ABDOMINAL PAIN-GENERAL
(Costarella)
I. Mechanism of abdominal pain
-intestines and associated organs
-peritoneal coverings (visceral or parietal)
-non GI (kidneys, ureter, bladder, spine, vascular, reproductive)
-pain of skin, skeletal muscle and fascia
-extraabdominal pain from the pleura or pericardium
-3 basic stimuli of pain: distention or contraction of a hollow viscus; noxious chemical stimuli or
ischemia; pain in solid organs (pain receptors generally in capsule)
II. Production of pain in the abdomen
a. no adequate explanation for why people experience visceral pain
b. Theoretical mechanisms
1)stretching of the viscera, usually the lining of the viscera; an example is an enlarged
liver with stretched capsule
2)distension of a hollow structure: sharp, crampy, pain of rapid distension of colon,
ureters, bladder, biliary tree, etc.
3)inflammation and edema of parenchyma of solid organs or peritoneum; an example is
bleeding into peritoneal cavity in endometriosis
4)tension or traction as would happen in the peritoneum or the mesentery; examples are
scarring from previous abdominal surgury;
5)ischemia from decreased blood supply to the organs
6)vigorous contraction of intestines as in partial bowel obstruction giving colicky type of
pain
7)invasion or inflammation of actual neurons supplying organs (the afferents) as in
cancer, or compression
III. Physical Exam: Abdominal exam plus think of chest exam with upper abdominal pain; pelvic
exam with lower abdominal pain & rectal and prostate exam in men
IV. Pain of Peritonitis
-needs to be ruled out immediately
-acute inflammation of lining of abdominal cavity by:
-chemical irritation
-pancreatic enzymes liberated into parenchyma and autodigest in acute pancreatis which
results in hemorrhage and bleeding into peritoneum
-ulcer can perforate through with stomach and duodenal enzymes are liberated into
peritoneal cavity
-inflammation of serosa or outer layer of an organ
-pain is severe, intense (with the exception of the elderly); usually a dull, deep, constant ache; the
intensity relates well to severity; appetite is disrupted
-physical exam: involuntary guarding (muscle rigidity, boardlike) vs voluntary guarding (person
tenses muscle in response to your palpation); tenderness to palpation; make sure person is
completely relaxed in the beginning
-in severe peritonitis, bowel sounds would be absent; intestine would stop peristalsis; patient will
probably be lying motionless, because movement of contents will come up against inflammed
peritoneum
-in cases which are chronic, pain could come and go for period of time as in the case of chronic
pancreatitis
V. Types of abdominal pain
A. Visceral
-felt at site of primary stimulation; dull; achy; poorly localized; difficult to describe
B. Parietal
-deep, more definite; usually from inflammation of the peritoneum or can be at the root of
mesentery
C. Referred
-esophagus : substernal in location but may be felt in neck and jaw and arm, intrascapular
in specific cases
-stomach: epigastrium, ocassional the LUQ and the back
-duodenum: epigastrium; ocassionally in the RUQ and back
-small intestine: periumbilically ;ocassionally above the point of lesion
-colon: below umbilicus, generally on the side of lesion
-pancreas: epigastrium but refers to back
-liver: RUQ, right shoulder and ocassionally the back
VI. Importance of 7 attributes
A. Chronology
1. acute
-ddx: see abdominal-acute
-distinguish between acute process and acute abdomen ( emergency)
-most abdominal emergenicies have acute onset
2. chronic
-ddx: see abdominal-chronic
-pain can come on gradually or quickly
B. Location
-use quadrant system; see VII
-referred pain: visceral afferents enter at T6 to T12 and overlap giving referred pain
-examples of referred pain:
1)appendicitis is often epigastric or periumbilical in the beginning
2)chest pain can go down to T9, as in a myocardial infarction in the lower heart,
impinging on the diaphragm
C. Aggravating/alleviating factors
-pain worse in particular position ie. bent over, fetal, worse when they cough, eat or not
eat
D. Quality
-visceral: solid organ: dull and achy ; hollow organ: cramping, burning, occasionally sharp
E. Quantity
-grade on scale of 1-10; how often the pain comes; how long it lasts
-pain can come/go; constant; or come in waves
-severe pain in severe causes; mild pain tends to be milder causes
F. Assoc. Symptoms
G. Setting: situation surrounding the pain
-particular setting ie. physical place
-temperature
-emotional or mental situation
-time of day
-relationship to meals: eating help or make it worse
VII. Location of pain
A. LUQ
