1. Approach To Abdominal Pain Dr. Nahla A Azzam MRCP Consultant Gastroenterology

2. Introduction Abdominal pain is an unpleasant experience commonly associated with tissue injury. The sensation of pain represents an interplay of pathophysiologic and psychosocial factors. Abdominal pain is an unpleasant experience commonly associated with tissue injury. The sensation of pain represents an interplay of pathophysiologic and psychosocial factors.

3. ANATOMIC BASIS OF PAIN Sensory neuroreceptors in abdominal organs are located within the mucosa and muscularis of hollow viscera, on serosal structures such as the peritoneum, and within the mesentery. Sensory neuroreceptors in abdominal organs are located within the mucosa and muscularis of hollow viscera, on serosal structures such as the peritoneum, and within the mesentery. sensory neuroreceptors are involved in the regulation of secretion, motility, and blood flow via local and central reflex arcs. sensory neuroreceptors are involved in the regulation of secretion, motility, and blood flow via local and central reflex arcs.

4. two distinct types of afferent nerve fibers: myelinated A-delta fibers and unmyelinated C fibers. two distinct types of afferent nerve fibers: myelinated A-delta fibers and unmyelinated C fibers. A-delta fibers are distributed principally to skin and muscle and mediate the sharp, sudden, well-localized pain that follows an acute injury. A-delta fibers are distributed principally to skin and muscle and mediate the sharp, sudden, well-localized pain that follows an acute injury.

5. C fibers are found in muscle, periosteum, mesentery, peritoneum, and viscera. Most nociception from abdominal viscera is conveyed by this type of fiber and tends to be dull, burning, poorly localized C fibers are found in muscle, periosteum, mesentery, peritoneum, and viscera. Most nociception from abdominal viscera is conveyed by this type of fiber and tends to be dull, burning, poorly localized

7. STIMULANTS OF PAIN The principal mechanical signal to which visceral nociceptors are sensitive is stretch. The principal mechanical signal to which visceral nociceptors are sensitive is stretch. Unlike for somatoparietal nociceptors, cutting, tearing, or crushing of viscera does not result in pain. Unlike for somatoparietal nociceptors, cutting, tearing, or crushing of viscera does not result in pain.

8. Abdominal visceral nociceptors also respond to various chemical stimuli Abdominal visceral nociceptors also respond to various chemical stimuli These receptors are directly activated by substances released in response to local mechanical injury, inflammation, tissue ischemia and necrosis, and noxious thermal or radiation injury. These receptors are directly activated by substances released in response to local mechanical injury, inflammation, tissue ischemia and necrosis, and noxious thermal or radiation injury.

9. Types of Pain Abdominal pain may be classified into three categories: Abdominal pain may be classified into three categories: 1.visceral pain 1.visceral pain 2.somatoparietal pain 2.somatoparietal pain 3.referred pain. 3.referred pain.

10. Visceral pain

11. Somatoparietal pain is generally more intense and localized than visceral pain. is generally more intense and localized than visceral pain. An example in acute appendicitis, which is followed by the localized somatoparietal pain at McBurney's point produced by inflammatory involvement of the parietal peritoneum. Parietal pain is usually aggravated by movement or coughing. An example in acute appendicitis, which is followed by the localized somatoparietal pain at McBurney's point produced by inflammatory involvement of the parietal peritoneum. Parietal pain is usually aggravated by movement or coughing.

12. Referred pain

13. APPROACH TO THE PATIENT WITH ACUTE ABDOMINAL PAIN Clinical EvaluationThe goal of the evaluation of the patient with acute abdominal pain is an early, efficient, and accurate diagnosis. Clinical EvaluationThe goal of the evaluation of the patient with acute abdominal pain is an early, efficient, and accurate diagnosis.

14. History: History: Chronology Chronology

15. Location Location Character Character Aggravating and Alleviating factors e.g positional changes, meals, bowel movements, and stress Aggravating and Alleviating factors e.g positional changes, meals, bowel movements, and stress

16. Associated Symptoms and Review of Systems e.g anorexia, nausea, vomiting, flatus, diarrhea, and constipation, jaundice, dysuria, menstruation. Associated Symptoms and Review of Systems e.g anorexia, nausea, vomiting, flatus, diarrhea, and constipation, jaundice, dysuria, menstruation.

