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. 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. 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. STIMULANTS
1
Mechanical trauma to the tissue .
2
Excess heat or cold .
3
Chemical damage.
4
Radiation damage .
5
Inadequate blood flow.
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 .
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
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. 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. Analysis of pain
need
DATA COLLECTION
1
2
3
History
Physical exam.
Lab.inv.
apply
your medical knowledge***
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. 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. 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. Mode of onset
Gradual Onset
( The
pat. Usually responds vaguely to questions
about time of onset )
Non mechanical or
chronic process
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. 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. 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 ? ????
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. Ischemic pain
Is a somatic pain
Occlusion of blood supply
cause
Necrosis
After 6-12 h
Tissue Hypoxia
With metabolic
changes
31. ?So how do we organize this
• Location
• Acute v. chronic
• Surgical v. nonsurgical
41. 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
43. 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
44. 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
45. 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
46. 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
47. 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
48. 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
49. Chronic abdominal pain
• Generally present for months to years
• Generally not immediately life threatening
• Outpatient work-up is prudent
