Abdominal Pain Flashcards
________ of the pain is a good starting point and will guide the evaluation. _____ and _____ are also pivotal features.
Location; Character; Acuity
Principle Mechanisms of Abdominal Pain
- Obstruction
- Peritoneal Irritation
- Vascular Insufficiency
- Mucosal Ulceration
- Altered Motility
- Metabolic Disturbances
- Nerve Injury
- Muscle Wall Disease
- Referred Pain
- Psychopathology
Review the Anatomy Slides…
Nonny taught you well.
If there is evidence suggestive of peritoneal irritation, what should we think?
- Appendicitis
- Cholecystitis
If there is evidence suggestive of obstruction or acute vascular compromise, what should we think?
- Aortic Dissection
- Mesenteric Ischemia
This type of pain is described as tension, stretching, ischemia stimulation of specific pain fibers. It is a dull, aching, diffuse, vague (poorly localized) pain felt at the midline in the epigastric, periumbilical or suprapubic areas. Utilizes C type fibers.
Visceral
This type of pain is described by ischemia, inflammation, or stretching stimulation of specific pain fibers. It is generally well-localized and significantly more intense than visceral. A type and C types fibers.
Parietal
This type of pain is described by pain felt at a distance from the affected organ supplied by the same dermatome. It is commonly an aching pain perceived near the surface. It shares the same central afferent pathway with the affected organ.
Referred
This pain fiber is a slow conduction and runs bilaterally and enters the spinal cord at multiple different levels.
Type C
This pain fiber is a rapid conduction that lateralizes to the dorsal root ganglia on the same side and dermatomal level as the origin of the pain.
Type A
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Appendix.
- Periumbilical Area
- RLQ
- RLQ
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Distal Colon.
- Hypogastrium and Left Flank for Descending Colon
- Over affected area
- LLQ and back (rare)
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Gallbladder.
- Middle Epigastrium
- RUQ
- Right Subscapular Area
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Ovaries/Fallopian Tubes/Uterus.
- Hypogastrium and Groin
- Over affected area
- Inner Thighs
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Pancreas.
- Middle epigastrium and LUQ
- Middle epigastrium and LUQ
- Back and Left Shoulder
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Proximal Colon.
- Periumbilical area and right flank pain for ascending colon
- Over affected area
- RLQ and back (rare)
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Small Intestine.
- Periumbilical Area
- Over affected site
- Midback (rare)
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Stomach.
- Middle epigastrium
- Middle epigastrium and LUQ
- Shoulders
Tell me the location of:
- Visceral Pain
- Parietal Pain
- Referred Pain
When the patient has an issue with the Ureters.
- Costovertebral Angle
- Over affected area
- Groin: Scrotum in men, Labia in women (rare)
Emergent Cases based on pain in the epigastrium could be:
- Myocardial Infarct
- Peptic Ulcer
- Acute Cholecystitis
- Perforated Esopagus
Emergent Cases based on pain in the RUQ could be:
- Acute Cholecystitis
- Duodenal Ulcer
- Hepatitis
- Congestive Hepatomegaly
- Pyelonephritis
- Appendicitis
- (R) Pneumonia
Emergent Cases based on pain in the LUQ could be:
- Ruptured Spleen
- Gastric Ulcer
- Aortic Aneurysm
- Perforated Colon
- Pyelonephritis
- (L) Pneumonia
Emergent Cases based on pain in the RLQ could be:
- Appendicits
- Salpingitis
- Tubo-ovarian Abscess
- Ruptured Ectopic Preggo
- Renal/Ureteric Stone
- Incarcerated Hernia
- Mesenteric Adenitis
- Crohn’s Dz
- Meckel’s Diverticulitis
- Perforated Cecum
- Psoas Abscess
Emergent Cases based on pain in the upper LLQ could be:
- Intestinal Obstruction
- Acute Pancreatitis
- Early Appendicitis
- Mesenteric Thrombosis
- Aortic Aneurysm
- Diverticulitis
Emergent Cases based on pain in the lower LLQ could be:
- Sigmoid Diverticulitis
- Salpingitis
- Tubo-ovarian Abscess
- Ruptured Ectopic Preggo
- Incarcerated Hernia
- Perforated Colon
- Crohn’s Dz
- Ulcerative Colitis
- Renal/Ureteral Stone
This term represents a rapid onset of severe symptoms that may indicate a life-threatening intra-abdominal pathology.
