12. Surgical Diagnosis: Physical Signs, Laboratory, Imaging Devices; Interventions

I. Physical Signs

General Inspection

• General condition: Toxic, septic, shocked, cachectic
• Color: Pallor, jaundice, cyanosis
• Previous surgery: Scars, stomas, drains, hernia repairs
• Abdomen: Distension, asymmetry, visible peristalsis, hernia

Palpation

• Mass: Size, mobility, tenderness, consistency, pulsation
• Tenderness: Localized or diffuse
• Guarding: Voluntary or involuntary muscle defense
• Rebound tenderness / Blumberg sign: Peritoneal irritation
• Organomegaly: Liver, spleen, gallbladder, kidney
• Hernial orifices: Reducibility, tenderness, strangulation signs

Percussion and Auscultation

• Percussion: Shifting dullness/fluid wave → Ascites
• Tympany → Dilated bowel/obstruction; dullness → Mass, fluid, organomegaly
• Auscultation: Absent bowel sounds → Ileus/peritonitis
• High-pitched/tinkling bowel sounds → Mechanical obstruction
• Bruits → Vascular lesion, stenosis, aneurysm, AV fistula

Special Signs

• Murphy sign: Inspiratory arrest during right subcostal palpation → Acute cholecystitis
• Rovsing sign: RLQ pain during LLQ palpation → Appendicitis/peritoneal irritation
• Psoas sign: Pain with hip extension/resisted flexion → Retrocecal appendicitis
• Obturator sign: Pain with internal rotation of flexed hip → Pelvic appendicitis/abscess
• Cullen sign: Periumbilical ecchymosis → Hemoperitoneum/severe pancreatitis
• Grey-Turner sign: Flank ecchymosis → Retroperitoneal hemorrhage/severe pancreatitis

II. Laboratory Investigations

• CBC: Leukocytosis → Infection/inflammation; anemia → Bleeding/chronic disease; thrombocytopenia → Bleeding risk
• CRP, ESR: Inflammation markers; trend helps follow infection/abscess/postoperative complications
• Electrolytes: Vomiting, ileus, obstruction, dehydration
• Renal function: Shock/dehydration, contrast risk, drug dosing
• Liver enzymes: Hepatitis/cholestasis/liver reserve
• Bilirubin, ALP/GGT: Biliary obstruction/cholestasis
• Amylase/lipase: Acute pancreatitis; lipase is more specific
• Lactate: Ischemia, shock or sepsis
• Coagulation profile: INR/PT, aPTT, fibrinogen → Bleeding risk/anticoagulant effect
• Tumor markers: CEA, CA19-9, AFP, CA-125 → Adjunct for baseline/follow-up, not primary diagnosis alone
• Blood group/screen: Needed before major operation or possible transfusion

III. Imaging Modalities

Ultrasound

• First-line for many abdominal problems: Gallstones, cholecystitis, biliary dilatation, AAA, fluid collections
• Useful for appendicitis in children/pregnancy and FAST in trauma
• Advantages: Non-invasive, no radiation, bedside, repeatable
• Limitations: Operator-dependent; difficult with obesity/bowel gas

X-Ray

• Erect chest/abdominal X-ray → Free air under diaphragm, bowel obstruction with air-fluid levels
• Useful for bones, foreign bodies and some radiopaque stones
• Fast and available but limited soft tissue detail

CT

• Cross-sectional imaging of choice in many surgical emergencies
• Uses: Trauma, appendicitis, diverticulitis, perforation, obstruction, abscess, pancreatitis complication, cancer staging
• Contrast CT: Vascular assessment, bleeding, ischemia, bowel wall and tumor evaluation
• Limitations: Radiation, contrast allergy, renal risk, pregnancy considerations

MRI / MRCP

• MRI: Best soft tissue contrast; useful for liver lesions, rectal cancer, pelvic fistulas, soft tissue tumors
• MRCP: Non-invasive biliary/pancreatic duct imaging → Stones, strictures, obstruction
• No radiation, but slower, expensive and less available in emergency

Contrast Studies

• Barium swallow/enema or water-soluble contrast study
• Uses: Strictures, fistulas, leaks, obstruction, anastomosis check
• Use water-soluble contrast if perforation/leak is suspected

IV. Interventions

Flexible Endoscopy

• Upper GI endoscopy / EGD: Dyspepsia with alarm signs, upper GI bleeding, ulcers, tumors, dysphagia

• Diagnostic: Visualization, biopsy, H. pylori testing
• Therapeutic: Bleeding control, variceal banding, dilatation, stent, PEG, foreign body removal

• Colonoscopy: Lower GI bleeding, colorectal cancer, IBD, unexplained anemia, polyp follow-up

• Therapeutic: Biopsy, polypectomy, bleeding control, decompression, selected stenting

• ERCP: Mainly therapeutic biliary/pancreatic endoscopy

• Indications: CBD stones, cholangitis with obstruction, biliary stricture, bile leak, pancreatic duct problem
• Procedures: Sphincterotomy, stone extraction, balloon/basket retrieval, biliary/pancreatic stent

Ultrasound-Guided Interventions

• Abscess/fluid drainage: Liver, pelvis, superficial collections
• Biopsy: Masses, lymph nodes, thyroid, liver, breast/soft tissue lesions
• Central venous catheter placement
• Paracentesis and thoracentesis

CT-Guided Interventions

• Deep abscess drainage: Retroperitoneal, pelvic, intrathoracic or peripancreatic collections
• Biopsy: Retroperitoneal, intrathoracic, bone, pancreatic or deep abdominal masses
• Percutaneous nephrostomy → Obstructive uropathy / infected obstructed kidney
• Percutaneous biliary drainage → Obstructive cholestasis/cholangitis when ERCP is impossible or failed