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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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8 SYMPTOM SORTER
Some ‘swellings’ turn out, on examination, to be impalpable or to represent normal anatomy.
e physical examination may have a therapeutic eect. If not, explore the patient’s concerns
more fully and consider anxiety, depression or other psychological problems if symptoms
persist.
Weight loss in conjunction with abdomina l swelling should immediately suggest malignancy.
Acute onset of swelling with abdominal pain suggests obstruction, requiring urgent surgical
attention.
Obesity presents diculties in examination and can be dicult to distinguish from ascites.
If in doubt, arrange an ultrasound.
Resonance on percussion does not rule out a solid mass: Retroperitoneal masses will push
bowel anteriorly and may be apparently tympanic.
NOTES:
https://t.me/med1917
9
ACUTE ABDOMINAL
PAIN IN ADULTS
The GP overview
e sudden onset of severe abdominal pain represents a genuine emergency in general practice
and is a common out-of-hours call. In the true acute abdomen, the patient is obviously ill, and
as the clinical condition may deteriorate rapidly, ensure that you examine the patient as soon
as possible.
NOTE: Upper and mid-abdominal pain are dealt with here. Lower abdominal pain is dealt with
under ‘acute pelvic pain’ and specically epigastric-type pain is covered in more detail in the
epigastric pain section.
Differential diagnosis
COMMON
peptic ulcer
biliary colic
appendicitis
gastroenteritis
renal colic
OCCASIONAL
cholecystitis (may follow biliary colic, but pain is constant and fever present)
diverticulitis
acute or subacute bowel obstruction (adhesions, carcinoma, strangulated hernia, volvulus)
pyelonephritis
muscular wall pain
pancreatitis
Meckel’s diverticulum
RARE
perforation (e.g. duodenal ulcer [DU], carcinoma) resulting in peritonitis
hepatitis
Crohn’s and ulcerative colitis
ischaemic bowel
https://t.me/med1917
10 SYMPTOM SORTER
dissecting/leaking aneurysm
diabetic ketoacidosis (DKA) and other occasional medical causes (e.g. myocardial infarction
[MI], pneumonia, sickle cell crisis)
Ready reckoner
Peptic ulcer Renal colic Biliary colic Appendicitis Gastroenteritis
Colicky pain No Ye s Ye s No Ye s
Localised pain Ye s Ye s Ye s Yes No
Abdominal tenderness Ye s No Possible Ye s Possible
Fever No No No Ye s Possible
Diarrhoea No No No Possible Ye s
Possible investigations
e only test likely to help the GP is urinalysis: is may reveal haematuria (renal colic), evidence
of urinary infection or glycosuria in DKA. In general, the following investigations will be done
in hospital aer acute admission.
Full blood count: WCC raised in many causes and conrms acute inammation or infection.
U&E essential as abnormalities common with diarrhoea or vomiting. Amylase raised in
ischaemic bowel and acute pancreatitis.
LFT may show raised bilirubin in biliary obstruction, and widespread derangement in
hepatitis.
Helicobacter pylori testing: Strong association with peptic ulcer disease.
Upper GI endoscopy: To visualise upper GI tract.
Plain erect abdominal X-ray invaluable to conrm perforated viscus (air under diaphragm).
Supine also necessary if obstruction suspected. Ninety percent of renal or ureteric stones will
be revealed with a plain abdominal X-ray.
Ultrasound: Helpful to conrm gallstones.
Renal imaging: For ureteric stones.
TOP TIPS
e aim of assessment is correct disposal rather than an exact diagnosis. Colicky pain may
be appropriate to manage at home; constant pain with tenderness is likely to need admission.
If treating a patient at home, arrange for review as appropriate and ensure that the patient is
aware of the symptoms which should prompt urgent reassessment.
e examination is likely to contribute signicantly to making the diagnosis – so take
particular care and don’t forget the basics such as pulse rate, temperature, bowel sounds and
a rectal examination.
https://t.me/med1917
ACUTE ABDOMINAL PAIN IN ADULTS 11
Beware ‘gastroenteritis’ mask ing or developing into an acute appendicitis. Make ar rangements
for follow-up and emphasise that constant pain needs urgent review.
Prejudice is easy if the patient has a history of functional problems or irritable bowel. Surg ical
pathology can happen to anyone, so be objective.
Beware the elderly patient with an irregular pulse: Mesenteric infarction causes severe pain
but few signs.
Don’t forget to examine the hernial orices, especially if obstruction is a possibility.
NOTES:
https://t.me/med1917
12
ACUTE ABDOMINAL
PAIN IN CHILDREN
The GP overview
is causes signicant worry in parents, oen about the possibility of appendicitis. Some of the
causes listed here (such as infant colic and constipation) can cause recurrent or chronic pain –
this is a less common presentation, but one which, in children, still has a tendency to be presented
as an ‘acute’ problem, either because of a perceived deterioration or parental anxiety. For more
details about recurrent childhood abdominal pain, see the section of the same name.
Differential diagnosis
COMMON
constipation
infant colic
gastroenteritis
urinary tract infection
appendicitis
OCCASIONAL
functional/IBS
stress/malingering (e.g. school problems, bullying)
gastritis/GORD/peptic ulcer
mesenteric adenitis
CMPI
muscular strain
RARE
inammatory bowel disease
pneumonia
Meckel’s diverticulum
intussusception
coeliac disease
intestinal obstruction
testicular torsion
Henoch–Schönlein purpura
https://t.me/med1917
ACUTE ABDOMINAL PAIN IN CHILDREN 13
sickle cell crises
lead poisoning/porphyria
renal causes (stones, hydronephrosis)
diabetic ketoacidosis
Ready reckoner
Constipation Infant colic Gastroenteritis UTI Appendicitis
Child under 6 months Possible Ye s Possible Possible Possible
Recurrent Possible Ye s No Possible No
Child acutely unwell No No Possible Possible Ye s
Pain constant No No No No Ye s
Urinary symptoms Possible No No Ye s No
Investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: FBC, ESR/CRP, U&E, abdominal ultrasound.
