Abdominal Pain

Abdominal Pain

Shouye Zhao Hepatobiliary Sugery Department

Abstract   

Common presentation, 25% Difficult to diagnose Classification: acute chronic

Acute abdominal pain Etiology and pathogenesis Parietal

peritoneal inflammation

bacterial contamination Acute

gastritis

chemical irritation

inflammation of abdominal organs enteritis

Mechanical

obstruction of hollow viscera

obstruction of the small or large intestine

Acute abdominal Etiology and pathogenesis pain Vascular

disturbances

embolism Referred

vascular rupture

pain

pneumonia coronary occlusion Abdominal

wall

trauma Metabolic

and toxic causes

allergic factors

Chronic abdominal pain Etiology and pathogenesis  Chronic inflammation of abdominal organs reflux esophagitis

chronic ulcerative colitis

Peptic ulcer  Distention of visceral surfaces  Metabolic and toxic causes uremia （尿毒症）  Infiltration of tumor  Neurogenic irritable colon neurosis 

Mechanisms of abdominal pain 

Visceral pain



Somatic pain



Referred pain

Visceral pain 

Results from stimulation of autonomic nerves in the visceral peritoneum which surrounds internal organs



The message may be transferred into the spinal cord via sympathic route

Clinical presentation of visceral pain 

Pain poorly localized



Intermittent, cramp( 痉挛 ) or colicky （绞痛） pain



Accompanied by nausea, vomitting and diaphoresis

Somatic pain 



Stimuli occurs with irritation of parietal peritoneum Sensations conducted along peripheral nerves which can localize pain better

Clinical presentation of somatic pain Precisely localized pain  Pain described as intense, constant  With local guarding or rigidity  Getting worse after coughing or position changes  May be caused by infection, chemical irritation, or other inflammatory process 

Referred pain 



Pain felt at a distance from it’s source The nerves distribution and visceral organs are listed below

The convergence-projection hypothesis of referred pain



Clinical Past history manifestation

Localization  Quality  Pain and position of the body 

Ptosis （下垂） of stomach or kidney: pain when standing for long time 

Associated symptoms Chronic infection esophagus

lymphoma

stomach

malignant tumor: fever

billary tree:

vomiting

Clinical manifestation Localization

Tenderness over the diseased organ Obstruction of small intestine: periumbilical( 脐周） supraumbilical （脐上） Obstruction of large intestine: infraumbilial area （脐下） acute distention of gallbladder: right upper quadrant with radiation to the right posterior region of the thorax or the tip of the right scapula （肩胛）

Clinical manifestation

Quality

and severity

Perforation: severe dull pain over abdomen Obstruction of hollow abdominal viscera: intermittent colicky Intraabdominal vascular disturbances: sudden and catastrophic in nature Acute pancreatitis: severe, steady upper, abdominal pain

Clinical manifestation



Provocation and relief

Acute gastritis and enteritis: eating unfresh or raw foods vomiting or discharge Peritoneum inflammation: accentuated by pressure palpation movement coughing IBS and constipation: relieved temporarily by bowel movements Obstruction: relieved temporarily by vomiting Ulcer: eating or taking antacids

Clinical manifestation Associated

manifestations Fever: inflammation Jaundice: liver gallbladder pancreatic disease Hematuria: renal stone Diarrhea/rectal bleeding: intestinal causes

Diagnostic points     

P: provocative-palliative factors Q:quality R:region S:severity T:temporal characteristics

Diagnostic points Pain

referred to the abdomen should be differentiated An accurate menstrual history in a female patient is essential Much attention has been paid to the presence or absence of peristaltic sounds, their quality and their frequency  PQRST

Question





How to differentiate the feature of colicky pain in these three abdominal diseases: intestinal obstruction,biliary calculus and renal calculus Suggestion: location, associated symptoms

Differentiation of three colicky pain Type

Location

Other manifestation

Intestinal

periumbilical infraumbilical

vomiting, nausea diarrhea, bowel sounds

Biliary

right upper quadrant

jaundice fever Murphy’s sign

Renal

ipsilateral flank changes in urine test radiate to genitalia hematuria groin, scrotum