- What is the Examination of patients in extrenal surgery
- The symptoms of Surveys of patients in extrenal surgery
- Diagnostic Examinations of patients in extrenal surgery
- Which doctors should be consulted if You have a Survey of patients in extrenal surgery
What is the Examination of patients in extrenal surgery -
In the practice of a doctor is crucial to the ability to recognize diseases that threaten the patient's life, and immediately provide him medical help. Emergency surgery is necessary especially timely accurate diagnosis, since surgical diseases of abdominal organs can have disastrous consequences, if it is admitted the delay in diagnosis. It is clear that the rapid orientation of the doctor in difficult clinical situations and conducting the necessary emergency treatment measures often determine the fate of the patient.
The peculiarity of examination of patients with acute abdomen pathology serves the need of diagnosis and determination of treatment tactics in a very short time, often heavy General condition of patients and the limited possibility to use special tools and methods.
The evaluation of patients with suspected acute surgical diseases before the doctor has two main goals:
1. To establish the diagnosis of the disease that caused immediate treatment of the patient for medical care.
2. To identify concomitant diseases of the vital organs, to assess the severity of the General condition of the patient and the risk of surgical intervention.
The basis of diagnosis in emergency abdominal surgery is a clinical examination of the patients. Usually when the pain in the abdomen until the search is pain relievers not prescribed. The surgeon must be able to evaluate the clinical picture is not deformed by the action of narcotic and non-narcotic analgesics. However, in some situations, such as when you need to transport the patient or when severe pain the patient gives himself to look to, the appointment of small doses of analgesics permissible to alleviate suffering, enhance confidence in the doctor and, eventually, for a more complete and careful examination.
The symptoms of Surveys of patients in extrenal surgery:
Abdominal pain is the most prominent symptom indicating the occurrence of acute diseases of abdominal cavity and forcing the patient to urgently seek medical help. Its intensity is very different from unbearable suffering until you feel slight discomfort. Difficulties in accurate diagnosis are related to the fact that this symptom may be accompanied by an extremely wide variety of diseases.
Causes of abdominal pain are diverse. They can be due to:
. lesions of the abdominal organs-
. diseases of organs located outside of it
. system diseases.
Bases of diagnostics of acute pain in the stomach lie in the understanding of the mechanism of their occurrence. In accordance with the anatomy of the nervous system of the abdomen there are two main types of pain.
Visceral pain. The abdominal cavity and overlying visceral peritoneum is supplied by a network of nerve endings that are related to the system of the splanchnic nerves. Nerves branch out and overlap each other, so visceral pain has no clear localization. Receptors that perceive visceral pain, react to stretching of the capsule of the parenchymatous organs, the increase in intracavitary pressure and ischemia, and not to direct irritation, such as tissue damage or burns. Stretching almost any hollow organ is initially manifested by a sense of vague discomfort in the centre of the abdomen, so this zone is called the "meeting place of all pain." An example of such a vague sensation can be a pain in periumbilical and epigastric regions, caused by the expansion of the lumen of the vermiform Appendix in the initial stages of acute appendicitis or pain in acute intestinal obstruction.
Parietal pain. Exactly are only localized somatic pain that occur in the structures innervated by the fast fibers of the spinal nerves. Parietal peritoneum is supplied by somatic afferent nerves, allowing you to pinpoint emerging in the field of nerve endings inflammatory process. For example, as in appendicitis develops TRANS-muralee inflammation and the process moves to the parietal peritoneum, the pain occurs with distinct localization in the right iliac region.
Pain radiating to the abdomen, diseases, localized outside of the abdominal cavity, occur quite frequently, as in this case affected the Central path of afferent neurons. The result is a myocardial infarction, pleurisy, and other
Table 1.1. The most common causes of pain radiating to the abdomen
Localization of the pathological focus
Fractures of the lower ribs pulmonary Embolism
Rupture of an aneurysm of the abdominal aorta Psoas-abscess
Ectopic pregnancy Endometriosis
Salpingitis , piosalpinks , power Torsion of ovarian cyst
Contusion and sprain of the muscles
primary disease of the chest can result in pain in the abdomen. Example lesions of the organs of the retroperitoneal space, accompanied by acute abdominal pain, can serve as renal colic and rupture of an aneurysm of the abdominal aorta. In table.2.1 shows the most common causes irreversi abdominal pain. Systemic diseases can also cause acute pain in the abdomen (PL. 1.2).
Table 1.2. Systemic diseases and pathological conditions that cause abdominal pain
Poisoning with heavy metal salts Drug disease
Reaction to insect bites
Sickle cell anemia
It should be remembered that diseases of the abdominal organs, accompanied by acute abdominal pain, quite numerous and not always require surgical treatment. Often the reasons for hospitalization in the Department of emergency surgery are functional digestive disorders, gastroenteritis, mesenteric lymphadenitis, diverticulitis and inflammatory diseases of the pelvic organs.
Origin and course of various urgent diseases of the abdominal organs have specific and thorough history is the basis of diagnosis "acute abdomen".
The questioning begins with clarification of circumstances of pain and other complaints. Below are summarized the main points that you should pay attention during history-taking in patients with acute abdominal pain.
Mandatory questions in patients with acute abdominal pain, which the doctor should ask
Pain: Location, radiation, character, duration, intensity, time of occurrence, causality, provoking and facilitating factors.
The nature of the vomiting.
The nature of the stool.
Lost whether the patient body weight.
Had there been any fainting or collapse.
