Abdominal Pain Flashcards by Emily Mosher

Differential diagnoses for abdominal pain

. Cholecystitis
. Small bowel obstruction
. Appendicitis 
. Abdominal aortic aneurysms (AAA)
. IBS

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Abdominal pain

. Acute or chronic

. Localized or diffuse pain in abdominal cavity

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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

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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

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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

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Aggravating and relieving factors for abdominal pain

. Body position
. Association w/ eating
. Med use
. Stress levels

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Temporal factors to look into with abdominal pain

. Time of day
. Activity that aggravates pain
. Pain waking patient up at night

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Retroperitoneum

. Part of abdominal cavity

. Kids btw post. Parietal peritoneum and an. To transversalis fascia

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Organs in retroperitoneum

. Suprarenal 
. Aorta/IVC
. Duodenum (2-3rd segments)
. Pancreas
. Ureters
. Colon (ascending/descending)
. Kidney
. Esophagus

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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

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Organs not palpable in right upper quadrant

. Gallbladder
. Inf. Aspect of liver
. Duodenum

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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

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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

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Right lower quadrant

. Bowel loops

. Appendix (not palpable if healthy)

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Pelvic cavity

. Contiguous w/ abdominal cavity 
. Angulated post. 
. Terminal ureters
. Bladder
. Pelvic genital organs 
. Bowel
. Protected by surrounding pelvic bones

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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

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GU disorder common and concerning symptoms

. Suprapubic pain 
. Difficulty urinating, urgency, frequency
. Hesitancy
. Urinary incontinence 
. Blood in urine 
. Flank pain and ureteral colic

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Hematochezia vs. melena

. Hematochezia: fresh blood per rectum, in or mixed w/ stool
. Melena: dark feces containing partly digested blood

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Reg flag symptoms w/ abdominal pain

. Early satiety
. Unintentional weight loss w/ abdominal pain
. Jaundice
. Unexplained anemia

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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

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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