Abdominal Mass/Hepatosplenomegaly 1 D a V I D T a T E

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Chapter Abdominal mass/hepatosplenomegaly 1 D a v i d T a t e

Introduction Systemic enquiry (‘red fl ags’ for malignancy ) Th e identifi cation of an abdominal mass can be a • Fever and night sweats stressful time for the patient. It is imperative to care- • Weight loss (unintentional ≥ 3 kg) fully formulate a diff erential diagnosis based upon the • Dysphagia abdominal fi ndings and the clinical context: patients • Change in bowel habit rarely present with just an abdominal mass . A prompt • Blood per rectum diagnosis may enable the patient to quickly be reas- • Visible haematuria sured of a benign cause or rapidly provided with access • Intermenstrual bleeding to appropriate specialist care and treatment. • Anorexia No table can be entirely inclusive on this topic; we Family history are confi dent you could recall additional causes under • Malignancy each aetiological heading listed in Table 1.1 . • Polycystic kidney disease Drug history SceS c en a ri r io 1 . 1 • Prescribed A 75-year-old75-year-old womanwoman presents on a SaturdaySaturday to the • Over the counter emergencemergencyy department; struggling to cope at home, she reports a 4-week history ooff progressive abdominal swell- Social history ing. During tthishis time sshehe hhasas not bbeeneen eating wewellll anandd hhasas • Alcohol consumption (binges?) lost a sisignifignifi cant amount of weiweight.ght. OnOn examinationexamination sheshe • Travel history, including areas visited (rural is cachectic and jaundiced;jaundiced; she has ascites and an epi- or urban), activities engaged in (safaris, water gastric mass whichwhich is 5 cm in diameter,diameter, craggy in nature sports, etc.); did they take malaria prophylaxis anandd tetheredtethered to tthehe ununderlyingderlying structures. and have the recommended vaccinations? • Sexual history (protected, high risk partners?) Th is patient has been deteriorating for some time • Intravenous drug use (clean needles or and unfortunately ( but not uncommonly ) presented out shared?) of hours. She probably has advanced cancer, and this • Occupation (e.g. sheep farming, associated should be recognized by the admitting doctor from the with hydatid disease) outset; the diff erential diagnosis at this early stage is Past medical history wide and so this diagnosis should not be given to the patient without further confi rmation. • Tuberculosis • Diverticular disease • I n fl ammatory bowel disease History • Solid tumours or haematological malignancy A careful and comprehensive history is required. In Th e presence of ‘red fl ags’ requires the exclusion of particular: malignancy as a priority when planning investigations, bearing in mind that they can clearly be compatible

Acute Medicine , ed. Stephen Haydock, Duncan Whitehead and Zoë Fritz. Published by Cambridge University Press. © Cambridge University Press 2015.

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Chapter 1: Abdominal mass/hepatosplenomegaly

Table 1.1 Common and important causes of an abdominal Mechanical Intestinal distension mass by aetiology obstructive • Obstruction Aetiology Diagnosis • Constipation Renal enlargement Neoplastic Malignant • Hydronephrosis (severe) Primary malignancy Bladder • Pancreatic • Urinary retention • Colorectal • Hepatocellular carcinoma Degenerative Hernia • Gastric • Umbilical • Renal • Paraumbilical • Ovarian • Spigelian • Endometrial Infl ammatory Pancreatic pseudocyst Secondary/metastatic disease Hepatomegaly • Hepatic metastasis • Sarcoidosis • Lymphadenopathy (testicular spread to • Early cirrhosis with portal hypertension para-aortic nodes) (with splenomegaly) • Splenomegaly (CML) • Non-alcoholic steatohepatitis • Peritoneal spread Splenomegaly Benign • Sarcoidosis • Uterine fi broids • Systemic lupus erythematosus • Lipoma (anterior abdominal wall) Metabolic Hepatomegaly Infective Abscess • Amyloidosis • Diverticular Iatrogenic Renal transplant (right or left iliac fossa mass • Appendix with scar overlying) • Empyema of the gallbladder (may Implants progress from cholecystitis) • Buscopan pump (used in multiple • Crohn’s disease sclerosis) • Liver abscess (most commonly • Gastric pacemaker caused by ascending pathogens from Embedded peritoneal dialysis catheter biliary tract) (inserted ready for externalizing when Hepatomegaly dialysis is required) • Malaria Incisional hernia • Leptospirosis Idiopathic Splenomegaly • Viral hepatitis • Idiopathic thrombocytopenic purpura Splenomegaly Physiological Pregnancy • Immune hyperplasia (bacterial endocarditis, EBV, etc.) Vascular Abdominal aortic aneurysm Hepatomegaly • Congestion (right heart with other aetiologies: a patient with a liver abscess failure/tricuspid regurgitation, may be will develop anorexia and lose weight, so initially it pulsatile) is important to keep an open mind and equally open • Budd–Chiari syndrome (hepatic vein diff erential diagnosis. Try not to increase the patient’s occlusion, normally by thrombus) anxieties at this early stage. Splenomegaly • Portal hypertension (liver cirrhosis) Inherited Renal Examination • Autosomal dominant polycystic kidney Perform a full examination of the patient, including: disease (ADPCKD) respiratory, cardiovascular and neurological exami- Hepatomegaly nations alongside the abdominal examination. Many • Riedel’s lobe (normal variant) pathologies resulting in an abdominal mass or orga- • ADPCKD with hepatic cysts (♀ >♂ ) nomegaly will have manifestations in other systems

