Pain Flashcards
What is referred pain?
Pain felt in a part of the body that is not the source of the pain.
What is the mechanism of referred pain
Uncertain — many theories
Afferent pain fibres in thorax/abdomen follow sympathetic back to spinal cord
These neurones have cell bodies co-located with dermatomal cell bodies
They share second order neuron synapses
What are examples of referred pain?
Brain freeze (vagus/ trigeminal), MI, Biliary colic, Pancreatitis, phantom limb pain
What colicky pain?
Pain characterised by either intermittent nature or variable/cyclical intensity
What are examples of colicky pain?
Biliary colic
Bowel obstruction
Renal colic
What is peritonitis pain?
Abdominal pain due to inflammation of the peritoneum
How is peritonitis pain evolved
First visceral
then somatic
How is visceral peritonitis pain characterised?
Vague, poorly localised
Dull ache
Embryological origin
How is somatic peritonitis pain characterised?
Sharp
Localised
What diseases are likely diagnosed for pain in the right upper quadrant abdomen
Biliary Colic Acute Cholecystitis Peptic ulcer (+/- perforation) Abscess Pancreatitis Pneumonia
What diseases are likely diagnosed for pain in the epigastrium
Peptic ulcer Reflux oesophagitis Gastritis AAA(+/- rupture) Pancreatitis Biliary colic Acute cholecystitis Myocardial infarction
What diseases are likely diagnosed for pain in the left upper quadrant abdomen
Peptic ulcer Pancreatitis Splenic rupture (or cyst rupture) Abscess Pneumonia
What diseases are likely diagnosed for pain in the central abdomen
Small bowel obstruction Appendicitis Mesenteric ischaemia AAA +/- rupture IBS
What diseases are likely diagnosed for pain in the right iliac fossa
Appendicitis Mesenteric adenitis Meckel's diverticulum TubaI/ovarian pathology (including ectopic) IBD PID Renal/ureteric colic Diverticulitis
What diseases are likely diagnosed for pain in the Low (suprapubic)
Diverticulitis IBD Large bowel obstruction PID Ectopic pregnancy Retention of urine
What diseases are likely diagnosed for pain in the left iliac fossa
Diverticulitis IBD Tubal/ ovarian pathology (including ectopic) PID Renal/ureteric colic
types of gallstones
Mixed
Pigment
Cholesterol
What is the biliary colic
Distension and contraction of a gall bladder against an obstructed cystic duct
How is pain described in peptic ulcers?
“Deep gnawing pain”, “burning pain”
Often worse at night -duodenal ulcer
More immediate- gastric ulcer
What is colicky pain indicate?
Viscera
Related to hollow viscus
Obstruction somewhere to do with peristalsis
How is colicky pain described?
Squeezing pain then stops then repeats
How is pain described for biliary colic?
Squeezing pain that never stops constant
How is pain described for renal colic?
Squeezing pain then stops then repeats
Why is pain constant in biliary colic?
Mediated by hormones wwhich are slow and take longer to wear off
Why is pain not constant in renal colic?
Mediated by nerves which are quick and doesn’t take longer to wear off
How is pain described for bowel obstruction? Why?
Squeezing pain then stops
Actin myosin stop interlocking
Where is pain located for harm in the upper abdomen
Epigastrium
Organs blood supplied by the celiac axis cause pain where?
Epigastrium
Organs blood supplied by the super mesenteric artery cause pain where?
periumbilical
Organs blood supplied by the inferior mesenteric artery cause pain where?
super pubic
What is located in the right upper right quadrant of the abdomen?
Liver Gallbladder Duodenum Pancreas Lung a little bit
What is most common disease to be found in the right upper quadrant
Gallbladder disease
What can biliary colic lead to? Why?
Acute cholecystitis
Biliary tube keeps pushing at gallstone starts becoming inflamed and infected
What signs lead to Acute cholecystitis?
Tenderness in RUQ
Fever
tachycardia
other signs of sepsis
What are causes of peptic ulcers?
Drink too much Smoke too much Underlying conditions- Helicobacter pylori Non-steriod anti-inflamatorities Physiological stress
What causes pancreatitis?
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune pancreatitis
Scorpion sting
Hyperlipidemia, hypothermia, hyperparathyroidism
Endoscopic retrograde cholangiopancreatography
Drugs(commonly azathioprine, valproic acid, liraglutide)
Ho does pancreatitis present in a patient?
Right upper quadrant pain
Epigastric pain
Radiating to the back
Associated vomiting
What is located in the epigastrium of the abdomen?
Oesophagus
Stomach
Parts of liver / galllbladder
Small intestine
What is AAA stand for?
abdominal aortic aneurysm
What is a patient AAA presented with?
Pain in upper abdomen
associated with hemodynamic instability
When is pancreatitis more likely to causing pain in thee left upper quadrant
When it happens in the tail of the pancreas
What is located in the left upper right quadrant of the abdomen?
Stomach
Pancreas (tail)
Spleen
What is located in the central quadrant of the abdomen?
Bowels
Apeendix
Who is at risk of having mesenteric ischaemia
People who already have underlying cardiovascular disease, atherosclerotic disease
Atrial fibrillation
What is hemodynamic instability
Low blood pressure
High pulse rate
What signs are associated with IBS?
Colicky pain
small bowel gut distension
central abdominal pain
What symptoms does appendicitis cause?
Periumbilical pain which moves to the right iliac fossa over short duration (<24hrs) Murphys triad Localised peritonism in the RIF Dyspareunia (for women) Rebound tenderness
What is murphy’s triad
lower right abdominal pain along with nausea, vomiting, and fever.
