6.4 - Abdominal pain tutorial Flashcards
What symptom do most intra-abdominal diseases present with alone?
Pain - so a careful history is never wasted
What are the 2 most significant properties of the abdominal pain?
- site
- character
- if you know these two, you have a good chance of making the correct diagnosis
What framework do we use to ask patients about (abdominal) pain?
- 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?
- Associated symptoms - 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?
What are the 2 main ways of marking surface anatomy for site of pain?
- abdominopelvic regions (9)
- abdominopelvic quadrants (4)
What are the nine abdominopelvic regions? (left to right, top to bottom)
- right hypochondriac
- epigastric
- left hypochondriac
- right lumbar
- umbilical
- left lumbar
- right iliac
- hypogastric/suprapubic
- left iliac
Abdominopelvic regions - What are the right and left vertical lines?
Mid-clavicular lines
Abdominopelvic regions - What is the top horizontal line?
Transpyloric line
Abdominopelvic regions - What is the bottom horizontal line?
Interspinous line through the 2 ASIS
What organs are the right hypochondriac region responsible for?
Gallbladder
What organs are the epigastric region responsible for?
Stomach, duodenum, pancreas
What organs are the left hypochondriac region responsible for?
Pancreas
What organs are the right lumbar region responsible for?
Kidney
What organs are the umbilical region responsible for?
Small bowel, caecum, retroperitoneal structures
What organs are the left lumbar region responsible for?
Kidney
What organs are the right iliac region responsible for?
Appendix and caecum
What organs are the hypogastric region responsible for?
Transverse colon, bladder, uterus and adnexae
What organs are the left iliac region responsible for?
Sigmoid colon
What are the four abdominopelvic quadrants?
- right upper quadrant
- left upper quadrant
- right lower quadrant
- left lower quadrant
What are the vertical and horizontal lines passing through in the four abdominopelvic quadrants?
Umbilicus
What are some different abdominal planes? (5)
- transpyloric plane
- subcostal plane
- supracristal plane
- intertubercular plane
- interspinous plane
What vertebral levels are the transpyloric, subcostal and supracristal planes?
- transpyloric plane - L1
- subcostal plane - L3
- supracristal plane - L4
What organ structures are found at the transpyloric plane?
- pylorus of stomach
- neck of pancreas
- fundus of gallbladder
- renal hilum of left kidney (right kidney pushed down a bit by liver)
- duodenojejunal flexure
- end of spinal cord in adult
What organ structures are found at the subcostal plane?
Origin of inferior mesenteric artery
What organ structures are found at the supracristal plane?
Bifurcation of the aorta
What is the foregut made of?
Distal oesophagus → proximal half of 2nd part of duodenum
What innervates the pain in the foregut?
T5-T9 (greater splanchnic nerve)
What pain is the foregut the site of?
Epigastrium
What is the midgut made of?
Distal half of 2nd part of duodenum → proximal 2/3 of transverse colon
What innervates the pain in the midgut?
T10 and T11 (lesser splanchnic nerve)
What pain is the midgut the site of?
Umbilical
What is the hindgut made of?
Distal 1/3 of transverse colon → superior rectum
What innervates the pain in the hindgut?
L1 and L2 (lumbar and sacral splanchnic nerves)
What pain is the hindgut the site of?
Hypogastrium
What main arteries supply the foregut, midgut and hindgut respectively?
- foregut - coeliac trunk (–> left gastric, splenic, hepatic)
- midgut - superior mesenteric artery
- hindgut - inferior mesenteric artery
What is the parietal peritoneum?
Covering of abdominal wall anteriorly + covering of abdominal cavity posteriorly
What is visceral peritoneum?
- peritoneum covering organs
- liver peritoneum, colon peritoneum
What is special about the pancreas and duodenum?
They’re both retroperitoneal structures (not actually inside abdomen)
What nerves supply the parietal peritoneum?
- somatic
- phrenic nerves that supply sensation from central tendon to diaphragm → C3, C4, C5
- C3 and C5 also innervate right shoulder - patients can present with right shoulder pain when something is going on under diaphragm
- segmental innervation from T5-L2 (umbilicus supplied by T10)
What nerves supply the visceral peritoneum?