Localization of pain. In the beginning of the interview you need to ask the patient to indicate the place where the pain is most intense and the area where it appeared originally. Some diseases of the organs of the abdomen accompanied by pain is quite specific localization. The presence of pain in the projection of the affected organ caused by irritation of the parietal peritoneum, for example, in acute appendicitis or cholecystitis. So the first thing you should assume the defeat of the organs are located in the vicinity of the center of pain.
It should be noted that diseases of organs, not in contact with the parietal peritoneum, as well as non-inflammatory diseases of the abdominal organs, such as mechanical bowel obstruction, accompanied by diffuse pain without clear localization.
In table. 1.3 lists the most probable disease, whose diagnosis may be suspected with different localization of acute abdominal pain.
Irradiation of the pain is an important diagnostic feature, complementing the clinical picture. With lesions of the subphrenic space (rupture or abscess of the spleen and liver with hemoperitoneum) there is irritation of the diaphragm (the diaphragm is innervated by IV cervical spinal nerve) and the pain radiates to shoulder girdle and lateral surface of the neck on the affected side. In biliary colic the pain covered the right upper quadrant and may radiate to the right shoulder and shoulder blade. Pain radiating to the back, characteristic of acute pancreatitis, rupture of aneurysm of the abdominal aorta, perforating ulcer of the posterior wall of the stomach and duodenum. The pain of renal colic typically begins in the side, radiating along the ureter to the groin and is accompanied by frequent and painful urination.
The nature of pain. Abdominal pain may be constant or cramping (colic). Constant pain may increase and decrease, but fails completely and is not leaking in the form of attacks. Unremitting pain characteristic of acute inflammatory diseases such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, diseases of the pelvic organs.
Cramping usually occurs when obstruction of a hollow organ and is manifested attacks, outside of which one can be held fully. This kind of pain is characteristic of intestinal obstruction, renal and biliary colic. The wave nature of pain obstruction of a hollow organ can be the same regardless of the location of the lesion in the gastrointestinal tract, biliary or urinary tract. The duration of pain relief can characterize the location of the obstruction in the GI tract, since the intervals between the fits of spasmodic pain the longer than is located distal to the site of obstruction.
Table 1.3. Possible causes of acute abdominal pain of different localization
Localization of pain in the abdomen
Right upper quadrant
The lungs and thorax
Right-sided lower lobe pneumonia
Fractures of the lower ribs on the right
Pulmonary embolism and infarction of the right lung
Trauma to the liver
The liver tumor
Sequestration of blood in the liver
Stenosis of the terminal segment of the common bile duct
The stomach and duodenum
Exacerbation of peptic ulcer disease
Acute gastric dilatation
Cancer head cancer
Cancer of the hepatic angle of the colon
The esophagus and stomach
Perforation of the esophagus
Acute gastric dilatation
Achalasia of the cardia
Hernia hiatal and its complications
Exacerbation of peptic ulcer disease
Fracture of the sternum
Tietze's syndrome ( rib hundred )
The continuation of the table . 1.3.
Localization of pain in the abdomen
The upper left quadrant
The lungs and thorax
Left lower lobe pneumonia
Fractures of the lower ribs on the left
Abscess of the spleen
Aneurysm of the splenic artery
Exacerbation of peptic ulcer disease
The tumor of the stomach
Cancer of the splenic angle of the colon
Acute appendicitis ( early stage )
Acute mesenteric ischemia
Functional digestive disorders
Strangulated umbilical hernia
Inversion of the greater omentum
Rupture of an aneurysm of the abdominal aorta
Poisoning by salts of heavy metals
Painful crisis in sickle cell anemia
The continuation of the table . 1.3.
Localization of pain in the abdomen
The lower right quadrant
Acute mesenteric adenitis
Inflammation of Meckel diverticulum
Perforation of the cecum ( tumor , foreign body ) Cancer of the cecum
Perforated ulcer of stomach and duodenum
Female sexual organs
The right ovary apoplexy
Acute salpingitis , piosalpinks , power
Torsion or rupture of ovarian cyst Endometriosis
Strangulation of an inguinal hernia
Hematoma of the rectus abdominis
Left lower quadrant
Diverticulitis of the sigmoid colon
Volvulus and necrosis of adipose pendant
Sigmoid colon cancer
Female sexual organs
Apoplexy of the left ovary
Acute salpingitis , piosalpinks , power
Torsion or rupture of ovarian cyst Endometriosis
Strangulation of an inguinal hernia
Rupture of an aneurysm of the abdominal aorta
Hematoma of the rectus abdominis
The duration of pain. In the majority of acute surgical diseases the pain lasts from several hours to several days. Such long persistent or paroxysmal abdominal pain almost always indicate a dangerous pathological process in the abdominal cavity.
Occasional short-term pain is not accompanied by other clinical symptoms and changes in laboratory values, commonly found in the various functional disorders and are rarely the result of serious illness.
Moderate pain lasting more than 3 months, characteristic of chronic diseases. While this urgent hospitalization is required only if their background has been a sharp increase in pain. A classic example of this situation can serve as perforation of ulcers.
The intensity of the pain. Decided to allocate 4 degree of pain intensity - mild, moderate, severe, very severe (intolerable). As a rule, heavier than surgical disease, the stronger the pain. The most intense sudden pain in the abdomen arise as a result of perforation of hollow organs and penetration of their contents into the peritoneal cavity with peritonitis. The same intense pain in the abdomen, but without peritoneal symptoms in the first hours of the disease lead to acute disorders of mesenteric circulation and retroperitoneal rupture of an aneurysm of the abdominal aorta. In acute inflammatory surgical diseases of abdominal pain are often less pronounced.
