ABDOMINAL PAIN

Dr Budi Enoch SpPD

 The correct interpretation of acute
abdominal pain is challenging. Few other
clinical situations demand greater judgment,
because the most catastrophic of events may
be forecast by the subtlest of symptoms and
signs.
 A meticulously executed, detailed history
and physical examination are of the greatest
importance.
 The etiologic classification in Table 13-1,
although not complete, forms a useful basis
for the evaluation of patients with abdominal
pain
The diagnosis of "acute or surgical abdomen" is not an acceptable one because of its
often misleading and erroneous connotation. The most obvious of "acute abdomens"
may not require operative intervention, and the mildest of abdominal pains may
herald an urgently correctable lesion. Any patient with abdominal pain of recent
onset requires early and thorough evaluation and accurate diagnosis.
 SOME MECHANISMS OF PAIN
ORIGINATING IN THE ABDOMEN
 INFLAMMATION OF THE PARIETAL PERITONEUM
 The pain of parietal peritoneal inflammation is steady and aching in
character and is located directly over the inflamed area, its exact
reference being possible because it is transmitted by somatic nerves
supplying the parietal peritoneum.
 The intensity of the pain is dependent on the type and amount of material
to which the peritoneal surfaces are exposed in a given time period.
 For example, the sudden release into the peritoneal cavity of a small
quantity of sterile acid gastric juice causes much more pain than the same
amount of grossly contaminated neutral feces.
 Enzymatically active pancreatic juice incites more pain and inflammation
than does the same amount of sterile bile containing no potent enzymes.
 Blood and urine are often so bland as to go undetected if their contact
with the peritoneum has not been sudden and massive.
 In the case of bacterial contamination, such as in pelvic inflammatory
disease, the pain is frequently of low intensity early in the illness until
bacterial multiplication has caused the elaboration of irritating
substances.
 The rate at which the irritating material is applied to
the peritoneum is important.
 Perforated peptic ulcer may be associated with
entirely different clinical pictures dependent only on
the rapidity with which the gastric juice enters the
peritoneal cavity.
 The pain of peritoneal inflammation is invariably
accentuated by pressure or changes in tension of the
peritoneum, whether produced by palpation or by
movement, as in coughing or sneezing.
 The patient with peritonitis lies quietly in bed,
preferring to avoid motion, in contrast to the patient
with colic, who may writhe incessantly.
 Another characteristic feature of peritoneal irritation
is tonic reflex spasm of the abdominal musculature,
localized to the involved body segment
 OBSTRUCTION OF HOLLOW
VISCERA
 The pain of obstruction of hollow abdominal viscera is classically
described as intermittent, or colicky. Yet the lack of a truly cramping
character should not be misleading, because distention of a hollow
viscus may produce steady pain with only very occasional
exacerbations.
 It is not nearly as well localized as the pain of parietal peritoneal
inflammation.
 The colicky pain of obstruction of the small intestine is usually
periumbilical or supraumbilical and is poorly localized.
 As the intestine becomes progressively dilated with loss of muscular
tone, the colicky nature of the pain may diminish. With superimposed
strangulating obstruction, pain may spread to the lower lumbar
region if there is traction on the root of the mesentery.
 The colicky pain of colonic obstruction is of lesser intensity than that
of the small intestine and is often located in the infraumbilical area.
 Lumbar radiation of pain is common in colonic obstruction
 Sudden distention of the biliary tree produces a steady rather than
colicky type of pain; hence, the term biliary colic is misleading.
 Acute distention of the gallbladder usually causes pain in the right
upper quadrant with radiation to the right posterior region of the
thorax or to the tip of the right scapula, but is not uncommonly
midline.
 Distention of the common bile duct is often associated with pain in
the epigastrium radiating to the upper part of the lumbar region.
 Considerable variation is common, however, so that differentiation
between these may be impossible.
 The typical subscapular pain or lumbar radiation is frequently
absent.
