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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2683_Библиотеки_им_академика_М_И_Перельмана.pdf
Abdominal pain
INVESTIGATIONS
Investigations will depend on a focused differential diagnosis. The diagnostic pathway is outlined in Fig.9.2.
Bedside investigations
• Blood glucose: hypoglycaemia in advanced liver
failure or Addison disease; hyperglycaemia will be
present in ketoacidosis and may complicate acute
pancreatitis.
• Urine dipstick test: positive for nitrites and leucocytes
indicates urinary tract infection; ketone positive
may indicate dehydration, anorexia or diabetic
ketoacidosis.
• Pregnancy test: any female of childbearing age presenting
with abdominal pain must have a pregnancy test.
Blood tests
• Full blood count: leucocytosis is seen in infection and
occasionally inflammation and malignancy. Anaemia
may be due to acute blood loss or chronic disease such
as malignancy.
• Serum amylase: hallmark of acute pancreatitis but
its level may also be raised in perforated peptic ulcer,
diabetic ketoacidosis, cholecystitis, ectopic pregnancy,
abdominal trauma and myocardial infarction. Note that
in chronic pancreatitis, serum amylase level may not be
raised.
• Urea and electrolytes: dehydration, acute kidney injury,
deranged electrolytes (e.g. low potassium level in
diarrhoea), high urea level in an upper gastrointestinal
tract bleed.
• Serum calcium: hypercalcaemia may cause renal stones
and pancreatitis; it may also indicate malignancy;
hypocalcaemia may be a consequence of pancreatitis.
• Liver function tests: abnormal findings in liver disease,
biliary disease and shock.
• Arterial blood gas: high lactate level in dehydration or
ischaemic bowel.
Imaging
• Abdominal X-ray: obstruction (dilated loops of bowel);
pancreatitis (sentinel loop due to ileus in overlying
loop of small bowel); volvulus (sigmoid and caecal);
infarction (‘thumb printing’ representing mucosal
oedema); renal stone (90% are radio-opaque).
• Erect chest X-ray: check for free gas under the
diaphragm – a sign of perforated viscus.
• Abdominal ultrasound scan: dilatation of biliary tree
and ureters; intraabdominal mass; ascites; abscess;
hydronephrosis.
• CT: useful in diagnosis of abdominal aortic aneurysm,
perforation of a viscus, abdominal malignancy.
Abdominal pain
History
Examination
MSU
Simple haematology
and biochemistry
Sudden onset,
severe pain
Urgent admission
Haemoglobin
2+
U&Es, Ca
Consider laparoscopy/
Fig.9.2 Diagnosis in the patient with abdominal pain. AXR, Abdominal X-ray; CT, computed tomography; CXR, chest
X-ray; Gluc, glucose; LFTs, liver function tests; MSU, midstream urine; U&Es, urea and electrolytes; US, ultrasound.
, Gluc, LFTs,
amylase
AXR: free gas?
US scan: aneurysm?
laparotomy
Perforation or
rupture of bowel
Aneurysm
Spleen
Pancreatits
Colicky pain
CXR erect
and supine
US scan
Bowel obstruction
Strangulated hernia
Gallstones
Renal stones
Irritable bowel
syndrome
Gradual onset,
sustained pain
Consider:
US scan
CT scan
Colonoscopy
Endoscopy
Small bowel enema
Abscess
Malignancy
Inflammatory
bowel disease
Atypical pain with
normal investigations
Consider:
Anxiety
Munchausen
syndrome
Unusual causes
68
Investigations
99
Further investigations
• Urine sample: microscopy, culture and sensitivity of
midstream urine.
• ECG to rule out myocardial infarction.
• Stool sample: microscopy, culture and sensitivity. Toxin
testing for Clostridium difficile.
• Endoscopic tests: upper gastrointestinal tract
endoscopy, flexible sigmoidoscopy and colonoscopy.
• Diagnostic laparoscopy: occasionally the
aforementioned investigations do not yield a
diagnosis and the abdominal pain persists. Diagnostic
laparoscopic surgery can be helpful in making a
diagnosis, but is more commonly useful in ruling out a
specific disease.
