EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN
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Transcript of EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN
EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN
BYDR OJIH
OUTLINE
• INTR0DUCTION• CAUSES• MECHANISM OF PAIN ORIGINATING FROM
THE ABDOMEN• HISTORY• EXAMINATION• INVESTIGATION• TREATMENT
INTRODUCTION• One of the most common causes of presentation at the accident and
emergency• Diagnosis is difficult because numerous causes exist -NSAP 34% -Acute appendicitis 28% -Acute cholecystitis 10% -small bowel obstruction 4% -perforated PU 3% -pancreatitis 3% -Diverticular disease 2% -0thers 13%• 20-40% admission rates• 50-65% inaccurate initial diagnosis
CAUSESPAIN ORIGINATING IN THE ABDOMEN
• PARIETAL PERITONEAL INFLAMMATION -Bacterial contamination -perforated appendix or other viscus -PID -Chemical irritation -pancreatitis
CAUSES CONTINUED
• MECHANICAL OBSTRUCTION OF HOLLOW VISCERA
-Obstruction of the small or large intestine -Obstruction of the biliary tree -Obstruction of the ureter
• VASCULAR DISTURBANCES -Embolism or thrombosis -vascular rupture -pressure or torsional occlusion -sickle cell anaemia
• Abdominal wall -distortion or traction of the mesentry -trauma or infection of muscles• DISTENSION OF VISCERAL SURFACES-e.g by haemorrhage -hepatic or renal capsule• INFLAMMATION OF A VISCUS -appendicitis -typhoid fever -typhilitis
PAIN REFERRED FROM EXTRAABDOMINAL SOURCE
• CARDIOTHORACIC -acute myocardial infarction -myocarditis ,endocarditis, pericarditis -Congestive cardiac failure -pneumonia -Pulmonary embolism -Pleurodynia -Pneumothorax -Empyema -Esophageal disease,spasm,rupture,inflammation• GENITALIA -Torsion of testis
METABOLIC CAUSES OF ABDOMINAL PAIN
• DM• Uremia• Hyperlipidaemia• Hyperparathyroidism• Acute adrenal insufficiency• Familial Mediterranean fever• Porphyria• C’1 esterase inhibitor deficiency( angioneurotic
oedema)
NEUROLOGIC /PSYCHIATRIC CAUSES
• Herpes zoster• Tabes dorsalis• Causalgia• Radiculitis from infection or arthritis• Spinal cord or nerve root compression• Functional disorders• Psychiatric disorders
TOXIC CAUSES
• Lead poisoning• Insect or animal envenomation• Black widow spiders• Snake bites
UNCERTAIN MECHANISM
• Narcotic withdrawal• Heat stroke
MECHANISM OF PAIN ORIGINATING IN THE ABDOMEN
• VISCERAL PAIN -afferent impulses from visceral organs poorly localized -pain generally felt in the midline - pain localization depends on the embryologic origin of the
organ Foregut structures------epigastrium midgut structures-------periumbilical region hindgut structures---------suprapubic region -visceral nociceptors are stimulated by distention, Stretch, vigorous contraction, ischaemia and
inflammation
• SOMATIC PAIN -usually from inflammation or chemical
irritants (gastric content) -localized to the dermatome above the site of
stimulus -transmitted by spinal nerve supplying the
parietal peritoneum or mesodermal structures
• REFERRED PAIN • Could be from the thorax, spine or genitalia• Produces symptoms not signs
HISTORY• Generally the cornerstone of accurate diagnosis• Complete description of the patient’s pain and associated
symptoms• Key points in the history include -P positional, palliating and provoking factors -Q quality -R region, radiation, referral -S severity -T temporal factors ( time and mode of onset,
progression, previous episodes)
LOCATIONwhere do you feel the pain
• Can be generalized or localized• visceral pain -foregut structures------epigastrium - midgut structures -----periumbilical - hindgut structures-----suprapubic• Somatic pain -localised above the dermatome producing
the stimulus
CHARACTERwhat kind of pain is it
• VISCERAL PAIN -dull, poorly localised, aching, colicky, or
gnawing.• SOMATIC PAIN -sharp, steady aching, more defined and well
localised
ONSEThow did it start
