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See slides, Lawson's notes

  • Lower zone pneumonia and testicular torsion can cause abdo pain
  • Sick patient who is pale, sweaty, tachycardic, hypotensive --> treat now
  • Peritonitis - syndrome: percussion tenderness and winces at gentle touch of abdomen
    • needs surgery

Gastric cancer

  • Post prandial heaviness, later pain. Malignant cells in the stomach generate abdominal pain
  • Anorexia - IL1, TNFa
  • Weight loss
  • Anaemia - abnormal gastric mucosa bleeds, occult fashion. Notice malena with time
  • Gastroscopy - biopsy, confirm tumour histologically
  • Gastrectomy - radical, nodal deposits along feeding blood vessels to stomach are excised

Pain

  • paii h d i in is t he pre dominant sensory nant sensory experience b experience by jg which humans which humans judge the existence of disease within themselves
  • physiological factors physiological factors
  • psychologic factors
  • culture
  • age - at either extreme of age, the textbook versions of pain don't hold true
  • Can have disease without pain e.g. liver mets

visceral-pain

  • visceral peritoneum: the continuation of parietal peritoneum which leaves abdominal wall and invests viscera, eg: stomach, bowel stomach, bowel
  • transmitted via autonomic fibres
  • occurs when viscera is stretched or ischaemic eg., small bowel distension
  • dull, deep pain
  • poorly localised
  • may roug may roughl d t t l hly correspon y correspond to segmen o segmental

distribution of somatic sensory fibres

  • early appendix pain --> umbilical region. When there is fibrin rubbing on mucosa --> somatic pain, well localised

somatic pain

  • parietal peritoneum: parietal peritoneum

li ll f bd i l it lines wa ll o f a bdominal cav ity

    • abdominal wall
    • diaphragm
    • root of mesentery
  • Indicates surgical problem - needs admission/surgery
  • transmitted by spinal (segmental) nerves
  • occurs in response to many stimuli eg occurs in response response to many stimuli stimuli eg., heat, pressure, tissue destruction or damage etc
  • sharp, distinct
  • well localised

referred pain

  • visceral pain is sometimes perceived as visceral visceral pain is sometimes sometimes perceived perceived as

coming from more superficial areas of the b d ft di t t f i body, o ften distant from v iscus

    • eg pg p y . dia . phragmatic pain ma y be sensed be sensed

around the shoulder

    • afferents from skin and viscera converge on afferents afferents from skin and viscera viscera converge converge on

same neuron (convergence same neuron (convergence - projection projection hypothesis)

  • After appendicectomy, CO2 irritates underneath the diaphragm --> irritate C3 --> shoulder tip pain
  • gallbladder can be hard to feel when it's in trouble - get them to breathe in to bring it down

How do you categorise abdominal pain (identify the key features) so that you can work out its cause? that you can work out its cause? Is it ?

  • Foregut - stomach, duodenum, hepatobiliary system, pancreas
  • Midgut - jejunum, ileum
  • Hindgut - colon, internal reproductive organs
  • Not coming from GI tract
    • Chest: heart, lungs
    • Other pelvic organs

history

 different different patterns of pain patterns of pain for different diseases: for different different diseases: diseases: typical patterns occur in about 70% of cases  location (foregut midgut hindgut?) (foregut, midgut, hindgut?)  "Exactly where is the pain?"  "Wh i th i t?" "Where is the pa in wors t?"  "Where did the pain start and has the pain moved?"  "D h i h l ?" ( di i ) "Does t he pa in go anyw n go anywhere e lse?" (radiation) • eg. to the back eg. to the back - ? stomach ulcer ? stomach ulcer - ? pancreatitis ? pancreatitis • eg. to the groin eg. to the groin - renal pain renal pain

timing and mode of onset (inflammation, perf ti )oraon  "When did the pain start?"  "Was it sudden or gradual?" eg ,. sudden  perforation  "Has it got worse since it started?"

character (visceral, somatic)

  • "Can you describe the pain? Can you describe describe the pain?"
  • crampy: intermittent pain lasting seconds or minutes
  • "colicky" - intermittent pain: pain, then relief, then pain again
  • dull or sharp
  • intermittent or constant intermittent or constant
  • what makes pain worse or better?