Chapter Summary
• Careful history taking and examination will point towards the diagnosis and guide
management.
• Cardiorespiratory conditions such as myocardial infarction or chest infection can present
as abdominal pain and mimic abdominal diseases.
• Acute abdomen can signify a medical emergency such as septic shock or ruptured
abdominal aortic aneurysm, and requires urgent assessment and management.
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Heartburn and indigestion
10
INTRODUCTION
‘Heartburn’ and ‘indigestion’, also known as ‘dyspepsia’, describe a group of symptoms that relate to the upper gastrointestinal tract. These include upper abdominal discomfort,
retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, heartburn and early satiety.
The approach to this common presenting complaint
involves directing investigations towards those most likely
to benefit (e.g. those at risk of cancer, where a firm endoscopic/histological diagnosis must be made) as opposed to
those in whom empirical therapy is safe and a firm diagnosis would not significantly alter the management (e.g.
a young, otherwise well, patient with dyspepsia and no
Helicobacter pylori infection).
CLINICAL NOTES
CAUSES OF DYSPEPSIA (SEE CHAPTER29)
Duodenal ulcer
Gastric ulcer
Oesophageal/gastric cancer
Oesophagitis/GORD
Gastritis/duodenitis
Nonulcer dyspepsia
Hiatus hernia
Oesophageal motility disorders
Biliary disease
GORD, Gastro-oesophageal reflux disease.
a
Condition associated with Helicobacter pylori infection. It is
unclear whether this infection is causative in all the conditions.
b
Responds favourably to eradication of Helicobacter pylori.
a,b
a,b
a
a,b
a,b
HISTORY AND EXAMINATION FINDINGS
Ask about the following, although correlation between
symptoms and the underlying cause is poor:
• Dyspepsia: usually retrosternal discomfort, often worse
with leaning forward or lying flat. May be associated
with waterbrash, excessive sour or tasteless saliva in
the back of the mouth, either in response to acid in
the lower oesophagus or due to reflux of fluid into the
upper pharynx.
• Chest pain: burning retrosternal pain, not related to
exertion (unlike angina), which may radiate between
the shoulder blades. This can relate to acid-provoked
oesophageal spasm, which, like angina, is relieved by
nitrates.
• Nocturnal cough/asthma: occasionally due to acid
reflux.
• Epigastric pain: feature of peptic ulcer disease.
Classically, a gastric ulcer is aggravated by food, and a
duodenal ulcer is aggravated by fasting, but these are
unreliable symptoms.
Aggravating factors for reflux include:
• Increased intraabdominal pressure: stooping/bending/
obesity/pregnancy.
• Spicy or fatty foods.
• Alcohol ingestion: also causes gastritis.
• Cigarettes, caffeine, theophylline, calcium channel
blockers, β-blockers, anticholinergic drugs: reduce
lower oesophageal sphincter tone.
• Nonsteroidal antiinflammatory drugs, which interfere
with prostaglandin cytoprotection of the gastric mucosa.
• Hiatus hernia.
Identifying patients who require endoscopy is key. This
depends on the presence of the ‘red flag’ features listed in
clinical notes: symptoms in patients with dyspepsia which
indicate that diagnostic endoscopy should be performed,
which must be looked for specifically. These features all
suggest an elevated risk of cancer.
CLINICAL NOTES
SYMPTOMS IN PATIENTS WITH DYSPEPSIA
WHICH INDICATE THAT DIAGNOSTIC
ENDOSCOPY SHOULD BE PERFORMED
Unintentional weight loss >3 kg
Evidence of gastrointestinal bleeding
Previous gastric surgery
Epigastric mass
Previous gastric ulcer
Unexplained iron-deficiency anaemia
Dysphagia/odynophagia
Upper abdominal pain
Persistent vomiting/nausea
Suspicious barium meal findings
Age ≥55years with recent-onset dyspepsia lasting
more than 4weeks
Raised platelet count
71
Heartburn and indigestion
INVESTIGATIONS
An approach to the dyspeptic patient is outlined in Fig.10.1.
