ankles will get in your way.
\par \pard \qj \fi226 \sl-221 \tx226 If the patient is lying on a soft bed make
him move towards you so that his buttocks are up on the edge of the bed. This ma
kes inspection easier and tips the abdominal contents for\-wards, which helps th
e bimanal examination.
\par \pard \qj \fi238 \sl-221 \tx238 You should never omit the rectal examinatio
n from your routine examination.
\par \pard \qc \sl-0 \tx238 Equipment
\par \pard \qj \fi221 \sl-221 \tx221 You need a plastic glove or finger stall, a
n inert lubricating jelly and a good light. If you do not have a finger cot, lub
ricate your index finger with soap lather and fill the space under your nail wit
h hard soap to keep it clean. Faeces on your finger will do you no harm and wash
off easily.
\par \pard \qj \fi238 \sl-221 \tx238 Proctoscopy and sigmoidoscopy are also part
of the routine examination in an outpatient department, so ensure that the nece
ssary equip\-ment is prepared. (These techniques will not be described in this c
hapter.)
\par \pard \qj \sl-221 \tx204 Tell the patient what you are going to do
\par
\par \pard \qj \sl-221 \tx204 Tell him that you are going to examine the \'91bac
k passage\'92 and the inside of the abdomen. Tell him it will be uncomfortable b
ut not pain\par \lang1033 \pard \qj \sl-578 \tx204 ful, and ask him to relax by breathing d
eeply and letting his knees go loose.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx204 Inspection
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Lift up the upper
most buttock with your left hand so that you can see the anus, perianal skin and
perineum clearly. Look for:
\par
\par \pard \qj \li334 \fi-334 \sl-221 \tx334 1.\tab Skin rashes and excoriation.
\par \pard \qj \li232 \fi-232 \sl-221 \tx232 2.\tab Faecal soiling, blood or muc
us.
\par \pard \qj \li283 \fi-283 \sl-221 \tx283 3.\tab Scars or fistula openings.
\par \pard \qj \li255 \fi-255 \sl-221 \tx255 4.\tab Lumps and bumps (e.g. polyps
, papillomata, condylomata, perianal haematomata, pro-lapsed piles, or carcinoma
ta).
\par \pard \qj \li243 \fi-243 \sl-0 \tx243 5.\tab Ulcers, especially fissures.
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx243 Palpation
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Place the pulp of
your right index finger (suit\-ably gloved) on the centre of the anus, with the
finger parallel to the skin of the perineum and in the mid-line. Then press gen
tly into the anal canal but at the same time press backwards against the skin of
the posterior wall of the anal canal and the underlying sling of puborectalis m
uscle. This overcomes most of the tone in the anal sphincter and allows the fing
er to straight\-en and slip into the rectum. Never thrust the tip of your finger
straight in.
\par \pard \qj \fi238 \sl-221 \tx238 Look at your finger when you remove it from
the rectum, to note the colour of the faeces and the presence of blood or mucus
.
\par \pard \qj \sl-221 \tx204 The anal canal As the finger goes through the anal
canal, note the tone of the sphincter, any pain or tenderness, any thickening o
r masses.
\par \pard \qj \fi238 \sl-221 \tx238 Patients with fissures or abscesses may hav
e so much spasm and pain that rectal examination is extremely difficult. In thes
e circumstances you should \i not \plain \fs20 \lang1033 try to pass a finger. I
f the pain is so severe the patient will need treatment, and your rectal examina
tion can be postponed until the patient is anaesthetized.
\par
\par
\par
\par
\par
\par \lang1033 \fs20 \f0 \fs8 \f1 \pard \sl-0 \tx6015 \tqr \tx9921 \tab i-.. \fs
10 \f1 t \fs12 \f0 \b I.~ \fs10 \f1 \plain \fs10 \f1 \lang1033 \b L \fs10 \f5 \p
lain \fs10 \f5 \lang1033 ~I\tab J I ~ \fs8 \f5 \b ~ \fs10 \f5 \plain \fs10 \f5 \
lang1033 f~\'95\'954~ ~
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 416 \i The Rectu
m and Anal Canal
\par
\par \plain \fs20 \lang1033 \pard \sl-221 \tx204 The rectum Feel all around the
rectum as high rectum and the presence of any masses or as possible. You may hav
e to push quite hard in ulcers. If you feel a mass, try to decide if it is a fat
patient. Note the texture of the wall of the within or outside the wall of the
rectum by
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs20 \f1 \pard \li4609 \sl-198 \tx4609 As you insert your finger pull back
wards to counteract
\par \pard \li4609 \sl-198 \tx4609 the tone in the puborectalis muscle.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \pard \li4609 \sl-198 \tx4609 After examining the anal canal and rectum, pl
ace your hand on the abdomen and examine the contents of the pelvis bimanually.
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \sl-198 \tx204 Figure 18.1 The techn
ique of anorectal examination.
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f1 \pard \sl-198 \tx204 P
lace the patient in the left lateral position, hips flexed to Part the buttocks
and inspect the anus and perineum.
\par \pard \sl-198 \tx204 900, knees less flexed to \fs14 \f1 1100.
\par
\par \fs16 \f1 \i \pard \qc \sl-0 \tx204 I
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f1 \pard \sl-198 \tx204 P
lace the pulp of your finger on the anus.
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5419 \sl-0 \tx5419 Tech
nique for anorectal examination \plain \fs20 \lang1033 417
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 testing the mobility of the mu
cosa over it.
\par \pard \qj \fi238 \sl-221 \tx238 Note the contents of the rectum. The rectum
may be full of faeces (hard or soft), empty and collapsed, or empty but \'91bal
looned out\'92. Faeces may feel like a tumour but are indentable; no other mass
is indentable.
\par \pard \qj \sl-221 \tx204 If you can feel a mass at your finger tip ask the
patient to strain down. This will often move the mass down 2 cm or so and bring
it within your reach.
\par \pard \qj \sl-221 \tx204 The rectovesico/rectouterine pouch Turn your
\par \pard \qj \sl-221 \tx204 finger round so that the pulp feels forwards and
\par
\par
\par \fs20 \f1 \pard \qj \li345 \sl-0 \tx345 The ioop of puborectalrs
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 can detect any masses outside
the rectum in the peritoneal pouch between the rectum and the bladder or uterus.
\par
\par \pard \qj \sl-221 \tx204 Bimanual examination
\par
\par \pard \qj \fi226 \sl-221 \tx226 The examination of the contents of the pelv
is is helped if you place your left hand on the abdomen and feel bimanually. Thi
s gives you a much better idea of the size, shape and nature of any pelvic mass.
\par \pard \qj \sl-221 \tx204 The cervix and uterus These structures are easy to
feel per rectum, and with the help of bimanual palpation you should be able to
define the shape and size of the uterus and any ovarian masses. Do not call the
hard mass that you can feel in the anterior rectal wall a carcinoma until you ar
e sure that it is neither the cervix nor a tampon.
\par \pard \qj \sl-221 \tx204 The prostate and seminal vesicles The normal
\par
\par
\par
\par
\par
\par \fs20 \f1 \b \pard \qj \li164 \sl-0 \tx164 THE PROSTATE \fs16 \f0 \plain \f
s16 \lang1033 \b GLAND
\par \pard \qj \li2579 \sl-0 \tx2579 NORMAL
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \qj \li2534 \sl-0 \tx2534 Smooth
\par \pard \qj \li2534 \sl-0 \tx2534 Symmetrical
\par \pard \qj \li2534 \sl-0 \tx2534 Median groove
\par \pard \qj \li2579 \sl-0 \tx2579 Rubbery
\par \pard \qj \li2534 \sl-0 \tx2534 Mobile mucosa
\par
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \li7143 \sl-0 \tx7143 HVPERTROPHIC
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \li7143 \sl-0 \tx7143 Smooth
\par \pard \li7143 \sl-0 \tx7143 Asymmetrical
\par \fs20 \f1 \b \pard \li7143 \sl-0 \tx7143 Large
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \li7143 \sl-0 \tx7143 Median gro
ove
\par \pard \li7148 \sl-0 \tx7148 Rubbery
\par \pard \li7143 \sl-0 \tx7143 Mobile mucosa
\par
\par \lang1033 \fs20 \f0 \fs20 \f1 \pard \li1508 \sl-198 \tx1508 Pull backwards
as you insert your finger to \fs18 \f1 counteract \fs20 \f1 the pull of puborect
alis
\par
\par
\par \b \pard \sl-198 \tx204 Figure 18.2 \plain \fs20 \f1 \lang1033 The puborect
alis muscle forms a loop which helps keep the anal canal closed. As you insert y
our finger into the anal canal you must oppose this tone by pressing your finger
backwards.
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \li2466 \sl-0 \tx2466 MALIGNANT
\par
\par
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \li2534 \sl-0 \tx2534 Irregular
\par
\par
\par \pard \li2534 \sl-0 \tx2534 Asymmetrical
\par
\par
\par \pard \li2534 \sl-0 \tx2534 Loss of median groove
\par
\par
\par \fs20 \f1 \b \pard \li2466 \sl-0 \tx2466 Hard
\par
\par
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \li2534 \sl-0 \tx2534 Mucosa may
be fixed
\par
\par
\par \pard \li2534 \sl-0 \tx2534 Lateral extension
\par \fs20 \f1 \b \pard \qc \sl-0 \tx2534 Figure 18.3
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \fs14 \f1 \pard \qc \sl-0 \tx253
4 -K
\par
\par \fs10 \f1 \pard \qc \sl-0 \tx2534 \'97 \'97
\par \fs8 \f1 \pard \qc \sl-0 \tx2534 ,, \fs10 \f1 \'97
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \sl-0 \tx204 418
\fs20 \f0 \plain \fs20 \lang1033 \i The Rectum and Anal Canal
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 prostate gland is firm, rubber
y, bibbed and 2\'973 cm across. Its surface should be smooth, with a shallow cen
tral sulcus, and the rectal mucosa should move freely over it. The seminal vesic
les may be palpable just above the upper lateral edges of the gland.
\par \pard \qj \fi238 \sl-221 \tx238 Benign hypertrophy of the prostate causes
\par \pard \qj \sl-221 \tx204 enlargement of the whole gland but the central sul
cus is one of the last features to disappear. The hypertrophy affects the whole
gland, which bulges backwards into the rectum. The gland may feel lobulated. The
overlying rectal mucosa remains uninvolved and mobile.
\par \lang1033 \pard \qj \fi221 \sl-221 \tx221 Carcinoma of the prostate causes
an irregular, hard enlargement which is often unilateral. The edge of the enlarg
ed area is indistinct.
\par \pard \qj \fi221 \sl-221 \tx221 If the tumour has spread out into the floor
of the pelvis you will feel thickening either side of the gland, which can some
times encircle the rectum. This lateral thickening is described as \'91winging\'
92 of the prostate.
\par \pard \qj \fi221 \sl-221 \tx221 The central sulcus may be distorted or obli
ter\-ated at an early stage of the disease and the rectal mucosa fixed to the un
derlying gland.
\par
\par \lang1033 \fs20 \f0 \fs36 \f1 \b \pard \sl-0 \tx204 Conditions presenting w
ith rectal bleeding
\par
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qc \sl-0 \tx204 HAEMORRHOIDS
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Haemorrhoids, com
monly called \'91piles\'92, are en\-larged congested patches of the mucosa and s
ubmucosa at the level of the anorectal junction.
\par \pard \qj \fi221 \sl-221 \tx221 The normal vascular plexus of the submucosa
is expanded at the anorectal junction to form three anal \'91cushions\'92. Thes
e cushions help close the anal canal, but if they enlarge they can prolapse, be
damaged, bleed, and even become pedunculated, that is to say, turn into piles.
\par
lain \fs20 \lang1033 Piles occur at all ages but are uncom\-mon below the age of
20 years. When they occur in children they are often secondary to vascular malf
ormations in the pelvis.
\par \i \pard \qj \fi238 \sl-221 \tx238 Symptoms. \plain \fs20 \lang1033 Uncompl
icated piles do not cause pain. The two common symptoms they cause are bleeding
and a palpable lump (or prolapse) after defaecation. They may also cause periana
l discomfort and pruritis and a mucous discharge.
\par \pard \qj \fi221 \sl-221 \tx221 The bleeding occurs after defaecation. If i
t is a small quantity it may just stain the toilet paper or streak the faeces, b
ut if it is copious it may splash around the lavatory pan and cause anaemia.
\par \pard \qj \fi238 \sl-221 \tx238 The patient notices the lump when cleaning
himself after defaecation. It may return to the rectum spontaneously or need to
be pushed back.
\par \lang1033 \pard \qj \fi238 \sl-221 \tx238 Piles are categorized into three
degrees on the basis of the history:
\par \pard \qj \li612 \fi-369 \sl-221 \tx243 \tx612 (a)\tab \i First degree \pla
in \fs20 \lang1033 piles bleed but do not pro\-lapse.
\par \pard \qj \li629 \fi-391 \sl-221 \tx238 \tx629 (b)\tab \i Second degree \pl
ain \fs20 \lang1033 piles prolapse but reduce spontaneously.
\par \pard \qj \li657 \fi-431 \sl-221 \tx226 \tx657 (c)\tab \i Third degree \pla
in \fs20 \lang1033 piles prolapse and must be reduced manually.
\par \pard \qj \fi226 \sl-221 \tx226 Although it is worthwhile classifying piles
in this way as it helps decide the form of treat\-ment, it is an artificial cla
ssification. All piles are prolapsed during defaecation and this is when they bl
eed. If they return to their proper place when the anal sphincter closes they ar
e never felt by the patient and are, therefore, called first degree piles. Secon
d degree piles are vascular pads which remain down below the sphincter when it c
ontracts and then return slowly but spontaneously, while third degree piles are
so big and pendulous that they have to be pushed back.
\par \i \pard \qj \fi238 \sl-221 \tx238 Cause. \plain \fs20 \lang1033 Many patie
nts with piles are consti\-pated and strain a lot during defaecation. The patien
ts believe this is the cause of their piles and they are probably right.
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi209 \sl-221 \tx209 First a
nd second degree piles. \plain \fs20 \lang1033 Piles which are not prolapsed can
not be felt with the finger. They are indistinguishable from normal mu\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5142 \sl-0 \tx5142 Conditions pre
senting with rectal bleeding \plain \fs20 \lang1033 419
\par \fs20 \f0 \lang1033 \fs20 \f0 \fs20 \f1 \pard \sl-198 \tx204 Third degree (
prolapsed) haemorrhoids. The epithelium covering the 3 o\'92clock pile is becomi
ng thick and white. The 7 o\'92clock pile is bleeding.
\par \lang1033 \fs20 \f0 \fs20 \f1 \pard \qj \sl-198 \tx204 Prolapsed, strangula
ted, thrombosed haemorrhoids. Note the bloody serous discharge.
\par
\par \fs20 \f0 \pard \qj \sl-221 \tx204 cosa, and can only be diagnosed with a p
rocto\-scope.
\par \pard \qj \fi238 \sl-221 \tx238 When a proctoscope is withdrawn through a n
ormal anal canal the red\'97blue mucosa can be seen collapsing over the end of t
he proctoscope. Piles are purple and bulge so much that they protrude into the e
nd of the proctoscope. The multiple longitudinal corrugations are lost and three
deep clefts appear between the bulging piles.
\par \pard \qj \fi221 \sl-221 \tx221 The three common primary piles are at 3, 7
and 11 o\'92clock (when the patient is in the
\par \lang1033 \fs8 \f5 \b \pard \sl-0 \tx204 - \fs12 \f1 \plain \fs12 \f1 \lang
1033 \b I \fs18 \f1 \plain \fs18 \f1 \lang1033 r \fs12 \f5 .~\'91~p4
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \qc \sl-0 \tx204 Figure 18.4
\tx204 420 \i The Rectum and Anal Canal
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \sl-0 \tx2375 A\tab \fs20 \f0 \plain
\fs20 \lang1033 B
\par \fs8 \f5 \b \pard \li3163 \fi-176 \sl-0 \tx2987 \tx3163 ~\tab + 4
\par \fs10 \f1 \plain \fs10 \f1 \lang1033 \pard \li3129 \sl-0 \tx3129 .4-,,
\par \fs8 \f5 \b \pard \li3163 \sl-164 \tx3163 \tx3395 +\tab 4 \fs10 \f1 \plain
\fs10 \f1 \lang1033 .4 +
\par \pard \sl-164 \tx3163 \tx3395
\par \pard \li3412 \fi-283 \sl-0 \tx3129 \tx3412 +\tab \fs8 \f5 \b +
\par \pard \qc \sl-0 \tx3129 \tx3412 + \fs8 \f6 \plain \fs8 \f6 \lang1033 \b 4
\par \fs10 \f1 \plain \fs10 \f1 \lang1033 \pard \qc \sl-0 \tx3129 \tx3412 -4\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 cumstances is painful and difficul
t because of spasm.
\par \pard \fi238 \sl-221 \tx238 Piles are painful only when such complica\-tion
s occur.
\par \lang1033 \fs20 \f0 \pard \qj \li2488 \sl-0 \tx2488 D
\par
\par
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx2488 e 0
\par \pard \qc \sl-0 \tx2488 o
\par \pard \qc \sl-0 \tx2488 66
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \b \pard \qj \sl-198 \tx204 Figure 18.
5 \plain \fs20 \f1 \lang1033 The way in which haemorrhoids bleed (A) The vascula
r pads which become haemorrhoids close the anorectal junction. (B) During defaec
ation the
\par \pard \sl-198 \tx204 sphincter relaxes, the anal canal everts and the haemo
rrhoids are compressed by the faeces. The faeces scratch the mucosa. (C) After t
he faeces have passed, the haemorrhoids are left scratched and unsupported so th
ey d\'f1p blood onto the faeces. (D) If they do not retract when the sphincter b
egins to close their venous drainage is obstructed and the bleeding is made wors
e so that \fs18 \f1 it \fs20 \f1 splashes into the pan.
\par
\par
\par
\par \fs20 \f0 \pard \qj \sl-221 \tx204 lithotomy position), the sites of the th
ree anal cushions.
\par \pard \qj \fi238 \sl-221 \tx238 Do not forget \fs8 \f1 \'97 \fs20 \f0 you c
annot diagnose haemor\-rhoids with your finger.
\par \i \pard \qj \fi221 \sl-221 \tx221 Third degree piles. \plain \fs20 \lang10
33 If you are fortunate (and the patient unfortunate!) you may see the piles pro
lapsed. They are bluish-purple swellings, usually 0.5\'971 cm in diameter, in th
e 3, 7 or 11 o\'92clock positions. Their distinguishing and di\-agnostic feature
is their mucosal covering, rec\-ognized by its soft, velvety, mucous-producing
surface.
\par \pard \qj \fi238 \sl-221 \tx238 The other common cause of a localized anal
swelling is the perianal haematoma. This lesion is always covered by skin, which
distinguishes it from a mucosa-covered prolapsed haemor\-rhoid.
\par \pard \qj \fi221 \sl-221 \tx221 If piles remain prolapsed they ulcerate and
bleed. If the submucous veins thrombose, the pile becomes tense, hard and oedem
atous. Palpation and rectal examination in these cir\\par \lang1033 \pard \qc \sl-0 \tx221 C
\par
\par
\par
\par \fs14 \f1 \pard \qc \sl-0 \tx221 ~Li \fs20 \f0 6
\par \fs20 \f1 \b \pard \qc \sl-0 \tx221 -J
\par \fs8 \f5 \plain \fs8 \f5 \lang1033 \b \pard \qc \sl-0 \tx221 + \fs10 \f1 \p
lain \fs10 \f1 \lang1033 + 4
\par \pard \qc \sl-0 \tx221 + 4
\par \pard \qc \sl-0 \tx221 f 4+
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 CARCINOMA OF THE
RECTUM
\par
\par
rectum is diagnosed on the history, the findings on rectal examination and sigmo
idoscopy, and finally by biopsy.
\par \pard \qj \fi221 \sl-221 \tx221 Seventy-five per cent of carcinomata of the
rectum occur in the lower part of the rectal ampulla, where they tend to be pap
illiferous or a simple ulcer with an everted edge. The re\-maining 25 per cent a
re in the upper part of the rectum and often have an annular (\'91cotton reel\'9
2) shape.
\par \pard \qj \fi238 \sl-221 \tx238 About 90 per cent of rectal cancers can be
felt with your finger.
\par \pard \qj \fi209 \sl-221 \tx209 Every patient with any rectal complaint mus
t have a rectal examination. You are being negli\-gent if you fail to perform a
rectal examination on a patient complaining of rectal bleeding.
\par
lain \fs20 \lang1033 Rectal carcinoma is common in middle and old age but can oc
cur in young adults.
\par \i \pard \qj \fi221 \sl-221 \tx221 Sex. \plain \fs20 \lang1033 It is common
in both sexes.
monest symptom is rec\-tal bleeding, usually a small amount of red blood streake
d on the stool. Sometimes enough blood accumulates in the rectum to be passed by
itself, but this is uncommon. Mucus may also be passed. \fs8 \f1 \par \fs20 \f0 \pard \qj \fi221 \sl-221 \tx221 Low rectal cancers cause a vague
change in bowel habit, usually a little constipation.
\par \pard \qj \fi221 \sl-221 \tx221 High cancers of the annular variety may cau
se partial obstruction which presents as alternating episodes of diarrhoea and c
onstipa\-tion. The constipation is caused by the obstruc\-tion. The diarrhoea fo
llows irritation of the colon above the obstruction by the impacted faeces, whic
h gradually liquefy and, when they are fluid, pass through the carcinomatous ste
no\-sis and appear as diarrhoea.
\par \pard \qj \fi221 \sl-221 \tx221 Tenesmus occurs when a tumour in the lower
part of the rectum reaches a size large enough to be mistaken by the patient\'92
s rectal sensory
senting with anal pain \plain \fs20 \lang1033 421
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 mechanisms for faeces. The pat
ient has a persis\-tent, sometimes painful, desire to empty his rectum but canno
t do so.
\par \pard \qj \fi226 \sl-221 \tx226 Even small, symptomless, primary lesions ma
y be associated with multiple metastases and cause general debility and malaise.
The preaor\-tic lymph nodes and the liver are the first sites to be invaded by
metastases.
\par \pard \qj \fi238 \sl-221 \tx238 Pain is an uncommon symptom of carcinoma of
the rectum. It can be of three types.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 1.\tab Colic, with distension and v
omiting, caused by annular tumours obstructing the lumen of the bowel.
\par \pard \qj \li238 \fi-238 \sl-221 \tx238 2.\tab Local pain in the rectum, pe
rineum or lower abdomen, caused by direct spread of the tumour to surrounding st
ructures, especially the sacral nerves.

