Abdominal Pain Tutorial Flashcards
Why is patient history so important?
Most intra-abdominal diseases present with pain alone
What does SOCRATES stand for?
S = site O = onset C = character R = radiation A = associations / additional symptoms T = time course E = exacerbations / relieving factors S = severity scale
What is colicky pain?
Gripping pain that comes and goes
Which of SOCRATES in abdominal pain are most important?
Site and character most important
And also radiation at times
What are the 9 abdominopelvic regions?
What is the pain associated with in each of these areas?
Right hypochondriac - gallbladder
Epigastric - stomach, duodenum, pancreas
Left hypochrondriac - tail of pancreas
Right lumbar - kidney
Umbilicar - small bowel, caecum, retroperitoneal structures
Left lumbar - kidney
Right iliac - appendix, caecum
Hypogastric - transverse colon, bladder, uterus, adnexae
Left iliac - sigmoid colon
What are the 4 abdominopelvic quadrants
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
What are the 5 planes in order from top to bottom?
Transpyloric - division of epigastrium and middle zone, level of L1
Subcostal plane - Origin of Inferior Mesenteric Artery (IMA), level of L3
Supracristal plane - bifurcation of the aorta, level of L4
Intertubercular plane
Interspinous plane
What is found in the transpyloric plane?
At level of L1
Contains:
Pylorus of Stomach Neck of Pancreas Fundus of Gallbladder Renal Hilum Duodenojejunal Flexure End of Spinal Cord (adult
What is found in the foregut, midgut and hindgut?
And what arteries are they supplied by?
Foregut = distal oesophagus to proximal half of 2nd part of duodenum = supplied by celiac trunk
Midgut = distal half of 2nd part of duodenum to proximal 2/3 of transverse colon = supplied by superior mesenteric artery (SMA)
Hindgut = Distal 1/3 of transverse colon to rectum = supplied by the inferior mesenteric artery (IMA)
What is the difference between the visceral and parietal peritoneum?
Parietal covers peritoneal cavity
Visceral covers organs
Why is is important to differentiate between the 2 periotenums?
They have diifferent innervations
What is the innervation to the visceral peritoneum?
What is the innervation to the parietal peritoneum?
Visceral peritoneum =
foregut = celiac plexus (CP), midgut = superior mesenteric plexus (SMP), hindgut = inferior mesenteric plexus (IMP)
Vagus - non-specific innervation
Parietal peritoneum = segmental from spinal nerves (T6-L3) and C3,C4,C5 = phrenic nerve to diaphragm
What is pain in the gut and right shoulder associated with?
Phrenic nerve
What are the innervations, site of pain, and character of pain for visceral VS parietal peritoneum?
Visceral =
Sympathetic innervation - T1 - T12, L1, L2
Parasympathetic innervation - CN III, VII, IX, X, S2 - S4
From embryological origin
Feels dull, crampy, burning
Parietal =
Somatic innervation
Well-localised pain
Usually described as sharp, aching
What are the innervations for sensation at the fore, mid and hindgut?
Where is the site of pain at these regions?
Foregut =
Innervation - T5 - T9
Epigastrium
Midgut =
Innervation - T10 - T11
Umbilical
Hindgut =
Innervation = L1 - L2
Hypogastrium
What are the 2 categories of abdominal pain?
- Inflammation =
Constant pain (‘aching’)
Made worse by movement
Persists until inflammation subsides
2. Obstruction of a muscular tube = Colicky pain (‘gripping’) Fluctuates in severity Move to try and get comfortable
What does a prolonged obstruction of muscular tube cause?
Distension
Stops blood getting into hollow organ = ischaemic
Changes from colicky to constant stretching pain
Different from ache of inflammation & not colicky - ischaemia
State whether the below organs will be colicky or constant pain:
Ureter Liver Biliary tree Spleen Kidney (Small) bowel
Colicky =
Ureter
Biliary tree
(Small) bowel - if obstruction present
Constant =
Kidneys
Liver
Spleen
Where would kidney pain radiate?
In loin & radiates to groin
What is typical of ureteric colicky pain?
What is typical of biliary colicky pain?
Severe pain intensity that slowly fluctuates
Comes and goes quickly, but lasts persistently
What is typical of intestinal colic?
Less severe
Moderate-mild
More frequent
Where does lower abdominal pain radiate?
Lower abdominal pain rarely radiates
Pain from structures deep in the pelvis referred to lower back/perineum
How does colicky pain differ and why may patients describe it as constant?
Slow frequency of colicky - often biliary colicky, e.g. gallstones are said to be constant by patients, due pain lasting for longer periods at a time
Intestinal colicky = lesser intensity than biliary or ureter colicky pain
Foregut radiation of pain:
Radiating around the right and back, up to scapula
Straight through to the back
Through to the back to the left
Midgut radiation of pain:
In loin and radiated to groin
Does not normally radiate - difficult to localise
In loin and radiates to groin
Hindgut radiation of pain:
lower abdominal pain rarely radiated
Pain from structures deep in the pelvis may be described as lower back pain by patients
What are general features of pain radiation?