Chapter 1: Abdominal mass/hepatosplenomegaly

as well. Th ere are oft en some subtle clues to the aeti- • Raised infl ammatory markers suggest infection, ology which may be present, so take care to examine for but are signifi cantly raised in IBD and frequently anaemia, splinter haemorrhages and lymphadenopathy . elevated with neoplasia. Once organomegaly or a mass has been identifi ed, • Low albumin, raised platelet count and anaemia examine it carefully and clearly document: all suggest neoplasia, but are compatible with • site (consider which organ it may be, or is signifi cant infl ammation of other causes. associated with) • Tumour markers should be used with caution in • size assisting initial diagnosis as none are specifi c for a • shape given malignant disease; they are more useful for • nature (smooth or craggy, soft or fi rm) monitoring response to treatment: • mobility • CA19-9, pancreatic cancer • reducibility (if it could represent a hernia) • CA125, ovarian cancer • appearance of the overlying skin (scar, stretch • CEA, colorectal cancer . marks). In addition a digital rectal examination and urinalysis Radiological imaging are essential elements of the clinical examination which Always give careful consideration to deciding the must not be forgotten . most appropriate initial imaging modality ( Table 1.2 ). Aft er completing the examination you may have fi nd- Th e aim is to gain accurate diagnostic information in ings that require you to go back and revisit the history. the shortest time frame with the minimum of risk to the Patients rarely mind a few additional questions asked patient . Th e modality selected will depend upon the dif- aft er or during the examination; it shows their physician ferential diagnosis formed, which guides the question is interested and considering their case carefully . you are asking of the imaging : • Has this well 45-year-old woman with nodular Investigation hepatomegaly whose grandfather died of renal failure got ADPCKD with multiple liver cysts? Blood tests • Ultrasound scanning will rapidly answer this question with virtually no risk to the patient . • FBC • In the 53-year-old male smoker who drinks 50 • U&E units of alcohol a week, who has lost 6 kg of weight • LFT over 2 months and examination revealed craggy • CRP hepatomegaly and anaemia, the question needing • Calcium an answer is ‘has he got cancer?’ and if so ‘what is • Clotting screen the primary and has it metastasized?’ • Tumour markers (use selectively, with caution) • CT chest, abdomen and pelvis with contrast is • Blood fi lm (if haematological malignancy is the fi rst-line imaging modality of choice, giving suspected) diagnostic and prognostic information, also • If infective symptoms clarifying potential biopsy sites for histological • Blood cultures confi rmation. • Urine cultures It is not the case that USS is more sensitive for • Stool culture (if diarrhoea) liver lesions than CT, but it does avoid exposing the • According to history; malaria screening, HIV, patient to the risks of ionizing radiation and iodinated hepatitis serology, CMV, EBV contrast . Th ese can be helpful in narrowing the diff erential diagnosis and identifying the unwell from the clinically sta- Surgical exploration ble patient. Despite modern imaging modalities, in certain cir- • Anaemia is never normal and always has a cause or cumstances surgical exploration by laparotomy or

causes; it should prompt haematinics (B12 , folate, more frequently laparoscopy into the cause of an iron studies) to be checked and acted upon . abdominal mass is still warranted. Th is needs careful

