Early Diagnosis

Of Abdominal Pain EDWARD B. FISH, MD SUMMARY Differential diagnosis of abdominal pain is vitally important in sorting out those patients who should be sent for immediate surgery and those who can be treated at home, or observed for a period. Careful history and examination are mandatory, since the patient may find the pain difficult to describe and the signs may be minimal. Dr. Fish is a lecturer in the Department of Surgery at the University of Toronto, and is on the staff of Women's College Hospital. Address for reprints: Women's College Hospital, 76 Grenville Street; Toronto, Ont. M5S 11B2. THE EARLY diagnosis of abdom- entire story and then to question occurred and the activity in which he inal pain is one of the most him carefully to fill in the im- was engaged. In acute , the important problems in family practice. portant details. early pain usually begins very gradu- The patient is usually anxious and The onset of the pain may be ally, making it difficult to give an upset that his daily routine has been sudden and severe, such as with a exact time of onset, and it is so diffuse interrupted by the unexpected occur- ruptured duodenal ulcer or rupture of and poorly localized that he often is rence of the pain and in his very an ovarian cyst. The patient may be unable to say just where it was. In anxiety he tends either to minimize his able to give the exact time when it , the pain typically complaint or overemphasize the comes in spasms in various portions of symptoms that he thinks are most ,.,s.Pain, the and it seems to move important. He is often seen within ! around. The early pain in appendi- a few hours of pain onset when the p > citis or intestinal obstruction is symptoms have been few and usually clearly intermittent the signs are minimal. There and there may be periods of is tremendous pressure on complete relief between the the doctor to make the episodes of distress. right diagnosis and give It is important to the best advice as note the severity of soon as possible. the pain. The pain of Many different dis- a ruptured ulcer is eases can give rise very severe and to abdominal stops the patient pain, yet a few in his activities. common condi- Biliary and tions account for are the great major- ( agonizing pains ity of the diag- which appear to nostic problems be continuous, and the doctor though they may who concentrates show gradual on differentiating changes in intensity between these, usu- over 3040 minute ally carnes out the periods. The patient right therapy. § writhes around and feels a tremendous tightness Describing the Pain and compression which A careful history of the makes him want to change his exact site and type of pain is a position, but finds that this gives most helpful start to the diagnosis. little relief. The pain of a ruptured It is best to let the patient give his viscous or sudden makes

38 CAN. FAM. PHYSICIAN 22:134 FEB. 1976 the patient lie still, since the slightest is felt in the flank or mid abdomen, otherwise healthy individual or are movement (even deep respiration) the diagnosis may be extremely diffi- there signs of chronic disease with a aggravates it. cult. Renal colic is usually a severe minor increase in distress? Is the The change in the pain's location pain but can be milder. It may last for patient in essentially good health with and character in appendicitis is very long periods of time or may appear to just minimal signs and symptoms? Are important in the differential diagnosis. be intermittent, and is usually asso- there signs of rapid deterioration? In the first 12 hours or so of the ciated with other signs and symptoms Temperature and vital signs should be disease there is a diffuse, intermittent of renal disease. recorded. and not too severe abdominal pain, Examination of the abdomen sometimes localized in the perium- Pelvic Inflammatory Disease should concentrate on presence or bilical area and sometimes just de- The pain from pelvic inflammatory absence of the few most significant scribed as "all over". Sometimes it's disease often starts as localized pain in signs. The examiner needs to ask him- described as moving around from one the right or left abdomen or the self: Is there abdominal distention? Is area to another. Anorexia and suprapubic region, showing evidence there pain when the patient is at rest? are common but the patient usually of peritoneal irritation early in the Is it aggravated by moving or cough- has no pain on breathing or coughing disease. There is a great variety in the ing? Can the patient localize it well or walking or any other activity that pain depending on associated com- and point to an exact area? On observ- jostles the abdomen. Later in the plications, e.g. partial may be ing the patient, there may be exacerba- course of the disease the patient be- accompanied by distention and inter- tions of the pain, which should lead comes gradually aware of a more mittent crampy abdominal pain just one to listen to the abdomen for the steady discomfort in the right lower like an intestinal obstruction. The typical active peristalsis, which accom- quadrant, which is aggravated by steadier pain and tenderness in the panies the intermittent pain of intes- movement and is associated with ten- right upper quadrant from