Benign GU and DU= peptic ulcer

What digests mucosa-ulcer-acid

pepsin
Ulcer = mucosal defect that extends
through the wall layers:
• perforation,
• penetration
Erosion = superficial mucosal defect
DU>GU; DU/GU ratio=2:1 UK, 20:1
India
More common in men
High incidence in professional men
Symptoms:
• epig. discomfort- severe pain
• DU pts. eating relieves pain
• GU pts. eating causes pain
• DU pts.- vomitting- pyloric stenosis
• GU- vomiting relieves pain
• Hematemesis and melena
DU –site- right paraombilical area
GU- epigastric region
Onset of pain:
• DU-late after eating,
• GU-soon after eating
Relieving factors:
• DU-eating,
• GU-vomiting
NSAID

Steroids- Prednison

Aspirin

may irritate gastro-duodenal

mucosa
Smoking

Alcohol

Coffee
Mild-moderate tenderness
Complications:
• Bledding- anemia
• Stenosis- dehydration, succusion splash
• Gastric cancer- wasting, anemia
 There is pooling of barium
in a defect in the posterior
surface and lesser curve
that extends beyond the
lesser curve margin.
 There is a distortion of the
uninterrupted mucosal
folds of the stomach, which
are drawn-in towards the
centre of the lesion.
Escape of gastric acid or alkaline bile
into the peritoneal cavity- chemical
peritonitis- bacterial peritonitis
 Chief symptom- severe and constant
pain
Sudden onset- epigastric area
Respiratory movements make the
pain worse
Previous history
• History of indigestion
• No history
Drug history: STEROIDS, ASPIRIN
General appearance: ill, in pain
Abdo. inspection: imobile
Ascultation: silent abdomen
Palpation: board-like rigidity
Percussion: not necessary
DRE- painful
Premalignant conditions:
• Pernicious anemia
• Gastric polyps
• Atrophic gastritis
Peak incidence- 50-70 years old
More common in men
Symptoms:
• Indigestion or epigastric pain
• Eating or vomiting does not relieve the pain
• Loss of appetite-loss of weight
• Dysphagia- carcinoma of the cardia
• Vomiting- carcinoma of the pylorus
GA- wasting, palor
Jaundice: liver MTS ot CBD
obstruction by porta hepatis
lymphadenopathy
Left supraclavicular node- Virchow’s
Abdomen- excavated, inelastic skin
Abdominal distension-ascitis
Sister Mary Joseph’s nodule
Mild epigastric tenderness
Palpable epigastric mass-
unresectability
Hepatomegaly- liver MTS
Pyloric obstruction- succusion splash
Ascitis-shifting dullness
NBS
DRE-pelvic mass- Blummer’s tumor
or Krukenberg’s tumor
A 13-year-old boy presented with
complaints of vomiting, weight loss and
generalized weakness.
 Cytological examination of blood showed
iron deficiency anemia with a hemoglobin
of 6.5 g/dl.
 Stools were positive for occult blood.
 Barium studies showed a large irregular
lobulated mass in the body of stomach and
there was no gastric outlet obstruction.
 An ultrasound showed a large mass with bowel
signature in the epigastric area; there were
multiple hepatic metastases, lymphadenopathy
and ascites .
 Osophagogastroduodenoscopy showed a large
ulcerated mass in the anterior and posterior walls
of the body and along the greater curvature of
stomach; the surface of the mass was friable;
there was significant bleeding noted at the base
of ulcer .
 A biopsy showed moderate to poorly
differentiated adenocarcinoma of stomach
 A computer tomography study revealed a large
mass in the body of stomach along the anterior
and posterior walls and along the greater
curvature with local extension into the perigastric
area, the gastro-splenic ligament, the transverse
mesocolon, the transverse colon, the pancreatic
body and the deep layer of the adjacent anterior
parietal wall;
 Multiple hepatic metastases, lymphadenopathies,
and ascites .
 The anemia was corrected by blood transfusion.
 He was offered palliative chemotherapy but he
couldn't afford it due to financial constraints.
 He received best supportive care for 2 months
until he died.
 Gastric carcinoma is the most common gastrointestinal
malignancies worldwide and is the world's second most
common cause of death due to cancer
 Patients with pernicious anemia have a twenty times
increased risk than that of the general population.
 Intestinal metaplasia (replacement of the gastric epithelium
by intestinal epithelium containing Goblet cells) appears to
be a precursor and this in turn may result from known
carcinogens and after gastric resection for a benign gastric
ulcer.
 Gastric cancer is thought to result from a combination of
environmental factors and accumulation of specific genetic
alterations, and consequently mainly affects older patients
(>50 years of age).
 Some authors have postulated that gastric cancer can be
related to chronic infection with Helicobacter pylori..
 In our case the patient did not have any premalignant
conditions of the stomach or a family history of carcinoma.
 There was no signs of protein energy malnutrition,
Helicobacter Pylori and genetic assay were not done in this
case.
 He presented with anemia, which was due to iron deficiency
secondary to melena.
 At the time of diagnosis he had widespread metastases to
the liver and the lymph nodes and the patient died within 2
months after diagnosis, again stressing the fact that the
childhood gastric cancers are more aggressive with poor
prognosis.
 Gastric carcinoma needs to be considered in any patient
with persistent gastro-intestinal symptoms, iron deficiency
anemia and melena, even in the young.
 Physicians may miss opportunities to respond with empathy

