CLASSIFICATION OF APPENDICITIS Acute appendicitis I. By the nature of morphological changes: 1. 2. 3. 4.
Simple surface appendicitis; Phlegmon appendicitis; Gangrenous appendicitis; Perforated appendicitis.
II. By the nature of pathological process: 1. Uncomplicated; 2. Complications: • appendicular infiltrate • appendicular abscess • Local peritonitis • Spreded peritonitis • the other complications (retroperitoneal abscess, abscess of Douglas pouch and the other abdominal abscesses, Pyle phlebitis (inflammation of portal veins), sepsis, etc.) III. By the clinical course: 1. rapidly progressive; 2. not progressive; 3. slowly progressive; 4. roughly progressing. Chronic Appendicitis 1. Primary chronic appendicitis. 2. Resudial chronic appendicitis. 3. Chronic recurrent appendicitis. We describe a large number of pain symptoms in the study of patients with acute appendicitis. The highest value in the clinic received the following from them: - Symptom-Kocher's Volkovich - anamnestic symptom of epigastric pain, moving plot (area) of onset, after 2-3 hours in the right iliac region; - Symptom Rozvynha - left hand pressing on sigmoid colon and fixing it, pressing and making wave like movements in the left iliac area. The pain in the right iliac area is intensified;
- Symptom Obraztsova - fix the right hand fingers in the right iliac area. When lifting straightened right leg to an angle of 30 degrees amplifies/increases pain. After dipping/releasing the leg pain diminishes. This symptom is especially informative when retrocecal location of vermiform appendix; - Symptom Ivanova - reducing the distance between the navel and the superior iliac spine in comparison with the left; - Sitkovskoho symptom - the patient is positioned on his left side as a result the pain is intensified in comparison with the position on the spine; - Symptom-Bartom'ye Mihelsona - pain while palpation of the right iliac area in the patient's position on the left side expressed much intense than the palpation of the patient lying on spine; - Voscresenskiy’s 1 symptom -(symptom of shirt, symptom of sliding) – It is increasing intensity of pain in right iliac fossa during the sliding palpation through the strained shirt Technique: with your left hand pull the shirt on the patient level lap, and with your right hand make sliding movement staarting from the epigastrium not isolating the stomach and ending to the right iliac fossa.Pain that occurs in the right iliac area, indicate acute appendicitis. In acute appendicitis early start to determine the right iliac fossa symptoms of peritoneal irritation (peritoneal signs): - Abdominal muscle tenderness; - Symptom-Schotkina Blyumberha - painful decompression; - Rosdolsky - pain at percussion anterior abdominal wall; - Diminished percussion sound- as a result of the accumulation of effusion in iliac cavity. - Absence of peristalsis on auscultation. During retrocecal presentation of vermiform appendix symptoms are as follows: - Yaure-Rozanovas - pain during palpation of the Petits triangle from the right side incase of retrocecal presentation of the appendix; - Gabays - quick withdrawal after pressing with finger
palpation at Petit triangle imposes pain; - Copes 1 - pain in the right iliac fossa during overextension of right leg from coxofemoral joint. For differential diagnosis right sided adnexitis defined symptoms in women: - Zhendrynskovo - position the patient prone to press on the abdominal wall at Kummell (2 cm right & below the navel) with a finger, without releasing it, asking the patient to stand. Increased pain indicates appendicitis, reducing – indicates acute adnexitis; - Promptova – painful uterus during invagenating and pressing your fingers up, through the vagina or rectum. This is the Evidence of disease of female genital organs; - Posnera - pain during the pendulous movements of the uterus, with the two fingers at vaginal examination. Symptom means disease of female genital organs; - Shylovtseva - shifting the point of pain to left if the patient is positioned on the left side. In patients with suspected acute appendicitis required is to determine symptom Pasternatskoho on both sides (the appearance of pain in tapping the hand over the lumbar region at the location of the kidneys).
