Chapter 7 Abdomen and gut problems
7.1 Introduction
History — analysis of abdominal pain
Abdominal pain is the most common presenting symptom of surgical diseases of the gastrointestinal tract. It is usually categorised by its site and mode of onset, for example, chronic epigastric pain or acute right iliac fossa pain. Analysis of abdominal pain lends itself very well to the principles of problem solving. The patient is encouraged to describe the pain in their own terms. Specific questions are interpolated to clarify and elaborate particular points and to detect the most significant symptoms. Abdominal pain is often accompanied by associated symptoms that establish a pattern and assist the clinician in making a diagnosis. Precise localisation of the pain is the most useful step in its characterisation. Although visceral pain is less precisely localised than somatic pain, in most cases the pain can be localised to an abdominal area or region: upper, lower, right, left, central or generalised. Of almost equal importance to site is the mode of onset of the pain — whether acute or chronic. For pain in each abdominal region, a limited and manageable list of common causes exists — some specific to the area and some not. With these causes in mind a careful history is taken and physical examination performed focusing on the identification of the most likely cause. A general systems review is always important in the analysis of abdominal pain, particularly in relation to the gynaecological and urinary systems. Disorders of other systems (such as diabetes) sometimes present solely with abdominal pain or in themselves need attention and may have a bearing upon prognosis.
Location and migration
Whether abdominal pain is generalised or localised to an abdominal segment is the most important piece of information to obtain first. Migration of abdominal pain also often assists in diagnosis (Fig 7.1). Central or generalised abdominal pain is a common initial symptom of many diseases (appendicitis, bowel obstruction, visceral perforation). Persisting severe generalised abdominal pain suggests generalised peritonitis. Epigastric or right upper quadrant pain extending in a band around the abdomen suggests a biliary origin (‘colic’). Migration of central pain to the right iliac fossa over the course of several hours indicates appendicitis. This is an example of visceral pain evolving into a somatic pattern as local peritonitis develops with pathological progression of appendicitis. Another example of this phenomenon is migration of pain from the left iliac fossa to the whole abdomen may be associated with initial sigmoid diverticulitis with subsequent perforation and the development of generalised peritonitis.
Onset and duration
The time, pattern and character of onset and the duration of symptoms are elicited. Acute abdominal pain that persists for six or more hours suggests the presence of a surgical abdomen; so does a history of awakening at night with the pain, especially if pain precedes other symptoms such as vomiting or diarrhoea. A sudden and dramatic onset of pain suggests rupture of a previously intact structure (e.g. duodenum, colonic diverticulum, splenic capsule, aortic aneurysm). A gradual onset, progressively worsening over hours or days, correlates with inflammation. The onset after excessive alcohol intake suggests pancreatitis. A history of abdominal injury may be of importance. A latent period can exist between the time of trauma and presentation, as is seen with delayed rupture of the spleen. A latent period can also be seen in other acute abdominal conditions such as perforated peptic ulcer, intussusception, large bowel obstruction, gallstone ileus and intestinal infarction. Sometimes such a latent period gives the illusion of resolution of the problem and can delay or obscure diagnosis.
Associated symptoms
Nausea, vomiting and anorexia often precede pain of non-surgical origin: profuse vomiting as a main feature suggests upper small bowel obstruction; persistent anorexia following pain favours an organic cause; persistent vomiting from any cause can occasionally give haematemesis from a Mallory-Weiss tear in the lower oesophagus.
Physical examination
A general inspection of the patient should include a careful assessment of alertness, demeanour and hygiene. This is an ideal opportunity to identify features of chronic liver disease such as the presence of jaundice, pallor, bruising or purpura, pigmentation and loss of body hair (Fig 7.2). A record of the patient’s nutritional state should note whether body habitus is normal, obesity levels (or morbid obesity), whether there is loss of body mass and cachexia or evidence of fluid and electrolyte depletion. The preferred posture of the patient should be noted (e.g. sitting forward in acute pancreatitis, or supine and still in peritonitis.)
