Abdominal Pain

Question 1

Red flag Hx/symptoms for acute abdominal pain

Answer 1

Hx: - Collapse at toilet (suggests intra-abdo bleeding) - Lightheadedness - IHD - Progressive vomiting pain, distension - Menstrual abnormalities - Malignancy

Question 2

Red flag signs for acute abdominal pain

Answer 2

Pallor and sweating Hypotension AF or tachycardia (flicking to leading to ischaemic bowel) Fever Prostration (extreme exhaustion) Rebound tenderness and guarding Decreased urine output

Question 3

Drugs to consider as a cause of abdominal pain

Answer 3

Alcohol Antibiotics (e.g. erythromycin) Aspirin Corticosteroids Cytotoxic agents Tricyclic antidepressants (e.g. imipramine) Iron preparations Nicotine NSAIDs/COX2 inhibitors Sodium valproate Phenytoin

Question 4

What is visceral pain?

Answer 4

• Visceral pain is perceived (referred) - Site of pain depends on the embryology and anatomy - Visceral pain is usually felt at the site of embryological origin (central) i. Epigastric: foregut origin ii. Perumbilical: midgut origin iii. Suprapubic: hindgut origin - Perception of pain depends on the innervation of the viscus and corresponding dermatome = referred pain

Question 5

What is parietal pain?

Answer 5

Localised to anatomical site of viscus (where it touches the parietal peritoneum)

Question 6

Where do paired organs (kidney and ureters) refer pain to?

Answer 6

Flank e.g. in obstruction

Question 7

What are the characteristics of peritonitis?

Answer 7

Pain is generalised Tenderness is generalised Guarding and rebound tenderness present

Question 8

What are the non-abdominal causes of abdo pain?

Answer 8

Heart: AMI Lung: lower lobe pneumonia Diaphragm Back/muscular skeletal Herpes zoster (pain precedes rash)

Question 9

Hx of abdominal pain - establish cardinal features and what other factors?

Answer 9

Special attention has to be paid to: - anorexia, nausea or vomiting - micturition - bowel function - menstruation - drug intake

Question 10

Key questions of Hx for abdo pain

Answer 10

Key questions Point to where the pain is and where it travels to. Questions to ask: 1. What type of pain is it: is it constant or does it come and go? 2. How severe would you rate it from 1 to 10? 3. Have you ever had previous attacks of similar pain? 4. What else do you notice when you have the pain? 5. Do you know of anything that will bring on the pain? Or relieve it? 6. What effect does milk, food or antacids have on the pain? 7. Have you noticed any sweats or chills or burning of urine? 8. Are your bowels behaving normally? Have you been constipated or had diarrhoea or blood in your motions? 9. Have you noticed anything different about your urine? 10. What medications do you take? 11. How much aspirin do you take? 12. Are you smoking heavily or taking heroin or cocaine? 13. How much alcohol do you drink? 14. How much milk do you drink? 15. Have you travelled recently? 16. What is happening with your periods? Is it mid-cycle or are your periods overdue? 17. Does anyone in your family have bouts of abdominal pain? 18. Do you have a hernia? 19.What operations have you had for your abdomen? 19. Have you had your appendix removed?

Question 11

Ix for abdo pain

Answer 11

• FBE: Hb, WCC - CRP - LFTs - Serum lipase - β-HCG: - Urine: —blood —white cells —bile pigments —porphobilinogen —ketones —air (pneumaturia) - faecal blood

Question 12

Imaging for abdo pain

Answer 12

• Plain AXR - Plan CXR - US - Gastrogaffin enema (worse contrast than barium but more safe (Ba often worsens obstruction as is solidifies)) - HIDA or DIDA nuclear scan - CT scan - ERCP - MRI scan Other: gastroscopy, colonoscopy

Question 13

Diagram for anatomy and causes of abdo pain

Answer 13

Question 14

Common AXR signs with abdo pain

Answer 14