perihepatic tinal obstruction. It is helpful to check derness. The history of this shift of disease may mimic cholecysfitis. the degree of peritoneal irritation by pain and the development of signs of seeing whether a minor movement, peritoneal irritation, make appendicitis The such as normal respiration will increase a strong possibility. Gastrointestinal symptoms, and the pain or whether it takes a deep function must then be specifically cough or marked jostling of the perito- Biliary and Renal Colic assessed in relation to the pain. neum. The pain of biliary colic is com- Patients will often not volunteer that monly felt in the mid-epigastrium, they have nausea or anorexia. In gas- Muscle Spasm radiating directly through to the right troenteritis there is early nausea and Nearly every patient with pain has infrascapular area or around both with minimal pain and little some voluntary muscle spasm. It is costal margins. Alternatively, it may or no tenderness. In appendicitis there well worth the time taken to gain the radiate around the right costal margin is usually mild anorexia, which later patient's confidence so that his or may be localized mostly in the right proceeds to nausea and vomiting only anxiety subsides, allowing the muscles upper quadrant. Sometimes the in some patients. In all forms of to relax and permit palpation of the patient points high up into the lower intestinal obstruction it is very im- abdomen. It is best to start in areas sternal area and describes the pain as a portant to note the relationship of where there is no pain and to palpate compressing feeling in the chest with nausea and vomiting to the degree of very lightly to see if the tone of the shortness of breath. abdominal distention. It is also im- rectus muscle is equal on both sides There may be such similarities with portant to note the history of con- and in the upper and lower quadrants. cardiac pain that the differential diag- stipation or diarrhea and the time Then pressure in the palpating hand nosis becomes extremely difficult. The when the patient last passed any stool can be gradually increased. Over an pain of biliary colic tends to come on or flatus. It is always necessary to inflammatory organ there is usually a rather suddenly and lasts for a long know when food or fluids were last tenseness of the muscles which pre- period - at least 30 minutes and consumed, if there is any possibility of vents the organ from being com- commonly four to six hours, or until giving an anesthetic. pressed. This is sometimes described as some analgesic is given. Then the Previous history must be carefully resistance. When there is peritonitis, patient is usually quite comfortable investigated, especially earlier episodes there is commonly an involuntary in- again and feels well. When the history of abdominal pain and investigation of crease in tone of the muscles in that shows attacks of intermittent but the gastrointestinal tract or surgery. It region, or the whole abdomen, so that severe pain lasting irregular lengths of is important to know whether there the muscles do not move on respira- time, with freedom from pain between was any change in the patient's usual tion and on palpation remain rigid. This these episodes, the diagnosis is usually state of health before the symptoms is what is usually meant by true biliary colic. began. Any symptoms related to the rigidity of the abdomen. Even a slight This may be felt most in the costo- urinary tract, plus menstrual and ob- difference in muscle tone between two vertebral area, where it is seldom stetrical history, are essential if ovarian sides on palpation can be very helpful difficult to differentiate from other or uterine pathology are in the differ- in localizing the most likely site of abdominal pain. If it radiates down ential diagnosis. peritonitis. These signs need to be through the flank to the groin and into looked for early in the examination the external genitalia or upper thigh, Examination while the patient is as comfortable as and is associated with urinary fre- This should begin with a general possible. Then palpation can gradually quency and hematuria, the diagnosis is assessment of the patient as a whole. Is increase to detect tenderness. It is usually apparent. When the main pain there an acute and serious change in an usually best to watch the patient's face

CAN. FAM. PHYSICIAN 22:135 FEB. 1976 39 and find out if very minor degrees of palpable or audible it is more likely disease, this clearly is a case for hos- pressure give any evidence of distress. that the patient has gastroenteritis or pital investigation. A chest film and Then the pressure can be gradually some other lesion than peritonitis. upright film of the abdomen may increased to find if you can palpate The sites need to be exposed reveal air under the diaphragm, con- well into the abdominal contents with- and palpated carefully. It is very easy firming the presence of a perforation, out distress. Final palpation should be to overlook a small or it may reveal a pneumonia or some reserved for the most tender point. which is presenting as just a small mass other chest lesion - a cardiogram and The presence or absence, and degree of in the groin - sometimes it's mistaken serum amylase will help clarify this