The time of occurrence of pain. You should install the exact time the attack has started. The pain from which the patient wakes up during sleep, is often a formidable symptom. In surgical diseases such as perforation of a hollow organ, volvulus of the midgut, visceral arterial thromboembolism, rupture of an aneurysm of the abdominal aorta acute abdominal pain appears suddenly, often against the background of good health, and the patient accurately indicates the time of onset of the disease. The patients condition is deteriorating very quickly. In inflammatory diseases of the abdominal pain develop gradually and the General condition of patients more or less long period of time remains satisfactory.
Equally important is the subsequent temporal characteristics of pain.
To determine the diagnosis, it is important to find out whether the pain attack or re-emerged for the first time. For example, biliary colic, peptic ulcer and chronic pancreatitis is characterized by recurrent pain attacks.
Provoking and facilitating pain factors. For example, biliary colic and ischemic pain in the gut intensifies after meals, while the pain of peptic ulcer becomes less intense due to the neutralizing action of food. Factors that may provoke pain in acute pancreatitis are alcohol intake, fatty and fried foods. Pain, worse when urinating, may indicate irritation of the right ureter with appendicitis or pelvic abscess, located in the bladder. In peptic ulcer disease and reflux esophagitis the taking antacids reduces the intensity of pain, and at penetrating ulcers to reduce the pain of such drugs is almost impossible.
It should be emphasized the importance of the accounting and other complaints of the patient and physical examination, for excessive attention to pain can cause gross medical errors and sometimes can cost the life of the patient.
Nausea and vomiting. Nausea occurs when the development of counter peristaltic waves in the gastrointestinal tract. If this occurs the reflex opening of the cardia, vomiting develops. Nausea and vomiting cause systemic disease, CNS disease
gastrointestinal tract, or they can be symptoms of adverse reaction to drugs. In women of childbearing age should avoid the relationship of nausea and vomiting of pregnancy.
The most common cause of nausea and vomiting in persons without chronic diseases - viral and bacterial infection. Often, however, they are also found in surgical diseases of abdominal organs. Some of them are always accompanied by persistent vomiting, in others it is rare or absent. Frequent vomiting are characteristic of acute pancreatitis. When mechanical intestinal obstruction frequency and intensity of vomiting depend on the location of obstruction: the higher it is, the more frequently vomiting. It can be uncontrollable and lead to the rapid development of water-electrolyte disturbances.
Also important are the time of occurrence and the nature of concomitant pain vomiting. The majority of surgical disease begins with pain in the abdomen, and nausea and vomiting appear later. Vomiting of gastric contents with bile can occur when the biliary and renal colic and obstruction of the proximal part of the small intestine. Vomiting turbid contents observed during obstruction of the distal part of the small intestine. Vomiting of fecal odor indicates the gastro-colic fistula or terminal stage of intestinal obstruction. The absence in the vomit of bile indicates obstruction of the biliary tract and obstruction of the duodenum proximal to the major duodenal papilla. Vomiting blood or "coffee grounds" is a characteristic sign of bleeding from the upper gastrointestinal tract.
The loss of body weight. A role in clarifying the diagnosis in acute abdominal pain plays information about weight loss in the months preceding the treatment of the patient to the doctor. Such sign may indicate the presence of cancer, which may be complicated by perforation of the tumor, obstruction of the intestines or bile ducts or bleeding.
Syncope and collapse. Loss of consciousness or dizziness on the background of abdominal pain may indicate hypotension and severe blood loss that is observed when disturbed ectopic pregnancy, trauma to the spleen or rupture of an aortic aneurysm.
The medical history can provide substantial assistance to establish the source of bleeding. Diseases such as peptic ulcer disease, broken ectopic pregnancy, ovarian apoplexy, trauma to internal organs, rupture of arterial aneurysms and aorticorenal fistula bleeding is usually preceded by pain. Bleeding for tumors, diverticula, varicose veins of the esophagus, hemorrhoids, syndrome Mallory-Weiss and Delagua not accompanied by pain.
Information about bloody vomit or vomit color of coffee grounds suggests that the source of bleeding is located above the ligament of Treitz. If the patient did not take iron supplements or bismuth, black tarry appearance to the stool causes suspected pathology of the upper gastrointestinal tract - however, this chair is sometimes observed as a result of bleeding on the right side of the colon. The selection of bright red blood from the rectum indicates bleeding from the colon, however, sometimes it is the result of massive bleeding in the upper gastrointestinal tract. Small amounts of blood in the stool suggest the presence of pathology in the sigmoid or rectum.
Heavy moved and comorbidities not only complicate the diagnosis of acute diseases of abdominal organs, but also significantly increase the risk of urgent surgery and significantly worsen the prognosis. They always require a consultation with related professionals and often affect treatment policy.
It is necessary to establish which of the disease suffered by the patient and what is suffering at the present time. Be sure to find out whether the patient has myocardial infarction, cerebrovascular accident, pneumonia, liver disease and kidney failure, if he suffers from coronary heart disease, hypertension, bronchial asthma and diabetes mellitus, as well as what medicines have an allergic reaction.
Should investigate the presence of common infectious diseases - AIDS, hepatitis, syphilis, tuberculosis, etc., It is fundamentally important, because these diseases do not only complicate the diagnosis and treatment of acute pathology of the abdominal organs, but also pose a high risk to patients and others medical staff, requiring a mandatory range of preventive measures.
It is also important to find out the existence of contact with infectious patients and being in areas with poor sanitation and epidemiological situation, which can significantly help in establishing a correct diagnosis in patients with suspected acute abdomen.
Be sure to find out what moved the patient because of postoperative adhesions are one of three major causes of intestinal obstruction along with the tumors and a strangulated hernia. Every patient with gastrointestinal bleeding undergoing surgery on the aorta, should be deleted aorticorenal fistula, to 2.5 because such transactions are accompanied by such a late complication.
