abdominal pain

ABDOMINAL PAINDR. WONG SEAK KHOON

(2 November 2011)

Present by: Soediqin Akmal

Introduction Abdomen

Abdomen is part of trunk that lies between the thorax and pelvis.

It is divided into 9 parts by 2 vertical lines, right and left midclavicular lines and also 2 horizontal lines, subcostal and intertubercular lines.

9 regions of abdomen

EpigastriumRight

Hypochondrium

Left Hypochondri

um

Umbilical

Right Lumbar Left lumbar

Right iliac fossa

Hypogastrium

Left iliac fossa

9 regions of abdomen

StomachPancreasLt lobe of

liver

LiverGallbladder

SpleenTail of pancreasFundus of stomachCoils of

small instesti

ne

Right kidneyAscending colon

Left kidneyDescending colon

CaecumAppendix

Urinarybladder

Sigmoid

colon

9 regions of abdomen

StomachDuodenumGallbladder Pancreas

Small intestin

eCaecum

Kidney Kidney

CaecumAppendix

Transverse colon

Bladder

Sigmoid

colon

Definition Abdominal pain is pain that is felt in the

abdomen Acute abdomen refers to a sudden, severe

abdominal pain of unclear etiology that is less than a week in duration◦ eg. acute peritonitis, acute pancreatitis, acute

cholecystitis, acute cholangitis, acute appendicitis diabetic ketoacidosis

Pathophysiology of abdominal pain:

1. Somatic pain: - due to irritation of parietal peritoneum

- parietal peritoneum covers: (a) anterior & posterior abd. wall

(b) undersurface of diaphgram (c) pelvic cavity

- Nerve supply: derived from nerve supplying muscles & skin of abdominal wall (T5- L2) *exception: central portion of diaphrgam (phrenic nerve: C3,C4,C5)

- Sensitive to: mechanical thermal chemical

- Response to irritation:

(i) reflex contraction of corresponding segment of muscle guarding (ii) hyperaesthesia of overlying skin

- Nature: sharp, localised, knife-like

2. Visceral pain:

- due to irritation of visceral peritoneum - visceral peritoneum covers partially/

completely the intra-abdominal viscera - pain is mediated through sympathetic branches of autonomic system, to thoracic (T6-T12) & lumbar (L1,L2) segment of spinal cord

- Sensitive only to tension

- Nature: dull, poorly localised, deep, referred to overlying skin with same embryological origin

Causes ofAbdominal Pain

Surgical

Medical

Non-traumatic

Traumatic

Cause of Abdominal Pain

Principal Causes of Abdominal Pain

Hemorrhage

Infarction/ Strangulation Obstruction

Perforation

Inflammation/Infection

Non- traumaticAbdominal Pain

Pathology Disease

Inflammation •Diverticulitis•Salphingitis•Acute Pancreatitis

•Acute appendicitis•Acute cholecystitis

Obstruction •Ureteric obstruction•Urinary retention

•Intestinal obstruction•Biliary obstruction

Ischaemia •Strangulated hernia•volvulus

•Torsion of ovarian cyst

Perforation •Perforated peptic ulcer•Perforated cancer

•Biliary peritonitis

Rupture •Ruptured ectopic pregnancy

•Ruptured aneurysm

Example of Non-traumatic causes

The causes of generalized abdominal pain :• Irritable bowel syndrome

• Recurrent adhesive obstruction• Mesenterric carcinoma

• Carcinomatosis• Chronic constipation

• Radiation damage• Reptriperitonial tumours

• Endomettriosis• Pelvic-uriteric junction obstruction

• Lumbar spine pain• Retroperitonial fibrosis

• psychosomatic•

General abdominal pain

Management:

1. Mild attack:◦ Fluid resuscitation and analgesia◦ NBM meant to rest the pancreas◦ Treat predisposing factors such as gall stones◦ Discouraged alcohol abuse◦ NG tube to aspirate stomach content and

prevent vomiting◦ Prophylactic antibiotic i.e. imipenem and

cephalosporin◦ Daily measurement of plasma amylase –

progression of ds◦ LFT and renal profile

2. Severe attack:◦ Resuscitate◦ Defined by Ranson’s or Glasgow criteria◦ Admit to ICU immediately◦ Fluid and electrolyte management◦ Treat hypocalcaemia◦ Ventilatory support

3. Surgery: - Abscess drainage - Cholecystectomy-if stone in gall bladder

Complications:1. Pancreatic necrosis & pseudocyst formation2. Abscess formation3. Haemorrhage4. Thrombosis5. Fistulae6. Recurrent edematous pancreatitis

The stomach and duodenum.

1.The insulin test: Consist of an injection of insulin which produces hypoglycemia Stimulates the nucleus of vagus in the brain stem Helpful when a patient develops a recurrent ulcer following vagotomy for

duodenal ulceration. The blood sugar has to fall below 45mg/100ml Measure before and after insulin in injected by slow i.v infusion

2.Plain x-ray: Patients lying in supine position Suspected peritonitis due to perforation of gastric or duodenal ulcer Gas maybe seen under the diaphragm Usually on the right side

Differentials diagnosis

3. Barium meal: Radiographic investigation Patient swallows a suspension of radiopaque barium sulphate Principally use in the diagnosis of gastric and duodenal ulcer and gastric

carcinoma. Chronic gastric ulcer: seen as a projection from the wall or as a ronded deposit. Duodenal ulcer:seen a face with a stellate appearance of the mucosal fold. Pyloric stenosis: an increased amount of resting juice present and grossly enlarged

stomach .

4.Endoscopy and biopsy: Possible to see the whole of the oesophagus,stomach and duodenum Biopsy forceps:to obtain specimens for histological and cytological examination. Can differentiate benign from malignant lesions Rapid diagnosis of upper gastrointestinal bleeding.

Small intestine.

1.Barium meal follow through X-rays: Studied by thaking filmx of abdomen at intervals after a barium meal. Abnormalities in the transit time to the colon and in small bowel pattern such as

dilatation,narrowing, fistula and mucosal abnormalities.

2. Biopsy: Small intestine biopsy importance in diagnosis of the malabsorption syndrome

where a flat mucosa is seen.

Colon ,rectum and anus.

1.Protoscopy: Can see piles as reddish/blue swelling which bulge into the lumen Can see internal opening of an anal fistula,an anal or low rectal polyp and chronic

anal fissure

2. Sigmoidoscopy: Necessary to examine the rectum and colon Proctitis,polyps and carcinomas may be seen. Particulary useful in the differential diagnosis of diarrhoea of colonic region.

3. Barium enema: Can see the obstruction of the colon,tumours,diverticular disease,fistulae and other

abnormalities can be recognize.

4.Colonoscopy: Inspect the whole colonis mucosa round to the caecum. Polyps and diverticulitis can be seen.

The liver.

1.Ultrasound scan: Diagnosis of fluid-filled lesions such as cysts and abcesses Detecting intrahepatic bile ducts.

2.Needle biopsy of liver: Diagnosis for liver abcess

3. Liver function test: To see the albumin,globulin,AST and ALT level.

Gallbladder and bile ducts:

1.Percutaneous transhepatic cholangiography: Useful investigation in patients with jaundice due to obstruction of the main bile

ducts. Investigations the site of the obstruction due to tumours of the head of the

pancreas,iatrogenic and alignant bile ducts strictures –can be accurately localized and diffrentiated.

2.ERCP(endoscopic retrograde cholangiopancreatography) Useful in the rapid diagnosis and localization of the different causes of jaundice

due to obstruction of the main bile ducts.

The pancreas.

1.Lundh test; Assessment of tryptic activity in pancreatic juice collected following duodenal

intubation Indirect stimulation of the pancreas by prior ingestion of a meal. Tryptic activity is less than 6 iu/litre.

