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CLINICAL DIAGNOSIS

OF
PATIENTS WITH
AN ABDOMINAL DISORDER

AN INSTRUCTIONAL PROGRAM FOR

PRIMARY HEALTH CARE PHYSICIANS

DESIGNED FOR:

PROBLEM-BASED LEARNING
COMPETENCY-BASED LEARNING
IN- AND OFF- CAMPUS LEARNING

Author:

Reynaldo O. Joson, MD, MHPEd, MS Surg


2000
PATIENTS WITH AN ABDOMINAL DISORDER
GOALS AND STRATEGIES

GOALS IN THE MANAGEMENT

In all patients with a chief complaint of an ABDOMINAL DISORDER,

the primary health care physician must be able to:

RESOLVE the ABDOMINAL DISORDER

in such a way that the patient does NOT end up

DEAD

WITH ANY KIND OF COMPLICATION


AND DISABILITY

and in such a manner that the patient

IS SATISTFIED

DOES NOT FILE A MALPRACTICE SUIT

STRATEGIES

RATIONALE, EFFECTIVE, EFFICIENT, HUMANE


MANAGEMENT

IN THE TASKS OF

RAPPORT, DIAGNOSIS, TREATMENT, ADVICE


Clinical Diagnosis of Patients with an Abdominal Disorder

Content

Title
Goals and Strategies

Content ..................................................................................................................................... A

About the Author ...................................................................................................... ................ B

Preface ..................................................................................................................................... C

The Course Pack - Content and How to Use ............................................................................... D

Folder 1: Instructional Design ................................................................................................... I

Folder 2: Hypothetical and Actual Patient Management ............................................................ II


Blueprint ................................................................................................................... .. IIA
Triggers for Problem-based Learning Sessions ............................................................ IIB
Patient with Trauma to the Abdomen ........................................................................... IIC
Patient with Nontraumatic Abdominal Pain.................................................................. IID
Patient with Abdominal Mass ...................................................................................... IIE
Patient with Jaundice ................................................................................................... IIF

Folder 3: Problem-based Learning Issues - Form ...................................................................... III

Folder 4: Learning Objectives ............................................................................................... .... IV


Clinical Diagnosis of Patients with an Abdominal Disorder ......................................... IV1
Clinical Diagnosis of Patients with Specific Abdominal Complaint ............................. IV2
Physical Examination of the Abdomen ....... ................................................................ IV4

Folder 5: Learning Resource Materials and References .............................................................. V


List of Recommended References ................................................................................. VA
Learning Resource Materials
R.O. Josons Writings
Approach to Patients with an Abdominal Problem
Approach to Patients with Abdominal Trauma
Approach to Patients with Acute Nontraumatic Abdomen
Approach to Patients with Nonacute Abdomen
Management of Patients with Peritoneal Irritation
Management of Patients with Hollow Visceral Obstruction
Management of Patients with Gastrointestinal Bleeding
Principles of Abdominal Surgical Oncology
Physical Examination of the Abdomen
Learning Objectives on Physical Examination of the Abdomen

Folder 6: Evaluation ........................................................................................................ ........... VI

A
About the Author

Present Academic Positions

Dr. Reynaldo O. Joson is presently a permanent professor at the Department of Surgery of the
University of the Philippines, College of Medicine.

He is at the same time an affiliate associate professor of the University of the Philippines Open
University as well as a faculty in the University of the Philippines College of Public Health.

He is currently the Chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue
Surgery at the Philippine General Hospital.

Academic Degrees

He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in
1974; his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in
Health Profession Education from the UP National Teachers Training Center for Health Profession in 1993;
his Master of Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.

His finished his residency in General Surgery at the Philippine General Hospital in 1981 after
which he became a Diplomate of the Philippine Board of Surgery.

Education for Health Development in the Philippines

One of his missions in life is to contribute to the health development in the Philippines through
education. This mission started in 1990 when, as Director of the UPCM Postgraduate Institute of
Medicine, he designed a structured Department of Health-UPCM Postgraduate Circuit Courses in four
provincial hospitals in the Philippines (Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal,
South Cotobato and Oroquieta, Misamis Occidental in Mindanao).

He then went on to develop a structured general surgery training program using a distance
education mode from 1991 to 1994 in Zamboanga City Medical Center. With this program, he added 7
trained general surgeons to the pool of 2 that served the 3 million population of Western Mindanao.

In 1994, he helped established the Zamboanga Medical School Foundation. He helped designed a
community-oriented, competency-based, and problem-based learning medical curriculum for the school.
This curriculum was adopted by a medical school in Legazpi, Albay in 1995 and by another medical school
in Cebu in 1996.

He is presently preoccupied with the full development of this curriculum as well as designing a
telehealth program.

Hospital Administration

He is currently an assistant medical director at the Manila Doctors Hospital in charge of its
quality assurance program.

B1
Writings

He started writing books, primers, self-instructional programs, and course packs in medicine,
surgery, hospital administration, and medical education in 1985. As of December of 1999, he has about 30
finished products.

Contact Numbers

Dr. Reynaldo O. Josons email address is rjoson@pacific.net.ph


His telephone number is 523-2774.

R.O. Josons Website

http://web.pacific.net.ph/~rjoson

B2
Preface

Dear Learner,

Mabuhay!

Welcome to a learning experience in becoming a health professional.

This program has been especially designed with you, the learner, and the principles of effective
teaching and learning in mind.

As you go through this learning program, please bear in mind the following:

1. I am treating you as an adult learner which

1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;

1.2 Gives you the privilege to use other learning strategies in achieving the objectives in
this program;

1.3 Welcomes you to go beyond the learning package as you so desire; and

1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.

2. We shall define learning as a positive observable change (for the better or improvement) in
human behavior, disposition, attitude, performance, or capability which persists over a
period of time.

3. Active learning strategies and activities will be utilized as much as possible.

4. The program will contain learning materials which I think will be relevant to your being an
effective, efficient, and humane health professional.

5. The ultimate goal of the learning program is to produce health professionals who will
contribute to the health development in the Philippines.

6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however,
that I am not infallible. Thus, analyze carefully everything in this program. Dont
hesitate to offer disagreements and constructive criticisms for own learning and for
the improvement of the program.

Best wishes for a fruitful learning with the help of this program.

Reynaldo O. Joson, M.D.


2000

C
The Course Pack
Content and How to Use

Content

The Course Pack on CLINICAL DIAGNOSIS OF PATIENTS WITH AN ABDOMINAL


DISORDER consists of six (6) folders:

Folder 1: Instructional Design


Folder 2: Hypothetical and Actual Patient Management
Folder 3: Problem-based Learning Issues
Folder 4: Learning Objectives
Folder 5: Learning Resource Materials and References
Folder 6: Evaluation

Folder 1: Instructional Design


This folder contains the course plan.

Folder 2: Hypothetical and Actual Patient Management


This folder contains hypothetical patient management exercises.
It also contains an instructional plan on Actual Patient Management.

Folder 3: Problem-based Learning Issues


This folder contains the instructions and a form on which a student can write down problem-
based learning issues.

Folder 4: Learning Objectives


This folder contains general and specific learning objectives of the course.

Folder 5: Learning Resource Materials and References


This folder contains a list of recommended learning resource materials, references, and selected
and prepared manuscripts.

Folder 6: Evaluation
This folder contains test blueprint and pretest examinations.

D1
The Course Pack
How to Use

Initial Steps:

Start by reading Folder 1 on Instructional Design.

Then, scan the rest of the Folders (2-6).

Subsequent Steps:

This consists of the study and learning proper.

In the study proper , start with the Hypothetical Patient Management.


Note down learning issues. Use the form provided in Folder 3.

Then tackle the Pretest examinations.


Note down learning issues. Use the form provided in Folder 3.
Take note that 50% of the questions in Posttest written examinations will be derived
from the Pretest.
Take note also that the Pretest gives a guide on where to focus when studying the course.

Then tackle the Actual Patient Management.


Note down learning issues. Use the form provided in Folder 3.
Take note that the experience and learning obtained in Actual Patient Management are
useful in preparing for the
written examination
practical examination
project on case presentation and discussion

Overall Advice:

During the study proper, be constantly guided by the instructional design, especially the learning
objectives, which shall serve as the steering wheel in whatever that should be done in the course. This
includes the evaluation.

Reynaldo O. Joson, MD, MHPEd, MS Surg


2000

D2
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 1

INSTRUCTIONAL DESIGN
Clinical Diagnosis of Patients with an Abdominal Disorder
Dear Learner,

Mabuhay!

Welcome to the course on CLINICAL DIAGNOSIS OF PATIENTS WITH AN


ABDOMINAL DISORDER!

WHY STUDY THE ABDOMINAL HEALTH PROBLEM?

ABDOMINAL HEALTH PROBLEM is any problem that affects the abdomen which in turn
affects the health of the individual.

The ABDOMINAL HEALTH PROBLEM affects the biopsychosocial well-being of any person
who has it. It frequently leads to disability and may even cause death.

The common types of ABDOMINAL HEALTH PROBLEM can be conveniently categorized by


the kind of structures and systems or functions involved.. These are as follows:

Based on kinds of structures involved:


1. Problems on the abdominal wall
2. Problems of the contents of the abdominal cavity
3. Problems of the contents retroperitoneal space

Based on kinds of systems or functions involved:


1. Digestive system or function
2. Excretory system or function
3. Endocrine and metabolic system or function
4. Reproductive system or function

The common causes of the various types of ABDOMINAL HEALTH PROBLEM can be
conveniently categorized by kinds of disorders and factors involved. These are as follows:

Based on kinds of disorders involved:


1. Congenital
2. Acquired
2.1 Trauma
2.2 Inflammation/infection/infestation
2.3 Lump
2.4 Metabolic and nutritional
2.5 Degenerative
2.6 Others

Based on kinds of factors involved:


1. Genetic
2. Environmental
3. Self-induced

IA1
The ABDOMINAL HEALTH PROBLEM is a universal phenomenon. It involves the young and
the old and both the female and the male gender.

In the newborn, the problem consists primarily of congenital anomalies (notably inguinal hernias).

In chidren and the adolescence, the problem consists primarily of


inflammatory/infectious/infestation disorders (notably gastroenteritis, appendicitis, and ascariasis) as well
as nutritional disorders (notably undernutrition).

In the young adult and middle age, metabolic/nutritional (notably stones in the biliary tree and
urinary tract and obesity) and inflammatory/infectious (notably acid peptic diseases and gastroenteritis)
disorders are most common.

In the elderly people, cancer is the primary concern. It can involve all the kinds of structures and
systems found within the abdominal domain.

Trauma to the abdomen is also a primary concern for everybody primarily because of high-speed
and modern transportation system, high-impact sports, and significant crime rate.

Every primary health care physician should know how to manage any patient with or with possible
ABDOMINAL HEALTH PROBLEM. He should also know how to handle ABDOMINAL HEALTH
PROBLEM in the community as well as to deal with issues associated with the problem, such as bioethical,
psychosocial, medicolegal and research issues.

BASIC TERMINAL COMPETENCIES EXPECTED OF A PRIMARY HEALTH CARE


PHYSICIAN ON ABDOMINAL DISORDERS

Overview of Abdominal Disorders

Clinical Diagnosis
Trauma
Pain (nontrauma)
Lump
Difficulty in eating
Vomiting
Difficulty in defecation
Diarrhea
Difficulty in urination
Polyuria
Abdominal Distention
Hematemesis
Hematochezia
Jaundice
Obesity
Loss of weight

IA2
Recognize
Acute surgical abdomen
Traumatic
Nontraumatic
Intestinal obstruction
Abdominal tumor
Gastrointestinal bleeding
Acute gastroenteritis
Acute appendicitis
Acute cholecystitis
Hepatitis
Pancreatitis
Acid peptic disease
Gastritis
Abdominal cancer
Esophageal problem
Inguinal hernia
Urinary tract infection
Ureteral stone
Reproductive tract infection
Malnutrition (under and over)
Intestinal parasitism
Hyperspleenism
Others

Algorithm for
Abdominal pain (nontraumatic and traumatic)
Abdominal mass
Jaundice
Gastrointestinal bleeding

Paraclinical Diagnostic Procedures


Indications for
Blood tests
Urine tests
Stool tests
Plain Abdomen
KUB-IVP
Ultrasound
CT scan
Endoscopy
Biopsy
Treatment
Nonoperative
Indications for
Analgesics
Antibiotics

Referral
Indications
When
To whom

IA3
Advice
Clinical Diagnosis
Paraclinical Diagnostic Process
Blood tests
Urine tests
Stool tests
Plain Abdomen
KUB-IVP
Ultrasound
CT scan
Endoscopy
Biopsy

Selection of Treatment Process


Operative
Nonoperative

COURSE FOCUS:
CLINICAL DIAGNOSIS OF PATIENTS WITH AN ABDOMINAL DISORDER

GENERAL LEARNING OBJECTIVES (Terminal Competencies)

At the end of the course, given a patient with any abdominal disorder, the student should be able
to:

1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).

2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.

3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.

4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.

5. Demonstrate skills in giving advice on clinical diagnosis.

SPECIFIC LEARNING OBJECTIVES (Enabling Competencies)

Given a hypothetical and/or actual patient with an abdominal disorder, the student must be able to:

1. Establish a good rapport.

2. Identify the main health problem.

IA4
3. Define the concept of the main health problem in terms of:

3.1 Anatomy of the system, organs, tissues, and cells involved


3.2 Physiology of the system, organs, tissues, and cells involved
3.3 Common types
3.4 Common causes
3.5 Pathophysiology of the more common causes

4. Identify reliable clinical cues of the more common causes of the health problem.

5. Gather relevant data using interview and fundamental methods of physical examination.

5.1 Interview to gather relevant data.


5.2 Perform indicated physical examination gently, completely and accurately.

6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.

7. Do medical recording.

7.1 Write down relevant data clearly and completely.


7.2 Line-draw physical finding data clearly and completely.
7.3 Write down primary and secondary clinical diagnoses.

8. Advice on clinical diagnosis.

CONTENT

Biological Foundation and Basis of Clinical Evaluation of Patients with Abdominal Disorder
Anatomy of the abdomen (wall, contents of peritoneal cavity and retroperitoneal space)
Physiology of the abdomen
Pathology of the abdomen
Clinical cues (pathophysiology) of abdominal disorders

Clinical Evaluation of Patients with an Abdominal Disorder


Establishment of rapport with patient
Clinical diagnostic process
Giving advice on diagnosis
Medical recording

IA5
TEACHING-LEARNING STRATEGY

Problem-based Learning
Hypothetical Patient Management (at least 6 patients)
Trauma
Nontraumatic Abdominal Pain
Abdominal Mass
Jaundice
Gastrointestinal Bleeding
Diarrhea
Actual Patient Management (at least 3 patients)
Demonstration-Return Demonstration
Self-instructional Programs and Hand-outs

SKILLS EXPECTED

Rapport
Interview
Physical Examination
Clinical Diagnostic Process
Advice
Medical Recording

END-OF-COUSE EVALUATION

Written Examination (one)

Practical Examination

One student randomly selected to interview and perform physical examination on an


actual patient and then do medical recording and present. The other students
watch and critic.