INTERNATIONAL CLASSIFICATION OF ABDOMINAL HERNIAS I. By origin Are divided into two groups: congenital (h. congenitalis) and acquired (h. acguisita). Acquired divided into groups depending on the reasons that led to the emergence of the defect of the abdominal wall: a) Preformed/Predestined hernia (h. praeformata). They arise in the typical natural "weak" places of the abdominal wall; b) postoperative hernia (h. postoperativae); c) recurrent hernias (h. recidiva); d) Traumatic hernia (h. traumatica); d) neuropathic hernia (h. neuropatica); e) artificial rupture (h. artificialis). II. Anatomical (or by the location)
1. Inguinal hernia (hernia inguinalis): a) Indirect/Oblique (hi. obligua); b) Direct (h.i. directa); c) Begning (h.i. insipiens); Occasionally a patient will come in who has groin pain from an incipient hernia (burning pain from stretching peritoneum) which has not yet become Palpable. There is no contraindication to observing such a patient and having him/her return in 3 months or 6 months for reexamination, or when a bulge develops. d) Cord (h.i. funicularis); funicular hernia an indirect inguinal hernia that includes part of the umbilical cord or spermatic cord. e) Scrotal (h.i. scrotalis); e) Sliding (h.i. labentis); f) Encysted, Cooper’s hernia/Hey’s (hi encystica). a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing immediately beneath the skin. Syn: bilocular femoral hernia, Hey's hernia. g) Pantaloon hernia: combined direct and indirect hernia.potrusion of peritoneum on either side of a.epigastrica.inf. Types of Repair:a) Herniotomy (Marcy repair) b)Herniorraphy 1)Bassanies Repair 2)Halsted repair (Poctemski)-Old age. 3)Shouldice repair. c)Hernioplasty/Meshplasty. 2. Femoral hernias (h. femoralis). Types of Repair: a) Lotheissen- McVay Repair. 3. Umbilical hernia (h. umbilicalis). 4. Paraumblical hernia (h. paraumbilicalis). 5. Epigastric hernia (h. lineae albae). 6. Lumbar hernia (h. lumbalis) 7. Spigelian Hernia (h. semilunaris)lateral ventral hernia through lenia semilunaris. 8. Perinial hernia (h. perinealis) 9. Obturator hernia (h. Obturatoria) 10.Isciatic hernia (h. ischiadica) 11.Xephoid process hernia(h. processus xyphoideus)
12) Richers Hernia:Part of bowl becomes incarcerated. (dangerous) 13) Litters Hernia:when meckels diverticulam is a content of hernial sac.
III. Clinical Classification (per course) 1. Reducible (h. reponibilis). 2. Irreducible hernia (h. irreponibilis). 3. Strangulated hernia (h. incarcerata). 4. Coprostasia.(Fecal impaction) 5. Inflammation of the hernia. 6. Traumatic hernia. Types of strangulation: 1. Elastic. 2. Fecal. 3. Retrograde (hernia Maidla). 4. Parietal (Richter/Litters hernia). a hernia in which only a portion of the wall of the intestine(Meckles diverticulam) is engaged. When studying/examining patients with hernia should identify: 1. Resistance of the abdominal wall, the degree of muscle wasting. You need to examine a patient with relaxed abdominal wall. 2. Examine all the typical location of hernia: inguinal area, the white line of the abdomen(midline/linea Alba), umbilical ring and others. Determine how hernial protrusion is located: above or below the crural arch or inguinal ligament or popart’s ligament (to distinguish inguinal or femoral hernia), or absence of gap between rectus abdominalis muscles, the presence or absence of bulging/protrusion in or around the area of old scars. 3. Patient with a hernia should be examined in two positions – prone/lying and standing. 4. For inguinal hernias we need to know hernial protrusion shape: round, oval, elongated (transcending the external inguinal ring, falls into the scrotum), the size of the external inguinal ring. Accordingly differentiate inguinal hernia - direct and indirect. In direct inguinal hernia elements of the spermatic cord and inferior epigastric artery are placed
