Gastrointestinal system：

Section2：Main symptoms and signs of common abdominal diseases

The Second Clinical Teaching and Research Department of CQMU Yang YingXue
Abdominal pain
Visceral sensation
• Normal visceral sensation: for the most part, is not consciously
perceived, except for sensation such as hunger and rectal
distention .

Abnormal visceral sensation: however, is perceived as diffuse pain.

Characteristic of the abdominal pain

uVisceral Pain内脏痛：Colicky，cramping，poorly localized type of pain

Visceral peritoneum has no somatic nerve supply, and pain is poorly
localized.

u Parietal Pain体壁痛：Sharp, localized pain

parietal peritoneum shares somatic innervation with the abdominal
wall. Thus the pain is localized.

u Referred Pain牵涉痛
 Characteristic of the abdominal pain
u Due to the differential innervation of viscera and the parietal
peritoneum, visceral pain results in cramping pain, whereas parietal
pain causes sharp pain.
u The pain fibers that originate in the viscera are transmitted via
autonomic nerves, mainly sympathetic, type C fibers, which only
transmit colicky, cramping, poorly localized types of pain.
u In contrast to the viscera and visceral peritoneum, the parietal
peritoneum is innervated by extensions of the peripheral spinal
nerves, which carry the same types of noxious pain sensations as
those overlying the dermatomes. Therefore parietal pain results in
sharp, localized pain.
 Characteristic of the abdominal pain

u 牵涉痛(放射痛referred pain)：
Many organs have an embrylogic origination in one location and then
migrate to another area, pulling their vascular and nervous supply with
them. Thus, visceral pain is often referred to the site of embryologic
origin rather than the actual location of the organ.
Location of pain referred from major
abdominal and thoracic organs
Embryology of the digestive
system
Foregut
Esophagus, stomach, duodenum proximal to the
bile duct, liver, pancreas, bile ducts, gallbladder
Midgut
duodenum distal to the bile duct, jejunum, ileum,
cecum, appendix, ascending colon, proximal
2/3 of transverse colon
Hindgut
Distal third of the transverse colon, descending
colon, sigmoid colon, rectum, upper portion of
the anal canal
Arterial supply and the nerve innervation of the GI tract

Foregut:

Blood supply :Celiac trunk

Nerve innervation：T5-T9
Arterial supply and the nerve innervation of the GI tract

Midgut

Blood supply ：superior

mesenteric arteries

Nerve innervation ：T8-L1

Arterial supply and the nerve innervation of the GI tract

Hindgut:

Blood supply ： Inferior

mesenteric arteries

Nerve innervation ：T11-L1

Surface projection of different parts:

Nerve innervation：
前
肠
T5-T9

中
T8-L1
肠

后肠 T11-L1
 Clinical classification of acute abdomen

1. Abdominal pain with shock

SHOCK Diffuse peritonitis
2. Diffuse peritonitis
Abdominal

3. Localized peritonitis pain

Localized peritonitis intestinal obstruction

4. intestinal obstruction

5.*other important medical acute abdomen*

Understand the pathology of clinical
manifestation:

Clinical manifestation+ the cause of the manifestation+the example of

the disease
1. Abdominal pain with shock

Clinical pain shock

manifestation

Sever abdominal pain Pale face、cold sweat

hypopressure
 1.Abdominal pain with shock
Intraperitoneal hemorrhage ： Rupture of
aortic aneurysm and ectopic pregnancy
Shock：
insufficient
circulating
capacity

Leakage of fluid into the "third cavity": acute

pancreatitis, acute mesenteric ischemia
 2.Diffuse peritonitis

Cause：

Chemical stimulation l Rupture of ulcer

fatigue Rupture of hollow l Rupture of colon
Clinical viscera： l Rupture of appendix
manifestation
Severe and
diffuse
abdominal
pain acute pancreatitis

