Thanks Miles for presenting an excellent case on a middle age male coming in with acute-subacute progressive constipation and bloating, new ascites with a diagnosis of peritoneal carcinomatosis of unknown primary.
- 1) When a patient comes in with bloating, ask whether alarm symptoms are present eg. anemia, unintential wt loss, progressive, new onset in elderly
- 2) The differential diagnosis for bloating can be broken down into anatomic, malabsorption, drugs, functional, infection, and neurologic
- 3) Biomarkers and genetic testing are helpful for diagnosis of carcinoma of unknown primary because it may identify the primary in some cases and can guide treatment. You can set up a free account to access the NCCN guidelines to learn more.
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Differential diagnosis for bloating
- When a patient comes in with bloating, ask about distention, gassiness, and stool quality as well as red flag sx
- 1) anatomic
- a) obstruction/ partial obstruction
- b) gastroparesis
- c) malignancy - classically ovarian carcinoma
- d) constipation
- 2) malabsorption - lactose intolerance, celiac, gluten sensitivity
- 3) drugs - Ca supplements, consumption of large amts of fiber, any constipating drugs (eg opiates, antihypertensives, anticholinergics, vitD, heavy metals, etc)
- 4) functional
- a) functional bloating/ dyspepsia
- b) aerophagia
- c) IBS
- d) dyssinergic defecation -> constipation
- 5) infection
- a) giardia, cyclospora
- b) SIBO
- 6) neurologic
- a) dysmotility - connective tissue dz
- b) Hirschsprung's
Ddx of radiographic "peritoneal carcinomatosis"
- Malignancy: metastatic dz from bladder, colon, gastric, breast, pancreatic, lung, lymphoma vs
- Non-malignancy: TB, sarcoidosis, crohn's, endometriosis
- This NEJM has a nice table of other tumors of the peritoneum that could be considered