DIAGNOSTIC APPROACH OF

ABDOMINAL PAIN
IN ADULT PATIENTS
Dr. Muhammad Miftahussurur, M. Kes., Sp.PD., Ph.D
Dr. Ulfa Kholili, Sp. PD-KGEH
INTRODUCTION

PRIMARY CARE
SPECIALIST
PHYSICIANS

ABDOMINAL
BENIGN SERIOUS ACUTE
PAIN
COMPLAINT
 ARBITRARY
INTERVAL

NEED A NO STRICT
CLINICAL TIME
JUDGEMENT PERIOD

ACUTE VS
CHRONIC

- VIEW DAYS ACUTE CHRONIC UNCHANGED

- PROGRESSIVE FOR MONTHS
SUB OR YEARS
ACUTE
 Cervellin G, et al., 2016. Epidemiology and outcomes of acute abdomianal pain in a large urban emergency
departement: retrospective analysis of 5340 cases. Ann Transl Med 4(19):362. DOI: 10.21037/atm.2016.09.10
 Cervellin G, et al., 2016. Epidemiology and
outcomes of acute abdomianal pain in a large
urban emergency departement: retrospective
analysis of 5340 cases. Ann Transl Med
4(19):362. DOI: 10.21037/atm.2016.09.10
 Cervellin G, et al., 2016. Epidemiology and
outcomes of acute abdomianal pain in a large
urban emergency departement: retrospective
analysis of 5340 cases. Ann Transl Med
4(19):362. DOI: 10.21037/atm.2016.09.10
Cervellin G, et al., 2016. Epidemiology and outcomes of acute abdomianal pain in a large urban emergency departement: retrospective
analysis of 5340 cases. Ann Transl Med 4(19):362. DOI: 10.21037/atm.2016.09.10
Farmer AD, Aziz Q, 2014. Mechanisms and management of functional abdominal pain. J of the Royal Society of Medicine 107(9):347-354
THE MEDIATORS INVOLVED IN THE PATHWAYS OF
VISCERAL SENSATION
• SEROTONIN (5-HT)
• NITRIC OXIDE (NO)
• SUBSTANCE P
• CALCITONIN GENE RELATED PEPTIDE (CGRP)
• NOREPHINEPHRINE
• OPIATES (ENDORPHINS, ENKEPHALIN, DYNORPHIN
• PROTEASE (TRYPTASE) ACTING ON PROTEASE-ACTIVATED RECEPTORS-
2 (PAR-2)

Camilleri M, 2013. Genetics of human gastrointestinal sensation. Neurogastroenterol Motil 25(6):458-466

Hymen PE, 2016. Chronic and recurrent abdominal pain. Pediatric in review 37(9): 377-390
The nerves of the
anterior abdominal wall
and their double–right-angle
course at the lateral edge of
the rectus abdominis muscle

Koop H, Koprdova S, Schurmann C, 2016. Chronic

abdominal wall pain. Dtsch Arztebl Int 113: 51-7
Cartwright SL, Knudson MP, 2008. Evaluation of acute abdominal pain in adults. Am Fam Physician 77(7):971-978
 MANAGEMENT OF ACUTE ABDOMINAL PAIN
• HISTORY
• ASSESSMENT OF THE PATIENT’S PAIN
• ASSESSMENT OF THE ASSOCIATED SYMPTOMPS
• PAST MEDICAL AND SURGICAL HISTORY
• SOCIAL HISTORY
• PHYSICAL EXAMINATION
• VITAL SIGNS
• THE ABDOMINAL EXAMINATION
• THE RECTAL EXAMINATION
• SPECIAL ABDOMINAL EXAMINATION
• OTHER EXAMINATION ELEMENTS
• ANALGESIA AND THE ABDOMINAL EXAMINATION
• APPROACH TO THE UNSTABLE PATIENT
• DIAGNOSTIC STUDIES AND DISPOSITION
Macalusso CR, McNamara RM, 2012. Evaluation and management of acute abdominal pain in emergency department. Int J of General Medicine 5: 789-797
 ASSESSMENT OF THE PATIENTS PAIN

PQRST MNEMONIC

P3 Q R3 S T3
POSITIONAL PALLIATING PROVOKING
QUALITY REGION RADIATION REFERRAL SEVERITY TEMPORAL FACTORS
FACTORS FACTORS FACTORS

TIME AND
PREVIOUS
MODE OF PROGRESSION
EPISODES
ONSET
Macalusso CR, McNamara RM, 2012. Evaluation and management of acute
abdominal pain in emergency department. Int J of General Medicine 5: 789-797
 ASSESSMENT OF THE ASSOCIATED SYMPTOMPS

• ANOREXIA
• VOMITING
• BOWEL SYMPTOMPS
• DIARRHEA
• BLOODY STOOL
• MELENA
• HEMATOSCHEZIA
• URGE TO DEFECATE
• OTHER SYMPTOMS
• PYURIA AND DYSURIA
• COUGH AND DYSPNEA
• SYNCOPE