\par \pard \qj \li238 \fi-238 \sl-221 \tx238 3.\tab Pain during defaecation; thi
s is uncommon but can occur if the tumour has spread downwards into the sensitiv
e anal canal.
Long-standing ulcerative colitis increases the chance of malignant change in th
e colon and rectum fortyfold. Always ask about any previous large bowel symptoms
, par\-ticularly recurrent episodes of diarrhoea associ\-ated with the passage o
f mucus and blood. The fact that the ulcerative colitis has been quiescent for m
any years does not reduce the increased chance of malignant change.
\par \i \pard \qj \fi238 \sl-221 \tx238 Family history. \plain \fs20 \lang1033 P
olyposis coli is a rare but definitely premalignant condition. The family histor
y may reveal that the patient\'92s parents or siblings have had rectal bleeding,
abdominal pain caused by their polyps. or even surgical excision of their colon
for carcinoma.
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Rectal
examination. \plain \fs20 \lang1033 There is usually nothing abnormal to see aro
und the anus, but in 90 per cent of cases rectal examination reveals the carcino
ma. What can be felt depends upon the site of the lesion. If the tumour is low i
n the ampulla the finger can feel the whole lesion. Papilliferous tumours feel s
oft and frond-like, and have a narrow pedicle. Sessile, soft lesions such as vil
lous carcinomata may be impalpable.
\par \pard \qj \fi232 \sl-221 \tx232 A carcinomatous ulcer feels hard and bulges
into the lumen of the rectum. Its edge is usually everted and its base is irreg
ular and friable.
\par \pard \qj \fi221 \sl-221 \tx221 Iry to decide if the tumour is fixed or mob
ile and whether there is any local spread.
\par \pard \qj \sl-221 \tx204 If the cancer is in the upper part of the rectum
\par \lang1033 \pard \qj \sl-221 \tx204 you may feel only its lower edge. In the
se circumstances it may be difficult to decide if the lesion you are feeling is
inside or outside the rectum. This question is answered by inspecting it through
a sigmoidoscope.
\par
\par
\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 General examination
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Lymph from the re
ctum drains to the preaortic lymph glands. These glands are rarely palpable.
\par \pard \qj \fi221 \sl-221 \tx221 The inguinal lymph glands become enlarged o
nly when the tumour has spread down to the lymphatics of the anal canal or ischi
orectal fossa.
\par \pard \qj \fi238 \sl-221 \tx238 It is important to examine all the sites li
kely to contain metastases, particularly the supracla\-vicular lymph nodes, the
lungs, the liver and the skin.
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 ADENOMA OF THE RECTUM
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Benign neoplasms
of the rectum are called ade\-nomas. They may be pedunculated or sessile, small
or large (occupying a large part of the rectum). Between 30 and 50 per cent of l
arge adenomata contain a focus of malignant inva\-sion, making them into carcino
mata.
\par \pard \qj \fi226 \sl-221 \tx226 There is bleeding, mucous discharge and dia
rrhoea.
\par \pard \qj \fi232 \sl-221 \tx232 Adenomata are soft and often difficult to f
eel on rectal examination.

