Constipation

Clarify what the patient means by constipation. Use the Bristol stool form scale to describe
the stools.

Constipation is the infrequent passage of hard stools.

Ask about:
 onset: lifelong or of recent onset
 stool frequency: how often the patient moves their bowels each week and how much
time is spent straining at stool
 shape of the stool: for example, pellet-like
 associated symptoms, such as abdominal pain, anal pain on defecation or rectal
bleeding
 drugs that may cause constipation.

Constipation may be due to:

 lack of dietary fibre
 impaired colonic motility
 mechanical intestinal obstruction
 impaired rectal sensation or anorectal dysfunction impairing the process of defecation

Constipation is common in irritable bowel syndrome.

Other important causes include:

 colorectal cancer
 hypothyroidism
 hypercalcaemia
 drugs (opiates, iron)
 immobility (Parkinson’s disease, stroke).

Absolute constipation (no flatus or bowel movements) suggests intestinal obstruction and is
usually associated with pain, vomiting and distension.

Tenesmus suggests rectal inflammation or tumour.

Faecal impaction can occasionally present as overflow diarrhoea.

Rectal bleeding

Establish whether the blood is mixed with stool, coats the surface of otherwise normal stool
or is seen on the toilet paper or in the pan.

Haematochezia: -fresh rectal bleeding

-indicates a disorder in the anal canal, rectum or colon.

During severe upper gastrointestinal bleeding, however, blood may pass through the intestine
unaltered, causing fresh rectal bleeding.

Common causes of rectal bleeding:

 Haemorrhoids
 anal fissures (blood on the toilet paper or in the pan)
 complicated diverticular disease

Haematemesis

Haematemesis is the vomiting of blood.

Ask about:
• Colour: is the vomitus fresh red blood or dark brown,resembling coffee grounds?
• Onset: was haematemesis preceded by intense retching or was blood staining apparent in
the first vomit?
• History of dyspepsia, peptic ulceration, gastrointestinal bleeding or liver disease.
• Alcohol, non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoid ingestion.

If the source of bleeding is above the gastro-oesophageal sphincter, as with oesophageal

varices, fresh blood may well up in the mouth, as well as being actively vomited.

With a lower oesophageal mucosal tear due to the trauma of forceful retching (Mallory–
Weiss syndrome), fresh blood appears only after the patient has vomited forcefully several
times.
Nausea and vomiting

Nausea is the sensation of feeling sick.

Vomiting is the expulsion of gastric contents via the mouth.

Both are associated with pallor, sweating and hyperventilation.

Ask about:
• relation to meals and timing, such as early morning or late evening
• associated symptoms, such as dyspepsia and abdominal pain, and whether they are
relieved by vomiting
• whether the vomit is bile-stained (green), blood-stained or faeculent

NB: Feculent vomiting, stercoraceous vomiting. Fecal vomiting is a kind of vomitingwherein the
material vomited is of fecal origin. It is a common symptom of gastrojejunocolic fistula and intestinal
obstruction in the ileum.

Nausea and vomiting, particularly with abdominal pain or discomfort, suggest upper
gastrointestinal disorders.

Dyspepsia causes nausea without vomiting.

Peptic ulcers seldom cause painless vomiting unless they are complicated by pyloric stenosis,
which causes projectile vomiting of large volumes of gastric content that is not bile-stained.
Obstruction distal to the pylorus produces bile-stained vomit.

Severe vomiting without significant pain suggests gastric outlet or proximal small bowel
obstruction.

Faeculent vomiting of small bowel contents (not faeces) is a late feature of distal small bowel
or colonic obstruction.

In peritonitis, the vomitus is usually small in volume but persistent. The more
distal the level of intestinal obstruction, the more marked the accompanying abdominal
distension and colic.

Vomiting is common in gastroenteritis, cholecystitis, pancreatitis and hepatitis.

It is typically preceded by nausea but in raised intracranial pressure may occur without
warning.

Severe pain may precipitate vomiting, as in renal or biliary colic or myocardial infarction.
Other non-gastrointestinal causes of nausea and vomiting include:
• drugs, such as alcohol, opioids, theophyllines, digoxin, cytotoxic agents or antidepressants
• pregnancy
• diabetic ketoacidosis
• renal or liver failure
• hypercalcaemia
• Addison’s disease
• raised intracranial pressure (meningitis, brain tumour)
• vestibular disorders (labyrinthitis and Ménière’s disease).
 Sickle Cell and Acute Abdomen

Attacks of acute abdominal pain with fever, muscle spasm and leukocytosis occur not
infrequently with sickle cell anemia.

