Abdominal Pain

Objectives

To be able to elucidate the various mechanism
of abdominal pain
To clearly be able to describe the importance
of history, physical examination, and other
investigations in defining the origin of
abdominal pain
To be able to list a good differential for
abdominal pain and solve real life examples
Why should we care?
Abdominal Pain is a huge topic
To understand it fully it requires a good clinical
judgment
It serves as a good case for history and physical
examination
Many chronic diseases go by unchecked with only
minor symptoms like abdominal pain
There are multiple classification or systems for
abdominal pain
Abdominal Pain and its mechanism
It can be due to multiple ways or origins, it
includes:
Parietal Peritoneum Inflammation
Obstruction of the lumen of the gut
Vascular problems in the gut
Referred pain from somewhere else
Abdominal wall problems
Metabolic problems
Nerve problems
Parietal Peritoneum Problems
The characteristic of the pain:
Steady and aching
Almost always localized in the area of the pain
Obstruction of the Gut
The characteristic of the pain:
Intermittent pain, or colicky
It can be steady sometimes due to distention
Obstruction - 2
Billiary tree pain
Can produce steady pain REMEMBER
DISTENSION
Billiary colic can be steady
It radiates to tip of right scapular (supscapular
pain) + epigastric
Carcinoma Head of the pancreas usually silent
Urinary bladder obstruction is suprapubic
Vascular Problems
Sometimes sudden and catastrophic like
sudden bleed, eg., Aortic Aneurysm
Mesenteric artery occlusion:
Can be continuous and diffuse before the
vascular bleed ( e.g., mesenteric artery
occlusion)
Abdominal Wall
Usually the pain from abdominal wall
It is constant, and aching
Referred Pain in Abdominal Disease
It can be from anywhere:
thorax, spine, or genitalia
It can be abdominal disease causing referred
pain somewhere else
Ex: acute cholecystitis or perforated ulcer
Common interthoracic diseases:
Especially in upper abdominal pain
MI, Pulmonary Infarction, pneumonia, pericarditis, and
esophageal disease
Metabolic Abdominal Crises
Many mechanisms cause this type of pain:
Hyperlipidemia accompanies by a process such as pancreatitis
C1 esterase deficiency associated with angioneurotic edema with
severe abdominal pain
If you dont know the cause, think of metabolic causes!!
It is difficult to do a differential because many diseases have similar
nature of pain
Porphyria or lead colic is similar to intestinal obstruction
Uremia or diabetes is non-specific type of pain
Diabetic acidosis is similar to acute pancreatitis or intestinal
obstruction
As a rule, if pain does not resolve with correction of metabolic
abnormality
Underlying ORGANIC problem is suspected!
Nerve problems
Spinal nerve or roots of spinal nerve pain:
Comes and goes suddenly
lacinating type of pain
Many causes:
Herpes zoster, impingement by arthritis, tumors,
herniated nucleus pulposus, diabetes, or syphilis.

Patterns of acute abdominal pain
. A, Many causes of abdominal pain
subside spontaneously with time
(e.g., gastroenteritis).

B, Some pain is colicky (i.e., the
pain progresses and remits over
time); examples include intestinal,
renal, and biliary pain (colic).
The time course may vary widely
from minutes in intestinal and renal
pain to days, weeks, or even
months in biliary pain.

C, Commonly, abdominal pain is
progressive, like its maturing, as in
appendicitis or diverticulitis.
D, Certain conditions have a
catastrophic onset, such as ruptured
aortic aneurysm.


Stereotypes of Pain Onset and Associated Pathology
Sudden onset
(full pain in
seconds)
Perforated
ulcer
Mesenteric
infarction
Ruptured
abdominal
aortic
aneurysm
Ruptured
ectopic
pregnancy
Ovarian
torsion or
ruptured cyst
Pulmonary
embolism
Acute
myocardial
infarction
Rapid onset
(initial sensation to full
pain over minutes or
hours)
Strangulated
hernia
Volvulus
Intussusception
Acute
pancreatitis
Biliary colic
Diverticulitis
Ureteral and
renal colic
Gradual onset
(hours)
Appendicitis
Strangulated
hernia
Chronic
pancreatitis
Peptic ulcer
disease
Inflammatory
bowel disease
Mesenteric
lymphadenitis
Cystitis and
urinary
retention
Salpingitis and
prostatitis

History
Course of pain
Radiation of pain
Factors that exacerbate or improve symptoms
Associated symptoms including fevers, chills
weight loss
Past medical and surgical history
Family history of bowel disorder
Alcohol intake
Intake of medications
Menstrual and contraceptive history in women
Physical Examination
Measurement of blood pressure, pulse, and
temperature
Examination of the eyes and skin for jaundice
Auscultation and percussion of the chest
Auscultation of the abdomen for bowel sounds
Palpitation of the Abdomen for masses,
tenderness, and peritoneal signs
Rectal exam include Occult blood
Pelvic Examination in women with lower
abdominal pain
DETAILED HISTORY IS MOST IMPORTANT THAN
ANYTHING!
Location of pain is very helpful
Time sequence of events is important
Be open minded and ask the right questions
Check extra-abdominal manifestation
If female, ask menstrual history