\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 DIVERTICULAR DISEASE
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Diverticular dise
ase usually presents with chro\-nic left-sided abdominal pain and constipation,
or acute abdominal symptoms. These are dis\-cussed in Chapter 16.
\par \pard \qj \fi232 \sl-221 \tx232 However, the disease may present with recta
l bleeding, hence its appearance in this chapter. The bleeding is typically acut
e, massive, and fresh. The patient feels a little faint, gets lower abdominal pa
in, and then has a desire to de\-faecate. When he empties his rectum he passes 1
00-500 ml of fresh blood.
\par \pard \qj \fi226 \sl-221 \tx226 This type of bleeding is uncommon and the w
ise clinician accepts diverticular disease as the cause of a patient\'92s rectal
bleeding only after he has excluded all other possible causes, such as carcinom
a, adenoma and vascular abnormali\-ties.
\par \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 422 \i The Rectum and Anal
Canal
\par
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 Conditions prese
nting with anal pain
\par
\par
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-215 \tx204 PERIANAL \'91HAEM
ATOMA\'92
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The name of this
condition is well established, but most authorities no longer believe that it is
an extravascular haematoma. It is probably a large thrombus in a vein of the su
bcutaneous perianal plexus, caused by excessive stretching of the anus when pass
ing a very bulky hard stool, or the sudden changes in sphincter tone and rectal
pressure that occur during the pre\-cipitous emptying of the rectum in acute di\
-arrhoea.
\par \pard \qj \fi221 \sl-221 \tx221 Perianal haematomata are also common after
childbirth, following the straining and stretch\-ing of the perineum during the
second stage of labour.
\par \pard \qj \fi226 \sl-221 \tx226 The thrombus causes a surrounding in\-flamm
atory reaction of pain and oedema.
\par
lain \fs20 \lang1033 Perianal haematomata occur at all ages. \i Sex. \plain \fs2
0 \lang1033 Excepting the postpartum variety, they are equally common in men and
women.
\par \i \pard \qj \fi221 \sl-221 \tx221 Symptoms. \plain \fs20 \lang1033 The dom
inant symptom is a pain, which begins gradually, increases in severity over a fe
w hours or days and then subsides spontaneously over a period of 4\'975 days. It
is a continuous discomfort, made worse by sitting, moving and defaecation.
\par \pard \qj \fi238 \sl-221 \tx238 It is clearly localized by the patient to t
he lump.
\par \pard \qj \fi238 \sl-221 \tx238 The lump appears at the same time as the pa
in. At first it is small and spherical but may gradually enlarge and become more
painful.
\par \pard \qj \fi221 \sl-221 \tx221 Bleeding occurs if the lump bursts through
the skin or if the skin over the lump ulcerates.
\par \pard \qj \fi238 \sl-221 \tx238 The patient often notices that the perianal
skin is moist and itchy. This is caused by an increased secretion from the anal
glands on to the surrounding skin.
\par \pard \qj \fi221 \sl-221 \tx221 Perianal haematomata are often multiple and
the patient has often had a previous \'91attack\'92.
t may remember that the symptoms began after an uncomfortable de\-faecation, but
as the haematoma may take a few hours to form the connection is not always obvi
ous.
\par \lang1033 \pard \qj \fi221 \sl-221 \tx221 The patient always thinks that he
has an attack of \'91piles\'92. Do not be misled by his belief. Perianal haemat
omata are \i not \plain \fs20 \lang1033 piles.
\par
\par
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Positio
n. \plain \fs20 \lang1033 The lump may be anywhere around the anal margin. More
than one may be present.
\par \i \pard \qj \fi238 \sl-221 \tx238 Colour. \plain \fs20 \lang1033 When it i
s close to the skin and the skin is not oedematous, the lump has a deep red\'97p
urple colour. If the skin becomes oedema\-tous the redness of the underlying blo
od clot cannot be seen.
\par \i \pard \qj \fi221 \sl-221 \tx221 Tenderness. \plain \fs20 \lang1033 The l
ump is tender, but disprop\-ortionately less than you would expect from the pain
felt by the patient; but it becomes very tender if it becomes oedematous and ul
cerated.
\par \i \pard \qj \fi221 \sl-221 \tx221 Shape and size. \plain \fs20 \lang1033 T
he initial lump is spherical, 0.3\'971.0 cm diameter. If the anal skin is lax th
e lump may become polypoid. This invariably happens when it becomes oedematous.
\par \i \pard \qj \fi238 \sl-221 \tx238 Surface. \plain \fs20 \lang1033 Perianal
haematomata are covered by skin. The skin may be normal or oedematous but it is
always clearly recognizable as skin. That part of the lump which rubs against t
he skin of the buttocks may be rubbed raw.
\par \pard \qj \fi238 \sl-221 \tx238 The surface of the lump beneath the skin is
smooth.
\par \i \pard \qj \fi238 \sl-221 \tx238 Composition. \plain \fs20 \lang1033 The
central lump can be felt as a hard, hemispherical mass. A cluster of many small
haematomata feels like a small bunch of grapes. Individual lumps are too small t
o feel fluctuant.
\par \i \pard \qj \fi238 \sl-221 \tx238 Relations. \plain \fs20 \lang1033 The ma
ss is under the perianal skin, and superficial to the external sphincter.
\par \pard \qj \fi238 \sl-221 \tx238 It is not fixed to the skin or the deep str
uc\-tures and cannot be reduced into the anal canal.
\par \i \pard \qj \fi238 \sl-221 \tx238 State \fs22 \f1 \plain \fs22 \f1 \lang10
33 \i of local \fs20 \f0 \plain \fs20 \lang1033 \i tissues. \plain \fs20 \lang10
33 The remainder of the anal skin and anal canal is usually normal but there may
be a palpable cord running up the anal canal from the haematoma. This is prob\ably caused by thrombosis in the vein that has been damaged.
\par \i \pard \qj \fi221 \sl-221 \tx221 Lymph drainage. \plain \fs20 \lang1033 T
he inguinal nodes should not be enlarged.
\par \fs24 \f1 \b \pard \sl-209 \tx4575 FISSURE-IN-ANO\tab \fs20 \f0 \plain \fs2
0 \lang1033 patient becomes frightened to defaecate. This\line \pard \sl-209 \tx
4575 \tab makes him more constipated, which makes the\line \pard \sl-209 \tx4575
An anal fissure is a longitudinal split in the skin\tab pain still worse when h
e eventually evacuates\line \pard \sl-209 \tx4575 of the anal canal.\tab his rec
tum. A vicious circle is established.\line \pard \sl-209 \tx4575 An acute tear