The attacks are often severe and may be associated with signs and symptoms strongly
suggesting various acute abdominal disease

Furthermore, persons with sickle cell anemia are just as subject to the other abdominal
diseases as any one else, and instances of cholelithiasis, appendicitis and other emergency
conditions are well known.

Porphyria and Acute Abdomen

Abdominal pain experienced by people suffering from porphyria may be one of three things.

 Pain unrelated to porphyria, and benign, e.g. pain caused by constipation, 'winds', irritable
bowel, etc.
 An acute attack of porphyria, mild or severe, and potentially dangerous.
 Pain indicating a more serious problem, e.g. appendicitis or a peptic ulcer.

Severe acute attacks

The patient usually experiences the following

 severe abdominal pain

 which may also be felt as a dragging discomfort in the lower back, loins and legs
 nausea; vomiting is not invariable
 mildly elevated blood pressure and pulse rate
 passage of dark urine
 and, perhaps, paralysis

Mild acute attacks are signified by the following

 abdominal pain as above, lasting continuously for several days,

 continuous throughout most of the day and night,
 accompanied by loss of appetite and possibly nausea
 Epigastric Mass

Gastric Cancer

Symptoms

Signs and symptoms of gastroesophageal junction cancer and stomach cancer may
include:

 Fatigue

 Feeling bloated after eating

 Feeling full after eating small amounts of food

 Severe, persistent heartburn

 Severe indigestion that is always present

 Unexplained, persistent nausea

  Stomach pain

 Persistent vomiting

 Unintentional weight loss

Risk factors

The main risk factors for gastroesophageal junction cancer are a history of GERD
and obesity.

Factors that increase your risk of stomach cancer located in the stomach body
include:

 A diet high in salty and smoked foods

 A diet low in fruits and vegetables

 Family history of stomach cancer

 Infection with Helicobacter pylori

 Long-term stomach inflammation

 Pernicious anemia

 Smoking

 Stomach polyps
Pancreatic Cancer

Symptoms

Signs and symptoms of pancreatic cancer often don't occur until the disease is
advanced. They may include:

 Pain in the upper abdomen that radiates to your back

 Loss of appetite or unintended weight loss

 Depression

 New-onset diabetes

 Blood clots

 Fatigue

 Yellowing of your skin and the whites of your eyes (jaundice)

Risk factors

Factors that may increase your risk of pancreatic cancer include:

 Chronic inflammation of the pancreas (pancreatitis)

 Diabetes

 Family history of genetic syndromes that can increase cancer risk, including a BRCA2
gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma
(FAMMM) syndrome

 Family history of pancreatic cancer

 Smoking

 Obesity

 Older age, as most people are diagnosed after age 65

Complications

Endoscopic retrograde cholangiopancreatography (ERCP)

As pancreatic cancer progresses, it can cause complications such as:

 Weight loss.

 Jaundice. Pancreatic cancer that blocks the liver's bile duct can cause
jaundice. Signs include yellow skin and eyes, dark-colored urine, and pale-
colored stools. Jaundice usually occurs without abdominal pain.

 Pain. A growing tumor may press on nerves in your abdomen, causing pain that
can become severe. Pain medications can help you feel more comfortable.

 Bowel obstruction. Pancreatic cancer that grows into or presses on the first
part of the small intestine (duodenum) can block the flow of digested food from
your stomach into your intestines

Aortic Aneurysm

Symptoms

Abdominal aortic aneurysms often grow slowly without symptoms, making them
difficult to detect. Some aneurysms never rupture. Many start small and stay small;
others expand over time, some quickly.

If you have an enlarging abdominal aortic aneurysm, you might notice:

 Deep, constant pain in your abdomen or on the side of your abdomen

 Back pain

 A pulse near your bellybutton

 Causes

 Hardening of the arteries (atherosclerosis). Atherosclerosis occurs when fat and

other substances build up on the lining of a blood vessel.

 High blood pressure. High blood pressure can damage and weaken the aorta's walls.

 Blood vessel diseases. These are diseases that cause blood vessels to become
inflamed.

 Infection in the aorta. Rarely, a bacterial or fungal infection might cause an abdominal
aortic aneurysms.

 Trauma. For example, being in a car accident can cause an abdominal aortic
aneurysms.

