羅東博愛醫院 Abdominal pain - 1/13 第三章. Abdominal Pain 蘇建維醫師

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1 羅東博愛醫院 Abdominal pain - 1/13 第三章 Abdominal Pain 蘇建維醫師

2 2/13 Abdominal pain 羅東博愛醫院 Management of Abdominal Pain General Guidelines Common etiologies of abdominal pain History taking. DDX of abdominal pain. Physical examinations. Laboratory tests. Diagnostic investigations. Acute abdomen that may require surgical intervention. Common etiology of abdominal pain Mucosal or muscle inflammation in hollow viscera Peptic disease: ulcers, erosions, inflammation Hemorrhagic gastritis Gastroesophageal reflux disease Appendicitis Diverticulitis Cholecystitis Cholangitis Inflammatory bowel diseases: Crohn s disease, ulcerative colitis Infectious gastroenteritis Mesenteric lymphadenitis Colitis Cystitis Pyelonephritis Visceral spasm or distention Intestinal obstruction: adhesions, tumor, intussusception Appendiceal obstruction with appendicitis Strangulation of hernia Irritable bowel syndrome

3 羅東博愛醫院 Abdominal pain - 3/13 Acute biliary obstruction Pancreatic ductal obstruction: chronic pancreatitis, stone Ureteral obstruction: kidney stone, blood clot Fallopian tubes: tubal pregnancy Vascular disorders Mesenteric thromboembolic disease Arterial dissection or rupture Occlusion from external pressure or torsion: volvulus, hernia, tumor, adhesions, intussusception Hemoglobinopathy: sickle cell disease Distension or inflammation of visceral surfaces Hepatic capsule: hepatitis, hemorrhage, tumor, Budd-Chiari syndrome Renal capsule: tumor, infection, infarction, venous occlusion Splenic capsule: hemorrhage, abscess, infarction Pancreas: pancreatitis, pseudocyst, abscess, tumor Ovary: hemorrhage into cyst, ectopic pregnancy, abscess Peritoneal inflammation Bacterial infection: perforated viscus, pelvic inflammatory disease, infected ascites Intestinal infarction Chemical irritation Pancreatitis Perforated viscus: stomach, duodenum Reactive inflammation: abscess, pleuropulmonary infection or inflammation Serositis: collagen-vascular diseases, familial Mediterranean fever Abdominal wall disorders Trauma Hernia Muscle inflammation or infection

4 4/13 Abdominal pain 羅東博愛醫院 Hematoma: trauma, anticoagulant therapy Traction from mesentery: adhesion Toxins Lead poisoning Black widow spider bite Metabolic disorders Uremia Ketoacidosis: diabetic, alcoholic Addisonian crisis Porphyria Angioedema Narcotic withdrawal Neurologic disorder Herpes zoster Tabes dorsalis Causalgia Compression or inflammation of spinal roots: arthritis, herniated disk, tumor, abscess Psychogenic Referred pain Heart: cardiac ischemia Lung: pneumonia, pneumothorax, pulmonary embolism Esophagus: esophagitis, esophageal spasm, esophageal rupture Genitalia History taking History is of critical diagnostic importance Pattern Provide clues to nature and severity, although acute abdominal crisis may occasionally present insidiously or on a background of chronic

5 羅東博愛醫院 Abdominal pain - 5/13 pain Visceral pain (due to distention of a hollow viscus) localizes poorly and is often perceived in the midline Intestinal pain tends to be crampy When originating proximal to the ileocecal valve -> localizes above and around the umbilicus Colonic origin -> hypogastrium and lower quadrants Pain from biliary or ureteral obstruction often causes patients to writhe in discomfort (relieving symptoms by bending position) Somatic pain (due to peritoneal inflammation) is usually sharper and more precisely localized to the diseased region (e.g. acute appendicitis; capsular distention of liver, kidney, or spleen) and exacerbated by movement Pain of radiation Right shoulder -> hepatobiliary origin Left shoulder -> splenic origin Midback -> pancreatic origin Flank -> proximal urinary tract Groin -> genital or distal urinary tract Chronology Pain that is sudden in onset, severe, and well localized is likely to be the result of an intra-abdominal catastrophe such as a perforated viscus, mesenteric infarction, or ruptured aneurysm. Such patients usually recall the exact moment of onset of pain Progression Gastroenteritis is often self-limited Appendicitis is progressive Renal colic may have colicky pain with crescendo-decrescendo pattern Duration: patients who seek evaluation of abdominal pain that has been present for an extended period (e.g., weeks) are less likely to have an acutely threatening illness than those who do so within hours to days of the onset of symptoms Aggravating and alleviating factors The setting in which pain occurs or is exacerbated may yield

