Acute Abdominal Pain
Acute Abdominal Pain
Acute Abdominal Pain
What is the pain like? Acute waves of sharp constricting pain that “take
the breath away” (renal or biliary colic)
Have you had it before? Yes suggests recurrent problems such as ulcer
disease, gallstone colic, diverticulitis, or
mittelschmerz
Was the onset sudden? Sudden: “like a light switching on” (perforated ulcer,
renal stone, ruptured ectopic pregnancy, torsion of
ovary or testis, some ruptured aneurysms)
How severe is the pain? Severe pain (perforated viscera, kidney stone,
peritonitis, pancreatitis)
Does the pain travel to any other part of Right scapula (gallbladder pain)
the body?
Left shoulder region (ruptured spleen, pancreatitis)
What other symptoms occur with the pain? Vomiting precedes pain and is followed by diarrhoea
(gastroenteritis)
Abdominal Pain
Mechanisms and physiology of abdominal pain
Nociceptors:
- Group III of A (fast pain fibres):
o cause bright, sharp, localised pain and
- Group IV or C fibres (slow pain fibres):
o Follows sharp pain with a dull, intense, diffuse, unpleasant sensation
caused by the latter fibres also called slow pain fibres.
The further from the brain the stimulus is applied; greater is the temporal separation of
the two components. Types of pain stimuli are mechanical, thermal, electrical, and
chemical.
Since deep somatic pain and visceral pain is poorly localised it may not be felt in the
viscera but in some somatic structure that may be a considerable distance away.
Referred Pain:
- The axons of primary afferent nociceptors enter the spinal cord via the dorsal
root.
- Terminate in the dorsal horn of the spinal grey matter.
- The terminals of primary afferent axons contact spinal neurons that transmit
the pain signal to brain sites involved in pain perception.
- When primary afferents are activated by noxious stimuli, they release
glutamate from their terminals that excite the spinal cord neurons
o Primary afferent nociceptor terminals also release peptides, including
substance P and calcitonin gene-related peptide, which produce a
slower and longer-lasting excitation of the dorsal horn neurons.
- The axon of each primary afferent contacts many spinal neurons, and each
spinal neuron receives convergent inputs from many primary afferents.
Pain experienced at a distance from the site of the damaged area. The affected somatic
structure developed from the same embryonic segment or dermatome as the structure
in which the pain originates.
- Dermatomal Rule
o Pain felt at the tip of the shoulder, when the parietal peritoneum on the
inferior surface of the diaphragm is irritated (like cholecystitis). This
area of peritoneum is innervated by somatic nerves (C4) as is the skin
over the tip of the shoulder.
o pain from distension of the midgut is referred to the peri-umbilical area
- Sometimes the initial pain is due to hyperaemia (increased blood flow) or
distension of the viscera but as the pathology extends it may result in
stimulation of the adjacent parietal peritoneum.
- The nature and site of the pain may then shift from one site to
another, e.g. shifting pain in appendicitis which may initially start as
a dull pain around the umbilicus and then may shift and localise as a
sharp severe pain at McBurney’s point in the right iliac fossa.
- When visceral pain is both local and referred, it may appear to spread or
radiate from the viscera to the referred area e.g. radiation of pain from the
loin to groin following distension of the ureter.
- All spinal neurons that receive input from the viscera and deep
musculoskeletal structures also receive input from the skin.
- The convergence patterns are determined by the spinal segment of the
dorsal root ganglion that supplies the afferent innervations of a structure.
- e.g. the afferents that supply the central diaphragm are derived from the third
and fourth cervical dorsal root ganglia. Primary afferents with cell bodies in
these same ganglia supply the skin of the shoulder and lower neck. Thus,
sensory inputs from both the shoulder skin and the central diaphragm
converge on pain-transmission neurons in the third and fourth cervical spinal
segments.
Because of this convergence and the fact that the spinal neurons are most often
activated by inputs from the skin, activity evoked in spinal neurons by input from deep
structures is mislocalised by the patient to a place that is roughly coextensive with the
region of skin innervated by the same spinal segment.
The brain has no way of knowing the actual source of input and mistakenly "projects"
the sensation to the somatic structure.
Thus, inflammation near the central diaphragm is usually reported as discomfort near
the shoulder. This spatial displacement of pain sensation from the site of the injury that
produces it is known as referred pain.
NB:
- For history-taking
o Pain referred to abdomen from thorax, spine or genitalia is important to
clarify because diseases of upper abdominal cavity such as acute
cholecystitis or perforated ulcer are frequently associated with
intrathoracic complications
o The possibility of intrathoracic disease must be considered in every
patient with abdominal pain, especially if the pain is in the upper part
of the abdomen.
Myocardial or pulmonary infarction, pneumonia, pericarditis, or
esophageal disease (the intrathoracic diseases that most often
masquerade as abdominal emergencies) will often provide
sufficient clues to establish the proper diagnosis.
• Diaphragmatic pleuritis resulting from pneumonia or
pulmonary infarction may cause pain in the right upper
quadrant and pain in the supraclavicular area, the latter
radiation to be distinguished from the referred subscapular
pain caused by acute distention of the extrahepatic biliary
tree.
o Palpation over the area of referred pain in the abdomen also does not
usually accentuate the pain and in many instances actually seems to
relieve it.
o Referred pain from the spine, which usually involves compression or
irritation of nerve roots, is characteristically intensified by certain
motions such as cough, sneeze, or strain and is associated with
hyperesthesia over the involved dermatomes.
o Pain referred to the abdomen from the testes or seminal vesicles is
generally accentuated by the slightest pressure on either of these
organs.
