Abdomen Trans part 1 Flashcards by joseph dizon

Solid viscera

Liver
Spleen
Kidneys
Pancreas 
Ovaries
Uterus

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The principal mechanical signal to which visceral nocireceptors are sensitive

Stretch

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Example of mechanoreceptors stimulation

From rapid distention of hallow viscus

Intestinal obstruction

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Example of mechanoreceptors stimulation

Forceful muscular contraction

Biliary or renal colic

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Example of mechanoreceptors stimulation

Rapid stretching of solid organs serosa or capsule

Hepatic congestion

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Example of mechanoreceptors stimulation

Torsion of mesentery

Cecal volvolus

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Example of mechanoreceptors stimulation

Tension from traction on the messentery or mesenteric vessels

Retroperitoneal or pancreatic tumor

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Chemical receptor are directly activated by substance

H+
K+
Histamine
Serotonin
Substance P
Bradykinin
Vasoactive amines
Calcitonin
Related peptides
Prostaglandin
Leukotrines

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Classification of abdominal pain

Visceral pain
Somatoparietal pain
Referred pain

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Not localized pain

Visceral pain

Because most viscera is multi segmental and low nerve endings

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Visceral pain is generally described as

Cramping
Burning
Gnawing
Aching

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Visceral pain

Secondary autonomic effects such as

Sweating
Restlessness
Nausea
Vomiting
Perspiration
Pallor

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Visceral pain

To relieve the pain

Patient move about in an effort

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More intense and more precisely localized

Somatoparietal pain

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Somatoparietal pain

Dermatomes corresponds

T6 to L1 region

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Somatoparietal pain

Usually aggravated by

Movement and coughing

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Somatoparietal pain

Palpation over the area is

Extremely painful

Patient lies as still as possible

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Somatoparietal pain

Overlying abdominal muscles contraction

Rebound tenderness

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Felt in areas remote to the diseased organ

Referred pain

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Referred pain

Result of convergence of what neurons

Visceral afferent neurons with
Somatic afferent neurons on
2nd order neurons in the spinal cord

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Referred pain

Maybe felt in skin or deeper tissues but is usually

Well localized

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Referred pain

Appears as the noxious visceral stimulus becomes

More intense

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Most important part of evaluation of a patient with abdominal pain

History

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Temporal considerations in the evaluation of a patient with acute abdominal pain include the rapidity of onset and the progression and duration of symptoms

Chronology

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Measure its significance | Pain that is sudden in onset, severe and well localized.

Rapidity of onset of pain

Rapidity of onset of pain Likely to be the result of an intra abdominal catastrophic events such as

Perforated viscus Mesenteric infarction Ruptured aneurysm

Example of self limited pain

Gastroenteritis

Example of progressive

Appendicitis

Colicky pain has crescendo-decrescendo patterns that may be diagnostic as in

Renal colic

Patient who seek evaluation of abdominal pain that has been present for an extended period are less likely to have an acutely threatening illness than those who do so within hours to days

Duration

Pain of less than 24 hours | Not always mandate surgical intervention

Acute abdominal pain

Pain present for at least 6 months | Divided into diagnosable and undiagnosable

Chronic abdominal pain

Changes in location may represent Progression from visceral to parietal irritation as in

Appendicitis

Changes in location may represent Represent the development of diffuse peritoneal irritation, as with

Perforated viscus

The point of reference varies among individuals depends on

Setting in which pain is occuring Past experienced with various types of pain Personality Culture

Intensity and character Severity of pain is loosely related to the magnitude of the

Noxious stimuli

Fatty food development of

Biliary colic

Pain with duodenal ulcer is alleviated by

Meals

Patients with gastric ulcer or chronic mesenteric may report exacerbation of pain with

Eating

History considered

Associated symptoms and review of symptoms | Information regarding changes in digestive functions

Vomitus clear suggest

Gastric outlet obstruction

Vomitus feculent suggest

More distal small bowel or colonic obstruction

Patients with a history of these are likely to have recurrences

Partial small bowel obstruction Renal calculi PID

Systemic illnesses such as ________________ often have abdominal pain as manifestation of their illness

``` Scleroderma Lupus Nephritic syndrome Porphyria Sickle cell disease ```

Social and family history

``` Familial disease Substance abuse Occupation Travel to other place Contact to animals or ill people ```

Location of the pain suggest

Organ involved

Pain that is vagued in onset but steadily worsened overtime suggest a

Progressive advancing obstructive lesion or mass effect

Intermittent pain with period of free pain suggest

Painful smooth muscle contraction Dynamic obstruction Recurrent inflammation Relapsing infection

Patient with an organic cause for abdominal pain is

Generally not hungry

Ask patient to finger point the pain

Kapag direct na tinuro significant

The farther from the navel the pain, the more likely it will be organic in origin

Apley rule

Patients with non specific abdominal pain keep their

Eyes closed during palpation

Patient with organic disease usually keep their

Eyes open

Sensation of sticking or obstruction of passage of food through the mouth, pharynx or esophagus

Dysphagia

Complete esophageal obstruction which is usually due to bolus impaction and represents a medical emergency

