By

Logeshwaran.K &

Rajasri.M

Just about everybody at one point or another will

experience abdominal pain.

Most of the causes are not serious and can be readily diagnosed and treated.

However, pain can also be a sign of a serious illness.

It's important to be able to recognize symptoms that are severe and know when to call a doctor.

Abdominal pain is pain that is felt in the abdomen.

Introduction

Abdominal pain is caused by

inflammation (for example, appendicitis, diverticulitis, colitis),

by stretching or distension of an organ (for example, obstruction of the intestine, blockage of a bile duct by gallstones, swelling of the liver with hepatitis),

or by loss of the supply of blood to an organ (for example, ischemic colitis).

Causes

To complicate matters, it is believed to be due either

to abnormal contractions of the intestinal muscles (for example, spasm) or abnormally sensitive nerves within the intestines that give rise to painful sensations inappropriately (visceral hyper-sensitivity).

These latter types of pain are often referred to as functional pain because no recognizable (visible) causes for the pain have been found - at least not yet.

Other causes

Doctors determine the cause of abdominal pain by

relying on:

characteristics of the pain,

findings on physical examination,

laboratory, radiological, and endoscopic testing, and

surgery.

Diagnosing the cause

The way the pain begins.

The location of the pain.

The pattern of the pain.

The duration of the pain.

What makes the pain worse.

What relieves the pain.

Determining the cause

The presence of fever suggests inflammation.

Diarrhoea or rectal bleeding suggests an intestinal cause of the pain.

The presence of fever and diarrhoea suggest inflammation of the intestines that may be infectious or non-infectious (for example, ulcerative colitis or Crohn's disease).

Associated signs and symptoms

The presence of sounds coming from the intestines that

occur when there is obstruction of the intestines,

The presence of signs of inflammation (by special maneuvers during the examination),

The location of any tenderness

The presence of a mass within the abdomen that suggests a tumor, enlarged organ, or abscess (a collection of infected pus)

The presence of blood in the stool that may signify an intestinal problem such as an ulcer, colon cancer, colitis, or ischemia.

Physical examination

Laboratory tests such as the complete blood

count (CBC), liver enzymes, pancreatic enzymes (amylase and lipase), and urinalysis are frequently performed in the evaluation of abdominal pain.

Laboratory test

The liver is the second largest organ in the body

(after the skin), and is essential in keeping the body functioning properly.

The liver is located in the upper right-hand side of the abdomen.

It performs many functions in the body, including processing the body's nutrients, manufacturing bile to help digest fats, synthesizing many important proteins, regulating blood clotting, and breaking down potentially toxic substances into harmless ones that the body can use or excrete.

Inflammation of the liver may, in severe cases, interfere

with these processes and allow potentially toxic substances to accumulate.

Inflammation can occur while the liver is performing its functions, such as metabolizing drugs.

The liver is able to regenerate or repair up to two-thirds of injured tissue, including hepatocytes, biliary epithelial cells, and endothelial cells.

Healthy cells take over the function of damaged cells, either indefinitely or until the damage is repaired.

Liver function

But no matter what type the individual has, the

damage to the liver is likely to progress in a similar way.

Viruses cause some of them, like hepatitis A, hepatitis B, and hepatitis C.

Other types of liver damage can be the result of drugs (such as acetaminophen), poisons (such as the death cap mushroom), or

drinking too much alcohol for a long period of time.

Different types of liver disease

If the liver forms scar tissue because of an illness, it is called cirrhosis.

Jaundice, or yellowing of the skin and eyes, can be one sign of liver disease.

Cancer can also affect the liver. Individuals may inherit a liver disease such as hemochromatosis, which is a liver condition causing iron overload.

The liver plays a central role in transforming and clearing chemicals and is susceptible to the toxicity from these agents.

Certain medicinal agents, when taken in overdoses and sometimes even when introduced within therapeutic ranges, may injure the organ.

Other chemical agents, such as those used in laboratories and industries, natural chemicals (e.g., microcystins) and herbal remedies can also induce hepatotoxicity.

Chemicals that cause liver injury are called hepatotoxins.

