Abdominal Pain 2023 with complete solution

Somatic vs Visceral Abdominal Pain Somatic Pain -originates from the abdominal wall and parietal peritoneum -associated with A-fibers (fast fibers, sharp pain) AND C-fibers (slow fibers, dull achey pain) -SHARPER MORE DISTINCT PAIN that is usually better LOCALIZED Visceral Pain -originates from internal organs and visceral peritoneum -associated with C-fibers only -VARIABLE LOCATION AND SENSATION -is NOT sensitive to cutting, tearing, burning, or crushing -is sensitive to stretching of walls of hollow organs or of the capsule of solid organs Major Causes of Acute Abdominal Pain Inflammation: -appendicitis -cholecystitis -pancreatitis -diverticulitis Perforation Obstruction Vascular Problems: -AAA -Ischemic Bowel Syndrome (more often in elderly who have greater risk of atherosclerosis or A-fib producing clots) Major Causes of Chronic Abdominal Pain Inflammation: -peptic ulcer -esophagitis -inflammatory bowel disease -chronic pancreatitis Vascular Causes: -chronic ischemia Metabolic Causes -diabetes -porphyria Abdominal Wall Pain -neurogenic -musculoskeletal Functional Causes -dyspepsia -irritable bowel syndrome Chronic Benign Abdominal Pain Syndrome History in Abdominal Pain onset location duration associated signs and symptoms characteristics of pain alleviating and aggravating factors radiation treatments severity (OLD ASS CARTS) determine past medical history, coexistent disease, past surgical history, look for similar past symptoms, medications, and social history Types of Pain that May Clue Diagnosis Perforated Viscous (perforated appendix) often described as INTENSE but may also be pain relief bc pressure building is relieved Dissecting Aneurysm often described as TEARING or ripping or crushing, often midthoracic back pain Acute pain often indicates more severe problem Chronic pain often indicates less severe problem Irritable Bowel or Dyspepsia is often described as dull constant pain Chronic Peptic Ulcer often described as gnawing or hunger pain Patterns of Pain in Acute Abdominal Conditions Appendicitis -begins diffusely in epigastric, general, or pelvic region THEN moves to sharp pain in RLQ Perforated Peptic Ulcer -begins as pain and tenderness in periumbilical region and then moves outwards Acute Cholecystitis -begins as RUQ pain then radiates to R shoulder/back Acute Obstruction to Bowel's Blood Supply -periumbilical pain moves outwards as diffuse pain Acute Pancreatitis -remains as periumbilical/epigastric pain and tenderness Acute Sigmoidal Diverticulitis -begins as diffuse periumbilical/pelvic pain that moves to sharp LLQ pain Basics of the Physical Exam for Abdominal Pain important to OBSERVE pt for their pain expression writhing, unable to find a position of comfort often indicates bowel obstruction (especially if guarding, hypertonicity of bowel sounds, and distention also) avoiding any motion with knees flexed may indicate peritonitis abdominal distention often indicates obstruction or ascites visual peristalsis may be a small bowel obstruction in its early stages focal areas of distention may indicate a hernia look for scars from previous surgery! Abdominal Auscultation always do auscultation FIRST for physical performed in all 4 quadrants to evaluate timber and pattern of bowel sounds and to search for bruits ABSENCE of bowel sounds indicates ileus (lack of motility/decrease peristalsis) HYPERACTIVE bowel sounds indicates obstruction (mechanical) multiple bruits should alert to possibility of significant vascular disease suggesting ischemia Abdominal Palpation should be gentle initially in an area away from pain -then add pressure and look for areas of localized tenderness and rebound look for masses and enlarged organs (determine degree of severity) check for guarding, rebound, rigidity (often indicates acute abdomen = surgical abdomen) rectal exam important for identifying rectal tumor in case of colon obstruction, GI bleeding, or tenderness high in rectum seen in acute appendicitis pelvic exam must be performed on ALL women of child bearing age presenting with abdominal pain (rule out PID, ovarian masses, etc) look for pulsatile mass (AAA) look for flank pain (kidney problems) Abdominal Percussion percussion is performed to identify size of organs also used to determine the presence of ascites pain upon percussion may indicate peritoneal reaction or inflammation (same as severe rebound tenderness) Acute Abdomen acute abdomen = surgical abdomen GUARDING, REBOUND, RIGIDITY are often your biggest indicators of an acute abdomen but also refers to intense, severe pain that may represent a surgical emergency caused by sudden inflammation, perforation, obstruction, or infarction of various intra-abdominal