Management of ABDOMINAL PAIN Yasar Kucukardalı MD Yeditepe University Department of Internal...

Management of Management of ABDOMINAL ABDOMINAL

PAINPAIN

Yasar Kucukardalı MD Yasar Kucukardalı MD

Yeditepe UniversityYeditepe University

Department of Internal Medicine Department of Internal Medicine

Presentation Presentation

Definition Definition

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Acute pain syndromesAcute pain syndromes

Chronic pain syndromesChronic pain syndromes

TYPES OF ABDOMINAL TYPES OF ABDOMINAL PAINPAIN

VisceralVisceral– originates in abdominal organs covered by originates in abdominal organs covered by

visceral visceral peritoneumperitoneum

ColicColic– crampy pain crampy pain

ParietalParietal– from irritation of parietal peritoneumfrom irritation of parietal peritoneum

ReferredReferred– produced by pathology in one location felt at produced by pathology in one location felt at

another locationanother location


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Acute pain Acute pain syndromessyndromes

Chronic pain Chronic pain syndromessyndromes


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Peritonun, karın duvarlarına yapışık olan kısımlarına “Parietal periton” adı verilir. Karın içersindeki iç organları kapatmakta olan periton yaprağına ise “Viseral plevra” adı verilir. Parietal periton ve viseral periton arasında meydana gelen boşluğa ise “Periton boşluğu” adı verilir.


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ORGANIC VERSUS FUNCTIONAL PAINHISTORY ORGANIC FUNCTIONAL

Pain character Acute, persistent pain Less likely to changeincreasing in intensity

Pain localization Sharply localized Various locations

Pain in relation to sleep Awakens at night No affect

Pain in relation to Further away At umbilicus umbilicus

Associated symptoms Fever, anorexia, Headache, dizziness,vomiting, wt loss, multiple system

com-anemia, elevated ESR plaints

Psychological stress None reported Present


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Epigastric PainEpigastric Pain

PUDPUD GERDGERD MIMI AAA- abdominal aortic AAA- abdominal aortic

aneurysmaneurysm Pancreatic painPancreatic pain Gallbladder and common Gallbladder and common

bile duct obstructionbile duct obstruction


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Right Upper Quadrant PainRight Upper Quadrant Pain

Acute Cholecystitis and Biliary Colic Acute Cholecystitis and Biliary Colic Acute Hepatitis or AbscessAcute Hepatitis or Abscess Hepatomegaly due to CHFHepatomegaly due to CHF Perforated Duodenal UlcerPerforated Duodenal Ulcer Herpes ZosterHerpes Zoster Myocardial IschemiaMyocardial Ischemia Right Lower Lobe Pneumonia Right Lower Lobe Pneumonia


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Left Upper Quadrant PainLeft Upper Quadrant Pain

Acute PancreatitisAcute Pancreatitis Gastric ulcerGastric ulcer GastritisGastritis Splenic enlargement, rupture or infarctionSplenic enlargement, rupture or infarction Myocardial ischemiaMyocardial ischemia Left lower lobe pneumoniaLeft lower lobe pneumonia


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Right lower Quadrant PainRight lower Quadrant Pain Appendicitis Appendicitis Regional EnteritisRegional Enteritis Small bowel obstructionSmall bowel obstruction Leaking AneurysmLeaking Aneurysm Ruptured Ectopic PregnancyRuptured Ectopic Pregnancy PIDPID Twisted Ovarian CystTwisted Ovarian Cyst Ureteral CalculiUreteral Calculi HerniaHernia


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Left Lower Quadrant PainLeft Lower Quadrant Pain

DiverticulitisDiverticulitis Leaking AneurysmLeaking Aneurysm Ruptured Ectopic pregnancy Ruptured Ectopic pregnancy PIDPID Twisted Ovarian CystTwisted Ovarian Cyst Ureteral CalculiUreteral Calculi HerniaHernia Regional EnteritisRegional Enteritis


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Periumbilical PainPeriumbilical Pain

Disease of transverse colonDisease of transverse colon GastroenteritisGastroenteritis Small bowel painSmall bowel pain AppendicitisAppendicitis Early bowel obstructionEarly bowel obstruction


