abd. pain (1).pdf

Abdominal Pain ❖ Types of abdominal pain : - 1. Visceral pain : This pain is resulted from stretching, distension, contraction and twisting. Unpaired organs` pain is felt usually , not always , in the midline. The Visceral pain is dull , and poorly localized. 2. Parietal pain : Th...

Abdominal Pain ❖ Types of abdominal pain : - 1. Visceral pain : This pain is resulted from stretching, distension, contraction and twisting. Unpaired organs` pain is felt usually , not always , in the midline. The Visceral pain is dull , and poorly localized. 2. Parietal pain : This pain is resulted from irritation of parietal peritonium ,which is innervated by somatic nerve. The parietal pain is well localized and lateralized , and resulted from infection, inflammation and neoplasia. 3. Referred pain : - gallbladder pain is referred to tip the shoulder , and back - M.I ………. Epigastrium 4. Psychogenic : - Some patient no organic cause is founded - This pain may be resulted from depression , or somatisation.  Analysis of abdominal pain according to (SOCRATES) questions :- Site of pain : The site of the pain can give a clue about the diagnosis and the cause of the pain. ❑ Epigastric pain : pancreatitis,gastritis,duodenitis,peptic ulcer, biliary disease, aortic aneurysm. ❑ Right upper quadrant : hepatitis,cholecystitis,biliary colick,peptic ulcer,subphrenic and periphrenic abscess, renal(stone , pyleonephritis),colonic cancer(hepatic flexure). ❑ Left upper quadrant : peptic ulcer, gastric or colonic cancer (splenic flexure),splenic rupure,subphrenic or periphrenic abscess ,renal(stone ,pyleonephritis). ❑ Loin ( lateral 1/3 of the back, between thorax and pelvis –merges with the flank ) : renal colick , pyleonephritis, renal tumor,perinephritis,pain referred from vertebral column. ❑ left-iliac fossa pain : diverticulitis,volvulus,colon cancer,plevic abscess, inflammatory bowel disease, hip pathology, renal colic, urinary tract infection(UTI),cancer of undescended testis,zoster,ectopic pregnancy, torsion of ovarian cyst, and salpingitis. ❑ Right-iliac fossa pain : appendicitis (mass, abscess) , Crohn's ileitis and all the causes of left iliac fossa pain ( but usually excluding diverticulitis). ❑ Pelvic pain :due to urological( UTI ,urine retention, bladder stone) and gynecological (menstruation,pregnancy,endometriosis, salpangitis,torsion of ovarian cyst) disorders. ❑ Central pain : mesenteric ischemia, abdominal aneurysm, pancreatitis ❑ Generalized abdominal pain : gastroenteritis, irritable bowel syndrom, peritonitis  Onset : the abdominal pain could be acute , or chronic …. THE ACUTE ABDOMEN :- ✔ acute abdomen accounts for about 50% of all urgent admission to the general surgery units. ✔ Acute abdomen resulted from certain pathological processes :- 1.Inflammation : Here abdominal pain develops gradually , usually over hours ,and its initiated as diffuse pain, until the parietal peritonium is irritated, when it becomes localised.Movements exacerbates the pain ; abdominal rigidity and guarding occur. 2. Perforation ; when the viscus perforated the pain started abruptly and severe , and leads generalized peritonitis. 3. Obstruction ; pain is colicky , with spasms (pain is disappears between spasms) which cause the patient to writhe and double up. Pain that does not disappear between spasms indicates severe inflammation. ✔ Table 1 shows the causes of acute abdomen  Table 1- Causes of acute abdomen Inflammation 1. Appendicitis. 5.Pancreatitis. 2. Diverculitis. 6.Pyelonephritis. 3. Cholecystitis. 7.Intraabdominal abscess. 4. Pelvic inflammatory diseases. Perforation / Rupture 1. Peptic ulcer. 2. Diverticular diseases. 3. Ovarian cyst 4. Aortic aneurysm. Table 1 Obstruction 1. Intestinal obstruction. 2. Biliary colic 3. Ureteric colic Other (rare) = extra intestinal causes Table 1  Character and pattern of the pain : ✔ Character (constant,colicky,sharp or dull, awakes the patient from sleep) ✔ Pattern (intermittent , continuous) Radiation ✔ Peptic ulcer disease radiates to the either upper quadrants ,or to the back ✔ Gallbladder diseases radiate to the tip of the right shoulder or the pack.  