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ABDOMINAL PAIN

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Title: ABDOMINAL PAIN


1
ABDOMINAL PAIN
  • The diagnosis of acute abdominal pain continues
    to be one of medicine's most daunting tasks. The
    abdomen might be thought of as an incredibly
    intricate biological "black box" in which it can
    be extremely difficult to pinpoint the source of
    distress.

2
QUESTION
  • A 23 yr-old female presents to the ED for
    evaluation of acute abdominal pain. She reports
    that she had multiple episodes of severe
    abdominal pain since age 15. These episodes have
    been very severe, once prompting exploratory lap.
    At age 18 with removal of appendix, which was
    histologically benign. Pain lasts 2-3 days and
    then resolves entirely. No aggravating or
    relieving factors. She had extensive w/u
    including pan-endoscopy, sbs, multiple cts and
    u/s, all negative

3
CONTD
  • Pt. recently c/o joint pain affecting her knees
    and ankles. She takes no medications. Multiple
    other family members have similar sxs.
  • P. Ex in moderate distress, lying still. T
    103F, HR130, BP112/66mmHg
  • pleural effusion on the rt side
    hypoactive bowel sounds and moderate diffuse
    abdominal tenderness and rebound tenderness
    Her left knee is swollen and erythematous
  • Labs wbc15, esr100 s,
  • Pts symptoms resolve spontaneously in 72 hrs

4
  • What is the best preventive therapy
  • Azathioprine
  • Colchicine
  • Hemin
  • Indomethacin
  • prednisone

5
QUESTIONS
  • A 36 yr-old female presents with the chief
    complaint of burning epigastric pain for many
    wks. Pain gets worst after she eats spicy or
    fatty food and occurs approx 90 mins. after
    eating. Occasionally the patient awakens at
    night with the pain
  • P.Ex mild epigastric tenderness
  • A 68 yr-old female has 2 day history of sharp
    right upper quadrant pain, low grade fever and
    nausea. Pain is constant and getting worst. It
    does radiates to her back.
  • On P.Ex tenderness on the rt. Upper
    quadrant

6
Visceral vs Somatic
7
Visceral pain
  • Is experienced when noxious stimuli trigger
    visceral nociceptors.
  • The pain is usually slow onset, poorly localized,
    vague ,dull, burning, gnawing discomfort in the
    midline epigastrium, periumbili-cal
    region, or lower midabdomenbecause abdominal
    organs transmit sensory afferents to both sides
    of the spinal cord.
  • The site where the pain is felt corresponds
    roughly to the dermatomes that correlate with the
    diseased organ's innervation.
  • The pain is not well localized because the
    innervation of most viscera is multisegmental and
    the number of nerve endings in viscera is lower
    than that in highly sensitive organs such as the
    skin.
  • Secondary autonomic effects such as sweating,
    restlessness, nausea, vomiting, perspiration, and
    pallor often accompany visceral pain.
  • The patient may move about in an effort to
    relieve the discomfort.

8
Visceral and NOT referred pain
  • referred to areas corresponding to the embryonic
    origin of the affected structure. Foregut
    structures (stomach, duodenum, liver, and
    pancreas) cause upper abdominal pain. Midgut
    structures (small bowel, proximal colon, and
    appendix) cause periumbilical pain. Hindgut
    structures (distal colon and GU tract) cause
    lower abdominal pain