The management of specific conditions is further explained
in Chapter29.
The investigations used are explained below. Specialized investigations are used predominantly in cases such as persistent
symptoms not responding to the approach in Fig.10.1 or atypical symptoms (e.g. laryngeal discomfort or atypical chest pain
that may result from acid reflux or oesophageal dysmotility).
It is important to remember that most patients with dyspepsia
can be managed safely without extensive investigations.
Dyspepsia >4 weeks
<55 years
No alarm symptoms/signs
HP breath test/serology
* Empirical therapy while
awaiting result
Negative
Alarm symptoms/signs
(see Fig. 9.2)
Positive
HINTS AND TIPS
Although dyspepsia or heartburn is
usually a gastrointestinal complaint, some older
patients with ‘dyspepsia’ actually have angina
pectoris. Make sure you take an adequate history
to ensure that the problem is gastrointestinal in
origin.
>55 years
Endoscopy ± HP testing
* Diagnosis confirmed
appropriate treatment
* Diagnosis uncertain
Modify lifestyle
Remove aggravating factors
(e.g., NSAID)
Consider empirical
anti-secretory treatment
Consider further
investigation
* Modify lifestyle
Remove aggravating factors
Consider empirical anti-secretory
treatment
Consider further investigation
** HP eradication regime
Asymptomatic
No action
* Re-evaluate
Modify lifestyle
Remove aggravating factors
Consider empirical antisecretory treatment
Consider further investigation
Symptomatic
HP breath test
Negative Positive
Repeat eradication
Fig.10.1 Algorithm for the investigation and management of patients with dyspepsia. See Chapter29. Seek local
microbiological advice. Further information on the management of dyspepsia can be obtained from https://www.nice.org.
uk/guidance/cg184. HP, Helicobacter pylori; NSAID, nonsteroidal antiinflammatory drug.
72
Investigations
1010
Common investigations
• Full blood count: iron-deficiency anaemia and/or
thrombocytosis may suggest gastrointestinal blood loss
and needs further investigation.
• Electrocardiography: if you are considering the
diagnosis of angina in cases of atypical chest pain.
• Helicobacter pylori testing: several tests are available.
Carbon-13 urea breath test (which depends on H.
pylori in the gastric lumen using urease to break down
urea to ammonia and CO2) is the most accurate, and
can confirm eradication following treatment. It is
unreliable in patients taking proton pump inhibitors or
bismuth or who have taken antibiotics within the past
4weeks. Stool antigen tests can be used. Urease tests
can be used on endoscopic specimens, and histology/
culture can confirm these findings.
• Endoscopy (oesophagogastroduodenoscopy): a
relatively safe investigation. It allows visualization of
the upper gastrointestinal tract to the second part
of the duodenum. It allows biopsy and therapeutic
manoeuvres (see Chapter29).
• Barium meal: an alternative for patients in whom
endoscopy is not possible (e.g. elderly frail patients in
whom sedation is dangerous). It is useful in diagnosing
strictures and dysmotility, but does not allow
intervention at the time of the procedure.
Specialized investigations
• Oesophageal motility studies: manometry demonstrates
motility disorders (e.g. achalasia, systemic sclerosis,
diffuse oesophageal spasm).
• Twenty-four-hour intraluminal pH monitoring:
confirms acid reflux in difficult cases.
• Abdominal ultrasound scan: if a mass or biliary disease
is suspected (see Chapter29).
Chapter Summary
• Symptom management is an approach appropriate for most patients presenting with
dyspepsia.
• Identifying patients at increased risk of a sinister cause for symptoms is key.
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Gastrointestinal bleed
11
INTRODUCTION
Haematemesis is the vomiting of blood; it can be fresh
bright red blood or altered (‘coffee grounds’). Melaena
is black, tarry, offensive smelling stool; it is usually due
to bleeding in the gastrointestinal (GI) tract above the
hepatic flexure. Both are typical signs of an upper GI
tract bleed. GI bleeding is an emergency, and treatment
is usually initiated before a diagnosis can be made (see
Chapter29).
