Abdominal Pains.pptx

Abdominal Pains Assist. Assist. Prof. Prof. Dr. Dr. Mert Mert BEKTAŞ BEKTAŞ Istanbul Aydın University Faculty of Medicine Department of Internal Medicine Abdominal Pains For many reasons, inside or outside the abdomen (60% digestive system), alone or with other signs and symptoms, subjective, acute...

Abdominal Pains Assist. Assist. Prof. Prof. Dr. Dr. Mert Mert BEKTAŞ BEKTAŞ Istanbul Aydın University Faculty of Medicine Department of Internal Medicine Abdominal Pains For many reasons, inside or outside the abdomen (60% digestive system), alone or with other signs and symptoms, subjective, acute or chronic, a symptom 2 Pathophysiology Four types of stimuli can stimulate nociceptors in the intra-abdominal organs 1. Stretching or pulling of internal organ walls 2. Inflammation mediated by bradykinin, serotonin, leukotrienes and prostaglandins and due to edema 3. Ischemia due to increased accumulation of toxic metabolites and chemical mediators in the tissue 3 Pathophysiology Visceral peritoneum (serosa), liver parenchyma and greater omentum are insensitive to pain There may be no pain in slowly developing strains (eg colon tm) The organs themselves may not be sensitive to pain Ex: endoscopic biopsies are painless Abdominal pain does not occur unless complications such as obstruction, ulceration, pressure on nerve plexuses or perforation occur with intra-abdominal organ neoplasia 4 Intra Abdominal Causes 1- Diffuse Peritonitis 4- Expansion of organs  organ perforation  Peritonitis (bacterial or nonbacterial)  F.M.F.  Obstructions (intestinal, biliary tract, ureter)  Capsule stretching (right heart failure, budd-chiari, liver with acute hepatitis and kidney with ureteral obstruction) 2- Localized peritonitis  acute appendicitis 5- Ischemia  acute cholecystitis  Intestinal ischemia  Diverticulitis in the colon  splenic infarction  pancreatitis  Tumor necrosis (hepatoma)  Torsion 3- Retroperitoneal tumors (stomach, bladder, spleen, ovaries) 5 Extra Abdominal Causes 1- Intra-thoracic 3- Toxins pneumonia Hypersensitivity (insect stings) Pulmonary embolism Drugs and chemicals (lead) empyema pneumothorax 4- Metabolic ischemic heart disease Uremia myocarditis diabetes mellitus Esophagitis porphyria Esophageal perforation Acute adrenal insufficiency hyperparathyroidism 2- Neurogenic / Psychiatric radiculitis 5- Other tabes dorsalis Hematoma, tumors, muscle injuries Zoster Psychiatric disorders 6 According to the source of pain and the way of pain transmission; 1-Visceral pain (splanchnic, primary) 2-Parietal pain (somatic, secondary) 3-Referred pain 7 1- Visceral pain  occurs as a result of stimulation of the visceral peritoneum  pain of the organs covered by the peritoneum  can be three forms Tension: distention in hollow organs or capsular tension in solid organs Inflammation Ischemia 8 Etiologies of Visceral Pain 9 Visceral pain Characteristics of visceral pain; diffuse and difficult to localize (blunt) deep continuous or wavy association of autonomic reflexes (restlessness, nausea, vomiting, sweating, tachycardia, bradycardia, hypotension, skin sensitivity and involuntary spastic contractions in the abdominal muscles) 10 Visceral pain Location of visceral pain;  Pain in the upper abdominal organs (stomach, duodenum, pancreas, liver, bile ducts) in the midline and epigastrium  Pain in the section from the ligament of Treitz to the transverse colon around the umbilicus  Pain originating from the distal parts of the colon, rectum, ureters, bladder and genital organs in the suprapubic region 11 2- Parietal (somatic) pain direct stimulation of the parietal peritoneum by inflammation or irritation Characteristics of parietal pain; more severe than visceral pain The organ where the pathology is located can be localized Since movement, cough and deep inspiration cause stimulation of the parietal peritoneum and increase pain, the patient restricts his movements 12 Visceral-Parietal Abdominal Pain Differences Visceral pain Parietal pain Blunt Sharp Wavy Continuous Not localized Well localized Restlessness limitation of movement Other autonomic symp. Pain is the dominant symptom Non-pain perception A clear pain 13 3- Referred pain It occurs when the impulses carried from the patient organ by visceral afferents enter the spinal cord at the same level as the somatic fibers in the distant anatomical location (innervation from the same neural segment). Location of pain; in a different location than the area where the intraabdominal organ affected by the disease is located; Ex: 1. Pain in inflammation of the gallbladder and its ducts; Depending on the stimulation of the spinal region between