Stomach popped out. Diastasis Recti vs Hernias: Understanding Abdominal Bulges in Men and Women
What are the key differences between diastasis recti and hernias. How can you identify and manage these abdominal conditions. What are the treatment options for diastasis recti and hernias. Who is at risk for developing these abdominal wall issues.
Understanding Diastasis Recti: Causes, Symptoms, and Diagnosis
Diastasis recti is a condition where the connective tissue between the rectus abdominis muscles stretches, creating an abnormally wide gap. This separation often manifests as a visible bulge in the upper abdomen, particularly noticeable during activities that engage the core muscles.
Common causes of diastasis recti include:
- Pregnancy
- Obesity
- Abdominal wall weakness
- Previous abdominal surgery
- Congenital factors
Typical symptoms of diastasis recti include:
- An oval-shaped bulge between the breastbone and belly button
- Increased visibility of the bulge when coughing, sitting up, or lifting heavy objects
- Difficulty with core exercises and weightlifting
- Abdominal wall weakness
Diagnosis of diastasis recti often involves a physical examination where a doctor observes a “classic bulge” when the patient sits up. In some cases, a CT scan may be used to confirm the separation of abdominal muscles.
Hernias: Types, Symptoms, and Diagnostic Approaches
A hernia occurs when there is a hole in the abdominal wall tissues, allowing fat, fluid, or an organ to protrude. Unlike diastasis recti, hernias can be located in various areas, including:
- Near or at the belly button
- In the groin
- At previous surgical incision sites
Hernias may be present at birth or develop over time. The primary symptom of a hernia is a visible bulge or protrusion on the abdomen or in the groin area. This bulge may become more apparent during activities that increase abdominal pressure, such as coughing, sneezing, or lifting heavy objects.
How are hernias diagnosed? Doctors typically use the following methods:
- Physical examination to visually inspect and palpate the affected area
- CT scan for a more detailed view of the abdominal wall
Diastasis Recti vs Hernias: Key Differences and Similarities
While both diastasis recti and hernias can cause abdominal bulges, there are several crucial differences between these conditions:
Pain Levels
Diastasis recti is generally not painful, although it may cause discomfort and abdominal wall weakness. In contrast, hernias often cause pain at the site of the bulge, especially during physical activity or straining.
Location
Diastasis recti typically affects the area between the breastbone and belly button, while hernias can occur in various locations, including the groin and around previous surgical incisions.
Underlying Cause
Diastasis recti results from stretched connective tissue, whereas hernias involve a hole or weakness in the abdominal wall.
Treatment Approaches
Treatment options for diastasis recti and hernias differ significantly. Diastasis recti often improves without surgery, particularly in postpartum women. Hernias, however, typically require surgical intervention to prevent complications.
Treatment Options for Diastasis Recti: Non-Surgical Approaches
For many individuals with diastasis recti, non-surgical treatments can be effective in managing the condition and improving abdominal strength. These approaches include:
Physical Therapy
A tailored physical therapy program can help strengthen the abdominal muscles and improve core stability. Exercises may focus on gentle engagement of the transverse abdominis and pelvic floor muscles.
Diet and Exercise
For individuals whose diastasis recti is related to obesity, a combination of a balanced diet and appropriate exercise can help reduce abdominal fat and alleviate symptoms.
Abdominal Binders
Compressive garments worn around the abdomen can provide additional support and help manage symptoms associated with diastasis recti. These binders come in various styles and sizes to suit individual needs.
Are there any risks associated with using abdominal binders? While generally safe, it’s important to use them as directed and not rely on them as a sole treatment method. Overuse may lead to muscle weakness if not combined with appropriate exercises.
Hernia Management: Surgical Interventions and Supportive Care
Unlike diastasis recti, hernias often require surgical intervention to prevent potential complications. The primary treatment options for hernias include:
Surgical Repair
The goal of hernia surgery is to repair the hole in the abdominal wall before tissue or intestines push through. Surgical techniques may vary depending on the size and location of the hernia.
Abdominal Binders
Similar to their use in diastasis recti, abdominal binders can help manage symptoms associated with hernias. They provide support and may help reduce discomfort, particularly before surgery.
When is hernia surgery necessary? While not all hernias require immediate surgery, most surgeons recommend repair to prevent potential complications such as intestinal strangulation or incarceration.
