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Diseases » Stomach cancer » Diagnosis

Diagnosis of Stomach cancer

Diagnostic Test list for Stomach cancer:

The list of medical tests mentioned in various sources as used in the diagnosis of Stomach cancer includes:

Stomach cancer Diagnosis: Book Excerpts

Tests and diagnosis discussion for Stomach cancer:

To find the cause of symptoms, the doctor asks about the patient's medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:

Fecal occult blood test -- a check for hidden (occult) blood in the stool. This test is done by placing a small amount of stool on a plastic slide or on special paper. It may be tested in the doctor's office or sent to a laboratory. This test is done because stomach cancer sometimes causes bleeding that cannot be seen. However, noncancerous conditions also may cause bleeding, so having blood in the stool does not necessarily mean that a person has cancer.

Upper GI series -- x-rays of the esophagus and stomach (the upper gastrointestinal, or GI, tract. The x-rays are taken after the patient drinks a barium solution, a thick, chalky liquid. (This test is sometimes called a barium swallow.) The barium outlines the stomach on the x-rays, helping the doctor find tumors or other abnormal areas. During the test, the doctor may pump air into the stomach to make small tumors easier to see.

Endoscopy -- an exam of the esophagus and stomach using a thin, lighted tube called a gastroscope , which is passed through the mouth and esophagus to the stomach. The patient's throat is sprayed with a local anesthetic to reduce discomfort and gagging. Patients also may receive medicine to relax them. Through the gastroscope, the doctor can look directly at the inside of the stomach. If an abnormal area is found, the doctor can remove some tissue through the gastroscope. Another doctor, a pathologist , examines the tissue under a microscope to check for cancer cells. This procedure -- removing tissue and examining it under a microscope -- is called a biopsy . A biopsy is the only sure way to know whether cancer cells are present. (Source: excerpt from What You Need To Know About Stomach Cancer: NCI)

Diagnosis of Stomach cancer: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Stomach cancer:

Diagnostic Tests for Stomach cancer: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Stomach cancer.

ABDOMINAL PAIN, CHRONIC RECURRENT: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Is there a family history of migraine or epilepsy? Migraine and epilepsy both present with abdominal pain.
Is the pain colicky or persistent? Chronic colicky abdominal pain may be due to chronic cholecystitis, cholelithiasis, renal calculus, or partial intestinal obstruction.
What is the location of the pain? If the pain is located in the upper abdomen, then one should consider peptic ulcer disease, pancreatitis, cholecystitis, and cholelithiasis. If the pain is located in the flanks, one should consider renal calculus and pyelonephritis. If the pain is located in the lower abdomen, one should consider diverticulitis, salpingitis, endometritis, and chronic appendicitis. Regional ileitis also may be located in the lower abdomen, particularly in the right lower quadrant.
What is the relationship to meals? Abdominal pain relieved by food may be due to a peptic ulcer. Abdominal pain brought on by food may be due to abdominal angina. If the pain comes on 2 to 3 hr after a meal, it may be due to a peptic ulcer. On the other hand, pain that comes on 1 to 2 hr after meals, especially if it's a fatty meal, may be related to cholecystitis and cholelithiasis.
Is there fever associated with the abdominal pain? Fever and abdominal pain may be due to pyelonephritis, diverticulitis, or appendicitis.
Is there a history of chronic alcoholism? The history of chronic alcoholism suggests acute and chronic pancreatitis.
Is there blood in the stool? The presence of blood in the stool would, of course, suggest peptic ulcer disease and diverticulitis.
Is there an abdominal mass? The presence of an abdominal mass, particularly in the midepigastrium, suggests a pancreatic cyst related to chronic pancreatitis. A mass in the right lower quadrant might be related to regional ileitis or salpingitis. A mass in the left lower quadrant may be related to diverticulitis and salpingitis.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, sensitivity, colony count, chemistry panel, serum amylase and lipase, pregnancy test, stool for occult blood, and stools for ovum and parasites. A chest x-ray, EKG, and flat plate of the abdomen should also be done. A urine porphobilinogen will help exclude porphyria.

If these tests are negative, then an upper gastrointestinal (GI) series, esophagogram, and gallbladder ultrasound would be done for upper abdominal pain; an IVP would be done for flank pain; and a barium enema and sigmoidoscopy would be performed for lower abdominal pain.

If these studies are inconclusive, a gastroenterologist should be consulted for endoscopic procedures. If there is upper abdominal pain, esophagoscopy, gastroscopy, and duodenoscopy would be performed. Endoscopic retrograde cholangiopancreatography (ERCP) may be required to diagnose cholangitis or common duct stones. If there is lower abdominal pain, colonoscopy would be performed. A CT scan of the abdomen and pelvis is a useful diagnostic tool also. Gallium scans may detect a diverticular abscess or other localized area of chronic inflammation. Pelvic ultrasound may be useful in lower abdominal pain, especially in females. Aortography and angiography will be useful in abdominal angina. Lymphangiography can be helpful in discovering retroperitoneal tumors. Ultimately, exploratory laparotomy may still be necessary in some cases.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ABDOMINAL PAIN, ACUTE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Where is the pain located? If it is diffuse, one should consider pancreatitis, mesenteric artery occlusion, or ruptured peptic ulcer. In addition, another viscus may be perforated, such as a ruptured ectopic, and there may be peritonitis. If it is focal, we need to know what quadrant it is in. For example, acute cholecystitis is in the right upper quadrant, whereas diverticulitis is usually in the left lower quadrant.
What is the nature of the pain? Colicky abdominal pain suggests intestinal obstruction, renal calculus, and cholelithiasis or common duct stone, whereas constant pain is typical of pancreatitis, a ruptured peptic ulcer, appendicitis, diverticulitis, and a ruptured ectopic pregnancy.
Does the pain radiate? The pain of acute cholecystitis typically radiates to the right scapular or right shoulder. The pain of a ruptured peptic ulcer may also radiate to the shoulder. The pain of acute renal calculus may radiate to the testicle.
What are the associated signs and symptoms? Shock with generalized tenderness and rebound and diminished or absent bowel sounds should suggest a ruptured peptic ulcer or acute pancreatitis. However, acute right upper quadrant pain with nausea and vomiting should suggest acute cholecystitis. On the other hand, appendicitis is more insidious in onset and is associated with anorexia and nausea, rarely vomiting, as well as constipation. Renal colic presents with hematuria.
Could this patient's abdominal pain be due to an extra-abdominal condition? Remember, lobar pneumonia, myocardial infarction, diabetic acidosis, and porphyria may be responsible for acute abdominal pain. There are numerous other conditions that need to be considered.

DIAGNOSTIC WORKUP

It is wise to consult a general surgeon at the outset. All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!

When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.

If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient's condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Abdominal Pain in Lower Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right lower quadrant

Appendicitis
Diverticulitis
Salpingitis/Pelvic inflammatory disease
Endometritis
Endometriosis
Ectopic pregnancy
Hemorrhage or rupture of ovarian cyst
Renal calculus
Intussusception
Pelvic/hypogastric region
Cystitis
Salpingitis/Pelvic inflammatory disease
Ectopic pregnancy
Diverticulitis
Strangulated hernia
Endometriosis
Appendicitis
Ovarian cyst
Ovarian torsion
Testicular torsion
Bladder distension
Nephrolithiasis
Prostatitis
Malignancy
Abdominal aortic aneurysm
Left lower quadrant
Diverticulitis
Intestinal obstruction
Colitis
Strangulated hernia
Inflammatory bowel disease
Gastroenteritis
Pyelonephritis
Nephrolithiasis
Mesenteric lymphadenitis or thrombosis
Aortic aneurysm
Volvulus
Salpingitis/Pelvic inflammatory disease

Workup and Diagnosis

Complete history and examination
–Note progression of symptoms (duration, rapidity of onset, intensity), associated complaints (e.g., anorexia, diarrhea, fever), urinary complaints, exposure to illness and medication, and past medical history including prior episodes
–Note body positioning that tends to relieve pain; signs of dehydration or fever
–Vitals and full pulmonary, cardiac, abdominal, back, pelvic, and rectal examinations
–Abdominal examination should include bowel sounds, distension, tympany, tenderness, palpation for masses and organomegaly, rebound tenderness, and guarding
Initial evaluation includes CBC with differential cell counts, electrolytes, BUN/creatinine, glucose, calcium, urinalysis, urine culture, and β-hCG level

Abdominal/pelvic ultrasound and/or CT, obstructive series, and KUB may be indicated
Consider endocervical gonorrhea/chlamydia cultures in sexually active females, laparoscopy, barium enema, intravenous pyelogram, stool cultures, and/or fecal fat

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain in Upper Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right upper quadrant pain

Cholecystitis
Fatty liver or NASH
Congested liver (e.g., secondary to heart failure)
Cholangitis
Hepatitis
Gastritis or pancreatitis (see below)
Pneumonia
Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis secondary to pelvic inflammatory disease)

Epigastric pain

Gastritis
PUD
Pancreatitis
Gastroenteritis
Intestinal obstruction
Myocardial infarction
Aortic aneurysm
Left upper quadrant pain
Peptic ulcer disease
Gastritis
GERD
Splenic infarct
Pulmonary embolism
Pancreatitis
Acute splenomegaly (e.g., mononucleosis)
Left lower lobe pneumonia
Nonfocal pain
Herpes
Sickle cell crisis
Irritable bowel
Mesenteric ischemia
Peritonitis
Pleurisy
Uremia
Lead poisoning
Porphyria
Toxin ingestion

