Abdominal Pain lecture Flashcards
LO:
- Abdominal pain: Relate the symptoms and signs of abdominal pain to the diagnosis and treatment of common intra-abdominal pathology
- Organs of the gastrointestinal tract: Summarise the structure of gastrointestinal organs and relate these to their functions.
Aims
Aims
- To apply anatomy to clinical presentation
- Pertinent history-so important to take a thorough history
- Surface anatomy
- Visceral & parietal pain
Abdominal pain
Most intra-abdominal diseases present with pain alone
•A careful Hx is never wasted
Two most significant properties of pain are site and character
•If you know these you have a good chance of making a correct diagnosis, add in radiation and should be able to get it most of the time.
Abdominal Pain - History
SOCRATES
Site-where in abdomen is it
Onset of pain-gradual or sudden, how quickly
Character/nature-type of pain
Nature
- Burning
- Throbbing
- Stabbing
- Constricting
- Colicky ie gripping pain which comes and goes
- aching
Radiation-does pain go anywhere else
Associated with anything eg eating
Timecourse-have you had pain before?
Exacerbating or relieving factors
Severity-what’s you pain 1-10?
Site - Surface Anatomy
Transpyloric plane
Interspinous plane – line through anterior superior iliac spines (when patient lies down these are the superficial bits most easily found)
Vertical lines-both mid clavicular lines
Upper zone-foregut innervation
Left/right loin is behind left/right lumbar region
Or quadrants (less specific)
Site - Surface Anatomy
Intertubercular plane – line through iliac tuberclew (L5)
Transpyloric plane-divides epigastrum and middle zone
Site - Surface Anatomy
What’s at the level of the Transpyloric plane?
- Transpyloric Plane – L1
- Pylorus of Stomach
- Neck of Pancreas
- Fundus of Gallbladder
- Renal Hilum (left kidney is a bit higher than the right)
- Duodenojejunal Flexure
- End of Spinal Cord (adult)
Site - Surface Anatomy
Supracristal is top of iliac crests
Anything below this is within the pelvis
Site-what is in the sites?
Think liver-biliary tree so gall bladder
Left upper zone is tail of pancreas
Right lumbar is kidney-think right loin is behind this area
Umbilical-think aorta so potential abdominal aortic aneurysm if pain here. Also think SAD PUCKERS for retroperitoneal organs
Site-foregut. midgut and hind gut
Foregut-coeliac trunk, upper zone
Midgut-SMA, middle zone
Hindgut-IMA, inferior zone
Anatomy of Site
Small bowel pain does not usually radiate but it does MOVE when somatic as well as visceral nerves are irritated
Visceral & Parietal Peritoneum
CP – coeliac plexus
SMP – superior mesenteric plexus
IMP – Inferior mesenteric plexus
Parietal peritoneum is the lining of the abdomen (think bag in bin)
Visceral peritoneum lines organs but also any hollow viscus (singular form of viscera.)
Visceral peritoneum has nerves coming from foregut, midgut, hindgut, you have sensory nerves going to then sympathetic chain. Foregut goes to the coeliac plexus, midgut to the superior mesenteric plexus and hindgut to the Inferior mesenteric plexus. So those are the sympathetic sensory innervation, you also get some innervation from the vagus nerve, but that’s not specific, it covers all levels. You also get some sensory nerves via the parasympathetic nerves, essentially S2, 3 and 4.
On the other hand, parietal peritoneum has segmental innervation, so can localise where the pain is easily with your segmental innervation. The visceral peritoneum is very non-specific, it’s difficult to work out exactly where it’s coming from.
Note: Phrenic nerve also has a sensory supply that covers not only the right diaphragm but the right shoulder, so often people have a collection on their diaphragm but can feel pain in right shoulder.
Difference Between Parietal and Visceral Pain
Visceral-not specific, difficult to localise pain
Parietal-well localised pain
Character of Pain
Most painful conditions in the abdomen fall into 2 categories:
1) Inflammation
- Constant pain (‘aching’)
- Made worse by movement
- Persists until inflammation subsides
2) Obstruction of a muscular tube eg ureter, small bowel, large bowel, bile duct etc.:
- Colicky pain (‘gripping’, comes and goes, fluctuates in severity)
- Fluctuates in severity
- Move to try and get comfortable
Note: Prolonged obstruction of a hollow viscus causes distension which stops blood getting into hollow organ so it becomes ischaemic:
- Constant stretching pain
- Different from ache of inflammation & not colicky - ?ischaemia
So look out for change in pain
Character of Pain
Kidney and uretic stones, typically colicky
Liver-constant
Spleen-constant
Trauma and bleed-irritates parietal peritoneum and is constant
Character of Pain
Diagram shows pain intensity vs time. Ureteric colic, severe pain and fluctuating relatively frequently
Biliary colic is in inverted commas because it is often described as colic but if you speak to a patient, they actually describe it as being constant, because when they get their pain it is very intense, but it lasts a long time before it relaxes. So just beware people may describe constant pain, but actually it is varying with intensity, it just takes longer.