Risk Factors and Prevention Strategies for Abdominal Wall Issues
Understanding the risk factors for diastasis recti and hernias can help individuals take preventive measures. Common risk factors include:
- Pregnancy and multiple pregnancies
- Obesity
- Chronic coughing or sneezing
- Heavy lifting or straining
- Previous abdominal surgeries
- Genetic predisposition
To reduce the risk of developing these conditions, consider the following strategies:
- Maintain a healthy weight through proper diet and exercise
- Practice proper lifting techniques, especially when handling heavy objects
- Engage in core-strengthening exercises regularly
- Manage chronic coughing or constipation
- Follow post-surgical care instructions carefully
Can these preventive measures guarantee you won’t develop a hernia or diastasis recti? While they can significantly reduce your risk, some factors, such as genetic predisposition, are beyond individual control.
When to Seek Medical Attention for Abdominal Bulges
Recognizing when to consult a healthcare professional about an abdominal bulge is crucial for proper diagnosis and treatment. Consider seeking medical attention if you experience:
- A persistent or growing bulge in your abdomen or groin
- Pain or discomfort associated with the bulge, especially during physical activity
- Difficulty performing daily activities due to abdominal weakness
- Nausea, vomiting, or constipation along with abdominal pain
- Redness, tenderness, or warmth around the bulge
How urgent is it to see a doctor for an abdominal bulge? While not all bulges require emergency care, it’s best to have them evaluated promptly to rule out serious conditions and prevent potential complications.
Living with Diastasis Recti and Hernias: Lifestyle Adjustments and Long-Term Management
For individuals diagnosed with diastasis recti or hernias, making certain lifestyle adjustments can help manage symptoms and improve quality of life. Consider the following strategies:
Modify Exercise Routines
Adapt your fitness regimen to include exercises that don’t exacerbate your condition. For diastasis recti, focus on gentle core-strengthening exercises recommended by a physical therapist. For hernias, avoid heavy lifting and high-impact activities until after surgical repair.
Use Supportive Garments
Incorporate abdominal binders or supportive underwear into your daily routine, especially during physical activities or when symptoms are more pronounced.
Practice Good Posture
Maintaining proper posture can help reduce strain on your abdominal muscles and potentially alleviate discomfort associated with both conditions.
Manage Weight
If obesity is a contributing factor, work with a healthcare provider to develop a safe and effective weight loss plan.
Follow-up Care
Attend regular check-ups with your healthcare provider to monitor your condition and adjust your management plan as needed.
How long does it take to see improvement in diastasis recti with conservative management? While individual results vary, many people see noticeable improvement within 6-12 weeks of consistent exercise and lifestyle modifications. However, severe cases may require longer-term management or surgical intervention.
For individuals with hernias, what can be expected after surgical repair? Most patients can return to normal activities within 4-6 weeks after surgery, but full recovery may take several months. It’s essential to follow your surgeon’s post-operative instructions carefully to ensure proper healing and reduce the risk of recurrence.
By understanding the differences between diastasis recti and hernias, recognizing symptoms, and seeking appropriate medical care, individuals can effectively manage these abdominal wall conditions. Whether through conservative treatments, lifestyle modifications, or surgical interventions, there are numerous options available to address abdominal bulges and improve overall quality of life.
Abdominal Bulging: Diastasis Recti or Hernia?
The main way to tell if you have a hernia or diastasis recti is whether you feel pain. Hernias can cause substantial pain while diastasis recti may increase discomfort and abdominal wall weakness.
Let’s take a deeper look into the difference between diastasis recti and hernias.
Diastasis recti
Diastasis recti happens when the connective tissue between your rectus abdominis (six-pack) muscles is stretched, creating an abnormally wide distance between the muscles. This separation can present as a bulge, usually of the upper abdomen, that you may notice when you cough, sit up in bed or lift something heavy.
The most common causes of diastasis recti are pregnancy and obesity, but abdominal wall weakness and previous abdominal surgery can also increase a person’s risk. Diastasis can also be congenital or something that developed in the womb.
Typically, diastasis recti are oval-shaped bulges between the breastbone and belly button and are not painful. A person may notice it during activities that cause them to contract the abdomen.
