Assessment of Abdominal Pain Flashcards
Distinguish between the characteristics of pain caused by obstruction, inflammation and perforation in terms of their localisation, quality, severity and chronology
List 5 important associated Sx to ask about in the setting of abdominal pain
N+V
Passing flatus or bowel motion
Urinary changes
Fever
Sweats
How is abdominal pain described in terms of site? Outline the associated structures for each site
Where is visceral pain felt vs parietal pain?
Visceral: usually felt at site of embryological origin (often central), dependent on innervation of viscus and corresponding dermatome (e.g. diaphragm and shoulder tip share C3/C4 innervation)
Parietal: localised to anatomical site of viscus (where it touches the parietal peritoneum)
Describe the classic description of pain in acute appendicitis
Initial pain is visceral and referred; largely perceived around the umbilicus
When inflammation becomes transmural and touches the peritoneum in the RIF, the pain “moves” and the patient can put a finger on McBurney’s point in the RIF
Describe the typical character of pain due to obstruction of a hollow viscus
Colicky pain which waxes and wanes, and repeats over time (as opposed to being constant)
Pay attention to site and frequency!
Describe the corresponding sites for visceral pain originating in the foregut, midgut and hindgut
Foregut: epigastrium
Midgut: periumbilical
Hindgut: suprapubic
Describe the different characteristics of pain resulting from obstruction of foregut, midgut and hindgut
Foregut (i.e. pyloric stenosis): immediate vomiting, pain not prominent
Midgut (i.e. SBO): every few minutes to half hourly
Hindgut (i.e. LBO): infrequent exacerbation or vomits
What groups of causes are there for obstruction of a hollow viscus? Provide an example for each
Intraluminal: e.g. stone blocking a narrow tube in renal colic
Intramural: e.g. colon cancer blocking the colon in LBO
Extrinsic: e.g. adhesions causing SBO
Where is pain from the kidneys and ureters referred to?
Flank
What associated Sx are common in the setting of bowel obstruction?
Loss of appetite
Fever
Tachycardia
Passage of flatus but not BM
Abdominal distension
What features may be seen O/E in the setting of bowel obstruction?
Abdominal scars (adhesions may cause obstruction, may indicate existing pathology which could be causative)
Abdominal distension
Hernia (including of scrotum or testes)
Tenderness, guarding and rebound (localised or generalised)
May be absent or high-pitched bowel sounds
Peripheral signs of anaemia or jaundice
What signs are seen in peritonitis?
Generalised pain and tenderness
Guarding and rebound tenderness present
What abnormal observations may indicate severe bowel obstruction? What Ix findings may indicate severity?
Fever
Tachycardia
Hypotension
Decreased UO
Ix: abnormal WCC, free gas under diaphragm on erect CXR
List 4 non-abdominal sources of abdominal pain
List 5 possible DDx for bowel obstruction
Pancreatitis
Ischaemic bowel
Retroperitoneal haematoma
Aneurysm
Pelvic pathology: menstrual pain, Mittelschmerz, ectopic pregnancy
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of biliary colic?
Usual site: RSC (but often epigastric, occasionally LSC)
Radiation: R side of back or interscapular
Quality: varies (“sharp”, “pushing”, but NOT colicky)
Severity: variable, often severe
Chronology: intermittent, fairly sudden onset, lasts at least 15 mins and up to several hours
Aggravating: N/A
Relieving: antispasmodics
Other Sx: nausea
Associations: often occurs 30 mins to a few hours after a fatty meal
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of acute cholecystitis?
Usual site: RSC
Radiation: N/A
Quality: usually sharp
Severity: severe
Chronology: onset may be sudden or gradual, persistent
Aggravating factors: movement
Relieving factors: analgesia
Other Sx: nausea, sometimes vomiting
Associations: not necessarily related to meal
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of acute pancreatitis?
Usual site: epigastrium
Radiation: through to back
Quality: usually sharp
Severity: usually severe
Chronology: fairly sudden onset, persistent, sometimes recurrent
Aggravating factors: movement
Relieving factors: analgesia
Other Sx: vomiting
Associations: recent heavy alcohol use, known gallstones, ERCP
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of choledocolithiasis?
Usual site: same as biliary colic (RSC, often epigastric, occasionally LSC)
Radiation: same as biliary colic (R side of back or interscapular)
Quality: same biliary colic (various; “sharp”, “pushing”, NOT colicky)
Severity: same as biliary colic (variable, often severe)
Chronology: same as biliary colic (intermittent, fairly sudden onset, lasts at least 15 mins and up to several hours)
Aggravating factors: N/A
Relieving factors: N/A
Other Sx: obstructive jaundice
Associations: N/A
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of peptic ulcer?
