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					    Abdominal Pain

   James S Newman, M.D.
The University of Texas Medical
            Branch
“All who have had much experience of
the group of cases known generally as
the acute abdomen will probably agree
that in that condition early diagnosis is
exceptional.”
 Zachary Cope
  June, 1921
    Types of abdominal pain
• Colicky pain - caused by distention of a
  hollow viscus, such as bowel.
• Somatic pain - caused by inflammation
  of the parietal peritoneum.
• Visceral pain - caused by inflammation
  of the visceral peritoneum and capsule
  of solid organs.
Quadrant View of the
    Abdomen
Right Upper
                 Cholecystitis
• Inflammation of the gall bladder caused by duct
  obstruction with a gall stone.
• Pain is usually steady for an hour or more after onset
  and made worse by eating.
• If there is significant inflammation associated with the
  cholecystitis, there may be local peritoneal pain
  (somatic pain).
• Pain may be referred to the scapular area and
  accompanies nausea, vomiting, and fever without
  jaundice.
• Diagnosed with ultrasound.
              Cholangitis
• Caused by obstruction of the biliary tract
  leading to bacterial overgrowth in the gall
  bladder.
• Marked by Charcot’s Triad - RUQ pain,
  jaundice and fever.
• Diagnosed by ultrasound.
• Is an emergency and must be treated with IV
  antibiotics.
• May require decompression via endoscopic
  or surgical means.
                 Hepatitis
• Caused by inflammation of the liver by
  viruses, alcohol or certain drugs.
• Marked by tender, enlarged liver with
  malaise, fever and jaundice.
• Diagnosed by history and laboratory
  evaluation - liver function tests and viral
  serologies.
• Treatment depends on etiology of disease.
               Pancreatitis
• Most commonly caused by alcoholism (50%) and gall
  stones (30%) obstructing the common bile duct.
• Constant mid-epigastric visceral pain usually
  occurring after a heavy meal or alcoholic binge.
• Pain may radiate to the back (50%) and is
  accompanied by nausea, vomiting and anorexia.
• Diagnosed by amylase and lipase. Imaging by CT
  scan may be desirable in some cases.
Left Upper
         Peptic Ulcer Disease
• Caused by increased gastric acid production or decreased
  mucosal protection.
• Increased gastric acid production may be caused by
  alcoholism or gastrin producing tumor (Zollinger-Ellison
  Syndrome).
• Decreased mucosal protection may be caused by overuse
  of NSAID’s or by infection with Helicobacter pylori.
• Pain is visceral and may become somatic if perforation
  occurs. There may be radiation to the back.
• Diagnosed by H. pylori antigen in the serum, abdominal x-
  rays detect free air if there is perforation, UGI and
  endoscopy
• Treatment consists of Omeprazole 20mg, Amoxicillin 1gm,
 Dissecting Abdominal Aortic
          Aneurysm
• Caused by tearing of the layers of the
  abdominal aorta secondary to atherosclerotic
  changes.
• Pain of dissection is described as an
  excruciating tearing sensation often referred
  to the midline back.
• May be accompanied by hypotension,
  pulsatile abdominal mass and diaphoresis.
• Diagnosed by abdominal ultrasound
• Is a surgical emergency!
Left Lower
                Diverticulitis
• Diverticula form in weakened areas of the colonic
  wall and may become impacted with feces leadingt to
  infection and possible perforation.
• Pain is described as cramping, steady visceral pain.
• May be accompanied by change in bowel habits,
  fever, nausea, vomiting and anorexia.
• May have leukocytosis on CBC.
• Diagnosed by CT scan - swollen edematous bowel
  wall. *Must avoid colonoscopy and barium enema in
  the acute setting to avoid perforation*
            Ovarian Cysts
• Pain caused by distention of cyst lining and
  may hemorrhage into the pelvic cavity.
• Pain is described as constant achy pain in the
  lower quadrants and may radiate to the groin
  area.
• Diagnosed by ultrasound
• Also consider ovarian torsion, pelvic
  inflammatory disease and ectopic pregnancy.
