ABDOMINAL PAIN DEPT. OF MEDICINE

Abdominal pain usually results from GI disorder, reproductive, genitourinary (GU), musculoskeletal, vascular disorder; drug use; or ingestion of toxins Abdominal pain arises from the abdominopelvic viscera, the parietal peritoneum, or the capsules of the liver, kidney, or spleen. It may be acute or chronic and diffuse or localized.

Visceral pain develops slowly into a deep, dull, aching pain that's poorly localized in the epigastric, periumbilical, or lower midabdominal (hypogastric) region. somatic (parietal, peritoneal) pain produces a sharp, more intense, and well-localized discomfort that rapidly follows the insult. Movement or coughing aggravates this pain. Mechanisms that produce abdominal pain stretching or tension of the gut wall, traction on the peritoneum or mesentery, vigorous intestinal contraction, Inflammation, ischemia, a sensory nerve irritation

Visceral abdominal pain distension of hollow organs, mesenteric traction or excessive smooth muscle contraction is a deep, poorly localized sensation in the midline. It is conducted via sympathetic splanchnic nerves. Somatic pain from the parietal peritoneum and abdominal wall is lateralized and localized to the area of inflammation. It is conducted via intercostal (spinal) nerves.

Pain arising from foregut structures (stomach, pancreas, liver and biliary system) is localized above the umbilicus Pain solely from the small intestine, e.g. small intestinal obstruction, is felt around the umbilicus (periumbilical). Colonic pain can be felt either below the umbilicus, e.g. in the left iliac fossa from diverticular disease of the sigmoid colon, or in the upper abdomen, e.g. in the right hypochondrium from disease in the hepatic flexure. If the parietal peritoneum is involved, the pain will localize to that area, e.g. right iliac fossa pain in acute appendicitis and in Crohn's disease of the terminal ileum.

Pain from an unpaired structure, such as the pancreas, is felt in the midline and radiates through to the back. Pain from paired structures is felt on and radiates to the affected side, e.g. renal colic. Boys with abdominal pain may have torsion of the testis. In women, consider gynaecological causes, e.g. ruptured ovarian cyst, pelvic inflammatory disease or an ectopic pregnancy. In any patient with acute right iliac fossa pain, consider appendicitis. Radiation of pain to either or both shoulder tips indicates peritoneal inflammation adjacent to the diaphragm, e.g. cholecystitis

In a previously asymptomatic patient, the sudden onset of severe abdominal pain, rapidly progressing to become generalized and constant, suggests perforation of a hollow viscus, a ruptured abdominal aortic aneurysm or mesenteric infarction. Preceding constipation suggests colorectal cancer or diverticular disease as the cause of perforation and prior dyspepsia suggests peptic ulceration. Co-existing peripheral vascular disease, hypertension, heart failure or atrial fibrillation may suggest a vascular disorder, e.g. aortic aneurysm or mesenteric ischaemia.

Development of peripheral circulatory failure (shock) following the onset of pain suggests intra-abdominal sepsis or bleeding, e.g. ruptured aortic aneurysm or ectopic pregnancy. Torsion of the testis or ovary produces severe acute abdominal pain and nausea. Torsion of the caecum or sigmoid colon (volvulus) presents with sudden abdominal pain associated with acute intestinal obstruction. Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute appendicitis, cholecystitis or diverticulitis.

Symptom progression During the first hour or two after perforation, a 'silent interval' may occur when abdominal pain resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. In appendicitis, pain is initially localized around the umbilicus (visceral pain) and spreads as the inflammatory response progresses to involve the right iliac fossa (parietal or somatic pain). If the appendix ruptures, generalized peritonitis may develop. Occasionally, a localized appendix abscess develops, with a palpable mass and localized pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the initial diagnosis was wrong, or that complications have developed. In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with abdominal tenderness suggests intestinal ischaemia, e.g. strangulated hernia, an indication for urgent surgical intervention. Accompanying features Abdominal pain due to irritable bowel syndrome, diverticular disease or colorectal cancer is invariably accompanied by an alteration in bowel habit.

