Abdominal pain Flashcards
What questions are key to ask about the abdominal pain in the history?
Site- pain spread from epigastrium to whole abdo - peritonitis, pain spread upwards to chest - cardiac?
Onset- sudden suggests perforation of a viscus e.g. boerhaave’s/duodenal ulcer/MI
acute pancreatitis/biliary colic - 10-20mins max intensity
inflammatory processes e.g. hepatitis takes hours
Character - constant/colicky, sharp/dull/crushing/burning- depends on the underlying cause
Radiation e.g. pancreatitis to back, phrenic nerve involved?
Time of occurrence and aggravating or relieving factors e.g. meals, defecation, sleep
Recall the causes of epigastric pain
GORD peptic ulcer (perforated) pancreatitis, gastritis/duodenitis, gallbladder disease, aortic aneurysm MI acute cholecystitis Perforated oesophagus
Recall the causes of left upper quadrant pain
peptic ulcer gastric/colonic (splenic flexure) cancer, splenic rupture, subphrenic/perinephric abscess, renal (colic, pyelonephritis) ruptured spleen L pneumonia Perforated colon
Recall the causes of right upper quadrant pain
acute cholecystitis duodenal ulcer hepatitis congestive hepatomegaly pyelonephritis appendicitis R pneumonia biliary colic colonic cancer (hepatic flexure), subphrenic abscess
Recall the causes of left lower quadrant pain
Diverticulitis volvulus colon cancer UTI Cancer in undescended testis Gynae: torsion of ovarian cyst, salpingitis, ectopic pregnancy Strangulated hernia Peforated colon Crohn's disease Ulcerative colitis Renal/ureteric stones
Recall the causes of right lower quadrant pain
Appendicitis Salpingitis Ruptured ectopic pregnancy renal/ureteric stone strangulated hernia mesenteric adenitis meckel's diverticulitis crohn's disease perforated caecum psoas abscess
Recall causes of generalised abdominal pain
gastroenteritis
IBS
Peritonitis
Constipation
Recall causes of central abdominal pain
Mesenteric ischaemia
Pancreatitis
Abdominal aneurysm
What would you look for on examination for someone with abdo pain?
Position - some pain can change with position
Jaundice- seen with acute hepatitis or post-hepatic causes of biliary obstruction, pancreatitis
Cullen’s or Grey Turner’s signs - extravasated blood in retroperitoneum, around the umbilicus and flank respectively. Seen in acute haemorrhagic pancretitis but are rare and non specific signs
Signs of small bowel obstruction: distended abdomen, absent/tinkling bowel sounds
Tenderness and guarding: localised e.g. acute cholecystitis (murphy’s sign) or mild pancreatitis. Generalised sever tenderness with guarding and rigidity - peritonitis
Masses
Respiratory examination - lung bases may masquerade as abdo pain - check for consolidation signs e.g. decreased expansion, breathsounds, increased vocal resonence, dull percussion
What is murphys sign and how would you interpret the results?
Lie patient supine and ask to exhale. Place hand just below costal margin approx MCL then instruct patient to inhale.
Positive sign- patient stops inhalation due to pain - caused my move of diaphragm pushing inflamed gallbladder into palpating hand. This indicates cholecystitis
Negative sign- patient comfortable and breathes all the way in without any pain. This may suggest pyelonephritis and ascending cholangitis
What investigations would you carry out for abdominal pain
Bloods: FBC for signs of infection/inflammation, blood loss (low Hb), neutrophilia (pancreatitis), CRP, Pancreatic amylase/lipase (amylase if 3-5 days, lipase longer half life), liver enzymes (AST+ ALT raised- pathology IN the liver, raised ALP, bilirubin + GGT- pathology in the biliary tree/extrinsic compression of it. Rise in ALP without GGT- source other than liver e.g. bone, placenta. Just GGT- alcohol), albumin-pancreatitis, U&Es + creatinine (esp if vomiting), calcium (pancreatitis), glucose, ABG(ARDS), troponin (MI)
ECG
Imaging: AXR - small bowel obstruction if dilated loops, calcification- gall stones, pancreatitis, outline of psoas muscle obscured with ruptured AAA or severe pancreatitis. CXR- perforated ulcer, lower lobe consolidation, pleural effusion can occur with pancreatitis and boerhaave’s perforation. Abdo USS: exclude gallstones, biliary dilation, AAA
