CONTENTS OF RIGHT HYPOCHONDRIUNy LOWER RIBS y LIVER y GALL BLADDER y DUODENUM y HEAD OF PANCREAS y HEPATIC FLEXURE y TRANSVERSE COLON y RIGHT KIDNEY

PAIN IN ABDOMEN

CAUSES OF PAIN IN RIGHT HYPOCHONDRIUM

y RIBS :

TRAUMA 2. FRACTURE OF RIB 3. MUSCULOSKELETAL STRESS1.

y LIVER DISEASES :

LIVER ABSCESS 2. HEPATOMA 3. HYDATID CYST 4. HEPATITIS1.

y GALL BLADDER DISEASES :

CHOLECYSTITIS 2. CHOLELITHIASIS 3. CHOLEDOCOLITHIASIS 4. CARCINOMA OF GALL BLADDER1.

y DUODENAL ULCER y PERFORATED PEPTIC ULCER

y PANCREATIC DISEASES :

PANCREATITIS 2. CARCINOMA OF PANCREAS1.

y LESIONS OF HEPATIC FLEXURE OF COLON : 1. 2. 3. 4. 5.

CARCINOMA DIVERTICULOSIS ISCHEMIC OBSTRUCTION CROHN S DISEASE CONSTIPATION

y RENAL DISEASES : 1. 2. 3. 4. 5.

PYELONEPHRITIS NEPHROLITHIASIS HYDRONEPHROSIS RENAL CELL CARCINOMA OTHER DISEASES OF KIDNEY OR URETER LEADING TO OBSTRUCTION OF URINARY TRACT.

y OTHERS :

REFERRED PAIN : FROM HEART OR OF RESPIRATORY ORIGIN OF LOWER LOBE OF LUNG. II. LOBAR PNUEMONIA III. INFARCTION FROM PULMONARY EMBOLISMI.

ANY METABOLIC DISEASE CAN GIVE SAME PICTURE AS IN; DAIBETIC KETOACIDOSIS II. ADDISON S CRISIS III. ADRENAL TUBERCULOSIS IV. METASTAIC CARCINOMAI.

INFECTIONS SUCH AS ; I. HERPES ZOSTER II. SUBPHRENIC ABSCESS

MANAGEMENT

HISTORYINTENSITY AND DESCRIPTION OF PAIN : y DULL SENSATION OF MILD TO MODERATE SEVERITY CAN BE CAUSED BY PEPTIC ULCERS.

y EXTREMELY INTENSE

PAIN OF SUDDEN ONSET MAY BE RESULT OF MESENTERIC ISCHEMIA OR PERFORATED PEPTIC ULCER.

y BILIARY PAIN

TYPICALLY PRESENTS WITH CONSTANT, STEADY PAIN WITHOUT INTERVENING PAIN FREE INTERVAL. y RENAL COLIC IS EPISODIC PAIN WITH INTERVENING PAIN FREE INTERVAL.

y SEVERE INTENSITY

y PATIENTS WITH POST-

AND TEARING QUALITY PAIN CAN BE DISSECTING ANUERYSM.

PARANDIAL PAIN,FOOD AVOIDANCE, WEIGHT LOSS AND KNOWN ATHEROSCLEROTIC DISEASE SHOULD BE EVALUATED FOR MESENTERIC ANGINA.

TIME COURSE OF PAIN :y Sudden onset (over y Rapidly progressive

seconds to minutes) of abdominal pain suggests a catastrophic event such as a perforated peptic ulcer.

(over 1-2 hours) pain is seen typically in pancreatitis, cholecystitis, diverticulitis, bowel obstruction, renal or biliary colic, and mesenteric ischemia.

y Gradual (over several hours) pain that progresses more slowly is more typical of peptic ulcer disease, distal small bowel obstruction, appendicitis, pyelonephritis, pelvic inflammatory disease, and malignant neoplasm, although it may be seen with many of the diagnoses in the more rapidly progressive categories as well.

y Pain occurring following the onset of vomiting often indicates a medical illness, whereas pain that precedes vomiting often indicates a surgical illness. Persistence of pain for over 6 hours after acute onset has a high likelihood of a surgical cause and requires admission for observation.