Board-like rigidity： The typical manifestation of the patient is unwilling to move in the lying position and
severe abdominal tenderness
 3.Localized peritonitis Localization of
peritonitis

cause：
RUQ LUQ
Clinical Pain limited to Local stimulates of a specific
one quadrant
manifestation organ
RLQ LLQ
2.Localized peritonitis
Localization of
peritonitis

Acute hepatobiliary RUQ LUQ ❌�

inflammation

Acute appendicitis, ileocecal RLQ LLQ

inflammation, tumor Acute diverticulitis
Female: gynecological acute Female: gynecological
abdomen acute abdomen
 Summary : Acute peritonitis
• Cause: bacterium, chemical substance such as pancreatic secretion
• Classification:
Ø diffuse or local
Ø secondary or primary
Øinfectious or aseptic
 Summary : Acute peritonitis

• Symptoms abrupt severe lasting pain in upper abdomen, becoming more severe
when deep breathing, coughing, changing positions vomitting ; fever; decreased blood
pressure; shock sign.

Sign:
1.inspection: abdominal movement disappearing; sometimes abdominal bulge seen
2.palpation: peritonitis trilogy -- rigidity of abdominal wall , tenderness ，rebound
tenderness
3.percussion: liver dullness area lessen or disappearing, shifting dullness
4.auscultation: bowel sound lessen or disappearing
 4.intestinal obstruction

Clinical Cramping pain near the umbilicus

manifestation Fullness, failure of stool and gas pass, vomiting
4.intestinal obstruction

Small intestinal obstruction or colonic obstruction?

Prominent symptoms： vomiting ? abdominal distention?

intestinal colonic

vomiting +cramping pain Constipation + abdominal

distension
4.Intestinal obstruction

• Classification:
• 1.mechanical: intestine adhesion, volvulus 肠扭转,intussusception 肠套叠
• 2. dynamic: paralytic or spasmic such as hypokalemia, acute peritonitis
• 3. hematogenous: embolism or thrombosis of mesenteric vessel

• Other classification:
1.simple or strangulated

2.complete or incomplete
3.acute or chronic
4.Intestinal obstruction

• Symptoms abdominal pain, vomitting, stopping defecation and

exhaust, abdominal distention
• Signs:
Inspection abdominal bulge, intestine pattern, peristalsis
Palpation: abdominal muscle tense, tenderness, or sometimes rebound
tenderness
Percution: increased tympany or shifting dullness
Ausculation: bowel sound: hyperactive with high pitch or
decreased or absent
4.Intestinal obstruction

• ◼ Cause:
1.inflammation: hepatitis, appendix abscess ileocecus tuberculosis, et al
2.tumor: hepatic carcinoma, gastric cancer, colon cancer, et al
3.obstruction: pyloric obstruction, intussusception, nephrohydros , et al
4.primary: liver cyst
5.parasite diseases: hepatic echinococcosis肝包虫病, intestinal
roundworm disease 肠蛔虫症
other: fatty liver, lipoma, hernia of abdominal wall, et al
4.intestinal obstruction
Four classic traps of small intestinal obstruction

The elderly and obese women without Incarcerated femoral

previous abdominal surgery showed small hernia
intestinal obstruction
"Simple" adhesive small bowel obstruction in Right colon tumor
the elderly

Repeated "remission and recurrence" of Cholelithic small

"incomplete" small intestinal obstruction in intestinal obstruction
elderly women
Recurrent obstruction in patients with Terminal ileal
previous gastric surgery gastrolith
5.other important medical acute abdomen

u Inferior myocardial infarction

u Diabetic ketoacidosis

u Severe acute pancreatitis

Examples of common diseases
• 1.Peptic ulcer
• 2. Liver cirrhosis
• 3. Acute appendicitis
• 4. Acute pancreatitis
• 5. Abdominal mass
1.Peptic ulcer

• Ulcer: defect more than mucosal muscularis (unlike the erosion)