SMALL PRINT: Coeliac screen, haemoglobinopathy screen.
Urinalysis: Positive nitrite, leucocytes and/or blood support a clinical diagnosis of UTI;
blood alone may indicate a stone (rare); urinalysis will also reveal sugar and ketones in
diabetic ketoacidosis.
FBC: May be iron deciency in IBD.
U&E: May occasionally be deranged in renal cause.
Abdominal ultrasound: If renal causes suspected.
Coeliac screen: Anti-endomysial and anti-gliadin antibodies suggest coeliac disease.
Haemoglobinopathy screen: If sickle cell suspected.
TOP TIPS
Be clear about safety netting – appendicitis may mimic gastroenteritis in the early stages.
Share doubt and emphasise the need for reassessment if the pain becomes worse and constant,
or if the general condition of the child deteriorates.
Don’t forget to examine the groin and testicles – strangulated hernias and torted testicles
are possible causes of this presentation, and the child may be too embarrassed to indicate the
site of pain or swelling.
Young children with less signicant causes have a tendency to indicate the umbilicus as
the site of pain. e further from the umbilicus the pain, the more you should consider an
important cause.
Recurrent ‘acute’ abdominal pain presenting on Mondays may indicate a school problem.
https://t.me/med1917
14 SYMPTOM SORTER
Constant pain and the child being unable to straighten up because of discomfort suggest a
surgical cause.
Remember the possibility of sickling in the appropriate ethnic groups.
Bear in mind that young children with pneumonia can present with abdominal pain – if
unclear about the cause in an unwell child, check vital signs, features of respiratory distress
and chest sounds.
Consider intussusception in the infant with apparent abdominal pain associated with bouts
of screaming and pallor.
NOTES:
https://t.me/med1917
15
ACUTE ABDOMINAL
PAIN IN PREGNANCY
The GP overview
A pregnant woman who develops this symptom is very likely to be extremely concerned that
there is a threat to her pregnancy. Anxiety levels may therefore be high in the patient and her
partner. Acknowledge this emotional distress by an urgent and full assessment. Listed here are
causes specic to pregnancy and conditions which may be exacerbated or altered by pregnancy;
‘run of the mill’ causes (such as gastroenteritis, IBS and dyspepsia) may obviously occur too, but
rarely create diagnostic problems and so are not considered in this section.
Differential diagnosis
COMMON
symphysis pubis and ligament strain
miscarriage: 20%–40% of pregnancies in rst trimester
labour: 6% premature
placental abruption: 1/80–200 pregnancies
pyelonephritis (especially around 20 weeks)
OCCASIONAL
constipation (common cause but only occasionally presents)
ectopic pregnancy (1/250 pregnancies)
appendicitis (1/1000 pregnancies)
red degeneration of broid
torsion/rupture of ovarian cyst or tumour
RARE
uterine rupture (in UK 1/1500 pregnancies, of which 70% due to Caesarian scar dehiscence)
uterine torsion (axial rotation >90°): 90% associated with broids, adnexal masses and
anatomical uterine anomalies
liver congestion due to pre-eclampsia
rectus sheath haematoma
https://t.me/med1917
16 SYMPTOM SORTER
Ready reckoner
S. pubis strain Miscarriage Labour Abruption Pyelonephritis
Localised tenderness Ye s No No Possible Ye s
Crampy pain No Ye s Ye s No No
Vaginal bleeding No Ye s No Yes No
Uterine rigidity No No No Ye s No
Fever, unilateral pain No No No No Ye s
Possible investigations
ese will be dictated by the clinical urgency of the situation. In severe pain, they will be done
in secondary care.
LI KE LY: Urinalysis, MSU.
POSSIBLE: Ultrasound, FBC.
SMALL PRINT: Laparoscopy.
Urinalysis: Proteinuria in pre-eclampsia. Blood, pus cells a nd nitrite in urinary tract infection
(UTI); the infecting organism will be conrmed on MSU.
FBC: Raised WCC in UTI.
Imaging ultrasound can be diagnostic in abruption and miscarriage; the presence of an
intrauterine pregnancy makes an ectopic very unlikely; ultrasound may also be helpful in
detecting a rectus sheath haematoma.
Laparoscopy: To conrm ectopic pregnancy.
TOP TIPS
Pain on standing a nd walk ing, and relieved by rest, with e xquisite pubic symphysis tenderness,
is ‘symphyseal pain’ – an oen overlooked cause.
Allay understandable anxieties as appropriate – particularly regarding the well-being of the
foetus or the possibility of premature labour.
Do not be too ready to diagnose U TI on the basis of an abnormal urinalysis – contamination
in pregnancy is common.
https://t.me/med1917
ACUTE ABDOMINAL PAIN IN PREGNANCY 17
Distortion of anatomy may alter symptoms and signs – appendicitis is notoriously dicult
to diagnose in the second trimester. If in doubt, admit.
A woman in early pregnancy who experiences unilateral lower abdominal pain followed by
light bleeding or blackish discharge has an ectopic until proved otherwise.
Don’t overlook the diagnosis of premature labour. Women with no previous experience of
labour pain might not consider this possibility.
Placental abruption causes severe, continuous pain with a tender, hard uterus. Vaginal
bleeding may be minimal. Admit immediately.
Don’t forget pre-eclampsia as a cause of epigastric pain in the third trimester – check the
blood pressure (BP) and urine.
NOTES:
https://t.me/med1917
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