@ Copyright 2013 by Mohammed El-Matary

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l"tPublished 2oo8
2nd Editio n 2O1O
3'd Edition 2011
4th Edition 2013

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Dedication
The author wishes to acknowledge with gratitude:

Kareem M. Ali, M.B.B.Ch

Ain Shams University

Amira Ahmed, M.B.B.Ch

Ain Shams University

Mariam El-rah9dy, M.B.B.Ch

Ain Shams'(Jniversity

Cover
Mohamed Abdel-Rahman, M.B.B.Ch
Cairo University
 r D.D of a swelling in the neck.
Head and neck r D.D of a swelling in the parotid region. 2
I D.D of lip ulcers.
I D.D of a breast mass (lump).
r D.D of a breast cyst.
Breast r Management of any breast cyst. 16
I D.D of a breast pain.
r D.D of nipple discharqe.
Chest and back I D.D of chest wall swellings.
28
I D.D of swellings of the back.
) Masses:
r D.D of a swelling in the axilla.
I D.D of a mass in the popliteal fossa.
Upper and lower r D.D of a swelling in the femoral triangle.
limb r D.D of an acutely inflamed swelling in tht 30
femoral triangle.
r D.D of a swollen limb.
) Pain:
r D.D of a painful limb.

lnguinoscrotal
r D.D of a swelling in the inguinoscrotal
swelling. 38
r D.D of a scrotal swelling.
r D.D of Dysphagia.
r D.D of Dyspepsia.
GIT symptoms
r D.D of pyloric obstruction.
r Vomiting. 44
I Abdominal distension.
r D.D of Acute abdomen.
I D.D of Anal pain.
! D.D of a swelling in Rt. Hypochondrium.
r D.D of a swelling in Lt. Hypochondrium.
GIT Masses of the GIT
r
I
D.D of a swelling in Rt. iliac fossa.
D.D of a swelling in Lt. iliac fossa.
55
r D.D of a swelling in the epigastrium.
r D.D of a swelling in the umbilical region.
r D.D of a swelling from the Anus.
r D.D of a swelling in suprapubic region.

Bleeding in GIT
r Upper GIT bleeding (hematemsis-
melena). 68
r Bleeding per rectum.

Trauma
r Polytraumatized patient.
r Neck injuries. 76
r Stab wound in the femoraltriangle.
Urosurgery r Hematuria,
86
r Urinary diversion.
D.D. in Tables Divided bv branches 92
DIFFERENTIAL DIa.euosls

Causes

A- Solid swellings:
r Large subnental LN.
r Goiter of the thyroid isthmus & pyramidal lobe.
. Peritradhreal & perilarngeal LN.
. Ectopic thyroid

I Thyroglossal cyst.
t Dermoid cyst (submental or suprasternal).
T Subhyoid bursitis. Rare tender, oval swelling, which lies transversely
below the hyoid bone. lt moves up and down with deglutition and with
protrusion of the tongue.
I Cysts in the thyroid gland.
I Laryngocele. Occurs in musicians playing with air-blown instruments.
The swelling is resonant, compressible and increases in size with
coughing and blowing.
Cold abscess, which is rare in the mid-line.

(see below)

> gEi
V Symptoms:
. Child 6-8 yrs presented by painless swelling infont of the neck,pain only
if infected.
M Signs:
1. Cystic mass in the mid-line of the neck ( by pagets test )
2. Moves with deglutition & protrusion of the tongue & moves from side to
side not from above down wards
US -+ cyst

> G/P!
Symptoms:
-fr . Child with slowly growing painless swelling in mid-line either sub-lingual
or suprasternal
tr Signs:
. Lax cystic swelling not attached to skin.

2
 SELF.A.SSESSMENT- PInT'II
ClPt
M Symptoms:
. Painless swelling in middle of neck.
g
. Signs:
Solid mass (by paget test)
. Thyroid deglutitioil only
. lf lingualmoves:with
: dyspnea,dysphagia,dysasthsia
. lf fetrosternal: pressure manifestation:
rnveedgatEons'
-Y3;g'l: to confirm whether its onty thyroid tissue or not.

Enlargeo suDmanorDular LNs.

Enlarged submandibular salivary gland.

upper deep cervical LNs.

. The upper part of an enlarged lateral obe of the thyroid gland. lt moves
up with deglutition
. Carotid body tumor. Rare, slowly growing, moves from side to side but
not vertically showing transmitted pulsations
>9rstt#Usuallyinchildrenandyoungadults.|tissoftandfluctuantwith
dusky skin. lt is slightly warm and slightly tender. There may be manifestations
of T.B in other parts of the body.
. Branchial cyst. Usually appears at the age of 20 years, deep to upper 1/3 of
sternomastoid protruding beneath its anterior border, tense and opaque.
. Cystic swelling in the upper part of an enlarged lateral lobe of the thyroid gland.

g Submental & submandibular LN swellinq

M Submandibular salivarv qland swellinqs.

A. Acute lvmphadenitis:
. G/O: painful swelling of short duration.
r o/E:
- Enlarged tender matted LNs. -+ usually apparent source of infection in
the catchment's area, e.g. the tongue, lips or teeth... Latent abscess
may form & the swelling becomes cystic,

- Firm matted LNs.

- Later, a cold abscess may form --- finally ruptures leaving a TB sinus.
C. Lvmphoma:
> C/Ps
- There is usually other LN swellings in the body.
- The spleen may be palpable.
3
DIFpEnENTIAL Dlq.eruosrs
) Invesdqadonc
- Biopsy is essential to. establish the diagnosis.
EI D. Metastatic carcinoma:
} G/P:
- LNs are hard & painless.
- Mobile at first & later fixed.
- The 1ry is usually apparent e.g. in the tongue.
) Investigadons
EI Directed to the 1rv lesion.

Submandibular salivary gland swelling is differentiated from submandibular LN

swelling on bimanual palpation.
Salivary gland swelling is solitary & can't be rolled over the edge of the mandible.
- felt bulging into the floor of the mouth
- LN swelling ---+ not felt.
g A. Submandibular sialoadenitis:
. C/O:
- Painful swelling. - Occurs during meals & gradually subsides.
. O/E:
- Firm & tender swelling.
- The orifice of the duct + reddish & pus discharged from it on pressing on
the gland.
- A stone may be palpable in the floor of the mouth.
. X-ray --- demonstrate size & position of the stone.
g
. Pleomorlhic adenoma:
- Symptoms --+ painless swelling of the gland which does not 1 with meals.
- Signs: well defined, lobulated, freely mobile, firm cystic in consistency
. Carcinoma
- Symptoms.' rapidly growing swelling manifestation of lingual or hypoglossal
N. paralysis
- Signs
- hard swelling (at 1st mobile + later fixed, infiltration of skin, Vs, Ns ).

"T[:F:'"s,i*H:arisingfromthebrachialplexus.Rare,tenderbutnot
painful, fusiform in shape, firm, mobile across but not along the nerve
trunk.
) cystic swel'lingi
stic hygroma. An infant with a large sweiling superficial to
sternomastoid. lt is large, irregular, lax and translucent
Pharyngeal pouch. Usually an old man with dysphagia and
regurgitation of undigested food on compression.
Cold abscess. Usually in children and young adults. It is soft and
fluctuant with dusky skin. lt is slightly warm and slightly tender. There
may be manifestations of T.B in other parts of the body.
Pneumatocele. Cystic swelling in the supraclavicular region which is
resonant and compressible.

4
 SELF'ISSESSMENT. PART,II

) ln addition, swellings of the skin and subcutaneous tissue are common in the neck
and should be put in mind. They are added to any of the previous lists.
1. Lipomas.
Sebaceous cysts.
Haemanoi

. lt's a clinical diagnosis which refers single thyroid nodule which may be :
o Discrete: one palpable in othenrise normalthyroid gland.
o Dominant: Large Palpable Nodule + Multiple Smaller Nodules.

dule may be part of multinodular goiter, other nodules are not clinically
palpable (commonest).
2. Colloid nodule. 4. Adenoma.
3. Toxic nodule. 5. Carcinoma.
6. Localized thyroiditis (hashimoto thyroiditis)
7. Thyroid cyst (as hydatid cyst).
(Need Good Hist , General Local& Examination)

. Female 30.40 yearc with nodular swelling on the front of the neck.

(painless slowly growing neck swelling).

a) Pressure on trachea ) positional dyspnea and cough especially at night

Retrosternal b) Pressure on esophagus ) dysphagia.
extension or c) Pressure on carotid artery )dizziness.
malignancy d) Pressure on internaljugular vein ) blackout increases on leaning fonryard.
e) Pressure on RLN ) change of voice.

- lt is uncommon but may be felt when hemorrhage occurs in a nodule or late

malignancy.

General: no thyrotoxic manifestations.

Local:
+ Clinical Picture of the disease:
1. lnspection:
- Asymmetrical thyroid swelling in lower part of the front of the neck moving up
& down with deglutition
2. Palpation:
- Thvroid swellinq:
1- Nodular (solitary, or multinodular).
 DIFFERENTIAL DIncT.IosIs
2- ftm.
- The trachea may be displaced from the middle line or tracheomalacia detected
by Kocher's test.
- Carotid artery: pulsation is felt but may be shifted in huge goitre.
Gomplications:
1. Pressure on trachea.
2. Secondary thyrotoxic changes.
3. Hemorrhage.
4. Cyst formation.
5. lnfection.
6. Retrosternal extension.
7. Calcification (in long-standing cases).
8. Malignant changes .

lnvestigations:

i T3, T4, TSH !

i fioxic nodule) :

U /S (To detect sin$le

qr,multiple nodules)

Criteria of Malignancy

. Can't differentiate between follicular adenoma To differentiate whether

& follicular carcinoma hyper function in nodules or
r We do Hemithyroidectomy + Paraffin Section in internoduar tissue

t Pre-operative investigations: CBC, FBS, KFT, LFT, ECG, CXR.

I Staging: CT, U/S, Bone scan, CXR.
I Thyroid Antibodies: in Haschimoto thyroiditis.
! The value of thyroid scan in cases of solitary thyroid nodule is:
1. May reveal the presence of multinodular goiter.
2. lf the nodule is hot, it is toxic and the possibility of malignancy is
nearly excluded.
3. lf the nodule is warm, it is a functioning adenoma and the
possibility of malignancy is nearly 3.5%.
4. lf the nodule is cold, the possibility of malignancy is 10-16%.

6
 SELF'ISSESSMENT- PART,II

-Partial thyroidectomy:
- Removal of the nodular parts leaving an equivalent of 8 gm of relatively normal
thyroid tissue (size of normal lobe) on each side if feasible to reduce the risk of
_ hyperparathyroidismthataccompaniestotalthyroidectomy.
-subtotal thyroidectomy: Removal of thyroid tissue leaving about 4-5 gm of thyroid
tissue on each side, so, total remnant on both sides equal one normal lobe.
-Total thyroidectomy:
- + Replacement therapy to prevent recunence and to avoid accidental malignancy.
-Total lobectomy if one lobe is more significantly involved than the other with either
subtotal resection or no intervention on the less affected side (Dunhill procedure).

Etioloqv: is a late stage of diffuse hyperplasia when TSH stimulation has fallen of and when
many follicles are inactive and full of colloid as patient may receive large doses of iodine --* it
will inhibit TSH and protease hyper-involution of the gland.
!
-
C\P: The gland is diffusely enlarged (Soft, Smooth, Symmetrical).
I Fate: lt may return to normal or cause pressure manifestations.
I Treatment: Conservative unless causing pressure manifestations----' Subtotal Thyroidectomy.

The disease has gradual onset and slowly Brogressive course.

Commonly in females at any age

As Grave's' but CVS or nervous manifestations according to age.

A- ToxlcManifiestations
B- Local Manifestatons (Thyroid Gland)
nodule is felt in the gland.

. Thvroid Functions: as Graves'.

' U/S of the neck: solitary nodule
hot nodule with suppression of the uptake of surrounding thyroid tissue.

1. SurqicalTreatment:
. lpsilateral total lobectomy.
. lndicated in patients < 45 years.
2. Radioactive iodine.
.Very effective (as the autonomous nodule is the only part that will take the iodine).
But used in patient > 45 years for fear of malignancy
3. Medical Treatment: as secondary thyrotoxicosis.

7
DrprenENTrAL Drloruosrs

Glinical picture:
Type of patient
- Middle age female, with goitrous myxedema & other autoimmune disease.
Symptoms
- Fluctuating course.
- Manifestations of thyrotoxicosis in 5% of cases.
- Manifestations of myxedema.
- Other autoimmune disease.
Signs
General:
- Manifestations of myxedema : usually associated with splenomegaly.
- Autoimmune manifestations e.g. erythema nodosum .

o Local:
- Asymmetrical large nodular firm asymmetrical swelling in the front of the neck
Moves up with deglutition.
lnvestigations:
o Laboratorv:
- Thyroid function V
- Antibody detection : Antithyroglobulin & Antimicrosomal antibody
- High ESR , leucocytosis
o Radioloqical:
- U/S. multiple nodules
- Thyroid scan : low uptake
o FNABC: Askanazy cells + lymphocytic infiltrations
(The best investigation although abundant lymphocytes may make the
cytol og ical d ifferentiation between a utoim m u ne thy roid itis and ly m phoma
very difficult)
Treatment:
+ Medical Treatment:
1 Cortisone.
2. L- Thyroxin. ( Main treatment)
3tnderalto con[rol toxic symptoms during Hashitoxicosis.
+ lndications for surderv
nifestations
2. Suspicion of malignancy. i.e. :
o
Rapid increase in size.
o Pain.
o Ulceration.

D.D of a Swelling in Parotid Region

Sebaceous cyst. . Abscess.

Hemangioma. . Hematoma
EI S.C tissue:
' Lipoma . Neurofibroma. . Neurofibrosarcoma.
8
 SELF.I.SSESSMENT' PART .II

Muscular (from masseter muscle): fibrosarcoma, masseter muscle

hypertrophy )Usually bilateral and common in females that have involuntary
grinding of their teeth.
g Bonv (from the ramus of mandible). Burkit's lymphoma

g Lvmphadenitis: acute & chronic (non-specific & specific e.g, TB

lymphadenitis).
V Maliqnancv: lymphoma & metastatic carcinoma.

g
. Acute (viral, bacterial). . Chronic (TB, sarcoidosis).
V Autoimmune:
. Sjogren's syndrome.
r Benign lymphoepithelial lesion.
M Tumors:
'Benign:
Pleomorphic adenoma - Oncocytoma.
Adenolymphoma - Monomorphic adenoma.
. Malignant:
- Mucoepidermoidcarcinoma
- Adenoid cystic carcinomao Acinic cell carcinoma
- Carcinoma ex pleomorphic adenoma.

EI A. Parotid sialoadenitis:
. C/O:
Painful swelling.
during meals & gradually subsides.
. br=?..rrs
Firm & tender swelling.
The orifice of the duct -, reddish & pus discharged from it on pressing
on the gland.
. Sialogram: best in parotid stones as they are radiolucent (filling defect)
M,*,o*n***-n1essswellingoftheglandwhichdoesnotfwith

meals.
r StGNg: mobile non-tender mass firm/cystic,lobulated,raising
lobule of ear,LN not enlarged.
Carcinoma --r hard swelling (at 1st mobile --- later fixed).
 DIFFERENTIAL Dl^a.oruosls

E A. Acute lvmphadenitis:
. C/O: painful swelling of short duration.
' O/E:
Enlarged tender matted LNs.
Usually apparent source of infection in the catchment area... Latent
abscess may form & the swelling becomes cystic.
EI B. Lvmphoma:
. CIP:
There is usually other LN swellings in the body.
The spleen may be palpable.
.lnvestigations:
essentialto establish the diagnosis'
M C. Metastatic rrr?i,l"tJ.,is
. C/P:
LNs are hard & painless.
Mobile at first & later fixed.
The 1ry is usually apparent e.g. in the tongue.
: directed to the 1 lesion.

DD of lip ulcers
Definition:
. lt's a break in the mucous membrane or the epithelium of the lips or surrounding the mouth
*
Causes
i- Traurna:
. Minor physical injuries e.g. sharp tooth, ill-fitting dentures
. Chemical injuries e.g. Aspirin, alcoholwith prolonged contact
ii- Iniection:
. Viral: the commonest is herpes simplex virus
. Bacterial: e.g. TB., syphilis or opportunistic by the nasal bact. flora
. Fungal: e.g. cryptococcus
. Protozoal: E.histolytica

iii- Im,nrunology:
'. Apthus ulcer
immunodeficiency as in HIV
. autoimmune, allergy
iv-Dietary: malnutrition e.g. Vit. C deficiency, Vit. 812 deficiency
v- Cancer: basal cell carcinoma, sq. cell carcinoma, melanoma
vi-Medical condifions ess. with mouth ulcers: e.g.
. Behcet's ds. .
Oralthrush
. Systemic lupus .
Gingivostomatitis
. Celiac ds. .
lnfectiousmononucleosis
, Ulcertive colitis .
Leukoplakia
. Chron's ds .
Oral lichen planus

10
 SELF'ASSESSMENT. PART .II

) The celmmonest lip ulcer is Apthous ulcer

) The 2nd most cominon is Herfes simptex virus ( known as cold utcer)
) The most serious is malignant ulcer ( sq. cell carcinoma)
. lt's a very common ulcer.
. Occurs in 10o/o of the population
. More common in females esp. with +ve family history
'. E!!9!9gE unknown
G/P: - Burning pain(very painful) - Edematous lips
- Superficial yellow ulcers
- Few mm in diameter & surrounded by red hyperemic halo
- Heals within 1 or 2 weeks, but may be multiple recurrent & chronic
- Needs no treatment for bland mouth wash & ttt of dyspepsia

. Etioloqv: caused by herpes simplex type I or ll

. c/P:. - Unilateral eruption of small vesicles on the skin & mm
- They don't cross the midline
- After they rupture they leave small superficial areas of ulcerations later on
forming characteristic scab
- They are extremely painful.
. INV: it's a clinicaldiagnosis
. ^,
TTT: only symptomatic e.g. analgesics, antihistaminics , we may give antiviral

lncidence: male, old age,

Historv of the PDF: eg. smoking, alcohol, prolonged exposure to sun
G/P:
{ Symploms:
Painful ulcer, edematous lips, manifestations of metastasis.
{ Signs:
Site: lower lip is more common esp at the mucocut. junction
: No: usually starts as a single cauliflower mass or flat nodule then
.ulcerates
Shape: oval, rounded or irregular
Edge: raised, everted edge
Floor: necrotic tissue
Margin: may be infiltrated with necrotic tissue
Base: indurated, later on fixed
LNs: enlarged, hard early mobile & later on fixed
o lf in the lower lip) in the middle part -+ submental LN
I in the lateral part -+ submandibular LN
o lf in the upper lip: submandibular LN on both sides
. !s. biopsy

11
DIFFERENTIAL DIIoTvosIs

It's a clinical diagnosis which refers single thyroid nodule which may be :
o Discrete: one palpable in otherwise normalthyroid gland.
o Dominant: Large Palpable Nodule + Multiple Smaller Nodules.

1. The nodule may be part of multinodular goiter, other nodules are not clinically
palpable (commonest).
2. Colloid nodule.
3. Toxic nodule.
4. Adenoma.
5. Carcinoma.
8. Localized thyroiditis (hashimoto thyroiditis)
yst (as hydatid cyst).
(Need Good History, General Local& Examination)

Personal historv:
. Aqe, sex: Cancer is common in old male while secondary thyrotoxicosis
Common around 45 years.
. Residence: in oasis endemic goiter.
HPI:

o Slowly progressive within years in S.N.G. or adenoma.

o Rapid within months in carcinoma.
2 Other swelling in metastasis.
3 Effect on the general condition
o Fever in sub acute thyroiditis.
.
o Cachexia in malignancy.
Toxic svmptoms (ln Toxic Nodule) e.g. Weight Loss ln Spite Of Good Appetite
intolerance to Hot Weather & Palpitation.
. Pressure manifestations (especially in malignancy) e.g dyspnea, dysphagia &
hoarseness of voice.
. Pain late malignancy or inflammation or hemorrhage in a nodule of SNG.
. Other Svstems
o Flushing ,diarrhea, bronchospasm in medullary carcinoma
o Metastatic manifestation e.g. skull module & bone ache
+ PH:
I Neck lrradiation in papillary carcinoma.
ry carcinoma (MEN-ll-).

a General:
a. Siqns of toxicitv :e.q.
1. Tachycardia (sleeping pulse > 90).
2. Eye manifestations e.g. exophthalmos.
b. Signs of metastasis Skull nodule

12
 SELF'I.SSESSMENT- PART .II
+ Local:
1. Thyroid Swelling ln muscular of the neck moving up & down with deglutition.
a- Hard with limited mobility in malignancy
b- Fleshy & mobile in adenoma & simple nodule.
2. LNS enlarqement in malignancy &thyroiditis.
3. Effect on surroundinos.
- Absent carotid pulse (berry's sign)
- Stridor on moving trachea(Kocher's)

@ findinqs that raise the suspicion of maliqnancv in a solitarv nodule:

1. History of previous irradiation.
2. Young and elderly patients.
3. Recent onset and rapid growth.
4. Pain.
5. lf the nodule is hard, irregular, with limited mobility.
6. Presence of local invasion or lymphatic or blood borne metastases.

aataaa t atIt taa

t-aa!tta.aataaaar!
TSH
j:
T3,T4, i
ffoxic nodule) :
?lrrrrrrlrrtttltlttttlllrtlo

U /S (To detect single U /S (To detect single

or multiple nodules) or multiple nodules)

. Can't differentiate between follicular adenoma To differentiate whether

& follicular carcinoma hyper function in nodules or
. We do Hemithyroidectomy + Paraffin Section in intermodular tissue

. Pre-operative investigations: CBC, FBS, KFT, LFT, ECG, CXR.

. Staging: CT, U/S, Bone scan, CXR.
. Thyroid Antibodies: in Haschimoto thyroiditis.
. The value of thyroid scan in cases of solitary thyroid nodule is:
1. May reveal the presence of multinodular goiter.
2. lf the nodule is hot, it is toxic and the possibility of malignancy is
nearly excluded.
3. lf the nodule is warm, it is a functioning adenoma and the
possibility of malignancy is nearly 3.5o/o.
4. lf the nodule is cold, the possibility of malignancy is 10-16%.