Parietal pain - localises well
Colicky abdominal pain is referred to the centre (visceral sensation)
Pain from parietal inflammation felt over inflamed area (somatic sensation)
When pain radiates it signifies other structures are becoming involved
Small bowel pain does not radiate, but may move when somatic as well as visceral nerves become irritated - intially visceral, but when becomes ischaemic / worse, somatic gets involved
Case 1: Central then shifts to right iliac Gradual onset Constant No radiation Nausea, anorexia, fever No previous pain like this Worse on movement Dull ache
What is the diagnosis for this pain? Appendicits Ruptured abdominal aortic aneurysm Ureteric colic Biliary colic Pancreatitis Bowel obstruction
Appendicitis
What are common signs of appendicitis?
Ketotic smell
Not hungry
Parietal peritoneum irritated on movement - that is why pain is worse on movement
Early = central pain, then later radiates to the right iliac region
Why might appendicitis present atypically?
Appendix lies in the pelvis = suprapubic pain
Retrocaecal appendix = appendix is behind the caecum and in front of the intra-abdominal wall = no symptoms until huge abscess is formed
Case 2: Central Gradual onset over last 2-3 days Colicky No radiation Vomiting, bowels not open for last 2-3 days Previous colicky pain - went away by itself Passing flatus relieves pain Moderate pain
What is the diagnosis for this pain? Appendicits Ruptured abdominal aortic aneurysm Ureteric colic Biliary colic Pancreatitis Bowel obstruction
Bowel obstruction
What are the common signs of bowel obstruction?
Gradual onset
Lack of bowel opening
Passing flatus relieves pain - some form of obstruction
Moderate colicky = bowel, unlikely to be biliary or uteteric
Central pain due to visceral innervation - and so less likely to radiate too
What is the most common form of bowel obstruction?
Adhesions (like these bands made of fibrotic tissue in the abdomen) exist congenitally or post-surgery as scar tissue
If forms closed loop, and part of the bowel can get caught in the adhesion loop - bowel then has a great chance of becoming ischameic
How is small bowel obstruction treated?
Nasogastric tube - empty out bowel caught in adhesion band
Case 3: Loin Sudden onset Colicky Radiating to groin Vomiting Previous colicky pain Cannot find comfortable position to relieve pain 10/10 pain
What is the diagnosis for this pain? Appendicits Ruptured abdominal aortic aneurysm Ureteric colic Biliary colic Pancreatitis Bowel obstruction
Ureteric colicky
What are the common signs of ureteric colic?
Radiating from loin to groin
Sudden onset as stone is too big to go through the ureter
How do ruptured abdominal aortic aneurysms present?
Central abdominal pain
OR
Left loin to groin pain
Case 4: Right upper quadrant Sudden onset Colicky Right scapula Nausea, indigestion Worse after eating Fatty foods make it worse Can be 10/10
What is the diagnosis for this pain? Appendicits Ruptured abdominal aortic aneurysm Ureteric colic Biliary colic Pancreatitis Bowel obstruction
Biliary colic
What are the common symptoms of biliary colic?
Right upper quadrant
Colicky pain that can be incredibly painful
Radiation to scapula
Indigestion often occurs with gallstones
Stone is pushed out of gallbladder after eating
What can the right hypochondriac region be associated with (esp. atypically)?
Right hypochondriac = Gallstones Cholangitis Hepatitis Liver abscess
What can the epigastric region be associated with (esp. atypically)?
Epigastric = Oesophagitis Peptic ulcer Perforated ulcer Pancreatitis Biliary tract disease
What can the left hypochondriac region be associated with (esp. atypically)?
Left hypochondriac =
Splenic abscess
Acute splenomegaly
Splenic rupture
What can the right lumbar region be associated with (esp. atypically)?
Right Lumbar = Renal colic Pyelonephritis Ovarian cyst Ovarian mass Ovarian torsion
What can the umbilical region be associated with (esp. atypically)?
Umbilical =
Appendicitis (early)
Mesenteric adenitis
Meckel’s diverticulitis
What can the left lumbar region be associated with (esp. atypically)?
Left lumbar = Renal colic Pyelonephritis Ovarian cyst Ovarian mass Ovarian torsion
What can the right iliac region be associated with (esp. atypically)?
Right iliac = Appendicitis Crohn’s Disease Ovarian cyst/torsion Ectopic pregnancy Hernias Renal colic
What can the hypogastric (or sometimes called suprapubic) region be associated with (esp. atypically)?
Hypogastric = Urinary retention Cystitis Uterine fibroid Endometriosis
What can the left iliac region be associated with (esp. atypically)?
Left iliac = Diverticulitis Ulcerative colitis Constipation Ovarian cyst/torsion PID Ectopic pregnancy Hernias Renal colic
When patient presents with foregut pain, what other causes can it be other than abdominal / GI?
Cardiac
Lung
