Sunday, March 4, 2001		Keeping fit

THERE is a good degree of public awareness about heart diseases, strokes and cancers because of their dramatic presentation and outcome. Abdominal medical and surgical emergencies are often ignored and their diagnosis and treatment delayed although the rate of morbidity and mortality in them is considerable. Surgeons call it "acute abdomen", which is a bagful of serious emergencies. Physicians call it as a "Pandora’s box" — anything may come out of this closed cavity. Unlike the chest and the skull, there are a large number of organs and systems in the abdomen including stomach, intestines and appendix attached to it, liver, spleen, gall bladder, kidneys and their drainage system, female reproduction organs and other support system (Fig. 1).

Pain may be a harbinger of any emergency to begin with. Surgeons and physicians have to piece together various symptoms to reach the proper diagnosis. Recent technological advancements such as ultrasound and CT scan have made their job easier but it still defies them for days and weeks. Patients and their families need to take note of it and should neither panic nor wishfully delay medical help beyond a reasonable time.

The term acute abdomen defines a clinical syndrome characterised by the sudden onset of severe abdominal pain requiring emergency medical or surgical treatment. A prompt and accurate diagnosis is essential. The differential diagnosis includes an enormous spectrum of disorders, ranging from simple self-limited disease to conditions that require emergency surgery. There is no way to predict or prevent an acute abdomen. It can occur in anyone, anywhere.

Although most causes of abdominal pain are related to diseases of the gastrointestinal tract, urinary tract and the gynaecological subsystem, one must be aware of abdominal pain from other causes. The subjective nature of pain and the fact that common symptoms may arise from a broad spectrum of diseases combine to make interpretation difficult. Time of onset of pain, its location, its referral, and whether a change in character occurs with various postures, needs to be highlighted.

It is important to notice the site of pain at the onset from the site at the time of presentation. Pattern of radiation of pain is helpful — right shoulder (gall bladder), left shoulder (spleen), mid back (pancreas), flank (urinary tract), groin (urinary tract).

Factors that precipitate or relieve pain should be enquired — relationship to eating (stomach, gall bladder, pancreas), urination (kidney), position (pancreas), or menstruation.

Location of pain (Fig. 2)

Appendix pain usually occurs in the lower right abdomen. It may start as a vague discomfort around and just above the umbilicus and later a sharper pain in the lower right quadrant of the abdomen, with possible nausea, vomiting and loss of appetite, fever and pain on pressing the lower right abdomen.

Gallstones can cause upper abdominal pain, nausea, vomiting, heartburn and back pain. Along with pain, one may have yellowing of the eyes (jaundice) and inflammation) of the pancreas (pancreatitis). Pain usually occurs in the upper right side of the abdomen and radiates to upper right side of the back. It usually begins one to three hours after a meal and persists for several hours. It may be accompanied by nausea and vomiting.

Kidney stones may cause severe pain in the flank (the area between the last rib and the hip) and/or pubic region. Chills, fever, frequent or difficult urination are common.

Upper mid-abdominal pain, between umbilicus and the end of the breast bone is because of peptic ulcer. Peptic ulcers are eroded areas in the protective lining of the stomach and are caused by excess stomach acids and other irritants.

Upper abdominal pain, diarrhoea, nausea and vomiting blood or what looks like coffee grounds may be because of gastritis (a painful inflammation of the lining of the stomach). Pain may be associated with heartburn (a burning sensation) from the upper abdomen and spreading into the lower breast bone and is caused by the flow of acid from the stomach into the food pipe.

In a patient with known inguinal hernia, increased or severe groin pain especially if accompanied by nausea and vomiting and groin bump feels very tender, is a pointer towards obstructed hernia or strangulated hernia (a part of the intestine gets pinched off). In event of an increasing pain in the abdomen, scrotum or groin, think of complication in a hernia and do not apply pressure to push hernia back into the abdominal wall.

Abdominal pain that begins in the midepigastrium, with a penetrating quality and radiating to back is a typical feature of acute pancreatitis. Nausea and vomiting frequently accompany the abdominal pain. Along with pain, patient may have fever, increased heart rate and abdominal distension. Pain may be relieved by sitting forward.

Pain that is sudden in onset, sharp and severe, wakes the patient from sleep or incapacitates at work suggests a perforated hollow organ.

Cramp in, intermittent type of pain in the centre of the abdomen is present in small bowel obstruction, Cramping, intermittent pain which subsequently becomes a dull constant pain is ominous and is indicative of gangrene of the intestine.

