B5.015 Abdominal Pain The Big Case

Question 1

types of pain

Answer 1

visceral
somatic-parietal
referred

Question 2

transmission of visceral pain

Answer 2

transmitted by C fibers that are found in muscle, peritoneum, mesentery, periosteum and viscera

• most painful stimuli from abdominal viscera are conveyed by these types of fiber
• highly sensitive to distention, inflammation, and ischemia

Question 3

characteristics of visceral pain

Answer 3

dull, cramping, burning, gnawing, squeezing, deep, sickening
poorly localized and more gradual in onset
often can be referred to a more distant superficial structure

Question 4

why is visceral pain usually perceived in the midline

Answer 4

abdominal organs transmit sensory afferents to both sides of the spinal cord

Question 5

3 regions of abdominal visceral pain

Answer 5

foregut = epigastric
midgut = periumbilical
hindgut = suprapubic

Question 6

secondary autonomic effects of visceral pain

Answer 6

sweating, restlessness, nausea, vomiting, perspiration, and pallor

Question 7

why may visceral pain have secondary autonomic effects?

Answer 7

pathways of visceral afferent fibers that mediate pain travel with autonomic nerves to communicate with the CNS
vagal and pelvic parasympathetic nerves

Question 8

somatic parietal pain transmission

Answer 8

mediated by alpha gamma fibers that are distributed principally to the skin muscle

Question 9

characteristics of somatic-parietal pain

Answer 9

sharp, stabbing, well localized

usually aggravated by movement or vibration

Question 10

why is there lateralization of somatic parietal pain

Answer 10

only one side of the nervous system innervates the given part of the parietal peritoneum

Question 11

referred pain

Answer 11

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 the same spinal segment

Question 12

example of referred pain

Answer 12

gallbladder inflammation can irritate the diaphragm which is innervated by C3,4,5
dermatomes of these spinal cord segments supply the shoulder

Question 13

Kehr’s sign

Answer 13

diaphragmatic irritation from a subphrenic hematoma or splenic rupture being perceives as shoulder pain

Question 14

chronological patterns of pain

Answer 14

1. subside spontaneously with time
2. colicky- pain progresses and remits
3. progressive
4. catastrophic onset

Question 15

appendicitis pain

Answer 15

gradual
periumbilical early, RLQ late
diffuse early, localized late
ache
no radiation

