CASE 6-14 BLOCK 2.4
Digestion and Defence II
4 APRIL 2017
MARIEKE DE JONG
ITM
,Case 6: Acute Abdominal Pain ≠ Acute Abdomen .................................................................................3
Acute Abdominal Pain .........................................................................................................................3
Parietal vs. Visceral Pain ......................................................................................................................4
Referred Pain .......................................................................................................................................4
Case 7: Stick It Up Your… Throat Gerd ...................................................................................................5
Dysphagia .............................................................................................................................................5
GERD ....................................................................................................................................................5
Barrett’s Metaplasia ............................................................................................................................5
Oesophageal Cancer ............................................................................................................................6
Case 8: Sitting Heavy on the Stomach ....................................................................................................7
Peptic Ulcer Disease ............................................................................................................................7
NSAIDs..................................................................................................................................................8
Endoscopy ............................................................................................................................................8
Case 9: No Guts, No Glory .......................................................................................................................9
Iron Metabolism ..................................................................................................................................9
Anaemia ...............................................................................................................................................9
Vitamin B12..........................................................................................................................................9
Bile Salts .............................................................................................................................................10
Steatorrhea ........................................................................................................................................10
Water Absorption ..............................................................................................................................10
Case 10: Foie Gras .................................................................................................................................11
Hepatitis .............................................................................................................................................11
Hepatitis A......................................................................................................................................11
Hepatitis B ......................................................................................................................................11
Hepatitis C ......................................................................................................................................12
Hepatitis D .....................................................................................................................................13
Hepatitis E ......................................................................................................................................13
Stages of Liver Damage ......................................................................................................................13
Diagnostics .........................................................................................................................................14
Case 11: Encore une Fois .......................................................................................................................15
Fibrosis and Cirrhosis .........................................................................................................................15
Complications ....................................................................................................................................15
Lactulose Treatment ..........................................................................................................................16
Korsakoff Syndrome vs. Hepatoencephaly ........................................................................................16
Portocaval Anastomosis ....................................................................................................................16
1
,Case 12: Four Shades of Yellow ............................................................................................................18
Jaundice .............................................................................................................................................18
Haemoglobin Breakdown ..................................................................................................................18
Gallstones + Cholecystitis ..................................................................................................................19
Haemolytic Anaemia ..........................................................................................................................19
Acute Pancreatitis ..............................................................................................................................19
Case 13: Abdominal Pain Again? See a Doctor! ...................................................................................21
IBS ......................................................................................................................................................21
IBD ......................................................................................................................................................22
Epidemiology .................................................................................................................................22
Pathophysiology ............................................................................................................................22
Diagnosis and Treatment ...............................................................................................................23
Case 14: Consumption ..........................................................................................................................24
Tuberculosis .......................................................................................................................................24
Etiology ..........................................................................................................................................24
Epidemiology .................................................................................................................................24
Pathophysiology ............................................................................................................................24
Symptoms and Clinical Features ....................................................................................................25
Prevention......................................................................................................................................25
Treatment ......................................................................................................................................26
MDR and XDR TB................................................................................................................................26
Bibliography ..........................................................................................................................................27
2
, Case 6: Acute Abdominal Pain ≠ Acute
Abdomen
Acute Abdominal Pain
An acute abdomen is a situation involving the abdomen where immediate intervention is necessary
to save the patient’s life. It does not always present with acute abdominal pain.
Important things to find out in acute abdominal pain:
- Age
- Timing/onset of pain
- Characteristics of pain
- Duration of symptoms
- Location/radiation to other sites
- Associated symptoms
- Nausea, emesis, anorexia
- Diarrhoea, constipation, changes in bowel habits
- Menstrual/obstetric history
Most common causes: acute appendicitis, nonspecific abdominal pain, urologic origin, intestinal
obstruction.
When the parietal peritoneum is inflamed, the pain is steady, aching and can be located because it is
transmitted by somatic nerves. When the irritation is caused by acidic or enzymatically active
material, pain is more severe. Blood and urine do not elicit major responses. Bacterial contamination
is also often mild. The rate at which the material enters the abdominal cavity also changes the
presentation.
Pain from peritoneal inflammation gets worse with pressure changes. There is also often passive
muscle guarding.
Obstruction of organs with a lumen leads to intermittent colicky pain that is difficult to localise. In
the small bowel, this is often peri- or supraumbilical. Colon pain is often infraumbilical, radiating to
the lumbar region.
Sudden distention of the biliary tree produces steady pain. Acute gallbladder disease causes pain in
the right upper quadrant, radiating to the right posterior thorax or to the midline. Pain caused by the
pancreatic ducts is often worsened by lying down and relieved by getting up. Urinary pain is often
suprapubic with radiation.
Vascular disturbances can cause both mild and severe pain. Radiation to the sacral region, flank or
genitalia indicates a need for investigation for aortic aneurysm.
Abdominal wall pain is generally constant and aching. It is worsened when the muscles are used.
Metabolic problems like hyperlipidaemia or C1 esterase deficiency can also cause abdominal pain,
often through other pathologies.
In immunocompromised patients, abdominal pain may be less severe. These patients may also
present with unusual infections.
Graft-versus-host disease causes fever and abdominal pain.
Neurological pain is often burning, and normally non-painful stimuli elicit pain. Pain originating from
a nerve root is transient or intermittent and stabbing.
Diverticulitis is an inflammation of diverticulae. Diverticulosis, the presence of diverticulae, is mostly
asymptomatic. It is more common in older people, and in the West it’s mostly left-sided, involving
the sigmoid colon. It is caused by (microscopic) perforation of a diverticulum.
IBS is generally diagnosed when other causes are excluded.
