Abdominal pain Ahmed khaled elgizawy N0 : 35 Round : 1

Anatomic background Parietal peritoneum

clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) .

Visceral peritoneum is the continuation of the

parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).

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1 – right hypochondrium2- epigastric 3- left hypochondrium4- Right lumbar5- umbilical 6- left hypochondrium7- right iliac 8-hypogastric9- left iliac

DEFINITION OF PAIN It is an unpleasant sensation of

varying intensity.

Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.

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2

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Mechanical trauma to the tissue .

Excess heat or cold .

STIMULANTS

Chemical damage.

Radiation damage .

Inadequate blood flow.

Intra-thoracic organs

Abdominal Extra-abdominal

Abdominal wall+

Intra-peritoneal organsRetro-peritoneal organsPelvic organs

Systemic dysfunction

Diabetes ,tabes dorsalis

porphyria

Functional abdominal

pain

Types of abdominal pain

1

Visceral pain is primitive and therefore related to

embryologic development .

Somatic pain is entirely different from visceral pain

2

Visceral painVisceral pain1- Receptor1- Receptor

( Visceral peritoneum )

2 - Stimulus

Pat. Experienced pain by traction ,distention & spasm

The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction

3 - Mediation3 - Mediation

Autonomic nervous System Interpreted at the thalamic level of the brain

4- Specificity4- Specificity

Vague , often dull , poorly described & associated with nausea & vomiting

5- Localization5- Localization

Is poor & the pat. Placing the entire hand over the involved region

Somatic pain

1- Receptor

Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves

P/ peritoneum

Somatic pain

2- Stimulus

Pat. experienced pain by

TouchPressureHeatInflammation

Somatic pain

3- Mediation

Central nervous system

&

Interpreted at a specific cortical location

Somatic pain

4- Specificity

Precisely described as

Cutting

Somatic pain

5- Localization

The pain is localized with great accuracy by the patient , who can often point to the site

with one fingerone finger

Referred pain

Pain felt at a site other than where the cause is situated. An example is

the pain from the pancreas, which is felt in

the back. Pain in internal organs is often referred to sites distant

from them.

Analysis of painneed

DATA COLLECTION

1 2 3

History Physical exam. Lab.inv.

apply

youryour medical knowledge***

The history of pain betrays the diagnosis

History of pain

SiteMode of onsetNature of painSeverityRadiationDurationFactors influencing

the clinical manifestation

Site of pain & radiation

Kidney

Stomach & duodenumGB Pancreas

Kidney

Small bowel

Caecum & rp.structure

T. Colon bladder uterus & adnexae

Sig. colon

App. & Caecum

Radiation of the pain

GB. Pain radiates through to the back & to

the right , to reach the tip of the shoulder blade

Radiation indicates source of the pain & also the extent of the diseaseLower abdominal pain rarely radiate

The structures in pelvis may radiate to the lower

back or perineum

Small bowel pain does not usually radiate but

may move when somatic as well as visceral nerves

become irritated

Stomach & duodenal pain goes

strait through the back

Pancreatic pain

tends to go

through to the back but to the left

Kidney pain

may radiate

down into the groin

Mode of onset

Sudden onset[The patient can tell you exactly when the pain started ] ]

The pain that start suddenly has a mechanical basis

Some thing has been

RupturedTwistedOccluded

Mode of onset

Gradual Onset

( The pat. Usually responds vaguely to questions about time of onset )

Non mechanical or chronic process

Nature of pain

Two Large Categories

(1)

Conditions associated with obstruction of a muscular conducting tube

( Small bowel , Ureter , Biliary )

(2)

Conditions associated with inflammation

( Mild & Localized Response or

Severe , Generalized Response )

Obstruction

Suddenprolonged

Distention of the viscus( constant stretching pain )

Colic pain = visceral pain

Three Types

( 1 ) Biliary System = ( foregut )

Foregut pain is experienced in the epigastrium

1

(2) Small Intestine = ( midgut )

Pain is experienced in the periumbilical region

(3) Renal system = ( retroperitoneal )

Pain is felt in the flank & radiates to the groin

Important features of colic pain

I. Pat . Is often restless & agitated during exacerbations.

II. Pat. Does not experience a totally pain –free interlude.

III. Colic pain is an intermittent pain .

IV. Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal

layers ) V. Failing to demonstrate guarding , tenderness ? ????

