Abdominal pain is a common pathology, yet the suspicion of a variety of diseases when it’s present. Acute pain is often an emergency and should be studied and treated promptly to avoid complications. However, chronic abdominal pain or pain with a long evolution should be studied and questions regarding associated symptoms are needed to reach a diagnosis. The quality, quantity, location and type of pain need to studied; how it began, it’s evolution, any aggravating and mitigating effects and if it radiates to another location. The symptoms associated with abdominal pain may be fever, fatigue, chest pain, referred pain to other parts of the body, nausea, vomiting, anorexia, urinary symptoms, gastrointestinal symptoms, headache or altered mental status. The most common diseases should be confirmed or discarded, such as bile duct disease (cholecystolithiasis or gallstones), pancreatitis, appendicitis, diverticulitis, intestinal obstruction, intestinal torsion, pelvic inflammatory disease, ovarian cyst, colitis, hernia of the abdominal wall, peptic ulcer, gastrointestinal reflux disease, abdominal malignancies (colon cancer), gastroenteritis, urinary tract infection, aortic aneurysm, among others. This is obtained through interrogation, physical examination and laboratory studies to complement blood or imaging studies.

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Cholecystitis is the inflammation of the gallbladder and primarily occurs because of stones in its interior, causing an obstruction and inflammation of the gallbladder, known as acute cholecystolithiasis. Treated timely and without complications, it has an excellent prognosis; however, delayed care and treatment can lead to complications such as perforation or gangrene of the gallbladder, leading to less favorable outcome. The disease is common in the Mexican population, occurring in up to 10-20% of the entire population. It is more common in women of childbearing age, with multiple pregnancies, and obese patients, however, anyone may have it and may manifest itself at any age. It is associated with symptoms such as pain in the stomach radiating to the right subcostal area, back or right shoulder. It is related to consuming heavy meals, greasy or irritating foods, as well as cholekinetic ingredients like milk, cheese, avocado, nuts and natural oils. It is accompanied by symptoms such as colic or constant pain, nausea, vomiting (sometimes bitter) and in rare cases fever, tachycardia or jaundice (yellowing of the skin and eyes). The diagnosis is confirmed by blood tests and imaging. Usually an ultrasound of the upper abdomen is sufficient to assess the gallbladder, its current status and the presence of calculi (stones) within. Once the diagnosis is confirmed, medical management may be indicated to control symptoms and inflammation of the gallbladder, however, the definitive treatment is surgical. Laparoscopic cholecystectomy is the ideal treatment, making an umbilical incision to introduce a trocar (valve) to insert a camera into the abdomen and inflate. Two incisions, one 1cm incision in the midline below the ribs and another 0.5cm incision below the right costal border are made to introduce the forceps and the surgery is performed, removing the gallbladder altogether. When patients are treated promptly, recovery is rapid with minimal discomfort. Surgical wounds are very aesthetic,  with the camera incision hidden in the umbilical mark (belly button), and the other two remain as small lines that fade with time. The prognosis is excellent and usually only requires a day of hospitalization; patients return to their daily activities in a short period of time. Prolonging or delaying treatment carries the risk of complications such as those already mentioned regarding perforation or gangrene of the gallbladder, others such as intestinal fistulas or small calculi (stones) exiting the gallbladder into the common bile duct, causing inflammation of the liver or pancreas by blocking drainage, which if untreated, may be very dangerous for the patient’s life.

