Approach To Abdominal Pain

1. Abdominal Pain

2. Objectives
• To be able to elucidate the various mechanism
of abdominal pain
• To clearly be able to describe the importance
of history, physical examination, and other
investigations in defining the origin of
abdominal pain
• To be able to list a good differential for
abdominal pain and solve real life examples

3. Why should we care?
• Abdominal Pain is a huge topic
• To understand it fully it requires a good clinical
judgment
• It serves as a good case for history and physical
examination
• Many chronic diseases go by unchecked with only
minor symptoms like abdominal pain
• There are multiple classification or systems for
abdominal pain

4. Abdominal Pain and its mechanism
• It can be due to multiple ways or origins, it
includes:
– Parietal Peritoneum Inflammation
– Obstruction of the lumen of the gut
– Vascular problems in the gut
– Referred pain from somewhere else
– Abdominal wall problems
– Metabolic problems
– Nerve problems

5. Parietal Peritoneum Problems
• The characteristic of the pain:
– Steady and aching
– Almost always localized in the area of the pain

6. Obstruction of the Gut
• The characteristic of the pain:
– Intermittent pain, or colicky
– It can be steady ‘’sometimes’’ – due to distention

7. Obstruction - 2
• Billiary tree pain
– Can produce steady pain ‘’REMEMBER
DISTENSION’’
– Billiary colic can be steady
– It radiates to tip of right scapular (supscapular
pain) + epigastric
• Carcinoma Head of the pancreas usually silent
• Urinary bladder obstruction is suprapubic

8. Vascular Problems
• Sometimes sudden and catastrophic like
sudden bleed, eg., Aortic Aneurysm
• Mesenteric artery occlusion:
• Can be continuous and diffuse before the
vascular bleed ( e.g., mesenteric artery
occlusion)

9. Abdominal Wall
• Usually the pain from abdominal wall
• It is constant, and aching

10. Referred Pain in Abdominal Disease
• It can be from anywhere:
– thorax, spine, or genitalia
• It can be abdominal disease causing referred
pain somewhere else
– Ex: acute cholecystitis or perforated ulcer
• Common interthoracic diseases:
– Especially in upper abdominal pain
• MI, Pulmonary Infarction, pneumonia, pericarditis, and
esophageal disease

11. Metabolic Abdominal Crises
• Many mechanisms cause this type of pain:
– Hyperlipidemia – accompanies by a process such as pancreatitis
– C’1 esterase deficiency associated with angioneurotic edema – with
severe abdominal pain
• If you don’t know the cause, think of metabolic causes!!
• It is difficult to do a differential because many diseases have similar
nature of pain
– Porphyria or lead colic is similar to intestinal obstruction
– Uremia or diabetes is non-specific type of pain
– Diabetic acidosis is similar to acute pancreatitis or intestinal
obstruction
• As a rule, if pain does not resolve with correction of metabolic
abnormality
– Underlying ORGANIC problem is suspected!

12. Nerve problems
• Spinal nerve or roots of spinal nerve pain:
– Comes and goes suddenly
– lacinating type of pain
– Many causes:
• Herpes zoster, impingement by arthritis, tumors,
herniated nucleus pulposus, diabetes, or syphilis.

13. Patterns of acute abdominal pain
• . A, Many causes of abdominal pain
subside spontaneously with time
(e.g., gastroenteritis).
• B, Some pain is colicky (i.e., the
pain progresses and remits over
time); examples include intestinal,
renal, and biliary pain (“colic”).
The time course may vary widely
from minutes in intestinal and renal
pain to days, weeks, or even
months in biliary pain.
• C, Commonly, abdominal pain is
progressive, like its maturing, as in
appendicitis or diverticulitis.
• D, Certain conditions have a
catastrophic onset, such as ruptured
aortic aneurysm.

14. Stereotypes of Pain Onset and Associated Pathology
Sudden onset
(full pain in
seconds)
 Perforated
ulcer
 Mesenteric
infarction
 Ruptured
abdominal
aortic
aneurysm
 Ruptured
ectopic
pregnancy
 Ovarian
torsion or
ruptured cyst
 Pulmonary
embolism
 Acute
myocardial
infarction
Rapid onset
(initial sensation to full
pain over minutes or
hours)
 Strangulated
hernia
 Volvulus
 Intussusception
 Acute
pancreatitis
 Biliary colic
 Diverticulitis
 Ureteral and
renal colic
Gradual onset
(hours)
 Appendicitis
 Strangulated
hernia
 Chronic
pancreatitis
 Peptic ulcer
disease
 Inflammatory
bowel disease
 Mesenteric
lymphadenitis
 Cystitis and
urinary
retention
 Salpingitis and
prostatitis

15. History
• Course of pain
• Radiation of pain
• Factors that exacerbate or improve symptoms
• Associated symptoms including fevers, chills
weight loss
• Past medical and surgical history
• Family history of bowel disorder
• Alcohol intake
• Intake of medications
• Menstrual and contraceptive history in women

16. Physical Examination
• Measurement of blood pressure, pulse, and
temperature
• Examination of the eyes and skin for jaundice
• Auscultation and percussion of the chest
• Auscultation of the abdomen for bowel sounds
• Palpitation of the Abdomen for masses,
tenderness, and peritoneal signs
• Rectal exam include Occult blood
• Pelvic Examination in women with lower
abdominal pain

