The Patient With Abdominal Pain

Front 1

Abdominal pain - types

Back 1

•Visceral
•Somatic (parietal)
•Referred
•Shifting pain

Front 2

Visceral pain

Back 2

•elicited by distension, inflammation or ischaemia
•intestines / associated organs developed as midline structures therefore visceral pain tends to be midline
•transmitted via sensory fibres of the ANS
(mainly sympathetic, but distal colon and rectum and bladder are parasympathetic)
•centrally perceived sensation is generally slow in onset, dull poorly localised and protracted
•embryologically the gut has a segmental origin, so that division into foregut, midgut and hindgut exactly correlates with the vascular supply and correspondingly pain is felt in the epigastrium, umbilical area and hypogastrium

Front 3

Parietal pain

Back 3

•the parietal peritoneum is innervated by somatic nerves
•pain is therefore accurately localised to the site of irritation of the abdominal wall and is accompanied by a reflex contraction of the abdominal wall muscles

Front 4

Referred visceral pain

Back 4

•sensation perceived at a site distant from the primary stimulus
•due to the confluence of afferent nerve fibres from widely different areas within the posterior horn of the spinal cord

Front 5

Shifting pain (radiation)

Back 5

•parallels the course of the underlying condition
•site of pain at onset (visceral) later shifts with progression of eg inflammation as the parietal peritoneum becomes involved (appendicitis)

Front 6

Upper abdominal pain

Back 6

Front 7

Central abdominal pain

Back 7

•small bowel
•caecum
•midline retroperitoneal structures (aorta)

Front 8

Lumbar

Back 8

•Kidneys - radiate to the groin / loin

Front 9

Lower abdominal pain

Back 9

•appendix (central -> RIF)
•caecum
•colon
•bladder
•uterus
•ovaries and fallopian tubes (-> inner thigh)

Front 10

Obstructive vs Inflammatory Pain

Back 10

Front 11

Direct questions relevant to GIT and a history of abdominal pain

Back 11

•appetite,
•weight,
•dyspepsia / dysphagia / flatulence / reflux
•nausea / vomiting
•haematemesis,
•bowel habit (constipation / diarrhoea / PR bleeding)
•Gynaecological symptoms
•Urinary symptoms

Front 12

Examination of the Abdomen

Back 12

•Discolouration
•Scars
•Distension
•Masses
•Bowel signs
•Movement
•Bruits

Front 13

As part of the examination
Don’t forget…….

Back 13

•Hernial orifices
•Rectal examination
•Genitalia
•Vaginal examination
•Femoral pulses
•Lymph node drainage

Front 14

Signs of Peritonitis

Back 14

•tenderness - examination causes pain
•guarding - reflex contraction of the abdominal wall muscles
•rigidity - localised or generalised increase in the voluntary tone of the abdominal wall
•rebound tenderness

Front 15

Investigations (directed!)

Back 15

•FBC
•U&E
•LFT
•Inflammatory markers
•Amylase / Lipase
•ABGs
•Gp and Hold
•Blood Cultures
•CEs
•Urinalysis
•bHCG (NEVER Foreget.. lectures story of discharging a patient and npt checking the bHCG result, turns out the patient had an ectopic)

Front 16

Drugs that can mask Sx in GI

Back 16

•Regular opiate analgesic orders (so only give PRN therefore you can tell if the demand for them is INC, or DEC...)
•Other drugs that may mask the condition eg buscopan

Front 17

Indications for Surgery

Back 17

1. Generalised peritonitis (except pancreatitis)
2. Increasing local tenderness
3. Suspected ischaemia (acidosis, fever, tachycardia)
4. Tense or progressive distension (clinical +/-
radiological)
5. Deteriorating clinical signs
6. Pneumoperitoneum

Front 18

Medical Conditions Simulating The Acute Abdomen

Back 18

•Lobar pneumonia and empyema
•Pulmonary Embolus
•Acute hepatitis
•Diabetic crisis
•Porphyrias
•Toxins - lead and other heavy metal poisoning
•Narcotic withdrawal
•Myocardial Infact
•Uraemia
•Sickle cell crisis
•Polyarteritis nodosa
•Herpes Zoster
•Diseases of the hip and back

Front 19

Physical Findings with various causes of an Acute Abdomen

Back 19

Front 20

Appendicitis

Back 20

•All ages !
•Diagnosis difficult at the extremes of age
•Classic - bizarre presentations
•Prodromal symptoms (hours 1-2 days)
•Vague central peri-umbilical pain
•Shift to RIF
•Anorexia
•Nausea
•(+/- constipation or diarrhoea / dysuria)
•Foetor oris
•Flushed
•Pyrexia
•Tachycardic
•Tender and guarding RIF
•Increased wbc
•Doubt consider CT / US
•Laparoscopy

Front 21

Biliary Colic

Back 21

•Impaction of a stone in Hartman’s pouch / cystic duct
•FFFF (Fat, Female, Forty, fertile)
•Upper abdomen -> back-> shoulder tip
•Severe pain - not a true colic, often constant
•N&V
•Tender and guarded RUQ
•US
•Mx: Strong analgesics
•Interval cholecystectomy

Front 22

Acute Cholecystitis

Back 22

•inflammation of the GB wall due to persistent impaction of a stone
•right hypochondrial pain -> back
•persistent
•exacerbated by movement
•nausea
•systemic upset
•tender and guarded RUQ
•+/- mass
•“Boas sign” / Murphy’s sign
•Increased wbc
•US
•Cholecystectomy

Front 23

Bowel Obstruction
4 cardinal S & S

SBO vs LBO

Back 23

•Vomiting (early SBO)
•Pain (central colic SBO, more ill defined LBO)
•Constipation (LBO)
•Distension (both)

•erect CXR / AXR
•wbc
•contrast study (gastrograffin enema LBO)
•SBO - CT
•rehydration
•NGT
•close observation
•LBO - OT
•SBO - conservative if improving

Front 24

Pancreatitis

Back 24

•epigastric pain -> back
•severe, constant
•relieved by sitting forward
•vomiting
•alcohol / GS
•systemic upset (severity)
•jaundice
•often generalised tenderness and guarding
•Grey Turners / Cullens Sign

•Increased wbc
•increased amylase / lipase
•decreased calcium
•abnormal LFTs
•CT
•Management supportive and conservative

Front 25

Renal Colic

Back 25

•dull loin pain (renal )
•severe loin - groin pain (ureteric)
(worse pain they’ve ever had)
•haematuria (macroscopic / microscopic)
•AXR / IVP / US / CT pyelogram
•Analgesia / Hydration

Front 26

Peptic Ulcer Disease

Back 26

•Epigastric discomfort -> back
•Heartburn / Reflux
•Relationship to eating (better / worse / time )
Complications:
• perforation -> S & S of an acute abdomen
UGIB

Front 27

Back 27

X-ray showing air in around the stomach possible perforation

Front 28

Diverticulitis

Back 28

•older patient
•LIF ache / pain (left sided appendicitis)
•+ / - disruption of bowel habit
•nausea
•pyrexia
•tender and guarding LIF

•increased wbc
•erect CXR / AXR
•abdominal CT
•management conservative unless complicated (perforation / abscess / fistula)

Front 29

Abdominal Aortic Aneurysm

Back 29

•aching pain - acute exacerbation
•radiates to back
•pulsatile mass
•hypotension
•obtunded

Front 30

Miscellaneous

Back 30

•Urinary retention
•PID
•ectopic pregnancy
•ruptured ovarian cyst
•torted ovarian cyst