Abdominal Pain
 -Localisation of the pathology which causes pain
 -Differs according to neural tracts conducting
pain
 -Main mechanisms: Increased tension of empty
organs,
 contractions,inflammatory-ulcerative lesions and
ischemia
 Slow progressing tension(colon tm.) may not cause
pain
 -Organs are not sensitive to pain(endoscopic
biopsies are not painful)
 -Malignant tumors of intraabdominal organs are
not painful unless there is a complication such as
obstruction, ulceration or perforation
 In inflamated or damaged regions:
 Mediaters like histamin,serotonin,
bradichinin, leucotriens affect neural ends and
cause pain
 -In ischemic regions:
 Increased toxic metabolites, inflammation
mediators and decreased pain threshold due to
ischemia cause pain
Three Types of Abdominal
Pain
 -Visceral pain
 -Somatoparietal pain
 -Radiating pain
Visceral Pain
 -Result
of tension,contraction,
 ischemia of intraabdominal organs
 -Stimulation of autonomic nerve ends
(thoracolomber symphatic plexus bilaterally,
n.vagus and pelvic plexus)
 -Pain localised at paraumbilical region
 -Is künt,sometimes hard, continious or with
fluctuations
 -Discomfort,emesis,vomiting, sweating,pale
looking tachycardia(autonomic findings) may
exist
Visceral Pain(continued)
 -Pain of upper abdominal organs
 (stomach,liver,biliary tract) localised at
mid-line and epigastrium
 -Pain of the region from Treitz ligament
up to transversal colon paraumbilically
 -Pain of distal colon,rectum,
 ureters,bladder and genital organs
suprapubically
Somatic or Parietal Pain
 -Results from stimulation of parietal
peritoneum
 -Much more severe
 -Affected organ can be localised
 -Moving,coughing,deep inspiration stimulate
parietal peritoneum;patient reduces movement
 -Hyperaesthesia can be observed
Comparison of Visceral and
Somatic Pain
 Visceral Pain
Somatic Pain
 Indefinite
 Fluctuating
 Not localised
 Discomfort
 Other autono.symp
Sharp
Continious
Localised
Reduced moves
Pain prominent
Radiating Pain
 Pain is felt far from the affected organ
but innervated from same neural segments
 -Perceived as burn, sensitivity, biting
 -Skin hyperaesthesia, muscular
hypertonicity
 -E.g. gall bladder pain; back, right shoulder
and scapula
 Peptic ulcer pain; back left 12th rib(Boas
point)
History Taking
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Several charasteristics should be considered:
-Duration
-Way of beginning
-Continious or not
-Intensity
-Localisation and radiation
-Relationship with meals
-Affecting factors
-Relationship with posture
-Coexisting findings(nausea,vomiting,
constipation,fever,jaundice,bleeding,
voiding etc.)
Abdominal Pain
 Acute abdominal pain
 Surgical acute abdominal pain
 Non-surgical acute abdominal pain
 Chronic abdominal pain
ACUTE ABDOMINAL PAIN
Acute Surgical Abdomen (ı):
 -History taking and careful physi. ex
 -In half of the patients no surgery
 -Most frequent:Acute appendecitis,
 -Ac. cholecystitis, peptic ulcer perfo.,
 -Small bowel obstruction
 -Abdominal pain…
 -Thereafter nausea-vomiting
 -Laparoscopic examination
Peptic Ulcer Perforation (I)
 Frequent in duodenal,rare in gastric ulcers
 -Acute onset,a penetrative and very severe pain
 -In the beginning at epigastric region,then whole
abdomen
 -Irritation of diaphragm may cause shoulder pain
 -Reflex efferent stimulation… rigidity of
abdominal muscles
Peptic Ulcer Perforation(II)
 -Patient motionless, superficial breathing, no
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abdominal respiration
-Fever,tachycardia,hypotension,
-Tendency to shock( due to peritonitis)
-Due to paralytic ileus no bowel sounds
-Reduced liver and spleen matite
-Radiologic ex. Perforation
Acute Cholecystitis(I)
 -Pain and tenderness in the right upper quadrant;
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fever and leukocytosis
-Frequent choledocolithiazis
-Obstruction in d.cysticus due to
choledocolithiazis….lasts long…infection and acute
cholecystitis
-Usually continious pain
-Visceral pain due to tension of d.cysticus in
epigastric and left upper regions
-When inflammation develops in gall bladder somatic
pain in right upper quadrant
Acute Cholecystitis(II)
 -Tenderness and muscular defense in right
upper quadrant
 -Back and shoulder pain
 -Nausea,vomiting and anorexia
 -Biliary colic ≥ 4-6 hours….
