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Approach to Abdominal Pain Prof.Dr .Fikret Sipahioğlu Dept . of Internal Medicine

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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Approach to Abdominal Pain Prof.Dr .Fikret Sipahioğlu Dept . of Internal Medicine

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  1. ApproachtoAbdominalPainProf.Dr.Fikret SipahioğluDept. of InternalMedicine

  2. AbdominalPain • -Localisation of thepathologywhichcausespain • -Differsaccordingtoneuraltractsconductingpain • -Mainmechanisms: Increasedtension of emptyorgans, • contractions,inflammatory-ulcerativelesionsandischemia

  3. Slowprogressingtension(colontm.) may not causepain • -Organsare not sensitivetopain(endoscopicbiopsiesare not painful) • -Malignanttumors of intraabdominalorgansare not painfulunlessthere is a complicationsuch as obstruction, ulcerationorperforation

  4. Ininflamatedordamagedregions: • Mediaterslikehistamin,serotonin, bradichinin, leucotriensaffectneuralendsandcausepain • -Inischemicregions: • Increasedtoxicmetabolites, inflammationmediatorsanddecreasedpainthresholdduetoischemiacausepain

  5. ThreeTypes of AbdominalPain • -Visceralpain • -Somatoparietalpain • -Radiatingpain

  6. 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

  7. VisceralPain(continued) • -Pain of upperabdominalorgans • (stomach,liver,biliarytract) localised at mid-lineandepigastrium • -Pain of theregionfromTreitzligamentuptotransversalcolonparaumbilically • -Pain of distalcolon,rectum, • ureters,bladderandgenitalorganssuprapubically

  8. SomaticorParietalPain • -Resultsfromstimulation of parietalperitoneum • -Muchmore severe • -Affected organ can be localised • -Moving,coughing,deepinspirationstimulateparietalperitoneum;patientreducesmovement • -Hyperaesthesia can be observed

  9. Comparison of VisceralandSomaticPain • VisceralPainSomaticPain • IndefiniteSharp • FluctuatingContinious • Not localisedLocalised • DiscomfortReducedmoves • Otherautono.sympPainprominent

  10. 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)

  11. HistoryTaking • Severalcharasteristicsshould be considered: • -Duration • -Way of beginning • -Continiousor not • -Intensity • -Localisationandradiation • -Relationshipwithmeals • -Affectingfactors • -Relationshipwithposture • -Coexistingfindings(nausea,vomiting, • constipation,fever,jaundice,bleeding, • voidingetc.)

  12. AbdominalPain • Acuteabdominalpain • Surgicalacuteabdominalpain • Non-surgicalacuteabdominalpain • Chronicabdominalpain

  13. ACUTE ABDOMINAL PAINAcuteSurgical Abdomen (ı): • -Historytakingandcarefulphysi. ex • -Inhalf of thepatients no surgery • -Mostfrequent:Acuteappendecitis, • -Ac. cholecystitis, pepticulcerperfo., • -Smallbowelobstruction • -Abdominalpain… • -Thereafternausea-vomiting • -Laparoscopicexamination

  14. 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

  15. PepticUlcerPerforation(II) • -Patientmotionless, superficialbreathing, no abdominalrespiration • -Fever,tachycardia,hypotension, • -Tendencytoshock( duetoperitonitis) • -Duetoparalyticileus no bowelsounds • -Reducedliverandspleenmatite • -Radiologicex. Perforation

  16. 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

  17. AcuteCholecystitis(II) • -Tendernessandmusculardefense in rightupperquadrant • -Backandshoulderpain • -Nausea,vomitingandanorexia • -Biliarycolic ≥ 4-6 hours…. • -A. Cholecystitis

  18. Physicalexamination: • -Painin rightupperquadrant • -Localtenderness • -Murphy’ssignpositive

  19. LaboratoryFindings • Mildincrease in t.bilirubin(≤4mg/dL) • Higherlevels; choledocholithiasisandcholengitis • Leukocytosis • Transaminasesand alkaline phosphatasemildlyincreased • USG and ERCP

  20. BowelPerforations: • -Infection( typhoidfever,dysentery) • -Diverticulitis, Meckeldiverticulitis • -Cancer • -Ulcerativecolitisandtoxicmegacolon • -Acuteappendecitisif not treated

  21. MechanicalIleus • -Primarybowelcancers;ileus,subileus • -Crohn’sdisease,boweltbc., lymphoma.. obstructionespecially in terminal ileumandcecum • -Fecaloma ( longlastingconstipation)

  22. 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

  23. MechanicalIleus(III) • -Painreliefedwithvomitingor NG decompression • -Increasedpainintensity,continousorlocalizedpainperitonealirritationfindings is a warningforbowelperforationandperitonitis • -Inparalyticileus no bowelsounds

  24. MechanicalIleus(III) • -Painrelievedwithvomitingor NG decompression • -Increasedpainintensity,continiousorlocalizedpainperitonealirritationfindings is a warningforbowelperforationandperitonitis • -Inparalyticileus no bowelsounds

