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Clinical approach to
       a patient with
     abdominal pain
ABDOMINAL PAIN

VISCERAL PAIN   SOMATIC PAIN

NOCICEPTORS     From ABDOMINAL
 STRETCH         WALL & PARIETAL
 CHEMICAL        PERITONEUM
SITE AND RADIATION
ORGAN       SITE OF PAIN   RADIATION



STOMACH     EPIGASTRIUM Rt HYPO,
                           LUMBAR,Rt
                           ILIAC,Lt
                           CHEST,VERTEBR
                           AL COLUMN

LIVER-Rt LOBE Rt         SHOULDER,SUP
              HYPOCHONDR RACLAVICULAR
                         & SCAPULAR
              IUM
                           REGION ON Rt
LIVER-Lt LOBE    EPIGASTRIUM      PRECORDIUM,
                                  Lt SCAPULAR, Lt
                                  CLAVICLE

GALL BLADDER     EPIGASTRIUM or   CHEST,Rt
                 Rt               SCAPULA,Rt
                 HYPOCHONDRI      CLAVICLE,SHOU
                 UM               LDER,BACK
                                  May resemble
                                  ANGINAL pain
SPLEEN           Dragging         Local inflamn of
(pain unusual)   sensation        peritoneum-
                 &fullness-Lt     Catching pain
                 HYPO &           respiration
                 LUMBAR
PANCREAS   EPIGASTRIUM   Acute-symps of
           OR BACK       shock
                         Chronic-vague in
                         nature & location

KIDNEYS    LOINS or      Obstructive
           LUMBAR        lesions-Penis or
           REGION        Labia + urgency
                         for urination


URINARY    HYPOGASTRIUM PERINEUM &
BLADDER                 URETHRA
SMALL       UMBILICUS
INTESTINE


LARGE       ILIAC or LUMBAR
INTESTINE


APPENDIX    Rt ILIAC FOSSA    Rt LUMBAR,
CAECUM                        UMBILICAL


RECTUM      Lt ILIAC FOSSA Assoc. with
            or             tenesmus
            HYPOGASTRIUM
UTERUS       HYPOGASTRIU     LOW BACK &
             M & UMBILICUS   FLANKS

DYSMENORRHOEA LOWER
             ABDOMEN
OVARY        ILIAC FOSSA     EXTERNAL
                             GENITALIA
PERITONITIS
LOCALISED               GENERALISED

Eg. Rt iliac fossa in   DIFFUSE affecting
 appendicitis             the whole abdomen



GUARDING AND RIGIDITY ON PALPATION
REFERRED PAIN

Pain arising from lesions outside
 abdomen
REFERRED to abdomen
Eg. MI radiate to epigastrium
Girdle pain B/L dorsal nerve root
 compression
Psycogenic Pain


Not due to any organic cause
More common at night
NATURE OF PAIN

SOLID ORGANS:DULL & CONSTANT
 aggravated by pressure.Organ
 enlarged,palpable,tender.

HOLLOW VISCERA:COLICKY PAIN
 reach max. in secs or mins & passes off.
Exception biliary tract & pancreas
DURATION OF PAIN
ACUTE               CHRONIC

Intense pain with   Periods of remissions
 dramatic onset       & exacerbations with
Reach maximum in     intervals of relief in
 hrs or days          btwn
                     Months or years
Relation to normal physiological events
Pain related to ingestion of   Gastric ulcer
food

Pain relieved by food intake Duodenal ulcer


Relief of pain by vomiting     Gastric outlet obstruction


Pain on recumbency &           GERD
relief on erect posture
Pain on ingestion of fat   Malabsorption



Pain on defaecation        Colonic disease



Blood and mucus in faeces Colonic ulcer



Pain as food pass down to Intestinal angina
be digested & absorbed
Past History
Trauma
DM, CRF-Metabolic cause of pain
Thrombotic disease-Vaso occlusion
CAD-Embolic occlusion


 Family History
 o DM
 o CAD
Personal History

Appetite & Loss of weight
Bowel habits- Malena-Upper GIT ds
Hematochezia-Lower GIT ds
Difficulty in micturition
Menstrual history
General Examination
PALLOR            Malabsorption,Acute or
                  chronic blood loss
ICTERUS           Hepatobiliary disease

CYANOSIS          Cirrhosis liver with portal
                  hypertension
CLUBBING          Cirrhosis,ulcerative
                  colitis,Crohn`s disease
LYMPHADENOPATHY   Generalised or localised
GIT Examination….