To pass, the student should be able to demonstrate skills in the following:

Rapport
Interview
Physical Examination
Clinical Diagnostic Process
Advice
Medical Recording

See Rating Scale for Actual Patient Management

Project - Hypothetical or actual case presentation and discussion up to clinical diagnosis


only (2 per student)

See Format and Evaluation for Case Presentation and Discussion

IA6
BEST WISHES ON YOUR LEARNING JOURNEY!

Reynaldo O. Joson, MD, MHPEd, MS Surg


2000

IA7
Clinical Diagnosis of Patients with an Abdominal Disorder

Actual Patient Management

Rating Scale

Key:
1= excellent, exceptional, present (if parameter is a choice between present or absent)
2= good, demonstrated at all times, complete
3= fair, demonstrated most of the time
4 = poor, demonstrated some time
NO (5) = not observed, absent (if parameter is a choice between present or absent)

Passing Grade: A grade of at least three (3) overall and in each of the six (6) standards.

Standard: The student used adequate and proper verbal and behavioral means to establish rapport
with the patient.

Parameters for Rapport Evaluation 1 2 3 4 NO (5)


1. Was courteous. (greets and introduces self)
2. Made patient feel s/he is approachable and easy to talk to.
3. Showed respect to the person (privacy) and beliefs of the
patient during interview and advice. (tries to know the
patients name and some personal background)
4. Gentle in use of words during interview and advice.
5. Gentle in deeds during physical examination.
6. Clear in giving advice on clinical diagnosis.

Standard: During the interview, the student systematically gathered relevantly complete data.

Parameters for Interview Evaluation 1 2 3 4 NO(5


Core data for chief complaint were gathered. 4/4 3/4 2to1/4
1. Onset
2. Characteristics of chief complaints
3. Associated symptoms and signs
4. Previous medical consult
Data were gathered systematically based on clues derived
from previously obtained data

Standard: During the physical examination, the student systematically and gently performed
relevantly complete manuevers and concisely interpreted data obtained.

Parameters for Physical Examination Evaluation 1 2 3 4 NO(5


Core physical examination data for chief complaint were complete most some
gathered.
Physical examination was gently done.
Physical examination maneuvers were systematically done.
Concise in interpretating physical examination findings.

1of 2 pages
Clinical Diagnosis of Patients with an Abdominal Disorder

Actual Patient Management

Rating Scale

Key:
1= excellent, exceptional, present (if parameter is a choice between present or absent)
2= good, demonstrated at all times, complete
3= fair, demonstrated most of the time
4 = poor, demonstrated some time
NO (5) = not observed, absent (if parameter is a choice between present or absent)

Passing Grade: A grade of at least three (3) overall and in each of the six (6) standards.

Standard: During the formulation of clinical diagnosis, the student systematically and concisely
used the processes of pattern recognition and prevalence to come out with the
primary and secondary clinical diagnoses.

Parameters for Formulation of Clinical Diagnosis Evaluation 1 2 3 4 NO (5


Systematic and concise use of pattern recognition and
prevalence.
Presence of primary and secondary diagnoses. YES NO

Standard: During the advice on clinical diagnosis, the student was systematic and clear and
complete.

Parameters for Advice on Clinical Diagnosis Evaluation 1 2 3 4 NO (5


Systematic
Clear (use of visual aids like illustrations)
Complete

Standard: In the medical recording, the student wrote down relevant data clearly and
completely; line-drew physical finding data clearly; and wrote down the primary
and secondary clinical diagnosis.

Parameters for Advice on Clinical Diagnosis Evaluation 1 2 3 4 NO (5)


Wrote down relevant data clearly and systematically.
Wrote down relevant data completely.
Line-drew physical finding data clearly.
Wrote down both primary and secondary clinical diagnoses. YES NO

2/2 pages
Clinical Diagnosis of Patients with an Abdominal Disorder
Case Presentation and Discussion Up to Clinical Diagnosis Only

Format and Evaluation


Format
Case Presentation and Discussion (Up to Clinical Diagnosis Only)
on a Patient with a
(Chief Complaint, ex. Abdominal Mass, Abdominal Pain, Jaundice)
(Name of Student)

I. Case Presentation
Present Database
General Data
Minimum: Initials of patient, age, sex
As needed: Occupation, residence, religion
Chief Complaint
History of Present Illness/Condition
As needed:
Past Medical History
Personal Social History
Obstetrical and Gynecological History
Physical Examination

II. Case Discussion Up to Clinical Diagnosis Only

1. Identify data from database which can serve as cues for a clinical diagnosis.
Age/Sex
Symptoms
Signs
2. Based on pattern recognition and prevalence, decide on the primary and
secondary diagnoses. Primary diagnosis is what you think is the most likely
diagnosis and secondary diagnosis is the closest second.
Primary Clinical Diagnosis:
Secondary Clinical Diagnosis:
3. Illustrate/explain how you arrive to the primary and secondary clinical
diagnoses.
Use the clinical diagnostic processes of pattern recognition and prevalence.
Use algorithm as much as possible.
Use pathophysiology to support your primary and secondary clinical
diagnoses.

III. References Used in Discussion of Pathophysiology, Clinical Cues, and Algorithm (at least 2
references)
Evaluation:
Evaluation Parameters 1 (excellent) 2 (good) 3 (fair) 4 (poor)
need to revise
1. Concise in use of pattern recognition
and prevalence processes
2. Clear in written communication and legible
Final Grade: Average of 1 and 2
Complete (3 parts, follow format, with REVISED IF INCOMPLETE
at least 2 references)
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 2

HYPOTHETICAL AND ACTUAL


PATIENT
MANAGEMENT
Clinical Diagnosis Of Patients With an Abdominal Disorder

Blueprint

I. Hypothetical Patient Management


Chief Complaints

1. Trauma
2. Pain (nontrauma)
3. Lump
4. Difficulty in eating
5. Vomiting
6. Difficulty in defecation
7. Diarrhea
8. Difficulty in urination
9. Polyuria
10. Abdominal Distention
11. Hematemesis
12. Hematochezia
13. Jaundice
14. Obesity
15. Loss of weight

(See Format on Discussion)

II. Actual Patient Management (with case presentation and discussion)


Mininum of 4 patients in the entire course
Priorities:

Trauma
Pain (nontraumatic cause)
Lump
Jaundice
Difficulty in Defecation

(See Format on Case Presentation and Discussion)

IIA1
Chief Complaints Clinical Entities

1. Trauma to the abdomen Penetrating trauma to the abdomen


Blunt or nonpenetrating trauma to the abdomen

2. Abdominal pain (nontraumatic cause) Acute abdomen / acute surgical abdomen


Acute appendicitis
Acute cholecystitis
Intestinal obstruction

3. Abdominal mass Organomegaly / mass


Hollow visceral mass (gastrointestinal)
Solid visceral mass (liver)

4. Difficulty in eating Esophageal cancer

5. Vomiting Intestinal obstruction

6. Difficulty in defecation Intestinal obstruction

7. Diarrhea Gastroenteritis

8. Difficulty in urination Urinary tract infection


Prostatic disorders
Stones

9. Polyuria Diabetes Mellitus

10. Abdominal Distention Intestinal obstruction


Ascites

11. Hematemesis Peptic ulcer


Esophageal varices

12. Hematochezia Hemorrhoids


Tumor
Arteriovenous malformation

13. Jaundice Biliary obstruction


Hepatitis

14. Obesity Overweight and obesity

15. Loss of weight Approaches to diagnosis

IIA2
Clinical Diagnosis Of Patients With an Abdominal Disorder

Triggers for Problem-based Learning Sessions


Trigger 1: Patient with an abdominal problem
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 2: Patient with trauma to the abdomen


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 2.1: Age/sex with trauma to the abdomen


Onset
Characteristics of trauma
Associated signs and symptoms
Previous medical consult

1. What is your primary and secondary clinical diagnoses?


Bases
2. Do you need other data?
3. Do medical recording

Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience

Trigger 3: Patient with nontraumatic abdominal pain


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

IIB1
Clinical Diagnosis Of Patients With an Abdominal Disorder

Triggers for Problem-based Learning Sessions


Trigger 3.1: Age/sex with nontraumatic abdominal pain
Onset
Characteristics of abdominal pain
Associated signs and symptoms
Previous medical consult

1. What is your primary and secondary clinical diagnoses?


Bases
2. Do you need other data?
3. Do medical recording

Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience

Trigger 4: Patient with an abdominal mass


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 4.1: Age/sex with an abdominal mass


Onset
Characteristics of mass
Associated signs and symptoms
Previous medical consult

1. What is your primary and secondary clinical diagnoses?


Bases
2. Do you need other data?
3. Do medical recording

Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience

IIB2
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 5: Patient with difficulty in eating
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 5.1: Age/sex with difficulty in eating


Onset
Characteristics of difficulty in eating
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the neck, chest, and abdomen
Actual patient experience

Trigger 6: Patient with vomiting


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 6.1: Age/sex with vomiting


Onset
Characteristics of vomiting
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the neck, chest, and abdomen
Actual patient experience
IIB3
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 7: Patient with difficulty in defecation
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 7.1: Age/sex with difficulty in defecation


Onset
Characteristics of difficulty in defecation
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and rectum
Actual patient experience

Trigger 8: Patient with diarrhea


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 8.1: Age/sex with diarrhea


Onset
Characteristics of diarrhea
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and rectum
Actual patient experience
IIB4
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 9: Patient with difficulty in urination
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 9.1: Age/sex with difficulty in urination


Onset
Characteristics of difficulty in urination
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and genitalia
Actual patient experience

Trigger 10: Patient with polyuria


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 10.1: Age/sex with polyuria


Onset
Characteristics of polyuria
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and genitalia
Actual patient experience
IIB5
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 11: Patient with abdominal distention
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 11.1: Age/sex with abdominal distention


Onset
Characteristics of abdominal distention
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and rectum
Actual patient experience

Trigger 12: Patient with hematemesis


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 12.1: Age/sex with hematemesis


Onset
Characteristics of hematemesis
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses?Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the oral cavity, neck, chest, and abdomen
Actual patient experience
IIB6
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 13: Patient with hematochezia
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 13.1: Age/sex with hematochezia


Onset
Characteristics of hematochezia
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen and rectum
Actual patient experience

Trigger 14: Patient with jaundice


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 13.1: Age/sex with jaundice


Onset
Characteristics of jaundice
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the sclerae and abdomen
Actual patient experience
IIB7
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 15: Patient with obesity
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 15.1: Age/sex with obesity


Onset
Characteristics of obesity
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the whole body
Actual patient experience

Trigger 16: Patient with loss of weight


1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.

Trigger 16.1: Age/sex with loss of weight


Onset
Characteristics of loss of weight
Associated signs and symptoms
Previous medical consult
1. What is your primary and secondary clinical diagnoses? Bases?
2. Do you need other data?
3. Do medical recording
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the whole body
Actual patient experience

IIB8
HYPOTHETICAL PATIENT MANAGEMENT

TRAUMA TO THE ABDOMEN

Trigger 1

Patient with complaint of Trauma to the Abdomen

Questions:

1. What is a Trauma to the Abdomen?

2. What are the possible causes of a Trauma to the Abdomen?

Organs/tissues involved General condition/disorder Specific condition/disease


(trauma)
___________________ __________________________ _____________________
___________________ __________________________ _____________________
___________________ __________________________ _____________________

3. What do you think are the more common/least common general and specific
condition causing Trauma to the Abdomen?

General condition/disorder Specific condition/disease


More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________

4. Select one common general or specific condition and diagram the pathophysiology
leading to the Trauma to the Abdomen.

IIC1
TRAUMA TO THE ABDOMEN
Trigger 2
Pertinent history
30 years old, male
Chief complaint: Trauma to the abdomen
3 hours ago, shot by a male assailant.
Physical examination:
Normal vital signs
A gunshot wound on the left periumbilical area
No other injuries

Questions:

1. What is your primary and secondary diagnosis?


Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________

2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis

3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]

TRAUMA TO THE ABDOMEN

Trigger 3
The diagnosis of the patients health problem is

Gunshot wound, abdomen, with perforation of small intestine


(jejunum and ileum), descending colon, and left kidney.

Questions:

Advice the patient and relatives on the pathophysiology of the disease. Use diagram.

IIC2
HYPOTHETICAL PATIENT MANAGEMENT

NONTRAUMATIC ABDOMINAL PAIN

Trigger 1

Patient with complaint of Nontraumatic Abdominal Pain

Questions:

1. What is a Nontraumatic Abdominal Pain?

2. What are the possible causes of a Nontraumatic Abdominal Pain?

Organs/tissues involved General condition/disorder Specific condition/disease

___________________ __________________________ _____________________


___________________ __________________________ _____________________
___________________ __________________________ _____________________

3. What do you think are the more common/least common general and specific
condition causing Nontraumatic Abdominal Pain?

General condition/disorder Specific condition/disease


More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________

4. Select one common general or specific condition and diagram the pathophysiology
leading to the Nontraumatic Abdominal Pain.

IID1
NONTRAUMATIC ABDOMINAL PAIN
Trigger 2
Pertinent history
30 years old, male
Chief complaint: Nontraumatic Abdominal Pain
12 hours ago, periumbilical pain. 4 hours after, pain localized at right lower
quadrant. No other associated symptoms.
Physical examination:
Normal vital signs
Abdomen: direct right lower quadrant tenderness with guarding, no mass

Questions:

1. What is your primary and secondary diagnosis?


Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________

2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis

3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]

NONTRAUMATIC ABDOMINAL PAIN

Trigger 3
The diagnosis of the patients health problem is

ACUTE APPENDICITIS

Questions:

Advice the patient and relatives on the pathophysiology of the disease. Use diagram.

