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1B abdominal pain Flashcards

1
Q

What symptom do most intra-abdominal diseases present with alone?

A

Pain- so a careful history is never wasted

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2
Q

What are the 2 most significant properties of the pain?

A
  • Site
  • Character
  • If you know these you have a good chance of making the correct diagnosis
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3
Q

What framework do we use to ask patients about pain?

A

SOCRATES

  • Site- where is it?
  • Onset- has it come on suddenly or gradually?
  • Character- what is the pain like? Is it burning? Colicky (sharp, localised)? Aching?
  • Radiation- where does it go to?
  • Association- is it associated with vomiting? Fever?
  • Time course- have they had that pain before?
  • Exacerbating or relieving factors- what makes it better? What makes it worse?
  • Severity- how bad is it e.g. /10?
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4
Q

What are the 2 main ways of marking surface anatomy for site of pain?

A
  • Abdominopelvic regions
  • Abdominopelvic quadrants
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5
Q

What organs is each region responsible for?

A

There is a big crossover between the 2 regions- a lot of people say they have biliary-colic pain but its epigastric. If not sure, endoscopy is good to check.

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6
Q

What are the vertical and horizontal lines passing through?

A

Umbilicus

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7
Q

What organ structures are found at the transpyloric plane?

A

L1
- Pylorus of stomach
- Neck of pancreas
- Fundus of gallbladder
- Renal hilum of left kidney (right kidney is pushed down a bit by liver)
- Duodenojejunal flexure
- End of spinal cord in adult

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8
Q

What organ structures are found at the subcostal plane and supracristal plane respectively?

A

Subcostal plane- L3

  • Origin of inferior mesenteric artery

Supracristal plane- L4

  • Bifurcation of the aorta
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9
Q

What is the foregut made of?

A

Distal oesophagus → proximal half of 2nd part of duodenum

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10
Q

What innervates the pain in the foregut?

A

T5-T9

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11
Q

What pain is the foregut the site of?

A

Epigastrium

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12
Q

What is the midgut made of?

A

Distal half of 2nd part of duodenum → proximal 2/3 of transverse colon

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13
Q

What innervates the pain in the midgut?

A

T10 and T11

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14
Q

What pain is the midgut the site of?

A

Umbilical

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15
Q

What is the hindgut made of?

A

Distal 1/3 of transverse colon → rectum

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16
Q

What innervates the pain in the hindgut?

A

L1 and L2

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17
Q

What pain is the hindgut the site of?

A

Hypogastrium

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18
Q

Describe the blood supply of the abdomen

A
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19
Q

What is the parietal peritoneum?

A

Covering of abdominal wall anteriorly + covering of abdominal cavity posteriorly

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20
Q

What is visceral peritoneum?

A
  • Peritoneum covering organs
  • Liver peritoneum, colon peritoneum
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21
Q

What is special about the pancreas and duodenum?

A

They’re both retroperitoneal structures (not acc inside abdomen)

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22
Q

What nerves supply the parietal peritoneum?

A

Phrenic nerves that supply sensation from central tendon to diaphragm → C3, C4, C5

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23
Q

What’s special about the parietal peritoneum nerve supply?

A

C3 and 5 also innervate right shoulder so patients can present with right shoulder pain when something’s going on under their diaphragm

  • Segmental innervation from T5 to L2 (umbilicus supplied by T10)
24
Q

What nerves supply the visceral peritoneum?

A
  • Parasympathetic supply from vagus nerve
  • Parasympathetic supply from S2-4
  • Sympathetic chain goes T1-12 and L1-2
25
Q

What nerve plexuses are there?

A
  • Coeliac plexus
  • Superior mesenteric plexus
  • Inferior mesenteric plexus
26
Q

What are the two main categories for character of pain?

A
  • Inflammation
  • Obstruction of a muscular tube
27
Q

What kind of pain does inflammation cause?

A
  • Constant ‘aching’ pain
  • Made worse by movement
  • Persists until inflammation subsides
28
Q

What kind of pain does obstruction of a muscular tube cause?

A
  • Colicky ‘gripping’ pain
  • Fluctuates in severity
  • Patient moves to try and get comfortable
29
Q

What happens if colicky has changed and has become a constant stretching pain?

A
  • There has been prolonged obstruction of a hollow viscus that has caused distension
  • This is different from ache of inflammation and isn’t colicky
  • There may be impending ischaemia
30
Q

What character of pain do you find in the ureter?

A

Colicky

31
Q

What character of pain do you find in the liver?

A

Constant e.g. could be hepatitis or liver abscess

32
Q

What character of pain do you find in the biliary-colic?

A

Colicky e.g. stone trying to get through duct like bile duct

33
Q

What character of pain do you find in the spleen?