Examination of the periphery
The hands are examined. Nail changes include clubbing, which may be found in a number of gastrointestinal conditions, chronic liver disease, inflammatory bowel disease and malabsorption. Other changes such as leuconychia, indicating malnutrition and hypoproteinaemia, or koilonychia, suggesting iron deficiency, may be present. Palmar erythema, spider naevi and Dupuytren’s disease (palmar nodules, bands, contractures, pits and sinuses and knuckle pads) suggest alcoholic liver disease (Fig 7.2). Asterixis is a flapping tremor best seen with the hands in extension and is found in patients with portal systemic encephalopathy.
Abdominal examination
Figures 7.3 and 7.4 depict anterior and posterior surface markings of the abdominal viscera.
After inspection, the patient is asked if there is any tenderness and, if there is, its site. Palpation is started gently with the hand flat, at a site away from the site of maximal tenderness and then in all quadrants (Fig 7.5).
Then the abdomen is palpated more deeply using the flexor surface of the fingers — the use of two hands often helps to define masses (Fig 7.6).
The hernial orifices and genitalia are examined. It is important to distinguish normally palpable structures from abnormal masses (Fig 7.7).
Routine examination for ascites is essential in the distended abdomen, by eliciting shifting dullness or a fluid thrill. Shifting dullness is shown to be present by rotating the patient about the long axis and demonstrating a change in the ‘Plimsoll line’ or transition line of dullness to percussion (Fig 7.8). Fluid thrill is detected by flicking the side of the abdomen and palpating for a transmitted impulse on the other side. Transmission of the impulse via the abdominal wall is blocked by another hand placed on the midabdomen.
The following physical signs are sought: tenderness or resistance on palpation (voluntary or involuntary guarding); rigidity (extreme guarding); and rebound tenderness (best assessed by gentle percussion). A full description of any detected mass is often most usefully recorded as a simple schematic sketch in the medical record. The edge of a mass may be best delineated by deep palpation during inspiration (liver and spleen) or by percussion (Table 7.1). The site and depth of a mass are very important diagnostic features. Other important features include shape and consistency and whether the mass is mobile or fixed. Faecal masses are indentable.
Anorectal examination
Initial inspection may reveal prolapsed haemorrhoids, perianal haematomas, external openings of fistulas and the dry or moist skin changes of pruritus. Examination of the anus during straining will be necessary to reveal prolapsing haemorrhoids or rectal prolapse. Anal fissures are normally not initially obvious on inspection, as they are located above the anal verge. Most fissures are seen in the midline posteriorly. Laterally placed fissures suggest an association with inflammatory bowel disease. Gentle retraction of the anal verge will usually expose the lower edge of a posterior fissure. Rectal examination (Fig 7.10) and proctoscopy may not be possible in such instances because of painful anal spasm. Palpation commences using the pulp of the index finger introduced slowly into the anorectum. The finger will usually reach 10 cm with a little pressure on the perineum or with the assistance of bimanual compression of the lower abdomen. As the finger is withdrawn the whole circumference of the rectum is examined. The indurated, elevated and ulcerated lesion of a carcinoma is characteristic. The capacity of the rectum should be noted. Masses outside the rectum in the pouch of Douglas may be palpable anteriorly. Anteriorly in the male the normal prostate is a firm rubbery bilobed structure about 3 cm in diameter. A shallow central sulcus may be palpated and the mucosa over the prostate should be freely mobile. In the male it is difficult to define anatomical structures above the base of the prostate. The prostate feels larger on examination if performed while the patient has a full bladder. In the female the cervix of the uterus or a vaginal tampon may be palpable anteriorly and should not be mistaken for a mobile extrarectal tumour. Faecal pellets in an intrapelvic sigmoid colon can simulate abnormal extrarectal lumps but faeces are regular and indentable. The glove should be examined for blood after completion of the digital examination.
