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Approach To Abdominal Pain

Approach To Abdominal Pain. Dr. Nahla A Azzam MRCP,FACP Assistant Professor &Consultant Gastroenterology. Abdominal pain. One of the most common causes for OP & ER visits Multiple abd and non-abd pathologies can cause abd pain, therefore an organized approach is essential

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Approach To Abdominal Pain

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  1. Approach To Abdominal Pain Dr. Nahla A Azzam MRCP,FACP Assistant Professor &Consultant Gastroenterology

  2. Abdominal pain • One of the most common causes for OP & ER visits • Multiple abd and non-abd pathologies can cause abd pain, therefore an organized approach is essential • Some pathologies require immediate attention

  3. Introduction • Abdominal pain is an unpleasant experience commonly associated with tissue injury. The sensation of pain represents an interplay of pathophysiologic and psychosocial factors.

  4. ANATOMIC BASIS OF PAIN • Sensory neuroreceptors in abdominal organs are located within the mucosa and muscularis of hollow viscera, on serosal structures such as the peritoneum, and within the mesentery. .

  5. two distinct types of afferent nerve fibers: myelinated A-delta fibers and unmyelinated C fibers. • A-delta fibers are distributed principally to skin and muscle and mediate the sharp, sudden, well-localized pain that follows an acute injury.

  6. C fibers are found in muscle, periosteum, mesentery, peritoneum, and viscera. Most nociception from abdominal viscera is conveyed by this type of fiber and tends to be dull, burning, poorly localized

  7. The abdominal pain receptors are directly activated by substances released in response to: • local mechanical injury • Inflammation • Tissue ischemia and necrosis • Thermal or radiation injury.

  8. Abdominal Pain Definitions • Acute abdominal pain with recent onset within hours-days • Chronic abdominal pain is intermittent or continuous abdominal pain or discomfort for longer than 3 to 6 months.

  9. Surgical Appendicitis Cholecystitis Bowel obstruction Acute mesenteric ischemia Perforation Trauma Peritonitis Medical Cholangitis Pancreatitis Choledocholithiasis Diverticulitis PUD Gastroenteritis Nonabdominal causes Abdominal Pain Acute abdominal pain

  10. Abdominal Pain History • Onset • Character • Location • Severity • Duration

  11. Abdominal Pain History Aggravating and alleviating factors • Eating • Drinking • Drugs • Body position • Defecation

  12. Abdominal Pain HistoryAssociated symptoms • Anorexia • Weight loss • Nausea/vomiting • Bloating • Constipation • Diarrhea • Hemorrhage • Jaundice • Dysurea • Menstruation

  13. Abdominal Pain History PMH: Similar episodes in past Other relevant medical problems Systemic illnesses such as scleroderma, lupus, nephrotic syndrome, porphyrias, and sickle cell disease often have abdominal pain as a manifestation of their illness. PSH: Adhesions, hernias, tumors, trauma Drugs: ASA, NSAIDS, antisecretory, antibiotics, etc GYN: LMP, bleeding, discharge Social: Nicotin, ethanol, drugs, stress Family: IBD, cancer, ect

  14. Abdominal Pain Physical Exam General appearance Ambulant Healthy or sick In pain or discomfort Stigmata of CLD Vital signs

  15. Abdominal Pain Physical Exam- Abdomen Inspection Distention, scars, bruises, hernia Palpation Tenderness Guarding Rebound Masses Auscultation Abd sounds: present, hyper, or absent

  16. Abdominal Pain Laboratory Testing • CBC • Liver profile • Amylase • Glucose • Urine dipsticks • Pregnancy test

  17. Abdominal Pain Imaging Plain films Ultrasonography Computed Tomography

  18. Abdominal Pain Endoscopy EGD Colonoscopy ERCP/EUS

  19. Abdominal Pain Approach Abdominal pain Acute Chronic Surgical nonsurgical

  20. Abdominal Pain RUQ-PAIN • Cholecystitis • Cholangitis • Hepatitis • RLL pneumonia • Subdiaphragmatic abscess

  21. Abdominal Pain LUQ- PAIN • Splenic infarct • Splenic abscess • Gastritis/PUD

  22. Abdominal Pain RLQ-PAIN • Appendicitis • Inguinal hernia • Nephrolithiasis • IBD • Salpingitis • Ectopic pregnancy • Ovarian pathology

  23. Abdominal Pain LLQ-PAIN • Diverticulitis • Inguinal hernia • Nephrolithiasis • IBD • Salpingitis • Ectopic pregnancy • Ovarian pathology

  24. Abdominal Pain Epigastric-Pain • PUD • Gastritis • GERD • Pancreatitis • Cardiac (MI, pericarditis, etc)

  25. Abdominal Pain Periumbelical-Pain • Pancreatitis • Obstruction • Early appendicitis • Small bowel pathology • Gastroenteritis

