Visceral pain Dull and poorly localized in the midline(epigastric, peri-umbilical,or lower midline). Cramping, burning, or gnawing.

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Naomi Simpson
7 years ago
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1 Approach to Patient with Acute Abdominal Pain

2 Types of Abd pain Visceral pain Dull and poorly localized in the midline(epigastric, peri-umbilical,or lower midline). Cramping, burning, or gnawing. Secondary autonomic effects such as sweating, restlessness, nausea, vomiting, perspiration, and pallor often accompany visceral pain Somatoparietal pain Generally more intense and more precisely localized than visceral pain. e.g. pain of appendicitis(visceral somatoparietal) Usually aggravated by movement of coughing Referred pain Pain felt in areas remote to the diseases organ It is a result of the convergence of visceral afferent anatomic regions on second order neurones in the spinal cord at the same spinal segment

4 Mechanism of referred pain

5 How to approach abd pain?? Most important elements in making an accurate early diagnosis are the history and physical examination HISTORY: Chronology Rapidity of onset of pain is usually a sign of its severity and significance and sudden sharp pain are likely secondary to an intra-abdominal catastrophe (mesenteric infarction, perforated viscus, ruptured aortic aneurysm) Progression of pain is also very important.(gastroenteritis vs appendicitis) Duration of the pain. The longer the duration of pain the less likely that it will be related to an acute event.

6 ,,,,History Location The location of the pain provides clues to its cause The location of the referred pain may be confusing The change in the location of the pain may be may signify the change from visceral type of pain to petitonial type of pain as in appendicitis. Intensity and character Aggravating and alleviating factors: The relationship to positional changes, meals, bowel movements, and stress may be significant Duoedenal ulcer pain is classically improved by eating while gastric ulcers pains are worsened by eating Biliary pain is often aggravated by fatty meals

7 ,,,,History Associated symptoms: Constitutional symptoms(fever, night sweat,chills, wt loss, myalgia, arthralgia). Digestive function( N&v, anorexia, diarrhoea constipation). Urinary. Gynacologic. Pregnancy. Hepatobilary. Past medical history Previous similar symptoms.(recurrence,,eg partial bowel obstruction,,renal calculi,,) Systemic illnesse(sle, scleroderma, porphyria, SCA) Use of medications. Family &social history SCA Alcohol & pancreatitis etc.

8 Patterns of abd pain

9 Intra abdominal Causes of acute abdomin& location Right Upper Quadrant Acute cholecystitis Biliary colic Acute hepatic inflammation or distention Right Lower Quadrant Appendicitis Infective terminal ileitis Crohn s disease Tubo-ovarian disorders Ectopic pregnancy Ruptured ovarian cyst Salpingitis Renal disorders Right ureteric calculus Pyelonephritis Pyogenic sacroileitis Central Abdominal Pain Gastroenteritis, gastritis, PUD. Small intestinal colic Acute pancreatitis Diffuse Abdominal Pain Peritonitis(from any cause) IBD and toxic megacolon Familial mediterranean fever Hemorrhagic pancreatitis Left Upper Quadrant Splenic infarct, rupture Splenic flexure ischemia Left Lower Quadrant Acute diverticulitis Infectious or inflammatory colitis Pyogenic sacroileitis Tubo-ovarian disorders

11 History is very important

12 Physical examination: Clinician must interpret his or her findings in the context of the patient's history. (old, or immuncompromized) Complete systemic examination Vital signs should be obtained to exclude conditions such as hypovolemia, tachypnea related to metabolic acidosis, or atrial fibrillation as a cause of mesenteric arterial embolus Patient's appearance, ability to converse, breathing pattern, position in bed, posture, degree of discomfort, and facial expression Examination of the extremities may provide evidence for inadequate perfusion, as in shock, or the presence of chronic vascular disease.

13 Abdominal Examination Inspection: for distension, scars, hernias, splinting during respiration, ecchymoses, and visible hyperperistalsisperitoneal. Palpation: Light, gentle palpation is superior to deep palpation in the identification of peritoneal irritation,the degree of tenderness, guarding, and rigidity should be determined.,,palapable masses(organs hematoma, tumors).

14 Abdominal Examination,,,,, Percussion: may elicit tympanic from excess abdominal gas, whether it is intraluminal (as occurs with intestinal obstruction) or extraluminal (as occurs with perforated viscus), for free fluid as well. Auscultation: Hyperperistalsis in intestinal obstruction or enteritis. Generalized peritonitis usually causes diminished peristalsis. Bruits may point to a vascular stenosis. Rectal examination is important as well as pelvic examination is some cases.

15 Laboratory tests Should reflect clinical suspicion. All patients with acute abd pain should have complete blood count with differential count and urinalysis Serum electrolyte, blood urea nitrogen, creatinine, and glucose concentrations is useful in ascertaining fluid status, acid-base status, renal function, and metabolic state but is not necessary for every patient. Liver function tests and serum amylase determination should be ordered in patients with upper abdominal pain Urine or serum pregnancy testing should be performed in all women of reproductive age with lower abdominal pain Others according to presentation.

16 Radiology investigations: Must be tailored to answer specific questions arising from a carefully derived differential diagnosis based on history, physical examination, and laboratory testing. Plain Abdominal series (two views-supine, erect,or lat decubitus on lt side down for pt unable to stand) may identify abnormal gas patterns. Three views of the abdomen are important but only 10% of them will lead to the diagnosis. CXR: basal pneumonia, air under diaphragm. Ultrasound. CT scan of the abdomen and pelvic is probably the most useful test.

17 What is the test and what abnormality?

18 What is the test and what abnormality?

19 Other tests Peritonial lavage in trauma pt. Laporoscopy. Laporotomy. Endoscopy.

20 THANK YOU

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