Lecture 8: Stomach Pain

Question 1

Two types of abdominal pain (describe)

Answer 1

1. Visceral (vague, poorly localized, dull, aching, burning, gnawing); 2. Somatic/Parietal (pinpoint, well localized, stabbing)

Question 2

Why is visceral pain difficult to localize?

Answer 2

Few in number, bilateral, diverge up to 8 segments when enter spine, converge in dorsal roots with afferents from different abdominal roots

Question 3

What do visceral nerves sense? (what causes pain)

Answer 3

Distension, traction, pressure, contraction, ischemia

Question 4

Visceral pain localization areas (give spinal roots)

Answer 4

Epigastric (T5-T8), periumbilical (T9-T10), hypogastric (T11-T12)

Question 5

Epigastric pain

Answer 5

Stomach, prox duodenum, pancreas, gallbladder, CBD, liver

Question 6

Periumbilical pain

Answer 6

Distal duodenum, small bowel, appendix

Question 7

Hypogastric pain

Answer 7

Colon, bladder, rectum, ureters, uterus

Question 8

Left shoulder pain can be referred from…

Answer 8

Central-left diaphragm

Question 9

Right shoulder pain can be referred from…

Answer 9

Liver, central-right diaphragm

Question 10

Right mid back pain can be referred from…

Answer 10

Gall bladder

Question 11

Mid back pain can be referred from…

Answer 11

Pancreas

Question 12

Tailbone pain can be referred from…

Answer 12

Rectum

Question 13

Somatic pain arises from where?

Answer 13

Peritoneal surface

Question 14

Why is somatic pain easy to localize? Where are they present?

Answer 14

Numerous, unilateral, highly segmental; present in abdominal wall, diaphragm, mesenteric roots, and superior hepatic ligaments

Question 15

Visceral pain reflex phenomena

Answer 15

Transmitted by peripheral and autonomic nerves at level of entry into spinal cord that include sweating, guarding, decreased bowel motility, muscle spasm, hypersensitivity

Question 16

T/F: An abdominal organ problem begins with somatic pain

Answer 16

False: starts visceral –> somatic w/ wall irritation (localizes itself)

Question 17

Pathophysiology of appendicitis

Answer 17

Luminal obstruction –> luminal pressure –> wall pressure/distension –> venous pressure exceeded –> cycle of increasing pressure –> ulceration of mucosa –> bacterial translocation –> peritoneal inflammation –> ischemia –> gangrene/perforation

Question 18

When do you start sensing visceral pain with appendicitis? What aggravates it?

Answer 18

During wall tension/distension phase of pathophysiology; aggravation by inflammation due to blocking of venous system

Question 19

How long until appendicitis becomes gangrene/perforation?

Answer 19

24-36 hours

Question 20

Atypical presentations of appendicitis

Answer 20

Pregnant woman (RUQ), situs inversus (LLQ), retrocecal appendix (RL back area), elderly (no pain but fever), infants

Question 21

What can block an appendix?

Answer 21

Fecalith (“stool stone”)

Question 22

What is catarrhal appendicitis?

Answer 22

Engorged vessels in an appendix

Question 23

What is suppurative appendicitis?

Answer 23

Appendix filled with pus

Question 24

Why do Westerners get diverticular disease?

Answer 24

Due to low fiber “Western” diets and “Western” sedentary lifestyle which leads to slow colonic transit and increased intraluminal pressures –> hard, dry stools and high work to propel feces

Question 25

Pathophysiology of diverticular disease

Answer 25

Muscular hypertrophy –> segmentation of sigmoid colon –> increased intraluminal pressure –> herniation of mucosa and submucosa at points of weakness

Question 26

What are the colon bands called? Why is this important for diverticular disease?

Answer 26

Teniae; create points of weakness

Question 27

What layers are included in these “pseudo” diverticula?

Answer 27

Mucosa, submucosa (no muscularis propria)

Question 28

What do diverticula look like on endoscopy? CT?

Answer 28

Craters/outpouchings; black holes

Question 29

Diverticular disease: clinical presentation

Answer 29

Most are asymptomatic (50% have them over 60 years); sx = crampy abdominal pain, generally LLQ (sigmoid colon common), constipation

Question 30

Diverticulitis: pathophysiology, sx, dx, tx

Answer 30

Blockage of one pocket; sx = pain, fever, WBC; dx = history, CT scan; tx = antibiotics, increase fiber, avoid constipation, surgery (multiple recurrences or fistula)

Question 31

What is a common complication of diverticula? Why? Describe

Answer 31

Bleeding; vessels are in the pocket; can cause dramatic bleeding that is bright red

Question 32

Is diverticular bleeding painful? Tx?

Answer 32

No (diverticulitis and bleeding don’t usually occur in same person); most stop on their own, but may have to attempt colonoscopic cauterization, angiographic embolization, surgery for multiple recurrences

Question 33

Is diverticular bleeding easy to dx?

Answer 33

No: hard to localize which is bleeding on colonoscopy, may require angiography or nuclear medicine RBC scan