100 cases in General Practice ABDOMINAL PAIN ANSWER Common things occur commonly. Viral gastroenteritis is still possible, although the recurrent symptoms make this less likely. Don’t forget appendicitis. Irritable bowel syndrome is very common, and could be considered likely in view of his family and personal history of anxiety, but can only be posited after excluding other serious or treatable conditions. All returning travellers should be suspected of malaria or a bowel infection. His exposure to ceramic glazes might hint at lead colic: does he have a blue line on his gum? Renal or biliary colic, owing to calculi or infection, are possible. Coeliac disease is also a possibility and is often missed as it can present with any number of non-specific symptoms, most people with this disease are of normal weight or even overweight on presentation and it can be easily confused with irritable bowel syndrome. A blood count, liver and renal function tests, serological tests for coeliac disease and an ultrasound scan of his abdomen would be helpful as would some stool samples looking for bacteria, ova, cysts and parasites. You may think of Crohn’s disease or colitis, and suggest a colonoscopy, or barium radiography. In this case all tests were normal apart from raised endomysial antibodies pointing to coeliac disease and he was referred to a gastroenterologist for jejunal biopsy. He has greatly improved on a gluten-free diet, prescribable on the NHS and he now gets lifelong free prescriptions. Don’t forget to call in his sister; your suspicion of anorexia may need to be revised: and what about his mother and father? KEY POINTS • Non-specific symptoms such as abdominal pain need an organized approach. • Consider whether the traditional rectal examination is indicated here. Many patients find it intrusive and undignified, and it may not add to your clinical knowledge. • Coeliac disease is considerably underdiagnosed in general practice so test for it with any patient with anaemia, tiredness or chronic abdominal symptoms.
Posted on: Sun, 23 Jun 2013 07:02:51 +0000
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