1. Abdominal Pain

2. Definition of pain A signal of disease Unpleasant sensation localized to a part of the body Penetrating or tissue destructive process stabbing burning twisting tearing squeezing Bodily or emotional reaction terrifying nauseating sickening Accompanied by anxiety Urging to escape or terminating the feeling Both sensation and emotion

3. Clinical characteristics Character of pain spastic pain: intermittent inflammatory: persisting Localization of pain: usually in the diseased part it may be referred

4. Clinical characteristics Quality and intensity of pain peptic ulcer: gnawing burning Referred pain Provocating, aggravating and relieving factors ulcer pain: relieved by ingestion of food

5. Clinical characteristics Associated symptoms Physical examination: neck lymph nodes chest examination abdominal examination Laboratory check up: sputum, stool, urine Serum X-ray film Ultra-sound

6. Clinical characteristics The following are important: severity duration frequency special time of occurrence

7. 10 Questions on Pain Site Referral Character Severity Duration Onset Frequency Aggravating factors Relieving factors Associated symptoms

8. Abdominal pain Acute abdominal pain Chronic abdominal pain

9. Etiology and pathogenesis Acute abdominal pain Parietal peritoneal inflammation bacterial contamination chemical irritation Acute inflammation of abdominal organs gastritis enteritis Mechanical obstruction of hollow viscera obstruction of the small or large intestine obstruction of the biliary tree

10. Etiology and pathogenesis Acute abdominal pain Vascular disturbances Embolism, vascular rupture, torsion of the organs Referred pain pneumonia coronary occlusion Abdominal wall trauma or infection of muscles, distortion or traction of mesentery( 肠系膜 ) Metabolic and toxic causes allergic factors etc.

11. Etiology and pathogenesis Chronic abdominal pain Chronic inflammation of abdominal organs reflux esophagitis chronic ulcerative colitis Peptic ulcer Distention of visceral surfaces hepatic or renal capsules, hepatitis, hepatic cancer

12. Etiology and pathogenesis Chronic abdominal pain Obstruction or torsion Infiltration or metastasis of tumor Metabolic and toxic causes uremia Neurogenic irritable colon neurosis

13. Mechanisms of abdominal pain Visceral pain Somatic pain Referred pain

14. 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

15. Clinical presentation of visceral pain Pain poorly localized Intermittent, cramp or colicky pain Accompanied by nausea, vomitting and diaphoresis

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

17. 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

18. Referred pain Pain felt at a distance from its source ----The diffuse pain arising from abdominal visceral structures tends to be projected to a more superficial region with the same segmental innervation The nerves distribution and visceral organs are listed in text book (page 37)

19. 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）

20. Stomach, duodenum Small bowel, proximal half colon Distal half colon Pain Localization, GI Tract

21. Acute epigastric pain referring to the back Posteriorly penetrating peptic ulcer Biliary pain Acute pancreatitis Dissecting aneurysm 夹层动脉瘤 Epigastric pain + repeated vomiting Food poisoning Acute pancreatitis Agonizing pain but insignificant signs Acute pancreatitis Mesenteric thrombosis at early stage 肠系膜血栓形成

22. 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

23. Pain Severity Ulcer Intestinal Colic Biliary Colic, Pancreatic

24. Clinical manifestation Provocation and relief Acute gastritis and enteritis: eating unfresh or raw foods relieved by 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

25. Clinical manifestation Associated manifestations Fever: inflammation Jaundice: liver gallbladder pancreatic disease Hematuria: renal stone Diarrhea/rectal bleeding: intestinal causes

26. Differentiation of three colicky pain Type Location Other manifestation Intestinal periumbilical vomiting, nausea infraumbilical diarrhea, bowel sounds Biliary right upper jaundice fever quadrant Murphy’s sign Renal ipsilateral flank changes in urine test radiate to genitalia 外阴 hematuria groin 腹股沟, scrotum 阴囊

27. Clinical manifestation of chronic abdominal pain Past history 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 lymphoma malignant tumor: fever esophagus stomach billary tree: vomiting esophagus stomach billary tree: vomiting Pain referred to the abdomen should be differentiated

28. Diagnostic points 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: provocative-palliative factors quality region severity temporal characteristics

29. WORK-UP OF ABDOMINAL PAIN HISTORY Onset Qualitative description Intensity Frequency Location - Does it go anywhere (referred)? Duration Aggravating and relieving factors

30. Common Acute Pain Syndromes Appendicitis Acute diverticulitis Cholecystitis Pancreatitis Perforation of an ulcer Intestinal obstruction Ruptured AAA （ abdominal aortic aneurysm ） Pelvic disorders

31. DIAGNOSTIC STUDIES Plain X-rays (flat plate) Contrast studies - barium (upper and lower GI series) Ultrasound CT scanning Endoscopy Sigmoidoscopy, colonoscopy