Symptoms and Differential Diagnosis




Abdominal Distention



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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.





Bleeding per Rectum



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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
    • – Meckel diverticulum
    • – congenital aneurysms

  • 2. Vascular

    • – ischemic colitis
    • – mesenteric ischemia
    • – vasculitis
    • – Osler disease
    • – rectal varices
    • – hemorrhoids
    • – anorectal Dieulafoy lesion
    • – acquired (pseudo-)aneurysms
    • – radiation injury
    • – esophageal varices

  • 3. Inflammatory

    • – colitis (infectious, idiopathic, postradiation)
    • – SRUS
    • – fissure
    • – perianal dermatitis
    • – peptic ulcer disease, Mallory-Weiss syndrome

  • 4. Tumor

    • – epithelial: cancer, adenomatous polyps
    • – mesenchymal: lymphoma, leiomyoma, GIST, etc
    • – neurogenic: melanoma
    • – endometriosis

  • 5. Degenerative/functional

    • – diverticulosis
    • – stercoral ulcers
    • – prolapse
    • – intussusception
    • – Mallory-Weiss syndrome

  • 6. Traumatic/posttraumatic

    • – blunt/penetrating trauma
    • – anal intercourse, autoeroticism, foreign body
    • – iatrogenic
    • – paraplegia with need for manual stimulation




Top of the List



Local Bleeding Source




  • 1. Fissure.
  • 2. Hemorrhoids.
  • 3. Neoplasm.
  • 4. Prolapse.
  • 5. Trauma.



Higher Bleeding Source




  • 1. Diverticulosis (distal > proximal).
  • 2. Tumor.
  • 3. Colonic AV malformation (proximal > distal).
  • 4. IBD.
  • 5. Ischemia.
  • 6. Bleeding proximal to ileocecal valve (Meckel, Crohn, varices, Mallory-Weiss, peptic ulcer, etc).



Children:




  • 1. Anal fissure
  • 2. Intussusception
  • 3. Meckel diverticulum
  • 4. Polyps




Keys to Diagnosis




  • • Clinical examination: general condition, abdominal exam, rectal exam, anoscopy/rigid sigmoidoscopy.
  • • Blood work: CBC, PT, PTT → rule out coagulopathy.
  • • Colonoscopy: limited by poor visibility (unprepped colon, strong light absorption of blood that results in darkness); distribution of blood in the colon has only limited value in localization of bleeding source.
  • • Tagged red blood cell scan: > 0.5 mL bleeding, particularly the first 15–30 min are meaningful for localization.
  • • Angiography: > 1 mL/min bleeding.
  • • Bleeding proximal to ileocecal valve: NGT insertion, EGD, capsule endoscopy.





Colitis or Proctitis



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Highlights of the Symptom




  • • Definition: visible inflammatory changes in colon or rectum (edema, ulcerations, friability).
  • • Localization/point of origin: begin at the dentate line? Most distal segment disease-free or with limited disease (caveat: distal begin of disease potentially masked by previous local therapy!).
  • • Associated symptoms: altered bowel habits, diarrhea, bleeding, mucous discharge, urgency, tenesmus, weight loss, pelvic or abdominal pain, abdominal distention, fever, toxic signs, urinary tract infections? Extraintestinal manifestations?
  • • Time factor: sudden onset, gradual onset, relapsing, one-time, continuous.
  • • Symptom evolution: gradual worsening, on/off relapsing.
  • • Appearance: diffuse involvement of affected segment, patchy/discontinuous involvement, very localized.
  • • Severity: extent of involvement, chronic/acute/fulminant/toxic.
  • • Underlying systemic disease: known IBD, status postcancer treatment (radiation, chemotherapy, bone marrow transplantation, etc).
  • • Probability of being sign of serious disease (liability issue): high.




Pathogenesis-Oriented Differential Diagnosis




  • 1. Malformation

    • – cavernous hemangioma (→ no true inflammation)

  • 2. Vascular

    • – ischemic colitis (peripheral vascular disease, embolic disease, vasculitis)
    • – radiation injury

  • 3. Inflammatory

    • – IBD: ulcerative colitis, Crohn disease
    • C difficile colitis, diverticulitis
    • – infectious colitis (amebic, shigella, enterohemorrhagic E coli, tuberculosis, cytomegalovirus, etc)
    • – STD proctitis: lymphogranuloma venereum, gonorrhea, etc
    • – side effect: bowel cleansing (aphthoid ulcers or diffuse), NSAIDs, etc
    • – eosinophilic colitis

