Differential diagnosis of abdominal pain Lakatos Péter László
Precise anamnesis Physical examination are prognosticated to the cause of the pain
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
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
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
Anamnesis Location The pain is not always fit to the organ
Anamnesis Location Appendicitis Early periumbilical pain Later right iliac fossa pain
Anamnesis Location Cholecystitis Right upper quadrant
Anamnesis Location Pancreatitis Epigastric Back
Anamnesis Location Diverticulitis Left-side lower abdomen
Anamnesis Location Peptic ulcer perforation epigastric pain
Anamnesis Location Ileus Periumbilical pain
Anamnesis Location Mesenteric ischaemia/infarction Periumbilical pain
Anamnesis Location Abdominal aneurysm rupture Abdominal-back pain
Anamnesis Location Gastroenteritis Periumbilical
Anamnesis Location Pelvic inflammation Lower abdomen
Anamnesis Location Extrauterine gravidity Lower abdomen
Anamnesis Intensity of the pain Difficult to measure
Anamnesis Location Appendicitis Intensity ++ Early periumbilical pain Later right iliac fossa pain
Anamnesis Location Cholecystitis Intensity ++ Right upper quadrant
Anamnesis Location Pancreatitis Epigastric Back Intensity ++ - +++
Anamnesis Location Diverticulitis Intensity Left-side lower abdomen + - ++
Anamnesis Location Peptic ulcer perforation Intensity +++ epigastric pain
Anamnesis Location Ileus Intensity ++ Periumbilical pain
X-ray findings of ileus
Anamnesis Location Mesenteric ischaemia/infarction Intensity +++ Periumbilical pain
Anamnesis Location Abdominal aneurysm rupture Intensity +++ Abdominal-back pain
Anamnesis Location Gastroenteritis Intensity Periumbilical + - ++
Anamnesis Location Pelvic inflammation ++ Lower abdomen Intensity
Anamnesis Location Extrauterine gravidity Intensity ++ Lower abdomen
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.
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
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
Anamnesis Pain and Previous diseases Family anamnesis
Physical examination Examination of the anamnesis Verify Exclude
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
Physical examination The patient position movement expression general imperssion
Physical examination Vital signs Other organs examination
Physical examination Abdomen Tenderness Abdominal resistance Defense Percussion Auscultation Rectal digital examination Gynecologic examination
Laboratory examination Blood test Electrolyte BUN, creatinine Blood glucose Astrup Liver function Amylase Urine Pregnancy test
X-ray Free abdominal air Air-fluid levels Ultrasound CT
X-ray Free abdominal air Air-fluid levels
Other diagnostics Peritoneal lavage Laparoscopy Explorative laparotomy
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
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
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)
The chronic abdominal pain Location Connection (mealtime, defecation, position, daytime, nervousness)? Other symptoms? General status Physical examination Precise examiantions (laboratory, radiology, ex juvantibus )
The chronic abdominal pain Chronic pancreatitis After eating Belt-like pain Severe status Steatorrhea
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
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
The chronic abdominal pain Mesenteric ischemia In a typical cause after maeltime (abdominal angina) Sometimes auscultated In a chronic case effect malabsorption Progressive
The chronic abdominal pain Pelvic inflammatory disease Lower abdominal pain on either side Gynecological exam (rectalis) confirm Common inflammatory symptoms
The chronic abdominal pain Endometriosis Lower abdominal pain Symptoms often worsen with the menstrual cycle
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
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
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
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