Abdominal Pain

How to Manage it .?
Pria Agustus Yadi
Department of Surgery, Digestive Division
School of Medicine University of Syiah Kuala
Dr. Zainoel Abidin General Hospital Banda Aceh

Introduction
Abdominal

pain the most common symptoms

evaluated by primary health care
A wide varieties may cause abdominal pain
The origin of pain should be determined by a
combination of clinical hystory, physical exam,
laboratories & imaging
Should Avoid overlooking the potentially
life-threatening conditions as a cause of pain
Consider

the distant origin as a cause of pain

Introduction
Potentially &

Unpotentially life threatening

abdominal pain ?
Local or distant origin as a cause of pain
Acute or Chronic abdominal pain ?
Acute pain require efficient & expeditious
evaluation Life threatening ?
1/3 of patients population has no etiology
identified following evaluation

Introduction
The

visceral pain is typically colicky in

nature & somewhat vague in location
The somatic pain usually constant & well
localized to the site of direct parietal
peritoneal irritation
Intra-abdominal disease can also cause
pain to be referred to other areas
through neural pathway or other
anatomic constraints

How to Manage it ?

Criterias of Pain
Abdominal

Visceral Pain
Distension - Stretching
Inflammation
Ischemia
Vague in location

Abdominal

Somatic Pain
Usually constant & well localized to
the site of direct parietal peritoneal irritation

Sensation Pathway

From Receptor to the Area of Sensation

The Viscus & Referred Pain

Pathophysiology
Abdominal

disease appendicitis, diverticulitis,

cholecystitis Critically ill ?
Develop more complex & unusual abdominal
processes variety of predisposing conditions
Recent surgery enteric anastomoses intra-abdominal abscess, bowel obstruction
Shock Mesenteric ischaemic, bacteriae &
toxins translocation
Trauma ? Missed intra-abdominal complications
Iatrogenic complications ?

Locations of common etiologies of AA

Epigastrium
- Esophageal disease
- Peptic ulcer disease
- Pancreatitis pseudocyst
- Cardiac disease
- Hiatal Hernia
Right Lower Quadrant
- Appendisitis, Diverticulitis
- Chrohn disease, Colonic Obstr.
- Psoas & Abscess, PID, KET
- Hernia Inguinal, Epididymitis

Left Lower Quadrant

- Diverticulitis, Sigmoid Volvulus, Colitis
- Renal Colic, Inguinal Hernia, Epididumitis
- PID, Pelvic or Psoas Abscess, Ovarial cyst

Right Upper Quadrant

- Cholecystitis Cholangitis - Hepatitis
- Hepatic abscess, Subphrenic abscess
- Pancreatitis, Cecal volvulus
- Renal colic
Left Upper Quadrant
- Pancreatitis, Splenic disease, Renal colic
- Left lower lobe pneumonia, Colitis
- Subphrenic abscess

Peri Umbilical
- Umbilical hernia, Early appendicitis
- Aortic Aneurysm, Mesenteric Ischemia

Suprapubic & Pelvic

- Cystitis, Renal Colic,Diverticulitis
- Proctitis, Pelvic Abscess

Organ Origin of Abdominal Pain

Intestinal Disorder
- Appendicitis, Diverticulitis, Gastroenteritis
- Intestinal Obstruction or Strangulation
- Bowel Perforation, Idiopathic IBD
Vascular Disorder
- Ruptured Aortic Aneurysm
- Ischemic Colitis, Splenic infarc
- Mesenteric Thrombosis
- Rupture of Spleen
Gynaecologic Disorder
- Ectopic Pregnancy with rupture
- Acute Salpingitis (PID)
- Ruptured Ovarian Follicle Cyst
- Ovarian Torsion, Endometriosis

Hepatobilier Disorder
- Biliary colic, Acute Cholecystitis
- Acute Suppurative Cholangitis
- Hepatitis, Hepatic Abscess

Urinary Disorder
- Renal Colic
- Pyelonephritis
- Renal Infarct

Acute Pancreatitis
Primary Peritonitis
Retroperitoneal Hemorrhage

Immediate Management
Life threatening Problems ?
Brief

Examination
Identify Candidates for urgent Surgery
Treat Shock
Re-evaluation
Early Surgeon Concultation
Operating room personal Preparation

Mode of Onset of Abdominal Pain

Abbrupt

Onset

- Well one moment Explosive pain the next

Common ethiologies:
Rupture of hollow viscus
Vascular Accident
- Moderately severe Worsens rapidly
Suggessts:
Acute Pancreatitis
Mesenteric Trombosis
Small bowel strangulation

Mode of Onset of Abdominal Pain

Gradual

Onset
Gradual onset of slowly worsening pain
is characteristic of peritoneal infection
or inflammation
eg. Appendicitis or Diverticulitis

Character of Pain
Severe

pain
Dull pain
Intermitten pain with Cramps
Absence of pain

Severe Pain
May

be caused by several conditions

including Renal & Biliary Colic or
Vascular condition, such as Myocardial
infarction, Rupture of Abdominal Aortic
Aneurysm or Mesenteric Ischemia
Others:
Pancreatitis, perforation of hollow viscus,
or peritonitis

Intermittent Pain with Cramps

Common

in Gastro-enteritis
Regular cycles of Pain subside to painfree interval mostlikely as diagnosis is
Mechanical bowel Obstruction
Occasionally Early subscute of
pancreatitis or in Renal colic

Location of Pain
Pain

fibers
Parietal Peritoneal localize pain
Visceral Peritoneal poorly localize
Blood vessels visceral ischemia
Abdominal pain becomes localized
It does so near or over the involved viscus
Right upper Q Acute Cholecystitis
Right lower Q Acute Appendicitis
Variants ?