• Common types: gastric ulcer, duodenal ulcer

1.Peptic ulcer

• Pain
• 1) location ：middle upper abdomen, below the xiphoid 2) quality: not
specific; blunt, bloating, burning like, et al
• 3) chronic, cyclical, rhythmical
• 4) inducible and relieving factors: fatigue, anxiety, diet/rest, acid inhibitor

• Other symptoms regurgitation, heart burn, nausea, vomitting , loss of

appetite
 1.Peptic ulcer
• Sign: no specific signs, such as tenderness on upper abdomen, pale
• Complications:
• bleeding : hematemesis, melena
• perforation ：severe pain, boar like rigidity, tenderness, rebound
tenderness, lessen or disappearance of liver dullness area and bowel sound
• pyloric obstruction : vomiting a mount of digestive food, gastric pattern
or gastrointestinal peristalsis succussion splash
• cancerous : gastric ulcer
1.Peptic ulcer
1.Peptic ulcer
Most common characteristics of peptic ulcer

Gastric ulcer Duodenal ulcer

percentage 25％ 75％
Common causes Hp(~80％),NSAIDs use Hp(90~95％),NSAIDs use
Presenting symptoms Pain with food Pain 2~3h after meals and relived
by food
complications Perforation, bleeding, malignancy, Perforation, bleeding, malignancy,
Gastric outlet obstruction Gastric outlet obstruction.
pancreatitis
malignancy 10％ Rare
location Type-dependent; typically lesser First portion of duodenum
curvature
2.Liver cirrhosis
• Common end of various hepatic damages.
• Cause: virus, chronic alcohol, metabolic disfunction, et al.
• Stages: compensatory and uncompensatory
Type of cirrhosis causes
Infection Viral hepatitis, brucellosis, capilariasis,
echinococcosis, schistosomiasis
Inherited/metabolic disorders AAT, Alagille syndrome, billary atresia, Fanconi
syndrome, hemochromatosis, Wilson disease,
glycogen storage disease
Drugs/toxins Alcohol, amiodarone, arsenic, oral contraceptive
pills
others Heart failure with long-standing congestion of the
liver, biliary obstruction, graft-versus-host-disease,
Nonalcoholic steatohepatitis(NASH), primary
sclerosing cholangitis, sarcoidosis
2.Liver cirrhosis

• Compensation:
• Symptoms: nonspecific, some dyspepsia symptoms, such as nause,
poor appettide, abdominal distention
• Signs: slight hepatomegaly and splenomegaly
2.Liver cirrhosis

• Decompensation:
• Hypohepatia(肝功能减损)
• Portal hypertension ( 门静脉高压)
 2.Liver cirrhosis
two main manifestation Hypohepatia+ Portal hypertension

• General: fatigue, weight loss, fever, liver face, edema

Digestive: poor appetite, anorexia nausea, vomiting , diarrhea
• Hemorrhagic tendency and anemia: ecchymosis, petechia, epistaxis( 鼻衄) errhysis of gum,
hypermenorrhea, anemia
• Endocrinal disorder: liver face, liver palm肝掌, spider nevus蜘蛛痣, gynecomastia 男性乳房发育
• Jaundice
2.Liver cirrhosis
two main manifestation Hypohepatia+ Portal hypertension

• Ascites frog belly, umbilical hernia, shifting dullness, edema of lower

extremities
• Collateral circulation gastrointestinal hemorrhage (hematemesis,
melena), hepatic coma.
Ø esophageal and gastric varices
Ø subcutaneous varices of abdominal wall
Ø hemorrhoid varicosity
Splenomegaly hypersplenism (pancytopenia)
3.Acute appendicitis

• Symptoms shifting right lower abdominal pain , vomitting, diarrhea,

fever
Signs tenderness and rebound tenderness in McBurney point
Rovsing sign 结肠充气证 right hand pressurizeding the
descending colon area, left hand pressing the upper part repeatedly, pain of
lower right abdomen being felt;
local peritonitis when perforation; masses when
abscess formation
 3.Acute appendicitis
shifting right lower abdominal pain
Appendicitis begins as dull, aching, cramping(visceral) periumbilical
pain(approximately in the T10 dermatome)

Once the appendiceal inflammation becomes transmural, the parietal

peritoneum become inflamed, resulting in sharp pain localized in the
area directly over the appendix(McBurney point)
4.Acute pancreatitis
• Caused by activation of pancreatic enzymes, which leads to
pancreatic autodigestion with liquefactive hemorrhagic necrosis
and fat necrosis of the pancreas.

