pain abdomen with case scenarios

1. DR VARUN K
PG GASTROENTEROLOGY

2. 
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Definition
Pain pathway
Types of pain
Natural history
Causes of pain abdomen
Clinical case scenarios
Management
Conclusion

3. 
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Pain less than one week duration.
Abdominal pain is the presenting complaint in 1.5
percent of office-based visits and in 5 percent of
emergency department visits.
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Annual incidence approx. 63/1000 ED visits.
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Admission rate varies (high as 63% in pts > 65 yrs
old.)
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1.Woodwell DA, Cherry DK. National Ambulatory Medical Care Survey: 2002 summar. Adv Data.
. 2004;(346):1–44.
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2. Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency
department evaluation of abdominal pain. Emerg Med Clin North Am. 2003;21(1):61–72

5. 
Three types of pain exist:
1. Visceral
2. Parietal
3. Referred

6. 
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Visceral pain is transmitted by C fibers.
Involves hollow or solid organs; midline pain
due to bilateral innvervation
Steady ache or vague discomfort to
excruciating or colicky pain
Poorly localized
Secondary autonomic symptoms present.

7. 
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Abdominal visceral nocioceptors respond to
mechanical and chemical stimuli.
The principal mechanical signal to which
visceral nocioceptors are sensitive is stretch.
Chemical nocioceptors are activated by
substances released in response to
inflammation and injury.

8. 
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Somatic-parietal pain is mediated by A-δ
fibers that are distributed principally to skin
and muscle.
Signals from this neural pathway are
perceived as sharp, sudden, well localized
pain, such as that which follows an acute
injury.
These fibers convey pain sensations through
spinal nerves.

9. 
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Stimulation of these fibers activates local
regulatory reflexes mediated by the enteric
nervous system and long spinal reflexes
mediated by the autonomic nervous system,
in addition to transmitting pain sensation to
the central nervous system.
Reflexive responses, such as involuntary
guarding and abdominal rigidity, are
mediated by spinal reflex arcs involving
somatic-parietal pain pathways.

10. 
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Somatic A-d fibers mediate touch, vibration, and
proprioception in a dermatomal distribution that
matches the visceral innervation of the injured
viscera and synapse with inhibitory interneurons
of the substantia gelatinosa in the spinal cord.
In addition, inhibitory neurons that originate in
the mesencephalon, periventricular gray matter,
and caudate nucleus descend within the spinal
cord to modulate afferent pain pathways.
These inhibitory mechanisms allow cerebral
influences to modify afferent pain impulses.

11. 
Referred pain is felt in areas remote from the
diseased organs and results when visceral
afferent neurons and somatic afferent
neurons from a different anatomic region
converge on second-order neurons in the
spinal cord at the same spinal segment.

13. 
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Subdiaphragmatic irritation → ipsilateral
shoulder or supraclavicular pain(kehr’s sign).
Biliary disease → right infrascapular pain
MI → epigastric, neck, jaw or upper extremity
pain

15. 
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Gastritis
Acute Gastroenteritis
Hepatic abscess
Rectal sheath hematoma
Herpes Zoster
UTI
Tabes dorsalis
Sickle cell disease
Diabetes Mellitus
Thyrotoxicosis
Addisonians disease
Poryphyria
Hereditary Spherocytosis

16. Acute appendicitis
Acute diverticulitis
Acute pancreatitis
Acute cholecystitis
Intestinal obstruction
Billiary colic
Ureteric colic
Acute retention of urine
Perforation of peptic ulcer
Perforation of appendix
Ruptured AAA
Perforated oesophgagus

17. 
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Ectopic pregnancy
PID
Salpingitis
Mittelschmerz
Endometriosis
Dysmenorrhoea
Fibroid degeneration
Ovarian cyst – rupture, torsion , hemorrhage

21. 
LOCATION OF PAIN
Right upper quadrant
Left upper quadrant
Right lower quadrant
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Left lower quadrant
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Suprapubic
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IMAGING
Ultrasonography
CT
CT with iv
contrast media
CT with oral and IV
contrast media
Ultrasonography

22. 
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24 year healthy male with one day history of
abdominal pain.
Pain was generalized at first, now worse in right lower
abd & radiates to his right groin.
He has vomited twice today. Denies any diarrhea,
fevers, dysuria or other complaints. No appetite
today.
ROS otherwise negative.
PMHx: negative
PSurgHx: negative
Meds: none
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory

23. 
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Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat:
100% room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to
palpation in RLQ with mild guarding;
hypoactive bowel sounds
Genital exam: normal

24. 
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Classic presentation
Periumbilical pain
Anorexia, nausea, vomiting
Pain localizes to RLQ
Occurs only in ½ to 2/3 of patients
26% of appendices are retrocecal and cause pain
in the flank; 4% are in the RUQ
A pelvic appendix can cause suprapubic pain,
dysuria
Males may have pain in the testicles
Addiss DG, Shaffer N, Fowler B, Tauxe RV. The epidemiology of appendicitis and appendectomy
in the United States. Am J Epidemiol 1990; 132:910-25. (Ref 21.)