Aside from the prominent bulge, abdominal wall weakness could make any type of weightlifting and core exercises more difficult.
A doctor may diagnose diastasis recti when they see a “classic bulge” present when the patient sits up. A CT scan showing a separation of ab muscles may also lead to a diagnosis.
Diastasis often does not require surgery. For pregnant people, the condition typically improves after childbirth.
Following diagnosis, prescribed treatment may involve physical therapy to strengthen the ab muscles or diet and exercise for weight loss purposes.
If abdominal wall weakness associated with the diastasis recti becomes problematic, an abdominal binder may help. There are many types of abdominal binders; however, the general concept is a compressive garment worn around the belly to provide additional support.
Hernias
A hernia is a hole in the tissues of the belly wall through which fat, fluid or an organ can stick out. Hernias can be located at or near the bellybutton, in the groin, or at a previous surgical incision. Some hernias are present at birth while others develop over time.
A hernia looks like a bulge or protrusion located somewhere on the abdomen or in the groin. You may notice the hernia when you cough, sneeze, lift a heavy item or during a bowel movement. The bulge can be visible during rest periods, as well.
Hernias will often cause pain at the site of the bulge.
A hernia can often be diagnosed during an exam; a doctor may be able to see or feel the hernia’s bulge or they will use a CT scan for a better look at the abdominal wall to determine if there is a hole.
Hernias can be repaired surgically, and the goal is to repair them before tissue or a stomach intestine pushes through the hole.
Abdominal binders are recommended for hernias, as well, to reduce symptoms.
If you would like a doctor to look at your abdominal bulge, call (713) 798-6363 to make an appointment at the Baylor Medicine Hernia Center.
By Heather West, PA-C, Specialty Abdominal Wall Surgery, Division of Trauma and Acute Care Surgery
Battling a Bulging Hernia | NIH News in Health
December 2017
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Don’t Ignore Your Groin Pain
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Usually, the wall of the abdomen is strong. The muscles keep your intestine in place. But if there’s a weak spot, the intestine can push through and form a hernia. A person may be born with a weakness there, or the weakness may develop over time later in life.
“It’s like when you look at an old tire on a car and you see kind of a bulge on the sidewall of the tire. That’s because there’s a weakness in the wall of the tire. And the air is pushing the wall of the tire outward to create that bulge,” says Dr. Dana K. Andersen, an NIH hernia expert.
A hernia developing in the abdomen is extremely common. Babies, children, and adults get them. Most of the time, hernias are found in men over 40. Can lifting heavy objects give you a hernia? Maybe if you already have a weakness in the wall of your abdomen.
“The majority—three-quarters—of abdominal wall hernias are in the groin,” Andersen says. The groin region is the lower abdomen.
The first sign of a hernia is a small bulge from the lower abdomen. You may notice it only when you stand up, cough, jump, or strain. That’s because those activities increase the pressure within your abdomen. That increased pressure can make a part of your intestine pop out of an area of weakness. When you lie down, the bulge may go away.
If you think you may have a hernia, ask your doctor. A doctor can usually detect a hernia during a physical exam. Your doctor can rule out other conditions that cause bulges or lumps.
If the bulge is very soft, your doctor may be able to massage the intestine back into the abdomen. A small, soft hernia that does not cause pain may not need treatment right away. The doctor may suggest watching and waiting for changes, like pain, to develop. If a hernia is painful or large, your doctor may suggest you see a surgeon for advice. You may need surgery to repair the hernia.
If your doctor can’t massage the intestine back into the abdomen, that means it’s trapped. A trapped intestine is dangerous because its blood supply can be cut off or strangulated.“The rim of the defect is forming a sort of a noose around the abdominal contents,” Andersen explains. “If that noose is tight enough so that the loop of intestine can’t be eased back through the defect, then the concern is that the intestine itself could be injured by strangulation.”
A strangulated hernia can be very serious and even life threatening. Symptoms include severe pain that doesn’t go away, nausea, and vomiting.
Surgery is usually needed if the intestine is trapped—and emergency surgery if it’s strangulated. A hernia is one of the most common reasons for surgery in the United States. “It’s a successful and low-risk procedure done about 800,000 times a year in the United States,” Andersen says.
