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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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28 SYMPTOM SORTER
Ready reckoner
Gastroenteritis Other systemic
infection
Toddler’s
diarrhoea
Medication
side effects
CMPI
Blood in diarrhoea Possible No No No Possible
Recent or current antibiotics No Possible No Ye s No
Fever Possible Possible No Possible No
Lasts more than 2 weeks Possible No Ye s Possible Ye s
Other localising symptoms
(e.g.respiratory, urinary or ear)
No Ye s No Possible No
Possible investigations
LI KE LY: None.
POSSIBLE: Stool culture, urinalysis, MSU, FBC, CRP, ESR, anti-endomysial and anti-gliadin
antibodies, faecal calprotectin.
SMALL PRINT: Hospital-based tests (e.g. for cystic brosis, IBD and to conrm coeliac disease).
Stool culture: For microbiological examination if the diarrhoea persists more than a week,
is bloody or there is relevant recent foreign travel; send three specimens for ova, cysts and
parasites if giardia suspected.
Urinalysis: May help if a UTI is suspected as the underlying cause.
MSU: For conrmation of a suspected UTI.
FBC, ESR, CRP: Hb may be reduced, and CRP/ESR raised in IBD.
Anti-endomysial and anti-gliadin antibodies: If coeliac is a possibility.
Faecal calprotectin: To help rule out IBD if diarrhoea is prolonged.
Hospital-based tests: ese might include endoscopy and biopsy in suspected IBD or coeliac
disease, and tests for possible cystic brosis.
TOP TIPS
It is not unusual for the diarrhoea in gastroenteritis to take a couple of weeks to settle;
consider a stool specimen if it is not starting to improve aer a week.
Don’t overlook faecal impaction as a cause of overow diarrhoea in children, the clues being
soiling and a preceding history of constipation.
Lactose intolerance tends to be over-diagnosed and oen confused with CMPI. e former
is less common, typically follows gastroenteritis and is usually short lived.
Undigested food (‘peas and carrots syndrome’) in the persistent loose stool of an otherwise
well and thriving child is virtually pathognomic of the harmless toddler’s diarrhoea.
https://t.me/med1917
DIARRHOEA IN CHILDREN 29
In the acute case – particularly in younger children with severe diarrhoea and associated
vomiting – assess for dehydration as a priority. If the child is signicantly dehydrated, then
admission will be needed regardless of cause.
Bloody diarrhoea raises the stakes somewhat. In the acute situation, this could be one of the
more severe forms of gastroenteritis or, especially i n those under 1 year of age, intussusception.
In more prolonged cases, it might indicate CMPI or IBD.
Very minor, transient weight loss is common during a bout of gastroenteritis. More prolonged
weight loss with persistent diarrhoea should, on the other hand, prompt urgent referral.
Remember that appendicitis can cause d iarrhoea. In such cases, the abdominal pain is usually
more marked and constant than in a typical gastroenteritis, where it is typically mild (and
therefore not the presenting complaint) and intermittent.
NOTES:
https://t.me/med1917
30
EPIGASTRIC PAIN
The GP overview
Up to 40% of the adult population suer this symptom in any 1 year. Only about one in ten
seek help from their GP, usually presenting with ‘indigestion’. e rst step involves sorting out
exactly what the patient means by this term. e second is to establish whether it is acute, chronic
or acute-on-chronic. And the third revolves around management, which is oen orientated
towards a pragmatic, symptomatic approach rather than establishing a precise diagnosis.
Differential diagnosis
COMMON
non ulcer dyspepsia (NUD)
gastro-oesophageal reux disease (GORD)/gastritis
IBS
gallstones
duodenal ulcer/duodenitis
OCCASIONAL
drug related, e.g. antibiotics, NSAIDs, bisphosphonates
pancreatitis (acute or chronic)
muscular
peritonitis (perforated DU or carcinoma)
carcinoma of the stomach
gastric ulcer
oesophageal spasm
aerophagy
RARE
angina or myocardial infarct
pneumonia
carcinoma of the pancreas
ruptured abdominal aortic aneurysm
gastrointestinal obstruction
referred from spine
epigastric hernia
https://t.me/med1917
EPIGASTRIC PAIN 31
Ready reckoner
NUD GORD/gastritis IBS Gallstones DU/duodenitis
Nocturnal pain Possible Possible No Possible Yes
Relief with antacids Possible Ye s No No Possible
Stress related Possible Possible Ye s No Possible
Radiates to back No No No Possible Possible
Vomiting No No No Possible Possible
Possible investigations
LI KE LY: FBC, H. pylori testing.
POSSIBLE: LFT, upper GI endoscopy, ultrasound.
SMALL PRINT: Serum amylase, barium swallow or meal, oesophageal manometry/pH studies,
cardiac biomarkers, ECG, CXR, erect and supine abdominal X-rays, further hospital-based
upper GI investigations.