Radiation of Pain
or Shift of Localization
Shoulder

Pain
- Ipsilateral diaphragmatic irritation from:
air, blood, or infection in peritoneal cavity
eg. Cholacystitis, hepatic abscess
referred as right shoulder pain or epigastric
Left Shoulder pain mimicking angina
Pain Radiating from the flank to the
groin or genitalia usually signifies ureter
colic as seen in urolithiasis

Radiation of Pain
or Shift of Localization
Early

appendicitis only visceral peritoneum

surrounding appendix involved in inflammatory
process visceral pain sensation poor in
localizing
Diffuse periumbilical & Epigastric pain
gradually localizing to Right Lower Quadrant
Classic sign of Appendicitis DD/ Peptic
Ulcer pain?
Inflammation then spread & involves parietal
peritoneum pain localizes on the right
lower Quadrant

Additional Symptoms
Anorexia,

Nausea & Vomiting

- Commonly in upper abdominal diseases
- If peritoneum is well protected may
retain a normal appetite
- If procede the onset of pain an acute
abdominal emergency unlikely requiring
operation Gastroenteritis, Pancreatitis,
Acute Gastritis, Food poisoning

Fever & Rigors

Fever is common with most causes of Abdominal Pain

In Appendicitis, fever usually not high & Rigors are
uncommon untill Viscus perforation occurs
High fever + Peritoneal signs in a female WO general
systemic illness Is characteristic of salpingitis with
peritonitis
Repeated shaking chills & fever most common in
infections of Biliary or Urunary tract
Acute Cholangitis Intermittenr rigors & fever
If Rigors + Jaundice + Fever & chills + Hypotension
Suggested as Supurative Cholangitis will need Urgent
Celiotomy

Diarrhea, Constipation & Obstipation

May

occur in the acute abdomen patient but

uncommon as major symptoms in acute
intra-abdominal dioseases requiring surgery
Colitis usually with early & severe diarrhea
Occasionally, appendicitis, diverculitis or
salpingitis may also experience diarrhea

Physical Examination
Inspection

- Patient position while walking or supine

and sitting position
- Abdominal distention, visible bowel
movement
- In painful or nervous

Physical Examination
Auscultation

A silent abdomen with complete absence of

audible peristalsis usually signifies diffuse
periotonitis
High-pitched, tinkling bowel sound are
suggestive of Acute small bowel obstruction
Usually be associated with abdominal
distension

Physical Examination
Palpation

- Examine Inguinal region & Male genitalia

Strangulated hernia with bowel obstruction
- Directing the patient to point the area of pain
- Establish the presence or absence of true
muscle spasm or rigidity
- Both side rectus muscle spasm in peritonitis
in renal colic one side muscle spasm only
- Strart far away from the area of pain
- Perform deep palpation

Physical Examination
Percussion

- Perforation of hollow viscus air under

the diaphragma will be diminished or
absence of liver dullness
- Tympany located laterally in the mid
axillary line or more above the costal
margin is due to free air

Special Signs

Ilio Psoas sign

Special Signs

Obturator Sign

Murphys Sign
The

patient is asked to take aslow, deep

breath as the examiner gentle palpates
the right upper quadrant
With descent of diaphragma, the liver & in
acutely inflammed gall bladder comes in
contact with examiner finger causing
pain and the patient will suddenly stops
inspiration in an attempt to avoid the pain

Pelvic & Rectal Examination

In

men Digital Rectal Examination plus

simultaneous lower abdominal palpation will
reveal masses or localized pain
Likewise, pelvic exam in women provides
essential information not revealed by other
maneuvers
Examination of stool for occult blood must be
performed in every patient with abdominal
pain intestinal tumors, Inflammatory Bowel
Disease, and Bowel Ischemic

Laboratory Examination
Blood

count Bleeding, Inflammation,

Infection or Sepsis, disease of blood
Serum Amylase & Lipase Pancreatitis
Liver Function Test Liver & Biliary
diseases, with or without jaundice
Urine UTI, Urolithiasis and Renal Colic
Serum Electrolyte & Renal Function Test
Pregnancy Test

Others
Electrocardiogram

?
Peritoneal Fluid Examination ?
Biopsy ?
Endoscopic ?

Radiologic Examination
Additional

tool in Diagnostic procedure

It is one but not the only one - important
thing in Diagnostic Procedure
Should be compared with all previously
examinations Clinical & Lab. findings
May provide important evidence for Diagnosis
of Acute Abdominal Disease
Close cooperation between Radiologist and
the Physician caring for the patient is Essential

Radiologic Examination
Abdominal

Radiographs 2 or 3 films
Special Studies
Barium Enema
Ultrasonography
CT Scan
Angiograms
MRCP

Additional Measures
Repeated

Examination
Relief of Pain
Antimicrobial
IVFD
Decompression
Surgical Consultation

Summary
Abdominal

pain is the most common and

predominant presenting feature of an
acute abdomen
The origin of pain sensation may arise as
visceral or somatic pain localized pain
or vague pain
Careful consideration of the location, the
mode of onset and progression, and
character of pain will suggest a preliminary
list of differential diagnosis

Summary
An

acute abdomen must be suspected

even if the patients has only mild or
atypical complaints
Hystory & Physical exam should suggest
the probable causes and guide the choice
of initial diagnostic studies
All clinicians should be familiar with the
disease patterns specific to the region and
locality

Summary
The clinician must then decide :
if

in hospital observation is warranted

if additional tests or studies are needed
if early operation is indicated
if non-operative treatment would be most
suitable
If Surgical consultation should be done earlier
Consultation is much more wise and smart and
absolutely is not a stupid thing

Terimakasih