The document discusses abdominal pain, outlining its common types (visceral, parietal, referred, and psychogenic) and the pathobiology behind them. It details causes of abdominal pain, accompanying symptoms, and the importance of thorough physical examinations and diagnostic tests to identify potential underlying conditions. Management strategies include conservative lifestyle modifications, medical treatments, and potential surgical interventions based on the severity of the condition.

1. DR. MOHAMMED SHAKIL
P.G. Scholar. Dept. of Moalajat (Medicine)
National Institute of Unani Medicine (NIUM),
Kottigepalya, Magadi Main Road, Bengaluru

2. ABDOMINAL PAIN
Abdominal pain, which is a frequent complaint among outpatients in the office setting and
emergency department, may be benign and self-limited or the presenting symptom of severe,
life-threatening disease.
Chronic abdominal pain that has been present for months or years in the absence of other
organic illness is almost always functional in origin and does not require urgent evaluation.

3. PATHOBIOLOGY
 Stimulation of hollow abdominal viscera is mediated by splanchnic afferent fibers within the muscle
wall, visceral peritoneum, and mesentery that are sensitive to distention and contraction. Visceral
afferent nerves are loosely organized, innervate several organs, and enter the spinal cord at several
levels.
 Thus, visceral pain is vague or dull in character and diffuse; patients attempting to localize the pain
often move their entire hand over the upper, middle, or lower abdomen. Most visceral pain is steady,
but cramping, intermittent pain or “colic” results from peristaltic contractions caused by partial or
complete obstruction of the small intestine, ureter, or uterine tubes.
 In contrast to visceral innervation, the parietal peritoneum is innervated unilaterally by a dense
network of nerve fibers that follow a spinal T6 to L1 somatic distribution.
 Pain fibers of the parietal peritoneum are stimulated by stretch or distention of the abdominal cavity
or retroperitoneum; direct irritation from infection, pus, or secretions (e.g., caused by a ruptured
viscus); or inflammation caused by contact between the parietal peritoneum and an adjacent
inflamed organ (e.g., appendicitis).
 Parietal pain is sharp, well characterized, and localized by the patient to a precise location on the
abdomen, often by pointing with one finger. The gastrointestinal viscera (liver, biliary system,
pancreas, and GI tract) arise during embryology from midline structures that have bilateral
innervation. Thus, GI visceral pain is typically localized to the abdominal midline.

4. Types of Abdominal pain
There are four types of abdominal pain
1. Visceral:- Gut organs are insensitive to stimuli such as burning and cutting but are
sensitive to distension, contraction, twisting and stretching. Pain from unpaired structures
is usually but not always felt in the midline.
2. Parietal:- The parietal peritoneum is innervated by somatic nerves, and its involvement
by inflammation, infection or neoplasia causes sharp, well-localised and lateralised pain.
3. Referred pain:- (For example, gallbladder pain is referred to the back or shoulder tip.)
4. Psychogenic:- Cultural, emotional and psychosocial factors influence everyone’s
experience of pain. In some patients, no organic cause can be found despite investigation,
and psychogenic causes (depression or somatisation disorder) may be responsible.

5. CAUSES OF ABDOMINAL PAIN
Pain Originating in the Abdomen Parietal:- peritoneal inflammation, Bacterial
contamination, Perforated appendix or other perforated viscus, Pelvic inflammatory
disease, Chemical irritation, Perforated ulcer, Pancreatitis, Mittelschmerz, Mechanical
obstruction of hollow viscera, Obstruction of the small or large intestine, Obstruction of
the biliary tree, Obstruction of the ureter, Vascular disturbances, Embolism or thrombosis,
Vascular rupture, Pressure or torsional occlusion, Sickle cell anemia, Abdominal wall
Distortion or traction of mesentery, Trauma or infection of muscles, Distension of
visceral surfaces, e.g., by hemorrhage Hepatic or renal capsules Inflammation,
Appendicitis, Typhoid fever, Neutropenic enterocolitis or “typhlitis”

6. Pain Referred from Extra abdominal Source Cardiothoracic:- Acute myocardial
infarction, Myocarditis, endocarditis, pericarditis, Congestive heart failure, Pneumonia
(especially lower lobes), Pulmonary embolus, Pleurodynia, Pneumothorax Empyema,
Esophageal disease, including spasm, rupture, or inflammation, Genitalia Torsion of the
testis.
Metabolic Causes:- Diabetes, Uremia, Hyperlipidemia, Hyperparathyroidism, Acute
adrenal insufficiency, Familial Mediterranean fever Porphyria C1-esterase-inhibitor
deficiency (angioneurotic edema).
Neurologic/Psychiatric Causes:- Herpes zoster, Tabes dorsalis, Causalgia Radiculitis from
infection or arthritis Spinal cord or nerve root compression, Functional disorders,
Psychiatric disorders.
Toxic Causes:- Lead poisoning, Insect or animal envenomation, Black widow spider bites,
Snake bites Uncertain Mechanisms, Narcotic withdrawal, Heat stroke.