Workup and Diagnosis

History of associated symptoms; relation of pain to eating; anorexia; alcohol use; and location, quality, and intensity of pain
Physical exam should focus on heart, lungs, abdomen, and back examinations
Initial laboratory tests may include CBC with differential, electrolytes, urinalysis, BUN/creatinine, liver function tests, LDH, amylase/lipase, magnesium, and PT/PTT/INR
Chest and abdominal X-rays
Abdominal ultrasound and/or CT scan
Hepatitis viral serology
Percutaneous transhepatic cholangiography (PTCA) and/or ERCP
Upper GI endoscopy (EGD) or upper GI series with barium swallow
Cultures of blood, urine, and trachea/gastric aspirates
Evaluation of possible cardiac and pulmonary etiologies may require ECG (pulmonary embolus may show S in I, Q in III, inverted T in III), cardiac isoenzymes, pleural tap, echocardiogram, and stress test

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain with Rebound Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

Appendicitis is the most common etiology
Cholecystitis
Diverticulitis
Gastroenteritis
Pancreatitis
Perforated duodenal ulcer
Gastritis
Biliary or renal colic
Mesenteric ischemia
Ruptured abdominal aortic aneurysm
Bowel obstruction
Bacterial peritonitis
Intra-abdominal or pelvic abscess
Colitis
Urinary tract infection or pyelonephritis
Perforated viscus
Sickle cell crisis
Gynecologic etiologies
–Pelvic inflammatory disease
–Tubo-ovarian abscess
–Ruptured ectopic pregnancy
–Ovarian cyst rupture or torsion
Intussusception
Nonabdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, atypical angina, pericarditis, pneumonia, pulmonary embolus, and pelvic pathology (e.g., pelvic inflammatory disease, ovarian torsion)

Workup and Diagnosis

Distinguish etiologies requiring emergent or urgent surgical intervention (e.g., ruptured aortic aneurysm, perforated viscus, appendicitis, intestinal obstruction, ischemic bowel, ruptured ectopic pregnancy) from non-emergent causes

History and physical examination
–Nature of pain, location, onset, duration, intensity, similarity to past episodes, aggravating and alleviating factors, guarding, bowel sounds, distension, presence of a mass, blood on rectal exam, and cervical or adnexal tenderness
–In general, patients who present with extremely severe pain of immediate onset require surgical intervention
–Crampy, colicky pain that occurs in waves implies distension of a hollow viscus (e.g., renal colic, intestinal obstruction)
–Constant, localized pain implies inflammation (e.g., appendicitis, diverticulitis, cholecystitis)
–Hypotension and shock may be present

Initial tests include CBC, electrolytes, BUN/creatinine, LFTs, amylase/lipase, urinalysis, and pregnancy test
Plain abdominal X-rays may reveal obstruction, perforation (free air), or other pathology
Ultrasound is a quick, inexpensive test for biliary tract disease, AAA, ectopic pregnancy, or peritoneal fluid
Abdominal CT will often establish the diagnosis for appendicitis, aortic aneurysm, and diverticulitis
Diagnostic peritoneal lavage may be indicated in cases of suspected trauma, bowel perforation, or peritonitis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Constipation/inability to pass stool
–Most commonly due to dehydration and/or low dietary fiber intake
–Hirschsprung's disease (congenital aganglionic megacolon)
–Medications: Narcotics, opiates, or anticholinergic medications
–Ogilvie's syndrome (colonic pseudo-obstruction)

Ascites
–May be due to malignancy, nephrotic syndrome, liver disease, or congestive heart failure

Large or small bowel obstruction

Soft tissue mass
–Tumor (e.g., ovarian, uterine, bowel, liver)
–Uterine fibroids
–Lipoma: Soft, fleshy, mobile, and contained in the subcutaneous tissue of the abdominal wall
–Hernia: Bowel sounds may be audible over the mass; incarceration causes pain; strangulation leads to bowel death
–Pyloric stenosis: Seen primarily in infants; palpable pyloric olive-shaped mass
–Pregnancy
–Massive lymphadenopathy (e.g., lymphoma)
–Organomegaly (e.g., hepatomegaly, splenomegaly)
–Infection: Intra-abdominal or tubo-ovarian abscess
–Abdominal aortic aneurysm: Associated with pulsatile mass and hypotension

Cyst
–Mesenteric cysts: Fluid collections in the mesentery; typically benign
–Hydatid cyst: Caused by larval form of Echinococcus granulosus; typically found in the liver in patients with history of travel to tropical areas
–Dermoid cyst: May be massive due to delayed presentation
Palpable gallbladder (Courvoisier's sign): Associated with common bile duct obstruction and a distended gallbladder

Workup and Diagnosis

History and physical examination
–Note associated symptoms (especially fever, changes in bowel habits, weight change, urinary symptoms, and rectal bleeding)
–Abdominal and pelvic examinations to localize areas of tenderness
Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, liver function tests, urinalysis, and β-hCG
Tumor markers (if malignancy is a concern), blood cultures (if infection is suspected), and toxicology screen may be indicated
Plain KUB X-rays may reveal constipation, obstruction, or free intraperitoneal air
Abdominal CT scan with IV and oral contrast will evaluate for abscess, bowel pathology, and hepatosplenomegaly
Barium enema may reveal abnormal bowel in cases of malignancy
Colonoscopy is useful for diagnosis of bowel pathology
Laparoscopy allows direct visualization of the intra-abdominal cavity
Paracentesis with fluid evaluation

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Epigastric pain

Peptic ulcer disease/GERD
–May be due to Helicobacter pylori or NSAID use

Gallbladder disease
–Most commonly with hemolytic disorders

Pancreatitis
–Trauma and idiopathic are common causes

Periumbilical pain

Functional abdominal pain/IBS
–Most common cause of nonorganic pain
–Occurs in children 3–15 years old
Appendicitis
–Periumbilical pain moves to RLQ
Gastroenteritis (virus, bacteria, parasite)
Carbohydrate intolerance
–Lactase, fructase, trehelase deficiency
Abdominal migraine
Drugs
–Antibiotics, anticonvulsants, bronchodilators
Small bowel bacterial overgrowth
Streptococcal pharyngitis
Suprapubic pain
Urinary tract infection
–With dysuria, fever, foul-smelling urine
–Pyelonephritis may have CVA tenderness
Constipation
–Accounts for 3% of visits to pediatrician
–May have a palpable fecal mass
Urinary retention

Hydrometrocolpos
–Associated with imperforate hymen
–Cyclic pain with onset of menstrual cycle

Right lower quadrant pain

Appendicitis
Ovarian torsion
Pelvic inflammatory disease
Ectopic pregnancy
Mittelschmerz
–Pain midcycle with ovulation
Inflammatory bowel disease
–Classic for terminal ileal Crohn disease
Iliopsoas abscess
Inguinal hernia
Right lower lobe pneumonia

Workup and Diagnosis

History
–Type of pain, location, radiation, duration
–Relieving and worsening factors including foods
–Awakens from sleep, activity level, emesis, diarrhea
–Nausea, hematochezia, melena, fever, dysuria, hematuria
–Sexual activity, anorexia, headache, cough, rashes
–Stool frequency, joint complaints

Surgical history: Previous abdominal surgery
Social history: Stressors, changes in school or family
Physical exam
–Height, weight, temperature, pulse
–General appearance, hydration status
–Pharyngeal erythema/exudates, abdominal tenderness
–Psoas sign, obturator sign, palpable masses
–Rectal exam including hemoccult
–Rashes, joint swelling, vaginal exam
Labs: Geared toward history and physical findings
–Consider CBC with differential, urinalysis, and culture
–stool for culture and O&P
–Amylase and lipase, LFTs, H. pylori antibody (IgG)
–Hydrogen breath test for sugar intolerance
–Pregnancy test, vaginal cultures
–Throat culture
Consider KUB or obstruction series
Abdominal CT scan with contrast versus ultrasound
Pelvic ultrasound for torsion, ectopic pregnancy, abscess, hydrometrocolpos

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Wilms tumor
–More common in younger children
Neuroblastoma
–More common in younger children

Leukemia/lymphoma
–Involvement of retroperitoneal nodes, liver, or spleen

Hepatic tumors
–Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease

Germ cell tumors
–Ovarian, teratoma
Soft tissue sarcoma
–Rhabdomyosarcoma

Rare malignancies in children
–Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor

Cystic masses
–Ovary, renal, mesenteric

Benign tumors
–Adenomas (especially of liver), hamartomas, pheochromocytoma

Vascular lesions (e.g., hemangioma)

Renal etiologies
–Distended, nonemptying bladder, bladder outlet obstruction
–Congenital mesoblastic nephroma
–Severe hydronephrosis

Gynecologic
–Ovarian torsion, endometriosis, pelvic inflammatory disease

Gastrointestinal
–Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia

Pancreatic pseudocyst

Infectious
–Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly

Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine

Workup and Diagnosis

History
–Mass duration, growth rate, pain; fever, weight loss, bone pain, night sweats
–Anorexia, vomiting, constipation or diarrhea, early satiety, jaundice; prematurity, umbilical catheterization; opsoclonus, myoclonus (neuroblastoma)
–Vaginal bleeding/amenorrhea, sexual activity, previous pregnancies/fertility, history of STDs; urinary dysfunction, congenital urinary tract anomalies
–Signs of catecholamine excess (sleeplessness, jitteriness, flushing, hypertension)

Family history: Wilms tumor, neurofibromatosis, hepatic tumors, Beckwith-Wiedemann
Physical exam: Vital signs, toxicity, pallor, puffiness; location, size, tenderness, consistency of mass; hemihypertrophy (with Wilms), lymph nodes; wheezing, rales, SVC syndrome; presence of ascites, visible venous dilation; testicular exam, rectal; pelvic examination in teenagers; petechiae, purpura/ecchymoses, café au lait spots
Labs: CBC with differential; electrolytes, BUN, Cr, LFT albumin, urinalysis; LDH, uric acid, PT/PTT/INR, ferritin, viral titers (EBV, CMV, hepatitis), tumor markers, stool guaiac
Studies: KUB/upright film, chest X-ray; CT of chest/abdomen/pelvis; abdominal ultrasound; bone marrow aspirate/biopsy

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

ABDOMINAL MASS, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

ABDOMINAL PAIN, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it.

