Abdominal Pain Flashcards
Differential diagnoses for abdominal pain
. Cholecystitis . Small bowel obstruction . Appendicitis . Abdominal aortic aneurysms (AAA) . IBS
Abdominal pain
. Acute or chronic
. Localized or diffuse pain in abdominal cavity
Visceral pain
. Hollow organs forcefully contract or are distended or stretched
. Caused by distension or organ capsule, stomach, or appendix
. Vague, dull, poorly localized
. Starts diffuse/midline stemming from embryological bilateral innervation or organs
Parietal pain
. Initiates from inflammation of parietal peritoneum (peritonitis)
. More severe then visceral pain
. Sharp, Localized over involved structure
. Patient prefers to lay still, pain worse w/ moving/coughing
. Causes: ruptured appendix, hemoperitoneum, perforated viscous
Referred pain
. Pain referred to distant site innervated by same spinal level
. Localized
. Starts as initial pain
. Duodenal/pancreatic referred to back
. Pleurisy/inf. Wall MI to epigastric region
. Gallbladder pain to shoulder
Aggravating and relieving factors for abdominal pain
. Body position
. Association w/ eating
. Med use
. Stress levels
Temporal factors to look into with abdominal pain
. Time of day
. Activity that aggravates pain
. Pain waking patient up at night
Retroperitoneum
. Part of abdominal cavity
. Kids btw post. Parietal peritoneum and an. To transversalis fascia
Organs in retroperitoneum
. Suprarenal . Aorta/IVC . Duodenum (2-3rd segments) . Pancreas . Ureters . Colon (ascending/descending) . Kidney . Esophagus
Right upper quadrant
. Lower margin of liver or liver edge palpable at right costal margin
. Kidney 12th rib, lat. and deep, palpable if thin
. Xiphoid process medially
. Abdominal aorta
Organs not palpable in right upper quadrant
. Gallbladder
. Inf. Aspect of liver
. Duodenum
Left upper quadrant
. Spleen in left midaxillary line
. 9-11th ribs protect spleen
. Tip of spleen may be palpable at left costal margin
. Pancreas, not palpable
Left lower quadrant
. Sigmoid colon (palpable as firm narrow structure)
. Transverse and descending colon (pay be palpable if constipated)
. Lower mid-line bladder, sacral promontory, and uterus
Right lower quadrant
. Bowel loops
. Appendix (not palpable if healthy)
Pelvic cavity
. Contiguous w/ abdominal cavity . Angulated post. . Terminal ureters . Bladder . Pelvic genital organs . Bowel . Protected by surrounding pelvic bones
GI disorders common, concerning symptoms
. Abdominal pain, acute and chronic
. Indigestion’s, nausea, vomiting w/ blood
. Difficulty swallowing/painful swallowing
. Change in bowel function
. Diarrhea, constipation
. Jaundice
GU disorder common and concerning symptoms
. Suprapubic pain . Difficulty urinating, urgency, frequency . Hesitancy . Urinary incontinence . Blood in urine . Flank pain and ureteral colic
Hematochezia vs. melena
. Hematochezia: fresh blood per rectum, in or mixed w/ stool
. Melena: dark feces containing partly digested blood
Reg flag symptoms w/ abdominal pain
. Early satiety
. Unintentional weight loss w/ abdominal pain
. Jaundice
. Unexplained anemia
Peritonitis
. Inflammation of parietal peritoneum . Dec. bowel sounds . Patients prefer to lie still . Exquisite pain throughout abdomen . Rebound tenderness . Rigidity of abdomen . Pain on coughing or heel tap . Involuntary guarding
Ascites
. Accumulation of fluid in peritonealcavity
. Exceeds 25 mL
. Seen in cirrhosis of liver, liver cancer
. Access for abdominal distension, fluid eave, and shifting dullness
Causes of ascites
. Cirrhosis . Sinusoidal obstruction syndrome . Bud-Chiari syndrome . Alcoholic hepatitis . HF . Nephrotic syndrome . Pancreatitis . Myxedema . Cancer . Postoperative lymph leak
Murphy’s sign
. Press down on abdomen in RUQ
. Breathe in, abdomen does down, gallbladder hits hand
. Inspiratory arrest on deep palpation of RUQ
Auscultation in abdomen
. Listen before palpation
. Use diaphragm except for aorta and spleen
. Listen for bruits at midline and L and R renal aa.