If you think you may have a hernia, talk with your doctor. And check out the tips in Wise Choices for how to keep a hernia from getting worse. Keep in mind that anyone with sudden pain in the groin should immediately seek medical help.
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Lipoma, or wen – causes, symptoms of the disease, diagnosis and treatment
Jaundice
Tumor
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IMPORTANT!
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.
Lipoma: causes, symptoms, diagnosis and treatment.
Definition
Lipoma is a common tumor composed of fat cells (adipocytes) and is usually separated from surrounding tissues by a thin connective tissue capsule. Lipomas can form anywhere where fat cells are present, usually located subcutaneously, but are sometimes found on internal organs (for example, in the stomach, esophagus or intestines, bronchi, heart, or muscles).
Lipomas are benign neoplasms that do not tend to become malignant and do not cause discomfort to patients. The exception is those cases when lipomas are unsuccessfully located (for example, in the joint area) or grow rapidly, which happens extremely rarely.
Lipomas are the most common mesenchymal tumors (mesenchymal tumors are soft tissue tumors and specific bone tumors). The incidence is about 2.1 per 1000 people per year, and men are diagnosed slightly more often than women.
Causes of lipomas
The exact causes of lipomas are unknown. Some researchers agree that genetic anomalies play a role in their formation. Another theory suggests a link between the occurrence of a lipoma and previous trauma. Risk factors for the development of lipomas can be obesity, alcohol abuse, liver disease, impaired glucose tolerance, hyperlipidemia. The appearance of a lipoma may be the result of another disease, for example, familial multiple lipomatosis.
Disease classification
Lipomas can be simple or multiple (multiple lipomatosis). The latter include Derkum’s disease, benign symmetrical lipomatosis (Madelung’s disease), familial lipomatosis, congenital infiltrating lipomatosis. Multiple lipomatosis accounts for approximately 5-10% of all detected cases of lipomas.
Depending on which tissue components are involved in the pathological process, fibrolipomas (with connective tissue elements), myolipomas (they contain muscle fibers), angiolipomas (include blood vessels), myxolipomas (contain mucous tissue), myelolipomas (contain hematopoietic tissues ).
Symptoms of lipoma
Lipomas in the subcutaneous adipose tissue feel soft and mobile, not soldered to the surrounding tissues. Lipomas are characterized by slow growth, and their size is usually from 1 to 10 cm. Larger lipomas are called “giant”. The lesions are usually painless unless they involve joints, nerves, or blood vessels. The skin over the lipoma is not changed.
In the gastrointestinal tract, lipomas are submucosal fatty tumors. They are asymptomatic, but can provoke ulceration and bleeding. Esophageal lipomas can make it difficult to swallow food and liquids, causing belching, vomiting, and reflux.
Lipomas of the small intestine are diagnosed, as a rule, in older people, most often located in the ileum and dangerous by blockage (obstruction) of the intestinal lumen.
In addition, intestinal lipomas cause pain, obstructive (mechanical) jaundice, and intussusception (invasion of one part of the intestine into another).
Extremely rarely, lipomas form in the heart: subendocardially – under the inner lining of the heart (endocardium) or intramurally – inside the muscle layer (myocardium). Usually, cardiac lipomas are not encapsulated and appear as a yellow mass protruding into the cavity of the heart. Cardiac lipomas can cause chest pain, arrhythmias, and shortness of breath.
Lipomas formed in the bronchi or lung parenchyma lead to impaired respiratory function.
Lipoma Diagnosis
Diagnosis requires a clinical examination by a physician and soft tissue ultrasound.
Ultrasound of soft tissues
Examination of soft tissues to detect pathological changes and diagnose neoplasms.
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If the gastrointestinal tract is affected, contrast studies can be used, and in the case of an atypical location of the lipoma (for example, in the heart), in addition to ultrasound, computed or magnetic resonance imaging is performed.
Which doctors to contact
Diagnosis can be made by a dermatologist,
family doctor or
therapist. Surgical treatment is performed
surgeon.
Lipoma treatment
If the lipoma is painless and does not cause discomfort, no treatment is required. An indication for the removal of subcutaneous lipomas is their unfortunate location, that is, a cosmetic defect. The most effective method of correction is surgical excision of the lipoma together with the capsule.
