Just because a patient is in a
surgical ward, it does not mean that the patient does not have a medical
problem. On the contrary, there are many medical conditions that mimic a
surgical problem. Many times a patients has been labeled a hypochondriac,
malingerer or having a psychiatric disorder but these are diagnosis of
exclusion and the fault lies with us because we have not ruled out the medical
mimics, rare as they may be. This is not a complete list and as your experience
and knowledge increase the list will definitely lengthen but these should
always be at the back of your minds when dealing with a surgical case
especially the ones with normal scans and operative findings because it may
well be a case of a medical patient misdirected to a surgical ward.
The
following list will be in the following format: the disease, the clinical
features, diagnosis and the basics of treatment.
1.
Lead poisoning
a.
Colicky abdominal pain, constipation, fatigue,
depression, cognitive decline, symptoms of anemia, exposure to lead paint and
pipes.
b.
Blood lead levels
c.
Decrease exposure, dimercaptosuccinic acid
(DMSA), calcium disodium EDTA.
2.
Hypercalcaemia
a.
Polyuria, polydipsia, anorexia, muscle weakness,
constipation, nausea, peptic ulcer disease (calcium mediated increase in
gastrin release), may cause pancreatitis rarely, nephrolithiasis, depression,
lethargy.
b.
Corrected calcium levels, intact parathyroid
hormone levels, vitamin D metabolite levels (high in granulomatous diseases and
lymphoma), parathyroid-related peptide, TFT, serum electrophoresis, urinary
calcium excretion.
c.
Hydration (restore euvolemia), calcitonin,
bisphosphonate. If resistant, denosumab (monoclonal antibody to receptor
activator of nuclear factor kappa ligand, prevents stimulation of osteoclasts).
3.
Familial Mediterranean fever
a.
Recurrent fevers (abrupt onset, last two to
three days), abdominal pain (generalized, may have ileus, adhesions, bowel
obstruction), serositis (chest pain from pleura involvement, joint pain).
Persons from Mediterranean area.
b.
Clinically from symptoms.
c.
Colchicine, canakinumab if resistant (monoclonal
IgG antibody to IL-1 beta)
4.
Porphyria
a.
Acute intermittent porphyria: severe abdominal
pain, seonsory and motor peripheral pneuropathy, neuropsychiatric symptoms
(agitation, hallucinations, seizures, paresis), red urine. Hereditary
coproporphyria/variegate porphyria: abdominal pain, motor neuropathy, seizures,
hyponatremia, blisters
b.
Urinary, serum and stool levels for
porphobilinogen, delta aminolevulinic acid, prophyrins.
c.
Hemin (blood product derivative that inhibit
delta aminolevulinic acid production) or glucose loading.
5.
Adrenal insufficiency
a.
Mineralcorticoid>glucocorticoid, hypoglycemia
therefore is rare, abdominal pain and rigidity (esp in adrenal injuries),
vomiting, lethargy, hypotension, hyperpigmentation (chronic), weight loss
(chronic)
b.
Morning serum or salivary cortisol
concentration, 24 hour urine cortisol concentration, ACTH stimulation
(high-dose: 250mcg, normal response 500 to 550 nmol/L in 1 hour)
c.
Hydrate with normal saline, intravenous
glucocorticoids (dexamethasone does not infeterfere with cortisol assay but
hydrocortisone preferred for its mineralcorticoid activities)
6.
Mesenteric ischaemia (Mesenteric angina)
a.
Dull crampy post-prandial epigastric pain within
one hour subsides in two hours, nausea, diarrhea, nausea, sitophobia, weight
loss, may present acutely. Must rule malignancy and chronic pancreatitis.
b.
CT abdomen and T angiography.
c.
Mesenteric angioplasty and stenting,
revascularization with bypass grafting.
d.
Coeliac artery compression syndrome is diagnosis
of exclusion that has similar symptoms are the same as mesenteric ischemia but
there is no evidence of ischemia but etiology is median arcuate ligament.
7.
Inflammatory bowel disease
a.