13
DlppgnENTrAL Dla.oruosls
TREATMENT
) According to cause of nodule
A-To:dc nodule:
if <45 years -+ Hemithyroidectomy
lf <45 years -+ Radio-active iodine.
B'Ma,!!enant!
+ Papillary:
Total or near total thyroidectomy.
Cherry picking (of affected L.N. only)
Lthyroxin (supplementary & to suppress TSH)
+ Follicular:
Total or near total thyroidectomy.
Radioactive iodine for metastasis
Lthyroxin (supplementary).

Another classification for neck swellings

) A single lump
) In the anterior triangle that doesntt move wittr swallowing
. Solid:
- A lymph gland
-
.9@Carotid body tumor
- Cold abscess
- Branchial cyst
) In ttre oosterior trfrangle that doesntt move with swallowing
'w,- A Iymph gland
'gJstlg
- Cystic hygroma
- Pharyngeal pouch
- Occasionally a secondary deposit of a papillary thyroid carcinoma
. Pulsatile:
- Subclavian aneurysm
>
.&I4
- thyroid gland
- PretrachealLN (Delphian LN)
'@
- Thyroglossal cyst

14
DIFFERENTIAL Dnerqosls

Causes

EI Skin:
. Sebaceous cyst. r Abscess.
. Haemangioma. r Haematoma.
g S.C tissg,
. Lipoma. . Neurofibroma. , Neurofibrosarcoma.
g Muscle laver: fibrosarcoma.

Congenital: Diffuse hypertrophy of the breast.

lnvolutional: Fibrocystic disease of the breast.
Traumatic:
- Breast hematoma. There may be history of trauma. Biopsy may be needed
to differentiate it from malignancy.
- Trauamatic fat necrosis. Coomonly forms a cyst rather than a mass.
lnflammatory:
- Acute mastitis & breast abscess. Usually occurs in a lactating females
- TB of the breast. There may be other manifestations of TB.
- Duct mastitis. There is retracted nipple and creamy white discharge
Gystic:
- Retention cyst.
- Galactocele. There is history of breast feeding. The swelling is solitary,
painless and near the nipple.
- Intra-acinar cysts (lymph, blood, hydatid cyst)
Neoplastic:
- Fibroadenoma & cystosarcoma phylloides
- Breast carcinoma.
Retromammary abscess.
m uscu la r (fibrosa rcoma), skeleta I (from ribs).

More in 30-50 yrs.

g Asvmptomatic.
g Svmptomatic (S/S t premenstrual & may disappear after menstruation.
r Luffip.
. Mastalgia (cyclic).
. Painful nodularity (commonest complaint): multiple, small, painful
u nilateral/bilateral nod ules.
. Nipple discharge: usually clear or yellow, sometimes brown or green.

16
 SELF.ASSESSMENT, PART .II

Usually clinical diagnosis, investigations may be needed to exclude carcinoma:

EI Radioloqe: U/S or mammography cysts. -
EI lnstrumental:
'
Aspiration -'

More in old Q
History: predisposing factors, e.g. F.H. early menarche, late menopause, low
parity, obesity...
fl cto:
. Accidentally discovered lump, painless in most of cases (the
commonest presentation).
. Mild breast pricking pain (less frequent presentation).
. Late cancer: symptoms of metastasis: axillary lump, dyspnea &
hemoptysis, hepatomegaly & jaundice
. Early canc€r: asymptomatic, discovered by screening programs.
EI O/E:
r Local:
- Breast: asymmetrically enlarged, skin dimpling & puckering, Pau d'
orange, skin nodule & ulceration.
- Mass: hard irregular, ill-defined, immobile with the breast, fixed to the skin.
- Nipple: retracted, maldirected.
- Axillary & supraclavicular LNs: for lymphadenopathy.
. .General:
- Cachexia.
- Metastasis: hepatomegaly, ascites, chest examination, PV (for
erg tumor).

M Radioloqv: U/S (particularly in young t), mammography -dense opacity

with speculated ill-defined outline & microcalcification.
EI lnstrumental:
'Biopsy (for histology):
-
Excision biopsy (most accurate). -
Frozen section (practical).
-
True-cut- needle biopsy.
.
FNAC (for cytology)

17
DITTEnENTI^A.L Dncruosts
DD of breast cyst
A. Acinar: ( arises from duct system):
1- Fibroadenosis ( commonest cause )
2- Duct papilloma (blood cyst)
3- Galactocele ( obstruction of milk duct)
B. Intra Acinar: occurs in the stroma
1. Sebaceous cyst
2. Traumatic cyst
3. lnflammatory ( TB, Abscess)
4. Neoplastic ( degenerating carcinoma )
5. Dermoid cyst

Management of any breast cyst

<4ojrs >40 yrs

US
t
Mammography & US
lsimple
Icrit"ri, susoicious

tI
of malignancy
Symptoms or >4cm asymptomatic & small
+
Mammography aspiration

Criteria suspicious
of malignancy
Excision of the cyst with trozen section Reassurance

Breast Pain (Mastalgia)

) lt is one of the commonest complaints
it Causes
a. physiological
b. pathological : 1. Fibroadenosis ( commonest)
2. Breast abscess
3. Mondor's dieases (superficial thrombophlebitis)
4. Trauma 6. Sarcoma
5. Duct ectasia 7. Advanced carcinoma (pain
is manifested in only 10%
of patients).
II. EXrn^nrrnrrMARY:
. Premammary ( infection of Montgomery glands)
. Retromammary e.g. Trietz'syndrome ( inflammation of costochondraljunction )

'18
 SELF.ASSESSMENT- PART'II

1. SAoe of milf enooro

* Svmptoms:
- Dullaching pain.
- Mild persistent pyrexia.
* Siqns: enlargement & induration of the breast
with no signs of inflammation.
2. Stage of Cellulitis
0 Svmptoms:
- The pain worsens
- Continuous high pyrexia
0 Siqns:
- Diffuse redness, hotness & tenderness of the breast (signs of inflammation)
- Enlarged elastic tender LNs.
3. Staoe of lcute eOsc
* Svmptoms:
- Throbbing pain.
- Discharge (pus).
Q Sions:
- Hectic fever (i.e. at night it may reach 40o or more due to absorption of
toxins due to vasodilatation).
,- Edema of the overlying skin.
. - No response to medicaltreatment. (Persistence of local signs > 5 days or
severe systemic upset > 2 days after full antibiotic treatment)
'-
Fluctuation is a late sign.
(NEVER WA|T FOR FLUCTUATTON tN BREAST ABSCESS)
4. Staoe of Cnronic AUs (See later)
- Attacks of remission & exacerbation
- Tender swelling with yielding center (Paget's Test).

(lt's mainly a clinical diagnosis)

1. TLC, ESR & CRP )
lncreased.
2. Gulture & sensitivity after drainage and to exclude mastitis carcinomatosis.
3. UrS ) for detection of maturity of pus loculus and its location.

a) EnggrgruE
- Evacuate the breast with a breast pump in combination with hot backs
u) 9e!!s!!!!s:
- As before with use of anti staph antibiotics (fluclxacellin or Augmentin @)
and analgesics , if the child is older than 9 monthes weaning should be
adviced

19
DrprenENTrAL Dncruosrs
c) Staqe of pvoqenic abscess :
l- General anesthesia.
ll- lncision.
a- Radial incision of the skin, not reaching areola
)
b- if small abscess circum-areolar incision may be used for cosmetic
purpose.
c- Counter incision might be needed to leave a drain (if the abscess is
large & in a non dependant region).
lll- lntroduce finger to destroy loculi and send pus for C & S.
lV- Antibiotics & postoperative dressing (till healing is complete).
V- Drain is removed when drainage stops

Definition:
. Superficial thrombophlebitis of the breast.
Glinical picture:
. Local pain & redness (it may cause skin gangrene)
Treatment=
. Rest of the arm, the condition usual subsides nta

DD Nipple Discharge
*
Causes
Phvsioloqical : serous discharge during pregnancy
Patholoqical : commonest cause is duct ectasia

One or more duct

One or more duct
3. Duct papilloma (commonest
cause of bloodv di

6. Hvoerorolactinemia
More than one duct

Glinical picture:
Type of patient
. Middle-aged female
. More common in smokers.
Symptoms
. May be asvmptomatic or presenting by one of the following:
1. Nipple discharqe:
1) Arises from one or more ducts
2) May be creamy white, serous, yellowish or blood-stained
20
 SELF.ASSESSMENT- PART'II
2. subareolar Painless or painfulswelling if an abscess develops
3. Recurrent and chronic mastitis
Signs
. The affected area may be hard with skin dimpling & retraction of nipple (Fibrosis)

lf the patient presenting with subareolar mass,

lf the patient presenting with nipple
with or without nipple retraction
discharqe

Triple assessment to exclude breast cancer Benzidene test to exclude presence of blood
(ductectasia shows coarse calcification in Cytolog ical exa mination to exclude intrad ucta I

mammography)

mild cases are treated by combination of antibiotic (flucloxacillin &

mitronidazole).
Correction of nipple inversion.
Persistent cases are treated by excision of major duct through circumareolar
incision (Hadfield's operation).

E See before.

female with bleeding per nipple.

Discharge:
- Bloody or blood stained nipple discharge 50%. (Commonest symptom).
- May be serosanginous discharge.
Swelling )
retention cyst.
No pain.

Bleedinq per nipple:

. By pressure on the swelling.
. lf there is no palpable swelling, zonal pressure will reveal the discharge.
Swellinq:
.
Small, fusiform, usually lateral to the areola
with its long axis pointing to the nipple.
3. Axillarv LNs: are not enlarged.

21
DITTEnENTIAL DI,AcNosTs
lnvestigations:
1) Benzidine test ) to make sure is it blood or not.
2) Galactography the papilloma appears as a regular filling defect.
3) Mammography) to screen the rest of the breast and the other breast.
Treatment!
. lt's a pre-cancerous (10%), so the treatment is:
1. Micro-dochectomy (remove the affected duct) through circumareolar incision
and wedge of the tissue 2.5 cm around it.
2. Histopathology.

Breast Handouts
Breast Pain (Mastalgia)
) lt is one of the commonest complaints
t Causes
G. physiological
d pathological : 1. Fibroadenosis ( commonest)
2. Breast abscess
3. Mondor's dieases (superficial thrombophlebitis)
4. Trauma 6. Sarcoma
5. Duct ectasia 7. Advanced carcinoma
IY. E>TTNA.UAMMARY:
. Premammary ( infection of montogomery glands)
o Retromammary e.g. Trietz'syndrome ( inflammation of costochondraljunction )

*ffii
i. Clinicol ossessment:
[:-ffi10{Y:
1) Personal history:
- Age:
a) Fibroadenoma -+ extremes of reproductive age
b) Most of breast cancer -+ after the age of 50 yrs
- Other risk factors for cancer breast:
. Menstrual history, marital status
o Menstrual irregularity
& late menooause
:. friillrlenarche
. 1B y).
Non tactating tady (if
. Contraceptive pills.
2) HPr:
- Pain with its nature:
(onset, course, duration, site, character, radiation,& relation to
menstrual cycle ) e.g.
a) cyclic pain -+ fibroadenosis or hormonal variation
b) throbbing pain -+ breast abscess
c) continuous pain -+ late malignancy
22
 SELF'I.SSESSMENT. PART -IT
- Swelling:
a) Cyclic -+ fibroadenosis
b) Accidental onset, short duration with toxic manifestation abscess
c) Accidental onset , short duration , rapidly progressive(ms)+
cachexia -+ can@r
- Nipple discharge:
a) Serous discharge -+ fibroadenosis (may be black or greenish)
b) Bloody discharge -+ cancer breast
c) Pus -+ abscess
3) PastS:".'#Lr"ast
of the other breast
o Medication specially hormones o Stress
4) Family history of cancer breast
B- lxamlnalion:
1) Underlying breast lump.
2) Breast discharge.
3) Examination of axillary LN (see breast lump)
ii. fnvestigotions :
1. Mammoqraphv:
a) Detect non plapable breast lesions
b) Exclude occult in both breasts.
2. US: diagnosis of nature of breast lump if present
a) Cystic : it could be benign or malignant (helped by aspiration cytology).
b) Solid: it could be benign or malignant
3. Biopsv:
a) FNABC b) Core-cut needle c) Open history
iii. Treotment:
1- lf breast mass is present :

@e.g.
- Drainage of breast abscess
- Treatment of cancer breast according to the stage:
Surgical excision , radio, chemo, and I or hormonal therapy
2- lf there is no mass + treated as fibroadenosis:
a. Minor Pain:
- Analgesics -+ NSAID
- Breast support -+ Firm bra
- Psychological support -+ reassurance
o Tell the patient that the pain is not secondary to cancer
(but do not tell that patient that nothing is wrong)
o lnform the patient that her pain will not T the risk of developing
cancer
Diet:
o Avoid caffeine & nicotine o Reduce fat.
b. Moderate to severe pain:
- Primrose oil (single morning dose)
- Regulation of the cycles by OCP

23
DITPEnENTIAL DlngNosls
Another way of enumeration is:
A- Cvstic swellinqs:
l - Arising from the duct system:
a) Cyst in fibroadenosis
b) Papillary cystadenoma
c) Galactocele
2- nrising from the snoma
a) Sebaceous cyst. b) Blood cyst
c) Hydatid cyst d) Abscess
e) Degenerative carcinoma
B- Solid swellinqs:
l. Small to moderate sire:
a- Early cancer breast b- Traumatic fat necrosis
c- Fibroadenoma
2. |
^rge
sizel.
a- Late cancer breast b- Diffuse hypertrophy.
c- Cystadenoma phylloides

Breast discharge
Clinicol ossessment:
A. HISIOIV:
a. Personal history:
- Age:
a) Fibroddenosis -+ extremes of reproductive age
b) Most of breast cancer -+ after the age of 50 yrs
c) 2% of breast cancer -+ before the age of 30yrs
- Other risk factors for cancer breast:
o Menstrual history, marital status
. Early menarche & late menopause
. Nullipara
. Non lactating lady (if . 18 y).
. Contraceptive pills.
b. HP!:
- Nipple discharse:
(color, amount, odor, unilateral or bilateral)
a) Character serous, bloody, etc...
1. Clear serous fluid -+ fibroadenosis
2. Black or greenish (altered blood) -+ fibroadenosis pr duct
ectasia
3. Bloody discharge -+ duct papilloma, papillary cyst-adenoma
or carcinoma of the breast
4. Pasty material -+ comedo carcinoma
5. Pus -+ breast abscess
6. Milk -+ galactorrhea (e.9. hyper-prolactinemia)
b) Location ( bilateral or bilateral)
-Pain with its nature (onset, course, duration, site, radiation & relation to
menstruation)
a) Cyclic ( premenstrual) e.g. Fibroadenosis
b) Dull aching e.g. duct ectasia
24
 SELF-AssEsSMENT- PnnT -II
c) Throbbing pain e.g. breast abscess
d) continuous pain e.g. late malignancy
- Lump:
a) Cyclic + fibroadenosis
b) Accidental onset, short duration with toxic manifestation -+ abscess
c) Accidental onset, short duration , rapidly progressive course(ms)
cachexia -+ can@r
c. Past history cancer breast of the other breast
d.Family history of cancer breast
B- lxamlnallon:
e General:
l.Toxemia
2. Metastasis (liver, spine, PR)
*@,
1. Discharge: differential squeeze by zonal pressure to identify the site the
discharge is coming from ( & if it's from one or multiple duct)
2. Lump & its relations to surroundings
3. LNs examination (axillary & supra -calavicular LNs bilaterally)
ii. :
fnvestigotions ( as breast pain +;
1) Benzidine test -+for occult blood
2) Cytology + for exfoliated cells
3) Mammography & sonography
4) Galactography may be needed
5) lnvestigations for hyper-prolactinaemia
a) Serum Prolactin, if elevated
b) CT scan for cella tursica to exclude pituitary adenoma
6) Purulent discharge -+ Gram stain, C/S
o
obular carcinoma)
o Sentinel LN biopsy
o Other investiqations:
. Hormonal replacement assay
o Survey for metastasis ( bone scan , lung CT, Liver U/S)
o Follow up by tumor marker ( CA 15.3)
trL Treotment:
a)
- Remove the lump + histopathology
b) lf not associated with lump -+ Zonal Pressure:
1. From One duct ( duct papilloma) -+ micro-dochectomy &histopathology
2. From many ducts -+ according to age
- if the patient > 40 yrs ( duct ectasia or multiple duct papilloma) major
duct excision is done.
- if the patient < 40 yr -+ observe until:
1 . Disappearance of the discharge
2. Apperance of lump -+ removal of lump + histopathology
3. localization to one duct -+ micro-dochectomy +histopathology
4. Patient reach 40 yrs + major duct excision.

25
DtprenENTIAL Dm,cruosIs

M Skin:
. Hemangioma, hematoma, sebaceous cyst, abscess
EI Subcutaneous tissue:
. Lipoma neurofibroma, neurosarcoma
M lntercostal muscles
. -
g Ribs Rhabdomyoma rhabdomyosarcoma
. Chondroma- chondrosarcoma, osteoma, osteosarcoma, osteomyelitis
g -Intercostal a. aneurvsm
g Others:
. Chronic empyema necessitans
. Cold abscess
. Surgicalempyhesma

EI Skin:
. Hemangioma, hematoma, sebaceous cyst, abscess
fl Subcutaneous tissue
. Lipoma neurofibroma, neurosarc,oma
g Back muscles
. Rhabdomyoma - rhabdomyosarcoma
fl Midline specific swellinqs
. Meningiocele
'. Spina bifida
Sacrococcygealteratoma
g Lateral ized swel nqs
I i :
. Lumbar hernia
V Others:
. Cold abscess

28
DrpreRENTrAL Dm,c ruosls

D.D of a Swelling in the Arilla

* Causes
, Skin:
- Abscess. Red, hot and tender.
- Sebaceous cyst. Cystic swelling that shows a punctum usually.
- Haematomas.
- Haemangioma.
S.C tissue:
- Lipoma.
- Neurofibroma. Tender but painless
- Neurofibrosarcoma.
Muscle laver: fibrosarcoma. Hard and rapidly progressive.

Axillarv vessels:
- Aneurysm of the axillary artery. Shows systolic thrill, expansile pulsations,
burit... ...
- A-V malformation. Shows continuous thrill.
Axillarv LNs:
- Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis).
- Malignancy: lymphoma & metastatic carcinoma.

T Muscular: flbrosarcoma
I Bone e.g. ribs: cold abscess, chondrosarcoma,
Humrerus: osteoma, osteosarcoma, osteoclastoma

* Diagrusls

EI A. acute lvmphadenitis:
. C/O: painful swelling of short duration.
' O/E:
- Enlarged tender matted LNs.
- Usually apparent source of infection in the catchment's area, e.g. the breast.
Latent abscess may form & the swelling becomes cystic.
30
 SELF,e.ssEssMENT. PART .II
M B. TB lvmphadenitis: more in children:
. C/O: slowly growing swelling.
. O/E:
- Firm matted LNs.
- Later, a cold abscess may form --+ finally ruptures leaving a TB sinus.

There is usually other LN swellings in the body.

The spleen may be palpable.
r lnvestigations:
- Biopsy is essentialto establish the diagnosis.
EI B.Metastatic carcinoma:
. C/P:
LNs are hard & painless.
Mobile at first & later fixed.
The 1ry is usually apparent e.g. in the breast.
. lnvestigations: Directed to the 1ry lesion, e.g. breast carcinoma:
- Laboratory: alkaline phosphatase for liver & bone 2ries.
- Radiology: U/S (particularly in young Q), mammography
---rdense opacity with speculated ill-defined outline &
microcalcification.
- lnstrumentalr
. Biopsy (for histology):
Excision biopsy (most accurate).
Frozen section (practical).
True-cut- needle'biopsy.
Cytology: FNAC.

* Causes

Sebaceous cyst. . Abscess.

Haemangioma. r Haematoma.
M S.C tissue:
. Lipoma. . Neurofibroma. . Neurofibrosarcoma.
M Muscle laver: fibrosarcoma.

EI Poplitealvessels:
r Aneurysm of the popliteal artery. Shows systolic thrill, expansile
pulsations, burit and decrease on size on proximal compression.
. A-V malformation.

31
DlrpenENTIAL DI^a,oxosts
EI Popliteal LNs:
. Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis).
. Malignancy: lymphoma & metastatic carcinoma.
lt\ratt\gtE r. t.Ct
g Muscular: (hamstring) fibrosarcoma
fl Bonv: osteoma, osteoclastoma, osteosarcoma

EI lt is a rounded fluctuating swelling that becomes tense on extension and flaccid

on flexion of the joint.

1. semimembranous bursitis.
2. Baker's cyst.
3. Popliteal artery aneurysm.

* Causes
t.
. Reducible ing.hernia . lneducible inguinal hemia

' Saphena varix . Subcutaneous lipoma . slippery

edoe and non tender swellino.
: Fe Aneury . l6gginallymphadenitis
Sh lepulsa i
burit...... .
. Psoas abscess. shows cross r Maldescended testis
fluctuation.

32
 SELF'I.SsEsSMENT' PaRT'II

M C/P of predisoosinq factorc. e.q. chronic cough, constipation.

.Swelling ccc by:
-Painless unless cofnplicated.
-Reducible, unless complicated.
-Gives expansile impulse on cough, unless strangulated.
-Direction of descent: downwards + fonruards --' upwards.
-Direction of reduction: downwards --+ backwards
- upwards.
M C/P of comolications: e.q. strangulation + painful, irreducible, no impulse on
of intestinal obstruc{ion.

r lt is a clinical diagnosis

EI lt occurs with varicose veins of the lower limbs.

. Varicose veins.
'

-',ll+;:"i$figi}* tb c,uberc e
- Shape: rounded.
- Color: bluish.
complications (in 2ry V.V), e.g. edema, eczema.

A. Acute lymphadenitis:
. G/O: painful swelling of short duration,FAHM.
' O/E:
- Enlarged tender matted LNs.
- Usually apparent sour@ of infection in the catchments area. Latent
abscess may form & the swelling becomes cystic.
B. TB lvmphadenitis:
. C/O: manifestations of TB toxemia,slowly growing swelling.
' - O/E:
Firm matted, enlarged non-tender LNs.
- Later, a cold abscess may form --+ finally ruptures leaving a TB sinus.
C. Lvmohoma:
. General: cachexia, anemia, pelepstien fever, pruritis.
. Enlarged painless LN which are rubbery in consistency,
Early discrete later on matted.
. There is usually other LN swellings in the body.
. The spleen may be palpable.
. Biopsy is essential to establish the diagnosis.

