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DIG > L20 - Abdominal pain > Flashcards

L20 - Abdominal pain Flashcards

1
Q

What are the two innervations of the abdominal pain pathways?

A
  1. Somatic

2. Visceral

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2
Q

Describe the pain pathway from abdominal organs

A

Visceral - sympathetics

  • Pain fibres pass through the sympathetic paravertebral ganglia without synapsing
  • Cell bodies are in the dorsal root ganglia
  • Neuron decussates at this level and then ascends in the lateral spinothalamic tract and on to the thalamus
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3
Q

Describe the pain pathway from pelvic organs

A

Visceral - parasympathetics

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4
Q

Describe the pain pathway from abdominal wall

A

Somatic - via the peripheral cutaneous nerves
Pain neurones are:
1. Adelta - initial sharp pain (myelinated fibres; pain sensation travels fast)
2. C - longer diffuse pain (non-myelinated fibres; pain sensation travels slow)

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5
Q

Describe the location/ character/ stimuli of visceral pain

A 
Location: - Diffuse 
Chara: - Dull/ ache 
- Colicky 
Stimuli: - Distension 
- Traction (mesentery) 
- Ischaemia
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6
Q

Describe the location/ character/ stimuli of somatic pain

A 
Location: - Localised
Chara: - Sharp
- Constant
Stimuli: - Pressure 
- Incision 
- Thermal
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7
Q

Which mechanism of pain is most common?

A

Pain fibres travelling with autonomic nerves more common than somatic nerves

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8
Q

Which mechanism of pain causes diffuse pain?

A

Pain fibres travelling with autonomic nerves

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9
Q

Which mechanisms of pain causes well localised pain?

A

Pain fibres travelling with somatic nerves

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10
Q

Describe the referred pain experienced in myocardial infarctions

A

Pain felt in neck, chest, shoulder and arm

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11
Q

Explain the referred pain experienced in myocardial infarctions

A
  • Pain fibres (general visceral afferents) from the heart travel with the sympathetic supply to the heart and converge upon spinal segments T1-T4
  • T1-4 dermatomes include neck, upper chest and inner arm
  • Thus, the CNS interprets this pain as originating from T1-4 dermatome region
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12
Q

What are some examples of where pain is felt from where the organ originated?

A
  1. Testicles
  2. Liver
  3. Diverticulitis
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13
Q

What is the cause of a poor localisation of pain in visceral fibres?

A

Visceral pain fibres spread over several spinal segments

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14
Q

Where is all gut pain felt on the body? +Examples?

A

ALL GUT pain felt anteriorly

  • All gut structures from lower oesophagus to upper anus
  • Including spleen, liver, gallbladder and pancreas
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15
Q

Where is pain felt for retroperitoneal structures? +Examples?

A

If retroperitoneal, pain felt in the back

  • Pain fibres in retroperitoneum
  • Pancreas
  • 2nd-4th parts of duodenum
  • Lower part of rectum
  • Aorta
  • Kidneys
  • Ureters `
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16
Q

Where is pain felt for pain fibres travelling with parasympathetic structures? +Examples?

A 
Felt in the back 
Thoracic = Oesophagus 
Pelvis = Uterus 
= Ovaries 
= Fallopian tubes
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17
Q

Where is bowel pain felt and why?

A
  • Bowel was a midline structure

- Pain felt anteriorly in the midline at the spinal level the organ developed form

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18
Q

What is the pain like when it is due to obstruction or increased activity of bowel

A

Pain due to obstruction of increased activity of bowel is colicky in nature due to spasm of smooth muscle

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19
Q

Describe the classic pain patterns for appendicitis [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Umbilical then RIF [midgut and then irritation of parietal peritoneum in RIF]
  2. Pattern: Colic initially and then constant
  3. No precipitating features
  4. Symptoms: Include anorexia, nausea and vomiting
  5. Diagnosis: Rovsing and Psoas stretch signs/ raised temp/ white cell count (WCC) should be elevated due to infection
  6. Misdiagnosis: Usually in under 5 year olds
20
Q

Describe the classic pain patterns for renal colic [Location; Pattern; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Loin - groin [lateral structure - retroperitoneal]
  2. Pattern: Colic lasts few mins, v intesnse (worse than childbirth), smooth muscle spasm
  3. Symptoms: Sweaty, vomiting, blood in urine
  4. Diagnosis: Stones on X rays or CT (calcification)
  5. Misdiagnosis: Aortic aneurysm
21
Q

Describe the classic pain patterns for pyelonephritis [Location; Pattern; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Loin [lateral structure - retroperitoneal]
  2. Pattern: Constant
  3. Symptoms: Sweaty, vomiting, temperature
  4. Diagnosis: Urinalysis and culture of bacteria
  5. Misdiagnosis: Musculoskeletal pain
22
Q