Crohn’s disease: crampy abdominal pain,
diarrhea, weight loss, fever, blood in stools, fistulas, mouth ulcers,
arthritis, uveitis, associated with primary sclerosing cholangitis. Ulcerative
colitis: colicky abdominal pain, diarrhea with blood, tenesmus, urgency,
mucosal layer of the colon, extraintestinal manifestation.
b.
Crohn’s: colonoscopy with terminal ileum
intubation and biopsy. Ulcerative colitis: Colonoscopy with biopsy.
c.
Crohn’s: sulfasalazine, steroids, azathioprine,
methotrexate, infliximab and adalimumab (anti-TNF therapies). Ulcerative
colitis: topical 5-aminosalicylates, sulfasalazine, steroid, infliximab.
8.
Budd-Chiari syndrome
a.
Hepatic venous outflow obstruction: Abdominal
pain, fever, ascites, jaundice, hepatic encephalopathy, variceal bleed, hepatosplenomegaly.
b.
Doppler ultrasound
c.
Thrombolysis is less than 3 weeks old,
anticoagulation, surgical shunts, liver transplantation.
9.
SLE caused serositis
a.
SLE because it is associated with serositis may
present with intestinal pseudo-ostruction, acute pancreatitis, mesenteric
ischaemia and or peritonitis, symptoms of peptic ulcer disease. Patient may
also have other symptoms of peritonitis.
b.
Anti-nuclear antibody, anti double stranded DNA
antibody. 2012 Systemic Lupus International Collaborating Clinics.
c.
Hydroxychloroquine (cutaneous), steroids,
cyclophosphamide and cyclosporine (nephritis)
10. Infection
a.
Dengue can present with abdominal pain with
warning signs. Lok out for thrombocyopaenia and leucopenia in a recently
defervescent patient. NS-1. Supportive.
b.
Kala-azar or visceral leishmaniasis may present
with fullness of left upper quadrant and abdominal discomfort due to the
splenomegaly. Skin will darken hence kala-azar. Endemic to India. Diagnosis is
by identification of the parasite Leishmaniasis donovan by smear or bone marrow
biopsy and culture. Liposomal amphotericin B and sodium stibogluconate
(pentavalent antimonials, no longer first-line)
11. Acute
colonic pseudo-obstruction (Olgivie’s syndrome)
a.
Abdominal distension, 80% have pain, naursea,
vomiting, constipation or diarrhea. No fever, marked tenderness or peritoneal
signs, which would suggest ischeamia or perforation. No obvious mechanical
obstruction
b.
Plain upright abdominal radiographs, abdominal
CT scan.
c.
Correct hydration and electrolytes. Withhold
opiates, calcium channel blockers, anticholinergics. Keep nil by mouth.
Decompression with nasogastric tube. Neostigmine only if caecal diameter
>12cm, >48 hours conservative therapy. Colonic decompression by placing
decompression tube.
12. Spleen
a.
Pancreatitis-induced splenic vein thrombosis: It
must be remembered if after a patient has had an episode of pancreatitis which
then resolves and the patient presents once more with left quadrant pain,
dyspepsia with upper gastrointestinal bleeding, one must have splenic vein thrombosis
in his or her mind. The inflammation from the pancreatitis especially if
chronic will cause the development of thrombosis in the splenic vein, which
lies posteriorly. Diagnosis is by abdominal ultrasound with Doppler and
abdominal CT scan. Management is screening for esophageal varices and
anticoagulation.
b.
Splenic infarct: the splenic artery may be
occluded by infection, emboli or clot this can be in the setting of hypercoagulability,
atrial fibrillation, hemoglobinopathy especially sickle cell disease, and myeloproliferative
disease Left-sided abdominal pain, fever, nausea, vomiting, splenomegaly,
leukocytosis.
13. Hypothyroidism
a.
Symptoms of hypothyroidism. However the
constipation may precipitate ileus and cause sub-acute intestinal obstruction.
Watch out for cold intolerance, weight gain, lethargy, anti-thyroid
over-treatment.
b.
Thyroid function test.
c.
Thyroid hormone replacement.
14. Vasculitis
a.
Behcet’s syndrome: vasculitis causing recurrent oral ulcers (>3 times/year),
genital ulcers, erythema nodosum, uveitis, arthritis, abdominal pain and
bleeding in Turkish or Mediterranean stock. Pathergy test positive. Treatment
is with steroids, colchicine, azathioprine, and cyclophosphamide. Biologics are
still under investigation.
b.
