Approach To Abdominal Approach To Abdominal PainPain

Dr. Nahla A Azzam MRCPDr. Nahla A Azzam MRCP

Consultant Gastroenterology Consultant Gastroenterology

IntroductionIntroduction

Abdominal pain is an unpleasant Abdominal pain is an unpleasant experience commonly associated experience commonly associated with tissue injury. The sensation of with tissue injury. The sensation of pain represents an interplay of pain represents an interplay of pathophysiologic and psychosocial pathophysiologic and psychosocial factors. factors.

ANATOMIC BASIS OF PAINANATOMIC BASIS OF PAIN

Sensory neuroreceptors in abdominal Sensory neuroreceptors in abdominal organs are located within the mucosa organs are located within the mucosa and muscularis of hollow viscera, on and muscularis of hollow viscera, on serosal structures such as the serosal structures such as the peritoneum, and within the mesentery.peritoneum, and within the mesentery.

sensory neuroreceptors are involved sensory neuroreceptors are involved in the regulation of secretion, motility, in the regulation of secretion, motility, and blood flow via local and central and blood flow via local and central reflex arcs.reflex arcs.

two distinct types of afferent nerve two distinct types of afferent nerve fibers: myelinated A-delta fibers and fibers: myelinated A-delta fibers and unmyelinated C fibers.unmyelinated C fibers.

A-delta fibers are distributed A-delta fibers are distributed principally to skin and muscle and principally to skin and muscle and mediate the sharp, sudden, well-mediate the sharp, sudden, well-localized pain that follows an acute localized pain that follows an acute injury. injury.

C fibers are found in muscle, C fibers are found in muscle, periosteum, mesentery, peritoneum, periosteum, mesentery, peritoneum, and viscera. Most nociception from and viscera. Most nociception from abdominal viscera is conveyed by abdominal viscera is conveyed by this type of fiber and tends to be dull, this type of fiber and tends to be dull, burning, poorly localized burning, poorly localized

STIMULANTS OF PAINSTIMULANTS OF PAIN

The principal mechanical signal to The principal mechanical signal to which visceral nociceptors are which visceral nociceptors are sensitive is stretch. sensitive is stretch.

Unlike for somatoparietal Unlike for somatoparietal nociceptors, cutting, tearing, or nociceptors, cutting, tearing, or crushing of viscera does not result in crushing of viscera does not result in pain. pain.

Abdominal visceral nociceptors also Abdominal visceral nociceptors also respond to various chemical stimuli respond to various chemical stimuli

These receptors are directly These receptors are directly activated by substances released in activated by substances released in response to local mechanical injury, response to local mechanical injury, inflammation, tissue ischemia and inflammation, tissue ischemia and necrosis, and noxious thermal or necrosis, and noxious thermal or radiation injury. radiation injury.

Types of PainTypes of Pain

Abdominal pain may be classified Abdominal pain may be classified into three categories: into three categories:

1.visceral pain1.visceral pain 2.somatoparietal pain2.somatoparietal pain 3.referred pain.3.referred pain.

Visceral painVisceral pain

Somatoparietal painSomatoparietal pain

is generally more intense and is generally more intense and localized than visceral pain.localized than visceral pain.

An example in acute appendicitis, An example in acute appendicitis, which is followed by the localized which is followed by the localized somatoparietal pain at McBurney's somatoparietal pain at McBurney's point produced by inflammatory point produced by inflammatory involvement of the parietal involvement of the parietal peritoneum. Parietal pain is usually peritoneum. Parietal pain is usually aggravated by movement or coughing. aggravated by movement or coughing.

Referred painReferred pain

APPROACH TO THE PATIENT APPROACH TO THE PATIENT WITH ACUTE ABDOMINAL PAINWITH ACUTE ABDOMINAL PAIN Clinical EvaluationThe goal of the Clinical EvaluationThe goal of the

evaluation of the patient with evaluation of the patient with acute abdominal pain is an early, acute abdominal pain is an early, efficient, and accurate diagnosis.efficient, and accurate diagnosis.

History:History:

ChronologyChronology

LocationLocation Character Character Aggravating and Alleviating factors Aggravating and Alleviating factors

e.g positional changes, meals, bowel e.g positional changes, meals, bowel movements, and stress movements, and stress

Associated Symptoms and Review of Associated Symptoms and Review of Systems e.g anorexia, nausea, Systems e.g anorexia, nausea, vomiting, flatus, diarrhea, and vomiting, flatus, diarrhea, and constipation, jaundice, dysuria, constipation, jaundice, dysuria, menstruation.menstruation.