IID2
ABDOMINAL MASS

Trigger 1

Patient with complaint of Abdominal Mass

Questions:

1. What is Abdominal Mass?

2. What are the possible causes of Abdominal Mass?

Organs/tissues involved General condition/disorder Specific condition/disease


(e.g. trauma, cancer, infection)

___________________ __________________________ _____________________


___________________ __________________________ _____________________
___________________ __________________________ _____________________

3. What do you think are the more common/least common general and specific
condition causing an abdominal mass?

General condition/disorder Specific condition/disease


More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________

4. Select one common general or specific condition and diagram the pathophysiology
leading to the abdominal mass.

IIE1
ABDOMINAL MASS

Trigger 2
Pertinent history
40 years old, female
Chief complaint: Abdominal mass
Noted 3 months ago
No associated symptoms

Physical examination:
Mass at epigastrium, 4 cm, nontender, movable, firm
No jaundice
No neck nodes
No associated distant mass

Questions:

1. What is your primary and secondary diagnosis?


Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________

2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis

3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]

ABDOMINAL MASS

Trigger 3
The diagnosis of the patients health problem is

COLONIC CANCER
Questions:

1. Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
2. Advice the patient and relatives on screening of the disease.
3. Advice the patient and relatives on early detection of the disease.

IIE2
HYPOTHETICAL PATIENT MANAGEMENT

JAUNDICE

Trigger 1

Patient with complaint of Jaundice

Questions:

1. What is Jaundice?

2. What are the possible causes of Jaundice?

Organs/tissues involved General condition/disorder Specific condition/disease


(e.g. trauma, cancer, infection)

___________________ __________________________ _____________________


___________________ __________________________ _____________________
___________________ __________________________ _____________________

3. What do you think are the more common/least common general and specific
condition causing a jaundice?

General condition/disorder Specific condition/disease


More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________

4. Select one common general or specific condition and diagram the pathophysiology
leading to the jaundice.

IIF1
HYPOTHETICAL PATIENT MANAGEMENT

JAUNDICE

Trigger 2
Pertinent history
40 years old, female
Chief complaint: Jaundice
Noted 3 months ago
No associated symptoms

Physical examination:
Jaundice
No tenderness or mass on the abdomen

Questions:

1. What is your primary and secondary diagnosis?


Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________

2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis

3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]

JAUNDICE

Trigger 3
The diagnosis of the patients health problem is

CHOLEDOCHOLITHIASIS CAUSING JAUNDICE

Questions:

1. Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
2. Advice the patient and relatives on screening of the disease.
3. Advice the patient and relatives on early detection of the disease.

IIF2
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 3

PROBLEM-BASED
LEARNING ISSUES
Problem-based Learning Issues

Instructions

Given hypothetical and actual patients, pretest questions and any kind of
ABDOMINAL DISORDER to solve, list down deficiencies and uncertainties in
competences as learning issues and decide on a specific learning plan. Use the form
below.

Trigger* Learning Issues Learning Plan**

*Hypothetical Patient Management (HPM)


Actual Patient Management (APM)
Pretest

**Reading - what and which books, journals


Asking - whom, where, when
Doing - what, where, when
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 4

LEARNING OBJECTIVES
Clinical Diagnosis of Patients with an Abdominal Disorder

General Learning Objectives (Terminal Competencies)

At the end of the course, given a patient with an abdominal disorder, the student should be able to:
1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).

2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.

3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.

4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.

5. Demonstrate skills in giving advice on clinical diagnosis.

Specific Learning Objectives (Enabling Competencies)

Given a hypothetical and/or actual patient with an abdominal disorder, the student must be able to:
1. Establish a good rapport.

2. Identify the main health problem.

3. Define the concept of the main health problem in terms of:

3.1 Anatomy of the system, organs, tissues, and cells involved


3.2 Physiology of the system, organs, tissues, and cells involved
3.3 Common types
3.4 Common causes
3.5 Pathophysiology of the more common causes

4. Identify reliable clinical cues of the more common causes of the health problem.

5. Gather relevant data using interview and fundamental methods of physical examination.

5.1 Interview to gather relevant data.


5.2 Perform indicated physical examination gently, completely and accurately.

6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.

7. Do medical recording.

7.1 Write down relevant data clearly and completely.


7.2 Line-draw physical finding data clearly and completely.
7.3 Write down primary and secondary clinical diagnoses.

8. Advice on clinical diagnosis.


IV1
Clinical Diagnosis on Patients with
Trauma
Pain (nontrauma)
Lump
Difficulty in eating
Vomiting
Difficulty in defecation
Diarrhea
Difficulty in urination
Polyuria
Abdominal Distention
Hematemesis
Hematochezia
Jaundice
Obesity
Loss of weight

General Learning Objectives (Terminal Competencies)

At the end of the course, given a patient with


Trauma
Pain (nontrauma)
Lump
Difficulty in eating
Vomiting
Difficulty in defecation
Diarrhea
Difficulty in urination
Polyuria
Abdominal Distention
Hematemesis
Hematochezia
Jaundice
Obesity
Loss of weight
the student should be able to:

1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).

2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.

3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.

4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.

5. Demonstrate skills in giving advice on clinical diagnosis.

IV2
Specific Learning Objectives (Enabling Competencies)

Given a hypothetical and/or actual patient with


Trauma
Pain (nontrauma)
Lump
Difficulty in eating
Vomiting
Difficulty in defecation
Diarrhea
Difficulty in urination
Polyuria
Abdominal Distention
Hematemesis
Hematochezia
Jaundice
Obesity
Loss of weight

the student must be able to:

1. Establish a good rapport.

2. Identify the main health problem.

3. Define the concept of the main health problem in terms of:

3.1 Anatomy of the system, organs, tissues, and cells involved


3.2 Physiology of the system, organs, tissues, and cells involved
3.3 Common types
3.4 Common causes
3.5 Pathophysiology of the more common causes

4. Identify reliable clinical cues of the more common causes of the health problem.

5. Gather relevant data using interview and fundamental methods of physical examination.

5.1 Interview to gather relevant data.


5.2 Perform indicated physical examination gently, completely and accurately.

6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.

7. Do medical recording.

7.1 Write down relevant data clearly and completely.


7.2 Line-draw physical finding data clearly and completely.
7.3 Write down primary and secondary clinical diagnoses.

8. Advice on clinical diagnosis.

IV3
Physical Examination of the Abdomen

Learning Objectives:

1. State the goal of physical examination of the abdomen.

2. Enumerate the two situations or purposes where physical examination of the abdomen is
being done.

3. State the expected result of a physical examination of the abdomen.

4. Differentiate physical diagnosis from clinical diagnosis.

5. Describe the basic physical diagnostic process.

6. Enumerate the core areas that should be included in screening physical examination of the
abdomen.

7. Enumerate the two most common methods of physical examination of the abdomen.

8. Gather essential data from an inspection of the abdomen.

9. Gather essential data from a palpation of the abdomen.

10. State the basic parameters for a quality inspection and palpation of the abdomen.

11. Make a written record of findings of a physical examination of the abdomen.


Line drawing of head and neck, whole or involved areas
Illustrate findings with description and explanation

12. Process data derived from physical examination of the abdomen to come out with a
physical diagnosis.

IV4
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 5

LEARNING RESOURCES
MATERIALS AND
REFERENCES
Clinical Diagnosis of Patients with an Abdominal Disorder

Recommended Reading Materials

Textbooks of

Anatomy

Physiology

Pathology

Physical Diagnosis

Internal Medicine

Pediatrics

General Surgery

Gastroenterology

Journal articles on Abdominal Disorders

R.O. Josons Writings


Approach to Patients with an Abdominal Problem
Approach to Patients with Abdominal Trauma
Approach to Patients with Acute Nontraumatic Abdomen
Approach to Patients with Nonacute Abdomen
Management of Patients with Peritoneal Irritation
Management of Patients with Hollow Visceral Obstruction
Management of Patients with Gastrointestinal Bleeding
Principles of Abdominal Surgical Oncology
Physical Examination of the Abdomen
Learning Objectives on Physical Examination of the Abdomen

Pictorials and Multimedia Learning Materials

Actual Patients with an Abdominal Disorder

Abdominal Disorder Specialists


Physical Examination of the Abdomen

Learning Objectives:

1. State the goal of physical examination of the abdomen.


diagnosis
2. Enumerate the two situations or purposes where physical examination of the abdomen is
being done.
for screening in those without abdominal symptoms
for evaluation of abdominal symptoms
3. State the expected result of a physical examination of the abdomen.
physical diagnosis of the abdomen
4. Differentiate physical diagnosis from clinical diagnosis.
physical examination data or findings - physical diagnosis
physical exam + history data or findings - clinical diagnosis
5. Describe the basic physical diagnostic process.
Search for anything unusual in structure and function
Usual - normal
Unusual - decide whether normal variant or abnormal
In general, unusual asymptomatic - normal
unusual symptomatic - abnormal
6. Enumerate the core areas that should be included in screening physical examination of the
abdomen.
Abdomen
Conjunctivae
Sclerae
Neck for nodes
Rectum as indicated
7. Enumerate the two most common methods of physical examination of the abdomen.
Inspection
Palpation
8. Gather essential data from an inspection of the abdomen.
With eyes, look for anything unusual in structure
Structure
Discoloration
Defects seen on the surface
Wounds
Discontinuity
Deformity
Bulge
9. Gather essential data from a palpation of the abdomen.
With hands, feel for anything unusual in structure and function
Structure Function
Lumps Tenderness
Unusual pulsation
10. State the basic parameters for a quality inspection and palpation of the abdomen.
Inspection Palpation
Complete / /
Accurate interpretation of findings / /
Gentle /

1/2 pages
11. Make a written record of findings of a physical examination of the abdomen.
Line drawing of abdomen, whole or involved areas
Illustrate findings with description and explanation

12. Process data derived from physical examination of the abdomen to come out with a
physical diagnosis.
Data from physical examination
|
Usual -Unusual
Nothing unusual - normal
Unusual - normal variant
Unusual - abnormal
|
Diagnostic Label
Name of disorder,
involved area, organ, or tissue
Descriptive label of unsual finding,
if name of disorder is not known,
involved area, organ, or tissue

2/2 pages
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER

FOLDER 6

EVALUATION
Clinical Diagnosis on Patients with an Abdominal Disorder
Comprehensive Exam
(Pretest/Posttest)

Content Blueprint

Content

The normal abdomen


Abdominal disorders

Breakdown

Anatomy
Physiology
Pathology
Microbiology
Clinical Diagnosis
Epidemiology and Miscellany
Written Examination

Instructions:

1. Use BLACK or BLUE ballpoint for your final answers.

2. Place your answers on the answer sheets provided.


Shade the appropriate circle under each number.
There must only be ONE shaded circle as your answer.

3. For those questions with lettered options (A, B, C, D, E),


choose ONE best answer.

4. For those questions with numbered options (1, 2, 3, 4),


answer as follows:

A - if only nos. 1, 2, and 3 options are correct


B - if only nos. 1 and 3 options are correct
C - if only nos. 2 and 4 options are correct
D - if only no. 4 option is correct
E - if all options are correct

5. For matching-type questions,


an option may be used MORE THAN ONCE.
Student ID: ________________________________ Score: __________________

Subject: Clinical Diagnosis of Abdominal Disorders


A B C D E A B C D E
1. O O O O O 26. O O O O O
2. O O O O O 27. O O O O O
3. O O O O O 28. O O O O O
4. O O O O O 29. O O O O O
5. O O O O O 30. O O O O O

A B C D E A B C D E
6. O O O O O 31. O O O O O
7. O O O O O 32. O O O O O
8. O O O O O 33. O O O O O
9. O O O O O 34. O O O O O
10. O O O O O 35. O O O O O

A B C D E A B C D E
11. O O O O O 36. O O O O O
12. O O O O O 37. O O O O O
13. O O O O O 38. O O O O O
14. O O O O O 39. O O O O O
15. O O O O O 40. O O O O O

A B C D E A B C D E
16. O O O O O 41. O O O O O
17. O O O O O 42. O O O O O
18. O O O O O 43. O O O O O
19. O O O O O 44. O O O O O
20. O O O O O 45. O O O O O

A B C D E A B C D E
21. O O O O O 46. O O O O O
22. O O O O O 47. O O O O O
23. O O O O O 48. O O O O O
24. O O O O O 49. O O O O O
25. O O O O O 50. O O O O O
Student ID: ________________________________ Score: __________________

Subject: Clinical Diagnosis of Abdominal Disorders


A B C D E A B C D E
51. O O O O O 76. O O O O O
52. O O O O O 77. O O O O O
53. O O O O O 78. O O O O O
54. O O O O O 79. O O O O O
55. O O O O O 80. O O O O O

A B C D E A B C D E
56. O O O O O 81. O O O O O
57. O O O O O 82. O O O O O
58. O O O O O 83. O O O O O
59. O O O O O 84. O O O O O
60. O O O O O 85. O O O O O

A B C D E A B C D E
61. O O O O O 86. O O O O O
62. O O O O O 87. O O O O O
63. O O O O O 88. O O O O O
64. O O O O O 89. O O O O O
65. O O O O O 90. O O O O O

A B C D E A B C D E
66. O O O O O 91. O O O O O
67. O O O O O 92. O O O O O
68. O O O O O 93. O O O O O
69. O O O O O 94. O O O O O
70. O O O O O 95. O O O O O

A B C D E A B C D E
71. O O O O O 96. O O O O O
72. O O O O O 97. O O O O O
73. O O O O O 98. O O O O O
74. O O O O O 99. O O O O O
75. O O O O O 100. O O O O O

Student ID: ________________________________ Score: __________________


Subject: Clinical Diagnosis of Abdominal Disorders

A B C D E A B C D E
101. O O O O O 126. O O O O O
102. O O O O O 127. O O O O O
103. O O O O O 128. O O O O O
104. O O O O O 129. O O O O O
105. O O O O O 130. O O O O O

A B C D E A B C D E
106. O O O O O 131. O O O O O
107. O O O O O 132. O O O O O
108. O O O O O 133. O O O O O
109. O O O O O 134. O O O O O
110. O O O O O 135. O O O O O

A B C D E A B C D E
111. O O O O O 136. O O O O O
112. O O O O O 137. O O O O O
113. O O O O O 138. O O O O O
114. O O O O O 139. O O O O O
115. O O O O O 140. O O O O O

A B C D E A B C D E
116. O O O O O 141. O O O O O
117. O O O O O 142. O O O O O
118. O O O O O 143. O O O O O
119. O O O O O 144. O O O O O
120. O O O O O 145. O O O O O

A B C D E A B C D E
121. O O O O O 146. O O O O O
122. O O O O O 147. O O O O O
123. O O O O O 148. O O O O O
124. O O O O O 149. O O O O O
125. O O O O O 150. O O O O O
Student ID: ________________________________ Score: __________________
Subject: Clinical Diagnosis of Abdominal Disorders
A B C D E A B C D E
151. O O O O O 176. O O O O O
152. O O O O O 177. O O O O O
153. O O O O O 178. O O O O O
154. O O O O O 179. O O O O O
155. O O O O O 180. O O O O O

A B C D E A B C D E
156. O O O O O 181. O O O O O
157. O O O O O 182. O O O O O
158. O O O O O 183. O O O O O
159. O O O O O 184. O O O O O
160. O O O O O 185. O O O O O

A B C D E A B C D E
161. O O O O O 186. O O O O O
162. O O O O O 187. O O O O O
163. O O O O O 188. O O O O O
164. O O O O O 189. O O O O O
165. O O O O O 190. O O O O O

A B C D E A B C D E
166. O O O O O 191. O O O O O
167. O O O O O 192. O O O O O
168. O O O O O 193. O O O O O
169. O O O O O 194. O O O O O
170. O O O O O 195. O O O O O

A B C D E A B C D E
171. O O O O O 196. O O O O O
172. O O O O O 197. O O O O O
173. O O O O O 198. O O O O O
174. O O O O O 199. O O O O O
175. O O O O O 200. O O O O O
AN APPROACH TO PATIENTS WITH AN ABDOMINAL PROBLEM

Reynaldo O. Joson, MD, DPBS


1989;2000

A student of medicine will encounter the phrase "acute abdomen" in his readings and in conferences.
"Acute abdomen" is a phrase that is very commonly used in medicine. Inspite of its common usage,
there exists confusion as to what the phrase actually means and as to how it should be used. The main
reason for this confusion is the absence of a universally accepted definition.

