Eponymous Signs in Splenic rupture

Ballance's  sign - Ballance's sign is dullness to percussion in the left flank LUQ and shifting dullness to percussion in the right flank seen with splenic rupture/hematoma. The dullness in the left flank is due to coagulated blood, the shifting dullness on the right due to fluid blood.

Kehr's  sign - Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classical symptom of a ruptured spleen. Kehr's sign is a classical example of referred pain: irritation of the diaphragm is signalled by the phrenic nerve as pain in the area above the collarbone.

Saegasser's  sign  - Palpation of  left upper quadrant  inferior to ribs  elicits neck pain in the  patient. 

Different Eponymous types of Hernia

Amyand's hernia :The term Amyand’s hernia refers to the presence of the appendix within the hernial sac, and has been variously defined as the occurrence of either an inflammed or perforated appendix within an inguinal hernia, or simply, the presence of a non-inflammed appendix within an irreducible inguinal hernia.

The pathophysiology of Amyand’s hernia is unknown. Weber et al [4], proposed that appendix in
hernia becomes inflamed as a result of repeated trauma,leading to adhesions and bacterial overgrowth.

Barth's hernia :Hernia of the loops of intestine between the serosa of the abdominal wall and that of a persistent vitelline duct.

Beclard's hernia - femoral hernia through saphenous opening

Berger's hernia - hernia in Pouch of Douglas

Bochdalek hernia :(congenital posterolateral hernia of the diaphragm)A Bochdalek Hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni's hernia.

The foramen of Bochdalek is a 2cm x 3cm opening in the posterior aspect of the diaphragm in the foetus, through which the pleuroperitoneal canal communicates between the pleural and peritoneal cavities. This canal normally closes by the 8thweek of gestation, failure or  incomplete fusion of the lateral (costal) with the posterior (crural) components of the diaphragm leads to the
development of Bochdalek hernia. Since the left canal closes later than the right, this type of hernia is found on the left side in 85% of cases

Cloquet's hernia :A femoral hernia perforating the aponeurosis of the pectineus and insinuating itself between this aponeurosis and the muscle, lying therefore behind the femoral vessels.

Cooper's hernia (bilocular femoral hernia ): 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.

De Garengeot's hernia : incarceration of the vermiform appendix within a femoral hernia.

Gibbon's hernia : hernia with hydrocoele

Gruber's hernia :Internal mesogastric hernia.

Hesselbach's hernia - hernia of a loop of intestine through the cribriform fascia presenting lateral to femoral artery

Hey's hernia :encysted hernia, scrotal or oblique inguinal hernia in which the bowel, enveloped in its own proper sac, passes into the tunica vaginalis in such a way that the bowel has three coverings of peritoneum

Holthouse hernia :an inguinal hernia that has turned outward into the groin.

Krönlein's hernia: An inguinoproperitoneal hernia; a hernia that is partially inguinal and partly properitoneal.

Larrey's hernia = (Morgagni's hernia)

Laugier’s femoral hernia- This is a type of femoral hernia through a gap in the lacunar ligament. It is more medial in position and nearly always strangulated.

Littre's hernia - hernia with Meckels's Diverticulum

lumbar hernia: hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains following entities:

• Petit's hernia - hernia through Petit's triangle (inferior lumbar triangle).
• Grynfeltt's hernia - hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle).

Maydl's hernia -(hernia-in-W) The hernia contains two loops of bowel arranged like a 'W'. The central loop of the 'W' lies free in the abdomen and is strangulated where as the two loops present in the sac are not.

Mesocolic / transmesenteric hernias:  occur through iatrogenically created defects in the mesentery. These defects include herniation of an abdominal viscus, usually through the small bowel mesentery or transverse mesocolon. These hernias are common following abdominal surgery, especially Roux-en-Y loop reconstruction,  which creates a defect in the mesentery.

Morgagni hernia (also known as retrosternal or parasternal diaphragmatic hernia) occurs due to the defective fusion of the septal transverses of the diaphragm and the costal arches. This anatomic defect lies posterolateral to the sternum and is called Larrey’s space . The exact aetiology of this hernia is unknown but it is postulated that it begins as a weakness in the diaphragm which is later stretched due to intraperitoneal pressure.