7.2 ‘Acute abdomen’ (acute abdominal surgical emergency)
The timing of urgent surgery is also important; there must be adequate resuscitation but no undue delay before surgery. Early evaluation of the patient for signs of hypovolaemia and fluid depletion is therefore essential. The timing of surgery depends upon the response to resuscitation. As resuscitation begins, plans are made for any investigations required prior to surgery.
History and physical examination
A routine for physical examination in assessing the acute abdomen is as follows:
1. Acute appendicitis with perforation (see also acute right iliac fossa pain)
Perforation, with presentation as an acute abdomen, is seen most frequently in the young, the old and in patients with diabetes. In many series, perforation at the time of appendicectomy has occurred in almost half those patients under 10 years and over 50 years. It is unusual for the acutely inflamed appendix to perforate within the first 12 hours. Pain in appendicitis is often initially central and diffuse, followed by a shift to the right iliac fossa within a few hours. Pain is deep-seated, continuous and gradually increases in intensity. Nausea and vomiting are common, but vomiting is rarely pronounced or persistent and is rarely the first symptom. Diarrhoea is also rarely the first symptom (Table 7.2). Its presence suggests pelvic appendicitis. The development of perforation is accompanied by more severe generalised abdominal pain and higher fever.
Perforated pelvic appendicitis | Gastroenteritis | |
---|---|---|
Progress | Steady deterioration | Usually nonprogressive |
Pattern | Insidious onset of pain; later development of diarrhoea and tenesmus | Sudden onset of anorexia, nausea, vomiting and diarrhoea before pain |
Associated upper respiratory tract infection (URTI) | No | URTI common with myalgia, photophobia and headache |
Movement | Exacerbates pain | Writhing with spasms of pain |
Abdominal signs | Often minimal early in the disease | Diffuse tenderness |
PR examination | Tenderness and fullness in pouch of Douglas | Normal rectal examination |
WCC | Leucocytosis | No leucocytosis |
2. Severe acute (haemorrhagic) pancreatitis
A small but important proportion of patients with severe acute pancreatitis present with an acute abdomen. The remaining patients with less severe disease present with localised acute upper abdominal pain (Ch 7.3). The most severe haemorrhagic form of the disease is associated with collapse and shock.
The onset of symptoms is occasionally explosive and can mimic a visceral perforation. Usually, however, increasingly severe pain develops over a period of several hours and spreads from the epigastrium throughout the whole abdomen and through to the back. Progressive dyspnoea and prostration (shock) are common. Persistent vomiting is often a feature of the illness (Table 7.3). Change of posture may aggravate or relieve the pain. Fever is variable.
Perforated ulcer | Acute pancreatitis | |
---|---|---|
Age and sex | Middle-aged males | Younger males |
Pain and peritonitis | Severe pain and board-like ridigity | Severe pain, less marked guarding, marked release tenderness |
Vomiting | Repeated vomiting uncommon | Vomiting common and persistent |
Dyspnoea and cyanosis | Uncommon | Common |
Abdominal distension | Scaphoid abdomen | Mild distension common |
Mass | Uncommon | Epigastric mass common |
Prostration and shock, dyspnoea, ventilatory insufficiency and cyanosis indicate a severe attack with poorer prognosis. Extraperitoneal fluid and blood extravasation may be indicated by staining in the flanks (Grey-Turner’s sign) or around the umbilicus (Cullen’s sign).These signs are typically delayed in onset and may not be present at the initial presentation. The common predisposing causes of severe pancreatitis are gallstones and alcohol. In alcoholic pancreatitis the patient may be agitated and confused, indicating imminent delirium tremens.
3. Perforated peptic ulcer
Signs. The clinical signs are usually unmistakable. Generalised peritonitis is present, with board-like rigidity in the epigastrium and elsewhere. The term is very appropriate and, once felt, is difficult to confuse with anything else. The abdomen is silent and loss of liver dullness to percussion may be elicited. Pulse, temperature and blood pressure are all likely to be normal. Shock does not develop until a late stage. The delayed ‘stage of reaction’ or of ‘masked’ peritonitis takes several hours to develop. This should not confuse the careful observer, as rigidity and ileus persist. More difficulty is found with a localised duodenal leak when the history is less typical and the abdominal signs are restricted to local tenderness in the upper abdomen (Ch 7.3).
