‫‪2024‬‬

‫كلية التمريض‬

‫جامعة المنوفية‬

‫الجراحة العامة‬
‫‪Dr | Ahmed Al-kilani‬‬
 Acute Appendicitis
Acute Appendictis: Is a severe and sudden case of appendicitis.

The symptoms tend to develop quickly over the course of one to two days . It requires
immediate medical treatment. If left untreated, it can cause your appendix to rupture. This can
be a serious and even fatal complication

Symptoms: Constipation; Abdominal pain; Pain

What causes appendicitis?

 Blockage of the opening inside the appendix.
 enlarged tissue in the wall of your appendix, caused by infection in the gastrointestinal
(GI) tract or elsewhere in your body.
 inflammatory bowel disease.
 stool, parasites, or growths that can clog your appendiceal lumen.
 trauma to your abdomen

Risk Factors
 Family history
o Twin studies suggest that genetics account for 30% of risk*
 Ethnicity
o More common in Caucasians, yet ethnic minorities are at greater risk of perforation if they
o do get appendicitis

 Environmental
o Seasonal presentation during the summer

Differential Diagnosis
There are a wide spectrum of potential differentials for suspected cases of appendicitis:

 Gynaecological: ovarian cyst rupture, ectopic pregnancy, pelvic inflammatory disease

 Renal: ureteric stones, urinary tract infection, pyelonephritis

 Gastrointestinal: inflammatory bowel disease, Meckel’s diverticulum, or diverticular disease*

 Urological: testicular torsion, epididymo-orchitis

*No specific gene has been identified specifically, but the risk is roughly three times
higher in members of families with a positive history
Investigations
Laboratory Tests

Urinalysis should be done for all patients with suspected appendicitis to help exclude

any renal or urological cause*. For any woman of reproductive age, a pregnancy test is

also essential.

Routine bloods, importantly FBC and CRP, should be requested to assess for raised

inflammatory markers, as well as baseline blood tests required for potential pre-operative

assessment. A serum β-hCG may also be taken, if ectopic pregnancy still has not been

excluded.

*Leucocytes can be present in the urine in low levels for those with an appendicitis,

especially if the appendix lies on the bladder

Imaging

Imaging is not essential to diagnose an appendicitis, as cases can be

a clinical diagnosis. Indeed, in certain cases (especially paediatrics), serial

examinations may be the only method employed to make the diagnosis.

Ultrasound scan or CT imaging (Fig. 3) are often requested if the clinical features are

inconclusive and an alternative diagnoses are equivocal:

Ultrasound – good first line investigation (especially with a transvaginal approach) if the

differential includes gynaecological pathology

Useful in children as can minimise radiation exposure

Computed Tomography – Good sensitivity and specificity, able to delineate multiple

differentials including gastrointestinal and urological causes

 Acute Cholecystitis
Acute cholecystitis is inflammation of the gallbladder. It usually happens when a gallstone
blocks the cystic duct.

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. The
cystic duct is the main opening of the gallbladder.

Symptoms

Signs and symptoms of cholecystitis may include:

 Severe pain in your upper right or center abdomen

 Pain that spreads to your right shoulder or back

 Tenderness over your abdomen when it's touched

 Nausea

 Vomiting

 Fever

Causes

Cholecystitis occurs when your gallbladder becomes inflamed. Gallbladder inflammation

can be caused by:

 Gallstones. Most often, cholecystitis is the result of hard particles that develop in your
gallbladder (gallstones). Gallstones can block the tube (cystic duct) through which bile
flows when it leaves the gallbladder. Bile builds up, causing inflammation.

 Tumor. A tumor may prevent bile from draining out of your gallbladder properly,
causing bile buildup that can lead to cholecystitis.

 Bile duct blockage. Kinking or scarring of the bile ducts can cause blockages that
lead to cholecystitis.

 Infection. AIDS and certain viral infections can trigger gallbladder inflammation.

