ABDOMINAL PAIN

1. ABDOMINAL PAIN The diagnosis of acute abdominal pain continues to be one of medicine's most daunting tasks. The abdomen might be thought of as an incredibly intricate biological "black box" in which it can be extremely difficult to pinpoint the source of distress.

2. QUESTION • A 23 yr-old female presents to the ED for evaluation of acute abdominal pain. She reports that she had multiple episodes of severe abdominal pain since age 15. These episodes have been very severe, once prompting exploratory lap. At age 18 with removal of appendix, which was histologically benign. Pain lasts 2-3 days and then resolves entirely. No aggravating or relieving factors. She had extensive w/u including pan-endoscopy, sbs, multiple cts and u/s, all negative

3. CONTD • Pt. recently c/o joint pain affecting her knees and ankles. She takes no medications. Multiple other family members have similar sxs. • P. Ex: in moderate distress, lying still. T= 103F, HR=130, BP=112/66mmHg pleural effusion on the rt side hypoactive bowel sounds and moderate diffuse abdominal tenderness and rebound tenderness Her left knee is swollen and erythematous Labs: wbc=15, esr=100 s, Pt’s symptoms resolve spontaneously in 72 hrs

4. What is the best preventive therapy • Azathioprine • Colchicine • Hemin • Indomethacin • prednisone

5. A 36 yr-old female presents with the chief complaint of burning epigastric pain for many wks. Pain gets worst after she eats spicy or fatty food and occurs approx 90 mins. after eating. Occasionally the patient awakens at night with the pain P.Ex= mild epigastric tenderness A 68 yr-old female has 2 day history of sharp right upper quadrant pain, low grade fever and nausea. Pain is constant and getting worst. It does radiates to her back. On P.Ex: tenderness on the rt. Upper quadrant QUESTIONS

6. Visceral vs Somatic

7. Visceral pain • Is experienced when noxious stimuli trigger visceral nociceptors. • The pain is usually slow onset, poorly localized, vague ,dull, burning, gnawing discomfort in the midline —epigastrium, periumbili-cal region, or lower midabdomen—because abdominal organs transmit sensory afferents to both sides of the spinal cord. • The site where the pain is felt corresponds roughly to the dermatomes that correlate with the diseased organ's innervation. • The pain is not well localized because the innervation of most viscera is multisegmental and the number of nerve endings in viscera is lower than that in highly sensitive organs such as the skin. • Secondary autonomic effects such as sweating, restlessness, nausea, vomiting, perspiration, and pallor often accompany visceral pain. • The patient may move about in an effort to relieve the discomfort.

8. referred to areas corresponding to the embryonic origin of the affected structure. Foregut structures (stomach, duodenum, liver, and pancreas) cause upper abdominal pain. Midgut structures (small bowel, proximal colon, and appendix) cause periumbilical pain. Hindgut structures (distal colon and GU tract) cause lower abdominal pain Visceral and NOT referred pain

9. Visceral pain-Mechanism • The principal mechanical signal to which visceral nociceptors are sensitive is stretch; cutting, tearing, or crushing of viscera does not result in pain. • Visceral stretch receptors are located in the muscular layers of the hollow viscera, between the muscularis mucosa and submucosa, in the serosa of solid organs, and in the mesentery (especially adjacent to large vessels). • Mechanoreceptor stimulation can result from -rapid distention of a hollow viscus (e.g., intestinal obstruction), -forceful muscular contractions (e.g., biliary or renal “colic”), and -rapid stretching of solid organ serosa or capsule (e.g., hepatic congestion). -Similarly, torsion of the mesentery (e.g., cecal volvulus) or tension from traction on the mesentery or mesenteric vessels (e.g., retroperitoneal or pancreatic tumor) results in stimulation of mesenteric stretch receptors. • Chemical nociceptors -are contained mainly within the mucosa and submucosa of the hollow viscera. -activated directly by substances released in response to local mechanical injury, inflammation, tissue ischemia and necrosis, and noxious thermal or radiation injury. Such substances include H+ and K+ ions, histamine, serotonin, bradykinin and other vasoactive amines, substance P, calcitonin gene-related peptide, prostaglandins, and leuko-trienes.