1. ACUTE INFLAMMATION:
o Well localised, patient indicates position of pain with palm of hand or finger
2. OBSTRUCTION
• Obstruction can occur anywhere along the lumen of GIT, resulting in proximal
distension and stasis; if obstructed bowel is open ended proximally, distension
progresses proximally. If lumen is closed proximally, luminal contents and organ
itself become infected (cholecystitis – inflammation of gall bladder, cholangitis –
inflammation of bile duct, appendicitis) or progressive distension can lead to
venous obstruction followed by arterial obstruction, then gangrene and
perforation (e.g. closed loop obstruction of bowel)
3. ISCHAEMIA AND OTHER VASCULAR DISTURBANCES
Sudden onset pain (over few min) and continuous (visceral pain)
o Severity depends on
degree of swelling
Signs of dehydration –
• dry tongue
• reduced skin turgor
• decreased eye turgor
• tachycardia
• possible arrhythmias
• Increased respiration
• Decreased sweating and
decreased capillary return
• Decreased urination
• Increased body
temperature
• Extreme fatigue
• Muscle cramps
• Headaches
• Nausea
• Tingling of the limbs
Conditions: Glossary
Gastroenteritis
The typical syndrome will consist of
diffuse, cramping abdominal pain,
fever, and nausea, with hyperactive
bowel sounds and mild diffuse
abdominal tenderness. Bacterial
infections will cause higher fever,
watery diarrhea, and foul-smelling,
often bloody stools.
Obstipation
The patient is distended with stool
palpable through the abdominal wall
and only mild abdominal tenderness.
There will usually be a history of
absence of bowel movements for
several days although a small
amount of diarrhea may pass around the fecal obstruction.
Mesenteric ischemia
Acute vascular occlusion usually presents with severe midabdominal pain out of proportion to
the physical findings. The pain begins as colic, then progresses. In later stages, fever and
hypotension occur. An embolic substrate (atrial fibrillation or acute MI) is a key clue. The stool
should be hemoccult positive. “Intestinal angina” presents with recurrent colicky abdominal pain
and distension occurring 20 to 30 minutes after a meal and lasting 2 to 3 hours. This may
manifest itself as food aversion or a malabsorptive diarrhea/steatorrhea with prominent weight
loss. There is often a bruit in the upper abdomen.
Peritonitis
There will be early vomiting, board-like abdominal rigidity, rebound tenderness, fever, and a
silent abdomen. The patient will lie absolutely still. The pain is often localized (e.g., appendicitis)
before becoming generalized.
Hepatitis
Following a prodromal phase of anorexia and malaise, the icteric phase is dominated by right
upper quadrant pain and tenderness, fever, jaundice, nausea, dark urine, and light stools.
Biliary colic
Sudden onset of steady and severe pain lasting 15 minutes to hours occurs with acute
obstruction of the common bile or cystic duct. Cystic duct obstruction causes right upper
quadrant pain whereas common bile duct obstruction causes epigastric pain, early jaundice, and
prominent emesis. Pain may radiate to the scapula.
Pyelonephritis
Typically, the patient has dysuria, fever, nausea, and costovertebral angle tenderness although
presentation with poorly localized abdominal pain is not uncommon either.
Acute cholecystitis
Right upper quadrant pain radiates to the scapula and is accompanied by nausea, vomiting, and
fever. Murphy sign (inspiratory arrest on palpation over the gallbladder) is present, and a
distended gallbladder is palpable in 30%. There is often a background of biliary colic. Fever and
rigors herald a suppurative cholangitis.
Appendicitis
Classically, it begins as poorly localized visceral pain in the periumbilical region, moving to the
right lower quadrant, where somatic pain is steadily progressive. There is localized tenderness
over McBurney’s point, with or without rebound tenderness. Anorexia/nausea and low-grade
fever are usually present.
Salpingitis
A sexually active woman presents with lower abdominal pain. Pelvic examination reveals yellow
discharge from the cervix, cervical motion pain (chandelier sign), or tender adnexa. An
exquisitely tender adnexal mass indicates a tubo-ovarian abscess.
Rectus abdominus muscle strain
The history will suggest strain or overuse. The pain is constant and aching and is exacerbated by
movement. There will be superficial tenderness over the rectus abdominis, and spasm may
mimic guarding. A hematoma may simulate a localized mass.
Ureteral calculus
Severe cramping flank pain radiates to the groin. The patient is pale and unable to find a
comfortable position. The urine will be dipstick positive for blood.
Ovarian torsion
The usual presentation is a young woman with acute onset of pain and a tender adnexal mass
but no fever.
Pancreatitis
Left upper quadrant pain boring through to the back, prominent nausea and vomiting, and a
history of heavy alcohol use or cholelithiasis are important clues. The patient sits up and leans
forward, or lies on the side in a knee-chest position. Rebound will be present just above the
umbilicus, and costovertebral angle tenderness occurs with inflammation of the tail of the
pancreas. Hiccups are often present.
Splenic infarction
Left upper quadrant pleuritic pain and tenderness occur in the setting of atrial fibrillation,
endocarditis, sickle cell anemia, or neoplastic splenic enlargement. There may be a localized
friction rub.
Myocardial infarction
Ischemia should be considered with upper abdominal pain although chest pain is usually
present. Nausea can be seen with inferior ischemia.
Diverticulitis
It presents subacutely with low-grade fever and left lower quadrant abdominal pain. A tender
mass with indistinct borders may be palpable on abdominal or rectal examination.
Sigmoid volvulus
Severe pain will suddenly occur while the patient is straining to defecate. Rapid, extreme left
upper quadrant distension occurs, with vertical peristalsis.