6 6/13 Abdominal pain 羅東博愛醫院 important diagnostic information Eating -> upper GI, biliary, pancreatic, ischemic bowel disease Defecation ->colorectal Urination ->genitourinary or colorectal Respiration -> pleuropulmonary, hepatobiliary Position ->pancreatic, gastroesophageal reflux, musculoskeletal Menstrual cycle -> tubo-ovarian, endometrial Exertion -> coronary ischemia, intestinal ischemia, musculoskeletal Medication or specific foods -> motility disorders, food intolerance, gastroesophageal reflux, porphyria, adrenal insufficiency, ketoacidosis, toxins Stress ->motility disorders, nonulcer dyspepsia, irritable bowel syndrome Associated symptoms Fever/chills -> infection, inflammatory disease, infarction Body weight loss -> tumor, inflammatory diseases, malabsorption, ischemia Nausea/vomiting ->obstruction, infection, inflammatory disease, metabolic disease Dysphagia/odennophagia -> esophageal disease Early satiety -> gastric disease Hematemesis -> upper GI tract disease with bleeding Constipation -> colorectal, perianal, genitourinary disease Jaundice -> hepatobiliary, hemolytic disease Diarrhea -> inflammatory disease, infection, secretory tumors, ischemia, genitourinary disease Dysuria/hematuria/vaginal or penile discharge -> genitourinary disease Hematochezia -> colorectal disease Skin/joint/eye disorders -> inflammatory disease, bacterial or viral infection Predisposing factors Family history -> inflammatory disease, tumors, pancreatitis

7 羅東博愛醫院 Abdominal pain - 7/13 Hypertension and atherosclerotic disease -> ischemia Diabetes mellitus -> motility disorders, ketoacidosis Connective tissue disease -> motility disorders, serositis Depression -> motility disorders, tumors Smoking -> ischemia, peptic ulcer Ethanol use -> motility disorders, hepatobiliary, pancreatic, gastritis, peptic ulcer disease Differential diagnosis of abdominal pain Condition Onset Location Character Descriptor Radiation Intensity Appendicitis Gradual Periumbilical early; RLQ late Diffuse early, localized late Ache RLQ ++ Cholecystitis Rapid RUQ Localized Constricting Scapula ++ Pancreatitis Rapid Epigastric, back Localized Boring Midback ++ to +++ Diverticulitis Gradual LLQ Localized Ache None + to ++ Perforated peptic ulcer Small bowel obstruction Mesenteric ischemia Ruptured abdominal aortic aneurysm Sudden Epigastric Localized early, diffuse late Burning None +++ Gradual Periumbilical Diffuse Crampy None ++ Sudden Periumbilical Diffuse Agonizing None +++ Sudden Abdominal, back, flank Diffuse Tearing Back, flank Gastroenteritis Gradual Periumbilical Diffuse Spasmodic None + to ++ Pelvic inflammatory disease Rupture ectopic pregnancy Gradual Sudden Either LQ, pelvic Either LQ, pelvic Localized Ache Upper thigh Localized Light-headed None ++ Physical examinations Inspection Inspect contour, symmetry, umbilicus, skin, pulsation or movement and hair distribution Scaphoid abdomen occurs with malnourishment Cutaneous angiomas (spider nevi) occur with portal hypertension or liver disease Everted umbilicus with skin glistening and taut occurs with ascites

8 8/13 Abdominal pain 羅東博愛醫院 Marked pulsation of the aorta occurs with widened pulse pressure -> hypertension, aortic insufficiency, thyrotoxicosis and aortic aneurysm Restlessness and constant turning to find a comfortable position occur with the colicky pain of gastroenteritis or bowel obstruction Auscultation Bowel sounds Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility. They occur with early mechanical bowel obstruction, gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus. Hypoactive or absent sounds follow abdominal surgery or with inflammation of the peritoneum or from late bowel obstruction Vascular sounds Note the presence of any vascular sounds or bruits. Using firmer pressure, check over the aorta, renal arteries, iliac and femoral arteries, especially in people with hypertension Note location, pitch, and timing of a vascular sound. A systolic bruit is a pulsatile, blowing sound Percussion Percuss lightly in all four quadrants Tympany should predominate because air in the intestine rises to the surface when the person is supine. Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass Hyperresonance is present with gaseous distension Liver span Measure the height of the liver in the right mid-clavicular line The normal liver span in the adult ranges form 6 to 12 cm. An enlarged liver span indicates liver enlargement or hepatomegaly Decreased liver span might occur in fulminant hepatitis Splenic dullness Locate it by a dull note from the 9 th to 11 th intercostals space just