Dorland's Illustrated Medical Dictionary (1981) defines acute abdomen as an abdominal condition of
abrupt onset, usually associated with abdominal pain due to inflammation, perforation, obstruction,
infarction, or rupture of intraabdominal organs. Emergency surgical intervention is usually required. It is
also called surgical abdomen.

Others define it as an abdominal condition of abrupt onset wherein prompt and immediate diagnosis is
required so that an appropriate early treatment may be instituted.

Still others define it as an abdominal condition if left undiagnosed and untreated can lead to a
catastrophy.

With such a variety of definitions comes a variety of interpretations and usages. Some physicians use
the phrase to mean an acute surgical abdomen. Some think that not all cases of acute abdomen end up
with surgery. In other words, some acute abdomen may be nonsurgical.

Some physicians use the phrase just to stress the urgency of treatment of the abdominal condition, such
as an immediate operation.

Some physicians use it to mean only those presenting with acute severe abdominal pain. Some use it
to include other abdominal manifestations beside pain, such as gastrointestinal bleeding, distention, and
vomiting. Some physicians confine it to nontraumatic abdomen whereas some extend it to traumatic
abdomen.

With such a variety of interpretations and usages, misunderstanding and confusion tend to ensue,
especially when it is used as an assessment label in a patient with an abdominal problem. The phrase
"acute abdomen" should only be used as a label for a book or for a symposium in which all kinds of
acute abdominal problems will be discussed. It should not be used as an assessment label for a particular
patient. A more specific and more informative assessment label should be used, such as acute surgical
abdomen, or simply, surgical abdomen; acute nonsurgical abdomen or simply, nonsurgical abdomen;
nontraumatic nonsurgical abdomen; nontraumatic surgical abdomen; traumatic nonsurgical abdomen; or
traumatic surgical abdomen, whichever is applicable.

All patients with an abdominal problem, whatever its clinical presentation, no matter how mild or
severe it is, no matter how sudden or insidious it is, are potential candidates for having a surgical
abdomen. An abdominal problem may be an abdominal pain or tenderness; an abdominal distention;
vomiting; diarrhea; constipation; bleeding; jaundice; mass; or any symptoms and signs referable to the
abdomen or which are considered manifestations of abdominal disorders. In the evaluation of
patients with an abdominal problem, the most important question to answer is whether a surgical abdomen
is present or not.

There are two types of diagnosis that a physician can make after evaluation of a patient with an
abdominal problem. These are, namely: 1) diagnosis of surgical abdomen or nonsurgical abdomen and
2) diagnosis of a specific abdominal disorder, such as acute appendicitis and acute cholecystitis.
Although it is a good practice to make a diagnosis of a specific abdominal disorder, realistically
speaking, more often than not, it is difficult. At times, it is impossible to get to a specific diagnosis. If
one will always go for a specific diagnosis, one may unnecessarily be consuming a lot of time,
effort, and money that the whole process may turn out not to be practical and cost-effective. Sometimes,
it may be detrimental.

If one cannot get to a specific diagnosis of an abdominal disorder with history, physical examination, and
some diagnostic procedures, then, it is sufficient to just decide whether a surgical abdomen is present
or not. A surgical abdomen is one that needs an operation. With a diagnosis of a surgical abdomen,
the physician can proceed right away to the next step in the management, which is surgery. The
operation not only provides treatment for the surgical disorder that may be present, it also provides
specific diagnosis of the abdominal disorder on operation. If the diagnosis, however, is a nonsurgical
abdomen, then the physician can institute nonsurgical forms of management.

Initial evaluation of any abdominal problem relies on history and physical examination. Subsequent
and further evaluation may consist of additional interview, repeat examinations, and diagnostic
procedures. Active observation, especially with serial monitoring of the abdomen, also forms part
of the subsequent evaluation. In fact, it is the most important among all the diagnostic tools. For serial
monitoring of the abdomen to be useful and reliable, it must be accurate and it must be done by the
same examiner at closed intervals.

In examining the abdomen, the physician must look for any abnormalities that may be present and which
may give clue to a diagnosis of the abdominal disorder.

Laboratory examinations and diagnostic procedures should be done only when indicated and not for
reasons of routine. They should be selected rationally. For example, one should not order for an
abdominal X-ray simply because one is dealing with an abdominal problem. A plain abdominal x-ray
is often not informative if ordered on the above basis.

If one is suspecting intestinal obstruction, it is enough to order for a supine abdominal x-ray. An upright
abdominal x-ray is not necessary.

In the evaluation of patients for possible acute appendicitis, complete blood count (CBC) and urinalysis
should not be routinely ordered. In fact, they are not necessary in ruling in or ruling out acute
appendicitis.

"When in doubt, operate" is a commonly heard saying. In fact, it has become a teaching and it has
frequently been used as a justification for operation. This saying should be qualified because it is
dangerous and it can be abused. As it is, it has led to a significant number of unnecessary operations.
The saying should be changed to "When in doubt, do not operate. Continue to observe and monitor
very closely. Operate only when surgical abdomen is strongly suspected. Let conscience and 'if I
were the patient' be the guide in the decision-making on whether to operate or not".

A surgical abdomen is one that needs an exploratory laparotomy procedure. An evaluation of surgical
abdomen is made based primarily on signs of surgical abdomen and secondarily on a diagnosis of a
specific surgical abdominal disease.

The signs of surgical abdomen consist of the following:

1. Signs of peritoneal irritation.


2. Signs of mechanical gastrointestinal obstruction.
3. Signs of biliary tract obstruction.
4. Signs of perforation.
5. Signs of intraabdominal bleeding.
6. Signs of intraabdominal abscess.
7. Signs of intraabdominal mass.
8. Evisceration.

Once a surgical abdomen is diagnosed, the next things to decide are:

1. The timing of the operation, whether immediately or as soon as possible.


2. The operative risk.
3. The preparations for surgery.

The timing of the operation can either be now or as soon as possible. Surgery is done right away in those
cases suspected of having bleeding actively going on, which if not controlled will soon lead to shock and
subsequent death. For other cases, the timing of surgery is done on an as soon as possible basis, that
means, as soon as all necessary preparations for surgery are through and without undue and
unnecessary delay due to whatever reason. As soon as possible may be within one hour, within 4 to
6 hours, or longer, depending on the situation.

In general, the timing of operation is such that an operation is done on a stat basis for active bleeding
that is life-threatening and on an as soon as possible basis for peritonitis, obstruction, abscess, and
intraabdominal mass.

Operations for peritonitis and obstruction are done sooner than those for abscess and intraabdominal mass.

The general preparations for patients with surgical abdomen consist of the following:

1) NPO (nothing per os);


2) Hydration;
3) Restoration of electrolyte loss, if present;
4) Preoperative laboratory examinations that will be needed;
5) Preoperative medications that are needed such as analgesics and antibiotics; and
6) Preoperative preparatory procedures as indicated such as insertion of nasogastric tube and cleansing
enema.

In summary, the approach to the management of patients with an abdominal problem consists essentially
and initially of evaluation to determine whether a surgical abdomen is present or not. If a surgical
abdomen is present, the patient is prepared for an operation. If a nonsurgical abdomen is decided upon,
the patient is managed accordingly. In equivocal cases, laboratory examinations, diagnostic procedures,
and closed monitoring are utilized as indicated.
APPROACH TO PATIENTS WITH AN ABDOMINAL TRAUMA

Reynaldo O. Joson, MD, DPBS


1991;2000

An overview of the management approach to patients with an abdominal trauma is shown in the diagram
below:

PATIENT WITH AN ABDOMINAL TRAUMA

EVALUATION

INITIAL TREATMENT

NONSURGICAL ABDOMEN SURGICAL ABDOMEN

INITIAL TREATMENT

NO EXPLOR LAP EXPLOR LAP


MONITOR DIAGNOSTIC
THERAPEUTIC
CONTROL BLEEDING
CONTROL SOILAGE
DEBRIDE
REPAIR
CLEAN

POSTOP CARE

An abdominal trauma is said to be present if an injury is inflicted on the abdominal torso with
possible or actual afflictions of the peritoneal and retroperitoneal organs. The peritoneal and
retroperitoneal organs may also be injured with the point of entry or point of initial impact being away
from the abdominal torso. Examples are impalement through the anus and missile injuries entering
through the shoulder reaching the peritoneal cavity. Such cases are also considered abdominal
trauma.

An abdominal trauma is usually caused by either blunt or penetrating injury. Blunt abdominal trauma
are usually those associated with vehicular accidents, falls, and punches. Penetrating abdominal
trauma are usually those caused by stab wounds, missile injuries, and hacking wounds.
The first step in the management approach of patients with abdominal trauma is evaluation. There are
several things to emphasize regarding evaluation.

The evaluation should be fast. Patients with abdominal trauma may be at any of the following stages
when first seen by a surgeon:

1. Patient is in cardiopulmonary standstill.


2. Patient is in hypovolemic shock.
3. Patient has peritonitis.
4. Patient may develop hypovolemic shock or generalized peritonitis.
5. Patient may not develop hypovolemic shock or peritonitis.

The first four situations require a fast evaluation to ensure a well-timed treatment. The last situation
also demands a fast evaluation in order to check its presence and to make sure that the other four
situations are not present.

The results of the evaluation should be concise and complete so that proper (accurate and adequate)
treatment may be instituted.

There is such a thing as initial evaluation and subsequent (including repeat or repeated) evaluation.
These contribute to the making of a fast, concise, and complete evaluation.

The diagnostic tools consist of interview, physical examination, laboratory examinations, diagnostic
procedures, and monitoring. These are done as indicated and as available.

The initial evaluation relies on physical examination with or without interview, depending on the latter's
availability. The most important question to answer when evaluating a traumatized abdomen is
whether a surgical abdomen is present or not. By surgical abdomen is meant an abdomen needing an
exploratory laparotomy. The following are the more common signs of surgical abdomen:

1. Signs of peritoneal irritation (definite, persistent, and increasing direct tenderness with or without
muscle guarding)
2. Penetrating missile injuries
3. Hypotension with blood loss as a suspect
4. Frank bleeding from the peritoneal cavity or from the gastrointestinal tract
5. Evisceration

Subsequent evaluation may consist of more interview, repeat physical examinations, some laboratory
examinations, some diagnostic procedures, and close monitoring. The subsequent evaluation is done
to make more certain and more complete the initial assessment. Below are some pointers in the evaluation.

Serial monitoring of the abdomen by palpation must be done by the same examiner and at close intervals.

X-ray examinations are done only when indicated, tolerable, and when they do not cause undue delay in
treatment.

A chest x-ray upright is the appropriate view to look for pneumoperitoneum. Anteroposterior-lateral
supine plain abdominal x-rays are used to evaluate patients with penetrating foreign bodies, such as
bullets and darts.

The serum amylase may be evaluated in patients suspected to have isolated pancreatic injuries.

Probing of a stab wound may be done aseptically when feasible to check for transgression of the
peritoneal lining. Ice-pick stab wounds cannot and should not be probed.
A nasogastric tube may be inserted to check for gastrointestinal bleeding. A urinary bladder
catheterization may be done to check for bleeding in the excretory system.

A peritoneal tap or a peritoneal lavage may be done in unconscious patients with a history of blunt
trauma and suspected of having intraperitoneal bleeding or rupture of viscus.

As mentioned, the most important question that a surgeon has to decide when evaluating a traumatized
abdomen is whether a surgical abdomen is present or not. If the evaluation is that the patient has no
or equivocal surgical abdomen, then no exploratory laparotomy is instituted. Monitoring should be
continued until such a time that the patient is finally cleared of a surgical abdomen.

If the evaluation is that the patient has a surgical abdomen, then the patient is prepared for exploratory
laparotomy. Preparations include the following as indicated:

1. Initial resuscitative measures.


2. Nothing by mouth.
3. Preparatory medications, such as antibiotics and antitetanus.
4. Preparatory procedures such as nasogastric tube and urethral catheter insertion, extraction of blood for
typing and cross-matching, insertion of intravenous lines, etc.

The timing of operation for patients with traumatic surgical abdomen is usually on a "right away" basis.
In patients with hypovolemic shock secondary to blood loss, the operation should be considered part of
the resuscitative measures and should be done right away even without waiting for the blood to arrive.

The exploratory laparotomy is done under general anesthesia usually using a liberal vertical midline
incision. Just like the preoperative evaluation, the intraoperative evaluation or exploration should also
be fast, concise, and complete. There is also such a thing as initial and subsequent evaluation.

For whatever injuries that may be seen on exploration, the topmost priority in terms of treatment is to
control bleeding. The second priority is to control soilage of the peritoneal cavity from perforated and
leaking hollow viscera.

In patients with abdominal trauma, all the intraperitoneal and the retroperitoneal organs may be
injured in varying combinations and severity. Essentially, the injuries consist of contamination, necrosis,
bleeding, rupture of organs, and soilage of the peritoneal cavity and retroperitoneal area. With such
kinds of injuries that may occur in abdominal trauma, treatment, therefore, can be categorized into five
general procedures. These are, namely: 1) control of bleeding; 2) control of soilage; 3) debridement; 4)
repair; and 5) cleansing or lavage.