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Diffuse PainDiffuse Pain

Generalized peritonitisGeneralized peritonitis Acute PancreatitisAcute Pancreatitis Sickle Cell CrisisSickle Cell Crisis Mesenteric ThrombosisMesenteric Thrombosis GastroenteritisGastroenteritis Metabolic disturbancesMetabolic disturbances Dissecting or Rupturing AneurysmDissecting or Rupturing Aneurysm Intestinal ObstructionIntestinal Obstruction Psychogenic illnessPsychogenic illness


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Referred PainReferred Pain

Pneumonia (lower lobes)Pneumonia (lower lobes)

Inferior myocardial infarctionInferior myocardial infarction

Pulmonary infarctionPulmonary infarction


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Karın ağrısı, bulantı , hafif ateş

History Taking in Abdominal History Taking in Abdominal Pain PresentationsPain Presentations

““OLD CARS”OLD CARS”– O- onsetO- onset– L- locationL- location– D- durationD- duration– C- characterC- character– A-alleviating/aggravating factorsA-alleviating/aggravating factors– R- radiationR- radiation– S- severityS- severity


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Physical Exam in Abdominal Physical Exam in Abdominal Pain PresentationsPain Presentations

InspectionInspection– Distention, scars, bruisesDistention, scars, bruises

AuscultationAuscultation– Present, hyper, or absentPresent, hyper, or absent– Actually not that helpful!Actually not that helpful!

PalpationPalpation– Often the most helpful part of examOften the most helpful part of exam– Tenderness versus painTenderness versus pain– Start away from painful area firstStart away from painful area first– Guarding, rebound, massesGuarding, rebound, masses


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Physical Exam in Abdominal Physical Exam in Abdominal Pain PresentationsPain Presentations

SignsSigns– IliopsoasIliopsoas– Murphy’sMurphy’s

Extra-abdominal examExtra-abdominal exam– Pelvic or scrotal examsPelvic or scrotal exams– Lungs, heartLungs, heart

RectalRectal– Adds very little (despite the angst) beyond Adds very little (despite the angst) beyond

gross blood or melenagross blood or melena


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LABORATORY TESTSLABORATORY TESTS

U/AU/A

CBCCBC

Additional depending on rule outsAdditional depending on rule outs– amylase, lipase, LFT’samylase, lipase, LFT’s


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DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

Plain X-rays (flat plate)Plain X-rays (flat plate)

Contrast studies - barium (upper and lower Contrast studies - barium (upper and lower GI series)GI series)

UltrasoundUltrasound

CT scanningCT scanning

EndoscopyEndoscopy

Sigmoidoscopy, colonoscopySigmoidoscopy, colonoscopy


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Abdominal Pain Across Abdominal Pain Across the Agesthe Ages

Ages 0-2Ages 0-2– Colic, GE, viral illness, constipationColic, GE, viral illness, constipation

Ages 2-12Ages 2-12– Functional, appendicitis, GE, toxinsFunctional, appendicitis, GE, toxins

Teens to adultsTeens to adults– Addition of genitourinary problemsAddition of genitourinary problems

ElderlyElderly– Beware of what seems like everything!Beware of what seems like everything!

Common Acute Pain Common Acute Pain SyndromesSyndromes

Appendicitis Appendicitis

Acute diverticulitisAcute diverticulitis

CholecystitisCholecystitis

PancreatitisPancreatitis

Perforation of an ulcerPerforation of an ulcer

Intestinal obstructionIntestinal obstruction

Ruptured AAARuptured AAA

Pelvic disordersPelvic disorders


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10320 patient10320 patient

AppendicitisAppendicitis 28%28%

CholecystitisCholecystitis 10%10%

Small bowel obstructionSmall bowel obstruction 4%4%

GynaecologicalGynaecological 4%4%

PancreatitisPancreatitis 3%3%

Renal colic Renal colic 3%3%

Peptic ulcerPeptic ulcer 2%2%

CancerCancer 2%2%

No clinical diagnosisNo clinical diagnosis 34%34%

De Dombal, Scand J De Dombal, Scand J Gastroenterol Gastroenterol 11988988

APPENDICITISAPPENDICITIS

Inflammatory disease of wall of Inflammatory disease of wall of appendixappendix

Diagnosis based on history and Diagnosis based on history and physicalphysical

Classic sequence of symptomsClassic sequence of symptoms– abdominal pain (begins epigastrium abdominal pain (begins epigastrium

or periumbilical area, anorexia, or periumbilical area, anorexia, nausea or vomitingnausea or vomiting

