B5.015 - Abdominal Pain Big Case Flashcards
what percentage of ED visits are due to abdominal pain
5-10%
how many abdominal pain patients have non specific findings and how many have a more serious disease
half and half
what are the 3 types of pain
visceral somatic parietal referred
how is visceral pain transmitted
transmitted by C fibers that are found in muscle, peritoneum, mesentery, periosteum and viscera
most painful stimuli from abdominal viscera are conveyed by which type of fiber
C fibers visceral pain
C fibers are highly sensitive to what
distension, inflammation, ischemia
describe visceral pain
dull cramping burning gnawing squeezing deep sickening poorly localized often referred to more distant superficial structure
why is visceral pain usually perceived to be midline
because abdominal organs transmit sensory afferents to both sides of the spinal cord
why is visceral pain not well localized
because the number of nerve endings and viscera is low
secondary autonomic effects of visceral pain
sweating restlessness nausea vomiting perspiration pallor pt may move to try and relieve pain
typical localization of visceral pain
epigastrium midabdomin hypogastrium
how does visceral pain interact with the CNS
visceral afferent fibers including vagal and pelvic parasympathetic nerves travel with autonomic nerves (SYM and PARA stimulated)
how is somatic parietal pain mediated
by alpha gamma fibers that are distributed principally to the skin and muscle
describe somatic parietal pain
sharp, stabbing, well localized usually aggravated by movement or vibration
describe lateralization of somatic parietal pain
only possible bc only one side of the nervous system innervates the given part of the parietal peritoneum
classic presentation of appendicitis
involves both visceral and parietal pain Pain of early presentation is often paraumbilical (visceral) but often localizes to the right lower quadrant when inflammation extends to peritoneum (parietal)
what is McBurneys point
localized somatic parietal pain seen in appendicitis produced by inflammatory involvement of the parietal peritoneum
compare and contrast visceral and somatic pain
describe referred pain
felt in areas removed from the diseased organ and results when visceral afferent neurons and somatic afferent neurons from a different anatomic region converge on second order neurons in the spinal cord at same spinal segement
examples of referred pain
gallbladder inflammation can irritate the diaphragm which is innervated by C3,4,5
dermatomes of these spinal cord segments supply the shoulder, hence you can get shoulder tip pain.
what is Kehrs sign
diaphragmatic irritation froma subphrenic hematoma or splenic rupture being perceived as shoulder pain
55 yo male presents to ER with 3 days of slowly progressing LLQ pain, constant, dull, has been having some increased constipation of the last few weeks and low grade fever. Some nausea, no vomiting. No blood in stool. What type of pain?
visceral
most important compontent of evaluation of abdominal pain
history taking
what components of the Hx are important for creating a differential
chronology
location
intensity, character
aggravating/relieving factors
associated symptoms
PMH
what can cause pain that subsides spontaneously with time
gastroenteritis
what is colicky pain and what can cause it
progresses and remits
intestinal, biliary, or renal pain
Gallstones, kidney stones
what can cause progressive pain
appendicitis, diverticulitis, pancreatitis
what can cause catastrophic onset of pain
ruptures of AAA, perforated viscus, mesenteric infarction
what pain chronolgies are associated with each line
a - subsides spontaneously with time, gastroenteritis
b - colicky, gall stones, kidney stones
c - progressive - appendicitis, pancreatitis
d - catastrophic, AAA rupture, perforated viscus, mesenteric infarction
noxious stimuli may result in what
visceral, somatic and referred pain
onset, location, character, descriptor, radiation and intenisty of appendicitis
gradual
paraumbilica –> RLQ
diffuse ealry, then localized
ache
no radiation
++
onset, location, character, descriptor, radiation and intenisty of cholecystitis
acute
RUQ
localized
constricting
scapula
++
pancreatitis
acute
epigastrum, back
localized
boring
midback
++
diverticulitis
gradual
LLQ
localized
ache
none
+++
onset, location, character, descriptor, radiation and intenisty of perforated peptic ulcer
sudden
epigastrum
localized –> diffuse
burning
none
+++
onset, location, character, descriptor, radiation and intenisty of small bowel obstruction
gradual
periumbilical
diffuse
cramping
none
++
onset, location, character, descriptor, radiation and intenisty of mesenteric ischemia
sudden
periumbilical
diffuse
agonizing
none
+++
onset, location, character, descriptor, radiation and intenisty of ruptured AAA
sudden
abdomen, back, flank
diffuse
tearing
none
+++
onset, location, character, descriptor, radiation and intenisty of gastroenteritis
gradual
periumbilical
diffuse
spasmodic
none
+, ++
onset, location, character, descriptor, radiation and intenisty of PID
gradual
either LQ, pelvis
localized
ache
