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Probability diagnosis

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Pregnancy

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Obesity

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Constipation, esp. chronic

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Irritable bowel syndrome

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Enlarged bladder

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Fibroid uterus/ovarian tumour/cyst

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Serious disorders not to be missed

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Vascular:

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  • CCF (ascites)

  • aortic aneurysm

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Infection:

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  • intrabdominal abscess

  • peritoneal tuberculosis

  • hydatid cyst

  • clostridial intra-abdominal infection

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Cancer:

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  • ovary, stomach, colon, other

  • carcinomatosis peritonei

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Other:

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  • ascites (several causes)

  • intestinal obstruction (large bowel)

  • acute gastric dilatation

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Pitfalls (often missed)

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Hepatomegaly, splenomegaly

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Hydronephrosis

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Massive lymphadenopathy/lymphosarcoma

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Rarities:

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  • chronic idiopathic pseudo-obstruction

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Is the patient trying to tell me something?

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Consider pseudocyesis.

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Consider the classic five:

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  • fat

  • flatus

  • fluid

  • faeces

  • fetus

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Key history

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  • Is the swelling intermittent, variable or progressive (the most serious)?

  • Associated symptoms, especially gastrointestinal, menstrual (?pregnancy)

  • Red flags, especially weight loss, fever, pain, lymph nodes

  • History of alcoholism, hepatitis, kidney disease, heart disorder

  • Past history of abdominal surgery, cancer

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Key examination

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  • General appearance

  • Vital signs

  • Abdomen (inspection, palpation, auscultation, percussion)

  • Rectal and vaginal examination

  • Tests for ascites (if present)

  • Dipstick of urine

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Key investigations

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  • FBE and ESR/CRP

  • Urinalysis

  • U&E and LFTs

  • Plain abdominal X-ray, ultrasound (best)

  • Pregnancy test in females with amenorrhoea

  • Specialised imaging according to findings, e.g. CT scan

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Diagnostic tips

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  • Be alert for pregnancy in women of childbearing age, especially teenagers and perimenopausal women.

  • Be alert for constipation, especially in the elderly.

  • Weight loss with abdominal swelling suggests malignancy.

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