Approach to abdominal pain
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1. Abdominal pain is a common presenting symptom that can be caused by many intra-abdominal and extra-abdominal processes. 2. A thorough history and physical exam is important to help determine the cause, including assessing location, character, and timing of pain. 3. Differential diagnosis depends on factors like location of pain and patient characteristics, and may include conditions like appendicitis, cholecystitis, pancreatitis, or diverticulitis. Laboratory tests, imaging, and other evaluations can help make the diagnosis.
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Approach to abdominal pain
- 1. APPROACH TO ABDOMINAL PAIN ATopic review by Yutchawit P. Under supervision of … Simasingha N. Department of Medicine,UdonThani Hospital
- 2. CONTENTS • Definition • Anatomic basis of pain • Types of pain • History • Physical examination • Laboratory evaluation • The differential Dx • Special consideration • Summary
- 3. ABDOMINAL PAIN • Unpleasant experience in abdomen • Common presenting symptom • Involving in many intra-abdominal and extra- abdominal processes and etiologies • Not a disease.
- 4. ANATOMIC BASIS OF PAIN • Sensory neuroreceptor • Type of pain • Mechanism of pain • Localization
- 5. NEURORECEPTOR IN NOCICEPTION • Mucosa and muscularis propria of hollow viscera • Serosal structures E.g. the peritoneum • Mesentery Sensory neuroreceptors involved in regulation of secretion, motility and blood flow
- 6. CONDUCTION OF PAIN • MyelinatedA – delta • found on skin and muscle • mediate sudden sharp well localized pain following acute injury • C fibers • found in muscle, periosteum, mesentary,peritoneum and viscera • pain usually dull, burning poorly localize, • gradual onset and long duration
- 7. TYPES OF PAIN • Visceral pain • visceral nociceptors triggered • dull, poorly localized pain in midline epigastrium, periumbilical region or lower midabdomen • crampy,burning and gnawing • Somatoparietal pain • noxious stimuli to parietal peritoneum • intense, well localized (McBurney’s point) • Referred pain : • pain felt in areas remote to the disease organ (subphrenic abscess felt as shoulder pain)
- 8. STIMULANTS OF PAIN • Abdominal visceral nociceptors respond to mechanical and chemical stimuli • Principal mechanical signal is stretching. • Cutting,tearing or crushing of viscera does not result in pain. • Mechanoreceptor stimulated with • Rapid distention of hollow viscus (intestinal obstruction) • Forceful muscular contraction (biliary/ renal colic) • Rapid stretching of organ or capsule (hepatic congestion)
- 9. STIMULANTS OF PAIN • Mechanism of abdominal pain 1. Stretching or tension 2. Inflammation 3. Ischemia 4. Neoplasm 5. Spasm
- 10. LOCATION OF PAIN • Visceral pain 1. Epigastric = foregut 2. Periumbilical = mid-gut 3. Suprapubic =hind-gut
- 11. LOCATION OF PAIN • Foregut • Esophagus • Stomach • Proximal duodenum • Liver and biliary tract • Pancreas
- 12. LOCATION OF PAIN • Midgut • Small intestine • Appendix • Descending colon • Proximal 2/3 of transverse colon
- 13. LOCATION OF PAIN • Hindgut • Distal 1/3 of transverse colon • Descending colon • Recto sigmoid
- 14. CLASSIFICATION • Acute abdominal pain • Chronic abdominal pain Chronic intermittent abdominal pain Chronic persistent abdominal pain
