Approach - Abdominal pain Flashcards
Describe the characteristics of abdominal pain due to obstruction of hollow viscus
- localisation
- quality
- severity
- chronology
- Poorly localised (visceral)
- Colicky (except biliary “colic”)
- Variable severity
- May be episodic if obstruction is intermittent
Describe the characteristics of abdominal pain due to inflammation
- localisation
- quality
- severity
- chronology
- Well localised (parietal)
- Usually sharp
- Often severe
- Constant pain
Describe the characteristics of abdominal pain due to perforation
- localisation
- quality
- severity
- chronology
- Well localised (unless generalised peritonitis)
- Sharp
- Usually severe
- Sudden onset (may be sudden exacerbation of pre-existing pain)
Compare the frequency of pain & vomiting depending on the anatomical site of abdo pain cause
- foregut
- midgut
- hindgut
Foregut: e.g. pyloric stenosis
- Immediate vomiting, pain not prominent
Midgut: e.g. SBO
- Every few minutes to half hourly
Hindgut: e.g. LBO
- Infrequent exacerbation or vomits
What are 3 anatomical groups of causes of obstruction of a hollow viscus?
- Intraluminal obstruction
–Stone blocking a narrow tube
e.g. Renal colic - In the wall
–Colon cancer blocking the colon
e.g. Large bowel obstruction - Extrinsic
–Adhesion
e.g. Small bowel obstruction
Name (4) non-abdominal causes of abdominal pain
- Heart
- Lung, diaphragm
- Back / muscular skeletal
- Herpes zoster (pain precedes rash)
Describe abdominal pain due to biliary colic (& choledocolithiasis)
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- RSC (but often epigastric, occasionally LSC)
- Right side of back or interscapular
- Various (“sharp”, “pushing”), NOT colicky
- Variable, often severe
- Intermittent, fairly sudden onset, lasts at least 15 mins, up to several hours
- better with Antispasmodics
- nausea
- Often occurs 30 mins to a few hours after fatty meal
NOTE: Choledocolithiasis: may present with obstructive jaundice
Describe abdominal pain due to acute cholecystitis
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- RSC
- Usually sharp
- Severe
- Onset may be sudden or gradual, persistent
- worse with movement
- better with analgesia
- Nausea, sometimes vomiting
- Not necessarily related to meal
Describe abdominal pain due to acute pancreatitis
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Epigastrium
- Through to back
- Usually sharp
- Usually severe
- Fairly sudden onset, persistent, sometimes recurrent
- worse with movement
- better with analgesia
- Vomiting
- Recent heavy alcohol use, known gallstones, ERCP
Describe abdominal pain due to peptic ulcer
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Epigastrium (+ no radiation)
- Aching
- Variable
- Intermittent, often at night
- better with PPIs
- NSAIDs, smoking
Describe abdominal pain due to perforated peptic ulcer
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Epigastrium
- Shoulder tip (radiation)
- Sharp
- Severe
- Sudden onset, persistent
- worse w/ movement
- better w/ analgesia
Describe abdominal pain due to gastroenteritis
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Epigastrium/centra
- Colicky
- Variable
- Usually gradual onset
- vomiting +/- diarrhoea
Describe abdominal pain due to AMI
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Epigastrium + retrosternal +/- left arm/jaw
- Heavy
- Severe
- Usually sudden onset
- better w/ analgesia, vasodilators
- +/- sweating, nausea, dyspnoea
- activity
Acute cholecystitis O/E
RUQ tenderness +/- guarding +/- positive Murphy’s sign
+/- Percussion tenderness RUQ
May have ileus (silent)
Acute pancreatitis O/E
+/- Grey Turner’s or Cullen’s sign
Epigastric tenderness, usually no involuntary guarding
+/- percussion tenderness in epigastrium
May have ileus (silent)
Describe abdominal pain due to inflammatory bowel disease
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- central
- Colicky if obstructive, otherwise sharp
- variable
- recurrent, relapsing
- worse w/ oral intake
- better a/ analgesia, steroids, antibiotics
- Diarrhoea, rectal bleeding/mucus (UC), tenesmus (UC), weight loss, fever, fistulae (CD)
- A/w PSC (UC), iritis/uveitis, ankylosing spondlylitis, pyoderma gangrenosum, erythema nodosum
Describe abdominal pain due to ruptured AAA
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- central & radiates to the back
- tearing pain
- severe
- sudden onset
Which abdominal pain cause is aggravated by oral intake?
Small bowel obstruction
Early acute appendicitis
Inflammatory bowel disease
Which abdominal pain cause is aggravated by movement?
Acute cholecystitis Acute pancreatitis Perforated peptic ulcer Acute appendicitis Ruptured ectopic pregnancy Testicular torsion
What should you ask in small bowel obstruction?
Previous abdo surgery, hernias & previous episodes of SBO
Describe abdominal pain due to large bowel obstruction
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- infra-umbilical
- colicky
- Variable
- Progressive
- better w/ Analgesia
- Constipation, preceding alteration of bowel habit/rectal bleeding
- a/w Known diverticulosis, previous colonic polyps, previous episodes of volvulus, family history of colon cancer
Describe abdominal pain due to diverticulitis
- usual site
- radiation
- quality
- severity
- chronology
- aggravating factors
- relieving factors
- other symptoms
- associations
- Usually LIF (varies depending on position of sigmoid colon)
- Sharp
- variable
- constant often recurrent
- better w/ analgesia, Abx
- Preceding alteration of bowel habit/rectal bleeding
- a/w Known diverticulosis, previous episodes of diverticulitis
Acute appendicitis O/E
Tender, usually RIF (classically McBurney’s point), guarding +/- positive Rovsing’s sign
Percussion tenderness
Usually normal (ileus if ruptured appendix)
Mx of possible appendicitis
- Admit, nil orally, IV fluids, analgesia
- Consent
- Laparoscopy, ?appendicectomy
- DVT and antibiotics prophylaxsis
Post-op:
- Explain findings to pt
- Analgesia ?oral
- Trial of fluids and food
- Discharge planning (?home today to family, timing of follow up visit)
- Check pathology of appendix
- Medical certificate
