Definition of pain• A signal of disease
• Unpleasant sensation localized to a part of the body
• Penetrating or tissue destructive processstabbing burning twisting tearing squeezing
• Bodily or emotional reactionterrifying nauseating sickening
• Accompanied by anxiety
• Urging to escape or terminating the feeling
• Both sensation and emotion
Clinical characteristics
•Character of pain
spastic pain: intermittent
inflammatory: persisting
• Localization of pain:
usually in the diseased part
it may be referred
Clinical characteristics
•Quality and intensity of pain
peptic ulcer: gnawing burning
•Referred pain
•Provocating, aggravating and relieving factors
ulcer pain: relieved by ingestion of food
Clinical characteristics• Associated symptoms
• Physical examination: neck lymph nodes
chest examination
abdominal examination
• Laboratory check up: sputum, stool, urine
Serum
X-ray film
Ultra-sound
Clinical characteristics
The following are important:
•severity
•duration
•frequency •special time of occurrence
10 Questions on Pain
• Site
• Referral
• Character
• Severity
• Duration
• Onset
• Frequency
• Aggravating factors
• Relieving factors
• Associated symptoms
Etiology and pathogenesis
Acute abdominal pain•Parietal peritoneal inflammationbacterial contamination chemical irritation
•Acute inflammation of abdominal organsgastritis enteritis
•Mechanical obstruction of hollow visceraobstruction of the small or large intestine
obstruction of the biliary tree
Etiology and pathogenesis
Acute abdominal pain Vascular disturbances
Embolism, vascular rupture, torsion of the organs
•Referred painpneumonia coronary occlusion
•Abdominal wall trauma or infection of muscles, distortion or traction of mesentery( 肠系膜 )
•Metabolic and toxic causesallergic factors etc.
Etiology and pathogenesis
Chronic abdominal pain• Chronic inflammation of abdominal organs reflux esophagitis chronic ulcerative colitis
• Peptic ulcer
• Distention of visceral surfaces hepatic or renal capsules, hepatitis, hepatic cancer
Etiology and pathogenesis
Chronic abdominal pain• Obstruction or torsion
• Infiltration or metastasis of tumor
• Metabolic and toxic causes uremia
• Neurogenic irritable colon neurosis
Visceral pain
• Results from stimulation of autonomic nerves
in the visceral peritoneum which surrounds
internal organs
• The message may be transferred into the spinal
cord via sympathic route
Clinical presentation of visceral pain
• Pain poorly localized
• Intermittent, cramp or colicky pain
• Accompanied by nausea, vomitting and diaphoresis
Somatic pain
• Stimuli occurs with irritation of parietal peritoneum
• Sensations conducted along peripheral nerves
which can localize pain better
Clinical presentation of somatic pain
• Precisely localized pain
• Pain described as intense, constant
• With local guarding or rigidity
• Getting worse after coughing or position changes
• May be caused by infection, chemical irritation, or
other inflammatory process
Referred pain
• Pain felt at a distance from its source
----The diffuse pain arising from abdominal visceral structures tends to be projected to a more superficial region with the same segmental innervation
• The nerves distribution and visceral organs are
listed in text book (page 37)
Clinical manifestation
•LocalizationTenderness over the diseased organ
Obstruction of small intestine: periumbilical( 脐周) supraumbilical (脐上)Obstruction of large intestine: infraumbilial area (脐下) acute distention of gallbladder: right upper quadrant with
radiation to the right posterior region of the thorax
or the tip of the right scapula (肩胛)
Acute epigastric pain referring to the back
• Posteriorly penetrating peptic ulcer• Biliary pain• Acute pancreatitis• Dissecting aneurysm 夹层动脉瘤
Epigastric pain + repeated vomiting
• Food poisoning
• Acute pancreatitisAgonizing pain but insignificant signs
• Acute pancreatitis• Mesenteric thrombosis at early stage 肠系膜血栓形成
Clinical manifestation
•Quality and severity
Perforation: severe dull pain over abdomen
Obstruction of hollow abdominal viscera: intermittent
colicky
Intraabdominal vascular disturbances:
sudden and catastrophic in nature
Acute pancreatitis: severe, steady upper, abdominal pain
Clinical manifestation
• Provocation and reliefAcute gastritis and enteritis: eating unfresh or raw foods
relieved by vomiting or discharge
Peritoneum inflammation: accentuated by pressure
palpation movement coughing
IBS and constipation: relieved temporarily by bowel movements
Obstruction: relieved temporarily by vomiting
Ulcer: eating or taking antacids
Clinical manifestation
•Associated manifestations
Fever: inflammation
Jaundice: liver gallbladder pancreatic disease
Hematuria: renal stone
Diarrhea/rectal bleeding: intestinal causes
Differentiation of three colicky pain
Type Location Other manifestationIntestinal periumbilical vomiting, nausea
infraumbilical diarrhea, bowel sounds
Biliary right upper jaundice fever
quadrant Murphy’s sign
Renal ipsilateral flank changes in urine test
radiate to genitalia 外阴 hematuria groin 腹股沟 , scrotum 阴囊
Clinical manifestation of chronic abdominal pain
• Past history
• Localization
• Quality
• Pain and position of the body Ptosis (下垂) of stomach or kidney:
pain when standing for long time
• Associated symptoms Chronic infection lymphoma malignant tumor: feverChronic infection lymphoma malignant tumor: fever
esophagus stomach billary tree: vomiting esophagus stomach billary tree: vomiting •Pain referred to the abdomen should be differentiated
Diagnostic points
•An accurate menstrual history in a female patient is essential
•Much attention has been paid to the presence or absence of peristaltic sounds, their quality and their frequency
• PQRST: provocative-palliative factors quality
region severity temporal characteristics
WORK-UP OF ABDOMINAL PAIN
HISTORY
• Onset
• Qualitative description
• Intensity
• Frequency
• Location - Does it go anywhere (referred)?
• Duration
• Aggravating and relieving factors
Common Acute Pain Syndromes
• Appendicitis
• Acute diverticulitis
• Cholecystitis
• Pancreatitis
• Perforation of an ulcer
• Intestinal obstruction
• Ruptured AAA ( abdominal aortic aneurysm)• Pelvic disorders