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Harrison's Practice Abdominal Pain Definition • •

Harrison's Practice Abdominal Pain Definition • •

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Published by: earicasilla on Mar 14, 2010
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Abdominal Pain
Abdominal pain refers to the perceived location of pain not necessarily to its site of origin, which may be remote fromthe abdominal cavity.
Acute pain requires rapid, often emergent assessment of likely causes (e.g., a perforated viscus) and equally rapidintervention.
Subacute and chronic pain may reflect a wide range of disease processes, many anatomic, some functional, and generallyallowing for a more leisurely diagnostic and therapeutic approach.Epidemiology
One of the most common presenting problems in emergency medicine
Accounts for ~10% of all emergency department visits
Half of healthy adults have abdominal pain on questioning.
Age and sex
Dependent on cause of abdominal pain, for example:
Acute cholecystitis is more common in women than in men.
Ischemic colitis is more common in the elderly.
Can affect anyone at any timeMechanism
Among the numerous mechanisms of abdominal pain are:
Pain originating in the abdomen
Inflammation of the parietal peritoneum, for example:
Release of acid into the peritoneum from a perforated duodenal ulcer 
Obstruction of a hollow viscus, for example:
Acute biliary obstruction by agallstone
Vascular disturbances, for example:
Embolism to the superior mesenteric artery with resultantintestinal ischemia
Injury to the abdominal wall, for example:
Tear in the abdominal musculature from trauma
Distension of visceral surfaces, for example:
Splenomegaly occurring rapidly in a patient with acute hemolysis
Pain referred from extraabdominal sources
Common sites include:
Thorax (for example, pleuritis)
Spine (for example, a herniated disc)
Pelvis (for example, epididymitis
Metabolic causes, for example:
Hyperlipidemia causing acute pancreatitis
 Neurologic/psychiatric causes, for example:
Herpes zoster (shingles)
Functional causes, for example:
Toxic causes, for example:
Lead poisoning
Still incompletely defined mechanisms, for example:
Signs and symptoms of abdominal pain reflect underlying pathophysiologic mechanism.
Symptoms are best described by referring to quality, location, intensity, duration, and timing of the pain.
Signs reflect the site of origin and, although critical to diagnosis, in many cases are nonspecific.
Pain of abdominal origin
Inflammation of the parietal peritoneum
Quality: steady and aching
Location: directly over the inflamed area
Intensity: dependent on the type and amount of material to which the peritoneal surfaces are exposed in a giventime period
Sudden release into peritoneal cavity of a small quantity of sterile acid gastric juice causes much more pain than the same amount of grossly contaminated neutral feces.
Enzymatically active pancreatic juice causes more pain and inflammation than the same amount of sterile bile containing no potent enzymes.
Blood and urine are often so bland they are detected only if contact with the peritoneum is sudden or massive.
In bacterial contamination (e.g.,  pelvic inflammatory disease
), pain is frequently of low intensity until bacterial multiplication has caused elaboration of irritating substances.
Rate at which irritating material is applied to the peritoneum is important.
In perforated peptic ulcer, the clinical picture depends on the rapidity with which gastric juice entersthe peritoneal cavity.
Pain is accentuated by pressure or changes in tension of the peritoneum.
Produced by palpation or movement, such as coughing or sneezing
Patient with peritonitis lies quietly in bed to avoid painful motion.
Patient with colic may writhe incessantly.
Tonic reflex spasm of the abdominal musculature may be present.
Localized to the involved body segment
Intensity of spasm is dependent on the location and rate of development of the inflammatory processand the integrity of nervous system.
Spasm over a perforated retrocecal appendix or a perforated ulcer into the lesser peritoneal sac may beminimal or absent because of the protective effect of overlying viscera.
A slowly evolving process often greatly attenuates the degree of spasm.
There may be little or no detectable pain or spasm in obtunded, seriously ill, debilitated elderly or psychotic patients, even in catastrophic abdominal emergencies.
Obstruction of hollow viscera
Classically described as intermittent or colicky
Produces steady pain with occasional exacerbations
 Not nearly as well localized as pain of parietal peritoneal inflammation
Obstruction of the small intestine
Colicky pain
Usually periumbilical or supraumbilical
Poorly localized
As the intestine becomes progressively dilated with loss of muscular tone, pain may become steadier and less colicky.
