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142 Chapter 4: Gastrointestinal system

Tenderness to palpation with associated guarding (the Serum amylase measurement is useful in diagnosing

reflex tensing of their abdominal wall musculature to pancreatitis.
prevent further pain on palpation). Urinalysis for sugar, ketones, protein, blood, bilirubin
Rebound tenderness (pain worse on sudden release and urobilinogen.

of palpation, which is often more severe than on Imaging: Erect chest X-ray, abdominal X-ray, ultra-
palpation). sound or CT scan may be helpful.
The patient is often generally unwell and may be shocked
due to dehydration and loss of fluid into extravascular Management
spaces such as the lumen of the bowel and the abdominal Patients may require resuscitation, and general manage-
cavity. See Table 4.1 for causes. ment includes the following:
Nilby mouth, nasogastric tube and i.v. fluids if vom-

iting, obstructed or perforated (drip and suck).
Investigations If shocked, a fluid balance chart should be started and
Full blood count (often normal, but leucocytosis may

where appropriate urinary catheterisation to monitor
be present).
output.
Urea and electrolytes, and liver function tests should Broad-spectrum antibiotics are often used.

be performed. Subsequent management is directed at the underlying
cause.
Table 4.1 Causes of an acute abdomen
Dyspepsia
Pathological
process Disease
Definition
Inflammation Dyspepsia is a group of symptoms that suggest disease
Appendix Acute appendicitis of the upper gastrointestinal tract.
Gallbladder Acute cholecystitis
Colon Diverticulitis
Fallopian tube Pelvic inflammatory disease Prevalence
Pancreas Acute pancreatitis Dyspepsia has a prevalence of between 23 and 41% in
Obstruction Western populations.
Intestine Intestinal obstruction
Biliary system Biliary colic Aetiology/pathophysiology
Urinary system Ureteric obstruction/colic. Acute
urinary retention Diagnosesmadeatendoscopyincludegastritis,duodeni-
Ischaemia tis or hiatus hernia (30%); oesophagitis (10–17%); duo-
Small/large bowel Strangulated hernia denal ulcers (10–15%); gastric ulcers (5–10%) and oe-
Volvulus sophageal or gastric cancer (2%); however, in 30% the
Mesenteric ischaemia
Perforation/rupture endoscopy is normal. Functional dyspepsia describes the
Duodenum/ Perforation of peptic ulcer or presence of symptoms in the absence of mucosal abnor-
stomach eroding tumour mality, hiatus hernia, erosive duodenitis or gastritis.
Colon Perforated diverticulum or tumour
Fallopian tube Ruptured ectopic pregnancy Clinical features
Abdominal aorta Ruptured aneurysm Patients may complain of upper abdominal discomfort,
Ruptured spleen Trauma retrosternal burning pain, anorexia, nausea, vomiting,
Nonsurgical causes Myocardial infarction,
gastroenteritis (inc. typhoid bloating, fullness and heartburn.
fever, cholera and E. coli ),
diabetes mellitus, Henoch Investigations and management
Sch ¨onlein purpura, lead colic, Current UK guidelines suggest
basal pneumonia, tuberculosis, All patients over the age of 55 years with new onset
porphyria, sickle cell crisis, of uncomplicated dyspepsia and patients of any age
malaria, phaeochromocytoma
with ‘alarm symptoms or signs’ (see Table 4.2) should