9
Visceral pain-Mechanism
  • The principal mechanical signal to which visceral
    nociceptors are sensitive is stretch cutting,
    tearing, or crushing of viscera does not result
    in pain.
  • Visceral stretch receptors are located in the
    muscular layers of the hollow viscera, between
    the muscularis mucosa and submucosa, in the
    serosa of solid organs, and in the mesentery
    (especially adjacent to large vessels).
  • Mechanoreceptor stimulation can result from
    -rapid distention of a hollow viscus (e.g.,
    intestinal obstruction), -forceful
    muscular contractions (e.g., biliary or renal
    colic), and -rapid stretching of solid organ
    serosa or capsule (e.g., hepatic congestion).
    -Similarly, torsion of the mesentery (e.g., cecal
    volvulus) or tension from traction on the
    mesentery or mesenteric vessels (e.g.,
    retroperitoneal or pancreatic tumor) results in
    stimulation of mesenteric stretch receptors.
  • Chemical nociceptors -are contained
    mainly within the mucosa and submucosa of the
    hollow viscera. -activated directly by
    substances released in response to local
    mechanical injury, inflammation, tissue ischemia
    and necrosis, and noxious thermal or radiation
    injury. Such substances include H and K ions,
    histamine, serotonin, bradykinin and other
    vasoactive amines, substance P, calcitonin
    gene-related peptide, prostaglandins, and
    leuko-trienes.

10
Referred pain
  • Is felt in areas remote from the diseased organ
    and results when visceral afferent neurons and
    somatic afferent neurons from a different
    anatomic region converge on second-order neurons
    in the spinal cord at the same spinal segment.
  • Referred pain may be felt in skin or deeper
    tissues but is usually well localized.
  • Generally, referred pain appears as the noxious
    visceral stimulus becomes more intense. An
    example is illustrated in which shows how
    diaphragmatic irritation from a subphrenic
    hematoma or abscess results in shoulder pain.

11
Locations of Referred Pain and Its Causes
  • Right Shoulder Liver Gallbladder Right
    hemidiaphragm
  • Left Shoulder Heart Tail of
    pancreas Spleen Left hemidiaphragm
  • Scrotum and Testicles Ureter

12
QUESTION
  • A 38 yr-old male is seen the urgent care center
    with several hours of severe abdominal pain. His
    symptoms began suddenly. He reports several
    months of pain in the epigastrium after eating,
    with a resultant 10 pound wt loss. Pain is
    worsened by movement. He has no other past
    medical history. His only medication is antacids.

13
Somatoparietal pain
  • arises from noxious stimulation of the parietal
    peritoneum
  • more sudden, sharp, well-localized, lateralizing
    than visceral pain. An example of this difference
    occurs in acute appendicitis, in which the early
    vague periumbilical visceral pain is followed by
    the localized somatoparietal pain at McBurney's
    point produced by inflammatory involvement of the
    parietal peritoneum.
  • Parietal pain is usually aggravated by movement
    or coughing. The nerve impulses that mediate
    parietal pain travel within somatic sensory
    spinal nerves. The fibers reach the spinal cord
    in the peripheral nerves that correspond to the
    cutaneous dermatomes from the skinthoracic (T6)
    to the first lumbar vertebra (L1).
  • Lateralization of the discomfort of parietal pain
    is possible because only one side of the nervous
    system innervates a given part of the parietal
    peritoneum.
  • The patient with peritonitis lies quietly in bed,
    preferring to avoid motion, in contrast to the
    patient with colic, who may writhe incessantly.

14
PARIETAL PAIN
  • The intensity of the pain is dependent on the
    type and amount of material
  • For example, the sudden release into the
    peritoneal cavity of a small quantity of sterile
    acid gastric juice causes much more pain than the
    same amount of grossly contaminated neutral
    feces.
  • Enzymatically active pancreatic juice incites
    more pain and inflammation than does the same
    amount of sterile bile containing no potent
    enzymes.
  • Blood and urine are often so bland as to go
    undetected if their contact with the peritoneum
    has not been sudden and massive.
  • The rate at which the irritating material is
    applied to the peritoneum is important.
    Perforated peptic ulcer may be associated with
    entirely different clinical pictures dependent
    only on the rapidity with which the gastric juice
    enters the peritoneal cavity.