In addition to excision for the treatment of small subcutaneous lipomas, there are conservative therapies, such as injections of lipolytic drugs, whose action is aimed at breaking down fat cells. However, after such treatment, relapses are possible.
Complications
Gastrointestinal lipomas can cause bleeding, blockage of the intestinal lumen, jaundice, and intussusception.
Cardiac lipomas can lead to embolism and cardiac arrhythmias.
Huge subcutaneous lipomas can compress nerves and surrounding structures. If a pedunculated lipoma occurs, there is a risk of its twisting, as a result of which the blood supply to the lipoma is disrupted, which is fraught with its necrosis or ulceration.
Prevention of lipoma
To prevent the occurrence of lipoma, factors that can provoke its growth should be minimized:
- avoid injury to soft tissues,
- maintain adequate weight,
- treat disorders of carbohydrate metabolism,
- monitor cholesterol levels and correct them in time.
Sources:
- Charifa A, Azmat CE, Badri T. Lipoma Pathology. 2021 Sep 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29493968.
- Kolb L, Yarrarapu SNS, Ameer MA, et al. Lipoma. [Updated 2021 Oct 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
www.ncbi.nlm.nih.gov - Usoltsev D.M., Davidyan A.A., Babich R.A. Experience in the removal of giant lipomas in the conditions of an outpatient surgery center. Inpatient replacement technologies: outpatient surgery. – 2016. – No. 1-2 (61-62). – S. 94-96.
Furuncle (boil) – symptoms, causes, signs and methods of treatment in adults in “SM-Clinic”
This disease is treated by a Dermatologist
, Surgeon
- About the disease
- Types of boils
- Symptoms of a boil
- Causes of boil development
- Diagnostics
- Expert opinion
- Treatment of furunculosis
- Prophylaxis
- Rehabilitation
- Questions and answers
- Doctors
About the disease
A furuncle is also called a boil. It occurs more often in adulthood. Men are affected somewhat more often than women. The main peak of incidence falls on the autumn and spring periods, when the body’s defenses weaken.
Unlike ostiofolliculitis and folliculitis, the formation of a furuncle is accompanied by the involvement of the surrounding tissue in the inflammatory process. This is due to the severe course of the disease.
On places devoid of hair (palms and palmar surface of the fingers, soles) boils do not develop. Most often they occur on areas of the skin that are subject to contamination (forearms, back of the hand) and friction (back of the neck, lower back, gluteal region, thighs).
Types of boils
Depending on the number of formations, single and multiple boils are distinguished. In the latter case, the disease is called furunculosis.
In the process of development, the pathology passes through three successive stages:
- infiltrative: accompanied by tissue infiltration;
- purulent-necrotic: characterized by purulent fusion of the central part of the boil and the formation of a purulent-necrotic rod;
- stage of healing: begins from the moment of spontaneous or artificial opening of the abscess and lasts until the formation of a scar.
Symptoms of a boil
At the initial stage of the development of the disease, the patient feels slight itching and tingling. On the 1st-2nd day, a formation appears that protrudes conically above the skin. The tissues turn red and become painful when touched. As the boil matures, a head appears on its top – a small accumulation of pus with a black dot in the center.
On the 3-7th day, in the form of a rod, together with the remnants of the hair, they are excreted with pus. The resulting wound is cleaned, filled with granulation tissue and healed. The swelling around it gradually decreases, the pain disappears. A small, whitish, somewhat retracted scar remains at the site of inflammation.
Multiple lesions of boils that appear simultaneously or sequentially one after another in different parts of the body – called furunculosis. A disease that lasts with small remissions for several years is considered chronic, relapsing.
Usually, a boil does not cause significant disturbances in well-being. With the defeat of a significant amount of tissue, symptoms of intoxication appear: weakness, headaches, fever. The intensity of pain depends on the location of the formation. In the face area (lips, forehead), as well as on the scrotum, the formation of a boil is accompanied by swelling of the surrounding tissues, which is explained by the looseness of the subcutaneous tissue.
Causes of the development of a boil
The main cause of the development of a boil is the defeat of the hair follicle or its surrounding tissues by Staphylococcus aureus, rarely white. An important factor is also a decrease in general or local immunity against the background of chronic diseases, metabolic disorders, and infections. Pathology occurs especially often in patients with diabetes mellitus, obesity, chronic liver and kidney damage, oncological diseases, etc. Infection of tissues often occurs against the background of skin damage: scratches, cuts, abrasions, constant exposure to sweat or purulent discharge (from the nose, ears).
