Approach to Abdominal pain

Question 1

Describe the location of pain in a px with appendicitis?

Answer 1

Initial: Visceral central (umbilical) (T10)

Subsequent: Somatic localised to right iliac fossa
(appendicitis progresses to irritate the parietal peritoneum

Question 2

What is the difference between colic and sharp pain in abdominal pain?

Answer 2

Colic:
- usually visceral
- tubular w peristalsis eg. S/LI, ureteric colic, biliary colic

Sharp:
- somatic

Question 3

How does pain radiate in appendicitis?

Answer 3

Central to right iliac

Question 4

How does pain radiate in pancreatitis?

Answer 4

Central to back

Question 5

How does pain radiate in ureteric colic?

Answer 5

Loin to groin

Question 6

What are 3 red flags for abdominal pain?

Answer 6

1) Bleeding
2) Unintentional weight loss
3) Fever

Question 7

What are some associated symptoms of abdominal pain?

Answer 7

GI symptoms:
- vomiting, diarrhoea, constipation

Hepatobiliary:
- jaundice

GU symptoms:
- dys/pyuria
- haematuria, per-vaginal bleeding
- amenorrhea

Extra-abdominal
- chest pain, SOB, cough
- back pain

Question 8

How do biliary colic and ureteric colic pain differ in their duration?

Answer 8

Both intermittent
Ureteric (w relief)
Biliary (w/o relief: pain from bad to worse, bad to worse)

Question 9

What are 4 exacerbating factors used to diagnose abdominal pain?

Answer 9

1) Hungry: duodenal ulcer
2) After meals: gastric ulcer
3) Oily food: Biliary colic
4) After alcohol: Alcohol-related GI: alcoholic gastritis, pancreatitis

Question 10

What is an example of an alleviating factor used to diagnose abdominal pain?

Answer 10

Better after defecation: Constipation colic

Question 11

What are 4 examples of emergent conditions associated with very severe abdominal pain?

Answer 11

1) Ischaemic bowel
2) Perforated viscus
3) Ruptured aortic aneurysm
4) MI

Question 12

Insult to the liver parenchyma (does/does not) typically lead to pain.

Answer 12

Does not
- at most dull, non-specific discomfort

Question 13

How does a hepatic cyst cause pain?

Answer 13

Cyst stretches liver capsule → stimulate visceral pain fibers → RUQ pain

Question 14

What is the (i) characteristic, (ii) exacerbating and (iii) alleviating factors of cholelithiasis?

Answer 14

Biliary colic: smooth muscle contraction against obstructed duct

i) Intermittent colic pain
ii) fatty meal
iii) stone dislodge

Question 15

How does cholecystitis pain present?

Answer 15

Right hypochondriac pain referred to right shoulder
(somato-somatic referred pain via phrenic nerve)

Question 16

How does pancreatitis pain present?

Answer 16

Central abdomen/epigastric
- radiate to back

Question 17

What is the (i) characteristic, (ii) exacerbating factors of peptic ulcer disease?

Answer 17

i) pain variable and depends on location (may radiate to back)

ii) duodenal worse when hungry; gastric worse after food

Question 18

What are 2 emergent conditions for stomach and small intestine and their associations?

Answer 18

Perforation:
- acute, sharp abdo pain

Intestinal obstruction
- abdo pain, abdo distension, complete constipation, vomitting

Question 19

What are 2 association of colitis with abdominal pain?

Answer 19

1) Diarrhea
2) Per-rectal bleeding

Question 20

What is acute appendicitis associated with?

Answer 20

Fever

Question 21

What is diverticulitis associated with?

Answer 21

Fever

Question 22

What is constipation colic associated with?

Answer 22

1) Hx of infrequent/hard stool
2) Pre-disposed risk factors for constipation: immobility, opiate use
3) Peristalsis → colicky pain

Question 23

What are 3 red flags for abdominal pain arising from the large intestine?

Answer 23

1) Tenesmus
2) Decreased stool calibre
3) Unexplained change in bowel habits

Question 24

How does pyelonephritis pain present?

Answer 24

Back pain over affected kidney
- pain on light pressure of lower back on affected side (renal punch)

Question 25

How does renal colic pain present?

Answer 25

Severe cramping flank pain radiating towards groin (“loin to groin”)

Question 26

What are 2 bladder causes of abdominal pain?

Answer 26

1) Cystitis
- suprapubic discomfort
- associated w fever, LUTI symptoms

2) Acute urinary retention
- anuria
- preceding symptoms of UTI/LUT obstructive symptoms

Question 27

What are 2 signs associated with abdominal emergencies?

Answer 27

1) Guarding
2) Rebound tenderness

Question 28

What are 3 signs associated with abdominal emergencies?

Answer 28

1) Abdominal distension, abdominal pain
2) Severe constipation/obstipation
3) Vomiting

Question 29

What are 4 causes of abdominal pain beyond the abdominal viscera?

Answer 29

1) AMI
2) HZV
3) Psoas abscess
4) Ruptured abdominal aortic aneurysm