EMQ: 16
Abdominal pain
a)
Appendicitis
b) Cholecystitis
c)
Mesenteric angina
d)
Peptic ulcer
e)
Biliary colic
f)
Pancreatitis
g)
Large bowel infarction
h)
Crohn’s disease
i)
Colon cancer
j)
Irritable bowel syndrome
1) A 67-year-old male who is known to have ischaemic
heart diseases and transient ischaemic attacks, presents with abdominal pain
related to meals. The pain comes on shortly after he eats and this has made
him reduce his intake of food and lose weight. On examination there is a bruit
over the upper abdomen.
Answer: c) mesenteric angina
The history of ischaemic heart disease and transient
ischaemic attacks should alert one to the possibility of vascular
insufficiency as a cause of the condition. Pain related to meals adds evidence
to this possibility. The bruit should give the final clue.
Loss of weight is common in patients with mesenteric
angina
2) A 56-year-old businessman presents with epigastric
pain. The pain is gnawing in nature and is relieved by food but increases when
he is hungry and wakes him up from his sleep in the early hours of the
morning. He is stressed at work and smokes heavily.
Answer: d) peptic ulcer
The history of pain relieved by meals and nocturnal pain
is suggestive of a duodenal ulcer.
3) A 30-year-old male presents with severe abdominal pain
of acute onset. The pain is relieved by leaning forward. He gives a history of
binge drinking and admits to a recent binge. On examination he looks unwell,
there is generalised tenderness over his abdomen and there is bruising in the
flanks.
Answer: f) pancreatitis
The severe pain precipitated by an alcoholic binge should
suggest pancreatitis.
The pain relieved by leaning forward is in keeping with a
retroperitoneal lesion. Severe tenderness and bruising in the flaks lends
weight to the diagnosis.
4) A 72 year old male who has had a previous myocardial
infarction and stroke is admitted with abdominal pain, diarrhoea and bleeding
per rectum. He awoke from his sleep with severe left sided abdominal pain and
this was followed by profuse watery diarrhoea and later he began passing fresh
blood per rectum. On examination he looked unwell was tachycardic and there
was a systolic bruit audible over the central abdomen.
Answer: g) large bowel infarction
The history of sudden onset abdominal pain followed by
diarrhoea and bleeding per rectum is suggestive of a large bowel infarction.
The fact that the patient is a known vasculopath lends weight to the
diagnosis. The finding of a bruit over the abdomen adds further weight to the
diagnosis of a vascular lesion in the abdomen.
5) A 27-year-old female presents with a history of
abdominal pain of several months duration. She admits to passing loose motions
and she has lost weight. She smokes 20 cigarettes per day. On examination
there are painful tender erythematous nodules over her shins and there is a
tender mass in the right iliac fossa.
Answer: h) Crohn’s disease
A young female with abdominal pain, weight loss and
diarrhoea should alert one to the possibility of inflammatory bowel disease.
Crohn’s disease tends to affect females more than males and the fact that she
smokes will be further evidence in favour of this diagnosis (the onset of
ulcerative colitis is related to cessation of smoking).
The tender red nodules over her shins should make one
think of erythema nodosum and the mass in the right iliac fossa would suggest
and ileocaecal mass in keeping with Crohn’s disease.
Revision Tip
Abdominal pain is an important symptom and one should
learn how to analyse it. The first step is to know the causes of abdominal
pain.
First read chapter 3 of ACES
for PACES and learn about the components of diagnosis and the
checklists that one may use to work out the components of diagnosis.
Use this to work out the causes of abdominal pain.
Use the lists on pages
286-287, 289 and 326 of ACES for PACES to guide you further.
