Chapter 22 Abdominal pain

Case 22.1

Bill is a 52-year-old male who presents with a sudden onset of severe, colicky, central abdominal pain, distension of his abdomen, and an episode of vomiting. The pain has been present for 4 hours. He states that he is not constipated, nor has he had any diarrhoea. There have been no previous episodes of this kind.

Relevant examination findings are abdominal distension, generalised tenderness on abdominal palpation, a scrotal mass, and loud, high pitched bowel sounds.

Questions

1. What information can you elicit from the following observations:

a pain is colicky

b pain is in the central part of the abdomen

c presence of a scrotal mass

d loud, high pitched bowel sounds.

2. What is your differential diagnosis? What will you do now?

3. What type of investigations will be performed which could facilitate the diagnostic considerations?

4. Plain abdominal X-ray showed distended loops of bowel with fluid levels. What is your final diagnosis?

5. Is it unusual for someone with this disorder to not complain of constipation?

6. What are the possible causes of this disorder? Which of these is most likely in Bill’s case?

Case 22.2

James is a 43-year-old male who presents with a sudden onset of sharp epigastric pain. He is anorexic, nauseated, and has had one episode of vomiting. There have been no previous episodes. Last night he ate a spicy meal, which is unusual for James. He woke early this morning with the pain, and had a coffee to ‘settle his stomach’. He stated that this made the pain much worse, and caused him to vomit.

Questions

1. What is meant by ‘anorexic’?

2. What is your differential diagnosis based only on this history?

3. Could the spicy meal be the cause of his problem?

4. What other pertinent questions should be asked?

Case 22.3

Mary, a 43-year-old female, presents with a sudden onset of right-sided hypochondrial pain, which is characterised by episodes of increased severity. The pain radiates around to her back and up between the scapulae. She has nausea and anorexia, but no bowel changes. Her symptoms have been occurring for about 6 hours. She states that over the last 2 weeks, she has had three episodes of similar (but less severe) pain. They generally lasted about 3 hours before disappearing.

Relevant examination findings are: temperature 38.5°C; pulse 100 per minute, with a strong volume; BP 145/90 mm Hg; tenderness on palpation in right hypochondrium; and a positive Murphy’s sign.

Questions

1. What information is given by the description of her pain?

2. What is your differential diagnosis?

3. Describe Murphy’s sign.

4. What is the possible relationship between the three earlier episodes and her current presentation?

Case 22.4

Oscar, a 59-year-old male, presents with a 5–6 month history of episodic epigastric pain, which occurs as soon as he eats. Nausea and vomiting occur intermittently. He feels unwell, is anorexic, and has had a weight loss of 4 kg over the last 6 months.

Questions

1. Given the description of Oscar’s pain, what organ is most likely to be involved? Why?

2. What types of pathologies may be causing his problem? Why?

3. Name the most useful investigation that could be done by a medical specialist in order to determine the diagnosis?

4. What other tests could be indicated?

Case 22.5

Anne, a 49-year-old female presents with a 9–10 month history of episodic and vague upper abdominal pain, in addition to occasional belching, anorexia, nausea, and vomiting. There are no other symptoms. Physical examination reveals no abnormalities.

Questions

1. Compile a differential diagnosis for this scenario.

2. Assume that your full history and physical examination reveal nothing. Describe, in general terms, the steps you would need to follow in order to ‘workup’ this patient.

Case 22.6

History

Leonie is a 34-year-old woman who presents with an 8-hour history of right iliac fossa pain. She states that it is quite severe, waking her up from sleep, and seems to be developing quite rapidly. It feels sore when she touches the area.

She feels anorexic and nauseated, but has not vomited. There have been no alterations in bowel activity or urination, and she denies the presence of a fever. There is no history of any similar episodes. Her last menstrual period was 2 weeks earlier. She has had no preceding peri-umbilical pain.

Social history reveals that Leonie is a non-smoker, social drinker, and has been on antidepressants for the last 3 years, following severe post-natal depression following the birth of her second child 4 years earlier. Leonie’s diet is balanced. She separated from her husband 4 weeks earlier. She has used an intra-uterine device as contraception, as she knew it would be ill-advised to go on the pill. There are no other relevant history findings.

Questions

1. Using only this information, list the possible causes of the patient’s abdominal pain. Justify your answer.

2. Why was she asked about the presence of preceding peri-umbilical pain?

3. Why do you think she was ill-advised to take oral contraceptive pills (OCPs)?

4. What do you need to examine in this patient?

Physical examination

General	Leonie appears unwell and in some distress
Vitals	•Pulse rate/min	92
	•Respiratory rate/min	18
	•Blood pressure mm Hg	122/82
	•Height (cm)	160
	•Weight (kg)	52
	•BMI	20.3
	•Temperature (degrees C)	38.7
HEENT	Unremarkable
Chest	Chest clear, no cardiomegaly, no murmurs
Abdomen	Tender in right iliac fossa with guarding No masses palpated

Questions

5. What information can you obtain from these findings? Can you now narrow your differential diagnosis?

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