Chapter 20 - Abdominal Pain

Question 1

Name the most common causes of abdominal pain on admission.

Answer 1

Acute appendicits, nonspecific abdominal pain, pain of urologic origin, and intestinal obstruction.

Question 2

The pain severity does not necessarily correlate with the severity of the underlying condition.
True or False?

Answer 2

True.

Question 3

Compare the different pain severities regarding the exposure of peritoneal surfaces to different materials.

Answer 3

“The intensity of the pain is dependent on the type and amount of material to which the peritoneal surfaces are exposed in a given time period. For example, the sudden release into the peritoneal cavity of a small quantity of sterile acid gastric juice causes much more pain than the same amount of grossly contaminated neutral feces. Enzymatically active pancreatic juice incites more pain and inflammation than does the same amount of steril bile containing no potent enzymes. Blood is normally only a mild irritant and the response to urine can be so bland, so exposure of blood and urine to the peritoneal cavity may go unnoticed unless it is sudden and massive.”

Question 4

What are the features of peritoneal pain due to bacterial contamination?

Answer 4

“Bacterial contamination, such as may occur with pelvic inflammatory disease or perforated distal itnestine, causes low-intensity pain until multiplication causes a significant amount of inflammatory mediators to be released.”

Question 5

Patients with perforated upper gastrointestinal ulcers may present entirely differently depending on how quickly gastric juice enter the peritoneal cavity. Thus, the rate at which any inflammatory material irritates the peritoneum is important.
True or False?

Answer 5

True.

Question 6

How do you explain pathophysiologically the process of tonic reflex spasm? Which factors might lead to different degrees of muscle spasm?

Answer 6

“Another characteristic feature of peritoneal irritation is tonic reflex spasm of the abdominal musculature, localized to the involved body segment. Its intensity depends on the integrity of the nervous system, the location of the inflammatory process, and the rate at which it develops. Spasm over a perforated retrocecal appendix or perforation in to the lesser peritoneal sa may be minimal or absent because of the protective effect of overlying viscera.”

Question 7

Which type of patients might have a catastrophic abdominal emerngy with minimal or no detectable pain or muscle spasm?

Answer 7

Obtunded, seriously ill, debilitated, immunosuppressed, or psychotic patients.”

Question 8

A slowly developing process also often greatly attenuates the degree of muscle spasm.
True or False?

Answer 8

True.

Question 9

A diagnosis of “acute or surgical abdomen” is not acceptable because of its often misleading and erroneous connotations. Most patients who present with acute abdominal pain will have self-limited disease processes.
True or False?

Answer 9

True.

Question 10

Which patterns of abdominal pain might be associated with intestinal obstruction?

Answer 10

“Intraluminal obstruction classically elicits intermittent or colicky abdominal pain that is not as well localized as the pain or parietal peritoneal irritation. However, the absence of cramping discomfort should not be misleading because distention of a hollow viscus may also produce steady pain with only rare paroxysms.”

Question 11

Compare the pattern of pain due to small-bowel versus colonic obstruction.

Answer 11

“Small-bowel obstruction often presents as poorly localized, intermittent periumbilical or supraumbilical pain. As the intestine progressively dilates and loses muscular tone, the colicky nature of the pain may spread to the lower lumbar region if there is traction on the root of the mesentery. The colicky pain of colonic obstruction is of lesser intensity, is commonly located in the infraumbilical area, and may often radiate to the lumbar region.”

Question 12

Sudden distention of the biliary tree produces a steady rather than colicky type of pain; hence, the term biliary colic is misleading.
True or False?

Answer 12

True.

Question 13

Compare the pattern of pain due to distention of the gallblader to that of common bile duct and pancreatic ducts.

Answer 13

“Acute distention of the gallbladder usually causes pain in the right upper quadrant with radiation to the right posterior region of the thorax or to the tip of the right scapula, but it is also not uncommonly found near the midline. Distention of the common bile duct often causes epigastric pain that may radiate to the upper lumbar region. Considerable variation is common, howver, so that differentiation between these may be impossible. The typical subscapular pain or lumbar radiation is frequently absent. Gradual dilatation of the biliary tree, as can occur with carcinoma of the head of the pancreas, may cause no pain or only a mild aching sensation in the epigastrium or right upper quadrant. The pain of distention of the pancreatic ducts is similar to that described for distention of the common bile duct but, in addition, is very frequently accentuated by recumbency and relieved by the upright position.”