Bleeding can be controlled by various techniques or methods such as ligation, hemostatic suturing, repair
of vascular tear, excision of bleeding organs, compression and packing.

Soilage can be controlled also by various techniques or methods, such as repair of ruptured hollow
viscera, resection-anastomosis, excision, and exteriorization.

After exploration, the specific types of surgical procedures that will be performed by the surgeon will be
dependent on a lot of factors, among which are the type of organs injured, the nature and severity of
the injuries in a particular organ, the general condition of the peritoneal cavity, the overall condition
of the patient, the availability of blood, and the surgeon's preference and decision-making. Whatever
will be the surgeon's decision as to the type of intraoperative treatment to be instituted, the ultimate
aims are to control bleeding successfully, to control peritoneal and retroperitoneal soilage
adequately, to repair properly, and to avoid intraoperative and postoperative morbidity and mortality.

Below are some pointers on the use of drains, controlling bleeding, and antibiotics.
Regarding the use of peritoneal and retroperitoneal drains, either Penrose, sump or tube drains may be
used. The two most important things to remember regarding a drain are that, one, if placed, it should
serve a purpose and two, it should serve its purpose adequately. For Penrose drains, the exit wound on
the abdominal wall should be big enough to allow free drainage.

Regarding intraoperative bleeding, the surgeon should control profused bleeders as soon as possible
and as skillfully as possible. The patient should not be allowed to bleed to death. Compression,
packing, or clamping should be used as necessary to control bleeding while waiting for blood to arrive,
while trying to place proximal and distal vascular controls, or while deciding on a maneuver that will
completely stop the bleeding.

Lastly, to prevent infection within the abdomen and on the abdominal wound, reliance should be placed
more on the surgical techniques of debridement, copious lavage, and drainage than on antibiotics. The
antibiotics that may be given are the broad spectrum ones that can cover for gram-positive, gram-negative,
and anaerobic organisms.
APPROACH TO PATIENTS WITH ACUTE NONTRAUMATIC ABDOMEN

Reynaldo O. Joson, MD, DPBS


1991;2000

A nontraumatic abdomen is an abdomen with disorders that are not due to trauma. A
nontraumatic abdominal problem may be any symptom or sign experienced by the patient himself or
sign observed by an onlooker (relative, friend, or physician) on a patient that is referable to the abdomen.
Examples of symptoms that may be manifestations of an abdominal disorder are abdominal pain,
discomfort, feeling of bloatedness, and nausea. Examples of signs that may be manifestations of an
abdominal disorder are vomiting, distention, tenderness, jaundice, obstipation, diarrhea,
hematemesis, and hematochezia.

The word "acute" as an adjective describing the nontraumatic abdomen will be used here from the
point of view of the patients. Whatever be the nature of the abdominal complaint of the patients, whatever
be the severity or the duration, if the patients think it is acute, then it is acute.

The word "acute" has various meanings, usages, and interpretations. For practical purposes,
the physician should just accept whatever be the interpretations of the patients and then decide whether
there is an acute nontraumatic surgical abdomen or not. After this decision, he then manages the patient
accordingly.

The first step in the management approach of patients with acute nontraumatic abdomen is
evaluation.

The diagnostic tools that are and may be used in the evaluation consist of interview, physical
examination, laboratory examinations, diagnostic procedures, and monitoring. These are done as
indicated and as available.

Initial evaluation of any nontraumatic abdominal problem relies on interview and physical
examination. Interview is done on conscious, communicable, and coherent patients to get clue as
to the nature of the abdominal problem. For unconscious, uncommunicable, and incoherent patients,
interview may be done with the relatives and watchers.

The physical examination is done also to get clue as to the nature of the abdominal problem as
well as to clarify, confirm, or dispel suspicions derived during the interview.

In examining the abdomen, the physician looks for any abnormalities that may be present.
Specifically, he looks for abdominal distention; palpates for guarding, rigidity, direct tenderness,
abnormal mass, and organomegaly; and auscultates for frequency of bowel sounds.

It is important to emphasize that there should be repeated physical examinations of the abdomen.
There should be at least two, with significant intervals in between. Another point to emphasize is that
the repeated examinations must be done by the same physician and this goes without saying that the
physician must be well-versed and accurate in his examination of the abdomen.

Laboratory examinations and diagnostic procedures should be done only when indicated and not
for reasons of routine. They should be selected rationally and on a cost-effective basis.

For example, one should not order for an abdominal X-ray simply because one is dealing with
an abdominal problem. A plain abdominal X-ray is often not informative if ordered on the above
basis.
If one is suspecting intestinal obstruction, it is enough to order for a supine abdominal X-ray. An
upright abdominal X-ray is not necessary as it does not add significant information on top of the physical
findings and plain supine abdominal X-ray.

If one wants to look for pneumoperitoneum, one orders for an upright chest X-ray and not an
upright abdominal X-ray. Pneumoperitoneum is best seen on an upright chest X-ray.

In the evaluation of patients with possible acute appendicitis, complete blood count (CBC) and
urinalysis should not be routinely ordered. In fact, they are not necessary in ruling in or ruling out acute
appendicitis.

Monitoring is another diagnostic tool and it includes additional interview, repeated physical
examinations, and serial laboratory examinations. Monitoring is important because it tends to get
information and valuable and accurate information at that, when one diagnostic tool and one doing are
unable to produce.

There are two types of diagnosis that a physician can make after evaluation of a patient with
an acute nontraumatic abdominal problem. These are, namely: 1) diagnosis of surgical abdomen or
nonsurgical abdomen and 2) diagnosis of a specific abdominal disorder, such as acute appendicitis
and acute cholecystitis.

Although it is a good practice to make a diagnosis of a specific abdominal disorder,


realistically speaking, more often than not, it is difficult. At times, it is impossible to get to a specific
diagnosis. If one will always go for a specific diagnosis, one may unnecessarily be consuming a lot of
time, effort, and money that the whole process may turn out not to be practical and cost-effective.
Sometimes, it may be detrimental.

If one cannot get to a specific diagnosis of an abdominal disorder with history, physical
examination, and some diagnostic procedures, then, it is sufficient to just decide whether a surgical
abdomen is present or not. A surgical abdomen is one that needs an exploratory laparotomy. With a
diagnosis of a surgical abdomen, the physician can proceed right away to the next step in the
management, which is surgery. The operation not only provides treatment for the surgical disorder that
may be present, it also provides a specific diagnosis of the abdominal disorder on exploratory
laparotomy. If the diagnosis, however, is a nonsurgical abdomen, then the physician can institute more
diagnostic work-ups, if needed, and nonsurgical forms of treatment.

Acute nontraumatic abdominal disorders that are surgical or potentially surgical in nature can be
classified as follows: (Note: This is only a practical classification.)

I. Presenting with peritoneal irritation


A. Inflammatory bowels
1. Appendicitis
2. Diverticulitis
3. Necrotizing enterocolitis
B. Perforated bowels
1. Perforated peptic ulcer
2. Perforated typhoid ileitis
C. Cholecystitis
D. Pancreatitis
E. Intraabdominal abscess
II. Presenting with hollow visceral obstruction
A. Gastrointestinal tract obstruction
B. Biliary tract obstruction
C. Ureteral and urinary bladder obstruction
III. Presenting with bleeding
A. Gastrointestinal tract bleeding
B. Intraperitoneal bleeding
1. Ruptured aortic aneurysm
2. Ruptured ectopic pregnancy

Once a surgical abdomen is diagnosed, the next things to decide are:


1. The operative risk
2. The timing of the operation
3. The preparation for surgery

For one reason or another, a patient may be a poor operative risk. The surgeon has to decide what
to do with this problem of poor operative risk. It should not be that simply because the patient is a poor
operative risk that the surgeon decides against operating when an operation is really needed. The surgeon
should face the challenge and should as much as possible come up with a live patient after the operation.
He can achieve this by properly deciding on the timing of the operation, properly preparing the
patient for the operation, and properly performing the operation. He should not hesitate to call in
colleagues and other subspecialists to help. If possible, he should try to improve the operative risk
before operating. He should not forget to inform the patient and his relatives of the risks involved..

The timing of the operation for patients with acute nontraumatic surgical abdomen can be
either now or as soon as possible. Surgery is done right away in those cases suspected of having active
bleeding, which if not controlled will soon lead to shock and subsequent death. For other cases, the
timing of surgery is done on an as soon as possible basis, that means, as soon as all necessary
preparations for surgery are through and without undue and unnecessary delay due to whatever reason.
As soon as possible may be within one hour, within 4 to 6 hours, or longer, depending on the situation.

In general, the timing of operation is such that an operation is done on a stat basis for active
bleeding that is life-threatening and on as soon as possible basis for peritonitis, obstruction, and
abscess. Operations for peritonitis and obstruction are done sooner than those for abscess.

The general preparations for patients with acute nontraumatic surgical abdomen consist of
the following:
l. No oral intake
2. Hydration, if dehydrated
3. Replacement of electrolyte losses, if present
4. Preoperative laboratory examinations, as indicated
5. Preoperative medications, as indicated
5.1 Analgesics
5.2 Antibiotics
5.3 Drugs for co-existing medical problems
5.4 Supportive drugs
5.5 Drugs prescribed by the anesthesiologists
6. Preoperative preparatoty procedures, as indicated, such as insertion of nasogastric tube and
urinary catheter

All patients with acute nontraumatic surgical abdomen are scheduled for an initial exploratory
laparotomy. Exploratory laparotomy simply means the peritoneal cavity is opened and the inside of the
cavity is explored and examined.

Any type of incision can be used for an exploratory laparotomy. The incision may be
vertical, transverse, or oblique. The incision may be at the midline, at the paramedian, at the subcostal
area, below or above the umbilicus, or at any quadrant of the abdomen. The incision may be short or
long.

The exploration may be total or limited. Whether it be total or limited, the exploration must
fulfil the following requirements:
1. It must come out with a complete and accurate evaluation of the abdominal problem.
2. It must not be associated with a missed diagnosis.
3. It must not be associated with iatrogenic injuries and complications.

A formal exploratory laparotomy inspects and palpates the following:


1. The intraperitoneal fluid
- normal
- ascites
- blood
- pus
2. The peritoneal lining
3. The diaphragm
4. The liver
5. The gallbladder and common bile duct
6. The spleen
7. The stomach
8. The duodenum
9. The omentum, lesser sac, and pancreas
10. The small intestines and mesentery
11. The large intestines and mesentery
12. The urinary bladder
13. The uterus, fallopian tubes, and ovaries
14. The pelvis
15. The retroperitoneum
16. The kidneys
17. Major blood vessels

The exploratory laparotomy is essentially an intraoperative evaluation. It either confirms or


disproves the preop diagnosis of surgical abdomen. If the abdomen is surgical, it provides the specific
diagnosis of the abdominal disorder.

After the intraoperative evaluation, operative procedures are carried out as dictated by the
specific diagnosis and as decided by the surgeon. In patients with acute nontraumatic surgical
abdomen, the operative procedures that may be possibly performed can be classified under three big
categories. These are, namely: 1) to control peritonitis; 2) to relieve obstruction; and 3) to control
bleeding.

The operative procedures that are usually performed under control of peritonitis are:
1. Excision or resection
Appendectomy
Cholecystectomy
Gastrointestinal resection
2. Repair
Repair of perforation
3. Debridement
4. Lavage
5. Drainage

The operative procedures that are usually performed under relief of obstruction are:
1. Adhesiolysis and release of bands
2. Resection and anastomosis
3. Bypass or internal drainage
4. External drainage
Colostomy
T-tube choledochostomy
5. Removal of stone
The operative procedures that are usually performed under control of bleeding are:
1. Suture ligation of bleeders
2. Resection and anastomosis
3. Decongestion of portal hypertension with or without esophageal transection and
anastomosis
4. Excision of ruptured ectopic pregnancy
5. Prosthetic graft replacement for ruptured aortic aneurysm

After the operation comes the postoperative care. This includes consideration of the following:
1. Postoperative medications
Analgesics, antibiotics, etc.
2. Care of tubes and drains
3. Care of wounds
4. Blood replacement
5. Nutrition
6. Fluid and electrolytes
7. Monitoring for the appearance of complications and, if they do occur, treating them
accordingly
8. Support of other systems of the body

In summary, the management of patients with an acute nontraumatic abdomen consists


essentially of evaluation and treatment. Initially, an evaluation is done to determine whether a surgical
abdomen is present or not. If a nonsurgical abdomen is decided upon, nonsurgical treatment is
instituted. If a surgical abdomen is present, the patient is prepared for an operation. The operation
consists initially of an intraoperative evaluation followed by the indicated operative procedures. After the
operation, care is given until the patient recovers from the treatment and is discharged, as much as
possible free from complications and cured of his abdominal problem.
PATIENTS WITH ACUTE NONTRAUMATIC ABDOMEN

EVALUATION

INITIAL TREATMENT

NONSURGICAL ABDOMEN SURGICAL ABDOMEN

INITIAL TREATMENT

NO EXPLOR LAP EXPLOR LAP

MONITOR DIAGNOSTIC

NONSURGICAL TREATMENT THERAPEUTIC

CONTROL PERITONITIS

RELIEVE OBSTRUCTION

CONTROL BLEEDING

POSTOP CARE
APPROACH TO PATIENTS WITH NON-ACUTE SURGICAL ABDOMEN
Reynaldo O. Joson, MD, DPBS
1991;2000

Patients with nontraumatic abdominal problem can be broadly categorized as follows:

NONTRAUMATIC ABDOMEN

ACUTE NON-ACUTE

SURGICAL NONSURGICAL SURGICAL NONSURGICAL

The word "acute" implies a problem of sudden onset and of a severity that must be urgently managed by a
physician. "Non-acute", on the other hand, connotes a problem that has no obvious urgency. The problem
may be tolerated by the patient who has it; insiduous in onset; and non-life threatening.

Just as an acute abdominal problem may either be surgical or nonsurgical, a non-acute abdominal
problem may likewise be categorized as such.

The first step in the management approach of patients with non-acute nontraumatic abdomen is
evaluation. The essential question to answer during evaluation is whether a surgical abdomen is
present or not. A surgical abdomen is ruled out first before a nonsurgical abdomen is accepted as a
diagnosis.