25. 
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Depends on duration of symptoms
Rebound, voluntary guarding, rigidity,
tenderness on rectal exam
Fever (a late finding)
Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
Addiss DG, Shaffer N, Fowler B, Tauxe RV. The epidemiology of appendicitis and appendectomy
in the United States. Am J Epidemiol 1990; 132:910-25. (Ref 21.)

26. Abdominal xrays
Appendiceal fecolith or gas, localized
ileus, blurred right psoas muscle, free air
 CT scan
Pericecal inflammation, abscess,
periappendiceal phlegmon, fluid
collection, localized fat stranding
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29. 
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NPO
IVFs
Preoperative antibiotics – decrease the
incidence of postoperative wound infections
Analgesia

30. 
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Alvarado Score is numerical, it has been
evaluated for ruling in and ruling out
appendicitis.
Studies ruling out appendicitis (using Alvarado <
3-4) have a sensitivity of 96%; studies ruling in
appendicitis (using Alvarado > 6-7) have a
sensitivity of 58-88%, depending on the study
and score cutoffs used.
The 2007 McKay study recommends CT scan for
Alvarado 4-6, surgical consultation for Alvarado
≥ 7, and for Alvarado ≤ 3, no CT for diagnosing
appendicitis, as appendicitis is unlikely

31. 
68 yo F with 2 days of LLQ abd pain,
constipation, fevers/chills, nausea; vomited once
at home.
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PMHx: HTN, diverticulosis
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PSurgHx: negative
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Meds: HCTZ
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Social hx: no alcohol, tobacco or drug use

32. 
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T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat:
99% room air
Gen: uncomfortable appearing, slightly pale
Abd: soft, moderately tender LLQ
Rectal: normal tone, guiac neg brown stool

33. 
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FINDINGS:
Steady, deep discomfort in LLQ
Change in bowel habits
Urinary symptoms
Tenesmus
Paralytic ileus

34. 
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Low-grade fever
Localized tenderness
Rebound and guarding
Left-sided pain on rectal exam
Occult blood
Peritoneal signs-Suggest perforation or
abscess rupture

36. 
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CT scan (IV and oral contrast)
Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular abscess
Leukocytosis present in only 36% of patients

37. 
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Hinchey grade I diverticulitis :localized
pericolic abscess or inflammation frequently
Hinchey grade II diverticulitis: pelvic,
intraabdominal, or retroperitoneal abscess.
Hinchey III :generalized purulent peritonitis
Hinchey IV generalized fecal peritonitis.

39. 
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Fluids
Correct electrolyte abnormalities
Antibiotics.

40. 
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46 yo M with hx of alcohol abuse with 3 days
of severe boring upper abd pain radiating to
back relieved on leaning forward , vomiting,
subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none;
Social hx: heavy alcohol use, smokes 2ppd,
no drug use

41. 
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Vital signs: T: 37.4, HR: 115, BP: 98/65, R:
22, O2sat: 95% room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses
normal
Lungs: clear
Abdomen: mildly distended, moderately TTP
epigastric, +voluntary guarding
Rectal: heme neg stool

42. 
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CLINICAL FEATURES
Epigastric pain -Constant, boring
pain,Radiates to back.
Vomiting.
Fever.

43. 
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Patients are usually tachycardic and
tachypneic.
Abdominal examination reveals hypoactive
bowel sounds and marked tenderness to
percussion and palpation in the epigastrium.
Abdominal rigidity is a variable finding.
In rare patients, flank or periumbilical
ecchymoses (Grey-Turner’s or Cullen’s sign,
respectively) develop in the setting of
pancreatic necrosis with hemorrhage.

44. 
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Lipase -Elevated more than 3 times normal
;Sensitivity and specificity >90%
Amylase-Nonspecific
USG abdomen if etiology unknown
CT scan-Useful to evaluate for complications

47. 
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NPO
IV fluid resuscitation
Maintain urine output of 100 mL/hr
NGT if severe, persistent nausea
No antibiotics unless severe disease

48. 
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72 yo M with hx of CAD on aspirin and Plavix
with several days of dull upper abd pain and
now with worsening pain “in entire abdomen”
today. Some relief with food until today, now
worse after eating lunch.
Med Hx: CAD, HTN, CHF
Surg Hx: appendectomy
Meds: Aspirin, Plavix, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or
drug use, lives alone

50. CLINICAL FEATURES
 Burning epigastric pain leading to sudden
onset severe diffuse abdominal pain
 Epigastric tenderness
 Severe, generalized pain may indicate
perforation with peritonitis
 Occult or gross blood per rectum or NGT if
bleeding.

