1. Abdominal pain
Ahmed khaled elgizawy
N0 : 35
Round : 1

2. Anatomic background
 Parietal peritoneum
clothes the anterior & posterior
abdominal walls the under
surface of the diaphragm & the
cavity of the pelvis.( supplied
segmentally by the spinal
nerves ) .
 Visceral peritoneum
is the continuation of the
parietal peritoneum, which leaves
the posterior wall of the
abdominal cavity to invest
certain viscera therein . ( has no
nerve supply ).

3. 1 2 3
4 5 6
7 8 9
1 – right hypochondrium
2- epigastric
3- left hypochondrium
4- Right lumbar
5- umbilical
6- left hypochondrium
7- right iliac
8-hypogastric
9- left iliac

4. DEFINITION OF PAIN
It is an unpleasant sensation of
.varying intensity
Pain fibers are stimulated any time a tissue is being
damaged . However , it is not felt very long after the
damage has been accomplished.

5. STIMULANTS
1
Mechanical trauma to the tissue .
2
Excess heat or cold .
3
Chemical damage.
4
Radiation damage .
5
Inadequate blood flow.

6. Abdominal
Extra-abdominal
Systemic dysfunction
Functional abdominal
Abdominal wall
+
Pelvic organs
Intra-peritoneal organs
Retro-peritoneal organs
Diabetes ,tabes dorsalis
pain
Intra-thoracic organs
porphyria

7. Types
of abdominal pain
2
1
Visceral pain is primitive
Somatic pain is entirely
and therefore related to
different from visceral pain
embryologic development .

8. Visceral pain
1- Receptor
( Visceral peritoneum )

9. 2 - Stimulus
Pat. Experienced pain by
traction ,distention & spasm
The visceral peritoneum is
insensitive to touch & heat or
any condition that promotes
an inflammatory reaction

10. 3 - Mediation
Autonomic nervous System Interpreted at
the thalamic level of the brain

11. 4- Specificity
Vague , often dull , poorly described &
associated with nausea & vomiting

12. 5- Localization
Is poor & the pat. Placing the entire
hand over the involved region

13. Somatic pain
1- Receptor
Pain stimuli start in the parietal peritoneum ,
which is innervated by peripheral nerves
P/ peritoneum

14. Somatic pain
2- Stimulus
Pat. experienced pain by
Pressure
Touch
Heat
Inflammation

15. Somatic pain
3- Mediation
Central nervous system
&
Interpreted at a specific cortical
location

16. Somatic pain
4- Specificity
Precisely described as
Cutting

17. Somatic pain
5- Localization
The pain is localized with
great accuracy by the patient ,
who can often point to the site
with one finger

18. Referred pain
Pain felt at a site other
than where the cause is
situated. An example is
the pain from the
pancreas, which is felt in
the back. Pain in
internal organs is often
referred to sites distant
from them.

19. Analysis of pain
need
DATA COLLECTION
1
2
3
History
Physical exam.
Lab.inv.
apply
your medical knowledge***

20. History of pain
The history of pain betrays the diagnosis
Factors influencing
the of pain
Natureof onset
Mode clinical
manifestation
Radiation
Severity
Site
Duration

21. Site of pain & radiation
Radiation of the pain
GB
Stomach &
duodenum
Pancreas
Small bowel Kidney
Kidney Caecum &
rp.structure
App. &
Caecum
T. Colon
bladder
uterus &
adnexae
Sig.
colon
Pancreatic pain
Small bowel pain does not
Radiation indicates source of the
Lower the extent of the disease
pain & also abdominal pain
usually radiate
Kidney pain pain
Stomach & duodenal
tends to go
rarely radiate radiates
Pain
but GB.radiate
may The structures in
goes
through to the back & to
may move whenback but
through to the somatic
pelvis may radiate to thethe
down as visceral nerves
into reach lower
strait
the right ,thethe groin
as well to to left
back or perineum
throughirritated
tip of the shoulder blade
become the back

22. Mode of onset
Sudden onset
[The patient can tell you exactly when the pain started ]
The pain that start suddenly has a mechanical basis
Some thing has been
Twisted
Occluded
Ruptured

23. Mode of onset
Gradual Onset
( The
pat. Usually responds vaguely to questions
about time of onset )
Non mechanical or
chronic process

24. Nature of pain
Two Large Categories
(2)
(1)
Conditions associated with obstruction
Conditions associated with
of a muscular conducting tube
inflammation
(( Mild & Localized Response or
Small bowel , Ureter , Biliary )
Severe , Generalized Response )

25. 1
Obstruction
prolonged
Distention of the viscus
( constant stretching pain )
Sudden
Colic pain = visceral pain
Three Types
(3) ((2)) Small Intestine = ((midgut )) )
Renal system = ( retroperitoneal
1 Biliary System
foregut
Pain felt pain is experienced in the epigastrium
Foregut in the flank & radiates to region
Pain is is experienced in the periumbilical the groin

26. Important features of colic pain
I.
Pat . Is often restless & agitated during exacerbations.
II. Pat. Does not experience a totally pain –free interlude.
III. Colic pain is an intermittent pain .
IV. Colic pain is an visceral pain .
( not influenced by changing relationships between the peritoneal
layers )
V. Failing to demonstrate guarding , tenderness ? ????

