Surgery - Non-acute abdominal pain and other abdominal symptoms and signs

Question 1

Non-acute abdominal pain and other abdominal symptoms and signs

Introduction

Answer 1

Main presenting symptoms of non-acute abdominal disorders:

• Abdominal pain
• Difficulty in swallowing (dysphagia)
• Weight loss
• Anorexia (loss of appetite)
• Nausea or intermittent vomiting
• Change in bowel habit, including rectal bleeding

Question 2

Non-acute abdominal pain and other abdominal symptoms and signs

Assessing abdominal pain from the history

Answer 2

1. Onset and duration of pain
2. Periodicity
3. Location of the pain
4. Severity and charcter of the pain
5. Variation of the pain severity with time
6. Ecacerbating and relieving factors
7. associated symptoms

Question 3

Diseases causing non-acute abdominal pain—typical patterns

Gallstones & gall bladder dysfunction

Peptic Ulcer disease

Answer 3

Gallstones and gall bladder dysfunction.

• Biliary colic presents with irregularly recurrent bouts of severe pain which, though described as colic, characteristically last continuously for 1–12 hours.
• Severe and prolonged episodes may bring the patient into hospital. Pain is usually located in the upper abdomen—most often on the right side—and may radiate around to the back.
• It is often precipitated by rich or fatty foods and may be associated with vomiting

Peptic ulcer disease.

• Typically there is intermittent ‘boring’ epigastric pain which recurs several times a year and lasts for days or weeks at a time.
• It is not as severe as biliary colic unless there is perforation, which presents acutely.
• Retrosternal ‘burning’ occurs in peptic oesophagitis and tends to occur after large meals and on lying down.
• The relationship of pain with food varies according to the site of the ulcer disease: duodenal ulcer pain is relieved by bland food and recurs 3–4 hours afterwards, typically in the early morning, whereas the pain of gastric ulcer and oesophagitis tends to be aggravated by food, especially if acidic or spicy.
• Peptic pain is generally relieved by antacids and virtually always by H2-blocking drugs (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole), this ‘trial of treatment’ providing evidence towards a diagnosis

Question 4

Diseases causing non-acute abdominal pain—typical patterns

Chronic pancreatitis/carcinoma of the pancreas

IBS/Constipation

Answer 4

Chronic pancreatitis and carcinoma of pancreas.

• Either is typically associated with severe ‘gnawing’, persistent and poorly localised central pain which usually radiates through to the back and is often associated with anorexia and weight loss.
• The pain may be relieved by leaning forwards (‘the pancreatic position’).
• Early carcinoma of the pancreas, however, is usually painless

Irritable bowel syndrome and constipation.

• These may cause a chronic symptom complex mimicking partial bowel obstruction and manifest by episodes of colicky pain.
• This is poorly localised, often ‘bloating’ pain, particularly post-prandially (after meals).
• Its intensity varies and it is often associated with transient disturbances of bowel function, particularly alternating diarrhoea and constipation.
• Passage of flatus or stool often temporarily relieves the symptoms

Question 5

Diseases causing non-acute abdominal pain—typical patterns

Diverticular Disease & Crohn’s

Chronic renal outflow obstruction (hydronephrosis) caused by stone, tumour or fibrosis

Answer 5

Diverticular disease and Crohn’s disease.

• Partial bowel obstruction can occur with sigmoid diverticular disease or with small bowel Crohn’s disease.
• Symptoms are similar to those of complete bowel obstruction but more low-key.
• In incomplete bowel obstruction, there is often passage of some flatus or even faeces but the patient otherwise appears obstructed.
• The term subacute obstruction is meaningless and should be abandoned

Chronic renal outflow obstruction (hydronephrosis) caused by stone, tumour or fibrosis.

• There may be a ‘dull’, poorly defined, fairly constant loin pain, which can radiate to the groin or genitalia and be accompanied by typical urinary tract symptoms, e.g. haematuria and dysuria.
• It is often aggravated acutely by high fluid intake

Question 6

Diseases causing non-acute abdominal pain—typical patterns

Gynaecological conditions

Non-surgical (i.e. ‘medical’) disorders causing abdominal pain

Answer 6

Gynaecological conditions,

• particularly chronic pelvic inflammatory disease and ovarian tumours.
• These may reach the general surgeon because of poorly defined lower abdominal pain.
• A gynaecological history should be taken in female patients; pelvic examination may reveal the cause and ultrasound is usually diagnostic

Non-surgical (i.e. ‘medical’) disorders causing abdominal pain.

• These include liver congestion in heart failure (common), splenic infarcts or diabetes (both uncommon but important), acute intermittent porphyria, sickle-cell anaemia or tertiary syphilis (very rare).
• Patients sometimes present with abdominal pain for which no organic cause can be found despite extensive investigation. In these, irritable bowel syndrome or sensitivity to certain foods, e.g. gluten or wheat protein, need to be considered.
• Only as a last resort should the pain be attributed to psychological disturbances