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Pancreatitis is an inflammation of the pancreas. It can be caused by history of alcoholism, abdominal trauma, high triglycerides, use of certain medications or in very rare cases infection, toxins, and other rare causes. The most common cause of this condition is obstruction the obstruccion of the bile duct by calculi (stones). This can be a complication of cholecystolithiasis (stones in the gallbladder/gallstones), when a small stone exits the gallbladder, blocking the drainage of bile from the liver and/or pancreas. Pancreatic inflammation is accompanied by symptoms such as abdominal pain in the stomach. This usually increases gradually to become persistent, severe, and disabling the patient, not allowing patients to continue their daily activities. Pain radiates through the abdomen to the back. It is accompanied mainly by nausea and vomiting and may even be accompanied by more severe symptoms such as fever, profuse sweating, anemia and jaundice (yellowing of the skin and eyes). Patients with suspected pancreatitis should be admitted and managed medically. In hospital stay is several days in which medical management and intra-venous hydration is given. Blood tests and imaging are ordered to verify the etiology or origin of the condition. The patient should be fasting until the condition of pancreatitis is resolved, and then the cause of the disease must be treated, either by medical or surgical treatment, as appropriate. Pancreatitis is a serious disease, which involves some degree of mortality, this being up to 30% in severe cases if not treated promptly; it can lead to multiple organ failure. After an episode of pancreatitis, patients need to follow the orders prescribed by the doctor to prevent subsequent episodes and risk of complications.

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An abdominal wall hernia is one of the most common surgical problems. A hernia is a weakness in the muscle wall through which a sac is formed and protrudes, often with abdominal content. There are different types of hernias, according to their origin and location. The most common are the umbilical hernia (manifested as a protruded belly button) and the inguinal hernia (which occurs most often in men, as a bulge in the groin that can descend into the scrotum). There are others types of hernias, such as an epigastric hernia (in the midline, above the belly button) and incisional hernia (hernia formation in an area where surgery was previously, preformed forming a hernia due to a tear of the muscle wall) as well as other type of hernias which are much less common. It is estimated that up to 10% of the Mexican population has some type of hernia, especially among people who perform daily activity involving great efforts or heavy exercise; however, anyone can suffer from a hernia at any age. Most hernias are identified by the patient. They tend to start asymptomatically, sometimes with a little bloating, tingling around the area, without pain, or only referring some mild discomfort. The hernia size increases in size with efforts or prolonged standing position; however, the hernia sac will eventually increase in size and with them the risks. The hernia sac often contains only fatty tissue surrounding bowel, but with increasing size, intestinal segments begins to herniate too. Patients complain of pain, tenderness of the area of ​​the hernia, painful increased volume of the sac and in more severe cases, nausea, vomiting and fever. The diagnosis of a hernia is done through a good physical examination and can be supplemented, if necessary with imaging studies such as ultrasound or computed tomography (CT). The acute management is manual reduction to avoid ischemia of the contents of the hernia sac. If the sac cannot be reduced, emergency surgery may be indicated. Otherwise, you can plan and schedule a surgical repair. In surgery, the hernia sac is reduced and the wall defect closed with sutures and the placing of a special prosthetic mesh, this done only in adults to reduce recidivism of this condition. The prognosis is very good with a quick recovery. Postoperative discomfort and pain are minimal. It is recommended that patients avoid making any efforts for a month after surgery to allow proper healing and prevent complications. Depending on the type and size of hernia, surgery can be managed as an outpatient or in some cases require a day of hospitalization. Failure to timely assess and treat a hernia may put the patient at risk for complications due to the progressive increase in the size of the hernia. The hernia sac can be trapped in the hernia along with its content making a manual reduction impossible, or it can strangle the sac and its content, causing an ischemia (not enough blood flow) which leads to intestinal perforation or gangrene of the tissues. If this happens, a small cosmetic incision is excluded and a larger and more invasive procedure to repair the damage may be necessary.

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A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm through the esophageal hiatus into the chest. Most patients are asymptomatic, but patients who show symptoms, mainly complain of symptoms of gastro-esophageal reflux. They refer a long evolution of symptoms with multiple treatments, and difficulty to control despite several medications, antacids and substances that protect the gastric mucosa. It can occur at any age, but its incidence in adulthood increases progressively from 40 years of age. It is more common in regions and countries with a diet low in fiber, such as the US and Mexico, and has a slight predominance in women. The diagnosis is made by upper endoscopy, or imaging methods as gastro-esophageal contrast series. The treatment, if the patient does not respond favorably to medical indications such as proton pump inhibitors (omeprazole and others alike), surgical treatment may be considered, a procedure like a fundoplication (Nissen fundoplication is the most common). In this method the hernia is reduced, closing the esophageal hiatus to prevent slippage of the stomach into the chest, and plication of the stomach around the abdominal esophagus is made to function as a valve. The procedure can be performed by laparoscopy, which involves several small incisions of 0.5 to 1cm to introduce trocars or valves to insert the camera and clamps into the abdomen and perform the procedure. This type of procedure allows for a faster recovery and minimal postoperative discomfort.