T5-T9; right shoulder, back and right arm 2. Since pain due to pancreatic causes covers a wide area between T3-T12, it can be felt in the abdomen, back, waist and hips 14 Possible origins of referred pain right shoulder - diaphragm - gall bladder - liver capsule - problems with the right-sided pleura right scapula - gall bladder - biliary tract Groin or genital area - kidney - ureter - aorta or iliac artery left shoulder - diaphragm - spleen - pancreatic tail - stomach - splenic flexure - left-sided pneumoperitoneum left scapula - spleen - pancreatic tail Back – midline - pancreas - duodenum - aorta 15 3) Referred pain Characteristics of pain; In an area far from the diseased organ Perception as burning, tenderness, pain sensation Hyperesthesia of the skin Increased muscle tone Well localized 16 Abdominal Pains Evaluation  Location of pain  The intensity and character of the pain  Symptoms accompanying pain  Factors that increase and decrease pain  Medical history of the patient  Physical examination and tests of the patient (laboratory, imaging) 17 Location of Abdominal Pains Dıseased Organ Location esophagus retrosternal spread to the neck, chin, arms and back Stomach Epigastric Duodenum Epigastric Small Intestines Periumblical Colon Hypogastrium, on the side of the lesion Rectosigmoid Suprapubic Rectum Sacrum Pancreas Epigastric and back Spleen Left upper quadrant, left shoulder Liver and Gallbladder Right upper quadrant, right shoulder, back Kidneys Lumbar Uterus Pelvis, Hypogastrium Bladder Suprapubic 18 Location of Abdominal Pains Upper Right Quadrant Epigastric Upper Left Quadrant cholecystitis peptic ulcer splenic abscess cholangitis Gastritis splenic infarct Hepatitis GOR splenic rupture pancreatitis pancreatitis Gastric Ulcer subdiaphragmatic Myocardial infarc. Gastritis abscess pericarditis pancreatitis pneumonia Ruptured Aortic subdiaphragmatic Pleurisy / Empyema Anev abscess Budd-Chiari Esophagitis pneumonia 19 Location of Abdominal Pains Lower Right Quadrant Periumblical Lower Left Quadrant Appendicitis Appendicitis (early) Diverticulitis salpingitis Gastroenteritis salpingitis inguinal hernia ileus inguinal hernia Ectopic Pregnancy Ruptured Aortic Anev Ectopic Pregnancy nephrolithiasis nephrolithiasis Inflammatory Bowel Inflammatory Bowel Disease Disease mesentery lymphadenitis Irritable Bowel Syndrome Tiflit 20 Location of Abdominal Pains Diffuse Non-localized Pain Gastroenteritis F.M.F. ileus Malaria mesentery ischemia Psychiatric Diseases Irritable Bowel Syndrome Peritonitis 21 22 Character of Abdominal Pain There is not always a correct relationship between the severity of pain and the severity of the underlying disease. Pain threshold and reaction to pain may be different. However, in the presence of ulcer perforation , acute cholecystitis , biliary colic, acute pancreatitis , mechanical ileus and peritonitis, the pain felt in the abdomen is almost always severe. 23 Character of Abdominal Pain  Stomach- duodenal ulcer; usually a dull /scraping-gnawing pain  Recurrent colic/cramp-like pain in intestinal obstruction  In ulcer perforation a severe pain that is described as stabbing and starts suddenly and spreads to the entire abdomen within a few hours and the appearance of widespread peritonitis symptoms  In acute cholecystitis It is not colic-like, it reaches its most severe level within a few hours and remains at the same intensity for hours  Appendicitis begins as a dull pain or discomfort around the umbilicus and moves to the lower right quadrant in the following hours  in pancreatitis usually becomes most severe within a few hours and is usually continuous 24 Character of Abdominal Pain Sudden severe abdominal pain causes :  Ulcer perforation  Infarction of intra-abdominal organs  rupture of abscess or hematomas  Aortic aneurysm dissection  esophagus rupture  Rupture of ectopic pregnancy In infectious and inflammatory pathologies, as the event progresses, its pain intensity increases pain caused by rupture ; more sudden and violent 25 Character of Abdominal Pain Peptic ulcer : flammable Peptic ulcer perforation : sudden and severe, as if stabbing Aortic aneurysm rupture : predatory Colic pain: excruciating Inflammatory conditions such as pancreatitis , pyelonephritis : blunt Intestinal obstructions : cramping Pain that wakes you up / prevents you from sleeping: severe pain 26 Character of Abdominal Pain Diarrhea or rectal bleeding ; an intestinal disease Icterus ; a disease of the biliary tract and liver Accompanied by inability to pass gas and stool + nausea and vomiting : intestinal obstruction Oily diarrhea ; malabsorption or chronic pancreatitis evident vomiting; cholecystitis , cholangitis , pyloric duct ulcer, pancreatitis , appendicitis , ileus or renal colic 27 Character of Abdominal Pain Chills and fever : intra-abdominal infection Charcot triad : fever, pain in right hypochondrium and icterus (cholangitis) 28 Character of Abdominal Pain irritable bowel disease due to certain foods, cold and emotional disorders peptic and duodenal ulcers, pain increases with fasting and is relieved with food or antacid intake or vomiting Chronic mesenteric ischemia ; elderly patient experiences abdominal pain that starts approximately 1 hour after eating and lasts for 1-3 hours 29 Character of Abdominal Pain Endometriosis ; Abdominal pain that has a periodic character in line with menstrual periods Colitis; Abdominal pain and diarrhea worsen after food intake Pain originating from the large intestine; decrease in the intensity of pain, usually after defecation Smooth muscle spasm due to functional causes , pain that is relieved or alleviated by applying heat to the abdomen 30 Character of Abdominal Pain pain originated by pancreas ; worse when you lie on your back and gets better when you lean forward Acute pancreatitis ; occurs 6-7 hours after a highcalorie meal, usually containing alcohol Biliary pain; provoked by eating fatty foods Peritonitis ; aggravate with body movements such as coughing and climbing stairs or jumping 31 Medical History in Abdominal Pain Previous surgical intervention + severe abdominal pain : brid ileus Occlusive vascular disease, vasculitis or atrial fibrillation : mesenteric ischemia A family history of recurrent abdominal pain : FMF or sickle cell anemia Diabetic ketoacidosis , acute adrenal insufficiency, porphyria and vasculitis are other metabolic and systemic diseases that can cause abdominal pain 32 Physical Examination in Abdominal Pain 1- Abdominal inspection ; in peritonitis patient is motionless Excessively distended abdomen and visible peristalsis , incision scars due to previous surgical interventions : ileus 2- Abdominal auscultation ; Inability to hear sounds : paralytic ileus Bowel sounds with hyperactive and metallic ringing : mechanical ileus 33 Physical Examination in Abdominal Pain 3-Abdominal palpation and/or percussion Defense : indicator of significant inflammation of the involved organ or peritonitis Rebound (pain occurs when the hands are suddenly withdrawn after slowly and deeply applying pressure to the sensitive area) : the parietal peritoneum participates in the event  Chronic abdominal pain and anemia : gastrointestinal bleeding  Icterus with pain in the right hypochondrium : hepatobiliary pathology  Sensitivity in digital rectal examination ; pelvic pathology 34 Laboratory examinations CBC, serum electrolytes, glucose , creatinine , amylase, lipase, liver enzymes, pregnancy test and complete urinalysis Radiology Standing direct abdominal radiography : easy and cheap, approximately 40% of patients presenting with acute abdomen are positive. USG; especially in hepatobiliary system, pancreas, urinary system and pelvic pathologies Other: Computed tomography (CT), magnetic resonance imaging (MRI), angiography and barium radiological examinations, ECG 35 Acute Abdomen non-traumatic condition that develops in a short time can require urgent surgical intervention early diagnosis and treatment difficult to diagnosis positive rebound tenderness and rigidity In nearly half of the patients who apply to emergency departments, the pain is not related to acute abdomen ( gastroenteritis , menstrual disorders or irritable bowel disease) The most common causes : acute appendicitis, acute cholecystitis , diverticulitis , intestinal obstruction, acute pancreatitis and ulcer perforation 36 Acute Abdomen A careful history and examination are very important in diagnosis The way the pain starts, its location, factors that change the severity of pain, other accompanying symptoms (jaundice, fever, loss of appetite, vomiting, hematemesis , melena , rectal bleeding, itching, etc.) should be investigated other diseases, medications used and family history should be questioned Rectal examination must be performed Necessary laboratory tests and radiological examinations should be requested 37 General Recommendations A distinction should be made between acute and chronic Detailed anamnesis and physical examination (except for very urgent cases) Opinions should not be made without examining the patient An anal- rectal examination must be performed Extra- abdominal causes should be reviewed It should not be forgotten that no finding alone will be sufficient for diagnosis Narcotics and analgesics should be avoided until the diagnosis is made 38