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همون جور که همه دوستان ذکر کردند باید بیمار احیا شود

سوالی که از خدمت دوستان دارم

منظور از احیا کردن و پایدار کردن بیمار را واضح تر بیان می کنید؟ یعنی از چه سرمی و با چه مقداری و چه الکترولیت هایی به چه مقدار استفاده می کنید؟

با سپاس

Correction!

4.Initial Treatment

• Fluid resuscitation (Isotonic) and Electrolytes level
• Urine output monitoring with catheter
• Central-venous or pulmonary-artery catheter monitoring (particularly in patients with underlying cardiac disease.)
• Broad-spectrum antibiotics (bacterial translocation)
• NG tube (decreases nausea, distention, and the risk of vomiting and aspiration)
• Surgery (Detailed explanation in the previous comment)

Imaging:

Distention of the stomach, loops of the small intestine and proximal parts of the large intestine filled with air could be regarded as the most notable finding in this figure implying some degrees of obstruction somewhere, most probably in large intestine. A few semi-opaque circles can also be seen in hypogastric area which could be interpreted as fecal material in distal parts of the large bowel. Also we can see signs of degenerative changes in vertebrae of the lumbar region.

Swelling:

Upon the data given, the most probable diagnosis for this lump could be a strangulated femoral hernia. Strangulation suspected because of fever, local tenderness in the RLQ, leukocytosis (having in mind that mild leukocytosis can occur in simple obstruction too)  and tachycardia; and femoral because the hernia sac looks like to be below the inguinal ligament. Also we can say that a part of bowel (more probably the large bowel because we see distention of the proximal colon too ) is trapped with resultant constellation of large bowel obstruction (abdominal distention, vomiting, lack of gas passage , imaging evidence for the distention of small bowel and proximal large bowel ). The presence of flatus passage may imply a partial obstruction but it`s coexistence with strangulation looks somehow strange.   

 Anatomical boundaries:

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness called the femoral canal. The femoral canal is located below the inguinal ligament on the lateral aspect of the pubic tubercle. It is bounded by the inguinal ligament anteriorly, pectineal ligament and pectineus muscle posteriorly, lacunar ligament and pubic bone medially, and the femoral vein laterally. It normally contains a few lymphatics, loose areolar tissue and occasionally a lymph node called Cloquet's node. The function of this canal appears to be to allow the femoral vein to expand when necessary.

Initial treatment:

Because we have an intestinal obstruction here and the patient is not so stable hemodynamically, the first measures to be taken for this patient seem to be resuscitative efforts like hydration with isotonic fluids (and monitoring with urine output evaluation and also CVP evaluation in elderly patients with cardiovascular derangements), a NG tube placement (both to decompress the stomach and also to prevent aspiration) and NPO order. Antibiotic therapy is recommended by some references not all of them.

An expeditious surgery look likes to be the second step regarding the strangulation suspected.

The DDx for a lump in groin region:

The X-Ray appearance is due to distension of small bowel.

It seems like an incarcerated inguinal herniation.

About boundaries we should consider the boundaries of the inguinal canal which herniation occurs through it. Inguinal's ligament, inferior wall, aponeurosis of transversus abdominis, superior wall, aponeurosis of external oblique, anterior wall and transversalis facia, the posterior wall.

This case should be stabilized. 2 IV lines and adequate hydration and emergent operation due to possibility of perforation.

Inguinal hernia, psudoaneurysm, lymphadenopathy can be the differential diagnoses for a groin lump.

1. Small intestine is distentended . It’s full of feces. Distention of intestine continues to cecum and proximal colon. Small intestinal loop is seen in the inguinal area that may resemble a hernia.
2. A hernia around femoral area may cause obstruction of intestine.
3. Anatomical Boundaries: (Femoral Canal)  Anterior: Inguinal Lig. / Medially: Lacunar Lig./  Laterally: Femoral Vein / Posteriorly: Pectineal line lying anterior to the superior pubic ramus
4. Surgery is treatment of choice to most patients with a groin hernia, regardless of symptoms. Femoral hernia are more apt to present with strangulation and require emergency surgery. Emergency surgery within four to six hours may prevent loss of bowel from a strangulated hernia. watchful waiting is not a prudent strategy in patients with femoral hernias, even those who are asymptomatic. There are two different approaches to femoral hernia repair depending upon the size of the hernia. The simplest approach is anterior to the inguinal ligament and caudad towards the upper aspect of the leg. If a large volume of intraabdominal contents has protruded into the sac or if there is bowel in the defect, the best approach may be from the preperitoneal aspect of the inguinal canal.   Mesh should not be used when there is gross contamination, but may be considered where contamination is minimal and broad-spectrum antibiotics administered during and for several days following surgery.
5. Lymph node Inflammation(Enlarged, Tender, Mobile node)/