lateral to the hernial protrusion. Whereas in indirect hernia - to the middle. 5. Correcting of hernia is defined in the prone/lying position. 6. The nature of the contents of hernia: intestinal loops during the exercises come’s out like bulging, during percussion give’s tympanic sound means omentum as content, but if percussion gives a dull sound means; involvement of bladder in the hernial sac, causing frequent urge to urinate. In the case when some organ descends to the hernial sac not covered by peritoneum or partially covered, this organ can make one of the walls of the hernial sac. This is called a sliding hernia. 7. Hernial defect is investigated after correction/reposition of hernial contents. Necessary to understand and to determine the diameter of hernial defect, their shape - round, elongated, irregular, thickness of the walls of hernial ring, especially in case of postoperative and recurrent hernias. 8. Determine cough shock symptom: cough sensation push finger induce into the hernial defect, or hand assigned to the protrusion. 9. Symptom leucency (light) of the contents of hernial sac. 10. In inguinal hernia it is necessary to determine the presence of testis in the scrotum and its relation with the hernial sac (a testis inside the hernial sac - a congenital hernia, but if the testis is not the content of the hernial sac - acquired hernia). 11. In the study of patients with hernia’s it is important to detect signs of their strangulation: a) Earlier reducible hernia is now irreducible; b) Constant intensity of pain in the hernial swelling/protrusion; c) In addition to this are seen symptoms of acute intestinal obstruction: cramping-like abdominal pain, impairment of intestinal passage, which is manifested by nausea, vomiting, delayed stool and gas; g) Hernia during palpation is thickened, hard and painful; d) Symptom cough shock is negative. AIO When reviewing the abdomen can be found apparent intestinal peristalsis - a symptom of Shalga, balloon
like distended bowel loop, pain during palpation, motion - symptom of Valya. Presence or absence of peristalsis in strangulated loop tells us, how much time has been passed since the strangulation took place. And bigger the time is the more reduced is the motor activity of the loop. However, progressive intestinal tympanites (swelling with gas) all lead to a gradual reduction and disappearance of symptom Valya. If you can identify during auscultation abdominal symptom Lotheissen - auscultation of respiratory and cardiac sounds at the umbilical level, in connection with the resonating effect of inflated loops of bowel below the diaphragm.In case of paralytic condition of the bowel (at the stage of peritonitis, or with paralytic intestinal obstruction) in the complete absence of peristalsis "dead silence" – is heard" noise of falling drop Symptom Spasokukotskovo. You can determine the boundaries of loops by percussion incase of volvulus of sigmoid colon or cecum – which is called high organic tympanic symptom (symptom Kivulya), the presence of free fluid in the abdominal cavity with a functional obstruction caused by peritonitis, etc. Abdominal palpation has the same importance in establishing diagnosis of bowel obstruction, as well as auscultation. On palpation the abdomen the surgeon must determine the presence or absence of symptoms of irritation of the peritoneum and try to find a "splashing" (symptom Sklyarov). "Splashing" is the path gnomonic symptom of acute intestinal obstruction. It can be identified only with the appearance of a certain number of loops in the intestine and, rarely, in a single loop. The existence of this evidence is sufficient for the diagnosis of intestinal obstruction, but it should be distinguished from the noise caused by the movement of liquid collected in the stomach, to determine it is necessary to determine it before application of enema. symptom Obukhovskoy hospital - reduction of sphincter tone, or hiatus anus, empty, cylindrical swelling of ampulla of the rectum. CLASSIFICATION of intestinal obstruction Among all forms of AIO depending upon the level of symptoms, disorders of intestinal passage there are two
kind of obstruction partial/complete bowel intestinal obstruction, by clinical course - acute, sub-acute, chronic and recurrent. Classification of acute intestinal obstruction (per YERYUHINYM IA, Petrov VP, HANEVYCHEM MD, 1999) I. 1. a) b)
By morpho-functional nature Dynamic Intestinal obstruction: paralytic; spastic.