With superimposed strangulating obstruction, pain may spread to the lower lumbar region if there istraction on the root of the mesentery.
Colonic obstruction
Colicky pain of lesser intensity than that of the small intestine
Often located in infraumbilical area
Lumbar radiation is common.
Acute distention of the gallbladder (cholecystitis)
Steady rather than colicky pain; the term
biliary colic
is misleading.
Usually felt in the right upper quadrant with radiation to the right posterior region of the thorax or thetip of right scapula
Acute distention of the common bile duct (typically from choledocholithiasis)
Often felt in the epigastrium with radiation to the upper part of the lumbar region
Differentiation between common bile duct pain and acute distention of the gallbladder may beimpossible; in either condition, typical patterns of radiation are frequently absent.
Gradual dilatation of the biliary tree (e.g., carcinoma of head of pancreas)
May cause no pain or only a mild aching sensation in the epigastrium or right upper quadrant
Acute inflammation of the biliary tree (acute cholangitis)
Sharp, cutting, or gnawing right upper quadrant or epigastric pain, often radiating to the right shoulder or interscapular region of the back 
Usually accompanied by fever (89%) and jaundice (60%); called Charcot’s triad
In suppurative acute cholangitis, confusion and hypotension may be present as well as Charcot’s triad(making Reynolds’s pentad).
Distention of the pancreatic ducts
Pain is similar to that of distention of the common bile duct.
Very frequently accentuated by recumbency and relieved by upright position
Obstruction of the urinary bladder 
Dull suprapubic pain, usually low in intensity
Restlessness without specific complaint of pain may be the only sign of a distended bladder in anobtunded patient.
Acute obstruction of the intravesicular portion of ureter 
Severe suprapubic and flank pain that radiates to the penis, scrotum, or inner aspect of upper thigh
Obstruction of the ureteropelvic junction
Pain in costovertebral angle
Obstruction of remainder of the ureter 
Flank pain that often extends into the same side of abdomen
Vascular disturbances
Pain is not always sudden or catastrophic.
Embolism or thrombosis of the superior mesenteric artery or impending rupture of an abdominal aorticaneurysm
Pain may be severe and diffuse (poorly localized).
Occlusion of the superior mesenteric artery
Pain may be mild, continuous, and diffuse for 2 or 3 days before vascular collapse or findings of  peritoneal inflammation appear, or severe and diffuse.
Early, insignificant discomfort is caused by hyperperistalsis rather than peritoneal inflammation.
Absence of tenderness and rigidity in the presence of continuous, diffuse pain is characteristic of vascular disease.
Rupturing abdominal aortic aneurysm
Abdominal pain with radiation to the sacral region, flank, or genitalia
Pain may persist over several days before rupture and collapse occur.
Abdominal wall pain
Usually constant and aching
Movement, prolonged standing, and pressure accentuate discomfort and muscle spasm.
Hematoma of rectus sheath
Occurs most often in patients on anticoagulant therapy
A mass may be present in the lower quadrants of abdomen.
Simultaneous involvement of muscles in other parts of body usually differentiates myositis of theabdominal wall from an intraabdominal process.
Referred pain in abdominal diseases
Referred pain of thoracic origin
Frequently accompanied by splinting of the involved hemithorax with respiratory lag (i.e., defined as anasymmetric expansion of the lungs on inspiration; it can signify splinting of muscles related to intrapleural or intraabdominal pain or intrathoracic disease such as pneumothorax or massive atelectasis) and decrease inexcursion, often more marked than that seen in intraabdominal disease
Diaphragmatic pleuritis from pneumonia or pulmonary infarction
May cause pain in the right upper quadrant or supraclavicular area
Apparent abdominal muscle spasm caused by referred pain
When caused by referred pain, spasm diminishes during inspiration.
Spasm is present during both inspiration and expiration when pain is of abdominal origin.
Palpation over the area of referred pain in the abdomen rarely accentuates the pain; in some cases may relieve it.
Referred pain from spine
Usually involves compression or irritation of nerve roots
Characteristically is intensified by certain motions (e.g., cough, sneeze, strain)
Associated with hyperesthesia over involved dermatomes
Referred pain from the testicles or seminal vesicles
Dull aching pain
Poorly localized
Generally accentuated by the slightest pressure on the testicles or seminal vesicles
Metabolic abdominal crises

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