EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN

BYDR OJIH

OUTLINE

• INTR0DUCTION• CAUSES• MECHANISM OF PAIN ORIGINATING FROM

THE ABDOMEN• HISTORY• EXAMINATION• INVESTIGATION• TREATMENT

INTRODUCTION• One of the most common causes of presentation at the accident and

emergency• Diagnosis is difficult because numerous causes exist -NSAP 34% -Acute appendicitis 28% -Acute cholecystitis 10% -small bowel obstruction 4% -perforated PU 3% -pancreatitis 3% -Diverticular disease 2% -0thers 13%• 20-40% admission rates• 50-65% inaccurate initial diagnosis

CAUSESPAIN ORIGINATING IN THE ABDOMEN

• PARIETAL PERITONEAL INFLAMMATION -Bacterial contamination -perforated appendix or other viscus -PID -Chemical irritation -pancreatitis

CAUSES CONTINUED

• MECHANICAL OBSTRUCTION OF HOLLOW VISCERA

-Obstruction of the small or large intestine -Obstruction of the biliary tree -Obstruction of the ureter

• VASCULAR DISTURBANCES -Embolism or thrombosis -vascular rupture -pressure or torsional occlusion -sickle cell anaemia

• Abdominal wall -distortion or traction of the mesentry -trauma or infection of muscles• DISTENSION OF VISCERAL SURFACES-e.g by

haemorrhage -hepatic or renal capsule• INFLAMMATION OF A VISCUS -appendicitis -typhoid fever -typhilitis

PAIN REFERRED FROM EXTRAABDOMINAL SOURCE

• CARDIOTHORACIC -acute myocardial infarction -myocarditis ,endocarditis, pericarditis -Congestive cardiac failure -pneumonia -Pulmonary embolism -Pleurodynia -Pneumothorax -Empyema -Esophageal disease,spasm,rupture,inflammation• GENITALIA -Torsion of testis

METABOLIC CAUSES OF ABDOMINAL PAIN

• DM• Uremia• Hyperlipidaemia• Hyperparathyroidism• Acute adrenal insufficiency• Familial Mediterranean fever• Porphyria• C’1 esterase inhibitor deficiency( angioneurotic

oedema)

NEUROLOGIC /PSYCHIATRIC CAUSES

• Herpes zoster• Tabes dorsalis• Causalgia• Radiculitis from infection or arthritis• Spinal cord or nerve root compression• Functional disorders• Psychiatric disorders

TOXIC CAUSES

• Lead poisoning• Insect or animal envenomation• Black widow spiders• Snake bites

UNCERTAIN MECHANISM

• Narcotic withdrawal• Heat stroke

MECHANISM OF PAIN ORIGINATING IN THE ABDOMEN

• VISCERAL PAIN -afferent impulses from visceral organs poorly localized -pain generally felt in the midline - pain localization depends on the embryologic origin of

the organ Foregut structures------epigastrium midgut structures-------periumbilical region hindgut structures---------suprapubic region -visceral nociceptors are stimulated by distention, Stretch, vigorous contraction, ischaemia and

inflammation

• SOMATIC PAIN -usually from inflammation or chemical

irritants (gastric content) -localized to the dermatome above the site of

stimulus -transmitted by spinal nerve supplying the

parietal peritoneum or mesodermal structures

• REFERRED PAIN • Could be from the thorax, spine or genitalia• Produces symptoms not signs

HISTORY

• Generally the cornerstone of accurate diagnosis• Complete description of the patient’s pain and

associated symptoms• Key points in the history include -P positional, palliating and provoking factors -Q quality -R region, radiation, referral -S severity -T temporal factors ( time and mode of onset,

progression, previous episodes)

LOCATIONwhere do you feel the pain

• Can be generalized or localized• visceral pain -foregut structures------epigastrium - midgut structures -----periumbilical - hindgut structures-----suprapubic• Somatic pain -localised above the dermatome producing

the stimulus

CHARACTERwhat kind of pain is it

• VISCERAL PAIN -dull, poorly localised, aching, colicky, or

gnawing.• SOMATIC PAIN -sharp, steady aching, more defined and well

localised

ONSEThow did it start

• Could be acute or gradual• Tells the duration of pain• Helps to interpret current findings and making

diagnosis

RADIATIONwhere else do you feel the pain

• Any inflammatory process / organ contiguous to the diaphragm can cause referred shoulder pain

