---

Headache Management

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1. Classification - Red Flags First

• "Thunderclap" - sudden, worst-ever headache (subarachnoid hemorrhage until proven otherwise)
• New headache in age >50 (giant cell arteritis, mass lesion)
• Fever + neck stiffness (meningitis)
• Headache with focal neurologic signs or papilloedema
• Progressive worsening over days/weeks
• Headache in a cancer or immunocompromised patient

90% of patients presenting to primary care with headache have migraine. - Harrison's Principles of Internal Medicine 22E, 2025

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2. Primary Headache Types & Their Management

A. Migraine

• Aspirin, acetaminophen, or NSAIDs (ibuprofen, naproxen)
• Combination: acetaminophen + aspirin + caffeine (FDA-approved)
• Add a dopamine antagonist (metoclopramide 10 mg, prochlorperazine 10 mg) if nausea is present - also enhances GI absorption

• IV prochlorperazine 5-10 mg (superior to opioids in RCTs)
• IV metoclopramide 10 mg
• IV ketorolac 15-30 mg
• IV mixture: prochlorperazine 5 mg + DHE 0.5 mg over 2 min (common protocol)
• Dexamethasone 6-10 mg IV as adjunct to reduce recurrence
• Magnesium sulfate 2 g IV over 30 min (nonvalidated)
• Opioids: Only for severe infrequent headache unresponsive to other therapies; avoid routine use as they worsen long-term outcomes and decrease future triptan responsiveness

• Single-pulse transcranial magnetic stimulation (sTMS) - FDA cleared
• Noninvasive vagus nerve stimulator (nVNS) - FDA cleared
• Remote electrical neuromodulation (arm device)
• Transcutaneous supraorbital nerve stimulation

---

---

B. Tension-Type Headache (TTH)

• Simple analgesics: aspirin, acetaminophen, NSAIDs (first-line for episodic TTH)
• More severe headaches may require prescription analgesics, but no specific preparation has proven superior
• Avoid opioids and barbiturate-containing combinations due to dependence and medication overuse risk

• Amitriptyline (single bedtime dose) - treatment of choice when anxiety/depression comorbid
• Some evidence for calcium channel blockers, phenelzine, cyproheptadine
• Propranolol and ergotamine are ineffective unless migraine features co-exist
• Biofeedback, relaxation techniques, massage for anxious/stressed patients
• Medication overuse is a key concern - gradual analgesic withdrawal is essential in chronic daily headache

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C. Cluster Headache

• 100% oxygen via mask for 10-15 min at attack onset (highly effective, no side effects)
• Sumatriptan 6 mg SC or zolmitriptan 5 mg nasal spray
• Intranasal lidocaine (adjunct)
• Ergotamine 2 mg orally at bedtime (for predictable nocturnal attacks)

• Verapamil (up to 480 mg/d) - first-line; requires ECG monitoring in older patients
• Prednisone 75 mg/d tapering over ~3 weeks (short-term bridge)
• Lithium 600-900 mg/d (chronic cluster; monitor for toxicity)
• Galcanezumab (anti-CGRP monoclonal antibody) - halved weekly cluster frequency in clinical trials
• Topiramate, melatonin as alternatives

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D. Trigeminal Autonomic Cephalalgias (TACs) Comparison

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E. Medication Overuse Headache (MOH)

• Occurs when acute medications are used >10-15 days/month
• Highest risk: opioids and barbiturates > triptans > NSAIDs
• Treatment: gradual withdrawal of the offending medication (can be done abruptly for triptans/NSAIDs; slower for opioids/barbiturates)
• Preventive therapy should be started during withdrawal
• Multidisciplinary support improves outcomes

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3. When to Refer

• No clear diagnosis
• Primary headache other than migraine or TTH
• Unresponsive to two or more standard therapies for the diagnosed type
• Any suspected secondary headache requiring specialist workup

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Recent Evidence Note

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Abdominal Tuberculosis (Koch's) - Pain Abdomen Management

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Overview

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Forms of Abdominal TB

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Clinical Presentation - Pain Abdomen in Abdominal TB

Chronic/Subacute:

• Abdominal pain - nonspecific, chronic; most common complaint (80-90% of patients)
• Weight loss, evening fever, malaise, night sweats
• Alternating diarrhoea and constipation
• Palpable RIF mass in 25-50% (ileocaecal involvement)
• Ascites and abdominal distension (peritoneal TB)
• "Doughy feel" of abdomen on palpation - a classical sign

Acute (Emergency presentation):

• Features of acute distal small bowel obstruction - colicky pain, abdominal distension, bilious/faeculent vomiting, absolute constipation
• Rarely: peritonitis from perforation of a tuberculous ulcer
• Acute-on-chronic: superimposed obstruction on longstanding disease

These patients are often extremely ill - dehydrated, malnourished, anaemic, often with active pulmonary TB. - Bailey & Love

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Investigations

• FBC - mild anaemia, normal or mildly elevated WBC
• Raised ESR/CRP
• LFTs (especially with hepatic involvement)
• Urea and electrolytes (dehydration in obstruction)

