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Approach to Abdominal Pain Prof. Dr. Fikret Sipahioğlu Dept

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Presentation on theme: "Approach to Abdominal Pain Prof. Dr. Fikret Sipahioğlu Dept"— Presentation transcript:

1 Approach to Abdominal Pain Prof. Dr. Fikret Sipahioğlu Dept
Approach to Abdominal Pain   Prof.Dr.Fikret Sipahioğlu Dept. of Internal Medicine  

2 Abdominal Pain -Localisation of the pathology which causes pain
-Differs according to neural tracts conducting pain -Main mechanisms: Increased tension of empty organs, contractions,inflammatory-ulcerative lesions and ischemia

3 Slow progressing tension(colon tm.) may not cause pain
-Organs are not sensitive to pain(endoscopic biopsies are not painful) -Malignant tumors of intraabdominal organs are not painful unless there is a complication such as obstruction, ulceration or perforation

4 In inflamated or damaged regions:
Mediaters like histamin,serotonin, bradichinin, leucotriens affect neural ends and cause pain -In ischemic regions: Increased toxic metabolites, inflammation mediators and decreased pain threshold due to ischemia cause pain

5 Three Types of Abdominal Pain
-Visceral pain -Somatoparietal pain -Radiating pain

6 Visceral Pain ischemia of intraabdominal organs
-Result of tension,contraction, ischemia of intraabdominal organs -Stimulation of autonomic nerve ends (thoracolomber symphatic plexus bilaterally, n.vagus and pelvic plexus) -Pain localised at paraumbilical region -Is künt,sometimes hard, continious or with fluctuations -Discomfort,emesis,vomiting, sweating,pale looking tachycardia(autonomic findings) may exist

7 Visceral Pain(continued)
-Pain of upper abdominal organs (stomach,liver,biliary tract) localised at mid-line and epigastrium -Pain of the region from Treitz ligament up to transversal colon paraumbilically -Pain of distal colon,rectum, ureters,bladder and genital organs suprapubically

8 Somatic or Parietal Pain
-Results from stimulation of parietal peritoneum -Much more severe -Affected organ can be localised -Moving,coughing,deep inspiration stimulate parietal peritoneum;patient reduces movement -Hyperaesthesia can be observed

9 Comparison of Visceral and Somatic Pain
Visceral Pain Somatic Pain Indefinite Sharp Fluctuating Continious Not localised Localised Discomfort Reduced moves Other autono.symp Pain prominent

10 Radiating Pain Pain is felt far from the affected organ but innervated from same neural segments -Perceived as burn, sensitivity, biting -Skin hyperaesthesia, muscular hypertonicity -E.g. gall bladder pain; back, right shoulder and scapula Peptic ulcer pain; back left 12th rib(Boas point)

11 History Taking Several charasteristics should be considered: -Duration
-Way of beginning -Continious or not -Intensity -Localisation and radiation -Relationship with meals -Affecting factors -Relationship with posture -Coexisting findings(nausea,vomiting, constipation,fever,jaundice,bleeding, voiding etc.)

12 Abdominal Pain Acute abdominal pain Surgical acute abdominal pain
Surgical acute abdominal pain Non-surgical acute abdominal pain Chronic abdominal pain

13 ACUTE ABDOMINAL PAIN Acute Surgical Abdomen (ı):
-History taking and careful physi. ex -In half of the patients no surgery -Most frequent:Acute appendecitis, -Ac. cholecystitis, peptic ulcer perfo., -Small bowel obstruction -Abdominal pain… -Thereafter nausea-vomiting -Laparoscopic examination

14 Peptic Ulcer Perforation (I)
Frequent in duodenal,rare in gastric ulcers -Acute onset,a penetrative and very severe pain -In the beginning at epigastric region,then whole abdomen -Irritation of diaphragm may cause shoulder pain -Reflex efferent stimulation… rigidity of abdominal muscles

15 Peptic Ulcer Perforation(II)
-Patient motionless, superficial breathing, no abdominal respiration -Fever,tachycardia,hypotension, -Tendency to shock( due to peritonitis) -Due to paralytic ileus no bowel sounds -Reduced liver and spleen matite -Radiologic ex. Perforation

16 Acute Cholecystitis(I)
-Pain and tenderness in the right upper quadrant; fever and leukocytosis -Frequent choledocolithiazis -Obstruction in d.cysticus due to choledocolithiazis….lasts long…infection and acute cholecystitis -Usually continious pain -Visceral pain due to tension of d.cysticus in epigastric and left upper regions -When inflammation develops in gall bladder somatic pain in right upper quadrant

