0
Abdominal pain
Ahmed khaled elgizawy
N0 : 35
Round : 1
Anatomic background
 Parietal peritoneum
clothes the anterior & posterior
abdominal walls the under
surface of the diaphr...
1 2 3
4 5 6
7 8 9

1 – right hypochondrium
2- epigastric
3- left hypochondrium
4- Right lumbar
5- umbilical
6- left hypoch...
DEFINITION OF PAIN
It is an unpleasant sensation of
.varying intensity

Pain fibers are stimulated any time a tissue is be...
STIMULANTS
1

Mechanical trauma to the tissue .

2

Excess heat or cold .

3

Chemical damage.

4

Radiation damage .

5

...
Abdominal

Extra-abdominal

Systemic dysfunction

Functional abdominal
Abdominal wall
+

Pelvic organs
Intra-peritoneal or...
Types
of abdominal pain
2
1
Visceral pain is primitive
Somatic pain is entirely
and therefore related to
different from vi...
Visceral pain
1- Receptor
( Visceral peritoneum )
2 - Stimulus
Pat. Experienced pain by
traction ,distention & spasm
The visceral peritoneum is
insensitive to touch & heat ...
3 - Mediation
Autonomic nervous System Interpreted at
the thalamic level of the brain
4- Specificity
Vague , often dull , poorly described &
associated with nausea & vomiting
5- Localization
Is poor & the pat. Placing the entire
hand over the involved region
Somatic pain
1- Receptor

Pain stimuli start in the parietal peritoneum ,
which is innervated by peripheral nerves
P/ peri...
Somatic pain
2- Stimulus

Pat. experienced pain by

Pressure
Touch
Heat
Inflammation
Somatic pain
3- Mediation

Central nervous system
&
Interpreted at a specific cortical
location
Somatic pain
4- Specificity

Precisely described as
Cutting
Somatic pain
5- Localization

The pain is localized with
great accuracy by the patient ,
who can often point to the site
w...
Referred pain
Pain felt at a site other
than where the cause is
situated. An example is
the pain from the
pancreas, which ...
Analysis of pain
need
DATA COLLECTION

1

2

3

History

Physical exam.

Lab.inv.

apply
your medical knowledge***
History of pain
The history of pain betrays the diagnosis
Factors influencing
the of pain
Natureof onset
Mode clinical
ma...
Site of pain & radiation
Radiation of the pain
GB

Stomach &
duodenum

Pancreas

Small bowel Kidney
Kidney Caecum &
rp.str...
Mode of onset
Sudden onset
[The patient can tell you exactly when the pain started ]
The pain that start suddenly has a me...
Mode of onset

Gradual Onset
( The

pat. Usually responds vaguely to questions
about time of onset )

Non mechanical or
ch...
Nature of pain
Two Large Categories
(2)
(1)
Conditions associated with obstruction
Conditions associated with
of a muscula...
1

Obstruction
prolonged

Distention of the viscus
( constant stretching pain )

Sudden
Colic pain = visceral pain
Three T...
Important features of colic pain
I.

Pat . Is often restless & agitated during exacerbations.

II. Pat. Does not experienc...
2

Inflammation
Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain

Peritonitis

Generalized
Loc...
2

Inflammation
Intra-abdominal inflammation is peritonitis

Peritonitis causes somatic pain
Contamination
BY

Foreign bod...
Important features of somatic
pain
I.

Pat. Laying quite in bed . ( movement is limited )

II.

Examination may demonstrat...
Ischemic pain
Is a somatic pain
Occlusion of blood supply

cause

Necrosis
After 6-12 h

Tissue Hypoxia
With metabolic
cha...
?So how do we organize this
• Location
• Acute v. chronic
• Surgical v. nonsurgical
Localizing pain -- RUQ
•
•
•
•
•

Hepatitis
Cholecystitis
Cholangitis
RLL pneumonia
Subdiaphragmatic
abscess
Localizing pain -- LUQ
• Splenic infarct
• Splenic abscess
• Gastritis/PUD
Localizing pain -- RLQ
•
•
•
•
•
•
•

Appendicitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ovari...
Localizing pain -- LLQ
•
•
•
•
•
•
•

Diverticulitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ova...
Localizing pain -- epigastric
•
•
•
•
•

PUD
Gastritis
Pancreatitis
GERD
Cardiac (MI,
pericarditis, etc)
Localizing pain -- periumbilical
•
•
•
•

Pancreatitis
Obstruction
Early appendicitis
Small bowel
pathology
• Gastroenteri...
Localizing pain -- pelvic
• UTI
• Prostatitis
• Bladder outlet
obstruction
• PID
• Uterine pathology
Localizing pain -- diffuse
•
•
•
•
•
•

Gastroenteritis
Ischemia
Obstruction
DKA
IBS
Others
▫
▫
▫
▫

FMF
AIP
Vitamin D def...
Acute abdominal pain
• Generally present for less than a couple weeks
▫ Usually days to hours old
▫ Don’t forget about the...
Acute abdominal pain
• Surgical
▫
▫
▫
▫
▫
▫
▫

