Dr David Swar Department of General Surgery (Resident) Stomach and colorectal diseases Qilu hospital, Shandong University

Appendix Caecum Right Ovary Small bowel

Urinary Bladder Uterus Small bowel Rectum

Sigmoid colon Left ovary Small bowel Rectum

Descending colon Small bowel Kidney Adrenal gland

Spleen Colon Stomach Kidney Adrenal gland

Stomach Duodenum Tr colon Aorta Pancreas

Liver Gallbladder Colon Duodenum Kidney Pancrease Adrenal gland

Ascending colon Kidney Adrenal gland

Aorta Small bowel

Right iliac fossa : GIT causes: - Appendix - caecum - crohn’s disease (abscess) - TB - carcinoid tumor - amoebic mass (amoeboma) extra-GIT causes: - ovarian tumor or cyst - psoas abscess - hernia - transplanted kidney - tumors of un-descended testis

Hypogastrium : - urinary bladder: full bladder, tumors or urine retention. - ovarian tumor or cyst - pregnancy - uterine tumors - small bowl obstruction

Left iliac fossa : GIT causes: - Loaded sigmoid colon (in sever constipation) - carcinoma of sigmoid or descending colon - diverticular abscess - Bilharzial colonic mass - amoebic mass (amoeboma) extra-GIT: - ovarian tumor or cyst - psoas abscess - hernia - transplanted kidney - tumors of un-descended testis

Left hypochondrium : - splenomegally - tumor in splenic flexure - stomach - kidney - suprarenal gland - subphrenic abscess

Epigastrium : - retroperitoneal lymphadenopathy - left lobe of liver - aortic aneurysm - stomach - pancreatic pseudocyst or tumor - carcinoma of the transverse colon - small bowl obstruction

Right hypochondrium : - hepatomegaly - gallbladder - subphrenic abscess - kidney - suprarenal gland Umbilical : - aortic aneurysm - small bowl obstruction - pancreatic pseudocyst or tumor

1- History. 2- Clinical Examination. 3- Investigations.

Abdominal mass is a common surgical presentation. A full history should be obtained.

1- When & Where ? Ask the Patient when he first noticed the mass and where. Be precise about the time course and location.

2- What ? What brought his attention to the mass. he felt / saw it felt a pain & saw a mass someone else told him

3- Associated symptoms Pain / tenderness. Fever. Nausea / vomiting. Weight loss / anorexia. Abdominal distension. Dysphagia. jaundice.

4- Changed or not ? Ask whether the mass changed in size. Ask if changed in consistency. Ask if he noticed a change in the color of the overlying skin.

5- Disappear or not ?

Perform a full physical examination. Examine the mass. 1- Inspection. a- site b- shape c- sized- color e- surfacef- edge g- pulsation

2- Palpation. a- temperature b- tenderness c- composition d- reducibility e- pulsation f- surface

h- composition 1-consistancy2- fluctuation 3-fluid thrill 4- translucency 5-percussion 6-pulsatility 7-compressibility 8-auscultation for bruit

i- relation to surrounding structures j- state of regional LN k- state of local tissue

* CBC* RFT* LFT * UA* electrolyte A- Ultrasonography B- Radiology 1- plain radiology 2- contrast radiology 3- CT 4- MRI

A- Upper GI endoscopy B- Lower GI endoscopy

Suspect Clinically. Confirm by Imaging. Prove by Histology.

Crohn's disease Intestinal TB Colon Cancer Abdominal Aortic Aneurism

ETIOLOGY The etiology of Crohn's disease is unknown, and possible causes have been the subject of many theories. Crohn's disease is more likely the result of a combination of multiple predisposing factors and environmental or infectious triggers that set an immunologic derangement into motion

Pathophysiology The earliest gross manifestation is the development of small aphthous ulcers →→enlarge and become stellate →→ coalesce to form longitudinal mucosal ulcerations. Further development of disease leads “cobblestone” appearance, The inflammation involves the mesentery and regional lymph nodes. cobblestone appearance

It is categorized based on the gross pattern. The three categories of Crohn's disease are: 1. inflammatory, Uncomplicated inflammation is manifested by mucosal ulceration and thickening of the bowel wall. it can often be relieved with medical treatment. 2.perforating, characterized by the development of fistulae and abscesses. It dictates the surgical strategy. 3.stricturing, is referred to as “fibrostenotic” lesions. Fibrotic strictures are not reversible with medical treatment, so that symptomatic stricturing disease often requires surgical management

