EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN BY DR OJIH

OUTLINE INTR0DUCTION CAUSES MECHANISM OF PAIN ORIGINATING FROM THE ABDOMEN HISTORY EXAMINATION INVESTIGATION TREATMENT

INTRODUCTION One of the most common causes of presentation at the accident and emergency Diagnosis is difficult because numerous causes exist -NSAP 34% -Acute appendicitis 28% -Acute cholecystitis 10% -small bowel obstruction 4% -perforated PU 3% -pancreatitis 3% -Diverticular disease 2% -0thers 13% 20-40% admission rates 50-65% inaccurate initial diagnosis

CAUSES PAIN ORIGINATING IN THE ABDOMEN PARIETAL PERITONEAL INFLAMMATION -Bacterial contamination -perforated appendix or other viscus -PID -Chemical irritation -pancreatitis

CAUSES CONTINUED MECHANICAL OBSTRUCTION OF HOLLOW VISCERA -Obstruction of the small or large intestine -Obstruction of the biliary tree -Obstruction of the ureter

VASCULAR DISTURBANCES -Embolism or thrombosis -vascular rupture -pressure or torsional occlusion -sickle cell anaemia

Abdominal wall -distortion or traction of the mesentry -trauma or infection of muscles DISTENSION OF VISCERAL SURFACES-e.g by haemorrhage -hepatic or renal capsule INFLAMMATION OF A VISCUS -appendicitis -typhoid fever -typhilitis

PAIN REFERRED FROM EXTRAABDOMINAL SOURCE CARDIOTHORACIC -acute myocardial infarction -myocarditis,endocarditis, pericarditis -Congestive cardiac failure -pneumonia -Pulmonary embolism -Pleurodynia -Pneumothorax -Empyema -Esophageal disease,spasm,rupture,inflammation GENITALIA -Torsion of testis

METABOLIC CAUSES OF ABDOMINAL PAIN DM Uremia Hyperlipidaemia Hyperparathyroidism Acute adrenal insufficiency Familial Mediterranean fever Porphyria C’1 esterase inhibitor deficiency( angioneurotic oedema)

NEUROLOGIC /PSYCHIATRIC CAUSES Herpes zoster Tabes dorsalis Causalgia Radiculitis from infection or arthritis Spinal cord or nerve root compression Functional disorders Psychiatric disorders

TOXIC CAUSES Lead poisoning Insect or animal envenomation Black widow spiders Snake bites

UNCERTAIN MECHANISM Narcotic withdrawal Heat stroke

MECHANISM OF PAIN ORIGINATING IN THE ABDOMEN VISCERAL PAIN -afferent impulses from visceral organs poorly localized -pain generally felt in the midline - pain localization depends on the embryologic origin of the organ Foregut structures------epigastrium midgut structures periumbilical region hindgut structures suprapubic region -visceral nociceptors are stimulated by distention, Stretch, vigorous contraction, ischaemia and inflammation

SOMATIC PAIN -usually from inflammation or chemical irritants (gastric content) -localized to the dermatome above the site of stimulus -transmitted by spinal nerve supplying the parietal peritoneum or mesodermal structures

REFERRED PAIN Could be from the thorax, spine or genitalia Produces symptoms not signs

HISTORY Generally the cornerstone of accurate diagnosis Complete description of the patient’s pain and associated symptoms Key points in the history include -P positional, palliating and provoking factors -Q quality -R region, radiation, referral -S severity -T temporal factors ( time and mode of onset, progression, previous episodes)

LOCATION where do you feel the pain Can be generalized or localized visceral pain -foregut structures------epigastrium - midgut structures -----periumbilical - hindgut structures-----suprapubic Somatic pain -localised above the dermatome producing the stimulus

CHARACTER what kind of pain is it VISCERAL PAIN -dull, poorly localised, aching, colicky, or gnawing. SOMATIC PAIN -sharp, steady aching, more defined and well localised

ONSET how did it start Could be acute or gradual Tells the duration of pain Helps to interpret current findings and making diagnosis

RADIATION where else do you feel the pain Any inflammatory process / organ contiguous to the diaphragm can cause referred shoulder pain Acute gall bladder distension gives ipsilateral scapular pain abdominal pain radiating to the sacral region, flank, or genitalia may raise suspicion of rupturing abdominal aortic aneurysm

