Introduction

The diagnosis of non-acute abdominal complaints is an important part of the general surgical clinic workload. Most patients with abdominal complaints can be managed as outpatients alone. Diagnoses made in a clinic are often quite different from those in emergency surgical admissions. Nevertheless, the surgeon in the clinic must remain alert to unfamiliar presentations which more usually present acutely, e.g. an appendix mass.

The principal presenting symptoms of non-acute abdominal disorders are shown in Box 18.1. In addition, patients are often referred to a surgeon after discovery of an abdominal mass, obstructive jaundice or an iron deficiency anaemia caused by chronic blood loss. As ever, the history can provide 70% or more of the clues to the diagnosis, and so must be taken thoughtfully, accurately and with great care.

Character, timing and site of the pain

Key points in taking a history of abdominal pain are summarised in Box 18.2. Pain is highly subjective and the description will be coloured by the patient’s perception of it and its possible significance. Patients often use vague terms such as ‘indigestion’ and ‘dyspepsia’; these terms are imprecise, so what the patient actually means should be clarified by further questioning. Time-related features of the pain are often highly significant in formulating a differential diagnosis but will only be elicited by diligent enquiry. It is important to establish when a pain first began. Sometimes, asking when the patient was last completely well helps pinpoint the real onset. When presenting a case history, say ‘the pain began 6 days ago’ rather than, say, ‘it began last Thursday’.

Patients describe pain in many different ways, and as each entity tends to have its own pattern, recognisable patterns only come to light if all aspects of the pain history are enquired into.

Diseases causing non-acute abdominal pain—typical patterns

Non-acute abdominal pain in children

This is common. The main organic causes are: ‘infantile colic’ (sometimes due to cow’s milk allergy), irritable bowel syndrome in older children, chronic inflammatory bowel disease, recurrent streptococcal infections, and sometimes hydronephrosis caused by urinary tract obstruction. The so-called ‘periodic syndrome’ is characterised by recurrent episodes of poorly defined and inconsistent abdominal pain and/or recurrent vomiting, sometimes sufficiently severe for the child to require admission and intravenous fluids. Abdominal migraine with or without nausea, pallor, photophobia and lasting for up to 3 days is most common in the years before puberty. Psychosomatic abdominal pain may be the explanation if organic causes have been excluded and thus psychological and environmental factors, including the possibility of child neglect and abuse, should be explored (see Table 51.2).

Approach to investigation of non-acute abdominal pain

A differential diagnosis must first be made on clinical grounds (Box 18.3 and Fig. 18.1). The choice (and order) of investigations should be efficient and economical, after considering how each will support or help eliminate the most probable (and common) diagnoses and how it might influence management.

Clinical presentation

Dysphagia is the term for difficulty in swallowing. The most common complaint is inability to swallow solids, which the patient describes as ‘becoming stuck’ or ‘held up’ before it passes into the stomach or is regurgitated. Fibrous foods such as chunks of meat, usually cause the most trouble. The patient can usually indicate a precise level for the perceived obstruction. The true level of obstruction is usually some distance below that point.

Dysphagia is almost always caused by disease in or near the oesophagus but occasionally the lesion is in the pharynx or stomach. Oesophageal narrowing usually causes symptoms only when the lumen is unable to expand beyond about 10 mm—the narrower the lumen, the more severe the symptoms. In many pathological conditions causing dysphagia, the lumen becomes progressively constricted and indistensible. Initially only fibrous solids cause difficulty but later this extends to all solids and later, even to fluids. Because narrowing is a gradual and insidious process, patients often compensate to a surprising degree (e.g. by liquidising all food) and may only present when they have difficulty swallowing fluids or even their own saliva. By this time there is usually marked weight loss.

The common causes of dysphagia are outlined in Box 18.4, p. 252. Pain on swallowing or odynophagia (usually provoked by both food and drink, particularly if hot) is a distinctive symptom highly suspicious of carcinoma.

Achalasia is an exception to the usual pattern of dysphagia, in that swallowing fluids causes more difficulty than solids. In achalasia, there is idiopathic destruction of the parasympathetic ganglia in Auerbach’s (submucosal) plexus of the entire oesophagus, which results in functional narrowing of the lower oesophagus and peristaltic failure throughout its length. Thus the oesophagus becomes markedly distended and dilated, with solids settling towards the lower end and fluids spilling over into the airways causing spluttering dysphagia, particularly when the patient is lying flat. Achalasia often presents with chronic chest infection rather than dysphagia and the diagnosis is often reached late. Similar overspill symptoms can be caused by bulbar palsy, most commonly after a stroke.

Bolus obstruction is an acute form of dysphagia, where a lump of food sticks at a narrowed part, completely obstructing the oesophagus.

Approach to investigation of dysphagia

Dysphagia, particularly of recent onset, must be regarded seriously and fully investigated. A plain chest X-ray should be taken to exclude bronchial carcinoma; occasionally an oesophageal fluid level behind the heart is seen, resulting from an oesophageal stricture, hiatus hernia or achalasia. In high dysphagia, flexible pharyngoscopy followed by a barium swallow and meal is the usual sequence of investigation. In lower dysphagia, flexible endoscopy (OGD) is usually performed, as this allows direct inspection and biopsy; however, contrast radiography can be helpful. In disorders of function, swallowing barium-soaked bread or a video record of a barium swallow may be diagnostic. Oesophageal physiology measurements using manometry and pH monitoring are helpful in reaching a diagnosis of achalasia, especially in its early stages.

• Intra-abdominal malignancies, e.g. carcinoma of stomach or pancreas, metastatic disease in the liver or widespread across the peritoneal cavity (arising particularly from stomach, large bowel, ovary, breast or bronchus), bowel lymphomas

• ‘Medical’ conditions, e.g. alcoholism and cirrhosis, viral diseases (e.g. hepatitis or infectious mononucleosis), uncontrolled diabetes or thyrotoxicosis, malabsorption, renal failure, cardiac cachexia

• Psychological disorders, e.g. anxiety, depression, anorexia nervosa, bulimia

• Chronic visceral ischaemia, a very uncommon condition resulting from atherosclerotic narrowing of at least two of the three main visceral arteries—the coeliac axis and the superior mesenteric and the inferior mesenteric arteries—resulting in ‘fear of food’ and massive weight loss

Approach to investigation of weight loss, anorexia and associated symptoms

There may be other clinical clues to the main diagnosis or to suggest a line of investigation, e.g. pain, signs of anaemia or jaundice, or a palpable abdominal or rectal mass. More difficult are cases where the symptoms occur alone. In that situation, basic screening investigations (full blood count and erythrocyte sedimentation rate, urea and electrolytes, liver function tests and urinalysis) begin to differentiate ‘medical’ conditions from ‘surgical’ ones. If these screening tests fail to produce a lead, abdominal imaging using ultrasound or CT scanning may be indicated to exclude liver metastases or occult intra-abdominal malignancy.

If investigations still reveal no cause, positive evidence of psychiatric disturbance should be sought. In practice, by this stage, previously concealed psychiatric features often become apparent, but except for anorexia nervosa or bulimia, these are rare.