If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed with an exploratory laparotomy immediately. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Abdominal distention: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat. (See Abdominal distention: Common causes and associated findings.)

The patient may also feel unable to bend at his waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites, page 4.) Also, note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, such as falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obesity. Inspect the abdomen for signs of inguinal or femoral hernia and for incisions that may point to adhesions. Both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash — a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. However, an abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient’s abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal mass: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menstrual period was.

A complete physical examination should be performed. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes.)

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal pain: History and physical examination

(Handbook of Signs & Symptoms (Third Edition))

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last period, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Common causes and associated findings, pages 14 to 17.)

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Introduction: Malignant Neoplasms: Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))

A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).

An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:

❑as a baseline during chemotherapy to evaluate the extent of tumor spread

❑to regulate drug dosage

❑to prognosticate after surgery or radiation

❑to detect tumor recurrence.

Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Gastric cancer: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis depends primarily on reinvestigations of any persistent or recurring GI changes and complaints. To rule out other conditions producing similar symptoms, diagnostic evaluation must include the testing of blood, stools, and stomach fluid samples.

Diagnosis of gastric cancer generally requires these studies:

❑Barium X-rays of the GI tract with fluoroscopy show changes (tumor or filling defect in the outline of the stomach, loss of flexibility and distensibility, and abnormal gastric mucosa with or without ulceration).

❑ Gastroscopy with fiber-optic endoscopy helps rule out other diffuse gastric mucosal abnormalities by allowing direct visualization and gastroscopic biopsy to evaluate gastric mucosal lesions.

❑ Photography with fiber-optic endoscope provides a permanent record of gastric lesions that can later be used to determine disease progression and effect of treatment.

Certain other studies may rule out specific organ metastasis: computed tomography scans, chest X-rays, liver and bone scans, and liver biopsy. (See Staging gastric cancer, page 84.)

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Malignant spinal neoplasms: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.

❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.

❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)

❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.

❑ Computed tomography scan shows cord compression and tumor location.

❑ Frozen section biopsy at surgery identifies the tissue type.

❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Abdominal distention: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal mass: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, take a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in its size or location.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the 1st day of her last menstrual period was.

Perform a complete physical examination. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal pain: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.

Also ask about appetite changes and the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. History of present illness. Medication use, alcohol and tobacco history, and menstrual history in women are vital. When did the pain begin and what are the characteristics of the pain? Use the “OPQRST” approach outlined below to question the patient about pain characteristics.

1. O: Onset of pain. Pain of sudden onset or that awakens a patient from sleep can represent appendicitis, leaking abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, or perforating ulcer. Gradual onset of pain can represent cholecystitis, diverticulitis, inflammatory bowel disorders, or pancreatitis. Longstanding pain without debility that is worsened by emotional stress is suggestive of irritable bowel syndrome.

2. P: Palliative or Provocative factors (diet, exercise, sleep, bowel movement, and so on).

3. Q: Quality of pain—pain descriptors are often associated with specific causes:

a. “Burning” pain—ulcer

b. “Agony”—pancreatitis

c. “Shearing” or “tearing”—abdominal aortic aneurysm

d. “Colicky” or “cramping”—cholecystitis, bowel obstruction, urolithiasis, irritable bowel syndrome

e. “Constant ache”—appendicitis, peritonitis, herpes zoster

4. R: Radiation or Referred—pain from appendicitis, simple colic, and bowel obstruction from strangulation or volvulus is often first felt in the epigastrium. Abdominal causes may result in referred or radiating pain to extraabdominal sites:

a. Abdominal aortic aneurysm—to the midback

b. Biliary colic—to the right scapula

c. Renal colic—to the costovertebral angles, testicle, or thigh

d. Hernias—to the genitalia

5. Extraabdominal pathology can cause referred pain to the abdomen.

a. Cardiac ischemia—to the epigastrium

b. Scrotal pathology—to the abdomen

6. S: Severity—level of intensity (some use a 1–10 scale)

7. T: Time or Temporal relationships—with meals, after bowel movement, menses, and so on

B. Past medical history. Is there a history of previous abdominal or pelvic surgery? Prior abdominal surgery increases the risk for bowel incarceration, obstruction, and strangulation. Fallopian tube surgery and prior pelvic inflammatory disease (PID) increase a woman’s risk for ectopic pregnancy (Chapter 11.3).

C. Review of systems. Are there associated symptoms that point to a specific etiology? Chills and fever suggest infectious causes (UTI, PID, prostatitis, and pneumonia). Emesis occurring before the onset of pain is associated with appendicitis; with the onset of pain, cholecystitis or urolithiasis; after onset of pain, gastroenteritis. Late onset or feculent emesis suggests bowel obstruction; bilious emesis occurs in cholecystitis. Postprandial right upper quadrant pain is common in cholecystitis. Diarrhea with a recent travel history suggests dysentery or parasitic infections. Genitourinary complaints (dysuria, frequency, hematuria, vaginal discharge, and dypareunia) should prompt evaluation for UTI, sexually transmitted disease, and PID.

Physical examination

A thorough, targeted physical examination, directed by a complete history, leads to a correct diagnosis in most cases (2).

Complete vital signs are essential. Tachycardia or hypotension can indicate hypovolemia and the need for urgent intervention (Chapter 7.12). Rapid, shallow breaths occur with peritoneal irritation. Inspect the abdomen for distention (obstruction), pulsations (AAA), or scars from past surgery. High-pitched hyperactive bowel sounds occur with bowel obstruction. Palpation and percussion help localize tenderness, organomegaly, and masses. Pain with movement, rebound tenderness, or rigidity are indicative of peritonitis and should prompt surgical consultation.

Cardiovascular, pulmonary, and digital rectal and genitourinary examinations should be included in all evaluations of significant abdominal pain. The pelvic examination must be done to exclude ectopic pregnancy and PID. Among patients in whom pregnancy is a possibility, the presence of peritoneal signs, cervical motion tenderness, or lateral (or bilateral) abdominal or pelvic tenderness should raise concern about possible ectopic pregnancy (3).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Chronic/Recurrent Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Irritable bowel syndrome

❑ Peptic ulcer disease

❑ Cholecystitis

❑ Chronic pancreatitis

❑ Inflammatory bowel disease

❑ Intermittent mesenteric ischemia

❑ Pancreatic cancer

❑ Gastric cancer

❑ Endometriosis

❑ Recurrent intestinal obstruction

❑ Sickle cell anemia

❑ Radiculopathy

❑ Adrenal insufficiency

❑ Lead poisoning

❑ Porphyria

Diagnostic Approach

Examining a patient during an episode of pain is important for diagnosis. A significant proportion of patients with chronic abdominal pain will remain undiagnosed despite extensive testing. For these patients, repeated history and examination, during which one looks for new symptoms or any change in the pattern of symptoms, may eventually yield a formulation.

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Source: Field Guide to Bedside Diagnosis, 2007

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

Diagnostic Approach

Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Generalized/Periumbilical

❑ Gastroenteritis

❑ Obstipation

❑ Small bowel obstruction

❑ Large bowel obstruction

❑ Mesenteric ischemia

❑ Peritonitis

❑ Abdominal aortic dissection

❑ Sickle cell crisis

Right Upper Quadrant/Epigastrium

❑ Hepatitis

❑ Biliary colic

❑ Peptic ulcer disease

❑ Pyelonephritis

❑ Acute cholecystitis

Right Lower Quadrant

❑ Appendicitis

❑ Inflammatory bowel disease

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Ovarian torsion

Left Upper Quadrant

❑ Pancreatitis

❑ Splenic infarction

❑ Pyelonephritis

❑ Myocardial infarction

Left Lower Quadrant

❑ Inflammatory bowel disease

❑ Diverticulitis

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ovarian torsion

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Sigmoid volvulus

Diagnostic Approach

Acute abdominal pain is a classic symptom that can herald conditions ranging from the trivial to the life-threatening. The accurate diagnosis and timely management of abdominal pain requires an understanding of the mechanisms of pain, recognition of typical patterns of clinical presentation, a broad differential of common causes, and an index of suspicion for variant presentations and unusual causes. The ultimate disposition decision may require a repeated history and physical examination over several hours. Narcotic analgesics should be withheld until a diagnosis is established because they can mask the expression of diagnostic characteristics of the disease. History indicates the diagnosis in 85% to 90% of cases. Consider organs located in the region of maximal pain and the time-course of onset. An intrathoracic source must always be considered with upper abdominal pain. Physical examination can demonstrate peritoneal inflammation and rebound tenderness by eliciting pain with gentle percussion of the abdomen as opposed to sharp release of the depressed hand. Muscular rigidity or “guarding” is an early sign of peritoneal inflammation. Auscultation may reveal silence, consistent with ileus or advanced peritonitis, hyperactive high-pitched sounds with early bowel obstruction, or a friction rub with splenic infarct or hepatic metastases. Pelvic and rectal examinations are mandatory in every patient who has abdominal pain.