• Sputum AFB smear and culture (even without pulmonary symptoms, CXR is essential)
• IGRA (Interferon-Gamma Release Assay) - Quantiferon or T-SPOT
• Ascitic fluid analysis: straw-coloured exudate, protein >25-30 g/L, WBC >500/mL with lymphocytes >40%, AFB smear often negative, culture takes 4-8 weeks
• Adenosine deaminase (ADA) in ascitic fluid - high sensitivity and specificity for peritoneal TB
• Xpert MTB/RIF assay (on tissue, stool, or fluid) - more sensitive than AFB smear (~65%)
• Tissue biopsy: granulomas with caseation on histology (seen in 50-80% of cases)

• Plain AXR in obstruction: dilated small bowel loops, valvulae conniventes (concertina effect), fluid levels, featureless ileum
• CXR: pulmonary infiltrates/TB lesions (may be normal)
• USS abdomen: ascites (may be loculated), lymphadenopathy, bowel wall thickening
• CT abdomen: ileocaecal valve thickening, asymmetric bowel wall thickening, massive lymphadenopathy with central necrosis (characteristic), cecal contraction, Stierlin sign
• Barium meal/small bowel follow-through: multiple ileal strictures, subhepatic caecum (caecum pulled up by fibrosis - pathognomonic), ileum entering caecum in a straight line from below (Figure 6.38)

• Colonoscopy with biopsy from ileocaecal region - most useful diagnostic procedure
• AFB staining, PCR, and culture on biopsy tissue (with drug sensitivity testing)
• Wear isolation masks when performing

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Management

A. General Supportive Measures (All Patients)

1. Nutrition - correct malnutrition; nasogastric or parenteral nutrition if required
2. Hydration/fluid resuscitation - IV fluids for dehydration, especially in obstruction
3. NGT decompression - in obstruction/ileus
4. Anaemia correction - transfusion if Hb critically low pre-operatively
5. Notify public health authorities - TB is a reportable disease; contact tracing

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B. Medical Management - Anti-TB Therapy (MAINSTAY)

For extrapulmonary TB including abdominal TB, a total duration of 12-18 months may be preferred in some guidelines/settings due to the depth of tissue penetration and risk of relapse. - Bailey & Love

• Send drug sensitivity testing (DST) from cultures - MDR-TB may be more prevalent in abdominal than pulmonary TB
• Add pyridoxine (Vitamin B6) 10-25 mg/day with isoniazid (prevents peripheral neuropathy)
• In HIV co-infection, ART should be initiated; standard TB regimens are used but with close monitoring for drug interactions (rifampicin and antiretrovirals)
• Adjunctive corticosteroids (prednisolone) may be considered in peritoneal TB with ascites to reduce inflammation and adhesion formation (though evidence is limited)
• Engage a TB specialist for management guidance

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C. Surgical Management

Indications for Surgery:

Key principle: Many cases of intestinal obstruction from TB will respond to anti-TB treatment without surgery. Always give adequate medical therapy before deciding on surgical intervention. - Bailey & Love, Summary Box 65.6

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Surgical Options (Elective / Post-Medical Treatment):

Surgical principles are similar to Crohn's disease - resections should be kept as conservative as possible to prevent short bowel syndrome. - Bailey & Love, 28th Ed.

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Emergency Surgery (Acute Obstruction/Perforation):

• IV fluids - vigorous fluid resuscitation
• NGT decompression
• Correct electrolytes
• Blood transfusion if severely anaemic
• Broad-spectrum antibiotics (for perforation/secondary peritonitis)

• Resection of the diseased segment + proximal ileostomy + distal ileal or colonic mucus fistula (preferred)
• This avoids primary anastomosis, which has a high leak rate in the presence of active infection and poor general condition
• One-stage resection and anastomosis is only performed if the patient's general condition permits (rare in the emergency setting)

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Peritoneal TB - Specific Management

• Primarily medical (anti-TB chemotherapy as above)
• Therapeutic paracentesis for tense ascites causing respiratory compromise
• Laparoscopy + peritoneal biopsy if diagnosis in doubt
• Distinguish from peritoneal metastases (CT-guided biopsy or laparoscopy)
• Intestinal obstruction in peritoneal TB (fibrous "dry" type - matted loops) may respond to anti-TB therapy + corticosteroids alone before considering surgery

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TB vs Crohn's Disease - Differential Diagnosis Points

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Summary Algorithm

Suspected Abdominal Koch's (Pain abdomen)
        ↓
Red flags? (Obstruction / Perforation / Haemorrhage)
        ↓                        ↓
      YES                       NO
        ↓                        ↓
Emergency resuscitation    Confirm diagnosis
  + surgery if required    (Colonoscopy + biopsy, CT, ADA)
                                  ↓
                        START ANTI-TB THERAPY
                        (2HRZE → 4HR, 6-18 months)
                                  ↓
                     Clinical response within 2 weeks?
                        ↓                    ↓
                       YES                  NO
                        ↓                    ↓
                  Continue ATT          Re-evaluate diagnosis
                        ↓             Consider MDR-TB / biopsy
              Post-treatment imaging
                        ↓
              Residual stricture/obstruction?
                        ↓
              ELECTIVE SURGERY
              (Strictureplasty / Limited resection)