 Gradual dilatation of the biliary tree, as in carcinoma of the head
of the pancreas, may cause no pain or only a mild aching sensation
in the epigastrium or right upper quadrant.
 The pain of distention of the pancreatic ducts is similar to that
described for distention of the common bile duct but, in addition,
is very frequently accentuated by recumbency and relieved by the
upright position.
 VASCULAR DISTURBANCES
 A frequent misconception, despite abundant experience to the
contrary, is that pain associated with intraabdominal vascular
disturbances is sudden and catastrophic in nature.
 The pain of embolism or thrombosis of the superior mesenteric artery
or that of impending rupture of an abdominal aortic aneurysm
certainly may be severe and diffuse. Yet, just as frequently, the
patient with occlusion of the superior mesenteric artery has only mild
continuous or cramping diffuse pain for two or three days before
vascular collapse or findings of peritoneal inflammation appear.
 The early, seemingly insignificant discomfort is caused by
hyperperistalsis rather than peritoneal inflammation.
 Indeed, absence of tenderness and rigidity in the presence of
continuous, diffuse pain in a patient likely to have vascular disease is
quite characteristic of occlusion of the superior mesenteric artery.
 Abdominal pain with radiation to the sacral region, flank, or genitalia
should always signal the possible presence of a rupturing abdominal
aortic aneurysm. This pain may persist over a period of several days
ABDOMINAL WALL
 Pain arising from the abdominal wall is usually
constant and aching. Movement, prolonged
standing, and pressure accentuate the discomfort
and muscle spasm.
 In the case of hematoma of the rectus sheath, now
most frequently encountered in association with
anticoagulant therapy, a mass may be present in
the lower quadrants of the abdomen.
 Simultaneous involvement of muscles in other
parts of the body usually serves to differentiate
myositis of the abdominal wall from an
intraabdominal process that might cause pain in
the same region.
 REFERRED PAIN IN ABDOMINAL
DISEASES
 Pain referred to the abdomen from the thorax, spine, or genitalia may prove a
vexing diagnostic problem, because diseases of the upper part of the abdominal
cavity such as acute cholecystitis or perforated ulcer are frequently associated
with intrathoracic complications.
 A most important, yet often forgotten, dictum is that 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.
 Systematic questioning and examination directed toward detecting 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.
 The ultimate decision as to the origin of abdominal pain may require deliberate
and planned observation over a period of several hours, during which repeated
questioning and examination will provide the diagnosis or suggest the
appropriate studies.
METABOLIC ABDOMINAL CRISES
 Pain of metabolic origin may simulate almost any other
type of intraabdominal disease. Several mechanisms may
be at work.
 In certain instances, such as hyperlipidemia, the metabolic
disease itself may be accompanied by an intraabdominal
process such as pancreatitis, which can lead to unnecessary
laparotomy unless recognized. C'1 esterase deficiency
associated with angioneurotic edema is often associated
with episodes of severe abdominal pain.
 Whenever the cause of abdominal pain is obscure, a
metabolic origin always must be considered. Abdominal
pain is also the hallmark of familial Mediterranean fever.
 The problem of differential diagnosis is often not readily
resolved
NEUROGENIC CAUSES
 Causalgic pain may occur in diseases that injure sensory nerves. It has
a burning character and is usually limited to the distribution of a given
peripheral nerve.
 Normal stimuli such as touch or change in temperature may be
transformed into this type of pain, which is frequently present in a
patient at rest.
 The demonstration of irregularly spaced cutaneous pain spots may be
the only indication of an old nerve lesion underlying causalgic pain.
 Even though the pain may be precipitated by gentle palpation, rigidity
of the abdominal muscles is absent, and the respirations are not
disturbed.
 Distention of the abdomen is uncommon, and the pain has no
relationship to the intake of food.
 Pain arising from spinal nerves or roots comes and goes suddenly and is
of a lancinating type. It may be caused by herpes zoster, impingement
by arthritis, tumors, herniated nucleus pulposus, diabetes, or syphilis.