upper thigh
++
describe aggravative and alleviated factors for peritonitis
they lie motionless
describe aggravative and alleviated factors for renal colic pain
may writhe in pain
describe aggravative and alleviated factors for biliary pain
fatty foods make it worse
describe aggravative and alleviated factors for duodenal ucler
relieved by foos
describe aggravative and alleviated factors for gastric ulcer or mesenteric ischemia
worsened by food
describe aggravative and alleviated factors for pancreatitis
relieved by sitting up or leaning forward
CVD raises suspicion for what
mesenteric ischemia
meds that can cause upper GI pain
NSAIDS - ischemia, PUD
narcotics - constipation
chronic steroid use - adrenal isufficiency, immunosuppressed and atypical presentation
hydrochlorothiazide is associated with what
pacreatitis
aspirin is associated with what
peptic ulcers
straie from pregnancy or weight gain
recent origin are pink or blue but turn silvery white over time
striae of cushings remain purplish
what is cullens sign
periumbilical ecchymosis results from tracking of blood from retroperitoneum to umbilicus along the gastrohepatic and falciform ligament and subsequently to subcutaneous tissues thru the connective tissue covering the round ligament
what is grey turners sign
produced by hemorrhagic fluid spreading from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and therafter to the subq tissues by means of a defect in the fascia of the flank
left - cullens sign
right - grey turners sign
what are borborygmi
stomach growling
what does high pitched tinkling suggest
intestinal fluid and air under pressure, suggests early bowel obstruction
what does a friction rub suggest
high pitched associated with inspirations
indicates inflammation of peritoneal surface from tumor, infection or infarct
how many minutes does it take to establish absent bowel sounds
5 minutes of continuous listening
what does shifting dullness of percussion suggest
ascites, hepatomegaly
where do you start palpation
where patient is experiencing least pain
assess for numbness that may be a nerve problem
assess for MSK pain
what is carnetts sign
ask pt to do a crunch/lift legs to activate abdominal muscles, if pain worsens thing MSK problem
what does a rectal exam check for
fecal imaction
what lab data do you want in abdominal pain cases
CBC with diff
CMP
UA
lipase/amylase
Urine pregancy test
what imaging studies do you want to get
US - can be used quickly and reliably to detect fluid in abdomen
eval quickly for AAA
what is a CT
combination of many x rays take from multiple angles to create a cross sectional image
what is MRI
use of magnetic fields to create virtual slices
different from CT bc doesnt use x rays or ionizing radiation
what is HIDA
hepatobiliary scan
uses tracer that is injected inot your vein that helps cature images of teh liver, gallbladder, bile ducts and small intestine
what is endoscopy
tube with camera that allows direct visualization of the GI tract
sigmoid diverticulitis with abcsess formation
sigmoid colon displaying mural thickening, diverticulosis and pericolic fat stranding (arrow)
circle - abscess formation bc low attenuation
what is the difference between diverticulosis and diverticulitis
diverticulosis is the development of diverticula (sac like protrusions of the colonic wall, form where the wall is weakest, typically where blood vessesl enter the colon)
diverticulitis - inflammation of the diverticulum, complications can lead to abceses, perforation, fistula, bowel obstruction
symptoms of diverticulitis acute
abdominal pain LLQ due to involvement of sigmoid
most commonly in mesenteric side of two bands of the tinea coli
pain constant and usually present for days prior to presentation
change in bowel habits
leukocytosis
serum amylase, lipase mildly elevated
imaging for diverticulitis
US shows peridiverticular inflammation, abscesses with or without gas bubbles, but not super sensitive/specific
CT is the go to, increase in soft tissue density, pericolonic fat stranding the presence of diverticula, super specific and sensitive
MRI can but ites expensive, avoids radiation not everyone has one
disease course of diverticulosis
70-80% asymptomatic
5-15% diverticular bleeding
4% diverticulitis
of those with diverticulitis 85% are simple
15% are complicated by abscesses, obstruction, perforation, fistula
management of diverticulitis
nutrition - higher fiber, low fat
medical - antibiotis (cipro) and flagyl vs augmentis, laxatives, stool softeners
complications - surgical consult, perforation, peritonitis, obstruction, hermorrhge
appendicitis
where is McBurneys point
1/3 of the distance from ASIS towards umbilicus
acute biliary disease, choledicolithiasis with pancreatitis
small bowel obstruction
upright abdominal x ray with dilated small bowel loops and air fluid levels in stair step pattern, indicative of small bowel obstruction
acute mesenteric ischemia
major causes of mesenteric ischemia
CVD
blood clots
drugs
hypercholesterolemia
peptic ulcer disease
Increased risk of H. Pylori infection leading to peptic ulcer desease and hes also using NSAIDs