Vomiting is a prominent symptom of inflammation of the pancreas, gall bladder and in acute appendicitis. Cramping abdominal pain, that is relieved by vomiting, is a feature of intestinal blockade. Constipation, diarrhoea and a recent change in bowel habits are important factors in a patient with abdominal pain. Absence of passage of both stool and flatus with progressive abdominal distension and vomiting is a feature of bowel obstruction.

Intense abdominal pain associated with syncope, low blood pressure, fever, points to perforation of a hollow viscus, gangrene of the intestine, or rupture of major blood vessels. Pain from gallstone or kidney stones often causes patient to writhe in discomfort. Pallor, sweating, cold clammy skin, increased heart rate, rapid respiration, low blood pressure along with pain indicates a serious intra abdominal disease.

Severe dehydration with dry mucous membranes, sunken hollow eyes and rapid shallow respiration suggests perforation of an abdominal organ. Patient lying perfectly still points to the diagnosis of a perforated viscus or gangrene of the intestine.

Many women suffer from painful menstrual cramps — mild to severe cramping in the lower abdomen, back or thighs, headache, diarrhoea, nausea, dizziness and fainting. Consult a doctor if cramps fail to respond to home treatment, and if symptoms do not subside when menstrual bleeding stops. Ectopic pregnancy needs to be considered when there has been a missed period.

Lower abdomen midline pain in women may be due to a number of causes like inflammation of the tubes and ovaries, or ectopic pregnancy. Pain may radiate to the right or left lower quadrant.

Tubal pregnancy (ectopic pregnancy) may present as an acute abdomen with sudden lower abdominal pain, which is sharp in character and persistent with or without nausea and vomiting. A missed menstrual period or an abnormally short scanty period precedes the abdominal pain. Pain may be referred to the shoulder. The pain worsens with time and patient may develop low blood pressure and increased heart rate.

Acute abdominal pain during pregnancy may be due to a number of conditions like acute appendicitis, acute cholecystitis and intestinal obstruction. These may occur during any trimester of pregnancy. Acute abdominal pain should not be ignored and should not be taken as a part of pregnancy. Always consult you doctor. Delay in presentation is hazardous both for the mother and the foetus.

(a) Consult your doctor especially — (i) if pain and vomiting is persistent, (ii) pain associated with shortness of breath, sweating or extreme pallor, (iii) disabling pain and unable to urinate, (iv) pain associated with chills, fever, rapid pulse, constipation, weakness or fatigue or a sickly appearance, (v) pain recurs and gets localised to a specific point in the abdomen, (vi) worsening of pain when the area is touched or with movement, deep breathing or coughing.

b) Do not take/give laxatives, they can stimulate the intestine and cause appendix to rupture.

c) Do not take/give strong pain medication. As the location and severity of pain are diagnostic clues, strong pain relievers may mask important information.

d) Keep a careful record of the following symptoms — nausea, vomiting, constipation, diarrhoea and fever.

e) Do not ignore acute abdominal pain in pregnancy.

f) Do not take or give food or drink until talking to your doctor. It is best to have an empty stomach if surgery is necessary.

g) Do not ignore your groin hernia or any previous operation. This may be the cause of your acute abdomen.

All complaints of abdominal pain must be considered serious until all reasonable diagnostic efforts prove to the contrary. A careful description of pain, time of onset, location and change in character and position provide helpful clues to the diagnosis. An accurate menstrual history is especially valuable in the assessment of abdominal pain in the female. Intra abdominal pain localised by the patient in various anatomic sites is helpful to the clinician in analysing the potential cause.

Referral of pain to the right shoulder is frequently noted in patients with gallstones and is rarely observed with other causes of abdominal pain. Pain from the small intestine rarely radiates to the back. The information provided helps the clinician in formulating diagnostic studies which can be performed rapidly on an emergency basis and treatment planning.

Finally, a word about ‘acute abdomen’ which does not originate in the abdomen. The chest and abdominal cavity is divided by the diaphragm which is the major respiratory muscle also. Food pipe and various blood vessels traverse through it both ways. Pain originating in the chest, mainly due to heart, can present in the upper abdomen and mislead not only the patient but the doctors as well. One knows numerous examples where a heart attack was passed as ‘acidity’ for precious many hours or days. The clue lies in the accompanying features of disproportionate weakness, sweating and changes in pulse and blood pressure. An electrocardiogram and other tests will help. Conversely some of the abdominal conditions like hiatus hernia and gastro-oesophageal reflux can present with chest symptoms. Seeking the medical help early is the key.