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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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18
CHRONIC/RECURRENT
ABDOMINAL PAIN
IN ADULTS
The GP overview
is problem may present in any age group. e causes in children are covered in another
section. In young to middle-aged adults, the cause is very likely to be benign, but this alters with
age: Malignancy should always be suspected in the elderly even though other causes are still
commoner. A precise diagnosis sometimes remains elusive.
Differential diagnosis
COMMON
IBS
recurrent UTI
chronic peptic ulcer (PU)
constipation
diverticular disease
OCCASIONAL
gallstones
hydronephrosis
post-herpetic neuralgia
inammatory bowel disease
ureteric colic
spinal arthritis
coeliac disease (commoner than traditionally thought: 1 in 300 adults)
RARE
mesenteric artery ischaemia (abdominal angina)
chronic pancreatitis
subacute obstruction (adhesions, malignancy and diverticulitis)
functional (psychogenic) abdominal pain
malignancy
metabolic causes, e.g. Addison’s disease, porphyria, lead poisoning
https://t.me/med1917
CHRONIC/RECURRENT ABDOMINAL PAIN IN ADULTS 19
Ready reckoner
IBS UTI PU Constipation Diverticulitis
High abdominal pain Possible No Ye s Possible Possible
Colicky Ye s No No Yes Yes
Weight loss No Possible Possible No No
Diarrhoea Ye s No No Possible Ye s
Rectal bleeding No No No Possible Possible
Possible investigations
LI KE LY: Urinalysis, FBC, ESR/CRP, MSU, H. pylori testing.
POSSIBLE: U&E , LFT, amylase, coeliac screen, CA-125, FIT, faecal calprotectin, plain abdomina l
X-ray, ultrasound, renal imaging, hospital-based lower GI investigations, gastroscopy.
SMALL PRINT: Specialised investigations such as mesenteric angiography and further tests for
rare medical causes.
Urinalysis: Blood alone with stone; blood, pus cells and nitrite in UTI.
MSU: To conrm urinary infection and guide treatment.
FBC and ESR/CRP: May suggest inammatory bowel disease, PU or malignancy. Raised
platelets associated with oesophageal or stomach cancer.
U&E may be deranged in hydronephrosis, renal stones or Addison’s disease.
LFT and amylase: LFT may be abnormal if carcinoma present. Amylase may be raised in
pancreatitis and bowel ischaemia.
Coeliac screen: Anti-endomysial and anti-gliadin antibodies – suggest coeliac disease if
positive.
CA-125: Especially in women aged 50 or more, may help exclude ovarian cancer.
H. pylori testing: Strong association with peptic ulcer disease.
FIT: A useful colorectal cancer ‘rule out’ test in those aged 50 and over.
Faecal calprotectin: To help rule out inammatory bowel disease, especially if recurrent or
persistent diarrhoea is also a feature.
Plain abdominal X-ray: May reveal constipation, subacute obstruction or kidney stones.
Renal imaging: For renal stones or recurrent UTI.
Ultrasound: Will show hydronephrosis and gallstones. Pelvic/abdominal ultrasound also
indicated if CA-125 elevated.
Hospital-based lower GI investigations: For various lower bowel disorders.
Gastroscopy: May be required to conrm PU and exclude gastric carcinoma.
Further tests such as angiography (for mesenteric ischaemia) or investigations for rare
medical causes may be arranged aer specialist referral.
https://t.me/med1917
20 SYMPTOM SORTER
TOP TIPS
Simply establishing what provokes or relieves the problem can provide helpful pointers – pain
occurring aer eating suggests gallstones, PU, gastric carcinoma or mesenteric ischaemia; if
relieved by defecation, the likely diagnoses are IBS or constipation.
In an otherwise well patient, the longer the history the less likely there is to be signicant
underlying disease.
Avoid repeated investigation if a patient has already been thoroughly assessed in the past –
unless the individual becomes unwell or develops new symptoms. Be frank with the patient
by explaining about the ‘law of diminishing returns’ in investigating chronic unexplained
abdominal pain.
Be prepared to make a positive diagnosis of IBS in a t young patient if the symptoms are
classical and basic investigations are negative; explanation and education are the keys to
eective management.
Weight loss in association with recurrent abdominal pain suggests signicant pathology.
Hard enlarged le supraclavicular nodes (Troisier’s sign) are pathognomic of gastric
carcinoma.
Beware that constipation itself is oen a symptom rather than a diagnosis. Be sure to establish
and treat any underlying cause if it doesn’t respond to simple treatment.
IBS is the commonest diagnosis – but consider other possibilities if the pain is always in
the same site, wakes the patient at night or is associated with rectal bleeding or weight loss.
