Conditions Presenting With Abdominal Pain

Benign

GU and DU= peptic ulcer What digests mucosa-ulcer-acid pepsin Ulcer = mucosal defect that extends through the wall layers: • perforation, • penetration Erosion

= superficial mucosal defect

DU>GU;

DU/GU ratio=2:1 UK, 20:1

India More common in men High incidence in professional men Symptoms: • epig. discomfort- severe pain • DU pts. eating relieves pain • GU pts. eating causes pain • DU pts.- vomitting- pyloric stenosis • GU- vomiting relieves pain • Hematemesis and melena

DU

–site- right paraombilical area GU- epigastric region Onset of pain: • DU-late after eating, • GU-soon after eating Relieving

factors:

• DU-eating, • GU-vomiting

NSAID Steroids-

Prednison

Aspirin

may irritate gastro-duodenal mucosa

Smoking Alcohol Coffee

Mild-moderate

tenderness

Complications:

• Bledding- anemia • Stenosis- dehydration, succusion splash • Gastric cancer- wasting, anemia

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There is pooling of barium in a defect in the posterior surface and lesser curve that extends beyond the lesser curve margin. There is a distortion of the uninterrupted mucosal folds of the stomach, which are drawn-in towards the centre of the lesion.

Escape

of gastric acid or alkaline bile into the peritoneal cavity- chemical peritonitis- bacterial peritonitis  Chief symptom- severe and constant pain Sudden onset- epigastric area Respiratory movements make the pain worse

Previous

history

• History of indigestion • No history Drug

history: STEROIDS, ASPIRIN General appearance: ill, in pain Abdo. inspection: imobile Ascultation: silent abdomen Palpation: board-like rigidity Percussion: not necessary DRE- painful

Premalignant

conditions:

• Pernicious anemia • Gastric polyps • Atrophic gastritis

Peak

incidence- 50-70 years old More common in men Symptoms: • Indigestion or epigastric pain • Eating or vomiting does not relieve the pain • Loss of appetite-loss of weight • Dysphagia- carcinoma of the cardia • Vomiting- carcinoma of the pylorus

GA-

wasting, palor Jaundice: liver MTS ot CBD obstruction by porta hepatis lymphadenopathy Left supraclavicular node- Virchow’s Abdomen- excavated, inelastic skin Abdominal distension-ascitis Sister Mary Joseph’s nodule

Mild

epigastric tenderness Palpable epigastric massunresectability Hepatomegaly- liver MTS Pyloric obstruction- succusion splash Ascitis-shifting dullness NBS DRE-pelvic mass- Blummer’s tumor or Krukenberg’s tumor

A

13-year-old boy presented with complaints of vomiting, weight loss and generalized weakness.  Cytological examination of blood showed iron deficiency anemia with a hemoglobin of 6.5 g/dl.  Stools were positive for occult blood.  Barium studies showed a large irregular lobulated mass in the body of stomach and there was no gastric outlet obstruction.

An ultrasound showed a large mass with bowel signature in the epigastric area; there were multiple hepatic metastases, lymphadenopathy and ascites .  Osophagogastroduodenoscopy showed a large ulcerated mass in the anterior and posterior walls of the body and along the greater curvature of stomach; the surface of the mass was friable; there was significant bleeding noted at the base of ulcer .  A biopsy showed moderate to poorly differentiated adenocarcinoma of stomach 

A computer tomography study revealed a large mass in the body of stomach along the anterior and posterior walls and along the greater curvature with local extension into the perigastric area, the gastro-splenic ligament, the transverse mesocolon, the transverse colon, the pancreatic body and the deep layer of the adjacent anterior parietal wall;  Multiple hepatic metastases, lymphadenopathies, and ascites .  The anemia was corrected by blood transfusion.  He was offered palliative chemotherapy but he couldn't afford it due to financial constraints.  He received best supportive care for 2 months until he died. 

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Gastric carcinoma is the most common gastrointestinal malignancies worldwide and is the world's second most common cause of death due to cancer Patients with pernicious anemia have a twenty times increased risk than that of the general population. Intestinal metaplasia (replacement of the gastric epithelium by intestinal epithelium containing Goblet cells) appears to be a precursor and this in turn may result from known carcinogens and after gastric resection for a benign gastric ulcer. Gastric cancer is thought to result from a combination of environmental factors and accumulation of specific genetic alterations, and consequently mainly affects older patients (>50 years of age). Some authors have postulated that gastric cancer can be related to chronic infection with Helicobacter pylori..

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In our case the patient did not have any premalignant conditions of the stomach or a family history of carcinoma. There was no signs of protein energy malnutrition, Helicobacter Pylori and genetic assay were not done in this case. He presented with anemia, which was due to iron deficiency secondary to melena. At the time of diagnosis he had widespread metastases to the liver and the lymph nodes and the patient died within 2 months after diagnosis, again stressing the fact that the childhood gastric cancers are more aggressive with poor prognosis. Gastric carcinoma needs to be considered in any patient with persistent gastro-intestinal symptoms, iron deficiency anemia and melena, even in the young.

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Physicians may miss opportunities to respond with empathy

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Empathy is an important element of effective communication between patients and physicians and is linked to improved patient satisfaction and compliance with recommended therapy.

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Patients who are more satisfied with the communication in their medical encounters have improved understanding of their condition, with less anxiety and improved mental functioning.

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However, responding to patients' emotional needs can be challenging for physicians; they may begin medical school with empathy for their patients but gradually learn detachment, perhaps in order to cope with time constraints or sadness.