33
DrprenENTrAL DtReNosrs
D. Metastatic carcinoma :
.
LNs are hard & painless.
.
Mobile at first & later fixed.
.
The 1ry is usua rent e. breast.

DD of Acutely lnflamed Swelling ln the Groin

orsron: tn ma testis acute e
2- Strangulated inguinal hernia
3- Strangulated femoral hernia
4- Acute inguinal lymphadenitis
5- Sub. inguinal abscess
6- Rupture adductor longus tendon

*Di
t. Torsion (see before)
z. Strangulated inguinal hernia

Glinical Picture:
) Symptoms
- History of painless swelling that become painful
- Picture of intestinal obstruction : projectile vomiting
Abd. pain /distention
Constipation
) Signs:
- General: bad general condition,shock,
- Loca!: no expansile impulse on cough, irreducible, tense, tender
lnvestigations:
. lt is a clinical diagnosis

DD of Swollen Limb
* Causes
Unilateral ii- bilateral ( causes of generallzed edema)
)Acute .Hepatic
. DVT o Cardiac
. Lymphedema(acute flaria) . Renal
. Cellulitis o Nutritional
. Rupture Baker's cyst . Angioneurotic
)Chronic
. Varicose veins
. Chronic flariasis
. Neuro fibromatosis elephantiasis
. Congenital. A-V fistula (local gigantism)

I. DW .Most serious (see later)

2. Varicose veins

34
 SELF'I.SSESSMENT. PART'I I

Glinica! picture
e svmDloms:
. Cosmetic disfigurement, aching discomfort, complications(pig., itching, ulcer)
* Si0ns:
) History suggestive of DW
General
) Water hummer pulse, bl. pr. (with A_V fistula), dilated Vs crossing
inguinal region
Local
t Thrill on cough (on blow out)
) Fegan sign (facialdefect)
) Superficialthrombophlebitis -+ firm cord like tender
lnvestigations
. For W: Doppler, Duplex: reversal of the bl. flow, incompetent valves
. For complication: Arteriography : A-V fistula , Biopsy from ulcer if suspecting
Malignancy

DD of Paintul Limb
* Causes
1- Traumatic: fracture - dislocation - crush injury
2- Vascular : acute ischemia ( empolism , thromposis )
DVT
chronic ischemia ( intermittent claudication )
3- lnfective: cellulitis - osteomylitis - myositis - septic arthritis
4- lnflammatory : Rh.afthritis - ankylosing spondylitis
5- Degenerative : osteo arthritis- baker's cyst
6- Neurological : sciatica - P.neuropathy
7- Metabolic . Gout
8- Miscellaneous: cramp
*
1- Acute ischemia: the most serious.
2- Chronic ischemia
3- DVT

Glinical picture
. Of the cause: - Embolism : AF,other systems ( painless hematuria, hemplagia, MVO)
- Thrombosis: intermittent claudication, other systems e.g. lHDs
- History of trauma

35
 DIFFERENTIAL DIaeTtosIs
. 9L!gg@jA: 6 Ps: - Pain (is the cardinalsymptom), sudden severe pain in the
most peripheral part of the limb
i Pulseless
) Progressive coldness
I Palor
) Paralysis 'l
I ) Parasthia late sign
.@gangrene-chr6nicischemia_Volkmannischemiccontracture

. E4liarc,lp:. Doppler , duplex: absent Bl.flow distal to the site of occlusion

Angiography: block of main tree, no or minimal collaterals
. Forthe cause: ECG, echo, US
Chronic isclremia:

- Burger: male 20-40 Yrs , heavy smoker

t Of chronic ischemia:
t
1- Pain: - Claudication pain: cramp like pain mainly in the calf Ms inc. by
walking & exercise & dec. by rest only
- Rest pain: burning pain in the dorsum of the foot awakens patient
from sleep , relived by uncovering limb & pufting it in a dependent
position
2- Other systems: lHDs ( angina), Leriche syndrome , post cibial angina
.t $iOns
1- Skin: pale, cold, trophic changes ( loss of hair, thin, trophic, with ulcer
resistant for healing)
2- Muscle weakness
3- Arteries: weak pulsation

) History of pelvic surgery, prolonged recumbency malignancy , previous DVT

,
. Mostly associated symptomatic, 1't presentation by PE.
.) Sl0ns:
. General
) Unexplained fever , tachycardia out of proportion to fever ( 3-7 day post
operative)
. Local
) Pain: aggravated by Ms exercise
) Swelling : most reliable physical sign.
) Tenderness: on grasping the calf Ms.
(Once suspected diagnosis must be confirmed or excluded by accurate investigations)
. For diaqnosis of DVT:
) Doppler, Duplex : )if complete obstruction + dead silence
)if partial obstruction -+ Ioss of augmentation
) Spiral CT ( most accurate)
36
DlppenENTIAL Dm.cruosls
D.D of a Swelling in lnguinoscrotal Area
* Causes
t According to scrotal neck test:
A- Purely inguinal
B- lnguinoscrotal

) According to impulse with cough

, With impulse on couqh:
.Oblique inguinal hernia (OlH) (Bubanocele)
.Direct inguinal hernia (DlH)
.Femoral hernia )more in females and lies below and lateral to the
pubic tubercle.
.Saphina varix ) Associated with varicose veins.
. Without impulse on couqh
. Solid:
.LNs enlarged
o lnflammatory (acute or chronic)
o Malignant (1ry or secondary)
.Testis:
r. Retractile )
The scrotum is well developed and can be
pushed in it.
)
z. Ectopic The testis can be pushed medially and not
laterally.
)
3. lncompletely descened The testis can be pushed
laterally but not medially'
. Cvstic:
1. Psoas bursa
2. Femoral a. aneurysm. Shows expansile pulsations, burit ... ... .

3. Cystic LNs enlargement

of femoral hernial sac

According to impulse on cough

1- With impulse on couqh:
. OIH
o Varicoele (primary)
2- Without impulse on couoh:
. Solid
o Lipoma of the cord
o Endemic funiculitis
' Cystic
o Congenital hydrocele
o lnfatile hydrocele of the cord
o Encysted hydrocele of the cord )
By gentle traction upon the
testis, the swelling moves downwards and becomes less mobile.
o Hydrocele of the hernial sac of OIH )History of irreducible
swelling that becomes irreducible and translucent.

38
 SELF'ASSESSMENT- PInT .II
EI From the coverinqs:
r Skin
Boil, sebaceous cyst, epithelioma
. Subcutaneous tissue
Neurofi broma, cellulites
)
(IE no lipoma no fat in the scortum)
. Tunica vaoinalis
' oCystic:
- Hematocele -
Vaginal hydrocele
- Chylocele
oSolid
- Clotted hematocele
- Calcified hydrocele
EI From the contents of testis and epididvmis
o Cystic
- Spermatocele
- Epidiymal cyst
- Hydatid cyst of morgagni
o Solid
- lnflammatory (chronic specific inflammation as TB and
syphilitic gumma)
: Tumors (e.9. seminoma)

> The most common causes are:

g Oblique inquinal hernia.
g Hvdrocele.
g Varicocele (especiallv 1 rv)

V C/P of predisposinq factors. e.q. chronic cough, constipation.

. Purely inguinalswelling ccc by:
- Painless unless complicated.
- Reducible, unless complicated.
- Gives expansile impulse on cough, unless strangulated.
- Direction of descent: directly downwards forwards and medially..
- Direction of reduction: upwards, laterally and backwards.
- lnternal ring test: +ve.
C/P of complications: e.q. stranqulation + painful, irreducible, no impulse on
couqh. tender + CIP of intestinal obstruction.

. it is a clinicaldiagnosis

39
DrprenENTrAL Drlonosrs

Glinical picture:
EI Purelv scrotalswellinq ccc bv beinq:
. Painless. . No impulse on cough.
. lrreducible. . Trans-illumination: translucent.

lnvestigations:
EI lt is a clinical diaqnosis. investiqations mav be done to:
. Assess the testes, if not palpable: scrotal U/S, if testes are not
palpable.
. Routinepreoperativeinvestigations.

Glinical picture:
EI lnquino-scrotal swellinq ccc bv:
. Dragging sensation or aching pain.
, Disappears on lying down.
. Fluid thrill on cough.
. Smallsecondary vag.hydrocele by pinching test
. . Scrotum of the affected side hangs lower down & it may show
varicosities.
M C/P of complications: e.q. hvpofertilitv.
lnvestigations:
EI For varicocele:
. Doppler or Duplex. detects reversed flow.
. Scrotal or transerectal US.
. Pelviabdominal U/S to exclude 2ry varicocele.
M For hvpofertilitv: semen analvsis.

D.D of a scrotal swelling

A- Inquinoscrotal (see before)
* Causes
B- Purelv Scrotal: (see before)

*
The most common causes are :
g oblique inquinal hernia
fl Hvdrocele
g Varicocele

40
DITT.enENTIAL DIac NosIs

Acute scrotum
*
1- Epididymis : acute epididymorchitis
Causes:
2- Testis . orchitistorsion
3- Cord :funiculitis
4- Tunica : byocele-hematocele
5- Torsion of hydatid of Morgagni

*
1- Testicular torsion

Glinical Picture:
) Symptoms:
History of trauma
- Sudden severe agonizing pain in scrotum
- Testicular swelling
- Reflex symptoms: nausea, vomiting
) Signs:
- General : pallor, sweating, tachycardia
- Local : scrotum: swollen, irreducible, red, tender, dimpling at site of
gabrunculm,
elevation of scrotum I Pain
Cord : twisting may be felt
Testis : high up, tender
!nvestigations:
- Doppler: obstructed testicular vessel

Glinical Picture:
- History of dysuria of adult or elderly
) Symptoms:
- General : FAHM
- Local : gradual increasing pain which is
lnvestigations:
- Urine analysis: pus cells
- Doppler: patent vessels.

41
DITFEnENTIAL Dleor.Iosls

Difficulty in swallowing

* Causes
g Stomatitis, glossitis
g Neoplasms, and ulcers of tongue and cheek.

g Pharyngitis and tonsillitis.

g Retropharyngeal abscess.
g Plummer.Vinson syndrome )
More in females. Associated with spooning of nails
and splenomegaly.
g Pharyngealdiverticulum )Usually in an old male. Associated with neck swelling
that regurgitates undigested food on compression.
g Postcricoid carcinoma ) Associated with dysphagia at a late stage and Moure's sign.

A. tliechonicol couses:
+ Lumen:
. Foreign body.
+ Wall:
TCongenital stenosis.
I Traumatic as corrosive stricture.
. lnflammatory as reflux esophagitis )More in obese females above 40 years '

old. Associated with heart burn. 24hour PH monitoring is diagnostic.

. Neoplastic as carcinoma.
4 Compression from outside:
r Malignant thyroid. r LNs.
r Thoracic aortic aneurysm.
B. Neunomusculor:
. Achalasia of the cardia.
r Neuritis of glossopharyngeal or vagus nerve.
. Myasthenia gravis, tetanus, rabies.
r Esophageal motility disorder e.g. corkscrew esophagus.
r Hysterical or bulbar palsy.

g 1. Achalasia.
g 2. Acaustic stricture.
g 3. Esophaqeal carcinoma.

44
 SELF'ASSESSMENT' P^InT -II

t Female More in 2nd to 4th decades.

. Dvsohaqia ccc bv:
,

- Onset: insidious.
- Course: initially intermittent, but later constant.
- Duration: long
- More to fluids, especially at night.
. Regurgitation,halitosis
. @,[, Bad nutritionalstatus, dehydration , Pulmonary symptoms: cough &
wheezes.
of weight: not prominent.

M Radioloov:
- CX&- absence of the gastric air bubble, widwning of the mediastinum.
- Barium swallow: early delayed gastric emptying, later on sigmoid Oes+
parrot peak appearance
M lnstrumental:
- Manometric study: disorganized perstalasis, pr. in the high pressure
zone>25mmhg
- Esophagoscopy: for diagnosis (shows wide red Oes. filled with dirty water)+
exclusion of

More common in d > 50:

t o'"?nh*#iEiff#nressive,
to sorids > fruids with excessive sarivation,
regurgitation, loss of Wt. & apetite
Signs:
- G: cachexia dehydration, chest infection
EI Pulmonarv svmptoms: Cough & wheezes.
prominent.

Dor dlaenocis
Esophysgope: early endoscopy is the key for good result +biopsy +cytology
.' Ba swallow: shows rat tail, shouldering, or irregular filling defect

More in children
g Historv of caustic aqent drinkino.
g Associated burns to lips. tounque & oropharvnx.
g
g
. More to solids.
r Coulse: stationary. r Regurgitation.
. Duration: long. . Failure to thrive.
. Pulmonary symptoms: cough & wheezes.

45
DrppenENTrAL Dlncruosrs
lnvestigations:
.'
Radioloqv: barium swallow ---+ multiple irregular strictures.
lnstrumental: esophagoscopy.

D.D of Dyspepria
Discomfort related to meals.
*
g Esophaqeal causes:
' GERD.
V Gastric causes:
. Chronic gastric ulcer.
. Chronic gastritis.
, Gastric carcinoma
EI Duodenal causes:
. Chronic duodenal ulcer. . Duodenitis.
V Biliarv causes:
. GB stones.
. Chroniccholecystitis.
. GB carcinoma.
g Pancreatic causes:
. Chronicpancreatitis.
. Pancreaticcarcinoma.
fl Conqestive dvspepsia (portal HTN)
g Appendicular dvspepsia (chronic appendicitis)
g Colonic dvspepsia specially CA caecum
*
fl PU is the most common.
rcrnoma ts

DD of pyloric obstruction
) lt's a serious condition which has many causes acc. to the patient age
Etlology
A- Inlants Ci children: - CHPS
- Corresives
-FB
& In adults: - Chronic healed DU
- Pyloric canal ulcer
- Malignant obstruction i.e. CA stomach
- pressure from outside i.e. CA head of pancreas, or metastasis in the
porta hepatis
- Others: as chrons disease, TB.
Glinical picturo
. Svmptoms:
. Of intestinal obstruction: - Abdominal pain & distention,
- Projectile vomiting non-bile stained
- Absolute constipation

46
 SELF.ASSESSMENT- P^InT'II
Sions:

rr#:ifl ,s:ililllj]il,'itf,'"Hllffi Jf$',",$,,,,,

. C/P of the cause:
1- CHPS: infant 2-6 wks presented as above+ olive like lump in the Rt.
hypochondrium
2- Healed DU: history of periodic pain that's now lost & become cont.
O/E: suction splash

' @,,.oillT'Ttijii i"H:Y,',l,: flJ?Jg 2 wks

- Obstructive group: vomiting
- Epigastric mass

. malisnant ascitis

"r, "r,n" "rH?1?i$15;""undice'

1. Dehydration: sunken eyes, dry tongue, inelastic skin
2. Metabolic alkalosis : decrease resp. rate, parathesia
: hypotonia, arrythemia

i- Laboratorvt
. Serum electrolytes: dec. Na, K, & Cl.
. Tumor markers if suspecting carcinoma
ifr.
. Ba meal: - Bengin obstruction -+ dilated stomach & delayed emptying
- Gastric €ncer -+ irregular filling defect
. Abdominal US:
- CHPS -+ thickening of the pyloric ms + dilated stomach
- Gastric @ncer -+ liver secondaries
. CXR: chest infection
iii- Instrumeotats
scopy: stenosed pyloric ring or take biopsy if suspecting malignancy

A. Pre-operative preparation :
1- NG suction & wash
2- lV alimentation
3- Correction of fluid & electrolytes ( Na., K, & Cl) & acid base balance
(alkalosis)
4- Chest physiotherapy & antibiotics
B. Specific treatment: acc. to the case
1- CHPS: Ramsted's pyloromyotomy
2- healed DU: truncalvagotomy + gastrojejonostomy
3- gastric cancer:
- Operable -+ total radicalgastrectomy
- lnoperable : if resectable -+ palliative gastrectomy
if irresectable -+ metal stenting

47
 DIPTEnENTIAL DIa.cNosIs

Vomiting
* Causes:
) According to age
In tlte neonates: . Pylorospasm
o Gastroenteritis
. Duodenal atresia: - True: failure of recanalization
- False -+ annular pancrease
. Wilikies ds.
. Band of ladd
. lntracranial hge.
. HiUh int obstruction (duodenum, jeujenium)
. lntussusception
fn tlte adulk:
I. GIT:
a. Pyloric obstruction due to: o Chronic duodenal ulcer

: ffii{: fl"ff l:'r':+i's,,ru;?u, po,,, hepa,is

in CA head of pancreas)
b. Acute abd.: . Appendicitis o Pancreatitis . Cholecystitis . lnt. obstruction
!l- CNS disorders: e.g. vestibular neuritis, migraine, inc. ICT)
lll- metabolic: DKA, Addison disease
lV- infections: G.E, hepatitis
* Discuss

Gllnlcal plcturo
) infant 2-6 WKs
* SymDlomS: projectile vomiting (non-bile stained), constipation, failure to thrive
* Sl{ns:
. General: - Wt loss
- De hyd ration (su n ken eyes-depressed fonta nels-d ry tong ue- ine lastic
skin-oliguria)
- Bad chest
. Local: upper abdominal distention, visible peristalsis, olive like lump in the Rt.
hypochond rium(tumor sig n)
lnvestlgatlons
. &Lglgqnosis:. 1- US (most diagnostic) -+ thickening of the pyloric ms, dilated
stomach
2- Gastrographin study: dilated stomach, delayed emptying,
persistent narrow pyloric canal(string sign)
. @.CXR . CBC o KFT
. Serum electrolytes 1J Na, K, CL)

48
 SELF'I.SSESSMENT. PART .II

q projectile vom ng(non

. iti bi le stai ned), constipation
q $lols:
. General: dehyduation, c*lest infection, Wt loss
. Local: upper abd. distention, visible perstalisis
0/DolfreGilse!
t.Healed duodenal ulcer: history of periodic pain of DU, now lost & become
cont. sucction splash
,.CA pylorus: (fufls in one of 5 groups) male >40 Yrs presented with
.
. Dyspepsia Cachexia . Eirigastric mass Obstruction: vomiting .
o Metastasis

. Lab.: . CBC .
Serum electrolses ( J Nq, K, CL)
o KFT Tumor o markers \
. Radiolosv: - Ba meal -+ benigrn obst.: dilated stomach , soup dish delayed gastric
ernptying
- CA stomach: irregular filling defed, ulcer niche, Carmen meniscus,
linitis plastica
- CX ray: chest infection
Abd.US: liver metastasis,
- Upper Gl endoscopy: bexclude malignancy& take biopsy, endoluminal

1- Fetus ( pregnancy is the commonest cause)

2- Flatus
3- Feces
4- Fat
5- Fluid (ftee/ encysted ascitis)
6- Large solidtrmor such as:
- Fibroid
- Causes of hepatomegaly
- Causes of splenomegaly
- Renal mass e.g. polycystic kidney
- Retroperitoneal sarcoma

I Pregnanry is the commonest cause

! C/P: female in the child bearing period with features of pregnant uterus:
- Smooth, firm, dull swelling arising out of the pelvis esp. after the 1"t12 weeks
- Bimanual examination reveals that it moves with the movement of the cervix &
cervix is soft & patulous

I Gas in the intestine can cause considerable abdominaldistention

I Etioloovi
-
Mecllanical intestinal obstruction, paralytic ileus, acute dilatation of the stomach
49
-
Drpp'EnENTTAL Dtlenosls

Of intestinal obstruction
Siqns:-
- lnspection: may be visible peristalsis
- Palpation: suction splash esp. with pyloric obstruction
- Percussion: hyperresonance

. lt's fecal impaction

ds, chronic int. obstruction ( CA. colon)

- History of change in the bowel habits, or chronic constipation, or spurious diarrhea

. Siqns:
- lnspection: fullness in the flanks
- Palpation: hard firm indentable masses mainly in the flanks or in the lower
epigastrium
- P/R: rectum full of feces, but in case of obstruction -+ empty rectum
Plain X-ray: abdominal erect -+ air fluid level
supine +
distended gas bowel
I Abdominal US.
I Barium enema

. Rarely causes abdominal distention (distention due to heavy thick omentum)

4,. FREE FLUTD IN THE PERITONEALGAVIff

' EllglsslE
1- lncrease in the portalvenous pr.: - Prehepatic
Hepatic
- Posthepatic
2- Causes of hypoproteinemia
3- Causes of chronic peritonitis
4- Chylous ascitis
. @. Signs: - Fluid thrill - Shifting dullness
E} FLUID EN TSTED IN A CTET
' E!!g!.ggvi
- Ovarian cyst
- Full urinary bladder

1. Cancer colon (see before).

2. Splenomegaly(see before)

50
 SELF'A.SSESSMENT, PART .II

* Causes
g Rt. Pneumonia:
g Marked chest symptoms, minimalabdominaltenderness and there is no rigidity.
g Tonsillar tummy:
g Child with acute tonsillitis E swallows pus n abdominalcolic.
g Diaphragmatic pleurisy.
g Myocardial infarction.

g Perforated Peptic Ulcer:

. HistoU of dyspepsia is present.
. Plain X-Ray shows air under the diaphragm.
V Acute Cholecvstitis:
. Pain in the right hypochondrium
. Fever is higher.
. U/S willconfirm the diagnosis.
g I ntestinal Obstruction :

. Repeated vomiting.
. Absoluteconstipation.
. Iltlultiple fluid levels in X-Ray abdomen erect.

V Non-specific Mesenteric Lvmphadenitis:

. Common in children.
. There is shifting tenderness
g Resional ileitis.
g Deep iliac adenitis:
. Child with septic focus in LL
. Pain in iliac fossa, psoas spasm
. Flexion deformity, high fever and O/E
. Tender nodular fixed mass in iliac fossa very close to inguinal ligament.
V Mickle's Divefticulitis.
g Perforated ileal Wphoid ulcer:
r HistoU of typhoid, tenderness allover the abdomen X-Rayl free gas in
peritoneum (erect ugas under diaphragm).

g Disturbed riqht ectopic preonancv:

. History of amenorrhea. . Vaginal bleeding.
. Shock. . Tender cervix.
g Acute salpinqitis:
. Fever, vaginaldischarge, tenderness often bilateral.
V Midcvclic pain (Mittelschmerz)
g Twisted riqht ovarian cvst from appendicular mass.
@ P!D:
. Vaginal discharge, bilateral pain, mass felt on PV.