 Blood vessel problems. A very severe illness can damage blood vessels and
decrease blood flow to the gallbladder, leading to cholecystitis.


Risk factors

Having gallstones is the main risk factor for developing cholecystitis.

Complications

Cholecystitis can lead to a number of serious complications, including:

 Infection within the gallbladder. If bile builds up within your gallbladder, causing
cholecystitis, the bile may become infected.

 Death of gallbladder tissue. Untreated cholecystitis can cause tissue in the

gallbladder to die (gangrene). It's the most common complication, especially among
older people, those who wait to get treatment, and those with diabetes. This can lead
to a tear in the gallbladder, or it may cause your gallbladder to burst.

 Torn gallbladder. A tear (perforation) in your gallbladder may result from gallbladder
swelling, infection or death of tissue.

Prevention

You can reduce your risk of cholecystitis by taking the following steps to prevent gallstones:

1. Lose weight slowly. Rapid weight loss can increase the risk of gallstones. If you
need to lose weight, aim to lose 1 or 2 pounds (0.5 to about 1 kilogram) a week.

2. Maintain a healthy weight. Being overweight makes you more likely to develop
gallstones. To achieve a healthy weight, reduce calories and increase your physical
activity. Maintain a healthy weight by continuing to eat well and exercise.

3. Choose a healthy diet. Diets high in fat and low in fiber may increase the risk of
gallstones. To lower your risk, choose a diet high in fruits, vegetables and whole
grains.

Diagnosis : Blood tests. - Imaging tests that show your gallbladder.

 A scan that shows the movement of bile through your body. Blood tests.
 Acute Pancreatitis

Acute pancreatitis means inflammation of the pancreas that develops quickly. The
main symptom is tummy (abdominal) pain. It usually settles in a few days but sometimes
it becomes severe and very serious. The most common causes of acute
pancreatitis are gallstones and drinking a lot of alcohol.

Causes of acute pancreatitis

Gallstones

Alcohol

High blood fat levels

Uncommon causes

Autoimmune

Symptoms of acute pancreatitis

 Tummy (abdominal) pain, just below the ribs, is the usual main symptom.

 Being sick (vomiting), a high temperature (fever) and generally feeling

very unwell are common.

 Your abdomen may become swollen.

 If the pancreatitis becomes severe and other organs become involved

Factors that increase your risk of pancreatitis include:

 Excessive alcohol consumption.
 Cigarette smoking. ...
 Obesity. ...
 Family history of pancreatitis.

Differential Diagnosis

There are a wide variety of causes of an acutely painful abdomen, as discussed

elsewhere. However causes specifically resulting in abdominal pain that radiates through
to the back include abdominal aortic aneurysm, renal calculi, chronic pancreatitis, aortic
dissection, or peptic ulcer disease.
Clinical Features
Patients will classically present with a sudden onset of severe epigastric pain, which

can radiate through to the back, with nausea and vomiting.

On examination, there is often epigastric tenderness, with or without guarding.

In severe cases, there may be haemodynamically instability, due to the inflammatory

response occurring.

Less common signs that are often described are Cullen’s sign (bruising

around the umbilicus, FIg. 2A) and Grey Turner’s sign ( bruising in the flanks,

Fig. 2B) , representing retroperitoneal haemorrhage. Tetany may occur

from hypocalcaemia ( secondary to fat necrosis) and, in select cases,

gallstone aetiology may also cause a concurrent obstructive jaundice.

Investigations
Laboratory Tests

Routine blood tests, as per investigation of any acute abdomen, are required. Specifically

for acute pancreatitis, it is important to consider:

Serum amylase – diagnostic of acute pancreatitis if 3x the upper limit of normal*

Amylase can also be marginally raised in pathologies such as bowel perforation, ectopic

pregnancy, or diabetic ketoacidosis

LFTs – assess for any concurrent cholestatic element to the clinical picture

Patients with acute pancreatitis noted that an alanine transaminase (ALT) level

>150U/L has a positive predictive value of 85% for gallstones as the underlying cause
 Serum lipase – A raised serum lipase is more accurate for acute pancreatitis (as it

remains elevated longer than amylase), yet it is not available or routinely performed in

every hospital

Acute abdomen
Acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a

medical emergency, requiring urgent and specific diagnosis. Several

causes need immediate surgical treatment.

