Abdominal Pain

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Abdominal Pain
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Definition of pain

• A signal of disease
• Unpleasant sensation localized to a part of the
  body
• Penetrating or tissue destructive process
• stabbing burning twisting
  tearing squeezing
• Bodily or emotional reaction
• terrifying nauseating
  sickening
• Accompanied by anxiety
• Urging to escape or terminating the feeling
• Both sensation and emotion

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Clinical characteristics

• Character of pain
• spastic pain
  intermittent
• inflammatory
  persisting
• Localization of pain
• usually in the diseased
  part
• it may be referred

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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

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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

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Clinical characteristics

• The following are important
• severity
• duration
• frequency
• special time of occurrence

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10 Questions on Pain

• Site
• Referral
• Character
• Severity
• Duration

• Onset
• Frequency
• Aggravating factors
• Relieving factors
• Associated symptoms

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Abdominal pain

• Acute abdominal pain
• Chronic abdominal pain

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Etiology and pathogenesis

• Acute abdominal pain
• Parietal peritoneal inflammation
• bacterial contamination chemical irritation
• Acute inflammation of abdominal organs
• gastritis enteritis
• Mechanical obstruction of hollow viscera
• obstruction of the small or large intestine
• obstruction of the biliary tree

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Etiology and pathogenesis

• Acute abdominal pain
• Vascular disturbances
• Embolism, vascular rupture, torsion of the
  organs
• Referred pain
• pneumonia coronary occlusion
• Abdominal wall
• trauma or infection of
  muscles,
• distortion or traction of
  mesentery(???)
• Metabolic and toxic causes
• allergic factors etc.

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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

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Etiology and pathogenesis

• Chronic abdominal pain
• Obstruction or torsion
• Infiltration or metastasis of tumor
• Metabolic and toxic causes uremia
• Neurogenic irritable colon
  neurosis

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Mechanisms of abdominal pain

• Visceral pain
• Somatic pain
• Referred pain

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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

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Clinical presentation of visceral pain

• Pain poorly localized
• Intermittent, cramp or colicky pain
• Accompanied by nausea, vomitting and diaphoresis

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Somatic pain

• Stimuli occurs with irritation of parietal
  peritoneum
• Sensations conducted along peripheral nerves
• which can localize pain better

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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

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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)

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Clinical manifestation

• Localization
• Tenderness over the diseased organ
• Obstruction of small intestine
  periumbilical(??)
• 
  supraumbilical(??)
• Obstruction of large intestine infraumbilial
  area (??)
• acute distention of gallbladder right upper
  quadrant with
• radiation to the right posterior
  region of the thorax
• or the tip of the
  right scapula (??)

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Pain Localization, GI Tract
Stomach, duodenum
Small bowel, proximal half colon
Distal half colon
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Acute epigastric pain referring to the back

• Posteriorly penetrating peptic ulcer
• Biliary pain
• Acute pancreatitis
• Dissecting aneurysm ?????

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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

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Pain Severity
Intestinal Colic
Biliary Colic, Pancreatic
Ulcer
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Clinical manifestation

• Provocation and relief
• Acute 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

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Clinical manifestation

• Associated manifestations
• Fever inflammation
• Jaundice liver gallbladder pancreatic
  disease
• Hematuria renal stone
• Diarrhea/rectal bleeding intestinal causes

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Differentiation of three colicky pain

• Type Location Other
  manifestation
• Intestinal periumbilical
  vomiting, nausea
• infraumbilical
  diarrhea, bowel sounds
• Biliary right upper
  jaundice fever
• quadrant
  Murphys sign
• Renal ipsilateral flank
  changes in urine test
• radiate to genitalia??
  hematuria
• groin???, scrotum??

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Clinical manifestation of chronic abdominal pain

• Past history
• Localization
• Quality
• Pain and position of the body
• Ptosis (??)of stomach or kidney
• pain when standing for long time
• Associated symptoms
• Chronic infection lymphoma malignant
  tumor fever
• esophagus stomach billary tree
  vomiting
• Pain referred to the abdomen should be
  differentiated

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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

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WORK-UP OF ABDOMINAL PAIN

• HISTORY
• Onset
• Qualitative description
• Intensity
• Frequency
• Location - Does it go anywhere (referred)?
• Duration
• Aggravating and relieving factors

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Common Acute Pain Syndromes

• Appendicitis
• Acute diverticulitis
• Cholecystitis
• Pancreatitis
• Perforation of an ulcer
• Intestinal obstruction
• Ruptured AAA (abdominal aortic aneurysm)
• Pelvic disorders

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DIAGNOSTIC STUDIES

• Plain X-rays (flat plate)
• Contrast studies - barium (upper and lower
• GI series)
• Ultrasound
• CT scanning
• Endoscopy
• Sigmoidoscopy, colonoscopy