Question 16

cholecystitis pain

Answer 16

acute 
RUQ
localized
constricting
radiation to scapula

Question 17

pancreatitis pain

Answer 17

acute
epigastrium, back
localized
midback radiation

Question 18

diverticulitis pain

Answer 18

gradual
LLQ
localized
ache
no radiation

Question 19

perforated peptic ulcer pain

Answer 19

sudden
epigastric
localized early, diffuse later
burning
no radiation

Question 20

small bowel obstruction pain

Answer 20

gradual
periumbilical
diffuse
cramping
no radiation

Question 21

mesenteric ischemic pain

Answer 21

sudden
periumbilical
diffuse
agonizing
no radiation

Question 22

ruptured AAA

Answer 22

sudden
abdomen, back, flank
diffuse
tearing
no radiation

Question 23

gastroenteritis pain

Answer 23

gradual
periumbilical
diffuse
spasmodic
no radiation

Question 24

pelvic inflammatory disease pain

Answer 24

gradual
either LQ, pelvis
localized
ache
radiation to upper thigh

Question 25

ruptured ectopic pregnancy pain

Answer 25

``` sudden either LQ, pelvis localized sharp no radiation ```

Question 26

examples of aggravating and alleviating factors

Answer 26

peritonitis patients lie motionless renal colic may writhe in pain fatty foods cause biliary pain duodenal ulcer relieved by food gastric ulcer or mesenteric ischemia worsened by food pancreatitis relieved by sitting up or leaning forward

Question 27

symptoms that may be associated with abdominal pain

Answer 27

constitutional symptoms (fevers, chills, night sweats, weight loss, myalgias) digestive function (nausea, vomiting, diarrhea) jaundice change in menses dysuria cardiopulmonary symptoms

Question 28

why is history of surgeries important in cases of abdominal pain

Answer 28

scar tissue increases risk of obstruction complication for surgery abscess

Question 29

cardiovascular disease history

Answer 29

raise suspicion for mesenteric ischemia (atherosclerosis)

Question 30

NSAIDs

Answer 30

risk for ischemia and peptic ulcer disease

Question 31

narcotics

Answer 31

constipation

Question 32

chronic steroids

Answer 32

adrenal insufficiency immunosuppression atypical abdominal pain presentations

Question 33

ethanol

Answer 33

liver disease or pancreatitis

Question 34

family history

Answer 34

IBD | cancer

Question 35

travel history

Answer 35

gastroenteritis

Question 36

glistening, taut appearance

Answer 36

ascites

Question 37

bluish periumbilical discoloration

Answer 37

intra-abdominal bleeding

Question 38

straie

Answer 38

pregnancy or weight gain recent origin are pink, but turn silvery white over time cushings are purplish

Question 39

writhing in pain and changing positions frequently

Answer 39

visceral pain (obstruction of gastroenteritis)

Question 40

Cullen's sign / Grey Turner's sign

Answer 40

ecchymosis bleeding from retroperitoneal areas medical emergency

Question 41

increased bowel sounds

Answer 41

hunger gastroenteritis bowel obstruction

Question 42

high pitched tinkling

Answer 42

intestinal fluid and air under pressure, suggests early bowel obstruction

Question 43

decreased bowel sounds

Answer 43

peritonitis | paralytic ileus

Question 44

friction rub

Answer 44

high pitched, associated with inspiration | inflammation of peritoneal surface from tumor, infection or infarct

Question 45

bruits

Answer 45

abdominal aneurysm

Question 46

predominant percussion sound in abdomen

Answer 46

tympany- air present in stomach and intestines

Question 47

Carnett sign

Answer 47

MSK pain localized lift legs or do crunches to contract abs makes pain worse

Question 48

what's included in a CMP

Answer 48

``` electrolytes BUN creatinine glucose aminotransferases alk phos bilirubin ```

Question 49

aortic aneurysm on imaging

Answer 49

dark central vessel | secondary lumen = aneurysm

Question 50

hepatobiliary scan

Answer 50

uses a tracer that is injected into your vein that helps capture imaged of the liver, gallbladder, bile ducts and small intestine

Question 51

acute diverticulitis

Answer 51

inflammation/ infection of diverticula

Question 52

acute diverticulitis pain

Answer 52

abdominal pain mainly in the LLQ due to involvement of the sigmoid

Question 53

site of acute diverticulitis

Answer 53

most commonly occur in the mesenteric side of 2 bands of tenia coli due to perforating nutrient arteries

Question 54

acute diverticulitis presentation

Answer 54

affect middle age men pain constant and usually present for days prior to presentation 20% can palpate tender mass due pericolonic inflammation or peridiverticular abscess change in bowel habits leukocytosis (maybe) serum amylase and lipase may be elevated if there is peritonitis or perforation

Question 55

acute diverticulitis ultrasound findings

Answer 55

peridiverticular inflammation, abscess with or without gas bubbles, bowel wall thickening, diverticula

Question 56

acute diverticulitis CT findings

Answer 56

localized bowel wall thickening increase in soft tissue density pericolonic fat stranding and the presence of diverticula

Question 57

acute diverticulitis MRI findings

Answer 57

colonic wall thickening, diverticula, pericolonic exudates, edema, narrowing of the colon, ascites, abcess

Question 58

what % of diverticulosis is symptomatic

Answer 58

5-15% bleeds | 4% diverticulitis

Question 59

nutritional management of diverticulitis

Answer 59

high fiber | low fat

Question 60

medical management of diverticulitis

Answer 60

antibiotics (Cipro) laxatives stool softeners hospitalization for refractory disease or immunocompromised with IV antibiotics colonoscopy is contraindicated in acute setting