Gastroenterology

Abdominal Pain

Acute Abdominal Pain

About

  • This is the provision of the surgeons as the management often requires surgery however these patients are not infrequently on the medical wards.
  • An "acute abdomen" infers a serious cause of severe abdominal symptoms and signs and should be treated with a degree of urgency.

Differential

  • Acute Peptic ulceration
  • Perforation
    • Gastric ulcer
    • Duodenal ulcer
  • Acute pancreatitis - elevated amylase. History of alcohol or gallstones or ERCP
  • Acute appendicitis - pain starts periumbilicus and moves to RIF as peritoneal inflammation localises the pain
  • Acute diverticulitis
  • Acute urinary retention
  • Acute renal colic - renal stones from loin to groin comes in waves of pain
  • Acute cholecystitis - may be RUQ pain. Murphy positive. Biliary colic is a constant not colicky pain. Pain goes to right side and back.
  • Bowel perforation
    • Related to colonoscopic removal of polyp
    • Diverticular disease
    • Malignancy
  • Abdominal aortic aneurysm
  • Bowel infarction - AF, Atherosclerosis
  • Splenic infarction
  • Hepatic vein thrombosis (Budd-Chiari syndrome) 

Medical causes

  • Lower zone lobar pneumonia
  • Diabetic ketoacidosis
  • Myocardial infarction especially inferior STEMI
  • Familial mediterranean fever
  • Acute intermittent porphyria
  • Addisonian crisis
  • Shingles (before rash apparent)

Pelvic causes

  • Ectopic pregnancy
  • Ovarian torsion ?
  • Acute salpingitis
  • Haemorrhage into ovarian cyst

Abdominal examination

  • Localisation of pain
    • Epigastrium : Acute Peptic ulceration, Perforation - Gastric ulcer, Duodenal ulcer, Acute pancreatitis
    • RUQ : Acute cholecystitis
    • LIF : Acute diverticulitis
    • Loin pain : Renal stones 
  • General Inspection
    • Patient distressed. Apprehensive. May be breathing shallow with only diaphragm as to minimise pain. Feverish.
    • Acute abdominal pain - assess out of 10
    • Observations - tachycardic. May be hypotensive Pulse and BP and respiratory rate are fundamental. O2 sats.
  • Palpation
    • Abdominal tenderness - allow patient to show you where it is sore. Often use patients hand to show signs. Examine all quadrants. Do not neglect the groin looking obstructed for herniae. Look for masses and fluid.
    • Abdominal guarding - Apprehensive patient with increased tone of abdominal muscles
    • Abdominal rigidity - abdominal muscles contract on palpation. Abdomen can be rigid as a board with patient Inspection
      • Cullen's sign - periumbilical bruising with acute pancreatitis
      • Grey Turner's sign - flank bruising from retroperitoneal bleeding due to Acute pancreatitis
    • Rebound tenderness - pressing and releasing can cause increased pain if peritonitis
  • Auscultation
    • Altered bowel sounds - silent if peritonitis, ileus
    • High pitched tinkling if obstructed, amphoric if distended bowel
  • PR
    • Looking for blood e.g. melaena from Upper GI tract or fresh blood from lower GI tract
    • Tenderness, fistulas with Crohn's disease
    • Anal cancer lesions
  • Testicular exam in men
    • Testicular mass - tumour is painless
    • Varicoele may suggest left renal mass
    • Testicular torsion
    • Epididymoorchitis

Investigations

  • FBC (WCC ??)
  • U&E, LFT, Amylase
  • Pregnancy test in all fertile females
  • Troponin where indicated
  • Arterial blood gas - metabolic acidosis and increased lactate are ominous signs
  • Blood glucose
  • Erect AXR - shows free air under diaphragm, distended bowel
  • USS abdomen - shows gallstones, fluid, liver congestion with Budd-Chiari, Abdominal aortic aneurysm
  • CT abdomen - shows free fluid, aneurysms, splenic infarct,
  • Gastroscopy - if upper GI disease suspected e.g. haematemesis but not usually required in an acute abdomen
  • ERCP for acute cholangitis or gallstone pancreatitis
  • Surgery
    • Diagnostic laparotomy may help show cause. Laparoscopy
    • Bowel resection for ischaemic bowel
    • Repair of perforation

Management

  • Keep patient nil by mouth as surgery may be needed.
  • Supportive measures such as maintaining ABCs. Set up IV fluids immediately if shocked.
  • Send blood for group and save/crossmatch and other blood tests as mentioned above.
  • Consider NG tube if severe vomiting, signs of intestinal obstruction or extremely unwell and danger of aspiration.
  • Analgesia: Do not withhold analgesia until surgical review 
  • Antibiotics if evidence of sepsis, peritonitis, severe UTI. IV cephalosporin and metronidazole are usually first line.
  • Arrange urgent surgical/gynaecological review as appropriate.
  • Arrange investigations such as ECG if medical cause likely

Chronic Abdominal Pain

About

  • Recurrent abdominal pain. Most usually presents to the GP and is referred to outpatients.
  • A list of causes is shown below. The issue is to pick out those that need further investigations
  • Red flags include weight loss, anaemia, swelling, PR bleeding, older patient

Causes

  • Irritable bowel syndrome - incomplete evacuation, pain relieved by defaecation, feeling of bloating
  • Crohn's disease
  • Ulcerative colitis
  • Peptic ulcer disease
    • Duodenal ulcer - takes anatacids. Milk at bedtime
    • Gastric ulcer
  • Chronic pancreatitis
  • Chronic cholecystitis (RUQ pain, Gallstones) - constant RUQ pain worse after a meal and with fatty intolerance
  • Chronic appendicitis (Gallstones, alcohol other)
  • Constipation
  • Gynaecological - relation to menstruation, vaginal discharge or bleeding, dyspareunia, back pain
  • Malignancy - weight loss
  • Mesenteric vascular disease- pain after eating, atherosclerotic risk factors

Epigastric pain

  • Peptic ulcer disease
  • Chronic pancreatitis
  • Chronic cholecystitis

RIF pain

  • Crohn's disease
  • Tuberculosis

LIF pain

  • Diverticulitis

Examination

  • Weight, nutritional status, jaundice, anaemia
  • Left Supraclavicular lymphadenopathy
  • Scars from old operations - adhesions can cause bowel obstruction. May suggest unwarranted surgery.
  • Abdominal distension - the 5 Fs
  • Rectal exam

Investigations

  • FBC - Anaemia.Assess if MCV low, normal, high
  • U&E - hypokalaemia if vomiting or diarrhoea
  • Calcium - hypercalcaemia causing abdominal symptoms e.g. peptic ulcer disease
  • Amylase - suggests acute pancreatitis, normal in chronic pancreatitis
  • Raised GGT alone - alcohol
  • Elevated ALP and GGT and Bilirubin - obstructive jaundice
  • Elevated ALT - hepatitis
  • Raised Urea - GI bleed, Dehydration, Renal failure. Low urea - liver disease
  • TFTs - High T4 causes weight loss, bowel frequency. Low T4 constipation
  • Elevated tumour markers CEA or CA19.9

Radiology

  • AXR = calcified pancreas, gallstones may occasionally be seen
  • USS - excludes gallstones and biliary disease. May visualise pancreas. Shows kidneys and spleen. Identifies ascites and other fluid or cysts. Liver metastases
  • CT abdomen - malignancy of pancreas or lymphoma or colorectal lesions may be seen.

Endoscopy

  • OGD for epigastric pain
  • Colonoscopy for lower GI symptoms

Laparoscopy

  • Suspected gynaecological disease