It was an incident some 12 years back. I entered into the surgical ward in our hospital only to find a boy’s right lower limb in traction.I thought the child perhaps is suffering from some orthopedic condition.
It is learnt that my senior surgeon has applied the traction to the boy.History taking revealed that the boy had fever at least for one week followed by limping gait.He was unable to stand erect and had to bent at the right hip.This was due to pain in the right lower abdomen.Incidentally the treating surgeon also came in and told me about it.So I asked our attendant to release the traction and made the boy stand.There was a distinct bend at right hip as the boy was having pain.The limb can not be made straight even passively.There was a diagnosis in my mind.The boy was asked to to lay down and I palpated the painful site in the lower abdomen. My diagnosis was found to be correct as similar cases had been seen by me some time back.One hard lump was felt in the right lower abdomen nearer to the inguinal region.That was a case of psoas abscess.
So this is a sort of spot the diagnosis for the doctor if he had seen it earlier .The mind knows it.If not,the doctor is sure to be in darkness .Of course, now-a-days it has been made easy by ultrasonogram.At that time ultrasound was not available in those places.Had it been to-day I would have ordered for an ultrasonogram.My senior colleague was skeptical about the diagnosis.The treatment was to drain the abscess either under general or local anaesthesia.Once pus comes out the patient is bound to get a lot of relief.
We took him to the operation theater to drain it.The knife was with me.First, I palpated the most painful and prominent part of the lump.I aspirated the lump and scanty pus was out in the syringe.But my colleague did not appreciated that.Still I went ahead to make an incision on that part by knife.Then I took another instrument called sinus forceps to make a path to the lump from outside.Pus was not found .Again it was a victory time for my senior colleague . He tried to persuade me to abandon the procedure.But I did not move.I knew that the path of exploration was not right.I tried again and could reach the lump.A gush of pus came out under pressure to much the relief of the patient and of course,myself.
At that time only, my senior could appreciate that.So in medical science there are some diseases which are to be spot diagnosed .Now a days it is much easier.Diagnosis is to be confirmed by ultrasound and an ultrasound guided needle will invariably yield pus.But we lack the clinical confidence to-day.
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Acid peptic disease commonly affects stomach,duodenum and/or lower esophagus .An uncommon site is Mackel’s Diverticulum. There may be the presence of ectopic stomach mucosa to cause the symptoms.Here there is the same pathology to cause ulcer or inflammation.
Mackel’s diverticulum is an out pouching of intestine in it’s lower end.It is of short length and is blind.The pain here may not have a time relation to food or periodicity.Sometimes it causes perforation.Pain is felt little to the right side of umbilicus .May confuse with an appendicitis or a stone in the right ureter.
It is difficult to diagnose.An ultrasonogram ,CT or barium meal follow through may help in diagnosis.Now-a-days a capsule endoscopy will accuratey diagnoses it.Nuclear imaging may help in diagnosing Mackel’s diverticulitis. Many a times when a normal looking appendix is found in a surgery for appendicitis a Mackel’s diverticulum is searched for.
Treatment is only surgery and is very effective.
- Interior Of Stomach
Pain in middle of upper abdomen in a commonly encountered complain from patients in any hospital.There are vast nuber of causes for it.Many of them are for academic interest.Among the most commonly encountered conditions Acid Peptic disease is one.
Here there is pain in the middle of upper abdomen .This pain may come in empty stomach or after taking food.It is typically colicky in nature,sometimes subsides after taking food or aggravated after taking food.It my appear seasonally in the winter.Gradually this timing of pain changes and pain is always felt. There may appear vomiting which may contain freshly eaten food to stale food, blood and bile.Some times there occurs blood vomiting and passing of black stool.Some times patient may present in the emergency with a complication called perforation of stomach or duodenum.
This disease may be seen in the stomach,duodenum,Lower esophagus or in a mackel’s diverticulum.The symptoms and signs may differ according to the site of disease. To-day we will see the disease of stomach and duodenum.
- Endoscopy Image of Stomach Ulcer
Hydrochloric acid secretion is an integral part of stomach inner layer called gastric mucosa.There in also secretion of protein digesting enzyme called pepsinogen.The digestion of own gastric mucosa hangs on a fine balance between the secretions and mucosal defense. Mucosal defense rests on the amount of bicarbonate and mucus present in the stomach.There are various means to dis-balance it.It my be stress and strain,Ingestion of analgesics and steroid,Severe trauma lading to blood loss and infection by a microbe called H.Pylori. There may occur inflammation to ulcerations in mucosa and may progress to other layers of stomach and duodenum.
The disease can very nicely be diagnosed by an endoscopy.This can be treated by newer proton pump inhibitor drugs.This drug has left the surgical option for this disease limited to the complications only.If drug treatment fails nice surgical options are available.
- A Lipoma On Abdominal Wall.
Patient comes with a swelling on his body to a doctor which has been there for along period.Many swellings are seen on the body surface which have to be differentiated from each other .A lipoma is a swelling on the body surface.This is painless,no pain on pressure,can be pushed in different directions to a little extent and soft to firm. And some amount of fluctuation as observed in fluid containing cavities can be elicited. This is not an actual fluctuation, called a pseudo-fluctuation .It grows in size over the years without much problem except a disfigurement. It can grow in any site but commonly in the neck region ,forehead and abdomen are affected.It also can be seen in the body cavities and near vital areas can to cause problem due to pressure.
It is a benign tumor of fat cells .Can be diagnosed basing the on the above findings.A fine needle aspiration cytology will clinch the diagnosis. An ultrasonogram is also helpful.Lipoma very rarely may turn to malignancy called a Liposarcoma.One important feature of this tumor is that it burrows into the surrounding tissue if not capsulated.But many times it is capsulated.
- Removed Lipoma
Surgical removal is the answer under local,regional or general anaesthesia.Recovery is uneventful and recurrence is usually not seen.If tumor tissue incompletely removed from holed up locations fear of recurrence remain.
- Flexible Endoscope.
One patient came to me in great distress with hiccup,pain in the abdomen and inability to stand. Apart from this ,patients present to a doctor with complains of vomiting of stale food some hours or days of taking food.There is loss of appetite ,weakness,malnutrition,hiccup and desire to induce vomiting to get relief from pain.
These are the cardinal symptoms of obstruction to passage of food from stomach called Pyloric obstruction/Duodenal stenosis.Causes are varied.Important common cause are development of stenosis after a benign duodenal or pyloric ulcer,a cancer obstructing the passage from stomach and a foreign body such as leaves or hair ball(eaten) seen in psychotics.After invent of stomach acid suppressing drugs these cases are seldom seen.But the patient in question was a road side vendor with irregular and bad eating habit.The patient said that he is in empty stomach .So to find out the cause in hope of some interesting findings the endoscope was put. (more…)