The following are conditions that are usually classified as non-acute surgical abdomen, especially when
they are in the early stage of their natural history and they have not caused complications that would
classify them as acute surgical abdomen (Note: all non-acute surgical abdomen are potential acute
surgical abdomen):

1. Gallbladder Stones
2. Splenomegaly
3. Abdominal Tumors

The diagnostic tools that may be used in the evaluation of patients with non-acute surgical abdominal
conditions consist of interview, physical examination, laboratory examinations, diagnostic
procedures, and monitoring. These are done as indicated and as available.
I. GALLBLADDER STONES

Gallbladder stones may be detected through a plain abdomen (if the stones are opaque); oral
cholecystogram; and ultrasound.

Patients with gallbladder stone may present with acute surgical abdomen; non-acute surgical
abdomen; or they can be completely asymptomatic, the stone detected only incidentally in
the process of an investigation for other problem.

Symptomatic gallbladder stones need to be removed. The treatment is cholecystectomy.

Asymptomatic gallbladder stones may not have to be removed. The patients are advised the following:

1. They have gallbladder stones.


2. The stones may not cause any problem at all in their whole lifetime.
3. The stones may cause problem in the future.
4. Multiple small stones are more notorious in causing problem than a solitary big stone.
5. They may or may not have a prophylactic cholecystectomy.
6. If they do not want a prophylactic cholecystectomy, they must see a surgeon right away at the
first sign of a problem.

II. SPLENOMEGALY

Splenomegaly as a surgical condition is usually encountered in patients with hematologic diseases.


The more common hematologic diseases that may call for a splenomegaly are the idiopathic
thrombocytopenic purpuras and the hemolytic anemias. Splenomegaly in these two conditions remove
the site of destruction of the erythrocytes, leukocytes, and platelets.

Though rare, splenomegaly may be done to palliate patients with massive spleen secondary to
leukemia, lymphoma, and myeloproliferative disorders.

Splenomegaly has also been used as a staging tool in lymphoma.

At present, the most common indications for splenomegaly in patients with non-acute surgical abdomen
are still idiopathic thrombocytopenic purpura and hemolytic anemia. The surgeon doing splenectomy in
such hemotologic disorders must closely work hand in hand with a hematologist.

III. ABDOMINAL TUMORS

Any organ or tissue in the abdomen can give rise to a tumor. Thus, tumors can originate in the following
abdominal organs and tissues:

1. Liver
2. Pancreas
3. Stomach
4. Small Intestines
5. Large Intestines
6. Mesentery and Omentum
7. Retroperitoneum

The tumors may either be benign or malignant.


Manifestations of abdominal tumors will be dependent on the size, whether palpable through the
abdominal wall or not, and on the complications they may cause, such as pain, obstruction, and
bleeding.

In general, if a tumor is palpable, its location on the abdomen is the first clue to its diagnosis. All
organs and tissues situated at the particular location of the tumor should be suspected to be a possible
source. For example, a tumor in the epigastric area can be a gastric, a transverse colonic, or a pancreatic
tumor. A tumor in the right lower quadrant can be an ileocecal, appendiceal, or an ovarian tumor.

The second clue to the diagnosis of a palpable abdominal mass is its mobility. If it is very mobile, then
it may be arising from structures which are mobile such as the omentum, transverse colon, and small
intestine.

The third clue to the diagnosis of a palpable abdominal mass is the accompanying symptomatology or
sign. The presence of gastrointestinal disturbance such as vomiting, constipation, and bleeding will
suggest an origin in the gastrointestinal tract. The presence of jaundice will suggest hepatobiliary
and pancreatic origin of the mass.

For nonpalpable abdominal tumors, the thing that will make a physician suspect their possible presence is
symptomatology of the patient. For example, an obstructive type of jaundice without a palpable mass
should lead to the suspicion of a mass obstructing the hepatobiliary tract.

After the history and physical examination, one should have a primary suspect as to the possible origin
of the abdominal tumor. This primary suspect should be one that is logically arrived at based on the
signs and symptoms of the patient.

An exploratory laparotomy can be selected as the next step after history and physical examination if the
surgeon is certain that there is an intra-abdominal mass and that this mass has to be surgically treated
regardless of what it will turn out to be on further examinations. Selecting an exploratory laparotomy as
the next step after history and physical examination presupposes that the surgeon will utilize the
intraoperative exploration as the diagnostic procedure and that he will make a decision on the
specific treatment procedure thereafter.

If the surgeon is not certain of the presence of an intra-abdominal surgical mass, he must perform
diagnostic procedures to ascertain at least its presence before deciding on exploratory laparotomy.
Diagnostic procedure may be done to get an idea where the mass is originating from.

At times, diagnostic procedures prior to exploratory laparotomy must be done. For example, a rectal
mass needs a confirmation of its malignancy before an abdominoperineal resection is done. A
tumor involving one kidney and which requires a total nephrectomy for its treatment requires a prior
excretory urography to evaluate the status of the contralateral kidney.

Depending on the primary suspect of where the mass is originating from, the following diagnostic
procedures may be done:

1. Gastrointestinal endoscopy.
2. Barium study of the gastrointestinal tract.
3. Ultrasound
4. Excretory urogram

Gastrointestinal endoscopy and barium study are best used to evaluate tumor that may possibly arise from
the gastrointestinal tract.

Ultrasound is best used to evaluate tumors that may possibly be arising from the liver, pancreas, uterus,
ovaries, and kidneys.
Excretory urogram is the best used when tumor is suspected to be coming from the kidneys and urinary
bladder.

The types of treatment that can be done on the various tumors in the abdomen depend on a lot of
factors:

1. Is it resectable or not ?
2. Is it benign or malignancy ?
3. Is it involving a solid organ ?
3.1 Is it involving the whole organ ?
3.2 Is a partial resection of the organ enough ?
3.3 Is a reconstruction needed ?
4. Is it involving a hollow organ ?
4.1 Is a partial resection of the organ enough ?
4.2 Is a reconstruction needed ?

The basic form of surgical treatment of intraabdominal mass is excision. If the mass is benign, simple
excision is sufficient. If the mass is malignant, a wide excision is called for.

After excision, a form of reconstruction may have to be done. In the abdomen, after an excision,
especially one that involves a hollow organ, the reconstruction is usually a re-establishment of the
gastrointestinal continuity.
PRINCIPLES OF ABDOMINAL SURGICAL ONCOLOGY

Reynaldo O. Joson, MD, DPBS


1991;2000

Surgical oncology is the study of management of tumors needing surgical intervention of some kind.

Abdominal surgical oncology is the study of management of abdominal tumors needing surgical
intervention of some kind.

A surgical oncologist is a surgeon who specializes in the treatment of tumors. He must possess
knowledge related to tumors needing surgery. He must also possess knowledge beyond cancer
surgery.

1. Detection
2. Diagnosis
3. Staging
4. Alternative options for therapy
5. Adjuvant therapies
6. Follow-up care
7. Detection and treatment of recurrence and metastasis

Abdominal tumors may be benign or malignant. The basic surgical treatment of malignant abdominal
tumors is a wide resection. Another definitive surgical treatment for abdominal cancers is a radical en
bloc resection.

The goals of surgical treatment of abdominal cancers may be curative or palliative. As much as
possible, the abdominal surgeon should always aim for cure. In unresectable tumors, palliative
procedures may be performed such as an exteriorization and bypass to relieve gastrointestinal obstruction
and resection to control gastrointestinal bleeding.

Below are some principles of intraoperative abdominal cancer surgery:

1. General plan of action


2. Good exposure
3. Gentle palpation of tumors
4. Early control of blood vessels
5. Staying away from the tumor and avoidance of cutting into the tumor
6. Wide excision or radical en bloc resection of all gross tumors
7. Prevention of contamination and spillage of cancer to prevent recurrence

Below is a list of definitive surgical procedures that may be done for the different abdominal cancers:

Liver cancers
Subtotal hepatectomy
Right hepatectomy
Left hepatectomy
Extended right hepatectomy
Wide excision
Pancreatic cancers
Subtotal pancreatectomy
Total pancreatectomy

Stomach cancers
Subtotal gastrectomy
Total gastrectomy

Small intestinal cancers


Resection

Large intestinal cancers


Resection
Right hemicolectomy
Left hemicolectomy
Sigmoidectomy
Abdominoperineal resection
Subtotal colectomy
Total colectomy

Mesentery and omental cancers


Wide excision

Retroperitoneal cancers
Wide excision
MANAGEMENT OF PATIENTS WITH PERITONEAL IRRITATION

Reynaldo O. Joson, MD, DPBS


1991;2000

One manner of presentation of patients with acute nontraumatic surgical abdomen is with signs
and symptoms of peritoneal irritation. For conscious patients, the most notable symptom of peritoneal
irritation is abdominal pain. On physical examination, signs of peritoneal irritation include direct
tenderness and guarding or rigidity of the abdominal wall. The earliest sign of peritoneal irritation is
direct tenderness. It is to be emphasized here that not all direct tenderness are signs of peritoneal
irritation. Serial monitoring of the direct tenderness is important. If the direct tenderness is definite,
progressive and associated with persistent guarding or rigidity of the abdominal wall, then there is
peritoneal irritation.

Peritoneal irritation is usually a sign of peritonitis or inflammation of the peritoneum. A patient with
purulent materials in the peritoneal cavity will manifest the signs of peritoneal irritation. A patient
with hemoperitoneum will likewise manifest the same signs of peritoneal irritation. A patient with an
intraabdominal abscess, expanding aortic aneurysm, and hydrops of the gallbladder may likewise
present with definite, progressive, direct tenderness and even guarding. The tenderness of the latter three
conditions, especially when they are in the earlier stages of the diseases, may not be due to peritonitis. It
may be due to the pressure produced by the palpation on a progressively distending hollow structure.

Although peritoneal irritation is not always synonymous with peritonitis, this phrase is used to indicate the
presence of a surgical or potentially surgical abdomen. Thus, in the presence of a definite and
progressive direct tenderness, a physician should strongly suspect surgical abdomen. The suspicion
should be more so if guarding or rigidity of the abdominal wall is present.

Usually, patients with peritoneal irritation requires exploratory laparotomy. There are exceptions. If a
specific diagnosis of amebic liver abscess, a non-necrotizing pancreatitis, a noncalculous
cholecystitis, and a colonic diverticulitis without perforation can be made, then exploratory
laparotomy is not needed. The patients with such conditions are treated with nonsurgical means. Surgery
is done only when these nonsurgical means fail and there is progression of the diseases to a situation in
which an operation is needed.

If a specific diagnosis of the diseases mentioned in the preceding paragraph and other diseases of the
same category cannot be made, then an exploratory laparotomy is indicated. The exploration will spell
out the specific diagnosis, the cause of the peritoneal irritation. This will be followed by a
definitive operative procedure for the specific condition that is present.

Another situation in which an operation is indicated in patients with peritoneal irritation is when the
physician strongly suspects a surgical condition as the cause. Examples are acute appendicitis,
perforated peptic ulcer, perforated typhoid ileitis, and abscess. Surgery is needed to control the
peritonitis.

Below is a list of categorizations and common conditions that fall under peritoneal irritation as the
presenting manifestation of acute nontraumatic surgical or potentially surgical abdomen.

I. Inflammatory bowels
A. Acute appendicitis
B. Diverticulitis
C. Necrotizing enterocolitis
II. Perforated bowels
A. Perforated peptic ulcer
B. Perforated typhoid ileitis
III. Cholecystitis
IV. Pancreatitis
V. Intraabdominal abscess

A. ACUTE APPENDICITIS

There are at least three forms of clinical presentation of acute appendicitis. These are,namely:
1. Acute appendicitis with nongeneralized peritonitis
2. Acute appendicitis with generalized peritonitis
3. Appendiceal abscess

In acute appendicitis with nongeneralized peritonitis, the peritoneal irritation is usually limited to the
right lower quadrant of the abdomen. It may extend to the hypogastrium or to the right upper quadrant.
The peritoneal irritation is not present in the whole abdomen. The appendix may be suppurative,
gangrenous , or with frank perforation but still with nongeneralized peritonitis.

In acute appendicitis with generalized peritonitis, the appendix has perforated and there is peritoneal
irritation all over the abdomen.

In appendiceal abscess there is a tender right lower quadrant abdominal mass. The appendix has
ruptured and the peritonitis has been contained through some defense mechanisms in the form of abscess
formation.

The diagnostic tools for acute appendicitis are usually limited to interview, physical examination, and
monitoring (repeated interview and physical examination). Complete blood count, urinalysis, X-rays,
and ultrasound cannot give out a definite diagnosis of acute appendicitis. Thus, they are not needed
and should not be used in evaluating patients with possible acute appendicitis.

The only ways in which a definitive diagnosis of acute appendicitis can be gotten are through 1) a
laparoscope, if this is available; 2) inspection on laparotomy; and 3) microscopic examination of the
appendix ( the presence of polymorphonuclear leukocytosis in the submuscularis layer).

Even the interview and the physical examination cannot give out a definite diagnosis of acute
appendicitis. However, especially with repeated interview and physical examination, they offer a reliable
basis for suspecting the possible presence of acute appendicitis. An advice is to first look for signs of
peritoneal irritation through palpation. If these signs are present and if there are no data to suggest
other pathologies, such as ectopic pregnancy and perforated typhoid ileitis, acute appendicitis is placed
as the primary consideration for the cause of the surgical abdomen. With such a diagnostic approach,
the accuracy rate for suspecting acute appendicitis is high. There can be errors in the specific diagnosis
of the abdominal disorder. The diagnosis may be an ectopic pregnancy or something other than acute
appendicitis. However, the decision to operate based on the presence of peritoneal irritation is still
correct. So, such an approach, even if there is an error in the specific diagnosis, will not be all in vain.

Here are some other practical tips in the evaluation of patients with possible acute appendicitis.

1. In all patients presenting with right lower quadrant pain and tenderness, always rule in or rule out
acute appendicitis.

2. In all patients presenting with a recent epigastric pain, watch out, for this may be the first symptom
of acute appendicitis.
3. An epigastric pain that later transfers to the right lower quadrant is not pathognomonic of acute
appendicitis.

4. During the interview, inquire at least on the following essential points: a) urinary disturbance; b)
bowel disturbance; c) vaginal discharge; d) time of most recent mense; and e) possible pregnancy.

5. In the absence of data that will suggest other diagnosis, strongly consider acute appendicitis.

6. In the presence of data that will suggest the possibility of another disease, weigh this disease against
acute appendicitis, which one has the higher probability of being the case. Bear in mind that two diseases
may be present at the same time, though this is rare.

7. There are times in which it is difficult to differentiate between acute appendicitis and pelvic
inflammatory diseases. Monitor and decide. With increasing tenderness and guarding, operate.