organs sudden crampy pain with abdominal distention may indicate OBSTRUCTION caused by a hernia or adhesions be aware of extra-abdominal conditions presenting with severe abdominal pain such as MI, nephrolithiasis, pneumonia, and metabolic disorders Laboratory Work Up in Abdominal Pain CBC with diff: remember generally the higher the WBC the sicker the pt HOWEVER a normal WBC does NOT rule out a disease state UA Amylase (elevated may indicate pancreatitis) Lipase Bilirubin Electrolytes Cardiac Enzymes (possibly) Imaging in Abdominal Pain plain abdominal X-rays often only show gas patterns, ileus, or an obstruction (otherwise not super helpful) Upright Abdominal Xray can reveal intra-abdominal air or obstruction Ultrasound helpful for identifying gallbladder disease or an appendicitis, or gynecologic disease (ovarian cysts) CT may help to identify intra-abdominal abscess, diverticulitis, appendicitis, traumatic rupture of organs, or acute pancreatitis Chronic Abdominal Pain postprandial N/V suggests chronic peptic ulcer, disorders of gastric emptying, or outlet obstruction unexplained weight loss requires identification of cause such as inflammatory bowel disease, celiac disease, cancer if anorexia accompanies weight loss, esp. in elderly, cancer must be ruled out -if no cancer found and all other tests negative, consider chronic depression psychiatric evaluation may be necessary or possible pain management specialist Functional Abdominal Pain the most common cause of chronic abdominal pain (as opposed to an organic chronic pain) has no known cause; characterized by: Dyspepsia -chronic intermittent epigastric discomfort, sometimes accompanied by nausea or bloating Irritable Bowel Syndrome -very similar to functional abdominal pain (no known cause) -very common disorder; presents with distention, faltulence, and disordered bowel function -primarily LLQ pain but can be diffuse Benign Chronic Abdominal Pain condition that has been present for months or years tends to be more common in females pts have undergone multiple exams, studies, and even surgical procedures without diagnosis or relief difficult to manage may have depression but may also be an extremely rare disease, difficult to diagnose there is NO change in bowel habits (differs from IBS) Appendicitis Clinical Presentation an acute inflammatory disorder caused by obstruction of the lumen by fecalith to the appendix most common in 2nd and 3rd decades and in pregnancy begins as poorly localized epigastric or periumbilical pain described as achy but becomes more steady an increasing severity; when peritoneum becomes inflamed the pain becomes more localized to RLQ -but may also have RUQ or pelvic pain depending on location of the appendix (can move/rotate) often accompanied by N/V/anorexia McBurney's Point tenderness is classic (but a retrocecal appendix will have decreased mcburney point) positive guarding, rebound, rigidity with peritonitis Obturator Sign: pain upon rotating flexed hip in supine Psoas Sign: pain upon raising straightened leg against resistance Rovsings Sign: pressure to LLQ results in pain in RLQ fever may be slight but often only in advanced cases Appendicitis Diagnosis and Treatment leukocytosis may or may not be present plain film xray may or may not reveal fecalith abdominal CT with contrast is best diagnostic tool US has poor reliability often repeat exams for surgical evaluation surgical removal is only treatment for acutely ill pts surgical exploration is mandatory Differential Diagnosis of Appendicitis Mesenteric Adenitis -inflammatory process of mesenteric lymph nodes in RLQ caused by viral or bacterial infection -presents similar but often N/V PRIOR to pain PID, Ovarian Cysts, Ovarian Torsions Terminal Ileus Ectopic Pregnancy Hernia Intussusception -telescoping of proximal bowel into the distal bowel -crampy paroxysmal pains followed by periods of calm -emesis, palpable mass, currant jelly stools Meckels Diverticulitis -congenital pouch 2 inches long and located at distal end of small intestine, occurs around age 2 -usually asymptomatic or pain with rectal bleeding -preoperative diagnosis difficult or Technetium 99 scan -must be treated surgically Colonic Diverticulitis mucosal outpouchings that form throughout the entire colon but more commonly found in left colon and sigmoid results when a fecalith becomes impacted in a diverticulumwith erosion through the serosa resulting in perforation more common in pts age 50 typically presents with gradual onset of LLQ pain low grade fever and leukocytosis often associated CT is best diagnostic tool must be treated with IV Antibiotics for anaerobe and gram negative coverage, along with bowel rest and hydration with IV fluids, possible surgical consult