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

Approach to Abdominal PainProf.Dr.Fikret Sipahiolu

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,contractions,inflammatory-ulcerative lesions and ischemia

Slow progressing tension(colon tm.) may not cause pain-Organs are not sensitive to pain(endoscopic biopsies are not painful)-Malignant tumors of intraabdominal organs are not painful unless there is a complication such as obstruction, ulceration or perforation

In inflamated or damaged regions:Mediaters like histamin,serotonin, bradichinin, leucotriens affect neural ends and cause pain-In ischemic regions:Increased toxic metabolites, inflammation mediators and decreased pain threshold due to ischemia cause pain

Three Types of Abdominal Pain -Visceral pain -Somatoparietal pain-Radiating pain

Visceral Pain

-Result of tension,contraction,ischemia of intraabdominal organs-Stimulation of autonomic nerve ends (thoracolomber symphatic plexus bilaterally, n.vagus and pelvic plexus)-Pain localised at paraumbilical region-Is knt,sometimes hard, continious or with fluctuations-Discomfort,emesis,vomiting, sweating,pale looking tachycardia(autonomic findings) may exist

Visceral Pain(continued)

-Pain of upper abdominal organs(stomach,liver,biliary tract) localised at mid-line and epigastrium-Pain of the region from Treitz ligament up to transversal colon paraumbilically-Pain of distal colon,rectum,ureters,bladder and genital organs suprapubically

Somatic or Parietal Pain

-Results from stimulation of parietal peritoneum-Much more severe-Affected organ can be localised-Moving,coughing,deep inspiration stimulate parietal peritoneum;patient reduces movement-Hyperaesthesia can be observed

Comparison of Visceral and Somatic PainVisceral Pain Somatic PainIndefinite SharpFluctuating ContiniousNot localised LocalisedDiscomfort Reduced movesOther autono.symp Pain prominent

Radiating Pain

Pain is felt far from the affected organ but innervated from same neural segments-Perceived as burn, sensitivity, biting-Skin hyperaesthesia, muscular hypertonicity-E.g. gall bladder pain; back, right shoulder and scapula Peptic ulcer pain; back left 12th rib(Boas point)

History Taking

Several charasteristics should be considered:-Duration-Way of beginning-Continious or not-Intensity-Localisation and radiation-Relationship with meals-Affecting factors-Relationship with posture-Coexisting findings(nausea,vomiting,constipation,fever,jaundice,bleeding,voiding etc.)

Abdominal Pain

Acute abdominal pain Surgical acute abdominal pain Non-surgical acute abdominal painChronic abdominal pain

-History taking and careful physi. ex-In half of the patients no surgery-Most frequent:Acute appendecitis,-Ac. cholecystitis, peptic ulcer perfo.,-Small bowel obstruction-Abdominal pain-Thereafter nausea-vomiting-Laparoscopic examination

ACUTE ABDOMINAL PAINAcute Surgical Abdomen ():

Peptic Ulcer Perforation (I)

Frequent in duodenal,rare in gastric ulcers-Acute onset,a penetrative and very severe pain-In the beginning at epigastric region,then whole abdomen-Irritation of diaphragm may cause shoulder pain-Reflex efferent stimulation rigidity of abdominal muscles

Peptic Ulcer Perforation(II)

-Patient motionless, superficial breathing, no abdominal respiration-Fever,tachycardia,hypotension,-Tendency to shock( due to peritonitis)-Due to paralytic ileus no bowel sounds-Reduced liver and spleen matite-Radiologic ex. Perforation

Acute Cholecystitis(I)

-Pain and tenderness in the right upper quadrant; fever and leukocytosis-Frequent choledocolithiazis-Obstruction in d.cysticus due to choledocolithiazis.lasts longinfection and acute cholecystitis-Usually continious pain-Visceral pain due to tension of d.cysticus in epigastric and left upper regions-When inflammation develops in gall bladder somatic pain in right upper quadrant

Acute Cholecystitis(II)

-Tenderness and muscular defense in right upper quadrant -Back and shoulder pain-Nausea,vomiting and anorexia-Biliary colic 4-6 hours.-A. Cholecystitis

Physical examination:

-Pain in right upper quadrant-Local tenderness-Murphys sign positive

Laboratory Findings

Mild increase in t.bilirubin(4mg/dL)Higher levels; choledocholithiasis and cholengitisLeukocytosisTransaminases and alkaline phosphatase mildly increasedUSG and ERCP

Bowel Perforations:

-Infection( typhoid fever,dysentery)-Diverticulitis, Meckel diverticulitis-Cancer-Ulcerative colitis and toxic megacolon-Acute appendecitis if not treated

Mechanical Ileus

-Primary bowel cancers;ileus,subileus-Crohns disease,bowel tbc., lymphoma.. obstruction especially in terminal ileum and cecum-Fecaloma ( long lasting constipation)

Mechanical Ileus (II)

-Severe and colical pain-Intensity increases and with time is reduced-Pain localized at periumblical and right lower quadrant in small bowel and proximal colon obstructions; at left lower quadrant in distal colon ob.-Vomiting( contains bile and fekaloid with time)-Increased bowel peristaltism-No faeces

Mechanical Ileus(III)-Pain reliefed with vomiting or NG decompression-Increased pain intensity,continous or localized pain peritoneal irritation findings is a warning for bowel perforation and peritonitis-In paralytic ileus no bowel sounds

23Mechanical Ileus(III)

-Pain relieved with vomiting or NG decompression-Increased pain intensity,continious or localized pain peritoneal irritation findings is a warning for bowel perforation and peritonitis-In paralytic ileus no bowel sounds

Acute Appendecitis (I)

-Most common reason for acute surgical abdomen

-Feaces,foreign body,parasites,and tumors

-Typically:Visceral pain periumblical or epigastric regions; afterwards nausea and vomiting, somatic pain at appendix and fever

Acute Appendecitis(II)

Differential Diagnosis:

Acute gastroenteritis, mesentery lymphadenitis,yersinia colitis,acute salpingitis, Mittelscherz, ectopic pregnancy rupture, ovarian cyst torsion,ureteral colic, acute pyelonephritis,perforated peptic ulcer, acute cholecystitis, basal pnomonia, diabetic ketoacidosis, acute porphiria, FMF

Acute Appendecitis(III)

-Most dangerous complication is perforation-Generally 48 hours after pain begins-Fever, disseminated abdominal tenderness, plastron in right lower quadrant, leukocytosis

Acute Mesenteric Ischemia -No significant clinical finding if small arteries are occluded-In splenic flexura or sigmoid colon where collateral circulation is not adequate ischeamic changes more easily-Embolism of superior mesenteric artery; atrial fibrillation, mitral stenosis,infective endocarditis, MI and aortic aneurism-Should be considered in patients with CV problems over 50 years of age-In patients without pain; abdominal distension and rectal bleedingIntestinal infarction-necrosis-peritonitis findings

Abdominal Aortic AneurismAlmost always atherosclerotic-Frequently diastal of renal artery-Usually without symptoms-Generally detected during imaging for other reasons-In some patients lomber pain-If greater then 5 cm dissection and rupture risk-Syncope and acute developing anemia should be warning

Subphrenic Abcess-More frequently right sided;-Between liver and diaphragm-Perforated peptic ulcer, perforated appendicitis,after abdominal surgery-High fever with chilling and trembling,pain in upper right quadrant-Chronic: subfebrile fever,loss of appetite, weight loss,fatigue-Leukocytosis,CT,USG

Spleen Infarction and Rupture

-An enlarged spleen may be ruptured even with small traumas-Enlarged spleen due to infections like IMN or malaria mey be ruptured spontaneously-Pain in left upper quadrant or in supraclavicular region,intraabdominal bleeding findings (paleness, tachycardia,hypotension, philiform pulse) and peritoneal irritation findings-Shock developes very quickly

-Ectopic Pregnancy Rupture-Ovarian Cyst TorsionACUTE ABDOMINAL PAINNon-surgical Acute Abdominal Pain

A) Pain of organs outside of abdomen:Lower lobe pneumonia, pleuritis, MI, acute peritonitis, eusophagus disorders, epidymitis, intercostal herpes zosterB) Abdominal pain resulting from a general illness: FMF, porphyrias, lead intoxication, diabetic ketoacidosis, Henoch-Schnlein purpura, sickle cell anemiaC) Pain of Intraabdominal Organs: Biliary colic, peptic ulcer, bowel colic, renal colic, acute gastritis, acute pancreatitis, acute enteritis,and acute salpingitis