17 Acute Cholecystitis(II)
-Tenderness and muscular defense in right upper quadrant -Back and shoulder pain -Nausea,vomiting and anorexia -Biliary colic ≥ 4-6 hours…. -A. Cholecystitis

18 Physical examination:
-Pain in right upper quadrant -Local tenderness -Murphy’s sign positive

19 Laboratory Findings Mild increase in t.bilirubin(≤4mg/dL)
Higher levels; choledocholithiasis and cholengitis Leukocytosis Transaminases and alkaline phosphatase mildly increased USG and ERCP

20 Bowel Perforations: -Infection( typhoid fever,dysentery)
-Diverticulitis, Meckel diverticulitis -Cancer -Ulcerative colitis and toxic megacolon -Acute appendecitis if not treated

21 Mechanical Ileus -Primary bowel cancers;ileus,subileus
-Crohn’s disease,bowel tbc., lymphoma.. obstruction especially in terminal ileum and cecum -Fecaloma ( long lasting constipation)

22 Mechanical Ileus (II) -Severe and colical pain
-Intensity increases and with time is reduced -Pain localized at periumblical and right lower quadrant in small bowel and proximal colon obstructions; at left lower quadrant in distal colon ob. -Vomiting( contains bile and fekaloid with time) -Increased bowel peristaltism -No faeces

23 Mechanical Ileus(III)
-Pain reliefed with vomiting or NG decompression -Increased pain intensity,continous or localized pain peritoneal irritation findings is a warning for bowel perforation and peritonitis -In paralytic ileus no bowel sounds

24 Mechanical Ileus(III)
-Pain relieved with vomiting or NG decompression -Increased pain intensity,continious or localized pain peritoneal irritation findings is a warning for bowel perforation and peritonitis -In paralytic ileus no bowel sounds

25 Acute Appendecitis (I)
-Most common reason for acute surgical abdomen -Feaces,foreign body,parasites,and tumors -Typically:Visceral pain periumblical or epigastric regions; afterwards nausea and vomiting, somatic pain at appendix and fever

26 Acute Appendecitis(II)
Differential Diagnosis: Acute gastroenteritis, mesentery lymphadenitis,yersinia colitis,acute salpingitis, Mittelscherz, ectopic pregnancy rupture, ovarian cyst torsion,ureteral colic, acute pyelonephritis,perforated peptic ulcer, acute cholecystitis, basal pnomonia, diabetic ketoacidosis, acute porphiria, FMF

27 Acute Appendecitis(III)
-Most dangerous complication is perforation -Generally 48 hours after pain begins -Fever, disseminated abdominal tenderness, plastron in right lower quadrant, leukocytosis

28 Acute Mesenteric Ischemia
-No significant clinical finding if small arteries are occluded -In splenic flexura or sigmoid colon where collateral circulation is not adequate ischeamic changes more easily -Embolism of superior mesenteric artery; atrial fibrillation, mitral stenosis,infective endocarditis, MI and aortic aneurism -Should be considered in patients with CV problems over 50 years of age -In patients without pain; abdominal distension and rectal bleeding Intestinal infarction-necrosis-peritonitis findings

29 Abdominal Aortic Aneurism
Almost always atherosclerotic -Frequently diastal of renal artery -Usually without symptoms -Generally detected during imaging for other reasons -In some patients lomber pain -If greater then 5 cm dissection and rupture risk -Syncope and acute developing anemia should be warning

30 Subphrenic Abcess -More frequently right sided;
-Between liver and diaphragm -Perforated peptic ulcer, perforated appendicitis,after abdominal surgery -High fever with chilling and trembling,pain in upper right quadrant -Chronic: subfebrile fever,loss of appetite, weight loss,fatigue -Leukocytosis,CT,USG

31 Spleen Infarction and Rupture
-An enlarged spleen may be ruptured even with small traumas -Enlarged spleen due to infections like IMN or malaria mey be ruptured spontaneously -Pain in left upper quadrant or in supraclavicular region,intraabdominal bleeding findings (paleness, tachycardia,hypotension, philiform pulse) and peritoneal irritation findings -Shock developes very quickly

