This document discusses the clinical approach to a patient presenting with abdominal pain. It covers the anatomical basis of abdominal pain, types of pain, history and physical examination findings, differential diagnosis, and special considerations. The key points are that abdominal pain can have many underlying causes, a thorough history and physical exam are important to localize and characterize the pain, and laboratory and imaging studies may be needed to make a diagnosis.

1. Clinical approach to
a patient with
abdominal pain

2. CONTENTS
• Introduction
• Anatomic basis ofpain
• T
ypes ofpain
• History
• Physical examination
• Laboratoryevaluation
• The differential Dx
• Special consideration
• Summary

3. ABDOMINAL
PAIN
• Common presenting symptom
• Involving in many intra-abdominal and extra-
abdominal processes and etiologies
• Not a disease.
• It is a symptom of underlying disease.

4. A N ATO M IC BA SIS
OF PAIN
• Sensory neuroreceptor
• T
ype of pain
• Mechanism ofpain
• Localization

6. ABDOMINAL PAIN
● VISCERAL PAIN
● NOCICEPTORS
● STRETCH
● CHEMICAL
● REFERED PAIN
● SOMATIC PAIN
● From ABDOMINAL
WALL & PARIETAL
PERITONEUM

7. N EURO REC EPTO R 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

8. STIMULANTS OF PAIN
• Mechanism ofabdominal pain
1. Stretching or tension
2. Inflammation
3. Ischemia
4. Neoplasm
5. Spasm

9. LOCATION OF PAIN
• Visceral pain
1.Epigastric = foregut
2. Periumbilical = mid-gut
3.Suprapubic =hind-gut

10. LOCATION OF PAIN
• Foregut
• Esophagus
• Stomach
• Proximal duodenum
• Liver and biliarytract
• Pancreas

11. LOCATION OF PAIN
• Midgut
• Small intestine
• Appendix
• Descendingcolon
• Proximal 2/
3 of transverse colon

12. LOCATION OF PAIN
• Hindgut
• Distal 1/
3 of transverse colon
• Descendingcolon
• Recto sigmoid

13. CLASSIFICATION
• Acute abdominal pain
• Chronic abdominal pain
Chronic intermittent abdominalpain
Chronic persistent abdominal pain

15. SITE AND RADIATION
ORGAN SITE OF PAIN RADIATION
STOMACH EPIGASTRIUM Rt HYPO,
LUMBAR,Rt
ILIAC,Lt
CHEST,VERTEBR
AL COLUMN
LIVER-Rt LOBE Rt
IUM
SHOULDER,SUP
HYPOCHONDR RACLAVICULAR
& SCAPULAR
REGION ON Rt

16. LIVER-Lt LOBE EPIGASTRIUM PRECORDIUM,
Lt SCAPULAR, Lt
CLAVICLE
GALL BLADDER
Rt
HYPOCHONDRI
UM
EPIGASTRIUM or CHEST,Rt
SCAPULA,Rt
CLAVICLE,SHOU
LDER,BACK
May resemble
ANGINAL pain
Local inflamn of
peritoneum-
Catching pain
respiration
SPLEEN
(pain unusual)
Dragging
sensation
&fullness-Lt
HYPO &
LUMBAR

17. PANCREAS EPIGASTRIUM
OR BACK
Acute-symps of
shock
Chronic-vague in
nature & location
KIDNEYS LOINS or
LUMBAR
REGION
Obstructive
lesions-Penis or
Labia + urgency
for urination
URINARY
BLADDER
HYPOGASTRIUM PERINEUM &
URETHRA

18. SMALL
INTESTINE
UMBILICUS
LARGE
INTESTINE
ILIAC or LUMBAR
APPENDIX
CAECUM
Rt ILIAC FOSSA Rt LUMBAR,
UMBILICAL
RECTUM Lt ILIAC FOSSA
or
HYPOGASTRIUM
Assoc. with
tenesmus

19. UTERUS
DYSMENORRHOEA
HYPOGASTRIU
M & UMBILICUS
LOWER
ABDOMEN
ILIAC FOSSA
LOW BACK &
FLANKS
OVARY EXTERNAL
GENITALIA

20. PERITONITIS
● LOCALISED ●GENERALISED
● Eg. Rt iliac fossa in
appendicitis
● DIFFUSE affecting
the whole abdomen
GUARDING AND RIGIDITY ON PALPATION

21. REFERRED PAIN
● Pain arising from lesions outside
abdomen
● REFERRED to abdomen
● Eg. MI radiate to epigastrium

22. Psycogenic Pain
● Not due to any organic cause
● More common at night

23. 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

24. DURATION OF PAIN
● ACUTE ●CHRONIC
● Intense pain with
dramatic onset
● Reach maximum in
hrs or days
● Periods of remissions
& exacerbations with
intervals of relief in
btwn
● Months or years

25. 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 &
relief on erect posture
GERD

26. Pain on ingestion of fat Malabsorption
Pain on defaecation Colonic disease
Blood and mucus in faeces Colonic ulcer
Pain as food pass down to
be digested & absorbed
Intestinal angina

27. Past History
● Trauma
● DM, CRF-Metabolic cause of pain
● Thrombotic disease-Vaso occlusion
● CAD-Embolic occlusion
Family History
o DM
o CAD

28. Personal History
● Appetite & Loss of weight
●Bowel habits- Malena-Upper GIT ds
Hematochezia-Lower GIT ds
● Difficulty in micturition
● Menstrual history

29. General Examination
PALLOR Malabsorption,Acute or
chronic blood loss
ICTERUS Hepatobiliary disease
CYANOSIS
Cirrhosis liver with portal
hypertension
Cirrhosis,ulcerative
colitis,Crohn`s disease
Generalised or localised
CLUBBING
LYMPHADENOPATHY

30. GIT Examination….
● Inspection
1. Shape
2. Umbilicus
3. Movements of the abdominal wall
4. Skin and surface of abdomen

31. •Palpation
1. Liver
2. Spleen
3. Kidneys
4. Palpable mass

32. • Percussion
●
●
●
Shifting dullness
Fluid thrill
Puddle sign
● Auscultation
1. Bowel sounds
2. Succusion splash

33. Also examine….
● Genitalia
● Hernial orifices
● Per rectal examination
● Per vaginal examination

34. LABORATORY EVALUATION
• Routine C BC ,UA ,?UPT, Stool exam
• Blood chemistryA mylase,LFT
• X - Ray Plain film
Contrast
• U ltrasonography
• C T
• Endoscope

35. The D i f f e r e n t i a l d i a g n o s i s
• Organ ?
• Pathogenesis ?
• Complication ?

36. SPECIAL CONSIDERATION
• Immunocompromised
• Chemotherapy
,organ transplants,
immunosuppression for autoimmune
disease,AIDS
• Symptom are subtle

37. 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