2. Triple test. Exocrine function. Cytology Hypotonic duodenography

3. ERCP

Pain1.Site-9 region2.Onset: acute or recurrent or gradual3.Character : -colicky- comes and goes in waves and indicates

obstruction of a hollow, muscular-walled organ (intestine, gallbladder, bile duct, ureter).

-burning-an acid cause and is related to the stomach, duodenum or lower end of the oesophagus

4.Radiation: -Right scapula: gallbladder -Shoulder-tip: diaphragmatic irritation -Mid-back: pancreas.

HISTORY TAKING

5.Associated symptoms, e.g vomiting, diarrhoea, painful micturition etc

6.Timing: since onset Episodic or continuous. If episodic, duration and

frequency of attacks; If continuous, any changes in the severity Variation by day or night, during the week or

month, e.g. relating to the menstrual cycle

7.exacerbation & relieving factor8.Severity

Past medical history Ask especially about: Previous surgical procedures including peri-

and postoperative complications and anaesthetic complications.

Chronic bowel diseases (e.g. IBD including recent flare-ups and treatment to date).

Possible associated conditions (e.g. diabetes with haemachromatosis).

Drug history Think about drugs that can precipitate abdominal diseases

and remember to ask about over-the-counter drugs. For example:

Hepatitis: halothane, phenytoin, chlorothiazides, pyrazinamide, isoniazid, methyl dopa, HMG CoA reductase inhibitors (statins, sodium valproate, amiodarone, antibiotics, NSAIDs.

Cholestasis: chlorpromazine, sulphonamides, sulphonylureas, rifampicin, nitrofurantoin, anabolic steroids, oral contraceptive pill.

Fatty liver: tetracycline, sodium valproate, amiodarone. Acute liver necrosis: paracetamol. Ask also about previous blood transfusions

Smoking Smokers are at risk of peptic ulceration,

oesophageal cancer, colorectal cancer. Smoking may also have a detrimental outcome on the natural history of Crohn's disease.

Alcohol a detailed history is required.If

dependence is suspected

Urethral pain: variable in presentation ranging from a tickling discomfort to a severe sharp pain felt at the end of the urethra (tip of the penis in males) and exacerbated by micturition. Can be so severe that patients attempt to hold on to urine causing yet more problems!

Small bowel obstruction: colicky central pain associated with vomiting, abdominal distension & constipation.

Colonic pain: as above under small bowel but sometimes temporarily relieved by defaecation or passing flatus.

PAIN...

Bowel ischaemia: dull, severe, constant, right upper quadrant/central abdominal pain exacerbated by eating.

Biliary pain: severe, constant, right upper quadrant/epigastric pain that can last hours and is often worse after eating fatty foods.

Pancreatic pain: epigastric, radiating to the back and partly relieved by sitting up and leaning forward.

Peptic ulcer pain: dull, burning pain in the epigastrium. Typically episodic at night, waking the patient from sleep. Exacerbated by eating and sometimes relieved by consuming

Acute appendicitis:

1. Commenest abdominal emergency (Lifetime incidence 6%)

2. Causes: (a) Obstruction by faecolith or lesion in caecum

(b) Recurrent inflammation(c) Enlargement of lymphoid follicles

Anatomy of appendix:

Base of appendix: McBurney’s point

Pathogenesis of acute appendicitis:Initiation of inflammation

Acute inflammation of mucosa

Extension of inflammation across appendiceal wall

Involvement of serosa by inflammation

Visceral peritonitis (referred pain)

Peritonitis spread to adjacent structure (localised pain)

Necrotic glandular mucosa sloughs into lumen

Lumen distended with pus

End-artery (appendiceal artery) thrombosed

Appendix infarction

Gangrenous appendix

Perforation of appendix wall

Attempt to wall off perforation by: omentum, adjacent bowel

Intense & extensive walling-off rxn Inadequate

containment

Appendiceal mass

Generalised peritonitis

Appendiceal abscess

Clinical features:1. Pain: -vague - begin at central abdomen/ retrosternal - poorly localised - colicky - assoc. with Nausea & Vomiting - duration: few hours/ days - pain then shifted to Rt iliac fossa