  25. AcuteAppendecitis (I) • -Mostcommonreasonforacutesurgicalabdomen • -Feaces,foreign body,parasites,andtumors • -Typically:Visceralpainperiumblicalorepigastricregions; afterwardsnauseaandvomiting, somaticpain at appendixandfever

  26. AcuteAppendecitis(II) • DifferentialDiagnosis: • Acutegastroenteritis, mesenterylymphadenitis,yersiniacolitis,acutesalpingitis, Mittelscherz, ectopicpregnancyrupture, ovariancysttorsion,ureteralcolic, acutepyelonephritis,perforatedpepticulcer, acutecholecystitis, basalpnomonia, diabeticketoacidosis, acuteporphiria, FMF

  27. AcuteAppendecitis(III) • -Mostdangerouscomplication is perforation • -Generally 48 hoursafterpainbegins • -Fever, disseminatedabdominaltenderness, plastron in rightlowerquadrant, leukocytosis

  28. 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

  29. AbdominalAorticAneurism • Almostalwaysatherosclerotic • -Frequentlydiastal of renalartery • -Usuallywithoutsymptoms • -Generallydetectedduringimagingforotherreasons • -Insomepatientslomberpain • -Ifgreaterthen 5 cm dissectionandrupture risk • -Syncopeandacutedevelopinganemiashould be warning

  30. SubphrenicAbcess • -Morefrequentlyrightsided; • -Betweenliveranddiaphragm • -Perforatedpepticulcer, perforatedappendicitis,afterabdominalsurgery • -Highfeverwithchillingandtrembling,pain in upperrightquadrant • -Chronic: subfebrilefever,loss of appetite, weightloss,fatigue • -Leukocytosis,CT,USG

  31. SpleenInfarctionandRupture • -An enlargedspleenmay be rupturedevenwithsmalltraumas • -Enlargedspleenduetoinfectionslike IMN ormalaria mey be rupturedspontaneously • -Pain in leftupperquadrantor in supraclavicularregion,intraabdominalbleedingfindings (paleness, tachycardia,hypotension, philiformpulse) andperitonealirritationfindings • -Shockdevelopesveryquickly

  32. -EctopicPregnancyRupture • -OvarianCystTorsion

  33. 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

  34. 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

  35. 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

  36. Porphyrias(II) • -Manydifferentfindingslikenausea,vomiting, constipation, tachycardia, mentalchanges, head, chest, extremitypains, periphericneuropathy, reducedmusclestrenght, • -Dysuria, andurineretension • -In a patientwithacuteabdominalpain a normal urineporphobilinogenlevelrulesoutacuteintermittentporphyria

  37. 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.

  38. AcuteAbdominalPainduetoDisorders of IntraabdominalOrgans • PepticUlcerPain: • -Chronicpainmayoccur • -Duetoreflexpyloricspasmandincreasedgastricperistaltismandtonus • -Nauseaandvomitingmayoccur • -No peritonealirritationfindings • -Pain in epigastricregion

  39. RenalCholic • Severe pain in thelomberregion • AcuteGastritis • Suddenonset of abdominalpain, hyperemesis, vomitingand/orgastroenteritis • Leukocytosisandfever

  40. 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

  41. AcutePancreatitis-II • Thepainradiatestowardsrightorlefthypochondrium • Thepainbecomesmore severe andlocalized as theproteolyticenymeseffecttheperitoneumand is accompaniedbymusclestrain • Especially in theearlyperiodphysicalexaminationsignsmay be vague

  42. Chronicabdominalpain-I • Epigastricpain: • Non-ulcerdyspepsia • Pepticulcer • Gastriccarcinoma • Acuteandchronicgastritis • Mesenteryarteryinsufficiency

  43. Chronicabdominalpain-II • Rightupperquadrant: • Painduetocholedoc • Hepaticabscess • HepaticCarcinoma • Congestivehepatomegaly

  44. Chronicabdominalpain-III • Rightlowerquadrantpain: • Crohn • Ileocaecaltbc • Malignanttumours of thecaecumandascendingcolon

  45. Chronicabdominalpain-IV • Leftupperquadrantpain: • Chronicpancreatitis • Pancreasca • Tumours of theleftflexura • Splenicdiseases

  46. Chronicabdominalpain-V • Leftlowerquadrantpain: • Ulcerativecolitis • Diverticulitis • Rectosigmoidcolonca • Fecalom

  47. HypogastricPain: • Gynecologicdiseases: dysmenorrhea, salphengitis, ectopicpregnancy, etc. • Urologicdiseases: bladderretansion, bladderstones,cystitis

  48. ApproachtothePatient-I- • Systematicapproachexcludingurgentconditions • Detailedanamnesis • Differentiatingacute-chronicconditions • Chronology • Menstruation in women • Avoidingnarcoticsandanalgesicsuntilthediagnosis

  49. ApproachtothePatient-II- • Pelvicandrectalexamination • Laboratory • Imaging • Physicalexamination

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