Aphagia

Painful swallowing

Odynophagia

Is the sensation of a lump lodged in the throat

Globus pharyngeus

Fear of swallowing

Phagophobia

Sensation of food being hindered in its passage | Food sticks, hang up or that food just won't go down

Dysphagia

Normally orophanyngeal swallowing, peristalsis of esophagus to stomach occurs within

10 seconds

Distinct type of Dysphagia Abnormalities of neuromascular mechanism of pharynx and upper esophageal sphincter

Orophanyngeal Dysphagia

Distinct type of Dysphagia Disorders that affect the esophageal body

Esophageal Dysphagia

Common cause of orophanyngeal Dysphagia

Neuromuscular Mechanical obstruction Skeletal muscle disorders Miscellaneous

Common cause of esophageal Dysphagia

Mechanical obstruction Motility disorders Miscellaneous

Orophanyngeal Dysphagia Neuromuscular diseases that affect the

Hydropharynx and upper esophagus

Orophanyngeal Dysphagia Coughing episode during a meal indicate

Concomitant tracheobronchial aspiration

Orophanyngeal Dysphagia Swallowing associated with a gargling noise may suggest

Zenker diverticulum

Food stops of sticks after swallowed | Difficulty in transporting the food down the esophagus

Esophageal Dysphagia

Esophageal Dysphagia Due to

Motility disorder | Mechanical obstruction

Esophageal Dysphagia Sensation of food hanging up somewhere behind the

Sternum

Esophageal Dysphagia Types

Motility disorder | Mechanical obstruction of esophagus

Esophageal Dysphagia Dysphagia with both solid and liquids

Motility disorder

Esophageal Dysphagia Motility disorder. Frequently can be relieve by various manuevers like

Repeated swallowing Raising the arm over the head Throwing the shoulders back Valsalva manuever

Esophageal Dysphagia Motility disorder Associated symptoms With bland regurgitation of undigested food especially at night Weight loss

Achalasia

Esophageal Dysphagia Motility disorder Associated symptoms With chest pain With sensitivity to either hot or cold liquids

Spastic motility disorder

Esophageal Dysphagia Motility disorder Associated symptoms With raynaulds phenomenon and sever heart burn

Scleroderma of esophagus

Esophageal Dysphagia Dysphagia after swallowing solid foods and never with liquid alone, except in high grade luminal obstruction If food impaction develops > regurgitate for relief

Mechanical obstruction of esophagus

Esophageal Dysphagia Mechanical obstruction of esophagus Associated with Episodic or non progressive dysphagia Without weight loss Hurried meal after with alcohol

Esophageal web or distal esophageal ring (schatzki ring)

Esophageal web or distal esophageal ring (schatzki ring) Bolus of food that sticks up can be passed by

Drinking large quantities of liquids

Esophageal web or distal esophageal ring (schatzki ring) Can finish meal without difficulty. Offending food is a piece of bread or steak

Steakhouse syndrome

Esophageal web or distal esophageal ring (schatzki ring) Daily Dysphagia is

Unusual

Solid food Dysphagia is progressive

Peptic esophageal stricture and carcinoma

Dysphagia associated symptoms

Odynophagia Weight loss Vomiting Coughing or regurgitation

Classic manifestation of gastroesophageal reflux

Heart burn (pyrosis)

Heart burn (pyrosis) Burning discomfort behind then

Breast bone

Heart burn (pyrosis) Often begins ______ and radiates up to the entire _______ to the neck; occasionally to the _____ and rarely to the arm

Inferiorly Restrosternal area Back

Heart burn (pyrosis) Patient usually signifies the relationship with the open hand moving from

Epigastric to the neck or throat

Heart burn (pyrosis) May have ______ and ______ in the mouth

Bitter acidic | Salty fluid

Heart burn (pyrosis) Regurgitation should be distinguished from vomiting. The absence of nausea,retching and abdominal contractions suggest

Regurgitation

Sudden filling of mouth with clear, slightly salty fluid, not regurgitated but secretions from salivary glands as part, vagus mediated reflex from distal esophagus