– followed by pain over appendix and followed by pain over appendix and low grade feverlow grade fever


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DIAGNOSISDIAGNOSIS of of APPENDICITISAPPENDICITIS

Physical examinationPhysical examination– low grade feverlow grade fever– McBurney’s pointMcBurney’s point– rebound, guarding, +psoas signrebound, guarding, +psoas sign

CBC, HCGCBC, HCG– WBC range from 10,000-16,000WBC range from 10,000-16,000

SURGERYSURGERY


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DIVERTICULITISDIVERTICULITIS

Results from stagnation of fecal Results from stagnation of fecal material in single diverticulum material in single diverticulum leading to pressure necrosis of leading to pressure necrosis of mucosa and inflammationmucosa and inflammation

Clinical presentationClinical presentation– most pts have h/o diverticulamost pts have h/o diverticula– mild to moderate, colicky to mild to moderate, colicky to

steady, aching abdominal pain - steady, aching abdominal pain - usually LLQusually LLQ

– may have fever and leukocytosismay have fever and leukocytosis


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PHYSICAL EXAMINATION• With obstruction bowel sounds hyperactive• Tenderness over affected section of bowelDIAGNOSIS• Often made on clinical grounds• CBC - will not always see leukocytosis

MANAGEMENT of DIVERTICULITIS• Spontaneous resolution common with low-grade fever, mild leukocytosis, and minimal abdominal pain• Treat at home with limited physical activity, reducing fluid intake, and oral antibiotics (bactrim DS bid or cipro 500mg bid & flagyl 500 mg tid for 7-14 days)• Treatment is usually stopped when asymptomatic• Patients who present acutely ill with possible signs of systemic peritonititis,, sepsis, and hypovolemia need admission


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CHOLECYSTITISCHOLECYSTITIS

Results from obstruction of cystic or Results from obstruction of cystic or common bile duct by large common bile duct by large gallstonesgallstones

Colicky pain with progression to Colicky pain with progression to constant pain in RUQ that may constant pain in RUQ that may radiate to R scapularadiate to R scapula

Physical findingsPhysical findings– tender to palpation or percussion RUQtender to palpation or percussion RUQ– may have palpable gallbladdermay have palpable gallbladder


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DIAGNOSIS of CHOLECYSTITIS

• CBC, LFTs (bilirubin, alkaline phosphatase), serum pancreatic enzymes• Plain abdominal films demonstrate biliary air hepatomegaly, and maybe gallstones•Ultrasound - considered accurate about 95%MANAGEMENT• Admission


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PANCREATITISPANCREATITIS

History of cholelithiasis or History of cholelithiasis or alcohol alcohol abuseabuse

Pain steady and boring, Pain steady and boring, unrelieved by position change - unrelieved by position change - LUQ with radiation to back - LUQ with radiation to back - nausea and vomiting, diaphoreticnausea and vomiting, diaphoretic

Physical findings;Physical findings;– acutely ill with abdominal distention, acutely ill with abdominal distention,

BS BS– diffuse rebounddiffuse rebound– upper abd may show muscle rigidityupper abd may show muscle rigidity


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• Diagnostic studies- CBC- Ultrasound- Serum amylase and lipase-Amylase rises 2-12 hours after onset and

returns to normal in 2-3 days- lipase is elevated several days after attack

Management- Admission


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PEPTIC ULCER PEPTIC ULCER PERFORATIONPERFORATION

Life-threatening complication of Life-threatening complication of peptic ulcer disease - more peptic ulcer disease - more common with duodenal than common with duodenal than gastricgastric

Predisposing factorsPredisposing factors– Helicobacter pylori Helicobacter pylori infectionsinfections– NSAIDsNSAIDs– hypersecretory stateshypersecretory states


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•Sudden onset of severe intense, steady epigasric pain with radiation to sides, back, or right shoulder• Past h/o burning, pain worse with empty stomach• Physical findings

- epigastric tenderness- rebound tenderness- abdominal muscle rigidity

• Diagnostic studies- upright or lateral decubitis X-ray shows air under the diaphragm or peritoneal cavity

REFER - SURGICAL EMERGENCY


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PEPTIC ULCER PEPTIC ULCER PERFORATIONPERFORATION

SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION

Distention results in decreased Distention results in decreased absorption and increased absorption and increased secretions leading to further secretions leading to further distention and fluid and electrolyte distention and fluid and electrolyte imbalanceimbalance