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Upper Limb (U/L) Swelling - Differential Diagnoses

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Framework for Approaching Upper Limb Swelling

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Differentials - Organized by System

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1. VASCULAR

Upper Extremity Deep Vein Thrombosis (UE-DVT) - MUST NOT MISS

• Accounts for <5% of all DVTs but carries 10-15% risk of PE
• Primary (Paget-Schroetter disease / Effort thrombosis): Axillary/subclavian vein thrombosis from repetitive strenuous arm activity in young, healthy, muscular individuals (weight-lifters, overhead athletes). Associated with thoracic outlet compression by cervical rib or first rib
• Secondary: Indwelling venous catheter (most common cause), mediastinal tumours, malignancy, hypercoagulable states, congestive heart failure, nephrotic syndrome, tamoxifen use

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Superior Vena Cava (SVC) Syndrome - MUST NOT MISS

• Obstruction of the SVC causes bilateral upper limb + face + neck oedema
• Causes: >90% malignant - bronchogenic carcinoma (right lung most common), lymphoma, mediastinal metastases; Non-malignant: sclerosing mediastinitis, goitre, indwelling catheter/pacemaker thrombosis, syphilis, mediastinal haematoma
• Features: Bilateral arm + face + neck swelling (worse in morning), JVD, dilated chest wall collaterals (caput medusae of chest), dyspnoea, headache, visual disturbance, Pemberton's sign (facial congestion on arm raising), hoarseness, dysphagia
• A neurological/oncological emergency if cerebral oedema develops

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Subclavian Artery Aneurysm / Arteriovenous Fistula

• Pulsatile swelling if aneurysm; thrill/bruit with AV fistula
• May follow trauma, thoracic outlet compression, or iatrogenic injury
• Post-traumatic AV fistulae cause distal venous hypertension and limb swelling

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Venous Insufficiency / Post-Thrombotic Syndrome

• Chronic oedema after previous axillary/subclavian DVT
• Venous hypertension leads to persistent limb swelling and skin changes

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2. LYMPHATIC

Secondary Lymphedema (Most Common Overall Cause)

• Breast cancer-related lymphedema (BCRL): Most common cause of upper extremity lymphedema
  • Follows axillary lymph node dissection + mastectomy + radiotherapy
  • Risk factors: high number of nodes dissected, positive nodes, higher BMI, inactive lifestyle, radiation therapy
  • Presents as chronic non-pitting oedema, typically starting in the upper arm/humeral region, spreading to shoulder and forearm
  • Cellulitis of the ipsilateral arm is a frequent complication (non-group A haemolytic Streptococcus)
• Other causes of secondary lymphedema: other malignancies with axillary/mediastinal nodal involvement, filariasis (Wuchereria bancrofti), post-infective (recurrent cellulitis), post-radiation, trauma

Primary Lymphedema

• Extremely rare in the upper limb
• Congenital (Milroy's-like), lymphedema praecox, lymphedema tarda
• Due to aplasia/hypoplasia/dysfunction of lymphatics

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3. INFECTIVE / INFLAMMATORY

Cellulitis

• Infection of deep dermis and subcutaneous tissue
• Presents as: diffuse non-palpable erythema with indistinct margins, generalised swelling, warmth, tenderness; lymphangitis (red streaks); tender regional adenopathy
• Organisms: S. aureus and Group A Streptococcus most common; MRSA in injection drug users, recurrent cases, abscess formation
• Risk factors: Underlying lymphedema or venous insufficiency, prior breast cancer treatment, eczema, tinea pedis (entry site identified in 77%), trauma, obesity, injection drug use
• Systemic features (high fever, rigors) suggest bacteraemia or necrotizing fasciitis

Erysipelas

• Superficial cellulitis with prominent lymphatic involvement
• Sharply demarcated raised erythematous border (distinguishes from cellulitis)
• Sudden onset fever (85%), rapidly spreading (2-10 cm/day)
• Risk factors: lymphedema, tinea pedis (portal of entry)

Necrotizing Fasciitis - MUST NOT MISS

• Deep infection tracking along fascial planes; disproportionate pain, woody oedema, systemic sepsis, skin necrosis/bullae/crepitus
• Surgical emergency

Septic Arthritis / Osteomyelitis

• Localised joint or bone pain, swelling, restricted movement, fever

Lymphadenitis (Axillary)

• Localised axillary swelling/tenderness; may cause mild arm swelling due to lymphatic obstruction
• Causes: bacterial (cat-scratch disease - Bartonella henselae, staphylococcal, streptococcal), viral (EBV, HIV)

Abscess

• Fluctuant, tender, localised; may track to produce diffuse swelling

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4. MUSCULOSKELETAL / TRAUMATIC