Intestinal colic is less severe than biliary and ureteric, and it is more frequent contractions they’re getting.
Colicky pain becomes constant when there is is ischaemia, so you have to act fast.
Radiation of Pain – Upper Zones
Right upper-to do with gall bladder, goes to tip of scapula
Epigastric-stomach and duodenum is source of pain, particularly pancreas as it is retroperitoneal
Radiation of Pain – Central Zones
Right-radiates to groin as ureter heads out of kidney this way
Umbilical: Specifically aorta, doesn’t normally radiate, difficult to localise
Radiation of Pain – Lower Three Zones
adnexae-ovaries and fallopian tubes etc.
Rarely radiate
Radiation of Pain in general:
In general:
- Colicky abdominal pain is usually referred to the centre (Visceral sensation) Difficult to localise
- Pain from parietal inflammation felt over inflamed area so localises well (Somatic sensation)
- When pain radiates it signifies other structures are becoming involved
- Small bowel pain doesn’t radiate but may move when somatic as well as visceral nerves become irritated. So appears that the pain has moved.
Eg Epigastric pain due to Duodenal ulcer pain radiating to back signifies inflammation beyond duodenum into structures of the posterior abdominal wall (pancreas)
Patient Cases:
Appendicitis, ruptured AAA, utereric colic, biliary colic, pancreatitis, or bowel obstruction
=appendicitis
We know visceral pain is experienced as central umbilical pain, so you get visceral stimulation from the inflammed appendix, which is felt around the umbilicus. And as the inflammation progresses, it starts irritating the parietal peritoneum, so that’s why it then localises to the right.
Central-appendicitis starts in umbilical region but then pain appears to move to right as at first only involves visceral but then picks up parietal sensation.
Constant pain as it’s inflammatory
No radiation-pain has just moved as gone from visceral to parietal irritation.
Often feel sick and don’t feel hungry (ask if they could eat if they could then it’s not an appendicitis but if they recoil at this idea, it’s likely to be an appendicitis)
Person has furry tongue and smell ketotic (ask to stick out tongue)
Note: can get atypical appendictis-appendix can be anywhere, (shown is typical), so could be in pelvis and so won’t get right iliac fossa pain, so have to bear that in mind, get suprapubic pain which is very non specific.
retrocaecal appendix-so appendix is not free in peritoneum, but is behind caecum, can also occur where appendix is behind caecum and in front of posterior abdominal wall, so when first get it they don’t feel anything until it gets big and inflammaed and is falling apart with abcess, so often presents very advanced as symptoms don’t prevent until late.
Patient 2
Appendicitis, ruptured aaa, utereric colic, biliary colic, pancreatitis, bowel obstruction
=bowel obstruction
Non specific, gradual onset and colicky fits in with something getting blocked. Doesn’t radiate as visceral peritoneum so not really sure where it is.
Moderate-less intense than biliary colic
Adhesions like fibrotic tissue within abdomen from surgery scars are common cause of obstruction. Adhesion, band of fibrous tissue has caught both causing a closed loop which is in danger of becoming ischaemic.
Previous surgery or congenital bands which can catch bit of bowel at random age and cause obstruction
NGT-best to use to empty all contents and this will collapse bowel and allow it to untwist
Patient 3
Appendicitis, ruptured aaa, utereric colic, biliary colic, pancreatitis, bowel obstruction
=Ureteric colic
Big clues-loin, quite specific, not much happens in loin. It radiates to groin. Loin to groin is pretty much always ureteric.
Vomiting is actually due to the pain
Often had stone which has moved and stopped etc.
Not inflammatory as can’t find comfortable positio, so has to be a tube
Patient 4
Appendicitis, ruptured aaa, utereric colic, biliary colic, pancreatitis, bowel obstruction
=Biliary colic
Ruptured AAA-this is one exception if left loin to groin pain (95% though is ureteric colic.) So if someone presents with ureteric colic, always feel for abdominal AA.
People with bilary colic-often have right upper quadrant pain, but remeber have large bowel (hepatic flexure) there too so could be perforation.
Clue-pain is going to right shoulder, often nothing else but biliary colic
Happens after eating as food with fat which causes the release of Cholecystokinin from the I cells of the duodenum, stimulating the gallbladder to contract and release stored bile into the intestine. This contraction causes pain.
Site of Pain
Left upper quadrant pain is usually spleen
Note: there are variations, things are not always typical
PID-pelvic inflammatory disease (gynacological pain)
When talking about upper zone ie foregut always think about lung and heart causes
