1. ABDOMINAL PAIN
Abdominal pain is a very common clinical symptom , which involves the patients’ subjective reaction to the stimulus. The approach to the patient with abdominal pain is one of a physician greatest challenges.
Generally, there are two kinds of abdominal pain, acute abdominal pain and chronic abdominal pain.

2. Cause: 1.acute abdominal pain 1) peritonitis
2) the acute inflammation of abdominal organs
3) the swelling and obstruction of cavum
4) the torsion and rupture of abdominal organs
5) thoracic illnesses
6) belly diseases
7) whole-length diseases

3. 1) peritonitis:
The perforation of stomach or duodenum is the most common reasons of peritonitis .
2) the acute inflammation of abdominal organs:
for instant: acute gastritis
acute enteritis
acute pancreatitis
acute cholecystitis ,and so on
If the patient has a history of eating some unclean or too cold foods, and accompanied with vomiting, diarrhea and acute abdominal pain, it’s highly suggestive of acute gastroenteritis.

4. Acute pancreatitis: the pancreas is necrosed and partially liquefied.

5. 3) the dilation and obstruction of cavum
for instant: cholelithiasis
ileus
4) the torsion and rupture of abdominal organs:
for instant: the torsion of intestine or ovary
the rupture of liver or spleen
caused by trauma.
5) thoracic illness: for instant: pneumonia
miocardial infarction

6. If you meet some old people who feel epigastric pain, you should pay attention to take a Electirocardiogram (ECG). It’s a good way to distinguish abdominal diseases from miocardial infarction.
6) belly diseases:
for instant: contusion of belly
7) whole-length diseases:
for instant: uraemia

7. Cause: 1.acute abdominal pain 1) peritonitis
2) the acute inflammation of abdominal organs
3) the swelling and obstruction of cavum
4) the torsion and rupture of abdominal organs
5) thoracic illnesses
6) belly diseases
7) whole-length diseases

8. 2. chronic abdominal pain:
1) Chronic inflammation of abdominal organs
for instant : chronic gastritis, chronic cholecystitis ,chronic
pancreatitis
2) gastric or duodenal peptic ulcer (most important )
3) the torsion and obstruction of stomach or intestine
for instant: chronic torsion of stomach or intestine
4) increased tension of envelope
for instant :liver cancer, liver abscess, hepatic gore
5) toxicosis and metabolic disfunction: uremia
6) encroachment and oppression of tumor

9. ULCER
Barium meal examination showing an ulcer crater with radiating mucosal folds reaching to its rim and strongly suggests that the ulcer is benign.

10. 2.chronic abdominal pain:
1) Chronic inflammation of abdominal organs
for instant : chronic gastritis, chronic cholecystitis ,chronic
pancreatitis
2) gastric or duodenal peptic ulcer (most important )
3) the torsion and obstruction of stomach or intestine
for instant: chronic torsion of stomach or intestine
4) increased tension of envelope
for instant :liver cancer , liver abscess, hepatic gore
5) toxicosis and metabolic disfunction: uremia
6) encroachment and oppression of tumor

11. The dilation of material organs (such as liver) can result in the increased tension of organ’s envelope , so the patients feel abdominal pain and other discomfort.

12. 2.chronic abdominal pain:
1) Chronic inflammation of abdominal organs
for instant : chronic gastritis, chronic cholecystitis ,chronic
pancreatitis
2) gastric or duodenal peptic ulcer (most important )
3) the torsion and obstruction of stomach or intestine
for instant: chronic torsion of stomach and intestine
4) increased tension of envelope
for instant :liver cancer , liver abscess, hepatic gore
5) toxicosis and metabolic disfunction: uremia
6) encroachment and oppression of tumor

13. Cause: 2.chronic abdominal pain:
1) Chronic inflammation of abdominal organs
2) gastric or duodenal peptic ulcer (most important )
3) the torsion and obstruction of stomach or intestine
4) increased tension of envelope
5) toxicosis and metabolic disfunction:
6) encroachment and oppression of tumor

14. Pathogenesis: Abdominal pain may be classified as visceral pain , somatic pain , and referred pain
Visceral pain originates from internal organs. Most visceral fibers have slow conduction, and the abdominal viscera lake the dense network of somatic afferent fibers.
a. dull
b. no distinct location
c. accompanied symptom: nausea,vomiting, sweating
such as: Pain derived from stomach, duodenum, liver, biliary system or pancreas most often presents with midline pain in the epigastrium.