AGGREVATING OR RELIEVING FACTORS :y Pain relieved by antacids suggests peptic ulcer disease or esophagitis. y Pain worsened by movement suggests peritonitis, whereas constant y y y

y

movement by the patient in an attempt to find a comfortable position is commonly seen in bowel obstruction and renal colic. Patients with partial relief by leaning forward, and aggravation by lying supine suggests a retroperitoneal process (such as pancreatitis) Pain relieved by defecation may suggest a colonic source. Patients with postprandial pain, food avoidance, weight loss, and known atherosclerotic disease should be evaluated for chronic intestinal ischemia (mesenteric angina) or intermittent intestinal obstruction (from internal or abdominal wall hernias, adhesions, or Crohn's disease). Pain that occurs at approximately monthly intervals should raise the suspicion of endometriosis.

PHYSICAL EXAMINATION:y Vital signs y Tachycardia & hypotension: Vital signs may show

tachycardia and hypotension indicative of intra abdominal hemorrhage or septic shock.

y Fever: The fever of appendicitis, diverticulitis, and

cholecystitis is typically low grade, whereas high fevers are seen in cases of cholangitis, urinary tract infections, pelvic inflammatory disease, or perforation of a viscus with frank peritonitis.

ABDOMINAL EXAMINATION :y Inspection y Abdominal distention:

Abdominal distention may suggest bowel obstruction or the presence of ascites.

y Scaphoid abdomen: A

scaphoid, tense abdomen is seen in cases of peritonitis.

Palpation : Tightening (rigidity) of the abdominal wall musculature occurs as a reflexive response to peritoneal inflammation. Involuntary guarding indicates peritoneal inflammation. Tenderness over McBurney's point should be considered very strong evidence of appendicitis . Cholecystitis and salpingitis are often well localized as well, and salpingitis may be confused with appendicitis. Patients with an unimpressive abdominal examination and complaints of severe, worsening pain should be suspected of having mesenteric infarction.

Murphy's sign refers to pain produced by deep inspiration during palpation of the right subcostal area and suggests acute cholecystitis. Pain produced by lightly punching the costovertebral angle ("punch tenderness") is often present in pyelonephritis. Carnett's test refers to the response of pain when the patient tenses the abdominal wall muscles by raising their head off the examination table. Worsening of pain during this maneuver suggests an abdominal wall source whereas improvement in the pain suggests a visceral origin. The iliopsoas sign refers to pain produced by passive extension of the leg and suggests a psoas abscess.

The obturator sign refers to pain produced by rotation of the thigh in a flexed position . A rectal examination can reveal focal tenderness from an intra abdominal abscess or appendicitis. A pelvic examination is mandatory in female patients to look for evidence of salpingitis or adnexal masses . The inguinal and femoral canals, umbilicus, and surgical scars should be evaluated for the presence of incarcerating hernias. .

y Percussion y Tenderness on percussion: Percussion

of the abdomen allows assessment of the presence of peritonitis. Pain produced by light tapping indicates inflammation of the parietal peritoneum. This pain may also be elicited by asking the patient to cough or by gently agitating the gurney upon which the patient is lying. tympany upon percussion suggests a bowel obstruction.

y Auscultation y Auscultation of the abdomen should be

performed before palpation or percussion so as not to interfere with the interpretation of bowel sounds. y Absence of bowel sounds: Absence of bowel sounds is a sign of diffuse peritonitis.y Hyperactive bowel sounds:

y Tympany: A distended abdomen with

Intermittent hyperactive bowel sounds occurring concurrently with worsening of pain suggest a bowel obstruction. High-pitched hyperactive bowel sounds may also be seen in gastroenteritis. succussion splash suggests gastric outlet obstruction.

y Succussion splash: The presence of a

INVESTIGATIONS :y ROUTINE BASELINE INVESTIGATIONS y SPECIFIC INVESTIGATIONS

TREATMENT :y TREAT THE CAUSE