Risk factors

Abdominal aortic aneurysm risk factors include:

 Tobacco use. Smoking is the strongest risk factor. It can weaken the aortic walls,
increasing the risk not only of developing an aortic aneurysm, but of rupture. The
longer and more you smoke or chew tobacco, the greater the chances of developing
an aortic aneurysm.

 Age. These aneurysms occur most often in people age 65 and older.

 Being male. Men develop abdominal aortic aneurysms much more often than women
do.

 Being white. People who are white are at higher risk of abdominal aortic aneurysms.

 Family history. Having a family history of abdominal aortic aneurysms increases your
risk of having the condition.

 Other aneurysms. Having an aneurysm in another large blood vessel, such as the
artery behind the knee or the aorta in the chest, might increase your risk of an
abdominal aortic aneurysm.

Signs and symptoms that your aortic aneurysm has ruptured can include:

 Sudden, intense and persistent abdominal or back pain, which can be described as a
tearing sensation

 Low blood pressure

 Fast pulse
Hepatomegaly

Symptoms

An enlarged liver might not cause symptoms.

When enlarged liver results from liver disease, it might be accompanied by:

 Abdominal pain

 Fatigue

 Nausea and vomiting

 Yellowing of the skin and the whites of the eyes (jaundice)

Causes

Many conditions can cause it to enlarge, including:

 Liver diseases

 Cirrhosis

 Hepatitis caused by a virus — including hepatitis A, B and C — or caused by infectious

mononucleosis

 Nonalcoholic fatty liver disease

 Alcoholic fatty liver disease

 Amyloidosis (protein accumulation)

 Wilson's disease (copper accumulation)

 Hemochromatosis (iron accumulation)

 Gaucher's disease (fatty substances accumulation)

 Liver cysts

Risk factors

 Excessive alcohol use. Drinking large amounts of alcohol can be damaging to your
liver.
 Kidney Stones

Symptoms

A kidney stone may not cause symptoms until it moves around within your kidney or
passes into your ureter — the tube connecting the kidney and bladder. At that point,
you may experience these signs and symptoms:

 Severe pain in the side and back, below the ribs

 Pain that radiates to the lower abdomen and groin

 Pain that comes in waves and fluctuates in intensity

 Pain on urination

 Pink, red or brown urine

 Cloudy or foul-smelling urine

 Nausea and vomiting

 Persistent need to urinate

 Urinating more often than usual

 Fever and chills if an infection is present

 Urinating small amounts

Risk factors

Factors that increase your risk of developing kidney stones include:

 Family or personal history. If someone in your family has kidney stones, you're more
likely to develop stones, too..

 Dehydration. Not drinking enough water each day can increase your risk of kidney
stones.

 Certain diets. Eating a diet that's high in protein, sodium (salt) and sugar may
increase your risk of some types of kidney stones.
  Being obese. High body mass index (BMI), large waist size and weight gain have
been linked to an increased risk of kidney stones.

 Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel

disease or chronic diarrhea

 Other medical conditions.

Symptoms

Urinary tract infections don't always cause signs and symptoms, but when they do
they may include:

 A strong, persistent urge to urinate

 A burning sensation when urinating

 Passing frequent, small amounts of urine

 Urine that appears cloudy

 Urine that appears red, bright pink or cola-colored — a sign of blood in the urine

 Strong-smelling urine

 Pelvic pain, in women — especially in the center of the pelvis and around the area of
the pubic bone

UTIs may be overlooked or mistaken for other conditions in older adults.

Types of urinary tract infection

Each type of UTI may result in more-specific signs and symptoms, depending on
which part of your urinary tract is infected.

Part of urinary tract affected Signs and symptoms

Kidneys (acute pyelonephritis)  Upper back and side (flank) pain

 Part of urinary tract affected Signs and symptoms

 High fever

 Shaking and chills

 Nausea

 Vomiting

Bladder (cystitis)  Pelvic pressure

 Lower abdomen discomfort

 Frequent, painful urination

 Blood in urine

Urethra (urethritis)  Burning with urination

 Discharge

Lumbar Hernia
Clinical presentation
Patients with lumbar hernias can present with a variety of symptoms, including a posterolateral mass, back
pain, bowel obstruction (if contents contain bowel), or urinary obstruction (if contents are kidney/ureter).

Pathology
Lumbar hernias occur through defects in the lumbar muscles or the posterior fascia, below the 12 th rib and
above the iliac crest.
Appendicitis

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects

from your colon on the lower right side of your abdomen. The appendix doesn't seem
to have a specific purpose.

