Abdominal Pain

Shouye Zhao
Hepatobiliary Sugery Department
Abstract

 Common presentation, 25%

 Difficult to diagnose
 Classification:
acute
chronic
 Acute abdominal
pain
Etiology and pathogenesis
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
 Acute abdominal
pain
Etiology
Vascular
and pathogenesis
disturbances
embolism vascular rupture
Referred pain
pneumonia coronary occlusion
Abdominal wall
trauma
Metabolic and toxic causes
allergic factors
 Chronic abdominal
pain
Etiology and pathogenesis
 Chronic inflammation of abdominal organs

reflux esophagitis chronic ulcerative colitis

 Peptic ulcer
 Distention of visceral surfaces

 Metabolic and toxic causes uremia （尿毒症）

 Infiltration of tumor

 Neurogenic irritable colon neurosis

 Mechanisms of abdominal pain

 Visceral pain

 Somatic pain

 Referred 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
 Pain poorly localized

 Intermittent, cramp( 痉挛 ) or colicky （绞痛） pain

 Accompanied by nausea, vomitting and diaphoresis

 Somatic pain

 Stimuli occurs with irritation of parietal peritoneum

 Sensations conducted along peripheral nerves

which can localize pain better
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

 Pain felt at a distance from it’s source

 The nerves distribution and visceral organs are

listed below
The convergence-projection hypothesis of referred pain
 Clinical
 manifestation
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
 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）
 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
 Clinical
manifestation
 Provocation and relief
Acute gastritis and enteritis: eating unfresh or raw foods
vomiting or discharge
Peritoneum inflammation: accentuated by pressure
palpation movement coughing
IBS and constipation: relieved temporarily by bowel
movements
Obstruction: relieved temporarily by vomiting
Ulcer: eating or taking antacids
 Clinical
manifestation
Associated manifestations
Fever: inflammation
Jaundice: liver gallbladder pancreatic disease
Hematuria: renal stone
Diarrhea/rectal bleeding: intestinal causes
Diagnostic points
 P: provocative-palliative factors
 Q:quality
 R:region
 S:severity
 T:temporal characteristics
 Diagnostic points
Pain referred to the abdomen should be
differentiated
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
Question

 How to differentiate the feature of colicky pain

in these three abdominal diseases: intestinal
obstruction,biliary calculus and renal calculus
 Suggestion: location, associated symptoms
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 hematuria
groin, scrotum