Number of causesNumber of causes

Sudden onset of crampy pain Sudden onset of crampy pain usually in umbilical area of usually in umbilical area of epigastrium - vomiting occurs early epigastrium - vomiting occurs early with small bowel and late with large with small bowel and late with large bowelbowel


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• Physical findings- hyperactive, high-pitched BS- fecal mass may be palpable- abdominal distention- empty rectum on digital exam

• Diagnosis- CBC- serum amylase- stool for occult blood- type and crossmatch- abdominal X-ray

• Management- Hospitalization


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SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION

RUPTURED AORTIC RUPTURED AORTIC ANEURYSMANEURYSM

AAA is abnormal dilation of AAA is abnormal dilation of abdominal aorta forming abdominal aorta forming aneurysm that may rupture aneurysm that may rupture and cause and cause masif bleeding masif bleeding into peritoneuminto peritoneum

More frequent in elderlyMore frequent in elderly

Sudden onset of pain may be Sudden onset of pain may be felt in chest or abdomen and felt in chest or abdomen and may radiate to legs and backmay radiate to legs and back


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• Physical findings - appears shocky-deficit or difference in femoral pulses• Diagnosis

- CT or MRI- ECG, cardiac enzymes

SURGICAL EMERGENCY


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RUPTURED AORTIC RUPTURED AORTIC ANEURYSMANEURYSM

PELVIC PAINPELVIC PAIN

Ectopic pregnancyEctopic pregnancy

PIDPID

UTIUTI

Ovarian cystsOvarian cysts


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CHRONIC PAIN CHRONIC PAIN SYNDROMESSYNDROMES

Irritable bowel syndromeIrritable bowel syndrome

Chronic pancreatitisChronic pancreatitis

DiverticulosisDiverticulosis

Gastroesophageal reflux disease (GERD)Gastroesophageal reflux disease (GERD)

Inflammatory bowel diseaseInflammatory bowel disease

Duodenal ulcerDuodenal ulcer

Gastric ulcerGastric ulcer


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IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROME

GI condition classified as GI condition classified as functional as no identifiable functional as no identifiable structural or biochemical structural or biochemical abnormalitiesabnormalities

Affects 14%-24% of females Affects 14%-24% of females and 5%-19% of malesand 5%-19% of males

Onset in late adolescence to Onset in late adolescence to early adulthoodearly adulthood

Rare to see onset > 50 yrs Rare to see onset > 50 yrs oldold


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IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROMESYMPTOMSSYMPTOMS

Pain described as Pain described as nonradiating, intermittent, nonradiating, intermittent, crampy located lower crampy located lower abdomenabdomen

Usually worse 1-2 hrs after Usually worse 1-2 hrs after mealsmeals

Exacerbated by stressExacerbated by stress

Relieved by BMRelieved by BM

Does not interrupt sleepDoes not interrupt sleep– critical to diagnosis of IBScritical to diagnosis of IBS


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DIAGNOSISDIAGNOSIS Of IBS Of IBSROME DIAGNOSTIC CRITERIAROME DIAGNOSTIC CRITERIA


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DIAGNOSTIC TESTSDIAGNOSTIC TESTS Of IBS Of IBS

Limited - R/O organic diseaseLimited - R/O organic disease

CBC with diffCBC with diff

ESRESR

ElectrolytesElectrolytes

BUN, creatinineBUN, creatinine

TSHTSH

Stool for occult blood and O & PStool for occult blood and O & P

Flexible sigmoidoscopyFlexible sigmoidoscopy


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MANAGEMENTMANAGEMENT OF IBS OF IBS

Goals of managementGoals of management

exclude presence of underlying exclude presence of underlying organicorganic disease disease

provide support, & reassuranceprovide support, & reassurance

Dietary modificationDietary modification

PharmacotherapyPharmacotherapy

Alternative therapiesAlternative therapies


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CHRONIC CHRONIC PANCREATITISPANCREATITIS

Alcohol major causeAlcohol major cause

Malnutrition - outside USMalnutrition - outside US

Patients >40 yrs with pancreatic Patients >40 yrs with pancreatic dysfunction must be evaluated for dysfunction must be evaluated for pancreatic cancerpancreatic cancer

Dysfunction between 20 to 40 yrs Dysfunction between 20 to 40 yrs old R/O cystic fibrosisold R/O cystic fibrosis