Most Common Abdominal Pain Causes

 Irritable Bowel Syndrome. Irritable Bowel Syndrome (IBS) is one of the most common

abdominal pain causes that doctors treat. ...

 Constipation. Constipation is another common cause of abdominal pain. ...

 Appendicitis.

 Lactose Intolerance.

 Ulcerative Colitis.

Risk factors for abdominal pain

 Older age.

 Prior abdominal surgery.

 History of bowel disorders.

 Exposure to stomach virus

Differential Diagnosis
The location of abdominal pain is one useful feature that helps narrow the differential.

These can be classified based upon quadrant or region affected, as shown in Fig. 2.
It must be remembered to always consider extra-abdominal organs as the cause for

abdominal pain, including cardiac, respiratory, and gynaecological or testicular

conditions.

Investigations
Laboratory Tests

The investigations in all cases of the acute abdomen share the same generic outline:

Urine dipstick – for signs of infection or haematuria ±MC&S. Include a pregnancy test for all

women of reproductive age

Arterial Blood Gas – useful in bleeding or septic patients, especially for the pH, pO2, pCO2, and

lactate for signs of tissue hypoperfusion, as well as a rapid haemoglobin level

Routine bloods – FBC, U&Es, LFTs, CRP, amylase*

Do not forget a group & save (G&S) if the patient is likely to need surgery soon

Blood cultures – if considering infection as a potential diagnosis

*Any amylase 3x greater than the upper limit is diagnostic of pancreatitis. Any raised value lower

than this may also be due to another pathology, such as perforated bowel, ectopic pregnancy, or

diabetic ketoacidosis (DKA)

Imaging

Following assessment, initial imaging may help to further help focus the diagnosis if still unclear:

An erect chest plain film radiograph (e CXR) – for evidence of free abdominal air (Fig. 3) or

lower lobe lung pathology

Ultrasound

Kidneys, ureters, and bladder (‘KUB’) – can check for hydronephrosis and cortico-medullary

differentiation
Biliary tree and liver – can check for the presence of gallstones, gallbladder thickening, or duct

dilatation

Transvaginal – for suspected tubo-ovarian pathology

CT imaging of the abdomen, often best discussed with a senior depending on the suspected

underlying diagnosis if required

In the emergency setting, every patient with abdominal pain should also have

an electrocardiogram to exclude cardiac pathology, as referred pain

Breast cancer
Breast cancer is cancer that forms in the cells of the breasts.

After skin cancer, breast cancer is the most common cancer diagnosed in women in the
United States. Breast cancer can occur in both men and women, but it's far more common
in women.

Causes
Doctors know that breast cancer occurs when some breast cells begin to grow abnormally.
These cells divide more rapidly than healthy cells do and continue to accumulate, forming a
lump or mass. Cells may spread (metastasize) through your breast to your lymph nodes or
to other parts of your body.

Risk factors
 Being female.

 Increasing age.

 A personal history of breast conditions.

 A personal history of breast cancer.

 A family history of breast cancer.

 Obesity.
Diagnosis=
:

Breast cancer can be diagnosed through multiple tests, including a mammogram,

ultrasound, MRI and biopsy.
Diagnostic Mammogram

Ultrasound

MRI

Lab Tests

Waiting For Results

Intestinal Obstruction
Definition:

Intestinal obstruction involves a partial or complete blockage of the

bowel that results in the failure of the intestinal contents to pass through.