2. Mechanical intestinal obstruction: a) strangulated:(volvulus, knot type, internal clamping) b) obstructed:(obstruction by tumour, foreign body obstruction, fecal stones, a ball roundworm, coprostasis) c) mixed forms of strangulated and obstructed form: (intussusceptions, adhesive obstruction.) II. By level of obstruction 1)Small bowel obstruction: a)High (jejunum) b)Low (ileum) 2)Large Bowel obstruction:
III. By the development of pathological process (stage) First - the acute stage of impairment of intestinal passage. Second - stage of acute intestinal disorders of intraluminal hemo circulation. Third - the stage of peritonitis. ACUTE CHOLECYSTITIS In acute cholecystitis with an objective study we should: 1. Determine the degree of participation of part of hypochondrium in breathing. 2. Determine the muscle tension/tenderness in the right hypochondrium. 3. Identify pain when tapped on the edge of the right hypochondrium with the hand (symptom Ortner Ă ). 4. Identify symptom Rumpel-Leede(the cyanosis over the
skin on the area of pinching). 5. Define symptom Murphy - the patient can not take a deep breath when you press it with the thumb of your left hand at point of Kera, i.e. at a point on the bisector of the angle formed by the right dome of ribs and the outer edge of the rectus muscle at 2.5 cm from its top. 6. Identify symptom Kera - increasing pain during deep inspiration on palpation of the right hypochondrium. 7. Identify symptom Musse-George - with pressure sore between the right sternoclavicular muscle the pain in the right hypochondrium increases. 8. Identify Boas symptom: pain in paravertebral points 810 in the right side. 9. Determine Lyahovitskovo symptom - pain when you press the xiphoid process of sternum, caused by inflammation of the lymph nodes, located on the xiphoid process. 10. Determine with the palpation in the right hypochondrium acute painfulness due to stretching of the fundus of the gall bladder, it is characteristic of obstructive cholecystitis. 11. Determine that there is no spreading of symptoms for irritation of the peritoneum (the muscle tenderness, symptoms Shchetkina-Blumberga, Razdolskogo) in the area from the right hypochondrium to the right flank of the abdomen. 12. Symptom Courvoisier - enlarged, mobile and painless gallbladder, which is characteristic for cancer of the head of the pancreas. Types of Stones on their chemical composition are divided into: 1. cholesterol, 2. pigment 3. mixed. Recently, isolated form of gallstones (Shalimov AA et al., 1993): 1. Cholesterol. 2. Metalcholestol. 3. Cholesterol-phosphate. 4. Phosphate-protein.
Classification of acute cholecystitis
(by A. Javadyan and LB Krylova) I. Uncomplicated cholecystitis 1. Catarrhal cholecystitis (calculic or acalculic), primary or exacerbation of chronic relapsing. 2. The destructive cholecystitis (calculic or acalculic), primary or exacerbation of chronic relapsing: a) abscess, abscess-ulcerative cholecystitis; b) gangrenous cholecystitis (here are rare forms, such as acalculic cholecystitis of vascular origin). II. Complicated cholecystitis 1. Occlusion (obstructive) cholecystitis (infected mucocele, abscess, empyema, gangrene of the gallbladder). 2. Breakthrough cholecystitis with symptoms of local or diffuse peritonitis. 3. Acute cholecystitis, complicated by lesions of the bile ducts: a) choledocholithiasis, cholangitis, obstructive jaundice; b) stricture of CBD, papillitis, stenosis of faterovs papilla; 4. Acute cholecysto-pancreatitis. 5. Acute cholecystitis, complicated localized biliary peritonitis (enzymatic cholecystitis). CLASSIFICATION OF CHOLECYSTITIS (by AA Shalimova et al., 1993) I. Chronic cholecystitis 1. Primary chronic cholecystitis (GBS, acalculous). 2. Chronic recurrent uncomplicated cholecystitis (GBS, acalculous). 3. Chronic recurrent cholecystitis complicated by: a) impaired patency of the bile ducts; b) septic cholangitis; c) obliterating cholangitis; d) pancreatitis; e) hepatitis and biliary cirrhosis of the liver; f) Mucocele of G.B; g) sclerosis of the gallbladder; h) chronic abscess; i) chronic empyema of the gallbladder.
II. Acute cholecystitis 1. Simple (catarrhal, infiltrative, ulcerative). 2. Abscess. 3. Gangrenous. 4. Perforated. 5. Complicated: a) biliary peritonitis; b) paracystic infiltrate; c) pre cystic abscess; g) with obstructive jaundice; d) abscess of liver; e) septic cholangitis; f) acute pancreatitis. In GBS there are different periods of flow: without symptoms and clinical manifestations of inflammation in the gallbladder.
PANCREATITIS Classification of acute pancreatitis (for Saveliev VS et al., 1983) I. Clinical-anatomical forms: 1. Edematous pancreatitis (abortive pancreo-necrosis). 2. Fatty pancreo-necrosis. 3. Hemorrhagic pancreo-necrosis. II. Prevalence: 1. Local (focal) process. 2. Subtotal process. 3. Total process. III. Flow: 1. Abortive. 2. Progressive. IV. Periods of illness: 1. Period of hemodynamic disturbances and pancreatogenic shock (1-3 days). 2. Period of functional insufficiency of parenchymal organs (4-7 days). 3. Period of degenerative suppurative complications (8-10 days).