8. There is no need to elicit rebound tenderness, Rovsing's sign, psoas sign, and obturator sign. They
are not reliable signs of acute appendicitis. If they are elicited, know how to interpret them.

9. Do not make a diagnosis of chronic appendicitis and use this as a justification for operation.

10. It is possible to come out with such diagnoses based on repeated interview and physical examinations:
a. Acute surgical abdomen most probably acute appendicitis with nongeneralized peritonitis
b. Acute surgical abdomen, most probably acute appendicitis with generalized peritonitis
c. Acute surgical abdomen, most probably appendiceal abscess

11. In cases of equivocal evaluation in that one cannot yet rule in or rule out acute appendicitis, the thing
to do is to monitor. Repeated interview, checking for any change in the intensity of the pain, and
repeated physical examination, especially of the abdomen ,looking for signs of peritoneal
irritation, must be done at closed intervals and by the same physician.

12. Do not operate on the basis of "if in doubt, operate. Morbidity is lower if an error of commission is
committed as compared to an error of omission." Proper monitoring should not lead to an error of
commission. Corollary to this, it reduces errors of commission. Morbidity is not increased with a delay in
the timing of the operation as a result of closed and proper monitoring.

Once a decision is made that the patient has an acute surgical abdomen most probably secondary to
acute appendicitis, the patient should be informed of the assessment and a formal consent gotten for the
operation. The contemplated operative procedure should be stated as "exploratory laparotomy (or right
lower quadrant abdominal exploration) and appendectomy," and not simply, "appendectomy". This is so
because the exploration may give a finding other than an appendicitis. If this is so, the surgeon has the
leeway to do other operative procedures as dictated by the exploratory laparotomy findings as well
as appendectomy, that is, if he decides to do an incidental appendectomy.

For patients suspected of having an appendiceal abscess, the consent will be for "exploratory laparotomy,
drainage of abscess, and appendectomy."

Once acute appendicitis and appendiceal abscess are strongly suspected, the treatment is a surgical
operation. The operation should be done as soon as possible to prevent the progression of the peritonitis
and to remove its source, which is the appendix.

To emphasize, a patient strongly suspected to have a right lower quadrant intraabdominal abscess,
which could be an appendiceal abscess, should be subjected to an operation as soon as possible and not
to an initial medical treatment followed by the so-called interval appendectomy. An early surgical
operation is not only safe, it is also cost-effective. It establishes the definitive diagnosis and cures the
condition at the earliest and shortest time possible and with lesser expense. There is no delay in
diagnosis and treatment if the abdominal disorder turns out to be something other than an appendiceal
abscess and a surgical condition at that.

Preoperative preparations for patients suspected to have acute appendicitis and appendiceal abscess
include the following:
1. No oral intake
2. Intravenous fluids
3. Preop antibiotics
4. Other preop preparations, checking and support

Anesthesia may be regional or general, depending on the following factors:


1. Extent of peritoneal irritation
2. Age of patient
3. Anesthesiologist's assessment and preference

The essential operative steps in patients with acute appendicitis with nongeneralized peritonitis
consist of the following:
Incision
Transverse right lower quadrant incision
Intraoperative evaluation
Appendectomy
Secured ligation of appendiceal stump with or without cecal burial
Cleansing and diluting of exudates
Sponging
Irrigating
Wound closure
Leaving subcutaneous and skin layers unsutured in the presence of heavy contamination, gangrenous, and
perforated appendicitis

The essential operative steps in patients with acute appendicitis with generalized peritonitis consist
of the following:
Incision
Long transverse incision, initially at the right lower quadrant extending towards the left as necessary
Intraoperative evaluation
Appendectomy
Copious peritoneal lavage
Wound closure
Leave subcutaneous and skin layers unsutured

The essential operative steps in patients with appendiceal abscess consist of the following:
Incision
Transverse right lower quadrant incision over the palpable mass
Intraoperative evaluation
Evacuation of purulent content of the abscess
Appendectomy
Look for the appendix by palpation
Copious lavage of the abscess cavity
Leaving of wound open, all layers

The incision is a transverse one in all patients suspected of having acute appendicitis. In such patients
because of unavoidable contamination of the wounds created on the abdominal wall to get to the inflamed
appendix, the wounds are usually best left open. Transverse incisional wounds left open are faster to heal
and their scars are more superior than vertical incisional wounds left to heal by secondary intention.
The intraoperative evaluation in patients suspected to have acute appendicitis consists initially of
confirming or disproving the preoperative suspicion.

An inspection of the appendix can lead to a definitive diagnosis of acute appendicitis. The presence
of suppurative fibrin on the wall of the appendix, gangrene, and perforation are diagnostic of suppurative
appendicitis, gangrenous appendicitis, and perforated appendicitis respectively. The presence of an
abscess around the appendix is diagnostic of appendiceal abscess. The presence of omentum enveloping
the appendix is diagnostic of appendicitis.

"Congestion" of the appendix is not diagnostic of appendicitis, although acute appendicitis may be
really present. The only way to establish whether a "congested appendix" is acute appendicitis is to
subject it to a microscopic examination. The presence of polymorphonuclear leukocytosis in the
submuscularis layer is diagnostic of acute appendicitis.

In the absence of obvious signs of acute appendicitis, the surgeon should look for an explanation of the
abdominal pain. Looking for an explanation of the abdominal pain does not always mean the surgeon
has to enlarge the incision to explore the entire abdominal cavity.

If a right lower quadrant incision has been utilized, if after examining the appendix, there are no obvious
signs of acute appendicitis, the surgeon should determine whether abnormal peritoneal fluids are
present or not. Abnormal peritoneal fluids are more often suppurative exudates and blood. If these
abnormal fluids are present, the surgeon should go all out to look for their source. He may have to
lengthen the incision if necessary.

If there are no abnormal peritoneal fluids, then the surgeon should evaluate at least the distal ileum to look
for a rare Meckel's diverticulitis; the mesentery of the distal ileum to look for abnormally enlarged
lymph nodes or masses; the uterus; the ovaries and the fallopian tubes, especially on the right side; the
cecum; and other structures located in the right lower quadrant area where there was tenderness
preoperatively.

If there is a surgical condition other than acute appendicitis, then it is treated accordingly. If the
abdomen turns out to be nonsurgical, an incidental appendectomy can be done if there is an informed
consent.

An abdominal wound created to take out an inflamed appendix may or may not be closed completely.
However, the best preventive measure against wound infection in such a situation is to leave the
subcutaneous and skin layers unsutured (NOT ANTIBIOTICS). This is strongly recommended for
gangrenous and perforated appendicitis, appendiceal abscess, and wounds that are heavily contaminated.
For suppurative appendicitis, the best protective measure against wound infection is still leaving the
subcutaneous and skin layers unsutured. However some patients may not like to see an open wound and
the incidence of wound infection with complete closure is not very common. The wound can be closed
completely but loosely, if there is minimal suppuration and minimal contamination of the wound.

Postoperatively, considerations and provisions for the following should be made:


1. Diet
Resume diet (as tolerated) as soon as possible ( when fully awake, right after the operation ) unless there
is a contraindication to it.
2. Analgesics
3. Antibiotics
With a preop antibiotics, with a cleansing of the peritoneal cavity and the peritonitis, with removal of the
source of the peritonitis (appendix), with drainage of abscess, and with the wound left open, there may
be no need for postop antibiotics. In high risk patients, however, such as patients with severe peritonitis
and malnourished patients, postop antibiotics are indicated.
4. Watching out for complications and treating them, if they occur. The most common complication is
wound infection.
B. OTHER INFLAMMATORY BOWEL DISEASES

Appendicitis is an example of inflammatory bowel disease. Other inflammatory bowel diseases consist
of the diverticulitis ( Meckel's and colonic). the enteritis, and the colitis.

Among the four inflammatory bowel diseases mentioned above, appendicitis is the most common and it is
one that once suspected clinically, calls for an exploratory laparotomy. Diverticulitis, enteritis, and colitis,
on the other hand, are not as common, are usually initially treated medically, and are treated only
surgically when with complications such as perforation and gangrene.

A specific diagnosis of complicated diverticulitis, enteritis, and colitis is difficult to make, short
of a laparoscopy or laparotomy. One usually starts off with a diagnosis of acute nontraumatic
surgical abdomen which leads to an exploratory laparotomy. The latter is the one that provides the
specific diagnosis of a complicated diverticulitis, enteritis, and colitis.

Clinically, however, there are clues to suspect some of the conditions. A right lower quadrant tenderness
will make one suspect acute appendicitis. A left lower quadrant tenderness will make one suspect left
colonic diverticulitis.

Meckel's diverticulitis will usually present with right lower quadrant problem. However, since it is
rare and since acute appendicitis is very common, one does not usually give out an impression of
Meckel's diverticulitis.

Complicated enteritis and colitis usually present with generalized abdominal tenderness that a specific
diagnosis based on abdominal findings is difficult. One has to rely on other data such as diarrhea,
dysentery, fever prior to onset of abdominal pain, and age. A newborn is more susceptible to
necrotizing enterocolitis.

As far as operative treatment of complicated diverticulitis, enteritis, and colitis (necrotizing, perforated,
and bleeding), the essential treatment is a resection. If a resection cannot be performed, then a diverting
enterostomy or colostomy is done. The primary objective of an operative procedure for complicated
inflammatory bowel diseases is to control the peritonitis.

C. PERFORATED PEPTIC ULCER

The primary bases for suspecting a perforated peptic ulcer are the following:

1. Signs of peritoneal irritation, more so at the upper abdomen


2. Adult patient with a chronic history of on and off epigastric pain
3. Pneumoperitoneum

Preop preparations consist of and should consider the following:


1. No oral intake
2. Analgesics
3. Antibiotics
4. Nasogastric tube

The essential parts of the operation consist of the following:

1. Vertical midline incision


2. Intraoperative evaluation
3. Decision of specific operative procedure
3.1 Debride, repair, with or without omental patching ( Make sure there is no distal
obstruction )
3.2 Resect if indicated and if feasible
3.3 Bypass if indicated
3.4 Vagotomy
3.5 Copious lavage
4. Decision on use of drains
5. Decision of manner of wound closure
5.1 Loose closure of wound
5.2 Open subcutaneous and skin layers
5.3 Tension sutures

The essential postop care and considerations consist of the following:

1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
5. Antipeptic ulcer medications

D. PERFORATED TYPHOID ILEITIS

The primary bases for suspecting a perforated typhoid ileitis are the following:

1. Signs of peritoneal irritation,, nongeneralized or generalized


2. History of high-grade fever prior to onset of abdominal problem
3. Pneumoperitoneum

Preop preparations consists of and should consider the following:

1. No oral intake
2. Analgesics
3. Antibiotics

The essential parts of the operation consist of the following:

1. Vertical midline incision


2. Intraoperative evaluation
3. Decision on specific operative procedure
3.1 Debridement and repair
3.2 Segmental resection and anastomosis
3.3 Segmental resection and exteriorization
3.4 Copious lavage
3.5 Drainage (as well as indicator drain)
4. Decision on manner of wound closure

The essential postop care and considerations consist of the following:

1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
E. PERFORATED LARGE BOWELS OF WHATEVER ETIOLOGY

The primary bases for suspecting a perforated large bowel are the following:

1. Signs of peritoneal irritation, nongeneralized or generalized


2. History suggestive of colitis or colonic diverticulitis
3. Data suggestive of large bowel obstruction prior to perforation

Preop preparations consist of and should consider the following:

1. No oral intake
2. Analgesics
3. Antibiotics

The essential parts of the operation consist of the following:

1. Vertical midline incision


2. Intraoperative evaluation
3. Decision of specific operative procedure
3.1 Exteriorization
3.2 Debridement and repair
3.3 Resection with anastomosis
3.4 Resection without anastomosis
3.5 Provision of proximal diverting and protective colostomy
3.6 Copious lavage
4. Decision on drains
5. Decision on manner of wound closure

The essential postop care and considerations consist of the following:

1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
5. Closure of colostomy

F. ACUTE CHOLECYSTITIS

The primary basis for suspecting acute cholecystitis is a direct right upper quadrant abdominal
tenderness in an adult patient. This suspect of acute cholecystitis has to be confirmed before an
operation is undertaken. This can be done through an ultrasound of the gallbladder. The finding of
gallstone(s) is a go-signal for operation on patients with a right upper quadrant tenderness that is suspected
to be due to acute cholecystitis. If ultrasound is not available, the following are used as bases to suspect a
surgical cholecystitis:

1. Signs of peritoneal irritation at the right upper quadrant


2. Adult patient with on and off colicky abdominal pain
3. Tender right upper quadrant mass suspicious of hydrops or empyema gallbladder
Preop preparations consist of and should consider the following:

1. No oral intake
2. Analgesics
3. Antibiotics

The essential parts of the operation consist of the following:

1. Right subcostal incision, either oblique or transverse


2. Intraoperative evaluation
3. Cholecystectomy
4. Decision on intraoperative cholangiogram and operative procedure on the common bile duct
5. Decision on use of drains
6. Decision on manner of wound closure

The essential postop care and considerations consist of the following:

1. Analgesics
2. Antibiotics
3. Diet
4. Watching out for complications

G. ACUTE PANCREATITIS

The primary basis for suspecting acute pancreatitis is a sudden severe epigastric pain and tenderness in
an adult patient. The suspect of acute pancreatitis may be confirmed through a serum amylase
determination. A marked elevation of the serum amylase is highly suspicious of acute pancreatitis.

Acute pancreatitis may be treated nonsurgically. Indications for exploratory laparotomy are signs
of peritoneal irritation and a tender mass suspicious of pancreatic abscess.

Nonsurgical management includes the following:

1. No oral intake
2. Analgesics
3. Antibiotics
4. Nasogastric tube decompression of stomach
5. Fluid and electrolyte maintenance
6. Monitoring for surgical pancreatitis

The essential steps in the operation of surgical pancreatitits are the following:

1. Vertical midline incision


2. Intraoperative evaluation
3. Decision on the specific operative procedure
3.1 Debridement
3.2 Formal pancreatectomy
3.3 Copious lavage
3.4 Drainage
4. Decision on tube jejunostomy
5. Decision on the use of continuous peritoneal lavage
6. Decision on the manner of wound closure
The essential postop care and considerations include the following:

1. Analgesics
2. Antibiotics
3. Nutrition
3.1 Intravenous alimentation
3.2 Enteral alimentation
4. Fluid and electrolyte maintenance
5. Watching out for complications

H. INTRAABDOMINAL ABSCESS

An intraabdominal abscess is suspected if there is a tender intraabdominal mass. A nonpostoperative


intraabdominal abscess is usually one of the following:

1. Appendiceal abscess
2. Colonic diverticular abscess
3. Pelvic inflammatory disease with abscess formation
4. Pancreatic abscess
5. Liver abscess
5.1 Pyogenic
5.2 Amebic

A suspected intraabdominal abscess in the right lower quadrant is most likely an appendiceal abscess.

