Lecture 8: Stomach Pain Flashcards
Two types of abdominal pain (describe)
- Visceral (vague, poorly localized, dull, aching, burning, gnawing); 2. Somatic/Parietal (pinpoint, well localized, stabbing)
Why is visceral pain difficult to localize?
Few in number, bilateral, diverge up to 8 segments when enter spine, converge in dorsal roots with afferents from different abdominal roots
What do visceral nerves sense? (what causes pain)
Distension, traction, pressure, contraction, ischemia
Visceral pain localization areas (give spinal roots)
Epigastric (T5-T8), periumbilical (T9-T10), hypogastric (T11-T12)
Epigastric pain
Stomach, prox duodenum, pancreas, gallbladder, CBD, liver
Periumbilical pain
Distal duodenum, small bowel, appendix
Hypogastric pain
Colon, bladder, rectum, ureters, uterus
Left shoulder pain can be referred from…
Central-left diaphragm
Right shoulder pain can be referred from…
Liver, central-right diaphragm
Right mid back pain can be referred from…
Gall bladder
Mid back pain can be referred from…
Pancreas
Tailbone pain can be referred from…
Rectum
Somatic pain arises from where?
Peritoneal surface
Why is somatic pain easy to localize? Where are they present?
Numerous, unilateral, highly segmental; present in abdominal wall, diaphragm, mesenteric roots, and superior hepatic ligaments
Visceral pain reflex phenomena
Transmitted by peripheral and autonomic nerves at level of entry into spinal cord that include sweating, guarding, decreased bowel motility, muscle spasm, hypersensitivity
T/F: An abdominal organ problem begins with somatic pain
False: starts visceral –> somatic w/ wall irritation (localizes itself)
Pathophysiology of appendicitis
Luminal obstruction –> luminal pressure –> wall pressure/distension –> venous pressure exceeded –> cycle of increasing pressure –> ulceration of mucosa –> bacterial translocation –> peritoneal inflammation –> ischemia –> gangrene/perforation
When do you start sensing visceral pain with appendicitis? What aggravates it?
During wall tension/distension phase of pathophysiology; aggravation by inflammation due to blocking of venous system
How long until appendicitis becomes gangrene/perforation?
24-36 hours
Atypical presentations of appendicitis
Pregnant woman (RUQ), situs inversus (LLQ), retrocecal appendix (RL back area), elderly (no pain but fever), infants
What can block an appendix?
Fecalith (“stool stone”)
What is catarrhal appendicitis?
Engorged vessels in an appendix
What is suppurative appendicitis?
Appendix filled with pus
Why do Westerners get diverticular disease?
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
Pathophysiology of diverticular disease
Muscular hypertrophy –> segmentation of sigmoid colon –> increased intraluminal pressure –> herniation of mucosa and submucosa at points of weakness
What are the colon bands called? Why is this important for diverticular disease?
Teniae; create points of weakness
What layers are included in these “pseudo” diverticula?
Mucosa, submucosa (no muscularis propria)
What do diverticula look like on endoscopy? CT?
Craters/outpouchings; black holes
Diverticular disease: clinical presentation
Most are asymptomatic (50% have them over 60 years); sx = crampy abdominal pain, generally LLQ (sigmoid colon common), constipation
Diverticulitis: pathophysiology, sx, dx, tx
Blockage of one pocket; sx = pain, fever, WBC; dx = history, CT scan; tx = antibiotics, increase fiber, avoid constipation, surgery (multiple recurrences or fistula)
What is a common complication of diverticula? Why? Describe
Bleeding; vessels are in the pocket; can cause dramatic bleeding that is bright red
Is diverticular bleeding painful? Tx?
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
Is diverticular bleeding easy to dx?
No: hard to localize which is bleeding on colonoscopy, may require angiography or nuclear medicine RBC scan