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Hemorrhoids are known as inflammation of the venous sacs (hemorrhoidal sacs) in the lower rectum. They are part of the most common anal disorders, followed by fistulas and anal fissures. They are a very common condition appearing in about 5% of the adult population, but many patients do not seek medical or surgical assessment by embarrassment and discomfort involved regarding the affected area. The anal area is a highly vascular area and the hemorrhoidal sacs may easily become inflamed o swell up, protruding into the anal canal or outside the anus. According to their anatomical location, they can be internal or external hemorrhoids. Other diseases that are related to hemorrhoids and may accompany these or develop on their own without the hemorrhoidal disease are, fissures and perianal fistula. The anal fissure is a tear in the skin and mucosa of the perianal region and anal fistula is a canal or conduit that forms and connects the anal mucosa or rectum with the perianal skin.

Patients suffering from hemorrhoids, the symptoms can range from a mild discomfort and itching, to a major aggravation with moderate to severe pain, bleeding episodes and persistent sense of a mass in the anal region. In cases of fissure and fistula, the symptoms are similar, referring more irritation and discomfort after using the WC, as well as complaining about the persistence of humidity in the region and stains in their underwear.

The causes of these diseases include poor venous return, chronic constipation or prolonged periods of time sitting in the bathroom. Hemorrhoids can become manifest also in the patient during the last months of her pregnancy due to increased intra-abdominal pressure caused by the baby’s growth. With a good medical evaluation, these conditions can be treated medically through change in daily habits, obtaining favorable outcome in most patients. However, 10% to 50% of patients may experience recurrence of the disease and higher risk of complications such as thrombosis of hemorrhoids, ulcers, infections, abscesses, bleeding or even incontinence. Repetitive or complicated episodes are an indication for surgery. Depending on the diagnosis and the degree of damage, the type of surgery that is indicated; either resection of a hemorrhoid, fistula or fissure, or the combination of several of these may be the case. The procedure is performed in the operating room and requires at least one day of stay. The rest of the surveillance can be through office visits combined with medical management. The evolution is generally good and the incidence of post-surgical complications is very low if doctor’s indications and care management are followed.

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Diverticulitis is a condition ranging from an asymptomatic diverticular disease, uncomplicated diverticular disease, chronic or complicated diverticulitis, to perforated diverticulitis. This is due to the formation of small sacs or herniations of mucosa through the muscular wall of the colon. This is more common in older adults and disease, but may exist in young people. The symptoms of this disease include pain in the left lower quadrant, changes in bowel habits, abdominal bloating and in some cases, evidence of blood in the stools. An acute severe pain, nausea, vomiting, abdominal bloating, abdominal wall rigidity and fever, may mean a severe complication of diverticulitis and emergency room visit for assessment and management is needed. The diagnosis and staging of diverticular disease is done through a CT scan; however, other studies such as barium enema are useful in diagnosing the illness. Depending on the condition of the patient and the disease, determines the treatment indicated. This may vary from medical management and monitoring in a mild case, to colon resection surgery and in severe cases.

