ABDOMINAL PAIN
TYPES OF ABDOMINAL PAIN
• Visceral– originates in abdominal organs covered by
peritoneum• Parietal
– from irritation of parietal peritoneum• Colic- spasmodic
– intermittent crampy pain
Epigastric pain
Intestinal causes• Duodenal ulcer
Non intestinal causes• Acute pancreatitis• Gastritis• GERD
Right lower Quadrant Pain
Intestinal causes Appendicitis Amoebic typhlitis Regional Enteritis Small bowel obstruction
Non intestinal causes Leaking Aneurysm Ruptured Ectopic Pregnancy PID Torsion Ovarian Cyst Torsion testis Ureteral Calculi Obstructed hernia
Left Lower Quadrant Pain
Intestinal causes Diverticulitis Regional enteritis
Non intestinal causes Leaking Aneurysm Ruptured Ectopic pregnancy PID Torsion Ovarian Cyst Torsion testis Ureteral Calculi Obstructed hernia
Periumbilical Pain
Appendicitis Colitis- Transverse colon Gastroenteritis Small bowel obstruction
Diffuse Pain
Intestinal causes Gastroenteritis Intestinal Obstruction Mesenteric Vein Thrombosis
Non intestinal causes Generalized peritonitis Acute Pancreatitis Sickle Cell Crisis Metabolic disturbances Dissecting or Leaking Aortic Aneurysm
INVESTIGATIONS
HISTORY• Onset• Qualitative description• Intensity• Frequency• Location - Does it go anywhere (referred)?• Duration• Aggravating and relieving factors
PHYSICAL EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation
• Rectal exam
• Pelvic exam
LABORATORY TESTS
• Complete blood count
• Urine analysis
• Additional depending on rule outs– amylase, lipase, CRP, LFT
DIAGNOSTIC STUDIES
• Plain X-rays- chest and abdomen
• Contrast studies - barium (upper and lower GI series)
• Ultrasound
• CT scanning
• Endoscopy
• Sigmoidoscopy, colonoscopy
Common Causes of Acute Abdomen
• Appendicitis
• Acute diverticulitis
• Perforation of an ulcer
• Intestinal obstruction
Appendicitis
– abdominal pain begins in periumbilical area, anorexia, nausea or vomiting
– followed by pain over RIF, low grade fever– tenderness over McBurney’s point– rebound tenderness, guarding
Acute diverticulitis
– most pts have h/o diverticula– mild to moderate, colicky to steady, aching
abdominal pain - usually LLQ– may have fever and leukocytosis– with obstruction bowel sounds hyperactive– tenderness over affected section of bowel
Perforation of an ulcer
– sudden onset of severe intense, steady epigastric
– pain with radiation to sides, back, or right shoulder
– past h/o burning, gnawing pain worse with empty stomach
– epigastric tenderness– rebound tenderness– abdominal muscle rigidity– tenderness in right lower quadrant
Intestinal obstruction
– sudden onset of crampy pain usually in umbilical area- vomiting occurs early with small bowel and late with large bowel obstruction
– hyperactive, high-pitched bowel sounds– fecal mass may be palpable– abdominal distention– empty rectum or ballooning of rectum
Common Causes of Chronic Pain Abdomen
• Irritable bowel syndrome
• Diverticulosis
• Inflammatory bowel disease
• Duodenal ulcer
Irritable bowel syndrome
• Pain described as nonradiating, intermittent, crampy located lower abdomen
• Usually worse 1-2 hrs after meals
• Exacerbated by stress
• Relieved by bowel movements
• Does not interrupt sleep– critical to diagnosis of IBS
Diverticulosis
• 80% - 85% remain asymptomatic - found during investigations for other reasons
• irregular defecation, intermittent abdominal pain, bloating, or excessive flatulence
• change in stool - flattened or ribbon like• recurrent bouts of steady or crampy pain• may mimic IBS except older age
Inflammatory bowel disease• Ulcerative colitis• Crohn’s disease
• Both have similar presentations• Abdominal pain may be only complaint and may have been intermittent
for years• Abdominal pain and diarrhea present in most pts• Pain diffuse or localized to RLQ-LLQ• Cramping sensation - intermittent or constant• Tenesmus & fecal incontinence• Stools loose and/or watery - may have blood• Rectal bleeding common with colitis• Other complaints
– fatigue– weight loss– anorexia– fever, chills– nausea, vomiting– joint pains– mouth sores
Duodenal ulcer
• Epigastric pain
• Sharp, burning, aching, gnawing pain occurring 1 - 3 hrs after meals or in middle of night
• Pain relieved with antacids or food
• Symptoms recurrent lasting few days to months
• Weight gain not uncommon
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