50% of pts with chronic 50% of pts with chronic pancreatitis die within 25 yrs of pancreatitis die within 25 yrs of diagnosisdiagnosis


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SYMPTOMSSYMPTOMS of of CHRONIC CHRONIC PANCREATITISPANCREATITIS

Pain - may be absent or severe, Pain - may be absent or severe, recurrent or constantrecurrent or constant

Usually abdominal, sometimes Usually abdominal, sometimes referred upper back, anterior referred upper back, anterior chest, flankchest, flank

Wt loss, diarrhea, oily stoolsWt loss, diarrhea, oily stools

NNauseaausea, V, Vomitingomiting, or abdominal , or abdominal distention less reporteddistention less reported


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DIAGNOSISDIAGNOSIS of of CHRONIC CHRONIC PANCREATITISPANCREATITIS

CBCCBC

Serum amylase (present during acuteSerum amylase (present during acute attacks)attacks)

Serum lipaseSerum lipase

Serum bilirubinSerum bilirubin

Serum glucoseSerum glucose

Serum alkaline phosphataseSerum alkaline phosphatase

Stool for fecal fatStool for fecal fat

CT scanCT scan


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MANAGEMENTMANAGEMENT of of CHRONIC CHRONIC PANCREATITISPANCREATITIS

Should be coShould be co--managed managed with a specialistwith a specialist

Pancreatic dysfunction Pancreatic dysfunction

- diabetes- diabetes

- steatorrhea & diarrhea- steatorrhea & diarrhea

- enzyme replacement- enzyme replacement


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DIVERTICULOSISDIVERTICULOSIS

Uncomplicated disease, Uncomplicated disease, either asymptomatic or either asymptomatic or symptomatic symptomatic

Considered a deficiency Considered a deficiency disease of 20th century disease of 20th century Western civilizationWestern civilization

Rare in first 4 decades - Rare in first 4 decades - occurs in later yearsoccurs in later years

Incidence - 50% to 65% by Incidence - 50% to 65% by 80 years80 years


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SYMPTOMSSYMPTOMS of of DIVERTICULOSISDIVERTICULOSIS

80% - 85% remain symptomless 80% - 85% remain symptomless - found by diagnostic study for - found by diagnostic study for other reasonother reasonIrregular defecation, intermittent Irregular defecation, intermittent abdominal pain, bloating, or abdominal pain, bloating, or excessive flatulenceexcessive flatulenceChange in stool - flattened or Change in stool - flattened or ribbonlikeribbonlikeRecurrent bouts of steady or Recurrent bouts of steady or crampy paincrampy painMay mimic IBS except older ageMay mimic IBS except older ageTherapy/ Therapy/ Increased fiber intake - Increased fiber intake - 35 g/day35 g/day


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DIAGNOSISDIAGNOSIS of of DIVERTICULOSISDIVERTICULOSIS

CBCCBC

Stool for occult Stool for occult bloodblood

Barium enemaBarium enema


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GASTROESOPHAGEAL REFLUX GASTROESOPHAGEAL REFLUX DISEASEDISEASE

Movement of gastric Movement of gastric contents from stomach to contents from stomach to esophagusesophagusMay produce May produce burning,pain burning,pain within esophagus, within esophagus, pharynx, larynx, pharynx, larynx, respiratory tractrespiratory tractMost prevalent condition Most prevalent condition affecting GI tractaffecting GI tract


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SYMPTOMSSYMPTOMS of GORD of GORD Heartburn - most common (severity of Heartburn - most common (severity of does not correlate with extent of tissue does not correlate with extent of tissue damage)damage)

Burning, gnawing in mid-epigastrium Burning, gnawing in mid-epigastrium worsens with recumbencyworsens with recumbency

Water brash (appearance of salty-Water brash (appearance of salty-tasting fluid in mouth because tasting fluid in mouth because stimulate saliva secretion)stimulate saliva secretion)

Occurs after eating may be relieved Occurs after eating may be relieved with antacids (occurs within 1 hr of with antacids (occurs within 1 hr of eating - usually large meal of day)eating - usually large meal of day)


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• Dysphagia & odynophagia predictive of severe disease• Chest pain - may mimic angina• Foods that may precipitate heartburn