51
DlrrenENTIAL Dle,eruosls

g Riqht ureteric coli:

r !
Pain from loin groin, pain does not increase with cough, patient
writhing on himself while in appendicitis patient lies flat as movement
increases pain.
g Rt. Pvelonephritis:
. Fever 40'C + rigors, tender pain, dysuria.
g Disease of the spine:
r Acute osteomyelitis & Pott's of dorsolumber veretebrae.
V Herpes Zoster in 1Oth. 1lth. 12th thoracic nerves.
fl Others:
r Diabetic abdomen.
. FMF.

See page

ccc 6 F's patient:

( Female, Fatty, Forty/Fifty, Ferti le, Fi lthy)
g C/P of biliarv stones: biliary colic, biliary dyspepsia & reflex retrosternal
chest pain t atrack of cholecystitis:
g Svmptoms:
r FAHM
. Pain: 1st diffuse upper abdominal colicky, later, localized Rt.
Hypochondrial dull aching.
. Nausea & vomiting.
g Sions:
. Fever & tachycardia.
. Rigidity, tenderness, rebound tenderness in the Rt. Hypochondrium.
. Specia! signs: Leak's sign & Boa's sign.
. GB mass: may be difficult to feel due to rigidity.
g Laboratory:
. CBC --+ PMN leucocytosis.
g Radioloqical:
r U/S + stone (sensitivity 97o/o), distended GB.
. HIDA scan: most accurate, least practical.

52
 SE LF'ASSESSMET.TT. PR.RT -I I

D.D of Aral Pain

Gauses
flAnalfissure.
EI Prolapsed strangulated piles.
EI Perianal suppuration.
M Acute perianal hemorroids.
EI Carcinoma of the anus.
M Proctalgia fugax.
Diagnosis
> The most common _causesllel
1. Anal fissure.
2. Anorectal abscess

Glinical picture=
More in middle aged women.
EI C/P of predisposinq factor. e.q. constipation.
g CIP of fissure:
. Pain:
- Onset. suddenly at defecation.
- Offset: suddenly: about t hr after defecation.
- CCC: sharp agonizing.
- Course: course: may have remissions for days/weeks.
. Constipation (to avoid pain)
. Bleeding: slight streaks on surface of stools.
. Slight anal discharge.
. Reflex symptoms: dysuria, dysmenorrheal
E siqns:

- tightly contracted anal verge, puckerd anus

- Small tear may be seen by gently separating the glutealfolds
. DRE: better to be avoided because it's very painful

By inspection:
- Fissure can be seen, anal papille or sentinel bile can be
seen
fissure is fibrotic & indurated' sphincter is fibrosed'
rnvestigrti;":lE:
M !t is a clinical diaqnosis. investiqations mav be done for:
. Exclusion of D.D ot 2ry causes, e.g. crohn's disease.
. Routine pre-operative investigations.

53
D IT.TEnENTIAL DIE,G rqoss

M Svmptoms:
. Generol: FAHM
. L@throbbing perianal pain inc. by movement & interferes with
sitting or walking.
EI Siqns:
. General: fever & tachycardia.
r Local: red, hot & tender swelling.
NB: pain & constitutional symptoms are not marked.

EI Laboratorv: CBG--- PMN leukocytosis.

EI Radioloqv: U/S - for pelvirectal abscess.

) See GIT book

F See GIT book

54
 SELF.I.ssEssMENr. PART'II

* Causes:

Abscess I Hematomas.
Sebaceous cyst. T Hemangioma
@ S.C tissue:
. Lipoma. Neurofibrosarcoma
. Neurofibroma.
g Muscle laver:
. Fibrosarcoma. . lncisional hernia.

EI Visceral:
. Liver:
o Amoeobic hepatltis ) Occurs usually in endemic areas and
responds to metronidazole within 72 hours.
o Hydatid cyst )usually occurs in endemic areas (e.g Algeria).
o Liver cirrhosis ) There may be history of the cause and
manifestations of cirrhosis, e.9., bleeding tendency
o Cancer ) Usually rapid deterioration of the condition in a
cirrhotic pt. GT scan is accurate and level of alpha feto protein
above 2000 ng/dl is diagnostic.
. GB:
o Mucocele.
o Empyemea ) Usually there is history of cholecystitis.
o )
Wth malignant obstructive jaundice Characterized by painless
progressive jaundice especially in old age.
o GB carcinoma ) Rare and occurs usually in females
. Hepatic flexure: colonic carcinoma ) More in females and usually
presents by a mass rather than l.O.
. Rt. Kidney:
o Hydronephrosis ) There may be history of the cause.
o Pyonephrosis.
o Solitary cyctic kidney.
o Polycyctic kidney.
o Hypernephroma.
o Wilm's tumor ) Usually in a child between 3-4 years old.
Present by abdomina! swelling in that does not cross the
midline in 90% of cases.
. Rt. Suprarenal qland: malignant tumors.
' Pancreas: pancreaticpseudocyct.
EI Retroperiotneal sarcoma.

55
DMTENENT}AL DIAG}IOSE

@ Mucocele of the GB.

g Pancreatic pseudocyst.
fl Renal cell carcinorna.

g Characterized bv: 6 F's patient (Female, F?tty, Forty, Fifty, Fertile, Filthy)
g Past historu of biliarv colics:
g Svmptoms (of acute cholecvstitis):
. FAHM.
. Pain: 1st diffuse upper abdominal colicky, later localized Rt. hypochondrial
dullaching.
. Nausea and vorniting.
g Siqns of (acute cholecvstitis):
. Fever and taehycardia.
. Rigidity, tenderness, rebound tenderness in Rt. hypochondrium.
. Special signs: Leak's sign and Boa's sign.
g Siqns (of mucocele complication of acute cholecvstitis):
. GB.mass: may be difficult to feel due to rigidity.
ature is not as high as in case of empyema.

g Laboratorv:
. CBC ) PMN leucocytosis (not as high as in empyema).
. LFTs ) usually normal.
g Radioloqical:
. U/S ) stone (sensitivity 98yo), distended GB.
. Plain X-ray (AP and lateral views) ) stones (sensitivity 10%) lie anterior to the
spine.
. HIDA scan: most accurate, least practical.

g History of acute pancreatitis or abodominal trauma, Du.

g Small pseudocyct )painless, detected by follow-up with U/S.
fl Large one ) upper abdominalwhich is fixed tender lying above the umbilicus &
giving transmitted pulsations (which disappears in knee elbow position)swelling,
discornfort,

EI Bv radioloqv:
r $arium meal (lateral view): fonruard gastric displacement.
r ll/S and CT scan: are the most accurate.

56
 SELF.nSSESSMENT. PART'II

g More in males. 50 vears. \

g Hematureia (50%): painless, periodic, and profuse{ Triad (1oo/o) usually)
g Pain (40%). f
advanced disease.
g Mass (30%): hard irregular. )
g Paramaliqnant svndrome e.q. HTN. hvpercalcemia. polvcvthemia.
g
g Laboratory:
. Urine analysis ) hematuria.
. CBC ) anemia, polycythemia, 4ESR.
V Radioloqv:
. IVP: shows irregular spider leg appearance
. U/S:
for metastasis: CXR bone scan.

* Causes:
g Skin:
. Abscess. I Sebaceous cyst.
, Haematomas. I Haemangioma.
g S.G tissue:
. Lipoma . Neuroflbroma. Neurofibrosarcoma.
g Muscles laver: fibrosarcoma &incisiona! hernia.

EI Visceral:
' Spleen:
. Metabolic ) Usually there is positive family history.
' Bacterial lnfections ) There is fever, enlarged tender spleen and
t TLC
. Tumors.
. Portal HTN.
. Blood disease )Usually there is a characteristic CBC.
'. CYst-
Collagen disease.
. Splenic flexure: carcinoma ) Common in males and usually present
by lO rather than a mass.
. Lt. kidnev:
1. Polycystic kidney ) There is positive family history and starts to
manifest after 30 years old.
2. Hypernephroma.
3. Wilm's tumor ) Usually in a child between 3-4 years old. Present
by abdominal swelling in that does not cross the midline in 90% of
cases.

57
DITTEnENTIAL Dn,c ruosIs
4. Hydronephrosis. 5. Pyonephrosis.
6. Solitary cystic kidney.
. Lt. suprasternal gland: malignant tumors.
. Tail of the pancreas.
EI Retroperitoned sarcoma.

1- Splenomegaly (comm'onest with portal hypertension).

2- Renal cell carcinoma.

EI C/P of the cause: e.g. Bilhaziasis or liver cirrhosis

M C/P of portal HTN
a. Opening of porto-systemic collaterals.
)
1- Esophageal and gastric varices hematemesis, melena and anemia.
2- Caput medusa.
3- Anorectal varices (hemorroids).
b. Congestion of the GIT )
anorexia, dyspepsia and indigestion.
c. Ascites.
d. Splenomegaly: Lt. upper abdominal swelling, discomfort + pain.
What are the characters of splenic swelling?

@ lnvestiqations for portal HTN:

. For etiology: viral markers, liver biopsy.
.For liver function: LFTs ) t
V albumin, PT, 4\ AST, 4 ALT.
.For esophageal varices: upper endoscopy.
fl I nvestiqations for splenomeqalv

.Laboratory: CBC )
anemia or pancytopenia (with hypersplenism).
r Radiotogy:
. U/S.
- 51Cr-labelled
RBCs isotope study )
4 spleen/liver index.
. Instrumental: BM examination )
hypercellularity.

See before.

58
 SELF.e,ssEssMENT- PIRT .I I

* Cau ses
\/af,aasrLrsra

fr Skin
. Sebaceous cyst.
. Haemangioma.
. Abscess.
. Haematomas.
g S.C tissue:
. Lipoma.
. Neurofibroma.
. Neurofibrosarcoma.
il Muscles laver: fi brosarcoma.
g lncisional and oaralvtic hernia.

tr GIT:
I lleum: Chron's disease
! Caecum: colonic carcinoma.
I lleocaecum: ileo-caecal TB, ileo-caecal actinomycosis.
T Appendix: appendicular mass or abscess.
g Tubo-ovarian:
. Ovarian cyst or tumor )May be bilateral and can be detected by PV and U/S.
. Hydrosalpinx or pyosalpinx.
. Tubal pregnancy )There is usually of induction therapy.
g Uterus: Fibroid.
a Renal:
. Ptosed kidney )The ureter is tortous and there is normal rotation on lVP.
. Ectopic kidney. The ureter is not tortous and there is abnormal rotation on
IVP
g Vascular:
r Rt. Iliac a. aneuroysm. Expansile pulsations, burit...
. Rt. lliac LNs:
- Lymphadenitis: acute and chronic (non'specific and specific e.g TB
lymphadenitis). lt is near the iliac vessels.
- Malignancy: lymphoma and metastatic carcinoma.
fl Muscular
g Retroperitoenal sarcoma or maliqnant undescended testis.

1- Appendicular mass or abscess.

2- Caecalcarcinoma.

59
DrrrenENTrAL Dureruosls

E C/P of aopendicitis.
nw.
. Acute severe pain:
. 1st ill-localized periumbilical dullaching pain.
. Later, well-localized.Rt. iliacfossa sharp pain.
r Nausea & vomiting.
r Constipation.
e O/E:
. Fever (not > 40.C unless complicated) & tachycardia.
. Rigidity, Tenderness, Rebound Tenderness in the Rt. iliac fossa.
. Special signs: Rovsing's sign, Psoas sign & obturator sign.
il C/P of appendicular mass (3,4 davs later).
r Abdominal examination -- Rt. iliac fossa mass.
. PV -+ pelvic mass.
il G/P of appendicular abcess (3,4 davs laterl:
As appendicular mass + veU high temperature,

g For aooendicitis:
. Laboratory:
.CBC: leucocytosis
.Urine analysis: to exclude UTI. I To exclude common
.Pregnancy test to exclude edopic pregnancy.
I genitourinary causes
. Ra4ioloov: U/S.
r lnstrumental: laoaroscopv.
g For appendicular mass and abscess: U/S.

g More in females
V Usuallv vaque presentation:
. Asthenia, Anorexia.
. Recurrent Attacks of Rt. iliac fossa pain..
g Rt. iliac fossa rnass hommon).
V lntestinal obstruction (rare. occurs if the lesion obstructs the ilieocaecal

Laboratorv:
r CBC --+ anemia (micro/macrocytic)
. CEA (prognostic rather than diagnostic).
il Radioloqical:
r Barium enema --r filling defect or apple core appearance
. U/S or CT scan (for liver 2ries).
V lnstrumental: colonoscopv & biopsv:

60
 SELF.ASSESSMENT. PART .II
D.D of Swelling in the Lt. lliac Fossa
* Causes
EI Skin:
. Abscess ! Haematomas.
. Sebaceous cyst. ! Haemangioma.
g S.C tissue:
. Lipoma. r Neurofibroma. . Neurofibrosarcoma.
g Muscle laver: fibrosarcoma.
g Hernia: incisional & paralytic.

ElVisceral:
- Pelvic colon:
. Bilharzial mass ) Hard nod0lar mass and may be associated with portal
HTN.
. Pelvic carcinoma.
. )
Diverticulitis Occurs usually in'old males and may cause massive
bleeding per rectum.
'
MTubo-ovarian:
Spastic colon.

. Ovarian cyst or tumor ) May be bilateral and can be detected by PV and U/S.
. Hydrosalpinx or pyosalpinx.
. Tubal pregnancy.
. Fibroid.
ERenal:
. Ptosed kidney )The ureter is tortous and there is normal rotation on lVP.
. Ectopic kidney )the ureter is not tortous and there is abnormal rotation on lVP.
ElVascular:
)
. Lt. iliac a. aneurysm Expansile pulsations, burit..
. Lt. iliac lymphadenopathy:
.Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis) near the iliac vessels.
.Malignancy: lymphoma & metastatic carcinoma.
ElMuscular: ileo-psoas abscess.
ElRetroperitoneal sarcoma. or maliqnant undescended testis.
* Diadnosis

lclinical
ElChanqe of bowel habits:
r Progressive constipation (commonest).
. Diarrhea.
. Constipation alternating with diarrhea.
. Spurious diarrhea.

61
DrprenENTrAL Dncruosrs
g
. Absolute constipation (early).
. Vomiting (late).
. Distention.
M Bleeding per rectum: common but rarely massive.
EI Mass in the Lt. iliac fossa (rare): usually due to impacted stool.
lnvestigations:
EILaboratorv:
. CBC --+ anemia (micro/macrocytic)
. CEA (prognostic rather than diagnostic).

MRadioloqical:
. Barium enema ---+ filling defect or apple core appearance
r U/S or CT scan (for liver 2ries).
Mlnstrumental: siqmoidoscopv & biopsv:

D.D of Swelling in the Epigastrium

* Causes

Abscess . Haematomas.
Sebaceous cyst. . Haemangioma.
S.C tissue:
.
Lipoma. . Neurofibroma. . Neurofibrosarcoma

g Muscle laver: fibrosarcoma.

g Hernia:
. lncisional hernia.
. Fatty hernia of linea alba.
' Epigastric hernia.
M Visceral:
. Lt. lobe of the liver:
1. Amoebic abscess )Occurs usually in endemic areas and responds
very well to metronidazole within 72 hours
2. Hydatid cyst )usually occurs in endemic areas (e.g Algeria) and
shows hydatid thrill in 70o/o of cases
3. Malignant nodule (cancer) ) CT scan is accurate and level of alpha
feto protein above 2000 ng/dl is diagnostic
4. Liver cirrhosis ) There may be history of the cause and
manifestations of cirrhosis, e.9., bleeding tendency
. Transverse colon:
1. Carcinoma )More in females and usually presents by a mass rather
than l.O
2. Bilharzial colitis )Hard nodular mass and may be associated with
portal HTN
3. Diverticulitis ) Occurs usually in old males and may cause massive
bleeding per rectum

62
 SElr"LssEssMErur, Panr .l t
r Greater omentum:
1. TB peritonitis) There may be ascites, pain or abdominal masses. lt
is best diagnosed by laparoscopy.
2. Malignant nodule "Tumo/'rare.
. Stomach:
1. Carcinoma. 2. Epigastric abscess.
3. Gastric outlet obstruction )Characteristic projectile, non bilious, foul
odor vomiting containing food from previous eals or days especially
at the night.
. Pancreas: pseudopancreatic cyst.
EI Vascular:
. Aorta: abdominalAortic aneurysm (AAA) but 95% below lvel of renal
arteries (i.e in the umblinicalregion)
. Aoftic L.Ns:
1. Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis).
2. Mali ;nancy: lymphoma & metastatic carcinom
EI Retroperitonea sarcoma

g Gastric carcinoma.
V AAA.
fl Pseudopancreatic cvst.

More in d > 50 yrs. Presentation usually falls in I of these 5 groups:

Ellnsidious presentation: with anemia, asthenia & anorexia.
EIDyspepsia.
MCachaxia
ElObstruction:
r Cancer at cardia
-'dysphagia. . Cancer at pylorus --, vomiting.
ElEpigastric mass (usually indicates advanced carcinoma).

ilLaboratorv:
. CBC + micro / macrocytic anemia.
. CEA (for prognosis rather than diagnosis).
g Radioloqv:
. CT (especially for LN deposits + pre-operative staging).
M lnstrumental: endoscopv & bioosv (earlv endoscopv is the kev for qood
result): may show lrregular filling defect, ulcer niche, Carmen minscus sign, linitis
plastica

g Of the cause: e.q atherosclerosis

fl Of the aneurvsm:
e Asymptomatic in 7 5o/o.
eSymptomatic: pain (commonest) vague abdominal pain in the flanks & back ache.

63
DrrrEnENTrAL Dnorvosls
M Of the complications:
' Rupture (triad of shock, acute abd.pain,pulsating epigastric mass
' lschemia due to: thrombosis,empolism,associated atherosclerosis
' Pressure manifestations: nerve: sensory or motor loss.
Bone: erosion of the vertebra
Vein: obstruction & thrombosis
lnveStigations: by radiological modalities:
EI U/S (for screening).
M Spiral CT scan: accurate investigation to determine the diam.& true extension of
aneurysm.
EI'MRl (alternative to CT scan, more

) See before
D.D of a Swelling in the Umbilical Region
* Causes

Abscess . Haematomas.
Sebaceous cyst. . Haemangioma.

EIS.C tissue:
. Lipoma. . Neurofibroma. . Neurofibrosarcoma.
MMuscle laver: fibrosarcoma.
MUmbilical hernia & para-umbilical hernia:

ElVisceral swellinss:
. Stomach:
1. Gastric carcinoma.
2. Epigastric abscess.
)
3. Gastric outlet obstruction Characteristic projectile, non bilious, foul
odor vomiting containing food from previous meals or days especially
at the night.
. Transverse colon:
1. Bilharzial colitis) Hard nodular mass and may be associated with
portal HTN
2. Diverticulitis )Occurs usually in old males and may cause massive
bleeding per rectum
)
3. Carcinoma (rare) More in females and usually presents by a mass
rather than l.O
. Greater omentum:
)
1. TB peritonitis There may be ascites, pain or abdominal masses. lt
is best diagnosed by laparoscopy
2. Malignant nodule (rare)
. Mesentry: mesenteric cyst )Shows Tillaux triad.

64
 SELF.ASSESSMENT. PART,II
ElVascular:
.
Aorta: abdominalAortic aneurysm (AAA).

r LNs (Aortic & mesenteric):

' 1) Lymphadenitis: acute & chronic (non-specific & specific e.g. TB
lymphadenitis),
2) Malignancy: lymphoma & metastatic carcinoma.
M Retroperitoneal sarcoma.
*

MPara-umbilical hernia.
ElGastric carcinoma.
EIAAA.

Glinica! picture:
More in middle-aged females.
EIC/P of predisposino factors, e.g. multi-parity, obesity, chronic cough...

ffin,T#r* i*ffi:rii: ixt"" l,...xli;*n or partia,y

' reducible.

. 3i::', :il: il :i".#

: H; ;:
;:',,1x ; n"T i:H':',1f tn e u m n c u s
ir i

EIC/P of complications: e.g. strangulation --- painful, irreducible, no impulse on

cough, tender + CIP of intestinal obstruction. ",1
lnvestigations:
.@

See before

DD of Swelling from the Anus

1. Piles.
2. Rectalpolyps
3. Rectal prolapse
4. Prolapsed intussception

1. External piles 3. Post-anal dermoid cyst.

2. Abscess 4. Carcinoma of the anus
5. Condylomas
65
DIFTEnENTIA.L Dner.losrs

* Causes

EI Skin:
. Abscess ! Hematomas.
. Sebaceous cyst. I Hemangioma.
g S.C tissue:
. Lipoma. r Neurofibroma. Neurofibrosarcoma.
g Muscle laver: fibrosarcoma.
> lntraabdominal swelling:
EI Visceral:
. Uterus:
- Fibroid.
- Pregnancy: normal, ectopic & vesicular mole.
- Malignancy: endometrial carcinoma, choriocarcinoma & uterine sarcoma.
- Pyometra & hematometra.
- Adenomyosis.
. Tubo-ovarian:
- Ovarian cyst or tumor ) May be bilateral and can be detected by PV and U/S.
- Hydrosalpinx or pyosalpinx.
- Tubal pregnancy ) There may be history of indudion therapy.
r Urinary system:
- Fullbladder: urinary retention.
- Malignancy ) There may be history of bilharziasis, haematuria.......
.

cystoscopy is diagnostic.
- Ectopic, ptosed or transplanted kidney.
. Siomoid colon:
- Bilhazial mass ) Hard nodular mass and may be associated with portal HTN
- Pelvic carcinoma ) More in males and presents usually by l.O rather than a
MASS.
- Diverticulitis ) OccUrs usually in old males and may cause massive
bleeding per rectum
- Spastic colon.
EI Retrooeritoneal sarcoma

66
 SELF'ASSESSMENT. PART .II

Rt. hypo-
chondriu
m
Hepatic Splenic -lleum. Pelvic -Transverse -Transverse Sigmoid
flexure flexure -Caecum. colon colon & colon & colon.
0s -Appendix greater greater
6.9
oc omentum. omentum.
oo -Stomach. -Stomach.

-Liver. -Spleen. -Liver (Lt.