What is mesenteric adenitis
swelling of the lymph nodes in the mesentery supplying the terminal ileum
What is Meckel’s diverticulum
outpouching of the small bowel which was embryological remnant
can get perforation and inflammation from that
What if you examine the appendix and cant find appendicitus
Walk through small bowel to check for Meckel’s diverticulum
What if a women presents herself with right iliac fossa pain? Why?
Make sure she has a negative pregnancy test
Ectopic pregnancy cause life-threatening bleeding and hemoperitonium
What is Crohn’s disease
Irritable bowel disease
How does pain radiate for renal colitis?
pain and inflammation which starts in the rectum and works proximally
What is PID?
Pelvic inflammatory disease
What diseases are part of pelvic inflammatory diseases
Hydrosalpinx
endometritis
pyosalpinx
What is Hydrosalpinx
Fluid built up in fallopian tubes
How is pain presented in renal ureteric colic?
Pain radiating from the flank down to the groin or to the towards the bladder
Where does diverticulitis pain normally occur? Why on the other side?
In the Left iliac fossa
Sigmoid colon flipped over to right because colon is very mobile or
rarily cecum or ascending colon inflamed
Where does diverticulitis normally occur?
In the sigmoid colon
What is the difference between diverticulitis and Meckel’s diverticulum
Meckel= congenital Doverticulitis= acquired
What is urinary retention
Not able to pass urine
What symptoms are associated with diverticulitus
Pain Fever Tachycardia Vomiting Haematochezia
Can you see gallstones on a CT or X-ray?
No
Can you see kidney stones on a CT or X-ray?
Yes
How is biliary duct mediated?
Hormonally by cholecystokinin
What secretes cholecystokinin
Stomach
What advice is given to people with gallstones? Why?
Eat less fatty foods
When fatty foods arrive in stomach More bile is trying to be forced out past gallstones so more pain is made as bile is used to emulsify fats
What is cholecystitis initially doing and what can it lead to?
Inflammation into infection
Can gallstones be asymptomatic?
Yes
What is the management of asymptomatic gallstones
No management needed unless bcomes symptomatoc
What happens if you have a stone that then blocks the outlet of the gallbladder?
Empyema
What is an empyema
Bag of pus
What can happen if there is an empyema in the gallbladder
it can make the wall of the gallbladder inflamed and weakened
swelling of the gallbladder
Gallbladder can perforate
What happens if gallbladder traps bile nothing leaves?(Mucus)
Mucus builds up because of mucosa secreting mucin causing a mucocoele
What is a mucocoele
A bag of mucin
What happens if the gallstone lodges in the bile duct?
Jaundice because bile cant be drained?
What if bile stays too long in the bile duct?
Infection- cholangitis
What is the difference between cholangitis and cholecystitis
Inflammation of the gallbladder- cholecystitis
Inflammation/ Infection of the bile duct- cholangitis
What are the main symptoms of cholangitis
Fever
Right upper quadrant pain
Jaundice
What happens if gallstones go into pancreatic duct
backwash of pancreatic enzymes irritates the pancreas causing pancreatitis
What are ways that gallstones can affect the body?
Blocking gallbladder
Blocking bile duct
Blocking pancreas
Eroding gallbladder wall and going in the duodenum
What happens if gallstones erode into duodenum?
Cholecystoduodenal fistula
What is Cholecystoduodenal fistula
It stops at the terminal ileum causing gallstone obstruction
What disease can cholecystitis lead to?
Generalised peritonitis
What disease is caused by perforated gallbladdr?
Generalised biliary peritonitis
What can happen in vessels because of gallstone diseases?
Thrombosis of the blood supply to the gallbladder get a dead gallbladder or ischemic or necrotic gallbladder
What are common causes of pancreatitis
Gallstones
Ethanol (Alcohol abuse)
Trauma or after endoscopic retrograde cholangiopancreatography
How is pancreatitis graded?
Modified Glasgow Score
APACHE-II
CT seventy grading
What does the Modified Glasgow Score record?
various factors of the systemic inflammatory response whether they need to be managed on a ward or
high dependency care for invasive blood pressure monitoring or medications to support the blood pressure
What are the main investigations for pancreatitis
Amylase vs lipase (serum vs urine)
Looking at CRP for inflamation
What scans are done for gallstones
USS
When are CT scans used for pancreatitis
Uncertain still
one of the complications at a later stage
What complications can arise from pancreatitis?
Pancreatic necrosis Acute fluid collections +/- infection Pseudoaneurysm/ bleeding ARDS +/- multi-organ failure Duodenal ileus Chronic pancreatitis Pseudo-cyst
What can happen to peptic uncomplicated ulcers?
EITHER
Bleed or
Perforate
What is mostly likely to be affected by ulcerations from the duodenum posterly?
Gastroduodenal artery Duodenal D1
Causing bleeding from there
What is mostly likely to be affected by ulcerations from the duodenum anteriorly?
Peritoneal cavity
Localised peritonitis
What investigations can be done for peptic ulcer disease?
Endoscopy
Consider H pylori- do biopses
CT if concern about perforation
CT angiogram if bleeding not arrested endoscopically
Why is perforation best seen on a CT Scan
best way of seeing free intraperitoneal air
What kind of fever does appendicitis have? Why?
Low grade fever
Pyrogens from the appendix go into the portal venous system and go into the liver
Kupffer cells take out a lot of pyrogens before the blood then continues around the systemic circulation and goes to the pyrogenic centers within the brain.
What are signs of appendicitis?
McBurney's sign- rebound tenderness Rovsing sign - palpating the left highlight fossa causes pain on the right due to the peritoneum Psoas stretch- particularly in children Obturator sign "Cervical excitation" or Chandelier sign
