ABDOMINAL PAIN

Inflammation Perforation Obstruction Hemorrhage Torsion (ischemia) Most common: appendicitis, colic, mesenteric adenitis International: non specific, appendicitis, cholecystitis Small bowel obstruction severe colicky midline umbilical abdominal pain- vomiting- distension Large bowel obstruction midline lower abdominal pain- distension- vomiting

Red flags: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. collapsing@ toilet light headedness progressive intractable vomiting progressive abdominal distension progressive intensity of pain prostration pallor and sweating hypotension AF or tachy Fever Rebound tenderness and guarding Decreased urine output

Guarding indicates peritonitis Rebound peritoneal irritation Finger pointing sign focal peritoneal irritation Spread palm sign- visceral pain Hypertympany mechanical obstruction Causes of silent abdomen 1. Diffuse sepsis

8. tension on mesentery or blood vessels diffuse and poorly localised Parietal peritoneal Nociceptors.not true colic Visceral mechano-receptor. 9. Advanced mechanical obstruction Porphobilinogen : porphyria (add Ehrlich s aldehyde reagent) Abdominal x-ray: 1. 7.appendicitis Sentinel loop of gas in left upper quadrant acute pancreatitis Upper abdominal pain= upper GIT lesions Lower abdominal pain= lower GIT lesions Early severe vomiting= high obstruction of the GIT Pain-anorexia-nausea. 3. Kidney/ureteric stones. thermal and chemical stimuli pain directly at the site of insult Infantile colic y y y y y y 2-16 weeks (worst @ 10) Prolonged crying =at least 3 hours Late afternoon and early evening At least 3 days a week Child flexing legs and clenching fist Normal PE .triggered by intestinal distenstion. 6.bowel obstruction Enlarged cecum .true colic Biliary and kidney.70% opaque Biliary stones 10-30% opaque Air in biliary tree Calcified aortic aneurysm Marked distension sigmoid. 4.large bowel obstruction Blurred right psoas shadow. 5. Ileus 3.2.sigmoid volvulus Distended bowel with fluid level.vomiting= appendix Colicky pain ( rhythmic pain with regular spasms of recurring pain building to a climax and fading intestinal obstruction Ureteric colic.mechanical. 2.

nausea. anxious. unwell Sudden onset of severe colicky abdominal pain with shrill cry 15 mins intervals Last 2-3 mins Sausage shaped mass in RUQ anywhere between the line of colon and umbilicus Due to telescoping of the segment of bowel into the adjoining distal segment ( ileocecal segment) Intestinal obstruction Signe de dance (emptiness in RIF to palpation) Alternating high-pitched active bowel sounds with absent sounds Rectal + blood Male > Female Vomiting Lethargy Pallor with attacks Intestinal bleeding: redcurrant jelly 60% Dx: ultrasound or oxygen or barium enerma Tx: hydrostatic reduction by air or oxygen from the wall supply or barium enema.Intussusception pale + sever colic + vomiting y y y y y y y y y y y y y y y y y y 3 months -2 yrs (6-12 mos) Pale. surgery Acute appendicitis Older Midline Shifting to R uncommon ++ 80% 20% + Usually pale No or Inc Tender in RIF Guarding + rigidity Invariably tender Usually + Mesenteric Adenitis younger RIF Can be midline Invariable : URTI to tonsillitis + Typical child Site of onset of pain Preceding respiratory illness Anorexia. vomiting vomiting diarrhea fever colour temperature Abdominal palpation Rectal examination Psoas and obturator tests Flushed: malar flush high Tender in RIF Minimal guarding Usually no rigidity Often tender but lesser degree Usually - Recurrent abdominal pain (RAP) y y 3 distinct episodes of abdominal pain over 3 or more months Occurs in 10% of school-aged children .

Plain X-ray Abdominal aortic aneurysm (AAA) y y y y y y y Ultrasound screening advisable in first-degree relatives > 50 Normal diameter.10-30 mm Aneurysm.just above umbilicus. ESR.Organic RAP Pain is other than periumbilical Pain radiates rather than remains localised Pain is accompanied by vomiting Pain wakens the child from sleep Failure to thrive Child not completely well bet attacks Wt loss Non-organic RAP Acute and frequent colicky abdominal pain Pain localised to or just above umbilicus No radiation of pain Pain less than 60 mins Nausea frequent vomiting rare Diurnal ( never wakes the child @ night) Minimal umbilical tenderness Anxious child Obsessive or perfectionist personality One or both parents intense about child s health and progress Causes: y y y y Constipation Childhood migraine Lactose intolerance Instestinal parasites ( may disturb child about 60 mins after falling asleep) Inv: Urine MCS.>30 mm If >50 operate Patency of Dacron graft after 5 yrs.95% Ruptured AAA (RAAA). FBC.intense pain + pale and shocked + back pain IV access for plasma expanding fluid and MAST(Medical Anti-Shock Trousers) Mesenteric arterial occlusion anxiety and prostration + intense abdominal central pain + profuse vomiting + bloody diarrhea y y y y y y y y Occlusion of superior mesenteric artery Due to embolus/thrombosis Atherosclerotic artery or AF High CRP/ Intestinal alkaline phosphatise X-ray : thumb printing due to mucosal edema on gas-filled bowel CT scan Mesenteric arteriography if embolus is suspected Usually diagnosed @ laparotomy Acute retention of urine Fecal impaction .