Gynecologistquarter history. In women, the importance of the nature of the menstrual cycle - amenorrhea suggests the presence of an ectopic pregnancy, pain in the middle of the cycle are often associated with ovulation. Inflammatory diseases of the uterus and appendages are often recurrent in nature. Women who have suffered an ectopic pregnancy, a high risk of repetition.
Medicinal history. When talking with the patient need to figure out what medicines he used earlier and was taking. You need to specifically ask about the reception of nonspecific anti-inflammatory drugs (NSAIDs), antiplatelet agents, anticoagulants, insulin, and antibiotics. This is necessary not only for continuity of care, but also for the diagnosis of acute diseases, predict possible complications and their prevention, and also to identify allergic reactions.
Some medicines can provoke the development of acute surgical diseases of abdominal organs. Acute abdominal pain, occurred in patients receiving corticosteroids or NSAIDs in the first place should be suspected perforated ulcer, and with the appearance of weakness and dizziness to exclude gastrointestinal bleeding.
It should be noted that for the diagnosis represents the value of actively collected history. The doctor after the conversation with the patient should have a clear idea of how it arose and developed the disease.
Diagnostic Examinations of patients in extrenal surgery:
The last decade is characterized by the widespread introduction of new instrumental methods. However, the basis for the diagnosis of acute surgical diseases has always been and remains a physical examination. The history and results of physical examination provide 60 information required for a correct diagnosis, the results of instrumental methods - on average up to 25 , and laboratory data - only 10-15 such information.
The patient's appearance helps to estimate the severity of the disease. Careful examination allows to determine - whether he suffers or watches TV or reads. Patients with peritonitis are very sensitive to the slightest shock. If unnoticed or "accidentally" push the bed, the patient will immediately complain about the pain. When transporting the patient should pay attention to his reaction when moving the cart through a door or knocks wheelchairs against the wall. These methods sometimes covert surveillance mean for the diagnosis of peritonitis is much more than deep palpation and symptom Shchetkina-Blumberg.
General examination of the patient is essential for the rapid assessment of disease severity. Pallor, drowsiness and cold cyanotic extremities may indicate the threat of hypovolemic shock due to blood loss or severe pancreatitis.
The position taken by the patients for the attenuation of pain is an important diagnostic feature. Patients with perforation of a hollow organ and distributed peritonitis of any cause lie still, because the slightest movement aggravates the pain. In case of renal colic, on the contrary, the patient rushes from the pain. When intra-abdominal bleeding, a ruptured spleen, broken ectopic pregnancy or apoplexy ovarian congestion of blood in the subdiaphragmatic space in horizontal position causes a sharp pain in the shoulder and neck, forcing patients to take a sitting position (symptom roly poly).
Severe inflammatory processes in the iliac regions and the cavity of the pelvis there is irritation of lumbar muscles, which leads to the appearance of psoas-symptom. Such patients try to lie down, bending the leg in the corresponding hip joint to decrease the tension of the iliopsoas muscle.
The fever is characteristic of many inflammatory processes in the abdominal cavity. For surgical diseases not normally associated with high hyperthermia. If the patient with suspected acute appendicitis or cholecystitis, the temperature rises to 39-40°C, such a diagnosis is questionable. The combination of hyperthermia with such abdominal pain may be only in the abdominal abscess and purulent peritonitis. Chills in combination with high hyperthermia characteristic of bacteremia in this case, blood is taken for planting.
Tachycardia in acute abdomen is caused by inflammation, dehydration or blood loss. Its absence in any case does not exclude severe diseases of abdominal organs (e.g., bradycardia with perforated ulcer).
The measurement of body temperature, blood pressure, heart rate and respiratory rate urine output must be used, but the significance of these indicators for the diagnosis of acute diseases of abdominal cavity organs of small. They are used mainly to assess the severity of the General condition of the patient. Violations of basic life functions of an organism help to identify patients with life threatening conditions.
The study of the abdomen should include the traditional approach: inspection, auscultation, percussion and palpation - it should start with manipulations that do not cause pain. Ignoring pain may hinder communication with the patient, to complicate the initial examination and subsequent examination.
Inspection. During the inspection assessment of the form and degree of distention, part of the abdominal wall in the act of respiration and the presence of postoperative scarring. In this way, may reveal swelling and asymmetry of the abdomen, and sometimes visible peristalsis of the intestine, which is characteristic for intestinal obstruction - limiting respiratory excursions of the abdominal wall, the inherent peritonitis - cyanosis of the skin of the lateral abdomen that appears in hemorrhagic necrotizing pancreatitis (symptom warming Turner).
Auscultation. An important step to correct diagnosis is determining the character of bowel sounds. Traditionally, the absence of bowel sounds for 5 minutes is considered a pathognomonic symptom of peritonitis or paralytic ileus, and is loud and clear peristaltic bowel sounds in the background of cramping abdominal pain - mechanical bowel obstruction. However, you must remember that active peristalsis sometimes persists in widespread peritonitis, and in the later stages of intestinal obstruction bowel sounds may be absent.
All patients with suspected acute abdomen it is necessary to determine the splashing, which is heard when sukoshi due to the presence in the GI tract simultaneously fluid and gas (symptom Sklyarov). This symptom is diagnosed in most patients with intestinal obstruction and can be determined in acute gastric dilatation.
Listening vascular noise in the abdomen, caused by turbulence of blood flow, may indicate abdominal aortic aneurysm or stenosis of the renal and mesenteric arteries. However, rupture of aortic aneurysm and ischemic bowel often occur without vascular noise.
