| ID | 16 |
|---|---|
| Name | ABDOMINAL PAIN |
| Cause | Causes of acute abdominal pain:2 A. Hyperacidity: Acute exacerbation of peptic ulcer. B. Inflammatory conditions: Acute gastro-enteritis, appendicitis, eolitis, diverticulitis, cholecystitis, hepatitis, pancreatitis, pyelonephritis, intra-abdominal abscess, pelvic inflammatory disease. C. Obstruction & stretching: Intestinal obstruction, biliary colic (due to obstruction of bile duct), ureteric colic (due to obstruction of ureteric duct). ; D. Perforation/rupture: Peptic ulcer, appendicitis, diverticular disease, ovarian cyst, aortic aneurysm. E. Loss of blood supply to an organ: Such as, Ischemic colitis.2 F. Other rare causes: Acute presentation of any extraintestinal causes of chronic or recurrent abdominal pain. Causes of chronic or recurrent abdominal pain:2 1. Gastro-intestinal causes: Dyspepsia, chronic peptic ulcer disease, amoebic and bacillary dysentery, enteric fever, irritable bowel syndrome (non-inflammatory), chronic inflammatory bowel diseases, malignant diseases of gastro-intestinal organs. Transformation of acute abdominal pain to chronic or recurrent abdominal pain, viz: Chronic gastro-enteritis, chronic appendicitis, chronic diverticulitis, chronic cholecystitis, chronic pancreatitis, chronic intestinal obstruction. 2. Extraintestinal causes of chronic or recurrent abdominal pain: Retroperitoneal- Aortic aneurysm, malignancy, lymphadenopathy, abscess. Metabolic/endocrine- Diabetes mellitus, Addison’s disease, acute intermittent porphyria, hypercalcemia. Locomotor- Vertebral compression, abdominal muscle strain. Hematological- Sickle-cell disease, hemolytic disorders. Neurological- Spinal cord lesions, radiculopathy, tabes dorsalis. Psychogenic- Depression, anxiety, hypochondriasis, somatisation. Drugs/toxins- Corticosteroids, lead, azathioprine, alcohol. |
| Signs Symptoms | Seek immediate medical help if pain is accompanied by other worrisome signs and symptoms, including: Severe pain Fever Bloody stools Persistent nausea and vomiting Weight loss Skin that appears yellow Severe tenderness when you touch your abdomen Swelling of the abdomen |
| Diagnosis | 1. Detailed history taking: Things to be considered: i. Initiation of pain (sudden or insidious ?). ii. Location of the pain. iii. pattern of the pain. iv. Duration of the pain. v. What makes the pain worse ? vi. What relieves the pain ? vii. Associated signs and symptoms. 2. Clinical examination: In initial assessment if there is signs of acute abdomen with peritonitis i.e presence of guarding and rebound tenderness with rigidity, patients should be resuscitated immediately and transferred to the hospital for operative management following minimal investigations. In cases of acute abdominal pain without sign of peritonitis, investigations should be done to reach a probable diagnosis for specific management. |
| Investigations | 3. Investigations: i. Complete blood count - leucocytosis suggests inflammation or infection. ii. Blood urea and serum electrolytes - dehydration (?) iii. Serum amylase - acute pancreatitis (?) iv. Urine analysis (frequently done in the evaluation of abdominal pain), v. Liver enzymes- may be elevated in acute hepatitis, cholelithiasis, vi. Chest x-ray in erect posture - subdiaphramatic gas vii. Plain x-ray abdomen in erect posture- detection of fluid level (intestinal obstruction, abscess viii. Plain x-ray KUB region - renal or ureteric stone ix. Abdominal ultrasonogram - cholecystitis, cholelithiasis, pancreatitis, renal or ureteric stones, ovarian cyst, soft tissue mass, detection of fluid level (intestinal obstruction, abscess x. Endoscopic/Colonoscopic procedures: Endoscopy is useful for detecing ulcers, gastritis or stomach cancer. Colonoscopy or flexible sigmoidoscopy is useful for diagnosing infectious colitis, ulcerative colitis, or colon cancer. 4. Specialised investigations (if needed): i. CT Scan- pancreatitis, retroperitoneal collections or masses, aortic aneurysm ii. Endoscopic ultrasound is useful for diagnosing pancreatic cancer or gallstones if the standard ultrasound or CT or MRI scans fail to detect them, iii. ERCP (Endoscopic Retrograde Cholangio-Pancreatogfaphy)- to examine and find any pathology in the duodenum, the papilla of Vater, the bile ducts, the gallbladder and the pancreatic duct, iv. Mesenteric angiography - mesenteric ischemia 5. Diagnostic Laparoscopy/Surgery: In acute abdomen, where decision to operate remains in doubt even after appropriate investigations, diagnostic laparoscopy/surgery is advised. Chronic or recurrent abdominal pain: 1. Detailed history taking. 2. Clinical examination. 