Aspect

Diagnosis

Epidemiology

(Who gets it? What are

enabling conditions?)

Temporal course

(How do the

symptoms develop

over time?)

Key features

(What are the main signs and

symptoms of the disease?*)

Pathophysiological

mechanisms

(What mechanisms cause

the disease and its

features?)

1. Acute appendicitis 80% of cases occur

between the ages of 5 and 35 years.

; males are affected

slightly more often than

females.

atypical presentation is

more common in very

young, elderly, pregnant

and immunosuppressed

patients

Initially, patients have

slight—at times only vague—abdominal

discomfort that is

present diffusely

throughout the

abdomen over a

period of less than

24 hours Eventually,

the pain become

pronounced, steady

and are localized to a

smaller area.

Beginning classically in the periumbilical

region, the initial

visceral pain of acute

appendicitis shifts to

become sharper

parietal pain localized

in the right lower

quadrant when the

overlying

peritoneum

becomes directly

inflamed

Periumbilical (referred)

become localized right lower quadrant (anatomic)

(right anterior iliac fossa)

abdominal pain

Physical examination findings:

- guarding

- rebound tenderness

- Maximum pain at McBurney's

point.

- Rovsing sign.

- Blumberg sign.

- Psoas sign.

- obturator sign (in pelvic appendix)(rare)

onset of pain followed by

Classic Features (2):

Nausea and vomiting

(maybe absent)

Anorexia

Low fever + leukocytosis

pain is exacerbated by

movement and coughing

(Initial) atypical or

nonspecific features (2): -

● Diarrhea

●Flatulence

●Bowel irregularity

● Indigestion

●Generalized malaise

normal true

diverticulum of the cecum

Obstruction causes:

- Lymphoid follicles

hyperplasia.

- Fecoliths.

- Tumor.

- Parasites.

rise in intraluminal

pressure that compromise

venous outflow. >

oedema, > circulatory disturbances + infection >

peritonitis > appendical

mass if left within 5 days

Diagnosis of acute

appendicitis requires

neutrophilic infltration

of the muscularis

propria.

2. Diverticulitis -The mean age is 63

years,incidence is lower in

younger individuals,

-low fiber western diet

- history of previous

constipation

The acute onset of a

gradual, steady pain

in the left lower

quadrant is most

common. Right lower

quadrant pain occurs

) The pain is usually in the

left lower quadrant due to

involvement of the sigmoid

colon. However, patients may

have right lower quadrant

or suprapubic pain due to

Reduced motility of

colon > increased

intraluminal pressure >

diverticulosis (false

diverticula consisting of

mucosal protrusion

Commented [Aa1]: Rovsing's sign If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis. Blumberg's sign, also referred to as rebound tenderness, pain upon removal of pressure rather than application of pressure to the abdomen.

Commented [Aa2]: Psoas Sign an exacerbation of pain on passive hyperextension of the right thigh with the patient lying on left side) indicates irritation to the iliopsoas indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal). McBurney’s sign: two-thirds of the way along the line from the umbilicus to the right anterior superior iliac spine where most pain is elicited by pressure in acute appendicitis.

Commented [Aa3]: the visceral afferent nerve fibers entering the spinal cord at T8-T10 are stimulated, leading to vague central or periumbilical abdominal pain. Well-localized pain occurs later in the course when inflammation involves the adjacent parietal peritoneum

Commented [Aa4]: The affected loop of a long ‘S-shaped’ left colon may indeed extend across the midline to the right, simulating appendicitis Most diverticula form in left colon especially the sigmoid colon

Left lower quadrant

pain is the most common complaint in

Western countries,

occurring in 70% of

patients.

Right-sided

diverticulitis is more

common in Asian

patients. unrelated to the

consumption of refined

food

in some cases. The

pain is usually constant and is often

present for several

days prior to

presentation. 50% of

patients have had

one or more prior

episodes of similar

pain. (3)

the presence of a redundant

inflamed sigmoid colon or, much less commonly, right-

sided (cecal) diverticulitis

which has a higher incidence

in Asian populations

) Nausea and vomiting have

been reported in 20-62% of

patients due to a bowel

obstruction or

) ileus due to peritoneal

irritation.

) low-grade fever common ) 2/3 Leukocytosis, 1/3

with normal WBC

) Hemodynamic instability with

hypotension and shock are

rare and are associated with

perforation and peritonitis.

) A tender mass is palpable

in approximately 20% of

patients.

outside the bowel wall

along the penetrating arteries).

> faecal stasis in

diverticula causing

micro perforation >

inflammation.

Severe inflammation

and mass lesions may

cause:

) acute bowel obstruction.

) erode into an adjacent viscus

) Colovesical fistula

) colovaginal fistula

.etc.

) when perforation is

sizable, diffuse purulent or

faeculent peritonitis with

free intraabdominal air

seen on an X-ray.