FBC: Anaemia in underlying malignancy or bleeding from peptic ulcer; WCC raised in
cholecystitis and pancreatitis. Raised platelets associated with oesophageal or stomach
cancer.
H. pylori testing: Strong association with peptic ulcer disease; possibly also with other
gastrointestinal pathologies.
LFT: May be abnormal in gallstones or malignancy.
Upper GI endoscopy: To visualise/biopsy the upper GI tract (in particular, to exclude
carcinoma of the stomach).
Ultrasound: For gallstones; may reveal other pathology such as pancreatic disease.
Barium swallow or meal: For investigation of the oesophagus, stomach and duodenum in
those unwilling to have, or unt for, endoscopy.
Serum amylase: Elevated in acute pancreatitis.
Other tests: Most of these are likely to be initiated in secondary care aer referral. ey
include oesophageal manometry/pH studies (if likely oesophageal problem but a normal
endoscopy), cardiac biomarkers and ECG (possible acute cardiac event), CXR (pneumonia),
erect and supine abdominal X-rays (obstruction), CT or MRI scan if a mass is suspected or
symptoms remain unexplained.
TOP TIPS
It’s important to address underlying concerns. Most patients with epigastric pain do not seek
medical help. ose that do usually fear signicant disease such as cancer.
A diagnosis of peptic ulcer still frightens many patients, especially older age groups, as
they may be unaware of recent therapeutic advances. Provide adequate explanation and
reassurance.
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32 SYMPTOM SORTER
Don’t overlook the medication history, as this may provide a simple solution to the problem.
A normal endoscopy does not rule out oesophageal problems such as GORD or spasm.
Cardiac pain can sometimes be epigastric. If suspecting angina, beware that a trial of GTN
can help or confuse – as it also eases oesophageal spasm.
Guidance on who to refer urgently to exclude carcinoma, and for what, can be complex and
confusing. Some degree of judgement is required, but certainly patients aged 55 or more with
unexplained dyspepsia and weight loss need urgent referral, as do patients with dysphagia.
In an obviously unwell patient with weight loss and epigastric pain, do not be ‘reassured’ by
a normal endoscopy. ere may well still be signicant pathology such as carcinoma of the
pancreas.
In at least 50% of cases, carcinoma of the pancreas presents with epigastric pain rather than
the classical painless, progressive jaundice.
In acute cases, do not overlook referred pain – from heart, lungs or spine.
NOTES:
https://t.me/med1917
33
LOIN PAIN
The GP overview
Doctors may disagree – with patients and among themselves – about where exactly the ‘loin’ is.
For the purposes of this chapter, it is the area between the lower ribs and the pelvis, anteriorly
or posteriorly. Loin pain is a common acute or subacute presentation, with patients tending to
assume that the symptom inevitably represents a renal problem. Occasionally, they are correct.
But a musculoskeletal aetiology is much more likely, and there are other possible causes to trip
up the unwary.
Differential diagnosis
COMMON
acute musculoskeletal pain
renal or ureteric stone
acute pyelonephritis
rib pain
shingles
OCCASIONAL
gynaecological causes (e.g. ectopic pregnancy, PID, ruptured or torted ovarian cyst)
gastrointestinal causes (e.g. appendicitis, biliary colic)
other urological causes in men (e.g. epididymitis, prostatitis)
pelvi-ureteric obstruction
radicular pain (e.g. from osteoarthritis or disc prolapse)
RARE
leaking abdominal aortic aneurysm
retroperitoneal brosis
renal infarction
renal tumour (either directly or by causing a blood clot in the ureter)
acute papillary necrosis
factitious (e.g. addicts seeking opioids)
idiopathic loin pain haematuria syndrome
https://t.me/med1917
34 SYMPTOM SORTER
Ready reckoner
Acute musculoskeletal
pain
Renal or
ureteric stone
Acute
pyelonephritis
Rib pain Shingles
Urinary symptoms No Possible Possible No No
Fever No Possible Yes No Possible
Macro or microscopic
haematuria
No Possible Possible No No
Pain worse with
movement
Ye s No No Possible No
Pain colicky No Ye s No No No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: U&E, sieving urine, renal imaging.
SMALL PRINT: Metabolic screen (usually secondary care); other hospital-based investigations.
Urinalysis: e presence of microscopic haematuria would support your diagnosis of renal/
ureteric colic (though its absence does not rule it out); urinalysis may also reveal evidence of
urinary infection or acute papillary necrosis (blood and white cells in the latter).
MSU: To conrm suspected infection; also might suggest acute papillary necrosis (blood
and sterile pyuria).
U&E: To assess renal function when underlying renal issue suspected.
Sieving urine: To retrieve stone in renal/ureteric colic for subsequent analysis.
