The common bile-duct. Biliary colic may occur in younger patients. When a patient is seized with severe epigastric pain and vomiting, and is found to be febrile, to have a moderately distended abdomen, and acute tenderness below the eighth and ninth costal cartilages on the right side as well as just below the xiphoid cartilage, and a rounded, tense tumour or less well-defined resistance can be felt beneath the upper part of the right rectus muscle, it is a case of acute cholecystitis ; a history pointing to the presence of gall-stones can usually be obtained. There is leucocytosis. If the patient is very obese the tumour cannot be felt. The symptoms are less severe—there is less collapse—and the pain and tenderness are more limited to the right side than in acute pancreatitis. <Callout type="important" title="Important">Always look for a history of gallstones before diagnosing cholecystitis.</Callout> 9. When a patient known to have gall-stones, or a distended gall-bladder, or in whom the history points strongly to such, is seized with sudden severe pain over the gall-bladder, vomiting, and shock, and on examination the whole abdomen is found motionless, and the enlarged gall-bladder can no longer be recognized, and free fluid is present in the peritoneum, rupture of the gall-bladder is to be diagnosed. 10. Or if a patient known or suspected to have an abscess or hydatid tumour of the liver, with great enlargement of that organ, has sudden severe pain and becomes collapsed, and there is evidence of free fluid in the peritoneum, rupture of hepatic abscess or of a hydatid will be recognized. It may be possible to make out a marked diminution in size of the liver simultaneously with the escape of fluid into the peritoneum. 11. When a patient is seized with severe and increasing sharp, cutting pain in one loin just below the last rib, and the pain shoots down into the groin, penis, testicle, or thigh, perhaps becomes agonizing in intensity, and is then associated with vomiting, or a rigor, cold sweat, and collapse, renal colic is to be diagnosed. Frequent micturition, a little blood in the urine, retraction of the testicle, the coming-on of the pain in the daytime, and a history of previous attacks of the same kind, or of the passage of gravel or of crystals in the urine, would support the diagnosis. 12. When a woman during active movement or effort experiences pain below the right ribs, and this pain steadily increases up to an agony and is then associated with vomiting and shock, and on examination a firm, very tender tumour is found in the right loin or iliac fossa, which can be moved upwards under the ribs, and the patient is then relieved, a diagnosis of displaced kidney with kinking of the ureter or torsion of the renal vessels can be made. A history of previous attacks or of slighter pain in the same situation, always coming on when upright and always relieved by lying upon the back and relaxing the abdominal walls, would support the diagnosis. 13 When a woman while making some effort is seized with pain in the left side of the abdomen about the level of the umbilicus, which steadily increases and brings on vomiting, and on examination a firm, tender tumour is felt in the situation of the pain, and the tumour can be pressed up beneath the left false ribs, and especially if a sharp or notched border can be recognized in it, it is a case of displaced spleen with torsion of its 'pedicle.' The patient may state that she was conscious of something slipping out of place, or that she had previously had minor attacks of the same nature. 14 If an infant or young child is suddenly seized with severe abdominal pain, and vomits, and the pain is noticed to come on in paroxysms and there is a frequent passage of mucus, and perhaps blood from the rectum, and on examination an elongated tumour is felt in the centre or towards the left half of the abdomen, hardening up under the flanks during each paroxysm of pain and then softening or even disappearing, unusually empty, it is intussusception. In large cases, the end of the intussusception can be felt per rectum. 15 men a patient is seized with vomiting, which frequently repeated and becomes intestinal and diarrhoea, nor flatus is passed from the rectum and an enema if it returns, no flatus with it, and purgatives if given and retained lead to a large amount of indican, there is acute intestinal obstruction. Pain may be absent, or slight, or severe. There may be nothing else to be made out in the case until fatal collapse or signs of peritonitis develop, but there may be a more or less definite or ill-defined abdominal swelling, or collapsed coils of ileum in the pelvis, or a distended coil of bowel in the abdomen, or distended coils of small intestine and an empty colon. For the further diagnosis of cases of intestinal obstruction, see Chap. XXXVIII. 16. When a worker in lead who has a blue line along his gums and lead in his urine is seized with severe griping pain referred to the umbilicus, and there is obstinate constipation and a hard retracted abdomen, he is suffering from lead colic. 17. When a patient is seized with vomiting, griping abdominal pains, and diarrhoea, with gradually increasing collapse, and there is no marked local abdominal tenderness, it is a case of irritant poisoning. Usually several members of a party or of a household are simultaneously attacked, and soon after taking some particular article of diet, e.g. sausage, tinned meat, etc. 18. When a patient complains of severe constricting pain in the upper abdomen, and the belly-wall is found to be motionless but neither retracted nor distended, and the pain becomes very acute at the end of a deep inspiration when the diaphragm descends, and there is no tenderness or altered percussion note at the epigastrium, the case is most probably one of diaphragmatic pleurisy ; the detection of friction will confirm the diagnosis. If one side of the chest is dull, and the breath-sound is absent or tubular, it is a case of lobar pneumonia. 