abdominal pain Flashcards
what are the pain receptors for the enteric nervous system
nociceptors, free nerve endings between the smooth muscle layers, serial surface, mesentery, mucosa. cell bodies in the dorsal root ganglion
what do the receptors respond to?
mechanical and chemical: stretch and tissue injury products.
what fibers carry the pain signal?
predominantly unmyelinated c fibers, and small A delta fibers
what are the C fibers for?
visceral sensation
what are the A belt fibers for/
this is pain transmission
where do the afferent paths run?
with regional splanchnic through the sympathetic chain and terminate in the dorsal horn
what kind of localization is there for visceral
poor
what pathways carry the sensation?
spinorecticular, spinothalamic and dorsal column
how does the sensation of pain elicit arousal?
because there are synapses in the RAS
where does pain relay in the brain?
the thalamus
where do pain sensation ultimately register?
in the cortex, and pain mapping is done by the somatosensory cortex.
what do the efferent fibers do?
they are descending fibers that modulate pain and are predominantly inhibitory
where do the efferents originate?
in the cortex, limbic with projections to the medulla and the midbrain.
where do the efferent fibers project?
to the dorsal horn, where they modify the input form the ascending system. they also give the sympathetic and parasympathetic supply
what causes referred pain?
visceral afferent neurons and somatic afferents synapsing on second order neurons it he spinal cord -central convergence. all spinal neurons that receive input from the viscera also get input from the skin.
what is hyperalgesia of the muscle often accompanied by?
spasm
Kehr’s sign
subdiaphragmatic irritation-iosalateral shoulder or supraclavicular pain
what is nociceptive abdominal pain
stimulation of peripheral nociceptors caused by mechanical: stretch, distention or injury: inflammation and ischemia
what is neuropathic abdominal pain
pain originating independently from nociception. structural or functional changes in the pain pathways peripheral or central causes this. examples are diabetic neuropathy and functional pain syndrome,
what is classic pain signals of gastroenteritis?
self-limiting, resolving in short period.
what is classic colicky pain?
periods of pain and resolution. this is classic muscular surges found in the blocked tublar syndrome. (renal colic, GI colic)
what is the classsic pain signals of appendicitis
linear, progressively worsening pain.
what are the classic pain signals of rupture or aortic aneurysm
catastrophic onset, sudden, very severe.
what are the right sided abdominal quadrant names
hypochondrium, lumbar and iliac
what are the center quadrant names
epigastric, umbilical, and hypogastric
what are the left sided abdominal names
hypochondrium, lumbar and iliac
characteristics of peritonitis
quiet abdomen, diminished movements, loss of abdominothroacic breathing pattern. distention and or lump, cullen/turners sign
cullen’s sign
superficial edema and bruising in the umbilical region
rovsing’s sign
when palpation of the left lower quadrant increases the pain felt due to appendicitis
carnett test
determines if the abdominal pain is arising from the abdominal wall or the intraabdominal cavity. patient raises head and the abdominal musculature is tensed. if there is greater pain on repeat palpation then the pain is in the abdominal wall
what does hypoactive bowel sounds indicate?
peritonitis
what does hyperactive bowel sounds indicate?
enteritis, colitis, early part of the obstruction
where does a peptic ulcer or gastroduodenal pain originate
epigastric that radiates to the back
what is the character of peptic ulcer pain?
gnawing, burning, lasting for 1-3 hours. aggravated by food
what relieves pain from gastric ulcer
fasting. food aggravates.
what relieves a duodenal ulcer pain
eating will relieve the pain. pain will come back at night when fasting ensues.
where does acute pancreatitis present?
epigastric radiating to the back.
character of acute pancreatitis
deep boring, severe, usually lasting 24 hours.
what relieves pancreatic pain?
sitting upright.
what other symptoms are associated with pancreatitis,
nausea and vomiting and associated ileus.
how does obstruction present
colicky pain, intermittent, crampy, poorly localized. it has a waxing, waning character
what is characteristic of proximal obstruction
vomiting, with transient relief. f
what characterizes distal obstruction
distention, obstipation
what happens if the bowel becomes ischemic?
the pain becomes sharp and localized.
intestinal angina
post prandial and occurs in individuals with insufficient blood flow to meet demands of the mesentery causes sitphobia
sitphobia
aversion to food.
tenesmus
frequent and painful indication to evacuate bowels with a feeling of incomplete evacuation
what is the cause of hepatic pain?
deep lesions are typically painless. hepatic pain is caused by stretching of glissons capsule by inflammation, vascular engorgement, rapidly expanding lesions
splenic pain?
LUQ occurs with stretching of the splenic capsule and infarction -look for sickle cell.
appendicitis presentation
PANT: pain, anorexia, nausea, tenderness. pain is initially periumbilical but when it becomes involved with the parietal peritoneum it becomes localized to the RLQ. test with mcburney’s point
diseases of the RLQ
appendicitis, terminal ileus, crohns, tuboovarian, ectopic, ruptured ovarian cyst, reanl disorders, uretic calculus, pyogenic sacroilitis, salpingitis
diseases of the RUQ
acute cholecystitis, biliary colic, hepatic inflammation or distention
diseases of the LUQ
splenic
disease of the LLQ
diverticulitis, colitis, sacroilitis, tuboovarian
diseases off the central abdomen
gastroenteritis, peptic ulcer, small bowel colic, acute pancreatitis.
what to keep in mind when there is an adult female with acute abdominal pain?
ectopic
what to keep in mind when there is upper abdominal pain?
cardiac and respiratory differentials.
chronic abdominal wall pain syndrome
women, depression and obesity, superficial pain localized to small area with significant tenderness and dysethesia. +carnett sign
causes of CAWPS
entrapment neuropathy, hernia. rectus nerve entrapment, ilioinguinal and iliohypogastric nerve entrapment. spontaneous rectus sheath hematoma.
median arcuate ligament syndrome/celiac artery compression syndrome MALS
congenital displacement of the arcuate ligament hat compresses and irritates the celiac ganglion
presentation of MALS
women 20-40, epigastric pain after eating that causes anorexia and weight loss. there is typically a bruit in the epigastric region. USG doppler shows increased velocity in the celiac artery
superior mesenteric syndrome
compression of the 3rd portion of the duodenum by the abdominal aorta and the overlying SMA. the mesenteric is lost and this can occur
presentation of superior mesenteric syndrome
early satiety, nausea, vomiting, post prandial abdominal pain and abdominal distention. symptoms tend to improve after weight gain.
irritable bowel syndrome
recurrent bowel pain or discomfort >_ 3days/month in the last 3 months with improvement on defecation, changes in the frequency of stool, change in the form or appearance of stool
functional abdominal pain syndrome
subgroup of somatoform, more common in women, psychosocial component with a history of sexual abuse common. typical pain is almost always there, constant, relatively unchanging in character, intensity and location. nocturnal pain is considered organic, however functional pain can awaken from sleep.
FAPS suggestive clues on exam
absence of autonomic features on exam (tachycardia, diaphoresis) there is usually a discrepancy between the stethoscope pressure eliciting pain and the examiners hand.
treatment options for FAPS
opiates, NSAIDs, topical lidocaine, tricyclic AD