intusussception. tender Xray: stepladder fluid levels in 3-4 hours Gastrografin follow through (don t give it in a virgin abdomen).esp on Left side Diverticulitis .foreign body. malignancy) Severe colicky epigastric and periumbilical pain Spasms -1 minute duration.Acute appendicitis y y y y y y y y y y y y Furred tongue and halitosis Tenderness @ McBUrney s point (RIF) Local rigidity and rebound tenderness Guarding + superficial hyperaesthesia + psoas sign pain on resisted flexion of right leg. blurred psoas shadow and fluid level in cecum Ultrasound thickened appendix. on hip extension or on elevating right leg ( due to irritation of psoas especillay with rectocecal appendix) + obturator sign pain on flexing patient s right thigh @ the hip with the knee bent and then internally rotating the hip ( due to irritation of internal obturator muscle)-pelvic appendix + Rovsings sign tenderness in RIF while palpating LIF PR: anterior tenderness to the R. decompression with nasogastric tube Laparotomy or hernia repair Large bowel obstruction. Lumen obstruction. hernia. esp if pelvic appendicitis or pelvic peritonitis Plain x-ray: local distension . loud borborygmi Abdomen soft Tender when distended Increased sharp tinkling bowel sounds Dehydration Empty rectum.colicky pain + distension + vomiting y y Colon CA (75%). every 3-10 mins Vomiting Absolute constipation No flatus Abdominal distension Weak and sitting forward in distress Visible peristalsis.can cause severe diarrhea and may be therapeutic in adhesive obstruction IV fluids. trichobezoar.80-90% accurate CT/laparoscopy Small bowel obstruction colicky central pain + vomiting + distension y y y y y y y y y y y y y y y y y y y y The more proximal the obstruction the more severe the pain Outside obstruction adhesions. gallstones.

bp normal @ first Tachy (later) and shock later (3-4 hrs) .pseudo-obstruction of the colon Sudden onset colicky pain Spasm < 1 min Hypogastric midline pain Absent vomiting Constipation/no flatus Increased bowel sounds Distension early and marked Local tenderness and rigidity PR: empty rectum X-ray : distension of large bowel with separation of haustral marking .y y y y y y y y y y y y y y y Volvulus of the sigmoid colon (10%) and cecum Constipation Ogilvie s syndrome. sweating or ashen @ first Board.common late symptom Patient lies quietly (pain agg by movement and cough) Pale. grey sweaty + deceptive improvement y y y y y y y y y y y y y y y y y y y y y 45-55 yrs old Males > F DU > GU 3 stages o Prostration o Reaction (2-6 hrs) symptoms improve o Peritonitis (6-12 hrs) Sudden onset severe epigastric pain Continuous pain but lessens for a few hours Epigastric pain at first. esp cecal distension Sigmoid volvulus shows a distended loop Gastrografin enema confirms diagnosis Perforated peptic ulcer sudden severe pain + anxious. and then generalized to whole abdomen Pain may radiate to one or both shoulders or RID Delayed N and V Hiccup. temp. still.like rigidity Guarding Max signs @ point of perforation No abdominal distension Contraction of abdomen (forms a shelf over lower chest) Reduced bowel sounds (silent abd) Shifting dullness Pulse.

