Abdominal pain
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Transcript of Abdominal pain
Abdominal pain Ahmed khaled elgizawy N0 : 35 Round : 1
Anatomic background Parietal peritoneum
clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) .
Visceral peritoneum is the continuation of the
parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).
11 2 34 5 67 8
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1 – right hypochondrium2- epigastric 3- left hypochondrium4- Right lumbar5- umbilical 6- left hypochondrium7- right iliac 8-hypogastric9- left iliac
DEFINITION OF PAIN It is an unpleasant sensation of
varying intensity.
Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.
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Mechanical trauma to the tissue .
Excess heat or cold .
STIMULANTS
Chemical damage.
Radiation damage .
Inadequate blood flow.
Intra-thoracic organs
Abdominal Extra-abdominal
Abdominal wall+
Intra-peritoneal organsRetro-peritoneal organsPelvic organs
Systemic dysfunction
Diabetes ,tabes dorsalis
porphyria
Functional abdominal
pain
Types of abdominal pain
1
Visceral pain is primitive and therefore related to
embryologic development .
Somatic pain is entirely different from visceral pain
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Visceral painVisceral pain1- Receptor1- Receptor
( Visceral peritoneum )
2 - Stimulus
Pat. Experienced pain by traction ,distention & spasm
The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction
3 - Mediation3 - Mediation
Autonomic nervous System Interpreted at the thalamic level of the brain
4- Specificity4- Specificity
Vague , often dull , poorly described & associated with nausea & vomiting
5- Localization5- Localization
Is poor & the pat. Placing the entire hand over the involved region
Somatic pain
1- Receptor
Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves
P/ peritoneum
Somatic pain
2- Stimulus
Pat. experienced pain by
TouchPressureHeatInflammation
Somatic pain
3- Mediation
Central nervous system
&
Interpreted at a specific cortical location
Somatic pain
4- Specificity
Precisely described as
Cutting
Somatic pain
5- Localization
The pain is localized with great accuracy by the patient , who can often point to the site
with one fingerone finger
Referred pain
Pain felt at a site other than where the cause is situated. An example is
the pain from the pancreas, which is felt in
the back. Pain in internal organs is often referred to sites distant
from them.
Analysis of painneed
DATA COLLECTION
1 2 3
History Physical exam. Lab.inv.
apply
youryour medical knowledge***
The history of pain betrays the diagnosis
History of pain
SiteMode of onsetNature of painSeverityRadiationDurationFactors influencing
the clinical manifestation
Site of pain & radiation
Kidney
Stomach & duodenumGB Pancreas
Kidney
Small bowel
Caecum & rp.structure
T. Colon bladder uterus & adnexae
Sig. colon
App. & Caecum
Radiation of the pain
GB. Pain radiates through to the back & to
the right , to reach the tip of the shoulder blade
Radiation indicates source of the pain & also the extent of the diseaseLower abdominal pain rarely radiate
The structures in pelvis may radiate to the lower
back or perineum
Small bowel pain does not usually radiate but
may move when somatic as well as visceral nerves
become irritated
Stomach & duodenal pain goes
strait through the back
Pancreatic pain
tends to go
through to the back but to the left
Kidney pain
may radiate
down into the groin
Mode of onset
Sudden onset[The patient can tell you exactly when the pain started ] ]
The pain that start suddenly has a mechanical basis
Some thing has been
RupturedTwistedOccluded
Mode of onset
Gradual Onset
( The pat. Usually responds vaguely to questions about time of onset )
Non mechanical or chronic process
Nature of pain
Two Large Categories
(1)
Conditions associated with obstruction of a muscular conducting tube
( Small bowel , Ureter , Biliary )
(2)
Conditions associated with inflammation
( Mild & Localized Response or
Severe , Generalized Response )
Obstruction
Suddenprolonged
Distention of the viscus( constant stretching pain )
Colic pain = visceral pain
Three Types
( 1 ) Biliary System = ( foregut )
Foregut pain is experienced in the epigastrium
1
(2) Small Intestine = ( midgut )
Pain is experienced in the periumbilical region
(3) Renal system = ( retroperitoneal )
Pain is felt in the flank & radiates to the groin
Important features of colic pain
I. Pat . Is often restless & agitated during exacerbations.
II. Pat. Does not experience a totally pain –free interlude.
III. Colic pain is an intermittent pain .
IV. Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal
layers ) V. Failing to demonstrate guarding , tenderness ? ????