Narath’s femoral hernia - The hernia lies hidden behind the femoral vessels. It occurs only in patients with congenital hip dislocation due to lateral displacement of the psoas muscle.

Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels

Perineal hernia(Mery’s hernia): A perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually, is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.

Phantom hernia - Localised muscle buldge following muscular paralysis

Richter's hernia: strangulated hernia involving only one sidewall of the bowel, which can result in bowel perforation through ischaemia without causing bowel obstruction or any of its warning signs.

Rieux's hernia :retrocecal hernia, protrusion of the intestine into a pouch behind the cecum.

Rokitansky's hernia :A separation of the muscular fibres of the bowel allowing protrusion of a sac of the mucous membrane.

Serofini's hernia - behind femoral vessels

Spigelian hernia - Spigelian hernia occurs through congenital or acquired defects in the spigelian fascia. This is the area of the transversus abdominis aponeurosis, lateral to the edge of the rectus muscle but medial to the spigelian line, which is the point of transition of the transversus abdominis muscle to its aponeurotic tendon.

Treitz's hernia is the eponymous name for a paraduodenal hernia. These are rare hernias that arise in the potential spaces and folds of the posterior parietal peritoneum adjacent to the ligament of Treitz.(duodenojejunal hernia)

Velpeau hernia: A velpeau hernia is a femoral hernia in front of the femoral blood vessels in the groin.

 

 

Hilton’s method to drain abscesses.

What's this?

 

 

The most commonly utilized contrast materials for GI examinations include barium sulfate and Gastrografin.

 

Barium represents the most widely used contrast agent.

Gastrograffin is the other alternative to Barium swallow and is used somewhat less commonly. This is a water-soluble contrast agent that can be diluted to varying strengths and ingested in a similar manner as barium sulfate.

 

Gastrograffin may be used both as a liquid drink, or as an enema.

 

Chemically it is Diatrizoate Meglumine .

 

Generally speaking, barium produces higher quality images than Gastrograffin.

It has the downside of having a chalky taste that is somewhat upsetting to some patient. It also has the disadvantage of producing a chemical peritonitis should a bowel perforation be present and the barium spills freely into the peritoneal cavity.

If GI transit is delayed, water will be progressively absorbed from the barium compound within the gastrointestinal tract, producing hard concretions which can form in the colon and cause constipation.

Gastrograffin, on the other hand, is water-soluble and well suited to performing GI examinations where suspicion for bowel perforation exists.

It has the main disadvantage of an extremely foul taste and is often poorly tolerated by patients when administered full strength. It also has been known to cause severe chemical pneumonitis if aspiration occurs.

For this reason, Gastrograffin should only be administered with extreme caution in patients known to aspirate or given through a conduit in patients presenting with a high risk for aspiration.

Gastrograffin is also hyperosmotic and tends to draw fluid into the bowel lumen as it passes through the GI tract. While this can be advantageous in helping eliminate stool in the constipated patient, this could be disaster in patients presenting with small bowel obstructions, as the osmotic pressure will produce a more progressive dilatation of the small bowel in the obstructed patient.

Saint's Triad

Saint, a South African surgeon, emphasized the importance of considering the possibility of multiple separate diseases in a patient whenever his or her history and the results of the physical examination were atypical of any single condition.

The triad that bears his name is the association of

• hiatal hernia,
• gallbladder disease(gall stones), and
• diverticulosis.
• There is no pathophysiological basis for the coexistence of these three diseases; that, perhaps, was his point.
• Saint emphasized that more than one disease may be responsible for a patient's clinical signs and symptoms.
• his Triad provides a counterexample to the commonly used diagnostic principle that "the explanation of any phenomenon should make as few assumptions as possible," also known as Occam's Razor.

William of Occam stated, "Plurality must not be posited without necessity." A subsequent version of this statement was expressed as "Among competing hypotheses, favor the simplest one" — hence the term "Occam's razor"

Surgery-Abdomen introduction

First we will deal with various common abdominal disease presentations, & history taking along with the important clinical findings to be noted.