9 羅東博愛醫院 Abdominal pain - 9/13 behind the left mid-axillary line. The area of splenic dullness is normally not wider than 7 cm in the adult. Enlarged spleen occurs in liver cirrhosis, mononucleosis, trauma and infection Palpation Light palpation in all four quadrants With the first four fingers close together, depress the skin about 1 cm. Muscle guarding, rigidity, large masses and tenderness Deeper palpation in all four quadrants Pushing down about 5-8 cm. If identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note its Location, size, shape, consistency (soft, firm, hard) Surface (smooth, nodular) Mobility, pulsatility and tenderness Palpate for liver, spleen, kidney Costovertebral angle tenderness Place one hand over the 12 th rib at the costovertebral angle on the back. Sharp pain occurs with inflammation of the kidney or paranephric area Special physical findings Icteric sclera Jaundice is observed when serum bilirubin levels exceed 2-3 mg/dl Bilirubin with hyperpigmentation deposits in sclera because of much elastin in sclera Flapping tremor Intermittent relaxation of the contracted muscle while dorsiflexion of f the wrist and extension of the elbow Found in hepatic encephalopathy stage II to III Caput medusae Recanalization of the umbilical vein identified by the presence of several veins converging in a large vein at the umbilical area

10 10/13 Abdominal pain 羅東博愛醫院 Seen in portal hypertension Murphy s sign The abrupt cessation in inspiration in response to pain on palpation of the right upper quadrant A classical finding of acute cholecystitis and could be observed in 60 to 70 % of patients Acute necrotizing pancreatitis Cullen sign: periumbilical ecchymoses Grey-Turner s sign: flank ecchymoses Gastric cancer with metastasis Virchow s node: left supraclavicular lymph nodes Rectal shelf: intraperitoneal seeding found by digital examination Rebound tenderness Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation Perform this test at the end of the examination because it can cause severe pain and muscle rigidity Fluid wave for ascites Ascites occurs with congestive heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer A positive fluid wave test occurs with large amounts of ascites Digital examination is a routine for each patients Laboratory tests Laboratory tests ordered should reflect the clinical suspicion raised during the history and physical examination Complete blood count with differential count Urinalysis Chemistry profile Serum electrolyte, blood urea nitrogen, creatinine and glucose concentrations is useful in ascertaining fluid status, acid-base status,

11 羅東博愛醫院 Abdominal pain - 11/13 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 should be performed in all women of reproductive age with lower abdominal pain Prothrombin time and blood albumin: for patients with suspected liver disease Diagnostic investigations CXR Determine the presence of diseases involving heart, lung, mediastinum and pleura ECG Exclude referred pain from cardiac disease Plain abdominal radiographs Evaluate bowel displacement Intestinal distension Fluid and gas pattern Free peritoneal air Liver size Abdominal calcifications: gall stones, renal stones, chronic pancreatitis Abdominal ultrasonography Provide rapid, accurate and inexpensive anatomic information about biliary ducts, gall bladder, liver, pancreas, spleen and pancreas Abnormal accumulation of fluid: ascites, Abnormal space occupying lesion: tumor, abscess, pseudocyst, hematoma

12 12/13 Abdominal pain 羅東博愛醫院 Doppler technology permits evaluation of vascular lesions such as aortic or visceral aneurysms, venous thrombi and anomalies Computed tomography scanning The most versatile imaging tool in the evaluation of acute abdominal pain Provides information about the presence of penumoperitoneum, abnormal bowel gas patterns, calcifications Evidence of inflammation: bowel wall thickening, mesenteric stranding, lymphadenopathy Neoplastic lesions: obstructing colon cancer, liver tumors, pancreatic tumors Trauma: spleen, liver and kidney Vascular lesions: aortic aneurysm, portal vein thrombosis, pyelophlebitis, intra-abdominal bleeding Upper GI endoscope, colonoscope Evaluates the mucosa lesions of esophagus, stomach, duodenum and colon Ulceration, neoplasia, ischemia inflammation Barium contrast radiographs Alternate modality for endoscope study Cholangiography Identify biliary lesions Could be performed by endoscopic, percutaneous, or via MRI (MRCP) Laparoscope, exploratory laparotomy: reserved for patients with intra-abdominal catastrophe whose diagnosis is obvious from clinical history and examination or patients in whom delay in therapy would be life-threatening

13 羅東博愛醫院 Abdominal pain - 13/13 Acute abdomen that may require surgical intervention Gastrointestinal Appendicitis Perforated peptic ulcer Intestinal obstruction Intestinal ischemia Diverticulitis Inflammatory bowel disease Meckel s diverticulitis Pncreaticobiliary tract, liver, spleen Acute pancreatitis Acute cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumor Splenic rupture Urinary tract Renal stone Ureteral stone Gynecologic Ectopic pregnancy Tubulo-ovarian abscess Ovarian torsion Uterine rupture Ruptured ovarian cyst or follicle Retroperitoneum Abdominal aortic aneurysm Supradiaphragmatic Pneumothorax Pulmonary embolus Acute pericarditis Empyema