Abdominal Pain

Definition of pain• A signal of disease

• Unpleasant sensation localized to a part of the body

• Penetrating or tissue destructive processstabbing burning twisting tearing squeezing

• Bodily or emotional reactionterrifying nauseating sickening

• Accompanied by anxiety

• Urging to escape or terminating the feeling

• Both sensation and emotion

Clinical characteristics

•Character of pain

spastic pain: intermittent

inflammatory: persisting

• Localization of pain:

usually in the diseased part

it may be referred

Clinical characteristics

•Quality and intensity of pain

peptic ulcer: gnawing burning

•Referred pain

•Provocating, aggravating and relieving factors

ulcer pain: relieved by ingestion of food

Clinical characteristics• Associated symptoms

• Physical examination: neck lymph nodes

chest examination

abdominal examination

• Laboratory check up: sputum, stool, urine

Serum

X-ray film

Ultra-sound

Clinical characteristics

The following are important:

•severity

•duration

•frequency •special time of occurrence

10 Questions on Pain

• Site

• Referral

• Character

• Severity

• Duration

• Onset

• Frequency

• Aggravating factors

• Relieving factors

• Associated symptoms

Abdominal pain

•Acute abdominal pain

•Chronic abdominal pain

Etiology and pathogenesis

Acute abdominal pain•Parietal peritoneal inflammationbacterial contamination chemical irritation

•Acute inflammation of abdominal organsgastritis enteritis

•Mechanical obstruction of hollow visceraobstruction of the small or large intestine

obstruction of the biliary tree

Etiology and pathogenesis

Acute abdominal pain Vascular disturbances

Embolism, vascular rupture, torsion of the organs

•Referred painpneumonia coronary occlusion

•Abdominal wall trauma or infection of muscles, distortion or traction of mesentery( 肠系膜 )

•Metabolic and toxic causesallergic factors etc.

Etiology and pathogenesis

Chronic abdominal pain• Chronic inflammation of abdominal organs reflux esophagitis chronic ulcerative colitis

• Peptic ulcer

• Distention of visceral surfaces hepatic or renal capsules, hepatitis, hepatic cancer

Etiology and pathogenesis

Chronic abdominal pain• Obstruction or torsion

• Infiltration or metastasis of tumor

• Metabolic and toxic causes uremia

• Neurogenic irritable colon neurosis

Mechanisms of abdominal pain

• Visceral pain

• Somatic pain

• Referred pain

Visceral pain

• Results from stimulation of autonomic nerves

in the visceral peritoneum which surrounds

internal organs

• The message may be transferred into the spinal

cord via sympathic route

Clinical presentation of visceral pain

• Pain poorly localized

• Intermittent, cramp or colicky pain

• Accompanied by nausea, vomitting and diaphoresis

Somatic pain

• Stimuli occurs with irritation of parietal peritoneum

• Sensations conducted along peripheral nerves

which can localize pain better

Clinical presentation of somatic pain

• Precisely localized pain

• Pain described as intense, constant

• With local guarding or rigidity

• Getting worse after coughing or position changes

• May be caused by infection, chemical irritation, or

other inflammatory process

Referred pain

• Pain felt at a distance from its source

----The diffuse pain arising from abdominal visceral structures tends to be projected to a more superficial region with the same segmental innervation

• The nerves distribution and visceral organs are

listed in text book (page 37)

Clinical manifestation

•LocalizationTenderness over the diseased organ

Obstruction of small intestine: periumbilical( 脐周） supraumbilical （脐上）Obstruction of large intestine: infraumbilial area （脐下） acute distention of gallbladder: right upper quadrant with

radiation to the right posterior region of the thorax

or the tip of the right scapula （肩胛）

Stomach, duodenum

Small bowel, proximal half colon

Distal half colon

Pain Localization, GI Tract

Acute epigastric pain referring to the back

• Posteriorly penetrating peptic ulcer• Biliary pain• Acute pancreatitis• Dissecting aneurysm 夹层动脉瘤

Epigastric pain + repeated vomiting

• Food poisoning

• Acute pancreatitisAgonizing pain but insignificant signs

• Acute pancreatitis• Mesenteric thrombosis at early stage 肠系膜血栓形成

Clinical manifestation

•Quality and severity

Perforation: severe dull pain over abdomen

Obstruction of hollow abdominal viscera: intermittent

colicky

Intraabdominal vascular disturbances:

sudden and catastrophic in nature

Acute pancreatitis: severe, steady upper, abdominal pain

Pain Severity

Ulcer Intestinal Colic

Biliary Colic, Pancreatic

Clinical manifestation

• Provocation and reliefAcute gastritis and enteritis: eating unfresh or raw foods

relieved by vomiting or discharge

Peritoneum inflammation: accentuated by pressure

palpation movement coughing

IBS and constipation: relieved temporarily by bowel movements

Obstruction: relieved temporarily by vomiting

Ulcer: eating or taking antacids

Clinical manifestation

•Associated manifestations

Fever: inflammation

Jaundice: liver gallbladder pancreatic disease

Hematuria: renal stone

Diarrhea/rectal bleeding: intestinal causes

Differentiation of three colicky pain

Type Location Other manifestationIntestinal periumbilical vomiting, nausea

infraumbilical diarrhea, bowel sounds

Biliary right upper jaundice fever

quadrant Murphy’s sign

Renal ipsilateral flank changes in urine test

radiate to genitalia 外阴 hematuria groin 腹股沟 , scrotum 阴囊

Clinical manifestation of chronic abdominal pain

• Past history

• Localization

• Quality

• Pain and position of the body Ptosis （下垂） of stomach or kidney:

pain when standing for long time

• Associated symptoms Chronic infection lymphoma malignant tumor: feverChronic infection lymphoma malignant tumor: fever

esophagus stomach billary tree: vomiting esophagus stomach billary tree: vomiting •Pain referred to the abdomen should be differentiated

Diagnostic points

•An accurate menstrual history in a female patient is essential

•Much attention has been paid to the presence or absence of peristaltic sounds, their quality and their frequency

• PQRST: provocative-palliative factors quality

region severity temporal characteristics

WORK-UP OF ABDOMINAL PAIN

HISTORY

• Onset

• Qualitative description

• Intensity

• Frequency

• Location - Does it go anywhere (referred)?

• Duration

• Aggravating and relieving factors

Common Acute Pain Syndromes

• Appendicitis

• Acute diverticulitis

• Cholecystitis

• Pancreatitis

• Perforation of an ulcer

• Intestinal obstruction

• Ruptured AAA （ abdominal aortic aneurysm）• Pelvic disorders

DIAGNOSTIC STUDIES

• Plain X-rays (flat plate)

• Contrast studies - barium (upper and lower

GI series)

• Ultrasound

• CT scanning

• Endoscopy

• Sigmoidoscopy, colonoscopy