Abdominal disease presentations:

• non-leading & misleading symptoms
• minimal signs
• require elaborate investigations

different complaints:

• pain
• dysfunction of diseased organs
• lump
• distension
• general disturbance depending upon disease process

Abdominal pain:pain may be produced by-

• somatic structures (abdominal wall ,parietal peritoneum)-these are innervated by somatic nerves & they are under cortical control.therefore pain is well localised & precise.
• visceral structures(gut, solid alimentary organs, genitourinary organs)-these are under autonomic control(not under control of cerebral cortex) & hence pain is diffuse

{note:autonomic nerves go to hypothalamus where pain cannot be sensed ,so now you might get a doubt then how visceral pain is felt ?

• Actually the somatic & autonomic nerves both travel closely in a spinal nerve & this leads to some amount of leakage of current from autonomic to somatic nerve ,so now the actual visceral pain is felt by brain as if coming from the area supplied by that particular somatic nerve ,this is referred(radiating) pain.i.e, it is felt on same dermatomal segment of abdominal wall.
• visceral pain felt only when organ is stretched ,spastic or ischemic or due to stretch of mesentry
• pain can be modified by neighboring somatic structures:

eg-in appendicitis -first pain in umbilical region ,then depending upon degree of inflammation exudate leaks out & collects in right illiac fossa peritoneum (which is supplied by somatic nerves) &hence causes pain in right illiac fossa}

• viscera in somatic compartment(pancreas, kidney etc)-to explain about how these organs feel pain let me tell you with an example-pancreas is supplied by Sympathetic nerves T8,T9,T10.so as you see the given illustration referred pain will be above umbilicus when pancreas is inflamed.as time passes the inflammatory exudate leaks out into somatic compartment(i.e, retroperitoneum) & irritates the somatic nerves & causes back pain also.

DIVISION	ARTERY	VEIN	LYMPHATICS	SYMPATHETIC	PARASYMPATHETIC
FOREGUT: Oesophagus Stomach Proximal half of duodenum (up to common bile duct (CBD)) Liver Pancreas	CELIAC ARETERY	PORTAL VEIN Spleenic vein Gastric vein	CELIAC NODES	CELIAC GANGLIA (T6 to T8)	VAGUS
MIDGUT: Distal half of duodenum (from CBD) Jejunum Ileum Appendix Caecum Ascending colon Right 3/4 of transverse colon	SUPERIOR MESENTERIC ARTERY	SUPERIOR MESENTERIC VEIN	SUPERIOR MESENTERIC NODES	SUPERIOR MESENTERIC GANGLIA (T9 to T10)	VAGUS
HINDGUT: Left 1/4 of transverse colon Descending colon All of rectum down to ano-rectal line	INFERIOR MESENTERIC ARTERY	INFERIOR MESENTERIC VEIN	INFERIOR MESENTERIC NODES	GANGLIA HYPOGASTRIC PLEXUS (T11 to T12 ,L1)	PELVIC SPLANCHNIC NERVES

[note:

so pain in gut viscera is referred to their respective dermatomes ,especially at midline & only in severe cases to sideways

1. pain in foregut-above umbilicus
2. midgut-at umbilicus
3. hindgut-below umbilicus]

Gall bladder pain:

pain along T7 -T9 segments(right hypochondrium to inferior angle of right scapula)

Diaphragm pain:

along C3,4,5 (pain over shoulder)

Urinary organs pain:

along dermatomes L1 & L2(along genitofemoral nerve)

retroperitoneal visceral pain:

pain is felt in back in addition to referred pain on sensory dermatomes

eg-pain in pancreas.

Nature of pain:varies with nature of disease

• continous pain -inflammatory
• colic (intermittent ,gripy ,in wave form) -spastic conditions.

