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Cinical casebook

Dr Tanvir Jami discusses diagnosis and management

Dr Tanvir Jami discusses diagnosis and management

Case History

Dorothy, age 76, has been a previously well nursing home resident for several years. You are asked to visit by a district nurse. Dorothy has been treated with laxatives and enemas for constipation and overflow incontinence. Her bowels are better but the nurse is worried that Dorothy has lost weight in the last three months and her abdomen looks 'a bit swollen'. Overnight she has developed vomiting. Dorothy has a very close-knit family and many of them arrive to see her at the same time that you do. This takes me back to my surgical house officer days! A quick history is the key here.

It's difficult not to sound patronising but you just cannot say it enough ­ history is the most important part of the consultation, so take your time and get all the details.

All medical students know the 'F' rule on the causes of abdominal swellings: fat, fluid, flatus, faeces and fetus. Intermittent or variable swelling is not usually caused by serious pathology whereas progressive swelling, particularly accompanied by suspicious symptoms, needs to be investigated quickly.

There is so much to get through ­ where to start?

A useful question is 'Do your clothes still fit?'. Then a mental trip down the GI tract will cover most things. So ask about changes in appetite, weight loss, swallowing difficulties or pain, vomiting, abdominal pain, belching, bloating, changes in bowel habit, stools and rectal bleeding. While you're thinking about the nether regions, also inquire about urinary and gynaecological symptoms. A relevant past medical history may also shed light on the present problem ­ so ask about a history of diverticulitis, irritable bowel syndrome, operations and herniae.

That's useful. What about a general approach to the examination?

Again think back to what your old surgical consultant taught you: first don't touch the patient ­ just look. Pallor, jaundice and cachexia can be noted 'at a glance'. Look at the patient's abdomen and see if a swelling is actually visible. A deep breath in and out can often highlight a mass. Look also for distension, visible peristalsis, herniae and scars.

After palpating any obvious swelling, look for the individual abdominal organs, test for ascites and finish off with a rectal and gynaecologic examination. If the patient is obese, ascites and even large tumours can go undetected.

So what kind of signs might I find on examining Dorothy and what do they mean?

Distension of the bowel occurs in obstruction and you need to think of volvulus of the sigmoid colon, chronic large bowel obstruction and megacolon.

A distended stomach may occasionally get large enough to fill the abdomen in very advanced cases of pyloric stenosis and acute gastric dilatation. Look for a succusion splash and the quality of the bowel sounds.

General abdominal swelling may occur in malignant disease with peritoneal involvement and growth of secondary nodules as well as ascites. Pancreatic swellings push forward and present as vaguely palpable deep-seated masses. Unless very large, these swellings are resonant on percussion due to overlying bowel. On occasion you can feel a mass from chronic pancreatitis or pancreatic cysts.

Palpable masses arising from the kidney are resonant because of overlying bowel and ballotable. An expansile mass situated just above the umbilicus is an abdominal aortic aneurysm.

Considering Dorothy's age and symptoms, I would be worried about a gynae problem.

A pelvis examination would be an important part of your examination. A swelling that you cannot 'get below' is arising from the pelvis, eg the distended bladder. Other pelvic swellings may originate from the uterus ­ fibroids, abscess, malignancy or cyst.

A large pelvic abscess can extend above the pubis or into the iliac fossae and can be palpated abdominally, pelvically and rectally.

What about investigations I can arrange after visiting?

  • urinalysis: look for microscopic haematuria in renal or bladder tumours·
  • FBC: look for anaemia, white cell count raised in abscess and appendix mass ·
  • ESR: elevated in malignancy·
  • U&Es: abnormal in gross kidney pathology·
  • LFTs: abnormal in hepatomegaly and live metastases·
  • Faecal occult bloods: positive in caecal carcinom
  • Plain abdominal XR
  • Ultrasound scan: most useful way in establishing a diagnosis in most situations

Other useful tests usually carried out in secondary care include CT scanning, sigmoidoscopy/colonoscopy and paracentesis.

So what shall we do with Dorothy?

A lot depends on what you find when you visit. Does she have an acute or chronic problem and are there any worrying accompanying symptoms? If she has a chronic swelling, investigations followed by referral would be appropriate. If you suspect cancer you will need to follow the NICE guidelines and refer urgently. Acute abdominal swellings and those accompanied with pain need immediate admission. Dorothy's family will probably want to know a lot of details. I can feel uncomfortable in this situation as sometimes the relatives interfere unnecessarily.

Families have an important role in the patient's care. When treated respectfully they can help with history, treatment preferences and discharge planning. When possible ask patients first for permission to talk with their relatives. Ask if it is all right to share information or if they want an specific details withheld. Give immediately needed information first, eg 'Your mother is OK for now but we need to carry out further tests. We'll have a much better idea of what's going on in the next few weeks.' Summarise what you can about her condition and outline a short-term plan of care. Try to tell them what to expect over the next 24-48 hours and give the family time to ask questions.

Some family members can have serious disagreement about the plan of care for their ill relative. Try not to take sides ­ a good phrase to use is 'You're all obviously concerned about your mother. What do you think she would have wanted?'

Tanvil Jamil is a GP in Burnham, Bucks

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