+++
Highlights of
the Symptom
++
- • 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.
+++
Pathogenesis-Oriented
Differential Diagnosis
++
- 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
++
- 1. Constitutional: obesity.
- 2. Bowel obstruction (SBO, LBO).
- 3. Hernia.
- 4. Megacolon/pseudoobstruction.
- 5. Ascites.
++
- • 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.
++
++
++
++
+++
Highlights of
the Symptom
++
- • 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.
+++
Pathogenesis-Oriented
Differential Diagnosis
++
- 1. Malformation
- – AV malformations, angiodysplasia, Osler disease
- – ...