Diffuse esophageal spasm (DES) is a motility disorder of unknown etiology that gives rise to dysphagia and chest pain. The dysphagia is nonprogressive and is encountered with both liquids and solids. The chest pain is nonexertional but may respond to nitroglycerin.
Typically, the illness begins with vague midabdominal discomfort followed by nausea, anorexia, and indigestion. The pain is persistent and continuous but not severe, with occasional mild cramps. There may be an episode of vomiting, and within several hours the pain shifts to the right lower quadrant, becoming localized and causing discomfort on moving, walking, or coughing. The patient may feel constipated.
Examination at this point shows localized tenderness to one-finger palpation and perhaps slight muscular guarding. Rebound or percussion tenderness (the latter provides the same information more humanely) may be elicited in the same area. Peristalsis is normal or slightly reduced. Rectal and pelvic examinations are likely to be negative. The temperature is only slightly elevated (eg, 37.8 °C) in the absence of perforation.
Contrary to traditional teaching, tenderness on rectal examination is not a sign of acute appendicitis. If present, it more often points to another cause of the symptoms. Another common misconception is that inflammation in a retrocecal appendix produces an atypical syndrome. This too is incorrect; the clinical findings in this situation are the same as for ordinary (antececal) appendicitis.
Rarely, the cecum may lie on the left side of the abdomen, and appendicitis may be mistaken for sigmoid diverticulitis. An inflamed appendix in the right upper quadrant may mimic acute cholecystitis or perforated ulcer. Even when the cecum is normally situated, a long appendix may reach to other parts of the abdomen, and acute appendicitis in these circumstances may be very confusing indeed.
A couple of general points are worth remembering: (1) People with early (nonperforated) appendicitis often do not appear ill and may even apologize for taking your time. Finding localized tenderness over McBurney's point is the cornerstone of diagnosis. (2) A rule that will help considerably with atypical cases is never to place appendicitis lower than second in the differential diagnosis of acute abdominal pain in a previously healthy person
A.THE Modified Duke Staging System:
Modified Duke A The tumor penetrates into the mucosa of the bowel wall but no further.
Modified Duke B B1: tumor penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. B2: tumor penetrates into and through the muscularis propria of the bowel wall.
Modified Duke C C1: tumor penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: tumor penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes.
Modified Duke D The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone).
B.THE TNM STAGING SYSTEM
TNM Staging System (Tumor, Node, Metastasis)
Tumor
T1: Tumor invades submucosa.
T2: Tumor invades muscularis propria.
T3: Tumor invades through the muscularis propria into the subserosa, or into the pericolic or perirectal tissues.
T4: Tumor directly invades other organs or structures, and/or perforates.
Node
N0: No regional lymph node metastasis.
N1: Metastasis in 1 to 3 regional lymph nodes.
N2: Metastasis in 4 or more regional lymph nodes.
Metastasis
M0: No distant metastasis.
C.THE Stage Groupings
Stage I: T1 N0 M0; T2 N0 M0
Cancer has begun to spread, but is still in the inner lining.
Stage II: T3 N0 M0; T4 N0 M0
Cancer has spread to other organs near the colon or rectum. It has not reached lymph nodes.
Stage III: any T, N1-2, M0
Cancer has spread to lymph nodes, but has not been carried to distant parts of the body.
Stage IV: any T, any N, M1
Cancer has been carried through the lymph system to distant parts of the body. This is known as metastasis. The most likely organs to experience metastasis from colorectal cancer are the lungs and liver.