Inspection of abdomen
. Note contour, hernias, umbilicus, rashes, pulsation
. Stretch marks (Cushing syndrome)
Cullen’s sign
Periumbilical darkening
Turner’s sign
Flank darkening
. Intra or retroperitoneal bleed
Types of bowel sounds
. Normal
. Hyperactive
. Absent
. Hyperactive
Shifting dullness vs fluid wave
. Dullness: percussions midline lat. to flank for dullness changes (tympany is ascites)
. Fluid wave: patient put hand at midline, tap one side to see if transmission occurs as thrill sensation (if it does ascites)
Types of percussion sounds
. Tympanic . Hyper-resonant . Normal resonant . Impaired resonant . Dull . Stony dull
Aaron sign
Epigastric pain while doing McBurney’s point
Rovsing sign
. RLQ pain w/ LLQ against examiner’s hand causing RLQ
Obturator sign
. Patient supine
., examiner rotates the thigh flexed internally and externally causing pain in the RLQ
Blumberg sign
. Rebound tenderness
. Sounds peritonitis
Guarding is a sign of ___
Intra-abdominal inflammation
. Can be voluntary or involuntary
Cholecystitis, acute
. RUQ pain worsens w/ fatty meal
. Murphy sign
. Courvoiser sign: oval mass felt in RUQ and is painless, could be obstruction from cancer of head of pancrea
. Pain radiates to right scapula, right shoulder, or right post. Thorax
Hernias
. Ventral/indirect vv scrotal/direct vs femoral/crura hernias
. Patient lay flat w/ head lifted, look for swelling
. Reducible, incarcerated (difficult to replace) or strangulated (does not replace)
. Typically bowel
Pyelonephritis
. UTI-like symptoms w/ extra features
. Systemic symptoms (fever/chills/rigor)
. Costovertebral angle tenderness on infected kidney side
. Murphy punch/pasternacki/goldflam sign (punch over kidney causing pain)
Pancreatitis
. Palpation pain at R/LUQ, epigastric, diffuse pain, pain into back
. IV fluids mainstay treatment and pain control
. Caused by alcoholism and gallstone
Ransom criteria for acute. Pancreatitis
. Severe and prognosis: 0-2 pts 0-3%, 3-5 pts, 11-15%, 6-11 pts, over 40%
. 6 hrs. Presentation (1 pt each): over 55 y/o, WBCs over 16k, glucose over 200, LDH over 350, AST over 250
. 48 hrs presentation (1 pit each): Hct less than 10%, BUN ride over 5, Ca under 8, pO2 less than 60, base deficit over 4
Differentials for RUQ
. Cholecystitis (4Fs), hepatitis,
RLQ differentials
. Appendicitis (can b fooled w/ mesenteric adenitis/lymphadenitis)
Epigastric differentials
. Pancreatitis
. Gastritis
. Gastric ulcer/PUD
LUQ differentials
. Gas distension, trauma to spleen
LLQ differentials
. Diverticulitis, acute
Suprapubic differentials
. UTI, STI
Diffuse/midline abdominal differentials
. Mesenteric ischemia, AAA/dissection
Abdominal Fs
. Fatt . Fibroid . Full bladder . Feces . Fetus . Flatus . Fatal tumor
Child specific abdominal pain differentials
. Meckel’s diverticulum . Hirschsprung disease . Malrotation . Volvulus . Intussusception . necrotizing enterocolitis . Meconium ileus . Familial adenomatous polyposis (FAP) . Gardner syndrome . Turbot syndrome . Peutz-Jeghers syndrome . Juvenile polyposis syndrome
Testing for abdominal pain
. Ultrasounds (fast)
. X-ray (fasT)
. Labs: fast but can get expensive
. Digital rectal exam or occult stool for blood: fast
. CT scan of abdomen and pelvis : fast (contrast for organs, no contrast for kidney stones,IV dye w/ special speed for PE)
. MRI: slow and expensive: solid masses/tumors