10. Is felt in areas remote from the diseased organ and results when visceral afferent neurons and somatic afferent neurons from a different anatomic region converge on second-order neurons in the spinal cord at the same spinal segment. Referred pain may be felt in skin or deeper tissues but is usually well localized. Generally, referred pain appears as the noxious visceral stimulus becomes more intense. An example is illustrated in which shows how diaphragmatic irritation from a subphrenic hematoma or abscess results in shoulder pain. Referred pain

11. Locations of Referred Pain and Its Causes • Right Shoulder Liver Gallbladder Right hemidiaphragm • Left Shoulder Heart Tail of pancreas Spleen Left hemidiaphragm • Scrotum and Testicles Ureter

12. QUESTION • A 38 yr-old male is seen the urgent care center with several hours of severe abdominal pain. His symptoms began suddenly. He reports several months of pain in the epigastrium after eating, with a resultant 10 pound wt loss. Pain is worsened by movement.He has no other past medical history. His only medication is antacids.

13. Somatoparietal pain • arises from noxious stimulation of the parietal peritoneum • more sudden, sharp, well-localized, lateralizingthan visceral pain. An example of this difference occurs in acute appendicitis, in which the early vague periumbilical visceral pain is followed by the localized somatoparietal pain at McBurney's point produced by inflammatory involvement of the parietal peritoneum. • Parietal pain is usually aggravated by movement or coughing. The nerve impulses that mediate parietal pain travel within somatic sensory spinal nerves. The fibers reach the spinal cord in the peripheral nerves that correspond to the cutaneous dermatomes from the skin—thoracic (T6) to the first lumbar vertebra (L1). • Lateralization of the discomfort of parietal pain is possible because only one side of the nervous system innervates a given part of the parietal peritoneum. • The patient with peritonitis lies quietly in bed, preferring to avoid motion, in contrast to the patient with colic, who may writhe incessantly.

14. PARIETAL PAIN • The intensity of the pain is dependent on the type and amount of material • For example, the sudden release into the peritoneal cavity of a small quantity of sterile acid gastric juice causes much more pain than the same amount of grossly contaminated neutral feces. • Enzymatically active pancreatic juice incites more pain and inflammation than does the same amount of sterile bile containing no potent enzymes. • Blood and urine are often so bland as to go undetected if their contact with the peritoneum has not been sudden and massive. • The rate at which the irritating material is applied to the peritoneum is important. Perforated peptic ulcer may be associated with entirely different clinical pictures dependent only on the rapidity with which the gastric juice enters the peritoneal cavity.

15. P.Ex: P=130/min, RR=24/min, BP=110/50 mmHg, Tm=100.4F • Abdominal Ex= absent bowel sounds, rigid, with involuntary guarding • Plain abdominal film= free air • Dx is • Necrotic bowel • Necrotic pancreas • Perforated duodenal ulcer • Perforated gastric ulcer • Perforated gall bladder

17. Pain due to a rectus sheath hematoma, muscle tear, or postoperative neuroma can be elicited by Carnett sign and Fothergill sign. • In Carnett sign, the patient who complains of an area of tenderness during conventional palpation is asked to tense the abdominal wall with neck flexion (protecting the abdominal viscera and cavity from the pressure of the examiner's hands), and the abdomen is then reexamined. If the patient's discomfort worsens, it suggests a disorder of the abdominal wall. If it lessens, an intra-abdominal process is more likely. • In Fothergill sign, a rectus sheath hematoma produces a painful, tender mass that does not cross the midline and remains palpable when the rectus is contracted.

18. QUESTON • A 67 year-old female is brought to the hospital with severe abdominal pain lasting 3 h. The pain came on suddenly while the pt was watching TV. After the pain he had nausea and vomiting without hematemesis. Her last bowel movement was the night before admission and was normal. She had a past medical hx. of hypertension and atrial fibrillation. Her medications include hctz, enalapril, and digoxin. • P.Ex: BP=118/60 mmHg, P=115/min, irregular, RR=20/min, Tm= 99F • Abdominal Ex= hypoactive bowel sounds and is mildly tender

19. Chronology or temporal • Temporal considerations rapidity of onset and progression and duration of symptoms The rapidity of onset of pain is often a measure of the severity of the underlying disorder. Pain that is sudden in onset, severe, and well localized is likely to be the result of an intra-abdominal catastrophe Affected patients usually recall the exact moment of onset of their pain.

