Abdominal pain by Dr Mohammed Hussien (lecturer of Hepatogastroentrology at Kafrelsheikh university )

1. Abdominal Pain
&
Drug induced liver Disease
Dr/ Mohammed Hussien,MD
Lecturer of Hepatology & Gastroentrology
Kafrelsheik University
Membership at American Collage of Gastroenterology (ACG)
Membership at Egyptian association for Research and training in
Hepatogastroentrology

2. What kind of pain is it?
• Visceral
• Involves hollow or solid organs; midline pain due to bilateral innvervation
• Steady ache or vague discomfort to excruciating or colicky pain
• Poorly localized
• Epigastric region: stomach, duodenum, biliary tract
• Periumbilical: small bowel, appendix, cecum
• Suprapubic: colon, sigmoid, GU tract
• Parietal
• Involves parietal peritoneum
• Localized pain
• Causes tenderness and guarding which progress to rigidity and rebound as peritonitis
develops e.g. appendicitis
• Referred
• Produces symptoms not signs
• Based on developmental embryology
• Ureteral obstruction → testicular pain
• Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
• Gynecologic pathology → back or proximal lower extremity
• Biliary disease → right infrascapular pain
• MI → epigastric, neck, jaw or upper extremity pain

3. The term Acute abdomen refers to a sudden, severe
abdominal pain of that is less than 24 hours in duration.
• Location
• Quality
• Severity
• Onset
• Duration
• Modifying factors
• Change over time

5. Causes
I- Abdominal

6. Extra-Abdominal Causes of the Abdominal pain

7. Non-surgical Causes of the Acute Abdomen
• Cardiac:
Myocardial infarction, Acute pericarditis
• Pulmonary:
Pneumonia, Pulmonary infarction
• Gastrointestinal:
Acute pancreatitis,Gastroenteritis,Acute hepatitis
• Endocrine:
• DKA, Acute adrenal insufficiency adrenal
insufficiency

8. Acute Pancreatitis
• Risk Factors
• Alcohol
• Gallstones
• Drugs
• Amiodarone, antivirals, diuretics,
NSAIDs, antibiotics, more…..
• Severe hyperlipidemia
• Idiopathic
• ERCP
• Infections: mumps
• Clinical Features
• Epigastric pain
• Constant, boring pain
• Radiates to back (increase in supine
position)
• Severe
• N/V
• bloating
• Physical Findings
• Low-grade fevers
• Tachycardia, hypotension
• Respiratory symptoms
• Atelectasis
• Pleural effusion
• Peritonitis – a late finding
• Ileus
• Cullen sign*
• Bluish discoloration around the
umbilicus
• Grey Turner sign*
• Bluish discoloration of the flanks
*Signs of hemorrhagic pancreatitis

9. Pancreatitis
• Diagnosis
• Lipase
• Elevated more than 2 times normal
• Sensitivity and specificity >90%
• Amylase
• Nonspecific
• more than 3 times…
• US if etiology unknown
• CT scan
• Insensitive in early or mild disease
• Confirm diagnose pancreatitis
• Useful to evaluate for complications
• Treatment
• NPO
• IV fluid resuscitation
• Maintain urine output of 100 mL/hr
• NGT if severe, persistent nausea
• No antibiotics unless severe
disease or infection
• Mild disease, tolerating oral
fluids
• Discharge on liquid diet
• Follow up in 24-48 hours
• All others, admit and pain
control e.g. meperidine

10. • Assessment of severity by
Ranson criteria
• Predict mortality:
• 0-2 : 2%
• 3-4 : 20%
• 5-6 : 40%
• 7-8 : 100%
• Complications
• Pancreatic necrosis
• Abscess
• Pseudo-cysts
• Splenic vein thrombosis
• Abdominal compartment syndrome
• ARDS, shock, renal failure, GI
bleeding
• Chronic pancreatitis

11. Acute Cholecystitis (Calcular 90%)
• Clinical Features
• RUQ or epigastric pain
• Radiation to the back or
shoulders
• Dull and achy → sharp
and localized
• Pain lasting longer than 6
hours
• N/V/anorexia
• Fever, chills
• Physical Findings
• Epigastric or RUQ pain
• Murphy’s sign
• Boas sign
• Patient appears ill
• Peritoneal signs suggest
perforation

12. Cholecystitis
• Diagnosis
• CBC, LFTs, Lipase
• Elevated alkaline phosphatase
• Elevated lipase suggests gallstone
pancreatitis
• RUQ US
• Thicken gallbladder wall
• Pericholecystic fluid
• Gallstones or sludge
• Sonographic murphy sign
• HIDA scan
• more sensitive & specific than US
• Treatment
• Surgical consult
• IV fluids
• Correct electrolyte
abnormalities
• Antispasmodics
• Analgesia: avoid morphine
• Antibiotics
• Ceftriaxone 1 gram IV
• NGT if intractable vomiting
• Emergency surgery:
Empyema, emphysematous
GB, perforation
• Delayed cholecystectomy: 1-4
moths

13. Chronic Cholecystitis
• Mostly calcular
• Common oraganisms: E coli,
Salmonella
• C/P=== pain + dyspepsia (fatty)
• Diagnosis: US
• Treatment
• Medical:
• Wt reduction
• Avoid fat
• Antispasmodics
• Medical dissolution by UDCA
• Antibiotics
• Surgery: open vs lap.

