1. 4 th year Gastroenterology Lectures Abdominal pain Yasir M Khayyat MBcHB,FRCPC,FACP Assistant Professor of Medicine

2. Objectives of approach to abdominal pain Pain mechanisms involved pathways. Recognize the appropriate analysis of abdominal pain and consistently apply it. Understand the differential diagnosis of abdominal pain by location and patient setting. Apply the necessary investigations pertinent to the presenting abdominal pain

3. Pain afferent transmission Sensory neuroreceptors ( mucosa,muscularis ) of hollow organs. Myelinated A delta fibers ( skin, muscles ) sharp,precise pain. Unmyelinated C fibers. ( dull,burning,poorly localized,more gradual onset and longer duration type of pain )

4. Clinical Assessment GI History Physical Examination Specific Investigations

5. Abdominal Pain Analysis SiteSeverityPattern PPT and reliving factors Radiation

6. Differential Diagnosis of Abdominal Pain by site Think also of non Abdominal organs Heart Lungs Spine Metabolic Aorta

7. Upper GI symptoms Abd PainDysphagiaHalithosis Nausea Vomiting Heartburn Regurgitation Hematemesis and Melena Lower GI Symptoms Hematochezia Constipation Diarrhea Abdominal pain Bloating

8. Basic principles: Introduce yourself Know what system or disease type you are evaluating Write down Be brief and focused

9. Physical examination General : appearance- breathing pattern- position in bed- posture- degree of discomfort-facial expression. Vital signs :Temp-Tachycardia-hypotension Lung: pneumonia Abdomen: ( I/P/P/A ) Elicits peritonitis by : light gentle palpation, shaking the bed, deep breath, cough

10. Laboratory investigations CBC and Differential Urinalysis serum electrolytes,BUN Glucose concentration. Pregnancy test ( serum/urine) LFT, Amylase/Lipase ( upper abdominal pain).

11. Radiologic Evaluation Plain Abdominal series ( supine/erect )  ?gas Abdominal US: check for solid organs,doppler technology to evaluate vascular organs. CT abdomen: check inflammatory – neoplastic – trauma.

12. Other diagnostic tests Peritoneal lavage:Trauma,? hemoperitoneum Laproscopy Exploratory laprotomy.

13. Special circumstances for abdominal pain Extremes of age : Pregnancy: the uterus displaces the organs and does not allow precise abdominal examination.the common causes are appendicitis-cholecystitis-pyelonephritis- adnexal problems. Immunocompromised host: with two usual causes of abdominal pain

14. Immunocompromised host: Usual causes of abdominal pain Special causes: Neutropenic enterocolitis-drug induced pancreatitis- GVHD-pnumatosis intestinalis- CMV infection- Fungal infection) ICU patient: No history available. Rely on CT scan of the abdomen. Acalculous cholecystitis- stress ulcer.