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Approach to Abdominal Pain Prof.Dr .Fikret Sipahioğlu Dept . of Internal Medicine. Abdominal Pain. - Localisation of the pathology which causes pain - Differs according to neural tracts conducting pain - Main mechanisms : Increased tension of empty organs ,
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ApproachtoAbdominalPainProf.Dr.Fikret SipahioğluDept. of InternalMedicine
AbdominalPain • -Localisation of thepathologywhichcausespain • -Differsaccordingtoneuraltractsconductingpain • -Mainmechanisms: Increasedtension of emptyorgans, • contractions,inflammatory-ulcerativelesionsandischemia
Slowprogressingtension(colontm.) may not causepain • -Organsare not sensitivetopain(endoscopicbiopsiesare not painful) • -Malignanttumors of intraabdominalorgansare not painfulunlessthere is a complicationsuch as obstruction, ulcerationorperforation
Ininflamatedordamagedregions: • Mediaterslikehistamin,serotonin, bradichinin, leucotriensaffectneuralendsandcausepain • -Inischemicregions: • Increasedtoxicmetabolites, inflammationmediatorsanddecreasedpainthresholdduetoischemiacausepain
ThreeTypes of AbdominalPain • -Visceralpain • -Somatoparietalpain • -Radiatingpain
VisceralPain • -Result of tension,contraction, • ischemia of intraabdominalorgans • -Stimulation of autonomicnerveends (thoracolombersymphaticplexusbilaterally, n.vagusandpelvicplexus) • -Painlocalised at paraumbilicalregion • -Is künt,sometimes hard, continiousorwithfluctuations • -Discomfort,emesis,vomiting, sweating,palelookingtachycardia(autonomicfindings) mayexist
VisceralPain(continued) • -Pain of upperabdominalorgans • (stomach,liver,biliarytract) localised at mid-lineandepigastrium • -Pain of theregionfromTreitzligamentuptotransversalcolonparaumbilically • -Pain of distalcolon,rectum, • ureters,bladderandgenitalorganssuprapubically
SomaticorParietalPain • -Resultsfromstimulation of parietalperitoneum • -Muchmore severe • -Affected organ can be localised • -Moving,coughing,deepinspirationstimulateparietalperitoneum;patientreducesmovement • -Hyperaesthesia can be observed
Comparison of VisceralandSomaticPain • VisceralPainSomaticPain • IndefiniteSharp • FluctuatingContinious • Not localisedLocalised • DiscomfortReducedmoves • Otherautono.sympPainprominent
RadiatingPain • Pain is felt far fromtheaffected organ but innervatedfromsameneuralsegments • -Perceived as burn, sensitivity, biting • -Skin hyperaesthesia, muscularhypertonicity • -E.g. gallbladderpain; back, rightshoulderandscapula • Pepticulcerpain; backleft 12thrib(Boaspoint)
HistoryTaking • Severalcharasteristicsshould be considered: • -Duration • -Way of beginning • -Continiousor not • -Intensity • -Localisationandradiation • -Relationshipwithmeals • -Affectingfactors • -Relationshipwithposture • -Coexistingfindings(nausea,vomiting, • constipation,fever,jaundice,bleeding, • voidingetc.)
AbdominalPain • Acuteabdominalpain • Surgicalacuteabdominalpain • Non-surgicalacuteabdominalpain • Chronicabdominalpain
ACUTE ABDOMINAL PAINAcuteSurgical Abdomen (ı): • -Historytakingandcarefulphysi. ex • -Inhalf of thepatients no surgery • -Mostfrequent:Acuteappendecitis, • -Ac. cholecystitis, pepticulcerperfo., • -Smallbowelobstruction • -Abdominalpain… • -Thereafternausea-vomiting • -Laparoscopicexamination
PepticUlcerPerforation (I) • Frequent in duodenal,rare in gastriculcers • -Acuteonset,a penetrativeandvery severe pain • -Inthebeginning at epigastricregion,thenwhole abdomen • -Irritation of diaphragmmaycauseshoulderpain • -Reflexefferentstimulation… rigidity of abdominalmuscles
PepticUlcerPerforation(II) • -Patientmotionless, superficialbreathing, no abdominalrespiration • -Fever,tachycardia,hypotension, • -Tendencytoshock( duetoperitonitis) • -Duetoparalyticileus no bowelsounds • -Reducedliverandspleenmatite • -Radiologicex. Perforation
AcuteCholecystitis(I) • -Painandtenderness in therightupperquadrant; feverandleukocytosis • -Frequentcholedocolithiazis • -Obstruction in d.cysticusduetocholedocolithiazis….lastslong…infectionandacutecholecystitis • -Usuallycontiniouspain • -Visceralpainduetotension of d.cysticus in epigastricandleftupperregions • -Wheninflammationdevelops in gallbladdersomaticpain in rightupperquadrant