Dysfunction:

In gut disease it results in Dyspepsia -it is a very vague term literally meaning -difficulty in digestion.

patient may complain of -

• lack of appetite
• nausea
• vomiting
• diarrhea
• constipation ,etc

now let us consider each abdominal organ dysfunction separately.

stomach:

1. mild dysfunction results in -anorexia
2. moderate - nausea
3. severe - vomiting

note:stomach has property of receptive relaxation(to receive food from oesophagus) & propulsive expulsion(to expel into duodenum).

• bloating sensation(due to absence of receptive relaxation)-patient feels heavy even with small amount of food ,since there is no relaxation of stomach.

small bowel:

• malabsorption,diarrhea

colon:

• altered bowel habits
• discharge of mucus per rectum

liver:jaundice

urinary organs:disturbance in micturation

female reproductive organs:menstural disturbance.

Modified presentation

due to exaggerated sympathetic response to some organs, especially stomach.

let me explain it to you with an example:

• suppose small bowel is diseased ,so to recover it needs rest from its usual work. so for this to occur the stomach causes symptoms like anorexia , nausea ,vomiting .so as a result the person wont like to eat anything & thus his small bowel gets some rest & it recovers fast.
• suppose the stomach doesn't make these manifestations to occur ,then the person keeps on eating & there is no rest for small bowel & its condition detiorates.
• Hence stomach acts as a BIG BROTHER of abdomen.
• sometimes its response is greater than the diseased organ & disease is mistaken as gastric disorder. so you should keep in mind about the other possibilities of each presentation.

presentation as lump:

site of lump indicates site of its origin unlike pain.

now lets go to clinical examination:

• detailed history taking
• general examination
• abdominal examination
• examination of scrotum ,supraclavicular nodes & spine.

detailed history taking:

points to be enquired

pain:

• site( initial & present)
• nature
• aggravating & relieving factors
• relation to food ,vomiting ,defecation
• periodicity

presenting features of dysfunction of viscera

• anorexia ,nausea ,vomiting(stomach)
• diarrhea(small bowel)
• altered bowel habits .mucus/ blood in stools (colon)
• frequency ,difficulty in micturation ,haematuria (urinary organs)
• menstural disturbance (female genital tract)
• jaundice(liver)
• any general disturbance like fever ,loss of weight (T.B. ,malignancy ,etc)

lump:

• initial site of appearance
• rate of growth
• associated with pain or not
• preceding history of abdomen disease.

general examination.

PICCKLE ,heart & lung sounds.

P-pallor(check lower palpebral conjunctiva)

I-icterus/jaundice(upper bulbar conjunctiva)

C-cyanosis(tongue)

C-clubbing

K-koilonychia

L-lymphadenopathy

E-edema

abdominal examination

Inspection:

skin & subcutaneous tissue:

• abdominal lump
• superficial engorged veins:

features	portal obstruction	inferior vena cava obstruction	superior vena cava obstruction
position	situated around umbilicus (caput medusa)	on sides of abdomen	on sides of abdomen
direction of blood flow	away from umbilicus	from below upwards	from above downwards

note:direction of blood flow is known by following technique-

• two index fingers of both hands are placed close together on engorged vein below umbilicus
• portion of vein is emptied by milking it with one of the index fingers
• remove the upper finger, the vein remains collapsed if flow is from below upwards .vein fills quickly if flow is from above downwards.
• repeat the same process of emptying the vein , but now remove the lower finger.the vein remains collapsed if flow is from above downwards .vein fills quickly if flow is from below upwards.

Cullen's sign & Grey-Turner's sign:

• Cullen's sign is ecchymosis (puplish blue discolouration) of the skin around the umbilicus.
• Grey-Turner's sign is ecchymosis in flanks.
• mainly associated with hemorrhagic pancreatitis (in 1 to 2 % cases seen)
• (typically after 2 to 3 days after acute pancreatitis)
• represent retroperitoneal hemorrhage that has dissected through fascial planes to skin

also seen in:

1. ruptured ectopic pregnancy ,severe trauma
2. leaking or ruptured abdominal aortic aneurysm
3. any condition associated with bleeding into retroperitoneal space

It is caused by pancreatic enzymes that have tracked along the falciform ligament and digested subcutaneous tissues around the umbilicus.

scar:

• linear scar -healing by primary intention
• irregular scar -indicating wound infection
• keloid , hypertrophic scar.

hard subcutaneous nodules near umbilicus:Sister Mary Joseph Nodule

• She was first to notice that a 'nodule' in the umbilicus was often associated with advanced malignancy
• Presents as firm, red, non-tender nodule
• Results from spread of tumour within the falciform ligament
• 90% of tumours are adenocarcinomas
• Commonest primaries are stomach and ovary
• Primary tumour is almost invariably inoperable

abdomen distention:5F's

1. fetus
2. faeces
3. flatus(gas)
4. fluid
5. fat

note : among these only in fat distention ,umbilicus is deeply inverted & in others it is flat or everted.(reason:umbilicus is a scar ,which is bound to linea alba & when fat increases, it fills around the umbilicus as subcutaneous fat & thus causes raising of level of skin around it)

umbilicus:

tanyol's sign:umbilicus is displaced upwards by swelling arising from pelvis or downwards by ascites.

any swelling on one side of abdomen will push umbilicus to opposite side.

movements:

respiratory - localised limitation indicates subjacent inflammation

peristaltic -

observed in	pyloric stenosis	obstruction in small bowel	obstruction in large bowel
features	rounded prominence will be seen travelling slowly from left costal margin to right	ladder pattern	opposite movement to that of pyloric stenosis

pulsatile:

• aortic aneurysm - expansile pulsation
• tumor in front of abdominal aorta - transmitted pulsation

palpation:

tenderness(pain on touch):

disease	tender spot location
gastric ulcer	mid-epigastrium below xiphoid process
duodenal ulcer	1&1/2 inch to right of midline on transpyloric plane
cholecystitis	Palpation under the right costal margin whilst asking the patient to breathe in causes pain as the inflammed gallbaldder touches with the palpating hand.(Murphy's sign) cartilage of right 8th rib becomes tender hyperaesthesia below the right scapula, called Boas' sign.
appendicitis	McBurney's point(McBurney's point refers to the location of the base of the appendix. It lies one third of the way along an imaginary line drawn from the anterior superior iliac spine to the umbilicus.)-this is McBurney's sign.

rigidity & guarding(stiffness):in both there is reflex contraction of abdominal wall

• in rigidity ,it is present at rest &
• in guarding it appears due to provocation from pressure of examining fingers

lump:

• character(consistency)
• its anatomical plane(intra-abdominal or parietal) :

abdominal muscles are made taut by asking patient :

1. to raise his shoulders from bed with arms folded on his chest 'the rising test'
2. to raise both extended legs from bed -'leg lifting test'(carnett's test)
3. try to blow out with nose & mouth shut.

results:if swelling is-

• parietal -swelling will become more prominent & will be freely moveable over the taut muscle.
• parietal but fixed to abdominal muscles = swelling will not be moveable over the taut muscle.(eg: recurrent fibroid of paget & haematoma in rectus muscle)
• intra-abdominal-disappears or becomes smaller.

note:if swelling moves vertically with respiration it is intra-abdominal.

Palpation of abdominal organs:

• stomach
• liver
• spleen
• gallbladder
• kidney
• pancreas
• colon

stomach:

• normally cannot be palpated.
• in cases of pyloric stenosis-look for

1. visible peristalsis
2. succussion splash

• the stomach becomes distended with fluid (ingested liquid ,saliva & gastric fluid) when the pylorus is obstructed by tumor or cicatricial stenosis.
• when the diaphragm of stethoscope is placed medial to left costal margin & patient is shaken from side to side by the lower ribcage ,a splashing sound is heard ,that is pathognomic for this condition.
• the test must be carried out after a 4hr fast.(since Succussion splash may be heard in normal subjects for up to 3 hours after a meal).
• A positive succussion splash indicates a hollow area containing both fluid and gas.
• For abdominal examination, the examiner's hand is placed in the area to be examined, a soft pressure is applied, and then the examiner gives short ,sudden ,jerky movements with fingers. This will, if the sign is positive, result in a palpable or audible splash.
• For thoracic examination, auscultates while gently moving the patient side to side on the examining table.
• A thoracic succussion splash is found in a pneumohydrothorax (air and fluid in the chest cavity) or rarely in hemopneumothorax.

