Clinical approach to a patient with

abdominal pain

ABDOMINAL PAIN

VISCERAL PAIN

NOCICEPTORSSTRETCHCHEMICAL

SOMATIC PAIN

From ABDOMINAL WALL & PARIETAL PERITONEUM

SITE AND RADIATION

ORGAN SITE OF PAIN RADIATION

STOMACH EPIGASTRIUM Rt HYPO, LUMBAR,Rt ILIAC,Lt CHEST,VERTEBRAL COLUMN

LIVER-Rt LOBE Rt HYPOCHONDRIUM

SHOULDER,SUPRACLAVICULAR & SCAPULAR REGION ON Rt

LIVER-Lt LOBE EPIGASTRIUM PRECORDIUM, Lt SCAPULAR, Lt CLAVICLE

GALL BLADDER EPIGASTRIUM or Rt HYPOCHONDRIUM

CHEST,Rt SCAPULA,Rt CLAVICLE,SHOULDER,BACK

May resemble ANGINAL pain

SPLEEN

(pain unusual)

Dragging sensation &fullness-Lt HYPO & LUMBAR

Local inflamn of peritoneum-Catching pain respiration

PANCREAS EPIGASTRIUM OR BACK

Acute-symps of shock

Chronic-vague in nature & location

KIDNEYS LOINS or LUMBAR REGION

Obstructive lesions-Penis or Labia + urgency for urination

URINARY BLADDER

HYPOGASTRIUM PERINEUM & URETHRA

SMALL INTESTINE

UMBILICUS

LARGE INTESTINE

ILIAC or LUMBAR

APPENDIX

CAECUM

Rt ILIAC FOSSA Rt LUMBAR, UMBILICAL

RECTUM Lt ILIAC FOSSA or HYPOGASTRIUM

Assoc. with tenesmus

UTERUS

DYSMENORRHOEA

HYPOGASTRIUM & UMBILICUS

LOWER ABDOMEN

LOW BACK & FLANKS

OVARY ILIAC FOSSA EXTERNAL GENITALIA

PERITONITIS

LOCALISED

Eg. Rt iliac fossa in appendicitis

GENERALISED

DIFFUSE affecting the whole abdomen

GUARDING AND RIGIDITY ON PALPATION

REFERRED PAIN

Pain arising from lesions outside abdomen

REFERRED to abdomenEg. MI radiate to epigastriumGirdle pain B/L dorsal nerve root

compression

Psycogenic Pain

Not due to any organic causeMore common at night

NATURE OF PAIN

SOLID ORGANS:DULL & CONSTANT aggravated by pressure.Organ enlarged,palpable,tender.

HOLLOW VISCERA:COLICKY PAIN reach max. in secs or mins & passes off.

Exception biliary tract & pancreas

DURATION OF PAIN

ACUTE

Intense pain with dramatic onset

Reach maximum in hrs or days

CHRONIC

Periods of remissions & exacerbations with intervals of relief in btwn

Months or years

Relation to normal physiological events

Pain related to ingestion of food

Gastric ulcer

Pain relieved by food intake Duodenal ulcer

Relief of pain by vomiting Gastric outlet obstruction

Pain on recumbency & relief on erect posture

GERD

Pain on ingestion of fat Malabsorption

Pain on defaecation Colonic disease

Blood and mucus in faeces Colonic ulcer

Pain as food pass down to be digested & absorbed

Intestinal angina

Past HistoryTraumaDM, CRF-Metabolic cause of painThrombotic disease-Vaso occlusionCAD-Embolic occlusion

Family History

o DM

o CAD

Personal History

Appetite & Loss of weightBowel habits- Malena-Upper GIT ds

Hematochezia-Lower GIT dsDifficulty in micturitionMenstrual history

General Examination

PALLOR Malabsorption,Acute or chronic blood loss

ICTERUS Hepatobiliary disease

CYANOSIS Cirrhosis liver with portal hypertension

CLUBBING Cirrhosis,ulcerative colitis,Crohn`s disease

LYMPHADENOPATHY Generalised or localised

GIT Examination….

Inspection

1. Shape

2. Umbilicus

3. Movements of the abdominal wall

4. Skin and surface of abdomen

•Palpation

1. Liver

2. Spleen

3. Kidneys

4. Palpable mass

• Percussion

Shifting dullness Fluid thrill Puddle sign

Auscultation

1. Bowel sounds2. Succusion splash

Also examine….

GenitaliaHernial orificesPer rectal examinationPer vaginal examination