3. Gall stones with

acute cholecystitis

Predisposing factors

include: obesity, female

gender, parity

and a diet high in animal

fat. Pregnancy + rappid

weight lose

prevalence increases

steadily with

age.

“The Four F’s” risk factors

for gall stones: Female,

Fertile, Fat, and Forty

1) Persistence obstruction > inflammation and oedema

(with or out bacteria) > infection onset (fever start)

> As transmural

inflammation develops, the pain becomes duller, unremmiting, localized. > may progress to necrosis + perforation

2) Emphysematous (gas-

forming organisms)

+gangrenous tend to

occur in elderly, diabetic and

immunosuppressed patients,

>

may result in gallbladder

perforation +morbidity

) progressive Pain in the upper right quadrant of the abdomen; ) REFERRED pain (radiation): more often perceived in the right scapular region, may mimic

angina pectoris if it is perceived in the anterior chest or left shoulder areas ) Nausea + vomiting+ sweat; Guarding and positive Murphy’s sign;

Low fever; Leucocytosis + alkaline phosphatase serum level; Elevated CRP; Abnormalities on ultrasound thickness >3mm; Icterus (jaundice) if stones are

Acute cholecystitis is

precipitated in 90% of

cases by obstruction of the

neck or the cystic duct by a stone.

(acalculous cholecystitis

10%)

two general classes of

gallstones:

cholesterol stones,

(common)

pigment stones composed

predominantly of bilirubin

calcium salt

When the stones move to occlude the common

Commented [Aa5]: The pain of biliary colic is visceral physical findings are minimal and limited to mild right upper quadrant tenderness.

Commented [Aa6]: The persistence of biliary colic for over a few hours

Commented [Aa7]: The omentum often seals off the area of inflammation, causing a tender and commonly palpable mass in the right upper quadrant.

present in the ducts of the biliary tract. (common bile duct)

bile duct this is life

threatining because it cause the dangerous

pancreatitis (Dr Inas)

4. Perforated gastric

ulcer

Smoking,

use of NSAIDs

chronic stress,

Helicobacter pylori

infection

advanced age (>60

years).

1) sudden onset of severe epigastric pain +vomiting + contamination of abdomen (diffuse

peritonitis) 1. REFERED PAIN: as

leaked gastric contents track down the right para-colic gutter, pain may

descend to the right lower quadrant

2) systemic toxicity signs (Tachycardia + shock signs)

1- severe sudden onset

epigastric pain, referral

to RI fossa, vomiting.

2- Abdominal examination:

no bowel sounds, a very

characteristic diffuse

‘board-like’ abdominal

rigidity.

3- Rectal examination:

occasionally elicit

tenderness in the

rectovesical pouch

4- Confirmed by abdominal

radiography: presence of

intraperitoneal gas

under the diaphrag

5- Back pain + attnuated abdominal signs if (retroperitoneal perforation)

acute perforation

of the gastrointestinal

tract results in the leak of

gastric or duodenal

contents into the

peritoneal cavity

and peritonitis.

5. Stones in ureter

a lifetime risk : 20% for men 10 % for women.

highest incidence of urinary tract stones occurs in the 20–50-year-old group Risk factors for stone

formation include a low urinary volume, metabolic abnormalities, UTI and drug-induced nephrolithiasis.

Colic Pain sually starts at the costovertebral

angle and radiates down into the groin and even into the penis or labia majora. The location of the obstructing stone can

often be estimated by the location of the referred pain: • mid-ureter on the right side, the pain is referred to the right lower quadrant of the

abdomen and may

Usually asymptomatic.

Common pain is: severe and

spasmodic pain, often referred

to as ureteric colic.

-nausea and vomiting

because of reflex stimulation

of the coeliac ganglion

Costovertebral angle

tenderness on fist percussion;

Dysuria;

Sometimes macroscopic

haematuria;

Urinanalysis: microscopic

Stone blocking the ureter,

unrelieved obstruction

almost always leads to

permanent

renal atrophy, termed

hydronephrosis or

obstructive uropathy.

Commented [Aa8]: Unver M, Fırat Ö, Ünalp ÖV, et al. Prognostic factors in peptic ulcer perforations: a retrospective 14-year study. Int Surg. 2015;100(5):942-8.

Commented [Aa9]: The omentum or overhanging liver will frequently seal the perforation, leading to focal and possibly self-limited peritonitis. In such cases, signs of peritoneal irritation may be present only in the epigastrium, and signs of systemic toxicity may be less pronounced.

Commented [Aa10]: The abdomen may become more distended, and the pain may diminish. Free intra-abdominal air and gaseous distension of bowel may lead to a tympanic abdomen on percussion.