20. . A, Many causes of abdominal pain subside spontaneously with time (e.g., gastroenteritis). B, Some pain is colicky (i.e., the pain progresses and remits over time); examples include intestinal, renal, and biliary pain (“colic”). The time course may vary widely from minutes in intestinal and renal pain to days, weeks, or even months in biliary pain. C, Commonly, abdominal pain is progressive, like its maturing, as in appendicitis or diverticulitis. D, Certain conditions have a catastrophic onset, such as ruptured aortic aneurysm. Patterns of acute abdominal pain

22. Cont: • Labs= mild AG metabolic acidosis elevated WBC with a left shift A/L= nl, Lfts= nl CT= bowel wall edema and air in the area of splenic flexure Dx= • Acute pancreatitis • Colitis • Colon ca • Mesenteric ischemia • Perforated duodenal ulcer

23. QUESTION • A 70 yr-old with a hx of cv accidents is living at a nursing home, was noted to complain about mild diffuse abdominal pain for 3 days with associated anorexia. He is brought to the ER with AMS. • P.Ex. P=100/min, rr=20/min, BP=90/60 mmHg, Tm=100.6 F

24. Abdominal pain in elderly • must be considered seriously, because nearly half the patients older than 65 years who present to the emergency department (ED) with abdominal pain are admitted, and as many as one third require surgical intervention at some time during their admission • The overall mortality for elderly ED patients with a chief complaint of abdominal pain exceeds 10%, rivaling that of an acute ST-segment elevation MI • Many factors make diagnosis difficult in elderly patients • These include difficulty in obtaining history from the patient, lack of consistent physiologic responses (including fever and leukocytosis), and confusing clinical presentations due to other comorbid conditions • The patient's ability to provide a history is frequently compromised by an altered ability to communicate. These communication difficulties may result from hearing and vision loss, cerebrovascular accidents leading to receptive or expressive aphasias, Alzheimer's disease, and other age-related dementias. Other barriers to obtaining an adequate history include the patient's fear of loss of independence and stoicism. • Altered pain perception in the elderly may influence the patient's ability adequately to describe and report pain • A number of medications can interfere with the diagnostic process or may be contributing causes of the presenting abdominal condition. • Nonsteroidal anti-inflammatory drugs (NSAIDs), may block the expected inflammatory response to peritonitis and thereby decrease the degree of abdominal tenderness for a given pathologic condition, or they may be a contributing source of a perforated peptic ulcer. Narcotic use for chronic conditions may also blunt the pain response that normally signifies an intra-abdominal catastrophe. This effect can cause a delay in the patient's presentation or lead the clinician to underestimate the severity of the condition.

25. Abdominal pain in elderly • Age-related physiologic changes These atypical features include longer time until presentation, normothermia or even hypothermia,and lower leukocyte counts in the face of serious intra-abdominal infections

26. Cont: • Pulmonary and cardiac ex is normal other than tachycardia • Abdominal examination is significant for absent bowel sounds, diffuse tenderness with rebound and guarding most pronounced in the RLQ. In addition to abx and fluid resuscitation, what is the next step? • LP • NG lavage • Mesenteric angiogram • Surgical consultation • CT abdomen without contrast

27. Abdominal pain in elderly • Appendicitis accounts for approximately 5% of all cases of acute abdomen in the elderly . • Less than one third of elderly patients have the classic presentation, defined as including all of the following: fever, elevated white blood cell count, anorexia, and right lower quadrant pain. • in one series, 54% of older patients who had appendicitis had an incorrect initial admitting diagnosis, which contributed to the high perforation rate (51%) found at the time of surgery . • The delay in presentation of the patients was also reported as a factor contributing to increased complication rates. • Importantly, right lower quadrant pain and tenderness are usually present, and appendicitis must remain high on the list of diagnostic possibilities when these symptoms are discovered. Although CT scanning has aided in the diagnosis of appendicitis in patients who have abdominalpain, its sensitivity is not 100%, and admission for observation is prudent when the cause of lower abdominalpain is unclear.

28. A 45 yr- old male is admitted to the ICU with acute onset of epigastric pain radiating to the back. No other significant past medical history. Denies alcohol. • P.Ex= RR=30/min, P=145/min, BP=90/50 mmHg, Tm=100.9F. • P.Ex: diffuse inspiratory crackles, with tachypnea, absent bowel sounds, and a diffusely tender abdomen. Cullen’s sign is present.