Chapter 1: Abdominal mass/hepatosplenomegaly

Table 1.2 C o m p a r i s o n o f d i ff erent abdominal imaging modalities

Modality Advantages Disadvantages Ultrasound Excellent in experienced hands Limited by body habitus Modality of choice for RUQ pain, acute jaundice Limited by operator experience and pelvic masses Limited information on metastatic spread or tissue invasion Images not standardized and more diffi cult to interpret for someone who has not performed the scan CT Quick to perform High dose of ionizing radiation Readily available Limited resolution compared to MRI Wealth of experience in interpretation Iodinated contrast exposure (see Chapter 39 ) Can detect metastatic spread, and tissue invasion Easily reviewed by multidisciplinary team (MDT) Abdominal X-ray Good acute investigation to exclude obstruction If normal may need further imaging and toxic bowel dilatation Will often require CT imaging if abnormal MRI Excellent diagnostic detail Not readily available Diffi cult to interpret (limited expertise) Slow image acquisition Claustrophobic patients often struggle with the examination

Adapted from the American College of Radiology, 2010 [ 1 ].

consideration and discussion between the physician, defi nition of mucosal and deeper infi ltration of can- surgeon and patient. cers. It is oft en the modality of choice for determining operability of cancers, particularly oesophageal . Strengths • Direct visualization Acute management of ‘suspected • Potential to biopsy abnormal tissues if seen cancer’ • Can proceed to defi nitive operation (if included in the consent process) Scenario Scenario 1.11.1 continuedcontinued Weaknesses A CT chest, abdomen and pelvispelvis is requested.requested. The CTCT iimagingmaging reveals a tumour at the head ooff the panpan-- • Risk of general anaesthesia and paralysis creas (Figure 1.1), wwhichhich was invainvadingding llocalocal structures. • Operative risk (infections, bleeding, pain, etc.) Metastases are evident in the liver and a larlargege amountamount • Expensive of ascites is present. FollowinFollowingg the CT scan the patienpatientt • Emotional trauma and anxiety provoking anandd herher son were keenkeen to kknownow wwhathat it sshowed.howed. It was expexplainedlained tthathat a pancreatic mass was seen anandd tthishis Although laparoscopy can be an excellent tool in the mmightight represent cancer; however, it was made clear to evaluation of the abdominal mass, it is rarely required. them that at this point the diadiagnosisgnosis was not confi rmed, but further results would soon be available and diadiagnos-gnos- Endoscopy tic certainty was needed beforebefore any specifispecifi cc treatmentstreatments coucouldld bbee planned.planned. AbdominalAbdominal paracentesis was per-per- Endoscopy ( gastroscopy and colonoscopy) is usually formed and ascitic fl uid sent for urgent ccytologicalytological exam exam-- performed in response to imaging showing a sus- iination.nation. The next dadayy the ccytologyytology from her ascitic fl uiuidd pected lesion of gastric or colonic origin. It is the only hhadad bbeeneen processedprocessed andand showedshowed aadenocarcinomadenocarcinoma cecells.lls. investigation to provide direct visualization of the gastrointestinal mucosa . Gastroscopy is the fi rst-line It is clear from the previous imaging discussion investigation for patients presenting with dysphagia or that a contrast-enhanced CT of chest, abdomen and an epigastric mass, alongside CT imaging of the abdo- pelvis was the most appropriate fi rst-line imaging. Th is men. Endoscopic ultrasound can provide excellent was likely to reveal the nature of the primary tumour

Chapter 1: Abdominal mass/hepatosplenomegaly

with information about distant spread. When cancer is suspected, cytology or histology should always be obtained if possible to confi rm the diagnosis and clas- sify the type of cancer. Beware the many cancer mim- ics which have caused physicians to mistakenly diagnose cancer from CT scans! For this patient urgent sampling of the ascitic fl uid for cytology was the easiest and safest way to try to confi rm the diagnosis. Ensuring the diagnosis is followed up – the