Commented [Aa11]: . Posterior and retroperitoneal perforation may mimic both pancreatitis and a dissecting aortic aneurysm

be misinterpreted as appendicitis. • Left mid-ureteric pain is referred to the left lower quadrant and can present in a similar

way to diverticulitis. • lower ureter, at the vesicoureteric junction, may cause irritative bladder symptoms, such as urinary frequency,

urgency and dysuria.

haematuria

-Ureter Cann’t be felt on physical examination

usually requires urinary tract

imaging and/or direct

endoscopic evaluation of the

ureter (distended pelvis)

6. Irritable bowel

syndrome (spastic

colon)

Female consulters

outnumber male

consulters by a factor

of 2–3

In western populations, up

to one in fve people

report symptoms consistent with IBS

tends to begin in

adolescence and the 20s,

rarely begin in late adult.

Risk factors;

See tabel below

Chronic recurring

abdominal pain with spams. Patients have abdominal discomfort, which varies considerably but is often located in the lower abdomen, steady or cramping in nature,

(see tables at the end of the

word file)

) recurrent abdominal pain

or discomfort 3 days/month

in the last 3 months

associated with two or more

of the following:

1. Improvement with

defecation or gases passage

2. Onset associated with a change in frequency of stool

(alternating diarrhea and

constipation)

3. Onset associated with a

change in form (appearance)

of stool.

) Pain incrase by eating or

emotional stress

) passage of mucus with

stool

) bloating or abdominal

distention, dyspepsia ) fever, weight loss

) Rectal bleeding (if

hemorrhoids present),

) nocturnal pain (rare),

) raised stool calprotectin

IBS co-exists with chronic

fatigue syndrome

fbromyalgia and

temporomandibular joint

dysfunction

The cause of IBS is

unknown. IBS is better

understood as a combination of

psychosocial

-Depression

-anxiety

physiologic factors.

-Altered motility,

-increased intestinal

sensitivity (visceral

hyperalgesia),

-various genetic and

environmental factors.

Commented [Aa12]: Pain or discomfort related to defecation is likely to be of bowel origin; that associated with exercise, movement, urination, or menstruation usually has a different cause.

Commented [Aa13]: (ie, loose or lumpy and hard).

Commented [Aa14]: https://www.msdmanuals.com/professional/gastrointestinal-disorders/irritable-bowel-syndrome-ibs/irritable-bowel-syndrome-ibs for durther reading about these factors

or lactoferrin would

suggest inflammation indicate further investigation.

) Extra GIT symptoms (see

table)

7. Pancreatitis Gallstones (40%)

Alcohol (30%)

Age >40 yr.

Less common causes:

medications, metabolic

causes (hyperlipidaemia

and hypocalcaemia),

trauma, endoscopic

retrograde

cholangiopancreatography,

pancreas divisum, viral

infections, vascular causes

(ischaemia and

vasculitis) and tumours.

severe acute upper abdominal pain with radiation to the back.

The pain is constant and slowly increases. in gallstone pancreatitis Pain usually develops

suddenly; (20min) in alcoholic pancreatitis, pain develops over a few days.(48 h)

The degree of the resulting inflammatory process ranges from: mild oedema >haemorrhage > necrosis > infection

Pancreatic pseudocysts may reach a large size and lead to: severe bleeding, gastric outlet obstruction or adjacent

organ erosion reactive left-sided pleural effusion is common

) Severe sudden, constant, gradually increasing Epigastric abdominal pain.

) May radiate to the back in 50%. Increased by: - coughing, vigorous movement, and deep breathing Reduced: - Sitting up and leaning forwards,

or lying on the side in the knee–chest position Increased Serum Amylase and

lipase ) vomiting and nausea ) Low-grade fever ) Tenderness is limited to the upper abdomen usually NO

SIGN of Pertoneal Irritation ) Ultrasonography and CT scanning ) Ongoing inflammation and necrosis > palpable epigastric mass

) severe pancreatitis, tachycardia,

hypotension and oliguria secondary to hypervolaemia. ) ileus > Abdominal distension > hyperresonance, and later be augmented by ascites, > dullness on

percussion. -Retroperitonealhaemorrhage may lead to bruising of the flanks (Grey Turner’s sign) or in the periumbilical region (Cullen’s sign)

intra-acinar activation of

pancreatic enzymes

(including trypsin,

phospholipase A2, and

elastase), leading to the

autodigestive injury of the

gland itself. The enzymes

can damage tissue and

activate the complement

system and the

inflammatory cascade,

producing cytokines and

causing inflammation and

edema. This process

causes necrosis in a few

cases.

Commented [Aa15]: Alcohol induces functional alterations of plasma membranes and alters the balance between proteolytic enzymes and protease inhibitors, thus triggering enzyme activation, autodigestion and cell destruction.

Commented [Aa16]:

Commented [Aa17]: Acute pancreatitis increases the risk of infection by compromising the gut barrier, leading to bacterial translocation from the gut lumen to the circulation.

*Features can be divided into a) defining features which different diseases can have in common and b) discriminating features that can exclude other diagnoses.