CLASSIFICATION OF ACUTE PANCREATITIS (Beger, 1993) Acute interstitial edematous pancreatitis Pancreatic necrosis • sterile • infected Pancreatic Abscess Pseudocyst Classification of chronic pancreatitis (for Shalimov AA et al., 1998) 1. Fibrous duct chronic pancreatitis without hypertension and dilatation of Pancreatic flow ПО. 2. Fibrous chronic pancreatitis with duct dilatation and hypertension of pancreatic flow ПО. 3. Fibrous degenerative pancreatitis complicated by: a) calcification of the pancreas ПО; b) the creation of pseudocysts; c) the formation of pancreatic fistula; d) the formation of an abscess of pancreas. - The appearance of purple spots on the skin of the face and waist (symptom Mondor); - The appearance of yellow-cyanotic coloration of the skin in the area of the umbilicus (Cullen sign)due to intraperitoneal hemorrhage; - Cyanosis abdominal skin (symptom Halstead), cyanosis of the skin flank (lateral surfaces of the abdomen) (GreyTurner sign). In the study of the abdomen to identify the symptoms: - Symptom Kurt – transverse pain resistance in mesogastrium; - Symptom voskrisenski II - absence of pulsation of the abdominal aorta due to placement of edematous and enlarged pancreas in the midline 4cm above the umbilicus; - Symptom Mayo-Robson - tenderness to palpation/pressure just above and right of the umbilicus (there is the tail near the pancreas); - Symptom Chuhrienka - the emergence of pain during wave
like movements of the abdominal wall from the bottom to up and from front to back with the fist of the doctor, set transverse across the abdomen below and slightly to the left of the umbilicus.
PEPTIC ULCER DISEASE Classification of peptic ulcer and Duodenal (By AF Chernousov, 1996) By Localization of ulcer: 1. Stomach: cardiac part sub cardial part, small curvature, large curvature, the body of the stomach, the anterior wall, posterior wall & the antral part. 2. Duodenum: follicles, postbulbar, anterior, on fundus, superior, inferior walls. 3. Combined gastric and duodenal ulcers. By their Clinical form: 1. Acute or first time diagnosed ulcer. 2. Chronic ulcer. By the phase of the process: 1. Exacerbation. 2. Partial remission. 3. Complete remission. By clinical course: 1. Latent ulcer. 2. Light (not often recurrent) disease. 3. Diseases moderate (1-2 relapses per year). 4. Hard (three relapses per year) or continuously relapsing course, the development of complications. By morphological pattern: 1. Small ulcer (less than 0.5 cm). 2. Medium size (0,5 - 1,0 cm). 3. Large ulcers (1 - 3 cm). 4. Giant ulcer (more than 3 cm). In terms of complications: 1. Ulcer complicated by hemorrhage (mild, moderate, severe, profuse, extremely difficult. 2. Ulcer complicated by perforation (open, closed). 3. Penetrating and callosum ulcers.
4. Ulcer complicated by scar deformity of the stomach and duodenum, pyloric stenosis (compensated, sub compensated, de compensated). 5. Malignancy ulcers. CLASSIFICATION of Stenosis of pyloroduodenal ZONE I. By etiological factors 1. Ulcerative. 2. Tumorous. 3. Postburning (after chemical burning of the esophagus and stomach). II. By degrees I degree - compensation (occasional vomiting, no weight loss, splashing sound in the stomach on empty stomach; hyperperistalsis, the delay of barium emptying in stomach during barium X-ray - up to 6 hours). II degree - sub compensated (daily vomiting, regurgitation, weight loss of 10-15 kg, splashing sound on empty stomach, increasing of the size of the stomach, on X-rays - delay of barium up to 12 hours). III degree - decompensated (vomiting after each meal, liquid, dehydration, cachexia, fluid and electrolyte disturbances, Dysproteinemia, the delay of barium in stomach in X-rays for 24 hours or more). Classification of Diseases of the already operated stomach : A. Post-resection syndromes I. Functional disorders 1. Dumping-syndrome 2. Hypoglycemic syndrome 3. Postresection (a gastral) asthenia 4. Small stomach syndrome 5. Afferent loop syndrome(functional origin) 6. Gastroesophageal reflux 7. Alkaline reflux gastritis II. Organic disorders 1. Peptic ulcer of anastomosis 2. Gastrocolic fistula 3. Syndrome driving loop (mechanical origin) 4. Scar deformity and narrowing of the anastomosis.