Water Brash

Water brash aggravated by multiple factors

Food and drugs Manuevers( bending over, straining at stool) Cigarettes

Lump or tightness in the throat unrelated to swallowing

Globus sensation or globus pharyngeus

Globus sensation or globus pharyngeus Described

Lump Tightness Choking Strangling

Globus sensation or globus pharyngeus It is present in

Between meals

Globus sensation or globus pharyngeus | May give temporarily relief

Swallowing of solids or large liquids boluses

Globus sensation or globus pharyngeus Absent

Dysphagia | Odynophagia

Globus sensation or globus pharyngeus Worsen by

Frequent dry swallowing | Emotional stress

Globus sensation or globus pharyngeus Psychological factors may be important genesis such as

``` Anxiety Panic disorder Hypochondriac Somatization Introversion ```

Subjective feeling of a need to vomit

Nausea

Oral expulsion of upper gastrointestinal contents resulting from contractions of gut and thoracoqbdominal wall musculature

Vomiting (emesis)

Effortless passage of gastric contents into the mouth

Regurgitation

Repeated regurgitation of stomach contents which are often re-chewed and swallowed

Rumentation

Components of vomiting

Nausea Fetching Emesis

Emetic stimuli cause vomiting by

Activating afferent vagal stimuli or sympathetic pathway | Indirectly by stimulating chemoreceptors trigger zone

Vomiting of blood | Indicates upper GI site of bleeding, almost always proximal to ligament of Treits,

Hematemesis

Blood may be either fresh, bright red or coffee ground

Hematemesis

Passage of black, tarry, foul-smelling stools

Melena

Melena confused with greenish character of

Ingested iron

Can be see in both UGIB and LGIB | Loss of atleast 60ml of blood

Melena

Melena Black tarry

Due to degradation of blood to hematin

Passage of bright red blood from the rectum that may or may not be mixed with stool

Hematochezia

Hematochezia Usually from

Lower GI bleeding | Massive upper GI bleeding (1L lost)

Bleeding that is not apparent to the patient Result from small amounts of GI bleeding No change in color of the stool

Occult GI bleeding

Occult GI bleeding Positive for

Guaic's test

Can be occult or obscure Manifest as hematemesis, melena or Hematochezia It difficult to pinpoint on routine examination ( as endoscopy )

Bleeding of obscure origin

Common cause of acute upper GI bleeding

Gastric ulcer Duodenal ulcer Esophageal varices Mallory Weiss tear

Rare causes of acute upper GI bleeding

``` Esophageal ulcer Erosive duodenitis Antroenteric fistula Hemobilia Pancreatic source Crohn's disease No lesion identified ```

Common cause of acute lower GI bleeding

Diverticula | Vascular ectasia

Rare cause of acute lower GI bleeding

Dieulafoy's lesion Colonic ulceration Varices

Take note, kung wala sa common at rare it means na nasa uncommon or less common.

Causes of nausea and vomiting Intra peritoneal

``` Obstructing disorders Enteric infections Inflammatory disease Impaired motor function Biliary colic ```

Causes of nausea and vomiting Extra peritoneal

``` Cardiopulmonary disease Labyrinthine disease Intra cerebral disorders Psychiatric illness Postoperative vomiting Cyclic vomiting syndrome ```

Comparison of common causes of acute abdominal pain Onset Gradual

``` Appendicitis Diverticulitis Small bowel obstruction Gastroenteritis PID ```

Comparison of common causes of acute abdominal pain Onset Sudden

Perforated pelvic ulcer Mesenteric ischemia infarction Ruptured abdominal aortic aneurysm Ruptured ectopic pregnancy

Comparison of common causes of acute abdominal pain Onset Rapid

Cholesystitis | Pancreatitis

Comparison of common causes of acute abdominal pain Location Periumbilical

Appendicitis ( early) Small bowel obstruction Mesenteric ischemia infarction Gastroenteritis

Comparison of common causes of acute abdominal pain Location Either LQ or pelvic

PID | Ruptured ectopic pregnancy

Comparison of common causes of acute abdominal pain Location Abdominal back, flank

Ruptured abdominal aortic aneurysm

Comparison of common causes of acute abdominal pain Location Epigastric

Perforated peptic ulcer

Comparison of common causes of acute abdominal pain Location RUQ

Cholesystitis

Comparison of common causes of acute abdominal pain Location Epigastric, back

Pancreatitis

Comparison of common causes of acute abdominal pain Location LLQ

Diverticulitis

Comparison of common causes of acute abdominal pain Character Localized

``` Cholesystitis Pancreatitis Diverticulitis PID REP ```

Comparison of common causes of acute abdominal pain Character Diffuse

SBO MII RAAA Gastroenteritis

Comparison of common causes of acute abdominal pain Character Localized early diffuse later

PPU

Comparison of common causes of acute abdominal pain Description Ache

Appendicitis Diverticulitis PID

Comparison of common causes of acute abdominal pain Description Agonizing

MII | Gastroenteritis

Comparison of common causes of acute abdominal pain Description Constricting

Cholesystitis

Comparison of common causes of acute abdominal pain Description Boring

Pancreatitis

Comparison of common causes of acute abdominal pain Description Burning

PPU

Comparison of common causes of acute abdominal pain Description Crampy

SBO

Comparison of common causes of acute abdominal pain Description Tearing

RAAA

Comparison of common causes of acute abdominal pain Description Light headed

REP

Comparison of common causes of acute abdominal pain Radiation None

``` Diverticulitis PPU SBO MII Gastroenteritis REP ```

Comparison of common causes of acute abdominal pain Radiation Upper thigh

PID

Comparison of common causes of acute abdominal pain Radiation Back, flank

RAAA

Comparison of common causes of acute abdominal pain Radiation Midback

Pancreatitis

Comparison of common causes of acute abdominal pain Radiation RLQ

Appendicitis

Comparison of common causes of acute abdominal pain Radiation Scapula

Cholesystitis

Comparison of common causes of acute abdominal pain Intensity Pinak grabe

Pancreatitis and diverticulitis Pero pancreatitis talaga

Normally not palpable but when distended by gas or fluid, may be felt

Hollow viscera