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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 10 GI symptoms
232
Acute central abdominal pain
Some differential diagnoses and typical outline evidence
Small bowel
obstruction
Suggested by: vomiting, constipation with complete
obstruction
Confirmed by: AXR
shows small bowel loops and fluid
levels
Crohn’s disease Suggested by: chronic diarrhea with abdominal pain,
weight loss, palpable RLQ mass or fullness, mouth
ulcers
Confirmed by: colonoscopy with biopsy, barium studies
showing “skip lesions,” string sign in advanced cases
Mesenteric
artery
occlusion
Suggested by: vomiting, bowel urgency, melena,
diarrhea
Confirmed by: mesenteric angiography, exploratory
laparotomy
Abdominal
aortic
dissection
Suggested by: tearing pain ± shock ± hypotension and
peripheral cyanosis
Confirmed by: ultrasound or CT of abdomen
ACUTE LATERAL ABDOMINAL PAIN1
233
Acute lateral abdominal pain
Some differential diagnoses and typical outline evidence
Pyelonephritis Suggested by: pain in loin (upper lateral), rigors,
fever, vomiting, frequency of micturition, renal-angle
tenderness
Confirmed by: FBC: leukocytosis. Urinalysis: pyuria,
urine culture and sensitivities
Renal calculus Suggested by: renal colic mainly in loin (upper lateral),
hematuria
Confirmed by: urinalysis, renal ultrasound, IVU, CT/MRI
Ureteral
calculus
Suggested by: renal colic, moving from loin (upper
lateral) down to RLQ, hematuria
Confirmed by: urinalysis, renal ultrasound, IVU, CT/MRI
Appendicitis Suggested by: pain initially central, then radiating to
RLQ, anorexia, low-grade fever, constipation. RLQ
tenderness and guarding
Confirmed by: Inflamed appendix at laparotomy
Salpingitis Suggested by: fever, nausea, vomiting, mucopurulent
cervical discharge, irregular menses. Bilateral lower
abdominal tenderness and guarding
Confirmed by: FBC: leukocytosis. High vaginal swab,
laparoscopy
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CHAPTER 10 GI symptoms
234
Acute lower central (hypogastric)
abdominal pain
Some differential diagnoses and typical outline evidence
Infective or
ulcerative
colitis
Suggested by: abdominal pain, diarrhea with blood and
mucus
Confirmed by: stool microscopy and culture,
colonoscopy
Large bowel
obstruction
Suggested by: severe distension, late vomiting, visible
peristalsis, resonant percussion, increased bowel
sounds. Supine AXR showing peripheral abdominal
large bowel shadow (with haustra partly crossing the
lumen). Fluid levels on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Cystitis Suggested by: frequency, urgency, dysuria, ± hematuria
Confirmed by: urine for microscopy and culture
Pelvic
inflammatory
disease
Suggested by: vaginal discharge, dysuria, dyspareunia,
pelvic tenderness on moving cervix, iESR and CRP.
WBC: leukocytosis
Confirmed by: High vaginal swab, pelvic ultrasound,
± laparoscopy
Pelvic
endometriosis
Suggested by: dysmenorrhea, ovulation pain,
dyspareunia, infertility, pelvic mass
Confirmed by: laparoscopy
Ectopic
pregnancy
Suggested by: constant unilateral pain ± referred
shoulder pain, amenorrhea, vaginal bleeding (usually
less than normal period), faintness with an acute
rupture
Confirmed by: pregnancy test positive, bimanual
examination reveals slightly enlarged uterus, pelvic
ultrasound shows empty uterus with thickened
decidua
SUDDEN DIARRHEA, FEVER, AND VOMITING1
235
Sudden diarrhea, fever, and vomiting
Sudden diarrhea can occur with fever, ± malaise, colicky abdominal pain,
and vomiting.