NOTES:
https://t.me/med1917
21
CONSTIPATION
The GP overview
Constipation is dened as the infrequent or dicult evacuation of faeces. One study of a large
normal working population showed variation in frequency from three times a day to three times
a week. e average GP will see about 18 presentations of constipation each year. In most cases,
there is a combination of aetiological factors, and serious causes are rare.
Differential diagnosis
COMMON
diet and lifestyle (inadequate bre and ignoring the urge to defecate)
inactivity (especially in the elderly)
irritable bowel syndrome (IBS)
painful perianal conditions: ssure, haemorrhoids, abscess, orid warts
drugs, e.g. opiates, iron, aluminium hydroxide
OCCASIONAL
poor uid intake
acquired megacolon, e.g. chronic laxative abuse, neurological problems, scleroderma
diverticulosis (with or without stricture)
hypothyroidism
carcinoma of rectum or colon
RARE
pressure from extracolonic pelvic masses
acute bowel obstruction (various causes)
hypercalcaemia
Crohn’s disease with stricture
infants and children: behavioural (‘stool holding’), Hirschsprung’s disease
https://t.me/med1917
22 SYMPTOM SORTER
Ready reckoner
Diet and lifestyle Inactivity IBS Perianal conditions Drugs
Likely in elderly Yes Ye s No Possible Ye s
‘Overow’ diarrhoea Possible Ye s No Possible Possible
Mucus PR No No Possible Possible No
Short history No No Possible Ye s Possible
PR exam very painful No No No Ye s No
Possible investigations
LI KE LY: None; if suspicion of signicant underlying bowel pathology, then FBC, FIT, hospital-
based lower GI investigations.
POSSIBLE: Urinalysis, thyroid function tests (TFT).
SMALL PRINT: Plain abdominal X-ray, serum calcium, ultrasound, CT scan, biopsy.
Urinalysis: Specic gravity high if inadequate uid intake.
FBC: May reveal iron deciency anaemia if underlying carcinoma.
FIT: A useful colorectal cancer ‘rule out’ test in those aged 60 and under with change in
bowel habit such as constipation (over 60s likely to be referred regardless).
TFT and serum calcium: Will reveal hypothyroidism or hypercalcaemia.
Plain abdominal X-ray: May reveal megacolon full of faeces; erect and supine views will
show obstruction.
Hospital-based lower GI investigations: May reveal carcinoma or diverticular disease.
Ultrasound/CT scan: May be helpful if a pelvic mass is present.
Biopsy: Of suspicious lesions or to conrm Hirschsprung’s disease.
TOP TIPS
Clarify what patients mean by constipation – they oen use the term inaccurately (e.g.
in reference to a perfectly ‘normal’ bowel habit or to describe another symptom such as
tenesmus).
e longer the history, the less likely there is to be any underlying or remediable cause.
Check the medication history (including over-the-counter treatment) – just about any
medication can alter the bowel habit.
Look at the patient – your immediate impression may give important clues to the underlying
diagnosis (e.g. hypothyroidism or weight loss in malignancy).
In children with constipation, continue treatment for weeks or even months to achieve easy
and pain-free bowel movements. Reassure parents that the use of laxatives does not lead to a
‘lazy bowel’ and that the constipation is not a sign of a ‘blockage’.
https://t.me/med1917
CONSTIPATION 23
Constipation alone in the elderly is rarely caused by sinister pathology – but if it is
accompanied by other signicant symptoms, such as weight loss, rectal bleeding or mucus,
or diarrhoea, carcinoma is likely.
Beware of attributing abdominal pain to constipation – the true dia gnosis might be intestinal
obstruction. Visible peristalsis with audible borborygmi is never due to simple constipation.
Cases of Hirschsprung’s disease can present ‘late’ – consider the diagnosis in a child with
chronic constipation, a persistently swollen abdomen and an empty rectum.
Beware of assuming that known pathology (such as diverticular disease or IBS) in an
individual is the cause of constipation. If the patient has presented with constipation, then
there may have been a signicant change in the pattern or the nature of the symptoms.
NOTES:
https://t.me/med1917
24
DIARRHOEA IN ADULTS
The GP overview
Diarrhoea is the passage of abnormal ly liquid and frequent stools. It is said to be chronic if it lasts
more than 2 weeks. It is the h-commonest presenting symptom in general practice. Patients
will use the term ‘diarrhoea’ when presenting, but they may just mean frequent stools.
NOTE: For diarrhoea in children, see separate section.