14. Cholelithiasis
• GB
• CBD stones
• Clinically:
• 1- Charcot triad (cholangitis)
• 2- Biliary colic
• 3- Silent
• Diagnosis: US
• Treatment
• Medical dissolution by UDCA
• ERCP

15. “ How to reach a diagnosis ?”

18. Examination

20. Investigations

22. Familial Mediterranean
fever
(FMF)
Periodic syndrome, Benign paroxysmal peritonitis, Periodic
abdomenlagia

23. Familial Mediterranean fever
• Rrecurrent, short-lived episodes (no more than 4 days) of fever
accompanied by peritoneal, pleural, or arthritic inflammation.
• the mechanisms leading to the clinical manifestations of the disease
are still unknown
• Periodicity is the hallmark of the disease

24. PATTERN OF INHERITANCE
• Autosomal recessive trait
• FMF is most prevalent in individuals of:
 Sephardic Jewish (1 in 6 – 8 )
 Armenian (1 in 7 )
 Ashkenazi (1 in 12 )
 Turkish
 Arab descent

25. The FMF gene ( MEFV )
MEFV is located on the short arm of chromosome 16
at least 23 mutations have been identified .

26. Attacks
• The febrile, painful attacks that are the hallmark of the disease are
characterized by;
• marked elevation of body temperature,
• acute inflammation of the peritoneum, synovia, or pleura,
• a duration of 12 to 48 h, and
• complete health between attacks .
• Repeated attacks at irregular intervals and in an unpredictable sequence

27. Abdominal attack
• The most frequent manifestation
• experienced by 90 per cent of patients
• They are marked by the sudden onset of fever (often with chills)
• Pain spreading over the entire abdomen from variable points of
origin.
• Guarding, rebound tenderness, board-like rigidity, distension, and
absence of peristalsis appear.
• Suggest an acute abdominal catastrophe.

28. Abdominal attack
• After 6 to 12 h the signs and symptoms recede, and within 24 to 48 h
the attack is usually over, leaving the patient as well as before.
• Organization of the exudate may result in fibrous adhesions,
• mechanical ileus
• sterility in some affected women .

29. pleural attack
• 45 % of patients, and in 5 % it was the presenting sign .

30. • Pericarditis-
• a rare feature of familial Mediterranean fever.
• No permanent sequelae have been reported.
• Muscle pains (20%)
• lasts from a few hours to 1 to 2 days, and
• subsides with rest or non-steroidal anti-inflammatory drugs.

31. articular attack
• the second most common form of attack. (75%)
• Arthritic attacks may recur for years as the only feature of the
disease, before other forms appear .
• Large joints are involved, particularly those of the lower extremities.
• In two forms:
• acute, or
• chronic and protracted.

32. Erysipelas-like erythema (11%)
• one of the most characteristic manifestations of FMF.
• usually combined with arthritis.

34. • Amyloidosis is major cause of mortality in FMF.

35. Tel-Hashomer Diagnostic criteria
Major criteria
1.Painful inflammatory manifestations in the abdomen, chest, joints,
or skin, associated with the fever.
2.Nephropathic amyloidosis.
3.Dramatic response to continuous colchicine treatment in abolishing
or reducing febrile attacks
Minor criteria
4.Short attacks of fever recurring at irregular intervals.
5. Family history
6. Erysipelas like rash
Diagnosis- 2 major or 1 major 2 minor criteria

36. Laboratory findings
• non-specific.
• Leucocytes increased
• Crp and ESR elevated

37. Laboratory findings
• Serum amyloid A is raised
• acute-phase protein
• the familial Mediterranean fever (FMF) gene located on the short
arm of chromosome 16

38. Treatment-to prevent attacks
• Daily prophylactic treatment with colchicine
• Treatment is started with 1 mg colchicine/day, regardless of age or
severity of attacks.
• This dose is increased if necessary to 1.5 to 2 mg, until remission
from attacks is achieved.
• Ccontinuous prophylactic treatment with colchicine in patients
inhibits the development of nephropathic amyloidosis
• Analgesia during the attack
.

