The abdomen

Chapter 7 The abdomen



SYMPTOMS OF ABDOMINAL DISORDERS



Gastrointestinal diseases



DYSPHAGIA


Dysphagia caused by a carcinoma usually progresses rapidly over 6–10 weeks and is worse for solids than liquids. Profound weight loss results from reduced food intake and the wasting effect of the cancer.


Patients with a benign ‘peptic’ stricture often have a long history of heartburn, a slower rate of progression and less marked weight loss. In dysmotility syndromes the dysphagia often varies in intensity and is not accompanied by profound weight loss. Solids and fluids may be equally difficult to swallow. When dysphagia is caused by disease of the swallowing centre in the brainstem the symptom is accompanied by coughing and spluttering.




imageQuestions to ask: Dysphagia



• At what level does food stick?

• Has the symptom developed over weeks, months or longer?

• Is the dysphagia intermittent or progressive?

• Are both food and drink equally difficult to swallow?

• Is there a history of reflux symptoms?


imageDifferential diagnosis: Dysphagia



• Benign oesophageal stricture

• Carcinoma of the oesophagus

• Oesophageal motor disorders

• Systemic sclerosis

• Old age (presbyoesophagus)

• Bulbar and pseudobulbar palsy


HEARTBURN


The pain is a scalding or burning sensation behind the sternum and radiates towards the throat. An acid taste may develop in the mouth and reflex salivation may cause it to fill with saliva (water brash).


A common cause of heartburn is a hiatus hernia. Heartburn is often provoked by postures that raise intra-abdominal pressure, such as stooping, bending or lying down.



PAIN ON SWALLOWING (ODYNOPHAGIA)


The symptoms suggest deep inflammation or ulceration of the oesophageal wall or intense spasm of the oesophagus.



LOSS OF APPETITE (ANOREXIA)


This is a non-specific symptom that commonly accompanies both acute and chronic ill health; return of appetite usually heralds recovery.


Profound anorexia occurs in anorexia nervosa, a psychiatric disorder occurring mainly in young women. Anorexia in these patients results in marked weight loss, malnutrition and cessation of menstruation (amenorrhoea). Suspect anorexia nervosa in teenagers and young adults, otherwise healthy, who present with an eating disorder associated with depression, vomiting or purgative abuse.



WEIGHT LOSS


Weight loss may be caused by inappropriate wastage of calories due to steatorrhoea, thyrotoxicosis or diabetes mellitus. Marked weight loss accompanies serious diseases such as chronic pancreatitis, advanced malignancy, chronic infections and failure of the major organs.



imageQuestions to ask: Weight loss



• Is your appetite normal, increased or decreased?

• Over what time span has the weight been lost?

• Do you enjoy your meals?

• Describe your usual breakfast, lunch and supper

• Is the weight loss associated with nausea, vomiting or abdominal pain?

• Are your motions normal in colour and consistency?

• Has there been a fever?

• Do you pass excessive volumes of urine?

• Have you noticed a recent change in weather tolerance?


DYSPEPSIA AND INDIGESTION


This term applies to a sensation of pain, discomfort or fullness in the epigastrium, often accompanied by belching, nausea and early satiety.




imageRisk factors: Dyspepsia



• Cigarette smoking

• Alcohol

• Aspirin

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids and NSAIDs

• Oral bisphosphonates

• Helicobacter pylori infection


imageDifferential diagnosis: Dyspepsia



• Non-ulcer dyspepsia

• Peptic ulcer disease

• Gastritis

• Gallstones

• Chronic pancreatitis


NAUSEA


Nausea usually comes in waves and is often associated with belching. The symptom may be provoked by unpleasant sights, smells and tastes or by abnormal stimulation or the inner-ear labyrinths (motion sickness). It is a characteristic of the prodromal phase of viral hepatitis and often accompanies biliary disease. Drugs causing gastric irritation (e.g. non-steroidal analgesics) or those stimulating the vomiting centre (e.g. digoxin) cause nausea. Early-morning nausea commonly occurs during the first trimester of pregnancy.



VOMITING AND HAEMATEMESIS


Vomiting may occur in diseases of the gastrointestinal and biliary tracts, as well as in a variety of systemic and metabolic disorders. It may also be the presenting symptom of psychological disorders such as anorexia nervosa, bulimia and fear. Try to establish whether the vomit is bile-stained because this indicates patency between the stomach and duodenum. The presence of undigested food and a lack of bile suggest pyloric obstruction. Early-morning vomiting is characteristic of alcoholism.


