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Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves
Several factors can modify expression of pain:
Vascular compromise (pain ‘out of proportion’)
Distention of the gut or other hollow abdominal organ
Traction on the bowel mesentery
Corresponds to the embryologic origin of the diseased organ (foregut, midgut, hindgut)
Irritation of the peritoneum
Sharp, localized pain
Absent bowel sounds
Pattern of referred pain Gastric pain Liver and biliary pain Colonic pain Ureteral or kidney pain Diaphragmatic irritation Biliary colic Pancreatic and renal pain , Uterine and rectal pain
Where does it hurt?
Know locations of major organs
But realize abdominal pain locations do not correlate well with source
What does pain feel like?
Steady pain - inflammatory process
Crampy pain - obstructive process
Was onset of pain gradual or sudden?
Sudden = perforation, hemorrhage, infarct
Gradual = peritoneal irrigation, hollow organ distension
Does pain radiate (travel) anywhere?
Right shoulder, angle of right scapula = gall bladder
Around flank to groin = kidney, ureter
> 6 hour duration = ? surgical significance
Nausea, vomiting? Bloody? “Coffee Grounds”?
Any blood in GI tract = Emergency until proven otherwise
Change in urinary habits? Urine appearance?
Change in bowel habits? Appearance of bowel movements? Melena?
Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss
Last menstrual period?
In females, abdominal pain = Gyn problem until proven otherwise
Lies perfectly still inflammation, peritonitis
Restless, writhing obstruction
Ecchymosis around umbilicus, flanks?
Tachycardia ? Early shock (more important than BP)
Rapid shallow breathing peritonitis
Physical Examination: The Quadrants
Special physical signs
Grey turner’s and Cullen's sign
Diagnosis: Right Upper Quadrant (RUQ) Pain
Upright and supine abdominal
Complete Blood count
Amylase, Creatinine, BUN, Electrolytes
Differential Diagnosis: RUQ Pain Fever, tachypnea, bronchial breathing Right lower lobe pneumonia Shift of pain, tenderness Retrocecal appendicitis Edema, dyspnea, elevated JVP Congestive heart failure Dysuria, fever, costovertebral angle tenderness Right pyelonephritis Alcohol history, jaundice, medications Acute hepatitis Recurrent attacks, tender over gall bladder area Biliary colic, acute cholecystitis clues Condition
Diagnosis: Left Upper Quadrant (LUQ) and Epigastric Pain
Upright chest XR
Upright and supine abdominal XR
Amylase and lipase (if available
Differential Diagnosis: LUQ and Epigastric Pain Fever, XR findings, bronchial breathing Pneumonia Recurrent, relationship to meals, relationship to posture Gastritis / Peptic ulcer disease History of alcohol consumption, history of similar event, elevated labs Pancreatitis History of trauma, gross deformity, extreme tenderness on palpation Fractured ribs History of trauma or splenic disease Splenic rupture clues Condition
Diagnosis: Right Lower Quadrant (RLQ) Pain
Urinalysis (to exclude obvious urinary causes)
Complete blood count
Differential Diagnosis: RLQ Pain … see next Gynecologic causes Recurrent, several days history Crohn’s disease Tender swollen testis, usually young age Torsed right testis Colicky pain, hematuria Right renal colic Fever, inconstant signs Mesenteric adenitis Shift of pain, anorexia, localized tenderness Acute appendicitis clues Condition