 -A. Cholecystitis
Physical examination:
 -Pain in right upper quadrant
 -Local tenderness
 -Murphy’s sign positive
Laboratory Findings
 Mild increase in t.bilirubin(≤4mg/dL)
 Higher levels; choledocholithiasis and cholengitis
 Leukocytosis
 Transaminases and alkaline phosphatase mildly
increased
 USG and ERCP
Bowel Perforations:
 -Infection( typhoid fever,dysentery)
 -Diverticulitis, Meckel diverticulitis
 -Cancer
 -Ulcerative colitis and toxic megacolon
 -Acute appendecitis if not treated
Mechanical Ileus
 -Primary bowel cancers;ileus,subileus
 -Crohn’s disease,bowel tbc., lymphoma..
obstruction especially in terminal ileum and cecum
 -Fecaloma ( long lasting constipation)
Mechanical Ileus (II)
 -Severe and colical pain
 -Intensity increases and with time is reduced
 -Pain localized at periumblical and right lower
quadrant in small bowel and proximal colon
obstructions; at left lower quadrant in distal colon
ob.
 -Vomiting( contains bile and fekaloid with time)
 -Increased bowel peristaltism
 -No faeces
 Mechanical Ileus(III)
 -Pain reliefed with vomiting or NG decompression
 -Increased pain intensity,continous or localized pain
peritoneal irritation findings is a warning for bowel
perforation and peritonitis
 -In paralytic ileus no bowel sounds
Mechanical Ileus(III)
 -Pain relieved with vomiting or NG decompression
 -Increased pain intensity,continious or localized
pain peritoneal irritation findings is a warning for
bowel perforation and peritonitis
 -In paralytic ileus no bowel sounds
Acute Appendecitis (I)
 -Most common reason for acute surgical abdomen
 -Feaces,foreign body,parasites,and tumors
 -Typically:Visceral pain periumblical or epigastric
regions; afterwards nausea and vomiting, somatic
pain at appendix and fever
Acute Appendecitis(II)
 Differential Diagnosis:
 Acute gastroenteritis, mesentery
lymphadenitis,yersinia colitis,acute salpingitis,
Mittelscherz, ectopic pregnancy rupture, ovarian
cyst torsion,ureteral colic, acute
pyelonephritis,perforated peptic ulcer, acute
cholecystitis, basal pnomonia, diabetic
ketoacidosis, acute porphiria, FMF
Acute Appendecitis(III)
 -Most
dangerous complication is
perforation
 -Generally 48 hours after pain begins
 -Fever, disseminated abdominal
tenderness, plastron in right lower
quadrant, leukocytosis
Acute Mesenteric Ischemia
 -No significant clinical finding if small arteries are
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occluded
-In splenic flexura or sigmoid colon where collateral
circulation is not adequate ischeamic changes more
easily
-Embolism of superior mesenteric artery; atrial
fibrillation, mitral stenosis,infective endocarditis, MI
and aortic aneurism
-Should be considered in patients with CV problems
over 50 years of age
-In patients without pain; abdominal distension and
rectal bleeding
Intestinal infarction-necrosis-peritonitis findings
Abdominal Aortic Aneurism
Almost always atherosclerotic
-Frequently diastal of renal artery
-Usually without symptoms
-Generally detected during imaging for other
reasons
 -In some patients lomber pain
 -If greater then 5 cm dissection and rupture risk
 -Syncope and acute developing anemia should be
warning
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Subphrenic Abcess
 -More frequently right sided;
 -Between liver and diaphragm
 -Perforated peptic ulcer, perforated
appendicitis,after abdominal surgery
 -High fever with chilling and trembling,pain in upper
right quadrant
 -Chronic: subfebrile fever,loss of appetite, weight
loss,fatigue
 -Leukocytosis,CT,USG
Spleen Infarction and Rupture
 -An enlarged spleen may be ruptured even with
small traumas
 -Enlarged spleen due to infections like IMN or
malaria mey be ruptured spontaneously
 -Pain in left upper quadrant or in supraclavicular
region,intraabdominal bleeding findings (paleness,
tachycardia,hypotension, philiform pulse) and
peritoneal irritation findings
 -Shock developes very quickly
 -Ectopic Pregnancy Rupture
 -Ovarian Cyst Torsion
ACUTE ABDOMINAL PAIN
Non-surgical Acute Abdominal Pain
 A) Pain of organs outside of abdomen:Lower lobe
pneumonia, pleuritis, MI, acute peritonitis, eusophagus
disorders, epidymitis, intercostal herpes zoster
 B) Abdominal pain resulting from a general illness:
FMF, porphyrias, lead intoxication, diabetic
ketoacidosis, Henoch-Schönlein purpura, sickle cell
