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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