The causes of localized furunculosis are most often incorrect methods of therapy and ignoring the doctor’s recommendations (use of compresses, undertreatment of residual compaction, washing the place where the elements appear).
Get advice
If you experience these symptoms, we recommend that you make an appointment with your doctor. Timely consultation will prevent negative consequences for your health.
You can find out more about the disease, prices for treatment and sign up for a consultation with a specialist by phone:
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Diagnosis
Diagnosis of boils is not difficult. During a visual examination of the patient, a dermatologist discovers a characteristic formation. Its appearance allows you to assess the stage of development of the disease. During the conversation, the doctor determines the possible cause of the development of boils, identifies risk factors. For an accurate diagnosis and determination of the pathogen, bakposev of the discharge is prescribed. In case of multiple lesions, additional diagnostics is carried out:
- general and biochemical blood test;
- immunogram;
- hormonal assessment;
- examination by ENT, endocrinologist and other specialists;
- examination of internal organs, paranasal sinuses, lungs, etc. depending on the specific clinical situation.
Expert opinion
Furuncle is a rather serious disease, which should be treated with great care. In no case should you self-medicate: you should not make compresses, use various ointments – in most cases this leads to the spread of the inflammatory process.
A complication of a boil can be lymphadenitis and lymphangitis (damage to the lymphatic vessels and nodes). Of particular danger are rapidly progressing acute thrombophlebitis and sepsis.
Acute thrombophlebitis usually develops with boils located near the large saphenous veins, and sepsis – with boils of the face. They are often the result of attempts to squeeze out the contents of the boil, cutting it off during shaving, trauma during massage. The prognosis for these complications is very serious.
Omarova Andzhelika Mutaevna
Coloproctologist, surgeon, Ph.D.
Treatment of furunculosis
Treatment of furuncle is only surgical, because no other therapy will be successful if the focus of purulent inflammation is not removed or opened and drained in a timely manner.
The opening of the boil is usually performed under local anesthesia and is painless for the patient. At the same time, antibiotic therapy, means for correcting immunity and eliminating background pathologies, if any, are prescribed.
Simple (uncomplicated) lesions can be treated on an outpatient basis and do not require hospitalization. But in case of a severe course, if the patient develops swelling of the soft tissues of the cheek, lip or eye, urgent hospitalization is necessary in the surgical department to constantly monitor the development of the process and prevent complications.
Strict bed rest and appropriate therapy are prescribed for high fever.
Prevention
To minimize the risk of developing boils, the skin must be regularly cleansed of impurities and fully treated for any tissue damage. People with hyperhidrosis and/or excess sebum need to pay special attention to hygiene. General measures are also important: proper nutrition, a healthy lifestyle, timely treatment of acute and chronic diseases.
Rehabilitation
After opening an uncomplicated boil, the patient goes home after 1-2. In the next 2 weeks, he needs to regularly visit a doctor for dressings, take prescribed medications. It is strictly forbidden to play sports, swim in open water or pools, overheat.
Questions and Answers
No. Self-medication and the use of folk remedies can cause complications.
Yes, when a purulent focus is located on the face, the infection can go to the meninges.
Gostishchev Victor Kuzmich. Clinical operative purulent surgery. Guide for doctors. GEOTAR-Media, 2016
Rodionov Anatoly Nikolaevich, Sydikov Akmal Abdikaharovich, Zaslavsky Denis Vladimirovich. Clinical dermatology. Illustrated guide for doctors. GEOTAR-Media, 2022
Nikolsky V. Yu., Imbryakov K. V. Furuncles and carbuncles of the face // Russian Dental Journal. 2013. No. 5.
Okulich V.K., Fedyanin S.D. RATIONAL USE OF ANTIBACTERIAL DRUGS IN PATIENTS WITH PURULENT WOUNDS, FURUNCULOSIS, BOILS AND CARBUNCULES // Bulletin of the Voronezh State Medical University. 2003. No. 4.
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Diseases referred by the Surgeon
Soft tissue abscess
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