• Presentation
classically presents as sudden onset epigastric abdominal pain
radiating to the back and flanks accompanied by anorexia and
nausea. May occur following a large meal or drinking binge.
4.Acute pancreatitis
Causes of acute pancreatitis—I GET SMASHED
I Idiopathic
G Gallstones
E Ethanol
T Trauma
S Steroids
M Mumps
A Autoimmune disease
S Scorpion sting
H Hypercalcemia/Hyperlipidemia
E ERCP
D drugs
4.Acute pancreatitis

• Morphine may cause spasm of the sphincter of oddi and worsen

the pain
• Meperidine is the preferred analgesic for treating the pain of
acute pancreatitis because it dose not cause spasm of the
sphincter of oddi .
5.Abdominal mass

• When you consider a mass, you should pay attention:

• Accompany symptoms
• Location: abdominal wall, abdominal cavity or retroperitoneal
• Size, shape, quality, tenderness, mobility, pulsation, thrill and number
5.Abdominal mass
• Colon cancer
1.left-sided(sigmoid)colon cancer:
Early symptoms of obstruction(the left side had a narrower lemen)
Tumor produce a “napkin-ring” or “apple-core” constrition
(encircling annular growth)

apple-core
5.Abdominal mass
• Colon cancer
2.Right-sided colon cancer:
anemia, weight loss, and abdominal pain.
stool is watery in the right colon, thus, obstruction seldom occurs.

• Either side :
• Stool changes or hematochezia
• Abdominal discomfort
• Constitutional symptoms such as weight loss
• Unexplained anemia in men and postmenopausal women—think colon cancer.
• Higher incidence of streptococcus bovis endocarditis
5.Abdominal mass
• Pancreatic adenocarcinoma
• Pancreatic adenocarcinoma is a malignancy of the exocrine
portion of the pancreas; it is one of the most deadly cancers(5-y
survival rate＜5％)
• Risk factors: age, smoking, family history, and chronic pancreatitis
associated with alcohol abuse.

Presentation: tumor are located in the head of the pancreas 75 ％of

the time, giving the classic presentation of painless obstructive
jaundice, and are silent until late in disease progression.
5.Abdominal mass

• Pancreatic adenocarcinoma
• The tumor marker is the CA19-9, it can not be used for screening,
but can be used to monitor progression of the disease.
 5.Abdominal mass
• Hepatic tumor
Hepatic tumor
Benign tumor Hepatic adenoma(HA)
Primarily in the right lobe and ophen
large(＞10cm)
Clinic: pain, palpable mass, signs of
intratumor hemorrhage
Malignant tumor Hepatocellular carcinoma(HCC)
Is one of the most common tumors in
the world, with the highest prevalence in
Asia and sub-Saharan Africa due to the
high prevalence of hepatitis B and C
Clinic: similar to chronic liver disease;
pain or mass in the RUQ. AFP elevated
Focal nodular hyperplasia (FNH)
Generally asymptomatic and incidental finding
on imaging studies as a solid tumor in the right
lobe consisting of a fibrous core with stellate
projections.
Metastatic tumor
In US is 20 times greater than HCC. The most
common metastases include tumors from Gitract,
the lung, the breast, and the melanoma.
Colon ＞Stomach＞ Pancreas ＞Breast ＞Lung
(Cancer Sometimes Penetrates Benign Liver)
Thanks！