  • 4. Tumor

    • – colorectal cancer (eg, signet cell cancer results in diffuse infiltration with lack of mass effect)
    • – extraintestinal cancer
    • – lymphoma, Kaposi sarcoma
    • – endometriosis

  • 5. Degenerative/functional>

    • – SRUS
    • – stercoral ulcerations (fecal impaction)

  • 6. Traumatic/posttraumatic

    • – anal intercourse, autoeroticism, foreign body
    • – iatrogenic




Top of the List




  • 1. IBD.
  • 2. Specific proctitis/colitis (C difficile, infectious, STD).
  • 3. Ischemic colitis (caveat: ischemic proctitis unlikely!).
  • 4. Radiation proctitis/colitis.




Keys to Diagnosis




  • • History: narration with specific details, identification of risk factors (family, travel, radiation, cardiovascular surgery, anoreceptive intercourse, etc).
  • • Clinical examination: anoscopy/rigid sigmoidoscopy or partial/full colonoscopy, endoscopic picture, and biopsies.
  • • Histology: type of inflammation, granulomatous disease.
  • • Stool analysis: cultures, C difficile toxin, ova and parasites, possible fecal WBCs.
  • • Serum analysis: possible serum titers for viral/amebic pathogens.
  • • Possible imaging studies, eg, small bowel follow-through or CT enterography: small bowel involvement?





Constipation



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Highlights of the Symptom




  • • Appearance: decreased frequency of bowel movements, increased consistency of the stools, change in shape (pencil-/pellet-like bowel movements), need for straining or manual support, incomplete evacuation; multiple/ repetitive small bowel movements.
  • • Localization/point of origin: intestinal transport, evacuation.
  • • Associated symptoms: bleeding, weight loss, fever, dehydration (primary/ secondary), vaginal bulging, etc.
  • • Time factor: acute vs chronic.
  • • Symptom evolution: one-time, gradually worsening, lifelong.
  • • Underlying systemic disease: tumor, cardiopulmonary disease, diabetes, renal disease, etc.
  • • Probability of being sign of serious disease (liability issue): age-dependent.




Pathogenesis-Oriented Differential Diagnosis




  • 1. Malformation

    • – atresia
    • – Hirschsprung disease

  • 2. Vascular

    • – ischemic stricture

  • 3. Inflammatory

    • – Crohn diseaes with stricture
    • – chronic diverticulitis with stricture
    • – anastomotic stricture

  • 4. Tumor

    • – tumor-related obstruction

  • 5. Degenerative/functional

    • – dietary
    • – social (poor habits)
    • – drug-induced
    • – immobility
    • – endocrine/metabolic: hypothyroidism, diabetes, hyperparathyroidism
    • – psychiatric/neurologic (Parkinson disease, multiple sclerosis, etc)
    • – constipation-predominant IBS
    • – slow transit constipation (colonic inertia)
    • – pelvic floor dysfunction: functional outlet obstruction, intussusception, prolapse, rectocele
    • – Chagas disease
    • – pregnancy (pelvic/abdominal lack of space, endocrine-induced decrease of motility, insufficient fluid intake)

  • 6. Traumatic/posttraumatic

    • – spinal injury, paraplegia
    • – retroperitoneal/spinal pathology (hematoma, fracture, etc)




Top of the List




  • 1. Habits.
  • 2. Drug-induced.
  • 3. Functional (IBS, slow transit constipation).
  • 4. Morphologic obstruction (tumor, stricture etc).
  • 5. Pelvic floor dysfunction.




Keys to Diagnosis




  • • Patient’s surgical/medical history: habits, daily routine (diary), alarm symptoms, previous abdominal surgeries, tumor, systemic disease, etc. Previous colonic evaluations?
  • • Clinical examination: patient’s general condition, abdominal distention, palpable mass, tenderness to palpation? Digital rectal exam: perineal descent, stool in rectal vault, stool quality, rectocele, sphincter and puborectalis muscle tone, etc?
  • • Based on evidence from H&P, the likelihood of a morphologic problem has to be determined in order to decide on further tests:

    • – Colonic evaluation.
    • – Colonic function tests: colonic transit time, defecation proctogram.
    • – CT scan.
    • – Contrast studies.