5. Strangulating intestinal obstruction
Signs. Although certain clinical features can create a suspicion that strangulation is present (Box 7.1), no clinical or laboratory findings exist that exclude with certainty the possibility of strangulation. In small bowel obstruction the bowel sounds are hyperactive. Signs of local peritonitis and a palpable mass strongly suggest strangulation. A strangulated external hernia (femoral, inguinal, umbilical or incisional) will be tense, tender, irreducible and will have lost the cough impulse. Always search for a hernia, even in the patient who has had previous abdominal operations. Signs of interstitial fluid and blood volume depletion will be present when bowel obstruction has persisted for one or more days. Early shock or poor response to resuscitation suggests the presence of strangulation.
In large bowel obstruction, distension is particularly marked in the flanks and in the right iliac fossa. Signs of fluid depletion are late. The distension is predominantly gaseous and signs of shock or peritonitis suggest that perforation has occurred. Careful sigmoidoscopy may reveal the cause of the obstruction.
9. Less common causes
The pain of renal infection can mimic an acute abdomen. Associated urinary frequency, dysuria and pyuria usually suggest the diagnosis. Rupture of an inferior epigastric vessel may be associated or follow treatment with oral anticoagulants. Rectus sheath haematoma may be spontaneous or precipitated by minor trauma and can mimic an acute abdomen or appendicitis. Similarly, ‘spontaneous’ retroperitoneal haematoma can occur in anticoagulated patients and present with lateralised abdominal or flank pain.
Diagnostic plan
Imaging techniques
These include plain radiology, ultrasound, contrast and computed tomography (CT scan) and are very often valuable. Erect chest X-ray (Fig 7.11), together with erect and supine films of the abdomen, are indicated in nearly all patients. (For patients too moribund to undergo an erect chest X-ray, a lateral decubitus film may be requested.) These X-rays may show primary chest pathology (pneumonia) or basal changes secondary to a subdiaphragmatic condition such as pancreatitis. Free gas under the diaphragm indicates a perforated viscus, usually a perforated ulcer or perforated diverticulitis. A grossly dilated stomach may be seen in patients in diabetic coma, falsely suggesting the possibility of a surgical condition.
If small bowel obstruction is suspected, erect and supine views show significant distension of the small bowel with gas fluid levels and a ladder pattern (Fig 7.12). In large bowel obstruction, the colon is distended down to the site of obstruction and small bowel dilatation may coexist. If the ileocaecal valve is incompetent specific causes such as sigmoid or caecal volvulus may show localised distended large bowel loops. Gastroenteritis can be associated with small gas–fluid levels with moderate intestinal distension. Air swallowing in association with severe pain and recent injury may cause confusion. The absence of free gas does not exclude perforated viscus, nor does the absence of fluid levels in the bowel exclude strangulation. Free gas is seen in only about two-thirds of cases of perforated peptic ulcer. In appendicitis, distended bowel with fluid levels on plain X-ray often indicates a localised ileus in the right iliac fossa. Pancreatic calcification or lithiasis or a sentinel small bowel loop in the region of the pancreas or a colonic ‘cut-off’ sign may be seen in pancreatitis. More commonly, generalised ileus is present, with evidence of ascites. Distended, gas-filled, small and large bowel loops with fluid levels are present and large bowel gas extends to the rectum. Mesenteric infarction causes a diffuse small bowel ileus. In ruptured aortic aneurysm a rim of calcium may be seen in the aneurysm, particularly in the lateral decubitus films. Radio-opaque gallstones may be seen in cholecystitis (20%); urinary calculi are usually visible (80%).
Catheter angiography is rarely required, apart from the context of mesenteric vascular insufficiency.