Describe the classic pain patterns for biliary colic [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Epigastric [foregut]
  2. Pattern: Colic lasts hour or more, ache
  3. Precipitating features: fatty meal
  4. Symptoms: Comes approx 30 min after eating, may have nausea
  5. Diagnosis: Ultrasound scan - see gallstones
  6. Misdiagnosis: Gastritis, GU?, DU?, pancreatitis
23
Q

Describe the classic pain patterns for cholecystitis [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: RUQ and R shoulder [somatic irritation and C3, 4 and 5]
  2. Pattern: Constant lasting for days
  3. Precipitating features: N/A
  4. Symptoms: May have temp
  5. Diagnosis: Murphy positive/ Ultrasound scan see thickened gallbladder wall/ elevated WCC count
24
Q

Describe the classic pain patterns for aortic aneurysm [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Midline back, may be in groin if iliac aneurysm
  2. Pattern: Constant lasting for days/ back pain, collapse and hypertension
  3. Precipitating features: N/A
  4. Symptoms: Expansile mass in epigastrium
  5. Diagnosis: USS or CT, but beware scanning hypotensive patient
  6. Misdiagnosis: Renal colic
25
Q

Describe the classic pain patterns for duodenal ulcer [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Epigastrium/ back if 2nd - 4th parts [foregut/ retroperitoneum]
  2. Pattern: Last hours
  3. Precipitating features: Worse during starvation relieved by eating
  4. Symptoms: Wakes at night with pain, gastric outlet obstruction in long term cases, haematemesis (vomiting blood), weight gain
  5. Diagnosis: Endoscopy and helicobacter CLO test
  6. Misdiagnosis: Other upper GI disease, no risk of malignancy
26
Q

Describe the classic pain patterns for gastric ulcer [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Epigastrium [foregut]
  2. Pattern: Last hours
  3. Precipitating features: Worse after eating 10-30 mins, relieved by starvation
  4. Symptoms: Gastric outlet obstruction in long term cases, haematemesis, weight loss
  5. Diagnosis: Endoscopy and helicobacter CLO test
  6. Misdiagnosis: Other upper GI disease, malignant gastric ulcer
27
Q

Describe the classic pain patterns for pancreatitis [Location; Pattern; Precipitating features; Symptoms; Diagnosis; Misdiagnosis]

A
  1. Location: Epigastrium and back [foregut/ retroperitoneal]
  2. Pattern: Constant
  3. Precipitating features: Alcohol, gallstones, idiopathic, drugs, truma
  4. Symptoms: Vomiting, may have temp and be profoundly unwell
  5. Diagnosis: USS, CT, amylase
  6. Misdiagnosis: Gastritis, GU, biliary colic
28
Q

Where is foregut pain referred to?

A

Epigastric region and lower thorax

29
Q

What is the sympathetic supply of the foregut?

A

Greater splanchnic nerve (T5-9)

30
Q

What is the parasympathetic supply of the foregut?

A

Vagus nerve

31
Q

Where is the site of the sympathetic ganglion of the foregut?

A

Coeliac ganglion

32
Q

What is the arterial supply of the foregut?

A

Coeliac trunk (anterior branch of abdominal aorta immediately below the aortic hiatus of the diaphragm)

33
Q

What is the venous drainage of the foregut?

A

Portal venous system - union of splenic being and the superior mesenteric vein

34
Q

What is the arterial supply of the midgut?

A

Superior mesenteric artery (unpaired branch of aorta)

35
Q

What is the venous drainage of the midgut:?

A

Portal venous system

36
Q

Where is the site of sympathetic ganglion for the midgut?

A

Superior mesenteric ganglion

37
Q

What is the parasympathetic supply of the midgut?

A

Vagus nerve

38
Q

What is the sympathetic supply of the midgut?

A

Lesser splanchnic nerve (T10-11)

39
Q

Where is the referred pain of the midgut?

A

Umbilical region

40
Q

What is the arterial supply of the hindgut?

A

Inferior mesenteric artery

41
Q

What is the venous drainage of the hindgut?

A

Portal venous system

42
Q

Where is the site of sympathetic ganglion for the hindgut?

A

Inferior mesenteric ganglion

43
Q

What is the parasympathetic supply of the hindgut?

A

Caudal outlfow (S2-4)

44
Q

What is the sympathetic supply of the hindgut?

A

Lumbar splanchnic nerve (L1-2)

45
Q

Where is the referred pain of the hindgut?

A

Pubic region, lateral and anterior thighs, and groin

DIG (31 decks)

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