PROVOCATIVE AND PALLIATNG FACTORS what worsens or relieves the pain Somatic pain- worsened by pressure or changes in tension of the peritoneum (palpation, coughing, sneezing) Pancreatitis – pain is worsened by bending forward and relieved by upright position Gastric ulcer – pain is aggravated by food Duodenal ulcer - relieved by food Ask about analgesics and NSAIDS

Associated symptoms Fever Anorexia nausea Vomiting Diarrhoea Cough Amenorrhoea Dysuria etc

PAST MEDICAL & SURGICAL HX, CURRENT MEDICATIONS Previous surgery– adhesions DM---DKA CKD– uraemia SCD– vasocclusive crises Steroids and NSAIDS

SOCIAL HX Substance abuse e.g cocaine Alcohol Domestic violence ( trauma )

PHYSICAL EXAMINATION Inspection -Bending forward : chronic pancreatitis -lying still, avoiding movt: peritonitis -Restless: visceral pain -Jaundiced : common bile duct obstruction -Dehydrated: peritonitis, small bowel obstruction.

SYSTEMIC EXAMINATION ABDOMEN Inspection -scaphoid or flat in peptic ulcer -distended in ascities or intestinal obstruction -visible peristalsis in a thin or malnourished patient (with obstruction) -surgical scar (adhesions) -caput medusa in chronic liver disease

SYSTEMIC EXAMINATION Palpation -check the hernia sites -tenderness -rebound tenderness - guarding(involuntary spasm of muscles during palpations) -rigidity (when abd. muscle are tense and board like) indicates peritonitis

SYSTEMIC EXAMINATION Epigastric tenderness -DU/GU -acute pancreatitis -esophagitis Local right iliac fossa tenderness -acute appendicitis -acute salpingitis in females -crohns disease

SYSTEMIC EXAMINATION Periumbilical tenderness -early appendicitis -SBO -acute gastritis -mesenteric thrombosis -ruptured AAA

Right upper quadrant tenderness -gall bladder disease -acute pancreatitis -Pneumonia -Subphrenic abscess - DU Suprapubic tenderness -acute urinary retension -PID -cystitis

Important Signs in Patients with Abdominal Pain SignFindingAssociation Cullen's sign Bluish periumbilical discoloration intraperitoneal haemorrhage Kehr's sign Severe left shoulder painSplenic rupture Ectopic pregnancy rupture McBurney's sign Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side Appendicitis Murphy's sign Abrupt interruption of inspiration on palpation of right upper quadrant Acute cholecystitis Iliopsoas sign Hyperextension of right hip causing abdominal painAppendicitis Obturator's sign Internal rotation of flexed right hip causing abdominal pain Appendicitis Grey-Turner's sign Discoloration of the flankRetroperitoneal haemorrhage Chandelier sign Manipulation of cervix causes patient to lift buttocks off table Pelvic inflammatory disease Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant Appendicitis

PHYSICAL EXAMINATION Percussion -differentiates between ascities ( shifting dullness ) and large bowel obstruction ( drum- like tympany)

Physical examination Auscultation – Has limited diagnostic utility – > 2min to confirm absent ( ileus) – High pitched in early SBO – Bruit in aortic, renal or mesenteric stenosis

Systemic Examination Digital Rectal Examination: - tenderness - indurations - mass - frank blood

Systemic Examination Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

Investigations FBC (Hb & WCC) Amylase (Pancreatitis) U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease) FBS/RBS G&S (X-match if necessary) ABG ECG Cardiac enzymes (if appropriate)

Investigations Urinalysis Pregnancy test RADIOLOGICAL INVESTIGATIONS -CXR(PA) -Abd XR( erect and supine) -IVU -CT Scan—gold standard for diagnosis of appendidcitis Laparoscopy

TREATMENT DEPENDS ON THE CAUSE May need resuscitation (ABCD) IV fluid if there’s dehydration Analgesic (iv opiods) H2 receptor antagonists and proton pump inhibitors( PUD ) Antibiotics if there’s evidence of infection Antispasmodic (hyoscine) Surgery

REFERENCES Harrisons principle of internal medicine 18 th edition Christopher R.M and Robert M.M,2012, International journal of internal medicine Dimitri R and Alec E, diagnosis and management of abdominal pain

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