Saint's triad

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Saint's triad is a medical condition of concurrence of the following:

Contents

  1. Cholelithiasis (gallstones)
  2. Hiatal hernia
  3. Diverticular disease (diverticulosis of colon) [1]

History

Saint's triad is named after the British surgeon Hunterian and Emeritus Professor Charles Frederick Morris Saint CBE (14 August 1886 – 15 February 1973), who established the first school of surgery in South Africa. He emphasised 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. [2] Traditionally, there is thought to be no pathophysiological basis for the coexistence of these three diseases. Saint emphasized that more than one disease may be responsible for a patient's clinical signs and symptoms, and 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. [3] The principle underlying Saint's triad is also expressed as Hickam's dictum.

Recent evidence

A twist to this philosophic discussion on the art of diagnosis is that, in recent times, the possibility of an underlying pathophysiology has been considered—obesity is associated with gallstones, hiatal hernia, and diverticular disease, and there is the suggestion of an underlying connective tissue defect such as a "herniosis." [4]

Related Research Articles

Occam's razor, Ockham's razor, Ocham's razor, also known as the principle of parsimony or the law of parsimony, is the problem-solving principle that "entities should not be multiplied beyond necessity". It is generally understood in the sense that with competing theories or explanations, the simpler one, for example a model with fewer parameters, is to be preferred. The idea is frequently attributed to English Franciscan friar William of Ockham, a scholastic philosopher and theologian, although he never used these words. This philosophical razor advocates that when presented with competing hypotheses about the same prediction, one should select the solution with the fewest assumptions, and that this is not meant to be a way of choosing between hypotheses that make different predictions.

Hernia Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. Various types of hernias can occur, most commonly involving the abdomen, and specifically the groin. Groin hernias are most commonly of the inguinal type but may also be femoral. Other types of hernias include hiatus, incisional, and umbilical hernias. Symptoms are present in about 66% of people with groin hernias. This may include pain or discomfort in the lower abdomen, especially with coughing, exercise, or urinating or defecating. Often, it gets worse throughout the day and improves when lying down. A bulge may appear at the site of hernia, that becomes larger when bending down. Groin hernias occur more often on the right than left side. The main concern is bowel strangulation, where the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness in the area. Hiatus, or hiatal hernias often result in heartburn but may also cause chest pain or pain while eating.

Gastroesophageal reflux disease Medical condition

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic condition in which stomach contents and acid rise up into the esophagus, resulting in symptoms and/or complications. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, regurgitation, breathing problems, and wearing away of the teeth. Complications include esophagitis, esophageal stricture, and Barrett's esophagus.

Hiatal hernia Type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest

A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

Gallstone Disease where stones form in the gallbladder

A gallstone is a stone formed within the gallbladder out of precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to presence of migrated gallstones within bile ducts.

Cholecystitis Medical condition

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

Bowel obstruction Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

Signs and symptoms Indications of a medical fact or characteristic

Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showing on a medical scan. A symptom is something out of the ordinary that is experienced by an individual such as feeling feverish, a headache or other pain or pains in the body.

Abdominal pain Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues.

Nissen fundoplication Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

Diverticulosis Condition of having diverticula (outpocketings) in the wall of the intestine

Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall, and may be due in part to low-fiber diet prompting changes in intestinal microflora with consequent low-grade inflammation. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.

Mallory–Weiss syndrome Bleeding from a laceration in the mucosa at the junction of the stomach and esophagus

Mallory–Weiss syndrome or gastro-esophageal laceration syndrome refers to bleeding from a laceration in the mucosa at the junction of the stomach and esophagus. This is usually caused by severe vomiting because of alcoholism or bulimia, but can be caused by any condition which causes violent vomiting and retching such as food poisoning. The syndrome presents with hematemesis. The laceration is sometimes referred to as a Mallory–Weiss tear.

Cryoglobulinemia Medical condition

Cryoglobulinemia is a medical condition in which the blood contains large amounts of pathological cold sensitive antibodies called cryoglobulins – proteins that become insoluble at reduced temperatures. This should be contrasted with cold agglutinins, which cause agglutination of red blood cells.

Diverticular disease is when problems occur due to diverticulosis, a condition defined by the presence of pouches in the wall of the large intestine (diverticula). This includes diverticula becoming inflamed (diverticulitis) or bleeding. Colonic perforation due to diverticular disease may be classified using the Hinchey Classification.

Ascending cholangitis Medical condition

Ascending cholangitis, also known as acute cholangitis or simply cholangitis, is inflammation of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum. It tends to occur if the bile duct is already partially obstructed by gallstones.

Gastric outlet obstruction Medical condition

Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, as well as malignant causes, such as gastric cancer.

Pulmonary insufficiency Medical condition

Pulmonaryinsufficiency is a condition in which the pulmonary valve is incompetent and allows backflow from the pulmonary artery to the right ventricle of the heart during diastole. While a small amount of backflow may occur ordinarily, it is usually only shown on an echocardiogram and is harmless. More pronounced regurgitation that is noticed through a routine physical examination is a medical sign of disease and warrants further investigation. If it is secondary to pulmonary hypertension it is referred to as a Graham Steell murmur.

Medical diagnosis Process to identify a disease or disorder

Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit. The information required for diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes posthumous diagnosis is considered a kind of medical diagnosis.

Roemheld syndrome (RS), or gastrocardiac syndrome, or gastric cardiac syndrome or Roemheld-Techlenburg-Ceconi-Syndrome or gastric-cardia, was a medical syndrome first coined by Ludwig von Roemheld (1871–1938) describing a cluster of cardiovascular symptoms stimulated by gastrointestinal changes. Although it is currently considered an obsolete medical diagnosis, recent studies have described similar clinical presentations and highlighted potential underlying mechanisms.

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

References

  1. Bailey & Love's/24th/1104
  2. Whitworth, Judith A.; Firkin, Barry G. (1996). Dictionary of medical eponyms (2nd ed.). New York: Parthenon Pub. p. 354. ISBN   1-85070-477-5.
  3. Hilliard AA, Weinberger SE, Tierney LM, Midthun DE, Saint S (Feb 2004). "Clinical problem-solving. Occam's razor versus Saint's Triad". N. Engl. J. Med. 350 (6): 599–603. doi:10.1056/NEJMcps031794. PMID   14762188.
  4. "Is herniosis the single etiology of Saint’s triad?" M. Hauer-Jensen, Z. Bursac and R. C. Read, Hernia (Volume 13, Number 1 February 2009 p1265-4906 (Print) p1248-9204