You are in a GP surgery.
A 48 year old lady presents with a 12 month history of vague abdominal symptoms including bloating, increased amounts of flatus, intermittent loose stools, vague abdominal cramping pains. Symptoms seem to be worse in the first few hours after eating.
Her trousers have become very tight.
She also notes feeling lethargic. She is a keen amateur athlete and normally goes to the gym several times a week, as well as running and cycling several times a week. However, she has been unable to do her usual exercise routine as she has felt too tired.
She also notes that she has put on about 2-3 kgs of weight unintentionally in the last 3-6 months. She puts this down to exercising less often because she doesn’t feel up to it.
Her periods have not changed. They have always been light and remain the same now.
She has no previous significant abdominal or gynaecological history, except that she has two healthy teenage children.
What is the most likely differential diagnosis?
On examination, there is a firm large area in the lower abdomen. You are not able to get below this area. It is at least 20cm in diameter. Mildly tender. You aren’t quite sure if this is guarding or a mass.
Her observations are;
HR 67 regular
BP 127/84
Temp 37.1
What should be your next Action?
Answers
This is a tricky one! The presenting complaint is suitably vague and very common in General Practice (and sometimes in Emergency too). Its very hard to tell the most likely diagnosis from the history.
All of the differentials listed are possible.
There are a few clues that might make you more suspicious in this one.
The fact that she has put on weight is somewhat unusual. If there was a serious cause like Inflammatory Bowel disease, or coeliac disease, or some other true dietary intolerance, she would be more likely to have lost weight. The same is true for any cancers.
It is also important to EXCLUDE the most serious diagnoses. And you want to make sure she doesn’t have an ovarian tumour.
In this case, the diagnosis is a large, benign ovarian cyst.
The weight she has gained is due purely to the mass of the cyst itself. Sometimes they can be very large (think: the size of a football) and can weight several kilograms. These tumours can cause GI symptoms due to the physical irritation of the bowels by such a large mass.
If this lady had not had an obvious mass, the most useful first investigation would likely be some blood tests – including full blood count, urea and electrolytes, liver function tests, inflammatory markers (for inflammatory bowel disease), serum tTG for coeliac disease, and probably bloods that would screen for fatigue – such as iron studies, thyroid function tests, B12 and vitamin D. You might also want to think about a stool sample for fecal occult blood.
IBS – irritable bowel syndrome – although common, is usually a diagnosis of exclusion, and more serious pathology should be sought and ruled out before diagnosing this as the cause.
When investigating a palpable abdominal mass, ultrasound is almost always the investigation of choice. Abdominal masses are usually caused by:
– Pelvic pathology (more common in women) e.g. ovarian cyst
– Liver mass / enlarged liver
– Splenic mass / enlarged spleen
– Hernias
– Constipation (Clinical diagnosis – imaging not usually required. May be seen on AXR or CT but not an indication for either)
– Abdominal aortic aneurysm (rarely causes a mass)
Bowel cancer rarely causes a palpable bowel mass – although if it metastasizes to the liver it may cause a palpable liver.
Constipation can sometimes be palpated as a vague mass in the LIF or RIF.
CT scanning is best for differentiating abdominal pain (as opposed to abdominal masses) – particularly in the acute setting. It can detect many pathologies, but commonly seen are:
– Causes of peritonitis / bowel rupture
– Diverticulitis
– Pancreatitis
– Inflammatory Bowel Disease
– Bowel obstruction (may also be detected with AXR)
– Bowel cancer (in the less acute setting probably colonoscopy is best. In the acute setting it is often the secondary effect – such as obstruction or perforation that is the reason for the pain)
– AAA with or without rupture
– Gall bladder pathologies (although many are better seen on USS)
– Appendicitis (may also be seen better on USS)
This lady doesn’t need to go urgently to hospital via A+E. Her condition has been stable for several weeks or months. Her observations are all within the normal range. She is not clinically acutely unwell. And she does not have uncontrollable pain. It is safe for her to go home and have work-up as an outpatient, providing there is suitable ‘safety-netting’.
The Real Case
This patient had her USS a few days after seeing the GP and had a large ovarian cyst. She was seen privately by a gynaecologist and had the mass removed within a week. It was over 25cm in diameter! On histopathology it was determined to be a simple cyst.
On follow up one month later her symptoms had completely resolved and she had gone back to going to the gym daily. She was very grateful for the prompt diagnosis and treatment.