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Abdominal Pain
This document discusses the evaluation and differential diagnosis of abdominal pain. It notes that history and physical examination are important for diagnosis as subtle symptoms can indicate serious conditions. The document outlines key components of a patient's history and details the examination. It describes various causes of abdominal pain classified by location, mechanism, and onset. Radiological investigations that may assist diagnosis are also summarized. The document stresses that the severity of pain does not always correlate with the severity of the underlying condition.
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Abdominal Pain
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- 2. • Abdominal painis the pain that occurs between chest and pelvic regions. • It is one of the most common reasons for OPD and emergency visits.
- 4. • History andExamination comprise an imperative part of diagnosing a patient with abdominal pain, as the most catastrophic events may be forecast by the subtlest of symptoms. • We should also remember that pain severity does not necessarily correlate with the severity of the underlying condition.
- 5. Key Components ofPatient’s History (Table 12-1 20th Harrison’s Principle of Internal Medicine Pg 81) Age Time of onset of pain Mode of onset of pain Characteristics of pain Duration of symptoms Location of pain Sites of radiation Associated symptoms Nausea, Emesis, Anorexia Changes in Urinary habits Changes in Bowel habits: Diarrhoea, Constipation Menstrual History in females
- 6. → Inflammation ofparietal peritoneum → Mechanical Obstruction by hollow viscera → Vascular disturbances → Abdominal wall → Distention of visceral surfaces → Inflammation
- 7. • Pain issteady and aching in character, located directly over the inflamed area. • The intensity of the pain is dependent on type and amount of material to which the peritoneal surfaces are exposed in a given time period. • The pain of peritoneal inflammation is invariably accentuated by pressure or changes in tension of peritoneum, whether produced by palpation or by movements like coughing, sneezing.
- 8. Bacterial contamination oPerforatedappendix or other perforated viscus oPelvic inflammatory disease Chemical irritation oPerforated ulcer oPancreatitis oMittelschmerz
- 9. • It elicitsintermittent or colicky abdominal pain, which is not well localized. • Obstruction of the urinary bladder : usually causes dull, low intensity pain in the suprapubic region • Obstruction of the small or large intestine: causes poorly localized intermittent pain
- 10. • Obstruction ofthe biliary tree : Sudden distention produces steady pain. Acute gall bladder distention pain radiates to tip of right scapula and right posterior region of thorax. Distention of the common bile duct often causes epigastric pain that may radiate to the upper lumbar region. Carcinoma of the head of the pancreas, may cause no pain or only a mild aching sensation in the epigastrium or right upper quadrant.
- 11. • Embolism orthrombosis of the superior mesenteric artery or impending rupture of an abdominal aortic aneurysm, can be associated with diffuse, severe pain. • Pain is mild continuous or of cramping diffuse type for 2 or 3 days before bleed, in cases of mesenteric artery occlusion. • Abdominal pain with radiation to the sacral region, flank, or genitalia should always signal the possible presence of a rupturing abdominal aortic aneurysm, it persists over a period of several days before rupture and collapse occur.
- 12. • Pain arisingfrom the abdominal wall is usually constant and aching. • Movement, prolonged standing, and pressure accentuate the discomfort and associated muscle spasm. • Some important causes: Traction of mesentery Trauma or infection of muscles
- 13. It occurs byhemorrhage , can be of hepatic or renal capsules. Appendicitis Typhoid fever Neutropenic enterocolitis or “typhlitis”
- 14. Pain referred fromextra abdominal surfaces • Pain can referred to the abdomen from the thorax, spine, or genitalia. • Abdominal disease may cause referred pain elsewhere, For example: acute cholecystitis or perforated ulcer. • A most important, yet often forgotten, dictum is that the possibility of intrathoracic disease must be considered in every patient with abdominal pain, especially if the pain is in the upper abdomen.
- 15. • Cardiothoracic ∆ Acutemyocardial infarction ∆ Myocarditis, endocarditis, pericarditis ∆ Congestive heart failure ∆ Pneumonia (especially lower lobes) ∆ Pulmonary embolus ∆ Pneumothorax ∆ Empyema ∆ Esophageal disease, including spasm, rupture, or inflammation • Genitalia : Torsion of the testis
- 16. ∞ Whenever thecause of abdominal pain is obscure, a metabolic origin always must be considered. ∞ Hyperlipidemia may be accompanied by pancreatitis. ∞ C’1 esterase deficiency associated with angioneurotic edema can cause severe abdominal pain ∞ Abdominal pain is also the hallmark of familial Mediterranean fever. ∞ Pain of porphyria is similar to intestinal obstruction, because severe hyperperistalsis is common in them. ∞ The pain of uremia or diabetes is nonspecific, frequently shifts in location and intensity. ∞ Hyperparathyroidism ∞ Acute adrenal insufficiency ∞ If prompt correction of the metabolic abnormality does not lead to resolution of abdominal pain then an underlying organic problem should be suspected.