MDT approach Figure 1.1 NICE recommends that every patient with a new diagnosis of cancer is reviewed by an MDT (multidisciplinary team) meeting. Such meetings (e.g. upper GI, lower more appropriate. Systems are in place to ensure the GI, gynaecological) commonly involve the relevant rapid outpatient investigation of patients with sus- physician, surgeon, radiologist, pathologist, oncolo- pected malignancy. Admission may be required for gist and oncology specialist nurse. Th e patient’s current associated problems: performance status and co-morbidities are considered • symptom control, e.g. pain, breathlessness alongside the CT imaging, cytology and pathology • inability to cope in their current state and home results. Th e tumour is staged according to the TNM circumstances classifi cation ( Box 1.1 ). Initial treatment is decided: • emergency complication, e.g. acute cord surgery, chemotherapy, radiotherapy or symptom con- compression. trol and palliative care. If they are to be discharged, robust arrangements for appropriate investigations and follow-up should Box 1.1 TNM staging ofof cancer be in place at discharge; this should not impede early TTumour umour – T1–T4 descdescribesribes diffdiff erenterent llevelsevels ooff llocalocal discharge. invasion specifi c to the ttypeype of tumour NodesNo des – N0–N3N0–N3 Communicating bad news MetastasesM etastases – M0/M1 indicates ppresenceresence or absence It is frequently the responsibility of the medical team ofof metastases looking aft er the patient on the ward to communicate the prognosis and treatment plan to the patient. It is dev- astating for most patients and relatives when a diagnosis Within the NHS, quality targets exist for the inves- of cancer is given and this must be given with the utmost tigation of symptoms suggestive of a cancer diagnosis sensitivity. Once the diagnosis has been confi rmed, it and subsequent treatment [2 – 4 ]. should be communicated in as timely a manner as pos- • All patients referred with suspected cancer from a sible. In this setting some patients are fully aware of the GP have a maximum wait of 2 weeks from referral likely cause of their recent ill health, others are either in to see a specialist. denial or blissfully ignorant of the true situation. • All cancer patients should wait no more than one Communication of a cancer diagnosis requires a month (31 days) from diagnosis to fi rst defi nitive thoughtful and empathic approach. In some situations treatment. the hospital palliative care team and oncology nurse • A maximum 2-month (62-day) wait from urgent specialists can be called upon to help support these GP referral for suspected cancer to fi rst defi nitive conversations. Th ey can off er continuity, accessibility treatment for all cancers . and time to patients and their families unrivalled by If a patient is referred to the acute medical take with physicians; their role should never be underestimated suspected cancer, the admitting team should always and they should be involved as early as possible in such consider whether outpatient investigation would be cases.

Chapter 1: Abdominal mass/hepatosplenomegaly

The principles of breaking bad news that hypovolaemia is the commonest precipitator of acute kidney injury in this patient group. • Choose an appropriate location; quiet and unlikely to be disturbed. In addition, signifi cant hepatosplenomegaly is com- • Allow time to perform this vital role properly monly encountered in the context of both myeloprolif- without rushing the patient or their relatives. erative and lymphoproliferative disorders. Outside the • Ensure that you know who you are speaking to and UK, the following causes predominate: have the patient’s consent. • malaria • Check prior knowledge. • tuberculosis • Send a ‘warning shot’. • schistosomiasis • Explain in clear and easy to understand language • kala-azar . the diagnosis and the likely outcome. • Do not shy away from words like ‘cancer’; all too Isolated hepatomegaly oft en ‘tumour’ or other medical terminology is Hepatomegaly commonly results from cirrhosis (usu- used, which clouds the situation. ally alcoholic in origin), malignancy and congestion • Ensure that the family and patient have a due to cardiac failure (Table 1.4). It can be misdiagnosed follow-up plan and have a point of contact (oft en in patients with hyperinfl ation due to COPD, due to the specialist cancer nurse). downward displacement of the liver by the diaphragm. Communication should be honest and upfront at all It may arise acutely, when it is frequently painful and/ times. Th ere is oft en heightened emotion which can be or tender as in viral or alcoholic hepatitis, or chronic- represented as anger towards medical and nursing staff ally, and more commonly painless as in fatty liver or in this situation; this should be handled sensitively and amyloidosis. Th e presence of hepatomegaly should be not taken personally. confi rmed by ultrasound imagining, which will pro- Imagining yourself in the patient’s or the relative’s vide information regarding the liver architecture. shoes is a distressing and uncomfortable exercise, but Th e size of the liver is not an indicator of the sever- it clearly helps empathy with the patient and better ity of disease as demonstrated in ADPCKD where appreciation of their reactions. Th e need for simple occasionally massive hepatomegaly occurs with min- clear unambiguous language in delivering this news imal impairment of liver function. can never be overstated. Repetition of the message can also be valuable as it can be ‘blocked out’ initially by Isolated splenomegaly patients or their relatives. Th e spleen is the largest lymphoid organ at 7–10 cm in length, and only has eff erent lymphatic vessels. Enlargement of liver and/or spleen It is generally only palpable when twice normal size. For this reason splenomegaly is oft en diagnosed on Hepatosplenomegaly imaging rather than examination. Th e functions of the Th e commonest cause of hepatosplenomegaly in spleen should be recalled when managing the patient the UK is liver cirrhosis with portal hypertension with splenomegaly. ( Table 1.3 ). Th is can present acutely and is oft en seen Splenic functions include: by acute physicians and intensivists. • reservoir of erythrocytes and thrombocytes, in Th e acute complications seen in these patients are case of signifi cant haemorrhage generally related to the portal hypertension: • destruction and recycling of old erythrocytes, life • Ascites with associated risk of spontaneous span ≈ 120 days bacterial peritonitis (see Chapter 3 ) • immune function destroying many bacteria • Oesophageal and gastric varices, which can bleed and viruses that enter the circulation, torrentially (see Chapter 26) especially important for encapsulated bacteria: • Hepatic encephalopathy, certainly under- Pneumococcus , Meningococcus , Haemophilus recognized at admission (see Chapter 36) infl uenzae type b (Hib), Klebsiella , salmonella and • Hepatorenal failure, less common at presentation group B streptococcus but also indicates a poor prognosis; bear in mind • haematopoiesis during gestation .

