Abdominal pain

. . . .

The abdomen is like a stage

Enclosed within a fleshy cage Distension, rigidity, vomiting & pain

Surgical emergency cases in Srinagarind

(1998-1999)

Non traumatic case 1737(75%) Traumatic case 581(25%)

Total 2,318 cases

Non traumatic cases in Srinagarind

Acute abdomen 1037 (60%) Soft tissue infection 323 (17%) Vascular 89 (5%) KUB 127 (7%) Anorectal 68 (4%) Other 128 (7%)

100

Acute abdomen
Percent

50

Srinagarind hospital 1037 cases Khon Kaen hospital 6338 cases

0 Peritonitis Gut obstruction GI bleeding

100
Percent

Peritonitis
Srinagarind hospital 777 cases Khon Kaen hospital 4550 cases

50

0
dic itis ngi tis cys titi atio per f or Me d& pen o le ola Gy n s n

Ap

Ch

Ch

PU

Abdominal pain
Anatomy
Histology Physiology Pathology

Rectus abdominis

Tendinous intersection

Semilunar line Linea alba Umbilicus

(T10 dermatomes) (intervertebral disc L3-4)

Illiac creast (vertebra L4)

Median plane

Transumbilical

Midclavicular plane

Subcostal plane

Intertubercular plane

Type of abdominal pain

Visceral pain Somatic-parietal pain Referred pain

Visceral pain
Unmyelinated C fiber Mesentery/mucosa of hollow viscus
Poorly localized pain

Dull aching/cramping/colicky/burning pain

Stomach-2nd duodenum Celiac trunk

2nd duodenum-2/3 transverse colon SMA

1/3 transverse colon-rectum IMA

Somatic-parietal pain
Myelinated A-delta fibers Skin/muscle/serosa /peritoneum Well localized pain

Shifting pain

Referred pain
Pain at a location other than the site of the painful stimulus Diaphragm shoulder/scapula

Kehr s sign

Clinical Evaluation
History taking Physical examination Lab investigation Radiologic imaging

History taking
Onset of pain Site Duration & Interval of pain Character of pain Aggravating & Alleviating factors

History taking
Associated symptoms Pain radiation Gyne History Past history

Nature of Vomitus
Clear

Bile stained Faeculent Blood : hematemesis & coffee ground

Relationship of Vomiting
High gut obstruction

: early, excessive
Low gut obstruction

: late or absent with abdominal distension

Bowel movements
color consistency
currant jelly

clay colored

blood stained mucus

melena
slime

Intussusceptum

Intussuscipiens

Urine

Women
Ectopic pregnancy Pelvic inflammatory disease (PID) Ruptured/ twisted ovarian cyst

Pain and menstrual cycle relationship & discharge

Physical Examination
Must be complete Must be repeated Must be careful

Physical Examination
General appearance Distension Absence or Active Bowel Sound Guarding Rigidity Hyperaesthesia

Sometimes the tummylike a drum & borborygmi go and come

Laboratory
CBC Urinalysis, UPT BUN, Creatinine Serum Electrolytes Serum Amylase Liver Function Test

Radiologic Imaging
Acute abdomen series
CXR Abdomen supine Abdomen upright

Abdominal ultrasound

CT abdomen

Extraluminal Air

Ruptured hollow viscus organ

Small bowel obstruction

Distal small bowel obstruction

Colonic Obstruction

Sigmoid Volvulus

Initial Imaging Test of Choice

CBD sludge collection Liver abscess

Ultrasonography

CT scan - Acute Abdomen

The best anatomical information

Retrocecal appendicitis

Acute pancreatitis

Subhepatic collection

Liver abscess

Acute Abdomen in the Tropic

Typhoid Fever Amoebiasis

Ascaris Ball of Worm Actinomicosis

Genetic disorders causing abdominal Pain

Porphyria

Sickle Cell Anaemia Haemophelia Vasculitis

Haemodynamically unstable caused by Peritonitis

Hollow Viscus Perforation

Prolonged Obstruction Intestinal Ischaemia

Urosepsis

Bowel Ischaemia
Severe Symptoms

Poorly Localized Relatively minimal physical sign

Haemodynamically Unstable Acute Abdomen

AAA ?

Extra-abdominal cause of addominal pain

Neurological Causes of Abdominal Pain
HZV, nerve root

Toxic substance ingestion

Alcohol crampy Abdominal Pain and diarrhea Lead colic

Endocrine
Glucocorticoid deficiency, hypercalcemia, DKA

Extra-abdominal cause of addominal pain

Thoracic
Esophagus : spasm, rupture (Boerhaave synd) Pleura : empyema, pneumothorax Lungs : pneumonitis, PE

Cardiac
CHF, MI, endocarditis

Hematologic
Acute leukemia, sickle cell anemia