3. Routine investigations: i. Blood tests - Complete blood count, Blood sugar, ii. Urine routine examinations, iii. Stool routine examinations with ocult blood, iv. Chest x-ray P/A or A/P vew. 4. Specific investigations (as required): i. Liver function tests (S. bilirubin, ALT, AST). ii. Serum amylase - Chronic pancreatitis, Pancreatic cancer iii. Renal function tests - (B. urea, S. creatinine). v. Plain x-ray abdomen - any radio-opaque shadow (gallstone, renal stone Or, vi. Plain x-ray KUB region - Renal or ureteric stone vii. Barium meal x-ray - Peptic ulcer, upper g.i tract anomalies, viii. Endoscopy - Peptic ulcer, upper g.i tract anomalies, ix. Barium enema - Colonic obstruction x. Sigmoidoscopy, or colonoscopy - Colonic obstruction, irritable bowel syndrome, rectal bleeding, inflammatory bowel diseases xi. Abdominal ultrasonogram- Chronic cholecystitis, cholelithiasis, chronic pancreatitis, hepatic metastases, renal or ureteric stones, ovarian cyst, soft tissue mass, detection of fluid level (intestinal obstruction, abscess xii. IVU - Renal or ureteric stones, or stricture. 5. Specialised investigations (if needed): i. CT Scan- Pancreatitis, retroperitoneal collections or masses, aortic aneurysm ii. Mesenteric angiography - Mesenteric ischemia |
| Management | Management:1,2 Acute abdominal pain: • General measures: i. Resuscitation of the patients - after initial assessment, adequate resuscitation should be done. - maintenance of hydration by i.v fluid. - nothing should be given by mouth until signs and symptoms of acute abdominal conditions are subsided. - relieve of acute pain by parenteral antispasmodic or narcotic analgesic. - observation of body temperature, pulse and heart rate, ii. In case of inflammatory conditions, appropriate broad-spectrum antibiotic can be started, iii. Patient should be transferred immediately to the hospital for further management. • Specific treatment: Treatments of common diseases causing acute abdominal pain have been discussed separately in the respective chapters. Chronic or Recurrent abdominal pain: General and specific management of common diseases causing chronic or recurrent abdominal pain have been discussed separately in this running and following respective chapters. |
| Introduction | Abdominal pain is a frequent cause of human suffering in all age groups. This is a symptom manifested by different abdominal diseases and conditions of the organs within the abdominal cavity (i.e beneath the skin and muscles), which include mostly gastro-intestinal organs. Some times pain arising from organs that are colse to but not within the abdominal cavity, such as lower lungs, kidneys, uterus or ovaries are also referred to as abdominal pain. Abdominal pain may be presented as- i. Acute abdominal pain and ii. Chronic or recurrent abdominal pain. Acute abdominal pain accounts for about 5-10% of emergency medical visits in many hospitals and clinics. Depending on organ involvement and underlying causes abdominal pain 4 may be of several types, viz:2 1. Visceral pain: Pain originated in the gut and other abdominal organs in response to stimuli from inflammation, distension, contraction, torsion and stretching. Gut organs are usually insensitive to stimuli such as burning and cutting. 2. Parietal pain: Parietal peritoneum is innervated by somatic nerve fibres from the body wall. Stimulation of these nerve fibres by any cause or disease processes, e.g inflammation, infection or neoplasia, tends to produce a sharp, localised and lateralised pain. 3. Referred pain: In some cases abdominal pain is felt as referred to different specific organ or part of the body, e.g gall bladder pain is referred to the back and/or shoulder tip. 4. Psychogenicpain: Sometimes no organic cause can be identified. Cultural, emotional or psychosocial factors may be responsible for experiencing pain, e.g depression, anxiety or somatisation disorder etc. |
| History | Chronic or recurrent abdominal pain: 1. Detailed history taking. 2. Clinical examination. 3. Routine investigations: i. Blood tests - Complete blood count, Blood sugar, ii. Urine routine examinations, iii. Stool routine examinations with ocult blood, iv. Chest x-ray P/A or A/P vew. 4. Specific investigations (as required): i. Liver function tests (S. bilirubin, ALT, AST). ii. Serum amylase - Chronic pancreatitis, Pancreatic cancer iii. Renal function tests - (B. urea, S. creatinine). v. Plain x-ray abdomen - any radio-opaque shadow (gallstone, renal stone Or, vi. Plain x-ray KUB region - Renal or ureteric stone vii. Barium meal x-ray - Peptic ulcer, upper g.i tract anomalies, viii. Endoscopy - Peptic ulcer, upper g.i tract anomalies, ix. Barium enema - Colonic obstruction x. Sigmoidoscopy, or colonoscopy - Colonic obstruction, irritable bowel syndrome, rectal bleeding, inflammatory bowel diseases xi. Abdominal ultrasonogram- Chronic cholecystitis, cholelithiasis, chronic pancreatitis, hepatic metastases, renal or ureteric stones, ovarian cyst, soft tissue mass, detection of fluid level (intestinal obstruction, abscess xii. IVU - Renal or ureteric stones, or stricture. 5. Specialised investigations (if needed): i. CT Scan- Pancreatitis, retroperitoneal collections or masses, aortic aneurysm ii. Mesenteric angiography - Mesenteric ischemia |