Inguinal Hernia (Above & Medial to pubic tubercle, Impulse on coughing)/

Femoral Hernia (Below & Lateral to pubic tubercle,Cough impulse rarely detectable, Usually irreducible)/

Strangulaated Hernia (irreducible, tense and tender, red, followed by symptoms and signs of bowel obstruction.)/

Lymphoma Or Secondary tumor (fixed nodes when infiltrated by tumour)/

Saphena Varix (soft and diffuse swelling that lies below inguinal ligament, empties with minimal pressure and refills on release, disappears on lying down, cough impulse.)/

Cold abscess of psoas sheath (fluctuant tender swelling arising below the inguinal ligament)/

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 Shayan Abdollahzadegan

1. در عكس ساده ي شكم اين بيمار اتساع در معده و روده ي باريك و بخش پروگزيمال كولون مشاهده مي شود.در كل روده بزرگ كثيف و حاوي مواد فكالوييد مي باشد. ايلئوس در سكوم و كولون صعودي مشخود است. در نهايت اين مي تواند مطرح كننده ي انسدادپارشيال يا سگمنتال روده ياشد.

2.an incarcerated irreducible hernia

در واقع روده باريك به داخل مجراي فمورال وارد شده و به صورت توده اي تظاهر كرده است.  (اين انسداد در برخي موارد به طرف گانگرن و ايسكمي روده و استرانگولاسيون پيش مي رود.)

The femoral vein and the superior pubic ramus are the borders of the femoral ring laterally and inferiorly. These two structures are more or less constant and therefore are not a factor in the development of this hernia. The iliopubic tract anteriorly and medially accounts for the variability that allows the development of the hernia. The iliopubic tract normally inserts for a distance of 1 to 2 cm along the pectinate line between the pubic tubercle and the midportion of the superior pubic ramus. A femoral hernia can result if the insertion is less than 1 to 2 cm or if it is medially shifted.

4.

Rapid resuscitation with intravenous fluids is essential, along with electrolyte replacement, antibiotics, and nasogastric suction. Urgent surgery is indicated once resuscitation has taken place.

)Small-bowel obstruction is usually associated with a marked depletion of intravascular volume caused by decreased oral intake, vomiting, and sequestration of fluid in bowel lumen and wall. Therefore, fluid resuscitation is integral to treatment. Isotonic fluid should be given intravenously and an indwelling bladder catheter placed to monitor urine output. Central venous or pulmonary artery catheter monitoring may be necessary to assist with fluid management, particularly in patients with underlying cardiac disease. Broad-spectrum antibiotics are commonly administered because of concerns that bacterial translocation may occur in the setting of small-bowel obstruction.The stomach should be continuously evacuated of air and fluid using a nasogastric (NG) tube.(

5.

1.

  - it’s a plain abdominal x ray

  - not a complete image ( diaphragm and both iliac crests cant be seen completely )

  - the patient has been in supine position (according to no air-fluid levels )

  - degenerative joint disease can be seen  in lumbar spines ( intra spine spaces are decreased )

  - {the colon can be recognized by its haustra, which usually form incomplete band across the colonic gas shadows.} in this image : the colon loops are full of solid feaces, and also its loops are dilated.

  - { the small bowel usually lies in the centre of the abdomen within the frame of large bowel } In this image : small bowle dilation is seen.

  - gas is present in the rectum.

  - both the large and small bowel are dilated, the dilation has extended down into the sigmoid colon and the gas is present in the rectum , SO THE DIAGNOSIS can be partial obstruction and ileus.

2.

   It’s a femoral hernia that has been presented in a groin swelling. ( an strangulated hernia that contains bowl loops.)

3.

  Femoral canal :

 - anterior : inguinal ligament

 - posterior : pectineal ligament and pectineus

 - medial : lacunar ligament and pubic bone

 - lateral : iliopsoas and femoral vein

4.