39. Bowel ischemia
• Acute or chronic
• Occlusive or nonocclusive
• Arterial or venous
• Small bowel or large bowel .
{{ ischemic enteritis or ischemic colitis }}.

40. Acute ischemia
• Acute interruption of blood flow to the bowel
• causes :
@ arterial
_ occlusive
* embolism {40-50%} : atrial fibrillation or endocarditis
(SMA most commonly involved)
* thrombosis { 20-40% } : atherosclerosis
* mechanical obstruction: strangulation, tumor
_ nonocclusive
hypoperfusion ( low flow states, hypotension, sepsis or
heart failure with diffuse mesenteric vasoconstriction )
( IMA most commonly involved )
@ venous
* Mesenteric venous thrombosis { 10% }

41. • Clinical details :
* clinical triad of {sudden onset of abdominal pain, diarrhea &
vomiting, Bleeding}
* diffuse abdominal pain, out of proportion to physical
examination.
* leukocytosis
* gross rectal bleeding (red current jelly stool)
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42. .•Chronic ischemia.
{ abdominal angina, Sitophagia}
* Most commonly caused by atherosclerosis of coeliac
and SMAs & symptoms are unlikely unless at least
two vessels are involved.

43. . ** clinical details
* post-prandial abdominal pain, 15-20 minutes after
food intake ( due to “gastric steal” diverting blood
flow away from intestine ) and the pain subsides
1-2 hours after meal.
* fear of eating large meals
* malabsorption
* weight loss

44. Ischemic colitis
• Most cases are thought to be related to diminished blood
flow within the bowel
• Predominantly a disease involving the distribution of IMA
.i.e., from distal transverse colon to rectum
• When the more proximal colon is involved, it is frequently
associated with extensive small bowel ischemia & a
correspondingly much graver prognosis.
• Patients are usually elderly .
• The clinical picture may mimic acute diverticulitis.
• Most common cause of colitis in elderly & is often self
limiting.

46. .
• Prognosis of ischemic colitis
1. complete resolution (75%) within 1-3 months
2. Stricturing ischemia (20%)
3. Gangrenous with necrosis and perforation (5%)

48. Imaging
• Plain abdominal radiography
• Barium study
• Angiography
• CT

54. Complications
• Sepsis
• Septic shock
• Multiple system organ failure
• death

55. Mortality
• Occlusive mesenteric infarction { embolus or thrombosis } has a 90%
mortality rate , whereas non-occlusive disease has a 10% mortality
rate .
• Ischemic enteritis----- 90% mortality rate
• Ischemic colitis-------- 10% mortality rate

56. Treatment
• Interventional Radiology
• Surgery
• Medical

57. • Drug Induced Liver Disease
• Mode of hepatic toxicity of important drugs
• • Direct toxicity (predictable, dose dependent)
• Acetaminophen.
• Amanita mushroom.
• Carbon tetrachloride.
• • Idiosyncratic reaction (unpredictable, dose independent)
• Halothane. - Phenytoin.
• Isoniazide. - Sodium valproate.
• An idiosyncratic drug reaction is a dose independent immune
reaction which is based on an individual patient's biochemical
alteration of drug metabolism (an abnormal susceptibility to an
agent peculiar to an individual).
• Both mechanisms!
• INH.
• Sodium Valproate.

58. •Types of Liver injury by drugs
• • Acute hepatitis
• - Halothane.
• - INH, rifampicin.
• - Cytotoxic drugs
• Chronic hepatitis
• - Methyldopa.
• - Nitrofurantoin – Fenofibrate.
• - INH.
• • Cholestasis
• - Anabolic steroids.
• - Oral contraceptive pills.
• - Oral hypoglycemic.
• - Phenothiazines.
• - Tricyclic antidepressants

59. • • Fatty liver
• - - Tetracyclines.
• - - Amiodarone.
• - - Sodium valproate ~ (anti epileptic).
• - - Corticosteroids.
• • Hepatic necrosis
• - Paracetamol (toxic dose> 15 gm = 30 tabs): This is one of the most
common cause of drug induced hepatic failure worldwide.
Paracetamol is the preferred analgesic antipyretic agents in certain
cituations:

60. •  Pelioses hepatis (vascular channels)
• - Anabolic steroids. - Contraceptive pills.
• • Hypersensitivity
• Allopurinol.
• Antithyroid drugs.
• Diltiazem.
• • Budd chiari syndrome: contraceptive pills.
• • Adenoma:
• - contraceptive pills, anabolic steroids.
• - Sulfonamides.
• - Phenytoin.
• - Penicillins.
• • Hepatoma ~ Danazole