Clinical manfistation a) Crohn's Disease of the Small Bowel The symptoms of small bowel Crohn's disease include 1.chronic abdominal pain(in up to 90% of cases), 2.weight loss, 3.fever, 4.anorexia. 5.a tender palpable mass associated with an abscess or phlegmon. 6.Fistulization to the skin, urinary bladder, or vagina may also occur. 7. An enlarged inflammatory mass that adheres to the retroperitoneum can compress the right ureter and cause symptomatic ureteral obstruction and hydronephrosis. b) Patients with Crohn's disease of the colon typically have 1.diarrhea along with abdominal pain 2.and hematochezia.

1. laboratory tests No specific laboratory test allows the diagnosis of Crohn's disease to be made. Occasionally, tissue obtained during endoscopic biopsy can be diagnostic.

Typical radiographic appearance of extensive jejunoileal Crohn's disease. 2. Radiography of the Small Bowel

Crohn's disease of the terminal ileum. Resultant mass effect has displaced several loops of small bowel from the right lower quadrant.

3. Colonoscopy The best for colon and rectum. Characteristic features of Crohn's disease seen on colonoscopy include: 1.aphthoid ulcers, 2.discrete ulcerations that usually track along the long axis of the bowel, 3.diseased mucosa separated by areas of normal mucosa, 4.rectal sparing, 5. and strictures

4.Computed Tomography The most typical finding of uncomplicated Crohn's disease is thickening of the bowel wall. CT can be useful in identifying the complications associated with Crohn's disease, and when an abscess or inflammatory mass is suspected, CT of the abdomen and pelvis should be performed.

Computed tomogram showing an abscess of the right lower quadrant resulting from Crohn's disease of the terminal ileum.

Indications for Operation 1.Failure of Medical Management 2.Intestinal Obstruction 3.Enteric Fistulae 4.Abscess and Inflammatory Mass 5.Hemorrhage is an uncommon complication 6. Perforation is a rare complication 7.Cancer and Suspected Cancer

Etiology: Caused by M.tuberculosis which come from : 1-Ingestion of contaminated food 2-From other TB focus in the body Pathophysiology Ulceration Lymph node enlargement Caseation and calcification Healing with formation of strictures

Low grade fever Weight loss Anemia Diarrhea Vague lower abdominal pain Frank rectal hemorrhage Ascites Intestinal obstruction

Plain x-ray of chest and abdomin Contrast enema show distortion of caecum US,CT,MRI show: 1. thickened bowel loops 2.Intestinal obstruction 3.Lymph node enlargement and calcification 4.Abscess or ascites

Primary treatment is chemotherapy like Isoniazid,rifampicin,streptomycin, Ethanbutol Surgeon task: 1.Establish diagnosis by laparoscopy if necessary 2.Manage complications such as bleeding,obstruction.

Accounts for 14% of all cancer death (second to lung cancer) Risk factors include: 1.Adenomatous polyps 2.Genetic Factor 3.Dietary Factors 4.Inflammatory Bowel Disease

abdominal pain & tenderness change in bowel habit blood in stool weight loss intestinal obstruction abd. & rectal exam. may reveal a mass.

Sigmoidoscopy It is a must along with PR examination Can show any mucosal abnormality up to mid sigmoid colon (25 cm) Barium enema Colonoscopy It visualize the entire colon but takes a long time and expensive

It is surgical and require hemicolectomy Complications include: Hemorrhage Damage to bladder,ureter,small bowel,spleen,sexual function Stenosis Diarrhea/constipation

pulsating abd. Mass. pain sudden, sever, constant,in the abdomin may radiate to back or flank paleness rapid pulse N/V, fatigue excessive sweating shock

X-ray Often diagnostic may show calcific rim(egg shell) US Can also evaluate blood flow in renal and visceral CT Accurate characterization of aorta ( wall thickness) Cardiac Work up

Replacement of blood loss Incise the aneurism, evacuate the surrounding hematoma Renal insufficiency is the most common complication Mortality rate up to 50%