Acute Abdominal Pain

Dr. Carlos Azañero Inope

ABDOMINAL PAIN IABDOMINAL PAIN I



EvaluationEvaluation ofof thethe patientpatient withwith acuteacute abdominal abdominal painpain isis oneone ofofthethe mostmost challengingchallenging aspectsaspects ofof emergencyemergency medicine.medicine.

ACUTE ABDOMINAL PAINACUTE ABDOMINAL PAIN



Abdominal Abdominal painpain isis thethepresentingpresenting complaintcomplaint in as in as manymany as 10% as 10% ofofemergencyemergency departamentdepartamentpatientspatients..



ThoughThough thethe etiologyetiology ofof painpain isisinitiallyinitially undeterminedundetermined in as 30in as 30--40% 40% ofof patientspatients, , recognitionrecognition ofofsurgicalsurgical oror lifelife--threateningthreateningcauses causes isis mostmost importantimportant thanthanestablishingestablishing a a firmfirm diagnosis.diagnosis.


ANATOMIC ESSENTIALSANATOMIC ESSENTIALS

Abdominal Abdominal painpain isis typicallytypically derivedderivedfromfrom oneone oror more more threethree distinctdistinctpainpain pathwayspathways: visceral, parietal : visceral, parietal ((somaticsomatic) ) andand referredreferred..


Visceral Abdominal Visceral Abdominal PainPain

Visceral Abdominal Visceral Abdominal PainPain isisusuallyusually causedcaused by by distentiondistention ofofhollowhollow organsorgans oror capsular capsular stretchingstretching ofof solidsolid organsorgans..


LessLess commonlycommonly, , itit si si causedcaused by isquemia by isquemia oror inflammationinflammation..

TheThe tissuetissue congestioncongestion sensitizessensitizes nervenerve endingsendings ofof visceral visceral painpain fibersfibersandand lowerslowers thethe thresholdthreshold forfor stimulusstimulus..



IfIf thethe involvedinvolved organorgan isis affectedaffectedby by peristalsisperistalsis, , thethe painpain isis oftenoftendescribeddescribed as as intermittentintermittent, , crampycrampy, , oror colickycolicky in in naturenature..



TheThe visceral visceral painpain fibersfibers are are bilateral, bilateral, unmyelinatedunmyelinated, , andand enterenterthethe spinalspinal cordcord at at multiplemultiple levelslevels..


TheThe visecralvisecral abdominal abdominal painpain isis usuallyusually dulldull, , poorlypoorly localizedlocalized andandexperiencedexperienced in in thethe midlinemidline....


Parietal (Parietal (SomaticSomatic) ) Abdominal Abdominal PainPain

ResultsResults fromfrom ischemiaischemia, , inflammationinflammation, , oror stretchingstretching ofof thethe parietal parietal peritoneumperitoneum ..



MyelinatedMyelinated afferentafferent fibersfibers transmittransmitthethe painfulpainful stimulusstimulus toto specificspecific dorsal dorsal rootroot gangliaganglia onon thethe samesame sideside andanddermatomaldermatomal levellevel as as thethe originorigin ofof thethepainpain..


TheThe parietal parietal painpain, in , in contrastcontrast totovisceral visceral painpain, , oftenoften can be can be localizedlocalized totothethe regionregion ofof thethe painfulpainful stimulusstimulus..

ThisThis painpain isis typicallytypically sharpsharp, , knifeknife--likelikeandand constantconstant; ; coughingcoughing andand movingmovingare are likelylikely toto aggravateaggravate itit....



TheThe classicclassic presentationpresentation ofofappendicitisappendicitis involvesinvolves bothbothvisceral visceral andand parietal parietal painpain..

TheThe painpain ofof earlyearly presentationpresentation isis oftenoftenperiumbilicalperiumbilical (visceral ) (visceral ) butbut localizeslocalizestoto thethe rightright lowerlower quadrantquadrant ( RLQ) ( RLQ) whenwhen thethe inflammationinflammation extendsextends totothethe peritoneumperitoneum (parietal).(parietal).


ReferredReferred PainPain

IsIs defineddefined as as painpain feltfelt at a at a distancedistance fromfrom thethe diseaseddiseasedorganorgan. . ItIt resultsresults fromfromsharedshared central central pathwayspathways forforafferentafferent neuronsneurons fromfromdiferentdiferent locationslocations..