A suspected intraabdominal abscess in the left lower quadrant is most likely a left colonic diverticular
abscess.

A suspected pelvic abscess in a female is most likely part and parcel of a pelvic inflammatory disease.

A suspected intraabdominal abscess in the left upper quadrant is most likely a pancreatic abscess.

A suspected intraabdominal abscess in the right upper quadrant is most likely a liver abscess.

To firm up the clinical suspicion of an intraabdominal abscess, an ultrasound, an upright abdominal x-ray,
and even a needle aspiration can be done.

Except for an amebic liver abscess, the primary treatment of all intraabdominal abscesses is an operation.
A medical therapy is the initial treatment for amebic liver abscess. If this fails, then an operation is
needed.

The operation consists of an open drainage of the abscess and controlling the source of the abscess.

For appendiceal abscess, open drainage and appendectomy are done.

For diverticular abscess, open drainage and colonic resection are done with protective colostomy.

For pelvic abscess in females, open drainage may have to be done if conservative measures fail. A total
hysterectomy and bilateral salpingo-oophorectomy may be indicated.

For pancreatic abscess, open drainage and pancreatectomy are done.

For pyogenic liver abscess, open drainage and removal of the stones in the common bile duct, which is the
culprit, are done.
MANAGEMENT OF PATIENTS WITH HOLLOW VISCERAL OBSTRUCTION

Reynaldo O. Joson, MD, DPBS


1991;2000

One manner of presentation of patients with acute nontraumatic surgical abdomen is with signs
and symptoms of mechanical hollow visceral obstruction. For conscious patients, the most notable
symptom of a hollow visceral obstruction is a colicky abdominal pain.

There are two categories of hollow visceral obstruction. These are, namely:

1. Gastrointestinal tract obstruction


2. Biliary tract obstruction

A. GASTROINTESTINAL TRACT OBSTRUCTION

The primary bases for suspecting mechanical gastrointestinal tract obstruction are the following:

1. Colicky abdominal pain


2. Inability to tolerate oral intake associated with vomiting
3. Abdominal distention
4. Constipation and distention
5. Collapsed rectal vault in complete obstruction
6. Hyperactive bowel sounds
7. Distended bowels with cut-off sign on plain supine abdominal X-ray
8. Obstructed antegrade or retrograde flow of barium dye in the gastrointestinal tract

Numbers 1 to 6 are clinical signs of mechanical gastrointestinal tract obstruction while numbers 7
and 8 are radiologic signs. A plain supine abdominal X-ray is usually done to firm up the clinical
suspicion of gastrointestinal tract obstruction. An upright film of the abdomen in patients with
suspected gastrointestinal tract obstruction is not needed because it does not add more significant
information than what can be obtained from the plain supine abdominal X-ray correlated with the clinical
findings. The only information that is looked for in upright abdominal X-ray in patients with
suspected intestinal obstruction is an air-fluid level. By the time the air-fluid level is present in the
upright film, the diagnosis of mechanical gastrointestinal tract obstruction is already obvious just from the
clinical findings and the findings from the supine film. Besides, air-fluid level is not pathognomonic
of mechanical gastrointestinal tract obstruction. It can also be seen in ileus.

There are a lot of information that can be gotten from the plain supine film. The following may be present:

1. Presence of distention of bowels


2. Discernment of which parts of the gastrointestinal tract are distended
3. Discernment of a cut-off distension sign

The presence of distention and a cut-off sign together with the clinical signs are diagnostic of mechanical
gastrointestinal tract obstruction. Beside suggesting the presence of mechanical intestinal obstruction, the
plain supine film can also suggest the possible etiology. This is suggested through the level of
obstruction correlated with the most common cause of obstruction at that level and correlated with the age
of the patient. In the newborn, the presence of obstruction at the jejunal level will suggest jejunal atresia
and at the ileal level, ileal atresia. In the adults, in a young Filipino patient, the presence of
obstruction at the ileocecal level will suggest the tuberculosis as the cause.

Barium instillation of the gastrointestinal tract may be done if necessary. It is done in situations in
which the diagnosis of obstruction is still equivocal despite monitoring of the clinical signs and serial plain
abdominal X-rays. It is done in the newborn and pediatric patients for early diagnosis of
intussusception, Hirchsprung's disease, and other causes of gastrointestinal tract obstruction. The
barium may be instilled antegradely or retrogradely through the gastrointestinal tract. It is
contraindicated in patients with frank signs of peritonitis. If the procedure is done, the surgeon should
be at hand ready to operate when complication of the procedure arises.

An entity which has to be differentiated from mechanical intestinal obstruction is ileus. Ileus is
suspected if the following are present:

1. Presence of gas throughout the length of the gastrointestinal tract on plain supine film of the
abdomen without a cut-off distension sign
2. Ballooned rectal vault
3. Hypoactive bowel sounds

Patients with mechanical intestinal obstruction will present with signs and symptoms corresponding to
the degree of the mechanical obstruction, either incomplete or complete. They will also present with
signs and symptoms corresponding to whether strangulation and rupture have occurred or not.

As a rule, early, incomplete, nonstrangulated mechanical gastrointestinal tract obstructions are harder to
diagnose than complete, nonstrangulated and strangulated obstructions. Thus, for the early,
incomplete, nonstrangulated obstructions, monitoring is very important. A maneuver which can be
done is bring out the diagnosis during the monitoring. In patients in which the diagnosis of intestinal
obstruction is equivocal, oral feeding may be continued. This maneuver will rule in or rule out
intestinal obstruction in the shortest time possible. The insertion of a nasogastric tube in such patients
will not help in bringing out the true diagnosis.

Once a diagnosis of mechanical gastrointestinal tract obstruction is made, efforts must be made to
determine the following:

1. Is there frank strangulation? The earliest sign of strangulation is definite direct tenderness. The late
signs are the signs of generalized peritonitis. If signs of strangulation are present, the operation is done as
soon as possible. If there are no signs yet of peritoneal irritation, if the diagnosis of mechanical
gastrointestinal obstruction is made, operation is also done as soon as possible before strangulation
and malnutrition set in.

2. What is the possible etiology? Hernia, if present, can be a cause. Adhesions as a cause is
considered if the patient has a previous abdominal operation. If there is no previous abdominal
operation, the suspected level of obstruction as gotten from the plain supine film of the abdomen, the age
of the patient, and other data from the history and physical examination may give a clue. Knowing
the possible etiology preoperatively is very important because it may influence the decision-making on
the type of treatment and what incision to use. For example, there is a tendency toward conservatism in
patients with adhesions. If an inguinal hernia is the cause of the obstruction, treating the hernia
through an inguinal incision can be performed. If the obstruction is due to a left-sided colonic cancer,
a loop transverse colostomy may be performed through an incision at the upper quadrants rather than
an outright formal exploratory laparotomy.

If the etiology is not known and if there are signs of strangulation and generalized peritonitis,
regardless of the cause, known or unknown, a formal exploratory laparotomy is done.

The preoperative preparations in patients with mechanical gastrointestinal tract obstruction consist of and
should consider the following:
1. No oral intake
2. Fluid and electrolyte maintenance
3. Antibiotics
4. Analgesics
5. Nasogastric tube insertion

The essential steps in the formal exploratory laparotomy for patients with mechanical gastrointestinal
tract obstruction consist of the following:

1. Vertical midline incision


2. Intraoperative evaluation
Boundary between dilated and collapsed bowels is the point of obstruction.
Determine cause.
Determine viability of obstructed bowels.
3. Decision on specific operative procedure
3.1 Adhesiolysis and release of bands
3.2 Resection with anastomosis
3.3 Resection without anastomosis
3.4 Bypass or internal drainage
3.5 Externally diverting or protective colostomy
4. Decision on the use of drains
5. Decision on the manner of wound closure

The essential postop care and considerations consist of the following:

1. Analgesics
2. Antibiotics
3. Fluid and electrolyte maintenance
4. Diet
5. Watching out for complications
6. Closure of colostomy
7. Definitive operation

B. BILIARY TRACT OBSTRUCTION

An acute biliary tract obstruction is usually caused by stones.

The cystic duct of the gallbladder can be obstructed by stones to cause cholecystitis. The common
bile duct can be obstructed by stones to cause cholangitis.

The primary bases for suspecting biliary tract obstruction consist of the following:

1. Colicky abdominal pain


2. Jaundice
3. Signs of peritoneal irritation at the right upper quadrant
4. Tender right upper quadrant mass which is suspicious of a distended gallbladder and which may
contain white bile (hydrops) or pus (empyema)
5. Fever
6. Ultrasound findings of stones in the gallbladder and common bile duct
7. Ultrasound finding of dilated common bile duct

The preoperative preparations and considerations consist of the following:


1. No oral intake
2. Antibiotics
3. Analgesics

The essential steps of the operation in patients with biliary tract obstruction consist of the following:

1. Right subcostal incision


2. Intraoperative evaluation
3. Decision on specific operative procedure
3.1 Cholecystectomy
3.2 Intraoperative cholangiogram
3.3 Extraction of common bile duct
3.4 T-tube choledochostomy
3.5 Biliary-enteric bypass
4. Decision on use of drains
5. Decision of manner of wound closure

The postoperative care and considerations consist of the following:

1. Analgesics
2. Antibiotics
3. Diet
4. Watching out for complication
5. Decision of reoperation in patients with residual stones
MANAGEMENT OF PATIENTS WITH GASTROINTESTINAL BLEEDING
Reynaldo O. Joson, MD, DPBS
1991;2000

One manner of presentation of patients with acute nontraumatic abdomen is with signs of gastrointestinal
bleeding. The patients may present with hematemesis or hematochezia.

The approach to patients with hematemesis and hematochezia consists of deciding on the following issues:

1. Is there really hematemesis or hematochezia?


2. Is the gastrointestinal bleeding profused and continuous?
3. What is the cause of the gastrointestinal bleeding ?
4. Based on the analysis of the cause, is surgery indicated?
5. If surgery is indicated, what are the preoperative preparations ?
6. If surgery is performed, what are the possible operative procedures that can be and should be
performed ?
7. If surgery is performed, what are the postoperative measures and considerations ?

IS THERE REALLY HEMATEMESIS OR HEMATOCHEZIA ?

Hematemesis is present if there is a vomitus of fresh blood. Hematochezia is present if there is a passage of
bloody stools. At the first encounter between the physician and the patient, there may be no frank
evidence of hematemesis or hematochezia. A nasogastric tube may be inserted and a rectal
examination performed to investigate the complaint of hematemesis or hematochezia. The finding of
fresh blood within the nasogastric tube supports the presence of hematemesis while the presence of
fresh blood on rectal examination, hematochezia.

IS THE BLEEDING PROFUSED AND CONTINUOUS ?

On the initial evaluation, the presence of signs of hypovolemic shock (hypotension and tachycardia)
suggests that massive bleeding had taken place. So is the presence of pallor.

Monitoring can also answer the question whether the bleeding is profused and continuous. The drainage
through the nasogastric tube and the anus can be monitored. So are the vital signs.

The presence of profuse and continuous bleeding dictates that the physician has to act fast in the
management of the patient.

WHAT IS THE CAUSE OF THE GASTROINTESTINAL BLEEDING ?

Hematemesis, fresh blood in the nasogastric tube, and melena point to a bleeding in the upper
gastrointestinal tract. The more common causes are bleeding esophageal varices, bleeding
peptic ulcer, gastritis, and gastric cancer.

Hematochezia points to a bleeding in the lower gastrointestinal tract. The more common causes are
bleeding from a colitis, rectal cancer, and hemorrhoids.

Bleeding can originate at any level of the gastrointestinal tract and it can be due to a myriad of causes.
To make the evaluation a little easier, the bleeding is first classified into upper and lower gastrointestinal
bleeding. Under each category is a list of all the possible and the more common causes. Using the data
in the interview and physical examination of a particular patient, the most probable diagnosis is
arrived at.

Aside from interview and physical examination, laboratory examinations, diagnostic procedures, and
monitoring are utilized as indicated in the evaluation of patients with gastrointestinal bleeding.
Endoscopy, barium studies, angiography, and scanning are used as indicated and as available.

BASED ON THE ANALYSIS OF CAUSE, IS SURGERY INDICATED ?

The causes of gastrointestinal bleeding can be categorized into two big groups in terms of treatment. One
group consists of those conditions which are outright surgical disorders upon diagnosis. This means,
that for these disorders, surgery is the treatment of choice. Examples under this group are the bleeding
tumors, the bleeding esophageal varices, the bleeding hemorrhoids, and the bleeding arteriovenous
malformations.

The second group consists of those conditions which are considered bleeding complications of medical
disorders. Examples are bleeding gastritis, bleeding peptic ulcer, and bleeding colitis. These medical
disorders can become surgical disorders because of the bleeding problem. In these cases, nonsurgical
measures are tried out first. If these measures fail, surgery is inidcated, especially if the bleeding is
continuous and massive to the point that the life of the patient is threatened.

IF SURGERY IS INDICATED, WHAT ARE THE ESSENTIAL PREOPERATIVE PREPARATIONS ?

1. No oral intake
2. Insertion of nasogastric tube for gastric lavage
3. Antibiotics
4. Blood transfusion
5. Blood for use during surgery

IF SURGERY IS PERFORMED, WHAT ARE THE POSSIBLE OPERATIVE PROCEDURES


THAT CAN BE AND SHOULD BE PERFORMED ?

1. Vertical midline incision


2. Intraoperative evaluation
Level of bleeding
Source of bleeding
3. Decision on specific operative procedure
3.1 Suture ligation of bleeders
3.2 Resection and anastomosis
3.3 Decongestion procedures with or without esophageal transection for bleeding esophageal
varices
3.4 Excision of bleeding hemorrhoids
4. Decision on ancillary procedures like vagotomy
5. Decision on use of drains
6. Decision of manner of wound closure

IF SURGERY IS PERFORMED, WHAT ARE THE POSTOPERATIVE MEASURES AND


CONSIDERATIONS ?

1. Analgesics
2. Antibiotics
3. Diet
4. Fluid and electrolyte maintenance
5. Blood volume maintenance
6. Watching out for rebleeding
7. Watching out for complications of the surgical procedures performed