It is not associated with food intake, abdominal distention, or changes
in respiration.
 Severe muscle spasm, as in the gastric crises of tabes dorsalis, is
common but is either relieved or is not accentuated by abdominal
palpation. The pain is made worse by movement of the spine and is
usually confined to a few dermatomes. Hyperesthesia is very common
 APPROACH TO THE
PATIENT ABDOMINAL PAIN
 Few abdominal conditions require such urgent operative
intervention that an orderly approach need be abandoned,
no matter how ill the patient.
 Only those patients with exsanguinating intraabdominal
hemorrhage (e.g., ruptured aneurysm) must be rushed to the
operating room immediately, but in such instances only a few
minutes are required to assess the critical nature of the
problem.
 Under these circumstances, all obstacles must be swept
aside, adequate venous access for fluid replacement
obtained, and the operation begun.
 Many patients of this type have died in the radiology
department or the emergency room while awaiting such
unnecessary examinations as electrocardiograms or CT scans.
 There are no contraindications to operation when massive
intraabdominal hemorrhage is present. Fortunately, this
situation is relatively rare. These comments do not pertain to
gastrointestinal hemorrhage, which can often be managed by
other means
 In the examination, simple critical inspection of the patient, e.g., of
facies, position in bed, and respiratory activity, provides valuable
clues.
 The amount of information to be gleaned is directly proportional to the
gentleness and thoroughness of the examiner.
 Once a patient with peritoneal inflammation has been examined
brusquely, accurate assessment by the next examiner becomes almost
impossible.
 Eliciting rebound tenderness by sudden release of a deeply palpating
hand in a patient with suspected peritonitis is cruel and unnecessary.
 The same information can be obtained by gentle percussion of the
abdomen (rebound tenderness on a miniature scale), a maneuver that
can be far more precise and localizing. Asking the patient to cough will
elicit true rebound tenderness without the need for placing a hand on
the abdomen.
 Furthermore, the forceful demonstration of rebound tenderness will
startle and induce protective spasm in a nervous or worried patient in
whom true rebound tenderness is not present.
 A palpable gallbladder will be missed if palpation is so brusque that
voluntary muscle spasm becomes superimposed on involuntary
muscular rigidity
 As with history taking, sufficient time should be spent in the examination.
 Abdominal signs may be minimal but nevertheless, if accompanied by
consistent symptoms, may be exceptionally meaningful.
 Abdominal signs may be virtually or totally absent in cases of pelvic
peritonitis, so careful pelvic and rectal examinations are mandatory in
every patient with abdominal pain.
 Tenderness on pelvic or rectal examination in the absence of other
abdominal signs can be caused by operative indications such as perforated
appendicitis, diverticulitis, twisted ovarian cyst, and many others.
 Much attention has been paid to the presence or absence of peristaltic
sounds, their quality, and their frequency. Auscultation of the abdomen is
one of the least revealing aspects of the physical examination of a patient
with abdominal pain.
 Catastrophes such as strangulating small intestinal obstruction or perforated
appendicitis may occur in the presence of normal peristaltic sounds.
 Conversely, when the proximal part of the intestine above an obstruction
becomes markedly distended and edematous, peristaltic sounds may lose the
characteristics of borborygmi and become weak or absent, even when
peritonitis is not present. It is usually the severe chemical peritonitis of
sudden onset that is associated with the truly silent abdomen.
 Assessment of the patient's state of hydration is important.
 Sometimes, even under the best circumstances
with all available aids and with the greatest of
clinical skill, a definitive diagnosis cannot be
established at the time of the initial examination.
 Nevertheless, despite lack of a clear anatomic
diagnosis, it may be abundantly clear to an
experienced and thoughtful physician and surgeon
that on clinical grounds alone operation is
indicated.
 Should that decision be questionable, watchful
waiting with repeated questioning and
examination will often elucidate the true nature
of the illness and indicate the proper course of
action.
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