PMHPMH

similar symptoms suggests a similar symptoms suggests a recurrent problem. Patients with a recurrent problem. Patients with a history of partial small bowel history of partial small bowel obstructions, renal calculi.obstructions, renal calculi.

Systemic illnesses such as Systemic illnesses such as scleroderma, lupus, nephrotic scleroderma, lupus, nephrotic syndrome, porphyrias, and sickle cell syndrome, porphyrias, and sickle cell disease often have abdominal pain as disease often have abdominal pain as a manifestation of their illness.a manifestation of their illness.

Physical examinationPhysical examination

General position in bed, posture, General position in bed, posture, degree of discomfort, and facial degree of discomfort, and facial expression. expression.

Vital signs Vital signs abdomen should be inspected for abdomen should be inspected for

distention, scars, hernias, muscle distention, scars, hernias, muscle rigidity, splinting during respiration, rigidity, splinting during respiration, ecchymoses, and visible ecchymoses, and visible hyperperistalsis. . hyperperistalsis. .

Light, gentle palpation is superior to deep Light, gentle palpation is superior to deep palpation in the identification of peritoneal palpation in the identification of peritoneal irritation. irritation.

Palpation should begin at the point of least Palpation should begin at the point of least tenderness and proceed to the point of tenderness and proceed to the point of greatest tenderness., and rigidity should be greatest tenderness., and rigidity should be determineddetermined

Abdominal percussion may elicit tympanAbdominal percussion may elicit tympan Enlargement of a diseased organ, tumor, or Enlargement of a diseased organ, tumor, or

minflammation may produce a palpable mass. minflammation may produce a palpable mass. Potential hernia orifices should be examined.Potential hernia orifices should be examined.

Investigation Investigation

Laboratory CBC,U&E, LFT, ABG, Laboratory CBC,U&E, LFT, ABG, Amylase Amylase

Radiological Radiological plain abdominal seriesplain abdominal series CXRCXR

UltrasonographyUltrasonography can provide rapid, can provide rapid, accurate, and inexpensive anatomic accurate, and inexpensive anatomic information about the liver, biliary information about the liver, biliary tree, spleen, pancreas, kidneys, and tree, spleen, pancreas, kidneys, and pelvic organpelvic organ

CT Scan of AbdomenCT Scan of Abdomen MRIMRI Other e.g. laparoscopy Other e.g. laparoscopy

Special CircumstancesSpecial Circumstances

Extremes of Age difficult HX, minimal Extremes of Age difficult HX, minimal physical , physical , ↑mortality↑mortality

Pregnancy Pregnancy

Acute Abdomen in the Intensive Care Acute Abdomen in the Intensive Care Unit Patients .e.g. trauma injuries; Unit Patients .e.g. trauma injuries; postoperative postoperative complications,anastomotic leak and complications,anastomotic leak and obstructionobstruction

complications of critical illness, complications of critical illness, including acalculous cholecystitis and including acalculous cholecystitis and stress ulcer. stress ulcer.

Immunocompromised patients Immunocompromised patients 1.1. diseases that occur in the general diseases that occur in the general

population population 2.2. diseases unique to the diseases unique to the

immunocompromised host (e.g., immunocompromised host (e.g., neutropenic enterocolitis, drug-neutropenic enterocolitis, drug-induced pancreatitis, GVHD,, induced pancreatitis, GVHD,, cytomegalovirus [CMV], and fungal cytomegalovirus [CMV], and fungal infections). infections).

Chronic Abdominal PainChronic Abdominal Pain

survey of more than 1 million Americans survey of more than 1 million Americans revealed that 13% experienced revealed that 13% experienced "stomach pain" and 15% experienced "stomach pain" and 15% experienced "pain in the lower abdomen."pain in the lower abdomen.

Chronic intractable abdominal pain is Chronic intractable abdominal pain is defined as abdominal pain that is defined as abdominal pain that is present for at least 6 months without present for at least 6 months without diagnosis despite appropriate evaluation diagnosis despite appropriate evaluation

Chronic Abdominal PainChronic Abdominal Pain