1、Jin Qun-xin Professor For clinical medicine graduate students in double language group,Abdominal Pain,* Abdominal pain of varying causes, ranging from the functional to the organic, is one of the top ten outpatient complaints; it is the chief complaint for 5% to 10% of patients presenting to emergen
2、cy departments .,Approach,Rapid assessment is aimed at determining whether the abdominal pain is emergent or nonemergent. This assessment should be tempered with the understanding that in certain populations (the elderly, the young, the immune compromised) signs and symptoms of ominous disease can b
3、e blunted or absent.,Emergent abdominal pain,Did the patient experience sudden or severe pain or demonstrate hemodynamic changes-hypotension or tachycardia?Is the patient pregnant? (Up to 13% of women with a positive pregnancy test and abdominal pain have an ectopic pregnancy.) Emergent intervention
4、 is required for abdominal aortic aneurysm (AAA), bowel obstruction, ruptured spleen, and ruptured ectopic pregnancy.,Nonemergent abdominal pain,When emergent causes are reasonably excluded, nonemergent causes can be considered. Common nonurgent conditions include functional bowel syndrome, urinary
5、tract infections (UTI),constipation,renal stones,cholelithiasis,gastroenteritis, and dysmenorrhea.,Types Classically,abdominal pain is separated into three categories: 1.Visceral Visceral pain is felt at the site of primary stimulation. It is usually dull, aching,d poorly localized, and frequently d
6、ifficult to describe. It may or may not be associated with referred pain.,Types Classically,2.parietal Parietal pain is a deep somatic pain that arises from irritation or inflammation of the parietal peritoneum or the root of the mesentery. It is more definite and easier to describe than visceral pa
7、in.,Types Classically,3.referred Referred pain is pain felt at a site other than that stimulated, but in an area supplied by the same or adjacent neural segments.,location of pain from specific organs,Orgarl Location Esophagus Substernal; occasionally neck, jaw, arm, or back Stomach Epigastrium; occ
8、asionally left upper quadrant and back Duodenal bulb Epigastrium;occasionally rightupperquadrant andback Small intestine Periumbilical; occasionally above the lesion Colon Below umbilicus, on the side of the lesion Splenic flexure Left upper quadrant Rectcsiginoid Suprapubic region Rectum Posteriorl
9、y, over the sacrum Pancreas Epigastrium or back Liver and gallbladder Right upper quadrant, right shoulder, and posterior chest,Clinical Syndromes,The acuteness of abdominal pain determines the clinical approach to this important symptom and is therefore discussed under the separate headings of Acut
10、e Abdominal Pain and Chronic and Recurrent Abdominal Pain.,Acute Abdominal Pain,Many diseases, some of which are nonsurgical, may cause acute abdominal pain. The most common causes of acute abdominal pain are *acute gastroenteritis, *flarnmatory disease (pritonitis,appendicitis, cholecystitis,divert
11、iculitis, pancreatitis, salpingitis) * renal colic * biliary colic * intestinal obstruction * perforation of a viscus *vascular occlusion of abdominal cavity *diseases of abdominal wall and pleura or lungs,Clinical Features,The salient findings of the more common conditions are outlined in the follo
12、wing. However, it must be borne in mind that many of these entities exhibit variant or atypidal patterns.,Acute gastroenteritis,A. Anorexia, nausea, vomiting (common) B. Crampy, rather poorly localized abdominal pain and tenderness C. Diarrhea (common) D. Fever and leukocytosis (common),Acute append
13、icitis,A. Perforation is uncommon before 24 to 36 hours from the onset of symptoms.Initially, pain is diffuse epigastric or periumbilical, eventually shifting to the right lower quadrant (RLQ) of the abdomen. B. Nausea and acute loss of appetite are common; vomiting less so. C. Constipation or diarr
14、hea is an inconsistent symptom. D. Tenderness, muscle spasm, and rebound tenderness in RLQ are frequently absent at the outset but become more evident after 24 hours. E. Fever is usually slight to moderate especially during the first 12 hours G. With a retrocecal appendix, pain, vomiting, and RLQ mu
15、scular rigidity are less common. F. Moderate leukocytosis with neutrophilia is a late finding.,Metabolic causes,A. Exogenous 1. Black widow spider bite 2. Lead and other poisoning B. Endogenous 1. Uremi 2. Diabetic ketoacidosis 3. Porphyri 4. Allergic factors (Cl-esterase deficiency),Neurogenic caus
16、es,A. Organic 1. Tabes dorsalis 2. Herpes zoster 3. Causalgia B. Functional,Acute cholecystitis,A. Previous history of fatty food intolerance, flatulence ,postprandial fullness, and RUQ discomfort (common, but nonspecific) B. Steady, severe pain in RUQ or epigastrium C. Tenderness, muscle guarding,
17、and rebound tenderness (common). The gallbladder may be palpable. D. Anorexia, nausea, and vomiting (common) E. Fever and leukocytosis (common),Acute cholecystitis,F. Radiopaque gallstonee occasionally revealed by plain abdominal radiographs. Imaging of the gallbladder and biliary tree with either u