Vomiting blood (haematemesis) indicates bleeding from the oesophagus, stomach or duodenum. If the bleeding is brisk the vomit may be heavily bloodstained but if bleeding is slower or vomiting delayed, gastric acid reacts with haemoglobin, turning it a dark brown or ‘coffee-ground’ colour. If the bleeding is preceded by repeated bouts of retching or vomiting, consider as the cause



imageDifferential diagnosis: Gastrointestinal bleeding



































Cause Frequency (%)
Gastric ulcer 30
Duodenal ulcer 21
Gastritis or erosions 9
Oesophagitis or oesophageal ulcer 8
Duodenitis 4
Varices 3
Tumours 2
Mallory–Weiss tear 1
Others 22


imageEmergency: Assessment of patient presenting with haematemesis and melena



• Pulse rate

• Respiratory rate

• Recumbent blood pressure

• Evidence of postural hypotension and reduced capillary filling time

• Hydration (dry tongue, sunken eyes, reduced skin turgor)

• Pallor (caused by shock and peripheral vasoconstriction or anaemia)

• Urine output

• Stigmata of liver disease (flap, jaundice, spider naevi)

a Mallory–Weiss tear, which results from mechanical disruption of the mucosa at the gastro-oesophageal junction. Enquire about ingestion of alcohol or other gastric irritants (e.g. aspirin). If there is evidence of coincident liver disease, consider oesophageal varices to be the cause of bleeding. Weight loss may suggest bleeding from a gastric cancer, and a history of epigastric pain or heartburn suggests bleeding from a peptic ulcer or ulcerated oesophagus.



ABDOMINAL PAIN


When taking a history of abdominal pain, aim to distinguish between visceral, parietal and referred pain.




imageQuestions to ask: Abdominal pain



• Describe the position, character and radiation of the pain

• Has the pain been present for hours, days, weeks, months or years?

• Is the pain constant or intermittent?

• Have you noticed specific aggravating or relieving factors?

• Is the pain affected by eating or defecation?

• Does the pain awake you from sleep?

• Is there associated nausea or vomiting?

• Has there been associated weight loss?

• Is there a history of ulcerogenic drugs?

• Has there been a change in bowel habit?

Visceral pain is caused by stretching or inflammation of a hollow muscular organ (gut, gallbladder, bile duct, ureters, uterus). It is perceived near the midline, irrespective of the location of the organ (Fig. 7.1). Visceral pain may also radiate to specific sites and this helps to establish its origin (Fig. 7.2).


image

Fig. 7.1 Perception of visceral pain is localised to the epigastric, umbilical or suprapubic region according to the embryological origin of the diseased organ.


image

Fig. 7.2 Characteristic radiation of pain from the gallbladder, diaphragm and ureters. The pain is not always felt in the organ


Colic signifies obstruction of a hollow, muscular organ, such as the intestine, gallbladder, bile duct or ureter, and consists of recurring bouts of intense, cramping pain. When the smaller organs such as the gallbladder, bile duct or ureters are acutely obstructed by a stone, the cyclical nature of colic soon gives way to a continuous visceral pain caused by the inflammatory effect of the impacted stone or secondary infection. Movement does not aggravate visceral pain, so the patient may writhe or double up in response to it.


Pain arising from the parietal peritoneum is well localised to the area immediately overlying the area of inflammation or irritation. The patient lies as still as possible. Palpation over the area is extremely painful, with the overlying muscles contracting to protect the peritoneum (guarding). When the pressure of the examining hand is suddenly released, the pain is further aggravated and the patient winces. This sign is known as ‘rebound tenderness’.


Abdominal pain may progress from a visceral sensation to a parietal pain. Acute appendicitis provides an excellent example of this transition. When this midgut structure becomes inflamed and obstructed, a dull pain localises to the periumbilical area. As the inflammation moves to the parietal peritoneum, the pain appears to shift to the right iliac fossa, where it localises over McBurney’s point. The character of the pain also changes from dull to sharp. The area overlying the appendix is very tender and palpation causes reflex guarding and rebound tenderness.



MESENTERIC ANGINA


The collateral supply to the bowel is well developed and the pain of bowel ischaemia usually becomes apparent only on eating, when the metabolic demands of digestion require an increase in the blood supply. Patients complain of a severe visceral periumbilical pain occurring soon after meals (mesenteric angina). The pain causes anorexia, which results in considerable weight loss.



WIND


Excessive belching (flatulence) or the passage of wind through the anus (flatus) are common symptoms. These symptoms are rather unspecific and occur in both functional and organic disorders of the gastrointestinal tract.