AcuteCholecystitis(II) • -Tendernessandmusculardefense in rightupperquadrant • -Backandshoulderpain • -Nausea,vomitingandanorexia • -Biliarycolic ≥ 4-6 hours…. • -A. Cholecystitis
Physicalexamination: • -Painin rightupperquadrant • -Localtenderness • -Murphy’ssignpositive
LaboratoryFindings • Mildincrease in t.bilirubin(≤4mg/dL) • Higherlevels; choledocholithiasisandcholengitis • Leukocytosis • Transaminasesand alkaline phosphatasemildlyincreased • USG and ERCP
BowelPerforations: • -Infection( typhoidfever,dysentery) • -Diverticulitis, Meckeldiverticulitis • -Cancer • -Ulcerativecolitisandtoxicmegacolon • -Acuteappendecitisif not treated
MechanicalIleus • -Primarybowelcancers;ileus,subileus • -Crohn’sdisease,boweltbc., lymphoma.. obstructionespecially in terminal ileumandcecum • -Fecaloma ( longlastingconstipation)
MechanicalIleus (II) • -Severe andcolicalpain • -Intensityincreasesandwith time is reduced • -Painlocalized at periumblicalandrightlowerquadrant in smallbowelandproximalcolonobstructions; at leftlowerquadrant in distalcolonob. • -Vomiting( contains bile andfekaloidwith time) • -Increasedbowelperistaltism • -No faeces
MechanicalIleus(III) • -Painreliefedwithvomitingor NG decompression • -Increasedpainintensity,continousorlocalizedpainperitonealirritationfindings is a warningforbowelperforationandperitonitis • -Inparalyticileus no bowelsounds
MechanicalIleus(III) • -Painrelievedwithvomitingor NG decompression • -Increasedpainintensity,continiousorlocalizedpainperitonealirritationfindings is a warningforbowelperforationandperitonitis • -Inparalyticileus no bowelsounds
AcuteAppendecitis (I) • -Mostcommonreasonforacutesurgicalabdomen • -Feaces,foreign body,parasites,andtumors • -Typically:Visceralpainperiumblicalorepigastricregions; afterwardsnauseaandvomiting, somaticpain at appendixandfever
AcuteAppendecitis(II) • DifferentialDiagnosis: • Acutegastroenteritis, mesenterylymphadenitis,yersiniacolitis,acutesalpingitis, Mittelscherz, ectopicpregnancyrupture, ovariancysttorsion,ureteralcolic, acutepyelonephritis,perforatedpepticulcer, acutecholecystitis, basalpnomonia, diabeticketoacidosis, acuteporphiria, FMF
AcuteAppendecitis(III) • -Mostdangerouscomplication is perforation • -Generally 48 hoursafterpainbegins • -Fever, disseminatedabdominaltenderness, plastron in rightlowerquadrant, leukocytosis
AcuteMesentericIschemia • -No significantclinicalfindingifsmallarteriesareoccluded • -Insplenicflexuraorsigmoidcolonwherecollateralcirculation is not adequateischeamicchangesmoreeasily • -Embolism of superiormesentericartery; atrialfibrillation, mitral stenosis,infectiveendocarditis, MI andaorticaneurism • -Should be consideredin patientswith CV problemsover 50 years of age • -Inpatientswithoutpain; abdominaldistensionandrectalbleeding • Intestinalinfarction-necrosis-peritonitisfindings
AbdominalAorticAneurism • Almostalwaysatherosclerotic • -Frequentlydiastal of renalartery • -Usuallywithoutsymptoms • -Generallydetectedduringimagingforotherreasons • -Insomepatientslomberpain • -Ifgreaterthen 5 cm dissectionandrupture risk • -Syncopeandacutedevelopinganemiashould be warning
SubphrenicAbcess • -Morefrequentlyrightsided; • -Betweenliveranddiaphragm • -Perforatedpepticulcer, perforatedappendicitis,afterabdominalsurgery • -Highfeverwithchillingandtrembling,pain in upperrightquadrant • -Chronic: subfebrilefever,loss of appetite, weightloss,fatigue • -Leukocytosis,CT,USG
SpleenInfarctionandRupture • -An enlargedspleenmay be rupturedevenwithsmalltraumas • -Enlargedspleenduetoinfectionslike IMN ormalaria mey be rupturedspontaneously • -Pain in leftupperquadrantor in supraclavicularregion,intraabdominalbleedingfindings (paleness, tachycardia,hypotension, philiformpulse) andperitonealirritationfindings • -Shockdevelopesveryquickly
-EctopicPregnancyRupture • -OvarianCystTorsion