Usual site: epigastrium
Radiation: N/A
Quality: aching
Severity: variable
Chronology: intermittent, often at night
Aggravating factors: N/A
Relieving factors: PPIs
Other Sx: haematemesis and malaena (usually absent)
Associations: NSAIDs, smoking
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of perforated peptic ulcer?
Usual site: epigastrium
Radiation: shoulder tip (due to air irritating the diaphragm)
Quality: sharp
Severity: severe
Chronology: sudden onset, persistent
Aggravating factors: movement
Relieving factors: analgesia
Other Sx: N/A
Associations: N/A
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of gastroenteritis?
Usual site: epigastrium/central
Radiation: N/A
Quality: colicky
Severity: variable
Chronology: usually gradual onset
Aggravating factors: N/A
Relieving factors: N/A
Other Sx: vomiting and diarrhoea
Associations: N/A
What is the usual site, radiation, quality, severity, chronology, aggravating and relieving fctors, other symptoms and associations of AMI?
Usual site: epigastrium, retrosternal +/- L arm/jaw
Radiation: N/A
Quality: heavy
Severity: severe
Chronology: usually sudden onset
Aggravating factors: N/A
Relieving factors: analgesia, vasodilators
Other Sx: +/- sweating, nausea, dyspnoea
Associations: activity
Distinguish between biliary colic, acute cholecystitic, acute pancreatitis, choledocolithiasis, peptic ulcer, perforated peptic ulcer, gastroenteritis and AMI in terms of findings on general examination (including general appearance and vital signs)
Distinguish between biliary colic, acute cholecystitic, acute pancreatitis, choledocolithiasis, peptic ulcer, perforated peptic ulcer, gastroenteritis and AMI in terms of findings on abdominal examination (including inspection, palpation, percussion and auscultation)
Describe the features of central abdominal pain (including usual site, radiation, quality, severity, chronology, aggravating and relieving factors, other Sx and associations) associated with SBO, early acute appendicitis, acute intestinal ischaemia, IBD and ruptured AAA
Describe the features of lower abdominal pain (including usual site, radiation, quality, severity, chronology, aggravating and relieving factors, other Sx and associations) associated with acute appendicitis, LBO, diverticulitis, ovarian cyst with complication (bleed/torsion), salpingitis, ruptured ectopic pregnancy and testicular torsion
Distinguish between SBO, early acute appendicitis, acute intestinal ischaemia, IBD and ruptured AAA in terms of findings on general examination (including general appearance and vital signs)
Distinguish between acute appendicitis, LBO, diverticulitis, ovarian cyst with complication (bleed/torsion), salpingitis, ruptured ectopic pregnancy and testicular torsion in terms of findings on general examination (including general appearance and vital signs)
Distinguish between acute appendicitis, LBO, diverticulitis, ovarian cyst with complication (bleed/torsion), salpingitis, ruptured ectopic pregnancy and testicular torsion in terms of findings on abdominal examination (including inspection, palpation, percussion and auscultation)
Distinguish between acute appendicitis, LBO, diverticulitis, ovarian cyst with complication (bleed/torsion), salpingitis, ruptured ectopic pregnancy and testicular torsion in terms of findings on other examination (including PV, PR, sigmoidoscopy and scrotal exam)
Distinguish between SBO, early acute appendicitis, acute intestinal ischaemia, IBD and ruptured AAA in terms of findings on abdominal examination (including inspection, palpation, percussion and auscultation)
24 year old male presents with abdominal pain moving from periumbilical to RIF with localised tenderness and guarding, maximal over McBurney’s point
O/E: temp 37.9
DDx? Ix? Mx?
DDx: acute appendicitis, mesenteric adenitis (rarely), terminal ileitis, Meckel’s diverticulum, caecal diverticulitis
Ix: basic bloods (paying particular attention to WCC), consider imaging (supine and erect AXR)
Mx: admit, nil orally, IV fluids and analgesia, consent for laparoscopy and ?appendicectomy, DVT prophylaxis, Abx for prophylaxis
Further Mx of pt day 1 post-lap appendicectomy
Explain findings
Analgesia (?oral)
Trial of fluids and food
?home today to family (organise timing of FU visit)
Check pathology of appendix
Medical certificate
Give an example of a good screening method when compiling a DDx
Neoplastic
Inflammatory
Infective
Traumatic
Drug-related
Endocrine/metabolic
Toxic
Degenerative
Idiopathic
Congenital
