Abdominal pain. Agnieszka Dobrowolska- Zachwieja, MD, PhD Department of Gastroenterology and Human Nutrition

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1 Abdominal pain Agnieszka Dobrowolska- Zachwieja, MD, PhD Department of Gastroenterology and Human Nutrition

2 Most common symptoms of abdominal disease Pain Nausea and/or vomiting Change in bowel movements Rectal bleeding Jaundice Abdominal distention Mass Pruritus (itching)

3 Pain Most important symptom Can result from: mucosal irritation, smooth muscle spasm, peritoneal irritation, capsular swelling, direct nerve stimulation

4 Pain Abdominal pain calls for speedy diagnosis and therapy!

5 Pain Time of start Acuteness Location Character Radiation Alleviating and aggravating factors Nocturnal pain

6 Location of pain in abdominal disease Area Substernal Shoulder Epigastric Organ Esophagus Diaphragm Stomach Duodenum Gallbladder Liver Bile ducts Pancreas Clinical example Esophagitis Subphrenic absces Peptic gastric ulcer Peptic duodenal ulcer Cholecystitis Hepatitis Cholangitis Pancreatitis

7 Location of pain in abdominal diseases Area Right scapula Midback Periumbilical Hypogastrium Sacrum Organ Biliary tract Aorta Pancreas Small intestine Colon Rectum Clinical example Biliary colic Aortic dissection Pancreatitis Obstruction UC, diverticulitis Proctitis, perirectal abscess

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10 Localization Of Common Causes Of Acute Abdominal Pain Right Upper Quadrant Acute cholecystitis Biliary colic Acute hepatic inflammation or distention

11 Localization Of Common Causes Of Acute Abdominal Pain Left Upper Quadrant Splenic infarct Splenic flexure ischemia

12 Localization Of Common Causes Of Acute Abdominal Pain Right Lower Quadrant Appendicitis Infective terminal ileitis Crohn s s disease Tuboovarian disorders (in females)

13 Localization Of Common Causes Of Acute Abdominal Pain Right lower Quadrant Ectopic pregnancy Ruptured ovarian cyst Salpingitis Renal disorders Right ureteric calculus Pyelonephritis Pyogenic sacroileitis

14 Localization Of Common Causes Of Acute Abdominal Pain Central Abdominal Pain Gastroenteritis, gastritis Peptic ulcer disease Small intestinal colic Acute pancreatitis

15 Localization Of Common Causes Of Acute Abdominal Pain Diffuse Abdominal Pain Acute infectious peritonitis Appendicitis Diverticulitis Inflammatory bowel disease and toxic megacolon Perforated ulcer (gastric or duodenal)

16 Localization Of Common Causes Of Acute Abdominal Pain Diffuse abdominal pain Spontaneous peritonitis in cirrhosis Acute noninfectious peritonitis Familial Mediterranean fever Hemorrhagic pancreatitis Postoperative Perforated duodenal ulcer

17 Acute recurrent abdominal pain Acute recurrent abdominal pain, characterized by repeated attacks of pain, with the patient being entirely well between these episodic bouts, can prove very difficult to diagnose It is important to try and see the patient during an attack as it is frequently the only opportunity for making the right diagnosis.

18 Acute recurrent abdominal pain Physical/Obstructive Ampullary stenosis Cholelithaisis Intermittent intestinal obstruction Intussusception Internal hernia Abdominal wall hernia

19 Acute recurrent abdominal pain Metabolic and/or Genetic Acute intermittent porphyria Familial Mediterranean fever

20 Acute recurrent abdominal Neurologic pain Abdominal epilepsy Abdominal migraine Diabetic and other forms of radiculopathy Nerve entrapment syndromes

21 Acute recurrent abdominal pain Miscellaneous Endometriosis Heavy metal (lead( lead) poisoning Mesenteric ischemia Acute recurrent pancreatitis

22 Chronic persistent abdominal pain Many conditions can cause abdominal pain much or all of the time for more than several months. Among the most frequent are malignancies, degenerative neurological and muscular disorders, autoimmune and infiltrative diseases, chronic pancreatitis, severe inflammatory bowel disease, previous abdominal trauma, and complications of surgery.

23 Chronic persistent abdominal pain In many of these patients, the cause of the pain, once identified, cannot be treated, and therefore the treatment should aim at decreasing suffering, relieving the symptoms, and improving the quality of life of the individual and his or her family.

24 Chronic undefined abdominal pain The functional abdominal pain syndrome (FAPS), also called chronic intractable abdominal pain or chronic undiagnosed abdominal pain, has been defined recently by an International Working Team Committee as follows:

25 Chronic undefined abdominal pain 1. Frequently recurrent or continuous abdominal pain for at least 6 months 2. Incomplete or no relationship of pain with physiologic events (e.g., eating, defecation, or menses) 3. Some loss of daily functioning 4. No evidence for organic disease to explain the pain and insufficient criteria for other functional gastrointestinal disorders (such as IBS) to explain the pain.

26 Approach to patients with chronic abdominal pain Our ability to treat most forms of chronic abdominal pain effectively has been limited by the lack of understanding of many of the critical components in the pathogenesis and pathophysiology of these syndromes.. New insights into these areas, along with significant advances in the fundamental aspects of pain in general, now raise the prospects of a more rational and effective therapy being made available for these patients.

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