This presentation covers both abdominal and pelvic masses, and general abdominal swelling. The patient may complain of a general increase in girth or of a discrete mass discovered accidentally; alternatively the GP might find the swelling while performing a physical examination.
The sudden onset of severe abdominal pain represents a genuine emergency in general practice and is a common out-of-hours call. In the true acute abdomen, the patient is obviously ill, and as the clinical condition may deteriorate rapidly, ensure that you examine the patient as soon as possible. NOTE: Upper and mid-abdominal pain are dealt with here. Lower abdominal pain is dealt with under ‘pelvic pain, acute’ and specifically epigastric-type pain is covered in more detail in the epigastric pain section.
This causes significant worry in parents, often about the possibility of appendicitis. Some of the causes listed here (such as infant colic and constipation) can cause recurrent or chronic pain – this is a less common presentation, but one which, in children, still has a tendency to be presented as an ‘acute’ problem, either because of a perceived deterioration or parental anxiety. For more details about recurrent childhood abdominal pain, see the section of the same name.
A pregnant woman who develops this symptom is very likely to be extremely concerned that there is a threat to her pregnancy. Anxiety levels may therefore be high in the patient and her partner. Acknowledge this emotional distress by an urgent and full assessment. Listed here are causes specific to pregnancy and conditions which may be exacerbated or altered by pregnancy; ‘run of the mill’ causes (such as gastroenteritis, IBS and dyspepsia) may obviously occur too, but rarely create diagnostic problems and so are not considered in this section.
This problem may present in any age group. The causes in children are covered in another section. In young to middle-aged adults, the cause is very likely to be benign, but this alters with age: Malignancy should always be suspected in the elderly even though other causes are still commoner. A precise diagnosis sometimes remains elusive.
Constipation is defined as the infrequent or difficult evacuation of faeces. One study of a large normal working population showed variation in frequency from three times a day to three times a week. The average GP will see about 18 presentations of constipation each year. In most cases, there is a combination of aetiological factors, and serious causes are rare.
Diarrhoea is the passage of abnormally liquid and frequent stools. It is said to be chronic if it lasts more than 2 weeks. It is the fifth-commonest presenting symptom in general practice. Patients will use the term ‘diarrhoea’ when presenting, but they may just mean frequent stools.
This is a very common ‘day duty’ presentation and is usually caused by gastroenteritis or some other acute infection. Less common is the subacute or prolonged case, where the differential is wider and where a more detailed analysis is required.
Up to 40% of the adult population suffer this symptom in any one year. Only about one in ten seeks help from their GP, usually presenting with ‘indigestion’. The first step involves sorting out exactly what the patient means by this term. The second is to establish whether it is acute, chronic or acute-on-chronic. And the third revolves around management, which is often orientated towards a pragmatic, symptomatic approach rather than establishing a precise diagnosis.
Doctors may disagree – with patients and among themselves – about where exactly the ‘loin’ is. For the purposes of this chapter, it is the area between the lower ribs and the pelvis, anteriorly or posteriorly. Loin pain is a common acute or subacute presentation, with patients tending to assume that the symptom inevitably represents a renal problem. Occasionally, they are correct. But a musculoskeletal aetiology is much more likely, and there are other possible causes to trip up the unwary.
Recurrent abdominal pain in childhood can be a calling card for a myriad hidden agendas. More than 85 causes have been listed, and as in most areas of general practice, the trick is to sift through the morass of information to find the keys to the diagnosis and open the way to effective management. The underlying cause in the most persistent cases is usually non-organic (90% of those referred to hospital).
Vomiting is one of the commonest reasons for an out-of-hours call – especially for children. While most cases are self-limiting and benign, the possible causes are numerous and the symptoms can herald serious pathology. Careful assessment is required, together with a willingness to review and admit if the diagnosis remains unclear.
This presentation may vary from a few red streaks in gastric fluid to copious quantities of bright red blood. Blood static in the stomach for a few hours will change to look dark and granular, like coffee grounds. Always do a full urgent assessment, and be prepared for the sudden need for resuscitation.
This is not a problem that GPs anticipate with relish. And it is not only the potential impact on clothes or carpet that they are worried about – in the acute scenario, the differential is wide and encompasses some serious illnesses. Ongoing vomiting is less of an urgent worry, with a narrower range of possibilities.