Abdominal and Abdominal Wall Diseases
Abdominal injury
History taking】
1, detailed understanding of the cause, extent, location, time and post-injury changes in the condition of the injury.
2. Pay attention to the mental state, the location and nature of abdominal pain and the presence of gastrointestinal symptoms or shock and other manifestations.
Physical examination
1, comprehensive and careful whole-body examination, to understand the presence of multiple injuries.
2, the presence of pallor, cold extremities, accelerated pulse rate, unstable or decreased blood pressure or even can not be measured; abdominal shape changes, the presence of abdominal breathing, abdominal pressure pain, muscle tension, the degree and extent of rebound pain, the presence of mobile turbid sounds, hepatic turbid boundary and intestinal tones changes.
Ancillary tests
1.Laboratory examination of blood routine, blood type, bleeding and clotting time and red blood cell pressure product, electrolytes, renal function, urine routine, blood and urine amylase, etc.
2, instrumental examination: chest, abdominal plain film, if necessary, feasible abdominal B ultrasound or CT examination.
3, diagnostic laparotomy or abdominal lavage.
Diagnosis and differential diagnosis
Diagnosis of abdominal injury based on history, signs and auxiliary examination results is generally not difficult, but to determine whether there is abdominal visceral injury, specific which or which organ injury is not easy, sometimes need to dissection to clearly diagnose.
1, the key to closed injuries is to determine the presence of visceral injuries, one of the following conditions should be considered to have abdominal visceral injuries.
(1) early signs of shock.
(2) persistent severe abdominal pain with nausea and vomiting.
(3) Significant peritoneal irritation.
(4) Pneumoperitoneum.
(5) Mobile turbid sounds in the abdomen.
(6) Blood in the stool, vomiting blood or hematuria.
(7) pressure or fluctuating sensation in the anterior wall of the rectal finger, or blood-stained finger sleeve.
(8) Positive findings on laparotomy or lavage.
(9) aggravated during the observation period, the signs more obvious.
2, the key to open injuries is to determine whether penetration into the abdominal cavity and the presence of visceral injury.
(1) the above-mentioned circumstances suggesting the presence of abdominal visceral injury also apply to penetrating injuries.
(2) The methods to determine whether the penetrating injury has entered the abdominal cavity are
(1) probe or probe probing.
(2) iodine imaging of the wound tract.
Treatment principles
1, non-surgical treatment.
(1) first deal with life-threatening injuries and maintain effective respiratory circulation.
(2) establish open intravenous access, infuse fluids and blood as soon as possible to maintain effective blood volume and acid-base balance.
(3) Closely observe changes in mental status, respiration, urine output and abdominal conditions, and strengthen monitoring of electrocardiography, blood pressure and pulse rate, and place a central venous pressure line if necessary.
(4) Prohibit analgesic drugs until the diagnosis is confirmed.
(5) fasting if intra-abdominal organ damage has not been ruled out.
(6) Early administration of broad-spectrum antibiotics and early injection of TAT for open wounds.
(7) those who have a clear diagnosis or highly suspected intra-abdominal organ injury should actively make emergency preoperative preparations and strive for early surgery.
2.Surgical treatment.
(1) surgical indications: timely caesarean section should be performed when the following conditions occur.
(1) abdominal pain and peritoneal irritation signs with progressive aggravation or expansion of the scope.
(2) Weakness or disappearance of bowel sounds or significant abdominal distension.
3) deterioration of general condition, thirst, irritability, increased pulse rate or rise in body temperature and white blood cell count.
4) manifestation of free gas under the diaphragm.
5) progressive decrease in red blood cell count.
6) unstable or even decreasing blood pressure.
7) aspiration of gas, non-coagulated blood, bile or gastrointestinal contents by laparotomy.
8) gastrointestinal bleeding.
(9) Active resuscitation of shock without improvement or continued deterioration.
(2) Surgical options.
(1) splenic rupture: splenectomy is the basic surgical method; splenic preservation surgery: including splenic repair, partial resection and splenic transplantation, especially suitable for pediatric patients.
(2) liver rupture: liver repair is suitable for mild liver rupture; hepatic artery ligation is suitable for those who cannot be locally sutured to stop bleeding; hepatectomy is suitable for severe liver rupture.
(3) pancreatic injury: suture drainage is suitable for pancreatic lacerations; caudal pancreatic resection is suitable for body caudal rupture; Y-type anastomosis and proximal suture of distal severed pancreatic jejunum is suitable for pancreatic head rupture injury; pancreatic head duodenectomy is only suitable for severe injury of pancreatic head combined with duodenum, which has to be done.
(4) duodenal injury: simple repair is suitable for those with small fissures, neat edges, good blood flow and no tension; repair with tipped intestinal piece is suitable for those with large fissures that cannot be sutured directly; resection anastomosis of injured intestinal segments is suitable for serious injury to the third and fourth segments of the duodenum; diverticulization of duodenum is suitable for those with serious injury to the first and second segments of the duodenum or with pancreatic injury at the same time; pancreatic head duodenectomy is only appropriate for those who have severe fragmentation of the second segment of the duodenum spilling over to the head of the pancreas and cannot be repaired.
(5) gastric perforation: gastric repair is suitable for those with less serious injury with hemostasis of the fissure and direct or trimmed suture; partial gastrectomy is suitable for those with extensive injury.