Differential diagnosis
COMMON
acute infective gastroenteritis, e.g. rotavirus, Campylobacter, food poisoning
antibiotics (and other drug side eects)
irritable bowel syndrome (IBS)
diverticulitis
overow constipation (especially in the elderly)
OCCASIONAL
lactose intolerance
chronic infection: Amoebiasis, giardiasis, hookworm
bowel neoplasia
inammatory bowel disease (IBD): Ulcerative colitis and Crohn’s disease
excess alcohol
toddler diarrhoea
coeliac disease
RARE
HIV infection
appendicitis
laxative misuse
thyrotoxicosis
malabsorption, various causes
allergy
ovarian cancer
https://t.me/med1917
DIARRHOEA IN ADULTS 25
Ready reckoner
Gastroenteritis Antibiotics IBS Diverticulitis Overow
Vomiting too Possible Possible No Possible No
Chronic or recurrent No No Ye s Possible Ye s
Constant severe pain No No No Ye s No
Marked abdominal tenderness No No No Ye s No
Blood in stool Possible Possible No Possible No
Possible investigations
LI KE LY: If persistent, stool specimen, FBC, ESR/CRP, TFT, anti-endomysial and anti-gliadin
antibodies, faecal calprotectin.
POSSIBLE: Urinalysis, LFT, FIT, hospital-based lower GI investigations, CA-125.
SMALL PRINT: HIV test, tests for malabsorption.
One stool sample is sucient in acute diarrhoea of more than a week to look for common
infections.
Series of three daily stool samples necessary to look for ova, cysts and parasites in chronic
diarrhoea.
FBC: Hb may be reduced and ESR/CRP elevated in IBD and malignancy; iron deciency
anaemia in neoplasia, coeliac disease; diverticulitis – check ferritin, B
12
and folate too; WCC
raised in IBD and infection.
TFT: Will reveal thyrotoxicosis.
Anti-endomysial and anti-gliadin antibodies: Suggest coeliac disease if positive.
Faecal calprotectin: Helps rule out inammatory bowel disease.
LFT: May suggest secondaries or alcoholism.
FIT: A useful colorectal cancer ‘rule out’ test in those aged 60 and under with change in
bowel habit such as diarrhoea (over 60s likely to be referred regardless).
Urinalysis: Specic gravity high in dehydration.
Hospital-based lower GI investigations: Will conrm diagnosis of malignancy, diverticulosis,
carcinoma and IBD.
CA-125: To help exclude ovarian cancer – especially in women aged 50 or more.
HIV test: For HIV infection.
Tests for malabsorption: Such as stool fat analysis, lactose tolerance test, small intestinal
biopsy (all secondary care).
TOP TIPS
Clarify what patients mean by diarrhoea – they may be referring simply to a minor change
in their normal habit or the frequent passage of normal stools.
https://t.me/med1917
26 SYMPTOM SORTER
Giardiasis is much more common than previously thought and may be dicult to isolate in
stool specimens. Empirical treatment is justied if the clinical picture is suggestive (recent
onset aer travel of persistent fatty diarrhoea with anorexia, nausea and bloating).
IBS rarely causes nocturnal diarrhoea.
Patients with gastroenteritis should steadily improve aer a few days, but may experience
symptoms for up to 10 days – warn them of this.
Do not be caught out by overow diarrhoea in the elderly. e only way to establish this
diagnosis is with a PR.
Remember to ask about foreign travel and occupation, which have implications for diag nostic
possibilities and management.
Weight loss in chronic diarrhoea is highly suggestive of signicant pathology.
In a young and otherwise well person, it is reasonable to make a positive clinical diagnosis of
irritable bowel syndrome with minimal investigation – but beware of making this diagnosis
for the rst time in the middle-aged and elderly. Signicant pathology mimicking IBS is
likely.
Initial telephone consultation is sucient for most cases of acute diarrhoea, but if in constant
(not colicky) abdominal pain, always see and examine to exclude an acute surgical condition.
Remember that acute diarrhoea in the elderly can precipitate or aggravate renal failure –
especially if they are on ACE inhibitors. Stop these drugs for the duration of the illness and
ensure adequate hydration.
NOTES:
https://t.me/med1917
27
DIARRHOEA IN
CHILDREN
The GP overview
is is a very common ‘day duty’ presentation and is usually caused by gastroenteritis or some
other acute infection. Less common is the subacute or prolonged case, where the dierential is
wider and where a more detailed analysis is required.
Differential diagnosis
COMMON
gastroenteritis
other systemic infection (e.g. UTI, otitis media, pneumonia)
toddler’s diarrhoea
medication side eects (usually antibiotics)
cow’s milk protein intolerance (CMPI)
OCCASIONAL
lactose intolerance (typically following a bout of gastroenteritis in babies)
faecal impaction (causing overow diarrhoea)
irritable bowel syndrome
coeliac disease
other gastrointestinal infections, e.g. giardia
RARE
inammatory bowel disease (IBD)
appendicitis (relatively common but rarely presents with diarrhoea)
intussusception
cystic brosis
https://t.me/med1917
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