Abdominal Pain

Objectives

• To be able to elucidate the various mechanism of abdominal pain

• To clearly be able to describe the importance of history, physical examination, and other investigations in defining the origin of abdominal pain

• To be able to list a good differential for abdominal pain and solve real life examples

Why should we care?

• Abdominal Pain is a huge topic• To understand it fully it requires a good clinical

judgment• It serves as a good case for history and physical

examination• Many chronic diseases go by unchecked with

only minor symptoms like abdominal pain• There are multiple classification or systems for

abdominal pain

Abdominal Pain and its mechanism

• It can be due to multiple ways or origins, it includes:– Parietal Peritoneum Inflammation– Obstruction of the lumen of the gut– Vascular problems in the gut– Referred pain from somewhere else– Abdominal wall problems– Metabolic problems– Nerve problems

Parietal Peritoneum Problems

• The characteristic of the pain:– Steady and aching– Almost always localized in the area of the pain

Obstruction of the Gut

• The characteristic of the pain:– Intermittent pain, or colicky– It can be steady ‘’sometimes’’ – due to distention

Obstruction - 2

• Billiary tree pain– Can produce steady pain ‘’REMEMBER

DISTENSION’’– Billiary colic can be steady– It radiates to tip of right scapular (supscapular

pain) + epigastric• Carcinoma Head of the pancreas usually silent• Urinary bladder obstruction is suprapubic

Vascular Problems

• Sometimes sudden and catastrophic like sudden bleed, eg., Aortic Aneurysm

• Mesenteric artery occlusion:• Can be continuous and diffuse before the

vascular bleed ( e.g., mesenteric artery occlusion)

Abdominal Wall

• Usually the pain from abdominal wall• It is constant, and aching

Referred Pain in Abdominal Disease

• It can be from anywhere:– thorax, spine, or genitalia

• It can be abdominal disease causing referred pain somewhere else– Ex: acute cholecystitis or perforated ulcer

• Common interthoracic diseases:– Especially in upper abdominal pain

• MI, Pulmonary Infarction, pneumonia, pericarditis, and esophageal disease

Metabolic Abdominal Crises• Many mechanisms cause this type of pain:

– Hyperlipidemia – accompanies by a process such as pancreatitis– C’1 esterase deficiency associated with angioneurotic edema – with severe

abdominal pain• If you don’t know the cause, think of metabolic causes!!• It is difficult to do a differential because many diseases have similar

nature of pain– Porphyria or lead colic is similar to intestinal obstruction– Uremia or diabetes is non-specific type of pain– Diabetic acidosis is similar to acute pancreatitis or intestinal obstruction

• As a rule, if pain does not resolve with correction of metabolic abnormality– Underlying ORGANIC problem is suspected!

Nerve problems

• Spinal nerve or roots of spinal nerve pain:– Comes and goes suddenly– lacinating type of pain– Many causes:

• Herpes zoster, impingement by arthritis, tumors, herniated nucleus pulposus, diabetes, or syphilis.

Patterns of acute abdominal pain• . A, Many causes of abdominal

pain subside spontaneously with time (e.g., gastroenteritis).

• B, Some pain is colicky (i.e., the pain progresses and remits over time); examples include intestinal, renal, and biliary pain (“colic”). The time course may vary widely from minutes in intestinal and renal pain to days, weeks, or even months in biliary pain.

• C, Commonly, abdominal pain is progressive, like its maturing, as in appendicitis or diverticulitis.

• D, Certain conditions have a catastrophic onset, such as ruptured aortic aneurysm.

Stereotypes of Pain Onset and Associated Pathology

Sudden onset (full pain in seconds)

Perforated ulcer

Mesenteric infarction

Ruptured abdominal aortic aneurysm

Ruptured ectopic pregnancy

Ovarian torsion or ruptured cyst

Pulmonary embolism

Acute myocardial infarction

Rapid onset (initial sensation to full pain over minutes or hours)

Strangulated hernia

Volvulus Intussusception Acute

pancreatitis Biliary colic Diverticulitis Ureteral and

renal colic

Gradual onset (hours)

Appendicitis Strangulated

hernia Chronic

pancreatitis Peptic ulcer

disease Inflammatory

bowel disease Mesenteric

lymphadenitis Cystitis and

urinary retention

Salpingitis and prostatitis

History

• Course of pain• Radiation of pain• Factors that exacerbate or improve symptoms• Associated symptoms including fevers, chills weight loss• Past medical and surgical history• Family history of bowel disorder• Alcohol intake• Intake of medications• Menstrual and contraceptive history in women

Physical Examination

• Measurement of blood pressure, pulse, and temperature

• Examination of the eyes and skin for jaundice• Auscultation and percussion of the chest• Auscultation of the abdomen for bowel sounds• Palpitation of the Abdomen for masses, tenderness,

and peritoneal signs• Rectal exam include Occult blood• Pelvic Examination in women with lower abdominal

pain

• DETAILED HISTORY IS MOST IMPORTANT THAN ANYTHING!