Diarrhea



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Highlights of the Symptom




  • • Localization/point of origin: intestinal, colonic, systemic.
  • • Associated symptoms: nausea, vomiting, abdominal pain and cramping, abdominal distention, high ileostomy output of watery (tealike) quality, bleeding, altered bowel habits, diarrhea, urinary tract infections?
  • • Time factor: acute vs chronic.
  • • Symptom evolution: single episode (self-limited).
  • • Appearance: increased frequency, decreased consistency (loose, watery, etc), added components (blood, mucus), etc.
  • • Severity: decompensated → dehydration; compensated → preserved hydration and organ function.
  • • Underlying systemic disease: IBD, celiac disease, history of previous abdominal surgeries, antibiotic use, etc.
  • • Probability of being sign of serious disease (liability issue): moderate.




Pathogenesis-Oriented Differential Diagnosis




  • 1. Malformation

    • – short bowel syndrome (postresection)
    • – internal fistula (eg, gastrocolic, enterocolonic, enteroenteric fistula)

  • 2. Vascular

    • – acute mesenteric ischemia (first stage)
    • – chronic intestinal ischemia
    • – massive GI bleeding

  • 3. Inflammatory

    • – infectious enteritis/enterocolitis (viral, bacterial, parasites, fungal, STDs, etc)
    • – toxic colitis (eg, C difficile colitis, chemotherapy)
    • – collagenous colitis (abortive form of ulcerative colitis?)
    • – microscopic colitis (abortive form of ulcerative colitis?)
    • – IBD (ulcerative colitis, Crohn disease)
    • – pouchitis
    • – radiation enteritis
    • – celiac disease

  • 4. Tumor

    • – neuroendocrine tumor (eg, VIPoma)

  • 5. Degenerative/functional

    • – contrast-induced
    • – IBS (diarrhea predominant)
    • – dietary (eg, artificial sweeteners, enteral tube feeding)
    • – drug-induced (eg, laxatives, bowel cleansing, HAART, chemotherapy, etc)
    • – bile acid–induced (eg, postileal resection, Crohn disease)
    • – malabsorption
    • – pancreatic insufficiency
    • – stress-induced
    • – paradoxical diarrhea (in fecal impaction)

  • 6. Traumatic/posttraumatic

    • – loss of bowel




Top of the List



Acute Diarrhea




  • 1. Infectious enterocolitis (including traveler’s diarrhea).
  • 2. Iatrogenic (contrast-induced, drugs, cleansing).
  • 3. Antibiotic-associated diarrhea.
  • 4. IBD.



Chronic Diarrhea




  • 1. IBS.
  • 2. IBD.
  • 3. Malabsorption.
  • 4. Collagenous/microscopic colitis.




Keys to Diagnosis




  • • Patient’s surgical/medical history: exposure (travel, foods, oral–anal intercourse, etc)? Other family members affected? Previous endoscopies? Previous abdominal surgeries, tumor, antibiotic treatment, immunosuppression (HIV, drug-induced), current medications, etc.
  • • Clinical examination: patient’s general condition (hydration, hemodynamic status), abdominal distention, hyperactive bowel sounds, focal/diffuse tenderness to palpation, peritoneal signs, stool in rectal vault (fecal impaction?), etc.
  • • Further testing (typically not needed for acute self-limited diarrhea):

    • – Stool analysis: cultures, toxins, O&P, 24-hour fat content.
    • – Blood/urine tests: celiac disease, 5-HIAA, etc.
    • – Endoscopy:

  • • Colonoscopy with biopsies (even if macroscopically normal → assess for collagenous or microscopic colitis).
  • • EGD → consider small bowel biopsy to rule out celiac disease?
  • • Capsule endoscopy?

    • – Imaging:

  • • Contrast studies: small bowel follow-through, CT enterography.
  • • Response to empirical treatment (antidiarrheals, cholestyramine, etc).





Discharge



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Highlights of the Symptom




  • • Localization/point of origin: per rectum, perianal, per vagina?
  • • Associated symptoms: perianal/perineal moisture (→ skin irritation), odor, bleeding, pain, itching, tenesmus, urgency, prolapse, altered bowel habits, diarrhea, weight loss, pulmonary symptoms?
  • • Time factor: onset, constant, cyclic, certain time, certain activity?
  • • Symptom evolution: continuous, intermittent, worsening, one-time, self-limited.
  • • Appearance: aqueous; clear, colorless mucus; brownish; feculent; purulent.
  • • Underlying systemic disease: fistula-in-ano, fecal incontinence/soiling, rectovaginal fistula, IBD (ulcerative colitis, Crohn disease), HIV, STDs, tuberculosis.
  • • Probability of being sign of serious disease (liability issue): moderate.




