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Diagnosis of acute abdominal pain hegazy

HEGAZY SURGERY

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Diagnosis of acute abdominal pain hegazy

  1. 1. ANALYSIS OF ACUTE ABDOMINAL PAIN PREPARED BY DR. BOOQ YUOSEF & DR FIAZ FAZILI SURGICAL DEPTT.OHUD HOSPITAL PRESENTED BY DR.MOUSTAFA HEGAZY
  2. 2. • depends in large measure on analysis of pain , which requires an understanding of the mechanisms of abdominal pain . DIAGNOSIS OF ACUTE ABDOMINAL PAIN
  3. 3. OBJECTIVITY OF THIS LECTURE IS To examine the physiologic background of abdominal pain As An aid to accurate interpretation of Symptoms & Signs .
  4. 4. Anatomic background  Parietal peritoneum clothes the anterior & posterior abdominal walls the under surface of the diaphragm & the cavity of the pelvis.( supplied segmentally by the spinal nerves ) .  Visceral peritoneum is the continuation of the parietal peritoneum, which leaves the posterior wall of the abdominal cavity to invest certain viscera therein . ( has no nerve supply ).
  5. 5. 11 2 3 4 5 6 7 8 9 T6-T9 T6-T9 T8-T12 T8 T10 L2 S4 foregut midgut hindgut
  6. 6. DEFINITION OF PAIN It is an unpleasant sensation of varying intensity . Pain fibers are stimulated any time a tissue is being damaged . However , it is not felt very long after the damage has been accomplished.
  7. 7. 1 2 3 4 5 Mechanical trauma to the tissue . Excess heat or cold . STIMULANTS Chemical damage. Radiation damage . Inadequate blood flow.
  8. 8. Intra-thoracic organs Abdominal Extra-abdominal Abdominal wall + Intra-peritoneal organsRetro-peritoneal organsPelvic organs Systemic dysfunction Diabetes ,tabes dorsalis porphyria Functional abdominal pain
  9. 9. Types of abdominal pain 1 Visceral pain is primitive and therefore related to embryonic devlepment therefore related to embryologic development . Somatic pain is entirely different from visceral pain 2
  10. 10. Visceral pain 1- Receptor ( Visceral peritoneum )
  11. 11. Visceral pain 2 - Stimulus Pat. Experienced pain by traction ,distention & spasm The visceral peritoneum is insensitive to touch & heat or any condition that promotes an inflammatory reaction
  12. 12. Visceral pain 3 - Mediation Thalamus Corpuscollosum Hypothalamus CerebralCortex Pons Medulla Spinalcord Cerebellum Autonomic nervous System Interpreted at the thalamic level of the brain
  13. 13. Visceral pain 4- Specificity Vague , often dull , poorly described & associated with nausea & vomiting
  14. 14. Visceral pain 5- Localization Is poor & the pat. Placing the entire hand over the involved region
  15. 15. Somatic pain 1- Receptor Pain stimuli start in the parietal peritoneum , which is innervated by peripheral nerves P/ peritoneum
  16. 16. Somatic pain 2- Stimulus Pat. experienced pain by TouchPressureHeatInflammation
  17. 17. Somatic pain 3- Mediation Central nervous system & Interpreted at a specific cortical location
  18. 18. Somatic pain 4- Specificity Precisely described as SharpKnifelikeCutting
  19. 19. Somatic pain 5- Localization The pain is localized with great accuracy by the patient , who can often point to the site with one finger
  20. 20. Analysis of pain need DATA COLLECTION 1 2 3 History Physical exam. Lab.inv. apply your medical knowledge***
  21. 21. The history of pain betrays the diagnosis History of pain SiteMode of onsetNature of painSeverityRadiationDuration Factors influencing the clinical manifestation
  22. 22. Site of pain & radiation Kidney Stomach & duodenum GB Pancreas Kidney Small bowel Caecum & rp.structure T. Colon bladder uterus & adnexae Sig. colon App. & Caecum Radiation of the pain GB. Pain radiates through to the back & to the right , to reach the tip of the shoulder blade Radiation indicates source of the pain & also the extent of the diseaseLower abdominal pain rarely radiate The structures in pelvis may radiate to the lower back or perineum Small bowel pain does not usually radiate but may move when somatic as well as visceral nerves become irritated Stomach & duodenal pain goes strait through the back Pancreatic pain tends to go through to the back but to the left Kidney pain may radiate down into the groin
  23. 23. Mode of onset Sudden onset [The patient can tell you exactly when the pain started ] The pain that start suddenly has a mechanical basis Some thing has been RupturedTwistedOccluded
  24. 24. Cont’ Mode of onset Gradual Onset ( The pat. Usually responds vaguely to questions about time of onset ) Non mechanical or chronic process
  25. 25. Nature of pain Two Large Categories (1) Conditions associated with obstruction of a muscular conducting tube ( Small bowel , Ureter , Biliary ) (2) Conditions associated with inflammation ( Mild & Localized Response or Severe , Generalized Response )
  26. 26. Obstruction Suddenprolonged Distention of the viscus ( constant stretching pain ) Colic pain = visceral pain Three Types ( 1 ) Biliary System = ( foregut ) Foregut pain is experienced in the epigastrium 1 (2) Small Intestine = ( midgut ) Pain is experienced in the periumbilical region (3) Renal system = ( retroperitoneal ) Pain is felt in the flank & radiates to the groin
  27. 27. Important features of colic pain I. Pat . Is often restless & agitated during exacerbations. II. Pat. Does not experience a totally pain –free interlude. III. Colic pain is an intermittent pain . IV. Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal layers ) V. Failing to demonstrate guarding , tenderness ? ????