- 17. Immunocompromised • It includesthose who have undergone organ transplantation; receiving immunosuppressive treatments for autoimmune diseases, chemotherapy, or glucocorticoids; who have AIDS; and who are very old. • In these circumstances, normal physiologic responses may be absent or masked. • Certain unusual infections may cause abdominal pain where the etiologic agents include cytomegalovirus, mycobacteria, protozoa, and fungi.
- 18. • Diseases thatinjure sensory nerves may cause causalgic pain. • It has a burning character and is usually limited to the distribution of a given peripheral nerve. • Pain arising from spinal nerves or roots comes and goes suddenly and is of a lancinating type. • It is not associated with food intake, abdominal distention, or changes in respiration. • Causes: Herpes zoster Tabes dorsalis Radiculitis from infection or arthritis Spinal cord or nerve root compression Functional disorders Psychiatric disorders
- 19. Irritable bowelsyndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits. The episodes of abdominal pain may be brought on by stress, and the pain varies considerably in type and location. Localized tenderness and muscle spasm are absent.
- 20. Toxic causes • Inchronic lead poisoning , pain is similar to intestinal obstruction, because severe hyperperistalsis is common in both. • Insect or animal envenomation. • Black widow spider bites produce intense pain and rigidity of the abdominal muscles and back. • Snake bites
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- 22. Differential Diagnosis ofAbdominal Pain by Location
- 23. In some cases,abdominal pain can be diffuse nonlocalized
- 24. TIME SEVERITY A- Pain subsides spontaneously B-Colicky in nature, pain progresses and remits over time C- Pain is progressive in nature D-Catastrophic onset
- 25. Stereotypes of PainOnset 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
- 28. Age Courseof pain- Time and Mode of onset. Characteristics of pain Radiation of pain Factors that exacerbate or improve symptoms, like food intake, position change. Associated symptoms including fever, chills weight loss, nausea, vomiting, anorexia Change in sleep, appetite, bowel, bladder Past medical and surgical history Family history Alcohol intake Intake of medications Menstrual and contraceptive history in women
- 29. • Inspection forfacies, position in bed, respiratory activity, can provide valuable clues. • Palpation of abdomen for Tenderness, masses, peritoneal signs and organomegaly. • Never elicit rebound tenderness by sudden release of a deeply palpating hand. • Asking patient to cough will elicit true rebound tenderness without placing hand on abdomen
- 30. • Percussion forquantity of gas, hard or soft masses, and sizes of certain organs, such as the liver and the spleen. • Auscultation of the abdomen for bowel sounds. • Rectal examination. • Pelvic Examination in women with lower abdominal pain. • Measurement of blood pressure, pulse, and temperature. • Examination of the eyes and skin for jaundice. • Auscultation and percussion of the chest
- 31. • Abdominal signscan be absent in cases of pelvic peritonitis. • Careful pelvic and rectal examinations are mandatory in patients with abdominal pain. • Tenderness in such examination is a sign of operative indication: » Perforated appendicitis » Diverticulitis » Twisted ovarian cyst
- 32. • Peristaltic sound Catastrophes like 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 sounds lose characteristics of borborygmi and become weak and absent Sudden Chemical peritonitis = silent abdomen
- 33. • Investigations arevaluable but they rarely establish diagnosis. • A white blood cell count >20,000/μL may be observed with perforation of a viscus. • But, pancreatitis, acute cholecystitis, pelvic inflammatory disease, and intestinal infarction may also be associated with marked leukocytosis. • A diagnosis of anemia may be more helpful than the white blood cell count, with relevant history.
- 34. • Urinary analysisis done to rule out: Renal disease Diabetes Urinary infection • Serum amylase levels can increase in: Pancreatitis Perforated ulcer Strangulating intestinal obstruction Acute cholecystitis • Other important tests: Liver function tests Blood urea nitrogen Glucose
- 35. • Radiographs ofabdomen can show perforated ulcers, and other conditions. • Water-soluble contrast or barium studies can demonstrate partial upper GI obstruction. • If there is any question of obstruction of the colon, oral administration of barium sulfate should be avoided. • In suspected colonic obstruction (with no perforation) – contrast enema may be diagnostic. • In the absence of trauma, peritoneal lavage has been replaced as a diagnostic tool by CT scanning and laparoscopy.
- 37. • Ultrasound: Presenceof gallstones, kidney stones Gall bladder Edema Abscesses Ascites Enlarged ovary Tubal pregnancy Enlarged pancreas • Laparoscopy: o Ovarian cysts o Tubal pregnancies o Salpingitis o Acute appendicitis
- 38. • Radio-isotopic hepatobiliaryiminodiacetic acid scans (HIDAs) may help to differentiate acute cholecystitis or biliary colic from acute pancreatitis. • A CT scan may demonstrate an enlarged pancreas ruptured spleen thickened colonic or appendiceal wall streaking of the mesocolon or mesoappendix characteristic of diverticulitis or appendicitis.