  26. Abdominal Pain Pelvic-Pain • UTI • Prostatitis • Bladder outlet obstruction • PID • Uterine pathology

  27. Abdominal Pain Diffuse Pain • Gastroenteritis • Ischemia • Obstruction • DKA • IBS • Others • FMF • AIP • Vitamin D deficiency • Adrenal insufficiency

  28. Abdominal Pain Chronic abd pain approach History continuous Intermittent biliary metastasis intest. obstruction Intest. tumor pancreatic disorder Intst. angina pelvic inflammation endometriosis Addison dis porphoryea IBS functional disorder Alarm symptoms Fever C&S CT Cholestasis US/CT ERCP IDA Hematochezia Endoscopy Weight loss Endoscopy CT

  29. Abdominal Pain Take Home Points • Good history and physical exam is important (History is the most important step of the diagnostic approach ) • Lab studies limitations. • Imaging studies selection (appropriate for presentation and location). • Alarm symptoms oriented investigations • Early referral of sick patients • Treatment initiation

  30. What Is IBS • Irritable bowel syndrome (IBS) is an intestinal disorder that causes abdominal pain or discomfort, cramping or bloating, and diarrhea or constipation. Irritable bowel syndrome is a long-term but manageable condition.

  31. Introduction • First described in 1771. • 50% of patients present <35 years old. • 70% of sufferers are symptom free after 5 years. • GPs will diagnose one new case per week. • GPs will see 4-5 patients a week with IBS.

  32. Who Gets IBS? • It is estimated that between 10% and 15% of the population of North America, or approximately 45 million people, have irritable bowel syndrome. • only about 30% of them will consult a doctor about their symptoms. • IBS tends to be more common in In women, IBS is 2 to 3 times more common than in men.

  33. Diagnostic Criteria • Rome III Diagnostic criteria. • Manning’s Criteria.

  34. The positive predictive value (PPV) of the Manning criteria for the diagnosis of IBS has ranged between 65 and 75%,

  35. Rome III Diagnostic Criteria. • At least 12 weeks history, which need not be consecutive in the last 12 months of abdominal discomfort or pain that has 2 or more of the following: • Relieved by defecation. • Onset associated with change in stool frequency. • Onset associated with change in form of the stool.

  36. Rome IlI Diagnostic Criteria. • Supportive symptoms. • Constipation predominant: one or more of: • BM less than 3 times a week. • Hard or lumpy stools. • Straining during a bowel movement. • Diarrhoea predominant: one or more of: • More than 3 bowel movements per day. • Loose [mushy] or watery stools. • Urgency.

  37. Rome IlI Diagnostic Criteria. • General: • Feeling of incomplete evacuation. • Passing mucus per rectum. • Abdominal fullness, bloating or swelling.

  38. Subtypes • Diarrhoea predominant. • Constipation predominant. • Pain predominant.

  39. Associated Symptoms • In people with IBS in hospital OPD. • 25% have depression. • 25% have anxiety. • Patients with IBS symptoms who do not consult doctors [population surveys] have identical psychological health to general population. • In one study30 % of women IBS sufferers have fibromyalgia

  40. IBS Pathophysiology Heredity; nature vs nurture Dysmotility, “spasm” Visceral Hypersensitivity Altered CNS perception of visceral events Psychopathology Infection/Inflammation Altered Gut Flora

  41. Luminal Flora Mast Cell Activation Immune Activation A New Paradigm

  42. STRESS INFECTION ALTERED MICROBIOTA Luminal Flora Mast Cell Activation Immune Activation

  43. Luminal Flora Mast Cell Activation Immune Activation

  44. * IL-6 * sIL-6r 6 5 4 3 2 1 0 150000 100000 IL-6 (pg/ml) sIL-6r 50000 0 IBS Controls IBS Controls Systemic Immune Compartment in IBSSerum Cytokines Dinan, et al. Gastroenterology. 2006.

  45. Mucosal Compartment • Frank inflammation • Immune Activation • ↑ IEL’s • ↑ CD3+, CD25+ Chadwick et al, 2002 • Decreased IgA+ B Cells Forshammar et al, 2008 • Altered expression of genes involved in mucosal immunity Aerssens et al, 2008

  46. 75 50 25 0 ** EC Cells Per hpf PatientControls Volunteers PI-IBS 300 200 100 0 ** Lamina Propria TLymphocytes Per hpf PatientControls Volunteers PI-IBS Post-Infectious IBS • 10-14% incidence following confirmed bacterial gastroenteritis Dunlop, et al. 2003. Mearin, et al. 2005. • Risk factors • Female • Severe illness • Pre-morbid psyche • Depression • Persistent inflammation • EC cells • T lymphocytes Dunlop, et al. 2003.

  47. Lessons from PI-IBS Inflammatory Response Disturbed Flora Susceptible Host Myo-Neural Dysfunction SYMPTOMS

  48. Differential Diagnosis • Inflammatory bowel disease. • Cancer. • Diverticulosis. • Endometriosis. • Celiac disease

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