Abdominal pain

Differential diagnosis
 Semiology of pain
Superficial cutaneus Localization
Deep somatic Radiation

Visceral Characteristics
Intensity
Referred
Duration
Radiated
Evolution
Precipitating factors
Relieve factors
Associated symptoms
Qualities of pain:

• sharp
• colicky, cramping
• dull
•burning
•pression

The intensity of pain does not always

correlate with severity of disease
Minor pain may have a serious cause!!!
Location

•What is where?
Location

•Epigastric
•Umbilical
•Hypogastric / suprapubic
•Right / left hypocondrium
•Right / left flank
•Right / left iliac fossa
Causes:

1. Pain originating in the abdomen

2. Pain referred from extraabdominal source
3. Metabolic causes
4. Neurogenic causes
5. Systemic disease
Pain originating in the abdomen
•Parietal peritoneal inflammation
•Localized inflammation
•Inflammation of organs
•Distension of visceral surfaces
•Mechanical obstruction of hollow viscera
•Vascular disturbances
•Abdominal wall
•Others (tumors, systemic disease…)
Pain originating in the abdomen

Parietal peritoneal inflammation

bacterial contamination
perforated appendix, PID

chemical irritation
pancreatitis, perforated ulcer
Pain originating in the abdomen

Localized inflammation

Abscess: liver,
intraabdominal,
tubo-ovarian…
Pain originating in the abdomen

Inflammation of organs
Gastritis
Pyelonephritis
Cholecystitis
Hepatitis
Diverticulitits, Crohn’s disease,Colitis, Enteritis
Salpingitis
Pain originating in the abdomen
distension of visceral surfaces

 hematoma,
 congestion,
 inflammation,
 infiltration
 tumors

liver
spleen
kidney
Pain originating in the abdomen

Mechanical obstruction of hollow viscera

obstruction of small or large intestine

(feces, tumors…)

obstruction of biliary tree

obstruction of ureter
obstruction of bladder
Pain originating in the abdomen

Vascular disturbances

embolism or thrombosis

vascular rupture

pressure or torsional obstruction

sickle cell anemia

Pain originating in the abdomen

Abdominal wall

trauma or infection of muscles

Pain originating in the abdomen
Others
Infections:
Malaria
Tuberculosis
Parasitosis
Tumours
Lymphoma,
tumor of the kidney
Systemic disease
Systemic lupus erythematodes
Pain referred from extraabdominal source
Any idea?
 
Metabolism

Systemic
Disease
Pain referred from extraabdominal source
throat
tonsilitis
thorax
pneumonia
coronary occlusion
spine
radiculitis from arthritis
genitalia
torsion from testicle
ectopic pregnancy
Metabolic causes
endogenous
uremia
diabetic ketoacidosis
exogenous
spider bite
drug withdrawal
Neurogenic causes

organic
tabes dorsalis
herpes zoster
causalgia and others
migraine

functional
Abdominal pain
can have
many causes…
Many more than
you can talk about
in one lecture…
How to differentiate ?
•Location
•Radiation
•Quality of pain
•Duration
•Accompanying symptoms
•Evolution
Myocardial infarct
Peptic ulcer
Perforated esophagus
Acute cholecystitis
Intestinal obstruction
Acute pancreatitis
Early appendicitis
Mesenteric thrombosis
Aortic aneurysm
diverticulitis
Bladder obstruction
Cystitis
Cramps of the uterus
IPD
Gastric ulcer
Ruptured spleen
Perforated colon
Pneumonia (left)
Acute cholecystitis
Duodenal ulcer
Hepatitis
Congestive hepatomegaly
Pneumonia (right)
Pyelonephritits
Kidney stones
Obstruction of ureter
Perforated colon

Appendicitis
Meckel’s diverticulitis
Salpingitis
Tubo-ovarian abscess
Ruptured ectopic pregnancy
Ureteric stone
Incarcinated hernia
Crohn’s disease, Colitis
Psoas abscess

Appendicitis
Perforated caecum

Sigmoid diverticulitis
Perforated colon
Radiation of pain

Biliary colic
-> right shoulder

Pancreatitis
-> back

Kidney stone
-> testicle
Quality of pain
Inflammation of parietal peritoneum

•Steady
•Aching character
•not well localized
•Spasm of abdominal wall
•Intensity depends on type and amount
of irritating material + time span
•Patient lies in bed without moving
Quality of pain

obstruction of small or large intestine

•Classically colicky / intermittent,

•not well localized
•When small intestine becomes dilated
-> pain diminishes
•Patient restless
Quality of pain

obstruction of biliary tree

Gall bladder:
Steady pain in right upper quadrant
radiation to right shoulder
Common bile duct
radiation to upper lumbar region
Quality of pain

obstruction of ureter (intravesicular)

•severe suprapubic and flank pain
•radiating to penis, scrotum, upper inner thigh

obstruction of bladder
•dull suprapubic pain,
•Low intensity,
•restlessness
Quality of pain
Vascular disturbances

•sudden and severe (rupture of aneurysm)

or
•Mild and diffuse, continuous
no rigidity or tenderness
(occlusion of art. mesenterica)

•Radiation to sacrum or genital

(rupturing abd. aortic aneurysm)
Quality of pain

Abdominal wall

Constant and aching

Movement or prolonged standing worsen
Quality of pain

Referred pain

Thoracic origin
more respiratory symptoms
pain diminishes during inspiration
abd. palpation does not accentuate pain
but patients may have abdominal and
thoracic problems
Quality of pain
Referred pain

Spinal origin
intensified by certain motions (cough etc.)
hyperestesia

Genital origin
accentuated by slight pressure
of organs (testicles etc.)
pain dull
poorly localized
Metabolic abdominal crises

Whenever the cause is obscure,

metabolic origin must be considered

Pain of metabolic origin can simulate

any other cause!!!
Neurogenic causes

Causalgic pain
burning character
distribution of nerve
no abd. distension
no rigidity of abd. wall

Psychogenic pain
does not conform any pattern
usually no relation to meals
History

•Time of onset?
•Character of pain (colicky, dull, sharp…)?
•Intensity of pain?
•Connection to meals, urinating, movements…?
•Radiation?
•Trauma?
•Other symptoms (vomits, diarrhea, cough…)??
•Last stool?
•Last menstruation?
Examination

•Inspection and
examination of the whole patient
•Auscultation
•Palpation (starting far away from painful area!)
•Rectal examination!!!
Diagnostic tools

•Laboratory (blood, urine)

•Ultrasound
•X ray
•(CT, MRI)
Summary I

Causes:
Pain originating in the
abdomen
Pain referred from
extraabdominal source
Metabolic causes
Neurogenic causes
Summary II

Location
Summary III

History
don’t forget menstruation and last stool

Examination
don’t forget rectal examination!!!

Intelligent use of diagnostic tools

  
Thank you very much!