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Abdominal Pain

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
Clinical characteristics
Character of pain
spastic pain: intermittent
inflammatory: persisting

Localization of pain:
usually in the diseased part
it may be referred


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




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

Clinical characteristics
The following are important:
severity
duration
frequency
special time of occurrence


10 Questions on Pain
Site
Referral
Character
Severity
Duration
Onset
Frequency
Aggravating factors
Relieving factors
Associated symptoms
Abdominal pain
Acute abdominal pain


Chronic abdominal pain
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

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.

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

Etiology and pathogenesis
Chronic abdominal pain
Obstruction or torsion

Infiltration or metastasis of tumor

Metabolic and toxic causes uremia

Neurogenic irritable colon neurosis
Mechanisms of abdominal pain
Visceral pain

Somatic pain

Referred pain

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
Clinical presentation of visceral pain
Pain poorly localized

Intermittent, cramp or colicky pain

Accompanied by nausea, vomitting and diaphoresis
Somatic pain
Stimuli occurs with irritation of parietal peritoneum

Sensations conducted along peripheral nerves
which can localize pain better
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
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)
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
Stomach, duodenum
Small bowel, proximal
half colon
Distal half colon
Pain Localization, GI Tract
Acute epigastric pain referring to the back
Posteriorly penetrating peptic ulcer
Biliary pain
Acute pancreatitis
Dissecting aneurysm
Epigastric pain + repeated vomiting
Food poisoning
Acute pancreatitis
Agonizing pain but insignificant signs
Acute pancreatitis
Mesenteric thrombosis at early stage

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

Pain Severity
Ulcer
Intestinal
Colic
Biliary Colic,
Pancreatic
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
Clinical manifestation

Associated manifestations
Fever: inflammation
Jaundice: liver gallbladder pancreatic disease
Hematuria: renal stone
Diarrhea/rectal bleeding: intestinal causes
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
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
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
WORK-UP OF ABDOMINAL PAIN
HISTORY
Onset
Qualitative description
Intensity
Frequency
Location - Does it go anywhere (referred)?
Duration
Aggravating and relieving factors
Common Acute Pain Syndromes

Appendicitis
Acute diverticulitis
Cholecystitis
Pancreatitis
Perforation of an ulcer
Intestinal obstruction
Ruptured AAA abdominal aortic aneurysm
Pelvic disorders
DIAGNOSTIC STUDIES

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

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