Macalusso CR, McNamara RM, 2012. Evaluation and management of acute abdominal pain in emergency department. Int J of General Medicine 5: 789-797
Hymen PE, 2016. Chronic and recurrent abdominal pain. Pediatric in review 37(9): 377-390
 Associated with
pain

Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-32
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-1132
 SPECIAL ABDOMINAL EXAMINATION

• CARNETT’S SIGN
• COUGH TEST
• CLOSED EYES TEST
• MURPHY’S SIGN
• THE PSOAS SIGN
• THE OBTURATOR SIGN
• THE ROVSING SIGN

Macalusso CR, McNamara RM, 2012. Evaluation and management of acute abdominal pain in emergency department. Int J of General Medicine 5: 789-797
CARNET TEST
COUGH TEST
• Cough causing a sharp, localized
pain
CLOSED EYE TEST
• Positive non specific abdominal pain if patients
keeps their eyes closed when abdominal
tenderness is elicited
• Negative: organic disease
MURPHY’S SIGN
PSOAS SIGN
OBTURATOR SIGN
ROVSING SIGN
Gans SL, Pols MA, Stoker J, Boermeester MA,
2014. Guideline for the diagnostic pathway in
patients with acute abdominal pain. Dig Surg
32:23-31
Cartwright SL, Knudson MP, 2015. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician 91(7):452-459
Cartwright SL, Knudson MP,
2008. Evaluation of acute
abdominal pain in adults. Am
Fam Physician 77(7):971-978
Cartwright SL, Knudson MP, 2015. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician 91(7):452-459
Cartwright SL, Knudson MP, 2008. Evaluation of acute Cartwright SL, Knudson MP, 2015. Diagnostic imaging of acute abdominal pain in adults.
abdominal pain in adults. Am Fam Physician 77(7):971-978 Am Fam Physician 91(7):452-459
Cartwright SL, Knudson MP, 2008. Evaluation of acute abdominal pain in adults. Am Fam Physician 77(7):971-978
Cartwright SL, Knudson MP, 2015. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician 91(7):452-459
Cartwright SL, Knudson MP, 2015. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician 91(7):452-459
Cartwright SL, Knudson MP, 2008. Evaluation of acute abdominal pain in adults. Am Fam Physician 77(7):971-978
Mendelson R, 2015. Imaging for chronic abdominal pain in adults. Aust Prescr 38:49-54
 MULTIDISCIPLINARY TREATMENT APPROACHES
• Establishing an effective patient-physician relationship
• Empathy
• Education
• Hepling the patient take responsibility
• Designing a treatment strategy based on severity of symptoms
• Dietary measures
• Pharmacotherapy for symptoms
• Psychological and behavioral interventions
• Multidisciplinary pain treatment centers
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-32
 Pharmacotherapy for symptoms
• Visceral pain
• Constipation
• Diarrhea
• Abdominal wall pain
• Narcotic bowel syndrome
• Nausea and vomiting

Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-32
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-1132
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-1132
Cartwright SL, Knudson MP, 2008. Evaluation of acute abdominal pain in adults. Am Fam Physician 77(7):971-978
 ABDOMINAL EMERGENCY IN THE GERIATRIC PATIENTS
ACUTE ABDOMINAL NON-ABDOMINAL
VASCULAR INTESTINAL MISCELLANEOUS
MESENTERIC AORTIC CAUSES OF
DISORDERS DISORDERS CAUSES
ISCHEMIA ANEURISMA ABDOMINAL PAIN

SUP MESENTERIC BOWEL PEPTIC ULCER MYOCARDIAL

ARTERY EMBOLUS OBSTRUCTION DISEASE INFARCTION

SUP MESENTERIC BILIARY DISEASE

DIVERTICULAR UNSTABLE
ARTERY AND
DISEASE ANGINA
THROMBOSIS PANCREATITIS

SUP MESENTERIC
PULMONARY
VEIN APPENDISITIS
PROCESSES
THROMBOSIS

NON-OCCLUSIVE
MESENTERIC HERPES ZOSTER
ISCHEMIA

GENITOURINARY
ISSUES

Spangler R, Pham TV, Khoujah D, Martinez JP, 2014. Abdominal emergencies in the geriatric patient. Int J of Emergency Med 7:43
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-1132
Bharucha AE, Chakraborty S, Sletten CD, 2016. Common functional gastroenterologic disorders associated with abdominal pain. Mayo Clin Proc 91(8):1118-1132
Farmer AD, Aziz Q, 2014. Mechanisms and management of functional abdominal pain. J of the Royal Society of Medicine 107(9):347-354
Mujagic Z, Keszthelyi D, Aziz Q, Reinisch W, Quetglas EG, Leonardis FD, et al., 2015. Systematic review: instruments to
assess abdominal pain in irritable bowel syndrome. Aliment Pharmacol Ther 42: 1064-1081
Cartwright SL, Knudson MP, 2008. Evaluation of acute abdominal pain in adults. Am Fam Physician 77(7):971-978