CM- Evaluation of Abdominal Pain Flashcards
What is acute abdomen?
What is the typical pathological process?
What are the 2 ways to manage it?
Acute abdomen is sudden onset of abdominal pain that develops within 24 hours or less with an unclear etiology.
The pathological process is inflammation of the peritoneum that results in diffuse abdominal tenderness and distension.
- Surgical abdomen- requires immediate surgical intervention (ex. perforated viscus)
- Conservative management (ex. pancreatitis)
What is the difference between visceral and parietal pain?
Visceral pain - nociceptive pain in the viscera that is dull, poorly localized and often presents as referred
Parietal pain- nociceptive pain from the activation of receptors in the parietal peritoneum. Sharp, localized.
What is Hirschprung’s disease? What is the cause?
It is megacolon due to the failure of migration of intestinal myenteric ganglion cells due to a deficiency in endothelin OR endothelin receptor
What are the 7 main intra-abdominal problems that can cause pain?
- appendicitis
- cholecystitis and biliary colic
- pancreatitis
- perforated viscus
- ischemic bowel
- bowel obstruction
- ruptured aortic aneurysm
What are 3 common non-abdominal pathologies that can present with abdominal complaints?
- pelvic inflammatory disease
- heart disease
- ectopic pregnancy
What constitutes the foregut, midgut and hindgut?
What is the blood supply to each?
Foregut: GI structures ending at the 2nd part of the duodenum - supplied by the Celiac Artery
Midgut: Ampulla of Vater to the proximal 2/3 of the colon– SMA
Hindgut: distal 1/3 of colon and rectum– IMA
Because nerves follow arterial supply, damage to the small intestine will present with ____________ pain whereas colon damage will present with _______________pain.
small intestine –> epigastric
colon–> hypogastric
Why does irritation of organs near the diaphragm lead to pain on the top of the shoulder?
The diaphragm develops in the region of the 4th cervical segment therefore the diaphragm and the shoulder share the same cervical roots (3,4,5)
What abdominal irritations give rise to referred pain in the shoulder?
Anything that occurs near the diaphragm so:
- perforated ulcer
- hepatic abscess
- pancreatitis
- ruptured spleen
- perforated appendicitis WITH peritonitis
Where does biliary pain radiate?
Right scapula
Where does renal pain radiate?
flank and buttock pain
Where does uterine pain radiate?
low back
What three structures were located in the peritoneal cavity but migrated to the retroperitoneal space in embryogenesis?
- head, neck and body of pancreas (NOT tail)
- duodenum (NOT the proximal first segment)
- ascending and descending colon
What 7 structures are exclusively retroperitoneal?
- kidneys
- ureters
- bladder
- aorta
- IVC
- adrenal glands
- rectum
A patient presents with sharp, excruciating pain at a very specific location. What is the likely cause?
Perforation - sudden, sharp, localized
ex. perforated bowel
A patient presents with intermittent dull pain. What is the likely cause?
Obstruction - colicy, dull
ex. biliary colic
A patient presents with constant poorly localized pain. What is the likely cause?
Infection
ex. the patient may give a history consistent with biliary colic but then describe constant RUQ pain. This is more consistent with cholecystitis.
A patient describes her pain as the worst pain she’s ever had in her life, but the physical exam is not impressive. What is the likely cause?
Ischemia = pain out of proportion to the physical exam
Visceral pain is non-specific and poorly localized. In general where does it appear?
Midline at the same dermatome level as the specific organ’s innervation
What organs are associated with RUQ pain? (8)
- liver
- gallbladder
- pancreas
- bililary
- duodenal
- renal
- right phrenic
- right lower lung
What organs are associated with RLQ pain? (6)
- appendix
- distal small bowel
- ascending colon
- right ureteral
- right ovarian
- right fallopian tubes
What organs are associated with LUQ pain? (6)
- spleen
- stomach
- pancreatic
- renal
- left phrenic
- left lower lung