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35 Cards in this Set
- Front
- Back
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The most common causes of abdominal pain on admission |
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"acute or surgical abdomen" |
Not acceptable! Because of its often misleading and erroneous connotations. Many patients who present with acute abdominal pain will have self-limited disease processes. |
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Pain severity and condition severity |
It is important to rememberthat pain severity does not necessarily correlate with the severity ofthe underlying condition. |
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Key components of the patient's history (when admitted with abdominal pain) |
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Impotant causes of abdominal pain - pain originating in the abdomen |
Parietal peritoneal inflammation Bacterial contamination
Mechanical obstruction of hollow viscera
Vascular disturbances
Abdominal wall
Distension of visceral surfaces, e.g., by hemorrhage
Inflammation
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Impotant causes of abdominal pain - pain referred from extraabdominal source |
Cardiothoracic
Genitalia
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Impotant causes of abdominal pain - metabolic causes |
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Impotant causes of abdominal pain - neurologic / psychiatric causes |
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Impotant causes of abdominal pain - toxic causes |
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Impotant causes of abdominal pain - uncertain mechanisms |
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Inflammation of the parietal peritoneum - charactertistics |
The pain is steady and aching in character and is located directlyover the inflamed area. Exact reference of pain is possible because of somatic innervation of the peritoneum. Theintensity of the pain is dependent on the type and amount and rate of materialto which the peritoneal surfaces are exposed in a given time period.
The pain of peritoneal inflammation is invariably accentuated by pressure or changes in tension of the peritoneum. The patient with peritonitis characteristically lies quietly in bed, preferring to avoid motion, in contrast to the patient with colic, who may be thrashing in discomfort. |
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Obstruction of hollow viscera - general characteristics |
Intraluminal obstruction classically elicitsintermittent or colicky abdominal pain that is not so well localized. However, it is not only possible presentation. |
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Obstruction of hollow viscera - possible pathologies, and their characteristics |
Small-bowel obstruction often presents as poorly localized, intermittent periumbilical or supraumbilical pain. As the intestine progressively dilates and loses muscular tone, the colicky nature of the painmay diminish. The colicky pain of colonic obstruction is of lesser intensity, is commonly located in the infraumbilical area, and may often radiate to the lumbar region. The term "biliary colic" is misleading, because sudden distention of the billiary tree causes a steady, not colicky, pain. Acute distention of the gallbladder usually causes pain in the RUQ, with radiation to the right posterior thorax or right scapula, but can also be near the midline. Distention of the common bile duct often causes epigastric pain that may radiate to the upper lumbar region. Distention of the pancreatic ducts is similar, but accentuated by recumbency and relieved by theupright position. Gradual dilatation of the biliary tree may cause mild pain, if any at all, in the epigastrium or RUQ. Obstruction of the urinary bladder usually causes dull, low-intensity pain in the suprapubic region. Distended bladder may cause only non-specific restlessness. Acute obstruction of the intravesicular portion of the ureter is characterized by severe suprapubic and flank pain thatradiates to the penis, scrotum, or inner aspect of the upper thigh. Obstruction of the ureteropelvic junction manifests as pain near the costovertebral angle, whereas obstruction of the remainder of the ureter is associated with flank pain that often extends into the same side of the abdomen. |
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Vascular disturbances - characteristics |
Pain due tointraabdominal vascular disturbances is not always sudden and catastrophic innature. Embolism or thrombosis of the SMA, or impending rupture of abdominal aortic aneurysm, can be associated with diffuse, severe pain - but can also cause relatively mild symptoms 2-3 days before catastrophe ensues. The early, seemingly insignificant discomfort is caused byhyperperistalsis rather than peritoneal inflammation. Absenceof tenderness and rigidity in the presence of continuous, diffuse pain - "pain out of proportion to physical findings" - in a patient likely to have vascular disease is quite characteristic of occlusion of the SMA. Abdominal pain with radiation to the sacral region,flank, or genitalia should always signal the possible presence of a rupturingabdominal aortic aneurysm. |
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Pain arising from the abdominal wall |
Pain arising from the abdominal wall is usuallyconstant and aching. Movement, prolonged standing, and pressureaccentuate the discomfort and associated muscle spasm. Simultaneous involvement of muscles in other parts of the body usually serves to differentiate myositisof the abdominal wall from other processes that might cause painin the same region. In the caseof hematoma of the rectus sheath, now most frequently encounteredin association with anticoagulant therapy, a mass may be present inthe lower quadrants of the abdomen. |
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Referred pain in abdominal disease - thoracic origin |
The possibility of intrathoracicdisease must be considered in every patient with abdominalpain, especially if the pain is in the upper abdomen. The intrathoracic disease that most often masquerade as abdominal emergencies:
Important differences:
Diaphragmatic pleuritis (from pneumonia or pulmonary infarction) may cause pain in RUQ and supraclavicular area- as opposed to acute distension of extrahepatic biliary tree, which causes referred subscapular pain. |
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Referred pain in abdominal area - non-thoracic origin |
Referred pain from the spine, which usually involves compressionor irritation of nerve roots, is characteristically intensified by certainmotions such as cough, sneeze, or strain and is associated with hyperesthesiaover the involved dermatomes. Referred pain from the testes or seminal vesicles is generally accentuated by theslightest pressure on either of these organs. The abdominal discomfortexperienced is of dull, aching character and is poorly localized. |
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Metabolic abdominal crises |
Pain of metabolic origin may simulate almost any other type ofintraabdominal disease. Whenever the cause ofabdominal pain is obscure, a metabolic origin always must be considered. Sometimes the metabolic disease itself may be accompanied by an intraabdominal process - e.g. hyperlipidemia and pancreatitis. C1esterase deficiency associated with angioneurotic edema is often associatedwith episodes of severe abdominal pain. Adominal pain is also the hallmark of FMF. Diabetic acidosis may be precipitated by acute appendicitisor intestinal obstruction, so if prompt resolution of the abdominalpain does not result from correction of the metabolic abnormalities, anunderlying organic problem should be suspected. |
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Abdominal pain in immunocompromised |
Normal physiologic responsesmay be absent or masked, and unusual infections may causeabdominal pain. The etiologic agents include CMV,mycobacteria, protozoa, and fungi, and they can affect all GI organs, including the gallbladder, liver, and pancreas. Splenic abscesses due to Candida orSalmonella infection should also be considered, especially when evaluatingpatients with LUQ or left flank pain. Acalculouscholecystitis is a relative common complication in patients with AIDS,where it is often associated with cryptosporidiosis or CMV infection. Neutropenic enterocolitis is often identified as a cause of abdominalpain and fever in some patients with bone marrow suppression due tochemotherapy. Acute graft-versus-host disease should be considered. |
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Neurogenic causes of abdominal pain - causalgic pain |
Diseases that injure sensory nerves may cause causalgic pain. It hasa burning character and is usually limited to the distribution of agiven peripheral nerve. Pain can occur at normal nonpainful stimuli such as touch or change in temperature, or even at rest. The demonstration of irregularly spaced cutaneous painspots may be the only indication that an old nerve injury exists. The pain may be precipitated by gentle palpation, but rigidity of abdominal muscles is absent, and respirations are not disturbed. Distention of the abdomen is uncommon, and the pain has no relation to food. |
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Neurogenic causes of abdominal pain - pain arising from spinal nerves or roots |
Pain arising from spinal nerves or roots comes and goes suddenly and is of a stabbing type. It is not associated with food intake, abdominal distention, or changes in respiration. Severe muscle spasm is common, but is either relieved or not accentuated by abdominal palpation. The pain is made worse bymovement of the spine and is usually confined to a few dermatomes. Hyperesthesia is very common. |
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Neurogenic causes of abdominal pain - functional causes |
Pain due to functional causes conforms to none of the aforementionedpatterns. Mechanisms of disease are not clearly established. IBS - Irritable Bowel Syndrome - is a functional gastrointestinal disordercharacterized by abdominal pain and altered bowel habits. The diagnosis is based on clinical criteria, and is made after exclusion of demonstrable structural abnormalities. The episodes ofabdominal pain are often brought on by stress, and the pain varies considerablyin type and location. Nausea and vomiting are rare. Localizedtenderness and muscle spasm are inconsistent or absent. The causes ofIBS or related functional disorders are not known. |
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The only abodimnal condition that needs to be rushed to the operating room |
Exsanguinating intraabdominalhemorrhage (for example - ruptured aneurysm) There areno contraindications to operation when massive intraabdominal hemorrhageis present. Few abdominal conditions require such urgent operative interventionthat an orderly approach need be abandoned, no matter howill the patient. Meaning - if it's not a ruptured aneurysm, diagnose properly. |
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Importance of location and chronological sequence of events to DDx |
Thelocation of the pain can assist in narrowing the differential diagnosis, but the chronological sequence of events in thepatient’s history is often more important than the pain’s location. Careful attention should be paid to the extraabdominal regions. |
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DDx of abdominal pain by location - RUQ |
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DDx of abdominal pain by location - Epigastric |
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DDx of abdominal pain by location - LUQ |
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DDx of abdominal pain by location - RLQ |
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DDx of abdominal pain by location - periumbilical |
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DDx of abdominal pain by location - LLQ |
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DDx of abdominal pain by location - diffuse nonlocalized pain |
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Causes of marked leukocytosis |
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Elevated serum amylase |
Can be elevated in:
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Ultrasound is useful for detecting: |
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Laparoscopy is especially helpful in diagnosing: |
Pelvic conditions, such as:
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