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

Facts :

  • 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:
  • epigastric
  • periumbilical
  • suprapubic

 

Causes of pain in each Quadrant are

 

Epigastric pain      

PUD

GERD

MI

AAA-abdominal aortic aneurysm

Pancreatic pain

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

Herpes zoster

Myocardial ischemia

Right lower lobe pneumonia

Left upper quadrant pain

Acute pancreatitis

Gastric ulcer

Gastritis

Splenic enlargement, rupture or Infarction

Myocardial ischemia

Left lower lobe pneumonia

Right lower quadrant pain

Appendicitis

Regional enteritis

Small bowel obstruction

Leaking aneurysm

Ruptured ectopic pregnancy

PID

Twisted ovarian cyst

Ureteral calculi

Hernia

Left lower quadrant pain

Diverticulitis

Leaking aneurysm

Ruptured ectopic pregnancy

PID

Twisted ovarian cyst

Ureteral calculi

Hernia

Regional enteritis

 

Periumbilical pain

Disease of transverse colon

Gastroenteritis

Small bowel pain

Appendicitis

Early bowel obstruction

Diffuse pain

Generalized peritonitis

Acute pancreatitis

Sickle cell crisis

Mesenteric thrombosis

Gastroenteritis

Metabolic disturbances

Dissecting or rupturing aneurysm

Intestinal obstruction

Psychogenic illness

Referred pain

  • pneumonia (lower lobes)
  • inferior myocardial infarction
  • pulmonary infarction

 

 

Types of abdominal pain

Visceral

– originates in abdominal organs covered by peritoneum

Colic

–crampy pain

Parietal

– from irritation of parietal peritoneum

Referred

-Produced by pathology in one location felt at another location

  • pain from hollow viscera
  • crampy/paroxismal
  • often poorly localized
  • related to peristalsis
  • patient writhing on exam table
  • pain from peritoneal irritation
  • steady/constant
  • often localized
  • patient lies still with knees up

Types and mechanisms

Types and mechanisms

  1. 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.
  2. The pain associated with obstruction of a hollow viscus is often intermittent or “colicky
  3. 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.
  4. 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

headache, dizziness,

multiple system complaints

Psychological stress                               none reported                               present

 

 

Work-up of abdominal Pain

History

 

  • Onset of pain

Qualitative description

Intensity

Frequency

Location -does it go anywhere (referred)?

Duration

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.

 

 

Work-up

Physical examination

 

Inspection

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.

 

 

 

Auscultation

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

 

 

Percussion

Dullness

Resonance

Obliteration of liver dullness

 

Palpation

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

 

 

Work-up

Laboratory tests

 

  1. Labs and Diagnostic Studies
    1. Urinalysis
    2. Complete Blood Count (CBC)
      1. Leukocytosis lags other findings in elderly
    3. Electrocardiogram
    4. Pulse oximetry
    5. Serum Phosphate (increased in Mesenteric Ischemia)
    6. Liver Function Tests
    7. Blood Cultures
    8. Amylase
      1. Pancreatitis (Lipase preferred)
      2. Bowel Obstruction
      3. Bowel perforation or peptic ulcer perforation
      4. Mesenteric Ischemia
    9. Lipase Indications
      1. Pancreatitis
      2. Bowel Obstruction
      3. Duodenal Ulcer
    10. Arterial Blood Gas
  2. Imaging: Protocol
    1. Directed imaging where specific cause is suggested
    2. Initial non-specific radiology studies
      1. Chest XRay findings
        1. Abdominal free air
        2. Congestive Heart Failure
        3. Pneumonia
      2. Kidney, Ureter, Bladder plain XRay (KUB) findings
        1. Small Bowel Obstruction
        2. Incarcerated Hernia
        3. Appendicitis
        4. Large Bowel Obstruction
        5. Diverticulitis
        6. Volvulus
        7. Mesenteric Ischemia

Contrast studies -barium (upper and lower Gi series)

Ultrasound

CT Scanning with & without Contrast

Endoscopy

Sigmoidoscopy, colonoscopy

Diagnostic Laparoscopy

 

     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

Gastro & General Surgery in Hyderabad