• Acute gall bladder distension gives ipsilateral scapular pain

• abdominal pain radiating to the sacral region , flank, or genitalia may raise suspicion of rupturing abdominal aortic aneurysm

PROVOCATIVE AND PALLIATNG FACTORSwhat worsens or relieves the pain

• Somatic pain- worsened by pressure or changes in tension of the peritoneum

(palpation, coughing , sneezing)• Pancreatitis – pain is worsened by bending

forward and relieved by upright position• Gastric ulcer – pain is aggravated by food• Duodenal ulcer - relieved by food• Ask about analgesics and NSAIDS

Associated symptoms

• Fever• Anorexia• nausea• Vomiting• Diarrhoea• Cough• Amenorrhoea• Dysuria etc

PAST MEDICAL & SURGICAL HX, CURRENT MEDICATIONS

• Previous surgery– adhesions• DM---DKA• CKD– uraemia• SCD– vasocclusive crises• Steroids and NSAIDS

SOCIAL HX

• Substance abuse e.g cocaine• Alcohol• Domestic violence ( trauma )

PHYSICAL EXAMINATION

• Inspection -Bending forward : chronic pancreatitis -lying still, avoiding movt: peritonitis -Restless: visceral pain -Jaundiced : common bile duct obstruction -Dehydrated: peritonitis, small bowel

obstruction.

SYSTEMIC EXAMINATIONABDOMEN

• Inspection -scaphoid or flat in peptic ulcer -distended in ascities or intestinal obstruction -visible peristalsis in a thin or malnourished

patient (with obstruction) -surgical scar (adhesions) -caput medusa in chronic liver disease

SYSTEMIC EXAMINATION

• Palpation -check the hernia sites -tenderness -rebound tenderness - guarding(involuntary spasm of muscles during

palpations) -rigidity (when abd. muscle are tense and board

like) indicates peritonitis

SYSTEMIC EXAMINATION

• Epigastric tenderness -DU/GU -acute pancreatitis -esophagitis• Local right iliac fossa tenderness -acute appendicitis -acute salpingitis in females -crohns disease

SYSTEMIC EXAMINATION

• Periumbilical tenderness -early appendicitis -SBO -acute gastritis -mesenteric thrombosis-ruptured AAA

• Right upper quadrant tenderness -gall bladder disease -acute pancreatitis -Pneumonia -Subphrenic abscess - DU• Suprapubic tenderness -acute urinary retension -PID -cystitis

Important Signs in Patients with Abdominal Pain

Sign Finding Association

Cullen's sign Bluish periumbilicaldiscoloration

intraperitoneal haemorrhage

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture

McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis

Obturator's sign Internal rotation of flexed right hip causingabdominal pain

Appendicitis

Grey-Turner's sign

Discoloration of the flank Retroperitoneal haemorrhage

Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant

Appendicitis

PHYSICAL EXAMINATION

• Percussion-differentiates between ascities ( shifting

dullness ) and large bowel obstruction ( drum-like tympany)

Physical examination

• Auscultation – Has limited diagnostic utility– > 2min to confirm absent ( ileus)– High pitched in early SBO– Bruit in aortic, renal or mesenteric stenosis

Systemic Examination

• Digital Rectal Examination: - tenderness - indurations - mass - frank blood

Systemic Examination

• Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

Investigations

• FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • FBS/RBS• G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)

Investigations

• Urinalysis• Pregnancy test• RADIOLOGICAL INVESTIGATIONS -CXR(PA) -Abd XR( erect and supine) -IVU -CT Scan—gold standard for diagnosis of

appendidcitis• Laparoscopy

TREATMENT• DEPENDS ON THE CAUSE• May need resuscitation (ABCD)• IV fluid if there’s dehydration• Analgesic (iv opiods)• H2 receptor antagonists and proton pump

inhibitors( PUD )• Antibiotics if there’s evidence of infection• Antispasmodic (hyoscine)• Surgery

REFERENCES

• Harrisons principle of internal medicine 18th edition

• Christopher R.M and Robert M.M,2012, International journal of internal medicine

• Dimitri R and Alec E, diagnosis and management of abdominal pain

Thank you