EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN

1. EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN BY DR OJIH

2. OUTLINE • INTR0DUCTION • CAUSES • MECHANISM OF PAIN ORIGINATING FROM THE ABDOMEN • HISTORY • EXAMINATION • INVESTIGATION • TREATMENT

3. INTRODUCTION • One of the most common causes of presentation at the accident and emergency • Diagnosis is difficult because numerous causes exist -NSAP 34% -Acute appendicitis 28% -Acute cholecystitis 10% -small bowel obstruction 4% -perforated PU 3% -pancreatitis 3% -Diverticular disease 2% -0thers 13% • 20-40% admission rates • 50-65% inaccurate initial diagnosis

4. CAUSESPAIN ORIGINATING IN THE ABDOMEN • PARIETAL PERITONEAL INFLAMMATION -Bacterial contamination -perforated appendix or other viscus -PID -Chemical irritation -pancreatitis

5. CAUSES CONTINUED • MECHANICAL OBSTRUCTION OF HOLLOW VISCERA -Obstruction of the small or large intestine -Obstruction of the biliary tree -Obstruction of the ureter

6. VASCULAR DISTURBANCES -Embolism or thrombosis -vascular rupture -pressure or torsional occlusion -sickle cell anaemia

7. Abdominal wall -distortion or traction of the mesentry -trauma or infection of muscles • DISTENSION OF VISCERAL SURFACES-e.g by haemorrhage -hepatic or renal capsule • INFLAMMATION OF A VISCUS -appendicitis -typhoid fever -typhilitis

8. PAIN REFERRED FROM EXTRAABDOMINAL SOURCE • CARDIOTHORACIC -acute myocardial infarction -myocarditis ,endocarditis, pericarditis -Congestive cardiac failure -pneumonia -Pulmonary embolism -Pleurodynia -Pneumothorax -Empyema -Esophageal disease,spasm,rupture,inflammation • GENITALIA -Torsion of testis

9. METABOLIC CAUSES OF ABDOMINAL PAIN • DM • Uremia • Hyperlipidaemia • Hyperparathyroidism • Acute adrenal insufficiency • Familial Mediterranean fever • Porphyria • C’1 esterase inhibitor deficiency( angioneurotic oedema)

10. NEUROLOGIC /PSYCHIATRIC CAUSES • Herpes zoster • Tabes dorsalis • Causalgia • Radiculitis from infection or arthritis • Spinal cord or nerve root compression • Functional disorders • Psychiatric disorders

11. TOXIC CAUSES • Lead poisoning • Insect or animal envenomation • Black widow spiders • Snake bites

12. UNCERTAIN MECHANISM • Narcotic withdrawal • Heat stroke

13. MECHANISM OF PAIN ORIGINATING IN THE ABDOMEN • VISCERAL PAIN -afferent impulses from visceral organs poorly localized -pain generally felt in the midline - pain localization depends on the embryologic origin of the organ Foregut structures------epigastrium midgut structures-------periumbilical region hindgut structures---------suprapubic region -visceral nociceptors are stimulated by distention, Stretch, vigorous contraction, ischaemia and inflammation

14. SOMATIC PAIN -usually from inflammation or chemical irritants (gastric content) -localized to the dermatome above the site of stimulus -transmitted by spinal nerve supplying the parietal peritoneum or mesodermal structures

15. REFERRED PAIN • Could be from the thorax, spine or genitalia • Produces symptoms not signs

16. HISTORY • Generally the cornerstone of accurate diagnosis • Complete description of the patient’s pain and associated symptoms • Key points in the history include -P positional, palliating and provoking factors -Q quality -R region, radiation, referral -S severity -T temporal factors ( time and mode of onset, progression, previous episodes)

17. LOCATIONwhere do you feel the pain • Can be generalized or localized • visceral pain -foregut structures------epigastrium - midgut structures -----periumbilical - hindgut structures-----suprapubic • Somatic pain -localised above the dermatome producing the stimulus

18. CHARACTERwhat kind of pain is it • VISCERAL PAIN -dull, poorly localised, aching, colicky, or gnawing. • SOMATIC PAIN -sharp, steady aching, more defined and well localised