(6) small intestine perforation: simple repair is suitable for general use with interrupted transverse sutures; intestinal resection anastomosis is suitable for large fissures or serious contusions of intestinal wall tissues at the margins, multiple ruptures of small segments of the intestinal canal, partial or complete rupture of the intestinal canal, and mesenteric injury affecting blood flow to the intestinal wall.
(7) colon perforation: one-stage repair or resection anastomosis is applicable to ruptured right hemicolectomy with small fissure, light abdominal contamination and good general condition; enterostomy is applicable to left hemicolectomy with severe contamination.
(8) rectal injury: rectal suture repair and sigmoid colon double-barrel stoma and perirectal gap drainage.
(9) retroperitoneal hematoma exploration, removal of hematoma, ligation or repair of broken blood vessels, and treatment of injured organs, but small hematomas and hematomas without extension can be treated without treatment.
【Efficacy criteria】
1.Cure: disappearance of symptoms, wound healing and return to normal function.
2.Improved: symptoms improve and some functions return to normal.
3.Not healed: no treatment or ineffective treatment.
Discharge criteria
Those who have achieved cure or improved efficacy.
Abdominal mass
History taking】
1.Inquire about the time of appearance and growth rate of the mass.
2.Whether it is accompanied by abdominal pain, fever, jaundice, blood in stool or hematuria, etc.
3.Changes in general condition, whether there is wasting, anemia, etc.
Physical examination]
1. Systemic examination: pay attention to the presence of superficial lymph nodes enlargement on the clavicle and other places.
2. Specialist condition: site, number, size, shape, texture, boundary, mobility and localized pain of the mass; rectal finger examination.
【Auxiliary examination
1.Routine preoperative examination of general surgery, AFP should be checked for suspected liver cancer.
2, instrumental examination: abdominal plain film, B ultrasound, CT or MRI examination, gastroscopy with biopsy, barium meal or barium enema, intravenous pyelogram, etc. according to specific conditions.
3.Perforation examination: It is helpful to determine the nature of cystic masses.
Diagnostic evaluation]
According to the history, physical signs and auxiliary examination, the nature of most abdominal masses can be clarified, but a few require abdominal dissection and pathological examination to confirm the diagnosis.
Differential diagnosis
There are several common abdominal masses as follows.
1, inflammatory masses: abdominal abscesses, etc.
2, traumatic masses: retroperitoneal hematoma.
3, giant spleen.
4, tumors: there are benign and malignant tumors of the liver and gallbladder, gastrointestines, pancreas, spleen, kidneys, ovaries and retroperitoneum.
5. Cysts: there are cysts in the liver and gallbladder, kidney, pancreas, ovary and other parts of the body as well as hydronephrosis.
【Treatment principles】
The diagnosis should be made as soon as possible and the treatment plan should be decided. Those who need surgery should be operated as soon as possible and the appropriate surgical procedure should be taken according to the specific disease.
Treatment standard
1.Cure: disappearance of clinical symptoms and signs and recovery of function.
2.Improved: clinical symptoms and signs improve and some functions are restored.
3.Not cured: no treatment or ineffective treatment.
Discharge criteria
Those who achieve cure or improvement effect.
Abdominal abscess
History taking】
1.History of acute peritonitis, abdominal trauma or abdominal surgery.
2, abdominal pain, nausea, vomiting, symptoms of infection poisoning, etc.
Physical examination
Abdominal lump can be found, soft, fixed, unclear boundary, local pressure pain is obvious.
Auxiliary examination
1, laboratory tests: elevated white blood cell count, increased neutrophil ratio, etc.
2.Instrumental examination: abdominal plain film, B-ultrasound or CT examination.
3.Diagnostic puncture: performed under the guidance of B ultrasound or X-ray.
【Diagnostic diagnosis
Whenever peritonitis or inflammation of intra-abdominal organs improves after treatment or when abdominal pain and fever appear several days after abdominal surgery with unclear causes, this disease should be thought of, and the diagnosis can be made by the above-mentioned auxiliary examinations.
[Differential diagnosis
1. abdominal abscesses are distinguished from subdiaphragmatic abscesses, inter-intestinal abscesses and pelvic abscesses, which need to be differentiated.
2.Sub-diaphragmatic abscess needs to be distinguished from abscess chest and liver abscess, and pelvic abscess needs to be distinguished from pelvic inflammatory mass.
Treatment principles
1.Non-surgical treatment.
(1) Position: semi-recumbent position.
(2) Fasting and gastrointestinal decompression.
(3) antibiotics: an adequate amount of antibiotics should be used according to the causative organism.
(4) Sedation, analgesia and oxygenation.
(5) Maintenance of water, electrolytes and acid-base balance.
(6) Supplementation of heat and nutrition, correction of anemia, etc.
(7) Puncture and pus extraction: can be performed under ultrasound, and antibiotics will be injected into the cavity after extraction.
2.Surgical treatment.
(1) Indications: abdominal abscess with ineffective non-surgical treatment, heavy toxic symptoms and large volume.
(2) Surgical selection: abscess incision and drainage, selection of appropriate incision and route according to the site of abscess.
【Efficacy criteria
1.Cure: disappearance of clinical symptoms and signs.
2.Good: basic normal body temperature and improvement of symptoms.
3.Not cured: no treatment or ineffective treatment.
Discharge Criteria
Those who have achieved cure or improved efficacy.