- 15. RUQ (ACUTE) • Acute hepatitis • Acute pancreatitis • Cholangitis • Chelecystitis • Cholelithiasis • Duodenal ulcer • Liver abscess • Hepatomegaly due to HF • Herpes zoster • Myocardial infarction • Pericarditis • Pneumonia • Retrocecal appendicitis
- 16. RLQ (ACUTE) • Acute appendicitis • Bowel obstruction • Diverticulitis • IBD • IBS • Mesenteric adenitis • Ectopic pregnancy • Endometriosis • Ovarian tumor or cyst • PID • Psoas abscess • Ureteric stone
- 17. LUQ (ACUTE) • Acute pancreatitis • DU • GU • Acute gastritis • Myocardial infarction • Pericarditis • Pneumonia • Splenic abscess • Splenic infarct • Splenic rupture
- 18. LLQ (ACUTE) • Bowel obstruction • Diverticulitis • IBD • IBS • Ectopic pregnancy • Endometriosis • Ovarian tumor or cyst • PID • Proas abscess • Ureteric stone
- 19. DIFFUSE (ACUTE) • Acute pancreatitis • Bowel obstruction • Dissecting aorta • Early appendicitis • Gastroenteritis • IBD • IBS • Mesenteric infarct / ischemia • Peritonitis
- 20. POORLY LOCALIZED (CHRONIC) • Irritable bowel syndrome • FamilialMediterranean fever • Metabolic • Vasculitis • Porphyria • Dyspepsia • Chronic mesenteric vascular • Occlusive disease
- 21. EPIGASTRIC (CHRONIC) • Gastroesophageal reflux • Peptic ulcer disease • Chronic pancreatitis • Malignancy • Panceratic cancer • Musculoskeletal pain • Biliary colic • Dyspepsia
- 22. LUQ (CHRONIC) • Gastroesophageal reflux • Peptic ulcer disease • Splenomegaly • Malignancy • Pancreatic cancer • Musculoskeletal pain • AAA • Chronic pancreatitis • Dyspepsia
- 23. LLQ (CHRONIC) • Crohn’s disease • Ulcerative colitis • Bowel obstruction • Mesenteric adenitis • Musculoskeletal pain • Herniated disc • Psoas abscess • Chronic pancreatitis • AAA • Functional / IBS • Pancreatic cancer • Malignancy colon • Malignancy other • Endometriosis • Ureterolithiasis • Prostatitis • Bladder outlet obstruction • Iliac artery aneurysm • Chronic mesenteric vascular occlusive disease • Colonic ischemia • Pelvic inflammatory disease
- 24. RUQ (CHRONIC) • Gastroesophageal reflux • Peptic ulcer disease • Hepatitis • Budd-Chiari • Chronic pancreatitis • Malignancy • Pancreatic cancer • Musculoskeletal pain • Biliary colic • Dyspepsia • Nephrolithiasis
- 25. RLQ (CHRONIC) • Meckel’s diverticulum • Crohn’s disease • Biliary colic • Mesenteric adenitis • Musculoskeletal pain • Hemiated disease • Psoas abscess • Chronic pancreatitis • AAA • Functional / IBS • Pancreatic cancer • Malignancy colon • Malignancy other • Endometriosis • Ureterolithiasis • Prostatitis • Bladeer outlet obstruction • Iliac artery abeurysm • Chronic mesenteric vascular occlusive disease • Colonic ischemia • Pelvic inflammatory disease
- 26. COMMON CAUSES • Appendicitis • Cholecystitis • Perforated viscus • Intestinalobstruction • Renal stone • Rupture ectopic • PU • Gastritis • Gastroenteritis • Pancreatitis • Peritonitis • Hepatitis • Pregnancy • MI • Pneumonia
- 27. TAKING HISTORY 1. Location organ • Epigastrium - Liver,stomach, duodenal ,GB,CBD • Periumbilical - Jejunum,ileum,cecum • Suprapubic - Large bowel, OB-GYN , KUB
- 28. TAKING HISTORY 1. Location organ • Epigastrium - Liver,stomach,duodenal ,GB,CBD • Periumbilical - Jejunum,ileum, cecum • Suprapubic - Large bowel,OB-GYN , KUB May not be specific Diaphragmatic irritation >> shoulder pain Change in location >> marker of progression ? E.g. appendicitis or perforated ulcer