Parietal pain, caused by inflammation of the parietal peritoneum, is
a sharp, steady, aching pain, well-localized over the inflamed area, and
accentuated by pressure. Tonic reflex spasm of the abdominal musculature is present. Visceral pain, caused by obstruction of a hollow viscera, is classically intermittent and cramping, but distension may produce dull, steady pain. The patient with visceral pain will writhe incessantly, while the patient with parietal pain lies still in bed. Referred pain is aching and perceived to be near the surface, accompanied by skin hyperalgesia and increased tone of the abdominal wall. Vascular occlusion can be recognized by severe pain out of proportion to physical findings in a patient with vascular disease or atrial fibrillation. Visceral pain is perceived at the level the nerves enter the spinal cord. An example is gallbladder pain which may be first perceived at the scapula, then later in the right upper quadrant when the somatically innervated overlying parietal peritoneum is inflamed.

If the patient is well one moment, then has excruciating pain, which is maximal at onset, consider a ruptured hollow viscera or a vascular event, such as myocardial infarction or ruptured aortic aneurysm.

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Source: Field Guide to Bedside Diagnosis, 2007

Gastric cancer: Diagnosis
(Handbook of Diseases)

Diagnosis depends primarily on reinvestigations of persistent or recurring GI changes and complaints. To rule out other conditions that produce similar symptoms, a diagnostic evaluation must include the testing of blood, stools, and stomach fluid specimens.

Gastric cancer commonly requires the following studies for diagnosis:

❑ Barium X-rays of the GI tract, with fluoroscopy, show changes (a tumor or filling defect in the outline of the stomach, loss of flexibility and distensibility, and abnormal gastric mucosa with or without ulceration).

❑ Gastroscopy with fiber-optic endoscopy helps rule out other diffuse gastric mucosal abnormalities by allowing direct visualization and gastroscopic biopsy to evaluate gastric mucosal lesions.

❑ Endoscopy for biopsy and cytologic washings and photography with fiber-optic endoscopy provide a permanent record of gastric lesions that can later be used to determine the progress of the disease and the effect of treatment.

The following studies may rule out metastasis to specific organs: computed tomography scans, chest X-rays, liver and bone scans, and a liver biopsy.

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Source: Handbook of Diseases, 2003

Abdominal pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition permits, obtain his history. Ask whether he has had this type of pain before. Because some patients report abdominal pain as indigestion or gas pain, it’s important to ask the patient to describe his pain in detail. For example, is it dull, sharp, stabbing, or burning? Ask him where the pain is located and whether it radiates to other areas. If a language barrier exists between you and the patient, use a pain rating scale with visual cues such as faces.

Ask the patient about factors that relieve the pain or make it worse. For example, do movement, coughing, exertion, vomiting, eating, elimination, or walking relieve the pain or worsen it? Ask him when the pain began and whether it’s intermittent or constant. If pain is intermittent, ask about the duration of a typical episode.

Intermittent, cramping abdominal pain suggests obstruction of a hollow organ. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity.

Ask the patient about substance abuse and a history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Has he experienced increased flatulence, constipation, diarrhea, or changes in stool consistency? When was the patient’s last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Physical examination

Obtain the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

Auscultate for bowel sounds in all four quadrants for at least 10 to 15 seconds and characterize their motility. Listen for systolic bruits in such locations as the abdominal aorta, renal artery, or iliac artery. (See Auscultating for vascular sounds.)

Percuss all quadrants, noting the percussion sounds.

ALERT: Abdominal percussion or palpation is contraindicated in patients with suspected abdominal aortic aneurysm, those who have received abdominal organ transplants, and children with suspected Wilms’tumor. If performing abdominal percussion or palpation in patients with suspected appendicitis, use extreme caution to avoid precipitating a rupture.

Palpate the entire abdomen for masses, rigidity, and tenderness. Involuntary rigidity is generally asymmetrical, evident on inspiration and expiration, unaffected by relaxation techniques, and painful when the patient sits up using his abdominal muscles alone. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. Peritonitis and appendicitis can cause rebound tenderness. Because appendicitis may be accompanied by increased abdominal wall resistance and guarding, perform the maneuver for rebound tenderness only once — repeating the maneuver can rupture an inflamed appendix. (See Eliciting rebound tenderness, page 4.)

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Abdominal distention: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing when lying flat or breathing deeply. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, and inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal mass: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menses was.

CULTURAL CUE:When taking a health history, consider your patient’s ethnic background. For example, Japanese patients are at higher risk for gastric cancer than non-Japanese patients and cirrhosis tends to be more common in Native American patients than in patients of other ethnic backgrounds.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal pain: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is his urine cloudy or pink?

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal Pain: Clinical Features and Diagnosis: Acute Abdominal Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Neonates

Colic

Historically thought of as cause of abdominalpain but now conceptualized more broadly. See Chap. 11, Crying and Irritability.

Necrotizing Enterocolitis

Infantsappear ill and usually have abdominal distension and often evidenceof GI bleeding.

Progression of illness commonly resultsin bowel infarction and often perforation.

See Chap.22, Gastrointestinal Bleeding).

Gastrointestinal Obstruction or Perforation of Any Viscus

Reasonableassumption is that neonates with GI tract obstruction or perforationof viscus have abdominal pain, which may be expressed by persistentcrying and irritability.

Vomiting and abdominal distension areprominent findings.

Common causes of obstruction in neonatesare pyloric stenosis, intestinal atresia, volvulus with malrotation,meconium ileus, and congenital aganglionic megacolon.

See Chap.55, Regurgitation and Vomiting.

Infants

Gastroenteritis

Usual presentingfeatures are vomiting, diarrhea, abdominal pain, and fever.

Rotavirus is most common pathogen.Frequent bacterial pathogens include Salmonella, Shigella, and Campylobacterspecies.

Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic. Positive stool culture is diagnosticof bacterial infection.

See Chap.14, Diarrhea.

Viral Illness

Many virusescan produce illnesses that may be accompanied by mild nonspecificabdominal pain. Some viruses produce disease in respiratory tractand include rhinoviruses, respiratory syncytial virus, parainfluenzaviruses, influenza viruses, and adenoviruses.

Illness is usually mild and self-limitedand resolves in 3–7 days.

Clinical findings include fever, rhinorrhea,cough, headache, anorexia, vomiting, mild sore throat, and myalgia.

Diagnosis is usually clinical; however,viral culture or polymerase chain reaction of nasal secretions canoften identify specific virus.

Incarcerated Inguinal Hernia

Common causeof intestinal obstruction.

Painful, tender mass is palpable ininguinal area with extension at times into scrotum.

Persistent vomiting, abdominal distension,and inability to reduce hernia suggest intestinal obstruction.

Surgery should be performed immediatelyif hernia cannot be reduced and bowel obstruction is suspected.If hernia can be reduced, surgery is usually planned in severaldays, after edema has diminished.

Intussusception

Clinicalfindings are intermittent abdominal pain, vomiting, abdominal mass,and currant jelly stools.

Not only is air-contrast enema diagnostic,but in many cases it also may be therapeutic.

Trauma, Including Child Abuse

Many abdominalinjuries are mild and cause only abdominal wall musculoskeletal pain.

More serious abdominal injuries includecontusion, laceration, or rupture of spleen, liver, kidney, or intestine.Pancreatic and major vessel injuries are less common.

Splenic injury causes tenderness andoccasionally splenic enlargement secondary to hematoma formation.CT is best method for diagnosing contusion, laceration, or ruptureof spleen.

With significant liver injury, serumaminotransferase levels are usually >3–5 timesnormal level. CT is the best method to determine type and degreeof liver injury.

Hematuria and flank pain may occurwith kidney injury. With history of mild trauma and possibilityof isolated renal injury, excretory urography may be performed.

If more serious injury has occurredwith possible involvement of other abdominal organs, CT is radiologicprocedure of choice. Elevated serum amylase level suggests pancreaticinjury, which can be delineated by CT.

Pelvic trauma may injure pelvis, bladder,urethra, or rectum.

Rectal exam should be performed to determinewhether rectal laceration has occurred.

Pelvic tenderness or pain may indicatepelvic fracture, which can be confirmed by plain radiography.

Bladder and urethral injuries may causesuprapubic pain and hematuria.

If blood is seen at meatus, prostateis higher than normal position, or there is evidence of scrotaltrauma, urethrography should be performed.

Child abuse should be suspected wheneverany unexplained injuries, burns, or fractures occur. Typical skinlesions include bruises in varying stages of healing, especiallyon face, back, chest and abdomen, and different types of scars indicativeof burns or trauma with various implements.