other features of abdominal

GIT disease  anorexia  constipation  diarrhoea  steatorrhoea  gastrointestinal bleeding eg., rectal bleeding  weight loss  jaundice, etc GU  dysuria  haematuria  frequency  vaginal discharge or bleeding etc vaginal vaginal discharge discharge or bleeding bleeding , etc

examination

  • looks unwell, looks "sick", sweating,
  • dehydrated
  • pale, ma lnourished, we ight loss
  • writhing p g, , in pain e g.., renal colic renal colic, pancreatitis
  • motionless eg perforated duodenal ulcer motionless motionless eg., . perforated perforated duodenal duodenal ulcer, appendicitis, cholecystitis
  • can they move easily
  • people with calculi can move OK because it won't cause friction of peritoneum if they move.
    • different to visceral pain
  • writhing on all fours = retroperitoneal disease
  • staying still afraid to move = peritonitis

indicators of severity

 vomiting  sweating

  • increase heart rate, decrease if severe
    • blood pressure

 significant abdominal tenderness significant abdominal tenderness  involuntary contraction of abdominal wall muscles (guarding) especially with somatic pain

abdominal examination  inspection  eg., scars, distension, signs of liver disease  auscultation  eg., rushes eg., rushes & SO tinkling bowel sounds in tinkling bowel sounds in SBO  eg., bruit eg., bruit - renal artery stenosis renal artery stenosis  shake or cough test: h test: - if positive = peritoneal inflammation  percussion tenderness = peritoneal inflammation  palpation  stt f t d tart away from tender area er area  define location of maximal tenderness  elect muscle s elect muscle sp gg asm = guarding  detect abdominal masses  hernial sites organomegaly eg., liver or spleen  rectal and pelvic examination rectal and pelvic examination

  • true guarding = persists when you distract the patient. These are the patients who need surgery
  • always ask for systemic signs
  • systemic signs
    • temperature
    • HR, BP
  • elsewhere
    • chest
    • flanks
    • genitals

extraperitoneal causes

  • arising from structures with similar segmental nerve supply to intra segmental segmental nerve supply to intra-peritoneal peritoneal structures

 chest • heart eg., myocardial ischaemia • lung eg pneumonia lung eg., pneumonia • oesophagus eg., reflux (heartburn)  retroperitoneum • kidney eg., renal stones • aorta eg leaking aneurysm aorta - profound hypotension • spine eg., osteomyelitis (rare)  pelvis • genitourinary eg., bladder infection

  • profound continuous pain in top of abdomen = cholecystitis going around to the back
  • cholangitis = pierces back through to the back
  • nagging RUQ pain = liver
  • appendicitis (common DDx = acute salpingitis. Left side = diverticulus)
  • upper abdominal persistent pain = pancreatitic
  • biliary colic: severe RUQ pain associated with nausea, vomiting = 2 hrs after fatty meal
  • ureteric pain: constant pain, not true colic
  • sudden severe pain in epigastrium, then moves down paracolic gutters = stomach ulcer
  • ruptured aneurysm = severe pain, hypotension
  • acute pancreatisis = constant burn at back of abdomen, want to lean forward
  • mesenteric thrombosis = thromboembolic disease involving mesenteric vessels = severe pain not adequately controlled with opiates, without a lot of signs. Possible AF associated. Order CT. Recent radiotherapy?
  • Appendicitis - central vague abdominal pain, 10 hours later, moves to iliac fossa, then you get localised peritoneal pain
  • Perforated peptic ulcer --> paracolic gutter; migration of gastric soiling causes pain far from its site

Putting it all together

 History of pain  Location,  Time/mode of onset  Character  History of other features  Anorexia, Diarrhoea  Examination  Tenderness, guarding  Other findings Other findings eg distension, bowel sounds distension, bowel sounds  Systemic signs

  • Cigar smoking --promotes elastase (e.g. in emphysema)--> aneurysm --> burst, hypotension, collapse
    • Old patient = abdominal pain and collapse = aneurysm. Need to resuscitate them, and then book surgery

Abdominal aortic aneurysm

  • Abdominal pain radiating to the back
  • Hypotension and collapse
  • Bloods and cross match Bloods and cross match
  • Resuscitate
  • Surgery: open or endoluminal
  • Current treatment: sew in a graft.
  • Treated by cellophane, then it burst again 5 years later, he died.