UTI Fever + ureteric colic obstructed infected kidney Incidence is inversely proportional to fibre intake Proportional to ingestion of animal protein and low urinary volume Formed from urinary supersaturation with calcium ( calcium oxalate 75-80%) Uric acid (7%) Cysteine Infected (struvite). level of obstruction. hyperoxaluria. abn Ultrasound.locate calculus.intense loin pain groin. hypercalcemia. thigh. NH4. 96% specificity).cold.will show easily missed radiolucent uric-acid stones Tx: morphine 15 mg IM or 10 mg IV and metoclopramide 10 mg IM or hyoscine 20 mg IM Avoid high fluid intake =provokes distension of ureter and aggravates pain Indomethacin suppositories Diclofenac 75 mg IM then 50 mg TDS for 1 week Ketoralac If < 5 mm may pass spontaneously If > 5 mm lithotripsy Find the cause of stones. exclude obstruction Non contrast spiral CT gold standard (97% sensitivity . testicle or labia < 8 hours duration + vomiting Patient restless Pale. PO4 (5%) Phony colic use ketoralac (Toradol) 10-30 mg IM or indomethacin suppository .microscopic hematuria y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y Loin pain stone in kidney Kidney/ureteric colic.hyperparathyroidism. clammy Tenderness @ CVA + abdominal and back muscle spasm Smoky urine due to hematuria Dipstick negative does not exclude calculus X-ray: radiopaque 75% (calcium oxalate and phosphate) IVP: confirms opacity.ureteric stone Stangury stone in bladder 30-50 yrs old Intense colicky pain in waves lasting 30 secs with 1-2 mins Begins in loin and radiates around the flank to the groin .y y y y Breathing is shallow and inhibited by pain PR: pelvic tenderness X-ray: chest free air under diapharagm (75%) need to sit upright for prior 15 mins Limited gastrografin meal can confirm Ureteric colic.Mg. kidney function .

fair. klebsiella. amox/ampi 1 g IV6 hourly + gentamicin 4-6 mg/kg IV daily . forty.Biliary pain severe pain + vomiting + pain radiation y y y y y y y y y y y y y y y y y y y y y 2 main types : cholesterol or pigment (bilirubin) female.coli. fat. restless . epig Radiate to tip of R shoulder or scapula Painful episode builds to crescendo for about 20 mins Relief by assuming flexed posture + N and V with retching Ppt by fatty meal Anxious. IV fluids. Localised tenderness (Murphy s ) over fundus of GB (on transpyloric plane) Slight rigidity Ultrasound/DIDA CT IV cholangiography if previous cholecystectomy Elevated bilirubin and alk phos Morphine 10-15 mg IM + hyoscine 20 mg IM or oral Lithotripsy . cholecystectomy Acute cholecystitis y y y y y y y y y y y y y y y y Aerobic bowel flora E. fertile acute onset severe pain post prandial or @ night (often wakes 2-3 am) constant pain (not colicky) 20 mins 2-6 hrs Max RUQ . enterococcus fecalis Steady severe pain and tenderness Localised to R hypochondrium or epigastrium N and V (bile) in 75% Agg by deep insp Patient tends to lie still Localised tenderness over GB ( + murphys) Muscle guarding Rebound tenderness Palpable GB (15%) Jaundice (15%) +fever Ultrasound HIDA scan WBC and CRP Bed rest.

tachy High WBC High amylase. guarding. ESR Pus and blood in stools Ultrasound/CT Chest x-ray Abd x-ray Amox + clavulanate 500 mg TDS for 5-7 days or metronidazole + cephalexin Ampi 2 g IV 6 hourly + gentamycin 5-7 mg /kg IV/day + Metronidazole 500 mg IV 12 hourly or metro + ceftiaxone 1 g IV/day Peritonitis . CRP.Acute Pancreatitis. anxious Epig tender Lack of guarding. rigidity Fever Inflamm mass in LIF High WBC. rigidity or rebound Reduced BS + distension Fever . glucose Low calcium X-ray: sentinel loop CT Ultrasound Chronic panc Acute diverticulitis.severe pain + N and V + relative lack of abdominal signs y y y y y y y y y y y y y y y y y y y Alcoholism (35%) Gallstone dse (40-50%) Sudden onset of severe constant epig pain Last hours or a day Pain radiate to back N and V Sweating and weakness Pale.acute pain + left sided radiation + fever y y y y y y y y y y y y y y y y y Over 40 yrs old Long-standing grumbling left-sided abdominal pain and constipation Irregular bowel habit Acute onset of pain in the left iliac fossa Pain increased with walking and change of position Asso with constipation Tenderness.

Amox/ampi + genta + Metro Abdominal Stitch = sharp stabbing pain in the epigastric or hypochondrium during running Chronic or recurrent abdominal pain Ultrasound single most useful screening test Endoscopy CT Laparoscopy Red flags for organic dise y y y y y y y y y Older patient Nocturnal pain or diarrhea Progressive symptoms Rectal bleeding Fever Anaemia Wt loss Abdominal mass Fecal incontinence or urgency Chronic appendicitis Adhesions Irritable bowel syndrome at least 3 mos of continuous or recurrent y y y y Cramping pain (relieved by defecation) Central or left lower quadrant pain Mucus in stool Altered stool form or passage Peptic ulcer y y y y y y Central /epigastric Burning Relieved by antacids/food or milk DU : 2-3 hours after meals or wakes from sleep GU: may occur after meals but inconsistent relationship to eating .

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