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Abdominal Pain. Definition of pain. A signal of disease Unpleasant sensation localized to a part of the body Penetrating or tissue destructive process stabbing burning twisting tearing squeezing Bodily or emotional reaction

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Presentation Transcript
definition of pain

Definition of pain

A signal of disease

Unpleasant sensation localized to a part of the body

Penetrating or tissue destructive process

stabbing burning twisting tearing squeezing

Bodily or emotional reaction

terrifying nauseating sickening

Accompanied by anxiety

Urging to escape or terminating the feeling

Both sensation and emotion

clinical characteristics

Clinical characteristics

Character of pain

spastic pain: intermittent

inflammatory: persisting

Localization of pain:

usually in the diseased part

it may be referred

clinical characteristics4

Clinical characteristics

Quality and intensity of pain

peptic ulcer: gnawing burning

Referred pain

Provocating, aggravating and relieving factors

ulcer pain: relieved by ingestion of food

clinical characteristics5

Clinical characteristics

Associated symptoms

Physical examination: neck lymph nodes

chest examination

abdominal examination

Laboratory check up: sputum, stool, urine

Serum

X-ray film

Ultra-sound

clinical characteristics6

Clinical characteristics

The following are important:

severity

duration

frequency

special time of occurrence

10 questions on pain
Site

Referral

Character

Severity

Duration

Onset

Frequency

Aggravating factors

Relieving factors

Associated symptoms

10 Questions on Pain
abdominal pain8

Abdominal pain

Acute abdominal pain

Chronic abdominal pain

etiology and pathogenesis

Etiology and pathogenesis

Acute abdominal pain

Parietal peritoneal inflammation

bacterial contamination chemical irritation

Acute inflammation of abdominal organs

gastritis enteritis

Mechanical obstruction of hollow viscera

obstruction of the small or large intestine

obstruction of the biliary tree

etiology and pathogenesis10

Etiology and pathogenesis

Acute abdominal pain

Vascular disturbances

Embolism, vascular rupture, torsion of the organs

Referred pain

pneumonia coronary occlusion

Abdominal wall

trauma or infection of muscles,

distortion or traction of mesentery(肠系膜)

Metabolic and toxic causes

allergic factors etc.

etiology and pathogenesis11

Etiology and pathogenesis

Chronic abdominal pain

Chronic inflammation of abdominal organs

reflux esophagitis chronic ulcerative colitis

Peptic ulcer

Distention of visceral surfaces hepatic or renal capsules, hepatitis, hepatic cancer

etiology and pathogenesis12

Etiology and pathogenesis

Chronic abdominal pain

Obstruction or torsion

Infiltration or metastasis of tumor

Metabolic and toxic causes uremia

Neurogenicirritable colon neurosis

mechanisms of abdominal pain

Mechanisms of abdominal pain

Visceral pain

Somatic pain

Referred pain

visceral pain

Visceral pain

Results from stimulation of autonomic nerves

in the visceral peritoneum which surrounds

internal organs

The message may be transferred into the spinal

cord via sympathic route

clinical presentation of visceral pain

Clinical presentation of visceral pain

Pain poorly localized

Intermittent, cramp or colicky pain

Accompanied by nausea, vomitting and diaphoresis

somatic pain

Somatic pain

Stimuli occurs with irritation of parietal peritoneum

Sensations conducted along peripheral nerves

which can localize pain better

clinical presentation of somatic pain

Clinical presentation of somatic pain

Precisely localized pain

Pain described as intense, constant

With local guarding or rigidity

Getting worse after coughing or position changes

May be caused by infection, chemical irritation, or

other inflammatory process

referred pain

Referred pain

Pain felt at a distance from its source

----The diffuse pain arising from abdominal visceral structures tends to be projected to a more superficial region with the same segmental innervation

The nerves distribution and visceral organs are

listed in text book (page 37)

clinical manifestation

Clinical manifestation

Localization

Tenderness over the diseased organ

Obstruction of small intestine:periumbilical(脐周)

supraumbilical(脐上)

Obstruction of large intestine:infraumbilial area (脐下)

acute distention of gallbladder:right upper quadrant with

radiation to the right posterior region of the thorax

or the tip of the right scapula (肩胛)

pain localization gi tract
Pain Localization, GI Tract

Stomach, duodenum

Small bowel, proximal

half colon

Distal half colon

acute epigastric pain referring to the back

Epigastric pain + repeated vomiting

  • Food poisoning
  • Acute pancreatitis

Agonizing pain but insignificant signs

  • Acute pancreatitis
  • Mesenteric thrombosis at early stage

肠系膜血栓形成

Acute epigastric pain referring to the back
  • Posteriorly penetrating peptic ulcer
  • Biliary pain
  • Acute pancreatitis
  • Dissecting aneurysm 夹层动脉瘤
clinical manifestation22

Clinical manifestation

Quality and severity

Perforation:severe dull pain over abdomen

Obstruction of hollow abdominal viscera:intermittent

colicky

Intraabdominal vascular disturbances:

sudden and catastrophic in nature

Acute pancreatitis: severe, steady upper, abdominal pain

pain severity
Pain Severity

Intestinal

Colic

Biliary Colic,

Pancreatic

Ulcer

clinical manifestation24

Clinical manifestation

Provocation and relief

Acute gastritis and enteritis:eating unfresh or raw foods

relieved by vomiting or discharge

Peritoneum inflammation:accentuated by pressure

palpation movement coughing

IBS and constipation:relieved temporarily by bowelmovements

Obstruction:relieved temporarily by vomiting

Ulcer:eating or taking antacids

clinical manifestation25

Clinical manifestation

Associated manifestations

Fever: inflammation

Jaundice:liver gallbladder pancreatic disease

Hematuria:renal stone

Diarrhea/rectal bleeding: intestinal causes

differentiation of three colicky pain

Differentiation of three colicky pain

Type Location Other manifestation

Intestinal periumbilical vomiting, nausea

infraumbilical diarrhea, bowel sounds

Biliary right upper jaundice fever

quadrant Murphy’s sign

Renal ipsilateral flank changes in urine test

radiate to genitalia外阴hematuria

groin腹股沟, scrotum阴囊

clinical manifestation of chronic abdominal pain

Clinical manifestation of chronic abdominal pain

Past history

Localization

Quality

Pain and position of the body

Ptosis (下垂)of stomach or kidney:

pain when standing for long time

Associated symptoms

Chronic infection lymphoma malignant tumor: fever

esophagus stomach billary tree: vomiting

Pain referred to the abdomen should be differentiated

diagnostic points

Diagnostic points

An accurate menstrual history in a female patient is essential

Much attention has been paid to the presence or absence of peristaltic sounds, their quality and their frequency

PQRST: provocative-palliative factors quality

region severity temporal characteristics

work up of abdominal pain

WORK-UP OF ABDOMINAL PAIN

HISTORY

• Onset

• Qualitative description

• Intensity

• Frequency

• Location - Does it go anywhere (referred)?

• Duration

• Aggravating and relieving factors

common acute pain syndromes

Common Acute Pain Syndromes

• Appendicitis

• Acute diverticulitis

• Cholecystitis

• Pancreatitis

• Perforation of an ulcer

• Intestinal obstruction

• Ruptured AAA (abdominal aortic aneurysm)

• Pelvic disorders

diagnostic studies

DIAGNOSTIC STUDIES

• Plain X-rays (flat plate)

• Contrast studies - barium (upper and lower

GI series)

• Ultrasound

• CT scanning

• Endoscopy

• Sigmoidoscopy, colonoscopy