Abdomen and gut problems

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Chapter 7 Abdomen and gut problems

Alan Saunder, Ken Farrell

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.

Type and intensity

The character of the pain is subjective. Patients often relate pain to previous or imagined occurrences (‘stabbed by a knife’, ‘struck by lightning’, ‘burning’). It is important to establish whether the pain has been constant and unremitting since onset or is periodic. If periodic, is it a true colic? Colic causes a spasmodic, gripping abdominal pain that returns every few minutes with a crescendo rise and fall in intensity often described by women as similar to labour pains. Colic associated with an urge to defaecate or pass flatus and with abdominal borborygmi is pathognomonic of intestinal colic due to obstruction or irritation. The colicky pain of obstruction is usually more severe than is found with gastroenteritis. Severe colicky pain that becomes constant suggests ischaemic bowel. Constant pain often varies in severity during the course of the illness, but careful questioning will distinguish this from a true colic. The need for narcotics to control upper abdominal pain is suggestive of renal or biliary pain. Severe pain persisting without relief requires hospital admission.

Severity is also subjective and best assessed by the effect of pain on the patient, the response to the suggestion that an operation may be necessary and the necessity for and whether relief from analgesics already administered has occurred. Inability to sleep because of pain suggests a surgical problem.

Severe unremitting pain may be due to localised peritonitis because of appendicitis, cholecystitis or diverticulitis, or due to widespread peritonitis from visceral rupture or mesenteric ischemia. Biliary pain tends to plateau, after a gradual onset; it is continuous but fluctuates in severity. Acute renal pain is a very severe and constant pain. Neither is a true colic.

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.)

In the emergency and urgent situations, the abdomen is assessed prior to the periphery. However, in the elective ambulatory situation, the periphery is often examined initially to gain both vital information and the confidence of the patient before examining the abdomen.

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.

The head and neck are then examined for abnormal pigmentation, spider naevi, xanthelasma of the eyelids, scleral jaundice or pallor and parotid enlargement. The neck is examined for cervical lymphadenopathy, especially left supraclavicular nodal enlargement (Troisier’s sign) as a sign of metastatic node involvement from carcinoma of the stomach.

The mouth is then examined for the smell of fetor hepaticus suggesting encephalopathy, mucosal thickening and ulceration, atrophy or erythema, gingivitis and angular stomatitis. A ketotic breath and coated tongue is suggestive of appendicitis or related conditions. Angular stomatitis (‘perlèche’) is seen frequently in patients with iron deficiency and malnutrition. Glossitis occurs in patients with iron, folate and vitamin B12 deficiency. Mouth ulceration may be present. The hydration status (i.e. skin turgor and moistness of mucous membranes) should be assessed at this time, especially in the acute setting.

Abdominal examination

The patient lies supine with arms by the side and with groin and hernial orifices exposed. The examination should be performed in a good light. The abdomen is inspected for abnormal contour, either distension or scaphoid appearance, for generalised or localised distension, for scars, discolouration, pigmentation or striae, for distended veins radiating from the umbilicus (caput medusae) and for visible pulsations or peristalsis. The patient is then asked to breathe deeply in and out through the mouth, to see if the contour changes or if a mass moves or becomes more obvious and to see if respiratory movement is painful. The patient is asked to cough and scars and the hernial orifices are watched to detect an expansile impulse. The patient is asked to lift the legs or shoulders from the bed and similar observations are made for an impulse. With this manoeuvre a visible mass, if subcutaneous, will become more prominent, an intra-abdominal mass less so.

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

Anorectal examination is usually performed on patients in the left lateral position if there are appropriate symptoms requiring this to assess the clinical problem. It is not required as part of all abdominal examinations. The spine and hips are fully flexed; the knees are flexed to a little less than 90° to obtain better access for sigmoidoscopy. The equipment required is a good light, examination gloves, lubricating jelly and paper tissues to clean the anus after examination. Proctoscopy (anoscopy) and sigmoidoscopy (rectoscopy) should be part of a routine office or outpatient examination by appropriately trained practitioners. The proctoscope permits visualisation of the anal canal up to 10 cm; the standard rigid sigmoidoscope up to 30 cm. The flexible sigmoidoscope is a specialist instrument, visualising up to 50 cm from the anal verge. Long biopsy forceps are also necessary should sampling for histology be necessary. Neither form of sigmoidoscopy is part of a standard non-specialist examination. Bowel preparation is not usually necessary for routine 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.

