101104 abdominal pain

Abdominal PainYu Funakoshi

04/Nov/10@Gunma University

HPI (History of Present Illness)

A 58-year-old woman consults her general practitioner (GP) with a 2-month history of intermittent dull central epigastric pain.

What do you want to ask?

What do you want to ask?

HPI-2 It has no clear relationship to eating

and no radiation. Her appetite is normal, she has no

nausea or vomiting and she has not lost weight.

Her bowl habit is normal and unchanged.

Past Medical History, Family History,Social History

There is no relevant past or family medical history.

She has never smoked, and drinks alcohol very rarely.

She has worked all her life as an infant school teacher.

What’ your DDx? Think

Anatomy × Pathophysiology!

Anatomy

This patients had an epigastric pain, so Stomach Liver Gallbladder Pancreatis Colon…

Pathophysiology VINDICATE-P

Vasucular Infection Neoplasm Degenerative Idiopathic, Intoxication, Iatrogenic Congenital Allergy, Auto-immune Trauma Endocrinopathy Psychogenic, Pregnancy

She comes again! An H2 antagonist was prescribed and

follow-up advised if her symptoms did not resolve.

There was slight relief at first, but after 1 month the pain became more frequent and severe, and the patient noticed that it was relieved by sitting forward. It had also begun to radiate through to the back.

Despite the progressive symptoms she and her husband went on a 2-week holiday to Scandinavia which had been booked long before.

During the second week her husband remarked that her eyes had become slightly yellow, and a few days later she noticed that her urine had become dark and her stools pale.

On return from holiday she was

referred to a gastroenterologist.

Physical Examination She was found to have yellow sclerae

with a slight yellow tinge to the skin.

There was no lymphadenopathy and her back was normal. As before her heart, chest, and abdomen were normal.

INVESTIGATIONSActual Predicted

Total bilirubin 97 mmol/L 3-17 mmol/L

Alkaline phosphatase 1007 IU/L 30-300 IU/L

Alanine aminotransferase

38 IU/L 5-35 IU/L

Gamma-glutamil transpeptidase

499 IU/L 11-51 IU/L

What’s top on your list?

Most likely diagnosis is

KEY POINTS Carsinoma of the pancreas can

present with non-specific symptoms in its early stages.

It is an important cause of obstructive jaundice.

Patients who have had a partial removal of the pancreas are at risk of diabetes.

疼痛のメカニズム 疼痛とは、

痛覚神経終末板（いわゆる痛覚レセプター）が、

セロトニンやブラジキニンなどの疼痛物質により刺激されて脳が認識する知覚。

1次痛（体性痛）

2次痛（内臓痛）

性質 鋭い 鈍い

局在 高い　 低い

神経線維 Aδ C

神経経路 新脊髄視床路 旧脊髄視床路

修飾 なしあり（ Aβ 繊維と心理的刺激）

Ex) Appendicitis

Important referred pains Chest pain radiating to left arm?

Ischemic heart disease Upper abdominal pain radiating to

left shoulder? Acute pancreatitis

Right upper abdominal pain radiating right shoulder? Acute cholecystitis

Take-home massages 痛みを見たら

解剖と病態を組み合わせて鑑別診断を考える！

VINDICATE-P のような mnemonics が便利！

急性疼痛の分類を覚えよう！ 関連痛 体性痛 内臓痛

References 100 Cases in Clinical Medicine, 2nd edition,

Rees, Hodder Arnold (Case69 を引用しました )

ハリソン内科学、第 3 版、福井次矢、黒川清監修、 メディカルサイエンスインターナショナル

問題解決型　救急初期診療、第 1 版、田中和豊、医学書院