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The thyroid gland is one of the largest endocrine glands of the body. It is located in the neck and plays an important role in the metabolism of the body, sensitivity to other hormones as well as acting as an important energy use and growth regulatory for the body. There are many diseases that can affect this gland, the most common are hyperthyroidism (increased thyroid activity), hypothyroidism (decreased thyroid activity), thyroiditis (inflammation of the thyroid) and thyroid nodules (which can be divided into benign / harmless or malignant / cancer)

In hyperthyroidism, there is an overproduction of thyroid hormones. Patients complain of heart palpitations, diaphoresis (excessive sweating), diarrhea, weight loss, muscle weakness, hot flashes or heat intolerance, fine hand tremors, nervousness, anxiety, decreased or loss of menstrual cycle in women and may even presented with a slight protrusion of the eyeballs. In these cases, patients are treated medically, but if there is no respond to treatment, a partial or total removal of the thyroid may be necessary. This involves an incision in the neck through which all or part of the gland is removed.

In hypothyroidism, there is a underproduction of thyroid hormones. In these cases patients have symptoms like unexplained weight gain, lethargy, fatigue, hair loss, dry skin, cold intolerance, bradycardia, constipation and lack of energy in general. Lab tests help us confirm a diagnosis and its treatment is the administration of replacement hormones, in this case levothyroxine, which works as thyroid hormone. Due to its underproduction, sometime the gland increases in size causing goiter. If the gland size does not diminish with treatment, surgical resection may also be indicated.

Thyroiditis is an inflammatory process characterized by autoimmune diseases in which hypothyroidism is caused by self-destruction of the gland. Patients present with symptoms similar to hypothyroidism and require medical treatment. In some cases, hypothyroidism causes a goiter or abnormal growth of the gland, presenting as a large mass in the neck, in which case surgical resection may be necessary as well.

Nodules in the thyroid gland can be of various types. The vast majority are benign or remnants of a congenital deformity. These should be biopsied by fine needle aspiration, by which cells are obtained from the node to examine under a microscope by a pathologist. This helps us determine if the nodule is benign (ie. An adenoma) or malignant (ie. A cancer), and determine the treatment to be followed, including resection of the nodule, a hemithyroidectomy (removal of half of the thyroid gland) , a total thyroidectomy (removal of the entire thyroid gland) or other procedures like when there is a persistent thyroglossal duct.

After thyroidectomy (removal of the thyroid), patients may experience symptoms such as slight discomfort or pain in the area, hoarseness or trouble talking in the early post-operative days due to the manipulation during surgery of the nerves that innervate the vocal cords. The thyroid gland moderates calcium levels in the body, which is why it is important to check the levels of this in the first postoperative day and is even common to present a significant decrease, requiring intra-hospital surveillance for several days after surgery. A decrease in thyroid hormones or hypothyroidism is expected due to total removal of the gland, requiring taking thyroid hormones to control this. Patients may require another treatment with radioactive iodine in specific cases, before or after surgery and continue monitoring.

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Varicose veins are not only a cosmetic problem, but also accompanied by symptoms and discomfort as a result of a problem of chronic venous insufficiency that causes venous hypertension and stasis (clogging and congestion) of venous blood in the peripheral veins. This is caused by the combination of valve failure, damage to the vein wall, and the hypercoagulability and congestion of the blood in the venous system. It is a common disease in women due to a hormonal factor involved and often manifests itself in patients during pregnancy. Up to 60% of the population may have venous insufficiency, manifested in about 40% of the population with some clinician degree of varicose reflux. Its location can be anywhere, but most of the cases are in the lower extremities (legs and thighs). It occurs mainly in women with a predominance of 5 to 1 when compared with men.

There are different variations to this disease; telangiectasia veins (very thin veins, reflected on the skin that looks like spiderwebs), reticular veins (thin veins of 1-3mm thick) and varicose veins (larger veins over 3 mm thick which can even protrude from the skin). Patient may also present skin changes such as darkening of the skin and in more severe cases, ulcers, which are infected easily and are very difficult to heal. Symptoms of chronic venous disease may include pain and heaviness in the legs, tiredness after prolonged periods of standing, and in some cases a burning sensation. Most can be treated medically with procoagulant and antivaricose drugs to improve symptoms and stop progression. It can be complemented with resting periods with leg elevation during the day and using compression stockings or elastic bandages on the extremities. When medical treatment is not sufficient, complementary assessment with Doppler ultrasound is needed to evaluate management options. The favored and most common is sclerotherapy.