15. 2.somatic pain:
Somatic pain originates from the abdominal wall and parietal peritoneum. Somatic afferent never fibers allow more precise location of stimulation, and the density of never fibers in the parietal peritoneum is significantly greater than in abdominal viscera. This allows better identification of the location .
a. It’s sharp, severe and continuous
b. Distinct location
c. Coughing and the change of body posture can aggravate the pain.
Such as: peritonitis

16. 3. referred pain :
It is a term that describes as pain localized to a site distant from the abdominal organ from which the pain originates.
Referred pain originates from the internal organs. It occurs because of the common site of entry into the spinal cord of cutaneous and sensory nerves and abdominal visceral afferents. Cutaneous and visceral afferents terminate on the same secondary neuron within the dorsal horn of the spinal cord, resulting in misinterpretation by the brain of the correct origin of the stimulations. So it has distinct location.
Such as: right upper shoulder pain may result from
cholecystitis.

17. summary visceral pain somatic pain referred pain dull sharp, severe
continuous
no distinct location distinct location distinct location
internal organs peritonitis cholecystitis

18. Clinical features: 1) location:
Pain site often indicates the organ responsible for the problem.
A. Right upper quadrant pain is more typical of cholecystitis.
B. Tenderness over McBurney ’s point should be considered strong evidence of appendicitis.
C.Pain caused by colon diseases most often presents in the midline lower abdomen.
D. Pain arising from the small intestine is commonly localized to the surrounding region of umbilicus .

19. 2) character and intensity :
A. Extremely intense pain of sudden onset caused by the perforation of gastric ulcer is often described as “burning” or “cutting”.
B. Biliary or renal calculus is often described as “cramy” constricting.
C. Persisting, wide-ranging severe pain accompanied with high intensity of abdominal muscles is highly suggestive of acute peritonitis.
D. Intestinal obstruction is often described as “gripping”.

20. E. The pain of peptic ulcer is usually described as a dull, gnawing sensation of mild to moderate severity.
It’s a hungry pain and nocturnal pain.
Periodic epigastric pain occuring 1/2 hour after eating is a typical symptom of gastric peptic ulcer and patients with a duodenal peptic ulcer have pain 2-3 hours after eating or before the next meal. So food tends to lessen the pain of duodenal peptic ulcer .

21. 3) time course:
Sudden onset: (over seconds to minutes )
rupture of liver or spleen
perforation of peptic ulcer
rapidly progressive: (over 1-2 hours)
pancreatitis ,cholecystitis
bowel obstruction
renal or biliary colic
gradual onset: (over several hours )
typical peptic ulcer , chronic appendicitis

22. 5) inducement : 4) aggravating or alleviating factors:
A. Pain worsened by movement suggests peritonitis .
B. Patients with a retroperitoneal process (such as pancreatitis) commonly find partial relief by leaning forward ,and aggravation by lying supine.
5) inducement :
a. heavy and fatty food cholecystitis
b. heavy food and drinking acute pancreatitis
c. Trauma rupture of liver or spleen.

23. 2) character and intensity :
Clinical features:
location:
2) character and intensity :
3) time course:
4) aggravating or alleviating factors:
5) inducement :

24. Accompanied symptoms:
1. fever, chill: the sign of inflammation
For instant: acute cholangitis
2. jaundice: biliary system and pancreas diseases.
3. the shock or hypotension: acute internal organs
bleeding
4. blood urine:
Blood urine is highly suggestive of the calculus of urogenital system diseases.

25. Summary Location: Character: right upper quadrant
tenderness over McBurney ’s point
surrounding region of umbilicus
midline lower abdomen
Character:
peptic ulcer:
peritonitis
intestinal obstruction
biliary or renal calculus
cholecystitis
appendicitis
small intestine diseases
colonic diseases
dull, gnawing, nocturnal, hungry
sharp, burning, cutting
gripping
cramy

26. Inquire points : 1. onset of the abdominal pain
Did the pain start suddenly?
2. severity and character
Can you describe the pain ? Is it sharp? burning? cramy?
Is the pain continuous?
Has there been any change in the severity or nature of the pain since it began?
What makes it worse?
What makes it better?

27. Do you feel the pain in any other part of your body?
3. site
Where is the pain?
Has the pain changed its location since it started?
Do you feel the pain in any other part of your body?
4. time course
How long have you had the pain ?
5. accompanied symptoms
Is the pain associated with nausea? vomiting ? sweating? diarrhea? blood stools? fever? chills?

28. SHORT SUMMARY
We can sum-up inquire points in “ PQRST”
P: provocative - palliative factors
(aggravating -alleviated factors )
Q: quality
R: region
S: severity
T: temporal characteristic