- high fat or sugar- chocolate, coffee, & onions- citrus, tomato-based, spicy

• Cigarette smoking and alcohol • Aspirin, NSAIDS, potassium, pills


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DIAGNOSISDIAGNOSIS of GORD of GORD

History of heartburn without other History of heartburn without other symptoms of serious diseasesymptoms of serious disease

Empiric trial of medication without Empiric trial of medication without testingtesting

Testing for those who do have Testing for those who do have persistent or unresponsive heartburn or persistent or unresponsive heartburn or signs of tissue injurysigns of tissue injury

CBC, CBC, H. pyloriH. pylori antibody antibody

Barium swallowBarium swallow

Endoscopy for severe or atypical Endoscopy for severe or atypical symptomssymptoms


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MANAGEMENTMANAGEMENT of GORD of GORD

Lifestyle changesLifestyle changes– smoking cessationsmoking cessation– reduce reduce alcohol alcohol consumptionconsumption– reduce dietary fatreduce dietary fat– decreased meal sizedecreased meal size– weight reductionweight reduction– elevate head of bed elevate head of bed


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• elimination of medications that are mucosal irritants or that lower esophageal pressure• avoidance of supine position for 2 hours after meal avoidance of tight fitting clothes

MEDICATIONSMEDICATIONS for GORD for GORD

Antacids with lifestyle changes may be Antacids with lifestyle changes may be sufficientsufficient

Histamine receptor antagonists in divided Histamine receptor antagonists in divided dosesdoses– approximately 48% of pts with esophagitis will approximately 48% of pts with esophagitis will

heal on this regimenheal on this regimen– tid dosing more effective for symptom relief tid dosing more effective for symptom relief

and healingand healing– long-term use is appropriatelong-term use is appropriate


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INFLAMMATORY BOWEL INFLAMMATORY BOWEL DISEASEDISEASE

Chronic inflammatory Chronic inflammatory condition involving intestinal condition involving intestinal tract with periods of remission tract with periods of remission and exacerbationand exacerbation

Two typesTwo types– Ulcerative colitis (UC)Ulcerative colitis (UC)– Crohn’s diseaseCrohn’s disease


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ULCERATIVE COLITISULCERATIVE COLITIS

Chronic inflammation of Chronic inflammation of colonic mucosacolonic mucosa

Inflammation diffuse & Inflammation diffuse & continuous beginning in continuous beginning in rectumrectum

May involve entire colon or May involve entire colon or only rectum (proctitis)only rectum (proctitis)

Inflammation is continuousInflammation is continuous


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CROHN’S DISEASECROHN’S DISEASE

Chronic inflammation of all Chronic inflammation of all layers on intestinal tractlayers on intestinal tract

Can involve any portion from Can involve any portion from mouth to anusmouth to anus

30%-40% small intestine (ileitis)30%-40% small intestine (ileitis)

40%-45% small & large 40%-45% small & large intestine (ileocolitis)intestine (ileocolitis)

15%-25% colon (Crohn’s 15%-25% colon (Crohn’s colitis)colitis)

Inflammation can be patchyInflammation can be patchy


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• Annual incidence of UC & Crohn’s similar in both age of onset & worldwide distribution•About 20% more men have UC• About 20% more women have Crohn’s• Peak age of onset - between 15 & 25 yrs


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SYMPTOMSSYMPTOMS / /CROHN’S DISEASECROHN’S DISEASEDefinition Definition

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PHYSICAL EXAMINATION PHYSICAL EXAMINATION CROHN’S DISEASECROHN’S DISEASE

May be in no distress to acutely illMay be in no distress to acutely ill

Oral apthous ulcersOral apthous ulcers

Tender lower abdomenTender lower abdomen

Hyperactive bowel soundsHyperactive bowel sounds

Stool for occult blood may be +Stool for occult blood may be +

Perianal lesionsPerianal lesions

Need to look for fistulas & abscessesNeed to look for fistulas & abscesses


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DIAGNOSIS DIAGNOSIS of of CROHN’S CROHN’S DISEASEDISEASE

CBCCBC

Stool for culture, ova & parasites, Stool for culture, ova & parasites, C. C. difficiledifficile

Stool for occult bloodStool for occult blood

Flexible sigmoidoscopy - useful to Flexible sigmoidoscopy - useful to determine source of bright red blooddetermine source of bright red blood

Colonoscopy with biopsyColonoscopy with biopsy

Endoscopy may show “skip” areasEndoscopy may show “skip” areas

May be difficult to distinguish one from May be difficult to distinguish one from other other