-gasseous distention (splenic flexure of the colon): sharp, crampy pain coming and going
with gas
-splenomegaly ( flank pain as well): capsule stretching pain
-stomach: depends on what going on; stomach cancer will not see sign and symptoms
until late stages
B. LLQ
- inflammatory bowel disease (ulcerative colitis): pain is crampy, intermittent, usually
relieved by defecation; urgency for defecation
(Crohn's would be LUQ or periumbilical if jejunum; RLQ with ileum)
-diverticulitis(outpouching of mucosa through muscularis): may be dull, crampy or sharp if
inflammed; relieved by defecation; over 50 years of age; most common location is
sigmoid
-colon cancer: sharp, crampy; relieved by passing gas or defecation; usually distention of
the colon proximal to the site of obstruction
-salpingitis; ovarian cysts(sharp); ectopic pregnancies
-inguinal hernia (achy)
C. Suprapubic
-cystitis (dull ache with sharp twinges; bladder spastic; burning on urination)
-ectopic pregnancy(severe pain)
-PID
-menstrual cramps (dull; usually radiate to legs, lower back )
-prostatitis(similar to cystitis pain)
-stone in ureter: alos in flank region producing renal or uretal colic; pain in flank radiating
to the groin area; quality: distension of hollow organ, sharp, crampy, wavelike pain, " the
most intense pain of their life", writhing in agony, no relief from physical position
D. Flank
-renal or uretal pains ; caused by stones; wavelike feeling, sharp and cramp; most intense
pain of their lifes; no position will ameloriate the pain
-muscular
-splenomegaly
-pylenephritis (feel posteriorly and the costovertebral angle)
E. RLQ
-appendicitis ; starts at periumbilical and moves to McBurney's point
-in chronic, there will be recurrent bouts of milder pain
-loss of appetite; within a day or several hours, pain becomes localized to RLQ
and person will feel nausea, or vomit; no diarrhea
-salpingitis
-inflammatory bowel disease if it affects the ileum (Crohn's)
F. RUQ
hepatitis (dull ache, distention of the capsule)
-biliary colic (sudden; crampy;double over in pain)
-cholecystitis (sudden ,parxosomal, crampy, knife-like pain; lasts 2-3 hours and then
subsides; radiation to shoulder and back)
-hepatic flexure (relieved with flatulence; gaseous distention gi ve crampy, sharp pain
under rib cage)
G. Epigastric
VASCULAR: aneurysm
-abdominal aorta; pain is pulsating, constant & dull; pain increases with increased flow;
hear bruits on exam
INFLAMMATION
-esophagitis
-pain will be localized to under sternal notch for upper esophagus; midesophageal
pain under sternum; lower esophageal pain would be near the sphincter located
under the xiphoid process
- reflux of stomach contents
-burning sensation especially after lying down after a heavy meal or alcohol or
cigs
-peptic ulcer (burning)
-acute pancreatis
-sudden, unremittent , severe pain that is boaring; last several hours
- can radiate through to the back
-possibly with some relief by sitting up and leaning forward
-usually caused by gall stones or alcohol
-chronic pancreatis
-constant pain for several months
-gradual onset, constant and less severe pain; same location as acute
-relieved by sitting up and leaning forward
-present for days or weeks; may have psychological overlays such as depression
with chronic pain; may be addicted to narcotics for pain relief
-inability to eat, loose, fatty stools,
-may develop pancreatic cancer
-gastritis (burning )
-inflammation or uleration of stomach
-burning; worse with empty stomach, stress, alcohol and cigarettes
-duodenitis
-more common than gastric ulcers; identical pain to gastritis
-perforated gasatral or duodenal ulcer giving peritonitis
H. Diffuse
-gastroenteritis
-infections
- intolerance to lactose
- food allergies
-lead poisoning (dull ache)
-peritonitis (acute abdomen): very severe pain; usually 3 things to watch for: muscle
guarding, absent bowel sounds, rebound tenderness; may also see: ascites,
hyperesthesia (incredible sensitivity to any palpation), pt. lies still
VIII. Associated abdominal symptoms
A. Dysphagia
-difficulty swallowing
B. Nausea
-revulsion to food; decreased motor activity and blood flow to the area
C. Vomitting
-sudden forceful expulsion of stomach contents; medulla, of the brain stem, is the
vomitting center
D. Hematemesis
¥vomitting blood; bright red; if at beginning of digestive process, it resembles coffee
grounds
E. Pyrosis
-heartburn; retrosternal; reflux of the acidity contents of the stomach; muscle tone is
decreased in the lower esophageal sphincter
F. Indigestion
G. Bloating/gas
-gaseous distention; by swallowing air; food intolerances, etc.
