Chapter 1. Symptoms and Differential Diagnosis

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
  • – hematoma

Top of the List

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

Keys to Diagnosis

• • 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.

Cross-Reference

Colorectal cancer—colon cancer (153.X) (Ch. 4)

Toxic megacolon (556.9) (Ch. 4)

Large bowel obstruction (LBO, 560.9) (Ch. 4)

Colonic pseudoobstruction (Ogilvie syndrome, 560.89) (Ch. 4)

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
  • – ...