Differential diagnosis of abdominal pain. Lakatos Péter László

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1 Differential diagnosis of abdominal pain Lakatos Péter László

2 Precise anamnesis Physical examination are prognosticated to the cause of the pain

3 Anamnesis Sudden pain Perforation Mesenteric infarction Aortic aneurysm rupture The onset is determinated Progressio Gastroenteritis has constant pain Appendicitis has rising pain Colic has decrease-increase-dedrease-increase pain The extended pain is rarely life threatening

Gastroenteritis has constant pain Appendicitis has rising pain Colic

4 Az acut hasi fájdalom Anamnézis A hirtelen fájdalom okai Perforáció Mesenteriális infarctus Aorta aneurisma ruptura A beteg szinte percre meg tudja mondani a kezdetet. Progresszió A gastroenteritis állandó Az appendicitis fokozódó A kólika csökken nő csökken nő Tartama A hetek A: spontaneously óta tartó fájdalom pass away f.g. gastroenteritis ritkán életet B: colic veszélyeztető (intestinal, kidney, gall bladder) C: progressive: appendicitis, diverticulitis

Progresszió A gastroenteritis állandó Az appendicitis fokozódó A kólika csökken nő csökken nő Tartama A hetek A:

5 Anamnesis Sudden pain Perforation Mesenteric infarction Aortic aneurysm rupture The onset is determinated Progressio Gastroenteritis has constant pain Appendicitis has rising pain Colic has decrease-increase-dedrease-increase pain The extended pain is rarely life threatening

6 Anamnesis Location The pain is not always fit to the organ

7 Anamnesis Location Appendicitis Early periumbilical pain Later right iliac fossa pain

8 Anamnesis Location Cholecystitis Right upper quadrant

9 Anamnesis Location Pancreatitis Epigastric Back

10 Anamnesis Location Diverticulitis Left-side lower abdomen

11 Anamnesis Location Peptic ulcer perforation epigastric pain

12 Anamnesis Location Ileus Periumbilical pain

13 Anamnesis Location Mesenteric ischaemia/infarction Periumbilical pain

14 Anamnesis Location Abdominal aneurysm rupture Abdominal-back pain

15 Anamnesis Location Gastroenteritis Periumbilical

16 Anamnesis Location Pelvic inflammation Lower abdomen

17 Anamnesis Location Extrauterine gravidity Lower abdomen

18 Anamnesis Intensity of the pain Difficult to measure

19 Anamnesis Location Appendicitis Intensity ++ Early periumbilical pain Later right iliac fossa pain

20 Anamnesis Location Cholecystitis Intensity ++ Right upper quadrant

21 Anamnesis Location Pancreatitis Epigastric Back Intensity

22 Anamnesis Location Diverticulitis Intensity Left-side lower abdomen

23 Anamnesis Location Peptic ulcer perforation Intensity +++ epigastric pain

24 Anamnesis Location Ileus Intensity ++ Periumbilical pain

25 X-ray findings of ileus

26 Anamnesis Location Mesenteric ischaemia/infarction Intensity +++ Periumbilical pain

27 Anamnesis Location Abdominal aneurysm rupture Intensity +++ Abdominal-back pain

28 Anamnesis Location Gastroenteritis Intensity Periumbilical

29 Anamnesis Location Pelvic inflammation ++ Lower abdomen Intensity

30 Anamnesis Location Extrauterine gravidity Intensity ++ Lower abdomen

33 Inguinal és femoral hernia Lateral inquinal, indirect Medial inquinal, direct Femoral 1. Invaginate loose scrotal skin with your index finger. 2. Follow the spermatic cord upward to above the inquinal ligament, and find the opening of the external inquinal ring. 3. If possible, gently follow the inguinal canal laterally. 4. Ask the patient to strain down or cough. 5. Note any palpable herniating mass as it touches your finger. Palpate the anterior thigh in the region of the femoral canal.. If the findings suggest a hernia, try to reduce it by sustained pressure with your finger. If the mass is tender or the patient reports nausea and vomiting, you have to finish this maneuver. Incarcerated hernia: when its contents can not be returned to the abdominal cavity. Strangulated hernia:when the blood supply is compromised (tenderness, nausea, vomiting) Bates B: A guide to physical examination. Fifth edition.