27. 2
Inflammation
Intra-abdominal inflammation is peritonitis
Peritonitis causes somatic pain
Peritonitis
Generalized
Localized

28. 2
Inflammation
Intra-abdominal inflammation is peritonitis
Peritonitis causes somatic pain
Contamination
BY
Foreign body
Chemicals
Bacteria
Trauma

29. Important features of somatic
pain
I.
Pat. Laying quite in bed . ( movement is limited )
II.
Examination may demonstrate guarding , tenderness .
III.
The pain is localized over the inflamed organ .
IV. Fever , tachycardia & tachypnea are systemic
manifestation for generalized inflammation .

30. Ischemic pain
Is a somatic pain
Occlusion of blood supply
cause
Necrosis
After 6-12 h
Tissue Hypoxia
With metabolic
changes

31. ?So how do we organize this
• Location
• Acute v. chronic
• Surgical v. nonsurgical

33. Localizing pain -- RUQ
•
•
•
•
•
Hepatitis
Cholecystitis
Cholangitis
RLL pneumonia
Subdiaphragmatic
abscess

34. Localizing pain -- LUQ
• Splenic infarct
• Splenic abscess
• Gastritis/PUD

35. Localizing pain -- RLQ
•
•
•
•
•
•
•
Appendicitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ovarian pathology

36. Localizing pain -- LLQ
•
•
•
•
•
•
•
Diverticulitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ovarian pathology

37. Localizing pain -- epigastric
•
•
•
•
•
PUD
Gastritis
Pancreatitis
GERD
Cardiac (MI,
pericarditis, etc)

38. Localizing pain -- periumbilical
•
•
•
•
Pancreatitis
Obstruction
Early appendicitis
Small bowel
pathology
• Gastroenteritis

39. Localizing pain -- pelvic
• UTI
• Prostatitis
• Bladder outlet
obstruction
• PID
• Uterine pathology

40. Localizing pain -- diffuse
•
•
•
•
•
•
Gastroenteritis
Ischemia
Obstruction
DKA
IBS
Others
▫
▫
▫
▫
FMF
AIP
Vitamin D deficiency
Adrenal insufficiency

41. Acute abdominal pain
• Generally present for less than a couple weeks
▫ Usually days to hours old
▫ Don’t forget about the chronic pain that has
acutely worsened
• More immediate attention is required

42. Acute abdominal pain
• Surgical
▫
▫
▫
▫
▫
▫
▫
Appendicitis
Cholecystitis
Bowel obstruction
Acute mesenteric ischemia
Perforation
Trauma
Peritonitis
• Nonsurgical
▫
▫
▫
▫
▫
▫
▫
Cholangitis
Pancreatitis
Nonabdominal causes
Choledocholithiasis
Diverticulitis
PUD/-itis
gastroenteritis

43. Surgical abdomen
• This is the first thing to be considered in acute
abdominal pain
▫ Early identification is a must as prognosis worsens
rapidly with delay in treatment
• Important to get surgeons involved early if this
is even mildly suspected
• This is a clinical diagnosis

44. Surgical abdomen
• Presentation is usually bad
▫ Fevers, tachycardia, hypotension
▫ VERY tender abdomen, possibly rigid
• Presentation can vary with other demographic
and medical factors
▫ Advanced age
▫ Immunosuppression

45. Surgical abdomen
• Peritonitis
▫ Often signals an intraabdominal catastrophe
 Perforation, big abscess, severe bleeding
▫ Patient usually appears ill
▫ Exam findings
 Rebound, rigidity, tender to percussion or light
palpation, pain with shaking bed

46. Surgical abdomen
• Obstruction
▫ May be acute or acute on chronic
▫ Symptoms include persistent vomiting, abdominal
distention (or not), pain
▫ Exam findings depend on level of obstruction
(proximal v. distal)
 Distal – distention, tympany, absent or high-pitched
bowel sounds
 Proximal – similar, but may not see distention and
tympany

47. Surgical abdomen
• Ischemia
▫ Mesenteric ischemia usually seen in patients with
CAD risk factors, but anyone can infarct bowel for
a variety of reasons
▫ Symptoms include pain OUT OF PROPORTION
TO EXAM
▫ Exam findings
 Severe tenderness to minimal palpation, unstable
vital signs, and a very uncomfortable patient

48. Surgical abdomen
• Work-up
▫ Start with stat labs
▫ Surgical abdominal series (plain films)
▫ Consider stat CT if readily available
• Sometimes patients go straight to surgery as
initial step
• Again, get surgeons involved early for guidance
and early intervention

49. Chronic abdominal pain
• Generally present for months to years
• Generally not immediately life threatening
• Outpatient work-up is prudent

50. Th
an
ky
ou