32 -Ectopic Pregnancy Rupture
-Ovarian Cyst Torsion

33 ACUTE ABDOMINAL PAIN Non-surgical Acute Abdominal Pain
A) Pain of organs outside of abdomen:Lower lobe pneumonia, pleuritis, MI, acute peritonitis, eusophagus disorders, epidymitis, intercostal herpes zoster B) Abdominal pain resulting from a general illness: FMF, porphyrias, lead intoxication, diabetic ketoacidosis, Henoch-Schönlein purpura, sickle cell anemia C) Pain of Intraabdominal Organs: Biliary colic, peptic ulcer, bowel colic, renal colic, acute gastritis, acute pancreatitis, acute enteritis,and acute salpingitis

34 FMF: Recurring fever,peritonitis and pleuritis attacks
Arthritis,skin lesions and amyloidosis may develop Most frequent cause of nephrotic syndrome due to amylodosis 50%of cases no family history Frequency of attacks may differ (most frequently 2-6 weeks lasts hours) Fever is the cardinal symptom( ) Abdominal pain with acute onset and with peritoneal irritation findings Leukocytosis ,high ESR and CRP during attack

35 Porphyrias (I) -Result of specific enzyme defects in hem biosynthesis
-Hepatic and erythropoetic porphyrias -Abdominal pain in hepatic porphyrias -Most important type acute intermittent porphyria; severe, diffuse abdominal pain, cannot be localised -Ileus, abdominal distension,and hyperperistaltism resembles acute surgical abdomen -Absence of fever,leukocytosis and peritoneal irritation findings is helpfull in differantial diagnosis

36 Porphyrias(II) -Dysuria, and urine retension
-Many different findings like nausea,vomiting, constipation, tachycardia, mental changes, head, chest, extremity pains, peripheric neuropathy, reduced muscle strenght, -Dysuria, and urine retension -In a patient with acute abdominal pain a normal urine porphobilinogen level rules out acute intermittent porphyria

37 Diabetic Ketoacidosis
-In a known diabetic patient(esp.Type I) -Severe abdominal pain,nausea and vomiting is a warning of diabetic keto-acidosis - Peritoneal layers get dry and the friction between them is due to extreme dehydration -Clinical situation becomes better after ketoacidosis is treated -If despite of treatment no significant improvement; precipating factor may be acute appendesitis or intestinal obstr.

38 Acute Abdominal Pain due to Disorders of Intraabdominal Organs
Peptic Ulcer Pain: -Chronic pain may occur -Due to reflex pyloric spasm and increased gastric peristaltism and tonus -Nausea and vomiting may occur -No peritoneal irritation findings -Pain in epigastric region

39 Renal Cholic Severe pain in the lomber region Acute Gastritis Sudden onset of abdominal pain, hyperemesis, vomiting and/or gastroenteritis Leukocytosis and fever

40 Acute Pancreatitis-I-
Its presentation may vary from mild, self-limiting disease to multiorgan insufficiency and sepsis The pain is felt in the epigastrium and umbilicus at first and can not be well localized, gets more severe and reaches its maximum Hyperemezis-Vomiting (+) Absence of periton irritation signs and rigidity and the pain not being in its maximum severity at the onset are important in differentiating it from peptic ulcer perforation

41 Acute Pancreatitis-II
The pain radiates towards right or left hypochondrium The pain becomes more severe and localized as the proteolytic enymes effect the peritoneum and is accompanied by muscle strain Especially in the early period physical examination signs may be vague

42 Chronic abdominal pain-I
Epigastric pain: Non-ulcer dyspepsia Peptic ulcer Gastric carcinoma Acute and chronic gastritis Mesentery artery insufficiency

43 Chronic abdominal pain-II
Right upper quadrant: Pain due to choledoc Hepatic abscess Hepatic Carcinoma Congestive hepatomegaly

44 Chronic abdominal pain-III
Right lower quadrant pain: Crohn Ileocaecal tbc Malignant tumours of the caecum and ascending colon

45 Chronic abdominal pain-IV
Left upper quadrant pain: Chronic pancreatitis Pancreas ca Tumours of the left flexura Splenic diseases

46 Chronic abdominal pain-V
Left lower quadrant pain: Ulcerative colitis Diverticulitis Rectosigmoid colon ca Fecalom

47 Hypogastric Pain: Gynecologic diseases: dysmenorrhea, salphengitis, ectopic pregnancy, etc. Urologic diseases: bladder retansion, bladder stones,cystitis

48 Approach to the Patient-I-
Systematic approach excluding urgent conditions Detailed anamnesis Differentiating acute-chronic conditions Chronology Menstruation in women Avoiding narcotics and analgesics until the diagnosis

49 Approach to the Patient-II-
Pelvic and rectal examination Laboratory Imaging Physical examination

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