Stabilization of patient with significantabdominal trauma is first priority.

After history and physical exam, thefollowing tests should be performed:

CBC with differential

Analysis of serum electrolytes, glucose,creatinine, amylase, aspartate and alanine aminotransferases, andblood urea nitrogen

Radiography of chest and abdomen

Cervical spine and pelvic radiographyshould be performed if indicated. In serious cases, abdominal CTshould be considered because it is most efficient and effectivemethod to investigate significant abdominal trauma.

Other

Less common causes of abdominal pain in infantsinclude appendicitis, cow milk protein sensitivity, lactose intolerance,GI obstruction, sickle cell pain episodes, lead poisoning, and neoplasms.

Preschool Children

Constipation

Definedas difficult and painful passage of hard stools.

Abdominal pain is usually intermittent,crampy, and generalized.

Stool may be palpable on abdominalor rectal exam.

After bowel movement, pain and palpablestool masses disappear.

See Chap.9, Constipation.

Urinary Tract Infection

Lower abdominal,suprapubic, or flank pain associated with dysuria suggests presenceof urinary tract infection.

Fever and vomiting are common findings.

Pyuria suggests diagnosis, which isconfirmed by positive urine culture.

See Chap.15, Dysuria.

Pneumonia

May producereferred epigastric or periumbilical abdominal pain, especiallyif inflammation occurs in lower lobes of lung.

Fever, cough, tachypnea, and pleuriticpain suggest its presence.

Chest radiography is usually confirmatory.

See Chap.10, Cough.

Lactose Intolerance

Common inpreschool and school-aged children, especially African-Americanand Hispanic children.

Clinical manifestations include diarrheaand recurrent abdominal pain in those individuals who have low lactaseactivity and who ingest large amounts of lactose-containing products.

See Chap.14, Diarrhea.

Sickle Cell Pain Episodes

Vasoocclusiveepisode may cause mild-to-severe abdominal pain. Chest, back, and extremitypain also may occur.

Diagnosis can be confirmed by Hgb electrophoresis.

Food Poisoning

Resultsfrom ingestion of food contaminated with bacteria.

Crampy abdominal pain, diarrhea, andvomiting are typical features.

Recovery usually occurs in 1–2days.

History and physical exam suggest diagnosis.Positive stool culture or culture of suspected contaminated foodconfirms diagnosis.

See Chap.14, Diarrhea.

Diabetic Ketoacidosis

Can be initialpresentation of insulin-dependent diabetes mellitus.

Omission of insulin, acute illness,and emotional stress can be predisposing factors to diabetic ketoacidosis.

History of polyphagia, polydipsia,and polyuria of <1 mo's duration is usually found.Mild nonspecific abdominal pain and vomiting also may occur.

Kussmaul respirations are compensatoryphenomena of severe metabolic acidosis.

Severe illness may produce alterationin mental status that ranges from drowsiness to coma.

Presence of glucosuria, ketonuria,hyperglycemia, and metabolic acidosis confirm diagnosis.

Gastrointestinal Obstruction

Should besuspected with presence of persistent bilious vomiting and abdominal pain.

In this age group, common causes includeincarcerated inguinal hernia and surgical adhesions.

Henoch-Schönlein Purpura

Common causeof vasculitis in childhood.

Characterized by purpuric rash on buttocksand lower legs, abdominal pain, GI bleeding, transient migratoryarthritis of large joints, and hematuria.

Diagnosis is usually clinical.

See Chap.28, Hematuria.

Neoplasm

Wilms tumor,neuroblastoma, and lymphoma usually present with abdominal masses, butabdominal pain also may occur, especially with Wilms tumor.

See Chap.1, Abdominal Masses.

Drugs and Toxins

Acute ingestionof significant amounts of alcohol, iron, lead, or aspirin may produce abdominalpain.

History and measurement of toxic agentin blood are diagnostic.

School-Aged Children and Adolescents

Common causesof abdominal pain in this age group are gastroenteritis, viral illness, constipation,urinary tract infection, pneumonia, trauma, and sickle cell disease,as discussed previously.

Functional abdominal pain, which isusually chronic, is discussed below.

Acute Appendicitis

Occurs mostcommonly between 5 and 15 yrs of age but can occur in children <2 yrs.

First clinical manifestation is usuallycrampy periumbilical pain with shift in pain to right lower quadrantduring next few hours and is due to irritation of parietal peritoneumby small amount of fluid from inflamed appendix.

Location of appendix determines locationof pain.

Retrocecal appendix may irritate psoasmuscle; retrocolic appendix may cause pain in right flank.

Pelvic appendix may produce mild abdominalpain yet distinct tenderness on rectal exam.

Irritation of rectosigmoid colon byinflammatory fluid may cause mild diarrhea; irritation of uretermay cause dysuria.

Low-grade fever usually occurs withnonperforated appendix, whereas perforation usually produces sickerchild with higher fever, more vomiting, and more severe abdominalpain because of peritonitis or a localized abscess. Abdomen is distendedand tender, and signs of septic shock may be present. Children <2yrs are more likely to present with peritonitis and septic shock.

Abdominal findings depend on when childis seen during course of illness. Early in illness, right lowerquadrant tenderness may be found. With progression of illness, involuntaryspasm and rebound tenderness occur.

Child favors right side of abdomenand walks bent over. Climbing up on exam table, coughing, or jumpingup and down aggravate pain and indicate peritoneal inflammation.

Leukocytosis is common.

Results of UA either are normal orshow pyuria because of inflammation of ureter.

Abdominal radiography may occasionallyshow fecalith, edema of lateral abdominal wall, concave lumbar scoliosis,dilated cecum with air-fluid level, or localized ileus in rightlower quadrant.

Diagnosis is usually clinical. Otherstudies are unnecessary if findings are characteristic

In equivocal cases, abdominal U/Sor CT may be helpful.

With suspected appendicitis, surgeryshould be performed, as it is only definitive way to confirm diagnosis.

Appendiceal colic can cause recurrentepisodes of acute right lower quadrant pain. Drinking fluids oreating usually exacerbate the pain within 5–15 mins. Findingof maximum tenderness at McBurney point is evidence for this disorder.No lab tests are diagnostic.

Resolution of pain after removal ofappendix is confirmatory.

Peptic Ulcer Disease

May occurin stomach or duodenum.

Ulcer development is related to gastritiscaused by Helicobacter pylori.

Secondary ulcers usually occur in stomachand may be due to septicemia, burns, head injury, or NSAIDs.

Abdominal pain typically occurs inepigastric area and can awaken individual from sleep.

In many cases, food or antacids relievepain.

Vomiting and GI bleeding (heme-positivestools, hematemesis, melena) also may occur.

Physical exam can be normal or revealepigastric tenderness.

Method of choice to identify ulceris endoscopy.

Biliary Tract Disease

Acute Cholecystitis

Usuallyrelated to presence of gallstones.

Clinical findings include right upperquadrant pain, vomiting, and low-grade fever. Enlarged gallbladdermay be palpable in right upper quadrant.

Abdominal U/S usually showsgallstones and thickened gallbladder wall.

Cholescintigraphy may be performedif individual is obese or has gas-filled loops of bowel.

Biliary Colic

Resultsfrom acute obstruction of cystic or common bile duct, usually by stone.

Pain is in right upper quadrant orepigastric region.

Associated symptoms often include nausea,vomiting, and jaundice.

Plain abdominal radiograph may showstones in some cases; otherwise, abdominal U/S is usuallydiagnostic.

Pancreatitis

Common causesinclude viral infection, blunt trauma, cystic fibrosis, and idiopathic etiologies.

Abdominal pain is usually epigastricand can range from mild to severe. Eating usually aggravates thepain.

Other clinical findings include fever,anorexia, nausea, and vomiting. Epigastric tenderness may be foundon exam. Serum amylase and lipase concentrations are usually increased.

Abdominal U/S and CT are usefulin demonstrating any abnormalities of pancreas.

Obstructive Uropathy

Any typeof obstructive uropathy may produce abdominal pain.

Most common type is ureteropelvic junctionobstruction, which may present with abdominal pain or recurringattacks of flank pain along with nausea and vomiting.

Various tests may be used to evaluateurinary tract obstruction including renal U/S, voiding cystourethrography,intravenous urography, and diuretic renography.

Urolithiasis

Characterizedby acute flank pain and hematuria.

At time of presentation, excretoryurography is useful for diagnosis of radiolucent stones and demonstrationof level of obstruction.

See Chap.28, Hematuria.

Intraabdominal Abscess

May occurwith localization of inflammatory process within abdominal cavity.

Common causes in pediatric populationare appendiceal abscesses.

Tender mass may be palpable on rectalexam with pelvic abscess. Leakage of abscess usually produces seriousillness with associated gram-negative septicemia.

Abdominal U/S or CT is usuallydiagnostic.

Primary Bacterial Peritonitis

May be associatedwith infection of preexisting ascites, which may be associated with nephroticsyndrome or chronic liver disease.

May occur spontaneously without anyprior underlying disease process.

S. pneumoniae, S. pyogenes, and gram-negativeenteric bacteria (e.g., E. coli) are common pathogens.

Usual clinical findings are fever,abdominal pain, and tenderness, especially with movement (coughing,jumping up and down). Vomiting and abdominal distension also mayoccur.