5. Errors/mistakes in surgical technique 6. Postresection ongoing diseases (pancreatitis, enterocolitis, hepatitis) III. Postvagotomy syndromes 1. Ulcer Relapse 2. Diarrhea 3. Disorder of the function of esophageal-cardial transection. 4. Disorder of gastric emptying 5. Dumping syndrome. 6. Reflux gastritis . 7. Cholelithiasis . Indications for surgical treatment of patient’s peptic ulcer by AA Shalimov and VF Saenko (1987) Absolute: 1. perforation; 2. organic stenosis pyloroduodenal zone or deformation disorder of evacuation; 3. malignancy of gastric ulcers; 4. profuse bleeding and if bleeding did not stop. Relative: 1. callosum ulcers; 2. penetrating ulcers; 3. ulcers that bleed recurrently; 4. greater curvature ulcers and cardiac ulcers, as has the most frequency of malignising; 5. ulcers often recurring; 6. non-healing ulcers with conservative treatment within 4-6 weeks.
PERITONITIS Among the local symptoms during the study of the abdomen it is very important to identify: 1. Abdominal pain, spontaneous and during palpation. 2. Muscle tension of the abdominal wall. 3. Symptom Schetkin-Blmberga - agonizing sharp decompression during deep palpation of the abdomen. 4. Symptom Rozdolski - percussion pain. 5. Dullness of percussion sound in lower areas of the
abdominal cavity (the accumulation of exudate). (Gravity) 6. The disappearance of peristalsis during abdominal auscultation. 7. At per rectal manual examination - patient overhang the front wall of the rectum (symptom Kulenkampffa), in women with per vaginal gynecological study - a painful protrusion of posterior vaginal vault/fornix (symptoms of pelvic peritonitis. Classification of acute peritonitis By etiological features the modern classification of acute peritonitis identifies three forms: primary, secondary, tertiary. Primary - rare (1%) of hematogenous origin. Secondary the most common form in which the source of infection is a destructive inflammatory processes in the abdominal cavity. Tertiary - peritonitis without manifestation of source of infection, often in patients with critical condition. In clinical practice, often used for classification By Savalev. By prevalence: 1. Local peritonitis (within the same anatomical region near the source of origin) could be: a) Bordered, i.e. process is completely dissociated/different with the abdominal cavity (infiltration, abscess); b) Associated, that is, in the future the process can progress. 2. The generalized peritonitis: in turn is subdivided into: diffuse, spread or total. In diffuse peritonitis, along with the defeat of a large part of the peritoneum, there are areas not yet covered by an inflammatory rocess (eg, upper abdomen), although the obstacles to further dissemination in to the peritoneum is not there. In total spread peritonitis all the departments of the abdominal cavity are engaged. By the phases of flow: 1. Reactive stage of peritonitis - in the first 24
hours. 2. The toxic phase of peritonitis - from 24 to 72 hours of the disease. 3. The terminal stage of peritonitis - from fourth day or later.
BREAST DISEASE CLASSIFICATION OF BREAST DISEASES: I. Abnormalities 1. Amastia. 2. Atelia. 3. Polymastia. 4. Nipple. 5. Micromastia. 6. Macromastia (hypermastia): a) early childhood; b) the period of puberty; c) child-bearing period. 7. Gynecomastia (diffuse, nodular): a) Young male; b) old male. II. Inflammatory diseases 1. Areolitis, galactophoritis. 2. Acute mastitis (lactating, nonlactating) pathologically anatomically it is divided into: a) serous; b) infiltrative; destructive forms: c) abscessed; g) superlative; d) gangrenous. Localization: a) supraalveolar, subcutaneous (ante mammary); b) intramammary; c) retromammary; g) Injury to the entire breast (pan-mastitis).