2. Localising symptoms depends on anatomical relations of inflammed appendix

e.g. inflammed retrocecal appendix: - irritates psoas muscle>> involuntary Rt hip flexion, pain on extension

Examination:

1. General appearance: - Facial flush - Low-grade pyrexia - Tachycardia

2. Abdomen: (i) Inspection: - Mild abdominal distension - Reduced abd. movement at Rt iliac fossa

(ii) Palpation: Rt iliac fossa: - Guarding (indicator of tenderness severity) - Tenderness, Rebound tenderness

- +ve Rovsing’s sign(iii) Percussion: pain at Rt iliac fossa(iv) Auscultaion: Bowel sound present Bowel sound absent when perforation & generalised peritonitis cause paralytic ileus

Cardinal features of acute appendicitis:

1. abdominal pain <72 hours2. Vomiting 1-3 times3. Facial flush4. Tenderness at Rt iliac fossa5. Low-grade pyrexia6. no evidence of UTI

Investigation:

No need if it can be diagnosed through history and physical examination

AXR for confusing findings, may detect free gas from perforated appendix.

Differential Diagnosis:

1. UTI2. Mesenteric adenitis3. Constipation4. Gynaecological disorder (ectopic pregnancy)5. Acute pancreatitis6. Diverticulitis7. Perforated ulcer

Management:

Medical◦Antibiotics

Surgical◦Appendicectomy Abdominal wall incision ( Lanz/ Classic Gridiron incision)

Dividing the blood supply Removing the appendix Closure

Complications:

1. Perforation2. Appendiceal mass (usually resolve in

the next 2-6 weeks) - pyrexia - LOA - malaise - dull on percussion3. Appendiceal abscess (formed from

appendiceal mass that fails to resolve) - swinging pyrexia - tachycardia

Acute pancreatitis:

Aetiology :

- Gallstones (38%-60%) - Ethanol (35%) - Trauma (1.5%) - Mumps - Autoimmune (PAN) - Scorpion venom - Hyperlipidemia, hypercalcemia, hyperthyroidism - ERCP (5%) & emboli - Drugs * 10%-20% idiopathic

Pathogenesis:

Duodenopancreatic reflux

Enterokinase reflux

Activate pancreatic proenzymes

Inflammation, arterioles thrombose, local infarction

More proenzymes leak out of necrotic cells to be activated

Widespread autodigestion

Obstuction of pancreatic duct

1. Mild attack: - Acute interstitial pancreatitis2. Severe attack: - Acute haemorrhagic pancreatitis - Acute necrotising pancreatitis

Clinical features:1. epigastric pain: - sudden onset - radiate to back - no relieving factor - aggrevated by movement - assoc. with - Nausea & Vomiting

Examination:1. General appearance: - in pain - pale - sweating - dyspneic & cyanosed (respiratory distress in severe attack) - jaundice - tachycardic - signs of hypovoolemic shock

2. Abdomen:

(i) Inspection: - mild abdominal distension - Grey Turner’s sign only in Acute

Haemorrhagic - Cullen’s sign Pancreatitis

- fullness in epigastrium (abscess, pseudocyst)(ii) Palpation:

- Tender - Guarding - Rebound tenderness (iii) Percussion: - Pain >> peritonitis - Dullness >> pseudocyst

(iv) Auscultation: - Bowel sound present in first 24 hrs - Bowel sound absent when paralytic ileus develops

Investigation:

1. FBC (WBC ,RBC )2. Plasma amylase (>1200 IU/mL), (rises

within 12 hrs, return to normal in next 48-72 hrs)

3. Plasma lipase (elevated level persists for 7-10 days), usefull in late-presenting cases

4. LFT (bilirubin usually )5. ABG (hypoxia occurs in severe attack)

6. Plain CXR (free gas under diaphragm)7. Plain AXR (no psoas shadow

>>retroperitoneal fluid)8. Ultrasound9. CT scan to confirm pancreatitis if amylase level normal10. ERCP (to find the cause)