Acute Abdomen
Signs and Symptoms of Acute Abdomen:
- Fever
- Protracted Vomiting
- Syncope
- Pre-syncope
- GI Blood Loss
T/F: In acute abdomen situations, pain is always a feature.
False, not always! Pain-free is more likely in the elderly, in children and in the third trimester of pregnancy.
Management of Acute Abdomen
Carefully assess before managing!
Pay close attention to the Signs and Symptoms that may indicate a need to investigate the situation further in the hospital.
T/F: Clinical Scenarios can change rapidly in a patient with an acute abdomen.
True!! Conclusions previously reached by yourself or colleagues may need to be revised as events evolve.
Pathophysiologic Mechanisms of Abdominal Pain
- Obstruction
- Peritoneal Irritation
- Vascular Insufficiency
- Mucosal Ulcertion
- Altered Motility
- Metabolic Disturbances
- Nerve Injury
- Muscle Wall Dz
- Referred Pain
- Psychogenic Causes
Locations of GI/GU Obstruction that causes Acute Abdominal Pain:
- Gastric Outlet (stricture/CA)
- Small Bowel – pain of SB>LB (the jejunum is probably the most painful site since there is no “natural” way to decompress the region
- Large Bowel (stricture/CA)
- Biliary Tree (stones/strictures/CA)
- - Cystic duct – biliary colic
- - Common Bile Duct
- – Ampulla of Vater - Urinary Tract (stones/strictures/CA)
- - Pyelonephritis
- - Kidney/ureteral stone
Causes of Peritoneal Inflammation that causes Acute Abdominal Pain:
- Infection
- Chemical irritation from perforation of a viscus (blood, bile, gastric acid)
- Systemic inflammatory process
- Spread from a focal inflammatory process
Causes of Vascular Insufficiency that causes Acute Abdominal Pain:
- Embolization (blood/lipid/atherosclerotic plaque)
- - PE
- - AF - Atherosclerotic Narrowing (Ischemic Bowel)
- - Acute Arterial Insufficiency or Acute Mesenteric Ischemia
- - Chronic Mesenteric Ischemia
- -Ischemia Colitis - AAA and Aortic Dissection
Causes of Mucosal Ulceration that causes Acute Abdominal Pain:
- PUD – Epigastric, gnawing, burning, can fistulize to pancreas in severe cases and become catastrophic.
- Gastric cancer
- IBD/gastroenteritis
- Celiac Sprue – Genetically predisposed, inappropriate T-cell response to ingested gluten – episodic bloating, diarrhea, flatulence, weight loss (Malabsorption).
Causes of Altered Motility that causes Acute Abdominal Pain:
- Malabsorption/Maldigestion
- IBD (UC or Crohn’s)
- IBS/IGS Irritable Bowel or Gut Syndrome)
- Diverticular Disease (and Diverticulitis)
Causes of Metabolic Disturbances that causes Acute Abdominal Pain:
- Diabetic Ketoacidosis
- Porphyria
- Lead Poisoning (affects hemoglobin synthesis)
Causes of Nerve Injury that causes Acute Abdominal Pain:
- Intra-abdominal (Pancreatic Cancer vs. Pancreatitis)
2. Extra-abdominal (Herpes Zoster)
Causes of Muscle Wall Dz that causes Acute Abdominal Pain:
- Trauma
- Myositis or Chondritis (inflammation of muscle or intercostal cartilage at point of traumatic contact)
- Fibromyalgia?
Causes of Referred Pain that causes Acute Abdominal Pain:
- Chest Sources (Lower Lobe PNA or Inferior MI)
2. Pelvic Sources (ovarian masses)
Causes of Acute Abdominal Pain caused by Psychogenic Issues:
- Somatization
- Depression
- Anxiety
Causes of Obstruction that causes Acute Abdominal Pain:
- Adhesions
- Hernia
- Volvulus
- Paralytic Ileus
- Intussusception
- Fecal Impaction
- Carcinoma
- Mesenteric Infarction
- Regional Ileitis
- Malrotation
THINK SURGICAL EMERGENCY!!!!!!
If working up a patient and there is no dx or ddx after labs, what should you do next?
Radiologic Studies!
- Upright X-Ray
- KUB Plain File
You’ve done labs and radiographic studies and still nothinggggg. When would you consider an U/S?
- RUQ Pain
- Biliary Tree Dz
You’ve done labs and radiographic studies and still nothinggggg. When would you consider a CT?