- autonomic
- parasympathetic supply from vagus nerve (CN III, VII, IX, X)
- parasympathetic supply from S2-4
- sympathetic chain goes T1-12 and L1-2 (T5 to L2 innervation)
What nerve plexuses are there of the visceral peritoneum? (3)
- coeliac plexus
- superior mesenteric plexus
- inferior mesenteric plexus
What is the site and character of the pain from visceral vs parietal peritoneum?
- embryological origin vs well-localised
- dull, crampy, burning vs sharp, ache
What kind of pain does abdominal organ inflammation cause?
- constant ‘aching’ pain
- worse on movement
- persists until inflammation subsides
What kind of pain does obstruction of a muscular tube cause?
- colicky ‘gripping’ pain
- fluctuates in severity
- patient moves to try and get comfortable
What happens if colicky pain has changed and has become a constant stretching pain?
- there has been prolonged obstruction of a hollow vicus that has caused distension
- this is different from ache of inflammation and is not colicky
- there may be impending ischaemia
What character of pain do you find in ureter?
Colicky
What character of pain do you find in liver?
Constant e.g. could be hepatitis or liver abscess
What character of pain do you find in biliary-colic?
Colicky e.g. stone trying to get through duct like bile duct
What character of pain do you find in spleen?
Constant e.g. splenic abscess or rupture
What character of pain do you find in kidney?
Constant e.g. pyelonephritis or abscess
What character of pain do you find in small/large bowel?
Colicky
Where does gallbladder (right hypochondriac region) pain radiate?
Through to the back and right - happens in 50% of cases
Where does stomach, duodenum, pancreas (epigastrium) pain radiate?
- straight through to back - especially since pancreas and duodenum are retroperitoneal structures
- people with pancreatic cancer present with back pain as tumour infiltrates posteriorly
- pancreatic cancer patients - sitting up and leaning forward helps as abdominal viscera are not pushing against pancreas
Where does tail of pancreas (left hypochondriac region) pain radiate?
Through to the back and the left
Where does right kidney (right lumbar region) pain radiate?
In loin and radiates to groin (following ureter) - loin to groin
Where does small bowel, caecum, retroperitoneal structures (umbilical region) pain radiate?
Does not normally radiate as it is visceral
Where does left kidney (left lumbar region) pain radiate?
In loin and radiates to groin (following ureter) - loin to groin
What can people with AAA present with regarding left kidney pain?
They can describe left ureteric colicky pain
Where do the lower zone organs (appendix and caecum, bladder, transverse colon, uterus, adnexae, sigmoid colon) pain radiate?
- lower abdominal pain rarely radiates
- pain from structures deep in pelvis referred to lower back/perineum
What are the key learning points regarding referral of abdominal pain?
- colicky abdominal pain is referred to the centre (visceral sensation)
- pain from parietal inflammation is felt over the inflamed area (somatic sensation)
- when pain radiates it signifies other structures are becoming involved
- small bowel pain does not radiate but may move when somatic as well as visceral nerves become irritated
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
WHAT IS THE DIAGNOSIS?
Appendicitis
What is important to know about the location of the appendix?
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
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
WHAT IS THE DIAGNOSIS?
Bowel obstruction (causing intestinal colic)
What is the commonest cause of small bowel obstructions?
- adhesions - if you have an operation you get a scar on anterior abdominal wall but some patients get scarring on inside too (adhesions) = fibrous bands
- can wrap around and cause a closed loop obstruction (nothing in or out)
- that part of bowel becomes ischaemic quickly and explode
How can we treat adhesions?
- these band adhesions can twist around bowel and obstruct
- put NG tube down and decompress = it will untwist
- can do surgery and cut band with pair of scissors
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
WHAT IS THE DIAGNOSIS?
Right ureteric colic
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
WHAT IS THE DIAGNOSIS?
Biliary colic (stone trying to get through tube = colicky)
How is cholelithiasis different to biliary colic?
- stone stuck in cystic duct
- bile cannot get in and out
- lining of gallbladder keeps producing mucus which has nowhere to go and become infected
- sometimes it can get out as pus
- causes localised pain, not radiating - Murphy’s sign
Cholelithiasis: stone in GB
Biliary colic: stone in bile duct
