Objectives of topic
1.key points in history & clinical examination
2.select most appropriate tests
3.determine differential diagnosis
4.identify diseases with high mortality
- 70% of diagnoses can be made based on history alone.
- 90% of diagnoses can be made based on history and physical exam.
- expensive tests often confirm what is found during the history and physical.examn
Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks on each side
- For Evaluation of Pain, Abdomen is divided into four quadrants:
- right upper quadrant
- right lower quadrant
- left upper quadrant
- left lower quadrant
- and three central areas:
Causes of pain in each Quadrant are
AAA-abdominal aortic aneurysm
Gallbladder and common bile duct obstruction
Right upper quadrant pain
Acute cholecystitis and biliary colic
Acute hepatitis or abscess
Hepatomegaly due to CHF
Perforated duodenal ulcer
Right lower lobe pneumonia
Left upper quadrant pain
Splenic enlargement, rupture or Infarction
Left lower lobe pneumonia
Right lower quadrant pain
Small bowel obstruction
Ruptured ectopic pregnancy
Twisted ovarian cyst
Left lower quadrant pain
Ruptured ectopic pregnancy
Twisted ovarian cyst
Disease of transverse colon
Small bowel pain
Early bowel obstruction
Sickle cell crisis
Dissecting or rupturing aneurysm
- pneumonia (lower lobes)
- inferior myocardial infarction
- pulmonary infarction
Types of abdominal pain
– originates in abdominal organs covered by peritoneum
– from irritation of parietal peritoneum
-Produced by pathology in one location felt at another location
- pain from hollow viscera
- often poorly localized
- related to peristalsis
- patient writhing on exam table
- pain from peritoneal irritation
- often localized
- patient lies still with knees up
Types and mechanisms
Types and mechanisms
- The pain associated with inflammation of the parietal peritoneum is steady and aching, and worsened by changes in the tension of peritoneum caused by pressure or positional change. It is often accompanied by tension of the abdominal muscles contracting to relieve such tension.
- The pain associated with obstruction of a hollow viscus is often intermittent or “colicky“
- The pain associated with abdominal vascular disturbances (thrombosis or embolism) can be sudden or gradual in onset, and can be severe or mild. Pain associated with the rupture of an abdominal aortic aneurysm may radiate to the back, flank, or genitals.
- Pain that is felt in the abdomen may be “referred” from elsewhere (e.g., a disease process in the chest may cause pain in the abdomen), and abdominal processes can cause radiated pain elsewhere (e.g., gall bladder pain—in cholecystitis or cholelithiasis—is often referred to the shoulder).
Organic versus functional pain
History organic functional
Pain character acute, persistent pain less likely to change
Increasing in intensity
Pain localization sharply localized various locations
Pain in relation to sleep awakens at night no affect
Pain in relation to
Umbilicus further away at umbilicus
Associated symptoms fever, anorexia,
vomiting, wt loss,
anemia, elevated esr
multiple system complaints
Psychological stress none reported present
Work-up of abdominal Pain
- Onset of pain
Location -does it go anywhere (referred)?
Aggravating and relieving factors
The history of abdominal pain is a critical element in the evaluation. Note the following:
Mode of onset, progression, character, and severity of pain. Pain that is sudden in onset, severe or explosive, progressive, continuous, and lasts more than 6 hours generally indicates surgical etiology. Pain that is gradual in onset, mild to moderate in intensity, intermittent, recurrent, or resolves partially or completely in less than 6 hours favors a nonsurgical diagnosis.
Pain arising in a hollow, tubular structure, such as the ureter, intestine, biliary radicles, or fallopian tubes, may be continuous or intermittent. The severity of such pain is inversely proportional to the diameter of the tubular structure involved.
Activity during which pain was first noted. Persistent pain that awakens the patient or begins during relative inactivity suggests a surgical resolution. Pain that occurs during or closely following strenuous activity—or after eating—favors a nonsurgical diagnosis.
Initial location of pain and any shift. In general, the farther from the umbilicus the pain localizes, the greater the chance that a surgical condition exists. Pain arising from foregut derivatives (stomach, duodenum, biliary tract, and pancreas) or the spleen presents in the epigastrium. Pain arising from midgut derivatives (jejunum, ileum, proximal third of the colon, and appendix) presents in the periumbilical area. Pain arising from the embryonic hindgut (distal two-thirds of the colon), internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate), and the urinary bladder presents in the hypogastrium.
A shift in pain occurs when the original inflammation extends to the parietal peritoneum. For example, appendicitis initially causes pain in the periumbilical area. Then, after 4 to 6 hours, the inflammation extends to the regional peritoneal surface and is perceived in the right lower quadrant.