Causes

Obstruction of the bowel may be caused by ileus, in which the bowel

doesn't function correctly called Functional obstruction or by mechanical

causes called Mechanical obstruction.

1) Functional obstruction: The intestinal musculature cannot

Propel the contents along the bowel.

Thyroid abnormalities are basically classified into three typesas the

following:
 Hypothyroidism

Clinical manifestations

Symptoms

Crampy pain that is wavelike and colicky

Abdominal distention

Projectile Vomiting ( is a type of severe vomiting in which

stomach contents can be forcefully propelled several feet away from the patient)

The patient may pass blood and mucus but no fecal matter and no flatus

Dehydration

If the obstruction continues uncorrected, hypovolemic shock

occurs from dehydration and loss of plasma volume.

In the large intestine, dehydration occurs more slowly than in the small

intestine because the colon can absorb its fluid contents .

Thyroid Disorders

Signs

While listening to the abdomen with a stethoscope reveals high-pitched at

the onset of mechanical obstruction.

If the bowel obstruction has persisted for too long or the bowel has

been significantly damaged, bowel sounds decrease, eventually becoming silent.

Early paralytic ileus is marked by decreased or absent bowel sound

The unmistakable signs of dehydration become evident: intense thirst,

drowsiness, generalized malaise, aching, and a parched tongue and

mucous membranes.

Assessment and Diagnostic Findings

Diagnosis is based on the symptoms described previously

 Imaging studies. Abdominal x-ray and CT findings include abnormal

quantities of gas, fluid, or both in the intestines.

Laboratory studies (i.e., electrolyte studies and a complete…

Function of Thyroxin and Triiodothyronine

The primary function of the thyroid hormone is to control the cellular

metabolic activity. T4, a relatively weak hormone, maintains body metabolism

in a steady state. T3 is about five times as potent as T4 and has a more rapid

metabolic action. These hormones accelerate metabolic processes by increasing

the level of specific enzymes that contribute to oxygen consumption and altering

the responsiveness of tissue to other hormones.

Hyperthyroidism

Definition

Hypothyroidism refers to a deficiency of thyroid hormone in the adult,

resulting in slowed body metabolism due to decreased oxygen consumption by

the tissues and pronounced personality changes. The term hypothyroidism is not

synonymous with myxedema.

Clinical Manifestations

1. Extreme fatigue make it difficult of the person to complete a full day's work

2. Hair loss, brittle nails and dry skin are common and numbness and

tingling of the fingers may occur.

3. The voice may become husky and the patient may complain from

hoarseness. Menstrual disturbances as menorrhagia or amenorrhea occur.

4. Hypothyroidism affect women five times more frequently than men and

occurs most often between 30 and 60 years of age

5. Severe hypothyroidism results in a subnormal temperature and pulse rate.

6. The patient usually begins to gain weight even without an increase food intake.

7. The hair thin and falls out, the face become expressionless and mask like.

8. The patient often complains of being cold even in a warm environment

Definition: It is an enlargement of the thyroid gland

Complications of hyperthyroidism (Graves' disease):

The three major complications of Graves' disease are

(1) Exophthalmos

(2) Heart disease

(3) Thyroid storm (thyroid crisis, thyrotoxicosis)

Hyperthyroidism is the second most common endocrine disorder, after

diabetes mellitus. Graves's disease, the most common type of hyperthyroidism

result from an excessive output of thyroid hormones

3-Goitre

Clinical manifestations:

a) If the goitre is small and Euthyroid, it has no clinical significance

b) If the goitre is very large, it may cause cosmetic deformity

c) May compress trachea and cause pressure symptoms.

d) Confusion with a thyroid neoplasm (fine-needle aspiration biopsy may be helpful).

e) Vena cava compression: if raise arms, Pembertons sign, their face turns cyanotic

Risk Factors:

Endemic goiter occurs in clients living in areas that are iodine-deficient in

the soil and water. The use of iodized salt and food additives has almost

eliminated this problem in this country.