ACUTE ABDOMINAL PAINNon-surgicalAcuteAbdominalPain • A) Pain of organsoutside of abdomen:Lowerlobepneumonia, pleuritis, MI, acuteperitonitis, eusophagusdisorders, epidymitis, intercostalherpeszoster • B) Abdominalpainresultingfrom a general illness: FMF, porphyrias, leadintoxication, diabeticketoacidosis, Henoch-Schönleinpurpura, sicklecellanemia • C) Pain of IntraabdominalOrgans: Biliarycolic, pepticulcer, bowelcolic, renalcolic, acutegastritis, acutepancreatitis, acuteenteritis,andacutesalpingitis
FMF: • Recurringfever,peritonitisandpleuritisattacks • Arthritis,skin lesionsandamyloidosismaydevelop • Mostfrequentcause of nephroticsyndromeduetoamylodosis • App.in 50%of cases no familyhistory • Frequency of attacksmaydiffer • (mostfrequently 2-6 weekslasts 24-48 hours) • Feveris thecardinalsymptom(38.5-40) • Abdominalpainwithacuteonsetandwithperitonealirritationfindings • Leukocytosis ,high ESR and CRP duringattack
Porphyrias (I) • -Resultof specificenzymedefects in hem biosynthesis • -Hepaticanderythropoeticporphyrias • -Abdominalpain in hepaticporphyrias • -Mostimportanttypeacuteintermittentporphyria; severe, diffuseabdominalpain, cannot be localised • -Ileus, abdominaldistension,andhyperperistaltismresemblesacutesurgical abdomen • -Absence of fever,leukocytosisandperitonealirritationfindings is helpfull in differantialdiagnosis
Porphyrias(II) • -Manydifferentfindingslikenausea,vomiting, constipation, tachycardia, mentalchanges, head, chest, extremitypains, periphericneuropathy, reducedmusclestrenght, • -Dysuria, andurineretension • -In a patientwithacuteabdominalpain a normal urineporphobilinogenlevelrulesoutacuteintermittentporphyria
DiabeticKetoacidosis • -In a knowndiabeticpatient(esp.Type I) • -Severe abdominalpain,nauseaandvomiting is a warning of diabeticketo-acidosis • - Peritoneallayersgetdryandthefrictionbetweenthem is duetoextremedehydration • -Clinicalsituationbecomesbetterafterketoacidosis is treated • -Ifdespite of treatment no significantimprovement; precipatingfactormay be acuteappendesitisorintestinalobstr.
AcuteAbdominalPainduetoDisorders of IntraabdominalOrgans • PepticUlcerPain: • -Chronicpainmayoccur • -Duetoreflexpyloricspasmandincreasedgastricperistaltismandtonus • -Nauseaandvomitingmayoccur • -No peritonealirritationfindings • -Pain in epigastricregion
RenalCholic • Severe pain in thelomberregion • AcuteGastritis • Suddenonset of abdominalpain, hyperemesis, vomitingand/orgastroenteritis • Leukocytosisandfever
AcutePancreatitis-I- • Itspresentationmayvaryfrommild, self-limitingdiseasetomultiorganinsufficiencyandsepsis • Thepain is felt in theepigastriumandumbilicus at firstand can not be welllocalized, getsmore severe andreachesitsmaximum • Hyperemezis-Vomiting (+) • Absence of periton irritationsignsandrigidityandthepain not being in itsmaximumseverity at theonsetareimportant in differentiating it frompepticulcerperforation
AcutePancreatitis-II • Thepainradiatestowardsrightorlefthypochondrium • Thepainbecomesmore severe andlocalized as theproteolyticenymeseffecttheperitoneumand is accompaniedbymusclestrain • Especially in theearlyperiodphysicalexaminationsignsmay be vague
Chronicabdominalpain-I • Epigastricpain: • Non-ulcerdyspepsia • Pepticulcer • Gastriccarcinoma • Acuteandchronicgastritis • Mesenteryarteryinsufficiency
Chronicabdominalpain-II • Rightupperquadrant: • Painduetocholedoc • Hepaticabscess • HepaticCarcinoma • Congestivehepatomegaly
Chronicabdominalpain-III • Rightlowerquadrantpain: • Crohn • Ileocaecaltbc • Malignanttumours of thecaecumandascendingcolon
Chronicabdominalpain-IV • Leftupperquadrantpain: • Chronicpancreatitis • Pancreasca • Tumours of theleftflexura • Splenicdiseases
Chronicabdominalpain-V • Leftlowerquadrantpain: • Ulcerativecolitis • Diverticulitis • Rectosigmoidcolonca • Fecalom
HypogastricPain: • Gynecologicdiseases: dysmenorrhea, salphengitis, ectopicpregnancy, etc. • Urologicdiseases: bladderretansion, bladderstones,cystitis
ApproachtothePatient-I- • Systematicapproachexcludingurgentconditions • Detailedanamnesis • Differentiatingacute-chronicconditions • Chronology • Menstruation in women • Avoidingnarcoticsandanalgesicsuntilthediagnosis
ApproachtothePatient-II- • Pelvicandrectalexamination • Laboratory • Imaging • Physicalexamination