- 29. TAKING HISTORY 2. Radiation • Eso >> middle of back • Stomach , duodenum >> back • GB,CBD >> scapular • Liver >> shoulder
- 30. TAKING HISTORY 3.Type and character • Colicky • Steady 4. Chronology • Acute • Progress
- 31. TAKING HISTORY 5. Onset / Chronology • Sudden - Perforation - Obstruction -Vascular • Subacute - Infection • Gradual -Tumor - Infection Sudden + well localized = intra abdominal catastrophe (Perforated viscus,mesenteric infraction, rupture aneurysm) Progression >> appendicitis – increase , Gastroenteritis – decreases, Colic – crescendo/decreascendo
- 32. TAKING HISTORY 6.Aggravating and alleviating factors • Peritonitis >> Lie motionless • Renal colic >> writhe, unable to find comfortable position • Fatty food >> worsen biliary colic • Pain improve with eating >> DU • Pain worsen with eating >> GU, mesenteric ischemia 7.Associated symptoms e.g. fever,sign of gut obstruction, preg ? 8. Menstruation 9. Drugs
- 33. PHYSICAL EXAMINATION • Vital sign • General appearance • Abdominal exam • General exam Still patient >> peritonitis Writhing patient >> colic or bowel obstruction
- 34. PHYSICAL EXAMINATION • Severe tender with rigidity >> peritonitis >> consult Sx • Palpate from area of least pain to area of most pain • Peritonitis (rebound tenderness and subtle methods– percussion, deep breath) • PV and PR in every patient with severe abdominal pain
- 35. SPECIAL CONSIDERATION • Very young • Appendicitis and abdominal trauma secondary to abuse • PID, Meckel’s diverticulum, cystitis, enteritis, IBD • Very old • Subtle symptoms • Compulsive evaluation
- 36. LABORATORY EVALUATION • Routine CBC, UA,?UPT, Stool exam • Blood chemistryAmylase, LFT • X - Ray Plain film Contrast • Ultrasonography • CT • Endoscope
- 37. THE DDX • Organ ? • Pathogenesis ? • Complication ?
- 38. THE DDX • Acute cholecystitis • Cystic duct obstructed, RUQ pain radiated to Rt scapula • Murphy’s sign, LFT, amylase • Acute appendicitis • Anorexia, N/V and vague Periumbilical pain • 6-8 hrs pain migrates to RLQ, fever • Progresses to localized peritoneal irritation
- 39. THE DDX • Pancreatitis • Acute diverticulitis • Most commonly in sigmoid colon • Symptoms related to inflammation or obstruction • CT useful early to R/O abscess, BE and endoscopy should be delayed for 4-6 wk • Rx : Rest bowel,IV ATB Sx for failure conservative tx
- 40. SPECIAL CONSIDERATION • Pregnancy • Appendicitis,cholecystitis, pyelonephritis • Adnexal problems (Ovarian torsion, ovarian cyst rupture) • Appendicitis 7/1000 pregnancies • 3% fetal loss with surgery but increased to 20% with perforated appendicitis
- 41. SPECIAL CONSIDERATION • Very young • Appendicitis and abdominal trauma secondary to abuse • PID, Meckel’s diverticulum, cystitis, enteritis, IBD • Very old • Subtle symptoms • Compulsive evaluation
- 42. SPECIAL CONSIDERATION • Immunocompromised • Chemotherapy, organ transplants, immunosuppression for autoimmune disease,AIDS • Symptom are subtle • Unique to IC host (neutropenic enterocolitis, GVH, CMV infections, KS, lymphoma/ leukemia obstruction)
- 43. SPECIAL CONSIDERATION • IBS (Rome III Criteria)
- 44. SUMMARY • Obtain detailed history • Careful physical examination • Consider patient circumstances (DM, Immunocompromised host, age, previous abdominal surgery) • Work-up thoroughly and thoughtfully • Frequent evaluation of progression