15
  • P.Ex P130/min, RR24/min, BP110/50 mmHg,
    Tm100.4F
  • Abdominal Ex absent bowel sounds, rigid, with
    involuntary guarding
  • Plain abdominal film free air
  • Dx is
  • Necrotic bowel
  • Necrotic pancreas
  • Perforated duodenal ulcer
  • Perforated gastric ulcer
  • Perforated gall bladder

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  • Pain due to a rectus sheath hematoma, muscle
    tear, or postoperative neuroma can be elicited by
    Carnett sign and Fothergill sign.
  • In Carnett sign, the patient who complains of an
    area of tenderness during conventional palpation
    is asked to tense the abdominal wall with neck
    flexion (protecting the abdominal viscera and
    cavity from the pressure of the examiner's
    hands), and the abdomen is then reexamined. If
    the patient's discomfort worsens, it suggests a
    disorder of the abdominal wall. If it lessens, an
    intra-abdominal process is more likely.
  • In Fothergill sign, a rectus sheath hematoma
    produces a painful, tender mass that does not
    cross the midline and remains palpable when the
    rectus is contracted.

18
QUESTON
  • A 67 year-old female is brought to the hospital
    with severe abdominal pain lasting 3 h. The pain
    came on suddenly while the pt was watching TV.
    After the pain he had nausea and vomiting without
    hematemesis. Her last bowel movement was the
    night before admission and was normal. She had a
    past medical hx. of hypertension and atrial
    fibrillation. Her medications include hctz,
    enalapril, and digoxin.
  • P.Ex BP118/60 mmHg, P115/min, irregular,
    RR20/min, Tm 99F
  • Abdominal Ex hypoactive bowel sounds and is
    mildly tender

19
Chronology or temporal
  • Temporal considerations rapidity of onset and
    progression and duration of symptoms The
    rapidity of onset of pain is often a measure of
    the severity of the underlying disorder. Pain
    that is sudden in onset, severe, and well
    localized is likely to be the result of an
    intra-abdominal catastrophe Affected patients
    usually recall the exact moment of onset of their
    pain.

20
Patterns of acute abdominal pain
  • . A, Many causes of abdominal pain subside
    spontaneously with time (e.g., gastroenteritis).
  • B, Some pain is colicky (i.e., the pain
    progresses and remits over time) examples
    include intestinal, renal, and biliary pain
    (colic). The time course may vary widely from
    minutes in intestinal and renal pain to days,
    weeks, or even months in biliary pain.
  • C, Commonly, abdominal pain is progressive, like
    its maturing, as in appendicitis or
    diverticulitis.
  • D, Certain conditions have a catastrophic onset,
    such as ruptured aortic aneurysm.

21
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22
Cont
  • Labs mild AG metabolic acidosis
  • elevated WBC with a left shift
  • A/L nl, Lfts nl
  • CT bowel wall edema and air in the area of
    splenic flexure
  • Dx
  • Acute pancreatitis
  • Colitis
  • Colon ca
  • Mesenteric ischemia
  • Perforated duodenal ulcer

23
QUESTION
  • A 70 yr-old with a hx of cv accidents is living
    at a nursing home, was noted to complain about
    mild diffuse abdominal pain for 3 days with
    associated anorexia. He is brought to the ER with
    AMS.
  • P.Ex. P100/min, rr20/min, BP90/60 mmHg,
    Tm100.6 F

24
Abdominal pain in elderly
  • must be considered seriously, because nearly half
    the patients older than 65 years who present to
    the emergency department (ED) with abdominal pain
    are admitted, and as many as one third require
    surgical intervention at some time during their
    admission
  • The overall mortality for elderly ED patients
    with a chief complaint of abdominal pain exceeds
    10, rivaling that of an acute ST-segment
    elevation MI
  • Many factors make diagnosis difficult in elderly
    patients
  • These include difficulty in obtaining
    history from the patient, lack of consistent
    physiologic responses (including fever and
    leukocytosis), and confusing clinical
    presentations due to other comorbid conditions
  • The patient's ability to provide a history is
    frequently compromised by an altered ability to
    communicate. These communication difficulties may
    result from hearing and vision loss,
    cerebrovascular accidents leading to receptive or
    expressive aphasias, Alzheimer's disease, and
    other age-related dementias. Other barriers to
    obtaining an adequate history include the
    patient's fear of loss of independence and
    stoicism.
  • Altered pain perception in the elderly may
    influence the patient's ability adequately to
    describe and report pain
  • A number of medications can interfere with the
    diagnostic process or may be contributing causes
    of the presenting abdominal condition.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs),
    may block the expected inflammatory response
    to peritonitis and thereby decrease the degree of
    abdominal tenderness for a given pathologic
    condition, or they may be a contributing source
    of a perforated peptic ulcer. Narcotic use for
    chronic conditions may also blunt the pain
    response that normally signifies an
    intra-abdominal catastrophe. This effect can
    cause a delay in the patient's presentation or
    lead the clinician to underestimate the severity
    of the condition.

