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Abdominal pain

นพ.วิเชียร ศิริธนะพล พบ. วว.ศัลยศาสตร์ ท่ วไป ั อ.นพ ภาควิชาศัลยศาสตร์ มหาวิทยาลัยขอนแก่ น

The abdomen is like a stage

Enclosed within a fleshy cage Distension, rigidity, vomiting & pain

Surgical emergency cases in Srinagarind
(1998-1999)

Non traumatic case 1737(75%) Traumatic case 581(25%)

Total 2,318 cases

Non traumatic cases in Srinagarind
Acute abdomen 1037 (60%) Soft tissue infection 323 (17%) Vascular 89 (5%) KUB 127 (7%) Anorectal 68 (4%) Other 128 (7%)

100

Acute abdomen
Percent

50

Srinagarind hospital 1037 cases Khon Kaen hospital 6338 cases

0 Peritonitis Gut obstruction GI bleeding

100
Percent

Peritonitis
Srinagarind hospital 777 cases Khon Kaen hospital 4550 cases

50

0
dic itis ngi tis cys titi atio per f or Me d& pen o le ola Gy n s n

Ap

Ch

Ch

PU

Abdominal pain
• Anatomy
• Histology • Physiology • Pathology

Rectus abdominis

Tendinous intersection

Semilunar line Linea alba Umbilicus
(T10 dermatomes) (intervertebral disc L3-4)

Illiac creast (vertebra L4)

Median plane

Transumbilical

Midclavicular plane

Subcostal plane

Intertubercular plane

Type of abdominal pain
• Visceral pain • Somatic-parietal pain • Referred pain

Visceral pain
• Unmyelinated C fiber • Mesentery/mucosa of hollow viscus
• Poorly localized pain

• Dull aching/cramping/colicky/burning pain

Stomach-2nd duodenum Celiac trunk

2nd duodenum-2/3 transverse colon SMA

1/3 transverse colon-rectum IMA

Somatic-parietal pain
• Myelinated A-delta fibers • Skin/muscle/serosa /peritoneum • Well localized pain

Shifting pain

Referred pain
• Pain at a location other than the site of the painful stimulus • Diaphragm  shoulder/scapula

Kehr ʹ s sign

Clinical Evaluation
• History taking • Physical examination • Lab investigation • Radiologic imaging

History taking
• • • • • Onset of pain Site Duration & Interval of pain Character of pain Aggravating & Alleviating factors

History taking
• • • • Associated symptoms Pain radiation Gyne History Past history

a

Nature of Vomitus
• Clear

• Bile stained • Faeculent • Blood : hematemesis & coffee ground

Relationship of Vomiting
• High gut obstruction

: early, excessive
• Low gut obstruction

: late or absent with abdominal distension

Bowel movements
• color • consistency
currant jelly

clay colored

blood stained mucus

melena
slime

Intussusceptum

Intussuscipiens

Urine

Women
•Ectopic pregnancy • Pelvic inflammatory disease (PID) • Ruptured/ twisted ovarian cyst

Pain and menstrual cycle relationship & discharge

Physical Examination
• Must be complete • Must be repeated • Must be careful

Physical Examination
• • • • • • General appearance Distension Absence or Active Bowel Sound Guarding Rigidity Hyperaesthesia

Sometimes the tummy’like a drum & borborygmi go and come

Laboratory
• • • • • • CBC Urinalysis, UPT BUN, Creatinine Serum Electrolytes Serum Amylase Liver Function Test

Radiologic Imaging
• Acute abdomen series
– CXR – Abdomen supine – Abdomen upright

• Abdominal ultrasound

• CT abdomen

Extraluminal Air

Ruptured hollow viscus organ

Small bowel obstruction

Distal small bowel obstruction

Colonic Obstruction

Sigmoid Volvulus

Initial Imaging Test of Choice
CBD sludge collection Liver abscess

Ultrasonography

CT scan - Acute Abdomen
The best anatomical information

Retrocecal appendicitis

Acute pancreatitis

Subhepatic collection

Liver abscess

Acute Abdomen in the Tropic
• •
• •

Typhoid Fever Amoebiasis
Ascaris “Ball of Worm” Actinomicosis

Genetic disorders causing abdominal Pain
• Porphyria

• Sickle Cell Anaemia • Haemophelia • Vasculitis

Haemodynamically unstable caused by Peritonitis
• Hollow Viscus Perforation

• Prolonged Obstruction • Intestinal Ischaemia
• Urosepsis

Bowel Ischaemia
• Severe Symptoms

• Poorly Localized • Relatively minimal physical sign

Haemodynamically Unstable Acute Abdomen

AAA ?

Extra-abdominal cause of addominal pain
• Neurological Causes of Abdominal Pain
• HZV, nerve root

• Toxic substance ingestion
• • Alcohol crampy Abdominal Pain and diarrhea Lead colic


Endocrine
Glucocorticoid deficiency, hypercalcemia, DKA

Extra-abdominal cause of addominal pain
• Thoracic
• • • Esophagus : spasm, rupture (Boerhaave synd) Pleura : empyema, pneumothorax Lungs : pneumonitis, PE

• Cardiac
• CHF, MI, endocarditis


Hematologic
Acute leukemia, sickle cell anemia