.GB. -Pancreas. lobe).
-Pancreas. -Pancreas.
esH
-Kidney.
-Suprarenal gland

(tr
Tubo-ovarian -Uterus &
=c adnexae
o
o -UB
-lliac artery. - Abdominal Aorta.
-lliac LNs. - Aortic LNs.
DrrrgnENTrAL Drlcruosrs

Upper gastrointestinal hemorrhage

(hematemesis and melena)
Definitions:
I Upper Gl hemorrhage is usually due to lesions above the ligament of Treitz (end of
duodenum).
I lt manifests by hematemesis and/or melena.
. Hematemesis: vomiting of blood which may be of a coffee ground material if it is
of small amount or bright red blood if it is of large volume.
. Melena: passage of black tarry stools. ln most cases it is caused by bleeding from
upper GlT. Rarely however, melena arises below the ligament of treitz, e.9., from
lesions of the small bowel as neoplasms, bleeding Meckle's diverticulum,
intussusception, MVO and bleeding typhoid ulcers.
. Occassionally upper Gl bleeding is so massive and the transit period is so fast to
the extent that it manifests by bleeding per rectum.
o Minor trickling of blood from any part of the gut does neither manifests in vomitus
nor in change of color of stools. This is called occult Gl bleeding.
+ ''''d $'f :*/;'3

Esophageal Esophageal Reflux Mallory weis Esophageal

causes varices esophagitis syndrome carcinoma
Gastric causes Hereditary Multiple gastric Gastric
hemorrhagic erosrons. caronoma.
telangectasia Acute gastritis. Leiomyoma.
Gastric ulcer. Gastric polyp.
Duodenal Aorto-duodenal Pudendal ulcer Peri-ampullary
causes fistula. caronoma.

g Bleedinq disorders. e.q. hemophylia, thrombocytopenia.

g Druqs : anticoaqulant therapv.
. The commonest causes of upper Gl hemorrhage are in the following order:
1. Esophageal varices.
2. Acute gastric erosions usually caused by ingestion of NSAlDs.
3. Acute hemorrhagic gastritis.
4. Chronic duodenal ulcer.
. ln this emergency situation you should not wait for a diagnosis. Life saving
resuscitative measures should be initiated immediately and are then followed by
diagnosis and definitive treatment.
1. Estimation of severity of bleeding and resuscitation.
2. Localization of the site and cause of bleeding.
3. Treatment of specific lesions.
68
 SELF'a.ssEssMENT- PI.nT -I I
)Estimotion of severitf of bleeding ond resuscitotion:
. Admit to hospital. severe bleeding cases require ICU admission.
Repeated clinical and hematocrite assessment.
' lnsert two peripheralvenous lines and withdraw blood for cross-matching and
blood tests.
. lnsert a Foley catheter. Urine output is the best monitor of tissue perfusion.
. A central venpus line is neede for monitoring in severe cases.
. lV sodium containing fluids is started until blood is available e.9., Ringer's lactate.
. A nasogastric tube is inserted for all cases.
. Correct coagulopathy by FFP and by giving missing factors.
r fl major c€luse of morbidity and mortality is aspiration of blood. To prevent this
complication in patients with altered mental status, endotracheal tube intubation
should be considered.

. Previous aftacks and their management.

I Hepatitis and bilhaziasis.
! Medications, particularly NSAIDs.
! Peptic ulcer symptoms.
I

a Stigmata of cirrhosis; spidre naevi, jaundice, gynecomastia, palmar erythema......

I Surgicalscars.
! Tenderness.

Hemoglobin percent and hematocrite value will show evidence of hemodilution after
three hours.
Liver functions tests will be disturbed in patients with cirrhosis and esophageal
varices.
. Blood urea and creatinine.
Exclude causes of bleeding tendency by the coagulation tests.

Endoscopy is the most important test. lt should be performed as early as possible

once the patient has been resuscitated. The procedure is done under mild sedative
as diazepam.
ln the majority of cases (90-95%) endoscopy will establish the cause of bleeding
and it may reveal the actual bleeding spot. Moreover, in cases of double lesions,
endoscopy will tell which one is bleeding.
o Endoscopy can also be used therapeutically to stop bleeding.
o Barium radiography is loosing favour because it is less accurate than endoscopy.

!n difficult Glses where radiography or endoscopy fails to diagnose the lesion that
causes the bleeding, it may be necessary to resort to celiac angiography to reveal
the source of bleeding, e .g., angiomatous malformation of the stomach.
Angiography needs to be performed during active bleeding

69
DIFFERENTIAL Dn.cruosIs
i Treotment of specific lesions
Refer to text

U pper Gastroi ntestina I

Resuscitation
Airway Protection
NG tube ) blood in the aspirate

After Stabilization

Upper GlT.endoscopy

lVarices Peptic ulcer disease and

erosive ga tis

. Proton Pump lnhibitors

o Sclerotherapy Or Banding

. . Endoscopic therapy
Glypressin
o Balloon Tamponade

lf Bleeding continues

lf Bleeding continues
Surgery

TIPPS

70
 Setr'+ssESSMEnT- Pnnt -Il
Bleeding per rectum
I Haematochezia is fresh bleeding per rectum.

Hemorrhoids. o Rectal
carcinoma.
o Anal
carcinoma.
o Mesenteric . Amebic dysentery. o Colonic
infarction o Crohn's disease. carclnoma.
o lntussusception o Ulcerative colitis. o Colonic &
o Bilhazialcolitis. small intestinal
o Angiodysplasia. o Diverticular polypi(e.g.
disease. FPC)
o Meckle's
diverticulum.
Esophageal PU
varices

c2 USeS:
M Bleedinq disorders. e.q. hemophylia, thrombocytopenia.
M Druqs: anticoagulant therapy.
I Hemorrhoidql bleeding is the commonest couse.
) iAossive bleeding pe? rectum in odulfs:
1. Diverticular disease.
2. UC.
3. lschemic colitis.
4. Angiodysplasia.
5. Massive bleeding from upper GlT.
) Mossive bleeding pq rectum in children
. Meckel'sdiverticulum.
) Focts obout bleeding per rectum
1. Spontanous remission rate is 8O%.Bleeding has usually ceased by the time the
patient presents to hospital.
2. No source of bleeding can be identified in 12o/o of cases.
3. Bleeding is recurrent in 25% of cases
4. Lower GIT bleedino is more difficult to bleeding.

) We oim ot:
1. Estimation of severity of bleeding and resuscitation.
2. Localization of the site of bleeding and cause of bleeding.
3. Treatment of specific lesions.

71
 DtFpenENTIAL Dneruosls
) Estimotion of severity of bleeding ond resuscitotion (in coses of mossive
bleeding):
.Admit to hospital. severe bleeding cases require ICU admission.
.Repeated clinical and hematocrite assessment.
'lnsert two peripheralvenous lines and withdraw blood for cross-matching and blood
tests.
'lnsert a Foley catheter. Urine output is the best monitor of tissue perfusion.
.A central venpus line is neede for monitoring in severe cases.
'Ryle tube.
.lV sodium containing fluids is started until blood is available e.9., Ringer's lactate.
.Correct coagulopathy by FFP and by giving missing factors.
t Locolizotion of the site ond couse of bleeding:
I Previous attacks and their management.
I Bilharziasis.
I Medications..
I Bleeding tendency.
I Same cases in the family (e.9., familial polyposis coli).
Haemorrhoidal blgeding is characterized by :
o Fresh bright red.
o Jet or drops separate from stools.
o Occurs with strainig usually by the end of defecation.
ln ulcerative colitis there is a long history of diarrhoea with rectal discharge of
mucous or blood.
Patients with ischemic colitis are usually elderly and complain of left sided
abdominal pain and bright red rectal bleeding.
. Recent change of bowel habits, esp. in carcinoma of colon.

Abdominal examination may revea! the presence of a mass e.9., cancer

sigmoid
DRE may reveal:
o Carcinoma of rectum.
in cases of FPC or bilharziasis..
clinical examination is usually irrelevant in cases of diverticular disease and

lnvestlgatlons
) Check thof the potient doesn't hove upper Gfi bleeding by possing o
nosogostric tr.rbe or by upper endoscopy.
1. Laboratory tests:
.Hemoglobin percent and hematocrite value will show evidence of hemodilution after
three hours.
.Stools examination may reveal bilharizial ova or trophozoites of amoebiasis.
.Blood urea and creatinine.
.Exclude causes of generalized bleeding tendency by the coagulation tests.
2. Proctoscopy will reveal internal haemorrhoids.
3. Sigmoidoscopy)The rigid sigmoidoscope can reach up to 30cm from the anal
verge while the fibreoptic sigmoidoscope can reach up to 70cm and so it can diagnose
most of the lesions of the rectum,sigmoid colon and descending colon.

72
 SELF-ASSESSMENT- PART'II
4. Colonoscopy:
. ' Can visualize the whole colon but it neeG proper preparation of the colon by
repeated enemas before the procedure.
' ln patients with massive colonic bleeding,the blood will obscure the field and so it is
better to postpone the procedure in these situations.Colonoscopy is the
investigation of choice for chronic blood loss.
5. lsotope scans:
. The patient's own RBCs are tagged with 99mTc and then injected intravenously.
. Abdominal scanning by a gamma camera can identify the site of bleeding.
6. Angiography:
. This invasive investigation is performed when colonoscopy cannot be performed
because of massive bleeding or when colonscopy cannot pinpoint the source of
bleeding e.g in angiomatous malformations of the colon.
. Selective catheterization of the superior or inferior mesentric artery will usually
succeed in localizing the source of bleeding ,an attempt can be made to stop the
bleeding by injection of vasoconstrictors or gel foam through the angiography catheter.
. Angiography is not an easy investigation and it is not available except in special centers.
7. Contrast radiology:
. Double contrast barium enema is only justified as an elective investigation in case
of chronic blood loss.
8. Laparotomy:
. lf all the previous investigations are not available ,or failed to pinpoint the site of
bleeding ,it may be inevitable to proceed to laparotomy in patients with massive
bleeding.
. Colonoscopy can be performed during exploration.
Treatment
a. llinor Dlee0ing
, ls treated on elective basis.
. There is enough time for meticulous examinmation and investigations to reach a
diagnosis before starting treatment.
B. ilassiYe Dleeflin0
. Treated on an emergency basis.
1. For massive bleeding start the usual resuscitative measures.
2. Fortunately in the majority of cases,bleeding will stop spontaneously and the
surgeon has the time to diagnose and treat the patient electively.
3. lf massive bleeding continues,proceed with colonoscopy or angiography
according to the available experienee and facilities.lf angiography succeeds in
localizing the bleeding point ,an attempt can be made to stop bleebing by
injection of vasopressin 0.2uniUminute or by embolization with thrombin or gel
foam.
- lf colonoscopy visualizes an area of vascular
malformation(angiodysplasia),bleeding can be stopped by diathermy or laser.
4. lf all the previous measures fail to stop bleeding or if the bleeding is massive
(blood loss more then 2,5 litres over 48 hours),surgical intervention will have a
lower mortality than continued conservative management.
5. lf the source of bleeding could be localized preoperatively,segmental resection
of the colon would be performed.
6. lf there are absolutely no clues as to the sour@ of bleeding,total colectomy may
be indicated.

73
DITPSRENTIAL DIIerqosIs

Vascular lnflammatory Traumatic

Esophageal causes Esophageal varices Reflux esophagitis Mallory weis Esophageal carcinoma
syndrome
Gastric causes Hereditary hemorrhagic . Multiple gastric erosions. . Gastric carcinoma.
telangectasia r Acute gastritis. o Leiomyoma.
. Gastric ulcer. . Gastric polyp.
Duodenal causes Aorto-duodenal fi stula. Pudendal ulcer Peri-ampullary carcinoma.
Anorectal causes Hemonhoids. Analfissure o Rectalcarcinoma.
o Anal carcinoma.
lntestinal Gauses o Mesenteric inhrction o Amebic dysentery. . Colonic carcinoma.
o lntussusception. . Crohn's disease. . Colonic & small intestinal
. Angiodysplasia. . Ulcerative colitis. polypi(e.9. FPC)
. Bilhazialcolitis.
o Diverticular disease.
o Meckle's diverticulum.
Esophageal & Esophageal varices PU
gastroduodenal
causes
Renal cause3 Renalinfarction Acute glomerulonephritis. . Renal stones. . Hypernephroma. Polycystic
TB. . Renaltrauma. o \Mlm's tumor. kidney.
. Transitional cell carcinoma.
Ureteric Gauses . Ureteric stones. Transitional cell carcinoma.
o Ureteric trauma.
Bladder causes Cystitis: UB stones. o Transitional cell carcinoma.
Non-specific, specific (TB, . Squamous cell carcinoma.
bilhazial)
Prostatic TB prostatitis Prostatic cancer SPE
ti Urethral Urethritis . Urethral stones. Urethral neoplasm.
o Urethral iniurv.
DIFFERENTIAL Dla,cuosls
Polytraumati zed Patients
IrucpeNcr
" Represent the commonest cause of death arnong people aged 1 -34yr
Errolocy
. Direct -+ blunt e.g. motor car accident fall from height.
. lndirect + fractur'e ribs
. Spontaneous rupture
gunshot wounds''stapping' iatrogenic
pnrxol.ocy
1- Parenchvmatous orqans:
- Subcapsular hematoma
- Superficial or deep tears
- Avulsion of a pole
- Complete debulbing
- lnjury of a vascular pedicle
2- Orthopedics: displacement
3- Vascular:
. With tear:
A-V fistula, false aneurysm

.
Tear: complete -+ J bleeding . lncomplete -+
o t bbeding
Without tear: spasm, contusion
4- Head iniurv; e.g. lC hge, skullfracture, scalp hematoma
CIaSSIFIcATIoN oF PoLYTRAUMAflZED P,ATIENT
) The classification is done by triage system.
) Triage is used in hospital emergency rooms, on battle fields & disasters when
limited medical resources must be allocated.
) Triage involves dividing patient into 3 groups by colored labels as follows.
1-Fled: those who will die anyway whether they receive medical attention or not.
2-Yellow: those who will survive only if they received timely medical attention.
3-Green: those who will survive anyway whether they receive medical attention or not.
CuNTcaI PIcTURE
1. Stage of concussion: immediately after trauma patient falls flaccid & loses his
conscrousness
2. Stage of lucid interval: period of recovery from coma of concussion foll. By coma
of compression
t
3. Stage of compression: s/s of lCT, localizing symptoms e.g. contralateral
hemiplegia & ipsilateral constriction of the pupil.
4. Terminal stage: decerbrate rigidity
(e.g pneumothorax, hemothorax, flial chest)
I Symptoms: history of trauma,
acute chest pain, dyspnea, cough, cyanosis.
I Signs:
-General: signs of shock, engorged neck veins, cyanosis, respiratory distress
- Local:

lnspection: ecchymosis & brusius, J chest movement on the affected

side or flial segment moves paradoxically with respiration
( in flial chest)
Palpation: shift of the trachea to the opposite site, J TVF

76
 SELF.ASSESSMENT' P^a.RT .I I
Percussion. tympanic resonance on the affected side (or dullness in
hemothorax)
Auscultation: J air entry
C. ()falxlornirrarl inirries:( e.g. liver-spleen-renal)
I Historv of trauma to the abdomen followed by abdominal pain.
) General: shock -+ rapid weak pulse, hypotension, subnormaltemp., cold
extremities, palor, oliguria.
) Local:
- lnspection: ecchymosis & bruises in the injuried area, rigidity
- Palpation: G, T, RT in the injuried area
- Percussion: shifting dullness
- Auscultation : dec. intestinalsounds
- DRE: fullness in the rectovesical pouch in males, or in the Douglas pouch in
females
) Special siqns:
. Kehrr's sisn: referred pain to the Lt. shoulder due to diaphragmatic lrritation
. 9g!!!!!_!!ru,!bluish discoloration around the umbilicus.
MANASEMENT oF PoLYTRAT,IYIATIZED PAflENT
) Successful management polytraumatized patients require the integration of
pre-hospital, in-hospitals & rehabilitation which are included in advanced trauma life
support system (ALTS) which is safe & reliablO approach for initial assessment &
treatment of trauma as follow:
* Pt'e-ltospital nanagement
1. Ensure Patient Ainray + Support Of Mandible Fonruards.
2. Ensure adequate ventilation
3. Control any apparent bleeding by tourniquet or compression.
4. Cover any wound with sterile dressing
5. Avoid flexion of the spine to avoid dislocation in unstable spine injuries.
6. lnform the hospital to activate the trauma team prior to arrival of the accident
r.'ffi ABCDE
A. Airuvav:
. Place the patient on his side and lower the head slightly.
. Prevent backwards failing of the tongue by oropharyngeal airway.
. Suck any secretion or blood in the mouth with oxygenation.
. ln comatosed patient + endo-trachealtube and mechanicalventilation.
B. Breathinq:
. Take care from hypoventilation or hypoxia evidenced by agitation or level of
consciousness.
. Easily detection and correction of pneumothorax ,cardiac tamponade, hemothorax
,bronco -pleural fistula or lung laceration or surgicalemphysema,
C. Circulation:
. Control bleeding by local compression or tourniquet,
, Treatment of shock either hypovolemic, cardiac or neurogenic.
D. Disabilitv:
. Any fracture should be splinted to relive pain and avoid soft tissue injury until
fixation is done

77
DrprenENTrAL Dncruosrs
E. Exposure:
. Of the patient to detect any soft issue, vascular orthopedic injury.
. This phase aims at resuscitation & monitoring of polytraumatlzed patient.
If. Secondalr Suryey
This phase includes:
1. Head to toe examination of undressed & stable patient
.
Head examination:
- lnjuries - Eye (pupil -+ size and reaction).
- Mouth - Ear and nose
.
Neck: neck collar for fixation:
-
Absent pain or neurological signs does not exclude injury.
. @f,,Penumothorax , hemothorax, cardiac tamponade.
. Abdomen:
- lndication of peritoneal lavage:
o Unconscious patient and hypotension of unknown etiology.
.E& o
lnjury below and above diaphragm and evidence of abdominal injury.

- Blood in lumen - Prostate

- Pelvic floor - Sphincter tone
. @lgglcaliGlasgow coma scale
. Limbs: for fracture and neurovascular bundle.
2. Historv of anv (AMPLE H/O):
- Allergies - Medications
- Past medical history - Last meal
- Event of injury
3. Urqent investiqations after basic life support:
. kEIS!9rv:.
- HB%,glucose level, Kidney functions,POz,PCOz,NA*,K*.
'EedisL@li
- Plain X-ray: chest and skeletal or visceral injuries.
- CT and MRI: chest, abdominalor head traumas.
- U/S: for abdominal injuries )
. lnstrumental:
- Abdominocentesis orthoracocentesis
- GIT or urinary endoscopies
[I. Deiinitive treatnrcnt
I During 2ry survey after stabilization of the patient, we can detect definitive injury by its
specific clinical picture & specific investigations & dealwith the patient according to the
type of injury & priorities
1. Head iniurv:
. lC hge -+ control bleeding by underrunning suture, cauterization, ligature or facial graft
. Scalp hematomas -+ apply cold followed by hot fomentation + prophylactic Abs
lf large -+ evacuation.
. Skull fracture -+ conservative treatment after exclusion of lChgh, unless there is
indication for surgery.
2. Chest iniurv:

space midaxillary line

. lf flial chest: 1't emergency strapping & emergency tracheostomy, then skeletal
traction, or open reduction & internalfixation, or PEEP.
-insertionofl.Ctubeunderwatersealinthe5th
78
 SELF-ASSESSMENT' PnnT'II
3, Abdominal iniurv:
. lmmediate laparotomy then control bleeding.
. !f liver injury -+ by pringle's maneuver
' lf splenic injury -+ splenectomy
' lf renal injury -+ suturing if small tear, partial or total nephrectomy if debulging injury
DY. BehabiEtation
ires of the medical staff & servtces.

. The neck is a compact structure formed of a compressed multiorgan systems

. Neck trauma accounts for 5-1 0% of the serious traumatic injuries

. More common in young adults & adolescents males.

1. Open trauma(penetratinql: the commonest

-
Gunshot, stab wound, iatrogenic (eig. during esophagescopy)
2. Glosed trauma (blunt)
-
14. g?r qg_qQglllstrangulation or cervicaI spine disruption

Musculosfeletql injuries: vertebral bodies, cervical Ms, tendons ligaments,

clavicle, 1st& 2nd ribs & hyoid bone
Neurological injuries: spinalcord, phrenic N., Brachial plexus, RLN., cranial Ns
(xl,x, xl, xll)
Vascular injuries: carotid( common , ext., int.), innominate & jugular veins
Visceral structures: thoracic duct, esopgagus, pharynx, larynx, trachea, thyroid
Ass. Structures: lung, Ht & great Vs

) The ant. Neck is divided into 3 zones:

) Zone l:
highest mortality because of the risk of great Vs (e.g subclavian & common
carotid) & intrathoracrc rn1Ury.
) Zone ll:
- Extends from the cricoid cartilage to the angle of the mandible.
) Zone lll:
- ls that part of the neck above the angle of the mandible.

t Histol of trauma (ask about mechanism of injury).

) Svmptoms: pain at the site of trauma.
t Siqns:
. General.' - Shock :

1- Hypovolemic shock. rapid weak pulse, hypotension, subnormaltemp.,

cold extremities, Palor, oliguria.