is quite a common event and\tab Acute fissures bleed sufficiently to streak the
\line \pard \sl-209 \tx4575 usually heals quickly. If the tear is reopened\tab s
tool with blood and stain the toilet paper.\line \pard \sl-209 \tx4575 every tim
e the patient defaecates, because he is\tab Chronic fissures bleed less and usua
lly cause\line \pard \sl-209 \tx4575 constipated and has a high sphincter tone,
its\tab just a little blood-staining of the toilet paper.\line \pard \sl-209 \tx
4575 base becomes fibrous and does not heal. \fs30 \f1 n\tab \fs20 \f0 A small
skin tag (called a sentinel tag) may\line \pard \sl-209 \tx4575 \tab form at the
lower end of a chronic fissure which\line \pard \sl-209 \tx4575 becomes, in fac
t, a chronic ulcer.\tab the patient can feel.
\par \pard \sl-221 \tx4575 \tab The patient complains of constipation and\line
\fs22 \f1 \i \pard \sl-221 \tx4575 History\tab \fs20 \f0 \plain \fs20 \lang1033
realizes that it \fs20 \f1 is \fs20 \f0 the hard bulky stool which\line \pard \s
l-221 \tx4575 \i Age. \plain \fs20 \lang1033 Acute fissures are quite common in
\tab causes the pain.\line \pard \sl-221 \tx4575 children who often pass bulky s
tools very\tab \i Persistence. \plain \fs20 \lang1033 The symptoms of fissure a
re\line \pard \sl-221 \tx4575 quickly.\tab slow to develop and long-standing. Th
ey hardly\line \pard \sl-221 \tx4575 Chronic fissures are most common in patien
ts\tab ever disappear spontaneously, but often vary in\line \pard \sl-221 \tx457
5 between the ages of 20 and 40 years. They\tab severity from week to week. Many
patients\line \pard \sl-221 \tx4575 frequently begin in women after childbirth.
\tab suffer for months before going to see their\line \pard \sl-221 \tx4575 \i
Sex. \plain \fs20 \lang1033 Fissure-in-ano is a little more common\tab doctor.\l
ine \pard \sl-221 \tx4575 in men than women.\tab \i Cause. \plain \fs20 \lang1
033 The patients either believe that their\line \pard \sl-221 \tx4575 \i Sympto
ms. \plain \fs20 \lang1033 Both acute and chronic fissures\tab symptoms are caus
ed by constipation or think\line \pard \sl-221 \tx4575 are very painful. The pai
n begins during de-\tab that their distressing pain must indicate some\line \par
d \sl-221 \tx4575 faecation and persists for minutes or hours\tab dreadful, incu
rable disease.
\par \pard \sl-311 \tx204 afterwards. The pain can be so severe that the
\par \fs20 \f1 \b \pard \sl-209 \tx4586 A \fs24 \f1 \plain \f1 \lang1033 \b B\ta
b \fs22 \f1 \plain \fs22 \f1 \lang1033 \i Examination\line \pard \sl-209 \tx4586
\tab \fs20 \f0 \plain \fs20 \lang1033 \i Position. \plain \fs20 \lang1033 The
majority of fissures are in the\line \pard \sl-209 \tx4586 \tab mid-line, poster
iorly, but some are anterior and\line \pard \sl-209 \tx4586 \tab a few lateral.\
line \pard \sl-209 \tx4586 \tab The diagnosis is made by gently parting the\lin
e \pard \sl-209 \tx4586 \tab skin of the anus and looking for a split in the\lin
e \pard \sl-209 \tx4586 \tab anal skin. This may be all that you will be\line \p
ard \sl-209 \tx4586 \tab allowed to do, because further examination is\line \par
d \sl-209 \tx4586
C\tab often prevented by pain.\line \pard \sl-209 \tx
4586 \tab \i Tenderness. \plain \fs20 \lang1033 The anal sphincter is usually
in\line \pard \sl-209 \tx4586 \tab spasm, and any attempt to open the sphincter\
line \pard \sl-209 \tx4586 \tab by firm traction on the buttocks or inserting a\
line \pard \sl-209 \tx4586 \tab finger into the rectum is exquisitely painful. I
n\line \pard \sl-209 \tx4586
\fs36 \f5 \b 0 0\tab \fs20 \f0 \plain \fs20 \l
ang1033 these circumstances rectal examination is con\--\line \pard \sl-209 \tx4
586 \tab traindicated.\line \pard \sl-209 \tx4586 \tab \i Rectal examination. \
plain \fs20 \lang1033 If the pain and tender\--\line \pard \sl-209 \tx4586 \tab
ness are not severe you may be able to perform\line \pard \sl-209 \tx4586 \tab a
rectal examination and feel the defect in the\line \pard \sl-209 \tx4586
18
.6 The way in which a fissure bleeds. (A) The\tab anal canal skin and some surro
unding indura\--\line \pard \sl-209 \tx4586 Figure\tab hon. There will often be
a streak of fresh blood\line \pard \sl-209 \tx4586 split in the anal canal is cl
osed when the anal canal is\line \pard \sl-209 \tx4586 shut. (B) Faeces split op
en the fissure as they pass it and\tab on the finger stall when it is withdrawn.
\line \pard \sl-209 \tx4586 make it bleed; they become streaked with blood. (C)
The\tab \i Proctoscopy. \plain \fs20 \lang1033 It is most unlikely that this wi
ll\line \pard \sl-209 \tx4586 fissure is painful so the sphincter closes tightly
. Any\tab be possible, but when it is you will see the open,\line \pard \sl-209
\tx4586 blood remaining on the perianal skin will be wiped away\tab raw base of
the fissure as the instrument is\line \pard \sl-209 \tx4586 on the toilet paper.
\tab withdrawn through the anal canal.
Canal
\par \lang1033 \fs20 \f0 \pard \qc \sl-0 \tx204 FISTULA-IN-ANO
\par
\par \pard \qj \sl-221 \tx204 A fistula is a track lined with epithelium or gran
ulation tissue connecting two epithelial sur\-faces such as those in two body ca
vities or one cavity and the body\'92s external surface.
\par \pard \qj \fi209 \sl-221 \tx209 A fistula-in-ano connects the lumen of the
rectum or anal canal with the external surface. It is usually lined with granula
tion tissue. In most instances it is caused by an anorectal abscess in the inter
sphincteric space bursting in two direc\-tions \fs8 \f1 \'97 \fs20 \f0 internall
y into the anal canal, and exter\-nally into the skin.
\par \pard \qj \fi221 \sl-221 \tx221 The abscess may be secondary to another rec
tal inflammatory disease such as ulcerative colitis or Crohn\'92s disease.
\par \pard \qj \fi221 \sl-221 \tx221 Some fistulae are caused by direct infiltra
tion and necrosis of a tumour. The rectal neoplasm most likely to present with a
fistula-in-ano is the colloid carcinoma.
\par \pard \qj \fi221 \sl-221 \tx221 Fistulae-in-ano can run through a variety o
f anatomical planes% subcutaneous, submucous, between the sphincter muscles, or
above the sphincter.
\par
\par
lain \fs20 \lang1033 Fistula-in-ano can occur at any time during adult life.
monest symptom is a watery or purulent discharge from the external opening of th
e fistula.
\par \pard \qj \fi238 \sl-221 \tx238 There may be recurrent episodes of pain if
the centre of the fistula fills with pus. If the pus does not discharge down the
fistula the pain becomes intense and throbbing.
\par \pard \qj \fi221 \sl-221 \tx221 The discharge makes the perianal skin wet a
nd macerated and causes pruritus ani.
\par \pard \qj \fi221 \sl-221 \tx221 There is not usually any difficulty with de
\-faecation or any bleeding.
\par \i \pard \qj \fi238 \sl-221 \tx238 Persistence. \plain \fs20 \lang1033 The
symptoms may be episodic as the degree of infection in the fistula varies, but t
he condition hardly ever cures itself be\-cause the external opening is always t
oo small to allow proper drainage.
\par \i \pard \qj \fi221 \sl-221 \tx221 Other symptoms \plain \fs20 \lang1033 (d
irect questions). Approx\-imately 50 per cent of fistulae may be secondary to Cr
ohn\'92s disease, tuberculosis, carcinoma of the rectum, or lymphogranuloma. The
se all pro\-duce systemic as well as local bowel symptoms, so take a careful gen
eral history.
\par \lang1033 \fs20 \f1 \b \pard \qc \sl-0 \tx221 L
\par
\par
\par
\par \fs18 \f1 \plain \fs18 \f1 \lang1033 \pard \qj \li566 \sl-0 \tx566 E \fs10
\f1 = \fs18 \f1 external sphincter
\par \pard \sl-0 \tx617 \tx827 \tab I\tab internal sphincter
\par
\par \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure \fs20 \f0 \plain \fs20 \lang10
33 18.7 \fs20 \f1 The varieties of fistula-in-ano.
\par
\par
\par
\par
\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 Local Examination
n. \plain \fs20 \lang1033 The external opening of the fistula will be visible as
a puckered scar or a small tuft of granulation tissue, within 2\'974 cm of the
anal canal.
\par \pard \qj \fi226 \sl-221 \tx226 Fistulae can open anywhere around the anus,
but the majority of openings are in the postero\-lateral area. There may be mor
e than one opening.
\par \i \pard \qj \fi221 \sl-221 \tx221 Tenderness. \plain \fs20 \lang1033 The o
pening of the fistula is not tender but the tissues deep to it may be thick\-ene
d and tender.
\par \i \pard \qj \fi238 \sl-221 \tx238 Discharge. \plain \fs20 \lang1033 The di
scharge, which can be ser\-ous or purulent, may be visible on the skin.
33 Rectal examination is not painful. The internal opening of the fistula can us
ually be identified as an area of induration under the mucosa. Two-thirds are po
sterior, one-third anterior.
\par \pard \qj \fi226 \sl-221 \tx226 The indurated track of the fistula between
the internal and external openings can be felt by palpating the wall of the anus
between your index finger in the rectum, and your thumb (or other hand) on the
perianal skin.
\par \pard \qj \fi226 \sl-221 \tx226 Take care to perform a full rectal examinat
ion. Look for other diseases, such as a carcinoma, which might be the cause of t
he fistula. Proctos\-copy and sigmoidoscopy are essential to ex\\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li5419 \sl-0 \tx5419 Conditions pre
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 18.8 \plai
n \fs20 \f1 \lang1033 Fistula in ano. Multiple openings behind and to the left o
f the anus. Although the opening looks as if it is healing there is a track lead
ing through the
\par \pard \qj \sl-198 \tx204 muscles to the anal canal.
\par
\par \fs20 \f0 \pard \qj \sl-221 \tx204 dude underlying diseases such as Crohn\'
92s dis\-ease, carcinoma and tuberculosis.
\par \pard \qj \fi238 \sl-221 \tx238 It is not a good idea for students to pass
probes into fistulae; leave that for the consul\-tant.
\par \i \pard \qj \fi209 \sl-221 \tx209 Local lymph glands. \plain \fs20 \lang10
33 The inguinal lymph glands which receive lymph from the anal canal should not
be enlarged unless the fistula is acutely inflamed or secondary to an infiltrati
ng carcinoma. Inguinal lymphadenopathy is a prominent feature of fistulae caused
by lym\-phogranuloma.
\par \i \pard \qj \fi221 \sl-221 \tx221 State of local tissues. \plain \fs20 \la
ng1033 It cannot be repeated too often that the anus and rectum must be careful\
-ly examined to exclude serious causes of the fistula. If the fistula was solely
caused by a simple intersphincteric or ischiorectal abscess, the rest of the an
us and rectum is likely to be normal.
\par
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Many of the disea
ses mentioned above may have associated abdominal and general clinical signs, so
\i never \plain \fs20 \lang1033 confine your examination to the patient\'92s pe
rineum.
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-0 \tx204 ANORECTAL ABSCESS
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 fection
probably begins in an anal gland from which pus either tracks down to the perin
eum between the sphincters or penetrates the exter\-nal sphincter to reach the i
schiorectal fossa.
\par
lain \fs20 \lang1033 Anorectal abscess is common between the ages of 20 and 50 y
ears.
\par \i \pard \qj \fi238 \sl-221 \tx238 Sex. \plain \fs20 \lang1033 It is seen m
ore often in men than women.
\par \i \pard \qj \fi221 \sl-221 \tx221 Symptoms. \plain \fs20 \lang1033 The mai
n symptom is a severe, throbbing pain which makes sitting, moving and defaecatio
n difficult and is exacerbated by them all.
\par \pard \qj \fi226 \sl-221 \tx226 The patient may have felt a tender swelling
close by the anus.
\par \i \pard \qj \fi238 \sl-221 \tx238 Systemic effects. \plain \fs20 \lang1033
The general symptoms of an abscess \fs8 \f1 \'97 \fs20 \f0 malaise, loss of app