Renal imaging: Non-contrast helical CT is the hospital investigation of choice in suspected
renal/ureteric colic; depending on how acute the presentation is, and on local pathways and
guidelines, plain abdominal X-ray or US may be helpful. Renal imaging may also be required
in acute pyelonephritis (especially if recurrent), possible renal tumour and in suspected
pelvi-ureteric obstruction. Ultrasound, IVU, CT or MRI may be needed to diagnose
retroperitoneal brosis.
Metabolic screen such as blood and 24 hour urine for calcium, phosphate and urate in stone
formers.
Other hospital-based investigations: Required to clarify the diagnosis in those admitted,
and will depend on whether the cause seems urological, gynaecological or gastrointestinal.
TOP TIPS
Remember that many patients fear kidney problems. ey may value reassurance that all is
well renally as much as your positive diagnosis of musculoskeletal pain.
Take care during busy telephone triaging sessions – be sure to check that the apparently
simple case of cystitis isn’t actually a developing case of acute pyelonephritis.
https://t.me/med1917
LOIN PAIN 35
e absence of microscopic haematuria does not rule out renal/ureteric colic but should
certainly prompt a consideration of alternative diagnoses.
Patients with genuine renal/ureteric colic tend to writhe about in pain.
ink of shingles, particularly in elderly patients with an otherwise unexplained short
history of burning loin pain, and warn them of the possibility of a rash developing – the
pain may precede the skin manifestations by a few days.
Beware of a rst diagnosis of renal/ureteric colic (especially le sided) in older men – a
leakingabdominal aortic aneurysm can cause very similar symptoms.
Some cases of renal/ureteric colic can be managed – at least initially – in the community.
But those with fever, prolonged or unresponsive pain, or known renal compromise should
be admitted.
Remember that acute pyelonephritis in men and children, and recurrent episodes in women,
require investigation to exclude any underlying urological problem.
Be cautious about using strong analgesics for possible renal/ureteric colic in patients with
past histories of drug addiction – this used to be a favoured way of engineering a free opioid
x, although the increasing use of diclofenac as the urgent treatment of choice has reduced
this problem.
NOTES:
https://t.me/med1917
36
RECURRENT
CHILDHOOD
ABDOMINAL PAIN
The GP overview
Recurrent abdominal pain in childhood can be a calling card for a myriad hidden agendas.
More than 85 causes have been listed, and as in most areas of general practice, the trick is to si
through the morass of information to nd the keys to the diagnosis and open the way to eective
management. e underlying cause in the most persistent cases is usually non-organic (90% of
those referred to hospital).
Differential diagnosis
COMMON
recurrent viral illnesses
anxiety and depression (sometimes known as periodic syndrome or abdominal migraine)
recurrent UTI
constipation
gastritis and GORD
OCCASIONAL
infant colic (which is assumed to cause abdominal pain)
cow’s milk protein intolerance (in infants)
Crohn’s and coeliac disease
duodenal ulcer (DU)
irritable bowel syndrome
diabetes mellitus
Henoch–Schönlein purpura
hydronephrosis, renal stones and ureteric reux
Meckel’s diverticulum
RARE
parasitic infestation of the gut
food allergy
sickle-cell disease
https://t.me/med1917
RECURRENT CHILDHOOD ABDOMINAL PAIN 37
tuberculosis (TB)
Hirschsprung’s disease
temporal lobe epilepsy
pica
Ready reckoner
Recurrent
viral illness
Anxiety/
depression
Recurrent
UTI
Constipation Gastritis/
GORD
School/home stress No Ye s No No No
Related to eating No No No Possible Possible
Diarrhoea Possible Possible No Possible No
Fever Yes No Ye s No No
Abnormal urinalysis Possible No Ye s No No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: FBC, blood lm, ESR/CRP, anti-endomysial and anti-gliadin antibodies.
SMALL PRINT: Faecal calprotectin, plain abdominal X-ray, abdominal ultrasound, further
hospital-based investigations (aer referral).
Urinalysis and MSU: Urinalysis will reveal evidence of a UTI, which will be conrmed
with an MSU for microscopy and culture. Urinalysis will also reveal glucose in diabetes and
possible haematuria in Henoch–Schönlein purpura.
FBC: Hb may be reduced in any chronic disorder; leucocytosis in bacterial infection;
eosinophilia in parasitic infestation or genuine food allergy. Blood lm may show sickling.
Raised ESR/CRP suggests organic disease.
Anti-endomysial and anti-gliadin antibodies: A positive result suggests coeliac disease.
Faecal calprotectin: If Crohn’s suspected.
Ultrasound: Non-invasive rst line investigation of renal tract. Other investigation for
conrmed UTI will be arranged by the paediatrician.
Further hospital-based investigations: If there is a high suspicion of organic disease, e.g.
endoscopy for DU, barium meal and follow-through for Crohn’s disease.
TOP TIPS
e majority of children with recurrent abdominal pain will not have organic pathology –
take the problem seriously and assess carefu lly, but avoid reinforcing worries with unnecessa ry
investigation or referral.
https://t.me/med1917
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