NON ALIMENTARY CAUSES OF ABDOMINAL PAIN

ABDOMINAL PAIN, INFANCY Acute gastroenteritis. Appendicitis. Intussusception. Volvulus. Meckel diverticulum. Other: colic, trauma.

ABDOMINAL PAIN, CHILDHOOD Acute gastroenteritis. Appendicitis. Constipation. Cholecystitis, acute. Intestinal obstruction. Pancreatitis. Neoplasm. Inflammatory bowel disease. Other: Functional abdominal pain. Pyelonephritis. Pneumonia. Diabetic ketoacidosis. Heavy metal poisoning. Sickle cell crisis. Trauma.

ABDOMINAL PAIN, ADOLESCENCE Acute gastroenteritis. Appendicitis. Inflammatory bowel disease. Peptic ulcer disease (PUD). Cholecystitis. Neoplasm. Diabetic ketoacidosis. Functional abdominal pain. Pelvic inflammatory disease (PID). Pregnancy. Pyelonephritis. Renal stone. Trauma.

ABDOMINAL PAIN, CHRONIC LOWER ORGANIC DISORDERS Common Gynecological disease. Lactase deficiency. Diverticulitis. Crohn’s disease. Intestinal obstruction. Uncommon Chronic intestinal pseudoobstruction. Mesenteric ischemia. Malignancy (e.g., ovarian carcinoma). Abdominal wall pain. Spinal disease. Testicular disease. Metabolic diseases (e.g., diabetes mellitus, fa -milial Mediterranean fever, C1 esterase deficiency [angioneurotic edema], porphyria, lead poisoning, tabes dorsalis, renal failure

ABDOMINAL PAIN, DIFFUSE Early appendicitis. Aortic aneurysm. Gastroenteritis. Intestinal obstruction. Diverticulitis. Peritonitis. Mesenteric insufficiency or infarction. Pancreatitis. Inflammatory bowel disease. Irritable bowel. Mesenteric adenitis. Metabolic: toxins, lead poisoning, uremia, drug overdose, diabetic ketoacidosis (DKA), heavy metal poisoning. Sickle cell crisis. Pneumonia (rare). Trauma. Urinary tract infection, PID. Other: acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, Henoch-Schönlein purpura, adrenal insufficiency.

ABDOMINAL PAIN, EPIGASTRIC Gastric: PUD, gastric outlet obstruction, gastric ulcer. Duodenal: PUD, duodenitis. Biliary: cholecystitis, cholangitis. Hepatic: hepatitis. Pancreatic: pancreatitis. Intestinal: high small bowel obstruction, early appendicitis. Cardiac: angina, MI, pericarditis. Pulmonary: pneumonia, pleurisy, pneumothorax Subphrenic abscess Vascular: dissecting aneurysm, mesenteric ischemia.

ABDOMINAL PAIN, LEFT UPPER QUADRANT Gastric: PUD, gastritis, pyloric stenosis, hiatal hernia. Pancreatic: pancreatitis, neoplasm, stone inpancreatic duct or ampulla. Cardiac: MI, angina pectoris. Splenic: splenomegaly, ruptured spleen, splenic abscess, splenic infarction. Renal: calculi, pyelonephritis, neoplasm. Pulmonary: pneumonia, empyema, pulmonary infarction. Vascular: ruptured aortic aneurysm. Cutaneous: herpes zoster. Trauma. Intestinal: high fecal impaction, perfora ted colon, diverticulitis.

ABDOMINAL PAIN, LEFT LOWER QUADRANT Intestinal: diverticulitis, intestinal obstruction, perforated ulcer, inflammatory bowel disease, perforated descending colon, inguinal hernia, neoplasm, appendicitis. Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, tuboovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis. Renal: renal or ureteral calculi, pyelonephritis, neoplasm. Vascular: leaking aortic aneurysm. Psoas abscess. Trauma

ABDOMINAL PAIN, PERIUMBILICAL Intestinal: small bowel obstruction or gangrene, early appendicitis. Vascular: mesenteric thrombosis, dissecting aortic aneurysm. Pancreatic: pancreatitis. Metabolic: uremia, DKA. Trauma.