etite, sweating and even rigors \fs8 \f1 \'97 \fs20 \f0 may be present.
n. \plain \fs20 \lang1033 The painful area lies lateral to the anus in the soft
tissues between the anus and the ischial tuberosity, but it may encircle the who
le of the posterior half of the anus.
\par \i \pard \qj \fi238 \sl-221 \tx238 Tenderness. \plain \fs20 \lang1033 The w
hole area is \i very \plain \fs20 \lang1033 tender.
\par \i \pard \qj \fi209 \sl-221 \tx209 Colour and temperature. \plain \fs20 \la
ng1033 The overlying skin eventually becomes hot and red, but the abscess \fs20
\f1 has \fs20 \f0 to be quite big before these skin changes appear.
\par \i \pard \qj \fi209 \sl-221 \tx209 Shape, size and composition. \plain \fs2
0 \lang1033 It is not usually possible to define the features of the mass. Its s
urface is indistinct. Its size, can be crudely assessed (when it is large) by bi
manual palpa\-tion with a finger in the rectum and one on the overlying skin. It
is usually too tender to test for fluctuation.
33 This is possible but very painful and best deferred until the patient is anae
sthetized. The abscess may bulge into the side of the lower part of the rectum,
and the rectum on the side of the abscess feels hot.
he inguinal glands are sometimes enlarged and tender.
\par \i \pard \qj \fi226 \sl-221 \tx226 Local tissues. \plain \fs20 \lang1033 Th
e nearby structures \fs8 \f1 \'97 \fs20 \f0 the anus, the rectum and the content
s of the pel\-vis \fs8 \f1 \'97 \fs20 \f0 may show evidence of previous abscesse
s and fistulae, such as scars and sinuses.
\par \fs20 \f1 \plain \fs20 \f1 \lang1033 \pard \qj \sl-221 \tx204 There \fs20 \
f0 is likely to be a tachycardia, pyrexia, sweating, a dry furred tongue and foe
tor otis.
\par \lang1033 \fs20 \f0 \pard \sl-221 \tx204 Anorectal abscesses occur in the s
pace between the internal and external sphincters (inters\-phincteric or periana
l abscess) or in the ischiorectal fossa (ischiorectal abscess). The in\par \lang1033 \fs20 \f0 \fs12 \f1 \b \pard \qc \sl-0 \tx204 I ~
\par \fs20 \f0 \plain \fs20 \lang1033 \fs20 \f0 \lang1033 \fs20 \f0 \pard \fi209
\sl-221 \tx209 426 \i The Rectum and Anal Canal
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qc \sl-0 \tx209 PILONIDAL SINUS
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The word \'91pilo
nidal\'92 means a nest of hairs. A pilonidal sinus is a sinus which contains a t
uft of hairs. These sinuses are commonly found in the skin covering the sacrum a
nd coccyx but can occur between the fingers, particularly in hair\-dressers, and
at the umbilicus.
\par \pard \qj \li238 \sl-209 \tx238 There is a continual argument about the sou
rce of the hairs. A pilonidal sinus is not lined by skin and there are no hairs
growing within it. In fact, the hairs in the sinus are short, broken pieces of h
air that either get sucked into a pre-existing dimple in the skin or actually pi
erce the normal skin in the gluteal cleft and then, by acting as foreign bodies,
aid and support the development and persistence of chronic infec\-B
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 B
\par \fs28 \f1 \plain \fs28 \f1 \lang1033 \pard \qc \sl-0 \tx238 9
\par \pard \qc \sl-0 \tx238 10
\par \pard \sl-0 \tqdec \tx1048 \tx1819 \tab \fs36 \f1 \b \ul 11\plain \fs36 \f1
\lang1033 \plain \fs36 \f1 \lang1033 \b \tab \fs50 \f1 \plain \fs50 \f1 \lang10
33 \b )
\par
\par \fs30 \f3 \plain \fs30 \f3 \lang1033 \ul \pard \qc \sl-0 \tqdec \tx1048 \tx
1819 12~L~\plain \fs30 \f3 \lang1033
\par \ul \fs28 \f1 \pard \qc \sl-0 \tqdec \tx1048 \tx1819 13~\plain \fs28 \f1 \l
ang1033
\par \fs20 \f1 \b \pard \sl-198 \tx204 Figure 18.9 A pilonidal sinus. \plain \fs
20 \f1 \lang1033 (A) The patient is lying on his right side with buttocks held a
part to expose the bottom of the natal cleft. The sinus, which is difficult to s
ee, is the small pale central pit. The stiff black hair which commonly covers th
e buttocks of these patients has been shaved off. (B) The hairs that were remove
d from the sinus shown in (A).
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 tion. The result is a chronic
abscess which contains hair and which flares up at frequent intervals into an ac
ute abscess.
\par
\par
lain \fs20 \lang1033 Pilonidal sinus is rare before puberty and in people over 4
0 years of age. This sug\-gests that it is a self-limiting condition. Perhaps th
e strength of the hairs and the likelihood of their pricking into the skin varie
s with age.
\par \i \pard \qj \fi238 \sl-221 \tx238 Sex. \plain \fs20 \lang1033 It is more c
ommon in men than women. \i Ethnic group. \plain \fs20 \lang1033 Piohidal sinuse
s are more common in dark-haired, hirsute men. This de\-scription does not defin
e an ethnic group but certain ethnic groups have more men with these characteris
tics.
\par \i \pard \qj \fi238 \sl-221 \tx238 Occupation. \plain \fs20 \lang1033 Short
hairs are very strong and easily pierce the skin. Men\'92s hairdressers some\-t
imes get pilonidal sinuses in the webs between their fingers.
mon symptoms are pain and \fs20 \f1 \b a \fs20 \f0 \plain \fs20 \lang1033 discha
rge, which develop when an ab\-scess forms in the sinus. The pain may vary from
a dull ache to an acute throbbing pain and the discharge will vary from a little
serum to a sudden gush of pus.
\par \pard \qj \fi238 \sl-221 \tx238 In between the acute exacerbations the sinu
s produces few symptoms and the patient often thinks it has disappeared.
\par \pard \qj \fi238 \sl-221 \tx238 The acute exacerbations occur at irregular
intervals. If a sinus becomes chronically in\-flamed it may discharge continuall
y.
\par
\par
\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 Local Examination
n. \plain \fs20 \lang1033 Pilonidal sinuses are often misdi\-agnosed as anal fis
tulae because of their proxim\-ity to the anus, but this misdiagnosis should not
be made because pionidal sinuses are always in the mid-line of the natal cleft
and lie over the lowest part of the sacrum and coccyx (whereas the opening of a
fistula can be anywhere around the anus). It is very rare for a pionidal sinus o
r a pilonidal abscess to involve the tissues between the tip of the coccyx and t
he anus, or the ischiorectal fossa. These are the common sites of fistulae.
\par \pard \qj \fi238 \sl-221 \tx238 There may be one or many sinuses, some with
a smooth epithelialized edge, others with a puckered scarred edge and some with
pouting granulation tissue. The latter are usually the
\par \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \qj \li5419 \sl-0 \tx5419 Conditions
presenting with anal pain \plain \fs20 \lang1033 427
\par \pard \qj \sl-221 \tx204 sinuses which are discharging pus and the
\par \pard \qj \sl-221 \tx204 orifices of the most recent abscesses.
\par \i \pard \qj \fi209 \sl-221 \tx209 Temperature and tenderness. \plain \fs20
\lang1033 The skin around a pionidal sinus is normal except when the sinus is a
cutely infected, when it becomes red and tender.
\par \i \pard \qj \fi238 \sl-221 \tx238 The sinus. \plain \fs20 \lang1033 The ac
tual sinus (or sinuses) is usually easy to see. It is a small mid-line pit with
epithelialized edges. Gentle pressure may pro\-duce a small quantity of serous d
ischarge and reveal the tips of a few hairs.
\par \pard \qj \fi221 \sl-221 \tx221 When a sinus is infected it becomes indisti
ng\-uishable from any other form of subcutaneous
\par \pard \qc \sl-0 \tx221 abscess.
\par \pard \qj \fi221 \sl-221 \tx221 Palpation of the skin and subcutaneous tis\
-sues around the sinus reveals areas of sub\-cutaneous induration which correspo
nd to the ramifications of the sinus beneath the skin. There may be scars well a
way from the mid-line, as high as the first sacral vertebra, where pre\-vious ab
scesses have discharged or been in\-cised.
he inguinal lymph nodes
\par \pard \qj \sl-221 \tx204 do not enlarge because the infection is mostly
\par \pard \qj \sl-221 \tx204 mild and chronic.
e underlying sacrum, the
\par \pard \qj \sl-221 \tx204 skin of the perineum, the anal canal and the
\par \pard \qj \sl-221 \tx204 ischiorectal fossa should be normal.
\par
\par
\par
\par
\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 PERIANAL WARTS
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 Perianal warts (condylomata ac
uminata) are multiple, pedunculated, papiliferous lesions that are easy to recog
nize. They are often spread over the whole perineum, including the labia majora
and the back of the scrotum.
\par \pard \qj \fi221 \sl-221 \tx221 They are caused by a virus which is a varia
nt of the papilloma virus responsible for skin warts, and can be transmitted by
sexual contact. Consequently they are often associated with other sexually trans
mitted diseases such as herpes genitalis, AIDS, gonorrhoea and syphilis.
\par \pard \qj \fi209 \sl-221 \tx209 They are also seen in patients whose immune
response has been depressed with steroids and other forms of chemotherapy.
\par \pard \qj \fi238 \sl-221 \tx238 Condyloma lata also occur as a manifestatio
n of secondary syphilis, but these are broad-based, flat-topped papules. They ar
e highly contagious.
\par \lang1033 \pard \fi221 \sl-221 \tx221 All condylomata cause irritation, dis
comfort and pain from rubbing, and may ulcerate and become infected.
\par
\par
\par \fs24 \f1 \b \pard \sl-0 \tx204 PROCTALGIA \fs22 \f0 \plain \fs22 \lang1033
FUGAX
\par
\par \fs20 \f0 \pard \sl-221 \tx204 This is an uncommon condition but is men\-ti
oned because the patient presents to the doc\-tor complaining of severe rectal p
ain.
\par \pard \fi238 \sl-221 \tx238 The pain comes on suddenly, often at night, is
cramp-like and deep inside the anal canal.
\par \pard \fi221 \sl-221 \tx221 Nothing relieves it and it passes off spon\-tan
eously within minutes or hours.
\par \pard \fi238 \sl-221 \tx238 General and rectal examination are normal. Its
cause is unknown, but there is some evi\-dence to suggest that it is caused by s
pasm (cramp) of the muscles of the pelvic floor.
fs20 \f1 \lang1033 Two examples of multiple perianal warts (condylomata).
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \pard \sl-0 \tx204 428 \i The Rectu
m and Anal Canal
\par
\par \fs36 \f1 \plain \fs36 \f1 \lang1033 \b \pard \sl-0 \tx204 Conditions prese
nting as an anal lump with or without pain
\par
\par
\par \lang1033 \fs20 \f0 \pard \qj \sl-221 \tx204 A number of the conditions alr
eady described present with pain and a lump but in the major\-ity the pain is th
e dominant symptom. The following conditions are not necessarily pain\-less but
the lump is the dominant symptom.
\par
\par
\par
\par \pard \qj \sl-0 \tx204 PROLAPSED \fs24 \f1 \b HAEMORRHOIDS
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The symptoms of h
aemorrhoids have already been described because their commonest symp\-tom is rec
tal bleeding; but some piles do not bleed (or the patient does not observe the b
leed\-ing) and are therefore not noticed until the patient feels them when clean
ing himself after defaecation. He often observes that the lumps retract spontane
ously or can be pushed back into the anal canal.
\par \pard \qj \fi238 \sl-221 \tx238 Piles which only prolapse during defaecatio
n are not painful, but if they become permanently prolapsed, strangulated, throm
bosed, or ulcer\-ated they become very painful and tender.
\par \pard \qj \fi238 \sl-221 \tx238 Examination then reveals two or three tense
, tender, red\'97purple mucosa-covered swellings protruding from the anal canal.
The covering of purple mucosa and the disposition of swellings at the 3, 7 and
11 o\'92clock positions (12 o\'92clock is anterior) make the diagnosis easy.
\par \pard \qj \fi238 \sl-221 \tx238 If the piles have been prolapsed and throm\
-bosed for a long time they may be so ulcerated and infected that they are diffi
cult to distinguish from a prolapsing carcinoma.