Fracture

• History of trauma; deformity, crepitus, point tenderness; confirmed on X-ray

Haematoma

• Trauma, anticoagulation, or spontaneous (haemophilia); tense, bruised swelling

Compartment Syndrome - MUST NOT MISS

• 6 Ps: Pain (disproportionate, especially on passive stretch), Pressure (tight compartment), Paraesthesia, Paralysis (late), Pallor, Pulselessness (late)
• Causes: fracture, crush injury, reperfusion, tight cast/bandage
• Surgical emergency (fasciotomy)

Muscle Tear / Haematoma

• Acute onset with exertion or trauma; ecchymosis, fusiform swelling

Tendon Rupture (Biceps Tendon)

• "Popeye" sign (retracted biceps muscle belly), sudden pain/swelling in antecubital fossa

Osteosarcoma / Bone Tumour

• Gradually enlarging, hard, fixed swelling over long bone; night pain, systemic symptoms

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5. NEOPLASTIC / COMPRESSIVE

Primary Tumours

• Soft tissue sarcoma: slow-growing, deep, firm mass
• Lipoma: soft, lobulated, non-tender (most common benign soft tissue tumour)
• Ganglion cyst: tense, transilluminant, arising near joints/tendons (wrist most common)
• Haemangioma/Vascular malformations

Secondary / Metastatic Disease

• Direct infiltration or nodal involvement from breast, lung, melanoma

Axillary Lymphadenopathy

• Causes arm swelling by proximal lymphatic/venous obstruction
• Causes: metastatic carcinoma (breast most common), lymphoma, leukemia, melanoma, sarcoidosis, infective

Thoracic Outlet Syndrome (TOS)

• Compression of neurovascular structures at the thoracic outlet (between clavicle/first rib) by cervical rib, fibrous band, or hypertrophied scalene muscles
• Neurogenic (most common): paraesthesia, weakness
• Venous (Paget-Schroetter): arm swelling, cyanosis (see DVT above)
• Arterial (rarest): pallor, cold hand, digital ischaemia

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6. SYSTEMIC / GENERALISED CAUSES (Bilateral > Unilateral)

---

7. DRUG-INDUCED

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Summary Table - Key Differentials

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Always think about DVT in a patient with unilateral limb swelling. - Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.

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Unilateral Upper Limb Swelling - Differentials

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Surgical Sieve - VITAMINC Framework

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Differentials in Order of Likelihood

MUST NOT MISS (Urgent/Emergency)

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1. Upper Extremity DVT (UE-DVT)

• Accounts for ~5% of all DVTs; carries up to 33% risk of PE
• Primary - Paget-Schroetter (Effort) Thrombosis:
  • Young, healthy, dominant arm of athletes (swimmers, weight-lifters, overhead workers)
  • Repetitive arm motion + anatomical compression at thoracic outlet (cervical rib, myofascial bands, hypertrophied scalenes) → subclavian vein DVT
  • Classic: sudden onset arm swelling after strenuous exertion
• Secondary (>90% of cases):
  • Indwelling central venous catheter / PICC line / pacemaker lead (most common cause)
  • Malignancy (occult or known) - idiopathic UE-DVT warrants cancer workup
  • Hypercoagulable state (thrombophilia, OCP, malignancy)
  • Mediastinal mass compressing subclavian vein

---

2. Compartment Syndrome

• Emergency requiring fasciotomy within hours to prevent permanent muscle/nerve damage
• Causes: fracture (especially supracondylar in children, radius/ulna), crush injury, tight plaster/bandage, reperfusion after ischaemia, burns, snake bite
• 6 Ps: Pain (disproportionate, worst on passive stretch of fingers - earliest sign), Pressure (tight, tense compartment), Paraesthesia (tingling/numbness), Paralysis (late), Pallor, Pulselessness (very late - do not wait for this)
• Compartment pressure >30 mmHg (or within 30 mmHg of diastolic BP) = fasciotomy threshold

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3. Necrotizing Fasciitis

• Deep-tissue infection tracking rapidly along fascial planes
• Clues: pain disproportionate to appearance, woody indurated oedema, skin crepitus (gas-forming organisms), haemorrhagic bullae, rapid systemic sepsis
• LRINEC score aids diagnosis (CRP, WBC, Na, creatinine, glucose, Hb)
• Emergency surgical debridement

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COMMON

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4. Cellulitis

• Infection of deep dermis and subcutaneous tissue
• Features: Diffuse non-palpable erythema with indistinct margins, generalised swelling, warmth, tenderness; lymphangitis (red streaking proximally); tender axillary adenopathy
• Organisms: S. aureus, Group A Streptococcus; MRSA in injection drug users, abscess-associated
• Portal of entry identified in 77% - skin break, wound, eczema, tinea, bite
• Risk factors: Underlying lymphedema (post-mastectomy patients especially), venous insufficiency, obesity, eczema, injection drug use, IV catheter sites
• Fever/rigors → bacteraemia or necrotizing fasciitis; do not miss