17. PMH similar symptoms suggests a recurrent problem. Patients with a history of partial small bowel obstructions, renal calculi. similar symptoms suggests a recurrent problem. Patients with a history of partial small bowel obstructions, renal calculi. Systemic illnesses such as scleroderma, lupus, nephrotic syndrome, porphyrias, and sickle cell disease often have abdominal pain as a manifestation of their illness. Systemic illnesses such as scleroderma, lupus, nephrotic syndrome, porphyrias, and sickle cell disease often have abdominal pain as a manifestation of their illness.

18. Physical examination General position in bed, posture, degree of discomfort, and facial expression. General position in bed, posture, degree of discomfort, and facial expression. Vital signs Vital signs abdomen should be inspected for distention, scars, hernias, muscle rigidity, splinting during respiration, ecchymoses, and visible hyperperistalsis.. abdomen should be inspected for distention, scars, hernias, muscle rigidity, splinting during respiration, ecchymoses, and visible hyperperistalsis..

19. Light, gentle palpation is superior to deep palpation in the identification of peritoneal irritation. Light, gentle palpation is superior to deep palpation in the identification of peritoneal irritation. Palpation should begin at the point of least tenderness and proceed to the point of greatest tenderness., and rigidity should be determined Palpation should begin at the point of least tenderness and proceed to the point of greatest tenderness., and rigidity should be determined Abdominal percussion may elicit tympan Abdominal percussion may elicit tympan Enlargement of a diseased organ, tumor, or minflammation may produce a palpable mass. Enlargement of a diseased organ, tumor, or minflammation may produce a palpable mass. Potential hernia orifices should be examined. Potential hernia orifices should be examined.

20. Investigation Laboratory CBC,U&E, LFT, ABG, Amylase Laboratory CBC,U&E, LFT, ABG, Amylase Radiological Radiological plain abdominal series plain abdominal series CXR CXR

21. Ultrasonography can provide rapid, accurate, and inexpensive anatomic information about the liver, biliary tree, spleen, pancreas, kidneys, and pelvic organ Ultrasonography can provide rapid, accurate, and inexpensive anatomic information about the liver, biliary tree, spleen, pancreas, kidneys, and pelvic organ

22. CT Scan of Abdomen CT Scan of Abdomen MRI MRI Other e.g. laparoscopy Other e.g. laparoscopy

23. Special Circumstances Extremes of Age difficult HX, minimal physical, ↑mortality Extremes of Age difficult HX, minimal physical, ↑mortality Pregnancy Pregnancy

24. Acute Abdomen in the Intensive Care Unit Patients.e.g. trauma injuries; postoperative complications,anastomotic leak and obstruction Acute Abdomen in the Intensive Care Unit Patients.e.g. trauma injuries; postoperative complications,anastomotic leak and obstruction complications of critical illness, including acalculous cholecystitis and stress ulcer. complications of critical illness, including acalculous cholecystitis and stress ulcer.

25. Immunocompromised patients Immunocompromised patients 1. diseases that occur in the general population 2. diseases unique to the immunocompromised host (e.g., neutropenic enterocolitis, drug-induced pancreatitis, GVHD,, cytomegalovirus [CMV], and fungal infections).

27. Chronic Abdominal Pain survey of more than 1 million Americans revealed that 13% experienced "stomach pain" and 15% experienced "pain in the lower abdomen. survey of more than 1 million Americans revealed that 13% experienced "stomach pain" and 15% experienced "pain in the lower abdomen. Chronic intractable abdominal pain is defined as abdominal pain that is present for at least 6 months without diagnosis despite appropriate evaluation Chronic intractable abdominal pain is defined as abdominal pain that is present for at least 6 months without diagnosis despite appropriate evaluation

28. Chronic Abdominal Pain