\par
\par
\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 TAGS
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 Small tags of ski
n, with narrow pedicles, are commonly found on the lax perianal skin. They follo
w minor trauma or small perianal haemato\-mata and are usually symptomless. If t
hey rub, catch or itch they may cause enough symptoms to warrant removal.
\par \pard \qj \fi221 \sl-221 \tx221 Sometimes part of the lining of the lower a
nal canal may develop into a papilla which pro-lapses (a fibrosed anal polyp).
\par \pard \qj \fi221 \sl-221 \tx221 A tag may develop at the lower end of an an
al fissure, the \'91sentinel tag\'92.
\par \lang1033 \fs24 \f1 \b \pard \qc \sl-0 \tx221 ~ARCI NOMA
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 A carcinoma of th
e rectum or the anal canal can present as an anal lump if it prolapses through t
he anus or spreads directly down the wall of the anal canal to the perianal skin
.
\par \pard \qj \fi238 \sl-221 \tx238 When the anal canal is invaded by tumour th
e patient usually has pain on defaecation, as well as a lump. This is one of the
few circumstances in which a low rectal carcinoma presents with pain.
\par \pard \qj \fi238 \sl-221 \tx238 Squamous cell carcinoma of the anal canal i
s rare. It presents with pain on defaecation and streaks of blood on the faeces
and the toilet paper, but ultimately causes a palpable lump.
33 A carcinoma of the anal canal which has spread into the skin of the perineum.
The patient was still able to defaecate. Patient in the lithotomy position.
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \li3611 \sl-0 \tx3611 Cond
itions presenting as an anal lump with or without pain \plain \fs20 \lang1033 42
9
\par \lang1033 \fs20 \f0 \fs24 \f1 \b \pard \qj \sl-0 \tx204 PROLAPSE OF THE REC
TUM
\par
\par \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 This is an eversi
on of the whole thickness of the lower part of the rectum and the anal canal. It
occurs when the structures in the floor of the pelvis that normally hold the re
ctum in the curve of the sacrum become weak and lax.
\par
\par
lain \fs20 \lang1033 Prolapse of the rectum is common in the elderly. The majori
ty of patients requiring treatment are over 65, many being in their 80s and 90s.
\par \i \pard \qj \fi238 \sl-221 \tx238 Sex. \plain \fs20 \lang1033 Prolapse is
much more common in women because the female perineum is weakened by the presenc
e of the vagina and the trauma of childbirth.
ient complains of a large lump which appears at the anus after defaeca\-tion, or
sometimes spontaneously when stand\-ing, walking or coughing.
\par \pard \qj \fi238 \sl-221 \tx238 The lump can usually be pushed back into th
e rectum or may return spontaneously when the patient lies down.
33 Prolapsing rectal mucosa which has become fibrosed and papillomatous \fs8 \f1
\'97 \fs20 \f1 a \'91fibrosed anal polyp\'92. The patient is in the lithotomy p
osition.
\par \lang1033 \fs20 \f0 \pard \qj \fi238 \sl-221 \tx238 A prolapsed rectum is u
ncomfortable, often slightly painful, and gives a persistent desire to defaecate
. The prolapsed rectal mucosa secretes mucus and, if it remains prolapsed, ulcer
ates and bleeds. Incontinence of faeces is common.

