abdominal pain - mans · appendicitis regional enteritis ... fever, mild leukocytosis, and minimal...
TRANSCRIPT
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ABDOMINAL PAIN
Dr. Sawsan Abd El-MoniemProf. Hepatology& Gastroenterology
Mansoura University
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Epigastric Pain
Peptic Ulcer Disease
GERD
Pancreatic pain
Gallbladder and common bile duct
obstruction.
Myocardial Infarction
AAA- abdominal aortic aneurysm
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Right Upper Quadrant Pain
Acute Cholecystitis and Biliary Colic
Acute Hepatitis or Abscess
Hepatomegaly due to CHF
Perforated Duodenal Ulcer
Herpes Zoster
Myocardial Ischemia
Right Lower Lobe Pneumonia
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Left Upper Quadrant Pain
Acute Pancreatitis
Gastric ulcer
Gastritis
Splenic enlargement, rupture or infarction
Myocardial ischemia
Left lower lobe pneumonia
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Right lower Quadrant Pain
Appendicitis
Regional Enteritis
Small bowel obstruction
Ruptured Ectopic Pregnancy
Twisted Ovarian Cyst
Ureteral Calculi
Hernia
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Left Lower Quadrant Pain
Diverticulitis
Ruptured Ectopic pregnancy
Twisted Ovarian Cyst
Ureteral Calculi
Hernia
Regional Enteritis
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Periumbilical Pain
Disease of transverse colon
Gastroenteritis
Small bowel pain
Appendicitis
Early bowel obstruction
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Diffuse Pain
Generalized peritonitis
Acute Pancreatitis
Sickle Cell Crisis
Mesenteric Thrombosis
Gastroenteritis
Metabolic disturbances
Dissecting or Rupturing Aneurysm
Intestinal Obstruction
Psychogenic illness
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Referred Pain
Pneumonia (lower lobes)
Inferior myocardial infarction
Pulmonary infarction
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TYPES OF ABDOMINAL PAIN
Visceral
originates in abdominal organs covered by peritoneum
Colic
crampy pain
Parietal
from irritation of parietal peritoneum
Referred
produced by pathology in one location felt at another location
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ORGANIC VERSUS FUNCTIONAL PAINHISTORY ORGANIC FUNCTIONAL
Pain character Acute, persistent pain Less likely to changeincreasing in intensity
Pain localization Sharply localized Various locations
Pain in relation to sleep Awakens at night No affect
Pain in relation to Further away At umbilicusumbilicus
Associated symptoms Fever, anorexia, Headache, dizziness,vomiting, wt loss, multiple system com-anemia, elevated ESR plaints
Psychological stress None reported Present
HISTORY ORGANIC FUNCTIONAL
Pain character Acute, persistent pain increasing in intensity
Less likely to change
Pain localization Sharply localized Various locations
Pain in relation to sleep
Awakens at night No affect
Pain in relation to umbilicus
Further away At umbilicus
Associated symptoms
Fever, anorexia, vomiting, wt loss, anemia, elevated ESR
Headache, dizziness, multiple system com-plaints
Psychological stress
None reported Present
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WORK-UP OF ABDOMINAL PAIN
HISTORY Onset Course Duration Character of Pain Intensity Frequency Location - Does it go anywhere (referred)? Aggravating and relieving factors Response to treatment. Complications
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WORK-UP
PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation
Guarding - rebound tenderness
Rectal exam
Pelvic exam
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WORK-UP
LABORATORY TESTS
CBC;ESR
Stool….
Additional depending on rule outs
amylase,
lipase,
LFT’s
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WORK-UP
DIAGNOSTIC STUDIES
Ultrasound
CT scanning
Endoscopy UGI
Sigmoidoscopy, colonoscopy
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Common Acute Pain Syndromes
Appendicitis
Acute diverticulitis
Cholecystitis
Pancreatitis
Perforation of an ulcer
Intestinal obstruction
Ruptured AAA
Pelvic disorders
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APPENDICITIS
Diagnosis based on history and physical
Classic sequence of symptoms
abdominal pain (begins epigastrium or periumbilical area, )
anorexia, nausea or vomiting
followed by pain over appendix and
low grade fever
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DIAGNOSIS
Physical examination
low grade fever
McBurney’s point
rebound, guarding, +psoas sign
CBC, HCG
WBC range from 10,000-16,000
SURGERY
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DIVERTICULITIS
Results from stagnation of fecal material in single diverticulum leading to pressure necrosis of mucosa and inflammation
Clinical presentation
most pts have h/o diverticula
mild to moderate, colicky to steady, aching abdominal pain - usually LLQ
may have fever and leukocytosis
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PHYSICAL EXAMINATION
•With obstruction bowel sounds hyperactive•Tenderness over affected section of bowel
DIAGNOSIS
•Often made on clinical grounds•CBC - ± leukocytosis
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MANAGEMENT
• Spontaneous resolution common with low-grade fever, mild leukocytosis, and minimal abdominal pain
•Treat at home with limited physical activity, reducing fluid intake, and oral antibiotics (bactrim DS bid or cipro 500mg bid & flagyl 500 mg tid for 7-14 days)
