Abdominal Pain Types and Analysis

Abdominal Pain

• Types of abdominal pain:

  • Visceral pain: resulted from stretching, distension, contraction, and twisting of unpaired organs; felt usually in the midline; dull and poorly localized.
  • Parietal pain: resulted from irritation of parietal peritoneum; well localized and lateralized; caused by infection, inflammation, and neoplasia.
  • Referred pain: e.g., gallbladder pain referred to tip of shoulder and back; M.I. referred to epigastrium.

• Analysis of abdominal pain using SOCRATES questions:

  • Site of pain: provides clues about diagnosis and cause of pain.
  • Onset: acute or chronic.
  • Character and pattern: constant, colicky, sharp, or dull; intermittent or continuous.
  • Radiation: e.g., peptic ulcer disease radiates to upper quadrants or back; gallbladder disease radiates to tip of right shoulder or back.
  • Associated symptoms: weight loss, vomiting, altered bowel habit.
  • Timing and duration: exacerbated and relieving factors; food, hunger, drugs, alcohol, posture, movement, defecation.
  • Severity: affects diagnosis and treatment.

Causes of Abdominal Pain

• Epigastric pain: pancreatitis, gastritis, duodenitis, peptic ulcer, biliary disease, aortic aneurysm.
• Right upper quadrant pain: hepatitis, cholecystitis, biliary colic, peptic ulcer, subphrenic and periphrenic abscess, renal stone, pyelonephritis, colonic cancer.
• Left upper quadrant pain: peptic ulcer, gastric or colonic cancer, splenic rupture, subphrenic or periphrenic abscess, renal stone, pyelonephritis.
• Loin pain: renal colic, pyelonephritis, renal tumor, perinephritis, pain referred from vertebral column.
• Left-iliac fossa pain: diverticulitis, volvulus, colon cancer, pelvic abscess, inflammatory bowel disease, hip pathology, renal colic, UTI, cancer of undescended testis, zoster, ectopic pregnancy, torsion of ovarian cyst, and salpingitis.
• Right-iliac fossa pain: appendicitis, Crohn's ileitis, and all causes of left-iliac fossa pain (except diverticulitis).
• Pelvic pain: urological (UTI, urine retention, bladder stone) and gynecological (menstruation, pregnancy, endometriosis, salpingitis, torsion of ovarian cyst) disorders.
• Central pain: mesenteric ischemia, abdominal aneurysm, pancreatitis.
• Generalized abdominal pain: gastroenteritis, irritable bowel syndrome, peritonitis.

Acute Abdomen

• Accounts for about 50% of all urgent admissions to general surgery units.
• Causes of acute abdomen:
  • Inflammation: gradual onset, usually over hours, diffuse pain, localized pain with parietal peritoneum irritation.
  • Perforation: sudden onset, severe, generalized peritonitis.
  • Obstruction: colicky pain, spasms, patient writhes and doubles up.
• Table 1: Causes of acute abdomen (inflammation, perforation, obstruction, and other rare causes).

Management of Acute Abdomen

• Careful history and clinical examination (vital signs, abdominal exam, guarding, and rebound tenderness).
• Investigations:
  • Full blood count (leukocytosis).
  • Urea and electrolytes (dehydration).
  • Amylase (pancreatitis).
  • X-ray (erect chest x-ray, plain abdominal x-ray, obstruction).
  • Ultrasound (renal or gall stones, free fluid, intra-abdominal abscess).
  • Contrast radiology (intestinal obstruction).
  • CT scan (pancreatitis, retroperitoneal collections, masses, aortic aneurysm).
  • Angiography (mesenteric ischemia).

Treatment of Acute Abdomen

• Depends on affected organ (perforation, obstruction, inflammation).
• Presence or absence of peritonitis affects spread of intervention and necessity of surgery.

Chronic or Recurrent Abdominal Pain

• Causes include intestinal and extra-intestinal disorders (table 2).
• Note patient's general behavior, mood, emotional state, signs of weight loss, fever, jaundice, or anemia.
• Look for evidence of diseases affecting other structures, especially vertebral column, spinal cord, lungs, and cardiovascular system.
• Table 2: Extra-intestinal causes of abdominal pain (retroperitoneal, psychogenic, neurological, drugs, metabolic, and hematological disorders).

Investigations for Chronic or Recurrent Abdominal Pain

• Depend on clinical features found during history and clinical examination.
• Endoscopy and US for gastric pain, dyspepsia, and symptoms suggestive of gallbladder disease.
• Colonoscopy for altered bowel habit, rectal bleeding, or features suggestive of colonic obstruction.
• Angiography for features suggestive of mesenteric ischemia.

Learn about the different types of abdominal pain, including visceral, parietal, and referred pain, and how to analyze them. Understand the causes and characteristics of each type of pain.