• Pelvic etiologies must be considered in any
  female patient presenting with signs of an
Right Lower
              Appendicitis
• Caused by obstruction of the appendiceal
  lumen usually by a fecalith.
• Pain starts as periumbilical and migrates to
  the RLQ (McBurney’s Point)
• Is accompanied by nausea, vomiting and
  anorexia. May have fever - especially if
  ruptured.
• Diagnosed by ultrasound or CT scan.
• Treatment is surgical and is an emergency if
  ruptured.
    General Abdominal Pain
• Some causes of abdominal pain are
  generalized and not restricted to any
  specific quadrant.
                 Gastritis
• Caused by inflammation of the
  gastrointestinal tract by microorganisms,
  radiation and other irritants.
• Described as diffuse crampy abdominal pain.
• Often accompanied by diarrhea, nausea,
  vomiting, dehydration and fever.
• Diagnosis is by history and stool cultures if
  indicated.
                Colon Cancer
• Caused by neoplastic growth in the ascending,
  transverse, descending or sigmoid colon. Increased
  incidence in high fat, low fiber diets, positive family
  history and history of inflammatory bowel disease.
• Pain is colicky and is similar to that caused by large
  bowel obstruction, especially left-sided lesions.
• Associated with change in bowel habits, heme
  positive stool and weight loss.
• Diagnosed by colonoscopy, flexible sigmoidoscopy
  and barium enema.
• Rectal exam should also be performed as 10% of
  cancers are palpable on rectal exam.
          Bowel Obstruction
• Caused by obstruction of the bowel lumen by mass,
  hernia entrapment, volvulus, intussusception and
  rotation around scar adhesions.
• Pain is colicky in nature.
• Accompanied by vomiting - especially if the
  obstruction is proximal.
• May be accompanied by watery diarrhea - evacuation
  of distal intestinal contents.
• Diagnosed by abdominal x-rays looking for distended
  loops of bowel and air-fluid levels.
             Kidney Stones
• Caused by obstruction of the upper urinary tract
  by a stone that is induced by dehydration,
  infection, hypercalcemia and other metabolic
  imbalances.
• Pain is described as colicky and located
  anywhere from the flank to the groin.
• Diagnosed by intravenous pyelogram, ultrasound
  or CT scan.
• Should also consider pyelonephritis, cystitis and
  prostatitis.
        Appropriate History
• Onset of pain, location, quality, severity,
  radiation, associated symptoms.
• Past medical and surgical history,
  medications and menstrual history -
  possibility of pregnancy.
• Description of emesis and stool - color,
  consistency, amount, presence of
  mucous and blood.
            Appropriate Exam
• Vital signs to evaluate for signs of infection,
  dehydration, shock, instability.
• Inspect visually for distention, scars,jaundice, signs of
  hernias or masses.
• Auscultate - high pitched bowel sounds may indicate
  early obstruction. No bowel sounds indicate ileus.
  Increased bowel sounds may be associated with
  gastritis.
• Palpate and Percuss - for tenderness, masses,
  pulsation, hernias, guarding, CVA tenderness, liver
  and spleen size, ascites and hyperresonance.
• Pelvic exam in women
       Laboratory/Radiology
• CBC with Diff, urinalysis, electrolytes.
• Liver function tests, amylase/lipase.
• CXR for free air under the diaphragm or lower
  lobe pneumonia.
• Supine and upright abdominal x-rays.
• Ultrasound, CT scan, IVP, barium enema,
  UGI, endoscopy and colonoscopy when
  indicated.
• Pregnancy test in all reproductive-aged
  females.
           Initial Treatment
• Must decide whether to admit and observe,
  discharge or operate.
• Keep NPO until diagnosis has been
  established.
• IV fluids for maintaining correct fluid balance
• Nasogastric tube for gastric decompression,
  vomiting or bleeding.
• Foley catheter to ensure adequate hydration
  and urine output.
• Pain medications as indicated.
             References
• The Virtual Hospital - www.vh.org
• The Mont Reid Surgical Handbook,
  Berry et al.
• Surgical Recall, Blackbourne.
• Special Thanks to Matt Davis, MSIII and
  Angela Hewlett, MSIII for their tireless
  efforts and assistance.