lump in pyloric region:

• congenital pyloric stenosis - thick pylorus
• carcinoma - mass is irregular , hard with varying degrees of mobility
• leaking perforation of peptic ulcer - firm ,less mobile ,more tender

{absence of lump by no means excludes carcinoma of stomach}

Liver:

• children upto end of 3 years - palpable
• adults - not palpable

Gall-Bladder:

when distended felt as tense globular swelling projecting downwards & forwards from below liver just lateral to outer border of right rectus muscle.

Courvoisier's law

• It states that, in the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; rather carcinoma of the pancreas or the lower biliary tree is more likely.
  • reason:
• Gallbladder distension has been thought to occur because the distal malignant obstruction leads to chronically elevated intraductal pressures. This contrasts with obstructions caused by stones, which are associated with chronic cholecystitis and fibrosis of the gallbladder wall, which precludes distension.
• In addition, stones may cause only partial obstructions (related to a "ball-valve" action of the stone) leading to less consistent intraductal pressure elevations, and less gallbladder dilatation.

Exceptions to Courvoisier's Law

1. Oriental cholangiohepatitis
2. Double stone impaction (one in cystic duct, other in Common Bile Duct)
3. a pancreatic calculus obstructing ampulla of vater
4. Mucocele of gall bladder due to an impacted stone at neck of gall bladder.

Spleen:

• spleen must be atleast two times larger than normal size to be detected clinically.
• splenic swelling:sharp anterior border where 1 or 2 notches felt (characteristic of splenic swelling)

Pancreas:best way to palpate it:

1. turn patient to right.
2. hips & knees flexed
3. left subcostal & epigastric regions deeply palpated.

if tenderness present - indicates pancreatitis (this is Guy -Mallet sign)

this pain & tenderness often radiates to left shoulder - Kehr's sign

Renal:

renal angle :check this area for signs of renal disease

• An area located on either side of the human back between the lateral borders of the erecter spinae muscles and inferior borders of the twelfth rib, so called because the kidney can be felt at this location.
• check for any dullness ,tenderness ,fullness.

percussion:

evaluate-

• free fluid in abdomen (by shifting dullness)
• presence of gas filled viscus in front of any lump: eg-if anterior to stomach -dull note on percussion.
• if posterior to stomach-resonant note on percussion
• borders of solid organs mapped out by their dull note

	ascites	ovarian cyst
resonance	anteriorly	flanks
dullness	flanks	anteriorly
shifting dullness	present	absent

Spleen: to evaluate splenomegaly -

Castell's sign -

• percussion in the lowest intercostal space(8th or 9th) in the left anterior axillary line.
• In normals this area is resonant( due to the air-filled stomach or splenic flexure of the colon.)in inspiration and expiration.
• With splenic enlargement this area becomes dull on maximal inspiration.

percussion over traube's space:

• It's a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver.
• Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin.

• Underneath Traube's space lies the stomach, which produces a tympanic sound on percussion.
• If percussion over Traube's space produces a dull tone, this might indicate splenomegaly

note:Castell’s has been shown to be superior in sensitivity to other spleen percussion signs as well as palpation, which is not likely useful due to the extreme enlargement necessary to feel the spleen below the costal margin.

auscultation:

• Systolic bruit heard over an artery indicates stenosis of the underlying artery. Systolic bruit may be heard also over very vascular intra-abdominal tumors.

• Venous hum is rarely heard. When present, it is a sign of venous collaterals developed secondary to portal hypertension.

Kenawy's sign:

• seen in splenomegaly due to portal hypertension
• hear a venous hum louder on inspiration with stethoscope placed below xiphoid process
• reason:due to spleen being compressed during inspiration results in engorgement of splenic vein & hum is heard

Left supraclavicular lymph nodes:

enlargement of these group of nodes occurs in carcinoma of stomach - Troisier's sign.