CHANGE IN BOWEL HABIT



Constipation


Normal expectations vary between individuals and cultures; some healthy individuals evacuate every other day or even only three times a week, whereas others, particularly people on high roughage diets, expect up to three bulky bowel actions daily. Constipation is described more precisely as a disorder of bowel habit characterised by straining and the infrequent passage of small, hard stools. Patients often complain that they are left with a sense of incomplete evacuation (tenesmus).


When constipation presents as a recent change, and especially if it is associated with colic, suspect an organic cause such as malignancy or stricture formation. Enquire about constipating drugs (e.g. codeine-containing analgesics) and rectal bleeding, an alarm symptom that raises the suspicion of cancer. Consider hypothyroidism or electrolyte abnormalities. Anal pain caused by a fissure or a thrombosed pile may cause profound constipation because of the patient’s fear of pain at stool.


Constipation caused by chronic partial obstruction may be punctuated by periods of loose or watery stool. This ‘spurious diarrhoea’ occurs in elderly patients with faecal impaction and also when colon



imageDifferential diagnosis: Constipation



• Low-residue diet

• Motility disorder (functional bowel disease)

• Physical immobility

• Drugs (especially opiates and antidepressants)

• Depression and dementia

• Organic disease
– colon cancer

– diverticular stricture

– Crohn’s stricture

– hypothyroidism

– electrolyte imbalance

cancer causes a partial obstruction. The proximal bowel dilates and fills with liquid, which then seeps around the obstruction, presenting as liquid diarrhoea.



Diarrhoea


Diarrhoea implies increased stool volume and frequency and a change in consistency from formed to semiformed, semiliquid or liquid. Functional diarrhoea caused by anxiety, stress or the irritable bowel syndrome does not wake the patient from sleep. Recent travel abroad, eating out or an outbreak among people living in close proximity suggests an infective cause.


Enquire about colour; in fat malabsorption, the stool is pale, malodorous, poorly formed and difficult to flush. When a cause is not readily apparent, consider laxative abuse and recent broad-spectrum antibiotic treatment.




imageQuestions to ask: Diarrhoea



• What is the normal stool frequency?

• How many stools daily?

• How long have you had diarrhoea?

• Are you awoken from sleep to open the bowels?

• What is the colour and consistency of stools?

• Are blood and mucus present?

• Any travel abroad or contact with diarrhoea?

• Is there associated nausea, vomiting, weight loss or pain?

• Any purgative abuse?

• Any antibiotics?


Rectal bleeding


Bright-red rectal bleeding usually arises from the sigmoid colon or rectum and more proximal colonic bleeding is often a darker red or maroon colour. In haemorrhoidal bleeding the blood may be most noticeable on the toilet paper. Colon cancer and polyps often present with intermittent rectal bleeding, whereas patients with inflammatory bowel disease pass blood, often mixed with mucus, with each stool. Torrential haemorrhage may occur from diverticular disease and marked bleeding may occur in mesenteric vascular disease. Microscopic blood loss (occult bleeding) usually presents with symptoms of anaemia. Always consider a diagnosis of gastric, caecal or colon cancer in older patients with unexplained iron-deficiency anaemia.


The passage of sticky, black stools with the consistency of tar (melena) usually indicates bleeding from the oesophagus, stomach or duodenum. Treatment with iron and certain drugs (e.g. bismuth-containing preparations) also blackens the stool and must be distinguished from melena.



Liver disease


Liver cell damage and obstruction of the bile duct both have numerous clinical consequences, the most striking of which are jaundice, pale stools and darkening of the urine.


In patients with portal hypertension, portal blood bypasses the liver (portosystemic shunting), and the brain is exposed to gut-derived products which depress brain function, causing hepatic encephalopathy.


A further clinical consequence of portal hypertension is fluid retention in the abdominal cavity (ascites).



LIVER CELL DAMAGE


Symptoms of liver damage are not very specific and include malaise, fatigue, anorexia and nausea. Viral hepatitis is preceded by prodromes such as fatigue, nausea and a profound distaste for alcohol and cigarettes. Before the onset of jaundice the patient may notice darkening of the urine and lightening of stool colour.


Enquire about the principal causes of liver damage. Calculate the number of units (or grams) of alcohol consumed in a week. Ask about foreign travel, intravenous drug abuse or exposure to blood products, and establish the patient’s sexual orientation. Enquire about drugs that may cause liver damage and ask about a family history of liver disease.




imageRisk factors: Factors predisposing to hepatitis B



• Intravenous drug abuse

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on The abdomen

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