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Abdominal pain
- 1. Abdominal pain Ahmed khaled elgizawy N0 : 35 Round : 1
- 2. Anatomic background Parietal peritoneum clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) . Visceral peritoneum is the continuation of the parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).
- 3. 1 2 3 4 5 6 7 8 9 1 – right hypochondrium 2- epigastric 3- left hypochondrium 4- Right lumbar 5- umbilical 6- left hypochondrium 7- right iliac 8-hypogastric 9- left iliac
- 4. DEFINITION OF PAIN It is an unpleasant sensation of .varying intensity Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.
- 5. STIMULANTS 1 Mechanical trauma to the tissue . 2 Excess heat or cold . 3 Chemical damage. 4 Radiation damage . 5 Inadequate blood flow.
- 6. Abdominal Extra-abdominal Systemic dysfunction Functional abdominal Abdominal wall + Pelvic organs Intra-peritoneal organs Retro-peritoneal organs Diabetes ,tabes dorsalis pain Intra-thoracic organs porphyria
- 7. Types of abdominal pain 2 1 Visceral pain is primitive Somatic pain is entirely and therefore related to different from visceral pain embryologic development .
- 8. Visceral pain 1- Receptor ( Visceral peritoneum )
- 9. 2 - Stimulus Pat. Experienced pain by traction ,distention & spasm The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction
- 10. 3 - Mediation Autonomic nervous System Interpreted at the thalamic level of the brain
- 11. 4- Specificity Vague , often dull , poorly described & associated with nausea & vomiting
- 12. 5- Localization Is poor & the pat. Placing the entire hand over the involved region
- 13. Somatic pain 1- Receptor Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves P/ peritoneum
- 14. Somatic pain 2- Stimulus Pat. experienced pain by Pressure Touch Heat Inflammation
- 15. Somatic pain 3- Mediation Central nervous system & Interpreted at a specific cortical location
- 16. Somatic pain 4- Specificity Precisely described as Cutting
- 17. Somatic pain 5- Localization The pain is localized with great accuracy by the patient , who can often point to the site with one finger
- 18. Referred pain Pain felt at a site other than where the cause is situated. An example is the pain from the pancreas, which is felt in the back. Pain in internal organs is often referred to sites distant from them.
- 19. Analysis of pain need DATA COLLECTION 1 2 3 History Physical exam. Lab.inv. apply your medical knowledge***
- 20. History of pain The history of pain betrays the diagnosis Factors influencing the of pain Natureof onset Mode clinical manifestation Radiation Severity Site Duration
- 21. Site of pain & radiation Radiation of the pain GB Stomach & duodenum Pancreas Small bowel Kidney Kidney Caecum & rp.structure App. & Caecum T. Colon bladder uterus & adnexae Sig. colon Pancreatic pain Small bowel pain does not Radiation indicates source of the Lower the extent of the disease pain & also abdominal pain usually radiate Kidney pain pain Stomach & duodenal tends to go rarely radiate radiates Pain but GB.radiate may The structures in goes through to the back & to may move whenback but through to the somatic pelvis may radiate to thethe down as visceral nerves into reach lower strait the right ,thethe groin as well to to left back or perineum throughirritated tip of the shoulder blade become the back
- 22. Mode of onset Sudden onset [The patient can tell you exactly when the pain started ] The pain that start suddenly has a mechanical basis Some thing has been Twisted Occluded Ruptured
- 23. Mode of onset Gradual Onset ( The pat. Usually responds vaguely to questions about time of onset ) Non mechanical or chronic process
- 24. Nature of pain Two Large Categories (2) (1) Conditions associated with obstruction Conditions associated with of a muscular conducting tube inflammation (( Mild & Localized Response or Small bowel , Ureter , Biliary ) Severe , Generalized Response )
- 25. 1 Obstruction prolonged Distention of the viscus ( constant stretching pain ) Sudden Colic pain = visceral pain Three Types (3) ((2)) Small Intestine = ((midgut )) ) Renal system = ( retroperitoneal 1 Biliary System foregut Pain felt pain is experienced in the epigastrium Foregut in the flank & radiates to region Pain is is experienced in the periumbilical the groin
- 26. Important features of colic pain I. Pat . Is often restless & agitated during exacerbations. II. Pat. Does not experience a totally pain –free interlude. III. Colic pain is an intermittent pain . IV. Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal layers ) V. Failing to demonstrate guarding , tenderness ? ????