- 39. • Abdomen isdivided into 9 regions and 4 quadrants, and differential diagnosis of pain is studied by its location. • Abdominal pain generating in the abdomen can be due to various mechanisms like parietal peritoneum inflammation, or obstruction. • It may be referred from extra abdominal regions like thorax, spine and genitalia. • Metabolic causes are also to be considered. • Acute abdominal pain may subside spontaneously, can be progressive in nature, it can be colicky, or sometimes have a catastrophic onset. • Conditions like ruptured aneurysm , ruptured ectopic should be diagnosed and handled efficiently to save lives. • History and physical examination is imperative for diagnosis of abdominal pain. • Certain lab investigations and USG are sometimes helpful in arriving at final diagnosis. • It is important to remember that pain severity does not necessarily correlate with the severity of the underlying condition.
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Editor's Notes
- #4 Abdomen is divided into 4 quadrants by two imaginary lines , one horizontal and one vertical that intersect at the umbilicus. Abdomen is divided into 9 regions by two vertical mid clavicular lines (mid point of each clavicle), upper horizontal line is subcostal line taken from the inferior part of lowest costal cartilages. The lower horizontal line is the intertubercular line connecting the tubercles of pelvis.
- #8 For example, the sudden release of a small quantity of sterile acidic gastric juice into the peritoneal cavity causes much more pain than the same amount of grossly contaminated neutral feces. Enzymatically active pancreatic juice incites more pain and inflammation than does the same amount of sterile bile containing no potent enzymes. Blood is normally only a mild irritant and the response to urine is also typically bland, so exposure of blood and urine to the peritoneal cavity may go unnoticed unless it is sudden and massive. Bacterial contamination, such as may occur with pelvic inflammatory disease or perforated distal intestine, causes low-intensity pain until multiplication causes a significant amount of inflammatory mediators to be released. Patients with perforated upper gastrointestinal ulcers may present entirely differently depending on how quickly gastric juices enter the peritoneal cavity, and its pH. Thus, the rate at which any inflammatory material irritates the peritoneum is important. Spasm over a perforated retrocecal appendix or perforation into the lesser peritoneal sac may be minimal or absent because of the protective effect of overlying viscera
- #10 In obstruction of the small intestine, pain is poorly localized, intermittent periumbilical, or supraumbilical. The colicky pain of colonic obstruction is of lesser intensity, is commonly located in the infraumbilical area, and may often radiate to the lumbar region Restlessness, without specific complaint of pain, may be the only sign of a distended bladder in an obtunded patient. In contrast, acute obstruction of the intravesicular portion of the ureter is characterized by severe suprapubic and flank pain that radiates to the penis, scrotum, or inner aspect of the upper thigh. Obstruction of the ureteropelvic junction manifests as pain near the costovertebral angle, whereas obstruction of the remainder of the ureter is associated with flank pain that often extends into the same side of the abdomen.
- #11 The pain of distention of the pancreatic ducts is similar to that described for distention of the common bile duct but, in addition, is very frequently accentuated by recumbency and relieved by the upright position
- #12 The early, seemingly insignificant discomfort is caused by hyperperistalsis rather than peritoneal inflammation. Indeed, absence of tenderness and rigidity in the presence of continuous, diffuse pain (e.g., “pain out of proportion to physical findings”) in a patient likely to have vascular disease is quite characteristic of occlusion of the superior mesenteric artery.
- #15 apparent abdominal muscle spasm caused by referred pain will diminish during the inspiratory phase of respiration, whereas it persists throughout both respiratory phases if it is of abdominal origin. Palpation over the area of referred pain in the abdomen also does not usually accentuate the pain and, in many instances, actually seems to relieve it.
- #16 Pain referred to the abdomen from the testes or seminal vesicles is generally accentuated by the slightest pressure on either of these organs. The abdominal discomfort experienced is of dull, aching character and is poorly localized.
- #17 Family Mediterranean fever
- #18 Splenic abscesses due to Candida or Salmonella infection should also be considered, especially when evaluating patients with left upper quadrant or left flank pain. Acalculous cholecystitis may be observed in immunocompromised patients or those with AIDS, where it is often associated with cryptosporidiosis or cytomegalovirus infection. Typhlitis is often identified as a cause of abdominal pain and fever in some patients with bone marrow suppression due to chemotherapy.
- #19 a constant usually burning pain that results from injury to a peripheral nerve and is often considered a type of complex regional pain syndrome. Other Words from causalgia.
- #20 The causes of IBS or related functional disorders are not yet fully understood.
- #25 Many causes of abdominal pain subside spontaneously with time like gastroenteritis- A Sometimes it is colicky in nature, i.e. pain progresses and remits over time, like intestinal, renal, and biliary pain- B Commonly it is of progressive nature like in appendicitis or diverticulitis- C Certain conditions can have a catastrophic onset like ruptured abdominal aortic aneurysm- D
- #30 Blumberg's sign (also referred to as rebound tenderness or the Shyotkin-Blumberg sign) is a clinical sign in which there is pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.) It is indicative of peritonitis.
- #34 Laboratory examinations may be valuable in assessing the patient with abdominal pain, yet, with few exceptions, they rarely establish a diagnosis.
- #36 If there is any question of obstruction of the colon, oral administration of barium sulfate should be avoided
- #38 Laparoscopy has a particular advantage over imaging in that the underlying etiologic condition can often be definitively addressed