19. If a stout patient who has had symptoms of gall-stones or of rather severe indigestion is suddenly seized with severe pain at the epigastrium, persistent vomiting, and marked and increasing collapse, accompanied by unusual cyanosis and extreme rapidity of the pulse, and on examination the abdomen is found distended but with flaccid walls, with tenderness on pressure above the umbilicus and possibly some ill-defined fullness or resistance in this situation, it is a case of acute pancreatitis. The symptoms of this affection are obscure: in some hemorrhage occurs, in others there are peritonitis and gangrene; leucocytosis is present from the first. The patients are usually chronic alcoholics. 20. If a patient is suddenly seized with acute abdominal pain, and collapse, cannot pass faeces or flatus, and the abdomen becomes rapidly distended by a resonant tense and tender swelling, it is a case of acute volvulus. In this variety of acute obstruction vomiting may be slight or altogether absent. 21. If a patient is seized with sudden severe abdominal pain and vomiting, and passes bloody, putrid stools, and becomes collapsed, thrombosis of the mesenteric vessels has probably occurred. The existence of old heart disease and arterial degeneration would support this diagnosis. _ 22. When a patient is seized with pain in the central part of the abdomen, followed by vomiting, increasing abdominal distension, fever, quick pulse, and leucocytosis, and there is no localized pain or tenderness, nor local swelling, nor is there intestinal obstruction, the case is one of acute peritonitis due to immediate infection of the serous membrane, e.g. by pneumococcus, streptococcus, or gonococcus. 23 If a man is suddenly seized with severe abdominal pain, vomiting, and collapse, and it is found that his pupils are small and do not react to light, that his knee-jerks are diminished or absent, and that he has had 'lightning pains' in his legs it is a gastric crisis in the course of a case of tabes dorsalis. There may be a history of previous attacks to support the diagnosis. 24. The rare condition of acute osteomyelitis of the spine, when it attacks the lumbar vertebrae, may be mistaken at its onset for an acute abdominal catastrophe. It is characterized by very intense pain and tenderness in one or both loins, the pain rapidly extending round the trunk as a girdle pain. With this there are all the signs of an acute toxsemia, fever, dry tongue, thirst, etc. It is to be distinguished, however, from an abdominal condition by the absence of abdominal signs corresponding with this degree of toxemia. 25. Certain cases of cortical abscess of the kidney are acute in onset, with fever, rapid pulse, and pain. The pain is situated in one or other loin, extending down to the iliac fossa. There will be tenderness over the kidney either in front or behind. The condition will be diagnosed from appendicitis or cholecystitis, etc., by the exact site of the tenderness and the want of correspondence between the general condition of the patient and the abdominal signs.
Key Takeaways
- Look for specific symptoms to diagnose various acute abdominal conditions, such as pain location, vomiting, and fever.
- History can be crucial in diagnosing conditions like cholecystitis or intussusception.
- Recognize the signs of peritonitis, which can be life-threatening.
Practical Tips
- Always consider a patient's history when making a diagnosis to avoid misdiagnosis.
- Be aware that symptoms can vary widely between different conditions and individuals.
- Maintain a high level of suspicion for severe conditions like acute pancreatitis or peritonitis, especially in chronic alcoholics.
Warnings & Risks
- Misdiagnosis can lead to improper treatment and worsen the patient's condition.
- Ignoring localized pain or tenderness can delay necessary surgical intervention.
- Failing to recognize signs of peritonitis can result in fatal outcomes.
Modern Application
While many of these conditions remain relevant today, modern diagnostic tools like imaging and laboratory tests have significantly improved accuracy. However, understanding the classic symptoms is still crucial for initial assessment before advanced testing becomes available.
Frequently Asked Questions
Q: How can one differentiate between acute pancreatitis and other abdominal pain conditions?
Acute pancreatitis often presents with severe epigastric pain that radiates to the back, persistent vomiting, and a tender abdomen. Leucocytosis is also common, but it may be absent in some cases. Chronic alcoholism is frequently associated with this condition.
Q: What are the key signs of peritonitis mentioned in the chapter?
Peritonitis typically presents with severe abdominal pain that worsens on deep inspiration, fever, quick pulse, and leucocytosis. There may be no localized tenderness or swelling, but the abdomen is distended and tender to palpation.
Q: How can one identify intussusception in infants?
Intussusception in infants often presents with severe paroxysmal abdominal pain, vomiting, and a passage of mucus or blood from the rectum. An elongated, hard tumour that softens during each episode of pain is characteristic.