Sclerotherapy is an outpatient procedure that can be done in the office. It consists in injecting veins with a pharmaceutical that helps to collapse and obliterate the insufficient or dysfunctioning veins and with it, the symptoms they cause. This not only relieves the discomfort, but the veins disappear, giving excellent cosmetic results. In more severe cases or when the veins are too thick for sclerotherapy, a surgery is indicated, done in the operating room called saphenectomy. In a saphenectomy a small incision is made in the groin and another one in the ankle to remove the saphenous vein. Complementary to this surgery an advanced technique of millimetric micro-incisions are made to remove collateral veins. This is done to favor the outcome of the surgery. The procedure is ambulatory and does not require hospitalization. Following medical instructions, the procedures have excellent success rate and evolution.

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Onicocriptosis is the medical name for an ingrown toenail, a fairly common condition that most often affects the first toe (big toe) in any of its edges. It is a traumatic condition in which the nail is embedded in the edge of the skin and soft tissue growing inside it and inflaming the tissues. It is often accompanied by infection or a small abscess. Its cause may be by direct trauma, use of inappropriate footwear or incorrect cutting of the toe nails. Symptoms include redness of the area, volume increased by swelling and moderate to severe pain that sometimes incapacitates the ability to walk properly. Treatment includes using local anesthesia to numb the toe for cleaning and removal of embedded nail segment. The ideal is to preserve the nail and only remove excess segment of matrix and abnormal growth. It is important to the proper and timely treatment to prevent complications like deformity of the toe or even risk losing the tow. Wound cleansing and medication may be needed after the procedure.

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Diabetes is a complicated disease that affects patients in many ways. One of these ways is the onset of microvascular disease (disease of small arteries) associated with neuropathy (disease of the peripheral nerves) in the feet, which together cause a disease known as diabetic foot. A diabetic foot presents vascular and nerve damage, due to poor diabetic control for a prolonged period of time. The foot is damaged and prone to bone deformities and infections. Infections are usually difficult to control and an ulcer places the foot at high risk for osteomyelitis (bone damage) from the infection, which in turn puts the foot at risk for amputation. Amputations are sometimes one or more toes or part or all of the foot. Poor circulation is always an important factor when such conditions are handled. A diabetic foot requires a multidisciplinary management. First you need to control the disease (Diabetes) with glucose control and monitoring of the function of systems and organs. For this, blood labs are necessary and in some cases, hospital admission. In most cases and depending on the progress of the wound or ulcer (assess with x-rays of the affected area), they may require a debridement in which the foot is cleaned and the damaged tissue is removed; this can be done in the doctor’s office or in procedures rooms, but sometimes an operating room may be needed. Advanced wound cleansing must be made in time for monitoring and assessing the evolution of the foot. These are complemented with medical management and antibiotics. In wound cleansing process, sometimes special ointments or medications that help with the debridement of damaged tissue and promote healing are added. According to the evolution of the wound is the type of treatment that follows. Wound dressing with repeat debridement may be continued or amputation may be needed in order to prevent endangering the patient’s life by advancing infection.

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Chronic wounds are defined as an injury that affects the skin and persists for more than six weeks without showing evidence of healing or closure. It is a condition that is found most often in the legs below the knee and causes pain, discomfort / social unrest. Ulcers weaken a patient, are exhausting, and significantly reduce the quality of life. The causes may be venous or arterial disease, diabetes, neuropathy of the leg, or a metabolic, hematologic or infectious condition. Because there are many factors that can affect this condition, it requires a multidisciplinary management to determine the pathology, diagnosis and establish the optimal treatment based on medical management and advanced wound healing. A correct diagnosis is imperative to prevent inappropriate treatment, which can further impair the wound.

