DasunklareAbdomen

WelcheLeitsymptome?

Unklar?

? ?

? ?Schmerz

Schmerz

Hämatemesis

Erbrechen

Ikterus

Ileus

Obstipation

Schwäche

GasproblemDurchfall

??

?

Diagnose / Modell

Klinischer Alltag

ModellFunktion-

Problem

Klinisches Fach

Struktur-Patho

Physiologie / Anatomie

Lehre

Strukturell ?Funktionell?

Therapie

Restitition

Prognose

Exitus

Erkenntnisgang

Experten-wissen

=Muster-

erkennen

Demonstration of the neuroanatomic basis of referred pain

• . Visceral afferent fibers innervating the diaphragm are stimulated by local irritation (e.g., subdiaphragmaticabscess). These visceral afferent fibers (A) synapse with second-order neurons in the spinal cord (B) at the samelevel as somatic afferent fibers (C) arising from the shoulder area (cervical roots 3 to 5). The brain interprets thepain to be somatic in origin and localizes it to the shoulder.

Pathways of visceralsensory innervation.

Pathways of visceral sensoryinnervation. The visceral afferentfibers mediating pain travel withautonomic nerves to communicatewith the central nervous system. Inthe abdomen, these include bothvagal and pelvic parasympatheticnerves and thoracolumbarsympathetic nerves. Sympatheticfibers (red lines); parasympathetics(blue lines).

Localization of visceral pain

Pain arising from organareas depicted in 1, 2, and 3is felt in the epigastrium,midabdomen, andhypogastrium, respectively,as shown in A.

Pa:ernsofacuteabdominalpain

A, Many causes of abdominal pain subside spontaneously with time (e.g., gastroenteritis).B, Some pain is colicky (i.e., the pain progresses and remits over time); examples include intestinal, renal, and biliary

pain ("colic"). The time course may vary widely from minutes in intestinal and renal pain to days, weeks, oreven months in biliary pain.

C, Commonly, abdominal pain is progressive, as in appendicitis or diverticulitis.D, Certain conditions have a catastrophic onset, such as ruptured aortic aneurysm.

AllgemeineRichtlinienzurDiagnoseundTherapieakuterabdominalerSchmerzen

PrakAschesVorgehenAnamnese

• Schmerzbeginn,Schmerzcharakter• VorausgehendeEreignisse• IniAale/jetzigeSchmerzlokalisaAon(beimÜbergang

vomviszeralenzumSomaAschenSchmerzhatdieErkrankungdieOrgangrenzenüberschri:en

• Regelanamnese(anEUGdenken!)

• Cave:StadiumderIllusion(abklingendeSchmerzsymptomaAknachdeminiAalstarkenPerforaAonsschmerzundvordemBeginnderPeritoniAssymptomaAk)

BlutuntersuchungenbeiAbdominalschmerz

SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen

RechterOberbauch1 akuter Zystikusverschluss2 akute Cholezystitis Gallenblasenempyem,

emphysematöse Cholezystitis3 Cholelithiasis4 Duodenalulkus5 Magenulkus6 Akute Pankreatitis7 Nieren-Ureterkonkrement8 akute Appendizitis bei retrozökal

hochgeschlagener Appendix9 rechtsbasale Pleuritis/Pneumonie10 Leberabszess, akute Leberstauung

AbdomenLeerRöntgenvs.CT

1 akute Appendizitis2 Lymphadenitis mesenterialis3 Meckel-Divertikulitis4 Enteritis regionalis (Mb Crohn)5 Divertikulits bei Sigma elongatum6 ZäkumKarzinom7 Nieren-/Ureterkonkrement re8 re-seitiger akuter Adnexprozess, Extrauteringravidität9 akutes Harnverhalten akute Zystitis

SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen

RechterUnterbauch

Dieses EKG befundet …..?

SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen

LinkerOberbauch1 Magenperforation2 akute Pankreatitis3 links-subphrenischer Abszess4 Milzinfarkt/-ruptur5 Herzinfarkt6 links-basale Pleuritis/Pneumonie7 Hiatushernie8 linksseitige Nierenerkrankungen Harnleiterkonkrement

SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen

LinkerUnterbauch1 Sigmadivertikulitis, Divertikelperforation,

Perforation nach endoskopischerPolypabtragung

2 Sigmakarzinom3 linksseitiger akuter Adnexprozess,

Extrauteringravidität4 Nieren-/Ureterkonkrement links5 akutes Harnverhalten, akute Zystitis

Pathophysiologie bei Darmobstruktion

CausesofChronicAbdominalPainThatMayManifestasanAcuteExacerba:on

ChronicIntermi<entPain

ChronicConstantPain

MechanicalIntermi:entintesAnalobstrucAon(hernia,intussuscepAon,adhesions,volvulus)GallstonesSphincterofOddidysfuncAonInflammatoryInflammatoryboweldiseaseEndometriosisandendometriAsAcuterelapsingpancreaAAsFamilialMediterraneanfeverNeurologicandMetabolicPorphyriaAbdominalepilepsyDiabeAcradiculopathyNerverootcompressionorentrapmentUremiaMiscellaneousIrritablebowelsyndromeFuncAonaldyspepsiaChronicmesentericischemiaMi:elschmerz(painwithovulaAon)

Malignancy(primaryormetastaAc)AbscessChronicpancreaAAsPsychiatric(depression,somatoformdisorder)Inexplicable(chronicintractableabdominalpain)

Extra‐AbdominalCausesofAcuteAbdominalPain

MetabolicUremiaDiabetes mellitusPorphyriaAcute adrenal insufficiency (Addison's disease)HyperlipidemiaHyperparathyroidism

HematologicSickle cell anemiaHemolytic anemiaHenoch-Schönlein purpuraAcute leukemia

ThoracicPneumonitisPleurodynia (Bornholm's disease)Pulmonary embolism and infarctionPneumothoraxEmpyemaEsophagitisEsophageal spasmEsophageal rupture (Boerhaave's syndrome)

CardiacMyocardial ischemia and infarctionMyocarditisEndocarditisCongestive heart failure

InfectionsHerpes zosterOsteomyelitisTyphoid fever

ToxinsHypersensitivity reactions, insect bites, reptile venomsLead poisoning

MiscellaneousMuscular contusion, hematoma, tumorNarcotic withdrawalFamilial Mediterranean feverPsychiatric disordersHeat stroke

NeurologicRadiculitis: spinal cord or peripheral nerve tumors,

degenerative arthritis of spineAbdominal epilepsyTabes dorsalis

Differential Diagnosis of Chronic or Recurrent AbdominalPainStructural (or Organic) Disorders

Peptic ulcer diseaseGallstones

Chronic pancreatitis Abdominal neoplasms

Inflammatory bowel diseasesMesenteric ischemia

Pelvic inflammatory diseasesEndometriosis

Abdominal adhesionsIntestinal obstruction

Functional Gastrointestinal Disorders

Irritable bowel syndromeFunctional (nonulcer) dyspepsia

Functional abdominal pain syndromeLevator ani syndrome

Biliary pain (gallbladder or sphincter of Oddi dysfunction)

AbiopsychosocialmodeloffuncAonalabdominalpainsyndrome(FAPS)

RomeIICriteriaforFunc:onalAbdominalPainSyndrome

Atleast6monthsofthefollowing:

ConAnuousornearlyconAnuousabdominalpainNooronlyoccasionalrelaAonshipofpainwithphysiologicevents

(e.g.,eaAng,defecaAon,menses)SomelossofdailyfuncAoningThepainisnotfeigned(e.g.,malingering)InsufficientcriteriaforotherfuncAonalgastrointesAnaldisordersthatwouldexplaintheabdominalpain

Zusammenfassung

AkuteundchronischeabdominelleSchmerzzuständehabenvielfälAgsteUrsachenundPathogenesen.

DerjungeArztistangehalten,PaAentensystemaAschzuuntersuchenundbreitedifferenAaldiagnosAscheÜberlegungenanzustellen.

ErsollsichdabeiabernichtselbstüberschätzenundzeitgerechtHilfebeimälterenKollegenholen.