79
DIPTenENTIAL DIAGNOSIS
2- Neurogenic shock
Associated lnjuries e.g. chest & Heart injuries, or associated fracture.
-
. Local:
- CVS manifestations: bleeding
- Airway: hemoptysis, dyspnea, hoarsness of voice, dysphonia
- GIT: dysphagia, hematemsis
- CNS: parathesia, hemiparesis/paralysis
. Signs of:
1- Arterial injury: hard signs/ soft signs
presence of pulse doesn't exclude arterial injury
2- Respiratory: stridor, crepitus( sub.cutanous emphysema), tenderness of the trahea
3- Neurological deficit:
- Spinalcord injury: e.g. quadreplagia, hemiplagia, priapism, urinary retention,
- Brachial plexsus injury(C5-C7 roots): sensory & motor lossin the upper arm
- Nerve injury: e.g. phrenic N. injury -+ paralysis of diaphragm
Cranial N. injury (V, lX, X, Xl, Xll), Horner syndrome
4- Visceral injury: Ht: cardiac tamponade
Chest: hemothorax

1. Tracheal/laryngeal edema or stenosis

2. Vocal cord paralysis
3. Aspiration & pulmonary complications
4. False aneurysm, A-V fistula
5. TES fistula
6. Air embolism
7, Wound infection
. Dissecting aortic aneurysm
' Spinal cord infections
' Acute disc prolapse

* I'wlmsoital mnnaour.stt
1. Ensure patient ainnray + support of mandible forwards'
2. Ensure adequate ventilation
3. Control any apparent bleeding by tourniquet or compression. ,)
4. Cover any wound with sterile dressing
5. Avoid flexion of the spine to avoid dislocation in unstable spine injuries.
6. lnform the hospital to activate the trauma team prior to arrival of the accident
* .tlt hosnital
I. Hmary survev
ABCDE
A. Airwav:
p1""" the patient on his side and lower the head slightly.
. Prevent backwards failing of the tongue by oropharyngeal airway.
-.. Suck any secretion or blood in the mouth with oxygenation'
. ln comatosed patient + endo-trachealtube and mechanical ventilation.
B. Breathinq:
, T"dke care from hypoventilation or hypoxia evidenced by agitation or level of
consclousness.
. Easily detection and correction of pneumothorax ,cardiac tamponade, hemothorax
,bronco -pleural fistula or lung laceration or surgical emphysema.
80
 SELF.aSSESSMENT. PIRT .II
C. Girculation:
. Control bleeding by local compression or tourniquet.
' Treatment of shock either hypovolemic, cardiac or neurogenic.
D. Disabilitv:
' Any fracture should be splinted to relive pain and avoid soft tissue injury until
fixation is done
E. Exposure:
.
Of the patient to detect any soft issue, vascular orthopedic injury.
.
This phase aims at resuscitation & monitoring of poly-traumatized patient.
II. tlecondars Survev
This phase includes:
1. Head to toe examination of undressed & stable patient
.
Head examination:
- lnjuries - Eye (pupil -+ size and reaction).
- Mouth - Ear and nose
. . Neck: neck collar for fixation:
- Absent pain or neurological signs does not exclude injury.
. @g!. Penumothorax , hemothorax, cardiac tamponade.
. Abdomen:
. Neuroloqical: Glasgow coma scale
.
Limbs: for fracture and neurovascular bundle.
2. Historv of anv (AMPLE H/O):
- Allergies - Medications
- Past medical history - Last meal
- Event of injury
3. Urqent investiqations after basic life support:
. Laboratorv:
- HB%,glucose level, Kidney functions,POz,PCO2,NA*,K*.
. Radioloqical:
- Plain X-ray: chest , spine and skeletal or visceral injuries.
- CT and MRI: chest, abdominalor head traumas.
- Conventional angiography
- Colored Doppler: Ar. lnjury
- Gastrographin study
. lnstrumentil:
- Endoscopic studies : laryngeoscopy, bronchoscopy, esophogoscpy
.
followinq:
1. Control blood loss, expanding hematoma, shock
2. Airuvay obstruction
3. Neurological deficit
4. Hemoptysis or hematmsis
m. Detlnitive treatment
) During 2ry survey after stabiltzation of the patient, we can detect definitive injury by
its specific clinical pic. & specific investigations & deal with the patient according to
the type of injury & priorities.
Pnocxosr
,
. @9L
the worst prognosis with inc. morbidity & mortality
Zone ll: the most common & have the best prognosis

81
DtppEnENTI^A.L Dlacxosts

) Anatomy of the femoral triangle:

. lt's a subfascial space occupying the front of the upper one third of the thigh just
below the inguinal ligament.
. Boundries:
Lat: medial border of Sartorius
Med: medial border of the adductor longus
Base: ing. Ligament
Apex: meeting of Sartorius & adductor longus
r Floor: from medial to lateral :adductor longus, pectinus, psoas major, iliacus Ms
. @skin, superficial fascia, deep fascia & in between great saphenous vein &
ilioinguinal N.
r Contentss
- Femoral ar. & its superfacial branch
- Femoralvein
- Femoral branch of genitofemoral N
- Femoral N. outsde the femoral sheath
- lnguinal LNs

r Represent 3% of the major injuries in the causality

. More in males esp. at the age ol 1-44 yrs

unqt: Ine
a- Open trauma(penetratinq): the commonest: gunsnol
gunshot, stab wound, iatrogenic
b- i e.g. car accident, crush injury

Musculoskeletal: Ms(as above), tendons, femur

Neurological injuries: femoral N.& it's branch saphenous N.
Vascular injuries: femoralA. & its superficial Branches & femoralvein, great
saphenous vein
Associated structures

) Historv of trauma (ask about mechanism of injury).

, Svmptoms: pain at the site of trauma.
) Signs:
. General: - Shock :
1- Hypovolemic shock: rapid weak pulse, hypotension, subnormal temp.
cold extremities, palor, oliguria.
2- Neurogenic shock
- Associated abdominal injuries & fractures.
'L@
- Neuroloqical: parathesia esp. in the anteromedial part of the thigh or
along saphenous N. distribution
- Vascular: bleeding, pulsating swelling, hematoma, acute ischemia (6ps)
crush injury or compartmental syndrome
- Musculoskeletal. inability to move the limb

82
 SELF'ASSESSMENT, PIRT,II
. Signs of:
-Arterial: hard signs/soft signs
-Venous: DVT: painful swollen limb
-Neurological: week hip flexion, week knee extension
Sensory deficit in the medial side of the leg

1- False aneurysm, A-V fistula

2- Wound infection
3- Chronic ischemia & gangrene
4- Compartmenta I syndrome
5- Air embolism

1. FemoralA. aneurysm
Swellinq in the femoral

* lDt.e-ltotilritol tnona qentent

1. Ensure Patient Airway + Support Of Mandible Fonrvards.
2. Ensure adequate ventilation
3. Control any apparent bleeding by tourniquet or compression.
4. Cover any wound with sterile dressing
5. Avoid flexion of the spine to avoid dislocation in unstable spine injuries.
6. lnform the hospital to activate the trauma team prior to arrival of the accident
.l . lt ltostriktl
I. hfrnary suryev
ABCDE
A. A!!rygE
. Plae,e the patient on his side and lower the head slightly.
. Prevent backwards failing of the tongue by oropharyngeal ainruay.
. Suck any secretion or blood in the mouth with oxygenation.
' ln comatosed patient -+ endo-trachealtube and mechanicalventilation.
B. Breathinq:
' Take care from hypoventilation or hypoxia evidenced by agitation or level of
consciousness.
' Easily detection and correction of pneumothorax ,cardiac tamponade, hemothorax
or lung laceration
,bronco -pleuralfistula or surgicalemphysema.
C. Circulation:
. Control bleeding by local compression or tourniquet.
. Treatment of shock either hypovolemic, cardiac br neurogenic.
D. Disabilitv:
'Any fracture should be splinted to relive pain and avoid soft tissue injury until
fixation is done
E. Exposure:
. Of the patient to detect any soft issue, vascular orthopedic injury.
' This phase aims at resuscitation & monitoring of poly-traumatized patient.
IL Secondarr Survev
This phase includes:
1. Head to toe examination of undressed & stable patient
. Head examination:
- lnjuries - Eye (pupil+ size and reaction).
- Mouth - Ear and nose

83
Dl pFenENTIAL D I^a.e rrlosls
. Nleck: neck collar for fixation:
- Absent pain or neurological does not exclude injury.
. Ghest: Penumothorax , hemothorax,signs
cardiac tamponade.
. Abdomen:
. Neuroloqical: Glasgow coma scale
' Limbs: for fracture and neurovascular bundle.
2. Historv of anv (AMPLE H/O):
- Allergies - Medications
- Past medical history - Last meal
- Event of injury
3. Urqent investiqations after basic life support:
'Eb9Et9s.
- HBo/o,glucose level, Kidney functions,POz,PCOz,NA*,K.
'&![]q!@!i
- Plain X-ray: chest , spine and skeletal or visceral injuries.
- CT and MRI: chest, abdominal or head traumas.
- Conventional angiography
- Colored Doppler: Ar. Injury
- Gastrographin study
. lnstrumental:
Endoscopic studies : laryngeoscopy, bronchoscopy, esophogoscpy

followinq:
1. Control blood loss, expanding hematoma, shock
2. Airway obstruction
3. Neurological deficit
4. Hemoptysis or hematmsis
m. IDetinitEvetreatment
) During 2ry survey after stabilization of the patient, we can detect definitive injury by
its specific clinical picture & specific investigations & dealwith the patient according
to the type of injury & priorities.

84
DrrpenENTrAL Dragrvosrs
Hematuria
. Presence of blood in urine ( always abnormal whatever its type)
TFEB
o Frank or microscopic.
o Painful or painless. Painless haematuria without other symptoms (silent) must be
considered as a symptom of a tumor until proved othenrvise.
o ln relation to urine stream:
. Total haematuria: passage of blood all over the stream. lt indicates that the
blood comes from the kidney or massive vesical bleeding. Haematuria from
the kidney is associated with cylindrical clots. Haematuria from the bladder is
associated with discoid clots. Stones, BPH and tuimors are common causes.
. Terminal haematuria: passage of blood at the end of micturition. lt indicates
pathology in the trigone, bladder neck, posterior urethra and sometimes BPH.
Bilharziasis is a common cause.
' lnitial haematuria. Passage of blood at the beginning of the act. lt indicates a
urethral origin.
Ca,uses
a- General causes:
1. Bleeding tendenc!: e.g. Pupura & hemophilia.
2. Hypertension.
3. Drugs: anticoagulants.
b- Local causes

Kidney Renal - Pyelonephritis Stone - Wilm's Polycystic

infraction .TB Rupture - RCC kidney
kidney - TCC & SCC of
the renal pelvis
Ureter TB Stone TCC of ureter
UB - Bilhaziasis Stone - TCC
-TB Rupture - SCC
- Non specific bladder - Adenocarcinoma
cvstitis
Urethra Urethritis - Stone Urethral
- Rupture carcrnoma
urethra
Prostate Prostatitis Cancer prostate BPH
) Txe coMMoNEsr cAUsEs ARE: stones, bilharziasis, BPH, hypernephroma , trauma
and urinary bladder tumors..
CuxTcIl. PRESENTATIoN oF IMPoRTArlT CAUSEE:
1. Stones

1. Painful hematuria ( terminal, initial or total according to the site)

2. Pain'.
- Dull aching pain in the flanks if renal stone
- Ureteric colic if ureteric stone (agonizing loin to groin pain usually with
' nausea & vomiting)

86
 S'LF-AssEssMENT' PART'II
- Suprapubic pain with dysuria, stranE y & frequency if bladder stone.
- Urethral pain referred to the tip of pe , if urethralstone.
1. General:
- Fever if infection occurred
2. Loca!: hypronephrosis - tender loin mass
2. RGG

1. Hematuria: painless, periodic, persistent, total.

2. Late: loin pain or clot colic, mass in the flank

1. Cachexia, metastasis (cough, hemoptysis)

2. Secondary varicocele
3. Paraneoplastic $ as: polycythemia, hypercalcemia, cushing dis.
3. Bilharzil cystitis:
1. History of bilhaziasis ( endemic area)
2. Painless terminal hematuria with anemic manifestations as:
pallor & easy fatigability
3. Pyuria & dysuria due to repeated infections
4. BPH

1. Prostatism (LUTs):
- Frequency , 1"t nocturnalthen day & night .
- Hesitancy, intermittent flow, post-micturition dribbling.
- Sexual : inc. libido then impotence

1. Non-tender bladder enlargement + tender lion mass.

2. DRE -+ smooth, soft, symmetrical, preserved sulci & mobile rectal mucosa

(cystoscopy is the most important one, better during the attack)

1--Laboratg4
1. Urine analysis
2. KFTs:
3. Tumor markers:
2- Radioloqical:
1. U/S: stones,tumor, congentilal polycystic kidney
2.lVU: stones, tumors (filling defect)
SEP (smooth elevation of bladder neck)
Hypernephroma (DEAD of pelvicalyceal system)
3- !nstrumental:
. Cystoscopy:
- With biopsy from any lesion

(Not mentioned if the question is DD of hematuria)

1. Anti-shock measures (lV fluids, blood transfusion.....)
2. Stop bleeding by: Vitamin K injection, dicinone & cyclokapron lM
3. Treatment of the cause e.g.

87
DIFFERENTIAL DNCNOSI
-@, -<1cm+conservatlve-s
- 1-2 cm -:Tiil.3'i.ilo"..
ureter + ESWL
o Lower ureter & bladder -+ endoscopic extraction
- >2cm or impacted -+ endoscopic extraction
- lf failed above measures + open Surgery according to the site
+ gEPi
- TURP (if small)
- Open prostatectomY (if large)
+ Hypernephroma + radical nephrectomy

Other causes of ied urine

1. Certain food (beet root)
2. Gertain drugs: carmurit, rifampicin.
3. Hemoglobinuria (hemolytic anemia), myoglubinuria'
4. Bilirubinuria (OJ).
5. During menstruation

. Ask the patient to Pass urine:

- The first Part of urine in a glass
-The midPart in another glass.
-The last Part in a 3d glass
a) lnitial hematuria is urethral in origin
b)Terminal hematuria is UB or prostate in origin
c) Total hematuria is renal in origin.

88
 SELF'ISSESSMENT. PART -II
Urinary dfirersion
to relieve distal obstruction)
1- Uretheral obstruction ( as in elderly patients unflt for prostatectomy):
a- lndwelling silicone urethral foley's catheter changed every 3 months (the
drawback is infection with long term catheterization)
a- Suprapubic cystostomy
2- Ureteric obstruction:
a- Double J ureteric pig tail stents changed every 4-5 months

lndications:
1. Removed Urinary bladder
2. Lost normal urological control of urinary bladder
3. lncurable fistula
4. lrremovable obstruction
Tvpes:
t. Externaldiversion:
a- llealconduit:
b- ureterocutaneous implantation
2. lnternaldiversion
a- Ureterocolic lmplantation
b- Rectal bladder.
c- Bladder reconstruction (neobladder)
Gomplications of internal diversion:
1- Stricture
2- Resorption of solutes:
- Effects:
A- Reabsorption of chloride and Urea -+ hyperchloromic acidosis,
B Diarrhea + K+ loss
2- Other complications according to the type of diversion (see below)

A-llElL conour ( rne BEsr):

. A Segment of the terminal ileum is isolated with intact blood supply.
. The 2 ureters are implanted into it. one end is closed and the other end
is flxed to the skin as an ileostomy.
:t Advantaqes:
r no urine leak , no infection & urine reservoir
* Disadvantaqes:
. Hyperchloremic acidosis may occur but less severe than colonic
diversion (absorption of chlorides by heal mucosa)
. Malabsorption of vitamin 812 --> so, monitoring of its level after 1 year is
important.

89
DrprenENTrAL Dleoruosls
)
B '
.llupurrrrnox
Prooedure The ureters are brought out on the skin The ureters are
surface through 2 small incisions implanted into sigmoid
colon
Indlcatlons 1- Bad kidney function Cases with good kidney
2- Contraind icated ureterocolic function
imolantation.'
[dYanlages Easy & best renaldrainage The patient is continent
DIsa0Yantages 1- Continuous soil in with skin excoriation 1- Ascending infection
2- Ammonical odor 2- Hyperchloremic
3- Ascending infection acidosis
3- Cancer colon

E}-RECTAL BI.ADDER:
- The sigmoid colon is divided above the recto-sigmoid junction.
- The proximal end is brought out as colostomy
- The distalend is closed and the 2 ureters are implanted into the rectum ,

which willwork as urinary bladder.

) Advantages:
- Easy and safe operation
- The patient will be continent to urine.
- No infection or hyperchrolremic acidosis.
) Disadvantages:
- Presence of colostomy

90
91
 DrrpEnENTrAL Dlncruosrs

BIIIIAST
-l- Congeniterl :urt[ aer;uir.rd ()ll o
l.etr.fletion
l'(.(I l'c of the lriplrl
ppre:
Conqenita[ Retraction /r,quhel recraction
Ilistory Since Birth Recent
Side Bilateral Unilateral
Mass No breast mass Presence of breast mass
Pu[inq Gan be pulled Can not be pulled

13- ()hronie breast :rllsoess :ul(I breast eareinomt:

Chronic breast Carcinonra of
abscess breast
Symptoms:
. History of acute abscess +ve -ve
. Purulent nipple discharoe May be present Absent
Signs:
. Fever Low grade Absent
. Surface convex Fat
. Tenderness present Absent
. Firm, mobile, discrete and Hard may be fixed &
Axillary LNs
tender. oainless.
Investigations:
. Aspiration Reveals pus Nothino
. Leucocytosis Moderate Absent

(l- Ilarrl ,uxl soft fillroarlenrlnra:

cular ( H ard
P en -c an ali I ln tra-can ali cular ( 5 oft I
(Benisn simplel (Caint fibroadenornal
Aqe: Aqe:
20-30 vears 30-50 vears
Macroscopic picture: Macroscopic picture:
1. Size: small 1. Size: large
2. Surface: smooth. 2. Surface: lobulated.
3. Color: whitish 3. Color: whitish
4. Consistencv: firm or hard. 4. Qslslgrsu soft
5. Gut section: whorly appearance. 5. Gut section: might show central
b. Capsule: 2 capsules true and false necrosrs
caosule and a oedicle. 6. Capsule: incomolete caosule.
Microscopic picture: Microscopic picture:
- Formed mainlv of fibrous tissue - Contains more glands
Complication: Complication:
- Never turn maliqnant. - Liable to turn to sarcoma.
92
SELp.IssEsSMErur' Pnnr -II
I)- I)uetal and lobular eareinorna in situ:
DCIS LCIS
frequency More common Less common
Eilaterality and Rare common
multicentricitv
Microcalcilication present Absent
Earlv detection Possible Less likely
Potential for invasive cancet 30-50% It is a marker of increased
risk of malignancy in the
same or other breast
Treatement As invasive cancer Strict follow up

E- Earlv and latee braest cflrlGer:

:
Eanly Breast Cancnt LateBreast Car,crat :
(TzNrMof or stage lllin (>TzMrMol ot stagellll
Manchester lV in Manches@r
o Painless swelling o Painfulswelling
Symptoms o negative occult presentations o Positive occult
presentations
May be positive for evidence of
General sigrns Negative
metastasis
Local signs:
a- Inspection 1- Breast enlargement and 1- Breast enlargement &
asymmetry. asymmetry.
2- Skin lesions: 2- Skin lesions:
a- Nipple retraction and skin a- Skin nodules.
dimpling. b- Sister joesph nodules.
b- Peau de'range c- Cancer en cuirasse
d- Skin ulceration.
b- Palpation e- Brawnv edema
1- Firm to hard mass freely mobile.
1- hard fixed mass.
2- Axillary LNs: negative or may be
2- Axillary LNs: hard and fixed.
enlarged (hard and mobile)

ofbreast I tull ps:

F- Cornmon trues o
Carcinoma Fibroadenoma Fibrocvsti c disease Solitary cyst
Usually >
lge 35v
15 - 30 y 35-55y 35-55y
Pain Painless Painless May be painful May be painful
Smooth (may be
Surface lrregular lndistinct Smooth
lobulated)
Firm & highly
Gonsislency Usually hard Firm Soft to hard
mobile
May be
fixillary LI[s palpable Free Free Free
axillarv LNs

93
 DrrpgnENTrAL Dlncruosrs
G. s disease and sezetna,ofthe
Paqet's Disease Beniqn Eczema
Unilateral Commonly bilateral
Commonlv at menooause Commonlv at lactation
Starts in the nioole Starts in the areola
Nioole is eroded Niople is intact
No itchinq Itchinq
No vesicles - not oozino Vesicles - oozino
No response to eczema treatment Resoonds to eczema treatment
Well defined llldefined
A breast lump inav be felt No lump

II- Mastitis cancinomatosa and acute lactational rnastitis:

Masti ti s C-arcinonratosa Acuce B actpn al Masti ti s
Affects more than 1/3 of the breast Affects one sector of the breast
Gradua! onset & slowlv oroqressive Acute onset & rapidlv proqressive
No or low qrade fever Hiqh fever
Skin is duskv red Skin is rosv or firv red
Mild tenderness Marked tenderness
Non-tender axillarv LNs Tender axillarv LNs
No response to antibiotics in one Responds either to antibiotics
week ) lndicatino bioosv (or an abscess will be formed)

A' Total end subtotal a

Total thvroidectomy Subtotal thvroidectorry

Gontol of loricitr lmmediate lmmediate
f,etun to euthyroid lmmediate Variable up to 12 months
slate
Bful of rocErrerce None Lifelong up to 5%
Risl of thwoiil failun 100% Lifelong up to 25o/o
Hst of Dermanenl 5% 1o/o

hnooaralhwoirlism
Ifeet for follm up Minimal lifelong

94
SELF-ASSESSMENT. PART .II
B- Grave's disease and to
ve's orsease toxie nodular o

Ctave's disease Toxic nodular qoitre

[ge Younq Elderly
0nset Abrupt Gradual
Exacerbations &
Goune Steady
remissions
Ifervous svmutoms +++
Metabolic manifestalions +++ +
Gardiovascular manifeslations + +++
f,ye siqrns Exophthalmos Usually no exophthalmos
Diffuse enlargement Multiple or solitary
Ttryroid
soft & vascular nodules

C- I)ifferent types of thyroid adenocnrcinorna:

Anaplastic
Papillary carcinonra Follicular carcinorna
carcinorra
Incidence 600/o 17% 13o/o
20 - 40 years 40 - 60 years (middle
lge. (children & vounq adults) aoed)
Elderly
Sex ff:M) 3.5:1 2:1 1 :1.3
1. External irradiation of
neck in children which
was previously used for
TTT of hemangiomas,
Predisposing T.B lymphadenitis. 1. SNG.
2. papillary adenoma 2. Follicular
Usually De Novo
factors
3. genetic factors . adenoma.
a- Godwen $
a- reUPTC3
oncooens
ilr-oeflneo mass rnilltrailng tne surrounotngs
Multipticity - 6U"h Multrcentenc due
to intrathyroid Rare
lvmohatic soread
Loss of polarity & signs of mitosis.
- Mailgnant papillae wttn Thyroid follicles L;lusters ot
vascular C.T. core with variable spindle
covered by malignant degrees of cells(small or
Micro cells differentiation large)
- Laminated calcified bodie Capsular & vascular Separated
(psammoma bodies) invasion by little
-The tumors shows Solid sheets may be fibrous tissue
characteristic pale empty present
nuclei (orphan Annie-evec
nuclei)

95
 DIPTEnENTIAL Dta.cNosls
, Mainly lymphatic to Matnly direct &
Mainly blood to skull
deep cervical L.N can infiltrate
(Aberrant thyroid) usually solitary, painful,
Spread pulsating, osteolytic carotid artery
. Solid sheets may be which may
(D.D. abscess)
oresent. ruoture.

TSII Dependant Less dependant Not dependant

GOOO except r tne pt at Very bad

Prognosis Bad
the peak of 40 years
l0 yean Encapsulated 97% Die within 'l-2
90o/o
suwival lnvasive 70% years

Testierrlflr' torsion antl aerrte

Adolescent & children Adult or elderly

Partially relieves pain

Obstru cted testicu lar Vs.