- Nonspecific Abdominal Pain
- Bowel Obstruction
- Appendicitis
- Pancreatitis (+/- Sepsis or Pseudocyst)
You’ve done labs and radiographic studies and still nothinggggg. When would you consider a CTA/MRA?
Mesenteric Ischemia
You’ve done labs and radiographic studies and still nothinggggg. When would you consider an endoscopy?
- PUD
- Cancer
- AVM
Sudden Onset Pain (few seconds) in the Abdomen makes your DDx include:
- Perforated ulcer
- Mesenteric infarction
- Ruptured AAA
- Ruptured ectopic pregnancy
- Ovarian torsion or ruptured cyst
- Pulmonary embolism
- Acute myocardial infarction
Rapid Onset Pain (few minutes to hours) in the Abdomen makes your DDx include:
- Strangulated hernia
- Volvulus
- Intussusception
- Acute pancreatitis
- Biliary colic
- Diverticulitis
- Ureteral & renal colic
Gradual Onset Pain (few hours) in the Abdomen makes your DDx include:
- Appendicitis
- Strangulated hernia
- Chronic pancreatitis
- Peptic ulcer disease
- Inflammatory bowel Dz
- Mesenteric lymphadenitis
- Cystitis & urinary retention
- Salpingitis & prostatitis
Red Flags when seeing Abdominal Pain (SEVERE cases)
- Hypotension
- Confusion or impaired consciousness
- Signs of shock
- Systemically unwell, septic-looking
- Signs of dehydration
- Rigid or distended abdomen
- Known pregnancy with severe pain
- Patient lying very still or writhing in pain (parietal pain)
- Absent or altered bowel sounds
- Associated testicular pathology
- Marked involuntary guarding, rebound tenderness
- Exquisite tenderness to percussion
- History of hematemesis, melena or evidence of blood on rectal examination
HPI Questions for Abdominal Pain
- Duration
- Severity
- Location
- Diffuse
- Localized
- Progression
- Timing
- Character
- Constant or Intermittent
- Position
- Onset
- Last meal
- Gas
- Menses
- Movement
- Last BM
- Prior Episodes
- Voiding
- Inspiration
- Radiation
- Travel
PMH Questions for Abdominal Pain
- Prior Abdominal Surgeries
- Kidney Stones
- Alcohol Abuse
- Non-Ulcer Dyspepsia
- Hernias
- Gallstones
- Coronary Disease
- Prior Testing
Ask about Aggravating and Alleviating Factors, such as (but not limited to)
- Particular Foods
- Medications
- Aspirin
- NSAID’s
- Anticholinergics
- Laxatives
- Antacids
- Change in position
Signs and Symptoms of Abdominal Pain
- Fever
- Chills
- Nausea
- Vomiting (< or > pain)
- Chest Pain
- Constipation
- Change in BM
- Change in stool
- Obstipation
- Diarrhea
- Dysuria
- Hematuria
- Vaginal D/C
- Penile D/C
- Hematochezia
- Melena
- Anorexia
- Weight Loss
- Odynophagia
- Early Satiety
Indications for Urgent Operation based on Physical Findings in Patients with Acute Abdominal Pain
- Involuntary guarding or rigidity, especially if spreading.
- Increasing or severe localized tenderness.
- Tense or progressive abdominal distention.
- Tender abdominal or rectal mass with high fever or hypotension
- Rectal bleeding with shock or acidosis.
- Abdominal pain along with:
- – Septicemia (high fever, marked or rising leukocytosis, mental changes, or increasing glucose intolerance in a diabetic patient)
- – Bleeding (unexplained shock or acidosis, falling hematocrit)
- – Suspected ischemia (acidosis, fever, tachycardia)
Indications for Urgent Operation based on Radiologic Findings in Patients with Acute Abdominal Pain
- Pneumoperitoneum
- Gross or progressive bowel distention
- Free extravasation of contrast material (always use water soluble contrast in patients with abdominal pain)
- Space-occupying lesion on scan, with fever
- Mesenteric occlusion on angiography
Indications for Urgent Operation based on Endoscopic Findings in Patients with Acute Abdominal Pain
Perforated or Uncontrollably Bleeding Lesions
Indications for Urgent Operation based on Paracentesis Findings in Patients with Acute Abdominal Pain
Blood, Bile, Pus, Bowel Contents or Urine
Take a look at…
the case studies! And the objectives!
