Approach to Abdominal Pain (2)

7/31/2019 Approach to Abdominal Pain (2)

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Approach To Abdominal

PainDr. Nahla A Azzam MRCP

Consultant Gastroenterology


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Introduction

Abdominal pain is an unpleasantexperience commonly associated withtissue injury. The sensation of pain

represents an interplay ofpathophysiologic and psychosocial factors.


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ANATOMIC BASIS OF PAIN

Sensory neuroreceptors in abdominalorgans are located within the mucosa andmuscularis of hollow viscera, on serosal

structures such as the peritoneum, andwithin the mesentery.

sensory neuroreceptors are involved in

the regulation of secretion, motility, andblood flow via local and central reflex arcs.


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two distinct types of afferent nerve fibers:myelinated A-delta fibers andunmyelinated C fibers.

A-delta fibers are distributed principally toskin and muscle and mediate the sharp,sudden, well-localized pain that follows an

acute injury.


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C fibers are found in muscle, periosteum,mesentery, peritoneum, and viscera. Mostnociception from abdominal viscera is

conveyed by this type of fiber and tendsto be dull, burning, poorly localized


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STIMULANTS OF PAIN

The principal mechanical signal to whichvisceral nociceptors are sensitive isstretch.

Unlike for somatoparietal nociceptors,cutting, tearing, or crushing of visceradoes not result in pain.


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Abdominal visceral nociceptors alsorespond to various chemical stimuli

These receptors are directly activated bysubstances released in response to localmechanical injury, inflammation, tissueischemia and necrosis, and noxious

thermal or radiation injury.


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Types of Pain

Abdominal pain may be classified intothree categories:

1.visceral pain

2.somatoparietal pain

3.referred pain.


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Visceral pain


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Somatoparietal pain

is generally more intense and localizedthan visceral pain.

An example in acute appendicitis, which isfollowed by the localized somatoparietalpain at McBurney's point produced byinflammatory involvement of the parietal

peritoneum. Parietal pain is usuallyaggravated by movement or coughing.


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Referred pain


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APPROACH TO THE PATIENT

WITH ACUTE ABDOMINAL PAIN

Clinical EvaluationThe goal of theevaluation of the patient with acuteabdominal pain is an early, efficient,

and accurate diagnosis.


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History:

Chronology


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Location

Character

Aggravating and Alleviating factors e.gpositional changes, meals, bowelmovements, and stress


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Associated Symptoms and Review ofSystems e.g anorexia, nausea, vomiting,flatus, diarrhea, and constipation,

jaundice, dysuria, menstruation.


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PMH

similar symptoms suggests a recurrentproblem. Patients with a history of partial

small bowel obstructions, renal calculi. Systemic illnesses such as scleroderma,

lupus, nephrotic syndrome, porphyrias,

and sickle cell disease often haveabdominal pain as a manifestation of theirillness.


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Physical examination

General position in bed, posture, degreeof discomfort, and facial expression.

Vital signs

abdomen should be inspected fordistention, scars, hernias, muscle rigidity,splinting during respiration, ecchymoses,and visible hyperperistalsis. .


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Light, gentle palpation is superior to deeppalpation in the identification of peritonealirritation.

Palpation should begin at the point of leasttenderness and proceed to the point of greatesttenderness., and rigidity should be determined

Abdominal percussion may elicit tympan

Enlargement of a diseased organ, tumor, orminflammation may produce a palpable mass.

Potential hernia orifices should be examined.


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Investigation

Laboratory CBC,U&E, LFT, ABG, Amylase

Radiological

plain abdominal series CXR


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Ultrasonographycan provide rapid,accurate, and inexpensive anatomicinformation about the liver, biliary tree,

spleen, pancreas, kidneys, and pelvicorgan


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CT Scan of Abdomen

MRI

Other e.g. laparoscopy


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Special Circumstances

Extremes of Age difficult HX, minimalphysical , mortality

Pregnancy


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Acute Abdomen in the Intensive Care UnitPatients .e.g. trauma injuries;postoperative complications,anastomotic

leak and obstruction

complications of critical illness, includingacalculous cholecystitis and stress ulcer.


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Immunocompromised patients1. diseases that occur in the general

population2. diseases unique to the

immunocompromised host (e.g.,neutropenic enterocolitis, drug-induced

pancreatitis, GVHD,, cytomegalovirus[CMV], and fungal infections).


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Chronic Abdominal Pain

survey of more than 1 million Americansrevealed that 13% experienced "stomachpain" and 15% experienced "pain in the

lower abdomen.

Chronic intractable abdominal pain isdefined as abdominal pain that is present

for at least 6 months without diagnosisdespite appropriate evaluation


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Chronic Abdominal Pain

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Approach to Abdominal Pain (2)