\par
\par \fs20 \f0 \plain \fs20 \lang1033 \i \pard \qj \fi221 \sl-221 \tx221 Colour
and shape. \plain \fs20 \lang1033 The prolapsed rectum forms a long tubular mass
protruding symmetri\-cally through the anus. The exposed mucosa is red, and thr
own into circumferential concentric
Canal
\par \lang1033 \fs20 \f0 \fs20 \f1 \b \pard \qj \sl-198 \tx204 Figure 18.14 \pla
in \fs20 \f1 \lang1033 A rectal prolapse.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs18 \f1 \pard \qj \li793 \sl-0 \tx793 Skin of anus
\par \pard \qj \li793 \sl-0 \tx793 and mucosa of
\par \pard \qc \sl-0 \tx793 rectum in
\par \pard \qc \sl-0 \tx793 continuity
\par \fs20 \f1 \b \pard \qc \sl-0 \tx793 / /
\par \fs10 \f5 \plain \fs10 \f5 \lang1033 \pard \qc \sl-0 \tx793 (~.
\par
\par
\par
\par
\par \fs20 \f1 \b \pard \qj \li2466 \sl-0 \tx2466 A
\par \lang1033 \fs20 \f0 \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 folds a
round a central pit, which is the lumen of the rectum.
\par \pard \qj \fi226 \sl-221 \tx226 Sometimes it is necessary to ask the patien
t to strain down to produce the prolapse. The di\-agnosis is made by inspection
and may be missed if this essential manoeuvre is omitted.
\par \pard \qj \fi226 \sl-221 \tx226 The prolapse may vary from 2\'973 cm to 20
cm in length.
\par \pard \qj \fi221 \sl-221 \tx221 The prolapsed bowel is not tender and can b
e handled without causing the patient discomfort.
\par \pard \qj \fi221 \sl-221 \tx221 The important area to examine is the juncti
on of the mass with the anal canal. If the lump is a rectal prolapse, its mucosa
l covering and the anal skin will be continuous. If the lump is an intussuscepti
on there will be a gap between the mucosa covering the lump and the anal skin. I
f you put your finger into this gap it will pass through the anal canal, into th
e rectum, along\-side the intussusception.
\par \i \pard \qj \fi221 \sl-221 \tx221 Reducibility. \plain \fs20 \lang1033 It
is usually possible to reduce a prolapse with gentle compression and upward pres
sure.
e rectum and anal canal are normal but the anal sphincter is very lax.
\par \i \pard \qj \fi209 \sl-221 \tx209 General examination.
\par \plain \fs20 \lang1033 \pard \qj \sl-221 \tx204 The patient is usually a th
in, small, elderly woman with a weak pelvic floor.
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par
\par \fs18 \f1 \pard \qj \li1695 \sl-192 \tx1695 Gap between the bowel and anus,
which
\par \pard \qj \li1695 \sl-192 \tx1695 leads into the rectum
\par
\par
\par
\par
\par
\par
\par \fs20 \f0 \pard \qc \sl-0 \tx1695 \pard \keepn \pvpara \dropcapli1 \dropcap
t1 {\fs130 \f1 U}\par
\pard \pard \qc \sl-0 \tx1695 \fs18 \f1 B
fs20 \f1 \lang1033 The difference between a rectal prolapse (A) and an intussusc
eption presenting through the anus (B).
\par \fs20 \f0 \fs20 \f0 \lang1033 \fs20 \f0 \i \pard \qj \li3611 \sl-0 \tx3611
Conditions presenting as an anal lump with or without pain \plain \fs20 \lang103
3 431
\par \fs24 \f1 \b \pard \sl-221 \tx4660 INTUSSUSCEPTION\tab \fs20 \f1 \plain \f
s20 \f1 \lang1033 \b The history will \plain \fs20 \f1 \lang1033 give a \fs20 \f
0 clue to the diagnosis.\line \pard \sl-221 \tx4660 \tab Intussusception usually
occurs in children be\\par
\par \pard \qj \sl-221 \tx204 lt is rare for an ileocolic or caecocolic intus- t
ween the ages of 9 months and 2 years, and is susception in a child to present a
t the anus, but associated with colicky abdominal pain, disten\-when it does it
forms a sae-shaed lum sion, vomiting and (rarely) the passage of blood\\par \pard \sl-0 \tx2375 \tx4660 \tab saugp\tab stained mucus \'97\'91red-curran
t jelly\'92.
\par \pard \qj \sl-221 \tx204 covered with red\'97purple mucosa, similar to a In
\par \pard \qj \sl-221 \tx204 rectal prolapse. The only way to distinguish it tu
ssusception of the \fs22 \f0 sigmoid colon and \fs20 \f0 from a prolapse is by f
inding, on rectal examina- upper rectum occurs in adults when a polyp or tion, t
hat the anal canal is normal and that a carcinoma acts as the head of the intuss
uscep\-finger can be passed into it, alongside the intus- tion. The causative le
sion will be visible on the susception (see Figure 18.13). apex of the intussusc
eption.
\par \pard \sl-0 \tx6173 \tqr \tx9705 \tab \fs10 \f1 \'91y \fs14 \f1 \'91I. \fs8
\f5 \b ~ \fs14 \f1 \plain \fs14 \f1 \lang1033 L Th \fs12 \f0 \b f.\tab I \fs16
\f1 \plain \fs16 \f1 \lang1033 \b .r) ~
\par \fs20 \f0 \plain \fs20 \lang1033 }

