Medical mimics of a surgical abdomen

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.