19. ONSEThow did it start • Could be acute or gradual • Tells the duration of pain • Helps to interpret current findings and making diagnosis

20. RADIATIONwhere else do you feel the pain • Any inflammatory process / organ contiguous to the diaphragm can cause referred shoulder pain • Acute gall bladder distension gives ipsilateral scapular pain • abdominal pain radiating to the sacral region , flank, or genitalia may raise suspicion of rupturing abdominal aortic aneurysm

21. PROVOCATIVE AND PALLIATNG FACTORSwhat worsens or relieves the pain • Somatic pain- worsened by pressure or changes in tension of the peritoneum (palpation, coughing , sneezing) • Pancreatitis – pain is worsened by bending forward and relieved by upright position • Gastric ulcer – pain is aggravated by food • Duodenal ulcer - relieved by food • Ask about analgesics and NSAIDS

22. Associated symptoms • Fever • Anorexia • nausea • Vomiting • Diarrhoea • Cough • Amenorrhoea • Dysuria etc

23. PAST MEDICAL & SURGICAL HX, CURRENT MEDICATIONS • Previous surgery– adhesions • DM---DKA • CKD– uraemia • SCD– vasocclusive crises • Steroids and NSAIDS

24. SOCIAL HX • Substance abuse e.g cocaine • Alcohol • Domestic violence ( trauma )

25. PHYSICAL EXAMINATION • Inspection -Bending forward : chronic pancreatitis -lying still, avoiding movt: peritonitis -Restless: visceral pain -Jaundiced : common bile duct obstruction -Dehydrated: peritonitis, small bowel obstruction.

26. SYSTEMIC EXAMINATIONABDOMEN • Inspection -scaphoid or flat in peptic ulcer -distended in ascities or intestinal obstruction -visible peristalsis in a thin or malnourished patient (with obstruction) -surgical scar (adhesions) -caput medusa in chronic liver disease

27. SYSTEMIC EXAMINATION • Palpation -check the hernia sites -tenderness -rebound tenderness - guarding(involuntary spasm of muscles during palpations) -rigidity (when abd. muscle are tense and board like) indicates peritonitis

28. SYSTEMIC EXAMINATION • Epigastric tenderness -DU/GU -acute pancreatitis -esophagitis • Local right iliac fossa tenderness -acute appendicitis -acute salpingitis in females -crohns disease

29. SYSTEMIC EXAMINATION • Periumbilical tenderness -early appendicitis -SBO -acute gastritis -mesenteric thrombosis -ruptured AAA

30. Right upper quadrant tenderness -gall bladder disease -acute pancreatitis -Pneumonia -Subphrenic abscess - DU • Suprapubic tenderness -acute urinary retension -PID -cystitis

32. PHYSICAL EXAMINATION • Percussion -differentiates between ascities ( shifting dullness ) and large bowel obstruction ( drum-like tympany)

33. Physical examination • Auscultation • Has limited diagnostic utility • > 2min to confirm absent ( ileus) • High pitched in early SBO • Bruit in aortic, renal or mesenteric stenosis

34. Systemic Examination • Digital Rectal Examination: - tenderness - indurations - mass - frank blood

35. Systemic Examination • Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

36. Investigations • FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • FBS/RBS • G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)

37. Investigations • Urinalysis • Pregnancy test • RADIOLOGICAL INVESTIGATIONS -CXR(PA) -Abd XR( erect and supine) -IVU -CT Scan—gold standard for diagnosis of appendidcitis • Laparoscopy

38. TREATMENT • DEPENDS ON THE CAUSE • May need resuscitation (ABCD) • IV fluid if there’s dehydration • Analgesic (iv opiods) • H2 receptor antagonists and proton pump inhibitors( PUD ) • Antibiotics if there’s evidence of infection • Antispasmodic (hyoscine) • Surgery

39. REFERENCES • Harrisons principle of internal medicine 18th edition • Christopher R.M and Robert M.M,2012, International journal of internal medicine • Dimitri R and Alec E, diagnosis and management of abdominal pain

40. Thank you