Percussion. Percussion is always carried out after auscultation, because she, like palpation, stimulates peristalsis. Percussion allows you to set the location of greatest pain.
With percussion you can assess whether the cause of the increasing abdominal accumulation of fluid in the abdomen (ascites, exudate) or gas in the intestine (intestinal obstruction). A dull sound give free fluid in the abdominal cavity, fluid-filled bowel loops and volume of education. The offset of the boundaries of the stupid sound when you change the position of the body is characteristic of free fluid in the abdominal cavity. Dulling in the sloping areas of the abdomen showing the emergence of effusion in the abdominal cavity intestinal obstruction, pancreatitis, or peritonitis, and may also indicate the presence of blood in the abdominal cavity in the gap parenchymal organs and disturbed ectopic pregnancy.
Tympanic sound is determined in the presence of free gas in the abdominal cavity and the accumulation of gas in the intestines. The disappearance of hepatic dullness and the appearance of high bloat of the liver means the presence of free gas in the abdominal cavity as a result of perforation of a hollow organ.
A sharp pain in mild percussion fingertips or coughing is a reliable sign of peritonitis. In these cases there is no need to resort to more "drastic" methods of examination, for example, the definition of symptom Shchetkina-Blumberg.
The increase in the bladder, which can also be defined by percussion, indicates obstruction of the urethra and sharp delay of urine output. Usually develops as a result of enlargement of the prostate gland in older men, but can be trauma of the urethra and the stones in the bladder.
Palpation. It is necessary to begin as far as possible from the painful hotbed, in order not to cause severe pain at the beginning of the study. A survey is significantly compounded when in the beginning of the examination, the patient experiences discomfort. Performed first approximate surface palpation and determine the areas of greatest pain and protective muscle tension. "Doskoobrazny" the abdomen is a classic symptom of perforated ulcer of the stomach. The action of hydrochloric acid on the peritoneum causes severe pain and muscle spasm.
Abdominal complete deep palpation. Use it to methodically examine all of the abdominal organs, identify space-occupying lesions and determine their size and consistency. When extreme pain to find education or boundary of the body is impossible, and in such cases more information is beneficial in determining the degree of pain study area and zones of its irradiation. If the diagnosis of peritonitis at this point is set deep palpation useless and Neumann. Deep palpation nowadays increasingly replaced by ultrasound scan and computed tomography to accurately and safely determine the size of internal organs and to detect the lesion.
Special attention palpation should be given to the examination of umbilical and inguinal and femoral rings of triangles to identify the hernia orifices of the channels and the possible infringement of the bodies.
Considerable help in the diagnosis of certain physical symptoms characteristic of certain diseases. Examples of such signs should be considered symptoms Sitkovskaya, Rousing, Bartomeu-Michelson and resurrection in acute appendicitis, symptoms Ortner, Kerala and Murphy in acute cholecystitis symptom Valya intestinal obstruction, symptom Mayo-Robson in acute pancreatitis.
In all cases of acute abdominal pain necessarily involves a careful examination of the pelvic area and rectum.
Digital examination of the vagina. Cautious introduction of only one well-oiled finger in the glove, you can get valuable information without resorting to the pressure on the abdomen. Thus it is possible to determine the tenderness of the urethra, vesico-vaginal folds and bladder. After that propel the finger up and reach the cervix. It is important to determine whether there is pain when moving the neck. If there is pain, the patient is asked to indicate in what place belly she feels it.
Then performed bimanual examination with the introduction of two fingers of one hand into the vagina, with the palm of the other hand palpates the abdomen and moving the bodies to the fingers introduced into the vagina. Palpation of the abdomen is performed by careful pressure in the direction of the symphysis. In this way determine the size, shape and consistency of the uterus, her tenderness. Then the fingers promote to the lateral vaginal fornix and with a slight pressure of the hand on the abdomen osupivaja appendages. Defining, thus, the consistency and tenderness of the epididymis, the doctor is able to decide, are the source of the pain of the epididymis, or the source of pain is higher.
In conclusion, examination of the index finger placed in the vagina, and well-lubricated middle finger into the rectum and feel recto-vaginal pocket on the protrusions.
Unilateral tenderness and palpation of the tumor - symptoms piosalpinks, BioWare or torsion of ovarian cyst. Soreness during the shift of the cervix during the study, characteristic of inflammatory diseases of the uterus and appendages. Tenderness to palpation knotty cervix, especially against the background of infertility, indicates the presence of endometriosis. Overhang the posterior vaginal fornix is characteristic of hemo-peritoneum or the accumulation of inflammatory exudate and is an indication for its diagnostic puncture. If this is nevertinamas blood or pus, the diagnosis becomes clear.
Digital examination of the rectum and held men and women. While appreciate the tone of the sphincter of the rectum, the nature of the content, the presence of pathological lesions and pain. Men feel both lobes of the prostate, seminal vesicles and urethrovesical peritoneal fold over the prostate. Overhang and sharp pain of the anterior wall of the rectum usually indicate the accumulation of inflammatory exudate in peritonitis ("Douglas Creek").
By rectal digital examination should always describe in detail the nature of feces. Liquid, tarry, black or maroon stools gives reason to suspect recent active bleeding from the upper gastrointestinal tract, and the presence of red blood pathologies of the sigmoid and rectum.
On the basis of complaints, anamnesis and physical examination the surgeon formulates preliminary (and sometimes final!) the diagnosis of the underlying disease or defines a narrow range of pathological conditions that give similar clinical picture. The doctor also identifies co-morbidities. The preliminary diagnosis is established at the initial examination of the patient, and determines the urgency and the amount of additional diagnostic tests.