Chapter 1: Abdominal mass/hepatosplenomegaly

Table 1.3 Common causes of signifi cant hepatosplenomegaly that may present on the acute medical take

Aetiology Comments Portal hypertension • Liver cirrhosis Stigmata of chronic liver disease • Budd–Chiari syndrome Rapid development of ascites with pain Myeloproliferative disorders • Chronic myeloid leukaemia • Myelofi brosis Lymphoproliferative disorders • Lymphoma Associated lymphadenopathy • Chronic lymphatic leukaemia Infectious • Viral hepatitis Stigmata of intravenous drug use • EBV, CMV, toxoplasmosis Glandular fever like illnesses • Brucellosis Farmers • Leptospirosis Environmental exposure to pathogen, jaundiced • Malaria, schistosomiasis, kala-azar, tuberculosis Patient travel history, outside of UK (although TB increasingly present in some UK communities) Metabolic • Amyloidosis May have evidence of primary cause • Gaucher’s disease (glucocerebrosidase defi ciency) May be massive splenomegaly in patient with known diagnosis Blood dyscrasias • Sickle cell disease Characteristic features in patient with known diagnosis • Thalassaemia major

Th ankfully for the asplenic patient it is not the seat of Other mechanisms (and examples) for develop- ‘one’s emotions or passions’, as our predecessors thought! ment of splenomegaly include: Th e cause of enlargement may be pathology requir- • Infi ltrative : amyloid, sarcoidosis, metastases or in ing upregulation of these functions: Gaucher’s disease* • Increased turnover of red blood cells as in inherited • Neoplastic : lymphomas, chronic lymphocytic spherocytosis. leukaemia (CLL) and chronic myeloid • Increased immune activity due to infection, most leukaemia* (CML) commonly in the UK due to glandular fever • Congestive : increased pressure within the venous (Epstein–Barr virus), but the infective causes are system such as portal hypertension or more rarely numerous and include several tropical diseases: splenic vein thrombosis. • malaria* (*May cause ‘massive’ splenomegaly >20 cm in • leishmaniasis* length.) • trypanosomiasis • ehrlichiosis Acute complications of splenomegaly • brucellosis Left upper quadrant pain: this can be the presenting fea- • typhoid fever. ture of patients with splenomegaly, most likely occur- • Abnormal immunoregulation in some patients ring as with most organ pain from rapid expansion or with autoimmune conditions such as SLE infl ammation. and rheumatoid arthritis can also result in Hypersplenism is an abnormally high rate and pre- splenomegaly. mature destruction of circulating blood cells; this may • Haematopoiesis and splenic enlargement can occur result due to the underlying cause of the splenomegaly in adult life if the bone marrow is failing, as in such as in chronic malaria or TB. Th e complications myelofi brosis*. include:

Chapter 1: Abdominal mass/hepatosplenomegaly

Table 1.4 Common causes of signifi cant isolated hepatomegaly that may present on the acute medical take