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DUODENAL ULCERSDUODENAL ULCERS

Incidence increasing secondary to Incidence increasing secondary to

increasing use of NSAIDs, increasing use of NSAIDs,

H. pyloriH. pylori infections infections

Imbalance both in amount of Imbalance both in amount of

acid-pepsin production delivered acid-pepsin production delivered

form stomach to duodenum andform stomach to duodenum and

ability of lining to protect selfability of lining to protect self


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RISK FACTORSRISK FACTORS / / DUODENAL ULCERSDUODENAL ULCERS

StressStressCigarette smokingCigarette smokingCOPDCOPDAlcoholAlcoholChronic ASA & NSAID useChronic ASA & NSAID use


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INCIDENCEINCIDENCE / / DUODENAL ULCERSDUODENAL ULCERS

About 16 million individuals will have during About 16 million individuals will have during lifetimelifetime

More common than gastric ulcersMore common than gastric ulcers

Peak incidence; 5th decade for men, 6th Peak incidence; 5th decade for men, 6th decade for womendecade for women

75%-80% recurrence rate within 1yr of 75%-80% recurrence rate within 1yr of diagnosis without maintenance therapydiagnosis without maintenance therapy

>90% of duodenal ulcers caused by >90% of duodenal ulcers caused by H.pyloriH.pylori


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SYMPTOMSSYMPTOMS / / DUODENAL ULCERSDUODENAL ULCERS

Epigastric painEpigastric pain

Sharp, burning, aching, gnawing pain Sharp, burning, aching, gnawing pain occurring 1 - 3 hrs after meals or in occurring 1 - 3 hrs after meals or in middle of nightmiddle of night

Pain relieved with antacids or foodPain relieved with antacids or food

Symptoms recurrent lasting few days Symptoms recurrent lasting few days to monthsto months

Weight gain not uncommonWeight gain not uncommon


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GASTRIC ULCERSGASTRIC ULCERS

H. pyloriH. pylori identified in 65% identified in 65% to 75% of patients with non-to 75% of patients with non-NSAID useNSAID use

5% - 25% of patients taking 5% - 25% of patients taking ASA/NSAID develop gastric ASA/NSAID develop gastric ulcers (inhibits synthesis of ulcers (inhibits synthesis of prostaglandin which is prostaglandin which is critical for mucosal critical for mucosal defense)defense)

Malignancy cause of Malignancy cause of


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OTHER RISK FACTORSOTHER RISK FACTORS //GASTRIC ULCERSGASTRIC ULCERS

Caffeine/coffeeCaffeine/coffee

AlcoholAlcohol

SmokingSmoking

First-degree relative with gastric ulcerFirst-degree relative with gastric ulcer


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SYMPTOMS SYMPTOMS / / GASTRIC GASTRIC ULCERSULCERS

Pain similar to duodenal but may Pain similar to duodenal but may be increased by foodbe increased by food

Location - LUQ radiating to backLocation - LUQ radiating to back

Bloating, belching, nausea, Bloating, belching, nausea, vomiting, weight lossvomiting, weight loss

NSAID-induced ulcers usually NSAID-induced ulcers usually painless - discovered secondary painless - discovered secondary to melena or iron deficiency to melena or iron deficiency anemiaanemia


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DIAGNOSISDIAGNOSIS / / GASTRIC GASTRIC ULCERSULCERS

CBCCBC

Serum for Serum for H. pyloriH. pylori

Carbon-labeled breath testCarbon-labeled breath test

Stool for occult bloodStool for occult blood

EndoscopyEndoscopy


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MANAGEMENT MANAGEMENT / / GASTRIC GASTRIC ULCERSULCERS

Treat Treat H.pyloriH.pylori if present if present

Proton pump inhibitors shown to be superior to HProton pump inhibitors shown to be superior to H22--RARA

Need to use proton pump inhibitor for up to 8 wksNeed to use proton pump inhibitor for up to 8 wks

Do not need maintenance if infection eradicated Do not need maintenance if infection eradicated and NSAIDs and NSAIDs discontinueddiscontinued

Consider misoprostol if cannot d/c NSAIDConsider misoprostol if cannot d/c NSAID


LocationLocation

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Management of ABDOMINAL PAIN Yasar Kucukardalı MD Yeditepe University Department of Internal...

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