Macleod's Clinical Examination PDF, 15th Edition 2024

108 THE GASTROINTESTINAL SYSTEM Dyspepsia candidiasis. It implies intact mucosal sensation, making oeso- Dyspepsia is pain or discomfort centred in the upper abdomen. phageal cancer unlikely. In contrast...

108 THE GASTROINTESTINAL SYSTEM Dyspepsia candidiasis. It implies intact mucosal sensation, making oeso- Dyspepsia is pain or discomfort centred in the upper abdomen. phageal cancer unlikely. In contrast, ‘indigestion’ is a term commonly used by patients for Abdominal pain ill-defined symptoms from the upper gastrointestinal tract. Characterise the pain using the acronym SOCRATES (see Ask about: Box 2.2). Ask about the characteristics described here. site of pain character of pain Site exacerbating and relieving factors, such as food and antacid Visceral abdominal pain from distension of hollow organs, associated symptoms, such as nausea, belching, bloating mesenteric traction or excessive smooth-muscle contraction is and premature fullness (early satiety). deep and poorly localised in the midline. The pain is conducted Clusters of symptoms are used to classify dyspepsia: via sympathetic splanchnic nerves. Somatic pain from the pari- etal peritoneum and abdominal wall is lateralised and localised to reflux-like dyspepsia (heartburn-predominant dyspepsia) the inflamed area. It is conducted via intercostal nerves. ulcer-like dyspepsia (epigastric pain relieved by food or Pain arising from foregut structures (stomach, pancreas, liver antacids) and biliary system) is localised above the umbilicus (Fig. 6.4). dysmotility-like dyspepsia (nausea, belching, bloating and Central abdominal pain arises from midgut structures, such as premature fullness (early satiety). the small bowel and appendix. Lower abdominal pain arises from Often there is no structural cause and the dyspepsia is func- hindgut structures, such as the colon. Inflammation may cause tional. Patients below the age of 55 without alarm symptoms and localised pain: for example, left iliac fossa pain due to diverticular with a negative Helicobacter pylori test can be positively diag- disease of the sigmoid colon. nosed as having functional dyspepsia thus avoiding unnecessary Pain from an unpaired structure, such as the pancreas, is investigations but if symptoms persist then further investigations midline and radiates through to the back. Pain from paired should be considered. However, in patients over the age of 55 structures, such as renal colic, is felt on, and radiates to, the organic pathology should always be excluded by upper gastro- affected side (Fig. 6.5). Torsion of the testis may present with intestinal (GI) endoscopy. abdominal pain (p. 267). In females, consider gynaecological Dyspepsia that is worse with an empty stomach and eased by causes such as ruptured ovarian cyst, pelvic inflammatory dis- eating is typical of peptic ulceration. The patient may indicate a ease, endometriosis or ectopic pregnancy (p. 247). single localised point in the epigastrium (pointing sign) and complain of nausea and abdominal fullness that is worse after Onset fatty or spicy meals. ‘Fat intolerance’ is common with all causes Sudden onset of severe abdominal pain, rapidly progressing to of dyspepsia, including gallbladder disease. become generalised and constant, suggests a hollow viscus perforation (usually due to peptic ulceration, diverticular disease Odynophagia or colorectal cancer), a ruptured abdominal aortic aneurysm or Odynophagia is pain from swallowing, often precipitated by mesenteric infarction. drinking hot liquids. It can be present with or without dysphagia Torsion of the caecum or sigmoid colon (volvulus) presents (see below) and may indicate oesophageal ulceration or oeso- with sudden abdominal pain associated with acute intestinal phagitis from gastro-oesophageal reflux or oesophageal obstruction. Foregut – pain localises to epigastric area Midgut – pain localises to periumbilical area Hindgut – pain localises to suprapubic area Fig. 6.4 Abdominal pain. Perception of visceral pain is localised to the epigastric, umbilical or suprapubic region, according to the embryological origin of the affected organ.  The history 109 Character Colicky pain lasts for a short time (seconds or minutes), eases off and then returns. It arises from hollow structures, as in small or Right shoulder large bowel obstruction, or the uterus during labour. Biliary and renal ‘colic’ are misnamed, as the pain is rarely Diaphragm colicky; pain rapidly increases to a peak and persists over several hours before gradually resolving. Dull, constant, vague and Tip of scapula poorly localised pain is more typical of an inflammatory process or infection, such as pelvic inflammatory disease, appendicitis or diverticulitis (Box 6.2). 6 Radiation Gallbladder Pain radiating from the right hypochondrium to the shoulder or interscapular region may reflect diaphragmatic irritation, as in Ureter acute cholecystitis (Fig. 6.5). Pain radiating from the loin to the groin and genitalia is typical of renal colic. Central upper Inguinal canal abdominal pain radiating through to the back, partially relieved by sitting forward, suggests pancreatitis. Central abdominal pain that later shifts into the right iliac fossa occurs in acute appen- dicitis. The combination of severe back and abdominal pain may Gallbladder pain indicate a ruptured or dissecting abdominal aortic aneurysm. Diaphragmatic pain Associated symptoms Ureteric pain Anorexia, nausea and vomiting are common but non-specific symptoms. They may accompany any very severe pain but Fig. 6.5 Characteristic radiation of pain from the