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                               Lecture 7 – Abdominal Pain

Pain is affected by:
   Physiological factors
           o Eg SNS activity
   Psychological factors
   Culture
   Age
           o Child > adult


Types of pain:
   Central – pain of neural origin
           o V rare for abdominal pain
   Somatic
   Visceral


Abdominal pain
   Visceral
   Somatic
   Referred eg from the chest (oesophageal reflux, pneumonia)


Visceral pain arises from visceral peritoneum
   Visceral peritoneum = continuation of parietal peritoneum which leaves the abdominal wall and
    invests viscera
           o Eg lungs may cause irritation of the peritoneum  abdominal pain
           o Extraperitoneal structures can  abdominal pain
           o Cardiac pain can also irritate peritoneum
   Visceral pain
           o Transmitted via autonomic ff
           o Occurs when viscera is stretched (inflamed) or ischaemia eg small bowel distension



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   Deep, dull
   Poorly localized
   May roughly correspond to segmental distribution of somatic sensory ff


Somatic pain arises from parietal peritoneum
   Parietal peritoneum = peritoneum lining wall of abdominal cavity
   Abdominal wall
   Diaphragm
   Root of mesentery
   Somatic pain
          o Teansmitted by pinal (segmental nn) especially T segments
          o Occurs in response to many stimuli
          o Sharp distinct
          o Well localized


Referred pain
   Visceral pain is sometimes perceived as coming from more superficial areas of the body, often
    distant from viscus
   Afferents from skin and viscera converge on same neuron (convergance  projection
    hypothesis)
   Upper abdo pain  irritation of diaphragm  referred to C3,4,5  shoulder pain




Diagram
   Foregut  upper abdomen
          o Many different origins, w/ different patterns
                      Stomach
                      Duedenum
                      Hepatobiliary system
                      Pancreas
   Midgut  mid abdomen


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          o Small bowel – jejunum, ileum
          o Ascending colon
          o Appendix
   Hindgut  lower abdomen
          o Hindgut - hepatic flexure  rectum
          o Reproductive organs


Chronic pain
    1. Recurrent pain
          o Many causes w/ characteristic pain patterns eg
                    Chronic peptic ulcer
                    Inflammatory bowel disease
          o Often due to irritable bowel syndrome:
                    ½ of GIT patients
                    Disease of western society, often assoc w/  fibre diet, stress, poor bowel
                     habits
                    Diagnosis of exclusion – check for other problems first
                    Usuall assoc w/ vague crampy pain, intermittent distention and diarrhoea
    2. Vague, non-specific pain
          o IN elderly – beware intra-abdominal cancer
    3. Intractable
          o Not usually amenable to surgical treatemnet eg
                    Unresectable carcinoma of pancreas
                    Metastatic intra-abdom cancer
                    Chronic pancreatitis – almost always due to alcohol abuse
          o Treated w/ opiates usually  addiction
          o Occasionally treated by destruction of nueral pathways
                    Alcohol injection
                    Division of sp-th tracts
                    If malignant , occasionally radiotherapy




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History
   Different patterns of pain for different diseases
           o But typical patterns only occur in about 70% of cases


    1. Location
           o Exactly where is the pain
           o Wehre is the pain worst?
           o Wehre did the pain start and has it moved?
                     Appendicitis – begins in mid-abdomen (visceral)  rt upper quadrant
                      (somatic – involves parietal peritoneum)
           o Does it radiate?
                     To the back
                            Stomach ulcer
                            Pancreatitis – retroperitoneal organ
                     To the groin
                            Renal pain (may start as abdo/lumbar pain)
    2. Timing and mode of onset
           o when did it start
                     Suddenly eg perforation
           o Was it
                     Sudden – perforation of stomach/duodenum
                     Gradual
           o Has it got worse since it started
    3. Character of pain
           o Can you describe the pain
           o Crampy/colicky = intermittent pain lasting seconds to minutes
           o Dull or sharp
           o Intermittent or constant
           o What makes it worse/better
                     Somatic – movement makes the pain worse eg severe parietal peritoneal
                      inflammation  constant pain worse on movement


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Shifting pain
   Acute appendicitis
   Perforated stomach ulcer
          o Starts upper abdomen  rt upper quadrant
          o Acid leaks out of stomach to sit in rt upper quadrant  pain
          o Can  generalised pain, generalized


Referred pain
See diagrams




Indicators of severe visceral or somatic pain
   Vomiting
   Sweating
    HR ( if severe)
          o Septis, old age  
    BP if severe


On examination
   Significant abdominal tenderness
          o Location – localized/general
   Involuntary contraction of abdominal wall mm = guarding
          o Especially w/ somatic pain
                    Eg w/ severe peritonitis
                            Abdo pain
                            Abdo tenderness
                            Guarding
                             gut fxn eg  bowel sounds
   Rebound pain



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           o Indicates irritation of parietal peritoneum
           o Often occurs w/ guarding
   Lump
           o Tender – localized inflammation eg abscess


Other indicators of abdominal disease
   Significance according to context of history eg location, timing, character of pain
   GIT
           o Constipation
           o Diarrhoea
           o Steartorrhea
           o GIT bleeding eg rectal
           o Bleeding
           o Weight loss
           o Jaundice
   GU
           o Dysuria
           o Haematuria
           o Frequency
           o Vaginal discharge
           o Vaginal bleeding


Examination of abdomen
General appearance
   Looks unwell, sick, sweating
   Dehydrated
   Pale, malnourished, wt loss
   Writhing in pain
           o Renal colic
           o Pancreatitis
   Motionless


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            o Perforated duodenal ulcer
            o Appendicitis
            o Cholecystitis


Abdomen
   Inspecction
            o Scars  prior surgery may cause adhesions  small bowel obstruction
            o Distension
            o Signs of liver disease
   Auscultation
            o Rushes, tinkling in SBO
                      Rush of contractions pushing against blockage
                      Tinkling due to fluid in bowel
            o Bruit – renal a stenosis
   Shake or cough test
            o Positive – peritoneal inflammation
   Percussion tenderness
            o Peritoneal inflammation
   Palpation
            o Start away from tender area
            o Define location of maximal tenderness
            o Elect mm spasm
            o Detect abdo masses
            o Hernial sites – organomegaly


Systemic signs
   Temperature
   HR, BP


Elsewhere
   Chest


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   Flanks
   Genitals


Intraperitoneal pain
   Perforated viscues
             o Duodenum
             o Colon
   Hollow organ
             o Appendiciis
             o Cholecystitis
   Solid organ
             o Pancreatitis
             o Hepatitis
   Pelvic organ
             o PID


Mech obst
   Hollow organ
             o Intestinal obstuction
             o Biliary obstruction
   Solid viscera
             o Acute hepatomegaly
   Pelvic
             o Ectopic pregnancy
             o Large ovarian cyst


Vascular
   Cause of i/p blood
             o Ruptured aneurysm
   Ischaemia
             o Twists


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                  Blockage of lumen
                  Blockage o blood supply w/ second twist
         o Thrombosis




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posted:10/20/2011
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