3
Digestion and Defence II
4 APRIL 2017
MARIEKE DE JONG
ITM
,Case 6: Acute Abdominal Pain ≠ Acute Abdomen .................................................................................3
Acute Abdominal Pain .........................................................................................................................3
Parietal vs. Visceral Pain ......................................................................................................................4
Referred Pain .......................................................................................................................................4
Case 7: Stick It Up Your… Throat Gerd ...................................................................................................5
Dysphagia .............................................................................................................................................5
GERD ....................................................................................................................................................5
Barrett’s Metaplasia ............................................................................................................................5
Oesophageal Cancer ............................................................................................................................6
Case 8: Sitting Heavy on the Stomach ....................................................................................................7
Peptic Ulcer Disease ............................................................................................................................7
NSAIDs..................................................................................................................................................8
Endoscopy ............................................................................................................................................8
Case 9: No Guts, No Glory .......................................................................................................................9
Iron Metabolism ..................................................................................................................................9
Anaemia ...............................................................................................................................................9
Vitamin B12..........................................................................................................................................9
Bile Salts .............................................................................................................................................10
Steatorrhea ........................................................................................................................................10
Water Absorption ..............................................................................................................................10
Case 10: Foie Gras .................................................................................................................................11
Hepatitis .............................................................................................................................................11
Hepatitis A......................................................................................................................................11
Hepatitis B ......................................................................................................................................11
Hepatitis C ......................................................................................................................................12
Hepatitis D .....................................................................................................................................13
Hepatitis E ......................................................................................................................................13
Stages of Liver Damage ......................................................................................................................13
Diagnostics .........................................................................................................................................14
Case 11: Encore une Fois .......................................................................................................................15
Fibrosis and Cirrhosis .........................................................................................................................15
Complications ....................................................................................................................................15
Lactulose Treatment ..........................................................................................................................16
Korsakoff Syndrome vs. Hepatoencephaly ........................................................................................16
Portocaval Anastomosis ....................................................................................................................16
1
,Case 12: Four Shades of Yellow ............................................................................................................18
Jaundice .............................................................................................................................................18
Haemoglobin Breakdown ..................................................................................................................18
Gallstones + Cholecystitis ..................................................................................................................19
Haemolytic Anaemia ..........................................................................................................................19
Acute Pancreatitis ..............................................................................................................................19
Case 13: Abdominal Pain Again? See a Doctor! ...................................................................................21
IBS ......................................................................................................................................................21
IBD ......................................................................................................................................................22
Epidemiology .................................................................................................................................22
Pathophysiology ............................................................................................................................22
Diagnosis and Treatment ...............................................................................................................23
Case 14: Consumption ..........................................................................................................................24
Tuberculosis .......................................................................................................................................24
Etiology ..........................................................................................................................................24
Epidemiology .................................................................................................................................24
Pathophysiology ............................................................................................................................24
Symptoms and Clinical Features ....................................................................................................25
Prevention......................................................................................................................................25
Treatment ......................................................................................................................................26
MDR and XDR TB................................................................................................................................26
Bibliography ..........................................................................................................................................27
2
, Case 6: Acute Abdominal Pain ≠ Acute
Abdomen
Acute Abdominal Pain
An acute abdomen is a situation involving the abdomen where immediate intervention is necessary
to save the patient’s life. It does not always present with acute abdominal pain.
Important things to find out in acute abdominal pain:
- Age
- Timing/onset of pain
- Characteristics of pain
- Duration of symptoms
- Location/radiation to other sites
- Associated symptoms
- Nausea, emesis, anorexia
- Diarrhoea, constipation, changes in bowel habits
- Menstrual/obstetric history
Most common causes: acute appendicitis, nonspecific abdominal pain, urologic origin, intestinal
obstruction.
When the parietal peritoneum is inflamed, the pain is steady, aching and can be located because it is
transmitted by somatic nerves. When the irritation is caused by acidic or enzymatically active
material, pain is more severe. Blood and urine do not elicit major responses. Bacterial contamination
is also often mild. The rate at which the material enters the abdominal cavity also changes the
presentation.
Pain from peritoneal inflammation gets worse with pressure changes. There is also often passive
muscle guarding.
Obstruction of organs with a lumen leads to intermittent colicky pain that is difficult to localise. In
the small bowel, this is often peri- or supraumbilical. Colon pain is often infraumbilical, radiating to
the lumbar region.
Sudden distention of the biliary tree produces steady pain. Acute gallbladder disease causes pain in
the right upper quadrant, radiating to the right posterior thorax or to the midline. Pain caused by the
pancreatic ducts is often worsened by lying down and relieved by getting up. Urinary pain is often
suprapubic with radiation.
Vascular disturbances can cause both mild and severe pain. Radiation to the sacral region, flank or
genitalia indicates a need for investigation for aortic aneurysm.
Abdominal wall pain is generally constant and aching. It is worsened when the muscles are used.
Metabolic problems like hyperlipidaemia or C1 esterase deficiency can also cause abdominal pain,
often through other pathologies.
In immunocompromised patients, abdominal pain may be less severe. These patients may also
present with unusual infections.
Graft-versus-host disease causes fever and abdominal pain.
Neurological pain is often burning, and normally non-painful stimuli elicit pain. Pain originating from
a nerve root is transient or intermittent and stabbing.
Diverticulitis is an inflammation of diverticulae. Diverticulosis, the presence of diverticulae, is mostly
asymptomatic. It is more common in older people, and in the West it’s mostly left-sided, involving
the sigmoid colon. It is caused by (microscopic) perforation of a diverticulum.
IBS is generally diagnosed when other causes are excluded.
3