96
SELF'ASSESSMENT. P^A.RT .I I

B- Seminoma and teratoma:

Seminiferous tubules. Totipotent cells which have trigerminal

Undescended testis especially intra abdominal verities. The incidence of malignancy

in undescended testis is 15 times more than normal population
. Trauma which attract the attention rather than causino it

* Map. rp..q.e.-o. pi.s..pie!r{Ie; * tsr.e:

M. esrs..q.-c.epie..p.is.
o Large, firm & smooth o Variable size, variable consistency
and irregular surface.
Cut section: Cut section:
o Homogenous & creamy or pink in o
Heterogenous & yellowish
color.
o Fibrous Septa divide the mass into
o
Areas of hemorrhage an necrosis
NB. Teratoma ,s sunounded by tunica
lobules.
o Areas of hemorrhage and necrosis
)
albuginea so shape of fesfrs is preserued.
o" M.isrp..p.s.p.niselly:
1. Teratoma differentiated (Dermoid cyst )
* Mi.er.o-qep.p.rsally - Cyst is lined with stratified squamous
Cells. epithelium and may contain hair bone,
o Rounded, cells with large rounded muscles as well as glandular element.
nuclei.
2. Malignant teratoma intermediate (IEg
commonesttvoel
o Arranged in sheets separated by
3. Malignant Teratoma Anaplastic:.
fibrous stroma. - Composed of anaplastic cell.
o Tumor is infiltrated by lymphorytes
- Cells derived from yolk sac produced
(good host reaction )
good prognosis) increased level of alpha-feto protein
4. Malignant teratoma troph o-blastica
(choriocarcinoma)
- Malignant villous or papillary cyto-
trophoblast produces HCG and
spread early by blood and lymph.
- Most maliqnant testicular tumor

97
 DTTTEnENTIAL Dncuosls

A-- Dmbolisrn & aeute thrombosis on

Acute thronrbosis on top
Embolism
of atherosc[erosis
f,istory Arrhythmia or recent M.l claudication
Source of emboli Usually present Absent
Radial uulse Usually irregular (AF) Ususlly regular
Skin colour White Dusky
Limb nutrition Normal Picture of chronic ischemia
f,ngiogrraphy Sharp cut-off Tapering stenosis
Minimal collaterals Diffuse atherosclerosis
Extensive collaterals

B- Prirnary and Secondar1F Ralmrrd's disease:

RavnaudtsDisease ltrvl Ravnau d/s phenorr sr.onlzt ll
fiae & sex young females (20 - 40 yrs) Vary according to underlying cause
Not exactly know, certain factors are - Collagen ) SLE, scleroderma.
suggested e.g.: - Arterial oDst )Atherosclerosis,
1- lncrease sympathetic tone. Burger's disease.
Gause 2- Psychological instability. - Nerve injury )Thoracic
3- Abnormal sensitivity of small arteries outlet $, carpal tunnel $.
and arterioles of hand to cold. - Environmental )
Vibrating tools
- Druqs ) beta-blockers.
It affects UL (may affect LL). - May affect LL.
Distribution It is almost always bilateral. - May be unilateral.
It is almost always svmmetrical. - lf bilateral, it is asvmmetrical.
ftophic
changes& Absent or minimal. More prominent.
!anslene
Radial &
Present May be absent.
ulnar oulse
No progression & no evidence of Progressive.
follow up underlvino disease. manifestations of underlvino dis.
Investigation Should be directed to the suspected underlying cause
Conservative (in early stages) - Treatment of the cause.
Care of patient
- Stop smoking. - Avoid cold weather. - Vasodilators and beta-blockers may
- TTT of anemia if present. be used.
Care of Hand
- Good hygiene, dryness of the hand
Trealment and wear woolen gloves in winter - No benefit from sympathectomy as there
- Hand exercise. may be:
* Vasculitis.
Druqs: as chonic. lschemia + * Cryo-antibodies )
- Vasodilators ) phenoxybenzamine, cause VC in
nifedipine. case of lowered blood temp to
- Baby aspirin (prophylactic for fear of 36-36.5o c
vaso-obliteration). - CCB.
98
 SELp'ISSESSMETIT' P^qRT -I I
Suroery (in seyere casesl
- Cervicodorsal Sympathectomy.
- lmmediate results are good, but may
recur after one or two years (due to
denervation

C- Athenosclerosis and Burger's disease:

Athercsclerosis Burse/s disuse
[ae of onset Elderly 20-40 years
$ex More in males Only in males
Etioloqy HTN, DM. Excessive smoking
Level of lesion Aorto-iliac, femoro-popliteal or Distal vessels with patchy
distal distribution
Pathology Mainly intimal (atheroma) lnflamed neurovascular bundle
and thrombi that block the lumen
Migrating Absent Usually present
lhrombophlebitis
Rest pain May be present Marked early feature
but late

I)- I)*1r and moist

rW Cangrene
z- Moist Aseptic
Gansrene
Pathogenesis - Acute ischemia
(cause) Chronic ischemia )allows dryness of - Chronic ischemia with pre-
tissues. existing edema (cardiac,
DW).
Pathology
Putrefaction Minimal. Marked
0dor little or no odor Very offensive
- Dry. -Mummified. The part remains of the
- Hard. - Wrinkled. same size and consistency.
Gross
- Dark in color. Colour: at'l't dead white the
purple or qreenish black..
Irine of ill deflned (no time for
welldefined
demarcation evaporation)
Separation ) Spread ) by
- Due to presence of line of demarcation - Direct extension.
fale ) appears between the dead & viable - Skipped lesions.
tissues.
-. Leaving a conical stump (deeper tissue
has better blood supolv).
1 The five cardinal signs of localdeath are.
c/P Lost (pulsation, Sensation, Heat, Function of affected part)
fixed color changes.

99
 DrppenENTrAL DrRenosrs

flft Patientsu e above

signs but the tissues are stillviable and local pressure causes some
modification of color, which returns when the pressure is released.
)
2. The affected part is see qross.
)
3. Minimaltoxemia better general 3. Severe toxemia ) poor
condition. general condition.
See chronic ischemia - Amputation tillthe level of
- Limb salvage (conservative pulsation (acute condition)
amputation). (non-conservative
Treatment
- Non-conservative amputation. amputation).
- Later on ttt of the cause if
possible.

E- Unftaetionated and low molee.ular

Unfractionated lrrtr molecular

Not required- if needed --

levelof Xa

The patient should be May be taken at home

'- I)unlex finding in normal eases and DY I':

Normal veins DW
Yein diameter Normal Dilated vein
Blood flow Spontaneous Poor
Echogenic material in None Present
lumen
Dislal comDression Augments blood flow Poor augmentation
Elood flow with respiration Phasic flow with respiration Loss of phasic flow
with resoiration

G- 'and sccondaFy Yaricos ) Yerns:

PrimarvV.V Se*rlrrdaw V.V
Secondary to DVT, A-V fistula,
Etiology !diopathic
oelvic tumors or oreonancv
Pain Sliqht or absent Marked
Along the long or short Haphazard veins crossing the
DistriDution oroin mav be seen
saphenous veins
Gomplications Minimal or absent More common

100
 SELF.ASSESSMEruT. PanT .IT

If-- Blood bonr and born trpes ofTB:

Lymphatic born
Blood born
(fibrocaseousl
lqe More common in elderly. More comnion in children.
Localized affection
(ftom colchment area) ) lry complex
Generalized affection.
- Upper deep cervical LNs (the
Occurs in milliary TB. OR
commonest r'r'1 )
portal is
tonsils (organism pass without
0rigin Blood borne from pulmonary
reaction)
or renalTB.
- Mediastinal LNs from )
pulmonary TB.
- Mesenteric LNs )
lntestinal
TB
Organisms reach L.N. through
Organisms reach L.N. through afferent lymphatics )
affection of
arterialsupply in hilum ) cortex
affection of medulla - Early affecting capsule
- Not affecting capsule (periadenitis)
Pathology
(periadenitis) - Early matting.
- No matting. - Early caseation forming cold
- No caseation. abscess
- No cold abscess or ) perforate deep fascia )
sinus is ever seen Collar stud
clinically in this type. ) Abscess may break
down ) sinuses
c/o:
) Painless swelling gradualonset,
slowly progressive.
o/E:
1- Manifestations of 1- Manifestations of T.B. toxemia
pulmonary TB. (2N21)
2- Manifestations of Pulmonary
TB.
Glinical picture (dyspnea, cough, expectoration &
hemoptysis)
)
3- Affected L.N. enlarged, not
2- Affected LNs ) enlarged, tender, firm early multiple then
not tender, rubbery, not matted
matted & discrete )
4- Cold abscess fluctuant (But
not as hot as pyogenic
abscess)
5- Multiple sinuses with undermined
edge & cyanotic margins.
- LNs secondaries
For Cold abscess
a. Hodgkin's lymphoma
(from other swelling in the neck)
DD b. Chronic non specific
For Sinus
lymphadenitis (from sinuses in neck)
thvroolossal - branchial-actinomvcosis
101
 DITT.enENTIAL DIRcNosIs

Non Hodskints disease

May be red, hot, & dilated veins

Mobile, discrete but late might

102
SELT.ISSESSMENT- PART'II

A- Different ffpes ofacute gastrie uleers:

o ICU patients
. Sever trauma
. Major burns
o Endotoxic Shock
o Occurs in the body and fundus These are multiple
of stomach erosions that if not
o They are multiple , shallow and recognized and treated
punished out coalesce to become the
. They varies in size from 1 mm condition known as acute
to 1 cm or more hemorrgic gastritis
o They are usually limited to the
mucosa and sub mucosa

B- Pathol of DU and GU
DU GU
ilumber Single (usually kissing) Single
$ite 1st inch of 1st part of duodenum Lesser curvature
(duodenal cap) anterior or prepyloric
posterior or both (kissinq ulcer) (the ulcer bearing area)
o
I Size Usually small Larger than DU
f
,
rounded or oval the same or saddle
.lt Shape
E Sloping (at first) or punched out (later)
0 f,dae
vl
o
)a Marqin Congested with mucosal folds
19
floor 1. Penetrate the muscle coat
2. Filled with:
. Granulation tissue during activity
. Fibrous tissue durinq healinq
Base lndurated (due to fibrosis) with destruction of mucosal coat,
.lt Base Dense fibrous tissue
E
o PNL, lymphocytic infi ltration,
t,
YI nerve ending around ulcer are thickened (bulbous)
o
L
.it
lrteries endarteritis obliterans
=

103
 DITPenENTIAL DIRcNosIs
C- Clinieal pieture
re of GU aand DLr
DU CU
. Male 25-40 yrs usually o Male 35-45 yrs usually thin
wellfed with no apparent and undenrveight
signs of ill health o Male : female = 2'. 1
. Male:female= 5:1
Twe Burning, stabbing, colic, shoot rg or dull aching
a. 2 - 3 hrsd,after meal (due
to passage of acid chyme
on the ulcer after gastric
evacuation) & persists till
the next meal (as hunger
pain)
Usually starts Y, - t hr or
Time b. Nocturnal pain awakens immediatelvE after meals
the patient in early
morning. due to:
1- Maximum HCI secretion
at night.
2- Stomach remains empty
t for a lonq time.
|! Above the umbilicus to the Rt. Epigastric in the midline or just
trr side of the midline to the left. May radiate to the
Site
back.
Exciting lrritant foods, nervousness,
factors Smoking, stress
Alkalis & Antacids
Food or anything the buffers Fasting & vomiting
Relieved
the gastric juice (patient lf antacids fall to stop pain )
by carries biscuits) possibility of malignancy or
Penetration
Marked by:
- Weather, worry, work
- lt occurs for 2 - 6 wks &
Periodicity Not marked
relieved for2- 6 months
- lt is commoner in spring
& autumn
2. Vomiting Not prominant Very common as it relieves
(Onlv if pvloric stenosis occurs) oain & mav be self induced
3. fippetite Good as eating relieves pain Good but the patient is afraid to
except for alcohol and eat (sitophobia) as it induces
smokinq Pain
4. Bodv wl. Gain weight Loss of weight
S.Ilematemesis & +ve
melena (more Hematemesis)
[nemia +ve +ve
l. Pointing sign The patient can localize site of pain exactly by one finger
2. Tenderness Above the umbilicus to the Rt. ln the epigastrium in the midline or
side of the midline iust to the left of it.

104
SELF.ASSESSMENT, PnRT .I I
D- Barium
llrn meal findines rn
in case of DU and GtI a
a

DU cu
lllcer niche ln the duodenal cap on the lesser curvature.
Earlv due to muscle spasm
Later on due to fibrosis (trifoliate Ulcer niche with opposite notch
deformity) due to spasm of circular
Deformity To be sure that the deformity is due muscles.
to either spasm or fibrosis & not Later on due to fibrosis of
due to peristaltic wave, Serial circular muscle fibers
duodenal film must be taken
Ulcer crater )
Post . A flake of Barium remains in the ulcer niche
evacuation (in patients with evacuation failure)
o The mucosalfolds are seen radiatino toward it
Tenderness Tenderness at site of the ulcer
Soup dish appearance
Gomplications
(in pvloric stenosis) Hourglass or teapot appearance

D- Darly and late dum a

Early Dumpins l-ate DtrmDinq

1- Hvpovolemia 1- Hvpoqlvcemia
z- within iiour iier meai 2 - J trouri itter meii
3-Due to:
Loss of the reservoir function of the stomach t CnO diet ) hyperglycemia ) J
) rapid passage of hypertonic chyme into insulin output ) hypoglycemia
small intestine )
shift of extracellular fluid
into lumen of intestine ) depletion of blood
volume.
4. CIP :
A- Gastrointestinal:
. Abdominalfullness followed by colic and
A- Sweating.
diarrhea
B- Hunger.
B- Vasomotor:
. Sense of weakness, flushing, palpitation C- Tremors.
D- Nausea.
:1 pql9e, J DleqC preq99re,
5- Prevention
, Smallfrequent meals, rich in proteins and . Smallfrequent
meals , low CHO
fats and less in CHO diet
. Liquids allowed only in between meals . Oral hypoglycemic
(Tolbutamide 500m9 before meals)
6- Treatment:
. Assuming the supine position . Avoid high CHO diet
. Polya converted to Reux-en-Y to delay . Somatostatin
emotvinq

105
 DIFFERENTI^A.L Dn,oruosls
F-- Different of stones:
Cholestercl Mixet Black i Br*^
pi.qment I pismenr
Pt with
Incidence 8%
hemolytic
80o/o@
anemia &
cirrhosis
Calcium Major --+
Cholesterol(60%) bilirubinate calcium
t bilirubinate
CaCO3,
Gonstituenls Pure cholesterol Ca bilirubinate Others --
Bile salts, bile calcium
pigments balmitate
Phospholipids and
colestero:
- Usually singleE multiable multiaple
(cholesterol
lfumber solitaire) Multiple
- Sometimes
multiple
0.5-2.5cm. <2.5 cm <2.5 cm
Arranged in
groups each
group contains
Size Large >2.Scm equal sized
stones &
represents an
attack of
infection.
Rounded or oval
Multiple laminated
Shape Faceted
specula
Surface Mamillated Smooth
Golor yellow Yellowish Tariy black brown
Gonsistency Hard & floats Hard & sinks
No nucleus Nucleated +
Gut section Radiating laminated
Radio Radio
Radio-opaqueE
X-Bay RadiolucentE
in 15o/o of cases
opaque in 50 opaque
% cases

106
SELF'ASSESSMENT- PanT .II
G- Caleular and obstruetive
C-alcular Ol Malisnant Ol
l. IlVc of 6F
Elderly male
oatienl
2. laundice Slowly progressive, not severe Grad ual, rapidly progressive
intermittent. or intermittent
l. Stool Clay colored Clay colored or silvery stool
{. hine ,Dark due to excess direct bilirubin.
rFrothy due to excess bile salts )
.l-surface tension.
5. Pain Recurrent attacks of dull aching pain .
May be absent
Rt. Hypochondrium -+ Rt. Shoulder r Boring
r Epigastrium -+ Back
Uhat f Fatty meals Lying down
Yhat J Antispasmodics Leaning forward
6. Yeioht loss -ve Marked
7. r,lls -ve +ve (Virchow's LNs)
8. trivet Enlarged, not tender Enlarged, not tender or
enlaroed. nodular & tender
9. Spleen, -ve +ve
ascites, P/fr
u. a/s Usually fibrosed gall bladder with - distended gall bladder
sfones with thin wal!
tL cr - Gall stones -Head neoplasm
D. ENCP - Stone in CBD -!rregular filling defect
13. GaIl bladdet - Usually impalbable -Commonly palbaple
14. fever - May be present -Usually absent
II- I)ifferent eauses ofaseites:
Cirrhotic Mali.qnant Tuberculous
[9e Any Early but may be Usually young
young rn ovanan
cancer
History Jaundice or hematemesis Short history Toxemia
Svmotoms of the 1rv
Generd exam Liver insufflciency Distant metastases Toxemia
lbdomind HSM may be present Multiple hard Doughy mass may be
abdominal masses palpable
examina6on mav be oalpable
LtT Poor Normal Normal
als Liver cirrhosis/ Abdominalmasses Abdominal masses
solenomeoalv mav be detected mav be detected
Tapping Transudate Exudate and cytology itraw colored exudates
may show malignant and culture may erveal
cells T.B bacilli
Treatment Medical lapprng Anti-tuberculous
Peritoneo-venous shunt Radioactive qold
a
progrnosrs Bad Very bad Good

107
 DIFFERENTIAL DIa.cruosIs
f- I)ifferent elases of Child elassffieation:
r point 2 DOmtS r points
lerum Bit!rubh I O-Z mg o/o
Senrm ahumin t g/t I glt I . gO q/i
I

> 35 eO+S
lscites I None I risilv eoiliioiEa 1 pooiiv Contioireo
Elqgplnflqp_ethy I None I VtitO oi moOerate I A6vanceO
Ilutrition lExcellentl GooO I poor
[i I F=t poqnt I suitabte for surqery
P;.....
Gt
I a,t t point I urarginiuv auitabae ior iuiirerv
I 12- 15 point Unsuitable for surqery

J- fleerative and pertrophie tf ofTB ofiutestine:

Hyperlrrophic We
Ulceative type
l1rco/ol
l. Etiology
. Mycobacterium tuberculosis.
a. 0rganism . 2ry to pulmonary TB. . Mycobacterium bovis.
b. f,oute . Swallowing of infected sputum. . lngestion of the TB
bacilli.
. lngestion of infected
milk.
c. Predisposing
factors chird
- flge
Adult
Usually bad (open case of TB ) relatively good
- Immunity least virulent
- virulence

- Sife )
terminal ileum (more - Site ) ileocaecal
lymphatics) region.
- Resulf )
transverse ulcers - Result )
thickening
(lymphatics circumferentia ly) of submucous and
-
I

Number )
multiple. subserosal
2. Palhology
- Edge )
Undermined (affection of layers)fibrosis )
connective tissue > epithelium) narrowing of terminal
(Lesion) - Margin )
Cyanotic (due to EAO). ileum, caecum,
- Floor ) covered with caseous ascending colon.
material. - Mesenteric LNs )
- Base ) lndurated. involved early & may
- Serosa) may be studed with caseate.
tubercles and thickened. - IVo gross caseous
aecroslb.

1oB
SELF.I.SSESSMENT' P^a.RT -I I
Hypetrophic type
Ulcsativeqvq,e
(<rco/ol
General General
- Manifestations of pulmonary TB
- Jweight&anemia
- ?,d
- j weight, anemia
Local Local
3. Glinical - Diarrhea, - Diarrhea
Picture - Colicky lower abdominal pain - Abdominal pain
- Fetid bloody stool. - Fixed firm tender
mass in Rt. iliac
fossa.
- Sometimes recurrent
episodes of subacute
to.
4, Gomplications
Stricture formation ) lO. Stricture ) lO.
Perforation (rare) Fecalfistula
Laboratorv:
- CBC anemia , lymphocytosis
- ESR & +ve C reactive protein
- +ve tuberculin test
5. Investigations - Stool culture on Lowenstein Jensen media
- PCR
- AbdominalX-ray may show extensive calcification.
Radioloqical: Radioloqical:
- Ba mealfollow through) Ba meal follow through
Narrowing of the ileum
with elevated caecum
Anti TB drugs + sanatorial ttt
Surgical ttt: Surgical ttt:
lndicated for: perforation, stricture lndicated for:
i. Treatment & bleeding. perforation, fecal
Operation: resection and fistula & obstruction.
anastmosis. Operation: right
hemicolectomv

I(- Yiable flnd non-viable intestine:

Viable Not vrable
Gonsistency Firm Floppy
Musculature
By pricking Contracts No response
Golor Pink Brown to black

Vasculature Mesenteric arleries Pulsating Non - pulsating

If iniured Bleeds No bleeding

Peritoneal coverinu Iruster Present Absent

109
 DtppEnENTIAL Dnergosts
I- Ditrerent levels of fO:
Hish 5.1. Low 5.1. Colonic
obstruction obstruction obstruction
Yomiting
Earty & repeated + Delayed for 12
Absent or delayed
earlv dehvdration hours
Marked especially
Distenlion Absent or little Central
in the flanks
Absolute, may be
Gonstipation delayed until passage Early
of distal stools

M- I)iver.tieular tlisease of the eolon & eareinorna of the

pelvie eolon:
Divercicu|prr Carcinonra of the
Disea,se of thecolon oelvtc colon
Eleeding per Small amount and
Profuse and periodic
rectum continuous
Symptoms o/o
Absent in 25 of
Pain Common
CASES

Duralion Long Short

Signs Mass Usually tender Usually not tender
Stricture, shou ldering
Barium MeaI Sawtooth appearance & apple-core
Investisations appearance
Shows the mouths of Visualizes the mass
$igmoidoscope
diverticulum and takes biopsv

N- FPC and bilhan'zial polypi:

Farnilial oolvpi Bilharuial oolvoi
Ige Young age Adult

Sex Both are equal More in males

r.H +ve -ve
Site Mainly sigmoid , rectum Mainly sigmoid , rectum
Micro Adenomatous polypi Bilharzial granuloma, +ve ova
Danger Precancerous 100 o/o -ve

110
SELr-ASSESSMEruT- Pe.nT .II

GI]NItrIBAI
,l- Dnter.otrcle and orncntot ele:
[ntestine Omenttrm
Gonsistency soft Doughy
Gurqlinq +ve -ve
Reduction difficult at 1st then easy Easy at 1st then difficult
Percussion!! Resonant Dull
X rav Gases No gases

B- Differe
t nt of e()nl pli eat ed rer[las:
lne/gcible lnflamed Obstructed Stransul ate/
Impulse on +ve +ve +ve (difficult) -ve
couqh
ReduciDilitv -ve -ve -ve -ve
[.I.0 -ve -ve +ve +ve
Tender -ve +ve +ve +ve
Tense -ve -ve -ve +ve

c- Obri ue ar rtl direet iI una herrri fls:

Obligue inguinal hernia Dirert inguinal hernia

Incidence More common Less common

lae & sex Any Old males
Side Unilateral or bilateral Common bilateral (50%)
Size Larger Smaller
Shape Oblong Hemispherical
Downwards, forwards &
Descent Forwards
mediallv
Upwards, backwards
Reducibility Backwards
& laterallv
Descent to scrotum sometimes Rare
Gomtlications 6 I
Internal rinc lest +ve -ve
External rinq tesl lmpulse at tip of flnger lmpulse at side of finger
Relalion of neck of
sac to inferior
Lateral to the artery Medialto the artery
epigastric a.
(inlra-operative)

111
 DIFFERENTIAL DIecruosls
I)- Seboc'eous and dermoid eysts:
Sebac*nus c:,tst Dermoid wst
lqe After adolescence At childhood
Site Related to hairy skin Related to lines of fusion
Gonsistencv Tense cystic Lax cystic
Attached to skin by punctum Not attached to skin
Skin
where sebum can be squeezed

Itr- I)ifferent indieations of bloott transfu sion:

Product lndication Precautions Storaqe life
Whole blood Class lll & lV ABO & Rh 21 days
hemorrhaqe
Red cell concenlrates Severe anemia ABO & Rh 21 days
fresh frozen plasma - Bleeding due to ABO 1 year at -
non-specifled 400c
coagulation factor
deficiency.
- Coumarin overdose
Platelet concentrates 1ry or 2ry ABO 24 - 72 hours
thrombocvtopenia
Eryoprecipitates of facto Bleeding with ABO 1 year at-
Ym & fibrinoqen fibrinogen depletion 400c
factor IX Hemophilia A 2 years
llbumin lo/o ot 200/o - Acute volume 4 years
expansion.
- Hypoalbuminemia.