51. 
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Acute abdominal x-ray series -Lack of free
air does not rule out perforation
Broad-spectrum antibiotics
Surgical consultation

52. 
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35 yo healthy F to ED c/o nausea and vomiting
since yesterday along with generalized
abdominal pain ,cramping in nature more in the
periumbilical area not radiating
No fevers/chills, +anorexia. Last stool 2 days
ago.
Med Hx: negative
Surg Hx: s/p hysterectomy (for fibroids)
Social Hx: denies alcohol, tobacco or drug use
Family Hx: non-contributory

54. 
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Crampy, intermittent pain
Periumbilical or diffuse
Inability to have BM or flatus
Nausea and vomiting
Abdominal bloating
Sensation of fullness, anorexia

55. 
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Distention
Tympany
Absent, high pitched or tinkling bowel sound
or “rushes”
Abdominal tenderness: diffuse, localized, or
minimal

56. 
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CBC and electrolytes
electrolyte abnormalities
WBC >20,000 suggests bowel necrosis,
abscess or peritonitis
Abdominal x-ray series-Air-fluid levels,
dilated loops of bowel,Lack of gas in distal
bowel and rectum
CT scan-Identify cause of obstruction,
Delineate partial from complete obstruction

57. 
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Fluid resuscitation
NGT
Analgesia
Hospital observation for ileus or for complete
obstruction

58. 
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48 yo obese F with one day hx of upper abd
pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no
diarrhea, subjective fevers. No prior similar
symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use

59. 
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T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat:
100% room air
General: moderately obese, no acute distress
CV: normal
Lungs: clear
Abd: moderately tender RUQ, +Murphy’s
sign, non-distended, normal bowel sounds

60. 
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RUQ or epigastric pain
Radiation to the back or shoulders
Dull and achy
Pain lasting longer than 6 hours
Nausea,Vomiting,anorexia
Fever, chills.

61. 
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Epigastric or RUQ pain
Murphy’s sign
Peritoneal signs suggest perforation

63. 
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RUQ US
Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic murphy sign
HIDA scan-more sensitive & specific than US

64. 
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Surgical consult
IV fluids
Correct electrolyte abnormalities
Analgesia
Antibiotics
NGT if intractable vomiting

65. 
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Sudden onset of acute, severe abdominal pain
localized to the midabdomen or paravertebral or
flank areas.
The pain is tearing in nature and associated with
prostration,lightheadedness, and diaphoresis.
Physical examination reveals a pulsatile, tender
abdominal mass in about 90% of cases.
The classic triad of hypotension, a pulsatile
mass, and abdominal pain is present in 75% of
cases and mandates immediate surgical
intervention.

66. 
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Consider this diagnosis in all elderly patients
with risk factors Atrial fibrillation, recent
MI,Atherosclerosis, CHF, digoxin therapy
Hypercoagulability, prior DVT, liver disease.
Severe pain, often refractory to analgesics
Relatively normal abdominal exam
Embolic source: sudden onset (more gradual
if thrombosis)
Nausea, vomiting and anorexia are common

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50% will have diarrhea
Eventually stools will be guiaic-positive
Metabolic acidosis and extreme leukocytosis
when advanced disease is present (bowel
necrosis)
Diagnosis requires mesenteric angiography or
CT angiography

68. 
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It is defined as pathologic elevation of
intraabdominal pressure.
An elevated intra-abdominal pressure may
develop in a patient who survives massive
volume resuscitation with resulting visceral
edema or who has a disease such as severe
pancreatitis that can cause visceral or
retroperitoneal edema.

69. 
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The World Society for Abdominal Compartment
Syndrome has established a consensus grading
scheme for ACS based on the measured bladder
pressure.
A normal value for bladder pressure is less than
7 mm Hg.
Grade I ACS is defined as a pressure of 12 to 15
mm Hg.
Grade II as 16 to 20 mm Hg,
Grade III as 21 to 25 mm Hg and
Grade IV as greater than 25 mm Hg.
An G, West M. Abdominal compartment syndrome: A concise clinical review. Crit
Care Med 2008; 36:1304-10

70. 
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Nonsurgical options for treating low-grade
ACS include gastric decompression, sedation,
neuromuscular blockade, placing the patient
in a reverse Trendelenburg position while
allowing the hips to remain in a neutral
position, and diuretics.
In a patient with high grade ACS, particularly
when renal and respiratory function is
compromised, laparotomy and creation of an
open abdomen is most effective.