Paracentesis with Gram stain and cultureof fluid may reveal pathogen.

Other

For inflammatorybowel disease, see Chap. 14,Diarrhea.

For hepatitis, see Chap. 36, Jaundice.

Adolescent Girls

Primary Dysmenorrhea

Common problemin adolescence.

Crampy lower abdominal pain usuallybegins 1–3 yrs after onset of menarche.

Occurs with menses or 1–2days before menses and may last a few hours or several days. Nausea,vomiting, headache, lower backache, thigh pain, nervousness, anddizziness also may occur.

Usually diagnosis of exclusion.

Mittelschmerz

Definedas lower abdominal pain that occurs at menstrual mid-cycle and lastsminutes, several hours, or (rarely) 2–3 days.

Pain may be due to spillage of fluidfrom follicular cyst during ovulation, which irritates peritoneum.

Timing of pain provides most importantdiagnostic clue.

Pelvic Inflammatory Disease

N. gonorrhoeaeand C. trachomatis are most common pathogens.

Clinical manifestations include vaginaldischarge, lower abdominal pain, cervical motion tenderness, adnexaltenderness, and fever. Occasionally, mass (abscess) may be palpablein adnexa or cul-de-sac.

Positive cervical culture is diagnostic.Laparoscopy may be necessary to confirm chronic disease.

Ovarian Disorders

Bleedinginto ovarian cyst or rupture of cyst may cause acute lower quadrantpain and tenderness.

Pain usually disappears within a dayafter rupture of physiologic cyst, whereas pain, nausea, vomiting,and fever may persist with other cysts.

Abdominal U/S may be diagnostic;otherwise, diagnosis may be confirmed by laparoscopy or at timeof surgery.

Torsion of ovarian cyst or fallopiantube (less common) may produce unilateral lower abdominal pain andpalpable mass.

In older children and adolescents,torsion is more likely with ovarian tumor. Other findings includenausea, vomiting, and fever.

Abdominal U/S usually demonstratescyst or tumor.

Endometriosis

Definedas presence of endometrial glands and stroma outside normal locationof uterine lining.

Usual presenting feature is pelvicpain, which may be cyclic or acyclic.

Pelvic exam in adolescents usuallyreveals mild-to-moderate tenderness rather than nodules or massesoften found in adult women.

If trial of NSAIDs followed by cyclicoral contraceptives fails to relieve pain, laparoscopy with biopsyshould be performed to confirm diagnosis.

Genital Malformations with Obstruction

Uterineand vaginal malformations that cause obstruction of genital tractmay produce pelvic pain, which is often chronic.

Lesions include imperforate hymen,transverse vaginal septum, vaginal or cervical atresia, and noncommunicatinguterine horn.

Pelvic U/S and MRI are usefulin defining anatomy of these lesions.

Complications of Pregnancy

Crampy abdominalpain and mild uterine bleeding are common findings with threatenedabortion. History usually includes ≥1 missed menstrual cycles.Internal os is closed, and no tissue has been expelled.

With incomplete abortion, uterine bleeding,painful uterine contractions, and passage of tissue fragments areusual findings. Presence of fever and pelvic pain during any stageof spontaneous or induced abortion suggests a septic abortion.

Any female with delayed menstrual period,lower abdominal pain, and abnormal vaginal bleeding should be suspectedof having ectopic pregnancy. There may be no history of missed menstrual periodor abnormal bleeding. Results of hCG urine pregnancy test are usuallypositive.

Pelvic U/S may be helpfulin demonstrating presence of ectopic pregnancy.

Positive culdocentesis with nonclottingblood also suggests ectopic pregnancy.

Laparoscopy or laparotomy confirmsdiagnosis.

Diagnostic Approach: Acute Abdominal Pain

Completehistory and reliable physical exam are far more valuable than anylab test or radiograph in diagnosis.

Ability of physician to make diagnosislargely depends on consideration of all possibilities, knowledgeof how they present, and planned orderly approach.

Age, type of onset, character and locationof pain, and associated findings are useful in diagnosis.

Abdominal pain of sudden onset is mostlikely to occur with intussusception, perforation of viscus, ortorsion of fallopian tube or ovary. Pain of gradual onset usuallyoccurs with appendicitis, pancreatitis, and cholecystitis. Severeintermittent pain may occur with gastrointestinal, genitourinary,or biliary tract obstruction.

Pain of peritonitis is diffuse, constant,and exacerbated by movement.

More recurrent or chronic pain usuallyoccurs with constipation, sickle cell pain episodes, and inflammatorybowel disease.

Lesions of stomach, duodenum, pancreas,and biliary tract commonly cause epigastric pain. Small bowel andproximal colon lesions usually produce umbilical pain. Distal colonlesions may cause hypogastric pain, whereas rectal lesions may producesacral pain.

Irritation of diaphragm may cause shoulderpain, and gallbladder disease may produce pain at right scapula.

Lesions involving ureter or femalegenital tract may produce lower abdominal and pelvic pain.

Most important diagnostic goal is todistinguish abdominal pain that may be life threatening.

2 clinicalcircumstances represent potentially serious disease and requireimmediate investigation: (a) abdominal pain associated with biliousvomiting, persistent vomiting, or abdominal distension, and (b)abdominal pain associated with either localized or diffuse reboundtenderness. Very few clinical problems require such urgent operativeintervention that orderly approach needs to be abandoned. Only exceptionis massive exsanguinating hemorrhage.

Children in whom the diagnosis is uncertainshould be admitted to hospital and observed.

Period of active observation is extremeimportance and is safe.

Most causes can be diagnosed at thebedside by careful and often repeated clinical observations.

Initial lab tests are CBC with differential,UA, urine culture, analysis of stool for blood, ESR, chest and abdominalradiography, and abdominal U/S.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal Masses: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Right Upper Quadrant

Liver

Hepatomegaly

Palpablein right upper quadrant of abdomen. Palpable in midline or leftupper quadrant with abdominal heterotaxia (commonly associated withcomplex congenital heart disease).

See Chap.30, Hepatomegaly.

Hepatic Cyst

May presentas asymptomatic hepatic mass.

Abdominal U/S is diagnostic.

Primary Hepatic Neoplasms

AbdominalU/S distinguishes between cystic or solid masses. CT defineslocation and extent of tumor.

Histologic diagnosis is definitive.

Benign

Hemangioma,mesenchymal hamartoma, and focal nodular hyperplasia usually presentin infancy as asymptomatic hepatic masses.

Hemangioendothelioma usually presentsbefore 6 mos of age as hepatic mass or with massive hepatomegalyand cardiac failure secondary to multiple arteriovenous communicationswithin tumor. Diagnosis may be confirmed by selective angiography.

Hepatic adenoma is rare tumor thatusually presents after puberty.

Hepatic teratoma can be benign or malignantand is rare in pediatric age group.

Malignant

Hepatoblastomais most common hepatic malignant tumor in pediatric population andusually occurs in children <2 yrs of age.

Hepatomegalyis most frequent physical finding. Discrete mass is usually notpalpable.

Abdominal U/S shows single,solid liver mass.

Serum alpha-fetoprotein (AFP) levelsare increased in most cases.

Hepatocellular carcinoma usually occursin children >3 yrs of age, with peak incidence in adolescence.

Clinical manifestationsinclude right upper quadrant mass, abdominal pain, anorexia, andweight loss.

Abdominal U/S shows solidhepatic mass, and AFP levels may be increased.

Often a complication of chronic hepatitisB infection.

Gallbladder

Cholecystitis

Occurrenceis usually related to presence of gallstones.

Right upper quadrant pain, vomiting,and fever are usual findings. Enlarged tender gallbladder may bepalpable.

Abdominal U/S usually revealsstones and thickened gallbladder wall.

Hydrops of Gallbladder

Hydropsrefers to distension of gallbladder without inflammation.

Causes include Kawasaki disease, nephroticsyndrome, staphylococcal or streptococcal infection, and, in neonates,septicemia and total parenteral nutrition.

Gallbladder is enlarged and often palpable.

Abdominal U/S confirms thatmass is gallbladder.

Biliary Tree

Choledochal Cyst

Infantsmay present with jaundice, acholic stools, and hepatomegaly. Childrenmay present with jaundice, abdominal mass, or abdominal pain.

4 types are fusiform dilation of commonbile duct (most common), diverticulum of common duct, dilatationof distal portion of common duct, and dilatation of extra- and intrahepaticbile ducts.

Diagnosis usually confirmed by abdominalU/S.

Intestine

Pyloric Stenosis

Hypertrophicpyloric stenosis produces an olive-sized mass in right upper quadrant ofabdomen, but it is not always palpable.

Usually occurs in infants 1–8wks of age.

Most consistent finding is persistentnonbilious vomiting during or immediately after feeding.

Physical exam can be diagnostic ifmass is palpable.

Diagnosis can be confirmed by abdominalU/S or upper GI radiographic series.

Duodenal Hematoma

Usuallycaused by blunt abdominal trauma.

Common findings are abdominal painand bilious vomiting. Mass may be palpable in right upper quadrantor epigastric region.

Abdominal U/S or upper GIradiographic series is diagnostic.

Duplication

Can occuranywhere in GI tract but most commonly involves ileum and colon.Compressible mass may be palpable anywhere in abdomen. Abdominalpain, vomiting, and GI bleeding are common findings.