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The skin and subcutaneous tumors are a common condition. They manifest as a lump or swelling palpable below the skin, well defined and in most cases mobile. They can occur anywhere in the body including head, neck, chest, abdomen, back and limbs. Its size is variable, and can measure from less than one centimeter up to a giant mass, measuring 10, 15 or 20cm in diameter. There are different types of skin and subcutaneous tumors. Among the most common are lipomas, epidermoid/sebaceous cysts, and moles/nevus. The lipoma is an accumulation of fat surrounded by a fibrous capsule in the subcutaneous tissue. On average, they measure between 1 to 3 cm, are painless, and can stay the same size or grow slowly over time. They can occur as a single lipoma or multiple lipomas in the body. The diagnosis is clinical by physical examination, but sometimes it may be necessary to assess with an soft tissue ultrasound to confirm the diagnosis. These can be removed surgically in the office or outpatient procedure room under local anesthesia if they are small, or in an operating room when dealing with a big or deep lipoma. Pathogenicity is usually benign, but it is always recommended to send the piece to be evaluated by a pathologist to confirm the absence of malignancy. Epidermoid or sebaceous cysts are semi-solid accumulations of skin tissue, cellular debris, glandular secretion, and keratin. They can form spontaneously in the skin or a blocked sweat or sebaceous (oily producing) gland. These, like lipomas, depending on their size can be removed in the office or outpatient procedure room or the operating room. They too are benign, but its pathological analysis is recommended. Moles or nevi are pigmented skin lesions known as “birthmarks” formed by accumulation of melanin (pigment cells). Some congenital and other acquired. These should be assessed directly by the doctor because depending on their morphometric characteristics, they can be a benign mole, a premalignant lesion or a skin cancer among other diagnostic options from a wide range of dermatological diagnosis. Surgical excision could vary depending on the diagnosis.

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The prepuce (foreskin or excess skin of the penis) is the skin that covers the glans of the penis and the patient should always be able to retract it regardless of whether the penis is flaccid or erect. Phimosis is when the foreskin forms a narrow ring making it difficult or impossible to retract and expose the glans. This causes discomfort for the patient, and causes difficulty urinating, pain or discomfort during common sexual activity or during erections. Likewise, it creates an environment of poor hygiene for the penis, predisposing to infections and accumulation of secretions inside, sexually transmitted infections once sexual activity is begun, and there is even evidence that demonstrates an increased risk of developing penile cancer.

There are various treatments for this condition. The most common and recommended is the circumcision, which is a surgical removal of the foreskin, exposing the glans. This procedure is performed in the operating room under the effects of regional anesthesia with sedation to avoid discomfort or pain during the procedure, and has excellent results. It is performed on an outpatient basis, without requiring hospitalization. It can be performed in children and adults. It does not affect function or sensitivity of the penis and is an important treatment option for phimosis and paraphimosis, improving penile hygiene and reducing risk of other complications like those already mentioned above. If the patient does not wish to undergo a circumcision and suffers from phimosis, other procedures exist, such as preputioplasty, in which the phimotic ring is released allow the skin to be retracted to expose the glans when desired.

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An abscess is an accumulation of purulent fluid (pus) consisting of affected inflammatory tissue and the presence of active infection and microorganisms. They are characterized by an area of tenderness, erythema (redness), hot skin and fluctuation (soft with presence of liquid inside). Most cases are superficial and visible, but in some cases these can be deep and difficult to diagnose. There are several types of abscesses, the most common being the subcutaneous tissue abscess caused by a wound, a foreign body or infection of the skin. Others like the perianal abscess caused by various diseases of anus and rectum. There other various abscesses, less common like the liver abscess (pyogenic or amebic), intra-abdominal, Bartholin, breast, lung, cervical, psoas, etc…

In any type of abscess, it is important to identify the organism responsible for the infection in order to choose the most appropriate antibiotic. Apart from medical management through antibiotic therapy, it is important to drain the abscess if possible, and perform wound cleansing to improve hygiene in the area.

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