Proctoscopy is the best method of diagnosing haemorrhoids, as these lesions are impalpable on digital examination unless thrombosed. Proctoscopy also provides a means of close viewing of tumours in the lower third of the rectum for biopsy and for the office treatment of haemorrhoids.

7.2 ‘Acute abdomen’ (acute abdominal surgical emergency)

The ‘acute abdomen’ is difficult to define but vital to recognise. The essential task is to recognise that an acute abdominal emergency exists and that surgery, when necessary, must not be delayed. Patients present with various combinations of pain, collapse, shock and peritonitis, but not all of these clinical features are present in each patient. Severe pain is the most striking symptom and is often generalised. Less severe forms of acute abdominal pain where more time exists to make a diagnosis are characterised by their localisation and are discussed under separate headings (acute upper abdominal pain, acute right iliac fossa pain). The requirement for the patient with an acute abdomen is usually to ‘operate and see’ rather than ‘wait and see’. Some will prove on exploration to have non-surgical conditions, but this price is necessary in the interests of survival.

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

The most vital concern is to identify those patients with a diagnosis requiring abdominal operation from those whose treatment is non-surgical while measures to resuscitate the patient are in progress. Pain usually precedes anorexia and vomiting in surgical conditions but often follows them in non-surgical conditions. Efforts should be taken to make and record a presumptive specific diagnosis in each case. A careful history and examination, and the grouping of symptoms into recognised clinical syndromes and patterns, enable a correct diagnosis to be made in a high proportion of cases.

The symptoms and signs associated with abdominal pain need careful analysis. These include nausea and vomiting, abdominal distension, change in bowel habit, peritonitis, pyrexia and prostration (shock).

Commonly, a typical association of symptoms and signs gives an early clue to the diagnosis. For example:

The integration of salient features of the history with examination findings will often disclose the clinical pattern or characteristics of a particular surgical condition or, at the very least, allow the formulation of a well-ordered differential diagnosis. Therefore, particular attention must be given to abdominal examination; the care with which the examination is performed often clinches the diagnosis. Systematic examination detects associated medical problems and evaluates circulatory status. The presence of fever suggests infection or aseptic inflammation and narrows down the diagnostic possibilities, as do signs of shock early in the illness.

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.

Table 7.2 Comparison of clinical features of perforated pelvic appendicitis and gastroenteritis

  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

Signs. With general peritonitis, there is diffuse abdominal tenderness with guarding, which is often maximal in the right iliac fossa. The degree of guarding depends upon the rapidity of onset of the peritonitis. Bowel sounds often persist for some time. If untreated the abdomen becomes silent and progressively distends, with diminution of tenderness as exudate accumulates. High fever, toxicity and eventually septic shock develop. A tender local mass may be felt in the right iliac fossa suggesting abscess formation. In such a case the patient is usually toxic and febrile due to irritation of the rectum. In pelvic appendicitis, abdominal signs are often delayed or less marked but rectal examination may reveal the presence of pelvic tenderness and peritonitis.

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.

Table 7.3 Comparison of perforated duodenal ulcer with acute pancreatitis

  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

Signs. Signs of generalised peritonitis are present. There is often a ‘doughy’ feel to the abdomen and the signs of peritonitis and muscle rigidity are less than one would expect from the severity of the pain and the degree of prostration (an important point of differentiation from perforated ulcer). Disparity between the signs of peritonitis and the severity of pain is sometimes a feature of bowel ischaemia.

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.

5. Strangulating intestinal obstruction

Simple intestinal obstruction is usually readily diagnosed on clinical assessment and a plain X-ray film of the abdomen and is discussed in more detail in Chapter 7.9. Strangulating obstruction is a complication of simple obstruction; it can be notoriously difficult to diagnose and is lethal without prompt surgery. In simple small bowel obstruction the abdominal pain is colicky and periumbilical. If the pain becomes continuous, strangulation should be suspected.

Obstruction with ischaemia or strangulation is also seen in the large bowel. In an important minority of patients with malignant large bowel obstruction, the ileocaecal valve is competent and prevents regurgitation into the small bowel and decompression of the large bowel so that a ‘closed loop’ obstruction develops. The main danger is then progressive distension and perforation of the caecum. Such patients may present with right-sided pain and tenderness with distension and will require urgent surgical treatment to prevent caecal perforation and the consequent faecal peritonitis. Sigmoid or caecal volvulus is of more abrupt onset with severe constant pain due to early ischaemia and rapid massive distension and imminent perforation.