gallbladder, dia- conversely may be absent, even in advanced intra-abdominal phragm and ureters. disease. Abdominal pain due to irritable bowel syndrome, 6.2 Diagnosing abdominal pain Disorder Peptic ulcer Biliary colic Acute pancreatitis Renal colic Site Epigastrium Epigastrium/right Epigastrium/left Loin hypochondrium hypochondrium Onset Gradual Rapidly increasing Sudden Rapidly increasing Character Gnawing Constant Constant Constant Radiation Into back Below right scapula Into back Into genitalia and inner thigh Associated Non-specific Non-specific Non-specific Non-specific symptoms Timing Frequency/ Remission for weeks/months Attacks can be Attacks can be Usually a discrete periodicity enumerated enumerated episode Special times Nocturnal and especially when hungry Unpredictable After heavy drinking Following periods of dehydration Duration 1/2–2 hours 4–24 hours >24 hours 4–24 hours Exacerbating Stress, spicy foods, alcohol, non-steroidal anti- Eating – unable to eat Alcohol – factors inflammatory drugs during bouts Eating – unable to eat during bouts Relieving factors Food, antacids, vomiting – Sitting upright – Severity Mild to moderate Severe Severe Severe 110 THE GASTROINTESTINAL SYSTEM diverticular disease or colorectal cancer is usually accompanied A change in the pattern of symptoms suggests either that the by altered bowel habit. Other features such as breathlessness or initial diagnosis was wrong or that complications have devel- palpitation suggest non-alimentary causes (Box 6.3). oped. In acute small bowel obstruction, a change from typical Hypotension and tachycardia following the onset of pain intestinal colic to persistent pain with abdominal tenderness suggest intra-abdominal sepsis or bleeding: for example, from a suggests intestinal ischaemia, as in strangulated hernia, and is an peptic ulcer, a ruptured aortic aneurysm or an ectopic indication for urgent surgical intervention. pregnancy. Abdominal pain persisting for hours or days suggests an in- flammatory disorder, such as acute appendicitis, cholecystitis or Timing diverticulitis. During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain resolves transiently. The initial Exacerbating and relieving factors chemical peritonitis may subside before bacterial peritonitis be- Pain exacerbated by movement or coughing suggests inflam- comes established. For example, in acute appendicitis, pain is mation. Patients tend to lie still to avoid exacerbating the pain. initially periumbilical (visceral pain) and moves to the right iliac People with colic typically move around or draw their knees up fossa (somatic pain) when localised inflammation of the parietal towards the chest during spasms. peritoneum becomes established. If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised Severity appendix abscess develops, with a palpable mass and localised Excruciating pain, poorly relieved by opioid analgesia, suggests pain in the right iliac fossa. an ischaemic vascular event, such as bowel infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by potent analgesia is more typical of acute pancreatitis or peritonitis secondary to a ruptured viscus. 6.3 Non-alimentary causes of abdominal pain Features of the pain can help distinguish between possible causes (Box 6.3). Disorder Clinical features The acute abdomen Myocardial infarction Epigastric pain without tenderness Angor animi (feeling of impending The majority of general surgical emergencies are patients with death) sudden severe abdominal pain (an ‘acute abdomen’). Patients Hypotension may be so occupied by recent and severe symptoms that they Cardiac arrhythmias forget important details of their history unless asked directly. Dissecting aortic aneurysm Tearing interscapular pain Seek additional information from family or friends if severe pain, Angor animi shock or altered consciousness makes it difficult to obtain a Hypotension history from the patient. Note any relevant past history, such as Asymmetry of femoral pulses known diverticular disease in a patient with a possible acute Acute vertebral collapse Lateralised pain restricting movement perforation. Causes range from self-limiting to severe life- Tenderness overlying involved vertebra threatening diseases (Box 6.4). Evaluate patients rapidly, and Cord compression Pain on percussion of thoracic spine then resuscitate critically ill patients immediately before under- Hyperaesthesia at affected dermatome taking further assessment and surgical intervention. Parenteral with sensory loss below opioid analgesia to alleviate severe abdominal pain will help, not Spinal cord signs hinder, clinical assessment. In patients with undiagnosed acute Pleurisy Lateralised pain on coughing abdominal pain, reassess their clinical state regularly, undertake Chest signs (e.g. pleural rub) urgent investigations and consider surgical intervention in a Herpes zoster Hyperaesthesia in dermatomal timely fashion. distribution Vesicular eruption Dysphagia Diabetic ketoacidosis Cramp-like pain Vomiting Patients with dysphagia complain that food or drink sticks when Air hunger they swallow. Tachycardia Ask about: Ketotic breath onset: recent or longstanding Pelvic inflammatory disease Suprapubic and iliac fossa pain, nature: intermittent or progressive or tubal pregnancy localised tenderness difficulty swallowing solids, liquids or both Nausea, vomiting the level where food is felt to stick Fever any regurgitation or reflux of food or fluid Torsion of testis/ovary Lower abdominal pain any associated pain (odynophagia) or heartburn Nausea, vomiting any recent weight loss. Localised tenderness past history of food bolus obstruction