abdominal pain

Question 1

What does transpyloric plane (L1) go through?

Answer 1

Pylorus of stomach, neck of pancreas, fundus of gallbladder, renal hilum, duodenojejunal flexure & end of spinal cord

Question 2

What does subcostal plane (L3) go through?

Answer 2

Origin of IMA

Question 3

What does supracristal plane (L4) go through?

Answer 3

Bifurcation of aorta

Question 4

What structures are in each of the 9 segments of the abdomen?

Answer 4

Right hypochondriac: gallbladder.
Epigastrium: stomach, duodenum, pancreas.
Left hypochondriac: tail of pancreas.
Right lumbar & left lumbar: kidneys.
Umbilical: small bowel, caecum, retroperitoneal structures.
Right iliac: appendix and caecum.
Hypogastric: transverse colon, bladder, uterus.
Left iliac: sigmoid colon

Question 5

What are the foregut structures? Midgut? Hindgut?

Answer 5

• Foregut: distal oesophagus, stomach, proximal half of duodenum, liver, gallbladder, pancreas, spleen.
• Midgut: distal half of the duodenum, rest of the small intestine (jejunum + ileum), caecem, ascending colon, proximal 2/3rds of the transverse colon.
• Hindgut: distal 1/3rd of transverse colon, descending colon, sigmoid colon, rectum

Question 6

What blood vessel supplies foregut, midgut, hindgut?

Answer 6

Foregut - coeliac trunk. Midgut - SMA. Hindgut - IMA

Question 7

What are the features of parietal pain?

Answer 7

• Caused by irritation of fibres innervating parietal peritoneum.
• Somatic innervation, site of pain well localised (localized to dermatome superficial to site of pain), with sharp ache.
• Can get tenderness, guarding, and as it develops further, rigidity and rebound terdenress
• Phrenic nerve C3,4,5 picks up sensation from right shoulder too so pain can refer there for parietal peritoneum.

Question 8

What are the features of visceral pain?

Answer 8

• Due to stretching of hollow viscus of capsule of solid viscus.
• Visceral fibres enter spinal cord at different levels so pain poorly localized and characterised (dull, cramping, burning).

Question 9

Where do foregut organs produce pain? Midgut organs? Hindgut organs?

Answer 9

Foregut organs produce pain in epigastric region.
Midgut in periumbilical region.
Hindgut hypogastric pain

Question 10

What kind of pain does inflammation produce + example?

Answer 10

Constant acheing pain made worse by movement. Eg. Hepatitis, cholecystitis.

Question 11

What kind of pain does obstruction of a muscular tube produce + example?

Answer 11

Colicky pain fluctuates in severity. Eg. Ureteric colic, biliary colic, gallstones, intestinal obstruction

Question 12

What kind of pain does prolonged obstruction of muscular tube cause and what does this indicate?

Answer 12

May change from colicky to constant stretching pain - can indicate ischaemia

Question 13

In terms of pain, what are the differences between ureteric, biliary and intestinal colic?

Answer 13

Ureteric very painful. Biliary colic painful but less, with mid-fluctuations. Intestinal colic less painful.

Question 14

What does it indicate when colicky pain becomes constant?

Answer 14

When something is becoming ischaemic (needs intervention)

Question 15

Where does gallbladder pain radiate to? Epigastric pain (stomach, duodenum, pancreas)? Tail of pancreas?

Answer 15

Gallbladder radiates to back and right.
Epigastric pain to back.
Tail of pancreas to back & left

Question 16

Where does kidney pain radiate to? Small bowel pain?

Answer 16

Kidney pain radiates to loin & groin (down ureters).

Small bowel pain usually doesn’t radiate but since small bowel moves pain can move

Question 17

Where does lower abdominal pain radiate?

Answer 17

Rarely radiates but structures deep in pelvis referred to lower back/perineum.

Question 18

In general where does colicky abdominal pain radiate to and why? Where is parietal inflammation felt?

Answer 18

Generally colicky abodminal pain radiates to centre (visceral sensation).

Question 19

When can small bowel pain move?

Answer 19

When somatic and visceral nerves become irritated

Question 20

What would gradual constant pain central shifting to right iliac region + fever, nausea, anorexia indicate?

Answer 20

appendicitis

Question 21

What would central gradual colicky pain + vomiting, unopened bowels, passing gas indicate?

Answer 21

Bowel obstruction

Question 22

What are adhesions?

Answer 22

After surgery can leave scar inside abdomen (bands of fibre), these adhesions can trap bit of bowel twisting it and causing obstruction (can become ischaemic)

Question 23

What would sudden loin colicky pain radiating to groin with vomiting, very severe indicate?

Answer 23

ureteric colic

Question 24

What would right upper quadrant colicky pain + right shoulder radiation, nausea, after eating fatty foods indicate?

Answer 24

biliary colic