Table11.1 gives the differential diagnosis of haemateme-
sis and melaena. It is important to note that melaena which
occurs in the absence of haematemesis may be caused by
disease in the small bowel or ascending colon.
HISTORY AND EXAMINATION FINDINGS
History
It is important to clarify whether the blood has been vomited or coughed up. Food mixed with the blood or an acid
pH suggests haematemesis. Haematemesis may also be due
to blood swallowed from the nasopharynx or mouth.
You must ask about:
• Nonspecific symptoms of hypovolaemia: faintness,
weakness, dizziness, sweating, palpitations, dyspnoea,
pallor, collapse. These symptoms may precede the
actual haematemesis/melaena.
• Symptoms of the blood loss being chronic (see later):
consider gastric carcinoma if the patient gives a history
of anorexia and weight loss.
• Heartburn: oesophagitis.
• Weight loss and anorexia: carcinoma.
• Dysphagia or odynophagia (pain on swallowing):
oesophageal carcinoma or oesophagitis.
• Retching, especially after an alcohol binge: Mallory–
Weiss tear.
• Sudden severe abdominal pain: possible bowel
perforation.
• Intermittent epigastric pain relieved with antacids:
peptic ulceration.
• Current drugs: antiplatelet agents, nonsteroidal
antiinflammatory drugs, steroids or excessive alcohol
consumption are suggestive of gastric erosions; iron
therapy causes black stools but this is not melaena;
anticoagulation will exacerbate bleeding.
Table11.1 The differential diagnosis of haematemesis
and melaena
Cause Notes
Peptic ulcer
disease
Erosive gastritis Causes 20% of upper GI tract
Mallory–Weiss tear Causes 10% of upper GI tract
Oesophagitis Due to GORD
Ruptured
oesophageal
varices
Vascular
abnormalities
Gastric neoplasm Causes 5% of upper GI tract bleeds
Rare causes Oesophageal ulcers or tumours,
GI, Gastrointestinal; GOJ, gastro-oesophageal junction; GORD,
gastro-oesophageal reflux disease.
• Chronic excessive alcohol intake and other causes
of liver disease (see Chapter14): oesophageal
varices.
• A history of GI bleeds and their cause.
• Family history: inherited bleeding disorders.
HINTS AND TIPS
NOVEL ANTICOAGULANT DRUGS AND
BLEEDING
If a patient presents with bleeding and gives a
history of taking any of the novel oral anticoagulants
(e.g. rivaroxaban, apixaban, dabigatran), consider
how you are going to manage this as the effects
of these drugs are difficult to reverse in an
emergency. Idarucizumab is a reversal agent
specific for dabigatran. Currently, there are no
Causes 50% of major upper GI tract
bleeds. Mortality 10%
bleeds, rarely severe
bleeds. Laceration in GOJ mucosa,
often following retching (e.g. after
alcohol binge)
Causes 10%–20% of upper GI tract
bleeds. High mortality. Due to portal
hypertension
Vascular ectasias or
angiodysplasias
aortoenteric fistula after abdominal
aortic surgery, pancreatic tumour,
biliary bleeding, blood dyscrasias
75
Gastrointestinal bleed
— Peutz–Jeghers
Eyes
Rectum
— Rectal
examination
Abdomen
— Rigid
(perforation)
bowel disease)
chycardia
approved reversal agents for the other novel oral
anticoagulants, and management of bleeding
includes use of antifibrinolytics or plasma factors
(prothrombin complex concentrates, fresh frozen
plasma and cryoprecipitate) and attempts to reduce
the drug’s absorption (consider activated charcoal
for apixaban, rivaroxaban and dabigatran) or
increase its removal from the circulation (consider
haemodialysis/haemofiltration for dabigatran). Seek
the advice of a coagulation specialist early.
