nhsManagers.net | Briefing | 24 February 2018

Medicine for Managers

Dr Paul Lambden BSc MB BS BDS FDSRCSEng MRCS LRCP DRCOG MHSM FRSM

There are many structures within the abdomen and most of them are capable of causing pain.

Much of the abdomen is occupied by bowel and it is the culprit in many of the cases.

There is over thirty feet of gut and, within the abdomen, is the lower end of the oesophagus, the stomach, duodenum, small bowel and large bowel, all engaged in the digestion of food, extraction of nutrients and elimination of waste.

Simple bowel causes of abdominal pain are generally intermittent, are poorly localised (that is they are not located in any one position) and they are associated with

bloating and the passage of wind up or down, with heartburn, with diarrhoea or with constipation.

Wind is a common problem, often associated with overeating, eating to quickly, or eating foods that ferment with the production of gas.

It is relieved by the passage of wind upwards (flatulence) or downwards (flatus).

The pharmacist will be able to advise something such as mebererine or

buscopan to ease the problem.

Abdominal pain, often developing quite quickly, with colicky pain and vomiting or diarrhoea is commonly caused by

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

Doctor, I’ve got Tummy Ache There are dozens of causes of abdominal pain. Pain in the tummy often causes a diagnostic conundrum for the clinician because symptoms may be vague and not suggestive of any particular cause. The pain may come and go, leaving little clue to its genesis. Most abdominal pain is minor in nature and frequently associated with the bowel, but a small proportion of causes are more serious.

bacterial or viral infection within the gut. Generally a regime of withholding food and drinking very large quantities of fluids (including rehydration fluid such as Diorylate or Rehydrat) will allow the body to clear the infection. If it does not settle in a few days, if there is blood in the diarrhoea, or if the symptoms worsen, then the doctor should be consulted.

If the symptom recurs repeatedly then the cause may be a more long-term disorder such as irritable bowel and advice should be sought.

Other causes of abdominal pain associated with the gut may include those relating to the oesophagus, stomach and duodenum, such as ulceration, gastro-oesophageal reflux disease (GORD) or a hiatus hernia.

They may relate to the small and large bowel such as Crohn’s disease, ulcerative colitis, appendicitis, diverticulitis, food intolerances, infections of various sorts, commonly irritable bowel and also more serious causes such as tumours, which may be benign or malignant.

Of course, there are many other causes of abdominal pain involving the other structures within the abdominal cavity. These may include:

• Liver causes, including infection, gall stones and biochemical disturbances

• Kidney causes including infections and kidney stones

• Bladder disorders such as cystitis • Gynaecological causes associated

with the ovaries or uterus. There are many causes and they may be suggested by the presence of uterine bleeding, cycle disturbances or pregnancy

• Causes associated with other organs such as the pancreas and spleen

Of course, symptoms may be caused by more generalised conditions such as anything affecting one of the bodily systems within the abdomen, such as blood vessels, lymph glands, primary and secondary tumours and other abnormalities.

The important distinction to make is whether the abdominal pain is a minor or a more serious cause of disease. If it is one of the common intestinal disturbances which is self-limiting, it is unlikely to be a cause of concern.

However, there are a number of symptoms which would suggest that an opinion should be sought from a doctor. These will include:

1. Severe abdominal pain 2. Pain associated with tenderness

of the abdomen when touched 3. Pain that is unremitting 4. Pain associated with abdominal

distension which cannot be relieved by passing wind

5. Intractible vomiting, especially if it appears like coffee grounds (altered blood)

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

6. Persistent diarrhoea leading to dehydration and diarrhoea that is black and tarry in appearance

7. Bleeding in vomit or diarrhoea 8. Bleeding from the bladder (in

urine) or the uterus (not associated with a period)

9. Vaginal discharge, especially if foul-smelling

10.Chest pain or breathlessness 11.Pain associated with pregnancy 12.Pain associated with injury some

days earlier 13.Pain associated with a high

unremitting fever Symptoms may be more serious in someone with a generalised disease such as diabetes, reduced immunity or undergoing treatment for an intercurrent illness with steroids or anti-cancer drugs.

Other systemic symptoms or collapse are an immediate indication for summoning medical assistance or an ambulance.

Most causes of abdominal pain are identifiable following a history, examination and simple investigations.

Other causes provide more difficult diagnostic conundrums, especially when the symptoms are vague and intermittent.

In such cases, scans, radiography, the insertion of endoscopes (telescopes which investigate the inside of structures) including laparoscopy (inserting a telescope into the abdomen itself through a small incision) or a full laparotomy where the abdomen is opened by traditional surgical approach, may be necessary.

There have been considerable advances in recent years of investigating abdominal symptoms in a less invasive manner. Dignosis is generally quicker and more accurate.

However sometimes it is delayed, either because the symptoms are mild and

intermittent or because they are not typical of the cause.

Abdominal pain represents 7-10% of all Accident and Emergency attendances. Data is poor but it is more common in women.

Non--specific abdominal pain, renal colic, biliary colic and diverticulitis are more common in people over 65 whilst urinary infections in women, renal colic and appendicitis are

more common in the young.

Like every other aspect of medicine the abdomen is slowly giving up its secrets as diagnosis improves but there is still a ay to go before the mysteries are all solved.

paulambden@compuserve.com

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.