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5. Erysipelas

• Superficial cellulitis with prominent lymphatic involvement
• Sharply demarcated raised, bright-red, indurated border (distinguishes from cellulitis)
• Abrupt onset, high fever (85%), rapid spread (2-10 cm/day)
• Organism: Group A Streptococcus (almost exclusively)
• Risk factors: same as cellulitis; lymphedema + tinea pedis are strongest risk factors

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6. Post-Mastectomy / Secondary Lymphedema

• Most common cause of chronic unilateral upper limb swelling in women
• Follows axillary lymph node dissection + mastectomy + radiotherapy for breast cancer
• Onset: weeks to years after treatment
• Features: Gradually progressive non-pitting oedema, starts at upper arm (humeral region), spreads to shoulder and forearm; skin thickening and fibrosis (late); recurrent cellulitis episodes
• Risk factors: extensive axillary dissection, positive nodes, radiotherapy, high BMI, inactivity
• Stewart-Treves syndrome: Angiosarcoma (bluish/reddish nodules) arising in chronic lymphedema - rare but fatal complication
• Other causes of secondary lymphedema: filariasis, any axillary/mediastinal malignancy, recurrent cellulitis, trauma

---

7. Fracture / Dislocation

• History of trauma; focal point tenderness, deformity, crepitus, abnormal ROM
• Any bone in the upper limb; distal radius most common in adults (Colles')
• Pathological fracture: fracture through bone metastasis/cyst - may be spontaneous or minimal trauma

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8. Haematoma

• Soft tissue bleeding following trauma, anticoagulation, or spontaneous (haemophilia, thrombocytopenia)
• Tense, bruised swelling; ecchymosis may track distally; fluctuant if large
• Can mimic DVT clinically; USS distinguishes

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LESS COMMON BUT IMPORTANT

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9. Superficial Thrombophlebitis (SVT)

• Thrombosis of a superficial vein
• Features: Linear, erythematous, tender, swollen cord along vein; localised rather than diffuse swelling
• Causes: IV cannula/catheter (commonest), varicose veins, trauma, thrombophilia, malignancy
• Trousseau's sign - migratory thrombophlebitis associated with occult malignancy (especially pancreatic tail)
• 3-15% have concurrent DVT - duplex USS if in doubt

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10. Septic Arthritis

• Acute, hot, swollen, painful joint - severely restricted range of motion
• Patient toxic/febrile; child with reluctant limb use
• Organisms: S. aureus (most common), Gonococcus in young adults, Gram-negatives in immunocompromised
• Joint aspiration is diagnostic and therapeutic
• Osteomyelitis can co-exist or present similarly

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11. Gout / Pseudogout

• Crystal arthropathy causing acute monoarthritis
• Wrist, MCP joints (gout); wrist, elbow (pseudogout/CPPD)
• Acutely red, hot, exquisitely tender joint with periarticular swelling
• Urate crystals (negatively birefringent) vs. calcium pyrophosphate (weakly positively birefringent) on joint aspirate
• Elevated serum urate (but may be normal during acute attack)

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12. Complex Regional Pain Syndrome (CRPS) - Reflex Sympathetic Dystrophy

• Follows injury, surgery, or stroke; often disproportionate to initial injury
• Features: Burning pain, allodynia, diffuse oedema, skin colour/temperature changes (warm/red early → cool/cyanotic late), trophic changes (shiny skin, hair/nail changes), hyperhidrosis
• Sudeck's atrophy: osteoporosis on X-ray
• CRPS Type 1 (no nerve injury) vs. Type 2 (with nerve injury = causalgia)

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13. Soft Tissue Tumours

• Lipoma: Soft, lobulated, compressible, non-tender; slowly enlarging; most common benign soft tissue tumour
• Ganglion cyst: Tense, transilluminant; arising near joint capsule/tendon sheath; wrist most common
• Soft tissue sarcoma: Deep, firm, >5 cm, painless, rapidly growing - refer urgently (2-week wait rule)
• Haemangioma/Vascular malformation: Soft, compressible, bluish; may enlarge on dependency

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14. Axillary Lymphadenopathy

• Enlarged axillary nodes causing proximal lymphatic/venous obstruction → arm swelling
• Causes: breast cancer metastasis, lymphoma/leukaemia, melanoma, sarcoidosis, reactive (infection)
• Associated: palpable axillary mass, non-tender (malignant) vs. tender (infective)

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15. Thoracic Outlet Syndrome (Venous Form)

• Compression at the thoracic outlet by cervical rib, first rib, or scalene muscles
• Venous TOS = subclavian vein compression → UE-DVT (Paget-Schroetter) or intermittent obstruction
• Arterial TOS: pallor, cold digits, emboli, digital ischaemia
• Neurogenic TOS (most common form): paraesthesia in ulnar distribution, weakness - not usually swelling

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16. IV Extravasation / Infiltration

• Leakage of IV fluid or chemotherapy agents into surrounding tissue
• Localised swelling, pain, blanching at cannula site; blistering/necrosis with vesicant agents

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17. Insect Bite / Envenomation / Anaphylaxis