72. 
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Mortality rate for abdominal pain in the
elderly is 11-14%
Perception of pain is altered
Altered reporting of pain: stoicism, fear,
communication problems

73. 
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Most common causes:
Cholecystitis
Appendicitis
Bowel obstruction
Diverticulitis
Perforated peptic ulcer
Don’t miss these:
AAA, ruptured AAA
Mesenteric ischemia
Myocardial ischemia
Aortic dissection

74. 
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Appendicitis – do not exclude it because of prolonged
symptoms. Only 20% will have fever, N/V, RLQ pain
and ↑WBC
Acute cholecystitis – most common surgical
emergency in the elderly.
Perforated peptic ulcer – only 50% report a sudden
onset of pain. In one series, missed diagnosis of PPU
was leading cause of death.
Mesenteric ischemia – we make the diagnosis only
25% of the time. Early diagnosis improves chances of
survival. Overall survival is 30%.
Increased frequency of abdominal aortic aneurysms
AAA may look like renal colic in elderly patients

75. 
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Pregnant women develop acute appendicitis
and cholecystitis at the same rate as their
nonpregnant counterparts.
A number of additional diagnoses, such as
placental abruption and pain related to
tension on the broad ligament, must be
distinguished from nonobstetric diagnoses.

76. 
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Appendicitis occurs in approximately 1 in
2000 pregnancies and is equally distributed
among the three trimesters.
Biliary tract disease is also common during
pregnancy.
Open or laparoscopic management of these
diseases is safe but is associated with a rate
of preterm delivery of approximately 12% for
appendectomy and 11% for cholecystectomy.

77. 
Immunocompromised hosts may manifest
with acute abdominal pain, including
neutropenic enterocolitis, drug-induced
pancreatitis, graft-versus-host disease,
pneumatosis intestinalis, and
cytomegalovirus (CMV) and fungal infections.

78. 
In general, immunocompromised patients
may lack the definitive signs of an acute
abdominal crisis usually seen in
immunocompetent persons; an elevated
temperature, peritoneal signs, and
leukocytosis may be absent in these cases.

79. 
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Acetaminophen
Non-steroidal anti-inflammatory drugs
(NSAIDs)
Opioids
Treatment of cause.

80. 
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In order to obtain the best therapeutic effect
while minimising side effects, many analgesic
drugs require careful titration and
individualisation of dose regimens.
Multimodal analgesia (that is, the concurrent use
of different classes of analgesics) improves the
effectiveness of acute pain management.
Drug administration can be by oral,
subcutaneous, intramuscular, intravenous,
epidural, intrathecal, inhalational, rectal,
transdermal or transmucosal routes

81. 
Some specialised analgesia delivery
techniques require greater medical and
nursing knowledge and expertise like
Patient-controlled analgesia, Epidural and
intrathecal analgesia ,Other regional
analgesic procedures, Continuous infusions
of opioids, local anaesthetics, ketamine and
other drugs.

82. 
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NON-PHARMACOLOGICAL THERAPIES
Non-pharmacological therapies must be
considered as complementary to
pharmacological therapies.
Psychological interventions, acupuncture,
transcutaneous electrical nerve stimulation
and physical therapy may be effective in
some acute pain settings.

83. 
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Sir Zachary Cope stated that “Morphine does
little or nothing to stop serious intraabdominal disease, but it puts an efficient
screen in front of the symptoms.
Six studies in which the early administration
of analgesia was compared with
administration of placebo in patients with
acute abdominal pain have shown that the
patients who receive analgesics are more
comfortable and do not experience a delay in
diagnosis.

84. 
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Significant abdominal tenderness should never
be attributed to gastroenteritis
Incidence of gastroenteritis in the elderly is very
low
Always perform genital examinations when lower
abdominal pain is present – in males and
females, in young and old
In older patients with renal colic symptoms,
exclude AAA
Severe pain should be taken as an indicator of
serious disease
Pain awakening the patient from sleep should
always be considered signficant

85. 
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Sudden severe pain suggests serious disease
Pain almost always precedes vomiting in surgical
causes; converse is true for most gastroenteritis
and NSAP
Acute cholecystitis is the most common surgical
emergency in the elderly
A lack of free air on a chest xray does NOT rule
out perforation
Signs and symptoms of PUD, gastritis, reflux and
nonspecific dyspepsia have significant overlap
If the pain of biliary colic lasts more than 6
hours, suspect early cholecystitis

86. THANK YOU