Abdominal U/S and CT are usuallydiagnostic. Technetium 99m–pertechnetate scan can detectectopic gastric mucosa.

Diagnosis is confirmed at surgery.

Left Upper Quadrant

Spleen

Splenomegaly

Enlargedspleen is normally palpable in left upper quadrant of abdomen, unlessabdominal heterotaxia exists, in which case it is palpable in midlineor right upper quadrant.

Abdominal heterotaxia is usually associatedwith congenital complex heart disease.

See Chap.62, Splenomegaly.

Splenic Cyst

May be congenitalor occur secondary to trauma.

Smooth mass that displaces stomachmedially is usually palpable.

Abdominal U/S is diagnostic.

Neoplasm

See Chap.62, Splenomegaly.

Epigastric

Stomach

Bezoar

May be palpableas epigastric mass. Vomiting and abdominal distension are common findings.

Abdominal U/S or upper GIseries is diagnostic.

See Chap.55, Regurgitation and Vomiting.

Duplication

Frequentmanifestations are vomiting and epigastric mass. Bleeding from duplication alsomay produce hematochezia.

Abdominal U/S is usually diagnostic.

Pancreas

Pancreatic Cyst

May presentas asymptomatic abdominal mass or with abdominal distension, vomiting,and jaundice.

Abdominal U/S or CT is usuallydiagnostic.

Pancreatic Pseudocyst

Accountsfor majority of cystic lesions of pancreas and is usually locatedin lesser sac.

Its wall is composed of granulationtissue and not epithelium.

Most common causes are abdominal traumaand pancreatitis (idiopathic).

Abdominal pain, vomiting, anorexia,weight loss, and epigastric mass are frequent findings.

Combination of abdominal U/Sand CT is usually diagnostic.

Neoplasm

Usuallycarcinomas or rare endocrine tumors.

Abdominal U/S and CT locateand define extent of mass. Histologic diagnosis is definitive.

Right/Left Mid-Abdomen

Kidney

In neonates, >50% of abdominalmasses involve urinary tract. Most are unilateral.

Hydronephrosis

Definedas distension of kidney pelvis and calyces produced by obstructionanywhere in genitourinary tract.

Most common abdominal mass in neonate;can be unilateral or bilateral.

Specific causes include ureteropelvicjunction, ureteral, or ureterovesical obstruction; ureterocele;posterior urethral valves; and prune belly syndrome. Besides largeabdominal or flank mass, abdominal or flank pain, hematuria, vomiting,poor weight gain, recurrent fever, and urinary tract infection mayoccur.

Abdominal U/S is usually diagnostic.

Useful tests to determine site of obstructioninclude excretory urography, voiding cystourethrography, cystoscopy,and retrograde pyelography.

Multicystic Dysplastic Kidney

Second mostcommon abdominal mass found in neonate.

Usually unilateral and asymptomatic.

Consists of cysts of various sizesand is almost always nonfunctional.

Although abdominal U/S isdiagnostic, renal scintigraphy is useful in demonstrating renal function.

Renal Vein Thrombosis

Occurs mostcommonly in neonatal period and can be unilateral or bilateral.

History of perinatal asphyxia or hypovolemiausually exists. Maternal diabetes mellitus is frequent association.

Common findings include flank mass,hematuria, proteinuria, azotemia, thrombocytopenia, and transienthypertension.

Abdominal U/S or CT is usuallydiagnostic.

Renal scintigraphy demonstrates kidneyfunction, which may be diminished in 1 or both kidneys.

Congenital Mesoblastic Nephroma

Usuallypresents as asymptomatic abdominal or flank mass.

Renal U/S locates solid tumor.

Histologic diagnosis is confirmatory.

Wilms Tumor

Definedas embryonal renal tumor that usually presents as unilateral, smooth,mobile flank mass before 3 yrs of age. May be bilateral. Abdominalpain, hematuria, fever, hypertension, aniridia, and hemihypertrophymay occur.

Combination of abdominal U/Sand CT define location and extent of tumor, including any presencein inferior vena cava. Histologic diagnosis is definitive.

Renal Cyst, Ectopic Kidney, and Horseshoe Kidney

May presentas abdominal or flank masses.

Abdominal U/S confirms diagnosis.

Renal or Perinephric Abscess

High spikingfever and abdominal or flank mass suggest renal or perinephric abscess.

Abdominal U/S and CT are usuallydiagnostic. Percutaneous needle drainage or surgery confirms diagnosis.

Polycystic Kidney Disease

Autosomal-recessivepolycystic kidney disease can present in neonatal period with bilateralflank masses, which are firm, large, irregular kidneys. Other findingsinclude hematuria, proteinuria, azotemia, and hypertension.

Abdominal U/S reveals largeechogenic kidneys.

Autosomal-dominant polycystic kidneydisease, which usually occurs in adults, also can present with unilateralor bilateral enlarged kidneys.

Beckwith-Wiedemann Syndrome

Autosomal-dominantdisorder that can occur sporadically.

Kidneys may be enlarged. Other manifestationsinclude generalized overgrowth, macroglossia, omphalocele, and hepatomegaly.

Hypoglycemia is most urgent featurein newborn.

Gene locus has been mapped to chromosome11p15.5.

Adrenal

Neonatal Adrenal Hematoma

May occurafter traumatic delivery, asphyxia, or septicemia.

With massive bleeding, infant may presentin shock. With less severe bleeding, abdominal mass may be palpable,usually on right side and accompanied by anemia and jaundice. Massusually decreases in size and disappears over several weeks.

Abdominal U/S is usually diagnostic.

Neuroblastoma

May arisefrom adrenal medulla or any site along sympathetic chain.

Mean age of presentation is about 2yrs of age.

Hard, fixed abdominal mass is commonfinding. Abdominal pain, weight loss, fever, bone pain, eyelid ecchymoses,and bluish subcutaneous nodules also may occur. In some cases opsoclonusand cerebellar ataxia have been noted.

Metastases may involve regional lymphnodes, bone marrow, bone, liver, and skin.

Abdominal radiographs may show massand typical punctate calcifications. Abdominal U/S alsocan locate mass, while CT or MRI can define its extent.

Increase in 24-hr urine excretion ofcatecholamines (norepinephrine, dopamine, normetanephrine, homovanillicacid, vanillylmandelic acid) is usually found.

Chest radiograph, skeletal bone survey,nuclear scintigraphy, and bone marrow aspirate should be performedsearching for metastatic disease.

Diagnosis confirmed by histologic examof tissue.

Periumbilical

Intestine

Mesenteric Cyst

Usuallyarises in mesentery of jejunum or ileum and enlarges slowly.

Abdominal mass is often palpable.

Abdominal U/S is usually diagnostic.

Volvulus

Infantspresent with symptoms and signs of intestinal obstruction such aspersistent vomiting and abdominal distension. Occasionally abdominalmass may be palpable.

See Chap.22, Gastrointestinal Bleeding and Chap. 55, Regurgitation and Vomiting.

Neoplasm

Tumors ofGI tract in newborn and young infant are extremely rare.

In their series, Longino and Martin(1958) described just 1 case of leiomyosarcoma of colon.

In children and adolescents, most commontumor of GI tract is non-Hodgkin lymphoma.

Right Lower Quadrant

Intestine

Abscess

May producemass in right lower quadrant.

Usual findings are high, spiking, persistentfever and localized abdominal pain and tenderness. Tender mass maybe palpable on rectal exam.

Many are due to ruptured appendix.

CT is usually diagnostic. Diagnosisof appendiceal abscess is confirmed at interval appendectomy, whichusually occurs about 6 wks after drainage of abscess.

Intussusception

Usuallyoccurs at 6–24 mos of age.

Other findings that suggest diagnosisare intermittent, colicky abdominal pain; vomiting; and currantjelly, blood-tinged, or guaiac-positive stools.

If suspected clinically, perform aircontrast enema, which may be therapeutic as well as diagnostic.

Lymphoma

May presentas abdominal mass ± intestinal obstruction.

Localized or generalized lymphadenopathymay provide clue to diagnosis, and lymph node biopsy may be diagnostic.

Abdominal U/S and CT usuallylocate and define extent of mass.

Histologic diagnosis is definitive.

Ovary

Cyst

May be asymptomaticand only found on routine exam. May also present with acute abdominalpain secondary to torsion or hemorrhage or with chronic abdominalpain.

Most occurrences in adolescence aresimple follicular cysts that persist because of failure of maturingfollicle to ovulate and involute. Resolution usually occurs in 1–2mos.

Abdominal U/S is diagnostic.

Torsion

Producesacute abdominal pain, which may be accompanied by nausea, vomiting,and fever.

Abdominal U/S is often diagnostic.Diagnosis confirmed at surgery.

Neoplasm

Rare inpediatric population.

Teratoma is most common benign tumor,whereas malignant tumors include dysgerminoma, endodermal sinustumor, immature teratoma, mixed germ cell tumor, embryonal carcinoma,and choriocarcinoma.

Palpable abdominal mass and varyingdegrees of acute or chronic abdominal pain may occur.

Less common findings are constipation,urinary incontinence, precocious puberty, vaginal bleeding, andamenorrhea.

Abdominal U/S localizes mass,determines whether it is cystic or solid, and detects any calcifications.