Critical inspection is inmportant
Facies, position in bed, respiratory activity
Be gentle and detailed
do not elicit rebound tenderness by sudden release of
a deeply palpating hand, ITS CRUEL!
Same way can be done by gentle percussion (rebound
tenderness on a miniature scale)
Ask patient to cough will elicit true rebound tenderness
without placing hand on abdomen
Sometimes, reactionary protective spasm will hinder your
other findings, eg., palpating gallbladder

Abdominal signs can be absent in cases of
pelvic peritonitis
Careful pelvic and rectal examinations are
mandatory in patients with abdominal pain
Tenderness in such examination:
Operative indication:
Perforated appenditis
Diverticulitis
Twisted ovarian cyst
Absence of peristaltic sound
Auscultation is one of the least revealing aspect
Catastrophes such as: Strangulating small
intestinal obstruction or perforated appendicitis
Occur in presence of normal peristaltic sounds
Conversely, when proximal area above obstruction
becomes edematous and distended
Peristaltic sound lose characteristics of borborygmi
Become weak and absent
Sudden Chemical peritonitis = silent abdomen
Remember, assess patients hydration status
LABS
Labs are very valuable but they rarely establish
diagnosis focus on History & physical
Example: Leukocytosis does not mean a person having
appendicitis and he should be admitted to operation
room
Other conditions occur in pancreatitis, acute cholecystitis,
pelvic inflammatory disease, intestinal infarction
We can establish diagnosis of anemia based on
CBC and history

We do urinary analysis to rule out:
renal disease, diabetes, urinary infection
Serum amylase levels can increase:
pancreatitis
Perforated ulcer
Strangulating intestinal obstruction
Acute cholecystitis
Other important tests: Blood urea nitrogen,
glucose, serum bilirubin

Radiographs of abdomen can show Perforated
ulcer, and other conditions
Water-soluble contrast or barium studies can
demonstrate partial upper GI obstruction
Contrast enema Suspected colonic obstruction
(with no perforation) contrast enema may
be diagnostic
US detect enlarged gallbladder or pancreas
Presence of gallstones, enlarged ovary or tubal
pregnancy
Helpful in diagnosing pelvic conditions:
Ovarian cysts, tubal pregnancies, salpingitis, and acute
appendicitis

Cases
A 23 year old female presents with severe,
intermittent right lower quadrant pain associated
with nausea and vomiting.
She has no medical history.
Her vital signs reveal tachycardia but are otherwise
normal.
Physical exam shows a soft abdomen, RLQ TTP
without peritoneal signs. Pelvic (which is part of
the physical exam), shows scant discharge.
If you could only order one test, what would it be?
What is on your differential?

Differential
Ectopic Pregnancy
Ruptured Ovarian Cyst
Appendicitis
Right-sided diverticulitis
TOA
Ovarian Torsion


Nephrolithiasis
Pyelonephritis
Endometriosis
UTI
Heterotopic pregnancy
Terminal ileitis
Ovarian Torsion


Increased ovarian volume (>15cc),
multiple follicles and decreased blood
flow.

Cases
A 60 y/o male presents after a syncopal event
with a complaint of abdominal pain.
His pain is poorly localized but radiating to his
back.
His history is significant for HTN and tobacco
abuse.
His vitals are normal and his physical exam
reveals only the following:
What is on the differential?
Pancreatitis
Mesenteric Ischemia
MI
Gallbladder Disease
GERD
Obstruction



Peritonitis
PE
PUD
AAA
Valvular Insufficiency
Perforated Viscus


Abdominal Aortic Aneurysm
What happens:
The media weakens over time, the vessel
dilates and expands over time. As the vessel
weakens and expands, rupture becomes more
likely.
The larger it becomes, the more likely is the
rupture.


AAA
Fun facts:
They are typically infrarenal
>3cm at this level is a AAA
Age, Family history, Atherosclerotic risk factors,
infection, trauma, connective tissue disease are risk
factors.
Rupture is associated with 80-90% mortality.
Vital signs can be normal. For now.
AAA: Diagnosis and
Management
H&P: May not be symptomatic until the rupture
Syncope and Abdominal pain
Cullens sign and Grey Turners sign
Imaging: U/S 100% sensitive when the aorta is visualized.
CT requires a stable patient but is also highly sensitive
and is better at detecting rupture and retroperitoneal
fluid.
Treatment is surgical!! Despite what surgery tells you:
There is no such thing as a stable rupture.
EDs role is maintaining hemodynamic stability with blood
products SBP 90-100mg until surgery.


CT of Rupturing AAA:
Thank you!