| Etiology | Less serious causes of abdominal pain include constipation, irritable bowel syndrome, food allergies, lactose intolerance, food poisoning, and a stomach virus. Other, more serious, causes include appendicitis, an abdominal aortic aneurysm, a bowel blockage, cancer, and gastroesophageal reflux. Acute The various conditions that cause acute abdominal pain are usually accompanied by other symptoms that develop over hours to days. Causes can range from minor conditions that resolve without any treatment to serious medical emergencies, including: • Abdominal aortic aneurysm • Appendicitis • Cholangitis (bile duct inflammation) • Cholecystitis • Cystitis (bladder inflammation) • Diabetic ketoacidosis • Diverticulitis • Duodenitis (inflammation in the first part of the small intestine) • Ectopic pregnancy (in which the fertilized egg implants and grows outside of the uterus, such as in a fallopian tube) • Fecal impaction (hardened stool that can't be eliminated) • Heart attack • Injury • Intestinal obstruction • Intussusception (in children) • Kidney infection (pyelonephritis) • Kidney stones • Liver abscess (pus-filled pocket in the liver) • Mesenteric ischemia (decreased blood flow to the intestines) • Mesenteric lymphadenitis (swollen lymph nodes in the folds of membrane that hold the abdominal organs in place) • Mesenteric thrombosis (blood clot in a vein carrying blood away from your intestines) • Pancreatitis • Pericarditis (inflammation of the tissue around the heart) • Peritonitis (infection of the abdominal lining) • Pleurisy (inflammation of the membrane surrounding the lungs) • Pneumonia • Pulmonary infarction (loss of blood flow to the lungs) • Ruptured spleen • Salpingitis (inflammation of the fallopian tubes) • Sclerosing mesenteritis • Shingles • Spleen infection • Splenic abscess (pus-filled pocket in the spleen) • Torn colon • Urinary tract infection (UTI) • Viral gastroenteritis (stomach flu) Chronic (intermittent, or episodic) The specific cause of chronic abdominal pain is often difficult to determine. Symptoms may range from mild to severe, coming and going but not necessarily worsening over time. Conditions that may cause chronic abdominal pain include: • Angina (reduced blood flow to the heart) • Celiac disease • Endometriosis • Functional dyspepsia • Gallstones • Gastritis (inflammation of the stomach lining) • Gastroesophageal reflux disease (GERD) • Hiatal hernia • Inguinal hernia • Irritable bowel syndrome • Mittelschmerz (ovulation pain) • Ovarian cysts • Pelvic inflammatory disease (PID) • Peptic ulcer • Sickle cell anemia • Strained or pulled abdominal muscle • Ulcerative colitis (a type of inflammatory bowel disease) Progressive Abdominal pain that steadily worsens over time, often accompanied by the development of other symptoms, is usually serious. Causes of progressive abdominal pain include: • Cancer • Crohn's disease • Enlarged spleen (splenomegaly) • Gallbladder cancer • Hepatitis • Kidney cancer • Lead poisoning • Liver cancer • Non-Hodgkin's lymphoma • Pancreatic cancer • Stomach cancer • Tubo-ovarian abscess (pus-filled pocket involving a fallopian tube and an ovary) • Uremia (buildup of waste products in your blood) |
| Clinical Features | Among the most important are nausea, vomiting, abdominal distention, diarrhea, constipation, obstipation, tarry stools, chills, fever, urinary frequency, hematuria, and jaundice. |
| Preventions | Eating enough fibreand doing regular exercise can help prevent constipation and keep your bowels working well, which will prevent some forms of abdominal pain. It will also reduce your long-term risk of some diseases, such as diverticular disease or bowel cancer. |
| Treatment | TREATMENT IS ACORDING TO CAUSE Bowel rest. Stop eating, or only eat easy-to-digest foods like crackers or bananas. Hydration. Drink plenty of water or a hydration formula. Heat therapy. Try a warm water bottle or a soak in the bath. Home remedies. |
| Complications | In addition, many of the underlying conditions that cause abdominal pain can lead to serious complications, including the possibility of structural damage to the digestive system from infection, cancer and its treatments, and inflammatory bowel disease (IBD) |
| Prognosis | AS PER Severity and Cause |
| Types | 1. Uncomfortable bloating Possible cause: excess gas 2. Sharp pain in the lower right side of your abdomen Possible cause: appendicitis 3. Sharp stabbing pain in your upper right abdomen Possible cause: gallstones 4. Pain or burning in your upper middle abdominal Possible cause: peptic ulcer 5. General abdominal pain with diarrhea Possible cause: gastroenteritis 6. General abdominal pain with bloating Possible cause: irritable bowel syndrome (IBS) 7. Pain with bloody diarrhea Possible cause: Inflammatory bowel disease |
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