7. CHARACTERISTIC FEATURES OF ABDOMINAL PAIN
Type and location provide a rough guide to nature of disease.
Visceral pain (due to distention of a hollow viscus) localizes poorly and is often perceived
in the midline.
Intestinal pain tends to be crampy; when originating proximal to the ileocecal valve, it
usually localizes above and around the umbilicus.
Pain of colonic origin is perceived in the hypogastrium and lower quadrants.
Pain from biliary or ureteral obstruction often causes pts to writhe in discomfort.
Somatic pain (due to peritoneal inflammation) is usually sharper and more precisely
localized to the diseased region (e.g., acute appendicitis; capsular distention of liver,
kidney, or spleen), exacerbated by movement, causing pts to remain still.

8. Pattern of radiation may be helpful
Right shoulder (hepatobiliary origin)
Left shoulder (splenic)
midback (pancreatic)
Flank (proximal urinary tract)
 groin (genital or distal urinary tract).

9. Factors that precipitate or relieve pain
Ask about its relationship to eating (e.g., upper GI, biliary, pancreatic, ischemic bowel
disease)
Defecation (colorectal)
Urination (genitourinary or colorectal)
Respiratory (pleuropulmonary, hepatobiliary)
Position (pancreatic, gastroesophageal reflux, musculoskeletal)
Menstrual cycle/menarche (tuboovarian, endometrial, including endometriosis)
Exertion (coronary/intestinal ischemia, musculoskeletal)
Medication or specific foods (motility disorders, food intolerance, gastroesophageal reflux,
porphyria, adrenal insufficiency, ketoacidosis, toxins)
Stress (motility disorders, nonulcer dyspepsia, irritable bowel syndrome).

10. Predisposing factors
 Inquire about family history (inflammatory disease, tumors, pancreatitis).
 Hypertension and atherosclerotic disease (ischemia).
 Diabetes mellitus (motility disorders, ketoacidosis).
 Connective tissue disease (motility disorders, serositis).
 Depression (motility disorders, tumors).
 Smoking (ischemia).
 Recent smoking cessation (inflammatory disease).
 Ethanol use (motility disorders, hepatobiliary, pancreatic, gastritis, peptic ulcer disease).

11. Associated symptoms
Look for fevers/chills (infection, inflammatory disease, infarction).
weight loss (tumor, inflammatory disease, malabsorption, ischemia).
Nausea/vomiting (obstruction, infection, inflammatory disease, metabolic disease).
Dysphagia/odynophagia (esophageal).
Early satiety (gastric).
Hematemesis (esophageal, gastric, duodenal).
Constipation (colorectal, perianal, genitourinary).
Jaundice (hepatobiliary, hemolytic).
Diarrhea (inflammatory disease, infection, malabsorption, secretory tumors,
ischemia, genitourinary).
Dysuria/hematuria/vaginal or penile discharge (genitourinary).
Hematochezia (colorectal or, rarely, urinary).
Skin/joint/eye disorders (inflammatory disease, bacterial or viral infection).

12. General examination
 Evaluate for evidence of hemodynamic instability
 Acid base disturbances
 Nutritional deficiency
 Coagulopathy
 Arterial occlusive disease
 Stigmata of liver disease
 Cardiac dysfunction
 Lymphadenopathy
 Skin lesions

13. Physical examination
 Evaluate abdomen for prior trauma or surgery.
 Current trauma
 Abdominal distention, fluid, or air
 Rebound and referred tenderness
 Liver and spleen size
 Masses
 Bruits
 Altered bowel sounds
 Hernias
 Arterial masses
 Rectal examination assesses presence and location of tenderness, masses, blood
(gross or occult).
 Pelvic examination in women is essential.

14. Inspection of the Abdomen
 First, the patient should be observed and the abdomen inspected.
 Most patients remain calm, cooperative, and freely capable of moving during the
examination.
 Patients who are writhing or restless may have pain due to visceral distention (e.g., renal
colic, intestinal obstruction).
 patients who lie motionless may have peritonitis.
 Gentle shaking of the bed or having the patient cough may elicit sharp, well-localized pain
in patients with parietal but not visceral pain.
.

15. Palpation of Abdomen
 The abdomen should be examined gently for sites of tenderness and the presence or absence of
guarding.
 This can be localized to one area or it may be generalized, involving the whole abdomen.
 Light palpation should be performed with one or two fingers (not the whole hand), beginning away
from where the patient localizes the pain and gradually moving to the site of pain. gentle, deeper
palpation of the entire abdomen is performed gradually, including the region of tenderness.
 An attempt should be made to palpate for an abdominal aortic aneurysm.
 The presence of focal tenderness indicates parietal peritoneal irritation.
 Voluntary or involuntary tightening of the muscle wall (“guarding”) may occur during palpation.
 Persistent involuntary guarding indicates peritonitis with reflex muscle wall contraction.
 Testing for “rebound tenderness” in patients with suspected peritonitis is not recommended because it
causes significant pain and is usually not necessary to establish the diagnosis.
 A digital rectal examination should be performed in most patients with acute abdominal pain to
evaluate for tenderness or fluctuance that suggests a perirectal abscess and to assess the stool for signs
of overt or occult blood.
 Women with lower abdominal pain should have a pelvic examination by a skilled examiner to evaluate
for gynecologic pathology. Some specific and dramatic findings point to particular diagnoses.
 Examination also should include the inguinal and femoral canals, umbilicus, and surgical scars for
evidence of incarcerating hernias.

