Dr. YK Amdekar, in the second part of the series on abdominal pain, stresses with the help of case studies, on the importance of understanding symptom onset in patients presenting with abdominal pain, which could be vital clues to aid in diagnosis.

Before you begin, take the quiz below to test your knowledge.

 

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Case 1

An 8-month old infant presented with acute onset of vomiting that was followed within hours by recurrent and severe crying episodes. This was followed with passing blood and mucus per rectum. There was no fever. Physical examination showed mild abdominal distension and no other abnormal findings. Considering acute bacillary dysentery, he was treated with antibiotics.

Acute onset of severe abdominal pain with vomiting suggests surgical cause and blood and mucus passed through rectum indicates intussusception. Over the next few hours, he looked sicker with increasing abdominal distension. USG confirmed intussusception and he was operated. Fortunately intestines did not show gangrene and so could be salvaged.

Acute onset of abdominal pain with vomiting and abdominal distension is a clear indication of surgical problem. Absence of fever and sudden onset rules out medical causes of inflammation such as acute bacillary dysentery. Blood and mucus passed through the rectum was not accompanied with passage of stools and so it was not an intestinal infection. Delay in the diagnosis may result in gangrene that may need resection of some part of the bowel.

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Case 2

An 8-year-old child presented with fever and loose stools for 2 days, got better with symptomatic treatment for a few hours but fever recurred with stools, with blood and mucus, and abdominal pain. Physical examination showed mild abdominal distension and vague tenderness all over the abdomen. CBC showed neutrophilic leucocytosis and RBCs and pus cells in stool microscopy. Considering it to be acute bacillary dysentery, he was treated with antibiotics without benefit. Afebrile period after initial fever rules out acute infection and so it is non-infective inflammation. Diagnosis of inflammatory bowel disease was confirmed.

Fever in acute infection does not subside unless infection gets cured. As this child’s fever abated for a few days before coming on again, it is not an infection. However fever, blood, and mucus in the stools, and abdominal pain are all symptoms of inflammation and hence the diagnosis of non-infective inflammation.

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Case 3

A 3-month old infant was diagnosed with inguinal hernia and was scheduled for surgery in the next few days. Meanwhile, he suddenly started crying and the inguinal swelling increased. He also had mild fever. The surgeon tried to reduce the hernia and he succeeded but the crying would not stop. Thinking about the rare situation where hernia is reduced but without relieving obstruction, urgent surgery was considered. At that time, the paediatrician’s opinion was asked to rule out any other conditions responsible for continued crying.

As this child had fever at onset of crying, acute intestinal infection was possible. Per rectal examination led to passing of stools with blood and mucus confirming diagnosis of acute bacillary dysentery. Any disease with fever at onset indicates most likely an infection. Obstructed hernia should not have presented with fever. Abdominal pain in this child led to crying that in turn increased scrotal swelling that was easily reduced and so it was not an obstructed hernia. Acute bacillary dysentery may start with fever and at times be followed by generalised convulsion due to toxic encephalopathy even before the onset of abnormal stools with blood and mucus.

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Case 4

An 8-year-old child presented with episodes of recurrent severe abdominal pain over last one year. Each episode started with poorly localised abdominal pain, not controlled by any drugs but getting relieved by itself. Mild abdominal discomfort remained for few more hours. Physical examination was totally normal even during the attack. Routine tests were also normal. Poorly localised abdominal pain suggested visceral affection likely to be intestinal, without peritoneal involvement and it has been recurrent but non-progressive.

It has not been a colicky pain but dull ache. This suggests persistent intestinal lesion with recurrent pain. Such a lesion may be induced by locally acting factor as there are no symptoms other than abdominal pain. It was finally diagnosed as Meckel’s diverticulum. It represents a localised acidic patch in some part of intestine, presenting same way as gastric ulcer does. It is suspected by microscopic blood in stools and further confirmed by radionucleide scan.

It is not a common disorder but sound analysis of history paves the way to a probable diagnosis even in absence of any physical signs. Of course, there could be few other conditions presenting in similar way but one must look for a clue as in this case, microscopic blood in stools.