• Rapid onset localised swelling at bite site ± urticaria; anaphylaxis causes rapid diffuse swelling
• Snake bite: fang marks, progressive oedema, coagulopathy
• Angioedema (bradykinin-mediated - ACE inhibitor, hereditary): rapid onset non-pitting, non-prurigenic swelling

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Clinical Decision Framework

UNILATERAL ARM SWELLING
         |
    ┌────┴─────┐
  ACUTE      CHRONIC
    |              |
  ┌─┴──┐      ┌──┴───┐
Hot/red? Pain/trauma?  Non-pitting?  Post-mastectomy?
  |         |          |                  |
Cellulitis  Fracture  Lymphedema    BCRL/lymphedema
Erysipelas  Haematoma  CRPS          Stewart-Treves
NF         Compartment
           syndrome
    |
History of catheter/
indwelling device/
malignancy/exertion?
    |
   DVT

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Key Distinguishing Features at a Glance

---

---

Upper Limb Unilateral Swelling - Differentials

---

Key Discriminating Questions

---

Differentials by Category

1. Vascular

---

2. Infective / Inflammatory

---

3. Traumatic / Orthopaedic

---

4. Lymphatic

---

5. Neoplastic

---

6. Neurological / Autonomic

---

7. Iatrogenic / Drug

---

8. Inflammatory / Rheumatological

---

Priority Summary - By Urgency

---

Investigation Pathway

Unilateral Upper Limb Swelling
           |
    Trauma history?
    YES → X-ray ± CT
    NO  ↓
    Hot/red/fever?
    YES → Cellulitis vs. NF vs. septic arthritis
          (bloods, cultures, LRINEC score, USS/MRI)
    NO  ↓
    Risk factors for DVT / catheter in situ?
    YES → Duplex USS → Venography/MRV if inconclusive
    NO  ↓
    Chronic, non-pitting, post-mastectomy?
    YES → Lymphedema (clinical diagnosis ± lymphoscintigraphy)
    NO  ↓
    Palpable mass?
    YES → USS ± MRI ± biopsy (sarcoma protocol if >5cm/deep)
    NO  ↓
    Post-injury, burning pain, allodynia?
    YES → CRPS (clinical diagnosis, 3-phase bone scan)

---

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Treatment of Pain Abdomen in a K/C of Abdominal Koch's (Abdominal TB)

---

Step 1 - Categorize the Pain

Perforation can occur even during anti-TB treatment - always exclude in a k/c of abdominal Koch's with acute pain. - Sleisenger & Fordtran's GI and Liver Disease

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Step 2 - Immediate Assessment

A. History

• Is the patient currently on ATT? For how long? Adherent?
• Character of pain: colicky (obstruction) vs. constant (peritonitis/abscess) vs. dull chronic (active disease)
• Vomiting - bilious/faeculent (obstruction)?
• Last bowel opening / flatus (absolute constipation = obstruction)
• Fever, rigors (superimposed infection, abscess, perforation)
• Weight trend (improving/worsening on ATT)

B. Examination

• Vitals: Tachycardia, hypotension, fever - sepsis, perforation
• Abdomen:
  • Distension + tinkling/absent bowel sounds → obstruction
  • Guarding + rigidity + rebound → peritonitis/perforation
  • Doughy feel + localised ascites → active peritoneal TB
  • RIF mass → ileocaecal disease, abscess
  • Shifting dullness → ascites

C. Investigations

• Bloods: CBC, CRP/ESR, LFTs (ATT hepatotoxicity), urea/electrolytes (dehydration)
• Plain AXR: Dilated small bowel loops with fluid levels (obstruction); free gas under diaphragm (perforation)
• USS abdomen: Ascites (loculated vs free), abscess, lymph nodes, bowel wall thickening
• CT abdomen (gold standard): Obstruction site and level, perforation, abscess, lymphadenopathy with central necrosis, disease extent
• LFTs - check before continuing ATT if hepatotoxicity suspected

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Step 3 - Treatment Based on Scenario

---

A. Chronic/Active Disease Pain (No Complication)

1. Continue/Optimise Anti-TB Therapy (ATT) - THE CORNERSTONE

Total duration 6-12 months standard; up to 12-18 months preferred for abdominal TB in many guidelines. Patients should be under combined physician and surgeon care. - Bailey & Love, 28th Ed.

• Pyridoxine (Vitamin B6) 10-25 mg/day with isoniazid (prevents peripheral neuropathy)

• Hepatotoxicity (isoniazid, rifampicin, pyrazinamide) → raised ALT/AST, jaundice, RUQ pain
  • If ALT >3x normal with symptoms or >5x normal without symptoms → stop all ATT, reintroduce sequentially once LFTs normalise
• Gastritis/GI upset (most common) → take drugs with food, use PPIs/antacids

2. Symptomatic Pain Relief

Avoid NSAIDs in malnourished patients and those with peritoneal involvement due to risk of GI ulceration and masking of perforation.