anemia
 C) Pain of Intraabdominal Organs: Biliary colic, peptic
ulcer, bowel colic, renal colic, acute gastritis, acute
pancreatitis, acute enteritis,and acute salpingitis
FMF:
 Recurring fever,peritonitis and pleuritis attacks
 Arthritis,skin lesions and amyloidosis may develop
 Most frequent cause of nephrotic syndrome due to
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amylodosis
App.in 50%of cases no family history
Frequency of attacks may differ
(most frequently 2-6 weeks lasts 24-48 hours)
Fever is the cardinal symptom(38.5-40)
Abdominal pain with acute onset and with peritoneal
irritation findings
Leukocytosis ,high ESR and CRP during attack
Porphyrias (I)
 -Result of specific enzyme defects in hem
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biosynthesis
-Hepatic and erythropoetic porphyrias
-Abdominal pain in hepatic porphyrias
-Most important type acute intermittent porphyria;
severe, diffuse abdominal pain, cannot be localised
-Ileus, abdominal distension,and hyperperistaltism
resembles acute surgical abdomen
-Absence of fever,leukocytosis and peritoneal
irritation findings is helpfull in differantial diagnosis
Porphyrias(II)
 -Many different findings like nausea,vomiting,
constipation, tachycardia, mental changes, head,
chest, extremity pains, peripheric neuropathy,
reduced muscle strenght,
 -Dysuria, and urine retension
 -In a patient with acute abdominal pain a normal
urine porphobilinogen level rules out acute
intermittent porphyria
Diabetic Ketoacidosis
 -In
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a known diabetic patient(esp.Type I)
-Severe abdominal pain,nausea and vomiting is a
warning of diabetic keto-acidosis
- Peritoneal layers get dry and the friction
between them is due to extreme dehydration
-Clinical situation becomes better after
ketoacidosis is treated
-If despite of treatment no significant
improvement; precipating factor may be acute
appendesitis or intestinal obstr.
Acute Abdominal Pain due to Disorders of
Intraabdominal Organs
 Peptic Ulcer Pain:
 -Chronic pain may occur
 -Due to reflex pyloric spasm and increased
gastric peristaltism and tonus
 -Nausea and vomiting may occur
 -No peritoneal irritation findings
 -Pain in epigastric region
 Renal Cholic
 Severe pain in the lomber region
 Acute Gastritis
 Sudden onset of abdominal pain, hyperemesis,
vomiting and/or gastroenteritis
 Leukocytosis and fever
Acute Pancreatitis-I Its presentation may vary from mild, self-limiting
disease to multiorgan insufficiency and sepsis
 The pain is felt in the epigastrium and umbilicus
at first and can not be well localized, gets more
severe and reaches its maximum
 Hyperemezis-Vomiting (+)
 Absence of periton irritation signs and rigidity
and the pain not being in its maximum severity at
the onset are important in differentiating it from
peptic ulcer perforation
Acute Pancreatitis-II
 The pain radiates towards right or left
hypochondrium
 The pain becomes more severe and localized as
the proteolytic enymes effect the peritoneum
and is accompanied by muscle strain
 Especially in the early period physical
examination signs may be vague
Chronic abdominal pain-I
 Epigastric pain:
 Non-ulcer dyspepsia
 Peptic ulcer
 Gastric carcinoma
 Acute and chronic gastritis
 Mesentery artery insufficiency
Chronic abdominal pain-II
 Right upper quadrant:
 Pain due to choledoc
 Hepatic abscess
 Hepatic Carcinoma
 Congestive hepatomegaly
Chronic abdominal pain-III
 Right lower quadrant pain:
 Crohn
 Ileocaecal tbc
 Malignant tumours of the caecum and ascending
colon
Chronic abdominal pain-IV
 Left upper quadrant pain:
 Chronic pancreatitis
 Pancreas ca
 Tumours of the left flexura
 Splenic diseases
Chronic abdominal pain-V
 Left lower quadrant pain:
 Ulcerative colitis
 Diverticulitis
 Rectosigmoid colon ca
 Fecalom
Hypogastric Pain:
 Gynecologic diseases: dysmenorrhea, salphengitis,
ectopic pregnancy, etc.
 Urologic diseases: bladder retansion, bladder
stones,cystitis
Approach to the Patient-I Systematic approach excluding urgent
conditions
 Detailed anamnesis
 Differentiating acute-chronic conditions
 Chronology
 Menstruation in women
 Avoiding narcotics and analgesics until
the diagnosis
Approach to the Patient-II Pelvic and rectal examination
 Laboratory
 Imaging
 Physical examination