Aetiology Comments Cancer • Hepatocellular carcinoma Hepatoma may occur in context of cirrhosis • Secondary deposits Malignancy often causes tender nodular hepatomegaly Toxic • Alcoholic hepatitis Stigmata of alcoholic liver disease • Alcoholic cirrhosis Acute alcoholic hepatitis is frequently painful Lymphoproliferative disorders • Lymphoma Associated lymphadenopathy • CLL Infectious • Viral infections, e.g. hepatitis, EBV History of intravenous drug use or recent glandular fever like illness • Leptospirosis Environmental exposure to pathogen, jaundiced • Hydatid disease Sheep farmers, especially in Wales • Amoebic abscess Tropical exposure Liver congestion • Cardiac failure Other features of right heart failure • Budd–Chiari syndrome Rapid development of ascites with pain • Tricuspid regurgitation Pulsatile liver Metabolic/granulomatous • Haemochromatosis Slate grey skin pigmentation, hypogonadism, diabetes mellitus, arthritis, cardiomyopathy • Amyloidosis May be evidence of primary cause • Sarcoidosis Lupus pernio, erythema nodosum, hilar lymphadenopathy, hypercalcaemia Miscellaneous • Riedel’s lobe Tongue-like enlargement of right lobe of liver. Benign anatomical variant • COPD Spurious apparent enlargement due to downward displacement of diaphragm

• thrombocytopenia and potentially spontaneous References bruising • anaemia 1. American College of Radiology . Appropriateness Criteria, 2010 . • leucopenia and potentially serious secondary sepsis. 2. NICE . Referral guidelines for suspected cancer CG27. Clinical Guideline, 2005 . Available to download at Splenic rupture: any patient with an enlarged spleen www.nice.org.uk/cg027 . should be cautioned to avoid contact sports or heavy 3. HM Government . Cancer Reform Strategy, 2007 . lift ing activities which may increase the risk of splenic Available to download at www.nhs.uk/NHSEngland/ rupture. Th is will oft en cause a large intra-abdominal NSF/Documents/Cancer%20Reform%20Strategy.pdf. bleed and hypovolaemic shock, requiring urgent sur- 4. Department of Health. National Cancer Strategy, 2011 . gical assessment. Th is is a recognized cause of death in Available to download at www.gov.uk/government/ patients with EBV infection . publications/the-national-cancer-strategy.

Chapter Abdominal pain 2 Stephen Haydock and Gareth Walker

Introduction from the approximate spinal cord level determined by the embryological origin of the organ : Establishing the cause of abdominal pain can be diag- nostically challenging in certain patient groups such • Epigastric pain due to organs of foregut origin as the elderly, women (especially if pregnant) and (stomach, duodenum, biliary system) immunosuppressed. A successful approach should be • Periumbilical pain due to organs of midgut origin based upon: (small bowel, appendix, caecum) • Hypogastric/suprapubic pain due to hindgut organs • understanding of the mechanisms of how pain (colon, intraperitoneal parts of genitourinary is generated and/or perceived in relation to system). abdominal structures • recognizing that patterns of presentation exist R e f e r r e d p a i n is perceived as arising distant from its based upon the localization of the pain, its quality source and results from convergence of nerve fi bres at and radiation the spinal cord. It also refl ects embryological origins. • recognizing ‘ red fl ags’ suggestive of signifi cant and Examples include: potentially life-threatening pathology • scapular pain due to biliary colic • recognizing that chronic abdominal pain is oft en • groin pain due to renal colic functional in origin. • shoulder pain due to blood or infection causing Abdominal pain is commonly described in terms of diaphragmatic irritation parietal, visceral or referred pain. • ureteric obstruction causing ipsilateral P a r i e t a l p a i n : aff erent nerves originate in the par- testicular pain. ietal peritoneum and enter the ipsilateral dorsal root ganglion at the corresponding superfi cial dermatomal Acute abdominal pain level. Th e pain receptors respond to irritation from infection, chemical or other infl ammatory processes. Scenario S c e n a r io 2.1 It is usually perceived as a sharp, well-localized pain YYou ou are askedasked to review a 75-year-old75-year-old woman on tthehe and results in localized tenderness and guarding that care of the elderlelderlyy ward in the earlearlyy hours of the mornmorn-- can progress to generalized peritonitis with abdominal ining.g. She has been awoken from sleep with a generalizedgeneralized rigidity and rebound tenderness . aabdominalbdominal pain. On examination sheshe llooksooks unwell,unwell, hashas a V i s c e r a l p a i n : aff erent nerves originate in the walls of tachycardia ofof 130 beats per minute, irregularly irregular, hollow organs (responding to ischaemia, distension and with blood pressure of 100/70 havinhavingg been 140/95 priopriorr infl ammation) and capsules of solid organs (responding to the pain. She has mild generalizedgeneralized abdominal tender-tender- to capsular stretching). Th ey enter the ipsilateral and ness but no gguardinguarding or rebound tenderness. Her bowebowell contralateral cord at multiple levels. Th e pain is there- sounsoundsds are increaseincreased.d. Her memedicationdication incincludesludes ddigoxinigoxin fore poorly characterized (dull, cramping, aching) and and warwarfarinfarin fforor atrial fi brillation,brillation, prednisoloneprednisolone 3030 mgmg poorly localized (being felt generally around the mid- for a recent diagnosis of polpolymyalgiaymyalgia rheumatica anandd reregulargular tramadol. line). It is interpreted at the cortical level as originating

