Surgery - Approach to investigation of non-acute abdominal pain

Question 1

Approach to investigation of non-acute abdominal pain

General examination

Answer 1

• Well-looking or ill (thin, emaciated, weak)?
• Alert and responding normally or obtunded and slumped in bed?
• Dehydrated (poor skin tone, sunken cheeks)?
• Abnormal skin colour (pale, jaundiced, grey)
• Signs of surgical wounds or dressings
• End-of-bed charts—fever, tachycardia, fluid balance, trauma chart, pain chart, drug chart (e.g. strength and frequency of analgesia), modified early warning scores (MEWS)
• ‘Medical accessories’—i.v. infusion, urinary catheter, parenteral nutrition, monitoring equipment, oxygen mask

Question 2

Approach to investigation of non-acute abdominal pain

Peripheral stigmata of abdominal disease

Answer 2

• Fingernails for koilonychia (spoon-shaped nails in iron deficiency) and leuconychia (whiteness and opacity of nails, sometimes due to hypoalbuminaemia)
• Hands for palmar erythema and Dupuytren’s contracture (association with liver disease)
• Eyes—yellow sclerae in jaundice, pale conjunctivae in anaemia
• Mouth and tongue—for ulceration suggestive of Crohn’s, angular stomatitis in anaemia, dehydration, telangiectasia in hereditary haemorrhagic telangiectasia
• Supraclavicular fossa palpation for enlarged lymph nodes, particularly medial left-sided Virchow’s node indicating upper GI malignancy (Troisier’s sign)
• Inspect abdominal skin for jaundice and scratch marks resulting from pruritus (itching), spider naevi (indicate likely liver disease)
• Chest in males for gynaecomastia in liver disease

Question 3

Approach to investigation of non-acute abdominal pain

Abdominal inspection

Answer 3

• Position the patient correctly (comfortable, near-flat, arms by sides) and expose the whole abdominal field (‘nipples to knees’, but not all at once)
• Distended or scaphoid (sunken) abdominal shape?
• Skin—wounds and scars, redness, purulent discharge or other signs of infection, erythema ab igne
• Bruising—umbilical or flank in acute pancreatitis; cloth printing (trauma cases)
• Herniation (including usual primary sites and incisional hernias)
• Caput medusae—enlarged veins radiating from umbilicus indicating portal venous obstruction
• Visible peristalsis—usually indicating long-standing small bowel obstruction

Question 4

Approach to investigation of non-acute abdominal pain

Abdominal palpation (do not hurt the patient; watch the face for signs of discomfort)

Answer 4

• Gentle overall palpation for obvious abnormalities
• Overall firmer palpation at a deeper level provides detailed examination of abnormal masses—relationship to abdominal wall, size, shape, position, mobility, texture, hardness, fixation posteriorly or anteriorly, tenderness. Likely site or organ of origin?
• Specific organ palpation—press in first, then ask the patient to breathe in deeply; gradually relax your pressure and seek the descending lower edge of the organ; repeat at 3 cm intervals moving upwards:
• Liver—start as low as it might have reached, e.g. right iliac fossa, and work upwards as above. Map out palpable lower liver edge. If large, palpate surface for irregularities, e.g. metastases. The enlarging liver usually remains in contact with the anterior abdominal wall and is dull to percussion. Percuss also for upper border to gauge liver size; auscultate a large liver for vascular bruits
• Spleen—tilt patient slightly towards right side, place left hand behind lower left ribs and gently lift. Start as low as enlargement might have reached, e.g. right iliac fossa, and palpate as for liver. Seek notch in lower edge. To be palpable, spleen needs to be enlarged 2–3 times normal. Percuss for overlying resonance due to gas in bowel superficial to it
• Kidneys—as with the liver, a renal mass usually descends with inspiration since the kidneys lie just beneath the diaphragm. Bimanual palpation enables the posteriorly placed kidney to be felt by displacing it anteriorly (see Fig. 18.3). Place left hand in loin and attempt to push enlarged organ forwards on to examining hand
• Examination for ascites
• Hernial orifices—inguinal and femoral for cough impulse; reducibility
• Rectal and/or vaginal examination if appropriate
• Percussion and auscultation if appropriate