25
Abdominal pain in elderly
  • Age-related physiologic changes
  • These atypical features include longer
    time until presentation, normothermia or even
    hypothermia,and lower leukocyte counts in the
    face of serious intra-abdominal infections

26
Cont
  • Pulmonary and cardiac ex is normal other than
    tachycardia
  • Abdominal examination is significant for absent
    bowel sounds, diffuse tenderness with rebound and
    guarding most pronounced in the RLQ. In addition
    to abx and fluid resuscitation, what is the next
    step?
  • LP
  • NG lavage
  • Mesenteric angiogram
  • Surgical consultation
  • CT abdomen without contrast

27
Abdominal pain in elderly
  • Appendicitis accounts for approximately 5 of all
    cases of acute abdomen in the elderly .
  • Less than one third of elderly patients have the
    classic presentation, defined as including all of
    the following fever, elevated white blood cell
    count, anorexia, and right lower quadrant pain.
  • in one series, 54 of older patients who had
    appendicitis had an incorrect initial admitting
    diagnosis, which contributed to the high
    perforation rate (51) found at the time of
    surgery .
  • The delay in presentation of the patients was
    also reported as a factor contributing to
    increased complication rates.
  • Importantly, right lower quadrant pain and
    tenderness are usually present, and appendicitis
    must remain high on the list of diagnostic
    possibilities when these symptoms are discovered.
    Although CT scanning has aided in the diagnosis
    of appendicitis in patients who have abdominal
    pain, its sensitivity is not 100, and admission
    for observation is prudent when the cause of
    lower abdominal pain is unclear.

28
  • A 45 yr- old male is admitted to the ICU with
    acute onset of epigastric pain radiating to the
    back. No other significant past medical history.
    Denies alcohol.
  • P.Ex RR30/min, P145/min, BP90/50 mmHg,
    Tm100.9F.
  • P.Ex diffuse inspiratory crackles, with
    tachypnea, absent bowel sounds, and a diffusely
    tender abdomen. Cullens sign is present.

29
  • Labs WBC20, Cr 2.3 mg/dl, AST115 U/L, ALT50
    IU/L and a total Bili.3 mg/dl
  • Amylase/lipase400/650 IU/L
  • Dx is
  • Choledocholithiasis
  • Necrotizing pancreatitis
  • Interstitial pancreatitis
  • Pancreatic Head mass
  • Pseudocyst

30
INTERVIEW FRAMEWORK
  • Determine whether this is acute or chronic
    abdominal pain (or an acute exacerbation of
    chronic abdominal pain). The differential
    diagnosis differs depending on the acuity of the
    pain.
  • Assess for alarm symptoms.
  • Identify the primary location of the pain (if
    possible), and determine whether the pain has
    moved to another location
  • Inquire about abdominal pain characteristics
    using the cardinal symptom features (PQRST)
  • Provocation What makes the pain worse or
    better?
  • Quality What is the character of the
    pain? Radiation Does the pain radiate?
    Severity Rate the pain on a scale
    from 0 to 10 (with 0 being no pain and 10
    being the worst pain
    possible). Timing/Treatment How long have you
    had the pain? Has the pain been persistent
    or intermittent over this period of time? What
    has been done to treat the pain?