1.Scoring system by Ranson2.Glasgow Criteria by Imrie

1.Ranson’s criteria:A. At admission or

diagnosis  B. During initial 48 hrs

1. Age >55 years (70yrs in gall stone disease) 1. Hematocrit fall >10 percent

2. Leukocytosis >16,000 /mm3 2. Fluid sequestration >6L

3. Hyperglycemia >10 mmol/L 3. Hypocalcemia <2mmol/L

4. Serum LDH >400 IU/L 4. Hypoxemia (PO2 <60 mmHg)

5. Serum AST >250 IU/L 5. BUN rise >10mmol/L after IV fluids

               6. Hypoalbuminemia <3.2 g/dL

2. Glasgow scoring system:

A - Age > 55P - PO2 < 8 kPa (60mmHg) n=10.6N - Neutrophil count ( > 16 x 109 /L ) C - Calcium < 2.0 mmol/LR - Raised Urea > 10 mmol/L E - Enzyme (LDH > 350 IU/L) A – Albumin (plasma) < 32 g/LS - Sugar (plasma glucose) >10mmol/L in the

absence of history of diabetes)* (3 or > factors indicates severe pancreatitis)

clinical assessment, relief of pain and resuscitation come before imaging tests

Investigation

Hematology

biochemistry

imaging

Blood tests1.Haemoglobin

◦ -may be normal immediately after an acute bleed ◦ -low haemoglobin concentration may represent chronic anaemia

due to occult blood loss

2.White blood count -leucocytosis is non-specific and rarely of much diagnostic value unless greater than about 14 × 103/L

3.Pcv—degree of hydration(vomit,diarhoea)4.Blood culture-only in patients with rigors or shock without

obvious blood loss5.Blood group and ordering of blood for transfusion-for

severely anaemic patients, in major haemorrhage or when major surgery is contemplated

Haematology

1.C-reactive protein ◦ -non-specific indicator of inflammatory activation ◦ -confirms organic illness if substantially elevated

2.Plasma amylase-whenever pancreatitis cannot be excluded 3.Urea and electrolytes-indicated in vomiting and diarrhoea,

dehydration, poor urine output, diuretic therapy, urinary tract disease, known or suspected renal failure, pancreatitis and sepsis

Biochemistry

4.Glucose-for diabetics or those with glycosuria (beware of hyperglycaemia due to acute stress or steroid therapy)

5.Liver function tests and calcium estimation-for pancreatitis and acute biliary disease

6.Clotting studies-for acute pancreatitis and septicaemia (DIC), severe bleeding (consumption coagulopathy) or those with a history of bleeding disorders

1.Plain radiography 1.Erect chest X-ray

◦ -cardiovascular disease or abnormality, e.g. cardiomegaly, thoracic aneurysm, aortic dissection, cardiac failure

◦ -respiratory disease ◦ -suspected visceral perforation (gas under

diaphragm)

Imaging

2.Supine abdominal X-ray (erect or decubitus if necessary)

◦ -bowel (gas pattern and dilatation, fluid levels, gas in the wall, faeces and faecoliths)

◦ -urinary tract ('KUB' = kidneys, ureters and bladder) shows kidney size and position, calculi

◦ -biliary tract (gallstones, gas in biliary tree in gallstone ileus)

◦ -aortic calcification (aneurysm) ◦ -psoas shadows (obscured by retroperitoneal

inflammation or haemorrhage

2.Ultrasound Gallstones Pelvic abnormalities in obstetric and gynaecological practice 'Chronic' enlargement of the spleen Abdominal aortic aneurysm (AAA) Free abdominal fluid and gas indicating perforated bowel Other stones Dilated ducts; air in biliary tree Hydatid, teratomas and other cysts Intra-abdominal abscesses and masses 3.Contrast radiology 'Instant' barium enema in colonic obstruction or acute colitis Emergency intravenous urography in ureteric colic

