Differential diagnosis of abdominal pain in adults. Györgyi Műzes 2015/2016-I. Semmelweis University, 2nd Dept. of Medicine
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1 Differential diagnosis of abdominal pain in adults Györgyi Műzes 2015/2016-I. Semmelweis University, 2nd Dept. of Medicine
2 Aspects of abdominal pain organic or functional classification abdominal or extraabdominal acute or chronic diffuse, localized, +/- referred patient s age (children, adolescents, adults, elderly population) common or rare etiologic factors special populations (AIDS, older subjects, etc.)
3 Abdominal pain: localization
4 Epigastric Pain reflux - GERD peptic ulcer gastritis pancreatitis gallbladder and common bile duct obstruction MI abdominal aortic aneurysm
5 Right Upper Quadrant Pain acute cholecystitis biliary colic cholangitis hepatitis subdiaphragmatic abscess peptic ulcer right lower lobe pneumonia, plerurisy
6 Left Upper Quadrant Pain acute pancreatitis gastric ulcer splenic enlargement, rupture or infarction left lower lobe pneumonia, pleurisy
7 Right Lower Quadrant Pain appendicitis IBD, regional enteritis small bowel obstruction mesenteric adenitis inq.hernia ectopic pregnancy twisted ovarian cyst salpingitis nephrolithiasis
8 Left Lower Quadrant Pain diverticulitis inq. hernia IBD IBS ruptured ectopic pregnancy twisted ovarian cyst salpingitis nephrolithiasis
9 Periumbilical Pain gastroenteritis small bowel pain: Crohn s early appendicitis bowel obstruction ruptuted abdominal aortic aneurysm
10 Diffuse Abdominal Pain diffuse peritonitis acute pancreatitis mesenteric ischaemia, thrombosis gastroenteritis intestinal obstruction IBS metabolic disturbances (e.g. porphyria) dissecting or rupturing aneurysm
11 ORIGIN OF ABDOMINAL PAIN Visceral originates in abdominal organs Colic crampy pain Somato-parietal relating to irritation of parietal peritoneum Referred produced by a pathology in one location but felt at another location
12 Referred abdominal pain
13 Functional disorders Functional dyspepsia Irritable bowel syndrome Functional abdominal pain Childhood functional abdominal pain syndrome Abdominal migraine pain Functional constipation*
14 ORGANIC VS.FUNCTIONAL PAIN HISTORY ORGANIC FUNCTIONAL Pain: character Acute, persistent, Less likely to change increasing in intensity Pain: localization Sharply localized Various locations Pain: its relation to sleep Awakens at night No affect Pain in relation to Further away At umbilicus umbilicus Associated symptoms Fever, anorexia, Headache, dizziness, vomiting, wt loss, multiple system comanemia, elevated ESR plaints Psychological stress Not reported Present
15 Cardiac Abdominal pain of extra-abdominal origin I. Neurologic Myocardial ischemia and infarction Myocarditis Endocarditis Heart failure Thoracic Pneumonitis Pleurodynia, Bornholm's disease Pulmonary embolism and infarction Pneumothorax Empyema Esophagitis Esophageal spasm Esophageal rupture (Boerhaave's syndrome) Radiculitis: spinal cord or peripheral nerve tumors, degenerative arthritis of spine Abdominal epilepsy Tabes dorsalis (tertiary syphilis) Metabolic Uremia Diabetes mellitus (ketoacidosis) Porphyria Acute adrenal insufficiency Hyperlipidemia Hyperparathyroidism
16 Abdominal pain of extra-abdominal origin II. Hematologic Sickle cell anemia Hemolytic anemia Henoch-Schönlein purpura Acute leukemia Toxins Hypersensitivity reactions: insect bites, reptile venoms Heavy metals and corrosives (eg, lead or iron) Infections Herpes zoster Osteomyelitis Typhoid fever Miscellaneous Muscular contusion, hematoma, or tumor Narcotic withdrawal Familial Mediterranean fever Psychiatric disorders Heat stroke
17 WORK-UP OF ABDOMINAL PAIN HISTORY onset quality description intensity frequency location referred? duration aggravating / relieving factors
18 WORK-UP PHYSICAL EXAMINATION inspection auscultation percussion palpation guarding - rebound tenderness rectal exam pelvic exam
19 WORK-UP LABORATORY TESTS depend on the affected organ! complete blood count with differential electrolytes, BUN, creatinine, and glucose aminotransferases, alkaline phosphatase, and bilirubin lipase urinalysis pregnancy test in women of childbearing potential IMAGING STUDIES plain X-rays contrast studies - barium (upper and lower GI series) ultrasonography CT scanning endoscopy: gastro / sigmoido, colonoscopy
20 Common Acute Pain Syndromes appendicitis diverticulitis cholecystitis pancreatitis perforated peptic ulcer intestinal obstruction ruptured AAA pelvic disorders
21 Surgical abdomen The two syndromes that constitute urgent surgical referrals are obstruction peritonitis
22 CHRONIC PAIN SYNDROMES irritable bowel syndrome chronic pancreatitis diverticulosis gastro-esophageal reflux disease (GERD) inflammatory bowel disease peptic ulcers
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