3. Supportive Measures

• Nutritional support: High protein, high calorie diet; correct malnutrition (key - poor nutrition impairs healing and drug metabolism)
  • Nasogastric/nasojejunal feeding or TPN if oral intake poor
• Fluid and electrolyte correction: IV fluids for dehydration
• Anaemia correction: Iron supplements or transfusion if severe
• Rest bowel if inflamed: Clear liquids → soft diet as tolerated

4. Adjunctive Corticosteroids

• Prednisolone may be considered in:
  • Tuberculous peritonitis with tense ascites - reduces inflammation, adhesion formation, and fibrous constriction
  • Severe constitutional symptoms not responding to ATT alone
• Typical dose: Prednisolone 1 mg/kg/day tapering over 6-8 weeks
• Use under specialist guidance; evidence is limited but practice is established

---

B. Subacute / Intermittent Obstruction (On ATT)

• NBM (nil by mouth) + IV fluids + NGT decompression
• Continue ATT - strictures from active inflammation may respond within 2 weeks of starting therapy
• Many cases of obstruction resolve with ATT alone
• Re-image small bowel after completion of full ATT course

"The surgical principles are very similar to Crohn's disease - resections should be kept as conservative as possible." - Bailey & Love, 28th Ed.

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C. Acute Intestinal Obstruction (Emergency)

1. IV access + vigorous fluid resuscitation (NS or Hartmann's) - correct dehydration and electrolytes
2. NGT insertion + free drainage - decompress bowel, reduce aspiration risk
3. Urinary catheter - monitor urine output
4. Blood transfusion if Hb critically low
5. Broad-spectrum IV antibiotics: (e.g., Ceftriaxone 1g BD + Metronidazole 500 mg TDS)
6. Analgesia - IV morphine titrated; do NOT withhold analgesia pending surgery
7. Correct coagulopathy if present

Avoid primary anastomosis in the presence of active infection, severe malnutrition, and poor general condition - anastomotic leak rate is very high. - Bailey & Love, 28th Ed.

• Continue/start ATT as soon as bowel function returns
• Nutritional support (TPN/enteral feeds initially)
• Plan for stoma reversal + elective disease resection after full course of ATT and when disease is no longer active (normalised inflammatory markers, weight gain, negative cultures)

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D. Perforation (Surgical Emergency)

• Sudden onset severe generalised abdominal pain + peritonism + free gas on AXR/CT
• Resuscitate aggressively first (ABC, IV fluids, antibiotics, analgesia)
• Emergency laparotomy:
  • Resection of perforated segment
  • Anastomosis if peritoneal contamination is minimal and patient condition is good
  • Resection + ileostomy if widespread contamination, poor condition, or active disease → restore bowel continuity as second stage after full ATT + nutritional recovery

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E. Abdominal Abscess

• Localised pain, fever, tender mass
• USS or CT-guided drainage (percutaneous) - first-line if accessible
• IV antibiotics (broad-spectrum to cover secondary bacterial infection)
• Continue/optimise ATT
• Surgical drainage if percutaneous approach fails or abscess not accessible

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F. ATT-Induced Hepatotoxicity as Cause of Pain (RUQ/Epigastric)

• Isoniazid, rifampicin, pyrazinamide are all hepatotoxic
• Check LFTs urgently
• If hepatotoxicity confirmed → stop offending ATT drugs, manage liver, restart sequentially

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Summary Algorithm

K/C Abdominal Koch's + Pain Abdomen
              ↓
    Emergency signs? (Guarding, Rigidity,
    Free gas, Obstruction, Haemodynamic instability)
         ↓                        ↓
        YES                       NO
         ↓                        ↓
  Resuscitate (IVF,         Is patient on ATT?
  NGT, catheter,                  ↓
  antibiotics, analgesia)    YES → Check:
         ↓                  1. ATT adequacy/adherence
  CT abdomen                2. LFTs (hepatotoxicity)
         ↓                  3. Drug sensitivities (MDR)
  Obstruction?  Perforation?       ↓
      ↓              ↓        Optimise ATT
  Resection +   Resection +   + Symptomatic pain relief
  Ileostomy     ±Anastomosis  (Antispasmodics,
  (or           or Ileostomy  Paracetamol, PPI)
  anastomosis                 + Nutrition support
  if fit)                     + Steroids if peritoneal TB
                                    ↓
                            Subacute obstruction on ATT?
                              → NBM + IV fluids + NGT
                              → Re-image post-ATT
                              → Elective surgery if persists
                              (Strictureplasty / Resection)

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Key Principles (Summary Box)

• ATT is the primary treatment - surgical intervention is reserved for complications
• Pain relief should not be withheld - analgesia + antispasmodics are appropriate
• Patients should be under combined physician-surgeon care throughout
• Vigorous supportive care (nutrition, hydration, anaemia) is mandatory in all cases
• Obstruction may respond to ATT alone - always give medical therapy first
• In the emergency setting, do the minimum life-saving procedure - avoid anastomosis in active disease
• After any surgery, complete the full ATT course before considering further elective procedures

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Continuous Loose Stools × 7 Days with Normal CBC - Management