Appendicitis
Cholecystitis
Bowel obstruction
Acute mesenteric ischemia
Perf...
Surgical abdomen
• This is the first thing to be considered in acute
abdominal pain
▫ Early identification is a must as pr...
Surgical abdomen
• Presentation is usually bad
▫ Fevers, tachycardia, hypotension
▫ VERY tender abdomen, possibly rigid

•...
Surgical abdomen
• Peritonitis
▫ Often signals an intraabdominal catastrophe
 Perforation, big abscess, severe bleeding

...
Surgical abdomen
• Obstruction
▫ May be acute or acute on chronic
▫ Symptoms include persistent vomiting, abdominal
disten...
Surgical abdomen
• Ischemia
▫ Mesenteric ischemia usually seen in patients with
CAD risk factors, but anyone can infarct b...
Surgical abdomen
• Work-up
▫ Start with stat labs
▫ Surgical abdominal series (plain films)
▫ Consider stat CT if readily ...
Chronic abdominal pain
• Generally present for months to years
• Generally not immediately life threatening
• Outpatient w...
Th
an
ky

ou
Abdominal pain
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Transcript of "Abdominal pain"

  1. 1. Abdominal pain Ahmed khaled elgizawy N0 : 35 Round : 1
  2. 2. Anatomic background  Parietal peritoneum clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) .  Visceral peritoneum is the continuation of the parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).
  3. 3. 1 2 3 4 5 6 7 8 9 1 – right hypochondrium 2- epigastric 3- left hypochondrium 4- Right lumbar 5- umbilical 6- left hypochondrium 7- right iliac 8-hypogastric 9- left iliac
  4. 4. DEFINITION OF PAIN It is an unpleasant sensation of .varying intensity Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.
  5. 5. STIMULANTS 1 Mechanical trauma to the tissue . 2 Excess heat or cold . 3 Chemical damage. 4 Radiation damage . 5 Inadequate blood flow.
  6. 6. Abdominal Extra-abdominal Systemic dysfunction Functional abdominal Abdominal wall + Pelvic organs Intra-peritoneal organs Retro-peritoneal organs Diabetes ,tabes dorsalis pain Intra-thoracic organs porphyria
  7. 7. Types of abdominal pain 2 1 Visceral pain is primitive Somatic pain is entirely and therefore related to different from visceral pain embryologic development .
  8. 8. Visceral pain 1- Receptor ( Visceral peritoneum )
  9. 9. 2 - Stimulus Pat. Experienced pain by traction ,distention & spasm The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction
  10. 10. 3 - Mediation Autonomic nervous System Interpreted at the thalamic level of the brain
  11. 11. 4- Specificity Vague , often dull , poorly described & associated with nausea & vomiting
  12. 12. 5- Localization Is poor & the pat. Placing the entire hand over the involved region
  13. 13. Somatic pain 1- Receptor Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves P/ peritoneum
  14. 14. Somatic pain 2- Stimulus Pat. experienced pain by Pressure Touch Heat Inflammation
  15. 15. Somatic pain 3- Mediation Central nervous system & Interpreted at a specific cortical location
  16. 16. Somatic pain 4- Specificity Precisely described as Cutting
  17. 17. Somatic pain 5- Localization The pain is localized with great accuracy by the patient , who can often point to the site with one finger
  18. 18. Referred pain Pain felt at a site other than where the cause is situated. An example is the pain from the pancreas, which is felt in the back. Pain in internal organs is often referred to sites distant from them.
  19. 19. Analysis of pain need DATA COLLECTION 1 2 3 History Physical exam. Lab.inv. apply your medical knowledge***
  20. 20. History of pain The history of pain betrays the diagnosis Factors influencing the of pain Natureof onset Mode clinical manifestation Radiation Severity Site Duration
  21. 21. Site of pain & radiation Radiation of the pain GB Stomach & duodenum Pancreas Small bowel Kidney Kidney Caecum & rp.structure App. & Caecum T. Colon bladder uterus & adnexae Sig. colon Pancreatic pain Small bowel pain does not Radiation indicates source of the Lower the extent of the disease pain & also abdominal pain usually radiate Kidney pain pain Stomach & duodenal tends to go rarely radiate radiates Pain but GB.radiate may The structures in goes through to the back & to may move whenback but through to the somatic pelvis may radiate to thethe down as visceral nerves into reach lower strait the right ,thethe groin as well to to left back or perineum throughirritated tip of the shoulder blade become the back
  22. 22. Mode of onset Sudden onset [The patient can tell you exactly when the pain started ] The pain that start suddenly has a mechanical basis Some thing has been Twisted Occluded Ruptured
  23. 23. Mode of onset Gradual Onset ( The pat. Usually responds vaguely to questions about time of onset ) Non mechanical or chronic process
  24. 24. Nature of pain Two Large Categories (2) (1) Conditions associated with obstruction Conditions associated with of a muscular conducting tube inflammation (( Mild & Localized Response or Small bowel , Ureter , Biliary ) Severe , Generalized Response )