This is end of todays post ,to sum up I will write the important high yield facts here:

• Cullen's sign is ecchymosis (puplish blue discolouration) of the skin around the umbilicus.Seen in hemorrhagic pancreatitis.
• Grey-Turner's sign is ecchymosis in flanks. seen in hemorrhagic pancreatitis.
• Guy -Mallet sign : tenderness present in left subcostal & epigastric regions when deeply palpated.seen in pancreatitis.
• Kehr's sign :pain & tenderness often radiates to left shoulder in pancreatitis.

• Sister Mary Joseph Nodule : a 'nodule' in the umbilicus seen especially in advanced stomach cancer.

• tanyol's sign: umbilicus is displaced upwards by swelling arising from pelvis or downwards by ascites.

• Boas' sign :hyperaesthesia below the right scapula in cholecystitis
• Murphy's sign :Palpation under the right costal margin whilst asking the patient to breathe in causes pain as the inflammed gallbaldder connects with the palpating hand

• Castell's sign - percussion in the lowest intercostal space(8th or 9th) in the left anterior axillary line. causes a dull note in splenomegaly
• Kenawy's sign :venous hum louder on inspiration with stethoscope placed below xiphoid process seen in splenomegaly due to portal hypertension

Basic body positions

Different surgical positions:

There are various type of positions in which the patient may be positioned during surgery include supine, prone, trendelenburg, reverse trendelenburg, lithotomy, sitting, lateral, and Jacknife position.

supine position:

The supine position is the most common position used

The most common complication of supine position is that pressure sores which can develop on any area that bears weight, such as heels and sacrum. Moreover, any unconscious patient lying in the supine position is at risk of aspirating gastric contents. The acidic nature of the gastric contents will severely burn the lung tissue and is a life threatening hazards, which is the major cause of morbidity and mortality.

trendelenburg position:

The trendelenburg position is a variation of the supine position in which the bed is flat, but the patient's head and body are lower than the heart. The patient is held in position by padded shoulder braces to prevent the patient from sliding on the OR table. This position is very useful in surgical procedures of lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen.

The Trendelenburg position increases the spread and accelerates the onset of epidural anesthesia for Cesarean section.

Myth: The Trendelenburg position improves circulation in cases of shock

modified trendelenburg position(shock position):

only legs elevated position,to treat hypotension

reverse trendelenburg position:

• variation of the supine position in which the bed is flat, but the head is higher than the heart level.
• This position is used almost exclusively for head and neck procedures and laparoscopic procedures.
• The main complication to look for in this position is peripheral pooling of the blood in the lower extremities.

Sims or lateral recumbent position:

• used for orthopedic, kidney, and some thoracic surgeries in which the patient is placed on the non operative site in the right or left side with an air pillow 12-15 cm thick under the loin, or a table with a kidney or back lifts .
• it may be used for administering rectal suppositories and enemas

Potential complications include, decrease in chest expansion and circulation. Blood can pool in dependent limbs causing pressure sores at the hip and ankle. Moreover damage to the brachial plexus also may occur if the patient is not positioned correctly.

prone position:

used for dorsal approach required in spinal cord procedures such as a laminectomy in which the patient is placed face down.

Jackknife position(kraske position):

variation of the prone position, with the patient flexed at the waist.

The complications associated include airway inaccessibility; potential for facial skin breakdown; tissue damage to knees, ankle, and chest. Potential exists for corneal abrasions, decreased blood pressure, decreased chest movement and femoral artery occlusion

lithotomy position:

patient is flat on the back facing upward with the legs and thighs flexed at right angles, and the feet are carefully positioned in stirrups

• often used for gynecological or genitourinary surgeries
• The patient is at risk for strained lumbosacral muscles, saphenous vessel and nerve damage, and perineal nerve damage. The potential for severe hypotension also exists, therefore both legs need to be raised and lowered together.

fowler's position:

semi-sitting position.

three variations are common-

1. low fowlers position:head & torso elevated to 30 degrees.
2. mid-fowlers /semi-fowlers position:head & torso elevated to 45 degrees.
3. high fowlers position:head & torso elevated to 60 to 90 degrees.

knees may not be elevated,but doing so relieves strain on spine.