Some differential diagnoses and typical outline evidence
Antibiotic-induced
bacterial
opportunist:
Clostridium difficile
Suggested by: diarrhea with a history of recent
antibiotic therapy, iWBC
Confirmed by: C. difficile toxin in stool
Viral gastroenteritis:
Rotavirus
Suggested by: diarrhea in children <5 years,
symptoms resolve in a week
Norwalk virus Suggested by: diarrhea in older children and adults,
symptoms resolve in 2 weeks
Food poisoning or
toxins:
Staphylococcus
aureus
Suggested by: eating “doubtful” meat, incubation
period <6 hours, marked vomiting
Confirmed by: isolation of Staph. aureus from
examination of suspected food
Bacillus cereus
Suggested by: eating “doubtful” rice, incubation
period <6 hours, marked vomiting
Confirmed by: stool microscopy and culture
Vibrio para
hemolyticus
Suggested by: “doubtful” seafood, incubation period
16–72 hours
Confirmed by: stool microscopy and culture
Clostridium
perfringens
Suggested by: eating “doubtful” meat, incubation
period 8–16 hours, abdominal cramps, little
vomiting
Confirmed by: organism isolation from feces or
suspected food
Botulism Suggested by: eating “doubtful” canned food,
incubation period 18–36 hours, but may vary from
4 hours to 8 days. Abdominal cramps, dry mouth,
diplopia, progressive paralysis
Confirmed by: C. botulinum toxin in serum or feces.
C. botulinum toxin isolation from suspected food
Salmonella
typhimurium
Suggested by: eating “doubtful” meat, egg, or
poultry. Fever (with relative bradycardia),
headache, dry cough
Confirmed by: stool microscopy and culture
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CHAPTER 10 GI symptoms
236
Recurrent diarrhea with blood ±
mucus—bloody flux
Recurrent diarrhea with blood-stained stools ± mucus or fever.
Some differential diagnoses and typical outline evidence
Crohn’s disease Suggested by: chronic diarrhea with abdominal pain,
weight loss, RLQ mass or fullness, mouth ulcers
Confirmed by: colonoscopy with biopsy, barium
studies showing “skip lesions,” string sign (in advanced
cases)
Ulcerative
colitis
Suggested by: lower abdominal cramps, i urgency to
defecate, severe diarrhea, i fever in acute attack.
CBC showing iWBC
Confirmed by: colonoscopy with biopsy, barium studies
show loss of haustration, mucosal edema, ulceration
Colonic
carcinoma
Suggested by: alternate diarrhea and constipation
Confirmed by: barium enema showing filling defect,
colonoscopy with biopsy shows mass and malignant
histology
Colorectal
carcinoma
Suggested by: sensation of incomplete evacuation.
Confirmed by: sigmoidoscopy with biopsy showing mass
and malignant histology, barium enema shows filling
defect
Diverticular
disease or
diverticulitis
Suggested by: middle-aged or elderly patient, diarrhea,
left iliac fossa pain, abdominal and rectal mass
Confirmed by: barium enema showing opaque filling
diverticula, colonoscopy showing inflammatory foci
ACUTE BLOODY DIARRHEA ± MUCUS—“DYSENTERY”1
237
Acute bloody diarrhea ± mucus—
“dysentery”
Some differential diagnoses and typical outline evidence
Shigella
(bacillary)
dysentery
Suggested by: blood and mucus, fever, abdominal pain
Confirmed by: stool microscopy revealing red cells, pus
cells, and appearance of organism
Campylobacter
enteritis
Suggested by: associated severe abdominal pain
Confirmed by: stool microscopy and culture of organism
Enteroinvasive
Escherichia coli
Suggested by: fever, watery diarrhea
Confirmed by: stool microscopy and culture of organism
Enterohemor-
rhagic type 0157
E. coli
Suggested by: bloody diarrhea ± hemolytic uremic
syndrome (HUS)
Confirmed by: stool microscopy and culture
of organism
Entameba
histolytica
(amebic)
dysentery
Suggested by: abdominal discomfort, flatulence,
frequent watery, bloody diarrhea
Confirmed by: stool microscopy and culture
of organism
First episode
of cause of
recurrent
“bloody flux”
(see p. 236)
Suggested by: no specific features
Confirmed by: barium enema and colonoscopy showing
evidence of chronic cause after acute episode
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CHAPTER 10 GI symptoms
238
Watery diarrhea
Note that diarrhea can result in severe dehydration.
