Abdominal pain Flashcards
Structures located in the RUQ
Liver Gall bladder Duodenum Head of the pancreas Right adrenal gland Portion of the right kidney Portions of the ascending and transverse colon
Conditions arising from the RUQ
Biliary colic Hepatitis Peptic ulcer Pancreatitis Renal colic Herpes zoster Myocardial ischaemia
Structures located in the LUQ
Left lobe of liver Stomach Spleen Body of the pancreas Left adrenal gland Portion of the left kidney Portions of the transverse and descending colon
Conditions arising from the LUQ
Gastritis Splenic enlargement or rupture Pancreatitis Renal colic Herpes zoster Myocardial ischaemia
Structures located in the RLQ
Lower portion of the right kidney Caecum and appendix Portion of the ascending colon Ovary and salpinx Uterus if enlarged Right ureter
Conditions arising from the RLQ
Appendicitis Diverticulitis Intestinal obstruction Renal colic Ectopic pregnancy Ovarian cyst Salpingitis Endometriosis
Structures located in the LLQ
Lower portion of the left kidney Sigmoid colon Portion of the descending colon Ovary and salpinx Uterus if enlarged Left ureter
Conditions arising from the LLQ
Diverticulitis Intestinal obstruction Renal colic Irritable bowel syndrome Ectopic pregnancy Ovarian cyst Salpingitis Endometriosis
Dyspepsia/gastritis -
LUQ
- Patients with dyspepsia present with a range of symptoms that commonly involve vague abdominal discomfort (aching) above the umbilicus associated with belching, bloating, flatulence, feeling of fullness and heartburn. It is normally relieved by antacids and aggravated by spicy foods or excessive caffeine. Vomiting is unusual.
Splenic enlargement or rupture
LUQ
- If the spleen is enlarged, generalised left upper quadrant pain associated with abdom-
inal fullness and early feeding satiety is observed (Fig. 7.17). Referred pain to the left
shoulder is sometimes seen. The condition is rare and is nearly always secondary to
another primary cause, which might be an infection, a result of inflammation or hae-
matological in origin.
Acute cholecystitis and cholelithiasis
RUQ
- Cholelithiasis (presence of gall stones in the bile ducts, also called biliary colic) is
the more common presentation. (Fig. 7.18) Typically, the pain lasts for more than
30 minutes, but less than 8 hours, is colicky in nature and often severe. Nausea
and vomiting are often present. Classically, the onset is sudden, starts a few hours
after a meal and frequently awakens the patient in the early hours of the morning.
In acute cholecystitis (inflammation of the gall bladder) symptoms are similar but
also associated with fever and abdominal tenderness. The pain may radiate to
the tip of the right scapula. The incidence of both increases with increasing age
and is most common in people aged over 50. It is also more prevalent in women
than in men.
Hepatitis
RUQ
- Liver enlargement from any type of hepatitis will cause discomfort or dull pain
around the right rib cage (Fig. 7.19). Associated early symptoms are general malaise,
tiredness, skin rash (pruritus) and nausea. On examination there is normally hepatic
tenderness.
Ulcers
RUQ
-Ulcers are classed as either gastric or duodenal. They occur most commonly in
patients aged 30 to 50 years old and are more common in men than in women.
Symptoms are variable but typically the patient will have localised mid-epigastric
pain (Fig. 7.20) described as ‘constant’, ‘annoying’ or ‘gnawing/boring’.
With gastric ulcers, symptoms are inconsistent but the pain usually comes on
whenever the stomach is empty – usually 15 to 30 minutes after eating – and is gen-
erally relieved by antacids or food and aggravated by alcohol and caffeine. NSAID
use is associated with a three- to fourfold increase in gastric ulcers.
Duodenal ulcers tend to be more consistent in symptom presentation. Pain occurs
2 to 3 hours after eating, and pain that awakens a person at night is highly sugges-
tive of duodenal ulcer.