Alternative names

Toxic liver diseaseToxin induced liver diseaseDrug induced liver diseaseDrug induced liver damageHepatogenous poisoning

Subordinate terms

Toxic hepatitisToxin induced hepatitisDrug induced hepatitisDrug-induced hepatic necrosisDrug induced hepatic fibrosisDrug induced hepatic granulomaToxic liver disease with hepatitisToxic liver disease with cholestasis

Drug metabolism in liver

Drug metabolism is usually divided into two phases: phase 1 and phase 2.

Phase 1 reaction is thought to prepare a drug for phase 2. However many compounds can be metabolized by phase 2 directly.

Phase 1 reaction involves oxidation, reduction, hydrolysis, hydration and many other rare chemical reactions.

phase 2 reactions take place in cytosol and involve conjugation with endogenous compounds via transferase enzymes

Age

Ethnicity and race

Gender

Nutritional status

Underlying liver disease

Renal function

Pregnancy

Duration and dosage of drug

Enzyme induction

Drug-to-drug interaction

Factors influencingdrug induced hepatotoxicity

Type of injury: Hepatocellular Cholestatic Mixed

ALT ≥ Twofold rise Normal ≥ Twofold rise

ALP Normal ≥ Twofold rise ≥ Twofold rise

ALT: ALP ratio High, ≥5 Low, ≤2 2-5

Examples

AcetaminophenAllopurinolAmiodaroneHAARTNSAID

Anabolic steroidChlorpromazineClopidogrelErythromycinHormonal contraception

Amitriptyline,EnalaprilCarbamazepineSulfonamidePhenytoin

Pattern of injury

Normal blood test results for typical liver function tests include:

ALT. 7 to 55 units per litre (U/L)

AST. 8 to 48 U/L

ALP. 45 to 115 U/L

Albumin. 3.5 to 5.0 grams per decilitre (g/dL)

Total protein. 6.3 to 7.9 g/dL

Bilirubin. 0.1 to 1.0 mg/dL

GGT. 9 to 48 U/L

LD. 122 to 222 U/L

PT. 9.5 to 13.8 seconds

Zonal necrosis

Hepatitis

Cholestasis

Steatosis

Granuloma

Vascular lesions

Neoplasm

Specific histo-pathological patterns of liver injury from drug-induced damage

Adverse drug reactions are classified as type A (intrinsic

or pharmacological) or type B (idiosyncratic). Type A drug reaction accounts for 80% of all toxicities.

Drugs or toxins that have a pharmacological (type A) hepatotoxicity are those that have predictable dose-response curves (higher concentrations cause more liver damage) and well characterized mechanisms of toxicity, such as directly damaging liver tissue or blocking a metabolic process.

Idiosyncratic (type B) injury occurs without warning, when agents cause non-predictable hepatotoxicity in susceptible individuals, which is not related to dose and has a variable latency period.

Adverse drug reactions

Acetaminophen

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Glucocorticoids

Isoniazid

Other hydrazine derivative drugs

Natural products

Industrial toxin

Herbal and alternative remedies that could contribute to liver failure

Specific drug or toxin

During the first phase, that is, the initial 12 to 24 hours or

so after ingestion, the patient experiences nausea and vomiting.

For the next perhaps 12 to 24 hours, which is the second phase or the so-called inactive (latent) phase, the patient feels well.

In the third phase, which begins about 48 to as late as 72 hours after the ingestion of acetaminophen, liver blood test abnormalities begin to appear. Most notably, extremely high (abnormal) levels of the liver blood tests, AST and ALT, are common with this type of liver injury.

Symptoms and signs of acetaminophen-induced liver

damage

In most cases, liver function will return to normal if the

offending drug is stopped early. Additionally, the patient may require supportive treatment.

In acetaminophen toxicity, however, the initial insult can be fatal.

Fulminant hepatic failure from drug-induced hepatotoxicity may require liver transplantation.

An elevation in serum bilirubin level of more than 2 times ULN with associated transaminase rise is an ominous sign.

This indicates severe hepatotoxicity and is likely to lead to mortality in 10% to 15% of patients, especially if the offending drug is not stopped.

Administration of antihepatocytotoxic serum helps in regeneration of liver’s cellular mechanism

Treatment and prognosis