tenderness, and its location should be for a lymph node. situation. They usually require hos- carefully recorded. A small firm mass attached to the pitalization and careful monitoring. During this palpation the presence femoral canal area is most likely a The perforated ulcer will require early of a mass or enlarged organ should be femoral hernia and not an inflamed surgery. apparent. In thinner or younger people inguinal node. If there is serious Intestinal obstruction in the early one can usually feel the edge of the doubt, it may be wiser to explore the stages, unless it's a strangulating ob- liver and confirm its level with per- mass and excise a strangulated femoral struction, may not make the patient cussion. The aortic pulsation and hernia sac before gangrene of the very sick. It is also not quite as urgent tissues around it are usually palpable, bowel occurs, even if on occasion it to make the diagnosis and a period of except in the obese. Both the sigmoid turns out that a lymphadenitis is observation is safe. When there is any colon and the should be pal- present. The patient should be exam- suggestion of a strangulating obstruc- pable. If one can gradually press into ined for costovertebral angle tenderness tion, urgent surgery is required. the abdomen, compressing the cecum and tenderness in the kidney regions. Tenderness in the abdomen or over against the posterior structures, it is It is usually best to leave the rectal a hernia, leukocytosis, fever and rapid very unlikely that the patient has and vaginal examinations until the deterioration of the patient's condi- appendicitis unless the is in end, but they are essential-in the early tion should alert one to the possibility the pelvis or the right upper quadrant. diagnosis of abdominal pain. The of strangulation and the need for Any mass should be delineated as presence of vaginal discharge neces- urgent surgery. clearly as possible by palpation and sitates cultures. Any evidence of ure- Biliary colic and renal colic in the percussion. In acute the thritis and cervicitis should be care- otherwise healthy patient can usually gall bladder is nearly always palpable if fully noted. The mobility and size of be treated with analgesics; after a short the muscle spasm is overcome and the the uterus and cervix and the presence period of observation the pain is usu- patient is not too obese. A rounded of adnexial masses or tenderness are ally completely relieved and further globular mass anywhere in the right very important - often in an ectopic elective investigation can be arranged. upper quadrant or sometimes even pregnancy there is simply tenderness If tenderness over the gall bladder or extending well down towards the but no clear mass. A low lying tenderness in the kidney regions per- lower quadrant but coming from the appendix will usually give tenderness sists, the patient is better taken into liver region indicates an enlarged gall on the right on rectal or vaginal hospital and investigation carried out bladder. examination. In , it is not immediately to exclude cholecystitis, Sometimes there is just indefinite uncommon to feel in the pouch of , pyelonephritis or urinary resistance, since the adjacent omentum Douglas an inflamed mass which repre- obstruction. and colon are adherent to an inflamed sents a loop of inflamed sigmoid There are a large group of mild gall bladder and form an irregular colon. It may be impossible to tell on abdominal pains caused by gastro- tender mass. A mass in the right lower physical examination whether a , , dysmenorrhea quadrant may represent an appen- patient has an appendiceal abscess, a and anxiety, etc., in which there are diceal abscess or cecal carcinoma. A twisted ovarian cyst, or an inflamed no signs of peritonitis and the diag- tender mass in the left lower quadrant loop of sigmoid colon lying in the nosis may not always be clear but it is commonly accompanies acute diver- pouch of Douglas. There may simply usually evident that the patient does ticulitis. This mass usually represents be a tender mass in this region. not have a life-threatening abdominal inflamed tissues around the colon or In the anxious patient, if the mere lesion. These patients usually respond an actual abscess. Any mass arising out doing of a rectal exam seems to cause to medical and dietary therapy, etc. of the pelvis should be carefully ob- more pain than the abdominal com- There is a group of conditions served for its mobility and outline, plaints, this is good evidence that the which may start out very mildly and because an enlarged bladder, uterus or abdominal pain, no matter how de- yet lead to serious complications. The ovarian cyst may be quite soft or quite scribed, is really not that severe. commonest is appendicitis, which in hard. the early stages may have minimal Percussion is usually most useful in Diagnosis symptoms and signs but may go on to outlining masses. It is unusual to be A careful weighing of the findings peritonitis, which can be prevented by able to detect shifting fluid in the in the history and physical examina- early recognition and operation. . The bowel sounds tion will usually make one diagnosis X-rays are usually of little value early should be listened for and any change almost certain. If it is clear that the in appendicitis, but may be helpful in noted. Hyperactive sounds suggest a patient has a major tragedy such as later stages when there is generalized mechanical obstruction. Absence of perforation of a duodenal ulcer with peritonitis. There is usually a leuko- sounds indicates some form of peri- widespread peritonitis, severe pan- cytosis of about 14,000. If the tonitis. Usually the sounds are slightly creatitis, severe cholecystitis, or a symptoms and signs strongly suggest decreased and are not of much diag- heart attack in which he has upper appendicitis the absence of a leuko- nostic help. When loud sounds are abdominal pain and signs of serious cytosis does not contraindicate an

