ABDOMINAL PAINIMS LARGE GROUP DISCUSSIONGROUP 1

INTRODUCTIONAbdominal Pain• Acute or Chronic

Causes• Inflammatory

• Mechanical

• Neoplastic

• Vascular

• Congenital

• Trauma

HISTORY TAKING

1. Location of the pain. Is the pain well localized to one particular area?

Onset of the pain. Did the pain occur suddenly, or has it gradually increased in intensity?

• Acute: Renal Calculi, Cholecystitis• Chronic: Crohn’s, Irritable Bowel Syndrome• Gradually and Steadily: Pancreatitis

Character of the pain. Is the pain sharp, burning, colicky, or cramping (squeezing)?

• Sharp pain: Peritonitis• Colicky: Intestinal obstruction• Burning: Gastroesophageal Reflux

Radiation of the pain.• Loin to groin: Renal calculi• Right scapula: cholecystitis• Shoulder tip: diaphragmatic irritation

Associated symptoms. Is the victim short of breath, nauseated, vomiting, suffering from diarrhea or constipation, or dizzy? Is the patient vomiting blood?

• Weight lost: Cancer (not necessarily), malnutrition,• Shortness of breath: Cardiovascular disease• Haematemesis: Peptic ulcer, severe GERD, severe gastritis

Timing of the pain. Relationship to food.• Pain before food: Peptic ulcer• Pain eating spicy food: Peptic ulcer, irritable bowel syndrome• Pain eating fatty food: cholecystitis

Relief of pain and aggravating of pain. Is there a position that the patient can assume that will lessen the pain? Is the patient agitated and constantly moving around?

• Peptic Ulcer: relieved by eating• Pancreatitis: relieved by sitting up and leaning forward• Peritonitis: aggravated by movements

Severity.• High intensity: Renal calculi, peritonitis, pancreatitis

PHYSICAL EXAMINATION

INSPECTIONClubbing – cirrhosis, IBD and coeliac disease

Leukonychia – hepatic disease, nephritic syndrome, malabsorption

Muehrcke’s lines – severe liver cirrhosis

Palmar erythema – chronic liver disease, pregnancy

Dupuytren’s contracture – alcoholic liver disease

Pallor – anaemia

B.P., pulse , temperature and dehydration

Eyes and skin for jaundice

Weight loss

Gynaecomastia

Scars and abdominal distension

PALPATIONPalpation of the abdomen for masses, rebound tenderness (peritonitis)and peritoneal signs

Murphy’s sign – cholecystitis

McBurney’s sign – appendicitis

Hepatomegaly – chronic liver disease

Pelvic examination in women with lower abdominal pain

Abdominal percussion – tympanic from proximally dilated loops of bowel

Bowel sounds – high pitched or absent (bowel obstruction)

INVESTIGATIONS

Full Blood Count and Erythrocyte Sedimentation Rate

Hb ↓: Peptic ulcer disease, Malignancy

WCC ↑: Infective / Inflammatory disease

ESR ↑: Inflammatory bowel disease, Tuberculosis Urea and Electrolytes

Urea & creatinine ↑: Ureamia

Electrolyte disturbance: Vomiting, Diarrhoea Liver Function Tests

Abnormal: Cholangitis, Hepatitis, Acute cholecystitis Serum amylase

↑: Acute pancreatitis, Perforated peptic ulcer, Infarcted bowel Midstream Urine

Blood, Protein, culture positive: Pyelonephritis

Red cells: Ureteric colic

*ESR= Erythrocyte Sedimentation Rate *Hb= Haemoglobin *WCC= White Cell Count

GENERAL INVESTIGATIONS

Chest X-ray

Gas under diaphragm: Perforated viscus

Lower lobar pneumonia: Referred pain

Abdominal X-ray

Dilated loops of bowel: Obstruction

Lead pipe appearance of colon: Ulcerative colitis

Renal calculi

Gallstones

Ultrasonography

Localised abscess: Appendix abscess, paracolic abscess in diverticular disease

Fluid: Peritonitis, Ascites

Aortic aneurysm

Ectopic pregnancy

Ovarian cyst

Gallstones

Empyema

Kidney cyst, tumour

Oesophago-gastro-duodenoscopy

Peptic ulcer malignancy Intravenous Pyelogram

Stones in urinary system Barium enema

Carcinoma, Volvulus, Intussusception Small bowel enema

Crohn’s disease, Malignancy Angiography

Superior mesenteric embolus or thrombosis Computed Tomography

Aneurysm, Pancreatitis, Tumour Magnetic Resonance Cholangiopancreatography

Biliary tract disease

SPECIFIC INVESTIGATIONS

Serum calcium

Hypercalcaemia: Calculi C-reactive Protein

Crohn’s disease, Ulcerative colitis Sickling test

Sickle cell anaemia Urinary porphobilinogens

Acute intermittent porphyria β-Human Chorionic Gonadotropin

Pregnancy, Ectopic pregnancy Electrocardiogram

Myocardial infarction (referred pain) Blood glucose

↑ in diabetic ketoacidosis

CONCLUSIONAbdominal pain is very common and has a wide range of severity and causes

Acute abdomen is a medical emergency because some causes of acute abdomen are lethal

All these causes should be ruled out first before attempting to look for chronic causes

Immediate intervention is warranted