Symptoms:RH

pain after eating fatty

meals Physical examination • GA- female, fair, fat, fertile, forty • Abdomen looks normal • Palpation- RH tenderness, below the tip of

the 9th rib, Murphy’s sign Diagnosis is based on history and USS Clinical signs are minimal

Symptoms:

sudden onset of moderate/severe pain in the RH Radiation- to the tip of the right scapula Exacerbation by movements and breathing Nausea, biliary vomiting Appetite lost

GA:

the pt. looks ill, lies quietly, breathing shallowly, tachycardia, fever, chills Abdomen: • Movements diminished • Tenderness/guarding in the RH • Palpable mass below the edge of the liver

Auscultation, RDE- WNL

Between 1 - 3% of people with symptomatic gallstones develop inflammation in the gallbladder (acute cholecystitis), which occurs when stones or sludge obstruct the duct.  The symptoms are similar to those of biliary colic but are more persistent and severe. They include the following: 

• Pain in the upper right abdomen is severe and constant and can

last for days. Pain frequently increases when drawing a breath. • Pain also may radiate to the back or occur under the shoulder blades. About a third of patients have fever and chills. • Nausea and vomiting may occur. •

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Infection develops in about 20% of these cases, which increases the danger.

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Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated.

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People with diabetes are at particular risk for serious complications

Chronic gallbladder disease (chronic cholecystitis) is marked by gallstones and low-grade inflammation.  In such cases the gallbladder may become scarred and stiff.  Symptoms of chronic gallbladder disease include the following: • Complaints of gas, • nausea, and • abdominal discomfort after meals are the most common,  Chronic diarrhea (4 - 10 bowel movements every day for at least 3 months) may be a common symptom of gallbladder dysfunction 

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Stones lodged in the common bile duct (choledocholithiasis) can cause symptoms that are similar to those produced by stones that lodge in the gallbladder, but they may also cause the following symptoms: • Jaundice (yellowish skin), dark urine, lighter stools, or both • Fever, chills, • Nausea and vomiting, and • Severe pain in the upper right abdomen. These symptoms suggest an infection in the bile duct (called cholangitis).

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As in acute cholecystitis, patients who have these symptoms should seek medical help immediately. They may require emergency treatment.

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Stones

in the CBD , usually migrated from the GB. Symptoms: RH pain, jaundice, acholic stools and dark urine

Infection

of the bile duct

Potentially Charcot’s

pain

life-threatening condition

triad: fever, jaundice, RH

Severe

pain caused by a spasm of the GB as it tries to force a stone down the cystic duct Biliary colic- severe constant pain with excruciating exacerbations 1/5th. of pts.- jaundice Abdomen: to tender to allow a deep palpation/guarding

Activated

pancreatic enzymes leak into the pancreatic parenchyma and initiate the auto digestion of the gland Cause: obstruction of the pancreatic duct Pathology: mild inflammation to acute hemorrhagic destruction

Female-

biliary obstruction Male- alcohol Symptoms: • Upper abdo. pain • Patient lies still • Breathes shallowly • Nausea, bouts of vomiting, retching

GA: the pt. looks ill, in pain, hypovolemic, pale, dyspnea, cyanosis, jaundice Abdomen: - imobile abdomen - distension- paralytic ileus - discoloration left flank( Gray Turner’s) - discoloration around umbilicus (Cullen’s sign)

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Acute pancreatitis varies from a mild uneventful disease to a severe life-threatening illness with multisystemic organ failure (MOF) with shock, renal failure, respiratory failure and death.

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Gallstones and alcohol abuse are the most common causes of acute pancreatitis, accounting for 80% of cases. Clinical forms: mild acute pancreatitis and a severe acute pancreatitis.

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80-85% of cases of acute pancreatitis run a mild course without the development of multiple organ failure. This group has a mortality of < 1%. 15-20% of cases of acute pancreatitis run a serious clinical course with pancreatic necrosis and the development of multiple organ failure. Of these, pancreatic necrosis remains sterile in 60% of patients, whereas in 40% of these patients the necrosis becomes infected. This last category of patients has the highest mortality rate of 25-70

Obstruction

of the lumen- fecolith

Symptoms:

• RIF pain • Loss of appetite • Nausea • vomiting

GA:

p. looks ill, flushed cheeks Fever>38 Neck-tonsils- mesenteric adenitis Chest-right sided basal pneumonia Abdomen: • Coughing causes pain • Tenderness RIF/guarding • Rebound tenderness • DRE- painful pelvis if pelvic position of

appendix

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• Right lower quadrant pain on palpation (the single most important sign) • Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever can occur • Peritoneal signs : Localized tenderness to percussion , guarding • Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis) : • Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix) • Obturator sign--pain on internal rotation of right thigh (pelvic appendix) • Rovsing's sign--pain in right lower quadrant with palpation of left lower quadrant • Dunphy's sign--increased pain with coughing • Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix) • Patient maintains hip flexion with knees drawn up for comfort

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Gastrointestinal Abdominal pain, cause unknown Crohn's disease Diverticulitis Meckel's diverticulitis Mesenteric lymphadenitis Necrotizing enterocolitis Neoplasm (carcinoid, carcinoma, lymphoma) Perforated viscus Volvulus

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Gynecologic Ectopic pregnancy Endometriosis Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular, corpus luteum) Tubo-ovarian abscess

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Systemic Diabetic ketoacidosis Porphyria Sickle cell disease Henoch-Schönlein purpura

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Pulmonary Pleuritis Pneumonia (basilar) Pulmonary infarction

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Genitourinary Kidney stone Prostatitis Pyelonephritis Testicular torsion Urinary tract infection Wilms' tumor

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Other Parasitic infection Psoas abscess Rectus sheath hematoma