Associated symptoms and their temporal relationship to the pain. Many abdominal conditions that cause pain also give rise to vomiting, nausea, anorexia, fever, chills, constipation, and diarrhea. In surgical conditions, pain may be followed by nausea, vomiting, and anorexia. In nonsurgical conditions nausea, vomiting, and anorexia typically precede pain. Additionally, clinical experience has shown that vomiting in the obese patient is an ominous symptom and virtually always suggests serious abnormalities.
Anorexia is uncommon in athletes, especially in obese individuals, and is therefore always a significant symptom in such patients. Fever is a common finding in patients who have abdominal pain; however, fever and chills is rarely seen in surgical processes. This combination suggests infection in the urinary tract, respiratory system, etc.
Constipation may accompany any abdominal condition that causes an illness. Obstipation—nonpassage of both stool and gas—however, always suggests a surgical problem. Diarrhea, especially with cramps, indicates gastroenteritis and other nonsurgical conditions like inflammatory bowel disease.
What aggravates the pain. Always ask first about which activities aggravate the pain. (One can generally assume that the opposite will ease the pain.) If the patient hears questions about what eases the pain, he or she may perceive it as minimizing the problem and become defensive.
Coughing, sneezing, rapid movements, and walking, especially down stairs, can cause peritoneal irritation. Musculoskeletal pain is often relieved by changing position. A bowel movement often eases the pain of gastroenteritis, but the pain may promptly recur.
Menstrual history and reproductive status. Many athletes are sexually active, and among sexually active people, women experience abdominal pain twice as often as men of the same age. Men who do experience abdominal pain, however, have a higher incidence of surgical disease. This disparity is generally because of the painful conditions affecting the female genitourinary tracts—nonsurgical (pelvic inflammatory disease, endometriosis, dysmenorrhea, and urinary tract infection) and surgical (torsion of ovary and ectopic pregnancy). In men, seminal vesiculitis, prostatitis, and urethritis can cause lower abdominal pain.
Pain that is severe, sudden in onset, and follows an abnormal menstrual period might stem from an ectopic pregnancy. Pain that is noted shortly after a normal menstrual period, is bilateral, and is accompanied by a fever and abdominal pain—but not nausea and vomiting—favors pelvic inflammatory disease.
Medications and supplements. Aspirin and other nonsteroidal anti-inflammatory drugs, erythromycin, potassium, and salt tablets commonly cause gastric irritation and abdominal pain.
Previous episodes, family history of similar problems, peers with the same symptoms, food intolerance, allergies, sudden changes in training or diet, and travel to regions with endemic disease. These all favor a nonsurgical diagnosis.
Inspection is always an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.
Position – patient should be supine and the bed or examination table should be flat. The patient’s hands should remain at his/her sides with his/her head resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend her knees so that the soles of her feet rest on the table will also relax the abdomen.
Lighting – adjusted so that it is ideal.
Draping – patient should be exposed from the pubic symphysis below to the costal margin above – in women to just below the breasts. Some surgeons would describe an abdominal examination being from nipples to knees.
Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent
Obliteration of liver dullness
Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient’s facial expression.
Look for Guarding -rebound tenderness and Rigidity
Rectal exam : Look for
Empty balloned rectum in Obstruction
Tender anterior wall in Pelvic Peritonotis
Mucus /blood on finger in Intususception
Pelvic exam Look For
Tenderness of fornices in Salpingitis
Tender movements of cervix in Pregnancy
Fullness of douglas pouch in Pelvic Abscess
- Labs and Diagnostic Studies
- Complete Blood Count (CBC)
- Leukocytosis lags other findings in elderly
- Pulse oximetry
- Serum Phosphate (increased in Mesenteric Ischemia)
- Liver Function Tests
- Blood Cultures
- Lipase Indications
- Arterial Blood Gas
- Imaging: Protocol
- Directed imaging where specific cause is suggested
- Initial non-specific radiology studies
Contrast studies -barium (upper and lower Gi series)
CT Scanning with & without Contrast
|Differentiating Common Nonmusculoskeletal Sources of Abdominal Pain|
|Condition||Typical Signs and Symptoms|
|Appendicitis, acute||Constant pain, progressively more severe; begins in periumbilical region, moves to right lower quadrant; nausea, vomiting, and anorexia follow pain; low-grade fever; patient appears ill|
|Cholecystitis, acute||Constant pain in right upper quadrant, onset often postprandial; nausea and vomiting; tenderness in right upper quadrant and right shoulder; splinting on right side|
|Perforated peptic ulcer||Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent|
|Ectopic pregnancy||Pain sudden, severe, and persistent, generally following a missed or abnormal period, typically epigastric; often associated with hypotension and tachycardia|
|Ovarian cyst||Pain constant with sharp, sudden onset; usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain|
|Pelvic inflammatory disease||Pain at end of or shortly after normal menstrual period; bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever|
|Urinary calculus||Pain location changes with movement of stone, may radiate to testicle, groin of involved side; pain very severe; patient cannot get comfortable|