clinical approach to a patient with abdominal pain

1. Clinical approach to
a patient with
abdominal pain

2. ABDOMINAL PAIN
VISCERAL PAIN SOMATIC PAIN
NOCICEPTORS From ABDOMINAL
 STRETCH WALL & PARIETAL
 CHEMICAL PERITONEUM

4. SITE AND RADIATION
ORGAN SITE OF PAIN RADIATION
STOMACH EPIGASTRIUM Rt HYPO,
LUMBAR,Rt
ILIAC,Lt
CHEST,VERTEBR
AL COLUMN
LIVER-Rt LOBE Rt SHOULDER,SUP
HYPOCHONDR RACLAVICULAR
& SCAPULAR
IUM
REGION ON Rt

5. LIVER-Lt LOBE EPIGASTRIUM PRECORDIUM,
Lt SCAPULAR, Lt
CLAVICLE
GALL BLADDER EPIGASTRIUM or CHEST,Rt
Rt SCAPULA,Rt
HYPOCHONDRI CLAVICLE,SHOU
UM LDER,BACK
May resemble
ANGINAL pain
SPLEEN Dragging Local inflamn of
(pain unusual) sensation peritoneum-
&fullness-Lt Catching pain
HYPO & respiration
LUMBAR

6. PANCREAS EPIGASTRIUM Acute-symps of
OR BACK shock
Chronic-vague in
nature & location
KIDNEYS LOINS or Obstructive
LUMBAR lesions-Penis or
REGION Labia + urgency
for urination
URINARY HYPOGASTRIUM PERINEUM &
BLADDER URETHRA

7. SMALL UMBILICUS
INTESTINE
LARGE ILIAC or LUMBAR
INTESTINE
APPENDIX Rt ILIAC FOSSA Rt LUMBAR,
CAECUM UMBILICAL
RECTUM Lt ILIAC FOSSA Assoc. with
or tenesmus
HYPOGASTRIUM

8. UTERUS HYPOGASTRIU LOW BACK &
M & UMBILICUS FLANKS
DYSMENORRHOEA LOWER
ABDOMEN
OVARY ILIAC FOSSA EXTERNAL
GENITALIA

9. PERITONITIS
LOCALISED GENERALISED
Eg. Rt iliac fossa in DIFFUSE affecting
appendicitis the whole abdomen
GUARDING AND RIGIDITY ON PALPATION

10. REFERRED PAIN
Pain arising from lesions outside
abdomen
REFERRED to abdomen
Eg. MI radiate to epigastrium
Girdle pain B/L dorsal nerve root
compression

11. Psycogenic Pain
Not due to any organic cause
More common at night

12. NATURE OF PAIN
SOLID ORGANS:DULL & CONSTANT
aggravated by pressure.Organ
enlarged,palpable,tender.
HOLLOW VISCERA:COLICKY PAIN
reach max. in secs or mins & passes off.
Exception biliary tract & pancreas

13. DURATION OF PAIN
ACUTE CHRONIC
Intense pain with Periods of remissions
dramatic onset & exacerbations with
Reach maximum in intervals of relief in
hrs or days btwn
Months or years

14. Relation to normal physiological events
Pain related to ingestion of Gastric ulcer
food
Pain relieved by food intake Duodenal ulcer
Relief of pain by vomiting Gastric outlet obstruction
Pain on recumbency & GERD
relief on erect posture

15. Pain on ingestion of fat Malabsorption
Pain on defaecation Colonic disease
Blood and mucus in faeces Colonic ulcer
Pain as food pass down to Intestinal angina
be digested & absorbed

16. Past History
Trauma
DM, CRF-Metabolic cause of pain
Thrombotic disease-Vaso occlusion
CAD-Embolic occlusion
Family History
o DM
o CAD

17. Personal History
Appetite & Loss of weight
Bowel habits- Malena-Upper GIT ds
Hematochezia-Lower GIT ds
Difficulty in micturition
Menstrual history

18. General Examination
PALLOR Malabsorption,Acute or
chronic blood loss
ICTERUS Hepatobiliary disease
CYANOSIS Cirrhosis liver with portal
hypertension
CLUBBING Cirrhosis,ulcerative
colitis,Crohn`s disease
LYMPHADENOPATHY Generalised or localised

19. GIT Examination….
 Inspection
1. Shape
2. Umbilicus
3. Movements of the abdominal wall
4. Skin and surface of abdomen

20. •Palpation
1. Liver
2. Spleen
3. Kidneys
4. Palpable mass

21. • Percussion
 Shifting dullness
 Fluid thrill
 Puddle sign
 Auscultation
1. Bowel sounds
2. Succusion splash

22. Also examine….
Genitalia
Hernial orifices
Per rectal examination
Per vaginal examination