Acute pancreatitis
Pain affecting both right and left upper quadrants
- Pain of pancreatitis develops suddenly and is described as agonising and constant
with the pain being centrally located (epigastric) that often radiates into the back
(Fig. 7.21). Pain reaches its maximum intensity within minutes and can last hours or
days. Vomiting is common but does not relieve the pain. Early in the attack patients
might get relief from the pain by sitting forwards. It is commonly seen in those that
misuse alcohol (25% of cases) or suffer from gallstones (50% of cases). Patients are
very unlikely to present in a community pharmacy due to the severity of the pain
but a mild attack could present with steady epigastric pain that is sometimes centred
close to the umbilicus and can be difficult to distinguish between other causes of
upper quadrant pain.
Renal colic
Pain affecting both right and left upper quadrants
Urinary calculi (stones) can occur anywhere in the urinary tract, although most fre- quently stones get lodged in the ureter. Pain begins in the loin, radiating around the
flank into the groin and sometimes down the inner side of the thigh (Fig. 7.22). Pain
is very severe and colicky in nature. Attacks are spasmodic and tend to last minutes
to hours and often leave the person prostrate with pain. The person is restless and
cannot lie still. Symptoms of nausea and vomiting might also be present. It is twice
as common in men than in women and usually occurs between the ages of 40 and
60 years old.
MI
Pain affecting both right and left upper quadrants
- Angina and myocardial infarction (MI) cause chest pain that can be difficult to dis-
tinguish initially from epigastric/retrosternal pain caused by dyspepsia (Fig. 7.23).
However, pain of cardiovascular origin often radiates to the neck, jaw and inner aspect
of the left arm. Typically, angina pain is precipitated by exertion and subsides after
a few minutes once at rest. Pain associated with MI will present with characteristic
deep crushing pain. The patient will appear pale, display weakness and be tachycardic.
Cardiovascular pain should respond to sublingual glyceryl trinitrate therapy.
Appendicitis
LRQ
Classically, the pain starts in the mid-abdomen region, around the umbilicus, be-
fore migrating to the right lower quadrant after a few hours (Fig. 7.27), although
right-sided pain is experienced from the outset in about 50% of patients. The pain
of appendicitis is described as colicky or cramp-like but after a few hours becomes
constant. Movement tends to aggravate the pain and vomiting might also be present.
Appendicitis is most common in young adults, especially in young men.
Conditions affecting women (other than period pain)
Generalised lower abdominal pain (Fig. 7.28) can be experienced in a number of
gynaecological conditions:
• Ectopic pregnancy: these are usually experienced between weeks 5 and 14 of the
pregnancy. Patients suffer from persistent moderate to severe pain that is sudden
in onset. Referred pain to the tip of the scapula is possible. Most patients (80%)
experience bleeding that ranges from spotting to the equivalent of a menstrual
period. Diarrhoea and vomiting is often also present.
• Salpingitis (inflammation of the fallopian tubes): occurs predominantly in young,
sexually active women, especially those fitted with an IUD. Pain is usually bi-
lateral, low and cramping. Pain starts shortly after menstruation and can worsen
with movement. Malaise and fever are common.
• Endometriosis: patients experience lower abdominal aching pain that usually starts
5 to 7 days before menstruation begins and can be constant and severe. The pain
often worsens at the onset of menstruation. Referred pain into the back and down
the thighs is also possible.
Gastroenteritis
Diffuse abdominal pain
- Other symptoms of nausea, vomiting and diarrhoea will
be more prominent in gastroenteritis than abdominal pain.
The patient might also have a fever and suffer from gen-
eral malaise.
Peritonitis
Severe pain in the upper abdomen is present. This is ac-
companied by intense rigidity of the abdominal wall
producing a ‘board like’ appearance; fever and vomiting
might also be present. Urgent referral is required due to
associated complications.
TRIGGER POINTS indicative of referral:
Abdominal pain
- Abdominal pain
with fever: Suggests potential diverticulitis,
peritonitis, biliary colic or
salpingitis
- Pregnancy or suspected pregnancy: Eliminate pain relating to pregnancy or ectopic pregnancy
- Abdominal pain
associated
with trauma: May indicate damage to organs
- Severe pain or pain that radiates: Suggests more sinister causes such as potential myocardial infarction or significant inflammation of the GI tract
- Elderly: Diverticulitis and obstruction more common
- Vomiting: Suggests conditions such as
peritonitis, pancreatitis,
appendicitis or renal or biliary
colic
Refer age
> 50 years