• Could be acute or gradual• Tells the duration of pain• Helps to interpret current findings and making
diagnosis
RADIATIONwhere else do you feel the pain
• Any inflammatory process / organ contiguous to the diaphragm can cause referred shoulder pain
• Acute gall bladder distension gives ipsilateral scapular pain
• abdominal pain radiating to the sacral region , flank, or genitalia may raise suspicion of rupturing abdominal aortic aneurysm
PROVOCATIVE AND PALLIATNG FACTORSwhat worsens or relieves the pain
• Somatic pain- worsened by pressure or changes in tension of the peritoneum
(palpation, coughing , sneezing)• Pancreatitis – pain is worsened by bending
forward and relieved by upright position• Gastric ulcer – pain is aggravated by food• Duodenal ulcer - relieved by food• Ask about analgesics and NSAIDS
Associated symptoms
• Fever• Anorexia• nausea• Vomiting• Diarrhoea• Cough• Amenorrhoea• Dysuria etc
PAST MEDICAL & SURGICAL HX, CURRENT MEDICATIONS
• Previous surgery– adhesions• DM---DKA• CKD– uraemia• SCD– vasocclusive crises• Steroids and NSAIDS
SOCIAL HX
• Substance abuse e.g cocaine• Alcohol• Domestic violence ( trauma )
PHYSICAL EXAMINATION
• Inspection -Bending forward : chronic pancreatitis -lying still, avoiding movt: peritonitis -Restless: visceral pain -Jaundiced : common bile duct obstruction -Dehydrated: peritonitis, small bowel
obstruction.
SYSTEMIC EXAMINATIONABDOMEN
• Inspection -scaphoid or flat in peptic ulcer -distended in ascities or intestinal obstruction -visible peristalsis in a thin or malnourished
patient (with obstruction) -surgical scar (adhesions) -caput medusa in chronic liver disease
SYSTEMIC EXAMINATION
• Palpation -check the hernia sites -tenderness -rebound tenderness - guarding(involuntary spasm of muscles during
palpations) -rigidity (when abd. muscle are tense and board
like) indicates peritonitis
SYSTEMIC EXAMINATION
• Epigastric tenderness -DU/GU -acute pancreatitis -esophagitis• Local right iliac fossa tenderness -acute appendicitis -acute salpingitis in females -crohns disease
SYSTEMIC EXAMINATION
• Periumbilical tenderness -early appendicitis -SBO -acute gastritis -mesenteric thrombosis-ruptured AAA
• Right upper quadrant tenderness -gall bladder disease -acute pancreatitis -Pneumonia -Subphrenic abscess - DU• Suprapubic tenderness -acute urinary retension -PID -cystitis
Important Signs in Patients with Abdominal Pain Sign Finding AssociationCullen's sign Bluish periumbilical
discolorationintraperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner's sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
PHYSICAL EXAMINATION
• Percussion-differentiates between ascities ( shifting
dullness ) and large bowel obstruction ( drum-like tympany)
Physical examination
• Auscultation – Has limited diagnostic utility– > 2min to confirm absent ( ileus)– High pitched in early SBO– Bruit in aortic, renal or mesenteric stenosis
Systemic Examination
• Digital Rectal Examination: - tenderness - indurations - mass - frank blood
Systemic Examination
• Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour
Investigations• FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • FBS/RBS• G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)
Investigations
• Urinalysis• Pregnancy test• RADIOLOGICAL INVESTIGATIONS -CXR(PA) -Abd XR( erect and supine) -IVU -CT Scan—gold standard for diagnosis of
appendidcitis• Laparoscopy
TREATMENT• DEPENDS ON THE CAUSE• May need resuscitation (ABCD)• IV fluid if there’s dehydration• Analgesic (iv opiods)• H2 receptor antagonists and proton pump
inhibitors( PUD )• Antibiotics if there’s evidence of infection• Antispasmodic (hyoscine)• Surgery
REFERENCES
• Harrisons principle of internal medicine 18th edition
• Christopher R.M and Robert M.M,2012, International journal of internal medicine
• Dimitri R and Alec E, diagnosis and management of abdominal pain
Thank you