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Y2 - BRS - GI > Abdominal Pain Tutorial > Flashcards

Abdominal Pain Tutorial Flashcards

1
Q

Why is patient history so important?

A

Most intra-abdominal diseases present with pain alone

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2
Q

What does SOCRATES stand for?

A 
S = site
O = onset
C = character
R = radiation
A = associations / additional symptoms
T = time course
E = exacerbations / relieving factors
S = severity scale
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3
Q

What is colicky pain?

A

Gripping pain that comes and goes

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4
Q

Which of SOCRATES in abdominal pain are most important?

A

Site and character most important

And also radiation at times

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5
Q

What are the 9 abdominopelvic regions?

What is the pain associated with in each of these areas?

A

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

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6
Q

What are the 4 abdominopelvic quadrants

A

Right upper quadrant (RUQ)

Left upper quadrant (LUQ)

Right lower quadrant (RLQ)

Left lower quadrant (LLQ)

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7
Q

What are the 5 planes in order from top to bottom?

A

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

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8
Q

What is found in the transpyloric plane?

A

At level of L1
Contains:

Pylorus of Stomach
Neck of Pancreas
Fundus of Gallbladder
Renal Hilum
Duodenojejunal Flexure
End of Spinal Cord (adult
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9
Q

What is found in the foregut, midgut and hindgut?

And what arteries are they supplied by?

A

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)

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10
Q

What is the difference between the visceral and parietal peritoneum?

A

Parietal covers peritoneal cavity

Visceral covers organs

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11
Q

Why is is important to differentiate between the 2 periotenums?

A

They have diifferent innervations

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12
Q

What is the innervation to the visceral peritoneum?

What is the innervation to the parietal peritoneum?

A

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

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13
Q

What is pain in the gut and right shoulder associated with?

A

Phrenic nerve

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14
Q

What are the innervations, site of pain, and character of pain for visceral VS parietal peritoneum?

A

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

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15
Q

What are the innervations for sensation at the fore, mid and hindgut?

Where is the site of pain at these regions?

A

Foregut =
Innervation - T5 - T9
Epigastrium

Midgut =
Innervation - T10 - T11
Umbilical

Hindgut =
Innervation = L1 - L2
Hypogastrium

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16
Q

What are the 2 categories of abdominal pain?

A
  1. 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
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17
Q

What does a prolonged obstruction of muscular tube cause?

A

Distension
Stops blood getting into hollow organ = ischaemic

Changes from colicky to constant stretching pain
Different from ache of inflammation & not colicky - ischaemia

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18
Q

State whether the below organs will be colicky or constant pain:

Ureter
Liver
Biliary tree
Spleen
Kidney 
(Small) bowel
A

Colicky =
Ureter
Biliary tree
(Small) bowel - if obstruction present

Constant =
Kidneys
Liver
Spleen

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19
Q

Where would kidney pain radiate?

A

In loin & radiates to groin

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20
Q

What is typical of ureteric colicky pain?

What is typical of biliary colicky pain?

A

Severe pain intensity that slowly fluctuates

Comes and goes quickly, but lasts persistently

21
Q

What is typical of intestinal colic?

A

Less severe
Moderate-mild
More frequent

22
Q

Where does lower abdominal pain radiate?

A

Lower abdominal pain rarely radiates

Pain from structures deep in the pelvis referred to lower back/perineum

23
Q

How does colicky pain differ and why may patients describe it as constant?

A

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

24
Q

Foregut radiation of pain:

A

Radiating around the right and back, up to scapula
Straight through to the back
Through to the back to the left

25
Q

Midgut radiation of pain:

A

In loin and radiated to groin
Does not normally radiate - difficult to localise
In loin and radiates to groin

26
Q

Hindgut radiation of pain:

A

lower abdominal pain rarely radiated

Pain from structures deep in the pelvis may be described as lower back pain by patients

27
Q

What are general features of pain radiation?

A

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

28
Q 
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
A

Appendicitis

29
Q

What are common signs of appendicitis?

A

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

30
Q

Why might appendicitis present atypically?

A

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

31
Q 
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
A

Bowel obstruction

32
Q

What are the common signs of bowel obstruction?

A

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

33
Q

What is the most common form of bowel obstruction?

A

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

34
Q

How is small bowel obstruction treated?

A

Nasogastric tube - empty out bowel caught in adhesion band

35
Q 
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
A

Ureteric colicky

36
Q

What are the common signs of ureteric colic?

A

Radiating from loin to groin

Sudden onset as stone is too big to go through the ureter

37
Q

How do ruptured abdominal aortic aneurysms present?

A

Central abdominal pain

OR

Left loin to groin pain

38
Q 
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
A

Biliary colic

39
Q

What are the common symptoms of biliary colic?

A

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

40
Q

What can the right hypochondriac region be associated with (esp. atypically)?

A 
Right hypochondriac = 
Gallstones
Cholangitis
Hepatitis
Liver abscess
41
Q

What can the epigastric region be associated with (esp. atypically)?

A 
Epigastric = 
Oesophagitis
Peptic ulcer
Perforated ulcer
Pancreatitis
Biliary tract disease
42
Q

What can the left hypochondriac region be associated with (esp. atypically)?

A

Left hypochondriac =
Splenic abscess
Acute splenomegaly
Splenic rupture

43
Q

What can the right lumbar region be associated with (esp. atypically)?

A 
Right Lumbar = 
Renal colic
Pyelonephritis
Ovarian cyst Ovarian mass 
Ovarian torsion
44
Q

What can the umbilical region be associated with (esp. atypically)?

A

Umbilical =
Appendicitis (early)
Mesenteric adenitis
Meckel’s diverticulitis

45
Q

What can the left lumbar region be associated with (esp. atypically)?

A 
Left lumbar = 
Renal colic
Pyelonephritis
Ovarian cyst Ovarian mass 
Ovarian torsion
46
Q

What can the right iliac region be associated with (esp. atypically)?

A 
Right iliac = 
Appendicitis
Crohn’s Disease
Ovarian cyst/torsion
Ectopic pregnancy
Hernias
Renal colic
47
Q

What can the hypogastric (or sometimes called suprapubic) region be associated with (esp. atypically)?

A 
Hypogastric =
 Urinary retention
Cystitis
Uterine fibroid
Endometriosis
48
Q

What can the left iliac region be associated with (esp. atypically)?

A 
Left iliac = 
Diverticulitis
Ulcerative colitis
Constipation
Ovarian cyst/torsion
PID
Ectopic pregnancy
Hernias
Renal colic
49
Q

When patient presents with foregut pain, what other causes can it be other than abdominal / GI?

A

Cardiac

Lung

Y2 - BRS - GI (14 decks)

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