In malignant large bowel obstruction, a history of altered bowel habit often precedes complete constipation for faeces and flatus. This is often due to left-sided colonic stenotic lesions. Pain is often late and is felt in the lower abdomen or back. Nausea is common, but vomiting is generally a late feature.

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.

6. Vascular catastrophes

Ruptured aortic aneurysm usually presents in elderly men with the sudden onset of central abdominal pain radiating to the back and/or groin, associated with collapse, pallor and severe shock. There may be previous knowledge of a pulsatile abdominal swelling. The patient with ruptured aortic aneurysm is pale and sweating with collapsed veins, the signs of haemorrhagic shock. The majority of patients have ‘contained retroperitoneal haematoma’ rather than a free intraperitoneal rupture. A poorly defined pulsatile upper abdominal swelling is present in the epigastrium to the left of the midline. Femoral pulses may be weak or absent, but this is not diagnostic. Ruptured visceral artery aneurysms should be considered as well in patients with hypotension and severe sudden upper abdominal pain.

Aortic dissection presents with sudden severe tearing pain felt in the interscapular region or lower chest, radiating to the back and abdomen. Signs of distal vascular insufficiency in the limbs with absent or diminished peripheral pulses may be present, depending on the anatomy of the dissection, with possible anuria and with mild general abdominal tenderness. The patient is not always elderly in contrast to most patients with ruptured abdominal aortic aneurysms.

Acute mesenteric ischemia is typified by the presence of generalised severe, continuous abdominal pain of sudden with surprisingly few abdominal signs initially. The development of peritonism and mental confusion, associated with gross prostration and often dark rectal bleeding is usually associated with a grave outcome. Often evidence of an underlying embolic focus exists — such as atrial fibrillation or a recent myocardial infarct. The triad of pain, rectal bleeding and prostration in an elderly patient with fibrillation is suggestive of the diagnosis.

9. Less common causes

Primary peritonitis is now mainly found in association with alcoholic liver disease and ascites and can lead to a ‘negative’ laparotomy or laparoscopy. Foreign body perforation is not rare and may be difficult to locate at laparotomy. Periodic peritonitis (familial Mediterranean fever), gonococcal peritonitis, tuberculous peritonitis and granulomatous peritonitis, are other causes to be considered in the differential diagnosis of the acute abdomen. Complications of inflammatory bowel disease need to be considered.

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.

Medical conditions do not usually simulate an acute abdomen to the degree where surgical intervention is necessary. Basal pneumonia, however, can present difficulties. In these patients respiratory signs may be minimal, although respiratory distress is often the clue that suggests the diagnosis. Myocardial infarction is rarely a cause of an acute abdomen, but the initial pain may be in the epigastric region. Acute painful hepatic engorgement secondary to acute right ventricular failure may give rise to diagnostic confusion such as occurs in large pulmonary embolism. Acute porphyria, precipitated by barbiturates and diabetic ketosis with abdominal pain and vomiting, are occasionally problems in diagnosis, especially when associated with collapse and a confused mental state.

Diagnostic plan

Always aim to have a differential diagnosis. The list of probable to possible diagnoses dictates the investigation and management plan. Selected judiciously ordered investigations can confirm or exclude specific diagnoses, thereby allowing a logical management plan to be devised.

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%).

Contrast-enhanced X-rays may be required in special instances to diagnose bowel leakage. A gastrografin meal or enema will not damage the peritoneum and can be very useful, especially if combined with a CT scan at the same time. A limited contrast enema is often used to confirm the diagnosis and the site of a large bowel obstruction prior to operation.

Ultrasound is the investigation of first choice in the diagnosis of gallstones and hepatobiliary conditions.

Aortic aneurysms are readily diagnosed with ultrasound and CT angiography may be useful in diagnosis of ruptured aortic aneurysm or dissecting aneurysm if the diagnosis is not clear, the patient is stable and renal function known to be satisfactory. When a focus of infection is suspected, CT scan with oral contrast can both facilitate the diagnosis and direct interventional or surgical treatment. Ascites may be seen in pancreatitis — aspiration and amylase level on the fluid may be diagnostic.

Catheter angiography is rarely required, apart from the context of mesenteric vascular insufficiency.