Henoch-Schonlein Purpura is an IgA vasculitiswhich
presents with palpable purpura, arthritis, colicky abdominal pain with or
without haemorrhage. In adults renal involvement is increased. Diagnosis is
with increased IgA levels, hypocomplementatia, high ESR and biopsy indicating
leucocytoclastic vasculitis with IgA deposition. Treatment of pain with
paracetamol, NSAID or prednisolone if severe. Rule out ichaemic bowels and
intussusception (rare in adults). Steroids or cyclophosphamide in severe renal
involvement.
c.
Polyarteriti nodosa is a systemic necrotizing
vasculitis affecting the medium-sized arteries. It presents with fatigue,
weight loss, fever, arthralgia, tender skin nodules or livedo reticularis,
glomerulonehritis (blood and protein in the urine with casts), sensory and
motor neuropathy, abdominal pain with gastrointestinal bleeding and mesenteric
ischaemia, coronary artery disease, testicular pain. Skin biopsy will show
leucocytoclastic vasculitis with necrosis in medium-sized arteries. ANCA and
ANA negative. There is an association with hepatitis B and hepatitis C.
Treatment is with steroid, then with azathioprine and methotrexate add-on. If
severe steroid is added on with cyclophosphamide.
15. Secondary
amyloidosis
a.
May present with lower gastrointestinal bleeding
due bleeding diasthesis from amyloid infiltration of blood vessels. Other
symptoms are nephrotic syndrome, restrictive cardiomyopathy, peripheral
neuropathy, hepatomegaly, macroglossia, gastroparesis. The patient looks like a
diabetic patient but this is associated with chronic inflammatory disease such
as rheumatoid arthritis, ankylosing spondylitis, dialysis-associated.
b.
Demonstration of amyloid on biopsy of affected
organs.
c.
Colchicine. Most treatments are investigational.
16. Adult
still’s disease
a.
May present as aseptic peritonitis or
pancreatitis. Daily recurring fever or double quotidian, salmon-coloured rash,
arthralgia, myalgia, pharyngitis, lymphadenopathy and hepatosplenomegaly.
b.
Raised ESR and CRP. Raised ferritin. ANA and RF
negative and even if positive will be low titre. Transamnitis.
c.
NSAID, prednisolone, methotrexate (If erosive
joint disease), severe disease (steroid pulse then combination prednisolone and
anankira [IL-1 inhibitor]) if resistant to anankira use tocilizumab (humanized
IL-6 MAB), if cannot tolerate anankira but responsive canakinumab ( human
anti-IL-1 beta)
17. Hereditary
angioedema
a.
Abdominal pain and idstension that lasts up to 4
days. Associated with ‘chicken-wire’ erythema of the skin, facial edema but has
NO urticaria.
b.
Family history, low complement, failure to
respond to antihistamine, response to therapy within 2 hours, low C1 inhibitor
levels.
c.
C1 inhibitor concentrate, recombinant C1
inhibitor, icatibant (synthetic bradykinin B2 inhibitor). Fresh frozen plasma
is second lne.
18. Abdominal
migraine
a.
Associated with migrane. Headache may not be
concurrent. Pain is poorly localized, dull. Lasts for 1 to 72 hours. Associated
with anorexia and nausea.
b.
Diagnosis of exclusion.
c.
As for migraines.
19. Pseudoappendicitis
a.
Right lower abdominal pain, fever, vomiting,
leukocytosis and mild diarrhea. Appendix is normal. Associated with Yersinia
enterocloitica and Campylobacter infection.
b.
Diagnosis is mostly academic as they are grown
in culture from normal appendices from appendicectomies.
c.
Yersinia enterocolitica should not be treated as
there is no evidence of benefit. Campylobacter is treated with fluoroquinolones
or azithromycin..
20. Anterior
cutaneous nerve entrapment syndrome
a.
Chronic pain with maximal tenderness over an
area less than two centimeter in diameter. Either sharp dull or burning and
aggravated with tensing of abdominal musculature.
b.
Response to trigger point injection of local
anesthetic.
