Main symptoms of acute abdomen: pain, indigestion, vomiting, dysphagia, altered bowel habit, anorexia, weight loss.
Pain is the most common and important symptom in surgical practice. (It used to be said with some truth that pain and blood were the only two events that brought patients quickly to the doctor.) Pain is universal and can be caused by benign or malignant disorders and elective or acute conditions. It is the symptom that is least commonly overlooked by patients, although the threshold for pain varies considerably from one person to another. The information required to establish the clinical significance of pain is shown:
- Relieving factors
- Aggravating factors
Pain maybe referred to the corresponding sensory dermatome. This is exemplified by shoulder tip pain due to a subphrenic abscess causing irritation of the ipsilateral phrenic nerve.
Indigestion or dyspepsia are loosely defined words that denote epigastric discomfort or pain occurring either during fasting or during or after meals and indicate disease within the upper digestive and biliary tract. The practical problem encountered with these symptoms relates to the frequency with which normal individuals experience indigestion. One study has shown that 70% of people living in the UK experience episodes of indigestion and heartburn from time to time and reports from other western countries indicate a similar prevalence. The key issue in clinical practice is what constitutes abnormal indigestion. This is difficult to define and for this reason diagnosis of serious conditions, such as gastric cancer, is often delayed as the general practitioner usually prescribes medication designed to produce symptomatic relief. Meanwhile the tumour progresses and is often incurable by the time the diagnosis is made. Thus in most western countries 90% of all gastric cancers are advanced at the time of presentation. There are certain practical considerations related to dyspepsia that must never be overlooked and which require investigation by endoscopy rather than empirical symptomatic treatment. From the symptomatic viewpoint, dyspepsia is often classified into:
- ulcer dyspepsia;
- reflux dyspepsia;
- malignant dyspepsia;
- non-ulcer dyspepsia;
- gallbladder dyspepsia.
Dysphagia signifies inability to swallow and maybe caused by motility disorders or organic disease that encroaches on the lumen of the oesophagus, such as stricture or neoplasm. This symptom always warrants urgent investigation by flexible endoscopy and a barium swallow. The difficulty in swallowing may be experienced in relation to liquids and solids. In some patients with inflammatory mucosal disease, the dysphagia is accompanied by pain. This symptom complex is known as odynophagia. Dysphagia due to organic disease is progressive and without treatment the patient may eventually be unable to swallow saliva due to complete occlusion of the oesophageal lumen. Dysphagia caused by motility disorders such as achalasia maybe intermittent. High dysphagia due to bulbar palsy or cricopharyngeal spasm is accompanied by spluttering and choking as the bolus, unable to negotiate the upper oesophageal sphincter, spills over into the larynx.
In the presence of significant oesophageal occlusion, dysphagia is accompanied by regurgitation, which is passive and effortless as opposed to vomiting. In patients with dysphagia, spillage of retained food debris in the dilated oesophagus across the cricopharyngeus into the larynx may occur in the supine position during sleep, leading to aspiration and pneumonitis. This accounts for the chronic productive cough and fever encountered in patients with long-standing dysphagia.
Anorexia, weight loss
Anorexia denotes loss of appetite. This may be due to an abnormal psychiatric state, e.g. anorexia nervosa, although in surgical patients loss of appetite is usually caused by malignant neoplasms, usually of the upper digestive tract and pancreas. Anorexia must be distinguished from fear of eating because of precipitation of symptoms or inability to eat consequent on a disordered swallowing mechanism from any cause. Anorexia is invariably accompanied by weight loss due to diminished protein-calorie intake. However, there are other causes of weight loss. Some malignant tumours are accompanied by the development of a catabolic state such that the weight loss is out of proportion to the reduced dietary intake (cachexia).
Some patients lose weight because they are unable to assimilate ingested food. This may be the result of impaired digestion of foodstuffs (e.g. diminished pancreatic enzymes in chronic pancreatitis), reduced bile salt pool from any cause (malabsorption of fats), bacterial overgrowth, intrinsic disease of the small-bowel mucosa (coeliac disease, brush-border enzyme deficiencies), disorders affecting the small bowel (Crohn’s disease) or extensive resection of the small intestine (short gut syndrome).
Vomiting is an active process, involving violent contractions of the abdominal musculature that forcibly expel the gastric contents in a retrograde fashion. During vomiting the lower oesophageal sphincter and the cricopharyngeus are reflexly opened and the glottis is closed. In surgical practice, vomiting may have a cerebral cause, such as raised intracranial pressure due to a space-occupying lesion. More commonly, however, it is the result of acute intra-abdominal disease or obstruction of hollow organs. Thus, nausea and vomiting may be a feature of such diverse conditions as acute appendicitis, acute gastritis (drug or alcohol induced), exacerbation of peptic ulceration, acute pancreatitis, renal and biliary colic. Vomiting is a predominant feature of an obstructed stomach (pyloric stenosis).
The nature of the vomit is important. In obstructions proximal to the pylorus, the vomit does not contain bile. Vomiting of blood (haematemesis) is encountered in bleeding lesions of the lower oesophagus, stomach, duodenum. The blood may be fresh or dark and ‘coffee- ground’ in appearance as a result of digestion by hydrochloric acid and pepsin in the stomach. In pyloric stenosis, the vomit often contains portions of food that the patient had ingested several hours, sometimes days, beforehand. In some of these patients, the vomiting may be selfinduced in an effort to relieve the upper abdominal discomfort caused by a distended stomach.
Vomiting in the unconscious state (e.g. head injury, alcoholic stupor and during recovery from general anaesthesia) is particularly dangerous in view of the distinct possibility of inhalation of vomit into the tracheobronchial tree, with severe pulmonary damage and the development of acute (formerly referred to as adult) respiratory distress syndrome.
Vomiting is a major clinical presentation of acute small- bowel obstruction, where it is accompanied by variable abdominal distension and constipation.
Altered bowel habit
Strictly speaking, this term is applied to patients with previously regular bowel habits who suddenly develop constipation, diarrhoea or diarrhoea alternating with constipation. This is a feature of some but not all patients who develop a colonic neoplasm in the left colon or upper rectum. The difficulty lies in establishing what was normal for the patient beforehand. Because of the diminished dietary intake of fibre in western countries, constipation and low-bulk stools are undoubtedly very common, as are disorders of colonic transit (diverticular disease, slow- transit constipation). There is also a tendency towards constipation with increasing age.
In patients with rectal, lower sigmoid carcinoma, the constipation may also be accompanied by a feeling of incomplete evacuation after defecation. This is often referred to as tenesmus. Other symptomatic accompaniments in these patients include the passage of mucus and rectal bleeding, which is mixed with the motion.
Bloody diarrhoea is a feature of colonic inflammatory bowel disease and infective colitis. Diarrhoea may also signify the presence of colonic motility disorders, exemplified by irritable bowel syndrome. This common obscure condition can also present with constipation.
Foul-smelling diarrhoea that floats and is difficult to flush away is encountered in malabsorption. Because the faeces contains a large amount of fat, the term steatorrhoea is often used in this condition. Passage of foul-smelling tar-like liquid or solid motion (melaena) indicates a proximal source of bleeding in the gastrointestinal tract.