Appendicitis causes pain in your lower right abdomen. However, in most people,
pain begins around the navel and then moves. As inflammation worsens,
appendicitis pain typically increases and eventually becomes severe.

Symptoms

Signs and symptoms of appendicitis may include:

 Sudden pain that begins on the right side of the lower abdomen

 Sudden pain that begins around your navel and often shifts to your lower right
abdomen

 Pain that worsens if you cough, walk or make other jarring movements

 Nausea and vomiting

 Loss of appetite

 Low-grade fever that may worsen as the illness progresses

 Constipation or diarrhea

 Abdominal bloating

Complications

Appendicitis can cause serious complications, such as:

 A ruptured appendix. A rupture spreads infection throughout your abdomen

(peritonitis). Possibly life-threatening, this condition requires immediate surgery to
remove the appendix and clean your abdominal cavity.

 A pocket of pus that forms in the abdomen. If your appendix bursts, you may
develop a pocket of infection (abscess). In most cases, a surgeon drains the
abscess by placing a tube through your abdominal wall into the abscess. The
tube is left in place for two weeks, and you're given antibiotics to clear the
infection.
Diverticular disease is the general name for a common condition that causes small bulges
(diverticula) or sacs to form in the wall of the large intestine (colon)

What Are the Symptoms of Diverticulitis?

Diverticulitis, infection and inflammation of diverticula,
can occur suddenly and without warning.
Symptoms of diverticulitis may include:

 Diarrhea and/or constipation

 Painful cramps or tenderness in the lower abdomen
 Chills or fever

What Are the Complications of Diverticulitis?

 Peritonitis (a painful infection of the abdominal
cavity)
 Abscesses ("walled off" infections in the abdomen)
 Obstruction (blockages of the intestine)

Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of

your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue,
weight loss and malnutrition. Inflammation caused by Crohn's disease can involve
different areas of the digestive tract in different people.

The inflammation caused by Crohn's disease often spreads deep into the layers of
affected bowel tissue. Crohn's disease can be both painful and debilitating, and
sometimes may lead to life-threatening complications.

While there's no known cure for Crohn's disease, therapies can greatly reduce its
signs and symptoms and even bring about long-term remission. With treatment,
many people with Crohn's disease are able to function well.
Crohn's disease care at Mayo Clinic

Symptoms

Digestive system
In some people with Crohn's disease, only the last segment of the small intestine
(ileum) is affected. In others, the disease is confined to the colon (part of the large
intestine). The most common areas affected by Crohn's disease are the last part of
the small intestine and the colon.

Signs and symptoms of Crohn's disease can range from mild to severe. They usually
develop gradually, but sometimes will come on suddenly, without warning. You may
also have periods of time when you have no signs or symptoms (remission).

When the disease is active, signs and symptoms may include:

 Diarrhea

 Fever

 Fatigue

 Abdominal pain and cramping

 Blood in your stool

 Mouth sores

 Reduced appetite and weight loss

 Pain or drainage near or around the anus due to inflammation from a tunnel into the
skin (fistula)
Other signs and symptoms

People with severe Crohn's disease also may experience:

 Inflammation of skin, eyes and joints

 Inflammation of the liver or bile ducts

 Delayed growth or sexual development, in children

When to see a doctor

See your doctor if you have persistent changes in your bowel habits or if you have
any of the signs and symptoms of Crohn's disease, such as:

 Abdominal pain

 Blood in your stool

 Ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications

 Unexplained fever lasting more than a day or two

 Unexplained weight loss

Symptoms of Peritonitis
The first symptoms of peritonitis are typically poor appetite and nausea and a dull abdominal
ache that quickly turns into persistent, severe abdominal pain, which is worsened by any
movement.
Other signs and symptoms related to peritonitis may include:

 Abdominal tenderness or distention

 Chills
 Fever
 Fluid in the abdomen
 Not passing any urine, or passing significantly less urine than usual
 Difficulty passing gas or having a bowel movement
 Vomiting

Causes of Peritonitis
When's the last time you had your cholesterol, blood pressure, or weight checked? Learn which
medical tests and screenings you should have and how often you should have them. The most
common risk factors for primary spontaneous peritonitis include:
Liver disease with cirrhosis . Such disease often causes a buildup of abdominal fluid
(ascites) that can become infected.
Kidney failure getting peritoneal dialysis.

Ascites

Ascites is the accumulation of intraperitoneal fluid (s