 Inspection
1. Shape
2. Umbilicus
3. Movements of the abdominal wall
4. Skin and surface of abdomen
•Palpation

1.   Liver
2.   Spleen
3.   Kidneys
4.   Palpable mass
• Percussion
 Shifting dullness
 Fluid thrill
 Puddle sign

 Auscultation

1. Bowel sounds
2. Succusion splash
Also examine….

Genitalia
Hernial orifices
Per rectal examination
Per vaginal examination
Clinical approach to a patient with abdominal pain

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Clinical approach to a patient with abdominal pain

  • 1. Clinical approach to a patient with abdominal pain
  • 2. ABDOMINAL PAIN VISCERAL PAIN SOMATIC PAIN NOCICEPTORS From ABDOMINAL  STRETCH WALL & PARIETAL  CHEMICAL PERITONEUM
  • 3.
  • 4. SITE AND RADIATION ORGAN SITE OF PAIN RADIATION STOMACH EPIGASTRIUM Rt HYPO, LUMBAR,Rt ILIAC,Lt CHEST,VERTEBR AL COLUMN LIVER-Rt LOBE Rt SHOULDER,SUP HYPOCHONDR RACLAVICULAR & SCAPULAR IUM REGION ON Rt
  • 5. LIVER-Lt LOBE EPIGASTRIUM PRECORDIUM, Lt SCAPULAR, Lt CLAVICLE GALL BLADDER EPIGASTRIUM or CHEST,Rt Rt SCAPULA,Rt HYPOCHONDRI CLAVICLE,SHOU UM LDER,BACK May resemble ANGINAL pain SPLEEN Dragging Local inflamn of (pain unusual) sensation peritoneum- &fullness-Lt Catching pain HYPO & respiration LUMBAR
  • 6. PANCREAS EPIGASTRIUM Acute-symps of OR BACK shock Chronic-vague in nature & location KIDNEYS LOINS or Obstructive LUMBAR lesions-Penis or REGION Labia + urgency for urination URINARY HYPOGASTRIUM PERINEUM & BLADDER URETHRA
  • 7. SMALL UMBILICUS INTESTINE LARGE ILIAC or LUMBAR INTESTINE APPENDIX Rt ILIAC FOSSA Rt LUMBAR, CAECUM UMBILICAL RECTUM Lt ILIAC FOSSA Assoc. with or tenesmus HYPOGASTRIUM
  • 8. UTERUS HYPOGASTRIU LOW BACK & M & UMBILICUS FLANKS DYSMENORRHOEA LOWER ABDOMEN OVARY ILIAC FOSSA EXTERNAL GENITALIA
  • 9. PERITONITIS LOCALISED GENERALISED Eg. Rt iliac fossa in DIFFUSE affecting appendicitis the whole abdomen GUARDING AND RIGIDITY ON PALPATION
  • 10. REFERRED PAIN Pain arising from lesions outside abdomen REFERRED to abdomen Eg. MI radiate to epigastrium Girdle pain B/L dorsal nerve root compression
  • 11. Psycogenic Pain Not due to any organic cause More common at night
  • 12. NATURE OF PAIN SOLID ORGANS:DULL & CONSTANT aggravated by pressure.Organ enlarged,palpable,tender. HOLLOW VISCERA:COLICKY PAIN reach max. in secs or mins & passes off. Exception biliary tract & pancreas
  • 13. DURATION OF PAIN ACUTE CHRONIC Intense pain with Periods of remissions dramatic onset & exacerbations with Reach maximum in intervals of relief in hrs or days btwn Months or years
  • 14. Relation to normal physiological events Pain related to ingestion of Gastric ulcer food Pain relieved by food intake Duodenal ulcer Relief of pain by vomiting Gastric outlet obstruction Pain on recumbency & GERD relief on erect posture
  • 15. Pain on ingestion of fat Malabsorption Pain on defaecation Colonic disease Blood and mucus in faeces Colonic ulcer Pain as food pass down to Intestinal angina be digested & absorbed
  • 16. Past History Trauma DM, CRF-Metabolic cause of pain Thrombotic disease-Vaso occlusion CAD-Embolic occlusion Family History o DM o CAD
  • 17. Personal History Appetite & Loss of weight Bowel habits- Malena-Upper GIT ds Hematochezia-Lower GIT ds Difficulty in micturition Menstrual history
  • 18. General Examination PALLOR Malabsorption,Acute or chronic blood loss ICTERUS Hepatobiliary disease CYANOSIS Cirrhosis liver with portal hypertension CLUBBING Cirrhosis,ulcerative colitis,Crohn`s disease LYMPHADENOPATHY Generalised or localised
  • 19. GIT Examination….  Inspection 1. Shape 2. Umbilicus 3. Movements of the abdominal wall 4. Skin and surface of abdomen
  • 20. •Palpation 1. Liver 2. Spleen 3. Kidneys 4. Palpable mass
  • 21. • Percussion  Shifting dullness  Fluid thrill  Puddle sign  Auscultation 1. Bowel sounds 2. Succusion splash
  • 22. Also examine…. Genitalia Hernial orifices Per rectal examination Per vaginal examination