3. • depends in large measure on analysis of
pain , which requires an understanding of
the mechanisms of abdominal pain .
DIAGNOSIS OF ACUTE
ABDOMINAL PAIN
4. OBJECTIVITY OF THIS
LECTURE
IS
To examine the physiologic background of
abdominal pain
As
An aid to accurate interpretation of
Symptoms & Signs .
5. 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 ).
7. 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.
8. 1
2
3
4
5
Mechanical trauma to the tissue .
Excess heat or cold .
STIMULANTS
Chemical damage.
Radiation damage .
Inadequate blood flow.
10. 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
12. 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
13. Visceral pain
3 - Mediation
Thalamus
Corpuscollosum
Hypothalamus
CerebralCortex
Pons
Medulla
Spinalcord
Cerebellum
Autonomic nervous System Interpreted at
the thalamic level of the brain
20. Somatic pain
5- Localization
The pain is localized with
great accuracy by the patient ,
who can often point to the site
with one finger
21. Analysis of pain
need
DATA COLLECTION
1 2 3
History Physical exam. Lab.inv.
apply
your medical knowledge***
22. The history of pain betrays the diagnosis
History of pain
SiteMode of onsetNature of painSeverityRadiationDuration
Factors influencing
the clinical
manifestation
23. 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
24. 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
25. Cont’ Mode of onset
Gradual Onset
( The pat. Usually responds vaguely to questions
about time of onset )
Non mechanical or
chronic process
26. 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 )
27. 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
28. 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 ? ????
31. 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 .
32. Ischemic pain
Is a somatic pain
Occlusion of blood supply
cause
Tissue Hypoxia
With metabolic
changes
Necrosis
After 6-12 h
36. 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 .
37. 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 .
38. 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 .
39. 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 )
41. Embryological division of the
gastrointestinal tract
• Foregut:
• Oesophagus
• Stomach
• Duodenum – first and second parts
• Pancreas
• Liver
• Gall bladder
42. • Midgut
• Duodenum –third and fourth
parts
• Jejunum
• Ileum
• Right colon
• Transverse colon
• Appendix
44. • 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
45. Sources of pain that evolve over
hours or days
■ Acute Appendicitis
Cholecystitis
Salpingitis
Mesenteric adenitis
• ■ Infarction
• ■ Free blood in the peritoneum
46. Sources of pain that evolve over
hours or days
■ Acute Appendicitis
Cholecystitis
Salpingitis
Mesenteric adenitis
• ■ Infarction
• ■ Free blood in the
48. 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)
50. 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 .
51. 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 .
52. 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 .
53. 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
54. 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.
55. 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 .
56. 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
????????
57. 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 .
58. 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 .
60. 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 .
