When I was a registered surgeon, one of the local doctors could diagnose an acute appendix over the phone with instructions; ‘Stand on your right leg and jump’. If light gymnastics exacerbated the pain, he would contact the hospital and announce that he would refer patients with appendicitis and a ‘positive hop test’.
I know it sounds strange, but it was so astonishingly accurate that for a while he hopped on one leg because it was a popular test with the youngsters in the A&E department.
Presumably the GP has long since been reinstated and his eccentric method of diagnosis seems to have been forgotten, but in retrospect I now realize that he unknowingly taught me a lot about abdominal pain, in particular, the simplicity of diagnosis. In fact, there are only two types.
- Colic is a moaning, fluttering pain that comes in waves. It is caused by abnormally strong peristalsis of a hollow virus due to an obstruction, such as a stone, tumor, or hernia, or irritation, perhaps associated with enteritis, chicken vindaloo, or laxatives.
- Continuous. Persistent, immobile pain that worsens with movement is caused by inflammation due to infection, peritonitis or ulceration, or ischemia associated with mesenteric infringement or embolism.
Forget burning, stabbing, excruciating, terrible, and any other adjectives that might be used. Your ears and eyes will tell you whether or not the patient is describing cramping or continuous pain. Or maybe you could ask if it makes them roll or stay put. Either way, it has to be crampy or constant and once this sets in, you’re halfway there: you know if the pain is due to a blockage, irritation, or inflammation. There is nothing else to consider.
Next, where exactly is the pain felt? For this, some embryological knowledge is required.
No! Please don’t give up on this point just because I’ve mentioned embryology. To keep your interest, I want you to remember the last time you suffered from ‘gastroenteritis’, or in some cases, an overdose of beer and curry. Those teeth marks you made on the bathroom door handle were the result of the suprapubic colic you felt when your intestines exploded the next morning.
The point is that afferent visceral impulses reach the brain via the splanchnic sacs and nerves, and are perceived simply as pain in the foregut (epigastric), midgut (periumbilical), or posterior (suprapubic) gut that is felt in the line of the gut. half. Typically, a patient will place their hand on the appropriate area when describing their viscellal pain or will do so when prompted.
So, at the risk of being boring, let’s repeat the facts. Foregut, midgut, and hindgut, along with colic or continuum, is almost always diagnosed. All we need to know now is which bits are which:
- Foregut: stomach, first and second duodenal clots, gallbladder, biliary tree, and pancreas.
- Middle intestine: Third and fourth parts of the duodenum to two thirds of the transverse colon.
- Hindgut: Last third of the transverse colon, descending colon, rectum and gynecological areas (the latter derived from the cloacal sac).
Let’s use an example that is frequently encountered in the clinic or on war rounds: a 60-year-old anemic with weight loss and a few months’ history of periumbilical (midgut) colicky abdominal pain.
Just on the story, it just has to be a transverse or right colon cancer and hopefully a hand on the abdomen will feel a mass on the right side. Easy.
