Abdominal Pain

Question 1

What are two most significant properties of pain

Answer 1

Site
Character

Question 2

What framework do we use to ask patients about pain?

Answer 2

• 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?

Question 3

• What organ structures are found at the transpyloric plane?

Answer 3

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

Question 4

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

Answer 4

Subcostal plane- L3

• Origin of inferior mesenteric artery

Supracristal plane- L4

• Bifurcation of the aorta

Question 5

Forget

Answer 5

Innervated by T5-T9
Pain is site if epigastrium

Question 6

Midgut

Answer 6

Innervated by T10-T11
Pain site of umbilicus

Question 7

Hindgut

Answer 7

Innervated by L1-L2
Pain is site of hypogastrium

Question 8

Parietal vs visceral peritoneum

Answer 8

Parietal covers the abdominal wall anteriorily
Visceral covers organs

Question 9

What nerves supply the parietal peritoneum?

Answer 9

Phrenic nerves that supply sensation from central tendon to diaphragm → C3, C4, C5
C3 and 5 Innervated right shoulder so patients can present with right shoulder pain when something’s wrong
Segmental innervating from T5-L2

Question 10

What nerves supply visceral peritoneum

Answer 10

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

Question 11

What kind of pain does inflammation cause

Answer 11

Constant aching pain
Made worse by movement
Persists until inflammation subsides

Question 12

What pain does obstruction cause

Answer 12

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

Question 13

What kind of pain does you find in the ureter liver biliary colic spleen kidney small or large bowel

Answer 13

• UreterColicky
• LiverConstant e.g. could be hepatitis or liver abscess

Colicky pain usually in tubular structures and is crampy
- Biliary-colic

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

• SpleenConstant e.g. splenic abscess or rupture
• KidneyConstant e.g. pyelonephritis or abscess
• Small or large bowelColicky

Question 14

Where does gallbladder (right hypochondriac region) pain radiate?

Answer 14

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

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Question 15

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

Answer 15

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

Question 16

What position do pancreatic cancer patients feel better in?

Answer 16

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

Question 17

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

Answer 17

Through to the back and the left

Question 18

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

Answer 18

In loin and radiates to groin (following ureter)

Question 19

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

Answer 19

Doesn’t normally radiate because it’s visceral

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Question 20

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

Answer 20

In loin and radiates to groin

Question 21

What can people with AAA present regarding left kidney pain?

Answer 21

They can describe left ureteric colicky pain

Question 22

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

Answer 22

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

Question 23

General points

Answer 23

• 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 doesn’t radiate but may move when somatic as well as visceral nerves become irritated

Question 24

Appendicitis

Answer 24

Appendix pain central then shifts in right iliac fossa
Gradual onset no radiation
Nausea anorexia fever
Worse in movement
Appendix can be retrocaecal and pelvic if we examine their abdomen and it’s pelvic we won’t be able to feel it
Dull ache

Question 25

Bowel obstruction

Answer 25

Central pain
Gradual,colicky
Vomiting bowels don’t open
Passing flatus relevies pain
Commonest chase if obstruction is adhesions which form after an operation ,scar tissue formation and fibrous bands,can wrap around small intestine causing closed loop obstruction,treate with ng tube to decompress it
Moderate pain

Question 26

Uteric colic

Answer 26

Loin pain
Sudden onset,colicky radiates to groin
Vomiting
Can’t find a comfortable position
Severe pain

Question 27

Biliary colic

Answer 27

Right upper quadrant
Sudden onset
Colicky spreads to right shoulder
Nausea indigestion after eating fatty food can be severe

Question 28

Cholelithiasis

Answer 28

• 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