Clinical examination of patients with acute diseases of the abdominal organs is not always possible to establish the correct diagnosis. A brilliant Clinician, S. P. Botkin in his time wrote: "I consider myself to be a good diagnostician, but I would be satisfied if 30 of my diagnoses were correct." Now even ordinary doctor can afford 70 erroneous diagnoses.
Over the past two decades in clinical practice introduced new highly informative methods of research, which greatly facilitated the diagnostic process. Currently the doctor has many objective methods of research, allowing you to quickly make an accurate diagnosis and determine the most effective treatment tactics. However, today doctors make a lot of mistakes. In emergency surgery, their frequency reaches 25 . That's why modern surgeon should have good understanding of laboratory diagnostic capabilities, endoscopic and radiological methods of diagnosis and to use them purposefully.
Regardless of their presumed diagnosis, primarily for suspected acute abdomen make the General analysis of blood and urine.
General analysis of blood. It is considered that the increase in the number of leukocytes in peripheral blood is a direct indicator of acute surgical pathology of abdominal organs. Leukocytosis, of course, characteristic of inflammation, although there are many exceptions to this rule. The shift of leukocyte formula to the left (increase in the relative number of immature granulocytes) is a more important diagnostic symptom than leukocytosis. Moreover, it is often significant leukocytosis is observed in diseases of non-inflammatory nature, (for example in the case of acute leukemia). The highest level of leukocytes occurs when rupture of the spleen and abnormalities of the mesenteric circulation. Under these conditions, it is greater than 20x109/L. At the same time, it must be remembered that the normal number of leukocytes is in the initial stages of intestinal obstruction, strangulated hernia, perforated ulcer and pancreatitis. Thus, counting the number of cells can be very useful for detection of acute process, but not always helps to clarify the diagnosis.
It is known that when bleeding occurs the reduction of hemoglobin and hematocrit, but it should be emphasized that in the early stages of this pathological condition these indicators usually are in the normal range even with significant blood loss (sometimes there may be an increase!), as for the offensive balance between the volumes of intra - and extravascular fluids and the development of compensatory hemodilution takes several hours.
Nonspecific tests, such as determination of ESR as a rule, completely useless in the diagnosis of acute diseases of abdominal organs, but can also serve as markers of ongoing pathological process.
The General analysis of urine. For analysis we take the average portion, but among women this should be done after washing. As this will in the urine may be vaginal discharge or blood, in the worst case scenario analysis should be repeated using the urine drawn by catheter. Hematuria confirms the diagnosis of renal colic, though it is not a mandatory feature. Pyuria and bacteriuria indicate a urinary tract infection. With piurii mandatory urine and to determine the sensitivity of microflora to antibiotics. Proteinuria is a nonspecific symptom. Urine specific gravity allows to estimate the water balance. The increased ratio of urine may reflect dehydration or glucosuria.
All women with acute pain in the pelvic area and the delay period should be tested for pregnancy. Such probes are typically highly sensitive uterine pregnancy, but less sensitive when ectopic her character. Ectopic pregnancy in 50 cases give false negative results of such tests, and in the presence of protein in the urine they may be a false positive. Radioimmunoassay determination of beta-subunit of human hCG stimulation (HCG) in plasma high-sensitivity ectopic pregnancy and can provide a positive result in the first month of pregnancy.
The amylase activity of the blood is determined in cases of suspected pancreatitis. Significant increase in the level of amylase confirms the diagnosis. In acute pancreatitis, the amylase activity usually reaches its maximum in a day and returning to normal by the end of 2-3 days. Nevertheless, even in patients with severe pancreatitis, the amylase concentration may not be elevated, usually with extensive pancreatic necrosis. Many other acute diseases of abdominal organs, such as cholecystitis, bowel ischemia, perforation, and bowel obstruction also cause mild elevation of serum amylase level. Since this enzyme excreted by the kidneys, renal failure its activity in serum is also increasing. Thus, anilazine observed in a large number of diseases, reduces the diagnostic value of this index, but a high level of amylase characteristic only for acute pancreatitis.
Biochemical blood test is used mainly to assess the extent of concomitant liver and kidneys. Elevated levels of creatinine, urea and potassium are characteristic of renal failure. High level ACT and ALT indicates the involvement of hepatocy tov in hepatitis and moderate increase occurs in acute cholecystitis and obstructive jaundice. Hyperbilirubinemia is predominantly due to the direct bilirubin and increased levels of alkaline phosphatase pathognomonic for obstructive jaundice.
Water and electrolyte disturbances are most pronounced in intestinal obstruction and pancreatitis. Along with signs of hypovolemia in these States fairly quickly develop deficiency of vital potassium ions, requiring timely and adequate correction. Hypokalemia also pathognomonic and mechanical jaundice.
Laboratory examination of patients with acute pathology of the abdominal cavity in addition to the diagnosis of the underlying disease and detection of related violations must include a definition of blood group and rhesus factor, the study of hemostasis. Many diseases and injuries of the abdomen complicated by bleeding and require transfusion of blood components. A significant part of urgent surgical patients is surgical intervention. The risk significantly increases with impaired coagulation.
The causes of anticoagulation and increases the risk of bleeding - thrombocytopenia, liver disease, jaundice, prolonged treatment with antibiotics and anticancer drugs, administration of anticoagulants and antiplatelets, hemophilia. All patients who have surgery, you must have a minimum holding of common coagulation tests such as bleeding time and prothrombin time. More accurate and informative indicators of the international normalized ratio ( MHO) and activated partial thromboplastin time (APTT). Their definition should be mandatory when using anticoagulants. If there is clinical evidence of increased bleeding, especially when normal coagulation tests, you first need to study the number of blood platelets, and their functional activity. Due to the high prevalence of diseases such as hepatitis b and C, syphilis, increase of infection by the human immunodeficiency virus are considered mandatory laboratory studies of markers of these diseases.