HISTORYHISTORY

1. 1. WhereWhere isis youryour painpain? Has ? Has ititalwaysalways beenbeen therethere??

KeepKeep in in mindmind thatthat thethe locationlocation ofofabdominal abdominal painpain may may varyvary withwith time, time, especiallyespecially as as thethe underlyingunderlying diseasediseaseevolvesevolves andand thethe painpain progressesprogresses fromfromvisceral visceral toto somaticsomatic..


HISTORYHISTORY

2. 2. DoesDoes thethe painpain radiateradiate anywhereanywhere??

TheThe painpain ofof biliarybiliary coliccolic may may radiateradiate totothethe rightright infraescapularinfraescapular regionregion ..

TheThe painpain ofof pancreatitis pancreatitis toto midbackmidback ..

PainPain thatthat radiatesradiates toto thethe flankflank ororgenitalsgenitals may may representrepresent a a kidneykidney stonestoneoror rupturerupture AAA.AAA.


HISTORYHISTORY

3. How 3. How diddid thethe painpain beginbegin ((suddensuddenvsvs gradual gradual onsetonset) ? How long ) ? How long havehaveyouyou hadhad thethe painpain??

SuddenSudden oror abruptabrupt onsetonset ofofabdominal abdominal painpain oftenoften indicatesindicatesa a seriousserious underlyingunderlying disorderdisorder..

RuptureRupture AAA .AAA .

PerforatedPerforated UlcerUlcer ..

EctopyEctopy PregnancyPregnancy ..


HISTORYHISTORY

3. How 3. How diddid thethe painpain beginbegin ((suddensuddenvsvs gradual gradual onsetonset) ? How long ) ? How long havehaveyouyou hadhad thethe painpain??

PainPain forfor > 6 > 6 hourshours oror < 48 < 48 hourshoursdurationduration, , oror painpain thatthat isis steadilysteadilyincreasingincreasing in in intensityintensity isis more more likelylikelytoto requirerequire surgicalsurgical interventionintervention ..


HISTORYHISTORY

4. 4. WhatWhat werewere youyou doingdoing thethe painpainbeganbegan? ?

SevereSevere PainPain thatthat awakensawakens a a patientpatient fromfrom sleepsleep : : PERFORATION OR ISCHEMIA PERFORATION OR ISCHEMIA


HISTORYHISTORY

4. 4. WhatWhat werewere youyou doingdoing thethe painpainbeganbegan? ?

Abdominal Abdominal PainPain followingfollowingtrauma : trauma : INTRAINTRA--ABDOMINAL ABDOMINAL INJURY INJURY toto thethe solidsolid organsorgans ororbowelbowel..


HISTORYHISTORY

5. 5. WhatWhat doesdoes thethe painpain feelfeel likelike? ?

BurningBurning oror GnawingGnawing PainPain: : PepticPepticUlcerUlcer DiseaseDisease


HISTORYHISTORY

5. 5. WhatWhat doesdoes thethe painpain feelfeel likelike? ?

SharpSharp PainPain: : BiliaryBiliary ColicColic

PenetratingPenetrating PainPain: : PancreatitisPancreatitis

TearingTearing PainPain: : AorticAorticDisecctionDisecction


HISTORYHISTORY

6. 6. DoesDoes anythinganything makemake thethe painpainbetterbetter oror worseworse? ?

Parietal Peritoneal Parietal Peritoneal PainPain isis aggravatedaggravatedby by movementmovement. . ThisThis findingfindingnecessitatesnecessitates thethe exclusionexclusion ofofappendictisappendictis..


HISTORYHISTORY

6. 6. DoesDoes anythinganything makemake thethe painpainbetterbetter oror worseworse? ?

TheThe PainPain ulcerulcer pepticpeptic diseasediseaseimprovesimproves withwith eatingeating whereaswhereas biliarybiliarycoliccolic worsensworsens withwith measlesmeasles


HISTORYHISTORY

TheThe PainPain accentuatedaccentuated by by recliningreclining andand relievedrelieved by by sittingsitting uprightupright shouldshould raiseraisesuspicionsuspicion forfor a a retroperinealretroperinealprocessprocess suchsuch as as pancreatitis.pancreatitis.

Acute Abdominal Pain

Health & Medicine

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