F. l)ifferent elasses of hemorrhage:

Class I Class ll C[ass lll Class lV
Elood loss 15- 30% 30 - 40%
in I0 kg person) (750-1500 mt) (1500-2000 mt)

Normalto Anxious to Aggressive to Drowsy to

Mental status anxious resf/ess drowsy unconsdous
< 100
PuIse 100 - 120 100 - 140 > 140
Systolic BP Normal Normal Low Low
Diastolic BP Normal Raised Low Low
Pulse or. Normal Low Low Low
Resp. rate 14-20 20-30 30-35 >35
Urine (mt/h) >30 20-30 10-20 0- 10
Gapillary refill Normal >2 sec >2 sec undetectable

112
SELF.ASSESsMENT- PIRT,II
G- f idy and untid.l' rvorurds:
Tidv wounds Untidv wound
Mechanism of
lncision Crushing or avulsion
iniurs
Gleanliness Clean Contaminated
Tissues Healthy Devitalized
Tissue loss No or little Much tissue loss
iledinq 1v intention 2v intention

II. I s rlf rvorrnd he:rlillg:

rry intention zry intention rry intention
- Tidy wounds Untidy wounds Wound initially
- Opposed edges Gapping of left open to allow
Gharacter edges drainage, then
of wound -No Complicated when healthy
complications wounds (e.9. closed by 2ry
infected) suturino
Extensive-weak
Scar Minimal-strong scar As primary
scar
Closed when the
Seals in 1-2 days Much more time is wound is healthy to
Duration
Heals in 1-2 weeks Needed avoid bacterial
contamination

I- [)ry anrl rrroist w'ounrl healilrg:

Dw Womd Healinq Moist Wound Healins
. Hard to epithelialize. '. Easy to epithelialize fast.
. No wound nutrition. Allows wound nutrition.
. Scabs delay healing due to '. Prevents scab formation.
desiccation of underlying tissues. Allows granulation through cell
. Dead tissues are a good media for migration.
anaerobic bacteria.

113
 DTPpEnENTIAL DTRcruosIs

UBOSUBGEBY
l- Intra
ntra amd extra peritoneal nrDture of fIB:
lnt a-peitoneal t uptute lzoo/ol Fs<tt a-pentoneal ruptute
lSoo/ol
v,
o
- Occurs in males > females. - More in males.
UI
a - Full bladder & direct trauma - Bladder is injured 2ry to fracture
rt applied to supra-pubic region. pelvis.
TJ
- Suroical iniurv. - Surqical iniurv is rare.
Urine extravasates into the peri-
Er - Sterile urine escapes into peritoneal cavity vesical & peri-prostatic spaces,
o
-o ) peritonism )
delayed peritonitis. retro-pubic space (cave of
-I€ - Rupture usually occurs between the roof Retzius) and then ascends up
t and post wall of the bladder. between peritoneum & fascia
transversalis.
vl
T
History of trauma.
!ts o Supra-pubic pain.
E Urine retention with NO desire to micturation intra-
e peritoneal type, but the desire is preserved extra-
u, peritonealtype.
Hematuria.
. General: shock.
'.89l!.!-r.
. General: shock.
lnspection: bruises, ecchymosis & . Local:
rigidity !nspection: bruises, ecchymosis
Palpation: guarding, rebound & rigidity in supra-pubic region
v, due to fracture pelvis.
e tenderness
Palpation: guarding, rebound
Er
.rl
v2 Percussion: shifting dullness tenderness in supra-pubic region.
A uscultation: dimin ished intestinal Percussion: no shifting dullness.
sounds DRE: empty recto-vesical pouch.
DRE: fullness in recto-vesical pouch
Catheter can be passed easily & no urine Catheter can be passed easily &
is obtained (only blood) blood + small amount of urine
vt
I
o
:l!
.Fl
. Pelvic abscess from infection of hematoma or urine collected.
t,
.l . Delayed peritonitis.
E o
Partial incontinence if bladder neck is injuried.
E
o
t
1-X-rav
v,
e Ground glass appearance (due to urine in
o Fracture pelvis.
.d
I the lower part of the abdomen).
IU
E! 2-UlS & CT scan:
.H
I
UI
€,
Free fluid in peritoneum )
peritonealtap
mav be of value
e
H 3- Ascendinq cystoqraphy or IVU
Leakino of the dve from the urinarv bladder

114
 SELF-ASSESSMENT- PRnT -II
B- E\t
x ra a ntl i rrtra rie mpture of I:B:
Exua-pelvrcruptute
(most conrmonl lntra-pelvi c tuptute
o
v,
I Trauma to perineum - latrogenic by catheterization
-
.E (Falling astride or kick).
C' - 2ry lo fracture pelvis
o The tear may be partial or complete. . Tear of the urethra, which is usually
B
o
o The urine collects under Camper's, Scarpa,s & complete.
o
Colle's fasciae at the penis, perineum, o Avulsion of the pubo-prostatic ligament )
scrotum, anterior abdominal wall & then floating prostate.
-t! descends down to the upper part of the thigh. o Extravasation of urine (in the cave of
e. Retzius).
Severe pain in perineum. Severe pain in hvpoqastrium.
vl History of trauma.
L
H

II
o Urine retention with desire to micturation.
Er Urethral bleeding.
H
The triad of urethral hemorrhage, perineal hematoma and retention
w, of urine is diaonostic of ertra-nelvic runf rrre
. General: Shock. . General: Shock.
. Local:
- Perineal hematoma
'!@
- Fracture pelvis
- Bleeding per urethra. - Bleeding per urethra.
- Bladder is full. - Bladder is full.
vl - Catheter is never used if urethral injury - Catheter is never used if urethral
T
.l
Ei suspected. injury is suspected.
w, - PR: orostate can not be felt-
vl
H
.-o
-r!t, I. Subcutenous extravasation in
E complete rupture.
-E\ ll. Stricture.
E
to
6 Plain X-ray
E
o -ve Fracture pelvis
.t
ET
. Urethrogram:
vl - Extravasation of the dye
c, . Cvstoqram:
H
I
- For associated UB injury.

(l-- f)iffer.e nt of urinarY stones:

Types Oxalate Cystine Phosphate Urate
$urface Spiky Smooth Smooth Smooth
Gonsistency Hard Very hard Hard Hard
try,2w 1tv 1tv ztv ltY
Radiological Opaque Opaque Opaque Lucent
Golor Brownish Pink to yellow Reddish
Dirty white
brown

115
 DrrrenENTrAL Dncruosls
l)- ('nlurlar anrrria :ulrl n(.rrte rtrtentiorr of urine:
Calculus anuria kue,rctertionof urine
History ureteric colic severe supra pubic pain
Examinalion bladder is empty bladder is distended
catheter is passed catheter is passed
Gatheterization
) no urine ) brinqs urine

1)- S(lC an(l'l'C(l of lrll:

scc TCC
lge 20-40 >60
Male: Female Male: Female
Sex
4:1 3:1
a. Chronic irritation:
a. Chronic irritation:
- Mechanical: by ova or stones.
- Chemical: by metabolites (N-
- Chemical:
. Smoking J the risk by 2-4 folds.
N itrose compound, tryptophan, . lndustrial carcinogens (e.9. aniline
serotonin).
dve)'
b. Chronic infection: especially . Chemotherapy
0 with ammon ia-prod ucing
L
o
!..
organisms.
(cyclophosphamide) J the risk 9
t|! folds.
tr ;. Abnormalities of trvptophan - Phvsical: pelvic irradiation.
Er metabolism.
e b. Genetic:
.Fa
YI
i. Precancerous lesions: - Activation of oncogenes e.g. RAS
o
fUI - Brunn's nests. & Cerb B-2.
.l - Cystitis cystica. - lnactivation of tumor suppressor
E - Leucoplakia & squamous
o
H genes e.g. P-53 (Le Fraumini).
t metaolasia.
€,
!I
Usually at the posterior & lateral Usually at the base and around ureteric
.Fl
u, walls orificies.

.-tE Papillary mass or papillae,

o
tvl Fungating mass (common)
Ulcer.
o Malignant ulcer
)a Nodule.
t6! Papillary mass (rare)
Localized eryhtematous patches.
= TCC is classified into:
t
.l
E 1. Superficial TCC (75o/o): commonly
B
o
o
tvl SCC ) Cell nests if well papillary type.
-o H
o differentiated 2. Muscle invasive type (25o/o).
'Ira- t, 3. Carcinoma in situ (CIS)
t! .t{
e. (associated in 5% of the cases).
=

116
SEIT.ISSESSMENT. PR.RT'II

IDIASTIO SUITGI ITY

l- l)ifft'r'cnt degrees oI'llul.n:
rct degren zrdDe4lter. 3rd degrce
.Only the
epidermis ) .Complete
erythema of .Epidermis + portion of destruction of
Damage
skin usual dermis. epidermis and
example is dermis.
sunbum.
.No healing only
' Epidermal regeneration migration of
can occur from
Epithelium
remnants of hair follicles
from edges of
and sweat glands in
.Heal rapidly burnt area
Ilealing dermis provided that no
.separation of
infection.
escahr by 3'o
)
.lf infection destruction
week
of epithelial remnants ) .Skin graft is
3'd degree.
needed
. Forms blisters surrounded by erythema . White or black
. Their surface is moist due to exudation of escars
plasma . The area is
dry
flppearance . Possible
visible
thrombosed
S.C vessels
. Painful . Painless (due
Presence of
pain ' Sensitive to air to affection of
nerve ending)

117
 DIPPEnENTIAL DIIeruosTs
B- Ditrerent p rcli ofgraft s:
I t)-pes
Split thic[<ness Fu[[ thicl<ness
Epidermis + superficial part of Epidermis + fullthickness of
Delinition dermis dermis
1- Covering large area of 1- Facialwounds
granulating tissue. 2- Palmar aspect of
2- Coverage after: hands and planter
Indications a) Deep burn. aspect of feet.
b) Malignant tumor 3- Site of pressure on
resection. sole of the foot
1- Trunk, thighs 1- Post-auricular skin
Donor sites 2- Upper arm, fore arm 2- Upper eye lid
3- supraclavicular
1- Early separation & 1- Direct closure of
application donar site.
2- lncrease TAKE by graft. 2- Minimal contraction.
3- Can cover wide area. 3- Better sensation
ldvantages 4- Early detection of 4- Better cosmosis
recurrence of 5- Resistant to trauma.
malignancy)
5- Donor site heals
soontaneouslv.
1- More liable contraction. 1- Limited donor site.
2- More liable for pigmentation. 2- Can't be applied on
3- Weak resistance to trauma. granulation tissue
Disadvantages 4- Poor sensation & cosmosis 3- Less TAKE
4- Asepsis must be perfect.
5- Scar at the donor site.

118
SELF-ASSESSMENT. PART .I I

C- BCC arrd SCC of skin:

BCC 5CC
Delinilion Locally malignant malignant
Incidence Male old age
Exposure to sun rays, Ultra-violr rt rays (Most important) so the
disease is more common in Farn rers & Sailors.
Albinism & Xerodermia Pigmentc sa (AR). Predispose to multiple
basal cell carcinoma all over the body.
lonizing radiation.
Patients receiving immunosuppre rssants.

PDI

Pathology: Any site

l. Sile
2. Macro- 1-2-3-4-5-6-7 Nodular or ulcer
3. Micro- Cell mass (pallisade)with fibrous differentiated (cell nest)
stroma &undifferentiated
Spread Only direct (locally malignant) Direct, blood & lymph
c/?
6 > 40 years, fair colored people, farmers & sailors
Type of Painless nodule Ulcer resistant for ttt.
patient slowly growing pidly growing
IIodule No LN except if infected or
IIlcer malignant transformation

L-node Enlaroed in metastasis

- Hemorrhage, infection, infi ltration
Gomplications Malignant transformation - Metastasis
;

119
 DTPT.EnENTIAL DIeoNosIs
lD- l)r'rrl:ll :urrl rk.llli
st iul
:l <.rsl l'(lt'(lllti (' st a

A-DentalCyst B- Dentigerous
Cyst
0rigin Paradental debris of M alassez

Etiology Decayed tooth Missing 3'd molar

Chronic
inflammation
Pathology Adults Children
ln upperjaw. Lower jaw
Granulation - Cystic
tissue with enlargement with
exudation. bone expansion &
thinning
Invesligations . X_tOy
- contain I -
Doesn't Contain a tooth
atooth I

Treatment Tooth extraction & curettege of cyst

NIII]ITOSIIITGT]ITY
t- I )rl r':r<lrrrll nlxl n('lrt(' sulxlrrral hetttatorttit:
kute extradwal kute subdural
hematorna hematorna
Etiolory - Usually mild trauma. Severe trauma.
Glinical piclure - Usually mild brain damage. - Severe brain damage &
laceration.
Lucid interval may be Persistent loss of
present. consciousness, no lucid
interval.
- The hematoma is usually - Commonly bilateral and
unilateral. extensive (coup & contre-
couo).
Investigations CT ) biconvex. C.T > cresenteric.
(concavo-convex)
Treatment - The patient has serious
brain damage and edema
Early surgery is successful. in addition to the
hematoma, and so results
of surgery are not very
successful. Mortality rate
is up to 50 %.
Prognosis Better prognosis - Worse prognosis

120
SELF.^ASSESSMENT. PRRT'I I
I B- Si rrr llle :uld e()nt lD()urrrl rlcllr.csscrl sliu I I li.:ret rrr.c.s:
Simple deorcssed Corrrpound depte,ssel
Localized sharp object or
Gause Blunt rounded object.
severe blunt obiect.
Common in infants & Common in adults
[ge children (oino-oono). (stronqer skull).
More common:
Less common: - Scalp)profuse bleeding.
- Mostly overlying - Dura: CSF leakage, brain
lssociated lesions hematoma. prolapse & infection.
& complications - Cerebral cortex: contusion &
epilepsy
- Venoussinous:
- lntracranial hemorrhaoe.
Conservative. - Surgical interference
Elevation when - Cranioplasty:
Trealment indicated. (in depressed comminuted
fracture).
('- lrisslrrc
ssllt'c eteur(l rleurcsscrl skrrll fi':tet
DI'(:SS(:fl S il I'('si:
Fissure ( linearl ft acture Dewesselfracture
Instnrment e.q. - Head trauma to the wall - Head trauma with a hummer
Gontact surface - Wide - Small
area
- Starts at site of impact - Localized under site of
Site &runs away from it impact
Gomplications - Less common - Common
- Conservative - Elevation if indicated + of
- Treatment of associated associated lesions if present.
Treatment - Cranioplasty if there is
Iesions if present
comminution of bone
)- Sulxrxr.iulrel ir :rl lrcntorrhetge rlrrc (o krt'etl ( r':rurrr:r :rrrtl
li'er<'(urc base of'thc skrrll:
5 u bconiunctival hemorrhage 5 u bconimctival hemorrhage
due to [oca[ tratrma due to ftacturebase
l. History
-trauma - To the eye. - To the head.
-conscious. - Not affected. - Loss of conscious.
-onset - lmmediate. - Delayed.
- Triangular apex to cornea.
2. Shape -Triangular, base to cornea. -The eye may be pushed
fonruard
3-Post limit - Definite. - Can not be seen.
4- color - Bright red. -Dark red.
5-movement Limitation of movement of
eveball
121
 DrppenENTrAL Dnoruosrs
E- Prae,tur.e vamlt antl fi.aeture base ofthe skull:
EtactweVault EractureBase of the Skull
Gompressing hematoma
Common Rare
(EDII)
T\mes Closed or open Open>>closed
Infeclion,
Less common Common
Pneumocerhdus
Eleedinq/ nose. ear Less common Common
[ssociated nelve iniurv. Rare Common
Close to or near
fracture. May be away from fracture.
lssociated brain iniury. Opposite side in Site in indirect fracture base
contre-couo
Elevation of depressed Aiming to control: CSF leak,
TTT of associated injurl lnfection.
Treatment (duraltear, EDH....) TTT of associated injuries
(brain & cranial ns)

l'- Ditrerent tf'pes of sealp hematomas3

Sufualeal
Subcutan erlus C-ephalhemtorna
lsubaponeuroticl
Under the
skin(Confined to
Under galea aponeurotica in
Site dense subcutaneous Under the periosteum
loose areolar tissue.
layer) Localized to
the site of trauma.
Trauma Direct trauma Scalp trauma Birth injury
Sourse of Scalp or fractured Fractured underlying
Scalp
bleeding underlying bone bone

Diffuse soft, fl uctuating

extending as far as the It is limited by suture
attachment of the galea, line of affected bone as
reaching anteriorly to the the periosteum is
Gharacters Small, painful
supraorbital ridges, attached at the suture
Posteriorly to superior lines (usually the
nucheal line & laterally to parietal bone)
temporalcrest

The scalp moves over

Moves with the scalp The scalp floats over the the swelling but the
Scalp
over the skull swelling swelling can not be
moved over the skull

122
SELr'^ISSESSMENT. PART'II
Subgaleal collections:
Depressed skull
DI} CSF(meningoeele),
fracture.
empyema

r. NeuraDraxia.
G- -L\ tllfillrl.ilXltl, axonotenresis and neurotemesi
ilXOIlOIeIlreSIS A[(l netlfofelnesls 3

Neuroprar<ia Axonotmesis Neurotmesis

- Nerve concussion: Rupture of nerve Division of the nerve (partial or
physiolog ical interruption fibers but outer complete).
of all its functions without sheath is intact
any organic (lntracecal rupture)
damage.(functional
paralvsis)
- Complete motor - Complete motor - Complete motor paralysis.
paralysis. paralysis.

- Patchy sensory loss. - Complete

loss.
sensory - Complete sensory loss.

- Wallerian Wallerian degeneration occurs

degeneration in but regeneration is impossible.
- No Wallerian distal part for 10 After surgical repair recovery is
degeneration. days followed by poorest in mixed nerves(Ulnar
regeneration & median) and in motor
- Recovery takes place 1mm/day with nerves (a large number of
spontaneously within 4-6 further 3 weeks small muscles) recovery is
weeks delay before best in purely motor nerves
complete activation (a few groups of large muscles
)such as the radial nerve

OIBTtrOIDIIDICS
A- I)elayed and malunion:
Delrvel Union Non-Union
Pathology Bone ends are decalcified The bone ends are
and the fractuire line is sclerosed and the medullary
widened into a gap full of canal is closed by dense
fibrous tissuse bone
Glinicdly Abnormal movement and Abnormal movement and
tenderness at the site of tenderness at the site of
fracture fracture
Spontaneous healing Possible with prolonged impossible
un interruoted immobilization.

123
 DIFFERENTIAL DIIcruosTs
B- Suprachondylar ftacturc ofthe humerrrs (extension
t and posterior elbow dislocotion:
"e)

Normal.

lnterrupted.

124
S ELF.ASSESSM EI.TT. PIRT -I I

('- ( )stt'tx'l:tstorn:t, Osl eos:u'e()nr:r :tntl l,)u i ng's silr.(.onra:

Osteoclastonra Osteosarrcma Ewinds
lge & -15 - 45 years. -10-25 years. -5 - 15 years.
Sex -F>M -M>F -M>F
-Most common 1ry
malionant tumor.
Site -Epiphysis of long -Metaphysis of long -Diaphysis & metaphysis of
bones. bone. long bones.
-Around knee and -(Rule of 80).
awav from elbow.
Gell of - Unknown (thought -Osteoblasts ) -Round cell (BM
origin to be osteoclasts osteogenic. reticulocytes).
hence the old
name
osteoclastoma)
- Osteolvtic.
Spread -Locally malignant -Direct. 1. Direct
(aggressive). -Blood ) BLBL 2. Blood)BLBL(common).
-(80%lung 3. Lymphatic) common.
metastasis).
-Lymphatic) Rare&
Late.
Glinical Picture
Sigrns Bony swelling whicl IS:

Swelling - Globular - Warm, tender, illdefined.

- Sharply defined
edges.
-Egg shell crackling
sensation.
UI -No LNs. -Late affected. -Common.

X-ray Soap bubble lll defined destructive -Onion peel appearance

appearance. lesion: (Osteolytic + periosteal
Thin expanded - Start in metaphysis new bone formation).
cortex. - Destroys the
Medullary plug. cortex
- lnvades the soft
tissue
New bone formation:
- Sun ray
appearance
(stretched BVs
around which new
bone formation)
- Codman A
Soft tissue mass

125