18. • DETAILED HISTORY IS MOST IMPORTANT THAN
ANYTHING!
• Location of pain is very helpful
• Time sequence of events is important
• Be open minded and ask the right questions
• Check extra-abdominal manifestation
• If female, ask menstrual history

20. • Critical inspection is inmportant
– Facies, position in bed, respiratory activity
– Be gentle and detailed
– do not elicit rebound tenderness by sudden release of
a deeply palpating hand, IT’S CRUEL!
• Same way can be done by gentle percussion (rebound
tenderness on a miniature scale)
• Ask patient to cough will elicit true rebound tenderness
without placing hand on abdomen
• Sometimes, reactionary protective spasm will hinder your
other findings, eg., palpating gallbladder

21. • Abdominal signs can be absent in cases of
pelvic peritonitis
– Careful pelvic and rectal examinations are
mandatory in patients with abdominal pain
• Tenderness in such examination:
– Operative indication:
» Perforated appenditis
» Diverticulitis
» Twisted ovarian cyst

22. • Absence of peristaltic sound
– Auscultation is one of the least revealing aspect
– Catastrophes such as: Strangulating small
intestinal obstruction or perforated appendicitis
• Occur in presence of normal peristaltic sounds
• Conversely, when proximal area above obstruction
becomes edematous and distended
– Peristaltic sound lose characteristics of borborygmi
» Become weak and absent
– Sudden Chemical peritonitis = silent abdomen
– Remember, assess patient’s hydration status

23. LABS
• Labs are very valuable but they rarely establish
diagnosis – focus on History & physical
Example: Leukocytosis does not mean a person having
appendicitis and he should be admitted to operation
room
Other conditions occur in pancreatitis, acute cholecystitis,
pelvic inflammatory disease, intestinal infarction
We can establish diagnosis of anemia based on
CBC and history

24. • We do urinary analysis to rule out:
– renal disease, diabetes, urinary infection
• Serum amylase levels can increase:
• pancreatitis
• Perforated ulcer
• Strangulating intestinal obstruction
• Acute cholecystitis
• Other important tests: Blood urea nitrogen,
glucose, serum bilirubin

25. • Radiographs of abdomen can show Perforated
ulcer, and other conditions
• Water-soluble contrast or barium studies can
demonstrate partial upper GI obstruction
• Contrast enema Suspected colonic obstruction
(with no perforation) – contrast enema may
be diagnostic

26. US  detect enlarged gallbladder or pancreas
• Presence of gallstones, enlarged ovary or tubal
pregnancy
– Helpful in diagnosing pelvic conditions:
• Ovarian cysts, tubal pregnancies, salpingitis, and acute
appendicitis

27. Cases…
• A 23 year old female presents with severe,
intermittent right lower quadrant pain associated
with nausea and vomiting.
• She has no medical history.
• Her vital signs reveal tachycardia but are otherwise
normal.
• Physical exam shows a soft abdomen, RLQ TTP
without peritoneal signs. Pelvic (which is part of
the physical exam), shows scant discharge.
• If you could only order one test, what would it be?
• What is on your differential?

28. Differential
• Ectopic Pregnancy
• Ruptured Ovarian Cyst
• Appendicitis
• Right-sided diverticulitis
• TOA
• Ovarian Torsion
• Nephrolithiasis
• Pyelonephritis
• Endometriosis
• UTI
• Heterotopic pregnancy
• Terminal ileitis

29. Ovarian Torsion…

30. Increased ovarian volume (>15cc),
multiple follicles and decreased blood
flow.

31. Cases…
• A 60 y/o male presents after a syncopal event
with a complaint of abdominal pain.
• His pain is poorly localized but radiating to his
back.
• His history is significant for HTN and tobacco
abuse.
• His vitals are normal and his physical exam
reveals only the following:

33. What is on the differential?
• Pancreatitis
• Mesenteric Ischemia
• MI
• Gallbladder Disease
• GERD
• Obstruction
• Peritonitis
• PE
• PUD
• AAA
• Valvular Insufficiency
• Perforated Viscus

34. Abdominal Aortic Aneurysm
What happens:
The media weakens over time, the vessel
dilates and expands over time. As the vessel
weakens and expands, rupture becomes more
likely.
The larger it becomes, the more likely is the
rupture.

35. AAA
Fun facts:
They are typically infrarenal
>3cm at this level is a AAA
Age, Family history, Atherosclerotic risk factors,
infection, trauma, connective tissue disease are risk
factors.
Rupture is associated with 80-90% mortality.
Vital signs can be normal. For now.

36. AAA: Diagnosis and
Management
H&P: May not be symptomatic until the rupture
Syncope and Abdominal pain
Cullen’s sign and Grey Turner’s sign
Imaging: U/S 100% sensitive when the aorta is visualized.
CT requires a stable patient but is also highly sensitive
and is better at detecting rupture and retroperitoneal
fluid.
Treatment is surgical!! Despite what surgery tells you:
There is no such thing as a stable rupture.
ED’s role is maintaining hemodynamic stability with blood
products – SBP 90-100mg until surgery.

37. CT of Rupturing AAA:

38. Thank you! 