 Empathy is an important element of effective

communication between patients and physicians and is
linked to improved patient satisfaction and compliance with
recommended therapy.

 Patients who are more satisfied with the communication in

their medical encounters have improved understanding of
their condition, with less anxiety and improved mental
functioning.

 However, responding to patients' emotional needs can be

challenging for physicians; they may begin medical school
with empathy for their patients but gradually learn
detachment, perhaps in order to cope with time constraints
or sadness.
Symptoms:RH pain after eating fatty
meals
Physical examination
• GA- female, fair, fat, fertile, forty
• Abdomen looks normal
• Palpation- RH tenderness, below the tip of
the 9th rib, Murphy’s sign
Diagnosis is based on history and USS
Clinical signs are minimal
Symptoms: sudden onset of
moderate/severe pain in the RH
Radiation- to the tip of the right
scapula
Exacerbation by movements and
breathing
Nausea, biliary vomiting
Appetite lost
GA: the pt. looks ill, lies quietly,
breathing shallowly, tachycardia,
fever, chills
Abdomen:
• Movements diminished
• Tenderness/guarding in the RH
• Palpable mass below the edge of the liver
Auscultation, RDE- WNL
 Between 1 - 3% of people with symptomatic
gallstones develop inflammation in the
gallbladder (acute cholecystitis), which occurs
when stones or sludge obstruct the duct.
 The symptoms are similar to those of biliary colic
but are more persistent and severe. They include
the following:
• Pain in the upper right abdomen is severe and constant and can
last for days. Pain frequently increases when drawing a breath.
• Pain also may radiate to the back or occur under the shoulder
blades. About a third of patients have fever and chills.
• Nausea and vomiting may occur.

•
 Infection develops in about 20% of these cases,
which increases the danger.

 Acute cholecystitis can progress to gangrene or

perforation of the gallbladder if left untreated.

 People with diabetes are at particular risk for

serious complications
 Chronic gallbladder disease (chronic cholecystitis)
is marked by gallstones and low-grade
inflammation.
 In such cases the gallbladder may become
scarred and stiff.
 Symptoms of chronic gallbladder disease include
the following:
• Complaints of gas,
• nausea, and
• abdominal discomfort after meals are the most
common,
 Chronic diarrhea (4 - 10 bowel movements every
day for at least 3 months) may be a common
symptom of gallbladder dysfunction
 Stones lodged in the common bile duct (choledocholithiasis)
can cause symptoms that are similar to those produced by
stones that lodge in the gallbladder, but they may also
cause the following symptoms:
• Jaundice (yellowish skin), dark urine, lighter stools, or
both
• Fever, chills,
• Nausea and vomiting, and
• Severe pain in the upper right abdomen. These
symptoms suggest an infection in the bile duct (called
cholangitis).

