A 64-year-old man presents to the emergency department with abdominal pain and distention, as well as constipation of 8 days’ duration. He denies vomiting, fever, diarrhea, or dysuria. Except for hypertension, he is otherwise healthy with no prior surgeries.

His vital signs are normal except for a borderline pulse of 99 bpm. His physical examination is unremarkable except for his abdomen, which is large, rotund, and tympanitic. There is diffuse tenderness everywhere in the abdomen.

1. What history would you want to obtain?
2. What differential diagnoses would you consider?
3. List and describe the specific diagnostic tests you might order to determine cause of his concern?

ANSWER

Abdominal Pain and Distention: Comprehensive Assessment and Diagnostic Approach

Introduction

A 64-year-old man’s presentation to the emergency department with abdominal pain, distention, and constipation prompts a thorough assessment to determine the underlying cause. This essay outlines the essential history to obtain, the potential differential diagnoses to consider, and the specific diagnostic tests to order for a comprehensive evaluation.

Obtaining Relevant History

To gain a comprehensive understanding of the patient’s condition, it is crucial to obtain a detailed history, including:

Onset and Duration: Inquire about when the symptoms started and how long they have persisted. This information helps establish the timeline of the condition.

Character of Pain: Ascertain the nature of the abdominal pain – its location, intensity, quality (sharp, dull, cramping), and whether it radiates to other areas.

Bowel Habits: Determine the patient’s usual bowel habits, recent changes, and any associated symptoms such as nausea, vomiting, or bloating.

Medical History: Explore the patient’s medical history, focusing on conditions like hypertension and any previous surgeries that could be relevant.

Diet and Lifestyle: Inquire about dietary habits, fluid intake, and physical activity. Discuss any recent changes in diet or routine.

Medications:List all current medications, including over-the-counter drugs, as some may contribute to gastrointestinal symptoms.

Social History: Understand the patient’s social habits, including alcohol consumption and tobacco use, which may influence the presentation.

Differential Diagnoses

Several potential differential diagnoses should be considered based on the patient’s symptoms, which include abdominal pain, distention, and constipation. These may include:

Obstruction: Mechanical bowel obstruction due to adhesions, hernias, tumors, or volvulus could cause symptoms.
Ileus: Non-mechanical bowel obstruction, often due to decreased bowel motility.
Gastrointestinal Perforation: In cases of perforation, abdominal pain and tenderness could be present.
Chronic Constipation: Long-standing constipation could lead to abdominal distention and discomfort.
Diverticulitis: Inflammation of diverticula may cause abdominal pain and changes in bowel habits

Diagnostic Tests

Based on the patient’s presentation and potential differential diagnoses, several diagnostic tests could be ordered:

Abdominal X-ray: To assess for bowel distention, air-fluid levels, and signs of obstruction.
Complete Blood Count (CBC): To evaluate for signs of infection or inflammation.
Electrolyte and Renal Function Tests: To assess for any metabolic imbalances.
Abdominal CT Scan: A CT scan can provide detailed images of the abdomen, aiding in identifying potential causes.
Colonoscopy: If indicated, a colonoscopy can visualize the colon and assess for any structural abnormalities or inflammation.

Conclusion

In cases of abdominal pain, distention, and constipation, a thorough history, consideration of potential differential diagnoses, and appropriate diagnostic tests are paramount. By systematically assessing the patient’s condition and utilizing evidence-based diagnostic approaches, healthcare professionals can accurately identify the underlying cause, enabling prompt and effective management.