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Embryology of pain: formation of the embryo and arrangements of pain fibres and
pathways that determine how we perceive pain as an adult.
Different patterns of pain can give a close indication of the pathology.
***ANATOMY ATLAS***
Large bowel problems largely in the periphery. Small bowel problems are usually
more central.
Some structures in the chest and pelvis are included in the abdomen.
Basic pathology
Inflammation (influx of inflammatory cells result of stimulus)
Infection (a stimulus)
Trauma (bowel can be split in a car accident)
Vascular (ischemia, infarction (tissue death)-thrombosis and embolism or
atherosclerosis; usually arterial)
Tumour (usually doesnt cause pain in itself-usually when is obstructive or
presses on a nerve doe sit cause pain-indirect means)
Obstruction (wall tries to contract to move obstruction): outside wall, inside
wall, inside lumen.
Distension (the result of obstruction to accommodate material, can give rise to
ischemia an then perforation (in extreme form))
Perforation (tumour, trauma or ischaemia)
Narrowest part of the small intestine -1/2 a metre from the ileocolic junction back
up the ileum. Common places for obstruction.
Pith (fruits), fibrous material (corn, nuts) and hair are not broken down by peristalsis
of the bowel or enzymes and cause obstruction.
Obstruction due to tumour and faecal boluses (faecaliths)
Clinical Pain
Visceral (vague)
Parietal (sharp)
Bowel Nervous system
Intrinsic Plexuses (sub mucosal and intermuscular plexuses)
Extrinsic inputs (brain and spinal cord)
Peristalsis: intrinsic automatic bowel contractions from proximal to distal. (one
direction only is a property o the arrangement of the nervous system and intrinsic
pacemaker function of the small bowel)
-helps move material along and keep it clean
-Physiological (housekeeping function to prevent stasis)
-Pathological (attempts to overcome artificial obstruction)
Clinical Signs
VISECRAL vague; diffuse; poorly lcoalised
Colic contraction/distension
Types of Colic
o Colic Biliary, renal, long waves, hours
o Colicky Pain shirt waves, seconds., more of a spasm like pain.
SOMATIC
Sharp;direct;localised.
Typical features
Location
Timing /duration
Character
Worsening /relieving factors
Tenderness, guarding, rebound.
LOCATION
The four quadrants: RUQ,LUQ,RLQ,LLQ
o Radiation shoulder tip, thigh, back, chest, arm, pelvis.
o Can lead to the confusion of pain because of embryological origin
and one level supplies many dermatomes.
The nine quadrants: R and L hyperchondrium, epigastrium, R and L lumbar,
umbilical, R and L iliac fossa, Hypogastrium.
TIMING
Intermittent/constant; draction (time)
Small bowel: sharp crmapy, spasm central (lasts seonds)
Biliary contant sevre-RUQ to back lasts hours
Renal constant and sever loin tog roin (lateralising)
Ischaemic dull, sevre symtks worse than signs
Labour intermittent dull, inceraing in severity-minutes, and contraction that
is everely and then reliqusihes. 9uterus e.g.)
Oesphageal sharpconatsnt and sevrer. lasts minytes
Bladder/Large Bowel/Uterine(Pelvic) deull, severe lsts hrs, suprapubic.
Isolated episode or recurrent
Character
Sharp/dull, sudden/gradual
Perforation-sudden, sever eonset oain or worsening. Affects peritoneum.
Inflammation gradual osnet, worsening of dull pain.
Ischaemia vague, dull worsening relentless, severe.
Tube Obstruction Colic, cramp type (crampy, colicky;Bilairy;Renalcolic;
distension)
Shift of pain due to the embryological origin of the pain fibres (the visceral pain),
then moves to somewhere else supplied by somatic fibres