Acute Medicine , ed. Stephen Haydock, Duncan Whitehead and Zoë Fritz. Published by Cambridge University Press. © Cambridge University Press 2015.

Chapter 2: Abdominal pain

Th is patient is unwell and requires urgent resusci- • Other associated symptoms: tation and surgical referral. Th e suspicion, given the • cardiorespiratory (may present as upper atrial fi brillation, generalized pain and increased bowel abdominal pain) sounds, is of gut ischaemia. Th e absence of severe pain, • v o m i t i n g tenderness, guarding and rebound is still consistent • diarrhoea with this, especially in a patient on regular high dose • rectal bleeding steroids and analgesia. Th e presentation of an acute • dysuria, frequency abdominal problem in the elderly is oft en less clear • scrotal swelling, penile discharge than in a younger individual and oft en results in sig- • vaginal discharge nifi cant delays in diagnosis and appropriate life-saving • fever intervention. • weight loss • vaginal bleeding and discharge. Clinical assessment of acute • Take a detailed medical, drug and social history. In abdominal pain particular note: Some patients with acute abdominal pain may be very • previous abdominal disease and surgery unwell and require urgent resuscitation; as always this is • recent sexual contact for females; was the priority . protection used? • alcohol intake History • smoking history • previous surgery or recent instrumental • When did the pain start? procedures • Did it come on suddenly or gradually? • immunosuppression due to HIV or drugs • Sudden onset suggests vascular occlusion • vascular disease including hypertension, atrial (ischaemic gut, torsion), small tubular fi brillation obstruction (biliary or ureteric colic). • other major co-morbidities that would • Gradual onset suggests infl ammatory disorder infl uence surgical risk. or bowel obstruction. Th e location of the pain and its radiation can help • Can you describe the quality of the pain? Dull or narrow the diff erential diagnosis. sharp, constant or waxing/waning, colicky? But remember the possible pitfalls : • Burning pain of dyspepsia • Poor localization of visceral pain • Tearing pain of dissection • Localization of pain in relation to embryological • Colicky pain of biliary or ureteric colic origins • Sharp localized pain of peritoneal • Anatomical variants, e.g. retrocaecal appendix infl ammation. • Change in the nature of pain over time, e.g. poorly • Where in abdomen do you feel it? Localized or localized pain of appendicitis becoming localized generalized? with onset of peritonitis. • Does it radiate anywhere? Shoulder, groin, back? • Does anything make it better or make it worse? Examination • Relation to meals (peptic ulcer better, biliary A full examination of all major systems is required as colic worse) abdominal pain may result from other systems (cardio- • Relation to position and movement (agitation vascular, respiratory, musculoskeletal) but in particular : of renal colic, curled up, still patient with • Is the patient unwell, do they look pale, are they peritoneal infl ammation). sick and in pain? • Has it changed in quality or location since onset? • Review the observations; are they tachycardic, • Generalized visceral pain becomes localized as tachypnoeic, hypotensive, pyrexial (elderly overlying peritoneum is infl amed. patients with infection may be hypothermic)? • Progression of renal stones down ureter. • Remember restlessness of renal colic and the still, • Progression of a vascular dissection. curled up patient with peritonitis. 10