Question 14

Summarize the abdominal findings in those with vascular disturbances such as embolism, thrombosis or abdominal aortic aneurysm.

Answer 14

“A frequent misconception is that pain due to intraabdominal vascular disturbances is sudden and catastrophic in nature. Certain disease processes, such as embolism or thrombosis of the superior mesenteric artery or impending rupture of an abdominal aortic aneurysm, can certainly be associated with diffuse, severe pain. Yet, just as frequently, the patient with occlusion of the superior mesenteric artery only has mild continuous or cramping diffuse pain for 2 or 3 days before vascular collapse or findings of peritoneal inflammation appear. The early, seemingly insignificant discomfort is caused by hyperperistalsis rather than peritoneal inflammation. Indeed, absence of tenderness and rigidity in the presence of continuous, diffuse pain (e.g., “pain out of proportion to physical findings”) in a patient likely to have vascular disease is quite characteristic of occlusion of the superior mesenteric artery. Abdominal pain with radiation to the sacral region, flank, or genitalia should always signal the possible presence of a rupturing abdominal aortic aneurysm. This pain may persist over a period of several days before rupture and collapse occur.”

Question 15

What is the most frequent cause of an abdominal hematoma?

Answer 15

Anticoagulant therapy.

Question 16

Is there any correlation between intrathoracic diseases and abdominal pain?

Answer 16

Yes.
“ amost important, yet often forgotten, dictum is that the possibility of intrathoracic disease must be considered in every patient with abdominal pain, especially if the pain is in the upper abdomen.”
“Systematic questioning and examination directed toward decteing myocardial or pulmonary infarction, pneumonia, pericarditis, or esophageal disease (the intrathoracic diseaes that most often masquerade as abdominal emergencies) will often provide sufficient clues to establish the proper diagnosis. Diaphragmatic pleuritis resulting from pneumonia or pulmonary infarction may cause pain in the right upper quadrant and pain in the supraclavicular area, the latter radiation to be distinguished from the referred subscapular pain caused by acute distention of the extrahepatic biliary tree.”

Question 17

How does one differentiate the referred abdominal pain due to intrathoracic disease from abdominal pain due to an intraabdominal process?

Answer 17

“Referred pain of thoracic origin is often acoompanied by splinting of the involved hemithorax with respiratory lag and decrease in excursion more marked than that seen in the presence of intraabdominal disease. In addition, apparent abdominal muscle spasm caused by referred pain will diminish during the inspiratory phase of respiration, whereas it persists throughout both respiratory phases if it is of abdominal origin. Palpation over the area of referred pain in the abdomen also does not usually accentuate the pain and, in many instances, actually seems to relieve it.”

Question 18

Name two metabolic causes of abdominal pain which have a hereditable association.

Answer 18

C1 esterase deficiency and familial Mediterranean fever.

Question 19

Diabetic acidosis might lead to abdominal pain as well as abdominal organic disease might lead to diabetic acidosis.
True or False?

Answer 19

True.
“The pain of uremia or diabetes is nonspecific, and the pain and tenderness frequently shift in location and intensity. Diabetic acidosis may be precipitated by acute appendicitis or intestinal obstruction, so if prompt resolution of the abdominal pain does not result from correction of the metabolic abnormalities, an underlying organic problem should be suspected.”

Question 20

Is there any feature of abdominal pain due to black widow spider bites that might help in the differential diagnosis?

Answer 20

Yes. The abdomen as well as the back are both involved, both with intense pain and rigidity. The back is infrequently involved in an intraabdominal process.

Question 21

Summarize the patients who might have abdominal pain, are imunocompromised and which differential diagnosis should one consider in these group.

Answer 21

“This includes those who have undergone organ transplantation; who are receiving immunosppressive treatments for autoimmune diseases, chemotherapy, or glucocorticoids; who have AIDS; and who are very old. In these circumstances, normal physiologic responses may be absent or masked. In addition, unusual infections may cause abdominal pain where the etiologic agents include cytomegalovirus, mycobacteria, protozoa, and fungi. These pathogens may affect all gastrointestinal organs, including the gallbladder, liver, and pancreas, as well as the gastrointestinal tract, causing occult or overtly symptomatic perforation of the latter. Splenic abcesses due to Candida or Salmonella infection should also be considered, especially when evaluating patients with left upper quadrant or left flank pain. Acalculous cholecystitis is a relative common complication in patients with AIDS, where it is often associated with crypstosporidiosis or cytomegalovirus infection.”