40 CAN. FAM. PHYSICIAN 22:136 FEB. 1976 appendectomy. There is usually a low acute diverticulitis limited to a short fever. If there is a higher fever, one segment of the colon and the adjacent should consider other possible causes colon is healthy and empty, a resec- for the fever, unless there is wide- tion with primary anastomosis can be spread peritonitis, or an appendiceal done safely. abscess. In the early stages (less than If there is abscess formation and 24 hours) when the symptoms and marked disease of the colon it is best signs are mild and the patient is not to drain the abscess and if feasible, very sick, it is useful to keep the remove the inflamed segment of colon. patient from eating or drinking and The distal colon can then be brought reobserve the abdomen carefully after out at the lower end of the wound or several hours. The signs will become closed. The proximal colon can be more distinct and an appendectomy brought out as an end colostomy can be carried out while the appendi- which can be closed at a later date citis is still at an early stage. Alter- when the infection has subsided. natively, the patient will clearly im- Drainage of an abscess and proximal prove, or another diagnosis will be colostomy often leads to a prolonged quite definite. illness with chronic infection until the Sometimes it is extremely difficult diseased segment of bowel is removed. to tell whether a patient has appendi- Ectopic or ovarian bleeding, or slow citis or salpingitis. There may be more leakage of fluid from an ovarian cyst marked pain and tenderness in the may mimic appendicitis. When a care- right lower quadrant, the movement of ful assessment of all the symptoms and the cervix may give slight pain but the signs leaves the diagnosis obscure, the adnexae may not be acutely tender possibility of appendicitis must be and in spite of surgical and gyne- carefully excluded. If there is per- cological consultations, the diagnosis is sistent localized pain and tenderness, sometimes indefinite. If there is with anorexia or nausea, appendicitis definite pain and tenderness at should be suspected unless it can be McBurney's Point, the patient nearly clearly ruled out. When the symptoms always has a considerable degree of are mild and the patient is healthy, the periappendicitis. diagnosis usually becomes quite clear Thermography may be helpful in when re-examined in eight to 12 -~~~~ a differential diagnosis. If appendicitis hours. cannot really be excluded, it is usually -~~~ 6 wiser to perform an appendectomy. Uncertain Diagnosis This confirms the diagnosis and if it is There are still a few cases in which appendicitis, the operation is per- the diagnosis may be uncertain. When formed early enough to avoid com- peritonitis is present, which is usually plications. If it is salpingitis a culture is evident from signs of systemic infec- obtained, the appendix is removed, tion (leukocytosis), fever, local pain, S a the patient responds well to antibiotics tenderness and ileus, surgery is in- - and in future attacks of pain, dicated unless the cause is clearly appendicitis can definitely be ruled identifiable as salpingitis or some other out. The operation adds very little to type of peritonitis which is best their morbidity. treated with antibiotics. Intraperi- II s Diverticulitis will sometimes mimic toneal hemorrhage, whether from appendicitis very closely. In the ectopic pregnancy or trauma, is usu- typical case of diverticulitis, the ally an indication for surgery. patient is aged 50-60 and has some Mechanical will change in bowel habit. Usually nearly always require operation, which patients have a little diarrhea, but should be performed early. When signs some will have . The pain of peritonitis, hemorrhage or obstruc- is intermittent or crampy and on the tion persist, it is usually wiser to left side, which is usually tender. operate than to delay. Sometimes this pain is in the midline or even described as on the right and there is definite evidence of peritonitis in the lower abdomen. When there is References an acute tender mass in the pouch of 1. REQUARTH, W.: The Acute Abdomen. Douglas it may be impossible to differ- Chicago, The Year Book Publishers, 19S8. entiate these two conditions. In this 2. MAINGOT, R.: Abdominal Operation. situation, a laparotomy is usually the New York, Appleton, Century, Crofts. 3. SHEPHARD, J. A.: Surgery of the Acute TM L _ best decision -an appendectomy can Abdomen. Edinburgh, £ & S Livingstone, be done if it is appendicitis, or if it's 1968.

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