16. Percussion of Abdomen
(1) Shifting dullness:- Presence of free fluid in the peritoneal cavity can be determined by eliciting
shifting dullness. When the patient lies on his back the fluid gravitates down to the flanks and the
intestine floats on the centre of the abdomen which will therefore be resonant and the flanks dull.
Percussion should be commenced from the centre of the abdomen and is carried down to one flank. At
the point where dullness starts the finger is kept in its position and the patient is asked to turn to the
opposite side. That particular area is again percussed after waiting for a few minutes to allow the fluid to
gravitate down. Now the note will be resonant to make the shifting dullness test positive.
(2) Fallacy:- Abnormal retention of enema may lead to distension of the intestine. In these cases shifting
dullness test may be positive due to shifting of fluid inside the descending or ascending colon as the
patient is rolled over. So the test becomes positive without the presence of free fluid inside the peritoneal
cavity.
(3) Fluid thrill:- The percussion note will be resonant in the upper part of the mid-axillary line. At the
upper border of the liver the resonant note is replaced by the dull note. If the liver dullness is replaced
by a resonant note it indicates presence of free gas under the diaphragm as occurs in perforation of the
gastrointestinal tract. It must be remembered that absence of this sign does not exclude perforation since
this sign will only be present when there is sufficient leakage of air.

17. Auscultation of Abdomen
 Increased high-pitch tinkling bowel sounds indicate fluid obstruction; this occurs because of fluid
movement within the dilated bowel lumen.
 Absent bowel sounds suggest peritonitis.
 In an obstructed patient, absent bowel sounds suggest strangulation, ischaemia or ileus.
 It is essential that the hernial orifices be examined if intestinal obstruction is suspected.
 An abdomen that is quiet except for infrequent squeaks or tinkles suggests peritonitis or ileus.
 Loud peristaltic rushes that occur in synchrony with abdominal pain suggest small bowel
obstruction.

18. Routine laboratory and radiologic studies
 Complete blood count
 Serum electrolytes
 Coagulation parameters
 Serum glucose
 Biochemical tests of liver, kidney, and pancreatic function
 Chest x-ray to determine the presence of diseases involving heart, lung, mediastinum, and
pleura.
 Electrocardiogram is helpful to exclude referred pain from cardiac disease
 Plain abdominal radiographs to evaluate bowel displacement, intestinal distention, fluid and
gas pattern, free peritoneal air, liver size, and abdominal calcifications (e.g., gallstones,
renal stones, chronic pancreatitis).

19. Special Investigations
 These include abdominal ultrasonography (to visualize biliary ducts, gallbladder, liver,
pancreas, and kidneys)
 CT to identify masses, abscesses, evidence of inflammation (bowel wall thickening,
mesenteric “stranding,” lymphadenopathy, appendicitis), aortic aneurysm
 Barium contrast radiographs (barium swallow, upper GI series, small-bowel follow-
through, barium enema)
 Upper GI endoscopy, sigmoidoscopy, or colonoscopy
 Cholangiography (endoscopic, percutaneous, or via MRI)
 Angiography (direct or via CT or MRI)
 Radionuclide scanning:- In selected cases,
 Percutaneous biopsy
 Laparoscopy
 Exploratory laparotomy may be required

20. Management
(1) Conservative
 Lifestyle Modification
• Weight loss
• smoking cessation
• alcohol reduction
• exercise
• modified diet (low fat/ high fibre)
 MDT:- Physio/ OT/ Nutrition Team/ Dietician/ Specialist Nurses, other
specialties

21. Medical
 Secure airway
 Oxygen 15L
 Fluid Balance:- large bore, IVF, catheter, bloods, Xmatch
 Resuscitation & analgesia (opioid IV)
 Full monitoring (including Urine Output)
 Low threshold in seeking senior help
 Blood Transfusion
 IV Antibiotics
 Thromboprophylaxis?
 Anti-emetics/ NG aspiration
 Supportive nutrition/ NBM
 Therapeutic procedures:- ERCP

22. Surgical
 Emergency Laparotomy or Watch+Wait?
• Monitor Pain
• Serial CTs
• Unstable?
• E.g.
• Appendicectomy
• Cholecystectomy
• Defunctioning Ileostomy
• Abscess drainage/ Necrosectomy