Key distinguishing features of the most common diagnoses
|Peptic Ulcer||Renal Colic||Biliary Colic||Appendicitis||Gastroenteritis|
- The only test likely to help the GP is urinalysis: This may reveal haematuria (renal colic), evidence of urinary infection or glycosuria in DKA. In general, the following investigations will be done in hospital after acute admission.
- Full blood count: WCC raised in many causes and confirms acute inflammation or infection.
- U&E essential as abnormalities common with diarrhoea or vomiting. Amylase raised in ischaemic bowel and acute pancreatitis.
- LFT may show raised bilirubin in biliary obstruction, and widespread derangement in hepatitis.
- Helicobacter pylori testing: Strong association with peptic ulcer disease.
- Upper GI endoscopy: To visualise upper GI tract.
- Plain erect abdominal X-ray invaluable to confirm perforated viscus (air under diaphragm). Supine also necessary if obstruction suspected. Ninety percent of renal or ureteric stones will be revealed with a plain abdominal X-ray.
- Ultrasound: Helpful to confirm gallstones.
- Renal imaging: For ureteric stones.
- The aim of assessment is correct disposal rather than an exact diagnosis. Colicky pain may be appropriate to manage at home; constant pain with tenderness is likely to need admission.
- If treating a patient at home, arrange for review as appropriate and ensure that the patient is aware of the symptoms which should prompt urgent reassessment.
- The examination is likely to contribute significantly to making the diagnosis – so take particular care and don’t forget the basics such as pulse rate, temperature, bowel sounds and a rectal examination.
- Beware ‘gastroenteritis’ masking or developing into an acute appendicitis. Make arrangements for follow-up and emphasise that constant pain needs urgent review
- Prejudice is easy if the patient has a history of functional problems or irritable bowel. Surgical pathology can happen to anyone, so be objective.
- Beware the elderly patient with an irregular pulse: Mesenteric infarction causes severe pain but few signs
- Don’t forget to examine the hernial orifices, especially if obstruction is a possibility.