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{\rtf1\adeflang1025 \ansi \deff0 \adeflang1033 {\fonttbl {\f0\froman Times New R

ade; but more often it is referred to

the sigmoid colon.

\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 History

some years ago which was \'91cured\'92 with medicine.

\par \pard \qj \fi249 \sl-221 \tx249 If there is a collection of inflammatory ex

ication of the puerperium and abortion.

lang1033 a prominent feature, but may Occur.

the sounds become resonant and high-pitched and even\-tually tinkling.

\par \pard \sl-311 \tx204

\par \pard \li221 \fi-221 \sl-221 \tx221 Kala-azar

\par \pard \li238 \fi-238 \sl-0 \tx238 5.\tab It is dull to percussion.

allel to the root of the mesen\-tery.

commonest cause of enlargement of the uterus, and of abdominal distension.

al symptoms of an abscess such as fever, rigors, sweating and increased local pa

\par \fs20 \f0 \plain \fs20 \lang1033 \pard \sl-0 \tx317

\par \fs24 \f1 \b \pard \qj \sl-215 \tx204 Fat

\par \pard \fi232 \sl-221 \tx232 Hydatid cysts

ension \plain \fs20 \lang1033 403

\par \fs24 \f1 \b \pard \qc \sl-0 \tx238 Haematuria

ec\-hon has arisen in a previously hydronephrotic kidney.

\par \fs22 \f1 \i \pard \qc \sl-0 \tx204 History

\par \fs22 \f1 \i \pard \qj \sl-0 \tx204 History

\tx204 412 \i The Kidneys. Urinary Tract and Prostate

flammatory bowel disease or di\-verticulitis, or it has passed down rapidly from

ructures, especially the sacral nerves.

\par \pard \qj \sl-221 \tx232

tum. A vicious circle is established.\line \pard \sl-209 \tx4575 An acute tear

\par \pard \qj \sl-221 \tx238

ates and bleeds. Incontinence of faeces is common.

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