H. Constipation
-hard, dry stools; decreased frequency of defecation
I. Diarrhea
-watery, semisolid stool; increased defecation
J. Melena
-dark, brown or black stools; described tarry looking stools; usually signifies bleeding is
high up in the GI tract
K. Hematochezia
-bright red blood in stool; bleeding happening somewhere lower in the GI tract
L Jaundice
-excess bilirubin
IX. Common causes-differential diagnosis
A. Gastroenteritis
-acute: anorexia, nausea and vomitting; poorly localized pain; sometimes crampy;
diahhrea; fever; leukocytosis
B. Acute appendicitis
-pain starts in periumbilical area and moves to RLQ
-nausea; vomitting not as common; RLQ after 24 hours will find rebound tenderness;
fever is low or moderate; moderate leukocytosis and neutrophilia(late finding); appendix is
retrocecal, the symptoms are less common
C. Acute cholecystitis
-fatty food intolerance, flatulence, and post prandial fullness
-pain in RUQ and epigastric in acute attack that starts and hour or two later postprandial
which gradually builds in intensity; ;can be referred due to overlap of splanchnic and
somatic, so can radiate to right shoulder or to scapula or back
-muscle guarding, and rebound tenderness; anorexia, nausea and vomitingare common;
fever and leukocytosis
-mild hyperbilirubemia and bilirubinuria
-can build to impending rupture and peritoneal signs develop; this is usually a result of a
gallstone impacting cystic duct causing ischemia and possible infarct ; or pain may be due
to gall bladder contracting trying to pass the stone and this pain would be colicky(called
biliary colic)
Chronic cholecystitis
-pain after a fatty meal, gradually subsiding
-recurrent bouts; less intense pain in a cyclical pattern, where in acute pain does not go
away
-repeat bouts of partial obstuction
-chronic can go to acute
D. Diverticulitis
-LLQ; might find nausea and sometimes vomitting; constipation; positive hemoccult may
be seen; pain is intense deep pain
E. Pancreatitis
-history of alcolohism and with cholelithiasis
-epigastric and radiates to back; sweating and shock
-nausea and vomitting are common
-may be hyperbilirubinia; elevated serum and urine amylase(not pathognomonic)
F. Intestinal obstruction
-crampy; proximal gut there will be vomitting, constipation, hyperperistalsis, borborygmi,
distention
G. Perforated viscus
-peptic ulcer commonly
-abdominal rigidity, rebound tenderness
H. Mesenteric vascular infarction
-pain moderate to severe; bloody diahhrea; congestive heart failure
ë. Acute salpingitis
¥adnexal(fallopian tube and ovaries) mass can be palpated, vaginal discharge (copious,
white); sexual history; positive results for chylmydia and
J. Sickle cell crisis
-sudden severe; chest, back hand or foot pain
-weakness; aching joints
-dyspnea
-scleral jaundice (icterus)
K. Gastritis, acute
-epigastric, LUQ
-mild or burning
-belching, fever, malaise, anorexia, nausea, bloody or coffee ground vomitus, melina