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Case 5

A 3-year-old child presented with acute onset of severe abdominal pain for last two weeks. There was moderate fever at the onset that settled within two days but pain continued though varying in severity but present most of the times and gradually getting more severe. There were no other symptoms. Physical examination showed healthy child but miserable with pain and mild abdominal distension without tenderness.

Sudden onset of severe generalised abdominal pain worsening over time suggests progressive disorder of non-infective aetiology. Infection does not present with sudden onset abdominal pain and hence fever in this child would favour immune-mediated disease. Such a disease could be vasculitis. It was proved to be Hennoch-Scholein purpura. Within the next few days, this child developed purpuric skin rash and also had haematuria.

Sudden onset of a symptom could be either mechanical (traumatic), vascular, neurogenic, metabolic or immunological but not infective. Abdominal pain in this child is obviously not traumatic, neurological or metabolic. Fever leads to immunological and hence diagnosis of general vasculitis, Primary vascular lesion is restricted to small area supplied by affected blood vessel as happens in a myocardial infarct but this child had generalised vasculitis affecting multiple organs – intestine, kidneys, and skin. It could also involve any other organs as well.

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Case 6

A 10-year-old child developed severe abdominal pain localised to the lumber region of the abdomen on one side that was described by him as burning. There were no other symptoms. Physical examination did not reveal any abnormality. Abdominal pain if visceral is dull ache and poorly localised while if it is parietal, it is sharp and well localised. This did not fit in either of these two types. This was well localised but burning. It suggests neurogenic pain. Next day this child came up with vesicular skin rash over the area of abdominal wall where child was describing burning pain. Diagnosis of herpes zoster was evident.

Character of pain gives a clue to probable diagnosis. Colicky pain arises from tubular structures such as intestine. Ureter or bile duct. Dull ache usually refers to solid organs and burning pain is characteristic of neurogenic pain.

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Case 7

An 8-year-old child presented with a history of abdominal pain, loose stools with mucus and fever on and off for the last three months. He was treated with antibiotics without improvement. Physical examination showed chronically sick looking child with abdominal distension and vague generalised abdominal tenderness. Finally, an endoscopy was performed and biopsy showed changes suggestive of intestinal tuberculosis. He was put on anti-TB treatment with steroids and he improved.

As steroids were tapered over the next few weeks, his symptoms recurred despite continuing anti-TB treatment. He was reviewed again with another endoscopy and biopsy that this time revealed diagnosis of inflammatory bowel disease. Anatomical lesion in intestinal tuberculosis is submucosal and mucosal and hence loose stools is not the primary manifestation of such a disease. In fact, classically, intestinal tuberculosis presents as subacute intestinal obstruction resulting in vomiting and at times overflow loose stools.

The primary symptom is constipation and vomiting and not loose stools. This case also highlights limitation of laboratory results if considered without clinical correlation. Histopathology of intestinal tuberculosis is often confused with that of inflammatory bowel disease but clinical profile of two diseases is different.

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Case 8

A 6-year-old child presented with acute onset of high fever and severe abdominal pain that was followed within the next eight hours by a generalised convulsion. Physical examination showed a highly febrile, drowsy child with abdominal distension. The next day, he passed stools with mucus and blood. Diagnosis of acute bacillary dysentery with toxic encephalopathy was made and the child recovered after treatment with antibiotics. Generalised convulsion within a few hours of the onset of fever rules out meningitis that would have presented as headache and vomiting first before leading to convulsion and that too such neurological symptoms would have appeared 2-3 days after onset of fever.

So convulsion was not due to intracranial infection. So it had to be either metabolic or immunological. Metabolic disorders do not start with high fever with abdominal pain and so that is unlikely. Combination of high fever, abdominal pain, and convulsions within a few hours is rare in immunological disorders. Hence one must consider toxin-mediated disorder as was in this child. Shigella infection produces toxin that may result from several complications and at times a complication presents before local intestinal symptoms. Such a presentation of shigella dysentery is not uncommon.