Pathogenesis-Oriented Differential Diagnosis




  • 1. Malformation

    • – ectropion (eg, post–Whitehead hemorrhoidectomy)

  • 2. Vascular

    • – prolapsing internal hemorrhoids
    • – radiation proctitis

  • 3. Inflammatory

    • – proctitis/colitis (infectious, idiopathic, postradiation)
    • – SRUS
    • – abscess
    • – fistula-in-ano
    • – anastomotic leak
    • – dermatitis (eczema, contact allergy, etc)

  • 4. Tumor

    • – large adenoma (particularly villous adenoma)
    • – anorectal tumors (cancer, Paget disease, Bowen disease)

  • 5. Degenerative/functional

    • – IBS
    • – rectal prolapse/intussusception
    • – fecal incontinence
    • – transpiration
    • – inadequate local hygiene

  • 6. Traumatic/posttraumatic

    • – anal intercourse, autoeroticism, foreign body
    • – rectourinary fistula




Top of the List




  • 1. Abscess/fistula.
  • 2. Incontinence/transpiration.
  • 3. Prolapse (rectal, hemorrhoidal).
  • 4. Villous adenoma.
  • 5. IBS.
  • 6. Neoplasm.
  • 7. Proctitis.
  • 8. Trauma.




Keys to Diagnosis




  • • Patient history: precipitating/risk factors, characterization of symptoms.
  • • Clinical examination: careful anorectal exam including inspection, palpation, anoscopy/rigid sigmoidoscopy.
  • • Colonoscopy: (a) for diagnostic purposes if diagnosis not clear from local exam; (b) colonic evaluation per guidelines.
  • • Functional studies: anophysiology testing, defecating proctogram, etc.





Extraluminal Air



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Highlights of the Symptom




  • • Radiologic finding: conventional x-ray, CT scan.
  • • Associated abdominal symptoms: nausea, vomiting, abdominal pain and cramping, distention, GI dysfunction, tissue crepitans?
  • • Evolution: primary progression/regression, temporary resolution (eg, postoperative) with secondary recurrence?
  • • Location: peritoneal, retroperitoneal, mediastinal, abdominal wall/soft tissue.
  • • Probability of being sign of serious disease (liability issue): high.




Pathogenesis-Oriented Differential Diagnosis




  • 1. Malformation

    • – Chilaiditi syndrome, situs inversus: pseudo–free air

  • 2. Vascular

    • – portal vein gas: sign of ischemic bowel necrosis

  • 3. Inflammatory

    • – perforated viscus (colon, peptic ulcer, appendicitis, etc): → confined or free perforation
    • – anastomotic leak → confined or free perforation
    • – abscess → small pocket of extraluminal air
    • – appendicitis: rarely leading to pneumoperitoneum
    • – emphysematous cholecystitis
    • – necrotizing soft tissue infection

  • 4. Tumor

    • – perforated tumor → confined or free perforation

  • 5. Degenerative/functional

    • – spontaneous pneumoperitoneum without peritonitis: aspiration of air, eg, through vagina and tubes
    • – peritoneal dialysis

  • 6. Traumatic/postsurgical

    • – postoperative pneumoperitoneum: normal resolution expected within 7 days, sporadically taking up to 2½–3 weeks (however, worsening not compatible with delayed absorption → new pathology has to be suspected)
    • – postoperative while nonvacuum drains still in place
    • – postcolonoscopy: small amounts of gas possible even without perforation
    • – colonoscopic/endoscopic perforation → generally massive pneumoperitoneum and/or retroperitoneal air (due to insufflation of pressured gas)
    • – post–transanal endoscopic microsurgery (TEM): extensive retroperitoneal gas expected.
    • – postcardiopulmonary resuscitation: air leak from pressured ventilation → pneumomediastinum/pneumothorax with abdominal extension; rib fractures → sharp injury to lung/diaphragm
    • – pneumobilia: status post-ERCP/sphincterotomy, status post-hepaticojejunostomy




Top of the List




  • 1. Perforated viscus.
  • 2. Normal postoperative.
  • 3. Anastomotic leak.
  • 4. Abscess.




Keys to Diagnosis




  • • Patient’s immediate surgical/medical history: type and time frame of previous abdominal surgeries or procedures, prodromal symptoms (eg, epigastric or LLQ pain, etc).
  • • Clinical examination: patient’s general condition, vital signs, abdominal distention, tenderness to percussion/palpation, peritoneal signs (involuntary guarding, rebound tenderness), bowel sounds, drains, etc.
  • • Context synthesis: combination of radiologic data with information from H&P.
  • • Additional imaging: eg, water-soluble contrast study.


Jan 14, 2019 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Symptoms and Differential Diagnosis
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