 As in acute cholecystitis, patients who have these

symptoms should seek medical help immediately.
 They may require emergency treatment.
Stones in the CBD , usually migrated
from the GB.
Symptoms: RH pain, jaundice, acholic
stools and dark urine
Infection of the bile duct

Potentially life-threatening condition

Charcot’s triad: fever, jaundice, RH

pain
Severe pain caused by a spasm of
the GB as it tries to force a stone
down the cystic duct
Biliary colic- severe constant pain
with excruciating exacerbations
1/5th. of pts.- jaundice
Abdomen: to tender to allow a deep
palpation/guarding
Activated pancreatic enzymes leak
into the pancreatic parenchyma and
initiate the auto digestion of the
gland
Cause: obstruction of the pancreatic
duct
Pathology: mild inflammation to
acute hemorrhagic destruction
Female- biliary obstruction
Male- alcohol
Symptoms:
• Upper abdo. pain
• Patient lies still
• Breathes shallowly
• Nausea, bouts of vomiting, retching
GA: the pt. looks ill, in pain,
hypovolemic, pale, dyspnea,
cyanosis, jaundice
Abdomen:
- imobile abdomen
- distension- paralytic ileus
- discoloration left flank( Gray
Turner’s)
- discoloration around umbilicus
(Cullen’s sign)
 Acute pancreatitis varies from
a mild uneventful disease to a
severe life-threatening illness
with multisystemic organ
failure (MOF) with shock, renal
failure, respiratory failure and
death.

 Gallstones and alcohol abuse

are the most common causes
of acute pancreatitis,
accounting for 80% of cases.
 Clinical forms: mild acute
pancreatitis and a severe
acute pancreatitis.
 80-85% of cases of acute
pancreatitis run a mild course
without the development of
multiple organ failure.
This group has a mortality of
< 1%.
 15-20% of cases of acute
pancreatitis run a serious
clinical course with pancreatic
necrosis and the development
of multiple organ failure.
 Of these, pancreatic necrosis
remains sterile in 60% of
patients, whereas in 40% of
these patients the necrosis
becomes infected.
This last category of patients
has the highest mortality rate
of 25-70
Obstruction of the lumen- fecolith

Symptoms:
• RIF pain
• Loss of appetite
• Nausea
• vomiting
GA: p. looks ill, flushed cheeks
Fever>38
Neck-tonsils- mesenteric adenitis
Chest-right sided basal pneumonia
Abdomen:
• Coughing causes pain
• Tenderness RIF/guarding
• Rebound tenderness
• DRE- painful pelvis if pelvic position of
appendix
 • Right lower quadrant pain on palpation (the single most
important sign)
• Low-grade fever (38°C [or 100.4°F])--absence of fever or high
fever can occur
• Peritoneal signs : Localized tenderness to percussion , guarding
• Other confirmatory peritoneal signs (absence of these signs does
not exclude appendicitis) :
• Psoas sign--pain on extension of right thigh (retroperitoneal
retrocecal appendix)
• Obturator sign--pain on internal rotation of right thigh (pelvic
appendix)
• Rovsing's sign--pain in right lower quadrant with palpation of left
lower quadrant
• Dunphy's sign--increased pain with coughing
• Flank tenderness in right lower quadrant (retroperitoneal
retrocecal appendix)
• Patient maintains hip flexion with knees drawn up for comfort
 Gastrointestinal
Abdominal pain, cause
unknown
Crohn's disease
Diverticulitis
Meckel's diverticulitis
Mesenteric lymphadenitis
Necrotizing enterocolitis
Neoplasm (carcinoid,
carcinoma, lymphoma)
Perforated viscus
Volvulus
 Gynecologic
Ectopic pregnancy
Endometriosis
Ovarian torsion
Pelvic inflammatory
disease
Ruptured ovarian cyst
(follicular, corpus
luteum)
Tubo-ovarian abscess
 Systemic  Genitourinary
Kidney stone
Diabetic ketoacidosis
Prostatitis
Porphyria Pyelonephritis
Sickle cell disease Testicular torsion
Henoch-Schönlein purpura Urinary tract infection
Wilms' tumor
 Pulmonary  Other
Pleuritis Parasitic infection
Pneumonia (basilar) Psoas abscess
Rectus sheath hematoma
Pulmonary infarction