Some differential diagnoses and typical outline evidence
Traveler’s
diarrhea
Suggested by: recent travel, no obvious ingestion of
contaminated water or food
Confirmed by: rapid resolution or response to
ciprofloxacin
Enterotoxigenic
E. coli
(most common)
Suggested by: incubation period 12–72 hours in
relation to contact to others with similar features
Confirmed by: stool microscopy and culture
Vibrio cholera Suggested by: incubation period from a few hours to
5 days, profuse watery diarrhea, fever, vomiting
Confirmed by: stool microscopy and culture
Rotavirus Suggested by: diarrhea in children <5 years, symptoms
resolve in a week
Norwalk virus Suggested by: diarrhea in older children and adults,
symptoms resolve in 2 weeks
RECURRENT DIARRHEA WITH NO BLOOD1
239
Recurrent diarrhea with no blood
Recurrent diarrhea with no blood
in the stools, no fever
Some differential diagnoses and typical outline evidence
Irritable bowel
syndrome
Suggested by: no weight loss, intermittent daytime
diarrhea, pain relieved by defecation, abdominal
distension, mucus but no blood in the stool
Confirmed by: normal colonoscopy and barium studies
HIV infection Suggested by: weight loss, other opportunistic
infection, lympadenopathy, Kaposi’s sarcoma
Confirmed by: HIV serology, stool microscopy and
cultures showing Cryptosporidium, microsporidia,
Isospora belli, enteropathy, etc.
Malabsorption
due to celiac
disease, lactose
intolerance,
pancreatic
disease,
Whipple’s
disease
Suggested by: pale, bulky offensive stools, weight loss,
signs of nutritional deficiencies
Confirmed by: celiac screen, small bowel biopsy; or
lactose tolerance test; intestinal biopsy shows foamy
macrophages containing periodic acid Schiff
(PAS)-positive glycoprotein in Whipple’s disease
Drug -induced Suggested by: history of laxative abuse, magnesium
alkalis, antibiotics, hypotensive agents, alcohol
Confirmed by: resolution on withdrawing drug
Fecal impaction
with overflow
Suggested by: elderly patient and hard feces on rectal
examination
Confirmed by: AXR may show fecal impaction.
Response to suppositories or removal of feces
Diabetic
autonomic
neuropathy
Suggested by: intermittent diarrhea, postural
hypotension, impotence, urinary retention, history of
diabetes
Confirmed by: lying and standing BP, loss of
beat-to-beat variation during slow deep breathing
Thyrotoxicosis Suggested by: heat intolerance, tremor, nervousness,
palpitation, frequent bowel movements, goiter
Confirmed by: ddTSH, iFT4 or iFT3
Carcinoid
syndrome
Suggested by: facial flushing ± wheeze, abdominal pain
Confirmed by: i24-hour urinary 5-HIAA
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CHAPTER 10 GI symptoms
240
Change in bowel habit
This may be an increase in constipation or diarrhea or both alternating.
Some differential diagnoses and typical outline evidence
Colonic
carcinoma
Suggested by: alternate diarrhea and constipation,
anemia or weight loss
Confirmed by: colonoscopy with biopsy, barium enema
Change in diet Suggested by: history of d diet fiber, d fluid intake
Confirmed by: normal endoscopy and response to diet
change
Drug induced Suggested by: constipating drugs (opioids, hypotensive
agents, aluminum alkalis, etc.), purgative dependence
Confirmed by: normal endoscopy and response to
withdrawal of suspected agent
Depression Suggested by: sleep disorders, social withdrawal, lack of
interest in usual activities
Confirmed by: normal endoscopy and response to lifting
of depression
Immobility Suggested by: history
Confirmed by: normal endoscopy and history
Cerebral or
spinal cord
lesion
Suggested by: neurological symptoms and signs ±
abnormal sphincter tone and anal sensation
Confirmed by: CT or MRI
Metabolic
disturbances:
hypothyroidism,
hyperthyroidism,
hypercalcemia,
hypokalemia
Suggested by: symptoms of metabolic disturbance or
absence of anatomical abnormality
Confirmed by: thyroid function tests (TFT), serum
calcium, potassium, etc.
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