35 Anamnesis The characteristic of the pain Connections Relating to mealtimes Decrease duodenal ulcer Increase- gastric ulcer, gall bladder, pancreas Relating to defecation - colon Relating to urination stimulus - nephrolith Relating to position Peritonitis- immobile Nephrolith- restless, look for the less painfull position

36 Anamnesis The relation of the pain with other symptoms Fever Shivering Nausea Vomiting Night sweats Loss og weight Myalgia Arhalgia Icterus Meteorism Dysuria Obstipation Diarrhoea

37 Anamnesis Pain and Previous diseases Family anamnesis

38 Physical examination Examination of the anamnesis Verify Exclude

39 Physical examination Examination of the anamnesis Verify Exclude The anamnesis and the physical examination can be atypical in elder patients, gravidity, diabetes, immundefections and ascites

40 Physical examination The patient position movement expression general imperssion

41 Physical examination Vital signs Other organs examination

42 Physical examination Abdomen Tenderness Abdominal resistance Defense Percussion Auscultation Rectal digital examination Gynecologic examination

43 Laboratory examination Blood test Electrolyte BUN, creatinine Blood glucose Astrup Liver function Amylase Urine Pregnancy test

44 X-ray Free abdominal air Air-fluid levels Ultrasound CT

45 X-ray Free abdominal air Air-fluid levels

46 Other diagnostics Peritoneal lavage Laparoscopy Explorative laparotomy

47 The definition of acute abdomen Life-threatening condition due to acute onset abdominal disease with typical symptoms and physical findings, which reqiures: Prompt surgical intervention Acute appendicitis Acute peritonitis Acute intestinal obstruction Acute mesenteric vascular insufficiency Rupture of the spleen, extrauterin gravidity, dissection of aortic aneurysm Emergent admission to a monitored bed or intensive care unit Acute pancreatitis Acute cholecystitis Purpura abdominalis

48 Physical findings in acute abdomen syndrome Abdominal pain The medication can influence. In case of shock the pain might be diminished Vomiting Mostly in cases of obstruction of intestine Involuntary muscular rigidity Inflammation(irritation) of parietal peritoneum Distension As a consequence of mechanic or paralytic ileus Shock Hypotension, sweating, pallor, tachycardy. In case of shock sometimes bradycardy because of the vagal (oarasympathic) activation

49 The chronic abdominal pain Organ disease Chronic pancreatitis Abdominal neoplasia Inflammatory bowel disease Mesenteric ischemia Pelvic inflammatory disease Endometriosis Functional disease Irritable bowel syndrome Non ulcer dyspepsia Gall bladder pain (dyskinesia)

50 The chronic abdominal pain Location Connection (mealtime, defecation, position, daytime, nervousness)? Other symptoms? General status Physical examination Precise examiantions (laboratory, radiology, ex juvantibus )

51 The chronic abdominal pain Chronic pancreatitis After eating Belt-like pain Severe status Steatorrhea

52 The chronic abdominal pain Abdominal neoplasia The pain slowly comes in to the life of the patient The location of the pain is depends on the location of the tumor Progressive

53 The chronic abdominal pain Inflammatory bowel disease The pain and the defecation is in a nexus (tenesmus!) The localisation of the pain nearly depends on the location The pain is caused by the activity of the disease

54 The chronic abdominal pain Mesenteric ischemia In a typical cause after maeltime (abdominal angina) Sometimes auscultated In a chronic case effect malabsorption Progressive

55 The chronic abdominal pain Pelvic inflammatory disease Lower abdominal pain on either side Gynecological exam (rectalis) confirm Common inflammatory symptoms

56 The chronic abdominal pain Endometriosis Lower abdominal pain Symptoms often worsen with the menstrual cycle

57 The chronic abdominal pain Irritable bowel syndrome Everything is around the stool After mealtime immediate defecation No symptoms during the night Normal gender status Other gastrointestinal signs Other psychology signs

58 The chronic abdominal pain Non ulcer dyspepsia Upper abdominal pain or dyscomfort A lot of types few regularity in the symptoms There is no alarm sign in the definition

59 The chronic abdominal pain Gall bladder pain (dyskinesia) After mealtime Pain under the right ribs Usually with other symptoms (nausea, meteorism) Long lasting compalint mainly females Negative bile examiantions

60 Summary-differencial diagnostics of abdominal pain ANAMNESIS (since when-how-associated to?) Location of the abdominal pain. Rebound tenderness Auscultation of bowel movement Free air in the abdomen percussion of liver span Hernial orifices should always carefully examined for the presence of a mass Appropriate imaging and laboratoy investigations Rectal digital examination

The Acute Abdomen. Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital

The Acute Abdomen. Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital The Acute Abdomen Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital Causes of the Acute Abdomen Hemorrhage in the GI tract Blood vessel GU tract Perforation of the GI tract Ulcer Infection