  28. 28. Inflammation2 Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Peritonitis LocalizedGeneralized
  29. 29. Inflammation2 Intra-abdominal inflammation is peritonitis Peritonitis causes somatic pain Contamination BY ChemicalsBacteriaTraumaForeign body
  30. 30. Important features of somatic pain I. Pat. Laying quite in bed . ( movement is limited ) II. Examination may demonstrate guarding , tenderness . III. The pain is localized over the inflamed organ . IV. Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .
  31. 31. Ischemic pain Is a somatic pain Occlusion of blood supply cause Tissue Hypoxia With metabolic changes Necrosis After 6-12 h
  32. 32. Severity of acute abdominal pain
  33. 33. Factors influencing clinical manifestation (1) Extent of the pathologic process The more severe the process , the more impressive the manifestation .
  34. 34. Factors influencing clinical manifestation (2) Time of Assessment Depending on the time of assessment , the characteristics will reflect what is present at that time – not previously & not subsequently .
  35. 35. Factors influencing clinical manifestation (3) Emotional factors Objective criteria are more reliable than subjective factors .When there is a discrepancy between the severity of pain & objective findings ,caution should be exercised .
  36. 36. Factors influencing clinical manifestation (4) The Patient’s Intelligence A clinical history is only as reliable as its source . If the pat. is Intellectually impairedSenileVery youngOr PsychoticVery ill The information obtained must be interpreted carefully . Objective & subjective findings should be compatible .
  37. 37. Factors influencing clinical manifestation (5) Level of consciousness Some neurologic problems make the interpretation of acute abdominal pain difficult . UnconsciousnessParaplegiaSympathetic denervation Bizarre manifestation of abd. Pain .
  38. 38. Factors influencing clinical manifestation (6) Drugs Many drugs influence both the character , perception & the course and effects of disease . Corticosteroids Suppress the inflammatory response Sedatives Influence pat. Recognition of problems Analgesics Decrease pain ( minimized or overlooked )
  39. 39. Medical causes of abdominal pain ■ Diabetic ketoacidosis ■ Porphyria ■ Pain arising from the heart or lungs
  40. 40. Embryological division of the gastrointestinal tract • Foregut: • Oesophagus • Stomach • Duodenum – first and second parts • Pancreas • Liver • Gall bladder
  41. 41. • Midgut • Duodenum –third and fourth parts • Jejunum • Ileum • Right colon • Transverse colon • Appendix
  42. 42. •Hindgut •Left colon •Sigmoid colon •Rectum
  43. 43. • Origins and presentation of abdominal pain • Parietal Well localised but can radiate forwards and backwards along the dermatome • Visceral Poorly localised; associated with sweating and nausea • Retroperitoneal Pain in the back • The nature of the pain will change as the cause evolves
  44. 44. Sources of pain that evolve over hours or days ■ Acute Appendicitis Cholecystitis Salpingitis Mesenteric adenitis • ■ Infarction • ■ Free blood in the peritoneum
  45. 45. Sources of pain that evolve over hours or days ■ Acute Appendicitis Cholecystitis Salpingitis Mesenteric adenitis • ■ Infarction • ■ Free blood in the
  46. 46. Causes of sudden onset abdominal pain ■Perforation Appendix Stomach Duodenum Colon
  47. 47. Aggravating features of pain Aggravating feature Moving or coughing Interpretation Peritoneal inflammation Aggravating feature Patient rolls around with pain Colic Interpretation (suggests obstruction of viscus)
  48. 48. THANK YOU
  49. 49. I. Clinical Exercise A male pat. ,aged 17, develops mild periumbilical discomfort not influenced by activity . Several hours later , his discomfort increases but is now situated in the right lower quadrant .Movement becomes painful . Examination reveals localized pain , tenderness , and rebound tenderness localized to a small area in the right lower quadrant .