Radial methods of diagnostics
Ultrasonography (ultrasound) should be recognized as one of the most significant advances in medicine over the past two decades. Technique this study has been improved to such an extent that this procedure has become the most common acute abdomen, helping to accurately diagnose many diseases of the abdominal cavity, Sabry-tire space and pelvis. To undoubted advantages of ultrasound include the quickness, relative efficiency, the trauma and no danger of exposure.
When scanning in oblique projection through the intercostal space is visualized podkapsul'nye ruptured spleen.
For ultrasound use linear, sector and convex probes with a frequency of 3.5 to 7.5 MHz. Typically, ultrasound is performed in b-mode. In cases of necessity it is possible to use digital zoom images (ZOOM). In assessing the state of regional and organ blood flow widely used color modes (DRC) and energy (TSEC) mapping, pulsed Doppler (ID). In the last decade appeared thin sensors that can be inserted via a catheter into the blood vessels and bile ducts, to obtain an image of a wall of a vessel or duct, probes, combined with fibre-optic endoscopes for visualization of the bowel wall, andaluminum sensors for razvlekavshego and transrectal examination.
Despite technological advances, the study urgently the quality of the obtained diagnostic information still depends on the potential acoustic interference, caused largely by gas in the bowel, which fully reflect the ultrasound. In this connection it is necessary to use the whole spectrum of methods and approaches scan that allow you to increase the efficiency of the examination unprepared for the study of patients (such as in emergency surgery the majority!). Informative research increases if the inspection is carried out after 6-10 hours after the last meal. In the absence of contraindications, it is appropriate to conduct cleansing enemas and medical correction of flatulence. Ultrasound is also necessary to perform radiographic contrast studies with barium suspension, which greatly complicates adequate visualization.
Usually ultrasound examination begins with inspection of the liver, gallbladder, pancreas, spleen and kidneys. Subsequently assess the state of the gastrointestinal tract. Special attention is paid to the presence of free fluid in the abdominal cavity, the retroperitoneum and pelvic cavity. Research should be carried out in various provisions of the patient: on the back, naturopathica, and in some cases standing or sitting.
Liver disease. To obtain a satisfactory image of liver scanning is performed in the epigastrium and right hypochondrium in oblique, longitudinal and transverse planes. In obese patients and in patients with severe flatulence it is advisable to use the access from the intercostal spaces. The study is performed with the patient lying on his back or on his left side, in different phases of respiration. During the inspection of the liver determine the size of its share, the state of the edges, record the presence of focal and diffuse lesions of the parenchyma (large and melanochlamys cirrhosis). Obligatory condition of the study should be considered as the measurement of the diameters of the hepatic vessels and ducts: portal vein, hepatic veins and inferior Vena, hepatic artery, left and right lobar ducts. Certainly need to identify the symptom "dostalek", which is due to dilatation of intrahepatic segmental ducts. When conducting research, it is necessary to consider and sonographic features
paintings that may arise when applying the surrounding organs and structures on the image of the liver.
Ultrasound is used to determine the size of the liver, to detect the presence of an abscess, cysts, hemangiomas, metastases, and to carry out differential diagnosis of jaundice. The main feature that distinguishes parenchymatous jaundice from mechanical, is the lack of expansion of intra - and extrahepatic bile ducts.
Acute cholecystitis. In recent years, acute cholecystitis was the most common acute disease of the abdominal organs. The use of ultrasound delivered the diagnosis of acute cholecystitis at a qualitatively new level, allowing not only to determine the nature of pathological changes in the gall bladder, but also to assess the condition of the bile ducts, to identify other changes in pancreatobiliary zone. The effectiveness of ultrasound diagnosis of acute cholecystitis is 99 , which greatly exceeds the capabilities of laparoscopy. Using this method, you can successfully solve all the tactical issues of urgent biliary surgery.
To determine the prognosis of the pathological process in acute cholecystitis and choice of method of treatment is useful to distinguish four variants ultrasound picture.
I option - acute cholecystitis without evidence of the destruction of the wall of the gallbladder. This variant is characterized by enlargement of the gallbladder, especially its lateral size (35 mm). In the gallbladder lumen is defined heterogeneous content, concrements, "suspension". The gallbladder wall is homogeneous, with smooth contour is thickened to 4 mm.
Option II - acute cholecystitis with evidence of destruction of the wall of the gallbladder. In this embodiment, the thickness of the gallbladder wall greater than 4 mm, it becomes inhomogeneous and "layered". Inside it are displayed anehogennoe zone, blurred or irregular inner contour.
Alternative III - acute destructive cholecystitis signs local perepisi-tion changes. The latter are visualized in the form of hyperechoic areas with indistinct irregular contours around the gallbladder with the development of the inflammatory infiltrate and anehogennoe sections of different forms in the cases of occurrence of accumulations of fluid or the formation perivesical abscess.
IV option - acute destructive cholecystitis with local or generalized peritonitis. In these patients with ultrasound free fluid visualized in subhepatic space and other departments of the abdominal cavity.
Biliary colic. In biliary colic gall bladder is normal in size, thickness of its walls does not exceed 2-3 mm and has smooth contours, homogeneous. In the lumen of the bladder, especially in the neck, usually defined concretions.