Associated symptoms ; weight loss, vomiting, altered bowel habit Timing and duration Exacebated (precipitated ) and relieving factors : food , hungry , drugs ,alcohol , posture , movement , defecation. Severity ❖ Management of acute abdomen Careful history Clinical exam. : vital signs , abd. ex. (looking for any signs of peritonitis including guarding and rebound tenderness , with rigidity). Every (2-4) hours the patient should be reassessed carefully , so that any changes in condition might alter both diagnosis and the clinical decision of treatment. Investigations : 1. Full blood count = for leukocytosis 2. Urea and electrolytes = for dehydration 3. Amylase = for pancreatitis 4. X – ray : erect chest x-ray ( for any air under diaphragm suggestive of perforation) , and plain abd. X- ray (may show evidence of obstruction). 5. Ultrasound : it can detect renal or gall stones, any free fluid in the abdomen or intra-abdominal abscess. 5. Contrast radiology : for further evaluation of intestinal obstruction(differentiate between pseudo-obstruction and mechanical large intestinal obstruction). 6. CT scan : commonly used , looking for evidence of pancreatitis, any retroperitoneal collections or masses including aortic aneurysm. 7. Angiography : for mesenteric ischemia Perforated peptic ulcer Intestinal obstruction  Treatment of acute abdomen : It`s generally depended on the affected organ (perforation is closed , obstruction is relieved and inflammation is treated with antibiotics and resection). The spread of intervention and the necessity of surgery is depending on no. of factors, the most important one is the presence or absent of peritonitis.  Chronic or Recurrent abd. Pain ✔ Causes of chronic or recurrent abdominal pain includes certain intestinal and extra intestinal disorders ( table 2 ) ✔ Note should be made about the patient `s general behavior ,mood, emotional state, signs of weight loss,fever,jaundice,or anemia. Also look for any evidence of diseases affect other structures , epically the vertebral colmun,spinal cord, lungs and cardiovascular system. ……..Table 2 - Extra- intestinal causes of abdominal pain Retroperitoneal 1. Aortic aneurysm 2. Malignancy 3. Lymphadenopathy 4. Abscess Psychogenic 1. Depression 3.Somatisation 2. Anxiety Neurological / Locomotors 1. Vertebral compression 5.Abdominal muscle strain 2. Spinal cord lesion 3. Tabes dorsalis 4. Radiculopathy Drugs and toxins : alcohol , lead , steroids , azathioprine Metabolic /Endocrine 1. Diabetes mellitus 4. acute intermittent porphyria 2. Addison`s disease 3. Hypercalcaemia Haematological disorders 1. Hamolytic disorders 2. Sickle – cell anemia Table 2 Investigations : depend to a large extent on the clinical features found during the history and clinical ex. :- Endoscopy and U/S for any patient with gastric pain , and for dyspepsia and symptoms suggestive of gallbladder diseases. Colonoscopy is indicated for patient with altered bowel habit ,rectal bleeding , or features suggested colonic obstruction. Angiography is indicated for patient with features suggestive of mesenteric ischemia (abd. Pain is provoked by eating in patient with wide spread atherosclerosis)  For young patient with pain that is relived by defecation, bloating and alternating bowel habit is likely to have irritable bowel syndrom(IBS) , which requires simple investigations (full blood count , faecal calprotectin and sigmoidoscopy) in the absent of weight loss, rectal bleeding or abnormal physical findings. A history of alcohol misuse, weight loss and diarrhea suggest chronic pancreatitis or pancreatic cancer. Those patients require ultrasound,abd.CT scan and faecal elastase. Plain abd. X-ray , ultrasound and I.V urography for patients with symptoms of renal or ureteric colic ( recurrent loin pain and urinary symptoms). In the case of psychiatric disturbances ,repeated negative investigation, or vague symptoms that do not fit any disease or organ pattern suggest psychological origin of the pain.