  25. 25. 1 Obstruction prolonged Distention of the viscus ( constant stretching pain ) Sudden Colic pain = visceral pain Three Types (3) ((2)) Small Intestine = ((midgut )) ) Renal system = ( retroperitoneal 1 Biliary System foregut Pain felt pain is experienced in the epigastrium Foregut in the flank & radiates to region Pain is is experienced in the periumbilical the groin
  26. 26. Important features of colic pain I. Pat . Is often restless & agitated during exacerbations. II. Pat. Does not experience a totally pain –free interlude. III. Colic pain is an intermittent pain . IV. Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal layers ) V. Failing to demonstrate guarding , tenderness ? ????
  27. 27. 2 Inflammation Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Peritonitis Generalized Localized
  28. 28. 2 Inflammation Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Contamination BY Foreign body Chemicals Bacteria Trauma
  29. 29. Important features of somatic pain I. Pat. Laying quite in bed . ( movement is limited ) II. Examination may demonstrate guarding , tenderness . III. The pain is localized over the inflamed organ . IV. Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .
  30. 30. Ischemic pain Is a somatic pain Occlusion of blood supply cause Necrosis After 6-12 h Tissue Hypoxia With metabolic changes
  31. 31. ?So how do we organize this • Location • Acute v. chronic • Surgical v. nonsurgical
  32. 32. Localizing pain -- RUQ • • • • • Hepatitis Cholecystitis Cholangitis RLL pneumonia Subdiaphragmatic abscess
  33. 33. Localizing pain -- LUQ • Splenic infarct • Splenic abscess • Gastritis/PUD
  34. 34. Localizing pain -- RLQ • • • • • • • Appendicitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology
  35. 35. Localizing pain -- LLQ • • • • • • • Diverticulitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology
  36. 36. Localizing pain -- epigastric • • • • • PUD Gastritis Pancreatitis GERD Cardiac (MI, pericarditis, etc)
  37. 37. Localizing pain -- periumbilical • • • • Pancreatitis Obstruction Early appendicitis Small bowel pathology • Gastroenteritis
  38. 38. Localizing pain -- pelvic • UTI • Prostatitis • Bladder outlet obstruction • PID • Uterine pathology
  39. 39. Localizing pain -- diffuse • • • • • • Gastroenteritis Ischemia Obstruction DKA IBS Others ▫ ▫ ▫ ▫ FMF AIP Vitamin D deficiency Adrenal insufficiency
  40. 40. Acute abdominal pain • Generally present for less than a couple weeks ▫ Usually days to hours old ▫ Don’t forget about the chronic pain that has acutely worsened • More immediate attention is required
  41. 41. Acute abdominal pain • Surgical ▫ ▫ ▫ ▫ ▫ ▫ ▫ Appendicitis Cholecystitis Bowel obstruction Acute mesenteric ischemia Perforation Trauma Peritonitis • Nonsurgical ▫ ▫ ▫ ▫ ▫ ▫ ▫ Cholangitis Pancreatitis Nonabdominal causes Choledocholithiasis Diverticulitis PUD/-itis gastroenteritis
  42. 42. Surgical abdomen • This is the first thing to be considered in acute abdominal pain ▫ Early identification is a must as prognosis worsens rapidly with delay in treatment • Important to get surgeons involved early if this is even mildly suspected • This is a clinical diagnosis
  43. 43. Surgical abdomen • Presentation is usually bad ▫ Fevers, tachycardia, hypotension ▫ VERY tender abdomen, possibly rigid • Presentation can vary with other demographic and medical factors ▫ Advanced age ▫ Immunosuppression
  44. 44. Surgical abdomen • Peritonitis ▫ Often signals an intraabdominal catastrophe  Perforation, big abscess, severe bleeding ▫ Patient usually appears ill ▫ Exam findings  Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed
  45. 45. Surgical abdomen • Obstruction ▫ May be acute or acute on chronic ▫ Symptoms include persistent vomiting, abdominal distention (or not), pain ▫ Exam findings depend on level of obstruction (proximal v. distal)  Distal – distention, tympany, absent or high-pitched bowel sounds  Proximal – similar, but may not see distention and tympany
  46. 46. Surgical abdomen • Ischemia ▫ Mesenteric ischemia usually seen in patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons ▫ Symptoms include pain OUT OF PROPORTION TO EXAM ▫ Exam findings  Severe tenderness to minimal palpation, unstable vital signs, and a very uncomfortable patient
  47. 47. Surgical abdomen • Work-up ▫ Start with stat labs ▫ Surgical abdominal series (plain films) ▫ Consider stat CT if readily available • Sometimes patients go straight to surgery as initial step • Again, get surgeons involved early for guidance and early intervention
  48. 48. Chronic abdominal pain • Generally present for months to years • Generally not immediately life threatening • Outpatient work-up is prudent
  49. 49. Th an ky ou
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