29. Labs: WBC=20, Cr =2.3 mg/dl, AST=115 U/L, ALT=50 IU/L and a total Bili.=3 mg/dl • Amylase/lipase=400/650 IU/L • Dx is • Choledocholithiasis • Necrotizing pancreatitis • Interstitial pancreatitis • Pancreatic Head mass • Pseudocyst

30. INTERVIEW FRAMEWORK • · Determine whether this is acute or chronic abdominal pain (or an acute exacerbation of chronic abdominal pain). The differential diagnosis differs depending on the acuity of the pain. • · Assess for alarm symptoms. • · Identify the primary location of the pain (if possible), and determine whether the pain has moved to another location • · Inquire about abdominal pain characteristics using the cardinal symptom features (PQRST): • ProvocationWhat makes the pain worse or better? QualityWhat is the character of the pain?RadiationDoes the pain radiate?SeverityRate the pain on a scale from 0 to 10 (with 0 being nopain and 10 being the worst pain possible). Timing/TreatmentHow long have you had the pain? Has the pain beenpersistent or intermittent over this period of time?What has been done to treat the pain?

31. ALARM SYMPTOMS

32. PQRST • ProvokeDoes eating worsen the pain?Pancreatitis, gastric ulcer,mesenteric ischemiaDoes eating alleviate the pain?Duodenal ulcer,gastroesophageal refluxdisease • Quality or associated symptomsIs the pain associated with nausea andvomiting?Pancreatitis, bowelobstruction, biliary colicIs the pain "tearing"?Aortic dissectionIs the pain "crampy"?Distention of a hollow tube(ie, bowel, bile duct orureter)Is the pain associated with emesis ofundigested food?Esophageal obstructionIs the pain associated with emesis ofundigested food with acidic, digestiveoutlet obstructionjuices from the stomach but no bile?Gastroparesis or gastricIs the emesis bloody?Gastroesophageal refluxdisease, esophageal orgastric varices, PUD,gastric cancer,aortoenteric fistula

33. RadiationDoes the pain radiate to the back?Pancreatitis, duodenal ulcer,gastric ulcerDoes the pain radiate to the right shoulder?Biliary colicDoes the pain radiate to the left shoulder?Splenomegaly or splenicinfarctionDoes the pain radiate to the left arm?Myocardial ischemia • SeverityDid the pain in your right lower abdomensuddenly improve from an 8 or 9 to a 2 or3? (on a scale of 0 to 10)Perforated appendixDid the pain hurt the most at its onset?Aortic dissection • Timing/TreatmentIs the pain continuous with intermittentwaves of worsening pain? Biliary colic, renal colic,small bowel obstructionAre there multiple waves of pain thatincrease in intensity, then stop abruptlyfor short periods of time? Small bowel obstructionDid you recently take antibiotics?Colitis due to ClostridiumdifficileDoes the pain occur once monthly around 2weeks after the beginning of your menses,occasionally associated with vaginalspotting?Mittelschmerz

34. THINK NON-GI CAUSES

35. QUESTION • A 42 yr-old female presents with rt sided pain for last 3 months. She notes that the pain is episodic and is characterizes it as crampy. She c/o loose stools but occasionally notes hard narrow caliber stools and a feeling of incomplete evacuation. Symptoms worsen with stressful situations. She has found blood on the toilet paper. No wt loss • P.Ex is benign • Next step is: A) Colonoscopy B) Antidepressant C) Dietary modification D) Lomotil E) Tageserod

36. No identifiable structural or biochemical abnormalities • Affects 14%-24% of females and 5%-19% of males • Onset in late adolescence to early adulthood • Rare to see onset > 50 yrs oldPain described as nonradiating, intermittent, crampy located lower abdomen • Usually worse 1-2 hrs after meals • Exacerbated by stress • Relieved by BM • Does not interrupt sleep – critical to diagnosis of IBS DIAGNOSIS ROME DIAGNOSTIC CRITERIA • 3 month minimum of following symptoms in continuous or recurrent pattern Abdominal pain or discomfort relieved by BM & associated with either: Change in frequency of stools and/or Change in consistency of stools Two or more of following symptoms on 25% of occasions/days: Altered stool frequency >3 BMs daily or <3BMs/week Altered stool form Lumpy/hard or loose/watery Altered stool passage Straining, urgency, or feeling of incomplete evacuation Passage of mucus Feeling of bloating or abdominal distention IRRITABLE BOWEL SYNDROME

42. QUESTION • A 58 y-old female presents with epigastric pain that is worst after eating. The pain is so severe that the patient avoid eating and has lost 25 pounds over 2 months. She describes the pain as burning in quality and somewhat relieved with antacid therapy