4. CT scanning rapid, cost-effective evaluation of acute abdominal pain

Assessment of abdominal trauma-severity and grading of solid organ injury, free intra-abdominal fluid and gas; retroperitoneal injuries including pancreatic and duodenal rupture and vascular injury

Often first choice for ureteric colic, suspected aortic aneurysm or aortic dissection

Useful where diagnosis remains in doubt, e.g. suspected bowel perforation (detects small amount of free gas), acute diverticulitis

Investigation of postoperative complications-abscesses, fluid collections

Severe acute pancreatitis, especially if necrosis suspected

Duodenal ulcer:

• Surgery (ulcer is sutured or plugged using an omentum patch)

• Supportive treatment with nasogastric suction

Gastric ulcer:

• ~15% of perforated gastric ulcer prove to be malignant. Therefore, definitive surgery is preferred

• Simple closure with biopsy @ local excision (in poor-risk patients)

Management:

Acute cholecystitis 1st line treatment (medical) : Fasting, intravenous fluid, analgesic Start IV antibiotics (if pt has systemic

signs or if no improvement after 12-24 hours)

Surgery: Emergency vs elective Open vs laparoscopic

Laparoscopic Cholecystectomy Optimal management

Management of gallstone disease

contraindications

advantages disadvantages

(i) Uncorrectable Coagulopathy

(ii) Unable to tolerate GA

(iii) Known GB ca

(i) Lower mortality

(ii) Less pain(iii) Shorter hosp

stay(iv) Recovery

rate faster

(i) Higher incidence of injury to the common hepatic and bile ducts

(ii) Inj tend to be more extensive

Pain after cholecystectomy (I) retained or recurrent stone (ii) iatrogenic biliary leak (iii) stricture of CBD (iv) papillary stenosis/dysfunction of

Sphincter of Oddi (v) incorrect pre-op dx (eg irritable bowel

syndrome, PUD, GOR

Management of gallstone disease

Other treatment modalities : (I) Oral bile acid treatment - monotherapy or combine therapy (6-12 months) - ursodeoxycholic acid and chenodeoxycholic acid (ii) Contact dissolution therapy - chemical litholysis of cholesterol stones (MTBE) (iii) ESWL - used when GB is functioning ; technically difficult

when it is subcoastal - long term recurrence rate high (between 28-61%) (iv) percutaneous cholecystectomy

Criteria for non surgical treatment of gallstones:

Cholesterol stones (<20mm in diameter) Fewer than 4 stones Functioning gallbladder Patent cystic duct Mild symptoms

MILD ATTACK Hourly pulse, BP, urine output Fluid resuscitation to replace fluid loss from profuse vomiting Analgesics for pain relief – pethidine, morphine Withhold oral intake Treat predisposing factors Remove stone endoscopically, stopped taking alcohol,

laparoscopic cholecyctectomy with operative cholangiography before discharge.

Nasogastric tube to aspirate gastric content & relief discomfort.

Prophylactic parenteral antibiotic (cephalosporin) given. Daily measurement of serum amylase, ABG, BUSE, LFT and

serum calcium & phosphate to monitor progress

ACUTE PANCREATITIS

SEVERE ATTACK

Admit to ICU for close monitoring and early Rx of complications Evaluated every 48 hours. May die early b’coz of systemic toxaemia and multiple organ

dysfunction. If PaO2 deteriorating- urgent ventilation support before ARDS Massive fluid & electrolytes loss esp protein-rich fluid into

peritoneal cavity and 3rd space lead to shock Rx- fluid resuscitation with large amount of colloid & crystalloid Monitor urine output & central venous pressure. Peritoneal lavage – reduce systemic absorption of enzymes &

toxins. Intravenous nutrition given in paralytic ileus patient

Medical◦ Antibiotics

Surgical◦ Appendicectomy

Gridiron / Lanz skin incision Abdominal wall incision Dividing the blood supply Removing the appendix Closure

Acute appendicitis