Pancreatitis

  • Epigastric pain
  • Vomiting - due to gastric distention in response to inflammation in peritoneum
  • Recent alcohol ingestion or gallstones
  • Abdominal tenderness
  • Raised lipase or amy pase or amylase
  • Resuscitate and Ranson's (compare with other signs of organ failure)
  • 90% of pancreatitis = EtOH or gallstones

Splenic laceration

  • Abdominal pain
  • Peritonism and hypotension
  • CT evidence of splenic injury and free fluid
  • Angiography
  • Splenectomy
  • Kerr's sign - shoulder tip pain from perisplenic hematoma -- blood bathes the splene and irritates the diaphragm
  • Triad: Hypotension, epigastric pain, Kerr's sign

Bowel obstruction

In Australia it usually presents with colonoscopy. But 25% present with bleeding or colicky abdominal pain

  • Colicky abdominal pain - late developing. Long-lasting, long episodes between them.
  • Constipation or obstipation (can't fart)
  • Abdominal distension (much more than small bowel obstruction) and tenderness (ischaemic viscera)
  • Dilated bowel and fluid levels on AXR
  • NG tube and resuscitation
  • Non-operative management for adhesive small bowel obstruction and Gastrografin (contrast studies) enema for large bowel obstruction

Recognise obstruction, then confirm on XRay, then put in NG tube and resuscitate them

Appendicitis

  • Abdominal pain shifting from the umbilicus to the right iliac fossa
  • Anorexia
  • Mild pyrexia (38C; spiking temp = viral, or an appendicoel abscess)
  • Rebound tenderness in the right iliac fossa
  • Peritonism
  • CT for confirmation
  • Laparoscopic appendicectomy

NB: never see traumatic appendicitis

Biliary colic

Low fat diet - prevents cholecystekinin, gallbladder contraction against obstruction and biliary colic

  • Right sided and central upper abdominal pain; 2-3 hours after a fatty meal
  • Nausea and vomiting
  • Symptoms occur after fatty meals
  • Abdominal tenderness; acute cholecystitis overlying
  • Confirm with abdominal ultrasound
  • Laparoscopic cholecystectomy

Crohn s’ disease

  • Abdominal pain and diarrhoea
  • Perianal sepsis
  • Extraintestinal disease (scerlosing cholangitis, ankylosing spondylitis, uveitis)
  • Confirm with colonoscopy or small bowel series (diagnose with biopsy)
  • Steroids, immunosuppression and surgery for complications

Fat-wrapped terminal ileum, corkscrewing arteries, enlarged lymph nodes = Crohn's

  • Granulomatous inflammation of all segments of bowel wall - chronic inflammation
    • Didn't used to remove appendix because it causes additional morbidity
  • Only operate on Chron's where medical management has failed

Renal colic

  • Severe pain
  • Writhing patient without peritonism
  • Haematuria
  • CT KUB
  • Analgesia - helps migration of stone down to bladder
  • Ureteric stenting (if stone doesn't migrate)
  • Loin-to-groin (as stone migrates through ureter)
  • Patient tries to move around because anterior peritoneum doesn't hurt
  • White with autonomic arousal
  • Stone in ureter causes haematuria

Peptic ulcer disease

  • Persistent epigastric pain
  • Gastric ulcer pain relieved with eating,duodenal ulcer pain worse with meals
  • Haematemesis
  • Malaena
  • Conirm with gastroscopy
  • Eradicate Helicobacter pylori
  • Surgery for complications

Proton pump inhibition abolishes acid secretion. Patients can erode an ulcer into the gastroduodenal ulcer --> haematemesis. 90% are caused by H Pylori. Surgery only reserved for complications (perforation/bleeding) not resolved with gastroscopy.

Diverticulitis

  • Left sided abdominal pain
  • Fever and peritonism
  • Leucocytosis
  • Abdominal CT
  • Resuscitate and give iv antibiotics
  • High anterior resection

Rupture can let GIT contents into peritoneal cavity. CT - stranding of fat outside colon - free air outside colon.

Recurrent attacks - sigmoid or high anterior resection


Meckels’ diverticulum

Sometimes contains gastric epithelium which can create acid --> cause ulcer --> bleeding

  • 2 inches long
  • 2 feet from the ileocaecal valve
  • 2% of the population
  • 2:1 male predominance
  • Pain
  • GIT bleeding or peritonism
  • Laparoscopy and small bowel resection
  • Migratory pain and peritonism


  • Ehlers Danlos -- collagen deficit - hypermobility of joints
    • Don't heal wounds