ABDOMINAL PAIN, RIGHT UPPER QUADRANT Biliary: calculi, infection, inflammation, neoplasm. Hepatic: hepatitis, abscess, hepatic congestion, neoplasm, trauma. Gastric: PUD, pyloric stenosis, neoplasm, alcoholic gastritis, hiatal hernia. Pancreatic: pancreatitis, neoplasm, stone in pancreatic duct or ampulla. Renal: calculi, infection, inflammation, neoplasm, rupture of kidney. Pulmonary: pneumonia, pulmonary infarction, right-sided pleurisy. Intestinal: retrocecal appendicitis, intestinal obstruction, high fecal impaction, diverticulitis. Cardiac: myocardial ischemia (particularly involving the inferior wall), pericarditis. Cutaneous: herpes zoster. Trauma. Fitz-Hugh-Curtis syndrome (perihepatitis).

ABDOMINAL PAIN, RIGHT LOWER QUADRANT Intestinal: acute appendicitis, regional enteritis, incarcerated hernia, cecal diverticulitis, intestinal obstruction, perforated ulcer, perforated cecum, Meckel diverticulitis. Reproductive: ectopic pregnancy, ovarian cyst, torsion of ovarian cyst, salpingitis, tuboovarian abscess, mittelschmerz, endometriosis, seminal vesiculitis. Renal: renal and ureteral calculi, neoplasms, pyelonephritis. Vascular: leaking aortic aneurysm. Psoas abscess. Trauma. Cholecystitis

ABDOMINAL PAIN, SUPRAPUBIC Intestinal: colon obstruction or gangrene, diverticulitis, appendicitis. Reproductive system: ectopic pregnancy, mittelschmerz, torsion of ovarian cyst, PID, salpingitis, endometriosis, rupture of endometrioma. Cystitis, rupture of urinary bladder

ABDOMINAL PAIN, NONSURGICAL CAUSES Irritable bowel syndrome. Urinary tract infection, pyelonephritis, salpingitis, PID. Gastroenteritis, gastritis, peptic ulcer.Diverticular spasm. Hepatitis, mononucleosis. Pancreatitis. Inferior wall myocardial infarction. Basilar pneumonia, pulmonary embolism. Diabetic ketoacidosis. Strain or hematoma of rectus muscle. Ruptured Graafian follicle. Herpes zoster. Nerve root compression. Sickle cell crisis. Acute adrenal insufficiency. Other: acute porphyria, familial Mediterranean fever, tabes dorsalis

ABDOMINAL PAIN, POORLY LOCALIZED EXTRAABDOMINAL Metabolic DKA, acute intermittent porphyria, hyperthyroidism, hypothyroidism, hypercalcemia, hypoka - lemia, uremia, hyperlipidemia, hyperparathyroidism. Hematologic Sickle cell crisis, leukemia or lymphoma, Henoch-Schönlein purpura. Infectious Infectious mononucleosis, Rocky Mountain spotted fever, acquired immunodeficiency syndrome (AIDS), streptococcal pharyngitis (in children), herpes zoster. Drugs and Toxins Heavy metal poisoning, black widow spider bites, withdrawal syndromes, mushroom ingestion.

Referred Pain Pulmonary: pneumonia, pulmonary embolism, pneumothorax. Cardiac: angina, MI, pericarditis, myocarditis. Genitourinary: prostatitis, epididymitis, orchitis, testicular torsion. Musculoskeletal: rectus sheath hematoma. Functional Somatization disorder, malingering, hypochondriasis, Munchausen syndrome.

ABDOMINAL PAIN, PREGNANCY GYNECOLOGIC (GESTATIONAL AGE IN PARENTHESES) Miscarriage (,20 wk; 80%, 12 wk) Septic abortion (,20 wk) Ectopic pregnancy (,14 wk) Corpus luteum cyst rupture (,12 wk) Ovarian torsion (especially, 24 wk) Pelvic inflammatory disease (,12 wk) Chorioamnionitis (.16 wk) Abruptio placentae (.16 wk) NONGYNECOLOGIC Appendicitis (Throughout) Cholecystitis (Throughout) Hepatitis (Throughout) Pyelonephritis (Throughout) Preeclampsia (.20 wk)

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