  50. 50. Analysis of case ( 1 ) The initial pain is visceral & midgut in origin but is replaced by somatic pain . The most common problem in this region & this age is app . Why visceral pain ???? The inflammation starts intraluminally , & the app. Becomes distended. Stretching is a stimulus for visceral pain . As it becomes transmural , the serosal surface is involved . Contact between V. peritoneum & P. peritoneum is established . Somatic pain replaces visceral pain & the localization changes .
  51. 51. II. Clinical exercise 47-year- old woman suddenly develops severe midepigastric pain . She cannot find a position that eases the pain , but the pain is not made worse by movement . Examination does not establish the presence of guarding , tenderness ,or rebound tenderness .
  52. 52. Analysis of case ( 2 ) This example illustrates all the characteristics of visceral pain. The most common type of colic in women in this age group is biliary . This diagnosis can be made with some confidence . Confirmation by ultrasonography is required . The epigastric localization is associated with foregut origin
  53. 53. III. Clinical exercise A 62 – year- old man is awakened at 2AM by severe abdominal pain that he describes as generalized over the entire abdomen . He complains also of pain in his left shoulder . He does not move , & his breathing shallow . He feels more comfortable sitting than lying . He is sweating , tachycardiac , & in acute distress . The abdomen is rigid . Tenderness , rebound tenderness , & guarding are evident in all four quadrants . Percussion over the liver demonstrates absence of liver dullness.
  54. 54. ANALYSIS OF CASE ( 3) This Pat. has generalized peritonitis This example illustrates all the characteristics of Somatic pain. Pain in the left shoulder suggests irritation of the diaphragm . Resonance over the liver is characteristic of air in the peritoneal cavity .This features keeping with bowel perforation .The most common site is the duodenum secondary to an ulcer .
  55. 55. IV. Clinical exercise A 76- year-old woman who lives alone in an apartment is discovered to be ill by the daughter . She is taken to the hospital, where examination reveals tenderness in the right upper abdomen . Breathing is shallow and rapid . Consolidation is suspected in the right lower lob & confirmed radiographically . Her temperature & wbc . are elevated . Does this pat. Have right –sided bronchopneumonia with pain referred to the upper abdomen , or acute cholecystitis with secondary changes in her chest ????????
  56. 56. Analysis of case ( 4 ) The differentiation is crucial Deep breathing causes discomfort ,when the GB. is inflamed . The pat. Takes shallow breaths & resists the urge to cough. Atelectasis develops & the atelectatic segment , becomes secondarily infected . Pat. Now has right lower lobe pneumonia & pain in the RUQ. With guarding & rigidity. If you operate the GB. When the correct DG. is pneumonia , the pat. will do poorly . If you miss the DG. Of necrotic GB. The pat may do very badly .
  57. 57. V. Clinical exercise A 47- year-old woman develops a severe sharp , knifelike pain in her Lt. Lower chest . She also complains of aching pain at the tip of her Lt . Shoulder . The onset was sudden & not associated with trauma or any other recognized cause . It is difficult for her to take a deep breath or cough effectively . The pain is controlled by analgesics prescribed by her physician ,who thinks she had pleurisy .within 48 hours the pain subsides,& within a week she has recovered uneventfully without further incident .
  58. 58. How should the woman’s physician have acted differently ?? V. Clinical exercise
  59. 59. This pat. had an infarct of a peripheral segment of the spleen ANALYSIS OF CASE ( 5 ) The sudden onset of chest pain was not typical of pleuritis secondary to bacterial or viral infection but of some mechanical event . The onset was in keeping with the sudden occlusion of a vessel .The infarcted area produced an inflammatory reaction that affected the diaphragmatic peritoneum , causing shoulder- tip pain . The movement of the diaphragm brought the infarcted segment into contact with the parietal peritoneum , mimicking pleuritic pain .

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