Examination
The approach to examining the patient with haematemesis
and melaena is given in Fig.11.1. Step back from the patient
for a few seconds. Does the patient look well, or pale and
clammy? If the patient is clearly unwell, follow the ABCDE
approach. Volume replacement in actively bleeding patients
should be started quickly, and the source of bleeding should
be identified and the ‘blood tap’ turned off. Once it is rec-
— Anaemia/
jaundice
— Xanthelasmata
(primary biliary cirrhosis)
Lymph nodes
— Virchow node
and other
lymphadenopathy
Stomach
— Epigastric mass/
tenderness
Mouth
syndrome
Blood
pressure
ognized that the patient needs transfusion, resuscitation
with O-negative blood should be commenced until groupspecific crossed-matched blood is available. Consider the
need for further blood products, platelets, clotting factors
and cryoprecipitate and whether a major transfusion protocol needs to be initiated.
Examination and findings include:
• Pulse and blood pressure: tachycardia is a reflex
response to hypovolaemia (due to bleeding) and usually
precedes a blood pressure fall. A young and healthy
patient may lose more than 500 mL of blood before a
rise in heart rate or fall in blood pressure occurs. If the
patient is hypotensive, intravenous fluid resuscitation
should be initiated.
• Skin: bruises, purpura (bleeding disorders) and
telangiectasia suggest Osler–Weber–Rendu disease
(hereditary haemorrhagic telangiectasia—autosomal
dominant); neurofibromata; pale and cold peripheries
(suggesting the patient is in hypovolaemic shock)
• Jaundice: may indicate liver disease, portal
hypertension and a potential clotting abnormality.
• Clubbing: inflammatory bowel disease, cirrhosis.
• Anaemia: mucous membranes. If the patient is
clinically anaemic, this may indicate chronic blood loss.
• Lymphadenopathy: especially Virchow node (left
supraclavicular lymph node) associated with gastric
carcinoma (Troisier sign).
• Mouth: pharyngeal lesions; pigmented macules (Peutz–
Jeghers syndrome).
• Cachexia.
• A rigid abdomen, suggesting bowel perforation.
• Epigastric tenderness, suggesting peptic ulcer disease,
oesophagitis or gastric carcinoma.
• Epigastric mass: gastric carcinoma.
• Signs of chronic liver disease and portal hypertension,
which are associated with a variceal bleed (see
Chapter14).
Skin
— Bruising/purpura
(bleeding disorders)
— Slate-grey pigmentation
(haemachromatosis)
— Osler–Weber–Rendu
disease
— Neurofibromata
Fig.11.1 Examining the patient with haematemesis and
melaena.
76
Pulse
— Ta
Hands
— Clubbing
(inflammatory
INVESTIGATIONS
HINTS AND TIPS
A large upper GI tract bleed may cause the
passage of fresh blood via the rectum rather than
melaena; in this setting the patient is likely to be
haemodynamically unstable.
An algorithm for investigating the patient with a GI
bleed is given in Fig.11.2. Investigations will aid in diagnosis and contribute to estimating mortality and morbidity
(see Further investigations and Tables 11.2 and 11.3)
Haematemesis/melaena
Investigations
1111
Non-GI bleeding
Further investigation,
e.g. haemoptysis
— Oesophagus
(e.g. Mallory–Weiss
tear, oesophagitis,
ulcer, tumour)
— Duodenum (e.g. ulcer)
— Stomach (e.g. ulcer,
erosions, tumour)
GI bleeding: local GI cause GI bleeding: systemic cause
FBC: chronic versus acute
U&Es: urea raised
ECG
CXR: perforation of bowel
Clotting: bleeding diatheses
LFTs: hepatic failure
Upper GI tract: endoscopy ± barium studies
No cause found
(~10%)
History suggests
Mallory–Weiss tear
Specialist investigations,
e.g. for bleeding diatheses
+
Observe
–
Melaena alone
(especially older patient)
–
Consider:
— Angiography
— Isotope scan
— Enteroscopy
— Laparotomy
— SB follow-through or enema
— Videocapsule endoscopy
Diagnosis
+
Investigate lower
GI tract
Observe: repeat
‘top-up’ transfusions
Fig.11.2 Algorithm for the investigation of the patient with haematemesis and melaena. ECG, Electrocardiogram; CXR,
chest X-ray; FBC, full blood count; GI, gastrointestinal; LFTs, liver function tests; SB, small bowel; U&Es, urea and
electrolytes.
77