Abdominal distention

Listening to your patient can reveal an uncommon problem masquerading as a minor illness, says Dr Keith Barnard.

We were all rushed off our feet because there was a virus doing the rounds that caused nausea and vomiting. We'd had many calls about it, and most patients were aware of the epidemic.

When Martha telephoned during a busy surgery to say she had colicky abdominal pain and vomiting for a couple of days, I concluded that she was another victim of the virus.

She felt bloated but had no fever or fainting, and no diarrhoea - in fact she hadn't had her bowels open for a couple of days. Martha was a sensible 53-year-old woman and she was happy with my advice about the management of an acute episode of vomiting.

The next day she called again and requested a visit.

'The pain is worse', she told me, 'I know there's a bug about, but I'm still vomiting, and I'm really bloated'.

Home visit
When I arrived Martha was in bed. There was a bowl by her bed containing some mucousy material that was a bit dark. It looked unremarkable.

She was afebrile, her pulse was a little raised, but otherwise there was little systemic upset. Her stomach looked distended.

I palpated her stomach, half-expecting to feel a mass, but there was nothing. It was tense, with some epigastric tenderness, but no real focal pain.

'I still haven't been to the toilet, doctor,' she volunteered. 'Not even passed wind.'

I examined her abdomen and noticed her hysterectomy scar. I remembered she had the operation a couple of years ago, for large fibroids. I listened all over her abdomen. I was convinced there were no bowel sounds. She had not passed flatus.

Hospital referral
The surgical SHO agreed to see her in A&E, and arranged a standing abdominal X-ray. This revealed distended loops of bowel and fluid levels.

Martha was treated with naso-gastric suction, IV fluids, analgesics and antiemetics, and her bowel strictly rested.

Apparently gallstone ileus, a tumour, a femoral hernia and inflammatory bowel disease were all on the agenda, but the surgeons were convinced that Martha had adhesions from her hysterectomy. They were reluctant to operate in case they caused more adhesions.

Happily for Martha, after a week everything started to work normally again.

The two messages here are that even when 'there's a lot of it about', there are uncommon problems that can masquerade as a current minor viral illness, and, always listen to what your patients are telling you.

Dr Barnard is a former GP in Fareham, Hampshire.

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