18、ltrasonography or isotope scanning with HIDA or PIPIDA is very helpfulfor a quick and accurate diagnosis. Oral cholecystography, although useful for the diagnosis of gallstones, requires 12 to 56 hours to becompleted.Endoscopic retrogradecholangiopanatography (ERCP) may be needed if acute cholangiti
19、s uspected. Intravenous cholangiography is obsolete. G. Mild hyperbilirubinemia and bilirubinuria (common),Acute pancreatitis,Common in alcoholic patients Common in patients with cholelithiasis C. May occur in patients with hyperlipidemia D. Abdominal pain variable, ranging from mild to severe, typi
20、cally epigastric with radiation to the back. May be accompanied by prostration, sweating, an shock,Acute pancreatitis,F. Abdominal tenderness in epigastrium (common) G. Elevated serum or urinary amylase levels, or both (not pathognomonic). Elevated serum lipase (common) H. Hyperbilirubinemia and hyp
21、ocalcemia may occur. I. Fever, leukocytosis (common),Acute intestinal obstruction,The symptomatologY depends on the site and completeness of the obstruction. A. Crampy abdominal pain (common) B. Vomiting (more common with obstruction of the proximal gut) C. Constipation; eventually complete inabilit
22、y to pass feces or flatus (common) D. Abdominal distention and tenderness (common) E. Hyperperistalsis and borborygmi are inconsistent symptoms. F. Radiographic evidence of bowel distended with gas proximal to the site of obstruction. Air-fluid levels common,Perforated viscus,A. Most commonly produc
23、ed by perforation of a peptic ulcer B. Sudden onset of severe abdominal pain,aggravated by movement C. Tenderness, abdominal rigidity, and rebound tenderness (common) D. Abdominal distention (uncommon initially) E. Obliteration of hepatic dullness (uncommon) F. Air demonstrable below the diaphragm i
24、n the roentgenogram (common) G. Hypotension and shock are common later on.,Mesenteric vascular infarction,A.Clinical setting often that of congestive heart failure, atrial fibrillation, or visceral hypoperfusion B.Moderate to severe abdominal pain (common) C.Vomiting (inconstant) D.Bloody diarrhea (
25、inconstant) E. Abdominal distention, tenderness, and rigidity in severe cases F.Hypotension and shock in severe cases,Acute salpingitis,A. Lower abdominal pain B. Chills and fever C. History of sexual exposure D. Vaginal discharge E. Adnexal mass(es) F. Demonstration of gonococcal infection or chlam
26、ydial infection,Diagnostic Approach,It is of the utmost importance to diagnose early. The most important question facing the clinician caring for a patient with severe acute abdominal pain is “Is prompt surgery needed?“ Thorough history and physical examination are far more valuable than laboratory
27、or radiologic tests. Surgical consultation should be promptly sought andanalgesics withheld until the surgeon completes evaluation of the patient. All acute abdominal crises give rise to one or more of the following main symptoms and signs: pain, collapse, vomiting, or abdominal wall rigidity.,Some
28、main clinical presentations are as follows:,I. Abdominal pain by itself. Often this is the only symptom in the earliest stages of a number of serious conditions of simple intestinal colic, acute appendicitis, smallbowel obstruction, and acute pancreatitis. II. Severe central abdominal pain with musc
29、ular rigidity (e.g., acute pancreatitis, ruptured aortic aneurysm, and mesenteric thrombosis) III. Pain with vomiting and increased distention but no rigidity usually indicates intestinal obstruction.,Some main clinical presentations are as follows:,IV. Pain with constipation, increased distention,
30、and perhaps Vomiting may indicate large-bowel obstruction. V. The presence of fever, tachycardia, perspiration, and hypotension suggests a serious disorder, such as sepsis or a perforated viscus. VI. Severe abdominal pain with collapse and generalized rigidity of the abdominalwall usually signifies
31、perforation of a viscus. Stomach and duodenum are more likely sites than colon.,Some main clinical presentations are as follows:,VII. Right hypochondrial pain and rigidity indicate acute cholecystitis or a perforated duodenal ulcer. Left hypochondrial pain and rigidity indicate acute pancreatitis,pe
32、rforated gastric ulcer, or splenic rupture. Right lower quadrant pain, tenderness, and rigidity indicate acute appendicitis or tuboovarian disease or ileitis. Left iliac fossa pain, tenderness, and rigidity indicate diverticulitis. Hypogastric pain and rigidity indicate perforated appendicitis, dive
33、rticulitis, or tuboovaria disease. VIII. Pelvic, genital, and rectal examinations are mandatory. Pelvic inflammatory disease, a twisted ovarian cyst, or an ectopic pregnancy may be found. Torsion of the testicle may be uncovered in men. Rectal examination may reveal an abscess or neoplasm.,History,I