Tumor markers (e.g., AFP, hCG, lacticdehydrogenase, carcinoembryonic antigen) may be useful for selectedtumors.

Abdominal CT and MRI help define siteand extent of tumor and if there are any local metastases. Histologicdiagnosis is definitive.

Left Lower Quadrant

Intestine

Constipation

Most commoncause of abdominal mass or masses in infancy and childhood.

History usually exists of strainingwhile attempting to have bowel movement. Stools are hard and difficultto pass. Multiple, mobile stool masses usually occur in left lowerquadrant and disappear with defecation.

Sometimes rectal exam reveals a fecalimpaction.

See Chap.9, Constipation.

Hypogastrium

Bladder

Distension/Obstruction

Can usuallybe recognized on abdominal exam, or if necessary, by abdominal U/S.

Common causes are urethritis, anticholinergicdrugs, and lower urinary tract obstruction from lesions such asposterior urethral valves (males).

Uterus

Pregnancy

Intrauterinepregnancy presents as midline lower abdominal or pelvic mass insexually active female.

Symptoms and signs of early pregnancyinclude missed menstrual period, nausea, vomiting, lack of usualenergy, and enlarged tender breasts.

After 12 wks' gestation, uterinefundus may be palpable above symphysis pubis.

After 20 wks' gestation, uteruscan reach level of umbilicus.

Positive urine hCG pregnancy test confirmsdiagnosis.

Hydrometrocolpos

Definedas fluid-filled dilated vagina and uterus that may be due to imperforatehymen or vaginal atresia.

Imperforate hymen can be noted on genitalexam. With vaginal atresia, dimpled area occurs where vaginal openingshould be.

Delay of diagnosis until adolescenceresults in failure of menstrual flow and enlarged palpable uterus.

Abdominal or pelvic U/S isuseful in diagnosis.

Diagnostic Approach

Age of child,location and characteristics of mass, and associated clinical findingsare important factors in diagnosis.

Liver masses are in right upper quadrant,splenic masses in left upper quadrant, and kidney masses in flanks;masses involving intestine and ovaries are likely to be palpablein lower quadrants.

Any solid mass should be consideredmalignant until proved otherwise.

If diagnosis is uncertain after historyand physical exam, abdominal radiographs should be performed.

Most useful single test is abdominalU/S, which usually locates involved organ of origin and whethermass is solid or cystic, renal or extrarenal.

CT and MRI play important role by demonstratinganatomic features of mass as well as local and metastatic extentof malignant lesions.

Chest radiograph may be useful, especiallywith suspected neoplastic lesions.

Renal Masses

Responsiblefor >50% of palpable abdominal masses in neonates.

If mass is intrarenal, cystic, andsolitary, it is usually benign renal cyst. If it is cystic and multiloculated,renal multicystic dysplasia is usual diagnosis.

In infants <1 yr, solid renalmasses are either congenital mesoblastic nephroma or Wilms tumor.These 2 tumors are indistinguishable by imaging exam.

In children >1 yr, nearlyall solid intrarenal masses are Wilms tumors.

Gastrointestinal Masses

Plain abdominalradiography and abdominal U/S are most important initialstudies.

Other studies depend on suspected diagnosis:air-contrast enema (intussusception), CT (intestinal duplication,abscess, neoplasm), and upper GI series (volvulus).

Liver Masses

Cystic lesionsare usually benign cysts, whereas solid intrahepatic lesions usuallysignify tumor. In latter case, CT and/or MRI help definelocation and extent of the mass.

Histologic diagnosis is confirmatory.

Splenic Masses

May be diagnosedby abdominal U/S.

Malignant disease usually is infiltrativein nature (leukemia) and causes splenomegaly rather than discretesplenic mass. Involvement of the spleen by lymphoma may be infiltrativeor with discrete tumor foci.

Biliary Tract Masses

Most arecystic and benign (choledochal cyst, hydrops of gallbladder) inchildren.

Can usually be diagnosed by abdominalU/S.

Adrenal Masses

Abdominal U/S can distinguish adrenalhematoma from neuroblastoma. Imaging cannot distinguish betweenneuroblastoma, ganglioneuroma, or ganglioneuroblastoma, and histologicdiagnosis is mandatory.

Genital Tract Masses

Usuallyovarian cysts in infant girls.

May be readily diagnosed by abdominalU/S.

Most common pelvic tumors in girlsare ovarian tumors. Further imaging is needed with CT or MRI.

With pelvic mass in postmenstrual female,pregnancy test and U/S should be performed.

If mass appears to be small functionalfollicular cyst, individual should be observed for 2–3mos to see whether it regresses.

If it is >5 cm in diameterat time of diagnosis or suspicion of malignancy exists, laparoscopy orlaparotomy should be performed to make definitive histologic diagnosis.

Pancreatic Masses

Most arepseudocysts and require no further imaging other than abdominalU/S.

Rarely, solid pancreatic tumors occurand are either carcinomas or endocrine tumors.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal distention: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's abdominal distention isn't acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat.

The patient may be unable to bend at the waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) When did the patient last have a bowel movement? Note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones such as falling off a stepladder.

Perform a complete physical examination. Don't restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it's also common in obesity and pregnancy. Inspect the abdomen for signs of inguinal or femoral hernia and for healed incisions that may point to adhesions. Both may lead to intestinal obstruction. Auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Palpate the abdomen for tenderness, noting whether it's localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney's point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient's abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal mass: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's abdominal mass doesn't suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient's medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and the first day of her last menses.

A complete physical examination should be performed. Inspect the abdomen for asymmetry, scarring, discoloration, or other skin abnormalities. Also observe for pulsations. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient's position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can't, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes, page 8.)

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal pain: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain in his own words. Ask him if the pain is dull, sharp, stabbing, or burning and to rate his pain on a scale, such as the visual analog scale, FACES pain scale, or verbal numeric scale for intensity of pain. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient to point where the pain is located and if it radiates to other areas.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menstrual cycle, changes in her menstrual pattern, or dyspareunia.

Perform a physical examination. Take the patient's vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal Mass, Generalized: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Abdominal Pain, Generalized: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. In contrast, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel. It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it. If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed immediately with an exploratory laparotomy. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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Dr. Huntley's Diagnosis Checklist

Diagnosis of Stomach cancer

Diagnostic Test list for Stomach cancer:

Stomach cancer Diagnosis: Book Excerpts

Tests and diagnosis discussion for Stomach cancer:

Diagnosis of Stomach cancer: medical news summaries:

Diagnostic Tests for Stomach cancer: Online Medical Books

ABDOMINAL PAIN, CHRONIC RECURRENT: Ask the following questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

ABDOMINAL PAIN, ACUTE: Ask the following questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

Abdominal Pain in Lower Quadrants: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Abdominal Pain in Upper Quadrants: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Abdominal Pain with Rebound Tenderness: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Abdominal Masses: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Abdominal Pain: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

Abdominal Masses: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

ABDOMINAL MASS, GENERALIZED: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

ABDOMINAL PAIN, GENERALIZED: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

Abdominal distention: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Abdominal mass: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Abdominal pain: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Introduction: Malignant Neoplasms: Diagnostic methods (Professional Guide to Diseases (Eighth Edition))

Gastric cancer: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Malignant spinal neoplasms: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Abdominal distention: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal mass: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal pain: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal Pain: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

Chronic/Recurrent Abdominal Pain: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Abdominal/Pelvic Mass: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Acute Abdominal Pain: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Gastric cancer: Diagnosis (Handbook of Diseases)

Abdominal pain: History (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Physical examination

Abdominal distention: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal mass: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal pain: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal Pain: Clinical Features and Diagnosis: Acute Abdominal Pain (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Neonates

Colic

Necrotizing Enterocolitis

Gastrointestinal Obstruction or Perforation of Any Viscus

Infants

Gastroenteritis

Viral Illness

Incarcerated Inguinal Hernia

Intussusception

Trauma, Including Child Abuse

Other

Preschool Children

Constipation

Urinary Tract Infection

Pneumonia

Lactose Intolerance

Sickle Cell Pain Episodes

Food Poisoning

Diabetic Ketoacidosis

Gastrointestinal Obstruction

Henoch-Schönlein Purpura

Neoplasm

Drugs and Toxins

School-Aged Children and Adolescents

Acute Appendicitis

Peptic Ulcer Disease

Biliary Tract Disease

Acute Cholecystitis

Biliary Colic

Pancreatitis

TREATMENTS &
RESEARCH

Dr. Huntley's
Diagnosis
Checklist

ABDOMINAL PAIN, CHRONIC RECURRENT: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

ABDOMINAL PAIN, ACUTE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Abdominal Pain in Lower Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain in Upper Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain with Rebound Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

ABDOMINAL MASS, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

ABDOMINAL PAIN, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Abdominal distention: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Abdominal mass: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Abdominal pain: History and physical examination

(Handbook of Signs & Symptoms (Third Edition))

Introduction: Malignant Neoplasms: Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))

Gastric cancer: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Malignant spinal neoplasms: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Abdominal distention: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal mass: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal pain: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Chronic/Recurrent Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Acute Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Gastric cancer: Diagnosis
(Handbook of Diseases)

Abdominal pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Abdominal distention: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal mass: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal pain: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal Pain: Clinical Features and Diagnosis: Acute Abdominal Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Abdominal Masses: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)