“Neutropenic enterocolitis is often identified as a cause of abdominal pain and fever in some patients with bone marrow suppression due to chemotherapy. Acute graft-verus-host disease should be considered.”

Question 22

Which diseases might be associated with spinal nerve or root pain irradiating to the abdomen? What are its features?

Answer 22

“Pain arising from spinal nerves or roots comes and goes suddenly and is of a lancinating type. It may be caused by herpes zoster, impingement by arthritis, tumors, a herniated nucleus pulposus, diabetes, or syphilis. It is not associated with food intake, abdominal distention, or changes in respiration. Severe muscle spasm, as in the gastric crises of tabes dorsalis, is common but is either relieved or not accentuated by abdominal palpation. The pain is made worse by movement of the spine and is usually confined to a few dermatomes. Hyperesthesia is very common.”

Question 23

Irritable bowel syndrome is rarely associated with nausea and vomiting.
True or False?

Answer 23

True.

Question 24

Patients with exsanguinating intraabdominal hemorrhage must be rushed to the operating room immediately. There are no contraindications to operation when massive intraabdominal hemorrhage is present. Indeed, many of these patients die while awaiting unnecessary examinations such as electrocardiograms or computed tomography (CT) scans.
True or False?

Answer 24

True.

Question 25

What is the most important characteristic that one should ascertain in a history of abdominal pain?

Answer 25

“the chronological sequence of events in the patient’s history is often more important than the pain’s location.”

Question 26

Once a patient with peritoneal inflammation has been examined brusquely, accurate assessment by the next examiner becomes almost impossible.
True or False?

Answer 26

True.

Question 27

A pelvic and rectal examinations are mandatory in every patient with abdominal pain.
True or False?

Answer 27

True.

Question 28

Abdominal catastrophes always occur with alterations on abdomen auscultation.
True or False?

Answer 28

False.
“Catastrophes such as a strangulating small intestinal obstruction or perforated appendicitis may occur int he presence of normal peristaltic sounds.”

Question 29

What is the meaning of borborygmi that disappear with the progression of an abdominal obstruction?

Answer 29

“when the proximal part of the intestine above obstruction becomes markedly distended and edematous, peristaltic sounds may lose te characteristics of borborygmi and become weak or absent, even when peritonitis is not present.”

Question 30

Give an example of truly silent abdomen.

Answer 30

Sudden chemical peritonitis.

Question 31

A white blood cell count >20 000/μL on a patient with abdominal pain is very suggestive of perforation of a viscus.
True or False?

Answer 31

False.
“A white blood cell count >20 000/μL may be observed with perforation of a viscus, but pancreatitis, acute cholecystitis, pelvic inflammatory disease, and intestinal infarction may also be associated with marked leukocytosis. A normal white blood cell count is not rare in cases of perforation of abdominal viscera.”

Question 32

Which measurement of the blood might be more helpful in acute abdominal processes?

Answer 32

Anemia.

Question 33

Elevated amylase levels reveal a pancreatic cause of abdominal pain, excluding the need for operation.
True or False?

Answer 33

False.
“Serum amylase levels may be increased by many diseases other than pancreatitis, e.g., perforated ulcer, strangulating intestinal obstruction, and acute cholecystitis; thus, elevations of serum amylase do not rule out the need for an operation.”

Question 34

Which contrast exam should one use or avoid to diagnose colonic obstruction?

Answer 34

“If there is any question of obstruction of the colon, oral administration of barium sulfate should be avoided. On the other hand, in cases of suspected colonic obstruction (without perforation), a contrast enema may be diagnostic.”

Question 35

Laparoscopy might be diagnostic in pelvic conditions.

True or False?

Answer 35

True.
“Laparoscopy is especially helpful in diagnosing pelvic conditions, such as ovarian cysts, tubal pregnancies, salpingitis, and acute appendicitis.”