- 27. 2 Inflammation Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Peritonitis Generalized Localized
- 28. 2 Inflammation Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Contamination BY Foreign body Chemicals Bacteria Trauma
- 29. Important features of somatic pain I. Pat. Laying quite in bed . ( movement is limited ) II. Examination may demonstrate guarding , tenderness . III. The pain is localized over the inflamed organ . IV. Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .
- 30. Ischemic pain Is a somatic pain Occlusion of blood supply cause Necrosis After 6-12 h Tissue Hypoxia With metabolic changes
- 31. ?So how do we organize this • Location • Acute v. chronic • Surgical v. nonsurgical
- 33. Localizing pain -- RUQ • • • • • Hepatitis Cholecystitis Cholangitis RLL pneumonia Subdiaphragmatic abscess
- 34. Localizing pain -- LUQ • Splenic infarct • Splenic abscess • Gastritis/PUD
- 35. Localizing pain -- RLQ • • • • • • • Appendicitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology
- 36. Localizing pain -- LLQ • • • • • • • Diverticulitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology
- 37. Localizing pain -- epigastric • • • • • PUD Gastritis Pancreatitis GERD Cardiac (MI, pericarditis, etc)
- 38. Localizing pain -- periumbilical • • • • Pancreatitis Obstruction Early appendicitis Small bowel pathology • Gastroenteritis
- 39. Localizing pain -- pelvic • UTI • Prostatitis • Bladder outlet obstruction • PID • Uterine pathology
- 40. Localizing pain -- diffuse • • • • • • Gastroenteritis Ischemia Obstruction DKA IBS Others ▫ ▫ ▫ ▫ FMF AIP Vitamin D deficiency Adrenal insufficiency
- 41. Acute abdominal pain • Generally present for less than a couple weeks ▫ Usually days to hours old ▫ Don’t forget about the chronic pain that has acutely worsened • More immediate attention is required
- 42. Acute abdominal pain • Surgical ▫ ▫ ▫ ▫ ▫ ▫ ▫ Appendicitis Cholecystitis Bowel obstruction Acute mesenteric ischemia Perforation Trauma Peritonitis • Nonsurgical ▫ ▫ ▫ ▫ ▫ ▫ ▫ Cholangitis Pancreatitis Nonabdominal causes Choledocholithiasis Diverticulitis PUD/-itis gastroenteritis
- 43. Surgical abdomen • This is the first thing to be considered in acute abdominal pain ▫ Early identification is a must as prognosis worsens rapidly with delay in treatment • Important to get surgeons involved early if this is even mildly suspected • This is a clinical diagnosis
- 44. Surgical abdomen • Presentation is usually bad ▫ Fevers, tachycardia, hypotension ▫ VERY tender abdomen, possibly rigid • Presentation can vary with other demographic and medical factors ▫ Advanced age ▫ Immunosuppression
- 45. Surgical abdomen • Peritonitis ▫ Often signals an intraabdominal catastrophe Perforation, big abscess, severe bleeding ▫ Patient usually appears ill ▫ Exam findings Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed
- 46. Surgical abdomen • Obstruction ▫ May be acute or acute on chronic ▫ Symptoms include persistent vomiting, abdominal distention (or not), pain ▫ Exam findings depend on level of obstruction (proximal v. distal) Distal – distention, tympany, absent or high-pitched bowel sounds Proximal – similar, but may not see distention and tympany
- 47. Surgical abdomen • Ischemia ▫ Mesenteric ischemia usually seen in patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons ▫ Symptoms include pain OUT OF PROPORTION TO EXAM ▫ Exam findings Severe tenderness to minimal palpation, unstable vital signs, and a very uncomfortable patient
- 48. Surgical abdomen • Work-up ▫ Start with stat labs ▫ Surgical abdominal series (plain films) ▫ Consider stat CT if readily available • Sometimes patients go straight to surgery as initial step • Again, get surgeons involved early for guidance and early intervention
- 49. Chronic abdominal pain • Generally present for months to years • Generally not immediately life threatening • Outpatient work-up is prudent
- 50. Th an ky ou