•Patients who present acutely ill with possible signs of systemic peritonititis, sepsis, and hypovolemia need admission
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CHOLECYSTITIS
Results from obstruction of cystic or common bile duct by large gallstones
Colicky pain with progression to constant pain in RUQ that may radiate to R scapula
Physical findings
tender to palpation or percussion RUQ
may have palpable GB
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DIAGNOSIS•CBC, LFTs (bilirubin, alkaline phosphatase),
serum pancreatic enzymes• Plain abdominal films demonstrate biliary air
hepatomegaly, and maybe gallstones•Ultrasound - considered accurate about 95%
MANAGEMENT•Admission
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PANCREATITIS
History of cholelithiasis or ETOH abuse
Pain steady and boring, unrelieved by position change - LUQ with radiation to back - nausea and vomiting,
Physical findings;
acutely ill with abdominal distention, BS
diffuse rebound
upper abd may show muscle rigidity
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• Diagnostic studies- CBC- Ultrasound- Serum amylase and lipase
- amylase rises 2-12 hours after onset andreturns to normal in 2-3 days
- lipase is elevated several days after attack
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PEPTIC ULCER PERFORATION
Life-threatening complication of peptic ulcer disease - more common with duodenal than gastric
Predisposing factors
Helicobacter pylori infections
NSAIDs
hypersecretory states
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SMALL BOWEL OBSTRUCTION
Distention ↓ absorption and↑ secretions further distention and fluid and electrolyte imbalance
Number of causes
Sudden onset of crampy pain usually in umbilical area of epigastrium - vomiting occurs early with small bowel and late with large bowel
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• Physical findings- hyperactive, high-pitched BS- fecal mass may be palpable- abdominal distention- empty rectum on digital exam
• Diagnosis- CBC- serum amylase- stool for occult blood- abdominal X-ray
• Management
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RUPTURED AORTIC ANEURYSM
AAA is abnormal dilation of abdominal aorta forming aneurysm that may rupture
More frequent in elderly
Sudden onset of pain may be felt in chest or abdomen and may radiate to legs and back
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•Physical findings- appears shocky- VS reflect impending shock- deficit or difference in femoral pulses
• Diagnosis- CT or MRI- ECG, cardiac enzymes
SURGICAL EMERGENCY
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PELVIC PAIN
Ectopic pregnancy
UTI
Ovarian cysts
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Q-Medical causes of acute Abdomen:Q-Non Surgical causes of acute abdomen.
* Endocrinal causes.
* Systemic diseases. * Metabolic diseases. * GIT disorders. * Referred pain. * CNS causes.
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Endocrinal Causes
1- Diabetic Ketoacidosis.
2- Addisonian Crises.
3- Hyperthyroidism.
4- Hyperparathyroidism due
to Calcium or Pancreatitis.
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Systemic Diseases
1- Collagen Vascular dis.
2- Blood dis (Henoch`s Purpura).
3- Haemolytic dis (Sickle cell dis)
4-Thrombotic state (Acute Leuk).
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5- Renal disInf.6- Familial Periodic Fever.
7- Abdominal Migraine.
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Metabolic Diseases
1-Heavy metal poisoning(Lead).
2- Narcotic Withdrawal. 3- Familial Hyperlipoproteinemia
Pancreatitis.
4-Food Poisoning.
5- Acute Intermittent Porphyria.
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GIT Disorders
1-Acute Gastritis&PU.2- Acute Cholecystitis.3- Biliary Colic.4- Intestinal Colic.5- Acute Pancreatitis.
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6- AcuteViral Hepatitis.
7- Diverticulitis.
8-Peritonitis.9-EnteritisTyphoid,Staph,Closteridium.
10-Ulcerative Colitis.
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Referred Pain
*ChestPleuritis;Pneumonia.
*Heart Pericarditis, MI.*AbdomenDissecting Aortic
Aneurysm.
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CNS
(1) Epilepsy.
(2) Migraine.
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A Patient with acute Abdominal Pain
History:-
Severe MI .(Sec) Perforated PU.
Rupture Aneurysm.Renal,Biliary Colic.
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*Rapid & severe over minutes:--Acute pancreatitis.
- Complete Int. Obst.- Mesenteric Thrombus.
*Gradual & Steady over hours:--Acute Cholecystitis.-Acute Appendicitis.- Diverticulitis.
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*Pain Characters
1- ColickyHollow organ.2- ThrobbingPus under tension.
3- Sawing Rh.Pain.
4- BurningPU,GERD.
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5- Dull achingSolid organ Swelling.
6-StitchingHepatic Congestion.
7-Heaviness,Dragging
Splenomegaly.
8- Constricting,Tightness,
Compressing IHD.
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*Intermittent & Colicky pain:-
(Over Hours)
- Early Subacute Pancreatitis.
- Mechanical Small bowel Obst.
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CHRONIC PAIN SYNDROMES
Irritable bowel syndrome
Chronic pancreatitis
Diverticulosis
Gastroesophageal reflux disease (GERD)
Inflammatory bowel disease
Duodenal ulcer
Gastric ulcer