A

Constant e.g. splenic abscess or rupture

34
Q

What character of pain do you find in the kidney?

A

Constant e.g. pyelonephritis or abscess

35
Q

What character of pain do you find in the small or large bowel?

A

Colicky

36
Q

Describe this graph of colicky pain

A
  • Ureteric colic is defo colic- comes in waves- pain intensity gets high then drops
  • Intestinal colic is still colic but less painful than ureteric
  • Biliary colic doesn’t have to be true colic as it gets to a high intensity but then fluctuates at that high level
37
Q

Where does gallbladder (right hypochondriac region) pain radiate?

A

Through to the back and right- this happens in 50% of cases

38
Q

Where does stomach, duodenum, pancreas (epigastrium) pain radiate?

A
  • Straight through to back- especially because pancreas and duodenum are retroperitoneal
  • People with pancreatic cancer present with back pain because tumour infiltrates posteriorly
39
Q

What position do pancreatic cancer patients feel better in?

A

Sitting up and leaning forward, because abdominal viscera aren’t pushing against pancreas

40
Q

Where does tail of pancreas (left hypochondriac region) pain radiate?

A

Through to the back and the left

41
Q

Where does right kidney (right lumbar region) pain radiate?

A

In loin and radiates to groin (following ureter)

42
Q

Where does small bowel, caecum, retroperitoneal structures (umbilical region) pain radiate?

A

Doesn’t normally radiate because it’s visceral

43
Q

Where does left kidney (left lumbar region) pain radiate?

A

In loin and radiates to groin

44
Q

What can people with AAA present regarding left kidney pain?

A

They can describe left ureteric colicky pain

45
Q

Where do the lower zone organs (appendix and caecum, bladder, transverse colon, uterus, adnexae, sigmoid colon) pain radiate?

A
  • Lower abdominal pain rarely radiates
  • Pain from structures deep in pelvis is referred to lower back/perineum
46
Q

What is the diagnosis for the following case:

S → Central then shifts to right iliac region

O → Gradual

C → Constant

R → No radiation

A → Nausea, anorexia, fever

T → No previous pain

E → Worse on movement

S → Dull ache

A

Appendicitis

47
Q

What is important to know about the location of the appendix?

A

It can be retrocaecal (64% of the time) and pelvic (32%) which means if we examine their abdomen and press it you won’t feel the appendix- when it’s pelvic they won’t even have abdominal pain

48
Q

What is the diagnosis for the following case:
S → Central

O → Gradual

C → Colicky

R → No radiation

A → Vomiting, bowels not open

T → Previous colicky pain

E → Passing flatus relieves pain

S → Moderate?

A

Bowel obstruction (causing intestinal colic)

49
Q

What is the commonest cause of small bowel obstructions?

A

Adhesions → if you have an operation you get a scar on anterior abdominal wall but some patients get scarring on inside as well (adhesions) which are fibrous bands

50
Q

When can adhesions be very bad?

A

When, just like in right pic, it wraps around and causes a closed loop obstruction (nothing can get in or out)

That part of bowel becomes ischaemic quickly and can explode

51
Q

How are band adhesions treated?

A

These band adhesions can twist around bowel and obstruct it- can be solved by putting NG tube down and decompress it and it’ll untwist and it’s fine

Can do surgery and cut band with pair of scissors

52
Q

What is the diagnosis for the following case:

S → Loin

O → Sudden onset

C → Colicky

R → To groin

A → Vomiting

T → Previous colicky pain

E → Cannot find a comfortable position

S → Severe 10/10

A

Right uteric colic

53
Q

What is the diagnosis for the following case:

S → Right upper quadrant

O → Sudden onset

C → Colicky

R → To right shoulder

A → Nausea, indigestion

T → After eating

E → Fatty foods

S → Can be severe 10/10?

A

Biliary colic (a stone trying to get through something- colicky muscular pain)

54
Q

How is cholelithiasis different to biliary colic?

A
  • Stone gets caught in cystic duct
  • Bile can’t get in and out
  • Lining of gallbladder keeps producing mucus which has nowhere to go and becomes infected
  • Sometimes it can get out as pus
  • Causes localised pain, not radiating- has Murphy’s sign
55
Q

What is mesenteric adenitis?

A
  • Can be mistaken for acute appendicitis
  • You have inflammatory process with bowel and you get reactive lymph nodes that cause pain
  • Could be caused by transient viral infection
56
Q

What is Meckel’s diverticulitis?

A
  • Outpouching of small bowel that causes inflammation
  • Can contain ectopic pancreatic or gastric tissue
  • Very non-specific and rare

gastro (7 decks)

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