FMF:

Recurring fever,peritonitis and pleuritis attacksArthritis,skin lesions and amyloidosis may developMost frequent cause of nephrotic syndrome due to amylodosisApp.in 50%of cases no family historyFrequency of attacks may differ(most frequently 2-6 weeks lasts 24-48 hours)Fever is the cardinal symptom(38.5-40)Abdominal pain with acute onset and with peritoneal irritation findingsLeukocytosis ,high ESR and CRP during attack

Porphyrias (I)

-Result of specific enzyme defects in hem biosynthesis-Hepatic and erythropoetic porphyrias-Abdominal pain in hepatic porphyrias-Most important type acute intermittent porphyria; severe, diffuse abdominal pain, cannot be localised-Ileus, abdominal distension,and hyperperistaltism resembles acute surgical abdomen-Absence of fever,leukocytosis and peritoneal irritation findings is helpfull in differantial diagnosisPorphyrias(II)

-Many different findings like nausea,vomiting, constipation, tachycardia, mental changes, head, chest, extremity pains, peripheric neuropathy, reduced muscle strenght,-Dysuria, and urine retension -In a patient with acute abdominal pain a normal urine porphobilinogen level rules out acute intermittent porphyria

Diabetic Ketoacidosis

-In a known diabetic patient(esp.Type I)-Severe abdominal pain,nausea and vomiting is a warning of diabetic keto-acidosis- Peritoneal layers get dry and the friction between them is due to extreme dehydration -Clinical situation becomes better after ketoacidosis is treated-If despite of treatment no significant improvement; precipating factor may be acute appendesitis or intestinal obstr.

Acute Abdominal Pain due to Disorders of Intraabdominal Organs

Peptic Ulcer Pain:

-Chronic pain may occur-Due to reflex pyloric spasm and increased gastric peristaltism and tonus-Nausea and vomiting may occur-No peritoneal irritation findings-Pain in epigastric region

Renal Cholic Severe pain in the lomber region

Acute Gastritis Sudden onset of abdominal pain, hyperemesis, vomiting and/or gastroenteritis Leukocytosis and fever

Acute Pancreatitis-I-

Its presentation may vary from mild, self-limiting disease to multiorgan insufficiency and sepsis The pain is felt in the epigastrium and umbilicus at first and can not be well localized, gets more severe and reaches its maximumHyperemezis-Vomiting (+)Absence of periton irritation signs and rigidity and the pain not being in its maximum severity at the onset are important in differentiating it from peptic ulcer perforation

Acute Pancreatitis-II The pain radiates towards right or left hypochondrium The pain becomes more severe and localized as the proteolytic enymes effect the peritoneum and is accompanied by muscle strain Especially in the early period physical examination signs may be vague

Chronic abdominal pain-I

Epigastric pain:

Non-ulcer dyspepsia Peptic ulcer Gastric carcinoma Acute and chronic gastritis Mesentery artery insufficiency

Chronic abdominal pain-II

Right upper quadrant:

Pain due to choledoc Hepatic abscess Hepatic Carcinoma Congestive hepatomegaly

Chronic abdominal pain-III

Right lower quadrant pain:

CrohnIleocaecal tbcMalignant tumours of the caecum and ascending colon

Chronic abdominal pain-IV

Left upper quadrant pain:

Chronic pancreatitisPancreas caTumours of the left flexuraSplenic diseases

Chronic abdominal pain-V

Left lower quadrant pain:

Ulcerative colitisDiverticulitisRectosigmoid colon caFecalom

Hypogastric Pain:

Gynecologic diseases: dysmenorrhea, salphengitis, ectopic pregnancy, etc.Urologic diseases: bladder retansion, bladder stones,cystitis

Approach to the Patient-I-

Systematic approach excluding urgent conditionsDetailed anamnesisDifferentiating acute-chronic conditionsChronologyMenstruation in womenAvoiding narcotics and analgesics until the diagnosis

Approach to the Patient-II-

Pelvic and rectal examinationLaboratoryImagingPhysical examination