31
ALARM SYMPTOMS
32
PQRST
  • Provoke Does eating worsen the pain?
    Pancreatitis, gastric ulcer, mesenteric
    ischemia Does eating alleviate the pain?
    Duodenal ulcer, gastroesophageal reflux
    disease
  • Quality or associated symptoms Is the pain
    associated with nausea and vomiting?
    Pancreatitis, bowel obstruction, biliary colic
    Is the pain "tearing"?
    Aortic dissection Is the pain "crampy"?
    Distention of a hollow tube (ie, bowel,
    bile duct or ureter) Is the pain associated
    with emesis of undigested food? Esophageal
    obstruction Is the pain associated with
    emesis of undigested food with acidic, digestive
    outlet obstruction juices from the stomach but
    no bile? Gastroparesis or gastric Is the
    emesis bloody? Gastroesophageal reflux
    disease, esophageal or gastric varices, PUD,
    gastric cancer, aortoenteric fistula

33
  • Radiation Does the pain radiate to the
    back? Pancreatitis, duodenal ulcer,
    gastric ulcer Does the pain radiate to the
    right shoulder? Biliary colic
    Does the pain radiate to the left
    shoulder? Splenomegaly or splenic
    infarction Does the pain radiate to the left
    arm? Myocardial ischemia
  • Severity Did the pain in your right
    lower abdomen suddenly improve from an 8 or 9 to
    a 2 or 3? (on a scale of 0 to 10)
    Perforated appendix Did the pain hurt the
    most at its onset? Aortic dissection
  • Timing/Treatment Is the pain continuous
    with intermittent waves of worsening pain?
    Biliary colic, renal colic, small bowel
    obstruction Are there multiple waves of pain
    that increase in intensity, then stop abruptly
    for short periods of time? Small bowel
    obstruction Did you recently take
    antibiotics? Colitis due to Clostridium
    difficile Does the pain occur once monthly
    around 2 weeks after the beginning of your
    menses, occasionally associated with vaginal
    spotting? Mittelschmerz

34
THINK NON-GI CAUSES
35
QUESTION
  • A 42 yr-old female presents with rt sided pain
    for last 3 months. She notes that the pain is
    episodic and is characterizes it as crampy. She
    c/o loose stools but occasionally notes hard
    narrow caliber stools and a feeling of incomplete
    evacuation. Symptoms worsen with stressful
    situations. She has found blood on the toilet
    paper. No wt loss
  • P.Ex is benign
  • Next step is
  • A) Colonoscopy
  • B) Antidepressant
  • C) Dietary modification
  • D) Lomotil
  • E) Tageserod

36
IRRITABLE BOWEL SYNDROME
  • DIAGNOSIS
  • ROME DIAGNOSTIC CRITERIA
  • 3 month minimum of following symptoms
  • in continuous or recurrent pattern
  • Abdominal pain or discomfort relieved by BM
  • associated with either
  • Change in frequency of stools
  • and/or
  • Change in consistency of stools
  • Two or more of following symptoms on
  • 25 of occasions/days
  • Altered stool frequency
  • gt3 BMs daily or lt3BMs/week
  • Altered stool form
  • Lumpy/hard or loose/watery
  • Altered stool passage
  • Straining, urgency, or feeling of incomplete
  • evacuation
  • Passage of mucus
  • No identifiable structural or biochemical
  • abnormalities
  • Affects 14-24 of females and 5-19
  • of males
  • Onset in late adolescence to early adulthood
  • Rare to see onset gt 50 yrs oldPain described as
    nonradiating, intermittent,
  • crampy located lower abdomen
  • Usually worse 1-2 hrs after meals
  • Exacerbated by stress
  • Relieved by BM
  • Does not interrupt sleep
  • critical to diagnosis of IBS

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QUESTION
  • A 58 y-old female presents with epigastric pain
    that is worst after eating. The pain is so severe
    that the patient avoid eating and has lost 25
    pounds over 2 months. She describes the pain as
    burning in quality and somewhat relieved with
    antacid therapy

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