Clinical approach to acute abdominal pain

By Dr : Allah Obhayo Unar Department of surgery USM

Acute abdomen

Definitions :It is a clinical syndrome , characterized by abdominal pain of great severity , which might necessitate urgent intervention An acute abdomen denotes any sudden , spontaneous , non-traumatic disorder

Acute abdomen

Acute abdomen is a term used synonymously for a condition that needs surgical intervention Term used to encompass a spectrum of surgical, medical , and gynaecological conditions Abdominal pain of less than 1 week duration

Abdominal pain

Pain is an un pleasant sensory and emotional experience Pain fibers are A delta and C class of peripheral nerves

Abdominal pain

Stomach Biliary tree Small intestine Colon Kidney Cervix Bladder Rectum

T5 7 T6 8 T8 10 T10 L1 T10 L1 S2 4 S2 4 S2 4

Classification

Visceral pain Parietal pain Referred pain

Visceral pain

It is perceived through neuronal pathways from lower thoracic and lumber splanchic nerves and parasympathetic pathways of vagus and sacral plexus Sensation / feeling is produced in response to stretch or distension of walls of hollow organs and capsule of solid organs

Visceral pain

It may be due to pull or twist of mesentery It is usually dull aching / colicky / griping in nature Associated symptoms may be , - Nausea - Vomiting - Sweating

Visceral pain

It is poorly localized in - Epigastric region - Peri- umbilical region - Hypo gastric region

Parietal pain

Somatic nerves supplying adjacent abdominal wall structures and skin , there fore it is , - steady - Localized - Intense - Burning in nature

Referred pain

Due to local irritation with referred along the nerves of innervations of the organ Origin ( primary site ), Perceived pain ( secondary pain)

Evaluation of abdominal pain

Time , < 6 hours , > 6 hours Mode of onset , sudden / slow Location of pain, RUQ, LUQ, RLQ, LLQ Shifting of pain , from peril umbilical to RIF Severity of pain , 1--- 10 , Character of pain , burning, cutting, griping Exacerbating factors / Relieving factors

What questions to be asked?

Have you had this pain before ? On scale from 1 to 10 , what would you rank this pain ? Fevers / chills? Duration ? (comes and goes versus constant) Quality ? (sharp versus dull)

What questions to be asked ?

Does any thing make the pain better or worse ? Migration ? Point of maximal pain ? Urinary symptoms ? Nausea , vomiting , or diarrhea ? Anorexia ?

What questions to be asked ?

Constipation ? Last bowel movement ? Any change in bowel habits ? Last menses? Last meal ? Vaginal discharge ? Malena ?

What question to be asked ?

Hematochezia ? Hematemesis ? Medications ? Allergies ? Past medical history ? Past surgical history ? Family history ?

What makes it better ?

Medication Eating or drinking Heat Urinating or bowel movements Sleep Position change Nothing

What makes it worse ?

Eating or drinking Lying down Urinating or bowel movements Position change Nothing