Inflammation2Intra-abdominal inflammation is peritonitis
Peritonitis causes somatic pain
Peritonitis
LocalizedGeneralized
Inflammation2Intra-abdominal inflammation is peritonitis
Peritonitis causes somatic pain
Contamination
BY
ChemicalsBacteriaTraumaForeign body
Important features of somatic pain
I. Pat. Laying quite in bed . ( movement is limited )
II. Examination may demonstrate guarding , tenderness .
III. The pain is localized over the inflamed organ .
IV. Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .
Ischemic pain
Is a somatic pain
Occlusion of blood supply
cause
Tissue HypoxiaTissue Hypoxia
With metabolic With metabolic changes changes
Necrosis
After 6-12 h
So how do we organize this?•Location•Acute v. chronic•Surgical v. nonsurgical
Localizing pain -- RUQ
•Hepatitis•Cholecystitis•Cholangitis•RLL pneumonia•Subdiaphragmatic
abscess
Localizing pain -- LUQ
•Splenic infarct•Splenic abscess•Gastritis/PUD
Localizing pain -- RLQ
•Appendicitis•Inguinal hernia•Nephrolithiasis•IBD•Salpingitis•Ectopic pregnancy•Ovarian pathology
Localizing pain -- LLQ
•Diverticulitis•Inguinal hernia•Nephrolithiasis•IBD•Salpingitis•Ectopic pregnancy•Ovarian pathology
Localizing pain -- epigastric
•PUD•Gastritis•Pancreatitis•GERD•Cardiac (MI,
pericarditis, etc)
Localizing pain -- periumbilical
•Pancreatitis•Obstruction•Early appendicitis•Small bowel
pathology•Gastroenteritis
Localizing pain -- pelvic
•UTI•Prostatitis•Bladder outlet
obstruction•PID•Uterine pathology
Localizing pain -- diffuse
•Gastroenteritis•Ischemia•Obstruction•DKA•IBS•Others
▫FMF▫AIP▫Vitamin D
deficiency▫Adrenal
insufficiency
Acute abdominal pain
•Generally present for less than a couple weeks▫Usually days to hours old▫Don’t forget about the chronic pain that
has acutely worsened•More immediate attention is required
Acute abdominal pain• Surgical
▫ Appendicitis▫ Cholecystitis▫ Bowel obstruction▫ Acute mesenteric
ischemia▫ Perforation▫ Trauma▫ Peritonitis
• Nonsurgical▫ Cholangitis▫ Pancreatitis▫ Nonabdominal causes▫ Choledocholithiasis▫ Diverticulitis▫ PUD/-itis▫ gastroenteritis
Surgical abdomen
•This is the first thing to be considered in acute abdominal pain▫Early identification is a must as prognosis
worsens rapidly with delay in treatment•Important to get surgeons involved early
if this is even mildly suspected•This is a clinical diagnosis
Surgical abdomen
•Presentation is usually bad▫Fevers, tachycardia, hypotension▫VERY tender abdomen, possibly rigid
•Presentation can vary with other demographic and medical factors▫Advanced age▫Immunosuppression
Surgical abdomen
•Peritonitis▫Often signals an intraabdominal
catastrophe Perforation, big abscess, severe bleeding
▫Patient usually appears ill▫Exam findings
Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed
Surgical abdomen•Obstruction
▫May be acute or acute on chronic▫Symptoms include persistent vomiting,
abdominal distention (or not), pain▫Exam findings depend on level of
obstruction (proximal v. distal) Distal – distention, tympany, absent or high-
pitched bowel sounds Proximal – similar, but may not see distention
and tympany
Surgical abdomen
•Ischemia▫Mesenteric ischemia usually seen in
patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons
▫Symptoms include pain OUT OF PROPORTION TO EXAM
▫Exam findings Severe tenderness to minimal palpation,
unstable vital signs, and a very uncomfortable patient
Surgical abdomen
•Work-up▫Start with stat labs▫Surgical abdominal series (plain films)▫Consider stat CT if readily available
•Sometimes patients go straight to surgery as initial step
•Again, get surgeons involved early for guidance and early intervention
Chronic abdominal pain
•Generally present for months to years•Generally not immediately life
threatening•Outpatient work-up is prudent
Than
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