Obstruction of the bile ducts. For optimal visualization of the biliary system scan is performed in several planes: longitudinal, transverse and oblique. The most common approaches are: oblique access from under the edge of the right costal arch, accesses through the intercostal spaces in the anterior axillary and mid-clavicular lines on the right. In most cases, the required delay is breathing in the background of deep breaths to minimize respiratory artifacts.
When conducting a condition assessment of the extrahepatic bile ducts assess the condition of hepaticopsida, the length of his visualization. Normal its diameter is less than 7-8 mm. Increasing the diameter of the reveal the cause of his dilation: the presence of concretions in the lumen, the lesion of the pancreatic head and pericholedochal lymph nodes, the presence of cancer in subhepatic space.
In 10-15 of patients with acute cholecystitis is accompanied by pathology of the extrahepatic bile duct and obstructive jaundice. In this situation, the ultrasound reveals the expansion of both the extrahepatic, intrahepatic ducts. The accuracy of the determination of extrahepatic cholestasis by the presence of dilated intra - and extrahepatic ducts with ultrasound and high is 96 . Rare causes of dilated ducts in the absence of obstacles include Caroli disease (congenital ectasia of the intrahepatic ducts and congenital cyst of the common bile duct. To determine the level of obstruction in obstructive jaundice using echography, perhaps in 90 cases, and to establish its cause - only 50-75 .
Acute pancreatitis. In connection with the peculiarities of the anatomical structure and location of the study of the pancreas difficult. Often ultrasound imaging of the pancreas prevent gases in the stomach and duodenum. To improve use the following techniques: delay, deep breath, and prolonged compression of the sensor, in which there is a gradual displacement of air from predlagash gastrointestinal tract. In pathological processes, accompanied by gastrostomy, stomach, on the contrary, is an acoustic window, because it is full of liquid contents and allows you to more clearly visualize the pancreas. In some cases, to improve the diagnostic capabilities of ultrasound, can fill the stomach liquid.
The study of the pancreas is performed in the longitudinal, transverse and oblique planes. Mutually perpendicular sections allow you to visualize various departments and structures, which is important for correct diagnosis. Besides scanning of the pancreas is possible through the intercostal spaces and parenchyma of the spleen. Usually this access is used to detect space-occupying lesions of the tail of the pancreas and the nature of their anatomical and topographical location.
When interpreting an ultrasound image of the pancreas carry out its dimension in the direction perpendicular to the plane along the front surface of each of its divisions, the evaluation circuit ehoplotnosti and uniformity of the pancreas, the homogeneity of the surrounding cellular tissue.
In acute pancreatitis ultrasonic method of research allows to identify both direct and indirect signs of the pathological process. Direct signs include: increased size of the head, body or tail of the pancreas over 27-29 mm, blurred, and blurred its outline, the absence of a clear boundary between breast tissue and the splenic vein, the heterogeneity of the parenchyma, weakening the transmission of pulsation of the aorta, the expansion of the Wirsung duct diameter more than 2 mm. The indirect signs are: paretic the extension of transverse colon and loops of the small intestine, the presence of infiltrative changes in the projection of the pancreas and the retroperitoneal tissue, the availability of free and reduced fluid in the abdominal cavity.
Pathology of the spleen. A study of the spleen is also fraught with difficulties. They are caused by the peculiarities of the anatomical location of the body (occurring behind the ribs acoustic shadows complicate the visualization of the greater part of the spleen). In addition, anterior to the spleen is the gas bubble of the stomach, and the top adjacent the left lung.
Examination of the spleen was carried out as from the left hypochondrium, and of the intercostal spaces, and from the back. Scanning is carried out by sections, performed in different planes, the provisions of the patient. Scan start with the patient on the back, which rarely achieve good results. The most informative scan of the intercostal spaces with the patient on his right side with a wound of the head with the left hand. This clarifies topographical relationships with the left light and left kidney.
As a result of a properly done research get the image of the spleen along the long axis of the body, including the gates with a clear visualization of blood vessels. In this scanning plane is measured lengthwise of the body, maximum sagittal dimension on the level of the gate of the spleen (width), evaluate the contour and condition of the parenchyma.
Most recurrent surgical pathology of the spleen is the destruction of its tissue, subcapsular hematoma, hematoma in the depth of the parenchyma, resulting from trauma, or inflammatory changes with abscess formation.
Acute intestinal obstruction. Normal bowel loops are not visualized. With the development of the clinical picture of mechanical or dynamic intestinal obstruction visualization of bowel loops is possible, due to the extension of the lumen of the intestine due to sequestration of fluid in the lumen. Only the presence of the symptom intraluminal deposition of a liquid enables an ultrasound to see the colon and to evaluate its condition: to measure the diameter, wall thickness, to visualize mucosal folds, judge the nature of the peristaltic movements.
In longitudinal scanning loop of intestine has the form of a cylinder with clear contours of the walls and inhomogeneous liquid contents in the lumen. Mucosal folds are determined in the form of a linear echo-positive structures arranged perpendicularly to the wall at a distance of 3-4 mm from each other. While transverse scanning bowel loops are a rounded education with clear contours of the walls and a liquid content in the space, while the folds of the mucosa are usually not defined.
In patients with intestinal obstruction, visualization of bowel loops from the anterior abdominal wall uninformative. This is due to the fact that the patient in a horizontal position on his back, the air accumulates above the liquid level and makes it difficult to scan. In this regard, inspection of the loops of bowel in patients with intestinal obstruction is needed from the side and from the intercostal space, using the acoustic window of the liver and spleen.
Bowel loops with fluid contents in the lumen can be identified in specific areas of the abdomen, and to occupy the entire abdominal cavity. Visualization of bowel loops located in the pelvis, is best done with a full bladder. When examining loops kishen