Inflammation2Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain

Peritonitis

LocalizedGeneralized

Inflammation2Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain

Contamination

BY

ChemicalsBacteriaTraumaForeign body

Important features of somatic pain

I. Pat. Laying quite in bed . ( movement is limited )

II. Examination may demonstrate guarding , tenderness .

III. The pain is localized over the inflamed organ .

IV. Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .

Ischemic pain

Is a somatic pain

Occlusion of blood supply

cause

Tissue HypoxiaTissue Hypoxia

With metabolic With metabolic changes changes

Necrosis

After 6-12 h

So how do we organize this?•Location•Acute v. chronic•Surgical v. nonsurgical

Localizing pain -- RUQ

•Hepatitis•Cholecystitis•Cholangitis•RLL pneumonia•Subdiaphragmatic

abscess

Localizing pain -- LUQ

•Splenic infarct•Splenic abscess•Gastritis/PUD

Localizing pain -- RLQ

•Appendicitis•Inguinal hernia•Nephrolithiasis•IBD•Salpingitis•Ectopic pregnancy•Ovarian pathology

Localizing pain -- LLQ

•Diverticulitis•Inguinal hernia•Nephrolithiasis•IBD•Salpingitis•Ectopic pregnancy•Ovarian pathology

Localizing pain -- epigastric

•PUD•Gastritis•Pancreatitis•GERD•Cardiac (MI,

pericarditis, etc)

Localizing pain -- periumbilical

•Pancreatitis•Obstruction•Early appendicitis•Small bowel

pathology•Gastroenteritis

Localizing pain -- pelvic

•UTI•Prostatitis•Bladder outlet

obstruction•PID•Uterine pathology

Localizing pain -- diffuse

•Gastroenteritis•Ischemia•Obstruction•DKA•IBS•Others

▫FMF▫AIP▫Vitamin D

deficiency▫Adrenal

insufficiency

Acute abdominal pain

•Generally present for less than a couple weeks▫Usually days to hours old▫Don’t forget about the chronic pain that

has acutely worsened•More immediate attention is required

Acute abdominal pain• Surgical

▫ Appendicitis▫ Cholecystitis▫ Bowel obstruction▫ Acute mesenteric

ischemia▫ Perforation▫ Trauma▫ Peritonitis

• Nonsurgical▫ Cholangitis▫ Pancreatitis▫ Nonabdominal causes▫ Choledocholithiasis▫ Diverticulitis▫ PUD/-itis▫ gastroenteritis

Surgical abdomen

•This is the first thing to be considered in acute abdominal pain▫Early identification is a must as prognosis

worsens rapidly with delay in treatment•Important to get surgeons involved early

if this is even mildly suspected•This is a clinical diagnosis

Surgical abdomen

•Presentation is usually bad▫Fevers, tachycardia, hypotension▫VERY tender abdomen, possibly rigid

•Presentation can vary with other demographic and medical factors▫Advanced age▫Immunosuppression

Surgical abdomen

•Peritonitis▫Often signals an intraabdominal

catastrophe Perforation, big abscess, severe bleeding

▫Patient usually appears ill▫Exam findings

Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed

Surgical abdomen•Obstruction

▫May be acute or acute on chronic▫Symptoms include persistent vomiting,

abdominal distention (or not), pain▫Exam findings depend on level of

obstruction (proximal v. distal) Distal – distention, tympany, absent or high-

pitched bowel sounds Proximal – similar, but may not see distention

and tympany

Surgical abdomen

•Ischemia▫Mesenteric ischemia usually seen in

patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons

▫Symptoms include pain OUT OF PROPORTION TO EXAM

▫Exam findings Severe tenderness to minimal palpation,

unstable vital signs, and a very uncomfortable patient

Surgical abdomen

•Work-up▫Start with stat labs▫Surgical abdominal series (plain films)▫Consider stat CT if readily available

•Sometimes patients go straight to surgery as initial step

•Again, get surgeons involved early for guidance and early intervention

Chronic abdominal pain

•Generally present for months to years•Generally not immediately life

threatening•Outpatient work-up is prudent

Than

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