• Location of pain is very helpful• Time sequence of events is important• Be open minded and ask the right questions• Check extra-abdominal manifestation• If female, ask menstrual history

• Critical inspection is inmportant– Facies, position in bed, respiratory activity– Be gentle and detailed– do not elicit rebound tenderness by sudden release

of a deeply palpating hand, IT’S CRUEL!• Same way can be done by gentle percussion (rebound

tenderness on a miniature scale)• Ask patient to cough will elicit true rebound tenderness

without placing hand on abdomen• Sometimes, reactionary protective spasm will hinder

your other findings, eg., palpating gallbladder

• Abdominal signs can be absent in cases of pelvic peritonitis– Careful pelvic and rectal examinations are

mandatory in patients with abdominal pain• Tenderness in such examination:

– Operative indication:» Perforated appenditis» Diverticulitis» Twisted ovarian cyst

• Absence of peristaltic sound– Auscultation is one of the least revealing aspect– Catastrophes such as: Strangulating small

intestinal obstruction or perforated appendicitis• Occur in presence of normal peristaltic sounds• Conversely, when proximal area above obstruction

becomes edematous and distended– Peristaltic sound lose characteristics of borborygmi

» Become weak and absent

– Sudden Chemical peritonitis = silent abdomen– Remember, assess patient’s hydration status

LABS

• Labs are very valuable but they rarely establish diagnosis – focus on History & physicalExample: Leukocytosis does not mean a person having appendicitis and he should be admitted to operation room

Other conditions occur in pancreatitis, acute cholecystitis, pelvic inflammatory disease, intestinal infarction

We can establish diagnosis of anemia based on CBC and history

• We do urinary analysis to rule out:– renal disease, diabetes, urinary infection

• Serum amylase levels can increase:• pancreatitis• Perforated ulcer• Strangulating intestinal obstruction• Acute cholecystitis

• Other important tests: Blood urea nitrogen, glucose, serum bilirubin

• Radiographs of abdomen can show Perforated ulcer, and other conditions

• Water-soluble contrast or barium studies can demonstrate partial upper GI obstruction

• Contrast enema Suspected colonic obstruction (with no perforation) – contrast enema may be diagnostic

US detect enlarged gallbladder or pancreas• Presence of gallstones, enlarged ovary or tubal

pregnancy

– Helpful in diagnosing pelvic conditions:• Ovarian cysts, tubal pregnancies, salpingitis, and acute

appendicitis

Cases… • A 23 year old female presents with severe,

intermittent right lower quadrant pain associated with nausea and vomiting.

• She has no medical history.• Her vital signs reveal tachycardia but are otherwise

normal.• Physical exam shows a soft abdomen, RLQ TTP

without peritoneal signs. Pelvic (which is part of the physical exam), shows scant discharge.

• If you could only order one test, what would it be?• What is on your differential?

Differential

• Ectopic Pregnancy• Ruptured Ovarian Cyst• Appendicitis• Right-sided diverticulitis• TOA• Ovarian Torsion

• Nephrolithiasis• Pyelonephritis• Endometriosis• UTI• Heterotopic pregnancy• Terminal ileitis

Ovarian Torsion…

Increased ovarian volume (>15cc), multiple follicles and decreased blood flow.

Cases…

• A 60 y/o male presents after a syncopal event with a complaint of abdominal pain.

• His pain is poorly localized but radiating to his back.

• His history is significant for HTN and tobacco abuse.

• His vitals are normal and his physical exam reveals only the following:

What is on the differential?

• Pancreatitis• Mesenteric Ischemia• MI• Gallbladder Disease• GERD• Obstruction

• Peritonitis• PE• PUD• AAA• Valvular Insufficiency• Perforated Viscus

Abdominal Aortic Aneurysm

What happens: The media weakens over time, the vessel dilates and expands over time. As the vessel weakens and expands, rupture becomes more likely.The larger it becomes, the more likely is the rupture.

AAA

Fun facts: They are typically infrarenal>3cm at this level is a AAAAge, Family history, Atherosclerotic risk factors,

infection, trauma, connective tissue disease are risk factors.

Rupture is associated with 80-90% mortality.Vital signs can be normal. For now.

AAA: Diagnosis and Management

H&P: May not be symptomatic until the ruptureSyncope and Abdominal painCullen’s sign and Grey Turner’s signImaging: U/S 100% sensitive when the aorta is visualized.

CT requires a stable patient but is also highly sensitive and is better at detecting rupture and retroperitoneal fluid.

Treatment is surgical!! Despite what surgery tells you: There is no such thing as a stable rupture.

ED’s role is maintaining hemodynamic stability with blood products – SBP 90-100mg until surgery.

CT of Rupturing AAA:

Thank you!