34、. In eliciting the history of pain, it is important to know its character, severity,localization, radiation, duration, frequency, times of occurrence, and the factors that alleviate or aggravate it. II. Information about associated symptoms, both GI and systemic, may be helpful in elucidating the ca
35、use of pain. III. Careful inquiry should be made concerning the presence or absence of disorders that may cause referred abdominal pain (e.g., pneumonia, pericarditis, myocardial infarction, spinal arthritis).,History,IV. Ask about symptoms that are associated with endogenous or exogenous metabolic
36、causes of pain, as well as those of neurogenic origin . V. Check the menstrual history. Midcycle follicular rupture is a frequent, harmless cause of abdominal pain. A history of a missed period followed by abdominal pain should suggest possible rupture of an ectopic pregnancy. VI. The family history
37、 may provide a clue to the cause of abdominal pain. Such familial disorders as hyperlipidemia, familial Mediterranean fever, thalassemia, sickle cell anemia, and acute intermittent porphyria are commonly associated with abdominal pain.,History,VII. Anticoagulants may be responsible for intraabdomina
38、l or retroperitoneal hemorrhage and thereby produce abdominal pain. VIII. A history of syphiliS or gonorrhea may be helpful in elucidating the AIDS, such as homosexuality an intravenous drug abuse. Abdominal Examination,Some important causes of acute abdominal pain cause of abdominal pain. Ask about
39、 risk factors for 1.greasy oily food 2.alcoholism 3.brute force 4.postopration of abdominal wall,Abdominal Examination,I. Abdominal examination is of paramount importance. A. Inspect the abdomen for distention and visible peristalsis. B. Check for hernia at all potential sites. C. Abdominal ausculta
40、tion, although valuable,is probabl yone of the least rewarding aspects of the physical examination, because perforation and strangulation of the gut can occur in the presence of normal peristalsis. D. Palpation of the abdomen must be thorough but gentle 1.Check for masses, ascites, and splanchnomega
41、ly. 2.Tenderness, rebound tenderness, and involuntary guarding are important signs of peritonitis.,Physical Examination,I. A complete physical examination is indicated. II. The status of the cardiovascular and respiratory systems and the state of hydration of the patient should be evaluated.,A perip
42、heral white blood cell count greater than 20,000/ mm2 may be seen with perforation, but also with pancreatitis. Conversely, the count may be normal with a perforated viscus. Routine urinalysis, serum electrolytes, and biochemical screening are of value in assessing the state of hydration and in ruli
43、ng out renal disease, diabetes, or other complications. Serum amylase testing is overrated because disorders other than pancreatitis (e.g., perforated peptic ulcer, strangulated gut) may be associated with marked elevations. Sometimes, a definite diagnosis cannot be made at the time of the initial e
44、xamination. The possibility that a patient has an “acute abdomen“ requires immediate consultation with a surgeon. If doubt exists, watchful waiting with repeated questioning and examination often indicates the proper course of action.,Chronic and Recurrent Abdominal Pain,When pain has been present f
45、or weeks or months, the workup can be more deliberate and planned. The patient must be questioned carefully about the location, intensity, character, chronology, and setting of the pain; aggravating or alleviating factors; and associated signs and symptoms. Generally, it is the relationship in which
46、 pain occurs that is important. Each organ has its “usual“ pain pattern-the location of pain being less useful information than its association with activity or the involved organ.,Common pain patterns are described in the following.,I. Peptic ulcer disease. Epigastric pain, described as burning, gn
47、awing, hunger, or aching, occurs 1 to 3 hours after a meal; about one-third of patients are awakened at night with pain. Most often it is quickly relieved with food or antacid,resulting in a pain-food-relief pattern. Some patients with gastric ulcer have increased pain after food, thus presenting a
48、pain-food-pain-relief pattern. Pain is almost always episodic, lasting several days to weeks and is followed by a remission of months.,Common pain patterns are described in the following.,II. Biliary tract disease. Major symptoms include nausea, vomiting, and epigastric or RUQ abdominal pain that is
49、 steady (not colicky). Postprandial fullness, eructations, flatulence, and fatty food intolerance are nonspecific symptoms that are commonly associated with many other abdominal disorders.,Common pain patterns are described in the following.,III. Pancreatic disease. A history of chronic, heavy alcohol ingestion or evidence of stones in the biliary tree are highly suggestive bf pain of pancreatic origin.,Common pain patterns are described in the following.,IV. Small intest