  Order :

  - NPO

  - NG tube

  - Sondage

  - two veins

  - ABG

  - ringer lactate  or NS  1000 ml / stat

  - rectal tube

  - Ceftriaxone    1 g / BD

  - Metronidazole   500 mg / BD

  - emergent surgery (hernioplasty)

5.

  - malignancy : lymphoma, retropritoneal  sarcoma, metastasis

  - primary testicular : testicular mass, varicocele, epydidymitis, testicular torsion, hydrocele,Ectopic testis, UDT

  - femoral aneurism and psudo aneurism

  - lymph node

  - sebaceous cyst,cyst of the canal of nuck

  - hidradenitis

  - saphenous varices

  - psoas abcess

  - hematoma , ascites

با سلام مجدد

یکی دیگر از تشخیص های افتراقی که جا افتاده بود:

انوریسم شریان فمورال است که با توجه به اینکه نبض دار نیست کمتر مطرح است.

باتشکر

با سلام

در عکس X-ray اتساع و وجود گاز در قسمت پروگزیمال دیده می شود در حالیکه در قسمت دیستال گاز دیده نمی شود.که احتمالا نشان از انسداد روده می باشد.

swelling در این ناحیه به احتمال زیاد ناشی از هرنی اینگوینال است که با توجه به دردبیمار و عدم بازگشت آن با معاینه احتمالا استرانگولاسیون صورت گرفته است.در تشخیص افتراقی لنفادنوپاتی اینگینال قرار می گیرد.

فتق معمولا در حدفاصل بین 1/3 و 2/3 داخلی ناحیه اینگوینال رخ می دهد جایی که عضلات شکم دچار ضعف هستند.

درمان اولیه در این بیمار stable نگهداشتن بیمار و با توجه به اقدامات تشخیصی (که بنظر کافی می رسد)بیمار برای جلوگیری از ایسکمی روده به اتاق عمل برده شود.

DDx : فتق اینگوینال ، لنفادنوپاتی ، آبسه چرکی در اثر عفونت ناحیه لگن یا در اثر پاره شدن آپاندیسیت .

در پناه خدا موفق باشید

1.According to the graphy which was taken in the supine position, multiple dilated air filled loops of large and small bowel are seen.The stomach is also dilated.Large bowel loops  are dirty and contain faeces.Cecum and ascending colon are dilated. In pelvis the ampulla of rectum contains gas and faeces. All of these findings can be suggestive of partial or complete obstruction.

2.Femoral hernia:Bowel enters the femoral canal presenting as a mass in the upper medial thigh, it occurs mostly in women especially in middle age and elderly.the neck of the hernia is felt inferior and lateral to the pubic tubercle.

3.The boundries of the femoral canal are anteriorly the inguinal ligament medially the lacunar ligament(and pubic bone) laterally the femoral vein and illliopsoas and posteriorly the pectineal ligament and pectineus.The canal contains fat and Cloquet`s node.

4.patient`s condition should be NPO.Fluid resuscitation is integral to treatment.Isotonic fluid should be given intravenously (N/S or ringer lactat according to PH in ABG) and an indweling bladder catheter placed to monitor urine output. Central-venous or pulmonary-artery catheter monitoring may be necassary to assisst with fluid management,particularly in patients with underlying cardiac disease. Electrolytes level(Na and K) should be observed if they fall or patient becomes symptomatic KCL or hypertonic salin should be infused. Broad-spectrum antibiotics may be necessary ( due to bacterial translocation that can occur in the setting of small bowel obstruction) The stomach should be continously evacuated of air and fluid using a NG tube. conservative therapy (as mentioned before) is the initial recommendation,if signs suggestive of peritonitis or strangulation occur surgery should be done.

Because patient is febrile,tachardic and has localized tenderness and elevated WBC count,strangulation is probable,so after initial therapy when the BP rises,and patient`s condition stabilizes for surgery,surgery should be done.The strangulated loops should be evaluated and put back in the abdomen(if it is viable).repair is recommended either hernioplasty or heniorrhaphy should be done inorder to avoid recurrence.

5.  A)Malignancy: lymphoma-retroperitoneal sarcoma-metastasis

      B)Femoral aneurysm/pseudoaneurysm

      C)lymh node

      D)sebaceous cyst

       E)hidradenitis

       F)cyst of the canal of Nuck(femoral)

       G)saphenous varix

        H)psoas abcess

        I)hematoma

        J)femoral hernia