Abdominal Pain

Question 1

What are the 2 most significant properties of the pain?

Answer 1

-Site
-Character

Question 2

What framework do we use to ask patients about pain?

Answer 2

SOCRATES:
S-Site
O-Onset
C-Character
R-Radiation
A-Association
T-Time
E-Exacerbating
S-Severity

Question 3

What is the foregut made of?

Answer 3

Distal oesophagus → proximal half of 2nd part of duodenum (major duodenal papilla)

Question 4

What innervates the foregut

Answer 4

T5-T9

Question 5

What pain is the foregut the site of?

Answer 5

Epigastrium

Question 6

What is the midgut made of?

Answer 6

Distal half of 2nd part of duodenum (major duodenal papilla) → proximal 2/3 of transverse colon

Question 7

What innervates the pain in the midgut?

Answer 7

T10-T11

Question 8

What pain is the midgut the site of?

Answer 8

umbilical

Question 9

What is the hypogastrium also known as?

Answer 9

Suprapubic region

Question 10

What is the hindgut made of?

Answer 10

Distal 1/3 of transverse colon → rectum

Question 11

What innervates the pain in the hindgut?

Answer 11

L1-L2

Question 12

What pain is the hindgut the site of?

Answer 12

Hypogastric pain

Question 13

What is the parietal peritoneum?

Answer 13

Covering of abdominal wall anteriorly + covering of abdominal cavity posteriorly

Question 14

What is visceral peritoneum?

Answer 14

• Peritoneum covering organs
• Liver peritoneum, colon peritoneum

Question 15

What nerves supply the parietal peritoneum?

Answer 15

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

Question 15

What nerves supply the parietal peritoneum?

Answer 15

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

Question 16

What nerve plexuses innervate the visceral peritoneum?

Answer 16

• Coeliac plexus
• Superior mesenteric plexus
• Inferior mesenteric plexus

Question 17

Describe the deference’s in site of pain and characteristic between visceral and parietal peritoneum’s.

Answer 17

Visceral:
Site of pain- Embryological origin.
Character- Dull, Crampy burning

Parietal:
Site of pain- Well localized
Characteristic- sharp, ache

Question 18

What are the two main categories of pain in the abdomen and what kind of pains do they cause?

Answer 18

Inflammation:
- Constant ‘aching’ pain
- Made worse by moving
- Persists until inflammation subsides

Obstruction of a muscular tube:
- Colicky ‘gripping’ pain
- Fluctuates in severity
- Patient moves to try and get comfortable

Question 19

What character of pain do you find in each of these organs?
- Ureter
- Liver
- Biliary-colic
- Spleen
- Kidney
- Small or large bowel

Answer 19

• Ureter
  Colicky
• Liver
  Constant e.g. could be hepatitis or liver abscess
• Biliary-colic
  Colicky e.g. stone trying to get through duct like bile duct
• Spleen
  Constant e.g. splenic abscess or rupture
• Kidney
  Constant e.g. pyelonephritis or abscess
• Small or large bowel
  Colicky

Question 20

Where does gallbladder (right hypochondriac region) pain radiate?

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Where does the tail of the pancreas pain radiate to?

Answer 22

Through to the back and the left

Question 23

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

Answer 23

Doesn’t normally radiate as they’re visceral.

Question 24

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

Answer 24

In loin and radiates to groin.

Question 25

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

Answer 25

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

Question 26

What does it signify when pain radiates?

Answer 26

Other structures are becoming involved.

Question 27

Where does colicky abdominal pain usual come from?

Answer 27

The centre

Question 28

Why does colicky pain happen?

Answer 28

Muscle contractions trying to excrete something

Question 29

What does it mean if colicky pain turns constant?

Answer 29

There is ischaemia

Question 30

Diagnose.

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

Answer 30

Appendicitis

Question 31

When wouldn’t someone with appendicitis have abdominal pain?

Answer 31

The location of their appendix is pelvic.

Question 32

Diagnose
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

Answer 32

Small bowel obstruction

Question 33

What is the commonest cause of small bowel obstructions?

Answer 33

Adhesions, scarring on the inside of abdominal wall post opp

Question 34

Diagnose
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

Answer 34

Right uretic colic, (kidney stone)

Question 35

Diagnose
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

Answer 35

Biliary colic

Question 36

What is an outpouching of the small bowel that causes inflammation called?

Answer 36

Meckel’s diverticulitis