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Highlights of the Symptom

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  • • Localization/point of origin: peritoneal cavity (ascites, bowel dilation), abdominal wall (hernia, obesity).
  • • Associated symptoms: nausea, vomiting, abdominal pain and cramping, altered bowel function, bleeding?
  • • Symptom evolution: acute/progressive, intermittent, recurrent, chronic.
  • • Appearance: diffuse, focal area.
  • • Grading: mild, severe.
  • • Underlying systemic disease: congenital malformation, malignancy, cardiovascular disease, IBD, history of previous surgeries.
  • • Probability of being sign of serious disease (liability issue): high.

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Pathogenesis-Oriented Differential Diagnosis

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  • 1. Malformation
    • – acquired: obesity, organomegaly (liver, spleen)
    • – cystic fibrosis (mucoviscidosis) with fecal impaction in the small bowel
    • – megacolon (Hirschsprung disease)
    • – colonic malrotation
    • – intestinal atresia
  • 2. Vascular
    • – ischemia-related bowel obstruction (ischemic stricture)
  • 3. Inflammatory
    • – inflammatory process with bowel obstruction (diverticulitis, Crohn disease)
    • – toxic megacolon
  • 4. Tumor
    • – tumor-related bowel obstruction (neoplasm, endometriosis)
    • – carcinomatosis
    • – pseudomyxoma peritonei
  • 5. Degenerative/functional
    • – adhesion-related bowel obstruction
    • – Ogilvie syndrome
    • – hernia
    • – pseudohernia from denervation of abdominal wall musculature
    • – fecal impaction
    • – ascites (eg, liver cirrhosis)
  • 6. Traumatic/posttraumatic
    • – hematoma

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Top of the List

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  • 1. Constitutional: obesity.
  • 2. Bowel obstruction (SBO, LBO).
  • 3. Hernia.
  • 4. Megacolon/pseudoobstruction.
  • 5. Ascites.

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Keys to Diagnosis

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  • • Patient’s surgical/medical history: habitus, symptom progression, previous abdominal surgeries, tumor, etc.
  • • Clinical examination: patient’s general condition and habitus, presence/absence of (tympanitic) bowel sounds, focal/diffuse tenderness to palpation, organomegaly, peritoneal signs, stool in rectal vault.
  • • Imaging:
    • – Abdominal x-ray series, chest x-ray: evidence of bowel obstruction (SBO vs LBO), free air, distended loops of bowel, air/fluid levels, gastric dilation, transition point, presence of air in distal colon, calcifications, pneumobilia.
    • – CT scan (if possible with oral and IV contrast): ascites, hernia, small or large bowel dilation, transition point, extensive mucosal thickening, intestinal pneumatosis, pneumobilia, portal vein gas, suspicion of closed loop, intraabdominal/retroperitoneal mass, extent and location of tumor burden, etc.
    • – Ultrasound: ascites, tumor.

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Cross-Reference

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Highlights of the Symptom

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  • • Localization/point of origin: upper GI, mid-GI, lower GI, anorectal.
  • • Associated symptoms: pain, pruritus, prolapse, altered bowel habits, constipation, diarrhea, dizziness, weakness, weight loss?
  • • Time factor: onset, constant, certain times, certain activity, link to menstrual cycle?
  • • Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
  • • Appearance: BRBPR, dark blood, melena, invisible/occult bleeding, false positive (nonhematogenous red color).
  • • Severity: acute/massive, acute/moderate, sporadic, occult, anemia.
  • • Underlying systemic disease: hematologic, liver disease, medications (ASA, warfarin).
  • • Probability of being sign of serious disease (liability issue): high.

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Pathogenesis-Oriented Differential Diagnosis

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  • 1. Malformation
    • – AV malformations, angiodysplasia, Osler disease
    • – Meckel diverticulum
    • – congenital aneurysms
  • 2. Vascular...

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