The document outlines an approach to diagnosing abdominal pain, distinguishing between acute and chronic cases. It includes detailed criteria for assessing pain characteristics, historical context, and performing physical examinations to aid in differential diagnosis. Additionally, it compares various intra- and extra-abdominal causes of pain across different patient demographics.

1. Approach to pain abdomen
Dr. Ankita Singh
Assistant Professor

2. Objectives
• Characteristics of pain
• Pain abdomen
– Acute vs. chronic
• Localization
– Differential diagnosis
– Diagnosis & Management

3. PAIN : on history
• Time of onset
• Mode of onset
• Duration
• Site- Shifting/ Radiating/ Referred
• Character
– Colicky/ Burning/ Agonizing/ Throbbing /Aching
– Change in character- position/ pressure/ food/
worse/ relief

4. PAIN : on history
• Association with
– Vomiting/ change in bowel habit/ jaundice/
micturition etc.
– Change in appetite/weight
– Constitutional symptoms
• Menstrual history
• Past history
– H/O recurrent attacks/ previous surgery

5. PAIN : on examination
• General appearance & vitals
– Abdominal facies/ Facies Hippocratica/ facies of
dehydration/ pale/ bluish discoloration/ jaundice/
gasping for air
– temperature
• Attitude/ decubitus
• Per abdominal examination on inspection
– Contour of abdomen
– Respiratory movements/ peristalsis/pulsations
– Signs of inflammation/ infection/ bleeding

6. PAIN : on examination
• Per abdominal examination on palpation:
– Hyperasthesia- e.g. Boas sign, Sherren’s triangle
– Tenderness- Pointing Test
• Murphy’s sign
• Mc Burney’s tenderness & appendicular tenderness
• Bapat/ bed shaking test
*Spread of tenderness
*Differentiation from Thoracic disease

7. PAIN : on examination
• Per abdominal examination on palpation:
– Rebound Tenderness
• AKA Blumberg’s/ Release sign
• Rovsing’s sign
• Cope’s Psoas Test
– Any associated
• muscular rigidity vs. guarding
• Distension
• Lump/ hernial sites

8. Acute vs. Chronic pain abdomen
• 'Acute abdomen' means
– the patient complains of an acute attack of
abdominal pain
– that may occur suddenly or gradually over a
period of several hours and
– presents a symptom complex which suggests a
disease that possibly threatens life and demands
an immediate or urgent diagnosis for early
treatment

9. Differentials: Acute Abdomen
• Extra-abdominal causes:
– Parietal wall- superficial cellulitis of the abdominal wall,
gas gangrene of the abdominal wall, abscess of the
abdominal wall, rupture of rectus abdominis muscle
– Thoracic conditions- diaphragmatic pleurisy, lobar
pneumonia, spontaneous pneumothorax, pericarditis,
angina pectoris, coronary thrombosis etc.
– Retro-peritoneal conditions- uremia, pyelitis, Dietl's
crisis, retroperitoneal lymphangitis and lymphadenitis,
leaking aneurysm of the aorta, dissecting aneurysm of the
aorta etc.

10. Differentials: Acute Abdomen
• Extra-abdominal causes:
– Diseases of the spine, spinal cord and intercostal
nerves- Pott's disease, acute osteomyelitis of lower dorsal
or lumbar vertebrae, gastric crisis in Tabes Dorsalis, herpes
zoster of lower intercostal nerves and intercostal neuralgia.
– General diseases- malaria, typhoid fever, porphyria,
diabetic crisis, sickle cell anaemia, haemophilia, purpura,
small pox, etc.

11. Differentials: Acute Abdomen
• Intra-abdominal causes:
– Inflammation- acute appendicitis, acute cholecystitis, acute
pancreatitis, acute diverticulitis, acute ulcerative colitis, acute
regional ileitis, acute salpingitis, acute pneumococcal peritonitis,
acute non-specific mesenteric lymphadenitis, amoebic liver
abscess, subdiaphragmatic abscess.
– Perforation of- peptic ulcer, typhoid ulcer, diverticular disease,
ulcerative colitis etc.
– Acute intestinal obstruction- mechanical/toxic/neurogenic/
vascular
– Haemorrhage- rupture of ectopic gestation, ruptured Lutein
cyst, spontaneous rupture of malarial spleen, Rupture or leaking
aortic aneurysm, aortic dissecting aneurysm.

12. Differentials: Acute Abdomen
• Intra-abdominal causes:
– Torsion of pedicle- twisted ovarian cyst, spleen
– Colics- (i) biliary, (ii) ureteric, (iii) appendicular and (iv)
intestinal

13. Differentials: Acute Abdomen
• The common causes in
– Children:
• Acute appendicitis; Intussusception; Intestinal
obstruction by round worms, congenital band or by
bands including Meckel's diverticula; Acute nonspecific
mcsenteric lymphadenitis; Meckel's diverticulitis;
Primary peritonitis.
– Females:
• Ruptured ectopic gestation; Ruptured lutein cyst;
Twisted ovarian cyst; Acute salpingitis; Tubo-ovarian
abscess; Torsion or degeneration of a uterine fibroid.

14. Differentials: Chronic Abdomen
• Peptic ulcers
– Gastric vs. duodenal ulcer
• Pyloric stenosis
• Carcinoma stomach
• Hiatus hernia
• Chronic cholecystitis & cholelithiasis
• CBD stones
• Chronic pancreatitis
• Carcinoma pancreas

15. Differentials: Chronic Abdomen
• Chronic appendicitis
• Crohn’s Disease
• Abdominal tuberculosis
– Intestinal, mesentric
• Diverticulitis
• Hirschsprung’s disease/ primary megacolon
• Ulcerative colitis
• Ischemic colitis
• Carcinoma colon

24. Thank you