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Clinical Interpretation of the Findings

• No leucocytosis → argues against invasive bacterial infection (Shigella, Salmonella, Campylobacter), severe colitis, or significant systemic inflammation
• No anaemia → no significant GI blood loss, malabsorption not yet severe
• No eosinophilia → makes parasitic infection (helminths) less likely (though not excluded)
• Strongly suggests: Viral gastroenteritis (prolonged/post-infectious), protozoal infection (Giardia, Cryptosporidium), functional/osmotic causes, or non-invasive bacterial toxin-mediated illness

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Step 1 - Assess Severity First

Signs requiring urgent admission / IV management:

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Step 2 - Further Investigations Needed (7 days, not resolved)

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Step 3 - Likely Causes at 7 Days with Normal CBC

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Step 4 - Management

A. REHYDRATION - Most Important Treatment

• Ringer's Lactate or Normal Saline bolus
• Replenish Na, K particularly
• Transition to ORS as soon as tolerated

• Children: Zinc sulfate 10-20 mg/day × 10-14 days - reduces severity, duration, and recurrence of diarrhoea
• Adults: 20 mg/day may be beneficial especially in malnourished patients

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B. DIET - BRAT / Low-residue Diet

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C. SYMPTOMATIC / ANTI-DIARRHOEAL DRUGS

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D. SPECIFIC TREATMENT BASED ON LIKELY CAUSE

Giardiasis (Most likely protozoal cause after 7 days)

"Treatment is not always successful regardless of drug used, and repeat courses may be necessary." - Tintinalli's Emergency Medicine

Entamoeba histolytica (Amoebiasis)

Cryptosporidiosis

• Usually self-limiting in immunocompetent
• Nitazoxanide 500 mg BD × 3 days if prolonged
• Immunocompromised: treat HIV/immunodeficiency; nitazoxanide

Post-viral / Secondary Lactose Intolerance

• Lactose-free diet for 2-4 weeks
• Resume dairy gradually after resolution

Post-infectious IBS / Functional

• Reassurance + dietary modification
• Antispasmodics: Mebeverine 135 mg TDS or Hyoscine 10-20 mg TDS
• Probiotics: Lactobacillus, Saccharomyces boulardii - may reduce duration and recurrence

Antibiotic-associated / C. difficile

• Stop offending antibiotic
• Mild-moderate: Oral vancomycin 125 mg QDS × 10 days or Fidaxomicin 200 mg BD × 10 days
• Metronidazole 400 mg TDS × 10-14 days (if vancomycin unavailable - less effective)
• FMT (faecal microbiota transplant) for recurrent cases

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E. EMPIRICAL ANTIBIOTICS

• Fever (>38.5°C) + moderate-severe illness
• Bloody/mucoid stools
• Traveller's diarrhoea
• Signs of systemic sepsis
• Immunocompromised patient

Avoid antibiotics if STEC (E. coli O157:H7) suspected (bloody diarrhoea + low-grade fever + recent undercooked beef exposure) - antibiotics increase risk of haemolytic uraemic syndrome (HUS) - Goldman-Cecil Medicine; Washington Manual

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F. PROBIOTICS

• Saccharomyces boulardii 250-500 mg BD - reduces duration and recurrence
• Lactobacillus rhamnosus GG (LGG) - evidence in children and post-antibiotic diarrhoea
• Useful as adjunct; not a substitute for specific therapy
• Note: Goldman-Cecil states "probiotics are not useful as treatment" for acute infectious diarrhoea - but post-infectious/antibiotic-associated benefit is established

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Summary Treatment Protocol

7 days loose stools + Normal CBC
           ↓
    Assess dehydration
           ↓
    Mild-Moderate              Severe
    ORS + Diet                 IV NS/RL + ORS
    Zinc supplementation       Electrolyte correction
           ↓
    Send: Stool R/E + C&S, Giardia Ag, Serum electrolytes
           ↓
    Symptomatic (no fever, no blood):
    Loperamide OR Racecadotril + Smectite
           ↓
    Empirical specific treatment:
    Likely Giardia → Tinidazole 2g single dose
    Likely Amoeba  → Metronidazole + Diloxanide
    Systemic features → Azithromycin or Ciprofloxacin
           ↓
    Review stool results → Targeted therapy
           ↓
    Not improving at 2 weeks?
    → Refer gastroenterology
    → Consider colonoscopy (IBD, microscopic colitis)
    → Lactose breath test, thyroid function

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Key Points

• Normal CBC does not exclude Giardia, Cryptosporidium, or post-viral causes - these are the most likely diagnoses at 7 days with normal CBC
• Rehydration is the most important treatment regardless of cause
• Loperamide is contraindicated if fever or blood in stool - risk of toxic megacolon
• Tinidazole 2g single dose is the easiest, most effective treatment for Giardia
• Antibiotics are NOT routinely indicated with normal CBC and no systemic features - most will resolve with ORS + targeted anti-protozoal therapy
• If not improving by 14 days → gastroenterology referral for colonoscopy to exclude IBD, microscopic colitis